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Are children with prolonged fever at a higher risk for serious illness? A prospective observational study

Lookup NU author(s): Professor Marieke Emonts-le ClercqORCiD, Dr Emma Lim



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.Objectives: To describe the characteristics and clinical outcomes of children with fever ≥5 days presenting to emergency departments (EDs). Design: Prospective observational study. Setting: 12 European EDs. Patients: Consecutive febrile children <18 years between January 2017 and April 2018. Interventions: Children with fever ≥5 days and their risks for serious bacterial infection (SBI) were compared with children with fever <5 days, including diagnostic accuracy of non-specific symptoms, warning signs and C-reactive protein (CRP; mg/L). Main outcome measures: SBI and other non-infectious serious illness. Results: 3778/35 705 (10.6%) of febrile children had fever ≥5 days. Incidence of SBI in children with fever ≥5 days was higher than in those with fever <5 days (8.4% vs 5.7%). Triage urgency, life-saving interventions and intensive care admissions were similar for fever ≥5 days and <5 days. Several warning signs had good rule in value for SBI with specificities >0.90, but were observed infrequently (range: 0.4%-17%). Absence of warning signs was not sufficiently reliable to rule out SBI (sensitivity 0.92 (95% CI 0.87-0.95), negative likelihood ratio (LR) 0.34 (0.22-0.54)). CRP <20 mg/L was useful for ruling out SBI (negative LR 0.16 (0.11-0.24)). There were 66 cases (1.7%) of non-infectious serious illnesses, including 21 cases of Kawasaki disease (0.6%), 28 inflammatory conditions (0.7%) and 4 malignancies. Conclusion: Children with prolonged fever have a higher risk of SBI, warranting a careful clinical assessment and diagnostic workup. Warning signs of SBI occurred infrequently but, if present, increased the likelihood of SBI. Although rare, clinicians should consider important non-infectious causes of prolonged fever.

Publication metadata

Author(s): Nijman RG, Tan CD, Hagedoorn NN, Nieboer D, Herberg JA, Balode A, Von Both U, Carrol ED, Eleftheriou I, Emonts M, Van Der Flier M, De Groot R, Kohlmaier B, Lim E, Martinon-Torres F, Pokorn M, Strle F, Tsolia M, Yeung S, Zachariasse JM, Zavadska D, Zenz W, Levin M, Vermont CL, Moll HA, MacOnochie IK

Publication type: Article

Publication status: Published

Journal: Archives of Disease in Childhood

Year: 2023

Volume: 108

Issue: 8

Pages: 632-639

Print publication date: 01/08/2023

Online publication date: 25/04/2023

Acceptance date: 10/04/2023

Date deposited: 09/06/2023

ISSN (print): 0003-9888

ISSN (electronic): 1468-2044

Publisher: BMJ Publishing Group


DOI: 10.1136/archdischild-2023-325343

ePrints DOI: 10.57711/vtet-jb07

PubMed id: 37185174


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Funder referenceFunder name
European Union’s Horizon 2020
National Institute for Health Research