武田裕子：発熱をめぐるオーバービュー、診断と治療 2007；95：972-977.
山中達宏：発熱、小児内科 2000；32：353-359.
柳原知子：乳児の発熱、小児科診療 2005；68：415-421.
熊谷直樹：乳児期早期の発熱児への外来での対応、小児科診療 1999；62：1250-1253.
厚生労働省：令和5年度第2回医療政策研修会及び第1回地域医療構想アドバイザー会議：（資料）新興感染症発生・まん延時における医療について.
厚生労働省：令和5年度 今シーズンのインフルエンザ総合対策について.
日本集中治療医学会・日本救急医学会 編：日本版敗血症診療ガイドライン2020（J-SSCG2020） 、2021.
Lopez JA, McMillin KJ, Tobias-Merrill EA, Chop WM Jr.
Managing fever in infants and toddlers: toward a standard of care.
Postgrad Med. 1997 Feb;101(2):241-2, 245-52. doi: 10.3810/pgm.1997.02.168.
Abstract/Text
Fever in infants and toddlers can portend a serious bacterial illness requiring a prompt medical response. When dealing with a febrile child between 1 and 36 months of age, physicians should consider toxicity, focal infections, age, and the results of a sepsis workup and then use a strategy based on the Rochester criteria to assess whether the patient is at low risk for a serious bacterial illness. On the basis of that determination, a plan for inpatient or outpatient management can be selected. Variations in treatment can reasonably be based on clinical judgment and physician and parent preferences.
Watson RS, Carcillo JA, Linde-Zwirble WT, Clermont G, Lidicker J, Angus DC.
The epidemiology of severe sepsis in children in the United States.
Am J Respir Crit Care Med. 2003 Mar 1;167(5):695-701. doi: 10.1164/rccm.200207-682OC. Epub 2002 Nov 14.
Abstract/Text
Despite extensive research into the etiology and treatment of severe sepsis, little is known about its epidemiology in children. We sought to determine the age- and sex-adjusted incidence, outcome, and associated hospital costs of severe sepsis in United States children using 1995 hospital discharge and population data from seven states (24% of the United States population). Of 1,586,253 hospitalizations in children who were 19 years old or less, 9,675 met International Classification of Diseases, 9th revision, clinical modification-based severe sepsis criteria or 42,364 cases of pediatric severe sepsis per year nationally (0.56 cases per 1,000 population per year). The incidence was the highest in infants (5.16 per 1,000), fell dramatically in older children (0.20 per 1,000 in 10 to 14 year olds), and was 15% higher in boys than in girls (0.60 versus 0.52 per 1,000, p < 0.001). Hospital mortality was 10.3%, or 4,383 deaths nationally (6.2 per 100,000 population). Half of the cases had underlying disease (49.0%), and over one-fifth (22.9%) were low-birth-weight newborns. Respiratory infections (37%) and primary bacteremia (25%) were the most common infections. The mean length of stay and cost were 31 days and $40,600, respectively. Estimated annual total costs were 1.97 billion US dollars nationally. Severe sepsis is a significant health problem in children and is associated with the use of extensive healthcare resources. Infants are at highest risk, especially those with a low birth weight.
Browne GJ, Currow K, Rainbow J.
Practical approach to the febrile child in the emergency department.
Emerg Med (Fremantle). 2001 Dec;13(4):426-35. doi: 10.1046/j.1035-6851.2001.00256.x.
Abstract/Text
Jaskiewicz JA, McCarthy CA, Richardson AC, White KC, Fisher DJ, Dagan R, Powell KR.
Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group.
Pediatrics. 1994 Sep;94(3):390-6.
Abstract/Text
OBJECTIVE: Prospective studies were conducted to test the hypothesis that infants unlikely to have serious bacterial infections (SBI) can be accurately identified by low risk criteria.
METHODS: Febrile infants (rectal T > or = 38 degrees C) < or = 60 days of age were considered at low risk for SBI if they met the following criteria: 1) appear well; 2) were previously healthy; 3) have no focal infection; 4) have WBC count 5.0-15.0 x 10(9) cells/L (5000-15,000/mm3), band form count < or = 1.5 x 10(9) cells/L (< or = 1500/mm3), < or = 10 WBC per high power field on microscopic examination of spun urine sediment, and < or = 5 WBC per high power field on microscopic examination of a stool smear (if diarrhea). The recommended evaluation included the culture of specimens of blood, cerebrospinal fluid, and urine for bacteria. Outcomes were determined. The negative predictive values of the low risk criteria for SBI and bacteremia were calculated.
RESULTS: Of 1057 eligible infants, 931 were well appearing, and, of these, 437 met the remaining low risk criteria. Five low risk infants had SBI including two infants with bacteremia. The negative predictive value of the low risk criteria was 98.9% (95% confidence interval, 97.2% to 99.6%) for SBI, and 99.5% (95% confidence interval, 98.2% to 99.9%) for bacteremia.
CONCLUSIONS: These data confirm the ability of the low risk criteria to identify infants unlikely to have SBI. Infants who meet the low risk criteria can be carefully observed without administering antimicrobial agents.
Baker MD, Bell LM, Avner JR.
The efficacy of routine outpatient management without antibiotics of fever in selected infants.
Pediatrics. 1999 Mar;103(3):627-31. doi: 10.1542/peds.103.3.627.
Abstract/Text
BACKGROUND: A previous study produced a protocol for outpatient management of febrile infants (FIs) judged to be at low risk for serious bacterial illness (SBI). This Philadelphia protocol demonstrated that 40% of FIs seen in the emergency department could be safely managed without antibiotics at home; and it was established by the emergency department staff as the standard of care at our institution.
OBJECTIVE: To determine 1) the actual practices of management of FIs 18 months after establishment of the Philadelphia protocol as the standard of care, and 2) the continued efficacy of noninvasive outpatient management of fever in FIs who, using the Philadelphia protocol, were identified as low risk for SBI.
DESIGN: Thirty-six-month consecutive cohort study.
SETTING: Urban pediatric emergency department.
PARTICIPANTS: Four hundred twenty-two infants, 29 to 60 days of age, with rectal temperatures >/=38.0 degrees C. Interventions. After a complete history taking, physical examination, and workup for SBI, infants were managed at the discretion of the attending physician in the emergency department. Subsequently, those management practices were reviewed and compliance with the Philadelphia protocol was evaluated. In addition, the overall efficacy and safety of that standard during 8 years of use was assessed.
RESULTS: Of the 422 FIs enrolled, 101 (24%) were prospectively identified as low risk for SBI, and safe for management without antibiotics. Twenty-eight (6%) FIs were managed out of accordance with the Philadelphia protocol. Seven were admitted out of accordance, 10 (2 with UTI) were discharged out of accordance, and 11 inpatients (1 with bacterial gastroenteritis) initially received no antibiotics out of accordance with the protocol. Physician failure to consider the results of the complete blood count or urinalysis accounted for errors involving FIs with SBI. None of the 43 FIs with SBI were identified by the Philadelphia protocol to be at low risk for SBI.
CONCLUSIONS: The Philadelphia protocol for outpatient management without antibiotics of FIs at low risk for SBI remains practical, reliable, and safe. Because breaches do occur, physicians must carefully scrutinize protocol compliance, especially with regard to the complete blood count and urinalysis.
Baskin MN, O'Rourke EJ, Fleisher GR.
Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone.
J Pediatr. 1992 Jan;120(1):22-7. doi: 10.1016/s0022-3476(05)80591-8.
Abstract/Text
STUDY OBJECTIVE: To determine the outcome of outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone.
DESIGN: Prospective consecutive cohort study.
SETTING: Urban emergency department.
PATIENTS: Five hundred three infants 28 to 89 days of age with temperatures greater than or equal to 38 degrees C who did not appear ill, had no source of fever detected on physical examination, had a peripheral leukocyte count less than 20 x 10(9) cells/L, had a cerebrospinal fluid leukocyte count less than 10 x 10(6)/L, did not have measurable urinary leukocyte esterase, and had a caretaker available by telephone. Follow-up was obtained for all but one patient (99.8%).
INTERVENTION: After blood, urine, and cerebrospinal fluid cultures had been obtained, the infants received 50 mg/kg intramuscularly administered ceftriaxone and were discharged home. The infants returned for evaluation and further intramuscular administration of ceftriaxone 24 hours later; telephone follow-up was conducted 2 and 7 days later.
RESULTS: Twenty-seven patients (5.4%) had a serious bacterial infection identified during follow-up; 476 (94.6%) did not. Of the 27 infants with serious bacterial infections, 9 (1.8%) had bacteremia (8 of these had occult bacteremia and 1 had bacteremia with a urinary tract infection), 8 (1.6%) had urinary tract infections without bacteremia, and 10 (2.0%) had bacterial gastroenteritis without bacteremia. Clinical screening criteria did not enable discrimination between infants with and those without serious bacterial infections. All infants with serious bacterial infections received an appropriate course of antimicrobial therapy and were well at follow-up. One infant had osteomyelitis diagnosed 1 week after entry into the study, received an appropriate course of intravenous antimicrobial therapy, and recovered fully.
CONCLUSIONS: After a full evaluation for sepsis, outpatient treatment of febrile infants with intramuscular administration of ceftriaxone pending culture results and adherence to a strict follow-up protocol is a successful alternative to hospital admission.
American Heart Association編：PALSプロバイダーマニュアル 日本語版 AHAガイドライン2005準拠 、シナジー、2008.
Gehri M, Guignard E, Djahnine SR, Cotting JQ, Yersin C, Di Paolo ER, Krahenbuhl JD, Pannatier A.
When fever, paracetamol? Theory and practice in a paediatric outpatient clinic.
Pharm World Sci. 2005 Jun;27(3):254-7. doi: 10.1007/s11096-004-4771-x.
Abstract/Text
OBJECTIVE: To determine how medical and nursing staff treat feverish children and compare the findings with their theoretical knowledge, evaluating how they might contribute to fever phobia in parents.
SETTING: Paediatric Emergency Department.
METHOD: In the first step, we analysed prospectively the files of all children having consulted the Paediatric Emergency Department with a history of fever or of body temperature above 38 degrees C during a 2-week period. The second step consisted of evaluating knowledge and perception of fever of doctors and nurses using a questionnaire.
MAIN OUTCOME MEASURES: Prospective study: final diagnosis (viral, non- invasive bacterial disorders, invasive bacterial disorders), site of measurement and average temperature. Evaluation of theoretical knowledge: definition of fever, site of measurement, evaluation of the child's clinical state, antipyretic drug choice.
RESULTS: A total of 114 children under 5 years of age were enrolled and 24 caregivers (12 doctors, 12 nurses, 90 of the staff) responded to the questionnaire. The results showed good consistency in theoretical knowledge, but an excessive fear about cerebral damage was also shown by doctors. This belief likely contributes to the transmission of fever phobia to parents. In contrast, analysis of children management showed that fever was often under-treated, especially by nurses and even more so by parents. Paracetamol remained the first-line antipyretic drug yet was often administered in insufficient doses. Non-steroidal anti-inflammatory drugs were seldom used, except by parents (16 of all the children). Contrary to literature, the favourite route of administration was the rectal one. Physical methods like sponging were largely used by nurses, despite the uncertainties in their real effectiveness and their known side-effects.
CONCLUSION: Our study showed that the management of feverish children was globally correct in the Paediatric Emergency Department, but several improvement measures have been taken (e.g. tables of normal and abnormal ranges of temperature, recommended temperature measurement techniques, dosage regimen of antipyretic drugs, guidelines to parents), justifying the implementation of a pharmaceutical follow-up.
Krantz C.
Childhood fevers: developing an evidence-based anticipatory guidance tool for parents.
Pediatr Nurs. 2001 Nov-Dec;27(6):567-71.
Abstract/Text
Misconceptions about childhood fevers heighten parents' concerns leading to frequent use of health care services. Designing, piloting, and evaluating nursing interventions to demystify parents' phobia of fevers are imperative. An evidence-based fever anticipatory guidance tool was designed to assist parents by: dispelling misconceptions, teaching proper care of their febrile child and appropriate use of antipyretics, and providing a list of serious signs that warrant medical attention. Concepts of the Health Belief Model (HBM) are applied to parent behavior to promote a greater understanding of their actions in the face of childhood fever. Informing consumers with accurate and consistent information has direct implications for changing practice in the hospital and community.
小柴美紀恵、宮本健一：「発熱」に対する薬物療法7.薬局58 49-52、2007.
早野恵子、東 理：発熱時のケアと解熱剤の選択について、治療86：63-68、2004.
田原卓浩：解熱剤の使い方、横田俊平、田原卓浩、橋本剛太郎編：直伝 小児の薬の選び方・使い方、改訂3版。南山堂、64-68、2010.
厚生労働省インフルエンザ脳症研究班：インフルエンザ脳症ガイドライン改訂版 2009.
熊谷直樹：乳児期早期の発熱児への外来での対応、小児科診療62：1250-1253、1999.
Axelrod P.
External cooling in the management of fever.
Clin Infect Dis. 2000 Oct;31 Suppl 5:S224-9. doi: 10.1086/317516.
Abstract/Text
Although physical methods of cooling are the treatment of choice for hyperthermia, their value in the treatment of fever remains uncertain. Methods involving convection and evaporation are more effective than those involving conduction for the treatment of hyperthermia. These same methods, combined with antipyretic medication, are preferable to immersion as treatment for fever in young children but are generally not practical in adults. Febrile children treated with tepid-water sponging plus antipyretic drugs are more uncomfortable that those treated with antipyretic drugs alone, although they exhibit slightly more rapid reductions in temperature. When febrile, seriously ill patients are externally cooled and are sedated or paralyzed with drugs that suppress shivering, they may have a more rapid reduction of fever and reduced energy expenditure than if treated with antipyretic drugs alone. A risk/benefit assessment of the consequences of such treatment is not yet possible.
谷口 繁：小児の発熱・頭痛、治療 83：1702-1707、2001.
社本奈美：小児用冷却貼付剤の効果について、チャイルドヘルス vol.3 383-384、2000.
Tessler H, Gorodischer R, Press J, Bilenko N.
Unrealistic concerns about fever in children: the influence of cultural-ethnic and sociodemographic factors.
Isr Med Assoc J. 2008 May;10(5):346-9.
Abstract/Text
BACKGROUND: Parental fear and misconceptions about fever are widespread in western society. Ethnicity and sociodemographic factors have been suggested as contributing factors.
OBJECTIVES: To test the hypothesis that undue parental concern about fever is less in traditional than in western cultural-ethnic groups.
METHODS: Bedouin (traditional society) and Jewish (western society) parents of children aged 0-5 years with fever were interviewed in a pediatric emergency unit. Interviews were conducted in the parents' most fluent language (Arabic or Hebrew). A quantitative variable (a 9 item "fever phobia" scale) was constructed.
RESULTS: The parents of 101 Jewish and 100 Bedouin children were interviewed. More Bedouin parents were unemployed, had less formal education and had more and younger children than the Jewish parents. Parents in both groups expressed erroneous beliefs and practices about fever; quantitative but not qualitative differences in fever phobia variables were documented. Compared with their Jewish counterparts, more Bedouin parents believed that fever may cause brain damage and death, administered antipyretic medications for temperature < or = 38 degrees C and at excessive doses, and consulted a physician within 24 hours even when the child had no signs of illness other than fever (all Pvalues <0.001). The mean fever phobia score was higher in the Bedouin than in the Jewish group (P< 0.001). By multivariate analysis, only the cultural-ethnic origin correlated with fever phobia.
CONCLUSIONS: A higher degree of fever phobia was found among parents belonging to the traditional Bedouin group as compared to western society parents.
Schmitt BD.
Fever phobia: misconceptions of parents about fevers.
Am J Dis Child. 1980 Feb;134(2):176-81.
Abstract/Text
Eighty-one parents bringing their children to a hospital-based pediatric clinic were surveyed about their understanding of fever. Most parents were unduly worried about low-grade fever, with temperatures of 38.9 degrees C or less. Their overconcern was designated "fever phobia." Most parents (52%) believed that moderate fever with a temperature of 40 degrees C or less can cause serious neurological side-effects. Hence, most parents treated fever aggressively: 85% gave antipyretic medication before the temperature reached 38.9 degrees C and 68% sponged the child before the temperature reached 39.5 degrees C. A review of the literature showed that the only serious complications of fever were febrile status epilepticus and heat stroke, two rare entities. The great concern of parents about fever is not justified. Health education to counteract "fever phobia" should be a part of routine pediatric care.
Betz MG, Grunfeld AF.
'Fever phobia' in the emergency department: a survey of children's caregivers.
Eur J Emerg Med. 2006 Jun;13(3):129-33. doi: 10.1097/01.mej.0000194401.15335.c7.
Abstract/Text
OBJECTIVES: To investigate children's caregivers' attitudes towards fever in an emergency department setting.
METHODS: A 25-item questionnaire was formulated, on the basis of similar previous published surveys, for administration to a convenience sample of caregivers. It was administered by a medical translator after triage, before assessment by a physician. Most questions were multiple choice, a few open-ended.
RESULTS: Three hundred questionnaires were administered to caregivers and 264 were analyzed. A high proportion (82%) of caregivers professed to be 'very worried' about fever. Temperatures that were felt to require treatment were relatively low (one-third treating <37.9 degrees C), but many respondents measured body temperature at the axilla. Similar to previously published studies, the main specific concerns were possible central nervous system damage (24%), seizures (19%) and death (5%), although worries about discomfort and signs of serious illness were also expressed by a significant number of respondents (11%). Similar to older surveys, home treatment of fever was worrisome, with too-frequent dosing (acetaminophen CONCLUSIONS: We found high levels of anxiety among caregivers presenting to a hospital emergency department with a complaint of fever in a child. Many caregivers appear to confuse effects of fever with the harmful effects of hyperthermia. Aggressive and potentially dangerous home therapy and monitoring of fever is common among the caregivers surveyed.
Sakai R, Okumura A, Marui E, Niijima S, Shimizu T.
Does fever phobia cross borders? The case of Japan.
Pediatr Int. 2012 Feb;54(1):39-44. doi: 10.1111/j.1442-200X.2011.03449.x. Epub 2011 Oct 30.
Abstract/Text
BACKGROUND: Undue parental fear of fever in children was termed "fever phobia" by Schmitt following a survey in the USA in 1980. In 2000, Crocetti et al. conducted the same survey and concluded that fever phobia existed even 20 years later. In this study, we explore differences in fever phobia between these two US populations and a Japanese sample, and determine whether parents of a single child or those whose child was previously hospitalized or had a febrile seizure report greater anxiety about fever.
METHODS: A questionnaire was distributed to parents of children who visited a pediatric outpatient clinic in Juntendo University Nerima Hospital between 19 and 30 November 2007.
RESULTS: Data was obtained from 211 parents who agreed to participate in the study. Compared with much smaller proportions reported in the two previous studies, 62% of caregivers considered a temperature below 37.8°C to be a fever, although less than half of parents reported that they were "very worried" about fever. Over 90% identified doctors and nurses as their primary information source. In contrast to 7% of parents in the US studies, almost no parents reported that temperatures could rise to or above 43.3°C if fever was left untreated; however, 63% of parents stated that they would visit a hospital.
CONCLUSIONS: Fever phobia exists on both sides of the border, and while caregivers in Japan appear to have a more accurate understanding of fever, they are more likely to rely on health-care professionals to manage the condition.
© 2011 The Authors. Pediatrics International © 2011 Japan Pediatric Society.
小児外来診療における抗菌剤適正使用のためのワーキンググループ編：小児上記道炎および関連疾患に対する抗菌剤使用ガイドライン、外来小児科 2005；8（2）.
Yamanishi K, Okuno T, Shiraki K, Takahashi M, Kondo T, Asano Y, Kurata T.
Identification of human herpesvirus-6 as a causal agent for exanthem subitum.
Lancet. 1988 May 14;1(8594):1065-7. doi: 10.1016/s0140-6736(88)91893-4.
Abstract/Text
A virus was isolated from the peripheral blood lymphocytes of patients with exanthem subitum, cultured successfully in cord blood lymphocytes, and shown to be antigenically related to human herpesvirus-6 (HHV-6). Morphological features, as studied by thin-section electronmicroscopy, resembled those of herpes group viruses. Convalescent-phase serum samples, tested against the new viral antigen and HHV-6 antigen, showed seroconversion. The results strongly suggest that the newly isolated virus is identical or closely related to HHV-6 and the causal agent for exanthem subitum.
Balachandra K, Ayuthaya PI, Auwanit W, Jayavasu C, Okuno T, Yamanishi K, Takahashi M.
Prevalence of antibody to human herpesvirus 6 in women and children.
Microbiol Immunol. 1989;33(6):515-8. doi: 10.1111/j.1348-0421.1989.tb02001.x.
Abstract/Text
The antibody prevalence to human herpesvirus 6 (HHV-6) was compared between pregnant women and control women of similar ages in Thailand. No significant difference was detected in the antibody positive rate and antibody titers between both groups. The antibody titers in sera collected from pregnant women at 1st and 3rd trimester remained unchanged. Next, the antibody prevalence in infants were examined and the positive rate decreased until 3 months and started to increase from 6 months after birth. The present results suggest that the reactivation of HHV-6 might not occur during pregnancy and this virus infects infants postnatally.
Yamanishi K, Okuno T.
[New human herpesvirus, human herpes virus-6].
Nihon Rinsho. 1989 Feb;47(2):285-9.
Abstract/Text
日本川崎病学会. 川崎病診断の手引き改訂6版 [Internet]. 2019. Available from: http://www.jskd.jp/info/tebiki.html
日本小児循環器学会学術委員会・川崎病急性期治療ガイドライン作成委員会 編：日本小児循環器学会 川崎病急性期治療のガイドライン （2020 年改訂版）、2020.
