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Fever Without Infection: De-escalating Diagnostic Workups In 313 Pediatric Craniosynostosis Patients Over 21 Years
Michael Hernandez, BS, Sophia E. Choi, BS, Tiffany Jeong, BS, Shelby Nathan, MD, Jesse A. Goldstein, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
PURPOSE: Postoperative fever is common after craniosynostosis repair but poorly characterized in children. While adult cranioplasty infection rates are 8-11%, comparable pediatric data are not well defined. Clarifying these patterns is essential to guide management and reduce unnecessary workups.
METHODS: Retrospective review of consecutive patients (ages 0-20) undergoing open craniosynostosis repair at a tertiary children’s hospital from 2003-2024. Fever was defined as ≥38.0°C. Outcomes included fever incidence, timing, culture use, and confirmed surgical site infection (SSI).
RESULTS: Of 313 patients, 119 (38.0%) developed fever, typically early and self-limited (median POD1). Cultures were obtained in 36/119 (30.3%), yielding only two positives (5.6%). Both infections were clinically distinct: one spiked to 40.3°C on POD2 with LOS 8 days, the other had persistent fevers with LOS 5 days. Compared with non-workup patients (n=83), those who underwent workup (n=36) had longer LOS (6.5 vs 3.5 days) and slightly higher POD1-2 fevers (38.6°C vs 38.2°C), yet infection remained rare (0.6% overall).
CONCLUSION: Postoperative fever occurs in one-third of pediatric craniosynostosis patients, but infection is exceedingly uncommon, with a 60:1 fever-to-infection ratio. Infections presented with more persistent or severe fever patterns, while most workups yielded negative results despite being obtained in clinically concerning cases. These findings support limiting routine fever evaluations and de-escalating diagnostic protocols in this low-risk population.
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