PECARN-Derived Evidence Changes Future of Newborn Fever Care
- Published January 15, 2026
A major article published Dec. 8 in JAMA, “Prediction of Bacteremia and Bacterial Meningitis Among Febrile Infants Aged 28 Days or Younger”, is poised to change how clinicians approach fever in newborns. This international pooled analysis evaluating an updated Pediatric Emergency Care Applied Research Network (PECARN) febrile infant prediction rule offers the strongest evidence to date that a subset of febrile infants can be safely managed without routine lumbar puncture (LP).
For more than four decades, standard practice has been to perform LPs, treat with antibiotics, and admit all febrile infants in the first month of life. This study provides the evidence needed to reconsider that approach.
What the Study Found
The PECARN rule was applied to more than 1,500 infants across six countries, with a secondary pooled analysis including over 2,500 infants. Performance of the rule was strong:
- Sensitivity: 94.2% for invasive bacterial infections
- Sensitivity for bacterial meningitis: 100%
- Specificity: ~42%
- Negative predictive value: 99.4%
- Critically: Zero missed cases of bacterial meningitis
When the secondary analysis added PECARN derivation and validation cohorts, the results held and there were no missed meningitis cases. At an estimated meningitis prevalence of 1%, the number of LPs needed to prevent one missed case is approximately 2,000 (95% CI: 415 to infinity), highlighting just how rare meningitis is among infants meeting low-risk criteria. As the authors emphasized in conversation:
“We finally have sufficient numbers of febrile infants in the first month of life to confidently say which infants can safely avoid LP.”
“This has the potential to change decades of practice and provides the evidence needed for guideline reconsideration.”
Why These Data Exist Now
This collaboration emerged as multiple prospective cohorts matured and investigators shared aggregate-level data from Canada, Spain, Europe, and the United States, creating the largest analysis to date of febrile infants aged 0-28 days.
Equally important, contemporary biomarkers, particularly procalcitonin, now allow clinicians to be more accurate and precise in identifying low-risk infants. The study is unique because of its combination of size, international collaboration, and modern diagnostics.
Methodologic Notes That Matter
- Primary analysis included only external international cohorts to avoid bias from derivation data.
- Secondary analysis added PECARN derivation and validation cohorts to improve precision (>2,500 infants total).
- No meningitis cases were missed in either analysis.
- Five infants who met low-risk criteria had bacteremia only (no meningitis), including cases with E. coli, H. influenzae, and S. aureus (some possibly contaminants). All were conservatively counted as true bacteremia, if any were contaminants, diagnostic accuracy would only improve.
Most infants were in weeks 2-4 of life. Importantly, age alone has not been shown to be an independent predictor of invasive bacterial infection when modern biomarkers are used. All infants were evaluated in emergency department settings, so applicability outside the ED should be considered carefully.
Why This Matters Clinically
- Routine LP in the first month of life can be questioned, for the first time with high-quality evidence. The risk of bacterial meningitis among low-risk infants is extremely low .
- Low specificity (~42%) means many infants will still be classified as non–low risk, but for the substantial minority who are low risk, the clinical paradigm changes dramatically.
- True shared decision-making becomes possible. Clinicians can now tell families:
“Based on this testing, your baby’s risk of meningitis is likely lower than 1 in 2,000.”
That conversation simply wasn’t possible with prior data. - HSV remains a separate consideration. The PECARN rule does not address HSV. Risk factors, clinical appearance, and the ill vs. non-ill distinction remain critical.
Bottom Line
This study is practice-informing, not yet guideline-replacing, but it provides evidence clinicians need to discuss risks and benefits with families and to consider less invasive approaches for carefully selected newborns. The authors anticipate that these data will drive future guideline changes.