Neonatal Fever

[DeadInside]

Long time lurker, new attending here. So I see a lot of variation amongst my colleagues when it comes to LPing febrile neonates. Obviously everyone taps kids <=28 days. Without a clear source (or even with for some of you) what are your cutoffs and rules that you all use?

Some of my colleagues do the full septic workup for all <= 60 days regardless. Some will do partial workup and only admit if something is positive, but will not, for example, lp a 40 day old even if the urine comes back positive. They will just call it a uti.

What is your practice?

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[xaelia]

Highly doubt you'll find consensus here, either.

I don't have much evidence or practice-precedent to do much less than Rochester-type evaluation in the well-appearing infant 28-60 days of life without a source. If I find a bacterial source (urine, pneumonia, etc.), I treat. My PEM colleagues vary as to whether they take apparent viral URI as a "source" or not.

You can also "sell" a test you don't think a child needs to parents in a shared decision-making fashion that allows you to document "offered, declined".

 

[WilcoWorld]

The recommendations have been getting rolled back over the past decade or two, probably due to vaccination success (H flu and S Pneumo). As such, I have seen that the older Peds providers will take their workup out a little later in life. Full work up up to 6 weeks is what I see some more seasoned Peds EM colleagues advocate, whereas I was always taught 28 days. Some go all the way out to 3 months, but that's getting more and more rare.

I do "everything" up to 28 days. Between 28 days and 6 weeks I'll skip the tap if non-toxic appearing, but I maintain a low threshold to admit for Peds to watch. 6 weeks-3 months I do urine, CBC and blood culture and will dc if everything looks good.

All above dates assume full term kiddos.

 

[Birdstrike]

The recommendations have been getting rolled back over the past decade or two, probably due to vaccination success (H flu and S Pneumo). As such, I have seen that the older Peds providers will take their workup out a little later in life. Full work up up to 6 weeks is what I see some more seasoned Peds EM colleagues advocate, whereas I was always taught 28 days. Some go all the way out to 3 months, but that's getting more and more rare.

I do "everything" up to 28 days. Between 28 days and 6 weeks I'll skip the tap if non-toxic appearing, but I maintain a low threshold to admit for Peds to watch. 6 weeks-3 months I do urine, CBC and blood culture and will dc if everything looks good.

All above dates assume full term kiddos.

I generally agree with this. It's a tough discussion though, because the guidelines attempt to do the impossible, which is to create a sharp cutoff date range for something (incidence of serious bacterial infection) that gradually reduces over time, and by no means is zero after whatever age cutoff you pick. Obviously, the incidence of sepsis/meningitis doesn't become zero suddenly after day 28, 60 or day 90. However, it's no easier to diagnose on days 29, 61 or 91, compared to the 24 hour period before the magical cutoff date. This will always be a tough area, and will get even tougher as incidence of serious bacterial infection decreases. The rarer it becomes, the less you will feel it necessary to work kids up for it, but it becomes no more easy to diagnose the rare few that do have it. There will always be those few with no fever, and only a non-specific work up, that just are septic with little to go on other than vague non-specifics, and who are just outside of whatever protocol-driven date range that you've chosen to.

 

[WilcoWorld]

I generally agree with this. It's a tough discussion though, because the guidelines attempt to do the impossible, which is to create a sharp cutoff date range for something (incidence of serious bacterial infection) that gradually reduces over time, and by no means is zero after whatever age cutoff you pick. Obviously, the incidence of sepsis/meningitis doesn't become zero suddenly after day 28, 60 or day 90. However, it's no easier to diagnose on days 29, 61 or 91, compared to the 24 hour period before the magical cutoff date. This will always be a tough area, and will get even tougher as incidence of serious bacterial infection decreases. The rarer it becomes, the less you will feel it necessary to work kids up for it, but it becomes no more easy to diagnose the rare few that do have it. There will always be those few with no fever, and only a non-specific work up, that just are septic with little to go on other than vague non-specifics, and who are just outside of whatever protocol-driven date range that you've chosen to.

You are correct. No disagreement from me.

Here I am guided by the same principle as I am with so many other ED evals where I can never get to 100% sensitivity, but where it's quite easy/non-invasive to get to, say, 95% sensitivity. I "follow the rules" and write a chart that shows I tried as hard as I could within reason. This usually includes some statement like "in light of the data available, further work up, including [invasive testing/ionizing radiation/other scary term] is more likely to be harmful to [Jayden] than it is to be helpful."

This, like my workups, will not be 100% effective in preventing bad outcomes or lawsuits. But I think that, in light of my experiences, further [worry/knowingly unnecessary workups/other burnout fuel] is more likely to be harmful to [me] than it is to be helpful.

 

[Hair Police]

This is why discharge instructions make or break 50% of malpractice cases. If you've gone through the effort to do your work up and write your justification for not pursuing anything further, you need to have a hard follow up date and instruction on the warning signs to make them come in sooner. This is actually the easiest in peds since people are generally motivated where their kids are concerned and all kids should have a pediatrician.

 

[RPedigo]

I am perhaps a little more conservative. Obviously 0-28 days is full-bore septic workup, antibiotics, admit. For 1-3 months with fever without an obvious source I do the Rochester criteria (e.g., everyone gets CBC, UA/urine culture, blood culture) and if WBC count not reassuring (not between 5-15 or presence of bandemia) then I will tap; if tap negative, 50 mg/kg of ceftriaxone and 1-day recheck if looks good, if tap positive admit. However, I use this criteria up until two weeks after the 2nd Prevnar administration (e.g., until around 4.5 months) because then the risk of occult bacteremia in a well-appearing kid is so low. I agree the rigid age cutoffs don't make much sense. I had a 3.5-month-old child that had 1 day of fever without a source, WBC 18-19, LP with >100 WBC just last shift. Technically didn't even need blood testing to begin with.

 

[da8s0859q]

.

 

[Cytarabine]

Curious how you all would have handled this one.

<28 day old w/5 day hx of fever. 2 sick contacts, both viral panel positive. Infant got viral panel at pediatrician's office before presentation, positive for same as contacts. Non-toxic appearing, good intake po, no alarm signs or obvious source of infection. T of 102 on presentation to our ED. Mom denied LP.

 

[TooMuchResearch]

Curious how you all would have handled this one.

<28 day old w/5 day hx of fever. 2 sick contacts, both viral panel positive. Infant got viral panel at pediatrician's office before presentation, positive for same as contacts. Non-toxic appearing, good intake po, no alarm signs or obvious source of infection. T of 102 on presentation to our ED. Mom denied LP.

Full workup.

 

[Cytarabine]

Full workup.

Approach to obtaining the LP? Empiric abx?

 

[coachB]

Approach to obtaining the LP? Empiric abx?

There's nothing to think about here. You do the full work up including LP. Give antibiotics. Admit.

 

[Cytarabine]

There's nothing to think about here. You do the full work up including LP. Give antibiotics. Admit.

This is how I'd have gone if I was treating. The resident wanted to pursue full work up and empiric coverage. The home pediatrician had told mom they didnt think baby needed LP. The attending was comfortable enough with no LP and just close obs, no abx, so that's what we did. Was afebrile shortly after presentation and remained so. Urine and blood NGTD, so it looks like it'll play out okay. Will be discharging today after NGx24hr. Was just wondering if there was anyone else who'd have gone that less conservative route

 

[xaelia]

Not that complicated.

Simply explain to the family the vast majority of physicians consider it unacceptably risky to attribute neonatal fever to a viral source, considering the lethal/disabling outcomes for meningitis. Odds are it is, in fact, just a virus, but there is only one way to be certain.

And then just document "offered etc., declined".

 

[Birdstrike]

Not that complicated.

Simply explain to the family the vast majority of physicians consider it unacceptably risky to attribute neonatal fever to a viral source, considering the lethal/disabling outcomes for meningitis. Odds are it is, in fact, just a virus, but there is only one way to be certain.

And then just document "offered etc., declined".

Agree. Full work up indicated. You explain that presence of a virus does not rule out coexisting serious bacterial infection and that due to the risks in this age group, full work up is indicated. Go down the list of what's indicated and check off boxes of what parents will allow, hopefully including antibiotics, and document informed refusal with signature for what they won't allow (in a pleasant non-confrontational way).

Where it gets more fun, is in the setting of unreasonable parents, a kid that looks critical, petechial rash/looks like death, and the parents want to check the kid out with no antibiotics, no treatment whatsoever and you're certain there's a life threatening event. Then you open the whole neglect/social services/protective custody can o' worms. Ugly.

 

[Cytarabine]

Thanks for the replies - that's mostly what I was wondering (pursuing the court route at that point or not)

 

[DeadInside]

I am perhaps a little more conservative. Obviously 0-28 days is full-bore septic workup, antibiotics, admit. For 1-3 months with fever without an obvious source I do the Rochester criteria (e.g., everyone gets CBC, UA/urine culture, blood culture) and if WBC count not reassuring (not between 5-15 or presence of bandemia) then I will tap; if tap negative, 50 mg/kg of ceftriaxone and 1-day recheck if looks good, if tap positive admit. However, I use this criteria up until two weeks after the 2nd Prevnar administration (e.g., until around 4.5 months) because then the risk of occult bacteremia in a well-appearing kid is so low. I agree the rigid age cutoffs don't make much sense. I had a 3.5-month-old child that had 1 day of fever without a source, WBC 18-19, LP with >100 WBC just last shift. Technically didn't even need blood testing to begin with.

This is similar to my current approach, although I tap all <= 60 days, but do the same as you until 90 days.

Your case of the 3.5 month old scares me a little. Was there anything on physical exam or history? Did the kid look bad? Just curious, why did you obtain a CBC in this kid since as you mentioned, she technically did not need one? Also, did you follow up, did it turn out to be viral meningitis?

Thanks to all for your replies, I find the wide practice variation very interesting.

 

[da8s0859q]

This is similar to my current approach, although I tap all <= 60 days, but do the same as you until 90 days.

Your case of the 3.5 month old scares me a little. Was there anything on physical exam or history? Did the kid look bad? Just curious, why did you obtain a CBC in this kid since as you mentioned, she technically did not need one? Also, did you follow up, did it turn out to be viral meningitis?

Thanks to all for your replies, I find the wide practice variation very interesting.

I almost asked that same question but presumed it was because there was no clear source. No viral URI symptoms, nothing. FUO.

Was that it?

 

[TheDudeMD]

gonna throw some truth bombs into the mix:

20% of febrile kids < 30 days old have an SBI, regardless of appearance.

And 9% of febrile kids between 30 and 56 days, who appear well on physical exam, have an SBI.

41% of kids between 3 and 90 days old *with* meningitis have a normal CBC.

 

[Cytarabine]

^I thought the prevalence of SBI for febrile <30 d/o was 12%

 

[TheDudeMD]

^I thought the prevalence of SBI for febrile <30 d/o was 12%

You could be right. Here's where I'm getting my number from:
http://m.adc.bmj.com/content/94/4/287.short

"A total of 449 neonates were evaluated. Eighty-seven (19.4%) neonates had an SBI."

Your 12% might be more up to date?

 

[Cytarabine]

You could be right. Here's where I'm getting my number from:
http://m.adc.bmj.com/content/94/4/287.short

"A total of 449 neonates were evaluated. Eighty-seven (19.4%) neonates had an SBI."

Your 12% might be more up to date?

I had remembered the number from looking at uptodate. Went back and found it, was referenced from this http://www.ncbi.nlm.nih.gov/pubmed/16574521 . Off campus and can't access it now. The article you referenced is 3 years more recent and from a journal with a higher IF. A sizable percentage either way

 

[DeadInside]

I think you just have to ask yourself what percent of SBI are you okay missing and what are your chances of missing an SBI at any given age.

Are you okay missing 0% but tapping every 4 month old? 0.3%? (Philadelphia criteria negative predictive value) 1.1? (Rochester criteria npv)

I use the PED EM podcast numbers when I explain to parents the chances of their child having an SBI for any given age. http://traffic.libsyn.com/pemed/Fever.pptx

However, I do think the trend is going to making a single cutoff at 28 days, where one workup is done before that and some other group of tests (varies by doc) after that. 1 colleague I spoke to doesn't even cbc after that and will do no SBI tests including ua if the kid has a runny nose "unless the kid looks bad" whatever that means for a 29 day old.

 

[TheDudeMD]

1 colleague I spoke to doesn't even cbc after that and will do no SBI tests including ua if the kid has a runny nose "unless the kid looks bad" whatever that means for a 29 day old.

Doesn't work-up a febrile 29-day old based on how the kid looks? Ballsy!

 

[Birdstrike]

I think you just have to ask yourself what percent of SBI are you okay missing and what are your chances of missing an SBI at any given age.

Are you okay missing 0% but tapping every 4 month old? 0.3%? (Philadelphia criteria negative predictive value) 1.1? (Rochester criteria npv)

I use the PED EM podcast numbers when I explain to parents the chances of their child having an SBI for any given age. http://traffic.libsyn.com/pemed/Fever.pptx

However, I do think the trend is going to making a single cutoff at 28 days, where one workup is done before that and some other group of tests (varies by doc) after that. 1 colleague I spoke to doesn't even cbc after that and will do no SBI tests including ua if the kid has a runny nose "unless the kid looks bad" whatever that means for a 29 day old.

Have a low threshold for doing an LP. What's the main risk and side effect of an LP in a four month old? Usually only non-fatal CPA.


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(Contagious Parental Anxiety)

 

[allendo]

At my hospital they are ordering lactates on any kid we culture? Anyone else experiencing this?

 

[Cheese Whiz]

Do anti vaxxers change your time frame practice patterns?

 

[Cheese Whiz]

Here's another question I debate: reliable parent took temperature and swears by temperature at home and actually gave appropriate antipyretic dose shortly before arrival. Now the temperature is below fever threshold. How far do you go with these?

 

[allendo]

Here's another question I debate: reliable parent took temperature and swears by temperature at home and actually gave appropriate antipyretic dose shortly before arrival. Now there temperature is below fever threshold. How far do you go with these?

If they quote a concerning number I work them up

 

[Birdstrike]

Here's another question I debate: reliable parent took temperature and swears by temperature at home and actually gave appropriate antipyretic dose shortly before arrival. Now the temperature is below fever threshold. How far do you go with these?

Easy: Work it up. I don't have a link to the source but that's been proven multiple times, that parental subjective assessment of fever is very accurate and should be taken as such. I kind of thought this was PC feel-good patient satisfaction BS until I had kids. You spend hundreds, thousands of times holding your baby, that you instantly notice when the temperature of that hot potato went up a degree. It's really amazing. I'll never forget the first time my first kid got a fever. I picked her up and in less than a second thought >boom< "She's warm, very warm." On goes the thermometer: Fever. After that I didn't doubt any parent's ability to discern fever. It's legit. Plus, if they made it up they'll back down from once you start suggesting LPs and cath UA's as an end result; unless rare Munchausen by Proxy, of course.

 

[Cytarabine]

Easy: Work it up. I don't have a link to the source but that's been proven multiple times, that parental subjective assessment of fever is very accurate and should be taken as such. I kind of thought this was PC feel-good patient satisfaction BS until I had kids. You spend hundreds, thousands of times holding your baby, that you instantly notice when the temperature of that hot potato went up a degree. It's really amazing. I'll never forget the first time my first kid got a fever. I picked her up and in less than a second thought >boom< "She's warm, very warm." On goes the thermometer: Fever. After that I didn't doubt any parent's ability to discern fever. It's legit. Plus, if they made it up they'll back down from once you start suggesting LPs and cath UA's as an end result; unless rare Munchausen by Proxy, of course.

This was contrary to what I remember learning, so I looked a bit. Off campus so don't have access, but this is the most recent review I could find

http://tropej.oxfordjournals.org/content/54/1/70.short

 

[primadonna22274]

Had just such a case last night. 28 day old term infant, previously well, with fever 101.5 rectal for a few hours. Sniffles since the day before. Sister with documented flu and baby +influenza A.
Baby looked great. ED still did the full workup which I appreciated as the admitting FM/peds resident. CSF gram stain no organisms and 1-3 WBCs. CXR good. UA normal. Cultures pending.
Still covered with amp/claforan until the cultures come back and started Tamiflu.
I was sorely tempted to argue for dialing back the antibiotics for what was surely a viral infection (and probably still is) but there's no rule that says a patient can't have flu and SBI.
I had a niece die of E. coli meningitis just shy of 7 mos exactly 9 yr ago today. Should never have happened. Still can't explain where the bug came from with 2 negative urine cultures and a mixed growth blood culture (no GNB). She wasn't tapped until the second seizure 2 days into her illness which started as a rather benign URI. Antibiotics weren't started until the next morning--also unclear what the thinking was. By that afternoon she had stroked out her left hemisphere and had to be life-flighted in winter to the children's hospital (her parents had to drive the 5-hr through mountains in an Oregon winter). She was clearly palliative by the time we all got there. I don't want to risk that if I can help it.

 

[Cytarabine]

Sorry about your niece, that's terrible.

Pertaining to concurrent viral infection and SBI, the risk of SBI in an infant with a VP(+) neonate is decreased (at least for influenza and RSV that I know of), but obviously still not zero

 

[primadonna22274]

Thanks. I didn't get to know her well (lived 3000 miles away) but it was still a shock. I did think of her last night while admitting the 28-day baby.

 

[Birdstrike]

This was contrary to what I remember learning, so I looked a bit. Off campus so don't have access, but this is the most recent review I could find

http://tropej.oxfordjournals.org/content/54/1/70.short

Right. 50% specific and therefore only 50% right. Yet you don't know which 50% were wrong about the tactile fever. Assume they're all wrong and risk missing SBI. Assume they're all right and risk negative work ups.

A - Missed SBI in infants = sentinel event & lawsuits.

B - Negative work up = "Phew."

Pick one.

 

[WilcoWorld]

Do anti vaxxers change your time frame practice patterns?

Yes.

 

[Cytarabine]

Right. 50% specific and therefore only 50% right. Yet you don't know which 50% were wrong about the tactile fever. Assume they're all wrong and risk missing SBI. Assume they're all right and risk negative work ups.

A - Missed SBI in infants = sentinel event & lawsuits.

B - Negative work up = "Phew."

Pick one.

That's fair, was only referring specifically to the accuracy of palpated temp

 

[WilcoWorld]

Here's another question I debate: reliable parent took temperature and swears by temperature at home and actually gave appropriate antipyretic dose shortly before arrival. Now the temperature is below fever threshold. How far do you go with these?

If they took a temp appropriately, I work it up as if that temp was taken in triage. If the baby "felt warm" I may or may not work it up. Depends on the context.

 

[RPedigo]

This is similar to my current approach, although I tap all <= 60 days, but do the same as you until 90 days.

Your case of the 3.5 month old scares me a little. Was there anything on physical exam or history? Did the kid look bad? Just curious, why did you obtain a CBC in this kid since as you mentioned, she technically did not need one? Also, did you follow up, did it turn out to be viral meningitis?

Thanks to all for your replies, I find the wide practice variation very interesting.

There was not much on physical examination, nothing concerning on history. I think the lack of a true source coupled with a high fever was what raised my index of suspicion. Did he have nuchal rigidity? I'm not sure -- it was supple, but the kid cried more when I ranged the neck, but I'm not sure if that's because I was messing with his neck or he had meningeal irritation. It ended up being viral meningitis, but I was still happy in the end that I pursued the route that I did.

 

[RuralMedicine]

Here's another question I debate: reliable parent took temperature and swears by temperature at home and actually gave appropriate antipyretic dose shortly before arrival. Now the temperature is below fever threshold. How far do you go with these?

From a pediatrics standpoint I document the parent reported temperature and proceed as if that temperature had actually been documented in my office/the ED.

To answer the original question:
-I generally lean towards a full sepsis w/u including LP with febrile kids until after 90 days corrected (so, yes, I will tap former preemies beyond 90 days).
-If I was less inclined to lean toward LP then I would definitely be tapping all febrile kids of GBS positive mothers (even if treated because treatment does not influence late onset GBS) through two months.
-My personal experience correlates well with the concept it is hard to rely on the clinical picture in infants below 3months. I have tapped two different babies one just under (I think 88) 90 days and one just over (but was a former 35 weeker) who both looked "great" and both had meningitis once I got the LP results back. One ended up growing out non-typable H.flu. The other was Strep pneumoniae. I also had a very happy 6 week old with GBS meningitis when I was a resident that happened to have a maternal grandfather who was an EM attending elsewhere. He said that experience (which ended generally positively) would change his practice because he was pretty sure he would not have tapped a baby who presented similarly to his grandchild.
-Prevnar is great but remember that it does only cover 13 strains of Strep pneumoniae. Also keep in mind that GBS, listeria, E.coli, non-typable H. Flu, and even Neisseria are still out there.

 

[RuralMedicine]

Sorry about your niece, that's terrible.

Pertaining to concurrent viral infection and SBI, the risk of SBI in an infant with a VP(+) neonate is decreased (at least for influenza and RSV that I know of), but obviously still not zero

There was a study that seemed to suggest that in regards to RSV. In contrast, post-influenza bacteremia is very plausible so that is something to keep in mind.

 

[da8s0859q]

I also had a very happy 6 week old with GBS meningitis when I was a resident that happened to have a maternal grandfather who was an EM attending elsewhere. He said that experience (which ended generally positively) would change his practice because he was pretty sure he would not have tapped a baby who presented similarly to his grandchild.

Curious -- any particular reason why did the kid got tapped? Another fever without any attributable symptoms type presentation?

 

[Cytarabine]

There was a study that seemed to suggest that in regards to RSV. In contrast, post-influenza bacteremia is very plausible so that is something to keep in mind.

http://pediatrics.aappublications.org/content/115/3/710.short

This is the study I was familiar with. Has there been more recent stuff thats come out?

Edit: just noticed you said post-influenza - no disagreement there

 

[RuralMedicine]

Curious -- any particular reason why did the kid got tapped? Another fever without any attributable symptoms type presentation?

Honestly, the baby got tapped because it was the practice in the Children's Hospital I trained in to tap all infants below 3 months of age with fever (i.e. T at or above 100.4). As I recall the mother also happened to have been GBBS positive during pregnancy so I suppose some people who don't tap all comers would have been more incline to tap this kid because of that fact. But, really I tapped this kid, who smiled at me before and after, because my attending had drilled into my head that this was what we did. This experience, plus a few subsequent experiences in residency, and some experiences I've had in practice have caused my own practice to fall in line with continuing to tap up to 3 months corrected age.

 

[dotcb]

I know you're not supposed to change your practice based on individual cases, but here's one of mine from about a year ago…

10 wk old full term male brought in for fussiness and feeling warm. Child w/ NL VS and well appearing. 4th ED visit in 10 wks of life - parents seemed to be worried well 1st time parents.

Repeat VS as the patient was being discharged noted fever. According to Boston Criteria, we planned full septic work-up.

Peds intern caring for patient "He really looks good, do we really need to do an LP?"
"The parents would rather not have an LP."
"The ear looks kind of red."
"Do we really need to give antibiotics?"

Child continued to look good, with negative sepsis work-up other than WBC 15.5. (LP was done). He was DC'ed after dose of abx w/ plan for 24 hr f/u in pecs urgent care per Boston literature.

Patient was called in the afternoon to return for admission - blood culture (+) for strep pneumo bacteremia.

Only the Boston criteria really go up to 90 days (other stop at 60). He was disqualified from Rochester due to receiving perinatal abx (mother had chorio - he got a sepsis w/u at that time, which was negative). Don't recall if he'd received Prevnar, but I think so.

The pearl: Under 90 days of age, well appearance of child is unreliable predictor for absence of serious bacterial infection. In most cases I will turn the brain off and do the work up.

 

[RuralMedicine]

http://pediatrics.aappublications.org/content/115/3/710.short

This is the study I was familiar with. Has there been more recent stuff thats come out?

Edit: just noticed you said post-influenza - no disagreement there

There was a somewhat similar chart review with RSV published a few years before the article you're citing.

A few things to think of in regards to your article:
-Their study population was infants 3months to 36 months so not necessarily applicable to the 0-3 month group we're discussing here.
-This study does underscore that even in older infants with URI and fever there is sometimes concurrent bacteremia and or UTI. This is why I often will do UA/Urine Culture and blood cultures in these kids. If the CBC and UA look good I will usually withhold antibiotics and follow the cultures. If they have a concurrent bacterial process like presumptive UTI, OM, or Pneumonia that will be treated with antibiotics then I may be more inclined to do two days worth of Ceftriaxone while cultures are pending and then complete the course with appropriate oral if negative (or once urine culture results show a sensitive drug). Honestly, I sometimes think that pursuing the UTI angle in little girls is more important because I have inherited two different kids with missed Grade III or IV VUR where, at least in retrospect, it seems pretty clear that the fever in most of their febrile URIs was likely actually due to the UTI. In one kid, since her original PCP treated all URIs with antibiotics, I guess the bladder infections were technically treated even if the underlying problem wasn't identified or managed appropriately.
-Perhaps a bit beyond scope but if your institution uses rapid viral tests for Flu or RSV remember that their sensitivity and specificity are influenced by prevalence. These tests are most helpful during whenever peak season is in your region. In early or late season you results are less reliable you will find a much higher percentage of false positive tests so using a rapid flu test as your explanation for fever in October or March is something I would be wary to do where I practice. I also will occasionally give Osteltamivir to bad asthmatic kids who have flu-like symptoms and wheezing even with a negative rapid flu swab because I believe that the benefits outweigh the risk (and after discussion of all of this parents/patients agree). Our hospital currently only does rapid testing so I wouldn't get a PCR test back in suitable time for it to influence clinical practice.

 

[RuralMedicine]

The pearl: Under 90 days of age, well appearance of child is unreliable predictor for absence of serious bacterial infection. In most cases I will turn the brain off and do the work up.

I'll never fault an ED doctor (or a peds colleague) who does that. I also won't throw you under the bus if you don't but I will likely come in and do the tap before I agree to let you just have them see me tomorrow in the office.

 

[deuist]

I guess that makes me the cautious one of the board. Every child under 90 days gets blood, urine, and CSF regardless of how well appearing he is. If the child is under 28 days, I automatically give antibiotics (usually ampicillin and gentamicin) and admit. For older children, I wait until I at least get something back on the urine or CSF before pushing antibiotics, although I will usually call the pediatrician and advocate for an admission with observation that point. I've never had push back on getting a kid under 90 days admitted.

 

[dchristismi]

Under 4 weeks slam dunk no brainer LP/abx/adm. Under 8 weeks still going to do most of it. May tap, depends on what else I find. The 8-12 weeks it helps to know if the kiddo just got their first big round of shots. Also REALLY helps if they have a good local pediatrician I can touch base with.

Fever isn't always the tipoff... I had a sick-as-s#it 4 week old ex-preemie yesterday with RSV. No fever but retracting, classic RSV story on 4th day of illness, looked so-so on arrival but started to look tired within a half hour and crashed and burned in front of me. Thankfully had a good EJ (I will forever be grateful to the pediatric intensivist who showed me the best way to get a line in a sick kiddo) in time to get her intubated, rescusitated and flown to children's mecca. I did debate with the flight crew about getting some empiric abx in her because she crumped before I could even get urine, much less the LP. They thought their pediatrician might want the LP first. I figured we might as well get the abx in her, because while her lactate was normal (yes, I checked), she dropped her BP and just kept looking worse. Not to mention that she was technically only at 39 weeks.

For the record, flu neg, RSV +, labs looked, on the whole, much better than the kiddo did.

The only other (unforgettable) ridiculously sick baby I have cared for came in already septic in DIC and was HYPOthermic. So neither of my two worst-case neonatal ID cases had fevers, now that I think about it. Wait, make that 3 cases... I wasn't counting the 2 day old who was basically DOA but we coded for an hour as she was still warm. Ug.

Ok, enough happy thoughts...

 

[dotcb]

I think the key point, especially for junior trainees, is that the presence of serious bacterial infections cannot reliably be ruled out in this age group (0-90 days) by performing a history and physical exam. You cannot rule out meningitis or bacteremia in children this age without testing, just like, for example - you can't rule out renal failure without checking a creatinine. You might be able to rule in something else, but it doesn't exclude these diagnoses.

I think everyone agrees on 0 to 30 days, people will usually do the full workup 30 to 60 days, and it's a mixed bag in 60 to 90 days. I will generally do the full work-up. I think in the event that you decide for whatever reason not to do the work-up, you need to make sure that your logic is really sound and the follow-up plan is rock solid. Even bacteremia patients will look good when their fever comes down from an antipyretic. It shouldn't reassure you.

The longer I practice emergency medicine, the challenge is not so much providing aggressive critical care to the sick patient, but being able to spot the patient who's sick and is hiding it very well.