Neonatal Fever

[Birdstrike]

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, to wait till 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.

Totally reasonable

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[Birdstrike]

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.

YES

 

[Birdstrike]

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...

Yes, low temp is probably worse than an elevated one. Also, low WBC, can be equally as much of a red flag, due to WBCs being consumed in serious infection. (You know this obviously.)