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Its just a virus? Tackling Pediatric Fever

Sepsis is uncommon in the term and late preterm neonates. Its estimated in 5 per 1000 cases, however it is 15% of all neonatal deaths.

Here, we define “term” as >37 weeks. Late preterm is 34-36 weeks. The earlier the gestational age, the higher the rates of neonatal sepsis. For purposes of workup, a late preterm neonate that did not have a complicated post-delivery course (prolonged NICU stay, comorbidities, etc) should be treated the same as a full term neonate.

Neonatal sepsis is defined as an infectious syndrome that occurs at any point during the period of birth to 28 days.

Sources: By far, the most common cause of fever in a neonate is some non-herpetic virus…

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Featured

 Febrile Neonates: Do They All Need an LP?

The febrile neonate has long been the ultimate anxiety generator in the pediatric emergency department. Fever in this age group may be the only sign of invasive bacterial infections (IBI), such as bacteremia or bacterial meningitis, which can be, well… anxiety generating. Historically, the reflex has been simple: Fever + neonate => Lumbar puncture for everyone. Antibiotics for everyone. Admission for everyone. As our guidelines evolve and, ideally, vaccinations improve, our risk stratifications change. Recent data evaluating the Pediatric Emergency Care Applied Research Network (PECARN) prediction rule suggests that a significant proportion of neonates may be safely identified as very low risk for bacterial meningitis, potentially allowing clinicians to avoid routine lumbar puncture in carefully selected patients

 How Low Can You Go? Rethinking Lumbar Punctures for Well-Appearing Febrile Infants

It’s always been a careful balancing act. We don’t want to perform unnecessary LPs, give antibiotics, or hospitalise babies who don’t need it. At the same time, we don’t want to miss any babies with invasive bacterial infections (IBI) like bacteremia and especially bacterial meningitis because that could be catastrophic.

 International study offers new path to reduce spinal taps in young infants with fevers

New evidence from a six-country study led by the Montreal Children’s Hospital and Children’s National Hospital shows simple blood and urine tests could spare many young infants with fevers from more invasive procedures.

 The End of Routine Lumbar Punctures for the Febrile Infant 28 Days and Younger?

For decades, the teaching in pediatric emergency medicine has been consistent: “Young febrile infants (0-28 days) with fevers get a full sepsis workup.” This traditionally means blood, urine, and cerebrospinal fluid (CSF) cultures, followed by admission and antibiotics. The fear of missing bacterial meningitis—a devastating infection—has driven this aggressive approach. But is a lumbar puncture (LP) truly necessary for every well-appearing febrile infants in the first month of life?

Articles of Interest

Step-by-Step Approach to Febrile Infants

We decided to design this tool because we commonly used different biomarkers that were not adequately included in existing protocols, and we wanted to get a good tool to identify young febrile infants suitable for outpatient management.

Neonatal Sepsis: A Brief Visual Guide

Presentations for neonatal sepsis can be vague, varied, and odd. Abnormal vital signs are often not part of the presentation. It can vary from something as subtle as "she just doesn't seem right" to something as ominous as focal seizures.

Gamechanger: Do we really need a lumbar puncture for all febrile infants 0-28 days old?

For more than four decades, the standard of care for febrile infants in the first month of life has been aggressive: full sepsis workup (including an LP), admission, and IV antibiotics. A new study in JAMA suggests this paradigm may be shifting.

Serious Pediatric Fever

The febrile neonate is a child 28 days and younger who presents with a fever. These children are at very high risk of serious bacterial infections, including urinary tract infection, pneumonia, meningitis, and bacteremia. Risk factors for serious bacterial infection in a neonate include prematurity, low birth weight, premature or prolonged rupture of membranes, meconium aspiration, or maternal group B streptococcus infection.

Fever under 60 days of age

Many of us will be familiar with the mantra that all children under 3 months get a full septic screen and antibiotics. It feels like we are over-treating, but this is a high risk group so is there any other way?

Neonatal Fever v6.0: ED Phase (0-28 days old)

Because the clinical exam alone is unreliable to predict serious illness in this age group, clinicians must rely on a combination of history, physical exam and diagnostics tests to determine a patient’s risk of Serious Bacteria infection (SBI) and balance this risk with the cost and morbidity of empiric treatment.

Sim Corner: The Sick Neonate

Broad spectrum antibiotics: Ampicillin + Gentamicin OR Ampicillin + Cefotaxime

The Sick Neonate

Neonates are a distinct population with physiological differences. The sick neonate in the ED is uncommon, but terrifying. Having an approach is the most important aspect. Rapid assessment and management is vital.

To LP, or not to LP (the febrile infant): That is the question

Although some practitioners continue to use screening criteria from the 1990s, clinical decision tools are still being created to help identify infants at low risk for SBI. Despite these new tools and evolving medical knowledge, there is still a wide practice variation in the evaluation of febrile infants in the emergency department.