Pediatric presentation
Newborn fever in children
Under 28 days the examination cannot exclude serious infection, so the workup is complete and the treatment is empiric.
What are you worried about?
- Late-onset sepsis: group B streptococcus, E. coli, Listeria
- Bacterial meningitis
- Urinary tract infection
- Herpes simplex virus disease, especially with seizures, vesicles, or a maternal history
Differential, by age
Newborn birth to 28 days
- Serious bacterial infection until cultures return
- Herpes simplex virus
- Enterovirus and other viral infections (a diagnosis after the rest)
- Overwrapping (rechecked after unwrapping, never assumed)
Key history
- Gestation, birth weight, mode of delivery, maternal group B streptococcus status and prophylaxis, duration of rupture of membranes, maternal fever or infection around delivery
- Maternal herpes history; any vesicles on the baby
- Feeding volumes, wet diapers, stools, weight trend since birth
- Behaviour: sleepy, irritable, high-pitched cry, apneas, colour changes
- Sick contacts at home, including siblings
Key examination
- Temperature, heart rate, respiratory rate, perfusion, saturation, and the weight
- Tone, activity, cry, the fontanelle
- Skin for vesicles, jaundice, mottling, omphalitis; the umbilicus
- Breathing effort, the abdomen, the hips, the genitalia and the perineum
Red flags
- Any temperature of 38.0 or more, or below 36.0
- Poor feeding, lethargy, irritability, apnea, poor perfusion
- Seizures, vesicles, hepatomegaly, or a raised alanine aminotransferase (herpes simplex)
- Jaundice with fever
Initial investigations
- Blood culture, urine culture by catheter or suprapubic aspirate, cerebrospinal fluid (cell count, glucose, protein, culture, polymerase chain reaction), full count, C-reactive protein or procalcitonin, glucose
- Herpes simplex polymerase chain reaction of cerebrospinal fluid, blood and surface swabs when risk features are present
- Chest X-ray only for respiratory signs
How to interpret them
- A cerebrospinal fluid white count in the first weeks has a higher upper limit than later in infancy; interpret against age-specific values
- Inflammatory markers rise late in the first hours of infection and cannot exclude it early
- The urine culture is positive in a meaningful fraction of febrile neonates with no urinary symptoms
When the child is deteriorating
- Empiric intravenous antibiotics (ampicillin plus an aminoglycoside or a third-generation cephalosporin, by local guidance) after cultures, without waiting for results; add aciclovir when herpes is possible
- Admit; monitor; reassess feeding, perfusion and temperature every few hours
- Shock: fluid boluses with reassessment, and neonatal intensive care early
Conditions under this presentation
The adult frame, for contrast