Fever in Infant 0 to 90 Days
Infant < 29 Days
Pt presents with sudden onset fever > 38.5 C. Parents report cough, increased WOB, diarrhea with blood/mucus in stool. Parents concerned about decreased oral intake, decreased production of wet/dirty diapers. Fever, tachypnea, grunting, nasal flaring, retractions, decreased responsiveness on exam.
Obtain CBC, BMP, blood culture, U/A with culture
Obtain CSF cell count/differential, glucose, and protein
Obtain CSF bacterial culture and enterovirus PCR
Obtain procalcitonin, CRP for risk stratification
Additional tests
Presenting during influenza season: Obtain influenza PCR
Respiratory distress: Obtain CXR
Diarrhea: Obtain stool culture
Treatment
Admit to hospital and start empiric coverage with cefotaxime, ampicillin
Positive influenza PCR and within 48h of symptom onset; consider oseltamivir 3 mg/kg/dose BID x 5 days vs. supportive care
Supportive care
Maintain adequate hydration
Titrate oxygen to maintain saturations > 92%
Notes
Empiric antibiotic doses vary depending on the child's age and weight; see the Red Book (AAP) or UpToDate.com for specific dosing.
Oseltamivir has been studied in children under 1 year, but may not be appropriate for those under one month; consult a pharmacist
Infant 29-60 Days
Pt with h/o prematurity, congenital abnormality presents with sudden onset fever > 38.5 C. Parents report cough, increased WOB, diarrhea with blood/mucus in stool, and treatment with antibiotics during previous 7 days. Tachypnea, grunting, nasal flaring, retractions on exam.
Obtain CBC, BMP, blood culture, U/A with culture
Presenting during influenza season: Obtain influenza PCR
Risk factors for invasive bacterial infection, not currently influenza season, or negative influenza PCR:
Obtain CSF cell count and differential, glucose, and protein
Obtain CSF bacterial culture and enterovirus PCR
Obtain procalcitonin, CRP for risk stratification
Additional tests
Respiratory distress: Obtain CXR
Diarrhea: Obtain stool culture
Treatment
Toxic appearing, ANC < 1,000, PNA on CXR, confirmed UTI, and/or CSF pleocytosis: Admit to hospital and start empiric coverage with cefotaxime
Non-toxic with reliable caregivers: Administer ceftriaxone 50 mg/kg IM and f/u in 24 hours
Concern for Enterococcus and/or Listeria infection: Add ampicillin
CSF positive for S. pneumoniae meningitis: Add vancomycin 15 mg/kg
Positive influenza PCR and within 48h of symptom onset: Start oseltamivir 3 mg/kg/dose BID x 5 days
Supportive care
Maintain adequate hydration
Titrate oxygen to maintain saturations > 92%
Notes
Manage according to adjusted chronological age = (chronological age in weeks - [40 - WGA at birth])
Infections of concern: Respiratory (most common), meningitis (most concerning), UTI
Factors that increase risk for bacterial infection: H/o prematurity/congenital abnormality, comorbid medical conditions, antibiotic therapy within the previous 7 days
U/A is indicated if s/sx of pediatric UTI and/or if respiratory complaints are present. UTI is confirmed with U/A showing positive LE, nitrites, or > 5 WBC/HPF.
Empiric antibiotic doses vary depending on the child's age and weight; see the Red Book (AAP) or UpToDate.com for specific dosing.
While oseltamivir is recommended within 48h of symptom onset, it may reduce morbidity/mortality in children if started later.
Children who do not meet hospitalization criteria (see plan), have confirmed influenza without respiratory distress, or who have confirmed UTI may be discharged to home with appropriate therapy and f/u within 24 hours.
Infant 61-90 Days
Pt with h/o prematurity, congenital abnormality presents with sudden onset fever > 38.5 C. Parents report cough, increased WOB, diarrhea with blood/mucus in stool, and treatment with antibiotics during previous 7 days. Tachypnea, grunting, nasal flaring, retractions on exam.
Labs
Obtain CBC, BMP, blood culture, U/A with culture
Presenting during influenza season: Obtain influenza PCR
Risk factors for invasive bacterial infection, not currently influenza season, or negative influenza PCR:
Obtain CSF cell count and differential, glucose, and protein
Obtain CSF bacterial culture and enterovirus PCR
Obtain procalcitonin, CRP for risk stratification
Additional tests
Respiratory distress: Obtain CXR
Diarrhea: Obtain stool culture
Treatment
Toxic appearing, ANC < 1,000, PNA on CXR, confirmed UTI, and/or CSF pleocytosis: Admit to hospital and start empiric coverage with cefotaxime
Non-toxic with reliable caregivers: Administer ceftriaxone 50 mg/kg IM and f/u in 24 hours
Concern for Enterococcus and/or Listeria infection: Add ampicillin
CSF positive for S. pneumoniae meningitis: Add vancomycin
Positive influenza PCR and within 48h of symptom onset: Start oseltamivir 3 mg/kg/dose BID x 5 days
Supportive care
Maintain adequate hydration
Titrate oxygen to maintain saturations > 92%
Notes
Manage according to adjusted chronological age = (chronological age in weeks - [40 - WGA at birth])
Infections of concern: Respiratory (most common), meningitis (most concerning), UTI
Factors that increase risk for bacterial infection: H/o prematurity/congenital abnormality, comorbid medical conditions, antibiotic therapy within the previous 7 days
U/A is indicated if s/sx of pediatric UTI and/or if respiratory complaints are present. UTI is confirmed with U/A showing positive LE, nitrites, or > 5 WBC/HPF.
Empiric antibiotic dosing depends on the child's age and weight: See the Red Book (AAP) or UpToDate.com for specific dosing.
While oseltamivir is recommended within 48h of symptom onset, it may reduce morbidity/mortality in children if started later.
Children who do not meet hospitalization criteria (see plan), have confirmed influenza without respiratory distress, or who have confirmed UTI may be discharged to home with appropriate therapy and f/u within 24 hours.