Mordechai Raskas MD, Children’s National Health System
with Kristen Breslin MD, Children’s National Health System

The Case
8 day old former FT male presenting with a rectal temperature at home of 99.6F and an ED temperature of 37.9C (100.2F). The challenge of this case is how to treat an otherwise well-appearing infant with a temperature of 37.9C.

Here’s How You Answered Our Questions

Other less than 3 yrs:
High risk labs, LP, and admit.
Other more than 3 yrs:
I wouldn’t have gotten labs to decide.
Low risk labs–admit off antibiotics. High risk labs – tap and antibiotics.
Had this scenerio just the other day, WBC and CRP normal, but urine very positive.
I have a hard time doing a partial sepsis workup in this age.  All or none.
If I was going to do any workup in this 8 d.o., I’d do a complete workup & admit.
High risk labs are helpful but low risk results are not.

Denouement
Labs:
WBC 13.5, Hemoglobin 16, Platelets 200, ANC 6130, no bands
UA, lab unable to run sample (volume too small), culture negative

Repeat temps over a 6 hour period in the ED were all < 37.9C. Provider discussed with the family multiple options in this scenario (dc home, LP and treatment for potential sepsis and admit, and other combinations). Parents ultimately opted to go home and monitor temps every 4-6 hrs and return if needed. PCP was not reachable at the time of discharge. Parents were contacted at home a few days later and patient had remained afebrile and required no further workup or treatment.

Teaching Points

1. Fever in neonates (less than 30 days) ≥38ºC (100.4ºF) would prompt our providers to do a full sepsis work-up, admission, and antibiotics due to the risk for SBI.
2. In this 8 day old with a temperature of 37.9C, providers would use the history, VS, and PE to guide management.  If any concerning factors (see below for examples), providers would complete a full sepsis work-up.  If no concerns most providers would observe (in ED or on floor) with repeat temperatures or discharge home with strict return precautions to come back to ED if fever.
3. Most providers felt that management should be an “all or none” practice.  If not worried about SBI, no tests needed.  If concerns for SBI, a complete sepsis rule-out and treatment should be performed as standard of care.  Providers agreed that abnormal labs are concerning, however, negative labs should not be reassuring as a rule-out for SBI.
4. Involving a family in high-risk medical decisions can be difficult.  Similarly, involving the PMD can be helpful for follow-up and/or determining caregiver reliability, but they cannot evaluate the patient to determine appropriate management.

Summarized from UptoDate:
An afebrile infant with a reported history of subjective (tactile) fever may avoid laboratory testing if all of the following conditions are met:
-Normal rectal temperature
-Has not received antipyretic medication
-No risk factors for SBI (eg, prematurity, PROM, recent antibiotics, or maternal colonization with GBS; normal behavior and feeding; and no associated difficulty breathing, apneic spells, or color changes)
-Normal appearance and PE
-Reliable follow-up within 12 to 24 hours
-Caregivers can monitor the rectal temperature at home, understand indications to seek medical attention, and have transportation