Hot Seat #68: 8 day old male w/ temp 37.9C
Posted on: January 25, 2016, by : Mordechai Raskas
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 patient presents due to a rectal temperature at home of 99.6. Parents checked as patient felt warm. Upon arrival to the ED had a temp of 37.9 C (100.2 F). The baby was appropriately dressed and not overly wrapped. No sick contacts.
Birth Hx: born FT, no complications during pregnancy or delivery, delivered vaginally, and GBS status unknown. Mom denies having herpes or genital lesions.
ROS: Has been feeding well, normal urine and bowel movements, no emesis. Umbilical cord stump had a drop of green drainage and reportedly had a foul odor earlier in the day.
PE: VS temp 37.9 rectal, HR 133, RR 36, BP 73/36
Gen: Well-appearing, active, no distress
HEENT: no eye discharge, normal conjunctiva, no oral lesions, no nasal congestion
CV: RRR, no murmurs or gallops, normal capillary refill, distal pulses intact
Lungs: CTAB
Abd: ND/NT, no masses, umbilical stump attached, base is clean w/ no drainage, no erythema
Lymph: No adenopathy
Skin: No rashes
Questions for you:
A previous provider caring for this patient opted to obtain a CBC, BCx, and UA/UCx (but no LP).
Repeat rectal temp two hours later was 37.6.
In this 8-day old with a temp of 37.9 (<38), consider how the lab results potentially influence your management:
Low risk (WBC 5-15k, no bands, UA negative) vs. high risk (such as WBC 20k or UA with 15 WBCs)
More questions:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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I’m a purist here, and am sure will be contradicted by others. If I was worried enough to do any work-up on this “almost” febrile 8 day old infant with no risk factors and no source on exam, I’d so a complete workup (not a partial work-up). UA and CBC don’t predict meningitis, only CSF does. However, I’m not so sure I’d jump the gun — I’d observe the child in the ED for ~4 hours clothed normally (not bundled, and not naked with only a diaper and flimsy hospital gown). If temperature goes above 38, then I’d do the workup — knowing full well that 90% of the time it is going to be negative. If one makes the cogent argument that 37.9 is not too far from 38.0, then they should do the full sepsis (not sepTIC) workup — not a partial workup.
Also, any high-risk febrile infant <2 months of age deserves the full sepsis workup, and any infant less than 28 days old deserves admission for 24-48 hours (if less than 14 days for 48 hours, if between 14-28 days for 24 hours) for antibiotics after complete sepsis workup.
I’m with Dewesh-it’s all or nothing in an 8-day-old, and low/high risk screening labs should not direct your management. I voted for observe & re-temp, and don’t give tylenol!
Oh, and discussing it with the parents is tricky. It’s reasonable to have an educated discussion about management options, but we shouldn’t put any burden of medical decision making on the parents, especially when they’re likely stressed out & tired. It’s hard to be objective when your child is in the hospital, even if you’re an MD yourself!
How yucky is the yucky umbilicus? If it’s pure hygiene and looks sticky from being mashed under the diaper and not touched (out of fear for damaging it), then I am all for sticking the edge of an alcohol prep pad in there and getting it cleaned out and re-temping in the Ed versus sending them home to re-temp. if, on the other hand, the stump gives me pause, then I’m in it for the long haul….
I also agree that it’s very hard to objective with your child. I like my doctors to doctor my children and NOT ask for my input. Just FYI.
I would admit off of antibiotics for 24 hours with plans for full sepsis workup if temp reaches 38. I would not send this patient home due to the mildly fishy umbilical stump situation, although that’s usually hygiene vs. granulation tissue vs. all kinds of nothing.
If you approached me in the ED and asked “what would you do with an 8 do with an unexplained (not bundled or environmentally overheated) temp of 37.9 rectal?” I’d say:
First, why did someone check? If they checked because the baby was unusually fussy, or wasn’t acting quite right, or wasn’t feeding, then my threshold for doing a full sepsis workup (blood, urine, CSF, and admit) would be low. But every now and then, babies do get checked without a good reason, or they “felt warm” but parents are confident they were completely fine and acting completely well. This kind of confidence is more common in a 2 or 3 week old than an 8 day old. If we are confident the baby is otherwise completely normal, then observation with serial temperatures seems reasonable. Duration of observation can range from 1-2 feedings to an overnight admission, and may depend on time of day, social situation, and subsequent temperature readings. Even with perfect primary care follow up and a family that lives nearby, it’s good to remember that one week old babies can get very sick very quickly – I’d like to see them for at least a feeding or two.
Next, if you mentioned there was some history of a smell and maybe a drop of discharge from the umbilical stump, but everything looks fine now on exam:
I don’t think that changes my answer above. I wouldn’t treat the baby for omphalitis with a normal clinical exam based on a certain WBC, so I don’t think more testing helps me here. It makes it even more important that I watch the temperature curve for a bit and recheck the umbilical stump exam. I don’t know the specificity of “history of smell from the umbilical cord” for umbilical infection, but it’s something I’ve heard more than a few times and I suspect that specificity is low.
If someone has gotten blood and urine on a baby this age with a temp of 37.9, and it’s abnormal, I would proceed to a full workup (do the LP) and admit. Someone was worried about infection, the baby is close to criteria for a workup, and now I have unexplained abnormalities in the tests. If I’m not sure the labs were truly necessary, I might admit off antibiotics to shorten the duration of hospitalization.
But I’m not being asked in the ED, I’m at my desk. So I’ll try to answer some of these questions.
1. What the risk of serious bacterial infection for an 8do baby with a temp of 38 rectal? The last evidence I remember on incidence of SBI in young infants was a secondary analysis of PECARN data looking at the risk of SBI in influenza-positive infants = 38 C (by history or in the ED), the prevalence of meningitis was 0.9% (6/698), bacteremia 2.2% (16/715), and UTI 10.8% (77/712).
b. For babies 0-30 days with temp >= 38 C, the overall rate of SBI was 13.1% (35/268, 95%CI 9.5%-17.6%).
c. This data was collected prospectively, 8 different EDs, 1998-2001, October – March, and excluded babies who did not have influenza testing. But if anything I would suspect we have fewer viral-related fevers in the summer than the winter, so actual year-round prevalence might be higher.
d. 94% of the babies 0-60 days were well appearing by the Yale Observation Score and the mean max temp was 38.6 – they don’t give mean temperature in the SBI positive babies.
So this doesn’t change my answer. A 1 in 10 risk of SBI at 0-30 days, and the mean temp may be as low as 38.6.
2. Next, I pulled Jim’s last few emails about normal temperature range. This one is most applicable to pediatrics:
Leduc & Woods, Canadian Paediatric Society, Temperature Measurement in Pediatrics, http://www.cps.ca/en/documents/position/temperature-measurement
It gives the normal rectal temp range as 36.6 to 38, and the normal oral range as 35.5 to 37.5. It does reassure me a little – I feel I don’t see a lot of 37.9 temps in completely healthy, uninfected patients, but most of those are probably oral or axillary temps.
3. Does WBC help to predict omphalitis?
First I checked UpToDate and came across this reassuring paragraph:
“Mild discharge from the umbilical stump in the absence of inflammatory signs may be a normal occurrence, even when accompanied by some odor. Some clinicians treat infants with minimal symptoms with topical applications such as alcohol, bacitracin, or mupirocin. However, there is no evidence of efficacy of this practice or on the efficacy of the administration of oral antibiotics in these infants.”
Then I went on to a PubMed search on omphalitis, and on a quick search found nothing relevant. The publications that do discuss omphalitis are mostly from the developing world (as UTD mentions, estimated incidence in industrialized countries is 0.7% and in developing countries 6%). UTD also reminded me that omphalitis is associated with immune abnormalities, including leukocyte adhesion defects. So at best, there’s no evidence WBC is helpful in the diagnosis of omphalitis.
So, this was a good review of SBI in infants, temperature measurement, and omphalitis, but no change to my original answer. An 8 do can have life-threatening illness without a fever; if you have concerns about the patient, a full workup is indicated. However, a completely fine 8 do with a temperature of 37.9 does not meet strict criteria for a full workup, and there are also downsides to hospital admission – from nosocomial infection to family stress to the impact on breastfeeding (hospitalists have actually studied this, by the way). If you aren’t doing a workup, you just have to be confident they’re completely fine, and that’s challenging when your patient is 8 days old. So a period of observation and serial exams/temperature measurements is a way to work your way to that confidence. Blood and urine is another tool sometimes used to get that confidence, but it has definite downsides – they can be falsely reassuring, and therefore dangerous if not combined with good reexaminations and temperature rechecks. They can also be abnormal in the setting of a reassuring clinical course, and then difficult to interpret. As with many management decisions in pediatrics, there’s an element of judgment here.
*Krief WI, Levine DA, Platt SL, Macias CG, Dayan PS, Zorc JJ, Feffermann N, Kuppermann N; Multicenter RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Pediatrics. 2009 Jul;124(1):30-9.
Same as some above: either full septic or none. repeat temps and observation is always helpful. 37.9 close to 38 yes, but there has to be a cut off somewhere I guess! So unless there is a concern for illness, 38 is my cut off.
The choice I would give parents is temp here or at home. Not regarding admission or partial/full work up.
Finally, I would be a real pain and quiz the previous provider as to why they did a partial, what their plan was, what they told the parents etc etc… and even hope that the labs come back before they leave and let them continue with their decision making. Sorry!
Continuing in the purist mindset, and attempting to correct Dewesh for once, it would not be full sepsis (or septic) work-up, but rather a rule out SBI workup. As I was taught in residency, especially in these infants, sepsis is a clinical diagnosis and if they are septic than it’s full workup anyhow, thus these academic discussions that become practical all the time really are about ruling out a serious bacterial infection, not sepsis.