- Recognition of dehydration in a neonate
- Going through a full septic work up in a febrile neonate
- Getting a good feeding and birth history from mother.
HPI: Patient is a 4 day old female who presents with fever of 101.7 at home obtained rectally and 100.5 in the PCP’s office. She was born 40 weeks 2 days to a GBS + mom via c/s secondary to failure to progress, cervix did not dilate after 9 cm. Mom went to Valley on Thursday night and 12 hours later, started cervidil and oxytocin. The mother recieved antibiotics about 1 hour after amniotomy. The child was delivered about 24 hours after arriving to the Valley. Mom had a fever and she was unsure whether or not she received abx after the delivery. The child as per mom, did not receive abx, but did get blood drawn. Mom was told the blood work was normal.
The child was d/c’d home with mom and dad. She was fed breast milk. However, she began to have decreased PO intake. She would not latch on as per mom. The last time she fed was 10 pm last night. She took in 15 min/breast for 30 min at that time. Temp was taken today and measured at 101.7. They took the child to the PCP today and were told to come to the ER. The child was not given any tylenol. Mom noticed the child has been tried, increased sleeping and not feeding. No sick contacts.
VS: HR 136, Temp 99.2, RR 62, Sp02 95%
PE: Was significant for dry membranes
Finger stick: 55
Creatinine : 0.7
Urine: positive for ketones, and protein.
LP: WBC 1, Glucose 61, Protein 57, no WBC seen, no bacteria seen and no growth.
ED course: Full septic workup was done, including LP, pt was given NS IV bolus with d5 ½ NS for hypoglycemia. Ampicillin and cefotaxime were started.
Inpatient course: Pt started to take more adequate amount of breast milk and increase amount of wet diapers. Pt was chemistry resolved and patient was more hydrated clinically. Pt was discharged and was going to be followed by PCP.
Morning Report Discussion 7/29/14
Does a fever in a neonate need a full septic work up including an LP?
In a study of 449 neonates with fever, 19.4% had serious bacterial infection. In 3-7 days the prevalence was 21.6%, 8-14 days it was 26.1%, 15-21 days it was 17.9% and in 22-28 days it was 12.1%. Of the 449 patient 226 were classified as “low risk”, and of this “low risk” group 6.2% had a serious bacterial infection one of which was bacteremia and meningitis. The rest were UTIs. The conclusion of the study was that even though neonates might be classified as low risk the risk of serious bacterial infection is still great and a full septic workup should be done along with empiric antibiotics for a neonate with a documented fever.
Tintinalli’s Emergency Medicine: Neonatal Emergencies and Common Neonatal problems, Hypoglycemia and Metabolic Emergencies in Infants and children.
Schwatz. (2009)A week-by-week analysis of low-rsik criteria for serious bacterial infection in febrile neonates. Archives of disease in childhood, 2009, Apr; 94(4): 287-92