Chapter 2

• The risk of serious bacterial infection (SBI) is greatest during the neonatal period, defined as birth to 28 days of life. Some authorities recommend that a child born prematurely should have the degree of immaturity subtracted from the child's chronological age for this consideration.
• It is generally accepted that a fever is a temperature of ≥38°C or 100.4°F taken with a rectal thermometer.
• A neonate who had a documented fever by any method but is afebrile on admission to the ED should be treated as a febrile neonate whether or not antipyretics have been given.
• The most frequent bacterial pathogens in the neonatal period are group B Streptococcus (GSB), Escherichia coli, and Listeria monocytogenes.
• Hypothermia is a rectal temperature less than 36°C or 96.8°F and, in the neonatal period, may actually be a more common presentation than elevated temperature. All neonates with hypothermia should be treated as septic.
• Causes other than SBI, especially herpes simplex virus (HSV) infection, should be considered and, if suspected, treated expectantly.
• Noninfectious problems, such as congenital heart disease (CHD) and inborn errors of metabolism, may present in a similar way and must always be on the list of potential causes of the septic-appearing infant.
• If the child is exhibiting signs of shock, such as tachycardia, mottling, apnea or prolonged capillary refill time, aggressive fluid resuscitation must be immediate.
• Antibiotics should be started after cultures have been obtained.
• If the child is unstable, the lumbar puncture may need to be postponed.

The risk of serious bacterial infection (SBI) is greatest during the neonatal period, defined as birth to 28 days of life. Some authorities recommend that a child born prematurely should have the degree of immaturity subtracted from the child's chronological age for this consideration. Since the initial publication of practice guidelines in 1993, many advances have occurred in the management of neonates with fever without source.1 Hematogenous spread is most frequent in neonates, resulting from colonization of the nasopharynx, which occurs early in life. Bacteria can enter the blood stream from the pharynx at any time, but more frequently following a viral prodrome. There is general consensus among emergency physicians regarding the management of the febrile neonate. With a documented history of a fever, infants will undergo a sepsis workup (Table 2–1) and be admitted to the hospital for 48 to 72 hours of antibiotic coverage. The length of treatment will depend on the findings of the initial workup and the child's clinical condition.2 Because of the increasing problem with drug resistance, iatrogenic problems, and the relatively low incidence of SBIs in febrile neonates, efforts are underway to see if any specific tests can allow febrile neonates with low-risk factors to be observed without use of antibiotics and hospitalization.3 Although some studies have shown that febrile neonates who fit low-risk criteria (Table 2–2) can be managed without antibiotics, hospitalization and close observation are still required at a minimum.4 A ...

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