Fever in the Neonate

The Case 3-week old girl whose mother says she “feels warm” and is “acting fussy” ???

The History Irritable, feeding slightly less frequently, sleeping more than usual 4 days ago had runny nose and cough Dev: Full-term infant; NSVD; GBS - mother

The Exam Baby asleep in mother’s arms. When woken up, immediately begins to cry. Mother attempts to feed, but baby is not interested. Vitals: T: 100.5° | HR 150 | RR 70 | BP 80/50 All other systems WNL

The Labs Gram Stain: CSF: - WBC 1100, 92%N - Glucose 24 - Protein 190

Late Onset Group B Strep Meningitis What Does this Baby Have?

GBS A G+ coccus colonizing GU, GI, and respiratory tracts. Important cause of infection in 3 groups: neonates, pregnant women, non-pregnant adults

GBS in Neonates Mode of Transmission: –In uterol –Vertical transmission –Late-Onset: colonized household contacts Classified by age-at-onset into early- onset (through day 6) and late-onset (1w to 3 months)

Early–Onset GBS Early-Onset (12 hours to 1 week) –Results in bacteremia, sepsis, PNA, meningitis –Generally apparent within 24 hours of birth –Now much less frequent due to preventative measures

Late-Onset GBS Typically presents with T > 38.0C (100.4F) May have history of recent URI Irritability, Lethargy, Poor Feeding, Tachypnea Associated Conditions: pneumonia, septic arthritis, bacteremia, adenitis, and cellulitis Less likely to present with severe shock than early-onset GBS patients

The Treatment Empiric: IV ampicillin + aminoglycoside/3G Once you are certain of GBS, may switch to Pen G. However higher doses are needed.

Prognosis About 25% may have hearing loss, vision loss, or learning disabilities Such outcomes more likely in low birth- weight, delayed treatment, leukopenia

Prevention Strategies Mechanism of late-onset GBS not known, therefore, prevention is difficult Much more success with early-onset form Screen all pregnant women for GBS Treatment of all high-risk pregnancies during labor

Cause of Neonatal Fever #1 = Viral (e.g. HSV, Influenza, RSV) About 7% are bacterial, mostly GBS and G - enterics

Workup of Febrile Neonate CBC & Blood Culture UA and Urine Culture LP CXR

Rochester Criteria A systematic approach to identifying low-risk children who may be observed without resorting to antimicrobial treatment Pediatrics (1994) : 98.9% negative predictive value

Summary – Fever in Neonate Fever may be the only sign of underlying disease Must not be neglected – disease may be significant Defined as T > 100.4º (38.0ºC) Tactile fever without documented rectal fever may be observed provided that caregiver is reliable

Summary – Fever in Neonate Main objective is to identify those at risk for serious illness –“Toxic Appearing”: irritability, decreased activity, lethargy – however these are dramatic findings – may not be present –History: Resp/GI symptoms, Sick contacts, Behavioral changes, Urine/Stool changes –Workup: CBC/Cx, UA/Cx, LP, ±CXR