FEVERS IN NEONATES, INFANTS, AND CHILDREN

Fever in the infant and toddler is one of the most common problems and greatest challenges faced by those caring for them, as it can be very worrisome and frustrating for the parent.  Some fevers are caused by viruses, and are generally not that severe, only requiring comfort care (hydration, Tylenol, and rest).  Bacterial infections can be more severe and require hospitalization, but both can lead to medical care.  In most cases the differences between the two are that viral infections tend to have a cough, general effects the mucous membranes (runny nose), and a fever <102F.  Generally bacterial infections do not have a cough, effect less of the mucous membranes, and can have fevers >102F, but there are always exceptions for both (i.e. viral exanthems).

Typically, infections that occur in the first 7 days of life are secondary to vertical transmission (acquired during birth), and those infections occurring after the first 7 days are usually community acquired or hospital acquired.  Bacterial meningitis is more common in the first month of life than at any other time. An estimated 5-10% of neonates with early onset group B streptococcal (GBS) sepsis have concurrent meningitis.  3% of neonates (< 1month old) have a serious bacterial infection.  A birth weight of less than 2500 g, rupture of membranes before the onset of labor, septic or traumatic delivery, fetal hypoxia, maternal peripartum infection, and galactosemia are all risk factors for a serious bacterial infection in the neonate.

Infants (1-2 months) with fevers can be challenging as these cases can lack classical signs and symptoms on physical exam.  Urine tract infections (UTIs) can be very common in this age group.  History of exposure to sick contacts in the household or daycare should be obtained, as well as a recent history of a previous illness, immunization, and recent antibiotic use.

For children 3 months - 3 years, serious bacterial infections have been reduced since the introduction of vaccines, now about 1/200.  S pneumonia and Escherichia coli are the most common pathogens, accounting for two thirds of cases. In infants with S pneumonia, many isolates are strains not covered by the currently available heptavalent conjugate vaccine.  Pneumococcal bacteria infections can have acute otitis media (ear infection), pneumonia, sinusitis, meningitis, cellulitis, and febrile seizures.  E. coli tends to present as UTIs and Staph infections usually have skin, musculoskeletal, and soft tissue infections, with about 15% being bloodstream infections.  A single intramuscular (IM) dose of ceftriaxone has been shown to prevent sustained bacteremia in children whose initial blood culture has yielded Streptococcus pneumonia.

Neonates and young infants should be hospitalized with IV antibiotics.  Infants receive IV ampicillin and gentamicin, or ampicillin and cefotaxime.  For infants, coverage is usually IV ampicillin, cefotaxime, and vancomycin. Treatment for children can be more liberal, but should be hospitalized with significant dehydration, meningitis signs (severe headache, stiff neck, vomiting/nausea, severe confusion, sensitivity to light, and skin rash), and significant decrease in level of consciousness/cognition.  As stated, neonates and young infants should be hospitalized and so care will be supported by medical professionals.  Neonates and infants without signs of serious illness can be treated at home with oral antibiotics if close follow-up is available.  Research suggests children who are non-toxic appearing do not require empiric antibiotics.  For children hospitalized, a single intramuscular (IM) dose of ceftriaxone has been shown to prevent sustained bacteremia in children whose initial blood culture has yielded Streptococcus pneumonia.  Ceftriaxone is effective for E. Coli and Staph infections can be treated with clindamycin.

Four viral exanthemas are common and include:  measles, rubella, erythema infectiosum, and roseola infantum.  All can be very concerning as cases have fevers and skin rashes.  Measles present with a high fever (>104F), spots on the mouth (Koplik’s spots), hacking cough, runny nose, and red eyes...then a spot-like rash develops that covers most of the body.  

Rubella presents like the flu, and has a rash that starts on the face and spreads to trunk and limbs.    Erythema infectiosum (fifth disease) has a “slapped cheek” on face that spreads to trunk and limbs. 

Fevers that develop for rubella and erythema infectiosum are generally not severe and rarely above 101F.  Roseola infectiosum (sixth disease) will have high fevers (102-104F), and many children appear normal otherwise.  After fever resolves, a rash appears on the trunk and then spreads to the legs and neck.  All cases are viral and so do not require antibiotics, but rather can be treated with  comfort care at home (hydration, tylenol, and rest), unless rare emergencies develop (breathing issues, loss of consciousness, severe dehydration, etc).