A concerned father calls your office because his three-week-old son has a fever of 39.5 degrees Celsius (103.1°F) measured axillary. He was born at term and had no complications after a spontaneous vaginal delivery. He was breast-feeding well until yesterday. Since then he has been sleeping more. He has a two-year-old brother who has a cold.
What is the best advice to give the parents?
Correct Answer C:
Febrile neonates (up to 28 days old) are at particularly high risk for bacterial infections. An immature immunologic system makes them vulnerable to more virulent bacteria as well as viral infections.
The routine workup for febrile neonates must be more aggressive than in other age groups because of the greater probability of a serious bacterial infection and our inability to predict which neonates have serious infections.
All febrile neonates should have a blood culture drawn, a lumbar puncture for cerebrospinal fluid culture and studies, and urine obtained by catheterization for urinalysis and culture. Chest films should be taken when respiratory symptoms are present. Stool leukocytes and culture are indicated in neonates with diarrhea. A white blood cell (WBC) count is usually obtained also.
All febrile neonates should be hospitalized and receive intravenous antibiotics, even when laboratory screening tests are normal. Treatment should include IV gentamicin (2.5 mg/kg) or a third-generation cephalosporin such as cefotaxime (50 or 100 mg/kg if meningitis is suspected).
The parents of a 40-day-old infant bring her to your clinic because she has had a persistent fever for the past 2 days with rectal temperatures between 38.1°C (100.5°F) and 38.9°C (102.0°F). She has been fussy and wants to be held, but has been nursing well. She is crying when you enter the room, and on examination she has good skin turgor and capillary refill. The examination does not reveal any obvious source of infection. By the time you complete the examination the infant is resting quietly in her father’s arms. You obtain a CBC and urinalysis. The WBC count is 12,500/mm³ (N 5000-19,500) with an absolute neutrophil count of 8500/mm³ (N 1000-9000). The urinalysis is within normal limits.
Which one of the following would be most appropriate at this time?
Correct Answer B:
Most children will be evaluated for a febrile illness before 36 months of age, with the majority having a self-limited viral illness. For the management of febrile infants, the most commonly used criteria in practice are the Rochester criteria. Clinical assessment involves deciding whether a child appears toxic. The clinical features that define toxicity include irritability, lethargy, and decreased social interaction.
Nontoxic-appearing febrile infants 29-90 days of age who have a negative screening laboratory workup, including a CBC with differential and a normal urinalysis, can be sent home and followed up in 24 hours (choice B). Occasionally it may be important to obtain blood cultures and stool studies, or a chest film if indicated by the history or examination, and spinal fluid studies if empiric antibiotics are to be given. This infant’s clinical status did not indicate that any of these additional studies should be performed and empiric antibiotic treatment is not planned. For example, if a child has diarrhea, stool studies are usually done.
→ Home care and parental observation only, as long as the temperature remains under 39.0°C (choice A) is incorrect. Observation with no follow-up is an appropriate strategy in nontoxic children, but only if the child is 3-36 months of age and the temperature is under 39°C. Nontoxic children 3-36 months of age should be reevaluated in 24-48 hours if the temperature is over 39°C. Although a positive response to antipyretics has been considered an indication of a lower risk of serious bacterial infection, there is no correlation between fever reduction and the likelihood of such an infection.
→ Oral antibiotics and reevaluation in 24 hours (choice C) is incorrect. This child is considered low risk, therefore, lumbar puncture or empiric antibiotic therapy are not recommended. For children whose condition warrants anti-biotherapy and re-evaluation in 24 hours, lumbar puncture should be done before antibiotics to avoid affecting sensitivity studies.
→ A complete sepsis workup, including blood cultures, stool studies, a chest radiograph, and cerebrospinal fluid studies (choice D) should be done for any infant younger than 29 days, and any infant or child with a toxic appearance regardless of age. They should undergo a complete sepsis workup and be admitted for observation until culture results are obtained or the source of the fever is found and treated.
→ Hospital admission and adequate antibiotic treatment and fluid resuscitation (choice E) are not recommended in this non-toxic child with initial studies showing no abnormality.
A 12-month-old girl is brought to the emergency department for the second time in two days for vomiting and passage of 8 to 10 watery stools per day. Of the following, which provides the best estimate of the patient’s volume deficit?
Correct Answer A:
Dehydration is significant depletion of body water and, to varying degrees, electrolytes. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree of dehydration progresses, tachycardia, hypotension, and shock. Diagnosis is based on history and physical examination. Treatment is with oral or IV replacement of fluid and electrolytes.
The most accurate method with acute dehydration is change in body weight; all short-term weight loss > 1%/day is presumed to represent fluid deficit. However, this method depends on knowing a precise, recent pre-illness weight.
A 1-year-old child with a rapid pulse, lethargy, oliguria, loss of skin turgor and dry oral mucosa should be considered most likely to be:
In infants, signs of 5% (mild) dehydration are slightly dry buccal mucous membranes, increased thirst and slightly decreased urine output.
In infants, signs of 10% (moderate) dehydration are dry buccal mucous membranes, tachycardia, little or no urine output, lethargy, sunken eyes and fontanelles, loss of skin turgor.
In infants, signs of 15% (severe) dehydration are same as moderate plus a rapid, thready pulse, no tears, cyanosis, rapid breathing, delayed capillary refill, hypotension, mottled skin and coma.
A 1-year-old child presents to the emergency room with a 3-day history of dehydration. Physical examination of the infant is consistent with 10% dehydration. Serum sodium level is 165 mmol/L.
All of the following about hypernatremic dehydration are true, except:
Correct Answer D:
Hypernatremic dehydration is seen in about 10-15% of patients with dehydration. The serum sodium level should be lowered slowly, no faster than 10-12 milliequivalents in 24 hours (choice D), due to the risk of cerebral edema and seizures.
→ Subdural hematomas (choice A) may occur due to intracellular fluid loss.
→ Hypernatremia (choice B) may be seen with improperly mixed formulas.
→ 20cc/kg normal saline or lactated ringers fluid boluses (choice C) should be given until the infant is clinically stable.
→ Hypernatremia (choice E) is seen in 10-15% of patients.
Click to expand