It is time for another EB Medicine special. The febrile young infant can be one of the scarier patients for a variety of reasons. They are so young they are unable to communicate, they have very real and serious pathogens that can have deadly consequences, and the family as well as other individuals taking care of the patient can be nervous or scared creating increased stress. In this post, we cover EB Medicine's recent article on this topic to better improve your practice.
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Sometimes the process to evaluate and treat the febrile young infant can seem very structured and methodical, especially at first glance. However, with different age ranges and a variety of data over time demonstrates that this is not totally the case. While the most structured and "routine" approach would be for neonates, there are even special considerations in these populations. We will break down some of the key highlights from the article to help guide us in our management based on the current evidence.
First, why is this such a big deal? Due to their immature immune system, there is a high-risk for seriously bacterial infections (SBIs) and invasive bacterial infections (IBIs) in children aged 60-90 days or less. What makes it more challenging is the lack of social responsiveness (social smile), verbal cues, and that even in the well-appearing young infant they can still harbor serious infections. Additionally, there is a medico-legal component as the most common diagnosis in pediatric medical malpractice claims from the emergency department is bacterial meningitis.
Causes for fever in well-appearing young infants:
Causes for fever in ill-appearing young infants:
The diagnosis of HSV can be rather challenging. Its presentation can vary depending on if it involves skin and mucous membranes, the central nervous system, or it is disseminated. EB Medicine has a great table to help break down the complexities.
The history and physical is a vital component to our evaluation in addition to lab findings:
There are a variety of risk-stratification tools with varying types of data and suggestions. The most common along with their year of publication are the Boston Criteria (1992), Philadelphia Criteria (1993), Rochester Criteria (1994), Step-by-Step (2016), and PECARN (2019). The last three have MDCalc breakdowns to remind us of the cutoffs and criteria. It is also important to know that the last one, PECARN (Pediatric Emergency Care Applied Research Network) has not yet been externally validated and should currently be used only in infants aged 29-60 days. This is due to elevated herpes meningoencephalitis risk and and limited numbers of episodes of bacterial meningitis in neonates.
It is vital to remember no matter what method we use that we involve our pediatrician colleagues in the decision making process. In the case of those who are not as familiar with or comfortable in managing the febrile young infant to have additional support. This can be in the form of that pediatrician or even another one of our emergency medicine colleagues. Whatever the case, the more support we have the better.
Final Pearls from the Article:
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