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