Neonatal Fever v6.0: ED Phase (0-28 days old)

Neonatal Fever Pathway v10.0: Table of Contents

Inclusion Criteria

? Fever ¡Ý 38 C (or a reliable history of fever) or hypothermia < 36 C

in children ¡Ü 60 days of age

Stop and

Review

Exclusion Criteria

? Patients currently admitted to ICU or admitted > 3 days

? Known immunodeficiency or cancer

? Patients with central venous catheters or VP shunts

Neonatal Fever Care

ED phase 0-21 days

ED phase 22-28 days

ED phase 29-60 days

ED phase 22-60 days with

Bronchiolitis

Inpatient Phase 0-21 days

Inpatient Phase 22-28 days

Inpatient Phase 29-60 days

Appendix

Version Changes

Last Updated: May 2023

Next Expected Review: November 2027

Approval & Citation

Evidence Ratings

Bibliography

For questions concerning this pathway, contact:

NeonatalFever@

If you are a patient with questions contact your medical provider, Medical Disclaimer

? 2023 Seattle Children¡¯s Hospital, all rights reserved

Neonatal Fever Pathway v10.0: ED Phase (0-21 days old)

Inclusion Criteria

? Fever ¡Ý 38 C (or a reliable history of fever) or hypothermia < 36 C

in children ¡Ü 21 days of age

Stop and

Review

Exclusion Criteria

? Patients currently admitted to ICU or admitted > 3 days

? Known immunodeficiency or cancer

? Patients with central venous catheters or VP shunts

Urgent Care Transfer Guidelines

(for 0-21 days)

Well appearing neonates with fever

transfer via POV to an ED.

!

Other differential

diagnosis for severely

ill neonates

Begin clinical assessment

Focal Infection?

CSF Normative Values

? 0-1 month: CSF WBC < 20/mm3

? >I month: CSF WBC < 10/mm3

(e.g., omphalitis, pneumonia)

Ill appearing neonates with fever:

? Initiate transport immediately

? Administer antibiotics (IV or IM)

? Attempt to obtain labs (do not delay

transport for labs)

Off Pathway

Yes

No

!

If CSF

pleocytosis consider

CSF Rapid Viral Qual.

PCR

Inability to obtain

CSF in ED

?

?

?

?

?

UA, urine culture

CBC with diff

Blood culture

CSF studies

HSV work up if indicated (see

box)

? Consider CXR and respiratory

viral panel (if respiratory

symptoms)

? Consider Stool PCR (if

diarrhea)

? Consider ammonia if ill or

septic appearing

Begin empiric treatment

? Ampicillin and ceftazidime

? Acyclovir if HSV work up

performed

? Admit all patients

HSV work up indications

Perform complete work up and begin

acyclovir for any of the following:

Historical and clinical features

? severe illness

? hypothermia

? lethargy

? seizures

? hepatosplenomegaly

? postnatal HSV contact

? vesicular rash

? conjunctivitis

? interstitial pneumonitis

Laboratory features

? thrombocytopenia

? CSF pleocytosis > 20 WBC/mm3

without clear bacterial infection

(e.g., + Gram stain)

Phase Change

Go to Inpatient Phase (0-21d)

Last Updated: May 2023

Next Expected Review: November 2027

!

In well-appearing

infants with multiple

maternal HSV risk factors,

consider HSV work up

For questions concerning this pathway, contact:

NeonatalFever@

If you are a patient with questions contact your medical provider, Medical Disclaimer

? 2023 Seattle Children¡¯s Hospital, all rights reserved

Neonatal Fever Pathway v10.0: ED Phase (22-28 days old)

Urgent Care Transfer

Guidelines (for 22-28

days)

Inclusion Criteria

? Fever ¡Ý 38 C (or a reliable history of fever) or hypothermia < 36 C

in children 22-28 days of age

Stop and

Review

Well appearing neonate:

? Transfer to the ED if

abnormal

inflammatory markers

(ANC, CRP,

Procalcitonin) or if

unable to obtain

inflammatory markers

Exclusion Criteria

? Patients currently admitted to ICU or admitted > 3 days

? Known immunodeficiency or cancer

? Patients with central venous catheters or VP shunts

Focal Infection?

!

No

Other differential

diagnosis for severely

ill neonates.

Gestational age < 37

weeks?

Ill appearing neonates with

fever:

? Initiate transport

immediately

? Administer antibiotics

(IV or IM)

? Attempt to obtain labs

(do not delay transport

for labs)

Off Pathway

Yes

(e.g., omphalitis, pneumonia)

Phase Change

Yes

Go to ED Phase

(0-21d)

No

Bronchiolitis?

(increased work of breathing,

cough, tachypnea, wheezing)

!

HSV work up

indications

Phase Change

Consider ED

Phase (22-60d) W/

Bronchiolitis

Yes

Perform complete work

up and begin acyclovir for

any of the following:

No

If CSF

pleocytosis consider

CSF Rapid Viral Qual.

PCR

?

?

?

?

CBC with diff

Blood culture

UA, urine culture

Procalcitonin or CRP if PCT

unavailable

? Consider CXR and respiratory

viral panel (if respiratory

symptoms)

? Consider Stool PCR (if

diarrhea)

Abnormal Inflammatory

Markers

? ANC > 4000/mm3

? CRP > 2.0 mg/dL

? Procalcitonin > 0.5 ng/mL

Historical and clinical

features

? severe illness

? hypothermia

? lethargy

? seizures

? hepatosplenomegaly

? postnatal HSV contact

? vesicular rash

? conjunctivitis

? interstitial pneumonitis

Laboratory features

? thrombocytopenia

? CSF pleocytosis > 20

WBC/mm3 without

clear bacterial

infection (e.g., + Gram

stain)

Inability to obtain

CSF

Abnormal inflammatory

markers or ill appearing?

No

Yes

Shared decision making to

perform LP for CSF studies

LP performed?

CSF Normative

Values

Perform LP for CSF studies

? 0-1 month: CSF WBC

< 20/mm3

? >I month: CSF WBC

< 10/mm3

Yes

CSF pleocytosis?

Yes

No

Phase Change

Inpatient Phase 22-28 days

? Admit for observation

? May administer antibiotics

per shared decision making

No

? Administer ceftriaxone

? Consider HSV workup if CSF

pleocytosis with negative

gram stain and give acyclovir

? Admit

!

No

Ceftriaxone

contraindicated with

hyperbilirubinemia

Will observation occur at

home?

Yes

? Administer ceftriaxone

? Must have follow-up within 24 hours scheduled with

PCP or SCH urgent care

Last Updated: May 2023

Next Expected Review: November 2027

For questions concerning this pathway, contact:

Neonatalfever@

If you are a patient with questions contact your medical provider, Medical Disclaimer

? 2023 Seattle Children¡¯s Hospital, all rights reserved

Neonatal

NeonatalFever

FeverPathway

Pathwayv10.0:

v9.0: ED

EDPhase

Phase(29-60

(29-60days

daysold)

old)

Inclusion Criteria

Stop and

Review

? Fever ¡Ý 38 C (or a reliable history of fever) or hypothermia < 36 C

in children 29-60 days old

Abnormal Inflammatory

Markers

Exclusion Criteria

? ANC > 4000/mm3

? CRP > 2.0 mg/dL

? Procalcitonin > 0.5 ng/mL

? Patients currently admitted to ICU or admitted > 3 days

? Known immunodeficiency or cancer

? Patients with central venous catheters or VP shunts

Focal Infection?

Yes

(e.g., omphalitis, pneumonia)

!

Other differential

diagnosis for severely

ill neonates

Off Pathway

No

Phase Change

Gestational age < 37 weeks?

Urgent Care Transfer

Guidelines (for 29-60 days)

? Initiate workup per ED

Phase (0-21d)

? Administer Ceftriaxone

? Admit

Yes

No

Well appearing patient:

? Transfer to the ED if

abnormal inflammatory

markers (ANC, CRP,

Procalcitonin) or if unable

to obtain inflammatory

markers

Bronchiolitis?

(increased work of breathing,

cough, tachypnea, wheezing)

Phase Change

Yes

Consider ED Phase (22-60d)

W/ Bronchiolitis

No

?

?

?

?

?

CBC with diff

Blood culture

UA, urine culture

Procalcitonin or CRP if PCT unavailable

Consider CXR and respiratory viral panel (if respiratory

symptoms)

? Consider Stool PCR (if diarrhea)

Ill appearing patient with fever:

? Initiate transport

immediately

? Administer antibiotics (IV

or IM)

? Attempt to obtain labs (do

not delay transport for

labs)

Abnormal inflammatory markers

or ill appearing?

Yes

Discharge Criteria

? Need not perform LP

? Need not administer

antibiotics

? Can be observed at home

? Must have follow-up within 24

hours scheduled with PCP or

SCH urgent care

No

Positive urinalysis

result?

No

Yes

Discharge Criteria

?

?

?

?

Shared decision making to

perform LP for CSF studies

LP performed?

Need not perform LP

Give IV/IM ceftriaxone

Can observe in hospital or at home

If going home, must have follow-up within 24

hours scheduled with PCP or SCH urgent care

AND provide prescription for PO cephalexin

CSF pleocytosis?

Yes

Will observation occur at

home?

No

Yes

? Administer meningitic

ceftriaxone

? Admit

!

Inability to

obtain CSF

No

If CSF

pleocytosis consider

CSF Rapid Viral Qual.

PCR

Yes

Phase Change

No

Inpatient Phase 29-60 days

Discharge Criteria

? Administer ceftriaxone

? May observe closely in hospital or at

home per shared decision making

? If going home, must have follow-up

within 24 hours scheduled with PCP

or SCH urgent care

Last Updated: May 2023

Next Expected Review: November 2027

? Give IV/IM ceftriaxone if UA is

positive

? May administer antibiotics per

shared decision making if UA is

negative

? Administer ceftriaxone

? Must have follow-up within

24 hours scheduled with

PCP or SCH urgent care

For questions concerning this pathway, contact:

Neonatalfever@

If you are a patient with questions contact your medical provider, Medical Disclaimer

? 2023 Seattle Children¡¯s Hospital, all rights reserved

Neonatal Fever Pathway v10.0: ED Phase (22-60 days old) with

Bronchiolitis

Inclusion Criteria

? Fever ¡Ý 38 C (or a reliable history of fever) or hypothermia < 36 C

in children ¡Ý 22 days of age

Exclusion Criteria

Stop and

Review

?

?

?

?

?

Patients currently admitted to ICU or admitted >3 days

Known immunodeficiency or cancer

Patients with central venous catheters or VP shunts

Infants ¡Ü 21 days old with fever

Premature infants < 37 weeks EGA

!

In patients PRESENTING with fever

and bronchiolitis, the risk of

bacteremia and meningitis is low.

Onset of NEW fever

during hospitalization

in patients with bronchiolitis

can be indicative of a serious

bacterial infection.

Symptoms of Bronchiolitis:

(increased work of breathing,

cough, tachypnea, wheezing)

UTI should be considered in patients

who are persistently symptomatic

with fever or vomiting.

Signs of poor perfusion or

mental status changes or sepsis

score > 3?

Yes

Continue workup per Neonatal

22-28d or 29-60d

Fever (22-28d

29-60d) pathway

No

Consider UA/Culture in patients

who are persistently febrile or

vomiting

UA +

UA ¨C

OR

UA NOT INDICATED

Consider Blood CX

? PO Cephalexin

? Consider Ceftriaxone if

concern for PO

tolerance

Off Pathway

Admit to inpatient on UTI

and Bronchiolitis pathways

Last Updated: May 2023

Next Expected Review: November 2027

CONSIDER

BRONCHIOLITIS

PATHWAY

For questions concerning this pathway, contact:

NeonatalFever@

If you are a patient with questions contact your medical provider, Medical Disclaimer

? 2023 Seattle Children¡¯s Hospital, all rights reserved

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