Surface swabs polymerase chain reaction local protocol dependent
Serum alanine aminotransferase
Blood herpes simplex virus polymerase chain reaction local protocol dependent
Point of care tests
Bedside screening
Glucose
Venous or capillary blood gas if respiratory distress
Lactate and perfusion adjunct
Lactate in shock concern
Trend after resuscitation
Imaging
Scoring Systems
Febrile infant risk stratification tools
AAP febrile infant guideline 8 to 60 days framework
Rochester criteria
Philadelphia criteria
Boston criteria
Step by Step approach
PECARN febrile infant rule
Tool use boundaries
Well appearing only
Exclusions for prematurity and comorbidity common
Local protocol dependent implementation
MRI
Indications uncommon and targeted
Suspected spinal infection
Suspected intracranial complication with stable physiology
Limitations and cautions
Need for sedation in infants
Delay compared with time critical sepsis care
CT
Indications uncommon and targeted
Focal neurologic deficit with concern for hemorrhage
Concern for intracranial infection complication when urgent
Radiation and contrast cautions
Dose minimization principle
Contrast nephrotoxicity risk consideration
Ultrasound
Point of care and diagnostic ultrasound roles
Bladder volume assessment for catheterization planning
Soft tissue abscess evaluation
Intussusception evaluation when symptoms suggest
Renal and bladder ultrasound
Not acute sepsis rule out test
Outpatient follow up consideration after first febrile urinary tract infection local protocol dependent
Special Tests
Bedside procedures and microbiology
Urine collection technique
Catheterized specimen preferred for culture reliability
Bag specimen high contamination risk
Lumbar puncture
Indicated in all febrile infants age 0 to 21 days unless unstable
In age 22 to 28 days typical by protocol
In age 29 to 60 days based on risk markers and appearance
Blood culture technique
Cultures before antibiotics when feasible
Adequate volume improves yield
Respiratory viral testing
When useful
Bronchiolitis phenotype
Cohorting and infection control
Limitations
Positive viral test does not exclude urinary tract infection
Positive viral test does not exclude bacteremia in youngest infants
ECG
When indicated in febrile infant
Indications
Persistent tachycardia disproportionate to fever
Poor perfusion without clear cause
Concern for myocarditis
Electrolyte abnormality concern
High risk patterns
Heart block
Supraventricular tachycardia
Ventricular ectopy with instability
Assessment
Age based risk framing
Neonate age 0 to 28 days
High baseline risk of invasive bacterial infection
Full sepsis evaluation typical
Admission typical
Young infant age 29 to 60 days
Risk stratification using appearance and inflammatory markers
Urinary tract infection common serious bacterial infection source
Disposition depends on low risk criteria and follow up reliability
Infant age 61 to 90 days
Management more variable by local protocol
Urinary evaluation common default
Working diagnoses to prioritize
Fever without source in high risk age
Bacteremia and meningitis exclusion priority
Urinary tract infection evaluation priority
Viral syndrome with apnea risk
Bronchiolitis phenotype assessment
Co infection risk in younger infants
Plan
First 5 minutes
Stabilization priorities
Airway and breathing support if apnea or respiratory failure
Oxygen if hypoxemia
Cardiac and pulse oximetry monitoring
Temperature confirmation
Access and fluids
IV or IO access if ill appearance
Isotonic bolus 10 to 20 mL per kg if shock
Repeat bolus if persistent shock with reassessment
Diagnostic sequencing
Culture timing
Blood culture before antibiotics when feasible
Urine culture before antibiotics when feasible
Lumbar puncture timing
Before antibiotics when meningitis evaluation planned
Defer only if unstable then treat first
Empiric antimicrobials local protocol dependent
Neonate suspected sepsis age 0 to 28 days
Ampicillin IV
Typical dose 50 mg per kg per dose
Interval age dependent
Gentamicin IV
Typical dose 4 to 5 mg per kg per dose
Interval age dependent
If meningitis concern
Ampicillin IV higher dosing for meningitis
Cefotaxime IV preferred over ceftriaxone in neonate
Age 29 to 60 days well appearing with higher risk features
Ceftriaxone IV or IM
Typical dose 50 mg per kg once daily
Avoid in neonates and consider bilirubin risk
If meningitis concern
Ceftriaxone IV meningitis dosing per protocol
Add vancomycin IV per local resistance patterns if bacterial meningitis suspected
Herpes simplex virus concern
Acyclovir IV
Typical dose 20 mg per kg per dose every 8 hours
Renal dosing adjustment consideration
Fever control and comfort
Antipyretics
Acetaminophen 15 mg per kg per dose every 4 to 6 hours
Maximum daily dose per local pediatric guidance
Avoidance
Ibuprofen avoidance under 6 months
Aspirin avoidance in children
Reassessment loop
Frequency and targets
Reassess vitals within 30 to 60 minutes after interventions
Reassess perfusion after each bolus
Escalation triggers
Worsening work of breathing
Persistent poor perfusion
New apnea
Rising lactate or worsening acidosis
Disposition
Admission and level of care
ICU criteria
Shock requiring repeated boluses or vasoactive support
Apnea or impending respiratory failure
Persistent altered alertness
Inpatient admission criteria
Age 0 to 28 days with fever 38.0 C or higher
Positive urinalysis with systemic features in young infant
Abnormal inflammatory markers with bacteremia risk
Cerebrospinal fluid pleocytosis or positive gram stain
Social unreliability for close follow up
Observation and outpatient pathways local protocol dependent
Possible outpatient management age 29 to 60 days well appearing
Normal inflammatory markers by protocol
Negative urinalysis
No focal bacterial source requiring admission
Reliable caregivers and access to care
Follow up within 24 hours arranged
Return to ED timing
Any clinical worsening
Persistent fever beyond expected window
Culture callback plan
Discharge Instructions
Copy discharge instructions
Your baby was seen for fever
Fever in young babies can be a sign of a serious infection
Some babies can look well early even with infection
What we did today
Exam and vital signs assessment
Urine testing and cultures when indicated
Blood testing and cultures when indicated
Spinal fluid testing when indicated
Medicines
Use acetaminophen only if recommended
Do not use ibuprofen if your baby is under 6 months
Give antibiotics exactly as prescribed if provided
Feeding and hydration
Keep offering feeds frequently
Watch wet diapers
Come back to the emergency department now if any of these happen
Trouble breathing
Blue or very pale color
Hard to wake or unusually sleepy
Poor feeding or refuses feeds
Fewer wet diapers than usual
New rash with purple spots
Seizure
Persistent vomiting
Your baby looks or acts worse
Follow up
Follow up within 24 hours as arranged
We may call you with culture results
References
Guidelines and decision tools
Febrile infant guidance sources
American Academy of Pediatrics clinical practice guideline evaluation and management of well appearing febrile infants 8 to 60 days 2021
PECARN febrile infant rule publication and validation studies
Step by Step approach for febrile infants validation studies
Rochester criteria original and subsequent evaluations
Canadian Paediatric Society position statements on fever in young infants local protocol dependent
Project instructions source
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.