Pediatric Fever By Age 0 to 28 DaysAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

546 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Fever In The Neonate And Young Infant Pediatric Fever By Age 0 To 28 Days Pediatric Fever By Age 29 To 60 Days Pediatric Fever By Age 2 To 24 Months Pediatric Respiratory Distress Croup And Stridor In Children Pediatric Dehydration Pediatric Abdominal Pain Febrile Seizure Rash In The Child Poor Feeding And Lethargy In The Infant Vomiting In The Child Diarrhea In The Child Pediatric Trauma Evaluation Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Lethargy And Altered Mental Status In The Child

Environmental and Exposure4▾

01History/hx81

Context and fever definition

›Fever context

›Temperature source

›Fever threshold rectal temperature 38.0 C or higher

›Hypothermia threshold temperature lower than 36.0 C

›Method of measurement

›Antipyretic exposure before measurement

Onset

›Onset

›Time of first fever

›Sudden onset

›Gradual onset

›Perinatal onset within first 72 hours

Provocation and palliation

›Provocation and palliation

›Overbundling or hot environment

›Recent bath or heat exposure

›Response to acetaminophen

›Response to cooling measures

Quality

›Quality

›Measured fever

›Subjective fever

›Fever pattern intermittent

›Fever pattern persistent

Region and radiation

›Region and radiation

›Focal symptoms absent

›Focal symptoms present

›Localizing sites

›Respiratory

›Gastrointestinal

›Genitourinary

›Skin soft tissue

›Central nervous system

Severity

›Severity

›Peak temperature

›Duration of fever

›Ill appearance during fever

›Baseline appearance between fevers

Timing

›Timing

›Time course hours

›Time course days

›Day of life at presentation

›Sick contacts timing

Associated symptoms

›Associated symptoms

›Poor feeding

›Decreased urine output

›Vomiting

›Diarrhea

›Lethargy

›Irritability

›Apnea

›Respiratory distress

›Cough

›Rhinorrhea

›Rash

›Jaundice

›Seizure like activity

Baseline and prior episodes

›Baseline and prior episodes

›Prior fever episodes

›Baseline feeding pattern

›Baseline urine output pattern

›Baseline stool pattern

Birth and perinatal history

›Birth and perinatal history

›Gestational age at birth

›Delivery type

›Prolonged rupture of membranes

›Maternal intrapartum fever

›Chorioamnionitis

›Maternal group B streptococcus status

›Maternal peripartum antibiotics

›NICU stay

Maternal infection history

›Maternal infection history

›Maternal HSV history

›Active genital lesions at delivery

›Maternal HIV status

›Maternal syphilis status

›Maternal hepatitis B status

Exposures and social context

›Exposures and social context

›Sick contacts household

›Daycare exposure

›Recent travel

›Pets and animal exposure

›Tuberculosis exposure

›Caregiver reliability

02Alarm Features/alarm30

Immediate escalation triggers

›Escalation triggers

›Toxic appearance

›Poor perfusion

›Altered level of consciousness

›Apnea

›Cyanosis

›Persistent tachycardia with poor perfusion

›Hypotension

›Seizure

›Bulging fontanelle

Vital sign danger thresholds

›High risk vital patterns

›Fever rectal temperature 38.0 C or higher in age 0 to 28 days

›Hypothermia temperature lower than 36.0 C

›Persistent tachypnea

›Oxygen saturation below local threshold

High risk exam findings

›High risk exam findings

›Mottling

›Capillary refill prolonged

›Petechiae or purpura

›Omphalitis signs

›Focal neurologic findings

›Nuchal rigidity

›Dehydration moderate or severe

High risk historical triggers

›High risk historical triggers

›Prematurity

›Recent antibiotics

›NICU discharge within past 7 days

›Congenital heart disease

›Immunodeficiency suspected

›Maternal HSV lesions near delivery

03Medications/meds14

Current medications and exposures

›Medication history

›Prescribed medications

›OTC medications

›Acetaminophen exposure

›Recent antibiotics

›Recent antivirals

›Herbal or supplement exposure

Contraindications and high risk medications

›Medication risks

›Ceftriaxone avoidance in neonates local protocol dependent

›NSAID avoidance in young infants local protocol dependent

›Maternal medications via breastfeeding

Dosing reconciliation

›Dosing details

›Last dose time

›Dose per kg if known

04Diet/diet14

Feeding intake and tolerance

›Feeding pattern

›Breastfeeding

›Formula feeding

›Mixed feeding

›Decreased intake

›Vomiting after feeds

Hydration indicators

›Hydration indicators

›Wet diapers count trend

›Tears present

›Dry mucous membranes

Exposure related intake

›Exposure related intake

›Unpasteurized products in household

›Well water exposure

›Honey exposure

05Review of Systems/ros33

General

›General symptoms

›Lethargy

›Irritability

›Poor feeding

›Weight change

Respiratory

›Respiratory symptoms

›Cough

›Rhinorrhea

›Increased work of breathing

›Apnea

Cardiovascular

›Cardiovascular symptoms

›Cyanosis

›Poor perfusion episodes

›Sweating with feeds

Gastrointestinal

›Gastrointestinal symptoms

›Vomiting

›Bilious emesis

›Diarrhea

›Blood in stool

›Abdominal distension

Genitourinary

›Genitourinary symptoms

›Fewer wet diapers

›Foul smelling urine

Skin and soft tissue

›Skin findings

›Rash

›Vesicles

›Cellulitis

›Umbilical redness or drainage

Neurologic

›Neurologic symptoms

›Seizure like activity

›Abnormal tone

›High pitched cry

›Bulging fontanelle

06Collateral History and Family History/chafh16

Source and reliability

›Collateral source

›Primary caregiver report

›EMS report

›Prior chart review

Family history

›Family history

›Immunodeficiency in family

›Metabolic disorders in family

›Early infant deaths in family

Household exposures

›Household exposures

›Sick contacts

›Caregiver illness

›Tuberculosis contact

Social support and follow up

›Follow up reliability

›Transportation access

›Phone access

›Ability to return within 24 hours

07Risk Factors/rf23

Host factors

›Host risk factors

›Age 0 to 28 days

›Prematurity

›Low birth weight

›Congenital anomalies

›Central line or shunt

Perinatal infection risks

›Perinatal infection risks

›Prolonged rupture of membranes

›Maternal fever in labor

›Chorioamnionitis

›Maternal GBS positive or unknown without adequate prophylaxis

HSV risk factors

›HSV risk factors

›Vesicular rash

›Seizures

›Elevated transaminases

›Maternal primary HSV near delivery

Exposure risks

›Exposure risks

›Sick contacts

›Crowded living setting

›Travel exposure

UTI risk factors

›UTI risk factors

›Uncircumcised male

›Known urinary tract anomaly

08Differential Diagnosis/ddx54

Life threatening

›Life threatening causes

›Neonatal bacterial sepsis

›Poor feeding

›Hypothermia or fever

›Bacterial meningitis

›Bulging fontanelle

›Seizure

›HSV disseminated disease

›Vesicles

›Hepatitis

›HSV encephalitis

›Seizure

›Focal neurologic findings

›Pneumonia

›Hypoxemia

›Increased work of breathing

›Pyelonephritis

›Abnormal urinalysis

›No other source

›Necrotizing enterocolitis

›Abdominal distension

›Bloody stool

›Omphalitis

›Umbilical erythema

›Umbilical drainage

›Bacteremia with shock

›Poor perfusion

›Hypotension

Common

›Common causes

›Viral upper respiratory infection

›Rhinorrhea

›Sick contacts

›Bronchiolitis

›Wheeze

›Increased work of breathing

›Viral gastroenteritis

›Diarrhea

›Vomiting

›UTI cystitis

›Positive leukocyte esterase

›Positive nitrites

Less common

›Less common causes

›Congenital heart disease decompensation

›Cyanosis

›Poor feeding

›Inborn error of metabolism

›Lethargy

›Metabolic acidosis

›Adrenal crisis

›Hypoglycemia

›Hyperkalemia

›Drug fever

›Recent medication start

›No infectious signs

09Past Medical History/pmh20

Birth history details

›Birth history

›Gestational age

›Birth weight

›Apgar concerns

›Resuscitation at birth

Prior hospital care

›Prior care

›NICU admission

›Recent hospitalization

›Prior invasive procedures

Chronic conditions and devices

›Chronic conditions

›Congenital heart disease

›Chronic lung disease of prematurity

›Known urinary tract anomaly

›Neurologic disorder

›Implanted devices

›VP shunt

›Central venous catheter

Immunizations and prophylaxis

›Preventive care

›Vitamin D supplementation

›Hepatitis B vaccine status

10Physical Exam/exam56

General and vitals

›General assessment

›Appearance well

›Appearance ill

›Consolability

›Tone normal

›Tone abnormal

›Vitals pattern

›Fever confirmed rectal

›Hypothermia

›Tachycardia

›Tachypnea

Perfusion and hydration

›Perfusion and hydration

›Capillary refill

›Peripheral pulses

›Skin temperature

›Fontanelle sunken

›Mucous membranes dry

HEENT

›HEENT

›Fontanelle bulging

›Otitis signs

›Oral thrush

›Conjunctivitis

Respiratory

›Respiratory exam

›Work of breathing

›Grunting

›Retractions

›Auscultation crackles

›Auscultation wheeze

Cardiovascular

›Cardiovascular exam

›Murmur

›Gallop

›Hepatomegaly

›Differential pulses

Abdomen and GI

›Abdominal exam

›Distension

›Tenderness

›Mass

›Bowel sounds abnormal

Skin and soft tissue

›Skin and soft tissue

›Petechiae or purpura

›Vesicular lesions

›Cellulitis

›Omphalitis findings

Genitourinary

›Genitourinary exam

›Circumcision status

›Scrotal swelling

›Labial adhesions

Neurologic

›Neurologic exam

›Level of alertness

›Tone

›Reflexes

›Seizure activity

Musculoskeletal

›Musculoskeletal exam

›Pseudoparalysis

›Joint swelling

›Bone tenderness

11Lab Studies/labs45

Core serious bacterial infection evaluation

›Core studies

›Blood culture

›Obtain before antibiotics when feasible

›Time to positivity affects early decisions local protocol dependent

›CBC with differential

›ANC abnormal values raise risk local protocol dependent

›WBC extremes raise risk local protocol dependent

›CRP

›Elevated supports inflammation

›Early illness false negative risk

›Procalcitonin

›Elevated supports invasive bacterial infection risk stratification local protocol dependent

›Early illness false negative risk

Urine testing

›Urine studies

›Urinalysis catheter or suprapubic specimen

›Leukocyte esterase positive supports UTI

›Nitrites positive supports UTI

›Urine culture catheter or suprapubic specimen

›Obtain before antibiotics when feasible

›Bag specimen contamination risk

CSF testing

›CSF studies

›CSF cell count and differential

›CSF glucose and protein

›CSF Gram stain and culture

›CSF viral PCR local protocol dependent

Metabolic and organ dysfunction screening

›Additional labs

›Serum glucose

›Electrolytes

›Creatinine

›AST

›ALT

›Bilirubin

›Lactate local protocol dependent

Viral testing

›Viral studies

›Respiratory viral PCR local protocol dependent

›SARS CoV 2 testing local protocol dependent

›Influenza testing seasonal local protocol dependent

HSV testing when indicated

›HSV evaluation

›HSV PCR blood

›HSV PCR CSF

›HSV surface swabs local protocol dependent

Culture limitations and pitfalls

›Limitations

›Antibiotics before cultures reduce sensitivity

›Early lumbar puncture after antibiotics lowers yield

›Urinalysis can be negative early in UTI in neonates

12Imaging/img22

Scoring Systems

›Risk stratification tools

›AAP febrile infants guideline 8 to 60 days

›Not intended for age 0 to 7 days

›Apply to age 8 to 21 days and 22 to 28 days only if local protocol allows

›PECARN febrile infant rule

›Supports low risk identification in selected infants

›Age and lab criteria must match rule definitions

›Step by Step approach

›Requires inflammatory markers and urinalysis

›Not validated for ill appearing infants

MRI

›MRI considerations

›Rare indication in initial fever workup

›Consider for suspected CNS complication after stabilization

›Sedation risk in neonates

›CT considerations

›Avoid routine CT due to radiation

›Consider CT head only with focal neurologic deficit or trauma concern

›Contrast risk and renal function review

Ultrasound

›Ultrasound uses

›Renal bladder ultrasound after first febrile UTI local protocol dependent

›Pyloric ultrasound if vomiting suggests pyloric stenosis

›Soft tissue ultrasound for abscess if focal cellulitis

13Special Tests/spec14

Lumbar puncture details

›Lumbar puncture considerations

›Strongly favored in age 0 to 28 days with fever

›Defer only with instability then perform after stabilization

›Traumatic tap interpretation limitations

Bedside glucose and perfusion checks

›Bedside checks

›Point of care glucose

›Capillary refill reassessment

›Continuous pulse oximetry if respiratory signs

Respiratory assessment adjuncts

›Respiratory adjuncts

›Nasal suction response

›Work of breathing trend over time

Procedures for source control

›Source control procedures

›Umbilical culture if omphalitis suspected local protocol dependent

›Abscess drainage consultation if fluctuance

14ECG/ecg8

Indications in febrile neonate

›When ECG helps

›Persistent tachycardia out of proportion to fever

›Suspected myocarditis

›Electrolyte abnormality concern

High risk ECG patterns

›High risk patterns

›SVT narrow complex tachycardia

›Heart block

›ST T changes consistent with myocarditis local protocol dependent

15Assessment/ax21

Clinical syndrome framing

›Working problem list

›Fever in infant age 0 to 28 days high risk

›Fever without source

›Suspected serious bacterial infection

›Suspected viral syndrome with high risk age

Risk stratification by age

›Age based risk

›Age 0 to 7 days highest risk

›Age 8 to 21 days high risk

›Age 22 to 28 days high risk with selective pathways local protocol dependent

Complications to rule out

›Cannot miss complications

›Sepsis with shock

›Meningitis

›HSV disease

›Pneumonia with hypoxemia

›UTI with bacteremia

Supporting features summary

›Supporting features

›Ill appearance

›Abnormal perfusion

›Abnormal inflammatory markers

›Abnormal urinalysis

›CSF pleocytosis

16Plan/plan48

First 5 minutes stabilization

›Immediate actions

›Escalate to resuscitation area if ill appearance or perfusion abnormal

›Cardiorespiratory monitoring

›Temperature confirmation rectal

›IV access

›Intraosseous access if IV access delayed and unstable

›Oxygen if hypoxemia or respiratory distress

Diagnostic sequencing

›Diagnostic sequence

›Blood culture before antibiotics when feasible

›Urine catheter specimen for urinalysis and culture

›Lumbar puncture early unless unstable

›Inflammatory markers

›Viral testing if it changes isolation or cohorting local protocol dependent

Empiric antimicrobials

›Empiric antibiotics for age 0 to 28 days

›Ampicillin IV

›Typical dosing 50 mg per kg per dose local protocol dependent

›Interval based on postnatal age and renal function local protocol dependent

›Gentamicin IV

›Typical dosing 4 to 5 mg per kg per dose local protocol dependent

›Interval based on gestational age and renal function local protocol dependent

›Cefotaxime IV alternative local protocol dependent

›Consider if meningitis suspected or aminoglycoside avoidance needed

›Avoid ceftriaxone in neonates local protocol dependent

HSV coverage when indicated

›Empiric acyclovir triggers

›Vesicular rash

›Seizure

›Ill appearance without source

›Elevated AST or ALT

›Maternal primary HSV near delivery

›Acyclovir IV regimen

›Typical dosing 20 mg per kg every 8 hours local protocol dependent

›Renal dose adjustment required

Fluids and hemodynamics

›Shock management

›Isotonic fluid bolus 10 to 20 mL per kg if poor perfusion

›Reassess perfusion after each bolus

›Early vasoactive support if fluid refractory shock local protocol dependent

Temperature and comfort measures

›Antipyresis

›Acetaminophen dosing per kg local protocol dependent

›Avoid masking clinical deterioration

Reassessment loop

›Reassessment triggers

›Repeat vitals within 30 to 60 minutes

›Perfusion reassessment after fluids

›Mental status trend

›New focal findings

Consultation plan

›Consultations

›Pediatrics or neonatology

›Infectious diseases for HSV or unusual pathogens local protocol dependent

›ICU for shock or respiratory failure

17Disposition/dispo22

Level of care criteria

›ICU criteria

›Shock or vasoactive support

›Apnea or respiratory failure

›Seizure requiring escalation

›Inpatient admission criteria

›All infants age 0 to 28 days with fever typically admitted local protocol dependent

›Positive urinalysis pending culture

›Abnormal inflammatory markers

›CSF pleocytosis or abnormal CSF indices

Observation pathway criteria

›Observation pathway local protocol dependent

›Age 22 to 28 days well appearing

›Normal inflammatory markers

›Normal urinalysis

›Reliable follow up within 24 hours

Transfer criteria

›Transfer triggers

›Need for pediatric ICU unavailable on site

›Need for neonatal specialty care unavailable on site

Discharge criteria

›Discharge rare and protocol dependent

›Age 22 to 28 days only in select pathways

›All studies low risk per local protocol

›Caregiver reliability high

›Clear return precautions and follow up arranged

18Discharge Instructions/di10

Copy discharge instructions

›Fever in a newborn can be a sign of a serious infection even if your baby looks well

›If your baby has a temperature 38.0 C or higher measured rectally return to the emergency department immediately

›If your baby is hard to wake return immediately

›If your baby is feeding poorly return immediately

›If your baby has fewer wet diapers than usual return immediately

›If your baby has trouble breathing return immediately

›If your baby turns blue or has pauses in breathing return immediately

›If your baby develops a new rash especially purple spots return immediately

›Do not give any new medications unless instructed by a clinician

›Follow up timing within 24 hours if discharged under a pathway

19References/r15

Guidelines and landmark sources

›American Academy of Pediatrics Clinical Practice Guideline Evaluation and Management of Well Appearing Febrile Infants 8 to 60 Days Old 2021

›Age range does not include 0 to 7 days

›Local protocol required for 8 to 28 day application

›National Institute for Health and Care Excellence Fever in under 5s assessment and initial management latest update local protocol dependent

›High risk group includes infants younger than 3 months with fever

›Recommends urgent assessment and investigation in young infants

›Canadian Paediatric Society Position Statements on fever in young infants and serious bacterial infection pathways local protocol dependent

›Canadian context for testing and admission practices

›Emphasizes low threshold for full evaluation in neonates

›Infectious Diseases Society of America guidance on management of neonatal HSV local protocol dependent

›Supports early empiric acyclovir when clinical risk factors present

›Emphasizes CSF and blood PCR testing

›PECARN febrile infant prediction rule original validation study

›Requires specific lab inputs

›Must match inclusion criteria for safe use

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Pediatric Fever By Age 0 to 28 DaysAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

546 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx81

Context and fever definition

›Fever context

›Temperature source

›Fever threshold rectal temperature 38.0 C or higher

›Hypothermia threshold temperature lower than 36.0 C

›Method of measurement

›Antipyretic exposure before measurement

Onset

›Onset

›Time of first fever

›Sudden onset

›Gradual onset

›Perinatal onset within first 72 hours

Provocation and palliation

›Provocation and palliation

›Overbundling or hot environment

›Recent bath or heat exposure

›Response to acetaminophen

›Response to cooling measures

Quality

›Quality

›Measured fever

›Subjective fever

›Fever pattern intermittent

›Fever pattern persistent

Region and radiation

›Region and radiation

›Focal symptoms absent

›Focal symptoms present

›Localizing sites

›Respiratory

›Gastrointestinal

›Genitourinary

›Skin soft tissue

›Central nervous system

Severity

›Severity

›Peak temperature

›Duration of fever

›Ill appearance during fever

›Baseline appearance between fevers

Timing

›Timing

›Time course hours

›Time course days

›Day of life at presentation

›Sick contacts timing

Associated symptoms

›Associated symptoms

›Poor feeding

›Decreased urine output

›Vomiting

›Diarrhea

›Lethargy

›Irritability

›Apnea

›Respiratory distress

›Cough

›Rhinorrhea

›Rash

›Jaundice

›Seizure like activity

Baseline and prior episodes

›Baseline and prior episodes

›Prior fever episodes

›Baseline feeding pattern

›Baseline urine output pattern

›Baseline stool pattern

Birth and perinatal history

›Birth and perinatal history

›Gestational age at birth

›Delivery type

›Prolonged rupture of membranes

›Maternal intrapartum fever

›Chorioamnionitis

›Maternal group B streptococcus status

›Maternal peripartum antibiotics

›NICU stay

Maternal infection history

›Maternal infection history

›Maternal HSV history

›Active genital lesions at delivery

›Maternal HIV status

›Maternal syphilis status

›Maternal hepatitis B status

Exposures and social context

›Exposures and social context

›Sick contacts household

›Daycare exposure

›Recent travel

›Pets and animal exposure

›Tuberculosis exposure

›Caregiver reliability

02Alarm Features/alarm30

Immediate escalation triggers

›Escalation triggers

›Toxic appearance

›Poor perfusion

›Altered level of consciousness

›Apnea

›Cyanosis

›Persistent tachycardia with poor perfusion

›Hypotension

›Seizure

›Bulging fontanelle

Vital sign danger thresholds

›High risk vital patterns

›Fever rectal temperature 38.0 C or higher in age 0 to 28 days

›Hypothermia temperature lower than 36.0 C

›Persistent tachypnea

›Oxygen saturation below local threshold

High risk exam findings

›High risk exam findings

›Mottling

›Capillary refill prolonged

›Petechiae or purpura

›Omphalitis signs

›Focal neurologic findings

›Nuchal rigidity

›Dehydration moderate or severe

High risk historical triggers

›High risk historical triggers

›Prematurity

›Recent antibiotics

›NICU discharge within past 7 days

›Congenital heart disease

›Immunodeficiency suspected

›Maternal HSV lesions near delivery

03Medications/meds14

Current medications and exposures

›Medication history

›Prescribed medications

›OTC medications

›Acetaminophen exposure

›Recent antibiotics

›Recent antivirals

›Herbal or supplement exposure

Contraindications and high risk medications

›Medication risks

›Ceftriaxone avoidance in neonates local protocol dependent

›NSAID avoidance in young infants local protocol dependent

›Maternal medications via breastfeeding

Dosing reconciliation

›Dosing details

›Last dose time

›Dose per kg if known

04Diet/diet14

Feeding intake and tolerance

›Feeding pattern

›Breastfeeding

›Formula feeding

›Mixed feeding

›Decreased intake

›Vomiting after feeds

Hydration indicators

›Hydration indicators

›Wet diapers count trend

›Tears present

›Dry mucous membranes

Exposure related intake

›Exposure related intake

›Unpasteurized products in household

›Well water exposure

›Honey exposure

05Review of Systems/ros33

General

›General symptoms

›Lethargy

›Irritability

›Poor feeding

›Weight change

Respiratory

›Respiratory symptoms

›Cough

›Rhinorrhea

›Increased work of breathing

›Apnea

Cardiovascular

›Cardiovascular symptoms

›Cyanosis

›Poor perfusion episodes

›Sweating with feeds

Gastrointestinal

›Gastrointestinal symptoms

›Vomiting

›Bilious emesis

›Diarrhea

›Blood in stool

›Abdominal distension

Genitourinary

›Genitourinary symptoms

›Fewer wet diapers

›Foul smelling urine

Skin and soft tissue

›Skin findings

›Rash

›Vesicles

›Cellulitis

›Umbilical redness or drainage

Neurologic

›Neurologic symptoms

›Seizure like activity

›Abnormal tone

›High pitched cry

›Bulging fontanelle

06Collateral History and Family History/chafh16

Source and reliability

›Collateral source

›Primary caregiver report

›EMS report

›Prior chart review

Family history

›Family history

›Immunodeficiency in family

›Metabolic disorders in family

›Early infant deaths in family

Household exposures

›Household exposures

›Sick contacts

›Caregiver illness

›Tuberculosis contact

Social support and follow up

›Follow up reliability

›Transportation access

›Phone access

›Ability to return within 24 hours

07Risk Factors/rf23

Host factors

›Host risk factors

›Age 0 to 28 days

›Prematurity

›Low birth weight

›Congenital anomalies

›Central line or shunt

Perinatal infection risks

›Perinatal infection risks

›Prolonged rupture of membranes

›Maternal fever in labor

›Chorioamnionitis

›Maternal GBS positive or unknown without adequate prophylaxis

HSV risk factors

›HSV risk factors

›Vesicular rash

›Seizures

›Elevated transaminases

›Maternal primary HSV near delivery

Exposure risks

›Exposure risks

›Sick contacts

›Crowded living setting

›Travel exposure

UTI risk factors

›UTI risk factors

›Uncircumcised male

›Known urinary tract anomaly

08Differential Diagnosis/ddx54

Life threatening

›Life threatening causes

›Neonatal bacterial sepsis

›Poor feeding

›Hypothermia or fever

›Bacterial meningitis

›Bulging fontanelle

›Seizure

›HSV disseminated disease

›Vesicles

›Hepatitis

›HSV encephalitis

›Seizure

›Focal neurologic findings

›Pneumonia

›Hypoxemia

›Increased work of breathing

›Pyelonephritis

›Abnormal urinalysis

›No other source

›Necrotizing enterocolitis

›Abdominal distension

›Bloody stool

›Omphalitis

›Umbilical erythema

›Umbilical drainage

›Bacteremia with shock

›Poor perfusion

›Hypotension

Common

›Common causes

›Viral upper respiratory infection

›Rhinorrhea

›Sick contacts

›Bronchiolitis

›Wheeze

›Increased work of breathing

›Viral gastroenteritis

›Diarrhea

›Vomiting

›UTI cystitis

›Positive leukocyte esterase

›Positive nitrites

Less common

›Less common causes

›Congenital heart disease decompensation

›Cyanosis

›Poor feeding

›Inborn error of metabolism

›Lethargy

›Metabolic acidosis

›Adrenal crisis

›Hypoglycemia

›Hyperkalemia

›Drug fever

›Recent medication start

›No infectious signs

09Past Medical History/pmh20

Birth history details

›Birth history

›Gestational age

›Birth weight

›Apgar concerns

›Resuscitation at birth

Prior hospital care

›Prior care

›NICU admission

›Recent hospitalization

›Prior invasive procedures

Chronic conditions and devices

›Chronic conditions

›Congenital heart disease

›Chronic lung disease of prematurity

›Known urinary tract anomaly

›Neurologic disorder

›Implanted devices

›VP shunt

›Central venous catheter

Immunizations and prophylaxis

›Preventive care

›Vitamin D supplementation

›Hepatitis B vaccine status

10Physical Exam/exam56

General and vitals

›General assessment

›Appearance well

›Appearance ill

›Consolability

›Tone normal

›Tone abnormal

›Vitals pattern

›Fever confirmed rectal

›Hypothermia

›Tachycardia

›Tachypnea

Perfusion and hydration

›Perfusion and hydration

›Capillary refill

›Peripheral pulses

›Skin temperature

›Fontanelle sunken

›Mucous membranes dry

HEENT

›HEENT

›Fontanelle bulging

›Otitis signs

›Oral thrush

›Conjunctivitis

Respiratory

›Respiratory exam

›Work of breathing

›Grunting

›Retractions

›Auscultation crackles

›Auscultation wheeze

Cardiovascular

›Cardiovascular exam

›Murmur

›Gallop

›Hepatomegaly

›Differential pulses

Abdomen and GI

›Abdominal exam

›Distension

›Tenderness

›Mass

›Bowel sounds abnormal

Skin and soft tissue

›Skin and soft tissue

›Petechiae or purpura

›Vesicular lesions

›Cellulitis

›Omphalitis findings

Genitourinary

›Genitourinary exam

›Circumcision status

›Scrotal swelling

›Labial adhesions

Neurologic

›Neurologic exam

›Level of alertness

›Tone

›Reflexes

›Seizure activity

Musculoskeletal

›Musculoskeletal exam

›Pseudoparalysis

›Joint swelling

›Bone tenderness

11Lab Studies/labs45

Core serious bacterial infection evaluation

›Core studies

›Blood culture

›Obtain before antibiotics when feasible

›Time to positivity affects early decisions local protocol dependent

›CBC with differential

›ANC abnormal values raise risk local protocol dependent

›WBC extremes raise risk local protocol dependent

›CRP

›Elevated supports inflammation

›Early illness false negative risk

›Procalcitonin

›Elevated supports invasive bacterial infection risk stratification local protocol dependent

›Early illness false negative risk

Urine testing

›Urine studies

›Urinalysis catheter or suprapubic specimen

›Leukocyte esterase positive supports UTI

›Nitrites positive supports UTI

›Urine culture catheter or suprapubic specimen

›Obtain before antibiotics when feasible

›Bag specimen contamination risk

CSF testing

›CSF studies

›CSF cell count and differential

›CSF glucose and protein

›CSF Gram stain and culture

›CSF viral PCR local protocol dependent

Metabolic and organ dysfunction screening

›Additional labs

›Serum glucose

›Electrolytes

›Creatinine

›AST

›ALT

›Bilirubin

›Lactate local protocol dependent

Viral testing

›Viral studies

›Respiratory viral PCR local protocol dependent

›SARS CoV 2 testing local protocol dependent

›Influenza testing seasonal local protocol dependent

HSV testing when indicated

›HSV evaluation

›HSV PCR blood

›HSV PCR CSF

›HSV surface swabs local protocol dependent

Culture limitations and pitfalls

›Limitations

›Antibiotics before cultures reduce sensitivity

›Early lumbar puncture after antibiotics lowers yield

›Urinalysis can be negative early in UTI in neonates

12Imaging/img22

Scoring Systems

›Risk stratification tools

›AAP febrile infants guideline 8 to 60 days

›Not intended for age 0 to 7 days

›Apply to age 8 to 21 days and 22 to 28 days only if local protocol allows

›PECARN febrile infant rule

›Supports low risk identification in selected infants

›Age and lab criteria must match rule definitions

›Step by Step approach

›Requires inflammatory markers and urinalysis

›Not validated for ill appearing infants

MRI

›MRI considerations

›Rare indication in initial fever workup

›Consider for suspected CNS complication after stabilization

›Sedation risk in neonates

›CT considerations

›Avoid routine CT due to radiation

›Consider CT head only with focal neurologic deficit or trauma concern

›Contrast risk and renal function review

Ultrasound

›Ultrasound uses

›Renal bladder ultrasound after first febrile UTI local protocol dependent

›Pyloric ultrasound if vomiting suggests pyloric stenosis

›Soft tissue ultrasound for abscess if focal cellulitis

13Special Tests/spec14

Lumbar puncture details

›Lumbar puncture considerations

›Strongly favored in age 0 to 28 days with fever

›Defer only with instability then perform after stabilization

›Traumatic tap interpretation limitations

Bedside glucose and perfusion checks

›Bedside checks

›Point of care glucose

›Capillary refill reassessment

›Continuous pulse oximetry if respiratory signs

Respiratory assessment adjuncts

›Respiratory adjuncts

›Nasal suction response

›Work of breathing trend over time

Procedures for source control

›Source control procedures

›Umbilical culture if omphalitis suspected local protocol dependent

›Abscess drainage consultation if fluctuance

14ECG/ecg8

Indications in febrile neonate

›When ECG helps

›Persistent tachycardia out of proportion to fever

›Suspected myocarditis

›Electrolyte abnormality concern

High risk ECG patterns

›High risk patterns

›SVT narrow complex tachycardia

›Heart block

›ST T changes consistent with myocarditis local protocol dependent

15Assessment/ax21

Clinical syndrome framing

›Working problem list

›Fever in infant age 0 to 28 days high risk

›Fever without source

›Suspected serious bacterial infection

›Suspected viral syndrome with high risk age

Risk stratification by age

›Age based risk

›Age 0 to 7 days highest risk

›Age 8 to 21 days high risk

›Age 22 to 28 days high risk with selective pathways local protocol dependent

Complications to rule out

›Cannot miss complications

›Sepsis with shock

›Meningitis

›HSV disease

›Pneumonia with hypoxemia

›UTI with bacteremia

Supporting features summary

›Supporting features

›Ill appearance

›Abnormal perfusion

›Abnormal inflammatory markers

›Abnormal urinalysis

›CSF pleocytosis

16Plan/plan48

First 5 minutes stabilization

›Immediate actions

›Escalate to resuscitation area if ill appearance or perfusion abnormal

›Cardiorespiratory monitoring

›Temperature confirmation rectal

›IV access

›Intraosseous access if IV access delayed and unstable

›Oxygen if hypoxemia or respiratory distress

Diagnostic sequencing

›Diagnostic sequence

›Blood culture before antibiotics when feasible

›Urine catheter specimen for urinalysis and culture

›Lumbar puncture early unless unstable

›Inflammatory markers

›Viral testing if it changes isolation or cohorting local protocol dependent

Empiric antimicrobials

›Empiric antibiotics for age 0 to 28 days

›Ampicillin IV

›Typical dosing 50 mg per kg per dose local protocol dependent

›Interval based on postnatal age and renal function local protocol dependent

›Gentamicin IV

›Typical dosing 4 to 5 mg per kg per dose local protocol dependent

›Interval based on gestational age and renal function local protocol dependent

›Cefotaxime IV alternative local protocol dependent

›Consider if meningitis suspected or aminoglycoside avoidance needed

›Avoid ceftriaxone in neonates local protocol dependent

HSV coverage when indicated

›Empiric acyclovir triggers

›Vesicular rash

›Seizure

›Ill appearance without source

›Elevated AST or ALT

›Maternal primary HSV near delivery

›Acyclovir IV regimen

›Typical dosing 20 mg per kg every 8 hours local protocol dependent

›Renal dose adjustment required

Fluids and hemodynamics

›Shock management

›Isotonic fluid bolus 10 to 20 mL per kg if poor perfusion

›Reassess perfusion after each bolus

›Early vasoactive support if fluid refractory shock local protocol dependent

Temperature and comfort measures

›Antipyresis

›Acetaminophen dosing per kg local protocol dependent

›Avoid masking clinical deterioration

Reassessment loop

›Reassessment triggers

›Repeat vitals within 30 to 60 minutes

›Perfusion reassessment after fluids

›Mental status trend

›New focal findings

Consultation plan

›Consultations

›Pediatrics or neonatology

›Infectious diseases for HSV or unusual pathogens local protocol dependent

›ICU for shock or respiratory failure

17Disposition/dispo22

Level of care criteria

›ICU criteria

›Shock or vasoactive support

›Apnea or respiratory failure

›Seizure requiring escalation

›Inpatient admission criteria

›All infants age 0 to 28 days with fever typically admitted local protocol dependent

›Positive urinalysis pending culture

›Abnormal inflammatory markers

›CSF pleocytosis or abnormal CSF indices

Observation pathway criteria

›Observation pathway local protocol dependent

›Age 22 to 28 days well appearing

›Normal inflammatory markers

›Normal urinalysis

›Reliable follow up within 24 hours

Transfer criteria

›Transfer triggers

›Need for pediatric ICU unavailable on site

›Need for neonatal specialty care unavailable on site

Discharge criteria

›Discharge rare and protocol dependent

›Age 22 to 28 days only in select pathways

›All studies low risk per local protocol

›Caregiver reliability high

›Clear return precautions and follow up arranged

18Discharge Instructions/di10

Copy discharge instructions

›Fever in a newborn can be a sign of a serious infection even if your baby looks well

›If your baby has a temperature 38.0 C or higher measured rectally return to the emergency department immediately

›If your baby is hard to wake return immediately

›If your baby is feeding poorly return immediately

›If your baby has fewer wet diapers than usual return immediately

›If your baby has trouble breathing return immediately

›If your baby turns blue or has pauses in breathing return immediately

›If your baby develops a new rash especially purple spots return immediately

›Do not give any new medications unless instructed by a clinician

›Follow up timing within 24 hours if discharged under a pathway

19References/r15

Guidelines and landmark sources

›American Academy of Pediatrics Clinical Practice Guideline Evaluation and Management of Well Appearing Febrile Infants 8 to 60 Days Old 2021

›Age range does not include 0 to 7 days

›Local protocol required for 8 to 28 day application

›National Institute for Health and Care Excellence Fever in under 5s assessment and initial management latest update local protocol dependent

›High risk group includes infants younger than 3 months with fever

›Recommends urgent assessment and investigation in young infants

›Canadian Paediatric Society Position Statements on fever in young infants and serious bacterial infection pathways local protocol dependent

›Canadian context for testing and admission practices

›Emphasizes low threshold for full evaluation in neonates

›Infectious Diseases Society of America guidance on management of neonatal HSV local protocol dependent

›Supports early empiric acyclovir when clinical risk factors present

›Emphasizes CSF and blood PCR testing

›PECARN febrile infant prediction rule original validation study

›Requires specific lab inputs

›Must match inclusion criteria for safe use

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.