Browse categories and answer follow-up questions to refine your symptom profile.
History
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
Alarm Features
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
Medications
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
Diet
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
Review of Systems
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
Collateral History and Family History
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
Risk Factors
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
Differential Diagnosis
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
Past Medical History
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
Physical Exam
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
Lab Studies
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
Imaging
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
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
Special Tests
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
ECG
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
Assessment
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
Plan
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.