Poor Feeding and Lethargy In The InfantAPPROACH

PEDIATRICS · 19 SECTIONS

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743 items

☷ Legend

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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/hx87

Presenting concern and timeline

›Symptom characterization

›Poor feeding pattern

›Breastfeeding

›Formula feeding

›Mixed feeding

›Intake change

›Reduced volume per feed

›Reduced frequency

›Refusal to latch

›Lethargy description

›Decreased responsiveness

›Hard to arouse

›Less interactive than baseline

›Baseline comparison

›Normal feeding amount and frequency

›Normal wakefulness and tone

OPQRST

›OPQRST framework

›Onset

›Time of first noted poor feeding

›Time of first noted lethargy

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with feeding attempts

›Improvement after antipyretic

›Improvement after suctioning

›Improvement after glucose

›Quality

›Weak suck

›Fatigues quickly

›Sleepy at breast or bottle

›Disorganized feeding

›Region and radiation

›Not applicable for primary symptoms

›Associated focal pain signals

›Ear tugging

›Abdominal guarding

›Severity

›Percent of usual intake

›Number of feeds in last 24 hours

›Number of wet diapers in last 24 hours

›Timing

›Progressive

›Episodic

›Post feed worsening

›Diurnal pattern

Associated symptoms

›Symptom clusters

›Fever or hypothermia

›Measured temperature history

›Home antipyretic exposure

›Respiratory symptoms

›Cough

›Congestion

›Increased work of breathing

›Gastrointestinal symptoms

›Vomiting

›Bilious emesis

›Diarrhea

›Abdominal distension

›Genitourinary symptoms

›Fewer wet diapers

›Foul smelling urine

›Hematuria

›Neurologic symptoms

›Apnea

›Seizure like activity

›Abnormal movements

›Skin and mucosa

›Rash

›Jaundice

›Oral thrush

Birth and perinatal history

›Perinatal risk context

›Gestational age

›Term

›Late preterm

›Preterm

›Delivery history

›Vaginal

›Cesarean

›Maternal infection risk

›Group B streptococcus status

›Prolonged rupture of membranes

›Intrapartum fever

›Neonatal course

›NICU stay

›Jaundice treatment

›Prior antibiotics

02Alarm Features/alarm55

Approach to the critical infant

›First 5 minutes priorities

›Immediate escalation triggers

›Apnea

›Cyanosis

›Persistent altered level of consciousness

›Poor perfusion

›Monitoring

›Continuous pulse oximetry

›Cardiorespiratory monitoring

›Temperature measurement

›Access

›IV access

›IO access if IV delayed and unstable

›Glucose

›Point of care glucose within minutes of arrival

›If glucose less than 3.0 mmol per L then dextrose immediately

›Oxygen and ventilation

›If SpO2 less than 92 percent then oxygen

›If apnea or inadequate ventilation then bag valve mask ventilation

›Shock pathway

›If delayed capillary refill or weak pulses then fluid bolus

›If hypotension or persistent poor perfusion after bolus then vasopressor pathway

High risk history features

›Red flag history

›Age based risk

›Less than 28 days

›Less than 3 months

›Feeding red flags

›No oral intake for 8 hours

›Repeated vomiting with poor intake

›Infection red flags

›Fever history

›Hypothermia history

›Neurologic red flags

›Seizure

›Apnea

›Bulging fontanelle history

›GI surgical red flags

›Bilious emesis

›Bloody stool

›Cardiac red flags

›Sweating with feeds

›Cyanosis with feeds

Vital sign danger thresholds

›Vital danger patterns

›Temperature extremes

›Fever in young infant local protocol dependent

›Hypothermia

›Respiratory danger

›Apnea

›Marked tachypnea with retractions

›Perfusion danger

›Capillary refill greater than 3 seconds

›Cool mottled extremities

›Circulation danger

›Persistent tachycardia despite calming and normothermia

›Bradycardia with lethargy

03Medications/meds30

Current and recent exposures

›Medication and substance exposure

›Infant prescribed medications

›Antibiotics

›Reflux medications

›OTC exposure

›Acetaminophen

›Ibuprofen

›Vitamins and supplements

›Vitamin D

›Herbal products

›Maternal medications

›Opioids

›Sedatives

›SSRI

›Toxic exposure risk

›Ingestion possibility in home

›Topical products

›Medication changes

›New medication within 7 days

›Missed doses

Medication considerations for likely therapies

›Contraindications and cautions

›Ceftriaxone cautions

›Neonate or young infant local protocol dependent

›Hyperbilirubinemia risk

›Acyclovir renal risk

›Need hydration

›Need renal dosing adjustment

›Fluid bolus cautions

›Known congenital heart disease

›Signs of pulmonary edema

04Diet/diet29

Feeding and hydration pattern

›Intake and output pattern

›Feeding type

›Breast milk

›Formula

›Feeding volume and frequency

›Usual pattern

›Current pattern

›Hydration indicators

›Wet diapers count in last 24 hours

›Tears when crying

›Emesis pattern

›Non bilious

›Bilious

›Stool pattern

›Diarrhea

›Constipation

›Weight trend

›Recent weights if available

›Failure to thrive concern

Exposure and preparation risks

›Feeding safety risks

›Formula preparation

›Mixing technique

›Water source

›Honey exposure

›Infant botulism risk

›Age less than 12 months risk

›Sick contact feeding changes

›Decreased intake during viral illness

›Increased work of breathing affecting intake

05Review of Systems/ros35

System based symptoms

›ROS clusters

›Constitutional

›Fever

›Hypothermia

›Respiratory

›Cough

›Congestion

›Cardiovascular

›Cyanosis

›Sweating with feeds

›Gastrointestinal

›Vomiting

›Bilious emesis

›Genitourinary

›Decreased urine output

›Malodorous urine

›Neurologic

›Lethargy

›Seizure like activity

›Dermatologic

›Rash

›Vesicles

›HEENT

›Poor latch due to nasal obstruction

›Oral lesions

Pertinent negatives that change management

›High value negatives

›No bilious emesis

›Lowers concern for malrotation with volvulus

›Does not exclude early obstruction

›No apnea

›Lowers immediate airway risk

›Does not exclude evolving sepsis

›No rash or vesicles

›Lowers HSV suspicion

›Does not exclude HSV without skin lesions

06Collateral History and Family History/chafh23

Collateral source and reliability

›Source context

›Primary caregiver report

›Reliability concerns

›Language barrier

›EMS report

›Home scene concerns

›Observed feeding or mentation

›Prior records

›Recent ED visit

›Recent hospitalization

Family and household context

›Familial and exposure risks

›Household sick contacts

›Respiratory viral illness

›Gastroenteritis

›Family history inherited disease

›Inborn errors of metabolism

›Congenital heart disease

›Sudden infant death history

›Prior SIDS in family

›Unsafe sleep environment

›Care environment safety

›Supervision reliability

›Substance use in household

07Risk Factors/rf29

Patient specific high risk factors

›High risk host factors

›Age based risk

›Less than 28 days

›Less than 90 days

›Prematurity

›Gestational age less than 37 weeks

›Chronic lung disease of prematurity

›Congenital heart disease

›Ductal dependent lesion risk

›Heart failure risk

›Immunization status

›Not yet immunized

›Under immunized

›Central lines or devices

›Ventriculoperitoneal shunt

›Central venous catheter

Exposure related risks

›Infection and toxin exposures

›Maternal HSV risk

›Genital lesions at delivery

›Primary infection late pregnancy

›Maternal GBS risk

›Positive and untreated

›Unknown status

›Environmental temperature risk

›Under dressing

›Over bundling

›Toxin access

›Caregiver medications

›Carbon monoxide exposure

08Differential Diagnosis/ddx69

Life threatening

›Cannot miss diagnoses

›Sepsis or septic shock (A41.9 R57.2)

›Poor perfusion

›Temperature instability

›Meningitis or encephalitis (G00.9 G04.90)

›Bulging fontanelle

›Seizure

›Neonatal HSV infection (B00.9)

›Vesicular rash

›Transaminitis

›Hypoglycemia (E16.2)

›Lethargy

›Seizure

›Congenital heart disease with ductal dependence (Q24.9)

›Cyanosis

›Shock after first days of life

›Arrhythmia (I49.9)

›Persistent tachycardia

›Poor feeding with pallor

›Inborn error of metabolism (E88.9)

›Metabolic acidosis

›Hyperammonemia

›Adrenal crisis congenital adrenal hyperplasia (E25.0)

›Hyperkalemia

›Hyponatremia

›Malrotation with volvulus (K56.2)

›Bilious vomiting

›Rapid deterioration

›Intussusception (K56.1)

›Episodic lethargy

›Bloody stool

›Non accidental trauma (T74.12)

›Bruising in non mobile infant

›Incongruent history

Common

›Common etiologies

›Viral bronchiolitis (J21.9)

›Increased work of breathing

›Poor feeding due to tachypnea

›Viral upper respiratory infection (J06.9)

›Congestion affecting feeding

›Mild fever

›Urinary tract infection (N39.0)

›Fever without source

›Poor feeding

›Acute gastroenteritis (A09)

›Vomiting

›Diarrhea

›Dehydration (E86.0)

›Reduced wet diapers

›Dry mucous membranes

›Otitis media (H66.90)

›Ear tugging

›Irritability

Less common

›Less common and mimics

›Pyloric stenosis (K31.1)

›Progressive non bilious vomiting

›Weight loss

›Hyperbilirubinemia (E80.6)

›Jaundice

›Poor feeding

›Congenital hypothyroidism (E03.1)

›Prolonged jaundice

›Constipation

›Anemia (D64.9)

›Pallor

›Tachycardia

›Infant botulism (A48.51)

›Hypotonia

›Weak cry

09Past Medical History/pmh26

Baseline health and prior episodes

›Baseline risk anchors

›Prior similar episodes

›Prior ED visits

›Prior admissions

›Birth history complications

›Resuscitation at birth

›NICU course

›Screening results

›Newborn metabolic screen results if known

›Hearing screen results if relevant

›Immunizations

›Up to date for age

›Delayed schedule

›Known conditions

›Congenital heart disease

›Chronic lung disease

Procedures and devices

›Device and procedure history

›Prior surgery

›GI surgery

›Cardiac surgery

›Indwelling devices

›VP shunt

›Central line

›Recent procedures

›Circumcision complications

›Recent catheterization

10Physical Exam/exam92

General and vital sign interpretation

›Initial impression and stability

›Appearance

›Toxic appearance

›Non toxic appearance

›Mental status

›Alert

›Lethargic

›Hydration

›Moist mucous membranes

›Sunken fontanelle

›Perfusion

›Capillary refill time

›Extremity temperature

HEENT and neck

›HEENT findings

›Fontanelle

›Flat

›Bulging

›Oral cavity

›Thrush

›Mucosal hydration

›Tympanic membranes

›Erythema

›Effusion

›Neck

›Stiffness

›Lymphadenopathy

Respiratory

›Respiratory status

›Work of breathing

›Retractions

›Nasal flaring

›Breath sounds

›Wheeze

›Crackles

›Apnea events

›Observed in ED

›Reported at home

Cardiovascular

›Cardiac and perfusion

›Heart rate pattern

›Persistent tachycardia

›Bradycardia

›Pulses

›Femoral pulses

›Pulse symmetry

›Murmur

›New murmur

›Known murmur

›Hepatomegaly

›Heart failure clue

›Sepsis clue

Abdomen and GI

›Abdominal exam

›Distension

›Present

›Absent

›Tenderness

›Focal

›Diffuse

›Bowel sounds

›Hyperactive

›Decreased

›Emesis features

›Bilious

›Non bilious

Genitourinary

›GU findings

›Diaper output

›Wet diaper in ED

›No wet diaper

›Genital exam

›Hernia

›Torsion signs

›Hydration related

›Sunken eyes

›Dry lips

Skin

›Skin and perfusion clues

›Rash pattern

›Petechiae or purpura

›Vesicles

›Color

›Pallor

›Cyanosis

›Bruising

›Bruises in non mobile infant

›Patterned bruising

Neurologic and tone

›Neuro status

›Tone

›Hypotonia

›Hypertonia

›Cry

›Weak cry

›High pitched cry

›Seizure signs

›Abnormal eye deviation

›Lip smacking

11Lab Studies/labs58

Point of care tests

›Immediate bedside labs

›Glucose

›Hypoglycemia threshold less than 3.0 mmol per L

›Hyperglycemia stress response

›Blood gas

›Metabolic acidosis pattern

›Respiratory failure pattern

›Lactate

›Elevated suggests hypoperfusion

›Normal does not exclude sepsis

Sepsis and serious bacterial infection workup

›Infection evaluation labs

›CBC with differential

›Neutropenia risk

›Left shift

›CRP

›Trend value with repeat

›Early normal possible

›Procalcitonin

›Bacterial infection enrichment

›Viral overlap possible

›Blood culture

›Before antibiotics if feasible

›Contamination risk

›Urinalysis and urine culture catheter specimen

›Positive leukocyte esterase

›Nitrites may be negative in young infants

›CSF studies if indicated

›Cell count and differential

›Culture and PCR local protocol dependent

Metabolic and endocrine evaluation

›Metabolic and endocrine labs

›Electrolytes and renal function

›Hyponatremia

›Hyperkalemia

›Ketones and beta hydroxybutyrate

›Starvation ketosis

›Ketosis plus acidosis concern

›Ammonia

›Hyperammonemia suggests metabolic disorder

›Sample handling limitations

›Liver enzymes

›Transaminitis in HSV

›Hepatic injury in shock

›Cortisol and 17 hydroxyprogesterone

›Adrenal crisis support

›CAH screen follow up

›TSH and free T4

›Hypothyroidism support

›Usually not emergent unless severe

Toxicology and ingestion

›Toxic exposure labs

›Acetaminophen level if exposure possible

›Timing dependent interpretation

›Low suspicion does not require level

›Salicylate level if exposure possible

›Mixed acid base disorders

›Tinnitus not reliable in infant

›Urine drug screen

›Limited sensitivity

›Does not rule out many toxidromes

12Imaging/img31

Scoring Systems

›Clinical scoring and screening

›Pediatric Early Warning Score

›Triage deterioration tracking

›Escalation thresholds local protocol dependent

›Pediatric sepsis screening tools

›Institution specific triggers

›False positives in viral illness

MRI

›MRI indications

›Brain MRI

›Encephalitis concern with stable airway

›Non accidental trauma evaluation adjunct

›Spine MRI

›Epidural infection concern

›Neurologic deficit concern

›CT indications and cautions

›CT head

›Non accidental trauma concern

›Altered mental status with focal deficits

›Radiation considerations

›Use pediatric dose protocols

›Prefer ultrasound or MRI when appropriate

Ultrasound

›Ultrasound and POCUS targets

›Pyloric ultrasound

›Progressive vomiting

›Weight loss

›Abdominal ultrasound

›Intussusception evaluation

›Free fluid assessment

›Cardiac POCUS

›Ventricular function

›Pericardial effusion

13Special Tests/spec21

Bedside procedures and specialty diagnostics

›Targeted tests

›Lumbar puncture

›Indications

›Suspected meningitis

›Ill appearing young infant with infection concern

›Contraindications

›Unstable airway or shock

›Signs of raised intracranial pressure local protocol dependent

›Viral respiratory testing local protocol dependent

›RSV

›Influenza

›Capillary blood smear if anemia concern

›Hemolysis clues

›Artifact limitations

Bedside response trials

›Therapeutic diagnostic responses

›Nasal suction response

›Improved feeding after suctioning

›Persistent work of breathing despite suctioning

›Glucose correction response

›Improved alertness after dextrose

›Recurrent hypoglycemia suggests endocrine or metabolic cause

14ECG/ecg17

Indications and high risk patterns

›ECG use in lethargy and poor feeding

›Indications

›Persistent tachycardia unexplained

›Cyanosis or shock without clear source

›High risk findings

›Supraventricular tachycardia

›Complete heart block

›Conduction patterns

›Long QT interval

›Pre excitation pattern

Serial ECG and monitoring logic

›Rhythm surveillance

›Continuous monitoring

›If unstable then continuous monitoring

›If intermittent symptoms then capture during episode

›Repeat ECG triggers

›After cardioversion or adenosine

›After electrolyte correction

15Assessment/ax23

Problem representation and severity

›Clinical synthesis

›Severity tier

›Ill appearing with altered mental status

›Well appearing but decreased intake

›Physiologic risk

›Signs of shock

›Respiratory failure risk

›Age based risk stratification

›Less than 28 days higher invasive bacterial infection risk

›29 to 90 days intermediate risk local protocol dependent

Working diagnoses and competing threats

›Working diagnostic framework

›Serious bacterial infection risk

›Sepsis

›Meningitis

›Metabolic endocrine risk

›Hypoglycemia

›Adrenal crisis

›Cardiorespiratory risk

›Bronchiolitis with feeding failure

›Congenital heart disease decompensation

›GI surgical risk

›Malrotation with volvulus if bilious emesis

›Intussusception if episodic lethargy

16Plan/plan58

Immediate stabilization and monitoring

›Stabilization sequence

›Airway and breathing

›If apnea or inadequate ventilation then bag valve mask ventilation

›If SpO2 less than 92 percent then oxygen

›Circulation

›If poor perfusion then isotonic fluid bolus 10 mL per kg

›Reassessment after each bolus

›Glucose correction

›Dextrose D10W 2 mL per kg IV or IO for symptomatic hypoglycemia

›Recheck glucose in 15 minutes

›Temperature management

›Active warming if hypothermic

›Antipyretic dosing weight based local protocol dependent

Empiric antimicrobials and antivirals

›Time critical infection treatment

›If suspected sepsis then antibiotics within 60 minutes local protocol dependent

›Neonate or young infant empiric regimen local protocol dependent

›Ampicillin IV weight based

›Gentamicin IV weight based

›Alternative regimen local protocol dependent

›Ampicillin IV weight based

›Cefotaxime IV weight based

›HSV coverage triggers

›Vesicular rash

›Seizure

›Transaminitis

›Acyclovir IV weight based if HSV concern

›Renal dosing adjustment prompt

›Ensure hydration

Fluids and vasopressors

›Shock management

›Fluid strategy

›10 mL per kg bolus increments in neonate local protocol dependent

›20 mL per kg bolus increments in older infant local protocol dependent

›Vasopressor escalation local protocol dependent

›If persistent shock after fluids then epinephrine infusion

›If warm shock pattern then norepinephrine option

Diagnostic sequencing and reassessment loop

›Reassessment loop

›Timing

›Recheck vitals every 15 minutes if unstable

›Recheck perfusion after each intervention

›Targets

›Improving mental status

›Improving perfusion markers

›Failure to improve triggers escalation

›Persistent lethargy

›Rising lactate or worsening acidosis

Consultation

›Specialty involvement

›Pediatrics

›Any ill appearing infant

›Any infant less than 28 days with poor feeding or lethargy

›PICU

›Need for respiratory support

›Shock requiring vasoactive support

›Pediatric surgery

›Bilious vomiting

›Intussusception concern

›Child protection team

›Bruising in non mobile infant

›Concerning caregiver history

17Disposition/dispo30

ICU criteria

›Higher level of care criteria

›Respiratory support requirement

›High flow nasal cannula

›Non invasive ventilation

›Shock physiology

›Need for vasopressors

›Recurrent fluid boluses with persistent poor perfusion

›Neurologic compromise

›Seizure

›Persistent altered mental status

Inpatient admission criteria

›Admission indications

›Age based

›Less than 28 days with lethargy or poor feeding

›Less than 90 days with serious bacterial infection concern

›Feeding failure

›Inadequate oral intake with dehydration

›Need for NG or IV fluids

›Infection management

›IV antibiotics required

›Pending cultures with high risk features

Observation and discharge criteria

›Lower acuity pathways

›Observation pathway criteria local protocol dependent

›Well appearing after ED interventions

›Normal glucose and stable vitals

›Discharge criteria

›Normal mental status for age

›Adequate oral intake observed in ED

›Follow up timing

›Primary care within 24 hours

›Earlier follow up if cultures pending local protocol dependent

18Discharge Instructions/di24

Copy discharge instructions

›Summary

›Seen today for decreased feeding and sleepiness

›Current exam and tests do not show an emergency cause right now

›Feeding and hydration

›Smaller frequent feeds

›Wet diapers should increase over the next day

›Medications

›Use medications only as directed for age and weight

›Do not use leftover antibiotics

›Follow up

›Follow up with your primary care clinician within 24 hours

›Return sooner if you cannot get follow up

›Return to emergency now for

›Trouble breathing

›Blue lips or face

›Hard to wake

›Seizure

›Fever in a young infant local protocol dependent

›Low temperature with sleepiness

›No wet diapers for 8 hours

›Repeated vomiting

›Green vomiting

›Blood in stool

›New rash with purple spots

19References/r6

Guidelines and key sources

›Evidence based references

›American Academy of Pediatrics clinical practice guideline for well appearing febrile infants 8 to 60 days 2021

›Surviving Sepsis Campaign international guidelines for management of septic shock and sepsis associated organ dysfunction in children 2020

›National Institute for Health and Care Excellence sepsis recognition diagnosis and early management NG51 updated regularly local protocol dependent

›World Health Organization IMCI danger signs and young infant illness guidance updated regularly

›Infectious Diseases Society of America guidance on management of bacterial meningitis updated regularly

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.

Poor Feeding and Lethargy In The InfantAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

743 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/hx87

Presenting concern and timeline

›Symptom characterization

›Poor feeding pattern

›Breastfeeding

›Formula feeding

›Mixed feeding

›Intake change

›Reduced volume per feed

›Reduced frequency

›Refusal to latch

›Lethargy description

›Decreased responsiveness

›Hard to arouse

›Less interactive than baseline

›Baseline comparison

›Normal feeding amount and frequency

›Normal wakefulness and tone

OPQRST

›OPQRST framework

›Onset

›Time of first noted poor feeding

›Time of first noted lethargy

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with feeding attempts

›Improvement after antipyretic

›Improvement after suctioning

›Improvement after glucose

›Quality

›Weak suck

›Fatigues quickly

›Sleepy at breast or bottle

›Disorganized feeding

›Region and radiation

›Not applicable for primary symptoms

›Associated focal pain signals

›Ear tugging

›Abdominal guarding

›Severity

›Percent of usual intake

›Number of feeds in last 24 hours

›Number of wet diapers in last 24 hours

›Timing

›Progressive

›Episodic

›Post feed worsening

›Diurnal pattern

Associated symptoms

›Symptom clusters

›Fever or hypothermia

›Measured temperature history

›Home antipyretic exposure

›Respiratory symptoms

›Cough

›Congestion

›Increased work of breathing

›Gastrointestinal symptoms

›Vomiting

›Bilious emesis

›Diarrhea

›Abdominal distension

›Genitourinary symptoms

›Fewer wet diapers

›Foul smelling urine

›Hematuria

›Neurologic symptoms

›Apnea

›Seizure like activity

›Abnormal movements

›Skin and mucosa

›Rash

›Jaundice

›Oral thrush

Birth and perinatal history

›Perinatal risk context

›Gestational age

›Term

›Late preterm

›Preterm

›Delivery history

›Vaginal

›Cesarean

›Maternal infection risk

›Group B streptococcus status

›Prolonged rupture of membranes

›Intrapartum fever

›Neonatal course

›NICU stay

›Jaundice treatment

›Prior antibiotics

02Alarm Features/alarm55

Approach to the critical infant

›First 5 minutes priorities

›Immediate escalation triggers

›Apnea

›Cyanosis

›Persistent altered level of consciousness

›Poor perfusion

›Monitoring

›Continuous pulse oximetry

›Cardiorespiratory monitoring

›Temperature measurement

›Access

›IV access

›IO access if IV delayed and unstable

›Glucose

›Point of care glucose within minutes of arrival

›If glucose less than 3.0 mmol per L then dextrose immediately

›Oxygen and ventilation

›If SpO2 less than 92 percent then oxygen

›If apnea or inadequate ventilation then bag valve mask ventilation

›Shock pathway

›If delayed capillary refill or weak pulses then fluid bolus

›If hypotension or persistent poor perfusion after bolus then vasopressor pathway

High risk history features

›Red flag history

›Age based risk

›Less than 28 days

›Less than 3 months

›Feeding red flags

›No oral intake for 8 hours

›Repeated vomiting with poor intake

›Infection red flags

›Fever history

›Hypothermia history

›Neurologic red flags

›Seizure

›Apnea

›Bulging fontanelle history

›GI surgical red flags

›Bilious emesis

›Bloody stool

›Cardiac red flags

›Sweating with feeds

›Cyanosis with feeds

Vital sign danger thresholds

›Vital danger patterns

›Temperature extremes

›Fever in young infant local protocol dependent

›Hypothermia

›Respiratory danger

›Apnea

›Marked tachypnea with retractions

›Perfusion danger

›Capillary refill greater than 3 seconds

›Cool mottled extremities

›Circulation danger

›Persistent tachycardia despite calming and normothermia

›Bradycardia with lethargy

03Medications/meds30

Current and recent exposures

›Medication and substance exposure

›Infant prescribed medications

›Antibiotics

›Reflux medications

›OTC exposure

›Acetaminophen

›Ibuprofen

›Vitamins and supplements

›Vitamin D

›Herbal products

›Maternal medications

›Opioids

›Sedatives

›SSRI

›Toxic exposure risk

›Ingestion possibility in home

›Topical products

›Medication changes

›New medication within 7 days

›Missed doses

Medication considerations for likely therapies

›Contraindications and cautions

›Ceftriaxone cautions

›Neonate or young infant local protocol dependent

›Hyperbilirubinemia risk

›Acyclovir renal risk

›Need hydration

›Need renal dosing adjustment

›Fluid bolus cautions

›Known congenital heart disease

›Signs of pulmonary edema

04Diet/diet29

Feeding and hydration pattern

›Intake and output pattern

›Feeding type

›Breast milk

›Formula

›Feeding volume and frequency

›Usual pattern

›Current pattern

›Hydration indicators

›Wet diapers count in last 24 hours

›Tears when crying

›Emesis pattern

›Non bilious

›Bilious

›Stool pattern

›Diarrhea

›Constipation

›Weight trend

›Recent weights if available

›Failure to thrive concern

Exposure and preparation risks

›Feeding safety risks

›Formula preparation

›Mixing technique

›Water source

›Honey exposure

›Infant botulism risk

›Age less than 12 months risk

›Sick contact feeding changes

›Decreased intake during viral illness

›Increased work of breathing affecting intake

05Review of Systems/ros35

System based symptoms

›ROS clusters

›Constitutional

›Fever

›Hypothermia

›Respiratory

›Cough

›Congestion

›Cardiovascular

›Cyanosis

›Sweating with feeds

›Gastrointestinal

›Vomiting

›Bilious emesis

›Genitourinary

›Decreased urine output

›Malodorous urine

›Neurologic

›Lethargy

›Seizure like activity

›Dermatologic

›Rash

›Vesicles

›HEENT

›Poor latch due to nasal obstruction

›Oral lesions

Pertinent negatives that change management

›High value negatives

›No bilious emesis

›Lowers concern for malrotation with volvulus

›Does not exclude early obstruction

›No apnea

›Lowers immediate airway risk

›Does not exclude evolving sepsis

›No rash or vesicles

›Lowers HSV suspicion

›Does not exclude HSV without skin lesions

06Collateral History and Family History/chafh23

Collateral source and reliability

›Source context

›Primary caregiver report

›Reliability concerns

›Language barrier

›EMS report

›Home scene concerns

›Observed feeding or mentation

›Prior records

›Recent ED visit

›Recent hospitalization

Family and household context

›Familial and exposure risks

›Household sick contacts

›Respiratory viral illness

›Gastroenteritis

›Family history inherited disease

›Inborn errors of metabolism

›Congenital heart disease

›Sudden infant death history

›Prior SIDS in family

›Unsafe sleep environment

›Care environment safety

›Supervision reliability

›Substance use in household

07Risk Factors/rf29

Patient specific high risk factors

›High risk host factors

›Age based risk

›Less than 28 days

›Less than 90 days

›Prematurity

›Gestational age less than 37 weeks

›Chronic lung disease of prematurity

›Congenital heart disease

›Ductal dependent lesion risk

›Heart failure risk

›Immunization status

›Not yet immunized

›Under immunized

›Central lines or devices

›Ventriculoperitoneal shunt

›Central venous catheter

Exposure related risks

›Infection and toxin exposures

›Maternal HSV risk

›Genital lesions at delivery

›Primary infection late pregnancy

›Maternal GBS risk

›Positive and untreated

›Unknown status

›Environmental temperature risk

›Under dressing

›Over bundling

›Toxin access

›Caregiver medications

›Carbon monoxide exposure

08Differential Diagnosis/ddx69

Life threatening

›Cannot miss diagnoses

›Sepsis or septic shock (A41.9 R57.2)

›Poor perfusion

›Temperature instability

›Meningitis or encephalitis (G00.9 G04.90)

›Bulging fontanelle

›Seizure

›Neonatal HSV infection (B00.9)

›Vesicular rash

›Transaminitis

›Hypoglycemia (E16.2)

›Lethargy

›Seizure

›Congenital heart disease with ductal dependence (Q24.9)

›Cyanosis

›Shock after first days of life

›Arrhythmia (I49.9)

›Persistent tachycardia

›Poor feeding with pallor

›Inborn error of metabolism (E88.9)

›Metabolic acidosis

›Hyperammonemia

›Adrenal crisis congenital adrenal hyperplasia (E25.0)

›Hyperkalemia

›Hyponatremia

›Malrotation with volvulus (K56.2)

›Bilious vomiting

›Rapid deterioration

›Intussusception (K56.1)

›Episodic lethargy

›Bloody stool

›Non accidental trauma (T74.12)

›Bruising in non mobile infant

›Incongruent history

Common

›Common etiologies

›Viral bronchiolitis (J21.9)

›Increased work of breathing

›Poor feeding due to tachypnea

›Viral upper respiratory infection (J06.9)

›Congestion affecting feeding

›Mild fever

›Urinary tract infection (N39.0)

›Fever without source

›Poor feeding

›Acute gastroenteritis (A09)

›Vomiting

›Diarrhea

›Dehydration (E86.0)

›Reduced wet diapers

›Dry mucous membranes

›Otitis media (H66.90)

›Ear tugging

›Irritability

Less common

›Less common and mimics

›Pyloric stenosis (K31.1)

›Progressive non bilious vomiting

›Weight loss

›Hyperbilirubinemia (E80.6)

›Jaundice

›Poor feeding

›Congenital hypothyroidism (E03.1)

›Prolonged jaundice

›Constipation

›Anemia (D64.9)

›Pallor

›Tachycardia

›Infant botulism (A48.51)

›Hypotonia

›Weak cry

09Past Medical History/pmh26

Baseline health and prior episodes

›Baseline risk anchors

›Prior similar episodes

›Prior ED visits

›Prior admissions

›Birth history complications

›Resuscitation at birth

›NICU course

›Screening results

›Newborn metabolic screen results if known

›Hearing screen results if relevant

›Immunizations

›Up to date for age

›Delayed schedule

›Known conditions

›Congenital heart disease

›Chronic lung disease

Procedures and devices

›Device and procedure history

›Prior surgery

›GI surgery

›Cardiac surgery

›Indwelling devices

›VP shunt

›Central line

›Recent procedures

›Circumcision complications

›Recent catheterization

10Physical Exam/exam92

General and vital sign interpretation

›Initial impression and stability

›Appearance

›Toxic appearance

›Non toxic appearance

›Mental status

›Alert

›Lethargic

›Hydration

›Moist mucous membranes

›Sunken fontanelle

›Perfusion

›Capillary refill time

›Extremity temperature

HEENT and neck

›HEENT findings

›Fontanelle

›Flat

›Bulging

›Oral cavity

›Thrush

›Mucosal hydration

›Tympanic membranes

›Erythema

›Effusion

›Neck

›Stiffness

›Lymphadenopathy

Respiratory

›Respiratory status

›Work of breathing

›Retractions

›Nasal flaring

›Breath sounds

›Wheeze

›Crackles

›Apnea events

›Observed in ED

›Reported at home

Cardiovascular

›Cardiac and perfusion

›Heart rate pattern

›Persistent tachycardia

›Bradycardia

›Pulses

›Femoral pulses

›Pulse symmetry

›Murmur

›New murmur

›Known murmur

›Hepatomegaly

›Heart failure clue

›Sepsis clue

Abdomen and GI

›Abdominal exam

›Distension

›Present

›Absent

›Tenderness

›Focal

›Diffuse

›Bowel sounds

›Hyperactive

›Decreased

›Emesis features

›Bilious

›Non bilious

Genitourinary

›GU findings

›Diaper output

›Wet diaper in ED

›No wet diaper

›Genital exam

›Hernia

›Torsion signs

›Hydration related

›Sunken eyes

›Dry lips

Skin

›Skin and perfusion clues

›Rash pattern

›Petechiae or purpura

›Vesicles

›Color

›Pallor

›Cyanosis

›Bruising

›Bruises in non mobile infant

›Patterned bruising

Neurologic and tone

›Neuro status

›Tone

›Hypotonia

›Hypertonia

›Cry

›Weak cry

›High pitched cry

›Seizure signs

›Abnormal eye deviation

›Lip smacking

11Lab Studies/labs58

Point of care tests

›Immediate bedside labs

›Glucose

›Hypoglycemia threshold less than 3.0 mmol per L

›Hyperglycemia stress response

›Blood gas

›Metabolic acidosis pattern

›Respiratory failure pattern

›Lactate

›Elevated suggests hypoperfusion

›Normal does not exclude sepsis

Sepsis and serious bacterial infection workup

›Infection evaluation labs

›CBC with differential

›Neutropenia risk

›Left shift

›CRP

›Trend value with repeat

›Early normal possible

›Procalcitonin

›Bacterial infection enrichment

›Viral overlap possible

›Blood culture

›Before antibiotics if feasible

›Contamination risk

›Urinalysis and urine culture catheter specimen

›Positive leukocyte esterase

›Nitrites may be negative in young infants

›CSF studies if indicated

›Cell count and differential

›Culture and PCR local protocol dependent

Metabolic and endocrine evaluation

›Metabolic and endocrine labs

›Electrolytes and renal function

›Hyponatremia

›Hyperkalemia

›Ketones and beta hydroxybutyrate

›Starvation ketosis

›Ketosis plus acidosis concern

›Ammonia

›Hyperammonemia suggests metabolic disorder

›Sample handling limitations

›Liver enzymes

›Transaminitis in HSV

›Hepatic injury in shock

›Cortisol and 17 hydroxyprogesterone

›Adrenal crisis support

›CAH screen follow up

›TSH and free T4

›Hypothyroidism support

›Usually not emergent unless severe

Toxicology and ingestion

›Toxic exposure labs

›Acetaminophen level if exposure possible

›Timing dependent interpretation

›Low suspicion does not require level

›Salicylate level if exposure possible

›Mixed acid base disorders

›Tinnitus not reliable in infant

›Urine drug screen

›Limited sensitivity

›Does not rule out many toxidromes

12Imaging/img31

Scoring Systems

›Clinical scoring and screening

›Pediatric Early Warning Score

›Triage deterioration tracking

›Escalation thresholds local protocol dependent

›Pediatric sepsis screening tools

›Institution specific triggers

›False positives in viral illness

MRI

›MRI indications

›Brain MRI

›Encephalitis concern with stable airway

›Non accidental trauma evaluation adjunct

›Spine MRI

›Epidural infection concern

›Neurologic deficit concern

›CT indications and cautions

›CT head

›Non accidental trauma concern

›Altered mental status with focal deficits

›Radiation considerations

›Use pediatric dose protocols

›Prefer ultrasound or MRI when appropriate

Ultrasound

›Ultrasound and POCUS targets

›Pyloric ultrasound

›Progressive vomiting

›Weight loss

›Abdominal ultrasound

›Intussusception evaluation

›Free fluid assessment

›Cardiac POCUS

›Ventricular function

›Pericardial effusion

13Special Tests/spec21

Bedside procedures and specialty diagnostics

›Targeted tests

›Lumbar puncture

›Indications

›Suspected meningitis

›Ill appearing young infant with infection concern

›Contraindications

›Unstable airway or shock

›Signs of raised intracranial pressure local protocol dependent

›Viral respiratory testing local protocol dependent

›RSV

›Influenza

›Capillary blood smear if anemia concern

›Hemolysis clues

›Artifact limitations

Bedside response trials

›Therapeutic diagnostic responses

›Nasal suction response

›Improved feeding after suctioning

›Persistent work of breathing despite suctioning

›Glucose correction response

›Improved alertness after dextrose

›Recurrent hypoglycemia suggests endocrine or metabolic cause

14ECG/ecg17

Indications and high risk patterns

›ECG use in lethargy and poor feeding

›Indications

›Persistent tachycardia unexplained

›Cyanosis or shock without clear source

›High risk findings

›Supraventricular tachycardia

›Complete heart block

›Conduction patterns

›Long QT interval

›Pre excitation pattern

Serial ECG and monitoring logic

›Rhythm surveillance

›Continuous monitoring

›If unstable then continuous monitoring

›If intermittent symptoms then capture during episode

›Repeat ECG triggers

›After cardioversion or adenosine

›After electrolyte correction

15Assessment/ax23

Problem representation and severity

›Clinical synthesis

›Severity tier

›Ill appearing with altered mental status

›Well appearing but decreased intake

›Physiologic risk

›Signs of shock

›Respiratory failure risk

›Age based risk stratification

›Less than 28 days higher invasive bacterial infection risk

›29 to 90 days intermediate risk local protocol dependent

Working diagnoses and competing threats

›Working diagnostic framework

›Serious bacterial infection risk

›Sepsis

›Meningitis

›Metabolic endocrine risk

›Hypoglycemia

›Adrenal crisis

›Cardiorespiratory risk

›Bronchiolitis with feeding failure

›Congenital heart disease decompensation

›GI surgical risk

›Malrotation with volvulus if bilious emesis

›Intussusception if episodic lethargy

16Plan/plan58

Immediate stabilization and monitoring

›Stabilization sequence

›Airway and breathing

›If apnea or inadequate ventilation then bag valve mask ventilation

›If SpO2 less than 92 percent then oxygen

›Circulation

›If poor perfusion then isotonic fluid bolus 10 mL per kg

›Reassessment after each bolus

›Glucose correction

›Dextrose D10W 2 mL per kg IV or IO for symptomatic hypoglycemia

›Recheck glucose in 15 minutes

›Temperature management

›Active warming if hypothermic

›Antipyretic dosing weight based local protocol dependent

Empiric antimicrobials and antivirals

›Time critical infection treatment

›If suspected sepsis then antibiotics within 60 minutes local protocol dependent

›Neonate or young infant empiric regimen local protocol dependent

›Ampicillin IV weight based

›Gentamicin IV weight based

›Alternative regimen local protocol dependent

›Ampicillin IV weight based

›Cefotaxime IV weight based

›HSV coverage triggers

›Vesicular rash

›Seizure

›Transaminitis

›Acyclovir IV weight based if HSV concern

›Renal dosing adjustment prompt

›Ensure hydration

Fluids and vasopressors

›Shock management

›Fluid strategy

›10 mL per kg bolus increments in neonate local protocol dependent

›20 mL per kg bolus increments in older infant local protocol dependent

›Vasopressor escalation local protocol dependent

›If persistent shock after fluids then epinephrine infusion

›If warm shock pattern then norepinephrine option

Diagnostic sequencing and reassessment loop

›Reassessment loop

›Timing

›Recheck vitals every 15 minutes if unstable

›Recheck perfusion after each intervention

›Targets

›Improving mental status

›Improving perfusion markers

›Failure to improve triggers escalation

›Persistent lethargy

›Rising lactate or worsening acidosis

Consultation

›Specialty involvement

›Pediatrics

›Any ill appearing infant

›Any infant less than 28 days with poor feeding or lethargy

›PICU

›Need for respiratory support

›Shock requiring vasoactive support

›Pediatric surgery

›Bilious vomiting

›Intussusception concern

›Child protection team

›Bruising in non mobile infant

›Concerning caregiver history

17Disposition/dispo30

ICU criteria

›Higher level of care criteria

›Respiratory support requirement

›High flow nasal cannula

›Non invasive ventilation

›Shock physiology

›Need for vasopressors

›Recurrent fluid boluses with persistent poor perfusion

›Neurologic compromise

›Seizure

›Persistent altered mental status

Inpatient admission criteria

›Admission indications

›Age based

›Less than 28 days with lethargy or poor feeding

›Less than 90 days with serious bacterial infection concern

›Feeding failure

›Inadequate oral intake with dehydration

›Need for NG or IV fluids

›Infection management

›IV antibiotics required

›Pending cultures with high risk features

Observation and discharge criteria

›Lower acuity pathways

›Observation pathway criteria local protocol dependent

›Well appearing after ED interventions

›Normal glucose and stable vitals

›Discharge criteria

›Normal mental status for age

›Adequate oral intake observed in ED

›Follow up timing

›Primary care within 24 hours

›Earlier follow up if cultures pending local protocol dependent

18Discharge Instructions/di24

Copy discharge instructions

›Summary

›Seen today for decreased feeding and sleepiness

›Current exam and tests do not show an emergency cause right now

›Feeding and hydration

›Smaller frequent feeds

›Wet diapers should increase over the next day

›Medications

›Use medications only as directed for age and weight

›Do not use leftover antibiotics

›Follow up

›Follow up with your primary care clinician within 24 hours

›Return sooner if you cannot get follow up

›Return to emergency now for

›Trouble breathing

›Blue lips or face

›Hard to wake

›Seizure

›Fever in a young infant local protocol dependent

›Low temperature with sleepiness

›No wet diapers for 8 hours

›Repeated vomiting

›Green vomiting

›Blood in stool

›New rash with purple spots

19References/r6

Guidelines and key sources

›Evidence based references

›American Academy of Pediatrics clinical practice guideline for well appearing febrile infants 8 to 60 days 2021

›Surviving Sepsis Campaign international guidelines for management of septic shock and sepsis associated organ dysfunction in children 2020

›National Institute for Health and Care Excellence sepsis recognition diagnosis and early management NG51 updated regularly local protocol dependent

›World Health Organization IMCI danger signs and young infant illness guidance updated regularly

›Infectious Diseases Society of America guidance on management of bacterial meningitis updated regularly

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.