• Management of febrile newborns can be difficult and requires considerable experience and expertise.
• If possible, febrile newborns should be urgently evaluated by a pediatrician. When this is not practical, then the criteria for infants age 1 to 3 months should be used as a guide to investigation and management.
• For newborns presenting with fever, use the criteria given for infants age 1 to 3 months

Age 1 to 3 months

• Low Risk Criteria (Bacteremia risk 0.5%)

Must have all of these:

• not preterm
• not lethargic/toxic¹
• no physical signs of infection
• WBC 5-15
• bands <= 1.5
• urine <=10 WBC/hpf

Management if low risk:

• urine culture
• (LP at discretion of MD)
• no antibiotics
• careful observation: at home, if family reliable, or in hospital if necessary
  
  
• High Risk Criteria (Bacteremia risk >= 10-15%)

Any one or more of these:

• baby is preterm
• baby is lethargic/toxic¹
• physical signs of serious infection
• does not satisfy all low risk criteria

Management if High Risk:

• estabish diagnosis (mother is a likely source of infection; are family members unwell?)
• remember serious viruses: HSV, RSV, enteroviruses
• perform lumbar pucture
• culture: CSF, blood, urine
• hospitalize & start antibiotics, e.g. amplicillin plus: gentamicin or cefotaxime or ceftriaxone

Age 3 to 36 months

• Low Risk Criteria (Bacteremia risk 2.5%)
  • child was previously healthy
  • not lethargic/toxic¹
  • no physical signs of bacterial infection
  • may have viral symptoms (runny nose, croup)
  • temp <39.5°C or
  • temp >= 39.5°C but WBC < 15

Management if low risk:

• if temp >=39.5°C, do WBC in order to confirm low risk
• consider urine culture
• blood culture not necessary
• no antibiotics unless otitis media almost certain (child has earache)
• careful follow-up
  
  
• Medium Risk Criteria (Bacteremia risk 10%-15%)
  
  
  • temp >=39.5°C and WBC >= 15

BUT

• child previously healthy and
• is not lethargic/toxic¹ and
• has no physical signs of bacterial infection

Management if medium risk:

• blood culture
• urine culture
• amoxicillin for otitis media only if that dx almost certain
• either no antibiotics or hi dose amoxicillin oral x 48 hours pending culture
• observation at home: return if child worse, shows new findings, or blood culture positive
  
  
• High Risk Criteria (Risk of serious bacterial infection 20% or more)
  
  
  • temp >= 39.5 and WBC >= 15

AND

• child is lethargic/toxic¹ or
• child has physical signs of serious bacterial infection

OR

• WBC < 5

Management if high risk:

• establish diagnosis (are family or playmates unwell?)
• perform lumbar puncture if: vomiting without diarrhea, or lethargic, or neck stiff
• culture: blood, urine, +/-CSF
• hospitalize for antibiotics, e.g. cefuroxime, cefoxime, cefotaxime or ceftriaxone

¹ Lethargic = Poor eye contact, poor interaction with parents or environment

Toxic = Poor perfusion, cyanosis, hypoventilating, hyperventilating, shock

Material extracted from The Foundation for Medical Practice Education, Education Module, Vol.8(9), October 2000