Neonatal Fever (30 d - 60 days)

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Neonatal Fever (30 d - 60 days)

Contraindications to acetaminophen

  • Allergy or hypersensitivity
  • Hepatic impairment
  • Severe hypovolemia
  • PKU or other liver disease
  • Chronic malnutrition

Cephalexin suspension


Discharge criteria

  • Reassuring vital signs
  • Laboratory findings reassuring
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 24 hours
  • Parents comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Consider pediatric or neonatal consult

Contraindications to acetaminophen?

Follow up within 24 hours

Complete Blood Count, Serum
Blood Culture (Aerobic and Anaerobic), Serum
Urinalysis with micro, Urine
Urine Culture, Urine
Procalcitonin, Serum
Acetaminophen suspension

Toxic appearing?


Respiratory symptoms?

Inclusion Criteria
  • Fever > 38.0 C (100.4 F) x1 at home, OSH or in ED
  • Hypothermia < 36.0 (96.8 F) x1 at home, OSH or in ED
Exclusion Criteria
  • Immunosuppressed, cancer
  • Central venous catheter
  • Ventriculoperitoneal shuts


Admit to ICU

Focal skin bacterial infection (ex. cellulits)?

Meets discharge criteria?

Ceftriaxone injection

Ceftriaxone injection
Enterovirus PCR, CSF
Meningitis/encephalitis PCR panel, CSF
Contact isolation

Start abx immediatly if ill-appearing, otherwise after CSF Cx is obtained

Ceftriaxone injection
Vancomycin injection

Respiratory Symptoms

  • Respiratory rate > 50
  • Rales, rhonchi, wheezing, stridor
  • Retractions
  • Cough, coryza
  • Grunting
  • Nasal flaring

If LP attempted and unsuccessful

  • Send any CSF obtained for Cx
  • Repeat LP within 24 hours if possible
  • Admit
  • No antibiotics unless ill-appearing

If caregivers refuse LP

  • Diagnostic tests almost never are obtained by court order
  • Admit
  • No antibiotics unless ill-appearing

If patient is well appearing after a period of observation it may be reasonable to give IV or IM ceftriaxone and consider discharge.

Ceftriaxone injection

Clinically well-appearing features

  • Reassuring vital signs
  • Tolerating PO with no signs of dehydration
  • Normal tone
  • Interactive with
  • Fussiness consolable by caregivers

If testing for RSV or Influenza is positive

  • May defer LP, but serum and urine tests should still be obtained as UTI and bateremia are still prevalent

Stool Cx/Gastroenteritis PCR, contact isolation

Gastroenteritis PCR, Stool
X-ray Chest, 1 view
Respiratory Viral Panel, Nasopharyngeal
Droplet isolation

Meets ALL low risk criteria?

  • Fever less than 41 C (106 F)
  • Clinically well appearing with normal vitals
  • Previously healthy
  • Full term (>37 wks)
  • No bacterial skin infection (cellulitis, etc.)
  • Serum WBC > 5k and < 15k mm3
  • Absolute bands < 1.5k mm3
  • Procalcitonin < 0.3 ng/mL
  • Normal CXR (if done)
  • No previous antibiotic use

Culture & Gram Stain, CSF
Glucose, CSF
Protein Total, CSF
Cell Count and Differential, CSF

CSF WBC >10/mm3?

  • Admit to ICU
  • Respiratory and contact isolation
Complete Metabolic Panel, Serum
Ceftriaxone injection
ISTAT Venous Blood Gas and Lactate, Serum
Vancomycin injection
Culture & Gram Stain, CSF
Glucose, CSF
Protein Total, CSF
Cell Count and Differential, CSF
Enterovirus PCR, CSF

If patient on prophylactic antibiotics

  • Full septic workup including LP
  • If labs neg, consider admission and observation for 24 hours

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