Infants under 90 days old with fever can present a diagnostic dilemma.
Join us as Russell McCulloh, MD discusses unresolved issues and common conundrums faced by front-line clinicians in the evaluation of neonatal fever, recent literature on laboratory testing for infants with fever, and potential management strategies for febrile infants.
Selected Podcast
Bacterial Infection in Neonates and Young Infants
Featured Speaker:
Learn more about Russell McCulloh, MD
Russell McCulloh, MD
Russell McCulloh, MD, a pediatric infectious diseases specialist and associate director, Infectious Disease Fellowship program, at Children’s Mercy Kansas City, and professor of pediatrics at University of Missouri Kansas City School of Medicine. He is a graduate of the University of Missouri Columbia. He completed a residency in Internal Medicine/Pediatrics at the University of Missouri Healthcare and a fellowship in Pediatric and Adult Infectious Disease at Lifespan/Brown University in Providence, Rhode Island.Learn more about Russell McCulloh, MD
Transcription:
Bacterial Infection in Neonates and Young Infants
Michael Smith, MD (Host): So, our topic today is bacterial infection and fever in neonates and young infants. My guest is Dr. Russell McCulloh. Dr. McCulloh is the Associate Director the Infectious Disease Fellowship Program at Children’s Mercy Kansas City and he is a Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. Dr. McCulloh, welcome to the show.
Dr. Rusell McCulloh, MD (Guest): Thanks for having me on.
Dr. Smith: So, infants with fever, right. How common is this? What is some of just the epidemiology around this presentation?
Dr. McCulloh: Well, fever in young infants is one of the most common reasons that they are brought to be seen in the emergency department or the outpatient setting and a lot of that is because there is a concern for a serious bacterial infection; something like bacteria infection in the urine or the bloodstream or even the spinal fluid that can be indicated just the presence of fever and no other initial signs or symptoms. It’s important to note though that it is most commonly when you are working with an infant with fever, that you are dealing with a viral infection or a simple uncomplicated infection. But it really takes having a discussion with a healthcare and a good thoughtful exam to really help suss that out for parents.
Dr. Smith: Well, I think you kind of already bring up one of the challenges, right bacterial versus virus. So, what are some of those other challenges that clinicians and healthcare providers have to face when they are presented with fever in an infant?
Dr. McCulloh: Well, the biggest issue is what is the appropriate evaluation based on an infant’s age and how they have been doing according to the parents and how they look on exam? And like I said, the most common thing that we encounter is viral infections; but there are certain bacteria that are commonly associated with infections in young infants. And in the office setting; which is the most common place where these infants are first brought; for infants in the first month of life in particular; the rule of thumb is often that you have to err on side of doing a bit more testing than may be ideally desired by the parents, to make sure that there is not an infection that if left untreated could result in some really serious illness.
Dr. Smith: So, you mentioned doing a little bit more testing. Let’s talk a little bit about that. So, what exactly are the current guidelines for working up an infant with fever and is there anything else that at Children’s Mercy that you guys like to do?
Dr. McCulloh: Right, absolutely. Well the first thing I would say is that we have had guidelines available for pediatricians for basically the last thirty years for helping evaluate these young infants. And they have not changed a whole lot during that time, though our vaccines and the diagnostic tests that we are able to do, have really moved forward. And so, a lot of the work that we do here at Children’s Mercy and that I do in particular is focused on trying to get some of this new testing and this new understanding of what causes these infections nowadays integrated into the care that these kids receive. But in terms of the testing that we talk about most commonly; you are testing three different sources on infants. One is urine to see if there is a urinary tract infection. One is the blood to see if there is bacteria in the blood and the third is spinal fluid to see if there is evidence of meningitis. And for infants under a month of age, those are the three routes of infection that are tested for and that are recommended to be tested for. In the second month of life, we can use some rules to help identify kids who can safely avoid getting particularly that spinal tap or that spinal fluid analysis at the beginning and can maybe be observed first.
Dr. Smith: So, let’s talk, so we are beginning that workup and speaking to the community physician, the nurse practitioners out in the community, at what point do you recommend that if this is in an outpatient setting; that the child be brought into an emergency room?
Dr. McCulloh: What I most commonly recommend outpatient providers when I get the call is if you are in the first month of life, it is safe to report to – do your initial testing there in your clinic; urine testing what have you but for most of those kids, I would recommend that they get an evaluation at least in the urgent care or perhaps the emergency department if it’s a true fever which is measured rectally and is above 38 degrees Celsius or basically 101.4 degrees Fahrenheit, so a significant fever. Sometimes it’s a well appearing infant who maybe was bundled tightly and may have seemed warm and if they unbundle and observe in the clinic and they are well-appearing, and a repeat temperature is completely fine; the close observation and maybe follow-up the next day is reasonable. But the hallmark of what I tell outpatient providers is that it’s a combination of your clinical judgment with that parent’s comfort and with really good follow-up in that first month of life. And in the second month of life, like I said, we have more leeway and so a well-appearing infant there we could do our initial testing maybe all of it in the outpatient setting without having to go to an urgent care or an emergency department and for those low risk infants just plan for very close follow up and good instructions for observation for the parents, if they are comfortable with it.
Dr. Smith: Yeah and so Dr. McCullough just to kind of conclude our conversation here, what would you like people, specifically the community physicians, the nurse practitioners to really know and understand about fever in an infant?
Dr. McCulloh: Okay, I think there are three things that I think should be understood. One is that ensuring that we teach our parents the optimal way to take a temperature which is still recommended either rectally without any temperature correction or with excellent technique sometimes under the armpit can be acceptable. And that a fever in that first month of life greater than 101.4 or 38 degrees Celsius. And what I would recommend in the first and second month of life is if they are calling in with a fever, bring them in, have them seen, lay eyes on them. The most important piece is that history and that clinician’s exam because outpatient providers know their kids better than anybody.
Dr. Smith: Right, that’s very good advice Dr. McCulloh and I want to thank you for the work that you are doing at Children’s Mercy and thank you for coming on the show today. You’re listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information, you go to www.childrensmercy.org that’s www.children’smercy.org . I’m Dr. Mike Smith. Thanks for listening.
Bacterial Infection in Neonates and Young Infants
Michael Smith, MD (Host): So, our topic today is bacterial infection and fever in neonates and young infants. My guest is Dr. Russell McCulloh. Dr. McCulloh is the Associate Director the Infectious Disease Fellowship Program at Children’s Mercy Kansas City and he is a Professor of Pediatrics at the University of Missouri Kansas City School of Medicine. Dr. McCulloh, welcome to the show.
Dr. Rusell McCulloh, MD (Guest): Thanks for having me on.
Dr. Smith: So, infants with fever, right. How common is this? What is some of just the epidemiology around this presentation?
Dr. McCulloh: Well, fever in young infants is one of the most common reasons that they are brought to be seen in the emergency department or the outpatient setting and a lot of that is because there is a concern for a serious bacterial infection; something like bacteria infection in the urine or the bloodstream or even the spinal fluid that can be indicated just the presence of fever and no other initial signs or symptoms. It’s important to note though that it is most commonly when you are working with an infant with fever, that you are dealing with a viral infection or a simple uncomplicated infection. But it really takes having a discussion with a healthcare and a good thoughtful exam to really help suss that out for parents.
Dr. Smith: Well, I think you kind of already bring up one of the challenges, right bacterial versus virus. So, what are some of those other challenges that clinicians and healthcare providers have to face when they are presented with fever in an infant?
Dr. McCulloh: Well, the biggest issue is what is the appropriate evaluation based on an infant’s age and how they have been doing according to the parents and how they look on exam? And like I said, the most common thing that we encounter is viral infections; but there are certain bacteria that are commonly associated with infections in young infants. And in the office setting; which is the most common place where these infants are first brought; for infants in the first month of life in particular; the rule of thumb is often that you have to err on side of doing a bit more testing than may be ideally desired by the parents, to make sure that there is not an infection that if left untreated could result in some really serious illness.
Dr. Smith: So, you mentioned doing a little bit more testing. Let’s talk a little bit about that. So, what exactly are the current guidelines for working up an infant with fever and is there anything else that at Children’s Mercy that you guys like to do?
Dr. McCulloh: Right, absolutely. Well the first thing I would say is that we have had guidelines available for pediatricians for basically the last thirty years for helping evaluate these young infants. And they have not changed a whole lot during that time, though our vaccines and the diagnostic tests that we are able to do, have really moved forward. And so, a lot of the work that we do here at Children’s Mercy and that I do in particular is focused on trying to get some of this new testing and this new understanding of what causes these infections nowadays integrated into the care that these kids receive. But in terms of the testing that we talk about most commonly; you are testing three different sources on infants. One is urine to see if there is a urinary tract infection. One is the blood to see if there is bacteria in the blood and the third is spinal fluid to see if there is evidence of meningitis. And for infants under a month of age, those are the three routes of infection that are tested for and that are recommended to be tested for. In the second month of life, we can use some rules to help identify kids who can safely avoid getting particularly that spinal tap or that spinal fluid analysis at the beginning and can maybe be observed first.
Dr. Smith: So, let’s talk, so we are beginning that workup and speaking to the community physician, the nurse practitioners out in the community, at what point do you recommend that if this is in an outpatient setting; that the child be brought into an emergency room?
Dr. McCulloh: What I most commonly recommend outpatient providers when I get the call is if you are in the first month of life, it is safe to report to – do your initial testing there in your clinic; urine testing what have you but for most of those kids, I would recommend that they get an evaluation at least in the urgent care or perhaps the emergency department if it’s a true fever which is measured rectally and is above 38 degrees Celsius or basically 101.4 degrees Fahrenheit, so a significant fever. Sometimes it’s a well appearing infant who maybe was bundled tightly and may have seemed warm and if they unbundle and observe in the clinic and they are well-appearing, and a repeat temperature is completely fine; the close observation and maybe follow-up the next day is reasonable. But the hallmark of what I tell outpatient providers is that it’s a combination of your clinical judgment with that parent’s comfort and with really good follow-up in that first month of life. And in the second month of life, like I said, we have more leeway and so a well-appearing infant there we could do our initial testing maybe all of it in the outpatient setting without having to go to an urgent care or an emergency department and for those low risk infants just plan for very close follow up and good instructions for observation for the parents, if they are comfortable with it.
Dr. Smith: Yeah and so Dr. McCullough just to kind of conclude our conversation here, what would you like people, specifically the community physicians, the nurse practitioners to really know and understand about fever in an infant?
Dr. McCulloh: Okay, I think there are three things that I think should be understood. One is that ensuring that we teach our parents the optimal way to take a temperature which is still recommended either rectally without any temperature correction or with excellent technique sometimes under the armpit can be acceptable. And that a fever in that first month of life greater than 101.4 or 38 degrees Celsius. And what I would recommend in the first and second month of life is if they are calling in with a fever, bring them in, have them seen, lay eyes on them. The most important piece is that history and that clinician’s exam because outpatient providers know their kids better than anybody.
Dr. Smith: Right, that’s very good advice Dr. McCulloh and I want to thank you for the work that you are doing at Children’s Mercy and thank you for coming on the show today. You’re listening to Pediatrics in Practice with Children’s Mercy Kansas City. For more information, you go to www.childrensmercy.org that’s www.children’smercy.org . I’m Dr. Mike Smith. Thanks for listening.