For decades, care for febrile infants between the ages of eight and 60 days has varied greatly, with some observed in the emergency room for only a few hours and others receiving full treatment, including a lumbar puncture and other invasive tests and hospitalization. may take up to five days.
But a new set of guidelines published in Pediatrics will help doctors decide which of these extremely vulnerable babies should be hospitalized and extensively tested and which not. And because the recommendations go hand in hand with the imprimatur of the American Academy of Pediatrics, they are likely to be followed by the vast majority of doctors.
“Most of these babies never get a fever, but when they do, it can be quite scary,” says Dr. Sean O’Leary, a co-author of the guidelines, vice chair of the Committee on Infectious Diseases of the American Academy of Pediatrics, and a professor of pediatrics at the University of Colorado, Anschutz Medical Campus. “What’s good about these guidelines from a parent’s perspective is that they’re based on all the science accumulated over the decades about how to treat a baby with a fever.”
For parents who don’t want a serious illness to be missed but don’t want their babies to receive comprehensive treatment that the baby doesn’t need, “they’re good news,” O’Leary said.
Any time a baby under 60 days develops a fever, even though the baby looks otherwise healthy, parents should contact their pediatrician for advice, O’Leary said. In older babies, the parents wait a day or so to see if the fever goes away.
This is the first effort to standardize care for babies with fever in this age group, said Dr. Eric Biondi, an associate professor of pediatrics at the Johns Hopkins School of Medicine and director of pediatrics at the Johns Hopkins Children’s Center in Baltimore.
These guidelines apply to babies who “look otherwise fine and just have a fever,” Biondi said.
“The problem is that these babies can’t tell us much and their immune systems aren’t as strong as they will be when they get a little older,” he added. “A little fever can be a sign of a serious bacterial infection, such as bacteria in the blood, meningitis or a urinary tract infection. That’s why we probably overdiagnosed, treated too much, did too many lumbar punctures and were hospitalized for a long time.”
Until now, the kind of care a baby received depended on where they were treated, Biondi said. “In one place, they can get a lumbar puncture, have invasive tests and be hospitalized,” he added. “The same baby in a different hospital may get a few hours of observation in the emergency room.”
Even with the new guidelines, “there will always be a subset of babies who get the full workup,” Biondi said. “But we can try to avoid doing that for every baby.”
The recommendations are also intended to encourage shared decision-making between the pediatrician and the family, Biondi said. In certain scenarios, there is a 1 in 1,000 chance that the baby will have meningitis, he added.
“Maybe the family thinks that risk is okay and they don’t want a puncture of the wood and they don’t want the baby to be hospitalized,” Biondi said. “Or the parents might say that’s too much of a risk, please admit the baby and rule that out.”
Involving parents will also help the doctor get a clearer picture of what’s going on with the baby, said Dr. Pamela Schoemer, a pediatrician and director of quality, safety, and outcomes at UPMC Children’s Community Pediatrics in Pittsburgh. “This reinforces doctors that they should discuss everything with families.”
Prior to the new guidelines, “we had one setup for all these babies,” Schoemer said. “This stratifies the children at risk.”
While some children have markers that indicate they are more at risk, “and maybe those babies should stay in the hospital and get IV antibiotics,” Schoemer said. “But some may just need to be observed and that may be something that can be done at home.”