History and Examination of Neonates
A thorough history is essential for all neonates with fever. Associated symptoms may be system specific (eg, diarrhea, cough) or nonspecific (eg, poor feeding, irritability, lethargy). Seizures have been reported in 20-50% of neonates with meningitis. Exposures to sick contacts in the household or daycare should be ascertained, as well as a recent history of a previous illness, immunization, or antibiotic use while in the birth hospital or since discharge.
Prenatal history
A review of the prenatal history, including maternal history of sexually transmitted infections (human immunodeficiency virus [HIV], hepatitis B and hepatitis C, syphilis, gonorrhea, chlamydia, herpes simplex), maternal group B Streptococcus (GBS) status and prophylaxis, mode of delivery, prolonged rupture of membranes, and history of maternal fever should be noted.
A birth weight of less than 2500 g, rupture of membranes before the onset of labor, septic or traumatic delivery, fetal hypoxia, maternal peripartum infection, and galactosemia are all risk factors for a serious bacterial infection in the neonate. Gestational age should be determined, because premature infants are at increased risk for serious bacterial infections. See the Gestational Age from Estimated Date of Delivery (EDD) calculator.
Nursery course
The neonate’s nursery course should be noted, including the age at which the patient went home from the nursery, whether or not a male neonate has been circumcised, and the use of peripartum or antepartum antibiotics. Any underlying diseases or conditions, as well as the use of medications that may increase the risk of infection, should be ascertained. Diet (ie, quantity and description of milk consumed; breast milk vs formula; and, if pertinent, the method the caregiver uses for preparing and storing the formula) and sleep histories should be obtained, because decreased oral intake or an acute change in sleep patterns may be clues to an invasive infection.
Household contacts
Any ill contacts in the household should also be noted. Exposure to any animals inside the home of the caregiver or outside the home (eg, in daycare facility) should be determined. The vaccination status of household members should be determined. A history of maternal fetal loss or death due to an infectious disease in a previous infant increases the suspicion of congenital anomalies and primary immunodeficiencies.
Identifying who is in the neonate’s household, who is the primary caregiver, contact with recent immigrants, and exposure to homelessness and poverty all impact the care the neonate receives.
Review of systems and physical examination
A thorough review of systems must be obtained to identify any other symptoms associated with the fever. A complete physical examination including vital signs (temperature 38°C = 100.4°F), pulse oximetry, and growth parameters with percentiles is necessary. General appearance should be noted for activity level, color, tone, and irritability. Signs of localized infection should be identified via a thorough examination of the skin, mucous membrane, ear, and extremities.
The presence of an umbilical stump after age 4 weeks should be noted, because it is a potential clue to leukocyte adhesion deficiency, and the lack of a circumcision in males should be noted, because it increases the risk for a urinary tract infection (UTI). In addition to fever, the most common clinical features of a UTI in a neonate include failure to thrive, jaundice (typically secondary to conjugated hyperbilirubinemia from cholestasis), and vomiting. Irritability, inconsolability, poor perfusion, poor tone, decreased activity, and lethargy can be signs of a serious infection in this age group.
Most neonates with bacterial meningitis have a full fontanelle with normal neck flexion at the time of presentation. Remember that neonates younger than 28 days with significant bacterial infections can appear to be at low risk when analyzing history, physical examination findings, and laboratory values; thus, a high index of suspicion must be maintained.
History and Examination of Young Infants
As is the case in neonates, a febrile infant aged 28-60 days may have symptoms that are nonspecific (eg, poor feeding, irritability, lethargy) or specific symptoms (eg, diarrhea, cough). History of exposure to sick contacts in the household or daycare should be obtained, as well as a recent history of a previous illness, immunization, and recent antibiotic use.
Past medical history and household contacts
The past medical history needed is essentially the same as in neonates. A prenatal, perinatal, and neonatal history should be obtained. Underlying diseases or conditions and the use of medications that may increase the risk of infection should be ascertained. In addition, as with neonates, diet and sleep histories should be obtained, because decreased oral intake or an acute change in sleep patterns may be clues to an invasive infection.
Exposure to any animals inside the home of the caregiver or outside the home such as in the daycare facility should be determined. A travel history of all household contacts should be obtained. The vaccination status of household members should also be determined.
As with neonates: (1) a family history of a previous death in a young infant from an infectious disease increases the suspicion of congenital anomalies and primary immunodeficiencies, and (2) identifying who lives in the household, who is the primary caregiver, exposure to any recent immigrants, and exposure to homelessness and poverty helps establish risk for infection and how to manage the patient.
Review of systems and physical examination
A thorough review of systems must be obtained to identify any other symptoms associated with the fever. A complete physical examination including vital signs (temperature 38°C = 100.4°F), pulse oximetry, and growth parameters with percentiles is necessary. A heart rate of more than 160 beats per minute in infants and a respiratory rate of more than 60 beats per minute are associated with an increased mortality risk and often signal the development of septic shock.
As with a neonate, general appearance should be noted for activity level, color, tone, and irritability. Irritability, inconsolability, poor perfusion, poor tone, decreased activity, and lethargy can be signs of a serious infection. Likewise, signs of localized infection should be identified via a thorough examination of the skin, mucous membranes, ear, and extremities. Lack of a circumcision in males should be noted.
Unfortunately, bacterial meningitis is often associated with minimal signs and symptoms in this age group, and a bulging fontanelle is a late sign. Nuchal rigidity is only present in 27% of infants younger than 6 months.
History and Examination of Children Aged 3 Months to 3 Years
The medical history should focus on factors that would predispose the infant or toddler to serious bacterial infection.
History of present illness
Documentation of the child’s temperature and how it was measured is essential. A rectal temperature of more than 38.5o C (101o F) is abnormal in this age group. In addition to identifying when the fever started and how long it has lasted, a detailed search should be made for other symptoms, including but not limited to diarrhea, vomiting, rhinorrhea, cough, rash, and changes in weight or feeding habits.
Past medical history
Every effort should be made to identify previous infectious episodes and risk factors for serious bacterial infections. Underlying chronic diseases, previous surgery, history of urinary tract infections (UTIs), and incomplete immunization to Streptococcus pneumoniae or Haemophilus influenzae type b must be specifically delineated. In children younger than 9 months, neonatal and perinatal history is also important.
Family history
Episodes of recurrent infections among siblings and first cousins or a history of maternal fetal loss raises suspicion of primary immunodeficiencies. Parental human immunodeficiency (HIV) status is essential information. A history of chronic infections (eg, hepatitis B, hepatitis C, tuberculosis) in the immediate or extended family is also important to obtain. The presence of acute illness in the family, such as croup or respiratory infection, is also important information.
Social history and household contacts
Animal, insect, and sylvan exposure; exposure to contaminated potable water and sewage; recent travel (particularly international travel); and attendance at daycare provide epidemiologic and environmental clues to the etiology of fever. Exposure to sick individuals outside of the household is also critical information.
Review of systems and physical examination
A detailed review of systems helps to identify other symptoms associated with fever. Important associations include rash, conjunctivitis, ear pain or drainage, lymphadenopathy, respiratory symptoms, changes in appetite, weight loss, diarrhea, vomiting, changes in frequency of voiding, pain with voiding, failure to bear weight, pain on passive motion of an extremity, and overt neurologic symptoms.
A careful and thorough physical examination is essential in the evaluation of the febrile child. Vital signs, including length and weight with percentiles, should be part of the evaluation. The child’s general state of nutrition, level of activity, and level of arousal should be noted.
Physical examination findings that suggest serious bacterial infections in febrile children (aged 3-36 mo) include ill appearance, fever, vomiting, tachypnea with retractions, and delayed capillary refill. These findings are associated with bacterial infection in more than 39.5% of febrile children aged 24-36 months and in more than 39% of children aged 3-24 months.
Close examination of the skin, lymphatics, eyes, ears, nose, and throat is necessary, because many febrile infants have viral infections with associated rashes or associated respiratory symptoms. Inspection and auscultation of the chest should be included in all evaluations. The abdomen should be inspected for signs of distention. Auscultation may reveal signs of ileus or hyperactivity. The extremities should be evaluated for capillary refill; range of motion, signs of infection, and local tenderness should be evaluated. Neurologic and developmental examinations appropriate for age should be performed.
