Fever is one of the most common complaints associated with neonates. Children younger than 3 months have higher risks for serious bacterial infections due to having an immature immune system.

Newborns that breastfeed have an advantage of keeping and maintaining the maternal immunity factors inherited at birth, but all neonates have some degree of immunological immaturity and therefore no neonates are immune from the risk of infection.

Infection most commonly presents initially with a fever. Neonates and young infants may manifest fever as the ONLY sign of significant underlying infection. The incidence of serious bacterial infection (SBI) such as urinary tract infection, bacteremia, meningitis, and pneumonia is higher in infants younger than three months of age, particularly those under 28 days, than at any other time in childhood

 

Definition

• Fever is a symptom.
• Temperature is a sign.

However, in the field, there is no clinical downside to using these terms interchangeably, as they often are.

Although most can subjectively ascertain that their child may have the symptom of fever, there is no diagnosis without measuring the SIGN of documented temperature. Because you are obligated to believe the report of a caregiver, however, this distinction is irrelevant in the field. Indeed, often caregivers report an elevated temperature in an infant who is afebrile at the time of evaluation. As EMS providers, however, you have an obligation, first, to believe any complaint, and then determine its relevance only after appropriate evaluation.

Although the terms "fever" and "temperature" are used interchangeably, rectal temperatures are the standard for detecting fever in infants less than three months of age.

A rectal temperature of 38°C (100.4°F) or greater is generally regarded as "fever" in infants 90 days of age and younger.

 

Why Fever?

The science of fever is still not straightforward. Some investigators claim that fevers are a limited ability of the body to control the temperature in response to infection. Others say that fever is a central nervous system (glial) "sickness response" to speed up recuperation via heat-mediated enhancement of the biochemical reactions that are necessary for healing. (In chemistry, heat is a catalyst in chemical reactions.) Regardless of whether fever is a result of--or a remedy for--sickness, a body temperature that is too high can injure a neonate.

 

Risk Factors for Neonatal Fever

Risk factors for neonatal fever include

• dehydration and
• infection.

It is important to understand that fever is a symptom, not a disease itself. The underlying causes, such as dehydration, infection, or other conditions, are responsible for the fever. However, if a newborn's temperature rises very high, the fever can lead to its own complications, potentially becoming a serious medical issue. Extremely elevated temperatures can result in problems like seizures or brain injury, so careful evaluation and treatment of neonatal fever are essential.

 

When Fever Becomes Its Own Disease

At what point does an elevated temperature itself become a danger? This varies from neonate to neonate. Certainly, every neonate can cross some absolute value above which there is danger and/or injury.

Another consideration is that some children may suffer seizures not necessarily based upon the amount of fever (which can happen), but on how fast the temperature changes.

For example, a baby who has 102° temperature may be in less danger than a baby who went from 98° to 101.5° in just minutes. Downward trends that are too fast are concerning as well, requiring pediatric medical consultation/direction before using antipyretics or more dramatic remedies such as cooling methods (water immersion, etc.)

 

Signs and Symptoms of Fever

• Mental: changes in mental status such as irritability or an inability to stay awake can be found in febrile neonates.
   
• Activity: febrile neonates will have increased work with breathing, demonstrated by the signs of hypoxia, i.e., nasal flaring, etc. They may also exhibit signs of lethargy.
   
• Skin: febrile neonates can be warm to the touch. There may be decreased perfusion leading to mottling of the skin or decreased capillary refill.

Make sure to observe patients for rashes and petechiae.

Petechiae are ominous findings indicating coagulopathy--thrombocytopenia--seen in serious, life-threatening infections such as meningococcemia meningitis. (Rashes blanch on pressure; petechiae do not.)

Premature infants may have no visible sweat, while term newborns will produce sweat on the brow but not on the rest of the body.

 

Management of Fever in Neonates and Infants

In the field, managing the febrile neonate consists mainly of supporting the ABCs (airway, breathing and circulatory function of the neonate).

The administration of antipyretics such as acetaminophen should be done only under medical direction when local protocols and indications allow. Just as there is danger with too fast a rise in temperature, likewise, a temperature that plunges too quickly can be dangerous.

The U.S. Food and Drug Administration initiated the process for a label change for acetaminophen (Tylenol and similar products) to reflect evidence suggesting that the use of acetaminophen by pregnant women and young children may be associated with an increased risk of neurological conditions such as autism and ADHD in children.

Keep the patient calm and maintain good communication with the parents. Transport under medical direction or according to EMS protocol.