When you get to either urgent care or the ER, a few different people are going to ask you a laundry list of questions about your child’s fever and associated symptoms (I mentioned a bunch of these in my last post). Again, it’s a good idea to really think through these things so that everyone gets a good story, and it’ll make the whole process more efficient and more likely to get the right diagnosis and treatment. It’s our primary goal to identify or rule out the most serious possible diagnoses first, then narrow it down from there.
I will reiterate this point 374682765 times on this blog in many contexts, but remember that you know your baby more than anyone else in the universe. Your opinion matters and your gut feeling matters. Don’t be afraid to ask questions and put your foot down if you feel like we’re overlooking or missing something. A good doctor will take your input to heart and, if they disagree, will diligently explain their clinical reasoning.
What we worry about the most are serious bacterial infections (SBIs). These include things like bacteria in the blood (bacteremia), urinary tract infections, pneumonia, skin infections, bone and joint infections, intestinal infections, and brain infections (meningitis). All of these things are crucial to rule out as soon as possible because they can be life threatening if they aren’t treated early. This is where vaccine history becomes really important, too–if your child is up to date with all of their required vaccinations, we can rule out some of the most deadly infections right away.
What happens next is largely based on age. Essentially, the younger the child, the more diagnostic tests we’ll perform regardless of symptoms and the greater the odds that we’ll want to admit them for observation. Keep in mind that every hospital and individual provider will have some variations in their approach, but most of what we do is based on the most current research and guidelines by our governing bodies. Basically, what we do is guided by the best science we have at any given time.
No matter how old the child is, we start with a complete physical and neurological exam and re-take their temperature. We are especially looking for signs of distress (inconsolable crying, drowsiness, lethargy, moaning, etc), signs of respiratory distress (blue color, shortness of breath, slow or rabid breathing, or irregular breath sounds), rashes, dehydration, abdominal pain, head or neck pain, etc. If there’s evidence of a sore throat, we’ll probably do a rapid strep test and during flu season, we will most definitely swab for flu as well.
Under 30 days old: We throw the book at newborns because they’re the most vulnerable and difficult to diagnose. We run pretty much every test we have and are very likely to admit them. Regardless of accompanying symptoms, we take blood and urine and get a lumbar puncture (also known as a spinal tap). If the baby has any diarrhea, we will get a stool sample. We will very likely get a chest XRay to evaluate for pneumonia.
1-3 months old: These kids will automatically get blood and urine taken as well. However, we won’t do the lumbar puncture if the baby isn’t having any neurological symptoms or signs of a more serious infection in their blood or urine (based on white blood cell counts). If the baby has any diarrhea, we will get a stool sample. We won’t get a chest XRay unless there are respiratory symptoms or signs of more serious infection on labs and urine.
3 months to 3 years: We’ll run blood and urine like before. All children under 2 years get a urinalysis and urine culture no matter what. We won’t do a lumbar puncture unless there are neurological symptoms, regardless of blood and urine results. Again, stool sample if there’s diarrhea.
Ok, so after you’ve been in the ER or urgent care for what seems like forever and your poor baby gets poked and prodded by a hundred different people, we will determine if we think that the fever is likely to be a serious infection or not and what we’d like to do about it. If it’s more likely than not that the infection is bacterial–and keep in mind that we are more cautious the younger the child is–then we’ll start the child on antibiotics based on where we think the infection is coming from. Based on vital signs, test results, and our overall feeling about the patient’s condition, we may decide to admit the child for a day or more to make sure they respond to treatment. Or, we may send you home, but with strict instructions to administer medication and follow up as soon as possible with your pediatrician or family doctor.
Having to run your sick baby to the emergency room is never anyone’s idea of a good time. Trust me, I know. Hopefully if and when it happens, I hope that this post gives you a better idea of what to expect and a little insight into the rhyme and reason for the tests and exams we do. It’s exhausting and frustrating for a lot of parents, but we always have the health and wellbeing of the child forefront in our minds for every decision we make. Again, we approach each patient with the hope that we can first exclude the most serious infections–we aren’t trying to scare you–then work our way down to the most likely causes of fever based on our battery of test results. Because they’re so young and more vulnerable than healthy adults, we err much more on the side of caution than we would with older patients and are more likely to prescribe antibiotics or admit to the hospital.
As always, prepare yourself by asking yourself questions about your child’s symptoms and medical history before you arrive and don’t be afraid to ask any and all questions about what’s happening. We’ll all get through it together 😉
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