Approach to the ill-appearing infant (younger than 90 days of age)
- Richard J Scarfone, MD, FAAP
Richard J Scarfone, MD, FAAP
- Associate Professor of Pediatrics
- University of Pennsylvania School of Medicine
- Christine Cho, MD, MPH, MEd
Christine Cho, MD, MPH, MEd
- Associate Professor of Clinical Pediatrics
- University of Southern California Keck School of Medicine,
- Children's Hospital Los Angeles
- Section Editors
- George A Woodward, MD
George A Woodward, MD
- Section Editor — Pediatric Signs and Symptoms
- Professor of Pediatrics
- University of Washington School of Medicine
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The approach to the ill-appearing infant is reviewed here. The evaluation of fever in infants younger than three months of age is discussed elsewhere. (See "Febrile infant (younger than 90 days of age): Outpatient evaluation" and "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm infants".)
Although infection is the most likely cause of ill appearance among neonates and young infants, a number of other clinical conditions have similar manifestations (table 1).
Infectious causes — Absence of fever does not exclude infection. Young infants with normal or low core temperatures may have serious infections. For example, hypothermia (rectal temperature <36.5°C [97.7°F]) is associated with systemic herpes simplex virus (HSV) infection, and many infants with pertussis are afebrile. (See "Bacterial meningitis in the neonate: Clinical features and diagnosis", section on 'Temperature instability'.)
●Bacterial sepsis – Infants can develop sepsis from infections such as urinary tract infections (UTIs), bacteremia, meningitis, pneumonia, skin abscess or cellulitis, mastitis, omphalitis, bacterial gastroenteritis, septic arthritis, or osteomyelitis. (See "Febrile infant (younger than 90 days of age): Outpatient evaluation", section on 'Invasive bacterial infection (IBI)'.)
Possible pathogens include the following:
- Tzimenatos L, Bond GR, Pediatric Therapeutic Error Study Group. Severe injury or death in young children from therapeutic errors: a summary of 238 cases from the American Association of Poison Control Centers. Clin Toxicol (Phila) 2009; 47:348.
- Kang AM, Brooks DE. US Poison Control Center Calls for Infants 6 Months of Age and Younger. Pediatrics 2016; 137:e20151865.
- American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics 2001; 108:776.
- Bertino E, Varalda A, Di Nicola P, et al. Drugs and breastfeeding: instructions for use. J Matern Fetal Neonatal Med 2012; 25 Suppl 4:78.
- Pollack ES, Pollack CV Jr. Incidence of subclinical methemoglobinemia in infants with diarrhea. Ann Emerg Med 1994; 24:652.
- Murone AJ, Stucki P, Roback MG, Gehri M. Severe methemoglobinemia due to food intoxication in infants. Pediatr Emerg Care 2005; 21:536.
- Piatt JP, Kaplan AM, Bond GR, Berg RA. Occult carbon monoxide poisoning in an infant. Pediatr Emerg Care 1990; 6:21.
- O'Sullivan BP. Carbon monoxide poisoning in an infant exposed to a kerosene heater. J Pediatr 1983; 103:249.
- Bonadio WA, Clarkson T, Naus J. The clinical features of children with malrotation of the intestine. Pediatr Emerg Care 1991; 7:348.
- Infectious causes
- - Bacterial infections
- - Viral infections
- Child abuse
- Surgical conditions
- Congenital heart disease
- Congenital adrenal hyperplasia
- Inborn errors of metabolism
- Cystic fibrosis
- Acquired glucose or electrolyte disturbance
- Other conditions
- INITIAL STABILIZATION
- EMPIRIC THERAPY
- Prostaglandin E1 (alprostadil)
- Stress-dose hydrocortisone
- - Nonspecific symptoms
- - Specific symptoms
- - Other history
- Physical examination
- Ancillary studies for infectious etiologies
- TARGETED EVALUATION
- Respiratory distress
- Abnormal cardiovascular examination
- Vomiting or abnormal abdominal examination
- Musculoskeletal findings
- Abnormal studies
- - Abnormal cerebrospinal fluid
- - Abnormal chest radiograph
- - Pyuria
- - Metabolic acidosis
- - Abnormal blood chemistries
- SUMMARY AND RECOMMENDATIONS