I have taken care of two 4-day old marginally hypothermic neonates in the
past two weeks.
The first one was sleeping a fair amount and not feeding great at home
(feeding frequently but not for a long time), but looked quite good (under
the warmer), good tone, active, eyes open, vitals good. So I did everything
short of the LP and thought I would watch the baby for an hour and get a
sense of what is going on. Very ambivalent about pulling the final trigger.
Had a "spell" during the observation period and I completed the septic
workup. Which prompted me to ask myself, what was I thinking?
The second kid looked quite well too, but I was less "thoughtful" and just
did the workup.
The first kid did well and my initial clinical impression that the kid was
not septic turned out to be correct.
But even though I was "right", it reminded me that we must always be
cautious about exercising any "judgment" at this age. What good reason is
there NOT to do the entire workup and what does "well-appearing" mean in a
4-day old anyway. I think that there are two exams in a 4-day old: looks
bad and looks like a 4-day old. I am not sure that there is "good", at
least good enough to comfortably exclude badness.
Which means that the workup needs to be based on other data, i.e. temp,
behavior (as reported by parents). And in general, these kids do not
present to the ED with isolated low temperature; they present with some
other, often vague, concern and low-ish temperature is noted on assessment.
As Peter noted, we are more used to responding to high temps in the less
than one month old. But I am not sure that this kid even belongs in that
category. A 4-day old is so much different than a 14 or 21 day old and I
suspect (but don't know) that hypothermia as a sign of infection is
actually more common than hyperthermia at this age. (Does anyone have
another opinion on this?)
So what's my point? I am a *huge* believer in practicing clinical medicine
and using algorithms as a guide, not a strict approach. But for me these
two cases were real time reminders that at this age we (or I) must be
cautious about exercising positive judgments. From a cognitive theory
standpoint, confirmation bias (deciding that the kid looks good and
interpreting other data, i.e. the presenting and vague concern, in a way to
support this assessment) is a real risk, especially in the neonate, no
matter what the concern.
I apologize to those of you who had to read this and who also immediately
thought, what WERE you thinking? (But James did point out that there was
some discussion at his institution....in the abstract). So I share my not
so abstract imperfections.
On Wed, Feb 26, 2014 at 1:11 PM, james reingold
<[log in to unmask]>wrote:
> Hello List,
> An interesting debate has broken out in our department over hypothermia in
> infants 0-30 days of age. The case in question was a 4d old who presented
> for jaundice and was noted to have a temp of 36.2C rectal in triage, 35.8C
> rectal when moved to the exam room. The mother said the baby had been
> feeding poorly and wasn't very active but the baby looked fine in the ED.
> Some docs have said they would perform a full r/o sepsis eval. Others
> have felt that as an isolated finding the low temp was not worth pulling
> the trigger since the child had a normal exam otherwise.
> Specific questions:
> 1. What is hypothermia in this age group? Some have cited <36.5, other
> <36.02. Is hypothermia as iron-clad an indication for r/o sepsis as fever?
> We perform the r/o sepsis eval for 100.4F or greater even if everything
> else is perfectly fine. Is it the same for hypothermia?3. Does the
> complaint of jaundice, which we know can be caused by infection, change
> anyone's approach to the low temp?
> Appreciate everyone's expertise and input.
> James Reingold, M.D.
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
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