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addition to sending bacterial culture and starting broad-spectrum antibiotics,
consider stool and CSF isolates for viruses.
If the physical examination suggests a specific problem, it may be necessary to
obtain additional tests ( Table 73.3 ). Pallor, cyanosis, or cardiac abnormality
(muffled heart sounds, murmur, unexplained tachycardia, or arrhythmia) raises
concern for various cardiac disorders or methemoglobinemia. An ECG, arterial
blood to measure PaO 2 , and possibly an echocardiogram should then be
obtained. Unusual neurologic findings, such as a bulging fontanel, warrant a
lumbar puncture and previously mentioned blood studies to rule out meningitis. A
seizure should prompt a CT scan, EEG, and culture and treatment for herpes
simplex infection. Retinal hemorrhages may suggest an intracranial bleed and,
thus, a noncontrast CT scan, MRI, and lumbar puncture would be valuable
studies. Likewise, abdominal distention, rigidity, mass, or bloody stools indicate a
gastrointestinal emergency. In such cases, abdominal radiographs, ultrasound, or
air-contrast studies are important diagnostic aids in addition to a sepsis workup.
If the physical examination reveals bruises or purpura, evaluate for child abuse,
coagulopathy, and sepsis. Obtain long bone radiographs, coagulation profile
(including platelet count). If vesicular lesions are seen on the skin, obtain a PCR
and culture for herpes. If ambiguous genitalia are noted, send blood for 17hydroxyprogesterone, renin, aldosterone, and cortisol levels to rule out CAH (see
Chapter 89 Endocrine Emergencies ). Finally, if wheezing is detected on chest
examination, consider a nasopharyngeal swab for rapid detection of RSV and
consider a chest radiograph.
Suggested Readings and Key References
Sepsis
Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” approach
in the management of young febrile infants. Pediatrics 2016;138:e20154381.
Kuppermann N, Dayan PS, Levine DA, et al. A clinical prediction rule to identify
febrile infants 60 days and younger at low risk for serious bacterial infections.
JAMA Pediatr 2019;173:342–351.
Polin RA; Committee on Fetus and Newborn. Management of neonates with
suspected or proven early onset bacterial sepsis. Pediatrics 2012;129:1006–

1015.
Scarfone R, Gala P, Murray A, et al. ED clinical pathway for evaluation/treatment
of febrile young infants (0-56 Days Old). The Children’s Hospital of
Philadelphia. 2010. Available online at />