I am always intrigued when a mom starts a visit with the phrase, "I'm probably over-reacting but...". More times than not we are both surprised by what unfolds during the course of the exam. Such was the case when Mrs. X. brought her three week old son, Brody, to the office. Call it coincidence, call it maternal instinct, or call it just plain luck, but Mrs. X. felt compelled to bring him into the office that day. Everything seemed to be O.K., but she just wanted to be sure. After all, Brody's three month old cousin had just gone to his doctor because he had a fever. His mom was told that he had a virus and it was not anything serious. She was told to give him plenty of fluids, and something for the fever. Mrs. X. wanted reassurance that Brody was all right...it was like a sixth sense that drove her.
"You're gonna think I'm one of those nervous moms," she started in. "Brody just seems a little off," she explained, "He is eating fine, but may be a little fussy. I just want to be sure that he didn't pick up his cousin's virus," she went on.
I asked about fever and she said that she took it under his arm and it seemed normal. He was breast feeding "like a champ" and there was no diarrhea or vomiting. He did not have a rash, and there wasn't as much as a sniffle. As I examined Brody, he was alert, and admittedly a little fussy. The soft spot on his head was soft and flat which suggested that he might not have meningitis. His ear drums were clear and there were no oral lesions like canker sores. His heart, lung and abdominal exams were normal as well. He moved all his joints normally and I told mom that his exam was textbook perfect. She sighed a big relief.
Looking at the chart I noticed that there was no temperature recorded. Mom apologetically explained that she had asked the nurse to hold off on taking the temp. unless it was absolutely necessary. I told her that a rectal temp. was in no way dangerous or harmful to the baby, and that it was the most accurate way to determine a fever. It was very important to do this so I called the nurse in the room.
Brody had a perfectly normal exam and this relieved mom greatly. But his temperature was 100.8 degrees. Mom broke down and cried when I told her that Brody would have to be admitted to the hospital. There was disbelief in her voice when she cried, "There must be a mistake---Are you SURE?"
There was no mistake. Brody's fever, by virtue of his age, meant that he had to be admitted to the hospital and treated with antibiotics. I explained to Mrs. X. that it is the standard of care in this country that when a newborn (a baby in the first month of life) has a documented fever greater that 100.4 degrees rectally, they are treated in order to rule out sepsis which means that they are treated AS IF they have an infection. The reason for this is that the immune system of a newborn is not fully developed. They are not able to localize or handle infections very well. Instead of walling off an infection to the ear (ear infection) or to the lungs (a pneumonia), the bacteria can make their way to the blood stream and lead to a life-threatening infection. All of this can happen with no obvious signs of illness other than fever.
It is widely accepted therefore, that when a newborn has a fever and is admitted to the hospital, a blood culture, a urine culture and a spinal tap with culture of the spinal fluid is done. These are performed to try to grow and identify the bacteria if present from all possible sights. After these are sent to the lab, the baby is immediately started on antibiotics "assuming" that there is an infection. The antibiotics chosen (usually two) are a combination that will treat ALL possibilities. To reiterate, a fever in a newborn may be an insignificant virus...or it may be a deadly bacterial infection. There is no way of predicting, and one is not afforded the luxury of waiting a day or so to see how the baby does.
In most cases, if the cultures are negative for bacteria and the baby has done well in the hospital, they can go home with the parents at 48-72 hours without antibiotics. What happened to Brody was a testament to why we do what we do. He was admitted, had the labs done and was started on antibiotics. The next morning he looked fabulous. Alert and content, he didn't have a fever since he was admitted the day before. When I made my rounds and was talking to mom, the resident came by and remarked how well Brody had done. Kiddingly she said, "It's almost a shame that he had that temperature. This could have been avoided". While we were standing in Brody's room, his nurse came running up with a fax from the lab. Brody's blood culture was positive for a bacteria. The resident looked stunned and said, "Wow! Thank God he was treated".
Mom, too, was thankful that Brody was in the hospital and getting antibiotics. She then paused and in deep reflection asked, "What would have happened if I hadn't brought him to the office...or we hadn't taken his temperature?" When I explained that he could have become very ill, and even have died, all the color left her face. In a contrite voice she lamented, "I almost didn't bring him in. What if...?" I interrupted her and took her arm and reminded her that it was SHE that brought him to the office, and that it was SHE that sensed something was not right. Coincidence? I think not. I have learned over the years that when a mom tells you that something is wrong with their child, the doctor or nurse had better take heed.
Brody received a total of ten days of antibiotics and never looked the least bit ill. He went home with mom and dad without incident. He is now a thriving and happy 4 month old. This brings me to my opening statement. I am always intrigued when a mom says, "It's probably nothing, but...". One never knows what journey is about to unfold.