Admission Criteria Must Take Fever Into Account
John W. Graef, MD, chief, Services Office at Children’s Hospital, Harvard Vanguard Services Office, Boston, responds: “The presence or absence of fever is an important variable. Dipstick urines are shortcuts and don’t provide such information as the presence or absence of casts, although the fact that the child is vomiting and irritable is suggestive of pyelonephritis as opposed to a simple UTI/cystitis. [The scenario doesn’t] mention how the urine is obtained. Presumably it is a cath specimen, but that needs to be specified.
“Jaundice can occur with a UTI, but usually in the first week or so of life. A 32-day-old infant with pyelo is unlikely to be jaundiced unless for some other reason.
“I certainly agree with routine admission of a febrile infant up to one month, but not necessarily an otherwise well female infant. The presence of vomiting and irritability with or without fever might prompt a full septic work-up, in which case the decision to admit an afebrile infant would depend on the results of the CBC/UA and probably an LP. A blood culture and CBC should be drawn in the ED.
“In other words, one can’t have it both ways. If the irritability and vomiting are due to pyelo, a septic work-up is warranted. If all parameters are normal, the only reason for admission is hydration of a vomiting infant. If the infant was afebrile and had an uncomplicated UTI, I would not automatically admit an otherwise well 32-day-old.
“Poor PO (per OS, i.e., oral, by mouth) intake in an infant with a UTI warrants IV fluid regardless of age.”
—John W. Graef, MD
True Emesis With Decreased Oral Intake Indicates Admission
Erin R. Stucky, MD, pediatric hospitalist, Children’s Hospital and Health Center San Diego, associate professor, UCSD Pediatrics, responds: “The decision to admit or discharge this one-month-old with vomiting, jaundice, poor eating, and irritability should include consideration of hydration status, toxicity, sepsis potential, and ability to secure close follow-up. We will make the assumption that the infant is term, with no past medical history, family history, or prenatal evaluation that would put the infant at greater risk for sepsis or likelihood of underlying anatomic genitourinary abnormality. In addition we will assume that the urinalysis was performed by catheterization in a non-pretreated infant.
“A careful history should elicit the change in urine output, frequency, and volume of emesis to contrast with small ‘spit-ups,’ and change in feeding duration or volume. Observation of a feeding in the office or emergency department can be of great value in determining likelihood of ability to maintain hydration at home. Feeding type should be confirmed [because] parents may dilute or alternately concentrate formula in response to vomiting. In this scenario, true emesis in an infant with decreased oral intake would be grounds for admission, intravenous hydration, and evaluation of electrolytes.
“A newly irritable infant evokes a visceral sensation for all pediatric hospitalists. An irritable one-month-old may be suffering from a single system infection, electrolyte imbalance, or other insult, but unfortunately may just as easily have multisystem involvement. Vital signs and physical exam findings of toxicity, such as tachycardia and delayed capillary refill, are not known to us. The presence of jaundice raises concern for cholestasis induced by E. coli or possibly rarer metabolic disease, such as galactosemia. Admission would allow for evaluation and monitoring of the more likely causes of irritability in our index patient, which include sepsis, meningitis, and electrolyte and acid-base imbalances.