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This is in reference to the recent article by Maayan-Metzger et al.1 The clinical implication of the study is questionable. It is difficult to make a prospective decision on retrospective data. What should a clinician do if a healthy asymptomatic 3 day old baby has a fever of 37.9°C? There is no problem in labelling the infant as having non-specific fever, which may be due to dehydration. The problem is to decide on the treatment. Unfortunately, the study in question not only lacks that information but also supports treatment with antibiotics. This inference is drawn from the results of the study, stating that 108 of 122 healthy asymptomatic babies (that is, 88%) were treated with antibiotics.
In five years (January 1997 to December 2001), 122 cases were identified with fever giving a rough figure of 25 febrile cases in one year—that is, about two cases a month. A prospective follow up of these febrile neonates after separating them into two groups, one receiving antibiotics (treatment group) and the other not (observation group) carried out in an ethical way, would be more informative for clinical decision making. Merely adding the risk factors in the list of possible causes for fever in neonates without solution or how one should deal with it is of very little clinical worth. It would be very brave of a paediatrician not to treat neonatal fever with antibiotics on the basis of the inference drawn from this study, but would it be wise and safe? These are the questions we should be struggling to answer.
I have reservations about the authors’ “standard work up protocol”. A cerebrospinal fluid analysis on asymptomatic, otherwise healthy neonates with fever is probably unwarranted. I think it is unwise to perform a spinal tap on a baby with suspicion of dehydration fever. In other words, if one suspects meningitis in a neonate, it is not fair to withhold antibiotics. About the treatment protocol, the authors treated 107 infants with antibiotics unnecessarily; only one had a positive culture. This approach of empiric antibiotic use needs critical appraisal in the protocol of the institution.
Fever without symptoms is not uncommon in healthy, full term babies in the postnatal ward. To carry out a prospective study on these babies would be feasible. There are two issues that need clarification, how to investigate and how to treat. I do not think that there is much controversy about investigating a febrile neonate. With our present knowledge, any febrile neonate with fever, irrespective of symptoms, should be investigated appropriately with full blood count and blood and urine cultures. It is the treatment that is the root of the controversy and needs further evaluation. However, in view of the present study, in spite of a promising conclusion, fever in healthy neonates should not be treated as something benign and dealt with casually.
Having said all this, I appreciate the methodology of the study and the authors’ endeavour to look further into the issue of fever in neonates. I hope my suggestion will generate intense discussion and not just be taken as a critical review of the paper. Lastly, in my view after reviewing the above paper in detail, dehydration still remains a diagnosis of exclusion, just as we take transient tachypnoea of the newborn as a diagnosis of exclusion in cases of respiratory distress in neonates.
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