Tylenol for newborn fever?

Specialties Ob/Gyn

Published

I became an RN last summer and was hired onto a Family Birthing unit. I have done postpartum since August and began L & D training last month. Doing PP I have had a few baby's go south and so I am very vigilant with them. Two nights ago during a NSVD recovery, I noticed both mom and baby temps rising every 15 minutes. This was a midwife delivery and there were many variable and some late decels the last four hours of labor during which my preceptor and I continually monitored, turned the pt, bolused, had her on 10 L O2 via face mask etc, as well as frequent contact with the midwife. The baby had yellow mec on it's back at birth.

An RN from our special care nursery caught the baby and was with her the first 20 minutes or so. I received an order for ibuprofen when mom's temp was 100.9. When I checked baby hers was 100.7, the nursery nurse was still at our desk so she offered to do a rectal temp, which was 100.9. I called the midwife again about baby and was given an order for Tylenol. She couldn't give me a dose so I called down to the nursery and asked what the normal dose is for a newborn.

At this point the nurse who answered the phone read me the riot act that I had just accepted an unsafe order and needed to call back and refuse it and demand a septic workup. I called back and (politely) mentioned that there was concern the child needed a workup and she ordered a CBC, CRP and blood culture. The nurse who caught the baby had been discussing the hx with the one who answered the phone. When I took baby to them to have the blood drawn I was given a stern talking to about never,ever, EVER giving Tylenol for newborn fever as it can mask the signs of infection. I was unaware of this and so were several of my coworkers, and some of them are quite seasoned OB nurses.

So... my question is, is this always true? Is it ever appropriate to give a newborn with a temp tylenol? I want to the best I can by my patients.

Thanks for taking the time to read this.

Specializes in Cardiac.

Great question! I learned alot.

Specializes in OB, Hospice.

Thank you all for your replies. I learned so much from them, particularly those of Jolie, babyktcher and rn/writer. I was already sure I would not accept that order again out of fear of doing the wrong thing, but now that I understand why I can feel confident in that decision.

from Jolie : “The immune system of a newborn baby or young infant (even a healthy, full-term baby) is immature and can't be relied upon to act in the same way as the immune system of an older child or adult. Fever in any infant 6 months or younger must be evaluated medically. Also newborns and young babies are typically unable to "localize" their symptoms. A baby with a relatively minor infection such as a UTI or ear infection will present much the same way as an infant with a serious infection such as pneumonia, meningitis or sepsis. Their symptoms are vague and non-specific and the only way to determine a minor illness from a potentially life-threatening infection is to do a thorough work-up.

While the use of antibiotics is appropriately dropping in most patient populations, the newborn infant is one patient who may need antibiotics based upon a presumptive, rather than proven infection. While practices vary somewhat, in most cases, if there is a high index of suspicion, a septic work-up is done and a baby placed on broad spectrum antibiotics while awaiting the results of cultures. To do otherwise may allow an infection to progress to a dangerous point.

If culture results all come back negative, then antibiotics will be stopped. If they come back positive, they will be modified to medications that are specific to the bacteria identified.

As for fever, the baby in your care likely had an elevated temp due to his surroundings and activity prior to birth. If mom had a temp, baby was exposed to a "sauna" prior to delivery. Also the work of labor and delivery may result in some temp elevation of both mother and baby. It was important for you to be able to continue to monitor the baby's actual temp after delivery (without interfering factors such as Tylenol or bathing), both of which would likely lower his temperature regardless of infectious process, and skew your information.

Finally, what may be even more dangerous in a newborn than a fever (which helps to fight infection) is a sub-normal temperature. Babies who are too sick to maintain their own body temperature will have a sub-normal temp. This is a danger sign that an infant is very ill..”

I really didn’t have a good understanding of any of this until your excellent explanation. Thank you so much for taking the time to write it! I just learned a lot. I’m also left wondering why the infant received a bath in the nursery an hour after I took her down there.

from babyktcher " All of this happening in the recovery phase? I would think to wait to do such drastic measures. This woman has just pushed out a baby, worked hard at it, and the baby has been thru a rough phase itself. Why not give it an hour or so for everyone to normalize and then evaluate for some pathology."

This is the same rational I heard from the experienced L&D nurses, that the infant may have been transitional and could normalize, so give it a little more time. What alarmed me about the mother's temp was that it was consistently in the 97s throughout labor and eventually rose to 102.0 before starting the come down.

"Do midwives generally order for newborns in your facility and not the pediatrician?"

In this particular instance the CNM was the provider for both mom and baby. This incident came to the attention of the head of all departments involved and is being reviewed I believe for the purpose of no longer having this CNM have pediatric privileges as she has made this same order in the past. I was unaware of the issue until after I accepted the first order and in retrospect I am really glad that I called the nursery for clarification. A ped took over care after I took the baby to the nursery to have blood drawn. She has been on antibiotics since yesterday morning.

from rn/writer “Do you know the GBS status of the mom? Was she experiencing any other s/s?”

The mom was GBS negative with no s/s other than fever.

I do have another question. When you guys mention low temps in a newborn, how low is low? It is wonderful to be able to come here and ask questions without being made to feel stupid for not knowing the answers :)

Thanks again:redbeathe

Specializes in NICU.

For us, temps that stay consistently low, 96-97.5 or so, during the recovery, are cause for concern. A baby that has to stay in an isolette for several hours is a worry. That being said, we have a ped who will tell the m/b nurse to keep the baby in the isolette overnight to keep it warm, and to stop the phone calls..... You have to look at the rest of the picture, though. Set-up for sepsis? Poor feeding? Lethargy? Respiratory distress? Then you keep on calling.

We don't have a newborn nursery, all normal newborns are admitted to couplet care unless they need NICU care. Many infants are followed by their regular pediatrician, unless they are admitted to the NICU.

"Do midwives generally order for newborns in your facility and not the pediatrician?"

In this particular instance the CNM was the provider for both mom and baby. This incident came to the attention of the head of all departments involved and is being reviewed I believe for the purpose of no longer having this CNM have pediatric privileges as she has made this same order in the past. I was unaware of the issue until after I accepted the first order and in retrospect I am really glad that I called the nursery for clarification. A ped took over care after I took the baby to the nursery to have blood drawn. She has been on antibiotics since yesterday morning.

It is within the scope of practice of a CNM to provide care to newborns up to six weeks. It does concern me that the CNM made this order, but it also concerns me that her priveliges will be pulled. Many, many, many providers make mistakes and/or have misconceptions that have to be corrected without losing their priveliges.

Specializes in Maternal - Child Health.
I’m also left wondering why the infant received a bath in the nursery an hour after I took her down there.

from babyktcher " All of this happening in the recovery phase? I would think to wait to do such drastic measures. This woman has just pushed out a baby, worked hard at it, and the baby has been thru a rough phase itself. Why not give it an hour or so for everyone to normalize and then evaluate for some pathology."

This is the same rational I heard from the experienced L&D nurses, that the infant may have been transitional and could normalize, so give it a little more time. What alarmed me about the mother's temp was that it was consistently in the 97s throughout labor and eventually rose to 102.0 before starting the come down.

I do have another question. When you guys mention low temps in a newborn, how low is low? It is wonderful to be able to come here and ask questions without being made to feel stupid for not knowing the answers :)

These are all good questions.

First off, babyktcher raises a valid point that mom's and baby's temps might be a result of hard work during labor. If both appear healthy, show no other risks for, or evidence of infection (positive GBS, chills, body aches, uterine pain or heavy bleeding in mom), (temperature instability, glucose instability, poor color, breathing problems in baby) then I agree that waiting and watching for an hour or two is appropriate. This means 1:1 care with the mother/baby couplet, constant observation, communication with the medical providers and immediate intervention in the event that any other s/s of infection occur. It concerns me that mom's temp rose to 102. That's higher than we would typically see in a patient who is simply physically overworked and possibly dehydrated. Most providers will move forward with a septic work-up based on a temp that high.

That brings me to my next point. If you are carefully observing a newly-delivered infant who is known to be at risk for a medical problem (any medical problem such as infection, breathing difficulties or blood sugar instability) it is imperative that you provide a quiet, stable environment for that baby that includes warmth, minimal stimulation and the ability to constantly observe the baby. This enables you to monitor the baby's vital signs and physical status without any interference from outside factors. It can be achieved by placing baby skin to skin with mom or dad or by placing the baby under a warmer. Either option gives the baby an opportunity to stabilize it's body temperature, while allowing you to oberve color, respiratory effort and monitor blood sugars if indicated. If the baby is unstable in any way, you will intervene by providing respiratory support and/or glucose in an appropriate form.

When babies are rushed into a bath, their ability to self-regulate breathing, body temperature and glucose is thrown off. Bathing almost always cold-stresses a baby to some extent, placing extra demands on the baby's metabolism for heat, and increasing the baby's glucose and oxygen requirements. This can "tip" a "borderline" baby over the edge, so to speak, causing overt s/s of glucose instability and respiratory distress. Except in the cases of HIV and Hepatitis exposure, there is no medical need to promptly bathe a baby. As we have discussed in the case of your patient, bathing may have distorted the baby's actualy body temperature, interfering with your ability to assess for s/s of infection. It is best to wait until a baby is at least a few hours old and has had a stable temperature (above 97.8) for at least 1-2 hours before bathing. When a healty baby is bathed, it should be done under a warmer to minimize heat loss. A sick baby shouldn't be bathed at all, unless HIV or Hepatitis are a concern. Following the bath, the baby should again be placed skin to skin or under a warmer until a normal temp is achieved.

Once stabilized after a bath, a healthy newborn should be able to consistently maintain a temp of greater than 97.6.

Specializes in Cardiac.

The unit I was on did not send baby to the nursery until it and mom were "recovered" for a least 2 hours.Now I know why.

Specializes in OB, Hospice.

Your answers cleared up a lot for me. I will be sure to consider these factors more from now on when giving newborn care. I kind of understood about subnormal temps, but your explanations made it much more succinct.

Thank you! I really do appreciate it.

Specializes in NICU. L&D, PP, Nursery.
The unit I was on did not send baby to the nursery until it and mom were "recovered" for a least 2 hours.Now I know why.

That's great. Every unit that I have ever worked on seemed so h... bent on getting the baby bathed in an hour.

Another thought (please, I am NOT starting a debate), I wonder what effect getting the Hep B vaccine in the delivery room has on infant temps? There seems to be alot of septic workups that are thankfully negative, initiated due to temp issues. The effects on the immune system might still be unknown from receiving Hep B vax so soon (high temp/low temp?). Could an alteration in temperature just be an immune response? But I agree that it always needs to be checked out with a thorough septic workup.

Having a peaceful two hours is a good idea in the delivery room (free of bathing and unneccesary stimulation--just nursing and cuddling).

What about having a vaccine free week before stimulation of the immune system occurs to let the baby stablize, and not complicate things with high temp/low temp/feeding issues, ect.?

Specializes in Maternal - Child Health.

Why on God's green earth is anyone giving Hepatitis B vaccines in the delivery room? Even babies with known exposure to Hepatitis B have a 12-hour window in which to optimally receive their first vaccine.

There is no medical reason for this to be done in the newborn transition and critical bonding period.

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