Tylenol for newborn fever?

[faithful64]

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.

[lpnstudentin2010, LPN]

I am not a nurse but what i would think would be that yes it may be infection, but you also want to lower the temp, so do the work up but also give tylenol. Maybe?

[Jolie, BSN]

No. Do the work-up and don't give the Tylenol.

Thank you for posting and asking for information on an aspect of your nursing practice that is critical to newborn patient safety. I understand you are precepting and learning. I am alarmed that your experienced co-workers and an experienced CNM would treat this newborn with Tylenol, given the high likelihood of sepsis, based upon the labor history and presentation of mom and baby at and shortly after delivery.

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.

[babyktchr, BSN, RN]

100.7 for a mom is not a fever. It is an increase in temp, the body's response to the immune system working. We do not treat a temp until it is over 101.5. Why not let the body do what it is supposed to do?

This temp for a baby could've been a lot of things. Was the baby skin to skin? If so, that could explain the temp. If mom had increasing temp, the baby would. Removing the baby to see if the temp normalizes would've been prudent. If it did not, then a workup would be the next thing.

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.

NEVER NEVER NEVER have I ever seen Tylenol prescribed for a newborn. Do midwives generally order for newborns in your facility and not the pediatrician?

[rn/writer, RN]

I agree with the above poster about taking some time to allow things to normalize. But not too long. You also have to look at the big picture. Do you know the GBS status of the mom? Was she experiencing any other s/s?

On the postpartum unit where I work, a rectal baby temp that high so soon after delivery would have gotten a septic work-up, especially in light of the fact that mom's temp was also high.

We give Tylenol for pain, but not for fever. You definitely don't want to mask an infection in a brand new baby. Years ago, before we knew to give prophylactic abx to GBS+ moms, their babies would sometimes become ill and occasionally they would die in just a day or two. There are other nasty bugs that can quickly overwhelm a fragile newborn. That temperature is a valuable assessment tool. It tells you that this baby needs a CBC with differential and blood cultures to figure out what's going on.

Cultures take a couple of days to grow out, so the normal course of action is for the doc to start the baby on one or more broad spectrum antibiotics as soon as the blood is drawn. You still don't want to give Tylenol because the only way you can tell if the abx treatment is working is by keeping track of the temp. You want to treat the problem, not just the symptoms.

Another reason not to give Tylenol is that newer research seems to bear out the idea that, while we don't want a baby's temp to shoot sky high and cause brain damage, fevers seem to be a necessary part of fighting infection. Bringing down the temp artificially may short-circuit the inflammatory process that helps attack whatever bugs are creating the problems in the first place.

A third reason is that a septic kid can experience a really drastic drop in temp that you need to be able to attribute to the illness, not anti-pyretic medication.

With a sick baby, frequent temps can help monitor the condition and ward off additional problems like dehydration and blood sugar issues. Tylenol is a wonderful tool to manage pain, but I see is as more of a problem when dealing with illness and possible sepsis in a newborn.

[Jolie, BSN]

Additionally, Tylenol is appropriate for pain in newborns, such as infants who have experienced birth trauma.

It is not appropriate for undiagnosed fevers in any young infant.

Any provider who is unaware of the safe and appropriate dose of any common medication ought not be ordering that medication. The CNM shouldn't have given the order.

[lpnstudentin2010, LPN]

OK I learned something here. I guess I was wrong.

[rn/writer, RN]

You were not wrong to ask. In fact, I'm so glad you did. You have just added another tool to your belt. Good job!

[HM2VikingRN, RN]

And this is why I never want to be a L/D nurse. I learned a lot from the posts but I am very grateful to those who specialize in this area.

[Jolie, BSN]

Viking, we rarely agree on anything, but you've hit the nail here.

I'm grateful for the nurses who enjoy the challenge and have the expertise needed to care for adults and psych patients. Those are groups that scare the heck out of me.

I thank my lucky stars every day that there are talented and dedicated nurses who care for these folks so that I can take care of mommas and children. It's the beauty of our profession.

[SmilingBluEyes]

No. Do the work-up and don't give the Tylenol.

Thank you for posting and asking for information on an aspect of your nursing practice that is critical to newborn patient safety. I understand you are precepting and learning. I am alarmed that your experienced co-workers and an experienced CNM would treat this newborn with Tylenol, given the high likelihood of sepsis, based upon the labor history and presentation of mom and baby at and shortly after delivery.

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.

could not have said it better. This post bore repeating. ALWAYS do sepsis workup on infants who display s/s infection like fever, low body temp, severe jitteriness/sugar irregularities, breathing issues or mom suspected of infection, to name just a few. Safe than sorry is the rule here. ANY ped worth his or her salt would say this.

[SmilingBluEyes]

PS you are learning. I am glad you asked as the only "bad" question is the one we don't ask!