Overbundling as a cause of fever in a 6-day old boy

Y M Fu 符儒明，D K K Ng 吳國強，C K L Kwok 郭嘉莉

HK Pract 2002;24:606-607

Summary

Fever is a common symptom in paediatric practice. Particular attention is given to infants less than 3-month old because of higher risk of bacteraemia and meningitis at this age. Overbundling is one of the causes of high temperature in infants. Careful history and observation lead to prompt diagnosis, avoidance of unnecessary investigations and treatment. This case report shows an example of management of overbundling in a 6-day-old neonate.

摘要

發燒是兒童常見的病徵。對三個月以下的嬰兒要格外注意，因為在這個年齡，患菌血症和腦膜炎的機會較高。過度包裹也是嬰兒體溫過高的原因之一。仔細的詢問病史和觀察，可以迅速做出診斷並避免不必要的檢查和治療。本文報告一例出生後六天包裹過度 的新生兒的處理。

Introduction

A neonate with fever is a challenging problem to a paediatrician. Paradoxically, a sick-looking neonate is more straightforward to manage than a febrile neonate who looks well. Hence, febrile neonates usually receive a full sepsis work-up, including lumbar puncture. They are often given empirical treatment with antibiotics.¹ Overbundling, a cause of fever in infants, is not often included in the differential diagnoses of neonate with fever.² This report serves to highlight the management of a febrile neonate as a result of overbundling.

Case report

A 6-day old Indian boy was admitted to the paediatric ward for management of fever within 24 hours of discharge from the postnatal ward. His temperature was not recorded at home. Rectal temperature was 38.9at the Emergency Department. Skin rash was noted for a few hours. There were no other symptoms. Formula feeding was given and was satisfactory. He was the first baby in the family, born at maturity of 38 weeks. He was delivered by emergency caesarean section for suboptimal cardiotocogram. Artificial rupture of membrane showed thick meconium-stained liquor. The Apgar score was 9 at both the 1st and 5th minute. The birth weight was 2.52kg. There was no evidence of meconium aspiration. Hence the baby did not require admission to the neonatal ward. He remained well in the postnatal ward and was discharged with his mother early on Day 6 of life. He was noted to be hot a few hours later and was brought to the emergency room. There was no history of contact with persons having fever or rash before admission.

Figure 1: Three layers of thick clothing for the index case on admission

On admission, the baby was wrapped with 3 layers of thick clothing (Figure 1). His parents were brought up in the Northern part of India where the temperature in October was about 15-20. They were used to putting on thick clothing for a baby in October. The mean temperature in Hong Kong on day of admission was 26. The rectal temperature of the baby on admission was 38.9. His body weight was 2.77kg. His general condition was satisfactory. He was pink with warm extremities and capillary refill was normal. There was a generalised erythematous maculopapular rash. Examination of other systems was unremarkable. Complete blood picture was normal and C-reactive protein was not elevated. Liver and renal function tests and blood gases were normal. Chest x-ray was unremarkable and urine microscopy was normal. The clinical picture was compatible with fever due to overbundling. Lumbar puncture was not performed. After removal of excessive clothing, body temperature normalised within an hour of admission. The duration of fever was one hour. The rash gradually subsided in a few hours. He was discharged two days later.

Discussion

Environmental causes of neonatal fever, i.e. rectal temperature over 38, include inadequate fluid intake, high environmental temperature or overbundling. Administration of oral or parenteral fluid, reduction of the environmental temperature or removal of excessive clothing leads to prompt resolution of fever. The diminished sweating capacity of neonates is also a contributing factor. The skin appears hot, dry and the infant may appear flushed and apathetic.³ When the diagnosis of overbundling is suspected, the child should be unbundled and the temperature should be rechecked in 15-30 minutes. If the temperature becomes normal in a healthy appearing infant who has not received an antipyretic before, the infant may be considered as afebrile.¹ The diagnosis of overbundling in this baby was based on the appearance of the baby when he was admitted, with 3 thick layers of clothes and the clinical findings of good peripheral circulation. This was further supported by the normal white cell count and negative urine culture.

The current practice adopted for fever in infants of less than 28 days of life is hospitalisation for evaluation of sepsis by performing lumbar puncture, urine and blood culture, and complete blood count.^1,2 However, for an infant of less than 3 months old who met the low risk clinical and laboratory criteria, the probability of having serious bacterial infection is only 0.2%⁴ (Table 1). With the evidence of overbundling and absence of fever after removal of excess clothing, lumbar puncture and blood culture are probably not necessary. In a study of a large number of full-term infants, a raised body temperature was found in 1% in the early neonatal period. Of these, 10% had bacterial infections and 90% were due to environmental causes.⁵

Conclusion

This case illustrates the importance of careful observation and detailed history in evaluating an infant with fever. This helps to avoid unnecessary investigations and treatment in case of overbundling.