How Should You Work Up Hypothermic Infants? Welcome to the Wild West!

Written by Vivian Lei

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There is significant practice pattern variation in the ED management of infants ≤90 days of age with hypothermia.

Why does this matter?
We have covered previous studies showing the prevalence of serious infection among hypothermic young infants is around 3% up to 5%. While the standardized management of febrile infants is backed by decades of research, there is no comparable evidence base for evaluating serious bacterial infections in hypothermic infants. This study illuminates the inconsistent practices that currently exist among EDs in managing this population.

Hypothermic infants – the Wild West of work-ups
In this retrospective cross-sectional study of infants ≤90 days old presenting to the ED with hypothermia over a 10-year period, patients were stratified into 3 age groups: ≤30 days, 31-60 days, and 61-90 days. Of the 7,828 patients included in the analysis, 81% were ≤30 days old. These youngest infants had significantly higher rates of blood, urine, and CSF cultures, HSV testing, and antibiotic/antiviral treatment. Older infants had significantly higher rates of RSV and influenza testing, chest x-rays, ICU admission, and mortality. Over the time period between 2009 and 2019, the use of CRP and procalcitonin significantly increased, despite there being no currently published studies evaluating the role of inflammatory markers in hypothermic infants. Among the 32 hospitals, testing of hypothermic infants varied widely: urine tests in 61-90%, CBC or blood culture in 74-95%, antibiotics in 56-92%, inflammatory markers in 8-88%, and CSF testing in 14-70%. Moreover, many hospitals did not apply the same utilization patterns of testing and treatment among the different age groups.

Data were drawn from a multicenter pediatric database based on ICD-9 and 10 codes for hypothermia, so there is a risk of misclassification and lack of granular data. Still, this study sheds light on the variability that exists in managing hypothermic infants due to a void of evidence.

Variability in emergency department management of hypothermic infants ≤90 days of age. Am J Emerg Med. 2022 Aug 3;60:121-127. doi: 10.1016/j.ajem.2022.07.058. Online ahead of print.

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