ICU and You · Emergency Medicine Landing Bay · Number 1
The infant from one month to one year, in the emergency department
You are not being asked to make a diagnosis. You are being asked, forty times a shift, whether this child can safely leave — and that is a different question with a different failure mode.
The emergency department sits between the two errors. Investigate every well-looking febrile infant and you will do harm at scale: lumbar punctures, antibiotics, admissions, and a department that stops moving. Discharge the wrong one and you will do harm to a single family, catastrophically, and you will remember it for the rest of your career. The whole craft is in holding both of those in mind at once, at two in the morning, with four more waiting.
Triage is the highest-leverage decision in the department, and it is made in ninety seconds by someone who may not see the child again. These are the things that should move an infant up a category regardless of how they look in the waiting room.
Under three months with a fever of 38 °C or more. The most dangerous patient in the department is the well-looking one in this group. · Any non-blanching rash. · Apnoea or a reported blue episode, even if entirely resolved now. · Bilious vomiting. · A parent who says this is not their child's normal. · A second presentation within 48 hours for the same illness — the reattendance is itself the finding.
Before you touch them, and from the end of the trolley: appearance, work of breathing, circulation to skin. It takes seconds, it survives handling in a way measurements do not, and it will tell you which of the three tracks you are on — well, sick, or about to be very sick indeed.
Most of winter. The decision is about feeding and trajectory, not about the diagnosis. Day three to five is the peak, so a comfortable infant on day one is a different proposition from the same child on day four. Admit for apnoea, for feeding under about half, for persistent hypoxia, or for a family who cannot return. High-flow is support, not treatment. The chest film mostly generates antibiotics nobody needed.
Under three months, a full septic screen and admission, and do not be reassured by appearance. Urinary tract infection is the commonest bacterial source and it is invisible without a catheter specimen. Between one and three months the published pathways diverge, and the useful thing is to know which one your department has adopted rather than to reason from first principles at 3 am. There is a podcast on exactly this if you want the twenty-minute version.
Green is surgical until proven otherwise. Intermittent pallor with drawing up of the legs, and lethargy in between, is intussusception — and the lethargic phase is what makes it look like sepsis. Examine the groin of every one of them; an incarcerated hernia takes five seconds to find and is catastrophic to miss. And check a glucose, because it is quick, it is often the answer, and it is routinely forgotten.
Feeding adequately, comfortable at rest, a clear diagnosis or a clearly benign course, and a family who can return easily. Written safety-netting, and a documented period of observation if you needed one to decide.
Feeding poorly, oxygen requirement, apnoea, uncertainty about the diagnosis, day two of an illness that peaks on day four, or a social situation that makes returning hard. Uncertainty is a legitimate reason to admit an infant.
Escalating support, shock, altered conscious state, a surgical diagnosis, or a department without the paediatric cover to hold them. Ring early and ring uncertain — NETS on 1300 36 2500 in New South Wales.
Safety-netting without continuity. You will never see this family again, so “come back if you're worried” puts the entire judgement on someone with no way of making it. Name the specific triggers: feeds under half, fewer than four wet nappies a day, breathing harder than now, less interested in you — and add that being frightened is reason enough on its own. Then document that you gave it.
The re-presentation. A child brought back within 48 hours has, by definition, a family who thought something had changed. Many departments treat the second visit as a repeat of the first. It should be the opposite: a lower threshold, a senior review, and a written reason for any decision to discharge again.
What happens in your department when an infant comes back for the second time in 48 hours?
Tap what actually happens, not what the policy says. I suspect the answers will vary more than anyone expects, and that is worth publishing.
Each tap opens a reply straight to me with your answer filled in. If your device blocks it, write to icuandyou@icloud.com instead.