# Fever in an infant under 3 months - Category: emergency - Review status: reviewed (every claim checked against a document named on this page) - Sources: Fever in under 5s: assessment and initial management - NICE Guideline NG143 (NCBI Bookshelf NBK552086) - https://www.ncbi.nlm.nih.gov/books/NBK552086/ · Fever in an infant under 3 months - disease-level clinical article (fever-in-infant-under-3-months-full.txt) · Fever in an infant under 3 months - disease-level clinical article (fever-in-infant-under-3-months-clinical.txt) · Egyptian National Drug Formulary - Antimicrobial 2023 (cefotaxime monograph, p246) · Egyptian National Drug Formulary - Antimicrobial 2023 (ampicillin monograph, p346) · Ampicillin for Injection USP - US prescribing information, DailyMed setid 3b683547-48ac-48ca-8fd4-6866fd17be34 (dailymed-ampicillin-injection-3b683547.html) - Verified date: 2026-08 ## Verified against - Fever in under 5s: assessment and initial management - NICE Guideline NG143 (NCBI Bookshelf NBK552086) - https://www.ncbi.nlm.nih.gov/books/NBK552086/ - Fever in an infant under 3 months - disease-level clinical article (fever-in-infant-under-3-months-full.txt) - Fever in an infant under 3 months - disease-level clinical article (fever-in-infant-under-3-months-clinical.txt) - Egyptian National Drug Formulary - Antimicrobial 2023 (cefotaxime monograph, p246) - Egyptian National Drug Formulary - Antimicrobial 2023 (ampicillin monograph, p346) - Ampicillin for Injection USP - US prescribing information, DailyMed setid 3b683547-48ac-48ca-8fd4-6866fd17be34 (dailymed-ampicillin-injection-3b683547.html) ## Treatment metadata - Cefotaxime — 500 mg — injection - Ampicillin — 500 mg — injection - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text FEVER IN AN INFANT UNDER 3 MONTHS Sources: Fever in under 5s: assessment and initial management - NICE Guideline NG143 (NCBI Bookshelf NBK552086) - https://www.ncbi.nlm.nih.gov/books/NBK552086/ · Fever in an infant under 3 months - disease-level clinical article (fever-in-infant-under-3-months-full.txt) · Fever in an infant under 3 months - disease-level clinical article (fever-in-infant- under-3-months-clinical.txt) · Egyptian National Drug Formulary - Antimicrobial 2023 (cefotaxime monograph, p246) · Egyptian National Drug Formulary - Antimicrobial 2023 (ampicillin monograph, p346) · Ampicillin for Injection USP - US prescribing information, DailyMed setid 3b683547-48ac-48ca-8fd4-6866fd17be34 (dailymed-ampicillin- injection-3b683547.html) Review status: REVIEWED against 5 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Take the parent seriously when they say the baby has been hot, even if the reading is normal by the time you see them - Under three months a temperature of 38 degrees or more places the baby in the high-risk group on its own - A recent vaccination can produce the fever itself at this age [fever] - How long the fever has run does not predict how ill the baby is, but five days or more prompts a look for Kawasaki disease [fever] - Amber features the parent can report: dry mouth, feeding less than usual, fewer wet nappies, and shivering attacks [dry mouth · reduced wet nappies · rigors] SIGNS - what you find (9) - High-risk colour: skin, lips or tongue that is pale, mottled, ashen or blue [pallor] - No response to social cues, or not waking, or not staying awake once roused - The cry is wrong: feeble, high pitched, or going on without stopping - Grunting, breathing faster than 60 a minute, or indrawing of the chest that is more than mild [chest recession] - Skin that stays pinched, or a fontanelle that bulges - Capillary refill of three seconds or longer is an amber marker - A fast heart rate puts the baby at least in the amber band [tachycardia] - The classic meningitis signs are often missing in a baby - stiff neck, bulging fontanelle and a high pitched cry may all be absent [bulging fontanelle · excessive crying · neck stiffness] - For dehydration look at refill, turgor, the breathing pattern, the pulse and how warm the hands and feet are [dehydration] TESTS (8) - Measure and write down the temperature, the heart rate and the breathing rate in every febrile baby of this age - The work-up under three months is a blood count, a blood culture, CRP and a urine test - Chest film only where there are respiratory signs, and stool culture only where there is diarrhoea - Lumbar puncture for every baby under one month, and for any one to three month old who looks unwell - Tap a one to three month old whose white cell count sits below 5 or above 15 - Do the tap before antibiotics wherever that can be managed, and do not put it off - Think of urine infection in any febrile baby under three months - Blood pressure if the pulse or the refill time is abnormal and a cuff is to hand IF NOT THIS - what else fits (8) - Meningococcal disease, where there is a rash that does not blanch - Spots wider than 2 mm, slow refill or a stiff neck make that far more likely - Bacterial meningitis: stiff neck, bulging fontanelle, drowsiness, or a fit that will not stop - Herpes encephalitis, where there are focal signs, focal fits or reduced consciousness - Pneumonia, with breathing over 60 a minute in the first five months of life - Crackles, flaring of the nostrils, indrawing, blue colour, or saturations at or below 95 percent - Urine infection - past three months the pointers are vomiting, feeding poorly, lethargy or irritability - Sepsis itself, where the reaction to an infection begins to damage the organs Score WHO Emergency Triage (sick child) - Is this sick child safe to wait? Source Fever in an infant under 3 months - disease-level clinical article (fever-in-infant- under-3-months-full.txt) Status traced to the source above !! MULTI-DRUG REGIMEN - all 2 drugs are given TOGETHER. Not a choice between them. !! the regimen: Cefotaxime + Ampicillin Rx: Empirical antibiotic | Main treatment EMPIRICAL ANTIBIOTIC - give all together 1. CEFOTAXIME [1 of 2 - GIVE ALL TOGETHER] Adult Not applicable - the patient is an infant under 3 months (see the paediatric dose) - Until cultures are back Peds Neonate (0 to 4 weeks): 0 to 7 days: 50 mg/kg IV every 12 hours - the formulary's maximum in the first 7 days is 100 mg/kg/day, with up to 150 mg/kg/day used off-label in meningitis. 8 days to 4 weeks: 50 mg/kg IV every 8 hours - maximum 150 mg/kg/day, with up to 200 mg/kg/day used off-label in meningitis. Both are written here because the age box cannot separate them; read the day of life. 1 month to 12 years: 50 to 180 mg/kg/day IV divided every 4 to 6 hours. Maximum 180 mg/kg/day under 50 kg; doses up to 300 mg/kg/day (maximum 12 g/day) have been used off- label in meningitis. From the twelfth birthday the formulary sends the reader to the adult dose, which is not on this card - it is for infants under three months. (Formulary dose, intravenous or intramuscular, by age. 0 to 7 days: 50 mg/kg every 12 hours. 8 days to 4 weeks: 50 mg/kg every 8 hours. 1 month to 12 years: 50 to 180 mg/kg/day divided every 4 to 6 hours. The formulary's stated ceilings for a child under 50 kg: 180 mg/kg/day approved, 150 mg/kg/day for a neonate 8 days and older, 100 mg/kg/day in the first 7 days - and it records higher figures used off-label in meningitis: 150 mg/kg/day in the first 7 days, 200 mg/kg/day from 8 days, and up to 300 mg/kg/day (maximum 12 g/day) beyond the neonatal period.) AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source Egyptian National Drug Formulary - Antimicrobial 2023 (cefotaxime monograph, p246) Why NICE NG143 states that when parenteral antibiotics are indicated for infants younger than 3 months, a third-generation cephalosporin such as cefotaxime or ceftriaxone should be given plus an antibiotic active against listeria, and that the cephalosporin is continued until culture results are available. The guideline names no amount. The amounts here are the Egyptian formulary's, whose cefotaxime monograph is written by neonatal age. Caution GIVE IT WITH THE AMPICILLIN, NOT INSTEAD OF IT. NICE's regimen for this age is the cephalosporin PLUS listeria cover. A cephalosporin alone does not treat listeria, which is why the pairing exists. CEFOTAXIME RATHER THAN CEFTRIAXONE IN A NEONATE. NICE names either, but the formulary contraindicates ceftriaxone alongside intravenous calcium-containing products in a neonate of 28 days or under, and warns against it in a jaundiced neonate, especially a premature one, because it displaces bilirubin from albumin. THIS IS THE HOSPITAL'S TREATMENT, AND THE REFERRAL COMES FIRST. Fever in an infant under 3 months is an admission. The regimen is printed so the GP knows what the child is going in for and can recognise it, not so it is started in the clinic. WHERE MENINGOCOCCAL DISEASE IS SUSPECTED, NICE ASKS FOR PARENTERAL ANTIBIOTICS AT THE EARLIEST OPPORTUNITY - either benzylpenicillin or a third-generation cephalosporin. It states no amount and no separate pre-transfer dose, so none is printed here; the formulary's benzylpenicillin figure for meningococcal disease is a full treatment regimen (300,000 units/kg/day divided every 4 to 6 hours, maximum 12 million units/day), not a single injection. Do not give in hypersensitivity to cefotaxime, any component, or another cephalosporin. Egypt CEFAXIM 500MG VIAL EL NASR 9.00 EGP PULOMOTAX 0.5 GM I.V. INF. / I.M. VIAL UP PHARMA > DEBEIKY 13.50 EGP SIGMATAXIM 500 MG I.V. / I.M. VIAL RAMEDA > SIGMA 13.50 EGP CEFALOMASH 500 MG I.M./I.V. VIAL MASH PREMIERE 26.50 EGP FOXIME 500MG I.M./I.V.VIAL TABUK PHARMAC... 29.00 EGP XORIN 500MG VIAL MUP 29.00 EGP OMNITAXIME 500 MG I.M./I.V.VIAL RAMEDA > BOST... 38.00 EGP CLAFORAN 500 MG I.M/I.V. VIAL SANOFI 41.00 EGP 2. AMPICILLIN [2 of 2 - GIVE ALL TOGETHER] Adult Not applicable - the patient is an infant under 3 months (see the paediatric dose) - Until cultures are back Peds Neonate (0 to 4 weeks): Dosed on gestational age as well as age since birth. Born after 34 weeks: 150 mg/kg/day divided every 8 hours. Born at 34 weeks or earlier, in the first 7 days: 100 mg/kg/day divided every 12 hours. Born at 34 weeks or earlier, from day 8: 150 mg/kg/day divided every 12 hours. All three are the label's figures for bacterial meningitis and septicaemia, which is what a newborn with fever is being covered for. 1 to 3 months: 150 to 200 mg/kg/day divided every 3 to 4 hours for bacterial meningitis, which is the label's figure for children beyond the neonatal period. The Egyptian formulary's general range for this age is 50 to 200 mg/kg/day divided every 6 hours to a maximum of 8 g a day; its severe-infection figure is 300 to 400 mg/kg/day divided every 4 to 6 hours to a maximum of 12 g a day. Where in that span an individual baby sits is set after the lumbar puncture. (There is no weight calculator on this drug on purpose. A newborn's ampicillin dose depends on gestational age and on the day of life, not on weight alone, and the Egyptian formulary states no neonatal figure at all - its 50 to 200 mg/kg/day is written for "Infants, Children, and Adolescents". The neonatal figures above are the US prescribing information's table for bacterial meningitis and septicaemia: 150 mg/kg/day every 8 hours for a baby born after 34 weeks; 100 mg/kg/day every 12 hours in the first 7 days and 150 mg/kg/day every 12 hours from day 8 for a baby born at 34 weeks or earlier. Beyond the neonatal period the same label gives 150 to 200 mg/kg/day divided every 3 to 4 hours for meningitis. The Egyptian formulary, for a child past the neonatal period, gives 50 to 200 mg/kg/day divided every 6 hours to a maximum of 8 g a day, and 300 to 400 mg/kg/day divided every 4 to 6 hours to a maximum of 12 g a day for severe infection. Treatment runs a minimum of 48 to 72 hours past the point at which the baby is well or the organism is shown to be cleared.) Source Ampicillin for Injection USP - US prescribing information, DailyMed setid 3b683547-48ac-48ca-8fd4-6866fd17be34 (dailymed-ampicillin-injection-3b683547.html); and Egyptian National Drug Formulary - Antimicrobial 2023 (ampicillin monograph, p346) Why NICE NG143 states that for children younger than 3 months an antibiotic active against listeria - for example ampicillin or amoxicillin - should also be given, alongside the third-generation cephalosporin. It names no amount. The amount here is the Egyptian formulary's general paediatric parenteral dose. Caution GESTATIONAL AGE CHANGES THIS DOSE, AND NOTHING ELSE ON THE CARD ASKS FOR IT. A baby born at 34 weeks or earlier gets less in the first week of life than a baby born at term, and gets it twice a day rather than three times. Ask how many weeks the pregnancy ran before working out the dose. GIVE IT WITH THE CEFOTAXIME, NOT INSTEAD OF IT. This is the listeria half of the regimen. It is not an alternative to the cephalosporin. THE MENINGITIS DOSE IS HIGHER AND IS NOT THE FIGURE ABOVE. The formulary gives 300 to 400 mg/kg/day for meningitis or endocarditis. Which regimen a given infant needs is decided by the unit that admits them, after the lumbar puncture. Do not give in hypersensitivity to ampicillin, any component, or another penicillin, or where the organism produces penicillinase. Egypt AMPICILLIN-EL NASR 500 MG VIAL EL NASR 2.50 EGP AMPICILLIN SODIUM 500MG I.M/I.V VIAL CID 5.00 EGP AMPICILLIN-MISR 500MG VIAL MISR 7.50 EGP AMPICILLIN-NILE 500MG VIAL EL NILE. 7.50 EGP EPICOCILLIN 500MG VIAL EIPICO 7.50 EGP MAIN TREATMENT 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Fever in under 5s: assessment and initial management - NICE Guideline NG143 (NCBI Bookshelf NBK552086) - https://www.ncbi.nlm.nih.gov/books/NBK552086/ Why Age alone decides the answer here. NG143 puts every infant under 3 months with a temperature of 38°C or higher into the highest-risk group before anything else about the baby has been assessed, so the destination is hospital and no medicine given in the clinic changes that. The antibiotics printed above are what the admitting unit starts, and they are here so the referral is an informed one - not so that anything is given in the clinic instead of the transfer. Caution AGE IS THE RED FLAG, ON ITS OWN - an infant below 3 months whose temperature reaches 38°C belongs, by age alone, to the group at high risk of serious illness. Nothing else about the baby has to be abnormal. A well-looking, feeding, smiling six-week-old with 38°C goes to hospital. AND A HIGH-RISK INFANT IS A REFERRAL, NOT A PRESCRIPTION - a child showing any 'red' feature, who is nonetheless not judged to be in immediate danger of death, is referred urgently into the care of a paediatric specialist. IF THE BABY LOOKS LIFE-THREATENINGLY ILL, DO NOT REFER - SEND - where the symptoms, or the symptoms and signs taken together, point to an illness that is immediately life- threatening (NG143 cross-refers here to its own recommendation on spotting those features), the child is referred at once for emergency care, by whatever transport suits best - normally a 999 ambulance. PARACETAMOL AND IBUPROFEN ARE FOR DISTRESS, AND NEITHER IS A REASON TO STAY HOME. NG143 permits them on that narrow ground only - either one may be considered for a feverish child who appears distressed - and says in the next breath that an antipyretic must NOT be used in a feverish child for the sole purpose of bringing the temperature down. Giving one to an infant under 3 months does not cancel the referral above. A TEMPERATURE THAT COMES DOWN PROVES NOTHING - once an antipyretic has been given, whether or not the temperature falls must NOT be used to tell serious illness from illness that is not serious. A septic baby who settles for two hours after syrup is still a septic baby. NEVER BOTH AT ONCE - NG143 1.6.6 puts four conditions on the use of paracetamol or ibuprofen in a feverish child: keep going only while the child still appears distressed; think about switching to the other one if the distress is not relieved; do NOT give the two together; and only consider alternating them if the distress carries on, or returns, before the next dose falls due. ANTIPYRETICS DO NOT STOP FITS - an antipyretic does NOT prevent a febrile convulsion, and must NOT be given for that purpose. Parents and clinics in Cairo dose hard on exactly that belief. AND NEITHER DOES COOLING THE BABY DOWN - sponging with tepid water is advised against as a treatment for fever, and a feverish child must NOT be left underdressed, nor wrapped up too warmly. DO NOT HAND OUT AN ANTIBIOTIC INSTEAD OF A REFERRAL - an oral antibiotic must NOT be prescribed to a feverish child in whom no source has been found. THE ONE ANTIBIOTIC THAT IS GIVEN BEFORE TRANSPORT - where meningococcal disease is suspected, a parenteral antibiotic is given at the first opportunity there is: benzylpenicillin, or a third-generation cephalosporin. TEST THE URINE - a feverish child has the urine tested, as NICE's own under-16s guideline on urinary tract infection directs, and urinary tract infection is to be considered in every feverish child below 3 months. WHAT THE HOSPITAL WILL DO, SO THE FAMILY CAN BE TOLD - a set list of investigations is carried out in any feverish infant below 3 months; and where a parenteral antibiotic is indicated at that age, the combination is a third-generation cephalosporin - cefotaxime or ceftriaxone, say - together with an antibiotic that covers listeria, such as ampicillin or amoxicillin. A RECENT VACCINATION IS NOT AN EXPLANATION TO REST ON - all NG143 says is that certain vaccinations have been found to bring on a fever below the age of 3 months, and it leaves the high-risk classification standing. FEVER LASTING 5 DAYS OR LONGER CHANGES THE QUESTION - how long a fever has run must NOT be used to predict how likely serious illness is; but a child febrile for 5 days or more is assessed for Kawasaki disease. Be aware too that a child under 1 year may show fewer of the clinical features of Kawasaki disease besides the fever, while carrying a higher risk of coronary artery abnormality than an older child does. SIGNS OF DEHYDRATION TO LOOK FOR WHILE ARRANGING TRANSFER - a capillary refill that takes too long; skin turgor that is abnormal; a breathing pattern that is abnormal; a pulse that is weak; hands and feet that are cool. OLDER BABIES ARE NOT SAFE EITHER, ONLY LESS UNSAFE - a child of 3-6 months whose temperature reaches 39°C is, at the least, in the intermediate-risk group for serious illness. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)