Neonatal Emergencies
Question 97 of 300
A 3 day old baby boy is brought to the Emergency Department by his parents. They are concerned he is irritable and not feeding well. He was born by normal vaginal delivery and mother and baby were discharged after 24 hours. His observations are recorded as:
- Heart rate: 145 beats per minute
- Respiratory rate: 30 breaths per minute
- Central capillary refill: 2 seconds
- Oxygen saturations: 97% on air
- Temperature: 33.4°C
On examination you note he is drowsy but can be roused with gentle stimulus. Your examination is otherwise normal. What is the most likely diagnosis?
Answer:
Neonates have poor thermoregulatory mechanisms, and neonatal hypothermia is relatively common after precipitous delivery. However, with proper care, the hypothermia resolves and does not cause long-term problems. Hypothermia 72 hours after birth is frequently caused by sepsis. A full septic evaluation is indicated in this case. Neonatal hypothermia is also associated with hypoglycemia and child neglect or abuse. Poor feeding and dehydration can result in hypernatraemia, whereas dilution of infant formula can result in hyponatremia. Neither should result in hypothermia. Congenital heart disease frequently presents with distress during feedings but, similarly, should not result in hypothermia. Still’s disease is a rare rheumatologic disease associated with fever, arthralgia, and rash.Neonatal Sepsis
Neonatal Emergencies
Last Updated: 20th January 2023
Neonatal infection is a significant cause of mortality and morbidity in newborn babies. It may be early-onset (within 72 hours of birth) or late-onset (more than 72 hours after birth). Neonatal infection can lead to life-threatening sepsis, which accounts for 10% of all neonatal deaths. Early-onset neonatal infection is less common than late-onset neonatal infection, but it is often more severe. Group B Streptococcus (GBS) and Escherichia coli are the most common organisms identified in early-onset neonatal infection. Coagulase-negative staphylococci (e.g. S.epidermidis), Enterobacteriaceae and Staphylococcus aureus are the most common organisms identified in late-onset neonatal infection.
Risk factors for early-onset neonatal infection
- Red flag risk factor
- Suspected or confirmed infection in another baby in the case of a multiple pregnancy
- Other risk factors:
- Invasive group B streptococcal infection in a previous baby or maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
- Pre-term birth following spontaneous labour before 37 weeks' gestation
- Confirmed rupture of membranes for more than 18 hours before a pre-term birth
- Confirmed prelabour rupture of membranes at term for more than 24 hours before the onset of labour
- Intrapartum fever higher than 38°C if there is suspected or confirmed bacterial infection
- Clinical diagnosis of chorioamnionitis
Clinical indicators of possible early-onset neonatal infection
- Red flag clinical indicators:
- Apnoea (temporary stopping of breathing)
- Seizures
- Need for cardiopulmonary resuscitation
- Need for mechanical ventilation
- Signs of shock
- Other clinical indicators:
- Altered behaviour or responsiveness
- Altered muscle tone (for example, floppiness)
- Feeding difficulties (for example, feed refusal)
- Feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension
- Abnormal heart rate (bradycardia or tachycardia)
- Signs of respiratory distress (including grunting, recession, tachypnoea)
- Hypoxia (for example, central cyanosis or reduced oxygen saturation level)
- Persistent pulmonary hypertension of newborns
- Jaundice within 24 hours of birth
- Signs of neonatal encephalopathy
- Temperature abnormality (lower than 36°C or higher than 38°C) unexplained by environmental factors
- Unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation
- Altered glucose homeostasis (hypoglycaemia or hyperglycaemia)
- Metabolic acidosis (base deficit of 10 mmol/litre or greater)
Clinical indicators of possible late-onset neonatal infection
| Behaviour |
|
| Respiratory |
|
| Circulation and hydration |
|
| Skin |
|
| Other |
|
Investigations
Investigations before starting antibiotics:
- When starting antibiotic treatment, perform a blood culture before giving the first dose.
- Measure baseline C-reactive protein concentration when starting antibiotic treatment.
- If it is safe to do so, perform a lumbar puncture to obtain a cerebrospinal fluid sample when there is a strong clinical suspicion of neonatal infection or there are clinical symptoms or signs suggesting meningitis.
- Do not routinely perform urine microscopy or culture as part of the investigations for early-onset neonatal infection or for late-onset neonatal infection in neonatal units. Perform urine microscopy and culture for babies outside of neonatal units in line with the NICE guideline on urinary tract infection in under 16s.
- Do not perform skin swab microscopy or culture as part of the investigations if there are no clinical signs of a localised infection.
Management of suspected early-onset neonatal infection
- General principles:
- In babies with any red flag, or with 2 or more 'non-red-flag' risk factors or clinical indicators:
- perform investigations
- start antibiotic treatment as set out below
- do not wait for the test results before starting antibiotics
- In babies without red flags and only 1 risk factor or 1 clinical indicator, use clinical judgement to decide:
- whether it is safe to withhold antibiotics, and
- whether the baby's vital signs and clinical condition need to be monitored. If monitoring is needed, continue for at least 12 hours using a newborn early warning system
- In babies with any red flag, or with 2 or more 'non-red-flag' risk factors or clinical indicators:
- Advice for site specific infection:
- Be aware that, although minor conjunctivitis with encrusting of the eyelids is common and often benign, a purulent discharge may indicate the presence of a serious infection (for example, with chlamydia or gonococcus). In babies with a purulent eye discharge take swab samples urgently for microbiological investigation, using methods that can detect chlamydia and gonococcus. Start systemic antibiotic treatment for possible gonococcal infection while awaiting the swab microbiology results.
- In babies with clinical signs of umbilical infection, such as a purulent discharge or signs of periumbilical cellulitis (for example, redness, increased skin warmth or swelling), perform a blood culture, take a swab sample for microscopy and culture, and start antibiotic treatment with intravenous flucloxacillin and gentamicin.
- Antibiotics for suspected early-onset infection:
- If a baby needs antibiotic treatment, give this as soon as possible and always within 1 hour of the decision to treat.
- Use intravenous benzylpenicillin with gentamicin as the first-choice antibiotic regimen for empirical treatment of suspected early-onset infection, unless microbiological surveillance data show local bacterial resistance patterns that indicate the need for a different antibiotic.
- Give benzylpenicillin in a dosage of 25 mg/kg every 12 hours. Consider shortening the dose interval to every 8 hours, based on clinical judgement (for example, if the baby appears very ill).
- Give gentamicin in a starting dose of 5 mg/kg. If a second dose of gentamicin is given this should usually be 36 hours after the first dose. Use a shorter interval if clinical judgement suggests this is needed, for example if the baby appears very ill or the blood culture shows a Gram-negative infection. Decide on subsequent gentamicin doses and intervals taking account of blood gentamicin concentrations.
- If there is microbiological evidence of Gram-negative bacterial sepsis, add another antibiotic to the benzylpenicillin and gentamicin regimen that is active against Gram-negative bacteria (for example, cefotaxime). If Gram-negative infection is confirmed, stop benzylpenicillin.
Management of suspected late-onset neonatal infection
- For babies with suspected late-onset neonatal infection who are already in a neonatal unit:
- give a combination of narrow-spectrum antibiotics (such as intravenous flucloxacillin plus gentamicin) as first-line treatment
- use local antibiotic susceptibility and resistance data (or national data if local data are inadequate) when deciding which antibiotics to use
- give antibiotics that are effective against both Gram-negative and Gram-positive bacteria
- if necrotising enterocolitis is suspected, also include an antibiotic that is active against anaerobic bacteria (such as metronidazole)
- For babies with suspected late-onset neonatal infection or meningitis who have been admitted from home, treat according to the NICE guideline on sepsis.
- Treat neonates who are more than 40 weeks corrected gestational age who present with community acquired sepsis with ceftriaxone 50 mg/kg unless already receiving an intravenous calcium infusion at the time. If 40 weeks corrected gestational age or below or receiving an intravenous calcium infusion use cefotaxime 50 mg/kg every 6 to 12 hours, depending on the age of the neonate.
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
