1. Chapter 3 Problems of the neonate and young infant Infection

2. Case study: Dominic
Dominic is a one week old boy. He was brought to the hospital with two day history of fever and lethargy. He was not able to breastfeed at all today.

3. What are the stages in the management of any sick child?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Discharge planning
Follow-up

5. What emergency and priority signs do you see?
Temperature: 35º C, pulse: 170/min, RR: 20/min

6. Triage Emergency signs (Ref. p. 2,6) Obstructed breathing
Severe respiratory distress
Central cyanosis
Signs of shock
Coma
Convulsions
Severe dehydration
Priority signs (Ref. p. 3)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable,
lethargic
Referral
Malnutrition
Oedema of both feet
Burns

7. What emergency treatment does Dominic need?

8. Emergency treatment □ Blood sugar Airway management? OK Oxygen
Not “respiratory distress”, but…slow breathing, periods of apnoea
Intravenous fluids
Unable to feed, prevention of hypoglycaemia
Correct hypothermia (Ref. p. 202, p. 259)
Immediate investigations?
□ Blood sugar

9. History
Dominic was delivered at term at home by a village birth attendant. He cried immediately. His cord was tied with a shoelace and then cut with a knife. He passed meconium within 24 hours of delivery. He was breast-feeding well until two days ago, after which he developed fever and lethargy (drowsiness). This morning he stopped sucking on the breast.
His mother Sarah did not attend any antenatal clinics during her pregnancy and she did not receive tetanus toxoid. Sarah’s pregnancy was uneventful. There is no history of premature rupture of membrane.

10. Examination Dominic was lethargic and had grunting respiration.
Vital signs: temperature: 35ºC, pulse: 170/min, RR: 20/min
Weight: 2.7 kg
Chest: Sometimes periods of not breathing for 10 seconds, bilateral air entry good
Cardiovascular: both heart sounds were audible and there was no murmur
Abdominal examination: soft, bowel sound was present; liver was 2 cm below the right costal margin
Ears-Nose-Throat: mouth: slightly dry, no oral thrush; ears: clear, no discharge
Neurology: lethargic; no neck stiffness; fontanelle normal
Skin: no rash

11. Differential diagnoses (Ref. Neonate with lethargy p. 25)
Birth asphyxia
Birth trauma
Intracranial haemorrhage
Neonatal tetanus
Sepsis (pneumonia, cord infection, skin infection, UTI)

12. Further examination based on likely sepsis
Look for signs of serious bacterial infection and for localizing signs of infection: (Ref. p )
Deep jaundice
Severe abdominal distension
Painful joints, joint swelling, reduced movement
Skin pustules
Umbilical redness, flare or pus
Bulging fontanelle
Assess hydration and nutrition (ill not feeding)

13. What investigations would you like to do to make your diagnosis ?

14. Investigations Blood glucose Haemoglobin Urine microscopy or culture
Lumbar puncture
Blood culture if possible

15. Full blood examination
Haemoglobin: 85g/l (125 – 205)
Platelets: x 109/l (150 – 400)
WCC: x 109/l (5.0 – 19.5)
Neutrophils: x 109/l (1.0 – 9.0)
Lymphocytes: x 109/l (2.5 – 9.0)
Monocytes: x 109/l (0.2 – 1.2)
Blood sugar: mmol/l (3.0 – 8.0)

16. Urine - Protein / Glucose: nil - Nitrate / Leucocyte esterase: nil
Urine dip-stick testing:
- Protein / Glucose: nil
- Nitrate / Leucocyte esterase: nil
- Blood: nil
Microscopy:
- Red Blood Cells: 0 x 106/l (<13)
- Leucocytes: x 106/l
Culture:
- No growth

17. Diagnosis  Sepsis Summary of findings:
Examination: hypothermia, lethargic, slow breathing, some apnoea, soft grunting respirations
Blood examination shows neutropenia and thrombocytopenia
Localizing signs of infections – unsterile cord care
Blood culture pending
 Sepsis

18. How would you treat Dominic?

19. Treatment □ IM / IV antibiotics for 10 days (Ref. p. 55):
 Ampicillin (or penicillin) and gentamicin (Ref. p )
If Staphylococcal aureus suspected (skin pustules, umbilical infection, boils, septic arthritis) administer Cloxacillin instead of ampicillin/penicillin
□ If not improving in 2-3 days the antibiotic treatment may need to be changed

20. What supportive care and monitoring are required?

21. Supportive Care Fluid management and feeding (Ref. p. 57)
Maintain a stable temperature in normal range (Ref. p. 56)
Strict attention to hand washing

22. Monitoring Monitor response to treatments and look for complications:
Oxygen saturation
Apnoea monitoring if possible
Vital signs
Treatments given
Feeding/nutrition given
Blood glucose
Use a Monitoring chart (Ref. p. 320, inside back cover)

23. Summary
Symptoms and signs of neonatal sepsis are non- specific: temperature instability, poor feeding, apnoea, bradycardia, jaundice, lethargy
Good history and examination are very important
Antibiotics, oxygen, prevention of hypothermia and hypoglycaemia, breast milk are good general treatments for very unwell neonates
Frequent monitoring and reassessment
Nurse with mother if not too sick