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 have you noticed?
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
Anticonvulsants? No
Correct hypothermia (Ref. p. 202, p. 259)
Immediate investigations?
□ Blood sugar

9. How to give oxygen
Place the prongs just inside the nostrils and secure with tape.
Use an 8 F size tube
Measure the distance from the side of the nostril to the inner eyebrow margin with the catheter
Insert the catheter to this depth and secure it with tape
(Ref. Chart 5, p p )
Start oxygen flow at 1-2 litres/minute, in young infants at 0.5 litre/minute

10. 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.
He is not immunised yet. He is not from a malarial area.
His mother Sarah did not attend any antenatal clinics during her pregnancy and she did not receive tetanus toxoid. The pregnancy period was uneventful. There is no history of premature rupture of membrane.

11. Examination
Dominic was lethargic, ill-looking, and had soft 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, some grunting respiration
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

12. Differential diagnoses
List possible causes of the illness
Main diagnosis
Secondary diagnoses
Use references to support diagnoses: neonate with lethargy (Ref. p. 25)

13. Differential diagnoses (Ref. p. 25)
Birth asphyxia
Hypoxic ischaemic encephalopathy
Birth trauma
Intracranial haemorrhage
Haemolytic disease of the newborn, kernicterus
Neonatal tetanus
Meningitis
Sepsis

14. Additional questions on history
Birth history
Antenatal care
Maternal tetanus toxoid
Duration of ruptured membranes
Maternal illness / fever
Cord care
Cut with knife and tied with shoelace
Immunization history & vitamin K at birth

15. Further examination based on differential diagnoses
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
Many or severe skin pustules
Umbilical redness, flare or pus
Bulging fontanelle
Assess nutritional state

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

17. Investigations □ Discuss expected findings from investigations
Blood glucose
Haemoglobin
Urine microscopy or culture
Lumbar puncture
Blood culture if possible
□ Discuss expected findings from investigations

18. 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)

19. Urine - Chemistry/Protein/ Glucose: nil
Urine routine:
- Chemistry/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

20. Diagnosis  Sepsis Summary of findings:
Examination: hypothermia, lethargic, slow breathing, some apnoea, soft grunting respirations
Blood examination shows moderate neutrophilia with moderate left shift and thrombocytopenia
No localizing signs of infections
Blood culture pending
 Sepsis

21. How would you treat Dominic?

22. 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

23. What supportive care and monitoring are required?

24. Supportive Care Fluid management (Ref. p. 57)
Maintain a stable thermal environment (Ref. p. 56)
Pay strict attention to hand washing

25. Monitoring Monitor response to treatments and look for complications
Oxygen saturation
Apnoea monitoring if possible
Vital signs
Treatments given
Feeding/nutrition given
Blood glucose
Observe the baby frequently and use a Monitoring chart (Ref. p. 320, 413)

26. Summary Neonate with sepsis Symptoms and signs are often non-specific
Neonates with any common serious problem can develop: apnoea, bradycardia, jaundice, lethargy, poor feeding
Good history and examination are very important
Antibiotics, oxygen, prevention of hypothermia and hypoglycaemia, breast milk are good general treatments for most seriously ill neonates
Importance of frequent monitoring