Chapter 3 Problems of the neonate and young infant Infection

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Chapter 3Problems of the neonate and young
infantInfection
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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.
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• What are the stages in the management of any sick
  child?

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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

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What emergency and priority signs have you
noticed?
Temperature 35º C, pulse 170/min, RR
20/min
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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

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What emergency treatment does Dominic need?
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Emergency treatment

• Airway management? OK
• Oxygen
• Not respiratory distress, butslow 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

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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. 11 p. 312-315)
Start oxygen flow at 1-2 litres/minute, in young
infants at 0.5 litre/minute
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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.

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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
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Differential diagnoses

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

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Differential diagnoses (Ref. p. 25)

• Birth asphyxia
• Hypoxic ischaemic encephalopathy
• Birth trauma
• Intracranial haemorrhage
• Haemolytic disease of the newborn, kernicterus
• Neonatal tetanus
• Meningitis
• Sepsis

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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

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Further examination based on differential
diagnoses

• Look for signs of serious bacterial infection and
  for localizing signs of infection (Ref. p.
  54-55)
• 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

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What investigations would you like to do to make
your diagnosis ?
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Investigations

• Blood glucose
• Haemoglobin
• Urine microscopy or culture
• Lumbar puncture
• Blood culture if possible
• ? Discuss expected findings from investigations

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Full blood examination
Haemoglobin 85g/l (125 205) Platelets
86 x 109/l (150 400) WCC
20.9 x 109/l (5.0 19.5) Neutrophils
9.0 x 109/l (1.0 9.0) Lymphocytes 6.1
x 109/l (2.5 9.0) Monocytes 4.8 x
109/l (0.2 1.2) Blood sugar 3.3
mmol/l (3.0 8.0)
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Urine

• Urine routine
• - Chemistry/Protein/ Glucose nil
• - Nitrate / Leucocyte esterase nil
• - Blood nil
• Microscopy
• - Red Blood Cells 0 x 106/l (lt13)
• - Leucocytes 0 x 106/l
• Culture
• - No growth

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Diagnosis

• 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

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How would you treat Dominic?
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Treatment

• ?IM / IV antibiotics for 10 days (Ref. p.
  55)
• ? Ampicillin (or penicillin) and gentamicin
  (Ref. p. 69-72)
• 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

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What supportive care and monitoring are required?
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Supportive Care

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

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Monitoring

• Monitor response to treatments and look for
  complications
• Monitor
• 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)

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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