Problems of the neonate and young infant Infection

Chapter 3

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.

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

Stages in the management of a sick child

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

What emergency and priority signs have you noticed?

Temperature: 35 C, pulse: 170/min, RR: 20/min

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

What emergency treatment does Dominic need?

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

How to give oxygen

Place the prongs just inside the nostrils and secure with tape. (Ref. Chart 5, p. 11 p. 312-315)

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

Start oxygen flow at 1-2 litres/minute, in young infants at 0.5 litre/minute

History
Domionic 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.

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

Vital signs: temperature: 35C, 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

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

Differential diagnoses
Birth asphyxia

(Ref. p. 25)

Hypoxic ischaemic encephalopathy

Birth trauma Intracranial haemorrhage Haemolytic disease of the newborn, kernicterus Neonatal tetanus

Meningitis
Sepsis

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

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

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

Investigations
Blood glucose Haemoglobin

Urine microscopy or culture

Lumbar puncture Blood culture if possible

Discuss expected findings from investigations

Full blood examination

Haemoglobin: Platelets: WCC: Neutrophils: Lymphocytes: Monocytes: 85g/l (125 205) 86 x 109/l (150 400) 20.9 x 109/l (5.0 19.5) 9.0 x 109/l (1.0 9.0) 6.1 x 109/l (2.5 9.0) 4.8 x 109/l (0.2 1.2)

Blood sugar:

3.3 mmol/l (3.0 8.0)

Urine

Urine routine: - Chemistry/Protein/ Glucose: - Nitrate / Leucocyte esterase: - Blood: nil nil nil

Microscopy:
- Red Blood Cells: 0 x 106/l (<13) - Leucocytes: 0 x 106/l

Culture: - No growth

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

How would you treat Dominic?

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

What supportive care and monitoring are required?

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

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)

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