Neonatal Infection: Case Study of Dominic

1. Chapter 3Problems of the neonate and young infantInfection

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 • 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. 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 How to give oxygen (Ref. Chart 5, p. 11 p. 312-315) 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. 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

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

17. 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: 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)

19. Urine • Urine routine: • - Chemistry/Protein/ Glucose: nil • - Nitrate / Leucocyte esterase: nil • - Blood: nil • Microscopy: • - Red Blood Cells: 0 x 106/l (<13) • - Leucocytes: 0 x 106/l • Culture: • - No growth

20. 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

21. How would you treat Dominic?

22. 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

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 • 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)

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