Management of a Sick Newborn: Case Study and Treatment Plan

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 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 • 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: 34.5ºC, 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. 54-55) • 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: 86 x 109/l (150 – 400) WCC: 2.9 x 109/l (5.0 – 19.5) Neutrophils: 0.5 x 109/l (1.0 – 9.0) Lymphocytes: 2.1 x 109/l (2.5 – 9.0) Monocytes: 0.3 x 109/l (0.2 – 1.2) Blood sugar: 3.3 mmol/l (3.0 – 8.0)

16. Urine • Urine dip-stick testing: - 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

17. Diagnosis 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. 69-72) • If Staphylococcal aureus suspected (skin pustules, umbilical infection, boils, septic arthritis) administer cloxacillin (or flucloxacillin) 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 • 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