S4E6: Neonatal sepsis - Paediatrics
We’re changing things up and bringing you to the Paediatric section of the TCR Emergency Department where Mo, Stephen and Rachel are concerned about a five day old baby. Today we’re talking all things feeding, fevers and the big S, sepsis!
Our Adult in the Room this month is Dr Rasha Sawaya, a Paediatric EM (PEM) consultant at Children’s Health Ireland. In the course of her career, Rasha has worked at Children’s National Health, Washington DC, and The American University of Beirut, Lebanon. While in Lebanon, she was Associate Director of the EM training program and then ED Director of Operations navigating the ED through the COVID pandemic and the country’s economic crisis. She is currently the Cross City PEM education Lead, International PEM Fellowship Lead, and was chair of IPEM2023.
Dr Sawaya’s interests lie in PEM education, both locally and internationally, making her a perfect AITR to review our work! She delves into the pearls and pitfalls of managing the unwell neonate as well as the dreaded topic of feeding difficulties in babies.
As always, don’t forget to follow us on socials on instagram, twitter and facebook to keep updated with all things TCR. Coffee in hand? Right then, let’s get to it!
Mission Impossible: The Approach to a sick baby
The history is very much based on the collateral you get from the parents and your examination can unlock a goldmine of information. Thus, investing some time to glean the relevant pieces can guide a child’s management direction.
Systematic approach to the History
We love a good structured history or mnemonic in medicine (so much so, we included one for causes of liver failure in our Liver cirrhosis episode!).
History taking should be focused, and there are some specific things to ask about when taking a collateral history from a neonate. Click on the dropdown boxes to learn more with added tips from our AITR included.
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Thinking here about frequency, volume and if there has been any change from their usual feeding pattern.
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How often do they need to get their nappies changed?
Any change in frequency?
Parents may note that the nappy does not feel as heavy as usual.
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How often are they having a bowel movement, what is the consistency and have they noticed any changes to the pattern?
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Weight loss / not gaining weight appropriately / dropping 2 centiles on the growth chart can be a red flag.
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Does the child appear to be their usual self?
Do they appear more lethargic than usual or off form?
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It’s key to determine gestation age at birth (term vs pre-term). Was it simple or complicated?
If a c-section - why?
As was the case in this episode, the length of time for rupture of membranes is important as is the fact that mum received antibiotics intrapartum.
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There are certain conditions which run in families which may manifest as disease in young children.
Does the neonate have any siblings who were sick around this time after birth, or who had unexplained deaths, thinking here of cardiac or metabolic abnormalities.
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With an underdeveloped immune system children are more likely to pick up infections, so screening for unwell contacts can be helpful in guiding your diagnosis.
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Any cardiac abnormalities? Any renal abnormalities eg. hydronephrosis.
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Did she receive prenatal care? If so, were there any maternal infections/STDs/lesions (thinking of herpes).
Any pregnancy associated complications eg pre-eclampsia or gestational diabetes
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Did the baby require a stay in NICU/SCBU and if they did how long was their NICU admission and why were they there? Did they need antibiotics or was it something slightly less concerning eg brief O2 for transient tachypnoea of the newborn?
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Any drug or alcohol use in pregnancy?
Who is living with the neonate? Do(es) the parent(s) or caregivers have support?
Non accidental injury can be very subtle and difficult to pinpoint in babies.
And just when you thought we didn’t have a mnemonic for the differential in this case, voilà! Our AITR Dr Sawaya makes particular reference to the need to keep your differential broad, and to be prepared to change your approach and management as more information (eg blood tests) become available. Here are some of the general topics to consider in the critically unwell infant:
Nuances in the Art of Paediatric Examination
Medicine is often described as an art. Some would say a paediatrician’s ability to settle the inconsolable infant (that refuses to respond to anyone else’s approach) is a prime example of that art in practice! Learning the subtleties in approach to examination may increase your yield of information from your physical exam.
Many PEM consultants advocate for a slow, graded approach to exam, with a large focus on general inspection from a distance. There is much to be gained from assessing the infant’s general appearance. Do they appear bright and alert, or are they listless? Are they interacting appropriately with their caregiver or other children? Make sure to look out for any obvious pallor, jaundice or cyanosis.
General inspection should be followed by a head-to-toe exam, sequentially examining the baby and undressing without fully exposing them.
Paediatric Sepsis and Fever: The Who, What and When?
We discussed fever in the child in great detail all the way back in season 1, in our first PEM episode! In today’s episode, we focus specifically on what to do about fevers in infants less than 3 months, and crucially, identifying, preventing and treating neonatal sepsis.
Neonatal sepsis refers to an infection involving bloodstream in newborn infants less than 28 days old. It continues to remain a leading cause of morbidity and mortality among infants. It may also be subcategorised into early-onset and late-onset sepsis (<24-48hrs for EOS and >72hrs for LOS)
Early onset sepsis (EOS) vs Late onset sepsis (LOS)
Pathogens in EOS
These are generally pathogens that can infect in utero or in the cervix during delivery eg, Listeria monocytogenes, E.Coli and Group B Streptococcus (GBS)
Risk factors in EOS
Risk factors include chorioamnionitis, GBS colonisation, delivery at <37 weeks and Prolonged rupture of membranes (PROM) of > 18hrs.
Late onset sepsis (LOS)
Transmission in LOS is often from the surrounding environment, though some will stem from vertical transmission. Of note, preterm neonates are at a higher risk for infection than term neonates, owing to a deficiency in IgG antibodies and complement activation, an immature epithelial barrier and increased need for invasive devices e.g. NG tubes.
Management of neonatal sepsis
The HSE has adopted the International Guidelines for the Management of Septic Shock & Sepsis-Associated Organ Dysfunction in Children (SSCGC) and has a national implementation plan which you can find here. There is also a paediatric sepsis form with guidance on completing the sepsis 6 bundle in children from 4 weeks of age.
“The SSCGC included term neonates (0–28 days) born at greater than
or equal to 37 weeks gestation within the scope of these guidelines because these infants may be recognized and resuscitated outside of a newborn or neonatal ICU setting. However, neonatal sepsis is recognised as an entity of itself and deserves special attention and a separate guideline in the future.”
NICE Guidelines
The NICE Neonatal Sepsis Guideline advises that neonates coming in from home should be investigated and managed under the NICE Fever in under 5s: assessment and initial management guideline.
Basic blood tests in these patients include an FBC and a CRP. Of note, Neutropenia has been consistently found to be specific in ruling out neonatal sepsis, whilst CRP has a significant role - two discrete normal CRP levels may be used to rule out sepsis, with high negative predictive value. However, it should be noted that both have situational applications and require critical appraisal in a patient specific manner on a case by case basis.
Additional testing may include, a chest x-ray if respiratory signs are present and a stool sample if a diarrhoeal illness is present.
Lumbar puncture
Recommended in all infants <1 month of age presenting with fever and those between 1-3 months of age with a fever if they appear unwell or if the WCC count is below 5 x 10⁹ or above 15 x10⁹. If performing a lumbar puncture, ideally complete it without delay and before administering antibiotics.
Tests that should be performed on the CSF (that our exams are seemingly obsessed with) include:
Cell count
Glucose level (get measurement of serum glucose at the same time)
Protein
Bacterial PCR
Viral PCR
Antibiotics
NICE provide a thorough guideline on antibiotic coverage for neonatal sepsis, which accounts for gestational age, whether it is community or hospital acquired among other factors, and specifies the dosing.
Children’s Health Ireland have national antibiotic guidelines for antibiotic coverage in the septic neonate.
Group B Strep and Neonatal Sepsis: Tell me more!
Group B Streptococcus (GBS) is an important pathogen in unwell infants. It is the most common cause for early onset neonatal sepsis (within 7 days of life) in high income countries. Late onset disease can happen up to 90 days of life. Sepsis from GBS after 90 days of life is less likely.
You can download our GBS infographic here.
Invasive Group B Streptococcus in infants <90 days old is notifiable in Ireland with the most recent figures from the Health Protection Surveillance Centre (HSPC) showing that there were 30 cases in Ireland in 2022, an improvement on numbers from previous years.
Risk factors for GBS sepsis include:
· Maternal GBS colonisation
· Pre-term delivery (<37 weeks gestation)
· Preterm prelabour rupture of membranes (PPROM)
· Intra-partum fever (≥38°C)
· Prolonged rupture of membranes of ≥18 hours
· Intra-amniotic infection (Chorioamnionitis)
· A sibling with GBS disease soon after birth
A number of initiatives have been implemented to try and reduce the incidence of GBS. These include giving intra-partum antibiotics for high-risk pregnancies. This has been shown to reduce the rates of early onset GBS infections but has no effect on late onset disease. The WHO is pushing for development of a maternal GBS vaccine to potentially prevent both early and late onset GBS infection in neonates.
Presentation
Early onset GBS sepsis usually occurs within the first 24 hours of life (but can be up to 7 days) and transmission is vertical from mother to child either in utero or during birth. Signs are often non-specific with respiratory symptoms, lethargy, irritability and feeding difficulties. There are multiple presentations including generalised sepsis, pneumonia and meningitis.
Late onset GBS sepsis occurs from the 7th day of life up until day 89. Transmission is less well described but can be from mucosal colonisation from the birth process or from contact with caregivers. The signs and symptoms can be very non-specific although rates of meningitis is higher in late onset disease than early onset. Due to often non-specific presentation it is important to maintain a high index of suspicion, investigate thoroughly and start prompt treatment.
Pearls and pitfalls from our Adult in the Room, Dr Rasha Sawaya
Identifying the sick vs the well baby
Examine, examine, examine the well baby!
Babies are different - the have big abdomens, their skin can be mottled in the cold. They can get strange spots and rashes. They naturally have less tone and they sleep all the time. In order to be able to identify the sick baby, you first need to know what a normal baby is.
Dr Sawaya believes you need to examine 100s of normal babies to be able to identify the one who is not normal and not overcall the well ones.
Trust yourself
We often doubt ourselves, but if you think a baby is sick, trust yourself and act. Ask for senior help early. It is better to take the first steps now and de-escalate later, than wait for something to go wrong.
When seeing sick babies, stabilise them first
A sick baby with a vague history is sepsis until proven otherwise. Stabilise them first, the ask the detailed questions afterwards. Look for signs of illness. Give fluid boluses as per the guidelines. Catheterise if you can for a more accurate urine output and to get a sample. Get cultures before giving antibiotics if possible (though PCR has become quite sensitive and can often pick up pathogens on CSF even after a number of doses of abx).
The history
We’ve included Dr Sawaya’s pearls and pitfalls in history taking in the drop down menu from the case above.
What if the baby doesn’t respond to your resuscitation, and you’re the most senior team member there?
In the case, infection was top of our differential, thus the patient was resuscitated appropriately. But what if they remain the same, despite these efforts?
The first thing you want to ask yourself is: what response are you looking for? In our case, Rocky presented with signs of poor perfusion, hypothermia. Thus we would expect an improvement in this. Re-examine and assess the capillary refill time (both centrally and peripherally), pulses and tone, as well as an assessment of movement, colour, breathing and vital signs. Blood pressure can be a tricky measurement in this age group, but is a key indicator - it’s worth ensuring you have the right cuff size for the most accurate measurement. It’s crucial that these parameters are compared to how the patient was on presentation to guage whether they have improved, stayed the same or are getting worse.
They aren’t getting better. What now?
Go through your mental checklist. Do they need wider coverage of antibiotics? Could this be something else? Be prepared to change your differential and act on new information. Here are some of Dr Sawaya’s top diagnoses and considerations to look out for if the baby isn’t responding to measures.
Metabolic conditions
Keep and eye on bloods and labs which might suggest this. Don’t forget to check the genitals for congenital adrenal hypoplasia and treat accordingly if so.
Head Trauma
Non accidental injury (NAI) can be subtle and hard to spot in a young child. As neonates have very little reserve, an intracranial bleed could result in a severe anaemia and resultant shock. Consider a CT head.
Cardiac abnormalities
This is the next thing Dr Sawaya thinks of if the baby is not responding to treatment for infection. In this case the baby is 5 days old. This is around the time the PDA is closing, and a coarctation may present with shock.
Work-up for congenital heart disease
When examining the child, ensure the femoral pulses are checked thoroughly - if they are not bilaterally strong, this should raise suspicion for coarctation of the aorta.
Assess pre and post ductal sats.
Consider a chest xray to assess for cardiomegaly, looking for significant findings.
POCUS won’t necessarily pick up any and every cardiac abnormality, but will give a sense of contractility and function.
Prostaglandin saves lives!
If any of the above exams are abnormal, start prostaglandin. It can always be stopped later on, and waiting may result in it being too late to make a difference. We’re leaving a big gap in text for dramatic effect so you don’t forget that.
And now, for a slight topic change…..
Feeding difficulties
Feeding is the main activity of infants. If they don’t have energy, they won’t feed well.
Baseline is key
It can be a little bit hard to know what’s normal and not normal when it comes to feeding habits in a 5 day old. They don’t have a baseline yet as feeds are increasing, as will urine output. In Ireland, as there is such good access to public health nurses, it may in fact be the well-appearing babies that have been referred with feeding problems that are of the most concern.
Babies are human beings
While we recognise this won’t come as a shock to many, there’s a point to be made: we all have our good days and our bad days.
In an infant with a change in feeding habit, it is persistent change that matters, ie not a single feed. In a young infant, a change that has been persistent for 12-24 hours may be long enough to heighten your suspicion that something is wrong. Specifically, you are interested in any drop in frequency, duration or quantity.
For breast fed babies, it’s key to ask how often they are going on the breast. Ask the mother if her breasts feel more congested as it may suggest the baby is not sucking as much. Breast milk is easier to digest than formula milk, so babies will usually feed every 1.5 - 2 hours, when compared to every 3-4 hours in those who take formula milk.
Ask about change in urine output, bowel movements and activity. Pay particular attention to babies who are sleeping a lot, or who are completely inconsolable.
Urine output
Top tip for normal urine in the first week of life
1 day old - 1 wet nappy
2 days old - 2 wet nappies
3 days old - 3 wet nappies
4 days old - 4 wet nappies
Etc., all the way to 8 days, at which point they may have a wet nappy for every feed.
Vomiting
Most babies have reflux, and it’s important to distinguish between vomiting and reflux. Is there more vomit out of the mouth than usual? Has the frequency changed to be now be after feeds and in between feeds?
Ask about the colour - if bilious (green/dark yellow) it could be a volvulus (typically pyloric stenosis and intususeption would present at a later age than the 5 day old in this case).
Ask yourself why there has been a drop in feeding
Is the baby congested? Do they have bronchiolitis? Are they fatigued when eating, or cyanosed and sweating? Simply asking why may reveal some worrying symptoms and lead you towards a cause. Time is your friend. If you are concerned, you can admit the baby for observations.
You call for senior help, but it doesn’t come… because you are the senior help
*****Internally screams*****
If you haven’t listened to the end of the episode yet, Dr Sawaya has some incredible advice for NCHDs who are graduating into more senior roles.
Don’t try to be a hero.
It can sometimes feel like you should know it all, now that you’re in a senior role. You don’t. Ask for help early.
Always listen to others
Your juniors, the nurses, the parents. When a younger NCHD is asking you questions, ask yourself why they are. Teach them, they will become seniors and will be the ones looking after your children. Examine the patient yourself if you feel you should. Teach them procedures and pass on learning.
Learn to say no, and set limits
Not just in an academic setting – in your ED as well. Learn to delegate – you are in charge of supervision and flow, and need to make sure the sick patients are seen early and fast. It isn’t your job to sit for hours and go through the history.
Get familiar with your surroundings
As you move from one hospital to another, things will be different. Get to know the resus bay on your first shift. Look at the paeds guidelines that are there. Look at Youtube to remind yourself about procedures you may have forgotten.
You are now a role model
Act accordingly
Always remember who your patient is
That is the child. Ultimately you have to advocate for them – which may involve swallowing a bit more than you may have liked from parents
Pick your battles
ED is full of personalities, some stronger, some weaker, some nicer, some meaner. Opinions are just that – but not every disagreement has to become a conflict. Most of the time in medicine there is a lot of grey space, with no clear right or wrong. Ultimately your patient comes first.
Dr Rasha Sawaya’s Take home messages
Listen
To parents. To the nurses. To seniors and juniors. Listen.
Examine, examine, examine normal babies
If you think the baby is sick, trust yourself, and do something about it.
Take the vague complaints seriously
Try and break them down into something you can manage. And think
What is the most dangerous thing that could be happening?
What is the most common thing that could be happening?
Feeding is the baby’s main job
Get the baseline, and check for persistent variation in it.
Constantly reassess and adapt your management according to the new data you are getting
Keep your differential broad, and be prepared to change your top differential as more information becomes available.
Our final episode of 2023… but season 4 has only just begun!
Our massive thanks to the team for an exceptional case, and to our AITR for a thorough run through of managing the critically ill neonate, how to perform as a senior EM physician medicine, and the things not to miss in the sick baby.
After a December jam packed with episodes (3 in the last 3 weeks!), this will be our last episode of 2023.
But fear not, we have a cracking bonus PEM episode with Dr Conor Davis coming early in the new year, as well as an unmissable episode from our new GEM lead.
If you enjoy our content, we’d really appreciate a review on Spotify or Apple podcasts, as it helps others to find us. Drop us a tweet on X, or have a listen to our audiograms on Facebook and Instagram.
In the mean time, we wish you a wonderful holiday season. And as always:
“May your coffee be strong, and your rounds grand.”
Further reading:
Core EM have a fantastic resource on the critically unwell infant and is well worth a read: https://coreem.net/core/the-critically-ill-infant/
References
1. Fleiss N, Coggins SA, Lewis AN, et al. Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants With Late-Onset Infection. JAMA Netw Open. 2021;4(2):e2036518. doi:10.1001/jamanetworkopen.2020.36518
2. https://www.jpeds.com/article/S0022-3476(15)01370-0/fulltext
3. Simonsen KA, Anderson-Berry AL, Delair SF, Davies HD. Early-onset neonatal sepsis. Clin Microbiol Rev. 2014 Jan;27(1):21-47. doi: 10.1128/CMR.00031-13. PMID: 24396135; PMCID: PMC3910904.
4. https://www.nice.org.uk/guidance/ng195
5. https://www.nice.org.uk/guidance/ng143
6. https://media.childrenshealthireland.ie/documents/antimicrobial-guidelines-2021_X9ADhIs.pdf
8. Tavares T, Pinho L, Bonifácio Andrade E. Group B Streptococcal Neonatal Meningitis. Clin Microbiol Rev. 2022 Apr 20;35(2):e0007921. doi: 10.1128/cmr.00079-21. Epub 2022 Feb 16. PMID: 35170986; PMCID: PMC8849199.
