Exam 4 - Newborn Infections and Health Maintenance Flashcards
What is the most common cause of conjunctivitis in newborns? How is it transmitted?
Chlamydia (also respiratory tract infections)
- Vaginal birth carries highest risk of transmission
- Small risk with c-sections
What is the incubation period of chlamydial conjunctivitis? How long before the infection could potentially spread to the other eye?
Incubation period: 5-14 days after birth
Infection starts in one eye but affects the other in 2-7 days
Chlamydial conjunctivitis symptoms
- Mild to significant swelling
- Watery eye discharge
- Mucopurulent or bloody discharge
- Severe infection –> thickened conjunctiva (chemosis)
If left untreated may lead to corneal and conjunctival scarring
Gold standard diagnostic testing for chlamydia conjunctivitis
NAAT
- Nasopharyngeal and conjunctival swabs
- Need scraping of conjunctival epithelial cells (not just exudate)
What other complication could occur other than conjunctivitis for mothers with active chlamydia infection?
Chlamydia PNA
- Occurs in 11-30% of infants - not as common as chlamydia conjunctivitis
When is the onset of chlamydial PNA? What are associated symptoms?
Delayed onset: 2-12 weeks but can be as far out as 19 weeks
Symptoms:
- “Staccato cough”, may be paroxysmal
- Nasal congestion with minimal discharge
- Afebrile
- Rales
What finding would be seen on blood tests for chlamydia PNA? Chest x-ray?
Blood test: eosinophilia
CXR: hyperinflation with bilateral, symmetrical interstitial infiltrates
Diagnostic testing for chlamydia PNA
- CXR
- Nasopharyngeal culture of respiratory secretions
- Symptoms
What is the recommended treatment for chlamydial conjunctivitis and chlamydial PNA? Why isn’t topical therapy indicated?
Erythromycin 50 mg/kg/day PO in four divided doses for 14 days
Topical therapy not indicated; systemic treatment needed because chlamydia colonizes in the nasopharynx and can lead to PNA
Is prophylatic treatment recommened for asymptomatic infants born to mothers with chlamydial infections?
No prophylatic treatment recommended
- Educate mothers to monitor for signs of infection
Should the provider be concerned if newborns are diagnosed with c. trachomatis?
A diagnosis of c. trachomatis in a neonate should prompt evalution for possible n. gonorrhoeae infection
What fetal risks are associated with untreated maternal gonorrheal infection?
Increases risk for preterm labor and chorioamnionitis
Where is the most frequent site of gonorrhea infections in newborns? Why should the provider be concered with such infections?
Ophthalmia neonatorum (conjunctivitis)
- Eye infections with n. gonorrhea can quickly lead to blindness, ulceration, scarring
- AAP recommended that every infant receive eye prophylaxis at birth
The AAP recommends eye prophylaxis for every infant due to risk of blindness with n. gonorrhea infection. What are the treatment options? How much time does the provider have to administer such treatment options?
Treatment can be delayed up to a maximum of one hour after birth
- 0.5% erythromycin ophthalmic ointment
- 1% tetracycline ophthalmic ointment
Ophthalmia neonatorum (gonorrhea): signs and symptoms
When do symptoms normally present?
Symptoms present 2-5 days after birth
- Purulent conjunctivitis
- Profuse exudate
- Swelling of eyelids
Diagnostic testing for gonorrhea (ophthalmic neonatorum)
- Culture and gram stain
- Always consider co-infection with chlamydia
- Treat mother and consider testing for other STIs
- Evaluate for systemic infection - disseminated gonorrheal infection (DGI)
Gonorrhea (ophthalmia neonatorum): treatment and management
- Ceftriaxone 25-50 mg/kg (max 125 mg), IV/IM once
- Isolate infant for 24 hours
Why are newborns more prone to infections that easily lead to sepsis?
Newborns are more susceptible due to immaturity of their immune systems
Early onset infections (sepsis)
- Onset
- Cause
Onset - before 72 hours
Cause - GBS, e. coli, staph
Late onset infections (sepsis)
- Onset
Onset: after 72 hours of life and up to 28 days
If parents say something isn’t right, investigate it
All infants <6 weeks of age with a rectal temperature of ___ or greater need immediate referral to the ER for septic workup
100.4
Signs and symptoms predictive of serious illness and need for hospitalization in infants under 2 months
- Feeding difficulty
- Moves only when stimulated
- Temp under 35.5 or over 37.5 axillary
- RR >66 breaths per minute
- Convulsions
Minor risk factors for neonatal sepsis
- Ruptured membranes >12 hours
- Foul smelling lochia
- Maternal fever >99.5 F (37.5 C)
- Low APGAR <5 at 1 minute, >7 at 5 minute
- Prematurity
- Multiple gestation
Prescence of 2 minor risk factors = high risk of sepsis
Major risk factors for neonatal sepsis
- Ruptured membranes >24 hours
- Maternal fever 100.4 F (38 C)
- Chorioamnionitis
- Sustained fetal heart rate >160 bpm
- Multiple obsteric procedures
Presence of one major risk factor - high risk of sepsis
How are newborn scales of sepsis scored?
Each item is assigned a score: max score is 55 points (20 lab, 35 clinical)
- Score <10 = neonate does NOT have sepsis
- Score >10 = “sick baby”, requires further diagnostic evaluation
Laboratory findings that could indicate neonatal sepsis
- WBC
- Total neutrophil ratio
- Platelet count
- Blood acidity
- ANC
Gold standard labs to diagnose neonatal sepsis
- Blood, urine, CSF
Also includes… CBC with diff, platelet count, chem 7, ABG
Radiologic tests to help diagnose neonatal sepsis
- CXR (if respiratory symptoms are present)
- Abdominal films
- Joint x-rays
Are labs/diagnostic tests 100% accurate in diagnosing sepsis?
There is no laboratory test that is 100% sensitive or specific for sepsis
Normal results do not rule out infection or sepsis in the newborn
True/false: There is a higher incidence of HSV in premature infants, infants with compromised skin integrity (use of scalp electrodes)
True - transmission greatest when a mother has a primary (active) infection
When do symptoms of HSV first appear in newborns?
Symptoms appear any time from birth to 4 weeks of age
HSV signs and symptoms: localized disease
- When do they present?
- Skin infection/vesicular lesions
- Skin, eye, mouth (SEM) disease
Presents in the 1st or 2nd week of life (often at areas of trauma)
HSV signs and symptoms: CNS disease
- When do symptoms occur?
- Encephalitis (involvement of brain/spinal cord)
- Seizures
Occurs more commonly in 2nd to 4th week of life
HSV signs and symptoms: disseminated disease
- When do symptoms present?
Most dangerous of the three
- General symptoms of bacterial sepsis
- Multi-organ involvement
- Frequently DIC
Symptoms present usually within the first week of life
HSV diagnosis: what labs should be collected?
- Surface swabs - collected from conjunctivae, mouth, nasopharynx, rectum
- Scraping of lesion - viral culture
- Blood or plasma - whole blood or plasma sample using PCR
- Other
- Viral culture or PCR on all specimens available (e.g. tracheal aspirates)
What is the recommended treatment for HSV in newborns? When should therapy be initiated?
Acyclovir 60 mg/kg/day IV divided every 8 hours as soon as HSV is suspected
- Start therapy in any infant up to 8 weeks of age (especially those with vesicular rash)
When should treatment be initiated in newborns with HSV (SEM disease)?
Minimum of 14 days if disseminated and CNS disease has been excluded
When should treatment be initiated in newborns with HSV (disseminated and CNS disease)?
Minimum of 21 days
- Repeat LP near the end of treatment to ensure PCR is negative
- Will then require oral suppressive therapy for 6-12 months
HSV: parental education and follow up
- Breastfeeding is acceptable as long as no lesions on breasts
- All persons with cold sores should follow strict hand washing guidelines, wear a mask when holding infant until lesion is crusted over
- Referral to ophthlamology and audiology
- Require close neurodevelopmental follow up
True/false: neonates born to mothers with active HSV lesions should be separated from other neonates and managed with contact precautions
True
What characterizes group B strep (GBS) infection?
Gram (+) bacteria that commonly colonizes the GI and genital tracts
- Maternal colonization is the primary risk factor for GBS in neonates
- Transmitted through vertical transmission
When does early onset GBS occur?
Presents at or within 24 hours of birth
- Can occur through 1 week of life
When does late onset GBS occur?
From 1 week to 3 months of life
When does late late onset GBS occur?
Occurs in infants older than 3 months
Late late onset GBS in more common for which population of neonates?
Common in infants who are born before 28 weeks gestation or in children with a history of immunodeficiency
When should prenatal screening for GBS occur?
Vaginal and rectal GBS cultures collected between 36-37 weeks
- Decline in U.S. due to universal screening
Does the CDC recommend prophylactic treatment for GBS?
Yes - maternal intrapartum antibiotic prophylaxis
- IV PCN given 4 hours before birth
GBS risk factors
- Infants born <37 weeks gestation with OB complications
- ROM for >18 hours before delivery
- Chorioamnionitis
- GBS bacteriuria during current pregnancy
- Temperature >38 C or 100.4 F during labor
- Prior delivery of an infant with GBS disease
Signs and symptoms of GBS - early onset disease
98% are asymptomatic
2% develop fulminate multisystem illness
- PNA
- Septicemia (or symptoms of sepsis)
- Meningitis
Signs and symptoms of GBS - late onset disease
- Bacteremia - fever, irritability, lethargy, poor feeding, tachypnea, grunting
- Meningitis - temperature instability, irritability, lethargy, poor feeding, vomiting
- Bone/joint infection
- Adenitis/cellulitis
Signs and symptoms of GBS - late late onset disease
- Commonly occurs in infants <28 weeks gestation
- Usually presents as bacteremia without a focus
What factors determine the type of diagnostic workup required for GBS?
- Dependent on infants gestational age
- Clinical presentation
- Status of maternal prophylaxis
- If there were signs of chorionamnionitis during delivery
Diagnostic testing for GBS
- What definitive finding would diagnose GBS?
- Same as sepsis workup (labs, cultures of CSF, urine, blood)
- CXR (if respiratory signs present)
Diagnosis: isolation of GBS from culture results
GBS treatment
PCN G followed by ampicillin
What substances can lead to neonatal abstinence syndrome (NAS)?
- Opioids
- Alcohol
- Barbiturates
- Benzodiazepines
- SSRIs
When should mothers be screened for substance use?
All mothers should be assessed for prenatal substance use
- Universal screening - every patient, every visit
Are premature infants more likely or less likely to experience NAS?
Premature infants have less NAS due to immature neurological systems
When do signs and symptoms of NAS first present in newborns?
Present within 48-72 hours of life but can be delayed up to 28 days
- Can persist for 4-6 months after birth
- If last dose was >1 week, then very low likelihood of withdrawal symptoms
Characteristic signs of NAS reflect dysfunction in what four domains?
- State control and attention
- Motor and tone control
- Sensory integration
- Autonomic functioning
What scoring system should be used to monitor symptoms of NAS? What score indicates withdrawal?
“Modified Finnegan score” - eating, sleeping, consoling care tool
- Assess 2 hours after birth and then every 4 hours
- Score >8 indicates withdrawal
NAS: signs and symptoms
- Sleep-wake cycle disturbance
- Hypertonicity, tremors, jitteriness
- Sweating, sneezing, nasal stuffiness, frequent yawning
- Hyperarousal resulting in irritability and crying
- Difficulties feeding
- GI problems (gassiness, vomiting, loose stools)
When is consent required and not required in terms of testing for NAS?
- Hospitals are prohibited from testing women for illegal drug use and reporting positive results to law enforcement without their consent
- Neonatal testing may be obtained without consent if infant displays signs of NAS whose mother denies any substance use
Methods in which diagnostic testing could be done for NAS - urine
- How long does alcohol, cocaine, opioids, and marijuana stay in the urine?
- Remains positive for hours after alcohol use, 1-3 days cocaine, 2-4 days opioids, up to 1 month marijuana
- Review medical record for any narcotics or sedatives given during delivery
Methods in which diagnostic testing could be done for NAS - meconium or hair
- At what time point would drugs be detected in meconium and hair?
- Can detect drug abuse during 2nd half of pregnancy
- Collect meconium from first 48 hours of life
What tool can be used to monitor NAS in newborns? How often is this tool used?
Eat, Sleep, and Console (ESC) tool - focuses on infant function and comfort rather than reducing signs and symptoms of withdrawal
- Performed every 3-4 hours for first 4-7 days of life
Non-pharmacologic management of NAS
- 4 “S” - shush, suck, swing, swaddle
- Keep environment calm to avoid overstimulation of infant
- Room in when possible
- Skin to skin when possible
When would pharmacologis therapy be indicated for newborns with NAS?
Medications are initiated for infants who do not respond to non-pharmacologic care
- Aimed at short term improvement of clinical symptoms
What is an important consideration that should be made when determining which medication to choose for pharmacologic therapy of NAS?
Choose a drug from the same class as exposure (gradually wean dose)
- Agents for opioid withdrawal: morphine, methadone, buprenorphine
- Second agents: clonidine, phenobarbital
What are risks associated with using medications to treat NAS?
- Longer length of stay
- May reinforce idea that discomfort or “annoying behavior” should be medicated
When should infants with NAS return for follow up?
Monitored for 4-7 days in the hospital
Require close outpatient care for neurodevelopmental concerns and ensure social situations are stable
True/false: alcohol is a teratogen that can cause irreversible CNS effects
True - there is no safe amount of alcohol that can be consumed in pregnancy
- Binge drinking has been linked with worse outcomes
Anomalies from alcohol exposure during the first trimester include…
Facial anomalies and major structural anomalies (including the brain)
Anomalies from alcohol exposure during the second trimester include…
Increased risk of spontaneous abortion
Anomalies from alcohol exposure during the third trimester include…
Weight, length, and brain growth
- Neurobehavioral effects may occur throughout gestation
What is considered the most severe form of fetal alcohol spectrum disorder?
Fetal alcohol syndrome (FAS) - associated with birth defects, mental retardation, lifelong disabling behavioral problems
Diagnostic criteria for FAS
- Confirmed maternal alcohol exposure
- Characteristic physical facial features
- Evidence of growth retardation
- Evidence of CNS/neurobehavioral abnormalities
Alchol related birth defects - cardiac, skeletal, renal, ocular, auditory
- Cardiac - ASD, VSD, TOF
- Skeletal - pectus, scoliosis, contracture
- Renal - ureteral duplication, hydronephrosis, dysplastic kidney
- Ocular - strabismus, retinal abnormalities, small globes
- Auditory - conductive and/or neurosensory hearing loss
What findings would lead to clinical suspicion of FAS?
- Facial dysmorphisms (short palpebral fissures, thin vermillion border, smooth philtrum)
- Intrauterine and/or postnatal growth retardation
- Structural brain anomaly
- Cognitive delays in older children
If clinical suspicion is present, child needs evaluation by interdisciplinary team (including genetics)
Down syndrome: aspects of ongoing screening required to monitor - growth, cardiac, hearing
- Growth - monitor thyroid and celiac related growth disorders, obesity, use DS growth chart
- Cardiac - perform echo at birth, refer to pediatric cardiology, screen for mitral valve prolapse at adolescence
- Hearing - screen at newborn and then ever 6 months up to 3 years
Down syndrome: aspects of ongoing screening required to monitor - ophthamologic, thyroid
- Ophthalmologic - assess as newborn, refer by 6 months if issues, then screen annually
- Thyroid - TSH and total T4 as newborn, repeat at 6 and 12 months, then annually
Down syndrome: aspects of ongoing screening required to monitor - hematology, atlantoaxial instability
- Hematology - CBC with diff at birth, hemoglobin annually through 1-13 years
- Atlantoaxial instability - screen cervical spine at 3-5 years, screen for hip dislocation through 10 years
What is the leading cause of death in infants between one month and one year of age in the U.S.?
SIDS
What is sudden unexpected infant death (SUID)? SIDS?
SUID: Sudden and unexpected death of an infant less than one year of life in which the cause was not obvious prior to investigation
SIDS: death by accidental suffocation/strangulation in a sleeping environment, and other deaths from unknown causes
SUID/SIDS risk factors
- Prone or side sleeping position
- Sleeping on a soft surface and/or with soft objects (pillows, stuffed animals)
- Bed sharing
- Maternal smoking during pregnancy and smoke exposure
- Preterm birth and/or low birth weight
- Young maternal age
- Late or no prenatal care
- Overheating
- Male gender
What is thought to be the pathophysiology of SUID/SIDS (two theories)?
- Disruption in sleep wake/arousal pathway
- “Triple risk” model - infants born with brain abnormalities that make them susceptible to SIDS
- Infant met with environmental challenge at critical developmental period and cannot respond adequately
Prevention of SUID/SIDS: components of the “safe to sleep” campaign
- Room sharing for at least 6 months to 1 year
- Offer pacifier prior to sleep
- Encourage breastfeeding
- Use a fan, keep environment cool
- Keep UTD on immunizations and well visits
- Avoid smoking, alcohol, drug use
