The Ill Newborn/Neonatal Collapse

Question 1

Define Early Onset Infection

Answer 1

Infection <48hrs after birth

Question 2

What are the causes of early onset infection?

Answer 2

1. Bacteria from the birth canal ascending and invading amniotic fluid with secondary infection of the foetus
2. Pneumonia and secondary bacteraemia/septicaemia
3. Congenital viral infections
4. Early onset Listeria monocytogenes infection

Question 3

List the risk factors for early onset infection

Answer 3

1. Prolonged or premature rupture of membranes

2. Maternal fever during labour

Question 4

How does neonatal infection present?

Answer 4

1. Respiratory distress
2. Temperature instability
3. Poor feeding
4. Vomiting
5. Apnoea and bradycardia
6. Abdominal distension
7. Jaundice
8. Neutropenia
9. Hypoglycaemia/Hyperglycaemia
10. Shock
11. Irritability
12. Seizures
13. Lethargy/drowsiness

Question 5

What investigations would you perform if you suspected neonatal infection?

Answer 5

1. CXR
2. Septic screen:
   - FBC
   - Blood cultures
   - CRP

Question 6

How can we manage neonatal infection?

Answer 6

1. IV antibiotics ASAP:
   - Amoxicillin + CefoTAXime
   - Gentamicin for gram negative cover
2. If confirmed GBS:
   - Benzylpenicillin IV + Gentamicin IV
3. If cultures and CRP negative and no clinical indicators:
   - Stop antibiotics after 36-48hrs
4. Blood culture positive or neurological signs:
   - CSF examined and cultured

Question 7

Define Late Onset Infection

Answer 7

Infection >48hrs after birth

Question 8

What are the sources of late onset infection?

Answer 8

1. Infant’s environment
2. NICU:
   - Indwelling CVC
   - Invasive procedures
   - Tracheal tubes

Question 9

What is the most common pathogen associated with late onset infection?

Answer 9

Coagulase negative staphylococcus - e.g Staph epidermidis

Question 10

What are the risks of prolonged broad spectrum antibiotic use in preterm infants?

Answer 10

Predisposes to invasive fungal infection

Question 11

How can we measure the response to therapy in neonatal infection?

Answer 11

Serial CRP measurements

Question 12

How does neonatal meningitis present?

Answer 12

1. Nonspecific signs
2. Late signs:
   - Bulging fontanelle
   - Hyperextension of the neck and back

Question 13

How is neonatal meningitis treated?

Answer 13

IV Amoxicillin and CefoTAXime and consider gentamicin for gram neg cover

Question 14

List the complications of neonatal meningitis

Answer 14

1. Cerebral abscess
2. Ventriculitis
3. Hydrocephalus
4. Hearing loss
5. Neurodevelopmental impairment

Question 15

When does Group B Streptococcal (GBS) infection present?

Answer 15

Can be early or late onset infection

Question 16

What are the features of early onset GBS disease?

Answer 16

1. Respiratory distress
2. Pneumonia
3. Mortality with positive blood or CSF cultures up to 10%

Question 17

How does late onset GBS disease present?

Answer 17

1. Meningitis
2. Focal infection (occasionally)
3. Can be developed up to 3mths of age

Question 18

What are the risk factors for developing GBS infection?

Answer 18

1. Preterm
2. Prolonged rupture of membranes
3. Maternal fever during labour (>38)
4. Maternal chorioamnionitis
5. Previously infected infant

Question 19

How can GBS infection be prevented?

Answer 19

Intrapartum antibiotic prophylaxis given to those at risk

Question 20

How is Listeria monocytogenes infection transmitted to the mother?

Answer 20

Transmitted in food:

1. Unpasteurised milk
2. Soft cheeses
3. Undercooked poultry

Question 21

How does Listeria infection present in the mother and transmit to the foetus?

Answer 21

Presents as mild bacteremia and mild flu-like illness in the mother
Transmits to foetus across placenta

Question 22

List the consequences of maternal infection with Listeria

Answer 22

1. Spontaneous abortion
2. Preterm delivery
3. Fetal/neonatal sepsis

Question 23

What are the characteristic features of Listeria infection?

Answer 23

1. Meconium stained liquor
2. Widespread rash
3. Septicaemia
4. Pneumonia
5. Meningitis

Question 24

What is the mortality rate with Listeria infection?

Answer 24

30%

Question 25

What are the common causes of neonatal conjunctivitis?

Answer 25

1. Staphylococcal and Streptococcal organisms 2. Gonococcal infection 3. Chlamydia trachomatis infection

Question 26

What are the features of Staph/Strep conjunctivitis and how is it managed?

Answer 26

``` Features: - Discharge - Redness of the eye Management: - Clean with saline or water - Topical antibiotic eye ointment (Chloramphenicol or Neomycin) ```

Question 27

What are the features of gonococcal conjunctivitis and how is it managed?

Answer 27

Features: - Purulent discharge (gram stained and cultured URGENTLY) - Swelling of eyelids (<48hrs after birth) Management: - Clean with saline or water - Immediate 3rd generation cephalosporin IV or penicillin - Cleanse eye frequently May lead to permanent loss of vision

Question 28

What are the features of Chlamydia conjunctivitis and how is it managed?

Answer 28

Features: - Purulent discharge (immunofluorescent staining) - Swelling of eyelids (1-2wks after birth) Management: - Clean with saline or water - Erythromycin PO for 2wks - Mother and partner checked and treated

Question 29

List the risk factors for Herpes Simplex Virus infection in neonates

Answer 29

1. Infant born to mother with primary genital infection 2. Recurrent maternal infection 3. More common in preterm infants

Question 30

How does HSV infection in neonates present?

Answer 30

1. Any time up to 4wks after delivery 2. Localised herpetic lesions on skin or eye 3. Encephalitis 4. Disseminated disease (HIGH MORTALITY)

Question 31

How can we prevent neonatal HSV infection?

Answer 31

``` Mother with primary genital infection: - Elective C-Section Mother with hx of recurrent genital infections: - Deliver vaginally - Maternal treatment before delivery ```

Question 32

How can we prevent vertical transmission of Hepatitis B infection?

Answer 32

Give the Hepatitis B vaccine shortly after birth Complete course of vaccinations during infancy Check antibody response

Question 33

What are The Sepsis Six?

Answer 33

``` GIVE THREE: 1. Oxygen 2. Antibiotics 3. Fluids TAKE THREE: 1. Blood cultures 2. Urine output 3. Lactate ```

Question 34

List the most common causes of neonatal meningitis/sepsis?

Answer 34

Group B Strep Eschericia coli Listeria moncytogenes

Question 35

What features will be present in the history of a neonate with sepsis?

Answer 35

1. Fever 2. Poor feeding 3. Miserable, irritable, lethargy 4. History of focal infection 5. Predisposing conditions

Question 36

List the features that may be present on examination of a neonate with sepsis

Answer 36

1. Fever 2. Tachycardia, tachypnoea, low BP 3. Purpuric rash 4. Shock 5. Multi-organ failure

Question 37

What are the management priorities in a neonate with sepsis?

Answer 37

1. ANTIBIOTICS without delay 2. FLUIDS and monitoring of fluid balance 3. CIRCULATORY SUPPORT - usually inotropic 4. Beware of DIC - treat clotting derangement with FFP, cryoprecipitate and platelet transfusions