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Chapter 3
Problems of the neonate and young infant
Infection
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.
What are the stages in the management
of any sick child?
Stages in the management of a sick child
(Ref. Chart 1, p. xxii)
1.
Triage
•
2.
History and examination
•
3.
Emergency treatment, if required
Laboratory investigations, if required
Differential diagnoses
•
Main diagnosis
4.
Treatment
5.
Supportive care
6.
Monitoring
7.
Plan discharge
•
Follow-up, if required
What emergency and priority signs have
you noticed?
Temperature: 35º C, pulse: 170/min, RR: 20/min
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
What emergency treatment does
Dominic need?
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
How to give oxygen
• Place the prongs just inside
the nostrils and secure with
tape.
(Ref. Chart 5, p. 11
p. 312-315)
• 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
Start oxygen flow at 1-2 litres/minute, in
young infants at 0.5 litre/minute
History
• Domionic 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.
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
Differential diagnoses
• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to support diagnoses: neonate with
lethargy (Ref. p. 25)
Differential diagnoses
(Ref. p. 25)
• Birth asphyxia
• Hypoxic ischaemic encephalopathy
• Birth trauma
• Intracranial haemorrhage
• Haemolytic disease of the newborn, kernicterus
• Neonatal tetanus
• Meningitis
• Sepsis
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
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
What investigations would you like to do
to make your diagnosis ?
Investigations
• Blood glucose
• Haemoglobin
• Urine microscopy or culture
• Lumbar puncture
• Blood culture if possible
□ Discuss expected findings from investigations
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)
Urine
•
•
Urine routine:
- Chemistry/Protein/ Glucose:
nil
- Nitrate / Leucocyte esterase:
nil
- Blood:
nil
Microscopy:
- Red Blood Cells: 0 x 106/l (<13)
- Leucocytes:
•
Culture:
- No growth
0 x 106/l
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
How would you treat Dominic?
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
What supportive care and monitoring
are required?
Supportive Care
• Fluid management (Ref. p. 57)
• Maintain a stable thermal environment (Ref. p. 56)
• Pay strict attention to hand washing
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)
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