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High-Risk Newborn

1. Sepsis
What is sepsis?

Sepsis is a term for severe infection that is present in the blood and spreads throughout
the body. In newborns, it is also called sepsis neonatorum or neonatal septicemia.

What causes sepsis?

Sepsis can develop following infection by microorganisms including bacteria, viruses,


fungi, and parasites. Infection in babies can be contracted during pregnancy, from the
mother's genital tract during labor and delivery, or after birth from contact with others.

Sepsis in a newborn is more likely to develop when the mother has had pregnancy
complications that increase the likelihood of infection. Such complications may include
the following:

• premature rupture of the membranes (amniotic sac), or membrane rupture for an


extended length of time

• bleeding problems

• a difficult delivery

• infection in the uterus or placental tissues

• fever in the mother

Babies can also develop sepsis by contracting infections after birth from infected persons
or objects. Babies in the newborn intensive care unit (NICU) are at increased risk for
acquiring nosocomial (hospital-acquired) infections. Many babies in the NICU are
premature or have low birthweight which makes them more susceptible to infection and
more likely to need invasive treatments and procedures. Microorganisms that normally
live on the skin may cause infection if they enter the body through catheters and other
tubes inserted into the baby's body.

What microorganisms cause severe infections and sepsis in babies?

Prenatal During Delivery After Birth


rubella (German Group B respiratory
measles) streptococcus syncytial virus
(GBS) (RSV)
cytomegalovirus E. coli Candida
(CMV)
varicella-zoster virus herpes simplex Haemophilus
(chickenpox virus) virus influenzae type b
(Hib)
Listeria . enterovirus
monocytogenes

Why is sepsis a concern?

Sepsis can be life threatening for newborns, especially if the baby has a weakened
immune system because of prematurity or another illness. When a baby's immature
immune system cannot fight the microorganism, the infection can quickly spread and
overtake the body, causing serious illnesses such as meningitis or pneumonia.

What are the symptoms of sepsis?

Sepsis in newborns is not always easy to identify since newborn babies often do not show
symptoms of infections in the same way older babies and children may show symptoms.
The following are some of the symptoms of infection in newborn babies. However, each
baby may experience symptoms differently depending upon the type of organism causing
the infection and the severity and location of the infection. Symptoms of infection may
include the following:

• apnea (stopping breathing) or difficulty breathing


• bradycardia (decreased heart rate)
• decreased temperature or temperature instability
• weak suck
• jaundice (yellow coloring of the skin and eyes)

How is sepsis diagnosed?

A sepsis workup may be needed to help identify the location of the infection and type of
microorganism causing the infection. A sepsis workup may include the following
procedures:

• blood tests

• lumbar puncture (Also called spinal tap.) - a special needle is placed into the
lower back, into the spinal canal. This is the area around the spinal cord. The
pressure in the spinal canal and brain can then be measured. A small amount of
cerebral spinal fluid (CSF) can be removed and sent for testing to determine if
there is an infection or other problems. CSF is the fluid that bathes your child's
brain and spinal cord.
• blood cultures

• urine culture (sometimes by suprapubic tap, insertion of a needle through the


lower abdomen into the bladder)

• culture of fluids from inside tubes and catheters that are inserted in the baby

• x-rays - a diagnostic test which uses invisible electromagnetic energy beams to


produce images of internal tissues, bones, and organs onto film.

Procedures may also be performed to determine which antibiotics or medications are


most effective for treating the specific microorganism.

Treatment of sepsis:

Specific treatment for sepsis will be determined by your baby's physician based on:

• your baby's age, overall health, and medical history


• extent of the disease
• your baby's tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

Early diagnosis and treatment of the infection are important in helping prevent sepsis
from overwhelming a baby's body. However, cultures of blood and body fluids may take
several days for the organism to grow and be identified. Because of this, babies who are
at increased risk for sepsis, such as premature or low birthweight babies, may have
preventive antibiotic treatment started as soon as cultures are taken. Most medications are
given intravenously (IV).

Sepsis can be life threatening as the infection can affect several body systems at the same
time. This can make providing treatment more difficult. Babies with sepsis will require
care in the newborn intensive care unit (NICU), and may need antibiotics, other
medications, and specialized treatment (such as a mechanical breathing machine). The
healthcare team will be working to provide the best care to treat the infection and care for
your baby.

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2. Sepsis Neonatorum
• Definition
• Symptoms
• Diagnosis
• Prognosis and Treatment

Sepsis in a newborn (sepsis neonatorum) is an infection that spreads throughout the


baby’s body. Sepsis occurs in less than 1 percent of newborns (1 out of every 100), but
accounts for up to 30 percent of deaths in the first few weeks of life. Infection is 5-10
times more common in premature newborns and in babies weighing less than 5½ pounds
than in normal-weight, full-term newborns. Complications experienced during birth, such
as premature or prolonged rupture of the membranes or infection in the mother, put the
newborn at increased risk of infection.

Symptoms

The onset of what is called early-onset neonatal sepsis is within six hours of birth in over
half the cases and within 72 hours in the great majority of cases. Sepsis that begins four
or more days after birth is called late-onest sepsis, and is probably an infection acquired
in the hospital nursery (a nosocomial infection). In both types of neonatal sepsis, the
infection may be only in the bloodstream, or may spread to the lungs (pneumonia), brain
(meningitis), bone (osteomyelitis), joints, or other organs in the body.

Typical symptoms of a newborn with sepsis include:

• listlessness (a very sleepy baby)


• feeding problems
• a high OR low temperature

Other symptoms include:

• difficulty breathing, rapid breathing, or apnea (when the baby stops breathing)
• seizures
• excessive jitteriness
• repeated vomiting or diarrhea
• a swollen abdomen

Diagnosis

The organism that is causing the infection may be identified by taking cultures of the
blood as well as from other sites of the body. Urine samples are often cultured for
bacteria to look for an infection in the urinary tract. Because only small samples of blood
and other body fluids are taken, sometimes no organism is found. However, the infant
may still be treated if other laboratory studies or the infant’s clinical appearance strongly
suggest an infection.

Other laboratory studies that doctors use to detect an infection include the following:
• White Blood Cell Count and Differential: When an infant is fighting an
infection, their white blood cell count may either go up, as the infant’s body
produces more infection-fighting cells, or it might also go down if the infant has
used up all of their white blood cells fighting the infection and can no longer
keep up with their production of white cells. Another change that is seen when an
infant is fighting an infection is an increase in the percentage of immature white
cells. This is due to the increased production rate of white blood cells, such that
more immature white blood cells are being released into the blood stream. This
higher percentage of immature white cells is sometimes referred to as a “left-
shift,” and is one of the things that can tell the doctors that the infant has an
infection.

• C-Reactive Protein (CRP): This is a laboratory test that measures a protein that
is a non-specific marker for inflammation and therefore infection. If the infant
has two normal CRP levels measured 24 hours apart, then there is a 99% chance
that the infant does not have an infection. Therefore, this test is most useful in
ruling out an infection.

• Lumbar Puncture: If the doctor suspects meningitis, which is more common if


something has grown in the baby’s blood culture, a spinal tap, or lumbar puncture
will be performed. Lumbar punctures allow the doctor to obtain a small amount of
cerebrospinal fluid (CSF), which is the protective fluid that surrounds the brain
and the spinal cord. The CSF can then be cultured to determine if the bacteria has
spread to the nervous system.

The doctor, nurse practitioner, or physician’s assistant will very carefully insert a
special spinal needle between two vertebrae, or backbones, in the baby’s back at a
level below where the actual spinal cord ends, so there is no danger that the
needle will come into contact with the baby’s spinal cord. After a very small
amount of fluid is removed, the needle is taken out, and a band-aid placed on the
baby’s back.
The spinal needle is inserted (left) below where the spinal cord ends (right.)

Prognosis and Treatment

Sepsis in a newborn is treated with antibiotics given intravenously. Antibiotics are often
started even before laboratory and culture results are available. The doctor may then
switch to a different antibiotic that is more specific to the baby’s infection once the results
of laboratory tests are back. The length of antibiotic treatment varies depending on the
infant’s clinical status, laboratory test results, and kind of infection. If blood cultures and
other laboratory tests are all negative, antibiotics may be stopped after 48 hours of
treatment. If the infant’s cultures are positive, or if the laboratory tests and clinical status
are suggestive of infection, the infant will be treated with antibiotics, usually anywhere
from 7-14 days. When appropriately treated with antibiotics and cared for in the intensive
care unit, the great majority of newborns with sepsis live without any long-term
problems.