The Newborn II

Dr : Maha Bamehriz

Neonatal Sepsis
Definition :Neonatal sepsis is a clinical syndrome of systemic
illness accompanied by bacteremia occurring in the first
month of life.
Incidence. The incidence of primary sepsis is 1-8 per 1000 live
births and as high as 13-27 per 1000 for infants weighing
<1500 g(small babies) , and babies in NICU are more
susceptible to have neonatal sepsis .

Neonatal Sepsis
Classification:
1. Early onset sepsis
first 72hrs after birth( 1st 3 days). (5-7 d)
It is associated with acquisition of microorganisms
from the mother (the intrapartum period from the
maternal genital tract).
It is usually a multisystem fulminant illness with
prominent respiratory symptoms.
Causative organisms:
- Bacterial
- Viral
- Fungal

Neonatal Sepsis
The microorganisms most commonly associated
with early-onset infection include:
- Group B Streptococcus (GBS)( most common)
- Escherichia coli
- Listeria monocytogenes
- Coagulase-negative Staphylococcus
- Haemophilus influenzae

Neonatal Sepsis
2.

Late onset sepsis:

It occurs at 4 - 90 days of life(from 4th day to the 3rd month of
life) .
It is acquired from the care giving environment.
These infants usually have an identifiable focus, most
often meningitis in addition to sepsis.
The most common causative organisms are:
- Coagulase-negative staphylococci ,Staphylococcus aureus ,GBS
- E coli,Klebsiella, Pseudomonas,Enterobacter
- Serratia , Acinetobacter ,Anaerobes.
- Candida

Neonatal Sepsis
Risk Factors:
Maternal :
1. Premature or prolonged (>18 h) rupture of
membranes.
2. Maternal peripartum fever (38 C/100.4 F) or
infection( Chorioamnionitis( inflammation of the fetal
membranes{amnion and chorion }due to bacterial
infect.), UTI, vaginal colonization with GBS, previous
delivery of a neonate with GBS disease, perineal
colonization with E. coli).
3. Meconium-stained or foul-smelling amniotic fluid.

Neonatal Sepsis
Risk factors:
fetal and Neonatal :
1. Prematurity and low birth weight .
2. Resuscitation at birth.
3. Multiple gestation.
4. Invasive procedures.
5. Males / Black.
6. Metabolic disorder.
7. Congenital anomaly

Neonatal Sepsis
Clinical features :
Clinical signs and symptoms of sepsis are nonspecific.
- Temperature irregularity.
- Change in behaviour.( crying and irritability)
- Skin changes, (rash )
- Feeding problems.
- Cardiopulmonary.
- Metabolic disturbances

Neonatal Sepsis

Diagnosis :
CBC ( platelets usually) & Differential.
Acute-phase reactants(CRP).
Cultures.
Radiologic studies ( CXR, Urinary tract imaging.)
Other studies (Examination of the placenta and fetal
membranes) if U think in congenital infection

Neonatal Sepsis

Deferential Diagnosis :
Respiratory distress syndrome (RDS)
Metabolic diseases
Hematologic disease
CNS disease
Cardiac disease ( cyanotic congenital heart disease)
Other infectious processes (ie, TORCH infections)

Neonatal Sepsis
Management :
1- ABC
2- IV fluid
3- Initial therapy : Immediately start Antibiotic
- Treatment is most often begun before a definite causative
agent is identified.
- It consists of a penicillin, usually Ampicillin, plus an
aminoglycoside such as Gentamicin .
- In nosocomial sepsis, the flora of the NICU must be
considered, generally, staphylococcal coverage with
Vancomycin plus either an aminoglycoside or a thirdgeneration cephalosporin is usually begun.

Neonatal Sepsis
Management :
Continuing therapy :
- Based on culture and sensitivity results, clinical course, and
other serial lab studies (CRP).
Complications and supportive therapy.

NEONATAL SEIZURE
seizure is defined clinically as a paroxysmal alteration in
neurologic function (ie, behavioral, motor, or autonomic
function) (Volpe, 2001).
In the neonatal brain, glial proliferation, neuronal migration,
establishment of axonal and dendritic contacts, and myelin
deposition are incomplete.
seizures in the neonate are different from those seen in older
children.

NEONATAL SEIZURE
Clinical types:
- based on clinical presentation, Four types of seizures, are
recognized:
1. subtle
2. clonic
3. tonic
4. Myoclonic
* Nerver come tonic clonic together as in adult .

NEONATAL SEIZURE
Clinical types:
1.
-

Subtle seizures:
These seizures are not clearly clonic, tonic, or myoclonic .
More common in premature than in full-term infants.
They consist of tonic horizontal deviation of the eyes with
or without jerking; eyelid blinking or fluttering; sucking,
smacking, or drooling ,"swimming," "rowing," or "pedaling"
movements ,and apneic spells

NEONATAL SEIZURE
2. Clonic seizures:
- More common in full-term infants than in premature
infants .
- Focal seizures and Multifocal seizures.
3. Tonic seizures
- Occur primarily in premature infants.
- Focal seizures and Generalized seizures
4. Myoclonic seizures
- Seen in both full-term and premature infants and are
characterized by single or multiple synchronous jerks.
- Focal , Multifocal , Generalized

NEONATAL SEIZURE
Is it seizure or jitteriness ?
It is important to distinguish jitteriness from seizures.
Jitteriness is not accompanied by abnormal eye movements,
and movements cease on application of passive flexion.
In jitteriness , movements are stimulus sensitive and are not
jerky.

SEIZURE

Jitteriness

pathological

Normal phenomena

If you try to control it :

It will NOT stop
( rhythmic , continuous )

will STOP once you hold

it

Start without any

stimulation ..

start if you stimulate

him ( eg : change his
clothes . )

Etiology of Neonatal seizure

Perinatal asphyxia
Intracranial hemorrhage
Metabolic abnormalities
Hypoglycemia ,Hypocalcaemia
Electrolyte disturbances:
Hypo- and Hypernatremia
Amino acid disorders
Congenital malformations
Infections

Inherited seizure disorders

Benign familial epilepsy
Tuberous sclerosis
Zellweger syndrome
Pyridoxine dependency
Drug withdrawal
Toxin exposure (particular
local anesthetics

NEONATAL SEIZURE
Management:

Because repeated seizures may lead to brain injury, urgent

treatment is indicated.
The method of treatment depends on the cause.
Anticonvulsant therapy:
Conventional anticonvulsant treatment is used when no
underlying metabolic cause is found.
Loading doses of phenobarbital and phenytoin control 70% of
neonatal seizures.

NEONATAL SEIZURE

1.
2.
3.
4.
5.
6.

Anticonvulsant therapy:
Phenobarbital is usually given first .
Phenytoin (Dilantin).
Midazolam.
Diazepam (Valium) and Lorazepam (Ativan)
Paraldehyde.
Pyridoxine. ( in pyridoxine deficiency cases)

NEONATAL SEIZURE
Prognosis :
the prognosis varies with the cause .
Infants with hypocalcemic convulsions have an excellent
prognosis.
seizures secondary to congenital malformations have a
poor prognosis.
Symptomatic hypoglycemia has a 50% risk of death or
complications.
CNS infection carries a risk of 70%.
Asphyxiated infants with seizures have a 50% chance of
a poor outcome ( CP ).
17% of patients with neonatal seizures have recurrent
seizures later in life.

Birth Injuries
Cephalohematoma :
- It is a subperiosteal hemorrhage ( due tear in blood vessels)
that never extends across the suture line.
- It can be secondary to a traumatic or forceps delivery.
- Most cephalohematomas resolve in 2-3 weeks ( so Dont
touch it ... Rarely : may need interference )
- Aspiration of the hematoma is rarely necessary.
Caput succedaneum: the bleeding is
- Diffused . - cross the suture .

Birth Injuries

Caput
succedaneum

cephalhaematoma

Birth Injuries
Erb-Duchenne paralysis: ( waiters tip position)
- Involves injury to the fifth and sixth cervical nerves.
- There is adduction and internal rotation of the arm. The
forearm is in pronation ,the power of extension is
retained ,The wrist is flexed.
- This condition can be associated with diaphragm
paralysis( phrenic nerve palsy )
- prognosis : resolve completely , if Not resolved by 6
weeks should be referred to orthopaedic surgeon
Klumpkes palsy : less often .
lower root of brachial plexus are injured , lead to hand
drop

Birth Injuries
Erbs palsy

Birth Injuries
Clavicular fracture:
- Most common newborn orthopaedic injury.
- Signs
Pain with movement and Moro reflex .
Pseudoparalysis of extremity on Fracture side.
Sternocleidomastoid muscle spasm on affected side .
Crepitus at Fracture site.
Palpable bony irregularity at Fracture site .

Birth Injuries
-

Prognosis
Excellent, even for displaced Fractures .
Palpable callus formation in 7 to 10 days
Fracture heals in 4 to 6 weeks ,

Birth Injuries

Reviewed by: Amal Alsomairi