CBD:

A Sick
Neonate
Group 1 :

Chia Jing Lyn SUKD1603269

Nur baiti mad nor SUKD1701024
Aly Morsy SUKD1701194
Case Scenario

A baby boy is born at 36 weeks’ gestation.

He is normal at birth but he vomits at 4 hours of life.
A newly graduated nurse and the parents are worried, and ask
you what the clinical features of a sick neonate are.
i) Explain to the parents and the nurse.
Follow Up Scenario

At 12 hours, he is tachypnoeic. Feeds are stopped and he

settles with nasogastric feeding.
i) What are the possible diagnoses, and should be
the management at this stage?
Follow Up Scenario
At 2 days of age he becomes apnoeic and has a fit. He is intubated and
ventilated. Here are some of the lab results:
Urea and electrolytes – normal

Blood glucose -- 5.4 mmol/l

Chest X’ray -- normal
CSF protein 1.4 g/L

CSF Glucose 2.4 mmol/L

CSF white cells 1000/mm3

CSF RBC 2/mm3

CSF Gram stain +ve cocci
i) What are the normal values for the above tests?

ii) What is the most likely diagnosis and aetiological causes?

iii) How would you manage this baby for this diagnosis?
 Clinical Features of Sick Neonate
● Respiratory distress
● Fever or temperature instability or hypothermia
● Poor feeding (volume taken in previous 24 hours <50% of normal)
● Vomiting
● Apnoea and bradycardia
● Abdominal distension
● Jaundice
● Hypoglycaemia/hyperglycaemia
● Shock
● Irritability
● Seizures
● Lethargy, drowsiness
● Tense or bulging fontanelle
● Head retraction (opisthotonos)
● Antibiotics are started immediately without waiting for culture results.

● Intravenous antibiotics are given to cover group B streptococci and listeria

monocytogenes and other Gram-positive organisms ( benzylpenicillin or ampicillin),
combined with cover for Gram-negative organisms (usually an aminoglycoside such
as gentamicin).

● If cultures and C-reactive protein are negative and the infant has no clinical
indicators of infection, antibiotics should be stopped after 36–48 hours.

● In case of congenital pneumonia, antibiotic therapy should be given for a minimum of

7 days.

● Continue feeding via NG tube to ensure adequate caloric intake

● Observe strict hand washing and infection control procedures.

● Provide parental counselling

Follow Up Scenario

At 12 hours, he is tachypnoeic. Feeds are stopped and he

settles with nasogastric feeding.
i) What are the possible diagnoses, and should be
the management at this stage?
Differential Diagnosis
● Respiratory distress syndrome
● Congenital pneumonia
● Neonatal sepsis
● Congenital anomalies:
○ Tracheoesophageal fistula
○ Congenital diaphragmatic hernia
○ Congenital heart disease with heart failure
○ Pulmonary hypoplasia
○ Bronchogenic cyst
○ Cystic adenomatoid malformation
○ Congenital lobar emphysema
 Investigations
(Respiratory distress syndrome)
Congenital Pneumonia
Tracheoesophageal fistula (TEF)

● Chest and abdominal X-ray

● Coiling of nasogastric tube
● Fundal gas seen
● Diagnosis: Esophageal atresia with TEF
Congenital diaphragmatic hernia
Pulmonary hypoplasia
Bronchogenic cyst
Cystic adenomatoid malformation
Congenital lobar emphysema
Management at this stage
Assess the airway patency, breathing, and circulation .

● Establish IV access. If the SPO2 is 93% and below, give oxygen therapy
● Monitor the pulse, respiratory rate, temperature, oxygen saturation.
● Monitor blood pressure, blood glucose, blood gases, weight,
input/output chart.
● Keep warm in incubator at the thermoneutral temperature to prevent
hypothermia
● Blood for invx: FBC (leukocytosis in case of bacterial infection and
leukopenia in case of viral infection, BUSE and Creatinine, culture (blood,
CSF, urine), blood glucose, CRP
● Chest and abdominal X Ray: assists in the diagnosis of respiratory
disorders and to confirm the position of the NG tube .
INVESTIGATION
● FBC: leukocytosis or leukopenia
● Rule out the lumbar puncture contraindications
● lumbar puncture (to differentiate types of meningitis)
● Full Spetic screen Blood, urine, CSF C&S (to isolate organism)
● Urine streptococcal pneumoniae antigen (to look for streptococcus
pneumoniae)
● Consider USG/ CT brain (if persistent Fever > 72 hrs and Neurological
deficit)
● BUSE for electrolyte imbalance
● Glucose: TRO hypoglycemia
● CXR: TRO look for chest infections (e.g pneumonia)
Follow Up Scenario
At 2 days of age he becomes apnoeic and has a fit. He is intubated and
ventilated. Here are some of the lab results:
Urea and electrolytes – normal

Blood glucose -- 5.4 mmol/l

Chest X-ray -- normal
CSF protein 1.4 g/L

CSF Glucose 2.4 mmol/L

CSF white cells 1000/mm3

CSF RBC 2/mm3

CSF Gram stain +ve cocci
i) What are the normal values for the above tests?

ii) What is the most likely diagnosis and aetiological causes?

iii) How would you manage this baby for this diagnosis?
Normal Values
Will edit soon
Normal values

CSF Neonates Children

Protein (g/L) 0.25 – 0.5 0.16 – 0.25

Glucose (mmol/L) > ⅔ of blood glucose > ⅔ of blood glucose

3 0 – 15 0-4
WCC (mm )

3 3.9 - 5.9 3.6 - 4.8

RBC (mm )
- Can still perform in neonate as fontanelles are still open and low risk for papilloedema.
 Normal Values
● Urea & electrolytes and chest X-ray are found normal.
● Blood glucose is within normal range (5.4 mmol/L; 3.3-7.0 mmol/L)
● CSF findings show as follows:
○ CSF protein is increased (1.4 g/L; normal: 0.25 – 0.5 g/L)
○ CSF glucose is < 2/3 of blood glucose (normal: > 2/3 of blood glucose)
■ Child’s blood glucose = 5.4 mmol/L (2/3×5.4= 3.6 mmol/L)
■ Child’s CSF glucose = 2.4 mmol/L (<3.6 mmol/L)
3 3
○ CSF WCC is heavily increased (1000/mm ; normal: 0 – 15/mm )
3 3
○ CSF RBC is within normal range (2/mm ; normal: 3.9 – 5.9/mm )
○ CSF Gram-stain = Gram (+) cocci
Increase in CSF WCC indicates presence of infection (leukocytosis). Increase in CSF protein
& decrease in CSF glucose indicate bacterial causes. CSF Gram-stain shows presence of
Gram(+) cocci.
 Most likely diagnosis and Aetiological causes

Diagnosis: Neonatal meningitis (due to increased CSF protein, decreased CSF glucose,
increased CSF WCC & presence of Gram(+) cocci)

Aetiology:-

Age Types of bacteria

Neonatal (<1 month) Group B streptococcus (Gram (+)); Escherichia coli, Listeria
monocytogenes (Gram (-))

1 - 3 months GBS, E.coli, Streptococcus pneumoniae, Haemophilus influenzae

>3 months Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus

influenzae
MUST KNOW
 How to manage convulsions in neonates
● ABC, IV therapy (if stopped feeding/electrolyte imbalance, etc.)
● Monitor vital signs, conduct blood tests (blood glucose, BUSE, check anticonvulsant drug levels)
administer oxygen if needed
● If convulsions occur, monitor and time the episodes, position on lateral side, ensure no hazards (risk of fall
or trauma during fit, etc.)
● Anticonvulsant therapy (Usually IV/IM)
st
○ Phenobarbitone (most common 1 line agent)
■ Loading dose = 15-20mg/kg
■ Maintenance dose = 3-4mg/kg daily
nd
○ Phenytoin (2 choice, may be equally as effective as phenobarbitone)
○ Fosphenytoin (pro-drug of phenytoin, can be given faster)
○ Sodium valproate
○ Benzodiazepines (diazepam, lorazepam, clonazepam, midazolam, etc.) ( can cause respiratory arrest)
 How to manage this case
● Assess airway + breathing + circulation
● Vital signs (temperature, heart rate/pulse rate, respiratory rate, SpO2)
● Monitor input/output, weight and stature, electrolyte levels; provide hydration/IV therapy if
needed
● Measure head circumference - check for hydrocephalus (>95th centile)
● Investigations - FBC (infections), BUSE (electrolyte imbalance) + creatinine & urea, blood
glucose, culture (blood, urine, CSF, etc.), chest X-ray
● Antibiotics: Benzylpenicillin (IV) + Gentamicin - antibiotic therapy for 2 weeks
○ Cefotaxime (IV) - 2nd line
○ If E.coli present - antibiotic therapy for 3 weeks
● Neurological assessment + seizure chart
● Observe for 24 hours after completing therapy, discharge if no complications
● Refer to audiology department (risk of hearing loss post-meningitis)
 Gentamicin
● Common side effects ● Gentamicin toxicity
○ Nephrotoxicity ○ Can occur due to accidental overdose, especially in
■ Accumulation in renal proximal neonates and young children (higher serum levels &
tubular cells longer half-life in this population)
■ Causes reduced glomerular ○ Complications
filtration rate & proteinuria ■ Kidney damage & renal failure
■ Kidney function should be ■ Hearing impairment & deafness
checked periodically during
● Management of gentamicin toxicity
therapy
○ Serum gentamicin concentration monitoring is usually
○ Ototoxicity
indicated for patients with prolonged exposure/high
■ Damage to auditory & vestibular
branches of CN8
risk of toxicity (in this case, neonates & young children)
■ Causes tinnitus, nausea & ○ If gentamicin toxicity is noted:
vomiting, vertigo, balance ■ Contact the audiology department for hearing tests
disorders (ototoxicity)
■ Conduct renal function tests & urinalysis (to check for
proteinuria, indicative of kidney injury)
Never give Ceftriaxone to neonates;
Can cause kernicterus in NNJ
 Complications of neonatal meningitis

● Early/Acute ● Late/Chronic
○ Increased ICP ○ Hearing loss/deafness
○ Cerebral edema ○ Visual deficits
○ Hydrocephalus ○ Balance disorders
○ Ventriculitis ○ Intellectual impairment
○ Brain abscesses ○ Seizures/epilepsy
○ Cerebral infarction ○ Behavioral abnormalities
○ Cerebral venous thrombosis
○ Subdural effusion/empyema
 REFERENCES
● Illustrated Textbook of Paediatrics, 6th Edition, Tom Lissauer, Will Carroll.
● Paediatric protocol for Malaysian Hospitals ,4th edition, Hussain Imam Hj Muhammad Ismail ,Hishamshah
Mohd Ibrahim ,Ng Hoong Phak , Terrence Thomas
● Pediatric Reference Ranges. Retrieved from Pediatric Reference Ranges (uiowa.edu)
● Neonatal Seizures. Krawiec C, Muzio MR. Retrieved from Neonatal Seizure - StatPearls - NCBI Bookshelf
(nih.gov)
● . Neonatal Meningitis. Bundy LM, Noor A. Retrieved from Neonatal Meningitis - StatPearls - NCBI
Bookshelf (nih.gov)
● . Gentamicin. Chaves BJ, Tadi P. Retrieved from Gentamicin - StatPearls - NCBI Bookshelf (nih.gov)
Thank
You !
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