Recognition of the seriously unwell neonate and young infant

• PIC Endorsed

• See also
  Sepsis
  Febrile child
  Sepsis in neonates
  Acceptable range of physiological variables

• Key Points

  • Infections are the most likely cause of an unwell neonate ( <28 days corrected age) and young infant (<3 months), however several other serious conditions can have similar initial presentations

  • A fever in any neonate (>38°C) warrants initial investigation and empiric IV antibiotics

  • Unwell infants can present with non-specific findings — a period of observation, serial examinations and baseline investigations are often helpful

• Background

  • Infection is the most common cause of illness, with urinary tract infections ( UTI) the most common bacterial infection

    • Fever is not always present, and neonates and young infants can present hypothermic (rectal temperature <36.5°C)

  • Neonates and young infants at particular risk include:

    • low birth weight and premature babies

    • those with a known medical condition eg congenital anomaly

    • babies from socially disadvantaged families

• Assessment

• History

  • Irritability

  • Fever

  • Lethargy or increased sleepiness

  • Poor feeding (volume taken in previous 24 hours <50% of normal)

  • Vomiting

  • Apnoea

  • Decreased tone

  • Past history of brief resolved unexplained event (BRUE) or seizures

• Antenatal complications: IUGR, gestational diabetes, congenital abnormality, infections, medication and toxin exposure, previous child with early onset sepsis
  Birth history: Prematurity, GBS status, perinatal stress, prolonged rupture of membranes, maternal fever, resuscitation requirements
  Poor Growth
  Urine output: <4 wet nappies in 24 hours

• Examination
  General aspects of the child's behaviour and appearance provide the best indication of whether serious illness is likely
  Features suggestive of an unwell child
  

Colour

Pallor (including parent/carer report)

Mottling

Cyanosis

Jaundice

Activity

Lethargy or decreased activity

Poor Feeding

Not responding normally to social cues

Does not wake or only with prolonged stimulation, or if roused, does not stay awake

Weak, high-pitched or continuous cry

Respiratory

Grunting

Tachypnoea

Increased work of breathing

Hypoxia

Circulation and Hydration

Poor feeding

Murmur, weak peripheral pulses

Persistent tachycardia

Central CRT ≥3 seconds

Dry mucous membranes, reduced skin turgor, sunken fontanelle

Reduced urine output / Hypotension

Neurological

Bulging fontanelle

Neck stiffness

Tone

Focal neurological signs

Focal, complex or prolonged seizures

Other

Non-blanching rash

Fever for ≥5 days

Swelling of a limb or joint

Not using an extremity

Distended abdomen

• Adapted from: Feverish illness in children NICE guideline 2017

• Causes that need to be considered in an unwell neonate and young infant

Condition

Salient Features

Infective

– Bacterial

UTI / Pyelonephritis

Others include:

Fever vomiting, poor feeding

• Skin

Skin erythema and tenderness

• Bone or Joint

Reduced movement of limb

• Bacteraemia/sepsis

• Pneumonia

• Meningitis

Fever, tachycardia, tachypnoea, increased work of breathing

Irritable, nuchal rigidity or bulging fontanelle

Infective

– Viral

Bronchiolitis

Tachypnoea, increased work of breathing

Primary HSV – in first 1 month of life

Skin vesicles (not present in 1/3 of neonates and can be afebrile), seizures.

Influenza

Fever, poor feeding, lethargic, snuffly

Enterovirus or Parechovirus

Fever, poor feeding, irritable, possible seizures, persistent tachycardia (myocardial involvement)

Surgical

Malrotation with volvulus

Bile-stained vomit

Pyloric stenosis

Progressive, non-bilious and projectile vomiting, mass , hypochloraemic hypokalaemic metabolic alkalosis

Incarcerated hernia

Irreducible inguinal swelling

Hirschsprung disease and Meconium ileus

Abdominal distention with absent or infrequent bowel motions

Necrotising enterocolitis ( NEC):

Abdominal distention, tenderness, vomiting, blood in stool

Intussusception

Intermittent severe abdominal pain, vomiting, pallor, lethargy and rectal bleeding (red currant stool)

Cardiac

Congenital cardiac disease

Cyanosis, murmur (not always present), diaphoresis (sweating) with feeding, Cardiac failure (tachypnoea, enlarged liver, hypoperfusion), poor or absent peripheral pulses

Supraventricular tachycardia ( SVT) and other arrhythmias

Persistent marked tachycardia, pallor, poor feeding

Respiratory

Meconium aspiration

Meconium stained liquor

Transient Tachypnoea of Newborn and Respiratory Distress Syndrome

Tachypnoea, increased WOB , possible cyanosis and radiological features

Pneumothorax

Tachypnoea, hyperresonance, decreased breath sounds

Endocrine and Metabolic

Congenital adrenal hyperplasia

Ambiguous genitalia, hypotension, dehydration, hyponatraemia, and hyperkalaemia, hypoglycaemia

Hypoglycaemia

Inborn errors of metabolism

Coma, hypotonia, seizures, jaundice, organomegaly, dysmorphism

Hypoglycaemia, metabolic acidosis

Other

Acute bilirubin encephalopathy

Jaundice

Non Accidental Injury

Bruising, unexplained injury

Brief resolved unexplained event ( BRUE)

Toxin

• Management

• Any neonate and young infant who appears unwell should be assessed promptly and discussed with a senior doctor

• Investigations

  • For unwell neonates and young infants: Perform FBE, CRP, blood culture, urine (SPA), BSL, LP

  • Investigate according to likely cause (see table above)

    • Consider blood gases

    • Consider chest X-Ray

• Treatment

  • All unwell neonates and young infants should receive:

    • early administration of empiric antibiotics (IV/IM/IO)

    • prompt management of sepsis

    • consider aciclovir

    • adequate analgesia and sedation

  • Careful fluid management:

    • fluid resuscitation as required

    • maintenance fluids (account for oral intake)

  • Treatment targeted to underlying suspected cause

  • Consider a nasogastric tube on free drainage if bowel obstruction is suspected

  • Early referral to the paediatric, surgical and/or sub-specialist teams as indicated

  • In neonates with suspected duct dependent congenital cardiac condition, consider IV prostaglandin.