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Sepsis in the Newborn

(Sepsis Neonatorum; Neonatal Sepsis)

By Robert L. Stavis, PhD, MD, Clinical Director, Neonatal ICUs;Associate Professor, Department of Pediatrics, Main Line Health, Bryn Mawr, PA; Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children;Thomas Jefferson University Hospital

Sepsis is illness due to infection in the blood.

  • Newborns with sepsis appear generally ill—they are listless, do not feed well, and often have a gray color.

  • Newborns may have a low body temperature—fever is unusual.

  • The diagnosis is based on the symptoms and on the presence of bacteria, a virus, or a fungus in the blood.

  • Treatment involves antibiotics and supportive treatments such as intravenous fluids, blood and plasma transfusions, assistance with breathing (sometimes with a mechanical ventilator), and drugs to support blood pressure.

  • Infection in the bloodstream may spread to the tissues covering the brain (meningitis) and the brain itself (encephalitis).

Sepsis is more likely to occur in

Other risk factors for and causes of sepsis differ depending on when sepsis develops (onset). The onset is categorized as

  • Early-onset sepsis: Before 3 days of life

  • Late-onset sepsis: After 3 days or more of life

Certain viruses , such as widespread herpes simplex, enterovirus, or adenovirus, may cause early-onset or late-onset sepsis.

Premature infants are at much higher risk of both early-onset and late-onset sepsis than are infants born at full term because of their immature immune system. Premature newborns lack certain protective antibodies against specific bacteria because they were born before they could receive them from their mother.

Early-onset sepsis

Newborns can develop early-onset sepsis if they are exposed to certain kinds of bacteria during birth.

Risk factors for early-onset sepsis include the following:

The risk of sepsis is greater if the fluid-filled membranes that surround the fetus rupture more than 18 hours before birth or if the mother has an infection (particularly of the urinary tract or lining of the uterus).

The most common types of bacteria causing sepsis in the newborn around the time of birth are Escherichia coli and group B streptococcus (GBS), which are usually acquired during passage through the birth canal. Sepsis caused by GBS was the leading cause of early-onset sepsis until screening of all expectant mothers for GBS became a routine part of prenatal care. If screening reveals GBS, the mother is given antibiotics when she goes into labor and the newborn is typically kept in the hospital for at least 48 hours so doctors can monitor it for any signs of infection.

Late-onset sepsis

Newborns can develop late-onset sepsis if they are exposed to bacteria, viruses, or fungi before, during, or after birth.

Important risk factors for late-onset sepsis include the following:

  • Prolonged use of catheters in arteries and/or veins

  • Antibiotic use in the newborn

  • Use of a breathing tube inserted through the newborn's nose or mouth (endotracheal tube) and attached to a machine that helps air get in and out of the lungs (ventilator) to help support breathing

  • Prolonged hospitalization of the newborn

Routine handwashing by caregivers, parents, and visitors before and after contact with the newborn is an important step in reducing the likelihood of certain types of late-onset sepsis.

Symptoms

Newborns with sepsis are usually listless, do not feed well, and often have an unstable body temperature. Although older children with a serious infection usually have a fever, newborns with an infection may have a fever or a low temperature. Other symptoms may include trouble breathing (respiratory distress), pauses in breathing (apnea), pale color, and poor skin circulation, with cool extremities, abdominal swelling, vomiting, diarrhea, seizures, jitteriness, and jaundice. Other symptoms occur depending on which organism is causing the infection.

Complications

One of the most serious complications of sepsis is infection of the tissues covering the brain (meningitis) and the brain itself (encephalitis). Newborns with meningitis may have extreme sluggishness (lethargy), coma, seizures, or bulging of the soft spot between the skull bones (fontanelle) and may die if not treated promptly.

Group B streptococcus and other types of infection may cause pneumonia.

Diagnosis

  • Cultures of blood and other blood tests

  • Culture of urine

  • Spinal tap with analysis and culture of the cerebrospinal fluid

  • Chest x-ray

Doctors diagnose sepsis based on the newborn’s symptoms and the results of tests. Doctors do several tests, including blood tests, to try to determine the specific bacterium, virus, or fungus that is causing the infection.

A blood culture, sometimes a urine culture, and a spinal tap (lumbar puncture) are also done. For cultures, doctors take samples of blood, cerebrospinal fluid, and urine and try to grow (culture) the bacteria in the samples in the laboratory and identify it.

Newborns with breathing problems have a chest x-ray done to evaluate their lungs.

Prognosis

Sepsis is a major cause of death in premature newborns. The risk of death is increased for less mature and lower birthweight infants.

Depending on the severity of the illness, infants who have sepsis, particularly those who have meningitis, may have developmental delay, cerebral palsy, seizures, or hearing loss.

Treatment

  • Antibiotics

  • Breathing support with continuous positive airway pressure (CPAP) or a ventilator

  • Blood product transfusions (red blood cells, plasma, or platelets)

  • Drugs that support the blood pressure

While awaiting blood culture results, doctors give antibiotics by vein (intravenously) to newborns with suspected sepsis. Once they identify the specific organism, they may adjust the type of antibiotic.

In addition to antibiotic therapy, other treatments may be needed, such as continuous positive airway pressure (CPAP—a technique allows newborns to breathe on their own while being given slightly pressurized air) or use of a machine that helps air get in and out of the lungs (ventilator), intravenous fluids, blood product transfusions, and drugs that support blood pressure and circulation.