Ghai Essential Pediatrics8th

Treatment consists of local warm water packs, breast massage and analgesics to relieve the pain. Milk should be gently expressed to soften the breast.

Breast abscess. If a congested engorged breast, cracked nipple, blockedduct or mastitis are nottreatedin the early stages, breast abscess formation can occur. The mother has high grade fever and a raised blood count. She must be treatedwith analgesics and antibiotics.The abscess may require incision and drainage. Breastfeeding must be continued.

Not enough milk. First make sure that the perception of "not enough milk" is correct. If baby is satisfied and sleeping for 2-3 hr after breastfeeding, passing urine at least 6-8times in 24 hr and gaining weight, the mother is producing enough milk. There could be a number of reasons for insufficient milk such as incorrect method of breastfeeding, supplementary or bottle feeding, no night breastfeeding, engorgement of breast, any illness, painful condition, maternal stress or insufficient sleep. Try to identify the possible reason and take appropriate actions. Advise mother to take sufficient rest and drink adequate fluids. Feed the baby on demand. Let the baby feed as long as possible on each breast. Advisethe mother to keep the baby with her.

Expressed Breast Milk (EBM)

If a mother is not in a position to feed her baby (e.g. ill mother, preterm baby, working mother, etc.), she should express her milk in a clean wide-mouthed container and this milk should be fed to her baby. EBM can be stored at room temperature for 6-8 hr, in a refrigerator for 24 hr and a freezer at -20°C for 3 months.

Method of Milk Expression

Ask the mother to wash her hands thoroughly with soap and water before she expresses. She should make herself comfortable. Gently massage the breast (Fig. 8.35). Hold thecontainerunder her nipple and areola. Place herthumb on top of the breast at least 4 cm from the tip of the nipple and the first finger on the undersurface of the breast opposite the thumb. Compress and release the breast tissue between her fingers and thumb a few times.

If the milk does not appear, she should reposition her thumb and finger closer to the nipple and compress and release the breast as before. Compress and release all the way around the breast. Express milk from both breasts.

To maintain adequate lactation, mother should express milk at least 8 to 10 times in 24 hr.

CARE OF LOW BIRTH WEIGHT BABIES

Lowbirthweight(LBW;birthweightlessthan2500g)babies have higher morbidity and mortality. LBW results from eitherpretermbirth (before37completedweeksofgestation) or due to intrauterine growth restriction (IUGR) or both.

Newborn Infants -

Step 2

Fig. 8.36: Baby with intrauterine growth retardation showing many loose folds of skin

Table 8.12: Major problems in preterm babies and those with intrauterine growth retardation (IUGR)

Preterm babies

Hypothermia Perinatal asphyxia

Respiratory (hyaline membrane disease, pulmonary hemorr- hage,pneumothorax,bronchopulmonarydysplasia, pneumonia) Bacterial sepsis

Apnea of prematurity

Metabolic (hypoglycemia, hypocalcemia) Hematologic (anemia, hyperbilirubinemia) Feeding problems and poor weight gain

Babies with IUGR

Perinatal asphyxia

Meconium aspiration

Hypothermia

Hypoglycemia

Feed intolerance

Polycythemia

Poor weight gain

•AsymmetricIUGR: The insult on the fetalgrowthoccurs during late gestation producing a brain sparing effect. Head circumference is relatively preserved compared to length and weight. Causes include placental insufficiency, pregnancy-induced hypertension or maternal medical diseases.

Smallfor gestational age (SCA): It is a statistical definition and denotes weight of infant being less than 2 standard deviation orlessthanthe tenthpercentileof thepopulation norms (plotted on intrauterine growth chart). SGA and IUGR are considered synonymous.

Issues in LBW Care

Besides the pathologies that can affect all neonates irrespective of weight and gestation, LBW may have additional complications requiring special care.

Resuscitation

Problems

•Compromised intrauterine environment with higher chances of perinatal asphyxia

•Preterm babies have immature lungs that may be more difficult to ventilate and are also more vulnerable to lung injury by positive pressure ventilation.

•Immature blood vessels in the brain are prone to hemorrhage

•Thin skin and a large surface area, which contribute to rapid heat loss

•Increased risk of hypovolemic shock caused by small blood volume

Management

•Prepare for high risk of need for resuscitation

•Gentle resuscitation (small tidal volume) using small bags for positive pressure ventilation, use of CPAP

•Take extra care to avoid hypothermia

Temperature Control

Problems

•Higher surface area to body weight ratio

•Low glycogen stores

•Low subcutaneous fat

Management

•Frequent monitoring and educating parents for need to check temperature

•Special attention to maintenance of the warm chain

•Kangaroo mother care

Fluids and Feeding

These have been discussed under the section on feeding.

Infection

Problems

•Immature defenses

•Greater probability of invasive interventions like mechanical ventilation, umbilicalvesselcatheterization.

Management

•Strict adherence to asepsis, hand hygiene

•Minimal handling of babies

•Low threshold for suspicion of sepsis, adequate and appropriate use of antibiotics

•Decreasing exposure to adults/other children with communicable diseases particularly respiratory.

Metabolic Derangements

Problems

•Low hepatic glycogen stores with rapid depletion in stress places these infants at increased risk of hypo­ glycemia.

•Immatureglucosehomeostaticmechanismsinpremature babies can also lead to decreased inability to utilize glucose and resultant hyperglycemia, especially during stressful periods like infection.

•Early onset hypocalcemia: Presenting within 3 days of life and is usually asymptomatic, detected on investi­ gation.Itis especially seenin premature babies, infants of diabetic mothers and those with birth asphyxia.

•Late onset hypocalcemia presents as classical neonatal tetany, jitteriness and seizures. Feeds with higher phosphate loadsuch as cow milk and some formulae, result in hyperphosphatemia with subsequent hypo­ calcemia.

Management

This has been discussed in appropriate sections.

Jaundice

Problems

•Larger RBC volume for body weight

•Immaturity of hepatic enzymes and hepatic excretory capacity

•Immature blood brain barrier-increased risk for bilirubin encephalopathy

Management

This has been discussed in section on jaundice.

Hematological Abnormality Problems

Polycythemia. Placental insufficiency with intrauterine hypoxialeads to stimulation of erythropoiesis and resul­ tant polycythemia, especially seen in IUGR babies. Poly­ cythemia(>65%hematocrit)produceshyperviscositywith decreasedorganperfusion.Manifestationsincludejitteri­ ness,respiratorydistress,cardiacfailure,feedingintolerance, hypoglycemia, hypocalcemia and hyperbilirubinemia.

Anemia. Accelarated destruction of fetal RBCs, low reti­ culocyte count and inadequate response of the bone marrow to erythropoietin cause anemia of premaurity. Low iron stores, higher incidence of sepsis and frequent bloodsampling in LBW babiesfurtherpredisposesto risk of severe anemia.

Management

•Treatment ofpolycythemia: Symptomatic infantsorthose with hematocrit >75% require partial exchange trans­ fusion. For others, management includes increasing the fluid intake.

•Anemia:

-Iron supplementation: All LBW babies should be started of 2-3 mg/kg of iron from 2 months till 2 yr of age.

-Samplingshouldbeminimizedandinsmall amounts

-Transfusionsmaybegivenasperinstitutionprotocol.

Immature Organ Systems in Preterms

Respiratory distress syndrome. This has been described in detail later.

Intraventricular hemorrhage. Preterms have a fragile highly vascular collection of vessels near the lateral ventricle of

Newborn Infants --

brain. Respiratory distress, mechanical ventilation or vigorous resuscitation, can cause rupture of these vessels leading to adverse neurological sequelae. Preventive measures include minimalandgentle handling, avoiding rapid changes in intravascular volume such as rapid boluses or infusion of hyperosmolar solutions, avoiding high pressures during ventilation and treating any bleeding diathesis. Treatment is essentially supportive and management of later complications such as hydrocephalus.

Retinopathy ofprematurity (ROP). Growthof retinalvessels occursfrom the optic disc to the peripheryfrom 18 weeks ofgestationtillterm. Anyinjurytothesevesselsduetothe still developing vessels of preterm retina when subjected totheprematuretransitionofpostnatallife(especiallyhigh oxygen saturation as may be used during resuscitation), maypathologicalproliferation,resultinginretinaldamage withvisionloss, if leftuntreated.Thiscomplication canbe decreasedwithrationaluseofoxygen,maintainingaSp02 between85-95% and regularscreeningforearlydetection and treatment. Advanced stages of ROP requires peripheral retinal ablation by laser or cryotherapy.

Hearing damage. Preterm infants are at higher risk of hearingloss due toimmaturity and complications thereof such as infections or drugs. Adjustment of drug doses accordingto gestational age,preventinghypoxia, treating jaundice and routine screening for early detection can minimize this complication.

Associated Conditions

An IUGR birth itself might be an indication of a pre­ existing problem leading to such occurrence. Examples includeintrauterineinfectionsandchromosomalanomalies which result in IUGR. These usually constituteasubgroup of IUGR babiesknown as symmetrical IUGR. The cause of growth restriction is a condition other than nutritional deficiencyand onsetoccursearlyinfetallife withpropor­ tionate restriction of head and body, unlike the nutri­ tionally restricted asymmetrical IUGR which has onset in third trimester and has head growth is spared.

Prolonged Hospital Stay

Requirement of frequent monitoring and intervention in these high risk babies results in their separation from parents at birth, and high cost. It is an emotionally and financially trying time for all families. Keeping parents involved in decision making with counseling sessions directed at theirconcernshelpsgreatlyin management.

Criteria for Discharge

•Screening tests are performed before discharge or on followup, e.g. those for ROP detection in infants <32 weeksandauditorybrainstemevokedresponse(ABER).

•Nutrition supplements including multivitamins, iron, calcium and vitamin D are started.

- Essential Pediatrics

•Immunization with BCG, Hep B and OPV is given.

•Weight gain should be consistently demonstrated for few days before discharge. Weight, length and head circumference should be recorded at discharge and plottedon a growthchart,whichcan be used on follow­ up to determine if growth is adequate.

•Baby should be feeding well; if on alternate feeding technique like paladai feeding, the mother should be confident regarding its details.

•Absence of danger signs and completion of treatment like IV antibiotics. If baby is being discharged on oral medication then parents should be well educated regarding how to administer.

•Methods of temperature regulation, either KMC practice or other methods should be well known to parents.

•All danger signs are explained in detail to parents with information regarding whom and where to contact clearly highlighted.

The following are the danger signs:

-History of difficulty in feeding

-Movement only when stimulated

-Temperature below 35·5°C or 37·5°C or more

-Respiratory rate over 60 breaths per minute

-Severe chest indrawing

-History of convulsions

•Followup within 3-7 days of discharge to ensure the baby has been adapted well to home environment.

Feeding of LBW Babies

Nutritional management influences immediate survival as well as subsequent growth and development of LBW infants. Early nutrition could also influence the longterm neurodevelopmental outcomes. Malnutrition at a vul­ nerable period of brain development has been shown to have deleterious effects in experimental animals.

Term infants with normal birth weight require some assistance for feeding in the immediate postnatal period, but they are able to feed directly from mothers' breast. In contrast, feeding of LBW infants, in particular the preterm infants, is relatively difficult because of the following limitations:

i.Though majority of these infants are born at term, a significant proportion are born premature with inadequate feeding skills. They might not be able to breastfeed and hence would require other methods of feeding such as spoon or gastric tube feeding.

ii.They are prone to have significant illnesses in the first few weeks of life, the underlying condition often precludes enteral feeding.

iii.Preterm infants have higher fluid requirements in the

first few days of life due to excessive insensible water loss.

iv.Since intrauterine accretion occurs mainly in the later part of the third trimester, preterm infants (parti­ cularly those born before 32 weeks of gestation) have low body stores of various nutrients at birth which necessitates supplementation in the postnatal period.

v.Because of the gut immaturity, they are more likely to experience feed intolerance necessitating adequate monitoring and treatment.

Methods

Direct and exclusive breastfeeding is the goal of feeding all LBW infants. However, because of the various limitations, not all LBW infants would be able to accept breastfeeding at least in the initial few days after birth. These infants have to be fed by either spoon/paladai or intragastric tube (gavage feeding). Those babies who cannot accept oral feeds by even these methods would require intravenous (IV) fluids.

The appropriate method of feeding in a given LBW infant is decided based upon the following factors:

•Whether the infant is sick or not; and

•Feeding ability of the infant (which depends upon the gestational maturity).

Level of Sickness

It is essential to categorize LBW infants into two major groups, sickand healthy, before deciding the initial method of feeding.

Sick infants. This group constitutes infants with respiratory distress requiring assisted ventilation, shock, seizures, symptomatic hypoglycemia, electrolyte abnormalities, renal/cardiac failure, surgical conditions ofgastrointestinal tract, necrotizing enterocolitis (NEC), hydrops. These infantsareusually started onIV fluids. Enteralfeedsshould be initiated as soon as they are hemodynarnically stable with the choice of feeding method based on the infants' gestation and clinical condition (see below).

Itis important to realize that enteralfeeding is important even for sick neonates. Oral feeds should not be delayed in them without any valid reason. Even infants with respiratory distress and/or on assisted ventilation can be started on enteral feeds once the acute phase is over and theinfants' color, saturation and perfusionhaveimproved. Similarly, sepsis (unless associated with shock/sclerema/ NEC) is not a contraindication for enteral feeding.

Healthy LBW infants. Enteral feeding should be initiated immediately after birth in healthy LBW infants with the appropriate feeding method determined by their oral feeding skills and gestation.

Ability to Feed

Breastfeeding requires effective sucking, swallowing and a proper coordination between suck/swallow and breathing. These complex skills mature with increasing gestation. A robust sucking pattern is not present until

32-34 weeks gestation. A coordination between sucking, swallowing and breathing does not mature until 34 weeks of gestation. This fully matures by 37 weeks of gestation. The maturation of oral feeding skills and the choice of initial feeding method at different gestational ages are summarized in Table 8.13.

However, it is important to remember that not all infants born at a particular gestation would have same feeding skills. Hence, the ideal way in a given infant would be to evaluate if the feeding skills expected for his/her gestation are present and then decide accordingly (Fig. 8.37).

All stable LBW infants, irrespective of their initial feeding method should be put on their mothers' breast. The immature sucking observed in preterm infants born

before 34 weeks might not meet their daily fluid and nutritional requirements but helps in rapid maturation of their feeding skills and also improves the milk secretion in their mothers

Figs 8.38A and B show the method of paladai and intragastric tube feeding in babies.

Progression of Oral Feeds

All LBW infants, irrespective of their gestation and birth weight, should ultimately be able to feed directly from the mothers' breast. For preterm LBW infants, the progression to direct and exclusive breastfeeding are summarized in Fig. 8.39.

Once the mother's condition becomes stable (or the contraindication to breastfeeding no longer exists), these infants should be started on exclusive breastfeeding.

How Much to Feed?

Infants who are breastfed Infants who are able tosuckle effectively at the breast should be breastfed on demand. Small babies usually demand to feed every 2-3 hr, sometimes more frequently. A small infant, who does not demand to be fed for 3 hr or more, can be offered the breast and encouraged to feed.

Infants who are fed by spoon/paladai or by intra­

gastrictube It is essential to knowhowmuchtofeed,the amount of expressed breast milk to be given, for those infants who are on alternative methods of feeding like gavage or spoon feeding.

The daily fluid requirements of neonates have been discussedin the section of fluids andelectrolytes.Preterm infantsneed more fluidsin the initial weeks of lifebecause of the high insensible water loss. It is usualclinicalpractice to provide VLBW infants (<1500 g) about 80 ml/kg fluids on the first day of life and increase by 10-15 ml/kg/day to a maximum of 160 ml/kg/day by the end of the first week of life. LBW infants 2'..1500 g are usually given about 60 ml/kg fluids on the first day of life and fluid intake is increased by about 15-20 ml/kg/day to a maximum of 160 ml/kg/day by the end of the first week of life. After deciding the total daily fluid requirement, the individual feed volume to be given every 2 or 3 hr (by OG tube or paladai) can be determined.

Nutritional Supplementation

LBW infants, especially those who are born preterm, require supplementation of various nutrients tomeettheir high demands. Since the requirements of VLBW infants differ significantly from those with birth weights of 1500-2499 g, supplementation regimes for these two groups have been discussed separately.

Supplementation for infants with birth weights of

1500-2499 g These infants are more likely to be born at term or near term gestation (2'..34 week) andare more likely to have adequate body stores of most nutrients.Therefore, theydonot require multinutrient supplementation (unlike VLBW infants). However, vitamin D and iron should be supplemented in them (Table

Supplementation in VLBW infants These infants who

are usually born before 32-34 week gestation have

inadequatebody stores of most of thenutrients.Since EBM has inadequate amounts of protein, energy, calcium, phosphorus, trace elements (iron, zinc)and vitamins D, E and K, it is often not able to meet the daily recommended intakes of these infants. Hence, these infants need multi­ nutrient supplementation till they reach term gestation (40 weeks, i.e. until the expected date of delivery). The following nutrients have to be added to the expressed breast milk in them:

i.Calcium and phosphorus (140-160 mg/kg/day and 70-80 mg/kg/day respectively for infants on EBM)

ii.Vitamin D (400 IU/day), vitamin B complex and zinc (about 0.5 mg/day) usually in the form of multi­ vitamin drops

iii.Folate (about 50 µg/kg/day)

iv.Iron (2 mg/kg/day)

Multinutrient supplementation can be ensured by one of the following methods:

i.Supplementing individual nutrients, e.g. calcium, phosphorus, vitamins, etc.Thesesupplements should be added at different times in the day to avoid abnormal increase in the osmolality.

ii.By fortification of expressed breast milk with human milk fortifiers (HMF): Fortification increases the nutrient content of the milk without compromising its other beneficial effects. Experimental studies have shown that the use of fortified human milk results in net nutrient retention that approaches or is greater than expected intrauterine rates of accretion in preterm infants. Preterm VLBW infants fed fortified humanmilk donotrequireany supplementation other than iron.

Fortification or supplementation of minerals and vitamins should be continued only till term gestation (40 weeks) in VLBW infants; after this period, only vitamin D and iron needs to be supplemented (similar to infants with birth weights of g).

Growth Monitoring of LBW Infants

Regular growth monitoring helps in assessing the nutri­ tional status and adequacy of feeding in LBW infants; it also identifies those infants with inadequate weight gain.

All LBW infants should be weighed daily till the time of discharge from the hospital. Other anthropometric parameters suchaslengthandhead circumference should be recorded weekly.

Both term and preterm LBW infants tend to lose weight (about 10% and 15% respectively) in the first 7 days of life; they regain their birth weight by 10-14 days.

Thereafter, the weight gain should be at least 15-20 g/ kg/day till a weight of 2-2.5 kg is reached. After this, a gain of 20 to 40 g/day is considered appropriate.

Growth charts. Using a growth chart is a simple but effective way to monitor the growth. Serial plotting of weightandother anthropometric indicators inthegrowth chart allows theindividual infant's growth to be compared with a reference standard. It helps in early identification of growth faltering in these infants.

The two postnatal charts that are most commonly used for growth monitoring of preterm VLBW infants are: Wright's and Ehrenkranz' charts. Once the preterm LBW infants reach term gestation (40 week), WHO growth charts should be used for growth monitoring.

Management of Inadequate Weight Gain

Inadequate weight gain is a common and pertinent problem in LBW infants. It starts at the time of initial admission and continues after discharge resulting in failure to thrive and wasting in the first year of life. The common causes are summarized in Table 8.15.

Table 8.15: Causes of inadequate weight gain Inadequate intake

Breastfed infants

Incorrect feeding method (improper positioning or attachment)*

Less frequent breastfeeding, not feeding in the night hours*

Infants on spoon or paladai feeds

Incorrect method of feeding* (e.g. excess spilling) Incorrect measurement or calculation Infrequent feeding*

Not fortifying the milk in VLBW infants

Increased demands

Hypothermia or cold stress*

Chronic illnesses, bronchopulmonary dysplasia Medications such as corticosteroids

*Common causes

Management of inadequate weight gain consists of the following steps:

i.Proper counseling of mothers and ensuring adequate support for breastfeeding their infants; including an assessment of positioning/attachment and managing sore or flat nipple.

ii.Explaining the frequency and timing of both breast­ feeding and spoon or pa/adai feeds: Infrequent feeding is one of the commonest causes of inadequate weight gain. Mothers should be properlycounseledregarding the frequency and the importance of night feeds. A time-tablewheremothercanfillthe timing andamount of feeding is veryhelpfulinensuringfrequentfeeding.

iii.Giving EBM by spoon or paladai feeds after breast­ feeding also helps in preterm infants who tire out easily while sucking from the breast.

iv.Proper demonstration of the correct method of expression of milk andpaladai feeding: It is important to observe how the mother gives paladai feeds; the technique and amount of spillage should be noted. This should be followed by a practical demonstration of the proper procedure.

v.Initiating fortification of breast milk when indicated

Suggested Reading

Nutrition. In: Edmond K, Bahl R (Eds). Optimal feeding of low-birth­ weight infants-Technical Review. World Health Organization 2006; p42

Sankar MJ, Agarwal R et al. Feeding of low birth weight infants. Indian J Pediatr 2008;75:459-69

INFECTIONS IN THE NEONATES

Infection by bacteria constitutes a common morbidity and accounts for nearly one-third of total neonatal deaths. Infections can be superficial and systemic.

Superficia l Infections

Omphalitis. Any redness or induration around the umbilicusorpus drainage from it shouldalert the clinician to omphalitis. Omphalitis starts as a local infection of the umbilicus, usually from unclean handling or application of unclean substances to the cord. It can spread to cause life-threatening systemic sepsis.

Local infection. When the redness extends to less than 1 cm of surrounding area and there is absence of any sign of sepsis. Local cleaning with antiseptic solution, followed by application of 0.5% gentian violet four times a day till redness subsides would take care

Severe infection. When area of redness extends beyond 1 cm of surrounding tissue or there are signs of sepsis local therapy plus systemic antibiotic should be started as in management of septicemia.

Oral thrush. White patchy lesions on the oral mucosa and tongue can occur in healthy newborns. True oral thrush lesions are difficult to wipe off and leave hemorrhagic points when removed. Local nystatin or clotrimazole application four times a day after feed is recommended.

Conjunctivitis. Conjunctivitis is caused by a variety of bacterial, viral and chalamydial infections. Infection should be differentiated from sticky eyes and blocked nasolacrimal duct. Sticky eyes generally manifests as mucoid discharge without anysigns of inflammation and requires cleaning with saline.

Blocked nasolacrimal duct manifests as persistent or intermittent discharge which can be mucopurulent. It requires massage to relieve obstruction and instillation of antibitiocs. Conjunctivitismanifests as purulent discharge and signs of inflammation and requires local instillation

of antibiotics. Gonococcal conjuctivtis can result in blindness and requires timely systemic antibiotics therapy.

Systemic Infections (Neonatal Sepsis)

When pathogenic organisms gain access into the blood stream, they may cause an overwhelming infection without much localization (septicemia), or may get predominantly localized to the lung (pneumonia) or the meninges (meningitis). Systemic bacterial infections are known by the generic term neonatal sepsis (NNS), which incorporates septicemia, pneumonia and meningitis.

Etiology

Escherichia coli, Staphylococcus aureus and Klebsiella sp. are the predominant organisms. Organisms like Acinetobacter, Pseudomonas and coagulasenegative staphylococci are also important pathogens in hospital acquired infections.

Early Versus Late Sepsis

Early-onset sepsis (EOS) (less than 72 hr) infections are caused by organisms prevalent in the maternal genital tract or in the delivery area. The predisposing factors include LBW, prolonged rupture of membranes, foul smelling liquor, multiple per vaginal examinations, maternal fever, difficult or prolonged labor and aspiration of meconiurn. EOS frequently manifests as pneumonia and less commonly as septicemia or meningitis.

Late-onset sepsis (LOS) (72 hr or later) infections are caused by the organisms thriving in the external environment of the home or the hospital. The infection is often transmitted through the hands of the care-providers. The presentation is that of septicemia, pneumonia or meningitis. The predisposing factors include LBW, lack of breastfeeding, poor cord care, superficial infections (pyoderma, umbilical sepsis), aspiration of feeds and disruption of skin integrity with needle pricks and use of intravenous fluids.

Newborn Infants -

Clinical Features

NNS oftenmanifests withvagueand ill-definedsymptoms and, therefore, requires high index of suspicion for early diagnosis. An early but non-specific manifestation is alteration in the established feeding behavior. The baby, who had been active and sucking normally, refuses to suck and becomes lethargic, or unresponsive. Poor cry, hypothermia, abdominal distension, vomiting and apneic spells are other common manifestations. Diarrhea is uncommon. Fast breathing, chest retractions and grunt indicate pneumonia. Most cases of meningitis do not have any distinct clinical picture per se, making it mandatory to suspect meningitis in all cases suspected of sepsis. Though the presence of excessive or high-pitched crying, fever, seizures, blank look, neck retraction or bulging anterior fontanel are suggestive of meningitis. Shock, bleeding, scleremaand renal failure are indicators of overwhelming sepsis.

Diagnosis of sepsis is fraught with poor specificity. A host of conditions like hypothermia, hyperthermia, hypo­ glycemia, hypoxia, late metabolic acidosis, congestive heart failure and even simple conditions like nasal block may mimic sepsis. A careful clinical examination and relevant investigations are necessary to differentiate these conditions from NNS and avoid unnecessary antibiotics therapy. Babies who are clinically stable can be observed, without admission and intravenous antibodies, while providing good supportive care (Fig. 8.40).

Investigations

No investigation is required to start treatment in a sick baby who has high probability of sepsis. Blood culture provides definitive diagnosis of NNS and should be taken before starting antimicrobial therapy. After cleaning the skin (alcohol, povidone-iodine and again alcohol, a specimen of 0.5 to 1.0 ml of blood can be taken in a small culture media bottle containing 5 to 10 ml of the liquid broth.

Sepsis screen should be performed in equivocal cases. A panel of tests (sepsis screen)consistingof totalleukocyte count (TLC; <5000/mm3), absolute neutrophil count (ANC; <1800/mm3), immature to total neutrophil ratio (I/T ratio; more than 20%), CRP (more than 1 mg/dl) and micro ESR (15 mm or more in the first hour) constitutes a useful sepsis screen for clinically doubtful cases. Sepsis screen is considered positive if two of these parameters are positive. Value of sepsis screen is more for exclusion of diagnosis of NNS.

Lumbar puncture should be performed in all cases suspected of NNS except in asymptomatic babies being investigated for maternal risk factors. Table 8.16 provides gestation specific cut offs for values of various parameters in cerebrospinal fluid.

Table 8.16: Nonnal CSF examination in neonates [(mean (range)J

Treatment

Institution of prompt treatment is essential for ensuring optimumoutcomeofneonateswith sepsis who oftenreach the health care facilities late and in a critical condition. Supportive care and antibiotics are the two equally important components of treatment. Antibiotics take at least 12 to 24 hr to show any effect, optimum supportive care improves the outcomes in sick septic babies.

Supportive care Good supportive care requires meticulous attention to various aspects:

•Provide warmth; ensure normal temperature (36.5°- 37.50C).

•Start oxygen by hood or mask, if the baby is cyanosed or grunting. Provide bag and mask ventilation if breathing is inadequate. Instilling normal saline drops in nostrils may help clear the nasal block.

•Assess peripheral perfusion by palpating peripheral pulses,capillaryrefilltime (normally <2-3 seconds)and skincolor.Serial measurement ofurine output is helpful for this purpose. Infuse normal saline or Ringer lactate 10ml/kgover5-10 minutes, ifperfusionis poor. Repeat the same 1-2 times over the next 30-45 minutes, if perfusion continues to be poor. Dopamine and dobu­ tamine may be required to maintain normal perfusion.

•Insert intravenous line. If hypoglycemia is suspected, infuse glucose (10%) 2 ml/kg stat. Do not use glucose boluses routinely. Provide maintenance fluid, electro­ lytes and glucose (4--o mg/kg/min). Add potassium to IV fluids once normal flow of urine has been documented.

•Ensuring optimal nutrition is extremely helpful in sick babies. Enteral feeds should be initiated early if there is no abdominal distension and baby is hemo­ dynamically stable. Feed mother's milk. Consider parenteral nutrition, if baby is not expected to receive enteral feeds for prolonged period.

•Administer vitamin K 1 mg intramuscularly.

•Transfuse packed cells, if baby has a low hematocrit (less than 35-40%). Do not use blood/plasma transfusion on routine basis for 'boosting' immunity.

Specific care Antimicrobial therapy constitutes the mainstay of treatment ofsepsis. In a seriously sick neonate suspected ofsepsis,appropriateantibioticstherapy should be initiated without any delay after obtaining blood samples forculture and sepsis screen. Oneneednot await for the results of sepsis screen for antibiotics treatment. However, in a baby who is otherwise stable or suspected of sepsis because of maternal risk factors, it is desirable to await results ofsepsis screenbefore initiation ofantibiotics. Since symptoms suggestive of sepsis may be caused by a variety of other illnesses, confirmation of sepsis by sepsis screenmay helpavoidingunnecessaryantibioticstherapy.

Empiric therapy when etiologic agent is not known. The empiric therapy of NNS should cover the major causative pathogens while awaiting reports of culture studies.

Since the antimicrobial spectrum and susceptibility profile is different in different settings, there cannot be a universal policy of empiric regimen. Antibiotics are often used in neonates on the slightest suspicion of sepsis because of the grave and fulminant nature of neonatal sepsis. But unbridled overuse of antibiotics is associated with the serious risk of emergence of resistant strains of pathogens. Most newborn units in the country are facing the problem of overwhelming resistance to practically all antibiotics including third generation cephalosporins. Rational use of antibiotics is, therefore, the responsibility of every physician.

Eachtreatingunit shouldadopt a suitable policy. Based on changes in the spectrum of etiologic agents and the antibiotics sensitivity pattern, the choice of antibiotics must be periodically reviewed and modified. Table 8.17 provides possible regimen of empiric antibiotics.

Therapy after an etiologic agent is known. Antimicrobial therapy can be made specific once a positive culture and sensitivity report is available. However, this would be known only after 2-3 days. Even in best institutions, only approximately one-fourth of babies suspected of sepsis have positive blood culture.

Mode of Administration and Dosage

Antibioticsshouldpreferablybe administered parenterally. In a baby with septicemia or pneumonia (but not meningitis), who hasreceived intravenous ampicillin and