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Questions and Answers
Which organism is the most common cause of neonatal sepsis in India?
Which organism is the most common cause of neonatal sepsis in India?
Late onset sepsis occurs in the first 72 hours of life.
Late onset sepsis occurs in the first 72 hours of life.
False
Name one risk factor for early onset sepsis.
Name one risk factor for early onset sepsis.
Unclean hands of health professionals
Signs of meningitis in a newborn can include fever and __________.
Signs of meningitis in a newborn can include fever and __________.
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Match the types of neonatal sepsis with their characteristics:
Match the types of neonatal sepsis with their characteristics:
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What is the initial step to take when risk factors are present for a neonate suspected of early-onset sepsis?
What is the initial step to take when risk factors are present for a neonate suspected of early-onset sepsis?
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For late-onset sepsis in neonates, if symptoms are absent, lumbar puncture is required.
For late-onset sepsis in neonates, if symptoms are absent, lumbar puncture is required.
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What procedures should be performed when symptoms of sepsis are present in a neonate with late-onset sepsis?
What procedures should be performed when symptoms of sepsis are present in a neonate with late-onset sepsis?
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In case of suspected early-onset sepsis with no symptoms, it is advised to perform __________.
In case of suspected early-onset sepsis with no symptoms, it is advised to perform __________.
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Match the following aspects of sepsis management with their corresponding situations:
Match the following aspects of sepsis management with their corresponding situations:
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What is the gold standard test for investigating sepsis?
What is the gold standard test for investigating sepsis?
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All symptomatic babies suspected of meningitis should undergo a lumbar puncture.
All symptomatic babies suspected of meningitis should undergo a lumbar puncture.
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What is the treatment duration for culture-negative sepsis?
What is the treatment duration for culture-negative sepsis?
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The newest marker for neonatal screening is increased __________.
The newest marker for neonatal screening is increased __________.
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Match the clinical scenario in sepsis with its appropriate treatment:
Match the clinical scenario in sepsis with its appropriate treatment:
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What percentage of newborns is affected by neonatal jaundice?
What percentage of newborns is affected by neonatal jaundice?
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Physiological jaundice in newborns typically requires treatment.
Physiological jaundice in newborns typically requires treatment.
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What is the best investigation for assessing jaundice in newborns?
What is the best investigation for assessing jaundice in newborns?
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In Kramer zones, the danger sign that indicates risk of Kernicterus appears in Zone ______.
In Kramer zones, the danger sign that indicates risk of Kernicterus appears in Zone ______.
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Match the following Kramer zones with their appropriate serum bilirubin levels:
Match the following Kramer zones with their appropriate serum bilirubin levels:
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What is a significant contributing factor to respiratory distress in newborns?
What is a significant contributing factor to respiratory distress in newborns?
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Preterm infants are at an increased risk of developing respiratory distress.
Preterm infants are at an increased risk of developing respiratory distress.
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Name one complication that can arise from respiratory distress in newborns.
Name one complication that can arise from respiratory distress in newborns.
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Respiratory distress due to preterm birth can be primarily associated with __________ immaturity.
Respiratory distress due to preterm birth can be primarily associated with __________ immaturity.
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Match the following conditions with their descriptions related to newborns:
Match the following conditions with their descriptions related to newborns:
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What is a normal respiratory rate for a newborn?
What is a normal respiratory rate for a newborn?
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Severe hypoxia in newborns can present with central cyanosis.
Severe hypoxia in newborns can present with central cyanosis.
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What does grunting in a newborn signify?
What does grunting in a newborn signify?
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A newborn exhibiting see-saw respiration has ________ chest retraction.
A newborn exhibiting see-saw respiration has ________ chest retraction.
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Match the criteria of the Downe's score with their descriptions:
Match the criteria of the Downe's score with their descriptions:
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Which stage of necrotizing enterocolitis is characterized by gross blood in stools?
Which stage of necrotizing enterocolitis is characterized by gross blood in stools?
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Stage III a includes induration, redness, and tenderness.
Stage III a includes induration, redness, and tenderness.
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What is the primary management intervention for a neonate in stage III b of necrotizing enterocolitis?
What is the primary management intervention for a neonate in stage III b of necrotizing enterocolitis?
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A triad of lab findings indicated for necrotizing enterocolitis includes thrombocytopenia, metabolic acidosis, and __________.
A triad of lab findings indicated for necrotizing enterocolitis includes thrombocytopenia, metabolic acidosis, and __________.
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Match the stages of necrotizing enterocolitis with their descriptions:
Match the stages of necrotizing enterocolitis with their descriptions:
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Which of the following is NOT a consequence of Meconium Aspiration Syndrome (MAS)?
Which of the following is NOT a consequence of Meconium Aspiration Syndrome (MAS)?
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Meconium Aspiration Syndrome is diagnosed primarily through imaging studies.
Meconium Aspiration Syndrome is diagnosed primarily through imaging studies.
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What is one of the management strategies for severe cases of Meconium Aspiration Syndrome?
What is one of the management strategies for severe cases of Meconium Aspiration Syndrome?
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Congenital Diaphragmatic Hernia is characterized by an anatomical defect in the __________.
Congenital Diaphragmatic Hernia is characterized by an anatomical defect in the __________.
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Match the type of diaphragmatic hernia with its location:
Match the type of diaphragmatic hernia with its location:
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Which condition is the most common cause of respiratory distress in newborns?
Which condition is the most common cause of respiratory distress in newborns?
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Transient tachypnea of newborn is more common in neonates delivered by lower segment caesarean section.
Transient tachypnea of newborn is more common in neonates delivered by lower segment caesarean section.
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What is the common time frame for improvement in transient tachypnea of newborn?
What is the common time frame for improvement in transient tachypnea of newborn?
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Fluid in the interlobar fissure is a common chest X-ray finding in __________.
Fluid in the interlobar fissure is a common chest X-ray finding in __________.
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Match the following conditions with their respective management strategies:
Match the following conditions with their respective management strategies:
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Which of the following is a contraindication for bag and mask ventilation in congenital diaphragmatic hernia (CDH)?
Which of the following is a contraindication for bag and mask ventilation in congenital diaphragmatic hernia (CDH)?
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The onset of respiratory distress in a newborn with CDH after 24 hours indicates a better prognosis.
The onset of respiratory distress in a newborn with CDH after 24 hours indicates a better prognosis.
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What is the first step in managing a newborn who does not cry at birth?
What is the first step in managing a newborn who does not cry at birth?
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The respiratory condition diagnosed by the presence of intestines in the thorax is called __________.
The respiratory condition diagnosed by the presence of intestines in the thorax is called __________.
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Match the following prognostic factors of congenital diaphragmatic hernia with their implications:
Match the following prognostic factors of congenital diaphragmatic hernia with their implications:
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Study Notes
Sepsis Algorithm
-
Early Onset Sepsis (Age < 72 hrs):
- Risk Factors Present: Start antibiotics, blood culture, close monitoring.
- Symptoms Present (Lumbar Puncture): Perform LP.
- Symptoms Absent (Lumbar Puncture): No LP.
-
Late Onset Sepsis (Age > 72 hrs):
-
Risk Factors Present:
- Symptoms Present: Close monitoring, antibiotics, blood culture, lumbar puncture.
- Symptoms Absent: Close monitoring.
-
Risk Factors Absent:
- Not Sick: Sepsis screen.
- Sick Baby: Sepsis screen.
-
Risk Factors Present:
Spectrum of neonatal sepsis
-
Generalized/Septicemia:
- Respiratory System: Pneumonia.
- CNS: Meningitis.
- Bones & Joints: Osteomyelitis, Arthritis.
-
Localized/Specific:
- Respiratory System: Pneumonia.
- CNS: Meningitis.
- Bones & Joints: Osteomyelitis, Arthritis.
Early Onset Sepsis
- Source of Infection: Chorioamnionitis, infection of maternal genitalia (foul-smelling liquor), rupture of membranes over 72 hours (Pneumonia > Sepsis).
- Risk Factors: Unclean hands of health professionals and caregivers, low birth weight (LBW) → reduced immunity, lack of breastfeeding.
Late Onset Sepsis
- Source of Infection: Hospital acquired infection, unclean hands of health professionals and caregivers, low birth weight (LBW) → reduced immunity, lack of breastfeeding.
Organisms Implicated
- India: Klebsiella (most common), Acinetobacter, S.aureus.
- Worldwide: Group B Streptococcus (GBS), E.coli, Listeria.
Symptoms
- Non-specific symptoms: Suspect sepsis in any sick baby due to weak immune response.
- Recognized Symptoms (Early symptoms): Change in feeding pattern, lethargy, hypothermia → fever, pneumonia, respiratory distress.
- Signs Specific to Organ Systems: Meningitis: Fever and irritability (non-specific), seizures.
Management
-
Investigations:
- Blood culture: Gold standard, time-consuming.
- Sepsis screen: Presence of >2 findings.
- Lumbar puncture (Indication): Suspicion of meningitis in all symptomatic babies.
- Empirical antibiotics (while awaiting culture reports):
| Clinical scenario | Treatment |
|---|---|
| Low resistance (Suspected meningitis) | Penicillin (Gram +ve cover) + Aminoglycoside (Amikacin/gentamicin) |
| High resistance (Suspected meningitis) | Ciprofloxacin (+Amikacin) or Piperacillin Tazobactam + amikacin (m/c) |
-
Duration of treatment:
- Culture negative: 5-7 days (1 week).
- Culture positive: 3 weeks.
- Others: 2 weeks.
Components and Values in Sepsis
| Component | Value in Sepsis |
|---|---|
| Total leukocyte count | ↓ ( 15 mm/hr) |
| CRP | ↑ (> img/dL) |
- Newest marker for neonatal screening: Increased procalcitonin.
Neonatal Jaundice
- Incidence: Seen in up to 60% of newborns.
- Pathological: 5-10% (require treatment).
- Physiological: Majority (no treatment required).
Bilirubin Metabolism
- Breakdown of RBCs: Haem → Biliverdin → Unconjugated bilirubin (water insoluble)
- Unconjugated bilirubin: Conjugated bilirubin (in liver) (water soluble).
- Conjugated bilirubin: Through bile duct → intestines.
- Stercobilinogen (in colon): 90% Excreted in stools.
- Urobilinogen: 10% Excreted in urine.
- Enterohepatic circulation:
Assessment of Jaundice
- Serum Bilirubin Levels: Best investigation, Bilirubin values: Total serum bilirubin (TSB).
- Screening of Baby: Initial clinical assessment, Kramer method: Visual assessment.
Kramer Zones
| Zone | Description | Appropriate Serum Bilirubin |
|---|---|---|
| 1 | Face & neck (Seen first in the eyes) | 5-7 mg/dL |
| 2 | Chest & upper abdomen | 7-9 mg/dL |
| 3 | Lower abdomen & thighs | 9-11 mg/dL |
| 4 | Legs, arms & forearms | 11-13 mg/dL |
| 5 | Palms & soles (Danger sign) | >13-15 mg/dL → Risk of Kernicterus (Brain injury) |
Respiratory Distress in Newborn
- Respiratory rate: Increased (>60 breaths/min.), normal newborn respiratory rate: 40-60 breaths/min.
- Chest retraction: Due to involvement of accessory respiratory muscles.
-
Severe hypoxia: Seen in severe cases.
- Manifestations: Central cyanosis (involves mucosa), Grunting (expiration against a partially closed glottis → prevents airway/alveolar collapse).
Monitoring of Respiratory Distress
Scoring Systems
Silverman Anderson Score (Used for Preterm Babies)
| Criteria | 0 | 1 | Severe (2) |
|---|---|---|---|
| 1. Upper chest retraction | Synchronized respiration b/w chest & abdomen | Lag: Chest lags behind abdomen during inspiration | See-saw respiration: Chest retracts, abdomen expands during expiration |
| 2. Lower chest retraction | Not seen | mild | Severe |
| 3. Nasal flaring | Not seen | mild | Severe |
| 4. Xiphoid retractions | Not seen | mild | Severe |
| 5. Grunting | Not present | Audible with stethoscope | Audible without stethoscope |
| Interpretation: | 7: Severe |
Downe's Score (Used for Term & Preterm Babies)
| Criteria | Mnemonic (CRARG) | 0 | 1 | Severe (2) |
|---|---|---|---|---|
| Cyanosis | C | Not present | Present in room air | Present even with O2 support, FiO2 ≥ 40% |
| Respiratory rate | R | 80/min | ||
| Air entry | A | B/L equal & normal | Decreased | Severely decreased |
| Retractions | R | Not present | mild | Severe |
| Grunting | G | Not heard | Audible with stethoscope | Audible without stethoscope |
| Interpretation: | 7: Severe (Impending respiratory failure) |
Necrotizing Enterocolitis & Neonatal Sepsis
Features
| Stage | Description |
|---|---|
| IA | Occult blood in stools |
| IB | Gross blood in stools |
| II a | Absent bowel sounds |
| II b | Absent bowel sounds + abdominal wall edema |
| III a | Induration, Redness/erythema, Tenderness |
| III b | Intestinal perforation |
Imaging
| Stage | Description |
|---|---|
| Normal | |
| Pneumatosis intestinalis (Characteristic of NEC) | |
| Air in the intestinal wall, enters venous drainage system | |
| Superior mesenteric vein | |
| Portal vein: Pneumatosis portal vein |
Management
- Triad of lab findings: Seen only after stage II b. Do not have great relevance in diagnosis.
-
Until stage III a: Medical management - Nil per oral (NPO), total parenteral nutrition (TPN), IV antibiotics:
- Penicillin + Aminoglycosides + metronidazole (Gram+ve) (Gram-ve) (Anaerobes).
-
Stage III b:
- Hemodynamically unstable: Peritoneal drainage (Emergency procedure).
- After stabilization: Laparotomy → Resection & Anastomosis.
- Untreated: m/c cause of neonatal mortality.
-
Duration of antibiotics:
- Stage Ia: 3 days.
- Stage Ib: 7-10 days.
- Stage II, III a: 14 days.
Causes of Respiratory Distress
Respiratory Distress (Onset within 6 hours of birth)
- Transient tachypnea of newborn (m/c overall).
- Respiratory distress syndrome.
- Meconium aspiration syndrome.
Transient Tachypnea of Newborn (TTNB): (AKA wet lung syndrome)
- Most common in: Term neonates, neonates delivered by lower segment caesarean section (LSCS).
Pathogenesis
- Inadequate stimulation and compression at birth canal.
- Delayed clearance of lung fluids.
Chest X-ray findings
- Perihilar radio-opaque streaks.
- Fluid in the hilum of the lung moves into bronchovascular structures.
- White streaks on X-ray (AKA sunburst appearance).
- Fluid in the interlobar fissure.
Management
- Supportive management (O2 inhalation) - Sufficient as it is transient.
- Improvement seen in 48-72 hours.
Respiratory Distress Syndrome: (AKA hyaline membrane disease (HMD))
- Most common in: Preterm babies ( # Meconium Aspiration Syndrome (MAS)
Pathogenesis
- Post-term baby (>42 weeks).
- IUGR baby.
- Birth stress.
- Meconium expulsion before birth.
- Aspiration of meconium-stained liquor (MSL).
Consequences of MAS
- Atelectasis: Due to complete airway obstruction.
- Air trapping: Difficulty expiring air due to partial airway obstruction.
- Hyperinflation of lung/obstructive emphysema:
- Chemical pneumonitis: Inflammatory response to meconium.
- Inactivation of surfactant:
- Impaired gas exchange:
- Hypoxia, hypercapnia:
- Chronic pulmonary vasoconstriction:
- Persistent pulmonary hypertension (PPHN):
Chest X-ray findings
- Infiltrates in lung fields, seen in chemical pneumonitis.
Diagnosis
- MAS is diagnosed by exclusion, with a history of meconium-stained liquor.
Management
- Supportive management: Oxygen (O2) inhalation, Continuous Positive Airway Pressure (CPAP).
- Mechanical ventilation (severe cases).
- Inhaled nitric oxide (iNO): Pulmonary vasodilator to treat PPHN.
Congenital Diaphragmatic Hernia (CDH)
Pathogenesis
- Anatomical defect in the diaphragm.
Clinical Features
- Respiratory distress: Lung compression in the uterus due to movement of intestines into the mediastinum.
- Pulmonary hypoplasia.
Types of Diaphragmatic Hernias
- Morgagni: Antero-medial diaphragm.
- Bochdalek (most common): Posterolateral diaphragm.
- (Note: The image description is included here but it was not possible to convert the diagram into a table or format it as intended.)*
Clinical Presentation
- Mediastinal shift: Heart sound heard on the right side.
- Sunken/scaphoid abdomen.
Investigations
- USG (Antenatal):
- Chest X-ray (Postnatal): Intestinal air shadows (air-filled bubble-shaped shadows due to bowel), absent diaphragm shadows on the affected side.
Management
- If the baby does not cry at birth: Resuscitation.
-
If the baby cries at birth:
- Medical management (First 48 hours): Intestinal decompression via NG tube → Lung compression, mechanical ventilation via endotracheal tube → Lung expansion.
- Surgical management ( >48 hours): Hernia repair.
Contraindications
- Congenital diaphragmatic hernia (CDH): Absolute contraindication for bag and mask ventilation. Cause: Forceful entry of air into the esophagus → Inflation of bowel loops → Further compression of lungs.
Prognostic Factors of CDH
-
Antenatal USG:
- Lung-head ratio (LHR): < 1: Bad prognosis.
-
Postnatal:
- PPNH (most important): Bad prognosis.
- Onset of respiratory distress < 24 hours: Bad prognosis.
- Presence of liver in the thorax: Bad prognosis.
- Unaffected lung to be considered.
- (Note: This document describes congenital diaphragmatic hernia (CDH) in newborns, including its presentation, investigations, management, contraindications, and prognostic factors. A chest X-ray image is part of this assessment.)*
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Test your knowledge on the sepsis algorithm for neonates, specifically focusing on early and late onset sepsis. This quiz covers risk factors, symptoms, and recommended actions for managing sepsis in newborns. Enhance your understanding of this critical clinical topic.
