Recognition of the seriously unwell neonate and young infant

PIC Endorsed

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
Cardiac	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
Endocrine and Metabolic	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.

Consider Consultation with local paediatric team when

Assessing any unwell neonate or young infant

Consider transfer when

Child requiring care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

The neonate/infant is clinically well and there is low likelihood of infection based on examination and negative infective indices
- In this setting, and if cultures are negative at 48 hours, antibiotics can be ceased

Note: a clinically well child (≥3 months) with normal investigations can be discharged with follow up in 12-24 hours

Parent information sheet

Fever in children
Crying and unsettled children
Meningitis
Urinary tract infections and Urine samples
Interacting with your baby

Last updated December 2019

Reference List

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The Royal Children's Hospital Melbourne

Clinical Practice Guidelines