Sepsis in the Newborn
Definition of Sepsis in a Neonate
Neonatal sepsis is “a clinical syndrome of bacteremia with systemic signs and symptoms of infection and a positive culture from central body fluid” (Guha et al., 2005). It is the most common cause of neonatal mortality (Guha et al., 2005) and comes in two forms, namely early- onset sepsis and late-onset sepsis. Early-onset sepsis usually occurs within 72 hours of birth and can be attributed to perinatal risk factors, which usually come with respiratory problems and pneumonia. Late-onset sepsis, on the other hand, occurs after 72 hours upon birth and can be caused by infections that are acquired within the hospital. This disease is characterized by the following features: signs of meningeal irritation or jaundice or both; refusal to feed; lethargy; hypotonia; and hyperpyrexia or hypothermia (Ashraf et al., 1991).
Pathophysiology of Sepsis in a Neonate
The infectious agents associated with neonatal sepsis have changed over the years, but by the 1990s, E. coli and GBS became primarily associated with neonatal infection, although the occurrence of coagulase-negative S. aureus has been increasing. In addition, organisms such as species of Clostridium and bacteroids; Enterobacter aerogens; Haemophilus influenzae; Chlamydia pneumonia; and Monocytogenes have been found in neonatal sepsis.
This disease makes the neonate incapable of effectively responding to infectious agents because of a weakening of the newborn’s physiological response to such agents (Guha et al., 2005). It also impairs the neonate’s ability for killing the bacteria when the neonate is critically ill and the neonate’s neutrophil reserves are easily depleted because of the bone marrow’s weakened response, especially in premature babies.
As well, although the concentration and function of neonatal monocyte are at adult levels, there is an impairment of the macrophage chemotaxis and its function continues to decrease until early childhood (Guha et al., 2005). There is also a decrease in the macrophages’ production of cytokine, which may be associated to a decrease in the production of T. cells.
Although neonates are naturally deficient in T. cells, its proliferation as the neonate grows is stunted because of neonatal sepsis. In addition, the neonatal T. cells are not capable of producing the cytokines that aid in the stimulation and differentiation of the B-cells, as well as in the “bone marrow stimulation of granulocyte/monocyte proliferation” (Guha et al., 2005, p. 656). Moreover, the formation of antigen-specific memory function is delayed. Particularly, infection causes the cytotoxic function of neonatal T. cells o be 50 to 100 percent as effective as those of adults (Guha et al., 2005).
Also, despite the newborn receiving IgG during the woman’s pregnancy, a premature infant still has a low level of IgG because of the shorter transmission period of the immunoglobulins. Moreover, this level of IgG can become even lower if the mother is immunosuppressed. Similarly, the neonate’s IgM levels are low and while igG and IgE may be synthesized while the baby is in the uterus, only traces will be found in the cord blood once the baby is delivered. As well, even if IgA is received during breastfeeding, it will not be secreted until the second to fifth week of birth. In addition, the neonate has a weakened response to bacterial polysaccharide, which remains unchanged until the early years of the child’s life. Finally, there is reduced expressivity of certain antigens by the cell membranes, which in turn reduces cytolyctic activity.
Midwifery and Medical Management
The prompt administration of treatment is important in obtaining optimum results for neonatal sepsis. The early detection of problems and the early administration of appropriate and effective antibiotic therapy, together with supportive care, are necessary in saving the life of an infant with sepsis (Datta, 2007). It should be noted that antibiotics take around 12 to 24 hours to take effect.
Antenatal care is also an important part of maternal health care (Bloom, Lippeveld & Wypij, 1999). In a study conducted by Hildingsson, Waldenstrom & Radestad (2002), it was found that women viewed antenatal care as very important in the checking of the baby’s health as well as the mother’s own health. In addition, antenatal care has indirect benefits (Bloom, Lippeveld & Wypij, 1999), which include health education and the promotion of awareness for the need for care when giving birth. It can also promote awareness about health facilities for women and their families, which will enable them to easily seek help when the need arises. The same is suggested by Hallgren, Kihlgren, Norberg & Orslin (1995) who assert that part of a midwife’s responsibility is to identify and provide support for the difficulties encountered during the pregnancy’s development process through parent education. In particular, Hallgren et al. (1995) suggest that parent education start between the twenty-fifth and thirtieth week of gestation and continue throughout the child’s first year at the child welfare center. Similarly, Proctor (1998) asserts that it is important for health care professionals to be able to understand women’s concerns during pregnancy as this can help in the improvement of the quality of service that they provide and in the management of risk.
This is particularly important as studies show that 90 percent of maternal deaths can be avoided if medical intervention is administered in a timely manner and if quick access to the necessary services is available (Bloom, Lippeveld & Wypij, 1999). Moreover, antenatal care and health education enable the woman to choose a well trained or qualified health professional for the delivery. In the study conducted by Bloom, Lippeveld & Wypij (1999), it was found that women who received a higher degree of antenatal care had increased chances of seeking safe delivery care. In the same manner, the study showed that women who were previously attended to by a health professional or who had previously gone to a health facility for the delivery had increased chances of seeking the service of trained health professionals (Bloom, Lippeveld & Wypij, 1999).
This stresses the importance of health professionals providing quality care, as this makes the women more comfortable with seeking professional help; thus, encouraging them to use the services of trained health professionals and health care facilities when giving birth. As a result, this can lead to a decrease in maternal mortality and morbidity, which can in turn decrease the risk of neonatal sepsis (Bloom, Lippeveld & Wypij, 1999). Health facilities are also more hygienic, which can further contribute to the prevention of sepsis. Moreover, with the need for quickly administering treatment for sepsis, health care facilities are sure to be properly equipped.
Similarly, the message that doctors and midwives give women during their antenatal care visits affect the women’s experiences and expectations (Hildingsson, Waldenstrom & Radestad, 2002). As such, it is important for these health care professionals to respond properly in order to alleviate the woman’s anxiety about the baby and to ensure that the woman forms realistic expectations of the pregnancy.
These findings are supported by those of Hildingsson, Waldenstrom & Radestad (2002), which showed that women considered it important that they be given time to talk about their pregnancy concerns and to obtain information about labor and birth during their antenatal care visits. Also supportive of the findings of Bloom, Lippeveld & Wypij (1999), the findings of Hildingsson, Waldenstrom & Radestad (2002) showed that most women considered it very important that they see the same midwife on all their visits as this enables them to build a more secure relationship with their midwife. The same assertion is made by Proctor (198) who also stated that pregnant women need information in preparing for parenthood, in making informed choices about their care, and in order to be reassured. In addition, it would be helpful for women if their midwives provided them with information regarding the various screening tests or procedures and their results.
As well, breastfeeding has been shown to serve as protection against neonatal sepsis (Ashraf et al., 1991). In a study conducted in Pakistan (Ashraf et al., 1991), it was found that 12 percent of the total deaths among newborns were due to neonatal sepsis, which in turn was due to the newborns being fed with food and fluids other than breast milk 48 to 120 hours after birth. The said food and fluids were usually contaminated with bacteria, specifically the Gram negative bacteria (Ashraf et al., 1991), which then caused sepsis. The study conducted by Ashraf et al. (1991) showed that even partial breastfeeding can help protect babies against neonatal sepsis.
As such, midwives and doctors should advocate for breastfeeding and provide women with information about its benefits during the women’s antenatal care visits. As found by Brodribb, Fallon, Hegney & O’Brien (2007), one of the reasons that women chose to breastfeed was because of advice from their mother, their doctor, or a nurse. Younger women were also found to be the most likely to be influenced by such advice (Brodribb, Fallon, Hegney & O’Brien, 1 .7) As well, health care professionals should integrate strategies for increasing the woman’s breastfeeding self-efficacy during antenatal care, as this influences the duration by which mothers breastfeed their babies (Blyth et al., 2002).
In particular, mothers with a high level of breastfeeding self-efficacy are more likely initiate breastfeeding and to breastfeed their babies longer than mothers with a lower level of breastfeeding self-efficacy. According to Blyth et al. (2002, p. 279), “breastfeeding self-efficacy refers to a mother’s perceived ability to breastfeed her newborn.”Blyth et al. (2002) also suggest that one of the interventions that health care professionals can employ to increase women’s breastfeeding self-efficacy is to review the woman’s past breastfeeding experience and to correct misperceptions on breastfeeding, as well as diminish any negative emotional responses such as anxiety and fear. Midwives and doctors should also encourage women to start breastfeeding immediately after birth and women should be given opportunities to do so before getting discharged from the hospital. In addition, medical professionals should provide support for the women in their attempts to breastfeed. It would also help if medical professionals can provide these women with individualized interventions. Moreover, lactating mothers can be brought together to allow them to share their experiences and enable them to get peer support. These are supported by the findings of Graffy & Taylor (2005), which showed that women wanted more information about breastfeeding and what to expect of it; information on how to properly position the baby for breastfeeding, as well as suggestions, advice, and emotional support.
Prognosis for the Treatment of a Neonate
Although there are newer antimicrobial agents that are now available, 25 to 30 % of infants still die when they contract neonatal sepsis. In particular, an extremely high mortality rate is “associated with endotoxic shock, sclerema, NEC, DEC” (Datta, 2007, p. 93) and others. In addition,
Associated congenital malformations like meningomyelocele, TEF, LBW and surgical procedure adversely affect the prognosis. The early onset sepsis due to group-Streptococci, nosocomial infections due to Klebseilla and Pseudomonas aeruginosa are also associated with adverse outcome. (Datta, 2007, p. 93)
The conduct of a sepsis screen, together with the administration of specific antimicrobial therapy, close monitoring and excellent supportive care, can increase the neonatal sepsis outcome.
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