Neonatal Sepsis and Meningitis*

Sepsis is an infection in the bloodstream that poses severe health risks. It can directly infect the central nervous system or its surrounding membranes. Infection is transmitted through the amniotic fluid or during vaginal delivery as the baby passes through the lower genital tract.

Given the severity of sepsis, the threshold for treating it is very low, prompting physicians to even treat cases where sepsis is suspected. Sepsis can also cause shock (known as septic shock), severely decreasing blood flow and pressure and compromising brain function. Doctors treat sepsis with antibiotic regimens. While the only way to confirm sepsis is to test cell cultures, treatment should begin even before test results come back.

Sepsis in a newborn, called neonatal sepsis, is a very dangerous condition in which a baby has an infection in her blood stream.  This infection can cause seizures, meningitis, septic shock, brain injury and cerebral palsy.  Sepsis can damage the brain either by direct infection of the central nervous system or indirectly, by causing inflammation in the brain (encephalitis).

Group B streptococcus (GBS) and chorioamnionitis are infections that can travel to the baby before or during delivery and cause sepsis, seizures, meningitis and cerebral palsy.  Other risk factors for sepsis include preterm delivery / premature birth and the mother’s water breaking early, called premature rupture of the membranes (PROM).

An infection can be transmitted to the baby through the amniotic fluid or during vaginal delivery, when there is bacteria colonizing or infecting the mother’s lower genital tract.  Sometimes infection occurs within the first 7 days of the baby’s life, called early-onset sepsis (EOS).  Late-onset sepsis (LOS) occurs after 72 hours of life, or after 7 days, depending on which definition is used.  Late-onset sepsis can occur when the baby is infected by the mother either right before or during delivery, with an initial colonization of bacteria in the baby that later evolves into sepsis.

Medical Explanations

Risk Factors for Neonatal Sepsis and Meningitis

The younger and smaller the baby is, the more risk she has of developing sepsis.  Some of the risk factors for and causes of neonatal sepsis, meningitis and resultant seizures and cerebral palsy include the following:

  • Traumatic delivery
  • Group b streptococcus (GBS), Escherichia coli (E coli), herpes simplex virus (HSV)
  • A lack of oxygen to the baby’s brain shortly before or during delivery (hypoxia / hypoxic ischemic encephalopathy (HIE))
  • Maternal infection
  • Psuedomonas, Klebsiella and Enterobacter species and Staphylococcus infections (Staph infections)
  • The baby is a very low birth weight (VLBW) baby
  • Urinary tract abnormalities in the mother
  • The mother has a genetic disorder called galactosemia, which means she has difficulty breaking down simple sugars, such as glucose, lactose and galactose
  • Premature rupture of the membranes (PROM)
  • Premature / preterm birth

Diagnosing and Treating Sepsis to Prevent Meningitis, Cerebral Palsy and Seizures

Sepsis must be diagnosed and treated very quickly because a delay in treatment may worsen the outcome for the baby.  Sepsis can not only cause permanent brain injury and cerebral palsy, but it is also a significant cause of death in babies, especially those that are premature and / or have a low birth weight.  In fact, the potential consequences of neonatal sepsis are so severe that researchers recommend that clinicians have a very low threshold for treating potential sepsis in a baby.  This means that in most cases, even suspected sepsis should be treated.

Signs and Symptoms of Neonatal Sepsis and Meningitis

A baby may have sepsis if she:

  • has seizures and / or jaundice;
  • has breathing problems and respiratory distress that range from mildly fast breathing to respiratory failure;
  • is on a breathing machine (ventilator) and needs more and more help from the vent;
  • has apnea (periods in which she stops breathing for 20 seconds or more), and the apnea is increasing;
  • has a slow heart rate (bradycardia). Bradycardia usually occurs in the later stages of sepsis;
  • won’t tolerate feeding;
  • has temperature instability and / or an increase in her heart rate (tachycardia);
  • has a low blood pressure or evidence of poor blood flow in her body (poor perfusion);
  • her extremities are cool and / or she looks bluish;
  • has neurological changes such as irritability, lethargy and non-responsiveness;
  • is not producing a lot of urine;
  • is lethargic or hypotonic (floppy).

Research shows that on the first day of sepsis, most infants have new onset of apnea or a slow heart rate (bradycardia).  One study found that the most common signs of neonatal sepsis were apnea, hypoxia (baby suffering from a lack of oxygen), lethargy and gastric problems.

Neonatal sepsis is considered severe when the baby has heart, blood flow and blood pressure problems (cardiovascular problems), sudden onset respiratory distress syndrome (RDS), or dysfunction in two or more organ systems, called multi-organ failure.  In babies with severe sepsis, there is inflammation in the baby’s body that can cause a lot of damage.  Inflammation caused by sepsis causes the body to produce a cascade of biochemical events that can be very harmful to almost all the baby’s organs, including the brain and lungs.  Multi-organ dysfunction caused by sepsis is called systemic inflammatory response syndrome (SIRS).

Sepsis can cause the baby to go into shock, which means her blood flow and blood pressure are severely hindered.  This happens because sepsis can cause the blood to move out of the blood vessels and into a space next to the vessels, which means the blood is then not useful for important functions, such as oxygen, glucose and nutrient transport.  Low blood pressure and poor perfusion can cause very serious heart problems.  Septic shock can cause a severe lack of blood flow to the baby’s brain, which can cause brain injury and cerebral palsy – even when there is no meningitis.  Thus, in addition to antibiotic treatment for sepsis, which is discussed later, doctors must give fluid therapy when a baby is in shock to increase the baby’s blood pressure and blood volume.  Volume expansion therapy includes crystalloids (solutions of mineral salts or other water-soluble molecules) or colloids (such as blood) to help improve circulation, blood return to the heart, and the amount of blood the heart pumps out to the body.  Failure to quickly treat shock can not only cause cerebral palsy, but it can cause death.

Early Diagnosis of Neonatal Sepsis and Meningitis Can Prevent Cerebral Palsy

The only true method of diagnosing neonatal sepsis is to do a blood test to determine if there is a certain bacterium in the baby’s blood.  Results from these blood cultures can take a long time, and there are false negative results in about 10% of cases, meaning that 10% of the results show that no sepsis is present in the baby when the baby actual does have the infection.  Because of this, it is very important for doctors to do clinical assessments and lab tests to determine if a baby is at risk of developing sepsis and resultant cerebral palsy.  If a baby is at risk, treatment must be initiated while waiting for the blood culture results.

If a baby’s blood culture is negative for sepsis but doctors suspect the baby probably has , clinical assessments and lab tests should continue, and a full course of antibiotic therapy should be given to the baby to treat the probable sepsis and prevent seizures and cerebral palsy.

Since the signs and symptoms of sepsis can be subtle, any deviation from a baby’s typical pattern of activity should be seen as a potential indication of sepsis.  Also, if a baby has identifiable risk factors and / or physical findings consistent with sepsis, she should be evaluated for the condition.

Evaluating a baby for sepsis

Of course, a blood culture is the only way to make a true diagnosis of sepsis.  Other methods of evaluating a baby for sepsis include:

  • Testing cerebral spinal fluid (CSF).  This can help diagnose sepsis and meningitis.
  • Testing for inflammatory markers
  • Urine culture

Using molecular diagnostic blood tests to identify sepsis-relevant microorganisms in the blood may be a faster and more reliable method of testing for neonatal sepsis, but these tests are costly and are not available in most hospitals.

When a baby has symptoms of sepsis, most doctors do blood cultures (two separate tests), a culture of the CSF, and a complete blood count (CBC).  Many also test the baby for signs of inflammation.

Treating Neonatal Sepsis | Cerebral Palsy Prevention

Antibiotics are the treatment for neonatal sepsis.  Ampicillin in combination with gentamicin or cefotaxime are commonly given.  Ceftriaxone should be avoided in most cases because it places a child at risk for kernicterus, which is an infection in the brain that causes cerebral palsy.  Clindamycin is another antibiotic that may be added to treatment if anaerobic species are a suspected cause of the neonatal sepsis.  This is rare, however.

How Do Sepsis and Meningitis Cause Cerebral Palsy?

When a baby has sepsis and the infection directly enters the central nervous system or causes inflammation in the brain, the baby may develop meningitis, which is inflammation of the membranes that surround the brain and spinal cord.  Meningitis can cause fluid build-up in the brain (edema), increased pressure in the brain (increased intracranial pressure), brain abscesses (pus-filled pockets), hydrocephalus and cerebral infarction and stroke.  These conditions are extremely damaging to the brain.  Doctors should promptly treat sepsis in order to decrease the chance of meningitis.

Signs of meningitis include a failure to respond to antibiotic therapy, bradycardia, respiratory depression, bulging fontanelle (soft spot), fast head growth, separation of parts of the skull (separation of cranial sutures), weakness on one side of the body, and seizures.  When meningitis occurs, it must be treated as soon as possible to try and minimize the brain damage that can occur.  Brain damage caused by meningitis can cause cerebral palsy, developmental delays, seizure disorders and learning disabilities.

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