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Referral and warning signs
When to refer
IMMEDIATE URGENT REFERRAL/ADMISSION to Hospital (H/RR with neonatal care capability) for ALL suspected cases of neonatal meningitis/sepsis.
Red flags
- Bulging fontanelle.
- Seizures.
- Apnea.
- Lethargy / Coma.
- Poor feeding.
- Temperature instability (fever or hypothermia).
- Signs of shock.
Signs and symptoms
- Often non-specific, can overlap with neonatal sepsis.
- Temperature instability (fever or hypothermia).
- Lethargy, poor feeding, irritability.
- Vomiting.
- Apnea (pauses in breathing) or respiratory distress.
- Seizures.
- Bulging fontanelle (late sign).
- Neck stiffness often absent in neonates.
- Poor tone (hypotonia).
Risk factors
- Prematurity.
- Low birth weight.
- Maternal Group B Streptococcus (GBS) colonization or infection.
- Prolonged rupture of membranes (>18 hours).
- Maternal fever during labour (chorioamnionitis).
- Difficult or traumatic delivery.
- Invasive procedures.
- Congenital anomalies.
Diagnosis
Clinical assessment
High index of suspicion in any neonate presenting with non-specific signs of illness (fever/hypothermia, lethargy, poor feeding, seizures, respiratory distress). Bulging fontanelle strongly suggestive.
Differential diagnosis
- Neonatal sepsis without meningitis.
- Hypoglycemia.
- Hypoxic-ischemic encephalopathy (HIE).
- Intracranial haemorrhage.
- Metabolic disorders.
- Congenital infections (TORCH).
Investigations
- Lumbar Puncture (LP) and CSF Analysis: Essential for diagnosis. CSF findings similar to older children (high WBC-neutrophils, low glucose, high protein) but interpretation needs age-specific reference ranges. Gram stain and Culture critical.
- Blood Culture: Obtain before antibiotics.
- Full Blood Count (FBC) and differential.
- C-Reactive Protein (CRP).
- Blood Glucose.
- Consider Urine culture.
Diagnostic criteria
Clinical suspicion in neonate + Abnormal CSF findings +/- Positive CSF/Blood culture.
Management
Non-pharmacological management
- Urgent Hospital Admission (Neonatal Unit/H).
- Supportive Care:
- - Maintain neutral thermal environment (keep baby warm).
- - Ensure adequate hydration and nutrition (IV fluids, NGT feeding/expressed breast milk).
- - Oxygen therapy if needed (maintain SpO2 >92%).
- - Monitor vital signs, glucose, hydration, neurological status closely.
- - Manage seizures (Phenobarbital often first line in neonates).
Pharmacological treatment
- Immediate Empirical IV Antibiotics: Cover common neonatal pathogens (Group B Strep, E. coli, Listeria, other Gram-negatives). Start ASAP after cultures obtained (or immediately if LP delayed).
- - Recommended Regimen (UCG): Ampicillin IV PLUS Gentamicin IV. (LOC: H)
- - Ampicillin Dose: Neonate <7d: 50-100mg/kg Q12H; Neonate >7d: 50-100mg/kg Q8H.
- - Gentamicin Dose: 5-7.5mg/kg/day given Q12-24H depending on gestational age/weight (consult neonatal protocols).
- - If Gram-negative meningitis suspected/confirmed or poor response: Consider changing Gentamicin to a third-generation cephalosporin like Cefotaxime (preferred over Ceftriaxone in neonates due to bilirubin displacement risk) - specialist advice needed.
- Duration: Typically 14-21 days, depending on pathogen and clinical course.
- Targeted Therapy: Adjust antibiotics based on CSF/Blood culture results and sensitivity.
Monitoring
Monitor clinical response, vital signs, feeding, neurological status. Repeat LP may be considered if poor response. Monitor for complications (hearing loss, hydrocephalus).
Complications
- Hearing loss (high risk).
- Seizures / Epilepsy.
- Hydrocephalus.
- Cerebral palsy.
- Cognitive impairment / Developmental delay.
- Visual impairment.
- Subdural effusion/empyema.
- Ventriculitis.
- Death.
Prevention
- Maternal screening for Group B Streptococcus (GBS) and intrapartum antibiotic prophylaxis (IAP) if positive.
- Good obstetric and neonatal care practices.
- Aseptic techniques during procedures.
Patient education
- (To Parents/Caregivers):
- Explanation of serious infection of baby's brain lining.
- Need for urgent hospital admission, LP, IV antibiotics.
- Explanation of supportive care (warmth, feeding, oxygen).
- Potential complications, including hearing loss and developmental issues.
- Importance of follow-up assessments (hearing screen, development).
Uganda-specific notes
Neonatal sepsis and meningitis are major causes of neonatal mortality. Early recognition of non-specific signs and prompt treatment with Ampicillin + Gentamicin is crucial. Access to CSF analysis and advanced neonatal care is limited. Emphasis on prevention (maternal GBS screening/IAP where feasible, clean delivery).
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.1.5.1
- Uganda Clinical Guidelines (UCG) 2023
Chapter 15 (Neonatal Care - Sepsis)