This second article in our series on sepsis, centers on this complex clinical problem in infants and children. Throughout the discussion, we suggest relevant pediatric and neonatal sepsis algorithms from our clinical knowledge base, which can be helpful tools for clinical decision support.
Sepsis is a multifaceted disorder that can affect many patients, especially vulnerable patients at the extremes of life. For some neonates and infants, sepsis is the first and last crisis in their lives. Early diagnosis and aggressive management are key to their survival.
A fetus or newborn may become infected in many ways including:
- Intra-uterine infection (chorioamnionitis, other)
- Premature rupture of the membranes
- Colonization of the mother with Group B streptococcus
- Prolonged intensive care for prematurity or malformations
An infection can result in intrauterine fetal demise, or the neonate may present with sepsis of early (before 72 hours) or late (after 72 hours) onset. The presentation may be subtle and easily missed, especially in a premie. Since a delay in diagnosis can be serious, it is important to closely monitor the neonate and to look for clues of deterioration.
- Clinical Score for Neonatal Sepsis
- Features for Early Onset Systemic Infection in a Preterm Neonate
- Late-Onset Neonatal Sepsis Score
Sepsis in Young Children
For infants and young children, sepsis occurs for reasons different than those for a neonate. These may include:
- A community-acquired bacterial infection (pneumonia, urinary tract infection, etc)
- A complication of a severe viral infection
- A congenital or acquired immunodeficiency
- A nosocomial infection
For a child who is an outpatient, caregivers are faced with a series of questions. A parent may question whether or not a sick child should be brought in for evaluation. If the child is brought in, then the clinician must decide if the child’s condition warrants hospitalization. In some cases even a slight delay in bringing the child in, or a decision not to admit a child can result in significant morbidity and mortality.
- Guidelines for When to Call a Pediatrician About a Febrile Child
- PRISA II (Pediatric Risk of Admission) Score
Sepsis in Developing Countries
The problem of sepsis is particularly acute in developing countries. Poverty, bad food, bad water, malnutrition and environmental exposures make infections common, resulting in high infant and childhood mortality rates. In addition, resources and access to trained clinicians are limited. Existing problems are compounded if HIV infection is present, as it disrupts families and overwhelms limited healthcare resources.
In response to this need the World Health Organization (WHO) has developed the IMCI (Integrated Management of Childhood Illness) program that tries to address the most common problems. This provides simple algorithms for patient management that partially solve the many problems involved.
Sepsis can affect the very young, resulting in death or disability. Early diagnosis and appropriate therapy are essential to avoid a catastrophe.
Medical algorithms can be helpful tools for decision support, especially when access to pediatricians is limited.