What Organisms Cause Neonatal Sepsis?

Patient Presentation
A female infant was born at 38 4/7 week gestation to a 34 year old gravida 2, para 1 mother. The mother was positive on Group B streptococcus screening 2 weeks prior to delivery.
Labor was induced because of late-term maternal hypertension. The mother received antibiotics during labor and delivery was by emergent cesarean section for fetal bradycardia.
The baby was vigorous at delivery but then became cyanotic at 4 minutes of age and received blow-by oxygen. Apgar scores were 4 at 1 minute, 6 at 2 minutes, and 7 at 5 minutes.
Her initial capillary blood gas was pH = 7.13, CO2 = 77, and base excess of +2. She was given oxygen by hood, 2 intravenous boluses of normal saline, and ampicillin and gentimicin after blood cultures were drawn.
She continued to have respiratory distress and was intubated and sedated before transfer
to a regional hospital. She was later extubated on day of life 1.
The pertinent physical exam on arrival showed a term infant with temperature of 35.6 degrees Celsius, heart rate = 106, respiratory rate = 40, and blood pressure = 69/40 with no evidence suggesting of coarctation of the aorta on 4 extremity blood pressures.
Her oxygen saturation was 100% on 40% oxygen. She did not appear dysmorphic. Skin showed a few red, blanching 3 mm macules on the face. Lungs were normal. Heart had a regular rate and rhythmn with no murmurs. Upper extremity pulses were equal to lower extremity pulses.
Abdomen had no organomegaly, normal bowel sounds and a 3 vessel cord. She had a good tone, strength, and appropriately reacted to handling.
The work-up included a complete blood count that showed a hemoglobin of 15.0, hematocrit of 45%, platelets of 233 with segmented neutrophils of 7889, lymphocytes of 5474 and bands of 483.
A C-reactive protein was <0.5 mg/dl. Her chest radiograph showed some mild hyperexpansion and general haziness of the lung fields (see below).
Over the next day, the patient’s clinical course showed her to be more awake, her respiratory distress resolved and she was extubated. She had no glucose instability.
Her blood cultures locally did not grow an organism.
The diagnosis of presumed neonatal sepsis was made and she received a 7 day course of ampicillin and gentimicin therapy. Her complete blood count was normal at discharge.


Figure 43 – AP radiograph of the chest on the first day of life demonstrates normally positioned tubes and lines along with diffuse fine interstitial infiltrates. The differential diagnosis for this finding would include transient tachypnea of the newborn versus neonatal pneumonia due to Group B Strep.

Discussion

Neonatal sepsis is an important contributor to neonatal morbidity including poor neurodevelopmental outcomes and neonatal death.
Early in the 20th century, group A streptococcus was the leading cause, but in the 1970s group B streptococcus (GBS) emerged.
In the 1990’s universal antenatal screening was recommended at 35-37 weeks gestation with recommendations for intrapartum prophylaxis for colonized women.
These guidelines decreased the rate of early GBS infection from 1.7/1000 live births to 0.34/1000 live births.
Although the rate of GBS infection has declined, the proportion of mothers exposed to intrapartum antibiotics has more than doubled.
Concerns of antibiotic-resistance have also been raised.

Early-onset neonatal sepsis is defined as occuring within the first 7 days of life. Most (85%) infants present in the first 24 hours. Overall GBS neonatal sepsis has decreased with the use of antibiotic protocols, but the overall incidence of early-onset sepsis has remained stable mainly because of increased sepsis resulting from Escherichia coli.
This is especially true for premature infants and the onset may be extremely rapid.
The organisms are acquired as an ascending infection from the cervix or transplacentally from the mother.
Most early-onset neonatal sepsis is not culture-proven and many infants are defined as having “clinical sepsis” such as the infant described above.

Late-onset neonatal sepsis is defined as occuring between 8-90 days. It is acquired from the environment by colonization of the conjunctiva, skin, gastrointestinal tract, respiratory tract, or umbilicus.

Pneumonia is a common early-onset sepsis presentation, whereas bacteremia and meningitis are more common in late-onset sepsis.
Other presentations include metabolic acidosis, hyper- or hypo-glycemia, jaundice, pulmonary hypertension, decrease cardiac output, necrotizing enterocolitis, thrombocytopenia, neutropenia, or disseminated intravascular coagulation.

Workup often includes complete blood count with differential, C-reactive protein, cerebrospinal fluid analysis and culture, urinalysis and culture, blood culture, chest radiograph, and possibly head imaging and/or other infectious disease markers.

Learning Point

Early-onset neonatal sepsis commonly is associated with GBS (most commonly), Escherichia coli, Haemophilus influenzae, and Listeria monocytogenes.

Late-onset sepsis syndrome is associated with Staphylococcus epidermidis (most commonly), coagulase-negative staphylococcus, Staphylococcus aureus, E. coli, Klebsiella, Pseudomonas, Enterobacter, Candida, GBS, Serratia, Acinetobacter, and anaerobes.

Empiric treatment for early-onset neonatal sepsis is usually begun with and includes combined IV aminoglycoside and expanded-spectrum penicillin antibiotic therapy in the U.S. and Canada. Clinical situation and local pathogen sensitivities must be considered when selecting antibiotic coverage.

Questions for Further Discussion
1. What are the local pathogens that cause neonatal sepsis?
2. What are the local pathogens’ sensitivities to antibiotics?
3. How long should treatment be given for presumed neonatal sepsis, i.e. culture-negative sepsis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sepsis, Streptococcal Infections and Infections and Pregnancy.

To view current news articles on this topic check Google News.

Schrag SJ, Stoll BJ. Early-onset neonatal sepsis in the era of widespread intrapartum chemoprophylaxis.
Pediatr Infect Dis J. 2006 Oct;25(10):939-40.

American Academy of Pediatrics. Group B Streptococcal Infections, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;620-627.

Anderson-Berry AL, Bellig LL. Neonatal Sepsis. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic2630.htm (rev. 8/18/06, cited 1/16/07).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    January 29, 2007

  • What Organisms Cause Sinusitis?

    Patient Presentation
    A 17-year-old female came to clinic with an 8 day continuous history of moderate rhinorrhea, nasal congestion and bad breath. She was taking pseudoephedrine which decreased the nasal congestion and she felt somewhat better. One day ago the rhinorrhea changed from clear and watery, to yellow-greenish and thick.
    Last night she began to have acute onset of pain in her left face, upper teeth and behind her eye. She also complains of a headache that is frontal and does not radiate. The pain worsens with bending over or tapping on the affected areas. The pain is somewhat responsive to acetaminophen.
    She has no fever. She has minor coughing because of the rhinorrhea and she also complains of some “popping” sounds in her ears occasionally. She is otherwise healthy.
    The pertinent physical exam shows a female who appears to have upper airway congestion with teary eyes and needing to clear her nose of yellow-green discharge.
    She has a de-nasal voice. She is tender to palpation over her frontal sinuses bilaterally and left maxillary sinus. Her conjunctiva are mildly injected. She has copious drainage in her nose with extremely swollen and red turbinates.
    Her pharynx is slightly red with nasal discharge. Her tympanic membranes show a small amount of fluid bilaterally with normal landmarks and movement.
    She has minor anterior cervical lymphadenopathy. Her lungs are clear and the rest of her examination is negative.
    The diagnosis of of left maxillary and bilateral frontal actue sinusitis is made. The patient is begun on Azithromycin for 10 days because of a history of hives with penicillin. The physician recommends continuing the pseudoephedrine as the patient states it has been helping with the symptoms and to try nasal saline to see if it helps symptomatically.
    The patient will return if the symptoms worsen or change.

    Discussion
    Sinusitis is defined as the inflammation of the paranasal sinuses, that are usually sterile, due to bacterial infection. Rhinosinusitis (RS) is a term currently used to describe inflammation believed to begin in the nasal epithelium (rhinitis).
    Duration of symptoms classify RS: acute is between 10-30 days, subacute is between 30 and 90 days, chronic is more than 90 days, and recurrent lasts less than 30 days but recurs after an asymptomatic time period of 10 or more days.
    Acute RS is diagnosed by history and is defined as symptoms lasting longer than 10 days or worsening of symptoms between 7 to 10 days of illness. As separate upper respiratory infections (URIs) can run consecutively, it is important to distinguish between one episode or more than one episode of symptoms.
    Acute RS symptoms include nasal discharge, coughing and halitosis. Adolescent and older children may also have face pain and/or pressure, headaches, dental pain in the maxilla, throat clearing and pharyngitis.
    A less common presentation of acute RS is high fever along with severe URI symptoms lasting 3 to 4 days concurrently. The illness is more likely to be viral if the fever precedes the URI symptoms.
    Physical examination may or may not assist in diagnosis. Pressure on the sinus that elicits tenderness or purulent discharge seen coming from the middle meatus on nasal examination are more consistent with sinusitis caused by bacteria. The definitive diagnostic treatment is direct aspiration, but most cases are diagnosed by history and physical examination.

    Chronic RS is associated with environmental pollution including tobacco smoke, recurrent viral URI, allergic and nonallergic rhinitis, ciliary dyskinesia, cystic fibrosis, immunodeficiency, gastroesophageal reflux, and anatomic abnormalities.

    Learning Point
    The common organisms causing acute RS are the same as for otitis media:

    • Streptococcus pneumoniae
    • Haemophilus influenzae, non-typeable
    • Moraxella catarrhalis
    • Staphylococcus aureus – more likely with chronic RS
    • Anaerobic organisms – more likely with chronic RS and include Peptococcus species, Peptostreptococcus species and Bacteroides species
    • Pseudomonas aeruginosa – in patients with cystic fibrosis
    • Fungus – in patients who are immunocompromised

    Amoxicillin is the drug of choice with penicillin-allergic patients being treated with second or third generation cephalosporins or a macrolide antibiotic.
    Other treatment regimens may be indicated depending on initial response to treatment. Most patients have some improvement within 3 days. The optimal therapy duration is not known but common treatment durations include 7, 10, 14, and 28 days.

    Questions for Further Discussion
    1. What are some of the potential complications of sinusitis?
    2. What are the indications for radiologic imaging for sinusitis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Sinusitis
    and at Pediatric Common Questions, Quick Answers for this topic: Sinusitis

    To view current news articles on this topic check Google News.

    American Academy of Pediatrics Clinical Practice Guideline. Management of Sinusitis. Pediatrics. 2001:108:798-808. Available from the Internet at: http://www.aap.org/policy/0106.html (cited 12/18/2006).

    Taylor A. Sinusitis. Pediatr Rev. 2006 Oct;27(10):395-7.

    Sharma G. Sinusitis. eMedicine.
    Available from the Internet at http://www.emedicine.com/ped/topic2108.htm (rev. 7/17/2006, cited 12/18/2006).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    January 22, 2007

  • How Should I Counsel about Injury Prevention?

    Patient Presentation
    An 18-month-old female returns to clinic to recheck the second degree burn she received on her arm yesterday.
    Her mother was using a curling iron in the bathroom and the child pulled the dangling cord and the hot iron fell on the dorsal aspect of her left arm.
    The mother immediately cooled the area with cold water and both parents took her to the emergency room, where the 2×1 cm blister with surrounding erythema was kept intact.
    Silvadene ointment was carefully placed on top of the blister and covered with a gauze dressing. The mother was told to give Tylenol for pain and to go to see her local physician after 24 hours.
    The mother was also given general wound and fever instructions. The family was also questioned concerning potential non-accidental trauma and family violence and the healthcare provider felt that there were no concerns about these issues currently.
    The pertinent physical exam showed a healthy female with a broken blistered area of approximately 2×1 cm with an additional 4-8 mm of surrounding erythema noted.
    Toward the distal end of the blistered area appeared one 3-5 mm circular area which was greyish in color.
    A complete physical examination found only a few small bruises of different colors on the child’s shins.
    The diagnosis of second degree burn with possible small area of 3rd degree burn was made. The wound was again cleaned and covered with Silvadene and a gauze dressing.
    Wound instructions and the importance of checking the wound for spreading erythema later in the day was emphasized. The mother was also told to call immediately if the child had a fever and was to follow-up the next day.
    The patient’s clinical course consisted of 2 more daily wound checks. She did not develop any complications, but had a 1.5 cm pinkish scar that continued to remodel at her 3rd year well child examination.

    Discussion
    Burns are common problems, especially minor burns.
    The depth of the burn is defined as:

    • First degree – erythema of the skin, e.g. sunburn
    • Second degree (partial thickness of skin) – blistering, swelling, and moist surface appearance
    • Third degree (full-thickness of skin) – charred, waxy appearance, white/grey in color and may be dry
    • Fourth degree (devastating full thickness) – burn goes into muscle and/or bone

    The “rule of 9s” is used to estimate the amount of body surface area (BSA) involved. For children the head contributes more and the upper legs less. In general, an area the size of the palm of the hand is 1% BSA.
    For older children and adults BSA can be estimated as:

    • Head/neck – 9%
    • Each arm – 9%
    • Anterior thorax – 18%
    • Posterior thorax – 18%
    • Each leg – 18%
    • Perineum – 1%

    Learning Point
    Injuries are the leading cause of death and life-years lost for people under 44 years of age in the U.S.
    Data regarding the most common injuries by age group is provided by the Centers for Disease Control at: http://www.cdc.gov/nchs/data/dvs/lcwk1_2003.pdf

    To understand what leads up to an injury, in 1980, Haddon defined 3 phases; pre-event, event and post-event. The contributing factors are cross-tabulated with the categories: host (victim), agent (vector or vehicle), and environment (both physical injury scene and the sociocultural/socioeconomic).
    A Haddon matrix for the burning above could look like this:

    
    Category	Pre-event  		Event 			Post-event
    Host		Lack of knowledge 	Inability to move  	Burn on arm
    (child)		- "Don't touch"		out of way
    
    Agent		Hot iron on counter  	Dangling cord verus 	Result of curling iron
    (curling iron)	cordless model					injury including burn
    								to otherpart of body
    								or mother
    
    Environmental  	Bathroom door open	Curling iron on vanity, Immediate burn treatment
    (injury scene)	Mother distracted	cord easily seen and 	at home, Emergency room
    					grabbed, Hot iron	treatment
    					present
    
    Environmental  	Burn education, 	Psychological stress  	Emergency room and
    (socioeconomic	purchase cordless  	on patient and mother	primary care physicians
    /cultural)	model, Economic losses				office care, potential burn
    		of family					unit and rehabilitation care

    Injury prevention is organized into 4 E’s:

    • Engineering to eliminate or decrease injuries by modifying the agent or product, e.g. decreasing the amount of acid in the bottle of false-nail etcher to decrease burns, alerting sounds on trucks that are backing-up to prevent driving over a pedestrian.

      This is theoretically one of the easier strategies to implement because once implemented they often do not require a person to do anything else, i.e. they are passive strategies. Many of these are also relatively low-cost. For example, replacing strings on the hooded children’s clothing with elastic to prevent strangling injuries

    • Enforcement to have laws or regulations that modify individual behavior, e.g. mandatory child restraint use in cars, mandatory bike or motorcycle helmet laws.

      Laws and regulations can make strategies easier to implement because of the social and economic pressures for individual behavior conformity or because they are passive strategies. For example, graduated driver’s licenses decrease motor vehicle accidents and flame-retardant placed on children’s clothing during manufacturing decreases burn injuries.
    • Education to inform and persuade individuals to adopt or change their individual behavior, e.g. using cord hooks on window blinds to prevent strangling injuries, using trigger locks on all guns, learning to swim.
      This should be advocated, however it requires active action to consistently implement and therefore can be difficult to do. However it can be effective for persons ready to learn and motivated to change their behavior.

    • Economics to create financial incentives to implement injury prevention strategies, i.e. car insurance discounts for families whose teenagers complete safer driving programs, government funding to build or modify separate bicycle trails or skateboarding parks from traffic areas.

      Economics can be a problem for many families. For example, the cost of placing window guards in a high rise building could be prohibitive for the individual family and/or the building owner.

    Injury prevention screening and education of the patient and family at all visits including health maintenance visits is important. The American Academy of Pediatrics uses TiPP sheets based on child age to assist healthcare providers and families with this education.
    As all possible injuries cannot be assessed and discussed at every visit, guidance must be individualized based upon several factors including:

    • Age – e.g. falls and choking hazards for infants, driving and suicide risks for teenagers

    • Developmental skills – e.g. able to climb on furniture or playground equipment and trees
    • Time of year – e.g. heat and cold injuries in summer and winter, fire and carbon monoxide in fall and winter
    • Geographical – e.g. proximity to bodies of water such as lakes, streams, pools, traffic
    • Family livelihoods and recreation – e.g. farm injuries, firearm injuries, lawnmowers, swimming, skiing
    • Resources to mitigate risks – e.g. purchase cabinet locks and gates, paint over peeling leaded paint

    Questions for Further Discussion
    1. What are some of the most common injuries in your local area and why?
    2. What are some of the methods that could be employed to decrease a common local injury?
    3. What are some of the government agencies who are responsible for decreasing injuries?
    4. When should screening for child abuse and family violence occur? How can a healthcare provider do this screening?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Burns and Injuries
    and at Pediatric Common Questions, Quick Answers for these topics: Burns and Child Safety

    To view current news articles on this topic check Google News.

    Haddon W. Options for the prevention of motor vehicle crash injury. Isr J Med. 1980;16;45-68.

    Mace SE, Gerardi MJ, Dietrich AM, et.al. Injury Prevention and Control in Children. Ann Emer Med. 2001:38(4);405-413.

    Centers for Disease Control National Vital Statistics System. Deaths, Percent of Total deaths, and death rates for the 15 leading causes of death in 5-year age groups, by race and
    sex: United States, 2003. Available from the Internet at http://www.cdc.gov/nchs/data/dvs/lcwk1_2003.pdf (rev. 2003, cited 12/13/2006).

    Degutis LC, Greve M. Injury Prevention. Emerg Med Clin N Am. 2006:24;871-888.

    Shudy M. Lihinie de Almeida M, Ly S, et.al. Impact of Pediatric Critical Illness and Injury on Families: A Systematic Literature Review. Pediatrics. 2006;118(Supp 3)S203-218.

    Oliver RI, Spain D. Burns, Resuscitation and Early Management. eMedicine.
    Available from the Internet at http://www.emedicine.com/plastic/topic159.htm (rev. 11/17/2006, cited 12/12/2006).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    January 16, 2007

  • How Do I Treat Her Vomiting When She has Diabetes and Can't Drink?

    Patient Presentation
    The mother of a 4-year-old female with Type I diabetes mellitus telephones because her daughter has woken up after her nap and has had two episodes of vomiting and one episode of diarrhea in the past 2 hours.
    She has been taking some sips of water. Her blood sugar is 246 with small ketones in her urine. She is afebrile with no upper respiratory tract symptoms or rashes. She has been previously well but there is gastroenteritis at the church daycare program where she went yesterday.
    This is her first significant illness since she was diagnosed with diabetes.
    The past medical history reveals that she was diagnosed 5 months ago with diabetes after her parents noticed that she had increased thirst, urination and then began vomiting.
    The family history showed coronary artery disease, and Type II diabetes mellitus in a maternal grandmother.
    The mother reports that physically she appears tired but has no mental status changes. She is willing to drink but has only taken about 2 ounces.
    The diagnosis of gastroenteritis with emesis in a child with Type I diabetes is made. The mother and the physician read over the illness treatment protocol together that the regional pediatric endocrinologist has supplied to both of them and asked them to follow.
    The protocol tells the mother to give an extra 10% of the total daily insulin dose immediately and to give this extra dose as short-acting insulin. The mother will not give anything to eat or drink for two hours and then re-check the blood sugar and ketones. She will then give small amounts of water or diet soda every 10 minutes for the next 2 hours.
    In 4 hours, if the blood sugar is still above 240 and ketones are still present, the mother will give another injection of short-acting insulin and will call the pediatric endocrinologist for more instructions. If the blood sugar and ketones appear to be improving the mother will call the local pediatrician to report on her daughter’s condition.
    The mother is instructed to call the local pediatrician back sooner if her daughter seems to worsen.

    Discussion
    Diabetes mellitus type 1 is a chronic metabolic disorder caused by the lack of insulin.
    Insulin is made in the Langerhans cells in the pancreas and congenital absence or destruction of the cells produced type 1 diabetes (or insulin-dependent diabetes mellitus) where patients are dependent on exogenous insulin.
    Overall there is an incidence of 15/100,000 annually for diabetes. An estimated 3/1000 children develop type 1 diabetes by age 20.

    Learning Point
    Diabetes treatment is always improving because of ongoing research efforts. Aggressive monitoring and treatment for intercurrent illness is imperative so as not to worsen the catabolic state.
    Treatment is directed at reversing the catabolic state and returning the patient to an anabolic state.

    Ketone Treatment without Emesis

     Urine Ketones	Blood Ketones 	Treatment
     		in mmol/L
     Negative	<0.6		Monitor blood sugar and ketones
     Trace		1.5		Drink extra sugar-free fluids
    				And if blood sugar is 240 mg/dl or higher also give
    				an extra 20% of the total daily insulin dose as extra
    				short-acting insulin (this is in addition to the regular
    				daily insulin dosing)
    

    Monitor blood sugar and ketones every 2 hours until ketones have cleared
    In 4 hours if the blood sugar is still 240 mg/dl or higher and ketones are still present give another dose of short-acting insulin and contact diabetes doctor for more instructions
    Extra insulin should not be given more than every 4 hours

    Ketone Treatment with Emesis

    • Check blood sugar hourly until no longer sick
    • Check for ketones
    • If ketones are not present, and
      • Blood sugar is > 150 mg/dl, wait two hours without eating then begin giving small sips of water or diet soda every 10-15 minutes.
        • if vomiting recurs and blood sugar is still >150, wait another 2 hours and then try again.
        • if vomiting resolves, gradually increase fluids
      • Blood sugar is 80-150 mg/dl, give small sips of sugar-sweetened fluids or hard candy
      • Blood sugar is <80 mg/dl and vomiting persists, call diabetes doctor
    • If ketones are present, and
      • Blood sugar is >150 mg/dl and ketones are small to moderate, give an extra 10% of the total daily insulin dose as extra short-acting insulin (this is in addition to the regular daily insulin dosing)
      • Blood sugar is >150 mg/dl and ketones are large, give an extra 20% of the total daily insulin dose as extra short-acting insulin (this is in addition to the regular daily insulin dosing)
      • Blood sugar is <150 and any ketones are present, give small sips of sugar-sweetened fluids until the blood sugar is >150 mg/dl then give the appropriate amount of extra short-acting insulin
      • Blood sugar cannot be brought >150 mg/dl, call the diabetes doctor.

    Extra insulin should not be given more than every 4 hours.

    Patients and family members should contact their physician if:

    • Vomiting persists for more than 6 hours or if vomiting occurs 3-4 times in a row without keeping down fluids
    • Blood sugar continues to be < 80 despite taking quick-acting carbohydrates
    • Vomiting with ketones
    • Ketones continue despite taking 2 doses of short-acting insulin
    • Ketones are in the urine and blood sugar is < 240 mg/dl
    • After glucagon is given
    • If they are unsure about what to do to manage the problem

    Questions for Further Discussion
    1. How should a child’s diabetes be managed who is undergoing surgery?
    2. What are the different options for glucose monitoring?
    3. What are the potential longer term complications of type 1 diabetes?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Diabetes, Type 1 and Diabetes
    and at Pediatric Common Questions, Quick Answers for this topic: Diabetes

    To view current news articles on this topic check Google News.

    Sheetz J, Huff S, Sheehan A, Osterhaus J, Tsalikian E, Donohoue P, Tansey M, Nordine L, Coffey J. “Diabetes Care for Children
    and Adolescents” University of Iowa. 2004: 43-48.

    Burdick J, Harris S, Chase HP. The Importance of Ketone Testing. Practical Diabetology. 2004 June;3-11.

    Lamb WH. Diabetes Mellitus, Type 1. eMedicine.
    Available from the Internet at http://www.emedicine.com/ped/topic581.htm (rev. 6/27/2006, cited 12/7/06).

    Laffel LMB, Wentzell K, Loughlin C. Tovar A, Moltz K, Brink S. Sick Day Management Using Blood 3-hydroxybutyrate (3-OHB) Compared with Urine Ketone Monitoring Reduces Hospital Visits in Young People with T1DM: A Randomized Clinical Trial.
    Diabetic Management. 2006;23:278-284.

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Michael Tansey, MD
    Associate Professor of Clinical Pediatrics, Children’s Hospital of Iowa

    Date
    January 8, 2007