This Signal concerns risks to newborn babies from failing to recognise that problems in maintaining body temperature may be a sign of sepsis in ‘at risk’ infants.
The NPSA was made aware of an incident involving a baby born at 37 weeks gestation following expectant management of pre-labour rupture of the membranes (35 hours). His mother became unwell with a fever and the infant had some problems in maintaining his temperature. He collapsed at 24 hours of age and died a few days later from complications of septicaemia. A review identified that the infant’s inability to maintain his temperature had not been recognised as a potential sign of infection.
Hypothermia is a common sign of sepsis with fever being less common. Signs of early-onset sepsis in newborn babies are often vague and therefore a greater level of vigilance is required to ensure the monitoring of infants who are identified as having a higher risk of developing neonatal sepsis. These include infants born to mothers with the following risk factors:
- Group B Streptococcus in this pregnancy;
- fever during labour;
- early post partum pyrexia;
- intravenous antibiotics;
- prolonged rupture of membranes; and,
- preterm labour.
A search of the National Reporting and Learning System (NRLS) identified 22 further relevant incidents that occurred over a three year period. All of these infants had a low temperature and there was evidence of, or concerns about, sepsis.
Themes identified included environmental issues leading to the infant getting cold, a failure to review an infant, a delay in checking an infant’s temperature or prescribing antibiotics and a failure to document prolonged ruptured membranes. Although the review suggested that these infants did not appear to suffer any lasting harm, there is potential for a more serious outcome.
Healthcare professionals caring for newborn babies need to be aware that a low temperature in an at-risk infant may be a sign of sepsis and an indication to take appropriate action.
Please contact us with information about your initiatives to reduce risk in this area.
Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS.