Case 20 A febrile neonate
Kai, a 3-week-old infant, presents to the emergency department at 9.30 am on a Sunday morning with a 1 day history of feeling hot, poor feeding, and occasional jerky movements. He has a temperature of 38.3°C, is quite lethargic and is observed to have some jerky movements of his left arm which last for a few seconds only. The nurse bleeps the paediatric ST1 doctor who has only done 5 weeks of paediatrics.
What would you do now?
The ST1 states that she is busy on the ward round and asks the nurse to get the ED’s FY2 doctor to see the patient first. The patient is seen by the FY2 who is concerned about the possibility of serious sepsis and he contacts the paediatric ST1 asking her to review the baby. The ST1 states that she has nearly finished the ward round and will come soon. Kai is seen by the paediatric ST1 at 12.30 pm. She observes that he has a brief 5-second apnoea. Kai has no rash, has a flat anterior fontanelle and no neck stiffness.
What is your differential diagnosis?
The ST1’s diagnosis is a septic neonate who requires a septic screen. Her differential diagnosis lists septicaemia, meningitis, pneumonia and a urinary tract infection.
Kai is transferred to the paediatric ward for a septic screen but the ST1 doctor is unable to get any blood and calls the registrar. The registrar who has so far been unaware of this baby and who is covering general paediatrics and neonates arrives at 3 pm. A urine dipstick has been done and is negative for nitrites with only a trace of leucocytes. A CXR is normal. He is concerned about the possibility of meningitis and that the jerky arm movements and the apnoeas have in fact been fits. He obtains a FBC, CRP, U and E’s, bone chemistry, LFTs, a blood culture and a glucose. The glucose is 1.9 mmol/L (normal 2.8–4.5 mmol/L) and he administers a 2 ml/kg, 10% dextrose bolus injection following which the glucose level normalizes. He performs a LP which reveals cloudy CSF and calls his consultant who recommends intravenous penicillin and gentamicin. The antibiotics are administered at 5 pm.
The LP shows a WBC of 1867/mm3 (normal ≤ 20/mm3) of which 90% are polymorphs, a protein of 3.2 g/L (normal < 0.7 g/L) and a glucose of 0.9 mmol/L (normal >60% simultaneous blood glucose). On microscopy Gram positive cocci are seen consistent with a diagnosis of Group B streptococcal meningitis.
At 6 pm Kai has a seizure with cyanosis, loss of consciousness and rhythmic arm movements lasting 7 minutes.
What treatment would you give?
An intravenous loading dose of phenobarbitone is administered and maintenance phenobarbitone is prescribed. Over the next few days the fits continue. An EEG is markedly abnormal and a MRI scan shows areas of infection, infarction and cerebral oedema.
Kai subsequently develops cerebral palsy with a hemiplegia, learning difficulties, deafness and epilepsy.
Kai’s parents complain and subsequently sue. They state that there was an unacceptable delay in the administration of antibiotics and that prompt treatment would have prevented or significantly diminished the neurological sequelae.
Do you think the parents will succeed in their claim?
Expert opinion
A fever ≥ 38°C in a neonate is a medical emergency. The ST1 doctor should have appreciated the urgency of the problem and prioritized her work appropriately. Sepsis in neonates can present in nonspecific ways such as fever, poor feeding and lethargy. Fits in neonates can present in subtle ways and the abnormal jerky arm movements and apnoeas should certainly have prompted the ST1 doctor to consider that the infant may be fitting. A bulging anterior fontanelle is a late sign in neonatal meningitis. Neck stiffness is an extremely poor sign in neonates as they in any case have poor head control and are often floppy when ill. Furthermore, the ST1 doctor should have discussed this case with her registrar following the phone call from the ED nurse. If the registrar was unable to come immediately after being contacted about this case due to other urgent work he should have phoned his consultant to obtain the necessary help. The delay of 7.5 hours between the child presenting to the ED and receiving antibiotics is unacceptably long. It is highly likely that Kai would have had neurological sequelae even with prompt treatment but the delay in the administration of antibiotics is likely to have been partially responsible for the subsequent morbidity.
Legal comment
The care provided to Kai was substandard and treatment should have been commenced earlier. A full valuation of the case could run to two or three million pounds, if it could be shown that all Kai’s injuries were caused by the delay. But the Expert Opinion indicates that this child would probably have suffered some neurological sequelae, even if he had been treated earlier. Kai’s family will have to show to what extent he has been affected by the negligence. If there would have been no practical difference in the outcome, then the claim will fail.
If, however, earlier treatment would have made a material difference, then compensation will be calculated to take account of the poorer outcome. The final figure could be anywhere between low tens of thousands to more than a million pounds, depending on the nature of the reports obtained by the hospital and the family.
