Neonatal sepsis and Group B strep

How does this happen?

A newborn's immune system is not yet practiced. Bacteria that an adult would clear without noticing can spread through a baby's bloodstream.

Early-onset sepsis appears in the first days and usually comes from bacteria in the birth canal that the baby encounters during labor and delivery. Group B strep and E. coli are the most common. ¹

Late-onset sepsis appears after the first days and often comes from the environment, including lines and equipment in babies who are in hospital.

Once bacteria are in the bloodstream, the body's response causes the damage. Blood vessels leak, blood pressure falls, and organs receive less blood. In a newborn this can happen quickly.

Sepsis can also injure the brain directly, through meningitis, and indirectly, through low blood pressure and low oxygen. That is why infection is one of the causes of cerebral palsy listed on this site. ³

Prevention rests on screening for GBS in late pregnancy and giving antibiotics through a vein during labor. The timing of the first dose matters, which is why it is recorded. ¹

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• Group B strep carriage, which is common and harmless in the adult carrying it. Being a carrier is not a health problem and is not caused by anything. ¹
• A negative screen that misses colonization, which happens, since the screen is a snapshot.
• A very fast labor with no time for antibiotics to work. ¹
• Preterm birth, which raises risk and often comes without warning. ⁴
• Prolonged rupture of membranes, which can occur despite good care.
• Other organisms, including E. coli, which are not covered by GBS screening.
• Late-onset infection in a baby who needed intensive care and central lines.

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• GBS screening not done in late pregnancy, where guidance sets out the recommended timing and method. ¹
• A positive result not acted on in labor, or antibiotics not given.
• Antibiotics given too late, or the wrong antibiotic used in someone with a penicillin allergy without appropriate testing. ¹
• Risk factors not acted on, including fever in labor, prolonged rupture of membranes, or preterm labor, each of which changes the recommendation regardless of screening. ¹
• chorioamnionitis not recognized or treated. ³
• A newborn with signs of infection not evaluated or not started on antibiotics, where the standard is to treat while investigating rather than to wait. ¹
• Vital signs not monitored in a baby with risk factors.
• A lumbar puncture not done where meningitis was possible, so treatment was too short. ⁵

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record. What is unusual about sepsis is how precise the record is: screening results, the time each antibiotic dose was given, and each set of vital signs.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• Poor tone, poor color, or a baby needing more help than expected at birth. ⁶
• Fast breathing, grunting, or apnea.
• Temperature that is low or high. Low temperature is common in newborn infection and is often the first sign.
• Low blood sugar. ⁷

The first week

• Poor feeding, or a baby who has stopped feeding as well as they were.
• Sleepiness or difficulty waking.
• Irritability.
• Temperature instability.
• Mottled or grey skin colour.
• Apnea.
• jaundice appearing early or worsening. ⁸
• Seizures, which suggest meningitis. ⁹

Around 3 months

• Late-onset infection presents the same way: poor feeding, sleepiness, temperature change, irritability.
• Any fever in a baby under 3 months needs urgent assessment.

Around 6 months

• Developmental follow-up where there was significant illness. ¹⁰
• Hearing assessment after meningitis. ¹¹

Around 12 months

• Most children who recover have no lasting effects.
• Where meningitis occurred, hearing and developmental issues may be present. ¹²

Toddler years

• Effects follow any brain injury or hearing loss rather than the sepsis itself.

School age

• Learning differences where there was brain injury.
• Hearing needs where meningitis caused hearing loss.

How is it diagnosed?

Blood cultures, taken before antibiotics start where possible, and the definitive test.

Blood count and inflammatory markers, which support the picture but do not rule infection in or out on their own.

lumbar puncture, to check the spinal fluid for meningitis. This matters because meningitis needs longer treatment and a different follow-up, and it can be present in a baby whose blood culture is negative. ⁵

Chest X-ray where breathing is affected, since pneumonia can be part of it.

Urine culture in late-onset infection.

Glucose and electrolytes. ⁷

The rule that matters most

Antibiotics are started before results are back. In a newborn who looks unwell or who has significant risk factors, treating first and stopping later if cultures are negative is the standard approach. Waiting for a culture in a sick newborn is not. ¹

Ask what risk factors were present, whether antibiotics were given in labor and at what time, and what the plan is for reviewing the baby.

What is the treatment?

Antibiotics, started promptly and given through a vein. The initial choice covers the likely organisms and is narrowed once cultures return. ¹

Duration depends on what is found. A negative culture in a well baby usually means a short course. Confirmed sepsis means a longer course. meningitis means longer still, and the exact duration depends on the organism. ⁵

Supportive care. Fluids, blood pressure support, breathing support, and correction of glucose and electrolytes. Some babies need intensive care.

Treating complications, including persistent pulmonary hypertension of the newborn, which is a recognized complication of newborn infection. ¹³

Cooling where there is also moderate or severe hypoxic-ischemic encephalopathy and criteria are met, though infection influences that decision and it is a specialist judgment. ¹⁴

Follow-up. Hearing assessment after meningitis, and developmental follow-up after significant illness. ^{11 10}

What is the long-term outlook?

Most newborns treated promptly for sepsis recover completely and have no lasting effects. Speed of treatment is the main thing that determines this. ¹

Where sepsis is severe or treatment is delayed, complications include meningitis, brain injury from low blood pressure and low oxygen, hearing loss, and death.

Where meningitis occurred, hearing assessment is essential and developmental follow-up matters. See neonatal meningitis. ¹¹

Where sepsis contributed to brain injury, the picture follows that injury. ³

What does daily life look like?

For a baby treated and recovered, ordinary life with a completed antibiotic course and a follow-up appointment.

For families whose baby was critically unwell, the fear afterward is often significant and lasting. Post-traumatic stress after a frightening newborn illness is common and it is treatable. ¹⁵ See the parent's own health guide.

For any future pregnancy, tell your team about this history early. It changes the plan for screening and for antibiotics in labor. ¹

What does care cost over a lifetime?

No agency publishes a lifetime cost estimate for neonatal sepsis.

For a baby who recovers, the cost is the hospital stay.

Where meningitis caused hearing loss or brain injury, the published anchors are CDC's estimates of about $417,000 for hearing loss and about $921,000 for cerebral palsy, both in 2003 dollars, which are separate population estimates that overlap and cannot be added together. ¹⁶

See the cost of care estimator.

What can you do this week?

1. Ask what the GBS screening result was and when it was taken.
2. Ask whether antibiotics were given in labor, which one, and at what time the first dose went in.
3. Ask what risk factors were present: fever in labor, prolonged rupture of membranes, preterm labor.
4. Ask whether a lumbar puncture was done and what it showed.
5. Ask what organism grew, if any, and how long the antibiotic course is.
6. Ask for a hearing assessment if meningitis was present or suspected.
7. Request the labor records with the records request builder.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the neonatologist

• What organism is suspected or confirmed?
• Was a lumbar puncture done, and what did it show?
• How long is the antibiotic course, and what decides that?
• Was there a period of low blood pressure or low oxygen?
• What follow-up do we need, including hearing?

For the obstetric team

• What was my GBS screening result, and when was it done?
• Were antibiotics given in labor, which one, and at what time?
• Did I have a fever in labor, and how long were my membranes ruptured?
• Was chorioamnionitis diagnosed?

You can also build a printable list with the question generator.