Neonatal pneumonia is a pulmonary infection presenting with a clinical Etiology/Pathophysiology:

picture of respiratory distress, associated with chest radiological
findings suggesting pneumonia and persisting for at least 48 hours.
Infections may be transmitted via the placenta, by aspiration, or
acquired postnatally. Neonatal pneumonia can be subdivided into 4
categories (with some overlap between them):
1. Congenital pneumonia (transplacentally acquired), e.g. rubella,
cytomegalovirus, toxoplasma, listeria, herpes simplex, Treponema
pallidum.
2. Intrauterine pneumonia (aspiration of infected amniotic fluid)
3. Early-onset pneumonia (due to an ascending infection “vertically”)
4. Late-onset pneumonia (due to organisms acquired nascomially
(”horizontally”) or in the community.
Early-onset pneumonia presents at birth or soon afterwards.
Associated maternal risk factors are:
• spontaneous onset of preterm labour
• prolonged rupture of membranes (>18
• maternal fever (> 37.5°C)
• chorioamnionitis
• offensive liquor
Microbes involved are group B betahaemolytic streptococcus (GBS),
pneumococcus and coliforms.
Late-onset pneumonia occurs at least 48 hours after delivery and
later. Presents more insidiously and may develop abdominal
distension and feeding intolerance. Microbes involved are streptococci,
staphylococci, E.coli, Klebsiella. Viral and chlamydial infections are
also associated with pneumonia. Chlamydial pneumonia usually
presents between 4 and 11 weeks of age (and earlier) with
tachypnoea, apnoea, nasal congestion, paroxysmal and staccato
cough and crepitations.
++++Neonatal pneumonia is lung infection in a neonate. Onset may be
within hours of birth and part of a generalized sepsis syndrome, or
after 7 days and confined to the lungs. Signs may be limited to
respiratory distress or progress to shock and death. Diagnosis is by
clinical and laboratory evaluation for sepsis. Treatment is initial broad-
spectrum antibiotics changed to organism-specific drugs as soon as
possible.
Early-onset pneumonia is part of generalized sepsis that presents at or
within hours of birth. Late-onset pneumonia usually occurs after 7 days
of age, most commonly in neonatal ICUs in infants who require
prolonged endotracheal intubation because of lung disease.
Etiology
Organisms are acquired from the maternal genital tract or the nursery.
These include gram-positive cocci (eg, groups A and B streptococci,
Staphylococcus aureus) and gram-negative bacilli (eg, Escherichia coli
, Klebsiella sp, and Proteus sp). In infants who have received broad-
spectrum antibiotics, many other pathogens may be found, including
Pseudomonas, Citrobacter, Bacillus, and Serratia.
There are three ways for the baby to acquire a neonatal pneumonia.
First is infection acquired prior to birth by an ascending route or
transplacental route. Classically this is Group B Streptococcus in the
mother's vagina which passes to the infant during birth, particularly in
cases with prolonged rupture of membranes and prolonged labor.
Other normal inhabitants of the birth canal - staph, strep, diphtheroids,
anaerobes, E. coli and Listeria - are other pathogens that may cause
neonatal pneumonia. Second is infection acquired by aspiration during
delivery, with the pathogens remaining the same. Third is via infection
acquired after birth.
Pathology:
There is a less uniform distribution of hyaline membranes in collapsed
alveoli than is seen in hyaline membrane disease. There are cocci in
the alveolar membrane and in the interstitial inflammatory exudate.
Imaging Findings:
Ascending infection may resemble hyaline membrane disease very
closely, especially in smaller infants. Most commonly seen are
extensive granular confluent infiltrates whose distribution is often less
uniform than that of hyaline membrane disease. There is less
atelectasis than in hyaline membrane disease. May have pleural fluid
and a normal lung volume, further distinguishing factors from hyaline
membrane disease. Infection acquired perinatally often has a confluent
miliary or nodular pattern that looks like meconium aspiration or
transient tachypnea of the newborn while postnatally acquired infection
often has a patchy more asymmetric pattern that looks like infection in
older children.
DDX:
• Hyaline Membrane Disease - usually has a uniform distribution of
pulmonary opacities, never has pleural effusions, has a decreased
lung volume.
• Meconium Aspiration - usually has nodular non homogeneous
densities, may have pleural effusions, usually has an increased lung
volume.
• Transient Tachypnea of the Newborn - usually has non homogeneous
densities, may have pleural fluid.
Etiology/Pathophysiology:
Common pathogens include Staphylococcus, Pneumococcus
(Streptococcus pneumonia), and Haemophilus influenza. Bacterial
pneumonia usually has primarily alveolar involvement without airway
involvement. Pneumatoceles may form during the recuperative phase
and are transient accumulations of interstitial air that have escaped
through necrotic bronchial foci and are usually of little significance,
resolving over time.
PATHOPHYSIOLOGY

Symptoms, Signs, and Diagnosis

Late-onset hospital-acquired pneumonia may begin gradually, with
more secretions being suctioned from the endotracheal tube and
higher ventilator settings. Other infants may be acutely ill, with
temperature instability and neutropenia. New infiltrates may be visible
on chest x-ray but may be difficult to recognize if the infant has severe
bronchopulmonary dysplasia.
Evaluation includes cultures of blood and tracheal aspirate, chest x-
ray, and pulse oximetry.

CHLAMYDIAL PNEUMONIA
Contamination with chlamydial organisms during delivery may result in
development of chlamydial pneumonia at 2 to 12 wk. Infants are
tachypneic but usually not critically ill and may also have conjunctivitis
caused by the same organism. Eosinophilia may be present, and x-
rays show bilateral interstitial infiltrates. Treatment with erythromycin
leads to rapid resolution.
Clinical Presentation:
Associated with premature rupture of the membranes (PROM) during
labor. The disease may have an early onset with septicemia and
fulminant progression to severe respiratory distress, shock and
respiratory failure within 24 hours; or a late onset 1 to 12 weeks after
birth with this more insidious onset frequently associated with
meningitis. Neonatal pneumonia can closely mimic hyaline membrane
disease clinically, and is the most frequent cause of septicemia in
neonate.
BACKGROUND: The cause and mechanism of most cases of sudden
unexpected death in infancy (SUDI) remain unknown, despite
specialist autopsy examination. We reviewed autopsy results to
determine whether infection was a cause of SUDI. METHODS: We did
a systematic retrospective case review of autopsies, done at one
specialist centre between 1996 and 2005, of 546 infants (aged 7-365
days) who died suddenly and unexpectedly. Cases of SUDI were
categorised as unexplained, explained with histological evidence of
bacterial infection, or explained by non-infective causes. Microbial
isolates gathered at autopsy were classified as non-pathogens, group
1 pathogens (organisms usually associated with an identifiable focus of
infection), or group 2 pathogens (organisms known to cause
septicaemia without an obvious focus of infection). FINDINGS: Of 546
SUDI cases, 39 autopsies were excluded because of viral or
pneumocystis infection or secondary bacterial infection after initial
collapse and resuscitation. Bacteriological sampling was done in 470
(93%) of the remaining 507 autopsies. 2079 bacteriological samples
were taken, of which 571 (27%) were sterile. Positive cultures yielded
2871 separate isolates, 484 (32%) of which showed pure growth and
1024 (68%) mixed growth. Significantly more isolates from infants
whose deaths were explained by bacterial infection (78/322, 24%) and
from those whose death was unexplained (440/2306, 19%) contained
group 2 pathogens than did those from infants whose death was
explained by a non-infective cause (27/243, 11%; difference 13.1%,
95% CI 6.9-19.2, p<0.0001 vs bacterial infection; and 8.0%, 3.2-11.8,
p=0.001 vs unexplained). Significantly more cultures from infants
whose deaths were unexplained contained Staphylococcus aureus
(262/1628, 16%) or Escherichia coli (93/1628; 6%) than did those from
infants whose deaths were of non-infective cause (S aureus: 19/211,
9%; difference 7.1%, 95% CI 2.2-10.8, p=0.005; E coli: 3/211, 1%,
difference 4.3%, 1.5-5.9, p=0.003).
INTERPRETATION: Although many post-mortem bacteriological
cultures in SUDI yield organisms, most seem to be unrelated to the
cause of death. The high rate of detection of group 2 pathogens,
particularly S aureus and E coli, in otherwise unexplained cases of
SUDI suggests that these bacteria could be associated with this
condition.
The Back to Sleep initiative reflects policy statements issued by the
American Academy of Pediatrics (AAP), commencing in 1992, that are
derived from a review of scientific evidence. These policy statements
are periodically revised to reflect advancements in knowledge and are
published in Pediatrics, the official journal of the AAP.2 The current
AAP SIDS policy recommendations, issued in 2005, including
references for the underlying research, can be accessed on-line at
www.aap.org/healthtopics/Sleep.cfm .
Education to reduce modifiable risk factors such as nonsupine sleep is
the most effective intervention currently available. Moreover, even as
genetic predispositions for SIDS are identified, it appears that a gene-
environment interaction must occur for the infant's vulnerability to be
realized. For example, in a study of a cardiac sodium channel variant
that may raise susceptibility to acidosis-induced arrhythmias in infants,
the authors noted, “It is imperative to continue to support effective
public health efforts to decrease known environmental risk factors
(e.g., prone sleeping position). SIDS is argued … to result, like many
common disorders, from a genetic predisposition that yields poor
tolerance of common challenges to physiological homeostasis.”5(p434)
NURSING IMPACT ON PARENTAL KNOWLEDGE AND
COMPLIANCE
Overall, infants are more likely to be placed to sleep in the supine
position if this recommendation had been provided by a healthcare
professional.15 For mothers of very-low-birth-weight infants, nursery
practices were the most important factor in choice of position.16 The
recommendations of both the physician and nurse mattered.17
However, compliance was greatest when parents not only heard
advice before discharge but also observed it in practice in the
nursery.18 Unfortunately, discrepancies exist between nursing
knowledge and practice, with those in practice longer found to be less
likely to believe in the association between SIDS and sleep position.19
However, teaching programs can be effective in providing an
understanding of the basis for the Back to Sleep policies. Such
programs can help nurses recognize the impact of their discussions
and role modeling on parental practices.20
The NICU poses a particularly challenging environment in which to
teach parents about SIDS risk reduction. For much of their stay, infants
may have been kept in the prone position. Prolonged exposure of
parents to this model has been hypothesized to be one reason why
very-low-birth-weight infants are more likely than larger low-birth-
weight infants to be placed prone after discharge.21 There is strong
evidence that whatever the benefits are of prone sleep in the NICU, the
risk of prone sleep after discharge is great. So too is the risk for SIDS
from sleeping laterally. Fleming and Blair note, “The evidence is clear
that for the overwhelming majority of preterm infants approaching
discharge from hospital there are no significant disadvantages, and
many potential advantages to the supine sleeping position.”22(p162) This
population is of particular concern because of the higher risk for SIDS
deaths in premature infants 23 and the increasing number of births in
this category.24
Lockridge et al 25 published one of the first articles on the need to
develop NICU policies and procedures that met the simultaneous
needs of developmentally appropriate care and SIDS risk reduction. In
the appendix, we provide resources from which nurses may obtain
model policies for NICUs and newborn nurseries as well as
educational materials for parents. These materials suggest methods
for integrating the newest SIDS risk reduction guidelines of the AAP
with hospital policies and procedures, nursing protocols, and parent
education. As with all policies, they are best achieved when nurses
contribute to the development of their unit's policies and help design
appropriate in-service programs to advance their knowledge of and
confidence in these policies.
Aris et al developed a survey for assessing the status of nursing
opinions and practices with respect to discharge teaching related to
sleep position and SIDS.26 They found that only 52% of neonatal
nurses routinely provide instructions that are consistent with the
promotion of supine sleep at home. The survey published in their
article covers a wide range of issues related to sleep and thus can
serve as a basis for identifying existing beliefs and practices upon
which in-service education programs and policy reviews can be built.
ADDRESSING NURSING CONCERNS ABOUT COMPONENTS OF
THE RISK REDUCTION GUIDELINES
To serve as role models and educators who promote SIDS risk
reduction guidelines, nurses need to feel knowledgeable about the
information they are presenting to families before discharge, reassured
that any potential adverse consequences have been identified and
addressed, and confident that the guidance is evidence-based and that
the benefits outweigh any possible risks.27 Yet, historically, the
research and review articles and policy statements on SIDS are
disproportionately found in medical rather than nursing journals.
Without access to this information, nurses' concerns about the
guidelines will remain a challenge to the provision of a consistent and
evidence-based message to parents.28,29 Nurses are therefore
encouraged to participate in continuing education, to collaborate in
multidisciplinary committees that share and update relevant
information, and to develop evidence-based policies.25,30
One of the more commonly voiced concerns by nurses has been
whether the supine position increases the risk of death from aspiration.
This issue has been studied, and although there has been a welcome
rise in the use of a supine sleep position for infants, there is no
evidence of an increased risk of death from aspiration.31,32
Another concern relates to an increased incidence of positional
plagiocephaly without stenosis. Without a population-based study of
the incidence of any flattening at the back of the head, it is unclear if
and by what degree plagiocephaly without stenosis is increasing or if a
possible rise may reflect an increase in awareness as well as in true
incidence.2 However, even with the possibility of an increase in true
diagnosis, the sections on Plastic Surgery and Neurological Surgery of
the American Academy of Pediatrics Committee on Practice and
Ambulatory Medicine continue to support the benefits of supine
sleep.33 The AAP policies also offer several suggestions for reducing
the risk for developing positional flattening, including the use of tummy
time for infants when they are awake and under supervision, the
avoidance of too much time in such devices as car-seat carriers and
bouncers, the use of upright “cuddle time,” and shifts in the direction
the infant faces while asleep. An additional benefit of tummy time is the
promotion of motor development, especially upper body muscle
development.
Finally, general health in the infant appears to benefit from the supine
sleep position. There were no increases in symptoms or illnesses in
the first 6 months.34 There were fewer cases of fever at 1 month,
fewer stuffy noses at 6 months, and fewer outpatient visits for ear
infections at both 3 and 6 months.
HEALTH BEHAVIOR CHANGE THEORY AS A TOOL FOR NURSES
An important element in changing health behavior is developing a
died of known causes, many infants who died of SIDS have toxigenic
relationship of trust with the parent and family. Nurses have a unique
opportunity to achieve an effective patient-provider relationship with bacteria, such as Escherichia coli, Staphylococcus aureus, and
new parents and caregivers and thus educate and influence the family. Clostridium difficile, as well as influenza and respiratory syncytial virus
By communicating conversationally with families, nurses can elicit and
address any fears and concerns that may serve as barriers to (RSV). Most strongly implicated is RSV, which is well known for its
compliance. Behavior change is more likely to occur if providers use association with central apnea.
nonjudgmental responses to beliefs associated with culture-based
infant care practices. Once cultural and personal beliefs are shared,
correct information regarding SIDS risk reduction practices can be • Start prenatal care early. Schedule frequent well-baby
discussed in this context and potential concerns elicited and
addressed. checkups, and ensure that immunizations are current.
• Avoid cigarettes, alcohol, and other drugs while pregnant.
By asking specific questions during hospitalization and at discharge, • Avoid exposing the baby to cigarette smoke.
the nurse will be able to tailor and thus personalize SIDS risk reduction
education. Who will provide care to the baby? What bedding will be
• If possible, breastfeed the baby.
used? Does anyone in the home smoke? Where and in what position • Burp the baby during and after feedings, especially before
will the infant sleep? Baseline awareness of SIDS risk factors can thus
be determined, and the nurse and family can work collaboratively to putting the baby to sleep.
improve safety. Thus, if a grandparent will serve as caregiver, it will be • Place the baby on a firm, flat mattress in a safety-approved
important to work with the family to discuss risk reduction with this
crib; avoid pillows, blankets, sheepskins, foam pads, or
essential family role model.43
waterbeds.
Nurses can also guide families by pointing out the reasons for any • Do not restrain the baby during sleep.
temporary discrepancies between hospital-based practices related to • Use of a fan in the infant's room was associated with a 72%
care and what will be recommended for SIDS risk reduction as the
hospitalization ensues and discharge occurs. In the context of the reduction in the risk of SIDS.32 It is thought that inadequate
trusting relationship, nurses can thus eliminate confusion about what ventilation may result in pooling of carbon dioxide around the
parents are being advised to do at home.
dead air space around an infant's mouth and nose,
Black infants are more likely than infants from other racial groups to be increasing the likelihood of rebreathing. The fan functions to
placed in the prone position after discharge.42,43 The greater use of dispense this accumulated carbon dioxide.
prone sleep is but one of many factors which may contribute to the
racial disparity in SIDS.5,36,44–46 Given the value families place on • The supine sleeping position
nursing guidance, nurses have a unique opportunity to use their role to
promote awareness of the modifiable risk factors for SIDS by all racial
and ethnic groups.

Nurses in newborn nurseries and neonatal intensive care units are

instrumental in educating parents about reducing the risk for SIDS.
Nurse participation is acknowledged and encouraged in the current
policy statement on SIDS Risk Reduction put forth by the American
Academy of Pediatrics. Despite the decline in SIDS, it remains the
leading cause of postneonatal infant mortality, and despite greater
public compliance with the risk reduction guidelines there is room for
improvement in how effectively and consistently they are disseminated.
To facilitate nursing participation as educators, role models, and
collaborators in the development of relevant hospital policies and
procedures, we review the current recommendations, addressing
issues that may serve as barriers to participation, describing the
biological plausibility underlying risk-reducing practices, and presenting
resources from which nurses may obtain teaching materials and model
policies.

The sudden death of an infant younger than 1 year of age that remains
unexplained after a thorough case investigation, including performance
of a complete autopsy, examination of the death scene, and a review
of the clinical history.

The sudden demise of an infant, thankfully, is not a common

occurrence. While the unexpected death of an infant may result from a
number of processes, the leading postneonatal cause is a syndrome
with an etiology that has not been fully elucidated.

The peak incidence of SIDS coincides with critical periods in the

development of the immune system; at such a time, the infant might be
transiently vulnerable to lethal infection. SIDS incidence increases in
the winter, during viral epidemics in a community, and 2 weeks after
viral infection. Compared with healthy control infants and infants who