Neonatal sepsis, a serious bloodstream infection in the first 28 days of life, is one of the leading causes of newborn death globally, especially in low- and middle-income countries. Newborns have immature immune systems and can deteriorate very quickly. The signs are often subtle and non-specific, which is why nurses and midwives, who spend the most time with newborns and mothers, are crucial in early detection.
Early-onset vs late-onset
- Early-onset (usually within the first 72 hours): often acquired from the mother before or during birth. Group B Streptococcus (GBS) and E. coli are common causes in many settings.
- Late-onset (after 72 hours): often acquired from the environment, including hospital-acquired infection, or from the community. Causes include Klebsiella, Staphylococcus aureus and others; antimicrobial resistance is a growing problem.
Risk factors
- Prolonged rupture of membranes (commonly more than 18 hours).
- Maternal fever in labour or chorioamnionitis (infection of the membranes).
- Maternal GBS colonisation, or a previous baby with GBS infection.
- Prematurity and low birth weight.
- Unclean delivery or cord care practices.
- Invasive procedures in neonatal units (lines, ventilation).
Danger signs in young infants
WHO and IMCI guidance identify signs in young infants that indicate possible serious bacterial infection and require urgent referral and treatment, including:
- Not feeding well (a very important early sign).
- Convulsions.
- Movement only when stimulated, or no movement at all (lethargy).
- Fast breathing (60 breaths per minute or more).
- Severe chest indrawing.
- Temperature of 37.5°C or above, or below 35.5°C.
Other signs include grunting, apnoea, jaundice in the first 24 hours, mottled or pale skin, vomiting, abdominal distension, a bulging fontanelle, prolonged capillary refill, and low or high blood glucose. Many babies with sepsis have a low rather than high temperature.
Listen to mothers
“My baby isn’t feeding like before” or “she’s too quiet” are important observations. Take parental concern seriously and assess properly.
Nursing and midwifery actions
- Escalate urgently to the neonatal or paediatric team, or refer to hospital if in the community.
- Keep the baby warm: skin-to-skin, cover the head, avoid hypothermia. See kangaroo mother care.
- Check blood glucose and treat hypoglycaemia.
- Support breathing: oxygen if hypoxic; be ready to resuscitate. See neonatal resuscitation.
- Obtain cultures (blood culture before antibiotics if it doesn’t delay treatment).
- Give antibiotics promptly: WHO recommends ampicillin (or benzylpenicillin) plus gentamicin as first-line for possible serious bacterial infection in many settings. Hospitals use local protocols and resistance patterns. Many guidelines aim for antibiotics within 1 hour of the decision to treat.
- Continue breastfeeding or expressed breast milk where possible; consider IV fluids or tube feeding if the baby is too unwell.
- Monitor closely: observations, feeding, urine output, jaundice.
In settings where hospital referral isn’t possible, WHO has guidance on simplified antibiotic regimens for young infants with some signs of possible serious bacterial infection when families cannot accept referral.
Prevention
- Clean birth practices: clean hands, clean surface, clean cord cutting and tying.
- Hand hygiene by everyone touching the baby. See WHO 5 Moments.
- Cord care: keep the cord clean and dry. In settings with high neonatal mortality, WHO recommends applying chlorhexidine to the cord stump; elsewhere, dry cord care is recommended. Discourage applying substances such as ash, dung or toothpaste.
- Early and exclusive breastfeeding: colostrum provides protection. See our breastfeeding guide.
- Intrapartum antibiotics for women with GBS risk factors, as per national policy.
- Maternal vaccination and antenatal care.
- Infection prevention in neonatal units: line care, avoiding overcrowding, antimicrobial stewardship.
Teach parents before discharge
Make sure every family leaves knowing the danger signs and where to go urgently. A baby who stops feeding, becomes floppy, has a fever or low temperature, or breathes fast needs care the same day, immediately.
Related: Neonatal jaundice · IMCI danger signs · Sepsis in adults
Based on WHO recommendations for management of serious bacterial infections in infants, WHO IMCI, WHO postnatal care recommendations and NICE NG195 (Neonatal infection). Educational content: follow local protocols.