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Management of asymptomatic term neonates born to mothers with group B streptococcus
EDITORS’
NOTE
In 1992 the American Academy of Pediatrics (AAP) provided guidelines for prevention of early-onset group B streptococcal (GBS) disease through intrapartum chemoprophylaxis of selected maternal GBS carriers (AAP, 1992). The guidelines selected only women with documented GBS colonization who had an obstetric risk factor. These screeningbased guidelines were poorly implemented for many reasons, including availability of culture results, timing of cultures, and cost. The American College of Obstetricians and Gynecologists (ACOG) subsequently developed an alternative, more pragmatic risk-based strategy in which all women with risk factors would be given intrapartum chemoprophylaxis without culture-based screening (ACOG, 1993). In 1996 the Centers for Disease Control and Prevention (CDC) published a screening-based strategy (CDC, 1996), and in 1997 the AAP published revised guidelines, allowing for a choice of either risk-based or screening-based strategies (AAP, 1997). Each strategy has its advantages and disadvantages, yet none has been adequately tested clinically. Likewise, the management of asymptomatic neonates born to mothers with GBS varies across the United States. The protocol
January/February
1999
presented in this article is utilized at the University of Texas Medical School at Houston and is not intended to be an exclusive approach of management. The editors recommend that our readers select one management protocol developed locally and use it consistently. BACKGROUND Definition Group B B-hemolytic streptococcus Chqvtococcus agalactiae) is a gram-positive aerobic coccobacillus. The gastrointestinal tract is the most common reservoir for CBS, and spread to the genitourinary tract is usually secondary.
Incidence/Etiology GBS is the leading cause of sepsis in infants from birth to 3 months and results in significant perinatal morbidity and mortality. GBS disease occurs in 1 to 2 cases per 1000 live births and has a casefatality rate of 6% to 20% (CDC, 1996). In colonized women, CBS occurs in 1 case per 100 to 200 live births. Of the 4 million deliveries occurring each year in the United States, as many as 8000 cases of the disease occur, with approximately 300 cases resulting in neonatal deaths (Glantz & Kedley, 1998). Transmission from mother to infant occurs in utero shortly before or during delivery. GBS disease of newborns has an early
This guideline was adapted for use in the Department of Pediatrics at the University of Texas-Houston Health Science Center; its use should in no way be construed as an endorsement by NAPNAP. Adaptation may be required (a) to fit the needs of one’s practice setting or(b) to meet state legislative requirements. Deborah Parks is Associate Professor of Pediatrics and Director, Texas Medical School at Houston. Jose Garcia is Associate Professor of Pediatrics and Director Hospital, Houston, Texas.
Division
of Nurse Practitioners,
of Pediatrics, Lyndon
University
Baines Johnson General
Virginia Moyer is Associate General Hospital, Houston,
Professor of Pediatrics and Director, Texas.
Well Baby Nursery,
Lyndon Baines Johnson
Robert Yetman is Associate Hospital, Houston, Texas.
Professor of Pediatrics and Director,
Well Baby Nursery,
Hermann
Reprint requests: Deborah Parks, MSN, RN, CPNP, Department of Pediatrics, Medical School, 6431 Fannin, MSB 3.140, Houston, TX 77030. J Pediatr Health Care. (1999). Copyright
+ 0
University
Children’s
of Texas-Houston
13,37-39.
0 1999 by the National Association
0891~5245/99/$8.00
of
of Pediatric Nurse Associates
& Practitioners.
25/8/94176
37
PRACTICE
GUIDELINES
Parks et al.
Mother IS GBS positrve Infant IS asymptomatrc and z 37 weeks gestatron
*
dose
of ampicrllin/penicillrn
yes
1
Infant
pz;;Ess,z::charge
yes
CBC
Management
of asymptomatic
onset (occurring less than 7 days after delivery and usually within 24 hours) in 80% of cases (ACOG, 1996). Although pneumonia and sepsis are the most common manifestations of disease, meningitis complicates up to 15% of cases. If meningitis occurs, 15% to 30% of affected infants have permanent neurologic damage.
RISK FACTORS Infants c37 weeks gestation . Rupture of membranes >18 hours l Maternal fever during labor >100.4” F l
Volume
13 Number
CBC abnormal’
normal*
+ 1
Do not discharge
2
Consider CBC and other evaluation as indicated
*Discharge checklist . Vltal s!gns stable for at least 12 hours Heart rate 90-160 . Respiratory rate 60 Axlllary temp 36 1°C-37% in open crib . Baby IS feeding well (strong suck, approximately cunce perfeed~ng) Baby has urinated and stooled . No jaundice IS present
3 8
CBC wrth drfferentraliplatelets
no
+
FIGURE
&,
/
1
*Abnormal CBC 1 WBC ~5000 or >35000 2 IUT rat10 >o 25 one
term neonate born to mother with GBS.
l
l
Previous delivery of a sibling with invasive GBS disease Maternal chorioamnionitis to include prolonged rupture of membranes and maternal fever WITH at least TWO of the following: - Maternal tachycardia (heart rate >9O/minute) - Fetal tachycardia (heart rate >170/ minute) - Maternal leukocytosis (white blood cell count >15,000) - Uterine tenderness - Foul-smelling amniotic fluid
MANAGEMENT Obtain a perinatal history to determine if an asymptomatic infant is at risk for infection: 1. Mother’s GBS status during this pregnancy is negative: Give routine newborn care. ZMother’s GBS status during this pregnancy is unknown: If infant is 237 weeks and the mother has no risk factors, give routine newborn care. If any maternal risk factors are present, treat the infant as if it were born
JOURNAL
OF PEDIATRIC
HEALTH
CARE
Parkset al.
to a GBS-positive mother and follow the algorithm. 3. Mother’s GBS status during this pregnancy is positive or mother has GBS bacteriuria: Follow algorithm.
Discharge checklist
. Baby l
has
urinated
No jaundice
and
defecated
is present
FOLLOW-UP Follow-up case basis
is determined on a case-byat the time of discharge.
REFERENCES
Vital signs stable for at least 12 hours Heart rate 90-160/minute Respiratory rate ~60 Axillary temperature 36.1” C to 37” C in open crib Baby is feeding well (strong suck, approximately 1 oz per feeding)
prevention of early-onset group B streptococcal (GBS) infection. Pediatrics, 99,489-496. American College of Obstetrics and Gynecologists. (1993). Group B streptococcal infections inpregnancy ACOG’s* recommendations. ACOG New&&r,
Opinion,
American Academy of Pediatrics, Commltke on Infectious Diseases and Committee on Fetus and Newborn. (1992). Guidelines for prevention of group B streptococcal infection by chemoprophylaxis. Pediatrics, 90,775-778. American Academy of l’edlatncs, Committee on Infectious Diseases and Committee on Fetus and Newborn. (1997). Revised guidelines for
37,l.
American College of Obstetrics and Gynecologists (1996). Prevention of early-onset group B streptococcal disease in newborns. ACOG Committee 273,1-7.
Centers for Disease Control and Prevenbon. (1996). Prevention of perinatal group B sheptococcal disease: A public health perspective. MMWR,
45, I-24.
Glantz, J C., & Kedley, K. E. (1998). Concepts and controversies in the management of group B streptococcus during pregnancy. Birth, 25,4553.
me NatIona, celt,fica*m” w NCBPNP/N ANNOUNCEMENTS
1. Certification Maintenance for CPNPs-Prices UP and DOWN The National Certification Board of Pediatric Nurse Practitioners and Nurses (NCBPNP/N) has announced price adjustment plans for activities related to participation in the Certification Maintenance Program for CPNl’s. Beginning in January 1999, the following price changes will be implemented: Board 0‘
PNP
l
l
l
Enrollment registration fee (paid once every 6 years for enrollment in the PNP Certification Maintenance Program)-$60 This price mcrease is the first price change since 1990 and will help support increased costs for certificate production, database management, and activities in support of CPNP certification issues with state boards of nursing and other national certification organizations. Self-assessment Exercise-$75 The price for the Self-assessment Exercise (SAE) has not changed for more than 9 years. This price increase was necessary to cover increased production and mailing costs and represents an overall price increase of less than 3% increase per year. Enrollment/Recording of CEU credit nance--PRICE DECREASE! Now only
2. More
CEUs As a result NAPNAP number of additional
JOURNAL
OF
for certification $55!
mainte-
for the SAE of a cooperative analysis of SAE participant data, and the NCBPNP/N have agreed to increase the CEUs awarded for participation in the SAE. Look for details about this new development in the future!
PEDIATRIC HEALTH CARE
3. Attention PNP Graduates-Prepare for the PNP Examination The NCBPNP/N offers its PNP SAE 1993-1998 for use in preparation for the national qualifying examination for PNPs. These exercises have recently been reviewed by CPNPs, pediatricians, and pharmacologists and reflect the core content that students will experience on the national PNP examination. Please call l888-641~CPNP (2767) to place your order for these valuable study aids.
4. Attention CPNPs-Time to Enroll in the Certification Maintenance Program The 6-year Certification Maintenance Program (CMP) for CPNPs is a unique and valuable mechanism to assist you in your continued growth as a CPNl? Your 1999 CMP enrollment forms for certification maintenance will be mailed by the end of November 1998. Choose the educational option (SAE OR documentation of earned CEUs) that meets your certification maintenance needs and return your CMP form to NCBPNP/N by January 31,1999. Please call us at l-888-641~CPNP (2767) if you need additional information. We always look forward to hearing from you. 5. Item Writers Needed for the SAE and the PNP National Qualifying Examination Help us improve and strengthen our testing processes! We are anxious to recruit expert clinicians and educators to participate in writing test items. The NCBPNP/N offers a manual for item writers and awards CEUs for all item-writing efforts. Please contact us at l-888~641~CPNP (2767) if you are interested in this creative effort.
January/February 1999
39
NOTE
In 1992 the American Academy of Pediatrics (AAP) provided guidelines for prevention of early-onset group B streptococcal (GBS) disease through intrapartum chemoprophylaxis of selected maternal GBS carriers (AAP, 1992). The guidelines selected only women with documented GBS colonization who had an obstetric risk factor. These screeningbased guidelines were poorly implemented for many reasons, including availability of culture results, timing of cultures, and cost. The American College of Obstetricians and Gynecologists (ACOG) subsequently developed an alternative, more pragmatic risk-based strategy in which all women with risk factors would be given intrapartum chemoprophylaxis without culture-based screening (ACOG, 1993). In 1996 the Centers for Disease Control and Prevention (CDC) published a screening-based strategy (CDC, 1996), and in 1997 the AAP published revised guidelines, allowing for a choice of either risk-based or screening-based strategies (AAP, 1997). Each strategy has its advantages and disadvantages, yet none has been adequately tested clinically. Likewise, the management of asymptomatic neonates born to mothers with GBS varies across the United States. The protocol
January/February
1999
presented in this article is utilized at the University of Texas Medical School at Houston and is not intended to be an exclusive approach of management. The editors recommend that our readers select one management protocol developed locally and use it consistently. BACKGROUND Definition Group B B-hemolytic streptococcus Chqvtococcus agalactiae) is a gram-positive aerobic coccobacillus. The gastrointestinal tract is the most common reservoir for CBS, and spread to the genitourinary tract is usually secondary.
Incidence/Etiology GBS is the leading cause of sepsis in infants from birth to 3 months and results in significant perinatal morbidity and mortality. GBS disease occurs in 1 to 2 cases per 1000 live births and has a casefatality rate of 6% to 20% (CDC, 1996). In colonized women, CBS occurs in 1 case per 100 to 200 live births. Of the 4 million deliveries occurring each year in the United States, as many as 8000 cases of the disease occur, with approximately 300 cases resulting in neonatal deaths (Glantz & Kedley, 1998). Transmission from mother to infant occurs in utero shortly before or during delivery. GBS disease of newborns has an early
This guideline was adapted for use in the Department of Pediatrics at the University of Texas-Houston Health Science Center; its use should in no way be construed as an endorsement by NAPNAP. Adaptation may be required (a) to fit the needs of one’s practice setting or(b) to meet state legislative requirements. Deborah Parks is Associate Professor of Pediatrics and Director, Texas Medical School at Houston. Jose Garcia is Associate Professor of Pediatrics and Director Hospital, Houston, Texas.
Division
of Nurse Practitioners,
of Pediatrics, Lyndon
University
Baines Johnson General
Virginia Moyer is Associate General Hospital, Houston,
Professor of Pediatrics and Director, Texas.
Well Baby Nursery,
Lyndon Baines Johnson
Robert Yetman is Associate Hospital, Houston, Texas.
Professor of Pediatrics and Director,
Well Baby Nursery,
Hermann
Reprint requests: Deborah Parks, MSN, RN, CPNP, Department of Pediatrics, Medical School, 6431 Fannin, MSB 3.140, Houston, TX 77030. J Pediatr Health Care. (1999). Copyright
+ 0
University
Children’s
of Texas-Houston
13,37-39.
0 1999 by the National Association
0891~5245/99/$8.00
of
of Pediatric Nurse Associates
& Practitioners.
25/8/94176
37
PRACTICE
GUIDELINES
Parks et al.
Mother IS GBS positrve Infant IS asymptomatrc and z 37 weeks gestatron
*
dose
of ampicrllin/penicillrn
yes
1
Infant
pz;;Ess,z::charge
yes
CBC
Management
of asymptomatic
onset (occurring less than 7 days after delivery and usually within 24 hours) in 80% of cases (ACOG, 1996). Although pneumonia and sepsis are the most common manifestations of disease, meningitis complicates up to 15% of cases. If meningitis occurs, 15% to 30% of affected infants have permanent neurologic damage.
RISK FACTORS Infants c37 weeks gestation . Rupture of membranes >18 hours l Maternal fever during labor >100.4” F l
Volume
13 Number
CBC abnormal’
normal*
+ 1
Do not discharge
2
Consider CBC and other evaluation as indicated
*Discharge checklist . Vltal s!gns stable for at least 12 hours Heart rate 90-160 . Respiratory rate 60 Axlllary temp 36 1°C-37% in open crib . Baby IS feeding well (strong suck, approximately cunce perfeed~ng) Baby has urinated and stooled . No jaundice IS present
3 8
CBC wrth drfferentraliplatelets
no
+
FIGURE
&,
/
1
*Abnormal CBC 1 WBC ~5000 or >35000 2 IUT rat10 >o 25 one
term neonate born to mother with GBS.
l
l
Previous delivery of a sibling with invasive GBS disease Maternal chorioamnionitis to include prolonged rupture of membranes and maternal fever WITH at least TWO of the following: - Maternal tachycardia (heart rate >9O/minute) - Fetal tachycardia (heart rate >170/ minute) - Maternal leukocytosis (white blood cell count >15,000) - Uterine tenderness - Foul-smelling amniotic fluid
MANAGEMENT Obtain a perinatal history to determine if an asymptomatic infant is at risk for infection: 1. Mother’s GBS status during this pregnancy is negative: Give routine newborn care. ZMother’s GBS status during this pregnancy is unknown: If infant is 237 weeks and the mother has no risk factors, give routine newborn care. If any maternal risk factors are present, treat the infant as if it were born
JOURNAL
OF PEDIATRIC
HEALTH
CARE
Parkset al.
to a GBS-positive mother and follow the algorithm. 3. Mother’s GBS status during this pregnancy is positive or mother has GBS bacteriuria: Follow algorithm.
Discharge checklist
. Baby l
has
urinated
No jaundice
and
defecated
is present
FOLLOW-UP Follow-up case basis
is determined on a case-byat the time of discharge.
REFERENCES
Vital signs stable for at least 12 hours Heart rate 90-160/minute Respiratory rate ~60 Axillary temperature 36.1” C to 37” C in open crib Baby is feeding well (strong suck, approximately 1 oz per feeding)
prevention of early-onset group B streptococcal (GBS) infection. Pediatrics, 99,489-496. American College of Obstetrics and Gynecologists. (1993). Group B streptococcal infections inpregnancy ACOG’s* recommendations. ACOG New&&r,
Opinion,
American Academy of Pediatrics, Commltke on Infectious Diseases and Committee on Fetus and Newborn. (1992). Guidelines for prevention of group B streptococcal infection by chemoprophylaxis. Pediatrics, 90,775-778. American Academy of l’edlatncs, Committee on Infectious Diseases and Committee on Fetus and Newborn. (1997). Revised guidelines for
37,l.
American College of Obstetrics and Gynecologists (1996). Prevention of early-onset group B streptococcal disease in newborns. ACOG Committee 273,1-7.
Centers for Disease Control and Prevenbon. (1996). Prevention of perinatal group B sheptococcal disease: A public health perspective. MMWR,
45, I-24.
Glantz, J C., & Kedley, K. E. (1998). Concepts and controversies in the management of group B streptococcus during pregnancy. Birth, 25,4553.
me NatIona, celt,fica*m” w NCBPNP/N ANNOUNCEMENTS
1. Certification Maintenance for CPNPs-Prices UP and DOWN The National Certification Board of Pediatric Nurse Practitioners and Nurses (NCBPNP/N) has announced price adjustment plans for activities related to participation in the Certification Maintenance Program for CPNl’s. Beginning in January 1999, the following price changes will be implemented: Board 0‘
PNP
l
l
l
Enrollment registration fee (paid once every 6 years for enrollment in the PNP Certification Maintenance Program)-$60 This price mcrease is the first price change since 1990 and will help support increased costs for certificate production, database management, and activities in support of CPNP certification issues with state boards of nursing and other national certification organizations. Self-assessment Exercise-$75 The price for the Self-assessment Exercise (SAE) has not changed for more than 9 years. This price increase was necessary to cover increased production and mailing costs and represents an overall price increase of less than 3% increase per year. Enrollment/Recording of CEU credit nance--PRICE DECREASE! Now only
2. More
CEUs As a result NAPNAP number of additional
JOURNAL
OF
for certification $55!
mainte-
for the SAE of a cooperative analysis of SAE participant data, and the NCBPNP/N have agreed to increase the CEUs awarded for participation in the SAE. Look for details about this new development in the future!
PEDIATRIC HEALTH CARE
3. Attention PNP Graduates-Prepare for the PNP Examination The NCBPNP/N offers its PNP SAE 1993-1998 for use in preparation for the national qualifying examination for PNPs. These exercises have recently been reviewed by CPNPs, pediatricians, and pharmacologists and reflect the core content that students will experience on the national PNP examination. Please call l888-641~CPNP (2767) to place your order for these valuable study aids.
4. Attention CPNPs-Time to Enroll in the Certification Maintenance Program The 6-year Certification Maintenance Program (CMP) for CPNPs is a unique and valuable mechanism to assist you in your continued growth as a CPNl? Your 1999 CMP enrollment forms for certification maintenance will be mailed by the end of November 1998. Choose the educational option (SAE OR documentation of earned CEUs) that meets your certification maintenance needs and return your CMP form to NCBPNP/N by January 31,1999. Please call us at l-888-641~CPNP (2767) if you need additional information. We always look forward to hearing from you. 5. Item Writers Needed for the SAE and the PNP National Qualifying Examination Help us improve and strengthen our testing processes! We are anxious to recruit expert clinicians and educators to participate in writing test items. The NCBPNP/N offers a manual for item writers and awards CEUs for all item-writing efforts. Please contact us at l-888~641~CPNP (2767) if you are interested in this creative effort.
January/February 1999
39