Risk factors and clinical indicators: late-onset neonatal infection

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When assessing or reviewing a baby:

check for possible clinical indicators of late-onset neonatal infection as shown in table 2 on clinical indicators of possible late-onset neonatal infection
take into account that prematurity, mechanical ventilation, history of surgery and presence of a central catheter are associated with greater risk of late-onset neonatal infection
think about infection in the other babies when 1 baby from a multiple birth has infection. [2021]

Seek early advice from a paediatrician when late-onset infection is suspected in non-inpatient settings. [2021]

Refer to NICE's guidelines on fever in under 5s and suspected sepsis in under 16s when assessing babies for late-onset neonatal infection who have been admitted to the hospital from home. [2021]

Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

**Table 2: Clinical indicators of possible late-onset neonatal infection (observations and events in the baby)**
Category	Indicators
Behaviour	Parent or care-giver concern for change in behaviour Appears ill to a healthcare professional Does not wake, or if roused does not stay awake Weak high-pitched or continuous cry
Respiratory	Raised respiratory rate: 60 breaths per minute or more Grunting Apnoea Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
Circulation and hydration	Persistent tachycardia: heart rate 160 beats per minute or more Persistent bradycardia: heart rate less than 100 beats per minute
Skin	Mottled or ashen appearance Cyanosis of skin, lips or tongue Non-blanching rash of skin
Other	Temperature 38°C or more unexplained by environmental factors Temperature less than 36°C unexplained by environmental factors Alterations in feeding pattern Abdominal distension Seizures Bulging fontanelle

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessing or reviewing babies for late-onset neonatal infection.