9.4 Subgaleal Hemorrhage, Neonatal Sepsis & Meningitis, and Perinatal Substance Exposure (NOWS)

Subgaleal Hemorrhage, Neonatal Sepsis & Meningitis, and Perinatal Substance Exposure

Subgaleal Hemorrhage: The Scalp Bleed That Causes Shock

The subgaleal space lies between the galea aponeurotica and the periosteum of the skull. It extends from the orbital ridges to the nape of the neck and ears and is not limited by sutures. Traction during vacuum-assisted delivery (the most common association), forceps, or difficult births can tear emissary veins and bleed into this large potential space.

Scalp swellings compared

Recognition and management

• Serial head circumference measurements and marking the swelling's edges show progression. A commonly cited estimate is that each 1 cm increase in head circumference represents roughly 40 mL of blood in a term infant.
• Watch for pallor, tachycardia, falling hematocrit, poor perfusion, and hypotension. Shock can develop hours after birth.
• Coagulopathy is common, both as a cause (for example, vitamin K deficiency) and as a consequence (consumption).
• Transport care: Establish reliable vascular access (UVC), give volume and packed red blood cells for hemorrhagic shock, correct coagulopathy with fresh frozen plasma, platelets, and cryoprecipitate as indicated, confirm vitamin K was given, and monitor for hyperbilirubinemia. Avoid pressure wraps, which can push blood elsewhere without stopping the bleeding.

Neonatal Sepsis and Meningitis

Timing and organisms

• Early-onset sepsis (EOS): Within the first days of life (commonly defined as the first 72 hours). Usually acquired from the mother. Group B streptococcus and E. coli predominate, with Listeria as a less common but important cause.
• Late-onset sepsis (LOS): After 72 hours, often in NICU patients with central lines. Coagulase-negative staphylococci, S. aureus, gram-negative rods, and Candida in ELBW infants.

Presentation

Neonatal sepsis and meningitis are nonspecific:

• Temperature instability (hypothermia is common in preterm infants)
• Apnea and bradycardia, respiratory distress
• Poor feeding, vomiting, abdominal distension
• Lethargy, irritability, poor tone, seizures
• Hypoglycemia or hyperglycemia, metabolic acidosis
• Poor perfusion progressing to shock (cold shock is common)

A bulging fontanelle and neck stiffness are late or absent in neonatal meningitis. Up to a quarter of septic neonates may have meningitis, and blood cultures can be negative in neonatal meningitis. That is why a lumbar puncture is planned when the infant is stable enough, but it is never allowed to delay antibiotics (Section 13.1).

Treatment

• Draw cultures, then give antibiotics without delay (Section 6.5):
  • EOS: ampicillin + gentamicin
  • Suspected meningitis: meningitic-dose ampicillin plus an extended-spectrum cephalosporin (ceftazidime or cefepime in the U.S.)
• Neonatal HSV: Consider when there are vesicles, seizures (especially focal), elevated liver enzymes, CSF pleocytosis with negative Gram stain, or maternal genital lesions. Neonatal HSV presents as skin-eye-mouth, CNS, or disseminated disease, typically in the first 1–4 weeks. Start acyclovir 20 mg/kg IV every 8 hours without waiting for results.
• Treat shock (Sections 8.3 and 12.1), hypoglycemia (Section 9.3), and seizures (Section 9.2).
• Infants with GBS or other bacterial meningitis are at risk of hearing loss, hydrocephalus, and cerebral abscess. The receiving team will need the exact culture times.

Perinatal Substance Exposure and Neonatal Opioid Withdrawal Syndrome (NOWS)

"Perinatal substance disorder" in the NCC outline covers exposure to opioids, other drugs, and alcohol in utero.

Neonatal opioid withdrawal syndrome

Timing depends on the drug:

• Short-acting opioids (heroin, many prescription opioids): signs usually appear within about 24–72 hours
• Methadone and buprenorphine: signs may appear from about 72 hours to 5 days or later

Signs: High-pitched cry, irritability, tremors, hypertonia, poor feeding and uncoordinated suck, vomiting, loose stools, sneezing, yawning, nasal stuffiness, sweating, poor sleep, tachypnea, and fever. Seizures are uncommon but possible.

Assessment and treatment:

• The traditional Finnegan scoring system has been widely replaced or supplemented by the Eat, Sleep, Console (ESC) approach. ESC asks whether the infant can feed, sleep, and be consoled. It emphasizes rooming-in, skin-to-skin contact, swaddling, a low-stimulation environment, and parental involvement.
• In a multicenter randomized trial published in 2023, ESC shortened the time until infants were medically ready for discharge compared with Finnegan-based care.
• Medication (usually morphine or methadone) is used when non-pharmacologic care is not enough.

The naloxone rule

Do not give naloxone to a newborn whose mother is known or suspected to be opioid dependent. It can precipitate acute withdrawal, including seizures. NRP does not recommend naloxone during neonatal resuscitation. Support ventilation instead.

Other exposures

• Cocaine and methamphetamine: Placental abruption, preterm birth, growth restriction, and vasoconstriction-related complications, rather than a classic withdrawal syndrome
• SSRIs: Neonatal adaptation syndrome (jitteriness, tachypnea, feeding problems) and a small increased risk of persistent pulmonary hypertension
• Benzodiazepines, barbiturates, and alcohol: Withdrawal that may be delayed. Heavy prenatal alcohol exposure causes fetal alcohol spectrum disorder.
• Maternal magnesium sulfate: Neonatal hypotonia, respiratory depression, and potentiation of aminoglycoside and neuromuscular blocking effects (Section 6.5)

Why transports involve these infants: NOWS alone is rarely a transport emergency, but exposed infants may need transfer for prematurity, respiratory depression, seizures, or co-existing conditions. Transport teams must also communicate sensitively and without judgment with the family (Section 2.4).