Transcript Common neonatal problems

Common Neonatal
Problems
Safiya Khamis Al-butaini
OMCF-07-065
What is a neonate
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A neonate is also called a newborn. The neonatal period
-- the first 4 weeks of a child's life -- represents a
time when changes are very rapid, and many critical
events can occur.
During the first 30 days, most congenital defects are
discovered.
Genetic abnormalities may show up.
Infections, such as congenital herpes, Group B
Streptococcus, toxoplasmosis, and other medical conditions
become apparent in the neonatal period as they begin to
have effects on the baby.
Objectives
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Minor problems of neonates and small babies:
 Sticky eyes
 Failure to regain weight by 2 wks
 Possetting
 colic
Problems of prematurity:
 Nutrition
 Thermoregulation
 RSV
 Jaundice
 Cot death
Other neonatal problems:
 Pyloric stenosis
 breast feeding,bottle feeding, weanin feeding problems
 Birth trauma ( head, nerve)
Minor problems of neonates and
small babies
 Sticky
Common in the neonatal period
starting on the 3rd - 4th day of life
 Usually due to a blocked tear duct
 a clear, white to yellow discharge at
the inner corner of a neonate's
eyes
Swab to exclude ophthalmia
neonatorum
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eyes: (Common)
Management:
bathe with cooled boiled
water to clear, when
changing nappies
Avoid the use of antibiotics unless overtly
infected
 Spontaneous resolution is the norm
 If fail to clear by 1 year, then refer to
pediatric ophthalmologist
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Minor problems of neonates and
small babies
 Failure
to regain birth weight by 2wk. of
age
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Usually due to a feeding problem or minor
intercurrent illness
Management:
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Monitor weight carefully
Refer to paediatrics if no cause is apparent or if,
despite treatment of the underlying cause, the baby
is not gaining weight.
Minor problems of neonates and small
babies
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Possetting (Common):
 The baby effortlessly brings back 5-10mls of each
feed during the feed or soon after
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Management:
 Only of concern if the baby is otherwise unwell or
failing to thrive
If thriving, advise parents to feed the child propped
up and slow down the speed at which feeds are
given
Minor problems of neonates and small
babies
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Colic (Very common in newborns up to ~3mo)
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Repeated bouts of intense, unsoothable crying commonly
attributed to abdominal pain (though there is no objective
evidence)
During an attack, the baby's body becomes tense and rigid,
face goes red, and knees draw up
Usually occurs in early evening
Examination is normal
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Infantile colic is extremely common; it occurs in up to
25% of infants
Cause is unknown and symptoms resolve
spontaneously with time.
Advise parents to try colic drops or gripe water
There is no evidence that changing from cows' milk
to soya-based formula is helpful
Refer to paediatrics if diagnosis is in doubt, severe
symptoms, other symptoms or signs (e.g. failure to
thrive, severe eczema), or fails to resolve by 12wk. of
age
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Diagnosis of infantile colic is based on Wessel criteria: 3,3,3
and 3:
Unexplained fussiness or crying lasting longer than 3 hrs/day, 3
days/week, and continuing for longer than 3 weeks in an infant
younger than 3 months old.
The most important d/d is infection
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e.g; UTI, otitis media, pharyngitis, pneumonia.
UTI is the 1st infection that should be ruled out by performing
urinalysis
Reassurance of the parent is as effective as any other therapy
and is the only treatment of choice
Medications including dicyclomine, antihistamines, and aspirin
should not be used
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A 28 year old mother of two comes to your office with
her 8 wk old infant. Her baby has been “crying
constantly” for the last 4 wks, and she is at her “wit’s
end”. She is bottle feeding her baby and is having no
significant feeding problems a part from what may be
“excessive” gas and burping following feeding. No other
symptoms have been identified. The mother also states
that her first child had “some crying” spells but it was
“nothing like this”. The baby has had no other problems,
specifically no constipation or diarrhea.
On examination, the infant is afebrile and has no
abnormalities of ears, throat, and lungs. The abdomen is
soft, and there are no palpable masses.
What is the most likely diagnosis?
What investigations should be undertaken in the infant
described?
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CBC
CBC with WCC deferential and ESR
CBC with WCC deferential, ESR, and urinalysis
Urinalysis
No investigation need to be done
What is the best treatment in this condition?
Prematurity
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Babies born at <37wk. gestation are considered premature
5-7% of babies are premature in most developed countries
There is a high incidence of disability in extremely premature
babies.
Prematurity affects all systems of the body and in general, the
problems are worse the more premature the baby
32-36 wks gestation---premature. Generally do well but many
need tube feeding and warmths.
28-32 wk gestation--- very preterm. Outlook is variable
<28 wk gestation--- extremely preterm. Some babies as
premature as 23-24 wk gestation survive, but there is high
incidence of disability
Problems of prematurity
 Nutrition:
 Preterm babies suck and swallow poorly so
commonly need naso-gastric tube feeding.
 They are also at particular risk of hypoglycaemia, so
need frequent feeds.
 Breast milk (sometimes with calorie supplements)
or special low birth weight formula is used.Vitamin
and iron supplements are routine.
FEEDING AND NUTRITION:
• Babies who are able to suck and swallow should be breastfed on demand.
• If the suckling reflex has not yet developed the baby should
be
fed with expressed breast milk (EBM) by a nasogastric tube.
Breast suckling should still be attempted for ‘let down’ reflex
and
psychological advantages for short periods.
• Nasogastric feeds should be introduced slowly then gradually
increased according to the baby’s tolerance.
• If babies cannot tolerate oral feeds an intravenous line should
be inserted and IV fluids given.
Problems of prematurity
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Thermoregulation
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Poor in preterm infants, as they have a high surface
area:body weight ratio and little subcutaneous fat.
A controlled temperature and adequate insulation
with clothes and blankets, where appropriate, is
important.
Facts about hypothermia
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Newborn babies lose heat rapidly at birth due to a large
surface area as the baby is wet and the delivery rooms are
usually cold.
Hypothermia increases the metabolic activity and therefore
oxygen consumption and can cause hypoglycaemia.
There is a direct relation between hypothermia and
neonatal mortality and morbidity.
Prevention of hypothermia is therefore essential in the
management of the sick and the low birth weight and
preterm babies.
Prevention of Hypothermia:
• Keep labour room, post-natal and nursery WARM
• Exclude draught (close doors & windows).
• Dry the baby thoroughly at birth before commencing
resuscitation and remove wet towels.
• Cover the baby with pre-warmed blankets.
• Cover the head, 40% of the heat loss, in the newborn, is
from the head.
• Place infant under radiant warmer if necessary.
• Monitor the temperature regularly (axilla not rectal
temp.)
• Nurse the baby in an incubator if :
 the temperature is unstable.
 the birth weight is 1,500 kg or less
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Respiratory Syncytial Virus Infection
•RSV, which causes infection of the lungs and breathing passages, is a
major cause of respiratory illness in young children.
•In adults, it may only produce symptoms of a common cold, such as
runny nose, sore throat, mild headache, cough, fever, and a general
feeling of being ill. But in premature babies, RSV infections can lead to
other more serious illnesses.
•RSV is highly contagious:
•spread through droplets containing the virus when someone
coughs or sneezes
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. Almost all kids are infected with RSV at least once by the
time they're 2 years old.
RSV infections often occur in epidemics that last from late fall
through early spring. Respiratory illness caused by RSV — such
as bronchiolitis or pneumonia— usually lasts about a week, but
some cases may last several weeks.
Doctors typically diagnose RSV by taking a medical history and
doing a physical exam.
Generally, in healthy kids it's not necessary to distinguish RSV
from a common cold.
But if a child has other health conditions, a doctor might want
to make a specific diagnosis; in that case, RSV is identified in
nasal secretions collected either with a cotton swab or by
suction through a bulb syringe.
Preventing RSV
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Frequent hand washing is key in preventing its
transmission.
Take precautions to prevent exposure
keep school-age child with a cold away from younger
siblings — particularly infants — until the symptoms
pass.
Palivizumab is a monoclonal Ab indicated for the
prevention of RSV infection in infants at high risk
infection
 1st dose given before the start of RSV season and
then monthly throughout the RSV season
Problems of prematurity
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Jaundice
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The immature liver is less able to process bilirubin,
so premature babies are at greater risk of
developing neonatal jaundice.
They are also more likely to develop kernicterus, so
have a lower threshold to refer for phototherapy.
Around 80%of preterm infants develop
hyperbilirubinaemia characterised by jaundice.
High levels bilirubin may require phototherapy or
exchange transfusion in rare severe cases.
Problems of prematurity
SIDS or cot death:
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Premature babies have a high risk of cot death or SIDS
~ 1:1500 babies/yr are unexpectedly found dead in the 1st
year of life in the UK
Most common in winter months and at night
An identifiable cause for the death is unexplained in most
of the cases
Theories include cardiac arrhythmia and apnoeic attacks
Reducing the risk of cot death:
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Cut smoking in pregnancy
Do not let anyone smoke in the same room as the baby
Place the baby on his/her back to sleep
Do not let the baby get too hot
Keep baby's head uncovered place the baby with feet to the foot of the
cot, to prevent wriggling down under the covers
It's safest to sleep the baby in a cot in the parents' bedroom for the first
6mo.
It's dangerous to share a bed with the baby if either parent:
 is a smoker no matter where or when they smoke
 has been drinking alcohol
 takes medication or drugs that might make them drowsy
 feels very tired
It's very dangerous to sleep together with a baby on a sofa, armchair, or
settee
If the baby is unwell, seek medical advice promptly
Management:
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If you are the first person contacted
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Check an ambulance is on its way and go immediately to the scene. If
in doubt, start resuscitation. Continue until the baby gets to hospital.
If it is clear the baby is dead and can't be resuscitated, inform the
parents sympathetically. Contact the police/coroner. Arrange for the
baby to be taken to A&E, not to a mortuary. Contact the
paediatrician designated for cot deaths who may wish to see the
baby and parents as soon as they get to A&E.
Take a brief history and record the circumstances of death (e.g.
position when found, bedding, vomit) immediately. Your notes might
be helpful later. Spend time listening to the parents. Mention the baby
by name and don't be afraid to express your sorrow.
If the baby is a twin, the surviving twin is at risk of cot death and
should be admitted to hospital for observation.
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If you learn the baby has died:
 Provide information as requested to the rapid
response team, and attend the initial case discussion
if possible
 Consider taking part in the scene of death visit to
support parents
• Parents faced with a dying child have usually not expected any
problem and often they have had little or no time to prepare
for the death of the baby.
• The death of a child makes a major impact on their lives and
their expectations for the future.
• Parents may be angry with the medical and nursing staff and
blame them for what has happened. This is just a way of
expressing their grief and if the staff understand this it is easier
for everyone to deal with the situation.
• Have an area or a room that can be used by the parents of a
dying baby.
• If possible an experienced neonatal nurse to care for the baby
and the parents.
• The same nurses for continuing of care and support for the
baby and parents.
Common errors of all medical staff, doctors and nurses
when dealing with parents of dying child
• Separation of parents from the child.
• Cheering with irrelevances “Cheer up, you’ll soon get over it.”
• Advise another pregnancy.”Have another baby soon.”
• Giving sedatives to the parents.
• Little respect for the parents feelings by joking and behaving as if all
is normal in sight or hearing of the parents.
• Gossiping about the baby’s problems with other parents on the
ward or other staff.
• Ignoring the need for privacy of these parents.
• Ignoring the parents because of fear as to how to behave, when
they need sympathy and support.
• Ignoring the need for follow up care.
Pyloric Stenosis
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Infantile hypertrophic pyloric stenosis usually develops in
the first 3-6 wk of life (rare >12wk)
failure of the pyloric sphincter to relax results in
hypertrophy of the adjacent pyloric muscle.
Typically affects first-born male infants.
More common in whites than in blacks, or Asians
Runs in families and is associated with turner’s syndrome,
PKU and oesophageal atresia
Pyloric Stenosis
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Presentation:
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Projectile vomiting– milk, no bile
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The child is still hungry after vomiting and immediately feeds again
Rarely there is haematemesis
Failure to thrive
Dehydration and constipation – ‘rabbit pellet stools’
A pyloric mass (feels like an olive) is palpable in the right upper
abdomen( 95%), especially if the child has just vomited
After a test feed, there is visible peristalsis of the dilated
stomach in the epigastrium
Pyloric Stenosis
D/D
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Posseting/ reflux
Overfeeding
Gastroenteritis
Milk allergy
Uraemia
Infection—especially UTI
Increased intracranial pressure
Adrenal insufficiency
Other causes of intestinal obstruction
Management
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Admit or refer urgently to paediatric surgery
Rehydration and investigation to confirm diagnosis
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Ultrasound of the abdomen
blood tests to find out whether the baby has a healthy level of
electrolytes
barium X-ray
Surgery with a Ramstedt pyloroplasty
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the pylorus is cut and resutured, to relax the muscle and widen
the opening into the intestine
There is usually no long-term consequences
Breast Feeding
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Initiating breast feeding within the first 30 min after birth
can increase the chance of successful breast feeding
Breastfeeding is the preferred way to feed infants from
birth until fully weaned, or longer.
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Advantages
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Prevents Gl and respiratory infections
Prevent obesity
Encourages a strong bond between mother and baby
Cheaper and more convenient than bottle feeding. The milk is ready
warmed and does not need sterilized bottles
Protective effect against breast cancer in the mother
Disadvantages
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Only the mother can feed the baby
Babies who have had oral vitamin K at birth require additional
vitamin K supplements
Certain diseases can be transferred in breast milk e.g. hepatitis B,
HIV
Drugs or foods taken by the mother can have adverse effects on the
baby
It is difficult to know how much milk a breastfed baby is taking at
each feed
If a baby is solely breastfed (rare) when >6mo. old, vitamin
supplements are needed
Bottle feeding
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Cow's milk formula feeds
 Prepared from cow's milk altered to simulate the
composition of human milk, with added iron and vitamins.
 Advise parents to choose a formula suitable for their baby
and make up the formula exactly as the manufacturer
suggests.
 Feeding bottles and teats should be well washed and, until
>6mo. of age, sterilized.
Unmodified cow's milk
 Not recommended until the baby is >1y. old as unmodified
cow's milk is less digestible.
Follow-on formula
 Not essential unless a child is not taking solids and is >6mo.
old. Baby milks suitable from birth can be used until a switch
is made to normal cow's milk.
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Soya protein based formula
 Available, for children with cow's milk allergy,
though this group are frequently also intolerant of
soya milk. Soya formula is useful for babies who
have transient intolerance after gastroenteritis,
but be careful—it contains large amounts of
glucose syrup and can damage the teeth of babies
fed on it long term. Soya formula is available on
NHS prescription.
Special artificial formula
 Available for children intolerant to soya and cow's
milk formulae. Prescribe on consultant
recommendation.
Weaning
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Advise parents to introduce solids at any time
from 4-6mo. of age. The baby is ready when he is
always hungry, even soon after a feed.
If making pures, advise parents not to add salt or
excess sugar.
Sterilize feeding bowls and cutlery before use until
the baby is >6mo. old.
Start with 1 flavour of finely pureed food e.g. baby rice.
Babies often only take 2-3 teaspoonfuls per meal when they start
taking solids.
It is usual for the baby's stool to change consistency when weaned.
Add different foods 1 by 1. Avoid eggs and gluten until >6mo. of age.
Introduce lumpy foods gradually after 6mo. and finger foods the baby
can feed itself (e.g. pieces of toast, rusks, biscuits) at 7-9mo.
Continue giving the baby at least 600ml of milk/d.
Feeding problems
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Parents commonly complain their child is not eating
enough or eating the wrong foods. Usually the child
continues to grow and develop normally. If so, reassure
the parents.
Advise them to:
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Restrict snacks between meals.
Show little emotion when putting food in front of the child at
meal times and remove the food after 15-20min. without
comment about what is or isn't eaten.
If the child is not growing or developing normally, seek an
organic cause refer to paediatrics.
An anxious mother with a 3 wk old infant came to your
clinic with many questions concerning feeding.
The infant is appears to be growing well and according to
his mother is happy and content.
The mother in low has suggested to her to change to from
breastfeeding to cow’s milk because she feels the infant’s
crying is waking her son (the baby’s father) and preventing
him from getting “the rest the poor boy needs”. The
mother appears somewhat tired herself. The child is at
50th percentile for weight and 50th percentile for length.
More importantly, the child has gained an average of 50
g/day since discharge from the hospital. The child is
feeding every 2 hrs at this time.
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What is the minimal appropriate weight gain following
discharge from hospital?
What would be your suggestion to the mother in term
of feeding her infant?
What is the antibody of particular importance and is
found in abundance in human colostrum?
Birth trauma
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Birth injuries happen as a result of:
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mechanical forces (forceps and vacuum),
compression (pressure from labor),
traction (the baby gets stuck requiring pulling) during delivery
In general, large babies (over 4500g) are more likely to
sustain birth injuries
Most injuries and trauma are temporary and reversible
while others are permanent and there is no treatment to
correct them
about three times in every hundred births, there are
serious birth injuries
Risk Factors for Birth Injuries
it’s the mother’s first birth
 the baby’s head is too large to fit through the mother’s pelvis
 labor that lasts longer than 24 hours
 pregnancy that goes longer than 42 weeks
 a quick (rapid) labor
 the baby stops moving down into the pelvis
 too little amniotic fluid
 abnormal presentation of the baby — feet first, shoulder first
 forceps or vacuum delivery
 baby needing to be turned or extracted
 very low birth weight or the baby is very premature
 a very large birth weight baby
 large fetal head
 the fetus has a developmental disorder
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Head trauma
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Caput succedaneum: Swelling, bruising, and oedema of
the presenting portion usually scalp.
Resolves spontaneously.
Cephalhaematoma:
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Uncommon.
Haemorrhage beneath the
periosteum. Unilateral and
usually parietal.
Presents as a lump (the size
of an egg) on the baby's
head.
Treatment is not required,
Anaemia or
hyperbilirubinemia may
follow.
Depressed skull fractures:
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Rare.
Most result from forceps
pressure; rarely caused by the
head resting on a bony
prominence in utero.
May be associated with
subdural bleeding,
subarachnoid hemorrhage, or
laceration of the brain itself.
Seen and felt as a depression
in the skull.
X-ray confirms diagnosis.
Neurosurgical elevation may
be needed.
Intracranial haemorrhage:
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Rare.
Suggested by lack of responsiveness, fits, respiratory
distress ±shock.
Admit as an emergency.
Nerve injuries
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Cranial nerve trauma: The facial nerve is injured, most
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often causing facial asymmetry, especially during crying.
Usually resolves spontaneously by 2-3mo. of age.
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Brachial plexus injury: Follows stretching
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caused by shoulder dystocia, breech extraction, or
hyperabduction of the neck in cephalic presentations.
Often associated with other traumatic injuries e.g.
fractured clavicle or humerus, subluxations of the
shoulder, or cervical spine.
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Partial injuries of the brachial plexus: Site
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and type of nerve root injury determine the prognosis.
If a significant deficit persists >3mo., refer to paediatric
neurology for further investigation.
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Injuries of the upper brachial plexus (C5,6)
affect muscles around the shoulder and elbow Erb's palsy.
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Injuries of the lower plexus (C7, 8 and T1) affect
primarily muscles of the forearm and hand Klumpke's palsy.
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Injuries of the entire brachial plexus: No
movement of the arm+ sensory loss. Refer immediately for
neurological opinion. Prognosis for recovery is poor.
•In erb's palsy there is adduction and
internal rotation of the shoulder with
resulting pronation of the forearm
(waiter’s tip position).
•May be accompanied by phrenic nerve
palsy causing elevated diaphragm
•Baby with Klumpke's palsy is likely
to be able to move his/her elbow and
wrist but usually has difficulty moving
the fingers. A clawing of the hand may
occur due to the muscular weakness
resulting from involvement of the
nerves.