Chapter 3Problems of the neonate Low birth weight babies

Case study: Jonah

Baby Jonah born at 30-31 weeks gestation.

He is floppy, pale with slow respiration, periods of apnoea and heart rate of 60/min.

The mother had no antenatal care and rupture of membranes for 26 hours prior to delivery.

Weight is 1.4kg

What are the stages in the management for any sick child?

Stages in the management of a sick child (Ref. Chart 1 p.xxii)

• Triage

• Emergency treatment

• History and examination

• Laboratory investigations, if required

• Diagnoses (main and secondary)

• Treatment

• Monitoring and supportive care

• Reassess

• Plan discharge

What emergency and priority signs have you noticed from the history

and from the picture?

Triage

Emergency signs (Ref: p2,6)

• Obstructed breathing

• Severe respiratory distress

• Signs of shock

• Coma

• Convulsing

• Severe dehydration

Priority signs (Ref: p.6)

• Severe wasting

• Oedema of feet

• Palmer pallor

• Young infant

• Lethargy, drowsiness

• Irritable and restless

• Major burns

• Any respiratory distress

• Urgent referral note

Triage

Emergency signs (Ref: p2,6)

• Obstructed breathing

• Severe respiratory distress

• Signs of shock

• Coma

• Convulsing

• Severe dehydration

Priority signs (Ref: p.6)

• Severe wasting

• Oedema of feet

• Palmer pallor

• Young infant

• Lethargy, drowsiness

• Irritable and restless

• Major burns

• Any respiratory distress

• Urgent referral note

What emergency measures will you take for this newborn baby?

Assessment of newborn at delivery

Dry and stimulate baby with clean cloth and place where the baby will be warm

Look for:

Breathing or crying

Good muscle tone

Colour pink

NO

NO

NO

Assessment of newborn at delivery

Does baby Jonah need resuscitation?

(Ref. WHO pocket book p.47)

Neonatal resuscitation (A=Airway)

• Open airway by positioning the head in the neutral position (Ref. p. 47)

• Clear airway and suction, if necessary

• Stimulate, reposition

• Give oxygen, as necessary

Baby Jonah is still blue and not breathing.

Neonatal resuscitation (B = Breathing)

• Use a correctly fitting mask:

• If the baby is still not breathing (Ref. p. 47) :

• Check position and mask fit• Continue to give breaths at rateof 40 breaths per minute• Use oxygen if available• Every 1-2 minutes stop and • see if the pulse or breathing has improved

• Observe the baby closely!

Neonatal resuscitation (C=Circulation)

• You check the heart rate (HR)• What steps would you take next?

Early Essential Newborn Care• Immediate and thorough drying with a

clean cloth• Maintain skin-to-skin contact

• Give the baby to mother as soon as possible, on chest or abdomen

• Cover the baby to prevent heat loss• Properly time cord clamping

• Wait for up to 1 - 3 mins or until pulsations stop. Keep umbilical cord clean and dry.

• Breastfeeding and non-separation• Initiate within the first hour keeping

mother and baby together

Further Management after 1hr:• Give vitamin K (phytomenadione), according to national

guidelines 1 ampoule IM once• Apply antiseptic ointment or antibiotic eye drops (e.g.

tetracycline) to both eyes once (prophylaxis), according to national guidelines

• Full examination and weight

Progress

• After brief resuscitation (about 30 seconds) with bag and mask ventilation, the baby has spontaneous respiration and the heart rate was more than 120/minute.

• Chest in drawing with grunting respiration observed

• SpO2 85%

• Birth weight is 1.4 kg (Very Low Birth Weight).

What further measures will you take?

What investigations would you like to proceed?

Will you start antibiotics in this newborn?

Management of VLBW babies - summary• Maintain temperature 36-37 C (Ref p.58)

• Oxygen via nasal prongs / catheter

– If ongoing apnoea, respiratory distress or cyanosis

• IV glucose / saline

– Fluids 60ml/kg/day

• Cautious introduction of breast milk feeding

• Aminophylline (or caffeine) for apnoea

• Penicillin and gentamicin

• Phototherapy for jaundice

• Vitamin K

Investigations

• Full Blood Examination

Haemoglobin: 180 gm/L (145 - 225)

Platelets: 175 x 109/L (84 – 478)

WCC: 4.2 x 109/L (5 – 25.0)

Neutrophils: 1.2 x 109/L (1.5 – 10.5)

Lymphocytes: 3.0 x 109/L (2.0 – 10.0)

Investigations continued

• Blood sugar: 3.8 mmol/l (2.5 – 5.0)

• Blood culture: No growth

• Chest X-ray:

• Any other investigationsyou want to do?

Chest x-raybilateral homogenous opacities (white lung fields) with air bronchograms

Progress

• On day 3 baby Jonah’s general condition looks better. His RR is 60/min with mild chest indrawing. His abdomen is soft. He is not grunting but looks slightly jaundiced. So he is commenced on feeding with expressed breast milk (EBM) 3 ml every three hourly by nasogastric tube.

• The following day he looks lethargic and more jaundiced and has some further apnoeas. SpO2 82%. His abdomen is distended and there is bile stained nasogastric aspirate.

What may be the cause of his deterioration?

What investigations you will perform now?

Investigations

• Full Blood Examination

Haemoglobin: 135 gm/L (145 - 225)

Platelets: 97 x 109/L (150 – 400)

WCC: 3.1 x 109/L (5 – 25)

Neutrophils: 1.1 x 109/L (1.0 – 8.5)

Lymphocytes: 1.8 x 109/L (2.0 – 10.0)

Investigations continued

• Blood glucose 3.2 mmol/l (3.0 – 8.0)

• Serum Bilirubin 294 µmol/L (277 UC / 17 C)

• Abdominal X-ray

What do you think may be wrong?

How will you manage the baby?

Progress• A diagnosis of necrotising enterocolitis was made.

Jonah’s feeds are withheld. 10% glucose + 0.45% NaCl was given intravenously.

• Metronidazole was added to penicillin and gentamicin.

• Oxygen

• Aminophylline was continued for apnoea

• He was also commenced on phototherapy for his jaundice.

What complications might occur in a VLBW baby?• General

– Hypothermia– Hypoglycaemia– Infection– Anaemia– Jaundice

• Respiratory– Apnoea– Hypoxaemia– RDS

• Gastrointestinal– Feeding intolerance– Necrotising

enterocolitis

• CNS– Intracranial

haemorrhage– Developmental

problems

What complications did occur?

• General– Hypothermia– Hypoglycaemia– Infection– Anaemia– Jaundice (p.64)

• Respiratory– Apnoea (p.61)– Hypoxaemia– RDS

• Gastrointestinal– Feeding intolerance

(p.60)– Necrotising enterocolitis

(p.62)

• CNS– Intracranial haemorrhage– Developmental problems

Summary• Baby Jonah was delivered prematurely. He needed brief

resuscitation after birth. He was managed for prematurity, VLBW, respiratory distress and possible sepsis. He was commenced on oxygen, antibiotics and IV fluid. He had some apnoeas early but these resolved with aminophylline.

• He developed necrotising enterocolitis after commencement of nasogastric feeding on the third day of life. This was treated with a change in his antibiotics for 10 days and stopping enteral feeds.

• Breast milk feeds were restarted after 5 days and very slowly increased. This time they were well tolerated and his feeding volume was gradually increased to 180ml/kg/day over 10 days. He was discharged when he tolerated breast milk well and had reached a weight of 2kg.

Better outcomes from VLBW means need for better follow-up to prevent

morbidity• Malnutrition

– Low birth weight– Difficult feeding– Mothers may have limited milk supply

• Anaemia (iron deficiency common)

• Neurological and development complications

– Cerebral palsy, visual and hearing problems

– Much worse if the child is malnourished

• Increased risk of infections– Pneumonia and bronchiolitis– Diarrhoea (zinc is helpful)