1. Chapter 3 Problems of the neonate Low birth weight babies

2. Case study: Jonah
Baby Jonah born at 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

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

4. 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

5. What emergency and priority signs have you noticed from the history and from the picture?

6. 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

7. Triage Emergency signs (Ref: p2,6) Priority signs (Ref: p.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

8. What emergency measures will you take for this newborn baby?

9. 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
Call for Help, check HR, attach sats probe if available
Remember A, B, C - added

10. Start the resuscitation now! Airway, Breathing Circulation
Assessment of newborn at delivery
YES NO
Start the resuscitation now!
Early Essential
Newborn Care
Remember: A,B,C
Airway, Breathing Circulation
Does baby Jonah need resuscitation?
Call for Help, check HR, attach sats probe if available
Remember A, B, C - added

11. (Ref. WHO pocket book p.47) NEW SLIDE Moved from chapter 3
Highlighted A B C

12. 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.

13. 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 rate
of 40 breaths per minute
Use oxygen if available
Every 1-2 minutes stop and
see if the pulse or breathing has improved
Merged slide 5/6 –
Give the baby 5 slow ventilations with bag (Ref. p )
Check the heart rate
Observe the baby closely!

14. Neonatal resuscitation
(C=Circulation)
You check the heart rate (HR)
What steps would you take next?

15. 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 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

16. 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).

17. What further measures will you take
What further measures will you take? What investigations would you like to proceed? Will you start antibiotics in this newborn?

18. Management of VLBW babies - summary
Maintain temperature 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

19. Investigations Full Blood Examination
Haemoglobin: 180 gm/L ( )
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)

20. Investigations continued
Blood sugar: 3.8 mmol/l (2.5 – 5.0)
Blood culture: No growth
Chest X-ray:
Any other investigations you want to do?
Chest x-ray
bilateral homogenous opacities (white lung fields) with air bronchograms

21. 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.

22. What may be the cause of his deterioration
What may be the cause of his deterioration? What investigations you will perform now?

23. Investigations Full Blood Examination
Haemoglobin: 135 gm/L ( )
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)

24. Investigations continued
Blood glucose 3.2 mmol/l (3.0 – 8.0)
Serum Bilirubin 294 µmol/L (277 UC / 17 C)
Abdominal X-ray

25. What do you think may be wrong? How will you manage the baby?

26. Progress
A diagnosis of necrotising enterocolitis was made. Jonah’s feeds are withheld. 10% glucose % 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.

27. 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

28. 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

29. 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.

30. 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)