Chapter 3 Problems 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) 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

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

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

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

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 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. 47-49) Check the heart rate 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 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 investigations you want to do? Chest x-ray bilateral 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 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)