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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)
Priority signs (Ref: p.6)
• Obstructed breathing
• Severe wasting
• Severe respiratory distress
• Oedema of feet
• Signs of shock
• Palmer pallor
• Coma
• Young infant
• Convulsing
• Lethargy, drowsiness
• Severe dehydration
• 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 wasting
• Severe respiratory distress
• Oedema of feet
• Signs of shock
• Palmer pallor
• Coma
• Young infant
• Convulsing
• Lethargy, drowsiness
• Severe dehydration
• Irritable and restless
• Major burns
• Any respiratory distress
• Urgent referral note
What emergency measures will you take
for this newborn baby?
(Ref. WHO pocket book p.47)
Summary of neonatal resuscitation
• Dry baby with clean cloth (Ref p. 48-49)
• Open airway by positioning the head in the neutral position
• Clear airway by suctioning
• Bag and mask ventilation to establish respiration
– Oxygen not necessary for initial resuscitation
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 investigations
you want to do?
bilateral
homogenous
opacities
(whiteness) 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)