Chapter 3 Problems of the neonate Low birth weight babies

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

2. Case study: Jonah Baby Jonah just born at 30 weeks gestation. Weight is 1.4kgHe is floppy, 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.

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 • Main diagnosis and other diagnoses • Treatment • Supportive care • Monitoring • Discharge planning • Follow-up

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 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 Emergency signs (Ref: p2,6) • Obstructed breathing • Severe respiratory distress • Signs of shock • Coma • Convulsing • Severe dehydration

8. What emergency measures are needed for this newborn baby?

9. 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 Assessment of newborn at delivery NO NO NO

10. YES Start resuscitation now Remember: A,B,C Airway, Breathing Circulation NO Early Essential Newborn Care Does baby Jonah need resuscitation? Assessment of newborn at delivery

11. (Ref. WHO pocket book p.47)

12. Neonatal resuscitation (A=Airway) • Open airway by gently positioning the head in the neutral position (Ref. p. 47) • Clear airway and suction, only if necessary • Give oxygen, as necessary Baby Jonah is still not breathing well

13. Neonatal resuscitation (B = Breathing) • Use a correctly fitting mask: • If the baby is still not breathing after opening the airway (Ref. p. 47) : • Check position and mask fit • Continue to give breaths at rate of 40 breaths per minute, be gentle and do not overinflate • Use oxygen if available • Every 1-2 minutes stop and see if the pulse or breathing has improved

14. Neonatal resuscitation (C=Circulation) • Check the heart rate (HR)

15. Progress • After brief resuscitation just 30 seconds with bag and mask ventilation, the baby has spontaneous breathing and the heart rate was up to 120/minute. • Mild chest indrawing, SpO291% on 0.5L oxygen

16. Early Essential Newborn Care • Dry 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 • Breastfeeding • Start breast feeding in the first hour • Keep mother and baby together Further Management: • Give vitamin K (phytomenadione) 1 ampoule IM • Apply antiseptic ointment or antibiotic eye drops (e.g. tetracycline) to both eyes once • Examination and weight

17. What further measures will you take?

18. Management of VLBW babies • Maintain temperature 36-37 C (Ref p.58) • Oxygen via nasal prongs / catheter • Target SpO2 88-95%, not higher • IV glucose / saline • Fluids 60ml/kg/day on first day of life • Initiation of breast milk feeding (including colostrum) • Aminophylline (or caffeine) for apnoea • Penicillin and gentamicin • Phototherapy if jaundice • Vitamin K

19. Investigations • Full Blood Examination Haemoglobin: 180 gm/L (145 - 225) Platelets: 175 x 109/L (84 – 478) WCC: 5.1 x 109/L (5 – 25.0) Neutrophils: 2.1 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: Bilateral opacities (white lung fields) with air bronchograms

21. Progress • On day 3 baby Jonah’s general condition looks better. His RR is 52/min with mild chest indrawing, SpO2 94% on 0.5 L/min oxygen. His abdomen is soft and passed meconium. So he is commenced on feeding with expressed breast milk (EBM) 3 ml every 2 hours by nasogastric tube. • The next day he looks lethargic and jaundiced and has some further apnoeas. SpO2 82% despite oxygen. His abdomen is distended and there is bile stained nasogastric aspirate.

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

23. Investigations • Full Blood Examination Haemoglobin: 135 gm/L (145 - 225) Platelets: 57 x 109/L (150 – 400) WCC: 3.1 x 109/L (5 – 25) Neutrophils: 0.9 x 109/L (1.0 – 8.5) Lymphocytes: 2.2 x 109/L (2.0 – 10.0)

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

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

26. Progress • Likely diagnosis is necrotising enterocolitis (NEC). • 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.

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 and respiratory distress. He was commenced on oxygen, antibiotics and IV fluid. He had some apnoeas early but these improved with aminophylline. • He developed necrotising enterocolitis after commencement of feeding on the third day of life. This was treated with a change in his antibiotics for 10 days and stopping feeds for 5 days. • Breast milk feeds were restarted after 5 days and very slowly increased. This time feeds 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. Follow-up – review monthly and check for • Nutrition • Monitor the child’s growth chart each month (weight, length and head circumference • Mothers may have limited milk supply – Susu Mamas • Multivitamins and zinc • Anaemia • Iron deficiency common, start iron when babies 6 weeks of age • Look for development complications • Cerebral palsy, visual and hearing problems • Infections • Pneumonia, bronchiolitis and diarrhoea common