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, brief periods of apnoea, and heart rate of 80/min.The mother had no antenatal care and rupture of membranes for 26 hours prior to delivery.

3. 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

4. What emergency or priority signs does baby Jonah have?

5. Triage Emergency signs (Ref: p2,6) • Obstructed breathing • Severe respiratory distress • Signs of shock • Coma • Convulsing • Severe dehydration Priority signs (Ref. p. 6) • Tiny baby • Temperature • Trauma • Pallor • Poisoning • Pain (severe) • Respiratory distress • Restless, irritable, lethargic • Referral • Malnutrition • Oedema of both feet • Burns

6. Triage Emergency signs (Ref: p2,6) • Obstructed breathing • Severe respiratory distress • Signs of shock • Coma • Convulsing • Severe dehydration Priority signs (Ref. p. 6) • Tiny baby • Temperature • Trauma • Pallor • Poisoning • Pain (severe) • Respiratory distress • Restless, irritable, lethargic • Referral • Malnutrition • Oedema of both feet • Burns

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

8. 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

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

10. Neonatal resuscitation • 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

11. Neonatal resuscitation • Check the heart rate (HR)

12. Further assessment • After brief resuscitation just 30 seconds with bag and mask ventilation, Jonah has spontaneous breathing and the heart rate was up to 120/minute. • Mild chest indrawing, SpO2 91% on 0.5L oxygen

13. 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 • Cord care – chlorhexidine swab • Examination and weight

14. Treatment of VLBW babies

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

16. Investigations • Full Blood Examination Haemoglobin: 160 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) • Blood glucose: 3.8 mmol/l (2.5 – 5.0) • Blood culture: No growth

17. Progress • On day 2 Jonah’s condition was better. Eyes open and active. RR is 46/min with mild chest indrawing, SpO2 94% on air. His abdomen was soft and passed meconium. • So commenced feeding with expressed breast milk (EBM) 3 ml every 2 hours by nasogastric tube. • What is the target feed for Jonah? (Ref p. 57 and 60) • 90ml/kg/day, Jonah is 1.4kg, 2 hourly feeds → • (90 x 1.4) / 12 = 10.5 ml every 2 hours

18. Progress • The next day he looks lethargic and jaundiced and has some further apnoea. SpO282%. • His abdomen was distended and there was bile stained nasogastric aspirate.

19. What may be the cause of this deterioration?What investigations you will do?

20. Investigations • Full Blood Examination Haemoglobin: 110 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)

21. Investigations • Blood glucose: 3.2 mmol/l (3.0-8.0) • Serum bilirubin: 294 µmol/L • Abdominal X-ray

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

23. Progress • Likely diagnosis is necrotising enterocolitis (NEC). • Jonah’s feeds are withheld. 10% glucose + NaClwas given intravenously. • Metronidazole added to benzylpenicillinand gentamicin. • Oxygen • Aminophylline was continued for apnoea • Phototherapy for jaundice.

24. 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

25. 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

26. Summary • Baby Jonah was delivered prematurely. He needed brief resuscitation after birth. He was commenced on oxygen, antibiotics and IV fluid. He had some apnoea early but these improved with aminophylline. • He developed necrotising enterocolitis after commencing feeding on the 2nd 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.

27. 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