Neonates general Flashcards
SIX WEEK WELL BABY CHECK
- Weight gain
- General alertness
- Head Circumference
- Vision (fixing and following , strabismus)
- Tone and posture
- Hips, including check for limitation of hip abduction
- Cardiac murmurs
- Descent of the testes
Problems commonly encountered at the six week check
- Failure to thrive
- Vomiting
- Snuffles
- Colic
- Skin rashes, especially nappy rash and seborrhoeic dermatitis
- Umbilical granuloma
- Constipation and diarrhoea
- Infection e.g. URTI, eye infection, UTI, gastroenteritis, pneumonia
Failure to thrive likely if weight gain is less than
140g per week
Vomiting Qs
- The amount and frequency of vomiting
- Any associated weight loss?
- Any associated dehydration?
- Blood or bile staining of vomitus
- Is the vomiting projectile?
- Is there abdominal distension, tenderness or a palpable mass?
non-organic causes of vomiting
Feeding problems e.g. overfeeding,
excessive handling after feeds, swallowed wind,
incorrect feed
preparation.
organic causes of vomiting
1) Neonatal intestinal obstruction
2) Ileus, e.g. prematurity, asphyxia, exchange transfusion via an umbilical vessel.
3) Septicaemia
Infection e.g. urinary tract infection, gastroenteritis, pneumonia, meningitis,septicaemia, omphalitis.
4) Necrotising enterocolitis
5) Metabolic causes – galactacaemia and congenital adrenal hyperplasia
6) Gastro-oesophageal reflux e.g. hiatus hernia or gastritis associated with swallowed meconium, or
blood.
Neonatal intestinal obstruction DDx
- Duodenal atresia (common in infants with Down’s syndrome)
- Malrotation
- Volvulus
- Small vowel atresia
- Meconium ileus – 10 to 20% infants with cystic fibrosis present with this.
- e.g. Large bowel obstruction
causes of vomiting in older infants
1) Gastroenteritis
2) U.T.I.
3) Pyloric stenosis
4) Regurgitation, gastroesophageal reflux
causes of hematemesis, melaena, bloody stools
1) Swallowed maternal/placental blood at delivery.
2) Swallowed maternal blood from cracked nipples.
3) Local trauma – nasogastric tube, laryngeal suction.
4) Fissure-in-ano
5) NEC
6) Haemorrhagic disease – DIC or haemorrhagic disease of the newborn
7) Gastroenteritis
RARE causes of hematemesis, melaena, bloody stools
- Trauma
- Meckels diverticulum
- Malrotation
- Peptic ulceration
- Rectal polyp/haemangiomas
- Intussusception
WHEN SHOULD THE DOCTOR BE CALLED
significant change in the infant’s usual colour, breathing, behaviour or activity, or if the
mother is in any doubt or worried about this
• Repeated forceful or projectile vomiting (in contrast to the fairly common spitting up or
regurgitation);
• Poor feeding and repeated refusal of feed:
• Frequent diarrhoea, with bowel movements becoming more numerous or watery:
• Excessive constant crying or a continuing cry different from babies usual kind of cry;
• Rapid laboured breathing, or frequent severe coughing, (in contrast to the common minor breathing
irregularities or occasional cough);
• Unusual skin rashes;
• Persistent fever, particularly in the first few months
Strategies used in the management of colic include:
• Gentle motion and physical contact,
• Use of a pacifier or dummy,
• Avoid too frequent feeding or overfeeding (not more than 3 hourly for formula fed infants),
• If the infant is breast fed check the mothers diet, (decreasing a high intake of milk, or coffee may
help; occasionally maternal ingestion of certain berries, tomatoes, onions, cabbage, chocolate or
spices may be a cause of symptoms)
• Carry baby in front-pack (3 hours per day) when not crying; there is less colic in countries where
infants are constantly carried by the mother,
• Maternal rest,
• Change formula (frequent changes are not encouraged); whey based formulas may be associated with
increased stomach emptying time and be less satisfying,
• A trial of soy formula (this has a lower lactose content and does not contain cows milk protein),
• A trial of early introduction of solids, i.e. Baby rice, (this delays gastric emptying),
• Occasionally admitting the infant to hospital (for maternal rest and to break the “cycle”),
• Follow the infant closely until the crying is improved or has resolved
General newborn discharge criteria
• Stable vital signs
• Passed urine & stool
• Feeding established
• Physical exam
– No abnormality that requires hospitalisation
– Jaundice (if present) assessed and appropriate management / follow-up arranged
• Mother’s knowledge, ability & confidence demonstrated
- Family members or other support staff (including medical) available
- Maternal & infant blood tests reviewed
- Family environment & social risks assessed
- Barriers to adequate follow-up care addressed
- Source of ongoing care identified for Mum & infant
Causes of altered metal status in a neonate
The MISFITS
T=trauma (accidental & non-accidental – shaken baby syndrome)
H=heart disease & hypovolemia
E=endocrine (congenital adrenal hyperplasia & thyrotoxicosis)
M=metabolic (electrolyte imbalance)
I=inborn error metabolism
S=sepsis (meningitis, pneumonia, UTI)
F=formula mishaps (under / over-dilution)
I=intestinal catastrophes (volvulus, intussusception, NEC)
T=toxins & poisons
S=seizures
SIDS risk factors
Prone position /co-sleeping, overheating,
parental alcohol / drug use, urban,
maternal smoking,
lower socio-economic status , premature infant
SIDS prevention
– Always place babies on back to sleep
– Pacifiers may reduce risk (delay for one month of breastfeeding, no need to replace if fall out of mouth or if infant doesn’t want)
– Keep temperature of room comfortable, avoid overheating
– Encourage Tummy Time when awake and supervised
– Keep cot in smoke-free room
Neonatal conjunctivitis under 24 hours
Silver nitrate drops
Resolves in 48 hours
Neonatal conjunctivitis day 2-5
neisseria gonorrhoea
thick copious discharge
Dx DNA probe
Tx IV PCN or Ceftriaxone for 7 days
Neonatal conjunctivitis after 5 days
bacterial - S aureus, H flu, S pneumo, Enterococcus, Pseudomonas
Dx gram stain, culture
Tx erythromycin, gentamicin
Neonatal conjunctivitis day 2-14
HSV
Dx rapid HSV test, culture
Tx acyclovir IV x 10 days and topical 2 hourly for 7 days
Neonatal conjunctivitis day 3-14
chlamydia
Dx conjunctival scraping, DNA probe, retest 6 weeks after tx
Tx oral erythromycin x 14 days
Cryptorchidism (undescended testis)
Descend into scrotum by 38 – 40 weeks
75% cryptorchidism in full terms and 90% in premature newborns will spontaneously descend by 9 months
Surgical intervention if not by 12 months
RESP DISTRESS signs
Tachypnoea Laboured breathing: intercostal/subcostal recession & nasal flaring Expiratory grunting Tachycardia Cyanosis
RESP DISTRESS pulmonary DDx common
- Transient tachypnoea of the newborn
- Meconium aspiration
- Pneumothorax
- Persistent Pulmonary Hypertension of the newborn
- Milk aspiration
