Problems of the neonate Low birth weight babies

Chapter 3

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 Priority signs (Ref: p.6) Severe wasting Oedema of feet Palmer pallor Young infant

Convulsing
Severe dehydration

Lethargy, drowsiness
Irritable and restless Major burns

Any respiratory distress

Urgent referral note

Triage
Emergency signs (Ref: p2,6) Obstructed breathing Severe respiratory distress Signs of shock Coma Priority signs (Ref: p.6) Severe wasting Oedema of feet

Palmer pallor
Young infant Lethargy, drowsiness

Convulsing
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 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 (Ref p.58)

Phototherapy for jaundice

Vitamin K

Investigations
Full Blood Examination Haemoglobin: Platelets: WCC: Neutrophils: Lymphocytes: 180 gm/L (145 - 225) 175 x 109/L (84 478) 4.2 x 109/L (5 25.0) 1.2 x 109/L (1.5 10.5) 3.0 x 109/L (2.0 10.0)

Investigations continued
Blood sugar:
Blood culture: Chest X-ray: Any other investigations you want to do?
bilateral homogenous opacities (whiteness) with air bronchograms

3.8 mmol/l (2.5 5.0)

No growth

Progress
On day 3 baby Jonahs 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: Platelets: WCC: Neutrophils: Lymphocytes: 135 gm/L 97 x 109/L 3.1 x 109/L 1.1 x 109/L 1.8 x 109/L (145 - 225) (150 400) (5 25) (1.0 8.5) (2.0 10.0)

Investigations continued
Blood glucose Serum Bilirubin Abdominal X-ray 3.2 mmol/l (3.0 8.0) 294 mol/L (277 UC / 17 C)

What do you think may be wrong? How will you manage the baby?

Progress
A diagnosis of necrotising enterocolitis was made. Jonahs 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 Gastrointestinal Feeding intolerance Necrotising enterocolitis CNS Intracranial haemorrhage Developmental problems

Respiratory Apnoea Hypoxaemia RDS

What complications did occur?

General Hypothermia Hypoglycaemia Infection Anaemia Jaundice (p.64) Gastrointestinal Feeding intolerance (p.60) Necrotising enterocolitis (p.62) CNS Intracranial haemorrhage Developmental problems

Respiratory Apnoea (p.61) Hypoxaemia RDS

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)