L/O/G/ORecognizing the ill baby

Out lines:Out lines:ObjectiveIntroduction Assessment of the

infant Physical assessmentSkin RespirationBody temperature

Cardiovascular systemCentral nervous systemRenal and genitourinary

systemNeeds of the ill baby and

family Developmentally focused,

family centred care

objectivesobjectives

assist the midwife in the assessment and identification of the ill neonate

provide an overview of the potential or presenting problems of the neonate

consider the needs of the family by the integration of family-centred care in the neonatal unit

Assessment of the infantAssessment of the infant Immediately after birth, all infants should be

examined for any gross congenital abnormalities or evidence of birth trauma.

They should also have their weight and gestational

age plotted on a standard growth chart

Classifying infants according to weight and gestation

within the next 24hrs, a more comprehensive, systematic, physical examination should take place.

Decreasing morbidity and mortality are the goal of all those involved with the care of the newborn infant. The early recognition of existing or potential problems is vital if the appropriate treatment is to be initiated as soon as possible.

Maternal healthMaternal health

maternal history is an essential starting point in understanding the potential or presenting problems of the neonate. Influencing factors include:

pregnancy-induced hypertension

history of epilepsy

maternal diabetes

history of substance abuse

history of sexually transmitted diseases.

Fetal well-being and health in pregnancyFetal well-being and health in pregnancy

significant questions that a midwife may ask herself as they may have a critical influence on the well-being of the infant:• was this a twin pregnancy?

• was the baby presenting by the breech?

• is the baby pre-term?

• is the infant SGA?

• was there poor growth in utero?

• was any evidence of congenital abnormality picked up on scanning, such as enlarged heart or bowel obstruction?

Perinatal and birth complicationsPerinatal and birth complications

Labour and birth may also have an effect on the general welfare of the newborn infant• prolonged rupture of membranes• abnormal fetal heart rate pattern• meconium staining• difficult or rapid birth• caesarean section and the reason for

this.

Physical assessmentPhysical assessmentMost of the information the midwife requires for the assessment of a baby's well-being comes from observation. The baby's breathing pattern will alter depending on his level of activity. Much can be learned by observing the baby's resting position. The normal baby will lie with his limbs partially flexed and active. The skin colour should be centrally pink, indicating adequate oxygenation; there should be no rashes or skin lesions

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The skinThe skin

The skinThe skin• The skin of a neonate varies in its

appearance and can often be the cause of unnecessary anxiety in the mother, midwife and medical staff. It is, however, often the first sign that there may be an underlying problem in the baby.

warning signs: Pallor

Central cyanosis

Jaundice

Apnoea lasting longer than 20 s

.

Heart rate <110 or >180 beats/min (taken during spells of inactivity)

Respiratory rate <30 or >60 breaths/min

Skin temperature (axilla) <36.2 °C or >37.2 °C

Lack of spontaneous movement and responsiveness

Abnormal lying position either hypotonic or hypertonic

Lack of interest in surroundings.

Pallor Pallor A pale, mottled baby is an indication of

poor peripheral perfusion low circulating blood volume circulatory adaptation and compensation.

The anaemic infant's appearance is usually pale pink, white or, in severe cases where there is vascular collapse, grey. Other presenting signs are tachycardia, tachypnoea and poor capillary refill (to assess capillary refill, press the skin briefly on the forehead or abdomen and observe how long it takes for the colour to return; this should be prompt).

causes of anaemia in the newborn period :

1) a history in the infant of haemolytic disease of the newborn

2) twin-to-twin transfusions in utero (which can cause one infant to be anaemic and the other polycythaemic)

3) maternal antepartum or intrapartum haemorrhage.

Problems associated with pallor include:

• anaemia and shock

• respiratory disorders

• cardiac anomalies

• sepsis (where poor peripheral perfusion might also be observed)

• hypothermic or hypoglycaemic

PlethoraPlethora Babies who are beetroot in colour

are usually described as plethoric IT indicate an excess of circulating red blood cells (polycythaemia).

Newborn infants can become polycythaemic if they are recipients of:• twin-to-twin transfusion in utero• a large placental transfusion.

Other infants at risk are:

small for gestational age babies

infants of diabetic mothers

those with Down syndrome

neonatal hypothyroidism

chromosomal disorders.

CyanosisCyanosisCentral cyanosis should always be taken very seriously. The mucous membranes are the most reliable indicators of central colour in all babies and if the tongue and mucous membranes appear blue this indicates low

oxygen saturation levels in the blood, usually of respiratory or cardiac origin

Peripheral cyanosis of the hands and feet is common during the first 24hrs of life; after this time it may be a non-specific sign of illness. Central cyanosis always demands urgent attention

JaundiceJaundice

Early onset jaundice (presenting within the first 12hrs of life) is abnormal and needs investigating. If a jaundiced baby is unduly lethargic, is a poor feeder, vomits or has an unstable body temperature, this may indicate infection and action should be taken to exclude this

Other factors that affect the appearance of the skinOther factors that affect the appearance of the skin

• Pre-term infants have thinner skin that is redder in appearance than that of term infants. In post-term infants the skin is often dry and cracked.

• The skin a good indicator of the nutritional status of the infant. The SGA infant may look malnourished and have folds of loose skin over the joints, owing to the lack or loss of subcutaneous fat. This can predispose the infant to problems with hypoglycaemia due to poor glycogen stores in the liver and can also cause problems with hypothermia.

• If the infant is dehydrated, the skin looks dry and pale and is often cool to touch. If gently pinched, it will be slow in retracting. Other signs of dehydration are: pallor or mottled skin, sunken fontanelle or eyeball sockets and tachycardia.

Skin rashe

Skin rashes are quite common in newborn babies but most are benign and self-limiting.

MiliaThese are white or yellow papules seen over the cheeks, nose and forehead. These invariably disappear spontaneously over the

first few weeks of life .

MiliariaThese are clear vesicles on the face, scalp and perineum, caused by retention of sweat in unopened sweat glands. They appear on the chest and around areas where clothes can cause friction. The treatment is to nurse the infant in a cooler environment or to remove excess clothing

Petechiae or purpura rashThese can occur in neonatal thrombocytopenia, which is a condition of platelet deficiency and usually presents with a petechial rash over the whole of the body. There may also be prolonged bleeding from puncture sites or the umbilicus, or both, and bleeding into the gut

Bruising

This can occur extensively following breech extractions, forceps and ventouse deliveries. The bleeding can cause a decrease in circulating blood volume, predisposing the baby to anaemia or, if the bruising is severe, hypotension.

Erythema toxicumSmall white /yellow papules or pustules on ared base seen on face, trunk and limbs.develop 1-3 days birth and usually disappear by one week

Infectious lesions

Thrush

This is a fungal infection of the mouth and throat. It is very common in neonates especially if they have been treated with antibiotics. It presents as white patches seen over the tongue and mucous membranes and as a red rash on the perineum.

Herpes simplex virus If acquired in the neonatal period, is a most serious

viral infection. Transmission in utero is rare; the infection usually occurs during birth with the illness presenting after 3 days. 70% of affected infants will

produce a rash, which appears as vesicles or pustules .Mortality depends on severity of the illness and whentreatment commenced

Umbilical sepsis

This can be caused by a bacterial infection. Until it separation, the umbilical cord can be a focus for infection by bacteria that colonize the skin of the newborn. If periumbilical redness occurs or a discharge is noted, it may be necessary to commence antibiotic therapy in order to prevent an ascending infection.

Staphylococcal

This commonly presents as a few yellow filled bullae. Severe infections can give rise to bullous impetigo which makes the skin look as though it has been scalded. It presents as widespread tender erythema, followed by blisters, which break leaving raw areas of skin. This is particularly noticeable around the napkin area but can also cause umbilical sepsis, breast abscesses, conjunctivitis and, in deep infections, there may also be involvement of the bones and joints.

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Respiratory system

•  Respiratory distress in the newborn can be a presentation of a number of clinical disorders and is the major factor in the morbidity and mortality in the neonatal period.

• It is important to observe the baby's breathing when he is at rest and active.

• The midwife should always start by observing skin colour and then carry out a respiratory inspection, taking into account whether the baby is making either an extra effort or insufficient effort to breathe.

Respiratory inspectionRespirations should be counted by watching the lower chest and abdomen rise and fall for a full minute. The respiration rate should be between 40 and 60 breaths/min but will vary according to the level of activity. Newborn infants are primarily nose breathers and so obstructions of the nares may lead to respiratory distress and cyanosis.

Remember if suction is required at any time; always suction the mouth first and then the nose. The chest should expand symmetrically. If there is unilateral expansion and breath sounds are diminished on one side, this may indicate that a pneumothorax has

occurred .

risk of pneumothorax or other air leaks are:

pre-term infants with respiratory distress

term infants with meconium-stained amniotic fluid

infants who require resuscitation at birth

Midwife observe infant respiration for TachypnoeaRetractionnasal flaring Grunting

ApnoeaApnoea defined as a cessation of breathing for

20s or more. It is associated with pallor, bradycardia, cyanosis, oxygen desaturation or a change in the level of consciousness

Any baby having apnoeic spells needs to be admitted to a neonatal unit to have his cardiorespiratory system monitored.

The most common cause of apnoea in preterm babies is pulmonary surfactant deficiency or the immaturity of the central nervous system control mechanism.

Causes that may produce apnoea : hypoxia pneumonia aspiration pneumothorax metabolic disorders

(e.g.hypoglycaemia, hypocalcaemia, acidosis)

anaemia maternal drugs

neurological problems (e.g. intracranial haemorrhage, convulsions, developmental disorders of the brain)

congenital anomalies of the upper airway.

stimulation of the posterior pharynx by suction catheters.

Body temperature• Thermoregulation is a critical physiological

function that is closely related to the survival of the infant. It is therefore essential that all those caring for newborn infants are aware of the importance of the thermal environment and understand the need for maintenance of normal body temperature

• A neutral thermal environment is defined as the ambient air temperature at which oxygen consumption or heat production is minimal, with body temperature in the normal range

• The normal body temperature range for term infants is 36.5–37.3 °C.

• Environments that are outside the neutral thermal environment may result in the infant developing hypothermia or hyperthermia. Babies who are too cold or too warm will try and regulate their temperature and this action, especially in the pre-term and SGA infant, can have a detrimental effect.

• Note: Intermittent temperature recordings have traditionally been taken using mercury thermometers. Research suggests that this practice is hazardous and should be eradicated

Hypothermia• defined as a core temperature below 36

When the body temperature is below this level the infant is at risk from cold stress.

This can cause complications such as: increased oxygen consumption, lactic acid production, apnoea, decrease in blood coagulability and, the most commonly seen, hypoglycaemia. In pre-term infants, cold stress may also cause a decrease in surfactant secretion and synthesis

After birth a baby's body temperature can fall very quickly. The healthy term baby will try to maintain his temperature within the normal range.

hypothermia can be disastrous:• severe asphyxia

• extensive resuscitation

• delayed drying at birth

• respiratory distress

• hypoglycemia

• sepsis – septic infants often have hypothermia rather than hyperthermia

• being pre-term or SGA – these infants have poor glucose stores, decreased subcutaneous tissue and little or no brown fat stores.

Methods of heat loss

Evaporation – wet surface exposed to air

Conduction – direct contact with cool objects

Convection- surrounding cool air - drafts

Radiation – transfer of heat to cooler objects not in direct contact with infant

• HyperthermiaHyperthermia is defined as cor temperature above 38.0 °C,usual cause of hyperthermia is overheating of the environment

• Note: Variability in body temperature, either high or low, may be the first and only sign that a baby is unwell.

Cardiovascular systemThe normal heart rate of a newborn baby is

110–160 b.p.m., with an average of 130 b.p.m. When heart rates persistently outside this

range at rest, may suggest an underlying cardiac problem

Warning sign suggestive congenital heart disease

Cyanosis (often the cyanosis is out of proportion to the degree of respiratory distress)

Persistent tachypnoea Persistent tachycardia at rest Poor feeding: infants may be

breathless and sweaty during the feed or after feeding; they may not complete their feeds and subsequently fail to thrive

A sudden gain in weight leading to clinical signs of oedema; this is usually noted as the baby having puffy feet or eyelids and, in males, the scrotum being swollen

A very loud systolic murmur is invariably significant

Evidence of cardiac enlargement on X-ray, persisting beyond 48 hrs of life

Enlargement of the liver.

Central nervous systemAssessment of an infant's neurological status is usually carried out on a baby who is awake but not crying. Abnormal postures, which include neck retraction, frog-like postures, hyperextension or hyperflexion of the limbs, jittery or abnormal involuntary movements and a high-pitched or weak cry, could be indicative of neurological impairment and a need for investigation

Neurological disordersNeurological disorders found at or soon after birth may be either prenatal or perinatal in origin. They include:

congenital abnormalities: hydrocephaly, microcephaly, encephalocele, chromosomal anomalies

hypoxic-ischaemic cerebral injuries

birth traumas: skull fractures, spinal cord and brachial plexus injuries, subdural and subarachnoid haemorrhage

infections passed on to the fetus (toxoplasmosis, rubella, cytomegalovirus (CMV), syphilis).

Neurological disorders that appear in the neonatal period need to be recognized promptly in order to minimize brain damage. These include:

infection: meningitis, herpes simplex, viral encephalitis

hypoxia: birth asphyxia, respiratory distress, apnoeic episodes

metabolic: acidosis, hypoglycaemia, hyponatraemia, hypernatraemia, hypothermia, hypocalcaemia, hypomagnesaemia

drug withdrawal: narcotics, barbiturates, general anaesthesia

intracranial haemorrhage or intraventricular haemorrhage (IVH)

secondary bleeding: intracranial haemorrhage from thrombocytopenia or disseminated intravascular coagulation (DIC).

Cerebral hypoxia and bacterial infections are of prime importance

Seizures• Seizures in the newborn period can

be extremely difficult to diagnose, as they are often very subtle and easily missed

• The most common causes of seizure activity are:

• asphyxia• metabolic disturbance• intracranial or intraventricul

haemorrhage• Infection• malformation or genetic defect.

Hypotonia (floppy infant)The term hypotonia or ‘floppy baby’ describes the loss of body tension and tone.

Subtle

Apnoea usually with abnormal eye movements, tonic horizontal deviation, blinking, fluttering eyelids, jerking, drooling, sucking, tonic posturing or unusual movements of the limbs (rowing, peddling or swimming)

Most frequent type and most commonly seen in pre-term infants

Clonic

• Jerking activity. Multifocal or unifocal distinct from jittering

• Term infants: hypoxic-ischaemic encephalopathy, or inborn errors of metabolism

Tonic• Posturing similar to decerebrate

posture in adults• Pre-term infants with

intraventricular haemorrhage

Myoclonic• Single or multiple jerks of upper

or lower extremities• Possible prediction of myoclonic

spasm in early infancy

• Pre-term infants below 30 weeks' gestation have a resting position that is usually characterized as hypotonic. By 34 weeks, their thighs and hips are flexed and they lie in a frog-like position, usually with their arms extended.

• At 36–38 weeks' gestation, the resting position of a healthy newborn baby is one of total flexion with immediate recoil.

• Hypotonia in a term infant is not normal and requires investigation. It is also important to determine whether the hypotonia is associated with weakness or normal power in the infant's limbs.

The causes of hypotonia include: maternal sedation

birth asphyxia

prematurity

Infection

Down syndrome

metabolic problems (e.g. hypoglycaemia, hyponatraemia, inborn errors of metabolism)

neurological problems (e.g. spinal cord injuries

endocrine (e.g. hypothyroidism)

neuromuscular disorders.

Renal and genitourinary system Urinary infections in the newborn period are

quite common, especially in males. The baby typically presents with lethargy,

poor feeding, increasing jaundice and vomiting

The genitourinary tract has the highest percentage of anomalies, congenital or genetic, of all the organ systems.

Prenatal diagnosis is possible with ultrasound and aids the early assessment and intervention .

Renal problems may present as a failure to pass urine.

The normal infant usually passes urine 4–10hrs after birth.

Normal urine output for a term baby in the first day of life should be 2–4ml/kg per hour.

A urine output of <1ml/kg per hour (oliguria) in the first few days of life should be investigated

Urinalysis using reagent strips will give information that may be helpful in diagnosis

Common causes of reduced urine output include:• inadequate fluid intake• increased fluid loss due to

hyperthermia, use of radiant heaters and phototherapy units

• birth asphyxia• congenital abnormalities• infection.

Gastrointestinal tract• Some congenital abnormalities of the

gastrointestinal tract can now be diagnosed antenatally by ultrasound. Other defects, however, may not be suspected until the infant becomes unwell

• . In the newborn period, gastrointestinal disorders often present with vomiting, abdominal distension, a failure to pass stools, or diarrhoea with or without blood in the stools.

• vomiting in the postnatal period can be caused by factors other than gastrointestinal obstructions.

• Early vomiting may be caused by the infant swallowing meconium or maternal blood at delivery

• All vomit should be checked for the presence of bile or blood. Observe the infant for other signs such as abdominal distension, watery or bloodstained stools and temperature instability.

• The normal term baby usually passes about eight stools a day. Breastfed babies' stools are looser and more frequent than those of bottle-fed babies, and the colour varies more and sometimes appears greenish.

• Diarrhoea caused by gastroenteritis is usually very watery and may sometimes resemble urine. The cause is either bacterial or viral.

• Loose stools can also be a feature of infants being treated for hyperbilirubinaemia with phototherapy

Some of the more commonly seen gastrointestinal problems include

Necrotising enterocolitis (NEC)• NEC is an acquired disease of the small and

large intestine caused by ischaemia of the intestinal mucosa

• It occurs more often in pre-term babies, but may also occur in term babies who have been asphyxiated at delivery or babies with polycythaemia and hypothermia

• In the early stages of NEC, the baby can display non-specific signs of temperature instability, unstable glucose levels, lethargy and poor peripheral circulation. As the illness progresses, the baby becomes apnoeic and bradycardic and may need ventilating.

Imperforate anus• All babies should be checked at birth for this.

Rectal fistulas• The midwife should look for the presence of

meconium in the urine or, in female babies, meconium being passed from the vagina.

Hirschsprung's disease• Hirschsprung's disease should be suspected

in term babies with delayed passage of meconium, certainly after the first 24hrs of life . Abdominal distension and vomiting are clinical signs, with the vomit becoming bile stained if meconium is not passed.

Metabolic disorders• Metabolic disorders, such

agalactosaemia and phenylketonuria, present in the newborn period with vomiting, weight loss, jaundice and lethargy

Meeting the needs of the ill baby and the familyThe baby

•Babies who are clearly unwell, distressed or less than 1800g at birth require admission to a neonatal unit (NNU). Early separation of mother and baby is very damaging and should be avoided unless absolutely necessary. Asymptomatic babies above 1800g, irrespective of gestation, should be able to stay with their mother either on a ward, or for infants with minor problems only, in a transitional care unit.

Drug administration• Antibiotics are the most common drugs

used in NNUs• Drugs can be given to neonates orally,

intramuscularly, intravenously, topically or rectally

• The most efficient and effective route to administer drugs to a baby is by the intravenous route

• absorption of drugs via the stomach is dependent on factors in the baby relating to gastric emptying time and gastric and duodenal pH

• Intramuscular administration is often a painful route and absorption is dependent on blood flow to the muscle, which can be compromised in a baby who is poorly perfused

• all drugs must be administered safely in accordance with unit/ward/hospital policy and meet the guidelines for administration of medicines

• drugs will need to be diluted prior to administration to allow for accurate measurement of the required dose.

• Unfortunately, mistakes in drug administration are not uncommon, and having two nurses/midwives calculate and check the dose will decrease the risk of an error occurring.

Before administering any drugs to a baby the midwife should always check that it is:

• the right drug• the right baby• the right route• the right dose• the right time. To avoid misinterpretation of doses

prescribed, only approved abbreviations should be used

Developmentally focused, family-centred care

• For parents, the birth of a baby is a mixture of joy, emotional exhilaration and relief. Most newborn babies are normal and healthy and few parents ever expect or consider the possibility of having a baby that is less than perfect

• So when a baby requires medical assistance the effect on the parents can be significant and force the family into a crisis that can be as devastating as bereavement. The parents' ability to resolve the crisis will depend on how realistically they perceive their baby's problems.

• parents should be given the opportunity to visit and meet some of the staff. They can be shown the room or area where their baby will be admitted, and a brief explanation of the various items of monitoring equipment may help to alleviate some of their fears about what will happen to their baby after it has been born

• Following the delivery and if possible, the parents should be allowed to hold or touch their baby, even if it is for just a few moments, before he is taken to the NNU.

• A supportive environment, in which the parents gain confidence in assuming the role of caregivers, is of fundamental importance to the general well-being of the baby

• In order to reinforce the parents' involvement in the care of their baby, it is important to discuss whether the baby is to be breast- or bottle-fed

• Breastfeeding or expressing milk may help the mother feel closer to her baby and may also make her feel that she is contributing to her baby's care in a way that nobody else can

• Minimal handlingCare should be individualized for each baby and not be performed routinely. This requires thoughtful planning to avoid repeatedly disturbing the baby. unnecessary procedures that are not vital to the individual baby's needs are stress-producing events and should be eliminatedDay and night cycles should be recognized, lights should be dimmed at nighttime and noise levels, which are often alarmingly high, should be reduced.

• Sibling relationshipsEncouraging brothers and sisters to visit their new baby is important. Parents are often anxious about the effect an ill baby may have on the family. However, this may cause anxiety in the siblings and they may feel worried, rejected and left out, causing them to demonstrate behavioural problems.

Discharge home• Effective discharge planning should

commence as soon as the baby is admitted to the NNU. Encouraging parents to participate in the care of their baby from the beginning enables them eventually to be the sole caregivers and assume total charge.

• Parents should learn how to feed, bathe, dress and generally care for their baby. If the baby has special needs like tube feeding or stoma care, training needs may span several weeks and must be backed up with written information. The parents must feel comfortable about caring for their baby before going home.

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Thank You!Thank You!

With best wishes ,Ayda khader 2015