Neonatal problems

November 14th 2012

Aims

• Neonatal and 6-8/52 exam• Common problems:

• Feeding• Breathing• Infection• Constipation• Skin• Sleep • SIDs

Newborn and 6/52 check• Head to toe…

– General– Head

• Fontanelles• Eyes• Palate• Tongue• Ears

– Chest– Abdo

• Umbilicus• Genitals• Anus

– Spine– Hips & femorals– Feet– Skin– Tone

HEAD

• All tongue ties require referral for surgery.

False

Only requires surgery if interferes with feeding talkingIf they need referral then send to ENT

• Cleft palates can be a routine OPA with paeds.

FalseRefer into cleft palate specialist team – they link in with Leeds if requires surgery

Help with specialist feeding bottles and support

Cleft palate, unilateral cleft palate, bilateral cleft palate

• Absent red reflexes indicate congenital cataracts.

True Requires referral to opthalmology

• Squints do not require referral to secondary care – they always correct themselves.

False

Require referral into paediatric optometryAsk about:

FHxParents notedBilateral reflexes

Chest• Only cardiac murmurs found after 6/52 need referral.

FalseAll murmurs (if I can hear them!) should be referred into paeds – particularly if doing neonatal check – when ductus arteriosus (aorta to pulmonary artery) closes baby could collapse.Refer if there is no murmur but they are symptomatic including cyanosis, breathlessness, not feeding, ‘not quite right’3 main causes : valve problems, narrowing (ie coarctation) holes – PDA/VSD/ASDTake home points: if it’s loud/diastolic/harsh/sick ADMIT Routine referral to Consultant of the Week

• Absent femoral pulses are diagnostic of Tetralogy of Fallot

False…indicates coarctation of aorta.

Pelvis

• Imperforate anus requires urgent referral to paeds and surgical intervention.

True

Remember to ask re bowel habits ie meconium…

• Bilateral undescended testes can be monitored until 1yr of age when requires referral to paeds.

FalseCould be female baby

Could have CAH and at risk of fits/serious illness and death

If there is one that is present then refer at 1yr if unable to find the other one…routine referral

• Hypospadias requires urgent referral to paeds.

FalseRoutine referral to paeds

Usually seen in combined clinic

Surgery is timed to avoid problems with pottytraining

Need to avoid being circumcised prior to repair

Case study…

• Risk factors for DDH include:• Female gender• Breech• Twin• FHx• Oligohydramnios

True All above are risk factors

Look at leg creases

Requires an USS at 6/52

Routine referral to paeds with results of USS

Spine• Referral is required if cannot see the bottom of a sacral

pit

True

Implication is of spina bifidaLook for hair, tone & power of lower limbsRoutine OPA

• All babies with talipes require a referral to paeds.

FalseCheck if positional in neonatal check

If still present at 6/52 or not correctable then refer to paediatric physio via paeds

Red Book

• Weigh, measure and plot!

Sticky eyes• Chlamydia, gonorrhoea, GBS, staph a and

pseudomonas can all cause conjunctivitis in the neonate.

TrueSwab for MC&S and treat with results

Admit if unwell - obviously!!!!

• Blocked tearducts need to be referred if not resolved by 6 months.

False

Refer to opthalmology at 1yr if not resolved but most do

Affects 1 in 5 babies

Can be unilateral/bilateral

Do nothing/ massage and keep eye clean

Feeding• Breastfeeding is a piece of cake and anyone can do it

straightaway.

FALSE!!!!

Baby Friendly Initiative implemented

Good support from midwives and health visitors

• Up to 6/12 of age babies need 100mls/kg/24hrs

False

They need 150mls/kg but should feed on demand initially

–Newborns feed three hourly, –6/52 feed four hourly, –6-16/52 reducing down as baby starts to sleep through the night –Some babies cluster feed in the evening

GORD• Nearly all symptomatic reflux will have resolved by 1yr of

age

True• ? Related to feeding/posture/maturation of sphincter• Frequent small meals• Gaviscon• Mild sx responds to thickener

– Carobel, Thick’n’easy, actimel antireflux• Cow’s milk free diet

– Nutramigen

Vomiting• Daily vomiting is not common in children at the age of 4/12

False

Regurgitation occurs at least once per day: 50% of infants between 0–3 months 67% of infants at 4 months 5% at 10 to 12 months of age

Often caused by rotavirus – will be vaccination soon

Colic• Infantile colic occurs in up to 20% of children?

– True• Differential diagnosis:

– OM– Strangulated hernia– UTI– Anal fissue– Intussusception

• Treat with infacol• Colief if they are lactose intolerant

Oral candidisis• Oral thrush always needs treating in the baby

False only treat if mum/baby is symptomatic (ie

painful/affecting feeding

Treat with nystatin solution for baby and topical miconazole for mum

Breathing problems• 90% of cases of bronchiolitis are caused by respiratory

syncytial virus

True• Parainfluenza, influenza, rhinovirus, adenoviruses• Recovery lasts for 7-10 days

• Whooping cough vaccines need to be given to pregnant women between 28-32wks gestation.

TrueGives immediate but short-lived immunity to newborn

Transmitted by droplets

7-14 day incubation period

5/7 exclusion (nursery) from start of Abx

Azithromycin, clarithromycin, erythromycin

Constipation• Red flags include:

– From birth/first few weeks

– Ribbon stools

– No meconium within 48hrs

– Locomotor delay/leg weakness

– Abdominal distension with vomiting

– Abnormal abdo, leg, spinal exam

• Faltering growth is an amber flag

TrueTreat constipation

Ix for hypothyroidism and coeliac disease

Consider maltreatment

• Refer urgently

• It is important to discuss diet and fluid intake with parents/guardians.

True. • Medication steps include:

– 1. macrogol– 2. lactulose– 3. senna

• Behavioural measures

Skin• Nappy rash can have secondary infection which requires

treatment

True

Treat with antifungal (canestan/timodine)

More likely to be fungal if spread to flexures

Persists despite tx and hygiene measures/avoidance of detergents then non-urgent referral

• Naevus > 2cm need referral to paediatricsTrue

At risk of malignant changeNot usually before puberty

Sleeping habits• Newborn babies sleep for 16hrs per day

True– At about 8/52 babies should be starting to get used to

sleeping in a cot and being put down to sleep whilst they are still awake…

• Newborn babies should sleep in their parents bed until they are 1.

– Ummm definitely not!!!– Sleep in the same room for first 6 months

• Newborn babies should sleep in their parents bed until they are 1.

FalseSleep in the same room for first 6 months

Can lay on front if is being observed from about 8/52

Cot death• 90% occur within the first 6/12 of life

TrueMost occur during the second month then risk gradually reduces– Risk factors include:

• Parental smoking• laying baby on front or side to sleep• Male• Prematurity• Low birth weight• Formula feeding

Cot death

Summary• If in doubt call the friendly paeds reg/consultant – better

to be safe than sorry.

References• Nice Guidelines: Routine postnatal care of women and

their babies 2006• www.patient.co.uk• Department of Health (2005) Reduce the risk of cot

death: an easy guide. London: Department of Health. Available from: www.dh.gov.uk

• Nice Guidelines: Constipation in children and young people