1. Neonatal Guidelines Dr Lesley Peers Consultant Paediatrician 5 th November 2013

2. Why bother? Primary care, STH, SCH and community services all deal with neonates Pathways are developed by one team that have an impact on other teams All neonates in Sheffield should be treated the same

3. Neonatal Guidelines Prolonged jaundice  Very common  NICE guideline  Developed from SCH guideline Weight loss/poor weight gain  Very common and usually due to feeding issues  STH guideline

4. Pale stools or unwell baby Well thriving baby with yellow stools Refer to AAU team Term baby with jaundice at 14 days Preterm baby (<37 weeks) at 21 days Book into Jaundice clinic – phone 0114 2717000 and ask to be put through to the jaundice clinic – need name, DOB, carer’s name and contact details, address, GP, ethnicity and religion. Jaundice clinics run Mon, Wed, Fri afternoon History (when did the jaundice start? how is baby fed? colour of urine and stools?) Examination (Is the baby well? is the baby dysmorphic? Thriving? Hepatosplenomegaly? handles normally?) Unwell – investigate for infection or Galactosaemia as well as “well baby” bloods Pale stools – conjugated screening tests (see guideline) Well baby FBC, blood film, direct Coombs’ test LFTs incl conjugated SBR (check result the same day) Free T4, Gal-1-Puridyl transferase Urine for M,C&S Conjugated SBR – urgent clotting and refer to gastro-hepatology team (Dr Connolly, Dr Narula, Dr Thomson) Arrange FU depending on results NB Isolated raised GGT is not significant

5. Causes Unconjugated  Prolonged physiological  Breast milk jaundice  Haemolysis  Crigler-Najjer syndrome Conjugated  Sepsis  Galactosaemia  Obstruction to biliary flow Intrahepatic – Alagille syndrome Extrahepatic – Biliary atresia

6. History Method of feeding Weight gain/loss When did the jaundice start? Colour of urine and stools?

7. Examination Is the baby well? Is the baby dysmorphic? Is there hepatosplenomegaly? Is the baby thriving?

8. Investigations NICE  FBC, DAT  Split bilirubin  Ensure Guthrie has been done  Urine culture SCH/STH  As above but Free T4 instead of relying on Guthrie  Gal-1-put

9. Follow up Admit for further investigations if there is conjugated hyperbilirubinaemia Repeat SBR if SBR>200 Treat UTI and investigate

10. Newborn weighing guideline Most babies lose some weight in 1 st few days Continuing weight loss in breast fed baby usually due to ineffective milk transfer Continuing weight loss in bottle fed baby is less common Most have regained birth weight by 14 days

11. Previously Monitored in community – may not have been referred Referred to SCH and seen as an acute admission Lack of breast feeding advisors at SCH Health professionals reassured that can’t be dehydrated if no signs of dehydration. NB Newborns with hypernatraemic dehydration do not exhibit the classical signs

12. 72 hours <7% weight loss – assess baby, feeding history, continue 7-10% - assess baby, feeding history, start a feeding plan, reweigh in 2-3 days >10% refer to Jessop  Telephone discussion - if well and milk just coming in may let midwife review the next day  Tend to do U&Es if >12% weight loss

13. Days 5-7 Gained/static weight – assess baby, feeding history, continue Weight loss – assess baby, feeding history, start or continue feeding plan, reweigh next day and refer if lost weight >10% - refer to Jessops  Telephone discussion - if well and milk just coming in may let midwife review the next day  Tend to do U&Es if >12% weight loss

14. Days 8-11 Back to birth weight – continue Below BW but gaining weight or static weight or weight loss<10% - assess, feeding plan, reweigh next day if static weight, reweigh in 2-3 days if gaining weight  If not gaining weight – refer to STH – usually still a feeding issue, or SCH  May be given advice over the phone

15. Day 14 Back to BW and gaining >30g per day – discharge Back to BW but gaining <30g per day – refer to Breastfeeding peer support, continue with feeding plan, reweigh in 7 days, plot weight on growth chart Not regained birth weight – refer to SCH  If gaining well but still below BW midwife may be given advice

16. Not regained birth weight Feeding history and examination If lost a lot of weigh initially but gaining weight adequately but not yet back to birth weight – reassure If slow weight gain despite good feeding plan – baseline investigations – FBC, U&Es, TFTs and urine culture

17. Day 21 Weight gain <20-30g per day or static – refer to breastfeeding peer support, discuss feeding plan and reweigh at 28 days, plot weight Weight falling 1 or more centile – refer to GP

18. Day 28 Weight gain <20-30g per day or static – refer to GP Weight falling 1 or more centile – refer to GP

19. Causes of poor weight gain Are they getting enough feed?  Bottle fed babies should gain weight on 150 mls/kg/day  Is the baby gaining weight when top-ups have been introduced Have they been unwell and had reduced feeding?  Blocked nose, bronchiolitis  Are they vomiting?

20. Causes 2 Do they have reflux/cow’s milk protein intolerance? Other medical causes – cardiac, respiratory, renal, thyroid UTI

21. Questions