1. Chapter 3 Problems of the neonate Low birth weight babies

2. Case study: Jonah
Baby Jonah just born at 30 weeks gestation. Weight is 1.4kg He is floppy, 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.

3. What are the stages in the management for any sick child?

4. Stages in the management of a sick child (Ref. Chart 1 p.xxii)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Discharge planning
Follow-up

5. What emergency and priority signs have you noticed from the history and from the picture?

6. Triage Emergency signs (Ref: p2,6) Obstructed breathing
Severe respiratory distress
Signs of shock
Coma
Convulsing
Severe dehydration
Priority signs (Ref: p.6)
Severe wasting
Oedema of feet
Palmer pallor
Young infant
Lethargy, drowsiness
Irritable and restless
Major burns
Any respiratory distress
Urgent referral note

7. Triage Emergency signs (Ref: p2,6) Priority signs (Ref: p.6)
Obstructed breathing
Severe respiratory distress
Signs of shock
Coma
Convulsing
Severe dehydration
Priority signs (Ref: p.6)
Severe wasting
Oedema of feet
Palmer pallor
Young infant
Lethargy, drowsiness
Irritable and restless
Major burns
Any respiratory distress
Urgent referral note

8. What emergency measures are needed for this newborn baby?

9. Assessment of newborn at delivery
Dry and stimulate baby with clean cloth and place where the baby will be warm
Look for:
Breathing or crying
Good muscle tone
Colour pink NO
Call for Help, check HR, attach sats probe if available
Remember A, B, C - added

10. Start resuscitation now Airway, Breathing Circulation
Assessment of newborn at delivery
YES NO
Start resuscitation now
Early Essential
Remember: A,B,C
Newborn Care
Airway, Breathing Circulation
Does baby Jonah need resuscitation?
Call for Help, check HR, attach sats probe if available
Remember A, B, C - added

11. (Ref. WHO pocket book p.47) NEW SLIDE Moved from chapter 3
Highlighted A B C

12. Neonatal resuscitation
(A=Airway)
Open airway by gently positioning the head in the neutral position (Ref. p. 47)
Clear airway and suction, only if necessary
Give oxygen, as necessary
Baby Jonah is still not breathing well

13. Neonatal resuscitation
(B = Breathing)
Use a correctly fitting mask:
If the baby is still not breathing after opening the airway (Ref. p. 47) :
Check position and mask fit
Continue to give breaths at rate of 40 breaths per minute, be gentle and do not overinflate
Use oxygen if available
Every 1-2 minutes stop and see if the pulse or breathing has improved
Merged slide 5/6 –
Give the baby 5 slow ventilations with bag (Ref. p )
Check the heart rate

14. Neonatal resuscitation
(C=Circulation)
Check the heart rate (HR)

15. Progress
After brief resuscitation just 30 seconds with bag and mask ventilation, the baby has spontaneous breathing and the heart rate was up to 120/minute.
Mild chest indrawing, SpO2 91% on 0.5L oxygen

16. Early Essential Newborn Care
Dry with a clean cloth
Maintain skin-to-skin contact
Give the baby to mother as soon as possible, on chest or abdomen
Cover the baby to prevent heat loss
Breastfeeding
Start breast feeding in the first hour
Keep mother and baby together
Further Management:
Give vitamin K (phytomenadione) 1 ampoule IM
Apply antiseptic ointment or antibiotic eye drops (e.g. tetracycline) to both eyes once
Examination and weight

17. What further measures will you take?

18. Management of VLBW babies
Maintain temperature C (Ref p.58)
Oxygen via nasal prongs / catheter
Target SpO %, not higher
IV glucose / saline
Fluids 60ml/kg/day on first day of life
Initiation of breast milk feeding (including colostrum)
Aminophylline (or caffeine) for apnoea
Penicillin and gentamicin
Phototherapy if jaundice
Vitamin K

19. Investigations Full Blood Examination
Haemoglobin: 180 gm/L ( )
Platelets: 175 x 109/L (84 – 478)
WCC: 5.1 x 109/L (5 – 25.0)
Neutrophils: 2.1 x 109/L (1.5 – 10.5)
Lymphocytes: 3.0 x 109/L (2.0 – 10.0)

20. Investigations continued
Blood sugar: 3.8 mmol/l (2.5 – 5.0)
Blood culture: No growth
Chest X-ray:
Bilateral opacities (white lung fields) with air bronchograms

21. Progress
On day 3 baby Jonah’s general condition looks better. His RR is 52/min with mild chest indrawing, SpO2 94% on 0.5 L/min oxygen. His abdomen is soft and passed meconium. So he is commenced on feeding with expressed breast milk (EBM) 3 ml every 2 hours by nasogastric tube.
The next day he looks lethargic and jaundiced and has some further apnoeas. SpO2 82% despite oxygen. His abdomen is distended and there is bile stained nasogastric aspirate.

22. What may be the cause of his deterioration
What may be the cause of his deterioration? What investigations you will do now?

23. Investigations Full Blood Examination
Haemoglobin: 135 gm/L ( )
Platelets: 57 x 109/L (150 – 400)
WCC: 3.1 x 109/L (5 – 25)
Neutrophils: 0.9 x 109/L (1.0 – 8.5)
Lymphocytes: 2.2 x 109/L (2.0 – 10.0)

24. Investigations Blood glucose 3.2 mmol/l (3.0 – 8.0)
Serum Bilirubin 294 µmol/L (277 UC / 17 C)
Abdominal X-ray

25. What may be wrong? How will you manage the baby?

26. Progress Likely diagnosis is necrotising enterocolitis (NEC).
Jonah’s feeds are withheld. 10% glucose % 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.

27. What complications might occur in a VLBW baby?
General
Hypothermia
Hypoglycaemia
Infection
Anaemia
Jaundice
Respiratory
Apnoea
Hypoxaemia
RDS
Gastrointestinal
Feeding intolerance
Necrotising enterocolitis
CNS
Intracranial haemorrhage
Developmental problems

28. What complications did occur?
General
Hypothermia
Hypoglycaemia
Infection
Anaemia
Jaundice (p.64)
Respiratory
Apnoea (p.61)
Hypoxaemia
RDS
Gastrointestinal
Feeding intolerance (p.60)
Necrotising enterocolitis (p.62)
CNS
Intracranial haemorrhage
Developmental problems

29. Summary
Baby Jonah was delivered prematurely. He needed brief resuscitation after birth. He was managed for prematurity and respiratory distress. He was commenced on oxygen, antibiotics and IV fluid. He had some apnoeas early but these improved with aminophylline.
He developed necrotising enterocolitis after commencement of feeding on the third day of life. This was treated with a change in his antibiotics for 10 days and stopping feeds for 5 days.
Breast milk feeds were restarted after 5 days and very slowly increased. This time feeds 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.

30. Follow-up – review monthly and check for
Nutrition
Monitor the child’s growth chart each month (weight, length and head circumference
Mothers may have limited milk supply – Susu Mamas
Multivitamins and zinc
Anaemia
Iron deficiency common, start iron when babies 6 weeks of age
Look for development complications
Cerebral palsy, visual and hearing problems
Infections
Pneumonia, bronchiolitis and diarrhoea common