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, brief periods of apnoea, and heart rate of 80/min. The mother had no antenatal care and rupture of membranes for 26 hours prior to delivery.

3. 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

4. What emergency or priority signs does baby Jonah have?

5. Triage Emergency signs (Ref: p2,6) Obstructed breathing
Severe respiratory distress
Signs of shock
Coma
Convulsing
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable, lethargic
Referral
Malnutrition
Oedema of both feet
Burns

6. Triage Emergency signs (Ref: p2,6) Obstructed breathing
Severe respiratory distress
Signs of shock
Coma
Convulsing
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable, lethargic
Referral
Malnutrition
Oedema of both feet
Burns

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

8. 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

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

10. Neonatal resuscitation
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

11. Neonatal resuscitation
Check the heart rate (HR)

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

13. 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
Cord care – chlorhexidine swab
Examination and weight

14. Treatment of VLBW babies

15. Management of VLBW babies
Maintain temperature C (Ref p.58)
Oxygen – if needed - via nasal prongs
Target SpO %, not higher
IV glucose / saline
Fluid 60ml/kg/day on first day of life
How many ml/hour for Jonah?
Commence breast milk feeding (including colostrum)
Aminophylline (or caffeine) for apnoea
Penicillin and gentamicin
Phototherapy if jaundice
Vitamin K

16. Investigations Full Blood Examination
Haemoglobin: 160 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)
Blood glucose: 3.8 mmol/l (2.5 – 5.0)
Blood culture: No growth

17. Progress
On day 2 Jonah’s condition was better. Eyes open and active. RR is 46/min with mild chest indrawing, SpO2 94% on air. His abdomen was soft and passed meconium.
So commenced feeding with expressed breast milk (EBM) 3 ml every 2 hours by nasogastric tube.
What is the target feed for Jonah? (Ref p. 57 and 60)
90ml/kg/day, Jonah is 1.4kg, 2 hourly feeds →
(90 x 1.4) / 12 = 10.5 ml every 2 hours

18. Progress
The next day he looks lethargic and jaundiced and has some further apnoea. SpO2 82%.
His abdomen was distended and there was bile stained nasogastric aspirate.

19. What may be the cause of this deterioration
What may be the cause of this deterioration? What investigations you will do?

20. Investigations Full Blood Examination
Haemoglobin: 110 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)

21. Investigations Blood glucose: 3.2 mmol/l (3.0-8.0)
Serum bilirubin: 294 µmol/L
Abdominal X-ray

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

23. Progress Likely diagnosis is necrotising enterocolitis (NEC).
Jonah’s feeds are withheld. 10% glucose + NaCl was given intravenously.
Metronidazole added to benzylpenicillin and gentamicin.
Oxygen
Aminophylline was continued for apnoea
Phototherapy for jaundice.

24. 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

25. 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

26. Summary
Baby Jonah was delivered prematurely. He needed brief resuscitation after birth. He was commenced on oxygen, antibiotics and IV fluid. He had some apnoea early but these improved with aminophylline.
He developed necrotising enterocolitis after commencing feeding on the 2nd 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.

27. 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