Neonatal problems November 14 th 2012 Aims Neonatal

Neonatal problems November 14 th 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 talking If they need referral then send to ENT

• Cleft palates can be a routine OPA with paeds. False Refer 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 optometry Ask about: FHx Parents noted Bilateral reflexes

Chest • Only cardiac murmurs found after 6/52 need referral. False All 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/ASD Take 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 1 yr of age when requires referral to paeds. False Could 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 1 yr if unable to find the other one…routine referral

• Hypospadias requires urgent referral to paeds. False Routine referral to paeds Usually seen in combined clinic Surgery is timed to avoid problems with potty training 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 bifida Look for hair, tone & power of lower limbs Routine OPA

• All babies with talipes require a referral to paeds. False Check 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. True Swab 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 1 yr 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 100 mls/kg/24 hrs False They need 150 mls/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 1 yr 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, rhinovirus, adenoviruses • Recovery lasts for 7 -10 days

• Whooping cough vaccines need to be given to pregnant women between 28 -32 wks gestation. True Gives 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 48 hrs – Locomotor delay/leg weakness – Abdominal distension with vomiting – Abnormal abdo, leg, spinal exam

• Faltering growth is an amber flag True Treat 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 > 2 cm need referral to paediatrics True At risk of malignant change Not usually before puberty

Sleeping habits • Newborn babies sleep for 16 hrs 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. False Sleep 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 True Most 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