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Flashcards in Recognising the sick neonate Deck (25):
1

How do you recognise the ill baby?

Listen to parents – you only see baby for approx 10 minutes Examine the baby undressed Observation of the baby’s appearance and behaviour is the first and most important stage of clinical assessment’ (Lumsden & Holmes (2010)) Record observations (e.g. TPR, O2 sats, Blood glucose, SBR, weight, BP) Get an accurate feeding history and if necessary watch feed Elimination – check nappy Refer if concerned

2

What should you assess?

ABC- Airway - Breathing-Circulation Colour Temperature Behaviour- Crying-Abnormal movements -Fits Feeding Vomiting Elimination Physical signs of infection

3

Meconium aspiration syndrome (MAS)

Babies at risk: term and post term, hypoxia in labour At birth if meconium is present in the liquor then care needs to be taken with resuscitation Handle gently If not breathing :check for meconium, suction under direct supervision only If crying and breathing: observe for signs of RDS over the next 12 hours (mec obs according to trust policy)

4

Noisy or difficult breathing

Grunting –Hypothermia or septicaemia Nasal flaring, Intercostal recession, Sternal recession –TTN and RDS –Obstructed airway Tachypnoea – consistently over 60/min –TTN and RDS –Pneumonia –Congenital heart disease –Metabolic acidosis

5

Transient tachypneoa of the newborn (TTN)

Transient tachypnea of the newborn (Full Term and preterm, more often boys) Birth to 48 -72 hours, ‘wet lungs’ (usually presents 2-4 hrs after birth) Almost always term babies following ELLSCS Rapid difficult breathing, grunting or moaning on expiration Usually mild but may progress to cyanosis and need oxygen or CPAP rarely ventilation Infection screen to exclude pneumonia X-ray to exclude other problems if needs treatment ?antibiotic therapy Nursed in SCBU Usually resolves itself

6

Respiratory Distress Syndrome (RDS)

Caused by a deficiency of surfactant (Cameron 2010) Factors that increase incidence Commonest respiratory disease of preterm infants and major underlying cause of death (incidence 80% babies up to 28/40, 50% up to 33/40) Can also occur in term infants if there is perinatal hypoxia, infants of diabetic mothers, pre-labour LSCS Factors that decrease incidence Stress in utero and narcotic addiction Steroids to mother at risk of pre-term delivery (24-34/40) diminish the risk/reduce the severity of RDS (pre-term labour guidelines (NICE, 2

7

What are the signs of RDS?

Tachypnoea/increased respiratory rate Apnoeic episodes Grunting Nasal flaring Sternal and intercostal recession Peripheral or Central cyanosis Cameron (2010) Onset usually within 1st 4 hours of birth

8

What is the treatment of RDS?

Surfactant (via ET tube) O2 with ventilation if needed Maintain temperature Biochemical balance Nutrition (IV if ventilated) NICU

9

What does the colour of a baby show?

Cyanosis when breathing–Congenital heart problems Cyanosis with apnoea–Investigate cause of apnoea Grey – shocked and very sick babies look grey rather than white Jaundiced- always suspect infection if pathological

10

How does temperature affect newborns?

Raised temperature: Usually from overheating - dangerous–Can present with some infections Hypothermia: May contribute to sickness if from chilling–Sepsis–Underfeeding/ hypoglycaemia–Intercranial bleeding–Baby must be warmed slowly if true hypothermia

11

What is the hypothermia (WHO def)?

•Mild – 36-36.4 –Skin to skin and hat –Ensure baby has fed –Full set of observations and repeat after 1 hour –Refer if worried •Moderate 32-35.9 –Follow trust policy for warming and feeding –Check blood sugar level –Paediatric referral •Severe <32–Paediatric emergency

12

What types of attitude and behaviour in a neonate would require paediatric assessment?

Floppy (hypotonia) Too tense (hypertonia) or clenched fists Not moving when awake or asymmetry of movements Persistent failure to latch on to the breast or suck Persistent head retraction

13

What are the causes of hypotonia?

Normal in preterm baby before 34 weeks Down’s syndrome Cerebral injury Hypoglycaemia or hyponatraemia (level of sodium in your blood is abnormally low. Sodium is an electrolyte, helps regulate amount of water in and around your cells) Infection Maternal drugs crossing the placenta especially diazepam and opiates Congenital conditions

14

What is an abnormal cry?

Persistent crying–Some babies do!–Hunger – investigate feeding–Wind/colic–Does baby appear to be in pain Grimace Avoidance of moving Cries when disturbed/handled Shrill, high pitch cry–Mild encephalopathy–‘Cri du Chat’ (chromosomal condition, very rare- high pitched/meow cry)

15

What are abnormal movements in a neonate?

Eyes rolling or crossing Neonatal fits: –Brief jerking or twitching of a single limb which move from one part of the body to the other –Sometimes this is so rapid it looks generalised –Generalised tonic seizures with hyperextension –Momentary changes in respiration, eye movement, drooling, lip smacking

16

What are the causes of neonatal fits?

Encephalopathy Cerebral haemorrhage or oedema from birth trauma or head injury Infection Metabolic disturbances and inborn errors of metabolism Structural abnormalities in brain Drug withdrawal Benign familial neonatal seizures Toxins

17

What is the management of neonatal fits?

Investigate cause Treat cause Anticonvulsants –Phenobarbital –Clonazepam or diazepam or phenytoin Prognosis depends on cause, frequency and length of time fitting

18

What are certain neurological problems in the newborn?

Birth injury or perinatal asphyxia leading to intracranial haemorrhage –Subdural –Intraventricular –Subarachnoid Encephalopathy- Hypoxic-ischaemic encephalopathy (HIE) syndrome is graded: mild (grade 1)(may not fit much), moderate (grade 2) and severe (grade 3) (severe fitting)

19

What is the idea behind therapeutic hypothermia?

Therapeutic hypothermia helps to protect brain following severe perinatal asphyxia Cool within 6 hours of birth to between 33°C and 35 °C for a maximum of 72 hrs NICU Warm up slowly(NICE, 2010) Prognosis will depend on severity of HIE

20

What are the causes of certain feeding behaviour?

Does not demand feeds –Affected by maternal medication/drugs? –Jaundiced? –Other? Too tired to suck long –Preterm? –Prolonged crying or disturbance? –Underfed or sick?

21

What are the features of dehydration?

Dry mouth Dry wrinkled inelastic skin Little darker urine and infrequent stool Sunken fontanelle and eyes Tachycardia, hypotension and greyish pallor Excessive weight loss

22

What are the causes of vomiting in newborns?

Common in 1st two weeks (posseting, oesophageal reflux, swallowed blood at birth) Refer if : persistent baby not keeping down any feed, if it contains bile, (obstruction or cerebral problem) is combined with diarrhoea (gastoenteritis)

23

What is abnormal urine or stool in a neonate?

Few urinary signs except reduced volume if underfed Stools- check for meconium plug Delayed changing stool–Undernutrition

24

What are the obvious signs of infection?

Eyes Paronychia (fungal infection of the nails) Mastitis Rashes Umbilicus Thrush Cuts/abrasions Odd smell?

25

What is the management for Group B Streptococcal Infection (RCOG, 2017)?

Universal screening not recommended Screening if woman presents with risk factors only (having a previous baby with GBS disease discovery of maternal GBS carriage through bacteriological investigation during pregnancy (for example, a urine infection or a swab taken to investigate a vaginal discharge) preterm birth prolonged rupture of membranes suspected maternal intrapartum infection, including suspected chorioamnionitis pyrexia IAP (intrapartum antibiotic prophylaxis) for women with previous pregnancy GBS, current pregnancy GBS, pyrexial in labour Can have a pool birth if having IAP IAP recommended: 3g Benzylpenicillin at beginning of labour then 1.5g benzylpenicillin every 4 hours