Significant problems in the newborn baby

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1 Significant problems in the newborn baby
Ayda khader Feb. 2018

2 Initial Examination and recognition of problems

3 Content s The Skin . Respiratory System. Central Nervous System.
Introduction The Skin . Respiratory System. Central Nervous System. Renal And Genitourinary. Gastrointestinal Tract . Recognetion of problem at the time of resuscitation Seizures And Abnormal Movement

4 objective assist the midwife in the assessment and identification of the sick newborn baby summarize possible problems that may be identified in a newborn baby and offer an approach to dealing with them

5 Introduction The majority of newborn babies are born in good condition and require no intervention after birth except to be dried with a warm towel and then to have skin-to-skin contact with their mother. Labour and birth may have been straightforward but the baby may still need to be observed at this time to ensure a healthy transition from uterine to postnatal life Approximately 5–10% of babies will require admission to a neonatal unit.

6 Many of these are preterm babies or those with antenatally detected problems; however 6–9% of term babies will also require some type of neonatal care The length of time a mother spends in hospital with her newborn baby has decreased significantly in recent years and many babies may be born outside the hospital setting, at home or in a midwifery-led unit

7 Initial examination and recognition of problems
Most of the information the midwife requires for the assessment of a baby's wellbeing comes from observation. The normal term baby will lie with their limbs partially flexed and active, the skin colour should be centrally perfused, indicating adequate oxygenation, and there should be no rashes or skin lesions. After the initial observation there should follow a more systematic examination to ensure the newborn baby is well The following areas should be examined carefully

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9 The skin The skin of a neonate varies in its appearance and can often be the cause of unnecessary anxiety in the mother, midwife and medical staff. first sign that there may be an underlying problem in the baby. The presence of meconium on the skin, which is usually seen in the nail beds and around the umbilicus, in a baby with respiratory problems may indicate meconium aspiration as a factor. the skin of all babies should be examined for pallor, plethora, cyanosis, jaundice and skin rashes.

10 Pallor A pale, mottled baby may be an indication of poor peripheral perfusion, however the hands and feet are often blue soon after birth (acrocyanosis) and this does not indicate an underlying problem. Always examine the baby's face and chest when assessing colour. The anaemic baby's appearance is usually pale pink, white or, in severe cases where there is vascular collapse, grey. Other presenting signs are tachycardia, tachypnoea and poor capillary refill (CR) (press the skin briefly on the forehead or chest and observe how long it takes for the colour to return; this should be less than 2 seconds)

11 The most likely causes of anaemia immediately after birth are:
a history in the baby of haemolytic disease of the newborn (HDN) twin-to-twin transfusions in utero (which can cause one baby to be anaemic and the other polycythaemic) feto-maternal haemorrhage fetal haemorrhage from vasa praevia or bleeding from the umbilical cord.

12 respiratory disorders cardiac anomalies sepsis.
Significant pallor can be associated with: anaemia and shock respiratory disorders cardiac anomalies sepsis.

13 Plethora Babies who are very red in colour may be described as plethoric. Their colour may indicate a high level of circulating red blood cells (polycythaemia). Newborn babies can become polycythaemic if they are recipients of: twin-to-twin transfusion in utero a large placental transfusion.

14 Other babies at risk are:
Contributing factors may include deferred clamping of the umbilical cord or holding the baby below the level of the placenta . The diagnosis of polycythaemia is based upon levels of haemoglobin and haematocrit (the relationship between red blood cells and plasma in the blood) and how they compare with normal values, based on gestational age Other babies at risk are: small for gestational age babies. infants of diabetic mothers.

15 Cyanosis Peripheral cyanosis of the hands and feet is common during the first 24 hours of life Central cyanosis should always be taken seriously. The tongue and mucous membranes are the most reliable indicators of central colour in all babies if they appear blue this indicates low oxygen saturation levels in the blood, usually of respiratory or cardiac origin Episodic central cyanosis may be an indication that the baby is having convulsions.

16 Other factors that affect the appearance of the skin :
Preterm babies have thinner skin that is redder in appearance than that of term infants. In post-term babies, the skin is often dry and cracked. The skin is a good indicator of the nutritional status of the baby. The SGA baby may look malnourished and have folds of loose skin over the joints, owing to the lack or loss of subcutaneous fat. This can predispose the baby to hypoglycaemia due to poor glycogen stores in the liver and can also cause problems with hypothermia

17 If the baby is dehydrated, the skin looks dry and pale and is often cool to the touch. If gently pinched, the skin will be slow to retract. Other signs of dehydration are tachycardia, pallor or mottled skin, sunken eyes and anterior fontanelle. The best clinical indicator of dehydration is the baby's reduced weight.

18 Skin rashes Skin rashes are quite common in newborn babies but most are benign and self-limiting. There are some rashes, however, which may indicate significant illness and should not be ignored: Petechiae or purpura rash over the upper part of the body, particularly the face and chest, may occur due to venous obstruction after normal or prolonged birth. Petechiae can occur when there is a low platelet count and this may present with a petechial rash over the whole body with prolonged bleeding from puncture sites and/or the umbilicus and bleeding into the intestinal system.

19 Bruising can occur following breech extractions, forceps and ventouse-assisted births.
Vesicular rash is where small fluid-filled raised lumps occur on the skin associated with some congenital viral infections, in particular herpes simplex or congenital chicken pox. Blistering rash is where areas of skin are raised and are fluid-filled. The surface of the skin may also slough off, leaving red raw areas. This can occur in bacterial infections. A blistering skin rash should always be treated with broad spectrum intravenous (IV) antibiotics

20 The respiratory system 
Healthy babies should establish normal regular respiration within minutes of birth. Many babies may display a slightly irregular breathing pattern for a few minutes after birth but should have regular respiration with a respiratory rate of 40–60 by approximately 2 minutes. The baby's breathing pattern will alter depending on his/her level of activity but a respiratory rate consistently above 60 breaths per minute is considered as tachypnoea.

21 Cardiorespiratory adaptations at birth
Before birth the lungs are fluid-filled. At birth the newborn must clear this fluid in order to breathe successfully. Some fluid is removed by physical means during normal labour but most is absorbed into the pulmonary lymphatics and capillaries. The lungs inflate and remain inflated as a result of the presence of surfactant. In some preterm babies, IDM and sick term babies, surfactant production may be decreased, resulting in respiratory distress.

22 Newborn babies are obligate nasal breathers.
The shape of the newborn thorax and the rib orientation tend to mean that the expansion potential of the thorax is limited. The baby's soft and flexible ribs also make the chest wall subject to collapse during increased respiratory efforts. To compensate for this the baby tends to elevate lung volume at end expiration by a rapid respiratory rate, intercostal activity and grunting.

23 Clinical signs of respiratory distress in the newborn
Expiratory grunting is a characteristic noise and occurs due to partial closure of the glottis during expiration. The baby is attempting to preserve some internal lung pressure and prevent the airways from collapsing completely at the end of the breath. Intercostal recession uses the intercostal muscles more effectively, but as a result the spaces between the ribs and the sternum are sucked in during each breath.

24 Tachypnoea is an increased respiratory rate that occurs as the baby attempts to compensate for an increased carbon dioxide concentration in the blood and extracellular fluids. A normal respiratory rate in the newborn is 40–60 breaths per minute. Apnoea is an absence of breathing for more than 20 seconds and may occur as a result of increasing respiratory fatigue in the term baby. The preterm baby may also experience apnoea of prematurity due to immaturity of the respiratory centre and/or obstructive apnoea from occluded airways

25 Nasal flaring is an attempt to minimize the effect of the airways resistance by maximizing the diameter of the upper airways. The nares are seen to flare open with each breath.

26 Body Temperature

27 body temperature control
A neutral thermal environment is defined as the ambient air temperature at which oxygen consumption or heat production is minimal, with body temperature in the normal range The normal body temperature range for term babies is 36.5–37.3 °C. assert the importance of the neutral thermal environment and how everyone caring for babies should understand the need for maintenance of normal body temperature. Mothers are often hot during labour and measures may be taken to produce a cooler environment for the mother's comfort

28 Its important to always consider this effect and maintain a suitable environmental temperature for the newborn baby In addition to skin-to-skin contact, this may require extra measures like use of a radiant heater or cot warmer, in some circumstances An abnormal temperature, either high or low, can be an early sign of an underlying problem such as an infection, a respiratory or cardiac problem, a metabolic abnormality or encephalopathy.

29 Hypothermia is defined as a core body temperature below 36 °C
The hypothermic baby often looks pale or mottled and may be uninterested in feeding. When the body temperature is below this level the baby is at risk from cold stress. This can cause complications such as increased oxygen consumption, lactic acid production, apnoea and hypoglycaemia. In preterm babies cold stress may also cause a decrease in surfactant production, which is associated with increased mortality

30 Hyperthermia is defined as a core temperature above 38.0 °C
The usual cause of hyperthermia is overheating of the environment, but it can also be an important clinical sign of sepsis as the baby will attempt to regulate its temperature by increasing his/her respiratory rate leading to an increased fluid loss by evaporation through the airways. Other problems caused by hyperthermia are hypernatraemia, jaundice and apnoea.

31 Methods of heat loss Evaporation – wet surface exposed to air Conduction – direct contact with cool objects Convection- surrounding cool air - drafts Radiation – transfer of heat to cooler objects not in direct contact with infant

32 Central Nervous System

33 Assessment of a baby's neurological status is usually carried out on a baby who is awake but not crying. Important signs are the tone and quality of a baby's movements level of activity posture and presence of normal newborn reflexes. An abnormal posture such as neck retraction, frog-like posture, hyperextension or hyperflexion of the limbs, jittery or abnormal involuntary movements a high-pitched or weak cry,

34 abnormal movement in babies is very variable and includes fits, convulsions, seizures, twitching, jumpy and jittery. a baby with poor muscle tone is described as hypotonic or floppy. The jittery baby has tremors, rapid movement of the extremities or fingers that are stopped when the limb is held or flexed Jiferiness can be normal but is sometimes seen in babies who are affected by drug withdrawal or in babies with hypoglycaemia

35 Hypotonia Hypotonia describes the loss of muscle tension and tone.
the baby adopts an abnormal posture that is noticeable on handling. If hypotonia and a lack of movement have been significant features before birth then limb contractures may also be seen Preterm babies below 30 weeks' gestation have a resting position that is usually characterized as hypotonic

36 By 34 weeks their thighs and hips are flexed and they lie in a frog-like position, usually with their arms extended At 36–38 weeks' gestation the resting position of a healthy newborn baby is one of total flexion with immediate recoil Hypotonia in a term baby is not normal and requires investigation

37 causes of hypotonia in the newborn.
I Systemic causes maternal sedation or drugs (in particular some antidepressants) prematurity infection Down syndrome endocrine (e.g. hypothyroidism) metabolic problems (e.g. hypoglycaemia, hyponatraemia, inborn errors of metabolism)

38 II Central (brain) causes
perinatal hypoxia-ischaemia or neonatal encephalopathy traumatic brain injury structural brain abnormality, e.g. holoprosencephaly III Peripheral nervous system causes neurological problems (e.g. spinal cord injuries sustained by difficult breech or forceps assisted birth) neuromuscular disorders (e.g. spinal muscular atrophy, myasthenia gravis related to maternal disease, myotonic dystrophy etc.)

39 The Renal and Genitourinary System

40 Documentation of the passage of urine after birth is important as it provides a record that may help if later concerns arise. The genitourinary tract has the highest percentage of anomalies, congenital or genetic, of all the organ systems. Prenatal diagnosis is possible with ultrasound and aids the early assessment and intervention Urine that only dribbles out, rather than being passed with a good stream, may be an indication of a problem with posterior urethral valves

41 The healthy baby usually passes urine within 4–10 hours after birth
Urinary infections in the newborn period are uncommon. The signs of urinary tract infection are often vague and can be mistaken for other problems. The baby typically presents with lethargy, poor feeding, increasing jaundice and vomiting.

42 Reduced urine output is usually due to low fluid intake, often in breast-fed babies, but also consider: increased fluid loss due to hyperthermia, use of radiant heaters and phototherapy units perinatal hypoxia-ischaemia congenital abnormalities infection.

43 The gastrointestinal tract

44 Assess the baby's abdomen, looking for signs of distension, discoloration or tenderness.
Most babies should feed early and pass meconium within the first 8–12 hours of birth Healthy babies should be able to feed within 30 minutes of birth Vomiting can be a sign of a problem but the midwife should distinguish between possetting, which occurs with winding and over-handling after feeding, and vomiting due to overfeeding, infection or intestinal abnormalities

45 Bile-stained vomiting
There should never be green bile in the vomit of a newborn baby and this always requires prompt investigation may indicate bowel obstruction and in the newborn one of the possible causes is malrotation and volvulus lead to bowel damage and bowel loss if not promptly investigated If bile-stained vomiting is seen or reported, check the baby carefully looking for abdominal distension or tenderness. Check that the anus is patent.

46 An X-ray and contrast study is usually required to rule out bowel obstruction and malrotation
Other possible causes include infection, bowel atresias, meconium ileus, anorectal malformations or necrotizing enterocolitis (NEC). NEC is generally a problem in premature babies but may also occur in term babies, particularly those who have risk factors such as perinatal hypoxia polycythaemia hypothermia

47 Necrotizing Enterocolitis (NEC)
an acquired disease of the small and large intestine caused by ischaemia of the intestinal mucosa. NEC may present with vomiting and this may be bile-stained. The abdomen becomes distended, stools may be loose and may have blood in them or the baby may not open its bowels. In the early stages of NEC, theres non-specific signs of : temperature instability, unstable glucose levels, lethargy poor peripheral circulation. As the illness progresses, the baby may become apnoeic and bradycardic and may need respiratory support

48 Passage of meconium 97% of babies will pass meconium by 24 hours of age, an event that should be documented. If a baby has not passed meconium ,examine the abdomen for signs of distension or tenderness. Check that the anus is patent causes of delayed passage of meconium include : bowel atresia, meconium ileus imperforate anus Hirschsprung's disease

49 suspected in term babies with failure to pass meconium in the first 48 hours aher birth. Passage of first meconium occurs later with earlier gestational age normal term baby usually passes about eight stools a day. Breastfed babies' stools are looser and more frequent than those of bottel-fed babies, and the colour varies more and sometimes appears greenish Loose stools can also be a feature of babies receiving phototherapy.

50 Neonatal encephalopathy
Neonatal encephalopathy is a clinical syndrome of abnormal levels of consciousness, tone, primitive reflexes, autonomic function and sometimes seizures in newborn babies The commonest cause is hypoxia-ischaemia, termed hypoxic ischaemic encephalopathy (HIE)

51 Encephalopathy can be due to:
cord obstruction (prolapse or compression) placental abruption breech shoulder dystocia Infective malformation trauma

52 a neonatologist should be asked to review any baby when:
the heart rate remains <100 for more than 1 minute normal respiration is not established by 5 minutes of age the Apgar score is <5 at 5 minutes gasping respiration is seen cord pH <7.0.

53 Neonatal encephalopathy is often classified according to a grading system :
Grade 3 (severe) Grade 2 (moderate) Grade 1 (mild) Decreased consciousness Hypotonia Frequent prolonged seizures Multi-organ involvement – breathing, kidneys, blood pressure affected Absent gag/sucking reflexes Lethargy, hypotonia Seizures Poor suck/ feeding for >24 hours Hyper-alert, staring Mild decreased tone/ activity Poor feeding for up to 24 hours Clinical features Intensive care, cooling Will need neonatal admission. May require cooling May be able to stay with mother on postnatal ward but needs observation/ feeding support Management Generally poor Death or significant neurodisability likely, but with cooling approximately 70% die or have major disabitly Most recover well but up to 25% may have long-term neurological problems. Cooling has significant benefits. Complete recovery, normal outcome Outcome

54 seizures and abnormal movements

55 Seizures in the newborn period can be difficult to recognize
its an important indicator of potentially serious problems and their recognition is therefore important. most common cause is neonatal encephalopathy, most commonly hypoxic ischaemic encephalopathy (HIE) but readily treatable causes such as hypoglycaemia must not be missed. Seizures in newborns differ from those in later life. They are often subtle and difficult to differentiate from other normal behaviour

56 Causes of seizures Seizures in the newborn almost always have an identifiable cause, e.g. HIE (49%) cerebral infarction (neonatal stroke) (12%) cerebral trauma (7%) infections (meningitis or encephalitis) (5%) metabolic abnormalities, including hypoglycaemia (3%) narcotic drug withdrawal (4%).

57 Jitteriness is symmetrical rapid movements of the hands and feet.
It is important to distinguish seizures from jitteriness and neonatal sleep myoclonus, both of which are benign. Jitteriness is symmetrical rapid movements of the hands and feet. It is often stimulus-sensitive and may be initiated by sudden movement or noise and there are no associated eye movements. sleep myoclonus involves bilateral or unilateral jerking during sleep It occurs during active sleep, is not stimulus- sensitive and tends to be seen in upper limbs more than lower limbs.

58 newborn is not at risk from the seizure
ensure that the airway is clear and the baby is breathing. Ensure that readily treatable causes are identified and treated. check the blood sugar to exclude hypoglycaemia, and electrolytes to include calcium and sodium; also consider infection. Hypocalcaemia can be a readily treatable cause of seizures in women with vitamin D deficiency

59 Thanks