COMMON NEWBORN ISSUES

PCC conference

Case

Joe is a now 4 day old term male AGA infant presenting for his first visit following discharge from the newborn nursery. His nursery course was uncomplicated. Mother is exclusively breastfeeding. His BW was 3.26 kg. His weight today is 2.90 kg.

What are your objectives for this infant’s first pediatric visit following hospital discharge?

Assess Family Readiness (accepting help from family, never hit/shake baby, make time for yourself, post-partum blues)

Infant behaviors (baby’s temperament, reactions, nurturing routines, physical contact, sleep)

Feeding Safety (car seat, smoke detector, infant

fall) Routine baby care (skin care, cord care,

reduce infection risk)

What are your objectives for this infant’s first pediatric visit?

Assess weight Assess jaundice Review newborn course Review that all routine screens were performed Review Hep B vaccine status Review outstanding labs Review home environment Answer questions Set expectations for future visits Start vitamin D supplementation

What do think about his weight? What additional pieces of information

would be helpful? How much weight do you expect a

neonate to gain daily? When do you expect a neonate to have

gained birthweight by?

What are possible causes of poor weight gain in an infant?

Inadequate feeding Congenital heart disease Metabolic defect Psychosocial problems Hyperthyroidism Cow’s milk protein allergy Trauma Anatomic abnormality

This is mother’s first baby. She would really like to breastfeed. She is putting Joe to the breast every 4 hours for up to 45 mins at a time. Her nipples are sore, cracked and bleeding a little. He seems to fall asleep at the breast alot.

What advice can you give her? What resources can you offer her? When do you want to see this baby

again?

Assessment of latch-on, position and suck

Mouth widely gaped, angle of top to bottom lip would be 120 to 150 degrees. Lips look like fish lips, not “pursed” Chin is pressed into breast so that bottom lip is not visible. Nose may be close to breast but not pushed into breast. Lower lip is placed further down on areola than upper lip is, an asymmetrical

latch. Nipple appears stretched and tip is round immediately after baby finishes

breastfeeding. Face of baby is facing breast. Chest and body of baby is facing mother Mother is comfortable. Baby’s upper back and hip areas are supported by mother. The whole lower jaw moves smoothly creating a “wiggle” of movement in

temple or in front of ear. Effective deep sucking continues in bursts and pauses. Flutter suck is a resting, shallow suck where only the chin moves, indicating the

baby is not getting milk. Remove baby and relatch or baby may be satiated.

Joe appeared jaundiced on exam. You decide to check a TCB in clinic which is 15.

What are your next steps? Assessment of risk factors When should this infant follow-up?

Joe is now 1 week old and gaining weight well. You are the intern on PCC pager and receive a call from Joe’s father. The operator tells you that the reason for the call is fever and father would like a prescription for tylenol.

What is considered a “fever” in a neonate?

Does it matter where it is measured? When should parents be advised to

check their infant’s temperature? Why do we care about fever in a

neonate? Should we give this infant tylenol?

Joe’s father tells you that their 5 yr old who just started kindergarten has a bad cold and they thought Joe was more cranky than usual. They checked an axillary temperature and it was 101 degrees F.

What do you tell Joe’s father?

What is the work-up for fever in a neonate <28 days old Blood culture Urinalysis and culture CBC with differential Lumbar puncture

What do you do next Hospital admission Parenteral antibiotics for at least 48hrs

pending cultures

Joe is now 2 weeks old. He did well following discharge from the hospital. He was treated with IV antibiotics for 48 hrs, cultures were no growth. He is here for this 2 week WCC. His mother is ‘done’ with breastfeeding and asks you to recommend an infant formula.

Cow milk-based formulas for term infants

Ready to use or powder (20 cal/oz) Protein

Human milk has higher whey to casein ratio (70:30) than formula (18:82)

Formula contains 50% higher total protein content

Carbohydrate Mostly lactose

Fat 50% of human milk Docohexanoic acid (DHA) and arachadonic acid

(AHA) accumulate rapidly in the fetal retinal and brain

Added to infant formulas since 2002

Vitamins and minerals Iron fortification of formula in 1959 Iron from human milk has a higher bioavailability.

Formula has 1.8mg/100cal compared to 0.45-0.9mg/100kcal in human milk

Nucleotides Comparable to human milk

Prebiotics Nondigestible short chain carbohydrates

that stimulate growth and function of specific species of bacteria

Probiotics Live microorganisms that colonize the colon ?prevention of NEC

Cow milk-based formula (intact protein) Enfamil Similac Goodstart Parent’s Choice

Review mixing formula Special baby water is unnecessary Sterilize bottles

At Joe’s 2 week visit, on physical exam, you have difficulty palpating his right testicle and suspect that it might be undescended.

What are you concerns? What do you tell Joe’s parents?

Undescended testicle

Incidence: 1-3% Risk factors: prematurity Increased risk for malignancy and

fertility issues Diagnosis: physical exam, ultrasound Treatment: timing is between 6-12 mos

After you talk with Joe’s parents about your plan with regard to his undescended testicle, Joe’s father tells you that they deferred getting Joe circumcised while he was in the nursery but heard something in the news that it’s may be beneficial to his health. They ask for your opinion.

AAP policy statement (Aug 27, 2012)

Preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.

The procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in life.

Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.

What do you say to Joe’s parents?

Joe’s cousin Josephine is also a PCC patient. She is a 5 day old ex late-preterm female, uncomplicated delivery. She had a brief NICU stay for hypoglycemia, required IV dextrose. Mother is breast and formula feeding. Infant’s weight loss is not concerning. On exam, you notice erythema and induration surrounding the umbilical stump and some serosanguinous drainage.

Are you surprised that the umbilical stump is still there?

What are you concerned about?

Omphalitis

Incidence of about 0.7% Risk factors

Protracted labor, non-sterile delivery, maternal infection, prematurity, LBW, umbilical catheters

Characteristics Periumbilical edema, erythema, tenderness

with or without discharge Implicated organisms

Staph aureus, staph epi, strep group A and B, E. coli, klebsiella, pseudomonas, c. diff

Clinical course Localized spread produces abdominal wall

complications Extension along umbilical or portal vessels

results in intra-abdominal pathology Complications include sepsis, necrotizing

fasciitis, abscess, peritonitis, SBO, hepatic vein thrombosis

Management Neonate with periumbilical cellulitis should

be admitted for IV antibiotics against staph aureus, streptococci and gram negative rods

Questions?