Signs and symptoms of Neonates

Unwell – Vital signs

• Heart rate (bradycardia <110 beats/minute and tachycardia >170 beats/minute)
• Temperature (fever >38°C; hypothermia <36.5°C)
  • can be the first indicator of a serious invasive infective illness
  • Rectal temperature most accurate 
  • hypothermia <36.5 can also be a sign of sepsis, as neonates have difficulty regulating temperatures
  • The health of neonates with sepsis can deteriorate
  • Requires immediate referral to ED for full septic workup, hospital admission empirical Abx
    • A full septic workup 
    • full blood count and film
    • blood culture
    • urine culture (through aseptic suprapubic aspiration)
    • lumbar puncture

 

• Respiratory rate (bradypnoea <25 breaths/minute and tachypnoea >60 breaths/minute)

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Signs of dehydration

• Weight loss (bare) in setting of acute illness or >10% of birthweight
• Decreased urine output
• Dry mucous membranes
• Sluggish capillary refill (>2 seconds)
• Poor tissue turgor
• Sunken eyes and anterior fontanelle

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Systemic specific signs

• Acute respiratory distress: 

• • • Tachypnoea
    • accessory muscle use
    • grunting
    • nasal flaring
    • central cyanosis

• Gastrointestinal: 

• • • acute abdominal distension that is firm
    • bilious vomiting
    • projectile vomiting

• Cardiac: 

• • • Cyanosis
    • cardiac murmurs

• Severe jaundice with signs of bilirubin toxicity: 

• • Lethargy
  • Dehydration
  • pallor
  • irritability
  • hypotonia or hypertonia
  • seizures
  • fever

• • Non-specific signs
    • Lethargy
    • Poor feeding
    • Inadequate weight gain
    • Irritability – persistent
    • Rashes

• Seizures

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Respiratory symptoms

• Common, usually benign
• Obligatory nose breathers – congestion leas to noisy breathing – consider saline drops or spray
• Most common cause noisy breathing – laryngomalacia
  • Stridor
  • If well can review in GP
  • Often becomes louder in first 6 months, resolves by 12-18mo
• Do not miss resp distress
• Irregular breathing
  • Often “periodic breathing” – normal development
    • Alternating cycles of 5-10 second breathing with a pause
    • Not associated bradycardia and cyanosis
    • Starts 2-4 weeks, resolves 6 months
  • Apnoea – last 20 secs, or associated pradycardio for cyanosis
    • Should be investigated
  • If no cause found – brief resolved unexplained event
• Any cough and red flag symptoms should be referred
• Suspected pertussis – refer ED – Abx, monitoring – risk complications apnoea, pneumonia, encephalopathy

 

Respiratory distress

Infection	Fever or hypothermia Irritability or lethargy Decreased feeds or poor urine output Infectious contacts
Foreign body	Acute onset Associated stridor or wheeze
Trauma	Physical signs of trauma (eg bruising) Suspicion of non-accidental injury Seizures
Congenital heart disease	Cyanosis Cardiac murmur Failure to thrive
Metabolic acidosis	Large volume fluid losses (eg vomiting, diarrhoea) Failure to thrive Apnoea Seizures

 

Cough

Respiratory infection	Coryzal symptoms Infectious contacts Prolonged episodic coughing (red flag for Bordetella pertussis) Fever
Tracheo-oesophageal fistula	Coughing and choking with feeds Antenatal polyhydramnios
Chronic lung disease	Prematurity Prolonged intubation
Tracheo-bronchomalacia	Cough present since birth Barking cough
Congenital heart disease	Cough with cyanosis Cardiac murmur Failure to thrive

 

Noisy breathing

• Laryngomalacia – stridor, worse when supine
• Tracheomalacia – noisy breathing expiration, barking cough
• Laryngeal mass – Cutaneous lesion (eg haemangioma) over face, neck or upper chest region
• Choanal atresia – grunting, cyanosis with feeding, unilateral nasal discharge 
• Vocal cord paralysis –  Hoarse cry, Other midline deformities

Apnoea

• irregular breathing or pauses 
  • will be due to ‘periodic breathing’, which is a normal developmental phenomenon. 
  • Periodic breathing is characterised by alternating cycles of five to 10 seconds of breathing and pauses in breathing. 
  • It is not associated with bradycardia or cyanosis. 
  • It increases in frequency between two and four weeks of age and resolves by six months of age. 
• Apnoea 
  • pauses in breathing of greater than 20 seconds, or shorter duration 
  • accompanied by cyanosis or bradycardia.
  • This is of great concern, and a significant medical cause needs to be excluded. 
  • If a medical cause is not evident following clinical assessment, these babies are classified as having had a brief resolved unexplained event (BRUE). 
• BRUE 
  • replaces the previous terminology: apparent life threatening event (ALTE)
  • BRUEs can be stratified into low risk and high risk, where low-risk BRUEs generally do not require hospital admission or invasive testing.
  • All neonatal BRUEs are categorised as high risk, given the age of the baby,  and should be reviewed by a paediatrician for further investigation

 

Brief resolved unexplained event	Apnoea with colour change, change in muscle tone, altered conscious state that completely resolves within one minute Other medical causes excluded on clinical assessment
Apnoea of prematurity	Baby <37 weeks’ gestation History of oxygen support
Infection	Refer to acute respiratory distress
Head trauma	History of birth asphyxia requiring resuscitation Risk factors for abusive trauma
Structural airway obstruction	Facial dysmorphic features Congenital malformations in chest or abdomen

 

Laryngomalacia

• congenital softening of the tissues of the larynx 
• Most common cause of chronic Stridor in infants
• Onset within first month of life and continues until 18-24 months of age
• Signs
  • Inspiratory Stridor
  • Provocative factors (Increases Stridor)
    • Crying or other Agitation
    • Exertion
    • Feeding
    • Upper Respiratory Infection 
  • Palliative factors (Decreases Stridor)
    • Prone position
    • Neck extension
  • Severe obstructive signs (rare)
    • Failure to Thrive
    • Apnea
    • Cyanosis
    • Pulmonary Hypertension
• Typically diagnosed on clinical features alone, Bronchoscopy MAY BE Indicated in severe cases 
• Management
  • Reassurance
  • Control Pediatric Gastroesophageal Reflux Disease 
  • Many infants with laryngomalacia are able to eat and grow normally, and the condition will resolve without surgery by the time they are around 20 months old. 

• However, a small percentage of babies do struggle with breathing, eating, and weight gain, and their symptoms require immediate treatment Epiglottoplasty or Supraglottoplasty)Head trauma
• Structural airway obstruction

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Gastrointestinal symptoms

Posset/GOR – see Colic

• Posseting: non-forceful return of small amounts of milk with swallowed air, physiological
• is a common problem in infancy and childhood
• usually is a result of mild gastroenteritis and gastro-oesophageal reflux
• Small amount, effortless – common
• If feeding adequately and thriving – reassure
• Consider – holding prone after feeding, thickening agents
• Only use acid suppression if complications 
  • Inadequate weight gain
  • oesophagitis
  • aspiration
• No clear link with infant irritability

• Vomiting with a more serious condition needs referral to ED
  • Projectile, bilious
  • acute abdominal distension
  • fever
  • lethargy
  • dehydration
  • bulging fontanelle

 

Bowels

• may pass bowel motions several times a day or have more than a week between bowel motions. 
• Formula-fed babies typically produce firmer and less frequent stools than breastfed babies, but unless these are hard and pellet-like, the baby is unlikely to be constipated

Diarrhoea

• normal for newborn babies to have frequent, loose stools. 
• Babies who have true diarrhoea will produce more watery and more frequent stools than usual. 
• The most common causes of diarrhoea in neonates are
  • viral or bacterial infections
  • cow’s milk protein allergy (CMPA)

Dyschezia

• Strain and cry for 10 minutes before passing a soft stool
• Inability to co-ordinate increase in intra-abdominal pressure with pelvic floor relaxation
• Functional, self-limiting
• Caution should be applied and organic pathology excluded before prescribing laxatives in neonates
• Exclude 
  • Hirschsprung’s disease, alerted by a history of delayed meconium passage (after 48 hours of life)
  • mechanical bowel obstruction suspected with firm abdominal distension on palpation
  • spinal dysraphism leading to autonomic or sphincteric dysfunction

 

Unsettled baby – see Colic

• All newborn babies cry
• Normal infant crying patterns tend to increase in duration week by week
• Crying peaks 6-8 weeks
• receding to lower, stable levels at around four to 5 months of age
• typical presentation
  • clustered periods of inconsolable crying
  • some for more than 2-3 hours in duration
  • often in the late afternoon and evening
• Otherwise well – reassure
• If acute onset or persistent – investigate
  •  infection
  • hair torniquet
  • cornea abrasion
  • NAI
  • cow milk protein allergy
• CMPA 
  • SIGNS
    • blood and mucus in stool
    • diarrhoea or constipation
    • inadequate weight gain
    • eczema
    • family history atopy
  • Trial exclusion diet (also in mother) to confirmed
  • Trial extensively hydrolysed formula
  • Soy formulas not recommended in < 6 months
  • Rice formulas can be used short term whilst awaiting specialist review – paeds or allergy specialist recommended

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Feeding difficulties

• Prematurity most common
  • DUE TO discoordination between sucking, swallowing and breathing
• tongue-tie
  • difficult breastfeeding and maternal nipple pain
  • Cochrane meta-analysis found that frenotomy (surgical release of tongue-tie) reduced maternal nipple pain in the short term, but did not find consistent positive effects on breastfeeding
• Lose up to 10% of birth weight in first week, may take 2 weeks to regain
• Should gain 30-40 grams per day
• If inadequate weight gain despite feeds – referral to paeds

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Jaundice

• Neonatal jaundice is unconjugated hyperbilirubinaemia
• Conjugated is pathological – immediate referral
• Risks for toxicity
  • Prematurity
  • Jaundice within 24 hours
  • Blood group incompatibility
  • Cephalohematoma/other birth trauma
  • Weight loss > 10%
  • Previous sibling required treatment
• If any signs of toxicity – refer to hospital
  • Lethargy, dehydration, pallor, irritability, hypotonia, hypertonia, seizures, fever
• If otherwise well, feeding, no risk factors – likely physiological/breast mild jaundice – can manage as outpatient
• Investigations
  • Bilirubin level – total and fractionated – check with earily follow up
  • Use bilirubin threshold tables