Management of Low Birth Weight Neonate: Baby Jonah Case Study Emergency Measures
Baby Jonah, born at 30 weeks gestation with low birth weight, exhibits emergency signs such as slow respiration and apnoea. The case highlights the importance of triage, emergency treatment, history and examination, laboratory investigations, diagnosis, treatment, supportive care, monitoring, discharge planning, and follow-up in managing sick newborns. Urgent assessment and interventions are crucial in addressing the health needs of low birth weight neonates like Baby Jonah.
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Presentation Transcript
Chapter 3 Problems of the neonate Low birth weight babies
Case study: Jonah Baby Jonah just born at 30 weeks gestation. Weight is 1.4kg He is floppy, with slow respiration, brief periods of apnoea, and heart rate of 80/min. The mother had no antenatal care and rupture of membranes for 26 hours prior to delivery.
Stages in the management of a sick child (Ref. Chart 1 p.xxii) 1. Triage 2. Emergency treatment 3. History and examination 4. Laboratory investigations, if required 5. Main diagnosis and other diagnoses 6. Treatment 7. Supportive care 8. Monitoring 9. Discharge planning 10.Follow-up
What emergency or priority signs does baby Jonah have?
Triage Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns Emergency signs (Ref: p2,6) Obstructed breathing Severe respiratory distress Signs of shock Coma Convulsing Severe dehydration
Triage Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns Emergency signs (Ref: p2,6) Obstructed breathing Severe respiratory distress Signs of shock Coma Convulsing Severe dehydration
What emergency measures are needed for this newborn baby?
Assessment of newborn at delivery Dry and stimulate baby with clean cloth and place where the baby will be warm Look for: Breathing or crying NO Good muscle tone NO Colour pink NO
(Ref. WHO pocket book p.47)
Neonatal resuscitation Use a correctly fitting mask: If the baby is still not breathing after opening the airway (Ref. p. 47): Check position and mask fit Continue to give breaths at rate of 40 breaths per minute, be gentle and do not overinflate Use oxygen if available Every 1-2 minutes stop and see if the pulse or breathing has improved
Neonatal resuscitation Check the heart rate (HR)
Further assessment After brief resuscitation just 30 seconds with bag and mask ventilation, Jonah has spontaneous breathing and the heart rate was up to 120/minute. Mild chest indrawing, SpO2 91% on 0.5L oxygen
Early Essential Newborn Care Dry with a clean cloth Maintain skin-to-skin contact Give the baby to mother as soon as possible, on chest or abdomen Cover the baby to prevent heat loss Breastfeeding Start breast feeding in the first hour Keep mother and baby together Further Management: Give vitamin K (phytomenadione) 1 ampoule IM Apply antiseptic ointment or antibiotic eye drops (e.g. tetracycline) to both eyes once Cord care chlorhexidine swab Examination and weight
Management of VLBW babies Maintain temperature 36-37 C (Ref p.58) Oxygen if needed - via nasal prongs Target SpO2 88-95%, not higher IV glucose / saline Fluid 60ml/kg/day on first day of life How many ml/hour for Jonah? Commence breast milk feeding (including colostrum) Aminophylline (or caffeine) for apnoea Penicillin and gentamicin Phototherapy if jaundice Vitamin K
Investigations Full Blood Examination Haemoglobin: 160 gm/L (145 - 225) Platelets: 175 x 109/L (84 478) WCC: 5.1 x 109/L (5 25.0) Neutrophils: 2.1 x 109/L (1.5 10.5) Lymphocytes: 3.0 x 109/L (2.0 10.0) Blood glucose: 3.8 mmol/l (2.5 5.0) Blood culture: No growth
Progress On day 2 Jonah s condition was better. Eyes open and active. RR is 46/min with mild chest indrawing, SpO2 94% on air. His abdomen was soft and passed meconium. So commenced feeding with expressed breast milk (EBM) 3 ml every 2 hours by nasogastric tube. What is the target feed for Jonah? (Ref p. 57 and 60) 90ml/kg/day, Jonah is 1.4kg, 2 hourly feeds (90 x 1.4) / 12 = 10.5 ml every 2 hours
Progress The next day he looks lethargic and jaundiced and has some further apnoea. SpO2 82%. His abdomen was distended and there was bile stained nasogastric aspirate.
What may be the cause of this deterioration? What investigations you will do?
Investigations Full Blood Examination Haemoglobin: 110 gm/L (145 - 225) Platelets: 57 x 109/L (150 400) WCC: 3.1 x 109/L (5 25) Neutrophils: 0.9 x 109/L (1.0 8.5) Lymphocytes: 2.2 x 109/L (2.0 10.0)
Investigations Blood glucose: 3.2 mmol/l (3.0-8.0) Serum bilirubin: 294 mol/L Abdominal X-ray
What may be wrong? How will you manage the baby?
Progress Likely diagnosis is necrotising enterocolitis (NEC). Jonah s feeds are withheld. 10% glucose + NaCl was given intravenously. Metronidazole added to benzylpenicillin and gentamicin. Oxygen Aminophylline was continued for apnoea Phototherapy for jaundice.
What complications might occur in a VLBW baby? General Hypothermia Hypoglycaemia Infection Anaemia Jaundice Gastrointestinal Feeding intolerance Necrotising enterocolitis CNS Intracranial haemorrhage Developmental problems Respiratory Apnoea Hypoxaemia RDS
What complications did occur? General Hypothermia Hypoglycaemia Infection Anaemia Jaundice (p.64) Gastrointestinal Feeding intolerance (p.60) Necrotising enterocolitis (p.62) CNS Intracranial haemorrhage Developmental problems Respiratory Apnoea (p.61) Hypoxaemia RDS
Summary Baby Jonah was delivered prematurely. He needed brief resuscitation after birth. He was commenced on oxygen, antibiotics and IV fluid. He had some apnoea early but these improved with aminophylline. He developed necrotising enterocolitis after commencing feeding on the 2nd day of life. This was treated with a change in his antibiotics for 10 days and stopping feeds for 5 days. Breast milk feeds were restarted after 5 days and very slowly increased. This time feeds were well tolerated and his feeding volume was gradually increased to 180ml/kg/day over 10 days. He was discharged when he tolerated breast milk well and had reached a weight of 2kg.
Follow-up review monthly and check for Nutrition Monitor the child s growth chart each month (weight, length and head circumference Mothers may have limited milk supply Susu Mamas Multivitamins and zinc Anaemia Iron deficiency common, start iron when babies 6 weeks of age Look for development complications Cerebral palsy, visual and hearing problems Infections Pneumonia, bronchiolitis and diarrhoea common
