Common neonatal presentations to the primary care physician - RACGP
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
CLINICAL
Common neonatal presentations to
the primary care physician
Alicia Quach COMMON NEONATAL (first 28 days of life admitted to hospital and treated with
post-term)1 presentations to general intravenous antibiotics; oral antibiotics
practitioners (GPs) include fever, may lead to only partial treatment and
This article is the first in a series respiratory symptoms, feeding difficulties, false‑negative culture results.6
on paediatric health. Articles in this unsettled babies, vomiting, constipation,
series aim to provide information jaundice and rashes. This article will
about diagnosis and management of Respiratory symptoms
discuss these clinical presentations and
presentations in infants, toddlers and
pre-schoolers in general practice how to approach them in general practice. Respiratory symptoms are common and
Table 1 outlines the general principles the majority will be benign. However, it is
Background for a routine neonatal assessment. important not to miss the acutely unwell
Newborn babies are very vulnerable These principles can also be applied to baby in respiratory distress, as these babies
in their first weeks of life. Timely and
babies who present for their first routine should be transferred to the emergency
appropriate management of neonatal
immunisations between six and eight department via ambulance.7 Table 2
conditions is paramount for health and
developmental outcomes. weeks of age, to potentially identify rare outlines the signs and causes of acute
but significant conditions that parents respiratory distress outside the first 24
Objectives may not have been aware of. hours of life, and other common respiratory
The aim of this article is to provide presenting concerns and conditions. In
an overview of common neonatal
Fever neonates, a cough can be due to a common
presentations to general practice, and
highlight significant conditions that
viral upper respiratory tract infection, but
may require referral to the emergency Fever (rectal temperature >38°C)2,3 it can also be a sign of a more significant
department and/or other specialist. in a newborn baby can be the first pathology. Babies who have a cough and
indicator of a serious invasive infective any associated ‘red flag’ signs or symptoms
Discussion illness. Conversely, hypothermia (rectal outlined in Table 2 should be referred for
Clinical history and examination are
temperatureCLINICAL COMMON NEONATAL PRESENTATIONS
months of life, but will usually resolve by
Table 1. General principles for a routine neonatal assessment 12–18 months. Babies who have associated
complications (eg poor feeding, gastro-
History Examination oesophageal reflux [GOR]) should be
referred to a respiratory paediatrician or
Maternal or antenatal history • Observe interaction with carers
otolaryngologist for further assessment.9
• Relevant maternal medical • Alertness of baby
Parental concerns regarding
history • General colour and tone
irregular breathing or pauses in their
• Antenatal visits • Signs of dysmorphism
baby's breathing are also common
• Investigations during • Inspect for skin lesions throughout examination
pregnancy
GP presentations. In the majority of
• Weight, length, head circumference measurements
• Fetal growth
neonates, these irregularities will be due
• Systematic head-to-toe examination
to ‘periodic breathing’, which is a normal
Peripartum history
developmental phenomenon. Periodic
Head and neck
• Gestational age
breathing is characterised by alternating
• Fontanelle
• Delivery mode
cycles of five to 10 seconds of breathing
• Sutures
• Resuscitation, Apgar
and pauses in breathing. It is not associated
• Oral cavity (eg palate)
scores with bradycardia or cyanosis. It increases
• Ears (eg position, pits)
• Vitamin K given in frequency between two and four weeks
• Neck (eg masses, range of movement)
• Birth weight of age and resolves by six months of age.10
• Red eye reflex can be left to end of examination
• Nursery or intensive care Apnoea is defined as pauses in breathing
admission of greater than 20 seconds, or shorter
Chest
• Interventions (eg oxygen, duration if accompanied by cyanosis or
• Cardiac examination (eg heart rate)
nasogastric feeds, bradycardia.10,11 This is of great concern,
• Respiratory examination (eg respiratory rate)
phototherapy, antibiotics) and a significant medical cause needs to be
• Chest deformities
excluded. If a medical cause is not evident
Postnatal period following clinical assessment, these babies
Abdomen
• Feeding method are classified as having had a brief resolved
• Umbilicus (eg hernia, granuloma, infection)
• Sleep or settling patterns unexplained event (BRUE). BRUE replaces
• Palpate for organomegaly, hernias
• Wet or dirty nappies the previous terminology: apparent life
• Femoral pulses
• Growth threatening event (ALTE).10 BRUEs can be
• Community maternal stratified into low risk and high risk, where
nurse visits Genitals
• Patent anus
low-risk BRUEs generally do not require
• Social context – supports,
• External genitalia hospital admission or invasive testing.12
maternal mental and
physical health, is family • Position of testes in male All neonatal BRUEs are categorised as
coping? • Position of urethral meatus high risk, given the age of the baby,12 and
should be reviewed by a paediatrician for
Address any concerns Limbs further investigation. Table 2 summarises
• Digits common causes of apnoea.
• Symmetrical movements
Gastrointestinal symptoms
Hips
• Barlow and Ortolani manouevres Small amounts of effortless posseting
or physiological GOR are common in
Back babies. In otherwise well babies who
• Ventral suspension are feeding adequately and thriving,
• Spinal dysraphism parental reassurance that this is most
likely to improve in the first year of life
Reflexes is sufficient. General measures, such as
• Rooting holding the baby in the prone position
• Suck after feeds and thickening agents,
• Moro may help reduce the vomiting. Acid-
• Tonic neck or fencing suppression agents (ie H2-agonists,
• Grasp proton-pump inhibitors) should be
• Stepping reserved for babies with associated
complications, such as inadequate weight
194 | REPRINTED FROM AJGP VOL. 4 7, NO. 4, APRIL 2018 © The Royal Australian College of General Practitioners 2018COMMON NEONATAL PRESENTATIONS CLINICAL
Table 2. Differential diagnoses for respiratory symptoms and signs
Clinical presentation Differential diagnoses Red flags or supporting features
Acute respiratory distress Infection • Fever or hypothermia
(eg tachypnoea, accessory • Irritability or lethargy
muscle use, central • Decreased feeds or poor urine output
cyanosis, nasal flaring, • Infectious contacts
expiratory grunting)
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 (ie noisy breathing on inspiration) worse in supine position
Tracheomalacia • Noisy breathing on expiration
• Barking cough
Laryngeal / subglottic mass • Cutaneous lesion (eg haemangioma) over face, neck or upper chest region
Choanal atresia • Grunting noise
• Cyanosis with feeding (if bilateral)
• Unilateral nasal discharge
Vocal cord paralysis • Hoarse cry
• Other midline deformities
Apnoea brief resolved • Apnoea with colour change, change in muscle tone, altered conscious state that
unexplained event completely resolves within one minute
• Other medical causes excluded on clinical assessment
Apnoea of prematurity • BabyCLINICAL COMMON NEONATAL PRESENTATIONS gain, oesophagitis or aspiration.13 There infections or cow’s milk protein allergy cause for the unsettled baby. Supporting is no clear causal link between GOR (CMPA). Babies with acute infective features for CMPA include blood and infant irritability, and anti-reflux diarrhoea (gastroenteritis) need to be and mucus in the stool, diarrhoea or medication is generally not warranted monitored closely for dehydration. constipation, inadequate weight gain, in these instances.14 Vomiting as a result Table 3 outlines the signs of dehydration eczema, and family history of atopy. of a more serious condition, such as and other signs of the unwell baby that A cow’s milk exclusion diet (including pyloric stenosis, intestinal obstruction, should prompt early transfer to hospital. mothers if breastfeeding) may be sepsis or neurological cause (eg Admission to hospital should also be trialled in these babies to confirm the subdural or intracranial haemorrhage, considered for those who are unlikely to diagnosis. In babies who are formula- hydrocephalus), needs to be promptly maintain adequate oral intake at home. fed, a trial of extensively hydrolysed referred to the emergency department. Antimicrobial therapy is rarely warranted formula and/or amino acid formula will Red flags for these conditions include in gastroenteritis, as most cases are viral be required. Soy infant formulas are not projectile vomiting immediately post- and/or self-limiting. recommended in infants younger than feeds (associated with demands to be six months of age. Rice protein-based re-fed soon after), bilious vomiting, acute Unsettled baby formulas can be used as a short-term, abdominal distension, fever, lethargy, non-prescription alternative while dehydration or bulging fontanelle. All newborn babies cry. Normal infant awaiting specialist review.23 Referral to There is no universally agreed clinical crying patterns tend to increase in a paediatrician or allergy specialist and definition of constipation for neonates. duration week by week, peaking at around dietitian is recommended for suspected They may pass bowel motions several six to eight weeks of age, and receding cases of CMPA to ensure adequate times a day or have more than a week to lower, stable levels at around four parental education and future dietary between bowel motions. Formula-fed to five months of age.17,18 The typical management. babies typically produce firmer and less presentation is clustered periods of frequent stools than breastfed babies, but inconsolable crying, some for more than Feeding difficulties unless these are hard and pellet-like, the two to three hours in duration, often in the baby is unlikely to be constipated.15 Some late afternoon and evening. In otherwise Prematurity (gestation
COMMON NEONATAL PRESENTATIONS CLINICAL
‘cholestatic jaundice’ is always pathological,
Table 3. Signs and symptoms of an unwell baby and detection of this should prompt
Vital signs • Heart rate (bradycardia 170 beats/minute) gastroenterologist.29 The following
• Temperature (fever >38°C; hypothermia 10% of
birthweight hyperbilirubinaemia. Assessment should
• Decreased urine output include detection of any signs of bilirubin
• Dry mucous membranes toxicity (Table 3), and identification of risk
• Sluggish capillary refill (>2 seconds) factors, including the following:30
• Poor tissue turgor • prematurity
• Sunken eyes and anterior fontanelle • jaundice within the first 24 hours
• blood group incompatibility
Systemic specific signs • Acute respiratory distress: tachypnoea, accessory muscle use,
grunting, nasal flaring, central cyanosis
• cephalohaematoma or other birth-
related trauma
• Gastrointestinal: acute abdominal distension that is firm,
bilious vomiting, projectile vomiting
• weight loss >10% of birthweight
• Cardiac: cyanosis, cardiac murmurs
• previous sibling with
hyperbilirubinaemia requiring
• Severe jaundice with signs of bilirubin toxicity: lethargy,
dehydration, pallor, irritability, hypotonia or hypertonia, treatment.
seizures, fever Babies with jaundice and added signs
of bilirubin toxicity require immediate
Non-specific signs • Lethargy
referral to hospital. Babies with prolonged
• Poor feeding
jaundice who are otherwise well looking,
• Inadequate weight gain
feeding adequately and with no risk factors
• Irritability – persistent
are most likely to have physiological
• Rashes
jaundice or breastmilk jaundice, and can
• Seizures
be managed as outpatients. A bilirubin
level (total and fractionated) should be
checked with early follow-up for results
Box 1. Educational resources and support services for parents of and clinical review. Bilirubin threshold
newborn babies tables (www.nice.org.uk/guidance/cg98)
should be used to determine whether the
• The period of purple crying, www.purplecrying.info
baby requires treatment with phototherapy
• Raising Children Network, or exchange transfusion.31
www.raisingchildren.net.au/behaviour/newborns_behaviour.html
• Australian Breastfeeding Association, www.breastfeeding.asn.au
Rashes
• Mother and baby units (Melbourne-based),
www.rch.org.au/genmed/clinical_resources/Mother_Baby_Units In any baby who presents with a
• Lactation Consultants of Australia and New Zealand, vesiculopustular rash, significant causes
www.lcanz.org/find-a-lactation-consultant such as bacterial, viral and fungal
infections need to be considered. If a rash
is accompanied by systemic signs of being
It is therefore more important to track a paediatrician for further investigation unwell, such as fever, lethargy or poor
the actual weight difference in grams and management should be made. feeding, then the baby needs to be referred
between visits. Following the initial immediately to the emergency department
postpartum weight loss, newborns are Jaundice for further assessment. Recent exposure to
expected to gain 30 –40 grams per day on infectious diseases such as Varicella‑Zoster
average.28 ‘Failure to thrive’ or inadequate Jaundice, or hyperbilirubinaemia, is the virus (VZV) or Herpes simplex virus (HSV),
weight gain is most commonly a result result of bilirubin pigment deposition in should also alert the physician to the
of inadequate oral intake. If a baby the skin and mucous membranes. In the possibility of an invasive infective disease.
continues to display inadequate weight majority of cases, jaundice in neonates is Common benign rashes that may
gain despite increased feed frequency due to unconjugated hyperbilirubinaemia. present in the newborn include erythema
and/or supplementary feeds, referral to Conjugated hyperbilirubinaemia or toxicum and milia. Erythema toxicum
© The Royal Australian College of General Practitioners 2018 REPRINTED FROM AJGP VOL. 47, NO. 4, APRIL 2018 | 197CLINICAL COMMON NEONATAL PRESENTATIONS
is a benign, self-limiting skin condition 6. Zea-Vera A, Ochoa TJ. Challenges in the diagnosis 24. Rommel N, De Meyer AM, Feenstra L, Veereman-
and management of neonatal sepsis. J Trop Wauters G. The complexity of feeding problems
categorised by small erythematous papules, Pediatr 2015;61(1):1–13. in 700 infants and young children presenting to
vesicles and pustules. It affects 30 –70% 7. Edwards MO, Kotecha SJ, Kotecha S. Respiratory a tertiary care institution. J Pediatr Gastroenterol
Nutr 2003;37(1):75–84.
of newborns, typically within the first two distress of the term newborn infant. Paediatr
Respir Rev 2013;14(1):29–36. 25. O'Shea JE, Foster JP, O'Donnell CP, et al.
weeks of birth.32 Erythema toxicum can Frenotomy for tongue-tie in newborn infants.
8. Winter K, Zipprich J, Harriman K, et al. Risk
be differentiated from an infective rash by factors associated with infant deaths from Cochrane Database Syst Rev 2017;3:CD011065.
its tendency to wax and wane over several pertussis: A case-control study. Clin Infect Dis
2015;61(7):1099–106.
days. It is also unusual for an individual
9. Carter J, Rahbar R, Brigger M, et al. International
erythema toxicum lesion to persist for more Pediatric ORL Group (IPOG) laryngomalacia
than one day. If the infant is otherwise well, consensus recommendations. Int J Pediatr
no investigation or treatment is required, Otorhinolaryngol 2016;86:256–61.
10. Patrinos ME, Martin RJ. Apnea in the term infant.
but recommendation for review should
Semin Fetal Neonatal Med 2017;22(4):240–44.
be made if the rash does not resolve after 11. Kondamudi NP, Wilt AS. Apnea, Infant. StatPearls.
one to two weeks. Milia, which are a result Treasure Island, FL: StatPearls Publishing, 2017.
of blocked pores, typically present as tiny, 12. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief
resolved unexplained events (formerly apparent
white cysts on the face in about 40 –50% of
life-threatening events) and evaluation of lower-
newborns.33 Most lesions resolve after one risk infants. Pediatrics 2016;137(5).
to two months. Parents should be reassured 13. The Royal Children's Hospital. Clinical practice
and advised to not squeeze or pick them as guidelines: Gastroesophageal reflux in infants.
Melbourne: RCH, 2017. Available at www.
this may result in infection or scarring. rch.org.au/clinicalguide/guideline_index/
gastrooesophageal_reflux_in_infants [Accessed 24
Nov 2017].
Conclusion 14. Heine RG, Jaquiery A, Lubitz L, Cameron DJ,
Catto-Smith AG. Role of gastro-oesophageal
Neonatal assessment can be challenging reflux in infant irritability. Arch Dis Child
because of the non-specific nature 1995;73(2):121–25.
of presenting signs and symptoms. A 15. den Hertog J, van Leengoed E, Kolk F, et al. The
defecation pattern of healthy term infants up
thorough clinical assessment, including to the age of 3 months. Arch Dis Child Fetal
relevant maternal medical, antenatal, Neonatal Ed 2012;97(6):F465–70.
peripartum and postpartum histories, 16. Kramer EA, den Hertog-Kuijl JH, van den
Broek LM, et al. Defecation patterns in infants:
with a systematic physical examination, A prospective cohort study. Arch Dis Child
is the most important tool in the primary 2015;100(6):533–36.
clinic setting. 17. Barr RG. Crying behaviour and its importance
for psychosocial development in children.
Montreal, Quebec: Encyclopedia on Early
Author Childhood Development, 2006. Available at
Alicia Quach MBBS, FRACP, MPH, General and www.child-encyclopediacom/crying-behaviour/
Developmental Paediatrician, Senior Research Officer, according-experts/crying-behaviour-and-its-
Murdoch Children’s Research Institute, Melbourne, Vic. importance-psychosocial-development [Accessed
alicia.quach@rch.org.au 14 July 2017].
Competing interests: None. 18. Hiscock H, Jordan B. Problem crying in infancy.
Provenance and peer review: Commissioned, Med J Aust 2004;181(9):507–12.
externally peer reviewed.
19. Halpern R, Coelho R. Excessive crying in infants. J
Pediatr (Rio J) 2016;92(3 Suppl 1):S40–45.
References 20. Akhnikh S, Engelberts AC, van Sleuwen BE,
1. World Health Organization. Health topics: Infant, L'Hoir MP, Benninga MA. The excessively crying
newborn. Geneva: WHO, 2017. Available at www. infant: Etiology and treatment. Pediatr Ann
who.int/topics/infant_newborn/en [Accessed 24 2014;43(4):e69–75.
Nov 2017]. 21. Harb T, Matsuyama M, David M, Hill RJ. Infant
2. Hui C, Neto G, Tsertsvadze A, et al. Diagnosis and colic – What works: A systematic review of
management of febrile infants (0–3 months). Evid interventions for breast-fed infants. J Pediatr
Report Technol Assess (Full Rep) 2012;(205):1–297. Gastroenterol Nutr 2016;62(5):668–86.
3. The Royal Children's Hospital. Clinical practice 22. Xu M, Wang J, Wang N, Sun F, Wang L, Liu XH.
guidelines: Febrile child. Melbourne: RCH, 2011. The efficacy and safety of the probiotic bacterium
Available at www.rch.org.au/clinicalguide/ lactobacillus reuteri DSM 17938 for infantile colic:
guideline_index/Febrile_child [Accessed 24 Nov A meta-analysis of randomized controlled trials.
2017]. PLoS One 2015;10(10):e0141445.
4. World Health Organization. Thermal protection 23. Australasian Society of Clinical Immunology and
of the newborn: A practical guide. Geneva: Allergy. Food allergy clinical update for health
WHO, 1997. professionals. Perth: ASCIA, 2017. Available at
5. Hofer N, Müller W, Resch B. Neonates presenting www.allergy.org.au/images/stories/pospapers/
with temperature symptoms: Role in the diagnosis ASCIA_HP_Clinical_Update_Food_Allergy_2017_HP_
of early onset sepsis. Pediatr Int 2012;54(4):486–90. version.pdf [Accessed 1 November 2017]. correspondence ajgp@racgp.org.au
198 | REPRINTED FROM AJGP VOL. 4 7, NO. 4, APRIL 2018 © The Royal Australian College of General Practitioners 2018You can also read
