Chapter Contents
Introduction 375
The normal small baby 375
Special care baby units and transitional care units 376
Observations and monitoring on the transitional care unit 376
Temperature control 376
Hypoglycaemia 376
Feeding on the transitional care unit 378
Non-nutritive sucking 378
Breastfeeding 378
Bottle-feeding 378
Tube-feeding 378
Cup-feeding 379
Milk expression and storage 379
Weight 379
Infection 379
Skin 379
Jaundice 379
Care of the intensive-care graduate 379
Feeding the convalescent premature baby 380
Nutritional supplements 380
Growth and weight gain 380
Anaemia of prematurity 381
Murmurs 381
Hernias and testes 381
Retinopathy of prematurity 381
Hearing 382
Discharging small babies 382
Advice to parents 382
Feeding and supplements 382
Immunisations 383
Post discharge support and follow-up 383
The normal small baby
Traditionally babies weighing below the 10th centile have been regarded as small for dates, although babies with birthweights between the 3rd and 10th centile rarely pose a problem if clinically well and feeding adequately. Modern antenatal care usually distinguishes genuine intrauterine growth retardation (IUGR) from the normal small baby. IUGR babies are more susceptible than normal small babies to some of the complications of prematurity and are discussed in greater detail in Chapter 10 .
Special care baby units and transitional care units
Whenever possible small, well babies should be cared for on postnatal wards with their mothers. Babies separated from their mother at birth display separation distress calls which cease at reunion ( ) and separation from the mother on the first night may increase the risk of allergy in later life ( ). The weight, gestation and other criteria which determine admission to the neonatal unit or TCU should be agreed locally between neonatal and postnatal ward staff. Typically, newborns less than 34 weeks’ gestation or below 1.7 kg require NICU admission. Any baby who needs continuous monitoring and oxygen, or who meets other high-dependency criteria, will require SCBU admission.
Unfortunately, in recent years the availability of TCUs has declined, owing to lack of funds or appropriately trained staff. However, they remain popular with staff and parents ( ) and may decrease the risks of mother–child separation and the risk of nosocomial infection. Nutritive sucking develops from around 32 weeks but regular sucking feeds are not usually established until 35 weeks, thus the necessity for tube-feeding is often the main factor requiring TCU admission and preventing discharge home ( Table 21.1 ). The organisation of neonatal care is further discussed in Chapter 2 .
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Observations and monitoring on the transitional care unit
Routines, including clinical examination, cord care, screening, weighing and administration of vitamin K, are as for term babies – remembering that low-birthweight (LBW) babies should have intramuscular (not oral) vitamin K ( Ch. 30 ). TCUs should be maintained at a stable temperature and contain essential equipment, including a fully equipped resuscitation area with piped oxygen, air and suction. The usual strict precautions to minimise nosocomial infection should apply ( Ch. 39.2 ); each baby should have his or her own equipment, e.g. stethoscope, cotton wool and alcohol for hand rubbing.
Small and preterm babies have a greater risk of developing illnesses in the neonatal period ( ) than mature well-grown babies. The TCU is often the ideal place to monitor babies who are at risk of conditions which could make them unwell, e.g. meconium aspiration, sepsis (group B Streptococcus exposure or after prolonged rupture of the membranes), narcotic withdrawal and hypoglycaemia. The length and nature of observations for such conditions vary and are rarely standardised between units. Historically ‘sepsis observations’ or ‘meconium observations’ have been recorded for up to 48 hours, which may be undesirable for staff and families and are probably unnecessary. The current National Institute for Health and Clinical Excellence guideline on intrapartum care (2007, section 1.11.8) recommends observations of well-being, feeding, skin colour, perfusion, temperature, pulse and respiration at 1 and 2 hours of age and then 2-hourly intervals for 12 hours in well babies born through meconium-stained liquor. A suitable chart is reproduced in Figure 21.1 . The modified Finnegan chart ( Ch. 26 ) is used in many units to monitor babies at risk of narcotic abstinence syndrome ( Ch. 26 ). All units need to adhere to strict guidelines for monitoring babies at risk of hypoglycaemia (see below and Ch. 34.1 ).
Temperature control
Small babies, with a larger surface area to body mass ratio than term babies, are prone to hypothermia. If the baby is in an ambient temperature below 22–23°C, he or she may be using the thermoregulatory mechanisms described in Chapter 15 , which will place a metabolic demand on the baby ( ).
If a small baby has a temperature of 36.0°C or less on admission to the TCU, examine him or her and check that the baby is otherwise well. Check the baby is dry then fully clothe him or her, including a hat, before swaddling in a sheet and blankets. Extra heat can be provided from a radiant heater or heated mattress . If, despite adequate warming attempts, the baby remains hypothermic, or if a stable baby develops hypothermia, an evaluation is required to exclude sepsis and measurement of glucose levels. The baby’s temperature should be rechecked after removing from a source of additional heat.
Hypoglycaemia (see Ch. 34.1 )
The definition and pathophysiology of hypoglycaemia are discussed in more detail in Chapter 34 part 1 . Preterm, small and IUGR babies are more likely to develop hypoglycaemia than term or appropriately grown babies. For healthy LBW and IUGR term or near-term babies, detection and prevention of hypoglycaemia by adequate feeding can be safely supervised in the TCU.
The blood glucose level at which adverse sequelae might arise is still uncertain. Some small babies have low glycogen stores and poor ketone body responses to hypoglycaemia. If the caloric intake is poor, then the baby is at risk of developing prolonged hypoglycaemia with a risk of adverse neurological sequelae. For an IUGR baby the risk of symptomatic hypoglycaemia is greatest between 24 and 48 hours of age, hence the importance of accurate and continued monitoring in this group, who are not generally suitable for transfer from hospital to community care before this vulnerable period has passed. Whole-blood glucometer readings, not reagent sticks, should be used for monitoring. Hypoglycaemia diagnosed on the ward using a glucometer should always be confirmed with a laboratory glucose level. Attempts should be made to keep the blood glucose above 2.0 mmol/l; this minimises the risk of developing severe hypoglycaemia (<1.0 mmol/l). There is no evidence that transient low levels of glucose, which are not associated with signs, cause any adverse long-term sequelae.
Hypoglycaemia: monitoring, prevention and treatment
For those at risk, feeds should be started as soon as possible after birth. The mother should be encouraged to hold her baby skin to skin and put the baby to her breast in the labour ward. In general, within the first 24 hours, every endeavour should be made to keep the blood glucose >2.0 mmol/l and thereafter above 2.5 mmol/l. Blood glucose monitoring should start at 4 hours of age (earlier if there is IUGR) and then every 4–6 hours until two consecutive levels are above 2.5 mmol/l. Monitoring should recommence if feeding is reduced or the baby is unwell. If there is difficulty keeping the blood glucose level above 2.0 mmol/l, an extra feed should be given by cup, bottle or tube and further investigations performed. A baby who cannot cope with breast, cup or bottle feeds should be tube-fed; syringe-/cup-feeding carries a high risk of aspiration (see below). If the glucose level remains low, or the baby has clinical signs or cannot tolerate feeds, then he or she should be admitted to the NICU.
Feeding on the transitional care unit
The following sections discuss the various methods of feeding. The route, type, frequency, volume and rate of increment of feeds vary widely and few good quality data exist to help inform practice. The mother should be involved as much as possible with the feeding of her baby and the ultimate method of feeding should be her preferred choice. The merits and nutritional aspects of the different types of milk are discussed in Chapter 16 .
Non-nutritive sucking
The sucking reflex develops from 28 weeks with effective suck, coordinated with breathing and swallowing, developing from 32 weeks and maturing fully by 35–37 weeks. Promoting non-nutritive sucking, using a pacifier or finger during tube-feeding, may help develop or maintain an effective sucking mechanism and decrease the length of hospital stay by easing the transition from tube to sucking feeds ( ).
Breastfeeding
If the mother intends to breastfeed the baby should, when possible, go to the breast in the delivery room soon after birth. Subsequently, regular breastfeeds help to stimulate colostrum and establish lactation. Preterm and LBW babies may need complementary feeds by cup, tube or bottle, until effective suckling feeds and weight gain are achieved. Monitoring for hypoglycaemia is often necessary for at least the first 48 hours or longer if the feeding is poor. Skin-to-skin contact, peer support, simultaneous breast milk pumping, multidisciplinary staff training and the Baby Friendly accreditation have been shown to improve successful breastfeeding ( ).
Bottle-feeding
Breastfeeding should be encouraged when possible but if bottle-feeding is the desired, or required, method of feeding, ideally the baby should be demand-fed, aiming for a 3–4-hourly schedule and 6–8 feeds per day. If most of the required volume is taken and the baby is not hypoglycaemic, no further ‘top-up’ feed is necessary. One of the few advantages of bottle-feeding is that the exact volume of feed is known; if the baby is not taking enough, particularly if there are concurrent problems with hypoglycaemia or weight gain, he or she should be topped up 3-hourly using a nasogastric tube. There is no firm evidence to support that using a teat causes ‘nipple confusion’ and the use of dummies has not been shown to affect breastfeeding.
Tube-feeding
Indications
The most common indication for tube-feeding is that a preterm or LBW baby is unable to suck the required amount of milk from the breast or bottle effectively. The decision to tube feed a baby is usually based on several factors, including:
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gestation at birth
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blood glucose levels
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frequency of waking for feed
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efficiency of sucking
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unsafe swallow
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inadequate volume taken
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dehydration, weight loss or paucity of weight gain.
Tube feeds can usually be administered on the TCU if they are not required more frequently than every 3–4 hours. Enteral feeding tubes may be placed via the nose or mouth. Evidence is lacking for superiority of either route ( ). Oral tubes are easier to pass but more prone to displacement, local irritation and vagal stimulation. Nasal placement may compromise respiration but the tubes remain in place more reliably. Breast- and bottle-feeding are both still possible with an indwelling nasogastric tube. Finger-feeding involves attaching a feeding tube to the side of a finger which is then inserted into the mouth in order to stimulate sucking. A breast supplementer is a similar device which may be attached to the breast whilst the baby sucks at the nipple and is another method that may encourage the baby to suck and swallow whilst breastfeeding is being established.
Complications of tube-feeding
Complications of tube-feeding in adults prompted the National Patient Safety Agency (NPSA), in consultation with the British Association of Perinatal Medicine, the Neonatal Nurses Association and the Royal College of Paediatrics and Child Health, to release guidance recommending that gastric tube position be confirmed by pH indicator strips, not litmus paper ( ). Other methods, including X-ray, auscultation, the presence of respiratory distress and the appearance of aspirate, or bubbling, are not to be used to confirm position. Reported complications from tube-feeding in neonates are rare but include pharyngeal, oesophageal, gastric, duodenal and bladder perforation with pneumomediastinum and peritonitis ( ; ; ). Soft silicone tubes have been passed into the bronchus ( ). Gastro-oesophageal reflux has been shown to be almost universal in tube-fed preterm infants, increasing the risk of aspiration pneumonia ( ).
Frequency and volume
In general, for preterm and small-for-gestational-age babies the volume given should be divided into a 3-hourly feeding schedule if there is normoglycaemia. Three-hourly feeds can usually be given on the TCU but if needed more frequently admission to SCBU is usually necessary. If the tube feed is complementing a bottle feed, the deficit should be made up. If the tube feed is complementing a breastfeed, in the first few days when only colostrum is likely to have been taken, the full volume should be given. Thereafter, a smaller proportion can be given based on clinical assessment.
Cup-feeding
Cup-feeding was reintroduced into the UK in the late 1980s by Sandra Lang. The technique involves swaddling the baby and sitting him or her in a semiupright position. The rim of a cup half-full of milk is then gently placed on the baby’s lower lip, directing the rim towards the corners of the upper lip, tipping the milk to touch the baby’s lip as he or she swallows it. Milk should not be poured into the baby’s mouth. The method appears safe if carefully monitored, and breathing and oxygen saturation remained stable during one study of 15 cup-feeding sessions ( ). Cup-feeding involves sipping and lapping rather than sucking, thus breastfeeding should continue in order to enhance the sucking experience. Cup-feeding improves the likelihood of exclusive breastfeeding by discharge but increases the length of stay ( ). Cup-feeding prolongs breastfeeding if frequent supplementary feeds are needed initially and following caesarean section ( ). Cup-feeding is a useful adjunct to other methods of feeding, but is a short-term solution which carries a risk of aspiration if not carefully supervised. Milk spillage is a real problem, particularly when expressed breast milk is in short supply.
Milk expression and storage
For babies unable to suckle at the breast successfully, mothers should be encouraged and supported to start milk expression as early as possible. Physical and emotional stress to the mother may inhibit adequate milk production. Skin-to-skin nursing, multidisciplinary support and Baby Friendly accreditation have been shown to improve the chances of successful breastfeeding ( ). Double pumping, skin-to-skin care and non-nutritive sucking at the breast can all help increase milk volume. Neonatal and maternity teams, with the help of lactation consultants, should support mothers to achieve this. Early (within 6 hours if possible), frequent (up to 10 times a day) and effective milk expression encourages maximum milk production. Adequately draining the breast is important as this stimulates further milk production and ‘hind milk’ has greater calorific value. If, despite frequent, effective expression, milk supply is inadequate, domperidone can increase maternal supply. Expressed breast milk can be safely stored in a refrigerator at less than 10°C for 3 days. It can be deep-frozen for 3 months and, once thawed, should be used within 24–48 hours.
Weight
All babies lose weight after birth – up to 10% of their bodyweight in the first 4–5 days – before gaining weight at 10–15 g/kg/day. It may take 6–10 days before the 32-week gestation, or 1.5–1.8-kg, baby shows steady weight gain.
Infection
Babies born at 32–35 weeks have physiological immunodeficiency ( Ch. 39.1 ). They are born before the transplacental transfer of maternal immunoglobulin is complete and developmental maturity of lymphocyte function. Babies nursed in TCUs are susceptible to infection and strict nosocomial precautions should apply. If the baby has been delivered after prolonged rupture of the membranes, or other risk factors for neonatal infection are present (e.g. maternal factors, including pyrexia), then the baby requires evaluation with consideration of a full infection screen plus antibiotic treatment pending results ( Ch. 39.2 ).
Skin
Skin integrity is an important barrier against infection. Tape should be thoughtfully applied and its use minimised as it is the primary cause of skin breakdown in LBW babies ( ).
Jaundice
Small and preterm babies are more likely to develop jaundice, particularly if they are not feeding well or have been polycythaemic. If jaundice becomes apparent the bilirubin level and maternal blood group should be checked. Phototherapy should be instituted at bilirubin levels appropriate for gestation ( Ch. 29.1 ), and a BiliBlanket can be chosen as first-line treatment in the preterm group. When assessing whether a jaundiced baby is fit for discharge many variables need to considered, including postnatal age, gestation, weight gain/loss, feeding, bilirubin trend, rate of rise/fall and time since cessation of phototherapy. The bilirubin level should be checked for rebound 12–18 hours after ceasing phototherapy but the baby does not necessarily have to remain in hospital for this to be done.
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