Feeding Difficulty in the Newborn (Case 24)

Chapter 61 Feeding Difficulty in the Newborn (Case 24)



Edelveis R.M. Clapp, DO




Case


A 7-day-old term infant has lost 9% of her birth weight. She is breastfeeding every 3 hours and has four wet and two stool diapers per day. The prenatal and newborn nursery course were normal, and she is well appearing.




Differential Diagnosis









Inadequate caloric intake Sepsis Maternal depression


Speaking Intelligently


When I approach a newborn who is not gaining weight at a rate of 15 to 30 g/day, I first consider the most obvious cause. Malnutrition is the most common culprit, especially in a breastfed infant. An accurate history is key in sorting out the difficulty. Is the infant latching well? Is mother’s milk in? How often is the infant feeding? Are there socioeconomic factors that could be affecting the well-being of the child? It is also important to rule out congenital abnormality or infection as the underlying cause of inadequate weight gain.



Patient Care



Clinical Thinking



• Review the prenatal history, newborn course, and family history.

• Check vital signs—is the heart rate or respiratory rate elevated? Is the baby in distress and requiring stabilization with IV fluids or antibiotics?

• Is the infant dehydrated? Jaundiced? Is the skin turgor poor? Wetting diapers?

• A complete evaluation may be needed if there is concern for sepsis.

• What is the interaction between the mother and child? Are there concerns for postpartum depression? How does the mother feel about breastfeeding?


History



• Any problems in the nursery?

• How frequently is the infant feeding? How long do the feedings last? Does the infant tire or sweat with feeds? Is there cyanosis? Does the baby spit up excessively or vomit? Has mother’s milk come in?

• Address hydration status by number of wet diapers, and stool frequency and quality.

• Check mental status. Is the baby alert and vigorous, or difficult to arouse? Is the infant irritable or in pain?

• Are there signs or symptoms of infection? Is there fever? Hypothermia?

• Has the infant had phototherapy?


Physical Examination



• Vital signs: Changes associated with dehydration include tachypnea, tachycardia, and weight loss. Hypotension is a late sign. Check for fever or hypothermia.

• Assess hydration status. Check the fontanelle, skin turgor, and mucous membranes.

• Check the tongue for short frenulum.

• Auscultate the heart for murmurs, abnormal rate and sounds.

• Palpate femoral pulses, and check capillary refill.

• Look for signs of focal infection, such as cellulitis.

• Watch the baby feed. Does he/she latch well? Is there milk transfer? Does the baby seem to swallow? Is the baby satisfied after a feed?


Tests for Consideration



• Newborn metabolic screen: Results may take up to 2 weeks. $227

• Electrolytes: If concern for dehydration. $174

• If the infant is lethargic, fontanelle is bulging, or infection is suspected:
• Complete blood count $116

• Urinalysis $95

• Urine culture $148

• Blood culture $152

• Cerebrospinal fluid (CSF) culture $152

• CSF cell count $150

• CSF Gram stain $180
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Related posts:

  1. The Special Needs Child
  2. Diarrhea (Case 6)
  3. Pediatric Poisonings (Case 54)
  4. Note Writing

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Feeding Difficulty in the Newborn (Case 24)

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