Neonatal presentations
Background
Newborn babies are difficult to assess. Sometimes neither parent nor clinician can put their finger on what the problem is. In the assessment of the newborn, we must make do with what we have and adopt a low threshold for assuming significant pathology if a baby is ‘not right’.
The most common presentation of the newborn is jaundice. Neonatal physiology makes jaundice all but inevitable. Besides a high rate of red cell breakdown, and an immature liver, there is the relatively poor fluid intake of the first few days.
Most babies who develop jaundice have physiological or ‘breast milk’ jaundice. A few will have a serious underlying reason for their jaundice.
Some of those with physiological jaundice will have it mildly, while some will require treatment. It is vital to never allow jaundice to reach the point where it can do harm. In the UK, it is now normal practice to test bilirubin levels in all jaundiced babies.
Assessment of a baby, whether jaundiced or not, is a hands-on skill that involves picking up the baby and getting a feel for their tone and responsiveness as well as the usual systems examination.
How to assess
•How old is the baby?
•Does the baby seem well?
•Is the baby feeding well?
•Are the nappies wet?
•Does the baby respond normally?
If jaundiced also ask:
•How quickly did the jaundice appear after birth?
•How far down the body does the jaundice go?
•What is Mum’s blood group?
•Are the stools normally pigmented?
•Is it getting worse, better or staying the same?
The ‘must do’s
A newborn that is not doing what newborns normally do (pass urine and stools, sleep and cry) in their normal way is presumed to have a serious infection and should be assessed as such.
Always assume that there is a serious cause for jaundice that appears in the first 24 hours. They may be haemolysing or septic (see pitfalls).
Have a lower threshold of referral for the jaundiced baby who seems uninterested in feeds, or cries excessively. At best, they need assessment because they won’t feed well enough to get better. At worst they may be septic.
Always refer a baby with jaundice and abnormally pale stools – if they have biliary atresia (a condition where the biliary tree closes up over the space of weeks), time to treatment is critical.
Physiological jaundice may take longer to resolve than two weeks, but by this point other causes become a concern. Refer for a ‘prolonged jaundice screen’.
Pitfalls to avoid
Septic babies often do not have the courtesy to look ill or have fevers. They are often just ‘a bit off’, feeding poorly or manifest with other such vague symptoms.
Babies often don’t look dehydrated, and it can be difficult to assess how well breastfed babies are feeding. Wet nappies are good, but dry nappies for longer than six hours are worrying. If in doubt, weigh the baby. The birth weight divided by their current weight gives you the percentage that the baby has lost since birth, eg 2.85 kg/2.54 kg = 1.12 – indicating a 12% weight loss.
Most of that loss is fluid, so a figure of >10% represents a significantly dehydrated child even if they look well.
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