Chapter 43 Recognizing the ill baby
The length of time a mother spends in hospital with her newborn infant is ever decreasing. The focus of this chapter is to aid the midwife in the early detection of diseases which can be used in conjunction with the newborn examination, thus allowing the midwife to distinguish the ill from the well baby.
The majority of newborn babies are born normal and healthy; they require no intervention after birth except to be dried with a warm towel and then to have skin-to-skin contact with their mothers. However, although the labour and birth may have been straightforward, the baby will still need to be observed at this time to ensure that the respirations are normal, there is good colour, the body temperature is stable and the baby is active and responsive.
The midwife soon becomes familiar with the appearance and behaviour of the well baby, but must also learn the signs and signals caused by illness, some of which may be subtle and non-specific. The labour and birth have an obvious effect on the well-being of the infant, but added to this are the genetic background, the mother’s illnesses in pregnancy and any drugs she may have taken or received during that period (Rennie 2005a).
Parents welcome the observation of their newborn as it provides an opportunity for them to discuss any concerns they may have and the midwife can reassure them that their baby is normal and healthy. If the baby is unwell, this needs to be identified quickly and parents need to be made aware of any problem as soon as possible.
Immediately after birth, all infants should be examined for any gross congenital abnormalities or evidence of birth trauma. They should also have their weight and gestational age plotted on a standard growth chart (see Ch. 42).
Classifying infants according to weight and gestation allows the midwife to assess infants who may require specialized care. Infants who are pre-term, small for gestational age (SGA) or large for gestational age (LGA) are at an increased risk of respiratory disease, hypoglycaemia, polycythaemia and disturbed thermoregulation. Later, usually within the next 24hrs, a more comprehensive, systematic, physical examination should take place.
Decreasing morbidity and mortality are the goal of all those involved with the care of the newborn infant. The early recognition of existing or potential problems is vital if the appropriate treatment is to be initiated as soon as possible.
Any disease in the mother can have an effect on the pregnancy. Some have more specific effects than others do and reviewing the maternal history is an essential starting point in understanding the potential or presenting problems of the neonate. Influencing factors include:
The following are examples of significant questions that a midwife may ask herself as they may have a critical influence on the well-being of the infant:
Labour and birth may also have an effect on the general welfare of the newborn infant. Listed below are important points that can confirm or rule out fetal compromise:
Over a period of a few hours the newborn baby needs to adapt to living without placental support, and it is during this time that some problems may manifest themselves. The midwife needs to be able to recognize warning signs and initiate prompt action if deterioration of the baby’s condition is to be prevented.
Most of the information the midwife requires for the assessment of a baby’s well-being comes from observation. The baby’s breathing pattern will alter depending on his level of activity but a respiratory rate consistently above 60 breaths/min is considered as tachypnoea. Much can be learned by observing the baby’s resting position. The normal baby will lie with his limbs partially flexed and active. The skin colour should be centrally pink, indicating adequate oxygenation; there should be no rashes or skin lesions. The signs listed in Box 43.1 may indicate an underlying problem.
After the initial observation there should follow a more systematic examination.
The skin of a neonate varies in its appearance and can often be the cause of unnecessary anxiety in the mother, midwife and medical staff. It is, however, often the first sign that there may be an underlying problem in the baby.
The presence of meconium on the skin, which is usually seen in the nail beds and around the umbilicus, is frequently associated with infants who have cardiorespiratory problems. More generally, the skin of all babies should be examined for pallor, plethora, cyanosis, jaundice and skin rashes.
A pale, mottled baby is an indication of poor peripheral perfusion. At birth, it can be associated with low circulating blood volume or with circulatory adaptation and compensation for perinatal hypoxaemia. The anaemic infant’s appearance is usually pale pink, white or, in severe cases where there is vascular collapse, grey. Other presenting signs are tachycardia, tachypnoea and poor capillary refill (to assess capillary refill, press the skin briefly on the forehead or abdomen and observe how long it takes for the colour to return; this should be prompt).
The most likely causes of anaemia in the newborn period are:
Pallor can also be observed in infants who are hypothermic or hypoglycaemic. Problems associated with pallor include:
Babies who are beetroot in colour are usually described as plethoric. Their colour may indicate an excess of circulating red blood cells (polycythaemia). This is defined as a venous haematocrit >70%. Newborn infants can become polycythaemic if they are recipients of:
Contributing factors are delayed clamping of umbilical cord, or holding the infant below the level of the placenta, thereby allowing blood to flow into the baby and giving a greater circulating blood volume (sometimes occurring in un-assisted births). Other infants at risk are:
Hypoglycaemia is commonly seen in plethoric infants because red blood cells consume glucose. The infant can exhibit a neurological disorder; irritability, jitteriness and convulsions can occur. Other problems that may manifest are:
The diagnosis of polycythaemia is based upon haemoglobin and haematocrit level comparisons with normal values based on gestation. The treatment for symptomatic polycythaemia is to replace red blood cells by means of a partial exchange using a crystalloid solution such as normal saline. Infants who are non-symptomatic should be observed. There is no evidence to support the use of fresh frozen plasma or albumin, both carry a significant risk of transfusion-related sepsis (Roberts 2003).
Central cyanosis should always be taken very seriously. The mucous membranes are the most reliable indicators of central colour in all babies and if the tongue and mucous membranes appear blue this indicates low oxygen saturation levels in the blood, usually of respiratory or cardiac origin. Episodic central cyanotic attacks may be an indication that the infant is having a convulsion. Peripheral cyanosis of the hands and feet is common during the first 24hrs of life; after this time it may be a non-specific sign of illness. Central cyanosis always demands urgent attention.
Early onset jaundice (presenting within the first 12hrs of life) is abnormal and needs investigating. If a jaundiced baby is unduly lethargic, is a poor feeder, vomits or has an unstable body temperature, this may indicate infection and action should be taken to exclude this (see Ch. 47).
Pre-term infants have thinner skin that is redder in appearance than that of term infants. In post-term infants the skin is often dry and cracked.
The skin is a good indicator of the nutritional status of the infant. The SGA infant may look malnourished and have folds of loose skin over the joints, owing to the lack or loss of subcutaneous fat. This can predispose the infant to problems with hypoglycaemia due to poor glycogen stores in the liver and can also cause problems with hypothermia.
If the infant is dehydrated, the skin looks dry and pale and is often cool to touch. If gently pinched, it will be slow in retracting. Other signs of dehydration are: pallor or mottled skin, sunken fontanelle or eyeball sockets and tachycardia.
Skin rashes are quite common in newborn babies but most are benign and self-limiting.
These are white or yellow papules seen over the cheeks, nose and forehead. These invariably disappear spontaneously over the first few weeks of life (Plate 16).
These are clear vesicles on the face, scalp and perineum, caused by retention of sweat in unopened sweat glands. They appear on the chest and around areas where clothes can cause friction. The treatment is to nurse the infant in a cooler environment or to remove excess clothing.
These can occur in neonatal thrombocytopenia, which is a condition of platelet deficiency and usually presents with a petechial rash over the whole of the body. There may also be prolonged bleeding from puncture sites or the umbilicus, or both, and bleeding into the gut. Thrombocytopenia may be found in infants with:
This can occur extensively following breech extractions, forceps and ventouse deliveries. The bleeding can cause a decrease in circulating blood volume, predisposing the baby to anaemia or, if the bruising is severe, hypotension.
This is a rash that consists of white papules on an erythematous base; it occurs in about 30–70% of infants. This condition is benign and should not be confused with a staphylococcal infection, which will require antibiotics. Diagnosis can be confirmed by examination of a smear of aspirate from a pustule, which will show numerous eosinophils (white cells indicative of an allergic response, rather than infection).
This is a fungal infection of the mouth and throat. It is very common in neonates especially if they have been treated with antibiotics. It presents as white patches seen over the tongue and mucous membranes and as a red rash on the perineum.
If acquired in the neonatal period, is a most serious viral infection. Transmission in utero is rare; the infection usually occurs during birth with the illness presenting after 3 days. Seventy per cent of affected infants will produce a rash, which appears as vesicles or pustules. Mortality depends on severity of the illness and when treatment commenced (Logan 1990) (Plate 24).
This can be caused by a bacterial infection. Until its separation, the umbilical cord can be a focus for infection by bacteria that colonize the skin of the newborn. If periumbilical redness occurs or a discharge is noted, it may be necessary to commence antibiotic therapy in order to prevent an ascending infection.
This commonly presents as a few yellow filled bullae (Plates 25, 26). Severe infections can give rise to bullous impetigo which makes the skin look as though it has been scalded. It presents as widespread tender erythema, followed by blisters, which break leaving raw areas of skin. This is particularly noticeable around the napkin area but can also cause umbilical sepsis, breast abscesses, conjunctivitis and, in deep infections, there may also be involvement of the bones and joints.
Respiratory distress in the newborn can be a presentation of a number of clinical disorders and is the major factor in the morbidity and mortality in the neonatal period.
It is important to observe the baby’s breathing when he is at rest and when he is active. The midwife should always start by observing skin colour and then carry out a respiratory inspection, taking into account whether the baby is making either an extra effort or insufficient effort to breathe.
Respirations should be counted by watching the lower chest and abdomen rise and fall for a full minute. The respiration rate should be between 40 and 60 breaths/min but will vary according to the level of activity. Newborn infants are primarily nose breathers and so obstructions of the nares may lead to respiratory distress and cyanosis. Remember if suction is required at any time; always suction the mouth first and then the nose. The chest should expand symmetrically. If there is unilateral expansion and breath sounds are diminished on one side, this may indicate that a pneumothorax has occurred. Infants at risk of pneumothorax or other air leaks are:
If the baby’s respiratory rate at rest is above 60 breaths/min, this is described as tachypnoea. When observing an infant’s respiratory rate the midwife must always take into consideration the environment and the temperature in which the baby is being nursed. Overheating will cause an infant to breathe faster.
Any infant with persistent tachypnoea may be described as having respiratory distress, and the midwife should also observe the quality of the respirations, noting if there is any inspiratory pulling in of the chest wall above and below the sternum, or between the ribs (retraction). If nasal flaring is also present, this may indicate that there has been a delay in the lung fluid clearance (transient tachypnoea of the newborn) or that a more serious respiratory problem is developing (respiratory distress syndrome, meconium aspiration, pneumonia) (Tappero & Honeyfield 2003).
Grunting, heard either with a stethoscope or audibly, is an abnormal expiratory sound. The grunting baby forcibly exhales against a closed glottis in order to prevent the alveoli from collapsing. These infants may require help with their breathing, either by intubation or continuous positive airway pressure ventilation (CPAP) (see also Ch. 44).
Apnoea is defined as a cessation of breathing for 20s or more. It is associated with pallor, bradycardia, cyanosis, oxygen desaturation or a change in the level of consciousness (American Academy 1978). Any baby having apnoeic spells needs to be admitted to a neonatal unit to have his cardiorespiratory system monitored.
The most common cause of apnoea in pre-term babies is pulmonary surfactant deficiency (see Ch. 44) or the immaturity of the central nervous system control mechanism. Other disorders that may produce apnoea in the newborn are:
It is very important to remember that apnoea may also be induced by stimulation of the posterior pharynx by suction catheters.
Thermoregulation is a critical physiological function that is closely related to the survival of the infant. It is therefore essential that all those caring for newborn infants are aware of the importance of the thermal environment and understand the need for maintenance of normal body temperature (Merenstein & Gardner 2006).
A neutral thermal environment is defined as the ambient air temperature at which oxygen consumption or heat production is minimal, with body temperature in the normal range (Lissauce & Faranoff 2006).
The normal body temperature range for term infants is 36.5–37.3 °C.
Environments that are outside the neutral thermal environment may result in the infant developing hypothermia or hyperthermia. Babies who are too cold or too warm will try and regulate their temperature and this action, especially in the pre-term and SGA infant, can have a detrimental effect (see also Ch. 42).
Note: Intermittent temperature recordings have traditionally been taken using mercury thermometers. Research suggests that this practice is hazardous and should be eradicated (Smith et al 1997).
Hypothermia is defined as a core temperature below 36 °C (Rutter 2005). When the body temperature is below this level the infant is at risk from cold stress. This can cause complications such as increased oxygen consumption, lactic acid production, apnoea, decrease in blood coagulability and, the most commonly seen, hypoglycaemia. In pre-term infants, cold stress may also cause a decrease in surfactant secretion and synthesis.
After birth a baby’s body temperature can fall very quickly. The healthy term baby will try to maintain his temperature within the normal range. If, however, he is compromised at birth by any of the following conditions, the added stress of hypothermia can be disastrous:
When a neonate is exposed to cold he will at first become very restless; then, as his body temperature falls, he adopts a tightly flexed position to try to conserve heat. The sick or pre-term infant will tend to lie supine in a frog-like position with all his surfaces exposed, which maximizes heat loss (Roberton 2002).
Adults can generate heat from shivering, whereas neonates perform non-shivering thermogenesis utilizing their brown fat stores. During brown fat metabolism, oxygen is consumed and this may cause an alteration in the respiratory pattern, usually increasing the rate. Added to this, the baby often looks pale or mottled and may be uninterested in feeding. Hypoglycaemia is a common feature of infants with increased energy expenditure associated with thermoregulation and this can cause the infant to have jittery movements of the limbs, even though he is quiet and often limp.
Hyperthermia is defined as a core temperature above 38.0 °C (Rutter 2005). The usual cause of hyperthermia is overheating of the environment, but it can also be a clinical sign of sepsis, brain injury or drug therapy. If an infant is too warm, he becomes restless and may have bright red cheeks. Hyperthermia has a similar effect on the body to that of hypothermia and is equally detrimental. An infant will attempt to regulate his temperature by increasing his respiratory rate and this can lead to an increased fluid loss by evaporation through the airways. Other problems caused by hyperthermia are hypernatraemia, jaundice and recurrent apnoea.
Note: Variability in body temperature, either high or low, may be the first and only sign that a baby is unwell.
The normal heart rate of a newborn baby is 110–160 b.p.m., with an average of 130 b.p.m. (Kozier et al 1998). The heart rate varies with respiration in the newborn; however, heart rates persistently outside this range when at rest, may suggest an underlying cardiac problem. Cardiovascular dysfunction should be suspected in infants who commonly present with lethargy and breathlessness during feeding. It is often the baby’s mother who first expresses concern: her baby may be slow with his feeds, and she may say he looks pale at times or that he feels very sweaty or has fast or laboured breathing.
It can be very difficult to identify infants with congenital heart disease because the clinical picture of tachycardia, tachypnoea, pallor or cyanosis may be suggestive of a respiratory problem or sepsis.
Problems that occur in neonatal cardiovascular function are usually caused either by congenital defects or by a failure of the transition from fetal to adult circulation. Persistent pulmonary hypertension of the newborn is usually seen in term or post-term infants who have a history of hypoxia or asphyxia at birth. The infants are slow to take their first breath or are difficult to ventilate. Respiratory distress and cyanosis are seen before 12hrs of age. Hypoxaemia is usually profound and may suggest cyanotic heart disease (see Ch. 46). Risk factors include meconium-stained amniotic fluid, nuchal cord, placental abruption, acute blood loss and maternal sedation.
Congenital heart disease affects just under 1% of newborn infants, many of whom will be asymptomatic in the neonatal period (Fowlie & Forsyth 1995). Infants who appear breathless but have little or no rib recession, are not grunting and have only a moderately raised respiratory rate may have heart disease. Cyanosis can be a prominent feature in some cardiac defects, but not all. Box 43.2 lists signs that may be indicative of congenital heart disease.
Box 43.2 Warning signs suggestive of congenital heart disease
Cardiac failure may be rapid in onset; the earlier it presents, the more sinister is the cause. Delays in recognizing and treating heart failure may lead to a rapid deterioration and cardiogenic shock. Cardiac shock may resemble early septicaemia, pneumonia or meningitis (David 1995). The first indication of an underlying cardiac lesion may be the presence of a murmur heard on routine examination. However, a soft localized systolic murmur with no evidence of any symptoms of cardiac disease is usually of no significance.
Assessment of an infant’s neurological status is usually carried out on a baby who is awake but not crying. Abnormal postures, which include neck retraction, frog-like postures, hyperextension or hyperflexion of the limbs, jittery or abnormal involuntary movements and a high-pitched or weak cry, could be indicative of neurological impairment and a need for investigation (Rennie 2005b).
Neurological disorders found at or soon after birth may be either prenatal or perinatal in origin. They include:
Neurological disorders that appear in the neonatal period need to be recognized promptly in order to minimize brain damage. These include:
Cerebral hypoxia and bacterial infections are of prime importance. Prompt diagnosis, investigation and treatment are vital as delay can have a significant impact on neurological development (Rennie 2005a).
Terminology that describes abnormal movement in babies is very variable and includes ‘fits’, ‘convulsions’, ‘seizures’, ‘twitching’, ‘jumpy’ and ‘jittery’. In contrast, a baby with poor muscle tone is described as ‘floppy’. It is often very difficult to distinguish a seizure from jitteriness or irritability. The jittery baby has tremors, rapid movement of the extremities or fingers that are stopped when the limb is held or flexed. Jitteriness can be normal but is more often seen in infants who are affected by drug withdrawal or in infants with hypoglycaemia.
Seizures in the newborn period can be extremely difficult to diagnose, as they are often very subtle and easily missed (Table 43.1).
Table 43.1 Neonatal seizure chart
| Type | Affected infant |
|---|---|
| Subtle | |
| Apnoea usually with abnormal eye movements, tonic horizontal deviation, blinking, fluttering eyelids, jerking, drooling, sucking, tonic posturing or unusual movements of the limbs (rowing, peddling or swimming) | Most frequent type and most commonly seen in pre-term infants |
| Clonic | |
| Jerking activity. Multifocal or unifocal distinct from jittering | Term infants: hypoxic-ischaemic encephalopathy, or inborn errors of metabolism |
| Tonic | |
| Posturing similar to decerebrate posture in adults | Pre-term infants with intraventricular haemorrhage |
| Myoclonic | |
| Single or multiple jerks of upper or lower extremities | Possible prediction of myoclonic spasm in early infancy |
Adapted from Volpe 2001.
The term hypotonia or ‘floppy baby’ describes the loss of body tension and tone. As a result, the infant adopts an abnormal posture that is noticeable on handling.
Pre-term infants below 30 weeks’ gestation have a resting position that is usually characterized as hypotonic. By 34 weeks, their thighs and hips are flexed and they lie in a frog-like position, usually with their arms extended. At 36–38 weeks’ gestation, the resting position of a healthy newborn baby is one of total flexion with immediate recoil. Hypotonia in a term infant is not normal and requires investigation. It is also important to determine whether the hypotonia is associated with weakness or normal power in the infant’s limbs. The causes of hypotonia include:
Urinary infections in the newborn period are quite common, especially in males. The baby typically presents with lethargy, poor feeding, increasing jaundice and vomiting. Urine that only dribbles out, rather than being passed forcefully, may be an indication of a problem with posterior urethral valves. Urine that is cloudy in appearance or smelly may be an indication of a urinary tract infection.
The genitourinary tract has the highest percentage of anomalies, congenital or genetic, of all the organ systems. Prenatal diagnosis is possible with ultrasound and aids the early assessment and intervention, which is essential if kidney damage is to be prevented. Renal problems may present as a failure to pass urine. The normal infant usually passes urine 4–10hrs after birth. Normal urine output for a term baby in the first day of life should be 2–4ml/kg per hour. A urine output of <1ml/kg per hour (oliguria) in the first few days of life should be investigated (Modi 2005). Urinalysis using reagent strips will give information that may be helpful in diagnosis (Table 43.2).
Table 43.2 Information obtainable from urinalysis with reagent strips
| Test | Significance |
|---|---|
| Urine pH | Failure to acidify the urine may indicate a dysfunction of the renal tubular system, which plays a primary role in the regulation of bicarbonate concentration |
| Specific gravity | Indicates urine concentration |
| Blood | Is suggestive of trauma or inflammation of the genitourinary tract |
| Protein | May suggest renal disease |
Common causes of reduced urine output include:
Documentation of the passage of urine after birth is important as it provides a record that may help if concerns arise.
Some congenital abnormalities of the gastrointestinal tract can now be diagnosed antenatally by ultrasound. Other defects, however, may not be suspected until the infant becomes unwell.
Intestinal obstructions may be caused by atresias, malformations or structural damage anywhere below the stomach. In the newborn period, gastrointestinal disorders often present with vomiting, abdominal distension, a failure to pass stools, or diarrhoea with or without blood in the stools. However, vomiting in the postnatal period can be caused by factors other than gastrointestinal obstructions. The midwife should distinguish between posseting, which occurs with winding and overhandling after feeding, and vomiting due to overfeeding, infection or intestinal abnormalities. Early vomiting may be caused by the infant swallowing meconium or maternal blood at delivery. This can cause a gastritis, which will eventually settle.
All vomit should be checked for the presence of bile or blood. Observe the infant for other signs such as abdominal distension, watery or bloodstained stools and temperature instability.
The normal term baby usually passes about eight stools a day. Breastfed babies’ stools are looser and more frequent than those of bottle-fed babies, and the colour varies more and sometimes appears greenish. The infant who has an infection can often display signs of gastrointestinal problems, usually poor feeding, vomiting or diarrhoea, or both. Diarrhoea caused by gastroenteritis is usually very watery and may sometimes resemble urine. The cause is either bacterial or viral. Infants with this condition must be isolated and scrupulous hand washing adhered to (Isaacs & Moxon 2000). Loose stools can also be a feature of infants being treated for hyperbilirubinaemia with phototherapy.
Some of the more commonly seen gastrointestinal problems include: duodenal atresia, malrotation of the gut, volvulus, meconium ileus (see Ch. 46), necrotizing enterocolitis, imperforate anus, rectal fistulas and Hirschsprung’s disease.
NEC is an acquired disease of the small and large intestine caused by ischaemia of the intestinal mucosa. It occurs more often in pre-term babies, but may also occur in term babies who have been asphyxiated at delivery or babies with polycythaemia and hypothermia (commonly found in SGA babies). NEC may present with vomiting or, if gastric emptying is being monitored, the aspirate is large and bile stained. The abdomen becomes distended (Plate 27), stools are loose and may have blood in them. In the early stages of NEC, the baby can display non-specific signs of temperature instability, unstable glucose levels, lethargy and poor peripheral circulation. As the illness progresses, the baby becomes apnoeic and bradycardic and may need ventilating. (See also Chs 44 and 47.)
The midwife should look for the presence of meconium in the urine or, in female babies, meconium being passed from the vagina.
Hirschsprung’s disease should be suspected in term babies with delayed passage of meconium, certainly after the first 24hrs of life (see Ch. 46). Abdominal distension and vomiting are clinical signs, with the vomit becoming bile stained if meconium is not passed.
Metabolic disorders, such as galactosaemia and phenylketonuria, present in the newborn period with vomiting, weight loss, jaundice and lethargy (see Ch. 48).
Babies who are clearly unwell, distressed or less than 1800g at birth require admission to a neonatal unit (NNU). Early separation of mother and baby is very damaging and should be avoided unless absolutely necessary. Asymptomatic babies above 1800g, irrespective of gestation, should be able to stay with their mother either on a ward, or for infants with minor problems only, in a transitional care unit. Managing these babies can be challenging for midwives as some of them may require tube feeding, monitoring of their blood glucose levels and antibiotic therapy. Drug administration is playing an ever-increasing role in the management of the ill baby. Table 43.3 lists some antibiotic drugs commonly used to treat suspected neonatal sepsis.
Table 43.3 Commonly used drugs to treat neonatal sepsis
| Drug | Some possible neonatal infections | Organism |
|---|---|---|
| Acyclovir | Chickenpox, rous sarcoma virus | Virus |
| Ceftriaxone | Meningitis | Gram −ve cocci |
| Ceftazidime | Meningitis | Gram −ve cocci |
| Clarithromycin | Chlamydia | Gram −ve cocci, Gram +ve cocci |
| Co-amoxiclav | Otis media, lower respiratory infections | Gram −ve cocci, Gram +ve cocci |
| Flucloxacillin | Skin infections, Staphylococcus aureus | Gram −ve cocci |
| Gentamicin | Escherichia coli, Klebsiella | Gram −ve cocci |
| Metronidazole | Necrotizing enterocolitis | Anaerobes |
| Penicillin G and V | Group B streptococcus | Gram +ve cocci |
| Vancomycin | Staphylococcus epidermidis, Staphylococcus aureus | Gram +ve cocci |
Antibiotics are the most common drugs used in NNUs. Premature babies have very little immunity to infections that can be acquired congenitally. Suspected infections are always treated with antibiotics, immediately after blood cultures have been taken. Once the results of the blood cultures are known, antibiotics may be continued or stopped.
Drugs can be given to neonates orally, intramuscularly, intravenously, topically or rectally. The most efficient and effective route to administer drugs to a baby is by the intravenous route; this is because the absorption of drugs via the stomach is dependent on factors in the baby relating to gastric emptying time and gastric and duodenal pH. Intramuscular administration is often a painful route and absorption is dependent on blood flow to the muscle, which can be compromised in a baby who is poorly perfused.
Whichever route is used, all drugs must be administered safely in accordance with unit/ward/hospital policy and meet the guidelines for administration of medicines (Nursing & Midwifery Council 2007). Many drugs will need to be diluted prior to administration to allow for accurate measurement of the required dose. Unfortunately, mistakes in drug administration are not uncommon, and having two nurses/midwives calculate and check the dose will decrease the risk of an error occurring.
Before administering any drugs to a baby the midwife should always check that it is:
To avoid misinterpretation of doses prescribed, only approved abbreviations should be used.
Before calculating the volume required to give the correct dose, the midwife should write down the strength of the drug in the ampoule or vial; for example, ampoules of gentamicin (paediatric) contain 20mg of gentamicin diluted in 2ml of water. If the dose prescribed is 8mg the calculation is as follows:
For parents, the birth of a baby is a mixture of joy, emotional exhilaration and relief. Most newborn babies are normal and healthy and few parents ever expect or consider the possibility of having a baby that is less than perfect (Cameron 1996). Neither will they have considered the implications of separation if their baby has to be admitted to the NNU. So when a baby requires medical assistance, because of prematurity, illness or congenital malformations, the effect on the parents can be significant and force the family into a crisis that can be as devastating as bereavement. The parents’ ability to resolve the crisis will depend on how realistically they perceive their baby’s problems.
Separation of mother and baby, even if it is for a short while, may increase the risk of the parents developing parental difficulties, with effects on their pattern of behaviour and general responses towards their baby (Coffman 1992).
The environment of the NNU, however thoughtful the layout and design, is an alarming place to enter, with machinery that bleeps and alarms continuously (Plates 18, 19). Anxiety levels are often high. Midwives, nurses and medical staff have an important part to play to enable parents to feel welcome and equal partners in the care of their baby.
NNUs should be bright, friendly and welcoming. Parents should be encouraged to bring in brightly coloured toys and mobiles for their babies; one or two of these can be placed in the incubator or cot. This is of special importance for longer stay babies to aid their neurological development. In most NNUs, a sitting room, often with kitchen facilities, is provided for parents and children. This is a place of retreat, away from the stresses and strains of busy nurseries. The provision of bedrooms or family rooms, or both, where parents can stay if their baby is critically ill, or sadly if their baby has died, is of crucial importance (see Ch. 38).
If it is known in advance that a baby may require admission to the NNU, parents should be given the opportunity to visit and meet some of the staff. They can be shown the room or area where their baby will be admitted, and a brief explanation of the various items of monitoring equipment may help to alleviate some of their fears about what will happen to their baby after it has been born. Following the delivery and if possible, the parents should be allowed to hold or touch their baby, even if it is for just a few moments, before he is taken to the NNU.
On admission to the NNU, a photograph should be taken. This photograph must be given to the parents as soon as possible, as this will go some way towards reassuring them that their baby is safe and alive (Slade 1988). Parents should be encouraged to visit their baby in the NNU as soon they are able. When discussing the baby with the parents, the midwife should try always to use the name that they have given their child as this establishes the baby’s identity and makes the conversation more personalized.
The pre-term infant may require a lengthy stay in the NNU, in which case parenting roles may be difficult to establish owing to the physical condition of the baby who may be on a ventilator, being fed intravenously, or be under phototherapy lights. All of these act as a barrier between the baby and the parents and undermine their confidence. They may look for areas of baby care with which they are familiar, and will often adopt a passive role and concentrate on family routines in order to cope (Redshaw & Harris 1995). It is during this time of crisis, when parents are at their most vulnerable, that they will look to staff to provide information and support. Communication at this time must be on a basic level and backed up with information leaflets in a language they can understand (Taylor 1996).
The most important visual aid for any baby is the human face, especially the talking face, which stimulates both visual and auditory pathways. Parents and siblings should be encouraged to communicate with their baby even if it has to be through the porthole window of the incubator (Gardner & Goldson 2006).
Involving the parents, as partners in care, should be encouraged as soon as the baby’s condition and tolerance to handling permits. This early involvement will strengthen their understanding of the baby belonging to them and increase their confidence in their ability to provide care. A supportive environment, in which the parents gain confidence in assuming the role of caregivers, is of fundamental importance to the general well-being of the baby. In order to reinforce the parents’ involvement in the care of their baby, it is important to discuss whether the baby is to be breast- or bottle-fed. Midwives and neonatal nurses should encourage mothers to breastfeed their babies, or to express their breastmilk, as it provides a greater protection against infection. Breastfeeding or expressing milk may help the mother feel closer to her baby and may also make her feel that she is contributing to her baby’s care in a way that nobody else can.
Care should be individualized for each baby and not be performed routinely. This requires thoughtful planning to avoid repeatedly disturbing the baby. Questions should be asked about performing unnecessary procedures such as repeated heel stabs. Painful, invasive procedures that are not vital to the individual baby’s needs are stress-producing events and should be eliminated. Studies by Sparshott (1991) and Becker et al (1993) have shown that babies’ responses to their environment can be directly linked to their experiences. Increasingly, NNUs are introducing a system of individualized developmental care for pre-term babies aimed at reducing their stress levels. This innovative care programme is based on the studies by Als et al (1994). Day and night cycles should be recognized, lights should be dimmed at nighttime and noise levels, which are often alarmingly high, should be reduced. Remember though that it is essential that ill babies are observed; when monitor alarms are cancelled they need to be reset.
Encouraging brothers and sisters to visit their new baby is important. Parents are often anxious about the effect an ill baby may have on the family. However, this may cause anxiety in the siblings and they may feel worried, rejected and left out, causing them to demonstrate behavioural problems.
Effective discharge planning should commence as soon as the baby is admitted to the NNU. Encouraging parents to participate in the care of their baby from the beginning enables them eventually to be the sole caregivers and assume total charge.
Parents should learn how to feed, bathe, dress and generally care for their baby. If the baby has special needs like tube feeding or stoma care, training needs may span several weeks and must be backed up with written information. The parents must feel comfortable about caring for their baby before going home.
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Becker PT, Grunwald PC, Moorman J. Effects of developmental care on behavioral organization in very low birth weight infants. Nursing Research. 1993;42(4):214-220.
Cameron J. Parents as partners in care. British Journal of Midwifery. 1996;4(4):218-219.
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Lissauce T, Faranoff A. Neonatology at a glance. London: Blackwell Science, 2006.
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Modi N. Fluid and electrolyte balance. In: Rennie J, editor. Roberton’s textbook of neonatology. 4th edn. Edinburgh: Churchill Livingstone; 2005:335-354.
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Kenner C, Wright Lott J. Neonatal nursing handbook. St Louis: Elsevier Science, 2004.
This book addresses the most common neonatal problems. The illustrations and charts are excellent and aid the reader to a more comprehensive understanding of the clinical situation.
Crawford D, Hickson W. An introduction to neonatal nursing care. London: Stanley Thornes Ltd, 2000.
An introduction to neonatal nursing care is written in a style that is easily understood by practising midwives, neonatal nurses and students. It covers all aspects of the nursing and medical management of the sick infant
Lissauce T, Faranoff A. Neonatology at a glance. London: Blackwell Science, 2006.
This easily understood textbook is a great starting point for midwives and neonatal nurses. It deals with the important aspects of neonatal problems, in a succinct manner, allowing the reader at their own pace to further explore a more in-depth understanding of clinical situations