Fig 1. Strawberry naevus. s c i r t a i d e a P New babies may have diffi culty co-ordinating feeding and breathing, and brie \202 y choke , gag, or turn blue. Exclude disease, check feeding technique (too much? too fast?) and rea ssure. Regurgitation is often due to over \201 lling a tiny stomach with milk and air. Check feed ing technique; if bottle fed, is the teat too big for the mouth or the hole too small or th e amount too great? Winding during feeds may help but is not essential to health. Red-stained nappy: This is usually due to urinary urates but may be blood from the cord or baby \200\231s vagina (estrogen withdrawal bleed). Neonatal sneezing clears nasal amniotic \202 uid. If jittery T \200\200/ muscle hyperto- nia, suspect \202 uoxetine or opi ate withdrawal. 182,183 RSV (p160) is another cause. Enteral and parenteral nutrition Breastfeeding ( expressed breast milk, p124 \200\2236) i s the ideal way to feed term babies; if <2kg, powder sachets of breast milk forti \201 ers (eg Cow & Gate) have a role. In prems, extrauterine growth restriction and neurodevelopmen tal delay from under-feeding is only partly preventable by oral/tube feeding \200\224owing to fear of necrotizing enterocolitis.1 Parenteral nutrition can meet many of their nutritio nal needs, but has signi \201 cant side eff ects \200\224intestinal atrophy, sepsis, incre ased susceptibility to in \202 ammatory stimuli, and systemic in \202 ammatory responses. 184 Nasogastric tube feeding Indications: Any sick infant who is too ill or too young to f eed normally (eg respiratory distress syndrome). Expressed breast milk or formula milk is f ed via a naso- or orogastric tube either as a bolus or as a continuous infusion. If gastro- oesophageal re \202 ux or aspiration is a prob- lem, then a silastic naso-jejunal tube can be used. After entering the stomach, the tube enters the jejunum by peristalsis: con \201 rm its position on x-ray. When the baby improves, start giving some feeds by mouth (PO), e g by increasing the ratio of oral to nasogastric feeds, either in whole feeds, or by fracti ons of each feed. If during oral feeds, cyanosis, bradycardia, or vomiting supervene, you m ay be trying too soon. Trophic feeding Synonyms: Minimal enteral or hypocaloric feeding; gu t priming. Rationale: If prems go for weeks with no oral nutrition, normal GI structure and function are lost despite an anabolic body state. Villi shorten, mucosal DNA is lost, and enzyme activity is less. Early initiation of subnutritional en- teral feeding may help by p romoting gut motility and bile secretion, inducing lactase activity, and by reducing sepsis and cholestatic jaundice. 185 Technique: Typically, milk volumes of 1mL/kg/h are given by tube starting on day 2 \200\2233. Use expressed breast milk (or a preterm formula, eg Nutr iprem ). Effects: Studies show that weight gain and head growth is better, and that there are fewer episodes of neonatal sepsis, fewer days of parenteral nutrition are needed, and t ime to full oral feeding is less. If too much is given, NEC (p120) may ensue. 186 Eligibili ty: Experience shows that almost all prems with non-surgical illness tolerate at least some milk as trophic feeds. 187 Parenteral nutrition (PN, via a central vein). Indications: pos t-op; trauma; burns; if oral nutrition is poor (eg in ill, low-birthweight babies) and necr otiz- ing enterocolitis (when the gut must be \200\230rested \200\231). Day-by-day guide: see BOX. \200\207Sterility is vital; prepare using laminar \202 ow units. Monitoring mus t be me- ticulous.2 Daily checks: Weight; \202 uid balance; U&E; blood glucose; Ca2+. Tes t for glyco- suria. Change IVI sets/ \201 lters; culture \201 lters, Vamin , and Intral ipid samples. Weekly: Length; head circumference; skinfold thickness. LFT; Mg2+; PO4 phos ; ammonia; triglycerides; FBC; ESR/CRP (helps determine if there is sepsis). Complications: Infection; acidosis; metabolic imbalances; thrombophlebitis; 3 \200\223 \200\201, consider hepatobiliary stenosis; cholelithiasis; osteopenia. 188 If plasma PO4 3 \200\223 (1mmol/kg /day for neonates, 0.7mg/kg/day if 1 \200\22324 months old) as giving PO4 the potassium sal t. Mix with glucose, but not Vamin or trace element mix- tures. PN is complex: get expert help. In addition, some precipitation errors are preventable by using computer-based decis ion support. 189 Stopping IV nutrition Do in stages to prevent hypoglycaemia. 122 s c i r t a d e a P i 3 \200\223; alk 1 What is it about NEC which makes oral feeding problematic? Relevant factors: \200 Ischae mia \200 Intro- duction of novel metabolic substrate into the gut \200 Gut maturation \200 In \202 ammation \200\224proin \202 ammatory cytokines (tumor necrosis factor- \200 , interleukin (IL)-6, IL-18, and platelet-activating factor) \200 Paucity of protective Gr am +ve organisms. \200\207The best way of providing protective bacteria with feeds is unkn own.190 2 See British Association for Parenteral and Enteral Nutrition Guidelines, ISBN 1-8 99-467 \200\223408 Fig 1. \200\230Gavage \200\231 (from an old French word meaning \200\230to gorge \200\231 ) denotes a controver- sial farming and gastronomic method entailing insertion of a long fu nnel into a goose \200\231s throat. Down this funnel is pumped a slurry of ground corn and water, to pro- duce obesity \200\224and, to some palates, a delicious (if unnaturally fatty ) p t \200\224p t de foie gras). On the neonatal unit, gavage feeding should not be q uite so enthusiastic. But French farmers were right about one thing: bolus gavage feeding i s better than continuous tube feeds, at least with regard to trophic feeding.191 123 s c i r t a i d e a P Parenteral nutrition: day-by-day guide. \200\207All values are per kg/day PROTEIN CARBO- HYDRATE Glucose 10%; mL IONS (mmol) FLUID FAT Type of baby Day of PN Age days Vamin- olact \210\217; mL 14 20 26 \211 35 12 18 24 Ca PO4 PN vol. Intra- lipidy \210\217 20%; mL 2.5 5 10 15 Na K mL1 97.5 115 115 100 Neonates & low- birth- weight babies Infants >1 month1 & <10kg 10 \200\22330kg 1&2 1 2 3 3 4 5 >5 3 3 3 3 3 3 3 3 1 1 1 1 0.4 \200\2231 120 0.4 \200\2231 150 0.4 \200\2231 165 0.4 \200\2231 165 M 95 \200\223125 80 \200\223110 65 \200\223125 5 10 15 2.5 2.5 2.5 1 2 2.5 2.5 2.5 0.6 0.4 0.6 0.4 0.6 0.4 120 \200\223150* 120 \200\223150* 120 \200\223150* M 8 16 \200\22318 14 \200\22310 14.5 45 \200\223100* 45 \200\223100* 45 \200\22375* 45 \200\22375* Note: M=maintenance. *See p23 4 for 24h \202 uid requirement. \200\207See datasheets/ SPC data Trace elements: Peditra ce eg 1mL/kg (max 10mL) if renal function OK \200\224caution if prolonged treatment, eg > 1 month, or if \200\201biliary excretion (stop if cholestasis); checking Mn+ may be needed . Vitamins: Solivito N : add 1mL/kg/day (max 10mL) to Vaminolact (protect from light). C ater for A, D, & K with Vitalip N 1 \200\2234mL/kg/ day (max 10mL/kg/day) to Intralipid . \200\207These values are a guide only. Individual needs vary greatly. Supplementing very preterm infants with selenium is con- troversial. It may help reduce sepsis; data are domi nated by one large trial from areas with low selenium levels and may not be readily transla ted elsewhere. 192 Get expert help. 23.5 \200\22378.5 7.5 7 \200\22357 26 \200\22356 14 \200\22351.5 0.2 0.1 2 2 0.2 0.1 1.5 \200\2232 1.5 \200\2232 0.2 0.1 1.5 \200\2232 1.5 \200\2232 0.2 0.1 2 2 10 \200\22315 5 10 \200\22312.5 M 1&2 >30kg M 1 This is the total volume of \202 uid required (60 & 90mL/kg for days 1 & 2). Learning to breastfeed It is better to be apprenticed antenatally to a breastfeeding mother than to rely on simple encouragement and lea \202 ets. 193 Re \202 exes Rooting (searchi ng, with wide-open mouth) \200\203suckling (jaw goes up and down while the tongue compresse s the areola against the palate) \200\203swallowing re \202 ex (as milk hits the oropharyn x, the soft palate rises and shuts off the nasopharynx; the larynx rises, and the epiglotti s falls, closing the trachea). Skill Don \200\231t assume this comes naturally; commonly, l earning to breastfeed is as hard as learning to drive \200\224and as anxiety-provoking. The best way to learn is from an experienced person in comfortable surroundings \200\224eg sit ting in an upright chair, rather than inadequately propped up in bed. Reassure that a few p roblematic feeds do not mean that the baby will starve, and that bottle feeding is needed. Most term babies have plenty of fuel reserves (earthquake infant-victims may survive for >1 week) \200\224and perseverance will almost always be rewarded. Furthermore, \200\230top-u p \200\231 bottle feeds may undermine con \201 dence, and, by altering the GI milieu, dimi nish the bene \201 ts of breastfeeding. 124 \200 A good time to start breastfeeding is just after birth (good bonding; PPH risk \200\201), b ut labor procedures may make this hard, eg intrapartum pethidine instrumental delivery, T and BP measurements, washing, weighing, going to a postnatal ward. \200\207It is never too late to put to the breast, provided lactation has been maintained. s c i r t a d e a P i Beware of intervening too quickly without observing the mother \200\231s eff orts. Rather t han saying \200\234that \200\231s completely wrong: do it like this \200 \200\235 try \200\234good: you and your baby are going to get on \201 ne. One extra tip might be \200 \200\235 From the baby \200\231s viewpoint, breastfeeding entails taking a large mouthful of breast- with-nipple, which he or she gets to work on with tongue and jaw. En- sure the baby is clos e to the mother with the shoulders as well as the head fac- ing the breast \200\224which, i f large, may need supporting (mother \200\231s \201 ngers placed \202 at on the chest w all at the base of the breast: avoid the \200\230scissors \200\231 grip which stops the ba by from drawing the lactiferous sinuses into his mouth). \200 Avoid forcing the nipple in to the mouth; so do not place a hand over his oc- ciput and press forwards. Cradle the head in the crook of the arm. Explain the signs of correct attachment: Mouth wide open, and chin touching the breast (nose hardly touching). \200 The baby should be seen to be drawing in breast, not just nipple. \200 Lower lip curled back, maximally g obbling the areola (so angle between lips >100 ). (Don \200\231t worry about how much areo la can be seen above the top lip: this gives little indication of where the tongue and lowe r jaw are.) \200 Slow, rhythmic, and deep jaw movements, as well as sucking movements. The 1st few sucks may be fast, shallow, and non-nutritive: here the baby is inducing the \200 \230let-down \200\231 re \202 ex, which promotes \202 ow. When helping with placing, it is quite appropriate to \200\230tease \200\231 the baby by b rushing his lip over the nipple, and then away. This may induce a nice big gape. With one m ovement bring to the breast, aiming his tongue and lower jaw as far as possible from the ba se of the nipple \200\224so his tongue can scoop in the nipple and a good mouthful of breas t. Keeping on the postnatal ward for a few days, and having the mother learn with an experienc ed, friendly midwife is very helpful, but this is rare in the UK, as cost and other pressur es make admissions shorter. 125 How to express breast milk It is good for every breastfeeding mother to learn this skill (a ccess to teach- ing is required before the accolade of \200\230baby-friendly \200\231 can be granted to UK hospitals). There are at least 4 times when expressing is valuable: \200 To relieve (sometimes very) painful breast engorgement between feeds. \200 To keep milk production going when it is necessary to give nipples a rest owing to soreness \200\224which is quite a common problem. To aid nutrition if sucking is reduced for any reason (eg prematurity or cleft lip). If the mother is going to be separated from her baby for a few feeds, eg going out to work. The best way to learn is from a midwife, and by watching a mother who is already successful ly expressing milk. Pumps are available from any chemist. If not, wash hands, and dry on a clean towel. Then, try to start \202 ow by: \200 Brie \202 y rolling the nipple: this may induce a let-down re \202 ex, especially if the s c i r t a i d e a P baby is nearby. Stroke the breast gently towards the nipple. \200 With circular movements, massage the br east gently with the 3 middle \201 ngers. Applying warm \202 annels, or expressing in the bath may aid \202 ow, eg while the moth er is learning, and only a few drops are being expressed. Teach the mother to \201 nd the 15 or so ampullae beneath the areola: they feel knotty on ce the milk comes in. Now with the thumb above the areola and the index \201 nger below, and whole hand pressing the breast back on the chest wall, exert gentle pressure on the amp ullae. With rhythmic pressure and release, milk should \202 ow. Use a sterile container. Take care that the \201 ngers do not slip down on to the nipple, and damage the narrowing ducts. Fingers tire easily: practice is the key. Concentration is also needed to be sure t o catch oddly angled jets. If kept in a fridge, the milk lasts 24 \200\22348h. Frozen milk should be used within 3 mon ths. It is thawed by standing it in a jug of warm water. Any unused milk should be discarde d after 24 hours, not refrozen. NB: it is known that the antioxidant level of stored breast milk falls, but it is not known if this matters. Refrigeration is better than freezing and thawing. 194 Breastfeeding and social/biological in \202 uences Factors which make starting breastfeedi ng harder \200 Family pressures, in- cluding partner \200\231s hostility (10% breastfeed vs 70% if he approves). \200 If mother and baby are separated at night in hospital. \200 Urbanization/unfriendly working environments. \200 Cultural reframing of breasts as sex objects; no non-sexual role models. \200 The commitment a breastfeeding mother makes is huge and sustained \200\22424/7 126 \200 for many months (WHO advises exclusive breastfeeding for 6 months).1 \201\201Breastfeeding advantages \200\207Mutual gaze \200\200emotional input from mother. \200 Sucking promo tes uterine contractions, so avoiding some PPHs. \200 Breastfeeding-induced oxytocin surg es promote trust and diminish fear. 195,196 \200 Less insulin resistance, BP \200\200 & o besity (growth is less rapid, p181) 197 due to \200\200breast milk Long-Chain Polyunsatura ted Fatty Acids. 198 \200\207LCPUFAs may also \200\200IQ. 199 \200 Breast milk is cheap and clean, and gives babies an attractive smell. \200 Colostrum has endorphins: good for birth-associated stress? 200 \200 IgA, macrophages, lymphocytes (with interferon) and ly sozyme protect from infection. Acids in breast milk promote growth of friendly lactobacilli in the baby \200\231s bowel. Gastroenteritis may be less severe if the mother makes and tr ansfers antibodies (an \200\230immune dialog \200\231). NB: one meta-analysis casts doubt vis vis prems and infection. 201 \200 Infant mortality, otitis media, pneumonia & diar rhea are less if breastfed. 202 \200 Breast milk contains less Na+, K+ and Cl \200\223 th an other milk, so aiding homeo- s c i r t a d e a P i stasis. If dehydration occurs, risk of fatal hypernatraemia is low. \200 Exclusive breast feeding may \200\201risk of: type 1 DM, rheumatoid arthritis, in \202 am- matory bowel di sease, food allergy/atopy (if family history +ve). 203 \200\223205 To reduce allergies, the USA Pediatric Academy 207 says to delay weaning till 6 months old, 208 and cows \200\231 m ilk to 1yr, egg to 2yrs, and peanuts, tree nuts & \201 sh to 3yrs old. This may be valuab le in prems; 209 evidence is con \202 icting in term babies. 210 \200 Breastfeeding help s mothers lose weight, and is contraceptive (unreliable!). \200 Some protection in premen opausal years against maternal breast cancer. Why is feeding on demand to be encouraged? \200 It keeps the baby happy, and enhances milk production. \200 Fewer breast problems ( engorgement, abscesses). NB: feeding by routine is possible with a structured plan (see the New con- tented little baby book), 211 which may help to promote a diurnal sleep cycle. NB : although co-sleeping (a baby sleeping in the parental bed) can aid parental sleep, there is a risk of inadvertent smothering (p148). Contraindications to breastfeeding \200 An HI V +ve mother in developed coun- tries \200 Amiodarone \200 Antimetabolites \200 Antit hyroid drugs \200 Opiates. See BNF. Problems Treat breast engorgement by better breast te chnique and better latching-on; aim to keep breasts empty, eg by hourly feeds or milk expre ssion. If a breast abscess forms, discard the milk if it is pus-like. Give the mother \202 u- cloxacillin 250mg/6h PO (it is safe for her baby). Surgery may be needed. Treat sor e nipples by ensuring optimal attachment (p124), and moist wound healing (paraffi n gauze d ressing or glycerin gel) 212 not by resting, except in emergency. Prematurity Preterm breas t milk is the best food for prems. Give unheated, via a tube (p122). Add vitamins D 1000U/d ay and K (p122). Phosphate sup- plements may be needed. Even term babies may (rarely) devel op rickets hypocalcaemia (eg \201 ts, recurrent \200\230colds \200\231, lethargy, or stridor) if exclusively breastfed, unless vitamin supplements are used (p150). 1 However, evidence is insuffi cient to say con \201 dently \200\234Breastfeed exclusivel y for 6 months \200\235 in developed countries, as breast milk may not meet full energy nee ds of some infants at 4 \200\2236 months old \200\224and there may be risk of speci \201 c nutritional de \201 ciencies. Further evidence is awaited.213 127 Bottle feeding There are few contraindications to breastfeeding but many pressures not to ( p126). In many communities >50% mothers are breastfeeding at 2 weeks but this reduces to \200\20540% at 6 weeks. Most change to bottle because of lack of knowledge or no encouragem ent. Advertising also has a role. The WHO/UNICEF International Code of Marketing of Breastm ilk Substitutes bans promotion of bottle feeding and sets out requirements for labeling and information on feeding. 214 The advantage of bottle feeding is that fathers and others can help; Knowing how much milk the baby is taking can be reassuring to mothers. Teats Babies fed with a cross-cut teat (lets the baby determine rate) cry less and spend more time awake and content than babies fed with standard teats. Standard infant formulas (Cows \200\231 m ilk \200\230humanized \200\231 by reducing the solute load and modifying fat, protein, and vitamin content.) As with breast milk, the protein component is whey-based. Many brands ar e available, eg SMA Gold Cap . Brands are similar so shopping around for a brand which \200\230suits better \200\231 is unlikely to be an answer to feeding problems. Follow-on fo rmula milks are like standard formulas, but the protein com- ponent is casein-based ( \200 \230 delays stomach emptying and allows less frequent feeds). These are marketed to satisfy hungrier babies before they start wean- ing. Typical age of use: 6 \200\22324 months. SMA White is an example. Soya milks These are no longer recommended. They contain high levels of phyto-oestrogens which have estrogen-like properties. This could aff ect im- munity and thyroid function, as well as the more obvious hormonal disrup- tion, especially in boys. S oya milks are still on sale in the supermarket: try to discourage parents from their use. S oya milk is not indicated in re-establishing feeding (regrading) after gastroenteritis. Hyd rolized formula is a cows \200\231 milk formula where protein is hydrolized into short pept ides (eg Nutramigen ). Indications: cows \200\231 milk allergy (seen in 1% of babies, eg w ith bloody diarrhea perioral rash) or soya allergy; prevention of atopy (eg in babies wi th a strong family history). Cows \200\231 milk can be reintro- duced eg at 1 year (can be risky: so do so in hospital). Specialist milks Many types exist (eg for gastro-oesophageal re \202 ux, mal- absorption, metabolic diseases, etc). Get help from a pediatric dietician . Preparing feeds Hands must be clean, equipment sterilized, and boiled wa- ter used \200 \224infective gastroenteritis causes many deaths in poor countries and considerable morbidi ty in the UK. Powder must be accurately measured. Understrength feeds lead to poor growth a nd overstrength feeds have caused dangerous hypernatraemia, constipation, and obesity. Feed ing After the \201 rst few days, babies need 150mL/kg/24h (30mL=1oz) over 4 \200\2236 fe eds depending on age and temperament. If small-for-dates up to 200mL/ kg/day is needed; if large-for-dates, <100mL/kg. Feeds are often warmed; there is no evidence that cold milk is bad. Flow should almost form a stream; check before each feed as teats silt up. The hole ca n be enlarged with a hot needle. Bottles are best angled so that air is not sucked in with milk. Weaning Introduce solids at 4 \200\2236 months by off ering cereal or pur ed food on a spoon. Don \200\231t add cereals to bottles. After 6 months follow-on formula may be tr ied; lumpy food is started so that the baby can learn to chew. Normal supermarket cows \200 \231 milk may be used from when the baby is 1 year old, but it may still be too rich in pr otein, Na+, K+, phosphorus \200\224and is poor in iron, trace elements, linoleic and alpha- linolenic acids1 and vitamins C & B complex. Infants must be able to cope with its higher s olute load. 215 s c i r t a i d e a P 1 Docosahexaenoic acid (DHA) is the main lipid in our brain \200\224derived endogenously vi a \200 -linolenic acid (ALA). Several studies have tried to improve blood DHA concentratio ns of formula-fed infants by \200\200 ALA in feeds and measuring changes in growth & devel opment. Results are far from clear.216 Preterm and light-for-dates babies Some de \201 nitions Preterm:1 A neonate whose calculat ed gestational age from the last menstrual period is <37 completed weeks \200\224ie prematu re. Low birth weight (LBW): Birth weight of <2500g regardless of gestational age. Thus a LB W baby may not be small for gestational age (see below) if they are born preterm. 6% of UK infants are <2500g at birth, and 50% of these are pre- term. 10% of pregnancies end in spon taneous preterm delivery, and 70% of all perinatal deaths occur in preterm infants. Very lo w birth weight (VLBW): Birth weight of <1500g regardless of age. Extremely low birth weight (ELBW): Birth weight <1000g regardless of age. Small for gestational age (SGA): Typically SGA refers to a birth weight below the 10th percentile (SGAW). However, SGA may also refer to reduced length (SGAL) or a combination of both (SGAW+L). SGAL children have normal body proportions except for head circumference (HC), which is relatively larger in many of these children. SGAL+W babies still have a smaller HC at the age of 6 years compared with SGAL children. Chief causes: \200\207Poverty/poor social support may account for 30% of varianc e in birthweights. 217 Constitutional/familial factors are also important. Other causes: Ma lformation; twins; placental insuffi ciency (mater- nal heart disease, BP \200\200, smoking , diabetes, sickle-cell disease, pre-eclampsia). 218 Gestational age (based on LMP and ultr asound) is more important for predict- ing survival than the birthweight alone. Intrauterin e growth restriction (IUGR) refers to a small subgroup of babies with proven intrauterine g rowth restriction (eg due to placental restriction, toxic eff ects or fetal infections). In fants with SGA need not have suff ered IUGR, and those with brief IUGR may be born at a nor mal weight so are not SGA. Are SGA effects permanent? 90% of SGA catch up growth in the fir st 2 yrs, however as adults they are on average 1 standard deviation shorter than the mean adult height. 219 There may be an association between SGA and adult risk of coronary heart disease and obesity. 219 Causes of prematurity are mostly unknown; smoking tobacco, poverty , and malnutrition play a part. Others: past history of prematurity; genitourinary in- fect ion/chorioamnionitis (eg ureaplasma 220)2; pre-eclampsia; polyhydramnios; closely separated pregnancies; twins; uterine malformation; placenta praevia; abruption; premature rupture o f the membranes. Labor may be induced early on purpose or accidentally (p62). Estimating th e gestational age Use the Dubowitz score (p228). Management If 32 weeks or less, transfer i n utero to a special center, if possi- ble. Once born, ensure airway/breathing is optimal; protect from cold. Take to NICU/SCBU. Plan supplemental breast milk or low-birth-weight for mula if <2kg. Measure blood glucose before each 3-hourly feed. Tube feed if oral feeds are not tolerated. If oral feeding is contraindicated (eg respiratory distress) IV feeding is n eeded (p122). Survival if very premature 40% of infants born before 23 weeks die on la- bou r ward ( \200\200 by 8% since 1995). Of those surviving labor ward, 75% died on the neonata l unit. 47% survive at 24 weeks and 67% at 25weeks. EPICure2 Mortality is associated with i ntracranial abnormalities seen ultrasonically. Disability As a percentage of live births: i f 23 weeks \200\231 gestation: 5% had no or minor subsequent disability (24 weeks \211\210 12%; 25 weeks \211\210 23%). Morbidity relates to cerebral palsy, squint, and retinopathy (p108). 221n>150 Disability may be subtle but speci \201 c: one pattern is \200\201numer acy if gestation is <30/40, from \200\201gray matter in the left parietal lobe. 222 ADD ri sk \200\200 (p212). 128 \200 s c i r t a d e a P i 1 Premature is now used as a synonym for preterm; beware older books, as premature once mea nt birth- weight <5lbs (2.5kg), before the diff erence between light-for-dates and preterm was recognized. 2 Ureaplasma also causes neonatal sepsis, resp. distress & intraventricular hemorrhage. Screening mothers in pregnancy can \200\201rates of prem birth (3% vs 5.3% in the control group).223 129 Is this baby small for gestational age? Use centile charts which take into account that \201 rst-borns are lighter than subsequent births: the table below gives sample data. Weeks gestation First born: Boy 32 1220 33 1540 34 1830 35 2080 36 2310 37 2500 38 2660 39 2780 40 2870 Very low birthweight: 1 \200\2231.5kg; extremely low birthweight: 500 \200\223999g. Preventing neonatal deaths \200\224worldwide224 Each year, of the 130 million babies who a re born, 4 million die in the 1st 4 weeks of life (the neonatal period) \200\224most from preventable causes. Two- thirds occur in India, China, Pakistan, Nigeria, Bangladesh, Ethio pia, the Democratic Republic of the Congo, Indonesia, Afghanistan, and Tanzania. Most of th e deaths are caused by pre-term births, infections, respiratory problems, and tetanus. (Mal aria and some diarrhoeal diseases are less im- portant in the neonatal period except in tho se areas of the highest neonatal mortality.) Prevention depends on: \200 Tetanus vaccinat ion, access to antibiotics and breastfeeding advice. \200 Sanitary delivery rooms with ba sic emergency services (cesarean sec- Tenth centile weight (grams) Girl 1260 1540 1790 2020 2210 2380 2530 2640 2730 Subsequent births: Boy Girl 1470 1340 1750 1620 2000 1880 2230 2100 2430 2310 2600 2480 2740 2620 2860 2730 2950 2 810 s c i r t a i d e a P tions and blood transfusion; obstructed labor is a major problem). Preventing and managing low birthweight. Low birthweight aff ects 14% of births worldwide, but accounts for 70% of neonatal deaths. Managing low birthweight babies need not require expensive technology. Much could be achieved by application of known primary care principle s of warmth, feeding, and the prevention and early treatment of infection. Preventing maternal mortality (0.5 million maternal deaths/yr) is a pre- requisite for prev enting many neonatal deaths. In one small but harrow- ing study from Gambia all the childre n born to mothers who died from pregnancy-related causes were themselves dead at one year. 225 MDG-4 Millennium Development Goals are internationally \200\230agreed \200\231 commit- men ts to reduce poverty and ill-health. The 4th goal aims to reduce mortality in under-5s by \205\224 before 2015. The developing world spends $2 billion annually on this. It is estima ted that another $4 billion is needed to do the job. Non-pharmacological methods to reduce pain in neonates Pain relief through non-nutritive su cking (NNS), rocking, massage, 20% su- crose (12mg may be enough), 226 distilled water and expressed breast milk (EBM) have been studied in a randomized way \200\224in the context of a heel- prick. Duration of cry and Douleur Aigu du Nouveaun score were used as objecti ve measures of pain. Pain scores and duration of crying were lowest in the NNS and rocking groups compared with sucrose, distilled water, expressed breast milk and massage. 227 Other trials show that for venepuncture, breastfeeding or glucose plus use of a paci \201 er pr ovides good analgesia. 228,229 Other alternatives: kangaroo care; morphine; fentanyl. Whene ver you hear siren cry (sequence of almost identical cries with a period of 1sec) think: \200\234How can I help this baby? What is going wrong? \200\235 230 s e i b a b r e t t e b = s s e r t s s s e l = n i a p s s e L Some GI malformations \200\207Bilious (green) vomiting in neonates always needs urgent hel p (pediatric surgeon + neonatology team) for prompt investigation and management. 231 Hirsc hsprung \200\231s disease Occurs in 1 in 5000 births. 232 Congenital absence of ganglia in a segment of colon (or in the rare \200\230long-segment \200\231 disease, can be all the w ay up to the stomach) leading to functional GI obstruction, constipation and megacolon. Fec es may be felt per abdomen, and PR exam may reveal tight anal sphincter and explosive disch arge of stool and gas. \200 : \200 \211\210 3 : 1. Com- plications: GI perforation, blee ding, ulcers, enterocolitis (may be life-threat- ening). Short-gut syndrome after surgery. Tests: Diagnosis through rectal suction biopsy of the aganglionic section, staining for ace tylcholinesterase- positive nerve excess, is most accurate. 233 Excision of the aganglionic segment is needed colostomy. Oesophageal atresia (OA) + Tracheo-oesophageal \201 stul a (TOF) A spectrum of abnormalities with OA plus a distal TOF being the most common (86%). Iso- lated OA (7%) and TOF without OA (4%) can also occur. 234 Prenatal signs: Poly- hydram nios; small stomach. Postnatal: Cough, airway obstruction, \200\200secretions, blowing bub bles, distended abdomen, cyanosis, aspiration. \201\231 : Inability to pass a catheter int o the stomach; X-rays show it coiled in the esophagus. Avoid con- trast imaging. \201\227: Stop feeding, suck out oesophageal pouch. Primary surgical repair is possible in the major ity of cases. 235 50% have other anomalies. Congenital diaphragmatic hernia (CDH) A develop mental defect in the dia- phragm allowing herniation of abdominal contents into the chest. Leads to impaired lung development (pulmonary hypoplasia and pulmonary hyperten- sion). Inc idence: 1 : 3700. 236 Diagnosis: Prenatal: ultrasound; postnatal: CXR. Signs: Diffi cult re suscitation at birth; respiratory distress; bowel sounds in one hemithorax (usually left so heart is best heard on the right). pH <7. 3 and cyanosis augur badly ( \200\223 lung hypop lasia). 237 Associations: other malforma- tions (neural tube in 50%); trisomy 18; chromosom e deletions eg at 15q2, Pierre Robin (p138). 238 Treatment: \200 Prenatal: Fetal surgery is not usually practical or available (tracheal obstruction may be tried: it encourages lun g growth, so pushing out other viscera) \200\224but premature birth may be caused. 239 \200 Post- natal: Insert a large-bore nasogastric tube when diagnosis suspected: at birth if prenatal diagnosis. The aim is to keep all air out of the gut. Facemask ventila- tion is contraindicated (so immediately intubate, ventilate, and paralyze, with minimal pressures) . Get surgery in an appropriate center. Inguinal hernias These are due to a patent processu s vaginalis (the passage which ushers the descending testicle into the scrotum). They prese nt as a bulge lateral to the pubic tubercle, eg during crying. In one series (n=6361), \200 : \200 \211\2105 : 1; there were 59% right, 29% left, and 12% bilateral hernias (almo st all indirect), with a hydrocele in 19%. 240 Incarceration occurred in 12%. Most sur- geo ns aim to repair these promptly (laparoscopic repair is possible) 241 to avoid incarceratio n. Hydroceles are hard to distinguish from incarceration \200\224explore if in doubt. Hydro celes in infancy A processus vaginalis patent at birth, and allowing only \202 uid from t he peritoneal cavity to pass down it, generally closes during the \201 rst year of life \200\224so no action is usually needed. If it persists until the age of 2 it may need surgi cal exploration. 242 If the \202 uid- \201 lled sac is adjacent to the spermatic cord, i t is called an encysted hydrocele or a spermatic cord cyst. If the proximal opening of the processus vaginalis is wide, a true inguinal hernia is formed, and action is always require d. 243 Imperforate anus Covers a variety of anorectal abnormalities. Babies may have an ass ociated \201 stula starting in the rectum. Most girls have a posterior fourchette \201 stula; boys have a posterior urethral \201 stula (may pass meconium 130 Meckel \200\231s diverticulum: see p651. s c i r t a d e a P i in urine). Absence of perineal \201 stula in boys indicates communication with the urethr a (so colostomy may be required). Do GU imaging to show commonly associated GU abnormalitie s. Posterior sagittal anorectoplasty is possible. 244 Babies with Trisomy 21 commonly have imperforate anus without \201 stula. Mid-gut malrotations \200\207Bilious neonatal vomit ing merits immediate surgical referral (pass NGT). 245 Absent attachment of the small intes tine mesentery can cause mid-gut volvulus or obstruction of the third part of the duodenum by \201 brotic bands. Presentation may be late; passage of blood per rectum heralds mid-g ut necrosis \200\224and is an indication for emergency surgical decompression. Acute gastri c volvulus causes non-bilious vomiting, epigastric distention and signs of pain, and is oft en associated with abnormalities of adjacent organs. There may also be feeding diffi culty. Anterior \201 xation of the stomach to the anterior abdominal wall may be needed after u pper GI imaging. Anterior abdominal wall defects Gastroschisis (Fig 1): A paraumbilical def ect with evisceration (extrusion of vis- cera) of abdominal contents. Incidence: 1.6 : 10, 000; rising (especially in babies of young mothers 246 or fathers 247 \200\224or, in mul- t ips, if there has been a new father for this pregnancy (hence the idea that maternal immune factors play a role)). 248 Another hypothesis is that it is caused by a vascular event rel ated to cocaine use. Corrective surgery has a good outcome in 90% (so deliver where there a re good pediatric surgical facilities, if diagnosed pre- natally \200\224aim to diagnose at ultrasound). 249,250 Manage as per diaphragmatic hernia: aim to have no air in the gut, so intubate and paralyze at birth if in respiratory distress. Exomphalos (omphalocele) (Fig 2 ): Ventral defects of the umbilical ring with herniation of abdominal viscera (which are co vered in peritoneum) are com- mon and often associated with malformations such as chromosom al, cardiac, or genitourinary abnormalities. A small exomphalos may contain only a Meck- el \200\231s diverticulum while a large defect may contain the stomach, liver and blad- der. The growth of viscera outside the abdominal cavity may lead it to be pro- portionately smal l making reduction of visera more diffi cult. Antenatal: Most are identi \201 ed by routin e fetal anomaly scans (AFP \200\200 too). 252 Postnatal manage- ment: \200 Protect hernia ted viscera \200 Maintain \202 uids and electrolytes. \200 Prevent hypothermia, gastr ic decompression, prevention of sepsis, and maintenance of cardiorespiratory stability. \200 Primary or staged closure may be used to re- pair the defect. With big defects, closu re can cause respiratory insuffi ciency, haemodynamic compromise, dehiscence, and inability to close the abdomen and subsequent death. 252 After pulmonary and other comorbidities hav e stabi- lized, the omphalocele may gradually be reduced with a loose elastic bandage, with delayed closure at 6 to 12 months old. 252,253 131 s c i r t a i d e a P Fig 1. Gastroschisis. Exomphalos Gastroschisis Matted loops of bowel with no covering Umbilical clip Bowel covered by sac of amnion Defect to the right of the umbilicus Fig 2. Exomphalos. Genitourinary diseases Pre-auricular tags are markers of GU problems; consider GU ultrasoun d. 254 Undescended testis \200\224cryptorchidism (2 \200\2233% of neonates, 15 \200\22330% of prems; bilateral in 25% of these). On cold days retractile testes may hide in the ingui-