Contents

Preface to the fifth edition

Foreword to the first edition

Prenatal assessment

Resuscitation of the newborn

Infants of low birthweight

Breathing difficulties in the newborn

Birth trauma

Some congenital abnormalities

Routine examination of the newborn

Dislocated and dislocatable hip in the newborn

Infection in the newborn

Jaundice in the newborn

Convulsions in the newborn

Vomiting

Diarrhoea

Mother-infant attachment

Growth and growth charts

Feeding and feeding problems

Failure to thrive

Weaning

Review at six weeks

Review at eight months

Respiratory infections in the older infant

Whooping cough

Fever in the older infant

Convulsions in the older infant

Crying babies

Non-accidental injury and selected drugs

103

Acknowledgements

106

Index

107

iii

Preface to the fifth edition

The First Year of Life was the first series of ABC articles commissioned and published weekly by the BMJ and later collected and

published as a book. This new fifth edition is called ABC of the First Year to identify it with the ABC series. The ABC series is

continuing to tackle new subjects in all branches of medicine and surgery: 46 series have been published and 43 books are still in

print. The first edition of The First Year of Life was printed in black and white and some colour was introduced in the last edition.

The majority of the pages in this new edition are in colour and nearly 100 new photographs have been added. Each chapter has

been thoroughly revised with considerable changes in the chapters on prenatal assessment, infants of low birthweight, breathing

difficulties in the newborn, and diarrhoea. The charts for developmental review have incorporated the latest recommendations of

the Department of Health. New sections have been added on the infant of low birthweight at home, advice on travelling abroad

with an infant, and paediatric HIV infection.

The book was written for family doctors, GP vocational trainees, medical students, midwives, and nurses. It has become the

standard textbook for several undergraduate and postgraduate courses. The emphasis has been on the practical aspects of

management, based on clinical experience, but theory is introduced where it is essential for understanding the basis of

management. No previous experience of paediatrics is assumed.

I welcome Dr Roslyn Thomas who has joined me as co-author of this edition. I wish to thank the staff of the BMJ, and

especially Alex Stibbe who has acted as midwife for the fifth edition of the book, and my wife who has constantly supported me

and encouraged me to write.

For ease of reading and simplicity a single pronoun has been used for both feminine and masculine subjects; a specific gender

is not implied.

Bernard Valman

Foreword to the first edition

The care of infants and their mothers has changed rapidly in the past 10 years and it is often difficult to identify those advances

that will prove of lasting value to the clinician.

Dr Bernard Valman’s articles on the first year of life, published recently in the BMJ and collected in book form, aim at

providing the clinician in the community and in hospital with generally accepted views on the medical management of infants.

The main difference between paediatrics and general medicine is the range of normality, which changes with age. The

greatest changes occur in the first year of life. Dr Valman’s articles provide an account of normal development during this year,

with particular emphasis on its assessment, so that deviations may be easily recognised. These articles have been collected together

to provide a practical guide for general practitioners and the many other staff who care for the new born and young infants.

Stephen Lock

Editor, BMJ 1980

Prenatal assessment

Recent advances in ultrasound technique, equipment, and

Box 1.1 Screening

training together with rapid advances in molecular biology have

• Ultrasound at 12 weeks

increased the range of antenatal diagnoses. Some methods are

• Ultrasound at 18 24 weeks

available only at specialised centres. This chapter will give a

• Maternal serum screening for Down’s syndrome

background to successful techniques. An anomaly may be

detected during routine examination of the fetus which is

carried out by ultrasound between 18 and 24 weeks of gestation.

Maternal serum screening for Down’s syndrome is performed as

a double, triple or two stage integrated test (see below).

After the birth of an abnormal baby or the detection of

genetic disease in an older child, a paediatrician or geneticist may

recommend a specific test at a particular week in the subsequent

pregnancy. Some tests are at an early stage in development and

the false positive and negative rates have not been assessed. Some

genetic tests are not yet sufficiently precise to enable an accurate

prognosis to be given to every family with that disease.

At the first antenatal visit it is still important to carry out a

Box 1.2 First antenatal visit

full blood count and haemoglobin electrophoresis, blood

•

Full blood count and haemoglobin electrophoresis

grouping, rhesus antibody titre, tests for rubella and

•

Blood group

hepatitis B, human immunodeficiency virus (HIV), and syphilis.

•

Rhesus antibody titre

The haemoglobin electrophoresis may show that the mother

•

Rubella

has

-thalassaemia trait or sickle cell trait and the father’s red

•

Hepatitis B

cell investigations may suggest that further studies of the fetus

•

HIV

are needed.

•

Syphilis

Ultrasound studies

The first routine examination of the fetus by ultrasound is

usually performed at the gestational age of 12 weeks. The

gestational age is confirmed and anomalies of the central

nervous system or cystic hygromas may be detected. A further

scan at 18-24 weeks may detect anomalies of the central nervous

system, heart, kidneys, intestinal tract, and skeleton. Signs which

suggest a chromosome abnormality include choroid plexus

cysts, echogenic cardiac foci, renal pelvic dilatation or echogenic

bowel. They occur in approximately 1: 250 pregnancies and are

associated with a 1: 300 risk of a chromosome abnormality.

These isolated signs in the presence of normal serum screening

probably do not merit the fetal risks of amniocentesis but full

discussion is necessary and the patient may still opt for

karyotyping to be performed. Mothers with a family history of

congenital heart disease should be offered a detailed cardiac

ultrasound scan at 18-24 weeks as the risk of the fetus having a

heart problem is 3-5%. The consultant obstetrician, ideally with

the paediatrician, should discuss the diagnosis and prognosis of

an anomaly with both parents. Termination of the pregnancy

may need to be considered or serial ultrasound examination

performed during the pregnancy and in the neonatal period.

Ultrasound guidance is used in taking samples of the

Figure 1.1

Ultrasound showing lumbar spine defect.

amniotic fluid (amniocentesis) and in selected centres it has

been used to take blood samples from the umbilical cord

(cordocentesis) and to give blood transfusion by that route.

The samples can be used in gene probe techniques, enzyme

estimation, and chromosome studies. In rhesus incompatibility

a low haematocrit in the cord blood indicates the need for fetal

transfusion.

Amniocentesis

Amniotic fluid is removed by passing a needle into the amniotic

cavity through the mother’s abdominal wall and uterus under

ABC of the First Year

ultrasound guidance. Amniocentesis yields amniotic fluid

containing cells that have been shed from the skin of the fetus.

Examination of the cultured cells reveals the chromosome

constitution of the fetus, including sex. Specific enzymes can be

sought and deoxyribonucleic acid (DNA) probes used. Women

who are found to be at higher risk for Down’s syndrome on

serum screening are offered amniocentesis. In high risk women

fluorescent in situ hybridisation (FISH test) may be offered

which uses the polymerase chain reaction (PCR) to detect

chromosome abnormalities such as the common trisomies, 21,

Cells

18, and 13 - Down’s, Edward’s, and Patau syndrome

respectively - the results of which are available within a

few working days.

Culture

Chorionic villus biopsy

Biochemical

Chromosome

DNA

analysis

studies

Chorionic villus biopsy is carried out mainly by the

transabdominal route under ultrasound guidance after 10

Figure 1.2 Examination of amniotic fluid.

weeks gestation. The main indications have been maternal age,

previous chromosome anomaly, fetal sexing, enzyme assay, and

gene probe assessment. Gene probes have been developed for

several diseases including cystic fibrosis, Duchenne muscular

dystrophy, and the haemoglobinopathies. DNA is extracted

from the chorionic villus sample and the probe is used to

determine whether a specific part of a particular gene is

Autosomal dominant

present or absent.

• Huntington's chorea

There is a higher miscarriage rate with chorionic villus

• Myotonic dystrophy

biopsy compared to amniocentesis. As there is a risk of limb

• Adult polycystic kidneys

reduction deformities and facial anomalies when it is

• Tuberous sclerosis

performed early, it should be carried out after the 10th week of

• Von Recklinghausen's disease

gestation.

X linked

• Duchenne muscular dystrophy

• Haemophilia A and B

Maternal serum screening for

• Fragile X

Down’s syndrome

Autosomal recessive

• and

-thalassaemia

The majority of babies with Down’s syndrome are born to

• Sickle cell disease

mothers under the age of 37 years because they form the

• Cystic fibrosis

• Phenylketonuria

largest proportion of mothers. The serum screening for Down’s

•

1-antitrypsin deficiency

syndrome should be offered to all mothers irrespective of

• Congenital adrenal hyperplasia

maternal age as it provides an assessment of the risk but not a

definite diagnosis of Down’s syndrome. The double or triple

test is offered at the initial antenatal visit to all mothers. Three

Figure 1.3 Examples in which DNA gene probes are available.

biochemical parameters (serum

-fetoprotein,

-human

chorionic gonadotrophin (HCG), and oestriol) are taken with

an accurate gestational age assessed by ultrasound and

maternal age to assess the risk of Down’s syndrome. If all those

mothers identified as being at risk (screen positive risk

greater than 1: 250) using the triple test had an amniocentesis,

Box 1.3 Two-stage integrated test

then it is thought that 60-65% of Down’s syndrome babies

Stage one at 10-13 weeks

would be detected. It is hoped that with the addition of

1. Ultrasound scan to determine gestational age and

nuchal

ultrasound to detect signs such as an increase in nuchal

thickness

thickness and other biochemical tests, it may be possible to

2. Blood level of plasma protein A (PAPP-A)

improve the risk assessment even more, using a

two-stage integrated test (see Box 1.3). It is hoped that in

Stage two at 15-22 weeks

1. Blood levels of:

future, with improved techniques of DNA gene replication, it

•

-fetoprotein (AFP)

might be possible to karyotype a fetus from fetal cells in the

• free

-human chorionic gonadotrophin ( -hCG)

maternal circulation.

• unconjugated oestriol (uE

3⁾

• inhibin-A (inhibin)

2. Integration of results from the two stages to estimate risk of

Risks

Down’s syndrome or a neural tube defect

The risk to a particular fetus depends on the gestational age of

the fetus, the indication for the procedure, and the experience

of the operator. The incidence of complications has fallen as

skill in the newer techniques has increased. The abortion rates

Prenatal assessment

are difficult to assess but Table 1.1 opposite has been compiled

Table 1.1 Risk of abortion

from expert advice on the available evidence. The risk of

abortion after amniocentesis at 15 weeks is about 1%, which is

Risk of

about twice the spontaneous incidence in normal pregnancies.

Gestational

abortion

Fetal or maternal bleeding has been considerably reduced by

age

Spontaneous after

the use of ultrasound, but a slight risk of infection remains and

performed

abortion

procedure

the incidence of respiratory distress syndrome and orthopaedic

Procedure

(weeks)

(%)

problems, such as talipes, is probably slightly increased in

Amniocentesis

14-18

0.5

fetuses who have undergone early amniocentesis. Chorionic

Chorionic villus biopsy

2-3

3-5

villus biopsy has a higher risk of abortion of about 5% against a

Cordocentesis

18-20

1-2

background of spontaneous abortion of 3%. Chorionic villus

biopsy carried out at about 10 weeks gestation provides a result

early in pregnancy, when termination of the pregnancy is less

traumatic and more acceptable for many mothers. Some tests

are slightly more accurate when the sample is obtained by

amniocentesis. Some investigations can be performed only on a

specific sample.

Screening for bacterial vaginosis

Preterm birth is the major cause of death and disability in

Bacterial vaginosis

babies. The aetiology of preterm labour is multifactorial but

there is increasing evidence to implicate infection as a possible

cause in up to 40% of cases. This information may not help

preterm labour

+ antibiotic

once a woman is admitted in preterm labour, since by that time

there may be irreversible changes in the cervix. Where the

information may be useful is in the prediction and prevention

? full term labour

of preterm labour. A few recent studies have reported that

abnormal colonisation of the vagina in the form of bacterial

Figure 1.4

Bacterial vaginosis.

vaginosis carries a risk of up to fivefold for the subsequent

development of preterm labour and late miscarriage. Whether

by reversing this condition it is possible to reduce the incidence

of preterm labour and delivery is currently being tested.

Follow-up of fetal renal tract anomalies

Mild dilatation (

10 mm) of the fetal renal pelvis is often

found on the routine antenatal ultrasound scan done at

18-20 weeks gestation. Serial scans at 2-4 weekly intervals will

establish whether there is any progressive change before birth.

The finding of reduced liquor, a distended thick-walled

bladder or progressive dilatation

20 mm may be suggestive of

an obstructive uropathy. Preterm delivery or antenatal surgical

intervention is rarely indicated, except very occasionally in a

male fetus where posterior urethral valves are causing renal

Figure 1.5

Ultrasound scan showing dilatation of left fetal renal pelvis.

compromise at

34 weeks gestation.

For most infants, postnatal investigation with several

ultrasound scans over the first few months of life and

sometimes a micturating cystourethrogram (MCUG) or renal

isotope scan will be necessary. Until the results of these

investigations are known, most infants will be given a small

daily dose of prophylactic oral antibiotics (usually

trimethoprim 1-2 mg/kg). This is to prevent urinary tract

infections in those infants who may be at risk because they

have vesicoureteric reflux. The radiological investigations are

rarely urgent and some are more meaningful when the infant

is a little older (for example, isotope scans).

All infants should be followed up postnatally as it is not easy

to predict which infants will have significant ongoing

dilatation, but most antenatally diagnosed fetal renal tract

dilatation is found to be benign or transient on serial postnatal

follow-up. A small number of infants will be diagnosed as

having pelviureteric obstruction, multicystic dysplastic kidney

or bladder outlet obstruction, but only the latter requires

urgent diagnosis and surgery in the neonatal period.

Figure 1.6

Postnatal scan showing dilation of renal pelvis.

Resuscitation of the newborn

Wherever babies are delivered there should be a person with

adequate skill and experience in resuscitation immediately

available throughout the 24 hours. The majority of babies can

be resuscitated with a closely fitting mask and an inflatable bag

with a valve. The equipment is cheap, simple to use, and can be

carried in a small case. Some infants cannot be resuscitated by

this method but require intubation, which to be successful

should be done by a doctor or midwife with continual

experience of the procedure.

Babies who have developmental brain abnormalities before

labour may develop fetal distress during the stress of labour

and may have difficulty in establishing spontaneous respiration.

For this reason, the contributions of brain development and

perinatal management in the causation of later cerebral palsy

are often difficult to resolve.

Figure 2.1 Resuscitation kit in case.

Assessment

The following high risk factors indicate that resuscitation may

be needed:

Table 2.1 APGAR scoring system

• fetal distress

• caesarean section

Appearance

Blue, pale

Body pink,

Completely

• preterm infant

(colour)

extremities

pink

• breech delivery

blue

• forceps delivery

Pulse

Absent

Below 100

Over 100

• twins

(heart rate)

• maternal anaesthetic

Grimace

No response

Grimace

Cry

(response to stimulation)

• maternal diabetes

Activity

Limp

Some

Active

• rhesus incompatibility.

(muscle tone)

flexion in

movements

These factors predict about 70% of the babies needing

extremities

Respiration

Absent

Slow

Strong cry

resuscitation. The remainder arise unexpectedly. The APGAR

(respiratory

irregular

scoring system is used to assess the infant’s condition one

effort)

minute and five minutes after birth. A numerical score is given

for each of five features. The heart rate and respiratory effort

determine the action to be taken.

Procedure

Suctioning the oropharynx

The rare indications for suction of the oropharynx are

meconium aspiration and blood in the mouth. It is best not to

use mucus extractors, as there is a risk of the operator

swallowing or inhaling infectious material. Use a suction

catheter (size FG 8) connected to the Resuscitaire or directly to

a wall suction unit. The mouth can safely be suctioned but care

must be taken in the oropharynx. This should be done under

direct vision and is usually part of tracheal intubation. Do not

blindly push the catheter as far as it will go since this can cause

a vagally mediated bradycardia and apnoea and is invariably

associated with a fall in oxygen saturation.

Administering facial oxygen

Set the oxygen flow rate to 5 l/min and hold the funnel-shaped

mask just in front of the baby’s face. The oxygen may be

connected either to the funnel-shaped mask or to the bag and

mask apparatus, but in the case of the latter, it is prevented

from flowing out of the mask by the valve unless the bag is

Figure 2.2

Giving oxygen.

Resuscitation of the newborn

compressed. However, it will come out of the corrugated tube

that is attached to the other end of the bag, so turn it round

and hold the end of this tube to the baby’s face.

Using the bag and mask

If the infant does not breathe by 30 seconds after birth, the

closely fitted mask is applied to the face with the head in

the neutral position. For a right handed person, the left hand is

used to hold the mask to the baby’s face while the right hand

squeezes the bag. Place the little and ring fingers of your left

hand under the baby’s chin, taking care not to push too hard.

Alternatively the jaw is elevated with two fingers on the angle of

the mandible. This prevents the head from moving around and

straightens the upper airways, ensuring their patency. With the

other fingers and thumb, apply the mask firmly to the baby’s

face to ensure a tight seal. A proper seal is confirmed when you

squeeze the bag, as there is a characteristic rasping noise as the

valve opens. If the seal is inadequate, the valve makes no noise

and you will not feel any resistance when squeezing the bag.

This can be practised with the mask against the palm of your

hand. Use only the thumb and two fingers, rather than your

whole hand, to squeeze the bag. Do not empty the bag but

Figure 2.3 Operator holding mask with right hand to show how to

gently depress it to a few centimetres only. This will safeguard

place the infant’s head in the neutral position.

against a pneumothorax. The smaller the baby, the more gentle

you must be. The rate should be maintained at 40/min with an

inflation time of approximately 1 second. The first five

inflations should be slightly prolonged as lung fluid is still

present in the airway. Check you are producing an adequate

chest expansion. Air can be used but oxygen should be used if

it can be introduced into a side arm.

Intubation

If there are no spontaneous respiratory movements at the

end of one minute after birth or if the heart rate is less than

100 beats/min at any time the infant should be placed supine

on a flat surface. A special resuscitation trolley is ideal. The

laryngoscope is held in the left hand and passed over the

infant’s tongue as far as the epiglottis. The tip of the blade is

advanced over the epiglottis about another 0 5 cm and is then

withdrawn slightly. This presses the epiglottis against the root of

the tongue, revealing the glottis. In the newborn the glottis is a

slit in the centre of a small pink mound and the slit may

Epiglottis

expand into a triangular opening during a gasp. Gentle

backward pressure on the infant’s larynx by an assistant may

help to bring the glottis into view. Secretions in the pharynx

Uvula

should be aspirated with a large catheter - for example, FG 9.

The endotracheal tube held in the right hand is then guided

Posterior

Laryngoscope

through the larynx about 1-2 cm into the trachea. A metal

blade

Tongue

introducer inside the endotracheal tube makes introduction

easier but it is essential to ensure that it does not extend

beyond the end of the tube.

Intermittent positive pressure should be applied at a rate of

40 times per minute with an inflatable bag with a valve.

The positive pressure applied should not usually be higher

than 30 cmH₂O; otherwise there is a danger of rupturing the

lung and producing a pneumothorax or pneumomediastinum.

These low pressures are enough to induce a gasp reflex, which

is then followed by normal respiratory movements of the chest.

Occasionally in an infant with a severe lung problem, such as

severe meconium aspiration or diaphragmatic hernia, higher

pressures are needed. A return to a normal heart rate is a good

Epiglottis

sign that resuscitation is satisfactory. If the endotracheal tube

has to be left in place for a short period the tube should be

fixed to the cheek by adhesive tape or a special tube holder.

Figure 2.4 Passing the laryngoscope over the tongue.

ABC of the First Year

Aspiration of secretions in the endotracheal tube and in the

trachea can be carried out with a fine catheter (suction

Laryngoscope

blade

catheter FG 6). Either a straight or a shouldered tube is

satisfactory for emergency resuscitation of the newborn. The

shoulder on the endotracheal tube is designed to prevent the

Base of tongue

tube going too far down through the vocal cords and therefore

into the right main bronchus, but this may still occur. If breath

Opening to trachea

sounds are heard equally on both sides of the chest the tube is

probably in the trachea and not beyond the bifurcation.

Oesophagus

Intermittent positive pressure should be stopped every

three minutes for about 15 seconds to determine whether

Uvula

spontaneous respiratory movements will start.

Endotracheal

During prolonged apnoea the blood pressure is maintained

tube

Posterior

initially but later falls. If the heart rate is less than 100/min a

short period of cardiac massage should be given at the same

Tongue

Laryngoscope

time as efforts to start respiratory movements. Cardiac massage

blade

is carried out by applying firm pressure with two fingers over

the lower sternum one finger’s breadth below an imaginary

line between the two nipples.

Opening to

Hypothermia is a special hazard for infants who have been

trachea

resuscitated and exposed during these procedures. Rapid initial

drying of the infant with a warm towel is the most important

preventive factor, but resuscitation should also be carried out

under a radiant heater of at least 400 watts. After resuscitation,

infants should be wrapped up and handed to their mothers for

at least a minute or two even if they have to be placed in a

transport incubator and taken to the special care unit. Most full

term infants who have required resuscitation do not need to be

Oesophagus

admitted to the special care unit.

Figure 2.5

Pressing the epiglottis against the root of the tongue.

Failure to improve

The best sign that resuscitation has been successful is an

increase in heart rate. If this does not occur within about

15 seconds the following should be considered. (1) The gas

cylinders may be empty or the pipe line disconnected. (2) The

endotracheal tube may have been misplaced into the

oesophagus or have slipped out of the trachea during

extension of the neck. If there is any doubt the tube should be

removed and a fresh tube inserted immediately. (3) The

endotracheal tube may be in the right main bronchus. After

these possibilities have been excluded other diagnoses to be

considered are pneumothorax, pulmonary hypoplasia

associated with Potter’s syndrome (renal agenesis with a

squashed facial appearance and large, low set floppy ears), and

diaphragmatic hernia.

Drugs

Ventilation using bag and mask or intubation is usually

effective in resuscitation of the newborn and drugs are rarely

necessary.

Figure 2.6

Misplacement of the endotracheal tube into the pharynx or

If the mother has recently received pethidine or morphine,

oesophagus.

a chemical antagonist can be given to the infant. If the infant

needs both intubation and drugs, intubation should always be

performed first. The only chemical antagonist available is

naloxone, but its period of action is short. The manufacturer’s

current recommended dose is 10-20 micrograms per kilogram

body weight, which can be given intramuscularly or

intravenously and may be repeated at 2-3 minute intervals.

Alternatively, a single dose of 60 micrograms/kg body weight

may be given intramuscularly at birth.

An adequate supply of oxygen quickly reverses acidosis and

it is rarely necessary to consider giving intravenous sodium

bicarbonate or glucose solution.

Resuscitation of the newborn

Table 2.2 Recommended doses

Dose

Dose for 3 kg

1st

2nd

Drug

Concentration Route

(ml/kg)

baby (ml)

Adrenaline

1 in 10 000

IT*, IV,

(0 1 mg/ml)

Sodium

8 4%

2-4

6-12

Naloxone

bicarbonate

(1 mmol/ml)

(diluted 1 in 2 with water)

Glucose

10%

1-2

3-6

Albumin

10-20

30-60

* Double the dose and add 2 ml of 0 9% sodium chloride solution for

intratracheal route.

If there are no spontaneous respiratory efforts by three

minutes after starting resuscitation, blood is taken for urgent

pH and bicarbonate estimations. Without waiting for the result,

the probable acidosis is partially reversed by giving

2-4 ml/kg of 4.2% sodium bicarbonate solution slowly at a rate

that does not exceed 2 ml/min. The standard 8 4% sodium

bicarbonate solution must be diluted 1 in 2 with sterile water

for intravenous use. The solution should be given by a

peripheral vein if possible, as the solution is hypertonic and

may cause local vascular damage. If this is not possible, an

umbilical vein catheter can be used in an emergency.

Ten percent glucose solution can be given if a glucometer

shows hypoglycaemia.

Adrenaline can be given if there is asystole or there is

Figure 2.7

Intubation is performed before giving drugs.

persistent severe bradycardia. If there is no response, the

adrenaline can be repeated. The use of volume expanders,

albumin or 0 9% sodium chloride solution is not

recommended routinely in the resuscitation of the newborn.

Shock in the newborn is usually related to hypoxaemia and

responds to administered oxygen but a volume expander may

be needed where there is volume loss. The infant is transferred

to the neonatal intensive care unit.

There is no specific treatment for the hypoxic-ischaemic

encephalopathy that may follow perinatal asphyxia. The infant

may be apnoeic and need continuous positive pressure

ventilation, have fits, episodes of bradycardia, lethargy, or be

reluctant to suck. Mannitol, frusemide, steroids, and

phenobarbitone in high doses have been used to prevent or

treat possible cerebral oedema but there is no evidence that

they are effective.

These infants will also need long term follow-up to assess

neurological development. The survival rate of full term

newborn infants who have taken 20 minutes to breathe

spontaneously is about 50% and about 75% of the survivors are

(a)

neurologically intact.

When to stop

Poor outcome can be predicted when spontaneous respirations

are not established by 30 minutes. If, in addition, there is no

cardiac output, then survival cannot be expected. It is at this

stage that attempts at resuscitation should cease.

When not to start

This can be an extremely difficult decision and should not be

made by the most junior paediatrician, so begin resuscitation

and call for help. If the heart rate has been recorded at any

(b)

time during the second stage of labour, resuscitation should be

attempted even if there is no heartbeat at birth. With fetal

Figure 2.8

(a) Resuscitation trolley. (b) Bag with face mask.

ABC of the First Year

monitoring it is uncommon for babies to die during labour and

stillbirths are usually expected. Babies who have been dead for

longer than 12 hours have an obvious “macerated” appearance

with gross peeling of the skin.

A baby born at less than 22 weeks gestation cannot survive

and often a paediatrician will not be called if the obstetrician is

sure of the dates. Certain conditions are non-viable, such as

anencephaly or gross hydrocephalus, but fortunately these are

usually detected prior to birth and a decision is reached with

the parents before delivery.

(a)

(b)

Vitamin K

Figure 2.9 (a) Small laryngoscope with straight 10 cm blade.

(b) Neonatal endotracheal tube.

Vitamin K is given to all babies as prophylaxis against

haemorrhagic disease of the newborn. More predictable blood

levels are produced by intramuscular compared to oral

vitamin K. A single intramuscular dose protects against the

early form of haemorrhagic disease, which occurs between the

second and fourth day, and the late form, which occurs after

three or four weeks. Following controversy on the safety of the

intramuscular route, some paediatricians recommend that

breastfed babies receive oral vitamin K in the neonatal period

and during the subsequent two months. Infants receiving a

commercial cows’ milk preparation exclusively have an

adequate intake of vitamin K.

Figure 2.10

Vitamin K may be given intramuscularly or orally.

Discussion with parents

An infant who is breathing normally should be given to the

mother after a rapid examination. She should be told that the

infant seems to be normal and that it is common for infants to

need help with breathing at birth. It is important to emphasise

that the infant’s progress will be no different from that of other

infants who have not needed resuscitation. Most infants who have

required intubation should go with their mothers to the postnatal

wards and receive routine observation. Only if there has been a

prolonged period before the establishment of spontaneous

respiration should the infant be taken to the special care unit.

When an infant dies

If resuscitation of an infant has not been successful, the most

senior clinician involved, preferably accompanied by a midwife

or nurse, should see the parents immediately to impart the

Figure 2.11

Discussion with parents.

news in a sensitive manner. The parents should be given as

much factual information as is known to the clinicians at the

time about the likely cause of the death. It should also be made

clear that further discussion will need to take place, particularly

if the death is sudden or unexpected. The term “birth

asphyxia” should not be used as it may be misleading and there

is increasing evidence that neonatal deaths and morbidity are

more likely to be due to developmental brain problems or

antenatal insults rather than problems occurring during birth.

The family doctor should be informed of the death by

telephone as soon as possible.

Parents should be encouraged to spend as much time as

they want with their infant after death and should be supported

by an experienced nurse or midwife. An infant with severe

congenital anomalies can be suitably wrapped for the parents

to cuddle. Many parents appreciate being able to see the

anomalies with a supportive clinician present to discuss any

questions they may have at the time. Other family members,

Figure 2.12

Anencephaly.

Resuscitation of the newborn

including siblings and grandparents, should also be

consultant. The nature of the autopsy process should be

encouraged to see the dead infant over the next few hours or

explained in a sympathetic but factual manner and parents

days. It is now clear that the grieving process is helped by family

should be aware of the possibility of a limited examination of

participation in seeing and cuddling their dead infant. Many

certain body cavities or organs if they do not want to

parents also welcome the opportunity to participate in the care

contemplate a full examination. They should be made aware

of their dead infant by bathing and dressing the infant in baby

that the face of the baby will not usually be disfigured by the

clothes of their choice with the assistance of a sympathetic and

autopsy and that the body can be viewed again later, suitably

unhurried nurse. However, health professionals should also be

clothed.

aware that there may be cultural and religious differences that

It is important that a health professional with knowledge of

should be respected if parents decline involvement in such

the local arrangements for the burial and cremation of infants

procedures after the death of their baby.

is available to meet with the parents within a few days of the

Photographs of the dead infant and the family group

death in order to assist them to decide how they wish to

together with the infant should be encouraged. Photographs

proceed with funeral arrangements. Although there is a legal

should be kept in a safe place if the family do not want to take

requirement to register the death of a baby within five working

them away with them immediately, and they may still request

days of the death in the UK, the funeral does not have to take

them, sometimes even many years later. Hand and footprints

place immediately unless it is a requirement of the religious

and a lock of hair can also be taken as lasting and tangible

beliefs of the family. Some families prefer to take some time to

mementoes for the family.

decide about arrangements, particularly when the mother of

Discussion with parents will help to decide who will be best

the infant may not be able to be present immediately after a

able to help the grieving family. There may be a supportive

difficult birth.

network of family and friends and for some, religious advisers

A follow-up bereavement appointment should be arranged

or bereavement counsellors may provide support. If the death

with the parents some weeks later. The results of the

occurs in hospital, the family doctor and health visitor should

postmortem examination should be conveyed to them and they

be informed as soon as possible as they will have an important

should be given the opportunity to ask questions about the

role in supporting the bereaved family in the long term.

illness and death of their infant. It is usually helpful to parents

Siblings should be able to see the dead baby with their parents

if the clinicians, including obstetricians or midwives who were

and should be reassured that they are loved, safe, and not in

present at the birth or involved in the care of the infant, can

any way to blame for the distress of the parents. Children can

attend this bereavement discussion. An assessment of whether

accept the death of a baby in a very matter of fact way if they

the family are likely to need expert help and support to

are allowed to be involved and are not excluded from the

progress with their bereavement can also be made at this time.

family at the time of the death. Expert help is rarely necessary

Some parents may also find it helpful to talk to other bereaved

for siblings with whom there has been communication and

families or voluntary organisations providing support, for

involvement in a manner that is understandable to the child in

example SANDS (Stillbirth and Neonatal Death Society).

the bereaved family.

The potential benefits of a postmortem examination should

be discussed with the parents by a senior doctor, preferably a

Infants of low birthweight

Low birthweight infants weigh 2500 g or less at birth. Infants

may be small at birth owing to a short gestation period (born

too early) or because of a restricted growth rate. When the

period of gestation is less than 37 completed weeks the infant is

called preterm. A baby with restricted growth rate is “light for

Head

dates” or small for gestational age (SGA) and may be either

malnourished or, rarely, hypoplastic (for example, an infant

with a chromosome abnormality). Some babies who are

preterm are also light for dates.

The length of gestation can be calculated from the first day

of the mother’s last menstrual period, provided the periods are

Length

regular. The routine ultrasound examination carried out before

18 weeks is considered to be the most accurate method of

assessing gestational age. Detecting restriction in growth of the

fetus is difficult, but palpation of the fetus can be

supplemented by serial ultrasound measurements of the fetal

skull, abdominal girth, femur length and crown-rump length.

The gestational age of the infant can be assessed by a

Weight

detailed neurological examination of the infant, as the

development of the central nervous system is related to the

gestational age. Scoring systems using both the neurological

Preterm

development and specific external features can be used to

estimate the gestational age but require considerable

Light for dates

experience for accuracy.

Most neonatal units consider that infants with a birthweight

below the 10th centile for the gestational age are light for

28 30 32 34 36 38 40

dates, although a more accurate definition is below the third

Weeks

centile with an adjustment for maternal size.

Ultrasound studies have shown that when intrauterine

Figure 3.1 Growth chart showing birth weights of preterm and light

malnutrition starts early in pregnancy the head circumference

for dates infants.

and weight are in proportion with each other, but when

malnutrition starts late in pregnancy the head is

disproportionately large, owing to relatively normal growth of

the brain.

The preterm infant is especially prone to developing

hypothermia, the respiratory distress syndrome, infection, and

intracranial haemorrhage. The light for dates infant is

particularly prone to hypothermia, hypoglycaemia, and

hypocalcaemia.

Temperature

Small infants become hypothermic quickly. Heat loss may be

considerable because they have a large surface area in relation

to body weight and they are also deficient in subcutaneous fat,

which provides insulation. They also lack “brown fat”, which

is usually present in a full term baby and can be metabolised

rapidly to produce heat.

Hypothermia is associated with a raised metabolic rate

and increased energy consumption. To prevent hypothermia

small infants should be kept in a high constant environmental

temperature. Excessive heat loss by radiation can be minimised

by an additional tunnel of Perspex, a heat shield, placed

immediately over an infant in an incubator. The dangers of

hypothermia can be reduced by carrying out resuscitation

under a heat lamp or radiation heat canopy, bearing in mind

the danger of burns if the lamp is too close. When an infant is

transferred from one hospital to another for special care, there

is a danger of hypothermia. A swaddler made of aluminium foil

has been designed to prevent this and is commercially available,

but wrapping the baby with Gamgee wool is also satisfactory.

Figure 3.2

Open incubator with infant receiving artificial ventilation.

Infants of low birthweight

The portable incubator must be kept warm continuously

and ready for immediate use.

Infection

A separate plastic apron or waterproof gown should be used for

nursing each infant, mainly to prevent soiling the nurses’

clothes.

Scrupulous washing of the hands should be carried out

before and after touching each infant. Washing with soap and

water is adequate, although many units use a disinfectant soap

solution. Scrubbing with a brush is unnecessary. Although

Figure 3.3

Light for dates: 1800 g at 40 weeks.

this principle is simple, it may be difficult to ensure that it is

carried out. Proper use of elbow taps is often difficult because

of their poor design. Using disposable plastic gloves when

changing infants’ napkins may reduce cross-infection.

Ideally, any infant who develops an infection should be

barrier nursed in a separate cubicle.

Feeding

Preterm infants have poor sucking and cough reflexes and

methods of feeding must prevent aspiration into the lungs.

Infants who are not able to suck are given frequent tube feeds

of small volumes or continuous intragastric feeds to avoid

sudden falls in arterial oxygen concentrations and apnoeic

attacks, which are associated with abdominal distension.

Intravenous feeding with glucose amino acid solutions and

lipids is used for infants who do not tolerate tube feeding, but a

Figure 3.4

Closed incubator.

scrupulous aseptic technique in managing the solutions is

necessary to avoid septicaemia.

Early feeding, within two hours of birth, prevents

hypoglycaemia and reduces the maximum plasma bilirubin

concentrations. Asymptomatic hypoglycaemia can be detected

early by performing regular blood glucose measurements

using a glucometer on all babies of low birthweight in the first

24 hours. If the infant is feeding well and the blood glucose

level is consistently above 2.6 mmol/l, the tests are stopped

after 24 hours. From the second week onwards vitamin

supplements are added so that infants receive an additional

dose of 400 units of vitamin D and 50 mg of vitamin C daily.

Vitamin preparations usually contain small amounts of vitamin B

complex and vitamin A. Vitamin supplements should be given

until the age of two years and additional iron supplements until

the age of six months.

Figure 3.5

Hand washing prevents cross-infection.

The low birthweight infant at home

As more extremely low birthweight infants are surviving,

community health professionals need to be aware of a few

specific needs and problems of these infants in the first year

of life.

Home oxygen

Infants who still require a small amount of oxygen but who are

feeding and are otherwise well can often be cared for at home

by their parents. The family doctor may be asked to prescribe

an oxygen concentrator for use at home as the continuous

provision of oxygen cylinders is impractical in the long term.

A small portable cylinder which can be carried on a pram or

pushchair will be useful to enable the infant to accompany the

family on brief trips outside the home environment.

Figure 3.6

Syringe pump for giving milk.

ABC of the First Year

A community neonatal or paediatric nurse will support the

family at home and will monitor the oxygen saturation of the

infant intermittently until no additional oxygen is required,

sometimes weeks or even months after discharge from hospital.

Family carers will have been taught basic life support by the

community nurse.

Respiratory problems

Preterm infants, particularly those who have required artificial

Figure 3.7 Oximeter for measuring blood oxygen saturation.

ventilation, have an increased risk of respiratory illnesses in the

first year of life. Wheezing is common in association with viral

infections, but only those infants with a strong family history

of atopy have an increased incidence of asthma. Smoking

should be strongly discouraged in homes where there is a

preterm infant.

Low birthweight

High plasma bilirubin

Immunisations

Rubella

Routine immunisation with DTP triple vaccine, Hib,

Deafness in family

meningococcal C and oral polio vaccine can be commenced

at two months after birth, irrespective of the gestational age

of the infant. Even infants of very early gestation have been

shown to mount an appropriate immune response

Audiologist

to childhood vaccines. In practice, many preterm infants will

still be in the neonatal unit at two months of age and some

will have had their immunisations commenced before

Figure 3.8 Indications for direct referral to the audiologist in the

discharge from hospital. The administration of oral polio

neonatal period.

vaccine will be delayed by three months if intravenous

immunoglobulin has been given to the infant at risk of serious

infection.

Vitamins and iron supplementation

Preterm infants require vitamin A, B, C, and D supplementation

Box 3.1 Supplements for preterm infants

until two years of age. Some extremely immature infants may

also require additional phosphate for adequate bone

• Vitamins A, B, C, D until two years of age

mineralisation during the period of rapid growth in the first

• Phosphate in the first year for extremely preterm infants

year of life.

• Iron from four weeks to six months

Additional oral iron is usually given from four weeks to

six months of age.

Growth and development

The growth and development of preterm infants born at

Mother 5' 4'

weeks gestation should be assessed according to their corrected

Father

5' 8"

age (chronological age period of prematurity). Most will have

caught up with their peers born at full term by around

Head

18 months to two years of age. Some extremely low birthweight

circumference

infants, particularly those born at

26 weeks gestation,

remain

3rd centile in all growth parameters despite being

otherwise healthy. Around 90% of infants

28 weeks gestation

who survive to go home achieve normal developmental

milestones for their corrected age, but many experience

minor motor and educational difficulties by school age.

Myopia is also common in children who were preterm.

Weight

2426283032 34 36 38 40 2

8 10 12 14 16 18 20 22

Weeks

Figure 3.9 Growth chart of a preterm infant.

Breathing difficulties in the newborn

Breathing difficulties in the newborn are called respiratory

distress. One or more of the following features are present:

• respiratory rate over 60 per minute

• an expiratory grunt

• subcostal or intercostal recession or sternal retraction

• cyanosis.

Respiratory distress syndrome

The respiratory distress syndrome (hyaline membrane disease)

is the commonest cause of respiratory problems in the

newborn and a common cause of death in preterm infants.

Cerebral ischaemia and haemorrhage or lung damage may

occur in the acute phase and cause death or long term

morbidity. Hypoxia before, during, or after birth is a

Normal

Surfactant

predisposing factor.

deficiency

The cause is a deficiency of pulmonary surfactant, a

substance normally present on the alveolar walls. Surfactant

lowers the surface tension in the alveoli so that during the first

Figure 4.1 Cross-section of lungs showing uneven expansion with

few breaths the same pressure is required to inflate them all.

alveolar collapse in the surfactant deficient lung.

This produces uniform inflation of all alveoli. Surfactant also

prevents the alveolar walls from collapsing during expiration.

Without surfactant the surface tension is great in the smaller

alveoli, causing them to collapse, while large alveoli continue to

expand easily. Thus there is uneven expansion, with

increasingly widespread alveolar collapse. Surfactant

production in the fetal lung increases with gestational age and

reaches adequate levels for normal lung function by about the

36th week. At 27-31 weeks 35-50% of all infants are affected by

the respiratory distress syndrome. The use of antenatal steroids

given to the mother has reduced this prevalence in infants of

less than 34 weeks gestation.

Microscopy of postmortem specimens often shows the

presence of amorphous material lining the terminal

bronchioles and alveoli, which is called hyaline membrane.

There are also multiple areas of alveolar collapse.

When animal surfactant extract or artificial surfactant is

placed in the trachea at birth or during the first day of life, the

severity and mortality of the respiratory distress syndrome are

reduced. Supplementary surfactant has been shown to be

effective in babies of more than 26 weeks of gestation.

Supplementary surfactant is given at birth to all babies less than

30 weeks gestation and to more mature infants who have

developed specific features of surfactant deficiency that suggest

that the course of the disease will be of moderate or greater

severity (rescue treatment).

Clinical features and general

management

An expiratory grunt, a respiratory rate over 60 per minute, and

Figure 4.2

Arrow indicates hyaline membrane.

recession of the chest wall begin within four hours of birth.

Central cyanosis may appear later. Usually auscultation of the

lungs reveals only reduced breath sounds, but crepitations may

be present. The present approach to intensive care is to

monitor the blood arterial oxygen, carbon dioxide, and pH

levels from birth and to start treatment early. This may prevent

the appearance of the features described above, especially

ABC of the First Year

where artificial ventilation is used electively from birth in

Box 4.1 Management

infants weighing less than 1 kg.

In most infants the chest radiograph shows normal lung

• Temperature

fields in the early stages of the disease, but later a fine reticular

• Arterial oxygen

• Carbon dioxide

pattern or generalised loss of translucency (the ground glass

• pH

appearance) may be present. The contrast between the air in

• Blood pressure

the bronchi and the opaque lung fields produces an air

• Plasma, Na, K, creatinine

bronchogram. The greatest value of the chest radiograph is in

excluding other conditions (see below).

The object of management is to support infants until

further surfactant is produced. Infants should be handled as

little as possible, as their condition may deteriorate abruptly.

Elective monitoring of blood oxygen saturation, heart rate,

temperature and respiratory rate has reduced the need to

handle the infant. Infants should be given oxygen, their

arterial blood oxygen and carbon dioxide concentrations

should be monitored, and body temperature, fluid, and

electrolyte balance maintained.

Oxygen treatment and measurement

During oxygen treatment the arterial oxygen tension should

not fall below 6 7 kPa (50 mmHg) or rise above 12 kPa

(90 mmHg). Below 6 7 kPa the risk of cerebral palsy and

mental retardation increases and above 12 kPa there is a

possibility of retrolental fibroplasia and subsequent blindness.

Figure 4.3

Intensive care in a closed incubator.

Some infants may need high concentrations of inhaled oxygen

to prevent hypoxia. This can be given safely only if there are

facilities for making frequent estimations of the blood oxygen

concentrations.

The ideal arterial carbon dioxide level is 5-7 kPa

(37 5-52 mmHg). Lower carbon dioxide levels may cause

cerebral artery constriction and reduce cerebral blood flow.

Higher carbon dioxide levels may lead to cerebral artery

dilatation followed by systemic hypotension or intraventricular

haemorrhage.

There are several methods of measuring oxygen

concentrations in the blood. Firstly, samples can be taken

from an umbilical artery catheter at regular intervals or they

can be obtained by repeated puncture of one of the radial

arteries.

Secondly, an oxygen sensitive electrode implanted into the

tip of an umbilical artery catheter measures oxygen levels

continuously, but the electrode must be calibrated at regular

intervals with samples of blood aspirated through the lumen of

the same catheter.

Thirdly, a heated transcutaneous oxygen and carbon

Figure 4.4

Blood oxygen analyser.

dioxide electrode increases the blood flow to the skin, where the

gas tensions are measured. The electrode must be moved every

four hours to avoid burns. The method is not invasive and the

electrode is calibrated with a gas mixture. The levels shown by

the transcutaneous electrode must be compared with levels

estimated in arterial blood at regular intervals. The blood

samples are also used to measure pH, bicarbonate, and base

deficit.

Artificial ventilation

Results of artificial ventilation have improved considerably and

deaths are now usually due to complications rather than

respiratory failure. Respiratory tract infection and displacement

of the endotracheal tube are constant hazards and this form of

treatment can only be undertaken where there are adequate

nursing and medical staff and enough patients for an effective

service to be provided.

Figure 4.5

Ventilator.

Breathing difficulties in the newborn

Positive pressure ventilation is needed if one of the

following is present:

• failure to establish effective spontaneous respiration at birth

• recurrent apnoeic attacks

• arterial oxygen tension (PaO₂) less than 7 kPa in 60%

oxygen

• arterial carbon dioxide tension (PaCO₂) more than 7 kPa

• rapid deterioration in blood gas values associated with

clinical deterioration.

Other aspects of treatment

Incubators are used to improve observation and to provide

warmth and humidified air. There are two types: the

conventional incubator and an open type. A perspex head box

can be used to maintain an oxygen concentration above that in

Figure 4.6

Pneumothorax.

the air.

Adequate fluids and electrolytes must be given. The

methods will vary with the severity of the respiratory problem.

Milk can be given by continuous gastric infusion. Alternatively,

small volumes of milk can be given intermittently at frequent

intervals. Some infants need intravenous fluids which may

include total parenteral nutrition (TPN) which contains

glucose, amino acids, lipids, and vitamins.

The group B Streptococcus may produce a clinical picture

similar to that of respiratory distress syndrome and infants with

the respiratory distress syndrome are given antibiotics to cover

this possibility. Intravenous antibiotics must be given until

blood culture results are known, as the syndrome cannot be

differentiated from group B streptococcal pneumonia in the

early stages.

Complications

A pneumothorax should be suspected in any infant who

deteriorates rapidly for no obvious reason. The diagnosis may

be confirmed quickly by transilluminating each side of the

chest with a powerful fibreoptic light source. A chest

radiograph can be used to confirm the condition, but if

Figure 4.7

Arrow shows intraventricular haemorrhage.

symptoms are severe the pneumothorax can be drained before

the radiograph has been obtained. A disposable cannula is

inserted into the pleural space and connected to an under

water seal. Pneumothorax may also follow intermittent positive

pressure ventilation during resuscitation of the newborn or it

may occur as a result of the initial vigorous spontaneous

respiratory efforts of a normal infant.

Cerebral lesions

Periventricular haemorrhage is the most common form of

haemorrhage in the newborn infant. Advances in neonatal care

have led to increased survival of preterm infants who are

susceptible to periventricular haemorrhage. When ultrasound

scans have been performed routinely within the first few days of

life about 10% of infants with a birthweight less than 1500 g

have evidence of periventricular haemorrhage. The majority of

these haemorrhages are small and localised and they are

associated with a good prognosis but early mortality is high and

long term handicap is common in infants with extensive

haemorrhages. These haemorrhages originate in the

subependymal germinal matrix and may spread to involve the

ventricular system or may extend into the cerebral parenchyma

adjacent to the lateral ventricle. Most of the infants with

Figure 4.8 Arrow indicates periventricular leucomalacia.

ABC of the First Year

periventricular haemorrhage have no specific symptoms but

some have recurrent apnoeic attacks, impaired spontaneous

limb movements, and hypotonia or sudden severe clinical

deterioration.

Periventricular leucomalacia is considered to be related to

hypoxia and ischaemia of the brain. Small cysts are shown in the

periventricular region in ultrasound scans of the brain taken after

the third week of life. These lesions are associated with later

major handicaps such as cerebral palsy, blindness, or deafness.

About 15% of infants who survive the neonatal period have

some degree of developmental problem but about 7% have a

severe problem.

Bronchopulmonary dysplasia

This is a chronic respiratory disease occurring in preterm

babies who are very preterm or have needed artificial

ventilation. The causes include inflammation, barotrauma from

artificial ventilation, recurrent aspiration of milk or

postnatal infection. The infant requires increased inflation

pressures or ambient oxygen concentrations as coarse streaking

and areas of hyperinflation appear on the chest radiograph

after the first two or three weeks of life. After weaning from the

ventilator, supplementary oxygen is often required for several

months and those with severe disease die usually about the

third month of life. The survivors have a high prevalence of

recurrent episodes of wheezing but usually have no further

clinical respiratory symptoms after about 18 months of age.

The duration of oxygen dependency may be reduced

by dexamethasone but further studies are needed to determine

Figure 4.9

Bronchopulmonary dysplasia.

the optimal time to start it. A transcutaneous oxygen saturation

monitor is used to monitor the oxygen requirement and to

assess the effects of treatment.

Other causes of respiratory problems

The main causes are pulmonary, cardiac, and central nervous

system disorders.

Transient tachypnoea of the newborn is found in full term

infants after a short labour or elective caesarean section, before

or at term. It can occur in preterm infants but there may be

difficulty in distinguishing it from mild respiratory distress

syndrome. Transient tachypnoea usually resolves within

48 hours. The chest radiograph often shows a streaky appearance

of the lung fields but may be normal. This syndrome may be due

to failure of normal reabsorption of the lung fluid at birth or it

may be a mild form of respiratory distress syndrome.

Diaphragmatic hernia may present with difficulty in

resuscitating the baby or with a raised respiratory rate and an

apex beat on the right side. The hernia is most commonly left

sided and the heart is often displaced to the right. Most

diaphragmatic hernias are detected by antenatal ultrasound

scans. The diagnosis is confirmed by a chest radiograph that

shows loops of small gut or solid organs in the thorax. It may

take 12 hours from birth for air to reach the colon and

produce the characteristic radiographic appearances.

The first symptoms of congenital heart disease are often

noticed by the nurse or mother when the infant has dyspnoea

during feeding or is reluctant to feed. There may be no

murmurs with some lesions. The respiratory rate is raised and

there may be recession of the chest wall. Excessive weight gain

and enlargement of the liver are early confirmatory signs. The

edge of the liver is normally about 2 cm below the costal margin

in the right midclavicular line in the full term newborn.

Figure 4.10

Diaphragmatic hernia.

Breathing difficulties in the newborn

Pneumonia may occur if there has been rupture of the

membranes for longer than 24 hours: the infant may inhale

infected liquor before birth and so develop pneumonia. If the

mother has had ruptured membranes for over 24 hours before

delivery antibiotics should be considered for the mother to

prevent or treat pneumonia in the fetus.

Group B streptococcal infection may present with a raised

respiratory rate and a chest radiograph may show extensive

areas of consolidation in both lungs or may appear normal.

Meconium aspiration usually occurs in an infant who has

become hypoxic before delivery. The infant may start respiratory

movements before the mouth and pharynx have been cleared.

Aspiration of meconium may cause bronchial obstruction,

secondary collapse, and subsequent infection of the distal

segments of the lungs. Oxygen and antibiotics are often needed

and mechanical ventilation may be required for a few days.

Preterm infants have a poor cough reflex and material such

as regurgitated milk in the pharynx is easily aspirated into the

lungs and may cause pneumonia. Signs may be minimal and

are often limited to a small increase in respiratory rate, but a

chest radiograph may show extensive changes.

Severe anaemia may cause a raised respiratory rate with a

metabolic acidosis.

Choanal atresia or stenosis - a congenital posterior nasal

obstruction makes it difficult for newborn infants to breathe, as

they depend on a clear nasal airway. An oropharyngeal

airway produces immediate improvement and an ENT surgeon

should be consulted. The diagnosis can be confirmed quickly

Figure 4.11

Large heart.

by noting the absence of movement of a wisp of cotton wool

placed just below the nares.

Apnoea

Apnoeic attacks are defined as episodes of cessation of

respiratory movements for more than 10 seconds. They may be

due to cerebral hypoxia during the perinatal period,

hypoxaemia due to the respiratory distress syndrome,

hypoglycaemia, or meningitis. An ultrasound scan of the brain

may help in determining the presence and site of

any intracranial haemorrhage.

Morphine or pethidine given to the mother before delivery

may cause apnoea in the newborn (see p. 6).

Recurrent apnoeic episodes are common in preterm infants

of less than 32 weeks gestation. The babies are

otherwise well and the episodes start when the infants are a few

days old. The apnoea may be accompanied by bradycardia and

a fall in oxygen saturation levels. Recent research suggests that

some episodes are of central and others of laryngeal origin.

The diagnosis of apnoea of prematurity can be made only after

excluding other causes; which are:

• pulmonary disease

• airway obstruction, for example due to aspiration of feeds

• hypoglycaemia

Figure 4.12

Apnoea sensor with alarm.

• hypocalcaemia

• intracranial haemorrhage

• convulsions, which may be misdiagnosed as apnoea

• cardiac disease.

Box 4.2 Causes of apnoea

Several attacks may occur daily for the first month of life.

• Prematurity

These may be difficult to manage and may be followed by

• Hypoxia

cerebral palsy at a later date if the episodes are prolonged.

• Intracranial haemorrhage

The various forms of treatment include stimulation of a limb

• Hypoglycaemia

during attacks or prophylaxis with oral caffeine or continuous

• Meningitis

positive airways pressure.

• Drugs

Birth trauma

Cephalhaematoma

Cephalhaematoma is a subperiosteal haemorrhage that

is limited by surrounding sutures. In most cases there

is probably a hairline fracture of the underlying cranial bone,

which may be difficult to demonstrate but is unimportant

since it affects only the outer table. There is usually no brain

damage. A surprisingly large amount of blood may be present

and blood transfusion is occasionally required. The lesion may

not be noticed until the third day.

During resolution a calcified rim may appear, which

wrongly suggests a depressed fracture, or there may be a hard

swelling that takes several months to disappear.

Cephalhaematoma must be distinguished from caput

succedaneum, which is a soft tissue swelling due to oedema of

Figure 5.1

Cephalhaematoma.

the part of the head presenting at the cervix and which is not

limited by the sutures.

Vacuum extraction injuries

Vacuum extraction is often associated with a “chignon”, which

is subcutaneous oedema where the cap has been applied. In

some cases a large haematoma may form and occasionally the

skin becomes necrotic. Nevertheless, the skin grows rapidly

from the borders to cover the area within a few weeks.

Reduced arm movements

Fractures of the clavicle or humerus and stretching of the

brachial plexus present as lack of spontaneous movement and

an absent Moro reflex in the arm on that side. The clavicle and

Figure 5.2

Chignon.

humerus should be radiographed. Fracture of the clavicle

needs no treatment, but if the humerus is fractured the arm

should be splinted to the infant’s body with a crêpe bandage.

Injuries to the brachial plexus (Erb’s palsy) will be recognised

as lack of spontaneous movement of the shoulder and arm

with the hand held in dorsiflexion at the wrist (waiter’s tip

position). Movements of the fingers are associated with good

long term prognosis with spontaneous resolution. Early

referral to a physiotherapist and orthopaedic surgeon is

advised as injuries to the brachial plexus sometimes have a

poor prognosis. Diaphragmatic paralysis often accompanies

stretching of the brachial plexus and may cause a raised

respiratory rate. Another condition that may be mistaken for

injury of the brachial plexus is temporary paralysis of the

dorsiflexors of the wrist caused by pressure on the radial nerve

in the radial groove of the humerus. A fracture of the humerus

may injure the radial nerve at this site.

Intracranial injuries

When the fetal head is large in relation to the pelvic outlet or

delivery is precipitate or by the breech, there is a risk of

extracerebral haemorrhage due to laceration of the tentorium

cerebelli or falx cerebri affecting a venous sinus.

Infants may be unduly lethargic or especially irritable

shortly after birth and there are usually no helpful

confirmatory signs then. Later there may be pallor, a high

pitched cry, poor muscle tone or increased tone, convulsions,

Figure 5.3

Three sites of injury causing reduced arm movements.

Birth trauma

reluctance to suck, vomiting, or apnoeic attacks, and fast or

periodic breathing. Rarely the tension of the anterior

fontanelle is raised, the heart rate is slow, or the pupils fail to

react to light. A blood glucose test should be performed to

exclude hypoglycaemia, a plasma calcium concentration

estimated, and a lumbar puncture considered to exclude

meningitis.

Infants should be nursed in an incubator for easy

observation but if they weigh over 3000 g, the thermostat

should be turned to the minimum level. This type of

haemorrhage is now rare. The prognosis is poor.

Other conditions

A sternomastoid “tumour” is not noticeable at birth but usually

presents after the first week. A firm mass, 1-2 cm in diameter,

is usually found in the middle or lower third of the

Figure 5.4 Extracerebral haemorrhage may be due to laceration of a

sternomastoid muscle but it may be anywhere along its length.

venous sinus.

It will disappear within a year and usually the infant will then

be perfectly normal. The mother is taught by a physiotherapist

to move the infant’s head passively through the whole range of

normal movements daily until the lesion resolves. Without

treatment about 10% of the infants develop torticollis in the

second year of life and a further 10% when they are over five

years old.

Subconjunctival haemorrhages, like petechiae on the head

and neck, are common and unimportant. But if there are

petechiae on the trunk further investigations are indicated.

Subcutaneous fat necrosis produces a firm subcutaneous

area at the site of pressure, especially of the obstetric forceps.

It may be red and tender. No treatment is needed. If the site is

unusual and the swelling not noticed until a few days after

birth, the area of necrosis may be confused with a pyogenic

abscess.

Pressure on the facial nerve before birth or from obstetric

forceps may cause a transient palsy which lasts up to two weeks.

Care of the exposed cornea is essential.

Figure 5.5 Facial palsy.

Some congenital abnormalities

Myelomeningocoele

A myelomeningocoele is a flat or raised neural plaque partly

devoid of skin in the midline over the spine due to abnormal

development of the spinal cord and associated deficiency of the

dorsal laminae and spines of the vertebrae. It is usually found

in the lumbar region. The absence of the various coverings that

normally protect the cord allows meningitis to occur easily. If

there are no active movements in the legs and the anus is

patulous, the infant will probably be incontinent of urine and

faeces for life and never be able to walk unaided. Thoracic

lesions and kyphosis are signs of poor prognosis.

Infants with a good prognosis need urgent treatment, so all

affected infants should either be seen by a consultant

paediatrician without delay or sent to a special centre, where

selection for surgery can be made. About 30% of the infants

have surgery as a result of this policy. During the first operation

the lesion on the back is covered by skin.

Most of these infants develop progressive hydrocephalus

later and those considered suitable for surgery require

insertion of a catheter with a valve from a cerebral ventricle to

the peritoneal cavity to reduce the cerebrospinal fluid pressure.

Hydrocephalus can be detected by ultrasound examination

of the brain. Serial measurements show whether ventricular size

is increasing rapidly. In addition, progressive hydrocephalus is

confirmed by measuring the circumference of the head at its

largest circumference (occipitofrontal) every three days with a

disposable paper tape measure, plotting these values on a growth

chart, and showing that the head is growing faster than normal.

Raised concentrations of

-fetoprotein are found in the

amniotic fluid when the fetus has an open myelomeningocoele

or anencephaly. In anencephaly there is absence of the cranial

vault and most of the brain.

A routine anomaly scan at 18-24 weeks of gestation will

detect most neural tube defects and the parents may decide

Figure 6.1

Myelomeningocoele.

that the pregnancy should be terminated in view of the poor

prognosis. Anencephaly is a lethal condition but some infants

survive for a few hours or days after birth.

Social problems

Fits

Microcephaly

The signs of microcephaly are a small head and forehead that is

Hydrocephalus

Mental

particularly small in relation to the face. The diagnosis is

retardation

confirmed by showing a small head circumference in relation

to the baby’ weight and gestational age. It is usually associated

with mental impairment. Other congential abnormalities may

be present. Evidence of an intrauterine infection such as

toxoplasmosis should be sought and the parents should receive

accurate genetic counselling. The diagnosis may be difficult at

birth but the increasing discrepancy between the head

Club foot

circumference centile and the weight and length centiles with

developmental delay clarifies the diagnosis.

Kidney

abnormalities

Dislocation

Cleft lip and palate

of hips

Mothers are often severely disturbed by the appearance of

these infants and may be reassured by seeing photographs of

similar patients before and after their repair operations. Cleft

lip and cleft palate are often associated. A cleft lip, caused by

Figure 6.2 Associated features of myelomeningocoele.

Some congenital abnormalities

failure of the maxillary process growing towards the midline to

fuse with the premaxilla, may be unilateral or bilateral. Minor

degrees of cleft palate may be easily missed if the posterior part

of the palate is not seen and palpated. Most of these infants

feed normally from the breast or bottle. If there are feeding

difficulties, a special teat, a large normal teat, a special

spade-like spoon, or an ordinary spoon may be tried. The lip is

usually repaired at three months and the palate by the age of a

year. The value of an obturator before operative closure of the

palate is controversial. If an obturator is needed, it should be

made and fitted within 24 hours of birth. Despite excellent

operative results these children are prone to recurrent otitis

media and problems with speech development.

Figure 6.3

Cleft lip and palate.

Figure 6.4

Same patient after

operation.

Umbilical hernia

An umbilical hernia, usually containing omentum and gut, is

most common in African infants or West Indians of African

descent. About 30% of preterm infants who have received

mechanical ventilation have an umbilical hernia. No treatment

is needed, as the hernia usually disappears spontaneously by

the age of three years, although in West Indian infants it may

take a further three years.

In contrast to an umbilical hernia the sac of an

omphalocoele is covered by peritoneum but incompletely by

skin. An omphalocoele is a hernia into the base of the

umbilical cord and contains gut and sometimes solid organs

like the liver. Immediate transfer to a surgical unit is needed.

Oesophageal atresia

Oesophageal atresia will be suspected in any newborn baby who

has a continual accumulation of frothy secretions in the mouth

with drooling, sometimes with cyanotic attacks.

The diagnosis of oesophageal atresia is confirmed by

attempting to pass a tube down the oesophagus. The tube

should have a relatively wide lumen (FG 10), must be stiff

enough to prevent coiling in the upper oesophageal pouch,

Figure 6.5

Umbilical hernia.

and should have a radio-opaque line so that the position can be

checked by a chest radiograph. The tube should be aspirated

every few minutes to keep the upper pouch clear until the

infant reaches a specialised surgical unit.

Oesophageal atresia will be suspected antenatally if there is

polyhydramnios and difficulty in detecting a normal stomach

Oesophagus

bubble at the routine 18-24 weeks anomaly scan.

Trachea

Figure 6.6 Oesophageal atresia.

ABC of the First Year

Multiple abnormalities

Infants with multiple abnormalities should be examined and

investigated by a paediatrician without delay to ensure correct

management of the infant and to provide the information

needed for genetic counselling. Some of the infants may have a

recognisable syndrome and the investigations may show a

chromosomal defect or evidence of intrauterine infection.

The most common problem is the infant with possible

Down’s syndrome (mongolism). Although a scoring system for

a large number of clinical features has been used it the past,

any infant with suspected Down’s syndrome should have a

blood chromosome analysis performed.

The most useful features suggesting the diagnosis are the

facial appearance with palpebral fissures that slant upwards and

outwards, prominent epicanthic folds, baggy cheeks, and white

spots on the iris. A flat occiput, poor limb tone, and single

palmar crease are suggestive but not specific signs. About 2% of

normal infants have a single palmar crease in one hand and

prominent epicanthic folds are even more common. If the

infant has congenital heart disease, it may be detected by

performing an ultrasound study, as a definite murmur may not

be present until several weeks after birth. All infants with

Down’s syndrome have developmental delay, but it may be

possible to reduce maternal depression and increase the

infant’s drive and ability to learn by introducing the parents to

an occupational therapist in the neonatal period.

Figure 6.7 Down’s syndrome.

Routine examination of the newborn

Immediately after birth all infants should be examined for the

presence of gross congenital abnormalities or evidence of birth

trauma. Later, preferably on the morning after delivery, every

infant should be examined again in detail. The obstetric notes

should be checked to determine whether the infant has been at

special risk - for example, from maternal rubella or a difficult

delivery. A systematic approach should be used so that

abnormalities are not missed. The infant must be completely

undressed and in a good light. The mother should be present

during the examination so that the results of the examination

can be discussed with her and so that she can voice her anxieties.

Skin

Diffuse capillary naevi on the face, eyelids, or occiput are

common and resolve within a few months.

Figure 7.1

Strawberry naevus.

The “strawberry mark” starts as a tiny red spot and grows

rapidly for several weeks until it has a raised red appearance

with small white areas, suggesting the seeds of a strawberry.

Such marks are common in preterm babies. They may occur

anywhere on the body but cause no symptoms, except on the

eyelids, where they may prevent easy opening of the eyes and

need treatment. Strawberry naevi grow, often rapidly, for

3-9 months, but at least 90% resolve spontaneously, either

completely or partially. Resolution usually begins at

6-12 months and is complete in half the children by the age of

five and in 70% by the age of seven years. In 80% of cases

these naevi resolve completely without trace.

The port wine stain is not raised and may be extensive. It

does not resolve, but the skin texture remains normal. When

the naevus occurs in the distribution of the trigeminal nerve,

there may be an associated intracranial vascular anomaly.

Neonatal erythema (erythema “toxicum”) consists of

blotchy ill defined areas of bright erythema surrounding white

or yellow wheals which may resemble septic spots. It usually

appears on the second day of life and in most infants clears

within 48 hours. The lesions contain many eosinophils and

have no pathological importance. Neonatal erythema is more

common in full term infants. By ringing individual lesions with

Figure 7.2

Port wine stain.

a skin pencil they can be shown to disappear in a few hours, to

be replaced by others elsewhere. This contrasts with septic

lesions, which appear later and do not resolve so quickly.

Mongolian blue spots are patchy accumulations of pigment,

especially over the buttocks and lower back in infants of races

with pigmented skins. They are common in babies of African

or Mongolian descent, but also occur in Italian and Greek

babies. They may be mistaken for bruises and a wrong

diagnosis of non-accidental injury made. They become less

obvious as the skin darkens.

A midline pit over the spine is most commonly found over

the coccyx, where it does not usually communicate with the

spinal canal. A midline pit anywhere else along the spine may

be connected with an underlying sinus, which may

communicate with the spinal canal and requires excision to

prevent the entry of bacteria and meningitis.

Head and neck

An infant with the Pierre Robin syndrome has a small lower

jaw, glossoptosis, and cleft palate. The infant must be nursed

prone to prevent his tongue falling backwards and occluding

Figure 7.3

Neonatal erythema.

ABC of the First Year

Figure 7.4 Pierre Robin syndrome.

the airway. A small jaw may occur alone or with other

Figure 7.5

Echocardiogram showing ventricular septal defect (VSD).

abnormalities. As the child grows the small size of the lower

jaw becomes less obvious.

Nodules of epithelial cells resembling pearls (Epstein’s

pearls) just lateral to the midline on the hard palate are a

normal finding. A cluster of these pearls is present at the

junction of the hard and soft palates.

Heart murmurs

In the first two days of life one of the most common problems

is an infant who is feeding normally but is found to have a

short systolic murmur during a routine examination. The

murmur is usually due to a patent ductus arteriosus and has

usually disappeared by the time the infant is examined again at

seven days. An electrocardiogram (ECG) or chest radiograph is

unnecessary.

If a long murmur is first heard around the eighth day of

life, a chest radiograph, ECG, and echocardiogram should be

performed and the infant seen by a paediatrician. Most of

these murmurs are due to a ventricular septal defect or mild

pulmonary stenosis with no symptoms. Most of the ventricular

septal defects (VSD) close spontaneously before the infant

reaches the age of five years.

The normal respiratory rate at rest is less than 60/min and

there should be no recession of the chest wall or below the

mandible. If there is any murmur and the infant is feeding

(a)

poorly or has a respiratory rate faster than 60/min at rest, a chest

radiograph and ECG should be performed and the baby seen by

a paediatrician urgently. These symptoms and signs indicate

congestive heart failure usually due to multiple heart defects.

Cyanosis of the hands and feet is common in newborn

infants and has no importance if the tongue is of normal

colour and the infant is feeding normally.

Distended

posterior

bladder

urethra

Abdomen

base

The liver edge is normally 1-2 cm below the costal margin in

the midclavicular line. In a thin, relaxed infant the kidneys

may be palpable bimanually.

The inguinal areas are inspected for the presence of a

hernia. Absence of the femoral pulses suggests that coarctation

of the aorta is present. The blood pressure is measured in all

four limbs and the advice of a cardiologist is obtained urgently.

Failure to pass urine in the first 36 hours or a poor urinary

stream suggests posterior urethral valves in a boy. An enlarged

bladder may be palpable. Diagnosis is confirmed by an

ultrasound examination, which may show hydronephrosis, and

(b)

cystourethrogram.

Figure 7.6 Ultrasound scan (a) and diagram (b) showing distended

Patency of the anus is confirmed by inspection.

bladder and distended posterior urethra due to urethral valves.

Routine examination of the newborn

Genitalia

The foreskin is attached to the penis at birth and no attempt

should be made to retract it.

A hooded prepuce suggests hypospadias with the urethral

orifice at the base of the glans penis. If the urethral meatus is

adequate, no immediate treatment is needed, but the infant

must not be circumcised and should be referred to the

paediatric urologist’s next clinic.

If the urethral orifice is nearer the perineum, the

adrenogenital syndrome should be considered. In the

adrenogenital syndrome cortisol secretion fails and the

adrenals produce excessive androgen. Girls become virilised,

with enlargement of the clitoris and fusion of the labia, and

may be mistaken for boys (see p. 52). In boys the genitalia are

normal.

Intersex is a less common cause of ambiguity of the

external genitalia and a paediatrician should be consulted

Figure 7.7

Hypospadias.

without delay. An accurate diagnosis is an emotional and social

emergency. The parents should be advised that the baby

should not be named until the results of chromosome studies

are available.

Small hydrocoeles usually disappear spontaneously during

the first month but an associated inguinal hernia should be

sought.

Poor development of the scrotum suggests that an

undescended testis is present. Undescended testis is especially

common in preterm infants, in whom the testes usually

descend during the first three months after birth. An

undescended testis is present in 30% of preterm and 3% of

term infants at birth. An infant with an undescended testis

should be seen again at the age of three months. At that time

5% of preterm infants and 1% of term babies will still have an

undescended testis and they should be referred for surgery,

which is performed at about the age of two years. If the baby

develops an associated hernia, the operation will be needed as

an emergency.

As the cremasteric reflex is usually absent at birth, the testis

cannot be retractile. If there is any doubt about whether a

testis is descended the examiner should (a) palpate the pubic

tubercle with one hand, (b) hold the testis between the thumb

and forefinger of the other hand and gently draw it down to its

fullest extent then (c) measure the distance from the pubic

Figure 7.8

Measurement of testicular descent.

tubercle to the centre of the firm globular testis. At term the

testis, if fully descended, lies 4-7 cm from the tubercle. If the

distance is under 4 cm the testis has not completely descended.

In preterm babies, who are more likely to have undescended

testes and whose testes are smaller, 2 5 cm has been arbitrarily

chosen to divide descent from non-descent.

Spontaneous primary descent of the testes rarely occurs

after the age of four months and never after one year. After

the neonatal period an active cremasteric reflex can easily

pull the testis out of the scrotum, especially if the examiner’s

hands are cold. The mother will often have noted whether the

testes are both in the scrotum after a hot bath, and a retractile

testis will descend into the scrotum when the thigh and knee

are maximally flexed on that side.

In girls a small amount of vaginal bleeding is common,

usually five to seven days after birth, and follows withdrawal of

maternal or placental oestrogens, which are transmitted to the

fetus before birth. White vaginal discharge or prolapse of the

vaginal mucosa is normal.

In either sex physiological enlargement of the breast may

occur towards the end of the first week. This enlargement,

which may be unilateral, resolves within a few weeks, but if

there is local redness, a breast abscess should be suspected.

Figure 7.9

Flexion of thigh and knee to determine testicular descent.

ABC of the First Year

Figure 7.10 Prolapse of the vaginal mucosa.

Circumcision

In 95% of babies the foreskin and glans of the penis are still

united at birth. It has been found that the foreskin can be

Figure 7.11 Stretching foreskin distally.

retracted by the age of one year in about half the babies and by

the age of three years in nine out of ten. But no attempt

should be made to retract the foreskin until the baby is about

four years old. Attempts to retract the foreskin earlier are likely

to injure the mucosa, causing bleeding followed by adhesions,

and circumcision may later become necessary. Mothers often

request circumcision to be carried out because the prepucial

orifice appears small. In most cases the adequacy of the orifice

can be shown by gently stretching the foreskin distally and no

attempt should be made to retract the foreskin. Before the age

of four years the only medical indications for circumcision are

recurrent purulent balanitis and ballooning of the foreskin at

the beginning of micturition.

Most circumcisions are performed as a religious ritual, in

(a)

(b)

Jewish families on the eighth day of life and in Muslim boys

Figure 7.12 (a)

Postural.

Figure 7.12 (b)

Structural.

between the ages of three and 15 years.

Club foot and extra digits

Muscular imbalance due to the posture of the infant’s feet

in utero is the commonest cause of club foot. In postural club

foot it should be possible to dorsiflex the foot fully and to

obtain passive inversion to 90°. The mother should be taught

to manipulate the foot through the whole range of movements

after each feed for several days after birth, although the shape

usually reverts to normal within a few weeks even without

treatment. In contrast, in structural club foot the range of

passive movements is restricted and orthopaedic advice on

strapping, manipulation, or serial plasters is needed within

24 hours of birth.

Figure 7.13

Extra thumb.

To detect extra digits, the digits should be counted with the

infant’s palms open, or an extra thumb may be missed.

Polydactyly requires the advice of a plastic surgeon to

determine which digit should be removed at the age of 3-4

years for the best functional results. Extra fingers and toes are

often familial and vary from an apparently normal digit to a

skin tag. The latter can be tied off with a sterile silk thread and

will separate by aseptic necrosis.

Central nervous system and eyes

To assess the central nervous system the alertness of the infant

and the symmetry of spontaneous movements should be noted.

The tension of the anterior fontanelle and the width of the

fontanelle should be palpated while the infant is at rest and

the head circumference should be measured. A more detailed

Figure 7.14 Eyes open when the infant is held over the mother’s shoulder.

Routine examination of the newborn

neurological examination is not required unless there is a

special indication.

Babies will open their eyes when being fed or when held

upright over their mother’s shoulder. Babies will follow the

movements of an examiner’s face provided that the distance is

50 cm or more. The pupils of every baby should be examined

with an ophthalmoscope at a distance of 50 cm. A bright red

glow is seen, which is a reflection of light from the back of the

retina. Absence of this “red reflex” is found in congenital

cataract, which produces a dull grey appearance.

Watering eye

If there is persistent watering of the eye with clear fluid, the

tear duct is probably blocked. No action is required until at

least the age of one year, when the infant can be referred to an

ophthalmic surgeon.

Rarely, the tear duct is probed, but most ophthalmic

surgeons prefer to take no action because the condition

resolves spontaneously in virtually all infants and probing may

Figure 7.15

Tear duct.

induce fibrosis of the tear duct. If there is repeated or

persistent purulent discharge, the possibility of chlamydia

infection should be considered and arrangements made with

the laboratory for specimens to be taken.

Taking blood

Capillary blood taken from infants aged up to two years can be

used for a variety of tests. The commonest is the Guthrie test,

but capillary blood may also be used for blood glucose testing,

haemoglobin estimations, and most biochemical tests.

The best site for taking capillary blood from an infant aged

under six months is the heel. In older infants the thumb is a

better site. The heel must be warm. If it is cold, the infant’s

foot should be dipped into hand hot water (40°C) for five

minutes and dried thoroughly. The examiner then holds the

infant’s foot by encircling the ball of the heel with thumb and

forefinger. The site selected for the heel prick must be on the

Figure 7.16

Holding foot for taking blood.

side of the heel; if the ball or back of the heel is used a painful

ulcer may form.

The site is wiped with isopropyl alcohol and allowed to dry.

A spring loaded lancet introducer is used.

The initial drop of blood should be wiped away with a dry

cotton swab and succeeding drops allowed to drip into the

container, onto the Guthrie test card or onto the end of a

glucometer strip. To milk blood into the heel the examiner

should squeeze and release the fingers around the infant’s

calf and keep the heel below the rest of the leg. Up to 2 ml

of blood can be obtained. When the required volume has

been obtained, the heel is wiped and the wound pressed

with a clean cotton wool ball. A small plaster should then be

applied.

Phenylketonuria and hypothyroidism

The Guthrie test detects high blood concentrations of

phenylalanine, which indicate that the infant probably has

phenylketonuria. Drops of blood are taken by heel prick after

six days’ breast or bottle feeding (usually the seventh day of

Insert lancet here

life) and placed on the special absorbent card provided. The

blood is usually taken by the midwife if the infant is at home

on the seventh day. If the test is positive, the infant should be

admitted to hospital to confirm the diagnosis, as he or she may

need a special low phenylalanine diet to prevent brain damage.

Figure 7.17

Sites for insertion of lancet.

ABC of the First Year

Figure 7.18 Screening blood card.

A capillary tube of blood can be used (for the Scriver test)

instead of the dried blood spot.

Some laboratories use the plasma thyroid stimulating

hormone and others the plasma thyroxine value as the

screening test for hypothyroidism. The screening blood

card is used for both the Guthrie test and the test for

hypothyroidism.

Talking to parents

Whenever possible both parents should be seen together. If

an abnormality is found during the routine examination

some indication must be given to the mother so that

arrangements can be made to see both parents. Particularly if

the problem is likely to be long term, the doctor who will

continue the long term care should speak to the parents

initially. Ideally, a nurse should be present as well since the

parents will probably ask all the questions again as soon as

the doctor has left.

The diagnosis should be explained in terms that the

parents can understand and the positive aspects should be

emphasised. For example, if the probable diagnosis is

ventricular septal defect, it is not necessary to explain that

there is a remote possibility of multiple cardiac defects. After a

difficult forceps delivery it is better to say that most babies

develop normally rather than say they may be slightly

Figure 7.19

Talking to parents.

backward. An unnecessarily pessimistic prognosis based on out

of date information may alter a mother’s attitude towards her

baby and impair her attachment to him or her.

In discussing management the help and support that will

be given by social workers or physiotherapists should be

emphasised and the parents advised to tell their relations and

friends the diagnosis rather than hide it.

A doctor with only limited experience of a particular

problem should tell the parents that he or she needs to seek

further advice rather than guess at the answer. Parents often

cling to the first opinion and may find it difficult to accept a

more experienced view later. A statement of the facts - for

example, that there is an abnormality of the spine - may be

given with the assurance that a more experienced doctor will

discuss them later.

Useful advice for new mothers

Sleeping position of infants

It is recommended that babies should be placed on their back

to sleep as this has been shown to reduce the risk of cot death.

Figure 7.20

Position for sleeping.

Routine examination of the newborn

Healthy babies placed on their backs are not more likely to

choke if they vomit. The mattress used in a baby’s cot should

be firm, flat, clean, and covered in waterproof material like

PVC. Pillows should not be used. To prevent the baby wriggling

down under the covers, a baby’s feet should be placed at the

foot of the cot or pram.

By 6-7 months of age, many babies will roll over onto their

front during sleep. There is no need for concern about this,

as the risk of cot death is markedly reduced by this age.

There are, however, certain circumstances in which babies

should be nursed on their side or prone (on their front). These

include some babies in neonatal units, babies with severe

gastro-oesophageal reflux, babies receiving treatment in splints

for unstable hips, and babies with Pierre Robin syndrome.

Cellular blankets are ideal and duvets or loose bedding

should be avoided. An infant should not sleep on a sofa or

bed with a parent. It has been recommended that the infant

should sleep in the same room as the parent for the first six

months of life.

Avoid smoking near babies

Figure 7.21 Correct sleeping position, with feet at the bottom

of the cot.

Smoking in pregnancy by the mother will reduce the

birthweight of the infant by approximately 200 g at term and

increases the risk of cot death. Babies exposed to cigarette

smoke after birth are also more likely to suffer wheezing and

ROOM

°F BEDDING

respiratory infections. It is best if everyone, especially parents,

refrains from smoking in the same house or room as a baby.

Sheet only

Too hot

Sheet + 1 blanket*

Temperature

Sheet + 2 blankets*

Overheating a baby may increase the risk of cot death. A room

Just right

Sheet + 3 blankets*

temperature of about 18°C (65°F) is comfortable for babies as

well as adults.

Too cold

Sheet + 4 blankets*

Car seats

*A double layer of blankets

Whenever a baby is taken in a car, he should always be

counts as two blankets

strapped into a baby seat or rear facing infant carrier. It is not

safe to nurse a baby on the lap in a car, even if the adult is

wearing a seat belt.

Figure 7.22 Amount of bedding required for a range of room

temperatures to keep the infant’s temperature at the optimum level.

Cot deaths

About one baby in every 2000 born alive dies suddenly and

Box 7.1 Foundation for the Study of Infant Deaths (FSID)

unexpectedly between the ages of one week and two years.

Typically, an apparently healthy baby (or, occasionally, one with

Artillery House, 11-19 Artillery Row, London SW1 1RT

General enquiries telephone: 020 7222 8003

only minor symptoms) is put in a cot to rest and some time

24-hour helpline: 020 7233 2090

later is found dead. Although an infant may be face down in the

cot with the bedclothes over him or her, suffocation should not

be assumed. Sometimes vomit, which may be blood tinged, is

found around the mouth or on the bedding, but regurgitation

usually occurs after death and is not the cause of death.

Box 7.2 Prevention of sudden infant death

In some cases necropsy discloses an unsuspected congenital

Although sudden infant death is very rare, it is important to follow

abnormality or rapidly fatal infection. But usually there is no

the latest guidelines for prevention. These are:

evidence of severe disease, though there might be slight

• Put your baby to sleep on his or her back

reddening of the tracheal mucosa, which in other babies

• Do not smoke; keep your baby out of smoky atmospheres

normally resolves spontaneously.

• Do not let your baby get too warm

Parents often blame themselves and may worry that the

• Put your baby at the foot of the cot so that he or she cannot

infant suffocated as a result of neglect. They should be told

wriggle under the covers

that their feelings of guilt are a natural reaction and the doctor

• Contact your doctor if you think your baby is unwell

should explain to them, and to anyone who was looking after

the baby when death occurred, that cot death is a well

recognised but ill understood condition and that no one is to

blame for the infant’s death.

ABC of the First Year

Birth details

Please use ball point pen and press firmly

Date of birth_________ / _________ / _________

Time of birth______________________________

Infant Hospital NO.________________________

Weeks of pregnancy_______________________

Birth Wt. ________ kg Head circ. _______ cm

Method of delivery________________________

Apgar at 1 & 5 mins _______________________

Place of birth _____________________________

(Tick box if examination done and write in

Problems during pregnancy or birth:

'comments' if problem)

(1) _______________________________________

Comments

(2) _______________________________________

Skull sutures

£ ______________________

(3) _______________________________________

Skin

£ ______________________

(4) _______________________________________

Eyes - red reflex

£ ______________________

Meconium passed within 24 hr

Yes/No

Palate

£ ______________________

In special care baby unit

Yes/No

Heart

£ ______________________

Any neonatal contraindication

Abdomen

£ ______________________

to immunisation

Yes/No

Genitalia

£ ______________________

Risk factors for congenital

Hips

£ ______________________

dislocation of hip

Yes/No

Limbs/spine

£ ______________________

Risk factors for hearing

loss

Yes/No/Not Known

Significant abnormality or condition _______

Feeding at discharge

Breast/bottle/both

__________________________________________

Blood tests done

__________________________________________

Phenylketonuria

Yes/No Norm/Abn

Follow-up hospital appointment

Yes/No

Thyroid test

Yes/No Norm/Abn

Reason/details ___________________________

Haemoglobinopathies

Yes/No Norm/Abn

__________________________________________

BCG

Yes/No

__________________________________________

Immunisations

ALL CHILDREN SHOULD RECEIVE IMMUNISATIONS except a very few children who:

1. are suffering from a feverish illness - when the immunisation should be postponed until full recovery.

2. have had a severe reaction to a previous immunisation.

3. have an illness or are taking medicines that interfere with their ability to fight infections.

CHILDREN TAKING ANTIBIOTICS CAN BE IMMUNISED.

Before each immunisation the doctor or nurse will make sure that it is all right to give your child the vaccine.

Please use ball point

Further comments on consultation sheets: YES/NO

pen and press firmly.

Age

Site of

Signature

Treatment

Vaccine

Date given

Batch number

due

injection

in full

centre code

RL/LL

*D.T.P or *D.T.

Dose 1

Polio

2 months

RL/LL

Hib

Meningo C

RL/LL

*D.T.P or *D.T.

Dose 2

Polio

3 months

RL/LL

Hib

Meningo C

RL/LL

*D.T.P or *D.T.

Dose 3

Polio

4 months

RL/LL

Hib

Meningo C

Measles, Mumps,

12 months

Rubella (MMR)

*Delete one

Figure 7.23

Routine examination of the newborn

Parents must also be told that because the death is of

Travel to foreign countries is best avoided until the

unknown cause the coroner will have to be told as a matter of

completion of the routine infant immunisations at four

routine and that there will be a necropsy. If the parents want to

months of age. BCG should also be given if travelling to

see the infant’s body (and they should be asked), the infant is

a country with a high prevalence of tuberculosis.

clothed and a doctor or nurse should be present to answer

Antimalarial prophylaxis is essential for young infants and can

questions and provide support. Parents should be encouraged

be safely given to all infants, provided that they do not have

to see the infant’s body as this will help the grieving process.

neonatal jaundice, if travelling to a country where malaria is

Discussion with the parents will determine who is best to help

endemic. The same drugs as are prescribed for adults can be

with their grieving.

used in appropriate dosage for infants:

The family doctor and health visitor should be informed

• first month of life - one eighth adult dose

of the death immediately. The family doctor should explain the

• one month to one year of age - one quarter adult dose.

results of the necropsy to the parents or arrange for

a paediatrician to do this.

Boiled or bottled water should be used for drinking water

Brothers and sisters of the infant who has died will need

and preparation of infant formula feeds abroad. Parents

reassurance that they will not die and are in a safe and loving

should be advised not to use commercially produced mineral

environment. The concept of the finality of death may not be

water with a sodium content more than 20 mg/l, as a high salt

attained until the age of eight years. Children may be disturbed

intake can be harmful in young infants. Changes in drinking

by the emotional distress of the parents and this may cause

water and diet may cause an alteration in intestinal flora and

behavioural or sleep problems.

diarrhoea in young infants. Meticulous attention to hygiene

will help to prevent gastroenteritis. Families of infants should

be advised to carry sachets of powdered oral infant rehydration

Foreign travel with infants

mixture when they travel abroad, as it may not be readily

available elsewhere.

Families are more mobile and are increasingly seeking advice

The skin of young infants is very susceptible to sunburn

about air travel with young children. Infants are at increased

and must always be protected with liberal applications of high

risk of experiencing earache during take-off and landing

factor sunblock, hats, and sun shields or umbrellas in hot

because the drainage of their Eustachian tubes may be partially

sunny climates.

blocked with fluid and mucus. Feeding the infant may help by

producing a partial Valsalva manoeuvre, but may not be

possible because of safety restrictions in the aircraft.

Dislocated and dislocatable hip in the newborn

Congenital dislocated hip and dislocatable hip are probably

the most important asymptomatic congenital abnormalities to

detect, as early treatment is simple and usually effective. In the

first 12 hours of life ten in 1000 infants in Britain have a hip

abnormality. When the examination is carried out 24-36 hours

after birth the incidence falls to about seven per 1000 births.

Formerly, when they were all left untreated in the newborn,

the incidence of established dislocated hip was one in 800

children. There may be a family history of the condition; the

anomaly is more common in girls and after the extended

breech position in utero. There is a higher incidence in some

countries, such as Italy and the former Yugoslavia.

The best time to examine the infant’s hips is between

the ages of 12 and 36 hours, as the tendency to provoke

regurgitation is less and there is less ligamentous laxity by that

time. The examiner’s hands should be warm and the infant

should be placed on her back with the sheet spread completely

flat. She should be fully relaxed and this may be encouraged

by putting an empty sterile feeding teat in her mouth if

necessary. The gentle abduction test, followed by Barlow’s test,

should be carried out in all cases. Unnecessary trauma to the

delicate hip joint and its capsule must be avoided.

Gentle abduction test

Figure 8.1

Gentle abduction test.

The gentle abduction test will detect hips that are in the

dislocated position at rest. Each hip should be examined

separately, while the opposite thigh is gently fixed by the

examiner’s other hand. Both the knee and the hip should be

flexed to a right angle and the knee held so that the

examiner’s thumb is parallel to the medical aspect of the lower

thigh, while the middle two fingers lie along the whole length

of the lateral aspect of the femur. The tips of the examiner’s

fingers thus lie over the greater trochanter.

The thigh should be held lightly and neither pushed down

towards the cot surface nor pulled up towards the examiner’s

face. It should then be allowed to abduct very gently and slowly

by the weight of the infant’s leg until abduction is complete.

The thigh should never be forcibly abducted and it is

unnecessary to obtain abduction beyond 10 above the flat.

While abducting the thigh, the examiner may feel or see the

head of the femur slip, jerk, or jolt forward into the

acetabulum. A temporary interruption in the flow of abduction

Figure 8.2

Gentle abduction test.

at a point about midway through abduction precedes the

sensation of this abnormal movement of the head of the femur.

If the joint capsule is very lax, the reduction jolt may be

missed unless great care is taken.

Barlow’s test

The object of Barlow’s test is to identify dislocatable hips in

which the head of the femur can be gently jolted posteriorly

over the posterior lip of the acetabular labrum to lie

temporarily out of the acetabulum and those dislocated hips in

which the head of the femur can be jolted forwards to lie

temporarily in the acetabulum.

Each hip should again be examined separately while the

opposite thigh is gently fixed by the examiner’s other hand. The

infant’s hip should be flexed to a right angle and the knee more

acutely flexed. The examiner should place a thumb as high as

Figure 8.3

Barlow’s test.

Dislocated and dislocatable hip in the newborn

possible on the medial aspect of the upper femur while the tips

of the middle two fingers grasp the greater trochanter laterally.

The thigh is held lightly in a position of only minimal

abduction and then an attempt is made to push the femoral

head gently posteriorly and slightly superiorly, while at the

same time the examiner’s hand is internally rotated through

not more than 25 . This is followed by reversing the whole

movement. No excessive force is used and only a very limited

range of movement employed in the test.

The movement of the head of the femur out and in, or in

and out, of the acetabulum produces a jolting or jerking

movement, which can be seen and felt by the examiner. It

cannot be heard by an individual with average hearing. The

sensation is like that of a gear lever engaging.

Hips that show excessive movement of the head of the

femur within the joint, without being actually dislocatable, are

classified as normal.

(a)

Ligamentous laxity. In at least 10% of infants this

examination evokes a noise, click, snap, or grating sensation,

NORMAL

60°

but there is no abnormal movement of the femoral head.

Such hips should be considered normal and no follow-up is

required. Because of confusion about its meaning, the term

“clicking hip” should be abandoned.

Examination of the hips should be performed more than 15

Fem

hours after birth because few ligamentous clicks will be found.

head

Ultrasound in screening

If ultrasound screening is undertaken in every infant before

leaving hospital, imaging facilities will be required seven days a

(b)

week. Twenty percent of hips may be considered abnormal and

the majority will resolve to normal within four weeks.

Figure 8.4 (a)

Ultrasound of normal hip (b)

diagram.

Selective screening with ultrasound of infants with a clinical

hip abnormality or risk factors for congenital dislocated hip

(breech delivery, positive family history, or foot deformity)

reduces the screened population and allows treatment options

to be delayed and targeted effectively. A recent study showed

that this approach has not reduced the prevalence of late cases

of congenital dislocated hip and it has been suggested that

selective ultrasound screening is dependent upon more

vigorous clinical screening and careful selection of risk factors.

Ultrasound in diagnosis and

management

Shallow acetabulae occur with normal hips and delayed

ultrasound screening examination to 4-6 weeks in

clinically stable hips will allow treatment to be targeted to

(a)

those hips that require splintage and thus reduce treatment

rates without compromising the results of this treatment.

Weekly ultrasound studies can be used to confirm hip

ABNORMAL

relocation and treatment progress while the infant is in a

60°

malleable splint or Pavlik harness. Sonographic evidence of

continuing femoral head dislocation, despite splintage, allows

treatment to be abandoned and thus the risk of avascular

Fem

necrosis is reduced. The appearance of the ossific nucleus in

head

the cartilaginous femoral head (usually delayed in congenital

dislocated hip) is identified sonographically several weeks

before it is visualised radiologically.

Recommended screening

(b)

Babies born after a vertex presentation who have normal hips

on clinical examination and do not have any risk factors will

Figure 8.5 (a) Ultrasound of abnormal hip (b) diagram.

ABC of the First Year

continue to receive clinical screening using the neonatal

Box 8.1 Special risk of congenital dislocated hip

examination and thereafter by their general practitioner in

surveillance clinics.

• Born in breech position

• Family history of congenital dislocated hip

Babies who are judged to be at risk of congenital dislocated

• Foot deformity

hip because they:

• Meningomyelocoele

• were born in breech position, or

• have a family history of congenital dislocated hip, or

• have a foot deformity

should have ultrasound at 4-6 weeks of age, in addition to the

clinical screening tests. If they are clinically normal and the

ultrasound is normal no follow-up is needed. The general

practitioner should be sent a standard letter advising that they

have been screened by ultrasound but still require follow-up in

the surveillance clinic.

If any of the above children have minor abnormalities on

the ultrasound scan then they should have a second ultrasound

scan six weeks later. Children with subluxed or dislocated hips

on ultrasound should be seen again in the paediatric

orthopaedic clinic.

Any child who has a clinically dislocated or dislocatable hip

at birth should have an immediate ultrasound and be referred

to the next paediatric orthopaedic clinic within a week.

Management of abnormal hips

Apart from cases of irreducible hip dislocation, an infant with

a dislocated or dislocatable hip should have a splint applied at

about the age of two weeks. Further delay may cause poorer

results. The Pavlik harness or variants of the von Rosen splint

are used. They are made of malleable metal that has been

padded and then covered with waterpoof material. The splint

acts equally on both hips, keeping both thighs flexed and at an

optimum degree of abduction. Unless substitution by a larger

splint is required, the splint must remain in position

continuously for at least two months if the hip is dislocatable

or for at least three months if it is dislocated at rest. Early

consultation with an orthopaedic surgeon, who will continue

long term care, is essential.

Before the splint is first applied, the mother must be told

exactly what this treatment entails. She should be encouraged

to continue breastfeeding, even though this may prove

awkward initially. The infant should be placed naked on the

Figure 8.6

Pavlik harness.

splint, which has been fashioned so that the posterior cross

bar is grooved to protect the skin over the spine. If the hip is

dislocated, the dislocation must first be gently reduced

and the thigh held in the abducted position while the splint is

carefully applied. Potential pressure points may be protected

by inserting pieces of cotton wool or similar material. The

mother should be told to replace these when they become

wet or soiled without disturbing the splint. The baby’s clothes

should be put over the splint and not under it.

Once the splint is in place, the infant should be washed,

weighed, and examined without the splint being removed.

The splint will need scrupulous adjustment at each visit to

allow for growth and to ensure that the hip is not being

overabducted. The degree of full abduction in a normal

infant diminishes slightly but steadily over the early weeks of

life so that the splint should give the comfortable degree

of full abduction that is appropriate for the child’s age.

Failure to adjust progressively for this may cause avascular

necrosis of the femoral head. On the other hand, if the

degree of thigh abduction is inadequate because the splint is

applied too loosely, the hip may remain dislocated.

The splint should be checked daily for several days after

Figure 8.7

Radiograph of normal hips at 18 months.

Dislocated and dislocatable hip in the newborn

application and thereafter at intervals of not more than one or

two weeks.

Once the splint is finally removed, an anteroposterior

radiograph of the hips should be taken with the thighs held

parallel, and the infant should be followed up at the ages of six

and 12 months, at the least.

Late diagnosis

If a dislocated hip is “missed” in the newborn infant the

clinical diagnosis is often difficult until, after some weeks, the

classic signs of lack of thigh abduction and, in unilateral cases,

asymmetry of the lower buttock creases become apparent.

Before the age of four months an ultrasound study is the most

useful aid to diagnosis. Radiologically, once ossification occurs

Figure 8.8 Radiograph of dislocated hip at eight months.

in the upper femoral epiphysis at about the age of 3-4 months

a dislocation can be more clearly shown.

Acknowledgement

This chapter was written for the first edition by Dr HVL Finlay

and has been revised for each edition.

Infection in the newborn

Some infections are fulminating and the infant dies within a

Box 9.1 Symptoms

few hours. More commonly, however, the onset is insidious and

the vague features may include the refusal of feeds by an infant

• Refusal of feeds

who has previously fed normally, lethargy, hypotonia, apnoeic

• Lethargy

attacks, or fever. Fever is arbitrarily defined as a temperature

• Hypotonia

• Apnoea

over 37.5 C, but newborn infants with infection often have a

• Fever

normal or even a subnormal temperature.

The most common pathogens are group B streptococci,

Escherichia coli, Staphylococcus aureus, and Pseudomonas. The

pathogens causing infection at a particular site can sometimes

Synergism

Antagonism

be predicted (for example, Staph. aureus in paronychia) but

Resistant

swabs for bacterial culture should still be taken before giving

an antibiotic. Usually an antibiotic needs to be given before the

organism has been isolated, but the treatment can be changed

Intermediate

later once the sensitivity of the pathogen to antibiotics has

Contamination

been tested in vitro. The sensitivity of the pathogens in a

particular unit is often known, which may give a guide to

effective treatment. If septicaemia is suspected and there is no

Sensitive

obvious site of entry of the pathogen, both a penicillin and an

aminoglycoside (for example, gentamicin) must be given after

Resistant

mutants

a blood culture has been taken.

Intestinal absorption is variable and regurgitation of

Enzyme

antibiotics common, so that the intramuscular or intravenous

Control

inactivation

route should always be used initially. Intramuscular injections

comparison

Selective action

should be given deeply into the upper lateral aspect of the

thigh. Schemes for rotating the sites are essential to prevent

local necrosis and to avoid further injections being given into a

Figure 9.1 Antibiotic disc susceptibility test.

relatively avascular area. Intravenous antibiotics are given

slowly by bolus injection rather than by adding them to the

bottle of intravenous fluid.

Box 9.2 Group B streptococcal infection

Early onset

•

Raised respiratory rate

•

Peripheral cyanosis

Group B streptococcal infections

Late onset

•

Insidious septicaemia

•

Meningitis

The group B Streptococcus is the commonest pathogen that

causes severe infection in the first week of life. It is acquired

during birth from the maternal vagina. Although about 10% of

mothers are colonised and about 25% of their infants acquire

this organism, only one in 1000 infants has symptoms. About

half of those with symptoms die. In the early onset type, which

occurs in the first few days of life, there may be a persistently

raised respiratory rate followed by the vague features of

septicaemia and later peripheral cyanosis. The chest

radiograph may show extensive areas of consolidation in both

lungs or it may be normal. The same organism may cause a

more insidious septicaemia and meningitis towards the end of

the first week.

Parents should be warned that recurrent group B

streptococcal infection may occur for up to three months after

birth and intravenous antibiotics will be the only effective

treatment.

Escherichia coli infections

The use of antibiotics with a wide spectrum of action tends to

eliminate all bacteria except E. coli and Pseudomonas, which

flourish in a warm, moist environment. The preterm infant,

who has a greater susceptibility to infection, nursed in an

incubator with increased humidity provides the ideal setting

for these infections, especially if broad spectrum antibiotics are

Figure 9.2 Infection of the umbilicus.

Infection in the newborn

being given. The umbilicus may become infected and this may

be followed by septicaemia and later meningitis.

Early symptoms are ill defined and the nurse may report

that the infant appears vaguely unwell. He may have lethargy,

anorexia, jaundice, and purpura. The early symptoms of

meningitis are similar to those of septicaemia, but late features

are vomiting, a high pitched cry, convulsions, raised anterior

fontanelle tension, but rarely neck stiffness.

A urinary tract infection may easily be missed if a specimen

of urine is not examined in every infant with fever or who is

unwell. Rarely, there are physical signs of an associated

congenital abnormality of the urinary tract, such as an

enlarged kidney due to hydronephrosis or a persistently

palpable bladder and poor urinary stream caused by

obstruction from urethral valves in a boy.

Outbreaks of acute gastroenteritis due to rotavirus may

Figure 9.3

Regular repeated examinations of the urine.

occur in newborn nurseries.

Staphylococcal infections

Conjunctivitis - Staph. epidermidis is often cultured from eye swabs

of infants with conjunctivitis and it is impossible to determine

whether this is the primary cause of the conjunctivitis or

whether it is secondary to chemical inflammation. Chemicals,

such as chlorhexidine, used in swabbing the mother’s perineum

may enter the infant’s conjunctiva during delivery. Primary

infection with Staph. aureus may cause severe conjunctivitis. After

taking an eye swab from an infant with conjunctivitis, neomycin

ophthalmic ointment should be applied to both eyes three times

daily for a week.

If mild conjunctivitis persists longer than a week, the

possibility of infection with Chlamydia trachomatis should be

considered. The laboratory may be able to isolate the organism

Figure 9.4

Pustules.

using special techniques. The best treatment consists of a

course of tetracycline eye ointment, which should be

continued for at least three weeks; a course of oral

erythromycin should also be given for two weeks. (See below

for gonococcal conjunctivitis.)

Skin sepsis - Clusters of yellow pustules in the axilla or groin

that first appear on the fourth day or later are usually due to

staphylococci. They may resemble the lesions of neonatal

erythema, but those lesions appear earlier and resolve within

48 hours. If there is any doubt, the lesions should be treated as

staphylococcal pustules.

Bullous impetigo of the newborn is a rare bullous eruption

which can be rapidly fatal and very infectious if adequate

antibiotics as intravenous flucloxacillin are not given.

Umbilical infection, shown by a localised red area and a

serous exudate, may be due to Staph. aureus or a wide variety of

other pathogens.

Figure 9.5

Bullous impetigo.

Paronychia is an infection along the side of the nail of the

fingers or toes. It often affects several digits together. The

lesion appears trivial but it may lead to any of the more serious

infections due to the Staphylococcus. Surgery is not required

but a long course of flucloxacillin should be given.

A breast abscess is a red, tender swelling, which may not

affect the whole breast; usually there are enlarged lymph nodes

in the axilla on the same side. Physiological enlargement may

be unilateral. Surgical drainage is usually required as well as

antibiotics for a breast abscess.

Pneumonia - The signs are the same as those of other types

of pneumonia: raised respiratory rate, recession, and

sometimes focal or generalised signs in the lungs. The infant

appears extremely ill because of the accompanying

septicaemia. A chest radiograph may initially show generalised

non-specific changes and later lobar consolidation with

Figure 9.6

Breast abscess.

ABC of the First Year

characteristic pneumatocoeles, which are air filled spaces.

Complications are pneumothorax and empyema.

In osteomyelitis there are often no specific signs, just an ill

infant who will not feed. Reluctance to move a limb and crying

when the limb is moved or touched are valuable localising

signs, but swelling at the site of the lesion is a late sign. A

radioisotope scan may show changes at an early stage

of neonatal osteomyelitis and later a radiograph of the limb

may show a soft tissue swelling or a raised and thickened

periosteum. Rarely, osteomyelitis in the newborn is not due to

Staph. aureus.

Gonococcal infection

Gonococcal conjunctivitis may be unilateral, usually does not

Figure 9.7

Osteomyelitis.

respond completely to local neomycin, and is often present

within 48 hours of birth. In cases of severe conjunctivitis,

particularly when bilateral and associated with severe oedema,

gonococcal infection should be suspected and special

arrangements for taking swabs must be made with the

laboratory. If the conjunctivitis does not respond rapidly to

treatment, swabs should be taken again for gonococcal

infection. The paediatrician should be told as soon as the

laboratory confirms the diagnosis in view of the medical and

legal implications. Urethral, cervical, and rectal swabs should

be taken from the mother.

If gonococcal infection is suspected, even if smears do not

confirm it, intravenous penicillin is given and the diagnosis is

reconsidered when the results of the cultures are available. In

addition, chloramphenicol eyedrops are given half hourly for

the first six hours and then chloramphenicol ointment is

applied two hourly for three days.

Figure 9.8

Gonococcal ophthalmitis.

Candida infections (fungal)

Candida infections are encouraged by the use of broad

spectrum antibiotics. Candida infection of the mouth produces

white plaques (thrush) and may make the infant reluctant to

feed. It also causes a fiery red scaly eruption of the perineum,

usually secondary to ammoniacal dermatitis. A swab made

damp with sterile sodium chloride solution should be used to

obtain a specimen for laboratory confirmation of the cause of

the perineal rash. Oral nystatin suspension should be given

after feeds for at least a week for the oral lesions. Nystatin

ointment should be applied to the perineal rash each time the

napkin is changed until the rash has resolved for a week.

Miconazole oral gel and miconazole ointment may be used if

nystatin suspension is not effective.

Figure 9.9

Candia infection.

Management and treatment

Careful evaluation of the features noted above may enable a

tentative diagnosis to be made and to be confirmed by a single

investigation. In many infants, however, there are no specific

signs and the following investigations should be carried out.

Urine microscopy and culture - Specimens must be collected

carefully and examined promptly to produce reliable results. A

fresh midstream clean catch specimen can often be obtained

after gentle suprapubic stimulation, especially in boys. If the

urine specimen contains more than 10

10⁶ pus cells per litre

or bacteria are seen in a fresh specimen, a further urine

specimen is obtained by suprapubic bladder puncture. Bacteria

cultured from this specimen confirm a urinary tract infection.

Figure 9.10 Suprapubic puncture for urine collection.

Infection in the newborn

Ultrasound renal scan should be performed in all infants

with a confirmed urinary tract infection before discharge from

the unit. Arrangements are made for the infant to be

reassessed at regular intervals in the outpatient clinic and

further investigations may be needed later. Inadequately

treated neonatal urinary infections may cause permanent renal

scars and later renal failure.

Other investigations that may need to be performed are

(a) culture of gastric aspirate, ear swab, and umbilical swab;

(b) chest radiograph; (c) blood culture from a peripheral

vein, avoiding the femoral vein; and (d) lumbar puncture.

After the age of two days a blood neutrophil polymorph

count higher than 10

10⁹/1 suggests infection. A very low

neutrophil polymorph count also suggests overwhelming

infection.

As infants may deteriorate rapidly, treatment is started

immediately for the most likely organisms involved if the child

is ill. If the infant appears ill, antibiotics suitable for

septicaemia should be given intravenously or intramuscularly

after all the specimens have been taken. If the diagnosis is

uncertain after physical examination, investigation of the

urine, chest radiograph, and examination of the cerebrospinal

fluid (CSF), and the infant appears well, it is better to withhold

antibiotics until a paediatrician has been consulted.

Suitable antibiotics are intramuscular or intravenous

flucloxacillin for staphylococcal infections; intravenous

penicillin for group B streptococcal infections; and intravenous

gentamicin for E. coli septicaemia. Intravenous cefotaxime or

ceftriaxone is suitable for E. coli meningitis.

Figure 9.11

Hydronephrosis.

To treat urinary tract infection intravenous or

intramuscular gentamicin and ampicillin should be given.

Once the sensitivities are established it may be possible to

continue treatment with one drug such as trimethoprim. In

any case gentamicin should not be given for longer than a

week, as eighth nerve damage may occur. Every infant who has

had a confirmed urinary tract infection should have a repeat

Box 9.3 Antibiotics for specific infections

examination of the urine for the presence of infection every

three months for two years.

Staphylococcus Flucloxacillin

Gentamicin is an effective antibiotic but it can cause

Streptococcus

Benzylpenicillin(IV)

deafness and blood levels must be monitored. The serum

E. coli:

concentrations of gentamicin should be between 5 and

Septicaemia

Gentamicin

10 mg/1 one hour after the previous dose. The trough blood

Meningitis

Cefotaxime

level, taken just before the next dose is due, should be less

than 2 mg/1.

Paediatric HIV

Perinatal transmission of HIV from an infected mother to her

Box 9.4 Clinical features of HIV

infant can now be reduced to

5% by preventive measures

taken during pregnancy and the perinatal period. It is

• Recurrent thrush

recommended that all mothers should be encouraged to have

• Generalised lymphadenopathy

• Parotitis

an HIV screening test as part of their routine antenatal

• Failure to thrive

screening. It is now known that infants are most at risk of

• Pneumocystis pneumonia

becoming infected with HIV during vaginal delivery, when they

• Developmental delay

swallow maternal secretions containing the virus, and later

during breastfeeding. The administration of anti-retroviral

therapy (ART) to the mother during pregnancy is not harmful

to the fetus and, together with elective caesarean section,

avoidance of breastfeeding, and the administration of AZT

(zidovudine) to the infant, has been shown to reduce the rate

of vertical transmission from l5-30% to

5 % in countries

where these measures are safe and affordable. The risk of

transmission is related to maternal viral load in the third

trimester and if this is undetectable in mothers who are on

ART, caesarean section may not confer any additional

ABC of the First Year

advantage. Although breastfeeding doubles the rate of vertical

transmission, in developing countries it may still be the

preferred method of infant feeding because of greater health

risks associated with formula feeding.

All infants born to HIV positive mothers will also test HIV

antibody positive for at least the first 12-18 months of life, even

those who are uninfected, because of the passage of maternal

IgG across the placenta to the baby. Uninfected infants can

usually be identified by showing absence of the virus on at least

2-3 tests by PCR (polymerase chain reaction) in the first four

months of life. Until the results of the PCR tests are known, the

infant will be given oral co-trimoxazole (daily or at least three

times a week) from one month of age, in order to prevent

infection with PCP (Pneumocystis carinii), which can cause a

severe life threatening pneumonia in infected infants. Routine

immunisation with the triple, Hib, and meningococcal vaccines

should be given at the usual age. Some paediatricians

recommend IM polio instead of oral polio vaccine for the

infant, in order to avoid the small risk of

immunocompromised adults in the family developing

poliomyelitis. BCG vaccination is usually delayed until the

infant is confirmed to be uninfected with HIV.

Infants infected with HIV may remain asymptomatic for

10-12 years after birth but around 20% will develop serious

problems in the first year of life. Recurrent thrush, skin rashes,

lymphadenopathy, hepatosplenomegaly, failure to thrive,

developmental delay, and severe respiratory tract infections are

common symptoms in HIV positive infants. ART is only

necessary when the infant is shown to have a high viral load

and a low number of CD4 lymphocytes. The survival of

infected children has been greatly improved by early diagnosis

Figure 9.12

Cervical lymphadenopathy due to HIV infection.

and treatment but there is no definitive cure for HIV infected

individuals as yet.

Families with HIV, even those where the children are not

infected, benefit from support and help from sympathetic, well

informed health care professionals.

Common napkin rashes

Napkin rashes are usually due to ammoniacal dermatitis,

seborrhoeic dermatitis, or perianal excoriation.

Ammoniacal dermatitis is caused by ammonia produced by

faecal bacterial enzymes acting on urea in the urine. Erythema,

papules, scaling, and erosions appear in areas that have been

in contact with napkins soaked with urine. The depths of the

skinfolds are spared and the prepuce and scrotum are

especially vulnerable. The principle of treatment is to keep

Figure 9.13

Ammoniacal dermatitis.

urine and faeces away from the skin. Initial treatment includes

changing napkins frequently or leaving the child without a

napkin. A zinc cream is applied to the affected area every time

the napkin is changed; in resistant cases a silicone cream is

used. Some authorities consider that the formation of

ammonia does not play a major part in this condition and they

prefer the term “irritant napkin dermatitis”.

If the rash does not improve within 10 days Candida

infection of the lesions should be considered. This rash has a

fiery red appearance with a scaly edge, often with a few early

papules separated from the main eruption. Nystatin cream

should be applied to the rash each time the napkin is changed

for at least a week. The infant’s mouth should be examined to

determine whether white plaques of Candida are present and

an oral suspension of nystatin is needed. Alternatively,

miconazole oral gel may be used. In breastfed infants the

mother’s nipples should be examined, as a scaling dermatitis of

the nipples can be due to Candida and may reinfect the infant.

Figure 9.14

Seborrhoeic dermatitis.

Infection in the newborn

Any infant with a rash in the napkin area should be

undressed completely to ensure that he or she does not have a

rash elsewhere. In seborrhoeic dermatitis the erythema and

scaling may also affect the axillae, neck, the area behind the

ears, scalp, forehead, and eyelids. The scalp may be covered

with adherent hard crusted plaques (cradle cap). Secondary

infection by staphylococci, streptococci, or Candida is

common. The condition always begins before the age of three

months and clears completely without treatment by nine

months. In contrast to the infant with ammoniacal dermatitis,

the infant with seborrhoeic dermatitis is oblivious of the rash.

The cause is unknown and there is usually no family history of

dermatitis. Treatment with 1% hydrocortisone ointment is

rapidly effective and the lesions usually clear completely within

a few weeks. In severe cases nystatin or an antibacterial agent

may be added to the cream. Cradle cap can be removed by

Figure 9.15 Perianal excoriation.

shampoo containing 0 5% salicylic acid.

If the rash affects mainly the perianal area, it is probably

due to persistently loose stools. Perianal excoriation is commonly

found in infants with gastroenteritis and resolves when the

diarrhoea stops. Zinc cream or exposure may hasten the

resolution of the lesions, but changes in the stool pH and

consistency are the most important factors.

Jaundice in the newborn

Jaundice is a yellow colour of the skin caused by a high

concentration of bilirubin. Very severe jaundice may damage

the cells of the basal ganglia and brainstem. This damage is

Red blood cells

produced by the fat soluble unconjugated bilirubin. If jaundice

is severe, high bilirubin levels may result in deafness, cerebral

palsy, or death.

Neonatal jaundice is due to an increased bilirubin load

with a transient inefficiency of hepatic excretion resulting from

decreased activity of glucuronyl transferase in the liver. There

are additional factors. Some of the conjugated bilirubin

excreted in the bile is normally deconjugated in the small

intestine and reabsorption is enhanced by the slower gut

transit in the newborn who takes small volumes of milk.

Breakdown

Bilirubin is absorbed from meconium and there is no intestinal

flora to degrade bilirubin to urobilinogen.

Jaundice in the skin is visible to the naked eye in white

babies at a serum bilirubin level of about 80

mol/l. In black

babies the sclerae should be examined as jaundice is more

difficult to recognise. Jaundice first appears in the face and

spreads to the periphery of the limbs (Figure 10.3). The level

Liver

Unconjugated bilirubin

is more than 270

mol/l if the hands or feet are jaundiced.

Common causes of jaundice in

Conjugated bilirubin

the newborn

Common causes of jaundice include hepatic immaturity, red

Bile

cell incompatibility, infection, and breastfeeding.

Jaundice due to hepatic immaturity, or “physiological”

jaundice, is common both in preterm and in full term babies.

A temporary deficiency of glucuronyl transferase enzymes

Figure 10.1

Formation and excretion of bilirubin.

reduces the rate of conjugation of bilirubin, with a consequent

retention of unconjugated bilirubin. In full term infants the

jaundice always appears after the first 24 hours of life and

reaches a peak on the fourth or fifth day. In preterm infants it

usually begins 48 hours after birth and may last up to two

Box 10.1 Causes of jaundice

weeks.

Cause

Onset

In babies with red cell incompatibility jaundice appears

within 24 hours of birth. The main causes are: (a)

Red cell incompatibility

Within 24 hours of birth

incompatible rhesus grouping, and (b) incompatible ABO

Physiological jaundice

After 24 hours

grouping; the mother’s blood is usually group O and the

Septicaemia

Usually after fourth day

infant’s group A or, less commonly, group B.

The common infective causes of jaundice are septicaemia

and urinary tract infection. Septicaemia is especially likely to

be present if the jaundice appears after the fourth day of life,

but it is a possibility in any infant who seems ill. In urinary

tract infections the jaundice is of hepatic origin.

In about 2.5% of infants who are breastfed the serum

bilirubin rises to levels between 260 and 360

mol/l in the

second or third week of life. These infants have no symptoms.

If breastfeeding continues the level remains constant for three

or four weeks and falls to normal levels at 4-16 weeks. An

abnormal progesterone has been shown in the milk of some of

the mothers.

Rare causes of jaundice in the newborn

Rare causes of jaundice include hypothyroidism,

galactosaemia, viral hepatitis, and atresia of the bile ducts.

These cause prolonged jaundice lasting more than 10 days.

Figure 10.2 Breast feeding.

Jaundice in the newborn

Glucose-6-phosphate dehydrogenase deficiency is another

cause of prolonged jaundice, but it can also produce a clinical

100

picture similar to blood group incompatibility.

In hypothyroidism physiological jaundice is prolonged, the

plasma thyroxine (T4) concentration is reduced, and the

thyroid stimulating hormone (TSH) concentration is

increased.

In infants with viral hepatitis, which is usually due to

150

intrauterine infection, the stools are pale, the urine dark owing

to bile, and there is a high level of conjugated bilirubin in the

plasma.

250

It is difficult to differentiate between hepatitis and atresia

of the bile ducts clinically, and they may represent the two ends

of a range of disease. If jaundice persists more than 10 days,

200

the advice of a paediatrician should be sought.

> 270

In galactosaemia the urine gives a positive result on testing

for reducing substances, but the test for glucose may be

negative. The infant needs to be referred to a paediatrician

immediately for special investigations.

Glucose-6-phosphate dehydrogenase deficiency occurs in

250

infants of Mediterranean, African, or Chinese stock. This

hereditary red cell enzyme defect is found in babies with

> 270

haemolytic episodes that often occur without the usual

precipitating factors of drugs or infection. The enzyme is

necessary for maintaining the stability of the red cell

Figure 10.3 Spread of jaundice in the skin.

membrane.

Box 10.2 Rare causes of jaundice

• Hypothyroidism

Management of jaundice starting in

• Galactosaemia

• Viral hepatitis

the first 24 hours

• Atresia of bile ducts

• Glucose-6-phosphate dehydrogenase deficiency

If jaundice appears within 24 hours of birth it must be

considered to be due to blood group incompatibility, with a

high risk of cerebral palsy, until proved otherwise. Most rhesus

problems should be anticipated before the neonatal period.

Rhesus

negative

Urgent exchange transfusion may be indicated in infants

severely affected by haemolytic disease of the newborn, and it

is advisable for the infant to be admitted to hospital

immediately for investigation. If the mother is rhesus negative,

the infant rhesus positive, and the Coombs test positive,

Rhesus

jaundice is due to rhesus incompatibility. The plasma bilirubin

positive

concentration should be measured every five to eight hours

and the results plotted on a special chart (see p. 44). Once the

second estimation has been performed the maximum

concentration can be predicted, as the rate of increase is

linear. When the serial concentrations fall below the printed

line, the infant is unlikely to need any treatment.

Management of jaundice starting after

Coombs test positive

the first 24 hours

The possibility of septicaemia or urinary tract infection

Figure 10.4 Rhesus incompatibility.

should be considered in any ill baby who develops jaundice

after the first 24 hours of life. If there is any doubt about

Box 10.3 Onset after 24 hours but serum bilirubin

when the jaundice first appeared, the possibility of blood

300

mol/l

group incompatibility should be investigated.

When a doctor visits the infant at home a guide to the

• Serum bilirubin - conjugated and unconjugated

plasma bilirubin concentration can be provided by the

• Full blood count and white count differential

dermal icterometer. This is a piece of transparent perspex

• Blood group

with yellow lines of various shades that correspond to plasma

• Coombs test

• Blood culture

bilirubin concentrations. It should be compressed gently on

• Urine culture (for asymptomatic infection)

the infant’s nose to indicate the approximate plasma bilirubin

• Glucose-6-phosphate dehydrogenase levels in the

concentrations. The dermal icterometer is not accurate in

appropriate racial groups

artificial light, when bilirubin values are rising rapidly, or

ABC of the First Year

Age (days)

500

Consider exchange transfusion term

450

400

Consider

Phototherapy term

exchange

350

transfusion

preterm

300

Phototherapy preterm

250

Figure 10.5 Dermal icterometer

200

150

when phototherapy has been given. In infants with pigmented

skin the dermal icterometer should be compressed against

100

the gums, not the nose.

In full term infants if the dermal icterometer suggests that

the plasma bilirubin concentration is about 250

mol/l or the

result lies above the line on the chart the infant should be

tranferred to hospital immediately. If the plasma bilirubin level

120

144

168

is very high, urgent exchange transfusion or phototherapy may

Age (hours)

be needed.

In neonatal units there is usually a ward bilirubinometer

that measures plasma bilirubin concentrations within a few

Bilirubin chart

400 mol/l

23.4 mg/100 ml

100 mol/l

5.8 mg/100 ml

minutes, using a small specimen of blood obtained by heel

300 mol/l

17.5 mg/100 ml

17.1 mol/l

1.0 mg/100 ml

prick. If two estimations fall below the line on the chart,

200 mol/l

11.7 mg/100 ml

treatment will probably not be needed. Those with values

Figure 10.6

Indications for phototherapy and exchange transfusion.

above the line may need exposure to light under a

phototherapy unit. Phototherapy produces geometric

stereoisomers of bilirubin, which have no known long term

deleterious effect on the infant. The infant’s eyes are shielded

with eye pads, but the mother should have the procedure

explained first. Although phototherapy units have a shield to

reduce transfer of heat from the lamp to the infant,

monitoring of the temperature of the infant is essential. Extra

fluids may be needed to compensate for the additional

evaporative loss and this can be given as plain water to

breastfed infants or additional milk to bottlefed babies. Oral

fluid decreases the gut transit time and improves the excretion

of bilirubin and the associated compounds. The indications for

phototherapy are controversial but many units give

phototherapy if the plasma bilirubin level is above the line on

the chart. Despite phototherapy, an exchange transfusion may

still be needed, but the critical level varies with the unit and

the gestational age of the infant. Exchange transfusion

should be considered if the plasma bilirubin level exceeds

450

mol/l in a full term infant and 300

mol/l in a preterm

infant. Some units start treatment at lower levels of bilirubin in

sick infants.

Figure 10.7

Phototherapy.

Prolonged jaundice

If jaundice persists longer than 14 days in a full term infant,

blood should be taken for plasma thyroxine and TSH

estimations and a specimen of urine collected to measure

reducing substances and glucose. The urine should be

examined in the laboratory for the presence of infection. If the

parents are of Mediterranean, African, or Chinese origin, the

screening test for red cell glucose-6-phosphate dehydrogenase

should also be performed.

Jaundice in the newborn

Pale stools and a plasma conjugated bilirubin level greater

Box 10.4 Prolonged jaundice

14 days

than 30

mol/l suggest the possibility of hepatitis or atresia of

the bile ducts, and the advice of a paediatrician is needed.

• Serum bilirubin - conjugated and unconjugated

• Full blood count

If there is a suspicion that the jaundice is related to

• Thyroid function tests

breastfeeding, the other conditions causing jaundice should be

• Liver enzymes

excluded and the mother advised to continue breastfeeding. If

• Glucose-6-phosphate dehydrogenase if appropriate

the plasma bilirubin concentration is rising rapidly and

• Urine culture

breastfeeding is stopped for 48 hours, the infant’s plasma

• Urine for reducing substances (for galactosaemia)

bilirubin concentration will fall abruptly and will not usually

• Urine for presence of bilirubin which reflects a high

rise on return to breastfeeding. Although the mother can

conjugated bilirubin (on a Labstix).

continue lactation by expressing her milk during this

diagnostic test there is a risk that breastfeeding will not be

resumed.

Convulsions in the newborn

Although the involuntary movements of a convulsion are

usually generalised, they may affect only one limb, the face, or

tongue. The distinctive feature is repetitive jerky movements,

which may be accompanied by loss of consciousness, apnoea,

or rigidity. Often the convulsion has stopped by the time the

baby is seen by a doctor. A brisk Moro reflex or jerky normal

movements in a baby may be misinterpreted as a convulsion by

an inexperienced observer. If the convulsion is not seen,

apnoea or cyanosis may indicate that it has occurred, and if

there is any doubt it is safer to investigate the baby on the

assumption that there has been a convulsion.

Management

A baby not already in hospital should be admitted. After

hypoglycaemia has been excluded by a blood glucose

Figure 11.1 Repetitive similar movements indicate a convulsion.

estimation, an anticonvulsant should be given if the convulsion

is continuing or recurs while waiting for the results of other

investigations. The order of carrying out the various

procedures is important. Hypoglycaemia and hypocalcaemia

Box 11.1

should each be sought for and excluded in that order before

Exclude:

the next test. Hypoglycaemia is the more dangerous condition.

hypoglycaemia

The infant is placed on his side and the airway cleared by

2 hypocalcaemia

suction of the pharynx under direct vision. The baby should be

nursed in an incubator to improve observation. Oxygen is

given in high concentration with a funnel or head box until

the convulsion has stopped.

If the plasma glucose and calcium concentrations are

normal, a paediatrician should decide whether a lumbar

puncture is indicated.

Hypoglycaemia

A specimen of blood should be taken from a heel prick

immediately for glucose measurement in a glucometer. If the

value is less than 3.0 mmol/l, hypoglycaemia may be present.

A further blood sample should be taken and part of it used to

repeat the glucometer test and the remainder taken into a

fluoride tube for the laboratory to check the blood glucose

concentration. Hypoglycaemia is defined as a laboratory

estimated blood glucose level less than 2.6 mmol/l. If the

Figure 11.2

Glucometer.

second glucometer value is low, 5 ml of 10% glucose solution

per kg body weight should immediately be given intravenously

slowly by a scalp or limb vein. A continuous intravenous

infusion of 10% glucose solution is then set up at a rate of

60 ml/kg a day.

Hypoglycaemia accompanied by fits is treated with

intravenous glucose and when the fits have ceased, continuous

intragastric milk should be given.

The amount of intravenous glucose should be reduced

gradually over at least 24 hours. During this period three

hourly glucometer tests are carried out, supplemented by

regular laboratory blood glucose measurements. If an

intravenous infusion of glucose is stopped suddenly by

accident, severe reactive hypoglycaemia may follow and cause

severe convulsions.

In contrast, asymptomatic hypoglycaemia has a good

prognosis. Intragastric milk should be given by continuous

infusion but the milk volume should be increased by 25% to

raise the blood glucose concentration. Oral or intravenous

Figure 11.3

Syringe pump for milk.

Convulsions in the newborn

glucose should be prescribed only on the advice of a senior

member of the unit. The blood glucose level is repeated an

hour after starting the milk.

Calcium estimation

Hypocalcaemia

If the glucometer test result is normal, blood should be taken

for emergency plasma calcium estimation. If convulsions are

still occurring or recur after hypoglycaemia has been excluded

by the glucometer intramuscular paraldehyde should be given

while the results of detailed tests are awaited. If the plasma

calcium concentration is lower than 1.8 mmol/l (7 mg/100 ml)

treatment depends on whether the convulsions are still

occurring or recurring. If the convulsions have stopped, 1-2 ml

Calcium

of 10% calcium gluconate is added to each feed. The calcium

gluconate

gluconate should be added to the feed and not given directly

to the infant. The total dose of calcium gluconate in 24 hours

should not exceed 12 ml of the 10% solution in the full term

infant.

If the convulsions continue and the plasma calcium

concentration is low, 10% calcium gluconate should be diluted

Figure 11.4

Calcium supplements.

to 2.5% with 5% glucose solution in a syringe and given slowly

intravenously into a scalp or limb vein until the convulsions

cease or until a maximum of 4 ml/kg body weight of the

2.5% diluted solution has been given. The heart rate is

monitored with a cardiac monitor or stethoscope during the

Plasma glucose normal

procedure and the injection stopped if bradycardia occurs.

Calcium gluconate should be added to the feeds until the

Estimate plasma calcium and magnesium levels

plasma calcium concentration rises to normal. Calcium

Low

Normal

gluconate must never be given intramuscularly or allowed to

escape out of a vein as severe tissue necrosis may occur.

Intravenous calcium may not control hypocalcaemic

Convulsions continuing

Convulsions stopped

convulsions immediately. Some authorities have found that

hypocalcaemic convulsions are treated effectively by

IV calcium

IV magnesium

Oral calcium

intramuscular magnesium sulphate (0.2 ml/kg of a

10% solution/dose).

Plasma calcium has not risen

IM magnesium

Hypomagnesaemia

Figure 11.5 Biochemical investigation of a convulsion.

In some units there is a high incidence of fits associated with

low plasma magnesium concentrations. If there are recurrent

fits or the plasma calcium concentration does not rise despite

supplementary calcium gluconate, the plasma magnesium

concentration should be estimated. If this is less than

Box 11.2 Prognosis

0.6 mmol/l (1.5 mg/100 ml) intramuscular magnesium

• Symptomatic hypoglycaemia: cautious prognosis

sulphate is given. The dose is 0.2 ml/kg of a 10% solution

• Symptomatic hypocalcaemia: good prognosis

given intramuscularly every six hours; if the plasma level is

normal no further treatment is needed. The plasma estimation

must be repeated after two days. The main toxic effect is

hypotonia, which can be reversed by intravenous calcium

gluconate if the features are severe.

Prognosis

Hypoglycaemia and hypocalcaemia may be found together,

especially in infants of diabetic mothers, but hypoglycaemia is

the more dangerous. Symptomatic hypoglycaemia may be

followed by mental impairment but symptomatic

hypocalcaemia or hypomagnesaemia has an excellent

prognosis, although enamel hypoplasia, which predisposes to

dental caries, is a late complication of hypocalcaemia.

Intravenous glucose is not hazardous provided that the correct

dose is given, but intravenous calcium salts may lead

to cardiac arrest.

ABC of the First Year

Cerebral lesions

Box 11.3 Cerebral causes of a convulsion

• Meningitis

After hypoglycaemia and hypocalcaemia have been excluded,

• Cerebral oedema

meningitis, intracranial haemorrhage, and cerebral oedema

• Intracranial haemorrhage

due to perinatal asphyxia should be considered. Lethargy,

hypotonia, and raised tension of the anterior fontanelle are

suggestive of a cerebral lesion but meningitis may be present

with no specific symptoms or signs. Lumbar puncture is

indicated if there is a possibility of meningitis. Ultrasound

examination is reliable in excluding an intraventricular or

intracerebral haemorrhage but may not detect a small

subarachnoid or subdural haemorrhage.

If the first convulsion is prolonged or the convulsion

recurs, intravenous phenytoin or phenobarbitone should be

given. The initial dose of phenytoin or phenobarbitone is

15 mg/kg given intravenously over half an hour. The

maintenance dose is started 24 hours later and is usually

required for only two or three days.

Vomiting

Vomiting in the newborn: types of vomit

Vomiting is the forceful expulsion of gastric contents through

Oesophagus

the mouth. Mothers often confuse vomiting with mild

regurgitation, which is the effortless bringing up of small

Trachea

amounts of milk during and between feeds, usually

accompanied by air. If the milk dribbles down the chest it is

likely to be regurgitation. Babies often bring up small amounts

of milk with air and this is of no importance. Recurrent

vomiting may be a sign of lethal disease, but a careful history

and examination enable a diagnosis to be made with the

minimum of special investigations.

Frothy mucoid vomit

Oesophageal atresia with tracheo-oesophageal fistula may

present with vomiting, coughing, and cyanosis when the infant

begins the first feed. Many of these infants drool frothy

material continuously rather than vomit. Vomiting of frothy

mucoid material may be the only definite observation, but the

condition should be suspected in any baby who

Figure 12.1

Oesophageal atresia.

has any symptoms during the first feed. As the fluid

expelled is not gastric contents, vomiting is not an accurate

description but this is the term often used.

Bilestained vomit

The vomit in infants with intestinal obstruction is usually

yellow, due to bile staining, but occasionally it consists only of

milk. The cause may be atresia, stenosis, or volvulus of the

small gut, necrotising enterocolitis, or congenital intestinal

aganglionosis (Hirschsprung’s disease) of the large gut.

Abdominal distension is usually present and there may be

visible peristalsis. A plain radiograph should be taken in the

erect position immediately. An alternative is a radiograph in

the supine position and, in addition a lateral view with the

baby lying on his or her back and a horizontal X-ray beam.

They often show fluid levels, dilated loops of gut proximal to

the obstruction, and the absence of gas shadows distally.

Ideally, every infant who vomits bile should be seen by a

Figure 12.2

Erect lateral (left) and anteroposterior (right) radiographs

surgeon within an hour.

to show fluid levels.

Bloodstained vomit

Bloodstained vomit may be caused by trauma from a feeding

tube, swallowed maternal blood, or, most seriously,

haemorrhagic disease of the newborn. Trauma caused by a

feeding tube may produce a few specks of blood in the vomit.

Maternal blood may be swallowed before delivery after

premature separation of the placenta or after delivery as the

result of bleeding from a cracked nipple. Maternal

haemoglobin in the vomit can be recognised in the laboratory.

Haemorrhagic disease of the newborn begins between the

Vitamin K₁

second and fourth days of life in the early type or in the third

or fourth week in the late type. The first symptom may be

haematemesis or melaena and the bleeding can be profuse.

An immediate dose of 1 mg vitamin K₁ should be given

intramuscularly and a transfusion of fresh blood given urgently

if bleeding has been severe or persists after vitamin K

treatment.

Figure 12.3 Treatment of haemorrhagic disease of the newborn.

ABC of the First Year

Milk

Vomiting of milk may be caused by infections, feeding problems,

necrotising enterocolitis, intracranial haemorrhage, or drugs.

Gastroenteritis, urinary tract infection, septicaemia, and

meningitis may all be associated with vomiting. A ravenous

infant may swallow excessive air at the beginning of the feed

and, if not properly “winded”, may later regurgitate milk with

air. Larger feeds, more frequent feeds, or a larger hole in the

teat is needed.

Necrotising enterocolitis occurs in epidemics in neonatal

baby units. Lethargy and refusal of feeds are followed by

vomiting and abdominal distension. In the majority of the

infants there is blood in the stool. Predisposing factors are

prematurity, perinatal hypoxia, hypotension, umbilical vessel

catheterisation, and prolonged rupture of the membranes.

Embolism or thrombosis of mesenteric vessels is followed by

ischaemic changes, which vary from mucosal ulceration to

complete necrosis of the gut wall. Bacteria invade the necrotic

tissue and healing is followed by scarring and sometimes a

stricture. Despite optimal treatment there is a 25% mortality

rate and early advice from a paediatric surgeon is advisable.

Figure 12.4 Drops of milk should follow quickly and there should not

Raised intracranial pressure due to intracranial

be a continuous stream.

haemorrhage may cause vomiting of milk, as may several

drugs, especially digoxin.

Vomiting from the first week to the first

year: causes

As in the newborn, vomiting in infants older than one week

may be a symptom of a feeding problem or an infection such

as urinary tract infection, otitis media, gastroenteritis,

septicaemia, or meningitis (see p. 90).

Box 12.1 Vomiting after the first week

If no cause of the vomiting is found and the symptoms are

•

Feeding problems

mild, urine should be collected for microscopy and culture

•

Infections:

and should be examined for protein, bile, and reducing

- Urinary tract infection

substances.

- Septicaemia

- Meningitis

Pyloric stenosis

Pyloric stenosis must be considered in every infant less than

three months of age who vomits. Rarely the vomiting may

occur in the first week of life, but it usually begins in the

second or third week, though there may be a delay before the

infant is seen by a doctor. Usually the vomit is produced

forcefully and reaches some distance from the infant. The

infant often accepts another feed immediately after vomiting.

Stools are infrequent. If the symptoms have been present for

more than a few days, there will be a loss of weight due to

dehydration and loss of subcutaneous fat. Scanty urine is

associated with dehydration.

The essential diagnostic sign is the presence of a pyloric

mass palpated during a test feed. Constant practice is needed

to appreciate a pyloric mass. Even if no pyloric mass is felt

during the first test feed, if the diagnosis of pyloric stenosis is

probable the infant should be admitted for rehydration and

the examination repeated. Preliminary aspiration and

measurement of gastric contents is helpful, particularly if no

feed has been given during the preceding four hours.

Metabolic alkalosis strongly suggests the diagnosis.

In a small proportion of infants the diagnosis of pyloric

stenosis is suspected clinically but no pyloric mass is palpable

during a test feed. The diagnosis may be confirmed, preferably

by an ultrasound study. A barium study is needed rarely.

Figure 12.5 Pyloric stenosis.

Vomiting

Intestinal obstruction

Infants who vomit greenish yellow bile are likely to have

intestinal obstruction. They should be admitted immediately

and seen by a surgeon within an hour. Abdominal distension is

often present and peristalsis may be visible. Duodenal stenosis

usually presents during the first few days of life but malrotation

of the gut with associated volvulus may produce symptoms at

any time during childhood.

An inguinal hernia is more likely to incarcerate in the early

months of life than later. Incarceration should be suspected if

the hernia is tender or is not reduced easily; immediate

surgery is required. The risk of obstruction is always present

and early surgical treatment is advisable in every baby with an

inguinal hernia. The baby must remain in the ward until the

operation is performed.

Figure 12.6

Inguinal hernia.

An intussusception is a partial or complete intestinal

obstruction due to invagination of a portion of the gut into a

more distal portion. It may occur at any age, although the

maximum incidence is at 3-11 months. An intussusception

may be easily diagnosed in a child who has all the typical

features, but these children are not common. The distinctive

feature is the periodicity of the attacks, which may consist of

severe screaming, drawing up of the legs, and severe pallor.

Some episodes consist of pallor alone. The attack lasts a few

minutes and may recur about 20 minutes later, though attacks

may be more frequent. There may be vomiting and one or two

loose stools may be passed initially, suggesting acute

gastroenteritis. Bloodstained mucus may be passed rectally or

shown by rectal examination. But some patients pass no blood

rectally. Between attacks the infant appears normal and may

have no abnormal signs apart from a palpable mass.

It is difficult to examine the abdomen during an attack

because the child cries continuously, but between attacks a

mass, most commonly over the right upper quadrant, can be

felt in 70% of children.

Area of

If surgical shock is present, then rapid resuscitation should

compression

be carried out and intravenous fluids, including blood, given.

of blood

Plain radiograph of the abdomen may show evidence of

vessels

intestinal obstruction or a density in the area of the lesion.

Ultrasound may show a doughnut configuration with

hypoechogenic rims and a dense central echogenic core. An

urgent surgical opinion should be obtained. If the symptoms

have been present for less than 48 hours and there are no

signs of intestinal perforation, an air or barium enema should

be given urgently while the surgeon remains nearby. In over

75% of cases it is possible to reduce the intussusception by the

enema. If the intussusception is not reduced, then immediate

Figure 12.7

Intussusception.

laparotomy is needed to reduce the lesion manually or to

perform an intestinal resection. In about 6% of cases there is a

persisting mechanical cause of the intussusception and this will

not be detected by the enema.

Gastro-oesophageal reflux

Vomiting due to gastro-oesophageal reflux starts during the

first week of life and the vomitus may be blood stained.

Aspiration into the lungs may cause recurrent bronchospasm

and severe vomiting may cause failure to thrive, dysphagia, or

stricture formation. During the first year the lower

Box 12.2 Features of gastrooesophageal reflux

oesophageal sphincter pressure increases and oesophageal

• Vomiting

mobility becomes more organised. These factors reduce the

• Aspiration

regurgitation of gastric contents into the oesophagus when the

• Failure to thrive

intra-abdominal pressure rises, for example during crying.

• Dysphagia

The diagnosis can be confirmed by 24 hour pH

• Stenosis (rare)

monitoring of the lower oesophagus. A probe the size of a

ABC of the First Year

nasogastric tube is placed just above the gastro-oesophageal

sphincter. The pH recording is analysed by computer. Barium

swallow examination is often negative despite typical

symptoms.

Vomiting usually resolves by the age of one year without

specific treatment. If symptoms are severe, the feeds can be

thickened with carob seed flour or ground rice and the infant

may be nursed with his head higher than his feet on his side. If

the vomiting is persistent and severe, a paediatrician should be

consulted. Most paediatricians recommend a trial period with

thickened feeds before a pH recording.

Catarrhal phase Paroxysmal phase

Convalescent phase

Whooping cough

Vomiting may be so severe in infants with whooping cough that

the mother is more worried by the vomiting than the cough.

Short dry Vomiting and whooping

During the first five days of the illness (catarrhal phase) there

is a short, dry nocturnal cough. Later, bouts of 10-20 short

cough

Bouts of 10-20 coughs

Coughing

coughs occur day and night. The cough is dry and each cough

at night

at day and night

is on the same high note or goes up in a musical scale. The

long attack of coughing is followed by a sharp indrawing of

breath, which causes the whoop. Some children with proved

pertussis infection never develop the whoop. Feeding often

Weeks

provokes a spasm of coughing and this may culminate in

vomiting. Afterwards there is a short refractory period during

Figure 12.8 Phases of whooping cough.

which the baby can be fed again without provoking more

coughing. In uncomplicated cases there are no abnormal signs

in the respiratory system.

Adrenogenital syndrome

The adrenogenital syndrome (salt losing type) commonly

presents with vomiting as the only symptom in boys. The

diagnosis is easier in girls, as virilisation of the external

genitalia will have been noticed at birth. Symptoms usually

begin between the seventh and tenth days and may be fatal

within a few days if extra salt and salt retaining

adrenocorticosteroids are not given. Intravenous fluids are

essential. The diagnosis is confirmed by raised plasma 17 OH-

progesterone concentrations, high plasma potassium, and low

plasma sodium concentrations. The plasma electrolyte

concentrations are normal at birth and pronounced changes

may occur suddenly.

Figure 12.9 Adrenogenital syndrome.

Diarrhoea

Diarrhoea is the passage of loose stools more often than would

be expected from the diet and age of the infant. It indicates a

change in bowel habit. A stool should be examined personally.

A rectal examination is often followed by a fresh stool, which

can be examined. When diarrhoea is severe, the stools may be

mistaken for urine. When this is a possibility, a urine bag

should be placed in position and the infant nursed on a sheet

of polyethylene.

The stools of newborn infants vary with their diet. The

normal stools of breastfed infants are never formed, may be

passed at hourly intervals, may contain mucus, and may be

green. When lactation becomes established between the third

and fifth days intestinal hurry is common, resulting in frequent

stools. Later the stools tend to become less frequent and more

pasty and by the age of three weeks they may be passed once

every two or three days. No treatment is needed. In contrast,

Figure 13.1

Stool of breastfed infant.

the normal stools of bottlefed infants are formed and do not

contain fluid or mucus. With certain cow’s milk preparations

the stools may be dark green, but this has no sinister meaning.

Acute gastroenteritis

Acute gastroenteritis is an acute infection mainly affecting the

small intestine that causes diarrhoea with or without vomiting.

The main danger is dehydration and electrolyte imbalance,

which may develop rapidly, but the infant may also be very

infectious for other infants in a ward or nursery. Gastroenteritis

is particularly dangerous to infants aged under two years.

The early signs of dehydration are often difficult to detect,

but recent weight loss is often a valuable indicator. Sunken

eyes, inelastic skin, and a dry tongue are late signs, but if the

infant has not passed urine for several hours severe

Figure 13.2

Changing stool (mixture of meconium and stool).

dehydration is probable. Clinical signs of dehydration are

particularly difficult to detect in fat toddlers.

The infant must be examined in detail to exclude any other

acute infection.

The rotavirus is the most common cause of gastroenteritis

Box 13.1

Dangers of acute gastroenteritis

in infants and children throughout the world. It affects every

• Dehydration

age group and infection easily spreads throughout a family,

• Electrolyte abnormalities

although the infected adults may have few or no symptoms.

• Cross infection

Several distinct episodes of diarrhoea can be due to the

rotavirus, as there are several serotypes. The incubation period

is 24-48 hours and a respiratory illness, including otitis media,

precedes the gastrointestinal symptoms in about half the

patients. Vomiting which lasts for one to three days is followed

by abnormal stools for about five days. Treatment is aimed at

keeping infants well hydrated until they recover spontaneously.

The frequency of the stools is reduced by dietary treatment, but

the abnormal consistency of the stools persists for up to a week.

If infants are given an antibiotic early in the illness (for

example, when acute otitis media is suspected as the primary

diagnosis) the subsequent diarrhoea may be attributed to the

antibiotic rather than to the rotavirus infection. Other drugs

(for example, iron) may be associated with diarrhoea.

Management

Figure 13.3 Rotavirus.

Clinical signs of severe dehydration or the loss of 5% or more

of body weight are definite indications for admission. If infants

relapse after treatment or social problems prevent them being

ABC of the First Year

treated at home they may need to be admitted. Infants who

vomit persistently usually need to be admitted, though mild

symptoms may be managed at home by giving small volumes of

liquid by mouth every hour.

In mild cases the main principle of management is to stop

cow’s milk and solids and give a glucose or sucrose solution

orally. After 24 hours fruit or vegetable purées may be

introduced and then other items from the child’s normal diet.

Sucrose

Cow’s milk and cow’s milk products are re-introduced

gradually after the first 24 hours of treatment. Vomiting may be

reduced by giving small volumes of fluid frequently. The child

200 ml

should be allowed to drink as much as he wants but needs at

least the volume shown in Table 13.1.

Rarely, a breastfed infant has gastroenteritis, but the

symptoms are usually mild. The appropriate volume of

rehydrating fluid is given by bottle or spoon before each

breastfeed.

Kaolin should not be prescribed as it deflects the mother’s

attention from the main treatment. No antibiotics should be

given to children with gastroenteritis treated at home.

The ideal oral rehydrating fluid is a glucose-electrolyte

mixture, but a 4% sucrose solution is easily available and safe.

Figure 13.4 Daily fluid intake requirement.

Single dose sachets of glucose-electrolyte powder (Dioralyte)

or glucose-sucrose-electrolyte powder (Rehydrat) are

available, which enable mothers to make up the mixture

accurately at home. A safe alternative is 4% sucrose solution,

Table 13.1 Fluid intake in relation to weight

which can be made up by the mother using two level

teaspoonfuls of granulated sucrose in 200 ml water. It is

Baby’s weight

Daily fluid intake

dangerous for mothers to add salt to this mixture.

fl.oz

In severe cases of dehydration or persistent vomiting oral

Under 4

Under 9

500

fluids must be replaced with intravenous fluids in infants

600

admitted to hospital. During the next day the fluid

750

requirement should be given as an oral glucose-electrolyte

900

mixture, alternating with full strength cow’s milk formula, and

1050

fruit and vegetable purées are introduced. Most children are

1200

discharged from hospital on normal diets within a few days of

1350

admission.

Over 10

Over 22

1500

Infants in hospital with diarrhoea must be barrier nursed in

a cubicle, which should ideally be in an annexe to the

children’s ward.

Investigations

Ideally a stool should be sent to the laboratory for detection of

Box 13.2 Investigations

pathogens, but this is not necessary for mild cases treated at

home. Only a small proportion of children have bacteria such as

• Stool culture

Campylobacter, Salmonella, Shigella, or pathogenic Escherichia

• ELISA rotavirus stool test

coli isolated from their stools. Cryptosporidium, a protozoon

• Urine microscopy and culture

which can be seen by light microscopy, is a common pathogen.

• Plasma sodium, potassium, and urea estimations

Most cases of gastroenteritis in children are caused by viruses,

usually rotavirus, and can be identified by an ELISA slide test.

Children needing intravenous fluids should have their

plasma electrolyte, bicarbonate, and urea concentrations

measured urgently.

Cryptosporidium

If two or more infants in a ward or nursery have diarrhoea

at the same time cross infection should be presumed, even if

Villus

their stool cultures show no pathogens. Stools from all the

infants on the ward should be sent for culture and tests for

rotavirus. Admissions to the ward may have to be stopped.

Progress

Feeder

organelle

The infant should be reviewed again by the doctor within

24 hours of starting treatment to ensure that the illness is

Figure 13.5 Cryptosporidium is intracellular, separated from rest of

resolving, the infant is not losing too much weight, and the

cytoplasm by a feeder organelle.

Diarrhoea

mother understands the management. Severe dehydration can

Box 13.3 Causes of relapse

occur within a few hours and it is helpful to have a specific

policy to ensure adequate follow-up visits.

• Failure to follow plan

• Temporary intolerance to cow’s milk protein

The main cause of relapse or persistent symptoms is failure

to follow a plan of treatment. Social problems may indicate the

need for admission to hospital. A few infants aged under two

years have temporary mucosal damage and are intolerant to

cow’s milk or other foods. This causes the diarrhoea to persist

for longer than two weeks and is considered on p. 69.

Gastroenteritis in developing countries

In developing countries the continuation of breastfeeding

during attacks of gastroenteritis may be essential for survival.

Although infants who are completely breastfed rarely have

severe gastroenteritis, weaning foods made up with water may

infect a breastfed infant. These infants can be managed by

continuing the breastfeeding and supplementing the fluid

intake to prevent dehydration until the infant spontaneously

recovers. Supplements may be given by mouth in mild cases

and intravenously in severe cases. An easier method is to give

them by continuous intragastric infusion, for which the fluid

does not have to be sterile.

Oral rehydrating fluids can be made up using specially

designed spoons to measure the sugar and salt. Mothers and

older siblings can be taught to use this mixture at the

beginning of an episode of diarrhoea rather than wait until the

child is dehydrated. Simple slogans such as “a cup of fluid for

every stool” are effective.

Figure 13.6 Spoons to measure sugar and salt for rehydration fluid.

14 Mother-infant attachment

There is no specific sensitive period immediately after delivery

that is the only time that emotional attachment can form. Any

important effects of separation do not persist beyond days or

weeks after reunion. Parents who have read obsolete

publications may need reassurance that early separation is not

followed by permanent damage to mother-infant relationships.

A comparison of preterm and term babies indicated that

parents find the behaviour of preterm babies less predictable

and more frustrating. Though frequent and sustained contact

with a sick or preterm baby may increase the degree of

parental anxiety, this anxiety induces a feeling of involvement

in the care of their baby.

A biological need

Figure 14.1

A newborn infant looking at mother.

Mothers and infants need a close attachment to give the infant

the degree of security necessary for optimal emotional and

physical development.

Most mothers have strong maternal feelings, which enable

them to achieve a firm bond of affection with their babies

without difficulty, even after an initial period of separation.

The strength of their maternal feelings probably depends on

the quality of mothering they received in infancy.

In contrast, a mother may be unable to achieve this

attachment without close contact with her baby and even then,

it may take a few days before the baby appears to her to be an

individual and her own. Failure to form a normal attachment

probably accounts for the higher incidence of “battered

babies” among preterm infants and among the infants of

mothers who were themselves deprived of maternal care.

Forming an attachment

Figure 14.2

Maternal feelings are related to the quality of the mother’s

own mothering.

Attachment occurs in five main ways. Firstly, infants can follow

the mother’s eyes immediately after birth and this eye to eye

contact is an important factor.

Secondly, a mother left with her naked infant touches each

part of the baby’s body with her fingertips.

Mother

Infant

Thirdly, during the first few days after delivery mothers

often appear to overprotect their infants and become

overanxious about crying and minor difficulties, such as those

of feeding.

Fourthly, even in the first days of life babies mimic the

Eye contact

facial expressions of others and can, for example, put out their

tongues at them, providing “feedback”.

Lastly, physical contact during breastfeeding and the

presence of the baby next to the mother throughout the entire

Touch

Crying

24 hours also promote attachment.

Breastfeeding

Separation

Breastfeeding

Separation is sometimes unavoidable if, for example, the infant

has to be transferred to another unit for surgery or the mother

is receiving heavy sedation for hypertension. The mother is

equally separated from her child when she is severely

depressed, but this may not appear so obvious.

Overprotectiveness

Mimicry

In the past many babies were separated from their mothers

for reasons that would not now be acceptable. Owing to

doctors’ anxiety, infants with jaundice were admitted to special

care units even though they needed no special care.

Figure 14.3 Factors in attachment.

Mother-infant attachment

The number of nursing staff available on individual maternity

wards will determine whether it is safe for babies to remain

with their mothers, but no infant should be separated from his

or her mother without good reason.

A postnatal ward should be staffed with midwives who have

special experience in nursing babies of low birthweight. This

allows babies needing tube feeding and other forms of special

care to remain with their mothers and avoids the separation

resulting from admission to the neonatal unit. The care of

healthy but low birthweight infants in the same environment as

their mothers is called transitional care to indicate that they

need more support than normal term infants.

Difficulty in forming attachments

Some aspects of the history may suggest that a mother may

have difficulty in forming an attachment to her infant and will

need special help from nursing and medical staff. Particularly

vulnerable are mothers who had poor maternal care in their

own childhood or who have had a request for an abortion

rejected or unmarried mothers who have not decided whether

they want the infant to be adopted. If a previous infant was

stillborn or died in the neonatal period or a close relative has

recently died, help may also be needed. Special attention

should be given to a mother under 17 or over 35 years of age

and having her first baby.

When the baby is born, the mother may refuse to handle or

Figure 14.4

Separation may be necessary for medical reasons.

feed him or her and be more concerned with her own minor

symptoms than the infant’s care. She may feel detached and

the infant’s problems may appear to her to be more serious

than they are. Similar symptoms may be the first indication of

a severe depression in the mother and she may need

psychiatric help.

Encouraging attachment

To encourage attachment the principle is to avoid unnecessary

separation. Unless infants require special nursing they should

be given to their mothers in the labour room, even if an

abnormality such as Down’s syndrome is present. Newborn

infants are able to feed moments after birth even if the mother

has received sedation and the mother should be encouraged to

put the baby to her breast if she intends to breastfeed. Infants

should remain with the mother throughout the 24 hours of the

day and be taken out at night only if they continually disturb

the other mothers in the room. Breastfeeding should be

Figure 14.5

Detachment due to depression.

actively encouraged, though this may take time and

perseverance by both mothers and nursing staff. Mothers of

preterm infants should be encouraged to express their milk

and thus feel that they are actively contributing to the infant’s

welfare.

In neonatal units the atmosphere should make mothers

feel that they are welcome at any time and they should be

encouraged to look at, touch, change, feed, and later

breastfeed their infants. When the mother is about to visit a

very sick infant the reasons for the use of special apparatus

should be explained beforehand. A mother can usually visit

her infant in the neonatal unit the day after a caesarean

section by being wheeled in a chair.

If a mother fails to visit her infant for long periods after she

has been discharged, an inquiry should be made whether any

remediable reason, such as lack of transport, is responsible.

Before the infant is discharged from the unit the mother

Figure 14.6

Parents should be encouraged to care for their infant in

should remain with her infant in a room on the unit for at

the neonatal unit.

ABC of the First Year

least 24 hours, but longer if possible. This gives her an

opportunity to gain confidence in her ability to cope with her

baby, who recently appeared to be so fragile and needing

expert nursing care to survive.

What the newborn baby can do

Many mothers, especially those having their first baby, believe

that newborn babies are blind until they are six weeks old. It is

not surprising that these mothers treat their babies like

inanimate dolls and feel ashamed when an unexpected visitor

catches them talking to the baby. The normal newborn infant

can see, hear, and appreciate pain immediately after birth,

even if the mother has received heavy sedation. During the

hour after birth the infant is often wide awake, looking round

Figure 14.7

Talking to and touching the baby.

for a feed before going to sleep for a few hours.

The distance between the eyes of the mother and the

infant when the mother is breastfeeding is the distance at

which infants can best focus on an object. This eye to eye

contact provides the first means of communication between

mother and infant and is probably the reason why mothers

find that covering the infant’s eyes during phototherapy

disturbs them. Mothers of blind infants have difficulty in

feeling close to their infants. Newborn infants will become

alert, frown, and gradually try to focus on a red object dangled

about 30 cm before them. They stare intently at the object and

will follow it with short jerking movements of the eyes if it is

moved slowly from side to side. Infants are also sensitive to the

intensity of light and will shut their eyes tightly and keep them

shut if bright light is turned on. They can discriminate shapes

and patterns and the arrangements of lines from birth. They

prefer patterns to dull or bright solid colours and look longer

at stripes and angles than at circular patterns.

Figure 14.8

Newborn infant looking at the camera.

Newborn infants can hear. They respond to sound by

blinking, jerking their limbs, or drawing in breath. They may

stop feeding. Mothers often speak to their infants in a high

pitched voice and an infant responds more consistently to his

mother’s than his father’s voice. An infant of three days of age

shows preference for sweet and dislike of bitter flavoured fluid.

At about the same age he can differentiate smells and

distinguish between his own mother’s and other mothers’

breast pads.

Analysis of sound films shows that both listener and speaker

are moving in time to the words of the speaker, creating a type

of dance. For example, as the speaker pauses for breath or

accentuates a syllable, the infant may raise an eyebrow or lower

a foot. The mother notices these changes and this may

encourage her to continue speaking. At a few weeks or even a

few days after birth the infant may mimic gestures such as

tongue protrusion, lip protrusion, or opening the mouth.

If the doctor talks to babies while examining them, mothers

will not feel foolish when they do it themselves.

Figure 14.9 Infant looking at mother’s face.

Growth and growth charts

Weight and head circumference

The size of the normal infant at birth is determined mainly by

the mother’s size. The greatest changes to adjust for other

hereditary factors take place during the first three months of

life. Although children tend to attain a stature between those

of their parents, some children take after one parent,

grandparent, or an even more remote member of the family.

All these children are perfectly healthy. It may be difficult to

distinguish these normal adjustments of growth from disease,

especially during the first few months of life. Growth charts are

therefore essential for diagnosis during this period and helpful

in discussions with parents.

Length (or height) is difficult to measure accurately in a

very young baby and for some years we have used the head

circumference as a reference measurement for comparison

Figure 15.1 Measuring the head circumference.

with the weight. The use of the head circumference in this way

is valuable only in the first two years of life. The head

circumference is measured round the occipitofrontal

circumference (the largest circumference), which should be

determined with a disposable paper tape measure. Linen tape

measures stretch and produce inaccurate results.

Mother 5' 0"

Father 5' 5"

Normal growth and small normal

infants

Head

circumference

An infant usually has a similar centile at birth for both head

circumference and weight. Children of large parents tend to

be towards the 98th centile and those of small parents near the

2nd centile. Most of these children remain on the same

centiles for the rest of their lives. Plotting these measurements

on a chart in routine clinics helps to confirm that the child is

Weight

receiving adequate food and is growing normally.

One of the most common problems in paediatric

outpatient clinics is short parents who think that their infant

does not eat enough. Plotting growth measurements on a chart

from measurements already recorded at the local clinic

confirms to the doctor and the parents that the child is normal

and that the child’s final size will be similar to that of the

Weeks

parents (chart A). Charts are better than cards for recording

growth.

Chart A

Small normal infant.

Growth and growth charts

Mother 5' 4"

Father 5' 3"

Father

5' 8"

Head

circumference

Weight

Weeks

Chart B Taking after father.

Chart D Obesity.

Taking after father or mother

Getting fat

Some children are more similar to one parent than the

Growth charts give an early warning of obesity. Chart D shows

other in final size. If only their weights are recorded,

that at the age of 20 weeks this child’s weight centile started

they may appear to be either failing to thrive if the father is

deviating upwards although the head circumference centile

small (chart B) or gaining weight excessively if the father is tall

remained the same. If the mother had been shown the growth

(chart C). If both weight and head circumference are plotted

chart at the age of 20 weeks she might have been able to

on a chart, the weight centile line and head circumference

prevent the phenomenon seen at 30 weeks.

centile line can be seen to be running in parallel. In other

The standard growth charts are based on data collected

words, the whole of the child’s size is approaching that of a

when the majority of babies were fed with cow’s milk

particular parent.

preparations. Some normal breastfed babies gain weight

rapidly in the first 10 weeks and then more slowly during the

subsequent 20 weeks (chart E). This is a normal growth

pattern and is not an indication of obesity.

Mother 5' 4"

Mother 5' 0"

Father

5' 5"

Father

6' 0"

Head

circumference

Weight

Weeks

Chart C Taking after father.

Chart E Normal breastfed infant.

ABC of the First Year

Mother 5' 4"

Father

5' 8"

Mother 5' 4"

Father 5' 8"

Head

circumference

Weight

Bottle

242628303234363840 2 4 6 8 10121416182022

Weeks

Chart F Poor lactation.

Chart H Catch-up growth in preterm infant.

Poor lactation and failure to thrive

Preterm

The increased incidence of breastfeeding has resulted in a few

infants receiving insufficient milk as a result of their mothers’

When preterm infants reach home, they may gain weight

not recognising poor lactation. This can be detected at an early

rapidly, when they will cross the centile lines for both weight

stage by weighing infants regularly, although normal breastfed

and head circumference in parallel (chart H). Preterm infants

infants may not regain their birthweights before the age of two

may have a relatively large head measurement because of the

weeks. The onset of full lactation is extremely variable and this

head’s discoid shape, but continuing growth on the same

must be taken into account when considering the adequacy of

centile line shows that the head is normal. Babies of extremely

weight gain (chart F). Plotting the infant’s weight on a growth

low gestational age, especially below 26 weeks, with chronic

chart is the first investigation required to diagnose whether

lung disease may continue to grow poorly despite feeding well.

failure to thrive is present and also to give a presumptive

Infants whose growth in utero has been restricted due to

diagnosis of the cause (chart G).

poor nutrition related to placental function may have catch-up

growth or may continue to grow poorly postnatally (chart I).

Mother 5' 4"

Father

5' 8"

Mother 5' 4"

Father 5' 8"

Head

circumference

Head

circumference

Gluten started

Weight

9820

Gluten-free

diet

Weight

242628303234363840 2 4 6 8 10121416182022

Weeks

Chart G Coeliac disease.

Chart I Poor weight gain and discoid head in preterm infant.

Growth and growth charts

Mother 5' 4"

Mother 5' 0"

Father

5' 8"

Father

5' 5"

Head

circumference

Weight

Familial

large head

Progressive

hydrocephalus

Weeks

Chart J Infant of diabetic mother.

Chart K Progressive hydrocephalus.

Infant of diabetic mother

Progressive hydrocephalus

The infant of the diabetic mother may be grossly obese at birth

Progressive hydrocephalus can be confirmed by showing a

but slims down within a few months of birth (chart J). These

head circumference centile that progressively increases while

infants may not gain any weight at all for the first two months

the weight centile shows no change (chart K). It may occur in

of life and the mother may be accused of starving the infant.

association with intraventricular haemorrhage in preterm

infants or myelomeningocoele. Hydrocephalus can be

confirmed by ultrasound examination of the brain if the

anterior fontanelle is still open. This condition must be

differentiated from familial large head, where the head

circumference centile remains constant and is parallel to the

weight centile.

Feeding and feeding problems

There has been no significant change in the incidence of

breastfeeding in Great Britain since 1980. In 1990, 63% of

mothers breastfed compared with 64% in 1984 and 65% in

Mother 5' 4"

1980. There is a steep gradient in the incidence of

Father

5' 8"

breastfeeding among mothers of first babies from 50% in social

class V to 89% in social class I. The incidence of breastfeeding

among mothers having their first child was 57% for those who

left full time education at the age of 16 years or under

Head

compared with 93% among mothers who left school at the age

circumference

of 19. In 1990 one third had stopped breastfeeding by six

weeks. The proportion of breastfed babies receiving additional

bottles at six weeks has been rising since 1980, when it was

28%, to 34% in 1985 and 39% in 1990.

Full term infants usually regain their birth weight between

the seventh and tenth day, and thereafter the infant should

gain about 20-40 g/day for the next 100 days. Unmodified

Weight

milk (“doorstep” milk) should not be given until after the age

of one year and should be accompanied by vitamin

supplements, particularly vitamin D, until the age of two years.

Progress on a growth chart is the best guide to ensuring that

an infant is receiving the correct amount of milk.

Breastfeeding

Breastfeeding should be encouraged. Firstly, the fat and

Weeks

protein of human milk are more completely absorbed than

those of cow’s milk. The composition of human milk varies

Figure 16.1 Normal growth chart.

during a feed and these subtle changes cannot be mimicked

by cow’s milk preparations. The significance of these changes

is unknown but may be related to the control of intake

by appetite.

Secondly, although the fat composition and therefore the

fatty acid composition of breast milk vary during a feed, these

changes cannot be replaced exactly by cow’s milk preparations

and the differences in body composition resulting from these

Mother-infant

different milks may have a long term effect.

attachment

Thirdly, human milk contains antibodies and iron binding

protein (lactoferrin) which may protect the infant against

infections. Gastroenteritis is rare in breastfed infants.

Breastfeeding also plays an important part in

mother-infant attachment. If the mother is encouraged during

the antenatal period to expect to be able to breastfeed her

baby and eventually to enjoy it, she is likely to accept

Varying fatty acid

early difficulties with patience and understanding. The close

Fat and protein

composition

contact and intimacy, and often supreme enjoyment,

more easily

of breastfeeding provide the best “feedback” between the baby

absorbed

and the mother. The mother’s intimate personal relationship

with her baby is something that she has to work out for herself.

Many feel insecure and inadequate at first and are only too

glad to change to bottle feeding whenever the slightest

difficulty arises. The attendant should resist such requests and

instead use sympathy, understanding, and skill to encourage

Protection against

the mother to gain confidence in handling her own baby.

infection

Latching to the breast

Figure 16.2 Advantages of breastfeeding.

The sensation of the nipple against the palate stimulates the

baby to suck. Placing the baby in the correct position

encourages successful feeding and avoids damage to the

nipple. The baby’s chin must drive into the breast to enable

Feeding and feeding problems

the nipple to reach the palate, so the baby needs to put his

head back and up. If the baby’s head becomes too flexed, the

nipple touches the lower jaw and the tongue and the nose is

too close to the breast. Helping the chin to thrust forwards

and the head to tilt back is hindered by pressure on the back

of the head but improved by supporting the baby’s back at

shoulder level, with the baby facing the mother, chest to chest.

Rooming in

A normal infant is put to the breast for a few minutes at each

side either immediately or a few hours after birth. Only a small

amount of colostrum is obtained but sucking by the infant

stimulates the production of more milk. Some infants are

reluctant to take the nipple initially and the mother needs

strong reassurance that this is common.

Figure 16.3

Breastfeeding.

During the first week, and probably later, most of the feed

is obtained within four minutes in some babies. Thus the

length of time that the baby is on the breast bears little relation

to the amount of milk received by the infant. Some infants take

a shorter time and others a longer time to take a full feed.

The most satisfactory method of breastfeeding is “on

demand”. Babies commonly feed every two or three hours

during the first few weeks and these frequent feeds are

a powerful stimulus to lactation. This is the main advantage of

rooming in, where the infant’s cot is by the side of mother’s

bed and she can pick him up and feed him when he cries.

Mothers should be encouraged to do this. Infants initially fed

on demand usually settle down to a regular schedule after a

few weeks. Most breastfed infants feed three hourly rather than

four hourly. After the seventh day, if the infant appears to be

hungry after a feed or is progressively losing weight test

feeding may be considered.

Figure 16.4

Rooming in.

Test feeding

Test feeding should be avoided whenever possible, as it can

create anxiety in some mothers. The infant is weighed, without

changing the napkin or clothes, before and after each feed

during a 24 hour period. If the feed is deficient, putting the

baby to the breast more frequently may stimulate increased

lactation in the early days or the deficit may be made up with a

bottle feed given after feeding from both breasts

(complementary feeding). Fortunately, a well nourished full

term infant can tolerate a degree of underfeeding without

harm for a few days.

Complementary feeds are rarely necessary in the first five

days, and after this they should be used only when absolutely

necessary. The feel of the bottle teat is quite different from

that of the nipple, and when the infant is accustomed to one it

may be difficult to persuade him to take from the other.

Figure 16.5

Test feeding.

Contraindications to breastfeeding

Box 16.1 Contraindications to breastfeeding

• Maternal dislike

There are few contraindications to breastfeeding. Some women

• Severely cracked nipple

have a revulsion to the idea and it would be a mistake to try to

• Rarely, drugs

persuade them, but psychiatric illness in the mother may be

aggravated if the baby is taken off the breast. Severely cracked

nipple is a temporary contraindication to feeding from the

affected breast, but the milk should be expressed with a pump.

Feeding should continue from a breast with acute mastitis

while the mother is receiving an antibiotic; it should also

continue if the nipple is only mildly cracked.

No drugs should be taken by a lactating mother unless

there are strong clinical indications. Most drugs that are

essential for the mother are secreted in the milk in

ABC of the First Year

insignificant amounts, so breastfeeding should not be stopped

Box 16.2 Problems with breastfeeding

unless there is a special reason. Antibiotics are excreted in

minute amounts in the milk but there is the theoretical

•

Intestinal hurry: no treatment

•

Cracked nipple: breastfeed or rest

possibility of sensitising the infant. Warfarin, senna,

•

Breast engorgement: expression

barbiturates, phenytoin, digoxin, steroids, antacids, and

•

Gulping: expression

occasional doses of paracetamol pass into the milk in

unimportant amounts. Kaolin is not absorbed by the mother.

Oestrogens in oral contraceptives may reduce lactation, but the

progesterone-only pill is an effective contraceptive and has no

effect on lactation. A mother receiving carbimazole

may continue to breastfeed provided that the infant’s plasma

thyroxine concentration is monitored.

Mothers receiving radioactive antithyroid treatment

or cytotoxic drugs should not breastfeed. Lithium given to the

mother may cause hypotonia, hypothermia, and episodes of

cyanosis in a breastfed infant.

Problems with breastfeeding

On the fourth or fifth day, when there is a plentiful supply of

breast milk, the infant may take up to eight feeds or more a

day. Intestinal hurry and frequent loose green stools are

common at this stage. Conversely, some normal breastfed

infants pass stools only once a week when they reach the age of

a few weeks, and this also requires no treatment.

Cracked nipple is usually due to malplacement of the

infant on the nipple so that the whole of the pigmented area is

not in the infant’s mouth. Pulling the infant off the breast

abruptly is another cause. If the nipple is slightly cracked,

breastfeeding should continue with advice on latching to

the breast. If the crack is severe, the infant should be taken off

that breast for a day or so and a bland ointment, such as

lanolin, placed on the nipple every few hours. A fissure of the

nipple occurring after the first few weeks is often aggravated by

thrush infection of the baby’s mouth and the mother’s nipple.

It is best treated with miconazole or nystatin gel to both until

four days after it appears to be clear.

In acute mastitis there is fever, pain, flushing, and

Figure

16.6

Good placement of the nipple in the infant’s mouth.

induration in one breast and enlarged axillary lymph nodes.

Flucloxacillin or erythromycin is given to the mother for at

least a week and feeding continues from both breasts.

Fluctuation in the indurated area indicates that an abscess is

present and the need for surgical incision and suppression of

lactation with bromocryptine.

Feeding on demand usually prevents maternal breast

engorgement, which can occur towards the end of the first

week of the baby’s life. This is easily alleviated by expression

after feeding, preferably with a pump. If engorgement has

already occurred the help of an experienced midwife

is necessary.

During the first feed of the morning milk may spurt quickly

from the breast and a ravenous infant may swallow excessive

air, which may be regurgitated later with milk. This is often

accompanied by severe crying. It can be alleviated by manual

expression of the first 30 ml of milk, which can be given to the

infant later if necessary.

Figure 16.7

Breast pump.

Bottle feeding

All the cow’s milk preparations available in Britain have

sodium and protein concentrations similar to those of human

milk. The powder should be measured accurately, avoiding

heaped on packed scoops. The instructions on each packet

must be followed. Ready to feed bottles are used in most

obstetric units.

Feeding and feeding problems

If feeds are made up for a 24 hour period they should be

stored in the refrigerator. Bottles can be sterilised in dilute

hypochlorite solution, but processing in an autoclave is the

best method in hospitals. Other methods include steam or a

special microwave oven kit. Teats should be well washed

before sterilisation.

The size of the hole in the teat should allow individual

drops of milk to follow each other quickly when the bottle is

inverted, and this should be checked each week.

“On demand” feeding

Feeds are usually given “on demand” or three or four hourly.

Most infants need to be fed every three hours. The milk must

not be made up to a stronger concentration than that

recommended on the packet. Few babies can manage without

a night feed for the first few months.

A normal full term infant receives 30 ml of milk per kg

body weight during the first day of feeding by bottle. Feeds

should be increased by 20 ml/kg each day until a maximum of

150 ml/kg is reached on the seventh day of feeding.

Underfeeding causes small amounts of green mucus to be

Figure 16.8

Container for sterilising bottles.

passed frequently, but this is more likely to be found with

breastfed than with bottlefed infants.

Problems with bottle feeding

If the hole in the teat is too small the infant may swallow

excessive air during the feed and regurgitate it later with milk,

accompanied by bouts of crying. It is valuable to observe the

rate at which the drops of milk are formed when the infant’s

bottle is inverted. The drops should follow each other quickly

but there should not be a continuous stream. If the hole is too

small it may be made larger with a hot needle. If the hole is

too large, infants may swallow excessive air as they gulp to

avoid choking.

By taking a careful history it is usually possible to

determine the likely cause of any symptoms. If growth is poor,

infants need more frequent or larger feeds. If the weather is

hot and infants are not receiving extra water, they may be

thirsty and should have additional water. Mothers tend to use

gripe water as a panacea, not realising that it contains

bicarbonate, which produces carbon dioxide in the stomach.

Figure 16.9

Drops should follow each other quickly.

Reluctance to feed

In an infant who has fed normally before, reluctance to feed

may be a dangerous symptom. It may be due to any severe

disease, such as congenital heart disease or a lower respiratory

tract infection. On the other hand, when an infant has a mild

upper respiratory tract infection the nose may become blocked

with mucus making it difficult for the baby to feed. Thrush

produces white plaques on the buccal mucosa and tongue,

which become sore. It can be treated by a five day course of

oral nystatin drops or miconazole oral gel, 1 ml twice a day.

Figure 16.10 Infant refusing a feed.

Failure to thrive

Mothers become anxious if their infants do not gain weight at

Box 17.1

the rate that is expected. The majority of these babies are

perfectly healthy but the expectations are too high. Initially, it

• Is the weight gain normal?

is essential to determine whether the baby is gaining weight

• If not, what is the cause?

normally. If weight gain is abnormal, failure to thrive is present

and a cause should be sought. Some of the material in this

chapter is also found in Chapter 15.

Normal weight gain

Mother 5' 0"

Small parents

Father

5' 3"

An infant usually has a similar centile at birth for both head

circumference and weight. Children of large parents tend to

Head

be towards the 98th centile and those of small parents near the

circumference

2nd centile. Most of these children remain on the same

centiles for the rest of their lives. Plotting these measurements

on a chart helps to confirm that children are receiving

adequate food and are growing normally. A common problem

is the infant of short parents who consider that their child does

Weight

not eat enough. Plotting growth measurements on a chart

from measurements already recorded at the local clinic

confirms to the doctor and the parents that the child is normal

and that his or her final size will be similar to that of the

parents. Charts are better than lists of measurements for seeing

the trends in growth.

Weeks

Taking after father or mother

Chart A Normal infant of small parents.

Some children are more similar to one parent than the other

in final size. If only their weight is recorded they may appear to

be either failing to thrive if the father is small (chart B) or gain

weight centile line and head circumference centile line can be

in weight excessively if the father is tall (chart C). If both

seen to be running in parallel. In other words, the whole of

weight and head circumference are plotted on a chart, the

the child’s size is approaching that of a particular parent.

Mother 5' 4"

Father

5' 3"

Father

6' 0"

Head

circumference

Weight

Weeks

Chart B Taking after father.

Chart C Taking after father.

Failure to thrive

Low birthweight

Infants who are of low birthweight may have been born early

Mother 5' 4"

Father

5' 8"

(preterm) or have experienced intrauterine malnutrition or

both. Although some of them have a period of “catch-up”

growth during the first few months of life, others remain below

the 2nd centile for the whole of their lives. This is considered

Head

circumference

to be related to the intrauterine malnutrition (see chart D).

Physical causes of failure to thrive

Weight

A progressive fall in the weight centile with a constant head

circumference centile is the best confirmation of failure to

thrive. Measurements on a single occasion may show a weight

centile that is below the head circumference and length

centile, but these findings may be present in a normal baby

whose family has a body shape that is slightly different from

the majority. The plotting of serial measurements on a growth

chart before starting to take a history often shortens that

Weeks

process.

Deficient intake of food or the excessive loss from

Chart D Low birthweight.

malabsorption or metabolic disease cause failure to thrive.

Psychiatric and social problems, which are the predominant

factor in the majority of the infants with failure to thrive in this

country, probably reduce the food intake.

A detailed history is taken, paying particular attention to

the family history, birth, feeding, and maternal anxieties.

Details of any vomiting, diarrhoea, or abdominal distension are

noted. The complete examination includes an assessment of

developmental age and evidence of wasting, particularly of the

inner aspects of the thighs and buttocks.

Deficient intake

Poor lactation - The high incidence of breastfeeding in some

areas has resulted in a few infants receiving insufficient milk as

a result of their mothers’ not recognising poor lactation. This

Figure 17.1

Wasting of buttocks.

can be detected at an early stage by weighing infants regularly

(see Chart E), although normal breastfed infants may not

regain their birth weights before the age of two weeks. The

onset of full lactation is extremely variable and this must be

taken into account when considering the adequacy of weight

gain (see Chapter 16)

Problems with bottle feeding - Poor tuition may result in

deficient milk intake (see Chapter 16)

Cerebral palsy - Infants with cerebral palsy may present with

slow feeding and resulting poor milk intake before changes in

the motor function in the limbs can be detected. These infants

will usually have some evidence of developmental delay.

Congenital heart disease

- There may be deficient milk

intake due to slow feeding and there is also a high metabolic

rate. Central cyanosis, a murmur, or both are usually present.

Urinary infection - A clean catch urine specimen examined

promptly in the laboratory is essential for this diagnosis.

Figure 17.2

Wasting of thighs.

Excessive loss

Gastro-oesophageal reflux - Persistent vomiting from birth may

result in failure to thrive if the infant does not take in

additional milk to compensate for the loss (see p. 51)

Congenital pyloric stenosis - This condition may present at any

time until the age of three months. It should be considered in

any baby less than that age who vomits persistently (see p. 50)

Malabsorption - In this country the main causes of

malabsorption are cow’s milk protein intolerance, cystic

ABC of the First Year

fibrosis, and coeliac disease (see Chart F). These conditions all

cause loose stools that are more frequent than normal but this

Mother 5' 4"

may not be recognised by a mother with a first child. A

Father

5' 8"

detailed history of bowel function should be taken and

personal examination of the stool may be helpful.

Diabetes mellitus

- This can be excluded by a negative

Head

multistix test for glucose in the urine.

circumference

Psychiatric and social factors of failure

to thrive

Weight

A physical cause for failure to thrive may be present in a family

with psychiatric and social problems and therefore a physical

cause must be excluded for all infants. The exclusion of a

physical cause is often helpful in persuading the parents to

Bottle

accept that psychiatric or social factors are the main reason for

the problem. Features in the history that may suggest this

possibility include maternal depression, marital discord, or a

disorganised household. Maternal food preferences may result

Weeks

in the exclusion of certain foods, such as cow’s milk, from the

Chart E

Poor lactation.

diet without reason and without adequate supervision, and may

result in a deficient energy intake.

There are more subtle ways in which maternal emotional

factors may affect the infant. The mother may be depressed

and tense, and this anxiety is transmitted to the child, who

does not feed. The mother then reacts by removing the food.

In other families the child may be intrinsically less responsive

than the average child to food and this may affect the mother’s

response to the child at mealtimes. In both these examples the

Mother 5' 4"

Father

5' 8"

amount of food taken by the child falls to a plateau where the

infant appears to be satisfied with the amount given. Another

possibility is that the mother keeps to a diet herself as she

Head

perceives that she is overweight and also gives a diet to the

circumference

infant in a similar way.

Some infants are deliberately underfed as part of child

abuse. Normal weight gain occurs when fostering has been

Gluten

carried out.

started

Effective management of infants with this diagnosis

Weight

requires a team approach involving a health visitor, the family

doctor, a child psychiatrist, and paediatrician. Regular advice

from a health visitor or dietitian often improves the rate of

weight gain.

Gluten-free

diet

Investigations

Weeks

Specific investigations are indicated by the history and

examination given above, but if there are no pointers to the

Chart F

Coeliac disease.

diagnosis the following investigations are performed: multistix

urine test for glucose, full blood count, sweat test, urine

microscopy and culture, and plasma creatinine.

Weaning

Weaning is the process of getting babies used to eating foods

other than milk, and using a spoon and cup. For the first four

months of life babies will need only milk and additional drinks

of boiled water. New foods should start to be introduced at

about four months. If solid foods are introduced too early

babies may become too fat; if they are introduced too late,

after seven months, there may be problems with chewing.

Once introduced, solid foods should be given regularly and in

gradually increasing quantities. As the amount of solid food

increases, the number or size of milk feeds should decrease.

In countries where commercially produced infant cow’s

milk preparations are safe and affordable, they should be used

for the first year of life. Advantages are that the protein and

calcium concentrations and vitamin content are more

appropriate for babies than unmodified cow’s milk.

Mothers need a small, wide plastic teaspoon with no sharp

Figure 18.1

Equipment for weaning.

edges, a small plastic cup or bowl, a feeding beaker,

and a cotton or plastic backed cloth bib. The feeding

equipment should be kept in a sterilising solution.

Firstly, babies have to be taught to take food from the

spoon rather than just sucking. As solids are increased,

the volume of milk should be reduced. The baby should also

be given plenty to drink to replace the milk; at least

100-150 ml of cooled boiled water each day. Diluted fruit

juices are not necessary. Most fruit squashes are unsuitable for

babies.

4-6 months

At 4-6 months babies will usually be having breast or bottle

feeds at 6-8 am, 10 am, 2 pm, 6 pm, and 10 pm. Solid foods

should be introduced to babies before the mid-morning or

lunchtime feed - usually a baby cereal or a fruit or vegetable

purée.

Mothers should start by using a cereal made from rice and

Figure 18.2

Feeding with a spoon while sitting on the mother’s lap.

should mix half to one teaspoon of cereal with one to two

tablespoonfuls of breast milk, infant formula, or water; it

should be given to the baby from the spoon. Sugar, honey or

salt should not be added. Wheat based cereals should not be

introduced until after the age of six months. At lunchtime

babies should be fed with vegetables such as potato or carrot,

or fruit such as apple. The vegetables can be fresh or frozen,

and the fruit fresh or canned in natural juice. The vegetables

Box 18.1

Menu at four to six months

should be boiled and the fruit stewed and then liquidised,

6-8 am

Milk

mashed into purée or sieved. Feeding should start with half or

10 am

Milk

one teaspoonful before or during the lunchtime feed and

Baby cereal

gradually increased.

2 pm

Milk

At about six months mothers should start to give a wider

Fruit or vegetable purée

variety of foods. Banana mashed with a fork is a favourite of

6 pm

Milk

10 pm

Milk

many babies. Mashed hard boiled eggs, soups, milk puddings,

and strained baby foods should all be tried, with the emphasis

on savoury flavours rather than sweet ones. Lightly boiled or

scrambled eggs or omelettes should not be given, as there is a

risk of salmonella infection.

Preparing food

Home prepared foods are best. The mother knows what is in

them and can prepare them easily and cheaply, as she can use

ABC of the First Year

a small portion of food cooked for the rest of the family. Many

families have an electric liquidiser or food processor, but a

manual blender is equally effective. A sieve is useful for making

fruit and vegetable purées. If there is a deep freeze, time can

be saved by preparing puréed food in bulk and storing

individual portions for up to three months.

Cans, jars, and packets of baby foods are useful but

should not replace home made foods. After opening, jars

and cans should be kept in a refrigerator and used within 24

hours.

Iron deficiency is common during weaning but can be

prevented by an appropriate diet. Iron from vegetables and

cereals is not as well absorbed as that from meat. Sources of

iron for vegetarians include breakfast cereals and other cereal

products, pulses, green vegetables, and nut purée.

6-8 months

When babies are six months old it is no longer necessary to

sterilise equipment for weaning. Bottles and teats should be

sterilised until a beaker or cup is used, and that should be

introduced at about this age.

At 6-7 months a greater variety of tastes and textures

should be introduced. A little finely minced chicken, lamb,

beef, or liver may be given mixed with potato purée.

Vegetables should be cooked until soft, then sieved, blended

or liquidised until smooth. White fish can be boiled with milk

and, after the bones have been removed, mashed in with

potato or vegetable purée. Dahls such as chama dahl and

Figure 18.3

Electric liquidiser.

dhudhi, lentils and rice can be given at this age, but should

not include salt or hot spices (chilli, ginger, cloves), fat or oil.

Soup can be made with lentils or soft chick peas and carrots,

cauliflower, or potato, which can then be blended, liquidised,

Box 18.2

Menu at six to eight months

or mashed. Grated cheese, cottage cheese, curd cheese, or

paneer may be given, mixed in with other foods, and mashed

6 am

Milk feed

hard boiled egg can be added to mashed potato. Babies often

9-10 am

Cereal + milk or

eat yoghurt plain, but they may need to be tempted with

hard boiled egg

Milk feed

added fruit.

1-2 pm

Minced/puréed meat or fish,

At around seven months parents should start changing the

puréed vegetables

texture of foods to encourage chewing. For example, meat and

and potato, gravy

fish should be less finely minced and potatoes and other

Diluted fruit juice or milk feed

vegetables can be mashed rather than puréed. Babies should

3-4 pm

Diluted fruit juice or water

also be given hard foods such as a crust of bread, a piece of

5-6 pm

Fruit purée/mashed banana

chappatti, pieces of apple, carrot, and banana, which they can

Custard or milk

hold in their hands, and this will encourage them to chew.

pudding

These foods should always be given under supervision to make

Milk feed

sure babies do not choke. Babies should not be given rusks or

biscuits every day, as these may encourage the taste for sweet

foods.

The timetable of feeds should also start to change at this

age and the number of milk feeds should fall.

Babies often reject food. This may be because they are not

used to a new taste or texture. However, it may also be because

they are thirsty or because the food is too hot, or simply

because they want to attract attention. Mothers should be told

to keep trying with new foods and to give them in different

ways. Babies who become constipated should be given more

fruit and vegetables and water.

At about eight months the baby can now sit in her high

chair at the table with the rest of the family. Two course meals

at lunch and teatime should be introduced - for example, a

savoury food followed by a fruit purée. The amount of milk

will decrease as more solids are taken. Breastfeeding is

continued or an infant formula milk should be given until the

end of the first year.

Figure 18.4

Sitting in highchair eating with the family.

Weaning

9-12 months

At this stage babies should be able to eat the same food as the

rest of the family, though the food will have to be cut up or

mashed. Food should not contain hot spices, particularly chilli,

ginger, or cloves, and not too much butter, ghee, or oil. Each

day the baby should drink a pint of milk, or less if he or she

eats some cheese or yoghurt; two small portions of meat, fish,

poultry, or eggs, some fruit, fresh fruit juice, or vegetables;

some cereals - for example, a cereal at breakfast and half a

slice of bread at tea; and a small amount of butter or

margarine. Babies should not be given too many sweet foods,

particularly between meals, as they can cause overweight and

tooth decay.

Box 18.3 Food safety

• Babies should never be left alone when eating, because of the risk

Vitamins

of choking.

• Heated foods should be warm but not hot enough to burn a

Breastfed infants under six months do not need additional

baby’s mouth.

vitamins, provided the mother had an adquate vitamin status

• It is not advisable to use a microwave oven to reheat food and

during pregnancy. From the age of six months infants

drink. This is because “hot spots” can occur in the middle of food

receiving breast milk as their main drink should be given

if it is not thoroughly stirred after reheating.

supplements of vitamins A and D.

• Eggs should be boiled until the white and yolk are solid (about six

Infants receiving 500 ml or more a day of an infant formula

minutes).

• Peanuts and food containing peanuts or unrefined groundnut oil

milk do not need vitamin supplements. Infants receiving a

should not be given to infants from atopic families until they are

smaller volume of formula milk or pasteurised whole cow’s

at least three years of age or to infants who are atopic or allergic

milk (after the age of one year) should be given vitamin

to peanuts.

A and D supplements until the age of five years. After the age

• Whole nuts should not be given to children less than 4-5 years of

of one year these supplements may be omitted if the diet has

age because of the risk of choking. However, smooth peanut

an adequate vitamin content and there is moderate exposure

butter or finely milled nuts are suitable.

to sunlight.

Review at six weeks

For many years, infants nursed in neonatal units have been

routinely assessed at regular intervals as have those who were

placed on “at risk” registers for handicaps. Total population

Developmental

screening was introduced when it was realised that many

specialist + team

children later found to have disabilities were not on registers

Other specialists

or being seen after discharge from neonatal units.

Examination of all infants at specific ages allows

abnormalities to be detected at an early stage, provides

mothers with a chance to discuss their anxieties, and gives

opportunities for education in preventive health.

Clinic

Developmental examinations should be considered on two

Surgery

Clinic medical

levels: the surveillance of an apparently healthy population and

officer

Health visitor

the detailed assessment of infants referred from primary

Health visitor

examinations because of suspected abnormalities. Primary

examinations, which should cover all infants in the district,

are best performed by the family doctor. In some districts

specially trained health visitors do this work, especially for

infants whose parents will not visit the surgery or clinic.

Nevertheless, this system is not ideal since health visitors may

Baby

consider up to 20% of infants abnormal and refer them to an

assessment clinic, with all the anxiety that this entails. Some

clinics are run jointly by a family doctor and health visitor, who

Figure 19.1

Organisation of primary and secondary care.

often has wide experience of managing feeding and behaviour

problems.

Infants found to be abnormal at the primary examination

need to be referred to a doctor with a special interest in

developmental assessment. This may be the community or the

hospital paediatrician. The more detailed examination

performed at this stage will probably need a team of

paramedical staff.

A mother who considers that her infant has an abnormality

of hearing, sight, or development must be sent straight to the

specialist because she cannot be reassured until a detailed

assessment has been performed, which usually needs several

members of the team. The mother is likely to be right.

Head circumference

Primary examination

Infants in the normal population should be assessed within

48 hours of birth, at six weeks, and again at seven or eight

months. Preterm infants should be examined about six weeks

after the expected date of delivery, when their development

Assessments

should be the same as that of a six week infant born at term.

The examination should take no more than about

15 minutes and should be confined to items that have

prognostic significance.

Many districts use a “parent held” manual record that, if

completed correctly by professionals and parents, is a complete

record of a child’s health. All child health surveillance data,

Weight

the dates of immunisations, and outcomes of visits to general

practitioners and hospitals, and contacts with other health

professionals can be recorded. Some health advice is also

included throughout this record. In addition, the Health

Education Authority’s book Birth to Five Years, which is issued to

all first-time mothers, is an excellent manual on child health

for all parents (and junior doctors).

The six week examination should include a physical

5 6 7 8 910 12

141618202224

examination and assessment of alertness, vision, and motor

function. The checks should be carried out as part of clinical

Months

care and not be regarded as pass or fail examinations. A simple

form is useful for recording the information quickly. Screening

Figure 19.2 Ages for assessments.

Review at six weeks

Review at 6-8 weeks

Health

Immunisation

For parent to complete:

topics

Recognition of illness

for

Nutrition

discussion:

Activities to aid development

This review is done by your health visitor

Dangers: fire, scalds, falls, overheating

and/or a doctor. Below is a list of things

Tick

Good child rearing practices

you may want to discuss when you see

them. However, if you are worried about your child's health, growth or development

you can contact your health visitor or doctor at any time.

Circle 'yes' or 'no' or 'not sure'

Do you feel well yourself?

Yes/no/not sure

Do you have any worries about feeding your baby?

Yes/no/not sure

Do you have any concerns about your baby's weight gain?

Yes/no/not sure

Does your baby watch your face and follow with his/her eyes?

Yes/no/not sure

Does your baby turn towards the light?

Yes/no/not sure

Does your baby smile at you?

Yes/no/not sure

Do you think your baby can hear you?

Yes/no/not sure

Is your baby startled by loud noises?

Yes/no/not sure

Are there any problems in looking after your baby?

Yes/no/not sure

Do you have any other worries about your baby?

Yes/no/not sure

Comment_________________________________________________________________________

__________________________________________________________________________________

How are you feeding your baby?

Breast/bottle/mixed

Keep hot drinks away

Check the water before

from children

you bath your baby.

Use a coiled-flex kettle.

Hot water can scald your baby badly.

Review at 6-8 weeks

* Please place a sticker (if available) otherwise write in space provided.

Date of examination ______ /______ /______

Surname

Age in weeks ____________

First names

Name of examiner

NHS number

Local no

Address___________________________________ Sex M/F

Examiner code number Examination centre

____________________Postcode____________ D.O.B.__ /__ /__

G.P.

Code

WEIGHT______________ kg ________centile

H.V.

Code

HEAD CIRC.__________ cm ________centile

Any previous ongoing medical problems? NO

Yes

FEEDING____________ Breast/Bottle/Mixed

If 'Yes' please specify (1) ______________________

(2)________________________

(3) _________________________

ICD Code

ITEM

GUIDE TO CONTENT

CODE (Ring one)*

COMMENT

Physical

Full physical exam. Fontanelles. Palate. Skin

S P O T R N

Vision

Eyes. Follows. Red reflex.

S P O T R N

Hearing

Ears. Risk factor. Parents observations

S P O T R N

Locomotion

Tone, movement, reflexes

S P O T R N

Manipulation

Moro and grasp

S P O T R N

Speech/Lang.

Vocalisation

S P O T R N

Behaviour

Social smile. Cry. Sleep

S P O T R N

Hips

and skeletal system

S P O T R N

Genitalia

S P O T R N

Heart

Femoral pulses

S P O T R N

*(If one or more codes seem to apply select the last one, e.g. R takes priority over T, T over O etc.)

S=Satisfactory (normal result)

Referred to

(1)__________________ (2)______________________

P=Problem (significant condition on record)

O=Observation (special recall arranged)

(3)___________________________________________

T=Treatment or investigation underway

Special recall in________ wks/mths Signature _______________

R=Referred to any community or hospital service

N=Not examined for this item

White copy: Stay in Record Yellow copy: to Child Health Office

Pink copy: to GP/HV

Figure 19.3

ABC of the First Year

for hearing defects is not usually done until seven or eight

months (see page 80), and other abilities are assessed more

sporadically, depending on whether the mother takes the child to

a local clinic or to the general practitioner’s special baby clinic.

50%

97%

Of greatest importance is the child’s alertness, interest in

Head circumference

his surroundings, responsiveness, and ability to concentrate.

The physical examination of the infant should always

include measurement of weight and head circumference.

These values, plotted on a growth chart, will show at a glance

whether the infant’s growth is normal.

Weighing and measuring

Being undressed and weighed is often the most worrying part

of the visit to the child. Weighing the child in vest and napkin

reduces upset and time taken. Weights of the vest and napkin

should be subtracted from the total weight. Suitable scales that

Weight

are checked regularly are an essential piece of equipment.

In very young infants it is easier to measure head

circumference than length. The measurement should be

made, using a paper tape measure, around the occipitofrontal

circumference (the largest circumference). Measurements can

Speak: 3 word sentences

then be plotted on a growth chart together with weights.

The length of infants aged under two years is measured on

Speak: 3 words

a special measuring board and accurate results can be obtained

Walk: 10 steps

only when there are two dedicated measurers present. One has

Sit: 1 minute

to hold the infant’s head against the top board while the other

brings the footboard up to the child’s feet while stretching him

or her out. When the child is old enough to stand a special

stadiometer can be used to measure height, but careful

104

attention to detail is necessary for reproducible results.

Weeks

Figure 19.4 Range of ages for attainment of milestones.

Vision and squint

The infant’s visual attention is engaged by the examiner

Box 19.1 Weights of napkin and vest at various ages

crouching about 60 cm in front of the infant so that their eyes

are on the same level. When the examiner slowly moves his

Baby

Napkin

Vest

head a short distance to one side then the other, the normal

0-3 months

35 g

30 g

infant will continue to hold his gaze. Failure to do so is

3-9 months

55 g

45 g

9-12 months

70 g

60 g

abnormal but may be due to something distracting the infant.

Infants who fail to follow must be examined again two weeks

later. Possible causes include lack of stimulation at home, delay

in development, or blindness.

The second routine test at this age is the detection of the

red reflex. If a bright ophthalmoscope is held about 45 cm

away from an infant’s eye, with the observer looking down the

beam of light, a bright red reflex is normally seen in a fair

skinned infant and a dark red or grey reflex in an infant with a

dark skin. Absence of the reflex indicates an abnormality of

the refractive media and requires urgent referral to an

ophthalmologist.

An infant who does not fixate on the examiner’s face at the

second visit should be referred to a developmental specialist.

At that stage additional tests will include an attempt to

determine whether the infant can see at all by showing him a

revolving Catford drum. This induces opticokinetic

nystagmus - an involuntary movement of the eyes, which

occurs even if the infant does not concentrate well.

In a young infant a squint can be noticed by observing the

position of the light reflex on each cornea when a torch is

shone into the eyes. Normally the reflex should be in the

centre of each pupil or at a corresponding point on each

cornea. If there is a possibility of a squint, movements of the

eyes should be assessed and the cornea, lens, and fundi should

Figure 19.5 Infant following movements of the examiner.

Review at six weeks

be examined. An infant with a squint needs to be referred to

an ophthalmologist.

Motor function

The baby should be placed prone on a couch; normally he will

lift his head for a few seconds, though some infants may take a

few minutes to do so. Infants who usually sleep prone are more

advanced in lifting their heads than others. If the infant does

not eventually lift his head he needs to be re-examined two

weeks later.

Figure 19.6

Lifting the head.

When the infant is held in the prone position, his head

rises to the same plane as his trunk and his legs do not fall

vertically.

Other assessments

The testes and hips should be examined by the methods

described for the newborn infant. It is difficult to detect an

abnormal hip at the age of six weeks and ideally the condition

should have been detected in the newborn infant.

Cardiac murmurs should be sought for and the femoral

pulses checked. Though hearing is not tested at six weeks, the

normal infant will respond to sounds by stopping crying,

opening his eyes widely or by a startle reflex, depending on the

intensity of the sound.

Figure 19.7

Examination of the hips.

Patterns of development in childhood

Progress in a particular field does not occur gradually but in

spurts, and when one skill is advancing quickly others tend to

go into abeyance.

There is considerable variation in the range of normal

development, but among the children who fall outside the

normal range there are some who later turn out to be normal.

The children who fall into this group need examining more

closely and more often to determine which are definitely

abnormal. They should be referred to developmental

specialists.

Lack of appropriate stimulation may cause delay in

physical, intellectual, or social development. This factor must

be taken into account if the child has been cared for in an

institution or if the mother has a learning disability or has had

puerperal depression. These children advance rapidly when

the mother is given advice on handling them or they are

placed in a better environment. Delayed speech development,

probably the commonest disability of childhood, may be

prevented by encouraging mothers to talk to their infants from

birth.

No child has impaired intelligence if development is

delayed in a single field and normal in all others. A child who

is slow at learning will be delayed in all fields, except

sometimes in walking. Intelligence cannot be assessed

Figure 19.8

Looking at the camera.

accurately until the age of about 41–

2 years and before that age it

is best to use the term developmental delay.

Review at eight months

Mothers are asked whether they have any problems and

whether the infants have had any illnesses since the last

examination. They are also asked whether the infants are

making sounds and the details of their diet, in particular

whether they are chewing solids.

As at six weeks, the infant’s alertness and interest are

checked. Head circumference and weight should be measured

and plotted on the growth chart.

Vision

Eye movements should be noted. If a squint is suspected, the

position of the light reflex in each cornea should be observed;

Figure 20.1

Near vision being tested.

if there is a squint, the reflex will be in a different position in

each eye. While the infant looks at an object one eye is covered

with the doctor’s hand. If the eye that is not being covered

moves to fixate the object, that eye has an overt squint. The

covering hand is slowly removed and if that eye moves to fixate

the object, there is a latent squint. If a squint is seen or

suspected at any time the infant should be seen by an

ophthalmologist.

Near vision may be tested by placing a raisin or pellet of

paper about 20 cm in front of an infant and watching whether

he reaches out to grab it. Testing distant vision is time

consuming at this age and is usually performed only at

specialist clinics.

Motor development

From the prone position infants should get up on their wrists.

Figure 20.2

Resting on the wrists in the prone position.

When pulled from the supine position they should be able to

sit spontaneously for a minute or two. Normal children can sit

without help by the age of eight months. Infants should also be

able to take their weight on their legs when they are held

standing.

If a cube is placed in front of the infant he should grab it

with his whole hand. This test should be tried for both the

right and the left hand, and the infant should transfer the

object from one hand to the other. Infants who perform all

these tests normally but are not sitting spontaneously should

be seen again two months later.

A dislocated hip will show reduction of abduction and a

proximal displacement of the lower buttock crease. Bilateral

dislocation is hard to detect clinically but radiographs of the

hips will confirm the diagnosis at this age.

Hearing

The distraction method is the hearing test used at this age.

The distractor holds the infant’s attention while the tester

produces a sound. Careful attention to detail is essential to

produce reliable results. The mother is requested to position

the infant at the edge of her lap and not to react to the

sounds. The distractor sits at the level of the infant’s face and

holds the infant’s attention with a toy that produces no noise.

Eye contact is avoided. The toy is withdrawn from sight and

immediately afterwards the tester produces the test sound at a

distance of 45 cm from the infant’s ear, on a level with the ear,

Figure 20.3

Taking weight on the feet.

ABC of the First Year

Review at 8-9 months

Health

Accident prevention: choking, scalds,

For parent to complete:

topics

safety in cars and house, sunburn

for

Dental advice

discussion:

Developmental needs

This review is done by your health visitor

Tick

Nutrition, etc

and/or a doctor. Below is a list of things

you may want to discuss when you see them. However, if you are worried about your child's health,

growth or development you can contact your health visitor or doctor at any time.

Circle 'yes' or 'no' or 'not sure'

Are you feeling well yourself?

Yes/no/not sure

Have you any worries about your child's health?

Yes/no/not sure

Do you have any worries about how your baby is feeding?

Yes/no/not sure

Are you happy your baby is gaining weight?

Yes/no/not sure

Do you have any worries about your baby's development?

Yes/no/not sure

(see pages 12-13)

Is your baby sitting alone?

Yes/no/not sure

Is your baby using both hands?

Yes/no/not sure

Does your baby babble (Ba-ba, da-da, etc.)?

Yes/no/not sure

Have you any worries about your baby's eyesight?

Yes/no/not sure

Can s/he recognise carer at a distance?

Yes/no/not sure

Have you noticed a squint (eyes not moving together?)

Yes/no/not sure

Do you think your baby can hear you?

Yes/no/not sure

Comment_________________________________________________________________________

__________________________________________________________________________________

Do you have fire guards to stop

Are all your child's immunisations up to date? Yes/no

your child touching heaters

and open fires?

Review at 8-9 months

* Please place a sticker (if available) otherwise write in space provided.

Date of examination ______ /______ /______

Surname

Age in months ____________

First names

NHS number

Local no

Name of examiner

Address___________________________________ Sex M/F

Examiner code number Examination centre

____________________Postcode____________ D.O.B.__ /__ /__

G.P.

Code

H.V.

Code

WEIGHT_____________ kg ________centile

Any previous ongoing medical problems? NO

Yes

HEAD CIRC._________ cm ________centile

If 'Yes' please specify (1) ______________________

(2)________________________

(3) _________________________

ICD Code

ITEM

GUIDE TO CONTENT

CODE (Ring one)*

COMMENT

Physical

Parents observations. Diet.

S P O T R N

Vision

Eye movements. Visual behaviour. Cover test.

S P O T R N

Hearing

Distraction test.

S P O T R N

Locomotion

Sitting. Some weight bearing.

S P O T R N

Manipulation

Transfers. Uses both hands.

S P O T R N

Speech/Lang.

Babble. Responds to speech.

S P O T R N

Behaviour

Knows strangers. Enjoys mirror image.

S P O T R N

Socialisation. Alertness.

Hips

Check for CDH

S P O T R N

Genitalia

Testicular descent (Ring 'N' for girl)

S P O T R N

*(If one or more codes seem to apply select the last one, e.g. R takes priority over T, T over O etc.)

S=Satisfactory (normal result)

Referred to

(1)__________________ (2)______________________

P=Problem (significant condition on record)

(3)___________________________________________

O=Observation (special recall arranged)

T=Treatment or investigation underway

Special recall in________ wks/mths Signature _______________

R=Referred to any community or hospital service

N=Not examined for this item

White copy: Stay in Record Yellow copy: to Child Health Office

Pink copy: to GP/HV

Figure 20.4

Review at eight months

Figure 20.5 Testing hips.

but slightly behind it so that the infant does not see the test

object or the tester’s shadow. The distractor detects whether

the infant turns the head or eyes abruptly towards the sound.

The speed with which the infant responds to the sound is a

useful indication of his alertness. The test sounds should

include those with a known pitch and intensity such as a

warbler. Voice sounds at minimal intensity should include

“psss”, “phth” (for high tones), or “oo” (for low tones). If an

infant fails to turn to the sound, the ability to turn the head to

Figure 20.6 Distraction test.

each side should be assessed. If the infant responds to sounds

on two out of three tests performed on one ear, hearing is

considered normal in that ear. If the infant fails to respond,

the ears should be examined with an auriscope.

The room where the test is performed must be quiet. It

should ideally have a carpet and be removed from the waiting

area and sounds of traffic. The commonest reasons for a child

failing to respond to the test sounds are lack of interest,

tiredness, distraction, wax blocking the external meatus, otitis

media, and lack of familiarity with the test sounds. It is

important to explain to the mother that these are far more

likely reasons for lack of response than deafness and that the

Figure 20.7 High-pitched rattle.

test will be repeated by the same person one month later.

Infants who fail to respond at the second visit should be seen

by an audiologist.

High tone deafness cannot be excluded by these tests and if

Low birthweight

there is a high suspicion of deafness - for example, if the

High plasma bilirubin

infant had a very high plasma bilirubin concentration in the

neonatal period, has congenital rubella syndrome, or has a

Rubella

family history of deafness - the infant should be seen by an

Deafness in family

audiologist even if the results of these simple tests appear

normal. Pure tone audiology may be needed and the

audiologist may have to see the child several times before a

hearing defect can be completely excluded.

Audiologist

Pattern of development

Figure 20.8 Indications for direct referral to the audiologist in the

neonatal period.

Most normal children sit unaided by the age of eight months.

African children tend to advance in most aspects of motor

development faster than other children up to the age of about

seven months. In some families one aspect of development - for

example, sitting, walking, or speech - may be unusually early

or late, the development in all other fields being normal.

Finding that an infant is not sitting by a certain age does

not necessarily mean that he is abnormal, as he may have a

variation of normal development. These children fall into a

group who are late in reaching a developmental milestone and

it is reasonable that they should be referred for further

examination to exclude more sinister problems.

Respiratory infections in the older infant

Infection of the respiratory tract is a common cause of illness

of infants. Although pathogens are often not confined to

anatomical boundaries, the infections may be classified as:

(a) upper respiratory tract - common cold, tonsillitis, and

otitis media; (b) middle respiratory tract - acute laryngitis and

epiglottitis; (c) lower respiratory tract - bronchitis,

bronchiolitis, and pneumonia.

Upper respiratory tract infection is usually the least serious

condition but blockage of the nose by mucus may completely

obstruct the airway in those infants who cannot breathe

through their mouths. Middle respiratory tract infection may

Tonsillitis

totally obstruct airflow at the narrowest part of the airway.

Epiglottitis

Lower respiratory tract infection produces trivial signs initially

but may be lethal within a few hours.

Viruses, which cause most respiratory tract infections, and

Laryngitis

bacterial infections produce similar clinical illness. Different

viruses may produce an identical clinical picture or the same

Figure 21.1 Sites of infection in the upper respiratory tract.

virus may cause different clinical syndromes. Clinically it may

not be possible to determine whether the infection is due to

viruses, bacteria, or both. If the infection is suspected of being

bacterial, it is safest to prescribe an antibiotic, as the results of

virus studies are often received after the acute symptoms have

passed. The commonest bacterial pathogens are pneumococci,

Haemophilus influenzae, group A

-haemolytic streptococci, and

Staphylococcus aureus. Group B streptococci, Gram negative

bacteria, and anaerobic bacteria are less common.

Common cold (coryza)

Box 21.1 Main symptoms of common cold

Preschool children have at least 3-6 colds each year. The main

symptoms are sneezing, nasal discharge, cough, and, rarely,

• Sneezing

• Nasal discharge

fever. Nasal obstruction in infants who cannot breathe through

• Cough

their mouths may cause feeding difficulties and, rarely, brief

• Fever (rare)

periods of apnoea. Similar symptoms may occur in the early

phases of infection with rotavirus and be followed by vomiting

and diarrhoea. Postnasal discharge may produce coughing.

The commonest complication is acute otitis media, but

secondary bacterial infection of the lower respiratory tract

sometimes occurs.

There is no specific treatment for the common cold and

antibiotics should be avoided. If an infant is not able to feed

due to nasal obstruction from mucus, two drops of

0 9% sodium chloride solution can be instilled into each

nostril before feeds three times daily. This will wash the mucus

into the back of the pharynx and relieve the obstruction.

There is a danger with nasal drops that they will run down into

the lower respiratory tract and carry the infection there.

Tonsillitis and pharyngitis

In children aged under three years the commonest presenting

features of tonsillitis are fever and refusal to eat, but a febrile

convulsion may occur at the onset. Older children may

complain of a sore throat or enlarged cervical lymph nodes,

which may or may not be painful. Viral and bacterial causes

cannot be distinguished clinically as a purulent follicular

exudate may be present in both. Ideally, a throat swab should

be sent to the laboratory before starting treatment, to

determine a bacterial cause for the symptoms and to help to

Figure 21.2 Picture of child in highchair pushing food off the table.

Respiratory infections in the older infant

indicate the pathogens currently in the community. There has

been a recurrence of group A haemolytic streptococci in

outbreaks of sore throat and a more liberal use of penicillin is

justified. As this organism is the only important bacterium

Sun

Mon

Tue

Wed

Thurs

causing tonsillitis, penicillin is the drug of choice and the only

justification for using another antibiotic is a convincing history

of hypersensitivity to penicillin. In that case the alternative is

erythromycin. In the absence of an outbreak of group A

Fri

Sat

Sun

Mon

Tue

streptococcus infection the indication for oral penicillin is fever

or severe systemic symptoms. The drug should be continued

for at least 10 days if a streptococcal infection is confirmed.

Parents often stop the drug after a few days as the symptoms

have often abated and the medicine is unpalatable. The

Penicillin

organism is not eradicated unless a full 10-day course is given.

Viral infections often produce two peaks on the

Figure 21.3

Antibiotics should be taken regularly.

temperature chart.

An extensive thick white shaggy exudate on the tonsils

(sometimes invading the pharynx) suggests infectious

mononucleosis and a full blood count, examination of the

blood film, and a Monospot test are indicated. Although rare

in Britain, a membranous exudate on the tonsils suggests

°C

diphtheria and an urgent expert opinion should be sought.

Fluids can be given while there is dysphagia and regular

40.0

paracetamol during the first 24-48 hours reduces fever and

39.5

discomfort.

A peritonsillar abscess (quinsy) is now extremely rare. It

39.0

displaces the tonsil medially so that the swollen soft palate

38.5

obscures the tonsil and the uvula is displaced across the

midline. The advice of an otolaryngology surgeon is needed

38.0

urgently.

37.5

37.0

Otitis media

Pain is the main symptom of acute otitis media and is one of

Days

the few causes of a fretful infant who cries all night. The pain is

relieved if the media drum ruptures. Viruses probably cause

Figure 21.4

Temperature chart in a viral infection.

over half the cases of acute otitis, but a viral or bacterial origin

cannot be distinguished clinically. The commonest bacteria are

pneumococci, group A

-haemolytic streptococci, and

H. influenzae.

Children are often fascinated by the light of the auriscope

and the auriscope speculum can be placed on a doll or the

child’s forearm for reassurance. Gentleness is essential and the

speculum should never be pushed too far into the external

meatus because this causes pain. If the pinna is pulled gently

outwards and downwards to open the meatal canal, the

tympanic membrane is visible with the tip of the speculum in

the outer end of the meatus. In early cases of otitis media there

are dilated vessels over the upper and posterior part of the

drum. Later, the tympanic membrane becomes red, congested,

and bulging and the light reflex is lost. Swelling or tenderness

behind the pinna should always be sought, as mastoiditis can

be easily missed.

The choice of initial treatment lies between amoxycillin

and erythromycin. If there is no improvement in the drums

after two or three days, another antibiotic should be

substituted. Cefaclor or amoxycillin with clavulanic acid may be

included in the second line drugs. The duration of the course

of antibiotics is controversial. The most common view is that

antibiotics should be given for seven days and the ears

examined again before the course is stopped. There is some

evidence that short courses of 3-5 days of antibiotics given at

high doses may be as effective as the longer courses. Ideally, a

hearing test should be performed three months after each

attack of acute otitis media to detect residual deafness and

Figure 21.5

Auriscope.

ABC of the First Year

“glue ear”. One study showed that after the first attack of acute

otitis media in infants, which was treated with antimicrobial

agents, 40% of patients had no middle ear effusion after one

month and 90% after three months.

Stridor

Stridor is noisy breathing caused by obstruction in the

pharynx, larynx, or trachea. It may be distinguished from

partial obstruction of the bronchi by the absence of rhonchi.

Although most cases are due to acute laryngitis and may

resolve with the minimum of care, similar features may be due

to a foreign body and may cause sudden death.

Stridor is recognised as one of the most ominous signs in

childhood. Any doctor should be able to recognise the sound

over the telephone and arrange to see the child immediately.

Examination of the throat may precipitate total obstruction of

the airway and should be attempted only in the presence of an

anaesthetist and facilities for intubation.

A glance at the child will show whether urgent treatment is

needed or whether there is time for a detailed history to be

taken. The doctor needs to know when the symptoms started and

Figure 21.6

Acute otitis media.

whether there is nasal discharge or cough. Choking over food,

especially peanuts, or the abrupt onset of symptoms after playing

alone with small objects suggests that a foreign body is present.

During the taking of the history and the examination

mothers should remain near their children and be encouraged

to hold them and to talk to them. All unpleasant procedures,

Box 21.2 Procedures to be avoided in the presence of

such as venepuncture, should be avoided. This reduces the

stridor

possibility of struggling, which may precipitate complete airway

Throat examination

obstruction. Agitation and struggling raise the peak flow rate

Venepuncture

Cardiac arrest

and move secretions, which results in increased hypoxia and

Struggling

the production of more secretions.

Acute laryngotracheitis

Acute laryngitis causes partial obstruction of the larynx. It is

characterised by inspiratory and expiratory stridor (noisy

breathing), cough, and hoarseness. The laryngeal obstruction

is due to oedema, spasm, and secretions. Affected children are

usually aged six months to three years, and the symptoms are

most severe in the early hours of the morning. Recession of the

intercostal spaces indicates significant obstruction and cyanosis

or drowsiness shows that total obstruction of the airway is

imminent.

A child often improves considerably after inhaling steam,

which is provided easily by turning on the hot taps in the

bathroom. Mild cases may be treated successfully at home

using this method, but children must be visited every few hours

to determine whether they are deteriorating and need to be

admitted to hospital. Continuous stridor or recession demands

Figure 21.7 Substernal recession.

urgent hospital admission. Hypoxaemia or thirst may cause

restlessness and should be corrected and sedatives avoided.

Nebulised adrenaline or betamethasone may produce

considerable improvement in symptoms within an hour. Rarely,

the obstruction needs to be relieved by passing an

endotracheal tube or performing a tracheostomy.

Acute laryngotracheitis is usually caused by a viral infection

and therefore infants with mild symptoms do not need

Box 21.3 Restlessness could indicate:

antibiotics. In a few cases Staph. aureus or H. influenzae is

• hypoxia

present and the associated septicaemia makes the child appear

• thirst

very ill. Bacterial infection is characterised by plaques of debris

• hunger

and pus on the surface of the trachea, partially obstructing it,

• fear

just below the vocal cords. Acute epiglottitis and acute

Respiratory infections in the older infant

laryngitis may be indistinguishable clinically since stridor and

progressive upper airway obstruction are the main features of

both. If bacterial infection is suspected cefotaxime is given

intravenously. Some paediatricians give steroids as well. The

dose of hydrocortisone is 100 mg intramuscularly or

intravenously repeated once after two hours. No effect is seen

for at least two hours. Later, betamethasone should be given at

a dose of 3 mg intravenously every six hours but only until

signs of improvement appear. Children with severe symptoms

should be managed in the intensive care unit.

Figure 21.8

Oximeter for measuring blood oxygen saturation.

Children with epiglottitis are usually aged over 2 years;

drooling and dysphagia are common, and the child usually

wants to sit upright. When the obstruction is very severe, the

stridor becomes ominously quieter. There is usually an

associated septicaemia with H. influenzae. Epiglottitis is now

rare due to the Hib vaccine.

Other causes of stridor

Even if the symptoms have settled and there are no abnormal

signs, a history of the onset of sudden choking or coughing

can never be ignored. A radiograph of the neck and chest

should be taken and may show a hypertranslucent lung

obstructed by a foreign body, a shift of the mediastinum, or,

less commonly, collapse of part of the lung or a radio-opaque

foreign body. The radiograph may be considered normal.

Bronchoscopy may be needed to exclude a foreign body even

if the chest radiograph appears to be normal. Stridor in a child

who has had scalds or burns or has inhaled steam from a kettle

suggests that intubation or tracheostomy may be needed

Figure 21.9

Foreign body in right main bronchus (tooth).

urgently.

If the cause of stridor is likely to be a foreign body below

the larynx, the object should be removed immediately by a

thoracic surgeon in the main or accident and emergency

operating theatre. If the object is above the larynx and if an

ENT surgeon or anaesthetist is not immediately available and

the child is deteriorating, the safest treatment is to insert a wide

needle, such as Medicut size 14, into the trachea in the midline

just below the thyroid cartilage. It may be preferable to insert

two needles. No attempt should be made to look at the mouth

or throat or remove the object, as the struggling that may follow

may impact the object and prove fatal. A first aid measure

usually performed before arrival is to slap the infant’s back

between the shoulder blades while holding the infant upside

down by the legs. The child should remain in the position he or

she finds most comfortable, which is usually upright. Forceful

attempts to make the child lie flat - for example, for a

radiograph - may result in complete airway obstruction.

Infants with congenital largyngeal stridor, which is due to

Figure 21.10 Slapping the back to dislodge a foreign body.

loose aryepiglottic folds, usually have inspiratory stridor only.

The symptoms begin during the first few weeks of life and

usually persist for several months, becoming more severe

during episodes of upper respiratory tract infections or while

crying, but subsiding in sleep.

Acute bronchitis

Acute bronchitis often follows a viral upper respiratory tract

Box 21.4 Upper limit for normal respiratory rate related

infection; there is always a cough, which may be accompanied

to age

by wheezing. There is no fever or difficulty with feeding. The

respiratory rate is normal and the symptoms resolve within a

2 months

60/min

week. The only signs, which are not always present

2-11 months

50/min

continuously, are rhonchi. Since bronchitis is usually due to a

12-60 months

40/min

virus, antibiotics are indicated only if secondary bacterial

infection is suspected.

ABC of the First Year

Acute bronchiolitis

Acute bronchiolitis is an acute infection that occurs in winter

epidemics in infants aged under one year. For the first few days

there may be only a rasping cough but deterioration may occur

within a few hours, causing a raised respiratory rate, indrawing

of the intercostal spaces, cyanosis, drowsiness, and apparent

enlargement of the liver. The respiratory syncytial virus is found

in over 70% of cases. During epidemics the disease may be

recognised at an early stage, but at the beginning of epidemics

the condition may be recognised only when the infant is

moribund. Signs in the chest vary at different stages of the

illness and there may be no adventitious sounds. The chest

radiograph may appear normal even in severely ill infants. In

units with ELISA or immunofluorescence techniques for

diagnosing respiratory syncytial virus, results are available the

same day, treatment can be planned, and cross infection

avoided. Oxygen is the most important aspect of treatment and

is efficiently given by a nasal cannula with a special low flow

Figure 21.11

Oxygen given by a nasal cannula.

regulator. Most infants need intragastric tube feeding or

intravenous fluids for a few days. Where a viral cause can be

confirmed immediately, antibiotics can be avoided but they

should not be withheld from severely ill infants, as there is a

possibility of additional bacterial infection. A few infants

develop progressive respiratory distress and intermittent

positive pressure ventilation may have to be considered.

The infant is discharged from hospital when feeding is

normal. The cough may persist for six weeks, but if there is no

improvement after three weeks, a sweat test should be

performed to exclude cystic fibrosis.

Bronchopneumonia and segmental

pneumonia

Pneumonia is acute inflammation of the lung alveoli. In

bronchopneumonia the infection is spread throughout the

bronchial tree whereas in segmental pneumonia it is confined

to the alveoli in one segment or lobe. A raised respiratory rate

at rest or indrawing of the intercostal spaces distinguishes

pneumonia from bronchitis. The upper limit for a normal

respiratory rate is related to age (see Box 21.4). Cough, fever,

and flaring of the alae nasi are usually present and there may

be reduced breath sounds over the affected area as well as

crepitations. A chest radiograph, which is needed for every

child with suspected pneumonia, may show extensive changes

when there are no localising signs in the chest. The

radiograph may show an opacity confined to a single segment

or lobe, but there may be bilateral patchy changes. Bacterial

cultures of throat swabs and blood should be performed

before treatment is started. Ideally, nasopharyngeal secretions

should be studied virologically and virus antibody titres of

serum collected in the acute and convalescent phases should

be measured.

Children with pneumonia are best treated in hospital, as

they may need oxygen treatment. Antibiotics should be

prescribed for all cases of pneumonia, although a viral cause

may be discovered later. If the child is not vomiting and not

severely ill, oral erythromycin or amoxycillin is given.

Cefotaxime is given intravenously if the symptoms are severe,

and erythromycin is added when failure to improve promptly

suggests infection with mycoplasma or chlamydia. Antibiotic

treatment can be modified when the results of bacterial

cultures are available. Intravenous fluids may be needed.

The chest radiograph of a child with segmental or lobar

pneumonia should be repeated after one month.

Figure 21.12

Chest radiograph showing pneumonia in the right lung.

Respiratory infections in the older infant

Recurrent respiratory infections

Although all doctors concerned with children are familiar with

the catarrhal child, the exact pathology of the condition is

unknown and it is called by many names - postnasal discharge,

perennial rhinitis, or recurrent bronchitis. These children have

an increased incidence of colds, tonsillitis, and acute otitis

media. Recurrent episodes of symptoms such as fever, nasal

discharge, and cough are most common during the second

half of the first year of life, the first two years at nursery school,

and the first two years at primary school. Recurrent viral or

bacterial infections contracted from siblings or fellow pupils

may be important, but the considerable differences between

the behaviour of children in the same family suggest the

possibility of a temporary immunological defect.

Various treatments including nasal drops and oral

preparations of antihistamines are given with little effect.

A chest radiograph should be performed to exclude persistent

segmental or lobar collapse. A sweat test should be carried out

to exclude cystic fibrosis and plasma immunoglobulin studies

Figure 21.13 Normal chest radiograph.

should be conducted to exclude rare syndromes.

Recurrent bronchitis

Box 21.5

Causes of recurrent cough and wheezing

Two separate episodes of acute bronchitis may occur in a

Recurrent bronchitis

normal child in a year. If attacks are more frequent at any age,

Bronchial asthma

bronchial asthma should be considered. Viruses cause the

majority of attacks of bronchitis and will precipitate most

attacks of bronchial asthma. Some paediatricians have

reverted recently to the older terms recurrent or wheezy

bronchitis, as most children with these features become free of

symptoms by the age of five. Although the pathological

processes and prognosis may differ between recurrent

bronchitis and bronchial asthma, there is no clinical or

laboratory method of distinguishing between them and

treatment is the same.

After an episode of severe symptoms during an infection

with respiratory syncytial virus (bronchiolitis), many children

have recurrent episodes of cough and wheezing during the

subsequent four years. It is not known whether the respiratory

syncytial virus predisposes the child to recurrent respiratory

symptoms or whether the child has a predisposition

Figure 21.14

Small spacer device with a face mask.

to produce severe symptoms with viral respiratory infections.

If there is a persistent or recurrent cough, a chest

radiograph should be performed to exclude persistent

segmental or lobar collapse. A Mantoux test for tuberculosis

and a sweat test to exclude cystic fibrosis should be performed

and plasma concentrations of immunoglobulins and IgG

subclasses should be measured to exclude transient or

permanent immune deficiencies.

The management of recurrent bronchitis or bronchial

asthma is the same. For infants with mild symptoms an oral

bronchodilator, for example salbutamol, can be given at the

beginning of an episode and continued for a week. If this is

not effective, a bronchodilator can be given by a small spacer

device with a face mask or by air pump and nebuliser. Infants

with severe or frequent episodes can be given an inhaled

steroid as a prophylactic drug for six weeks and the course can

be extended to six months if there is an improvement in

symptoms.

Prophylactic drugs can be given with a small spacer device

or by an air pump and nebuliser. If infants are receiving

both a bronchodilator and a prophylactic drug, the dose

of bronchodilator should be given just before the

prophylactic drug.

Figure 21.15

Air pump and nebuliser.

Whooping cough

Young infants receive no protective immunity to whooping

cough from their mothers and have the highest incidence of

complications. Immunisation is directed at increasing herd

Measles

immunity and reducing the exposure of infants to older

Whooping cough

children who have the disease. Recent changes in advice on

contraindications to whooping cough vaccine have been

associated with the increased use of this vaccine.

Contraindications to immunisation

Convulsions and encephalopathy have been reported as rare

complications, but these conditions may arise from other

causes and be falsely attributed to the vaccine. Neurological

complications after whooping cough itself are considerably

more common than after the vaccine.

As with any other elective immunisation procedure, if a

child is suffering from any acute illness then vaccination

should be postponed until the child has fully recovered.

1988

1989

1990

1991

1992

Minor infections without fever or systemic upset, however, are

not reasons to delay immunisation. Vaccination should not be

Year

carried out in children who have a history of a severe local or

general reaction to a preceding dose; the following reactions

Figure 22.1 Prevalence of measles and whooping cough.

should be regarded as severe.

(Source: OPCS)

Local - an extensive area of redness and swelling, which

becomes indurated and covers most of the anterolateral

surface of the thigh or a major part of the circumference of

the upper arm.

Box 22.1 Mothers can fill out a card in the waiting room at

General - fever (a temperature of 39 5 C or higher) within

each visit for immunisation

48 hours of vaccination, anaphylaxis, bronchospasm, laryngeal

Is the baby unwell in any way? YES/NO

oedema, generalised collapse, prolonged unresponsiveness,

Has the baby had any side effects from previous immunisation?

prolonged inconsolable screaming, and convulsions occurring

YES/NO

within 72 hours.

Did the baby behave normally during the first week of life? YES/NO

A personal or family history of allergy is not a

Has the baby, or anyone in the immediate family, ever had fits or

contraindication to immunisation against whooping cough;

convulsions? YES/NO

nor are stable neurological conditions such as cerebral palsy or

Is the baby developing normally? YES/NO

spina bifida.

Children with problem histories

When there is a personal or family history of febrile convulsions

then there is an increased risk of these occurring after

Box 22.2 Post-immunisation fever

pertussis immunisation. In such children immunisation is

The doctor should advise the parent that if fever develops after

recommended, but advice on the prevention of fever (see Box 22.2)

immunisation the child may be given a dose of paracetamol followed,

should be given at the time of immunisation.

if necessary, by a second dose 4-6 hours later. The dose of paracetamol

In a recent British study, children with a family history of

for post-immunisation fever for an infant aged 2-3 months is 60 mg; an

epilepsy were immunised with pertussis vaccine without any

oral syringe can be obtained from any pharmacy to give the small

appreciable adverse events. These children’s developmental

volume required. The doctor should warn the parent that medical

progress has been normal. In children who have a close (first

advice should be sought if the fever persists after the second dose.

degree) relative with idiopathic epilepsy there may be a risk of

developing a similar condition, irrespective of whether they are

vaccinated. Immunisation is recommended for these children.

When there is a still evolving neurological problem

immunisation should be deferred until the condition is stable.

When there has been a documented history of cerebral damage

in the neonatal period immunisation should be carried out unless

there is evidence of an evolving neurological abnormality. If

immunisation is to be deferred, this should be stated on the

neonatal discharge summary. When there is doubt,

appropriate advice should be sought from a consultant

paediatrician, district immunisation coordinator, or consultant

in public health medicine rather than withholding the vaccine.

Whooping cough

Diagnosis

Catarrhal phase Paroxysmal phase

Convalescent phase

Whooping cough is difficult to diagnose during the first

7-14 days of the illness (catarrhal phase), when there is a short

dry cough at night. Later, bouts of 10-20 short dry coughs

occur day and night; each is on the same high note or rises in

Short dry Vomiting and whooping

pitch. A long attack of coughing is followed by a sharp

indrawing of breath, which may produce the crowing sound or

cough

Bouts of 10-20 coughs

Coughing

whoop. Some children, especially babies, with Bordetella pertussis

at night

at day and night

infection never develop the whoop. Feeding with crumbly food

often provokes a coughing spasm, which may culminate in

vomiting. Afterwards there is a short period when the child can

be fed again without provoking coughing. In uncomplicated

Weeks

cases there are no abnormal respiratory signs.

The most important differential diagnosis in infants is

Figure 22.2

Phases of whooping cough.

bronchiolitis; this is usually due to the respiratory syncytial

virus, which produces epidemics of winter cough in infants

under one year. For the first few days there may be only bouts

of vibratory rasping cough, which never produce a whoop.

Later, rhonchi or crepitations are heard in the chest and the

infant either deteriorates or improves rapidly within a few days.

Older siblings infected with the virus may have a milder illness.

Other viruses may cause acute bronchitis with coughing but

there are seldom more than two coughs at a time.

A properly taken pernasal swab plated promptly on a

specific medium should reveal B. pertussis in most patients

during the first few weeks of the illness. A blood lymphocyte

count of 10

10⁹/l or more with normal erythrocyte

sedimentation rate suggests whooping cough.

Management

If the diagnosis is suspected in the catarrhal phase (usually

because a sibling has had recognisable whooping cough) a

10-day course of erythromycin may be given to the child and to

other children in the home. Parents must be warned that an

antibiotic may shorten the course of the disease only in the

early stages and is unlikely to affect established illness. Vomiting

Figure 22.3

Pernasal swab for culture of B. pertussis.

can be treated by giving soft, not crumbly, food or small

amounts of fluid hourly.

No medicine reliably reduces the cough. Oral salbutamol

has been used in a dosage of 0.3 mg/kg/24 hours divided into

three doses, When sleep is disturbed some authorities

recommend that the child should be given a bedtime dose of

3-5 mg/kg of phenobarbitone. In severe cases mothers can be

taught to give physiotherapy, which may help to clear

secretions, especially before the infant goes to sleep. An attack

may be stopped by a gentle slap on the back.

The threshold for admission to hospital should be lower for

children aged under six months. Convulsions and cyanosis

during coughing attacks are absolute indications for admission

to an isolation cubicle. Parents often become exhausted by

sleep loss and arranging for different members of the family to

sleep with the child will give the mother a respite. The cough

usually lasts for 8-12 weeks and may recur when the child has

any new viral respiratory infection during the subsequent year.

If the child is generally ill or the cough has not improved after

six weeks, a chest radiograph should be performed to exclude

bronchopneumonia or lobar collapse, which need treatment

with physiotherapy and antibiotics. Long term effects on the

lung, such as bronchiectasis, are rare in developed countries.

The infant will not be infective for other children after

about four weeks from the beginning of the illness or about

two days after erythromycin is started. The incubation period

is about seven days and contacts who have no symptoms two

weeks after exposure have usually escaped infection.

Figure 22.4

Normal radiograph.

Fever in the older infant

Examining an ill child

Infants should be allowed to adopt whatever position they like

(usually on their mother’s knee) where they can be observed.

The history taken from the mother must contain enough detail

to provide a differential diagnosis before the physical

examination begins.

A systematic examination may prove impossible in a

protesting infant, so the most relevant system should be

examined first. If the infant objects to being fully undressed,

only the part being examined need be exposed. The examiner

needs warm hands and should talk to the infant continuously

to soothe him. Patience and gentleness at this stage are often

rewarded by the infant accepting a full examination without

protest.

The baby’s abdomen is best examined as the infant lies on

his mother’s knees during a feed. Abdominal breathing is

normal and the edge of the liver is easily palpable. Even the

newborn will show abdominal tenderness by grimacing or

Figure 23.1

Throat examination.

crying. Rectal examination may be performed with the little

finger.

Instruments such as auriscopes and stethoscopes should be

shown to the infant first and rested on his forearm so that he

can see what they are. The auriscope must be used gently and

the speculum not pushed too far into the external meatus.

When the pinna is pulled gently outwards and downwards, the

tympanic membrane can be seen with the tip of the speculum

in the outer end of the meatus.

Examination of the throat, which is the most disliked

procedure, should be left until last. It should never be

performed in an infant with stridor unless the examiner has

the facilities to intubate the infant immediately.

The infant should be examined again no longer than

24 hours later and the initiative for this review should not be

left to the parents, who may not appreciate the danger of

features that have developed.

The normal oral or rectal temperature is about 37.5 C

(99.5 F) and the normal axillary (skin) temperature 37.0 C

(98.4 F). If the temperature is 0.5 C above these levels, the

infant has a fever. In the prodromal period of any infectious

Figure 23.2

Ear examination.

disease of childhood, fever may be the only symptom.

Specific causes

Tonsillitis - There may be small areas of pus on the tonsils or

the throat may be generally red. The presence of pus does not

help to distinguish between bacterial infection due to group A

streptococcus (Streptococcus pyogenes) and a viral infection.

Petechiae on the soft palate usually indicate a viral infection.

A throat swab should be taken and a 10-day course of oral

penicillin given (see p. 82).

Acute otitis media - An early sign is an increase in the size of

the vessels of the upper posterior part of the drum. Later the

drum becomes dull pink or red and in severe cases there is

bulging. Ear drums can be examined efficiently only if the

auriscope has a magnifying lens. It is important to look for

swelling or tenderness over the mastoids. The first choice of

drugs is oral amoxycillin or erythromycin. If these are not

effective, amoxycillin with clavulanic acid or cefalexin is given.

The drum should be examined again after two days and if

there is no improvement the antibiotic should be changed.

Figure 23.3

Auriscope.

ABC of the First Year

carried out during the acute phase, cystourethrography is

performed when the urine is sterile, and isotope (^90mTc

dimercaptosuccinic acid (DMSA)) scanning is carried out at

least six weeks after the acute phase. DMSA scanning detects

scars, ultrasound examination shows obstructive lesions, and

cystourethrography detects vesicoureteric reflux and should be

performed under the protection of a suitable antibiotic.

Regular urine cultures are advisable at three monthly

intervals as well as at times of fever or recurrence of symptoms.

The urine should be cultured regularly while vesicoureteric

reflux persists and in children with renal damage at least until

the age of five years. The child’s growth and blood pressure

should be measured regularly.

Figure 23.7

Regular repeated examinations of the urine.

Pneumonia - A raised respiratory rate at rest and fever may

be the only signs of pneumonia and a chest radiograph may be

necessary to show consolidation. The upper limit for the

normal respiratory rate is 60 per minute for infants less than

two months of age and 50 per minute between two and

12 months. Movements of the alae nasi and indrawing of the

chest wall between the ribs are confirmatory signs.

Osteomyelitis or septic arthritis may present with fever. In the

early stages the only helpful sign may be the infant’s reluctance

to move a limb and radiographs are often normal. Later there

is redness, swelling, and tenderness at the site of the

osteomyelitis, which usually affects the maxilla, long bones, or

vertebrae in infants. Early blood culture and radioisotope bone

scans are helpful in the diagnosis.

Malaria - If within the previous two years the child has

been in an area where malaria is endemic, blood films should

be examined immediately for malarial parasites. The parasites

are most numerous during fever but may be found at any time.

Figure 23.8

Ultrasound scan of kidney: dilated renal pelvis.

Pyrexia of undetermined origin

Infants have no localising symptoms or signs. If they simply

have fever, they should be seen again within a few hours or

admitted to a cubicle on a children’s ward for observation.

Usually these children will have a full blood count, urine

microscopy, and culture and sometimes blood culture and CSF

examination.

Persistent fever lasting more than a few days should prompt

the consideration of Kawasaki disease. Features include

conjunctivitis, cracked lips, red throat, cervical

lymphadenopathy, blotchy rash, oedema of the hands and feet,

and reddening of the palms and soles. In the second week

there may be peeling of the skin of the finger tips and toes.

Figure 23.9

Malarial parasite in red cell.

Prompt admission for intravenous gammaglobulin reduces the

risk of coronary artery aneurysms.

Microscopy

Culture

Protein

Glucose

Figure 23.10 Urine examination.

Convulsions in the older infant

In infants between the ages of one month and one year

Box 24.1 Features of a tonic clonic convulsion

convulsions are usually associated with fever. If there is no

fever, epilepsy should be considered.

Tonic

Fits can be divided into generalised or partial seizures.

• Cry

Generalised seizures include tonic-clonic and myoclonic fits.

• Loss of consciousness

Partial seizures include focal and temporal lobe fits. During

• Rigidity

some episodes partial seizures may be followed by generalised

• Apnoea

seizures.

Generalised tonic-clonic fits are the most common type.

Clonic

The child may appear irritable or show other unusual

• Repetitive limb movement (rate can be counted)

behaviour for a few minutes before an attack. Sudden loss of

Sleep

consciousness occurs during the tonic phase, which lasts

20-30 seconds and is accompanied by temporary cessation of

respiratory movements and central cyanosis. The clonic phase

follows and there are jerky movements of the limbs and face.

The movements gradually stop and the child may sleep for a

few minutes before waking confused and irritable.

Although a typical tonic-clonic attack is easily recognised,

Box 24.2 Dangers

other forms of fits may be difficult to diagnose from the

• Inhalation of vomit

mother’s history. Infantile spasms may begin with momentary

• Hypoxaemia

episodes of loss of tone, which can occur in bouts and be

followed by fits in which the head may suddenly drop forward

or the whole infant may move momentarily like a frog.

Recurrent episodes with similar features, whether they are

changes in the level of consciousness or involuntary

movements, should raise the possibility of fits.

Differential diagnosis

Convulsions must be differentiated from blue breath holding

Box 24.3 Breath holding attack

attacks, which usually begin at 9-18 months. Immediately after

Pain or frustration

a frustrating or painful experience infants cry vigorously and

? Breath holding attack

suddenly hold their breath, become cyanosed, and in the most

severe cases lose consciousness. Rarely, their limbs become

rigid and there may be a few clonic movements lasting a few

seconds. Respiratory movements begin again and infants gain

consciousness immediately. The attacks diminish with age with

no specific treatment. The mother may be helped to manage

these extremely frightening episodes by being told that the

child will not die and that she should handle each attack

consistently by putting the child on his side.

Rigors may occur in any acute febrile illness, but there is no

loss of consciousness.

Febrile convulsions

A febrile convulsion is a fit occurring in a child aged from six

Box 24.4 Simple febrile convulsions

months to five years, precipitated by fever arising from

All the following:

infection outside the nervous system in a child who is

•

20 minutes

otherwise neurologically normal.

• No focal features

Convulsions with fever include any convulsion in a child of

• Six months to five years

any age with fever of any cause. Among children who have

• No developmental or neurological abnormalities

convulsions with fever are those with pyogenic or viral

• Not repeated in the same episode

meningitis, encephalitis, or cerebral palsy with intercurrent

• Complete recovery within one hour

infections. Children who have a prolonged fit or who have not

completely recovered within one hour should be suspected of

having one of these conditions.

Most of the fits that occur between the ages of six months

and five years are simple febrile convulsions and have an

excellent prognosis.

ABC of the First Year

By arbitrary definition, in simple febrile convulsions the fit

lasts less than 20 minutes, there are no focal features, and the

child is aged between six months and five years and has been

developing normally.

Often fever is recognised only when a convulsion has

already occurred. Febrile convulsions are usually of the tonic-

clonic type. The objective of emergency treatment is the

prevention of a prolonged fit (lasting over 20 minutes), which

may be followed by permanent brain damage, epilepsy, and

developmental delay.

An electroencephalogram (EEG) is not a guide to

diagnosis, treatment, or prognosis.

Emergency treatment

Figure 24.1

Position should be on the side or prone with the head to

one side.

A child who has fever should have all his clothes removed and

should be covered with a sheet only. He should be nursed on

his side or prone with his head to one side because vomiting

with aspiration is a constant hazard.

Rectal diazepam (0.5 mg/kg) produces an effective blood

concentration of anticonvulsant within 10 minutes. The most

convenient preparation resembles a toothpaste tube (Stesolid).

Early admission to hospital or transfer to the intensive care

unit should be considered if a second dose of anticonvulsant is

needed.

All children who have had a first febrile convulsion should

be admitted to hospital to exclude meningitis and to educate

the parents, as many fear that their child is dying during the

fit. Physical examination at this stage usually does not show a

cause for the fever, but a specimen of urine should be

examined in the laboratory to exclude infection and a blood

glucose test should be performed. Blood should be taken for

blood culture and plasma glucose and calcium estimations.

Most of these children have a generalised viral infection with

viraemia. A febrile convulsion may occur in roseola at the

onset and three days later the rash appears. Occasionally, acute

Figure 24.2

Rectal diazepam tube.

otitis media is present, in which case an antibiotic is indicated,

but most children with febrile convulsions do not need an

antibiotic. A pupuric rash suggests meningococcal septicaemia

and the need for penicillin to be given immediately either

intravenously or intramuscularly (see p. 91).

Lumbar puncture - A lumbar puncture should be performed

if the child is under 18 months old or any of the following are

present:

• signs of meningism such as neck stiffness

• drowsiness, irritability, or systemic illness

• complex convulsion that contains any feature that does not

conform with the definitions of a simple convulsion.

Ideally, the decision should be taken by an experienced

doctor, who may decide on clinical grounds that lumbar

puncture is unnecessary even in a younger child, but when in

doubt the investigation should be performed. The doctor

deciding not to undertake a lumbar puncture should review

the patient personally within a few hours. Children less than

two years of age may have meningitis with no neck stiffness or

other specific signs.

A child who has had severe vomiting or is in coma must be

examined by an experienced doctor before lumbar puncture

because of the risk of coning.

Management of fever - There is no evidence that antipyretic

treatment influences the recurrence of febrile convulsions, but

fever should be treated to promote the comfort of the child

and to prevent dehydration. The child’s clothes should be

taken off and he should be covered with a sheet only.

Figure 24.3

Repeated similar movements indicate a convulsion.

Convulsions in the older infant

Paracetamol is the preferred antipyretic and adequate fluid

should be given.

Failure to respond to paracetamol is an indication to add

ibuprofen to the paracetamol or to give ibuprofen alone.

Anticonvulsant drugs - Rectal diazepam should be used as

soon as possible after the onset of the convulsion. The parents

should be advised not to give it if the convulsion has stopped.

The indications for long term anticouvulsant prophylaxis

have changed and the sole indication - frequent recurrences,

which should be treated with phenobarbitone - is rare. There

PARACETAMOL

is no evidence that in the minority of children who later

develop epilepsy the prophylactic use of anticonvulsant drugs

would have prevented it.

Immunisation

As routine immunisation is given to children 2-4 months old,

this schedule is usually completed before febrile convulsions

Figure 24.4

Paracetamol is the preferred antipyretic.

occur. Babies having convulsions with fever aged under six

months should be assessed by a paediatrician. Children who

have febrile convulsions before immunisation against

diphtheria, pertussis, and tetanus because the immunisation

has been delayed should be immunised after their parents have

been instructed about the management of fever and the use of

rectal diazepam.

Measles, mumps, and rubella immunisation should be given

as usual to children who have had febrile convulsions, with advice

about the management of fever to the parents. Rectal diazepam

should be made available for use should a convulsion occur.

Local reaction

Prognosis

Unless there is clinical doubt about the child’s current

developmental or neurological state, parents should be told

that prognosis for development is excellent. The risk of

subsequent epilepsy after a single febrile convulsion with no

complex features is about 1%. With each additional complex

feature the risk rises to 13% in those children with two or more

complex features. Only about 1% of children with febrile

Figure 24.5

Immunisation may be followed by a febrile convulsion.

convulsions are in this group.

The risk of having further febrile convulsions is about 30%.

This risk increases in younger infants and is about 50% in

infants aged under one year at the time of their first

Box 24.5

Features of complex febrile convulsions

convulsion. A history of febrile convulsions in a first degree

• Lasting

20 minutes

relative is also associated with a risk of recurrence of about

• Focal

50%. A complex convulsion or a family history of epilepsy is

• More than one on the same day

probably associated with an increase in the risk of further

• Developmental or neurological abnormalities

febrile convulsions.

Information for parents

Information for parents should include:

• an explanation of the nature of febrile convulsions,

including information about the prevalence and prognosis

• instructions about the management of fever, the

management of a convulsion, and the use of rectal diazepam

• reassurance.

Verbal and written advice should be given (see p. 96).

Basic life support in the community

Box 24.6 ABC of basic life support

• Airway

Basic life support (BLS) should be given immediately whenever

• Breathing

an infant stops breathing, even if no specialised equipment is

• Circulation

available. It may be life saving.

ABC of the First Year

Advice to parents: Febrile convulsions

Your child has had a febrile convulsion. We know it was a very

Do febrile convulsions cause permanent brain damage?

frightening experience for you. You may have thought that your child

Almost never. Very rarely, a child who has a very prolonged febrile

was dead or dying, as many parents think that when they first see a

convulsion lasting half an hour or more may suffer permanent

febrile convulsion. Febrile convulsions are not as serious as they

damage from it.

appear.

What starts febrile convulsions?

What is a febrile convulsion?

Any illness that causes a high temperature, usually a cold or other

It is an attack brought on by fever in a child aged between six months

virus infection

and five years.

Will it happen again?

What is a convulsion?

Three out of 10 children who have a febrile convulsion will have

A convulsion is an attack in which the child becomes unconscious

another one. The risk of having another febrile convulsion falls

and usually stiff, with jerking of the arms and legs. It is caused by

rapidly after the age of three years.

unusual electrical activity of the brain. The words convulsion, fit, and

Does the child suffer discomfort or pain during a

seizure have the same meaning.

convulsion?

What shall I do if my child has another convulsion?

No. The child is unconscious and unaware of what is happening.

Lay him on his side, with his head on the same level or slightly lower

What shall I do if my child has fever?

than the body. Note the time. Do not try to force anything into his

You can take the child’s temperature by placing the bulb of the

mouth. Do not slap or shake the child.

thermometer under his armpit for three minutes with his arm held

The hospital may give you medicine to insert into your child’s

against his side. Keep him cool by taking off his clothes and reducing

bottom. This is called rectal diazepam. If the convulsion has not

the room temperature. Give plenty of fluids to drink. Give children’s

stopped by the time that you have found the tube, insert it into the

paracetamol medicine to reduce the temperature. The following

child’s bottom and express the contents of the tube. This treatment

doses should be given:

should stop the convulsion within 10 minutes. If it does not, take your

Up to 1 year old

one 5 ml spoonful (120 mg)

child to the hospital. You may need to dial

999 to obtain an

Aged 1 to 3 years

two 5 ml spoonfuls (240 mg)

ambulance. Let your doctor know what has happened.

Aged 4 years and over

three 5 ml spoonfuls (360 mg).

About one child in 30 will have had a febrile convulsion by the age

Repeat the dose every four hours until the temperature falls to

of five years.

normal, and then every six hours for the next 24 hours.

Is it epilepsy?

If the child seems ill or has ear ache or sore throat, let your doctor

No. The word epilepsy is applied to fits without fever, usually in older

see him or her in case any other treatment, such as an antibiotic, is

children and adults.

needed. Antibiotics are not necessary for most children with fever

due to virus infections.

Do febrile convulsions lead to epilepsy?

Rarely; 99 out of 100 children with febrile convulsions never have

Is regular treatment with tablets or medicine necessary?

convulsions after they reach school age, and never have fits without

Usually not. The doctor will explain to you if your child needs regular

fever.

medicine.

Adapted from a pamphlet produced by the British Paediatric Association

Assessment of condition

Box 24.7 Sequence of basic life support

The level of consciousness of the infant should be quickly

• Call for help

assessed by gentle pressure on the shoulders or limbs together

with a verbal command. Even young infants may open their

• Check environment is safe

eyes or move in response to sound if they are not unconscious.

• Assess condition

Young infants should not be shaken as this may result in brain

• Airway

haemorrhage from trauma caused by the mobile brain hitting

• Breathing

the inside of the skull. If the infant is not responsive, then the

• Circulation

ABC of basic life support should be followed.

Airway

The rescuer can assess whether the infant is breathing by

placing their face closely above the infant’s face in order to

look, listen, and feel for breathing and chest movement. If the

infant is not breathing, the head of the infant should be

maintained in the neutral position (head in line with body) by

gentle pressure with one of the rescuer’s hands on the

forehead and chin lift or jaw thrust under the angles of the

mandible with the other hand. Flexion or overextension of the

neck of an infant may cause obstruction of the upper airway by

the tongue blocking the pharynx. Attempts to improve an

obstructed airway with the rescuer’s finger are not

recommended and may be dangerous.

Convulsions in the older infant

Breathing

The rescuer should give five exhaled breaths, each lasting

approximately one second into the infant’s mouth or mouth

and nose. The chest of the infant should be seen to expand

with each breath or else the airway is not clear and airway

opening manoeuvres should be repeated.

Circulation

After five initial breaths, the pulse should be assessed by

palpation of the brachial artery in the medial aspect of the

antecubital fossa or femoral artery in the groin. The carotid

Figure 24.6a

Chin lift in an infant.

artery is difficult to palpate in infants because the neck is often

short and fat. If the pulse is absent or

60 beats per minute as

assessed over 10 seconds, then external cardiac compressions

should be commenced.

External cardiac compression

Cardiac compressions should be applied with the infant lying

flat on the back on a firm surface. There are two methods of

compressions in small infants.

• Hands encircling the thorax with the thumbs compressing

the sternum one finger breadth below an imaginary line

drawn between the nipples. This method is only possible in

very small infants and is difficult for a lone rescuer to

perform along with mouth to mouth with or without nose

breaths.

• Two finger technique with the ball (not tips) of two fingers

compressing the chest with the fingers again placed one

finger breadth below the imaginary line between the

nipples.

Figure 24.6b

Feeling for the brachial pulse.

Whichever method is used, the chest should be compressed

by about one-third depth in order to propel blood to the

coronary arteries.

Continue CPR

Cardiopulmonary resuscitation (CPR) should be continued

with a ratio of five chest compressions to one breath for

approximately one minute (20 cycles) before reassessment. It is

not necessary to simulate the heart rate of a normally

breathing infant and, indeed, it may not be possible to do so in

an effective manner. The rescuer should continue CPR until

the emergency services arrive and take over resuscitation or if

no help has arrived within a few minutes, the infant should be

carried quickly to where help can be summoned.

Figure 24.6c

External cardiac

Figure 24.6d

External cardiac

compression.

Crying babies

I NEED

Apart from the subtle method of eye to eye communication,

babies have no other way of signalling their needs to their

mothers than by crying. Babies who are quiet or “good” may

be abnormal or ill. As crying is a non-specific call for help,

obvious needs should be investigated. In most cases no

remediable cause is found and the problem may resolve

spontaneously when infants are about three months old.

By then, however, parents may have become exhausted from

lack of sleep and marital discord may follow while the infant

remains fresh. As well as suggesting any appropriate

management, the family doctor should encourage parents to

take one or two evenings off together each week to visit

friends or go to a film. Parents often worry that the infant is

suffering from lack of sleep and wrongly ascribe poor appetite

or frequent colds to this cause.

Sound spectrography has confirmed the clinical

Figure 25.1

Crying signals needs.

impression that cries of cerebral irritability, pain, and

hunger are different in quality, but this method is not

available to most clinicians. During the first month infants do

not shed tears when they cry and even after the age of

about six months many infants cry at night without

shedding tears.

The doctor needs to take a full history, including details

of the pattern of crying, when the problem began, and

measures taken to resolve it. It should be possible to

determine whether the infant has always needed little sleep or

whether he has developed a habit of crying in order to get

into his parents’ comfortable bed. The doctor should also

explore the reason why the parents have sought advice at this

stage. The mother should be asked about any change in the

house, where the infant sleeps, and who looks after him

during the day. Illnesses in the child or family and marital

and social backgrounds also need considering. A physical

examination usually shows no abnormality, but occasionally

Figure 25.2

A bath is a bedtime ritual.

there may be signs of acute otitis media.

Difficulty in getting to sleep may be avoided by starting a

bedtime ritual in infancy. A warm bath followed by being

wrapped in particular blankets may later be replaced by the

mother or father reading from a book or singing nursery

rhymes before the light is turned out. A soft cuddly toy of any

type can lie next to the infant from shortly after birth, and

seeing this familiar toy again may help to induce sleep.

The parents should be told that during the night babies

often open their eyes and move their limbs and heads.

They should be asked to resist getting up to see their baby, as

the noise of getting out of bed may wake him and he may

then remain awake. Babies who do wake may be pacified

with a drink and may then fall asleep. The drink is to provide

comfort rather than to assuage any thirst.

Parents whose young children sleep a great deal during

the day can discourage them from doing this by taking them

out shopping or giving them other diversions, and they may

then sleep well at night.

Sleep disturbance is a common reaction to the trauma of

admission to hospital or moving house, and taking the child

into the parents’ room for a few weeks may help to reassure

the infant that he has not been abandoned.

If the infant is prepared to go to sleep at a certain time

but the parents would like to advance it by an hour, they can

put him to bed five minutes earlier each night until the

planned bedtime is achieved.

Figure 25.3

Father reading from a book.

Crying babies

Hunger and thirst

Babies often cry and become restless just before a feed is due

150

and in the early weeks of life the infant may demand to be fed

three hourly or even two hourly. This is perfectly normal.

Preterm infants need particularly high milk intakes for

130

“catch-up” growth and they may become less demanding when

they reached their final centiles for weight.

110

The volumes of bottled milk recommended are only

average amounts and many infants will therefore need more to

prevent excessive hunger. Regular weighing and use of a

growth chart to plot the results are the only ways of ensuring

that the infant is obtaining the correct amount of feeds.

Feeding at regular intervals is apt to cause crying in many

babies and demand feeding is preferable. Some infants scream

when they approach the breast and the help of an experienced

midwife is needed to overcome this problem.

The age at which infants sleep through the night and do

not require a night feed varies greatly. It usually occurs when

infants weigh about 5 kg and parents may be worried because

their neighbour’s child of a similar age has already omitted the

Days

night feed. Similar competition between mothers over which

baby first manages three meals a day may also lead to

Figure 25.4

Milk intake increases with age.

inadequate feeding, followed by crying.

It is impossible to determine the difference between a cry

due to hunger and a cry due to thirst. The only way of solving

this problem is to offer infants water twice daily. This can easily

be given mid-morning or mid-afternoon. Some infants dislike

the taste of boiled tap water so a little fruit juice or half a

teaspoon of sugar can be added to 100 ml of water.

Even newborn infants cry to obtain physical contact and

the crying stops as soon as they are picked up. It does not spoil

babies to pick them up when they want contact. Once they are

a few weeks old infants begin to have periods of waking and

some will not tolerate being left in a pram or cot by

themselves. A harness that allows them to remain in contact

with their mother’s body will often satisfy these infants.

Alternatively, a canvas chair can be used even as early as one

month and can be placed in a safe position in the kitchen or

wherever the mother is working.

If babies do not stop crying when held, walking with them,

rocking them, or taking them for a car ride may stop the crying.

Wrapping infants in a blanket and putting them firmly into

a carrycot or a very small cot may also provide contact,

although by an impersonal method.

Non-nutritive sucking stops crying, provided babies are not

hungry. Putting a dummy into the mouth of a crying baby who

is not hungry may be effective as a temporary measure.

Three months’ colic and feeding

problems

Three months’ colic is the name given to a syndrome that

usually begins at about two weeks of age and has usually

stopped by four months. The infant screams, draws up his legs,

Figure 25.5

Close contact often stops crying.

and cannot be comforted by milk, being picked up, or having

his napkin changed. This usually occurs in the early evening,

when the mother is busy getting supper ready, has less time to

play with the baby, and may be anxious. Breastfeeding mothers

may have less milk at that time of the day.

Some babies swallow excessive air during feeding as a result

of milk spurting from the breast or a very small hole in the teat

of the bottle. Mothers usually complain that these infants gulp

at the beginning of the feed and they have particular difficulty

in bringing up the wind. This problem does not occur in

ABC of the First Year

societies where babies are held on the mothers’ backs for most

of the day. The infant’s abdomen is pressed against the

mother’s back and the infant is kept upright, which is the best

position for releasing excessive gastric air.

If the milk spurts from the breast, the first 25 ml or so

should be expressed manually and given to the infant later if

necessary. If the baby is fed by bottle, the size of the hole in

the bottle teat should be checked and made larger with a hot

needle if necessary. The infant can be winded most easily by

putting him prone with his head higher than his feet, but he

must be observed constantly while in this position.

Teeth and teething

Although mothers consider that the eruption of the first tooth

is a milestone in development, the age at which this occurs is

of no practical importance. The first teeth to appear, at

6-12 months, are the lower incisors.

From the age of a few weeks infants normally put their

fingers, and later anything else that comes to hand, into their

mouths and mothers often wrongly ascribe this to teething.

Teething produces only teeth. It does not, contrary to

common belief, cause convulsions, bronchitis, or napkin rash.

Figure 25.6

Evening colic begins about 5 pm.

Some mothers insist their infants are particularly irritable

when they are teething, but it is important to examine the

infant to exclude disease such as otitis media or meningitis

before accepting the mother’s explanation.

Dummies temporarily affect the growth of the mouth but

there are no objections to using them. They should not be

dipped in honey. Severe dental caries also follows the use of

“comforters” or “dinky-feeders”, which are filled with fluid

containing sugar.

Tetracycline or its derivatives should never be given to

children less than eight years of age, as permanent brownish

yellow staining of the teeth may occur.

Other causes

Illness - If the infant starts crying persistently, especially if he

has not cried like this before, disease should be suspected.

Figure 25.7

Severe discoloration due to tetracycline.

Acute otitis media often causes persistent crying at night, but

meningitis or a urinary tract infection may have no specific

signs. An intussusception is an invagination of a proximal part

of the gut into a more distal portion and may result in partial

or complete intestinal obstruction. The infant has sudden

attacks of screaming and pallor that last for a few minutes and

recur every 10-20 minutes. Between attacks the infant appears

normal. Bloodstained mucus may be passed rectally. The

abdomen is tender only during attacks, but often there is a

mass over the course of the colon. If intussusception is

suspected the infant should be admitted to hospital

(see p. 51).

Mechanical problems - Babies do not seem distressed when

their napkins are wet or soiled, though some cry when they are

being undressed or changed. An open safety pin is an

extremely rare cause of crying.

Fatigue - When young infants have been on a long journey

or have been stimulated more than usual by playing with

relatives, they may become irritable and not keen to sleep.

Failure of mother-infant adjustment - Crying may be a sign of

this failure, which may be related to the character of the infant

as much as the response of the mother. The crying may

represent the difficulties of each adjusting to the other. If an

infant has been crying persistently for several weeks the

possibility of severe depression in the mother should be

Figure 25.8

Non-accidental injury behind the ear.

100

Crying babies

considered. This depression could be the cause or the result of

the crying. The mother is exhausted by lack of sleep and

particularly liable to injure her infant, and both mother and

infant may need to be admitted to hospital for diagnosis and

management.

For most infants none of the above reasons for crying are

present. The parents need reassuring strongly after

examination that their infant is healthy and that the problem

will resolve spontaneously. Sedation of the infant with chloral

hydrate for a week during a difficult period may enable the

mother to regain some of her strength. The drug should not

be used for longer, since it loses its effect. Only a few doses

should be prescribed, as the mother may take them herself or

give too many to her infant in a depressive episode.

Special problems after the age of

three months

Loneliness is probably the commonest cause of crying after the

age of three months. While they are awake during the day

some infants will not tolerate being left alone but are happy if

they are left in the room where the mother is working. These

infants are extremely interested in their surroundings and

need the stimulation of things going on around them.

Similarly, infants need to be propped up when out in their

prams and when they begin to reach out they need simple toys

Figure 25.9

A chair in the kitchen reduces loneliness.

to play with.

Separation from the mother during admission to hospital

or when parents go on holiday by themselves may be followed

by bouts of crying. An infant can relate to only two or three

adults at a time and frequent changes in caretaker may be

associated with crying.

After about five months infants may cry when a stranger

approaches them or when they sleep in a different room. They

may wake suddenly and appear terrified, which might be due

to a nightmare, although there is no method of proving this.

Infants who do not sleep after three months

During the first few weeks of life some babies sleep almost

continuously for the 24 hours whereas others sleep for only

about 12 hours. Many mothers consider that a newborn baby

should sleep continuously and do not realise that babies take

an interest in what is going on around them. Infants who need

Figure 25.10 Playing with toys suspended across the cot.

little sleep may wake regularly at 2 or 4 am and remain awake

for two or three hours. Some are settled by a drink, but others

cry persistently after this and the mother may take the infant

into her own bed before they go to sleep. Some infants wake in

a similar way but are then content to remain awake looking at

Mon

Sleep

Nap

Sleep

mobiles above their cots or playing with toys left in the cot.

Shade in the times your child is asleep

Leave blank the times your child is awake

Midnight

Noon

Midnight

Behaviour modification and drugs

Mon

When infants wake frequently during the night and cry

Tue

persistently until they are taken into their parents’ bed, a plan

of action is needed. If there is an obvious cause, such as acute

Wed

illness or recent admission to hospital, the problem may resolve

Thur

itself within a few weeks, and at first there need be no change in

management. If there is no obvious cause, the parents are asked

Fri

to keep a record of the infant’s sleep pattern for two weeks (see

Sat

Figure 24.10). This helps to determine where the main problem

Sun

lies and can be used as a comparison with treatment.

Both parents are seen at the next visit; both need to accept

that they must be firm and follow the plan exactly. Behaviour

Figure 25.11 Record of sleep pattern.

101

ABC of the First Year

modification is the only method that produces long term

improvement, but it can be combined with drugs initially if the

Time to

First

What did

Second

What did

Time woke up

Day

bed

sleep

problem

you do?

problem

you do?

in morning

mother is at breaking point.

Behaviour modification separates the mother from the

Mon

child gradually or abruptly, depending on the parents’ and

Tue

doctor’s philosoply. The slow method starts with the mother

Wed

giving a drink and staying with the child for decreasing lengths

Thur

of time. In the next stage no drink is given. Then she speaks to

Fri

the child through the closed door and, finally, does not go to

the child at all. The abrupt method consists of letting the child

Sat

cry it out; he stops after three or four nights. There are an

Sun

infinite number of variations between these extremes and the

temperament of the parents, child, and doctor will determine

Figure 25.12 Record of action by parents.

what is acceptable.

Another approach is to increase the waiting time before

going to the infant. In severe cases a written programme of

several small changes can be given to the mother and she can

be seen again by the health visitor or family doctor after each

step has been achieved. The mother will need to be reassured

that the infant will not develop a hernia from crying or vomit

or choke, and neighbours may be pacified by being told that

the child will soon be cured.

If your child is still crying

Many sleep problems can be resolved without drugs, but

some mothers are so exhausted by loss of sleep that they

At first

Second

Third

Subsequent

Day

episode

episodes

cannot manage a programme of behaviour modification unless

the infant receives some preliminary sedation. The most

satisfactory drug for this age group is chloral hydrate 30 mg/kg

body weight given one hour before going to bed. The full dose

is given for two weeks, followed by a half dose for a week; the

drug is then given on alternate nights for a week. The objective

is to change the pattern of sleeping. A behaviour modification

Figure 25.13 Number of minutes to wait before going into your child

plan is needed during the third and subsequent weeks.

briefly.

102

Non-accidental injury and selected drugs

Non-accidental injury

This section has been restricted to physical abuse, as sexual

abuse is rare in infants less than a year of age.

Non-accidental injury inflicted by adults on children is

often hard to detect. Symptoms that are difficult to explain

may be the result of inflicted injury. In Britain as many as

100 children a year may die from non-accidental injuries.

Non-accidental injury should be suspected, especially in a

child aged under three, whenever: (a) there has been a delay

between the accident occurring and the parents seeking

medical help; (b) the explanation of the injury is inadequate,

discrepant, or too plausible; (c) the child or sibling has a

history of non-accidental or suspicious injury; (d) there is

evidence of earlier injury; (e) the child has often been

brought to the family doctor or accident department for little

apparent reason; (f ) the parents show disturbed behaviour or

unusual reactions to the child’s injuries or have a history of

psychiatric illness; (g) the child shows obvious neglect or

failure to thrive.

Typical initial injuries are: (a) burns, abrasions, or small

bruises on the face; (b) injuries to the mouth or torn

fraenulum of the tongue; (c) bruises caused by shaking or

rough handling, including finger-shaped bruises;

(d) subconjunctival or retinal haemorrhages. If the doctor

suspects non-accidental injury, the child should be undressed

completely and examined fully, with all signs of injury noted.

Figure 26.1

Non-accidental injury.

If the doctor’s suspicions are not allayed, he or she should

ensure the immediate examination of the child by a consultant

paediatrician. The family doctor should, if possible, not

mention any suspicions to the parents, as they may refuse to

allow this examination and it may impair his relationship

with them.

If parents refuse to allow their child to be seen or want to

remove the child from hospital too soon, the social services

department, the police or National Society for the Prevention

of Cruelty to Children may seek an emergency protection order,

which allows the child to be kept in hospital for eight days.

Children with genuinely accidental injuries will occasionally

be admitted unnecessarily, but this should not deter any doctor

from admitting a child when there is reasonable doubt about

the cause of an injury.

Figure 26.2

Non-accidental injury behind ear.

Preventable causes of death

Six preparations of drugs are especially associated with

Box 26.1 Drugs which are potentially dangerous

avoidable deaths in children.

• Digoxin

Ampoules of digoxin for use in adults should never be

• Penicillin intrathecally

supplied to children’s wards. Ampoules of digoxin made

• Chloramphenicol

especially for children ensure that a fatal overdose cannot be

• Glucose

20%

given.

• Sodium bicarbonate

4.2%

Penicillin given intrathecally has no therapeutic value.

• Potassium chloride solution

Errors are often made in dispensing the correct dose of

penicillin for intrathecal use, with fatal results. This route

should therefore never be used for penicillin.

Excessive doses of chloramphenicol can easily be given if

the special infant preparation is not used.

Intravenous glucose solution should never be given at a

concentration higher than 20%. Sodium bicarbonate solution

should never be given intravenously at a concentration higher

than 4.2%. Higher concentrations of either of these solutions

103

ABC of the First Year

are severely hypertonic and may be followed by sudden death

or permanent brain damage.

A bag of intravenous fluid to which potassium chloride

solution has been added should be shaken thoroughly to avoid

giving a bolus of potassium chloride solution, which may cause

a fatal arrhythmia.

Selected drugs in the newborn

Intestinal absorption is variable and regurgitation of antibiotics

common, so the intramuscular or intravenous route should

usually be used initially. Intramuscular injections are given into

the upper lateral aspect of the thigh. Schemes for rotation of

sites are essential to prevent local necrosis and to avoid further

injections being given into a relatively avascular area. Drugs are

usually given intramuscularly or orally every eight hours and

intravenously by slow bolus injection every 12 hours. In

preterm infants an adjustment of dose and frequency of

administration may be needed and specific texts should be

consulted.

Amoxycillin

(oral, IM, or IV)

50-100 mg/kg/24 h

Ampicillin

(oral, IM, or IV)

50-100 mg/kg/24 h

Ceftazidime

(IM or IV)

60-100 mg/kg/24 h

Chloral hydrate

(oral)

30-50 mg/kg per dose

Figure 26.3

Wrapping the infant may prevent spillage of medicine.

Diazepam

(IM or IV)

200-300

microgram/kg per dose

Flucloxacillin

(oral, IM, or IV)

50-100 mg/kg/24 h

Gentamicin

(IM or IV)

7 mg/kg/24 h (12-18

hourly). Blood

concentration must be

checked

Miconazole gel

(oral)

2.5 ml twice daily

Naloxone

(IM)

60 microgram/kg per

dose

Nystatin

(oral)

100 000 units/dose

(after feeds)

Paraldehyde

(IM)

0.1-0.2 ml/kg per dose

Benzylpenicillin

(IM or IV)

50-100 mg/kg/24 h

Phenobarbitone

(IM or IV)

15 mg/kg once only

followed by 3 mg/kg

per dose 12 hourly

Phenytoin

(IV)

15 mg/kg per dose

slowly once followed

by 3 mg/kg per dose

12 hourly

(oral)

5 mg/kg/24 h

Sodium ironedetate (oral)

1 ml twice daily

Triclofos

(oral)

50 mg/kg per dose

Trimethoprim

(oral)

4 mg/kg/24 h

Figure 26.4 Special medicine syringes (which have no needles) can be

used to measure and give small volumes accurately.

104

Non-accidental injury and selected drugs

Selected drugs in older infants

Infants treated at home and most of those in hospital need oral

Diazepam

200-300 microgram/kg orally per

drugs three times a day. The drugs should be given before

dose or slowly intravenously

feeds and the infant need not be woken specially for them.

Erythromycin

30-50 mg/kg/24 h

Some preparations, particularly the penicillins, have an

Flucloxacillin

50-100 mg/kg/24 h

unpleasant taste and the medicine should not be mixed with

Gentamicin

7 mg/kg/24 h intramuscularly

food as the infant may then hate both. Syrup, which is a

or intravenously

sucrose solution that forms the base of most elixirs, may cause

Hydrocortisone

100 mg per dose intramuscularly

dental caries if it is given regularly for a long time. If only one

or intravenously

adult is present to give the medicine, wrapping the infant

Nystatin

100 000 units per dose

securely in a blanket may prevent spillage. Special medicine

(four hourly)

syringes (which have no needles) can be used to measure and

Paracetamol

75 mg/kg/24 h

give small volumes accurately.

Paraldehyde

0.15 ml/kg per dose

intramuscularly

Amoxycillin

50-100 mg/kg/24 h

Benzylpenicillin

(intramuscularly or intravenously)

Ampicillin

100 mg/kg/24 h

Betamethasone

3 mg per dose intramuscularly or

Phenoxymethylpenicillin

60 mg/kg/24 h

intravenously =

Phenobarbitone

5 mg/kg/24 h

100 mg hydrocortisone

Phenytoin

5 mg/kg/24 h

Cefaclor

40 mg/kg/24 h

Trimethoprim

1-2 mg/kg single daily

Cefotaxime

100 mg/kg/24 h intramuscularly

prophylactic dose

or intravenously (12 hourly)

8 mg/kg/24 h

Chloral hydrate

30-50 mg/kg/per dose

Trimeprazine tartrate

3 mg/kg per dose once daily

105

Acknowledgements

We thank Blackwell Scientific Publications for allowing us to adapt liberally material that has appeared in Practical Management of

the Newborn, Accident and Emergency Paediatrics, and Paediatric Therapeutics and use the two photographs of resuscitating a newborn.

We also thank Susan Thomason, Maire Sullivan, Richard Bowlby, Joanna Fairclough, Brian Pashley, Jeanette McKenzie,

Derek De Witt, and Ann Shields of the department of medical illustration at Northwick Park Hospital for taking most of the

photographs. The remaining photographs were supplied as follows:

Early prenatal diagnosis: ultrasound scans Dr H B Meire and Sujata Patel.

Breathing difficulties in the newborn: micrograph of respiratory distress syndrome, Dr G Slavin; apnoea monitor, Graesby.

Some congenital abnormalities: cleft lip, Mr R Saunders.

Routine examination of the newborn: cardiac ultrasound, Miss Varrela Gooch.

Dislocated and dislocatable hips in the newborn: the ultrasound scans were provided by Dr Dennis Remedios and the photograph of the

Pavlik harness by Mr L Freedman.

For all photographs apart from those mentioned specifically above, Dr H B Valman and Dr R M Thomas retain the copyright.

We thank Mr R Lamont for providing extensive new material for the chapter on prenatal assessment. We are indebted to the Child

Growth Foundation for allowing the use of data to construct the growth chart on p.66, and Dr Judith Wilson for the Harrow

version of the personal health record which is used for recording health surveillance data.

106

Index

Page numbers in bold refer to figures in the text: those in italic to tables or boxed material

ABC of basic life support 95-7

equipment for 78

abdomen

specialist referrals 74

distension 11, 49, 50

asthma 12, 87

examination 24-5, 90

atopy 12

mass 51

audiologist referrals 12, 81

radiography 91-2

auriscope 78, 83, 90

tenderness 90

abortion

bacterial vaginosis 3

induced 1

bag and mask 5, 7

risk with prenatal screening tests

barbiturates 66

2-3

barium enema 51

acidosis 6, 7, 17

barium swallow 52

adrenaline 7, 84

Barlow’s test 32-3, 77

adrenogenital syndrome 25, 52

basal ganglia 42

African babies 21, 23, 43, 44, 81

basic life support 95-7

air enema 51

bathing 98

air swallowing 50, 66, 67, 99, 100

BCG vaccination 31, 40

air travel 31

bedding 29

airway obstruction 84

bedtime rituals 98

alae nasi flaring 86, 92

behaviour modification 101-2

albumin 7

benzylpenicillin 39, 104, 105

alertness 76

bereavement 9, 29, 31

alkalosis 50

betamethasone 84, 85, 105

-fetoprotein 20

-thalassaemia trait 1

aminoglycosides 36, 39, 105

bile duct atresia 43, 45

ammoniacal dermatitis 40

bilirubin 11, 81

amniocentesis 1-2

breastfed infant 42, 45

risk 2-3

formation and excretion 42

amoxycillin 83, 86, 90, 104, 105

measurement and monitoring 43-4

ampicillin 39, 104, 105

bilirubinometer 44

anaemia 17

birth

anencephaly 8, 20

breech presentation 18, 32, 34

antacids 66

details record 30

anterior fontanelle tension 19, 26, 37, 48, 91

trauma 18-19

antibiotics

vertex presentation 33-4

completing course 83

blindness 16

gastroenteritis 53

blood group incompatibility 42, 43

intramuscular 36, 91, 104

blood tests

intravenous 36

antenatal 27

newborn 104

culture 92

older infant 105

lymphocyte count 89

oral 90, 105

neutrophil count 39

pneumonia 86

newborn 27-8

specific infections 39

taking blood 27

susceptibility disc 36

blood transfusion 1, 43, 44

anticonvulsants 46, 94, 95, 104, 105

Bordetella pertussis 89

antipyretics 94-5

bottle feeding 50, 66-7, 69

antiretroviral therapy (ART) 39, 40

bottles, sterilisation 67

antithyroid treatment 66

brachial plexus injury 18

aorta, coarctation 24

brachial pulse 97

APGAR scoring system 4

bradycardia 4, 7, 47

apnoea 17, 19

brainstem damage 42

newborn 4, 6

breast abscess 25, 37

aryepiglottic folds 85

breast engorgement 66

assessment

breast enlargement 25

ages for 74

breastfed infant

at eight months 79-81

growth 61, 62

at six weeks 74-7

gulping 66, 99, 100

107

Index

plasma bilirubin 42, 45

cerebral palsy 16, 17, 42, 43, 69, 88, 93

stools 53, 67

chest radiograph

breastfeeding

bronchopulmonary dysplasia 16

advantages 64

diaphragmatic hernia 16

complementary feeds 65

foreign body 85

contraindications 65-6

normal 89

frequency 65

pneumonia 55, 86

HIV positive mother 40

pneumothorax 15

incidence 64

chewing 71, 72

latching to breast 64-5, 66

“chignon” 18

mother-baby attachment 56, 57

child abuse 56, 70

poor lactation 62, 69, 70

Chinese babies 43, 44

problems 66

chlamydia infection 27, 37, 86

test feeding 65

chloral hydrate 101, 102, 104, 105

vitamin supplements 73

chloramphenicol 38, 103

breast milk

chlorhexidine 37

expression 66, 100

choanal atresia/stenosis 17

value 64

choking 73, 84

breast pump 66

chorionic villus biopsy 2

breath holding attacks 93

risk 2-3

breathing difficulties

chromosomal anomalies 1-2, 22, 25

bronchopulmonary dysplasia 16

circumcision 26

cerebral lesions 15-16

clavicle, fracture 18

low birthweight infant 12

clavulanic acid 83, 90

respiratory distress syndrome 13-15

cleft lip and palate 20-1