Common Neonatal Presentations to the Primary Care Physician

CLINICAL

Common neonatal presentations to the primary care physician

Alicia Quach COMMON NEONATAL (first 28 days of life admitted to hospital and treated with post-term)1 presentations to general intravenous antibiotics; oral antibiotics practitioners (GPs) include fever, may lead to only partial treatment and This article is the first in a series respiratory symptoms, feeding difficulties, false‑negative culture results.6 on paediatric health. Articles in this unsettled babies, vomiting, constipation, series aim to provide information jaundice and rashes. This article will about diagnosis and management of Respiratory symptoms discuss these clinical presentations and presentations in infants, toddlers and pre-schoolers in general practice how to approach them in general practice. Respiratory symptoms are common and Table 1 outlines the general principles the majority will be benign. However, it is Background for a routine neonatal assessment. important not to miss the acutely unwell Newborn babies are very vulnerable These principles can also be applied to baby in respiratory distress, as these babies in their first weeks of life. Timely and babies who present for their first routine should be transferred to the emergency appropriate management of neonatal immunisations between six and eight department via ambulance.7 Table 2 conditions is paramount for health and developmental outcomes. weeks of age, to potentially identify rare outlines the signs and causes of acute but significant conditions that parents respiratory distress outside the first 24 Objectives may not have been aware of. hours of life, and other common respiratory The aim of this article is to provide presenting concerns and conditions. In an overview of common neonatal neonates, a cough can be due to a common presentations to general practice, and Fever highlight significant conditions that viral upper respiratory tract infection, but 2,3 may require referral to the emergency Fever (rectal temperature >38°C) it can also be a sign of a more significant department and/or other specialist. in a newborn baby can be the first pathology. Babies who have a cough and indicator of a serious invasive infective any associated ‘red flag’ signs or symptoms Discussion illness. Conversely, hypothermia (rectal outlined in Table 2 should be referred for Clinical history and examination are temperature <36.5°C)4 can also be a sign further investigation with a paediatrician. the most important tools in neonatal assessment. Babies often present with of sepsis, as neonates have difficulty Clinical suspicion of pertussis infection non-specific symptoms, but a thorough regulating temperatures.5 The health warrants referral to the emergency clinical assessment can identify the of neonates with sepsis can deteriorate department for laboratory confirmation, ‘unwell baby’ who requires immediate rapidly; therefore, if a fever is detected antimicrobials and monitoring, as these transfer to hospital. This includes (gold standard is to take the rectal babies are at greatest risk of complications babies with sepsis, moderate‑to‑severe temperature, but axillary or temporal with apnoea, pneumonia, encephalopathy dehydration or who are in acute artery temperature are acceptable), and death.8 cardiorespiratory compromise. A comprehensive neonatal assessment the baby requires immediate referral Neonates are obligatory nose breathers, will also help to differentiate babies with to the emergency department for a full and nasal congestion with mucus often significant conditions that may warrant septic workup, and hospital admission results in noisy breathing. Normal saline further specialist input from those with for empirical antibiotics. Ambulance drops or spray may relieve some of the normal neonatal development where retrieval may be necessary for babies who nasal congestion. The most common parental support and reassurance may have associated signs of haemodynamic pathological cause of noisy breathing be sufficient. instability, acute respiratory distress and/ is laryngomalacia. This developmental or are non-responsive. A full septic workup anomaly causes stridor through should include a full blood count and collapse of the supraglottic structures film, blood culture, urine culture (through during inspiration. Babies with mild aseptic suprapubic aspiration), lumbar laryngomalacia who are feeding well and puncture and, if clinically indicated, a chest thriving can be regularly reviewed in the X-ray.3 Where possible, it is recommended GP setting. Parents should be advised that that neonates with suspected sepsis be stridor may become louder in the first six

months of life, but will usually resolve by Table 1. General principles for a routine neonatal assessment 12–18 months. Babies who have associated complications (eg poor feeding, gastro- History Examination oesophageal reflux [GOR]) should be referred to a respiratory paediatrician or Maternal or antenatal history • Observe interaction with carers otolaryngologist for further assessment.9 • Alertness of baby • Relevant maternal medical Parental concerns regarding history • General colour and tone irregular breathing or pauses in their • Antenatal visits • Signs of dysmorphism baby's breathing are also common • Investigations during • Inspect for skin lesions throughout examination GP presentations. In the majority of pregnancy • Weight, length, head circumference measurements neonates, these irregularities will be due • Fetal growth • Systematic head-to-toe examination to ‘periodic breathing’, which is a normal developmental phenomenon. Periodic Peripartum history Head and neck breathing is characterised by alternating • Gestational age • Fontanelle cycles of five to 10 seconds of breathing • Delivery mode • Sutures and pauses in breathing. It is not associated • Resuscitation, Apgar • Oral cavity (eg palate) with bradycardia or cyanosis. It increases scores • Ears (eg position, pits) in frequency between two and four weeks • Vitamin K given • Neck (eg masses, range of movement) of age and resolves by six months of age.10 • Birth weight • Red eye reflex can be left to end of examination • Nursery or intensive care Apnoea is defined as pauses in breathing admission of greater than 20 seconds, or shorter Chest • Interventions (eg oxygen, duration if accompanied by cyanosis or • Cardiac examination (eg heart rate) nasogastric feeds, bradycardia.10,11 This is of great concern, • Respiratory examination (eg respiratory rate) phototherapy, antibiotics) and a significant medical cause needs to be • Chest deformities excluded. If a medical cause is not evident Postnatal period following clinical assessment, these babies Abdomen • Feeding method • Umbilicus (eg hernia, granuloma, infection) are classified as having had a brief resolved • Sleep or settling patterns • Palpate for organomegaly, hernias unexplained event (BRUE). BRUE replaces • Wet or dirty nappies • Femoral pulses the previous terminology: apparent life • Growth threatening event (ALTE).10 BRUEs can be • Community maternal Genitals stratified into low risk and high risk, where nurse visits low-risk BRUEs generally do not require • Social context – supports, • Patent anus hospital admission or invasive testing.12 maternal mental and • External genitalia physical health, is family • Position of testes in male All neonatal BRUEs are categorised as 12 coping? • Position of urethral meatus high risk, given the age of the baby, and should be reviewed by a paediatrician for Address any concerns Limbs further investigation. Table 2 summarises • Digits common causes of apnoea. • Symmetrical movements Gastrointestinal symptoms Hips • Barlow and Ortolani manouevres Small amounts of effortless posseting or physiological GOR are common in Back babies. In otherwise well babies who • Ventral suspension are feeding adequately and thriving, • Spinal dysraphism parental reassurance that this is most likely to improve in the first year of life Reflexes is sufficient. General measures, such as • Rooting holding the baby in the prone position • Suck after feeds and thickening agents, • Moro may help reduce the vomiting. Acid- • Tonic neck or fencing suppression agents (ie H2-agonists, • Grasp proton-pump inhibitors) should be • Stepping reserved for babies with associated complications, such as inadequate weight

194 | REPRINTED FROM AJGP VOL. 47, NO. 4, APRIL 2018 © The Royal Australian College of General Practitioners 2018 COMMON NEONATAL PRESENTATIONS CLINICAL

Table 2. Differential diagnoses for respiratory symptoms and signs

Clinical presentation Differential diagnoses Red flags or supporting features

Acute respiratory distress Infection • Fever or hypothermia (eg tachypnoea, accessory • Irritability or lethargy muscle use, central • Decreased feeds or poor urine output cyanosis, nasal flaring, • Infectious contacts expiratory grunting) Foreign body • Acute onset • Associated stridor or wheeze

Trauma • Physical signs of trauma (eg bruising) • Suspicion of non-accidental injury • Seizures

Congenital heart disease • Cyanosis • Cardiac murmur • Failure to thrive

Metabolic acidosis • Large volume fluid losses (eg vomiting, diarrhoea) • Failure to thrive • Apnoea • Seizures

Cough Respiratory infection • Coryzal symptoms • Infectious contacts • Prolonged episodic coughing (red flag for Bordetella pertussis) • Fever

Tracheo-oesophageal fistula • Coughing and choking with feeds • Antenatal polyhydramnios

Chronic lung disease • Prematurity • Prolonged intubation

Tracheo-bronchomalacia • Cough present since birth • Barking cough

Congenital heart disease • Cough with cyanosis • Cardiac murmur • Failure to thrive

Noisy breathing Laryngomalacia • Stridor (ie noisy breathing on inspiration) worse in supine position

Tracheomalacia • Noisy breathing on expiration • Barking cough

Laryngeal / subglottic mass • Cutaneous lesion (eg haemangioma) over face, neck or upper chest region

Choanal atresia • Grunting noise • Cyanosis with feeding (if bilateral) • Unilateral nasal discharge

Vocal cord paralysis • Hoarse cry • Other midline deformities

Apnoea brief resolved • Apnoea with colour change, change in muscle tone, altered conscious state that unexplained event completely resolves within one minute • Other medical causes excluded on clinical assessment

Apnoea of prematurity • Baby <37 weeks’ gestation • History of oxygen support

Infection • Refer to acute respiratory distress

Head trauma • History of birth asphyxia requiring resuscitation • Risk factors for abusive trauma

Structural airway obstruction • Facial dysmorphic features • Congenital malformations in chest or abdomen

gain, oesophagitis or aspiration.13 There infections or cow’s milk protein allergy cause for the unsettled baby. Supporting is no clear causal link between GOR (CMPA). Babies with acute infective features for CMPA include blood and infant irritability, and anti-reflux diarrhoea (gastroenteritis) need to be and mucus in the stool, diarrhoea or medication is generally not warranted monitored closely for dehydration. constipation, inadequate weight gain, in these instances.14 Vomiting as a result Table 3 outlines the signs of dehydration eczema, and family history of atopy. of a more serious condition, such as and other signs of the unwell baby that A cow’s milk exclusion diet (including pyloric stenosis, intestinal obstruction, should prompt early transfer to hospital. mothers if breastfeeding) may be sepsis or neurological cause (eg Admission to hospital should also be trialled in these babies to confirm the subdural or intracranial haemorrhage, considered for those who are unlikely to diagnosis. In babies who are formula- hydrocephalus), needs to be promptly maintain adequate oral intake at home. fed, a trial of extensively hydrolysed referred to the emergency department. Antimicrobial therapy is rarely warranted formula and/or amino acid formula will Red flags for these conditions include in gastroenteritis, as most cases are viral be required. Soy infant formulas are not projectile vomiting immediately post- and/or self-limiting. recommended in infants younger than feeds (associated with demands to be six months of age. Rice protein-based re-fed soon after), bilious vomiting, acute Unsettled baby formulas can be used as a short-term, abdominal distension, fever, lethargy, non-prescription alternative while dehydration or bulging fontanelle. All newborn babies cry. Normal infant awaiting specialist review.23 Referral to There is no universally agreed clinical crying patterns tend to increase in a paediatrician or allergy specialist and definition of constipation for neonates. duration week by week, peaking at around dietitian is recommended for suspected They may pass bowel motions several six to eight weeks of age, and receding cases of CMPA to ensure adequate times a day or have more than a week to lower, stable levels at around four parental education and future dietary between bowel motions. Formula-fed to five months of age.17,18 The typical management. babies typically produce firmer and less presentation is clustered periods of frequent stools than breastfed babies, but inconsolable crying, some for more than Feeding difficulties unless these are hard and pellet-like, the two to three hours in duration, often in the baby is unlikely to be constipated.15 Some late afternoon and evening. In otherwise Prematurity (gestation <37 weeks) is the babies will strain and cry for longer than well babies, reassurance, support and most common cause of feeding difficulties 10 minutes before passing soft stools. review in the first few months can be in neonates. Their immature physiology This phenomenon, known as dyschezia, therapeutic tools in their own right. The can result in discoordination between is caused by an inability to coordinate the exclusion of pain or ‘wind’ as the cause of sucking, swallowing and breathing.24 increase in intra-abdominal pressure with crying will help to reassure parents. Box 1 Breastfeeding, however, can be a pelvic floor relaxation.16 It is a functional, lists some parental education resources challenging process for any new mother. self-limiting condition, and is not due to on normal infant development, unsettled Support from a maternal child health constipation. Caution should be applied babies and breastfeeding. Alternative nurse or lactation consultant can result in and organic pathology excluded before therapies, such as simethicone, herbal positive outcomes for both mothers and prescribing laxatives in neonates. Clinical treatment, acupuncture and manipulation their babies. Tongue-tie, or ankyloglossia, history and examination will detect some techniques, are not supported by the has long been linked with difficult significant conditions, including: evidence.19 Advice to change from breastfeeding and maternal nipple pain. • Hirschsprung’s disease, alerted by a breastmilk to formula, or to change A Cochrane meta-analysis found that history of delayed meconium passage between formula brands, should be frenotomy (surgical release of tongue-tie) (after 48 hours of life) avoided.20 There is emerging evidence reduced maternal nipple pain in the short • mechanical bowel obstruction that probiotics may be helpful in settling term, but did not find consistent positive suspected with firm abdominal breastfed babies, but currently there is effects on breastfeeding.25 Maternal distension on palpation no universal consensus for this to be a nipple pain is, however, a common reason • spinal dysraphism leading to autonomic standard recommendation.21,22 for cessation of breastfeeding and early or sphincteric dysfunction. As part of the assessment of an referral for frenotomy may prevent this.26 Cutaneous lesions over the sacrococcygeal unsettled baby, it is important not to Breastfeeding may not be a viable region may be indicative of closed spinal miss a pathological cause. If there is option for all mothers, and advice dysraphism. a sudden onset of persistent crying, regarding infant formula, expressed breast It is also normal for newborn babies an acute pathology such as infection, milk, or a mixture of the two should be to have frequent, loose stools. Babies hair tourniquet (ie strangulation of an made available in a supportive and non- who have true diarrhoea will produce appendage or digit by a thread-like judgemental manner. Babies can lose up more watery and more frequent stools material, such as hair), corneal abrasion to 10% of their birthweight in the first than usual. The most common causes of and non-accidental injury should be week of life, and may take a further two diarrhoea in neonates are viral or bacterial considered.19 CMPA is a recognised weeks to regain their birthweight.27,28

196 | REPRINTED FROM AJGP VOL. 47, NO. 4, APRIL 2018 © The Royal Australian College of General Practitioners 2018 COMMON NEONATAL PRESENTATIONS CLINICAL

‘cholestatic jaundice’ is always pathological, Table 3. Signs and symptoms of an unwell baby and detection of this should prompt Vital signs • Heart rate (bradycardia <110 beats/minute and tachycardia immediate review with a paediatric >170 beats/minute) gastroenterologist.29 The following • Temperature (fever >38°C; hypothermia <36.5°C) discussion is in relation to unconjugated • Respiratory rate (bradypnoea <25 breaths/minute and hyperbilirubinaemia. tachypnoea >60 breaths/minute) Visual assessment of jaundice alone is

Signs of dehydration • Weight loss (bare) in setting of acute illness or >10% of an unreliable indicator of the degree of birthweight hyperbilirubinaemia. Assessment should • Decreased urine output include detection of any signs of bilirubin • Dry mucous membranes toxicity (Table 3), and identification of risk 30 • Sluggish capillary refill (>2 seconds) factors, including the following: • Poor tissue turgor • prematurity • Sunken eyes and anterior fontanelle • jaundice within the first 24 hours • blood group incompatibility Systemic specific signs • Acute respiratory distress: tachypnoea, accessory muscle use, • cephalohaematoma or other birth- grunting, nasal flaring, central cyanosis related trauma • Gastrointestinal: acute abdominal distension that is firm, weight loss >10% of birthweight bilious vomiting, projectile vomiting • previous sibling with • Cardiac: cyanosis, cardiac murmurs • hyperbilirubinaemia requiring • Severe jaundice with signs of bilirubin toxicity: lethargy, dehydration, pallor, irritability, hypotonia or hypertonia, treatment. seizures, fever Babies with jaundice and added signs of bilirubin toxicity require immediate Non-specific signs • Lethargy referral to hospital. Babies with prolonged • Poor feeding jaundice who are otherwise well looking, • Inadequate weight gain feeding adequately and with no risk factors • Irritability – persistent are most likely to have physiological • Rashes jaundice or breastmilk jaundice, and can • Seizures be managed as outpatients. A bilirubin level (total and fractionated) should be checked with early follow-up for results Box 1. Educational resources and support services for parents of and clinical review. Bilirubin threshold newborn babies tables (www.nice.org.uk/guidance/cg98) should be used to determine whether the • The period of purple crying, www.purplecrying.info baby requires treatment with phototherapy • Raising Children Network, or exchange transfusion.31 www.raisingchildren.net.au/behaviour/newborns_behaviour.html • Australian Breastfeeding Association, www.breastfeeding.asn.au Rashes • Mother and baby units (Melbourne-based), www.rch.org.au/genmed/clinical_resources/Mother_Baby_Units In any baby who presents with a • Lactation Consultants of Australia and New Zealand, vesiculopustular rash, significant causes www.lcanz.org/find-a-lactation-consultant such as bacterial, viral and fungal infections need to be considered. If a rash is accompanied by systemic signs of being It is therefore more important to track a paediatrician for further investigation unwell, such as fever, lethargy or poor the actual weight difference in grams and management should be made. feeding, then the baby needs to be referred between visits. Following the initial immediately to the emergency department postpartum weight loss, newborns are Jaundice for further assessment. Recent exposure to expected to gain 30–40 grams per day on infectious diseases such as Varicella‑Zoster average.28 ‘Failure to thrive’ or inadequate Jaundice, or hyperbilirubinaemia, is the virus (VZV) or Herpes simplex virus (HSV), weight gain is most commonly a result result of bilirubin pigment deposition in should also alert the physician to the of inadequate oral intake. If a baby the skin and mucous membranes. In the possibility of an invasive infective disease. continues to display inadequate weight majority of cases, jaundice in neonates is Common benign rashes that may gain despite increased feed frequency due to unconjugated hyperbilirubinaemia. present in the newborn include erythema and/or supplementary feeds, referral to Conjugated hyperbilirubinaemia or toxicum and milia. Erythema toxicum

is a benign, self-limiting skin condition 6. Zea-Vera A, Ochoa TJ. Challenges in the diagnosis 24. Rommel N, De Meyer AM, Feenstra L, Veereman- and management of neonatal sepsis. J Trop Wauters G. The complexity of feeding problems categorised by small erythematous papules, Pediatr 2015;61(1):1–13. in 700 infants and young children presenting to vesicles and pustules. It affects 30–70% 7. Edwards MO, Kotecha SJ, Kotecha S. Respiratory a tertiary care institution. J Pediatr Gastroenterol of newborns, typically within the first two distress of the term newborn infant. Paediatr Nutr 2003;37(1):75–84. Respir Rev 2013;14(1):29–36. 25. O'Shea JE, Foster JP, O'Donnell CP, et al. weeks of birth.32 Erythema toxicum can 8. Winter K, Zipprich J, Harriman K, et al. Risk Frenotomy for tongue-tie in newborn infants. be differentiated from an infective rash by factors associated with infant deaths from Cochrane Database Syst Rev 2017;3:CD011065. its tendency to wax and wane over several pertussis: A case-control study. Clin Infect Dis days. It is also unusual for an individual 2015;61(7):1099–106. 9. Carter J, Rahbar R, Brigger M, et al. International erythema toxicum lesion to persist for more Pediatric ORL Group (IPOG) laryngomalacia than one day. If the infant is otherwise well, consensus recommendations. Int J Pediatr no investigation or treatment is required, Otorhinolaryngol 2016;86:256–61. but recommendation for review should 10. Patrinos ME, Martin RJ. Apnea in the term infant. Semin Fetal Neonatal Med 2017;22(4):240–44. be made if the rash does not resolve after 11. Kondamudi NP, Wilt AS. Apnea, Infant. StatPearls. one to two weeks. Milia, which are a result Treasure Island, FL: StatPearls Publishing, 2017. of blocked pores, typically present as tiny, 12. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief white cysts on the face in about 40–50% of resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower- 33 newborns. Most lesions resolve after one risk infants. Pediatrics 2016;137(5). to two months. Parents should be reassured 13. The Royal Children's Hospital. Clinical practice and advised to not squeeze or pick them as guidelines: Gastroesophageal reflux in infants. Melbourne: RCH, 2017. Available at www. this may result in infection or scarring. rch.org.au/clinicalguide/guideline_index/ gastrooesophageal_reflux_in_infants [Accessed 24 Nov 2017]. Conclusion 14. Heine RG, Jaquiery A, Lubitz L, Cameron DJ, Catto-Smith AG. Role of gastro-oesophageal Neonatal assessment can be challenging reflux in infant irritability. Arch Dis Child because of the non-specific nature 1995;73(2):121–25. of presenting signs and symptoms. A 15. den Hertog J, van Leengoed E, Kolk F, et al. The defecation pattern of healthy term infants up thorough clinical assessment, including to the age of 3 months. Arch Dis Child Fetal relevant maternal medical, antenatal, Neonatal Ed 2012;97(6):F465–70. peripartum and postpartum histories, 16. Kramer EA, den Hertog-Kuijl JH, van den Broek LM, et al. Defecation patterns in infants: with a systematic physical examination, A prospective cohort study. Arch Dis Child is the most important tool in the primary 2015;100(6):533–36. clinic setting. 17. Barr RG. Crying behaviour and its importance for psychosocial development in children. Montreal, Quebec: Encyclopedia on Early Author Childhood Development, 2006. Available at Alicia Quach MBBS, FRACP, MPH, General and www.child-encyclopediacom/crying-behaviour/ Developmental Paediatrician, Senior Research Officer, according-experts/crying-behaviour-and-its- Murdoch Children’s Research Institute, Melbourne, Vic. importance-psychosocial-development [Accessed [email protected] 14 July 2017]. Competing interests: None. 18. Hiscock H, Jordan B. Problem crying in infancy. Provenance and peer review: Commissioned, Med J Aust 2004;181(9):507–12. externally peer reviewed. 19. Halpern R, Coelho R. Excessive crying in infants. J Pediatr (Rio J) 2016;92(3 Suppl 1):S40–45. References 20. Akhnikh S, Engelberts AC, van Sleuwen BE, 1. World Health Organization. Health topics: Infant, L'Hoir MP, Benninga MA. The excessively crying newborn. Geneva: WHO, 2017. Available at www. infant: Etiology and treatment. Pediatr Ann who.int/topics/infant_newborn/en [Accessed 24 2014;43(4):e69–75. Nov 2017]. 21. Harb T, Matsuyama M, David M, Hill RJ. Infant 2. Hui C, Neto G, Tsertsvadze A, et al. Diagnosis and colic – What works: A systematic review of management of febrile infants (0–3 months). Evid interventions for breast-fed infants. J Pediatr Report Technol Assess (Full Rep) 2012;(205):1–297. Gastroenterol Nutr 2016;62(5):668–86. 3. The Royal Children's Hospital. Clinical practice 22. Xu M, Wang J, Wang N, Sun F, Wang L, Liu XH. guidelines: Febrile child. Melbourne: RCH, 2011. The efficacy and safety of the probiotic bacterium Available at www.rch.org.au/clinicalguide/ lactobacillus reuteri DSM 17938 for infantile colic: guideline_index/Febrile_child [Accessed 24 Nov A meta-analysis of randomized controlled trials. 2017]. PLoS One 2015;10(10):e0141445. 4. World Health Organization. Thermal protection 23. Australasian Society of Clinical Immunology and of the newborn: A practical guide. Geneva: Allergy. Food allergy clinical update for health WHO, 1997. professionals. Perth: ASCIA, 2017. Available at 5. Hofer N, Müller W, Resch B. Neonates presenting www.allergy.org.au/images/stories/pospapers/ with temperature symptoms: Role in the diagnosis ASCIA_HP_Clinical_Update_Food_Allergy_2017_HP_ of early onset sepsis. Pediatr Int 2012;54(4):486–90. version.pdf [Accessed 1 November 2017]. correspondence [email protected]