Performing the newborn check

Cite this article as:
Taryn Miller. Performing the newborn check, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25986

There are two situations in which you would examine a newborn:

  • As part of the newborn screening examination as a “baby check”
  • In the emergency department

Both situations are slightly different, but the same structured approach can be applied

Before you begin…gather what you might need

  • Examine the baby in a warm, well-lit environment- get a blanket if needs be, or examine in the neonatal resuscitaire if available
  • Preferably with parent/ guardian present (if newborn screening exam, if not call parent)
  • Tongue depressor
  • Ophthalmoscope that works!
  • Stethoscope – In NICU/SCBU usually each baby will have their own special stethoscope. If you are using your own, make sure to give it a good wipe before and after use
  • Measuring tape for head circumference and a set of weighing scales to examine the baby without the nappy!
  • Keep the baby warm by wrapping them in a blanket or rocking the baby
  • Auscultate the lungs and heart in mum’s arms or when the baby is settled
  • If a newborn is unsettled or crying, consider whether the examination needs to be done at that exact moment. Perhaps suggest that the baby has a feed or a cuddle with mum or dad.

Before you begin

  1. Introduce yourself with “Hello, my name is…
  2. Check the name and DOB on the name band
  3. Explain to parent/guardian why it is important and what the examination will involve
  4. Gain consent
  5. Wash your hands and don gloves!

PS – don’t forget to congratulate mum, it is a really nice touch and makes the parent or guardian feel at ease.

Before the baby cries – Perform these things first!

Assessment of breathing (0:17) – Respiratory rate, look for respiratory distress – intercostal and subcostal recession, tracheal tugging, nasal flaring

Assessment of circulation (0:36) – Auscultate the heart rate (all four areas), auscultate the lungs, feel the femoral pulses on both sides

Abdomen (0:48)- Palpate the abdomen for organomegaly, specifically the liver and the spleen. And look for any hernias

Structured assessment – Top to toe (1:14)

Head (1:14)

General inspection – Look for facial asymmetry and dysmorphic features.
Fontanelle –Palpate the anterior and posterior fontanelles
Ears- Look for skin tags or pits
Mouth – Assess the hard and soft palate. Ideally, you should use a tongue depressor and look directly with a light. Use a gloved finger in the mouth to look at the sucking reflex

*Chest and abdomen as before*

Extremities (1:50)

Hands – count the fingers, and look at the creases, assess the grasp reflex
Feet – count the toes, and look at the grasp reflex
Genitalia – Check for hypospadias and feel both testes
Bottom – make sure the anus is patent

STOP – warn parents- what you are going to do and not “I’m going to drop your baby”!!

Reflexes (2:24)

Head lag (2:30)
Moro reflex (2:42)
Stepping reflex (2:45)
Tone and ventral suspension (2:49)

Spine (2:30) – Look at the sacrum for birthmarks, hairy patches, or for any sacral dimples 

Hips (3:04) – Perform Barlow’s and Ortolani’s test to assess for developmental dysplasia of the hip

And finally

Pre-and post-ductal saturations (3:12)  – right hand for pre-ductal saturations and post-ductal saturations can be either foot

Eyes – Check for the red reflex

TOP TIP! Wrap the baby in a blanket and sit them upwards, the baby should open their eyes and let you get a good look with the ophthalmoscope.

Look at the baby book and plot previous weight measurements and today’s weight on an age-specific growth chart along with the head circumference

This video was created by Bec Packton, Aarani Somaskanthan, Alice Munro, and Izolda Biro with special thanks to Lisa Crouch and baby James. Check out our YouTube channel for more great teaching.

Selected references

American Academy of Pediatrics. Ear Pits, Skin Tags, and Hearing Loss. AAP Grand Rounds. 2009 Jan 1;21(1):2-.DOI: 10.1542/gr.21-1-2

Assessing for a patent anus in a neonate – Turowski, C., Dingemann, J. & Gillick, J. Delayed diagnosis of imperforate anus: an unacceptable morbidity. Pediatr Surg Int 26, 1083–1086 (2010). https://doi.org/10.1007/s00383-010-2691-5

Pre and post ductal saturations – Rüegger, C., Bucher, H.U. & Mieth, R.A. Pulse oximetry in the newborn: Is the left hand pre- or post-ductal?. BMC Pediatr 10, 35 (2010). https://doi.org/10.1186/1471-2431-10-35

Plotting growth chart UK – https://www.rcpch.ac.uk/resources/uk-who-growth-charts-guidance-health-professionals & Plotting growth charts Australia https://www.rch.org.au/childgrowth/Growth_Charts/

Immunisations –  DFTB – Immunisation Quick reference

Bibliography and some other approaches

Queensland Maternity and Neonatal Clinical Guidelines Program – Neonatal Examination

Davies, Cartwright & Inglis, Pocket Notes on Neonatology, 2nd Ed. 2008. Elsevier: Australia

Examination Adapted from; Examination of the Newborn: A Practical Guide. Helen Baston, Heather Durward Pg 3

Neonatal ventilation basics

Cite this article as:
Jasmine Antoine. Neonatal ventilation basics, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.19875

A term infant is admitted to the intensive care nursery with severe respiratory distress. They are currently on CPAP 8cm H2O and FiO2 0.50  with no signs of improvement. You begin preparing for intubation. The nurse looking after the baby is setting up the ventilator. “What ventilator setting would you like, doctor”?

 

Before listing off some ventilator settings, there are several decisions that we need to make. What type of ventilation should we be using for this baby? What settings will we start them on? What do we need to do post ventilation? This post will begin to answer some of these questions, but as always, it is advisable to be guided by your unit policies and senior staff members.

 

Ventilation modes

This post will discuss the basics of conventional ventilation. High-frequency oscillatory ventilation (HFOV) is also commonly used in the nursery, particularly for extremely preterm infants or those with persistent pulmonary hypertension. Stay tuned for an upcoming post on HFOV.

Synchronized intermittent mandatory ventilation (SIMV)

This type of ventilation administers a set amount of mechanical breaths that are synchronized with the patient’s own inspiration. When the infant breaths above the set ventilator respiratory rate, these additional breaths do not receive a ventilator breath. This mode can be useful when weaning ventilation.

Synchronized intermittent positive pressure ventilation (SIPPV) or patient triggered ventilation (PTV) or Assist Control (AC)

This form of ventilation confusingly has many different names. It supports every breath the infant makes. The set ventilator respiratory rate is the backup number of breaths that will be mechanically administered if the infant makes no spontaneous breaths. Each mechanical breath is synchronized with the patient’s own inspiration.

Pressure support ventilation (PSV)

Similar to SIPPV in that every breath is supported with mechanical ventilation. However, the inspiratory time is limited depending on the infant’s own inflation. The infant sets their own mechanical breath rate and inspiratory time.

Volume controlled (VC) or volume guarantee

This mode of ventilation can be used with SIMV or SIPPV. The ventilator aims to deliver tidal volumes (VT) set by the clinician. A maximum peak inspiratory pressure (PIP) is set, the ventilator’s PIP will vary to reach the target volume.

 

So, which is better for our infant?

There have been no large prospective trials that have determined if SIMV or SIPPV is the superior format of ventilation. The choice of ventilation will largely depend on unit preference. Studies have illustrated that volume-controlled ventilation reduces the duration of ventilation, risk of pneumothorax, grade 3/4 intraventricular haemorrhage, and chronic neonatal lung disease.

 

So what’s on your ventilator screen?

Peak end expiratory pressure (PEEP):

The maximum pressure that provides continuous distension of the lungs. Usually between 6-8cmH20

Peak inspiratory pressure (PIP):

Maximum pressure used during inspiration. Consider the tidal volumes achieved to determine a suitable PIP. VT are usually around 4-5ml/kg.

Respiratory rate (RR):

Set number of mechanical breaths administered in a minute. Usually between 40-60. In SIMV the set RR is both the maximum and minimum rate while in SIPPV the RR is the minimum but not the maximum rate.

Inspiratory time (Ti):

Set time for inspiration during a breath. Usually between 0.3-0.5s

Patient Circuit Flow Rate or Rise Time or Rise Slope:

Depending on the manufacturer or the unit policy, one of these options will be available. If only the patient circuit flow rate is available then this is set 6 – 10 L/min. If rise time or slope is available then this is set to 30 – 50% of the Ti.

Pmax:

In the volume-controlled mode this is the maximum peak inspiratory pressure you wish the ventilator to administer to reach target tidal volumes. Usually set 5 cmH2O higher than the average PIP used to achieve the set tidal volume.

FiO2:

The amount of supplementary oxygen. Target saturations will depend on the gestational age and the underlying condition affecting the infant. Your unit’s policy on SpO2 targets should guide the FiO2 setting.

Many other ventilators exist

 

What are the ventilator measurements we should be aware of?

Minute volume (MV):

Amount of gaseous exchange in one minute. MV= VT x RR

Tidal volume (VT):

The amount of gas in an expiration. Usually around 4-5ml/kg.

Leak:

Traditionally in neonates, uncuffed tubes are used for intubation due to concerns regarding subglottic stenosis and pressure necrosis. As a result, most infants will have a percentage of leak. It will change during an infant’s respiratory cycle, it is usually greater in inspiration.

 

What do we need to do next?

After attaching our infant to the ventilator, clinical checks should once again be undertaken to ensure adequate ventilation. Review the infant, is there misting of ETT, equal air entry by auscultation, symmetrical chest rise, stable observations and adequate tidal volumes being achieved.

A post-intubation chest x-ray should be taken as early as possible to check the placement of the endotracheal tube. The ideal placement is between T1-3,  just above the carina.

An arterial gas should be undertaken post-intubation to check adequate ventilation, within an hour. The timing of the next gas will depend on the results, clinical condition and how old the patient is. Your boss will be able to give you some guidance.

 

Take-home messages

  • Avoiding mechanical ventilation using early continuous positive airway pressure (CPAP) with, or without, surfactant administration is the most effective way to reduce the risk of lung injury.
  • Using volume-controlled ventilation reduces the risk of chronic neonatal lung disease.
  • If you’re not sure where to start or how to alter ventilation, ask for your boss’ help.

 

Resources

Keszler M. State of the art in conventional mechanical ventilation. Journal of Perinatology. 2009 Apr;29(4):262.

Mechanical ventilation of the premature neonate. Respir Care. 2011 Sep;56(9):1298-311; discussion 1311-3. doi: 10.4187/respcare.01429

Prematurity for the acute paediatrician: Camilla Kingdon at DFTB19

Cite this article as:
Team DFTB. Prematurity for the acute paediatrician: Camilla Kingdon at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22288

Camilla Kingdon is the Vice President for Education and Development at the Royal College of Paediatrics and Child Health. Her day job is working as a neonatologist at Evelina London Children’s Hospital.

Whilst the core work of a neonatologist takes place behind closed doors in the safety and security of the NICU babies do not choose where or when they are born. Sometimes, just sometimes, they like to surprise us and pop out early, when we least expect it. What do we do then?

 
 
#doodlemedicine sketch by @char_durand 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Sensational Solids

Cite this article as:
Annabel Smith. Sensational Solids, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22364

You are a paediatric registrar, discharging a 5-month-old boy (Sam) home after an overnight admission with a respiratory illness. When you check if there are any final questions, Sam’s parents want to know whether they should be commencing solids now, and if so, how they should go about it.

This is a great opportunity for some quick education for the family, made a little more efficient on a busy ward with the provision of some written information (see the resources section for my favourite websites). There have been lots of changes to infant feeding advice over the years, and a plethora of ideas about what comprises a healthy infant diet, so families can easily become confused. Some targeted, sensible advice can get most families on track towards safe and healthy eating for their infants, with positive implications for long term health and wellbeing.

 

When to introduce solids?

According to the World Health Organisation, all infants should ideally be exclusively breastfed for the first 6 months of life – no food and no extra water (medicines are, of course, allowed) – as introducing solids too early can interfere with this provision of nature’s perfect nutrition. However, the Australasian Society of Clinical Immunology and Allergy (ASCIA) has advised that food exposures can start occurring from (but not before) 4 months and that this is beneficial for allergy prevention. I encourage this for families in my care, explaining that from 4-6 months, these are to be just exposures, not meals – e.g. a lick of nut butter from a parents’ finger, a taste of bolognaise sauce, a finger play with mushy vegetables, and so forth.

From 6 months, babies particularly need sources of iron (as placental-derived stores will have run out), so regular small meals can commence – all solids should be offered AFTER a breastfeed until around 9-10 months of age when this can usually be reversed. Babies will need to be developmentally ready to start solids, with good head and neck control, ability to sit upright with support, showing an interest in food, and opening their mouth when offered a spoon. If not showing these signs by 7 months, the infant should be seen by their GP.

Infants can be fed purees, and/or soft hand-held foods (including foods they can safely suck on, such as a strip of toast or meat). There are different philosophies around the benefits of each method, but practically, it can work best for families to use a mixture of spoon- and finger-feeding. Finger-feeding provides great sensory and developmental experiences, but is messy and time-consuming, and requires a developmental level equivalent to around 8-9 months of age to reliably consume anything, so purees do have their place. Regardless of the feeding method, all meals must be closely and actively supervised by a competent adult.

 

What foods can be given and what should be avoided?

Infants can and should be exposed to all food groups from as early an age (at least prior to 12 months) as possible, except for honey, due to the risk of botulism (this can be introduced after 12 months if desired). Hard foods pose a choking hazard, so fruit and vegetables should be softened with cooking, and nut butter should be used instead of whole nuts. Home-cooked wholefoods are typically best for health, but there are some healthy commercial preparations. 

To avoid confusion if allergic reactions occur, families should, according to ASCIA, introduce food types one at a time, a couple of days apart. This also gives the infant time to adjust to all the new, exciting textures and flavours.

Water should be offered with all solids from 6 months onwards to encourage good drinking habits. Infants and children shouldn’t drink juice, and cow’s milk shouldn’t be used a drink until after 12 months, although small amounts can be used on cereals or as a component of other meals for dairy exposure. After 12 months, limit cow’s milk to 500ml per day (less or none is fine, especially if still breastfeeding, and/or if having plenty of other calcium sources, such as other dairy products, or green leafy vegetables). ‘Toddler formula’ is almost never needed, and then only on specialist advice.

 

What happens if Sam has a reaction to a food?

Allergic reactions to food can be immediate or delayed and are highly variable and sometimes controversial. Symptoms may include rashes, respiratory difficulty, or gastrointestinal issues. Any suspected reactions require an immediate cessation of the suspected food(s), and medical review (urgency dependant on the severity of the symptoms) should be sought.

 

What if the family follows a special diet, like veganism?

Vegetarian and vegan families, or any other families following a relatively restricted diet for any reason, would benefit from an early assessment by a registered dietician. These diets may lack vitamins and minerals critical for the health of the developing infant, but can usually be safely adhered to with support and planning. Restrictive diets do increase the risk for food allergy and intolerance on later exposures, however, and families must be aware of this.

Ultimately, food should be about fun, togetherness, and good health. Families should be encouraged to keep mealtimes positive and family-centred, with everyone eating together at a table whenever possible (with all devices turned off). Parents should evaluate their own diet and ensure they are setting a good example, and empowering and teaching their children how to fuel their amazing, active bodies with a wide variety of healthy, delicious foods. It’s never too early to start forming good habits and positive food relationships.

 

References and Resources:-

Australasian Society for Clinical Immunology and Allergy (allergy.org.au)

Useful handouts;

  • Information on how to introduce solid foods to infants (
  • Infant feeding and allergy prevention (

Raising Children’s Network (raisingchildren.net.au)

The Royal Children’s Hospital Melbourne (rch.org.au)

How low can you go: Neonatal hypoglycaemia in the HypoEXIT trial

Cite this article as:
Singer, R, Antoine J, Munro A. How low can you go: Neonatal hypoglycaemia in the HypoEXIT trial, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23677

You are called to the post-natal wards to review an infant of a diabetic mother. He is Day 1 and has a BSL of 2.4 … 

We all agree newborns are sweet, but what is the minimal sweetness we should be accepting? Many of our neonates are monitored for hypoglycaemia after birth, including but not limited to babies of diabetics, small babies, large babies and premature babies. This can represent up to 30% of our neonatal populations. There is no published consensus regarding the threshold blood glucose level at which we should treat asymptomatic hypoglycaemia in neonates.

Many institutions, both in the UK and Australia, are currently using 2.0 mmol/L (36mg/dL) as a cut-off, which is also included in the UK BAPM Guidelines. However, the RCH Guideline (commonly used at many Australian institutions), recommends 2.6 mmol/L (47 mg/dL) as the cut off for treatment. Treatment can include buccal dextrose gel but may be more invasive such as IV glucose infusions and tube feeding.

Part of the reason for the discrepancy was the lack of high-quality evidence surrounding what is “normal” blood sugar during the first hours of life, and what the risks are with accepting a lower threshold. Until now…

A.A.M.W. van Kempen, P.F. Eskes, D.H.G.M. Nuytemans et al for the HypoEXIT, Study Group. Lower versus Traditional Treatment Threshold for Neonatal Hypoglycemia, N Engl J Med, 2020;382:534-44. DOI: 10.1056/NEJMoa1905593

What was the study design?

This was a multi-centre, randomised non-inferiority trial. This means patients were randomised into one of the two interventions, and that the analysis plan was to determine that one intervention was no worse than the other.

Population

This was a trial including newborn babies who were high risk for hypoglycaemia, and would normally be routinely screened for low BMs after birth. Babies were included if they were >35 weeks gestation and their birth weight >2000g. Recruited babies were divided according to four groups:

  1. Infants who were <10th centile for weight
  2. Infants who were >90th centile for weight
  3. Infants whose mothers were diabetic
  4. Late preterm infants

Of note, infants were excluded if they were unwell, had initial severe hypoglycaemia defined as <1.9 mmol/L, congenital abnormalities, or suspected inborn errors of metabolism/congenital hyperinsulinaemia.

Intervention

Threshold of 2.0 mmol/L (36mg/dL) for intervention for hypoglycaemia

Comparator

Threshold of 2.6 mmol/L (47 mg/dL) for intervention for hypoglycaemia

Outcome

The primary outcome was neurodevelopment. The infants were followed for 18 months, with a primary outcome of cognitive and motor development assessed with the Bayley-III-NL scale of infant and toddler development. The lower threshold was considered to be non-inferior if the Bayley score were < 7.5 points lower than the standard threshold for hypoglycaemia group. This reflects a 1-month delay in development, which in the trial protocol, the authors suggest as being a clinically important difference (however there is no explanation as to how this was determined).

The Bayley scale is a developmental assessment tool which was designed to detect developmental delay. It has not been widely validated as for its clinical application, so great caution should be taken with interpreting it as a clinical outcome.

Closer to the time of hypoglycaemia, the secondary outcomes were the number of glucose tests, treatment type (IV, NGT or bottle) and duration of breastfeeding. These are all important patient-orientated outcomes, as they reduce interruption on normal neonatal-maternal bonding and feeding.

How was the data analysed?

The study was designed to have 90% power for the primary outcome in each of the 4 subgroups.

Clinical situations don’t necessarily go according to a script, and management decisions were made based on each individual newborn, making a per-protocol analysis very difficult to complete. The authors therefore only presented an intention-to-treat analysis. This does make it difficult to determine how many infants were actually managed according to their assigned protocol.

Due to there being several scores provided by the Bayley assessment (motor and cognitive), the authors used more stringent confidence intervals (97.5%) to adjust for multiplicity (the increased chance of observing statistically significant differences due to analysing a greater number of results).

All things considered, this was an impressive effort at conducted a high powered study including for subgroup analysis, and with stringent adjustment for multiple outcome testing.

Results

A total of 689 newborns were included in the study, of which 341 infants in the standard threshold of hypoglycaemia, and 348 into lower threshold for treatment of hypoglycaemia. 582 infants were included in the final analysis, with 15.5% lost to follow up at 18 months of age.

Primary outcome

In asymptomatic healthy newborns lower threshold for hypoglycaemia of <2.0mmol/L was non-inferior to standard <2.6mmol/L when comparing psychomotor development at 18 months. This was true across all 4 subgroups

Secondary outcomes

  • Fewer blood glucose measurements (9% less) were taken in the lower threshold group.
  • Number needed to treat to save 1 neonate from IV glucose was 7.
  • Number needed to treat to save 1 newborn from tube feeding was 12.
  • Number needed to treat to save 1 neonate from supplementation feeding was 5.
  • Episodes of hypoglycaemia (<2.6mmol/L) occurred in 57% neonate in lower threshold versus 47% in the traditional threshold group with a mean difference of 10% (95% confidence interval 2-17).
  • Similar duration of stay between two groups.
  • Two serious adverse events in lower threshold group both unlikely to be related to hypoglycaemia – one infant with HIE had seizures, one infant died in infancy from a respiratory infection.

Limitations and considerations

There was a moderate amount of children lost to follow up (15.5%), however, it is uncertain whether this is informative (related to the outcome; neurological development) and would influence the results.

The number of infants of diabetic mothers was lower than predicted, so results for this subgroup should be interpreted with caution (however, despite the wider confidence intervals the limits are well within the non-inferiority margin)

The primary outcome was development at 18 months, and so we can’t say for certain whether any longer-term impacts would be demonstrated. The Bayley score is a crude tool which may miss more subtle developmental problems.

Whilst this is a truly pragmatic, randomised study which reflects current practice at many institutions, the results should not be interpreted beyond their scope – care must be taken in assessing the cause of hypoglycaemia in newborns, and recurrent or severe hypoglycaemia should be managed aggressively, as should hypoglycaemia in children who are unwell or who have comorbidities which make them higher risk (inborn errors of metabolism, congenital hyperinsulinaemia etc).

 

You check your hospital protocol which suggested it’s safe to only intervene if the baby is otherwise well and BM >2.0. You advise he has another breast feed, and his subsequent BMs are all >3.0. He is discharged the next day.

The bottom line

  • This study provides the highest quality of evidence to date regarding safe limits for intervention in neonates with moderate hypoglycaemia
  • The evidence suggests treating at a limit of 2.0 mmol/L (36mg/dL) in asymptomatic hypoglycaemia is non inferior to a limit of 2.6 mmol/L (47 mg/dL) in regards to neurological development
  • Hypoglycaemia must always be assessed in context, and these results would not apply to unwell or symptomatic neonates, those with recurrent or severe hypoglycaemia, those with uncertain cause for hypoglycaemia, or those at higher risk due to inborn errors of metabolism or congenital hyperinsulinaemia.
  • The best strategy is still to avoid hypoglycaemia – get babies feeding early, keep them warm and screen babies at risk.
  • The correct threshold for intervention in hypoglycaemia is important to reduce the risks to infants, reduce the number of blood tests, episodes of overtreatment, separation from parents and interruption to establishing suck feeding.

 

References

BAPM guidelines for neonatal hypoglycaemia

https://www.bapm.org/resources/40-identification-and-management-of-neonatal-hypoglycaemia-in-the-full-term-infant-2017

Royal Womens Hospital Melbourne guidelines for neonatal hypoglycaemia

https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/hypoglycaemia-infant-management_160517.pdf

Queensland District guideline for neonatal hypoglycaemia

https://www.health.qld.gov.au/__data/assets/pdf_file/0019/142156/g-hypogly.pdf

Human Donor Breastmilk

Cite this article as:
Annabel Smith. Human Donor Breastmilk, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22355

You are a junior doctor working in ED. A 4-month-old girl, Lisa, is brought in by her parents with suspected bronchiolitis. On reviewing her history, her Dads tell you that Lisa is adopted, and is being fed donor breastmilk (and formula when they can’t access sufficient volumes). You’ve never encountered a baby on donor breastmilk, so you aren’t sure of the implications. You ask your friendly paediatric registrar about it…

Given that human milk is vastly superior to formula, it stands to reason that if a baby can’t be fed milk by his or her own mother, donor breastmilk should be the next step. Families wishing to access such milk must utilize either formalized milk banks, wet nurses, or private donor arrangements. The use of wet nurses (direct feeding of an infant by a lactating woman other than the infant’s mother) is very unusual these days, though still occurs in some cultures.

Charles et Henri Beaubrun anciennement attribué à Anonyme France XVIIe siècle Title Français : Louis XIV et la Dame Longuet de La Giraudière

Milk Banks

Formal ‘milk banks’ were quite prevalent a few decades ago, until HIV fears in the 1980s shut many facilities down. With new protocols for screening and techniques for pasteurization available, a resurgence in milk banking is being seen across the globe. Currently, a small handful of milk banks exist across Australia, predominantly to provide donor milk to vulnerable premature and low birth weight infants in Neonatal Intensive Care Units.

Formal milk banks cost a lot of money to set up (AUD$200,000-$250,000) and to run (AUD$150,000-$250,000 per year). Donors are screened in a very similar fashion to blood donors, with questionnaires and blood tests, and the milk is pasteurized to remove bacteria and viruses. Some live components of breastmilk are denatured in this process, but many important immunological and nutritional features remain. NICU infants are prime donor milk recipients, given they require so little compared to their older infant counterparts, and human milk has been shown to reduce rates of necrotizing enterocolitis and sepsis (compared with formula).

 

Private Breastmilk Sharing

For the rest of the Australian community, accessing milk banks is almost impossible, so many families who require a breastmilk alternative are utilizing social media and other community networks to find donors. These are entirely unregulated, although some web pages provide guidelines for collection, handling, ‘home pasteurization’, and storage of breastmilk. Donors will sometimes sell their milk, which is considered highly unethical, although reimbursement of a donor’s costs may be acceptable.

The Australia Breastfeeding Association does not endorse private exchanges of breastmilk supplies, as there can be no guarantees of safety for infants. It does provide web links to sites with guidelines for private milk sharing in case members are interested in this route, so that families (and donors) can be appropriately educated.

 

Conclusion

Ideally, formal human milk banks should be accessible to all families who, for whatever reason, require a safe alternative to maternal breastmilk. However, given the high set-up and running costs, and the fact that most mothers should be able to feed their own infants if given adequate support, perhaps any funds would be better spent for now on improving health sector lactation support, maternity leave financial support and breastfeeding infrastructure. Informal exchange of breastmilk is hard to endorse, given the inherent risks, however, if families are well educated, and guidelines are adhered to, the risks can likely be significantly reduced. Given the myriad health benefits in utilizing human milk over formula, many families will likely consider these risks acceptable and will continue to utilize donor human milk where available. 

In Lisa’s case, her dads explain that they are sourcing the milk from three altruistic donors who are all long-term friends of the family. They are all healthy women, and all have been strictly following the advice provided on the ‘eats on feets’ and ABA websites to ensure the milk is managed safely. The paediatric registrar has discussed this with the parents and reminded them about the risks of viral and bacterial transmission even with all due care, but as Lisa is otherwise a thriving baby, with just a mild case of bronchiolitis, there appears to be no cause for further investigation or cessation of the current feeding regimen.

 

References and Resources:

Commonwealth of Australia. Donor Human Milk Banking in Australia – Issues and Background Paper. 2014. Available from: https://www.health.gov.au/internet/main/Publishing.nsf/Content/D94D40B034E00B29CA257BF0001CAB31/$File/Donor%20Human%20Milk%20Banking%20in%20Australia%20paper%20(D14-1113484).pdf

Australian Breastfeeding Association. Position Statement on Donor Milk. Updated 2014. Available from: https://www.breastfeeding.asn.au/policy/statement-donor-milk

Websites providing advice and networks for private breastmilk sharing;

  • www.hm4hb.net

Neonatal respiratory distress

Cite this article as:
Jasmine Antoine. Neonatal respiratory distress, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19877

You are the paediatric registrar on shift overnight, your phone rings. “Its Mary in birth suite, can you please review a term baby in room 1, born one hour ago via vaginal delivery is tachypnoeic.

Respiratory distress is common; it affects 7% of term infants. It is the most common reason that term babies are admitted to special and intensive care nurseries. There are several factors that increase the likelihood of respiratory distress to occur in a term neonate, meconium exposure, maternal gestational diabetes, chorioamniotitis, oligohydramnios and delivery by caesarian section.

Common causes of respiratory distress include:

  • Transient tachypnea of the newborn (aka retained fetal lung fluid)
  • Respiratory distress syndrome (aka hyaline membrane disease)
  • Persistent pulmonary hypertension
  • Pneumothorax
  • Meconium aspiration
  • Sepsis

 

What are the less common ones that we don’t want to miss?

  • Congenital pneumonia
  • Congenital pulmonary airway malformation
  • Pleural effusion
  • Congenital cardiac disease
  • Oesophageal atresia with/out trans oesophageal fistula
  • Congenital diaphragmatic hernia
  • Metabolic problems: hypothermia, hypoglycemia
  • Airway obstruction: choanal atresia, micrognathia, macroglossia, tracheomalacia, subglottic stenosis, airway haemangioma
  • Bony abnormalities: skeletal dysplasia
  • Hypoxic- ischaemic encephalopathy
  • Neuromuscular causes: congenital myotonic dystrophy, spinal muscular atrophy, congenital myopathies, seizures

 

So what should we be looking for on examination?

  • Is the newborn pink or blue? What are the oxygen saturations? Pre-ductal (taken on the right hand) and post ductal (taken on one of the feet)
  • Is the infant distressed? What is their respiratory effort: subcostal and intercostal recessions, head bob, tracheal tug is often difficult to spot in newborns due to their large head/lack of neck combination. Is the baby grunting?
  • What is the respiratory rate, is it >60?
  • What are the other vital signs: heart rate and temperature?
  • Chest wall movement: is the chest moving adequately and symmetrically?
  • Air entry: is it equal, are there added sounds, are there bowel sounds in the chest?

 

On your arrival the infant is on the resuscitaire. She is receiving CPAP of 8cm via mask. She has increased work of breathing with subcostal and intercostal recessions, grunt and remains tachypnoeic with a respiratory rate of 80. You continue to administer CPAP of 8cm. What else needs to be undertaken in birth suite?

 

  • Keep the infant warm: make sure the heater is on and the infant is on the portion of the resuscitaire that the radiant heater impacts. Is she wearing a beanie? Has she been dried off? Is she on warm and dry wraps?
  • Is her position ideal: neutral airway position
  • Does she require any oxygen: what are the oxygen saturations?
  • Are you getting adequate pressures: is the CPAP maintaining 8cm? Is the mask an appropriate size? Is the flow correct? Is the upper airway obstructed? Does she need to be suctioned?

 

You decide to take the baby to the nursery for further assessment and treatment. What do you need to do to get prepared for the move?

 

Most rescuitaires cannot maintain enough power to adjust the height of the cot or provide heat whilst transiting. Consider if you have enough warm wraps, enough oxygen and air in the cylinders and appropriate monitoring.

 

The newborn is admitted to the nursery for ongoing respiratory distress. CPAP is continued at 8cm in 30% oxygen. What investigations should be done?  

  • FBC and Blood culture: respiratory distress can be the first sign of sepsis.
  • Blood glucose
  • Consider a gas: an arterial gas will be the most accurate but can be difficult to obtain without intra arterial access. Venous or capillary gases are more practical. Capillary gases are more prone to error when infants are poorly perfused but are quick and easy to undertake.
  • CXR: with a nasogastric tube insitu, this will help identify an oesophageal atresia.

 

Why do infants get respiratory distress?

The etiology of respiratory distress is as varied as the causes. Many infants struggle with the transition following birth to neonatal life. Whatever the underlying pathology; surfactant deficiency, meconium aspiration or persistent pulmonary hypertension, these cause atelectasis and ventilation perfusion (V/Q) mismatch. Leading to hypoxemia and hypercarbia and ultimately respiratory acidosis. Tissues then become poorly perfused leading to metabolic acidosis, which furthers pulmonary vasoconstriction, causing endothelial and epithelial injury and respiratory distress syndrome.

 

What next?

  • Keep the infant warm
  • Positioning of the infant: in an isolette so you can monitor their respiratory distress, head neutral position, consider prone.
  • Respiratory support:
    • start with CPAP 8cm in the oxygen required to maintain saturations >/= 90%
    • indications for intubation are: FiO2 >40%, extreme prematurity, recurrent apnoea that require stimulation or apnoea requiring resuscitation, respiratory failure (pCO2 > 70 and pH < 7.2)
  • IV antibiotics to cover for sepsis: use broad spectrum antibiotics. Your hospital will have a policy. Amoxicillin and gentamicin are a good starting point. Remember to cover for the common pathogens; Group B streptococcus and Escherichia coli.
  • Nutrition: a term baby with significant respiratory distress will find it difficult to suck feed. Consider starting IV dextrose and small amounts of enteral feeds via a nasogastric tube when expressed breast milk is available.
  • Decompress the stomach with an NGT

Just remember there are a few contraindications to CPAP

  • Bilateral choanal atresia and tracheoesophageal fistula, upper airway anomalies can make CPAP unsafe or ineffective
  • Unrepaired gastroschisis
  • Unrepaired congenital diaphragmatic hernia, as CPAP can lead to gastric distension and affect the thoracic organs.

 

What is the bottom line?

  • Respiratory distress can be the first sign of sepsis
  • Manage respiratory distress early so it does not progress. Start CPAP at 8cm in the oxygen required to maintain saturation.
  • CPAP has been shown to reduce the need and duration of mechanical ventilation 

 

Selected resources

Reuter S, Moser C, Baack M. Respiratory distress in the newborn. Pediatrics in review. 2014 Oct;35(10):417.

Queensland health clinical guideline Neonatal respiratory distress including CPAP

A pair of palsies

Cite this article as:
Abbey Ward. A pair of palsies, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21393

A 20 day old baby girl was referred to PAU from her midwife. She had shortness of breath since birth and it was worsening. She was pale and at times mottled and blue. The colour change and work of breathing were worse on feeding. She was born at 37+6 weeks with forceps, and she had been jaundiced with a right sided cephalhaematoma at birth. Her right sided Erb’s palsy was awaiting specialist review. Parents said she had moderate work of breathing since birth, but it was now much worse.

Blood Lactate: Freshly Squeezed

Cite this article as:
Alasdair Munro. Blood Lactate: Freshly Squeezed, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20682

Hermione is a 15-day old baby girl brought in for prolonged jaundice. She is breastfed and has no other risk factors. Her examination is normal other than being a bit on the yellow side. You ask the nurse to perform a blood gas to check her bilirubin, which is below 200. You notice the lactate on the gas is 4, but the nurse reports it was a “squeezed sample” which she suggests could explain the result?

BRUE v ALTE – have the new guidelines made a difference?

Cite this article as:
Roland D, Davis T. BRUE v ALTE – have the new guidelines made a difference?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20773

This week sees the publication of a new paper in Pediatrics by the team at the Children’s Hospital of Pittsburgh and the University of Pittsburgh.

Ramgopal SR, Noorbakhsh KA, Callaway CQ, Wilson PM, Pitetti RD. Changes in the management of children with brief unresolved unexplained events (BRUEs). Pediatrics.

Why was this study needed?

In 2016, the American Academy of Pediatrics published a guideline which renamed and redefined ALTEs (acute life-threatening event). The new term was BRUE (brief resolved unexplained event).

ALTE was initially coined in 1986 and the definition was:

an episode that is frightening to the observer and that is characterised by some combination of apnoea (central or occasionally obstructive), colour change…marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died.

This was a broad definition and caused some difficulties for those of us assessing babies in hospitals. Although an ALTE could indicate a serious underlying problem – NAI, infection, seizure – commonly the infant was completely well. ALTEs by definition were subjective and this made the management of them tricky. Often these babies had overnight admissions to hospital for observation.

The new definition for BRUE is:

A BRUE has occurred if the observer reports a sudden, brief, and now resolved, unexplained episode of ≥1 of the following:

  • cyanosis or pallor
  • absent, decreased, or irregular breathing
  • marked change in tone (hyper- or hypotonia)
  • altered level of responsiveness

As well as the new definition, the guideline also stratifies patients and recommends management for those in the low-risk group.

Read our DFTB summary of the change in guidance here.

It has now been three years since the change from ALTE to BRUE. The aim of this study was to see whether the new guidance has affected rates of admission, investigations, or outcomes.

The objectives of the study were cleared stated and relevant to paediatric emergency medicine.

Who were the patients?

Patients were taken from the Pediatric Health Information System, which is a database with all information from presentations and admissions in hospitals across 26 states in the USA.

Patients were included if they were under 1 year old and had a diagnosis coded of either ALTE or BRUE between 2015 and 2017.

Exclusions were if patients had been transferred from another hospital, or had ambulatory surgery.

A control cohort was also used from all ED presentations of children under one year old during the inclusion period with no diagnosis of ALTE and BRUE (same exclusion criteria). The aim of the cohort group was to check whether there were any confounding trends in admissions/investigations during that time period.

This was an appropriate choice of patient group and the use of control cohort was beneficial. Sample size estimates were not stated explicitly but were alluded to.

The limitation here is the reliance on coding. However, additionally the authors were unable to determine if the diagnosis was correct, or if the patient could be classified as a low-risk BRUE as these assessments require a history and examination.

9,501 patients were used for the cohort analysis (5508 patients 0-60 days old, and 3993 who were 60 days to 1 year old). This group was split into a 2015 cohort (i.e. before the new guidelines) and a 2017 cohort (after the introduction of the new guidelines)

A second analysis was an interrupted time series analysis to look at trends in admissions over time. 13,977 patients were included in this group.

1.4 million patients were in the control cohort.

What analysis was carried out on these groups?

The cohort analysis looked at the rate of admissions as the primary outcome. Secondary outcomes included revisits and investigations performed. A comparison was also conducted by using the control cohort.

The interrupted time series analysis looked at whether admission rates changed over time following the introduction of the guideline. Admission rates were analysed in one-week batches throughout the three year time period.

The subjects were all accounted for and appropriate outcomes were considered.

What were the findings?

Admissions: the proportion of admissions in the 61-365 day old group was 86.2% in the 2015 cohort and 68.2% in the 2017 cohort. The admissions were also significantly lower in the 0-60 days group – 89.9% in the 2015 group and 84.1% in the 2017 group.

Investigations: the 2017 group had significantly lower rates of EEG, MRI, CXR, FBC, U+Es, LFT, and urinalysis. Those in the 0-60 day old group (2017) had significantly lower rates of blood gas measurement, blood sugar testing, head CT, metabolic studies, and lumbar puncture.

Revisits: in the 0-60 day old group, revisits within 3 days were significantly lower in the 2017 group (3.7%) than in the 2015 group (5.2%). The rest of the revisit rates were similar.

Analysis of the control cohort here suggested that the decreased rates of these outcomes were independent of other trends over time.

Interrupted time series analysis: in the 0-60 day old group the introduction of the guideline did not affect trends in admissions rates. However, in the 61-365 day old group, the admission rates decreased each week after the guideline was published.

The authors were clear on what was measured and how it was measured. Follow up was for a 30 day period so should have picked up most complications. The measurements were reliable, valid, and the basic data was adequately described.

What did the authors conclude?

Between 2015 and 2017 there has been a significant reduction in the rates of admission and investigations for patients with ALTE/BRUE. This rate decreased steadily following the guideline publication.

The authors note that this reduction is seen in the 0-60 day old group, even though that age group would be stratified as higher risk in the new guidelines. The fact that BRUE is a diagnosis of exclusion, whereas ALTE was all-encompassing may mean that this diagnosis is being applied to a smaller, safer group over time, which might explain the findings. There were less patients diagnosed with ALTE/BRUE in 2017 compared to 2015.

The results are discussed in relation to existing knowledge and the discussion seems balanced and not biased. The conclusions are justified by the data.

Will this paper change my practice?

Changing practice is challenging, changing a definition is a little easier.

This study is a great example of how to review the impact of guideline change and determine whether the outcomes have improved for patients without unintended consequences. At face value the BRUE approach has had beneficial clinical impact. We see an overall decline in admission and investigations with no obvious harm (returns don’t increase).

There are a few caveats that are important to consider though. This study was from a chain of hospitals likely working with similar cultures and convergent working practices. A random selection of children’s hospitals may have interpreted the AAP guideline with a greater degree of variance (and therefore application). With this in mind the relevance of quite a profound change in coding should be highlighted. In a similar timescale 25% of patients with a prior diagnosis of ALTE are no longer coded as such and it appears that these patients are not replaced with a BRUE code (as there was a 25% reduction overall in either code). This means that either the guidance has been successful in making staff think hard about about the underlying reason for the infant’s presentation or that perhaps initial coding was not as precise as it could have been (“I’m not sure what happening here so I’ll just call it an ALTE“). Of note the return rate isn’t supplied for those not coded as BRUE or ALTE so we don’t know if the cohort of patients now coded as something else have actually come to increased harm. It is also interesting to note the significant fall in admissions for those less than 60 days old. This wasn’t the intention of the initial guidance and while this group’s re-admission rates didn’t increase this study wasn’t powered (or designed) to look at whether the re-admission changes would be significant or not. The fact that it appears safer is a statistical construct, not a clinical one. This means a type II error is possible (there is actually a problem but we aren’t seeing it).  

Ultimately, while these risks are real, and do need investigation in future study, it is likely that altering to using BRUE will effectively rationalize your investigation and management pathways without causing additional harm. The challenge for those outside the United States is whether national organizations are happy to formally endorse the BRUE concept as staff may feel uncomfortable applying new rules without official sanction. Locally certainly, we use the BRUE criteria in our risk assessment and this study only further endorses that approach.

Post-publication commentary from one of the authors

This is a really wonderful summary and analysis of the study. The findings do suggest that patients in the low risk cohort identified by the AAP BRUE guidelines are being discharged safely without an increase in return visits. It is important to note that this narrower definition of BRUE has not excluded all high acuity conditions, as patients with high acuity co-diagnoses were identified in both age groups after the practice guideline publication.
 
Overall, I think our findings support continued clinical application of the BRUE definition and guidelines. While not within the scope of our study, the results did make us wonder about the impact of guidelines published by a national medical organization. How much of the change we saw in a three-year period were due to influence by the AAP and how much was because the medical community was ready for a change in ALTE management? Finally, we hope that our findings are able to support further research into management of both low-risk and high-risk BRUE and into understanding what has changed in the management of infants who are now excluded from the BRUE diagnosis.
 
Katie Noorbakhsh (author)

Here’s a printable A4 summary of the paper & our thoughts:

Changes in the management of children with Brief resolved unexplained events (BRUEs)