Oxford Handbook of Midwifery (130 page)

Advantages

Disadvantages

1. Blackburn S (1995). Hyperbilirubinaemia and neonatal jaundice.
   Neonatal Network
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   , 7.
   
2. Edwards S (1995). Phototherapy and the neonate; providing a safe and effective nursing care for jaundiced infants.
   Journal of Neonatal Nursing
   1
   (5), 9–12.
   
3. Rennie JM, Roberton NRC (eds) (1999).
   Textbook of Neonatology
   , 3rd edn. London: Churchill Livingstone, pp. 715–30.
   
4. National Institute for Health and Clinical Excellence (2010).
   Neonatal Jaundice
   . Clinical guideline
   

   98. London: NICE. Available at: M
   www.nice.org.uk/cg98 (accessed 29 June 2010).
   

5. Hey E (1995). Neonatal jaundice; how much do we really know?
   MIDIRS Midwifery Digest
   5
   , 1.
   
6. Hey E (1995). Phototherapy: Fresh light on a murky subject.
   MIDIRS Midwifery Digest
   5
   , 3.
   
7. Day C (1995). Phototherapy for neonates: A step by step guide.
   Journal of Neonatal Nursing
   3
   , 4.
   

   CHAPTER 23
   Care of the newborn
   

   610‌‌
   

   Vomiting in the newborn
   

   • Vomiting small amounts of milk after feeding is a common event in healthy babies during the first 2 weeks of life. It is physiological and universal.
     
   • The normal baby swallows a variable amount of air during a feed which can be expelled easily by sitting the baby upright and gently rubbing his or her back.
     
   • A teaspoon or two of milk is often regurgitated within the first 10min after feeding. This is known as posseting and is considered to be a normal response.
     ^1,
     2
     
   • Vomiting has many possible causes, most of which are simple and benign. Should the vomiting become persistent then more serious causes will be considered.
     ¹
     

     Causes
     

     The causes of vomiting can be non-organic or organic.
     

   • Non-organic:
     
     • Overfeeding
       
     • Incorrect preparation of feeds
       
     • Overstimulation and excessive handling
       
     • Crying
       
     • Air swallowing.
       
   • Organic:
     
     • Infection
       
     • Gastroenteritis
       
     • Meningitis
       • Otitis media
       
     • Gastro-oesophageal reflux
       
     • Gastritis from swallowed meconium or blood
       
     • Bowel obstruction
       
     • Pyloric stenosis
       
     • Hiatus hernia
       
     • Feeding intolerance/allergy
       
     • Metabolic disorders.
       

       Bile-stained vomiting may indicate malrotation of the bowel.
       ^2,3
       Bile stained or projectile vomiting may indicate intussusception of the bowel.
       

       The cause can be determined by a taking a history of:
       

   • Feeding technique
     
   • Description of the vomiting
     
   • Preparation of the feed
     
   • Other symptoms.
     

     Investigations
     

     If the history and physical examination of the baby prove inconclusive, the following investigations are carried out:
     

   • U/E
     
   • Abdominal X-ray for bowel obstruction
     
   • Oesophageal pH monitoring
     

VOMITING IN THE NEWBORN

611

• Oesophageal anomalies
  
• Hiatus hernia
  
• Gut malrotation
  

• Malrotation
  
• Gastric outlet obstruction
  

• Blood cultures
  
• Urine microscopy
  
• CSF culture
  

• Alkalosis with pyloric stenosis
  
• Persistent acidosis with inborn errors of metabolism serum electrolytes
  
• Hypokalaemia in paralytic ileus
  
• Hypochloraemic alkalosis in pyloric stenosis
  ²
  

• Urine amino and organic acids
  
• Plasma amino acids
  
• Lactate.
  ²
  ,
  3
  

  Management
  

  Management involves identifying and treating the cause and maintaining the baby’s fluid balance.
  

  2 Throughout the period of investigation and management the midwife must remember the need for accurate and detailed documentation, and
  

  the need for advice, support, and clear explanations to the parents.
  

  The above list of investigations is not necessary for every vomiting baby. Vomiting can often be transient and attention to the frequency and volume of feeds is enough to improve the situation.
  ²
  ,
  3
  

  Abdominal distension
  

  Feeding should be stopped where there is vomiting accompanied by mild to moderate abdominal distension. Carry out an abdominal X-ray. If this is satisfactory but the baby continues to vomit when feeds are reintroduced, stop feeding for 3 days to rest the gut and provide fluids and electrolytes via an IV line, then gradually reintroduce enteral feeding again.
  

  Feeding intolerance
  

  This is not common in the newborn but should be considered where simple remedies have failed to improve the baby’s condition, or if there is a family history of feeding intolerance. It may then be necessary to intro- duce the baby to a soya-based formula.
  

  Irritation due to swallowed fluids
  

  During birth amniotic fluid, meconium, and mucus can be swallowed, which can irritate the stomach, causing gastritis and the rejection of early feeds. A small stomach wash-out via a nasogastric tube can usually cure the problem.
  ¹
  

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  Care of the newborn
  

  612
  

  Vomited blood
  

  Vomited blood in the first few days is usually swallowed maternal blood. This can be distinguished easily from the baby’s own blood as it will not contain any fetal haemoglobin.
  

  Vomited bile
  

  2 Vomited bile is more serious and can indicate intestinal obstruction, which can occur at different levels in the gut. Abdominal X-rays will confirm or exclude this as the problem. Bile-stained vomiting may also occur with a cerebral disorder such as intracranial bleeding or meningitis.
  ¹
  

  Gastro-oesophageal reflux
  

  This is characterized by repeated small vomits occurring shortly after feeds. It is caused by an incompetent lower gastro-oesophageal sphincter and is common in:
  

  • Premature babies
    
  • Babies who have neurological abnormalities causing hypo- or hypertonia
    
  • Following surgery for repair of diaphragmatic hernia or oesophageal atresia.
    

    The baby may fail to thrive due to loss of calories in the vomit and there is a risk of aspiration into the lungs. The problem can be treated in several ways:
    

  • Thickening feeds with:
    
    • Nestargel
      ^®
      
    • Carobel
      ^®
      
    • Thixo-D
      ^®
      
  • Nursing the baby in a prone position with the cot tilted up 30–40°
    
  • Drugs, such as:
    

    • Gaviscon
    ^®
    1–2g with each feed, but this can cause constipation
    

    • Cisapride (discontinued), a prokinetic drug, to improve gastric
      

      emptying, but this can cause arrhythmias
      

    • Antacids, such as cimetidine, can help to relieve gastritis. Where medical treatment fails, fundoplication will be tried.
      

      The natural history is for a gradual improvement as the baby grows and the condition is usually better by the end of the first year of life.
      ^1,3
      

      Projectile vomiting
      

      Projectile vomiting usually indicates pyloric stenosis. This is more common after the first month of life and rarely occurs in the first week. There is usually a family history and it is more common in boys.
      

      Diagnosis can be made by observing visible peristalsis and a palpable ‘tumour’ in the area of the pyloric sphincter (the muscle that regulates the flow of milk from the oesophagus into the stomach).
      

      Because this muscle is too tight, the milk stays in the oesophagus for longer. The amount of milk in the oesophagus increases as the baby feeds and it is forcibly ejected. Treatment usually involves surgery to split the muscle (Ramstedt’s operation).
      ³
      

      1. Johnston PGB (1998).
         The Newborn Child
         , 8th edn. London: Churchill Livingstone, pp. 88–9.
         
      2. Mupanemunda RH, Watkinson M (2000).
         Key Topics in Neonatology
         , 2nd edn. Oxford: Bios Scientific, pp. 275–7.
         
      3. Levene MI, Tudehope DI, Thearle MJ (2000).
         Essentials of Neonatal Medicine
         , 3rd edn. London: Blackwell, pp. 93–115.
         

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      Care of the newborn
      

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      Metabolic disorders and the neonatal blood spot test
      

      Although these conditions can present in the neonatal period, diagnosis is difficult or delayed because the clinical signs may not be specific to an indi- vidual disorder or to an inborn error of metabolism. Routine screening is designed to detect the affected infants before symptoms develop, allowing treatment to be initiated as soon as possible.
      ¹
      

      Genetic inheritance
      

      These conditions are usually inherited as autosomal recessive conditions, which have the following pattern:
      ¹
      

  • Both parents are normal and do not have the condition
    
  • Both parents are carriers of a faulty gene
    
  • Both carrier genes from both parents must be inherited to produce a child with the condition
    
  • This gives a 1:4 risk of having an affected child with the condition with each pregnancy
    
  • 2:4 will be normal, but carriers of the faulty gene
    
  • 1:4 will be normal, non-carrier.
    

    Clinical presentation
    

  • There may be a family history of neonatal death or siblings with a known inborn error of metabolism.
    
  • A period of ‘well-being’ followed by illness and collapse.
    
  • Infection may be suspected and a full infection screening done, but the
    baby will not respond to treatment.
    
  • Parental consanguinity.
    ¹
    

    General signs and symptoms
    

  • Unexplained metabolic acidosis
    
  • Reducing substances in the urine
    
  • Feeding difficulties/vomiting/diarrhoea
    
  • Hepatomegaly
    
  • Convulsions/cerebral oedema
    
  • Ketosis/hypoglycaemia/hyperglycaemia
    
  • Respiratory distress
    
  • Bradycardia/apnoea
    
  • Hypothermia
    
  • Abnormal tone (hypertonia or opisthotonus)
    
  • Axial hypotonia
    
  • Smelly urine
    

    Don’t forget that antibiotics also make the urine smell of yeast.
    ¹
    

    Initial investigations
    

  • Non-specific
    blood and urine tests, with the test results available within a few hours, can place the error within a diagnostic category, allowing appropriate emergency treatment to be instigated. These are available in all units providing neonatal care:
    
    • FBC
      
    • U/E
      

  METABOLIC DISORDERS AND THE NEONATAL BLOOD SPOT TEST
  

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  • Blood gas
    
  • Blood ammonia
    
  • Urine-reducing substances
    
  • Urine ketones.