Baby - common presentations

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS clinical disclaimer

Aim

To guide PCH ED staff with the assessment and management of common presentations in babies.

Background

• Parents regularly bring their newborn babies to the Emergency Department with all manner of concerns.
• The ability to be able to identify those with significant illness is a skill that is learnt throughout paediatric training.
• Where no significant illness is identified, the challenge is to reassure parents that their concerns are valid but that their child is well and that there is no underlying pathology.
• Below is a list of common presenting complaints and a lay-person explanation of the condition. If you have concerns about the diagnosis, please discuss the patient with the Senior ED Doctor before speaking to the parent(s) / carer.
• This guideline should not be printed and given to the parents. 

These scenarios have been written to assist in the management of common small baby issues that present to ED to reduce family anxiety and unnecessary investigations and admissions.

‘My baby is breathing very fast or seems to stop breathing’. There is no colour change.

Diagnosis: Periodic breathing^1,2,3

• Babies have an immature respiratory centre.
• Periodic breathing is characterised by alternating cycles of five to ten seconds of breathing and pauses in breathing. It is not associated with bradycardia or cyanosis. It increases in frequency between two and four weeks of age and resolves by six months of age.
• When they breathe normally, they blow off their carbon dioxide. This causes them to become hypocapnic and they stop breathing in response. This causes their carbon dioxide to increase and they then become tachypnoeic to blow off their increased carbon dioxide and they subsequently become hypocapnic and the cycle starts again.

Concerning features

• Recessing, grunting, stridor or coughing especially after feeding
• Tachypnoea with reduced feeding
• Apnoea, cyanosis or bradycardia
• Exclude infection, congenital lung or heart conditions and structural anomalies
• Consider chest X-ray, electrocardiogram (ECG), viral swabs and blood tests if concerning features present

‘My baby’s lips turn blue when they feed’

Diagnosis: Peri-oral cyanosis^2,3

• There is a venous plexus below the top lip. When the baby sucks, this becomes engorged and is visible through the skin.
• The important things to ensure are that it is the area around the lips that turns blue and not the mucosa itself, and that the baby is feeding well, not sweating during feeds and growing.

Concerning features

• Recessing, grunting, stridor or coughing especially after feeding
• Tachypnoea with reduced feeding
• Exclude infection, congenital lung or heart conditions and structural anomalies
• Consider chest X-ray, ECG, viral swabs and blood tests if concerning features present

‘My baby hasn’t opened their bowels for 5 days’

Diagnosis: Normal neonatal bowel function^2,3

• There is no universally agreed clinical definition of constipation for neonates. It can be completely normal for babies to not open their bowels for up to 7 days at any one point. This is especially common in breast fed babies.
• Some babies will strain and cry for longer than 10 minutes before passing soft stools. This phenomenon, known as dyschezia, is caused by an inability to coordinate the increase in intra-abdominal pressure with pelvic floor relaxation. This is a self-limiting condition.
• Initially breast fed babies open their bowels regularly as colostrum is a stimulant laxative. This clears out the meconium and their stool changes to a yellow seedy consistency.

Concerning features

• Meconium not passed in first 24-48 hours of life – these babies must be referred to the General Surgical Team
• Excessive straining to pass stool
• Blood passed with stool
• Caution should be applied and organic pathology excluded before prescribing laxatives in neonates

‘My baby vomits after every feed’

Concerning features in vomiting babies^2,4

• Fever and vomiting
• Projectile non-bilious vomiting in a hungry baby
• Bilious vomiting – bile is a green substance drained into the duodenum. The presence of bile in vomit could signify an obstruction and should be treated as a surgical emergency.
• Vomiting in a baby who looks unwell or has a history of injury
• Weight loss or failure to regain birth weight
• Failure to tolerate feeds in the Emergency Department
• Exclude infection and surgical causes (e.g. pyloric stenosis, bowel obstruction, necrotising enterocolitis, malrotation)

Diagnosis: Posseting³

• All babies bring up a small amount of milk after feeding with resolution expected in the first year of life.
• It is a normal mild form of gastro-oesophageal reflux – the muscle at the oesophageal-gastric entrance is weak and they are fed a liquid diet and spend most of the time lying down, they also swallow a lot of air whilst feeding and burping causes a small amount of milk to return.
• General measures, such as smaller frequent feeds, burping, holding the baby in an upright position after feeds and thickening agents, may help reduce the posseting.

Diagnosis: Over Feeding³

• A full term healthy baby should feed (from Day 4) about 150 mL/kg/day divided into regular 2-4 hourly feeds.
• It is vital that all babies you see have a calculated total daily intake of milk written as mL/kg/day.
• For breast fed babies please document how often they are feeding and for how long and whether they are having bottle top-ups.

Diagnosis: Gastro-Oesophageal Reflux (GOR)^2,4

• As explained above, all babies reflux to some degree
• In the setting of poor weight gain GOR requires treatment and / or further investigation:

1. Painful reflux

• Acid is refluxed into the oesophagus and the baby screams during feeds and refuses feeds
• This type of reflux may respond to acid suppression e.g. omeprazole. These babies can be trialled on acid suppression with appropriate follow up (GP or general paediatrician) to monitor response
• Medications should be started and monitored by their GP

2. Excessive vomiting

• It is important to recognise that there is no definitive treatment for this type of reflux
• The only cure is a Nissen fundoplication which is used in children with profound reflux causing regular aspiration pneumonia
• The first step in treating this type of reflux is positioning. During feeding and for at least 30 minutes after feeding, the baby should be kept as upright as possible
• Regular winding during feeds can also help
• If this does not work feed thickeners can be used – mixed with water and given via a syringe for breast fed babies or added to the formula milk
• Babies that are vomiting so much that they are not gaining weight should be referred to the General Paediatric Team for further investigation
• Parents should be advised that most babies will grow out of this condition once solids are introduced

‘There’s a lump sticking out of my baby’s belly button’

Diagnosis: Umbilical Hernia^2,3

• A weakness in the abdominal muscles around the umbilical cord is extremely common
• It will appear larger when the baby cries because as they inflate their lungs the abdominal contents get pushed down and out
• It is not causing them pain
• They do not obstruct and therefore do not need surgical repair
• Most will have disappeared by 1 year of age but some remain for longer
• Consider General Surgical Team referral in children over 1 year of age with a large umbilical hernia

Diagnosis: Umbilical Granuloma^2,3

• Fibrous tissue at the umbilicus
• Granulomas previously were commonly treated by cauterising with a silver nitrate stick. However, due to risk of significant burns to surrounding healthy tissue, this is no longer routinely recommended at PCH
• They will resolve and do not need any treatment. Discuss concerns with a senior doctor if required

‘My baby has blood in their wee’

Diagnosis: Urate Crystals

• Excretion of calcium and urate in the urine can be visible as orange-red staining in the nappy.
• It is common, occurring in up to 25% of neonates in the first few days but can be a sign of significant dehydration later on

‘My baby is bleeding from her vagina’

Diagnosis: Hormonal withdrawal²

• This is a completely benign and common condition that causes great stress for parents. It occurs in up to 4% of neonates
• It is related to maternal hormone withdrawal and only lasts a few days

Concerning features

• Vaginal bleeding outside the neonatal period

‘My baby boy has boobs’²

Diagnosis: Maternal hormone response

• This can occur in both male and female neonates and is completely benign. Resolution occurs within two weeks in boys and several months in girls. Stimulation of the breast tissue may slow resolution.

Concerning features

• Breast enlargement outside the neonatal period
• Unilateral swelling
• Signs of infection: hot red swelling, pus formation.

‘My baby is producing breast milk’²

Diagnosis: Maternal hormone response – ‘Witches milk’

• As above, this is a completely benign, if somewhat alarming, condition which occurs in neonates as a result of maternal hormonal surges.

‘My baby is moving funny, are they fitting?’

Diagnosis: Moro Reflex – ‘Startle response’^2,3

• Normal response to noise, sudden movement or touch
• The reflex is present from birth and disappears at 4-6 months
• Concerning features:
  • Tonic-clonic movements
  • Unilateral movements
  • Associated colour change

‘My baby isn’t gaining weight’^2,3

• Understanding weight loss and gain in the neonatal period is vital
• Assessment of any infant should include plotting their weight and head circumference on an appropriate growth chart
• Day 1 – birth weight
• First week of life – weight loss of up to 10% of the birth weight is acceptable
• Days 10-14 – baby should have regained their birth weight
• Further weight gain can be remembered by the old adage ‘an ounce (30g) a day except on Sundays’, i.e. a healthy baby should gain approximately 120-200g per week.

Average weight (50th centile)

• Birth – 3.5kg
• 6 weeks – 4kg
• 6 months – 7kg
• 1 year – 10kg

‘My baby has spots’^1,2,3

Diagnosis: Erythema Toxicum Neonatorum

Diagnosis: Milia

Diagnosis: Neonatal Acne

Diagnosis: Seborrheic Dermatitis

References

Endorsed by:	Co-Director, Surgical Services	Date:	Nov 2022
		Review date:	Aug 2025

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