Sick Baby: undifferentiated infant under 3 months

29 December, 2011 by: colinparker

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Young infants under 3 months can be pretty scary when they get properly sick. It seems quite ‘veterinary’, and in many ways we just have to screen and treat for sepsis – and ask questions later… But there are a number of other differentials to consider.

Signs of illness may be obvious, such as when we are presented with a pale, floppy baby, or they may be more subtle – when either the caregiver or the doctor just knows that the baby is just NQR – Not Quite Right. In this episode, we consider the assessment and management of the non-specifically unwell young infant, that is, under 3 months of age, using an ABCD structure (of course).


PEMcast Outline: undifferentiated sick young infant (<3 months)

[CP] Intro, disclaimer

[RR] What’s different about neonates / young infants?
They are brand new
Physiological changes
Possibly inexperienced parents
No chance to know what is “normal” for them
They are SCARY!
However…It is easy once you have a system as we have such a low threshold for investigation and treatment.

[CP] The background history
Antenatal problems
Birth- PROM, distress, NICU
Family history
Vitamin K

[RR] History & Examination: Systematic approach

[CP] Airway & Breathing Problems

Hx:
Congenital problems?
Progressive problem, or manifests with episodes of Infection?
Ex:  Stridor, Air entry, Sats,
Ix: CXR

[RR] Circulation

Hx:
Antenatal scans don’t pick up everything
Many cardiac problems progress over first few days (duct closure)
Feeding – tiring / sweating
Weight gain less obvious (peripheral oedema does not really happen)
Ex:
Sometimes it is easy to spot cyanosis…. (smurf)
Usually it isn’t- do saturations on both arms (pre and post ductal)
Listen for murmurs and feel for a liver
Always feel for femoral pulses
Ix: ECG and CXR

[CP] Disability (and sepsis)
Hx:
Antenatal risk factors
Fever?- if any documented fever TREAT as sepsis
Ex:
Posture?
How does the baby handle? (reactive? lively on handling?)
Fontanelle
Blood sugar (DEFG)
Ix:
? Sepsis: If any concern about sepsis- full septic screen (incl urine, CXR, BC, CSF)
? Cardiac- CXR and ECG
? Metabolic- urine, full septic screen, ammonia and cortisol

[RR] Treatment
Sepsis- cefotaxime, gentamicin and amoxycillin
Cardiac- prostin to keep duct open
Metabolic- IV glucose and NBM

Differentials for the collapsed young infant:

[CP] A: (congenital airway abnormality) Allergy/anaphylaxis

[RR] B: apnea (RSV/FB), ALTE, pneumonia, pneumothorax

[CP] C: coarctation, duct-dependent pulmonary or systemic circulation, SVT

[RR] D: intracranial bleed eg Vitamin K deficiency, NB inflicted injury (NAI)
Envenomation or poisoning (DIMTOPPE mnemonic)

[CP] E: (fever – sepsis): UTI, bacteraemia, meningitis, viraemia

[RR] DEFG: Hypoglycaemia, other metabolic incl CAH (boys)

[CP] GI: Intussusception, other causes of bowel obstruction (green vomits) incl obstructed inguinal hernia

[CP] ALTE’s: a well baby that gets admitted (see previous PEMcast)
4 features (Detailed history is important)
Not a ‘near-miss SIDS
[RR] Should be taken seriously and needs paediatric follow-up
Encourage parents to go on a life support course
Many parents buy apnoea alarms (pros & cons)

[RR] Summary
Most unwell babies will be treated for sepsis pending further investigation
It is important to look for cardiac and metabolic problems
Don’t forget Non-Accidental Injury as a differential

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