Well Baby Oddities

12 January, 2012 by: colinparker

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Well babies can cause angst too… Except that neither parents nor doctors can be sure that they are well, until they have been properly assessed. From funny breathing to blue lips, baby boobs to milk regurgitation, a range of neonatal and infant oddities can present to our Emergency Departments.

Some of these babies have real pathology and some have a minor but scary condition, with a great deal of ‘normal for young babies’ thrown into the mix. In this episode we discuss a few common problems, and provide some pointers towards differentiating baby wellness from baby illness. A huge thank-you to Dr Kate Bradman for allowing us to use her ‘Small Babies’ guideline!

PEMcast outline: Well Baby Oddities

Introduction, welcome, disclaimer

‘My baby is breathing very fast or seems to stop breathing’. There is no colour change.
Could be: Periodic breathing
Babies have an immature respiratory centre. When they breathe normally they blow off their CO2 – this causes them to become hypocapnoeic, and they stop breathing in response. This causes their CO2 to increase and they then become tachypnoeic to blow off their increased CO2 and they subsequently become hypocapnoeic and the cycle starts again…

‘My baby’s lips turn blue when he feeds’
Could be: Peri-oral cyanosis
There is a venous plexus below the top lip, when the baby sucks this becomes engorged and is visible through the skin. The important thing is to ensure that it is the area around the lips that turn blue and not the mucosa, and that the baby is feeding well, not sweating during feeds and is growing normally.
Concerning features:
Recession/Grunting or Stridor
Coughing especially after feeding
Tachypnoea with reduced feeding

‘My baby hasn’t opened their bowels for 5 days’
Could be: Normal neonatal bowel function
It is 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. Initially breast-fed babies open their bowels regularly as colostrum is a stimulant laxative. This clears out the meconium and their poo changes to a yellow seeded mustard consistency.
Concerning features:
Meconium not passed in first 24-48 hours of life – these babies must be referred to a surgeon
Excessive straining to pass stool
Blood passed with stool

‘My baby vomits after every feed’
Possible Diagnoses:
1. Possetting – all babies posset (bring up a small amount of milk after feeding). It is a normal mild form of GOR – the sphincter muscle at the oesophago-gastric junction 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.
2. Overfeeding – a full-term healthy baby should feed (from Day 4) about 150 mls/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 mls/kg/day. For breast-fed babies it is useful to document how often they are feeding, and for how long, and whether they are having bottle top-ups.
3. Gastro-oesophageal reflux – as explained above all babies reflux to some degree.
The first step in treating reflux is positioning: during feeding, and for at least 30 mins after feeding, the baby should be kept as upright as possible. Regular winding during feeds can also help.
In addition, feed thickeners can be used – mixed with water and given via syringe for breast-fed babies, or added to formula milk. Corn-flour works just as well as commercial products.
Parents should be advised that most babies will grow out of this condition once solids are introduced.
There are 2 concerning types of reflux that result in poor weight gain and therefore require treatment and/or further investigation:
Painful reflux – acid is refluxed into the oesophagus and the baby screams during feeds and refuses feeds. This type of reflux often responds to proton pump inhibitors e.g. omeprazole, lansoprasole
Excessive vomiting – with failure to gain weight and / or regular episodes of aspiration pneumonia. These babies should be referred for investigation. In many cases the only effective treatment is a Nissen fundoplication.
Concerning features:
Fever & vomiting
Projectile non-bilious vomiting in a hungry baby (pyloric stenosis)
Bilious vomiting (surgical obstruction)
Vomiting in a baby who looks unwell
Weight loss or failure to regain birth weight

‘My baby has blood in his wee’
Could be: Urate crystals
Excretion of calcium and urate in the urine can be visible as orange-red staining in the nappy. It is extremely common in the first few days of life, but can be a sign of significant dehydration later on.

‘My baby is bleeding from her vagina’
Diagnosis: Hormonal withdrawal
This is a completely benign and common condition that freaks parents out – especially fathers! It is related to maternal hormone (progesterone) withdrawal, and only lasts a few days.
Concerning features:
PV bleeding outside the neonatal period

‘My baby boy has boobs’
Diagnosis: Response to maternal hormones
This can occur in both male and female neonates and is completely benign and self-resolving.
Concerning features:
Breast enlargement with onset outside the neonatal period
Unilateral swelling
Hot red swelling
Pus formation

‘My baby is producing breast milk’
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 hormones crossing the placenta before birth.

‘My baby is moving funny – are they fitting?’
Could be: Moro Reflex – ‘Startle response’
Normal response to noise, sudden movement or touch. The reflex is present from birth and disappears by about 4-6 months of age.
Concerning features:
Tonic-clonic movements
Unilateral movements
Associated colour change

‘My baby isn’t gaining weight’
Understanding weight loss and gain in the neonatal period is vital. Your 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 – up to 10% of the birth weight is acceptable
Day 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 around 180g per week
Average weights (50th centile):
Birth: 3.5 kg
6 weeks: 4.0kg
Six months: 7 kg
1 year: 10 kg

‘My baby has spots’
Could be: Erythema Toxicum (Neonatorum)
Most common pustular eruption in newborns
Aetiology is unknown (sterile collections of eosinophils)
Usually appear day 2-3 and fade by day 7 although they may recur for several weeks
Fluctuating generalised eruption
No treatment is needed

Could be: Milia (‘Milk Spots’)
Caused by retention of keratin within the dermis
Occur mainly on face but can occur anywhere
Usually disappear within the first month
No treatment is needed

Suggested websites for parents (Australian):
Health Directhttp://www.healthdirect.org.au/pbb
Raising Childrenhttp://raisingchildren.net.au/

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4 Responses to “Well Baby Oddities”
  1. Ben S says:

    To the EMPEM team,

    Really enjoyed this one. As a beginning paediatric nurse with no kids of my own babies are scary squishy little people to me and the pemcasts have really helped me get a feel for what I need to be on the look out for.
    I was lucky enough to work with some of you in the ED a while back as a student and pass on my encouragement in person, but since working upstairs I’ve come accross a few situations I’d love to hear a pemcast focus on in the future.

    First up – congenital cardiac kids .. a sort of how to guide would be useful for docs and nurses to work out what to do with them investigations/treatment/observations wise when they’re well and unwell and present to us. Or even a rough guide of what to expect from the various congenital cardiac defects at different stages of life and/or repair.. what to be aware of and look for.

    Secondly .. a primer on clotting and bleeding disorders in kids? or siezure disorders.. might be useful.

    Keep up the great work,


  2. dr r a smith says:

    Hi there, the refluxing baby:

    Take a careful feeding history to establish when the baby started vomiting. Did it relate to the onset of artificial feeding or if the baby has been artificially fed, how many different feeds have they been on? Is there a family history of atopy/ allergy? Did the baby start to feed and then cry in pain and now it cries as soon as the teat is put to the mouth? Does the mother try to feed the baby when it is sleepy? Is the baby constipated? It is often the reaction to the babies symptoms that leads to “overfeeding” (though there are some genuine cases)
    CMPA (cows milk protein allergy) frequently presents with crying, possetting, adversive feeding and reflux. Up to 44% of reflux is secondary to CMPA. Furthermore an Australian study about 4-5 tears ago clearly showed that PPIs are ineffective in the treatment of reflux, which is logical as the drugs are not designed to prevent reflux but to supress acid secretion. The trials on feed thickeners and of comfort milk have failed to show they are efficacious too, but may be worth trying.

    Paradoxically CMPA has been shown to cause constipation.
    The cure is either an extensively hydrolysed whey formula or an artificial feed such as Neocate (and other). Remember some of these formulae contain lactose but of course under the age of a year this does not matter for congenital lactase deficiency is very rare, 1:100,000 and the children have profound diarrhoea and waste away. Breastmilk contains approx 7g/100ml of lactose so babies must have the enzyme. what is true is that in the majority of people worldwide the levels of lactase decline significantly in the second year of life.
    With the correct therapy the vomiting will stop at around three days, the skin and constipation take up to two weeks. If they are on a synthetic feed and the baby is not significanly better then the symptoms are not due to CMPA.

    Declaration of Interest: I have given international lectures on CMPA for Niutricia

  3. colinparker says:

    Dear Dr Smith

    Thank you for that informative discourse on reflux and cows milk protein allergy. I’m not convinced that “up to 44% of reflux is secondary to CMPA”. I might take that one with a pinch of salt… I guess it depends on the population studied but I would be flabbergasted if that were the case for our usual refluxing infants presenting to the Emergency Department or Family Medicine.
    Thanks for declaring your potential conflict of interest.



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