Problems in Small Babies

Growth restricted, or premature babies are more prone to the ailments that can affect all newborn infants because many of their physiological systems are not yet fully developed. Many of these problems are not life threatening or have long term sequelae. However, some of them can also develop into a severe condition if not treated effectively and promptly.

These are the most frequently encountered problems associated with prematurity. Most of them are relatively mild and easily managed but, on occasions, they can be life-threatening. If in doubt refer urgently to hospital.

Periodic breathing

Apnoeic attacks

• Anaemia (see below)
• Gastro-oesophageal reflux
• Hypoglycaemia
• Cerebral bleeding
• Infection
• Electrolyte disturbance

Management:

• The infant should be gently massaged during an attack to stimulate breathing and given O₂ if saturation levels do not rise quickly.
• Constant monitoring is required including using an apnoea monitor.⁵
• Caffeine or aminophylline are often effective in preventing attacks but where these fail assistance via continuous positive airway pressure or even artificial ventilation may be needed.

Respiratory distress syndrome

Respiratory distress syndrome is characterised by:

• Rapid breathing
• Grunting
• Recession of sternum/rib margins

The commonest cause is hyaline membrane disease associated with the failure to produce surfactant.⁶ It is treated by assisted ventilation and the administration of artificial surfactant.

Gastro-oesophageal reflux

• It can be confirmed by imaging or by monitoring lower oesophageal pH.

Management

• Raising the infant's head and thickening the milk with antacid/alginate.⁷

Distended abdomen

This is mainly seen after 7-10 days and is due to trapped gas.
Changing feeding schedule usually cures problem.
Also be aware that it may reflect more serious disorders such as:

• Sepsis
• Congenital GI anomalies
• Obstruction due to milk curd
• Impacted faeces

• If anaemia is causing significant problems it can be treated with either a blood transfusion or by using erythropoetin. There may be a statistically significant increased risk of retinopathy of prematurity (ROP) with early EPO treatment.⁸
• Untreated, normal Hb starts to return at 4-6 weeks of age if full term.
• Anaemia is often seen later associated with iron and folate deficiency and can be prevented by supplementation. However, some research suggests supplementation may have adverse effects.⁹

• Small babies are particularly at risk of kernicterus with levels as low as >250-300(mol/l depending on the degree of prematurity.
• Treatment is with phototherapy at an early stage, or exchange transfusions if severe.¹²

Oedema with pitting is commonly seen in the face, hands and feet and genitalia.

• It usually slowly disappears of its own accord but a more severe form is associated with respiratory distress syndrome, heart failure and hydrops fetalis.

An impaired immune response make infections both more common in pre-term infants and more difficult to diagnose with atypical presentations.
Atypical signs include:

• Falling temperature
• Lethargy
• Jaundice
• Pallor
• Feeding problems
• Vomiting

Common ones include:

• Maldescended testes
  • Refer for possible orchidopexy if not descended
• Umbilical and inguinal hernias
  • The latter need surgical correction as may strangulate
• Strawberry marks
  • These can appear in large numbers
• Delayed neurological development
  • Small for gestational age infants have been found to have significantly retarded neurological development compared with average-for-gestational age (AGA) infants from 2 months onwards.¹³
  • However, good growth in the following months is associated with a similar improvement in development.