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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
| Periodic breathing is characterised by short periods where the baby either stops breathing or only breathes very shallowly. |
Apnoeic attacks
| In contrast with periodic breathing, apnoeic attacks last at least 20 seconds, sometimes resulting in cyanosis and bradycardia.3 |
There may not be any discernible underlying cause, but the following factors are frequently found in this situation and need to be dealt with:4
- 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
| Most pre-term infants are prone to some degree of gastro-oesophageal reflux, but where it develops into vomiting it carries the risk of aspiration of gastric contents. |
Diagnosis:
- 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
| The haematocrit falls after birth in preterm infants due to physiological factors and frequent blood taking. |
- 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
| Jaundice is common in pre-term infants and is associated with a relative inability to excrete bilirubin.10 |
- 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.
Document references
- Kelly DH, Shannon DC; Periodic breathing in infants with near-miss sudden infant death syndrome. Pediatrics. 1979 Mar;63(3):355-60. [abstract]
- Tin W; Oxygen therapy: 50 years of uncertainty. Pediatrics. 2002 Sep;110(3):615-6.
- Finer NN, Higgins R, Kattwinkel J, et al; Summary proceedings from the apnea-of-prematurity group. Pediatrics. 2006 Mar;117(3 Pt 2):S47-51. [abstract]
- Nimavat DJ, Sherman MP; Apnea of prematurity. eMedicine, September 2007.
- No authors listed; Apnea, sudden infant death syndrome, and home monitoring. Pediatrics. 2003 Apr;111(4 Pt 1):914-7. [abstract]
- McClure P, Patel MR; Hyaline Membrane Disease. eMedicine, September 2005.
- Liburd JDA, Hebra A; Gastroesophageal reflux. eMedicine, February 2005.
- Aher SM, Ohlsson A; Early versus late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004865. [abstract]
- Domellof M; Iron requirements, absorption and metabolism in infancy and childhood. Curr Opin Clin Nutr Metab Care. 2007 May;10(3):329-35. [abstract]
- Hansen TWR; Neonatal Jaundice. eMedicine, June 2006.
- Sarici SU, Serdar MA, Korkmaz A, et al; Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns. Pediatrics. 2004 Apr;113(4):775-80. [abstract]
- Dennery PA, Seidman DS, Stevenson DK; Neonatal hyperbilirubinemia. N Engl J Med. 2001 Feb 22;344(8):581-90.
- Ounsted M, Moar VA, Scott A; Neurological development of small-for-gestational age babies during the first year of life. Early Hum Dev. 1988 Mar;16(2-3):163-72. [abstract]
Internet and further reading Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2458
Document Version: 20
DocRef: bgp24677
Last Updated: 10 Apr 2008
Review Date: 10 Apr 2010
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