Newborn Presentations

People get worried about newborn babies.  When presented with a baby problem, there are a few basic rules to apply:

Most things that newborns present with are unlikely to have a significant cause.  Some presentations are more concerning that others and while there are no absolutes, it is good to know which things to be more suspicious of.

In many cases, it is possible to significantly change the index of suspicion by knowing the red flags to look out for.

Let's look at a few examples:

Imperfectly shaped head

Since the discovery that putting a baby to sleep on their back dramatically reduces the risk of sudden infant death, there has been a significant rise in the number of babies and infants with asymmetrically shaped heads.

Picture credit: https://commons.wikimedia.org/wiki/File:Plagiocephalie.JPG

The vast majority of babies with this presentation will have plagiocephaly - the result of gravity on a compliant skull.  Plagiocephaly has no apparent risk of harm and requires no intervention.  However, this presentation nicely illustrates the general principles of assessing any presentation in a baby because there is a significant pathology that is rare but significant - craniosynostosis.

So while the head shape is very likely to be nothing to worry about, it is still necessary to look for evidence to support that decision.  The head should be palpated and measured (and plotted), the baby should be given a neurological examination and development should be assessed.

It also follows another rule of newborn presentations: where there is no credible pathology, we should do as much nothing as possible.  We should avoid unnecessary tests and treatments. Remember that the baby is your patient.  Don't do anything to them that does not stand to benefit them directly.

Sticky eyes

While the temptation is to presume that sticky eyes are due to infection, this is rarely the case in newborns.  In most cases the problem is a blocked tear duct.  True eye infections are uncommon and usually quite obvious.  This presentation nicely illustrates the general principles of:

• Assess the problem - Is the conjunctiva red?  Is there periorbital redness and swelling?
• Look at the baby - Do they appear well?
• Decide if there is a significant problem (ophthalmia neonatorum)
• If not, don't do an unnecessary test (swab) or give an unecessary treatment (antibiotic drops)

Excessive crying

Babies cry.  How much is excessive is hugely subjective and open to interpretation.  Although excessive crying in the absence of pathology has been given a name (colic) this scenario demonstrates the principle that we can't always offer a diagnosis.  Calling the problem colic implies that we know what causes the problem and validates an interventional approach.  There is no treatment for excessive crying in the absence of pathology that has a good evidence base.  Sometimes honesty about uncertainty and futility of intervention is the best policy.

Regurgitation of Feeds

Note the use of the word regurgitation.  People often use the word vomiting or even "projectile vomiting" when neither is what is happening.  Babies often bring back some milk after a feed.  This is generally a passive event, as opposed to vomiting, which is what happens when peristalsis works in reverse or against an obstruction such as pyloric stenosis.

By now, you probably know what I'm going to suggest.

• Assess the problem - Is regurgitation the only symptom?  Are there red flag features (see above)?  How long has the problem been occurring?  Has it changed much and if so how rapidly?
• Look at the baby - Do they appear well?  Do they appear well grown?  Plot their growth on a chart.
• Decide if there is a significant problem (e.g. Pyloric Stenosis) or whether they could be in a feed-cry cycle.
• If not, don't do an unecessary test or give an unnecessary treatment.  If you give alginates to every regurgitating baby, you'll double your workload as they come back the next week with constipation and without the original symptom having improved.

Not opening bowels for X number of days

Guess what?  Yes: in most cases, the baby who has not passed a stool for the past few days is usually going through something that is normal in the first few weeks of life.

As with all of the low risk newborn presentations, if the baby looks well, examines normally and is growing and developing normally, they are normal.  If something is significantly wrong, it should manifest itself in the history or examination.  In most cases, we should normalise this presentation rather that give something to treat it.

It can be really difficult to do nothing when faced with a baby and a concerned parent.  However, a careful clinical assessment and evaluation are the most important interventions you can offer.  If you have done that and not come up with something serious, explanation and safety netting are the premium service, not the economy class package.

Umbilical presentations

There are rare and significant pathologies that can affect the umbilicus.  Most of these will present at birth or in a way that alerts the clinician to the fact that something is clearly not right,  The more common presentations and the best approach to each are:

• Umbilical granuloma - leave it alone
• Umbilical hernia - leave it alone
• Umbilical stump being sticky and smelly - leave it alone unless there is evidence of omphalitis

Skin presentations

Lots of things can happen to the skin of a baby in the first few days and weeks.  Most presentations are either normal phenomena (peeling skin), dysfunctional but harmless (erythema toxicum) or problematic but mostly uncomplicated (cradle cap).

Picture credit: Skin Deep - a DTFB project

In each case there are simple questions to be answered

• Peeling skin - Is the baby well?  Is there dermis exposed by the peeling skin (if so then epidermolysis bullosa is a possibile diagnosis)?
• Erythema toxicum - Is the baby well (erythema toxicum is completely harmless)?
• Cradle cap (seborrheaic dermatitis capitis) - Is the baby well?  Does the skin have signs of infection?

Peeling skin and erythema toxicum are best left alone.  Cradle cap can be treated with olive oil in most cases.  Occasionally it can become infected.

Jittery Movements

Sleep myoclunus is a normal phenomenon at all ages.  In babies it can cause people to worry thet their child is having a seizure.  This is partly due to the protective reflexes that they are born with such as the moro reflex.

Here we go again with the standard procedure for a newborn presentation:

• Assess the problem - Are the movemments occuring during or around sleep time?  Is the baby otherwise normal in between episodes?
• Look at the baby - Do they appear well?  Are they developing normally. Measure and plot head circumference.
• Decide if there is a significant problem (e.g. Infantile spasms/ West syndrome)
• If not, don't do an unecessary test or give an unnecessary treatment.  Explain, reassure and give safetynetting advice.

Demedicalising infancy is a good thing to do.  The simple apprach of assess, look and decide will allow you to do that in the majority of cases.  In the rare cases of the discovery of a red flag or atypical presentation, there are always the options of advice or referral.

Edward Snelson
@sailordoctor

Something or nothing - why topical antibiotics are not for neonates with eye and umbilical infections

Newborn babies cause clinicians a lot of anxiety.  The worry about infections can lead to the use of antibiotics "just to be safe."  This is usually not the best approach.  Most of the time, the symptoms are nothing, and when they are something more significant, sending the baby home with topical antibiotics is not the solution.

Let's look at two common scenarios.

Scenario 1 - The baby with a sticky eye

A one week old presents with a unilateral sticky eye.  The baby is otherwise well, feeding and growing.   The left eye has a yellow discharge around the margin of the eyelid.  The baby's examination is otherwise normal.

What's the problem?  Something or nothing.

The nothing problem is the more common scenario.  Many babies are born with a non-patent nasolacrimal duct.  The inability to drain tears from the eye to the nose leads to the sticky eye.  Tears are made up mainly of water and lipid (for lubrication).  The water mostly evaporates leading to a thick secretion which accumulates.  This is not a sign of an infection.

Most blocked tear ducts will self-resolve over weeks or months.  It is unusual for them to persist until the infant's first birthday.  If it does, an ophthalmologist can unblock the duct with a probe.

Rarely, there will be a cystic collection in the tear duct.  This presents with the same sticky eye but with a swelling visible at the inner canthus of the eye.  There are some good pictures of what that looks like here.  Although these do sometimes self resolve, dacrocystoceles can be problematic and should be referred to an ophthalmologist.

The something problem is infective conjunctivitis, but not as you know it in older children.  Babies have all those lovely maternal antibodies to protect them from common viral infections, so viral conjunctivitis is relatively rare in newborns.  In addition to the increased likelihood of bacterial infections, there are two other factors that make topical antibiotics a bad idea for newborn eye infections.

Firstly, the infection may be congenitally acquired.  Chlamydia and gonorrhoea are two organisms that cause bacterial eye infections in neonates.

Secondly, the baby's immune system is heavily reliant on the aforementioned maternal antibodies.  Their own immune system is immature and relatively unresponsive.  That is one reason why newborns have vague symptoms during serious bacterial infections, while a one year old has a temperature of 39C and can look really unwell with an uncomplicated viral illness.

If this baby does have a bacterial eye infection, it is high risk both for the eye and the baby.

Opthalmia Neonatorum - from the Centers for Disease Control and Prevention's Public Health Image Library #3766

As a result of all of these factors, eye infections in newborns (ophthalmia neonatorum) should be taken seriously and referred for acute assessement and management by paediatrics or ophthalmology depending on your local pathways.

How do I tell the difference between the something and the nothing?

It's actually quite simple.  There are a few quick things to check:

The answers to these questions give you the answer to what you should do next.

While it might feel like the safe option to just give topical antibiotics to every baby with a sticky eye, this is not the case.  If the problem is a blocked tear duct, the eye drops may cause a chemical conjunctivitis and make things worse.  If the problem is an infection, it is higher risk for the eye and the baby and so needs careful assessment and management.

Scenario 2 - The baby with red skin around the umbilical stump

A three day old baby is brought to you by one of their parents.  There is some redness around the umbilical stump.

What is the problem?  Something or nothing.

The nothing option if the umbilical stump is still attached is non-infective inflammation.  From the moment of birth, the umbilical stump is devitalised tissue.  In the absence of a blood supply, it goes through a process that leads to separation, usually about a week or two after birth.  During this time it can either just become dry and shrivelled or it can become a bit sticky and smelly.  Often, the skin around the base has been repeatedly cleaned to remove any stickiness.  This itself can cause a small halo of red skin.

Image taken from the Stanford Newborn Nursery site and used with permission. This material was compiled by Janelle Aby, MD for educational purposes only.  Reproduction for commercial purposes is prohibited.  Utilisation of the materials for educating those who care for newborns is permitted with proper citation of source.
The nothing option if the umbilical stump has separated is an umbilical granuloma.  These benign growths are quite common and will self resolve.  They have a tendency to produce some exudate.  Again, repeated cleaning can cause a bit of inflammation to the surrounding skin.

The something scenario is omphalitis.  Infection of the umbilical stump carries a high risk of invasive infection.  This of course is partly due to the immunology of a newborn (see above).  It is also because the umbilicus retains its connection to the circulation.  The external part may be dead but the vessels inside are still patent and may help to seed the infection systemically.

Image taken from the Stanford Newborn Nursery site and used with permission. This material was compiled by Janelle Aby, MD for educational purposes only.  Reproduction for commercial purposes is prohibited.  Utilisation of the materials for educating those who care for newborns is permitted with proper citation of source.
Omphalitis is now a rare occurrence in the UK and other similar counties.  It remains a more frequent presentation in countries with limited healthcare resources, especially where it is common to give birth in unclean environments.

Since most of these neonates will be cared for in a hospital setting, babies that present to GP or ED are likely to be low risk.

In a low risk baby, the decision about what to do is fairly straightforward.

While it might feel like the safe option to just give topical antibiotics to every baby with a sticky umbilicus, this is not the case.  If the problem is non-infective inflamed skin, applying chemicals is only likely to make that worse.  Inflamed and broken skin does not make a good barrier to infection.  If the problem is an infection, it is a high risk situation best managed in a secondary care setting.

So if it's nothing, leave it alone.  This of course always requires good safetynetting advice.  If it is something significant, this is usually best managed in a secondary care setting.  There's no real role for the practice of doing something to make us feel like we've done something.

Edward Snelson
Cautious binarian
@sailordoctor