Recognising deterioration in the neonate
Early recognition of the unwell and/or deteriorating neonate is essential to ensure a timely referral, diagnosis, treatment and management to prevent problems that can lead to increased morbidity and even death.
Deterioration can be very obvious or initially non-specific. Neonates can deteriorate very quickly, so early recognition is essential. The midwife must have the knowledge and skills to recognise normal and to be able to identify deviation from the normal or what is normal for a particular baby (Table 63.1).
In adults and children early warning scoring systems are well developed to assist the practitioner to identify deterioration. The Neonatal Early Warning (NEW) tool is an example of tools being developed to assist midwives in recognising deterioration in neonates following delivery, on the postnatal wards and during community visits.
The signs of deterioration will be discussed using a systems approach. Parental observations of changes in their infant’s behaviour, temperature, feeding and bodily functions should not be ignored (Figure 63.1).
Neurological presenting signs could include:
- Sucks poorly
- High-pitched cry
- Full, bulging or depressed fontanelle
- Seizure activity
- Temperature change.
Parents may observe and report an increase in their baby’s sleepiness, decrease in activity, the baby lies not flexed but with arms at their side, baby feels hot or cold and the temperature cannot be explained by the baby’s environment. Their baby may cry a lot and appears inconsolable.
Cardiovascular presenting signs could include:
- Decreased urine output
- Poor cutaneous circulation resulting in a delayed capillary refill time
- Weak/bounding femoral pulses.
Parents may observe and report a decrease in the number of wet nappies their baby produces (less than four wet nappies in 24 hours should cause concern and should be reported).
Respiratory presenting signs could include:
- Nasal flaring
Parents may observe and report that their baby is breathing faster than usual and that they have noted blueness around the mouth. They may note that the baby makes an unusual noise when breathing.
Gastrointestinal presenting signs could include:
- Not interested in feeding
- Poor weight gain/weight loss greater than 10%
- Abdominal distension.
Parents may observe and report a decreased interest to feed and if bottle feeding the baby taking less than 50% of the usual volume in 24 hours, stools become watery and have passed at least six in the past 24 hours, an episode of vomiting or frequent vomiting, which could be digested, undigested, bile-stained and contain fresh or dark blood. They may have also noted that the baby’s mouth and gums have become dry.
Hepatic presenting signs could include:
- Altered coagulation (heel stabs for glucose sampling, bilirubin levels and blood spot screening do not readily stop bleeding).
Parents may observe and report that their baby looks yellow, especially the nose and white of the eyes.
Skin presenting signs could include:
- Localised heat and redness.
Parents may comment that the base of the cord is red or the cord is ‘mucky’.
Midwifery is guided by evidence that includes knowledge gained from experience/continuity in care, resulting in the midwife suspecting a problem or all is not well, even though there are no overt or even non-specific signs yet to be observed. These are described as tacit or intuitive signs and can also be expressed by parents. Common expressions of concern include:
- ‘She’s just not right’
- ‘He handled better yesterday’
- ‘She doesn’t seem to want to feed’
- ‘Very sleepy, yesterday he was full of beans’.
Any concerns should be brought to the attention of appropriate personal such as a mentor/senior midwife, a paediatrician, neonatologist or advanced neonatal nurse practitioner. The referral, depending upon the condition and degree of concern, should be made in a timely manner. Effective interprofessional working and communication can be achieved by using the SBAR framework (situation, background, assessment, recommendation).
Deterioration of an infant can be as a result of a variety of problems or conditions. These include infection, hypoglycaemia, respiratory conditions and congenital abnormality (e.g. bowel obstruction, congenital heart disease).
Neonatal infection is a leading cause of deterioration during the neonatal period. Midwives need to be knowledgeable of the risk factors and red flags that can result in early-onset infection (neonate is <72 hours old) associated with group β streptococcus (NICE 2012).