Danger signs in Newborn

Newborns are tender and they are easily gets affected by various factors if not
properly taken care.
Mortality among sick neonates is very high and is therefore important that they are
identified early and treated.
Early identification of a sick newborn however, has some problems. The
clinical features are nonspecific e.g. whether the illness is of infective or
metabolic origin, the signs do not help us in differentiating the cause
(etiology).
Moreover, the distinction between variation of normal behavior
and early signs of illness becomes more difficult in low birth weight and
preterm infants.

Here are some Danger signs in Newborn babies which will help us in identifying sick
neonates early, so that early intervention can be taken.

The signs include,

1. Lethagy/ Poor feeding

2. Abnormal Movements – Seizures/ Jitteriness
3. Cyanosis (central Cyanosis/ Acrocyanosis after a period of Normalcy)
4. Poor capillary refill time (>3 secs)
5. Jaundice – On day1/ involving Palms/soles
6. Respiratory distress
7. Vomiting -Bilious
8. Stools – colour/ not passing stools
9. Hypothermia
10. Hyperthermia
1) Lethargy/Poor Feeding:
In a baby who is feeding well earlier and active, and if Mother complains
Decrease in intake of feed/ Prolonged time to complete feed.
Baby is less active/ not getting up for feeds for longer time.

Look for underlying causes:

Temperature – Hypothermia
Glucose - Hypoglycemia
Sepsis - Irritability sometimes/ Fever rarely

If Normal Reassure – Mother after discussing with Doctor/ or Doctor must have
seen the baby.
In Preterm Babies – sometimes after ruling above mentioned causes, it may be a
normal behaviour.

2) Abnormal Movements :
Jitteriness Vs Seizures

Jitteriness : Rapid jerking of upper limbs & Lower limbs

Stops on holding the involved area.
Normal Finding – not a danger sign

If it Persists Look for – Hypoglycemia

Hypocalcemia
Drug withdrawl syndrome

Most of the times it may be NORMAL - Transient & idiopathic in origin

Seizures:
Cannot be stopped by holding the area
Its a pathologic finding

Manifests as – Focal seizures – Involving one hand or leg – clonic movements

Cycling
Sucking movements/ chewing
twitching of perioral area/ Twitching of eyelids
Stare/ uprolling eyes
Posturing

Mostly associated with

Desaturations
Tachycardia
Underlying causes:
Hypoglycemia
Hypocalcemia
Birth asphyxia
Meningitis/ sepsis
CNS anomalies
Metabolic disorder

Note : Video shown to differentiate Jitteriness & seizures and various types of seizures.

3. Cyanosis :

Cyanosis is bluish discoloration of skin and mucosa.

Peripheral cyanosis or acrocyanosis:

seen in the extremities only.
It may be normal in babies in the first few hours of life, especially when
they are cold.

Central cyanosis
is a very important danger sign.
seen all over especially on lips and tongue.

Indicates underlying
cardiac or respiratory disease .

It's a late sign of neonatal sickness.

4) Poor or Prolonged Capillary Refill time:

CRT/CFT signifies Perfusion
Perfusion signifies adequacy of circulation.
Poor perfusion indicates hypotension.

It is measured as follows:
1. The skin over the mid-sternum is pressed with ball of the thumb for 5
seconds so that it blanches.
2. The thumb is then lifted and time taken for refilling of the capillaries
and return to original skin color is noted.
(Count 1001, 1002,1003 ,1004,1005)
Each count is equal to 1 second (1001-1 sec)
3. Normal CRT is < 3 seconds.
It means that it take 3 seconds or less for the blanched skin to regain its pink color.
If it takes longer than 3 seconds for blanching to reverse, it indicates poor perfusion.

Underlying Conditions:
Hypothermia
Hypoglycemia sometimes in extreme
Sepsis/ NEC

5) Jaundice

Jaundice in the newborn may be physiological.

When it is a Danger sign?

when it appears on the first day of life or
the skin staining is up to palms and soles or
it persists beyond 2 weeks of life

Why it is Dangerous?
Hyperbilirubinemia in the first week could lead to kernicterus and severe
disabilities and Cerebral palsy.

Babies at risk of very High Bilirubin?

Born to Rh Negative Mother
( Mother – Negative Blood group; Father – Positive blood group;
Baby – Positive blood group)

Other Conditions: Infection/ Sepsis

G6PD Deficiency
IUGR Babies
Polycythemia
Cephalhematoma
Birth Asphyxia
6) Respiratory Distress :
Signs:
Tachypnoea – Respiratory rate > 60/mins (count for one full Minute)
Retractions – Subcostal retractions/ Intercostal retractions
Grunting
Flaring of alae Nasi
Cyanosis
Desaturations

Conditions:
Prematurity- RDS
Congenital Pneumonia
Meconium aspiration syndrome
Birth asphyxia
Hypoglycemia
Sepsis

Apnea : cessation of breathing (apnea) for 20 seconds and more

accompanied fall in heart rate (bradycardia)
and or by cyanosis

Respond immediately to an apnea .

Stimulate the baby for breathing by gently stroking the foot
Position the baby with slight head extension by placing a rolled towel/sheet under
the shoulder
Clear secretions briefly from the throat.
If stimulation fails, give bag and mask ventilation with oxygen connected.

Causes of apnea
hypo -or hyperthermia, hypoglycemia, septicemia, anemia, meningitis,
intracranial hemorrhage or apnea of prematurity.
7) Vomiting:
Normal Variants:
Ingestion of meconium stained amniotic fluid may lead to vomiting on the
first day in many neonates.
If it is persistent, stomach wash with saline is performed.

Regurgitation or vomiting soon after feeds is often due to faulty feeding technique or
aerophagy.

Danger sign:
In case of persistent, projectile or bile stained vomiting
in association with failure to pass meconium during the first 24 hours
or with abdominal distension,

Causes:
Intestinal obstruction
NEC
Sepsis
Meningitis/IVH/asphyxia

8) Stools:
All healthy babies must pass meconium within 24 hours of age.

Non passage of meconium by 24 hours of age - is abnormal .

Pass a lubricated rectal thermometer/ NG tube ;
few babies may pass meconium or meconium plug after this stimulation.
Failure to do so or with abdominal distension – rule out intestinal obstruction.

Colour of stools:
Normal – Black/ Green/ yellow

Abnormal:
Blood in stool – NEC/Sepsis/ Bleeding Disorders/ Intestinal anomalies
Clay stools - Due to Cholestatic jaundice (TPN); Biliary atresia
9/10) Hypo & Hyperthemia:
Temperature instability is a very important danger sign in neonates.

Hypothermia (temperature below 36.5 degrees centigrade)

is a common sign in sick neonates especially in low birth weight babies.
Cold Stress – 36 deg C – 36.4 deg C
( palms /soles – cold to touch
Trunk (abdomen) – warm to touch)

Moderate to severe Hypothermia – look for underlying serious pathology.

\
Fever (temperature above 37.5 degrees centrigrade)
is a sign of infection usually in term neonates.

Temperature Regulation is a separate class by itself.

Will discuss in detail during the respective session.