Oxford Handbook of Midwifery (124 page)

SCREENING TESTS

581‌‌

Screening tests

Screening tests aim to identify the likelihood of potential abnormality within a normal population. During the early neonatal period, various tests and examinations may be undertaken to detect specific abnormali- ties that could undermine the infant’s health. Screening procedures are only appropriate when diagnostic tests are available that are inexpen- sive, simple, and specific to the condition. Effective treatment or inter- vention should also be readily available before the onset of symptoms or pathology is apparent. Early diagnosis of some conditions can result in curtailing disease processes that have devastating effects on the individual. An excellent example is the screening test for phenylketonuria (PKU)— early diagnosis of this inborn error of metabolism prevents severe mental impairment, by prescribing a specialized diet.

Hearing

Approximately 1–2 babies in 1000 are born with hearing loss in one or both ears. Recent technological advances have led to major improvements in screening methods for detecting hearing loss in the neonate.

Early detection of hearing loss in infancy ensures that full investigation into the cause and possible therapy or treatment can be commenced that will be important for the baby’s speech development.

Oto-acoustic emissions (OAE) test

which only takes a few moments to perform.

outer ear, which transmits clicking sounds to the inner ear. A computer detects how the ears respond to sound emissions.

Automated auditory brainstem response (AABR)

If the second test shows a poor response, then referral to the audiology department is necessary for further tests and follow up.

Further reading

Department of Health (2004).
NHS Newborn Hearing Screening Programme. MRC Institute of Hearing Research in collaboration with The National Deaf Children’s Society
. London: DH.

CHAPTER 23
Care of the newborn

582‌‌

Growth

Due to physical and psychological limitations the baby is reliant on its mother to provide dedicated care to enable its ongoing survival, growth and development. Providing the baby has been born with no physical or neurological abnormalities it will require the following in order to grow and develop normally:

• Nutritional needs met
  
• Safe environment
  
• Adequate exercise, rest, and sleep
  
• Psychological/emotional stimulation.
  

  To some extent the physical growth and development of the baby depends on the nutritional status of the mother before, during, and after pregnancy (especially if breastfeeding), as well as the adequacy of the infants diet if bottle feeding.
  

• Nutrition—establishing infant nutrition in the early days is an essential part of midwifery care of the newborn whether the baby is breast
  

  or bottle feeding. Observation of the baby’s feeding technique is important to ensure correct attachment to the breast or the baby’s sucking and swallowing behaviour if bottle feeding.
  

• Environment:
  
  • Safety
    : ensuring that the environment is free from potential hazards/ dangers that may impair adequate growth, such as tight clothing. Over-swaddling the baby may restrict movement. Avoid a smoky environment. There is some debate about the practice of bed sharing; parents should be encouraged to carefully weigh up the
    

    risks and benefits.
    

  • Thermoregulation
    : in mature infants heat loss may pose a problem
    

    to the baby’s survival and health status due to the immaturity of the heat regulatory system. Because of the baby’s immobility and lack of ability to shiver, there is still a risk of hypothermia if the environment is not adequately warm. If the baby is cold the nape of the neck may still feel warm, therefore it is best to check the skin of the abdomen for a more reliable assessment of temperature.
    

    Observing the baby’s behaviour is crucial; initially babies may generate more heat by crying and creating activity. However, in the later stages of hypothermia the baby may become lethargic, with a poor response to stimuli, even though their pallor may be deceivingly healthy.
    

  • Prevention of infection
    : during the first 6 months of life babies are at increased risk of infection due to immaturity of the immune system. Care should be taken to ensure sound hygiene standards when caring for or handling newborn babies. Infection can seriously undermine a baby’s health and growth, leading to morbidity and sometimes mortality.
    
• Psychological development—although the baby sleeps for long periods during the first 6–8 weeks, it is important to communicate and provide sensory stimulation during the wakeful times and at feed time. It is well known that emotional deprivation results in poor growth and delayed development.
  

  GROWTH
  

  583
  

  Indicators of sound nourishment and adequate growth are:
  

Some pre-disposing/inhibiting factors may need to be considered when assessing growth.

established.

• Cleft lip and cleft palate—special teats may need to be used
  
• Oesophageal atresia
  
• Pyloric stenosis—projectile vomiting occurs between the third and fifth week of life and affects males more than females.
  

In order to monitor a baby’s growth and development various checks may be carried out:

CHAPTER 23
Care of the newborn

584

if using it to monitor adequate growth patterns. A correct supine stadiometer should be used and two people are required for the procedure.

• Head circumference—measurements for the head circumference at birth and up to 24h may be inaccurate due to moulding. Some units delay this measurement until 24–48h post delivery. The head circumference provides a good baseline for later comparisons. An unusually large or small head circumference indicates abnormality.
  
• Percentile charts are the most common means of assessing growth, usually these consist of graphs plotting the upper, lower, and midpoint levels of average growth patterns—the baby’s weight, length, and head circumference readings can be plotted and compared with normal expectations. Babies below the 9th centile will have reduced glycogen stores and are therefore more prone to hypothermia and hypoglycaemia.
  
• Feed charts may be employed where strict feeding regimens are important to ensure that exact calorific requirement are provided.
  

  

  This page intentionally left blank
  

  CHAPTER 23
  Care of the newborn
  

  586‌‌
  

  Minor disorders of the newborn
  

  Skin rashes
  

  Babies commonly present with non-infective skin rashes within the first few weeks of life, which usually resolve spontaneously without treatment.
  

• Erythema toxicum
  : also known as urticaria neonatorum, is a blotchy red rash with pinhead papules, which usually occurs within the first week of life and normally disappears within a day or two.
  
• Heat rashes
  : appear as reddened areas, often in the skin folds and have hard pinpoint centres. The rash resolves quickly when the baby cools down.
  
• Milia
  : also know as a sweat rash, is seen in babies who become overheated and is due to blocked sweat glands. Less clothing and fewer cot blankets should be used and more fresh air may help.
  

  Other skin rashes that may occur but require remedial action include:
  

• Chafing or intertrigo
  : this is due to inadequate drying of the skin, particularly in the groin or axilla area, after washing or bathing. The skin should be dried using a dabbing movement with the towel and then a slight dusting of antiseptic power applied.
  
• Sore buttocks
  : presents as soreness and excoriation around the anus and buttocks and is usually a result of frequent loose stools. It is more common in formula-fed babies than breastfed babies. Other causes may include infrequent nappy changes, poor hygiene, incorrect laundering of nappies, diet, and infections such as candidiasis (thrush). It is usually very painful. Treatment includes identifying the cause, good hygiene, and exposure of the buttocks to the air. If candidiasis
  

  infection is thought to be present, the mouth should also be examined
  

  and treatment with local and oral nystatin is required. If sore buttocks persist for more than a day or two medical advice should be sought.
  

  Any rash
  that presents as watery, filled pustules, or appears infected, should be seen by the paediatrician or family doctor without delay.
  

  Nappy rash (ammoniacal dermatitis)
  

  The skin beneath the nappy area becomes red and excoriated. This usually results from infrequent changing of the nappies (either cloth or dispos- able), hot weather, and the use of plastic pants. Increased contact of urine with the skin leads to production of ammonia and chemical burns. The condition is preventable by avoiding the precipitants and the use of com- mercial barrier creams. However, care should be taken with their applica- tion as they can cause the one-way process design of disposable nappies to become ineffective by blocking the perforations within the nappy linings. This will result in the urine not being able to soak through into the inner lining of the nappy, which may exacerbate the condition.
  

  Treatment involves the protection of the damaged skin and exposure of the skin in a warm dry atmosphere to promote healing of the excoriated skin. Care needs to be taken to prevent secondary infection. If this occurs, refer for a medical opinion.
  

  Breast engorgement
  

  Breast engorgement may occur in both male and female babies on or about the third day of life. The drop in serum oestrogen levels following
  

  MINOR DISORDERS OF THE NEWBORN
  

  587
  

  the separation of the mother and baby at birth stimulates the breasts to secrete milk. No treatment is required as the condition will resolve spon- taneously. Mothers must be advised not to squeeze the breasts as this may result in infection.
  

  Pseudo-menstruation
  

  A blood-stained vaginal discharge may occur in baby girls. This is due to oestrogen withdrawal following separation of mother and baby. The mother should be reassured that it is a normal physiological process, which will resolve without treatment.
  

  Constipation
  

  Constipation is defined as the difficult passage of infrequent dry, i.e. hard, stools. A baby’s constipated stool resembles rabbit droppings or gravel in its size and consistency. Not all hard stools are constipated. The stools of a formula-fed baby will be bulkier, firmer, and often drier than that of a breastfed baby. Babies will often appear to strain even when passing normal soft stools.
  

  Constipation is unusual in breastfed babies although they may not pass a stool for 2–3 days once feeding is established, but this is quite normal, provided that the stool is of a normal soft consistency. Constipation most commonly occurs in formula-fed babies. If a formula-fed baby is constipated the following should be considered: