OBJECTIVES When you have completed this unit you should be able to: Manage a jaundiced infant. Manage an infant with infection. Manage an infant with trauma. Manage a bleeding infant. Manage an infant with convulsions. List the common congenital abnormalities.

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40-1 WHAT ARE THE IMPORTANT COMPLICATIONS OF INFANTS BORN IN A LEVEL 1 CLINIC OR HOSPITAL?

1. Asphyxia.
2. Hypothermia.
3. Hypoglycaemia.
4. Respiratory distress.
5. Jaundice.
6. Infection.
7. Trauma.
8. Bleeding.
9. Convulsion.
10. Congenital abnormalities.

It is important that the nursing and medical staff at these clinics and hospitals are able to prevent, diagnose and manage these conditions.

The management of asphyxia is discussed in unit 36; the management of hypothermia is discussed in unit 38; and the management of hypoglycaemia and respiratory distress are discussed in Unit 39.

40-2 CAN THESE COMPLICATIONS BE PREVENTED?

Many of these complications can be prevented with good antenatal and labour care, together with good care of the infant after delivery. Whenever possible, women who are at risk of delivering an infant with complications should be identified before delivery. These women can then be referred for delivery at a level II or III hospital where special care for the infant is available.

40-3 WHAT IS THE MANAGEMENT OF THESE COMPLICATIONS IF THE INFANT IS BORN IN A LEVEL I CLINIC OR HOSPITAL?

1. They should be prevented antenatally if possible.
2. The mother should be transferred to a level II or III hospital before delivery if possible.
3. The condition should be prevented after birth if possible.
4. The condition should be diagnosed as soon as possible after delivery.
5. Emergency management must be given.
6. The infant should be discussed with the staff of the referral hospital.
7. A decision must be made as to whether the infant should be transferred or continue to be managed at the level I clinic or hospital.
8. Infants kept at the level I clinic or hospital must be correctly managed.

MANAGEMENT OF AN INFANT WITH JAUNDICE

40-4 WHAT IS JAUNDICE?

Jaundice is a yellow colour of the skin caused by deposits of bilirubin in the skin. Jaundice is a clinical sign and not a laboratory measurement.

40-5 WHAT IS BILIRUBIN?

Red cells in the blood contain a red pigment called haemoglobin, which carries oxygen. Red cells live for a few months only. Therefore, the body is continually forming new red cells in the bone marrow and destroying old red cells in the liver and spleen. The haemoglobin in old red cells is broken down into a yellow pigment called bilirubin. As newborn infants normally have a high haemoglobin concentration, they produce a lot of bilirubin.

40-6 WHAT IS HYPERBILIRUBINAEMIA?

Hyperbilirubinaemia is defined as a concentration of total serum bilirubin that is higher than the normal range. Normally the bilirubin concentration in the serum is low at birth, as it has been rapidly removed by the placenta during pregnancy. The bilirubin concentration climbs steadily for the first few days after deivery, before returning to an adult level by 2 weeks.

40-7 HOW IS BILIRUBIN EXCRETED?

After birth, bilirubin is carried by the blood stream to the liver where a special enzyme changes the bilirubin into a water soluble form. This chemical process is called conjugation. Only when the bilirubin is water soluble (i.e. conjugated) can the liver cells excrete it into the small bile ducts. From here the conjugated bilirubin is carried in the bile to the small intestine, where it is broken down further by bacteria and is excreted in the stool.

During the first weeks of life the enzyme system, that conjugates bilirubin in the liver, functions slowly. Therefore, the amount of bilirubin increases in the serum and the newborn infant may become jaundiced. After a few days the rate of conjugation in the liver increases and much more bilirubin is excreted. As a result, the amount of bilirubin in the serum slowly returns to the normal adult range and any jaundice disappears.

Some of the bilirubin that is conjugated and excreted by the liver in the first weeks of life is often broken down (uncongugated) by another enzyme in the intestine. This bilirubin is then reabsorbed back into the blood stream, adding to the hyperbilirubinaemia. The reabsorption of bilirubin from the intestine is greater in starved and breast fed infants.

40-8 HOW IS BILIRUBIN MEASURED?

It is both difficult and inaccurate to assess the concentration of bilirubin in the serum by clinical examination of the degree of jaundice, especially in an infant with a dark skin. Therefore, it is important to measure the bilirubin concentration of the serum if an infant is very jaundiced. Usually a sample of blood is collected into a capillary tube and spun down to separate the serum from the red cells. The total serum bilirubin (TSB) is then measured with a bilirubinometer and expressed in µmol/l.

THE TOTAL SERUM BILIRUBIN (TSB) CANNOT BE ESTIMATED ACCURATELY BY ASSESSING THE DEGREE OF JAUNDICE IN THE SKIN

40-9 WHAT IS PHYSIOLOGICAL JAUNDICE?

This is the mild jaundice that is seen in up to 50% of all healthy, term infants during the first 2 weeks of life. Many of these infants are breast fed. These infants are well and do not need any treatment. Physiological jaundice in newborn infants is the result of:

1. The normally high haemoglobin concentration which results in a lot of bilirubin being produced.
2. The slow rate of conjugation of bilirubin by the liver, which results in only small, amounts being excreted.
3. The reabsorption of bilirubin from the intestines during the first few weeks after birth.

All these factors usually disappear by 2 weeks and the jaundice disappears.

MANY HEALTHY INFANTS HAVE MILD JAUNDICE

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