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Problem solving in clinical practice
When pneumonia does not respond to antibiotics: a challenging neonatal diagnosis
  1. A J Jones1,
  2. L D Starling2,
  3. T Keith1,
  4. R Nicholl1,
  5. A N Seale2,3
  1. 1Paediatric Department, Northwick Park Hospital, Harrow, UK.
  2. 2Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
  3. 3Department of Paediatric Cardiology, Birmingham Children’s Hospital, Birmingham, UK
  1. Correspondence to Dr Andrew J Jones, Paediatric Department, Northwick Park Hospital, Harrow HA1 3UJ, UK;andrewjones7{at}nhs.net

https://doi.org/10.1136/archdischild-2013-304193

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    Introduction

    Baby girl C was born at 41+2 weeks, weighing 2.8 kg, by vaginal delivery after induction of labour. This was the 24-year-old mother's first pregnancy, which was uncomplicated, with normal routine antenatal scans and serology. Her membranes ruptured 17 h prior to delivery: liquor was clear and there was no maternal peripartum pyrexia.

    After delivery, initial bradycardia responded rapidly to airway manoeuvres and intermittent positive pressure ventilation, and the Apgar score was 10 at 10 min.

    The baby was given to her mother and had her first breast feed. There were no concerns and mother and baby were transferred to the postnatal ward.

    The routine newborn examination at 8 h of age revealed a pink baby with warm peripheries and easily felt peripheral pulses. There were no signs of respiratory distress. No added heart sounds or murmurs were heard on auscultation and the baby was declared fit for discharge. Pulse oximetry screening was not performed.

    Comment: Routine oxygen saturation screening in the newborn

    The newborn check is completed to confirm the fitness of a baby for discharge and to screen for congenital abnormalities, specifically, developmental dysplasia of the hip, congenital cataracts, cryptorchidism and congenital heart disease (CHD).1

    In 2005, a Health Technology Assessment (HTA) review of newborn screening for CHD concluded that the current system performs poorly, but that pulse oximetry screening may provide a promising adjunct to clinical examination alone. In the HTA model, only 32% of babies with life-threatening CHD would be diagnosed by clinical examination alone.2

    There is good evidence to explain why the routine newborn examination is suboptimal in identifying all cases of CHD. Half the babies in the postnatal ward with CHD have no distinctive murmur, while cyanosis may be difficult to detect clinically, particularly in non-Caucasian ethnic groups.3

    In a study of infants with life-threatening CHD from 1984 to 2004, 8% of …

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