Common Neonatal Presentations

(Adapted from Quach A. Common neonatal presentations to the primary care physician. Aust Fam Physician 2018;47:713- 20)

History
- Maternal / Antenatal: medical disorders, infections, medications, growth scans, serology, GBS status.
- Peripartum: gestation, mode of delivery, Apgars, resuscitation, birthweight, Vit K, nursery/SCN stay.
- Post-natal: feeding method & volumes, wet/dirty nappies, sleep/settling, weight trajectory, community nurse reviews, social supports & maternal mental health.
Examination (head-to-toe)
- Observe colour, tone, interaction.
- Head & neck (fontanelles, sutures, palate, red reflex).
- Cardiorespiratory (HR, RR, murmurs, work of breathing).
- Abdomen & umbilicus, femoral pulses.
- Genitalia & anus patency.
- Limb movement, digits, hips (Barlow/Ortolani).
- Back for dysraphism, sacral pits.
- Primitive reflexes (root, suck, Moro, grasp, tonic neck).
Vital “Red Flag” Thresholds
- HR < 110 or > 170 bpm, RR < 25 or > 60 /min, Temp < 36.5 °C or > 38 °C, weight loss > 10 % BW.

Definition: rectal T > 38 °C (fever) or < 36.5 °C (hypothermia).
Action: treat as sepsis until proven otherwise → urgent hospital transfer ± ambulance.
Septic Work-up: FBC & film, blood & urine cultures (SPA), lumbar puncture ± CXR.
Empiric Tx: IV benzylpenicillin + gentamicin (local protocol). Oral antibiotics are inadequate.

Symptom	Key Differentials	Red Flags → ED/Paeds review
Acute respiratory distress (tachypnoea, grunting, recessions, cyanosis)	Infection (sepsis, pneumonia), CHD, metabolic acidosis, airway obstruction, trauma	Cyanosis, poor perfusion, apnoea, lethargy
Cough	URTI, pertussis, tracheo-oesophageal fistula, chronic lung disease (preterm), tracheo-/laryngo-malacia, CHD	Prolonged paroxysms, apnoea, feeding-related choking, failure to thrive
Noisy breathing / stridor	Laryngomalacia (inspiratory), tracheomalacia (expiratory), subglottic haemangioma, choanal atresia, vocal-cord palsy	Feeding difficulty, cyanosis, weight loss
Apnoea	Sepsis, seizures, reflux-related aspiration, head trauma, obstructive lesions, BRUE	All neonatal BRUEs = high risk → hospital assessment

Counsel parents on normal “periodic breathing” (≤10 s pauses without colour change).

Posseting / GOR: common; reassure if thriving. Trial thickened feeds, upright positioning. Reserve acid-suppression for complications (oesophagitis, poor growth).
Vomiting – Red Flags: projectile post-feed (→ pyloric stenosis), bilious, abdominal distension, fever, bulging fontanelle → ED.
Constipation / Dyschezia: hard pellets or delayed meconium (>48 h) → exclude Hirschsprung, obstruction, spinal anomalies. Dyschezia = benign, no laxatives.
Diarrhoea: think viral GE, bacterial enteritis, cow’s-milk protein allergy (CMPA). Monitor hydration (see Table below).

Signs of Dehydration / Unwell Neonate

Weight loss >10 % BW, ↓ urine, dry mucosae, cap-refill > 2 s, sunken fontanelle/eyes.
Tachycardia, tachypnoea, fever/hypothermia, lethargy, poor feeding.
→ Escalate early; IVF if oral intake inadequate.

Normal pattern: peaks 6–8 wks, resolves ~4 mo. Educate & reassure.
Exclude pathology: sudden persistent cry → sepsis, hair-tourniquet, corneal abrasion, non-accidental injury.
CMPA clues: blood/mucus in stool, eczema, poor growth, FHx atopy → trial maternal dairy elimination or extensively hydrolysed / amino-acid formula & refer.
Ineffective interventions: simethicone, herbal drops, routine formula switching. Limited evidence for probiotics (not yet standard).

Common causes: prematurity (poor suck-swallow-breath), poor latch, maternal nipple pain, tongue-tie (consider frenotomy if painful feeding).
Weight expectations: lose ≤10 % BW first week; regain BW by 2–3 wks; then gain 30–40 g/day.
Failure to thrive: inadequate intake most common; if persists despite feed optimisation → paediatric work-up.

Unconjugated hyperbilirubinaemia: physiologic vs breast-milk jaundice.
Risk factors needing closer monitoring: prematurity, onset <24 h, ABO/Rh incompatibility, cephalo-haematoma, BW loss > 10 %, affected sibling.
Assessment: transcutaneous/serum bilirubin ± fractionation; use NICE nomograms for phototherapy/exchange thresholds.
Refer urgently if signs of bilirubin encephalopathy (lethargy, hypotonia/hypertonia, high-pitched cry, seizures) or conjugated fraction ↑ (cholestasis).

Benign	Features	Management
Erythema toxicum	30–70 % newborns; blotchy papules/pustules, migrate & resolve <7 d	Reassure; review if persists > 2 wks
Milia	White 1–2 mm facial cysts; 40–50 % infants	Reassure; avoid picking; resolve in 1–2 mo

Red-flag vesiculopustular lesions → consider HSV, VZV, bacterial sepsis; admit for IV therapy if systemically unwell.

Transfer immediately (preferably by ambulance) if any of:

Fever > 38 °C or hypothermia < 36.5 °C
Apnoea, cyanosis, moderate–severe respiratory distress, persistent tachypnoea >60 /min
Projectile / bilious vomiting, acute firm abdominal distension
Weight loss >10 % BW with dehydration signs
Suspected sepsis, pertussis, meningitis, CHD cyanotic spell
Jaundice with neurological signs or conjugated bilirubin rise
Vesiculopustular rash with systemic illness