Under the weather: What to do when baby is ill
13:57 (GMT+2), Tue, 23 March 2010
Sam Tormey, health writer and emergency medicine doctor, aims to assist new parents whose baby is unwell for the first time. This ‘beginner’s guide’ takes you through the stages of assessing and treating your sick baby.
Welcoming a new baby into your life is wonderful, exciting – and stressful. Even if the pregnancy and delivery go without a hitch, and your baby is healthy and feeding well, the first year of life can be incredibly stressful. Sleep deprivation, relationship tensions, changes to work and social life, more time with the in-laws – these can all add up to a rather harrowing 12 months. And for many of us, it is the first time in our lives that we are directly responsible for the health and well-being of another person. That’s quite a task when that person can’t clearly communicate problems such as fever, pain, thirst or nausea.
When baby is unwell
When your baby becomes unwell for the first time it can be a truly frightening experience. Typically this occurs in the middle of the night, when everything is shut, and when you and your partner are feeling rotten with the same bug. All sorts of questions come into your fuzzy head: How unwell is she? Have I done something wrong? Do I take her to the doctor right now or do I wait?
I meet parents in this situation most days in the hospital’s emergency department, and the first thing I tell them is that I am always happy to see any sick baby, no matter how trivial the problem seems to be. Sometimes those parents have received the raised eyebrow and the loaded ‘first-time parent? query from the triage nurse, with the implication of parental inexperience and undue panic. Others – usually experienced parents or grandparents – have been on the end of the ‘you should know better’ frown if the child has been sick for some time. Neither of these attitudes makes you feel very good as a parent, and only compound your anxiety. No illness seems trivial wn you are used to having a happy, healthy baby.
Remember, this was going to happen!
When your baby refuses a feed, spikes a fever, or starts to vomit, remember a couple of things first: this was always going to happen, and it will nearly always turn out for the best. Every baby gets sick at one point or another. There are so many common viral and bacterial infections that your baby’s growing immune system must face. Some of these will pass virtually unnoticed, causing no more than a little crankiness or a disturbed night’s sleep. Others can cause a very trying week or fortnight, and some times the infections occur so regularly that your little one seems to be constantly sick – this week the gastro bug, next week the flu, the following week a middle-ear infection.
It will (nearly) always be okay Babies will nearly always recover fully from all of these illnesses, usually with no medical treatment whatsoever. Western countries have spectacularly low infant mortality rates. It is dreadful to imagine a baby dying, but that is the unspoken horror that lurks at the back of the anxiety when a baby is sick. In most developed countries, less than 10 in 1 000 babies will die in the first 12 months of life. Most of those deaths occur in the first 4 weeks of life (the neonatal period) and are largely related to the complications of premature birth and serious congenital malformations. Of babies that die after this period, Sudden Infant Death Syndrome (SIDS) is the most frequent cause. While it is awful to contemplate infant death, looking at the statistics can at least reassure us that a sick baby is most unlikely to die. Remember: this was always going to happen, and it will nearly always turn out okay.
How sick is your baby?
Once a baby is sick, we have to decide how sick she is. Is this going to turn out to be one of those common, annoying viral infections or is this a serious illness that needs a doctor’s opinion? There are a couple of good rules of thumb that can help us make this assessment. Firstly, and most importantly, the younger a baby is the more suspicious we should be that there is a serious cause for the illness. Babies in the first 4 weeks of life do not have the immune capacity of older babies and are much more prone to serious illness, particularly bacterial infections. Also, although most babies are checked for major congenital problems via the heel-prick test and the ‘baby check’ in the first days of life, these screening tests will not pick up all congenital abnormalities. Problems with the heart, gut or nervous system can all cause illness in young babies that was not apparent at birth. So the younger your sick baby is, the lower your threshold for seeking a medical opinion should be.
Another good rule is to reassess the situation frequently. The physiology of an infant is different to that of an adult in several important ways, and this changes the way that illnesses behave. Babies tire more easily than adults do when breathing rapidly, for example. This is because they have differently shaped chests, rely almost entirely on one muscle (the diaphragm) to breathe, and have different types of muscle fibres, which are more likely to become fatigued.
Dehydration, glucose and seizures
There are lots of other relevant differences – babies become dehydrated much more quickly than adults, are more prone to run low on glucose when sick and can suffer seizures as a result of high fevers. Although your baby might seem to be coping with being sick, this can change rapidly. Babies are generally resilient, but they can fall in a heap much faster than we do when we are sick.
A checklist of basic life functions
Let’s try to tackle the question of just how sick your baby is. Although hundreds of different things can go wrong, there are only a handful of symptoms as endpoints of these varied illnesses. A baby cannot, like an adult, complain of specific symptoms such as a painful throat when swallowing. She simply stops feeding. There is a very simple checklist of the basic life functions of a baby to run through when illness strikes: Is your baby breathing, sleeping, playing, feeding, weeing and pooing as she usually does? These six things are reliable indicators of how well your baby is coping with the illness, and a doctor or nurse will want to know how each one has changed. Try to quantify any abnormalities and compare them to what is normal for your baby.
Breathing is not something we think about much when our baby is well. Babies breathe much faster than adults do; 30–60 breaths per minute is normal for a neonate and 30–40 breaths per minute for a 12-month-old. It is easy to measure how fast your baby is breathing by exposing her tummy and counting how many times it rises and falls in one minute (this is best done when your baby is resting quietly or sleeping, not when crying). An increased rate of breathing is a reliable measure of breathing difficulties. If your baby is working hard to breathe, you might notice a soft grunting noise with each breath. Other signs of respiratory distress are louder noises such as coughing and wheezing, flaring of the nostrils and the tummy being sucked in further than usual with each breath.
Most illnesses will disturb sleeping patterns, usually for the worse. Sick babies tend to wake more often at night and sleep more during the day. The major feature to watch for here is excessive drowsiness. If your baby is not waking to feed and is difficult to keep awake, it’s time to see a doctor. Conversely, if a sick baby will not settle and is constantly crying, she is likely to be in discomfort or pain and a source for the symptoms should be sought. Some clues can be gleaned from your baby’s behaviour – persistent pulling of one ear can indicate a middle-ear infection; drawing up the legs while screaming can indicate tummy pain, and shying away from bright light can mean a headache.
Babies who are still interested in their environment and their usual playthings are unlikely to be seriously ill. As babies become sicker, they become less interested in the toys and objects that usually stimulate them. They are less interactive with their parents and it can be hard to get a smile. Any sick baby that appears flat and listless should be taken to the doctor. This is especially important if your baby feels floppy when picked up, as lack of muscle tone is a good indicator of a seriously unwell baby.
Feeding – whether milk, fluids or solids – often becomes erratic with illness. Particularly in younger babies, refusing feeds can be the first (and sometimes only) sign that something is amiss. Again, try to quantify how much less your baby is taking in. This is far more important for liquids than solids. Babies who are old enough to be taking solids will be fine without them for a day or two as long as they are taking inadequate milk and fluids.
ehydration is a common and potentially serious complication of many illnesses in infancy. The younger your baby, the more rapidly she can become dehydrated. It’s important to remember that it is not just about the fluids that we see going in and coming out – any baby with a fever will lose more fluid from the skin, and any baby who is breathing faster than usual will lose more fluid from the airways. It is easier to calculate how much fluid goes in with bottle-fed babies, but the duration of a breastfeed can give a rough idea of how much breast milk is being taken. Quantifying what comes out is much harder, but a few tips may help: most people grossly overestimate the volume of vomit. My advice is don’t even try – simply decide whether it is a small or large amount of vomit and count how many times your baby throws up.
The number of wet nappies is crucial, as urine output is a very reliable indicator of the hydration of a baby. Look at her nappy to see whether the urine is pale or dark yellow, and feel how heavy the nappy is as a rough guide to volume. Most babies should have at least four wet, heavy nappies a day.
Similarly with diarrhoea – count the number of nappies each day, look for the presence of blood in the stool and feel how heavy the nappy is. The definition of diarrhoea depends on how often your baby normally opens her bowels, and this is incredibly variable with each baby. Diarrhoea refers to an increased frequency of stools rather than their texture. Lots of large, watery motions will pose more fluid problems than the same number of small, formed stools. If your baby has copious and frequent diarrhoea it can be hard to tell how much urine she is making. There are other signs of dehydration, such as dry lips and tongue, scanty tears when crying, drowsiness and skin texture changes. In my experience, these are signs of advanced dehydration and it is better initially to keep an eye on the urine output. If your baby has so much diarrhoea that it is hard to tell how much urine she is making, she should be taken to see a doctor anyway.
There’s one more important thing to add to the above six basics, and that is your baby’s temperature. This is easy to measure at home with a digital thermometer, which is cheap and easy to use. A rectal temperature is the most reliable measure but a reading from under the armpit is usually adequate and generally easier to obtain. Armpit readings will tend to underestimate a baby’s temperature by a small margin, but are perfectly acceptable for use in the home, as long as you leave the thermometer in long enough (usually until it beeps).
Definitions of fever vary; I use a figure greater than 37.5°C. The most important thing to remember about fevers is that their significance depends on the age of your baby. Any fever in a baby 3 months or younger requires a medical assessment, as it is far more likely to indicate a serious infection than in an older baby. The absence of a fever does not exclude a serious infection, particularly in a younger baby. A fever that is high (above 39.5°C) will not come down with simple treatment, and is accompanied by either uncontrollable shivering or mottling of the skin, which can indicate a serious infection and requires medical input. Finally, a temperature persistently lower than 35.5°C in a sick baby is an indication to get some help – some illnesses manifest as lower rather than higher temperatures.
When to get help
Deciding when to ask for help requires looking at all these factors as a whole, and this will get easier once your child has suffered her first few illnesses.
Always seek help if:
• your baby is less than 4 weeks old and becomes unwell or refuses more than two feeds in a row.
• your baby is listless, difficult to wake, or floppy.
• your baby has rapid or noisy breathing that is getting worse. • your baby is less than 3 months old and has a fever higher than 38°C.
• your baby is older than 3 months with a fever higher than 38.5°C, which won’t come down with simple treatment and/or is accompanied by uncontrollable shivering or mottled skin.
• your baby has other symptoms such as fever, vomiting or diarrhoea and has had no wet nappies for more than six hours (you can allow a little longer for babies older then 6 months).
• your baby has bloody diarrhoea.
• your baby will not stop screaming despite the usual consoling measures.
• your baby is sick and develops a reddish/purple rash that will not blanch briefly to white with pressure from a finger.
Where to get help
It is becoming less common for family medical practices and Emergency Departments to offer a phone advice service, so seeking help usually means a trip to the hospital or the medical centre. Some governments have recognised this trend and set up telephone advice services, which can be very useful. If your baby is less than 4 weeks old, the maternity unit where she was delivered is usually happy to offer advice. Always remember that an ambulance is available – it is never a good idea to rush your baby to hospital by car. Ambulances carry all the necessary equipment to start treatment and if the situation is desperate the operator can give you crucial instructions over the phone.
Help at home
If your baby is sick, but you don’t think she needs immediate attention, there are several simple things you can do at home:
• Babies with blocked noses can have difficulties feeding. Dropping some breast milk, water or saline drops into the nostrils, ideally inducing a good sneeze, can usually clear the mucous.
• There are several ways to get more fluid into your baby when she is falling behind.
• Smaller, more frequent feeds are more likely to be absorbed by the baby with vomiting or diarrhoea. There are specific rehydration solutions, which come as powders or ice blocks. These are very useful for sicker babies, but initially it is worth persisting with what your baby usually drinks.
• If breastfed, try shorter, more frequent breastfeeds.
• If your baby is bottle-fed, the same applies, but add more water than usual to the formula to dilute it more. Half-strength formula is perfectly acceptable for a day or so.
• Similarly with juices and cordials, make them about a third as strong as usual by adding extra water.
• Plain water is also acceptable so long as it is in addition to milk or juice.
• Cool fluids and soft foods can soothe sore throats, and try your baby’s favourite drink if she is old enough to have one.
• Fluids can be gently syringed in small quantities into your baby’s mouth if she is reluctant to drink.
• Carbonated soft drinks are dreadful and should be totally avoided in babies and young children.
• Fevers are very uncomfortable for infants and should be treated. You do not need to reach straight for the drugs. Try a lukewarm bath, sponging down your baby’s skin. Avoid rugging babies up when they have a fever – fewer clothes will help bring the fever down, and cool fluids such as juice or water can help.
• Simple drugs such as paracetamol and ibuprofen are extremely safe and effective in babies (over 1 month old for paracetamol and 3 months for ibuprofen). In my experience they are generally under- rather than over-used. Remember that they are useful for pain as well as fever.
• Paracetamol suppositories are very effective for hot babies who are vomiting. These drugs should brighten up your sick baby for a while – if they are ineffective in reducing fever and other symptoms this can be a sign of a serious illness.
• Always follow the instructions closely and do not give any other medications (including alternative medicines) to your baby without medical advice.
• Never give aspirin to your baby or child. Finally, remember that your baby was always going to get sick at some point, and she will get sick again. Be reassured that your baby will cope with most of these illnesses by herself, but never be afraid to get help, even if that means calling an ambulance. And since you are going to be in charge of someone that gets sick from time to time, a first aid course is a very good idea, particularly to learn how to assist a choking baby or child
NOTE: This advice refers to babies that are usually well. If your baby was born significantly premature or has a diagnosed condition such as a heart abnormality, or a chronic illness such as cystic fibrosis, then more vigilance is necessary in the case of an acute illness. All ages are assumed to be ‘corrected age’. This article provides general advice only and is no substitute for a formal medical opinion. •