Neonates and Infants

Parents often seek medical care with concerns about newborns and young infants. Pediatricians must be able to distinguish those patients presenting with a medical emergency from those who can be managed as outpatients. This section covers the following concerns:

• Fussiness and Colic

• Eye Redness/Drainage

  • Congenital Nasolacrimal Duct Obstruction (Dacryostenosis)

  • Dacryocystocele and Dacryocystitis

  • Ophthalmia Neonatorum (Gonorrhea/Chlamydia)

• Vomiting

• Umbilical abnormalities

  • Omphalitis

  • Umbilical Granuloma

Other emergent and nonemergent conditions in the neonate and young infant that are pertinent to urgent care are covered in the following rotation guides:

• Ill or Lethargic Infant, Fever in Young Infants, Neonatal Herpes Simplex Virus (HSV), Pyloric Stenosis (Pediatric Emergency Medicine)

• Hyperbilirubinemia, Jaundice (Neonatal Care)

• Neonatal Dermatoses (Pediatric Dermatology)

• Congenital Infections (Pediatric Infectious Diseases)

Fussiness and Colic

Infants cry as their sole means of communication with their parents. Some babies cry as much as 3 hours a day during the first 3 months of life. Despite it being normal, crying can be stressful to parents and is the highest risk factor for physical abuse in this age group. An appreciation of the stress related to crying helps in educating parents and preventing abuse.

A careful history and thorough physical examination are important in the evaluation of infants for fussiness before considering a diagnosis of colic. Colic, by definition, is a diagnosis of exclusion. If all of the following conditions associated with abrupt onset of inconsolable crying in young infants are ruled out, colic should be considered:

Colic

Diagnosis: A diagnosis of colic is typically considered after the causes above have been excluded. Colic is defined as crying for at least 3 hours per day for at least 3 days per week in an otherwise healthy infant with no obvious cause. A thorough history and physical examination can help distinguish colic from other causes of fussiness. Infants with colic should not have signs of illness, abuse, or fever and should display normal weight gain. If history or physical exam suggest any abnormality (e.g., feeding difficulty, trauma, infection, vomiting, or constipation), further evaluation is required before a diagnosis of colic is made.

Evaluation of a fussy infant and associated normal findings expected include:

• weight (growing appropriately)

• fontanelle (neither bulging nor sunken)

• eyes (no redness, drainage, or corneal abrasion)

• ears (no signs of otitis media)

• extremities, including digits (no bruising or tenderness of long bones, no hair tourniquets)

• cardiopulmonary and abdominal exam (no signs of abnormalities)

• diaper area (no fissures, testicular pain, or hair tourniquet)

• skin (no bruising or swelling)

• urine (toxicology testing if concern for illicit drug exposure or urinalysis if concern for infection)

Treatment: Soothing techniques (e.g., utilizing a pacifier, swaddling, and rocking the infant) are useful in the treatment of colic. Herbal remedies, teas, and probiotics have not been shown to reduce colic. The safest treatment involves adequate education and reassurance. Providers should also discuss the parents’ support system.

Eye Redness/Drainage

Congenital Nasolacrimal Duct Obstruction (Dacryostenosis)

Congenital nasolacrimal duct obstruction, or dacryostenosis, is the most common cause of tearing and discharge from the eyes during the neonatal period. Patients typically present after 2 weeks of age, with excessive tearing and matting of the eyes without erythema, tenderness, or swelling of the conjunctiva. Dacryostenosis is due to failure of the Hasner valve to open, which is at the nasolacrimal duct. Children with congenital abnormalities of the face are more likely to have dacryostenosis. Distinguishing dacryostenosis from infection of the nasolacrimal sac (dacryocystitis) is important (see Dacryocystitis below).

The diagnosis of dacryostenosis is made clinically, and treatment is conservative management with warm compresses and gentle massage of the nasolacrimal duct multiple times a day. Antibiotic ointments are not necessary. Patients should be referred for ophthalmology consultation if the condition does not resolve by age 6 to 12 months.

Dacryocystocele and Dacryocystitis

Dacryocystocele is a mucocele due to an obstructed nasolacrimal sac and presents as a bluish subcutaneous mass below the medial epicanthus. In some cases, dacryocystocele extends intranasally, and these infants should be evaluated for nasal obstruction and respiratory distress. Infants with dacryocystocele are at risk of developing dacryocystitis and should be closely evaluated for signs of infection. Patients with dacryocystocele should be referred to pediatric ophthalmology.

(Source: Congenital Dacryocystocele with Spontaneous Resolution. EyeRounds.org, March 7, 2013. Accessed November 2, 2020).

Dacryocystitis is infection of the lacrimal sac due to obstruction at the nasolacrimal system. Unlike dacryocystocele, dacryocystitis is tender and erythematous. Patients with dacryocystitis require pediatric ophthalmology consultation and treatment with systemic antibiotics.

(Source: Acute Dacryocystitis. N Engl J Med 2018.)

Ophthalmia Neonatorum

Ophthalmia neonatorum describes conjunctivitis in infants younger than 4 weeks. Causes can be chemical, bacterial, and viral. Prenatal history and onset of disease are important in the evaluation of a newborn with conjunctivitis in order to determine etiology and treatment.

(Source: Ophthalmia Neonatorum. N Engl J Med 2019.)

Vomiting

Vomiting during the newborn period may be due to a number of conditions, ranging from gastroesophageal reflux to surgical emergencies (e.g., volvulus). Emergent causes of vomiting (intussusception and volvulus) in the neonate and young infant are reviewed in the Pediatric Emergency Medicine rotation guide.

History and physical examination for a young infant presenting with vomiting should include evaluation of the following factors:

• diet (what baby is eating, quantity, and frequency)

• stooling and urine output

• weight gain

  • During the first month of life, weight gain should be approximately 30 grams per day.

  • Infants between ages 3 and 6 months should gain approximately 20 grams per day.

• hydration status

• abdominal exam

Common causes of vomiting in infancy include:

• Gastroesophageal reflux can range from benign to severe and can be associated with poor weight gain.

• Overeating in bottle-fed infants can occur as parents learn feeding cues from the infant. Overfeeding is diagnosed clinically based on a history of feeding higher quantities of milk than can be accommodated in an infant’s stomach. On average, all infants should consume one ounce per kilogram of body weight per feeding. However, each infants’ specific feeding cues are important to note. Vomiting due to overfeeding should be accompanied by normal physical exams and growth. The physiologic basis of breastfeeding helps exclusively breastfed infants control feeding.

Umbilical Abnormalities

Omphalitis

Omphalitis is a neonatal infection of the umbilical stump, often due to the use of unhygienic tools during delivery. Omphalitis is uncommon in developed countries but continues to be prevalent in developing countries. Other risk factors include prolonged rupture of membranes, maternal infection, home birth, umbilical catheterization, and improper cord care. Symptoms are erythema and induration of the umbilicus and surrounding skin, with purulent discharge or bleeding of the cord. The high risk for progression to necrotizing fasciitis or sepsis necessitates emergent evaluation with full sepsis evaluation, administration of antibiotics, and hospitalization for close observation.

Umbilical Granuloma

Once the umbilical stump falls off, usually about 1−2 weeks after birth, a raw erythematous surface can remain and typically heals within a few days. The area must be kept clean to reduce the risk of infection.

An umbilical granuloma appears as a persistent, red swelling or stalk that can form at the site of umbilical cord separation. It may have a mild, sticky discharge. Treatment of this granulation tissue often involves cautery with silver nitrate.