13 Nov My Baby Is Sick…

Dr Sam Tormey discusses the signs of sickness in infants.

There is a very simple checklist of the basic life functions of a baby to run through when illness strikes. Is the baby breathing, sleeping, playing, feeding, weeing and pooing as he or she usually does? These six things are reliable indicators of how well a baby is coping with an illness. A doctor or nurse will want to know how each one has changed.

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 – they can all add up to a rather harrowing 12 months.

When your baby becomes unwell for the first time, it can be a truly frightening experience.

And, for many of us, it is the first time in our lives when we are directly responsible for the health and well-being of another person. Quite a task when that person can’t clearly communicate problems such as fever, pain, thirst and nausea. 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 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?

No illness feels very trivial when you are used to having a happy, healthy baby.

I meet parents in this situation most days in the emergency department. 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 these parents have received the raised eyebrow and the loaded “first-time parent?” query from the triage nurse, with the implications of parental inexperience and 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. They only compound your anxiety. No illness feels very trivial when you are used to having a happy, healthy baby.

So, 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. Sometimes the infections seem to come one after another so 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…

Looking at the statistics can at least reassure us that a sick baby is most unlikely to die.

Babies will nearly always recover fully from all of these illnesses, usually with no medical treatment whatsoever. We live in one of the safest countries in the world to have a baby, with very low infant-mortality rates. It is dreadful to imagine a baby dying. This is the unspoken horror that lurks at the back of the anxiety over a sick baby. About 4 in 1000 babies born in Australia will die in the first 12 months of life. Most of those deaths occur in the first four weeks of life (the neonatal period) and are largely related to the complications of premature birth and serious congenital malformations. Of babies who die after this period, Sudden Infant Death Syndrome (SIDS) is the most frequent cause. So, 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.

1. Once a baby is sick, we have to decide how sick he or 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 four weeks of life do not have the immune capacity of older babies. They 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 that were not apparent at birth can all cause illness in young babies. So the younger your sick baby is, the lower your threshold for seeking a medical opinion should be.
2. Another good rule is to reassess the situation frequently. The physiology of an infant is different from that of an adult in several important ways. This changes the way in which illnesses behave. For example, babies tire more easily than adults do when breathing rapidly. 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 that are more likely to become fatigued. 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. So, 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.

Let’s tackle the question of just how sick the baby is.

Bearing these two rules in mind, let’s try to tackle the question of just how sick the 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 complain of specific symptoms, such as a painful throat when swallowing. He or she simply stops feeding. So there is a very simple checklist of the basic life functions of a baby to run through when illness strikes is the baby:

1. breathing
2. sleeping
3. playing
4. feeding
5. weeing and
6. pooing

as he or she usually does?

These six things are reliable indicators of how well a baby is coping with the illness. 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 to 60 breaths per minute is normal for a neonate and 30 to 40 breaths per minute for a 12 month old. It is easy to measure how fast a baby is breathing by exposing the 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 a 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, he or she is likely to be in discomfort or pain, and a source for the symptoms should be sought. Some clues can be gleaned from the 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 from bright light can mean a headache.

Any sick baby who appears flat and listless should be taken to the doctor.

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 raise a smile. Any sick baby who appears flat and listless should be taken to the doctor. This is especially important if the baby feels floppy when picked up, as lack of muscle tone is a good indicator of a seriously unwell baby.

Feeding – whether via milk, fluids or solids, feeding 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 adequate milk and fluids. Dehydration is a common and potentially serious complication of many illnesses in infancy. The younger the baby, the more rapidly he or 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. A baby with a fever will lose more fluid from the skin. A 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 vomit and count how many the baby has. The number of wet nappies is crucial. Urine output is a very reliable indicator of the hydration of a baby. Look at the nappy to see whether the urine is pale or dark yellow. Feel how heavy the nappy is as a rough guide to volume. Most babies should have at least four wet, heavy nappies a day.

Diarrhoea – count the number of nappies each day, look for the presence of blood in the stools and feel how heavy the nappy is. The definition of diarrhoea depends on how often your baby normally opens his or her bowels. This is incredibly variable with each baby. Diarrhoea refers to 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 a baby has copious and frequent diarrhoea, it can be hard to tell how much urine is being made. 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 a baby has so much diarrhoea that it is hard to tell how much urine is being made, the baby should be taken to see a doctor anyway.

Temperature – one final important thing to add to the six basics above, is your baby’s temperature. This is easy to measure at home with digital thermometers, which are 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 amount, 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 37.5ºC. The most important thing to remember about fevers is that their significance depends on the age of your baby. Any fever in a baby three months or younger requires a medical assessment, as it is far more likely to indicate a serious infection than in an older baby. Conversely, the absence of a fever does not exclude a serious infection, particularly in the younger baby. A fever that is high (above 39.5ºC) will not come down with simple treatment and, if accompanied by either uncontrollable shivering or mottling of the skin, can indicate a serious infection and requires medical input. Finally, a temperature persistently lower than 35.5ºC in a sick baby is an indication to get some help – some illnesses manifest as lower rather than higher temperature.

Deciding when to ask for help requires looking at all of these factors as a whole. This will get easier once your child suffers his or her first few illnesses.

Finally, remember that your baby was always going to get sick at some point, and will get sick again. Be reassured that your baby will cope with most of these illnesses without intervention by a medical professional. Never be afraid to get help, even if that means calling 000. And since you are going to be in charge of someone who gets sick from time to time, undertaking a first-aid course is a very good idea.

Dr Sam Tormey is a doctor who writes on medical issues. For further advice, see our My Baby is Sick…checklist

Note: This article provides general health information and in no way constitutes medical advice. Ideas and information expressed may not be suitable for everyone. Readers wishing to obtain medical advice should contact their own doctor.

Illustrations by Harry Afentoglou