newborn care charts - healthy newborn network · newborn care charts management of sick and small...
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NewborN Care ChartsMaNageMeNt of siCk aNd
sMall NewborNs iN hospital
MaNageMeNt of siCk aNd sMall NewborNs
principles of newborn care• Maintain body temperature• Oxygen therapy• Maintain normal glucose• Feeds and fluids for sick and small babies• Infection prevention and control• Transfer and referral
Specific problems• Apnoea and respiratory distress• Preterm and low birth weight• Serious acute infection• Local infection • Neonatal encephalopathy• Jaundice• Congenital abnormalities• Syphilis• Tuberculosis• HIV-affected mothers and babies
Assess feeding
Counsel
• Baby’s illness
• Feeding
• When to return
Written discharge policy
Written summary
Complete clinical notes and RTHC
Follow up Child Health visits• Day 3• 6 weeks
Follow up low birth weight and high risk babies
• 3 days after discharge• 2 weekly until 2.5kg• 4 months• 9 months
MaNageMeNt of NewborNs
birth: assess Need for resUsCitatioN resUsCitate
roUtiNe Care iN laboUr ward
siCk or sMall well
roUtiNe Care iN postNatal ward
Triage
2. TREAT, OBSERVE AND CARE 3. COUNSEL 4. FOLLOW-UP
If present EMERGENCY TREATMENT until stable
1. ASSESS AND CLASSIFY
Assess need for emergency care
Assess for priority signs
Assess for abnormalities or local infections
Check risk factors and special treatment needs
1.1. NEED
FOR Em
ERgEN
cy c
aRE
51.2. PRiO
Rity sigN
s
6
1.3. abN
ORm
alitiEs a
ND
lOc
al iN
FEctiO
Ns
81.4. Risk Fa
ctO
Rs aN
D sPEc
ial tREa
tmEN
t NEED
s
10
table o
f Co
NteN
ts
2.1. PRINC
IPLES OF N
EWBO
RN C
ARE
2.1.1. m
aiN
taiN
bOD
y tEmPERa
tuRE
12
2.1.2. Oxyg
EN thERa
Py
17
2.1.3. ma
iNta
iN N
ORm
al g
lucO
sE
21
2.1.4. FEEDs a
ND
FluiDs FO
R sick a
ND
sma
ll babiEs
22
2.1.5. iNFEc
tiON
PREvEN
tiON
aN
D c
ON
tROl
25
2.1.6. tRa
NsFER a
ND
REFERRal
272.2. SPEC
IFIC C
ON
DITION
S
2.2.1. a
PNO
Ea a
ND
REsPiRatO
Ry DistREss
28
2.2.2. PREtERm a
ND
lOw
biRth wEig
ht
30
2.2.3. sERiO
us ac
utE iNFEc
tiON
35
2.2.4. lOc
al iN
FEctiO
N
36
2.2.5. N
EON
ata
l ENc
EPhalO
Pathy
37
2.2.6. Ja
uND
icE
39
2.2.7. cO
Ng
ENita
l abN
ORm
alitiEs
42
2.2.8. syPhilis
45
2.2.9. tubERculO
sis
47
2.2.10. hiv a
FFEctED
mO
thERs aN
D ba
biEs
48
3.1. assEss FEED
iNg
iN bREa
stFED ba
by
503.2. a
ssEss FEEDiN
g iN
baby REc
EiviN
g REPla
cEm
ENt m
ilk
51
3.3. assEss FEED
iNg
aN
D w
Eight g
aiN
iN lO
w biRth w
Eight ba
biEs 52
3.4. cO
uNsElliN
g PRiN
ciPlEs
543.5. FEED
iNg
mEthO
Ds: c
ORREc
t POsitiO
NiN
g a
ND
atta
chm
ENt,
aN
D c
uP FEEDiN
g
55
3.6. REPlac
EmEN
t FEEDiN
g
56
3.7. whEN
tO REtuRN
58
4.1. NEO
Na
tal FO
llOw
uP
604.2. D
EvElO
PmEN
tal sc
REENiN
g c
haRt
61
5.1. ROutiN
E ca
RE iN la
bOuR w
aRD
635.2. REsusc
itatiO
N
655.3. RO
utiNE c
aRE iN
POstN
ata
l wa
RD
67
5.4. DRug
DO
sEs
695.5. km
c c
haRt
72
5.6. REcO
RDiN
g FO
Rm
735.7. g
ROw
th aN
D hEa
D c
iRcum
FERENc
E cha
Rt
745.8. D
aily w
Eight, FEED
iNg
aN
D tREa
tmEN
t cha
Rt
755.9. list O
F abbREv
iatiO
Ns
76
5.10. REFERENc
Es
77
1. ASSESS A
ND C
LASSIFY
4 - 10
2. TREAT, O
BSERVE AN
D CA
RE
11 - 48
3. ASSESS FEEDIN
G A
ND C
OUN
SEL
49 - 58
4. FOLLO
W UP
59 - 61
5. ROUTIN
E CA
RE FOR A
LL NEW
BORN
S, CHA
RTS, REC
ORDIN
G FO
RMS A
ND REFEREN
CES
62 - 77
assess aNd ClassifYTREAT, OBSERVE AND CAREassess feediNg aNd CoUNselfollow UpROUTINE CARE FOR ALL NEWBORNS,CHARTS, RECORDING FORMS & REFERENCES
1.1 Assess need for emergency care 5
1.2 Assess priority signs 6 •Apnoea •Respiratorydistress •Lowbirthweight •Temperature •Colourandskin •Tone,movementandfontanel •Abdominalsigns
1.3 Assess for abnormalities or local infection 8
1.4 Assess risk factors and special treatment needs 10
Key to colours used in this chart booklet:
eMergeNCY CareImmediate life-threatening situation: provide emergency care
iMMediate CarePotential life-threatening situation: provide immediate care
speCialised UrgeNt CareProvide care and refer as soon as possible
SPECIALISED NON-URGENT CAREProvide care and referral
NoN speCialised Care: iNpatieNt Care and treatment needed as soon as possible
Baby can be discharged home
1. ASSESS AND CLASSIFY4
1.1 ASSESS AND CLASSIFY: NEED FOR EmERgENcy caRE Rapidlyassessallnewbornsonarrivalintheward,casualty,oroutpatients,fortheneedforemergencycare.
ASK, CHECK, reCord
LOOK, LISTEN, feel sigNs ClassifY aCt Now
Assess breathing•Isbabybreathing?•Isbabygasping?•Counttherespiratoryrate
•Isthebaby’stongueblue?
Assess circulation •Counttheheartrate•Pallor•Extremelylethargicorunconscious
assess for hypoglycaemia•Checkbloodglucosewithglucoseteststrip
•Notbreathingatall,or
•Gasping,or•RR<20,or•Heartrate<100•Tongueblue
respiratorYfailUre
•Resuscitatethebabyusingabagandmask(p.65)
•Giveoxygen(p.17 - 20)•Callforhelp•Keepwarm•Arrangenurseryadmission
•HR>180,or•Pallor,or•Extremelethargy,or
•Unconscious
CirCUlatorY failUre •Giveoxygen(p.17 - 20)•Callforhelp•EstablishanIVline• Infusenormalsaline10ml/kgbodyweightover1hour
•Theninfuseneonatalyteor10%glucoseatrecommendedvolumeforweightandage(p.22; 23)
•Keepwarm(p.12 - 16)•CheckVitaminKadministration
• Glucose<2.5mmol/L
hYpoglYCaeMia •Give10%glucoseIVasrecommendedvolumeforweightandage(p.22; 23)
•Manageforhypoglycaemia(p.21)
5assess aNd ClassifY
1.1 ASSESS AND CLASSIFY: NEED FOR EmERgENcy caRE 1.1
ASK, CHECK, reCord
LOOK, LISTEN, feel sigNs ClassifY aCt Now
Whatisthebaby’scurrentproblem?
Isthebabyhavingaproblemwithfeeding?
Hasthebabyhadanyconvulsionsorabnormalmovements?
Assess respiration •Countthebreathsinoneminute
•Listenforgrunting•Lookforseverechestindrawing
•Doesbabyhaveapnoea?(spontaneouslystopsbreathingformorethan20seconds)
Assess colour•Centralcyanosis(bluetongue)
•Nobreathsfor>20secondsandneedsstimulation
apNoea •Stimulateorresuscitate,asrequired•Manageforapnoea(p.28)
•Severechestindrawing
AND/OR•Grunting,AND/OR•RR>80
SEVERE respiratorY
distress
•Startoxygen• IfpretermandCPAPisavailable,commenceCPAP(p.20)
•Monitortheresponsetooxygen(p.17)•MobileCXR(p.28)•Observehourly•Startantibiotics(p.29) •Keepnilbymouthfor24hours•Treat,careandobserve(p.28,29)
•RR60-80butNOcyanosis,gruntingorchestindrawing
Mild respiratorY
distress
•Checkoxygensaturation–ifO2saturation<88%orcyanosis,manageassevererespiratorydistress
•Observe3hourly•Startantibioticsifatriskforsepsis•CXRifnoimprovementafter6hrs
•CentralcyanosisbutNOchestindrawingorgrunting
possible heart abNorMalitY
•Giveoxygen(p.17 - 20)•Consultspecialistforpossiblereferral
1.2 ASSESS AND CLASSIFY: PRiORity sigNs Checkallbabiesforprioritysigns,beforetakingadetailedhistory.Examinethebabyunderaradiantheater.ClassifyandACTNOWtomanagepriorityproblems.
6
ASK, CHECK, reCord LOOK, LISTEN, FEEL sigNs ClassifY aCt Now
Baby’sbirthweight
Baby’scurrentweight
Documentfindingsinthenewbornrecord.
Assess for low birth weight
Assess temperatureAxillarytemperature(Usethermometerwhichreadsbelow35°C)
Assess tone, movement and fontanelle
•Decreasedtone(floppy)
•Increasedtone(stiff)•Irregularjerkymovements
•Reducedactivity•Lethargic•Fullfontanelle
Assess abdominal signs•Abdominaldistension•Vomitingbileorblood
Assess colour and skin•Jaundice
•Birthweight<1kg•Birthweight1-1.49kg•Birthweight1.5-1.99kg
eXtreMelY lbwVERY LBW
LBW (< 2 kg)
•Ensurewarmth•Commencefluidsorfeeds(p.22 - 24)
•Checkbloodglucose(p.21)•Seelowbirthweightchart(p.30 - 34)
•Temp<36.0°C hYpotherMia •Re-warm(p.12 - 16) •Checkbloodglucose(p.21)
•Temp<32.0°C•Temp>38°C
•Notfeeding•Decreasedtone• Increasedtone• Irregularjerkymovements/convulsions
•Reducedactivity/lethargic
•Fullfontanelle
•Abdominaldistension•Vomitingbile
•Jaundiceinfirst24hours
SEVERE DISEASE
(Classifyifanyonesignispresent)
•Treatconvulsionsifpresent(p.37)
•CommenceIVinfusionatmaintenancerate(p.22,23)
•Checkglucosenowand3hourly(p.21)
•Re-warmifcold(p.12 - 16)•Keepwarm(p.12 - 16)•Checkforriskfactorsanddeterminethecause(p.10)
•Treatthecause•Startantibioticsifsepsisissuspected(p.35)
•Reassess1-3hourly
•Jaundiceafterthefirst24hours
JAUNDICE •Determinethebilirubinlevelandmanage(p.39 - 41)
•Determinethecause(p.39)
•Birthweight2-2.5kg LBW (2-2.5 kg) •Keepskin-to-skin/KMC•Assessbeforedischarge:KMC,warmth,feeding
7
7assess aNd ClassifY1.2 ASSESS AND CLASSIFY: PRiORity sigNs 1.2
ASK, CHECK, reCord
LOOK, LISTEN, feel sigNs ClassifY aCt Now
Askthemother“Haveyounoticedanyabnormalityoristhereanythingthatconcernsyou?”
Hasthebabypassedmeconium?
Documentfindingsinthenewbornrecord.
•Opentissueontheheadorback
NeUral tUbe defeCt / spiNa
bifida
•CoverthelesionwithOpsite•Refer
•Omphalocoele•Gastroschisis•Imperforateanus,notpassedmeconiumin24hours
MAJOR gastroiNtestiNal
abNorMalitY
• IVfluids(p.22 - 23)•Ensurewarmth•Refer
•Headcircumferenceabovethe97thcentile
hYdroCephalUs •Refertotertiarycentreforneuro-imagingandneurosurgery
•Headcircumference<3rdcentile
MiCroCephalY •Assessforotherabnormalities•Determinethecause•Counselthemother
•Clubfoot ClUb foot •Assessotherproblems•Refertoorthopaedicserviceforearlyserialplasters
•CleftlipAND/ORpalate
Cleft lip aNd / or palate
• Startfeeding•Consult/refer
1.3 ASSESS AND CLASSIFY: abNORmalitiEs aND lOcal iNFEctiONs
Assessallbabiesforanybirthinjuriesorabnormalitiesthatmaybepresent.
This chart does not cover all abnormalities
and local problems.
Consult standard texts, or the local referring centre for advice on problems not covered here.
Assess the baby from head to toe:
Head and face •Headcircumference•Swellingofscalp•Unusualappearance
Mouth and nose•Cleftlipand/orpalate
Eyes•Pusdrainingfromeye•Redorswolleneyelid
Abdomen and back•Gastroschisis/ omphalocoele
•Spinabifida/ myelomeningocoele
•Imperforateanus
Skin •Pustules/rash•Umbilicusred/pus
Limbs•Abnormalposition•Poorlimbmovements(lookatfemurorclavicle)
•Babycrieswhenleg,armorshoulderistouched
•Clubfoot•Extrafingerortoe•Swollenlimb/joint
Other
8
ASK, CHECK, reCord
LOOK, LISTEN, feel sigNs ClassifY aCt Now
•Swollenhead(bumpononeorbothsides)
•Abnormalpositionoflegs
•Poorlimbmovement/pain
•Extradigit•Unusualappearance
•Otherabnormalities
BIRTH INJURY / abNorMalitY
•Counseltheparents•Handlegently•Determinethecause•Checkforriskofsyphilis
•Pusdrainingfromtheeye
•Umbilicalredness•Skinpustules
loCal baCterial iNfeCtioN
•Treatskin,umbilicalandeyeinfection(p.36)
• IfpusintheeyesgiveonedoseIMCeftriaxone(p.36)
9assess aNd ClassifY
1.3 ASSESS AND CLASSIFY: abNORmalitiEs aND lOcal iNFEctiONs 1.3
1.4 ASSESS AND CLASSIFY: Risk FactORs aND sPEcial tREatmENt NEEDs
Evaluateformaternalandperinatalconditionsthatmayputthebabyatriskofseriousillness.
ASK, CHECK, reCord sigNs ClassifY aCt Now
Reviewandrecordthehistoryofthemother’santenatalcare,pregnancy,labour,birthandresuscitationofthebaby
Pregnancy•Durationofpregnancy•Motherdiabetic•MotherhashadTBinlast6months
•MothertestedRPRpositiveorunknown
•MothertestedHIVpositiveorunknown
•Mother’sbloodgroupOorRhNeg
Labourandbirth•Uterineinfectionorfever•Membranesrupturedfor>18hours
•Difficultlabour•Complicationsafterbirth•Apgarscore
•Motherhasdiabetes,OR•Baby>4kg•Lowbirthweight•Severedisease
risk of hYpoglYCaeMia
•Feedimmediately•Hourlyglucosefor6-12hours•Treathypoglycaemia(p.21)
•MotherbloodgroupO,OR•MotherRhesusNeg,OR•Birthinjuries
RISK OF JAUNDICE •Measurebilirubinat6hours•Commencephototherapyifbilirubin>80mmol/l(p.39 - 41)
•Membranesrupture>18hours,OR•Maternalfever,OR•Offensivesmellofliquoratbirth
risk of baCterial iNfeCtioN
•Followmaternalchorioamnionitisprotocol(p.36)
•Apgarscore<7at5minutes risk ofNeoNatal
eNCephalopathY
•Observefor12hours•Evaluateandmanageforneonatalencephalopathy(p.37 - 38)
•MothertestedRPRpositive,OR•Mother’sRPRnotknown,OR•Motherpartiallytreated
risk of CoNgeNital sYphilis
•Evaluateandmanageaccordingtocongenitalsyphilisprotocol(p.45, 46)
•MothertestedHIVpositive,OR•UnknownmaternalHIVstatus,OR•Unknownfeedingchoice
RISK OF HIV traNsMissioN
•ManageaccordingtoPMTCTprotocol(p.48)
•MotherstartedTBtreatmentwithinthepast6months,OR
•Mothercoughingfor>3weeks
risk of tUberCUlosis
•ManageaccordingtoTBprotocol(p.47)
10
2.1 Principles of Newborn Care 2.1.1 Maintainbodytemperature 12 2.1.2 Oxygentherapy 17 2.1.3 Maintainnormalglucose 21 2.1.4 Feedsandfluidsforsickandsmallbabies 22 2.1.5 Infectionpreventionandcontrol 25 2.1.6 Transferandreferral 27
2.2 Specific Problems 2.2.1 Apnoeaandrespiratorydistress 28 2.2.2 Pretermandlowbirthweight 30 2.2.3 Seriousacuteinfection 35 2.2.4 Localinfection 36 2.2.5 Neonatalencephalopathy 37 2.2.6 Jaundice 39 2.2.7 Congenitalabnormalities 42 2.2.8 Syphilis 45 2.2.9 Tuberculosis 47 2.2.10HIVaffectedmothersandbabies 48
2. TREAT, OBSERVE AND CARE
11TREAT, OBSERVE AND CARE
2. TREAT, OBSERVE AND CARE 2.
2.1.1 MAINTAIN NORMAL BODY TEMPERATURE: PREvENt aND tREat hyPOthERmia
PREVENT HYPOTHERMIA
Dry the baby well at birth
When the baby is warm:•Keepthebabycoveredorclothedasmuchaspossible•Delaybathinguntilafterthefirst24hours•Provideskintoskincareifpossible•Ifskintoskincareisnotpossible,clothethebabywithbootiesandcap.
•Uncoveronlypartsthatneedobservationandtreatment•Changenappywhenwet•Forincubatorcareseep.15
Feed the baby early:•Encourageearlybreastfeeding•Feedthebabyandcheckthebloodglucoseifappropriate
Maintain a warm environment in the newborn unit •Keeptheroomat25-26°C(Check4x/daywithawall thermometer)
•Keeptheroomfreeofdraughts•Donotplacethebabyonornearcoldobjects(examinationtable,wall,window)evenifthebabyisinanincubator
•Ensurewarmthduringprocedures•Havecurtainsdrawninthenursery
Observe body temperature •Hourlyif<1.2kgandseriousinfection•3hourlyinbabies1.2-1.5kg•6hourlyinbabies>1.5kgandstable
Encourage skin-to-skin care•Placingmotherandbabyskin-to-skincanbeusedtore-warmbabieswithhypothermia
•Inadditiontore-warming,skin-to-skincareimprovesfeeding,reducesinfections,andencouragesbonding
•Itisonlyusedforstablebabies,unlessnootheroptionisavailable
•SmallbabiesshouldbecaredforinKangarooMotherCare(p.14)
12
2.1.1 MAINTAIN NORMAL BODY TEMPERATURE: PREvENt aND tREat hyPOthERmia
Moderatehypothermia(32-36°C)butstable
•Measurebloodglucoseandfeed•Measuretemperatureeveryhour,aimingforanincreaseof0.5°Ceveryhour•Ifbabyisstable,introduceKMC(p.14)
Severehypothermia(<32°C) •Radiantwarmerorincubatorat38°C•Ifusingaservo-controlledincubator,setskintemperatureat36.5°Candensureskinprobeisfixedsecurely(p.16)
•Measuretemperatureafter30minutesandthenhourlyuntilnormal.•Thetemperatureshouldincreasebymorethan0.5°Ceveryhour•Treatforsepsis•GiveIVfluidsandmonitorbloodglucose,keepnilbymouthuntilre-warmed•Giveoxygenbynasalprongsuntilthebaby’stemperatureisnormal•Continuallyreassessforemergencysigns.Thebabyisatriskforcardio-respiratoryfailure•Oncethebabyiswarmedandstable,considerKMC(p.14)
Babysick,or<1kg •Radiantwarmerorincubatorat38°C•Ifnoincubatorisavailableortransferringbaby,thenKMCisanacceptablealternative(p.14)
METHODS FOR WARMING THE SMALL OR SICK BABY AND MAINTAINING A THERMONEUTRAL ENVIRONMENT
13TREAT, OBSERVE AND CARE
2.1.1 MAINTAIN NORMAL BODY TEMPERATURE: PREvENt aND tREat hyPOthERmia 2.1.1
continuesonnextpage
What is KMC?•KMCisamethodofcaringforsmallbabiesthathasbeenshowntomaintainwarmth,improvefeeding,reduceinfections,andencouragebonding
•KMCcanreducemortalitybyuptohalfinbabiesweighinglessthan2000g
•KMChasthreemaincomponentsincludingthermalcarethroughcontinuousskin-to-skincontactusuallywiththemother,nutritionthroughexclusivebreastfeeding,andsupportfromhealthstaffthroughearlyrecognitionandresponsetocomplications
•IfcontinuousKMCcannotbepracticedduetospaceorotherconstraints,intermittentKMCisalsobeneficial
•Allstablesmallbabiesandtheirmotherswillbenefitfromkmc
KMC monitoring•6hourlyheartrate,respiratoryrate,temperature,activity,colour,intakeandoutput
•Dailyweight•DailyKMCscore(seep.72)
KMC nutrition•Babieswhoareunabletosuckleshouldbefedexpressedbreastmilkviaanasogastrictubeorcup.BabiesmaybekeptintheKMCpositionwhiletubefeeding.Allowthemtotrysucklingduringthetubefeed
•Babieswillshowthattheyarereadytosuckleastheirrootingandsucklingreflexesdevelop
•Oncethebabyisabletosuckle,allowbabytobreastfeedondemand,andfeedatleasteverythreehours
•MotherswhoformedicalreasonsareusingreplacementfeedscanstillprovideKMCandcupfeedthebaby
KMC position•Dressthebabyinanappyandcap•Placethebabyinanuprightpositionagainstthemother’sbarechest,betweenherbreastsandinsideherblouse
•Coverbothmotherandbabywithablanketorjacketiftheroomiscold
•Youmayuseaspecialgarment;ortuckthemother’sblouseunderthebabyorintoherwaistband
•Thebabymustbesecureenoughsothatthemothercanwalkaroundwithoutholdingherbaby
•Explainanddemonstrateuntilthemotherisconfidenttotrythekangarooposition
KMC support•KMCwardshouldbewarmandinviting•ThemothermustkeepherbabyinKMCpositionatalltimes(exceptwhileshebathes)
•Goodhygieneisimportant,includinghandwashingafterusingthetoiletandbeforefeeding
•MotherscanwalkaroundthewardandoutsidewiththeirbabiesintheKMCpositioniftheweatherconditionsarefavourable
•Occupythemothersandencourageappropriatedevelopmentalstimulation
•Healthstaffshouldbeavailabletorespondearlyandquicklytocomplications
2.1.1 MAINTAIN NORMAL BODY TEMPERATURE: kaNgaROO mOthER caRE
kaNgaroo Mother CareThebabywhoispretermand/orlowbirthweightneedsadditionalwarmthtomaintainbodytemperature.
14(continuedfromthepreviouspage)
A) RADIANT WARMER•Usesradiantheattowarmthebaby•Mainlyusedintheresuscitationarea•Keeptheradiantheaterswitchedonintheresuscitationarea,readyforuseatalltimes
•Changethelinenaftereachbaby
B) SERVO-CONTROLLED OPEN INCUBATOR•Usesradiantheattowarmthebaby•Setasforservo-controlledclosedincubator.Thetempera-tureprobeistapedtothebaby’sskinandsetto36.5°C
•Thebabyneedstobeundressedandexposedexceptforanappy•Aheatshieldwillpreventheatlossthroughradiation•AnopenincubatorisusefulformanagingsickandsmallbabiesinICUorhighcare
opeN warMers
15TREAT, OBSERVE AND CARE
2.1.1 MAINTAIN NORMAL BODY TEMPERATURE: usiNg iNFaNt waRmERs aND iNcubatORs 2.1.1
continuesonnextpage
(continuedfromthepreviouspage)
A) MANUAL •Placethebabyinawarm(37°C)cleanincubator•Determinetherecommendedincubatortemperatureforthebaby,usingTable1•Settheincubatortothistemperature•Measuretheincubatorandbaby’stemperatureafter30minutesandadjusttheincubatortemperatureifthebaby’stemperatureisnotnormal(36.0-37.0°C)•Monitortheincubatorandbaby’stemperature3hourlyaspartofroutineobservations.Altertheincubatortemperaturewheneverthebaby’stemperatureisoutsidethenormalrange
Ifthebabyremainscolddespiterecommendedtemperature,then:•theroomistoocold,ortheincubatorisnearawindow•thebabyhasaninfection•theincubatorismalfunctioning
B) SERVO-CONTROLLED•Switchthecontroltomanual(AIR)andpreheatto37°C•Placethebabyintheincubatorandattachthetemperatureprobetothebaby’sskin(Theleftsideoftheabdomenisbest)
•Makesurethatthecablefromthebaby’sskiniscorrectlypluggedintotheincubator
•Switchtheincubatorcontrolfrommanual(AIR)toservo-controlled(SKIN)
•Settherequiredskintemperatureto36.5°Conthecontrolpanel
•Theactualskintemperaturewillbedisplayedonthepanel
•After30minutescheckthatthebaby’sskintemperatureisthesameastherequiredtemperature.Ifnotthentheskinprobeisnotcorrectlyappliedortheincubatorismalfunc-tioning•Checkthetemperatureofbothbabyandincubatorevery1-3hours
NOTE: If the skin probe comes loose, the incubator will con-tinue to warm up and the baby will become TOO HOT!
(hyperthermic)
table 1: teMperatUre Chart for iNCUbatorsBirth
WeightDays after delivery
0 5 10 15 20 25 301000g 35.5 35.0 35.0 34.5 34.0 33.5 33.01500g 35.0 34.0 33.5 33.5 33.0 32.5 32.52000g 34.0 33.0 32.5 32.0 32.0 32.0 32.02500g 33.5 32.5 32.0 31.0 31.0 31.0 31.03000g 33.0 32.0 31.0 30.0 30.0 30.0 30.0
Closed iNCUbators
2.1.1 MAINTAIN NORMAL BODY TEMPERATURE: usiNg iNFaNt waRmERs aND iNcubatORs16
WHICH BABIES NEED OXYGEN? •Duringresuscitation•Severehypothermia•BabywithSEVERERESPIRATORYDISTRESS:
oRR>80oseverechestindrawingorgruntingooxygensaturationlessthan88%ocentralcyanosis(bluetongueandlips)
gUideliNes for oXYgeN adMiNistratioN (see flow chart, next page)•Start head box oxygenforallbabieswithrespiratorY
distress•MonitortheoxygensaturationwithaPULSEOXIMETERcontinuouslyfor30minutesaftercommencementonoxygen
•Apretermbaby’soxygensaturationshouldbebetween88%and93%
•Atermbaby’soxygensaturationshouldbebetween94%and96%
•Ifthebabyispinkandcomfortable(lessgrunting/chestindrawing)andsaturation>88%,in<60%oxygenonheadbox,changetonasalprongs
•Ifthebabyisdistressedorblueortheoxygensaturationis<88%on>60%oxygen,useCPAPifavailable,ortransfer
•Ifthebabyremainsdistressedorblue,ortheoxygensaturationremains<88%onoptimumCPAP(asdefinedbyexperiencedstaff)thenintubationandventilationisneeded
CoNCeNtratioN of oXYgeN •Theconcentrationofoxygeninroomairis21%,andtheconcentrationofpureoxygenis100%
•Toomuchortoolittleoxygenisbadforthebaby,somixtheamountofoxygenandairtomeetthebaby’srequirements.Thiscanbedoneby:
•Anair/oxygenblenderthatmixespureoxygenwithairtogivetherequiredconcentration(between21%and100%)
•Aventurithatmixespureoxygenwithroomair–theventuriisasimpleapparatusthatusesajetofoxygentosuckinafixedamountofroomair
•Venturisareavailablethatdeliveroxygenconcentrationsfrom24%-80%
•Eachventurihasaspecifiedflowrate
Adjust the oxygen concentration to keep the saturation between 88 - 93% in a preterm baby and 94 - 96% in a term
baby.
For Head box use%Oxygen 80% 60% 40% 28% 24% 21%Flow 12 10 8 6 4 4
2.1.2 OXYGEN THERAPY
17TREAT, OBSERVE AND CARE
2.1.2 OXYGEN THERAPY 2.1.2
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Provide CPAP O2 flow at 6 - 8 litres
**NB** Entry is at any point Head Box OxygenWith venturi system
> 60% O2
flow at 10 litres
> 40% O2 < 40% O2 and
Saturations > 88%
Signs of respiratory distress NO Signs of respiratory
distress
Assess for intubation and referral for IPPV
< 60% O2 flow at 10 litres oxygen
Wean by changing venturis to 30%
Provide nasal prong oxygen
2.1.2 OXYGEN THERAPY18
Indication Method Flow and concentration
Observations Advantages Disadvantages
•Forbabieswithsevererespiratorydistress
•TostabilisebabiestoassesswhethertheywillrequirecPaP
•Forbabiesnotmaintainingoxygensaturationonnasalprongorcannula
•Alwaysensurethattheheadstayswithintheheadbox
•4-12L/minofoxygenisrequired(p.17)
•Applyafacemaskifyouneedtomovethebaby
•5L/min•Mustuseair/oxygenblenderorventuri
•Oxygenconcentration25%-80%
•Observeandrecordtheoxygensaturationandcolourhourly
•Observeandrecordoxygenconcentration
•alwaYs MoNitor the oXYgeN satUratioN
•Highconcentrationscanbeachieved
•Doesnotobstructthenasalpassages
•Humidificationofoxygennotnecessary
•Babycannotbemoved
•Mustfeedbynasogastrictube
•Highflowofoxygenneededtoreachtherequiredconcentration
•Dangerofoxygenpoisoning(retinopathy,broncho-pulmonarydysplasia),especiallyinapretermbaby,iftoomuchoxygenisgiven
•Mildrespiratorydistress,orcopingonHBO2
•Nonasogastrictubeinsitu-babymayhaveanorogastrictube
•Placetheprongsjustbelowthebaby’snostrils.Use1mmprongsforsmallbabiesand2mmprongsfortermbabies
•Securetheprongswithtape
•1Lperminute•Concentration~30%
•Monitortheoxygensaturation3hourly
•Ensuresconstantconcentration
• babycanbefedorally(cuporbreast)
•Idealforbabieswithmildrespiratorydistress
•Notforbabieswithmoderateorseverebreathingdifficulty
•Prongscaneasilygetdisplaced
•Mildrespiratorydistress,orcopingonHBO2
•Nonasogastrictubeinsitu-babymayhaveanorogastrictube
•InsertaFG5orFG8nasogastrictube2–3cmintothenostril.
•Securewithtape
•0.5Lperminute •Monitortheoxygensaturation3hourly
•Ensuresconstantconcentration
•Babycanbefedorally(cuporbreast)
•Idealforbabieswithmildrespiratorydistress
•Useslittleoxygen
•Notforbabieswithanasogastrictubeinsituasthismayobstructbothnostrils
•Iftubefeedingisneededuseanorogastrictube
2.1.2 OXYGEN THERAPY: mEthODs FOR PROviDiNg OxygEN tO babiEs whO aRE bREathiNg sPONtaNEOusly
Headbox (hbo2)
Nasal prongs
Nasal Cannula
19TREAT, OBSERVE AND CARE
2.1.2 OXYGEN THERAPY: mEthODs FOR PROviDiNg OxygEN tO babiEs whO aRE bREathiNg sPONtaNEOusly 2.1.2
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(continuedfromthepreviouspage)2.1.2 OXYGEN THERAPY: mEthODs FOR PROviDiNg OxygEN tO babiEs whO aRE bREathiNg sPONtaNEOusly
Indication Method Flow and concentration
Observations Advantages Disadvantages
•Forpretermbabieswithsevererespiratorydistress,e.g.hyalinemembranedisease,wetlungsyndrome,pneumonia,atelectasis,pulmonaryoedema
•Apnoeaofprematurity
•Applyspecialnasalprongstothebaby
•ConnecttheCPAPmachine
•Startwithapressureof5cmofH2Owater
•Whenweaningthebaby,firstturndowntheoxygenpercentageandthenthecmpressureofwater
•Oxygenandmedicalairmixedthroughablender
•Observeandrecordtheoxygensaturationcontinuously
• alwaYs MoNitor the oXYgeN satUratioN
•Deliversoxygenandprovidesapositiveairwaypressuretopreventcollapseofairways
•Decreasestheworkofbreathing
•Optimisessurfactantproduction.
•Reducestheincidenceofapnoea.
•Babiesmustbebreathingspontaneously
•Cannotbefedinitially•Latersmallfeedsviaanorogastrictube
•Dangerisgastricdistensionandvomiting
•Riskofairleaksyndromes
•Reductionincardiacoutput
•Traumatothenostrilsandskin
•Stomachdistension•Inadvertentdisconnection
startiNg aNd stoppiNg Cpap•Startonpressuresof5cmH2O•UtilisechestX-raytoassesslungexpansion(7-8posteriorribsvisibleabovethe diaphragm)
•Weaning:oFirstreducetheoxygenifsaturationsaremaintainedoThenreducethepressuretoseeifthebabywillcopeonnasalprongoxygen
•ChangetonasalprongoxygenoIftheoxygenrequirementis<40%andtheoxygensaturationsaremaintainedoAndwhenthepressureisat2cmwateroAndtherearenoapnoeicepisodes
CPAP IS NOT ADVISABLE WITH THE followiNg•Upperairwayabnormalities,e.g.choanalatresia,tracheo-oesophagealfistula,cleftpalate
•Severecardio-respiratoryinstability
•Unstablerespiratorydrivewithsevereapnoeaand/or
bradycardia•Iftheoxygensaturationisworsening,considerintubationandmechanicalventilation
•ThebabyrequiresreferralandtransferforventilationifCPAPisadequateandapplied at5cmpressurefor1hourand:oIftheoxygenrequirementisstill>40%,therespiratoryrateisstill>60,orthere aresignsofsevererespiratorydistress
oThereisrepeatedapnoeaonCPAP
Continuous Positive Airway Pressure (CPAP)
20
2.1.3 MAINTAIN NORMAL GLUCOSE
CheCk the blood glUCose of the followiNg babies:•Smallandsickbabiesevery3hoursforthefirst24hoursanduntilnormalfor24hours•Babiesofdiabeticmothers:hourlyforthefirst6hours•Babieswhoarehypothermic•Babieswhohavenotbeenfed
PREVENT HYPOGLYCAEMIA:•Putthebabytothebreastimmediatelyafterbirth•Ifthebabyisnotsucking,passanasogastrictubeandgiveafeed,orcupfeed
•Ifmilkfeedsarecontraindicatedstartintravenousfluids(Neonatalyte)immediately
•Keepthebabywarm
hYpoglYCaeMia If the blood glucose is 1.4 - 2.5mmol / l •Breastfeedorfeedexpressedbreastmilk.Onlyifbreastfeedingisnotpossible(motherverysickorHIV-positiveandhaschosennottobreastfeed)thengive10ml/kgappropriatereplacementmilkfeed
•Repeatbloodglucosein15minutes•Ifthebloodsugarremainslow,treatforseverehypoglycaemia
•Ifthebloodglucoseisnormal,givenormalmilkfeedsandcheckthebloodglucose3hourly
SEVERE HYPOGLYCAEMIA If the blood glucose is < 1.4mmol / l •Giveabolusof10%glucoseinfusion(Neonatalyte)at5ml/kg.Thencontinuewiththe10%glucoseinfusionattherecommendedrateforageandweight(p.22, 23)
•Repeatbloodglucosein15minutes•IMglucagon:dose0.2mg/kg/dosetoincreaseglucoserapidlyor•Ifstilllow,give5mghydrocortisoneIVaNddiscusswithpaediatrician
CliNiCal sigNs of hYpoglYCaeMiaThebabymaybeasymptomaticorhavethefollowingprioritysigns:irregularjerkymovements,lethargy,apnoeaorhypothermia.
treat hYpoglYCaeMia
Ifababyhasapersistentorrecurrenthypoglycaemiacheckthatthebabyisinathermo-neutralenvironment,isgettingadequatefeeds,andthathedoesnothavesepsis.
babY of a diabetiC Mother aNd a large for gestatioNal age babYAdmitbabiesofmotherswithdiabetesORbabiesweighing>4kgtothenurseryforhourlybloodglucoseobservationforthefirst6hoursafterbirth•Feedthebabyimmediately,orstartIVNeonatalyteifthebabycannotbefed•Checkthebloodglucosehourly•Ifhypoglycaemiaoccurs,manageaccordingtothehypoglycaemiaprotocol(p.21,above)•Dischargethebabybacktothemotherafter6hoursiftheglucosehasbeennormalandthebabyiswell
21TREAT, OBSERVE AND CARE
2.1.3 MAINTAIN NORMAL GLUCOSE 2.1.3
FOR BABIES < 1.5 KG OR SICK BABIES•CommenceonIVfluidsandkeepnilbymouthforthefirstday•CalculatetheIVfluidandfeedforeachbabyusingTable2andTable3asguides(p.22,23)
•Graduallyintroduceexpressedbreastmilk(EBM)fromday2bynasogastrictube-Feedbabiesevery3hours-Increasethefeedsdailyifthereisnovomiting,apnoeaorabdominaldistension
•Progresstoacup/spoonassoonasthebabydoesnotneedheadboxoxygen
•BreastfeedthebabyinsteadofgivingEBMassoonasthebabycansuckle•Verylowbirthweightbabies(1-1.5kg)mayrequire75ml/kgonday1•Extremelylowbirthweightbabies(<1kg)mayrequire100ml/kgonday1and2andmayneedtostartoralfeedswith½ml2hourly(p.30)
FOR BABIES > 1.5 KG AND THOSE THAT CAN TAKE ORAL FEEDS BUT CANNOT SUCK•Feed3hourlyaccordingtosuggestedvolumesinTable4 feediNg Method Nasogastric / orogastric feeds•Babieswhocannotsuckle-usuallygestationalage<34weeks•Babieswhohaverespiratorydistressandareinheadboxoxygen•BabiesonnasalprongsorcannulaoxygenorCPAPwhoneedgastricfeeds,shouldhaveanorogastrictube
Cup feed (p. 55)•Babieswhocannotbreastfeed•Cannotyetsucklebutcanswallow
Babies to be kept nil by mouth: •Birthweight<1.5kgonday1•Sickbaby,untilstable•Ababywithadistendedabdomenandvomiting•Ababywithneonatalencephalopathyuntilbowelsoundsheard
•Tocalculatefeeds,usebirthweightuntilthebabyhasre-gainedbirthweightandthentheweightonthatday
•Tocalculatethedriprate:wtxvolume/kg=ml/hour 24•Usea60drop/mlintravenousinfusionadministrationset(ml/hour=drops/min)
•Alwaysuseaburetrolandaninfusioncontrollerordial-a-flowwhenadministeringfluidstoneonates
•FeedsandfluidsmustbecalculatedandprescribedEVERY daY
Suggested IV fluid•Neonatalyte/neolyte(contains10%dextrose)
Calculate 3 hourly feeding: wtxvolume/kg=ml/feed 8Suggested feeds:•EBM•IfnoEBMormotherisHIV-positiveandhasdecidednottobreastfeed
If<1.5kg–appropriatereplacementforpretermsIf>1.5kg–appropriatereplacementfeeding(p.56)
2.1.4 FEEDS AND FLUIDS FOR SICK AND SMALL BABIES
TABLE 2: RECOMMENDED FLUIDS FOR SMALL OR SICK BABIESTotalFluids SuggestedIVI Suggestedoral
Day 1 60ml/kg 60ml/kg NilDay 2 75ml/kg 50ml/kg 25ml/kgDay 3 100ml/kg 50ml/kg 50ml/kgDay 4 125ml/kg 50ml/kg 75ml/kgDay 5 + 150ml/kg Nil 150ml/kgDay 7 + 150–180ml/kg Nil 150–180ml/kg
22
TABLE 3: FLUIDS AND FEEDS FOR SICK AND VERY SMALL BABIES ON IV AND NASOGASTRIC OR CUP FEEDSdaY 1 1 2 3 4 5+ 7+
Total fluid volume 60 75 100 125 150 (fullfeeds)
180(maxfeed)
ivi Oral ivi Oral ivi Oral ivi Oral ivi Oral ivi Oral
Total ml / kg IV
Total oral
60
-
-
0
50
-
-
25
50
-
-
50
25
-
-
100
0
-
-
150
0
-
-
180
< 1.2 kg 3 0 3 3 3 6 2 12 - 20 - 25
1.2 - < 1.5 kg 3 0 3 4 3 9 2 15 - 25 - 30
1.5 - < 1.75 kg 4 0 4 5 3 12 2 20 - 30 - 35
1.75 - < 2.5 kg 5 0 4 6 3 15 2 25 - 35 - 45
2.5 - < 3.5 kg 7 0 6 10 6 20 2 40 - 55 - 70
3.5 - < 4.5 kg 10 0 8 15 6 25 4 50 - 75 - 90
IV: ml / hour or drops / minute (60 drops / ml giving set) Oral: ml / feed 3 hourly UsethisasaguidetodeterminehowmuchIVIfluidandfeedstogivesickandsmallbabies.Ifababyisnottoleratingtheamountoforalfeeds,
thendecreasetheoralfeedsandincreasetheIVfluids–ensurethatthetotal fluid volumeiscorrectforthebaby’sageandweight
23TREAT, OBSERVE AND CARE
2.1.4 FEEDS AND FLUIDS FOR SICK AND SMALL BABIES 2.1.4
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TABLE 4: AMOUNT (ml) OF 3 HOURLY CUP OR NASOGASTRIC FEEDS FOR BABIES ON oral feeds oNlY bUt who are Not able to breastfeed
daY of life 1 2 3 4 5 If not gaining
Fluidvolume/day 60ml/kg 75ml/kg 100ml/kg 125ml/kg 150ml/kg 180ml/kg1.5-<1.75kg 12 15 20 25 30 35
1.75-<2.5kg 15 20 25 30 35 45
2.5-<3.5kg 25 30 35 50 55 70
3.5–<4.5kg 30 35 50 60 75 90
2.1.4 FEEDS AND FLUIDS FOR SICK AND SMALL BABIES24
Hand washing
•Towashhands:wethandsthoroughly,applychlorhexidinecon-tainingsoaporsolutionandwashfor15seconds,rinseunderrun-ningwater,airdryoruseacleandisposabletowel
•Alwayswashyourhandsonenteringthenurseryandbeforeandaftertouchingababy,orafterhandlingsoiledlinenorinstru-ments
•Instructmothersandvisitorstowashtheirhandsbeforeandaftertouchingtheirbabieswhileintheneonatalunit
•Analcoholbasedhandlotionmaybeusedinsteadofhandwashingbeforeandafterhandlingbabies
•Eachincubatororcotmusthaveabottleofalcoholcontaininghandlotion
•Eachcubicleneedsabasinwithrunningwaterandchlorhexidinecontainingsolution
Nursery procedures
•Encourageexclusivebreastfeeding•Eachbabyshouldremaininhis/herowncot/incubator(onlyonebabyperincubator)
•Ensurethateachcriborincubatorhasit’sownthermometer,stethoscope,alcoholhandlotionandswabs
•Avoidcommunalactivitieslikebathing•Performallproceduresinthecot/incubator•Wearsterileglovesforcontactwiththemucousmembranesorbodyfluids
•Alwaysuseaseparatepairofglovesforeachbaby
Isolation and admission
•Isolationofinfectedbabiesisusuallynotneededifapolicyoffrequenthandwashingispracticed.Howeverbabieswithgastroenteritisshouldbenursedinaprivateroom
•Outbornbabiesshouldbeadmittedinthenursery;theydonotspreadinfectiontothebabiesborninthehospital
• Do not admit neonates to a paediatric ward
Preventive care
•Administerprophylacticeyecareafterbirth(chloramphenicoleyeointment)
•Applyalcohol(surgicalspirits)totheumbilicalstumpevery6hours
•Checkthemother’sRPRandifpositivetreataccordingtoprotocol(p.45, 46)
•Checkthemother’sHIVstatusandifpositivetreataccordingtoprotocol(p.48)
•Checkthedurationofruptureofmembranes(>18hours)andtreataccordingtoprotocol(p.36)
•Managepreterminfantsbornastheresultofunexplainedpretermlabouraccordingtotheprotocol(p.31)
2.1.5 INFECTION PREVENTION AND CONTROL Infectioniscommoninnewbornsbecauseoftheirimmatureimmunesystem.Failuretofollowinfectionpreventionroutineswillresultinhospitalacquiredinfectionsanddeaths.
25TREAT, OBSERVE AND CARE
2.1.5 INFECTION PREVENTION AND CONTROL 2.1.5
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Cleaning equipment
•WipestethoscopeswithalcoholswabsorD-germ(0.5% chlorhexidineand70%alcohol)betweenuse
•Washheadboxeswithsoapandwaterbetweenuse•Cleanincubatorswith0.5%chlorhexidinebetweenuseandallowtodrybeforeusing
•Removeanddestroysharpscontainerwhen2/3full•Cleanspillsofbloodwith0.5%chlorhexidine•Cleancontainersusedtoexpressbreastmilkwithsoapandwater,thensoakinMiltonorautoclave.
Staff
•Avoidhavingtoomanypeoplehandlingthebaby•Avoidovercrowdingofthenurseryandunderstaffing•Staffshouldbepatientallocated,nottaskallocated•Excludestafforvisitorswitharespiratoryinfection,feverblistersoropenskinlesionsfromtheunituntiltheyhaverecovered
•Ensurethatstaffworkinginthenurseryareuptodatewithallrou-tineimmunisationsandencouragethemtohaveannualinfluenzaimmunisation
•Clothing:-Protectiveclothingisnotneeded.-Shortsleevesonly
•Cleanoxygentubing,andrespiratorcircuitswithsoapandwater,soakinHibiscrub(4%Chlorhexidinegluconate)for30minutes,rinsewithcleanwaterandthensoakin5mlCydex(10%isopropylalcohol)mixedwithabucketofwaterforan-other30minutes,thenrinsewithtapwater.Usinggloves,re-movethetubing,drainwater,hangonaIVstandandthenblowdrywithoxygen
2.1.5 INFECTION PREVENTION AND CONTROL 26
WHO SHOULD BE REFERRED?•Birthweight1000g-1500gwhoareunwell•Respiratorydistresswithoxygensaturation>40%onheadboxoxygen•Uncontrolledseizures•Recurrentapnoeain>1000gbabies•Hypoglycaemianotrespondingtotreatmentin1hour•Jaundice: >200μmol/londay1 400μmol/latanytime >300μmol/latanytime,ifweight<2.5kg•Persistentvomiting•Bilestainedvomiting•SurgicalproblemsNB** Dysmorphic babies who are otherwise well need to be seen by a paediatrician but this is not a reason for urgent transfer.
dUtY of referriNg CliNiCiaN•Informthereferringhospitalof:
-Progressofthebaby-Conditionofthebabyontransfer-Whentheambulanceleavesyourhospital
•Tearoutthefirstpageofthenewbornrecordandwritethereferralletterontheback
•Nursingobservationsmustbedonewhilewaitingfor,andimmediatelybeforedischarge
•Adequatemedicationmustbeavailablefortransit•Themother’sdetailsandcontactnumbersmustbeinthebaby’srecordsifshecannotaccompanythebaby
iMportaNt thiNgs to CheCk before traNsfer•Namebandofthebaby•Vitalsigns•Bloodglucose•Secureairway•SecureandreliableIVline•Nasogastrictubeinsitu,ifapplicable•Ensurethatthetransferringambulancehasafunctioningwarmtransportincubator,resuscitationequipment,oxygenintheambulance,andsmalloxygencylinderfortransport,andapulseoximeter.
traNsfer of blUe babY: CoNgeNital heart disease•Resuscitateandstabilise•GiveProstaglandinE2,¼tablethalfhourly.Crushthetablet,mixwith2-5mlofwaterandgiveitthroughanasogastrictube.
•Intubateifatallpossible•Treatshockbeforetransfer•Keepthebabynilpermouth
2.1.6 TRANSFER AND REFERRAL
2.1.6 TRANSFER AND REFERRAL Thekeytosuccessfultransportthatwillminimiseriskforthebabyisaccurateanddetailedcommunicationamongtherespectivestaffofthereferringhospital,thetransportteamandtheacceptinghospital.Thelistforwhichababyshouldbereferredisexhaustive,andtheruleis:IF IN DOUBT, DISCUSS WITH THE DOCTOR AT THE REFERRAL HOSPITAL
27TREAT, OBSERVE AND CARE
2.1.6 TRANSFER AND REFERRAL 2.1.6
respiratorY distressThemainmanagementofrespiratorydistressis:
•Oxygentherapy(p.17 - 20)•Maintainingathermo-neutralenvironment(p.12 - 16)
•Fluids(p.22 - 24) •Minimalhandling
Investigations:•MobileCXR(IfHyalineMembraneDiseaseissuspecteditisbesttowaituntilthebabyis4-6hoursoldbeforedoingtheX-Ray)
•CRP48hoursafterbirth•Bloodglucose
apNoeaStimulatethebabybyrubbinghis/herbackfor10seconds:ifthebabydoesnotbegintobreatheimmediately,resuscitatethebabyusingabagandmask.Preterm baby:•Giveanoraltheophylline5mg/kgloadingdosefol-lowedby2mg/kg12hourly
•Observethebabyforapnoea•OncestabilisedKMCcanbecontinuedorstarted•Ifthereareintermittentapnoeicepisodes,treatforsepsis.•Ifthereispersistentapnoea,assessforCPAPanddiscussfortransfer
Term baby:•Apnoeaisunusualintermbabies.Observe,investigateandreferifnecessary
•Monitorfor24hoursusinganapnoeamonitor,orskin-to-skin•Investigateandtreatforsepsisifthereisa2ndepisodeofapnoea•Ifthebabyisfreefromapnoeafor24hoursandthebabyisfeed-ingwellandhasnootherreasonforhospitalisation,thenpreparetodischargethebaby
2.2.1 APNOEA AND RESPIRATORY DISTRESS
Pneumonia, meconiumaspiration
Clear peripheries
Chest X-ray
> 7 ribsposterior
Yes No
Wet lung
Granuality toperipheries
Clear peripheries
Hyaline Membrane
disease
Atelectasist
Large lung volumes
Patchy or lobar infil-trates
Small lung volumes
28
TABLE 5: SPECIFIC TREATMENT FOR RESPIRATORY DISTRESSFeatures Possible diagnosis Specific treatment
•Preterm;gestationalage<37weeks•CXR:smalllungvolumes,granularopacitiesinperiphery
hYaliNe MeMbraNe disease •StartCPAPifpossible-otherwiseuseoxygen(p.17 - 20)
•Surfactantinfirst12hoursunderpaediatricsupervision
•PenicillinandGentamicinfor48hours,thenreviewCRP
•Bornatorbeforeterm,oftenbyC/S•Mildrespiratorydistress,resolvesin72hrs•Overinflatedchestclinically,CXR:hyperinflatedlungs
wet lUNg •Oxygenandsupportivetreatment•Penicillinandgentamicinfor48hours,thenreviewCRP
•Anygestationalage•Historyofchorioamnionits•Developsrespiratorydistressafteradmission•CXR:areasofcollapseandconsolidatio
pNeUMoNia •Oxygenandsupportivetreatment•Penicillinandgentamicinfor7–10days•Iftheinfectionishospitalacquiredorisnotresponding,consultpaediatrician/referralhospital
•Termorpostterm•Historyofmeconiumstainedliquor•CXR:hyperinflated,areasofconsolidation
MeCoNiUM aspiratioN •Oxygenandsupportivetreatment•Penicillinandgentamicinfor48hours,thenreviewCRP
•Ifthebabyhasamurmur,orremainscyanosedwithnoormildrespiratorydistress,suspectacardiacproblem
CardiaC •Refertodoctorforfurtherevaluation
CXR = Chest X-ray CRP = C-reactive protein FBC = Full blood count LP = Lumbar puncture
29TREAT, OBSERVE AND CARE
2.2.1 APNOEA AND RESPIRATORY DISTRESS 2.2.1
< 1kg (ELBW) 1 – 1.5 kg (VLBW) 1.5 – 2 kg (LBW) 2 – 2.5 kg (LBW)Admission criteria •Admitallbabiestohigh
care•Admitallbabiestohighcare
•Admitbabiesforassessmentintheneonatalunit
•TransfertoKMConceintermittentKMCissuccessfulandotherproblemsareresolving
•Admitbabiesiftheyarenotwell
Warmth(See p. 12 - 16)
•Useaservo-controlledincubatorifpossible
•Standardincubator•IntermittentKMCwhenstable
•Incubatoruntilstable
•Oncestable,docontinuousKMC
•ContinuousKMC
Investigations •Ballardscore •Ballardscore •Ballardscore •BallardscoreFluids and feeds (See p. 22 - 24)
•Day1:EstablishIVlineandgiveonlyIVfluids
•Day2:Start½mlEBMfeeds2hourlyvianasogastrictube
•Day3:Give2hourlyEBMvianasogastrictube
•EstablishanIVlineandgiveonlyIVfluidsforthefirst24hours
•Thenstart3hourlynasogastrictubefeeding
•Ifthebabyisabletosuckle,breastfeed3hourly
•Ifthebabyisunabletosuckle,feedEBMviacup3hourly
•Ifthebabyisabletosuckle,breastfeed3hourly
•Ifthebabyisunabletosuckle,feedEBMviacup3hourly
Observations •Hourlyrespiratoryandheartrates(RR,HR)
•Intakeandoutput•3hourlyglucoseforfirst72hours
•Hourlyoxygensaturation
•3hourlyRR,HR,Temp,colour,activity
•Intakeandoutput•3hourlyglucoseforthefirst24hours
•1-3hourlyoxygensaturationforbabiesonoxygen
•6hourlyRR,HR,Temperature,colourandactivity
•Intakeandoutput•3hourlybloodglucoseforthefirst24hours
•1-3hourlyoxygensaturationforbabiesonoxygen
•12hourlyRR,HR,Temperature,colourandactivity
•Intakeandoutput
2.2.2 PRETERM AND LOW BIRTH WEIGHTAdmitbabieswithabirthweightoflessthan2kgorwithagestationalagelessthan37weeksforobservationandmanagement.
30
All weightsFluid / feed volume and method
•Followfluidmanagementguidelinesonp.22 - 24fordailyfluidvolumeincreases•Progresstocupfeeding•Progresstobreastfeedingassoonasthebabycansuckle
Apnoea prevention •<1.5kgor<35weeksgestation:-Oraltheophylline:Loadwith5mg/kgthen2mg/kg/dose12hourly-Apnoeamonitorforbabieswithaweightof<1.5kg
•Stopwhenthebabyweighs1.8kgorwhenbabyisapnoea-freefor7days
Oxygen therapy •Babieswitharespiratoryrate>80,severechestindrawing,ORgrunting,ORoxygensaturationlessthan88%.
• Note: not all low birth weight babies will need oxygenAntibiotics •Giveantibioticstothefollowinggroupsofbabies:
-Babiesfromapotentiallyinfectedenvironment,e.g.borntomotherswithprolongedruptureofmembranes
-Babieswithobvioussignsofinfection-Babies<37weeksgestationwherethereisnoobviousreasonforthepretermlabour-Babieswithrespiratorydistress
•GiveIVpenicillin100000u/kg/dosetwicedailyANDgentamicin5mg/kg/daygivendailyfor5days.Formeningitisseep.35
•DoaCRPafter48hoursandstoptheantibioticsiftheCRPisnormal,andthebabyisclinicallynormal
HIV exposed infants Seeflowdiagramonp.48Vitamins 0.6mlofmultivitamindrops(preparationmustinclude400iuVitaminD)dailyoncethebabyison
fullfeedsiron 0.6mlferrouslactate(Ferrodrops)dailyoncethebabyisonfullfeeds
31TREAT, OBSERVE AND CARE
2.2.2 PRETERM AND LOW BIRTH WEIGHT 2.2.2
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All weightsMeasurement •Measurethefollowingandchartonthebabyrecord:
-Dailyweight,assesstheweightgain2timesperweekaccordingtothechartonp.52-Weeklyheadcircumference-Weeklyhaemoglobin
Discharge •Dischargewhenthebaby’sweightisbetween1.8–2kgANDscores20ontheKMCscoresheet(p.72)•Thebabytomustcontinuewithmultivitaminandironfor6months.WritethisontheRoadtoHealthChart(RTHC).
Follow up •Ensurethatyourhospitalhasahighriskfollowupclinictofollowupbabiesuntiltheyare9monthsold.
•Babieswithabirthweight<1.5kgandbiggerbabieswithacomplicatedcoursemustbefollowedupatahighriskclinic
•AfterdischargefromKMCfollowupbabyin3-5days•Ifthebabyisgainingwell,followupevery2weeksuntilthebabyis2.5kg.Thereafterthebabycanbefollowedupattheclinic
•Babieswithabirthweight<1.5kgorwhohavehadacomplicatedcourseneedaneuro-developmentalevaluationat4and9months
•BabieswhoareHIVexposedmusthavetheirHIVfollowupsiteidentifiedanddocumented,andaspecificdategivenfortheir6weekHIVPCRtest
•AllrelevanthealthinformationMUstbedocumentedintheRTHC
2.2.2 PRETERM AND LOW BIRTH WEIGHT(continuedfromthepreviouspage) 32
NeUrologiCal MatUritYAll 6 neurological features areassessed with the baby lyingsupine (the baby’s back on thebed).Thebabyshouldbeawakebutnotcrying.
POSTURE: Handle the baby andobserve the position of the armsand legs. More mature babies(with a higher gestational age)havebetterflexion(tone)of theirlimbs.
SQUARE WINDOW: Gently presson the back of the baby’s handto push towards the forearm.Observe the degree of flexion.Morematurebabieshavegreaterwristflexion.
ARM RECOIL: Fully bend the armatelbowsothatthebaby’shandreaches the shoulder, and keepit flexed for5 seconds. Then fullyextend thearmbypullingon thefingers.Releasethehandassoonas the arm is fully extended andobserve the degree of flexion atthe elbow (recoil). Arm recoil isbetter in more mature babies.
POPLITEALANGLE:Withyouronehandholdthebaby’skneeagainsttheabdomen.Withtheindexfingeroftheotherhandgentlypushbehind the baby’s ankle to bring the foottowardstheface.Observetheangleformedbehindthekneebytheupperandlowerlegs(thepoplitealangle).
SCARF SIGN: Take the baby’s hand andgently pull the arm across the front of thechestandaroundthenecklikeascarf.Withyourotherhandgentlypressonthebaby’selbow to help the arm around the neck.Inmorematurebabies thearmcannotbeeasilypulledacrossthechest.
HEELTOEAR:Holdthebaby’stoesandgentlypullthefoottowardstheear.Allowthekneeto slidedownat the sideof theabdomen.Unlike the illustration, thebaby’spelvismayliftoffthebed.Observehowclosetheheelcanbepulledtowardstheear.
33TREAT, OBSERVE AND CARE
2.2.2 PRETERM AND LOW BIRTH WEIGHT 2.2.2
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2.2.2 PRETERM AND LOW BIRTH WEIGHT(continuedfromthepreviouspage)
phYsiCal MatUritYSix external features are examined. Thebabyhastobeturnedovertoexaminetheamountoflanugo.Ifthebabyistoosicktobeturnedover,thentheamountoflanugoisnotscored.
SKIN:Examinetheskinoverthefrontofthechestandabdomen,andalso lookat thelimbs. More mature babies have thickerskin.
LANUGO:Thisisthefine,fluffyhairthatisseenoverthebackofsmallbabies.Exceptforveryimmaturebabiesthathavenolanugo,theamountoflanugodecreaseswithmaturity.
PLANTAR CREASES: Use you thumbs tostretchtheskinonthebottomofthebaby’sfoot.Veryfinewrinkles,thatdisappearwithstretching,arenotimportant.Morematurebabieshavemorecreases.
BREAST:Boththeappearanceofthebreastandthesizeofthebreastbudareconsidered.Palpateforthebreastbudbygentlyfeelingunderthenipplewithyourindexfingerandthumb.Morematurebabieshaveabiggerareolaandbreastbud.
EAR: Both the shape and thickness of theexternalearareconsidered.Withincreasingmaturity the edge of the ear curls in. Inaddition, the cartilage in the ear thickenswithmaturitysothattheearspringsbackintothenormalpositionafteritisfoldedagainstthebaby’shead.
GENITALIA:Male and female genitalia arescoreddifferently. Withmaturity the testesdescend in the male and the scrotumbecomes wrinkled. In females the labiamajoraincreaseinsizewithmaturity.
sCoriNgAddupthescoresfromthephysicalandneurologicalfeaturesandusethetablebelowtoestimatethegestationalage.
Score -10 -5 0 5 10 15 20 25 30 35 40 45 50
Weeks 20 22 24 26 28 30 32 34 36 38 40 42 44
2.2.2 PRETERM AND LOW BIRTH WEIGHT34
Signs ClassifiCatioN Investigations First line treatment•Lethargy,poorfeeding,abdominaldistension,pallor,jaundice,purpura,recurrentapnoea,hypothermia,oedema
sEPticaEmia •Bloodculture•Lumbarpuncture•CXR•FBC•CRP
•StartampicillinORcefotaximePlus•Gentamicinfor7–10days•Nurseinhighcare•Supportivecare
•Apnoea•Convulsions•Bulgingfontanelle•Lumbarpuncture–puscells
mENiNgitis •Lumbarpuncture•Bloodculture
•Cefotaximeandampicillin•Grampositiveorganismtreatfor14days
•Gramnegativeorganismtreatfor21days
•Termbabywithprenatalhypoxia,orpretermbaby
•Signsofsepticaemiaorshock•Abdominaldistension•Bilestainedvomiting•Bloodinthestool
NEcROtisiNgENtEROcOlitis
•AbdominalX-Ray-Distendedstaticloopsofbowel
-Airinbowelwall-Perforation
•Cefotaximeandampicillin•Grampositiveorganismtreatfor14days
•Gramnegativeorganismtreatfor21days
•Historyofunhygienictreatmentofthecord
•Inabilitytosuck•Increasedtone•Convulsions
tEtaNus •Referallcasestoalevel3hospitalurgently
•NOTIFYALLCASES
•Admittohighcare/ICU•TetanushumanimmunoglobulinIM500iu
•Benzylpenicillinfor10days•DiazepamIV0.25–1mg/kg4–8hourlytitratedaccordingtotheresponse
•PhenobarbitoneIVorIM,5–10mg/kg/24hours(p.71)
2.2.3 SERIOUS ACUTE INFECTION
•Ifthebabyhassuspectedsepsis,dothefollowinginvestigationsCXR,FBC,CRP,LP,BloodCulture.•Decideonthesiteofinfectionandcommencetreatment.Usethetablebelowtoassistwithdiagnosis,investigationandfirstlinetreatment•Ifthebabyhassignsofsepsisbutthesiteofinfectionisnotyetclear,treatforsepticaemia•Thebabymayalsohavecongenitalsyphilis,refertop.45, 46fortreatment•Ifconvulsionsarepresent,givealoadingdoseofphenobarbitone20-40mg/kgIMI.Considermaintenancephenobarbitone5mg/kg/dayin2divideddosesorally.
35TREAT, OBSERVE AND CARE
2.2.3 SERIOUS ACUTE INFECTION 2.2.3
Signs ClassifiCatioN Investigations First line treatment•Mildconjunctivitis:-Mildeyedischarge•Severeconjunctivitis:-Exudative(pussy)discharge-Redconjunctivae-Oedemaoftheeyelid
CONJUNCTIVITIS •Ifnoresponsetotopicaltreatment,doGramstainandcultureoftheexudates.
•Causedby:-N.gonorrhoeae-C.trachomatis-S.aureus(commoncause)-E.coli
•Canbepreventedbytheinstillationofchloramphenicoleyeointmentimmediatelyafterbirth
If mild: •Cleanwithwater,andapplychloramphenicolointment3–4timesperday
•Ifnoresponse,thentreatassevere
If severe: •CeftriaxoneIMonedoseonlyPlus•Erythromycinfor10–14days•Irrigatetheeyewithcleanwater1–2hourlyuntilthedischargeisbetter
•Chloramphenicoleyeointment1–2hourly
•Blisterscontainingpusintheskin
•Blistersruptureleavingreddishdryskin
UsuallycausedbyS.aureus
staphYloCoCCalskiN iNfeCtioN
•Ifsevere,do:-Bloodculture-Gramstainandcultureofthepus
•Washskinwithantisepticsoap2timesperday
•Fewsmallblistersgiveflucloxacillinorally•ExtensiveandthebabyisillgivecloxacillinIVfor7–10days
•Pussydischargefromcord•Rednessandswellingofskinaroundumbilicus
oMphalitis •IfnoresponsetoIVtreatment: -Bloodculture -Gramstainandcultureofpusswab
•Cleanthebaseofthecordwithspirits3–4timesperday
•BenzylpenicillinandGentamicinfor5–7days
Suspectwhen•PROM>18hours•Offensivesmellatbirth•UnexplainedLBWbaby
Mostofthecolonisedbabieswillbeclinicallywellandonlyneedobservationfor24hours.Somewilldevelopsignsofinfectionsoonafterbirth.
MaterNal ChorioaMNioNitis
•CRPat48hours •Ifclinicalsignsofinfection,or•Iflowbirthweight: -treatwithBenzylpenicillinandGentamicinfor5days,unlesstheCRPisnormal
•Ifnotlowbirthweightandthebabyiswell,breastfeedandobservefor48hours
•Explaintothemotherthesignsofsepsisbeforedischarge
2.2.4 LOCAL INFECTION36
Classify Course ManagementMild•Jittery,hyper-alert•Increasedmuscletone•Poorfeeding•Normalorfastbreathing
Featuresusuallylastfor24-48hoursandthenresolvespontaneously
•Ifthebabyisnotreceivingoxygen,allowbreastfeeding•Ifthebabyisreceivingoxygenorcannotbebreastfed,giveexpressedbreastmilkviaanasogastrictube
•Provideongoingcare(seebelow)
ModerateAsabove,plus:•Lethargy•Feedingdifficulty•Occasionalapnoea/convulsions
Itresolveswithinoneweek,butlong-termneurodevelopmentalproblemsarepossible
Observations3hourlyRR,HR,Temperature,colourandactivityDailyHIEscore(p.38)Temperature•Donotoverheatthebaby•Coolthebabywithafanoricepacktothehead,tokeeptheaxillarytemperaturearound34°C
Fluids•EstablishanIVlineandgiveonlyIVfluidsforthefirst12-24hours–donotfeedorally
•Restrictthefluidintaketo60ml/kgbodyweightforthefirst3days•Monitortheurineoutput:Ifthebabypassesurine<6timesperdayorproducesnourine,donotincreasethefluidvolumeonthenextday
•Whentheamountofurinebeginstoincrease,increasethevolumeoffluidintakegradually,regardlessofthebaby’sage–i.e.progressfrom60ml/kgto80ml/kgto100ml/kgto120ml/kg
•Ifthebabyisunabletosuck,givethefeedsbynasogastrictube•Whenthebabyisabletosuck,startbreastfeedingConvulsions•Givephenobarbitone20mg/kgslowlyIVorIM•Iftheconvulsionscontinue,giveanotherdoseofphenobarbitone10mg/kgIVslowlyover5minutes,orIM
•Iftheycontinue,loadwithphenytoin•Iftheconvulsionsarecontrolled,trytostopthephenobarbitone•Ifthebabyisabletosuck,allowbreastfeeding.Ifthebabycannotbreastfeed,feedviaagastrictube.
Encourage the mother to hold and cuddle her baby
Severe•Floppy/unconscious•Unabletofeed•Convulsionscommon•Severeapnoeacommon
Thebabymayormaynotimproveoverseveralweeks.
Ifthesebabiessurvive,permanentbraindamageiscommon(cerebralpalsy,mentalhandicap)
2.2.5 NEONATAL ENCEPHALOPATHY Ifatermbabyislessthan3daysold,andcannotsuck,andhasahistoryofpro-longedlabouroranApgarscore<7,treatforneonatalencephalopathy(NE)
Ongoing care for babies with asphyxia•Ifthebaby’sconditiondoesnotimproveafter3days:Reassessforsignsofseriousinfectionorseveredisease(p.7, 35)
•Ifthebaby’sconditiondoesnotimproveafter1week:Ifnosepsis,andnootherhospitalmanagementisneeded,discharge.
Thebabycanbedischargedonphenobarbitoneifnecessary.Themotherwillneedadviceonfeeding.
•Discussthebaby’sprognosiswiththemotherand/orfamily
•Followupin1week.Thebabymustcomesoonerifhe/sheisnotfeedingwell,orhasconvulsions,orissick.
37TREAT, OBSERVE AND CARE
2.2.5 NEONATAL ENCEPHALOPATHY 2.2.5
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(continuedfromthepreviouspage)2.2.5 NEONATAL ENCEPHALOPATHY
score Day 1 2 3 4 5 6 7 8 9 10Sign 0 1 2 3 Date
tone normal hyper hypo flaccidConsciouslevel
normal hyperalert,stare
lethargic comatose
Fits none infrequent<3/day
frequent>3/day
Posture normal fistingcycling strongdis-talflexion
decerebrate
Moro normal partial absentgrasp normal poor absentSuck normal poor absentRespiration normal hyperventilation brief
apnoeaiPPv
(apnoea)Fontanelle normal full-nottense tense
Total score per day
< 10 mild HIE 11 - 14 moderate HIE > 15 severe HIE
Thescoreusuallyincreasesforthefirstfewdaysafterbirthandthenreturnstonormalby1weekinmildlyaffectedbabies.Ahighscoreisgenerallyassociatedwithahighmortality,whileascorewhichremainshighbeyond1weekisassociatedwithahighriskofabnormalneurologicaldevelopment.
HYPOXIC ISCHAEMIC ENCEPHALOPATHY (HIE) SCORING SYSTEM•TheHIEscoringsystemisasimpleclinicaltoolwhichhelpstopredicttheinfant’slongtermoutcome.•Thischartiseasytouse.Itconsistsofaclinicalassessmentof9signs,whichneedtobeassesseddaily,andascorerecorded.•Infantswithamaximumscoreof10orless,willalmostcertainlybeneurologicallynormal.Thosewithamaximumscoreof15ormore,andwhoarenotsuckingbyday7,willprobablynotbeneurologicallynormal.(Ref3)
38
Risk for jaundice Investigations Treatment
Uncommon but potentially severe•Jaundiceonday1 •Doatotalserumbilirubin(TSB)level
•Checkthemother’sbloodgroups(ABOandRhesus)
•Coombs’test,ifpossible
•Startphototherapyimmediately•CheckTSB6hourly
•Mother’sbloodgroupOorRhnegative
•CheckTSBat6hoursofage•Coombs’test,ifTSBrising>8.5μmol/L/hr
•IfTSB>80μmol/l,startphototherapy•IfCoombs’testpositive,giveIVgammaglobulin500mgover1hour
•Prolongedjaundice(>14days) •Doconjugatedandunconjugatedbilirubinlevels
•Consultpaediatricianforfurthermanagement
Common•Jaundiceafterday1 •DoTSBifthebabylooksyellow •StartphototherapyifTSBaboveline
onthegraph(p.41)
•Pretermbaby •DailyTSBuntilday5,orTSBisgoingdown
•StartphototherapyifTSBabovelineonthegraph(p.41)
•StopphototherapyiftheTSBisbelowthephototherapylineonthegraph(p.41)byatleast50μmol/l
2.2.6 NEONATAL JAUNDICE Physiologicaljaundiceiscommon.Itusuallystartsonday3,andseldomlastsbeyondday10.Treatmentisnotusuallyneededasthebilirubinisseldomabove275μmol/L
39TREAT, OBSERVE AND CARE
2.2.6 NEONATAL JAUNDICE 2.2.6
continuesonnextpage
(continuedfromthepreviouspage)
phototherapY
StartphototherapywhilewaitingfortheTSBresult•IftheTSBisabovethelineonthegraph(p.41),startphototherapy.
•Checkthelevelforexchangetransfusiononthesecondgraph(p.41).Thisvariesdependingonthebaby’sweight,ageandillness
•RepeattheTSBevery12–24hours,dependingontheseverityofthejaundice.
•Ensurethatthebabyisgettinganadequatefluidintake.
•Encouragebreastfeeding,asitenhancestheexcretionofbilirubin.
•StopphototherapywhentheTSBis50μmol/Llowerthanthelineongraph(p.41),andrepeattheTSBthenextday.
Notes on phototherapy •Thedistancebetweenthemattressandthelightshouldbeabout40cm
•Thelightbulbsmustbechangedevery1000hours•Thebabyshouldbenaked•Coverthebaby’seyeswhenunderphototherapy(removethecoverforfeeding)
•Turnthebabyovereveryhour•Donotcovertheincubator,orcot,orphototherapylightswithblanketsorsheets
eXChaNge traNsfUsioN•ExchangetransfusionisneedediftheTSBisabovethelineontheexchangetransfusiongraph(p.41)
•Ababyshouldbereferredforexchangetransfusion:-IftheTSBleveliscloseto,orisabove,theexchangetransfusionlevel
-IftheTSBisrisingatmorethan17μmol/L/hour
•Exchangetransfusionsshouldbediscussedwith,andifatallpossible,doneatthelevel3hospitals.
•Inanewbornwithjaundice,alwaysdeterminethedegreeofjaundicebymeasuringtheTSBandplottingthisonagraph.
•TheresultoftheTSBneedstobeavailablewithin1hourfromthelaboratory.
•Bilicheckscanbeusedtoscreenforjaundice.Howeverifthelevelis>200μmol/l,takebloodforaTSBandstartphototherapy.
2.2.6 NEONATAL JAUNDICE40
Reference2
phototherapYguiDEliNEs FOR all wEights aND gEstatiONs
Inpresenceofsepsis,haemolysis,acidosis,orasphyxia,useonelinelower(gestationbelow)orlevels20μmollowerif<1000g
Ifgestationalageisaccurate,usegestationalage(weeks)ratherthanbodyweight
eXChaNge traNsfUsioNguiDEliNEs FOR all wEights aND gEstatiONs
Inpresenceofsepsis,haemolysis,acidosis,orasphyxia,useonelinelower(gestationbelow)orlevels20μmollowerif<1000g
Ifgestationalageisaccurate,usegestationalage(weeks)ratherthanbodyweight
TSB
(μm
ol /
l)
Time (age of baby in hours) Time (age of baby in hours)
Mic
ro m
ol /
L TS
B (t
otal
ser
um b
iliru
bin)
41TREAT, OBSERVE AND CARE
2.2.6 NEONATAL JAUNDICE 2.2.6
featUres ClassifiCatioN MaNageMeNt
•Ameningocoeleisanopenlesionoverthespine,onlycoveredbymembranes.
•Amyelomeningocoeleisanopenlesionoverthespinewithnervetissueinthesac.Thereislowerlimbparalysiswithbladderandbowelaffected.Manychildrenhaveanassociatedhydrocephalus.
NeUral tUbe defeCt/ spiNa
bifida
•Coverthelesionwithsterileopsiteorgauzesoakedinsalinetopreventdamage,leakageandinfection.
•Babieswhodonothaveanyneurologicaldeficitatbirthshouldbeurgentlyreferredtoatertiaryneurosurgicalserviceforimmediateclosure.
•Referallbabieselectivelytotheneurosurgicalserviceforrepairexceptwhenthereisanencephalyoranothermajorcongenitalabnormality
•Monitortheheadcircumferenceofbabiesdailywhileinhospitalandweeklythereafter.Referearlyandurgentlyifhydrocephalusdevelops.(80%ofchildrenwilldevelophydrocephaluseitherbeforeorafterclosureofthelesion)
•Counselthemother•Referandfollowupataspecialclinicthatwillmonitordevelopment,providetherapyandbladderandbowelcare
•Themothermustbeadvisedtoplanhernextpregnancyandtotakefolicacidbeforeshebecomespregnant.Giveheralettertotaketotheclinicwhensheisplanninghernextpregnancy
•Anomphalocoeleisadefectintheabdominalwallwheretheabdominalcontentsarecoveredwithperitoneum
•Agastroschisisisadefectintheabdominalwallwheretheviscerahavenocovering
•Imperforateanus
MAJOR gastroiNtestiNal
abNorMalitY
•Keepthebabynilpermouth•CommenceIVfluids(p.22)•Coverthedefectwithsterilegauzesoakedinsalineandensurethatthegauzeismoistatalltimes
•Ensurewarmth•Refertoatertiarypaediatricsurgicalcentre
2.2.7 CONGENITAL ABNORMALITIES Counseltheparents,confirmthediagnosisandprovideinformationtotheparentsaboutthecondition,treatmentoptionsandtheneedforreferral.
42
featUres ClassifiCatioN MaNageMeNt
•Aheadcircumferenceabovethe97thcentileiscalledmacrocephaly.Hydrocephalusisacauseofmacrocephaly.
hYdroCephalUs •Iftheheadis>97thcentilethenreferimmediatelytoatertiarycentreforneuro-imaging.Surgeryforhydrocephalusisanemergencyandshouldnotbedelayedforweeks.
•Aheadcircumference<3rdcentile MiCroCephalY •Comparetheweightandheadcircumferencecentiles•Assessforotherabnormalities•Determinethecause.Itmaybeduetoacongenitalinfections,astructuralabnormalityofthebrainorcouldbepartofageneticsyndrome.Refertoapaediatrician.
•Extremeplantarflexion(bendingofthefootdownwards)attheankleandmedial(inward)angulationoftheforefoot.ThisiscalledTalipesEquinovarus.Thismaybeduetoanin-uteroposition,developmentalabnormalityoftheboneorcartilage,neuromuscularproblem,oraspinalcordproblem.
ClUb foot •Assessforotherproblemsofthebone,spineorCNS•Ifthereisanyneuromuscularproblemorotherabnormalityreferthebabytothetertiarypaediatricservice
•Referthebabyimmediatelytotheorthopaedicservice,whocancommencegentlemanipulation,serialsplintingandplasterofParis
•Ifthesemeasuresdonotworksurgicalcorrectionmustbeplannedat10weeks.Delayinmanagementoftheclubfootwillleadtopermanentdisability
•Agapoccursinthelipand/orpalateduetofailureorincompleteclosureoftheskin,boneandormuscles.Thecleftmaybeunilateral,bilateral,midline,completeorincomplete.Itmaybeassociatedwithageneticcause,environmentalfactororteratogenbutinmostcasesismultifactorial.
Cleft lip aNd / or palate
•Conductathoroughexaminationtoexcludeotherproblemsorsyndromes.Ifthesearefoundorsuspectedrefertothetertiaryunitforassessment
•Counselthemother•Assistwithfeeding;breastfeedingispossible•Referearlytoacleftlipclinic/maxillofacialclinicatatertiarydentalhospital;theywillinitiallymakeaplatetoaidfeedingandthenrepairthelipataround3monthsandthepalateataround9months
43TREAT, OBSERVE AND CARE
2.2.7 CONGENITAL ABNORMALITIES 2.2.7
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(continuedfromthepreviouspage)
featUres ClassifiCatioN MaNageMeNt
•Abnormalpositionoflegs•Poorlimbmovement•Painonmovementofthelimb
LIMB INJURY •Counseltheparents•Handlegently•DoanX-rayoftheaffectedlimb•CheckforafractureorsyphilisonX-ray•Ifafractureispresent,immobilisethelimbandtreatwithadvisefromorthopaedicdoctors
•Ifanarmisnotmoving,andflaccid,andnofractureispresent,abrachialnervepalsyislikely.Allowgentlemovementsandrefertophysiotherapy.Ifnotimproving,refertoorthopaedicsurgery
•Onemajorabnormalityand2minorabnormalitiesOR
•3minorabnormalities
MAJOR CoNgeNital abNorMalitY
•Thesebabiesarelikelytohaveachromosomalproblem•Refertoapaediatrician,orexperiencedgeneticsister•Discusswithapaediatricianandconsidertakingbloodforchromosomeanalysis,orforQuantitativeFluorescent(QF)PCRforAneuploidy,iftherearefeaturesofTrisomy13,18or21
•Oneor2minorabnormalities MiNor abNorMalitY
•Ifachildhasanextradigitwithoutanybonyattachmentandanarrowpedicle,itcanbetiedoff.
•Consultneonataltextbooks,discusswithapaediatricianorgeneticnurse
2.2.7 CONGENITAL ABNORMALITIES44
At risk Observe Treatment
Mother’sRPR•+ve,titre>1:4•Untreated•Treated<1monthbeforedelivery•Unknown
•Hepato-splenomegaly•Petechiae•Pallor•Lowbirthweight•Jaundice•Respiratorydistress•Blistersonhandsandfeet•Osteitis•Large,paleplacenta•Sometimesnosymptomsorsigns
Ifsignsofsyphilis •NOTIFY•Admittoneonatalunit•Procainepenicillin50000units/kgIMdailyfor10–14days,OR
•PenicillinG150000units/kgIV12hourlyfor10–14days
If asymptomatic baby AND•IfthemotherisRPRpositive,and
•fullytreatedatleastonemonthbeforedelivery
•Notreatment
If asymptomatic baby AND •IfthemotherisRPRpositiveandNOTtreated,OR
•treated<1monthbeforedelivery
•BenzathinePenicillin50000units/kgIM-onedoseonly
If asymptomatic babyAND •UnknownmaternalRPR
•BenzathinePenicillin50000units/kgIM-onedoseonly
2.2.8 SYPHILIS Congenitalsyphilisisachronicintrauterineinfectioncausedbythespirochaete,Treponemapallidum.Ifthemotherwasuntreatedduringpregnancy,thebabyhasa50%chanceofbecominginfected.
45TREAT, OBSERVE AND CARE
2.2.8 SYPHILIS 2.2.8
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(continuedfromthepreviouspage)
Ensurethatthemother’sRPRisknownand,ifpositive,thatsheandpartnerarefullytreated.
Management of the baby of a mother who has positive or unknown syphilis serology
Motheruntreatedorstatusunknown
Motherfullytreated
Mothernotfullytreated
Babyclinicallynormal
Babyclinicallynormal
Babysymptomatic
Babyclinicallynormal
Babysymptomatic
Notreatment Benzathinepenicillin50000u/kgIMIsingle
dose
Procainepenicillin
50000u/kgdailyIMIfor10days
Benzathinepenicillin50000u/kgIMIsingle
dose
Procainepenicillin
50000u/kgdailyIMIfor10days
Mother not fully treated:Mothertreatedlessthan1monthbeforedelivery,and/orshehasnotcompletedafullcourseoftreatmentBaby symptomatic:Babyshowsclinicalevidenceofsyphilis
2.2.8 SYPHILIS46
At risk Treatment
•Ifthemotherhasbeenontuberculosistreatmentforlessthan2months
Or, if the mother has been on treatment for more than 2 months and if: •Sputumpositivemother,OR•Motherwithprimaryinfection,OR•HIV-positivemother
•Thebabyshouldreceivethreedrugtreatmentfor6months(Table7)
•GiveBCGoncompletionoftreatment
•Ifthemotherhashadmorethan2monthstreatment •BabyshouldgetINHfor6months(IPT).Seedrugdoses(Table6)
•GiveBCGoncompletionoftreatment
TABLE 6: Dosing for Isoniazid Preventive Therapy (IPT) in infants
TABLE 7: Dosing for full drug treatment in infants of TB untreated mothers
2.2.9 TUBERCULOSIS AllmothersshouldhavebeenofferedVCTduringantenatalcareandthisshouldberepeated6weekslaterifitwasnegative.
Body Weight (kg)
Daily Isoniazid (INH)(100mg tablet)
2–3.4 1/43.5–6.9 1/27–9.9 110–14.9 1+1/4
Body Weight
(kg)
RHZ dissolvable tablets (60 / 30 /
150mg)
RH dissolvable tablets
(60 / 30mg)2–2.9 0.5 0.53–5.9 1 16–8.9 1.5 1.59–11.9 2 212–14.9 2.5 2.5
47
47TREAT, OBSERVE AND CARE2.2.9 TUBERCULOSIS 2.2.9
2.2.10 HIV AFFECTED MOTHERS AND BABIES AllmothersshouldbecounselledandtestedforHIVatthefirstantenatalvisit.IfthemotherisHIVnegative,arepeattestisoffered6weekslater.
Determine the mother’s HIV statusAskthemother:
ifsheknowsherHIVstatus•If she is HIV positive,• whattreatmentshehasreceivedandwhenitcommencedIfsheisHIVpositiveandnotonHAART•
DetermineherCD4countandWHOstageo If she is HIV negative, • whenlastshehadanHIVtestIfshehasnotbeentested,counselheronHIVtesting•
Follow up motherIfsheisonHAART,continueHAARTespeciallyifbreastfeed-ing,referbacktoARVsite,andcounselonadherenceIfsheisnotonHAART,ensureshecompletesthetreatmentforPMTCT,andensureshehasarecentCD4countandWHOstagedone.IfherCD4countis<350mm3,referherforhaaRtIfHIVnegative,counselonsafesex,anduseofacondom,especiallywhilebreastfeeding
Treat the babyGiveallHIVexposedbabiespost-exposureprophylaxiswithARVtherapyaccordingtothecurrentnationalPMTCTguidelineCheckthetreatmentrequiredandthedurationoftreatmentEnsurethatthebabyhasanadequatesupplyoftreatmentanddocumentthisontheRoadToHealthChartCounselonadherencePost-exposureprophylaxismayextendthroughthedurationofbreastfeedingifthemotherisnotonHAART
The national PMTCT guideline may change from time to time and you need to be aware of the latest guidelines
Test the babyIfthebabyiswell,ensures/hehasanappointmentforanHIVDNAPCRtestat6weeksofageIfthebabyhasfeaturesofHIVinfection(seriousacuteinfection,severelocalinfection,oralthrush,poorgrowth,inadequateweightgain)before6weeksthendoanHIVDNAPCRtestbefore6weeks
IfPCRtestispositive,counselmotherandpreparetostartARVo treatmentaccordingtolatestnationalprotocol(consultapaediatricianontreatmentforneonates)IfPCRtestisnegative,repeatHIVDNAPCRtestat6weekso
Infant feeding and HIV Determinehowthemotherhasdecidedtofeedherbaby•Ifsheisnotsurehowtofeedherbaby,counselheronsafe•feeding,andhelpherchoosetheoptionthatisbestforherSupportthemother’sfeedingchoice,eitherexclusive•breastfeedingorexclusivereplacementfeedingIfshechoosesreplacementfeeding,ensurethatsheknows•howtoprepareandstorefeeds(p.56)Ifsheisbreastfeeding,assessbreastfeedingbeforedis-•chargeandensurebabyiswellattachedandpositionedduringfeeding(p.55) Ifsheisbreastfeeding,determineifmotherorbabyrequire•HAARTaccordingtothenationalprotocol.
Follow up babyFollowupat4-6weeks•
DoaHIVDNAPCRtestonbabyo Commenceco-trimoxazoleprophylaxiso Infantfeedingsupportandroutinechildhealtho
Followup2weekslaterforPCRtestresult•IfPCRtestispositiveo
ReferimmediatelytopaediatricARVsiteContinueco-trimoxazoleprophylaxisandbreastfeeding
IfPCRtestisnegativeo OfferinfantfeedingsupportIfbreastfeeding,ensuremomorbabyisonARVtreatmentac-cordingtonationalprotocolIfbreastfeeding,repeatPCRtest6weeksaftercessationofbreastfeeding
48
3. ASSESS FEEDING AND COUNSEL
3.1. Assess feeding in the breastfed baby 50
3.2. Assess feeding in the baby receiving replacement milk 51
3.3. Assess feeding and weight gain in low birth weight babies 52
3.4. Counselling principles 54
3.5. Counsel on feeding 55
3.6. Counsel on replacement feeding 56
3.7. When to return 58
49assess feediNg aNd CoUNsel
3. ASSESS FEEDING AND COUNSEL 3.
3.1 ASSESS FEEDING IN BREASTFED BABY
ASK, CHECK, reCord LOOK, LISTEN, FEEL sigNs ClassifY aCt Now
assess breastfeeding
Howisbreastfeedinggoing?
Howmanytimesin24hoursdoyoubreastfeed?
Doesyourbabygetanyotherfoodordrink?
Hasthebabyfedinthelasthour?
Assess weight gain
Assess for possible feeding problem•Isbabyabletoattach?oNotatalloPoorattachmentoGoodattachment
•Tocheckattachmentlookfor:oChintouchingbreastoMouthwideopenoLowerlipturnedoutwardoMoreareolavisibleabovethanbelowthemouth
•Checkpositioning•Isthebabysuckingwell?oNotatalloNotsuckingwelloSuckingwell
•Clearablockednoseifitinterfereswithbreastfeeding
•Lookforthrushandmouthulcers
Assess all babies for growth•Hasthebabygainedweightaccordingtoexpectations?
•Notabletofeed.OR•Noattachmentatall,
OR•Notsuckingatall
Not able to feed
•Treatforseriousacuteinfectionorseveredisease
• Ifthebaby<3daysoldandnoriskfactorsforsepsis,treatforencephalopathy
•Notwellattachedtothebreast,OR
•Notsucklingeffectively,OR
•Feeding<8timesin24hours,OR
•Babyreceivingotherfoodsorfluids,e.g.formulamilkorwateraswellasbreastmilk
feediNg probleM
•Teachthecorrectpositioning
•Assessthemotherforbreastproblems
•Counselthemothertobreastfeedondemandandatleast8timesin24hours
•Counselthemothertoexclusivelybreastfeed
•Poorweightgain poor growth
•Encourageexclusivebreastfeedingondemand
•Excludesepsis
•Goodweightgain growiNg well
•Encouragethemothertocontinueexclusivebreastfeeding
Assessfeedinginababywhodoesnotneedemergency,urgentorimmediatecare.Inthesechildrenwaituntilthebabyisreadytofeeduntilyouassessfeeding.Assessfeedingonallbabiesbeforedischargeandonfollowupvisits.
•Usethischarttoassessfeedingonallbabieswhoarebreastfeeding.•Usethealternatefeedingcharttoassessthefeedingifthemotherhasdecidedonreplacementfeeding(p.51)•Usethechartsonp.52, 53toevaluateweightgaininlowbirthweightbabies.
50
3.2 ASSESS FEEDING IN THE BABY RECEIVING replaCeMeNt Milk
Usethischarttoassessfeedingifthemotherhasdecidedonreplacementfeeding
ASK, CHECK reCord
LOOK, LISTEN, feel sigNs ClassifY aCt Now
Assess replacement feeding
Howisfeedinggoing?
Whatmilkareyougiving?
Howmanytimesduringthedayandnightdoyoufeedthebaby?
Howareyoupreparingthemilk?Letthemotherdemonstrateorexplainhowafeedisprepared.
Areyougivinganybreastmilkatall?
Howisthemilkbeinggiven?Cup?Bottle?
Howarethebottle/utensilswashedandcleaned?
Assess weight gain
assess for a possible feeding problem
•Lookforthrush/mouthulcers
•Clearablockednoseifitinterfereswithfeeding
assess all babies for growth
•Hasthebabygainedweightaccordingtoexpectations?
•Notabletosuck/feed
Not able to feed
•Treatforseriousacuteinfectionorseveredisease
• Ifthebaby<3daysoldandnoriskfactorsforsepsis,treatforasphyxia
•Milkincorrectlyorunhygienicallypreparedor
•Givinginappropriatereplacementmilkorotherfoods/fluidsor
•Givinginsufficientamountsofmilkor
•Mixingbreastmilkandreplacementmilkor
•Thrush
feediNg probleM
•Counselthemotherappropriately(p.56, 57)
•Poorweightgain poor growth
•Checkthefeedingvolumes•Checkthatthefeedisbeingcorrectlyprepared
•CheckifthemotherisdoingKMC(p.14)andassessfeedingandweightgaininLBWbabies(p.52, 53)
•Goodweightgain growiNg well
•Encouragethemothertocontinuefeeding
51assess feediNg aNd CoUNsel
3.2 ASSESS FEEDING IN THE BABY RECEIVING REPLACEMENT MILK 3.2
3.3 ASSESS FEEDING AND WEIGHT GAIN iN low birth weight babies
ASK, CHECK, reCord LOOK, LISTEN, FEEL sigNs ClassifY aCt Now
•Weighdailyandrecordweight
•Plotdailyweightonthegraph
•Calculateweeklyweightgain
Assess weight gain•Ifthebabyislessthan10daysold,hasthebabylostmorethanexpectedbodyweight?
or•Hasthebabyregainedbirthweightat10days?
or•Isthebabygainingsufficientweight?
•Morethan10%weightlostinfirstweek
•Weightgaininsufficient
iNadeQUate weight gaiN
•Determinethecauseofinadequateweightgain
•Adequateweightgainor
•Lessthan10%weightlossinfirstweek
adeQUate weight gaiN
•Continuefeeding•Whenabletosuckle,startbreastfeeding
Expected weight loss •Babiesmaylose10%oftheirbirthweightinthefirstweekExpected weight gain •Initiallossregainedin7-10days•Thereafterminimumweightgainshouldbe:
Preterm=10g/kg/day,Term=20g/kg/day
Usethischartonceortwiceaweekuntildischargetoevaluateweightgaininlowbirthweightbabies.
•Beforedischargingbabiesevaluatebreastfeeding(p.55)orreplacementfeeding(p.56, 57)inlowbirthweightbabies.•Usethischarttoevaluateweightgainafterdischarge.
=10%birthweightBirthweight10
Calculation % Weight Loss:
52
ASK, CHECK, reCord
LOOK, LISTEN, feel sigNs ClassifY aCt Now
Assess feeding •Whatfeedvolumeisbeinggiven?(ml/kg/day)
•Howisthebabyfed?(Cup/breast/nasogastrictube)
•Isthisappropriateforthebaby’sdevelopmentorcondition?
Assess thermo-neutral environment Isthebabymaintaininganormaltemperature?
Isasmallbabyinanincubatoradequatelydressed?(woollencap,booties,plasticwrap)
IfinKMC,isthiscontinuous?
Assess for priority signs•Lethargy•Lessthannormalmovements
•Babyseemsunwell,lethargic,lessthannormalmovement
serioUsillNess
• Investigateandtreatforsepsisorspecificinfections
•CheckforPDA,otherrarecauses
•Inadequatefeedvolumeforweightandage
iNsUffiCieNt feeds •Correctfeedvolume• Increasefeedsby20ml/kg/dayuntil180ml/kg/dayoffeeds(p.22, 23)
•Baby<1.8kgisnotgettingcontinuouskmc
•Baby<1.5kgisnotadequatelyheated
iNadeQUate teMperatUre
CoNtrol
•Correctthermoneutralenvironment(p.14 - 16)
•Pretermbaby<1.5kgissucklingfrombreast
•Baby<1.5kgiscupfed
iNCorreCt feediNg Method
•Correctfeeding(p.22, 23)
•Noproblemsidentified
NO OBVIOUS CAUSE foUNd
•Considerrarercauses•Consultapaediatricianatthereferralhospitalforadvice
IfiNadeQUate weight gaiN,determinecauseandclassifyforcause
53assess feediNg aNd CoUNsel
3.3 ASSESS FEEDING AND WEIGHT GAIN IN LOW BIRTH WEIGHT BABIES 3.3
3.4 COUNSELLING PRINCIPLES
Communication
•Berespectfulandunderstanding.•Listentothefamily’sconcernsandencouragethemtoaskquestionsandexpresstheiremotions.
•Usesimpleandclearlanguage.•Ensurethatthefamilyunderstandsanyinstructionsandgivethemwritteninformation.
•Ifababyneedstobetransferred,explainthereasonforthetransferandhowthebabywillbetransferred.
•Ifababyhasapoorprognosis,isnotimprovingorhashadasuddendeterioration,discussthiswiththemotherandex-plainthecurrentmanagement.
•Respectthefamily’srighttoprivacyandconfidentiality.•Respectthefamily’sculturalbeliefsandcustoms,andac-commodatethefamily’sneedsasmuchaspossible.
•Rememberthathealthcareprovidersmayfeelanger,guilt,sorrow,painandfrustration.
•Obtaininformedconsentbeforedoinganyprocedures.
Listening and Learning skills
•Usehelpfulnon-verbalbehaviour.•Askopen-endedquestions.•Useresponsesandgesturesthatshowinterest.•Reflectbackwhatthemothersays.•Avoidjudgingwords.
Confidence Building skills
•Acceptwhatthemothersays,howshethinksandfeels.•Recogniseandpraisewhatthemotherisdoingright.•Givepracticalhelp.•Giverelevantinformationaccordingtothemother’sneedsandcheckherunderstanding.
•Usesimplelanguage.•Makesuggestionsratherthangivingcommands.•Reachanagreementwiththemotheraboutthewayfor-ward.
54
3.5 FEEDING METHODS: cORREct POsitiONiNg aND attachmENt aND cuP FEEDiNg
Teach the Correct Positioning and Attachment for BreastfeedingSeatthemothercomfortably
Showthemotherhowtoholdherinfant:•withtheinfant’sheadandbodystraight•facingherbreast,withtheinfant’snoseoppositehernipple•withtheinfant’sbodyclosetoherbody•supportingtheinfant’swholebody,notjusttheneckandshoulders.
Showherhowtohelptheinfantattach.•sheshouldtouchherinfant’slipswithhernipple.•waituntilherinfant’smouthisopeningwide.•moveherinfantquicklyontoherbreast,aimingtheinfant’slowerlipwellbelowthenipple.
Lookforsignsofgoodattachmentandeffectivesuckling.Iftheattachmentorsucklingisnotgood,tryagain.Ababysucklesbypushingthenippleagainsthispalatewithhistongue.
Good attachmentSignsofgoodattachment:•Moreareolaabovebaby’smouth•Mouthwideopen•Lowerlipturnedoutwards•Chintouchingbreast•Slow,deepsucksandswallowingsounds
Poor attachmentSignsofpoorattachment:•Babysuckingonthenipple,nottheareola•Rapidshallowsucks•Smackingorclickingsounds•Cheeksdrawnin•Chinnottouchingbreast
Cup feedingHowtofeedababywithacup(idealforexpressedbreastmilk):•Holdthebabysittinguprightorsemi-uprightonyourlap•Holdthesmallcupofmilktothebaby’smouth.Tipthecupsothatthemilkjustreachesthebaby’slips.Thecuprestslightlyonthebaby’slowerlipandtheedgeofthecuptouchestheouterpartofthebaby’supperlip.Thebabywillbecomealert•Donotpourmilkintothebaby’smouth:Alowbirthweightbabystartstotakemilkwiththetongue.Abigger/olderbabysucksthemilk,spillingsomeofit•Whenfinishedthebabyclosesthemouthandwillnottakeanymore.Ifthebabyhasnothadtherequiredamount,waitandthenofferthecupagain,oroffermorefrequentfeeds
55assess feediNg aNd CoUNsel
3.5 FEEDING METHODS: CORRECT POSITIONING AND ATTACHMENT AND CUP FEEDING 3.5
3.6 REPLACEMENT FEEDING
1.Washyourhandswithsoapandwaterbeforepreparingafeed.
2.Boilthewater.Ifyouareboilingthewaterinapan,itmustboilforthreeminutes.Putthepot’slidonwhilethewatercoolsdown.
Thewatermuststillbehotwhenyoumixthefeedtokillgermsthatmightbeinthepowder.
3. Carefully pour the amount of water that will be needed in the marked cup. Check if the water level is correct before adding the powder.4.Onlyusethescoopthatwassuppliedwiththeformula.Fillthescooplooselywithpowderandlevelitoffwithasterilisedknifeorthescraperthatwassuppliedwiththeformula.
Makesureyouadd1scoopofpowderforevery25mlofwater.
Mixinacupandstirwithaspoon.Coolthefeedtobodytemperaturebyleavingittocoolorplacingitinacontainerofcoolwater.
Pourthemixedformulaintoacuptofeedthebaby.
Onlymakeenoughformulaforonefeedatatime.
5.Feedthebabyusingacup.
6.Washtheutensils.
•Exclusivebreastfeedingisthepreferredmethodoffeeding,unlessAFASScriteriaaremet
•IfreplacementfeedingisAccessible,Feasible,Affordable,SustainableandSafe(AFASS),thenusereplacementfeedexclusively(i.e.nobreastmilkatall)
•Foodandfluidsotherthanmilkarenotnecessary
•Preparethecorrectstrengthandamountjustbeforeuse.(correctnumbersofscoopsofpowderforthevolumeofwater)
•Usethemilkwithinanhouranddiscardanythatisleftover(afridgecanstoreformulafor24hours)
•Cupfeedingissaferthanbottlefeeding
•Cleanthecupandutensilswithsoapandwater
•Ifusingabottle,alsoboilitfor5minutesorsteriliseitaftereachuse
Safe preparation of formula milk
56
Table 9: Amount of replacement feed to be given 6 to 8 times per day
Ageinmonths Weightinkilos Approx.amountof
replacementfeedin24hours
Previouslyboiledwaterperfeed
Numberofscoopsper
feed
Approx.numberoffeeds
Numberoftinsofformula
Birth 3 400ml 50 2 8x50ml 2
2weeks 3 400ml 50 2 8x50ml 4
6weeks 4 600ml 75 3 7x75ml 6
10weeks 5 750ml 125 5 6x125ml 8
14weeks 6.5 900ml 150 6 6x150ml 8
4months 7 1050ml 175 7 6x175ml 8
5months 8 1200ml 200 8 6x200ml 8
NB:1scoopofmilkpowderisusedin25mlboiledwater.
57assess feediNg aNd CoUNsel
3.6 REPLACEMENT FEEDING 3.6
3.7 WHEN TO RETURN
When to return immediately Where When What For•Breastfeedingpoorlyordrinkingpoorly•Convulsions•Fever•Bleeding•Diarrhoea
Return to the hospital
Immediately Assessment,treatmentandcare
•Pusdrainingfromtheeyes•Skinpustules•Cordstumpredordrainingpus•Yellowskinoreyes(jaundice)
Return to the PHC clinic
Immediately Assessment,treatmentandcare
When to return for follow up•Allbabies •PHCClinic •3daysofage
•6weeksandnormalroutine
•Weightgain•Jaundiceassessment•Feedingassessment
•Immunisation•HIVexposedbabies •PHCClinic,OR
•PMTCTfollowupclinic
•6weeksandmonthlyforfirstyear
•PCR•Cotrimoxazole•Routinecare•Immunisation
•Babieswhoweighed<2kgatbirth •Neonatalfollow-up •3daysafterdischargethenweeklyuntil2.5kg
•6weeks
•Weightgain•Feedingassessment•Immunisation
high risk: Babieswhohadthefollowingproblems•Birthweight<1.5kg•Meningitisorsepsis•Moderateorsevereneonatalencephalopathy•Severehypoglycaemia•RequiredCPAPorIPPV•Majorcongenitalabnormalities•Necrotisingenterocolitis•Severejaundice
•Highriskfollow-upclinic
•3daysafterdischarge•Weeklyuntil2.5kg•4months•9months
•Weightgain•Feedingassessment•Developmentalassess-ment
58
4. FOLLOW-UP
4.1. Neonatal follow up 60
4.2. Development chart (0-12 months) 61
59follow Up
4. FOLLOW-UP 4.
4.1 NEONATAL FOLLOW UP
Visit assess Treat, Counsel, Follow up3daysafterdischarge
•Assessandclassifyweightgain(p.52, 53)
•Assessandclassifyforprioritysigns
Counselonfeeding
Low birth weightGainingwell:followupin2weeksNotgaining:followupin3daysLosingweight:readmitMultivitamindrops0.6ml/dayFerrouslactate0.6ml/day
Lowbirthweightvisitsuntil2500g
•Assessandclassifyweightgain(p.52, 53)
•Assessandclassifyforprioritysigns
•Measureandrecordheadcircumference
Multivitamindrops0.6mldailyfor6monthsFerrouslactate0.6mldailyfor6monthsCounselonfeedingIfwellat2500g,forroutinePHCclinicfollowup•Birthweightlessthan1500g,AND/OR•Seriousillness(seep.58)•Followupat18weekscorrectedageand9monthsfordevelopmentalscreen
6weeksHIVexposed
•Assessgrowthandfeeding•DoPCR
•Counselonfeeding•GetPCRresultin2weeks.If+ve,doaCD4countandfollowupatthepaediatricHIVclinic
•PCR–ve:routinefollowupatclinic•PCR–ve,andbreastfeeding,repeatPCR6weeksbeforestoppingand6weeksafterstoppingbreastfeeding.
•RepeatHIVantibodytestat18months18weekscorrectedage
•Assessgrowthandfeeding•Measureandrecordheadcircumference
•Assessdevelopment(p.61)
•Accordingtoproblemsidentified•Ifdelayedmotordevelopment,startphysiotherapy
9months •Assessgrowthandfeeding•Measureandrecordheadcircumference
•Assessdevelopment(p.61)
•Accordingtoproblemsidentified•Ifdelayedmotordevelopment,startphysiotherapy•Ifdelayedspeechdevelopment,assesshearing
60
4.2 DEVELOPMENT CHART (0 – 12 MONTHS)
Months Gross-motor Fine-motor-adaptive Communication Personal-social12 Walksalone(10steps)
WalkswithonehandheldRetains3cubesSimpleformboard(onecirclein)Replacespegman
JabberswithexpressionWhere’sdaddy-looksatfather
Holdsaspoon
11 Standsatfurniture-liftsonefootatatimeCruisesaroundfurnitureCreepslikeabear
HoldscarandexploreswithindexfingerThumbindexfingeropposition
Imitatesoneortwowords2-3wordswithmeaning(in-cludemama,dada)
Fingerfeeds
10 Sitting,canrecovertoybehindhim
ThrowsobjectsClickstwocubestogether
OnewordwithmeaningShakesheadfornoObjectpermanence,findcubeundercover
DeliberatecastingPushesarmintosleevePullsoffhat
9 CrawlsPullsuptostand
RemovespegmanfromcarExploratorymouthing
Saysmama,dadaBabblestunefullyWavesbyebye
StrangeranxietyHoldsandeatsabiscuit
8 Sitsalonefor1minuteProne-pivotsinacircleusingarm
RetainsonecubeineachhandGraspsringbythestring
Combinessyllablese.g.ba-ba,ma-ma
Playspeek-a-boo
7 Sitsalonefor1minute Retains1cubeinhandatatime
ShoutsforattentionRespondswhencalled
Drinksfromacup
6 Prone-extendedarmsupportrollsfromsupinetoprone
Shakes,wavesandbangsob-jectsGraspsring,mouthandtransfer
MakesmsoundObjectpermanence-looksafterdroppedobject
Smiles,patsmirrorimageChewssolids
5 Rollsfrompronetosupine GraspsringCrumplespaper
Combinessoundse.g.ag-hoo Holdscup
4 Pullstosit-noheadlag 4partsequence,reach,grasp,retrieve,mouth
GigglesandlaughsInitiatesvocalisation
Friendlytowardsstrangers
3 Prone-elbowsupportSupine-symmetricallie
Followsthrough180Fingersonehandwithotherwhenlyingquietly
Coos,chucklesandsqueals Obviouspleasureatbeinghandled
2 supportedsitting-headvertical FollowspastthemidlineHandtomouthasvoluntaryact
Vowelsounds EnjoysabathSmilesatmother
1 Liftsheadwhenprone Followstomidline CrieswhenhungryThroatysoundsStartlestosound
SuckswellWatchesmotherwhenfeeding
61follow Up
4.2 DEVELOPMENT CHART (0 – 12 MONTHS) 4.2
5. ROUTINE CARE FOR ALL NEWBORNS, CHARTS, reCordiNg forMs aNd refereNCes
5.1 Routine care in labour ward 63
5.2 Resuscitation 65
5.3 Routine care in postnatal ward 67
5.4 Drug doses 69
5.5 KMC chart 72
5.6 Recording form 73
5.7 Growth and Head Circumference chart 74
5.8 Daily Weight, Feeding and Treatment Chart 75
5.9 List of abbreviations 76
5.10 References 77
62
Immediately after birth •Checkifthebabyneedsresuscitation?
•CheckandrecordtheApgarscore
Is the baby breathing?Is the heart rate > 100?Is the baby centrally pink?
•Drythebabywithawarmtowel• IfNOtoanyquestion,resuscitateimmediatelyp.
65, 66• Ifthereareexcesssecretions,turntheinfantontotheside.Avoidsuctioning
•Clampthecordafterthefirstfewcries.•Replacetheforcepswithadisposableclamporsterilecordtie3-4cmfromtheabdomen
•AdmittotheneonatalunitifthebabyrequiredresuscitationoriftheApgarscoreat5minis7orless
• Ifintheatre,andthebabyisnormal,placethebabyinawarmincubatorinthetheatre(noblanketsorclothes),andthentakethebabytothepostnatalwardwiththemother.
Check risk factors•Membranesrupturedformorethan18hours
•Motherdiabetic
•Smellyliquororbaby •Admittotheneonatalunitforobservation
•MotherHIVpositive •Checkthefeedingchoice
ASK, CHECK, RECORD LOOK, LISTEN, FEEL TREAT, OBSERVE, CARE
ApgarScore
0 1 2
Heartrate Absent <100/min >100/minRespiration Absent Slowor
irregularGood,crying
MuscleTone
Limp Slightflexion
Active,moves
Responsetostimulation
Nore-sponse
Grimace Vigorouscry
Colour Blueorpale
Bodypink,limbsblue
Pinkallover
5.1 ROUTINE CARE: labOuR waRD OR thEatRE
63ROUTINE CARE FOR ALL NEWBORNS,
CHARTS, RECORDING FORMS & REFERENCES
5.1 ROUTINE CARE: labOuR waRD OR thEatRE 5.1
continuesonnextpage
(continuedfromthepreviouspage)
Check baby from head to toe and over•Checktheweight•Checktheheadcircumference
•Centralcyanosis•Grunting•Fastbreathing•Chestindrawing•Floppy•Lessthannormalmovements•Majorcongenitalabnormality
Admittotheneonatalunitif•Weight>4kg•Weight<2kg•Headcircumference<3rdcentileor>97thcentile•Anyofthesignsarepositive
Check Vitamin K and Eye prophylaxis
•Administer1mg of Vitamin KIMintheanterolateralaspectofthemidthigh
•Administerchloramphenicoleyeointmentintobotheyes
Initiate bonding and feeding
•Placethebabyonthemother’schest• Initiatebreastfeeding
Identify and record, and transfer
•Formallyidentifythebabywiththemother
•Placealabelwiththemothersnameandfoldernumber,infant’ssex,timeanddateofbirthontheinfantswristandankle
•Transfertothepostnatalwardwiththemotherunlessthereisareasonforthebabytobeadmittedtotheneonatalunit
ASK, CHECK, RECORD LOOK, LISTEN, FEEL TREAT, OBSERVE, CARE
5.1 ROUTINE CARE: labOuR waRD OR thEatRE64
5.2 RESUSCITATION OF THE NEWBORN
Questions to ask at birth1)Isthebabybreathingadequately?2)Isthebaby’sheartrateabove100beatsperminute?3)Isthebabycentrallypink?
If“YES”toall3thebabydoesnotneedresuscitation.
aNtiCipate: Alwaysbereadytoresuscitateeverybabywhoisborn.
a. aiRway•Suctionthemouthandpharynxatthedeliveryofthehead•Warm,position,clearairway,dryandstimulate• ASSESS BREATHING, COLOUR AND HEART RATE •Ifbluebutbreathing,andHR>100,administeroxygen
b. bREathEIfblue,HR<100,orapnoeic:•Ventilatewithbagandmask:Squeezebagfirmlyatarateof40–60breaths(Counting“bag,2,3”willachievethecorrectrate.)
•Mostbabieswillbesuccessfullyresuscitatedbybagandmaskonly.
•Repeatventilationsfor30seconds• ASSESS BREATHING, COLOUR AND HEART RATE
c. chEst cOmPREssiONsIfheartrate<60perminute:•Beginchestcompressionsusingthehandencirclingtechniqueiftwopeopleareavailable.Otherwise,usethetwofingertechnique.Givethecompressionsatthelowerthirdofthebaby’ssternumandcompressto1/3thedepthofthebaby’schest.•Give3compressionsfollowedbyonebreathina2secondcycle.(Counting1,2,3,bagwillachievethecorrectrate)
•Repeatcompressionsfor30secondsthenreassess• ASSESS BREATHING, COLOUR AND HEART RATE •IfHRisstill<60intubateandgivedrugs
D. DRugs•Giveadrenaline(0.01mg/kg(IV/viaendotrachealtube)every3-5minutesasrequired)
•Administernaloxone0.1mg/kg(IM/Subcutaneously/viaendotrachealtube)onlyifmotherreceivedpethidineormorphinewithin4hoursofdelivery
Refer to Reference 7.
ASSESS THE BREATHING, COLOUR AND HEART RATEevery30secondsduringtheresuscitation.Ifthebabyisimprovingthentheinterventioncanbestopped.Ifthebabyisnotrespondingorgettingworsethenfurtherinterventionisneeded.Almostallbabieswhodonotbreatheatbirthwillonlyrequirebagandmaskresuscitation.
65
5.2 RESUSCITATION OF THE NEWBORN 5.2
continuesonnextpage
ROUTINE CARE FOR ALL NEWBORNS,CHARTS, RECORDING FORMS & REFERENCES
(continuedfromthepreviouspage)5.2 RESUSCITATION OF THE NEWBORN
airw
aY
RemoveM
ECONIUM
orBLOODif
presentbeforestimulating
Warm
,Position,ClearA
irway,D
ryand
Stimulate
a
assess
Breathing, Colour
and HR
Breathing,Blueand
HR>100Breathing,Pinkand
HR>100
30s
SupportiveCare
Administer
Oxygen
Apnoeaor
BlueorHR<100
breathe
(Ventilationatrateof40–60/m
in)Count:Bag,2,3
assess
Breathing, Colour
and HR
b30s
Chest C
oM
pressioN
(Rateof120/min)
Ratio:3Com
pressions:1VentilationuntilintubatedCount:1,2,3,Bag
HR>60HR<60
assess
Breathing, Colour
and HR
C
drUgs
Adrenaline(0.01m
g/kgIV/ETevery3-5m
insprnNaloxone(0.1m
g/kgIV(diluted)onlyifnarcoticused)
Dextrose(0.5-1g/kgIV(diluted)onlyifhypoglycaem
ic)
HR>60HR<60
d
30s
66
Identify and care in ward•Referringnurse,receivingnurseandmotheridentifythebabyeverytimethatthebabymovestoanotherareainthehospital
•Keepthebabywiththemotheratalltimes
•Weighnormalbabiesdailyifstillinhospital.Recordtheweightatdischarge
•Allowdemandfeeding•Charttheintakeandoutput•Observe12hourlytemperature,respiratoryrate,heartrate,colourandactivity
•Applysurgicalspiritstothecordevery6hours•Donotbaththebaby.Instead,wipethebaby’sface,neckandears,bottomandgenitalsanddry(“topandtail”).RemovebloodandmeconiumbutNOTvernix
MotherisRPR positive •Examinebabyforsignsofcongenitalsyphilis
•Treatthemotherandbaby.Refertop.45, 46
Mother’sRPR status is unknown
•TakebloodforRPRfromthemother •Treatthemotherandbaby.Refertop.45, 46•Donotdischargeuntiltheresultisbackorthebabyhasreceivedprophylaxis
MotherhashadTB in the last 6 months
•Examinebabiesforsignsofrespiratorydistress
•Treataccordingtotheprotocolonp.47
MotherisHIV positive •Manageaccordingtotheprotocolonp.48 andensurethattheHIVexposure,theARVtreatmentprescribed,andthefeedingchoicearedocumentedontheRTHC.
Mother’sHIV status is unknown
•CounselandtestforHIV •Accordingtotheprotocolonp.48
Mother’sblood group is O or Rh Neg
•CheckTSBorbilicheckorat6hours •StartorreferforphototherapyiftheTSBisgreaterthan80μmol/l
5.3 ROUTINE CARE: POstNatal waRD iN hOsPital OR cliNic
ASK, CHECK, RECORD LOOK, LISTEN, FEEL TREAT, OBSERVE, CARE
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5.3 ROUTINE CARE: POstNatal waRD iN hOsPital OR cliNic 5.3
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ROUTINE CARE FOR ALL NEWBORNS,CHARTS, RECORDING FORMS & REFERENCES
(continuedfromthepreviouspage)
Mother’sblood group is unknown
•Checkthemother’sbloodgroup•Checkthebaby’sbilirubinat6hoursofage
• Ifthemother’sbloodgroupisRhnegativeorO,checktheTSBofbabyandmanageaccordingtothebilirubingraphonp.41
Check: Abnormalities or illness
•Doesthemotherhaveanyconcerns?
•Hasthebabypassedmeconiumyet?
•Examinethebabyinthepresenceofthemother.
•Usetheexaminationchartinthematernityrecord
•Documentthefindingsintheexaminationpageoftheinfantrecord.
Check: Jaundice daily •Lookforjaundiceorassesswithabilicheck
•Treataccordingtothegraphonp.41
Check: Feeding •AssessbreastfeedingorreplacementfeedingifanHIVpositivemotherhaschosenreplacementfeeding
• Ifthebabyisnotfeedingwell,checkpositioningandattachmentaccordingtothechartonp.55
•Counselthemotheronreplacementfeedingifrelevant(p.56)
Check: Routine preventive care
•GivepoliodropsandBCGwithin5daysofbirthandBEFOREdischarge.
•GiveVitaminKandeyeprophylaxisifnotgivenatbirth,e.g.BBA
Check: Discharge and plan follow up
•Checkthatalltheriskfactorsaremanaged,andthatallpreventivetreatmentisgiven
•Checkthatthebabyisfeedingwellandisactiveandwell
•RecordalltheinformationontheRTHC•Givethemotheranappointmenttogototheclinicat3daysofageand6weeks
ASK, CHECK, RECORD LOOK, LISTEN, FEEL TREAT, OBSERVE, CARE
5.3 ROUTINE CARE: POstNatal waRD iN hOsPital OR cliNic68
Drug dose Frequency and CommentAmoxicillinAugmentin
50mg/kg/doseorally <7days: 12hourly7-21days: 8hourly
Ampicillin 50mg/kg/doseIV100 mg / kg / dose for meningitis
<7days: 12hourly7-21days: 8hourly
aZt* Term: 4mg/doseorally 1.5mg/kg/doseIVPreterm: 2mg/kg/doseorally 1.5mg/kg/doseIV
Term: 12hourly 6hourlyPreterm: 12hourly 12hourly,giveover1hour
Cefotaxime 50mg/kg/doseslowlyIVorIM <7days: 12hourly7-21days: 8hourly
Ceftriaxone Sepsis:50mg/kg/doseMeningitis: 80 mg / kg / dose GonococcalOpthlamia50mg/kg/dose
24hourly 1doseforGonococcalopthalmia
Cloxacillin 25–50mg/kg/dose <7days: 12hourly7-28days: 8hourly
Cotrimoxazole 2.5ml(40/200mg/5ml) DailyFrom6weeksprophylaxisagainstPCP
Erythromycin 12.5mg/kg/dose 4timesdaily Givefor14daysforChlamydia
Ferrouslactate (25mg/ml)0.6ml Dailyfromwhenbabyissuckingwellto6months
Furosemide 1mg/kg/24hours Orally24hourly
Gentamycin 5mg/kg/dose 24hourly
5.4 DRUG DOSAGES
•Determineappropriatedrugsanddosagesforbaby’sweight•Tellthemotherthereasonforgivingthedrugtothebaby•Giveintra-muscularantibioticsintheantero-lateralthigh–useanewsyringeandneedleforeachantibiotic
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5.4 DRUG DOSAGES 5.4
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ROUTINE CARE FOR ALL NEWBORNS,CHARTS, RECORDING FORMS & REFERENCES
(continuedfromthepreviouspage)
Drug dose Frequency and CommentGlucagon 0.2mg/kg/dose SingledoseIM
Givebeforereferringpatient.iNh 10mg/kg/dosedaily Givefor6monthsifmotherhasbeenonTBtreatmentfor
lessthan2months,thenadministerBCGCombinationTBtreatment RHZ(60,30,150)
3–4kg½tabdaily Give6monthsoftreatmentifthemotherhashad <2monthstreatmentorisHIVpositive
GiveRHZfor2monthsfollowedbyRHfor4monthsLamivudine(3TC)* 2mg/kg/dose 12hourlyincombinationwithAZTforMTCT
Lopinovir/Ritonavir* 10–12mg/kg/dose 12hourly
Metronidazole 7.5mg/kg/doseIV 12hourly
Nevirapine* >2kg:6mg(0.6ml)/doseorally<2kg:2mg(0.2ml)/kg/doseorally
Daily
Nystatin 1ml(100000u)orally 6hourly
PenicillinG(Benzylpenicillin) Sepsis/Pneumonia,andSyphilis50000u/kg/doseIV
Meningitis100000u/kg/doseIV
12hourlyforfirstweek 8hourlythereafter
DurationoftreatmentSyphilis: 10daysSepsis/Pneumonia: 14daysMeningitis: 21days
Penicillin(Benzathine) 50000u/kg/doseIM 1doseforbabiesborntomotherswithsyphiliswhoareuntreatedorpartiallytreated
ProcainePenicillin 50000u/kg/doseIM24hourly Forsymptomaticcongenitalsyphilis:10days
5.4 DRUG DOSAGES70
Drug dose Frequency and CommentPhenobarbitone Forconvulsions
Load:20mg/kg/IVover10minutesthen5–10mg/kg/dose(Maximumcumulativedose40mg/kg)hiE: 40mg/kgwithinthefirsthouroflifemayimproveoutcome
Maintenance:3-5mg/kg/doseorally/IV/IM/rectally24hourly
Phenytoin Load:20mg/kg/IVover30minutesMaintenance:4-8mg/kg/dose
Orally/IV/rectally24hourly
ProstoglandinE2 ¼tablethalfhourly Crushthetablet,mixwith2–5mlofwaterandgiveitthroughanasogastrictube
Stavudine(d4T)* <14days 0.5mg/kg/dose>14days 1mg/kg/dose
Orally12hourlyOrally12hourly
Sucrose Preterm:0.2-0.5ml24%sucrosesolutionTerm:5ml24%sucrosesolution
Givebydropper2minutesbeforepainfulprocedure.(Avoidtheuseofparacetamolininfants)
Theophyline(oral) Load:5mg/kgorally
Maintenance:2mg/kg/dose12hrly
Giveinpre-terminfants(<35weeksgestationalagetopreventapnoea)12hourly
VitaminD2 400–800iuorally Dailyinpreterminfantsupuntil1.5kg
VitaminK 1mgIM Prophylaxisatbirth
Multivitamin DailyrequirementsVitaminA1500–3000u/dayVitaminC25–50mg/dayVitaminD400u/day0.3–06mlmultivitaminpreparation
Dailyuntil6months
*ConsultcurrentPMTCTguidelineswhenprescribingpost-exposureprophylacticARVtreatmentforneonates.ConsultpaediatricARTguidelinesandaneonatologistwhenprescribingARVtreatmentforneonates.
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5.4 DRUG DOSAGES 5.4ROUTINE CARE FOR ALL NEWBORNS,
CHARTS, RECORDING FORMS & REFERENCES
5.5 KMC Score Sheet
KMC Daily Score SheetBased on the Intra-hospital KMC Training Programme in Bogota, Colombia
Date of birth......./....../......Date ___________
Name: Breastfeeding: Date started24 hour KMC ......./....../......
Day1
Day2
Day3
Day4
Day5
Day6
Day7
Hospital No: Formula:
Evaluation score Weight________
0 1 2 RemarkSocio-economicsupport Nohelpor
supportOccasionalhelp
Goodsupportsystem
Mother’smilkproduction Expresses0-10mlbreastmilk
Expresses10-20mlbreastmilk
Expresses20-30mlbreastmilk
Mustscorebeforedischarge. N/Aforformula
Positioningandattachingofbabyontobreast
Alwaysneedassistance
Occasionallyneedsassistance
Noassistanceneeded
Notapplicableforformulafeeding
Baby’sabilitytosuckleatthebreast/cupfeed
Getstiresveryquickly
Getstiredinfrequently
Takesallfeedingwell
Confidenceinhandlingbaby,e.g.feeding,bathing,changing
Alwaysneedassistance
Occasionallyneedsassistance
Noassistanceneeded
Baby’sweightgainperday 0-10g 10-20g 20-30g Mustscore1or2beforedischarge
Confidenceinadministeringvitaminandirondrops
Noconfidence
Someconfidence
Fullyconfident
KnowledgeofKMC Noknowledge
Someknowledge
Knowledge-able
Acceptance&applicationofKMC
DoesnotacceptorapplyKMC
Partlyaccepts&appliesKMCmethod
AppliesKMCwithouthavingtobetold
AppliesKMCwithouthavingtobetold
Confidenceincaringforbabyathome
Doesnotfeelsureorable
Feelsslightlyunsureandunable
Feelsconfident
TOTALSCOREperday
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Date:________Time_______Name:________________________________________Dateofbirth:_______________Weight:________kgask:Howoldisthebaby?____________________Wherewasthebabyborn?______________________________Whatisthebaby’scurrentproblem?_____________________________________________________________________________________Isthebabyhavingaproblemwithfeeding?______________________________________________________________________________Hasthebabyhadanyconvulsionsorabnormalmovements?_____________________________________________________________
assess Need for eMergeNCY CareBreathingwell?YNGasping?YNRespiratoryRate<20YNPaleorcold?YNHeartRate>180or<100YNIsbabyextremelylethargic?YNGlucoseteststrip<2.5mmol/lYN
Respiratory failure Yes NoCirculatory failureYes NoHypoglycaemiaYes No
assess for prioritY sigNs: apNoea aNd respiratorY distressCentralcyanosisYNApnoeaYNFastbreathingYNRespiratoryRate_______SeverechestindrawingYNGruntingYN
Classify for apnoea and respiratory distress
assess for other prioritY sigNs: Temperature_________BirthWeight_______________JaundiceYNIncreasedtoneYNDecreasedtone/floppyYNIrregularjerkymovementsYNReducedactivityYNLethargicorUnconsciousYNBulgingfontanelYNAbdominaldistensionYNBilestainedvomitingYN
Classify for priority signs
ASSESS FOR BIRTH INJURIES, MALFORMATIONS, LOCAL INFECTIONSHeadcircumference_____<3rdcentileYN>97thcentileYNNormalYNSwellingofscalpYNUnusualappearanceYNCleftlip/CleftpalateYNEyes:PusdrainingYNRedorswolleneyelid/SubconjunctivalhaemorrhageYNNeuraltubedefectYNGastroschisis/omphalocoeleYNImperforateanusYNPustules/rashYNUmbilicusred/pusYNAbnormalpositionYNAsymmetricmovementsYNCrieswhenlimbtouchedYNClubfootYNExtradigitYNSwollenlimborjointYNOther__________________________________________________________
Classify for all problems
assess risk faCtors aNd speCial treatMeNt NeedsMotherhasdiabetesYNBaby>4kgYNMother’sbloodgroup:RhNegYNGpOYNUnknownYNRuptureofmembranes>18hoursYNMaternalfeverYNOffensiveliquorYNApgar<7at5minutesYNMother’sRPR: Positive Partiallytreated UnknownMotherHIVstatus: Positive Negative UnknownMotherhasTB,orhasbeenonTBtreatmentwithinthelast6monthsYN
Classify for all risk factors
assess ClassifY aCtioN
5.6 INITIAL ASSESSMENT: sick aND small NEwbORNs iN hOsPital
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5.6 iNitial assessMeNt: sick aND small NEwbORNs iN hOsPital 5.6ROUTINE CARE FOR ALL NEWBORNS,
CHARTS, RECORDING FORMS & REFERENCES
5.7 GROWTH AND HEAD CIRCUMFERENCE CHART74
5.8 WEIGHT, FEEDING AND TREATMENT SUMMARY CHARTM
onth__________
DateO
xygen
CPA
P/IP
PV
Anitbiotics
Phototherapy
KM
C or H
IE score
HCHb
4500g / 2500g
4250g / 2250g
4000g / 2000g
3750g / 1750g
3500g / 1500g
3125g / 1250g
3000g / 1000g
2750g / 750g
2500g / 500g
Days
12
34
56
78
910
1112
1314
1516
1718
1920
2122
2324
2526
2728
2930
Feeds
ivi dpm
ml/kg
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5.8 WEIGHT, FEEDING AND TREATMENT SUMMARY CHART 5.8ROUTINE CARE FOR ALL NEWBORNS,
CHARTS, RECORDING FORMS & REFERENCES
5.9 LIST OF ABBREVIATIONS
APH AntepartumhaemorrhageAIDS AcquiredimmunodeficiencysyndromeAGA AppropriateforgestationalageANC AntenatalcareARV Anti-retroviralAZT Azidothymidine(antiretroviraldrug)BBA BornbeforearrivalBD TwicedailyCA Chorio–amnionitisCHD CongenitalheartdiseaseCNS CentralnervoussystemCPAP ConstantpositiveairwaypressureCRP C-reactiveproteinCXR ChestX-rayEBM ExpressedbreastmilkEBF ExclusivebreastfeedingFBC FullbloodcountGA GestationalageGPH GestationalproteinurichypertensionHIE Hypoxic-ischaemicencephalopathyHIV HumanimmunodeficiencyvirusHMD HyalinemembranediseaseHR HeartrateICU IntensivecareunitIDM InfantofdiabeticmotherIM Intramuscularinjection
IPPV IntermittentpositivepressureventilationIV IntravenousinjectionIVF IntravenousfluidsIVH Intra-ventricularhaemorrhageKMC KangaroomothercareLBW LowbirthweightLP LumbarpunctureNEC NecrotisingenterocolitisNG Naso-gastricNMR NeonatalmortalityrateNND NeonataldeathNTD NeuraltubedefectNVP NevirapinePCR PolymerasechainreactiontestPDA PatientductusarteriosusPMTCT PreventionofmothertochildtransmissionPROM ProlongedruptureofmembranesRDS RespiratorydistresssyndromeRPR Rapidplasmareagin(syphilis)ROM RuptureofmembranesRR RespiratoryrateRTHC RoadtohealthchartTSB TotalserumbilirubinTSR TimetosustainedrespirationTTN TransienttachypneaofthenewbornVCT Voluntarycounsellingandtesting
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5.10 KEY REFERENCES
1. Standard Treatment Guidelines and Essential Drugs List for South Africa: Hospital Level paediatrics. NationalDepartmentofHealth,SouthAfrica,2006.2. HornAR,KirstenGF,etal.Phototherapy and exchange transfusion for neonatal hyperbilirubinaemia S. Afr. Med. J 2006;
96:819-824.3. ThompsonMC,PutermanAS,etal.Thevalueofascoringsystemforhypoxicischaemicencephalopathyinpredicting
neuro-developmental outcomes. Acta paediatr1997;86:757-7614. McCormickM(ed).Managing Newborn Problems: A guide for doctors, nurses, and midwives. 2003 whO.5. WoodsDL(ed).Perinatal Education Programme: Newborn Care.PerinatalEducationTrust.6. Integrated Management of Childhood Illness: South African Adaptation 2007.7. South African Handbook of Resuscitation of the Newborn, Revised2006.PrintedundertheauspicesoftheSouthAfrican
PaediatricAssociationandavailablefromtheDepartmentofPaediatrics,UniversityoftheWitwatersrand.
ThischartbookonnewborncarehasbeendevelopedbytheLimpopoInitiativeforNewbornCare,UniversityofLimpopoandDepartmentofHealth,LimpopoProvince.WewouldliketoacknowledgetheCentreforRuralHealth,UniversityofKwaZulu-Natal,SavetheChildrenUSandUNICEFfortheirsupport.
Contributors Reviewers
DrAnneRobertsonProfAttiesMalanDrDaveGreenfieldMsLollyMashaoDrNatashaRhodaDrAmeenaGogaMsKateKerberDrJoyLawn
ProfDaveWoodsDrMarkPatrickMsZoMzoloDrMikeEnglishDrStevenWallDrFrancoisBonniciDrGonzoloMansilla
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5.10 KEY REFERENCES 5.10ROUTINE CARE FOR ALL NEWBORNS,
CHARTS, RECORDING FORMS & REFERENCES
Each year in South Africa, 20,000 newborns die, most from preventable causes. Most births and most newborn deaths occur in hospitals. Improving the quality and timeliness of care is a critical step to save these lives. Since 2003 the Limpopo Initiative for Newborn Care (LINC) has advanced the quality of care of newborns in district and regional hospitals in the Limpopo province. LINC is a joint venture between the Department of Paediatrics and Child Health in Polokwane and the provincial Maternal, Child and Women’s Health directorate. These Newborn Care Charts for Management of Sick and Small Newborns in Hospital are designed to be used by doctors and nurses at the district and regional hospital level and provide a ready reference for assessment, classification, and treatment of sick and small newborns as well as an overview of routine care that should be provided to all newborns.
First edition, 2009.