NewborN Care Charts - Healthy Newborn Network · NewborN Care Charts MaNageMeNt of siCk aNd sMall...

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


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


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


•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


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


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


2.1.2 OXYGEN THERAPY 2.1.2

continuesonnextpage


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


2.1.2 OXYGEN THERAPY: mEthODs FOR PROviDiNg OxygEN tO babiEs whO aRE bREathiNg sPONtaNEOusly 2.1.2

continuesonnextpage

(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


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


2.1.4 FEEDS AND FLUIDS FOR SICK AND SMALL BABIES 2.1.4

continuesonnextpage


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.


2.1.5 INFECTION PREVENTION AND CONTROL 2.1.5

continuesonnextpage


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


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


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


2.2.2 PRETERM AND LOW BIRTH WEIGHT 2.2.2

continuesonnextpage

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.


2.2.2 PRETERM AND LOW BIRTH WEIGHT 2.2.2

continuesonnextpage

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.


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.


2.2.5 NEONATAL ENCEPHALOPATHY 2.2.5

continuesonnextpage

(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


2.2.6 NEONATAL JAUNDICE 2.2.6

continuesonnextpage


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)


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


•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


2.2.7 CONGENITAL ABNORMALITIES 2.2.7

continuesonnextpage



•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.


2.2.8 SYPHILIS 2.2.8

continuesonnextpage


Ensurethatthemother’sRPRisknownand,ifpositive,thatsheandpartnerarefullytreated.

Management of the baby of a mother who has positive or unknown syphilis serology

Motheruntreatedorstatusunknown

Motherfullytreated

Mothernotfullytreated

Babyclinicallynormal


Babysymptomatic


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


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


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


3.2 ASSESS FEEDING IN THE BABY RECEIVING REPLACEMENT MILK 3.2

3.3 ASSESS FEEDING AND WEIGHT GAIN iN low birth weight babies


•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


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


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


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.


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


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


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


67

5.3 ROUTINE CARE: POstNatal waRD iN hOsPital OR cliNic 5.3

continuesonnextpage



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


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

69

5.4 DRUG DOSAGES 5.4

continuesonnextpage



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.

71

5.4 DRUG DOSAGES 5.4ROUTINE CARE FOR ALL NEWBORNS,


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

72

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

73

5.6 iNitial assessMeNt: sick aND small NEwbORNs iN hOsPital 5.6ROUTINE CARE FOR ALL NEWBORNS,


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

75

5.8 WEIGHT, FEEDING AND TREATMENT SUMMARY CHART 5.8ROUTINE CARE FOR ALL NEWBORNS,


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

76

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

77

5.10 KEY REFERENCES 5.10ROUTINE CARE FOR ALL NEWBORNS,


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.

NewborN Care Charts - Healthy Newborn Network · NewborN Care Charts MaNageMeNt of siCk aNd sMall...

Documents

Transcript of NewborN Care Charts - Healthy Newborn Network · NewborN Care Charts MaNageMeNt of siCk aNd sMall...