indications For Admission To NICU BHK Low Apgar score <6 at 5 ‘Minutes or cord pH < 7.1 ncern about condi ui | . eer eee £ nal afer initial resuscitation eg : poor perfusion, acidosis "um stained liquor or i i dlicmcra 'QuOr oF any meconium stained liquor required Post resuscitation care Birth weight < 1.8 kg or < Birth weight > 4 kg 35 weeks gestational age Infant of major congenital anomalies — Infant of Rhesus negative mother Infant of diabetic mother on insulin Infant of d- = Infant with p: syndromic babies, cleft lip/p .Jate “°pendant / other Substance abuse mother ‘U8 siblings with sus sen: Infant with persistent signs of respir labour room /0, ¢ Infant with birthitraUma=SAH, Erb pals,» ccupes ete © | fant of mother Suspected chorioar) Ss / ISK OF sepsis | fant with ambiguous genitalia * Infant of mother with significant illness Infectious disease : HIV positiv., Vi.AL po; ‘ed or confirmed IM IY «istte ss ter initial oBservation in itive, Dengue ‘even Active al chicken fernes Simplex, Ruveila P Hemop illa .e-:hyrotoxiccsl Myasthenia os 7 ‘fe > . a r. i a A ¥; r “3 canned with CamScannerIndications For Referral To Peadiatric Team (NICU HEBHK) 2) Urgent a. "Flat" / not vigorous baby ». Respiratory distress (cyanosed, grunting, tachypnoiec) «. Grossly dysmorphic or Lethal Congenital Malformation 2) Standby For Delivery ‘A. Prematurity <35 weeks or expected birth weight <1.8kg b. Cord prolapsec Fetal distress (_strumental or Lscs) 4. Antepartum ble«. ng {abruption placenta or placi--ta pracvia) €. Moderate(MIMSL) or hick meconium stained iiquor(ThSt) f. Antenatally detected {>I anomalies(surgical eeu mmediat~ se vent @. Placenta praevia type 3.0” 1 (elective or ene. zency) h. Anticipated difficult deliveries in OT (e.g hand prolapsed, transverse lie) i. Assisted bree !olivery 3) Maternal Conditions a. Diabetic mother (GOM or impaired OGTT) b. Risk of sepsis (chorioamnitis, PROM>24 hours, fever > 38°C, UTI, «Infectious of transmissible disease (e.g RV, Hep B carrier, VDRL/T pos... .e; hicken pox, Dengue, Zika, PTB) ~— 4. Maternal autoimmune (e.g SLE) % €. Maternal substance abuse f. Maternal medication (e.g antithyroid, anticonvulsant, chemotherapy and other teratogenic drug) . Rhesus negative mother 4)Neonatal Condition 3. Premature <35weeks or birth weight <1.8kg b. Term SGA (<2.5ke) CLGA> 4.0kg 4. Apgar score at Sminutes <7 Born with MMSL or TMSL f. Congenital anomalies or syndromic (antenatally or postnatally detected, including Down's syndrome) 8. Post instrumental delivery A. Birth trauma or injury i, Suspected twin-to-twin transfusion syndrome i. G6PD deficient k. NNJ requiring phototherapy or exchange transfusion |. Clinical sepsis (fever, poor feeding, hypoglycaemia, respiratory distress, seizure) May 2018 Scanned with CamScanner———___ = zz Guideline summa Intrapartum antibiotic Prophylaxis. For women in labour identify and assess any risk factors for early-onset {able 1), Throughout labour monitor for the emergence of new isk facto {ever higher than 38°C, or the development of choroamionits, | | (fe intrapartum antibiotic neonatal infection (see 8, Such as intrapartum Manage prelabour rupture of Prophylaxis using intravenous membranes at term according to the benaylpeniciin to prevent earty- recommendations in Inapartum care Conset neonatal infection for (NICE cleal guideline 55) women who have had. rou baby whan Consider intaparum —antbiotc invasive group i Prophylaxis using intravenous Sirwplococeal infection bbenzylpenicilin to prevent early-onset | group B streptococcal Preterm labour if there is prelabour eco oes Denaylpeniciin to prevent eary-onset eonalalinfecion for women in retem labour if there i Suspected or | confirmed inkapertum rupture of membranes lasting more than 18 hours | ‘Continue prophylaxis unti the birth of the baby. ene : te ran ot ins ant ts od icrobiological surveilence data indicate @ diferent antici Scanned with CamScannerAntibiotics for early- inset neonatal infection ae 1 Risk factors for early-onset neonatal inf uuu, including © 24 Risk factor [Red flag | Tnvasive group B streptococcal infection in a previous baby Waternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy Prelabour rupture of membranes | Preterm birth following spontaneous labour (before 37 weeks’ gestation) Suspected or confirmed rupture of membranes for more than 16 hours in a preterm birth Tnirapartum fever higher than 36°C, or confirmed or suspected chorioamnionitis | Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in a the 24-hour periods before and after the birth (This does not refer to intrapartum antibiotic prophylaxis) ‘Suggested or CoTined Ven hana baby ne case oe mute 2 pregnancy a Scanned with CamScannerDetermine the need for antibiotic treatment in the baby Use table 1 to ident risk factors for early-onset neonatal infection anc table 2 to ident clinical incicators of eary-onset neonatal infection Use tables 1 and 2 to identify red flags (risk factors and clinical indicators that should prompt a high level of concern regarding early-onset neonatal infection) I there are any risk factors for early-onset neonatal infection (see table 1) or if there are clinical indicators of possible early- ‘onset neonatal infection (see table 2) perform a careful clinical assessment without delay. Review the maternal and neonatal history and carry outa physical examination of the baby inclusing an assessment ofthe vita signs. Use the following framework to direct antibiotic management decisions, Any red lag, or + Two ormore risk factors or dlnical indicators that are not ed fags (see tables 1 and 2). No red flags, and | + Necinizainaiatrs (ee lable 2), but + One "isk factor that is not a red fag (see table 1), No red fags, and + No risk factors (see table 1), but + One cinical indicator that is not red fag (cee No risk factors, ‘and No clinical inieators, and No laboratory ‘evidence of possible infection Do not routinely give antbiotic treatment. Continue routine postnatal care (see Postnatal care, NICE liical guideline 37). Perform investigations {and start entbiotic treatment Using cnc udgement, conser . "epetner t is safe to withhold antibiotics, and 1 hehe tis neceseary to montor te babys vl tigre and anal concion = montorng fs teed continue for atteast 12 hour (a 8 hours and then 2 nour for YO nous). Cinical concems arise during the period of observation Inbabies being monitored for possible infection if No further concems arse ‘during the period of observation Consider performing investigatons and starting antbotc teatment Reassure he family and, ifthe baby is to be discharged, give ‘advice to the parents and carers. | Scanned with CamScannerAntibiotics for early-onset neonatal infection ji indicators of possible-early-onset neonatal infection Table, aflons and events in the baby), including ‘red flags’ el Clinical indicator Red flag ‘Aitered behaviour or responsiveness Titered muscle fone (for example, floppiness) | Feeding affcuties (for example, feed refusal) Feed intolerance, including vomiting, excessive gastric aspirales and abdominal v “Abnormal hear rate (bradycardia or tachycardia) distension ‘Signs of respiratory distress Respiratory distress starting more than 4 hours after bith Tiypoxia (for example, ceniral cyanosis or reduced oxygen saturation level) “Jaundice within 24 Roure of birth Apnaes ‘Seizures v Teed or eario-puTorary eaTaNT | Need for mechanical ventilation in a preterm baby . Persistent fla circulaon (parisien pulmonary hypertension | Tempers absomaliy (ower Tan 36°C or nigh han 36°C) unexplained by ‘Signe of shock [7 Unexplained excessiv e bleeding, thr jopenia, or abnormal on (internat eee ave Bleeding, thromboeviopenia, or abnormal coagula ised Ratio greater than 2.0) ‘Oliguria persisting beyond 24 hours after Bian ‘Altered glucose homeostasis (hypoglycaemia or hyperaveaeri@) Metabolic acidosis (base deficit of 10 mmoliive or greater) Local signs of infection (for example, afecing he Sk Or Bye) Scanned with CamScannerHypothermia Therapy for Neonates 2 35 Weeks Gestation With Moderate or Severe Hypoxic Ischaemic Encephalopathy (HIE All four criteria must be met before cooling is commenced 1. Newborn Infant born 2 35 weeks gestation & > 2kg 2. <6 hrs post birth 3. Evidence of asphyxia as defined by the presence of at least 2 of the following 4 Criteria: a. Apgar scores < 6 at 10 min or continued need for resuscitation with positive pressure ventilation +/- chest compressions at 10min after birth b. Any acute perinata! event that may result in HIE (ie. Placental abruption, cord prolapse, severe FHR abnormality etc) oO c. Cord pH < 7.0 or base deficit of -12mmol/. or more d. If cord pH is not available, arterie! pH <7.0 or BE > -12mmoL/L within 60 min of irth 4, The baby has Thompson Score > 7 or seizures oO Exclusion criteria Oxygen requirement > 80% that is not responsive to treatment Major lethal congenital abnormalities Severe clinical coagulopathy (including low platelet counts) not responsive to treatment / coagulopathy with overt bleeding Baby unlikely to survive. This should be discussed with and de: nier. by the neonatologist /eyevalist . When to start cooling | 2 » Cooling should be started as soon as possible after resuscitation is completed. S Cament evidence suggests that cooling is unlikely to be beneficial if started more than 6-8 hours after birth. jefore cooling ; Boor reure adequate resuscitation and support for the neonate including airway, breathing, circulation and dextrose Avoid hyperthermia > 37°C as this can increase the risk of adverse outcome. ee Scanned with CamScanneiMethods of cooling + Total body cooling (with therapeutic hypothermia device) + Passive cooling +/- active cooling (with cool packs) Passi ool This is a process of allowing the infant to cool down of their own accord through the removal of the usual interventions undertaken to keep infants warm, Aims * To achieve an axillary temperature between 33.5°C and 34. 8°C or rectal temperature between 33°C and 34°C within 60 minutes of commencing cooling + Totarget hypothermia initially with passive cooling + If rectal temperature remains > 36°C or axitary temp >35.6°C within 60 minutes of starting, then active cooling should be commenced * Toco! baby for 72 hours then rewarm slowly over 12 hours, Procedure * Infant must be nursed on open bed wh warmer off (DO NOT nurse infant in incubator) Nurse infant naked: NO clothes, cap or any wraps. Leave r ~ Full cardiopulmonary monitoring and ©. saturation monitor Record: Time of commencement of pc sive cooling and rectal (wherever possible) oF axillary temperature every 15min If rectal temperature. drops < 33,59C ( warmer on servo-control mode at the temperature at 33.5-34.5°C or rectal t Active Cooling Active cooling must only be infant's rectal temperature i oy udastened {axillary temperature below 34% lowest temperature to maintai temperature at 33.0 ~ 34,0°C C) set radiant in axillary Started i passive cooling has been underway for 1 hoy 's >35°C (axillary temp >35.59C), Pit Aims * Toachieve target temperature range within 1 hour Procedure * Use cool packs from the fridge, NEVER frozen. AWays wra bags. They should never be applied directly to the skin * Cold packs can be placed under the shoulders/upper back under the head angy, across the chestbody but not in the axilla where the accuracy of temperature” monitoring, Refer to Fig. 1 for number of coo} Packs to be used and the algorithm in, Fig. 2 Aim for rectal temperature 33 . 34°C within the first hour of cooling, F, temperature, aim for 33.5 ~ 34 50¢ " ‘9: For axittary a .,,Figure 1 Rectal Temperature algorithm (Axillary temp in brackets) Number of cool packs to be applied Areas to apply 335.0C (35.550) ¥ under shoulders, along sides 34.0 - 35.0°C (34.5 -35.5°C) 7 along sides <34.0°C (<34.5°C) 0 Nil NB: Having more than 2 packs prevents radiant loss of heat into th vironment and makes it more difficult to cool the baby + Record time of initiating active cooling and monitor temperatures every 15 minutes. ‘* Ifrectal temp drops to <34°C (axillary temp <34.5C), remove all cool packs and repeat temperature in 15 minutes. ‘* Ifrectal temperature continues to fall <33.5°C (axillary temp <34°C ), set radiant warmer on servo-control mode at the lowest temperature to maintain rectal temp at 33.0 - 34.0°C (axillary temp at 33.5-34.5°C) Application of Rectal Thermistor Probe «Insert Rectal Thermistor/Probe at least Scm into anus © Secure the probe at the 10cm (first marking) measurement with tape to the upper inner thigh | Note: The probe must be at least Scm into the anus to accurately measure the baby's core temperature. Connect rectal probe to cable, temperature module and monitor Set temperature alarm limits at 33°C (low) and 34°C (high) during the cooling period Record time of initiating Active Cooling and monitor Rectal Temperatures every 15 minutes. Duration of therapeutic cooling. «Normal cooling should be continued for 72 hrs from the commencement of cooling. «Consider stopping cooling early If there Ie: 1. Persistent hypoxemia in 100% oxygen Coagulopathy with overt bleeding 5 a canyon requiring medical treatment (not sinus bradycardia), or ‘palliative care considered and after mutual agreement between parents and ior clinicians. se ne ty scanned win ConeeemicrRewarming ‘Aim: To rewarm slowly over about 12 hours and to avoid making the baby hyperthermic. F Method: . ‘Apply skin probe and turn the radiant warmer on with the servo set at 345°C 2 Increase the set temperature by 0.5°C every 2 hours until reach 36.2 to 36.5°C and rectal temperature ts 37°C. (It should take up to 12 hours for rewarming)"* 3. Monitor axillary temperatures frequently as the rectal temperature approaches the target range. Monitor infant's temperature carefully for 24 hours after normothermia has been achieved to prevent rebound hyperthermia NB : Rewarming can occur too rapidly so babies need close monitoring. If baby is rewarming too rapidly increase set temperature by 0.5°C every 4 hrs instead of 2 hourly. Avoid hyperthermi ‘Ongoing Monitoring * Continuous arterial BP and rectal temperature + aEEG monitoring if available. en (arterial access is usually obtained); 4-6 hourly at least initial y clinical state (includes glucose and lactate and ionised calci * Full blood count ly then as. ium) * INR and APPT ciot 9 studies; on admission & if deranged as needed LET/ RP on day 2 and § | * Hypotension: Treat - at Considered if the m milkg of norm: | using inotropes ( ment with volume replacement and/or inotrope: ean arterial blood pressure is less than 40 mm He eld be al saline may be given initially and if the BP remaing eos of 10. either dopamine or dobutamine) OW, Consider Renal i 7 TPairment: Resuscitation of fluids as needed. TF 40-6omincgig, lay * Enteral Feedi Troph i biochemioa "9: ToPhic feeding of 1-3co/hourly can be introdu and metabote disturbance are corrected, Usually after qenc® the initi Out 24 hou! edative Th : itabilty, A noah’, S'9Ns of distress include tachycardia, facial gr infant may bona te consistently above 110 BPM IN costed infanty ToD an 10ugikaihr, Mont"@SS€4. Ventilated infants may be sedated wath mes abests that hi "7 . accumulation andl reenay be ciscontrued ater 24-48 ROUTS to loggers infusign © tisk of ne = canned with CamScannerSide effects / Complications / Precautions Sinus bradycardia-usually transient and reversible Decreased blood pressure - usually transient and reversible Increased oxygen requirement Mild thrombocytopenia (50,000- 80,000) Increased bleeding tendency Prolonged drug half-life - morphine (only need half the amount) and phenobarbitone Too rapid rewarming causing peripheral vasodilatation and hypotension ‘Adapted from: Royal Hospital For Women Sydney Guideline on “Cooling For Hypoxic-Ischaemic Encephalopathy (HIE) In Infants > 35 Weeks Gestation Encephalopathy Scoring System used : Thompson Score Thompson CM, Puterman AS, Linley LL, Hann FM, van der Elst CW, Molteno CD, Malan A The value of a scoring system for hypoxic ischaemic encephalopathy in predicting heurodevelopmental outcome. Acta Paediatr 1997; 86: 757-61 Scanned with CamScanner _2 3 Tone normat hyper hypo flaccid Loc normal hyperalert, stare lethargic comatose | Fits none <3 per day > 2 per day | Bosture normal —_ fisting. cycling strong distal flexion decerebrate Moro normal partial absent Grasp normal poor absent Suck normal poor absent + bites Respiration normal —_hyperventiation brief apnea IPPV (apnea) Respiraiie, normal —_‘full,nottense tense Date a Time | | — i ‘Tone — _ [_ Loc | 1 Fits Posture i Moro c —|— | Grasp. = [Suck | Respiration = = Fontanelle 7 TOTAL Tt Thompson CM, Puterman AS, Linley LL, Hann FM val : ; . n der Elst C.V Malan AF. The value of a scoring system or hypoxic Seer ereS 2, topathy in predicting neurodevelopmental outcome. Acta Paediatr Near Tees 757-61 canned with CamScannerFigure 2 Passive Cooling +/- Active Cooling (cool packs Baby > 35 weeks and < 6 hours after birth Probable intrapartum hypoxia 's Thompson Score > 7 or presence of seizure? I [re] Commence Passive Cooling ‘© Continue to observe and * Monitor rectal (or axillary) temperature maintain normothermia every 15 mins * Repeat Thompson Score every + Aim for rectal temperature of 33°C - 34°C hour and commence cooling if (axillary temperature 335°C 34,5°C) score > 7 or presence of seizure J One hour after commencing Passive Cooling, rectal temperat...e sul > 35°C (or axillary temperature > 35. = ite ‘Commence Active Cooling with Cool Packs E ntinue F ssive Cooling See Fig 1 on number of Cool Packs to xc * Monitor rectal (or axillary) temperature used every 30 mins x4, than hourly * Monitor rectal (or axillary) temperature every 15 mins x 4, if stable, 30 mins x 4, than hourly ‘Aim for rectal temperature of 33°C - 34°C {axillary temperature 33.5°C ~ 34.5°C) to be achieved within 1 hour. © Aim for rectal temperature of 33°C- 34°C (axillary temperature 33.5°C — 34.5°C) to be achieved within 1 hour. If not, to start Active Cooling ‘Slowing down Active Cooling ] ‘* When rectal temperature < 34.5°C - reduce Active Cooling by removing one/some ‘Cool Packs’, ‘* When rectal temperature < 34,0°C - stop Active Cooling by removing all ‘Cool Packs’. Continue Passive Coolin « If rectal temperature falls < 33.5°C - Commence Servo Control. Set Servo Temperature control at the lowest | temperature to maintain target rectal temperature at around 33.5°C. | Rewarming starts 72 hours after commencement of cooling ‘© Apply skin probe and turn the radiant warmer on with the servo set at 34.5°C «Increase the set temperature by 0.5°C every 2 hours until set at 36.2 to 36.5°C and rectal temperature is 37°C. It should take up to 12 hours for rewarming. if baby Is rewarming too rapidly, increase set temperature by 0.5°C every 4 hours + Monitor with frequent axillary temperatures as the rectal temperature approaches the target range. | ey . el Scanned with CamScannerFEI EDING PROTOCOL FOR PRETERM BABIES OF BIRTH WEIGH) 8 KG SHART A {NORMAL RISK BaBiEs For those less than 1500 bj rth weight. ‘milk (EBM) available. feeding can be started within 24 hours Only if expressed breast rls/kg/day/ BIRTH WT | <800G6M__| 5 801-1200 GRAM 1202-1500 | — | GRAM 120 {150 _} 180 1501-1800 T cua 200 li [so [awe | JOM IS STRONGLY RECOMMENDED, to start feeding within 24-48 hours 5 Only with colostrum ‘expressed breast mik. NBM until EBM avalabie for fst ve days of feeding ISK FACTORS ~ (High risk babes are those with any one of thea) 1. Intrauterine Growth Retardation (IUGR) <10 th centile, 3 Prenatal Doppler study showing absent or reversed fw during diastole 3. Significant Asphyxia (Apgar Score 5 and below, at § min) 4. Hypotension requiring inotropes > 24 hours Consider starting feeds when in with unknown Dopplers ‘otropes 6 mcg/ kg/min and below. uring the weaning phase. pay Ta 2s a RTH Wr com | eam 4mm above tre srermnaaic Hed on ‘othe most lateral aspect of to vee, (V1), Ventricie in yp. Measu Behe Blane ot Canug, Yentcuter Scanned with CamScanner(Para-Sagittal) * Midline + Through ech lateral ventricie - showing «2udo-thalamic notch + Through eact: laterai ventricle - showing Anterior and Posterior Horns + Parenchyma :ateral to the ventrici: ur deep white matter imaging 4.0 Image storage ‘All images should include the infant's name and hospi performed. Electronic PACS preferred or hard copy should be key feaching purposes. Printed thermat paper images degrade with tim recommended for storage. ital number as well as the date pt for record, audit and ye and are not 5.0 Reporting The person who pet have seen the images in notes, and it is recommend Reports should include comments about.. ‘The ventricular system - size, shape, measurements (f appropriate) Presence of absence of Haemorrhage and a description of tis Presence or absence of Periventricular parenchymal changes Any other findings Rexommendation for follow up imaging if indicated. position to report their findings, as they rt for each study should be filed in the PACs ) forms the scan is in the best real time. A written repor fed also kept on a central database. ( to describe the appearance af the images, as there has been a Mave ing haemorthages according to ‘grade’ in recent years. These It is good practice ‘correlated to the pathological processes. away from classifyi classifications do not 6.0 Documentation : curate documentation is essential Patient Name and Hospital number tbe documented on each image ‘Archive to PACS preferred ; File Hard copy of images in the notes oF scanning folder. File copy of report in the notes OF appropriate document this according Ye local procedures Mosca ono by a Consultantsenior colleague Document when a scan is reviewed 7.0 Communication with Parente 7.2, mnportant to explain 10 parents about the iascx and premature babies at 2” early stage pecome extremely anxious, 8Bovt the results of scans and so it is essential to rare ne rth et sat oo ro limitations of scanning 48 @ predictor of fong tor functional outcome, routine nature of cranial ultrasound scanning ‘of their child's admission. 8.0 Audit ‘This guideline should be regulary ‘audited. Suggested specific standards Include: of preterm infants ‘scanned according to suggested timetable 2 Percentage tof timely discussion about scan findings with parentsAppendix 1 How to Measure Ventricular Index Image in the Coronal plane Capture an image showing both the Lateral ventricles and the Third ventricle Measure Horizontally from ti: midline, to the later! most border of each Lateral ventricle ! \ ' ' ! | 1 1 i vi vi 1 Scanned with CamScannerOe ee 4mm over 97th centile 97th centile Ventricular index (mm) Source: Levene et al. 1 26 28 30 32 34 36 38 40 Arch Dis Child Gestational age (weeks) 1981; 56:900-904 Appendix 2 G Scanned with CamScannerINFANT BORN TO MOTHER WITH CHICKEN POX (VARICELLA) maternal infection (onset of rash) within 5 days chance of developing neonatal ‘Mortality is high (20%-60%). Infants born to a mother with before and 2 days after delivery have a 17-30% varicella with lesions appearing at 5-10 days of life. TREATMENT Infants born to mothers who develop varicella between 7 days antenatally and 7 days postnatally should receive: * 125units Zoster immunoglobulin (ZIG) as soon as p hours). + IFZIG is not available, give IV Im effective) AND Acyclovir 20 mark; Ikg/day) for 7 days. jossible (within 72 mmunoglobulin 400 mg/kg stat ( this is less g over 1 hour every Bhrly (total 6Omg 10 mg/kg over 1 hour Infants who develop vesicles should receive IV Acyclovir 21 immunoglobulins are every Bhrly (total 60mg /kg/day) for 7 days. In such cases, nao longer helpful sions at time of delivery should be isolated from their is contraindicated. Mothers should express their ith the EBM. Breast-feeding is commenced when all Women with varicella les babies and breast-feeding breast milk and babies fed wi the lesions have crusted. Infants with varicella lesions should be isolated from other infants but not from their mothers. ee Edition 2018 Page 8 Scanned witl amScannerMANAGEMENT In non-haemolysed Bl potassium level: food, | Management 85-65 mmol + Exclude iatrogenic source of K™ + Exclude renal impairment 6570 mmol + Exclude the above + Doanéce + IFECG normal, no need treatment >7.Ommal + Exclude the above + DoanECG, irespective of ECG to start treatment + 18 line : glucoserinsulin Infusion (0.1 Uikgthour insulin in 25% extrose given as an intravenous infusion via central ine). + line: Salbutamol infusion 4 mogikg in Smis water over 20 ‘minutes (repeat as necessary) ‘Anihythmias appearing Refractory hyperkalemia | + Giveimmeditely + IV 10% calcium gluconate 0.Smik dilute 1:1 with water, slow bolus AND + {stline: Glucose-insulin infusion (0.1. Ukg/hour insulin in 25% dextrose given as an intravenous infusion via central line, ‘(CK rise persists: Salbutamal infusion 4 megikg in Smis Water over 20 minutes (repeat as necessary) + acidosis: ge bicarbonate (Give calcium gluconate before bicarbonate) DO NOT GIVE CALCIUM AND BICARBONATE THROUGH THE ‘SAME LINE Consider resonium +} Ecc i TM Figure: Hyperkalaemi ia leads to tall peaked T waves, ventcuar antythm {hen sine wave QRS complex (before cardiac ares!) Nas widening of ORS REFERENCE; 1, Textbook of Neonatology .NRC Roberton 2 Neonatal Medicine Protocol Book , RPAH Edition 2018 ee Page Lt Scanned with CamScannerGLUCOSE IMBALANCE: NEONATAL HYPOGLYCAEMIA OSE LEVEL easier of ena Foponyesen ema cotton tis general aecoted as fucselovac2¢mnoit hn atema pret fln + InTeAifns estan have ca! Gels han Sol acceptale Means wc, sypomose an Sees ae HGH RISKINFANTS + irate Daetc Mars (OM) Shins Preterm fants Mazes ants» 404g Sikitrs neh hos wth evn Aaa resus deems Poke sen Hypothermia ‘SYMPTOMS + eriness and irtaitty ‘Apnoea and cyanosis, Hypotonia and poor feeding Convulsions ‘semi may be asymotomatt therefore montorng is portant for high risk cases PREVENTION AND EARLY DETECTION + dentify at risk infants + Well infants who are at risk * reealate feesing (Intl feeding shoul be given within + hour of given in Labour Room ) bith & can be 7, Supplement feeding uni breastfeeding is established * Unwell infants or those who cannot tolerate enter feecs + Setup dextrose 10% dip + Regular glucameter mortorng * Feary iCal onadisen, then 2:3 hou (belo feain) ng readings > 2.8 mmol/L least "Mucor: below the target tood glucose level 'epeat the glucometer and send RBS slat. {Examine and document any symptoms {Note when the ast feeding was given “Won dip, check ithe W detrse Is adequate and running we TANAGEMENT OF HYPOGLYCAEMIA ‘nslnfntls symptomatic AND the Woe sugar< 2.8 molt {Bots 10% at 23 malty + Followed by Di0% a day (or a ite glove (ei pt% dip at Bomikglday (or day one of ie ) tO maintain Hoon 2s recurs margins cos cee normaly : iready on D10% drip, consider increasine the rate or the gh + Repeat glucemeter ater yen ° =°8® concen ‘ood, "ration Edition 2018 Pagete Scanned with CamScannerBoe sugar 1 ~2.7 rl + "ie spline Er tr peal {flood spar remare es tan 28 rela ay inte, {hss on Dio ap conurnzeaang oreo Be centre coer GLUCOMETER MONTTORNG fi ucometeris<28mmlf,checlucometer vey rin + Hfglucometer > 2.8 mmol for 2 readings: 7 we Monto hour 2 © Then 2 hourly x2; Then 38 hourly (before feeding blood sugar remains normal PERSISTENT HYPOGLYCAEMIA + Re-evaluate the infant 1 Gonfrm nypogiycaemia wth RBS but treat as such while waling for RBS resut J Gonsider antibiotics if there are signs and symptoms of sepsis sk of sepsis Foams arp by 20miKg/day andlor increase the destrose concentration {012 Sor 15% eaneast alone of > 12.5% must be infused trough a central ne «hypogaea sl persists despite gucose delve >YOgKgi, conser glucagon infveton (especially IDMs) 6-20 megkg/hour cider giving Intravenous hydrocortisone 1 mal (dose 6 + In others especialy SCA, hourly mt needs > t2malkgmin fucose, consider hypernsuism ee te irverousdetose, const MOY Specs! srean CSOT yra meen + Oral fteding auld be encouraged 250 Te etogenic 1 Semmes + tone ogiycaemi sec soy ek fesse manined nea 1 Retracement (epee seats med ae mm Se gone to min. ent wth neritet detose boluses sore tment to palin aking no consideration problems ike mn 0 rena le Seto ness saa a ead une ¥ GM mothers fo" 3 i + RitorLGa fort pareurs aiucose requirement (mayan) = 1% of dentro x3 a a) — Page 17 Edition 2018 Se (oe) x 0.167GLUCOSE IMBALANCE: NEONATAL HYPERGLYCAEMIA DEFINITION ‘Serum biood glucose > 6.ammolf in term infants ‘Serum blood glucose > 8.3mmol in preterm infants MANAGEMENT 1. Confirm diagnesis, ‘+ Glucometer oF RBS > 1OmmolN on 2 occasions at least 2 hours apart +/ or positive Utne glucose 2. Investigate and treat underlying cause + Sepsis: start antibiotics + Excess glucose infusion : decrease rate or concentration of glucose (6-7mg/kg/min) Excess lpi infusion (>0.25q/kg/h) :decrease lipid infusion rate + Continue oral feeds + Consider insulin infusion 3. Inulin Infusion ‘© Criteria fr starting + Tolerating < 100 caloriesikg/day AND + Persistent glycosuria = 2+ 0° Blood glucose 2 on i Perot aycousia fr 10mmol on two occasions reper COTING FDTOR wth 3 p= ocalreskgdayy + Preparation + Make a 4 unin stock solution by sting 04 Dine ae (ston (0.4m todays tome a AO Us to . pee Osmikkg (2 writikg) of the 4 unitimt ‘stock solutic "om OSI ag ake @ O-tunit/Kgiml solution’ SOON to 20m with Nis Sse Aun)* 200 soitons tung = ‘unitsrkgm our. 010.4 ukgmhe leometer ‘+ Continuous insulin infusion: 0, + Sling seale according te gu [comments | To inform Mo + Monitoring + Intaly glucometer shoula ‘commenced = be monitor shen infusi Imerais* ~ 80 minutes: gmontored. closely ion is first 'r starting Infusion and then at oust Edition 2018 Pageis Scanned with CamScannerAPNOEA IN THE NEWBORN DEFINITION Pause in breathing lasting > 15 sec (term) or >20sec (preterm) during which the infant may develop cyanosis (SpO2 < 80%) and bradycardia (heart rate <100 per min). In very immature infants, shorter duration of apnoea may produce bradycardia and cyanosis. TYPES Central - absence of respiratory effort with no gas flow Obstructive — continued ineffective respiratory effort with no gas flow Mixed central and obstructive Perioc breathing ~ Regular sequence of respiratory pauses of 10-20 sec interspersed with periods of hyperventiation (4-16 sec) and occurring at least Sx/minute, not ‘associated with cyanosis or bradycardia AETIOLOGY 1. Respiratory conditions — RDS, pulmonary haemorrhage, pneumothorax, upper airway obstruction, respiratory depression secondary to drugs 2. Sepsis 3. Hypoxaemia 4. Hypothermia 5. CNS abnormality e.g. IVH, asphyxia, increased ICP, seizures 6. Metabolic disturbances - hypoglycaemia, hyponatraemia, hypocalcaemia 7. Cardiac failure, congenital heart disease, anaemia 8. Aspiration/ Gastro-oesophageal reflux 9. NEC/ Abdomen distension 10. Vagal reflex: Nasogastric tube insertion, suctioning, feeding Recurrent apnoea of prematurity Usually occurs after 3 days of life with no other pathological conditions. Most disappear by 34 - 36 weeks, but some may persist even after 40 weeks ‘corrected’ gestation. MANAGEMENT 1. Immediate resuscitation. + Surface stimulation (Flick soles, touch baby) * Gentle nasopharyngeal suction (Be careful: may prolong ay + Ventilate with bag and mask on previous FO (Be ea met to supplementary oxygen ifthe infant has been in ait as the child's lungs are usually normal and a high PaO2 may result in ROP.) nas are + Intubate and IPPV if child cyanosed or apnoea recurenvpersistent 2. Review possible causes (a8 above) and institute specific therapy * e.g. Septic workup If sepsis suspected and commen © Remember to check blood glucose via glucometer. ae Edition 2018 — Page S Scanned with CamScannerManagement to prevent recurrence. oN TKaep al Instone! range, Nursing prone "ay cedu~ -yisodes «i apnoea . Titrate the Fi02 to keep the PaO2 between 50 - 80 mmHg o: ~, 95% Monitoring - Cardio respiratory monitor ~ Pulse Oximeter Drug therapy: * Oral Caffeine sponte ancPhline (if patient is unable to tolerate orally ) Ifrepeated attacks, © Regular prophylactic tactle/surtace stimulation ¢ Nasal CPAP (PEEP 3-4 cm H20) © HENC (02 flow 2L kg) NIPPV (usually low settings) Edition 2036" Pages Scanned with CamScannerHIV Positive MO"HER Peri "inatal transmission rate: 13 — 30% (Breastfeeding increases the risk by 5%) 1 Infants to be admited tothe Nursery 5 Examine for signs of overt HIV infection + Review for any other neonatal problems * Exclude contraindications for Zidovudine 2. Oral Zidovudine is to be started wat s thin 12 hours after bir Zidovudine is Amgikg per dose (Term Fa a8 fo Sy weeks. Infants) every 12 hours and continued for 8 3. If mother is not treated or inadequately treated, to give Nevirapine &mg ( bith We'GN = 2k) or 2m (bith wea > ay ford doses see og ih ‘and 96hours after 2 dose. ‘ urs ee 4. Investigations © Atbirth FBC Refer table below for subsequent investigations 5. Immunisation to continue according to schedule * BCG can be given routinely at birth except if the infantis symptomatic — infants with HIV infection are rarely significantly immunodeficient at bith, + There have been no reports of adverse reactions to live polio, triple vaccines, measles or MMR. ‘+ OPVis safe for asymptomatic infants but IPV is preferred especially if the caretakers are HIV infected. ‘+ Hib and pneumococcal vaccines are also strongly recommended discharge 6. Counselling - to counsel the parents before ‘* Risk of having an HIV positive infant _ * Role of Zidovudine in reducing the risk of Lebel ted to the infant, its id risks and the importance of compliance Pax et weseleedhg (refer to Hospital Social Welfare for formula milk aid Fisk fr " two feat lug sees ood es needed tfno complications, infant can be discharged after 12 hours. inthe NICU at 2 weeks and 6 weeks old for blood taking and review. Follow up atic Clinic at 4 weeks. in the Paediatric Cinic at 4 9. stot ua ‘and development ton Crome or ‘signs and symptoms of HIV infection intolerance iors ‘social and financial problems Page 35 Edition 2018 Scanned with CamScannerFOLLOW UP AGE INVESTIGATIONS MANAGEMENT 2 weeks FBC, 1" PCR, LFT Continue ZDV 4 weeks or 2] Trace PCR, FBGLFT Continue ZDV Weeks after 1% PCR sent —_ [8 weeks. PCR, FBC Cease ZDV Start Bactrim prophylaxis (TMP4mg/kg OD) until the status is confirmed 2 weeks Trace 2° POR, FEC Continue Bactrim months 37 PCR | Continue Bactrim 5 months Trace POR ITPCR X'S negative, stop Bactrim confirmed HIV positive to refer Paediatrician [78 months HIV serology i negative POR —— 24 months HIV serology if negative PCR ‘Continue yearly follow up unt] /ears old ZIDOVUDINE i. Contra indications: Any fe threatening conditions of the INFANT Arpsitrbinaemia that requir treatment ether than photothe + Absolute neutrophil count « 750mm ad + Hb 8X normal 1m gandion that show a signicant iver and renal compromise * Hin doubts, consult the Paediaticnn Side Ertects: + General + Fever Nausea * Headache Malaise * band term carcinogenesis + GUgYomiina abd cstenion bleating + ens, + eta + Muse PNY 1 Myopay + Skin and nai + Haemataog 22! lamentation + Anemia Decrease In Twac In platelet + Neutropenia. Edition 2015 P, Bea Scanned with CamScanner