Government of Nepal

Ministry of Health
Department of Health Services
Child Health Division
IMNCI Section
2073
 PREFACE

In Nepal, annually 13,000 newborn babies die within the first 28 days of life and amongst
them one-third deaths occur in the first day of life. Risk analysis of premature deaths shows
that risk of death during the neonatal period is the highest. Seventy-eight percent of these
neonatal deaths is avertible and can be prevented through cost-effective interventions.

In order to prevent these deaths Government of Nepal, Ministry of Health has been extending
newborn care services from community to national level health facilities. Simultaneously,
efforts are also being made to enhance the knowledge and skills of the neonatal health care
providers.

As a result of the step towards reducing newborn deaths this "Comprehensive Newborn Care
Training Package (For Level II Hospital Care)" has been developed in order to provide training
to paediatricians, senior medical officers and medical officers working in the hospitals
providing level II care services.

I would like to thank Dr Rajendra Pant, Director, Child Health Division, Mr. Parashu Ram
Shrestha, IMNCI Section Chief, all the working staffs of IMNCI Section, IMNCI Technical
Working Group Members and External Development Partners who were involved in the
development of this training package.

Director General
Department of Health Services
Ministry of Health
 ACKNOWLEDGEMENT
It is a well-proven fact that Nepal has made remarkable progress in the survival of mothers
and children. However, the neonatal mortality (i.e. deaths during the first 28 days of life) rate,
which constitutes 63% of under-five mortality, has not reduced proportionately.

As indicated by various evidences, extra efforts are necessary in overcoming barriers to

accelerate the reduction in neonatal mortality. This indicates that apart from other things
focus is needed on building a strengthened health system supported by fully trained and
skilled health workers in all tiers of health facilities. Comprehensive Newborn Care Training
Package (For Level II Hospital Care) has been developed in order to provide training to
paediatricians, senior medical officers and medical officers working in the hospitals providing
level II care services, which I hope will be helpful in meeting this need.

I would like to thank all the contributors involved in the development of this training Package.
Special thanks goes to Dr Nisha Keshary Bhatta (BPKIHS), Dr Rupa Rajbhandari, Dr Kalpana
Subedi, Dr Laxman Shrestha, Dr Dhan Raj Aryal, Dr JR Dhakwa for their technical inputs. I
would also like to thank all partners specifically UNICEF team for their invaluable assistance
in developing and finalizing the package. Finally, I would like to acknowledge the leadership
taken by Mr Parashu Ram Shrestha, IMNCI chief and the team in giving this training package
its current form.

I strongly believe that this Training Package will be helpful in ensuring an uninterrupted
delivery of neonatal health care services through various levels of health care facilities by
developing quality human resources.
 LIST OF CONTRIBUTORS

S.N. Name of Participant Designation Organization

1 Dr. Rajendra P Pant Director CHD
2 Parashuram Shrestha Chief IMNCI CHD
3 Dr. Amrit Pokhrel Sr. MO (Pediatrician) CHD
4 Deepak Jha PHO CHD
5 Dr. Nisha Keshary Bhatta Professor BPKHIS, Dharan
6 Dr. Kalpana Upadhayay Chief Consultant PMWH, Thapathali
Subedi Pediatrician
7 Dr Rupa Rajbhandari Professor BPKIHS, Dharan
Singh
8 Hem Raj Pandey PHO FHD
9 Dr. Tekendra Karki Consultant Sumeru Hospital
10 Dr. Shrijana Shrestha Pediatrician Patan Hospital
11 Dr. Dhan Raj Aryal Consultant Pediatrician
12 Dr. Jyoti R. Dhakhwa Consultant Pediatrician Ishan Hospital
13 Dr. Ram Chandra Bastola Consultant Pediatrician WRH, Kaski
14 Dr. Kamal Raj Sharma Sr. Consultant Pediatrician SZH, Dhangadi
15 Dr. Laxman Shrestha Professor IOM
16 Dr. Deepeshwara Nepal Sr. Consultant Pediatrician NAMS
17 Dr Suchita Joshi Sr. Consultant Pediatrician PAHS
18 Dr. Shrijana Basnet Sr. Consultant Pediatrician IOM
19 Maiya Manandhar Matron PMWH, Thapathali
20 Kiran Bajracharya President MIDSON
21 Dr. Asha Pun MNH Specialist UNICEF
22 Dr. Ashish KC Child Health Specialist ,,
23 Chahana Singh Rana PO ,,
24 Deepak Paudel Health Director Save the Children
25 Bharat Ban ,,
26 Leela Khanal Manager JSI
27 Dr. Niraj Nakarmi SPO ,,
28 Bindu Bajracharya MNH Consultant UNICEF
29 Babu Ram Acharya NO ,,
30 Sabita Tuladhar Program Specialist USAID
31 Uttam Neupane PO H4L
32 Bhimsen Pant PHI CHD
33 Shyam Nepal DA CHD
34 Sita Sunar PO Save the Children
35 Deepak Kumar Chaudhary Consultant UNICEF

v
 TABLE OF CONTENTS
PREFACE ................................................................................................................................................. iii
ACKNOWLEDGEMENT ............................................................................................................................ iv
LIST OF CONTRIBUTORS .................................................................................................................. v
LIST OF FIGURES ............................................................................................................................. viii
LIST OF FLOW CHARTS .................................................................................................................... ix
LIST OF SKILL CHECKLISTS............................................................................................................. x
CHAPTER ONE COMMUNICATION/COUNSELING SKILLS ........................................................ 1
CHAPTER TWO INFECTION PREVENTION .................................................................................... 5
CHAPTER THREE ESSENTIAL NEWBORN CARE ....................................................................... 19
CHAPTER FOUR FEEDING NORMAL BIRTH WEIGHT AND LOW BIRTH WEIGHT
NEWBORN .......................................................................................................................................... 43
CHAPTER FIVE NEONATAL RESUSCITATION ............................................................................ 57
CHAPTER SIX THERMAL PROTECTION OF NEWBORN ............................................................ 73
CHAPTER SEVEN PMTCT AND MANAGEMENT OF INFANT BORN TO HIV POSITIVE
MOTHER.............................................................................................................................................. 89
CHAPTER EIGHT FLUID MANAGEMENT IN NEWBORN........................................................... 95
CHAPTER NINE SHOCK ................................................................................................................... 99
CHAPTER TEN HYPOGLYCEMIA ................................................................................................. 103
CHAPTER ELEVEN HYPOCALCEMIA ......................................................................................... 109
CHAPTER TWELVE PERINATAL ASPHYXIA ............................................................................. 113
CHAPTER THIRTEEN HYPERBILIRUBINEMIA ......................................................................... 117
CHAPTER FOURTEEN IDENTIFICATION OF SICK NEONATES ............................................. 127
CHAPTER FIFTEEN RESPIRATORY DISTRESS .......................................................................... 135
CHAPTER SIXTEEN NEONATAL SEIZURE ................................................................................. 139
CHAPTER SEVENTEEN DISORDER OF WEIGHT AND GESTATION ...................................... 147
CHAPTER EIGHTEEN NEONATAL SEPSIS ................................................................................. 157
CHAPTER NINETEEN ANEMIA AND BLEEDING IN NEWBORN ............................................ 167
CHAPTER TWENTY SAFE TRANSPORT OF SICK NEONATES ............................................... 173
CHAPTER TWENTY-ONE CLINICAL SKILLS ............................................................................. 179
1. Inserting a gastric tube ................................................................................................................ 179
2. Umbilical vein catheter ............................................................................................................... 181
3. Capillary blood sample (heel prick) ............................................................................................ 183

vi
 4. Continuous Airway Positive Pressure (CPAP) ........................................................................... 185
5. Oxygen therapy by hood ............................................................................................................. 187
6. Oropharyngeal suction ................................................................................................................ 188
7. Weighing technique .................................................................................................................... 189
8. Lumbar puncture (Nurses are required to assist the doctors performing Lumbar puncture) ...... 189
CHAPTER TWENTY-TWO EQUIPMENT REQUIRED FOR NEWBORN CARE ....................... 193
1. Radiant warmers ......................................................................................................................... 193
2. Pulse Oximeter ............................................................................................................................ 194
3. Infusion syringe pumps ............................................................................................................... 195
4. Phototherapy ............................................................................................................................... 196
5. Glucometers ................................................................................................................................ 197
6. Thermometer, Clinical, digital, 32-430C ..................................................................................... 197
7. Suction Machine ......................................................................................................................... 198
8. Weighing Machine (Electronic/Mechanical) .............................................................................. 198

vii
LIST OF FIGURES

Figure 1: Hand washing technique ............................................................................................ 9

Figure 2 proper technique to wearing and removing sterile gloves ......................................... 11
Figure 3 Toxic erythema .......................................................................................................... 34
Figure 4 Cutis marmoratum ..................................................................................................... 34
Figure 5 Milia .......................................................................................................................... 34
Figure 6 Stork bites .................................................................................................................. 34
Figure 7 Mongolian blue spot .................................................................................................. 35
Figure 8 Subconjunctival haemorrhage ................................................................................... 35
Figure 9 Epstein pearls............................................................................................................. 35
Figure 10 Umblical hernia ....................................................................................................... 35
Figure 11 Anecephaly .............................................................................................................. 37
Figure 12 Frontal enecphalocele .............................................................................................. 37
Figure 13 Occipital encephalocele ........................................................................................... 37
Figure 14 Nasal encephalocele ................................................................................................ 37
Figure 15 Spina bifida .............................................................................................................. 38
Figure 16 Cleft palate............................................................................................................... 39
Figure 17 Cleft lip, bilateral ..................................................................................................... 39
Figure 18 Cleft lip, unilateral ................................................................................................... 39
Figure 19 Cleft hard palate with bilateral cleft lip ................................................................... 39
Figure 20 Cleft hard palate with cleft lip ................................................................................. 40
Figure 21 Talipes equinovarus ................................................................................................. 40
Figure 22 Reduction defects of upper and lower limbs ........................................................... 40
Figure 23 Congenital Anomalies of Gastrointestinal Tract ..................................................... 41
Figure 24 Gastroschisis ............................................................................................................ 41
Figure 25 Advantages of Breast feeding .................................................................................. 44
Figure 26 Anatomy and physiology of lactation...................................................................... 45
Figure 27 Oxytocin reflex ........................................................................................................ 46
Figure 28 Prolactacin reflex ..................................................................................................... 46

viii
LIST OF FLOW CHARTS

Flow Chart 1 Primary apnoea .................................................................................................. 59

Flow Chart 2 Secondary apnoea .............................................................................................. 59
Flow Chart 3 Resuscitate the newborn as per the Helping Baby Breath (HBB) Guidelines ... 62
Flow Chart 4 Management of Hypothermia and Hyperthermia .............................................. 82
Flow Chart 5 KMC according to birth weight ......................................................................... 84
Flow Chart 6 Management of Shock ..................................................................................... 102
Flow Chart 7 Identify a baby with hypoglycemia ................................................................. 106
Flow Chart 8 Management of baby with symptomatic hypoglycemia .................................. 107
Flow Chart 9 Classification of Hypoglycemia....................................................................... 110
Flow Chart 10 Triage of sick newborns ................................................................................. 128
Flow Chart 11 Assessment and treatment of newborns displaying emergency signs ........... 129
Flow Chart 12 Flow chart for the management of acute neonatal seizure............................. 144
Flow Chart 13 Approach to newborns at risk of sepsis ......................................................... 162
Flow Chart 14 Approach to anaemia in NEWBORN ............................................................ 170
Flow Chart 15 Approach to bleeding Newborn ..................................................................... 172

ix
LIST OF SKILL CHECKLISTS

Skill Checklist 1 Infection prevention .................................................................................................. 16

Skill Checklist 2 Skin preparation for IM Injection / IV Cannulation .................................................. 17
Skill Checklist 3 Check list for Immediate Newborn Care at Birth ...................................................... 23
Skill Checklist 4 Initial detailed history and physical examination of the newborn (before 24 hours) 29
Skill Checklist 5 Newborn examination history and physical examination before discharge .............. 41
Skill Checklist 6 Breast feeding assessment ......................................................................................... 52
Skill Checklist 7 Expression of breast milk .......................................................................................... 56
Skill Checklist 8 Positive pressure ventilation (PPV) ........................................................................... 66
Skill Checklist 9 Maintenance of warm chain of babies in postnatal ward and advise to mother ........ 79
Skill Checklist 10 KMC procedure ........................................................................................................ 87
Skill Checklist 11 Feeding baby by cup.............................................................................................. 156
Skill Checklist 12 Insertion of gastric tube ......................................................................................... 181
Skill Checklist 13 Collecting blood samples by heel prick method.................................................... 185
Skill Checklist 14 Oxygen therapy by hood ....................................................................................... 187
Skill Checklist 15 Oro-pharangeal suction ......................................................................................... 189
Skill Checklist 16 Weighing ............................................................................................................... 189

x
 CHAPTER ONE
COMMUNICATION/COUNSELING SKILLS
1.1 Learning objectives:
After completing this session, the participant would be able to build trust and confidence
in sharing the health information to mother and
 Give better care and make the mother feel more comfortable and respected.
 Provide more effective and empathetic counselling

1.2 Good Communication:

Good communication skills are essentially the techniques you can use to show the mother
or family that you care and respect them and that you want to help. Their use will help you
to give better care and make the mother feel more comfortable and respected. Good
communication skills also involve body language, every gesture or action you make
should be culturally appropriate. It builds trust and confidence in sharing the information

The good communication skills include;

a. Showing respect
 Greet mother appropriately and ask her to sit with her baby.
 Treat the mother as someone who can understand her baby’s health problems and
can make good decisions about care.

b. Not being judgmental

 Never blame a woman for her or her baby’s problem, cultural practices, or past
decisions she has made.

c. Speaking clearly and using words the mother understands

For communication to happen, what is said needs to be understood by both the health
worker and the mother. If possible, speak with the woman in the language with which
she is most comfortable.

d. Listening actively
 Listen to what the mother says and how she says it
 Maintain silence for some time. Give the mother time to think, ask questions, and
talk.
 Offer feedback to encourage the mother to continue.
 Summarize what the mother has said.
 Provide praise and encouragement for positive behaviours or practices

e. Using good body language

 Smile.
 Maintain eye contact while talking and listening.
 Speak gently.
 If culturally suitable and acceptable, touch the mother gently on her arm or shoulder.

f. Encouraging the woman to voice her concerns and ask questions

 Answer her questions honestly
 Be communicative.

1
 g. Respecting the mother’s right to make decisions about her own health care and
that of her baby
 It is your responsibility to give the woman all the information she needs to make a
decision, not to make the decision for her.

h. Listening to what the mother has to say

 Give her enough time to tell you what she thinks is important.

1.3 Types of information to be provided in Neonatal Unit / Special Newborn Care Unit
Communication begins right at the time of admission of the neonate to the unit till time the newborn
is discharged or referred to higher centre and during follow up visit. Parents need to be informed at
each step of the neonatal care which includes
 The reasons for admission
 Initial diagnosis of the newborn at the time of admission
 Outline management plan
 Initial/current prognosis
 Changing clinical course /adverse event
 Information and consent regarding any intervention/procedure
 Reasons for referral and care during transport in case of emergency referral to higher centres
 Follow up information in case of discharge

1.4 Remember information provided should be

 Practical and in simple language easily understood by the parents/relatives
 Should be of immediate relevance
 Do not flood the parents with too much information at a single contact
 Avoid use of technical jargon
 Information provided may require repetition and reiteration for the parents to understand it
 Timing of providing information is crucial. Fix up a specific time daily
 Discussion should be unhurried and relaxed
 Preferably provided bedside so that the parents are oriented to the current situation of the baby
 Any bad news/adverse event should be disclosed in a quiet and private setting
 Documentation of the information provided to the parents is important. Hence document and
put signature especially after explaining poor prognosis/adverse events

1.5 Levels of communication

i. Communication at the time of admission to nursery
Discussion should be done after stabilization of the baby. Give honest opinion about the
condition of the baby. If congenital malformation is present inform parents about the
consequences of the disorders/malformation.

ii. Communication during stay

Communicate with the parents about the condition, treatment plan of the baby every morning
and evening and clear their doubts and quarries about the condition of the baby more frequently
if required. Mother should also be involved in the care of the baby whenever possible.

iii. Communication in case of death

If the babies are critically ill the family members should have been prepared for any eventuality.
The exact cause of death should be informed to the parents in the simple language
As soon as possible sit down with the parents to tell them about the condition of the baby.
Support the parents by giving clear and honest information in supportive and caring manner
Avoid negative comments.

2
 iv. Communication on discharge
Give standardize information to ensure that every family member receive uniform information
The family may be counselled regarding care, nutrition, immunization and follow up
Parents should be encouraged to contact the unit for any quarries and write contact number in
discharge sheet. Give clear information about the address of well-baby clinic, developmental
issues, information regarding ROP and hearing test and infection prevention

v. Communication at the time of referral to a higher centre

Explain clearly to the parents about clinical condition and reasons why baby needs referral.
Explain where to go, how to go and whom to contact on reaching. Explain the care that baby
requires during transport.

1.6 Counselling
Good communication skills are a significant part of counselling. When you counsel, you
talk person-to-person to help someone. If you use good communication skills, your
counselling will be more effective

1.7 Situation
Sabita gave birth to a healthy full term baby yesterday at BPKIHS. The baby is feeding
well and warm. The baby has passed stool and urine. Sabita is also fine. The doctor/ health
worker has examined the baby and all findings are normal. Now health worker advises
Sabita and Rama Devi about taking care of newborn at home.

3
 CHAPTER TWO
INFECTION PREVENTION
2.1 Learning objectives
At the end of this session, participants will be able to:
 Outline the sources of infection and different modes of transmission of infection in
newborn
 Enlist the standard precautions that are needed to follow to protect the newborn and
health workers from transmitting disease and infection
 Enlist the proper waste disposal
 Outline the post-exposure prophylaxis
 Enumerate six steps of effective hand washing

2.2 Introduction
Infection is a leading cause of newborn death. Newborn babies are more susceptible to
infection because of immature immune system. This is more so for preterm babies and low
birth weight babies. The neonatal sepsis accounts for one thirds of neonatal death. A good
antenatal care with immunization against tetanus, adequate treatment of infections in
mother decreases the incidence of infection in the newborn babies. Along with antenatal
preventive care, the simple infection preventive steps at home and health care facility adds
on to reduces the chances of newborn getting infected as well as reducing the risk of health
care worker getting exposed to infected persons. Prevention of infection is more cost
effective than treating infection. Every hospital should have written policies of infection
prevention. Prevention of infection is more cost effective than treating infection.

2.3 Sources of infection in newborn

Newborn with immature immune system, sick babies, premature and low birth weight
babies are always at high risk of developing infection. The infection is spread or caused by;
 Touching
o Touching an object that is dirty or contaminated spreads germs and contaminates
the hands.
 Blood and body secretion
o By a mother to her baby during pregnancy, birth, or with breastfeeding.
o Through sexual contact (parents).
o By contact with blood or amniotic fluid from an infected person.
 Air
o Infectious germs coughed into the air by an infected person and passed to others
who breathe in the air.
 Food and water
o Contaminated food and water (bottle feeding).

2.4 Persons at risk of infection while caring for the newborn

i. Health care workers
 Contaminated needles or sharp instrument may puncture skin.
 Contaminated blood or body fluids may splash on mucous membranes i.e. eyes,
nose or mouth.
 Infectious germs may enter broken skin.

5
 ii. Mother and babies
 Mother and babies are at risk when health workers do not wash their hands between
patients and procedures.
 They are at risk when used instrument and other items are not cleaned and processed
correctly.

iii. Community
 Improper disposal of medical waste including contaminated dressing, tissue,
placenta, needles, syringe creates a risk to the community.

2.5 Standard precautions and cleanliness needs to be followed while caring for the
newborn
These are routine procedures to protect both health care workers and patients from contact
with infectious materials.

While caring for the newborn certain precaution need to be taken to prevent infection.
These are as follows:
 Consider every person as potentially infectious.
 Wash hands.
 Wear gloves before every procedure.
 Wear protective clothing.
 Use aseptic technique.
 Use clean newborn clothes.
 Protect yourself from blood and other body fluids during deliveries and procedures.
 Practice safe waste disposal.
 Prevent injuries with sharps.
 Keep the newborn unit/patient care room clean.
 Isolate babies with infection to prevent nosocomial infections.

2.6 Basic requirements to follow infection prevention:

 Running water supply.
 Soap.
 Elbow or foot operated taps.
 Strict hand washing practice
 Adequate amount of disposables, such as;
 Sterile gloves
 Needle and syringe
 Disinfectant/antiseptic solutions.
 Instrument decontamination with 0.5% chlorine solution (virex) for 10 minutes
 Strict adherence to asepsis routines and good housekeeping.
 Rational use of antibiotics.

2.7 Infection prevention practices to follow during routine newborn care

i. At delivery
 Clean delivery area.
 Aseptic precautions while conducting deliveries
o Wash hands

6
 o Wear sterile gloves
o Wear protective clothing
 Clean delivery surface.
 Use sterile blade to cut cord and apply sterile cord tie/cord clamp.
 Use clean and dry newborn clothes.
 Clean cloth to cover the mother.
 Breast feed within half hour of delivery.
 Do not bathe the baby before 24 hours of birth.
 Practice safe waste disposal
 Sharp instruments
 Contaminated laundry
 Solid waste
 Liquid waste
 Sterilize and clean contaminated equipment
 Prevent injuries with sharps.

ii. During routine care

iii. After delivery
 All caregivers should wash the hand before touching the baby.
 Exclusive breast feeding.
 Keep cord clean and dry and use chlorhexidine
 Use clean cloth as diaper or napkin.
 Wash hands after changing diaper/napkin.
 Keep baby covered and wrapped with warm dry cloth and cover head.
 Consider every person potentially infectious.
 Reduce number of people handling newborn
 Reduce overcrowding (people and materials).
 After hand washing dry hand with clean cloth before touching the baby.
 Use dry and clean cloth (washed with soap and water and sun dried).

2.8 Guidelines for entry into the newborn corner/nurseries/NICU:

 Remove shoes, socks, woollens, watch, bangles and rings.
 Roll up the full sleeves up to elbow.
 Put on new slippers.
 Wash hands with soap and water.
 Put on gown.

2.9 Guidelines for Visitors for newborn corner/nurseries/NICU

 Babies are kept with mother in nurseries and newborn corner unless very sick and
requires NICU care.
 NICU should have limited person entering the areas.
 Only parents of the baby should be allowed to enter the NICU.
 Mothers should wear clean cloth and wash hands.
 Parents should be guided and supervised about proper hand washing technique.
 Any person with active infection should not be allowed into the baby care area.

2.10 Nursery environment:

 The nursery temperature should be maintained between 28-30 ̊ C.

7
  The environment should be calm and clean.
 There should be 24-hour water and electric supply with adequate ventilation and
lighting.
 Overcrowding should be avoided.
 Floor should be cleaned with dilute phenyl.
 Clean the walls with 2% disinfectant solution (such as bacillocid) once daily
 Dustbins should be washed with soap and water daily.
 Always use sterile gloves for invasive procedure.
 Wash gloved hands to remove the blood stains and secretion.
 Remove gloves and put in the black bucket
 Wash hands again with soap and water

2.11 Surveillance
 It is the monitoring of infection in the unit by conducting periodic surveys in order to
identify unusual pattern of flora and infections.
 Once in month
 It also includes monitoring of antibiotic use and resistance, whereby positive cultures
are reviewed every 4-6 months based on which antibiotic policy of the unit is revised,
if necessary.

2.12 Terminal Disinfection

Terminal disinfection is done after transferring out, discharge or death of a baby
Preferably all items of the baby to be kept in the incubator (babies infected with
multidrug resistance antibiotics)

Otherwise one can just do routine cleaning thoroughly

 Cleaning of bed:
o Clean the radiant warmer with soap water/ Disinfectant solution 2%
(such as bacillocid)
o Use autoclaved linen

2.13 Common infection preventive procedure

2.13.1 Hand washing
 It is the single most important means of preventing nosocomial infections.
 It is very SIMPLE and CHEAP.
 2 minutes hand washing to be done before entering the unit.
 20 seconds hand washing to be done before and after touching babies.
 Wash hands with soap and water.
o Before and after caring/touching for newborn and before any treatment
procedure
o Whenever hands (or any other skin area) are contaminated with blood or other
body fluids
o After removing gloves, because they may have holes
o After changing soiled napkins or clothing
o Keep nails short and do not apply nail polish

2.13.1.1 Preparing for hand washing:

 Remove jewellery (rings, bracelets) and watches before washing hands
 Ensure that the nails are clipped short

8
  Roll the sleeves up to the elbow.

2.13.1.2 Steps of Hand washing

 Wet the hands and wrists, keeping hands and wrists lower than the elbows
(permit the water to flow to the fingertips, avoiding arm contamination).
 Apply soap and lather thoroughly.
 Palms and fingers and web spaces by putting right palm over the left and then
left over the right
 Palm to palm and finger interlaced
 Back of the finger to opposing finger over-locked
 Rotational rubbing of right thumb clasped in left palm and vice versa
 Rotational rubbing backwards and forwards with tops of the fingers and thumb
of right hand in left and vice versa
 Wash wrist and forearm up to elbow
 Do not lower hand i.e. keep hand folded at elbow
 Close tap with elbow
 Dry hand using sterile cloth
 Hand rinsing with alcohol is not a substitute for proper hand washing.
 Keep hand folded at elbow
 Close tap with elbow
 Dry hand using sterile cloth / or dry hand in air
 If running water is not available, use a bucket and pitcher. Do not dip your
hands into a bowl to rinse, as this re-contaminates them.

Figure 1: Hand washing technique

9
2.13.2 Wearing sterile gloves

2.13.2.1 Indication for wearing sterile gloves

 Wear sterile gloves
o Receiving baby at delivery
o Cutting cords
o Eye care
o Invasive procedure
 Blood sampling
 Venous/umbilical catheterization
 Urethral catheterization or supra-pubic tap for urine collection
 Starting IV lines and giving IV/IM injections
 Giving skin, umbilical or eye care when infected

2.13.2.2 Procedure for wearing sterile gloves

 Scrub hands thoroughly with soap and water.
 Dry them completely
 Open the glove packet carefully without touching the gloves or the inside surface
of the packaging material (The cuffed gloves should be with the palms up)
 Pick up the first glove by the cuff, touching only the inside portion of the cuff
(the inside is the side that will be touching your skin when the glove is on).
 While holding the cuff, slip your other hand into the glove (Pointing the fingers
of the glove toward the floor will keep the fingers open)
 Be careful not to touch anything, and hold the gloves above your waist level.
 Pick up second glove by sliding fingers of the gloved hand under the cuff of the
second glove.
 Be careful not to contaminate gloved hand with ungloved hand as the second
glove is being put on
 Put second glove on ungloved hand by maintaining a steady pull through the cuff
 Roll back cuffs (unfold them).
 Adjust the glove fingers until the gloves fit comfortably
 Once sterile gloves are on, hold your hands up and away from your body and
always above your waist.
 After a procedure, rinse gloves in chlorine solution while still on hands, including
disposables
 After the procedure, always wash gloved hands to remove the blood stains and
secretions and rinse gloves in chlorine solution while still on hands, including
disposables
 Turn gloves inside out as you take them off and put into 0.5% chlorine solution
 Wash hands again with soap and water.

10
 Figure 2 proper technique to wearing and removing sterile gloves

2.13.3 Skin preparation for administering parenteral drugs

2.13.3.1 Indication
 Before IV cannulation or IM injection.
 For collection of blood samples for culture sensitivity and other investigations.

2.13.3.2 Steps of venepuncture

 Wash and dry hands.
 Wear sterile glove.
 Prepare skin site, confine to smallest area (5 cm) of skin.
 Swab with alcohol first, allow it to dry.
 Swab with iodine on site and allow it to dry.
 Swab again with alcohol to wipe off iodine.
 Skin is now ready for puncture or prick.

2.13.4 Common infection preventive steps to be taken in Nurseries newborn corner,

SNCU, NICU:
 Keep separate spirit and povidone iodine swab containers, stethoscope, measuring
tape and thermometer for each baby.
 Change IV set daily (as per feasibility).
 Use syringe, suction catheter once only
 Feeding tubes can be left alone as long as baby can keep.
 Do not keep fomites on the baby cot.
 Change the solution in suction bottles and sterile water in oxygen chamber every
day and sterilize the bottle daily by dipping in 2% gluteraldehyde for 4-6 hrs.
 Do not use a single dextrose/saline bottle for >24 hours.
 There should be a separate IV fluid bottle for each baby.
 Label the bottle with date and time of opening.
 Use syrup within 1 week of opening.
 Antibiotics vials to be changed after 24 hours.

11
  Use separate IV set for giving antibiotics.

2.14 Safe disposal of waste

The proper disposal of hospital waste is very important to prevent spread of infection in
hospital to other patients, health care workers and prevent the community from
contracting infection from hospital waste.

2.14.1 Disposal of various waste products

 Needle and syringe
o Burn needle with needle burner and cut the hub of the syringe with hub cutter
o Put these in a separate disposable box (Puncture-proof container)
o Send for incineration when box is three-quarter full

 Blood and body tissue

o Burn or burry solid waste
o Send for incineration in leak proof plastic bags
o Liquid waste into flushable drain if drainage system does not mix with stream

 Contaminated laundry
o Rinse off contaminated clothes with gloved hand.
o Do not mix with others
o Wash with soap

2.15 Terminal Disinfection

 Terminal disinfection is done after transferring out, discharge or death of a baby
 Preferably all items of the baby to be kept in the incubator (culture positive sepsis)
 Otherwise one can just do routine cleaning thoroughly
 Cleaning of bed:
 Clean the radiant warmer with soap water/ 2% (Disinfectant solution such as
bacillocid)
 Use autoclaved linen
 Put all the contaminated instruments in 0.5% virex for 10 minutes for
decontamination

12
2.16 The following equipment are cleaned as follows:
Articles Methods Frequency
Wash with soap and water and
Feeding utensils Before each use
then boil for 10 mins
Swab container, injection & Wash with soap and water and
Daily morning
medicine tray autoclave
Oxygen hood Soap and water Daily
2% Disinfectant solution (such
Weighing scale Daily
as bacillocid)
Stethoscope Spirit swab Daily
Body Linen Wash and autoclave Every use
Cotton gauze Autoclave As required
Procedures sets Autoclave Every use
Soap water/ 2% Disinfectant
Incubator solution (such as bacillocid - Daily
not occupied)
Cheattle forceps Autoclave Daily

Resuscitation bag and

Soap and water. Immerse in Weekly for resuscitation
reservoirs, oxygen tubing,
gluteraldehyde for 4-6 hrs. bag and reservoir. Daily
bottle and tubing of suction
Rinse in distilled water for others.
machine

Clean with soap and water,

immerse in 2% gluteraldehyde
Daily and after each use
Face mask for 20 mins, rinse in distilled
water, dry and wrap with
autoclaved linen
If used in infected baby,
Clean with spirit swabs wash with soap and
Laryngoscope
thoroughly daily and after each water. Put the blade in
use. Wrap in autoclaved cloth. 2% gluteraldehyde after
removing the bulb.

Bacillocid (each 100-gm composed—1,6, dihydroxy2,5 Dioxy hexane11.2 gm,

Glutaraldehyde 5.0 gm, Benzylkonium chloride 5.0gm, Alkyl urea derivatives 3.0gm)

13
2.17 Recommended colour-code for the container, labelling and international signs for
segregation of HCW

Waste category, symbol and labelling Colour code Examples of wastes

for
container
Non-risk health Non-risk waste Green Left over stuff foods, gardens,
care waste Biodegradables fruits peels, flowers, etc.

Non-risk waste Dark blue Non-biodegradable, which can be

recyclable recycled: plastic bottles, cans,
metals, glass, plastics, papers,
rubber, etc.

Other non-risk health Light blue Other health care waste, that do
care waste not belong to bio-degradable and
recyclable.
HCW requiring Pathological waste Red Human body parts, organs
special
attention

Hazardous sharps Red Needles, glass syringes with fixed

needles, scalpels, blades, glass,
etc. which may cause puncture and
cuts
Pharmaceuticals Red Unused and date expired drugs
Cytotoxic Red Waste with anti-neoplastic effect
pharmaceutical waste such as: alkylated substances, anti-
metabolites, antibiotics, plant
alkaloids, hormones, etc.

Infectious and Hazardous infectious Brown Discarded items contaminated

Highly waste with blood and body fluids from
infectious clinically confirmed infected
waste patients including cotton, dressing
materials, soiled plaster, linen,
bedding, swabs, gloves, syringes
without needle, infusion
equipment without spike,
bandages, other materials
contaminated with blood, dialysis
equipment, blood from patients
infected with HIV, viral hepatitis,
brucellosis, respiratory tract
secretion from patients infected
with TB, anthrax, rabies.

14
 Highly infectious Brown Waste generated from the
waste microbiological cultures,
laboratory waste, such as sputum
cultures of TB laboratories, highly
concentrated microbiological
cultures

Other To be discarded by Yellow Waste with high content of heavy

hazardous authorized staff only metals, such as batteries,
waste pressurized container, organic and
inorganic chemicals

Radioactive Radioactive waste Black Waste includes solid, liquid and

waste gaseous waste contaminated with
radionuclides such as Cobalt,
Technetium, Iodine, Iridium,
generated from in-vitro analysis of
body tissue and fluid, in-vivo body
organ imaging and tumour
localization

15
Skill Checklist 1 Infection prevention
Learner Name:
Date:
No. INFECTION PREVENTION Rating
Y ¥ NA
Wet hands with RUNNING WATER. When a water tap is not
available, use:
 A bucket with a tap, or
1
 A bucket and mug. One person pours clear water over the
hands of the person who is washing
 Use alcohol hand rub if no clean water is available
2 Put soap on hands
Each step below consists of 5 strokes backwards and
3
downwards
4 Rub palm to palm.
Rub right palm over left dorsum and left palm over right
5
dorsum.
6 Rub palm to palm, fingers interlaced.
Rub back of fingers to opposing palms with fingers
7
interlocked.
Do rotational rubbing of right thumb clasped in left palm and
8
vice versa.
Do rotational rubbing backward and forwards of tips of fingers
9 and thumb of right hand in left palm and vice versa. hand in
left palm and vice versa.
10 Continue washing hands and wrists for one minute.
11 Rinse hands under RUNNING WATER until all soap is gone.
If washing for pre-operative use, apply soap again and
12
continue washing for 2 minutes
Dry hands with clean paper or cloth towel, blower or air-dry
13
when no clean towel is available.
If you wash your hands before a procedure, do not touch any
14 unclean surfaces before touching the patient, touching clean
instruments, or before putting on gloves.
PUTTING ON STERILE GLOVES
Scrub hands thoroughly with soap and water. Dry them
15
completely.
Open the glove packet carefully without touching the gloves or
16 the inside surface of the packaging material. The cuffed gloves
should be with the palms up.
Pick up the first glove by the cuff, touching only the inside
17 portion of the cuff (the inside is the side that will be touching
your skin when the glove is on).
While holding the cuff, slip your other hand into the glove.
Pointing the fingers of the glove toward the floor will keep the
18
fingers open). Be careful not to touch anything, and hold the
gloves above your waist level.
Pick up second glove by sliding fingers of the gloved hand
19
under the cuff of the second glove. Be careful not to

16
 Date:
No. INFECTION PREVENTION Rating
Y ¥ NA
contaminate gloved hand with ungloved hand as the second
glove is being put on.
Put second glove on ungloved hand by maintaining a steady
20
pull through the cuff.
21 Roll back both cuffs (unfold them).
22 Adjust the glove fingers until the gloves fit comfortably.
Once sterile gloves are on, hold your hands up and away from
23
your body and always above your waist.
24 Be careful not to touch anything outside the sterile field.
After a procedure, rinse gloves in chlorine solution while still
25
on hands, including disposables
Turn gloves inside out as you take them off and put into 0.5%
26
chlorine solution

Skill Checklist 2 Skin preparation for IM Injection / IV Cannulation

Learner Name:
Date:
No. Rating
Y ¥ NA
Remove rings, fold the sleeves above shoulder and nail
1
clipped
2 Wash hand with soap and water
3 Wear sterile gloves
Swab with alcohol first in circular manner from inner to outer
4
and allow it to dry
Now swab with iodine in circular manner from inner to outer
5
and allow it to dry
Swab again in same manner with alcohol to remove extra
6
iodine

17
 CHAPTER THREE
ESSENTIAL NEWBORN CARE

This session includes:

 Preparation before delivery
 Care of the baby at the time of birth
 Assessment of newborn baby during first 24 hours of birth and before discharge
 Counsel mother and family members about good newborn care practices

Preparation before delivery of baby

3.1 Learning objectives

After completing this session each participant will be able to:
 Outline the preparation needed to be done before the birth of a baby
 Enlist the equipment required at the time of delivery of a baby
 Enlist the essential history in mother to anticipate the problems

3.2 Introduction:
Newborn care starts before the birth of the baby. The good newborn health depends upon
a good maternal health and nutrition, especially during pregnancy, labour and post-
delivery. The well monitored antenatal care with adequate immunization, screening for
various diseases and micronutrient supplementation helps to have healthy newborn. A well-
prepared birth plan helps to prevent from having complication related to delivery as well
as prepare the facilities to deal with complications. Ideally all deliveries should be
conducted in well-equipped health care facilities with skilled obstetrician and paediatrician.
However, all the centres where deliveries occur should have certain minimum basic
infrastructure and equipment, infection prevention guidelines and well trained human
resource to conduct delivery, provide immediate newborn care, conduct basic resuscitation
and appropriately identify and manage life threatening problems at birth. Following are the
certain basic requirements of the centres where deliveries are done.

3.3 Infection Prevention at delivery:

3.3.1 Clean delivery
 Clean hand
o Hand washing
 Clean delivery surface
 Clean cord cutting instrument
 Clean string to tie cord/cord clamp
 Clean and warm cloths to wrap the baby

3.4 Basic Infrastructure/equipment:

3.4.1 Adequate space
3.4.2 Adequate ventilation
3.4.3 Delivery room
o Radiant warmer/blower/heater (25 – 28OC)
o Adequate light
o Privacy Maintained

19
3.4.4 Furniture
o Clean bed for mother
o Bed curtain
o Clean surface to put equipment and baby
o Watch with second hand
o Light sources

3.4.5 Linens
o For mothers
 Clean and dry bed linen for mother
 Blankets
 Macintosh or plastic sheet to put under the mother
 Extra cloths to use as perineal pads

o For newborn
 Clean towels for baby
 Clean, warm and dry clothes for baby

2.4.6 Equipment needed to prepare for birth

o Protecting clothes
 Sterile gloves
 Mackintosh
o Delivery kit
o Newborn resuscitation equipment
o Apply chlorhexidine gel (4% w/v) to the Cord
o Stethoscope
o Weighing scale
o Wall clock with second hand/ digital watch
o Identification tag

2.5 Skilled human resource for adequate management:

A well-trained healthcare worker to provide immediate newborn care, basic resuscitation
and to appropriately identify and manage life threatening condition at birth. To anticipate
the problem in advance and prepare accordingly following are noted:

3.5.1 Problem anticipation

o Reach delivery room at least 15 min before delivery
o Important history in mother
 Diabetes
 Hypertension
 Eclampsia
 Fever
 Urinary tract infection
 Gravida and Parity
 Time of rupture of membrane
 Duration of first stage
 Medications
 Chronic diseases
 Bad Obstetric History

20
 o Find out foetal heart sounds FHS
o Signs of foetal distress include
 Foetal heart rate <120 or >160 before labour begins or
 Foetal heart rate <100 [during labour] or
 Foetal heart rate >180 [during labour]
 Thick meconium stained amniotic fluid
o Read partograph
o Recording progress of labour
o Alert and action lines
o Danger signs of labour and delivery
o Prolonged labour >24 hours
o Labour before completion of 37 weeks of gestation
o Baby in an abnormal position
o Vaginal bleeding
o Severe headache/visual disturbances/convulsion
o Fever and/or foul-smelling vaginal discharge/PROM> 18 hours
o Check proper functioning of equipment

3.6 Care of the baby at the time of birth

(From birth to 1 hour of birth)

3.6.1 Learning objectives

At the end of this session each participant will be able to:
 Outline and perform routine care of the baby at birth

After birth the newborn needs to adapt to survive independently outside the uterus and
requires smooth transition from dependent intra-uterine life to independent extra-uterine
life. The first and most important changes are to start breathing. Following which there are
few basic needs of the baby which has major influence on the survival, wellbeing and future
health of the baby. To achieve these, basic needs of baby should be provided at birth. These
basic needs are as follows:

I. Basic needs of baby at birth

 Warmth
 Normal breathing
 Feeding
 Protection from infection

These are the basic needs of ALL babies at the time of birth. Newborn are dependent
on mother and/or the care-givers to provide these basic needs. These basic needs
directly influence the newborn for their proper growth and development and disease
free survival.

II. Normal newborn care during second stage of labour

These are the steps followed other than initial basic resuscitation to provide the basic
needs of the baby at the time of birth. (Details of basic steps of resuscitation will be
discussed later).
These are;
 Call out time of birth

21
 o Accurate time of birth
o Alert others if help is required
 Receive the baby on a clean and warm towel and keep on mother’s abdomen
 Thoroughly dry the baby and stimulate while drying
o With warm towel dry thoroughly most of the fluid from baby’s body and head
(do not try to remove vernix)
o Remove wet towel
o Place the baby on mother’s abdomen over a clean dry towel and cover with
dry warm towel
o Asses baby’s breathing
 Normal breathing
o Crying/good effort
 Breathing regularly at the rate of 40- <60/min
o No grunting, chest in-drawing or gasping
o Pink lips, face and chest
 Decide if the baby needs resuscitation
o Not breathing
o Gasping (follow resuscitation protocol)

If baby does not require any resuscitation, then

 Clamp/tie and cut umbilicus
 2-3 mins after birth
o Put first clamp or tie 3 cm from baby’s abdomen and second clamp or tie 5 cm
from baby’s abdomen.
o Cut between the tie/clamp with sterile instrument
o Observe for oozing blood
 Place baby on mother’s chest with skin-to-skin contact
o This will help to maintain the temperature of the baby as well as promote early
breastfeeding
o Cover mother and baby with warm cloth and blanket and cover head with cap
 Encourage breast feeding
o Within 1 hour when ready. Indication of baby ready to be feed are:
 Baby looking around
 Moving
 Mouth open and searching
 Check for position and attachment
o Apply 4 % chlorhexidine gel wearing gloves
 Do not bandage or bind the stump
 Weigh the baby
 Give vitamin K prophylaxis (I/M 0.5 for < 1000 and 1 mg for rest)
 Monitor the baby
o Monitor baby every 15 min for next 1 hour and 1 hourly for next 6 hours
 Breathing
o Grunting
o Chest indrawing
o Fast breathing
 Heart rate
 Colour
 Warmth

22
  Bleeding from the cord
 Examine the baby quickly for malformation/birth injury. Quick but
thorough clinical screening is essential to identify any life threatening
congenital anomalies e.g. Meningomyelocele, trachea-oesophageal fistula,
anal atresia and omphalocele.
 Determine the sex of the baby and place identification tag

After immediate newborn care

Record
 Write records of immediate newborn care.
 Report to an appropriate person.
 Explain findings to mother and family (normal and abnormal)
 Make the room and equipment ready for next use.

Skill Checklist 3 Check list for Immediate Newborn Care at Birth

Learner Name:
Date:
No. Rating
Y ¥ NA
Preparation for a baby's birth
Preparation of facility, equipment and taking care of
measures to prevent infection
1 Ensure all surfaces, linens, supplies and equipment are clean
Adjust room temperature is (at least 25° - 28°C) and prevent
2 draught
3 Prepare warm, dry linens and make it ready for the baby
4 Prepare warm, dry, flat surface in case resuscitation is needed
5 Assure enough light to assess baby colour and breathing
Assist the mother to choose the person(s) to be with her for
6 support during delivery
7 Maintain privacy of the woman delivery
Make pen, new born identification tag, clock with seconds
8 hand and newborn record card, ready in room
Ensures availability of drugs/consumables for the immediate
9 newborn care
Protect self from splashes and spills by wearing protective
10 barrier
11 Wash hands using hand-washing guidelines.
12 Wear gloves
8 IMMEDIATE NEWBORN CARE STEPS (STEPS 1-3
HAPPEN AT ALMOST THE SAME TIME
13 Step 1: Call out the time of birth
• Receive baby on a clean cloth and warm cloth (Transverse)
14 on mother's abdomen
• Dry the entire baby, including the head with a clean warm
15
cloth (avoid removing vernix)
16 Discard wet cloth.

23
 Date:
No. Rating
Y ¥ NA
Keep baby on mother’s abdomen and cover with dry, clean and
17 warm clothes
18 Step 2: Assess breathing
19 • Check baby's breathing (normal, troubled, not breathing).
20 Step 3: Decide if the baby needs resuscitation.
21 • If baby needs resuscitation, use resuscitation learning guide.
22 If baby is breathing normally
23 Step 4: Tie and cut cord according to guidelines.
24 Clamp cord after 2-3 min
• If first clamp available, clamp 3 fingers from the cord and
25 second clam/tie 5 cm from the cord
26 • Use a sterile scissor/ blade to cut the cord between 2 clamp
• Use gauze or cloth to cover cord while cutting to prevent
27 splashing of blood.
28 • Apply chlorhexidine on the cord or stump.
29 Step 5: Give the baby to the mother to keep warm
30 • Put baby close to mother's chest or skin-to-skin.
• Cover both mother and baby together with a warm, dry cloth
31 or blanket.
32 • Cover baby's head.
33 • Explain to mother how important it is to keep the baby warm.
34 Step 6: Put identification mark on the baby
Step 7: Help the mother start breastfeeding within first
hour of birth.
• Do not separate mother and baby until baby has completed
35 first breastfeed.
36 • Help mother with her position.
37 • Help mother with baby's position.
38 • check for good attachment.
39 • Check for good baby suck.
Step 8: Give Vitamin K: Dose- 1mg IM for term babies,
40 0.5mg IM for preterm babies <1kg
AFTER IMMEDIATE NEWBORN CARE
Record
41 Write records of immediate newborn care.
42 Report to an appropriate person.
43 Explain findings to mother and family (normal and abnormal)
44 Make the room and equipment ready for next use.

3.7 Assessment of newborn baby during first 24 hours of birth and before
discharge
At the end of this session each participant will be able to:
 Provide the normal newborn care
 Assess the newborn baby during first day of life

24
 Counsel mother and family members about good newborn care practices at home.

3.7.1 Normal newborn care

The following are the most important steps while providing normal newborn care after
delivery and beyond;
1. Prevention of infection
2. Temperature maintenance
3. Breathing, heart rate, colour, capillary feeling time and activity
4. Cord Care
5. Eye care
6. Skin
7. Head
8. Mouth
9. Chest
10. Abdomen
11. Back and spine
12. Arms and legs
13. Anus
14. Female external genitalia
15. Male external genitalia
16. Breast feeding /Nutrition
17. Maternal counselling

3.7.1.1 Prevention of infection

After delivery
 All caregivers should wash the hand before touching the baby
 Exclusive breast feeding
 Keep cord clean and dry; do not apply anything except chlorhexidine gel
 Use clean cloth as diaper or napkin
 Wash hands after changing diaper/napkin
 Keep baby covered and wrapped with warm dry cloth and cover head
 Consider every person as a source of infection
o Reduce number of people handling newborn
o Reduce overcrowding (people and materials)
o After hand washing dry hand with clean cloth before touching the baby
o Use dry and clean cloth (washed with soap and water and sun dried)

3.7.1.2 Temperature maintenance

o Environmental temperature of 25⁰ - 28⁰C
o Keep windows close to prevent draught of air
o Ensure baby is wrapped and covered well
o Axillary temperature measurement
o Periphery equally warm and pink

3.7.1.3 Breathing, heart rate, capillary refilling time and activity

 Normal Breathing (count for 1 min)
o 30-60 breaths in 1 min
o No indrawing of chest or nasal flare
o No apnoea (periods of no breathing)

25
  Normal Heart rate
o 100-160 beats per minute

 Normal Capillary refilling time (CRT)

o Press over the sternum gently with thumb for 5 seconds and then release count
01, 02, 03
 < 3 seconds
 Colour
o Face, chest, tongue, and lips are pink
o Hands and feet may be bluish during the first 48 hours

 Posture and tone

o Arms and legs flexed

 Activity
o The baby moves both legs and arms equally and symmetrically
o The baby opens his mouth and turns his head to search for the nipple when his
cheek is stroked gently

3.7.1.4 Cord care – Apply Chlorohexidine

Umbilical Infections and Sepsis

Infection is the major cause of neonatal deaths in Nepal. The umbilicus is a major route
of entry of infectious agents in newborn, which can easily pass through the cord and
lead to sepsis and death. Infectious agents enter into the baby during the birth process
and through the umbilical cord. Ensuring chlorhexidine cord care at birth and in the
first week of life irrespective of place of births is a crucial strategy to prevent life-
threatening sepsis and cord infections, and avert preventable neonatal deaths. Diagram
below presents pathways of infections that could occur through umbilical cord
No local signs of infection Local signs of infection

Bloodstream infection No bloodstream infection

Survival Death Survival

Importance of Navi Malham (chlorhexidine gel)

 Chlorhexidine is a broad-spectrum antiseptic.
 Application of Chlorhexidine gel helps to prevent infections and deaths of
newborns.
 Chlorhexidine gel is safe and has no side effects.
 Chlorhexidine gel can be used by mother and family members easily after washing
their hands with soap and clean water
 Use of Chlorhexidine gel can replace traditional harmful practices of cord care

Points to consider before applying Chlorhexidine gel

Chlorhexidine gel should be applied after cord cutting. While applying Chlorhexidine
gel, only navel area of the baby should be exposed to prevent baby from hypothermia.
26
 Baby should be wrapped properly and kept warm before and after Chlorhexidine gel
application. Chlorhexidine gel takes 3-5 minutes to dry. So, naval area should be
covered lightly to prevent wiping off.
 Use sharp protuberance of the lid to break the inner shield of the tube and keep tube
in clean place
 Wash hand before and after cord care
 Fold nappy below stump
 Keep cord stump loosely covered with clean clothes
 If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean
cloth
 Look for redness or draining pus or blood Counsel mother for umbilical care

3.7.1.5 Eye care

 Redness, swelling and discharge
 Do not apply anything on eye

3.7.1.6 Skin
 Tiny white bumps on the face (milia)
 Bluish area over the lower back.
 Some peeling of the skin
 No icterus and pallor

3.7.1.7 Head
 Elongated or uneven (asymmetrical) shape due to moulding
 Caput succedaneum, a soft swelling over the presenting part of the head Flat
anterior fontanelle

3.7.1.8 Mouth
 No cleft of mouth and palate
 No teeth

3.7.1.9 Chest
 Symmetrical chest moving equally with breathing.
 Enlarged breast nodules >5mm

3.7.1.9 Abdomen
 Round and soft
 Umbilical cord
– Dry
– No bleeding
– No reddening of skin in and around the umbilical

3.7.1.10 Back and spine

 No curvature, dimple and tuft of hair

3.7.1.11 Arms and legs

 Equal and symmetrical movements of both upper and lower limbs
 No bowing, club feet, absent limbs and digits
 Equal number of digits
27
3.7.1.12 Anus
 Presence of clear cut opening
 Passage of stool within 24 hours

3.7.1.13 Girl’s external genital organs

 A white vaginal discharge or a bloody vaginal discharge that starts on day 2-3 and
continues up to day 7 is normal

3.7.1.14 Boy’s external genital organs

 The urethra opens at the end of the penis
 One or both testes are felt in the scrotum.

3.7.1.15 Breast feeding/ Nutrition (refer feeding and nutrition)

 Position
 Sucking
 Attachment

3.7.1.16Maternal counselling
 Breast feeding
 Infection prevention
 For checking adequate breathing, warmth and colour
 Cord care

28
Skill Checklist 4 Initial detailed history and physical examination of the newborn
(before 24 hours)
Learner Name:
Date:
No. Initial newborn examination Rating
Y ¥ NA
PREPARE BEFORE EXAMINATION
Prepare equipment: Thermometer, watch or clock with
1 second hand, scale for weighing (if available), clean clothes,
gloves
GET HISTORY OF PREGNANCY, BIRTH AND
IMMEDIATE NEWBORN PERIOD
Ask the mother or look at her prenatal and intrapartum
records to find out the following information:
2 Fever during labour
Duration of labour, mode of delivery, Bag of water broken more
3
than 18 hours before delivery, APGAR score
any other infections (hepatitis B, syphilis or other sexually
4
transmitted infections, HIV/AIDS)
Any other diseases (TB, Malaria, diabetes, chronic infections,
5
pre-eclampsia) or medicines and immunization?
6 Method, time and place of delivery
7 Was the amniotic fluid clear?
8 Was newborn resuscitation done?
9 How many times baby had passed urine in last 24 hours?
10 How many times has the baby breastfed?
Any prelacteal feed being given?
11 Does the baby feed on the breast well?
12 Do you think the baby is well?
13 Are you (mother or family) worried about anything?
PREPARE TO DO THE PHYSICAL EXAMINATION
14 Explain to the mother and family what you are going to do
15 Wash your hands thoroughly with soap and water
16 Dry with a clean dry cloth or air-dry
17 Place of Exam:
•Do exam with baby in mother's lap, if possible
• or do exam on a table or bed with a clean warm cloth covering
surface close to mother
Throughout the exam:
Explain to the mother and family what you are doing and answer
18
any questions they ask
19 Praise the baby as you do the exam
20 Handle the baby gently
DO PHYSICAL EXAMINATION
Without touching the baby, observe and teach the mother to
21
observe the baby's:
22 Breathing (count for 1 full minute):
• 30-60 quite breaths in 1 minute
• No indrawing of the chest or nostril flaring

29
 Date:
No. Initial newborn examination Rating
Y ¥ NA
• No apnoea (periods of not breathing for more than 20 seconds)
• Chest and abdomen move with each breath
23 Look at colour:
• Face, chest, tongue and lips are pink
• Hands and feet may be bluish during first 48 hours
24 Look at posture: Arms and legs are flexed.
25 Look at activity:
• Moves legs and arms equally
• Opens mouth and turns head to search for nipple when cheek is
stroked gently
• Touch the baby gently and check the following:
26 Heart rate (count for 1 full minute):
HR • 100-160 beats in 1 minute
27 Temperature:
• Normal: Axillary temperature between 36.5°C - 37.5°C
• If no thermometer available. Use back of hand to feel
abdominal wall and both lower limbs. Severe hypothermia
present if both the abdomen and feet feel cold.
• If baby is cold, either delay examination until baby is warm or
do exam near a heat source.
28 Look at skin:
• Normal: (Milia [white bumps on face] bluish area over lower
back, peeling of skin, pustules, blisters, red or purple spots)
29 Look at and feel the head:
• Moulding, caput
• Anterior fontanelle flat or bulging
30 Look at eyes: No discharge, not sticky
31 Look at and feel the mouth: Lips, gums, and palate intact
32 Look at the chest:
• Both side of chest move equally
• Breast nodules maybe enlarged in both girls and boys at birth
33 Look at and feel the abdomen:
• Rounded and soft
• Umbilical cord tied tightly, dry, not bleeding
34 Look at back and spine: Any swelling over spine
Look at anus: Do not insert finger or instrument to inspect the
35
anus
36 Look at girl’s external genital organs:
•Vaginal opening present (Discharge: normal to have white
vaginal discharge and bloody vaginal discharge that starts on day
2 or 3 and continues up to day 7)
37 Look at boy’s external genital organs:
• Urethra opens a end of penis
• one or two testes felt in the scrotum
38 Weight: Normal range is 2.5 - 4 kg
Watch the baby breastfeed
30
 Date:
No. Initial newborn examination Rating
Y ¥ NA
39 Position
40 Sucking
41 Attachment
42 Watch Mother-Baby interaction
43 Dress the baby or place the baby close to mother and cover both
DECIDE NEEDS / PROBLEMS
46 Compare your findings with the normal findings
47 If all is normal, tell mother her baby is healthy and normal.
If any of the findings not under " Normal Findings":
Gently explain to mother what abnormal findings may mean and
48
what action is needed
49 Explain Dos and Don’ts while caring for normal newborn

3.8 Examination of baby after 24 hours and before discharge

These steps are very important and need to be remember while providing the general
examination and care of newborn. While assessing the baby during first day of life there are
few important histories and examination which needs to be evaluated for identification of any
risk factors that can lead to sickness in baby. These are as follows:
1. History of antenatal care, birth and immediate newborn period
Mother
a. Fever, diabetes, hypertension, tuberculosis and chronic illness
b. Medication
c. Immunization
At birth
a. Duration of labour
b. Duration of rupture of membrane
c. Mode of delivery
d. APGAR score or neonatal resuscitation
e. Time and place of birth
f. Colour of amniotic fluid

Immediate newborn period

a. First breast feeding given
i. Any pre-lacteal feed
ii. Number of breast feeding in last 24 hours
iii. Number of times passage of urine and stool
a. History of poor feeding, vomiting, lethargy, abnormal movement and bleeding
from the cord

3.8.1 Newborn physical examination: normal findings

These helps in early identification and appropriate management of problems if present

31
1 Breathing Quiet breathing
No chest indrawing or flaring of nostrils
Chest and abdomen movement with each breath

2 Rate of breathing Count the baby’s breathing for 1 full minute:

o 30-60 breaths in 1 minute (when the baby is not
crying)
o May be periodic pause even up to 20 secs
without a breath
3 Heart rate 120-160 beats per minute
4 Colour Face, chest, tongue, and lips are pink
Hands and feet may be bluish during the first 48
hours
5 Warmth Baby’s abdomen, back and feet feels to be equally
warm
6 Posture and tone Arms and legs flexed
7 Activity The baby moves both legs and arms equally and
symmetrically
The baby opens his mouth and turns his head to
search for the nipple when his cheek is stroked
gently
8 Skin Tiny white bumps on the face (milia)
Bluish area over the lower back.
Some peeling of the skin
No icterus and pallor
9 Head Elongated or uneven (asymmetrical) shape due to
moulding
Caput succedaneum, a soft swelling over the
presenting part of the head
Flat anterior fontanelle
10 Eyes No discharge and the eyes are not sticky
11 Mouth No cleft of mouth and palate
No teeth
12 Chest Symmetrical chest moving equally with breathing.
Enlarged breast nodules >5mm
13 Abdomen – Round and soft
– Umbilical cord
o Dry
o No bleeding
o No reddening of skin in and around the
umbilical
14 Back and spine No curvature, dimple and tuft of hair
15 Arms and legs Equal and symmetrical movements of both upper
and lower limbs
No bowing, club feet, absent limbs and digits
Equal number of digits

16 Anus Presence of clear cut opening

32
 Passage of stool within 24 hours
17 Girl’s external genital organs A white vaginal discharge or a bloody vaginal
discharge that starts on day 2-3 and continues up to
day 7 is normal
18 Boy’s external genital organs The urethra opens at the end of the penis
One or both testes are felt in the scrotum.
19 Temperature Axillary 36.5 - 37.5ºC
20 Weight 2.5 up to 4 kg
Newborns normally lose 5% to 10% of their birth
weight but gains back the birth by 10- 14 days

3.8.2 Counselling mother and family member before discharge

Counselling helps a mother/family member decide what to do and how to do while caring
for a newborn. The most important things to tell to mother/family member are:
– Keeping baby warm
Adequate cloth with head cover and limbs cover
Check for hypothermia
 Keeping baby warm is more important than bathing
 Clean the perineal area with water and dry immediately after baby passes urine
or stool

– Prevention of infection
Washing hands before and after touching newborn
Minimal visitors
Washing nappies with soap and water after baby soils
Keep umbilicus clean and dry

3.8.3 Dos and Don’ts while caring for normal newborn

 Exclusive breast feeding
 Immunize as appropriate
 Learn about danger signs
 Mother should be getting iron and folic acid and adequacy about mother’s diet
 Do not put oil in eyes, ear, nose and umbilicus
 Do not squeeze newborn’s breast
 Do not apply kajal or gajal
 Do not try to warm baby by using coal and fire
 Do not give vigorous massage to the newborn
 Do not give water or any other medicine without consulting doctor

3.9 Common developmental peculiarities

These conditions do not require treatment just needs reassurance.

33
1. Toxic erythema or urticaria neonatrum
 An erythematous rash with central
pallor appearing on second day of life
 Starts on face and spreads to trunk and
other parts of the body within 24 hours
 Disappears spontaneously after 2-3
days
 Rare below 32 weeks of gestation

Figure 3 Toxic erythema

2. Peeling skin
 Dry skin with peeling and exaggerated
transverse skin crease
 Post-term and term babies

Cutis marmoratum
 Lacy, reticulated, red or blue marbled
cutaneous vascular pattern over
extremities in infants exposed to low
environmental temperature
 Preterm or near term babies Figure 4 Cutis marmoratum

4. Milia
 Yellow white spots on the nose
 Disappears spontaneously

Figure 5 Milia
5. Stork-bites
 Pinkish-grey sparse capillary
hemangioma
 Located in nape of the neck, upper
eyelids, forehead and root of the nose
 Disappears after few months

Figure 6 Stork bites

34
6. Mongolian blue spot
 Irregular blue patches of skin
pigmentation present over sacral area
and buttocks

Figure 7 Mongolian blue spot

7. Subconjunctival haemorrhage
 Outer canthus of eyes
 Blood resorbs after few days

Figure 8 Subconjunctival
haemorrhage

8. Epstein pearls
 White spots on the hard palate

Figure 9 Epstein pearls

9. Umbilical hernia
 Most disappear by one to two years
 If > 2 cm, requires intervention

Figure 10 Umblical hernia

35
3.10 Neonatal problems

3.10.1 Vomiting
 Vomiting on day one of life may be due to irritation caused by swallowed amniotic
fluid. If persistent, needs further evaluation.
 If vomitus is dark green, consider pathological
 Regurgitation after feed
o If weight gain is adequate. Reassess again.
 Proper feeding advice and burping
o If inadequate weight gain
 Needs detail evaluation
o Projectile with altered sensorium
o Raised intracranial pressure

3.10.2 Constipation
 Babies on cow’s milk/formula feed
o Breast feeding counselling

3.10.3 Diarrhoea
Most normal newborn on breast feeding have loose semi-liquid stool
 First few days’ green meconium to yellow
 Transitional stool third and fourth day
o Semi-loose
o Greenish-yellow
o Increased frequency
 Yellow seedy stool on breast feed babies
o Passage of small stool just after stool
 No associated dehydration or loss of weight

3.10.4 Breast discharge

 Maternal hormone causes hypertrophied breast and milk discharge
 Resolve spontaneously
 Squeezing should be avoided

3.10.5 Vaginal discharge

 Scanty vaginal bleeding on day 3-5 of life
 Greyish white vaginal secretion
 Benign
 Lasts 2-4 days
 Oestrogen withdrawal

3.10.6 Caput succedaneum

 Baggy, diffuse, oedematous swelling of scalp over the presenting part
 Pitting, non-fluctuant and not limited by sutures
 Disappears spontaneously over few days

3.10.7 Cephalhematoma
 Sub periosteal collection of blood
 Fluctuant swelling and does not cross suture line

36
  Disappears spontaneously (in weeks to months)
 Aspirated only if associated with infection or critical hyperbilirubinemia.

3.10.8 Visible birth defects

Congenital anomalies, also known as birth defects, are structural or functional abnormalities,
including metabolic disorders, that are present from birth. Congenital anomalies are a diverse
group of disorders of prenatal origin that can be caused by single gene defects, chromosomal
disorders, multifactorial inheritance, environmental teratogens or micronutrient malnutrition.
Major structural anomalies are the conditions that account for most of the deaths, morbidity and
disability related to congenital anomalies. Whereas minor congenital anomalies, although more
prevalent among the population are structural changes that pose no significant health problem in the
neonatal period and tend to have limited social or cosmetic consequences for the affected individual.
 Identify an initial list of congenital anomalies to consider for monitoring
 Define specific congenital anomalies under surveillance.

Congenital malformations of the nervous system: neural tube defects

Most of these defects are associated with various forms of neurological abnormalities at birth.

Figure 11 Anecephaly Figure 12 Frontal enecphalocele

Anencephaly Frontal encephalocele
A total or partial absence of the brain, Herniation of brain tissue, usually covered
together with total or partial absence of the by meninges, through a defect in the frontal
cranial vault and the covering skin. bone.

Figure 13 Occipital Figure 14 Nasal

encephalocele encephalocele
Occipital encephalocele Nasal encephalocele

37
Herniation of brain tissue, usually covered Herniation of brain tissue, usually covered
by meninges, through an opening in the by meninges, through an opening in the
occipital bone. nasal region

Figure 15 Spina bifida

Spina bifida
Most cases of cervical, thoracic and lumbar spina bifida will eventually develop
hydrocephalus, although this may not be immediately obvious at birth. Whereas only few
cases of sacral spina bifida develop hydrocephalous. Close follow-up of these neonates is
important for consideration of shunt surgery

Cleft palate and cleft lip

Many of these abnormalities lead to feeding difficulty and repeated aspiration while
feeding leading to aspiration pneumonia.

38
 Figure 16 Cleft palate
Cleft palate
Fissure of the palate, which can affect the
soft and hard palate, or only the soft palate.
Figure 18 Cleft lip, unilateral
Cleft lip, specified as unilateral
Partial or complete unilateral fissure of the
upper lip that may be associated with a cleft
of the gum.
39
Figure 17 Cleft lip, bilateral
Cleft lip, bilateral
Partial or complete bilateral fissure of the
upper lip that may be associated with a cleft
of the gum.
Figure 19 Cleft hard palate with bilateral
cleft lip
Cleft hard palate with bilateral cleft lip
Partial or complete bilateral fissure of the
upper lip, associated with a fissure of the
palate.
Figure 20 Cleft hard palate with cleft lip Figure 21 Talipes equinovarus

Cleft hard palate with cleft lip, specified Congenital malformations and
as unilateral deformations of the musculoskeletal
Partial or complete unilateral fissure of the system
upper lip, associated with a fissure of the Talipes equinovarus
palate. Combination of forefoot and hindfoot in
equinus (plantar flexed) and in varus
(rotated toward the midline).

Figure 22 Reduction defects of upper and lower limbs

Reduction defects of upper and lower limbs

Congenital complete absence of upper limb(s); amelia of upper limb
Complete absence of one or both upper limbs.
Congenital absence of both forearm and hand
Complete or partial absence of both the forearm and hand.

40
 Figure 23 Congenital Anomalies of
Gastrointestinal Tract
Congenital Anomalies of
Gastrointestinal Tract
Exomphalos/omphalocele
Congenital anomaly of the anterior
abdominal wall, in which the abdominal
contents (gut, but at times also other
abdominal organs) are herniated in the
midline through an enlarged umbilical ring.
The umbilical cord is inserted in the distal
part of the membrane covering the
anomaly. The herniated organs are covered
by a membrane consisting of the
peritoneum and amnion (but this
membrane can be ruptured).
Figure 24 Gastroschisis
Gastroschisis
Gastroschisis is a congenital anomaly of the
anterior abdominal wall, accompanied by
herniation of the gut and occasionally other
abdominal organs. The opening in the
abdominal wall is lateral to the umbilicus,
and the herniated organs lack a protective
membrane. Note that the extruded
abdominal contents can be matted and
covered by a thick fibrous material, but this
membrane does not resemble skin.

Skill Checklist 5 Newborn examination history and physical examination before

discharge
Learner Name:
Date:
No. Preparation Rating
Y ¥ NA
Prepare equipment you will need:
Thermometer, watch or clock with second hand, scale for
1 weighing (if available), immunizations with syringe, needle,
gauze (if needed), gloves, records
Explain to the mother and family what you are going to do,
2
encourage them to ask questions, listen to what they say.
HISTORY
3 Ask to see the newborn birth care records.
ASK about the Baby:
4 What have you noticed about your baby?
5 Have you seen anything in the baby that worries you?
6 Is the baby sucking well?
7 How often does the baby feed during the day and at night?

41
 Date:
No. Preparation Rating
Y ¥ NA
Does your baby wake up to breastfeed at least every 2-3 hours,
8
or do you need to wake the baby up?
9 How many times does the baby urinate in 1 day?
10 Does the baby seem very sleepy? Is the baby hard to wake up?
11 How do the baby's stools look?
12 Has the baby received any immunizations? If so, what?
ASK about the Mother
How may meals do you eat a day? How much and what food is
13
in each meal?
14 How much fluid are you drinking in one day?
15 Have you taken your Vitamin A capsule?
16 Have you taken an iron tablet or capsule every day?
17 Are you getting enough rest?
18 Do you have any problem?
PHYSICAL EXAMINATION OF BABY
Without touching the baby, observe and teach the mother to
19
observe the baby's:
20 Breathing
21 Colour
22 Posture and activity
23 Touch the baby gently and check the following
24 Temperature
25 Eyes
26 Skin (rashes, skin folds)
27 Umbilicus
Examine other parts of the baby's body, if any problem is
28
present
29 Weight
30 Watch the baby breastfeed
31 Position
32 Suck
33 Attachment
34 Watch mother-baby interaction
36 DECIDE NEEDS / PROBLEMS
PLAN OF CARE
Make a plan of care for each problem or need found. Include
37
(if appropriate):
Education: Continue to advise the mother on care for the baby
38
and herself.
39 Counselling: Review newborn danger signs and what to do
40 Medical Treatment: Give immunizations if needed
42 Referral: If needed
43 Follow-up:
44 Plan for next newborn visit
46 Record history, physical examination findings and plan of care.

42
 CHAPTER FOUR
FEEDING NORMAL BIRTH WEIGHT AND LOW BIRTH
WEIGHT NEWBORN
Learning outcomes for feeding normal birth weight and low birth weight newborn and
Monitoring growth and nutrition of newborn
After the training, the participants will be able to:
 Describe feeding of normal and low birth weight babies
 Describe the process of breastfeeding counselling and support (management of breast
conditions, expression of breast milk)
 Demonstrate feeding by cup, cup and spoon and oro-gastric tubes
 Outline the nutritional requirements and nutritional supplementation
 Monitor growth of preterm and term babies

Feeding of normal and low birth weight babies

The best milk for newborn baby is breast milk. All babies should be exclusively breastfed till
6 months of age. It contains all the nutrients required for normal growth and development of a
baby from birth till six months of age. There are certain terms used for feeding of babies.

Terms used in infant feeding:

Optimal Infant and Young Child Feeding:
 Exclusive breastfeeding from birth to six months of age and there after continued
breastfeeding for 2 years or beyond with adequate safe and proper additional foods and
liquids to meet the nutritional needs of a young child

Exclusive Breastfeeding:
 Only breast milk and may receive expressed breast milk
 Exception: drops or syrups consisting of vitamins, mineral supplements or medicine and
ORS as directed by a doctor

Predominant breastfeeding:
 Breastfeeding but also giving small amounts of water or water-based drinks

Full breastfeeding:
 Breastfeeding either exclusively or predominantly

Bottle feeding:
 Feeding a baby from a bottle

Artificial feeding:
 Feeding a baby on artificial feeds

Partial breastfeeding:
 Some breastfeeds, and some artificial feeds

Timely complementary feeding:

 Giving a baby other food in addition to breastfeeding after the age of 6 months

43
Breastfeeding

Figure 25 Advantages of Breast feeding

Variations in the composition of breast milk

Colostrum
 Breast milk that women produce in the first few days after delivery
 Thick and yellowish or clear in colour
 Secreted in small quantity but rich in protein
 Antibody rich and has many white cells
o Protect against infection and allergy
 Purgative
o Clears meconium
o Help to prevent jaundice
 Growth factors
o Help intestine to mature
o Prevents allergy and intolerance
 Vitamin A rich
o Reduce severity of infection
o Prevent eye disease

Transitional milk
 Secreted following two weeks
 Decreased protein and immunoglobulin content
 Fat and sugar content increases

Mature milk (after 2 weeks)

The quantity becomes larger, and the breasts feel full, hard and heavy.
 Foremilk is the milk that is produced early in a feed.

44
 o Produced in larger amounts
o Provides plenty of protein, lactose, and other nutrients
 Hind milk is the milk that is produced later in a feed.
o Whiter than foremilk but contains more fat that provides the energy

Anatomy and physiology of lactation

The breast consists of glandular tissue, supporting tissue and fat. Milk is secreted by glands
travels through tubules which drain into lactiferous sinuses. The sinuses which stores milk lie
beneath areola and open out to the nipple through lactiferous ducts. Myo-epithelium muscle
surrounds the gland and contraction of which leads to ejection of milk.

Figure 26 Anatomy and physiology of lactation

Milk secretion and ejection

Prolactin reflex
 When baby suckles in nipple the message carried by nerve ending in nipples leads to
secretion of prolactin by anterior pituitary
 Which stimulates the gland to milk secretion?
 Earlier and more effective suck produces more milk

45
“Milk secretion reflex”

Figure 27 Prolactacin reflex

Oxytocin reflex
 When baby suck in nipple/thought/sound of baby the message carried by nerve ending in
nipples leads to secretion of oxytocin by posterior pituitary
 Contracts the myo-epithelium leading to ejection of milk

“Milk ejection reflex”

Figure 28 Oxytocin reflex

Technique of breastfeeding
Most of the mothers can breastfeed successfully but some mothers require some support to
initiate breast feeding especially primipara mothers, mothers who had problems in breast-
feeding in previous pregnancy, mothers with retracted nipple or unmotivated mothers.

Positioning a baby at the breast:

Mother should take any position that is comfortable to her and her baby.

46
 CORRECT POSITION INCORRECT POSITION
Figure 29 Positioning a baby at breast

Position of baby
Correct positioning:
 Baby’s whole body should be well supported
 The baby’s head and body should be in a straight line.
 Baby’s body turned towards the mother with baby’s abdomen touching mother’s abdomen
 Baby’s nose at the level of nipple

Attachment:
After good positioning, the baby’s cheek is touched. The baby will wide open the mouth and
baby should be quickly brought on to the breast ensuring that the nipple and most of the areola
is within baby’s mouth.
Signs of good attachment:
 Mouth wide open
 Chin touching the breast and nose close to breast
 Lower lips turned outwards
 More areola above baby’s mouth than below

47
 Poor attachment
Good attachment

Figure 30 Attachment of baby at breast

Effective sucking:
 Baby suckles slowly and pauses in between to swallow.
 Cheeks are full

Recommendations
 Start breastfeeding within 1/2 hour of birth
 Breastfeed exclusively from 0-6 months of age
 Give complementary foods to all children from 6 months of age
 Continue breastfeeding up to 2 years of age or beyond

Assessing adequacy of breastfeeding

Breast feeding is adequate if:
 Passes urine 6-8 times in 24 hour
 Goes to sleep for 2-3 hours after the feeds
 Gains weight @ 10-15gm/kg/day
 Crosses birth weight by 2 weeks

Ten steps to achieve successful breastfeeding

1. Have a written breastfeeding policy that is routinely communicated to all health care
staff
2. Train all health care staff in skills necessary to implement this policy every 6 months
3. Inform all pregnant women about benefits and management of breast feeding
4. Help mothers initiate breastfeeding within 1 hour of birth of baby
5. Show mothers how to breastfeed and how to maintain lactation even if they are
separated from their infants
6. Give newborn infants no food or drink other than breast milk, unless medically
indicated
7. Practice rooming – in: allow mothers and infants to remain together for entire 24
hours in a day
8. Encourage breastfeeding on demand

48
 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding
infants
10. Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic

Breastfeeding technique
For mothers to produce enough milk, the baby must suckle often enough, and must also suckle
in the correct manner. Correct positioning ensures effective suckling and prevents breast
engorgement as well as sore nipples.

Proper positioning involves:

1. Baby’s whole body should be
well supported
2. The baby’s head and body should
be in a straight line.
3. Baby’s body turned towards the
mother with baby’s abdomen
touching mother’s abdomen
4. Baby’s nose at the level of nipple

Figure 31 Correct positioning

Proper attachment involves:

1. Mouth wide open
2. Chin touching the breast and
nose close to breast
3. Lower lips turned outwards
4. More areola above baby’s
mouth than below

Figure 32 Good attachment

General principles of exclusive breastfeeding

 Encourage early and exclusive breastfeeding whenever possible
 Explain to mother and her family the benefits of early and exclusive breastfeeding:
o Breast milk contains the exact nutrients the baby needs and promotes the baby’s
development

49
 o Breast milk is easily digested and efficiently used by the baby’s body
o Breast milk protects baby from infection
o Breastfeeding can be used as a contraceptive method (lactational amenorrhea method)
 Encourage the mother to breastfeed the baby on demand, both day and night (ten or more
times in 24 hours), for as long as the baby wants.
 Ask the mother to offer second breast once the baby releases the first breast on her/his
own.
 Advise the mother that she should not:
o Force the baby to feed
o Interrupt a feed before the baby is done
o Use artificial teats or pacifier
o Give the baby any other food or drink (e.g. commercial breast milk substitute, animal
milks, local porridges, tea, water etc.) other than breast milk for the first six month of
life.
 Include the family member or other support person in discussion about breastfeeding if
possible
 Ensure that the mother eats nutritious food
 Ensure that the mother can wash or shower daily but tell her to avoid washing or wiping
her nipples before breastfeeding.
 If mother is too ill or baby is too sick to breast feed
o Advise the mother on expression of breast milk
 Suggest mother to apply warm compression before expression and cold
compression afterward to reduce swelling
o Give the baby a breast milk substitute only if expression is not possible or is
contraindicated because of maternal illness or drugs

Problems in breastfeeding
Inverted nipples:
 Manually stretch the nipple and roll out several times a day

50
 A plastic syringe is used to draw out the nipple and then baby is put on to the breast

Figure 33 Technique to use syringe to treat sore nipple

Sore nipple
Caused by
 Incorrect attachment
 Frequent washing

Treatment
 Correct positioning and latching of the baby to the breast
 Apply hind milk to the nipple after feed
 Avoid too much washing

Breast engorgement
By the third day milk output increases and if there is delay in starting of feeding or infrequent
feeding, milk accumulates in excessively in the alveoli leading to swollen, hard, warm and
painful breast known as breast engorgement.
Treatment
 Early and frequent feed with proper attachment
 Local warm water packs, breast message and analgesic
 Express breast milk gently if baby not able to suckle

Breast abscess
If congested, engorged breast and cracked nipple not treated in early stage it will lead to breast
abscess.
Treatment

51
 Incision and drainage
 Analgesic and antibiotics
 Continue breast feeding

Not enough milk

Mothers often complain about not enough milk. If baby is satisfied, gaining weight, sleeps 2-3
hours after feed and passing urine 6-8 times in 24 hours then mother is producing enough milk.
Causes
 Not breast feeding frequently
 Too short or hurried breastfeeding
 Poor position
 Breast engorgement or mastitis

Treatment
 Identify the possible reasons make sure the attachment is proper
 If baby is not gaining weight, ask mother to breast feed more frequently especially during
night
 Treat condition like mastitis or sore nipple
 Advise mother for adequate rest and sufficient fluid
 Give demand feed and breast feed as long as baby wants
 Back message is especially useful for stimulating lactation and metoclopramide may help
in some case

Skill Checklist 6 Breast feeding assessment

No. Steps Rating

Y ¥ NA
1. Greet the mother
2. Ask and listen to the mother
3. Assess whether mother is relaxed
4. Assess for the position of the baby
4.1 Baby’s whole body should be well supported
4.2 The baby’s head and body should be in a straight line.
4.3 Baby’s body turned towards the mother with baby’s
abdomen touching mother’s abdomen
4.4 Baby’s nose at the level of nipple
5 Assess for the attachment
5.1 Mouth wide open
5.2 Chin touching the breast and nose close to breast
5.3 Lower lips turned outwards
5.4 More areola above baby’s mouth than below
14. Assess for effective suckling - Slow deep suck with pause
15. Give mother practical help if needed
16. Thank mother for her cooperation

52
Expressing breast milk:
Introduction
There are many situations in which expressing breastmilk are useful and important to enable a
mother to initiate or continue breastfeeding.

Expressing milk is useful to:

 Relieve engorgement, blocked duct or milk stasis
 Feed a baby while he learns to suckle from an inverted nipple
 Feed a baby who has difficulty in coordinating suckling
 Feed a low-birth-weight baby who cannot breastfeed
 Feed a sick baby, who cannot suckle enough, baby with cleft palate
 Keep up the supply of breast milk when a mother or baby is ill
 Leave breast milk for a baby when his/her mother goes out or to work
 Prevent leaking when a mother is away from her baby.
 Help a baby to attach to a full breast
 Express breast milk directly into a baby's mouth

The most useful way for a mother to express milk is by hand.

Techniques of expression
1. Hand expression
 Most useful method
 Easy when breast is soft
 Difficult when breast is engorged or tender

2. Using appliance
Easy and useful when breast is engorged or tender
a) Rubber pump
b) Syringe pump
c) Hot fomentation

Expressing breast milk (Figure 1)

Teach the mother to
 Wash hands with soap and water before expression.
 Sit comfortably
 Hold the clean container under the nipple
 Place thumb above and first finger below and behind the nipple approximately 4cm from
the base of the nipple.
 Support the breast with other three fingers
 Press the breast gently slightly inwards towards the chest wall
 Press the breast between the fore-finger and thumb. Press and release, press and release.
This should not hurt
 Avoid rubbing or sliding fingers along the skin
 Rotate the position of the thumb/finger around the breast with each compression
 Express breast milk until milk drips, then express the other breast
 Alternate between the breasts 5-6 times
 Avoid squeezing the nipple. Express one breast for at least 3-5 minutes until the flow
slows, then express the other side, then repeat.
53
 To express breast milk adequately and comfortably takes 20-30 minutes
 Consider massage of breasts and use of warm compresses prior to or during expression to
improve milk flow

Express milk at the times when a baby would normally feed (every 2-4 hours and at
least 10 times during a 24-hour period).

Storing expressed breast milk (EBM)

 Store in clean, covered container
 EBM can be kept at room temperature for 8 hours and in the refrigerator for 24 hours
 EBM stays in good condition longer than animal milk. Do not boil the EBM. For
warming, place the container in a bowl of warm water
 Before feeding gently shake the container or use a stirrer to recombine the separated fat
globules with the rest of the milk
 Feed with cup, never feed with bottle

Rubber bulb breast pump

These are not very efficient, and they are easily contaminated.

Figure 34 Rubber bulb breast pump

Syringe Breast Pump

 More efficient
 Easy to clean and sterilize
 Can be used for feeding

Technique
 Put the funnel over the nipple
 Ensure airtight seal
 Pull the piston and release and pull again
 After a minute or two, milk flows and starts collecting
 When milk stops flowing, break the seal, pour the milk and repeat the procedure

54
 Figure 35 Syringe breast pump

Figure 36 Technique of manual expression of breast milk

55
Skill Checklist 7 Expression of breast milk
Rating
No. Steps
Y ¥ NA
1. Wash hands with soap and water before expression.
2. Ask mother to sit comfortably
3. Ask mother to hold the clean container under the nipple
4. Helps mother to place thumb above and first finger below and
behind the nipple approximately 4cm from the base of the
nipple.
5. Ask mother to support the breast with other three fingers
6. Ask mother to press the breast gently slightly inwards towards
the chest wall
7. Ask mother to press the breast between the fore-finger and
thumb. Press and release, press and release.
8. Ask mother to avoid rubbing or sliding fingers along the skin
9. Ask mother to rotate the position of the thumb/finger around the
breast with each compression
10. Ask mother to express breast milk until milk drips, then
express the other breast
11. Ask mother to alternate between the breasts 5-6 times (20-30
minutes)
12. Ask mother to consider massage of breasts and use of warm
compresses prior to or during expression to improve milk flow

56
 CHAPTER FIVE
NEONATAL RESUSCITATION
Learning outcomes for Neonatal Resuscitation
After the training, the participants will be able to:
 Understand the epidemiology of birth asphyxia
 Anticipate the conditions requiring assistance at birth for normal transition
 Prepare the necessary basic infrastructure/equipment
 CPR technique, use of drugs
 Resuscitate the newborn
 Identify the babies requiring specialized care

Introduction
Approximately 10% of newborns require some assistance to begin breathing at birth.
Approximately 1% requires extensive resuscitative measures. Nearly 3 million babies die each
year1 because they do not breathe normally. Hence neonatal resuscitation is life saving for
many newborn babies.

Physiology of asphyxia
In utero, the foetus is dependent on placenta for gas exchange. Alveoli of lungs are filled with
fluid and arterioles are constricted. At birth newborn makes vigorous efforts to inhale air into
the lung. The pressure created assists the fluid in alveoli to be absorbed into lung tissue and
replaced by air which contains oxygen.

Figure 37 Physiology of asphyxia (a)

The oxygen diffuses into blood vessels that surround alveoli. The umbilical arteries and vein
constrict after they are clamped resulting in increased systemic blood flow. All this will lead
to decrease pulmonary resistance and increases pulmonary blood flow.

1
Lancet, 2014

57
 Figure 38 Physiology of asphyxia (b)
The blood oxygen level rise and ductus arterious constricts.

Figure 39 Physiology of asphyxia (c)

If this sequence is interrupted, the pulmonary arterioles can remain constricted, the alveoli
remained filled with fluid and systemic arterial blood may not become oxygenated.

When the baby does not begin, or sustain adequate breathing at birth, the oxygen supply
decreases
 Initial response
Constriction of vascular beds in lungs, intestines, kidneys, muscle and skin to redistribute
blood flow to heart and brain
 Late response
Impaired myocardial function leading to decrease cardiac output and irreversible brain
or organ damage

58
Physiology of asphyxia - Apnoea
The respiration is the first vital signs to cease when newborn is deprived of oxygen.
Primary apnoea
Rapid breathing attempts

Respiration ceases

Heart rate decreases

Blood pressure is usually maintained

Respond to stimulation

Flow Chart 1 Primary apnoea

If oxygen deprivation continues during primary apnoea, baby will make several
attempts to gasp and then enter a period of secondary apnoea.

Risk factors associated with the need for resuscitation

Secondary apnoea
Respiration ceases

Heart rate decreases

Blood pressure decreases

No response to stimulation / requires assisted ventilation

Flow Chart 2 Secondary apnoea

59
Physiology of asphyxia - Apnoea

Figure 40 Physiology of asphyxia - Apnoea

During delivery, though careful consideration of risk factors we can anticipate which baby will
require resuscitation but it can be a complete surprise. Moreover, at delivery when baby is not
breathing we cannot tell baby is in primary apnoea or secondary apnoea and for how long they
are in apnoea. Hence anticipation, adequate preparation, accurate evaluation, and prompt
initiation of support are critical for successful neonatal resuscitation

Basic Infrastructure/equipment:

 Delivery room/Labour room

o Clean
– Radiant warmer
– Adequate light
– Privacy Maintained

 Furniture
o Clean bed for mother
o Bed curtain
o Clean surface to put equipment and baby
o Watch with second hand needle
o Light sources

 Linens
o For mothers
 Clean and dry bed linen for mother
 Blankets
 Macintosh or plastic sheet to put under the mother
 Extra cloths to use as perineal pads
o For newborn
 Clean, warm and dry wrapper for baby – 4

Suction equipment
 Penguin suction / Foot operated/wall suction

60
 Mechanical suction and tubing- pressure not exceeding 100 cm of water
 Suction catheters: 10 Fr and 12 Fr

Bag and mask equipment

 Neonatal resuscitation bag 450ml with a pressure-release valve or pressure manometer
(capable of delivering 90% to 100% oxygen)
 Face masks, newborn and premature sizes (cushioned-rim masks preferred) (0,1)
 Oxygen source with flowmeter (flow rate up to 10 L/min) and tubing

Intubation Equipment
 Laryngoscope with straight blades: No. 00 (very-low-birth-weight infant); No. 0
(preterm infant); and No. 1 (term infant)
 Endotracheal tubes, 2.5-, 3.0-, 3.5-, 4.0-mm internal diameter
 Pulse oximeter (if available)

Medications
 Epinephrine 1:10,000 (To make1: 10,000 → 1 ml drug + 9 ml NS)
 Isotonic crystalloid (normal saline) for volume expansion: 100 or 250 mL
 Normal saline for flushes
 Chlorhexidine gel (4%)

Miscellaneous
 Feeding tube, 5 and 8 Fr
 Syringes with needles: 15, 10
 I/V cannula 24 G, 26G
 Wall clock with second hand/ digital watch
 Stethoscope (neonatal head preferred)
 Tape: ½ or ¾ inch
 Oropharyngeal airways
 Cord clamps Weighing scale digital with pan
 Identification tag

Skilled human resource for adequate management:

A well-trained healthcare worker to provide immediate newborn care, basic resuscitation and
to appropriately identify and manage life threatening condition at birth.

61
Flow Chart 3 Resuscitate the newborn as per the Helping Baby Breath (HBB)
Guidelines

Term Gestation? Routine care

 Provide warmth
Breathing or crying? Yes,
 Clear airway if necessary
Birth Good tone stay with mother
 Dry
No  Ongoing evaluation

Warm, clear airway

if necessary, dry,
stimulate

HR below 100, Laboured breathing

30 sec No
gasping or apnea Persistent cyanosis
Yes Yes

PPV, Clear airway,

60 sec SpO2 monitoring SpO2 monitoring,
30 sec Consider CPAP
HR below 100 ?
Yes No Post resuscitation care

No Take ventilation
corrective steps

HR below 60 ?
Targeted Preductal SpO2 after birth
Yes

Take ventilation Consider intubation, 1 min 60% - 65%

corrective steps Chest compression, 2 min 65% - 70%
Intubate if no chest rise Coordinate with 3 min 70% - 75%
PPV 4 min 75% - 80%
No
5 min 80% - 85%
HR below 60 ? 10 min 85% - 90%

Consider
hypovolemia
pneumothorax IV Epinephrine

Preparation of Birth
 Identify helper and review the emergency plan
 Prepare area for delivery
 Wash hands
 Prepare an area for ventilation
 Assemble clean equipment and supplies
 Check instruments
 Call out time loudly
 Receive baby in clean, dry and warm towel
 Put on mother’s abdomen
 Dry thoroughly

62
  Remove wet linen
 Put on mother’s abdomen and cover with another clean dry and warm towel
Assess respiration
 Breathing/Crying
o Proceed for routine care
 NOT Breathing/ crying
o Look airway for secretion
 If present
 Introduce 5 cm catheter into the baby’s mouth and suctions
while withdrawing the catheter (Penguin suction can be used as
alternate)
 Introduces catheter into each nostril 3cm and suctions while
withdrawing catheter
 If clear
 Stimulate by rubbing baby’s back 2-3 times
Assess respiration
 Breathing/Crying
o Proceed for routine care
 NOT crying
o Proceeds for Bag and Mask ventilation

These steps are completed within ONE MINUTE, and BAG and MASK
VENTILATION started within one minute known as “GLODEN MINUTE”

63
Skill Checklist 8 resuscitation of newborn as per Initial steps
Participants Name
Case scenario
You are attending a birth of a baby. The delivery room is clean, warm with adequate light
and private. You have washed your hand and put on gloves. You have checked the equipment.
Baby is delivered and has not cried. Provide the care

Rating
No. Steps
Y ¥ NA
1. Ensure the helper is available if required
2. Discuss the emergency plan with the helper
3. Wear protective barriers
4. Wash hands as per guidelines
5. Wear sterile gloves
6. Check functioning of equipment and availability of drugs
7. Call out loud time of birth
8. Receive baby in clean and dry towel and put baby on mother’s
abdomen
9. Dry the baby thoroughly and remove wet towel
10. Place the baby on another clean, dry, and warm towel on
mother’s abdomen
11. Assess the baby’s respiration while drying
12. If not crying
Position the baby with neck slightly extended
13. If excessive secretion in mouth and nose:
Suction of mouth then nose, using suction tube or penguin
suction
14. Introduce 5 cm catheter into the baby’s mouth and suction
while withdrawing the catheter / use penguin suction
15. Introduce catheter into each nostril 3cm and suction while
withdrawing catheter / use penguin suction
16. Reposition
17. If baby is still not crying give tactile stimulus
 Rubbing back 2-3 times
18. Evaluate
 Respiration
o Observing infants’ chest movement
19. If not crying/ no respiration
Inform parent or family members about baby’s condition and
procedure that you are going to perform
20. Clamp and cut the cord immediately and put the baby on clean
warm resuscitation table
21. Start bag and mask ventilation
22. These steps are completed within GOLDEN ONE MINUTE

64
POSITIVE PRESSURE VENTILATION
NOT Breathing/ crying
 Cut the cord
 Place the baby with head toward you on the area of ventilation
 Stand at the baby’s head
 Position the head slightly extended
 Select correct mask and apply the mask to the face
 Make a tight seal between the mask and face
 Squeeze the bag at the rate of 40-60 breaths in one minute and VENTILATE for ONE
MINUTE
 Check whether the chest moving well or not
 If the chest is not moving well
o Reapply the mask
o Reposition the head
 If chest is moving well with each ventilation continue to ventilate until baby begins
to breath/cry/breathing quietly and regularly
o Stop ventilation and monitor with mother
 OR the baby may be
o Taking fast, irregular or shallow breaths
o Grunting with chest wall indrawing
 MONITOR with pulse oxymeter
 Provide oxygen/bag and mask /intubate as necessary
 If baby is not crying or breathing well baby may be
o Gasping
o Not breathing at all
 CONTINUE ventilation with good chest movement
o Call for help
o Improve ventilation if chest is not moving
 Reapply mask
 Reposition head
 Clear mouth and nose of secretion
 Open mouth slightly
 Squeeze the bag harder
 If baby is not breathing well after improved ventilation
o Evaluate heart rate after 1 minute to decide if ventilation is adequate
 Listen to the heartbeat with stethoscope
 Decide if heart rate is normal or slow
 Normal >100 breaths per minute
 Slow < 100 breaths per minute
 If baby is breathing well, HR>100 but has central cyanosis
o Provide oxygen 5 litre/min
o Provide enough oxygen for the baby to become pink
o Oxygen given for long periods must be heated and humidified
o Avoid unheated oxygen at high flow rates (10L/min) to decrease heat loss
o Gradually withdraw oxygen when baby is pink

 If the heart rate is normal and the baby is not breathing or gasping
o Continue ventilation
o Re-evaluate breathing continuously and check heart rate every 3-5 minutes

65
 If the heart rate is slow or < 100 bpm and the baby is gasping or apnoeic, follow the
steps below
o Clear airway and begin SpO2 monitoring
o Continue positive-pressure ventilation or intubate
o Consider supplementary oxygen
o If the baby improves, institute post resuscitation care

Skill Checklist 9 Positive pressure ventilation (PPV)

Rating
No. Steps
Y ¥ NA
1 Baby is positioned with neck slightly extended
2 Apply mask correctly
4 Compress the bag at rate of 40-60 per minute
5 Observe for the rise of chest with each compression
6 If the baby’s chest is not rising, re-evaluate the procedure
7 Ensure correct position
8 Ensure air is not leaking from the mask
9 Squeeze full bag for ventilation
10 Re-suction if necessary
11 Reassess baby’s breathing and heart rate (auscultation
after 1 minute of ventilation
12 If improving spontaneous respiration, HR>100
 Discontinues PPV
13 Monitor respiration and HR
14 If HR > 60/min, not breathing or apnoeic
 Check for adequate chest movement
15  Check for tight sealing of the face-mask
16  Check for blockage of airways by secretion
17  Continue ventilation 40-60 breaths/min

CHEST COMPRESSION
o If the heart rate is < 60 bpm, follow the steps below
 Start chest compressions
 Intubation can be considered; intubate if no chest rise
 Chest compression
 Position of Baby
o Firm support for the back
o Neck slightly extended
 Compressions
o Same location, depth and rate
 Location of Compression
o Pressure is applied in lower third of sternum
o Just below the imaginary line between two nipples
o Approximately 1/3rd of antero-posterior diameter of the chest
 Rate
o Three compression followed by one ventilation
o In one minute 90 chest compression and 30 breaths

66
 Figure 41 Chest compression technique

 After approx. 60 sec of Chest Compression (CC) and Positive pressure ventilation
(PPV)
o Count Heart Rate
o If > 60 - Stop Chest compressions
o Continue PPV till heart rate>100
 Continue PPV at 40 - 60 bpm Till
o Baby breathing spontaneously
o Heart rate >100 and
o Baby pink
 Heart rate <60 bpm
o Continue CC and PPV
o Medication (epinephrine)

67
Skill Checklist 10 Chest compression
 Even after 60 seconds of effective positive pressure ventilation baby is not
improving and HR is <60 seconds

Rating
No. Steps
Y ¥ NA
1 Position the baby with firm support for the back neck slightly
extended
2 Ask help to continue PPV
3 Outline the location of chest compression
4 Apply pressure over the lower third of sternum
5 Depth of compression is 1/3rd of anteroposterior diameter
6 Co‐ordinate with the PPV (90 compressions one breath)
7 Evaluate HR after 60 seconds of chest compression

Medication
Indication
 Heart Rate is below 60 bpm despite administration of effective chest compressions and
effective positive-pressure ventilation with 100% oxygen:
When heart rate <60 beats/min
 Recheck effectiveness of
o Ventilation
o Chest compression
o Consider Endotracheal intubation

 Consider possibility of
o Hypovolemia
o Severe metabolic acidosis

Epinephrine
Dose and route
Epinephrine (1:1000): First dilute 1.0 ml epinephrine (1: 1000) with 9.0 ml normal saline to make
epinephrine (1: 10,000)
o 0.1 - 0.3 ml/kg of 1: 10,000 dilution
o Route: IV
o Repeat dose if no response after 60 seconds

Volume Expanders
 Not given routinely
 Useful in hypovolemia
 Suspected where there is a pale, tachycardic infant, CRT> 3 second
 Normal saline: 10 ml/kg over 5-10 minutes given IV or UAC
 Repeat dose if no response after 60 seconds

Targeted preductal SpO2

 1 minute: 60% - 65%
 2 minutes: 65% - 70%
 3 minutes: 70% - 75%
68
  4 minutes: 75% - 80%
 5 minutes: 80% - 85%
 10 minutes: 85% - 95%

* Babies which require resuscitation care

- Follow Post- Resuscitation care

Stop resuscitation if
i. After ensuring no signs of life from the beginning and even after 10 minutes of continuous
resuscitation
ii. In live born if there is no response to ventilation, chest compression and medication after 20
minutes then stops ventilation, provides emotional and psychological support to the mother and
family and declares the baby dead

Endotracheal Intubation (Optional) – (Nurses need to assist)

Indication
 Prolonged PPV required
 Bag and mask ventilation ineffective: Inadequate chest expansion
 If chest compressions required: Intubation may facilitate coordination and efficiency of
ventilation
 Diaphragmatic hernia

Prerequisites for Intubation

 Pre-oxygenate before intubation PPV with 100% oxygen
 Deliver free flow oxygen during intubation
 Not more than 20 secs per attempt: Not more than 3 attempts
 Ventilate with bag and mask with 100% oxygen in between attempts

Equipment for intubation

 Bag and mask (0, 1)
 Oxygen cylinder
 Suction machine (pressure set at 80-100mm of Hg) with suction catheters
 Sterile water
 Sterile gloves
 Laryngoscope with blades (Size 00, 0 ,1) with extra bulb
 ET tube (Size 2.5, 3, 3.5, 4)
 Pulse oximeter
 Scissors
 Tape
 Stethoscope

69
Size of ET Tubes
Tube size Weight Gestational age
ID-mm Grams Age (weeks)
2.5 <1000 <28
3.0 1000-2000 28-34
3.5 2000-3000 34-38
4.0 >3000 >38

Suction catheter size

ET tube size Suction catheter size
2.5 5F 0r 6 F
3.0 6F or 8 F
3.5 8F
4.0 8F or 10F

Landmark for placement of laryngoscope

 Lift the blade this will make epiglottis and glottis visible.

Figure 42 Placement of laryngoscope (a)

 Once the epiglottis and glottis is visible insert ET tube holding in the right hand.
 Introduce through the right angle of the mouth.
 Keep glottis in view.
 Insert the tube in glottis till the vocal cord guide is at the level of glottis.

70
 Figure 43 Placement of laryngoscope (b)
 Remove laryngoscope while holding the ET tube in place by just pressing it over the
mouth.
 Check for the position of ET tube

Signs of ET Tube in Oesophagus

 Poor response to intubation (cyanosis, bradycardia etc.)
 CO2 detector fails to show presence of Expired CO2
 No audible breath sounds
 Air heard entering stomach
 Gastric distension may be seen
 No mist in tube
 Poor chest movements

ET Tube Too Far in Trachea

 Heart rate or colour shows no improvement
 Breath sounds heard over right and not on left side of chest
 Breath sounds are louder on right side of chest than on left side

Length of the tube to be inserted (Tip to lip distance)

Weight in Kg Depth of insertion (cm from upper lip)
1 7
2 8
3 9
4 10

 Once the ET tube in place fix the tube by tape and continue PPV

71
 CHAPTER SIX
THERMAL PROTECTION OF NEWBORN
Learning outcomes of Thermal protection of newborn/KMC/Hypothermia
After the training, the participant will be able to:
 Outline the temperature regulation by newborn
 Outline mechanism of development of hypothermia
 Enlist the consequences of hypothermia
 Outline the assessment of baby’s temperature and monitoring
 Outline the maintenance of warm chain
 Enlist the factor causing hypothermia in newborn
 Define hypothermia and hyperthermia
 Enlist the appropriate intervention for prevention and treatment of hypothermia
 Teach mother how to keep baby warm

Temperature regulation in Newborn

Baby comes out naked and wet in labour room environment from warm and well insulated
aqueous uterine environment. After birth, skin and core temperatures falls by 0.3°C and 0.1°C
per minute respectively. It is estimated that 15% of newborn babies develop hypothermia at
birth in developing countries.

Temperature ranges
Normal axillary temperature 36.5-37.5°C
Mild hypothermia or cold stress 36-36.4°C
Moderate hypothermia 32-35.9°C
Severe hypothermia <32°C
Hyperthermia >37.5°C

Mechanism of heat loss in newborn

After birth, skin and core temperatures falls by 0.3°C and 0.1°C per minute.
Heat loss in a newborn occurs through 4 primary routes:
1. Radiation (to surrounding environment not in direct contact with baby)
2. Convection (to air flowing in surrounding)
3. Conduction (to substances in direct contact with baby)
4. Evaporation (of amniotic fluid and moisture from baby’s skin to atmosphere).

Figure 44 Four ways Newborn can lose heat to the environment

Four ways Newborn can lose heat to the environment

73
Evaporation:

Loss of heat when liquid is converted to vapour

Conduction:
Loss of body heat when it comes in contact with cooler surface

Radiation:
Loss of body heat to the surrounding environment not in direct contact with body

74
Convection:
Loss of heat to cooler air flowing to the surrounding

Reasons of increased susceptibility to hypothermia in newborns;

Large surface area of babies compared to their weight
 Head constitutes large portion of surface area and can be a source of great heat loss.
 Limited heat generating mechanisms.
 Vulnerability to getting exposed, being dependent on others for early detection and
rectification.
Heat loss in LBW babies is more because of:
 Decreased thermal insulation due to lack of subcutaneous fat
 Reduced amount of brown fat
 More permeable skin due to poorly keratinized stratum corneum
 Even large surface area than term babies
 Poorer homeostatic response to hypothermia and early exhaustion of metabolic stores like
glucose.
Heat production
Two heat production modalities
 Basic heat production - result of increased cellular metabolic activity
 Extra heat production - when necessary as in cold stress.
o Extra heat production includes non-shivering thermogenesis (NST) and
shivering thermogenesis.
 Since neonatal muscles are relatively immature to produce heat, shivering thermogenesis
is insignificant factor.
 The significant role of non-shivering thermogenesis at birth has been well recognized.
 Heat is produced in brown adipose tissue.
 Brown adipose tissue contains many mitochondria, fat vacuoles, abundant sympathetic
innervations and abundant blood supply.
 Brown adipose tissue constitutes about- 1.4% of the body mass of human newborns over
2000 grams.
 Brown adipose tissue - prominent in nuchal subcutaneous tissue, intra-scapular region,
mediastinum, surrounding spinal cord and around the kidneys.
 In order to survive thermally stressful extra-uterine life, a foetus must accumulate brown
adipose tissue in utero.
 Since foetal brown adipose tissue accumulates later in gestation, premature infants have
minimal ability to initiate NST in response to cold extra-uterine environment.
 This is also true for SGA infants who have decreased subcutaneous adipose tissue.
 Moreover, these neonates have thin skin layer which readily transmits heat to the external
environment.

75
Non-shivering thermogenesis (NST):
 When skin of baby becomes cold, afferents convey message to heat regulating centre
located in hypothalamus.
 Neurogenic afferents, on reaching the brown fat, trigger local release of noradrenaline so
that triglycerides are oxidized to glycerol and fatty acids.
 Fatty acids are locally consumed for generation of heat.
 The areas of brown fat become warm.
 Blood is warmed as it passes through brown fat and it in turn warms the body.

Thermoneutral environment (TNE):

This is a gestational and postnatal age specific temperature range in which
1. Basal metabolic rate of the baby is at minimum
2. Oxygen utilization is least
3. Baby maintains its normal body temperature

Range of neutral temperature varies accordingly for the gestation and postnatal age
As opposed to TNE, thermoregulatory environment refers to environmental temperature
beyond TNE range, at which baby would be able to maintain its body temperature but by
increasing its BMR. The infants therefore should be kept in TNE so that their energy is utilized
for growth and other vital functions.

Thermoneutral zone for Incubator setup2

Recommended ambient
Weight of
temperature
the baby
35°C 34°C 33°C 32°C
Less than 1500 g 1 to 10 days 11 days to 3 More than 5 weeks
3-5 weeks old
old weeks old old
1500 to 1999 g 1 to 10 days 11 days to 4 More than 4 weeks
old weeks old old
1 to 2 days 3 days to 3 More than 3 weeks
2000 to 2499 g
old weeks old old
2500 g or more 1 to 2 days old 3 days old or more

Predisposing conditions of hypothermia in newborn

 When delivery room is too cold.
 Baby is not dried immediately after birth.
 Baby is kept away from mother.
 Baby has inadequate clothing.
 Exposure during bath.

Newborn at highest risk to develop hypothermia are:

 LBW babies
 Sick babies
 Babies immediately after birth

2
If Incubator is to be given to the Level II hospital

76
Response to hypothermia
 Babies attempt to conserve heat by peripheral vasoconstriction.
 This leads to increased anaerobic metabolism at the ill perfuse areas with acidosis.
 With continued hypothermia, usually when temperature drops to 32°c, oxygen cannot be
released from haemoglobin, resulting in the blood having bright red colour which should
not be mistaken for good perfusion.
 With severe hypothermia, hypoxemia, hypoglycaemia and metabolic acidosis develop
leading to mortality.

Recording temperature
 It is not necessary to measure the temperature of healthy newborn babies routinely,
particularly when the warm chain is strictly followed.
 Temperature should be monitored every 1-2 hour for a baby with serious illness, twice daily
for babies weighing between 1500 to 2499 gm, four times daily for babies below 1500 gm
and once a day for other babies who are doing well

Methods of recording temperature

Touch method
Abdomen skin temperature is assessed by touch with dorsum of hand. Abdominal temperature
is representative of the core temperature. Baby’s temperature can be assessed with reliable
accuracy by human touch, which can be easily taught to parents and can be practiced at home
as well. The interpretation is as follows:
 Baby’s feet and hands are warm: Thermal comfort
 Peripheries are cold, the trunk is warm: Cold stress
 Peripheries and the trunk both are cold: Hypothermia

Thermometers
WHO recommends the use of low reading thermometer which can record up to 30°C. American
Academy of Paediatrics (AAP) recommends against using mercury thermometers because the
glass can break, and mercury is poisonous. The best is to use a digital thermometer.

Thermister probe
Skin temperature can be recorded by a thermistor. The probe is attached to skin over upper
abdomen. The thermistor will sense the skin temperature and display on the panel.

The concept of warm chain

The warm chain is a set of ten interlinked steps carried out at birth and later which will reduce
the chances of hypothermia in all newborns

1. Thermal care in delivery room

After birth, newborn’s temperature can drop at a rate of 0.1°C and 0.3°C per minute for core
and skin temperature respectively. Delivery room needs to be prepared much in advance. The
room should be clean, warm (at least 25°-28°C) and free from draughts from open windows
and doors or from fans.

If the temperature of the room is less than optimal, a heater should be available to warm the
room. All the towels, blankets, caps, baby’s clothes should be pre-warmed. The radiant warmer

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should be switched on at least 20 to 30 minute in advance and put into manual mode with 100%
heater output.

2. Warm resuscitation

3. Immediate drying
After birth, the baby should be immediately dried with a dry towel, starting with the head. After
drying thoroughly, the baby should then be covered with a second, dry towel and a cap put on
its head.

4. Skin-to-skin contact
Baby can be kept in mother’s chest in skin contact while mother is being attended including
placental delivery, episiotomy, suturing, transferred and kept in postnatal ward for initial few
hours. If a baby is in cold stress, the baby should be immediately put in skin to skin contact
with mother.

5. Breast feeding
Breast feeding should begin as soon as possible after birth preferably within half an hour. This
ensures adequate supply of calories for heat generation.

6. Bathing / weighing postponing

Do not bathe till 24 hours of life. Weighing should be done only after covering the baby
adequately and making zero correction for clothing.

7. Clothing and bedding

Newborns should be covered with one (or) two layers of clothes and cap, socks and hand
gloves. Swaddling, a custom of wrapping bands should be avoided.

8. Rooming in
Babies and mother should be attached together for 24 hours in the same bed and breast fed on
demand.

9. Warm transportation
In case of transport- whether to home, to another hospital / another section, thermal protection
should be ensured. Stable babies including preterm and LBW babies should be transported well
wrapped and in skin to skin contact with mother.

VLBW, unstable, admitted babies should be transported using an incubator. Temperature

should be checked before and after transport. All peripheral hospitals caring for high risk
mothers should go for in-utero transfer as early as possible.

10. Training and awareness rising:

All the health care personnel involved in the newborn care should be adequately trained and
informed about the principles of warm chain.

Prevention of hypothermia /hyperthermia during neonatal period

First day and later
 Wrap the baby in clean dry cloth and cover head with cap
 Ensure the baby is wrapped and covered well

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 Assess baby’s temperature by touching baby’s abdomen and feet with back of the hand.
The temperature should feel same and baby’s feet should be warm and pink
 If not re-warm the bay
o Ensure adequate clothing
o Skin-to-skin contact and extra cloth and blanket
o Keep room warm

At home
 One or more layer of clothes than children
 Keep room warm
 During day dress and wrap the baby
 Change napkin each time baby soils
 Lower limbs should also adequately covered
 At night baby, should sleep with mother for breastfeeding

Skill Checklist 11 Maintenance of warm chain of babies in postnatal ward and advise to
mother

Rating
No. Steps
Y ¥ NA
1. Wash hand and dries before touching the baby
2. Wrap baby in a clean and dry cloth and cover head with cap
3. Ensure the baby is wrapped and covered well
Assess the baby’s temperature by touching baby’s abdomen
4.
and feet with back of the hand
If baby is not warm, ensure adequate clothing, skin‐skin
5.
contact and extra cloth and blanket
6. Check room temperature
7. Advise the mother on how to keep baby warm
8. Ensure and advise breast feeding.

Thermal management in preterm babies

Apart from the routine procedures and adhering to warm chain, extra care is required for
preterm babies.

Polythene occlusive wraps

Use of polythene wraps for all babies <28 weeks this technique involves the covering the
premature infant in a polyethylene bag or a cover that can be applied on neck, drying of the
baby is not done. The baby should be immediately received on to a radiant warm. Wrapping
reduces evaporative heat loss, while allowing radiant heat delivery to the baby

All preterm babies <34 weeks should be admitted and nursed either in a radiant warmer. All
preterm babies when transferred to open cot / to mother, kangaroo mother care should be started
and be ensured minimum 10-14 hours a day

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Radiant warmers
Radiant warmer is an ‘open care’ convenient system for management of preterm and sick
babies, because maintenance is easy and allows easy access for doing procedures, but the
disadvantage is that insensible water is greater increased under radiant warmer.

The radiant warmers produce radiant heat by a heating rod usually made of quartz crystal; this
is uniformly reflected onto the surface by parabolic reflectors. They also reduce conductive
heat loss by warming the microenvironment.

Kangaroo mother care:

For LBW babies, who are stable, KMC is perhaps the most effective way of keeping babies
warm. KMC is a no cost, easy, applicable at home, which has multiple added advantages.
Regular breast feedings and skin-skin contact are encouraged for all LBW babies who are prone
for hypothermia.

Hypothermia:
Clinical features of hypothermia can be discussed under the four different situations
1. Initial signs of hypothermia are generally those which appear because of peripheral
vasoconstriction like pallor, acrocyanosis, cool extremities, decreased peripheral perfusion,
there can be early signs of CNS manifestations like irritability.
2. Later signs include features of CNS depression like lethargy, bradycardia, apnoea, poor
feeding, hypotonia, weak suck or cry, emesis. Because of increase in pulmonary artery
pressure, there can be symptoms of respiratory distress mainly tachypnea. Abdominal signs
like increased gastric residuals, abdominal distention or emesis can occur.
3. Prolonged hypothermia leads to increased metabolism leading to hypoglycaemia, hypoxia,
metabolic acidosis, coagulation failure, sometimes, PPHN like situation, ARF in extreme
case high likely hood of mortality.
4. Chronic periods of cold stress lead to weight loss and poor weight gain.

Management:
a) Cold stress
 Cover the baby adequately- remove cold/wet clothes, cover the baby adequately with
warm clothes
 Warm the environments including room / bed
 Ensure skin to skin contact with mother, if not possible, kept next to mother after fully
covering the baby
 Immediately breastfeed the baby
 Monitor axillary temperature every ½ hour till it reaches 36.5°, then hourly for next 4
hours, 2 hourly for 12 hours thereafter

b) Moderate hypothermia:
In this situation, one should provide the baby with additional source of heat.
 Maintain skin to skin contact
 Warm room / bed
 Take measures to reduce heat loss
 Provide extra heat by room heater, radiant warmer, incubator, applying warm towel or
using phase changing mattresses

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c) Severe hypothermia
 All babies with severe hypothermia (<32°C) should be immediately admitted to the
hospital
 Rapid rewarming should be done immediately which can be done using a radiant warmer
or air heated incubator
 Rapid rewarming is done up to 34°C, then slow rewarming to 36.5°C
 Take all measures to reduce heat loss
 Start IVF at 60-80 ml/kg of 10% dextrose
 Possible oxygen if needed
 Check whether the baby received Inj Vit K or not. Give Inj Vit K1 mg in all babies and
0.5mg for babies < 1000g
 If not improving immediately, think of causes like sepsis

Hyperthermia
Hyperthermia is also a common problem with neonates. Very common in dry warm climate
areas. Temperature of more than 37.5°C is defined as hyperthermia in newborns.

Causes
 Too hot environment – high room temperature
 The baby has many layers of covers / clothes
 Dehydration fever – the baby may be in a dehydration state
 Sepsis

Dehydration fever
Dehydration results in excess weight loss for the baby and hence one of the important clue for
dehydration fever is excess weight loss. Fever generally subsides with correction of
breastfeeding issues or when extra feeds given properly.

Symptoms
Early: Irritable, tachycardia, tachypnea, flushed face, hot and dry kin
Late: Apathetic, lethargic and then comatose
Severe forms of hyperthermia can lead to shock, convulsions, even death in neglected cases

Management
Place the baby in a normal environment (25-28°C) away from heat source
 Undress the baby partial / fully
 Give frequent breast feeds give breast milk or by cup if needed
 If temperature >39°, sponge can be done with tap water

Practice tip: Don’t use cold / ice water for sponge. Tap water is good enough

Prevention of hypothermia during transport:

 Let temperature stabilize before transfer.
 Document temperature and take remedial measures.
 Carry close to chest.
 Cover adequately, avoid undressing.
 Use thermocol box with pre-warmed linen or plastic sheet or water filled mattress with
thermostat.
 Use transport incubator wherever possible

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 For safe transport refer (safe transport of baby)

Flow Chart 4 Management of Hypothermia and Hyperthermia

Hypothermia and Hyperthermia

 Axillary temperature <36.5 or >37.5 °C

 Palms and soles cold to touch
 At risk neonate (LBW, preterm or sick)

 Identify possible cause of temperature instability

 Check room temperature (maintain 25-28°C)
 Look for signs of infection

Normal temperature Hypothermia Fever

36.5 to 37.5° C (Low temperature < 36.5°C) Temperature > 37.5° C

 Cover adequately  Keep baby away from source of

 Keep baby next to mother heat (warmer, heater, sunlight)
 Continue breast feeding  Remove extra clothes
 Monitor baby s temperature  Decrease environmental
regularly temperature (if needed)
 Recheck baby s temperature every
1 hour till normal
 If >39°C, sponge the baby with
luke warm tap water
 Treat underlying causes

Moderate hypothermia Mild hypothermia 36° - Severe hypothermia

32° - 35.9°C
 Cover mother and baby
together adequately
using pre-warmed
clothes
 Ensure room is warm
 Provide warmth using a
warmer
 Reassess every 15
minutes, if temperature
does not improve
provide additional heat
 Continue breast feeding
36.4°C <32°C
 Position baby skin-to-  Rapid re-warming till
skin with mother baby is 34°C and then
(KMC) slow re-warming
 Cover adequately  Oxygen
 Ensure room is warm  IV fluids (Dextrose
 Continue breast feeding 10%)
 Recheck temperature in  IV antibiotics
1 hour  Reassess every 15
 Prevent heat loss minutes, if temperature
does not improve
provide additional heat

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Kangaroo mother care (KMC)
KMC is a care for preterm or low birth weight babies as an adjuvant to technology based care.
In KMC babies are carried skin-skin with mother which will promote effective thermal control,
effective breast feeding, infection prevention and bonding

The two components of KMC are:

 Skin-skin contact
o Keeping baby only in napkin in vertical position between two breasts under her clothes
o Continuous or intermittent
 Exclusive breast feeding
o Skin-skin contact promotes lactation and facilitates exclusive breast feeding

The two pre-requisites of KMC are:

 Support to the mother in hospital and at home
o A mother needs counselling, support, and supervision from healthcare providers for
initiating KMC in the hospital.
o She also requires assistance and cooperation from her family members for continuing
KMC at home.
 Post discharge follow-up
o KMC is continued at home after early discharge from the hospital.
o A regular follow up and access to healthcare providers for solving problems, if any,
are crucial to ensure safe and successful KMC at home

Benefits of KMC
 Increase milk production in mother
 Promotes exclusive breast feeding
 Reduces the incidence of respiratory tract and nosocomial infection
 Improved weight gain
 Thermal protection and reduces chance to develop hypothermia
 Improves emotional bonding
 Reduces the duration of hospital stay

Eligibility criteria for KMC

Baby:
1. All stable low birth weight babies
2. Started after the baby is hemodynamically stable
o Birth weight>1800 g
o Birth weight 1200-1799 g
 After babies become stable (after few days)
o Birth weight <1200g (days to weeks)
2. Baby can be given KMC when babies are still on IV fluids, oxygen or orogastric feeding

Mother:
 All mothers irrespective of age, parity, education, culture and religion
 Willingness to provide
 Free from serious illness
 Adequate diet and micronutrient supplement

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 Supportive family
o Apart from supporting the mother, family members should also be encouraged to
provide KMC when mother wishes to take rest or she is too sick to provide KMC.
Mother would need family's cooperation to deal with the daily household chores while
baby is requiring KMC
 Supportive community
o Community awareness about the benefits should be created. This is particularly
important when there are social, economic or family constraints

PREPARING FOR KMC

Initiation of KMC
Counselling
 When baby is ready arrange a time that is convenient to the mother and baby
 Demonstrate her KMC procedure in a caring, gentle manner with patients
 Answer her all her quarries and allay her anxieties
 Allow her to bring other family members during this time
o It helps in building positive attitude of the family and ensuring family support to the
mother which is particularly crucial for post-discharge home-based KMC.
o It is helpful if the mother starting KMC interacts with someone who is already
practicing KMC.

Mothers clothing
 Front open light dress

Baby’s clothing
 Cap, socks, nappy and front open sleeveless shirt

Flow Chart 5 KMC according to birth weight

Birth Weight

< 1200 gm 1200 to 1800 gm > 1800 gm

 Most infants suffer from
serious morbidities;
therefore, birth should take
place in specialized centres
the neonatal
 Many infants suffer from Generally, stable at
serious morbidities birth
 Transfer to a specialized
centre, if possible
 Best transported in STS with
mother / family member

May take days to weeks May take days before KMC can be initiated
before KMC can be initiated KMC can be initiated immediately after birth

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Timing of KMC initiation for different birth weight categories

TIME OF INITIATION
 KMC can be started as soon as the baby is stable.
 Babies with severe illnesses or requiring special treatment should be managed according
to the unit protocol.
 Short KMC sessions can be initiated during recovery with ongoing medical treatment (IV
fluids, oxygen therapy).

KMC procedure:
 Provide privacy
 Kangaroo position
o Baby should be placed between mother’s breast in upright position
o Head should be turned to one side in slightly extended position. The slightly extended
head keeps the airway open and allows eye to eye contact with mother
o Hips should be flexed and abducted in a “frog” position and arms should also be flexed
o Baby’s abdomen should be at the level of mother’s epigastrium. Mother’s breathing
stimulates the baby thus reducing apnoea.
o Support the baby’s bottom with a sling/binder

Figure 45 Kangaroo Mother Care procedure

Monitoring
 Important especially in early stage
 Make sure neck in slightly extended position
 Airway clear
 Regular breathing
 Pink in colour
 Temperature normal

Feeding
 Explain about breast feeding while in KMC
 Can give express breast milk cup/spoon, orogastric tube

85
Privacy
 Since it requires some exposure of mother culturally acceptable privacy should be given in
nursery, wards and NICU

Duration
 Skin-to-skin contact should start gradually in the nursery, with a smooth transition from
conventional care to continuous KMC.
 Sessions that last less than one hour should be avoided because frequent handling may
be stressful for the baby.
 The length of skin-to-skin contacts should be gradually increased upto 24 hours a day,
interrupted only for changing diapers.
 When the baby does not require intensive care, she should be transferred to the post-natal
ward where KMC should be continued.

Can the mother continue KMC during sleep and resting?

 The mother can sleep with baby in kangaroo position in reclined or semi recumbent
position about 30 degrees from horizontal.
 This can be done with an adjustable bed or with pillows on an ordinary bed.
 A comfortable chair with an adjustable back may be used for resting during the day

When to stop KMC?

 Till baby finds it comfortable and cosy
 Once baby’s weight > 2500gm and gestation >37 weeks

Post-discharge follow-up
 Close follow up is a fundamental pre-requisite of KMC practice. Baby is followed once or
twice a week till 37-40 weeks of gestation or till the baby reaches 2.5 to 3 kg of weight.
 Thereafter, a follow up once in 2-4 weeks may be enough till 3 months of post-conception
age.
 Later the baby should be seen at an interval of 1-2 months during first year of life.
 The baby should gain adequate weight (15-20 gm/kg/day up to 40 weeks of post-conception
age and 10 gm/kg/ day subsequently).
 More frequent visits should be made if the baby is not growing well or his condition
demands.

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Skill Checklist 12 KMC procedure

Rating
No. Steps
Y ¥ NA
1. Check for privacy of the room
2. Dress the baby with cap, socks, nappy and front open clothes/
shirt.
3. Place the baby in between mother’s breast in upright position
4. Turn the baby’s head in one side in slightly extended position

5. Ensure the hips are flex and abducted and arms are also flexed
(frog’s position)
6. Ensure baby’s abdomen is at the level of mother’s
Epigastrium
7. Ensure baby is supported at the bottom by a sling/binder

8. Monitor for position of head and neck, airway,

breathing, colour and temperature

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 CHAPTER SEVEN
PMTCT AND MANAGEMENT OF INFANT BORN TO HIV
POSITIVE MOTHER
Learning objectives of PMTCT and management of infant born to HIV positive mother:
After the training the participant will be able to:
 Provide an overview of mother-to-child transmission of HIV (MTCT)
 Identify factors that increase the risk of MTCT
 Discuss mother-to-child transmission of HIV infection
 Describe the risk of transmission without any intervention
 Describe the four-pronged comprehensive approach to the prevention of mother-to-child
transmission (PMTCT) of HIV
 Describe the various strategies to reduce this transmission through ARV to mother/baby
 Counsel the mother for infant feeding choices

Introduction:
Human Immunodeficiency Virus:
Lentivirus (slow virus)
Long interval between initial infection and serious symptoms
Retrovirus (RNA containing virus)
Uses the enzyme reverse transcriptase to convert viral RNA into DNA
Incorporates its new DNA into the genes of the host (human) cells

Mode of transmission:
 Mother to child (Vertical transmission)
 Sexual abuse
 Injecting Drug Users (IDU)
 Sexual
 Blood and blood products transfusion

MTCT:
 Mother-to-child transmission of HIV (MTCT), ‘vertical transmission’ or ‘perinatal
transmission’
 From an infected mother to her baby during pregnancy, labour and delivery and
breastfeeding
 Most children with HIV acquired the virus through MTCT

Estimated risk and timing of MTCT in the absence of interventions:

During pregnancy 5 to 10 %
During labour and delivery 10 to 15 %
During breastfeeding 5 to 20 %
Overall without breastfeeding 15 to 25 %
Overall with breastfeeding to 6 months 20 to 35 %
Overall with breastfeeding to 18 to 24 months 30 to 45 %

89
Factors that may increase the risk of MTCT of HIV:

Pregnancy
– High maternal viral load (new HIV infection or advanced clinical disease)
– Low CD4 cell count
– Viral, bacterial or parasitic placental infection (e.g. malaria)
– Sexually transmissible infections
– Maternal malnutrition (indirect cause)

Labour and Delivery

– High maternal viral load (new HIV infection or advanced clinical disease)
– Rupture of membranes more than 4 hours before labour begins
– Invasive delivery procedures that increase contact with mother's infected blood or body
fluids (e.g. episiotomy, foetal scalp monitoring)
– First infant in multiple birth
– Chorioamnionitis (e.g. from untreated STI or other infection)

Infant
– High maternal viral load (new HIV infection or advanced clinical disease)
– Duration of breast feeding
– Mixed feeding (i.e. any food or fluids in addition to breast milk)
– Breast abscess, nipple fissures, mastitis
– Poor maternal nutritional status
– Oral thrush or sores

PMTCT:
– PMTCT: common term for programs, services and interventions whose goal is to reduce
the risk of MTCT
– PMTCT services include:
– HIV testing and counselling during ANC, labour and delivery and postpartum
– Provision of ARV drugs to mother and infant
– Safer delivery practices
– Infant feeding information, counselling and support
– Referrals to comprehensive treatment, care and social support for mothers and families with
HIV infection
– Early infant diagnosis to be done at 6 weeks by DNA PCR

Four-Pronged UN Strategy for PMTCT of HIV:

1. Prevent HIV infection in women of reproductive age
2. Prevent unintended pregnancy in HIV-positive women
3. Prevent mother-to-child transmission of HIV by:
a. Providing antiretroviral therapy during pregnancy
b. Implementing safer delivery practices
c. Providing counselling and support on infant feeding methods
1. Provide care, treatment and support to HIV-infected parents, Infants and families

Comprehensive Approach to Preventing HIV Infection in Infants and Young Children

To significantly reduce MTCT and achieve targets, PMTCT must be viewed as a
comprehensive public health approach

90
Focus is on:
 Women with HIV and their partners, children and families
 Parents-to-be whose HIV status is unknown or who have tested HIV-negative

Four Elements of a Comprehensive Approach:

PMTCT programs:
 Identify pregnant women with HIV
 Provide HIV-infected pregnant women with interventions for PMTCT
 Involving both men and women in all 4 elements is vital for the success of PMTCT
 Both partners should be:
o Participating in decisions about preventing HIV transmission
o Playing an important role in using family planning methods
o Getting tested and counselled for HIV

Key Points:
 Risk of MTCT without intervention is 20–45%
 Effective PMTCT programs provide access to interventions that can significantly
reduce the rate of MTCT
 Risk of transmission to the infant is highest when the mother’s viral load is high. Two
of the main reasons that a mother may have a high viral load are: recent HIV infection
and advanced AIDS
 A comprehensive approach is needed to prevent HIV infection in infants, young
children.

Interventions to reduce MTCT:

 Reduction of Maternal viral load by ARVs
 Reducing exposure of foetus by C-section, avoiding invasive obstetric practices as
forceps, episiotomy, foetal blood sampling from scalp.
 Safe infant feeding practices
 Promotion of primary and secondary prevention strategies against HIV infection
Nepal has chosen Option B+ as recommended in the WHO consolidated Guidelines-June 2013,
which recommends that all HIV-infected pregnant women are started on life-long ART
regardless of WHO clinical stage and CD4 cell count. Programs need to put methods in place
to support these women for rapid evaluation as soon as possible. The three elements of PMTCT
during labour and post-partum are:
 Providing ARV therapy to the mother, and to the baby following delivery,
 Implementing safer delivery practices,
 Providing ongoing counselling and support on safer infant feeding
 A once-daily fixed-dose combination of TDF + 3TC + EFV is recommended as
first-line ART in pregnant and breastfeeding women, including pregnant
women in the first trimester of pregnancy and women of childbearing age.

Recommendations on breastfeeding and infant feeding

The mothers known to be infected with HIV should exclusively breastfed their infants for the
first six months of life, introducing appropriate complementary foods thereafter, and continue
breastfeeding same as mother without HIV.

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All pregnant women with HIV who are on ART are recommended to continue breastfeeding
as per the national breastfeeding protocol, however during breast infection (especially mastitis)
and cracked or bloody nipples, there is additional risk for HIV transmission; and the sores or
oral thrush (candidiasis) in the infant’s mouth may also facilitate infection occurring during
breastfeeding, and is suggested to avoid breastfeeding until complete cure or give expressed
breast milk.

HAART for pregnant women and BF

Recipient Timing ARVs
Start ASAP in pregnancy
and continue throughout
TDF 300mg/ 3TC 150mg + EFV 600 once a
Mother pregnancy, labour, delivery
day
and postpartum, for life
long
Infant NVP once daily for 6 weeks. NVP dose
is: 10mg (1ml) if birth weight <2.5 kg, 1.5 ml if
Baby Newborn
≥2.5kg. First dose should be given ASAP after
birth.

HIV-infected mothers:
PMTCT program of Nepal recommends that HIV infected mothers in Nepal should;
 Exclusively breastfeed for the first 6 months of life, start complementary feeding from 6
month of age
 Continue breastfeeding for 24 months, while giving complimentary feeds and continuing
to take triple ARVs.
 All mothers who are HIV-infected should be informed that breastfeeding is recommended
to give the best chance to a healthy baby.

RISKS OF REPLACEMENT FEEDING

 Risk of dying 6 fold in first 2 months, 4 fold between 2 to 3 months, 2.5 fold between
4 to 5 months
 Cry more and difficult to pacify
 Diarrhoea, ARI, sepsis, asthma and atopy
 Abdominal pain, vomiting and constipation, anal fissure and abdominal distension
 Anaemia and hypocalcaemia
 Malnutrition
 Poor development
 Say “no” to mixed feeding

Summary
 Breast feeding
 Drug
 Attend immunization clinic for test

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Cases scenario:
Case scenario 1
Anita, a 24-year mother has been tested positive for HIV.
1. What is the risk for baby?
2. Do you advise her to continue pregnancy?
3. Can baby be protected from transmission? How?
4. What more investigations will you like to do?
5. Do you want to give her medicine? What? When?
6. Where should she deliver?
7. What precaution will you like to take during delivery?

She delivers a 3 kg healthy baby.

8. Do you want to give medicine to baby? What? How long?

Case Scenario
Now Anita asks you whether she can breast feed her baby? What do you suggest?
1. What is the risk of transmission by breast feeding?
2. What is the risk of not breast feeding?
3. Anita again comes to you when baby is 6 months old and tells you that she wants to
wean her baby now with complementary feeding.
4. What do you suggest?

93
 CHAPTER EIGHT
FLUID MANAGEMENT IN NEWBORN
Learning outcomes of fluid and electrolyte management
After the training, the participant will be able to:
 Identify insensible of water loss in neonate
 Use appropriate fluid according to age and gestational age
o Fluid requirement ml/kg/day according to age and weight
 Know how to estimate maintenance fluid needs
Disorder of fluid is commonly encountered in preterm and sick neonates. The aim of fluid
therapy is for smooth transition from aquatic in-utero environment to dry ex-utero environment.
Newborn develops fluid and electrolyte disturbances because of:
Changes of body water and solute after birth
 Efflux of fluid from intracellular (ICF) to extracellular compartment
 Diuresis by 48-72 hours
 Weight loss
o Term up to 10% by 7 day
o Preterm up to 15% by 14 day

Renal function
 Limited capacity to excrete concentrated and diluted urine
 Salt and water diuresis at 48-72 hours

Insensible water loss (IWL)

There is large amount of insensible water loss in neonate and affected by prematurity and
birth weight.
Body weight in gm Insensible water loss (ml/kg/day)
<1000 60-80
1000-1500 40-60
>1500 20
(Avery; 1999:345-361)

Meticulous about fluids in newborn

 Water content is high
 Renal immaturity
 Insensible water loss is high
 Small variation of fluids has grave implications
Fluid overload: PDA, BPD, IVH

Assessment of Fluid and Electrolytes Status

History:
 Baby’s fluid and electrolyte status partially reflects maternal fluid and electrolyte status
 Excessive use of oxytocin, diuretics, hypotonic IVF to mother will lead to hyponatremia
in baby

95
  ACE inhibitors, Aminoglycoside, Frusemide, Aspirin given to mother can alter
neonatal renal function
 Antenatal steroids may increase skin maturity and decreases insensible water loss

Physical Examination
 Weight:
o Reflects Total Body Water (TBW)
 Skin/Mucosa: Altered skin turgor, sunken AF, dry mucosa, oedema etc.
are not sensitive indicators in babies
 Cardiovascular:
o Tachycardia can result from too much (ECF excess in CHF) or too little ECF
(hypovolemia)
o Delayed capillary refill can result from low cardiac output
o Hepatomegaly can occur with ECF excess
o Alteration in blood pressure may be very late in newborn.

Initial fluid therapy

Fluid rate (ml/kg/d)

B. WT (kg) Hours Days

24 48 72 4 5 6 7

<1 80 100 120 130 140 150 160

1-1.5 80 95 110 120 130 140 150

>1.5 60 75 90 105 120 135 150

Types of fluid
 10% dextrose with no electrolyte with glucose infusion rate of 4-6 mg/kg/min for term
babies for 48hrs
 10% dextrose with no electrolyte with glucose infusion rate of 4-6 mg/kg/min preterm
babies with birth weight ≥1000gm for 48hrs
 5% dextrose with no electrolyte with glucose infusion rate of 4-6 mg/kg/min birth
weight <1000 gm
 After 48 hours N/5 10% dextrose with 1ml per 100ml of potassium chloride fluid is
started.

Fluid Requirements

Decrease by 1/3rd of total requirement in:

 Patent ductus arteriosus
 Congestive cardiac failure
 Broncho pulmonary dysplasia
 Acute renal failure

Increases

96
  Use of equipment
o Radiant warmer increase by 20%
o Phototherapy increase by 10% (No need for Lead Phototherapy)
 Clinical conditions
o Fever
o Cold stress

Factors modifying fluid requirement

 Maturity
o Mature skin reduces Insensible Water Loss (IWL)
 Elevated temperature (body/environment)
o Increases IWL
 Humidity: Higher humidity
o Decreases IWL up to 30% (over skin and over respiratory mucosa)
 Skin breakdown, skin defects (e.g. omphalocele)
o Increases IWL (proportional to area)
 Radiant warmer
o Increases IWL up to 50%
 Phototherapy
o Increases IWL up to 50% (not in case of lead phototherapy)
 Plastic Heat Shield
o Reduces IWL by 10-30%

Fluid to be use
 Volume expander
 Vehicle for phenytoin, sodabicarb, aminophylline.
Normal saline
 Replacement of gastric aspirate
 Correction of hyponatremia
10% dextrose with N/5  Replacement after 48 hours
saline with K+, 1 ml/100ml  (Refer page…)
5% dextrose  First 48 hours maintenance in <1000gm

10% dextrose  First 48 hours maintenance in >1000 gm

Monitoring
 IV cannula site for swelling
 Body weight
 Clinical examination
o Dehydration
 Serum biochemistry if available
o Sodium 135-145 mEq/L and potassium 3.5-5.5mEq/L
o Hyponatremia with weight gain
 Water excess
o Hypernatremia with weight loss
 Dehydration
 Urine output specific gravity

97
 o Urine output 1-3ml/kg/hr
 Blood gas if available
o Hypoperfusion associated with metabolic acidosis

98
 CHAPTER NINE
SHOCK
Learning outcome of shock
After the training participants, will be able to
 Enlist the causes of shock in newborn
 Outline the clinical features of shock
 Describe the management of shock

Introduction
Acute, complex state of circulatory dysfunction leading to insufficient oxygen and nutrient
delivery
Maintenance of tissue perfusion depends on 3 factors:
 Cardiac output (HR x SV)
 Local autoregulation
 Normal blood characteristics

Aetiology
 Hypovolemic
o Excessive insensible water loss
o Inadequate feeding
o Perinatal blood loss
o Placental haemorrhage
 Cardiogenic
o PDA, Hypoplastic left heart, Aortic stenosis, Coarctation of aorta
o Birth asphyxia
o Cardiomyopathy (Infant of diabetic mother)
o Arrhythmias
 Distributive
o Sepsis
o Third space loss, peritonitis
 Obstructive
o Cardiac tamponade
o Tension pneumothorax

Clinical conditions that particularly require monitoring for shock:

1. Babies on ventilation
2. VLBW
3. Sepsis
4. Asphyxia
5. Blood loss

Clinical features
 Tachycardia
 Hypotension
 Pallor, poor skin perfusion
 Cool extremities
 CNS signs of lethargy

99
  Decreased urine output

Management of shock
 Rapid recognition of shock state
 Initial Fluid resuscitation
o Infuse normal saline 10ml/kg over 20-30 min, if capillary refill time (CRT) more than
3 second. This can be repeated 1-2 times till CRT< 3 sec over 30-45 minutes
o If no improvement, then start inotropes
 Supportive care (temperature, oxygenation)
 Start antibiotics if infection is suspected
 Correct negative inotropic factors – hypoxia, acidosis, hypoglycaemia, other metabolic
derangements
 Ionotropes
o Dopamine
 Inotrope of choice when shock associated with hypotension.
 Dose 5-20 mcg/kg/min
 To add Dobutamine, if no response even at dose of 10mcg/kg/min
o Dobutamine
 Inotrope of choice in shock without hypotension, cardiogenic shock, shock with
CVP>10cm, shock with CCF.
 Dose 5-20 mcg/kg/min
o Adrenaline
 In patient not responding to combination of dopamine and dobutamine
 Inotrope of choice for anaphylactic shock, septic shock, post cardiac arrest.
 Dose 0.1 -2 mcg/kg/min
o Noradrenaline
 In septic shock
 Consider IV Hydrocortisone in case of vasopressor-resistant shock

Hydrocortisone for vasopressor-resistant hypotension:

 Day  Dose/frequency
 Day 1 initial dose  1mg/kg/dose q8h x 3 doses
 Day 2 follow in 12 h with  0.5mg/kg/dose IV q12 h x 2 doses
 Day 3 follow in 12 h with  0.25 mg/kg/dose IV q12h x 2 doses
 Day 4 follow in 24 h with  0.125 mg/kg/dose IV x 1 dose
If BP improves and other vasopressors have been weaned off, treatment may stop after 24
hours.

Ionotropic Agents

100
Preparation before infusion
Inotrope Commercial Dilution  Dilution Final
ly available Step 1 Step 2 concentrati
concentratio  NEONATAL on
n
Dopamine 1ml=40mg 2ml of undiluted 1.6mg/ml
Dopamine
+48ml NS or 5% Dextrose
Epinephrine 1ml=1mg 1ml of diluted Epinephrine 1.6mg/ml
(mg/ml) + 49ml NS or 5%
Dextrose
Dobutamin 250 mg  Dilute in 6.4 ml of Dobutamin 1.6mg/ml
powder 20 ml (12.5mg/ml) + 43.6ml NS
WFI or 5% Dextrose
 1ml=12.5
mg

Dobutamin 250 mg  Dilute in 6.4 ml of Dobutamin 1.6mg/ml

powder 20 ml (12.5mg/ml) + 43.6ml NS
WFI or 5% Dextrose
 1ml=12.5
mg

Practical Tips for using inotropes

 Amount of Dopamine to be infused in 24 hours (mg)
= 1.5 X weight X dose (mcg/kg/min)

 Points to remember
o Diluted in 5 or 10 % dextrose
o Infusion syringe must be placed horizontally
o Should not be interrupted (short half-life 1-2min), weaning gradually
o Labelling in bold
o Look for extravasations

101
Flow Chart 6 Management of Shock

Shock

Normal saline bolus 10 ml/kg over 20 – min

Improvement (decreased
Partial or no improvement
HR, improved CRT/BP)

Continue monitoring and Repeat bolus

supprotive care

Start Dopamine at 10
mcg/kg/min

Continue monitoring
Treat underlying cause
Continue supportive therapy

Monitoring Chart of all sick neonates

Parameter/ time Adm Hours
2 4 6 8 10 12 16 20 24 28 32 36

Temp
HR
RR
SpO2
MBP
Urine output 8
hourly (ml/kg/hr)
Downe score
Blood glucose
Electrolytes
S. Calcium
BUN

102
 CHAPTER TEN
HYPOGLYCEMIA
Learning outcomes of hypoglycaemia
After the training the participants will be able to:
 Outline the epidemiology, definition and identification of hypoglycaemia
 Identify risk factors and aetiology
 Outline the investigation required and glucose monitoring technique
 Enlist the management
 Enlist the follow up care

Epidemiology
Hypoglycaemia is the most common preventable metabolic problem of neonates. Almost
16% of large for gestational age (LGA) babies and 15% of small for gestational age (SGA)
babies develop hypoglycaemia in neonatal period.

Definition
A blood glucose value of < 45 mg/dl is considered as having hypoglycaemia.

Common causes of hypoglycaemia

Inadequate substrate
 Small for gestational age (weight for gestation < 3rd percentile)
 Preterm babies (especially <35 weeks)
 Low birth weight babies (especially <2000g)
 Delayed initiation of feeding

Relative hyperinsulinemia
 Infant of diabetic mother
 Large for date babies (weight for gestation >97th percentile)
Rh isoimmunisation
Increased glucose utilization

Hypothermia
 Sepsis
 Asphyxia
 Polycythaemia

Identification of hypoglycaemic babies

Generally asymptomatic, but if any newborn with known predisposing factors develop
following features, then one should suspect hypoglycaemia.
 Tremors, jitteriness or irritability
 Weak or high pitched cry
 Poor feeding, vomiting
 Cyanosis
 Severe hypothermia
 Lethargy, apathy and limpness
 Apnoea
 Seizures, coma
103
Screening
Serial blood glucose levels should be routinely measured in infants who have risk factors for
hypoglycaemia.

Following schedule for glucose monitoring is generally done

Predisposing Conditions Monitoring schedule
LBW (<1800 grams)
IUGR
Preterm(≤35wks)
LGA
Infants 2,6,12,24,48 and 72 hours
 Rh-Haemolytic diseases,
 Mother on
o Oral Hypoglycaemic Agents
o Propranolol
o Terbutaline.
Sick babies in active phase of illness
 Sepsis
6 to 8 hourly
 Shock
 Asphyxia
Infant of diabetic mothers 1,2,3,6,12,24,36 and 48 hours
After 1 hour of oral or, then 6hrly till 48
hours
 if blood sugar>45 mg/dl, the
target blood glucose value 50-
Asymptomatic babies with blood sugar
120mg/dl
between 25 to 45 mg/dl.
 if repeat blood sugar < 45 mg/dl,
IV dextrose is started and further
management is as for
symptomatic hypoglycaemia
After 1 hour of starting iv dextrose and
then every hour (after every stepwise
Asymptomatic babies with blood sugar level
augmentation of GIR by 2mg/kg/min till
less than 20 mg/dl.
blood sugar levels remain below
50mg/dl)

Management:
Anticipation and identification of the condition is the key to the management.
 Blood sugar level between 25 to 45mg/dl in asymptomatic
o Trial of oral feeds (expressed breast milk or formula)
o Repeat sugar after I hour is more than 45 mg/dl
 2 hourly feeding is ensured with RBS monitoring 6-hourly for next 48 hrs.
o Repeat sugars <45 mg/dl
 IV therapy is started.
 Oral feeds
o Breast feeding or expressed breast milk or formula feeds

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IV-therapy
 Inability to tolerate oral feeds.
 Symptomatic
 Oral feeding not able to maintain normal glucose levels.
 Glucose level <25 mg/dl

Urgent treatment
 2ml/kg of 10% dextrose infused over 1 minute.
 Recheck blood glucose after 30 minutes and hourly until stable, to determine if additional
therapy is needed.

Continuing therapy
 Glucose infusion at an initial rate of 6mg/kg/min should be started
 Subsequent hypoglycaemic episodes to be treated with repeat bolus at 2ml/kg and
increment in glucose infusion rate (GIR) by 2 mg/kg/min till 12 mg/kg/min.
 If 2 or more values more than 50 mg/dl over 24 hours, then GIR can be decreased by 2
mg/kg/min every 6-hourly with RBS monitoring.
 Tapering to be accompanied by concomitant increase in oral feeds.
 Abrupt tapering may cause rebound hyperglycaemia.
 Not to give more than 12.5% glucose via peripheral veins for the risk of thrombophlebitis.
Consider as refractory hypoglycaemia (for management refer to Flow chart) For more
than 12.5%, central venous access has to be achieved.

Follow-up and assessment

 The babies can be assessed at 1-month corrected age for vision / eye evaluation.
 At 3, 6, 9,12 and 18 months corrected age they can be followed up for growth,
neurodevelopment, vision and hearing loss.

Recurrent / resistant hypoglycaemia

If baby unable to maintain normal blood glucose level despite the infusion of 12 mg/kg/min of
glucose infusion or stabilization is not achieved by 7 days of therapy, then baby is having
recurrent /resistant hypoglycaemia.

Management of refractory hypoglycaemia

 If hypoglycaemia persists despite GIR >12 mg/kg/min, give
 Injection hydrocortisone-
o 2.5 mg/kg IV and refer

105
Flow Chart 7 Identify a baby with hypoglycemia
Flowchart 1:
Identify a baby with hypoglycemia

Suspect
a. Small for gestational age
b. Large for gestational age
c. Infant of diabetic mother
d. Preterm babies
e. Symptomatic babies Jitteriness, cyanosis , seizures, apneic
episodes, tachypnoea, weak or high pitched cry, floppiness or
lethargy, poor feeding , eye rolling, severe hypothermia

Check blood glucose at 1 hour

Blood glucose 25-45mg/dl & asymptomatic

Breastfeeding or expressed breast milk by cup

Monitor blood glucose after 3 hours or before next feed

> 45 mg/dl 25-45 mg/dl < 25 mg/dl

Increase frequency (if

breast-fed) or Increase Follow Flowchart 2
volume of feed (if cup fed)

Monitor blood glucose before next feeds; Discontinue

monitoring if blood glucose is 50 mg/dl or more on two
consecutive measurements

106
Flow Chart 8 Management of baby with symptomatic hypoglycemia
Flowchart 2:
Management of baby with blood glucose <25 mg/dl or symptomatic hypoglycemia

Blood glucose<25 mg/dl

OR
Blood glucose 25-45 mg/dl and symptoms of hypoglycemia

Give bolus of 2 ml/kg 10% dextrose IV over 5 minutes

If no IV access, give same by nasogastric tube.
Continue IV 10% dextrose at daily maintenance rate (GIR* 6mg/kg/min

Check blood glucose after 30 min

Blood glucose <25mg/dl or symptomatic Blood glucose >45 mg/dl

Repeat bolus 10% dextrose 2ml/kg
Increase infusion rate to 8mg/kg/min.
Measure blood glucose after 30 min
If blood glucose <45mg/dl, increase
Infusion rate to 10mg/kg/min
Continue dextrose infusion at same rate
Monitor blood glucose every 3 hours
If blood glucose mg/dl or more on 2
consecutive measurements start decreasing
glucose infusion by 2mg/kg/min.

Repeat measurement after 3 hours, Increase oral feeding gradually

Stop IV fluids when oral feeding reaches at

least 2/3rd of daily requirement. Allow baby
to breast feed. Stop monitoring when 2 pre-
feed values are > 45mg/dl on full feed.

If Blood glucose <45 mg/dl If Blood glucose >45 mg/dl

Continue at this rate till 2

Refer for level III care consecutive pre-feed values
6 hours apart are >45mg/dl
*GIR-Glucose Infusion Rate

107
Achieving appropriate glucose infusion rates using a mixture of D10 and D25
Volume of Glucose Infusion Rate
fluids
6 mg/kg/min 8 mg/kg/min 10 mg/kg/min
D10 D25 NS DW D10 D25 NS DW D10 D25 NS
(ml/kg/day) DW
(ml) (ml) (ml) (ml) (ml) (ml) (ml) (ml) (ml) (ml) (ml)
60 42 18 - - 24 36 - - 5 55 - -
75 68 7 - - 49 26 - - 30 45 - -
90 60 10 20 - 40 30 20 - 20 50 20 -
105 85 - 20 - 65 20 20 - 45 40 20 -
120 86 - 20 14 88 12 20 - 70 30 20 -
135 86 - 20 29 115 - 20 - 80 25 20 -
150 86 - 20 44 115 - 20 15 120 10 20 -

Formula for GIR Calculation - (% of dextrose X ml/kg/day) / 144

For example, if 10% Dextrose is used at 80 ml/kg/day that gives,
GIR = (10X80)/144= 5.6mg/kg/min

108
 CHAPTER ELEVEN
HYPOCALCEMIA
Learning outcomes of Hypocalcaemia
After the training the participants will be able to:
 Outline the definition of hypocalcaemia.
 Identify risk factors and aetiology.
 Enlist the investigation and calcium monitoring plan.
 Outline the management.

Definition
Calcium is the most abundant mineral in the body. Neonatal hypocalcaemia is defined as a
total serum calcium of <7 mg/dl or an ionized calcium concentration of <4mg/dl.

Aetiology
Early neonatal hypocalcaemia (48-72 hours)
 Prematurity
o Poor intake,
o Hypoalbuminemia
o Reduced responsiveness to vitamin D
 Birth asphyxia
o Delayed feeding
o Increased calcitonin
o Endogenous phosphate load high
o Alkali therapy
 Infant of diabetic mother
o Magnesium depletion → Functional hypoparathyroidism → Hypocalcemia
 Sepsis
 Shock
 IUGR

Late onset hypocalcaemia

 Hypomagnesemia
 Increased phosphate load
o Cow’s milk
 Vitamin D deficiency
o Preterm babies
o LBW babies

Clinical presentation:
 Asymptomatic:
o Early onset hypocalcaemia is usually asymptomatic unlike the late onset variety and
is diagnosed on routine screening.
 Symptomatic:
o Non-specific and not related to the severity of hypocalcaemia.
 Jitteriness
 Lethargy
 Apnoea

109
  Hypotonia
 High-pitched cry
 Stridor
 Irritability
 Seizures

Investigations
 Laboratory: Total or ionized serum calcium (total <7 mg/dL or ionized <4.0 mg/dL).
 Ionized calcium is the preferred mode for diagnosis of hypocalcaemia.

Monitoring
 Ionized calcium at 12, 24 and 48 hours of life.
o VLBW Perinatal depression
o Infants of diabetic mothers.
 Total serum phosphorus and magnesium
o Infants with hypocalcaemia.

Flow Chart 9 Classification of Hypoglycemia

Hypocalcemia
(tCa < 7 mg/dl)

Symptomatic Asymptomatic

IV calcium gluconate (10%) Oral calcium preparation

-2ml/kg as bolus (1:1 dilution with 5% dextrose Calcium Solution
over 10 min) -80 mg/kg/D for 48 hours
-80 mg/kg/D for 48 hours -40mg/kg/day for 24 hours
-Document normal serum calcium & reduce to -Then stop
40mg/kg/day for 24 hours
-Then stop

1 ml of calcium gluconate contains 9 mg of elemental calcium

Dilute 1:1 with 5 % dextrose and infuse with cardiac monitoring

Management
Patients at increased risk of hypocalcaemia:
 Preterm infants (<32 weeks)
 Sick infants of diabetic mothers
 Severe perinatal asphyxia
o 40 mg/kg/day of elemental calcium (4 ml/kg/day of 10% calcium gluconate) for 72
hours of life
 Infants tolerating oral feeds
o Oral calcium 80 mg /kg/day in 4 divided doses for 72 hours
 Asymptomatic hypercalcaemic infants
110
 o 80-mg/kg/day elemental calcium (8 ml/kg/day of 10% calcium gluconate) for 48
hours.
o Tapered to 50% dose for another 24 hours and then discontinued.
 Symptomatic hypocalcaemia infants
o Bolus dose of 2 ml/kg/dose diluted 1:1 with 5% dextrose over 10 minutes, under
cardiac monitoring.
o Continuous IV infusion of 80-mg/kg/day elemental calcium (8 ml/Kg/day of 10%
calcium gluconate) for 48 hours.
o Tapered to 50% of the original dose for the next 24 hours and then discontinued.

111
 CHAPTER TWELVE
PERINATAL ASPHYXIA
Insult to the foetus or newborn due to lack of oxygen and lack of perfusion leading to ischemia
of various organs. WHO defines Apgar 0-3 and 4-6 at 1 minute as severe and moderate birth
asphyxia. As per the AAP (American Academy of Paediatrics) and ACOG (American College
of Obstetrics and Gynaecology), all the following must be present for designation of asphyxia:
(i) Profound metabolic or mixed acidemia (pH <7.00) in umbilical artery blood
sample, if obtained
(ii) Persistence of an Apgar score of 0–3 for longer than 5 min
(iii) Signs of neonatal neurologic dysfunction (e.g., seizures, encephalopathy, tone
abnormality)
(iv) Multiple organ involvement (e.g., kidney, lungs, liver, heart, intestines)

Hypoxia due to perinatal asphyxia is an evolving process that starts at the onset of insult and
continues after resuscitation and thereafter manifests in form sequelae. Management and
prognosis depends upon stage at which it has been picked up. Hence the preventive
management should begin from antennal period.

Antenatal
- Early detection and management of high risk factors stated earlier

Perinatal
- Foetal heart rate monitoring
- Foetal movement monitoring
- Non-stress test

Delivery Room
- Prevention of heat loss
- Rapid establishment of effective ventilation and circulation

Postnatal
- Evaluation of risk factors associated in antepartum and intrapartum period with
resuscitation detail, APGAR score and neurological examination help in diagnosis. The
following are the presentation and baseline management needed to be done in newborn
with asphyxia.

Classification of HIE (Levene)

Features Mild Moderate Severe
Consciousness Irritable Lethargy Comatose
Tone Hypotonia Marked hypotonia Severe hypotonia
Seizure No Yes Prolonged
Sucking/Respiration Poor Suck Unable to suck Unable to sustain
spontaneous
respiration

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Clinical features of severe HIE in time frame
Birth to 12 hours Depressed level of alertness, periodic breathing or respiratory failure,
intact pupillary and oculomotor responses, hypotonia, seizures

12 to 24 hours Variable change in level of alertness, more seizures, apnoeic spells, jitteriness,
weakness in proximal limbs, upper>lower (full term), hemiparesis (full term),
lower limbs (premature)

24 to 72 hours Stupor or coma, respiratory arrest, brain stem pupillary and oculomotor
disturbances, catastrophic deterioration with severe intraventricular
haemorrhage and periventricular haemorrhagic infarction (premature)

After 72 hours Persistent yet diminishing stupor, disturbed sucking, swallowing, gag and
tongue movements, hypotonia>hypertonia, weakness in proximal limbs,
upper>lower (full term), hemiparesis (full term), lower limbs or hemiparesis
(premature)

Management of a neonate with perinatal asphyxia

Management is mainly supportive and involves maintaining optimum oxygenation, ventilation,
perfusion, metabolic profiles and control of seizures.

Delivery room care

1. Collect arterial cord blood for analysis (if available):
Presence of metabolic acidosis (pH <7.00 and base deficit greater than 16 mmol/L) indicates
relatively long standing asphyxia (many minutes to hours), while presence of respiratory
acidosis in absence of metabolic acidosis indicates presence of acute asphyxia (minutes) as in
cord prolapse, acute abruption of placenta etc.

Baby requires SNCU admission if:

 Apgar score 0-3 at 1 minute
 Prolonged bag and mask ventilation (60 seconds or more)
 Chest compression

2. Maintain normal temperature

 After drying, place the baby under the radiant warmer
 Maintain normal body temperature of the baby (36.5-37.5 °C)
 Avoid Hyperthermia

3. Maintain Airway and Breathing

 Maintain airway by appropriate positioning and clear if any secretion is present
 Assess the infant for adequacy of oxygenation and ventilation and provide support as
needed
o Keep under oxygen hood in case of adequate spontaneous breathing
 Assisted ventilation is required if there is apnoea, or spontaneous respiration is
inadequate or there is continuing hypoxia or hypercarbia,
 Maintain saturations between 90% and 95% and avoid any hypoxia or hyperoxia
 If oxygen saturation does not improve put on CPAP or refer for ventilation

114
4. Maintain normal tissue perfusion
 Ensure normal perfusion i.e. normal blood pressure, capillary refill time of less than 3
seconds, normal urine output, and absence of metabolic acidosis
 Start intravenous fluid in all infants with APGAR scores <4 at 1 minute or <7 at 5
minutes of age or a baby that is not well- having respiratory problems, encephalopathy
or abnormal tone.
 If the tissue perfusion is inadequate, infuse normal saline 10 mL/kg over 20-30 minutes
 Administer dobutamine (preferred) or dopamine to maintain adequate cardiac output,
as required.

5. Maintain normal haematocrit and metabolic milieu

 Check blood glucose levels and maintain blood glucose levels between 75 mg/dL and
100 mg/dl.
 Check haematocrit. Correct Anaemia and maintain haematocrit between 45% and 55%.
If the venous haematocrit in a baby is above 65%.
 In case of severe asphyxia, provide calcium in a maintenance dose of 4 mL/kg/day (of
10% calcium gluconate) for 1-2 days as a continuous infusion or as 1:1 diluted bolus,
slowly under cardiac monitoring and maintain serum calcium concentration in the
normal range.

6. Treat seizures
 Refer to seizure protocol

7. Nutrition:
 Keep NPO for 24 horus in mild HIE, 48 hrous in moderate – Severe HIE. Before
starting feed, look for abdominal distension, passage of stool, normal bowel sound.
Baby should be hemodynamically stable and vasopressors should be stopped before
feeding.

8. Miscellaneous
 Administer Vitamin K1 (1 mg IM for weight 1 kg and 0.5 mg for 1 kg) to all infants
with perinatal asphyxia

Post Resuscitation care

Organ System Potential Complication Post – Resuscitation Action
Monitor for apnoea
Support ventilation as needed
Apnoea
Monitor RBS, Electrolytes
Brain Seizures
Avoid hypothermia
Consider Anticonvulsant therapy
Whole body cooling/Head cooling
Pulmonary Hypertension Maintain adequate ventilation and
Pneumonia oxygenation
Pneumothorax Consider Antibiotics
Lungs
Transient Tachypnoea Obtain X-Ray if respiratory distress
MAS Consider Surfactant therapy
Surfactant Deficiency Delay enteral feedings
Cardiovascular Hypotension Monitor BP and heart rate

115
 Post Resuscitation care
Organ System Potential Complication Post – Resuscitation Action
Consider Ionotropes and/or volume
replacement
Monitor Urine Output
Fluid restriction if baby oliguric and
Kidneys Acute tubular necrosis
vascular volume adequate
Monitor electrolytes
Delay initiation of feedings
Ileus
Gastrointestinal Give IV Fluids
Necrotizing enterocolitis
Consider Parental nutrition
Hypoglycaemia Monitor Random blood sugar
Metabolic/ Hypocalcaemia, Hyponatremia Monitor electrolytes
haematological Anaemia Monitor Haematocrit
Thrombocytopenia Monitor platelets

Follow-up:
 Call them back
 Immunization
 Investigations
 HC measurement / monitoring

Monitoring
 Neurological status by using Levene’s score every 8 hours
 Respiratory status by Downe’s score every 2-3 hours
 Cardiovascular status by HR, Colour, CRT, peripheral pulse, SpO2, BP
 Abdominal girth -12 hourly
 Urine output every 8 hours
 Blood glucose every 6 hours
 S. Electrolytes every 12 hours

Exercise
1. Baby Ambika was born to primigravida mother through vaginal delivery needed
positive pressure ventilation for 5 min and was admitted to neonatal unit. How will
you manage this baby?
2. At 12 hours of life baby starts having tonic clonic seizure. How will you manage
now?
3. After 48 hours the baby is hemodynamically stable. How will you take of the fluid
requirement?
4. How will you counsel the parents?

116
 CHAPTER THIRTEEN
HYPERBILIRUBINEMIA
Learning outcomes of neonatal hyperbilirubinemia
After the training the participants will be able to
 Define neonatal hyperbilirubinemia
 Outline the risk factors and causes of jaundice
 Differentiate between physiological and pathological jaundice
 Enlist the appropriate investigation of a neonate with jaundice
 Outline the treatment of physiological and pathological jaundice

Introduction
Increased plasma concentrations of bilirubin occur when there is an imbalance between its
production and excretion. Clinically present as having icterus/jaundice. Jaundice is an
important problem in the first week of life. High bilirubin levels may be toxic to the developing
central nervous system and may cause neurological impairment and kernicterus even in term
newborns. Nearly 60% of term newborn becomes visibly jaundiced in the first week of life and
among them approximately 5-10 % of them have clinically significant hyperbilirubinemia.

Clinical assessment
Jaundice appears in newborn when serum bilirubin level exceeds 5 mg/dl. In newborn infants,
jaundice can be detected by blanching the skin with digital pressure, revealing the underlying
colour of the skin and subcutaneous tissue

Figure 46 Kramer's criteria to clinically estimate severity of jaundice

Serum levels of total bilirubin are approximately 4-6 mg/dl (zone 1), 6-8 mg/dl (zone 2), 8-12
mg/dl (zone 3), 12-14 mg/dl (zone 4) and >15 mg/dl (zone 5) Yellow staining of palms and
soles is a danger sign and requires urgent serum bilirubin estimation and further management.
In general, the estimation of bilirubin levels by dermal zones is unreliable particularly at higher

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TSB levels, after phototherapy and when it is carried out by an inexperienced observe. Total
serum bilirubin can be assessed non-invasively by a transcutaneous handheld device.

Causes:
1. Physiological jaundice
2. Pathological jaundice

Causes of pathological jaundice:

Increased Production
 Feto-maternal blood group incompatibility: Rh, ABO
 Hereditary spherocytosis
 G6PD deficiency, Pyruvate kinase deficiency, alpha thalassemia, Vit K induced
haemolysis
 Sepsis
 Increased enterohepatic circulation – Pyloric stenosis or large bowel obstruction
Decreased clearance
 Inborn errors of metabolism: Criggler-najjar syndrome
 Hypothyroidism, Breast milk jaundice
Causes of Jaundice according to Age of onset
Within 24 hrs of Birth:
 Haemolytic disease of newborn:
o ABO incompatibility
o Rh incompatibility
 Intrauterine infections:
o TORCH
 Deficiency of red cell enzymes:
o G6PD
o Pyruvate kinase
 Administration of drugs to mothers:
o Vitamin K
o Salicylates
o Oxytocin
 Hereditary spherocytosis
 Criggler-Nagar syndrome

24- 72 hrs:
 Physiological jaundice
 Aggravated and prolonged by
o Prematurity
o Birth asphyxia
o Acidosis
o Hypothermia
o Hypoglycaemia
o Polycythaemia
o Cephalhaematoma
o Concealed haemorrhage
o Bruising
 Breast feeding
 Infections

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After 72 hrs:
 Septicaemia
 Neonatal hepatitis
 Extra hepatic biliary atresia
 Breast milk jaundice
 Galactosaemia
 Cystic fibrosis
 Alpha 1 antitrypsin deficiency
 Hypertrophic pyloric stenosis
 Hypothyroidism
 Intestinal obstruction

Physiological jaundice
Jaundice attributable to physiological immaturity of neonates to handle increased bilirubin
production.
 Appears between 24-72 hours of age
 Total serum bilirubin (TSB) level with the peak of 6 to 8 mg/dL by 3 days
 Physiologic range 12mg/dL in term babies and upto 15mg/dl in premature infants

Pathological jaundice
 Total serum bilirubin of 5 mg/dl on first day of life in term neonate, 10 mg/dL on second
day, or 12-13 thereafter
 Appearance of jaundice within first 24 hours of life
 Presence of clinical jaundice beyond 3 weeks or jaundice involving palms and soles
 Conjugated bilirubin >2 mg/dl (20% of TSB)

Measurement of TSB levels:

Newborns with yellow discoloration of the skin beyond the legs, in case of suspicion of
pathological jaundice.

Biochemical:
Laboratory estimation of TSB
Micro method for bilirubin estimation:
 Spectro-photometry
Transcutaneous bilirubinometer

Clinical approach to jaundice:

Is the newborn term or preterm?
 Basic pathophysiology of jaundice is same in term and preterm neonates but at lower
gestation babies are at higher risk of developing hyperbilirubinemia
Is there evidence of haemolysis?
 Setting of Rh or less frequently ABO incompatibility
 Onset of jaundice within 24 hours
 Presence of pallor and hydrops
 Presence of hepato-splenomegaly
 Presence of haemolysis on the peripheral blood smear
o Raised reticulocyte count (>8%)
 Rapid rise of bilirubin (>5 mg/dl in 24 hours or >0.5 mg/dl/hr)
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Family history of significant jaundice
Does the infant have an underlying serious disease? (sepsis, galactosaemia)
 Presence of lethargy
 Poor feeding
 Failure to thrive
 Hepatosplenomegaly
 Temperature instability
 Apnoea
Does the infant have cholestatic jaundice?
 Presence of jaundice (>10 mg/dl) beyond 3 weeks
 Presence of dark urine
 Pale coloured stools

Management of neonatal jaundice:

Advise for physiological jaundice:
 The parents should be explained about the benign nature of jaundice
 Frequent and exclusive breast-feed
 Bring the baby to the hospital if the baby looks too yellow or yellow discoloration of
the skin beyond the legs
 Any newborn discharged prior to 72 hours of life should be evaluated again in the next
48 hours for adequacy of breast-feeding and progression of jaundice.
 Earlier or more frequent follow-up for those who have risk factors

Management of pathological Jaundice:

Laboratory confirmation of jaundice is indicated in:
 Any term or near-term newborn with yellow staining of the skin beyond the legs /
estimated clinical
 Jaundice appearing within 24 hours should be managed as hemolytic jaundice.
o All infants with bilirubin levels in the phototherapy range should have the
following investigations (as per availability at the facility):
o Blood group
o Coombs’ test
o Complete blood count
o Smear for haemolysis and red blood cell morphology
o Reticulocyte count
o G6PD estimation
o Repeat TSB in 4–24 h depending on infant’s age and TSB level
 After 4-6 hours of phototherapy for those babies with exchange range
 12-24 hours without exchange range or haemolytic setting
For preterm and VLBW infants guidelines for phototherapy are not so clear for lack of data.

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Management of neonatal hyperbilirubinemia in low birth weight babies based on
bilirubin levels (mg/dl) and relative health of the newborn
Serum Total Bilirubin Level(mg/dl)
Healthy Sick
Birth Phototherapy Exchange Phototherapy Exchange
weight(gm) transfusion transfusion
Premature
<1000 5-7 11-13 4-6 10-12
1001-1500 7-10 13-15 6-8 11-13
1501-2000 10-12 15-18 8-10 13-15
2001-2500 12-15 18-20 10-12 15-18
Term
>2500 15-18 20-25 12-15 Variable

For term babies AAP nomogram is followed for Phototherapy and exchange
AAP provides the age specific nomogram.
The nomogram has three different risk categories.
 Lower risk babies (38 weeks or more and no risk factors)
 Medium risk babies (38 wk or more with risk factors or 35 to 37 week without risk
factors)
 High risk (35 to 37 week with risk factors)

AAP normograph for phototherapy in hospitalized infants of 35 weeks or more

For newborn > 35 weeks: Consult Normograph 1 to identify requirement for phototherapy
Consult Normograph 2 to identify requirement for exchange transfusion

 Use of bilirubin. Do not subtract direct reacting or conjugated bilirubin

 Risk factors= isoimmune hemolytic disease, GandPD deficiency, asphyxia, significant,
lethargy, temperature instability, sepsis, acidosis , or albumin <3.0 g/dl (if measured)

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 For well infants 35-37 6/7 week can adjust TSB levels for intervention around the
medium risk line. It is an option to intervene at lower TSB levels for infants closer to 35
weeks and at higher TSB levels for those closer to 37 6/7 wk.

Age in hrs Consider phototherapy Phototherapy Exchange transfusion

25-48 ≥12 ≥15 ≥20
49-72 ≥15 ≥18 ≥25
>72 ≥17 ≥20 ≥25

AAP normograph for exchange transfusion in hospitalized infants of 35 weeks or more

 The dash line for first 24 hours indicates uncertainty due to wide range of clinical
circumstances and range of response to phototherapy
 Immediate exchange transfusion is recommended if infant shows signs of acute
bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos fever, high
pitched cry) or if TSB is ≥ 5 mg/dl (85mol/L) above these lines.
 Risk factors-isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant
lethargy, temperature instability, sepsis, acidosis.
 Use total bilirubin. Do not substract direct reacting or conjugated bilirubin
 If infant is well and 35-37 6/7 week (median risk) can individualize TSB levels for
exchange based on actual gestational age

Haemolytic jaundice
Common causes of haemolytic jaundice
 Rh haemolytic disease
 ABO incompatibility
 G-6-PD deficiency
 Minor blood group incompatibility.

Rh haemolytic disease:
A baby born to a Rh-negative mother (and Rh-positive father)
Cord blood
 Rh typing

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  Direct Coomb’s test (DCT)
 PCV
 Serum bilirubin
 Reticulocyte count prior to the first exchange transfusion (ET)
Intensive phototherapy should be started at birth and continued till two consecutive readings
are below phototherapy range

Indication of exchange transfusions:

An exchange transfusion soon after birth is indicated if (any one of the following):
Cord bilirubin ≥5mg/dl
Cord hemoglobin≤10mg/dl, PCV<30
Previous sibling history and positive DCT
Subsequent exchange transfusion is indicated if (any one of the following):
1. Bilirubin ≥10mg/dl within 24 hours of age
2. Bilirubin ≥15 mg/dl between 25-48 hours of age
3. Bilirubin ≥20 mg/dl after 48 hours of age
4. Rate of rise of bilirubin is≥0.5mg/dl/hr

 Intervention for Rh haemolytic disease in preterm babies is indicated at lower values.

 A level greater than 0.5% and 1% birth weight (gram) can be used as a rough guide for
phototherapy and exchange blood transfusion, respectively
 Intravenous immunoglobulin (IVIG) is an alternative therapy which may be effective
in treating isoimmune haemolytic jaundice.
o IVIG 0.5g to 1g/kg (single dose) after the first ET / as early as possible if ET not
indicated

ABO Incompatibility:
Mother having O positive blood group and baby of other Rh positive blood group also develops
ABO incompatibility leading to haemolysis. Jaundice due to ABO incompatibility usually
appears in the first 24 hours. In the presence of significant jaundice or jaundice appearing
within 24 hours, the work up for pathological jaundice should be done.

Other haemolytic states:

 G6PD deficiency, hereditary spherocytosis, minor group incompatibilities should be
managed similar to ABO incompatibility.
 Investigations for G-6-PD deficiency in all term and near-term infants with jaundice
o Requiring phototherapy
o Family history of significant jaundice
o Geographic origin associated with G-6-PD deficiency.
Jaundice in preterm babies
 TSB levels well within the "physiologic range" might be hazardous and sometimes need
to be treated with phototherapy.
 All premature infants are routinely monitored for the development of jaundice
 Measure serum bilirubin at 24 hours of age
 Every 12-24 hours until the levels stabilize
 Repeat bilirubin within 24 hours of stopping phototherapy or sooner if clinical jaundice
reappears
 Healthy low birth weight infants
 A sick VLBW baby requires intervention at lower levels.

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Jaundice in a sick newborn
 At high bilirubin levels sick neonates are more prone for bilirubin induces brain damage
than the healthy neonate of similar gestation and weight.
 Intervention for jaundice in this group should start at lower levels of TSB
 Additional investigations in a sick newborn
o Direct bilirubin
o Septic screen
o Blood and urine culture
o Urine for reducing substances

Treatment options:
Phototherapy (PT)

Factors That Affect the Dose and Efficacy of phototherapy

 Spectrum of light emitted:
o Blue-green spectrum
 Spectral irradiance (irradiance in certain wavelength band):
o Irradiance of at least 35 μW/cm2 per nm
 Spectral power (average spectral irradiance across surface area)
o For intensive PT expose maximum surface area of infant
o Double surface phototherapy
 Cause of jaundice
o Less effective if jaundice is due to haemolysis
o Cholestasis
 TSB level at start of PT
o The higher the TSB, the more rapid the decline
o Rapid decrease in TSB when TSB >20 mg/dL (342 μmol/L)
 Continuous phototherapy
o More effective

Intensive phototherapy:
Double surface
 Place the infant on bili-blanket and using additional overhead phototherapy units with
special blue lights
 Lower the phototherapy units to within a distance of 15-20 cm.
 Maintain adequate hydration and good urine output

Precautions for phototherapy

 Baby should be naked
o Eyes and genitals should be covered
 Newborn should be kept at a distance of not more than 45 centimeters below the light
source
o They can be kept as close to the phototherapy units as possible
 Frequent feeding every 2 hours and change of posture should be promoted
 Once under phototherapy, clinical assessment is not reliable. Serum bilirubin must be
monitored

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Failure of phototherapy:
Failure of phototherapy has been defined as an inability to observe a decline in bilirubin of 1-
2 mg/dl after 4-6 hours and/ or to keep the bilirubin below the exchange transfusion level.

Exchange transfusion:
An exchange transfusion (ET) may be performed at the slightest suspicion of bilirubin
encephalopathy irrespective of the bilirubin value.

When should Phototherapy be stopped?

 For infants who are readmitted for phototherapy at the levels of 18 mg/dL or higher,
discontinue at the serum bilirubin level below 13 to 14 mg/dL
 Repeat TSB after 24 hours of discontinuation
 If phototherapy is used for infants with haemolytic diseases or is initiated early and
discontinued before the infant is 3 to 4 days old, a follow-up bilirubin measurement
within 24 hours after discharge is recommended.

Follow-up:
Neuro-developmental outcome
Hearing assessment (BERA)
 Serum bilirubin >20 mg/dl
 Exchange transfusion

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 CHAPTER FOURTEEN
IDENTIFICATION OF SICK NEONATES
After the training, the participants will be able to:
 Identify of at risk neonates
 To assess and categorize newborns as normal /at-risk/sick
 To give supportive management in stabilizing neonates presenting in emergency
 To treat specific conditions commonly seen in sick neonates

The signs of sick newborn are often nonspecific. Early identification and prompt management
of these conditions are very important for saving newborn lives. The most important signs of
sick neonates are;
 Not feeding well
 Less active/ impaired consciousness
 Fast breathing > 60/minute
 Slow breathing < 30/minute
 Chest indrawing
 Grunting
 Convulsions
 Bulging fontanelle
 Floppy or stiff
 Fever>37.5⁰C
 Hypothermia< 36.5⁰C
 Umbilical discharge/ bleeding/ redness
 More than 10 pustules or bullae, or swelling, redness or hardness of skin
 Pallor

Presence or absence of above signs and symptoms can categorize the newborns into normal,
at risk and sick. This will help in prioritizing the newborn and providing prompt evidence
based management.

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Flow Chart 10 Triage of sick newborns
Triage of sick newborns
Assess: Triaging is sorting of neonates to rapidly screen
 Temperature,
sick neonates for prioritizing management
 Respiration,
 Colour,
 Capillary refilling time
 Look for seizure and Triage of a sick or at risk
consciousness level
newborn who presents at SNCU
Assess TABC

 Hypothermia  Cold stress (temp 36.5ºC -36ºC,  Transitional stools

(temp<36ºC, 96.8°F) 97.7°F-96.8°F)  Posseting
 Apnea or gasping  Respiratory distress (rate>60,  Minor birth trauma
respiration no retractions)  Superficial
 Severe respiratory  Irritable/restless/jittery infections
distress (rate>70, severe  Abdominal distension  Minor
retractions, grunt)  Severe jaundice malformations
 Central cyanosis  Severe pallor  Jaundice
 Shock (cold periphery,  bleeding from any sites  All cases not
CRT>3 secs, weak &  major congenital malformations categorized as
fast pulse)  Weight less than 1.8 kg or more Emergency/Priority
 Coma, convulsions or than 4 kg
encephalopathy

Emergency signs Priority signs Non-urgent signs Classify

Initiate emergency
treatment Access and act rapidly signs Access and counsel Act

*Newborns classified as "emergency" require urgent intervention and emergency measures. All such newborns
will be admitted to SNCU after initial stabilization.
Newborns classified as "Priority" are sick and need rapid assessment and admission to SNCU.
Newborns classified as non-urgent do not require urgent attention but require further assessment and
counselling.

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Flow Chart 11 Assessment and treatment of newborns displaying emergency signs

ASSESS FOR EMERGENCY TREAT EMERGENCY SIGNS

SIGNS
(in all cases)
Re-warm hypothermic
babies
Rapidly re-warm if there is
severe hypothermia
IF POSITIVE (<32ºC, 89.6°F) up to
TEMPERATURE Cold to touch (abdomen) 34°C, 95°F and then
gradual re-warming
Maintain the blood glucose
Make sure young infant is
warm

Not breathing or gasping

or
Central cyanosis or Manage airway
Severe respiratory Provide tactile stimulation if
distress ANY SIGN apnoeic
AIRWAY AND Respiratory rate 70/min POSITIVE If still apnoeic or gasping –
BREATHING o Severe lower chest provide PPV
in-drawing Give oxygen
o Apnoeic spells Make sure neonate is warm
o Grunting
o Unable to feed

Give oxygen
Insert IV line and give 10
Capillary refill longer ml/kg normal saline over
than 3 seconds and IF POSITIVE 30 min
CIRCULATION
Weak and fast pulse Proceed immediately to full
(>160) assessment and treatment
Make sure neonate is warm

Manage airway
IF Check and correct
CONVULSIONS Convulsions CONVULSING hypoglycaemia
Give anticonvulsant
Make sure neonate is warm
Further assessment and management
After providing the immediate emergency care and stabilizing the babies the newborn needs to
be assessed in detail such as
History
At-risk neonates
Maternal characteristics
 Age: <16 years or >40 years
 Personal factors:
 Poor nutritional status
 Smoking
 Drug/alcohol
 Trauma
 Maternal medical conditions

129
 o DM, thyroid, renal, UTI, cardiac and lung disease
o HTN, anaemia, thrombocytopenia
 Obstetric history and associated risk for neonate
o Bleeding in early pregnancy, third trimester
o PROM, fever, TORCH infection
o Maternal medications, trauma
o Past history of infant with prematurity, jaundice, RDS, congenital anomalies.
 Foetal conditions
o Multiple gestation
o IUGR
o Macrosomia
o Abnormal foetal presentation
o Polyhydramnios/ oligohydramnios
o Decreased foetal movement
o Abnormality in the heart rate, rhythm
 Conditions of labour and delivery and associated risk for newborn
o Premature labour
o Post term labour
o Rapid labour
o Prolonged labour
o Abnormal presentation
o Maternal hypotension, maternal fever
o Meconium stained amniotic fluid
o Prolapsed cord
o Caesarean section
o Obstetric analgesia and anaesthesia
o Placental abnormalities
 Immediate neonatal conditions
o Prematurity
o Perinatal depression, birth asphyxia
o Pallor / shock
o Foul smelling amniotic fluid/membrane
o SGA
o Post mature

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Examine the baby
Examination Finding Management Plan
Respiratory  Respiratory rate>60 breaths/min  Give oxygen
rate
 Respiratory rate <30 breaths/min  Give oxygen and monitor

 If goes below 20 breaths /min  Positive pressure

ventilation by bag and
 Apnoea (spontaneous cessation of mask (B and M)
breathing >20 seconds)
 Stimulate baby to breathe
by rubbing for 10 seconds.
 If does not begin to breath,
then positive pressure
ventilation (B and M)
Colour  Pallor  Stop bleeding
 H/O bleeding  Vitamin K
 No h/o bleeding  Fluid resuscitation
 Sepsis with shock  Blood transfusion
 IVH (if required)
 Hypoglycaemia  Manage according to
 Haemolytic disease of newborn specific conditions
 Iatrogenic (frequent blood
sampling)
 Jaundice
 Cyanosis
Circulation  Prolonged CRT  Warmth
 Weak and fast pulse  Oxygen
 IV access, bolus NS/RL
@10ml/kg
 Fluid and Inotropes
Temperature  Cold stress (temperature between  Treat hypothermia
36⁰C to 36.4⁰C  Wrap baby with extra
 Hypothermia (temperature<36⁰C) layers of clothing
 Cover head and limbs
 Place baby in contact with
mother, if possible KMC
 In winter warm room
with heater
 Warm baby by putting
under radiant warmer
 Give 2ml/kg of 10%
dextrose
 Start oxygen
 Investigate for
underlying sepsis

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Examination Finding Management Plan
 Hyperthermia  Remove from hot
(More than 37.5⁰C) environment
o Overwarming /high ambient  Undress the baby fully
temperature  Observe for signs of
dehydration and sepsis
 Monitor hourly

o If temperature >39⁰C  Remove from hot

environment
 If persistently high, treat
for sepsis
 Look for signs of
dehydration and manage
 Investigation for sepsis,
hypoglycaemia
 Ongoing monitoring
Posture and  Opisthotonus  Management of specific
movements  Tetanus conditions
 Meningitis
 Kernicterus
 Convulsion
 Jitteriness
 Hypoglycaemia
 Hypocalcaemia
 Lethargy
 Irritability
 Drowsiness
 Reduced activity
 Unconsciousness
 Birth asphyxia
 Sepsis
 Meningitis
 Hypoglycaemia
 Hypothermia
 Intraventricular bleed
Skin  Redness or swelling  Manage accordingly
 Multiple pustules
o Cellulitis/abscess/ severe skin
infection
 Bruises
o Trauma at birth
o Spontaneous bleeding disorder
Umbilicus  Red, swollen, draining pus or foul  0.5% gentian violet four
smelling times daily till no pus
o Local infection of umbilicus  Treat as sepsis
 Skin around the umbilicus is red  Re-clamping
o Severe umbilical infection  Manage for shock if present

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Examination Finding Management Plan
 Bleeding
Eyes  Pus draining from eyes  Manage accordingly
 Conjunctivitis  Reassess
 Subconjunctival bleed
Head  Hydrocephalus  Referral
 Bulging fontanel  According to specific
o Meningitis conditions
o Intraventricular haemorrhage  Manage accordingly
 Sunken fontanel
o Dehydration
Mouth  Cleft lip and palate  Manage accordingly
 Thrush
 Cyanosis
 Respiratory insufficiency
 Cardiac disease
 Dry tongue and mucosa
 Dehydration
Abdomen  Distension  Management accordingly
 Sepsis
 Necrotizing enterocolitis
 Obstruction of small or large
bowel
 Ascitis
Weight  Birth weight < 2500g  Manage accordingly
 Low birth weight
 Birth weight>4kg
 Large weight babies
Urine and  Less urine (<6 times after 2 days)  Assess feeding
stool  Diarrhoea
 Sepsis if associated  Manage accordingly
 Lethargy
 Poor feeding
 Vomiting
 Blood
 Not passed meconium within 24
hours
 Imperforate anus  Surgical management
 Hirschsprung disease
Feeding  Fed well at birth but now feeding  Management as sepsis
poorly  Manage according to
 Sepsis condition
 Not able to feed since birth
 Sick
 Birth asphyxia  Breast feeding counselling
 Respiratory problems
 Sepsis
 Baby otherwise well
133
 CHAPTER FIFTEEN
RESPIRATORY DISTRESS
Learning outcome of respiratory distress
After the training the participants will be able to;
 Enlist the common causes of respiratory distress in newborn
 Identify and monitor newborn having respiratory distress
 Manage newborn with respiratory distress

Common causes of respiratory distress in newborn:

1. Pulmonary causes
 Respiratory distress syndrome (RDS/HMD)
 Meconium aspiration syndrome (MAS)
 Pneumonia
 Transient tachypnoea of newborn (TTN)
 Persistent pulmonary hypertension (PPHN)
 Pneumothorax
 Laryngomalacia
 Congenital malformations
o Tracheoesophageal malformation
o Diaphragmatic hernia
 Upper airway obstruction
o Bilateral choanal atresia
2. Non Pulmonary causes
 Cardiac
o Congestive heart failure
o Congenital heart disease
 Metabolic
o Hypothermia
o Hypoglycaemia
o Metabolic acidosis
 CNS
o Asphyxia, HIE
o Apnoea of prematurity
o Intracranial haemorrhage
 Chest wall deformity
o Myopathies, thoracic cage abnormality

Respiratory distress in a newborn is defined as Respiratory rate ≥60/min and /or any of the
following signs:
 Grunting
 Chest retractions
 Central cyanosis

135
Assessment of severity of respiratory distress using Downe’s score

Score Respiratory Cyanosis Air entry Grunting Chest

rate Retraction
0 <60/min Nil Normal None Nil
1 60-80/min In room air Mildly On auscultation Mild
reduced with stethoscope
2 >80/min In >40% O2 Markedly Audible with naked Moderate
reduced ear
Score of ≥ 4 for at least 2 hours during the first 8 hours of life denotes clinical respiratory
distress.
Score of ≥ 6 is an indication for ventilatory assistance.
Add Silverman’s scoring System for pre-term babies

Management
Management of mild respiratory distress

Monitoring of a newborn with respiratory distress (2-4 hourly)

 Clinical assessment with respiratory distress charting
 Start oxygen
o If the baby's respiratory distress score is ≥ 4
o Give oxygen at a high flow rate (5-10L/min by headbox)
 Continuous pulse–oximetry is desirable. Change probe site regularly to avoid pressure
sores
 Maintain saturations between 88-92% in preterm and 90-95% in term neonates.
Titrate oxygen flow as per SpO2
 Treat underlying condition
 If improves start feeding
 If the baby’s respiratory distress score is ≥ 6, or not improving on high flow oxygen
o Either Organize transfer to a tertiary hospital for assisted ventilation and further
diagnosis evaluation
o Give first dose of antibiotics (Ampicillin and gentamicin) prior to transfer
 Or If persistently high score ≥ 6or central cyanosis or oxygen saturation < 90% with
10Lof free flow oxygen by hood
Nasal CPAP

Severe breathing difficulty

 Start oxygen by hood at rate of 5-10L/min
 Establish IV line start maintenance fluid
 Insert oro/nasogastric tube to empty stomach for air and secretions
 Identify the underlying cause and treat accordingly
 Treat for sepsis
 Monitor and record every 2 hourly
o Respiratory rate
o Heart rate, pulse volume and temperature
o Capillary filling time
o Chest indrawing and grunting
o Oxygen saturation and cyanosis
o Apnoea
o Activity and sensorium

136
 o Classify according to degree of respiratory difficulty
 Respiratory distress score ≥6 despite CPAP
o Requires endotracheal intubation and mechanical ventilation REFER

Device for oxygen delivery

Nasal prong
 Use appropriate size prongs
 Appropriate sixed prong fits
into nostrils without
blanching columella or ala
nasai
 Flow rates: 0.5 to 1 L/min
for preterm and 1 to 3L/min
for term
O2 Hood Nasal catheter/ Cannula
 Choose appropriate sized  Use 6-8 Fr catheter
hood  Measure distance of
 Use transparent hood insertion from nostril to
 Flow rate > 5 L/min inner margin of eyebrow
 Gently insert into nostril
 Flow rate 0.5-1 L/min

Apnoea of prematurity
Apnoea is defined as cessation of respiration for >20 sec or cessation of respiration of any
duration accompanied by bradycardia (HR <100/min) and/or cyanosis.
 Usually presents after 1-2 days of life and within the first 7 days

Emergency treatment
 Checked for bradycardia, cyanosis and airway obstruction
 The neck should be positioned in slight extension; oro-pharynx gently suctioned
 Give tactile stimulation immediately at the onset of apnoea
o Most apnoeic spells respond to tactile stimulation
 Provide oxygen if patient is hypoxic (maintain saturation 92-95%) by head box or
nasal cannula.
 If the newborn continues to remain apnoeic and does not respond to tactile
stimulation, ventilation with bag and mask (BMV) using 100% oxygen should be
initiated.
 If BMV fails to initiate spontaneous respiration in the newborn, then the infant
should be referred for management without interrupting positive pressure
ventilation(BMV)

Specific measures
 Drugs
o Caffine citrate
 Loading dose 10 mg/kg IV or oral (20 mg/kg)
 Followed by maintenance dose of 5 mg/kg once a day
o Aminophylline therapy
 Loading dose of 5-7 mg/kg
 Followed by maintenance dose of 1.5-2 mg/ kg/dose 6-8 hourly
o Given till 34 weeks of gestational age /apnoea free period of 1 week
 CPAP
 Requires mechanical ventilation if frequent or persistent apnoea.
NB: Do not discharge before 48 hours of stoppage of Aminophyline therapy

Pneumonia
- Common cause of respiratory distress in term and preterm babies.

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Aetiology
 Bacterial
o Most common
 E. coli
 Staph. aureus
 Klebsiella pneumoniae
 Viral
 Fungal

Predisposing factors
1. Maternal
 UTI
 Fever
 Sepsis
 Prolonged rupture of membrane
 Chorioamnionitis
 Multiple vaginal examination during labour

2. Newborn
 LBW
 Birth asphyxia
 MAS
 No breast feeding
 Hypothermia
 Prelacteal feed

Clinical features
 Respiratory distress with clinical features of sepsis

Investigation
 Positive septic screen
 Chest X-ray pneumonia

Management
 TABC
 Antibiotics (IV)
o Ampicillin
o Gentamicin
 Supportive
o IV fluids
o Oxygen/ventilation
o Ionotropes in case of associated septic shock
o Nutrition

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 CHAPTER SIXTEEN
NEONATAL SEIZURE
Learning outcome of neonatal seizure
After the training the participants will be able to
 Identify different types of seizure and differentiate from seizure mimicking conditions
 Discuss common causes of seizure
 Explain the approach in a newborn with seizure
 Enlist management of seizure at stepwise manner
Seizures are the most distinctive manifestation of neurological dysfunction of newborn brain.
Seizures are more common in the newborn period than at any other time of life and with greater
incidence of recurrent seizure and status epilepticus.

Types of different seizure in newborn

Seizure type
Subtle
Tonic (i.e. generalized or focal)
Clonic (i.e. multifocal or focal)
Myoclonic
(generalized, focal, multifocal)
Clinical manifestation
 Repetitive blinking
 Eye deviation
 Staring
 Repetitive mouth or tongue movements
 Autonomic phenomena:
o Apnoea
o Tachycardia
 Progression movement:
o Bicycling-rowing movements
 Tonic extension of limb or limbs
 Tonic flexion of upper limbs
 Extension of lower limbs
 Multifocal
 Synchronous, or asynchronous limb
movements
 Repetitive jerky limb movements
 Non-ordered progression
 Localized repetitive clonic limb movements
with preservation of consciousness
 Single or several flexion jerks of upper limbs
(common) and lower limbs (rare)

Condition mimicking seizure

 Jitteriness(tremor)
o Equal amplitude and faster equiphasic rhythm
o Movements are stimulus sensitive
o Abolish or restrain by passive flexion
o No autonomic disturbances
 Sleep myoclonus
o Abolished by arousal
o Precipitated by gentle rhythmic rocking or tactile stimuli
o Gentle restraint increases myoclonus

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Aetiology
 Less than 24 hrs
o Perinatal asphyxia
o Hypoglycaemia
o Accidental injection of local anaesthetic in to foetal scalp vein
 24-72 hrs
o Perinatal asphyxia
o Hypoglycaemia
o Hypocalcaemia
o Intracranial bleed
 3-7days
o Meningitis
o Intracranial bleed
o CNS malformation
o Late hypocalcaemia
o Neonatal epilepsy syndromes
 More than 7days
o Meningitis
o Late haemorrhagic disease of newborn
o CNS malformation
o Late hypocalcaemia
o Neonatal epilepsy syndromes

Approach to newborn with seizure

Seizure history: Ask for;
 Onset of seizures
 Duration of seizures
 Associated eye movements
 Restraint of episode by passive flexion of the affected limb
 Autonomic phenomenon like sweating, apnoea, change in colour of the skin
 Level of consciousness- lethargy/ alert

Causes of seizures according to the day of life:

• Day 0-3
• Perinatal asphyxia
• Intracranial haemorrhage
• Metabolic and developmental defects.
• Day 4-7
• Sepsis
• Meningitis
• Metabolic causes and developmental defects

Antenatal history:
• Intrauterine infection
• Maternal diabetes mellitus
• Substance abuse
• A history of sudden increase in foetal movements (intrauterine convulsions)

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 • Maternal hypertension

Perinatal history:
• Foetal distress,
• Decreased/increased foetal movements
• Instrumental delivery
• Need for resuscitation
• Low Apgar scores
• Abnormal cord pH and base deficit if available
Family history:
• History of consanguinity in parents (IEM)
• Family history of seizures (NES)
• Mental retardation
• Early foetal/neonatal deaths (IEM)
• Inborn errors of metabolism

Examination
Vital signs:
• Heart rate, respiration, blood pressure, capillary refill time and temperature

General examination:
• Confirm gestational age
• Birth-weight and weight for age (Seizures in a term ‘well baby’ may be suggestive of sub-
arachnoid haemorrhage, Seizures in a large for date baby may be due to hypoglycaemia.)
• Look for malformation or dysmorphic features
CNS examination:
• Bulging anterior fontanel: meningitis or intracranial haemorrhage.
• Consciousness (alert/drowsy/comatose)
• Tone (hypotonia or hypertonia)
• Fundus examination for chorioretinitis
Systemic examination:
• Hepatosplenomegaly or an abnormal urine odour may be suggestive of inborn error of
metabolism.
• The skin: neuro-cutaneous markers.
• Presence of hypo-pigmented macules / ash-leaf spot: tuberous sclerosis.

Investigation (as available):

 Blood glucose (Dextrostix), Calcium, blood urea nitrogen, Phosphorus, Magnesium,
electrolytes
 Complete blood count, differential, platelet count; urinalysis
 Blood oxygen and acid-base analysis
 Blood, CSF and other bacterial cultures
 CSF analysis
 EEG (as available)
 USG head / CT scan head (as available)

Seizure management (Go to the next step only if seizure not controlled) - TABC
 Step 1: Stabilize vital functions

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  Step 2: Correct transient metabolic disturbances
 Hypoglycaemia
o 10% dextrose IV bolus @2ml/kg
o Continuous infusion @6-8mg/kg/min
 If blood sugar is in normal range, sample for total serum calcium or ionized calcium
should be withdrawn
o Hypocalcaemia (serum calcium <7mg/dl or ionized calcium <4mg/dl)
 10% calcium gluconate 2 ml/kg IV under cardiac monitoring
 If blood gas ionized calcium <0.6mmol/l and seizure persist
 Repeat IV calcium
 If no response
 Hypomagnesaemia
o 50%MgSO4 IM@ 0.2 ml/kg

 Step 3: Phenobarbitone3
 Load @20 mg/kg IV over 30 min – Dissolve in 20 ml NS
 Reloading @ 10 mg/kg max- 40 mg/kg
 Maintainance@5mg/kg to be continued - After 12 hours
 Cardio respiratory monitoring
 Consider intubation / ventilation

 Step 4: Phenytoin4
 load @20 mg/kg IV over 30 min with cardiac monitoring
 Reloading @ 10 mg/dl max 30 mg/kg
 Maintainance@5mg/dl to be continued - after 12 hours

 Keep both in maintenance, switch off Phenytoin first

 Step5:
 Midazolam
 Infusion 0.15mg/kg IV bolus, followed by continuous infusion (1µg/kg/min)
increasing by 0.5 to 1µg/kg/min every 2 minutes until favourable response or a
maximum of 18µg/kg/min
 Lidocaine
 Loading dose 2mg/kg followed by intravenous infusion of 6 mg/kg/hour, then 4
mg/kg/hour for 12 hours, followed by 2 mg/kg/hour for 12 hours

 Step 6: A trial of Pyridoxine

 50 – 100 mg/kg IV

3
Phenobarbitone is not available as syrup. Oral can be started after oral intake is established.
4
Consider referral after Phenytoin

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Case scenario: B/O Manisha Limbu
Twenty-five years old Manisha Limbu gave birth to a 3.2 kg baby by C-section 4 days
back. Baby has been feed with cow’s milk since birth as there was not enough milk
produce by mother. Baby was having poor feeding and lethargic from last 1 day and
from last 6 hours baby is having abnormal movement with altered sensorium. On
examination, HR 156/min with good volume pulse, RR 46/min, temperature 370 C, pink
and CRT 2 seconds. Sensorium is altered with bulging fontanel. Investigation showed
PCV 52/min, glucose 68 mg/dl, TLC 4500 cubic/mm3 and micro-ESR 12 at 1 hour.
Baby is still throwing seizure.
1. Outline the management plan

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 For Level II and III units

Flow Chart 12 Flow chart for the management of acute neonatal seizure
Neonate with seizure

 Identify and characterize the seizure

 Secure airway and optimize breathing, circulation, and temperature
 Start oxygen if seizures are continuous
 Secure IV access and take samples for baseline investigations including sugar, calcium,
sodium, potassium, haematocrit, sepsis screen including lumbar puncture, ABG, magnesium
 If hypoglycaemic (blood sugar <45 mg/dl): administer 2 ml/kg of 10% dextrose as bolus
followed by a continuous infusion of 6-8 mg/kg/min
 If blood sugar is in normal range, sample for total serum calcium or ionized calcium should
be withdrawn; if total serum calcium <7mg/dl or ionized calcium <4mg/dl then 2 ml/kg of
calcium gluconate (10%) should be given IV under cardiac monitoring

If blood gas ionized calcium <0.6

 Administer phenobarbitone 20mg/kg IV stat over 30 mmol/L and seizures persist, repeat
minutes IV calcium, if no response
 Watch for apnoea, respiratory depression and hypotension considers 50% Magnesium
Sulphate 0.2ml/kg IM
Seizures continue

Repeat phenobarbitone in 10 mg/kg/dose aliquots until 40 mg/

kg dose is reached
Monitor respiratory status and Blood pressure
Seizures continue

Administer phenytoin 20 mg/kg IV slowly

over 30 minutes under cardiac monitoring

Seizures continue

Repeat phenytoin 10 mg/kg/dose

For Level II facilities, Seizures continue Consider endotracheal intubation

consider referral and mechanical ventilation

Give Pyridoxin 50-100 mg/kg IV

Start midazolam infusion 0.15mg/kg IV bolus, followed by continuous infusion (1µg/
kg/min) increasing by 0.5 to 1µg/kg/min every 2 minutes until favourable response or
a maximum of 18µg/kg/min OR give I.V lidocaine loading dose 2mg/kg followed by
intravenous infusion of 6 mg/kg/hour, then 4 mg/kg/hour for 12 hours, followed by 2
mg/kg/hour for 12 hours

Consider other antiepileptic drugs,

pyridoxine,
Seizures continue

Consider alternate drugs

Levetiracetam or Topiramate

Follow up after 1 month. If EEG/Neurological tests are normal, then taper in 7 days. If abnormal EEG
or Neurological findings is not equal continue till 3 months as per protocol.

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Adequacy of anticonvulsant therapy
Occasional subtle seizures not interfering with vital functions may be left alone if maximal
doses of phenobarbitone and phenytoin have already been reached

Maintenance therapy
Monotherapy is the most appropriate strategy to control seizures. Attempts should be made to
stop all anti-epileptic drugs and wean the baby to only phenobarbitone at 3-5 mg/kg/day. If
seizures are uncontrolled or if clinical toxicity appears, a second AED may be added. The
choice may vary from phenytoin (5-8 mg/kg/day IV or P.O in two divided doses).
Bioavailability of Phenytoin may be reduced if the tablets are crushed.

Duration of therapy
This depends primarily on the risk of recurrence of seizures, which is determined by the
neurological examination, the cause of seizures and EEG. Cranial USG or MRI head should be
done once newborn is stable to identify the underlying aetiology.

Seizures due to hypoglycaemia, hypocalcaemia do not need long term anticonvulsants. Most
of the seizures due to HIE also do not need long term anticonvulsants.
Long term anticonvulsant may be considered in the following situations
1. Recurrent seizures especially those with persistent neurological abnormality, EEG
abnormality or family history of epilepsy
2. If neurological examination is normal and seizures are controlled, anticonvulsants are
usually stopped in 5-7 days. Anticonvulsants are continued for longer duration if
seizures are recurrent or neurological examination is abnormal. Periodic reassessment
should be done and one should try to stop anticonvulsants as soon as possible.

If neurological examination remains abnormal at 4 weeks, do an EEG. If EEG does not show
seizure activity, taper off phenobarbitone over 2 weeks. Babies whose EEG is abnormal will
usually require long term anticonvulsant therapy.

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Flow Chart 13 Guideline for weaning anticonvulsant drug (ACD)

Newborn with seizures

Treat the cause;

Transient metabolic problem Yes Stop ACD immediately if
started initially
No
Stop ACD; observe for at least
Difficult to control seizures No 48 hours for seizure
recurrence

Yes

Continue Phenobarbitone; stop rest all ACD Discharge on Phenobarbitone;

Assess neurological status after stoppage of Abnormal repeat neurological exam at 1
ACD and do not discharge before 72 hours of month
stoppage of AED
Abnormal Normal
Normal

Stop Phenobarbitone Taper and stop

Do EEG
Phenobarbitone over 2 weeks

Abnormal Normal

Reassess at 3 Taper and stop Phenobarbitone

months of age over 2 weeks

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 CHAPTER SEVENTEEN
DISORDER OF WEIGHT AND GESTATION
Learning outcome of disorder of weight and gestation
After the training the participants will be able to
 Define low birth weight babies (LBW)
 Enlist the conditions leading to LBW
 Identify preterm and intrauterine growth restriction IUGR) babies
 Enlist the common causes of prematurity and IUGR
 To differentiate between types of IUGR
 Enlist the problems associated with LBW
 Provide care for LBW babies
 Manage the problems associated with LBW babies
 Enlist the discharge criteria for LBW babies

Introduction:
Birth weight is the single most important marker of adverse perinatal, neonatal and infant
outcome. Low Birth Weight (LBW) babies are those babies with birth weight less than 2.5 kg,
irrespective of the period of their gestation. LBW infants have 2 -3 times increases risk of
mortality.

Two clinical types of LBW

1. Preterm or premature (< 37 weeks of gestation)
2. Small for gestational age (SGA) or intrauterine growth retardation or restriction (IUGR)
or Small for date (SFD)

Epidemiology:
WHO estimates that globally about 20 millions LBW babies are born each year that is 15.5%
of all live birth. Most of these babies are born in developing countries. In Nepal, 21% of babies
are LBW.

Classification of LBW:
 Low birth weight: - Birth weight less than 2500gms irrespective of the gestational age.
 Very low birth weight: Birth weight less than 1500gms irrespective of the gestational
age.
 Extremely low birth weight: Birth weight less than 1000gms irrespective of the
gestational age.
Types of LBW
 Preterm birth: Baby born before 37th week of gestation, thus has not reached full
maturity and is smaller than term babies.
 Small for dates neonate or IUGR: Neonate whose intrauterine growth has been
hampered thus is below 2 S.D. or 10th percentile for its gestational age at birth.
Features of Prematurity:
 Small
 Head relatively large, sutures separated
 Face small
 Buccal pad of fat minimal

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  Abundant lanugo
 Little vernix caseosa
 Breast nodule – less then 5mm wide.
 Ears soft and flat, cartilage is deficient, has poor elastic recoil.
 Genitalia
o Males:
 Testes not descended into scrotal sac.
 Scrotum small, poorly pigmented, scanty rugosities.
o Females:
 Labia majora widely separated and labia minora fully not covered
 Deep creases not well developed in sole
 Neonatal reflexes sluggish
 Hair is woolly in appearance
Precise estimation of gestational age can be done by physiological and neurological
examination using modified Ballard’s score.

Features of IUGR:
 IUGR or SGA infants are often term or near-term in gestation.
 Birth weight usually falls below the 10th percentile
 Emaciated look
 Loose skin because of lack of subcutaneous tissue
o Over the buttocks and the thighs
 Alert and plethoric
 In infants with appropriate growth, the head size is usually bigger than the chest by
about 2-cm. In SGA infants, the head circumference usually exceeds the chest
circumference by more than 3 cm.
 A preterm SGA, infant would have a combination of clinical features suggestive of
both, prematurity and IUGR.

Features of asymmetrical IUGR:

Intrauterine insult occurs at later stages of pregnancy when growth is mostly determined by
increase in cell size.
 Long, thin, alert
 Marasmic with poor subcutaneous fat and poor muscle mass
 Excess skin folds on buttock and thighs.
 Internal organs shrunken
 Ponderal Index * <2
 Head circumference normal
 Meconium staining
 Poor maternal nutrition
 Placental insufficiency preeclampsia frequent

𝑤𝑒𝑖𝑔ℎ𝑡 (𝑔𝑟𝑎𝑚)
* Ponderal Index = 𝑥 100%
𝑙𝑒𝑛𝑡𝑔ℎ (𝑐𝑚3 )

Features of hypoplastic IUGR:

Intrauterine insult at the early stages when growth is predominantly by increase in cell number
 Ponderal Index normal or increased
 Small head circumference

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  Congenital anomalies
 Intrinsic foetal problems
 Postnatal physical growth and mental development poor
 Small in all parameters

Causes of LBW:

Causes of Preterm birth:

 Maternal causes
o Medical:
 Severe uncontrolled Diabetes Mellitus
 Hypertension including (pre-)eclampsia
 Cardiovascular diseases
o Antepartum haemorrhage
o Premature rupture of membranes
o Incompetent cervix
o Infections
o Rh incompatibility and hydrops foetalis
o Previous history of preterm delivery
 Foetal and feto-placental
o Multiple gestation
o Congenital malformation
o Extreme IUGR
o Foetal hypoxia
 Iatrogenic Cause

Causes for IUGR babies

 Environmental factors
o Race and Ethnicity
o Geographic location
o Lower socioeconomic status
o Nutritional insufficiency
 Maternal Factors
o Short stature of mother
o Primi or grand multipara
o Young/adolescent mother
o Low pre pregnant weight
 Smoking and tobacco or alcohol abuse
 Maternal illness; anaemia, heart disease, malaria
 Complications of pregnancy – pre-eclampsia, hypertension
 Previous similar baby
 Placental Factors
o Improper implantation
o Abruptio placenta
o Structural or functional anomalies of placenta.
 Foetal factors
o First born babies are generally smaller
o Genetic or chromosomal aberrations
o Multiple pregnancy

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 o Intrauterine infections

Management of preterm baby

Principles of management of LBW neonates:
1. Care at birth
 Suitable place of delivery ‘in utero’ transfer to a place with optimum facilities if a LBW
delivery is anticipated
 Prevention of hypothermia
 Neonatal resuscitation

Management at birth
 Preterm delivery should be attended by a skilled health worker trained in newborn
care
 The baby should be promptly dried, effectively covered and kept warm.
 Vitamin K 0.5mg IM should be given if ˂1000 gm and 1 mg if ≥ to 1000 gm
Monitoring
 Vital signs
 Activity and behaviour
 Colour: pink, pale, blue, yellow.
 Tissue perfusion/capillary refill time
 Urine output: >1.5 ml/kg/hr
 Fluid, electrolytes and blood gas
 Weight gain
 Tolerating feeds
 Look for development of RDS, apnoeic attacks, sepsis, PDA, NEC, IVH
Establishment of spontaneous breathing and maintenance of body temperature should
receive top priority in the care of a preterm newborn.
Vigilant observation and prompt intervention by skilled and experienced personnel

Effective resuscitation should have the following components (TABC)

 T-Maintenance of Temperature
 A-Establishment of an open Airway
 B-Initiation of Breathing
 C-Maintenance of Circulation

Oxygen Therapy
 Only when indicated
 Administer when SaO2 falls below 85% and gradually withdraw when >92% (maintain
Spo2 between 85-92%)

2. Appropriate place of care

 Birth weight>1.8kg:
Postnatal ward with mother
 Monitor
 Train mother
1) KMC and assessment of temperature by touch technique
2) Breast feeding and expression of milk
3) LBW feeding (content and technique)
4) Recognition and reporting of danger sings
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 5) Inputs all quarries related to care of LBW babies
 A baby who is unable to feed from the breast /cup or sick should be immediately
admitted to nursery

 Birth weight 1.5-1.8kg: Level II neonatal unit

 Birth weight<1.5kg: NICU Level III
3. Thermal protection
 Delay bathing
 Maternal skin-skin contact (Kangaroo mother care)
 Warm room
 External heat resource (incubator, radiant warmer)
4. Safe transport
 Keep the baby warm with skin-to-skin contact with mother or caretaker
 Cover the baby with a blanket and cover his/her head with a cap.
 Protect the baby from direct sunlight.
 Encourage breastfeeding during the journey.
 If the baby does not breastfeed and the journey is over 3 hours, consider giving
expressed breast milk by cup/ spoon
5. Fluids and feeds
 For very small and sick babies- Intravenous fluids
 Expressed breast milk
 Direct breastfeeding
6. Monitoring, early detection and treatment of complications
 Weight and other clinical signs
 Monitoring: HR, RR, Temp, CFT, SpO2
 Biochemical monitoring: glucose, electrolytes
7. Additional needs of the small baby
 Special support for breastfeeding
 Additional warmth
 Daily assessment
 Planned discharge

Feeding of Low Birth Weight and sick babies:

The term low-birth-weight (LBW) means a birth weight of less than 2,500 grams. A LBW baby
may be premature, or small for gestational age, or both. LBW babies need breast milk even
more than larger babies. The best milk for a LBW baby is his own mother's milk. Preterm milk
is specially adapted to the needs of a preterm baby. It contains extra protein, and extra anti-
infective factors.

Feeding is relatively difficult in LBW babies because

1. Inadequate feeding skills
2. Prone to have significant illness, in first few weeks of life which precludes enteral feeding
3. Higher feed requirement due to excessive insensible water loss
4. Low body stores of various nutrients at birth hence require supplementation
5. Gut immaturity leading to feed intolerance

Newborns that require assisted feeding:

 Preterm <34weeks or birth <1800 g

151
 Babies having mild respiratory distress
 Babies with inability to feed at breast or cup
 Oro-facial defects/malformations (cleft lip or palate)

Guidelines for the modes of providing fluids and feeding:

Birth weight (grams) <1200 1200-1800 >1800
Gestation (weeks) <30 30-34 >34
Initial feeding Intravenous fluids try Gavage, try cup and Breastfeeding, if
gavage feeds, if not spoon if not sick unsatisfactory, give
sick cup and spoon feeds
After 1-3 days Gavage Cup Breastfeeding
Later (1-3 weeks) Cup Breastfeeding Breastfeeding
After some more Breastfeeding Breastfeeding Breastfeeding
time (4-6 weeks)

 Breast milk is the ideal feed for low birth weight babies.
 Those unable to feed directly on the breast can be fed expressed breast milk (EBM) by
gavage or cup and spoon
Methods of feeding LBW / sick babies
 Intravenous feeding
 Orogastric feeding
 Cup feeding
 Breast feeding

For the first few days, a baby may not be able to take any oral feeds. He may need to be fed
intravenously. Oral feeds should begin as soon as the baby tolerates them.

 Babies who are less than about 30 weeks gestational age usually need to be fed by orogastric
tube. Give expressed breast milk by tube.
 Babies between about 30-32 weeks gestational age can take feeds from a small cup, or from
a spoon.
 Babies of about 32 weeks gestational age or more are able to start suckling on the breast.
 Let the mother put her baby to her breast as soon as he is well enough. Offer a cup feed
after the breastfeed. Or offer alternate breast and cup feeds.
 Make sure that the baby suckles in a good position.
 Good attachment may make effective suckling possible at an earlier stage.
 Babies from about 34-36 weeks gestational age or more (sometimes earlier) can usually
take all that they need directly from the breast.
 Continue to follow babies up and weigh them regularly to make sure that they are getting
all the breast milk that they need.

All stable LBW infants, irrespective of their initial feeding method should be put on their
mothers’ breast. The immature sucking observed in preterm infants born before 34 weeks might
not meet their daily fluid and nutritional requirements but helps in rapid maturation of their
feeding skills and also improves the milk secretion in their mothers (‘Non-nutritive sucking’).

How to feed a baby by cup

 Hold the baby sitting upright or semi-upright on your lap.

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  Hold the small cup of milk to the baby’s lips.
Tip the cup so that the milk just reaches the baby’s lips.
The cup rests lightly on the baby’s lower lip, and the edges of the cup touch the outer part of
the baby’s upper lip.
 The baby becomes alert, and opens his mouth and eyes.
o A LBW baby starts to take the milk into his mouth with his tongue.
o A full term or older baby sucks the milk, spilling some of it.
 DO NOT POUR the milk into the baby’s mouth. Just hold the cup to his lips and let him take
it himself.
 When the baby has had enough, he closes his mouth and will not take any more. If he has not
taken the calculated amount, he may take more next time, or you may need to feed him more
often.
 Measure his intake over 24 hours – not just at each feed.

Figure 47 Feeding baby with a cup

Feeding with oro-gastric tube

 Place an oro-gastric feeding catheter of size 5-6 Fr after measuring the correct insertion
length from ala of nose to tragus and from tragus to midway between xiphisternum and
umbilicus. (Refer to page No 153-155 for technique of insertion)
 Check correct placement by pushing in air with 10 ml syringe and listening with
stethoscope over upper abdomen.
 Attach 10 ml syringe (without plunger) at the outer end of the tube, pour measured
amount of milk and allow milk to trickle by gravity. Close outer end of tube after feeding
 Place baby in left lateral position for 15 to 20 minutes to avoid regurgitation
 Leave oro-gastric tube in situ
 Measure pre-feed abdominal girth just above the umbilical stump. Do not attempt pre-
feed aspirates

Intravenous fluid therapy for newborns

Choice of intravenous fluids
 Determine required volume of fluid as per birth weight and age (Table 2)
 Use 10% Dextrose for initial 48 hours of life
 After 48 hours, if baby is passing urine, use commercially available IV fluids such as
IsolyteP or 10% Dextrose+ 1/5 NS

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Administration of intravenous fluids
 Use micro-drip infusion set (where 1 ml =60 micro drops)
 In this device, ml of fluids per hour is equal to number of micro-drops per minute e.g.
6ml/hr = 6 micro drops/minute
 Calculate rate of administration, monitor to ensure that micro-dropper delivers required
rate
 Change the IV infusion set and fluid bag every 24 hours
 Before infusing IV fluid, carefully check:
 Expiry date of the fluids
 Seal of the infusion bottle or bag
 Fluid is clear and free from any visible particles
 Inspect infusion site every hour for redness and swelling
 If redness and /or swelling is present, stop infusion, remove cannula and establish a
new IV line in a different vein
 Check the volume of fluid infused, compare to the prescribed volume and record all
findings
 Measure blood glucose every nursing shift, i.e. 6-8 hours
 If the blood glucose is less than 45 mg/dl, treat for low blood glucose
 If the blood glucose is more than 150 mg/dl on two consecutive readings: change to
5% dextrose solution –measure blood glucose again in three hours
 Weigh the baby daily weight loss is more than 5%, increase the total volume of fluid
by 10 ml/kg body weight for one day
 If there is excessive weight gain (3-5%) decrease the fluid intake by 15 to 20
ml/kg/day
 Check urine output: normally a baby passes urine 5-6 times everyday

Fluid Requirement [ml/kg/day]:

Days <1000 gm 1000-1500gm >1500gm

1st and 2nd 100-120ml 80-100ml 60-80ml

3rd and 4th 130-140ml 110-120ml 90-100ml
5th and 6th 150-160ml 130-140ml 110-120ml
7th and 8th 170-180ml 150-160ml 130- 140ml
9th and + 190-200ml 170-180ml 150-160ml

Energy requirement of LBW

Requirement Cal/Kg kj/gm

Resting energy 50 210

Intermittent activity 15 63
Occasional cold stress 10 42
Specific dynamic Action 8 34
Fecal loss 12 50
Allowance of growth 25 105

TOTAL 120 504

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Initiation of feeding:
Trophic feed (Gut priming): Feedings that are delivered in very small volumes (10-20
ml/kg/d) for the purpose of gut maturation rather than for nutrition.

Feeding increment:
 For less than 1500 gm-10-15ml per kg per day.
 For more than 1500gm-15-20 ml per kg per day.
 However, assessment and observation are the more important tools.
 Once the feeds reach 100 ml/kg /day or two third maintenance IV fluids can be stopped

Supplementation in LBW infants:

 Calcium and phosphorus- 140-160mg/kg/d and 70-80 mg/kg/d respectively on EBM upto
40 weeks of corrected gestational age
 Vitamin D 400IU/d for 1 year
 Vitamin B –complex; Folate 50mcg/kg/d -6 months
 Iron 2 to 3mg/kg/d-start at the age of one month upto 1 year
NB: Supplementation only after oral intake is established

Feed intolerance:
It is the major problem in preterm and LBW babies requiring prolonged hospitalization.

Management of feed intolerance:

 Bile or blood stained aspirate/vomit
o Withhold feeds for 24 to 48 hrs. look for local and systemic causes.
 Clear prefeed <2 to3 ml or less than 25%
o Look for local cause. Monitor and continue feeds.

How to help breastfeeding if a baby is sick

Babies who are sick recover more quickly if they continue to take breast milk during the illness.

If a baby is in hospital:
Admit his mother too so that she can stay with him and breastfeed him.

If a baby can suckle well:

Encourage his mother to breastfeed more often.
She can increase the number of feeds up to 12 times a day or more for her child when he is
sick.
If a baby suckles, but less than before at each feed:
Suggest that the mother gives more frequent feeds, even if they are shorter.
If a baby is not able to suckle, or refuses, or is not suckling enough:
Help his mother to express her milk, and give it by cup or spoon.
Let the baby continue to suckle when he is willing.
Even babies on intravenous fluids may be able to suckle, or to have expressed breast milk.
If a baby is unable to take expressed milk from a cup:
It may be necessary to give the EBM through a nasogastric tube for a few feeds.
If a baby cannot take oral feeds:
Encourage his mother to express her milk to keep up the supply for when her baby can take
oral feeds again.

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As soon as her baby recovers, she can start to breastfeed again

Volume of milk for babies

The amount of milk that a baby takes at each feed varies with all methods of feeding.
 If a baby takes a very small feed, offer extra at the next feed, or give the next feed early.
 Assess a baby's 24-hour intake.
 Give extra by orogastric tube only if the 24- hour total is not enough.
 If a mother produces only a small amount of breast milk, be sure to give it all to her baby.
Help her to feel that this small amount is valuable, especially to prevent infection.
 If a mother expresses more than her baby needs, let her express the second half of the milk
from each breast into a different container. Let her offer the second half of the EBM first.
Her baby gets more hindmilk, which helps him to get the extra energy that he needs.

Skill Checklist 13 Feeding baby by cup

No. Steps Rating

Y ¥ NA
1. Washes hand
2. Holds the baby on upright position on lap
3. Holds the small cup of milk baby’s lip in such a way that cup
rests lightly on the baby’s lower lip and edges of the cup
touches the outer part of the baby’s upper lip
4. Waits for baby to become alert and open his mouth and eye
5. Watches the baby taking milk into his mouth
6. Does not pour the milk into the mouth
7. Waits till the baby stop taking the milk and closes his mouth
8. Measures the amount taken
9. Burps the baby
10. Puts the baby on bed semi reclined on left lateral position

Discharge planning of LBW babies

 There should be consistently demonstrated weight gain for 3 consecutive days
 Mother should be confident in feeding and taking care of baby
 Mother confident on KMC practice at home
 Mother should be explained about all danger signs and clearly given information where
to bring in emergency
 Immunization
 BCG within 6 weeks
 DPT, Hib, HBV, and OPV at 6,10 and 16 weeks
 IPV at 14 weeks
 Pneumococcal at 6weeks, 10 weeks and 9 months

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 CHAPTER EIGHTEEN
NEONATAL SEPSIS
Learning outcomes of Neonatal sepsis
After the training the participants will be able to:
 Outline the epidemiology and definition of neonatal sepsis.
 Identify newborn having sepsis.
 Enlist the role of “septic screen” evaluation.
 Outline the rational use of antibiotics.
 Provide the supportive care.
 Enlist the measure to prevent neonatal sepsis.

Introduction
Neonatal sepsis is the most important cause of morbidity and mortality especially among low
birth weight and preterm babies in developing countries. It is a clinical syndrome of
bacteraemia (pure growth of bacteria from one or more sites) characterized by systemic signs
and symptoms of infection which incorporates septicaemia, pneumonia, meningitis, arthritis,
osteomyelitis and urinary tract infection in the first four weeks of life. When clinical and
laboratory findings are consistent with bacterial infection but blood culture is sterile then infant
is known to have suspected sepsis.

Incidence
Neonatal sepsis is the most common cause of neonatal mortality almost accounting for one
third of world’s 4.0 million neonatal deaths.
 Mortality is 3-5 times more for neonates with sepsis in NICU.
 In developing countries, 10-50 in 1000 live births develop sepsis
 20 – 30 % of them have associated with meningitis which is more common in late
onset sepsis

Classification
The neonatal sepsis has been classified as early onset neonatal sepsis (EoNNS) and late onset
neonatal sepsis (LoNNSS) on the basis of time of development of sepsis.
 Early onset neonatal sepsis (EoNNS):
o Development of symptom of sepsis < 72 hours of life.
 Bacteria acquired before and during delivery.
o 5-7/1000 live births.
o 1.5% of VLBW infants.
 Late onset neonatal sepsis (LoNNS):
o Development of symptom of sepsis > 72 hours of life.
o Bacteria acquired after delivery (Nosocomial or community).

There are certain characteristic differences between EoNNS and LoNNS

Early onset late onset
Age <72 hours >72 hours
Prematurity Prematurity
Risk factor Amnionitis LBW
Maternal infection

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 Maternal genital Environmental
Source
tract (nosocomial)
Fulminant Slowly progressive
Presentation Multisystem May be multifical
Pneumonia frequent Meningitis frequent
Mortality 5-50% 10-15%

Aetiology
Early onset neonatal sepsis (EoNNS)
It is caused by organism prevalent in the genital tract or in the labour room and maternal
operation theatre.
 Escherichia coli
 Klebsiella
 Enterobacter species
Majority of neonates with EoNNS present as perinatal hypoxia, neonatal depression and
respiratory distress due to intrauterine pneumonia.
High risk factors associated with development of EoNNS
1. Very low birth weight (<2500g) or preterm baby
2. Febrile illness in mother during or within two weeks of delivery
3. Foul smelling and/or meconium stained liquor
4. Prolonged rupture of membrane (>18hr)
5. Single unclean or more than three vaginal examinations during labour
6. Prolonged labour (>24 hours both stages) and difficult delivery with instrumentation
7. Birth asphyxia and difficult resuscitation
Foul smelling liquor alone can be considered as having sepsis and warrants initiation of
antibiotic therapy. Presence of at least three of the above mentioned risk factors is considered
to be infected and requires investigation and treatment with appropriate antibiotics therapy.
Late onset neonatal sepsis (LONNS): (more than 72 hour)
The sepsis is caused by organisms thriving in the external environment of home or hospital.
The most common organisms are:
 E. coli
 Klebsiella
 Staphylococcus
 Enterobacter
The most common presentation is septicaemia, pneumonia or meningitis
The common risk factors for LoNNS are:
1. LBW
2. Lack of breastfeeding
3. Poor cord care
4. Superficial infections (pyoderma, umbilical sepsis)
5. Aspiration of feeds
6. Disruption of skin integrity with needle pricks
7. Use of intravenous fluids

Clinical features of Neonatal Sepsis

The manifestations of neonatal sepsis are often vague and requires high index of suspicion for
early diagnosis. The common manifestation is respiratory distress in early onset sepsis and
alternation of feeding pattern of established feeding in late onset sepsis. Neonates with sepsis
may present with one or the more of the following non-specific signs and symptoms.

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 1. Hypothermia (preterm and LBW babies) or fever
2. Lethargy, poor cry, refusal to suck
3. Poor perfusion, prolonged capillary filling time
4. Hypotonia, absent neonatal reflexes
5. Bradycardia/tachycardia
6. Respiratory distress, apnoea and gasping respiration
7. Hypo/hyperglycaemia
8. Metabolic acidosis
There are certain signs and symptoms which are related to specific system in neonatal sepsis
Initial signs and symptoms of infection in Newborn infants
History
 Presence of risk factors
 History of
o Poor feeding
o Lethargy
o Convulsion
o Difficulty in breathing
o Jaundice
o Eye, cord or skin infection
o Abdominal distension, vomiting and diarrhoea

Examination
Examine the baby for the following:
General
 Hypothermia/ hyperthermia and temperature instability
 Poor feeding /refusal to suck
 Poor cry
 Oedema
 Icterus
Gastrointestinal
 Diarrhoea, vomiting, poor weight gain
 Abdominal distension
 Redness around umbilicus
 Hepatomegaly
Respiratory system
 Apnoea/ gasping
 Tachypnoea, retraction
 Flaring, grunting
 Cyanosis
Renal system
 Oliguria
Cardiovascular system
 Pallor, mottling, cold, clammy skin and capillary filing time (CRT)>3sec
 Tachycardia
 Hypotension
 Bradycardia
Central nervous system (Meningitis)
 Irritability, lethargy
 Tremors, seizure

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  Hyperreflexia, hypotonia
 Abnormal Moro reflex
 Irregular respiration
 Bulging fontanel
 High-pitched cry

Haematological system
 Jaundice
 Splenomegaly
 Pallor
 Petechiae, purpura
 Bleeding
WHO has identified certain most important signs in newborn and considered to be having
neonatal sepsis.

Clinical Signs of possible bacterial infection

according to WHO/IMCI
 Respiratory rate ≥60 breaths/min
 Retraction, flaring, Grunting
 Crepitation
 Cyanosis
 Temperature >37.5°C (or feels hot) or <35.5°C (or feels cold)
 Convulsions, Lethargic or unconscious
 Reduced movements and activity)
 Not able to feed (sustain suck)
 Bulging fontanels

Diagnostic lab tests

 Isolation of bacteria from central body fluid is the most specific in diagnosis for
neonatal sepsis. These are
o Blood culture
o Urine culture
o Pleural fluid
o CSF culture
o Pus culture
 Blood culture must be sent in all the babies with suspected neonatal sepsis

Indirect method:
There are varieties of test which helps in screening of neonates with possible sepsis. These
are
 An absolute neutrophil count (ANC) < 1800per cmm
 Immature/Total neutrophil > 0.2%. Immature neutrophils are band cells, myelocytes
and metamyelocytes
 Platelet count <100,000 per cmm
 Toxic granules
 CRP positive (According to lab standard)
 Micro ESR - > 15

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Septic screen
There are varieties of the test but sepsis screen said to be positive when
Two or more of the following positive tests
1. Leucopenia (TLC<5000/cmm)
2. Neutropenia(ANC<1800/cmm)
3. I/T ratio>0.2
4. Micro ESR - > 15
5. CRP positive

CSF Examination and Culture is done in all neonates with septic screen positive and or
LoNNS or when presented with features suggestive of meningitis.
All neonates with possible sepsis the CSF analysis needs to be done

Meningitis if (NNF guidelines):

Parameters Term Preterm
White Blood Cells >8cells OR >10cells OR
Protein (mg/dl) >120 OR >170 OR
Glucose (mg/dl) <20 <24

CSF Test
Term Preterm
WBC upto 30 upto 90
Polymorphs 60% 60%
Protein upto 150 upto 150
Glucose 35-120 25-65

Indications for Radiological investigation in neonatal sepsis:

Radiological features of neonatal sepsis comprise of
 Chest X-ray
o Respiratory distress
o Apnoea
 Abdominal X-ray
o Abdominal distension with vomiting with or without presence of bowel sound

Management
Early recognition, prompt administration of effective and appropriate antibiotic therapy with
optimal supportive management is crucial to improve intact survival. No investigation is
required as a prerequisite to start treatment. It takes 12 to 24 hours to show any effect of
antibiotics. Hence adequate supportive care is mandatory to improve the survival of newborn
with sepsis.
Foul smelling liquor alone can be considered as having sepsis and presence of at least three
of the high-risk factors is considered to be infected and requires investigation and treatment
with appropriate antibiotics therapy. Hence at PHC and Level I

 Give first dose of IV antibiotics and refer for further evaluation

161
Flow Chart 14 Approach to newborns at risk of sepsis

Approach to newborns
at risk of Sepsis

Symptomatic Asymptomatic

Do Sepsis screening
Do Sepsis screening
and blood culture

Positive Negative Positive Negative

Repeat Sepsis screening

Start antibiotics Start antibiotics Monitor clinically
after 12 hours

Duration of treatment See blood C/S report

according to clinical
course and culture report

Duration of antibiotics according to

clinical course and culture report
Culture sterile – 7-10 days Culture Positive – 10-14 days
* Do lumber puncture if meningitis suspected clinically; if positive then treat for 21 days

Antibiotic therapy for a newborn with sepsis

Choices of antibiotics
 Antibiotic therapy should cover the common causative bacteria namely
Escherichiacoli, Staphylococcusaureus and Klebsiellapneumonia
 A combination of Ampicillin and Gentamicin is recommended for the treatment of
sepsis and pneumonia
 In suspected or confirmed meningitis, add cefotaxime with an aminoglycoside
(+Amikacin)
 Following table provides the antibiotics and dosages of antibiotics for newborn sepsis

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Antibiotic therapy of neonatal sepsis
1. Septicaemia or pneumonia
Frequency
Antibiotic Each dose Route Duration
<7 days age >7 days age
Inj. Ampicillin 50 mg/kg/dose 12 hourly 8 hourly IV 7-10 days
and
Inj. Gentamicin 5 mg/kg/dose 24 hourly 24 hourly IV 7-10 days

2. Meningitis
Frequency
Antibiotic Each dose Route Duration
<7 days age >7 days age
Inj. Ampicillin 100 12 hourly 8 hourly IV 3 weeks
and mg/kg/dose
Inj. Gentamicin 12 hourly 12 hourly IV 2 weeks
and 2.5 mg/kg/dose
Inj. Cefotaxime 6 hourly 6 hourly IV 3 weeks
50 mg/kg/dose

Supportive care of a newborn with sepsis

1. Provide warmth, ensure consistency normal temperature
2. Start intravenous line
3. If CRT>3 seconds, infuse normal saline 10 ml/kg over 30 minutes, repeat the same 1-
2 times, if perfusion continues to be poor
4. Infuse 10% dextrose 2 ml/kg stat
5. Inject Vitamin K1 mg IM (if ≥ 1000 gm) and 0.5 mg if <1000 gm
6. Start oxygen by hood or mask, if cyanosed or grunting
7. Provide gentle physical stimulation, if apnoeic. Provide bag and mask ventilation with
oxygen if breathing is inadequate
8. Avoid enteral feed if hemodynamically compromised, give maintenance IV fluids
9. Consider use of dopamine if perfusion is persistently poor

Rational Use of Antibiotics

 Indication of antibiotics
 Appropriate choice and correct combination antibiotics
 Correct regimen - dose, duration, frequency
 The cost effectiveness with adequate efficacy

Indication of antibiotics
The indication for starting antibiotics for at risk neonates with early onset sepsis are
1. Presence of ≥ 3 risk factors for EoNNS
2. Presence of foul smelling liquor
3. Presence of 2 antenatal risk factors and a positive septic screen
4. Strong clinical suspicion of sepsis
The indication for starting antibiotics for at risk neonates with late onset sepsis are:
1. Positive septic screen and or
2. Strong clinical suspicion of sepsis

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Choice of Antibiotics
Depends on
 Most probable etiological agent
 Bacterial isolate from culture
 Sensitivity pattern
 Hierarchy and combination

Empirical choice of antibiotics for treatment of neonatal sepsis

Clinical situation Septicaemia and Pneumonia Meningitis
FIRST LINE Ampicillin and Gentamicin Add Cefotaxime
Community acquired (resistance
unlikely)
SECOND LINE Ampicillin or Cloxacillin and Add Cefotaxime
Hospital acquired Gentamicin or Amikacin
Some strain likely to be resistance
THIRD LINE Cefotaxime or Piperacillin- Cefotaxime or
Hospital acquired sepsis (most Tazobactam or Ciprofloxacin Piperacillin-
strain likely to be resistance) and Amikacin Tazobactam and
Consider Vancomycin if Amikacin
MRSA suspected

The choice of antibiotics also depends upon the prevalent spectrum of organism generally
isolated in that setup and its sensitivitypattern. The antibiotics should be changed accordingly
on the basis of culture report wherever possible.

Duration of course of antibiotics in neonatal sepsis

1. Meningitis (with or without positive blood/CSF culture)- 21 days
2. Blood culture positive but no meningitis-14 days
3. Culture negative, sepsis screen positive and clinical course consistent with
sepsis-7-10 days
4. Culture and sepsis screen negative, but clinical course compatible with
sepsis-5-7 days
Antibiotics therapy of neonatal sepsis
1. Sepsis or Pneumonia
Antibiotic Each dose Frequency Route Duration
<7 days age >7 days age
Ampicillin 50mg/kg/dose 12 hrly 8 hrly IV, IM 7-10 days
Cloxacillin 50mg/kg/dose 12 hrly 8 hrly IV 7-10 days
Gentamicin 5mg/kg/dose 24 hrly 24 hrly IV, IM 7-10 days
Amikacin 7.5mg/kg/dose 12 hrly 12 hrly IV, IM 7-10 days
Cefotaxim 50mg/kg/dose 12 hrly 8 hrly IV, IM 7-10 days
Piperacillin+ 50-100
12 hrly 8 hrly IV 7-10 days
Tazobactam mg/kg/dose
Ceftriaxone 50mg/kg/dose 12 hrly 8 hrly IV, IM 7-10 days
10-
Ciprofloxacin 12 hrly 12 hrly IV, PO 7-10 days
20mg/kg/dose
Vancomycin 15mg/kg/dose 12 hrly 8 hrly IV 7-10 days

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II. Meningitis
Antibiotic Each dose Frequency Route Duration
>7days
<7days age
age
Ampicillin 100mg/kg/dose 12hrly 8hrly IV, IM 21 days
Cloxacillin 50mg/kg/dose 12hrly 8hrly IV 21 days
Gentamicin 5mg/kg/dose 24hrly 24hrly IV, IM 21 days
Amikacin 7.5mg/kg/dose 12hrly 12hrly IV, IM 21 days
Cefotaxim 50mg/kg/dose 6hrly 6hrly IV, IM 21 days
Ceftriaxone 50mg/kg/dose 12hrly 8hrly IV, IM 21 days
Vancomycin 15mg/kg/dose 12hrly 8hrly IV 7-10 days
Ceftazidime 50 mg/kg/dose 12hrly 12hrly IV 7-10 days

Prevention of neonatal sepsis

 Use infection prevention practices while caring for mother and newborn.
 Treat mother’s infection adequately during pregnancy.
 Use clean delivery practices during labour and birth.
 Treat mother with antibiotics if she has prolonged rupture of membrane (>18 hours).
 Keep umbilical cord dry and uncovered.
 Teach mother and family infection prevention practices
o Hand washing
o Minimum visitors
o Clean clothing
 Exclusive breast feeding.
 Adequate and timely immunization.

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 CHAPTER NINETEEN
ANEMIA AND BLEEDING IN NEWBORN
Learning objectives
Participant should be able to
1. Assess and identify the causes of anaemia and bleeding in newborn
2. Provide guideline for blood transfusion

Neonatal anaemia
Anaemia is common finding in preterm babies and less common in term babies. Timely diagnosis and
appropriate management are essential for optimal management of these babies

Definition
In newborn period, the haemoglobin concentration undergoes constant physiological changes. Foetal
haemoglobin increases with gestation. At term gestation, cord haemoglobin ranges between 14-
20mg/dl. Hb level in VLBW babies are 1-2mg/dl lower than term gestation. In neonate anaemia is
generally defined as venous haemoglobin lass than 13mg/dl for first 2 weeks of life and less than
12mg/dl in premature babies less than 28 weeks of gestation.

Anaemia of Prematurity
• RBC mass and iron stores decreased
• Hb levels are same
• Hb nadir (7-9g/dl) reached earlier
– Decreased RBC survival
– Rapid growth
– Iatrogenic phlebotomy
– Deficiency of Vitamin

Haemoglobin nadir in babies in first year of life

Maturity Hb Level at Nadir Time of Nadir (weeks)
Term 9.5 – 11.0 6-12
Preterm (1,200 – 2,500 gm) 8.0 – 10.0 5 – 10
Small Preterm (<1200 gm) 6.5 – 9.0 4–8

Causes of anaemia
 Blood loss
 Haemolysis
 Decreased production
Blood loss
 Obstetric cause
o Abruptio placentae
o Placenta previa
o Incision of placenta at caesarean section
 Occult blood loss
o Fetomaternal bleeding
o Fetoplacental bleeding
o Twin-to-twin transfusion
 Intracranial bleed
 Massive Cephalohematoma
 Retroperitoneal bleeding
 Bleeding from umbilicus
 Iatrogenic cause
 Gastrointestinal bleeding

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  Necrotizing enterocolitis

Haemolysis
• Immune haemolysis
– Rh incompatibility
– ABO incompatibility
• Hereditary RBC disorder
– RBC membrane defect
– Metabolic defect
– Hemoglobinopathies
• Acquired haemolysis
– Infection
– DIC
– Vitamin E deficiency
• Diminished RBC production
– Infection
– Physiological anaemia or anaemia of prematurity
– Drug induced suppression of RBC production
Approach to anaemia in Newborn
• Family history
• Obstetric history
• Physical examination
– Acute blood loss
– Chronic blood loss
– Chronic haemolysis (organomegaly)
Lab test
• Complete blood cell count
• Reticulocyte count
• Blood smear
• Coombs test and bilirubin level
• Apt test
• USG abdomen and head
Once anaemia is detected, recticulocyte count provides further clue to the diagnosis. Normal
reticulocyte count is about 1% of normal RBC
High retic count
 Haemolysis
Low retic count
 Decreased RBC production
Normal retic count
 Peripheral smears
o Normocytic
 Acute blood loss or infection
o Microcytic
 Chronic blood loss
 Iatrogenic

168
Guidelines for packed red blood cells (PRBCs) transfusion thresholds for term neonates
Condition Hb (gm/dl)
Severe pulmonary disease <13
Moderate pulmonary disease <10
Severe cardiac disease <13
Major surgery <10
Symptomatic anaemia <8
Asymptomatic anaemia <7

Guideline for Packed Red Blood Cell (RBC) transfusion in premature baby
S Level of respiratory Oxygen <28 days ≥ 28 days
N support requirement PC Hb PCV Hb
V
1 Assisted ventilation FiO2 ≥ 0.3 < 40 <12 <30 <
FiO2< 0.3 <35 <11 10
2 CPAP Any FiO2 <30 <10 <25 <8
3 Spontaneously breathing Any Age
a Symptomatic FiO2 ≥ 0.35 <35 <11
anaemia
FiO2>0.21- <30 <10
<0.34
b Oxygen FiO2>0.21 <25 <8
therapy
c Room air <20 <7

Symptomatic anaemia as defined by more than 9 apnoeic and bradycardic episodes in 12 hours
or 2 or more requiring bag and mask ventilation in 24 h while on adequate methyl xanthine
therapy or HR>180/min or RR >80/min sustained for 24h or weight gain less than 10 g/day for
4 days on 100 kcal/kg/day or requiring surgery
i. Amount of transfusion to be given: 20 mL/kg (3-4 hours – whole blood)
ii. Fresh RBCs less than 7 days old
iii. Volume of packed RBC = Blood volume (mL/kg) x (desired minus actual
haematocrit)/ haematocrit of transfused RBC
iv. Rate of infusion should be less than 10 mL/kg/hour in the absence of cardiac failure.
v. Rate should not be more than 2 mL/kg/hour in the presence of cardiac failure.

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Flow Chart 15 Approach to anaemia in NEWBORN

Anemia

Reticulocyte count

Low Normal High

Congenital P/S  ABO/Rh

hypoplastic anemia incompatibility
 Alpha Thalessemia
 Hereditary
spherocytosis
 G6PD deficiency

Microcytic hypochromic Normocytic

anemia anemia

 Chronic fetomaternal
 Acute blood loss
blood loss
 Infection
 Iatrogenic anemia

Bleeding in Newborn
Bleeding in neonate is an emergency. A variety of disease process and disorders can exacerbate the
physiological haemostatic immaturity present in the newborn and can lead to significant bleeding.

Causes of bleeding in newborn

• Deficient clotting factors
– Transient deficiency
• Vitamin K dependant
– II, VII, IX, X, protein C and S
– Administration of antibiotics
– Due to negligible stores
– Maternal drug exposure e.g. AED - Warfarin
• Disturbances in clotting
– DIC
• Inherited abnormalities
– Haemophilia
– von Willebrand disease
• Platelet disorder
– Qualitative disorders
• Hereditary
– Quantitative
• Neonatal alloimmune thrombocytopenia
• HELPP syndrome
• DIC
• Sepsis
• Drug induced

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Approach to bleeding neonate
• History
– Family history
– Maternal medication
– Pregnancy and birth history
– Illness and medication
• Examination
– Sick
• DIC
• Infection
• Severe hypoxia
– Well
• Vitamin K deficiency
• Isolated clotting factor deficiency
• Immune throbocytopenia
• Petechiae, small superficial echymosis or mucosal bleeding
– Platelet problem
• Large bruise
– Clotting factors
– DIC
– Vitamin K
– Liver disease
• Enlarged spleen
– Congenital infection
• Jaundice
– Infection
– Liver disease
• Abnormal retinal findings
– Infection
Laboratory test
• Apt test
– Maternal blood from newborn blood
• Peripheral blood smear
• Platelet count
• Prothrombin time(PT), aPTT
• Fibrinogen
• D-Dimer assays
Treatment
• All newborn babies Vitamin K1
• FFP – all newborn with active bleeding
• PRP- platelet reduced
• Clotting factor concentrate
• Fresh whole blood

171
Flow Chart 16 Approach to bleeding Newborn

Bleeding neonate

Vitals stable (Temp, HR, RR, CRT)

No

Yes Stabilise vitals

Assess site of bleeding

Bleeding from area of trauma/injection site/Bleeding from multiple sites

Local cause Systemic cause

Sick Well

1. Sepsis if signs of sepsis +

1. Vitamin K deficiency (Missed Vit K)
2. DIC if mucosal, skins, GI bleed together at
2. Platelet deficiency (petechial bleed)
birth, maternal drugs)
3. Hereditary coagulation factor
3. Liver disease if jaundice, hepatosplenomegaly,
deficiency (Family history, ecchymosis)
clay coloured stool, high coloured urine

Give Vit K 1 mg IV stat

Blood transfusion (15-20 ml/kg) with cross-matched blood if life threatening bleeding

Treat cause if possible, if not refer

172
 CHAPTER TWENTY
SAFE TRANSPORT OF SICK NEONATES
After the training, the participants will be able to:
 Outline the methods of safe transport of sick neonates
 Define and manage according to SAFER and NEST

From the moment a perinatal problem is recognized to the point of its resolution, there is a
continuum of care. A common feature of disease in the neonatal period is a rapidly progressive
course. Use of special centres for the treatment of the sick newborn has been accompanied by
improvement in survival, and the safe transfer of these infants to the centre is an important part
of their overall care. Appropriate stabilization, initiated on recognition of a problem, is
necessary throughout the transfer process. In developing countries, the problem of transporting
small and sick neonates is compounded by several practical constraints like:
 Facilities are scarce and not easily available
 Families have poor resources
 Organized transport services are not available. At times the baby may have to be
transported on foot or on bullock cart.
 No health provider is available to accompany the baby
 Facilities are not fully geared up to receive sick neonates
 Communication systems are non-existent or inefficient

Prepare well before transport

 Stabilize (STABLE) before transport
1. Assess
Make careful assessment of the baby. Make sure that there is a genuine indication for
referral.

2. Correct hypothermia
Normalize the temperature before commencing the transportation.

3. Write a note
Write a precise note for the providers at the referral facility
 Details of the baby’s condition
 Need for referral
 Treatment given to the baby.

4. Encourage mother to accompany

 Mother should accompany the baby for breast feeding and for providing supportive
care to the baby on the way and in the hospital

5. Arrange a provider to accompany

 If feasible doctor/nurse/health worker should accompany the baby

6. Communication
 Explain the condition, the prognosis and the reasons for referral of the baby to the
family
 Explain where to go and indicate whom to contact.
 Inform the referral facility beforehand, if possible

173
Assess and Stabilize (STABLE)
It is of utmost importance that a neonate is stabilized before the transport is begun, as an
unstable neonate is going to deteriorate on the way and may reach the referral facility in a
moribund state defeating the very purpose.
i). Temperature:
Assess temperature by touch or by using a thermometer.
 Hypothermia
o Warmed either under a warmer or by providing KMC.

ii). Airway:
Assess the airway for patency
 Position of the neck
 correct position putting shoulder roll
 Secretions in mouth/nose
 Suction
 Chest movements

iii). Breathing:
Assess the baby for breathing efforts
 Tactile stimulation
 Ventilation using a bag and mask with 100% oxygen
 Respiratory distress, he may require
 Oxygen supplementation using

iv). Circulation:
Assess the status of circulation
 pulse volume and capillary refilling time
o CRT > 3 secs and/or peripheral pulses are poor with normal temperature
 Fluid bolus of 10ml/kg normal saline or Ringer lactate should be provided over
20-30 minutes
 Reassess for need of further boluses.
v). Fluids:
If the neonate to be transported is sick and cannot be fed
 Maintenance fluid based on birth weight and the age in day of life
 Presence or absence of abnormal losses needs to be calculated and started

vi). Medications:
Assess the need for antibiotics, anticonvulsants vitamin K

vii). Feeding:
Assess the baby for feeding using
 Cup or gavages
 Directly at the breast.
 If the neonate can be fed, he should be fed enterally.

174
Care during transport (NEST)
The accompanying person should be explained to ensure the following:
1. No Noxious stimuli
2. Emergent
a. Stabilize and arrange for early referral
3. No sepsis
a. Infection control practices during transport with minimal handling
4. Stabilize prior to transport
5. Maintenance of warm chain while transport of neonate
a. KMC
b. Properly covered in cotton or cloth
c. Improvised containers
d. Transport incubator
6. Prevention of hypoglycaemia
a. Provide feeds
i. If baby is in a position to suck on the breast, he should be offered breast feeds.
ii. If he can take spoon feeding, expressed breast milk can be provided carefully.
iii. If the distance is long, a nasogastric catheter may be inserted and gavage feeding
given
7. Maintenance of airway and breathing
a. Keep the neck of the baby in slight extension
b. Do not cover the baby’s mouth and nose
c. Gently wipe the secretions from the nose and the mouth with a cotton or cloth covered
finger.
d. Check breathing
i. Watch baby’s breathing
ii. If the baby stops breathing, provide tactile stimulation to the soles to restore it.
8. Educate the parents about danger sign while transport
9. Triage of sick newborns
10. Triaging is sorting of neonates to rapidly screen
11. Sick neonates for prioritizing management

175
 Transfer Check List
Name: Age: Sex: Hospital number:

Date of transfer: Time of transfer: Reason for transfer:

Transfer from:

Transfer to:

Doctor/ health worker accompanying the patient:

When potential transfer is identified First Second

check check
 Identify the problem and the reason for transfer
 Inform the senior doctor on call
 Inform parents
 Ensure that the problems of the patient is communicated to the receiving unit
 Ensure the receiving unit is happy about the transfer and bed is available
 Identify transfer ‘team’
 Evaluate urgency of transfer
 Prepare equipments for transfer
 Book ambulance (with oxygen) and ensure that the ambulance will take the transfer
team back to our hospital
Patient preparation
 Patient must have a ‘definitive’ airway. If in doubt, intubate electively
 Secure endotracheal tube
 Ensure normal blood glucose
 Chest drains must NEVER be clamped. Use one-way valve drainage bag instead of
underwater bottles if possible
 At least two reliable intravenous access should be obtained
 For short transfers and/ or for older children, maintenance fluid may sometimes be
omitted but must be carried in case of unexpected delays
 For neonates, intravenous fluid should be continued via a syringe pump.
 Sedation and paralysing agents can be given by bolus injections
 Ensure patient is wrapped properly to prevent hypothermia
Equipment preparation
 Resuscitation box (Use NRP equipment checklist).
 Transfer cot
 Portable pulse oxymeter
 Portable oxygen- 2 X [FiO2 (L/min) X expected journey time (minutes)]L
 (A full transfer cylinder contains 250L oxygen)
 Patient’s transfer notes, x-rays, investigation reports
 Ensure the transfer team has a mobile phone, the receiving unit’s contact number
and the contact number of a senior doctor on call in our unit
 Money for emergency
 Confirm route to receiving hospital

Time of leaving the referral unit:

176
Sample referral note
Date________________________ Time___________________________
Address___________________________________________________________________________________
____________________________________________________________

Name______________________ Mother’s name_______________ Father’s name____________________

Date and Time of Birth____________________ Sex____________ Mother’s Blood GP: __________________

Birth Details
Mode of Delivery________________________ Place of Delivery______________________
Time or 1st Cry________________ Apgar 1 min___________5 min__________10 min______

Resuscitation details Initial steps/Free flow oxygen/Bag and Mask Ventilation / Chest compressions/
Medications

Duration of: O2___________________, Bag and Mask Vent. _____________, Chest compression
_____________
Birth weight ______________grams

Clinical course
Feeding well Yes/No, Breast feeds Yes/No, Spoon Feeds
Yes / No
Type of feeds EBM / Formula / Any other milk Diluted Milk Yes / No
Passage of Urine Yes / No Stool Yes / No

Reason for transfer LBW / Respiratory distress / Not feeding well / Convulsions / Jaundice / Malformation /
Birth asphyxia / Any other

Examination Findings
Jaundice Yes / No Any congenital malformation ___________________________________
Soles Warm/Cold, Trunk Warm/Cold, Temperature _______°C
Heart Rate_____/min Resp Rate___/min Chest Retractions Yes/No
Central Cyanosis Yes / No CRT < 3 sec / > 3 sec
Receiving oxygen Yes / No With Nasal Cannula / Face mask / Hoodbox
SpO2 ___% Blood sugar____ mg%
Time of last feed ____am/pm

Investigations with date

__________________________________________________________________________________________
____________________________________________________________

Treatment given
__________________________________________________________________________________________
____________________________________________________________

Place to which being referred___________________________________________________

Mode of transport _______________________Accompanying person___________________

Name and Phone Number of person at Referral Hospital______________________________

Signatures, Name, Date and Time

177
 CHAPTER TWENTY-ONE
CLINICAL SKILLS

1. Inserting a gastric tube

Indication
 Feeding
 Emptying gastric content or gastric lavage
 Checking patency

A gastric tube may be inserted via one nostril or the mouth

Equipment needed
 Sterile gloves
 Nasogastric tube
o 5-F tube for < 2 Kg
o 8-F tube > 2 Kg
 Writing pen or flexible tape measure
 3- to 5-ml syringe (for aspiration)
 Stethoscope
Methods
 Wash hands and put on sterile gloves.
 Estimate the required length of tube:
o Hold the tube from the mouth or the tip of the nostril to the lower tip of the ear lobe
and then to the stomach, just below the rib margin and place a mark on the tube with a
pen or a piece of strapping.

Figure 48 Inserting a NG tube (a)

 Flex the baby’s neck slightly and gently pass the tube through the mouth or through one
nostril to the required distance. If using the nasal route:
o If a nasal catheter is in place for administration of oxygen, insert the gastric tube
through the same nostril.
o If the tube does not slide easily into the nostril, try the other nostril.
o If the tube still does not slide easily into the nostril, use the oral route.

179
  Never force the gastric tube into the nostril, if resistance is encountered.

Figure 49 Inserting a NG tube (b)

 Secure the tube in position with adhesive strapping

Figure 50 Inserting a NG tube (c)

Confirming proper placement of gastric tube

 Confirm proper placement of the tube:
o Fill a syringe with 1 to 2 ml of air and connect it to the end of the tube. Use a
stethoscope to listen over the stomach as air is quickly injected into the tube:
 If a whistling sound is heard through the stethoscope as the air is injected, the end of the
tube is correctly positioned in the stomach.
 If a whistling sound is not heard, the tube is not properly positioned. Remove the tube and
repeat the procedure.
 Replace the tube with another clean gastric tube after three days, or earlier if it is pulled
out or becomes blocked

Using a gastric tube for drainage

 If the gastric tube is inserted for drainage, leave the tube uncapped and wrap clean gauze
around the end, fastened with tape, to keep the tube clean and to absorb the drainage from
the stomach.

Gastric decompression
Steps for gastric decompression
 Secure the tube.
 Place the cover of the tube below the level of stomach.
 Aspirate with syringe every 4-6 hours.
 Record the infant’s response to procedure, amount, colour, consistency.
 Flush or change the tube as and when required.

Gastric lavage
Steps for gastric lavage

180
 Secure the tube.
 Gently aspirate the gastric content and discard
 Instil the solution into stomach
 Gently re-aspirate the solution and gastric content
 Repeat the above cycle till the aspirate appears clear
 Record the infant’s response to procedure, volume and characteristic of aspirate removed,
volume of prescribed solution instilled
 Withdraw the tube.

Skill Checklist 14 Insertion of gastric tube

Rating
No. Steps
Y ¥ NA
1. Prepare all materials
2. Wash hand
3. Put gloves
4. Estimate the required length of the tube by measuring the
distance from tip of the nostril to the tragus of the ear to just
below xiphisternum
5. Flex the baby’s neck slightly and gently pass the tube
through the mouth upto the length measured
6. Confirm the proper placement by auscultation while pushing
air by syringe
7. Fix the tube by adhesive tape

2. Umbilical vein catheter

Indications
 In emergency situation when urgent IV assess is required
 For single and double volume exchange transfusion
 For measurement of central venous pressure
 Administration of total parental nutrition (TPN)
 Administration of >12.5% Dextrose concentration
 Administration of vasopressors/ ionotropes

181
 Figure 51 Umbilical vein catheterization

Contraindication
 Omphalitis
 Omphalocele
 Peritonitis
 NEC

Equipment
 Sterile gloves 3 pairs
 Cap, mask, gowns (each of 2 pairs)
 Sterile umbilical catheter or gastric tube or nasogastric tube (5 Fr,6Fr).
 Crucifix splint
 Sterile infusion set with IV fluid
 Sterile 5 and 10 ml syringe
 Swabs or cotton-wool balls
 Antiseptic solution
o Spirit
o Povidone iodine
 Sterile blades
 Sterile forceps
 Sterile forceps, mosquito forceps, irish forceps
 Sterile drape

Procedure:
 Arrange all necessary equipment
 Follow aseptic technique of infection prevention
 Prepare the solution to be infused
 Restrain the baby by using a padded crucifix splint and put baby under radiant warmer
 Wear cap and mask
 Wash hands, wear sterile gown and put sterile gloves

182
  Prepare umbilicus and surrounding by washing in an around spiral motion with a swab
or cotton ball form inward outwards with spirit, Povidone Iodine and spirit each time
with different swab
 Allow it to dry
 Remove the gloves
 Wear another sterile gloves
 Drape area with sterile eye cloth
 Fill the catheter with normal saline using closed syringe attached to the end of the
catheter and make sure that there is no air
 Cut the umbilicus stump with the sterile blade about 2 cm from the skin
 Hold the stump with toothed forceps and identify the vein.
 The umbilical stump has the two umbilical arteries, which are thicker-walled and the
single umbilical vein, which usually has a wider opening
 Remove the clot and debris from the umbilical vein.
 Insert gently the catheter filled with saline and attached with syringe towards the head
of the baby and to the baby’s right side
 As the catheter is advanced, periodically apply gentle suction with the syringe until
blood flows back. Once blood flows back freely through the catheter (usually after the
catheter is inserted 5 to 7 cm), do not advance the catheter any further
 If resistance is encountered while advancing the catheter, especially in the first 2 to 3
cm, do not continue. Remove the catheter and try again
 Tie the cord tie or suture around the stump of the umbilicus to hold the catheter in place
and prevent bleeding around the catheter or from one of the arteries.
 Remove the syringe and connect the infusion set to the catheter, ensuring that there are
no air bubbles in the set. Secure the catheter with suture material or adhesive tape to
prevent it from being dislodged.
 Do check X ray to see the position of catheter tip, it should be just above the dome of
right diaphragm at T9-10, if it is in hepatic or portal vein remove it and try again
 Now umbilicus vein is ready for various procedure line
o Infusion of fluid
o Exchange transfusion

For infusion of fluid

 Connect to infusion set and transfuse fluid in required infusion rate
 Inspect the infusion every hour:
o Look for redness and swelling around the umbilicus, which may indicate
infection.
o If redness or swelling is seen at any time, stop the infusion and remove the
umbilical vein catheter. Attempt to establish a peripheral IV line again, and treat
for infection of the umbilicus
 Check the volume of fluid infused and compare to the prescribed volume
 Record all findings.

3. Capillary blood sample (heel prick)

Indication:
 Capillary blood gas sampling
 Complete blood count and biochemistry analysis

183
 Metabolic screening

Contraindication:
 Oedema
 Injury or anomalies that precludes putting pressure on the foot
 Poor perfusion
 Local infection

Supplies
 Sterile gloves
 Swab or cotton-wool ball soaked in antiseptic solution
 Dry cotton-wool ball
 Sterile 24-gauge needle/ quick heel lancet
 Capillary tubes or other appropriate glass collection tubes
Procedure
 Gather necessary supplies.
 Follow principles of infection prevention
 Wash hands and put on sterile gloves.
 Heel warmer (used gloves filled with lukewarm water): the warmer should be applied for
5 minutes and then removed prior to heel prick
 Prepare the skin of the heel using a swab or cotton-wool ball soaked in antiseptic solution,
and allow to dry
 Flex the foot up towards the leg and hold it in this position with one hand.
 Squeeze the heel firmly enough to make it flush red. Puncture the skin (about 1 to 2 mm
deep):
o Aim towards the lateral or medial side of the heel
o Wipe away first drop of blood with gauge
o Using capillary action fill blood gas tube, holding tube horizontally
o Release pressure, allowing capillaries to refill
o If blood stop flowing, wipe site to remove clot with alcohol swab, then reapply
pressure to leg
o Avoid the heel pad because of the risk of infection;
o Avoid using previously used sites, if possible.

Figure 52 Site for heel prick

 Squeeze the heel gently and intermittently to enhance blood flow.

 Avoid excessive squeezing and rubbing of the heel, as this will cause bruising and
dilution of blood with tissue fluid, giving an inaccurate result.

184
 Collect blood into the tube, taking enough blood to perform all necessary laboratory
investigations.
 After blood is collected, apply gentle pressure to the puncture site with a dry cotton-wool
ball for several minutes to prevent bruising.
 Record the volume of blood taken.

Skill Checklist 15 Collecting blood samples by heel prick method

No. Steps Rating

Y ¥ NA
1. Prepare all materials
2. Wash hand
3. Put gloves
4. Prepare the skin over the heel
5. Flex the foot up and hold by another hand
6. Squeeze the heel firmly to flush it red.
7. Puncture the skin of 1‐2 mm deep on the lateral or medial side
of the heel
8. Squeeze the heel gently and intermittently to enhance blood
flow
9. Take blood in a tube to perform all necessary investigation
10. After blood collection apply gentle pressure over the puncture
site by dry cotton‐wool ball till bleeding stops
11. Dispose the needle safely

4. Continuous Airway Positive Pressure (CPAP)

CPAP is applied to premature babies for with RDS for re-expansion of collapsed alveoli,
splinting the airway, reducing the work of breathing and improving the pattern and regularity
of respiration.
The most important prerequisite for starting the CPAP is presence of good respiratory effort.
Indication
Spontaneously breathing premature babies with
 Respiratory distress
 Recurrent apnoea not responding to medical measure
 Post extubation from mechanical ventilation
In term babies
 Respiratory distress
 Low volume lung
Contraindications
 Neonate with poor respiratory effort
 Tracheo-oesophageal fistula
 Chonal atresia
 Cleft palate
 Severe cardiovascular instability
 pH < 7.25 and PaCO2> 60 mm of Hg (progressive respiratory failure)

Procedure
Preparation of machine;
 Connect the machine to oxygen and air gas inlets

185
  Connect inspiratory limb of the machine from gas flow to humidifier to baby
 Ensure this limb has heating wire in it
 Connect the expiratory limb to bubble chamber
 Connect bubble chamber and humidifier with distil water

Fixing the cap

 Put cap covering upto ear

Applying nasal prong

 Choose correct size prong which fit snugly into nostril without distending it
Nasal prong size
Size 0 Birth weight < 700 gm
Size 1 Birth weight 700 - 1000 gm
Size 2 Birth weight 1000- 2000 gm
Size 3 Birth weight 2000-3000gm
Size 4 Birth weight 3000-4000 gm
Size 5 Birth weight > 4000 gm
 Secure nasal prong to the nostril
 Connect nasal prong to the circuit
 Stabilize the head so that the prong does not get dislodged
 Insert orogastric tube

Setting pressure, fiO2 and flow

 Pressure is increased or decreased by the depth of the expiratory limb into the bubble
chamber or by dialling the knob on the pane of CPAP ventilator
 Start with the pressure of 5 cm of H2O in case of RDS and pneumonia and 4 cm of H2O
for apnoea
 Start with FiO2 40 to 50 % after adjusting the pressure and titrate the FiO2 to maintain
SPO2 of 89%-92%
 Flow should be minimum to produce continuous bubbling in the bubble chamber. In
most babies flow of 2l-5L is adequate

Adjustment of pressure, fiO2 and flow

 Ideal pressure is 4 cm to 8 cm of H2O. Pressure is increased or decreased to minimize
chest retraction, maintain 6-8 posterior rib on X-ray and if ABG is available PO2 should
be > 50 mm Hg
 Ideal FiO2 21 to 60 %
 Minimal flow to maintain pressure

Monitoring the baby on CPAP

 Vitals: Heart rate, respiratory rate, blood pressure and SPO2
 Assessment of circulation: Capillary refill time, blood pressure and urine out put
 Scoring for respiratory distress: it can be done with using Downe’s score (page 275-
276)
 Neurological activity; Tone activity and response
 CXR; At starting and if deterioration occurs
 ABG (if available): once a day / as required

186
Weaning from CPAP
 Wean pressure in steps of 1 cm and FiO2 5-10%
 Decrease FiO2 before decreasing pressure
 If baby is stable on CPAP wean FiO2 to 30% in steps of 5% and pressure to 4 cm of
H2O in step of 1 cm of H2O
 If baby maintains normal SPO2 with minimal retraction on pressure of 4 cm of H2O
and FiO2 of < 30% then baby can be removed
 If CPAP is given for apnoea it can be removed within 24- 48 hours of apnoea free
period

Complications
 Excessive pressure
o Over distension
o Alveolar rupture
 Pulmonary interstitial emphysema
 Pneumothorax
o Decrease venous return
o Increase pulmonary vascular resistance
o Reduce cardiac output
 Erosion or pressure necrosis of nasal septum

5. Oxygen therapy by hood

Indication for oxygen therapy
 Baby with respiratory distress, grunting, central cyanosis, pallor, cold extremities with
poor pulses, sick look.
 Pulse oximeter saturation <90%.
 Arterial blood gas pO2<60
Equipment
 Hood
 Humidification device
 Tubing
 O2 supply
 Flow meter
Procedure
 Place neonate in hood, (use shoulder roll, if necessary).
 Initiate oxygen flow of at least 5 litres/min from flow meter.
 Monitor baby for respiratory rate, distress and colour.

Skill Checklist 16 Oxygen therapy by hood

Rating
No. Steps
Y ¥ NA
1. Prepare all materials
2. Wash hand
3. Place the baby under clean hood box
4. Initiate minimum oxygen flow rate of 5Liters/minute
5. Monitor the baby’s breathing pattern, respiratory rate and
colour

187
6. Oropharyngeal suction
Suctioning is used to remove secretion from oral and nasopharyngeal area to ensure the
airway patency.
Indication
 Inability to clear the secretions present in the oropharynx by the neonate on its own.
 Before bag and mask ventilation or intubation.
 Presence of milk in the airway.
 After physiotherapy.

Equipment
 Suction catheter with thumb control or Y connector.
o FG 5 or 6 for preterm
o FG 8 for term
 Portable suctioning machine or wall suctioning with tubings.
 Gloves.
 Distilled or boiled water.

Important point to remember before undertaking this procedure

 Avoid suctioning for 30 minutes to 1 hour after feeding unless it is emergency and keep
the airway open.
 Suction only when necessary. Vigorous suctioning can lead to vasovagal attack.
 Do not exceed suction pressure to 100 mm of Hg (130cm of water).
 Emergency resuscitation trolley containing bag and mask, oxygen, laryngoscope, ET-tube
and drugs like adrenaline should be present bedside before starting suctioning.
 Change suction bottle and tube every day to avoid bacterial contamination.

Procedure
 Attach appropriate size catheter to the suction tubing and insert suction catheter to sterile
water.
 Occlude the catheter completely and set pressure of 100cm of water
 Estimate the length of the catheter to be inserted by measuring tip of the nose to tip of the
ear lobe.
 Gently insert the catheter of measured length to the mouth. Pinch of the tube while
inserting to keep suctioning off.
 Apply suction only while removing. Limit attempts to 3-5 seconds.
 Rinse the catheter on sterile water before applying the suction and in between the
attempts
 Gently insert catheter in one nares and apply suction. Repeat on other side.
 Insert the catheter gently upwards and back into the nares. If catheter is difficult to pass,
try with smaller catheter. It is not necessary to pass catheter completely through the nares
to clear secretion. Applying suctioning to external nares is sufficient.
 Discard the catheter after single use.

188
Skill Checklist 17 Oro-pharangeal suction
Rating
No. Steps
Y ¥ NA
1. Prepare all materials
2. Wash hand
3. Put gloves
Attach the appropriate size suction catheter to suction tube of
4.
machine and insert catheter in sterile water bottle
Occlude the catheter completely and set the pressure of 100 cm
5.
of water
Estimate the length of the catheter to be inserted by measuring
6.
tip of the nose to tip of ear lobe
7. Gently insert the catheter of measure length with occlusion
8. Apply the suction only when removing for only 3‐5 seconds
Rinse the catheter again in sterile water before applying the
9.
suction
10. Dispose the catheter safely

7. Weighing technique
 Use a precise and accurate scale, with 5- or 10-g increments, made especially for
weighing babies.
 Place a clean cloth/paper in the weighing pan.
 Adjust the scale to zero with the cloth/paper in the pan.
 Place the naked baby gently on the cloth/paper.
 Wait for the baby to settle and the weight to stabilize.
 Read the weight to the nearest 5 or 10 g.
 Record the weight in the baby’s record and plot it on the weight chart

Skill Checklist 18 Weighing

Rating
No. Steps
Y ¥ NA
1. Prepare all materials
2. Wash hand
3. Ensure the room is warm
4. Place the cloth in the weighing pan
5. Adjust the scale to zero with cloth in a weighing pan
6. Place the naked baby on the cloth
7. Wait for baby to settle and records the weight
8. After taking weight, put adequate cloth to the baby

8. Lumbar puncture (Nurses are required to assist the doctors performing

Lumbar puncture)

Indication
Lumbar puncture is used to confirm the diagnosis when the baby has signs suggestive of
meningitis

189
Equipment:
 Sterile gloves
 Sterile drapes
 Swabs or cotton-wool balls
 Spirit and Povidone Iodine
 Spinal needle or intravenous needle (22- to 24-gauge)
 Appropriate collection tubes
 Dry cotton-wool ball
 Adhesive bandage

Procedure:
Consent to be taken
 Be prepared to resuscitate the baby using a bag and mask, if necessary.
 Gather necessary supplies.
 Place the baby under a radiant warmer
 Follow principles of infection prevention and aseptic technique
 Position the baby:
o Have an assistant hold the baby in a sitting position
o Position the baby so that the baby’s legs are straight and the back is arched
Ensure that the baby’s neck is partially extended and not flexed towards the chest, which
could obstruct the baby’s airway

Figure 53 Procedure for lumbar puncture (a)

 Alternatively, place the baby on her/his side facing the assistant

o Position the baby so that the baby’s back is closest to the side of the table from
which the lumbar puncture is performed;
o Have the assistant place one hand behind the baby’s head and neck, and place the
other hand behind the baby’s thighs to hold the spine in a flexed position
o Ensure that the baby’s neck is partially extended and not flexed towards the chest,
which could obstruct the baby’s airway.

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 Figure 54 Procedure for lumbar puncture (b)

 Wash hands and put on sterile gloves.

 Prepare the skin over the area of the lumbar spine and then the remainder of the back by
washing in an outward spiral motion with a swab or cotton-wool ball soaked in
antiseptic solution. First with spirit and allow it to dry, then with Povidone Iodine and
allow it to dry. Then wipe with spirit to remove excess Iodine and allow it to dry.
 Identify the site of the puncture between the third and fourth lumbar processes (i.e. on a
line joining the iliac crests).
 Remove gloves and put on another sterile glove.
 Place sterile drapes over the baby’s body so that only the puncture site is exposed.
 Insert the needle in the midline of the vertebrae, angled towards the baby’s umbilicus.
 Slowly advance the needle to a depth of about 1 cm. A slight “pop” may be felt as the
needle enters the subarachnoid space.
 If bone is encountered, pull the needle back to just beneath the skin and reinsert the
needle directing it slightly upward while aiming for the baby’s umbilicus.

Figure 55 Procedure for lumbar puncture (c)

 Collect the cerebrospinal fluid (CSF):
o Collect about 0.5 to 1 ml (about 10 to 20 drops) of CSF in each collection tube.
o If CSF does not come out, rotate the needle slightly.
o If CSF still does not come out, remove the needle and reinsert.
o If blood comes out, the needle probably went through the spinal canal.
o Collect enough CSF for Culture/Sensitivity.
 After the CSF is collected, remove the needle.
 Apply gentle pressure to the puncture site with a cotton wool ball until bleeding or
leakage of fluid stops.
 Apply an adhesive bandage to the site.

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 CHAPTER TWENTY-TWO
EQUIPMENT REQUIRED FOR NEWBORN CARE
1. Radiant warmers
Open care system: ‘open incubator’. Overhead quartz heating element produces heat and
parabolic reflector reflects the heat to the bassinet. Microprocessor inside control panel
processes the desired skin temperature and matches against actual temperature of the baby and
sends feedback.

Indication
1. Preterm, sick and low birth weight babies unable to maintain temperature
2. Severe hypothermia requiring rapid warming
Parts
2. Bassinet (for placing the neonate)
3. Radiant heat source
4. Skin probe (for measuring baby’s skin temperature)
5. Air probe
6. Controls panel (Displays and control knobs)
i. Mode selector (selects manual or servo mode)
ii. Heater output control key/knob (to increase or decrease the heater output manually)
iii. Heater output display (indicates heater output)
iv. Temperature selection key/knob (select desired skin temperature)
v. Temperature display (displays temperature of baby’s skin, the set temperature and air
temperature)
vi. Alarm display

Procedure of placing the babies on radiant warmer

 The temperature of the room should be ≥220 C for its optimal functioning of radiant
warmer
 Clean the mattress and cover with clean linen
 Turn on the warmer 20 min before to pre warm the linen and mattress if the baby is
known to arrive
 Adjust the heater according to babies’ temperature
o High: If babies’ temperature below 360 C (if temperature below 320 C slow
warming should be done
o Medium: If babies’ temperature between 360 C-36.50 C
o Low: If babies’ temperature between 36.5⁰C-37.5⁰C
 Use manual mode initially
 Once the baby’s temperature is between 36.5⁰C -37.5⁰C, switch on to servo/skin mode
 Apply probe over the right hypochondrium in supine position and in flank in prone
position
 Connect skin probe to the baby’s abdomen with sticking tape.
 Check sensor probe regularly to ensure it is in place every 2-3hours
 Check and record the temperature every 2-3 hours and record
 Cover probe with a reflective cover pad (foil covered foam adhesive pad), if available.
 Change probe site once in every 24 hours
 Do not apply probe to bruised skin and do not use fingernails to remove skin surface
probes.

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  Use of cling wrap (transparent polythene) over the baby reduces insensible water losses
and is better in VLBW (<1.5 kg) babies.
 Temperature stability is usually with an accuracy of ± 0.5°C
 The control and power units should be calibrated every 4-6 months and thorough
servicing should be done annually as required.

Modes:
1. Manual mode:
o Heater output increased or decreased manually.
o Used for initial preparation of bed and for rapid warming of a severely
hypothermic baby
o Select the desired set temperature of baby as 36.50 C.
o In the manual mode, record baby’s axillary temperature at 30 minutes and then
2 hourly.
o Respond to alarm immediately. Identify the fault and rectify it
2. Servo mode:
o Heater output automatically based on skin temperature.
o Increase in 0.5°C above the set temperature alarm is activated.
o Problems with fever and displacement of probe

Disinfection:
 External surfaces cleaned daily with light detergent solution and then by an antiseptic
solution like 2 % bacillocid or gluteraldehyde. No spirit or other organic solvent.
 For disinfection of reusable probe, isopropyl alcohol swab.
 Cleaned thoroughly
o Every seventh day
o After shifting the baby to another cot

Advantages
1. Easy accessibility
2. Easy to connect the tubes of ventilated baby and do procedures
3. Better monitoring
4. Less risk of infection as compared to closed incubator
5. Can be used as resuscitation trolley in the labor room

Disadvantages
1. More insensible water losses
2. Not uniform heating as compared to closed system
3. More risks of episodes of hypothermia or hyperthermia
4. Skin blisters

After use
 Clean and cover the equipment with linen cover to store properly

2. Pulse Oximeter
It is a simple, non-invasive and portable method to monitor oxygen saturation and heart
rate with good accuracy.

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Indications
 All sick newborn as fifth vital parameter oxygen saturation (SpO2)
 Assessment of response to resuscitation.
 Titration of oxygen therapy in newborns.
 Apnoea monitor.
 Valuable during transport of newborn.

Situations in which pulse-oximetry does not work

1. Hypovolemic states or low perfusion states
2. Dyshemoglobinemias – COHb, Meth Hb
3. Optical interference from external light sources (phototherapy unit, fluorescent light,
sunlight.)

Target oxygen saturation in newborn to avoid oxygen toxicity

 Usually 85% to 95%
 Preterm 89% to 95%
 <29weeks 85% to 92%
 Avoid persistent value > 95%
Procedure
 Clean the probe with spirit and alcohol and let it dry
 Switch on the pulse oximeter
 Apply the probe to the site which is warm and well perfused
 Ensure both the sides of probe are directly opposite each other
 Secure probe in place
 Set high and low alarms limits for saturation and heart rate (2% above and below
desired limit)
 Observer and change site every 6-8 hourly (If applied continuously)
 Record the reading every2 hourly
 After use switch it off. Clean the probe with spirit and keep covered if not required for
any baby.

Clean/sterilize
 Clean with spirit swab and let it dry before using on another baby.

Complications of pulse-oximetry
 Pressure necrosis on prolonged contact

3. Infusion syringe pumps

Indication
 An accurate fluid infusion and drug administration
 Continuous and controlled infusion of drugs and fluids
 Transfusion of small volume of blood

Syringe infusion pumps are good to deliver small amounts of medication at steady rates.
 This Micro-Infusion Syringe Pump uses a precision motor to inject medication and
desired fluids into the patient. The features provided by infusion pumps are:
o Self-Test, Self-Diagnoses when the pump is turned on the first time

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 o Audible and Visual Alarms of “Near Empty”, “Complete”, “Occlusion”, and
“Low Batt”
o Wide range of compatible syringe: 20ml, 30ml, 50ml, 60ml, 100ml
o Wide flow rate range: 0.1ml/hr-300ml in 0.1ml/hr increments
Procedure
1. Pump can be used either on any horizontal surface or on the IV pole with pole clamp.
2. Plug power cord into a wall outlet
3. Turn the power switch on. Follow according to manual of the model. Press “Number
Set Key” (up and down arrows) to set desired flow rate.
4. Load syringe with medication or desired fluid.
o
5. Lift up the Syringe Securing Bar and rotate right 90 . Place the syringe into the bed. Be
sure to insert the nozzle into the syringe slot.
6. Then press the release button on the plunger driver block and slide the driver blocks
into position so that the end of the syringe plunger can be placed into the slot in the
driver block.
7. Turn the Syringe Securing Bar to the left 90 degrees to secure the syringe barrel. Make
sure the syringe barrel is secure.
8. Press and hold the PURGE button to purge air from the syringe and associated tubing
before connecting to patient.
9. Press “RUN” to start infusion.
10. After use clean and store in cardboard box if not required for babies.

Cleaning the pump

1. Damp cloth soaked in soap-water used for cleansing panel
2. Use disposal syringe and tubing

4. Phototherapy
Jaundiced babies have high levels of bilirubin in blood. Phototherapy involves exposure of the
skin of the jaundiced baby to blue light of wave length 450-460nm. The light converts bilirubin
to water soluble nontoxic forms which are easily excreted.

Indication
 Babies having hyperbilirubinemia

Procedure
 Babies kept naked for larger surface area exposure. With cover of eyes and gonads
 Continue frequent breast feeding
 After each feed or 2 hourly change position of the baby
 Monitor temperature of baby every two hour
 Record weight daily
 Distance between surface of the baby and light source is kept about 45 cm.
 Flux decreases with increasing age of light source so it should be changed every 2000
hours of use.
 Monitor bilirubin level at least once in 24 hours
 Repeat bilirubin level after 24 hour of discontinuation of phototherapy.
 After use always clean with mild detergent and dry. Keep covered with linen if not in
use.

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Complications
 Diarrhoea
 Dehydration
 Hypothermia/hyperthermia
 Bronze baby syndrome if phototherapy is given in the presence of conjugated
hyperbilirubinemia
 Skin rashes

5. Glucometers
Measures glucose by glucose oxidase method

Indication
 Newborn with suspected hypoglycaemia
o Signs of hypoglycaemia
 Poor feeding/ Lethargy
 Jitteriness
 Seizure
 Hypothermia
 Sepsis
 Monitoring blood glucose in the babies with
o Preterm/IUGR
o Large for date babies
o Infant of diabetic mother
o Birth asphyxia
o Sepsis
o Rh- haemolytic disease

Procedure
 Wear sterile gloves
 Sterilize the part with spirit-povidone iodine-spirit
 With sterile hypodermic needle puncture heel (Refer page)
 On Special glucosticks (as per glucometer) put 1 drop of blood
 Insert in glucometer
 Record the reading

6. Thermometer, Clinical, digital, 32-430C

 Digital thermometer Celsius scale
 Safe to use, atraumatic, no glass, no mercury
 Measurement range: 320 C to 430C
 Accurate measurement: +/- 0.10 C between 350 C to 410 C
 Liquid crystal display, easy to read
 Switch on the thermometer
 Wipe axilla before applying thermometer
 Keep sensor side of thermometer on axilla till beep sound heard
 Record temperature and switch off
 Water proof for ease of cleaning
 Battery powered
 Low battery indicator

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7. SUCTION MACHINE

Parts
i. Suction tubing
ii. Suction bottles
iii. Pressure gauze

Type
i. Mechanical: Foot operated
ii. Electrical
iii. Wall suction
Working

Electrical
i. Connect to the mains
ii. Switch on the unit and occlude distal end with your thumb to check the suction pressure.
Ensure it does not exceed 100 mm of Hg
iii. Use disposable suction catheters
iv. Connect the desired size disposable suction catheter to the suctioning tubing
v. Perform suction gently by inserting only 5 cm in mouth and apply pressure while
withdrawing. Suction only intermittently
vi. Switch off the suction machine

Foot operated
i. Pedal to build the desired level of suction pressure
ii. Steps ii-vi are same
Wall suction
i. Turn knob to ON position
ii. Check and adjust pressure gauze
iii. Steps iii-iv same as above
Cleaning and disinfection
i. Wash suction bottle and tubings with soap and water daily
ii. After cleaning soak the tubings and bottle in 2% glutaraldehyde solution for 20 min
iii. Take out from glutaraldehyde solution and wash under running water
iv. Connect to the machine after placing disinfectant solution (3% phenol or 5% Lysol) in
the bottle. Flush the suction tubing by suctioning with clean water after each use.

8. WEIGHING MACHINE (Electronic/Mechanical)

Parts
i. Pan or tray for the baby
ii. Weight scale dial or digital display
iii. Machine proper (Base)

Weighing technique
 Use a precise and accurate scale, with 5- or 10-g increments, made especially for
weighing babies.
 Place a clean cloth/paper in the weighing pan.
 Adjust the scale to zero with the cloth/paper in the pan.

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 Place the naked baby gently on the cloth/paper.
 Wait for the baby to settle and the weight to stabilize.
 Read the weight to the nearest 5 or 10 g.
 Record the weight in the baby’s record and plot it on the weight chart

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