NEONATAL OPERATIONAL

AND CLINICAL GUIDELINES

MINISTRY OF HEALTH
MATERNAL AND NEWBORN HEALTH
DEPARTMENT OF PUBLIC HEALTH
Table of Contents
...................................................................................................................................................... 1
FOREWORD ................................................................................................................................... 4
1. ROUTINE CARE OF ALL NEWBORNS. ........................................................................................... 5
1.1 Personnel and Equipment to be present at delivery ............................................................. 5
1.2 Immediate Care at delivery (within the first hour of life) ...................................................... 5
2 NEONATAL RESUSCITATION ........................................................................................................ 6
2.1 Which babies are likely to require resuscitation at birth? ..................................................... 6
2.2 Preparation for resuscitation................................................................................................ 6
2.3 Resuscitation Equipment...................................................................................................... 6
2.4 Resuscitation steps .............................................................................................................. 7
2.5 Cessation of resuscitation .................................................................................................... 8
3. ROUTINE CARE OF ALL NEWBORNS AFTER DELIVERY................................................................ 10
3.1 Care on the postnatal ward ................................................................................................ 10
3.2 Discharge ........................................................................................................................... 10
4. RAPID ASSESSMENT AND IMMEDIATE MANAGEMENT OF ALL NEONATES................................ 11
4.1 Triaging .............................................................................................................................. 12
4.2 Management of Neonatal Seizures..................................................................................... 12
5. PERINATAL ASPHYXIA MANAGEMENT ...................................................................................... 16
5.1 Risk factors for perinatal asphyxia ...................................................................................... 16
5.2 Diagnosis: .......................................................................................................................... 17
5.3 Initial management ............................................................................................................ 19
5.4 Supportive care .................................................................................................................. 19
6. PRETERM AND LOWBIRTH WEIGHT BABIES .............................................................................. 20
6.1 Complications associated with prematurity ........................................................................ 20
6.2Management of a Low birth weight baby ............................................................................ 21
6.3 Fluid Plan: .......................................................................................................................... 22
6.4 Kangaroo Mother Care ....................................................................................................... 23
6.5 Vitamin and iron supplementation for preterm babies ....................................................... 24
6.6 Apnoea prevention ............................................................................................................ 24
6.7 Key facts for providers– discharge of the LBW/preterm baby .............................................. 25
6.8 Follow- up .......................................................................................................................... 26
7. NEONATAL INFECTIONS ........................................................................................................... 26
7.1 Management of Neonatal Sepsis ........................................................................................ 26
 7.2 Management of Neonatal Meningitis ................................................................................ 27
7.3 Conjunctivitis ..................................................................................................................... 28
7.4 Management of Congenital Syphilis at a Hospital ............................................................... 29
7.5 Infection of the umbilicus................................................................................................... 29
7.6 Management of Baby after PROM, maternal pyrexia in labour and maternal uterine
infection .................................................................................................................................. 30
7.7 Management of Baby Born Following Offensive Vaginal Discharge ..................................... 30
7.8 Management of HIV Exposed Baby at All Levels of Care (Refer to the PMTCT Guidelines) ... 30
8. NON-INSTITUTIONAL DELIVERIES (BORN BEFORE ARRIVAL AT A HEALTH FACILITY) .................. 31
9. ABANDONED/ORPHANED BABY AT A HOSPITAL ....................................................................... 31
10. COMMON NEONATAL CONDITIONS ....................................................................................... 32
10.1 Breathing Difficulties. ....................................................................................................... 32
10.2 Hemorrhagic Disease of the Newborn .............................................................................. 35
10.3 Neonatal Hypoglycemia ................................................................................................... 36
10.4 Vomiting and Abdominal Distension................................................................................. 41
10.5 Macrosomia ..................................................................................................................... 44
10.6 Neonatal Jaundice ............................................................................................................ 44
10.7. Thermal Management..................................................................................................... 50
11. REFERRAL GUIDELINES ........................................................................................................... 55
11.1 The process of referral ..................................................................................................... 55
FOREWORD
In the last decade, Botswana has made significant progress in the reduction of deaths of
children under the age of five, from 76 for every 1000 live births to 28 for every 1000 live
births between 2001 and 2011. However reduction in neonatal deaths has been slow now
contributing at least 60% of under-five deaths in Botswana. It is therefore crucial that
reduction in neonatal deaths be accelerated

The guide provides clinical guidelines for use by the doctors, nurses, midwives, and other
health care workers who are responsible for the care of neonates at primary and secondary
level facilities babies in Botswana. The guide can also be used to identify less common
conditions that require referral to a tertiary level.

The clinical conditions included in this manual were selected based on the commonest
causes of neonatal morbidity and mortality in Botswana. The guidelines were developed
through an extensive consultative process, which included paediatricians, nurse/midwives
DHMT members, regulatory bodies, teaching institutions, and partners involved in maternal
and newborn health. The newborn technical working group led by the ministry of health
brought together current evidence-based knowledge in an effort to provide the highest
quality of healthcare to the public.
The Ministry of Health is grateful for the efforts of all those who contributed in various ways
to the development, review, and validation of the Clinical Treatment Guidelines. We would
like to thank our colleagues from District, Referral, and the teaching institutions, and
specialized departments within the Ministry of Health, our development partners, and
private health practitioners.
We would like to especially thank UNICEF for both their financial and technical support in
the development of the guidelines.
1. ROUTINE CARE OF ALL NEWBORNS.
The vast majority of newborns require no intervention at birth other than routine normal
care. If this is done well, it vastly reduces the likelihood of problems.

1.1 Personnel and Equipment to be present at delivery

 One health provider (physician or nurse) trained in neonatal resuscitation must be

physically available at time of birth of all infant irrespective of its risk status (high or
low). It is not good enough to have someone on call.

 If the delivery is anticipated to be high risk because of presence of risk factors

identified before birth, more advanced neonatal resuscitation may be required. In
these cases, 2 persons should be present to manage the baby.

 The resuscitation corner must be physically located in the delivery room itself.

 The health professional designated to care for the baby at birth should check for
the “Resuscitation Preparedness” at the birthing place well in time before the
baby is delivered.

1.2 Immediate Care at delivery (within the first hour of life)

 Dry the baby with a clean towel whilst skin to skin on the mother’s abdomen.
 Observe the baby while drying, are they crying? If not follow Chart 1.
 Check breathing, if abnormal follow resuscitation protocol (see Chart 1).
 Cover the baby with a warm, dry cloth and a cap
 If the baby is stable wait for at least 1 minute and up to 3 minutes or wait for
cessation of the cord pulsation to clamp or tie and cut the cord.
 Check APGAR score at 1, 5 and 10 minutes
 Identify and label the baby
 Initiate breastfeeding within the first 30 minutes to 1 hour
 Conduct initial assessment of baby at one hour after delivery
 Check vital signs quarter hourly for the first hour and then half hourly for the next
hour
(Temperature, Heart rate, Respirations rate and effort)
 Weigh the baby, measure the length and head circumference
 Apply eye prophylaxis (Tetracycline eye ointment)
 Give Vitamin K intramuscularly
o 1mg for term babies
o 0.4mg/kg for preterm babies (max dose 1mg)
 Document all care provided and complete all necessary registers.
 Transfer mother and baby to postnatal ward after two hours, keep the baby in skin
to skin contact on the mother’s chest or at her side in a warm, draught-free room
  Assess if baby is passing urine and stools in the first 24 hours
 Give BCG and Hep B vaccines within the first 24 hours
 Keep the umbilical cord clean and dry

2 NEONATAL RESUSCITATION
Spontaneous establishment of respirations immediately after delivery is essential.
Approximately 10% of newborns require some assistance to begin breathing at birth;
very few, only about 1% need more than basic resuscitation to survive.

2.1 Which babies are likely to require resuscitation at birth?

 Fetal distress during labour
 Preterm delivery especially before 37 weeks.
 Abnormal presentation-breech
 Multiple gestation
 Difficult /traumatic deliveries
 General Anesthesia within 4 hours before delivery
NB: Any infant can be born with perinatal asphyxia without prior warning

2.2 Preparation for resuscitation

 Always have resuscitation equipment ready
 Every delivery needs at least 1 person….
o whose only responsibility is the baby
o who is capable of initiating resuscitation
o that person or another person needs to be immediately available to perform
a complete resuscitation
 When significant resuscitation is anticipated, have additional personnel present- who
are trained in Neonatal Advanced Life Support (midwife, neonatal nurse, medical
officer, neonatologist or paediatrician).

2.3 Resuscitation Equipment

 Clock
 Temperature probe
 Appropriate size Ambu bag (self-inflating) with Oxygen reservoir
 Appropriate sized mask(newborn & premature sizes)
 Oxygen source ,flow meter, O₂ tubes, pulse oximeter
 Suction machine and catheters (F10 end hole)
 Warm bed & blankets
 Pre-heated resuscitaire with radiant heater
 Stethoscope and gloves
 Laryngoscope with straight blade (size 0 &1) with spare batteries and bulbs.
 Endotracheal tubes (2.5,3.0,3.5 cm), introducer
  Needles, cannulas, syringes, IV fluids, dextrose, adrenaline, naloxone
 NGT (sizes 5 ,6,7 and 8)
 Adhesive tape
 Disposable gloves

2.4 Resuscitation steps

Step 1:
Airway:
 Warm and dry the baby with pre-warmed clean dry towels. Remove all wet towels
from the baby’s bed.
 Stimulate by drying the infant and gently rubbing the back 2-3 times
 Suction (if needed) only if airway obstruction is present. Suck the mouth, nose and
oropharynx by direct vision; do not suck right down the throat, as this can cause
apnoea or bradycardia. Routine suctioning in meconium stained liquor is no longer
advised.
 Assess for breathing
o Look for chest movement (or crying)
o Newborn needs to have a good chest rise with every breath.
Step 2:
Breathing
 Call for help if the baby is not breathing or is gasping
 Begin bag-mask ventilation within 30 seconds from birth if the baby is not breathing
(apneoic) or is gasping
o Open airway by placing baby in neutral position
 Chin lifted slightly up
 Neck flexion or hyperextension closes airway
o Choose mask that covers nose and mouth but doesn’t extend below chin
o Use “C-grip” to hold mask to face, use remaining 3 fingers to gently pull jaw
up to mask
o Give breaths (40-60 breaths/min)
o Watch for good chest rise with every breath
 Re-assess after 30 seconds for airway, breathing and circulation
Step 3:
Circulation
 begin chest compressions if HR<60 after 30-60 secs
o Give chest compressions (90 per minute)
o Place thumbs on lower sternum, just below nipple line, ensure firm support
of back of the neonate
o Compress about 1/3 of chest depth
 o Give 3 compressions for every breath (90 compressions and 30 breaths per
minute)
o Leave thumbs or fingers in contact with newborn’s chest during relaxation
phase
o Coordinate compressions with continuing bag-mask ventilation at 30
breaths/minute
o Call for assistance (for IV access, intubation, Adrenaline)
o Re-assess after 60-90 seconds

Step 4:
Consider intubation and administration of drugs e.g Adrenaline if heart rate remains
<60/minute.

Medications:
 Give Adrenaline 1:10,000 0.1ml/kg intravenously or 1ml/kg via endotracheal tube
o {Using 1:1,000 draw up 1 ml of Adrenaline and 9 ml of saline > dilutes to
10 ml of 1:10 000 Adrenaline}
 Volume resuscitation (suspected history of abruption or clinically pale infant) give
normal saline at 10 mL/kg bolus.
 Manage hypoglycemia with10% dextrose 2-4 mls/kg intravenously

2.5 Cessation of resuscitation

It is appropriate to consider discontinuing after effective resuscitation efforts if:
 The baby is not breathing and heartbeat is not detectable beyond 10min.
 Record the event and explain to the mother or parents.
 Give them the baby to hold if they so wish.
CHART 1. NEONATAL RESUSCITATION ALGORITHM
BIRTH
 Dry the infant immediately with a
clean cloth.
 Keep warm by skin-to-skin contact
and covered.

Look for ■ Breathing or crying

■ Good muscle tone or vigorous Routine Care
movements Yes
■ Term gestation?

NO

 Stimulate by rubbing the back 2 to 3

times.
 Suction only if the mouth or nose is Routine care and
full of secretions. Normal Breathing closely observe vital
signs and breathing

Not breathing, or gasping

CALL FOR HELP.

Transfer to newborn resuscitation area
-Position the head/neck slightly extended. Observe closely if
-Start positive pressure ventilation with mask Breathing well continues to breathe
and self-inflating bag within 1 min of birth well
-Make sure the chest is moving adequately.

After 30–60 s

If Heart rate <60/min Chest compressions

Check the heart rate (HR) with a stethoscope until HR ≥ 100/min
- Give higher
Oxygen concentration.
■ If HR remains at < 60/min,
consider:
If HR ≥ 60/min -Other ventilator support.
_ IV adrenaline 0.1ml/kg of 1
in 10,000.
-Refer where possible
■ If no HR for > 10 min or
remains < 60/min for 20
min, discontinue
HR 60–100/min: HR >100/min
-Take ventilation -Continue to
corrective steps. ventilate at 40
-Continue to ventilate breaths per
at 40 breaths per min. min.
-Consider higher -Every 1–2 min stop
oxygen concentration. to see if breathing
-Suction, if necessary. spontaneously.
-Reassess every 1–2 -Stop ventilating
min. when respiratory
rate is > 30 breaths
per min.
-Give post
resuscitation care
3. ROUTINE CARE OF ALL NEWBORNS AFTER DELIVERY
3.1 Care on the postnatal ward

 Check vital signs three hourly (Temperature, Heart rate, Respirations-rate and effort)

 Check haemoglobin once in the first 4 hours and blood glucose within 30 minutes of
birth if less than 2.8 feed the baby and repeat after 30 minutes.

 Check for danger signs such as; respiratory distress, hypothermia, fever, failure to
suck convulsions, drowsiness, floppiness, jaundice, bleeding from the cord,
hypoglyceamia .

 Ensure hygiene (follow infection prevention protocols)

 Do not bath the baby within the first 24 hours

 Check weight daily

 Assess the elimination pattern (if passing urine and stools)

 Keep warm by covering the baby with dry cloth and a cap

 Advise the mother on exclusive breastfeeding- on demand minimum 8 feeds in 24

hours.

 Teach the mother on correct positioning, attachment and effective suckling of the
baby.
 Administer immunizations polio 0, BCG and hepatitis B according to immunization
guidelines.

 Assess the baby’s exposure to; HIV, Hep B, TB and Syphillis; follow the appropriate
guidelines.

 Document all care provided.

3.2 Discharge

 Conduct a full physical examination of a baby and document.

 Give health education to the mother on the following areas;

 Danger signs such as convulsions, poor feeding, fever, hypothermia, being

drowsy or unconscious, movement only when stimulated or no movement at
all, central cyanosis, fast breathing, grunting, severe chest in-drawing and
jaundice to seek medical care as soon as possible.
  Hygiene of the baby

 Advise mother to keep the cord clean and dry.

 Advise mother not to add anything on the cord stump.

 Exclusive breastfeeding

 Family planning

 PMTCT

 Advise mother or caregiver to attend postnatal checks at 72 hours, 1 week and 6

weeks.

 Birth registration – Encourage the mother to register the baby

 Document all details in the child health passport book.

4. RAPID ASSESSMENT AND IMMEDIATE MANAGEMENT OF ALL NEONATES.

 Assess every baby for emergency signs as soon as the baby arrives, regardless of
whether the baby is coming from another ward in the health care facility, is
transferred from another health care facility, or is brought from home.

 A few babies may have emergency signs that indicate a problem that is so serious
the baby may die within minutes if not immediately treated.

 The triage concept is used to identify emergencies. This is a logical and quick
way of identifying how sick a child is;

 It does not take the place of a thorough examination to make a diagnosis but is
a screening tool to identify problems that require immediate attention.

 All newborns should be reviewed immediately by a health worker.

 Follow infection prevention principles and practices at all times when examining and
treating babies.
4.1 Triaging

In triaging a neonate one needs to assess airway, breathing, circulation, coma, convulsions
and dehydration in a neonate

Emergency Signs Emergency Treatment

AIRWAY and
Not breathing, centrally Manage the airway,
BREATHING cyanosed, noisy Bag and mask
breathing, severe ventilation, Give
respiratory distress oxygen,

Cold hands, Capillary Refill Stop any bleeding

CIRCULATION >3secs, Weak fast pulse Give oxygen
Start IV fluidsNormal saline
bolus 10ml/kg

Unconscious, Manage airway, Give

Convulsing oxygen, Manage
COMA CONVULSION hypoglycaemia and
Low blood sugar
convulsions

DEHYDRATION Lethargy
Sunken eyes Give IV fluids
Prolonged skin pinch

4.2 Management of Neonatal Seizures

Neonatal seizures (NS) are the most frequent and distinctive clinical manifestation of
neurological dysfunction in the newborn infant. Infants with NS are at a high risk of neonatal
death or neurological impairment/epilepsy disorders in later life.

Definition A seizure is defined clinically as a paroxysmal alteration in neurologic function,

i.e. motor, behavior and/or autonomic function.

Classification
Four major types of NS have been identified;
Subtle Seizures:
They are called subtle because the clinical manifestations are mild and are often missed.
They are the commonest type, constituting about 50% of all seizures. Common examples of
subtle seizures include:
a. Ocular - Tonic horizontal deviation of eyes or sustained eye opening with ocular fixation
or cycled fluttering
b. Oral–facial–lingual movements - Chewing, tongue-thrusting, lip-smacking, etc.
c. Limb movements - Cycling, paddling, boxing-jabs, etc.
d. Autonomic phenomena - Tachycardia or bradycardia
e. Apnea may be a rare manifestation of seizures, particularly in term infants. Apnea due to
seizure activity has an accelerated or a normal heart rate when evaluated 20 seconds after
onset. Bradycardia is thus not an early manifestation in convulsive apnea but may occur
later due to prolonged hypoxemia.

Clonic seizures:
 They are rhythmic movements of muscle groups.
 They have both fast and slow components, occur with a frequency of 1-3 jerks per
second, and are commonly associated with EEG changes.
 Focal clonic seizures have the best prognosis.

Tonic seizures:
 This type refers to a sustained flexion or extension of axial or appendicular muscle
groups.
 These seizures may be focal or generalized and may resemble decerebrate (tonic
extension of all limbs) or decorticate posturing (flexion of upper limbs and extension
of lower limbs).
 Usually there are no EEG changes in generalized tonic seizures.
Myoclonic seizures:
 These manifest as single or multiple lightning fast jerks of the upper or lower limbs
and are usually distinguished from clonic movements because of more rapid speed
of myoclonic jerks, absence of slow return and predilection for flexor muscle groups
  Common changes seen on the EEG include burst suppression pattern, focal sharp
waves and hypsarrhythmia.
 Myoclonic seizures carry the worst prognosis in terms of neurodevelopmental
outcome and seizure recurrence

Causes of Neonatal seizures

 Hypoxic-ischemic encephalopathy (HIE): HIE secondary to perinatal asphyxia is the

commonest cause of neonatal seizures.
 Metabolic causes: Common metabolic causes of seizures include hypoglycemia,
hypocalcemia, and hypomagnesemia. Rare causes include pyridoxine dependency
and inborn errors of metabolism (IEM).
 Bilirubin encephalopathy
 Infections: Meningitis should be excluded in all neonates with seizures.
Meningoencephalitis secondary to intrauterine infections (TORCH group, syphilis)
may also present as seizures in the neonatal period.
 Intracranial hemorrhage: Seizures due to subarachnoid, intraparenchymal or
subdural hemorrhage occur more often in term neonates, while seizures secondary
to intraventricular hemorrhage (IVH) occur in preterm infants.
 Most seizures due to intracranial hemorrhage occur between 2 and 7
days of age.
 Seizures occurring in a term ‘well baby’ on day 2-3 of life is often due to
subarachnoid hemorrhage.
 Developmental defects: Cerebral dysgenesis and neuronal migration disorders are
rare causes of seizures in the neonatal period.
 Miscellaneous: They include;
 Polycythemia,
 Maternal narcotic withdrawal,
 drug toxicity (e.g. theophylline, doxapram),
 Local anesthetic injection into scalp- Accidental injection of local
anesthetic into scalp may be suspected in the presence of fixed and
dilated pupil and absence of doll’s eye reflex.
 Phacomatosis (e.g. tuberous sclerosis, incontinentia pigmentii).
 Multifocal clonic seizures on the 5th day of life may be related to low zinc
levels in the CSF fluid (benign idiopathic neonatal convulsions).
Seizures due to SAH and late onset hypocalcemia carry a good prognosis for long term
neuro-developmental outcome while seizures related to hypoglycemia, cerebral
malformations, and meningitis have a high risk for adverse outcome.
Management

Immediate treatment

 Maintain airway and breathing

 Stabilise vital signs
 Check blood sugar, If less than 2.6 mmol/l, give 2 mls/kg of 10% dextrose and re-
check blood sugar after 30 minutes.

o NB If blood glucose cannot be measured give empirical treatment with

glucose. 2 mls/kg of 10% dextroseControl convulsions with a loading dose
of phenobarbitone 20 mg/kg IV over 5-10minutes .
 If still fitting after 10 minutes give additional phenobarbitone 10mg/ kg IV up to a
total maximum of 40mg/kg. Watch for apnoea. Always have a bag-mask
available.
o NB: If in a primary facility where there is no neonatal unit refer after the
first loading dose and repeat the subsequent loading doses on the way to
the next facility.
 If seizures are not aborted give Phenytoin loading dose 20mg/kg in normal saline
at a rate of not more than 1 mg/kg/min under cardiac monitoring.

o May repeat dose of 5mg/kg to a total maximum dose of 30mg/kg

 If seizures have not arrested with above measures, patient will require
benzodiazepines.
o This group of drugs may be required in up to 15-20% of neonatal seizures.
o The commonly used benzodiazepines are lorazepam and midazolam.
o Diazepam is generally avoided in neonates because of its short duration
of antiepileptic effect but very prolonged sedative effect, narrow
therapeutic index, and the presence of sodium benzoate as a
preservative.
o Lorazepam is preferred over diazepam as it has a longer duration of
action and results in less adverse effects (sedation and cardiovascular
effects).
o Midazolam is faster acting than lorazepam and may be administered as an
infusion. It causes less respiratory depression and sedation than
lorazepam.
o The doses of these drugs are given below:
- Lorazepam: 0.05 mg/kg IV bolus over 2-5 minutes; may be repeated
- Midazolam: 0.15 mg/kg IV bolus followed by infusion of 0.1 to 0.4
mg/kg/hour.
Maintenance treatment

Phenobarbitone 5mg/kg per day IV/PO daily OR Phenytoin 3-8mg/kg in 2-4 divided doses.
Phenytoin oral suspension has very erratic absorption from the gut and should be avoided in
neonates.

Investigations

-Serum electrolytes (sodium, calcium, magnesium)

-Cerebral spinal fluid analysis,
-Full blood count,
-Cranial Ultra sound scan
-Blood culture if sepsis is suspected
-EEG
-Serum bilirubin if icteric
-TORCH screen if congenital infections are suspected
After investigations:

 Treat the cause accordingly.

 Continue monitoring the neonate every 15minutes until stable then hourly.
 Explain the condition of the neonate to the Mother (Guardian).

5. PERINATAL ASPHYXIA MANAGEMENT

Perinatal asphyxia is a common neonatal problem and contributes significantly to neonatal
morbidity and mortality worldwide.
Ninety percent (90%) of asphyxial insults occur in the antepartum or intrapartum periods as
a result of lack of oxygen and/or perfusion to vital organs before, during or immediately
after birth
DEFINITIONS.
Neonatal depression: All neonates with clinical events of poor cry, hypotonia, and
bradycardia, absent or irregular respiration within the first hour of life with blood gas
changes suggesting of acidemia.

Neonatal encephalopathy: All neonates with above criteria after one hour of birth
presenting with clinical seizures/other neurological findings

Hypoxic ischemic encephalopathy: All neonates with above and with evidence of multi organ
dysfunction and or radiological, EEG evidence of hypoxia.

5.1 Risk factors for perinatal asphyxia

 Decreased blood flow from the placenta to the fetus:

  Complicated labour
 placental abruption,
 cord prolapse, cord entanglement, true knot, cord compression and
abnormality of the umbilical vessels

 Impaired gas exchange across placenta or fetal tissues:

 maternal hypertension (PIH or essential),
 post maturity,
 maternal vascular disease,
 maternal diabetes,
 drug abuse,
 placental calcification, infarct or fibrosis

 Increased fetal oxygen requirement:

 as in fetal anaemia,
 fetal infection
 IUGR.

 Impaired maternal oxygenation: as in maternal hypoxia due to pulmonary, cardiac or

neurologic disease in the mother.

 Decreased blood flow from the mother to the placenta: as in maternal infection,
shock, dehydration, hypotension and anaemia.

NB: 70% of risk factors are due to intrapartum events, 20% are due to ante natal, 10%
post-partum.

5.2 Diagnosis:

History:
Maternal Data.

 FHR Patterns; Reactive FHR and subsequent prolonged FHR decelerations,

repetitive late decelerations and persistent non-reactive FHR tracings, fixed
baseline rate from admission till delivery.
 Umbilical Cord Gases; pH less than 7 and base deficit more than/equals
12mmol/l.
 Placental Pathology:
 Improper cord attachments
 Chorioamnionitis.
Neonatal Data: Apgar score less than 3 at 10 minutes is predictive.

Clinical

 Encephalopathy: features such as lethargy, poor cry, hypotonia, poor resp

effort, apnoea
  Cranial Nerve And Mid Brain Dysfunction:
 poor respiratory effort, temperature instability, poor suck, nystagmus,
eye rolling, decerebrate spasms-episodic/sustained, cranial nerve
involvement, respiratory failure, coma
 Seizure Activity
 usually subtle, not generalised and may consist of eye rolling, lip
smacking, cycling movement of limbs or focal fits
 Features of raised intracranial pressure
 lethargy, bradycardia, apnoea, irritability

NB: movements that can be restrained are unlikely to be seizures. A seizure is often associated with
increased heart rate and can be confirmed by EEG

Table1. SARNAT Staging of Hypoxic Ischaemic Encephalopathy

Grade I Mild Grade II Moderate Grade III Severe

Alertness Hyperalert Lethargy Coma

Muscle tone Normal or Hypotonic Flaccid

increased

Seizures None Frequent Uncommon

Pupils Dilated, reactive Small, reactive Variable, fixed

Respiration Regular Periodic Apnoea

Duration < 24 Hours 2 - 14 Days Weeks

Multi organ dysfunction can present at any time:

 Renal the commonest, but pulmonary, cardiac, hepatic, hematologic,

Gastrointestinal and metabolic involvement can occur.

Laboratory & imaging

 FBC, Blood Culture, Serum Electrolytes, Creatinine, Cardiac and Liver

enzymes, Coagulation profile
 Imaging studies including Xray abdomen & chest , Echocardiography,
EEG, CT, MRI if available
  Cranial Ultrasound
 Arterial blood gases,

5.3 Initial management

1. Resuscitation
2. Assisted Ventilation:
 In the form of Oxygen (Room Air to gradual increments in oxygen
concentration) using free flow oxygen, Ambu Bagging, or Intubation.
Mechanical Ventilation where facilities available.

5.4 Supportive care

The management consists of supportive care to maintain temperature, perfusion,
ventilation and a normal metabolic state including glucose, calcium and acid-base balance.
Early detection by clinical and biochemical monitoring and prompt management of
complications must be done to prevent extension of cerebral injury.
O
 Temperature should be strictly maintained in the range of 36.5 – 37.0 C. Hypo- and
Hyperthermia impose additional stress to the baby by increasing the metabolic
needs.
 Oxygenation should be kept in the normal range by monitoring percent oxygen
saturation (SO2) by pulse oximetry. SpO2 should be maintained between 90-93 %.

Hypoxia should be treated with 02. . Hyperoxia should always be avoided.

 Blood glucose level should be kept within the normal ranges to provide adequate
substrate for the brain. Hypoglycaemia should be managed as per guidelines.
 Fluid management
-Start 10% dextrose at 40-50ml/kg/day the first 24 hours. Fluid restriction is of
essence.
-Keep NPO for 48hrs
-Enteral feeding is started when there are normal bowel sounds, normal abdominal
x-ray and clinical status is stable.
 In sick babies, start TPN (if available) after 24 hrs post-delivery.

 Seizures control: refer to seizure protocol

  Pressor Support: Evidence of delayed capillary refill, cold extremities, brady/
tachycardia, mottled extremities, hypotension would necessitate
-fluid resuscitation first
-Dopamine which can be started at 10mcg/kg/min intravenously and titrated
upwards to 20mcg/kg/min
6. IV first line
- Antibiotics may be started if Sepsis is a consideration. Do not give Aminoglycosides
in event of renal impairment.
Prognosis

Mild HIE, according to the scale, usually has a normal outcome, whereas in severe HIE the
mortality rate is 75%, and most of the survivors have neurological sequelae.

NB Referral to be done always in consultation with referral hospital.

6. PRETERM AND LOWBIRTH WEIGHT BABIES

Definition of Prematurity

Babies born less than 37 completed weeks of gestation.

6.1 Complications associated with prematurity

Preterm babies are prone to complications, some of which include:

 Feeding difficulties, aspiration
 Hypothermia
 Respiratory distress
 Apnoea of Prematurity
 Hypoglycaemia
 Jaundice
 Anaemia
 Intraventricular bleeding
 Necrotizing enterocolitis
 Nosocomial infections
 Patent ductus arteriosus
 Retinopathy of prematurity
 Drug toxicity*
*Side effects of drugs can be reduced by giving lower doses at increased intervals
according to formularies
Low Birth Weight Babies

Low birth weight babies can be categorized in 3 groups;

a - Low birth weight - 1.5-2.5 kg
b -Very low birth weight- between 1-1.5 kg
c - Extremely low birth weight- less than 1,000 g
LBW may be due to either prematurity or intra uterine growth restriction (IUGR).

6.2Management of a Low birth weight baby

6.2.1 Babies weighing between 2.0-2.5kg

 Babies with a birth weight of 2kg or above are usually strong enough to breastfeed
and maintain their body temperature (Mother may need support with feeding).
 Check and record the blood glucose level of all low birth weight babies at birth then
every 4 hourly for first 24 hours. If less than 2.6mmol/L manage as per
hypoglycaemia guideline.
 All low-birth-weight babies are at risk of infection and infection control should be
closely observed.
 Routine care of the newborn should be done.

6.2.2 Babies weighing between 1.5-2.0kg

 Babies weighing below 1.8 kg should be admitted to a neonatal unit [above 1.8kg
manage by Kangaroo Mother Care(KMC) in Post Natal Ward]
 Feed babies within 30 minutes of birth
 The baby should be monitored 6 hourly the first 24 hours to assess feeding ability.
 Check and record the blood glucose level of all low birth weight babies at birth then
every 4 hourly for first 24 hours. If less than 2.6mmol/L manage as per
hypoglycaemia guideline.
 Low-birth-weight neonates (weighing < 2 kg) who are clinically stable should be
given Kangaroo mother care starting soon after birth and ensured at all times, day
and night.

 More than 1.5 kg birth weight – cup feed

 More than 1.8kg – put to the breast

6.2.3 Management of very low birth weight babies (1-1.5kg birth weight)

 These babies should be admitted to the neonatal unit

 The baby should be monitored 3 hourly the first 24 hours
 Aminophylline (in absence of caffeine) to be started in neonates weighing less than
1200gms at 7-8 mg/kg loading dose and 2 mg/kg/dose 8 hourly subsequently.
Apnoea monitoring is important.
  Keep NPO and start IV fluids- refer to fluid guidelines.
 Keep NPO for the first 24hrs
 Babies whose birth weight is less than 1.5 kg birth feeds should be given via a
nasogastric/orogastric tube.

6.2.4 Management of extremely very low birth weight babies (< 1kg birth weight)
 These babies should be stabilized and referred.
 Keep NPO and start IV fluids- refer to fluid guidelines.
 NPO for first 24hrs.
 Less than 1.0 kg birth weight – NG feed
 Aminophylline (in absence of caffeine) to be started in neonates weighing less than

1200gms at 7-8 mg/kg loading dose and 2 mg/kg/dose 8 hourly subsequently.

Apnoea monitoring is important.

6.3 Fluid Plan:

TABLE 2. TOTAL FLUIDS INTAKE PER DAY

DAY/ 1 2 3 4 5
ml/kg/day ml/kg/day ml/kg/day ml/kg/day ml/kg/day
ELBW 80 100 120 140 150

VLBW 70 90 110 130 150

LBW 60 90 120 140 150

TABLE 3. ORAL INTAKE

DAY DAY1 DAY2 DAY3 DAY4 – DAY10

ELBW NPO 1 ml/3hrly 1 ml/3hrly Increase by 10- 150 ml/kg/day

<1kg 20 ml/kg/day

VLBW NPO Start at 20 Increase by 20- Increase by 20- 150 ml/kg/day

1 -1.5kg ml/kg/day 30 ml/kg/day 30 ml/kg/day
given 8 hrly
via OGT

LBW 60 90 120 140 150

>1.5kg ml/kg/day ml/kg/day ml/kg/day ml/kg/day ml/kg/day
Cup
Feeding

 If weight gain is inadequate, increase feeds by 10ml/kg/day to 180 ml/kg/day

(formula fed) or 200ml/kg/day (EBM fed) when more than 10 days of age
 Start fortifying with FM85 when 100 ml/kg/ day are reached as directed by dietician
 Nasogastric feeds should be discontinued at 1600gms if the neonate is cup feeding
well and cardiovascular status is stable and is gaining weight at 10-15 gms/ kg/ day.

ANTIBIOTICS:

 Antibiotics to be commenced on babies <1.5kg or unstable babies.

 Blood culture should be done prior to starting antibiotics.

 Initial therapy is with Ampicillin and Gentamycin. Monotherapy is not

recommended.

 Review them after 72hrs, if no signs of infection can be discontinued.

6.4 Kangaroo Mother Care
 Kangaroo mother care (KMC) is care of a small baby who is continuously carried in
skin-to-skin contact (at least 20 hours a day) by the mother/guardian and exclusively
breastfed (ideally).

 Initiate Kangaroo Mother Care for all LBW babies less than 2,000g, continuous KMC
for stable babies and intermittent KMC for sick babies.

 While the baby is recovering from an illness, the mother/guardian can begin to hold
the baby in skin-to-skin contact for short periods of time (minimum of 1 hour at a
time).
  Once the baby’s condition is stable and the baby does not require special treatment
(e.g. oxygen or IV fluid), the mother can begin continuous KMC.
 Before initiating KMC, counsel the mother on KMC. Ensure that the room is at least
25 °C.
 While the mother/guardian is holding the baby, describe to her each step of KMC,
demonstrate them, and then allow her to go through the steps herself.

 Provide counseling of benefit of KMC, newborn danger signs and general hygiene

 Support the mother/guardian in putting and maintaining baby in KMC position.

6.5 Vitamin and iron supplementation for preterm babies

Table 4 Vitamin and Iron Supplementation

Supplement Route Timing and

duration
Vitamin K 0.4mg/kg in pre term neonates IM Birth
National Guidelines

When taking full

Multivitamin
preparation 0.3-0.6ml (5-10 drops) /day (which feeds until 12
usually provides vitamin A of 1000 months of age
IU/day and vitamin D 400 IU/day)

Iron Start iron supplements at 2 weeks of age 2 weeks until 12

if tolerating full enteral feeds at a dosage months of age
of 2–4 mg/kg per day until 6 months of
age.

Syrup usually contains 50mg iron in 5 mls

or 10mg per ml so a 2 kg baby will get 0.5
mls

6.6 Apnoea prevention

 Aminophylline (in absence of caffeine) to be started in neonates born at a gestation

of less than <34 weeks at 7-8 mg/kg loading dose and 2 mg/kg/dose 8 hourly
subsequently. Apnoea monitoring is important.
 Babies with a birth weight of <1.5 kg or a gestational age <34 weeks are prone to
apnoea and should be commenced on oral caffeine and monitored for apnoea.
  The loading dose of caffeine citrate is 20 mg/kg orally. A maintenance dose of 5
mg/kg per day should be prescribed 24 h later
 Continue caffeine for 4–5 days after cessation of apnoea
 Discontinue caffeine when baby is >34 weeks corrected gestation of > 1.5 kg.

6.7 Key facts for providers– discharge of the LBW/preterm baby

A well LBW baby can be discharged when:
 She/he is fully breast fed or breast feeding supplemented by EBM by cup
and gaining adequate weight for 3 consecutive days.
 All vital signs are stable
 Mother is confident of taking care of the baby
 Weight of ideally 1.8kg reached
 Give supplementation for the first year of life;
 0.6 ml multivitamin (Increase to 2.5 ml when >2.5 kg)
 2-4 mg/kg elemental iron
 Follow-up appointments
 Weight check local clinic after 1 week, then after 6 weeks
 Then 3 monthly for neurodevelopment until 2 years of age
 Increase feeds by 3 ml every 3 to 4 days until they reach 50 mls then increase as
per baby’s requirements afterwards.
 Continue kangaroo at home (less than 2 kg) to facilitate growth of baby
 ENT and Opthalmology if the pre-term baby had a stormy NNU admission, or was <
32 weeks gestation or less than 1.2 kg (if not sure discuss with the paediatrician)
 If the LBW baby is not sick, the vaccinations schedule is the same as for term
babies

 Document the followings in the health passport;

 The birth weight and gestational age if known.
 Indicate if any problems in addition to LBW such as jaundice or sepsis.
 Ensure HIV exposure status is known and recorded in the passport.
 Ensure Vitamin K has been administered and recorded.
 Ensure BCG and Hep B has been received and recorded.
 Counseling for care of LBW at home.
 Counsel on exclusive breast feeding, keeping baby warm and to seek
health care early if they identify any of the danger signs in-between
postnatal care visits. Ask the parent to repeat the danger signs so that
you know they have remembered them.
 Inform mother about postnatal care visits
 Educate the guardian on nutrition and health.
6.8 Follow- up
• Low birth weight babies have to be followed up in clinic weekly till when they reach 2.5kgs
weight
• Babies with a birth weight of < 1.5 kg, or who have had a complicated course, need a
neurodevelopmental evaluation every 3 months for the first year of life.

7. NEONATAL INFECTIONS

7.1 Management of Neonatal Sepsis

Definition
Systemic bacterial infection in the neonate
Symptoms

 Fever > 38C *

 Hypothermia
 Symptoms of respiratory distress (Grunting respirations & Severe chest in-drawing)
 Central Cyanosis
 Abdominal distension
 Floppy baby
 Convulsions
 Poor feeding
 Irritability
 Apnoeas
 Seizures
 Body stiffness
 Tachycardia

NB: However, most symptoms are non-specific.

Management

 Do a rapid assessment (ABC)

 Take blood sample for Haemoglobin & Blood culture, FBC , blood glucose
 Do a lumbar puncture when signs of meningitis are present
 Treat with antibiotics immediately for at-least 7 days
 Ampicillin (50mg/kg/dose 8 hourly) and Gentamicin (5mg/kg/day)
 If not improving in 2-3 days:
 Check culture results or consider changing antibiotics depending on
the results.
 Do blood culture if it was not done.
 Switch to 2nd line antibiotics cefotaxime 50mg/kg/dose
  Check blood glucose- If there is hypoglycaemia, manage according to the
hypoglycaemia protocol
 If there are signs of skin infection, (Staphylococcal infection), treat with Cloxacillin
12.5 – 25mg /Kg IV 6 hourly for 7 days. Can be given orally if the baby is clinically
stable.
 Monitor the baby every 15 minutes until the baby is stable, and thereafter every 30
minutes for 1 to 2 hours there after hourly. If the condition is still stable, monitor 4
hourly. .

NB: For the district hospital, refer to next level if no improvement after 5 days.

7.2 Management of Neonatal Meningitis

Definition

Infection of the meninges of the brain. In neonates, the common causes are Group B
Streptococcus and coliforms-E coli

Signs and symptoms

 Fever
 Convulsions
 Bulging fontanelle
 Lethargy
 Irritability
 High pitched cry
 Generalised signs of infection
 Apnoeas
 Poor feeding

Diagnosis

Do lumbar puncture and CSF analysis for all babies suspected of having meningitis except if
there is severe respiratory distress, the lumbar skin is infected, there is bleeding tendency,
or hemodynamically unstable.

Management

 Start antibiotics immediately after doing a lumbar puncture

 First line: Ampicillin 100 mg/kg/dose 12 hourly and Gentamicin 5 mg/kg/day
 If convulsing manage accordingly.
 Give oxygen if desaturating.
 For unconscious babies
  Maintain open airway.
 Prevent pressure sores.
 Maintain food intake by NGT if necessary.
 Clean the mouth well with saline swab.
 Prevent sensory over stimulation (noise, smell, light, etc.)

Follow-up

 Babies who have had neonatal meningitis have a higher risk of developing
neurological sequelae.
 3 monthly follow-up in the first year of life where neurodevelopmental assessments
are done.

7.3 Conjunctivitis

7.3.1 Sticky eyes and mild conjunctivitis

 Treat as outpatient if child has no other serious problem.
 Show the mother how to wash the eyes with water or breast milk and how to put
ointment into the eyes. The mother must wash her hands before and after doing so.
 Tell the mother to wash the eyes and put in tetracycline eye ointment four times a
day for 5 days.
 Review 48 h after starting treatment if the child is not improving treat as for severe
conjunctivitis.

7.3.2 Opthalmia Neonatarum

Definition
Infection and inflammation of the conjunctiva of the eye. The infection is acquired during
delivery and most commonly due to gonococci. The eyes are swollen, red, eye lids are
tender and have thick yellow pus.

Management:

 Treat as in-patient
 Isolate and monitor the baby
 Wash the eyes with Normal saline 2 hourly until the discharge is eliminated
 Start antibiotics - , give Ceftriaxone 50 mg/ Kg im stat then Erythromycin 12.5mg/kg
orally 6 hourly for 7 days.
 Give 1% Tetracycline eye ointment (TEO) 6 hourly OR erthyromycin eye ointment
tds.

NB: At district level, refer baby for specialised care if baby not responding to
 treatment or complications arise

7.4 Management of Congenital Syphilis at a Hospital

Definition

Syphilis infection acquired in-utero.

Commonly contributes to pre-term births and low birth weight.

Clinical signs

 Asymptomatic
 Red rash, grey patches, blisters or skin peeling on palms and soles
 Snuffles: Rhinitis with nasal obstruction
 Abdominal distension
 Hepatosplenomegaly, Jaundice
 Anaemia
 babies have signs of severe sepsis

Diagnosis
Do RPR test on mother and / or neonate if clinical suspicion, unexplained premature labour
or IUGR.
Management
Asymptomatic neonates born from RPR positive mothers

 Start Benzathine Penicillin 50,000 IU/ Kg IM stat.

Symptomatic neonates

 Start Benzyl-Penicillin 50,000IU / Kg IV 12 hourly for the first 10days

uninterrupted

Treat the mother and partner/s with Benzathine-Penicillin 2.4 Mega units IM stat.
Check HIV and Hep B status for the parents.

7.5 Infection of the umbilicus

 The umbilicus usually separates one week after birth, and the wound heals within 15
days. Until the wound is healed, this is an important entry point for infection, which
can quickly lead to sepsis.
 Early recognition and treatment of an infected umbilicus are essential to prevent
sepsis.
  Observe strict infection prevention practices at all times to prevent spreading one
baby’s infection to other babies in the nursery.

7.5.1 Local infection of umbilicus

 Wear clean examination gloves:
 Wash the umbilicus using normal saline

7.5.2 Management severe infection of umbilicus

 The baby’s umbilicus is swollen, draining pus, or foul smelling (infected).
 The skin around the umbilicus is red and hardened- extending more than 1cm
beyond the umbilicus
 Treat with IV/IM antibiotics or oral Augmentin.
 Provide general care as described for a local infection of the umbilicus.

7.6 Management of Baby after PROM, maternal pyrexia in labour and maternal
uterine infection

 Take history to find out when membranes were ruptured

 Thorough examination of the baby including vital signs to determine signs of
infection
 Observe in the ward for at least 48hrs if no signs of infection at delivery.
 Any neonate with signs of infection, treat according to neonatal sepsis protocol.
 If drainage of liquor for more than 18 hours or foul smelling liquor, give the baby
antibiotics (Benzyl penicillin and Gentamicin) for 7 days.

7.7 Management of Baby Born Following Offensive Vaginal Discharge

 Administer stat dose of chloramphenicol/tetracycline eye ointment both eyes

 Septic work up and add Ampicillin and Gentamicin. Monitor with FBC, blood MCS.
Antibiotics at least for 5 days
 Take proper history of the mother
 Observe for features of severe conjunctivitis with thick yellow pus and eyelid
oedema
 Counsel parents and treat according to STI protocols.
 Ascertain exposure status to HIV, HEP B and syphilis

7.8 Management of HIV Exposed Baby at All Levels of Care (Refer to the PMTCT
Guidelines)

*For dosage of antibiotics ref to Appendix 2 of Botswana Antimicrobial Guideline 2012*

8. NON-INSTITUTIONAL DELIVERIES (BORN BEFORE ARRIVAL AT A
HEALTH FACILITY)
Definition
This includes babies who are born outside a health facility whether at home or on the way
to the hospital.
Management
 Conduct an initial assessment and manage accordingly
 Assess airway, breathing and circulation.
 Assess the skin colour (cyanosis and jaundice)
 Cover the baby with a warm, dry cloth and a cap
 Check haemoglobin and blood glucose
 Change the cord clamp and clean cord with normal saline
 Initiate breastfeeding
 Check vital signs quarter hourly for the first hour
 Apply eye prophylaxis (TEO)
 Give vitamin K intramuscularly as per guideline
 Follow routine care of the newborn
 If there are any other complications manage accordingly. Refer to
appropriate guidelines.
 Ascertain the baby’s exposure status to HIV, Syphillis, Hep B and TB as per
guideline
 Provide child health passport and document all care provided
 Advise the mother/guardian to register the baby

9. ABANDONED/ORPHANED BABY AT A HOSPITAL

Definition:
Abandoned baby: Refers to a baby who has been left in public or private place without an
adult assuming responsibility for the baby.

NB: Abandoned babies fall under the care of Child Protection Services

Children under adoption fall under the care of Social Welfare Services

Management
 Admit the baby and assess for emergency signs and manage accordingly.
 Do a thorough assessment to identify whether the baby has any conditions that
needs treatment
  If there are signs of infection treat
 Keep the baby warm to prevent hypothermia
 Assess age and gestational age
 Follow appropriate feeding procedures for the baby- formula feeding is allowed in
abandoned babies.
 This child should be in the care of the hospital until social welfare identifies a place
for the baby
 Report the issue to police and social worker
 All family issues should be referred to the social worker.
 Follow PMTCT guidelines and do RPR and treat accordingly.
 Document all care provided.

10. COMMON NEONATAL CONDITIONS

10.1 Breathing Difficulties.

Newborns at risk of developing breathing problems

 Preterm babies
 Babies with perinatal asphyxia
 Babies of Diabetic Mothers
 Babies born by Caesarean Section
 Babies born to mothers with fever, Prolonged ROM, foul-smelling amniotic fluid.
 Babies born with meconium stained liquor
 Babies with congenital abnormalities.
Signs and symptoms
 Fast breathing- respiratory rate of more than 60 breaths per minute.
 Respiratory rate is less than 30 breaths per minute.
 Grunting
 Chest in-drawing
 Nasal flaring
 Cyanosis
 Desaturation (<88)
 Apnoea
 Abnormal breathing sounds e.g. wheezing, crepitations
Common Causes:
 Primary lung problem
 Respiratory Distress Syndrome (RDS),
 Meconium aspiration,
 Bacterial pneumonia,
 Transient tachypnoea of the newborn (TTN).
 Pneumothorax
 Congenital diaphragmatic hernia
  Non-pulmonary
 Hypovolemia/hypotension,
 Congenital heart disease,
 Hypoxia, acidosis,
 Hypo- and hyperthermia,
 Anaemia,
 Polycythaemia,
 Pain.
 Mucous plugging of the nostrils
 Choanal stenosis or atresia
 Micrognathia e.g. Pierre Robin sequence
Management
 Clear airway and ensure the airway is patent (see Chart 1).
 Give humidified Oxygen via nasal cannula 1-2 liters per minute or face mask oxygen
 Ensure the baby is kept warm (axillary temperature 36.5-37.5 degree Celsius)
 Give antibiotics (Benzyl Penicillin 50,000 IU/ Kg intravenous or intramuscular 6
hourly OR Ampicllin 50mg/kg IV or IM 12 hourly and Gentamycin 5mg/Kg once daily
intravenous or intramuscular) if persistent respiratory distress after 6 hours of age.
 Identify and treat underlying cause (see section on specific conditions)
 Monitor condition for improvement – i.e. improved work of breathing, improved
respiratory rate, improving oxygen saturation,
 Feed via a NGT if the baby is in respiratory distress.
 Refer if there is no improvement after above measures or the baby’s condition
deteriorates.
 Monitor the baby closely for at least 2 hours.

10.1.1 Meconium Aspiration Syndrome

Occurs when a baby born with meconium stained liquor aspirates the meconium into the
lungs. The aspirated meconium can cause inflammatory pneumonitis and mechanical
bronchial obstruction resulting in a syndrome of respiratory distress.

Risk factors

 Physiologic stress at time of pregnancy, labour and delivery

 Post dates
 Prolonged or difficult labour
 Gestational hypertension
 Gestational diabetes
 Chorioamnionitis

Signs and Symptoms

 Rapid breathing (Tachypnoea)

 “Flat baby” (General body weakness)
  Nasal flaring
 Retractions
 Cyanosis or desaturation
 Rattling sounds (Rales)
 Rhonchi (wheezing)
 Greenish yellow staining of the umbilical cord, nail beds or skin

Management

 Suction any visible secretions (mouth and nose)

 Bag mask ventilation or Endotracheal intubation as needed
 Supplemental oxygen (1-2 litres per minute via nasal prongs)
 Mechanical ventilation as needed
 Blood gas test to evaluate Oxygen and Carbon dioxide levels (arterial blood gases
where available)
 Chest X-ray
 IV antibiotics (Benzyl Penicillin 50,000 IU/ Kg intravenous or intramuscular 6 hourly
OR Ampicllin 50mg/kg IV or IM 12 hourly and Gentamycin 5mg/Kg once daily
intravenous or intramuscular)
 Monitor vital signs (Heart rate, respiratory rate, temperature, oxygen saturations,
blood pressure)
 Keep the baby warm at all times

10.1.2 Apnoea

Definition: cessation of breathing for longer than 20 seconds, or for any duration if
associated with cyanosis desaturation and/or bradycardia.

Babies at risk of Apnoea

 Preterm
 Respiratory Distress
 Perinatal Compromise
 Infections
 Hypoglycaemia
 Central Nervous System disorders
 Hypovolaemia or low Hematocrit
 Maternal sedation or analgesia in labor (need to discuss with obstetricians on pain
management during labor.)
 Neonatal drugs e.g. sedatives
 Metabolic Disorders

Determine cause

 Blood sugar
  Check baby’s temperature
 Rule out a seizure
 sepsis work up
 Chest x-ray
 Electrolytes
 Hematocrit
 Prematurity

Treatment

Prevention

Give caffeine or aminophylline prophylaxis for all pre terms <34 weeks gestation (see
preterm management protocol)

Immediate management

 Stimulate
 Resuscitate refer to the resuscitation algorithm
 Mechanical ventilation where necessary
 Manage underlying cause
10.2 Hemorrhagic Disease of the Newborn

Also known as vitamin k deficiency bleeding (VKDB) is a coagulation disturbance in newborn

infants due to vitamin k deficiency. It usually occurs within the first 24 hours after birth or as
late as the first week.

Risk factors

 Infants born to mothers on:

o anticoagulants,( vitamin k antagonist e.g warfarin)
o anticonvulsants ( phenytoin, carbamazepine and barbiturates) and or
o anti-tuberculous( rifampicin and Isoniazid)
(NB usually occurs within 24hrs)
 Babies who did not receive preventative vitamin K (usually occurs after 24hrs)

Signs and Symptoms

 Blood in the stools

 Blood in the urine
 Bleeding on the baby,s umbilical cord
 Bleeding on the skin
 Bleeding post circumcision
 Bleeding in the nostrils
 Hematoma at vaccination sites
Management

 Prevention
o Giving every newborn baby vitamin K 1mg for term babies intramuscular
after birth. Preterm give 0.4mg/kg (max 1mg) intramuscular
 Immediate treatment
o Vitamin k subcutaneous (don’t give IM it can cause hematoma, IV has been
associated with anaphalactoid reactions)
o Apply pressure at the injection site
o Give fresh frozen plasma for moderate to severe bleeding
o Do coagulation profile, platelet count and fibrinogen levels
o BABIES SUSPECTED OF INTRACRANIAL BLEEDING REFER TO A TERTIARY
FACILITY AFTER STABILIZING AND ADMINSTRATION OF SUBCUTANEOUS
VITAMIN K.

10.3 Neonatal Hypoglycemia

Definition

 Blood glucose <2.6 mmol/L

 Persistent neonatal hypoglycaemia; Defined as recurrent hypoglycemia which does

not resolve within 5-7 days or requiring infusions above 10 mg/kg/min of glucose
o It occurs in 5% of infants with hypoglycaemia
TABLE 5. INFANTS AT RISK OF HYPOGLYCAEMIA

Increased demand/ decreased supply Hyperinsulinism

Preterm Infant of a diabetic mother
Intra-Uterine Growth Restriction (IUGR) Large for gestation age
Hypothermia Macrosomia
Infection/sepsis Haemolytic disease of the newborn
Asphyxia Beckwith-Wiedemann syndrome
Polycythaemia Transient or Persistent hyperinsulinaemic
hypoglycaemia of infancy
Islet cell adenoma

Endocrinopathies Inborn errors of Metabolism

Pituitary e.g. GH deficiency, septo-optic Carbohydrate metabolism disorders
dysplasia Glycogen storage disease
Galactosaemia
Adrenal e.g. congenital adrenal hyperplasia
Amino acidopathies
Organic acidaemias
Fat oxidation defects

Maternal medications Others

Salicylates Congenital Heart Disease(transposition of
Beta-Sympathomimetics great arteries)
Chlorpropamide Benzothiadiazide CNS abnormalities

SYMPTOMS
Refusal to feed
Jitteriness
Irritability
Abnormal cry
Hypotonia
Apnoea
Tachypnoea
Tachycardia
Pallor
Sweating
Subnormal temperature
Convulsions
Drowsiness
Cyanotic spells

MANAGEMENT

 Prevention of babies at risk of hypoglycaemia is key

 Feed early (within 30minutes to 1hr after birth)

 if enteral feeding is contraindicated, start IV infusion of Dextrose 10% (within 1 hour

post-delivery)

 Check blood sugar before 3 consecutive feeds and until there have been at least 2
satisfactory measurements (i.e. >2.6 mmol/L).

 If a baby is already on IV fluids ensure that the glucose intake is adequate:

Term appropriate for gestational age: 4 – 6 mg/kg/min
Preterm appropriate for gestational age: 6 – 8 mg/kg/min
Small for gestational age: 6 – 8 mg/kg/min
If the baby requires glucose in excess of 10 mg/kg/min, consider hyperinsulinism
TREATMENT
If sugar is < 2.6 mmol/L:
 Feed immediately, appropriate volumes, and check sugar after 30 minutes,
o if normal in a baby with risk factors check again before the next feed
o If blood sugar is still low, in most cases will need admission and IV dextrose
o NB if enteral feeding is contraindicated, give an IV bolus as stated below
 if still hypoglycaemic after 30 minutes give IV 10% dextrose 2ml/kg bolus
 Ensure that the maintenance fluid is running at the appropriate rate
 Inform the doctor
 Check blood glucose 30 minutes after the IV bolus, then hourly afterwards until 2
consecutive satisfactory readings thereafter 2 - 4 hourly
 If 3 normal readings, then check 4-6 hourly
 Adjust IV maintenance rate as needed to keep blood glucose above 2.6mmol/L
 If still hypoglycaemic, consider increasing glucose concentration from 10 % to 12.5%)
  NB Dextrose concentration of >12.5% requires a central line/ umbilical line
 When blood glucose level stabilizes for 12 to 24 hours, consider weaning infusion
appropriately
 Admit to NNU
 Send blood sample to lab for true sugar (grey topped tube)
 For severe or persistent hypoglycaemia (more than 3 days), refer to a tertiary centre
for further management

AT TERTIARY LEVEL
NB In consultation with the paediatric endocrinologist
Persistent hypoglycaemia management
Add the following if glucose infusion rate >12mg/kg/minute:
 Hydrocortisone IV/PO 5mg/kg/day in 2 divided doses. OR
 Prednisone PO 2mg/kg/day
 Glucagon 0.2-0.3mg IV/IM/SC can be given to babies with adequate glycogen stores
(not to be used in SGA babies)
 Wean steroids after glucose stable for few days.
Hyperinsulinism
The following drugs may be considered in consultation with the paediatric endocrinologist
 Glucagon infusion
 Diazoxide 10-15 mg/kg/day
 Somatostatin analogue 3.5 – 4 ug/kg/min
 MANAGEMENT OF HYPOGLYCAEMIA

CHECK BLOOD SUGAR LEVEL

Blood sugar < 2.6 mmol/L Blood sugar < 2.6 mmol/L with
With no clinical symptoms clinical symptoms
Or
Blood sugar < 1.5 mmol/L

Feed enterally Administer IV bolus 10% dextrose

Check blood sugar 30 2 ml/kg
minutes post feed Check blood glucose after 30
minutes of bolus and step up
glucose concentration, **Central
line required for > 12.5% dextrose

If remains low, commence IV

>2.6 mmol/L If < 2.6 mmol/L infusion, 10% dextrose
Continue feeds Inform medical
Increase IV infusion by 20ml/kg/day,
Check blood sugar officer/ resident
Monitor serum sodium levels
before next 2 feeds Admit to NNU

BS remains < 2.6 mmol/L

Continue feeds
No further blood
sugars required unless
clinical condition
changes

If have glucagon, give bolus IV 0.02

mg/kg
Commence glucagon infusion if
hypoglycaemia continues
Or
Consider steroids
Table 6. Conversion of rate of glucose infusion from ml/kg/24 hours to mg/kg/min
depending on strength of dextrose solution.

RATE OF INFUSION Strength dextrose solution mg/kg/min

Ml/kg/24hrs mg/kg/min 4% 10% 15% 20%

60 2.5 1.7 4.2 6.2 8.4

80 3.0 2.2 5.6 8.3 11.2
90 3.3 2.5 6.3 9.4 12.5

100 4.2 2.8 6.9 10.4 13.8

120 5.0 3.3 8.3 12.5 16.6

150 6.3 4.2 10.4 15.6 20.8

180 7.5 5.0 12.5 18.7 25.0
200 8.3 5.6 13.9 20.8 27.8

10.4 Vomiting and Abdominal Distension

VOMITING

 Spitting or regurgitation of small quantities of milk after a feed is common in a

newborn baby, it is usually transitory, and has no effect on growth.
 If regurgitation is persistent and in large amounts it may indicate Gastro
Oesophageal Reflux Disease.

 A single incidence of vomit is not necessarily pathological. Feeding should continue

as normal under close supervision. Repeated vomiting must be investigated and
managed.

 Vomiting is problematic if it:

 is forceful
 occurs regardless of method of feeding
 Involves vomiting entire feedings after every feed
 Contains bile or blood.
 Occurs in a baby who has abdominal distension
 Associated with instability of vital signs
ABDOMINAL DISTENSION
Table 7: Causes of abdominal distension
History
-Time of onset day 1 or later
-Maternal uterine infection
-Maternal pyrexia fever in
labour to 3 days after
birth,
-PPROM
-Poor or no feeding
after having fed well
-Has not passed meconium
within 24 hours after birth
-Baby coughing and choking at
every feed since birth
-Time of onset day 1 to 2
-preterm delivery
-Asphyxia
•If mother had a
serologic test for
syphilis during
pregnancy, it was
positive
• Mother not treated
or treated inadequately for
syphilis
• Time of onset- at birth
-Mother breastfeeding with
cracked nipples (time of onset
day 2 or later)
-Maternal bleeding
during labour or from
episiotomy
-time of onset day 1 or 2)
Examination findings Probable Diagnosis
• Baby looks ill Suspected sepsis
• Vomiting
• Abdominal distension
• Breathing difficulty
• Abnormal body
temperature
• Irritability or lethargy
• Convulsions or unconsciousness
.Gastric tube does not pass or tip of Suspected
tube returns gastrointestinal
• Increasing abdominal distension malformation or
• Bile in vomitus obstruction
• Dark or bloody stools
• Floppiness or lethargy Suspected necrotizing
• Baby looks ill enterocolitis
• Abdominal distension,
tenderness
• Preterm or LBW
• Blood or bile in vomitus
• Blood or mucus in stool
• Diarrhoea
• Pallor
• Progressive signs of ill health
(temperature instability and/or
apnoea)
Generalized oedema (body Possible congenital
swelling) syphillis
• Abdominal distension (from
enlarged liver and/or spleen or
from fluid in abdomen)
• Blistering skin rash on palms and
soles
• Profuse nasal discharge
(“snuffles”)
• Blood in vomitus Swallowed maternal
• Dark stools blood
• Baby looks otherwise well
General management of babies with vomiting and abdominal distension
 Manage Airway, Breathing, Circulation
 Insert a naso- gastric tube for free drainage
 monitor and replace gastric losses accordingly
 Keep NPO on maintenance IVF at appropriate rates
 Investigate for underlying causes
 Do an abdominal and chest X-ray with the NGT in-situ

Specific management for conditions causing vomiting and/or abdominal distension in a

neonate

Necrotizing enterocolitis
 General management as above
 Treat for sepsis with Benzyl-penicillin/ampicillin, gentamicin and
metronidazole.(triple antibiotics)
 Refer to a tertiary hospital for NEC grade III and above.

Suspected gastrointestinal malformation or Obstruction

 General management as above
 Organize transfer, and urgently refer the baby to a tertiary hospital for surgical
intervention.
Swallowed maternal blood/meconium
• If vomiting is caused by blood swallowed during breastfeeding (cracked nipples):
 Observe the mother while she breastfeeds. Assess her technique and suggest
changes as necessary;
 If the baby is feeding well and there are no other problems requiring hospitalization,
discharge the baby.
 If vomiting is caused by blood swallowed at the time of birth:
 Attach a syringe to the gastric tube and aspirate the stomach contents; do a
stomach wash out with normal saline 10ml/kg
 Allow the baby to begin breastfeeding. If the baby cannot be breastfed, give
expressed breast milk
 Remove the gastric tube after two successful feeds;
 If the baby is feeding well and there are no other problems requiring
hospitalization, discharge the baby.
10.5 Macrosomia

Definition

Any baby born weighing more than 4000g or more than 90 th percentile for gestational age.
Macrosomic babies are at risk of the following:

 Hypoglycaemia (50%),
 Polycythaemia
 Electrolyte disturbances (up to 50%)
 Meconium Aspiration Syndrome
 Birth injuries

Management
NB: the management will be according to the clinical complication that they present with.

 Check blood glucose at birth, if hypoglyceamia-refer to the guideline on

hypoglyceamia

 Assess for birth injuries of the clavicles

 Assess for any respiratory distress- refer to the guidelines on RDS

10.6 Neonatal Jaundice

Definition
Jaundice refers to the yellowish discolouration of the skin, sclera, mucous membranes and
nails caused by the presence of bilirubin in elevated concentration.
TABLE 8. CAUSES OF NEONATAL JAUNDICE

Increased production of bilirubin Altered hepatic clearance of bilirubin

A Increased RBC destruction due to:
 Rh, ABO and minor group
incompatibility
 RBC membrane defect
 Sepsis
 Haemorrhage e.g.
cephalohaematoma
B Increased amount of haemoglobin
 Polycythaemia
 Delayed cord clamping
C. Increased entero-hepatic circulation
 Delayed passage of meconium
 Delayed introduction of feeds
Mixed
 Sepsis
 Intrauterine Infections
 Respiratory distress syndrome
 Birth trauma
 Infant of diabetic mother
 Alteration in uridine diphosphate
glucuronyl transferase (UDPGT)
production or activity
 Immaturity
 Metabolic or endocrine disorders
 Alteration in hepatic function and
perfusion
 Sepsis
 Asphyxia
 Acidosis
 Drugs and hormones
 Hepatic obstruction
 Congenital anomalies e.g biliary
atresia
 Biliary stasis
 Excessive bilirubin load
Breast milk jaundice

Risk Factors for Jaundice

 LBW babies
 Preterm babies
 A baby with a sibling who had neonatal jaundice
 presence of haemolysis
 infections
 Babies poorly fed,
 Babies with cephalohaematoma /bruising
 Blood incompatibility
 Mother Rhesus negative

Classification
A. Physiological jaundice
B. Pathological jaundice

Physiological Jaundice
Characteristics
  Appears after 24 hours
 Maximum intensity by 4th-5th day in term & 7th day in preterm
 Serum bilirubin level depend on age and gestational age at delivery (See chart)
 Clinically not detectable after 14 days
 Disappears without any treatment
Note: Baby should, however, be watched for worsening jaundice.

Management
 Can be managed at home
 Should be followed up postnatal at 72 hours and day 6 of life (domiciliary)
 Encourage exclusive breastfeeding
 Explain the condition of the neonate to the caregiver
 Health education given to mother should include:
o To return if jaundice does not resolve by two weeks of age
o If condition worsens or danger sign(s) appear

Note: Baby should, however, be watched for worsening/persistent jaundice.

Pathological Jaundice
 Appears within 24 hours of age
 Increase of bilirubin 87 μmol /l / day / day (> 5 mg / dl)
 Jaundice persisting after 14 days in term babies and 21 days in preterm babies
 Clay / white colored stool
 Direct bilirubin >20% of the total serum bilirubin
Management

 Take history on the following:

 Onset of symptoms
 Previous history of jaundiced sibling
 Blood group and Rhesus factor of mother
 Maternal infections (TORCHES)- prolonged jaundice
 Maternal malaria
 Carry out laboratory tests as below;
NB: investigations will be guided by onset and type of jaundice
o FBC, peripheral blood smear, Blood culture
o Serum bilirubin: direct , indirect and total
o Direct Coombs’ test
o Rh factor and Blood grouping for both mother and baby
o TORCH screening
o LFTs
o Abdominal Ultrasound
 Encourage exclusive breast feeding or expressed breast milk by cup or through NGT
 Begin PHOTOTHERAPY according to the table below
 NB babies under phototherapy have to be fully exposed with only eyes that are covered
o Bilirubin levels should be done daily
o Stop phototherapy when the level is 50 micro mol/L below the threshold level
o Babies with haemolytic disease, bilirubin levels should be checked 12 – 24 hours
after cessation of phototherapy to monitor for significant rebound
o For levels above the threshold for exchange transfusion, start double
phototherapy and discuss with paediatrician at referral centre.
NB: Babies who had excessive jaundice will need follow up post discharge

ANNEXURE 1
Kramer's rule
There is a normal progression of the depth of jaundice from head to toe as the level of bilirubin rises.
Kramer's rule describes the approximate SBR level with the level of skin discolouration:

Zone Head & Chest Lower body Arms & legs

Hands& feet
neck & thighs below knees
SBR 100 150 200 250 >250
(mol/L)
NAME: D.O.B. GA: BLD GRP&RHESUS:

MOTHER’S BLOOD GROUP& RHESUS: DCT: PREVIOUS

RHOGAM:

DATE COMMENCED ON PHOTOTHERAPY………………………………………… TSB VALUE

…………………..

DATE STOPPED PHOTOTHERAPY……………………………………………………… TSB VALUE

…………………..
NAME: D.O.B. GA: WT: BLD GRP&RH:

MOTHER’S BLOOD GROUP &RHESUS: DCT: PREVIOUS RHOGAM:

DATE COMMENCED ON PHOTOTHERAPY………………………………………… TSB VALUE…………………

DATE STOPPED PHOTOTHERAPY……………………………………………………… TSB VALUE…………………

AMOUNT OF EXCHANGE TRANSFUSION:

OTHER THERAPY USED:

10.7. Thermal Management

A newborn baby is homeothermic, but his ability to maintain his body temperature can be
easily overwhelmed by environmental temperatures. Thermal protection of the newborn is
a set of continuing measures, which starts at birth, to ensure that he maintains a body
temperature of 36.5°C to 37.5°C

Table 9. Temperature Ranges

Normal 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

Thermoneutral environment (TNE)

 TNE refers to a narrow range of environmental temperature at which the basal
metabolic rate (BMR) of the baby is at a minimum, oxygen consumption is at least
and baby maintains its normal body temperature is called thermoneutral range of
temperature.
 Range of neutral temperature varies accordingly for the gestation and postnatal age
(Table ).
 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.
Table 10. Thermoneutral zone

Weight of the Recommended Ambient Temperature

baby

35°C 34°C 33°C 32°C

Less than 1,500g 1-10 days old 11 days to 3 3 weeks to 5 weeks More than 5 weeks
weeks old old old

1,500-1,999g 1-10 days old 11 days to 4 weeks More than 4 weeks

old old

2,000-2,499g 1-2 days old 3 days to 3 weeks More than 3 weeks

old old

2,500g or more 1-2 days old 3 days old or more

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 prewarmed.
 The radiant warmer 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 an hour.
This ensures adequate supply of calories for heat generation.
6. Bathing / weighing postponing
 Bathing should be postponed in a term baby at least till next day.
7. Clothing and bedding
 Newborns should be covered with one (or) two layers of clothes and cap, socks and
hand gloves.
8. Rooming in
 Babies and mother should be attached together 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.

Hypothermia:

Clinical features of hypothermia can be discussed under the four different situations;

a) 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.
b) Later signs include features of CNS depression like lethargy, bradycardia, apnea,
poor feeding, hypotonia, weak suck or cry, emesis. Because of increase in pulmonary
artery pressure, there can be symptoms o respiratory distress mainly tachypnea.
Abdominal signs like increased gastric residuals, abdominal distention or emesis can
occur.
c) Prolonged hypothermia leads to increased metabolism leading to hypoglycemia,
hypoxia, metabolic acidosis, coagulation failure, sometimes, PPHN like situation, ARF
in extreme case high likely hood of mortality.
d) 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 hr till it reaches 36.5°, then hourly for next 4
hours, 2 hourly for 12 hour 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 or applying warm
towel
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
 Check the blood glucose
 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 vitamin K 1mg in term and
0.4mg/kg in preterm babies
 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.

Clinical features
 Signs of dehydration (sunken eyes or fontanelle, loss of skin elasticity, or dry tongue
and mucous membranes)
 Poor or no feeding
 Respiratory rate consistently more than 60 breaths per minute
 Heart rate more than 160 beats per minute
 Lethargy
 Irritability
 Severe forms of hyperthermia can lead to shock, convulsions, even death in
neglected cases.
Management of hyperthermia
 Check servocrib probe position and environmental temperature
 Remove external heat sources e.g. blankets, heaters
 If the hyperthermia is due to overwarming under a radiant warmer or in an
incubator:
 Reduce the temperature setting of the warming device.
 If the baby is in an incubator, open the incubator portholes until the
temperature of the incubator is within the normal range;
 Undress the baby partially or fully for 10 minutes, then recheck the temperature
 Observe for signs of sepsis (e.g. poor feeding, vomiting, breathing difficulty) and
repeat when the baby’s temperature is within the normal range.
 Manage dehydration if the baby has signs of dehydration
 Measure the baby’s temperature every hour until it normalises
 If the cause of hyperthermia is not environmental, consider infection as a cause of
the pyrexia, do septic work up and start antibiotics
Ongoing management of hyperthermia

 Ensure that the baby receives adequate food or fluid:

  Allow the baby to begin breastfeeding. If the baby cannot be breastfed, give
expressed breast milk using an alternative feeding method
 If there are signs of dehydration (sunken eyes or fontanelle, loss of skin elasticity, or
dry tongue or mucous membranes) manage accordingly.
 Measure blood glucose. If the blood glucose is less than 2.6 mmol/l (45 mg/dl), treat
for hypoglycaemia.(follow hypoglycaemia protocol)
 Once the baby’s temperature is within the normal range, measure the baby’s
temperature every three hours for 24 hours.
 If the baby’s temperature remains within the normal range continue with routine
monitoring.

11. REFERRAL GUIDELINES

 For specific conditions please refer to the specific subsections or chapters for
guidance on when to refer.

 In general, babies who appear unwell or raise concern must be immediately

discussed with the neonatal team and assessed for potential admission to neonatal
unit.

 Risk cases need to be identified and transferred as early as possible ideally in utero
transfer.

11.1 The process of referral

Effective communication

The referral facility has to be informed about the patient beforehand

- Call the admitting doctor to explain the baby’s condition including vitals

- Clarify reasons for referral on the referral form providing details of the baby, reasons for
referral and management/treatment given to the baby.

- The transporting team (Emergency Medical Services) has to be informed about the patient
to be transferred once accepted at the referral institution.

- Explain the baby’s condition to the parents and reason for transfer and state where the
patient is being referred to and which ward.
Preparation before transport

-Assess necessity of transport i.e. will the baby survive the transfer, is it beneficial to
transfer the baby (to be discussed with the next referral facility).

-Ensure that the baby is correctly identified and has a visible identification tag on

-Record the parents contact details

-Correct hypothermia (keep temperature between 36.5 – 37.5 degrees Celsius)

-Document vitals i.e. Temperature, Heart rate, Respiratory rate, Blood pressure and Oxygen
saturation where available)

-Encourage the mother to accompany the baby

-Arrange for a trained health care provider to accompany the patient during transfer

Pre-transfer stabilization

Before transfer assess the following:

Airway:

-Is the airway patent?

-Is the airway secure (make sure the ETT is well secured prior to transfer)

Breathing

-Is there sufficient spontaneous respiratory effort?

-If not breathing spontaneously is artificial ventilation adequate?

Circulation

-Is perfusion to essential organs adequate? Check capillary refill time and ensure it is >3
seconds, if prolonged consider a 10ml/kg Normal saline bolus over 20-30 minutes. Check
blood pressures where feasible and consider inotropes in consultation with the
paediatrician.

Fluids
-Infants who are stable can safely be given a milk feed before transportation
-Infants who cannot feed should be transported with IV access and IV fluids running at the
appropriate rate
Metabolic

-Is the blood sugar normal? (maintain blood sugar >2.6mmol/L)

Temperature control

-Is the temperature normal (36.5-37.5 oC)

Medication

-Ensure that tetracycline eye ointment and Vitamin K has been given to a newly born baby
-Ensure all prescribed medication has been given especially antibiotics
-Continuous infusions like inotropes must not be interrupted during transportation

Comfort

-Ensure the baby’s comfort throughout transportation

-Does the baby need sedation?

Infant care during transport

-Ensure that minimal active intervention should be required during the transfer
-Maintain the baby’s temperature within normal range during transfer
-Minimise heat loss during transport
-Assess the baby continuously
-Keep a clear concise record of events
-Anticipate potential problems e.g. dislodged ETT and intravenous line

Transport equipment

-Incubator
-Ventilator
-Gases
-Monitor
-Suction machine and suction catheters
-Intravenous infusion pump
-Equipment for intubation i.e. various sizes ETT tubes, Laryngoscope and blades, strapping
to secure the ETT
-Intravenous cannulas
-Glucometer
-Drugs – adrenaline