BLOCK THREE

BABY AT RISK

BROAD OBJECTIVE
Students will acquire skills ,attitude and knowledge
that will enable them to identify and provide
quality care for new born babies
 CONTENT 1
• Review characteristics and physiology of anew born
• Describe the organization and management of
special care baby unit
• State the indications of admission to special care
baby unit
• Prevention of infections
• Care of incubator and other equipment
• Care activities for babies requiring special care
• Resussitation and medication used
 CONTENT 2
• Describe management of common disorders
of the new born
• Jaundice
• Asphyxia neonatorum
• Ophthalmia neonatorum
• Respiratory distress syndrome
• Low birth /Premature/light for date
• Baby of a diabetic mother
 Neonatal infections
• Neonatal sepsis
• Ompharatis
• Neonatal Tetanus
• Gastro enteritis
• Pemphigus
 Hypothermia
 Hypoglycemia
 CONTENT 3
• Identify and describe management of less
common conditions of new born
 Birth injuries
 Malformations
 Baby of a mother who has history of
substance abuse
 Physiology of the Newborn
• Knowledge on the physiology of a newborn is necessary to ensure
appropriate care of the neonate.
• Immediately at birth, there are three main adjustments that take
place involving the lungs, the cardiovascular system and the
temperature regulating centre to allow for the independent
existence of the newborn baby.
Changes in the Lungs
• The onset of respiration in a newborn confirms life. The start of
pulmonary respiration is due to physiological and mechanical
reasons. Lack of oxygen and high levels of carbon dioxide in the
circulation occur when placental circulation ceases. This stimulates
the respiratory centre in the medulla to initiate normal respiration.
 CONT
• Mechanically, respiration is stimulated when the chest
wall, which was compressed during the passage of the
baby in the birth canal, allows the fluid to drain from the
lungs. Consequently, the cool air on the baby’s face and
handling during birth will stimulate the baby to cry as
soon as they are born. After the baby takes in their first
breath, the blood vessels in the lungs expand to initiate
respiration.
• At first the baby’s breathing may be rapid and irregular. It
is mainly abnormal at a rate of 40 - 50 respirations per
minute.
 Thermo (Heat) Regulation

• The neonate leaves a thermo constant environment

of 37.1 degrees Celsius, where they have survived
for nine months and enters a much cooler
atmosphere at delivery. This affects the neonate in
various ways.
• Firstly, heat regulation in the neonate is poor
because of their inefficient heat regulating centre.
• The subcutaneous fat layer of the neonate is thin and
provides poor insulation, allowing the transfer of core
heat to the environment and also cooling of the
baby’s blood.
 CONT
• In addition to evaporation, further heat
will be lost by conduction when the baby is in
contact with cold surfaces, by radiation to cold
objects in the environment and by convection
caused by currents of cool air passing over the surface of
their body. Incidences of the latter may be substantially
increased by air conditioning systems in some of our
modern delivery rooms.
• Since the neonate’s temperature regulating centres are
not very efficient, there is a risk of either overheating or
chilling.
 Circulatory Changes

• Foetal type of circulation ceases as the respiration

commences
• Normal circulation starts when the temporary
structures stop functioning
the four temporary structures in foetal circulation?
• Foramen ovale
• Ductus arteriosus
• Ductus venosus
• Umbilical vein and hypogastric arteries
 CONT

• As the placental circulation ceases soon after birth when

the umbilical cord is ligated, the blood flow to the right side
of the heart decreases and the blood on the left side
increases causing the foreman ovale to close.
• With the establishment of pulmonary respiration, the
ductus arteries close. Complete closure happens within
eight to ten hours of birth.
• The cessation of placental circulation will result in the
collapse and subsequently drying of the umbilical veins, the
ductus venosus and the hypogastric arteries.
 
 Liver Function

• Physiological jaundice is usually seen in 50% of

normal neonates from the third to the sixth day of
life. This is due to excessive break down of red blood
cells resulting from a high hemoglobin level (Hb of 14
- 18mgs/100mls).
• The process of breaking down red blood cells leads
to formation of bilirubin.
• The liver is not able to conjugate the excess bilirubin
to enable its secretion through the kidneys.
This leads to jaundice.
 Digestion
T
• The neonate is capable of passing the first stool,
known as meconium, within the first two to three
days of life. This is because the foetus swallows
liquor amnii in utero. Thus, their sucking and
swallowing reflexes are usually present at birth.
• The colour of the meconium is dark greenish and
later changes to a mustard (yellowish) colour. The
bowels may be opened three to five times daily.
 Weight

• The average normal birth weight ranges from

2.5 - 3.5 kilograms. During the first three days
of life, the baby loses approximately 10 - 20%
of their birth weight but regains it again within
one to two weeks.
Possible reasons for weight loss in a newborn:

• Due to tissue fluid loss during the heat loss when

the baby is born
• When the baby opens their bowels, the meconium
which was present in the gut is lost, leading to
weight reduction
• Poor sucking on the breast due to tiredness incurred
during the baby’s passage through the birth canal
during labour will affect the baby’s weight since they
are not getting enough fluid intake
 CONT
Skin
• The skin of a newborn is covered with vernix caseosa
in utero to protect and help retain heat and also act
as a lubricant during delivery.
• The sebaceous glands cease to produce vernix after
birth, which may lead to dryness of the skin. The
vernix caseosa will peel off within three days of
delivery if left alone. There is also plenty of fine hair
(lanugo) on the skin which falls off in the first month
of life.
 ORGANIZATION AND MANAGEMENT OF
SPECIAL CARE UNIT
• This is a place where newborn who need special care are
admitted and their needs met.
STRUCTURE OF SPECIAL S.C.B.U
• The unit is divided into smaller rooms to allow care of
different groups of babies
• ROOM A
• The low birth weight and sick babies are admitted there
and nursed in incubator.
• Emergency drugs , o2 and rescusation equipments
should be ready
 ROOM B
• This room is for other well babies who are
being prepared for discharge.
• Drug refrigerators are kept here
• ROOM C
• Has babies delivered before arrival to the
hospital.
• ISOLATION ROOM
• An isolation for very sick , infectious babies,
 STORE ROOM
• For equipments, cleaning equipment
• STAFF CHANGING ROOM
• For different shift staff to change
 INDICATIOND FOR ADMISSION
• Babies born thru instrument e.g. vacuum delivery
• Babies born b4 arrival to hosp
• Babies with congenital malformations
• Sick babies
• Low birth weight babies
• Big babies due to large surface are predisposing them to
hypothermia
• Premature babies
• Neonatal sepsis
• Respiratory problems
• Breech delivery
 PREVENTION OF INFECTION IN SCBU
• SOURCES OF INFECTION
• Intrauterine thru placenta known as
transplacental
• Ascending infection thru mother to baby e.g HIV
, Syphilis
• During labour and delivery
• After birth from environment's airborne,
droplets, objects ,clothing or infectious persons
 PREDISPOSING FACTORS
• Low immunity
• Skin and mucous membranes are soft and
delicate
• Low cellular immunity e.g. leukocytes
• Health facilities are inadequate and
overcrowded leading to cross infection
• Prolonged labour
• Long rescusation after birth
ROLE OF MIDWIVES IN INFECTION CONTROL
ANTINATALY

• Health education on proper hygiene

• Early detection of risk factors e.g. vaginal discharges
and HJV
• Advice the mother to take good diet to boost immunity
• Educate the mothers on importance of hosp delivery
• Identification of risk factors that may complicate labour
• Immunization of antenatal mothers
 DURING LABOUR
• Use of aseptic technique in all invasive procedures
• Minimize the Number of VE TO 4-6HOURLY

• Proper monitoring of labour using partograph to avoid prolonged

labour
• Prophylactic antibiotics incase of early rapture of membranes
• Avoid rupturing of membranes artificially
• Hand washing b4 and after procedures
• Decontamination of soiled instruments after use
• Housekeeping to keep environment safe
• Control the traffic flow in labour ward
 IN SPECIAL CARE BABY UNIT
• Maintain a safe environment by controlling traffic
flow
• House keeping
• Wash and keep Incubators clean
• Wearing of protective gowns, masks and gloves
when necessary
• Hand washing with soap and water which removes
90% of microorganisms
• Avoid overcrowding
 cont
• Each baby in his/her own incubator
• Prophylactic antiretroviral drugs
• Decontamination bath taps, basins and top tailing
equipment
• Hygiene of babies
• Encouraging mothers to breast feed to bost immunity
• Treatment of infected babies
• Sick staff members not to nurse babies
• Start babies on immunization according to immunization
schedure
 CARE OF EQUIPMENT
• INCUBATORS
• Determine appropriate temperature
depending on babies weight and age
• RECCOMENDED INCUBATOR TEMPERATURES
 ̊̊̊
̊̊
RECOMMENDED INCUBATOR TEMPERATURE
WEIGHT AGE TEMPERATURE

1.5kg 1-10 days 3 5°C

11 days –-------- 3weeks 33 °C

3wks--------------5wks 32 °C

5wks and above 32 °C

2kg-----2.5kg 1-----------2 days34 34 °C

3 days ------3wks 33 °C

3wks and above 32°C

2.5kg + 1-------2day 33 °C

2days + 32 °C
 ROOM TEMP FOR LOWBIRTHWEIGHT AND
SICK BABIES
BIRTH WEIGHT/KG ROOM TEMPERATURE

1-------1.5Kg 34-35 °c

1.5………2kg 34--35 ⁰c
 cont

• Warm the incubator to desired temp b4 placing baby

inside
• Increase incubator temp one degree Celsius for every
7 degree Celsius difference btw the room and the
incubator temp
• Clean the mattress and with cover and place clean
linen
• Ensure incubator reservoir is dry to avoid bacterial
growth when not in use
 cont

• Cover babies lightly or undressed as necessary

• Place only one baby in each incubator
• Close the hooks immediately after placing the baby
inside
• Close potholes to keep the incubator warm
• Check incubator temps hourly for the 1st two hours
then three hourly Take babies temp hourly for the
1st 8 hrs then 3hourly normal 36.5-37.5
• Clean incubator immediately baby is discharged and
change the water reservoir
 OTHER EQUIPMENTS IN NBU
Sucker
Heaters
Concntrators
Laryngoscope
Torch
Weighing scale
Torch
Airways
Equipment for vital signs
Masks
Ambubags
Baby cots
Feeding utgensils
ALL EQUIPMENT SHOULD BE IN GOOD WORKING ORDER
 CARE ACTIVITIES FOR BABIES IN SPECIAL
CARE UNIT
1.MAINTANANCE OF NORMAL BODY TEMP
 A sick or small baby needs additional thermal
protection and warmth to maintain normal body
temp by:
 Keeping baby clothed as much as possible always
 During procedures expose only the area needed
 Keep rooms free from draught
 Do not place babies on cold surfaces
 cont
 Prewarm hands when handling babies
 Don’t place babies near cold objects, walls or
windows
 Ensure warmth during procedures
 Change soiled line immediately
 Avoid bathing within the 1st few hrs if not well
 Monitor babies temp 3hrly or depending on
condition
METHODS THAT MAINTAIN BODY TEMP
a)Kangaroo mother care appropriate for babies weighing
1.5-2.5kgor when transferring baby to a next health
facility
b) Radiant warmer-used for sick or premature babies to
keep during he first initial assessement,treatment
and procedures
c) Incubators- used in life threatened babies
d) Warm rooms-used for babies recovering from
illnesses and small babies who do not need frequent
procedures
 2) FEEDING AND FLUID MANGEMENT
I. Beast feeding should be initiated immediately after birth if
condition of baby allows. Baby is admitted and mother is
encouraged breastfeed or express milk for the baby
II. Feeding with alternative methods whereby the baby cannot suck.
III. Mother is asked to express milk and baby is fed by cup and
spoon or NGT
IV. Breast milk substitutes
V. Commercially prepared milk Nun depending on age and weight
of the baby
VI. Iv parenteral feeding and breastfeeding on dehydrated babies
who may need extra fluids
 3) .OXYGEN THERAPHY
• Oxygen is given to the very sick babies who need
additional oxygen
• METHODS OF OXYGEN ADMINISTARION
a) Nasal prongs-
For low oxygen -0.5l/min
Moderate - 1l/min
High- more than 1 L/min
This has the disadvantage of passing cold o2 to the
lungs
 cont
• a) Nasal catheters
• For low oxygen ---0.5L/min
• Moderate ………..above 0.5L/min
• High give more than 1L/min
 cont
• C) HEAD BOX…………Low 3 L/min
• Moderate ……………3-5 L/min
• High………………………..more than 5 L/min
• NB –High flow is needed to achieve high
concentration
 4) ANTIBIOTIC THERAPHY

• Selection of drugs that are most effective against

organisms causing babies illnesses
• Administer iv in sepsis, menegitis,tetanus and
congenital syphilis
• Avoid over dilution drugs that may cause fluid
overload
• Ensure you give the right dose
• Monitor for side effects
 5) INFECTION PREVENTION
• AS PER INFECTION PREVENTION
 6) BOOD TRANFUSSION
• Only needed to relieve clinical signs and to prevent
morbidity
• 7) IMMUNIZATION
• Important to start as per the national policy
• 8) ASSESSING GROWTH
• Common method used is weight although length
can be used.
• The baby initially loses weight up to 10% of initial
for the 1st two days then starts to pick up
 9) COMMUNICATION AND EMITIONAL
SUPPORT
• Need for baby to remain in Hosp although disturbing for
the family and mother
• Mother has fear of baby dying
• Respect the and understand her situation
• Listen to the family's concerns and encourage them to
express their emotions
• Use simple language when giving information
• Respect families cultural , customs and religion
• Obtain informed consent b4performing procedures and
respect the client's rights
 10) DAILY HEAD TO TOE EXAMINATION
• To rule out deviation from normal
 Skin-check for jaundice,palour,cynosis, septic spots,
umbilical cord infection
 GIT- If breastfeeding well, vomiting after feeds,
abdominal distension, or DH
 Cvs-bleeding,any signs of heart problems
 Respiratory system-A ny distress, irregular breathing
 CNS-Convulsions ,weak or high pitched cry, rigidity
of muscles
 11)RECORD KEEPING
• Important because it shows care given,
response to care and recommendations
• Serves ar legal document when need be
• 12) TRANSFER AND REFERALS
• Transfere to the next level where they canget
the best care
 RESPIRATORY DISTRESS SYNDROME
Hyaline Membrane Disease

• This is a lung disorder resulting from lack of pulmonary

surfactant factor in the lungs
• It is a disease of prematurity caused by lack of pulmonary
surfactant.
• The production of surfactant increases with gestational age.
• Lack of surfactant causes collapse of alveoli with each
expiration. Thus, unlike in the normal lung, no residual
capacity is established
• For an infant with RDS, each breath is like the first, requiring
high pressures to reopen collapsed alveoli.
 cont
• Damage to the alveoli and pulmonary capillary
epithelium, secondary to surfactant deficiency,
causes the formation of a hyaline membrane
consisting of fibrin and sloughed cells.
• This further compromises gas exchange.
• Improvement will be evident in three to five
days.
• Morbidity and mortality vary depending on
gestational age.
 Predisposing factors

• Prematurity
• Asphyxia –develops within 4 hours of birth
• Maternal diabetes
• Congenital heart disease
• Caesarean section without labour
• Maternal infections
• Perinatal hypoxia
• Profound hypothermia leading to injury of cells that produce surfactant
• Meconium aspiration
• Antepartum hemorrhage-reduces surfactant synthesis
• Trauma to CNS due to difficult delivery or precipitate labour
 cont

• Second twin, which, if delayed in delivery, may

breath while in utero
• Male infants are more prone to RDS than
female infants for reasons not known
 Diagnosis

• Symptoms and signs include:

• Difficulty in breathing
• Tachypnoea with Fast breathing > 60/min
• Costal and sternal retraction
• Reduced or increased heart rate
• Chest x- ray shows collapsed alveoli
• Poor muscle tone
• Hypothermia
• Chest in drawing
• Nasal flaring
• Grunting
• Cyanosis (may be present or not)
• Resolves or death occurs within 3-days
 Note:
A baby having any 2 of the S/S could be having
respiratory distress syndrome (RDS) if
premature or pneumonia
 Prevention

• Adequate prenatal care

• Adequate treatment of maternal infections during
pregnancy and labour
• Prevent preterm labour if possible
• Give dexamethasome to the mother at least 48
hours before delivery
• Prevention of hypothermia at birth
• Prevention of perinatal asphyxia
• Adequate resuscitation
 Specific management

• Management is symptomatic until disease resolves

• Keep warm
• Give oxygen
• Where oxygen is not available refer
• Give antibiotics – Crystalline Penicillin and Gentamicin
• Feed the neonate
• Give vitamin K - If term 1mg stat IM; If preterm 0.5mg stat
• Admit or refer
 Follow up in the hospital:

• If no response to gentamicin and crystalline

penicillin after 3 days, add erythromycin
• Exclude other conditions
• Provide adequate feeding for the baby
• Keep baby warm
• Counsel the mother
 ASPHYXIA NEONATORUM

• Refers to condition in which the baby fails to initiate and

maintain respiration at at birth
• TYPES
• The degree of asphyxia is determined by APGAR scores in
which the following features are observed and scored 0-2
• Appearance (color of the baby)
• Pulse rate
• Grimace (response to stimuli)
• Activity (muscle tone)
• Respiratory effort
 cont
• A score of 8-10 does not show asphyxia
MILD ASPHYXIA
• Apgar score of 6-7
• It requires clearing of airway and application of external stimuli to initiate
breathing
MODERATE ASPHXIA
• Apgar score of 4-5
• It requires resuscitation, administration of oxygen and drugs
SEVERE ASPHYXIA
• Apgar score is below 4, weak, slow or absent heart rate, gasping or making
attempts to breath, muscle tone is poor, does not respond to stimuli, color is
bluish
• It requires intensive resuscitative measures and intubation to survive
 PREDISPOSING FACTORS
• Any condition causing foetal distress eg cord prolapse,
prolonged labour,APH,
• Intrauterine hypoxia due to placental insufficiency, placental
abruption, anaemia ,pre-eclampsia
• Prematurity due to undeveloped respiratory centre
• Blockage of the airway by mucus or liquor amni at birth
• Birth injuries
• Severe maternal disease in pregnancy eg sickle cell anaemia,
cardiac disease
• Depression of respiratory centre due to drugs eg GA and
narcotics
 SIGNS AND SYMPTOMS
• In mild and moderate asphyxia:
• Apex beat(pulse rate 100/ min or less
• Skin colour is pink with blue extremities
• Response to stimuli may be present
• Makes efforts to breath and may
 The Premature Infant (Preterm)

• A preterm infant is a baby born before the 37th completed

week of gestation.
• A high percentage of premature births occur with female
births and pregnancies with multiple foetuses.
• This is most often due to the early over distension of the
uterus, which leads to the fetus being born prematurely.
• Premature births also occur more frequently in low socio
economic and illiterate groups in the population, largely as a
result of the poor nutritional intake of the pregnant mother.
• Common when there is concurrent maternal metabolic or
systemic disease, for example, hypertension and renal disease.
 causes of prematurity.

• Multiple births (twins or more), which causes early

distension of the uterus hence early birth
• Hypertension associated with the pregnancy leading to
early induction of labour, for example, preeclampsia
and eclampsia
• Premature rupture of membranes due to physical or
psychological stress
• Polyhydramnios which causes over distension
• Trauma leading to premature rupture of membranes
 cont
• Chronic infections or diseases in the mother, such as syphilis,
tuberculosis, chronic nephritis, cardiac disease, diabetes and
thyroid disease, may lead to premature labour
• Acute infections in the mother, like pneumonia, influenza,
rheumatic fever and malaria could induce premature labour
• Physical stress caused by non obstetric surgery may lead
to premature labour if the mother has this procedure
while pregnant
• Congenital malformation of the foetus
• Habitual abortion owing to incompetent cervical OS or
uterine malformation
 Prevention of Premature Birth

• Give early and continued prenatal care with stress on dietary and
general hygienic education to the expectant mother.
• Ensure immediate treatment of those complications of pregnancy
likely to cause, or be associated with, premature labour.
• Postpone or inhibit uterine contractions in some cases of premature
labour through the use of certain pharmaceutical agents such as:
 Those that act by preventing the release or synthesis of a known
uterine stimulant, for example, prostaglandin inhibitors, non steroidal
anti inflammatory drugs like aspirin, endomethacin, declofenac
 Those that act by the direct effect on the myometrial cells, for
example, beta adrenergic receptor stimulants like retodrine, fenoterol,
salbutamol
 CONT
• Prolonged bed rest should be encouraged,
especially where the mother has any of the
conditions that predispose to preterm labour
• Use of sedatives during preterm labour to
ensure complete bed rest
• Avoidance of strenuous exercise and calming
the mother, because any strain or stress may
aggravate preterm labour
 Physical Characteristics of Prematurity

• Generally the characteristics depend on the gestational age.

• The generalized description is that the baby may appear pink or dark
red, hands and feet may be cyanosed and may be jaundiced early.
• Wakefulness
When the infant is awake, the lower extremities are rarely extended.
There may be slow prolonged contraction of the facial muscles,
quivering movements or transient smiles. There may also be fine
movements of the fingers and toes. These may be confused with
convulsions but they are not.
• Cry
The cry is feebler than that of a full term infant. In fact, a premature
infant usually cries very little, if at all.
 CONT
• Skin and Appendages
The skin is covered by a small amount of vernix caseosa. Lanugo is present
on the sides of the face and on the extremities and the back.
• There is scanty hair on the head and the eyebrows are usually absent.
• The nipples and areola are inconspicuous.
• The nails are soft.
• Generalized oedema is apparent at birth and later the tissue fluid
decreases, leaving the skin loose and wrinkled.
• Blood vessels can be easily seen under the skin because subcutaneous
tissue is thin.
• Neck and Thorax
The thorax is cone shaped and the rib cage is weak, owing to immature
osseous calcification.
 CONT
• Obstruction to the free flow of air causes marked
sternal retraction, a rapid heart rate and
respiratory noises.
• Occasionally, cardiac murmurs are heard.
• A change in position may cause periods of
apnoea.
• Very small infants will not open the mouth to
breathe. The nose should therefore be checked
for occlusion frequently.
Management of a Premature Baby
• Avoid depression of the foetal respiratory centre
• Sedatives of opium derivatives should not be
used during premature labour
• Shorten the perineal phase during delivery of a
preterm baby by performing an episiotomy. As
this will reduce the possibility of intracranial injury
• Transfer a woman in premature labour to a well
equipped hospital for adequate resuscitation and
care of the premature infant
 Care of a premature infant
• Clear the airway using a fine mucus extractor/catheter
• Administer oxygen at 1 litre per minute till respiration
is well established and colour is satisfactory
• Put the infant in an incubator or cover with warm
towels and transfer to a special baby care unit as soon
as practicable
• Infants weighing less than 2 kilograms that have been
delivered in a health centre or in the home should be
transferred to a well equipped hospital with nursery
for baby care
 Aims of management
• Maintenance of respiration and good colour
• Provision of warmth
• Prevention of infection
• Ensuring good progress and growth
• Educating the mother to take care of her
infant
• Ensuring baby gets adequate nutrition
Maintenance of Respiration of the Preterm Baby

• Assist in the establishment of respiration since the

respiratory centre in the medulla is immature.
• The lungs tend to be atelectatic and are not well
developed due to inadequate surfactant.
• The airway should be repeatedly cleared
• The infant should be laid with its head to one side and
the foot of the cot should be slightly raised to aid with
the drainage of mucus.
• Watch the infant closely for signs of respiratory distress
and cyanosis.
 Cont
• Give oxygen in such cases (avoid high
concentrations of oxygen) to the premature
infant.
• Note that prolonged administration of a high
concentration of oxygen may lead to the
development of fibrous tissue behind the lens,
which results in a condition known as
retrolental fibroplasia leading to blindness in
the newborn.
Provision of Warmth and Maintenance of Body Temperature

• Ensure that the baby’s temperature is prevented

from reaching very low levels as the heat regulation
centre in premature babies is underdeveloped.
• Small babies weighing less than 1.5 kilograms should
ideally be nursed in an incubator with temperature
of about 30 degrees Celsius and relative humidity of
65%.
• If there is no incubator available, they should be
nursed in warm towels (which may be warmed with
hot water bottles).
 Feeding
• Breast milk is ideal because of its digestibility,
nutrients and the immunity it gives to the newborn.
• The first feed should be small and ideally given per
tube. 
• The amount of feeds given depends on the size of
the infant and its tolerance levels
• . Infection control and prevention measures are
highly recommended with regard to handling
expressed milk.
 Method of feeding

• The method of feeding is determined by the

infant’s size, general health and presence of
sucking and swallowing reflexes.
• Breast feed as soon as the infant’s condition allows.
• Infants of 1.8 kilograms and over, with good
sucking and swallowing reflexes, may be spoon fed.
• In cases where neither of the aforementioned
options is possible, naso-gastric tube feeding is
preferred
 Naso-gastric method of feeding

• The aspirate colour and amount should be noted

and recorded.
• If the aspirate consists of clear milk it should be returned
and the feed decreased by same amount.
• If the aspirate is blood or bile stained discard and replace
by equal volume of normal saline in the intravenous fluids.
• The barrel of a syringe is used as a funnel for giving the
feeds which should be allowed to flow by gravity and not
pushed by a syringe piston.
• The amount of feed the infant has taken is recorded.
 CONT
• After feeding, the baby is left to rest quietly on their back
with the head turned to one side or made to lie on the right
side for 15 minutes.
• Cleanliness must be observed. Feeding utensils should be
decontaminated and soaked in a solution of jik (1:6) for 10
minutes then dried.
• Record the actual amount of feed.
• Supplements of vitamins A, B, C, D, folic acid and iron are
usually given to the premature infant because they have no
store of iron, vitamins and mineral salts before birth. Artificial
feeds cannot provide all the nutritional needs of an infant.
 CONT
• Staff in baby care unit should be in good health and have no foci of
infection or colds.
• Staff should be meticulous in cleanliness and should be proficient
at resuscitation of the baby.
• Frequent hand washing is imperative in a premature baby nursery.
Principles of infection prevention should always be practiced
• Visitors should not be allowed into the premature unit because
they may bring in micro-organisms.
• Only the parents should handle the infant if nursed at home or
maternity centre.
• The infant should not be brought out into the open until it can
maintain its body temperature.
Monitoring the progress of the premature infant.

• Respiration of the infant, that is, do they exhibit laboured

breathing and periods of apnoea. The respiration rate should be
taken and recorded four hourly or more frequently, in case it is
unsatisfactory.
• The temperature should also be recorded four hourly since fever
and hypothermia are bad signs. A premature neonate who is
progressing should be able to maintain their body temperature.
• Auscultation of the heart and recording of the heart rate (Apex
beat).
•     Observe closely for colour changes like jaundice
occurring within 24 - 36 hours  of birth.. Other colour
          changes include cyanosis, pallor and grayness 
 CONT
    Rashes, discharge from the eyes or moist umbilical cord, grey colour and    constantly
low temperature are usually signs of prematurity.
   Note the amount of feed taken by the infant, the method of feeding and any
    vomiting of feeds.
 Abdominal distension and oedema of the face, abdomen and legs should be
          reported if severe.
 If the infant is passing urine well. Absence of urine in the first 24 hours   must be reported.
Frequent stools also are noted. Loose stools may indicate infection
 The neonate should be weighed 12 - 24 hours after birth. Thereafter, weighing  is usually
done twice weekly because weight gain is usually slow. Weight loss   in a premature infant
should not alarm the midwife, provided the infant’s   general condition is satisfactory and
there is no vomiting.
 The haemoglobin level should be estimated at birth and thereafter on a weekly
          basis to exclude anaemia.
   The general behaviour of the infant with particular attention to its activity should
          be noted.
 Education of the Mother

• The mother may see the infant as a fragile little

being and is often scared of handling them.
• It is necessary to introduce the mother
gradually to handling, feeding and general care
under supervision before discharge.
• In some hospitals, the mothers stay in a
mother’s home and come up to the premature
unit every three hours to feed and nurse their
infants under supervision.
 cont
• Immunization should be given when the child
attains a weight of 2 kilograms and should be
followed up in a paediatric special clinic until
the developmental milestone is passed.
• The mother should also be encouraged to
attend follow up sessions in a child welfare
clinic until her child is five years old.
 Complications:
• Cyanotic attacks
• Cerebral hemorrhage
• Heart failure and pulmonary oedema
• Jaundice
• Anaemia
• Infection
• Poor mental and intellectual development in later
years
• Respiratory Distress Syndrome
 NEONATAL HYPOGLYCAEMIA

• Definition
• This occurs when the Blood glucose level is
below 2.6 mmol /l (45 mg/dl) irrespective of
gestation and postnatal age.
 Diagnosis

• May be asymptomatic especially in pre-term

infants
• Features include jitteriness, sweating,
convulsions, apnoea, cyanosis, hypotonia
 Prevention

• Early, adequate and regular feeding for all babies

Infants at risk
• - Pre-term babies
• - Small for gestational age
• - Large for gestational age
• - Infants of diabetic mothers
• - Any sick infant e.g. asphyxiated babies, babies with
sepsis and babies with hypothermia
 MANAGEMENT
•
• Blood glucose less than 1.1 mmol /l (25 mg/dl)
• Give a bolus of 2 ml/kg body weight of 10%
glucose IV slowly over five minutes
• If an IV line cannot be established quickly, give 2
ml/kg body weight of 10% glucose by gastric tube
• Infuse 10% glucose at the daily maintenance
volume according to the baby’s age
 cont
• Assess the blood glucose 30 minutes after the
bolus of glucose
• - If the blood glucose is less than 1.1mmol/L
(25 mg/dl), repeat the bolus of glucose
(above) and continue the infusion then assess
blood glucose again after 30 minutes
 CONT
• - If the blood glucose is between 1.1mmol/L
(25mg/dl) and 2.6mmol/L (45 mg/dl) continue the
infusion and repeat the blood glucose testing every
three hours until the blood glucose is 2.6mmol/L (45
mg/dl) or more on two consecutive tests
• - Allow the baby to breastfeed. As the baby’s ability
to feed improves, slowly decrease (over a three-day
period) the volume of IV glucose while increasing
the volume of oral feeds. Do not discontinue the
glucose infusion abruptly
 CONT
• Blood glucose between 1.1 -2.6m/mol/l (25-45mg/dl)
• If the blood glucose is between 1.1mmol/L (25mg/dl)
and 2.6mmol/L (45 mg/dl) allow the baby to
breastfeed and repeat the blood glucose testing every
three hours until the blood glucose is 2.6mmol/L (45
mg/dl) or more on two consecutive tests
• Once the blood glucose is 2.6mmol/L (45 mg/dl) or
more for two consecutive tests;
• - If the baby cannot breastfeed, give expressed breast
milk using an alternative feeding method
 Frequency of blood glucose measurements after blood glucose
returns to normal

• If the baby is receiving IV fluid for any reason,

continue blood glucose testing every 12 hours for as
long as the baby requires IV fluid. If the blood
glucose is less than 2.6mmol/L (45 mg/dl), treat as
described above
• If the baby no longer requires or is not receiving IV
fluid, assess blood glucose every 12 hours for 24
hours (two more tests):
• - If the blood glucose remains normal, discontinue
testing
 HYPOTHERMIA

• Definition
• This is a condition where the baby’s temperature falls below 36.5o C (based
on axillary temperature)

• Causes
• Exposure to cold environment (Low ambient temperature, cold surface or
draught)
• Wet baby
• Under-dressed baby
• Prematurity
• Delayed feeding
• Infections
 CONT
• Note: Classification of hypothermia:
• Low body temperature 35.5oC to 36.40C
• Very low temperature less than 35.50C
 Diagnosis

• Baby feels cold on touch especially the extremities

• Poor feeding
• Axillary temperature below 36.5ºC
• Extremities are blue and may be edematous
• Heart rate may be low
• Difficulty in breathing or slow shallow breathing
• Lethargy
• Hardened skin
 Prevention
• All newborn babies should be dried
immediately after birth and provided with a
warm environment
• Provide skin-to-skin contact with the mother
and initiate breastfeeding as early as possible
within one hour of birth
• Prevent conditions that precipitate
hypothermia
 Management

• Keep the baby warm by:

• Removing wet/cold clothes
• Skin-to-skin contact with the mother and cover with warm linen
• Adequately clothe the baby (including hat and socks)
• Keep clothed baby under radiant heat source; Nurse in a warm incubator if
possible
• If baby is blue or having difficulty in breathing give oxygen
• Pass nasogastric tube and give breast milk or other milk if breast milk is
contraindicated
• Re-check the temperature after one hour and repeat hourly until it reaches the
normal range (36.50C -37.40C)
• If after the re-warming procedure the temperature does not rise, refer urgently
 cont
• Management of Hypothermia
• Examine Temperature by:
• Touching the feet of the baby
• Taking rectal / axillary temperature

• Low body temperature

• Very low temperature (<35.5oC)
• Low temperature (35.5oC –36.4o C)
• Take temperature frequently
• Fix IV drip of 10% dextrose and / or Naso-Gastric tube feed
• Identify and treat cause

• Skin to skin contact with the mother or,

• Wrap baby under heat source or incubator
• Breast feed or give milk
 BLEEDING IN THE NEWBORN
• Definition
• This is when a baby presents with bleeding
• Diagnosis
• There may be bleeding from:
• The umbilical cord
• The Gastrointestinal tract
• Into the skin

• Others areas where bleeding may occur include:

• Intracranial hemorrhage
• Pulmonary
 Predisposing factors

• Prematurity
• Infections
• Birth trauma
• Asphyxia
• Vitamin K deficiency
 cont
• Prevention
• Prevent the predisposing factors
• Give Vitamin K at birth

• Investigations
• Take blood for full blood count
• Group and cross-match blood
 Note:
• Transfuse whole blood at 20 mls/kg (do not
use packed cells)
• Review baby at the end of transfusion and
decide whether baby needs more
 Management
• Take history and Examine baby; Ensure warmth
• Investigate to identify cause
• Treat the cause immediately.
• - If from cord stump, re-tie or re-clamp
• - If cut, press on bleeding site with sterile gauze
• Give Vitamin K 1 mg/kg IV even if the baby had already been given
• Transfuse if the signs of shock are present and also give oxygen. Give enough
blood to correct hypovolaemia
• For babies whose Hb is less than 12 gms/100 mls in the first week of life,
transfuse
• For babies whose Hb is less than 10 gms/100 mls after the first week of life,
transfuse
• Review baby at the end of transfusion and decide whether the baby needs more
FLUID MANAGEMENT IN THE NEONATE
• Encourage the mother to breastfeed frequently to prevent
hypoglycaemia. If they are unable to feed, give expressed breast milk by
nasogastric tube.
• Withhold oral feeding if there is bowel obstruction, necrotizing
enterocolitis or the feeds are not tolerated, indicated by increasing
abdominal distension or vomiting everything
• Withhold oral feeding in the acute phase in babies who are lethargic or
unconscious, or having frequent convulsions
• If IV fluid are given, reduce the IV fluid rates as the volume of milk feeds
increases
• Babies who are suckling well but need an IV drip for antibiotics should
be on minimal IV fluid to avoid fluid overload, or flush cannula with 0.5
ml Sodium Chloride 0.9% and cap.
Increase the amount of fluid given over the first 3–5 days (total amount, oral
and IV) as shown below

• Day 1 - 60 ml/kg/day
• Day 2 - 80 ml/kg/day
• Day 3 - 100 ml/kg/day
• Day 4 - 120 ml/kg/day
• Day 5 - 140 ml/kg/day
• Then increase to 150 ml/kg/day
 NOTE
• When babies are tolerating oral feeds well, this may be increased to 180
ml/kg/day after some days. But be careful with parenteral fluid, which can
quickly overhydrate a child.
• When giving IV fluid, do not exceed this volume unless the baby is dehydrated
or under phototherapy or a radiant heater.
• This amount is the TOTAL fluid intake a baby needs and oral intake must be
taken into account when calculating IV rates.
• If the baby is dehydrated, assess and classify as per IMCI guidelines and correct
accordingly.
• Give more fluid if baby is under a radiant heater (1.2–1.5X)

• DO NOT use IV glucose and water (without sodium) after the first 3 days of
life. Babies over 3 days of age need some sodium (for example, 0.18% saline /
5% glucose).
 Monitor the IV infusion very carefully!

• Calculate drip rate

• Check drip rate and volume infused every hour; and
monitor using a fluid chart
• Weigh baby daily
• If baby needs blood transfusion, count it as part of the
total fluid intake
• Watch for facial swelling: if this occurs, reduce the IV
fluid to minimal levels or take out the IV.
• Introduce milk feeding by nasogastric tube or
breastfeeding as soon as it is safe to do so
 NEONATAL INFECTIONS

• Skin infections
• Eye infection
• Oral thrush
• Cord infection
• Septicemia
• Neonatal Tetanus
 SEPTIC SKIN SPOTS

• Definition
• This is inflammation of the skin due to
bacterial infection.
• Diagnosis:
• Signs and symptoms include:
• Redness of the skin
• Pustules or sores on the skin
 cont
• Common causative organisms:
• Staphylococcus aureus
• Streptococcus

• Prevention
• Wash hands before and after handling baby
• Educate mother on personal hygiene and skin
care of the baby
 Management

• Wash hands with soap and water before and after handling baby
• Clean skin with antiseptic lotions like Hibitane
• For mild cases give syrup Amoxicillin 62.5mg tid x 5/7 or
Cloxacillin 62.5mg tid x 5/7
• For extensive skin lesion admit and start treatment with
Crystalline Penicillin and Gentamicin

• Counsel the mother on subsequent care:

• - Return baby for review after 2 days
• - Return immediately if baby becomes sicker. (See features of
neonatal septicemia
 NEONATAL EYE INFECTION/Ophthalmia neonatorum

• This is when the baby’s eyes are swollen, red and draining pus. It is any
purulent discharge from the eyes of an infant ithin 21 days of birth
• Causes
• Gonococcus- signs appear within the first 21 days of delivery
• Chlamydia trachomatis- signs appear within 5 to seven days
• Staphylococcus strepty7eaococcus pneumoniae Haemophilus influenzae,
Escherichia coli, Klebsiella , Pseudomonas, Chlamydia tromatis and
Neisseria gonorrhoeae
• Prevention
• Treatment of the pregnant mother / partner using Erythromycin 2g/day for
7 days
• Tetracycline ointment at birth routinely for all newborns
• ``
 Management

• Observe infection prevention practices which

include washing hands before and after procedure
• Clean babies eyes with normal saline before
administering medication
• Administer 1% tetracycline eye ointment 8 hourly
(tds) for 10 days
• If no improvement after 24 hours, refer to hospital
 Follow up in two days

• Look for pus drainage

• If still draining, check to see if mother is
administering treatment correctly
• If incorrect teach her the correct treatment
procedure and follow up in two days
• If treatment has been correct refer to hospital

• Counsel the mother and show her how to clean

the eyes and apply the eye ointment
 At the hospital
• If infection is due to Gonorrhoea, give
Ceftrioxone50 mg/kg or Kanamycin 75mg IM
stat single dose
• If infection is due to Chlamydia – give
erythromycin 50mg 6 hourly (qid) for 14 days
 ORAL THRUSH
• This is diagnosed when there are thick white patches on tongue or
inside the mouth
• Management:
• Wash hands
• Clean baby’s mouth with a clean soft cloth
• Instill Nystatin drops 1 ml 4 times a day
• Continue breast feeding
• Treat mother’s breast with the same medicine
• Follow up after 2 days

• Review after 2 days: If worse, refer to hospital, if improving, continue

treatment for 5 days
 CORD INFECTION/Omphalitis
• Definition
• Cord infection is inflammation of the umbilical
stump usually occurring in the first week of life.
• Diagnosis
• Signs and symptoms may be early or late
• Early signs
• Redness at base of stump
• Wetness of Stump
• Offensive smell
 CONT
• Late Signs
• Baby looks ill
• Temperature may be elevated
• Baby may refuse to feed
• Pus discharge from the umbilicus
• Jaundice
 Prevention
• Clean hands
• Clean/sterile delivery instruments
• Clean surface
• Clean cutting of the cord
• Clean ligature
• Avoid application of harmful traditional substances
(e.g. talcum powder, saliva, cow dung, etc)
• Educate mother on personal hygiene
 Management

• Wash hands before handling the cord

• Wear clean gloves
• Clean the cord with antiseptic solution e.g. povidine (tincture) iodine with clean gauze/
cotton wool
• Apply Gentian Violet four times a day
• Keep cord dry
• Keep baby clean
• Continue breast feeding
• Give Amoxicillin 62.5g mg/kg – three times a day for 5 days
• Admit baby with late signs
• Review baby after two days
• - Refer or admit if pus or redness remains
• - IAsk the mother to return immediately if the baby gets worse (see signs of Septicemia).
improved continue antibiotic for 5 days
 NEONATAL SEPTICAEMIA (SEPSIS)

• Definition
• This is when a baby has generalized clinical
features of a sick infant; ideally blood culture
positive.
• Diagnosis
• Any sick infant is regarded as having neonatal
sepsis until proved otherwise.
 Clinical Features

• Poor feeding or refusal to feed

• Lethargy or poor cry or unusually sleepy
• Cry excessively (irritable)
• Unconscious
• Has difficulty in breathing
• Frequently stops breathing (apnoeic attacks)
• Convulsions
 cont

• Feels too cold or warm (temperature < 35.5oC

or ≥ 37. 5oC)
• Diarrhoea and vomiting
• Appearance of pustules all over the body
• Yellow body (Jaundice)
• Periumbilical redness or pus from cord
 Investigations

• Do a full blood count including WBC

differential
• Blood culture
• Blood glucose
• Chest x-ray if indicated
 Prevention

• Adequate treatment of maternal infection during pregnancy,

labour and delivery
• Vaginal swabbing with antiseptic during labour (e.g. hibitane)
• Clean delivery
• Clean/sterile equipment
• Observe infection control at all levels of handling baby
• Hand washing before and after handling baby
• Early initiation of breast feeding
• Exclusive breast feeding
• Avoid overcrowding especially in the newborn unit
Management of Neonatal septicemia

• Immediate Care:
• Give pre-referral treatnt (IV Crystalline
Penicillin and Gentamicin)
• Keep baby warm
• Prevent hypoglycemia by feeding the baby
(breast feeding/ Expressed Breast Milk)
• If blood sugar low refer to section on
hypoglycemia
 Subsequent Care (Hospital)

• Keep baby warm depending on baby size

• Isolate as much as possible
• Give (IV Crystalline Penicillin and Gentamicin), if there is skin
infection use Cloxacillin instead of Crystalline Penicillin
• Ensure adequate feeds - oral or IV (refer to section on fluid
management)
• Frequently monitor vital signs (hourly for the first 6 hours then
3 hourly till stable)
• Counsel the mother
• On discharge refer to MCH
 NEONATAL TETANUS
• Definition
• Any neonate with normal ability to suck and
cry during the first 2 days of life and who,
between 3 and 28 days of age, cannot suck
normally and becomes stiff or has spasms (i.e.
jerking of the muscles)
 Diagnosis
• Inability to feed orally
• Muscle spasms
• Clenched mouth – risus sardonicus
• Stiff body that is arched backward like a bow
(opisthotonus)
• Stiff arms and legs
 Prevention

• Ensure that all pregnant mothers are given

Tetanus Toxoid according to the National
Immunization schedule
• Provide education on the importance of the 5
cleans (see section on appropriate cord care)
• Appropriate cord care
 Management

• Sedate the baby by giving IV or rectal:

• Phenobarbitone 20 mg/kg stat; or
• Diazepam 0.2mg/kg over 3 minutes. Repeat every
30 minutes up to 3 doses
• Do not exceed 2mg/kg/24 hrs

• While baby is sedated:

• Clean the cord thoroughly
• Pass a nasogastric tube for feeding
 Subsequent Care:

• Counsel the mother

• Keep baby in a quiet dark room
• Frequent monitoring of vital signs – watch
respiration
• Avoid too much handling
• Keep umbilical cord clean and dry
• Paint cord with povidine iodine or spirit
 CONT
• Feed Expressed Breast Milk through
nasogastric tube
• Maintain sedation with:
• - Phenobarbitone 5mg/kg/day in 2 doses
• - Chlorpromazine 2mg/kg/day

• (These can also be given as continuous

infusion
 cont

• Give antibiotics – IV Crystalline Penicillin

50,000 units/kg 12 hourly
• Refer to ICU if facility is available
• Immunize the mother and ask her to complete
immunization as per the National schedule
• If baby recovers refer to MCH for
immunization
 NEONATAL JAUNDICE

• Definition:
• It is the yellow discoloration of the skin and
mucous membranes as a result of raised
bilirubin levels occurring in the first 28 days of
life.
• It may be classified as physiological or
pathological jaundice.
 Physiological Jaundice

• This is a common problem in the newborn

especially the pre-term
• Usually appears after 48 hours of birth and
resolves in 7-10 days or a little longer in the
pre-term
• Mainly occurs in the skin and eyes
• Baby looks and feeds well
 Pathological Jaundice- refers to

• Pathological Jaundice-
• Jaundice which appears any time within the
first 24-48 hours of life and later
• Lasts longer than 14 days in term babies and
21 days in the pre-term
• Jaundice with fever
• Deep jaundice usually involving palms and
soles
 Common causes

• Physiological jaundice
• It is due to normal physiological breakdown of the large red blood cell
mass.
• Pathological Jaundice- may be caused by:
• Rhesus incompatibility
• ABO incompatibility
• Neonatal infections
• Intra-uterine infection
• Congenital hypothyroidism
• Liver diseases such as hepatitis and biliary atresia
• Asphyxia
• Birth injuries
 Investigation
• Full haemogram
• Blood for bilirubin levels
• Baby and mother’s blood groups
• Direct Coombs test
• Septic screen if indicated
• Syphilis test
 Prevention
• Good antenatal care with proper management
of a Rhesus negative mother
• Prevention of birth injuries and birth asphyxia
• Infection prevention and prompt treatment
during pregnancy, labour and delivery and
thereafter
 Management

• Take history to determine the cause of jaundice for all

babies
• History of previously affected siblings, and if so, what
treatment e.g. phototherapy or blood exchange
transfusion
• Colour of urine and stool
• Mother’s blood group
• For RH negative mothers, ask if she has had abortions
previously and whether she received Anti-D
 On examination check on:

• Yellowness of skin and mucus membranes

• Colour of urine and stools
• General behavior and activity
• Signs of infection
• Ability to suck properly
• Check for pallor
• Monitor for signs of kernicterus and act promptly
• Monitor bilirubin levels
 Treatment

• No treatment is necessary for most cases of physiological

jaundice but encourage breastfeeding
• Keep baby warm
• Continue breastfeeding or give EBM
• Give antibiotics when indicated
• Phototherapy if:
• - Jaundice on day 1
• - Deep jaundice involving palms and sole of feet
• - Prematurity and jaundice
• - Jaundice due to haemolysis
• Exchange blood transfusion when indicated
• Note: RH-ve Mothers should be delivered
where there are facilities for exchange blood
transfusion
• Indications for immediate Exchange blood
transfusion (i.e. at birth)
• Hb below 11g/100 mls
• Bilirubin levels above 4 mg/100 mls (70 mmol/L)
• Signs of Congestive Cardiac failure
INFECTION CONTROL IN A NEWBORN UNIT

• Methods to prevent infection

• Have a separate room specifically for newborn
babies in a low traffic area with restricted
access
• Avoid overcrowding and understaffing
• Do not place two or more babies in the same
cot or incubator or under the same radiant
warmer or phototherapy unit
 People as sources of infection

• Do not allow personnel with skin infections or

lesions to come into direct contact with babies
• Individuals handling the baby should wash
their hands with soap and water
 Hand washing

• Wash hands with soap and water, but if hands are visibly
clean, disinfect them using an alcohol-based hand rub;
• - before and after caring for a baby and before any
procedure
• - after removing gloves
• - after handling soiled instruments or other items
• Instruct the mother and family members to wash their
hands before and after handling the baby
• To wash hands:
• - Thoroughly wet hands
• - Wash hands for 10 to 15 seconds with plain soap and running or
poured water
• - Allow hands to air-dry or dry them with a clean paper towel
• An alcohol-based hand rub, made from adding 2 ml of glycerin (or
other emollient) to 100 ml of 60% to 90% ethyl or isopropyl
alcohol, is more effective in cleaning hands than hand washing
unless the hands are visibly soiled. To clean hands using an alcohol-
based hand rub:
• - Apply enough hand rub to cover the entire surface of hands and
fingers
• - Rub the solution into hands until they are dry
• Protective clothing
• It is not necessary to wear gowns or masks when providing
routine care for newborn babies

• Housekeeping and waste disposal

• Regular and thorough cleaning will decrease microorganisms on
surfaces and help prevent infection
• Every newborn special care unit should have a housekeeping
schedule:
• - Post the cleaning schedule in a visible area
• - Educate staff regarding cleaning, and delegate responsibility
 LOW BIRTH WEIGHT INFANT

• Definitions:
• Low birth weight infant
• Any baby whose birth weight is below
2500gms at birth.
• Very low birth weight infant
• Any baby whose birth weight is below
1500gms at birth
• Pre-term Baby
• Any baby born before 37 completed weeks of gestation.
• Small for Gestational Age Baby
• Any baby whose birth weight falls below the 10th
percentile for that gestational age.
• Diagnosis of pre-term baby
• Diagnosis is made through:
• History taking to determine maturity by dates
• Neonatal assessment to determine gestational age
clinically
• Diagnosis of Small for Gestational Age Baby / Intra uterine growth
retardation (IUGR)
• The baby has dry wrinkled skin
• Looks wasted
• The weight is below the 10th percentile for that age

• Prevention
• Encourage mothers to seek health care services as soon as possible
• Adequate antenatal care, with early diagnosis and proper treatment
of complications e.g. infections, anemia and pregnancy related
complications
• Adequate maternal nutrition
 Management

• If a mother who is in early labour comes where

there are no neonatal facilities transfer her
immediately to a centre with a newborn unit
• All babies weighing 2000gms and below at birth
should be admitted in the newborn unit or
referred
• Small for gestational age babies do not need
admission unless they are less than 34 weeks or
weigh below 1900gms
General principles for care of the low birth weight baby

• Provide adequate warmth

• Adequate feeding
• Prevent infections
 Means of keeping baby warm (thermal
control)
• If the baby is born at home, or in a place without
facilities for care, the following should be
instituted:
• Immediate drying and wrapping in warm clothing
• Keep baby skin to skin with the mother
(“Kangaroo method”); he/she should be
transferred using skin to skin method
• In the newborn unit use heated rooms or nurse in
incubators if available preferably dressed
Keeping Preterm, Low Birth Weight and sick
babies warm
BITH WEIGHT ROOM TEMPERATURE
1.0 – 1.5 34 – 35 ºC

1.5 – 2.0 34 – 35 ºC

2.0 – 2.5 34 – 35 ºC

Greater than 2.5 34 – 35 ºC

 Calculation of Feeds - Day 1

Feeds are calculated as follows:

• 1500gms and below - 80mls/kg/day
• 1501gms and above - 60mls/kgs/day

• Increase feeds by 20mls/kg daily up to

200mls/kg/ day.
 Up to 1500gms

• Starting volume is 3mls and increase by the

same amount until the calculated amount for
the day is reached. The rest of the fluid is
given IV and is decreased gradually.
 1501 -1800gms
• Starting volume is 6mls and increase by the
same amount until the calculated amount for
the day is reached. The rest of the fluid is
given IV and is decreased gradually.
 Methods of feeding

• 1500gms and below feed by tube

• Between 1500gms – 1650gms feed by cup
and, also encourage breastfeeding
• Above 1650gms and above, breastfeeding is
recommended
 NOTE:
If one method is insufficient, a combination of
two can be used.
 Feeding by tube:
• Measure nasogastric tube
• Pass the tube
• Ensure that it is in the stomach by (a) aspirating
back (b) with sterile syringe push 10ml air
through tube as you listen with stethoscope over
the stomach
• Aspirate the stomach before each feed. If you get
aspirate note amount and colour then manage as
indicated below
 Management of aspirates

• Clear/milk return and decrease feed by same

amount
• Blood or bile stained discard and replace by
equal volume of normal saline in the
intravenous fluid
 LARGE FOR GESTATIONAL AGE (LGA) BABY
AND INFANT OF DIABETIC MOTHER

• Definition
• This is a baby with a birth weight of more than 4.0kg; OR
• A baby whose birth weight is above the 90th percentile
for the gestation.
• Diagnosis:
• Suspect or expect LGA if there is:
• History of diabetes in pregnancy
• History of previous large babies
complications are associated with LGA babies

• Hypoglycemia
• Birth Asphyxia
• Birth injuries
• Jaundice
• In addition, babies born of a diabetic mother
are prone to Infections and Respiratory
distress syndrome
 Prevention
• Adequate control of diabetes in pregnancy
• Anticipate and refer early to deliver in a health
facility
 Management

• Initiate breastfeeding immediately and continue feeding on

demand. If the baby sleeps, wake him/her up and feed at
least every three hours
• Closely monitor the baby to promptly recognize the
associated problems
• Manage any complications detected
• Test the blood sugar levels where possible
• Keep the baby warm
• If the mother is not already diagnosed as diabetic, investigate
to rule out diabetes mellitus. If confirmed positive, manage
the diabetic mother or refer.