Management of sick neonates

1. Management of sick neonates Doug Simkiss Associate Professor of Child Health Warwick Medical School

2. Introduction • Revise the danger signs in neonates and young infants • Often non-specific • Unable to breast feed • Convulsions • Drowsy or unconscious • Respiratory rate < 20 / minute

3. Danger signs in neonates and young infants • Bleeding • Central cyanosis (blueness) • Hypothermia • Hyperthermia • Hypoglycaemia • Dehydration

4. Danger signs in neonates and young infants • Apnoea (cessation of breathing for > 15 seconds) • Respiratory rate > 60 / minute • Grunting • Severe chest indrawing • Central cyanosis • Deep jaundice • Severe abdominal distension

6. Emergency management • Give oxygen 0.5 l / minute by nasal prongs or catheter if infant is cyanosed or in severe respiratory distress • Give bag and mask ventilation with oxygen (or room air if oxygen is not available) if respiratory rate is too slow (< 20 / minute) • Give ampicillin (or penicillin) and gentamicin

7. Emergency management • If drowsy, unconscious or convulsing, check blood glucose • If glucose < 1.1 mmol/l (<20mg/100ml), give i.v. glucose • If glucose 1.1 – 2.2 mmol/l (20-40mg/100ml) feed immediately and increase feeding frequency

8. Emergency management • If you cannot check blood glucose quickly, assume hypoglycaemia and give glucose i.v. If you cannot insert an i.v. drip, give expressed breast milk or glucose through a nasogastric tube • Give phenobarbital if convulsing (I dose of 20mg / kg). If fits continue for 30 minutes give 10 mg / kg. If needed continue with phenobarbital 5mg/kg once daily

9. Emergency management • Admit or refer urgently if treatment is not available locally • Give vitamin K (if not given before) • Monitor the baby frequently • If baby is from a malarious area and has fever, take blood film to check for malaria also. Neonatal malaria is very rare. If confirmed treat with quinine

10. Supportive care for the sick infant • Thermal environment • Keep the infant dry and well wrapped • Use a bonnet to reduce heat loss • Keep the room warm (> 25°C) • Keeping the young infant in close skin to skin contact with the mother for 24 hours a day is as effective as using an incubator or external heating device to avoid chilling

11. Supportive care for the sick infant • Pay special attention to avoid chilling the infant during examination or investigation • Regularly check that the infants temperature is maintained in the range 36.5-37.5°C rectal or 36.0-37.0°C axillary.

12. Supportive care for the sick infant • Fluid management • Encourage the mother to breast feed frequently to prevent hypoglycaemia. If unable to feed, give expressed breast milk by nasogastric tube • Withhold oral feeding if there is bowel obstruction, necrotising enterocolotis or the feeds are not tolerated (indicated by increasing abdominal distension or vomiting)

13. Supportive care for the sick infant • Withhold oral feeding in the acute phase in babies who are lethargic or unconscious , or having frequent seizures • If i.v. fluids are given, reduce the iv fluid rates as the volume of milk feeds increases • Babies who are suckling well but need an i.v. drip for antibiotics should be on minimal i.v. fluids to avoid fluid overload, or flush cannula with 0.5ml of 0.9% saline and cap

14. Supportive care for the sick infant • Increase the total amount of fluid (oral and i.v.) over the first 3-5 days • Day 1 60ml/kg/day • Day 2 90ml/kg/day • Day 3 120ml/kg/day • Then increase to 150ml/kg/day • When babies are tolerating oral feeds well, this can be increased to 180ml/kg/day after some days.

15. Supportive care for the sick infant • Be careful with parenteral fluids which can quickly overhydrate a baby. Do not exceed 180ml/kg.day i.v. unless the baby is dehydrated or under phototherapy or a radiant heater. • Remember to include oral intake when calculating the i.v. fluid intake a baby needs • Give more fluid if under a radiant heater (1.2-1.5 times more)

16. Supportive care for the sick infant • Do not use i.v. glucose and water (without sodium) after the first 3 days of life. Babies over 3 days need some sodium (e.g. 0.18% saline / 5% glucose). • Monitor the i.v. infusion very carefully • Use a monitoring sheet • Calculate the drip rate • Check drip rate and volume infused very hour • Weigh baby daily

17. Supportive care for the sick infant • Watch for facial swelling; if this occurs reduce the i.v. fluid to minimal levels or take out the i.v. • Introduce milk feeds by nasogastric tube or breast feeding as soon as it is safe to do so.

18. Supportive care for the sick infant • Oxygen therapy • Give oxygen to infants with any of • Central cyanosis • Grunting with every breath • Difficulty in feeding due to respiratory distress • Severe lower chest wall indrawing • Head nodding - indicates severe respiratory distress

19. Supportive care for the sick infant • Pulse oximetry, use if available and give oxygen if saturation < 90%. Aim for 92-95% saturation levels. Stop oxygen if baby can maintain oxygen saturations above 90% in air . • Nasal prongs is preferred method for oxygen delivery. Use flow of 0.5 litre / minute. Use suction to remove thick secretions from nose and throat if baby is too weak to clear them.

20. Supportive care for the sick infant • High fever • Assess the cause • If signs of infection, treat with appropriate antibiotics • Do not use antipyretic medication like paracetamol for controlling fever in young infants. Control the environment. If necessary, undress the baby.