Management of sick neonates Doug Simkiss Associate Professor

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

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

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

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

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

Emergency management • If drowsy, unconscious or convulsing, check blood glucose – If glucose < 1. 1 mmol/l (<20 mg/100 ml), give i. v. glucose – If glucose 1. 1 – 2. 2 mmol/l (20 -40 mg/100 ml) feed immediately and increase feeding frequency

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 20 mg / kg). If fits continue for 30 minutes give 10 mg / kg. If needed continue with phenobarbital 5 mg/kg once daily

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

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

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.

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)

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. 5 ml of 0. 9% saline and cap

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

Supportive care for the sick infant – Be careful with parenteral fluids which can quickly overhydrate a baby. Do not exceed 180 ml/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. 21. 5 times more)

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

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.

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

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.

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.