Child Health Resource Package: Neonatal … Child Health Resource Package: Neonatal Experiential Learning Site Neonatal Resuscitation Do it right now… Department of Paediatrics:

WarmthPrevent Hypothermia• Labour ward and theatre must be kept at 24 - 26°C• Dry babies immediately after birth with a soft towelling towel and wrap in a second warm, dry towel• Ensure that there is a good overhead heater in the infant resuscitation area• Keep incubators and resuscitaires warm, even when not in use• Keep the baby with the mother in the kangaroo position (KMC)• Nurse babies less than 1.5kg in an incubator or in KMC, continue KMC even after discharge• Keep the room (nurseries, post natal wards) warm i.e. at 24 - 26°C, but not higher• Dress all babies in a vest, nappy, booties and a woollen cap. If incubated, do not wrap in a blanket• Keep the baby away from windows and draughts

Temperature settings for closed incubatorsCheck the temperature of manual incubators every hour and keep them at the following temperatures according to the

baby’s weight and age. Record the incubator temperature AND the baby’s temperature every hour using the “Basic Neonatal Care Nursing Observations” chart.

These settings are a guide. They must be increased or decreased according to baby’s temperatureNever set incubator to more than 1ºC higher than the baby’s temperature at a time

Child Health Resource Package: Neonatal Experiential Learning Site

Cornerstones of Neonatal CareMaking life easier…

Department of Paediatrics: Pietermaritzburg Metropolitan Hospitals

FoodHow Much to Give

What to GiveFeed all babies within 30 minutes of birth (unless contra-indicated e.g. severe respiratory distress)

For preterm babies, start multivitamin (0,6ml concentrated drops) and vitamin D 400IU daily on day 14, and Ferrodrops 0,6ml daily on day 42. Continue iron and vitamins for the first year of life

AirThe single most important event in the transition from foetal to neonatal life is the INFLATION of the lungs.

If baby cannot do this, you must do it for her/him (see Neonatal Resuscitation Poster and Guideline)

Oxygen Do’s and Don’ts• Do give a baby oxygen, who needs oxygen• Do use the minimum O2 necessary to maintain O2 saturation 85-93%• Don’t give more O2 than is needed and don’t give less O2 than is needed• Don’t transport a baby who needs O2 out of oxygen• Don’t take a baby out of O2 for feeds or drugs or cuddles or bathing or procedures (use a nasogastric tube

for feeds if necessary)• Do monitor oxygen delivery and saturation on a designated monitoring sheet

Oxygen TechniquesThe mainstays of O2 therapy for neonates should be NASAL Prong, Catheter or CPAP. Headboxes are good in the acute

scenario, but should be done away with as soon as possible. Give theophylline (5mg/kg load and 1-2mg/kg 12 hourly maintenance to prevent apnoea in ALL preterm babies.

Pulse oximeters should be used in ALL hospitals on ALL babies requiring oxygen

Infection(See guideline “Sepsis Neonatorum”)

By getting the basics right, and picking up and managing “Sepsis Neonatorum” early, you will make this common neonatal problem less difficult for you to handle, and less deadly for the babies you look after

Babies at RiskSmall BabiesGrowth restricted Immature

<2500g <35 weeks

Sick Babies• Blue, pale, cold

• Lethargic +/- poor feeding

• Jittery

• “Distressed”

• Congenital abnormalities

Days after deliveryBirth weight 0 5 10 15 20 25 30

< 1000g – 1500g 35.5 35.0 35.0 34.5 34.0 33.5 33.01500g – 2000g 35.0 34.0 33.5 33.5 33.0 32.5 32.52000g – 2500g 34.0 33.0 32.5 32.0 32.0 32.0 32.02500g – 3000g 33.5 32.5 32.0 31.0 31.0 31.0 31.0

> 3000g 33.0 32.0 31.0 30.0 30.0 30.0 30.0 Requires medical and nursing expertiseLife savingMinimum settings for babies

requirementRefer to appropriate NICUIPPV

Nasal piece MUST fit properly and can be dislodged.

Requires minimal medical and nursing expertise

Flow 8-12 l/min to obtain CPAP of 6-8 cmH2OFiO2 to keep sats 85-93%

Should be used in all district hospitalsNasal CPAP

Watch out for blocked nostrils. Watch out for pressure sores

Baby can be fed orally/breastfeed0.5 – 2 l/minute

Place the prongs just into the baby’s nostrilsSecure the prongs with tape

Nasal Prongs

Watch out for blocked nostrils

Baby can be fed orally/breastfeed0.5 – 2 l/minute

Cut 2 small holes in a FG5 feeding tube, align with the nostrils & secure with tape

Nasal Catheter

ProblemsAdvantagesFlow and concentrationCommentsMethod

LoveThe baby friendly hospital initiative

is about LOVE and CARING, not DICTATES and DOGMA

Treat• Maintain and monitor temperature, blood sugar

and O2 saturationUse:1. Ampicillin 50mg/kg/dose 12 hourly IV and 2. Gentamicin 5mg/kg/dose 24 hourly

Find and IdentifyIf bacteraemia is possible do:1. Blood culture2. Lumbar puncture 3. Urine dipstix

Suspect• Regard all preterm babies as at risk • Take non-specific signs (lethargy, poor feeding,

hypothermia, hypoglycaemia, respiratory distress) seriously

Prevent• Screen for syphilis antenatally• Ensure the PMTCT protocol is followed exactly• Take maternal pyrexia, P/PROM seriously• Wash your hands between every baby• Staff your nursery properly, and with a clearly

identified sister in charge at all times• Do not overcrowd• Ensure adequate spacing between babies• Have dedicated nursery equipment• Ensure sterile preparation of ALL feeds

If the baby is able to suckle• Babies more than 34 weeks gestation are usually able to suckle• Initiate breastfeeding within 30 minutes of birth• Breastfeed and encourage EXCLUSIVE breastfeeding• Allow mothers to breastfeed on demand (at least 8 times a day) and

practice rooming in

If the baby should not be fed yet (GIT or airway problems)

• Commence IVI maintenance fluids (neonatolyte) at the appropriate rate• Gradually add feeds from day 2• Increase the feeds gradually if there is no vomiting, apnoea or

abdominal distension• IVI fluids can be continued alone for a maximum of 3 days. Thereafter,

if still unable to feed, arrange for transfer

If the baby is unable to suckle or the mother and baby are separated

• Give EBM via NGT or cup• Use formula if EBM is not available• VLBW babies may need 2 hourly or even 1 hourly feeding

If baby’s mother has chosen to formula feed• < 1.5 kg – use pre-term formula• > 1.5 kg – use normal formula• Use a cup, but don’t stop mother using a bottle if she wants to

If baby REQUIRES exclusive breast milk (PMTCT), and mother cannot provide

• Give intravenous neonatalyte until mother can breastfeed (review daily)

Notes• Always individualise intake• Give an extra 20 ml/kg/day if preterm• Give an extra 30 ml/kg to babies under radiant warmers or phototherapy• Don’t rush orals (starting or increasing), but also don’t delay unnecessarily• Take extra care in immature, small and sick babies• Use urine output as a guide for adequate intake

120

Total fluids (ml/kg/day)

150Day 7150Day 6

Day 5120Day 490Day 390Day 260Day 1

Department of Paediatrics N e o n a t a l G u i d e l i n e s PROVINCE OF KWAZULU-NATAL HEALTH SERVICES

ISIFUNDAZWE SAKWAZULU EMPILO P i e t e r m a r i t z b u r g

M e t r o p o l i t a n H o s p i t a l s C o m p l e x KWAZULU-NATAL PROVINSIE

GESONDHEIDSDIENSTE

N E O N A T A L R E S U S C I T A T I O N Do it right now

A S S E S S B R E A T H I N G , C O L O U R A N D H E A R T R A T E e v e r y 3 0 s e c o n d s d u r i n g t h e r e s u s c i t a t i o n . I f t h e b a b y i s i m p r o v i n g t h e n t h e i n t e r v e n t i o n c a n b e s t o p p e d . I f t h e b a b y i s n o t r e s p o n d i n g o r

g e t t i n g w o r s e t h e n f u r t h e r i n t e r v e n t i o n i s n e e d e d . T h e H E A R T R A T E i s t h e b e s t m a r k e r o f p r o g r e s s , i n e i t h e r d i r e c t i o n .

A: Airway Remove meconium or blood, if present, before stimulation (by wiping face, nose and mouth and suctioning the

mouth then nose) Warm, position, clear airway, dry and stimulate Assess HEART RATE, BREATHING and COLOUR If blue, but breathing and HR > 100 per minute administer oxygen

B: Breathe If blue, HR < 100 per minute and/or inadequate or absent breathing

Ventilate with bag and Laerdal® neonatal mask (round, clear, silicone): squeeze bag firmly at a rate of 60 breaths (counting “bag, 2,3” for the correct rate). DON’T use a “Sampson Pump”

Most babies will be successfully resuscitated by bag and mask only Ventilate for 30 seconds then reassess Assess HEART RATE, BREATHING, and COLOUR

I n t u b a t e i f t h e h e a r t r a t e s t a ys < 6 0 p e r m i n u t e , o r r e s p i r a t o r y e f f o r t i s p o o r

C: Chest Compressions If heart rate < 60 per minute

Begin chest compressions, using the hand encircling technique, if two people are available, otherwise the two finger or single hand encircling technique. Give the compressions at the lower third of the baby’s sternum and compress to 1/3 the depth of the baby’s chest. Squeeze the blood out of baby’s heart

Give three compressions followed by one breath, in a 2 second cycle (counting “1,2,3 bag” for the correct rate) Compress for 30 seconds then reassess Assess HEART RATE, BREATHING, and COLOUR

I f H R i s l e s s t h a n 6 0 p e r m i n u t e , i n t u b a t e a n d g i v e d r u g s

D: Drugs Give ADRENALINE 1:10 000 (1ml 1:1000 + 9ml normal saline in a 10ml syringe) in dose of 0.1ml/kg IV or via

ETT every 3-5 minutes as required to get HR > 100 per minute Administer “adult” NALOXONE 0.1mg/kg (=0.25ml/kg of naloxone 0.4mg/ml) IM/SC/ETT only if mother

received pethidine or morphine within 4 hours of delivery (DO NOT use “neonatal narcan”)

E: Exit (i.e. when to stop) No heartbeat for 15 minutes Spontaneous breathing not established in 20-30 minutes

W h e n m a k i n g t h e d i f f i c u l t d e c i s i o n t o s t o p r e s u s c i t a t i o n , m a k e t h e d e c i s i o n j o i n t l y w i t h a c o l l e a g u e , e v e n i f t h i s i s o v e r t h e t e l e p h o n e w h i l e yo u r a s s i s t a n t c o n t i n u e s v e n t i l a t i o n

M a k e s u r e y o u h a v e a c o p y o f t h e N e o n a t a l R e s u s c i t a t i o n P o s t e r i n y o u r L a b o u r w a r d , T h e a t r e a n d N u r s e r y

Anticipate

Child Health Resource Package: Neonatal Experiential Learning Site

Neonatal ResuscitationDo it right now…

Department of Paediatrics: Pietermaritzburg Metropolitan Hospitals

Stimulate

Accommodate

Inflate

Aspirate

Medicate

Circulate

Investigate

Educate

Communicate

Perambulate

When called to resuscitate a baby you must know about:•

Gestation

•

Meconium

stained liquor •

Maternal drugs, esp

opiates •

Foetal distress•

Indication for assisted delivery (including caesarean)

If there is meconium

present, you must get rid of it using a proper SUCTION catheter of adequate SIZE (FG10)

•

Suction the mouth & nose before delivering the shoulders•

On resuscitation surface, suction under direct vision

•

The best way to stimulate babies is to dry them with a pre-warmed towel

•

The single most important event in the transition from foetal to neonatal life is the INFLATION of the lungs. If baby cannot do this, you must do it for her/him

•

Always record time to spontaneous respiration (TSR), and apgars

• Naloxone, if indicated, should be given early

• Adrenaline, if indicated, should be given stat

•

Bicarbonate, if indicated, should be given only if adequate ventilation

has been achieved

•

Explain to baby’s parents what has happened (good and bad)•

Document your resuscitations, and reflect on whether or not everything was “done right now”

•

If baby needs to go to the nursery, for ongoing care, use a warmed transport incubator with an adequate oxygen supply

•

Always ask the birth attendant (doctor or midwife) for a loop of cord, when foetal distress has been present, for acid-base investigation (if available), within ½

hour of birth•

ALL hospitals should have acid-base analysis capacity

•

There is no point compressing the heart, if the preceding resuscitation steps have not been followed

•

Decide timeously

where baby will go after resuscitation, so that plans can be made to accommodate her/him in the nursery if necessary

Find the risk factors that predict neonatal problems:•

Maternal•

Foetal•

Intrapartum

A previous stillbirth

or neonatal death

is the single most important predictor of problems in this and future pregnancies

ETT length (oral)1kg: 7cm2kg: 8 cm3kg: 9cm

(add 1 cm for nasal intubation)

ETT sizeSmall baby: 2.5

Normal baby: 3.0 Big baby: 3.5

IS BABY…1. Breathing adequately?2. Heart rate above 100?

3. Centrally pink?

AIRWAYRemove MECONIUM or

BLOOD if present, before stimulating

Assess

BREATHING,COLOR

and HEART RATE

Breathing, blue,HR > 100

ADMINISTER OXYGEN

B

D

C

A

HR < 60 HR > 60

Apnoeic, blue, HR < 100

BREATHEBag and mask ventilation40-60 breaths / minute

Breathing, pink, HR > 100

GIVE BABY TO MOTHER

Assess

BREATHING,COLOR

and HEART RATE

CHEST COMPRESSIONS

120/minute3 compressions : 1 breath

Assess

BREATHING,COLOR

and HEART RATE

DRUGS

NO

YES

EXIT• Asystole > 15 minutes

• TSR > 20 minutesE

Correct all correctable problems

HR > 60HR < 60

The SAPA (South African Paediatric Association) Algorithm

Compress⅓

of

chest diameter

Use an ambubag…

NOT a Samson Pump

TSR = time to spontaneous respiration; HR = heart rate; ETT = endo-tracheal tube; IV = intravenous; IM = intramuscular; SC = subcutaneous; kg = kilogram; mg = milligram;

ml = millilitre; FG = French Gauge

Drug&Dose Points to note Give Route

Naloxone(0.1mg/kg)

•Use “adult”

naloxone

ampoules• 0.1mg = 0.25ml

1kg = 0.25ml2kg = 0.50ml3kg = 0.75ml

IV/IMSC/ETT

Ringers Lactate or Normal Saline

(10ml/kg)

•Normal saline = 0.9% saline•For volume expansion

1kg = 10ml2kg = 20ml3kg = 30ml

IV

Adrenaline(0.3ml/kg 1:10000)

•Dilute

1ml 1:1000 adrenaline with 9ml normal saline for a 1:10 000 solution

1kg = 0.3ml2kg = 0.6ml3kg = 0.9ml

IV/ETT

Sodium Bicarbonate(2ml/kg 4.25%)

•Dilute 8.5% NaBic

with equal volume of water or use 4.25% •Do not give via ETT


Slow IV push

Glucose(2ml/kg 10%)

•10% dextrose (neonatolyte

is 10%)•Use to correct hypoglycaemia


IV or oral

ETT length (oral)1kg: 7cm2kg: 8 cm3kg: 9cm

(add 1 cm for nasal intubation)

ETT sizeSmall baby: 2.5

Normal baby: 3.0 Big baby: 3.5




GESONDHEIDSDIENSTE

F O R M A T F O R C L E R K I N G N E W B A B I E S As near to a “gold standard” as possible

A t m e d i c a l s c h o o l w e a r e t a u g h t t h a t g o o d c l i n i c a l m e t h o d o l o g y r e q u i r e s f o r e a c h p a t i e n t a h i s t o r y , e x a m i n a t i o n , a s s e s s m e n t a n d p l a n . A f t e r m e d i c a l s c h o o l , h i s t o r y t a k i n g s e e m s t o f a l l b y t h e w a ys i d e , n o w h e r e m o r e s o t h a n f o r n e o n a t e s . T h i s i s t o r e m i n d yo u t h a t h i s t o r y t a k i n g

i s j u s t a s i m p o r t a n t f o r n e o n a t e s a s f o r a n y o t h e r c a t e g o r y o f p a t i e n t , a n d t o p r o v i d e a s t r u c t u r e f o r h i s t o r y t a k i n g a n d c l e r k i n g .

Write the DATE and TIME, and PRINT your name, every time you see the patient State the reason for admission: The main problems (# list)

Background Father: Name, age, occupation, health status Mother: Name, age, occupation Past Medical History: HIV, medical, surgical, smoking, alcohol Past Obstetric History: gravida, parity, problems (a history of a perinatal death in a previous pregnancy is

one of the most important predictors of problems in this pregnancy)

Current 1) Pregnancy Booking date, LMP, EDD (by dates/palpation/ultrasound) HIV (including CD4 & ARV’s, feeding choice), VDRL, Blood group ANC attendance and problems (maternal/foetal)

2) Labour Onset and duration, reason for onset Rupture of membranes (mode and duration) Problems (maternal and foetal) Nevirapine

3) Delivery Mode and reason, presentation, liquor, problems

4) Resuscitation Interventions and response, apgars Doctors and nurses present, by name

5) Examination Weight and estimated gestational age, nevirapine, feeding choice Full neonatal examination (use the checklist on page 2 of the “Infant Care Record”)

6) Assessment: The problem list (this is why you do a history and examination, and the baby needs you to construct a clear

and complete problem list) 7) Plans For each listed problem, separately

Continuation Review active problems as required using the problem specific approach (Subjective; Objective; Assessment; Plan). Think about each problem every day until it is resolved or there is a long term plan. Never allow a problem to fall off the list by default. Never overlook a newly identified problem.

Medico-legal PRINT your surname at least on the first occasion that you write notes for each baby.




GESONDHEIDSDIENSTE

N E O N A T A L S U N D R I E S NB The procurement process requires that you may not stipulate a specific company Where a company has been selected below it is following extensive sampling and the decision has been made on quality, cost effectiveness and reliability

When ordering state that the item has been previously ordered from that company to guide the awards committee Effective use of standard complaint forms can also help in eliminating those items that are of poor quality. We do not have to accept poor quality products at the expense of our patients just because we are in the state health system.

ITEM SIZE CODE COMPANY AIRWAY MAINTENANCE

6 Various companies Suction tubes 8 2.5 520.25 / 100/105/025 Vygon OR Portex 3.0 520.30 / 100/105/030 Vygon OR Portex ET tubes (neonatal: soft, non-rigid,

straight, non-cuffed, non-shouldered) 3.5 520.35 / 100/105/035 Vygon OR portex 000 Pega 92000 Trigate Oropharyngeal airway 00 Pega 9200 Trigate

Nasal prongs Small - premature 1611 050 70040

Ibuki (Newco Medical) OR Hiline medical

00 15000 C.J. Healthcare 0 1500 Face mask (Transparent Infant Round

Silicon) 1 1501 Replogle suction catheter 10CH 8888-256503 Sherwood NB: 02 blender and a SATS monitor essential IV ACCESS

22G Jelco IV cannula 24G Jelco Umbilical catheter 5F ACL 7158307 Vygon Rate minder (Flow rate controller) 05010 Axel Medical 3-way Stopcock 4310022 Eastern Medikit 60 dropper giving set (or dedicated giving set for infusion pump, depending on infusion pump)

Various (Sabac)

Mini volume extension set (T-connector) 2C5681 Baxter (and various)

Paediatric low volume syringe pump set +/-150 cm Various depending on pump

Blood giving set Sabac Syringe (for use with syringe pump) 50ml 8728810F Various eg BD, terumo, OPSBuretrol AFC 2421 various Neonatalyte /neolyte FSN 000200 various STRAPPING Zinc oxide strapping 75cm Micropor (for IV strapping) Neonatal transparent dressing (tegaderm) 4.4cm x 4.4cm 1622w 3m

TBCO (for skin prep) ELIMINATION

Nappies Premature “Little Miracle” SA Preemies ASC

Nappies Small Logan medical / Kimberly Clark

Paediatric urine collector (bag) 100 ml Various Urine catheter silicon (no bulb) 5FG SIUDC 5.0 Arrow Urine catheter with bulb and introducer 6FG Various Neonatal urine catheter bag 5156 Convatec

Last modified: 14 June 2007 For review: 2009 2

ITEM SIZE CODE COMPANY GIT FEEDING / DRAINAGE Litmus paper Various

6 136 Various Feeding tubes (with depth marking) 8 136 Various 2 5202 Various 3 5203 BP cuffs (soft) 4 5204

Phototherapy eye shields Micro, prem, regular 900644,900643 900642 Brittan Healthcare Sheath grip for attaching SATS probes (normally used for palls tubing) Various

E Various Tubigrip (for baby caps) - Prem - Term H Various INTER-COSTAL DRAINS

8 Ch 8888560805 TYCO Chest drain (trocar) 10 Ch 8888561019 Sherwood Blood giving sets (cut off to use as drainage tubes) Various

Urine specimen container (for underwater bottle) Provincial Laboratory

Transparent dressing (to secure chest drain to chest) 10cm x 12cm 4630 Various

MEDICATION AND BLOODS Disposable syringe (tuberculin) 1 ml Various Heparinised syringe 2 ml Various Paediatric blood tubes Various Provincial Laboratory 23G needle Various 25G needle Various

PACKS QUANTITY Neonatal Procedure (packed in dressing towel) Keyhole drape 1 Gown 1 Gauze 10 Galley pot 1 Mosquito forceps 2

1 Iris dilating forceps - toothed - untoothed 1 General Procedure (packed in dressing towel)

Keyhole drape 1 Gown 1 Galley pot 2 Gauze 10




GESONDHEIDSDIENSTE

R E F E R R A L C R I T E R I A F O R S I C K N E O N A T E S

I t i s N a t i o n a l H e a l t h P o l i c y t h a t A L L b a b i e s s h o u l d h a v e E Q U A L a n d A P P R O P R I A T E a c c e s s t o A L L l e v e l s o f c a r e . W h e n d e c i s i o n s n e e d t o b e m a d e a b o u t w h e r e s i c k b a b i e s s h o u l d b e s t b e c a r e d

f o r , i t i s n e c e s s a r y t o b e g u i d e d b y r e g i o n - s p e c i f i c a d m i s s i o n a n d e x c l u s i o n c r i t e r i a , s o t h a t , f o r e a c h b a b y , A P P R O P R I A T E c a r e p l a n s c a n b e d e v i s e d .

T h e s e c r i t e r i a , a n d t h e f i n a l d e c i s i o n s t h a t a r e m a d e f o r i n d i v i d u a l b a b i e s , a r e b a s e d b o t h o n r e s o u r c e s a v a i l a b l e a n d o n t h e i n d i v i d u a l b a b y ’ s p r o g n o s i s

Admission Criteria If any of the following conditions exist or are suspected contact your referral centre to discuss possible transfer of your patient for further care: Gestation and Weight

Preterm infants > 28 weeks or birth weight > 1 kg Respiratory System

Respiratory distress from any cause which requires > 60% head box oxygen to maintain oxygen saturation above 85%

Congenital abnormalities Cardiovascular System

Congenital cyanotic heart disease Cardiac failure unresponsive to treatment

Central Nervous System

Status epilepticus Convulsions with inadequate facilities to investigate

Gastrointestinal Tract

Congenital abnormalities including abdominal wall defects, intestinal obstructions and anorectal malformations Necrotising enterocolitis Persistent GIT bleeding

Genitourinary System

Severe congenital abnormalities of kidney, bladder or genitalia Renal failure

Haematological

Severe or persistent bleeding Metabolic

a. Neonatal Jaundice: onset within first 24 hours of life if associated with positive Coomb’s test if approaching exchange levels

b. Persistent or recurrent hypoglycaemia c. Inborn errors of metabolism (acidosis / hypoglycaemia / neurological signs)

N o t m e e t i n g t h e s e d e s i g n a t e d i n c l u s i o n c r i t e r i a d o e s n o t i m p l y t h e m e e t i n g o f e x c l u s i o n c r i t e r i a


Exclusion Criteria Babies with the following conditions are not suitable for ventilation or more sophisticated care and are unlikely to be admitted to a referral centre. If you are uncertain please discuss individual babies with your referral unit (See guideline: “Transferring Neonates to a Higher Level of Care”).

Gestation and Weight

Babies < 1000 grams or 28 weeks gestation Between 900 and 1000 grams, IPPV may be considered in special circumstances, following discussion with a

Paediatrician Perinatal Hypoxia / Birth Asphyxia Babies exposed to perinatal hypoxia, which have the following problems:

no heartbeat at 15 minutes time to spontaneous respiration > 20 minutes 10 minute apgar < 6 AND cord arterial blood base excess < -10 AND / OR pH < 7.1 Grade III / severe Hypoxic Ischaemic Encephalopathy

Major Congenital Abnormalities

Babies with major congenital abnormalities where involvement of one or more organ systems is deemed incompatible with life

Intra / Periventricular Haemorrhage

Grade IV Grade III, with other complications / other organ involvement Severe periventricular leukomalacia

HIV / AIDS / MTCT Babies known to be HIV-exposed who are severely ill at birth, with multi-organ involvement Babies who are sick at birth, and whose mothers have advanced, symptomatic AIDS

N o t m e e t i n g t h e s e d e s i g n a t e d e x c l u s i o n c r i t e r i a d o e s n o t i m p l y t h e m e e t i n g o f i n c l u s i o n c r i t e r i a

A p p r o p r i a t e m a n a g e m e n t m u s t b e p r o v i d e d f o r b a b i e s n o t e l i g i b l e f o r a d m i s s i o n t o a n I C U . T h i s m u s t f o c u s o n p r o v i d i n g w a r m t h , o x y g e n , f l u i d s a n d n u t r i t i o n .




GESONDHEIDSDIENSTE

P R O C E D U R E F O R T R A N S F E R R I N G N E O N A T E S T O T H E P I E T E R M A R I T Z B U R G M E T R O P O L I T A N H O S P I T A L S C O M P L E X

T h e m o v e m e n t o f s i c k n e w b o r n b a b i e s i s f r e q u e n t l y h a z a r d o u s a n d h a s t h e p o t e n t i a l t o c o m p r o m i s e t h e w e l l b e i n g o f t h e b a b y

1) There are therefore a number of different ways to support healthcare workers and newborn babies in district hospitals:

A telephonic consultation During a monthly consultant visit to the district hospital Transfer to a referral centre for an out patient consultation or admission

G r e y ’ s H o s p i t a l f u n c t i o n s a s a s i n g l e e n t r y p o i n t f o r a l l c h i l d r e n i n t h e W e s t e r n h a l f o f K w a Z u l u -N a t a l i n t o t h e p a e d i a t r i c a n d c h i l d h e a l t h s e r v i c e s i n P i e t e r m a r i t z b u r g . I f y o u n e e d t o r e f e r a

n e w b o r n b a b y f o r a d m i s s i o n t o t h i s s e r v i c e p l e a s e p r o c e e d a s f o l l o w s .

2) To access support from the Pietermaritzburg Metropolitan Hospitals Complex the referring MO needs to:

Phone the appropriate person listed below to discuss the patient:

Ask for… NICU registrar 033-8973783 08h00 – 16h00

If no response… Dr Graham Ducasse 083-325-7569

After hours & weekends Ask for… Nursery MO on-call 033-8973783 / 3363

If no response at any time, ask Grey’s switchboard to contact the paediatric consultant on call.

Provide details of the patient and an easily contactable telephone number (preferably a cell number and NOT a switchboard number) for the Grey’s doctor to contact you

The Grey’s Hospital doctor will either provide telephonic advice or will identify a bed in Pietermaritzburg and notify the referring MO of the relevant details

The referring MO then needs to arrange transport with Emergency Medical Rescue Service 3) In all instances it is essential that:

Telephonic discussions occur to access support and to prevent or arrange for the transfer of the baby The mother/caregiver must ALWAYS accompany the baby (if this absolutely not possible, it is the responsibility

of the referring MO to arrange for tracing and transporting a caregiver) Detailed documentation must accompany the baby with full antenatal, intrapartum and postnatal records of both

the mother and the baby, either in a letter or as copies of the original records

F o r a l l p a e d i a t r i c a n d n e o n a t a l t r a n s f e r s , u s e t h e “ M o n i t o r i n g S h e e t f o r N e o n a t a l T r a n s f e r s ” ( F o r m P a e d / 3 1 ) t o m o n i t o r t h e c o n d i t i o n o f t h e c h i l d a n d t r a c k t r a n s f e r p l a n s

A n y p r o b l e m s w i t h t h e a b o v e p r o c e s s n e e d t o b e r e p o r t e d t o D r N M c K e r r o w , C h i e f S p e c i a l i s t a n d H e a d o f D e p a r t m e n t a t 0 3 3 - 8 9 7 3 2 6 4 .




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T R A N S P O R T I N G N E O N A T E S

T r a n s p o r t i n g s m a l l o r s i c k n e w b o r n b a b i e s a l w a y s p o s e s t h e r i s k o f a g g r a v a t i n g t h e i r c l i n i c a l c o n d i t i o n . I t i s t h e r e f o r e e s s e n t i a l t h a t t h e t r a n s f e r o f a s m a l l o r i l l b a b y i s d o n e i n a m a n n e r

t h a t w i l l m i n i m i z e p o t e n t i a l h a r m a n d e n s u r e a r r i v a l a t t h e r e f e r r a l h o s p i t a l i n a s o p t i m a l a s t a t e a s p o s s i b l e .

Communication Contact referral centre telephonically:

initially to ensure acceptance of the patient and to obtain advice on interim management at departure to give time of departure, and estimated time of arrival

A referral letter with full antenatal, intrapartum and postnatal details must accompany the baby. You can also photocopy the Newborn Care Record to send with the baby.

Stabilization Phase Fluid resuscitation:

ensure IV access ringers lactate, plasma or blood, whichever is appropriate, in 10 to 20ml/kg boluses, repeated

twice to achieve capillary filling time of < 3 seconds and/or adequate blood pressure Check for hypoglycaemia, and correct if blood glucose is < 2.5mmol/l Ensure adequate airway and oxygen saturation Ensure adequate warmth Insert nasogastric tube with open drainage to decompress the bowel

C o n t i n u e s t a b i l i s a t i o n m e a s u r e s a n d m o n i t o r i n g r i g h t u p t o t h e t i m e o f h a n d o v e r t o t h e p a r a m e d i c a l s t a f f .

T h e r e I S N O P O I N T i n s t a b i l i s i n g a p a t i e n t , a r r a n g i n g t r a n s f e r a n d t h e n a l l o w i n g t h e b a b y t o d e t e r i o r a t e t h r o u g h n e g l e c t , w h i l e w a i t i n g f o r t h e t r a n s p o r t t e a m t o a r r i v e .

Transportation Phase Ensure stabilization phase is complete and baby stable

D O N O T T R A N S P O R T A N U N S T A B L E B A B Y

Ensure adequate and appropriate personnel, equipment and supply of consumables (drugs, fluids, oxygen, etc)

for the trip Maintain warmth by transporting in a transport incubator, or with kangaroo mother care if stable enough Monitoring:

monitor pulse and oxygen saturation of all ill neonates. Aim for oxygen saturation of 88-93% monitor capillary refill time and blood glucose (especially for trips > 1hour) if feasible, also monitor bood pressure and aim for a mean arterial pressure of 35mmHg

F O R AL L T R AN S F E R S U S E T H E “ M O N I T O R I N G S H E E T F O R N E O N AT AL T R AN S F E R S ” ( F o r m P a e d / 3 1 )




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N E O N A T A L A P N O E A

A p n o e a i n t h e n e o n a t a l p e r i o d i s a p o t e n t i a l l y l i f e - t h r e a t e n i n g o r b r a i n - t h r e a t e n i n g c o n d i t i o n . A p n o e a o f i m m a t u r i t y M U S T b e p r e v e n t e d . I n o t h e r s , t h e u n d e r l y i n g c a u s e m u s t b e t r e a t e d .

Definition Apnoea is the cessation of breathing for long enough (usually > 20 seconds) to cause bradycardia together with cyanosis and/or pallor.

A p n o e a s h o u l d b e d i s t i n g u i s h e d f r o m p e r i o d i c b r e a t h i n g , w h i c h u s u a l l y o c c u r s i n b a b i e s l e s s t h a n 3 4 w e e k s g e s t a t i o n . B a b i e s w i t h p e r i o d i c b r e a t h i n g s t o p b r e a t h i n g f o r a s h o r t e r d u r a t i o n ,

d o n o t d e v e l o p c ya n o s i s o r b r a d y c a r d i a , a n d s p o n t a n e o u s l y r e s u m e b r e a t h i n g w i t h o u t s t i m u l a t i o n .

Who is at risk? The commonest cause is apnoea of immaturity due to an immature respiratory centre, usually in preterm infants < 34 weeks gestation. Apnoea of immaturity is uncommon in the first 4 days, or in a baby who has been apnoea-free. Those at risk who catch us out… Apnoea may be the first or only manifestation of: 1) Convulsions: if you treat the convulsions the apnoea often goes away (see Convulsions guideline) 2) Sepsis neonatorum: (See Sepsis neonatorum guideline) 3) Anatomical or exogenous (including mucous) obstruction of the respiratory tract (nose to alveolae): remove or

bypass the obstruction 4) Hypothermia and hypoglycaemia (see specific guidelines) 5) Acidosis

Investigations Check blood sugar and temperature immediately Other investigations, guided by clinical examination, include CXR, FBC and differential, U&E, calcium, glucose, septic screen (blood culture, LP, urine MCS)

Management It it’s not apnoea of immaturity, assess and manage the underlying cause OTHERWISE…

P r o p h y l a c t i c A m i n o p h y l l i n e / T h e o p h y l l i n e / C a f f e i n e m u s t t o b e g i v e n t o a l l p r e t e r m b a b i e s < 3 4 w e e k s . ( C a f f e i n e i s b e t t e r ) G i v e i t a s s o o n a f t e r b i r t h a s p o s s i b l e .

T o x i c i t y w a r n i n g s i g n s : t a c h y c a r d i a , f e e d i n t o l e r a n c e , s e i z u r e s

Prevent apnoea of immaturity through pharmacological stimulation of the respiratory centre. Prescribe at birth: AMINOPHYLLINE IV slowly or THEOPHYLLINE PO: loading dose 5mg/kg. Maintainance 1-

2mg/kg/dose, 12 H. Continue to +/- 34 weeks. OR…

CAFFEINE PO loading dose: 20mg/kg. Maintenance 5mg/kg 24H PO. Continue to +/- 34 weeks

Monitor (apnoea monitor, pulse oximeter, cardiac monitor) and give O2 if required to keep sats between 85 – 95%

I t i s d a n g e r o u s t o g i v e o x y g e n t o i n f a n t s w i t h a p n o e a o f i m m a t u r i t y i f t h e y d o n o t n e e d i t

Manual stimulation when needed

I n f a n t s w i t h r e p e a t e d a p n o e a , i n s p i t e o f t h e o p h y l l i n e , s h o u l d b e r e f e r r e d t o a s p e c i a l i s t h o s p i t a l f o r i n v e s t i g a t i o n a n d n a s a l C P A P / v e n t i l a t o r y s u p p o r t i f r e q u i r e d . T h e y m a y n e e d m a s k

a n d b a g v e n t i l a t i o n b e f o r e b e i n g t r a n s p o r t e d




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D U B O W I T Z / B A L L A R D S C O R I N G F O R G E S T A T I O N A L A G E Instructions for doing it properly

O b t a i n a g e s t a t i o n a l a g e s c o r e o n a l l b a b i e s w e i g h i n g l e s s t h a n 2 0 0 0 g , w i t h i n 2 4 h o u r s o f d e l i v e r y . T h i s a s s i s t s i n m a k i n g a p p r o p r i a t e c a r e p l a n s , e s p e c i a l l y a t t h e l i m i t s o f v i a b i l i t y . I t i s p r e f e r a b l e t o w a i t u n t i l b a b y i s “ s e t t l e d ” b e f o r e s c o r i n g , b u t s o m e t i m e s a n e a r l y s c o r e ( s o o n a f t e r d e l i v e r y ) i s e s s e n t i a l

Score for both neuromuscular and external/physical features. Add each to give a final score, and then give a maturity rating (in weeks) by referring to the conversion table. Complete the process by plotting baby’s weight and length on the neonatal growth chart, and documenting whether baby is appropriate, under- or overweight for gestational age.

Neuromuscular Maturity Assess all six features with baby lying supine (spine on bed), and awake but not crying. Refer to the chart while assessing. Accuracy is improved if you assess both sides of the body, and use the average score. 1) Posture: Observe the posture. Handling the infant may improve the assessment. 2) Square Window: Flex the hand at the wrist. Exert pressure sufficient to get as much flexion as possible. The angle between the hypothenar eminence and the anterior aspect of the forearm is measured and scored. 3) Arm Recoil: Fully flex the forearms with the hands at the shoulders for 5 seconds, then fully extend by pulling the hands. Release as soon as the elbows are fully extended, and observe the recoil (degree of flexion at the elbows). Random movements do not count. 4) Popliteal Angle: With the pelvis flat on the examining surface, use one hand to bring the knee onto the abdomen. With the other hand, gently push behind the ankle to bring the foot towards the face. 5) Scarf Sign: Take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible, like a scarf. Assistance to the elbow is permissible by lifting it across the body. Score according to the location of the elbow. 6) Heel to Ear: Hold the infant's foot with one hand and move it as near to the head as possible without forcing it. The knee may slide down the side of the abdomen. Keep the pelvis flat on the examining surface.

Physical Maturity The six features examined are self explanatory in the table below.

Sign -1 0 1 2 3 4 5

Skin Sticky, friable, transparent

Gelatinous, red, translucent

Smooth, pink, visible veins

Superficial peeling and/or rash, few veins

Cracking, pale areas, rare veins

Parchment, deep cracking, no vessels

Leathery, cracked, wrinkled

Lanugo None Sparse Abundant Thinning Bald areas Mostly bald

Plantar Creases

Heel-toe 40-50 mm = -1, Heel-toe >50 mm, no creases

Faint red marks Anterior transverse crease only

Creases over anterior 2/3

Creases over entire sole

Breast Imperceptible Barely perceptible Flat areola, no bud Stippled areola, 1-2 mm bud

Raised areola, 3-4 mm bud

Full areola, 5-10 mm bud

Eye & Ear Lids fused, loosely = -1, tightly = -2

Lids open, pinna flat, stays folded

Slightly curved pinna, soft with slow recoil

Well-curved pinna, soft but ready recoil

Formed and firm, with instant recoil

Thick cartilage, ear stiff

Genitals, male Scrotum flat, smooth Scrotum empty, faint rugae

Testes in upper cannal, rare rugae

Testes descending, few rugae

Testes down, good rugae

Testes pendulous, deep rugae

Genitals, female

Clitoris prominent, labia flat

Prominent clitoris, small labia minora

Prominent clitoris, enlarging minora

Majora and minora equally prominent

Majora large, minora small

Majora cover clitoris and minora

Maturity Rating Add up the individual Neuromuscular and Physical Maturity scores for the twelve categories, then obtain the estimated gestational age from the table below.

Total Score -10 -5 0 5 10 15 20 25 30 35 40 45 50 Gestational Age (in weeks ) 20 22 24 26 28 30 32 34 36 38 40 42 44

U s e a s c o r i n g s h e e t w i t h w e i g h t c h a r t ( F o r m P a e d / 0 2 ) . W r i t e t h e s c o r e i n t h e d e s i g n a t e d s p a c e o n p a g e 1 o f t h e I n f a n t C a r e R e c o r d ( F o r m P a e d / 0 1 ) .




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N E O N A T A L C O N V U L S I O N S Often a manifestation of an underlying serious problem

M o s t n e o n a t a l s e i z u r e s w i l l n o t p e r s i s t i n t o i n f a n c y a n d t h e r e i s n o e v i d e n c e t h a t t r e a t m e n t o f

c l i n i c a l s e i z u r e s w i t h a n t i c o n v u l s a n t s i m p r o v e s o u t c o m e s . H o w e v e r , t h e r e i s c o n s e n s u s t h a t n e o n a t a l c l i n i c a l s e i z u r e s s h o u l d b e t r e a t e d , p a r t i c u l a r l y i f t h e y a r e f r e q u e n t , p r o l o n g e d o r

h a v e a d v e r s e e f f e c t s o n c a r d i o r e s p i r a t o r y f u n c t i o n

Diagnosis Neonatal convulsions may be overt and obvious, they may be subtle and look like “something else” (like apnoea), or they may be subclinical and detected only on EEG (where available!). The following table describes neonatal seizures.

Seizure type Incidence Physical characteristics

Subtle Most common i.e. 50 – 75%

Orofacial: mouthing, chewing, lip smacking, blinking, eye deviation, fixed open stare Limb movements: e.g. pedalling, boxing Autonomic: unstable blood pressure, tachycardia, central apnoea

Clonic 23 – 40% Repetitive jerking that cannot be suppressed if limb is held Focal or generalised Differentiate from jittering

Tonic 2 – 23% Stiffening, sustained posturing of the limbs or trunk or deviation of eyes Generalised or Focal (less common)

Myoclonic 8 – 18% Tend to occur in flexor muscle groups, rapid isolated jerks Focal, multifocal or generalised Differentiate from benign sleep myoclonus

Things that can look like convulsions 1) Jitteriness (usually a sign of ill health: e.g. hypoglycaemia, meningitis)

no associated eye movements or autonomic phenomena induced by stimulus or spontaneous suppressed by holding the limb

2) Benign neonatal sleep myoclonus (usually a sign of good health and contentment) occurs during REM/active sleep not stimulus sensitive

Causes of neonatal seizures In our setting, the main causes are: 1) Hypoxic-ischaemic encephalopathy (HIE) 2) Intracranial haemorrhage (IVH/PVH) 3) Intracranial infection: meningitis > encephalitis 4) Electrolyte disturbances: hypoglycaemia, hypocalcaemia, hypomagnesaemia, hyper- and hypo-natraemia 5) Kernicteris

N . B . B a b i e s w i t h H I E a r e b e s t m a n a g e d i n t h e i r d i s t r i c t h o s p i t a l . N e i t h e r b a b i e s w i t h s e v e r e ( g r a d e I I I ) H I E n o r s e c o n d a r y a p n o e a a r e c a n d i d a t e s f o r v e n t i l a t i o n .


Management 1) Immediate

Evaluation of airway, ventilation and perfusion with resuscitation to commence immediately if needed Hypoglycaemia should be looked for and treated promptly History: pregnancy, labour, delivery, resuscitation and a detailed description of the seizure should be

documented 2) Stop the convulsion…

Indication for treatment of clinical seizures Prolonged > 3 min Recurrent > 3 convulsions in 1 hour Associated with cardiorespiratory compromise

LORAZEPAM 0.3mg/kg/dose IV works quickly and has enduring anticonvulsant activity. Refractory cases may need MIDAZOLAM load 0.1-0.3mg/kg + infusion 3mg/kg in 50ml D5W at 1-4 ml/hour. 1ml/hour = 1mcg/kg/min

I n t r a v e n o u s p h e n o b a r b i t o n e i s v a r i a b l y a v a i l a b l e i n S o u t h A f r i c a

3) Investigations

Blood glucose level Electrolytes: Na+, Ca2+, Mg2+ Full blood count Cranial ultrasound may be indicated to exclude gross CNS pathology, but is not effective at detecting subdural

and epidural bleeds or identifying parenchymal injury Further investigations will be dependent on underlying aetiology.

Acid-base status Blood culture Lumbar puncture: in our setting HIE and meningitis sometimes occur concurrently, because both are common

4) Treat the underlying cause when known Refer to the relevant guidelines Hypocalcaemia: CALCIUM GLUCONATE 10% (0.22 mmol calcium/ml). If symptomatic, give 0,5 - 1ml/kg (0,11-

0,22mmol/kg) IV over 10 minutes stat. Then give 2 - 4 ml of 10% solution/kg/day (0.44 - 0.88 mmol/kg/day) as a continuous infusion IV (this can be added to the neonatalyte)

Hypomagnesaemia: MGSO4 50% solution (2 mmol/ml). Give 0,1-0,2ml/kg/dose (0.2-0.4 mmol/kg/dose) 12H IV or IM

5) Maintenance anticonvulsant If baby is going to need ongoing anticonvulsant, use PHENOBARBITONE PO: load 20mg/kg, then 5mg/kg/dose

24H In most cases, anticonvulsant can be stopped prior to discharge (do this a few days before discharge)

When to refer Babies with seizures should be referred:

if not contra-indicated by generic exclusion criteria (especially severe HIE) if the seizures are intractable if a cause cannot be identified

Follow up Follow up needs are determined by underlying cause and residual or anticipated neurological deficit




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P E R I N A T A L H Y P O X I A ( “ B I R T H A S P H Y X I A ” ) A N D H Y P O X I C I S C H A E M I C E N C E P H A L O P A T H Y

The commonest avoidable cause of perinatal mortality and morbidity in term babies in South Africa

Definition Hypoxic ischaemic encephalopathy is a clinical condition that presents with neurological signs in term infants, during the early neonatal period.

A l t h o u g h t h e f o c u s i s o n t h e b r a i n , i t i s a m u l t i - o r g a n d i s e a s e , w i t h a l l o r g a n s h a v i n g b e e n e x p o s e d t o s e v e r e p e r i n a t a l h yp o x i a

Cause It is caused by severe perinatal hypoxia together with secondary cerebral ischaemia. A severe re-perfusion injury occurs maximally at about 72 hours.

Diagnosis

D o n o t j u m p t o t h e d i a g n o s i s o f H I E i n a n y b a b y w i t h e n c e p h a l o p o t h y . A L W A YS c o n s i d e r t h e t h r e e o t h e r C O M M O N c a u s e s – M E N I N G I T I S , H Y P O G L Y C A E M I A A N D E L E C T R O L Y T E

A B N O R M A L I T E S – i n b a b i e s w i t h n e o n a t a l e n c e p h a l o p a t h y .

Take a good labour, delivery and resuscitation history and document the use of and findings on the PARTOGRAM. Also document time to spontaneous respiration.

Clinical signs and severity assessment Lethargy with poor sucking, increased or decreased tone and poor Moro reflex, irritability, fisting, convulsions, full fontanelle and apnoea. Severity score Use the HIE score to measure the severity of the clinical signs on a daily basis. Anyone can do this.

HIE Scoring Chart 0 1 2 3 Score

Level of consciousness Normal Hyper-alert Lethargic Comatose Tone Normal Hypertonia Hypotonia Flaccid

Seizures None Infrequent Frequent Posture Normal Fisting, cycling Strong flexion Decerebrate

Moro Normal Partial Absent Grasp Normal Poor Absent Suck Normal Poor Absent

Respiration Normal Hyperventilating Brief apnoea Apnoea (IPPV) Fontanelle Normal Full Tense

TOTAL SCORE Score babies daily using this chart. Use the HIE Scoring sheet (Form Paed/05). The score will usually increase a little up until the 4th day and then decrease. Severity grading A grading system is also used, but you need to have some experience in looking after neonates, and EEG parameters should be used. Grade 1: mild encephalopathy with infant hyper-alert, irritable, and over-sensitive to stimulation. There is evidence of sympathetic over-stimulation with tachycardia, dilated pupils and jitteriness. The EEG is normal and there are no seizures Grade 2: moderate encephalopathy with the infant displaying lethargy, truncal hypotonia, proximal weakness, and partially depressed primitive reflexes. There is parasympathetic over-stimulation with low resting heart rate, small pupils, and copious secretions. The EEG is abnormal and 70% of infants will have seizures. Grade 3: severe encephalopathy with a stuporous, flaccid infant, absent reflexes, and drooling of saliva due to poor swallow and gag. The infant may have seizures and has an abnormal EEG with decreased background activity and/or voltage suppression.


Management

N O s p e c i f i c i n t e r v e n t i o n s h a v e b e e n s h o w n t o a l t e r t h e o u t c o m e f o r b a b i e s w i t h H I E . B u t y o u s t i l l h a v e t o g e t t h e b a s i c p r i n c i p l e s o f n e o n a t a l c a r e r i g h t , t o o p t i m i s e t h e o u t c o m e o f t h o s e

b a b i e s w h o w i l l n o t d i e

Prevention

Reduce perinatal hypoxia with good antenatal and labour ward care Resuscitation

Do not over-oxygenate baby. If the lungs are normal, use air or 60% O2 (leave the resivoir off the ambubag) Prevent postpartum hypoxia by competently resuscitating the baby. Give oxygen ONLY if needed to keep the

O2 saturation between 85-90% DO NOT give naloxone unless maternal opiates were given within 4 hours of delivery

Convulsions

DO NOT USE “prophylactic phenobarbitone” (sedation masks neurological signs and has no benefits) LORAZEPAM 0.3mg/kg/dose IV works quickly and has enduring anticonvulsant activity. Refractory cases may

need midazolam infusion (use MIDAZOLAM 3mg/kg in 50ml D5W at 1-4 ml/hr: 1ml/hr = 1mcg/kg/min). Consider referral.

Intake

Initiate IV fluids and keep nil per os for 24 hours (lessens risk of Necrotizing Enterocolitis) and then gradually commence nasogastric feeds and breastfeeding when the baby can suck and swallow

Restrict fluid intake to ¾ maintenance requirements on days 1-3 Observation

Monitor the HR, RR, temperaure, saturation, BP, intake and output 3 hourly, and respond accordingly Prevent hyperthermia by making sure that the incubator temperature is not set too high Watch out for hypoxic injury to other organs

Lungs: ARDS Heart: hypoxic myocardopathy Liver: hypoglycaemia Kidneys: ATN Marrow: thrombocytopaenia GIT: necrotising enterocolits

Follow up

Follow up at 6 weeks and 4 months for neuro-developmental assessment and refer to physiotherapy if required.

Referral criteria

Babies with HIE need to be managed in their district hospital. It is important to pay attention to supportive care so as to prevent further deterioration.

A baby with a high HIE score is not a candidate for referral for ventilation, neither is a baby who fails to breathe spontaneously by 20 minutes post-delivery, despite full resuscitation.

Prognosis

A baby who scores a maximum of 10 or less and is normal by day 7 will usually have a normal outcome. A baby whose score peaks higher than 15 or who remains abnormal after day 7 must have a guarded prognosis. This must be communicated to the family.

Babies may be discharged once they are feeding well and stable.




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P R E V E N T I N G M O T H E R T O C H I L D T R A N S M I S S I O N O F H I V ( P M T C T )

Prevention is better, there is no cure

Why is it important?

1 i n 3 b a b i e s b o r n t o H I V - i n f e c t e d m o t h e r s w i l l b e i n f e c t e d w i t h H I V d u r i n g p r e g n a n c y , d e l i v e r y a n d v i a b r e a s t m i l k , w i t h o u t i n t e r v e n t i o n .

N e v i r a p i n e g i v e n c o r r e c t l y t o m o t h e r s a n d b a b i e s a l m o s t h a l v e s t h e r i s k o f H I V t r a n s m i s s i o n . ( M o r e c o m p l e x A R V r e g i m e n s c a n r e d u c e t r a n s m i s s i o n t o l e s s t h a n 2 % . )

The BEST practice is to reduce the mother’s viral load to as low a level as possible prior to delivery Most transmission occurs during delivery so good obstetric management is vital, apart from ARVs Don’t forget the father – prevention and/or treatment of HIV infection, and planning for future parenthood

Determine the mother’s HIV status Ask every pregnant woman if she knows her status at the time of confirmation of pregnancy (check this for

private sector patients as well) If YES, ask if she has ever taken / is taking ARVs If NO, recommend VCT as soon as possible

A L L m o t h e r s s h o u l d b e o f f e r e d v o l u n t a r y c o u n s e l l i n g a n d t e s t i n g f o r H I V d u r i n g a n t e n a t a l c a r e

Plan for the HIV-infected mother During pregnancy

Regular, careful antenatal care (especially if mother’s CD4 < 200) It is very important to discuss feeding choice with the mother, either:

exclusive breast for 4-6 months, OR exclusive replacement/formula feeding, if mother has access to clean water and is able to sterilise

bottles etc

The CD4 level is important: if < 200 cells/mm3, mother should be started on HAART if > 200 cells/mm3, mother should receive PMTCT according to provincial protocol

NEVIR API NE (NVP) fo r mother : Nevirapine 200mg PO stat at onset of labour, OR when membranes rupture, OR prior to Caesarean section.

NVP must be taken between 72 and 2 hours before the birth REMEMBER to give the nevirapine to the mother when she is 34 weeks pregnant

During delivery

Do an elective C/S if the viral load high at 37 weeks AND before the onset of labour Do not artificially rupture membranes Do not do invasive procedures (eg scalp pH monitoring of baby) Avoid episiotomy, if possible

Post partum REMEMBER to implement the feeding choice the mother made antenatally Ongoing HIV care for mother including ARVs, prophylaxis for opportunistic infections and contraception

EXCLUSIVE FEEDING is essential – either breast (i.e. nothing else, not even water) OR formula. When WEANING, make the switch from breast to formula as quickly as possible, to minimise the period of

mixed feeding (i.e. breast AND formula), which is the most risky for HIV transmission.


Plan for the HIV-exposed infant Antiretrovirals

Determine what ARVs mother received if single dose nevirapine was given between 2 hours before birth and 72 hours after birth, give a single

dose of nevirapine to baby between 12-72 hours after birth if single dose nevirapine was given to mother < 2 hours before birth or > 72 hrs after birth: give

immediate dose nevirapine to baby (within 6 hours of birth) and a repeat dose 12-72 hours after birth

NEVIR API NE (NVP) fo r baby: B i r t h w e i g h t > 2 k g , g i v e 0 . 6 m l P O s t a t

B i r t h w e i g h t < 2 k g , g i v e 0 . 2 m l / k g P O s t a t

if baby’s mother is on the HAART regimen, baby will need 2 drug therapy (AZT + 3TC for 4 weeks) –

DISCUSS with consultant Feeding choice

This must be an informed choice based on the specific social circumstances of each individual woman, and ideally with the full support of her family

The choice should best be made antenatally (see “Plan for the HIV-infected mother”) Document the feeding choice clearly on the neonatal record (Form Paed/01)

Follow up

Document all HIV information and plans in all designated places on the “Newborn Care Record” (Form Paed/01)

Regular monthly clinic visits are essential for: growth monitoring feeding support treatment of intercurrent illnesses

COTRIMOXAZOLE prophylaxis should be started from 6 weeks (single daily dose of 2,5 ml given Monday - Friday)

Immunisation should be given according to SA EPI schedule, unless baby has signs suggestive of AIDS HIV testing

PCR must be done for definitive diagnosis at 6 weeks ELISA from 18 months, and at least 3 months after cessation of breast feeding

P r e g n a n c y i s o f t e n t h e f i r s t t i m e w h e n w o m e n b e c o m e a w a r e o f t h e i r H I V s t a t u s – m a x i m i s e t h i s o p p o r t u n i t y f o r e d u c a t i o n , c a r e , s u p p o r t a n d g o o d m e d i c a l t r e a t m e n t




GESONDHEIDSDIENSTE

N E O N A T A L H Y P O G LY C A E M I A A common AND serious neonatal problem

F e e d A L L b a b i e s w i t h i n h a l f a n h o u r o f b i r t h ( w i t h b r e a s t m i l k u n l e s s m o t h e r h a s c h o s e n t o

f o r m u l a f e e d )

S t a r t t h i s p r o t o c o l a s s o o n a s b a b y h a s a g l u c o s e r e a d i n g o f 2 . 5 m m o l / l o r l e s s A g l u c o m e t e r r e a d i n g b e l o w 2 . 5 m m o l / l m e a n s t h a t t h e b a b y i s a t r i s k o f B R A I N D A M A G E

Who is at risk? All babies who are small, sick, cold and/or not fed, and those born to mothers with diabetes.

Monitor the blood glucose of small and/or sick babies every 3 hours for the first 24 hours and continue until the level is normal for 24 hours

Check the blood glucose of infants of diabetic mothers hourly, for the first 6 hours If milk feeds are contraindicated, start intravenous fluids (neonatolyte) immediately Keep the baby warm

What are the clinical signs? Often there are no symptoms or signs. There may be jitteriness or lethargy, apnoea, convulsions, or hypothermia. Remember the vicious cycle:

↓ glucose

Can’t feed

Weak

Oral management: mild hypoglycaemia (glucose 1.8- 2.5 mmol/l) 1) When the glucometer reads 1.8-2.5 mmol/l, give 10 ml/kg breast milk (or artificial feed if indicated) IN ADDITION TO

SCHEDULED FEEDS 2) Repeat the glucometer 15 minutes after COMPLETION of the feed 3) If glucometer reads more than 2.5 mmol/l, continue with normal feeds and monitor glucose level three hourly 4) If glucometer again reads under 2.5 mmol/l, oral management has FAILED. Proceed to intravenous management

Intravenous management: severe hypoglycaemia (glucose < 1,8 mmol/l) 1) If glucometer reading is less than 1.8 mmol/l, OR oral management has failed, start an IV infusion with neonatolyte

(10% dextrose + electrolytes) IMMEDIATELY, at the appropriate rate for weight, gestation and age 2) When you have finished strapping and splinting the cannula give a 3ml/kg bolus 3) Repeat the glucometer reading after 15 minutes 4) If the glucometer reads more than 2.5 mmol/l, continue with normal feeds and monitor glucose level three hourly 5) If the glucometer again reads less than 2.5 mmol/l, change infusion to a 15% dextrose infusion (180ml neonatolyte +

20ml 50% dextrose). At the start give a 2ml/kg bolus, then continue at required rate for age 6) Repeat the glucometer reading 15 minutes after changing to 15% solution 7) If glucose remains low, give GLUCAGON 0,2mg/kg IV or IM, and arrange transfer to a regional or tertiary hospital

R e c o r d a l l r e a d i n g s a n d a c t i o n s o n “ H y p o g l yc a e m i a M a n a g e m e n t C h a r t ” ( F o r m P a e d / 1 9 )




GESONDHEIDSDIENSTE

N E O N A T A L H Y P O T H E R M I A A common AND serious neonatal problem

A b a b y i s h y p o t h e r m i c w h e n a x i l l a r y t e m p e r a t u r e i s b e l o w 3 5 . 5 o C o r c o r e t e m p e r a t u r e ( r e c t a l ) i s b e l o w 3 6 o C . C o l d b a b i e s h a ve a h i g h m o r b i d i t y a n d m o r t a l i t y

Who is at risk? Wet infants (after delivery or bathing) Low birth weight infants Infants requiring resuscitation Sick infants, particularly if there is infection

Infants who are in a cold room Infants who are not fed Hypoglycaemic infants Infants undergoing medical procedures

Prevention is the cornerstone of management Dry the infant well after birth and wrap in a second warm and dry towel

Keep the baby with the mother in the kangaroo position (KMC)

Nurse babies less than 1.8kg in KMC or in an incubator (at appropriate temp)

Feed all babies within 30 minutes after birth (unless contra-indicated e.g. severe respiratory distress)

Ensure that there is a good overhead heater in the infant resuscitation area

Keep the room warm i.e. at 25-26oC, but not higher Dress babies in incubators in a vest, nappy, booties and a woollen cap. Do not wrap in a blanket

Keep the baby away from windows and draughts Keep incubators and resuscitaires warm, even when not in use

Temperature settings for closed incubators Check the temperature of manual incubators every hour and keep them at the following temperatures according to the baby’s weight and age. Record the temperature on the incubator, using the “Basic Neonatal Care Nursing Observations” chart.

Days after delivery Birth weight

0 5 10 15 20 25 30 < 1000g – 1500g 35.5 35.0 35.0 34.5 34.0 33.5 33.0 1500g – 2000g 35.0 34.0 33.5 33.5 33.0 32.5 32.5 2000g – 2500g 34.0 33.0 32.5 32.0 32.0 32.0 32.0 2500g – 3000g 33.5 32.5 32.0 31.0 31.0 31.0 31.0

> 3000g 33.0 32.0 31.0 30.0 30.0 30.0 30.0 Note: These settings are a guide. They must be increased or decreased according to baby’s temperature. Never increase more than 1ºC higher than the baby’s temperature at a time.

Clinical signs of hypothermia I n i t i a l l y t h e r e m a y b e n o s i g n s . Yo u a n d t h e m o t h e r m a y t h i n k t h a t t h e b a b y i s a s l e e p .

Cold, lethargy, apnoea, peripheral oedema, sclerema. In severe cases, bleeding and pulmonary haemorrhage may occur.

Treatment of hypothermia 1) Give oxygen until the baby’s temperature is normal (longer if indicated by respiratory problem) 2) Ensure an adequate glucose level:

monitor and record the blood glucose levels feed the baby with breastmilk, milk or IVF if temperature is less than 350C, start IVF (neonatolyte)

3) Warm up as quickly as possible place baby in the KMC position

OR in an incubator, set the temperature to 1ºC higher than the baby’s temperature, and increase as baby

warms up. Cover baby with a plastic sheet to protect radiant heat loss. Do not cover with blankets or tin foil check the temperature ½ hourly until it is normal you will need to decrease the incubator temperature as baby’s temperature returns to normal (use the table

as a guide) 4) Identify and treat the underlying cause




GESONDHEIDSDIENSTE

“ S E P S I S N E O N A T O R U M ” A deadly and difficult clinical problem

Why is it important? 8 % o f p r e t e r m b a b i e s w i t h r e s p i r a t o r y d i s t r e s s a r e i n f e c t e d , 2 5 % o f N I C U a d m i s s i o n s a r e d u e t o

o r d e v e l o p i n f e c t i o n s , a n d 3 0 % o f p r e t e r m b a b i e s w i t h “ b a c t e r a e m i a ” w i l l h a v e m e n i n g i t i s .

There is very little scientific evidence to guide treatment for or prophylaxis of neonatal bacterial infections. Babies get bacteria from their mothers perinatally, or from healthworkers postnatally. It is important to identify:

babies at risk for acquiring an infection babies already with an infection the extent of the infection (i.e. does the infection include meningitis, is the Systemic Inflammatory Response

Syndrome / SIRS already established?)

I f y o u p u t a b a b y o n t o a n t i b i o t i c s , t h e n y o u t h i n k t h a t t h e b a b y i s a t r i s k f o r a n d h a s a l r e a d y a c q u i r e d a b a c t e r i u m . A n d t h e r e f o r e y o u m u s t m a n a g e a c c o r d i n g l y .

What causes sepsis neonatorum? Host Babies have immature, undeveloped defences, and with decreasing gestational age defence systems become even weaker. Organisms a. Primary Group B streptococcus, E.coli, listeria, staphylococcus aureus, other streptococci, haemophilis, anaerobes etc. b. Nosocomial Staphylococcus epidermidis, klebsiella, pseudomonas, MRSA, etc. Carriers If a baby is born without a bacterium, and later acquires one, it has been transmitted via hands. Organisms on mother’s hands are usually important for normal colonisation of baby (unless she’s picked it up in the hospital). Organisms on healthworkers hands are lethal.

W AS H Y O U R H AN D S

How to suspect SN? You must know the risk factors… Maternal risk factors In order of importance: 1) Group B streptococcus (GBS) colonisation 2) Chorioamnionitis 3) P(P)ROM 4) Maternal pyrexia (> 38.0º C) during labour

I t i s r a r e i n s t a t e h o s p i t a l s t o k n o w w h e t h e r o r n o t t h e m o t h e r i s c o l o n i s e d w i t h G B S

It is important, in the presence of maternal risk factors, to establish whether or not baby was “pretreated” with antibiotics. If mother received antibiotics ≥ 4 hours prior to delivery, this is considered pretreated. Neonatal risk factors Preterm (< 34/40), low birth weight (< 2kg) And you must know the clinical features… When it’s obvious, it’s easy… “Collapse”, shock, purpura, coma etc When it’s subtle, it’s not… “Handles poorly”, apnoea, lethargy, O2 requirement, respiratory distress, not feeding so well, a little abdominal distension, low birthweight, etc.


What then? 1) Confirm the “sepsis” diagnosis

Do a septic workup 2) Start intravenous antibiotics

GENTAMICIN 5mg/kg/dose 24H and BENZYL PENICILLIN (Penicillin G) 50 000 units/kg/dose 12H or AMPICILLIN 50mg/kg/dose 12H

3) Assess how sick the baby is Clinical, FBC, ABG

What is a “septic workup”? 1) Blood culture

Finds the organism 2) CSF analysis

Determines duration of antibiotics, and long term follow up.

I f b a b y i s t o o s i c k o r u n s t a b l e , t h e L P c a n b e d e l a y e d . H o w e v e r , f o r m a n a g i n g t h e “ s e p s i s n e o n a t o r u m ” p r o b l e m , t h e e a r l i e r i t ’ s d o n e t h e b e t t e r .

3) Urine analysis Bag and dipstix is an unreliable screen, especially in the first 24 hours. A negative dipstix for white cells and nitrites does not exclude a UTI. A positive dipstix for WC’s and/or nitrites should be followed by a suprapubic aspirate for formal M,C&S.

What about the FBC? N o p a r a m e t e r i n t h e f u l l b l o o d c o u n t i s a g o o d p r e d i c t o r o f t h e p r e s e n c e o f i n f e c t i o n s i n b a b i e s ,

e s p e c i a l l y i n t h e f i r s t 2 4 h o u r s . S e n s i t i v i t y f o r t h e a b s o l u t e W C C p i c k i n g u p i n f e c t i o n i s o n l y 4 4 % .

The full blood count is useful for determining how sick baby is. If the WC (< 5) and/or platelet (< 50) counts are low, and infection is present, then the infection is likely to be advanced.

What about the CSF? The risk for having meningitis starts climbing when the total CSF white cell count starts climbing from 8. Most neonatologists use a “cut-off” of 20, above which meningitis is extremely likely.

A C S F w h i t e c e l l c o u n t b e l o w 2 0 d o e s n o t e x c l u d e m e n i n g i t i s

If CSF suggests meningitis, change antibiotics to CEFOTAXIME 100mg/kg/dose 12H (and AMPICILLIN 100mg/kg/dose 12H). Treat for 14 days for gram positive organisms, and for 21 days for gram negative organisms.

What are the markers of severity? It is important not only to determine the presence or absence of infection, but also to assess how sick baby is, and this will assist with deciding on the appropriate place of management. The following clinical markers indicate severity: Immaturity: the more preterm the more at risk - refer according to “Referral Criteria for Sick Neonates” guideline Apnoea: refer if apnoea persists after standard apnoea prophylaxis and treatment (“Neonatal Apnoea” guideline) Respiratory failure (any cause): refer according to “Respiratory Distress” guideline Necrotising enterocolitis (NEC): refer all cases once baby’s condition is stabilised The following laboratory markers indicate severity: Acidosis (as indicated by a low bicarbonate on a standard U&E printout, or on a formal Acid-Base assay) There are three big causes of acidosis in babies: 1) Hypoxia (peri and post natal) 2) Shock 3) Dead tissue (typically NEC) Hypoxia and shock must always be corrected prior to transfer. Neutropaenia, thrombocytopaenia (see above)

B y g e t t i n g t h e b a s i c s r i g h t , a n d p i c k i n g u p a n d m a n a g i n g “ S e p s i s N e o n a t o r u m ” e a r l y , y o u w i l l m a k e t h i s c o m m o n n e o n a t a l p r o b l e m l e s s d i f f i c u l t f o r y o u t o h a n d l e , a n d l e s s d e a d l y f o r t h e

b a b i e s yo u l o o k a f t e r




GESONDHEIDSDIENSTE

N E O N A T A L J A U N D I C E : U N C O N J U G A T E D H Y P E R B I L I R U B I N A E M I A A lighter touch, a righter touch

T h e n e u r o t o x i c s e q u e l a e o f a h i g h u n c o n g u g a t e d b i l i r u b i n a r e u n p r e d i c t a b l e , p o t e n t i a l l y d e v a s t a t i n g , a n d t o t a l l y p r e v e n t a b l e . T h e o c c u r r e n c e o f k e r n i c t e r i s i n K Z N i s a l a r m i n g l y h i g h .

R A T H E R O V E R - R E F E R T H A N U N D E R - R E F E R

What is jaundice? Jaundice is the yellow discoloration caused by the presence of bilirubin in the soft tissues.

What causes jaundice ALL babies develop an elevated bilirubin in the first week of life. This, on the bilirubin pathway, is due to the NORMAL: 1) increased production = accelerated red cell breakdown 2) decreased removal = reduced liver bilirubin handling capacity 3) increased reabsorption = increased enterohepatic recirculation

W h e n j a u n d i c e b e c o m e s s e v e r e e n o u g h t o t r e a t , t h e c a u s e i s r e l a t e d t o a n e x a g g e r a t i o n o f o n e o r m o r e o f t h e s e f a c t o r s

1) Increased production: Haemolysis (especially rhesus disease and ABO incompatibility), bruising, haematoma, polycythaemia, immaturity, sepsis

2) Decreased removal: Immaturity, hepatitis, (pathological enzyme deficiencies are very rare)

3) Increased reabsorption Delayed passage of meconium, breast feeding

If you find a baby who is, or may be, or may become jaundiced/yellow… 1) Anticipate jaundice

Rhesus negative mother: do cord TSB and repeat at six hours Immaturity: do TSB with first bloods, then 12-24 hourly Sick babies: do a TSB with first bloods, then 12-24 hourly

2) If baby is yellow, do a TSB stat

T S B m a y b e d o n e a s a c a p i l l a r y ( h e e l p r i c k ) o r v e n o u s s a m p l e a n d s h o u l d b e a v a i l a b l e ( b i l i r u b i n o m e t e r o r l a b o r a t o r y ) i n l e s s t h a n o n e h o u r

3) Start phototherapy while awaiting the result if baby is preterm or markedly jaundiced 4) The result must be plotted on a Phototherapy Guideline Chart (Form Paed/34) according to TSB level

(micromoles/l), baby’s age (in hours NOT days) and weight/gestational age, and acted on immediately 5) All babies whose TSB is high enough for phototherapy should have:

mother’s blood group baby’s blood group baby’s Coomb’s

G e t t i n g t h e s e t e s t s o f f e a r l y a s s i s t s m a n a g e m e n t p l a n n i n g a n d m a y p r e v e n t e x c h a n g e t r a n s f u s i o n s

6) Well babies should receive phototherapy if their TSB is on/over the phototherapy line for age and weight. Sick babies should go under lights at TSB levels of 30 micromoles/L lower than the line (see both charts overleaf).

7) Repeat TSB for babies under phototherapy must be done 12-24hrly 8) Phototherapy should continue until TSB is 50micm/L less than photo level. TSB must be checked 24hrs after cessation

of lights 9) Note the pattern or TSB tracking on the phototherapy chart. Note departure from “physiological” pattern e.g. early TSB

rise suggesting haemolysis, or raised TSB after 10 days when phototherapy is no longer indicated (but further investigation may be indicated)

10) If rate of rise of TSB is high, send a blood specimen for conjugated bilirubin, FBC/PCV, and blood culture 11) Check TSB level against Exchange Transfusion chart indicating potential need for exchange transfusion (ETF) 12) Anticipate the need for an exchange transfusion early and consult referral hospital

PHOTOTHERAPYWESTERN CAPE 2006 C


Phototherapy ONSENSUS GUIDELINES

In presence of risk factors use one line lower (the gestation below) until <1000g.If gestational age is accurate, rather use gestational age (weeks) instead of body weight

Start intensive phototherapy when the TSB is ≥ the line accordinStart intensive phototherapy when the TSB is ≥ the line according to gestation or weight.g to gestation or weight.

Infants under phototherapy : Check the TSB 12 – 24 hly but if TSB >30 μmol/L above the line , check TSB 4 – 6hly.STOP phototherapy :If TSB > 50 μmol/L below the line. Recheck TSB in 12 – 24hr.

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806040200

The distance fom the light source to mattress must be as close as possible

Use correct phototherapy bulb – 400 to 850 nm wavelength Use adequate light intensity: log of hours “on”. Bulbs must be

changed after every1000 hrs of use. Intensity on lightmeter must be > 8 microwatts/cm2/nm

Baby must be optimally exposed (no clothes, no nappy)

The baby under phototherapy Hydration: give an extra 20ml/kg/day of fluids, unless

competently demand breast feeding Eyes must be shielded Breast feeding: give EBM via NGT when TSB is rapidly rising

or when close to exchange levels so that baby is not removed from the phototherapy

Monitor temperature, dextrostix and urine output 3 hourly

Exchange transfusion There is increased risk of kernicteris when: preterm baby rapidly rising bilirubin (> 17micm/l/hr) low levels serum albumin (ALBUSOL® 20% 5ml/kg slowly IV is

protective) concomitant illness (e.g. sepsis, acidosis)

Exchange transfuse to prevent or lessen kernicteris: use the graph to decide on whether to transfuse the decision on when to exchange is based on both the

absolute level and rate of rise of TSB in babies who are ABO or Rhesus incompatible, and

Coomb’s positive, POLYGAM® 1g/kg IV over 3 hours, with LASIX 1mg/kg stat, may prevent an exchange transfusion

B a b i e s w i t h p r o l o n g e d N N J ( T S B > 1 5 0 o n d a y 1 5 ) s h o u l d b e i n v e s t i g a t e d . S t a r t w i t h u r i n e d i p s t i x f o r U T I , T F T ’ s f o r h yp o t h y r o i d i s m , a n d u r i n e r e d u c i n g s u b s t a n c e s f o r g a l a c t o s a e m i a , t h e n

c o n s i d e r b r e a s t m i l k j a u n d i c e .

B a b i e s w i t h c o n j u g a t e d h yp e r b i l i r u b i n a e m i a m u s t b e r e f e r r e d

Micr

o mo

l / L

TSB

(tota

l ser

um b

ilirub

in)

Time (age of baby in hours)6h 12h 24h 36h 48h 60h 72h 84h 96h 108h 120h

XXX XX X X

X

X38+ wks or 3000+g35 – 37w6d or 2500 – 2999g34 – 34w6d or 2000 – 2499g32 – 33w6d or 1500 – 1999g30 – 31w6d or 1250 – 1499g28 – 29w6d or 1000 – 1249g<28w or <1000gX

Infants > 12 hours old with TSB level below threshold, repeat TSB level as follows: 1- 20μmol/L below line:repeat TSB in 6hrs or start phototherapy and rept TSB in 12- 24hrs,21 - 50 μmol/L below line: repeat TSB in 12 – 24hrs, >50 μmol/L below line: rept TSB until it is falling and/or until jaundice is clinically resolving

EXCHANGE TRANSFUSIONWESTERN CAPE 2006 CONSENSUS GUIDELINES

In presence of sepsis, haemolysis, acidosis, or asphyxia, use one line lower (gestation below) until <1000g

If gestational age is accurate, rather use gestational age (weeks) than body weight

Note: 1. Infants who present with TSB above threshold should have Exchange done if the TSB is not expected to be below the threshold after 6 hrs of intensive phototherapy.

2. Immediate Exchange is recommended if signs of bilirubin encephalopathy and usually also if TSB is >85 μmol/L above threshold at presentation

3. Exchange if TSB continues to rise >17 μmol/L/hour with intensive phototherapy

Time (age of baby in hours) 6h 12h 24h 36h 48h 60h 72h 84h 96h 108h 120h

450440430420410400390380370360350340330320310300290280270260250240230220210200190180

Micro

mol

/ L T

SB (t

otal s

erum

bilir

ubin)

38+ wks or 3000+g35 – 37w6d or 2500 – 2999g34 – 34w6d or 2000 – 2499g32 – 33w6d or 1500 – 1999g30 – 31w6d or 1250 – 1499g28 – 29w6d or 1000 – 1249g<28w or <1000g

XX X XX X X

X

X X

X

Photocopy the “Jaundice Poster” and put it up in your nursery and use individual charts for each patient

Guidelines for interventions in babies with jaundiceUnconjugated hyperbilirubinaemia only

South African Neonatal Academic Hospital guidelines: 2006

PHOTOTHERAPYWESTERN CAPE 2006 CONSENSUS GUIDELINES In presence of risk factors use one line lower (the gestation below) until <1000g.

If gestational age is accurate, rather use gestational age (weeks) instead of body weight



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806040200

Micr

o mo

l / L

TSB

(tota

l ser

um b

ilirub

in)


XXX XX X X

X



PHOTOTHERAPYWESTERN CAPE 2006 CONSENSUS GUIDELINES In presence of risk factors use one line lower (the gestation below) until <1000g.

If gestational age is accurate, rather use gestational age (weeks) instead of body weight



340320300280260240220200180160140120100

806040200

Micr

o mo

l / L

TSB

(tota

l ser

um b

ilirub

in)


XXX XX X X

X










450440430420410400390380370360350340330320310300290280270260250240230220210200190180

Micro

mol

/ L T

SB (t

otal s

erum

biliru

bin)


XX X XX X X

X

X X

X








450440430420410400390380370360350340330320310300290280270260250240230220210200190180

Micro

mol

/ L T

SB (t

otal s

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biliru

bin)


XX X XX X X

X

X X

X




GESONDHEIDSDIENSTE

K A N G A R O O M O T H E R C A R E ( K M C ) Let nature do the nurturing

T h e c o m m o n p r o b l e m s o f s m a l l b a b i e s – h yp o t h e r m i a , h yp o g l y c a e m i a , a n d h yp o x i a - a r e a l l e v i a t e d , i f n o t c u r e d , b y a c o m m o n s o l u t i o n : k a n g a r o o m o t h e r c a r e ( K M C )

A L L f a c i l i t i e s w i t h m a t e r n i t y s e r v i c e s S H O U L D i m p l e m e n t K M C a s R O U T I N E p r a c t i c e

What is KMC?

Kangaroo mother care consists of skin-to-skin care of babies (usually low birth weight or very low birth weight). KMC also promotes early and exclusive breastfeeding, but may be used even when babies are formula fed.

What are the cornerstones of KMC? 1) Kangaroo Position

Dress the baby in a nappy and cap and place in an upright position against the mother’s bare chest, between her breasts and inside her blouse. One may use a special garment, or one can tuck the mother’s blouse under the baby or into her waistband. Cover both mother and baby with a blanket or jacket if it is cold. Many hospitals have designed their own wraps (for example, out of old theatre drapes), or have involved community based organisations in the making of wraps. You too can be innovative.

2) Kangaroo Nutrition

Babies who are unable to suckle should be fed expressed breast milk via a nasogastric tube or cup if they can swallow. Keep babies in the KMC position whilst being tube fed. Allow them to try to suckle during the tube feed.

In the KMC position, babies will declare themselves ready to suckle, as their rooting and suckling reflexes become manifest. Once the baby is able to suckle, allow the baby to breast feed on demand but at least every three hours.

3) Kangaroo Support

It is very important to explain and demonstrate to the mother until she is motivated and confident to try the kangaroo position. In Kwazulu-Natal the word “Ukugona” (to hug or embrace) is used. Assist the mother with positioning and feeding, and give emotional support. The concept should be explained to other family members (especially the maternal grandmother), and they can also practise KMC (especially the father).

4) Kangaroo Discharge

Use the KMC score chart (Form Paed/26) to evaluate readiness for discharge. Discharge when the baby has a sustained weight gain and has a KMC score of 19 or more.. Bring the baby back for follow up in the next few days to ensure that baby is well and growing. It is good practice to follow up KMC babies in a designated place near the KMC ward.

When do we start KMC?

Intermittent KMC can be practised while the baby is still in the nursery. It is possible even with babies on oxygen and IV therapy. Frequency is determined by how stable baby is. A common sense approach is best. Aim for a minimum of 3 times a day.

Continuous KMC can be instituted once the baby is stable, suckling well, preferably > 1500g (but at any weight if confidence and competence has been established) and needs no additional care. The baby can then be transferred to an adjoining KMC ward. Smaller babies may be able to go onto continuous KMC if they are stable and do not require oxygen.

Where do we do continuous KMC?

The KMC ward should be in close proximity to the Neonatal unit and under the supervision of the neonatal staff, with 24 hour nursing coverage. The ward should be comfortable, homely and warm but not heated. There should be no cribs.

What is the daily routine of a KMC Ward? 1) Monitoring

Babies should be weighed daily, and feeds adjusted according to weight gain. If not yet breastfeeding on demand, they should receive 175ml/kg/day, in 8 feeds 3 hourly.

Babies on oxygen should have their oxygen saturation monitored 3 hourly. The Basic Neonatal Nursing Observation chart can be used.

2) Record Keeping

For babies who are “just growing”, use only the KMC Daily Score (Form Paed/26) sheet. If babies have any other problems (like oxygen dependency) carry on using the normal continuation sheet.

3) Medication

From two weeks of age, use VIDAYLIN® 0,6ml/dose 24H and VITAMIN D 400U/dose 24H. Add FERRODROPS® 0,3ml/dose 24H at 6 weeks. All preterm babies should be on THEOPHYLLINE 1-2mg/kg/dose 12H until they weigh about 1800g.

4) Immunisation

Give the BCG and Polio vaccines when baby weighs 1800g, or at discharge, whichever comes first. 5) Complications

It is important to watch out for:

a. Anaemia of immaturity Transfuse preterm babies if their Hb is less than 9g%.

b. Patent Ductus Arteriosus (PDA) Bounding pulses are the hallmark of PDA’s in small babies. Check pulses daily, and if they are bounding, listen for a murmur. Refer to a regional hospital if a PDA is present, and reduce intake to 120ml/kg/day

c. Sepsis Neonatorum Babies in KMC are less likely to acquire infections, but they are still at risk. At any sign of infection, fully and carefully assess baby, and manage according to the “Sepsis Neonatorum” guideline.

KMC discharge

Use the KMC scoring sheet to decide when to discharge. Discharge on medications as above (usually it is appropriate to stop the vitamin D at discharge). Iron and

multivitamins should be continued for the first year of life. Try and develop the follow up clinic as part of the neonatal/nursery service. Don’t make KMC babies go and sit

in an outpatient queue. Do use the same scale to weigh them when they come for follow up.





GESONDHEIDSDIENSTE

L A R G E F O R G E S T A T I O N A L A G E ( L G A ) I N F A N T S Definitions

Large for Gestational Age (LGA): a baby with a birth weight > 90th percentile for gestational age. In term babies, this amounts to a birthweight > 4000g.

Macrosomia: a baby which has a large body and increased body mass.

L G A a n d m a c r o s o m i a a r e s y n o n y m o u s t e r m s , a n d i n c l u d e I n f a n t s o f D i a b e t i c M o t h e r s ( I D M ’ s )

Causes

Maternal diabetes Genetics: “big parents - big baby” Excessive maternal weight: “fat mother - fat baby” Rare genetic disorders e.g. Beckwith-Wiedemann Syndrome

Complications and Risks

Antenatal and Intrapartum risks: Increased stillbirth rate (8x in IDM’s) Obstructed labour and shoulder dystocia Foetal distress

Neonatal: Birth trauma (fractures of clavicle/humerus; brachial plexus injury; hypoxic-ischaemic damage)

Hypoglycaemia (in all, but especially in IDM’s) In addition, in IDM’s:

Immature lungs with RDS Polycythaemia Neonatal Jaundice Cardiac defects

o Asymmetrical ventricular septal hypertrophy with left and/or right HOCM o VSD

Rare: sacral agenesis; microcolon Long-term: increased risk of type I and type II diabetes in baby

I D M ’ s a r e B I G b u t I M M A T U R E

Management 1) Delivery is high risk: expect and manage complications 2) Examine for:

Birth trauma Dysmorphia Macrosomia Plethora Cardiac murmurs RDS


3) Look for and manage hypoglycaemia, with reference to the “Neonatal Hypoglycaemia” guideline

R e c o r d a l l r e a d i n g s a n d a c t i o n s o n “ H y p o g l yc a e m i a M a n a g e m e n t C h a r t ” ( F o r m P a e d / 1 9 )

Feed within 30 minutes of birth (unless severe RDS or intrapartum hypoxia)

breast; or formula 10 ml/kg (only if medically indicated). Try NOT to give formula to a breast feeding baby,

unless no alternative exists

L o w b l o o d s u g a r r e a d i n g s o n a g l u c o m e t e r M U S T b e c o n f i r m e d b y a l a b o r a t o r y t e s t

Do a blood glucose 1 hr post-delivery:

if ≥ 2.5 mmol/l

continue frequent breast feeding 2-3hrly (or formula, according to “Feeding and Fluid Management” guideline)

continue 3hrly blood glucose tests for 24 hours if 1.8 - 2.5 mmol/l

feed as above and check blood glucose again after 30 minutes. Repeat until ≥ 2.5 mmol/l if < 1.8 mmol/l

insert drip take blood for lab serum glucose and FBC from cannula before connecting drip give bolus 3ml/kg Neolyte (10% dextrose) and then run drip as follows: If breast feeding: continue drip at 30ml/kg day and continue breast 2-3hrly. Wean drip slowly if blood

sugar is maintained > 2.5mmol/l. If hypoglycaemic, increase drip rate to 60-80mls/kg/day and continue breast feeding.

If formula feeding: calculate formula feeds at 60ml/kg/day and divide 2-3hrly feeds, while running drip at 2ml/hr. Wean off drip if blood sugar is maintained > 2.5mmol/l.

if persistently < 1.8 mmol

give GLUCAGON 0.2mg/kg and change drip to 15% dextrose * if still < 1.8mmol/l, take blood for insulin, cortisol, growth hormone and TFT, then start

HYDROCORTISONE 5mg/kg stat, then 10mg/kg/dose 6H IV

* T o m a k e a 1 5 % I V I s o l u t i o n : a d d 2 0 m l 5 0 % d e x t r o s e t o a 2 0 0 m l b a g o f N e o l y t e




GESONDHEIDSDIENSTE

F E E D I N G A N D F L U I D M A N A G E M E N T E n s u r e t h a t b a b i e s a r e f e d w i t h i n a n h o u r o f b i r t h , p r e f e r a b l y w i t h i n t h e f i r s t 3 0 m i n u t e s

Feeding (refer also to your “Cornerstones of Neonatal Care” poster) If the infant is able to suck (Babies who are more than 34 weeks gestation are usually able to suck, unless they are ill)

Breast feed and encourage EXCLUSIVE breast feeding Initiate breast feeding within the first 30 minutes of birth Allow mothers to breast feed on demand and room-in

If the baby is unable to suck or the mother and baby are separated Give Expressed Breast Milk (via NGT or cup) Use formula only if EBM is not available

< 1.5 kg – pre-term formula > 1.5 kg – normal formula

If the baby is not able to feed (The infant may be < 1.5 kg or ill e.g. severe respiratory distress or septicaemia)

Commence IV maintenance fluids (neonatolyte) at the appropriate rate Keep on IV fluids only Gradually add feeds from Day 2 (refer to the table below as a guide) Increase the feeds if there is no vomiting, apnoea or abdominal distension If the baby is unable to tolerate feeds at all, IV fluids can be continued alone for a maximum of 3 days.

Thereafter, if still unable to feed, arrange for transfer. Frequency and method of feeding

Allow breastfed babies to feed on demand – at least 8 times in 24 hours Feed other babies 3 hourly or on demand VLBW babies may need 2 hourly or even 1 hourly feeding If the baby is not breastfeeding then feed with a cup If the baby is unable to swallow or is on head box oxygen then feed by nasogastric tube (never remove a baby

from oxygen to feed)

Fluid requirements The following daily fluid requirements are recommended:

< 1000g 1 – 1.5kg > 1.5kg

Total fluids (ml/kg) Total fluids (ml/kg) Total fluids (ml/kg) Suggested IV

(ml/kg) Suggested

oral** (ml/kg)Day 1 90* 75* 60 60 Nil Day 2 115 100 90 50 25 Day 3 140 125 120 50 50 Day 4 140 150 150 50 75 Day 5 165 165 150 50 100 Day 6 165 165 150-180 25 125 Day 7 150-180 150-180 150-180 Nil 150

* Very low birth weight babies may require more than 60ml/kg on Day 1 ** Feeds can be increased more quickly if well tolerated or more slowly if not

To calculate the drip rate: wt x volume/kg/24 = ml/hour If using a 60 drop/ml intravenous infusion administration set, then ml/hour = drops/min Always use an infusion controller, buretrol or dial-a-flow when administering fluids to neonates To calculate 3 hourly feeding: wt x volume/kg/8 = ml/feed

Y o u M U S T c a l c u l a t e a n d p r e s c r i b e t h e c o r r e c t i n t a k e , f e e d a n d f l u i d f o r e v e r y b a b y , e v e r y d a y i n c l u d i n g o n w e e k e n d s . U s e t h e f r o n t p a g e o f t h e “ N e w b o r n C a r e R e c o r d ” ( F o r m P a e d / 0 1 ) .

D o c u m e n t i n t a k e a n d o u t p u t o n F o r m P a e d / 2 1 ( I V a n d o r a l s ) o r 2 2 ( o r a l s o n l y )

Department of Paediatrics N e o n a t a l G u i d e l i n e s PROVINCE OF KWAZULU-NATAL

HEALTH SERVICES

ISIFUNDAZWE SAKWAZULU MPILO

P i e t e r m a r i t z b u r g M e t r o p o l i t a n

H o s p i t a l s C o m p l e x KWAZULU-NATAL PROVINSIE GESONDHEIDSDIENSTE

T H E P P I P M O R T A L I T Y R E V I E W P R O C E S S Making perinatal mortality meaningful

I t i s t h e s t r u c t u r e d c l i n i c a l a u d i t o f a l l p e r i n a t a l d e a t h s ( s t i l l b i r t h s , n e o n a t a l d e a t h s , m a t e r n a l d e a t h s ) t h a t e n a b l e s a t h o r o u g h a s s e s s m e n t o f t h e q u a l i t y o f c a r e t h a t m o t h e r s a n d b a b i e s

r e c e i v e i n t h e h e a l t h s y s t e m .

For a clinical audit / mortality review to be successfully implemented there are two vital requirements: 1) dedicated individuals willing to spend time and effort to make the process happen 2) a carefully structured system where roles and responsibilities are well-defined

Thus the system for a mortality review process in a maternity unit consists of two main activities: A. data collection B. the actual mortality review process

A. Data collection To conduct a mortality review, two data sources are needed:

1) the labour ward admissions, discharges and deaths register 2) the individual clinical records of the mothers and their stillbirths and neonatal deaths

K e e p a s e p a r a t e r e g i s t e r o f s t i l l b i r t h s a n d n e o n a t a l d e a t h s s o t h a t t h e i r m e d i c a l r e c o r d s c a n b e t r a c e d . D e l i v e r i e s a n d d e a t h s b y b i r t h w e i g h t a r e c a p t u r e d o n T o t a l B i r t h s d a t a s h e e t s .

D e t a i l e d i n f o r m a t i o n o n e a c h d e a t h i s c a p t u r e d o n t h e P e r i n a t a l D e a t h d a t a s h e e t . ( s e e a l s o t h e “ P P I P ” g u i d e l i n e )

To organise and keep track of the data it is helpful to compile a lever arch file, clearly labelled PPIP. The file can be divided into two sections, one for perinatal data and the other for maternal data. It is helpful to order the contents in each section as follows:

1) Laminated copies of code lists (Cause of death and Avoidable factors) 2) Monthly dividers for each month followed by a Total Births data sheet for that month as well as a Perinatal

Death data sheet completed for every stillbirth and neonatal death that occurred during that month 3) Spare data capture forms

B. The mortality review process Efficiency and effectiveness depends on your following the four components of the mortality review process:

Component When Who Purpose

1. 24 hour review Each stillbirth/neonatal

death should be reviewed and summarised within 24

hours

The attending doctor or nurse at the time of

the death

Ensure all necessary information is captured at a time when information is available

2. Preparatory meeting

Before the Perinatal Mortality Review Meeting

The doctor and nurse in charge of the labour ward and

neonatal unit

A detailed analysis of all deaths, with case selection for presentation at the Mortality Review Meeting

Compilation of monthly statistics for presentation at the meeting

3. Mortality review / PPIP meeting (see

below) Weekly to monthly depending on load

The whole perinatal care team (doctors and nurses) as well as antenatal clinic

staff

Presentation of statistics, case discussions and task reviews

Assign new tasks based on each meeting’s discussion

Ensure all data capture sheets have been completely completed

4. Epidemiology & Analysis 6 monthly/annually Managers and clinical

personnel

Broader problem identification with trend assessment, and with proposed solutions/recommendations

1. The 24 hour review Every single stillbirth/neonatal/maternal death occurring in your hospital should be summarised using the PPIP Perinatal or Maternal Death data sheet at the time of death. The person best placed to do this is either the birth attendant (doctor or midwife) for stillbirths, or the on duty doctor (or by way of handover the daytime nursery team) for neonatal and maternal deaths. The death summary should be regarded as no more burdensome, and no less important, than the discharge summary for other babies and mothers leaving the unit.

I t i s s t i l l b e s t t o h a v e a s i n g l e p e r s o n i n t h e l a b o u r w a r d a n d n u r s e r y m a k i n g s u r e t h a t t h i s p r o c e s s h a p p e n s . T h i s c a n b e a d o c t o r o r a n u r s e .

Last modified: 14 June 2007 For review: 2009

2

2. The preparatory meeting This meeting is crucial. All data capture sheets must be completely completed, to the stage of readiness for entry onto the computer. This means that all fields must be filled in, and codes must be entered where required. This makes data entry onto the computer efficient and accurate, and allows for any category of employee to enter data. Careful selection of cases for presentation will enhance learning opportunities and facilitate problem identification and task definition and allocation.

T h e p r e p a r a t o r y m e e t i n g i s t h e r e s p o n s i b i l i t y o f t h e m o s t s e n i o r d o c t o r a n d m o s t s e n i o r n u r s e i n t h e l a b o u r w a r d a n d n u r s e r y .

3. The mortality review meeting Mortality meetings must be well organised and managed by the nurse and doctor responsible for perinatal care. 1) Meetings should be held weekly to monthly depending on the number of deaths. 2) A suitable time and venue is needed. 3) All staff involved with perinatal care should be invited (nurses, doctors and administrators). Staff must understand

that mortality meetings are very important. It is especially helpful to invite staff from referring clinics . 4) Case presentations should be concise and professional. Discussion is encouraged if the presenter does not provide

the cause of death and avoidable factors. This is best done by the group. 5) The meeting should by consensus establish the obstetric and neonatal (for babies born alive) causes of death and

then look carefully for avoidable factors. The meeting must never become a “witch hunt”, and should be confidential. 6) All decisions (causes and avoidable factors) made must be recorded/revised on the mortality sheets (Perinatal

Death data sheets) for entry later onto a computer. 7) Problems with the process of providing perinatal care in the hospital, the referring clinics and in

communities must be identified and prioritised, and plans should be made and documented for addressing each problem.

8) Tasks arising out of discussions around cases should be assigned to team members, and minuted. Progress with the tasks should be reviewed at the start of the next meeting.

The meeting agenda A typical mortality review agenda is a follows:

1) Welcome and introductions, and identification of a minute taker 2) Review of tasks set at last meeting 3) Summary of last meeting’s statistics 4) Summary of this meeting’s statistics 5) Case presentations 6) Task identification and allocation 7) Closure and date of next meeting

4. Epidemiology and Analysis The power of PPIP lies in its ability to provide instant feedback on perinatal death and quality of care information to labour ward and neonatal staff. By simply initiating this systematic review process, change will happen. It is however important both for the identification of broader system problems and for monitoring change that 6 monthly or annual reviews are performed. These reviews should be compiled into reports, which document both findings and recommendations arising out of the findings. This is the point at which the power of PPIP can be used for communicating problems to managers. Once the process of mortality review is established in your site, the report will also look at success of implementation, and of response to, previous recommendations.

Making change happen When making recommendations, it is important to link each recommendation clearly to specific information arising out of your PPIP review process. It is then useful to clearly define its requirements for implementation at each of the following levels:

1) Policy 2) Administration 3) Clinical practice 4) Education

Finally, responsibility for implementation at each level should be assigned, so that at the next review, implementation (or lack thereof) can be accounted for (as an example of this, see “Saving Children 2005”).

B y c o n d u c t i n g m o r t a l i t y r e v i e w s i n t h i s s y s t e m a t i c w a y , w e w i l l b o t h s a v e l i v e s a n d i m p r o v e q u a l i t y o f c a r e , t h r o u g h d e a t h a u d i t i n g .

(Adapted from Philpott and Voce: “4 Key Components of a Successful Perinatal Audit Process”, Kwikskwiz #29, 2001)

Department of Paediatrics N e o n a t a l G u i d e l i n e s PROVINCE OF KWAZULU-NATAL

HEALTH SERVICES

ISIFUNDAZWE SAKWAZULU MPILO

P i e t e r m a r i t z b u r g M e t r o p o l i t a n

H o s p i t a l s C o m p l e x KWAZULU-NATAL PROVINSIE GESONDHEIDSDIENSTE

P E R I N A T A L P R O B L E M I D E N T I F I C A T I O N P R O G R A M ( P P I P ) Perinatal Mortality Auditing Made Simple

P P I P i s a m o t h e r a n d b a b y h e a l t h c a r e a u d i t s y s t e m , w h i c h u s e s t h e p e r i n a t a l m o r t a l i t y r e v i e w p r o c e s s t o a s s e s s q u a l i t y o f c a r e . I t s e e k s t o d e t e r m i n e t h e s i z e a n d n a t u r e o f p e r i n a t a l p r o b l e m s , w i t h a v i e w t o

c r e a t i n g i m p l e m e n t a b l e s o l u t i o n s d i r e c t e d a t i m p r o v i n g t h e q u a l i t y o f c a r e a n d d e c r e a s i n g m o r b i d i t y a n d m o r t a l i t y .

Keep a large lever arch file in your Labour Ward for all PPIP documentation. (see “PPIP Mortality Review” guideline)

PPIP Deaths Register (overleaf) Apart from the Maternity Register, if doing PPIP, it is extremely useful to have a PPIP Deaths Register (see overleaf): 1) Keep a PPIP Deaths Register in Labour Ward, under the responsibility of a named professional nurse (usually the

PN/Midwife in charge of Labour Ward) 2) Enter all stillbirths occurring in any of the obstetric/gynaecology/maternity units, preferably at the time of death, or as

soon as possible thereafter (you must record the birth weight) 3) Include babies born and dying before arrival 4) All neonatal deaths occurring in any of the neonatal units/paediatric wards should be entered into this register,

preferably at the time of death, or as soon as possible thereafter (you must record the birth weight)

Total Deliveries (PPIP printout) Use the PPIP Total Deliveries monthly tally form for this. The information is taken from the Maternity Register. Make sure that your Maternity Register collects all the required information.

E V E R YB O D Y m u s t m a k e s u r e t h a t t h e b i r t h w e i g h t i s r e c o r d e d i n t h e b i r t h r e g i s t e r

1) The PN in charge of Labour Ward should fill in the form “Total Deliveries” for each month 2) Total deliveries includes all live and still births weighing 500 grams or more 3) Totals should be filled in on the form for each weight category 4) The number to be filled in for multiple pregnancies is the actual number of babies or foetuses delivered (NOT the

number of pregnancies) i.e. triplets are counted as 3, not 1

Perinatal Deaths (PPIP printout) I t i s u s e f u l t o i d e n t i f y m o t h e r s ’ f o l d e r s b y s t i l l b i r t h o r b y n u r s e r y a d m i s s i o n ( i f b a b y i s a c t u a l l y

a d m i t t e d ) . T h i s m a k e s t r a c k i n g a n d t r a c i n g f o l d e r s e a s i e r a f t e r m o t h e r h a s b e e n d i s c h a r g e d .

Stillbirths 1) A red sticker can be attached to “Stillbirth Folders” (get them from radiology or your pharmacy). Write “PPIP” on the

sticker 2) One “Perinatal Death” form should be completed for each stillbirth weighing 500 grams or more 3) For each STILLBIRTH the attendant midwife should complete the details “mother’s IP number, delivery date, date of

death, birth mass, syphilis and HIV serology and single or multiple pregnancy” (Note: the AT ADMISSION serology status should be recorded). It is useful to write the mother’s surname in the top left corner (but remember confidentiality)

4) It is VERY HELPFUL for the birth attendant (midwife or doctor) to write a case summary on the back of the form 5) The form should be filed in the Labour Ward PPIP file immediately 6) At mother’s discharge, the mother’s folder should be kept in Labour Ward in a PPIP folders box. Keep this box and the

lever arch file together Neonatal Deaths

1) If mother is discharged before baby then her folder should go to the baby’s bed in the nursery (this should apply to all neonatal admissions)

2) When/if a neonatal death occurs, a red sticker should be attached to baby’s folder and the mother’s folder. Write “PPIP” on the sticker

3) One “Perinatal Death” form should be completed for each neonatal death weighing 500 grams or more 4) For each NEONATAL DEATH, the PN in charge of the nursery should complete the details “mother’s IP number,

delivery date, date of death, birth mass, syphilis and HIV serology and single or multiple pregnancy” (Note: the AT ADMISSION serology status should be recorded). Write the surname in the top left corner. Mother’s folder should be obtained if not with baby’s folder

5) It is VERY HELPFUL for the doctor on duty at the time of the death to write a case summary on the back of the form 6) The form and the folder should then be placed in the Labour Ward PPIP File and Box

T h e “ C a u s e o f d e a t h ” a n d “ A v o i d a b l e f a c t o r s ” s e c t i o n s t o b e c o m p l e t e d a t t h e P P I P m e e t i n g s

Maternal Deaths It is wise, and beneficial, to use PPIP for Maternal Deaths, remembering that the Confidential Enquiry process MUST still be followed

Last modified: 14 June 2007 For review: 2009

2

P P I P D E A T H S R E G I S T E R Unit: __________ Month: ____________ Year: _____________

Consecutive num

ber

Date of B

irth

Date of

Death

Nam

e

Mother’s folder

number

Baby’s

folder num

ber

Birth w

eight

Folder in box

PP

IP form

filled

PP

IP

entered

Folder returned to

registry




GESONDHEIDSDIENSTE

R E S P I R A T O R Y D I S T R E S S R e s p i r a t o r y d i s t r e s s i s a n e x t r e m e l y c o m m o n n e o n a t a l p r o b l e m , w i t h a l i m i t e d n u m b e r o f

c o m m o n c a u s e s . T h e c o r n e r s t o n e o f m a n a g e m e n t i s o x y g e n , n o t f o r g e t t i n g t h e o t h e r b a s i c s o f w a r m t h , f o o d / g l u c o s e , a n d i n f e c t i o n p r e v e n t i o n / m a n a g e m e n t

Definition Respiratory distress is marked by one or more of the following signs (listed in increasing severity):

Respiratory rate > 60/minute (tachypnoea/fast breathing)

Recession or indrawing of the chest Alar nasae flaring

Grunting Cyanosis Irregular breathing, then apnoea

Assessment of severity Mild: Respiratory rate > 60/minute with minimal (< 30%) oxygen requirements Moderate: Respiratory rate > 60/minute, recessing, flaring, cyanosis (requiring up to 60% oxygen) Severe: Respiratory rate > 60/minute, grunting, cyanosis (requiring > 60% oxygen), irregular respiration

(progressing to apnoea)

I f o x y g e n r e q u i r e m e n t s g o a b o v e 6 0 % , b a b y m a y n e e d v e n t i l a t o r y s u p p o r t

Common causes Pulmonary causes

Hyaline membrane disease (HMD) Meconium aspiration syndrome Wet lung syndrome Pneumonia Pneumothorax

Extrapulmonary causes Congenital heart disease/heart failure Hypothermia Metabolic acidosis Anaemia and polycythaemia Diaphragmatic hernia Upper GIT anomalies (e.g. trache-

oesophageal fistula)

Investigations Chest X-ray (wait 4-6 hours if hyaline

membrane disease or transient tachypnoea of the newborn (TTN) are suspected)

Gastric aspirate for a shake test and gram stain

FBC, CRP and glucose Blood pressure Transilluminate the chest if a pneumothorax is

suspected

Management Oxygen

Give enough oxygen to keep the oxygen saturation between 85 and 93%. If you do not have a pulse oximeter ensure that the baby’s tongue is pink. You MUST get one in your nursery FOR THE BABIES

If it is not possible to keep the infant pink in oxygen then continuous positive pressure (CPAP) via nasal prongs or endotracheal tube should be given – discuss referring your patient

Monitor oxygen saturation and oxygen requirement using the “Oxygen Monitoring Sheet (Form Paed/18) Supportive Care

Keep the infant warm in an incubator If the respiratory distress is mild, do intermittent KMC provided that he/she maintains oxygen saturation (85-

93%) on nasal cannula oxygen Keep nil per mouth for the first 24 hours Give appropriate volumes of neonatolyte Observe the RR, saturation, BP, HR hourly, and check the blood glucose 3 hourly

Criteria for referral If patient is not maintaining oxygen saturation despite 50% oxygen, or the baby develops apnoea, the baby

should be referred to a hospital that has the ability to provide CPAP or IPPV PDA that does not respond to treatment Severe HMD – discuss early referral to a hospital that may have surfactant Possible cyanotic CHD, diaphragmatic hernia, trache-oesophageal fistula

Documents

Child Health Resource Package: Neonatal … Child Health Resource Package: Neonatal Experiential Learning Site Neonatal Resuscitation Do it right now… Department of Paediatrics: