NEONATOLOGY HEALTH

CARE SERVICES
POWER POINT
TRAINING PACKAGE
PRESENTATIONS
INFECTION PREVENTION AND
CONTROL
 BACKGROUND
Patients receiving healthcare in hospitals are at risk of
becoming infected unless precautions are taken to prevent
infection

Every person(patient or staff) must be considered

potentially infectious
 NOSOCOMIAL INFECTIONS
Also known as healthcare associated infections

This is infection that is neither present nor incubating at

the time the patient came to the health facility

DISEASE TRANSMISSION CYCLE
 DISEASE TRANSMISSION CYCLE
Understanding the disease transmission cycle is important for

healthcare workers in prevention of infection

 Teach others how to break the cycle!!!

 INFECTION PREVENTION
STRATEGIES
We can never get rid of infections completely… BUT we
can reduce the risk

 Hand hygiene compliance

 Aseptic, non-touch technique

 Early recognition & management of sepsis

 Cleaning & sterilising equipment between patient contact

 INFECTION PREVENTION
STRATEGIES CONT’
Use of Personal Protective Equipments (PPEs)

Medical waste management

Sharps disposal

 Documentation/ Labelling

 Isolation where possible

 WASTE MANAGEMENT
 Key principles
 Waste minimization and containment
 Waste segregation – separation of waste by type at place of
generation
 Waste collection, handling and storage, done using correct
equipment appropriate waste transportation
 Waste treatment to render waste non hazardous
 Waste disposal – burial or incineration
 Disposal of waste at least 50 meters away from water sources
 GENERAL RECOMMENDATIONS ON
HEALTH CARE WASTE
 Proper handling of contaminated waste (blood or body fluids
contaminated items)
 Wearing utility gloves
 Transporting solid contaminated waste to the disposal site in
covered containers
Disposing of all sharp items in puncture-resistant containers
 Burning or burying contaminated solid waste
 Washing of hands with soap and running water after disposal of
waste
 Decontaminating utility gloves and containers after disposal of
infectious waste
HAND HYGIENE
 ALCOHOL – BASED HAND RUB
FORMULA
FORMULATION 1 FORMULATION 2

Ethanol 96% 8333ml Isopropyl alcohol 7515ml

99.8%

Hydrogen Peroxide 417ml Hydrogen Peroxide 417ml

3% 3%

Glycerol 95% 145ml Glycerol 95% 145ml

Distilled or boiled and 1105ml Distilled or boiled 1923ml

 DECONTAMINATION
Process that makes inanimate objects safer to handle by staff before
cleaning
It inactivates HBV, HCV, HIV & reduces the number of organisms
but does not eliminate them)

The process of decontamination includes:

 Handling soiled instruments with gloves
 Soaking in 0.5% chlorine solution
 Rinsing metal objects before cleaning to prevent corrosion
 CHLORINE (JIK) DILUTION TABLE
TABLE 1
Desired concentration 0.5% Chlorine 0.3% Chlorine
Available 3.5% 3.5%
Volume of chlorine to be added 833.3ml 468.8ml
Amount of water 5000ml 5000ml
TABLE 2
Desired concentration 0.5% Chlorine 0.3%
Available 3.5% 3.5%
Volume of chlorine to be added 750ml 750ml
Amount of water 4500ml 8000ml
Formula:
% Conc Chlorine 1 x Volume Chlorine 1 = % Conc Chlorine 2 x Volume
 CLEANING

Process that physically removes all visible dust, soil, blood or

other body fluids from inanimate objects (kills approximately
80% of microorganisms)
 It consists of:

 Thoroughly washing with soap & water,

 Rinsing with clean water

 Drying
 HIGH LEVEL DISINFECTION
Process that eliminates all microorganisms except endospores from

inanimate objects (Kills approximately 95% of microorganisms)

 Can be achieved by 20 minutes of:

 Boiling

 Steaming

 Chemical disinfectants with chlorine 0.1%

 STERILIZATION
Process that eliminates all microorganisms (Kills microorganisms
100%)
 Methods include:

 High pressure steam (autoclave),

 Dry heat (oven)

 Chemical sterilants (cidex for 10 hours or formaldehyde for 24

hours )
 Radiation
HELLO !!!
 HAND HYGIENE
DEMONSTRATION PLUS
PRACTICE
 THE END

QUESTIONS???
TEAM WORK
WHAT IS TEAM WORK TO YOU?
 DEFINITIONS

Teamwork in health care employs the practices of

collaboration and enhanced communication to expand
the traditional roles of health workers and to make
decisions as a unit that works toward a common goal
 NEONATAL RESUSCITATION
Is a team activity
 Involves at least two people who work together to achieve a shared
goal
 Communication breakdowns are the root cause of 72% of perinatal
deaths
 BRAIN STORM

What problems have you experienced

when working in a team?
 BRAIN STORM

 How can you develop good

communication?
CLOSED LOOP COMMUNICATION

 DISCUSS
 SBAR
 Develop techniques such as SBAR
 Situation

 Background

 Assessment

 Recommendations
 SBAR CONT’
S – Situation: The Clinical state of the baby.

He is a 34 week premature, born by emergency caesarean

10 minutes

 B – Background: Baby’s identification, demographics,

medical and social history, medications.

 SBAR CONT’
 A – Assessment: Evaluation of baby s condition, medical

problems, needs and prognosis; current Management plan.

He is pink, with improving tone and heart rate 100, but takes slow

shallow breathes if we do not assist breathing.

 R – Recommendation: Advice given or discussion about

future plan. We would like you to review if Baby requires intubation

prior to Transfer to NICU

 BRAIN STORMING

How do you achieve good effective team work in a

resuscitation?
 ACTION POINTS
 Identify a team leader-ideally one managing the airway
 Assign roles-IV access, chest compressions and prepares drugs
 Precise instructions calling the team members by name
 Closed loop communication
 Practice drills
 DOCUMENTATION

Accurate and comprehensive records are important particularly in

resuscitations

 Why do you think this is important?

 WHAT INFORMATION SHOULD BE
RECORDED
When you were called, by whom and why
 Time of arrival
 Who attended
 Time of birth
 Condition of the baby at birth
 Action taken- what, when, why?
 Effect of actions
IMMEDIATE CARE AT
BIRTH
 AIM

To discuss the principles related to facilitating physiological

transition at birth as a basis for understanding when to intervene.
 LEARNING OUTCOMES
 Womb to world (Suzanne Colson)

 Initial assessment & importance of thermoregulation

 SSC (Skin to skin contact)

 DCC (Deferred cord clamping)

 Oral intake - Feeding

 Managing risk - recognising when to intervene

WISDOM at birth
WHO Senegal 2013
 OPHTHALMIA NEONATORUM
PROPHYLAXIS
 All neonates must receive eye ointment as part of immediate care
according to WHO guidelines for developing countries.

 Antibacterial based ointments such as Chloramphenicol,

Tetracycline etc. can be used to prevent and manage ophthalmia
neonatorum.
 VITAMIN K PROPHYLAXIS
 Every neonate needs it and it’s a must have essential drug at all
delivery centers.
 In utero, the fetus does not produce Vitamin K and until the gut is
colonized after birth, there is high risk of bleeding tendencies in a
neonate.
 Intramuscular administration for both term (1mg) and preterm
(0.5mg) babies provides a reservoir while awaiting production.
 VITAMIN K PROPHYLAXIS CONT’
 Double vitamin K administration is however done when the
neonate has hemorrhagic disorders.
 IV for treatment (immediate) while IM is also still given for slow
release as a reservoir.
 IV dosage is still at 1mg and 0.5mg respectively.
 Whether or not to dilute depends on the concentration available.
 PREMISE
 Most babies well at birth – nature (Resuscitation Council UK
2015)
 Right environment + right support = smooth transition
WOMB TO WORLD
JUST BORN…
 INITIAL ASSESSMENT
 Colour

Tone

Breathing

 Heart rate
 SSC
 Temperature regulation (Crenshaw, 2007)  Respiratory rate regulation

 Cry 10 times less (Moore et al, 2012)

 Lower levels of stress hormones

(Crenshaw, 2007)

 Neonate
‘colonised’
(Waller, 2010
 Cardio regulation (Phillips, 2013)

 More stable
blood sugar
levels
 WHAT IS HYPOTHERMIA?
 Normal temperature is 36.5 to 37.5°C

Temperature less than 36.5°C is hypothermic in a newborn

HOW DO BABIES LOSE HEAT?
 WHY DOES IT MATTER?
 Hypothermia means baby is more likely to die!

 Mild hypothermia 36.0 – 36.4⁰C: risk of death 1.8 times higher

 Moderate hypothermia 35.0 – 35.9⁰C: risk of death 3 times higher

 Severe hypothermia 34.0 – 34.9⁰C: risk of death 10 times higher

 Very severe hypothermia ≤33.9⁰C: risk of death 25 times higher

 Risk of death increased by approximately 75% for every 1°C

decrease in axillary temperature
Mullany et al. (2010) Arch Pediatr Adolesc Med. (2010)Jul;164(7):650-6.
Risk of mortality associated with neonatal hypothermia in southern Nepal.
 HYPORTHEMIA MORBIDITIES
 Hypoglycaemia

 Respiratory distress

 Increased tendency to bleeding particularly:

 pulmonary haemorrhage and

 intraventricular haemorrhage
 MORBIDITIES CONT’
 Peripheral oedema

 Poor feeding and Poor weight gain

 Late onset sepsis

 HYPOGLYCEMIA
Cold stress

Increased metabolism

Increased glucose utilisation

Depletion of glycogen stores

Hypoglycaemia
 RESPIRATORY DISTRESS
Cold stress Increased metabolism

Increased oxygen consumption

hypoxemia

Anaerobic metabolism

Metabolic acidosis

pulmonary vasoconstriction

Worsening Hypoxemia

Worsening Respirator Distress

HOW DO WE PREVENT HYPOTHERMIA?
Delay bathing

WHO (2007); Global health media (2015)

PREVENTION CONT’
 EFFICACY AND SAFETY OF
POLYTHENE WRAP
 In a randomized controlled
trial done in India between
April-June, 2015; application
of polythene wrap to preterm
LBW neonates after delivery
and subsequent transfer to
NICU helped in temperature
regulation
The delivery room remains the key
area for effective and immediate
thermoregulatory interventions,
including environmental
temperatures!!
 DEFERRED CORD
CLAMPING
The definition ‘deferred cord clamping’ means not clamping until at least 1-3 minutes after
delivery.
RCOG (2015) Clamping of the
umbilical cord and placental
transfusion

(2015)

(2014) Intrapartum care guidelines

 BENEFITS OF DCC
 Increased circulating blood volume
 Cardiovascular stability
 Reduced need for blood transfusion
 Reduced risk for NEC

NOTE:
DCC is not always mandatory, alternatively cord milking
is done.
ORAL INTAKE - INFANT FEEDING

Benefits…
 MANAGE RISK
 History (pre-empting e.g. maternal PET (pre-eclamptic
toxaemia; PROM; GBS; IUGR etc.)

 Vigilance

 Listen to the mother

 Recognise when to intervene

Any questions?
 SUMMARY
 Most babies do well at birth
 Facilitate physiological transition
 Apply WISDOM
 Recognise when intervention is required

Therefore important to understand physiology of

resuscitation…
 REFERENCES
 Crenshaw (2007) Care Practice 6: No Separation of Mother and Baby, With
Unlimited Opportunities for Breastfeeding, Journal of Perinatal Education 16(3):39-
43
 Moore ER, Anderson G, Bergman N, Dowswell T. (2012) Early skin-to-skin
contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev.
 National Institute of Health and Care Excellence (NICE)(2014) Intrapartum care
for healthy women and babies
 Newborn Life Support (2016) 4th ed. Resuscitation council UK
 RCOG (2015) Clamping of the umbilical cord and placental transfusion Scientific paper
number 14
 [Link]
 [Link]
 Phillips R. (2013) Uninterrupted Skin-to-Skin Contact Immediately After Birth
 Waller P (2010)Holistic anatomy: An integrative guide to the human body. Berkeley, CA:
North Atlantic Books,U.S.
NEWBORN PHYSIOLOGY
 OBJECTIVES
To understand why we follow a certain approach to newborn
resuscitation
 23% of neonatal mortality is due to birth asphyxia
 Around 10% of newborns require assistance at birth
 Less than 1% require extensive resuscitation
 Good resuscitation skills will help babies survive
BRAIN STORM
WHAT STIMULATES BABIES TO
BREATHE?
 WHAT STIMULATES BABIES TO
BREATHE
 Separation of the placenta
 Clamping of the cord

 These cause hypoxia which is a major stimulant to breath

 Physical discomfort may also provoke a respiratory response

 FIRST BREATHS
 Push fluid from airway and alveoli

 Establish resting lung volume

AERATION OF THE LUNGS
 AERATION OF THE LUNGS

Lind J. Initiation of breathing in the newborn infant.

J Ir Med Assoc 1962;50:88-93
HOW DO WE DECIDE
WHICH BABIES NEED
HELP?
DOES THIS BABY NEED HELP?
 GASPING
Primitive spinal centre

Usually suppressed by the respiratory centre

 6-12 breaths/minute

Involves all accessory muscles in maximum respiratory effort

 PATHOPHYSIOLOGY
Knowledge from animal work in the early 1960's
 Interrupted placental oxygen supply to animal fetus
 Graphs depict what happens to HR, RR, BP over time
 Cord is clamped and obstructed at time 0
 Breaths © Northern Neonatal Network
Primary
apnoea
PaO2

160

120

80

40
0
0 10 20 30 40 minutes

1. Interrupt placental oxygen - decrease oxygen in fetus 2. Fetus hypoxic - attempts to breathe

3. In utero - this will not provide an alternative oxygen supply 4. Decreased oxygen to the respiratory centre - breathing stops -
PRIMARY APNOEA
 Breaths © Northern Neonatal Network
Primary Terminal
apnoea apnoea
PaO
2
PaCO2

16
Heart
0
12 rate
0
80

40
BP
0
0 10 20 30 40 minutes

1. HR decreases and maintained due to glycogen stores in the heart

2. BP maintained as peripheral vasoconstriction and blood directed away from non vital organs

3. After a period of primary apnoea, primitive spinal centre - gasping

4. If hypoxia continues - gasping will cease - TERMINAL APNOEA

 Breaths © Northern Neonatal Network

PaO2

PaCO2

160 Heart
120 rate

80

40
BP
0
0 10 20 30 40 minutes
Birth
1. If baby born in primary apnoea

2. Will gasp (spinal reflex)

3. If HR present, oxygen carried to the coronary arteries, increased oxygen delivery to heart and brain

4. Baby will establish normal respirations

 Breaths © Northern Neonatal Network

PaO2

PaCO2

160 Heart
120 rate

80

40
BP
0
0 10 20 30 40 minutes
Birth
1. If baby born in terminal apnoea 2. No gasping

3. No increase in oxygen 4. HR decreases

5. Baby will die without intervention

 Breaths © Northern Neonatal Network

PaO2

PaCO2

160
Heart
120 rate

80

40
BP
0
0 10 20 30 40 minutes
Birth
1. If baby born in terminal apnoea 2. No gasping

3. No increase in oxygen 4. HR decreases

5. BABY WILL DIE WITHOUT INTERVENTION

 Breaths © Northern Neonatal Network

PaO2

PaCO2 Lung
inflation
Ventilation
160 Heart
120 rate

80

40
BP
0
0 10 20 30 40 minutes
Birth
1. If baby born in terminal apnoea - LUNG INFLATION 2. Oxygen increases

3. Provided HR adequate, increase oxygen supply to heart and brain

4. Baby gasps - respiratory centre oxygenated - spinal centre suppressed

5. Baby establishes regular respirations

 CONCLUSION
 Important to understand the physiology to understand a logical
approach to resuscitation

 Most babies will respond to airway support

 If no HR despite appropriate airway support - chest compressions

to move oxygenated blood to the coronary arteries.
QUESTIONS?
 REFERENCES
 NLS (Newborn Life Support) Guidelines 2016, Resuscitation
Council (UK)

 ILCOR (International Liaison Committee on Resuscitation)

Guidelines 2015

 RCPCH (Royal College of Paediatrics and Child Health, UK)

website
 APPROACH TO
RESUSCITATION
AT BIRTH
 INTRODUCTION

 This lecture should enable you to: develop a logical approach to

resuscitation at birth
EQUIPMENT
 APPROACH
Dry & cover the baby
 Assess the situation
 Airway
 Breathing
 Inflation breaths
 Chest compressions
 (Drugs)
 INITIAL ACTIONS
 Start the clock
 Dry the baby
 Assess

 Do you need help?

 INITIAL ASSESSMENT
 Colour

 Tone

 Breathing

 Heart rate
 SCENARIO 1
Blue hands and feet, pink trunk

 Good tone

 Breathing regularly

 Fast heart rate

ACTION
 SCENARIO 2
Blue

Moderate tone

Breathing irregularly

 Slow heart rate

ACTION
 SCENARIO 3
Blue or pale

 Floppy

Not breathing

Slow or very slow heart rate

ACTION
 AIRWAY
In the unconscious baby airway
obstruction is usually due to
loss of pharyngeal tone
Not foreign material in the airway
IMPORTANT POINT TO NOTE
 AIRWAY & BREATHING

Hold head in neutral position

Apply mask with jaw support

 Give inflation breaths

NEUTRAL POSITION
APPLY A WELL FITTING FACEMASK
 AIRWAY & BREATHING
Hold head in neutral position

Apply mask with jaw support

Give inflation breaths

START WITH AIR

INFLATION BREATHS

 five breaths,
each sustained for 2-3 s
at 30 cm water pressure
 ACTION
 Give inflation breaths then reassess

What would you hope to find ?

An increase in HEART RATE

HOW WILL YOU ASSESS HEART RATE?
Stethoscope

 Pulse oximetry

 ECG
 FINDING

If the heart rate responds

you can assume
the lungs have been inflated
 FINDING
If the heart rate does not respond
to inflation breaths then:-
either
You have NOT inflated the lungs
or
The heart needs help to respond
How can you tell which is true ?
 FINDING

If the lungs are being inflated

then the chest will move
 FINDING
If the chest is not moving
the lungs are not being inflated

Check A & B
TWO PERSON AIRWAY SUPPORT

Jaw thrust
+
Bag valve mask
JAW THRUST
OROPHARYNGEAL AIRWAYS
 PARTICULATE AIRWAY
OBSTRUCTION
 Meconium
 screaming babies have an open airway
 floppy at birth - ?have a look

 Thick mucus
 Blood
 Vernix
 INSPECTION AND SUCTION

Laryngoscope

 Large bore sucker

 Suction under direct vision

 FINDING

The heart rate has increased

and is now above 100…

but the baby is not breathing

Ventilate at ~ 30 breaths per minute until the baby is breathing well

 WHAT IF…

…. the chest IS moving

but the heart rate is still very slow/absent

 30 seconds of ventilations

If the heart rate remains very slow/absent

Commence chest compressions
 CHEST COMPRESSIONS - 3:1
 You want to move oxygenated blood from the lungs to the
coronary arteries

 It’s not that far and won’t take long

 Consider supplemental oxygen

 REASSESS
 Has the heart rate improved?
No?

 Check airway
 Check chest movement
 Check chest compressions
 CONSIDER DRUGS
 Glucose
 3 to 5ml/Kg
 Adrenaline (1: 10 000) at
 0.1ml/Kg first dose
 0.3 ml/Kg second dose
 Bicarbonate
 Dose is 1 to 2 mmol/Kg/dose
 N.B If you have bicarbonate of concentration of 0.84, 1ml=
1mmol
 If you have bicarbonate of concentration 0.42, 1ml=0.5mmols

 (Volume - rarely)
 WHAT NEXT ?
Reassessment
 Temperature
 Blood sugar

 Parents
 Records
Team debrief
 POOR PROGNOSIS IF :

RESUECITATIONS GOES FOR 20MINUTES OR OVER

END OF PRESENTATION
 SUMMARY
Dry & cover the baby
 Assess the situation
 Airway
 Breathing
 inflation breaths
 Chest compressions
 (Drugs)
Prematurity
 WHY IS THIS IMPORTANT?
 Important to understand the different needs of the premature
neonate

 To enable a better approach to resuscitation of the premature

baby
 PHYSICAL SIGNS OF PREMATURITY?
 Body hair (lanugo)

 Skin thin and shiny

 Less body fat

 Lower muscle tone

 Less active

 May have problems feeding, poor suck with uncoordinated

suck/swallow
 PROBLEMS OF PREMATURITY?
 Temperature Control get cold even faster

 Less Body fat have fewer reserves

 Fragile lungs don’t breathe effectively

 Infection risk Need to think about need for antibiotics

 Feeding difficulties May require tube feeding

 Jaundice May need phototherapy

 NEC Cautious increase of milk feeds

WHICH PREMATURE BABIES DO WE
WORRY ABOUT?

 37 to 42 weeks Term Babies

 34 to 36 weeks
 31 to 33 weeks

30 weeks and below DIFFERENT

 ASSISTANCE VS RESUSCITATION
 Most premature babies are breathing at birth and only need help
with their transition to air breathing

Most premature babies do not need to be resuscitated

(ASSISTED TRANSITION VS RESUS)

 AT BIRTH
 Consider delayed cord clamping (1-3 minutes)

 Keep babies warm

Gentle lung inflation

 ADVANTAGES OF DELAYED CORD
CLAMPING:

 Increases circulating blood volume

 Improves cardiovascular stability
 Decreases the need for a blood transfusion
 Decreases intraventricular haemorrhage (all grades)
 Decreases the risk of necrotising enterocolitis (NEC)
 DELAYED CORD CLAMPING:
Provided babies are kept warm - delayed cord clamping for at
least 1 to 3 minutes

 However, if resuscitation required, this takes priority

 KEEP WARM
 Dry baby
 For those < 1.5kg, wrap in plastic
(polythene) bag
 Wrap in dry warm towels
 Hat on head
 Keep environmental temperature at
24-26 degrees Celsius.
 Avoid draughts – close windows
 GENTLE LUNG INFLATION:
 If baby not breathing or breathing
ineffective and needs ventilation-
 Choose appropriate size mask
 Use gentle bag-valve-mask ventilation
 Enough 'squeeze' to see chest wall rise
 Once lungs aerated, ventilate at about 30
breaths a minute
 POST RESUSCITATION CARE
 Transfer to the neonatal unit
 Keep warm (hypothermia with a
temperature < 36.5 degrees is
associated with increasing mortality
and morbidity) – kangaroo care if
possible
 Commence early feeds with
breastfeeding or expressed breast
milk
 Antibiotics if risk of infection is
present.
MECONIUM
 MECONIUM
 Meconium is formed at 12-14 weeks gestation

 More common in term neonates

 Prevalence at 38 weeks approximately 10%

 Aspiration (Meconium below vocal cords) occurs in 20-30% of infants

born through Meconium

 1-9% of these babies will develop MAS (Meconium aspiration syndrome)

 Mortality associated with MAS and PHT (pulmonary hypertension) can be

as high as 20%
 CURRENT RECOMMENDATIONS:
 Do not perform oropharyngeal suctioning at the perineum as
the baby is being delivered

 Do not routinely perform tracheal intubation for suctioning of

Meconium in nonvigorous babies born through Meconium

 However, if thick particulate Meconium present then

reasonable to rapidly visualise the oropharynx and
suction under direct vision
 CURRENT RECOMMENDATIONS
 Emphasis should be on rapid initiation of ventilation in babies who
are not breathing or are ineffectively breathing
 If not able to move the chest wall and difficulty ventilating, then
consider a Meconium plug and suction under direct visualization/
intubate
 POST RESUSCITATION CARE IN
MECONIUM ASPIRATION
Significant Meconium at birth and baby well enough to stay on
postnatal ward with mother -
Closely observe the baby at 1 and 2 hours of age and then
2-hourly until 12 hours of age
Non- significant Meconium, observe the baby at 1 and 2 hours of
age in all birth settings.
Temp, HR, RR

Look at responsiveness and colour

Discuss with doctor if any concerns or measurements outside

normal values
 REFERENCES
NLS (Newborn Life Support) Guidelines 2016, Resuscitation
Council (UK)

ILCOR (International Liaison Committee on Resuscitation)

Guidelines 2015

RCPCH (Royal College of Paediatrics and Child Health, UK)

website
END OF PRESENTATION
 DRUGS USED IN
RESUSCITATION AND
INFECTION PREVENTION
 DRUGS USED IN RESUSCITATION
Drug Concentration Dose Monitoring
Adrenaline 1: 10000 1st dose: 0.1ml/kg body Blood pressure and heart rate.
injection weight.
If heart rate still ˂ 60
beats/minute give
2nd dose at 0.3ml/kg body
weight

Dextrose 10% 3-5ml/kg bolus Blood glucose levels.

Hyperglycemia causes osmotic fluid
shifts that may result in rapid
dehydration and
intraventricular hemorrhage in
neonates.
Following hyperglycemia, rebound
hypoglycemia can occur because of
stimulation of
 INTRAVENOUS FLUIDS
RECONSTITUTION
 To prepare Dextrose 10%
 To 500ml 5% dextrose, add 62.5ml 50% Dextrose

 To prepare ⅟₄ strength darrows in 10% dextrose

 To 500ml ⅟₂ strength darrows in 2.5% dextrose, add 93.8ml
50% Dextrose
 INTRAVENOUS FLUIDS
RECONSTITUTION CONT’
 To prepare ⅟₄ strength darrows in 12.5% dextrose
 To 500ml ⅟₂ strength darrows in 2.5% dextrose, add 133.3ml
50% Dextrose

 To prepare ⅟₄ strength darrows in 15% dextrose

 To 500ml ⅟₂ strength darrows in 2.5% dextrose, add 178.6ml
50% Dextrose
 INTRAVENOUS FLUIDS RECONSTITUTION
CONT’

 To prepare 5% dextrose in ringers lactate

 To 500ml ringers lactate, add 55.6ml 50% Dextrose

 To prepare 10% dextrose in ringers lactate

 To 500ml ringers lactate, add 125ml 50% Dextrose
 INTRAVENOUS FLUIDS RECONSTITUTION TABLE 1
Desired Dextrose ⅟₄ ⅟₄ ⅟₄ strength 5% 10%
darrows in
concentr 10% strength strength Dextrose dextrose
15%
ation darrows darrows dextrose in in ringers
in 10% in 12.5% ringers lactate
dextrose dextrose lactate
Available Dextrose ⅟₂ ⅟₂ ⅟₂ Ringers lactate Ringers lactate
5% 500ml strength strength strength 500ml 500ml
darrows darrows darrows
in 2.5% in 2.5% in 2.5%
dextrose dextrose dextrose
500ml 500ml 500ml
Volume of 62.5ml 93.8ml 133.3ml 178.6ml 55.6ml 125ml
50%
dextrose to
be added
IN TABLE 1.
The calculated volume of 50% dextrose is added to the available fluid to come up
with a final volume which is more than 500ml. This may present a problem with
mixing especially if the volume to be added is large.
 INTRAVENOUS FLUIDS RECONSTITUTION TABLE 2

Desired 500ml ⅟₄ strength ⅟₄ strength ⅟₄ strength 5% dextrose 10%

concentrati Dextrose darrows in darrows in darrows in in ringers dextrose in
on 10% 10% 12.5% 15% lactate ringers
dextrose dextrose dextrose 500ml lactate
500ml 500ml 500ml 500ml
Available Dextrose 5% ⅟₂ strength ⅟₂ strength ⅟₂ strength Ringers lactate Ringers lactate
500ml darrows in darrows in darrows in 500ml 500ml
2.5% 2.5% 2.5%
dextrose dextrose dextrose
500ml 500ml 500ml
Subtract
from 500ml 55.6ml 79ml 105.3ml 131.6ml 50ml 100ml
of available
Volume of
50% 55.6ml 79ml 105.3ml 131.6ml 50ml 100ml
dextrose to
be added

IN TABLE 2
the calculated volume of is subtracted from the available fluid and the same
volume of 50% dextrose is added to keep the final volume at 500ml. This provides
for better mixing and efficient dosing.
 DRUGS USED IN RESUSCITATION

Drug Concentration Dose Monitoring

Sodium chloride 0.9% 10-20ml/kg over 5 Assess for fluid overload
(Normal saline) – 10 minutes if
evidence of APH in
mother

Sodium 4.2% 1-2 mmol /kg Electrolytes, including potassium

bicarbonate bicarbonate(2-4ml/ and calcium.
Kg of 4.2% solution Measurement of arterial blood gas.
Of bicarbonate)

Example : If Sodium bicarbonate in stock is 7.5%( 0.892 mmol/ml):

0.892mmol = 1ml
6mmol = Xml
X = 6.7ml of NaHCO₃ 7.5% to be drawn and infused in 60ml of 10% Dextrose ( or
 SODIUM BICARBONATE(NaHCO₃) INFUSION
PRESENTATION:

PERCENT OF CONCENTRATION IN CONCENTRATION IN mmol/ml

SODIUM mmol/5ml (meq/ml)
BICARBONATE (meq/5ml)
4% 2.4 mmol/5m l (2.4meq/5ml) 0.48mmol/ml (meq/ml)

4.2% 5 mmol/5m l (2.4meq/5ml) 0.5mmol/ml (meq/ml)

7.5% 8.92 mmol/10ml 0.892mmol/ml (meq/ml)

(2.4meq/10ml)

8.4% 10 mmol/10m l (2.4meq/10ml) 1.0mmol/ml (meq/ml)

THANKS FOR LISTENING
 OUTLINE
 Introduction
 Brain Development Processes
 Neurobehavioral and cognitive morbidities related to neonatal
period
 Developmentally Supportive Care
 Neonatal Care Practice
 INTRODUCTION
 Developmentally supportive care
 a philosophy of care
 integrates the developmental needs of each individual infant
and their family
 it is within a medical framework (Sehgal & Stack, 2006).
 It maximises neurological development and reduces long-term
cognitive and behavioural problems.
 INTRODUCTION CONT’
Neonatal nursery environments can provide stressful stimuli to
premature and sick infants.

 Preterm infants are born prior to or during critical periods of

brain development.
BRAIN DEVELOPMENT PROCESSES
Stage Tasks Period
 BRAIN DEVELOPMENT PROCESSES
Stage Tasks Period

Neurogenesis Forming neurons Embryonic until before birth

Neural migration Organizing the brain -neurons to Prenatally up to 8 to 10 months

specific areas after birth.

Myelination Coating the axon Before birth until late in

adolescence.
(Breast feeding contributes
more)

Synaptogenesis Forming networks of connections Prenatally and continues

in the brain throughout life.

Pruning Weeding out unnecessary Begins from early childhood

connections and strengthening
 Neurobehavioral and Cognitive
Morbidities related to neonatal period
 Early
 Cerebral palsy,
 Hearing loss,
 Visual impairments
 Developmental delay,
 Later - preschool or school age problems
 Cognitive
 Behavioural
 DEVELOPMENTALLY SUPPORTIVE
CARE
 Aims to implement modifications of nursery environment and
care practices

 Reduce stress on infants and promote normal neurological

development to reduce morbidity.
The Universe Developmental Care Model
NEONATAL CARE
PRACTICE
 Pain & Stress Assessment &
Management
Assess
 Neonatal Infant Pain Scales

 Manage
 Pain should be presumed in ALL NEONATES IN ALL SITUATIONS
that are usually identified as painful in children and adults
 Pain management should be instituted in ALL CASES WHERE PAIN
IS PRESUMED
 PAIN & STRESS ASSESSMENT &
MANAGEMENT
 Mitigate
 Breastfeeding - the neonate must have an effective
latch, with sustained sucking and swallowing for at least 5
minutes prior to the procedure

Skin-to-skin care / Kangaroo Care - diminishes pain

responses in term and preterm neonates and supports their
recovery following completion of painful procedures

Non-nutritive sucking - supports regulation of

preterm and new-born infants and reduces acute
procedural pain compared to no treatment
 PROTECTED SLEEP
 Sleep is very important in neonatal development
 Assess
 Protect
 Modify the neonatal nursery environment
 Reduce noise levels
 Minimal light
 Minimal handling
 FAMILY CENTRED CARE
 Equal family participation
 Mothers given unrestricted access to the infants.

Collaboration
 Involved in the plan of care – KMC

Family respect and dignity

 Assessment of family’s level of emotional well-being and
parental confidence and competence
 Family knowledge

Education and involvement of Parents/Caretakers and

acknowledging their role
 HEALING ENVIRONMENT
 Physical
 Infrastructure, necessary equipment and accessories
 Human
 Knowledgeable and skilled human resource capital
 System
 A collaborative healthcare team that emanates
teamwork, mindfulness and caring.
 ACTIVITIES OF DAILY LIVING
 Neuro-muscular-skeletal Development Support (Nesting and
posture boundaries)
 Infection prevention
 Provision of warmth
 Fluids and nutrition
 Monitoring
 INTRODUCTION
 Neonatal nursery/NICU environments can
influence the neonate and we can influence the
environment
 Autonomic Stability
 Posture and movement
 State regulation
 Active engagement
 Otherwise the infant may develop
 Nursery acquired morbidities
INTRAUTERINE ENVIRONMENT VS EXTRA-
UTERINE ENVIRONMENT

Intrauterine Extra-uterine
Extra-uterine Intrauterine
 NEURODEVELOPMENT
 Tone develops
 Caudal-cephalo direction

 Distally to proximally

 Influenced by cramped environment

MUSCULOSKELETAL DEVELOPMENT
 NURSERY ACQUIRED DEFORMITIES
 Retracted shoulders

 Hyperextended neck

 Frogged legs

 Everted Feet

 Plagiocephaly
 NESTING PROCEDURE
 Nesting plays a role in maintaining position. (Joanna Briggs
Institute, 2010)

 Materials: - 2 pieces of linen or Chitenje (Chitenge)

MANAGEMENT – NESTING
MANAGEMENT – NESTING
MANAGEMENT – NESTING
MANAGEMENT – NESTING
MANAGEMENT – NESTING
MANAGEMENT – NESTING
 MANAGEMENT –POSITIONING
 Developmentally supportive positioning is important to
optimise musculoskeletal development and behavioural
organisation
 Prone: - Symptomatic preterm infants with signs of respiratory
distress VLBW and severe GRD may benefit from this position
during sleep (Joanna Briggs Institute, 2010)
 Supports sternum and rib cage
 Optimal for oxygenation
 Increase time in quiet sleep
 Lowers energy expenditure
 Baby must be monitored
 MANAGEMENT –POSITIONING
 Supine: - Healthy preterm infants should be positioned supine
during sleep while in the NICU (John Hunter Children’s
Hospital, 2012)

 Increased heat loss and energy consumption.

 Difficult for the infant to move against gravity and get into a
flexed (tucked up) position.
 MANAGEMENT –POSITIONING
CONT’
 More startle behaviours and motor disorganisation.

 Safest position for sleeping for babies who are off monitors and
at home.

 Nesting or wrapping should support bringing the arms to the

middle/face and minimise hip abduction (frog legged position).
 MANAGEMENT – POSITIONING
CONT’
 Left lateral: position can be adopted for reducing
gastroesophageal reflux in premature infants (John Hunter
Children’s Hospital, 2012)
 Easy for baby to comfort self e.g. hand to mouth/face.
 Allows hands midline.
 Prevents retraction of shoulders and abduction of legs.
 Reduces heat loss and energy consumption.
 Boundaries to support this position are necessary.
MANAGEMENT – POSITIONING CONT’
 Changing position: - change in body position from
horizontal to head-up tilt should be induced smoothly in
very immature and unstable infants, because this
intervention may affect cerebral perfusion. (Joanna
Briggs Institute, 2010)
 CONCLUSION
 Neonatal care should recognise the physical, psychological and
emotional vulnerabilities of premature and/or critically ill
infants and their families.
 Our care should focus on minimizing potential short and long-
term complications associated with the hospital experience.
 REFERENCES
 Coughlin, M., Gibbins, S. & Hoath, S. (2009). Core measures for
developmentally supportive care in neonatal intensive care units:
theory, precedence and practice. Journal of Advanced Nursing,
65(10): 2239–2248. DOI: 10.1111/J.1365-2648.2009.05052.X
 Joanna Briggs Institute. (2010). Positioning of preterm infants for
optimal physiological development: best practice. Evidence-based
information sheets for health professionals, 14(18):1–4
 John Hunter Children’s Hospital. (2012). Positioning for the
preterm or sick neonate in NICU.
JHCH_NICU_6.02, 1-14
 REFERENCES CONT’
 Sehgal, A. & Stack, J. (2006). Developmentally supportive care and
neonatal individualised developmental care and assessment
programme. Indian Journal of Paediatrics, 73(1): 1007–1010.
The Women’s. (2015). Developmental Care: Newborn intensive
and special care. The Royal Women Hospital.
KANGAROO MOTHER
CARE
 OUTLINE
 Introduction
 Components
 Referral
 Discharge
 Implementation
 Demonstration
 Definition
 Types of KMC
 Eligibility Criteria
 Benefits
 Requirements
BACKGROUND OF KANGAROO CARE
Kangaroo mother care is a simple, inexpensive way to care for
LBW infants.

 The method was first introduced in Bogotá, Columbia in 1979

by Dr Martinez and Rey to deal with overcrowded neonatal units
and a shortage of incubators.
 BACKGROUND CONT’
 Almost two decades of implementation and research have made
it clear that KMC is more than an alternative to incubator care.

 It has been shown to be effective for thermal control,

breastfeeding and bonding in all new-born infants, irrespective
of setting, weight, gestational age, and clinical conditions.
 KMC EXTENT
 It has been introduced into the medical establishment of both
the developed and developing world as a safe and effective
alternate and complement to incubator care for LBW babies.

 Many hospitals in Europe, Asia and the Americas have adopted

KMC
 KMC EXTENT CONT’
 In Africa, it is being practiced in several countries, including
Zimbabwe, Mozambique, South Africa, Ethiopia, Nigeria and
Malawi.

 In Zambia, implementation in progress-KMC implementation

guidelines recently done.
 DEFINITION 1
 Early, prolonged and
continuous skin-to-skin contact
between a mother or a
substitute of the mother
and her low birthweight
neonate, both in hospital and
after discharge, until at least
the 40th week of post-natal
gestational age, with ideally
exclusive breastfeeding and
proper follow-up”
 Acta Paediatrica 1998;87:440-5
 DEFINITION 2
 A method of caring for small babies that has been shown to
maintain warmth, improve feeding, reduce infections, and
encourage bonding

 KMC can reduce mortality by up to half in babies weighing less

than 2000g.
 TYPES OF KMC
 Continuous KMC
 KMC continuously practiced ideally for 24 hours a day except for
very short periods when the mother requires to attend to her
personal needs.
 Usually done on stable babies.

 Intermittent KMC
 KMC practiced intermittently for shorter periods within 24 hours.
 It is mostly used for clinically unstable, sick or very small babies
that can only tolerate being in KMC position for a few hours.
 INDICATIONS FOR INTERMITTENT
KMC
 Babies who have been started on antibiotics for suspected
infection.
 Babies on nasal oxygen.
 Babies on CPAP.
 Babies under phototherapy.
 It is also used when mothers are not able to practice continuous
KMC for various reasons e.g. Maternal illness, immediate post
caesarian section and when there is no other family members to
assist in putting the baby in KMC position.
 ELIGIBILITY CRITERIA
Preterm or Low birth weight and baby should be stable.

 No major illness present e.g. septicaemia, Pneumonia, Respiratory

distress and Convulsions.

 Mother should be willing to do KMC

 BENEFITS OF KMC
 To the baby
 Improved cardiac and respiratory stability.
 Fewer episodes of desaturation & apnea.
 KMC can successfully treat mild respiratory distress.
 Improved gastrointestinal function.
 BENEFITS TO THE BABY CONT’
 Initiation and increased duration of breastfeeding
leading to satisfactory weight gain
 Decreases energy expenditure.
 Protection against infections
 Effective thermal control
 BENEFITS TO THE BABY CONT’
 Infants are much less stressed and this provides
neurological protection.
 Improved neurodevelopment.
 Better organised sleep patterns
 More mature and organised electrical brain activity
 BENEFITS OF KMC

Benefits to the mother

 Confidence in caring for her infant is boosted
 Improved bonding with infant due to the physical
closeness.
 Empowered to play an active role in their infants care
 Enabled to become the primary care giver of the infant
 Breast feeding is promoted
 BENEFITS OF KMC CONT’

Benefits to the Hospital

 Significant cost-savings as well as better outcomes
 Less dependence on incubators
 Less nursing staff necessary
 Shorter hospital stay
 Improved morale & quality of care
 KMC REQUIREMENTS
An adult ( Mother, Father or Guardian)
 Wrappers
 Towels
 Head gear
 Napkin
 Socks
 COMPONENTS OF KMC

 There are 4 components of KMC

 Kangaroo position (skin to skin contact-warmth):

 Kangaroo nutrition

 KMC support

 KMC Discharge
 KANGAROO POSITION

Dress the baby in a nappy and cap

With the mother’s top open, place the baby between the mother’s
breasts in an upright position.

 Turn the head on the side in a slightly extend position.

 This is to keep the airway open
 It also allows eye to eye contact between
mother and baby.
 POSITION CONT’
Tie the binder firmly enough so that the baby will not slide out.
 Ensure that the tight part of the cloth is over the baby’s chest and
beneath the ear.
 The baby’ abdomen should not be constricted and should be
somewhere at the level of the mother’s stomach.
 Ensure that the baby has enough room to breath.
 The thighs should be flexed at the hip joint in a frog like position.
KMC POSITION
EXAMPLES OF DIFFERENT BINDERS
 KANGAROO NUTRITION
Exclusive breastfeeding at regular intervals every 2-3 hours.
 Initially tube or cup feeding before breastfeeding is established
 KMC SUPPORT
 As the mothers are doing the KMC they need to be supported

physically and emotionally by:

 The medical staffs

 Relatives and spouses

 The community at large.

 MONITORING OF BABIES ON KMC

 This should be done at least every 4 hours

 Temperature
 Pulse/Heart rate
 Respiratory rate
 Activity
 Colour
 Fluid Intake and output
 MONITORING OF BABIES ON KMC
CONT’

 If there is a problem, e.g. hypothermia or hypoglycaemia,

more frequent monitoring is needed, at least every 2
hours.

 If vital signs are abnormal, specify what actions should be taken and
monitor whether actions made a difference
 MONITORING CHARTS
 Weight

 Feeds

 Vitals (TPR)

 KMC Scoring Sheet

KMC MONITORING/
PRE-DISCHARGE
SCORE SHEET
 DISCHARGE

 Criteria for discharge from KMC

 Consider early discharge of the baby from facility if:
• Baby is feeding well
• Maintaining stable body temperature in KMC position (axillary
temperature of 36.5oC – 37.5oC)
• The baby is gaining weight (15g per day on three consecutive
days).
 DISCHARGE CONT’
 In addition, criteria for the mother includes:
 The mother is capable of breastfeeding and expressing breast

milk.
 The mother accepts the method, is willing to continue with

KMC at home and has support from family.

 The mother should be able to identify danger signs and bring

back the baby to the hospital.

COUNSELLING OF MOTHER AND
FAMILY ON DISCHARGE

The most important element for the mother or guardian

to remember is the skin-to-skin contact.
 This skin-to-skin contact is to be maintained
continuously, as practically, as possible, day and night,
even during work, such as preparing food and ironing
 During the time the mother is not able to perform skin-
to-skin contact (e.g. when taking a shower or bath), a
relative or husband as applicable, can take over.
 DANGER SIGNS REQUIRING
RE-ADMISSION
 When the baby:
 Stops feeding, is not feeding well, or vomits;
 Becomes restless and irritable, lethargic or unconscious;
 Has fever (body temperature above 37.5°C);
 Is cold (hypothermia - body temperature below 36.5°C) despite
rewarming;
 DANGER SIGNS REQUIRING
RE-ADMISSION CONT’
Has convulsions;
 Has difficulty breathing;
 Has diarrhoea;
 If the baby is not gaining weight despite feeding counselling in
the previous visit need to be readmitted
 DISCONTINUING KMC

KMC should be discontinued when the baby reaches

term (gestational age around 40 weeks) or 2500g
 Usually, around that time the baby also outgrows the
need for KMC
 He or she starts wriggling to show that he or she is
uncomfortable, pulls his limbs out, cries and fusses
every time the mother tries to put him back skin-to-
skin.
 This is the right and safe time for the baby to be
gradually weaned from KMC.
 FOLLOW-UP OF BABIES /COMMUNITY
KMC
 It is important to ensure follow-up after discharge.

 This can be done either at the facility or by a skilled provider near

the baby’s home.

 The smaller the baby is at discharge, the earlier and more frequent

follow-up visits s/he will need.

 FOLLOW-UP OF BABIES /COMMUNITY
KMC

 In most circumstances, the following guidelines will be valid:

 Two follow-up visits per week for babies less than 1.5kgs
 Follow-up visit every 2 weeks from 1.5kgs to 2kgs.
 However, in very LBW babies, daily follow-up may be
needed.
 If this is not possible, the discharge may need to be
delayed until fewer visits are required.
REFERRAL FOR BABIES IN KMC
 Babies who are already in kangaroo mother care should be referred
back to NICU if:
 Their weight gain is less than 10g per day for three consecutive
days
 They are losing weight
 They exhibit danger signs, e.g. difficulty in breathing, fever or
reduced activity, diarrhoea and difficulty with feeding.
 REFERRAL CONT’
 Explain the reasons for referral to the mother and
family and respond to their concerns.

 A referral note is crucial to provide the reasons for

referral to the referral facility

 SBAR communication technique must be used.

 KMC IMPLEMENTATION
Setting up KMC in a hospital
 Requirements:
• Staff to be trained in KMC.
• A well-ventilated room preferably near the maternity and nursery
• Equipment and supplies
• Cardiac or low wide beds, Mattress, Linen and Pillows.
• Linen for mothers and babies (gowns and wrappers).
 KMC IMPLEMENTATION CONT’
Feeding items (cups, small buckets, NG tubes).
 Plastic buckets with decontamination solutions.
 Heaters
 Infant weighing scales
 Comfortable chairs for both mothers and nurses.
 Recreational facilities (TV, Radio, Wool, Needles and Magazines)
 Bed side lockers
 KMC IMPLEMENTATION CONT’
 Wall thermometers
 Disinfectants
 Hand soap
 Hand wash facility.
 Cupboard for storing medicines cups and NGTs.
 Rubbish bins and bin liners etc
 COMMUNITY KMC
 It is important to have well-functioning facility-based services
available before introducing KMC in the community as community
KMC must link with facility-based services for successful
implementation.

 Institutions planning to implement KMC should have both a policy

and guidelines on KMC.
Demonstration on how to
put the baby in KMC
Position
END OF PRESENTATION
BREASTFEEDING
 OBJECTIVES

Understand the importance of

exclusive breastfeeding
 To acquire knowledge on benefits
of breastfeeding
 List the composition of breastfeeding
 Explain the physiology of lactation
DISCUSS breastfeeding counseling
and contraindication
 INTRODUCTION
 Breastfeeding is a normal way of providing infants with appropriate nutrients
that is needed for growth and development
 Breast milk is best milk for the baby, always advocate for exclusive
breastfeeding for the first six months of life.
 Therefore, it is encouraged for infants to receive appropriate
complementary foods and continued breastfeeding for at least 2 years.
 PHYSIOLOGY OF LACTATION

 The milk production reflex

When the baby suckles, the sensory nerve ending in the brain causes vagal
stimulation of impulses in the hypothalamus

This causes the anterior pituitary to release prolactin

Prolactin acts on the milk producing cells on the breast

The milk is stored in Alveolar of the mammary gland

 MILK EJECTION
Sensory nerve impulses start as the baby suckles on the nipple causing the
posterior pituitary to release oxytocin

This make the myoepithelial cells around the alveoli and ducts to contract

This squeezes milk from the alveoli ducts and sinuses towards the nipples

This causes ejection of milk/let down reflex

 TYPES OF MILK CONT’
Breast milk is also composed of foremilk and hind milk.

Foremilk is high in carbohydrates and is good for energy

production. This milk is released first during a feeding session.

 Hind milk follows later in the breastfeeding session and is high in

fat content. It therefore aids in building the adipose layer of the

newborn.
 TYPES OF MILK CONT’
 It is important that the newborn receives both hind and fore milk when feeding
hence a mother must be counselled to feed the baby for at 20mins per session.
 After suckling from one breast the newborn must be placed on the second
breast.
 For the next breastfeeding session the newborn must start suckling from the
second breast from the previous breastfeeding session.
 BENEFITS OF BREAST MILK
TO THE BABY
Breast milk facilities a successful transition to extra uterine
environment
 Ideal nutrition for growth and development of the baby
 Contains immunoglobulins that builds the immunity
 Lessens the incidence of gastrointestinal infections, allergies
Breast milk promotes healthy weight
 BENEFITS OF BREASTMILK CONT’
TO THE MOTHER
 Improves bonding
 Reduces stress levels (by production of endorphins)
 Promotes lactation
 Promotes involution to also avoid PPH and anaemia (by the action of
Oxytocin)
 Lowers risk of breast and ovarian cancer
 May prevent menstruation (Lactational Amenorrhea)
 Saves time and money
 BREASTFEEDING COUNSELING
 Adequate and timely information during the antenatal period is very cardinal,
hence breastfeeding education has to be commenced early, continued during
intrapartum, and postnatal period has shown to increase breastfeeding rates.
 Mother with preterm infants, should understand the benefits of breast milk,
therefore, the practical aspects of expressing breast milk should be emphasized.
 Mothers who want to use formula milk should be assessed on AFASS
(Acceptable, Feasible, Affordable, Sustainable and Safe) to ensure safety for the
infant.
BREASTFEEDING COUNSELING CONT’
Mother has to be counselled on the importance in order to facilitate a successful
breastfeeding period regardless of parity (not just first time mothers)
 Position and latching
 Mother has to attain a correct position and attachment which is vital to achieve
adequate seal, sufficient negative pressure and an adequate suckling mechanism
for effective milk transition.
 Position for breastfeeding include the following cradle hold, football hold,
cross cradle and lying down.
BREASTFEEDING POSITIONS
BREASTFEEDING COUNSELING CONT’
Signs of effective attachment  Signs of poor attachment
 Baby’s mouth wide open  Painful breastfeeding
 Lower lip turned outwards with
 Baby latching just the nipple and
the baby’s chin touching not hearing the baby swallow
the mother’s breast
 Their cheeks are drawn in and
 Majority of areola inside baby’s
dimpled
mouth
 You hear clicking or smacking
noises as the baby tries to suckle
BREASTFEEDING COUNSELING CONT’
DEMAND FEEDING
Initiate breastfeeding within an hour of delivery
 The infant is allowed to feed on demand and taught how to
recognize hunger cues
 Infants should be allowed to feed as long and frequently as they
want
 DEMAND FEEDING CONT’
In preterm, the ability to breast feed from the breast will mature
with time, hence it’s important to allow the successful transition
from tube feeding to breastfeeding.
 Nutritional adequacy can be provided by expressed breast milk
administered via tube or cup initially to precise assessment.
 Its important to understand that before discharge, the infant
should have feeds established, feeding well and picking on weight.
 Acceptable premature weight loss (5-10%) post-delivery.
 BREASTFEEDING PROBLEMS
Inadequate lactation
 Incomplete breast emptying
 Inadequate frequency of feeds and duration
 Incorrect latching
 Tender and cracked nipples
 BREASTFEEDING PROBLEMS CONT’
Incorrect position and latching
 Correct positioning and latching prevents nipple cracking and
injury

 Cracked nipple can result in engorgement

BREASTFEEDING PROBLEMS CONT’
 Breast engorgement and blockage
 Caused by incomplete emptying of the breast.
 Engorgement and blockage can be resolved by:
 Correct position and complete emptying of the breast
 Manually expressing of breast milk and massaging towards the nipple
 BREASTFEEDING PROBLEMS CONT’

Breast abscess and mastitis

 Incision and draining surgically

 Express regularly

 Mastitis is treated with antibiotics, warm compress and analgesics

 MANAGEMENT OF HIV-EXPOSED INFANT
All HEI should receive prophylaxis for at least 12 weeks; stop when
mum has documented viral suppression 3months postnatal

If mum not suppressed (or not on ART), extend prophylaxis until
she is suppressed

If mum refuses treatment continue counselling and initiate ART as

soon as possible while baby remains on extended prophylaxis
 CONTINUOUS POSITIVE
AIRWAY PRESSURE (CPAP)
 INTRODUCTION TO CPAP
 CPAP It is a constant pressure applied to the airway, generated by
continuous, consistent flow of air with the aim of opening collapsed
lung segments and maintaining patency in already opened air
spaces.

 bCPAP stands for bubble continuous positive airway pressure.

 BACKGROUND
15 million babies born globally, 10% are premature

 1.1 million preterm babies die every year

 More than 1 million premature babies die shortly after birth,

majority due to RDS or respiratory distress of other aetiology

 With inexpensive treatment 75 percent could survive
 WHY NOW??
Respiratory problems are the most common cause of illness and
death in Babies/children.

 In our hospitals, there is really nothing on offer for children whose

severe respiratory distress fails to respond to oxygen therapy.

 Studies have shown that introducing bCPAP could improve survival

in babies with severe respiratory disease by about 70%.
 HOW DOES CPAP HELP?
 On inspiration, bCPAP drives air with additional
pressure into collapsed alveoli and opens them

 This process is sometimes called ‘recruitment’ which

increases the surface area available for gaseous
exchange.
 HOW DOES CPAP HELP?
The pressure is maintained even when the patient
breathes out, therefore the alveoli do not collapse at
the end of expiration

 The lung expands easily thus improving oxygenation

and reduces the need for increased work of breathing.
 CPAP MECHANISM

Infants with respiratory distress classically will grunt

 This is an attempt to retain some expansion of the alveoli

 Expansion of the alveoli provides a functional residual capacity by

keeping air in the lungs on expiration

 CPAP MECHANISM
CPAP is used for patients who have a respiratory drive

 CPAP mechanically ‘splints’ the airways open

 CPAP stabilises the chest wall and reduces the work of breathing

 It may be used when weaning a patient off ventilation.

In Africa, COST has been the major barrier…this
model would cost around $6000..
 Effective, LOW COST innovations are the answer!
Up to 1year of age/less than 10kg baby
The Pumani bCPAP was developed at Rice University & Texas Children’s Hospital
●Evaluated at Queen Elizabeth Central Hospital
 INDICATIONS FOR CPAP
 RDS: respiratory distress syndrome
 TTN: transient tachypnea of the newborn
 Pneumonia/sepsis
 MAS: meconium aspiration syndrome
 PPHN: persistent pulmonary hypertension of the newborn
 INDICATIONS FOR CPAP CONT’
 Bronchiolitis
 Upper airway obstruction
 Apnea of prematurity
 Post surfactant administration
 Post mechanical ventilation
RESPIRATORY DISTRESS SYNDROME

RDS occurs primarily in premature infants; its incidence is

inversely related to gestational age and birth weight

 It occurs in 60–80% of infants less than 28 wks, 15–30% of those

between 32 and 36 wk, about 5% beyond 37 wk, and rarely at term

 Surfactant deficiency is the primary cause of RDS
RESPIRATORY DISTRESS SYNDROME
 Increased risk in maternal diabetes, multiple births, Caesarian
Section, precipitous delivery, asphyxia, cold stress, and a history of
previously affected infants.

Reduced risk with antenatal steroid use.

 Management: oxygen, CPAP, ventilation, surfactant, antibiotics,

NGT
WHERE CPAP MAY NOT BE EFFECTIVE
Severe Birth Asphyxia
 Upper airway abnormalities
 Choanal atresia,
 cleft palate,
 tracheoesophageal fistula
 Severe cardiovascular instability and impending
arrest
 Unstable respiratory drive
 Ventilatory failure – non spontaneous breathing
patients.
 Diaphragmatic hernia
 TRY CPAP

T TONE
TONE IS GOOD

R RESPIRATORY DISTRESS
O2 SATS LESS THAN 90% ON 02 1L/MIN

Y YES
HR GREATER THAN 100/MIN
TRY CPAP
Baby Breathing
HR > 100/min

Tone is good Tone is poor

Baby Active Baby Floppy

Weight <1.3kg RR > 60min DO NOT START

CPAP
SP02 < 90%
START 02 1L/min if
Retractions or Grunting
Start Early CPAP SPO2 <90 ON ROOM
AIR

Start 0xygen 1
L/Min

After 1 hour : SP02 <90%

on Oxygen 1L/Min

Start CPAP
 SETTING A PATIENT ON CPAP
 Nasal Patency
 Prime importance
•If the nares are obstructed air cannot enter the lungs
• But bubbling will be forceful
 Suction secretions and blood as needed
 Avoid trauma/observe turbinate bones for irritation
 No Nasogastric tubes—Use only orogastric tubes
 TRY CPAP

Baby Breathing
HR > 100/min
 CPAP AND NEONATES
CPAP is frequently used as the method of ventilation for mild RDS

in neonates.

 It has been shown that less Surfactant treatment is necessary when

using CPAP in neonates.

 However neonates on CPAP are at higher risk of pneumothorax.

 CPAP AND NEONATES

CPAP is usually provided with nasal cannular ( prongs).

 The size of the cannular ( prong) is very important – they must fit

well.
 REQUIREMENTS FOR CPAP
Working CPAP machine and power cable
 Patient tubing
 Hat , clips or safety pins and elastic bands
 Suction machine and suction catheter
 Nasal prongs, OGT, adhesive tape
 Working Oxygen concentrator and o2 tubing
 REQUIREMENTS FOR CPAP CONT’
Nasal saline
 Pulse Oximeter
 Monitoring chart

EXTRAS FOR PUMANI

 End cap
 Bottle /lid and bottle tubing
 NASAL PRONG SIZE

 SIZE 0- Below 1kg

 SIZE 1 -1-1.25
 SIZE 2 – 1.25-2Kg
 SIZE 3 – 2-3Kg
 SIZE 4- 3-4 Kg
 SIZE 5 - Above 4kg
HAT SIZE/ LENGTH :
Small 61cm, ( <1.5kg) Medium 66cm ( 1.5-3kg)and large
71cm(>3kg)
 SETTING A PATIENT ON CPAP
Nasal Patency
 Prime importance
•If the nares are obstructed air cannot enter the
lungs
• But bubbling will be forceful
Suction secretions and blood as needed
Avoid trauma/observe turbinate bones for irritation
 No Nasogastric tubes—Use only orogastric tubes
 SETTING A BABY ON CPAP
Initial setting

 Pressure-6cmH2O

 Oxygen- 3L/min

 Total flow- 6cmH2O

 DEMONSTRATION ON
HOW TO SETUP CPAP AND
SETTING A BABY ON CPAP
 POSSIBLE PROBLEMS
 Obstruction of the nose and prongs by secretions. Careful
monitoring is necessary

 Pressure loss through an open mouth. May consider using a

dummy to help keep mouth closed

 Distension of the stomach – place an open OGT

 Pneumothorax in older infants with immature lungs and surfactant

deficiency.
 POSSIBLE PROBLEMS
Necrosis and erosion of the nasal septum is a possible
complication which must be carefully observed for

 Nasal prongs that are properly secured and fitted should not cause
this problem

 Place nasal prongs 0.5cm space between the prongs and septum

 Regular observation is important in this regard.

 MONITORING
 Require more than average monitoring
 Our recommendation:
 Check vitals 30min after CPAP commencement
then every two hours (Check CPAP settings, heart
rate, respiratory rate, oxygen saturation, signs of
distress, general clinical condition)
 Then review every hour for the first two hours
 **Remember each time you review a patient on
CPAP to look in the nostrils for signs of nostril
blockage
 ESCALATING SUPPORT
 Some babies require more support than CPAP 6 and 3 Litres Per
Minute Oxygen:
 After placing CPAP, measure saturations and observe work of
breathing
 Adequate CPAP should begin to decrease work of breathing and
improve saturations
 If saturations are less than 90%, check all connections and re-
suction nares (Suction distance 1.5 times distance from nose to ear)
 ESCALATING SUPPORT CONT’
Re-measure saturations:
 If saturations are less than 90%, increase oxygen to 4

 If after this increase saturations are less than 90% and work of
breathing is high—increase oxygen to 5 and CPAP gradually to
8. This is often necessary for babies with severe RDS
If saturations are still less than 90%, increase oxygen to 6 and call
for assistanc
Do not increase CPAP more than 8 cm H2O
 Increasing CPAP Treatment
Start **Always Check Connections
before increasing treatment:
CPAP water level: 6 cm Is the water bubbling?
Oxygen: 3 L/min Suction baby once more.
Blended Flow: 6 L/min

Is O2 saturation greater than 90% Yes

No

Increase Oxygen by 1 L/min

After 1 hour:
No Is O2 saturation Yes
greater than 90%?
Substantial in-drawing, Baby is responding to
recessions, retractions, No treatment.
Increase settings: work of breathing? Continue management.
Oxygen to 5 L/min
Yes
CPAP water level to 7 cm
Blended Flow to 7 L/min
Increase Oxygen to 5 L/min, consider
increasing CPAP water level to 7 cm, and
blended flow to 7 L/min. Reassess for
complications or alternative diagnosis

O2 Saturation greater than 90%

No

Increase oxygen to 6 and CPAP to 8cm of water if it is not

already, then call for assistance. CPAP cannot be increased
past 8cm of water without discussing with seniors.
Reassess for complications or alternative diagnosis
 ESCALATING SUPPORT
Saturations less than 90% but without an increased work of breathing
is less common.
 If saturations are less than 90%, check all connections and re-

suction nares (Suction distance 1.5 times distance from nose to ear)

 If saturations are less than 90%, increase oxygen to 4

 If after this increase saturations are less than 90% and work of

breathing is not high—increase oxygen to 5 and consider

increasing CPAP to 7.
 WEANING

Indications that the infant is not coping include

increased work of breathing and dropping saturations.

 WEANING A PATIENT OFF OF CPAP
 ‘Clinical respiratory stability’ is the main criteria, but as a
guide, the following must be achieved:
 Patient has been on bCPAP at least 24 hours
 RR less than 60/minute for at least 6 hours (for
neonates)
 Oxygen saturation consistently > 90% for at least 6
hours
 No significant grunting, recessions, nasal flaring,
apnea or bradycardia for at least 6 hours
 WEANING PROCEDURE
Procedure:
 Reduce CPAP pressure by 1 cm every 6 hours
until 5 cm is reached
 Once 5 cm is reached, start reducing oxygen flow
by 0.5 L/min every 6 hours until 1 L/min is reached
 After 6 hours on 1.5 L/min or less, and patient is
stable, remove CPAP and place patient on 2 L/min
of oxygen
 Once off CPAP, review baby at 30min then 2hourly
for 6hours and once stable 4hourly.
 Weaning a Patient from CPAP
Start
Weaning Criteria:
Patient is clinically stable as below: Does patient meet
1. Patient has been on bCPAP at least 24 hours weaning criteria?
2. RR less than 60/minute for at least 6 hours
3. O2 saturation consistently greater than 90% for at least 6 hours
4. No significant grunting, recessions, nasal flaring, apnoea or
bradycardia for at least 6 hours
Yes No

Keep on
Water level is more than 5cm Water level is at 5cm
CPAP
O2 is more than 1 L/min O2 is at 1 L/min
Blended flow is more than 6 L/min Blended flow is at 6 L/min

Decrease water by 1 cm every 6 hours if patient Take patient off CPAP and
continues to meet weaning criteria. place on 2 L/min O2
Until a water level of 5cm is reached

Decrease O2 by 1 L/min every 6 hours if patient

continues to meet weaning criteria until O2
reaches
a minimum of 1.5 L/min

Water level is at 5cm

O2 is at 1.5 L/min
Blended flow is at 6 L/min for
6 hours and patient is stable

Reassess patient after

Take patient off CPAP and 30min,hourly for 2 then 2hrly
place on 2 L/min O2 If meets criteria for CPAP again at any point,
restart CPAP and discuss patient with seniors.
 CPAP ALONE DOES NOT ASSURE
SUCCESS

Remember the basics:

 Temperature stability

 Glucose homeostasis

 Optimal positioning and airway clearance of

secretions

 Adequate caloric intake for continued growth

 Prevention and treatment of infection

 REMEMBER THE BASICS:
Temperature stability
 For an ill baby—receive, dry, and remove the wet

blanket

 Place in a warm environment

 Place a hat

 Monitor temperature on an ongoing basis

Maintain neutral thermal environment

 REMEMBER THE BASICS:
Adequate caloric intake
 Babies need 100-120 kcal/kg/day for growth and
repair
 Equivalent to 180 ml/kg/day of human milk

 These amounts are when baby is in a neutral thermal

environment
 Significantly more calories are required when baby is
cold stressed
 REMEMBER THE BASICS:
Prevent and treat infection
 Hand hygiene is everyone’s responsibility

 Check HIV and VDRL status

 Not all babies need antibiotics

 Obtain appropriate cultures and check results

 Use most appropriate, narrow spectrum antibiotics when

feasible
 Stop antibiotics when no longer needed
 TROUBLE SHOOTING
 Machine fails to switch on-Check if plugged to socket and switch
on
 Alarm sounding-power may have been lost
 Water does not bubble- check tubbings which should be
correctly connected
 Water bubbles when prongs are uncovered- total flow may be
too high or tubbings kinked
 There is no o2 flow- check concentrator connections
 TROUBLE SHOOTING
 Flow knob has detached from the meter- insert knob into
the metre and turn the knob to the right until it tightens
 Water does not bubble when prongs are placed in the
airway- prongs may be too small or improperly positioned
 Prongs do not stay in the nose-the hat is too large, hat clips
improperly aligned, tube improperly positioned
 Patient does not tolerate prongs- prongs are pushing up
against the septum, it takes a few minutes for a patient to
settle.
 CAUTION / WARNING
Use for its intended purpose
 Device should not be used around flammable substances
 No modification should be made on the equipment
 Its normal for the device to be warm when in use
 Portable and electro magnet devices such as pagers and cellular
phones should be kept away from machine( electro magnetic
compatibility)
 CAUTION / WARNING
Do not obstruct air vents on the unit
 Unplug the unit from electrical outlet when not in use
 Use the original cable for the unit, the power cable cannot be
replaced by use ( contact Hadleigh Health technologies for
replacement of cable)
 Do not use unit if it has cracks or damaged
 not submerge it in water when cleaning.
 Use only manufacturer supplied original accessories and
components
 CPAP Works
But Only when Attention is Given to the
Basics of Neonatal Care
END OF PRESENTATION
 INTRODUCTION
 Hypoxic ischaemic encephalopathy is characterized by clinical and
laboratory evidence of acute or subacute brain injury due to
asphyxia.

 It is responsible for some,but not all cases of neonatal

encephalopathy

 Neonatal encephalopathy is emerging as a preferred term for the

clinical syndrome of CNS dysfunction in neonates,regardless of the
cause.
 INTRODUCTION
 NE is characterised by
 Disturbed neurologic function in the earliest days of life at or
beyond 35 weeks gestation

 Manifested by a reduced level of consciousness or seizures

Difficulty with initiating and maintaining respiration

Depression of tone and reflexes

NB: Confirming if HIE caused neonatal encephalopathy is
challenging as there is no gold standard for diagnosis
 INTRODUCTION
 The various clinical signs of HIE may occur in the absence of global
hypoxic-ischemic brain injury.

 Markers helpful for determining the likelihood that an acute

peripartum or intrapartum hypoxic-ischemic event contributed to
NE are;
Apgar score of <5 at 5 minutes and 10 minutes
 INTRODUCTION CONT’
 Foetal umbilical artery pH <7.0, or base deficit ≥12 mmol/L,
or both

 Acute brain injury seen on brain MRI or magnetic resonance

spectroscopy consistent with hypoxia–ischemia

 Presence of multisystem organ failure consistent with HIE

 INCIDENCE
1.5 per 1000 live births in developed countries

 2.3-26 per 1000 live births in developing countries

 A study done in Uganda showed 30.6 per 1000 live births

 HIE carries high case fatality rates between 10-60% with 25%
survivors developing adverse long term neurodevelopmental
outcomes
 RISK FACTORS
 Maternal , Placental or foetal

 Social risks i.e.

 Poor antenatal services
 Home delivery
 Unskilled birth attendants
 CLINICAL FEATURES
CNS
 Mild HIE
• Hyperalert, brisk deep tendon reflexes, slightly reduced tone
initially
• Poor feeding, irritability, excessive crying alernating with
sleepiness
• Resolves in 24hrs with no sequelae
 CLINICAL FEATURES CONT’
 CNS CONT’
 Moderately severe HIE
• Lethargic, hypotonia, diminished reflexes
• Occasional apnoea
• Seizures
• May have full recovery in 1-2 wks
 CLINICAL FEATURES CONT’
CNS CONT’
 Severe HIE
• Coma, stupor
• Irregular breathing pattern
• Absent primitive reflexes
• Disturbed ocular movements i.e. nystagmus, bobbing
• Severe forms of seizures, worsen with time
• Cardio-respiratory failure
NB: Those who survive may have persisting feeding difficulties and
hypotonia
CNS EFFECTS
MULTI ORGAN EFFECTS
 CVS
 Diminished contractility
 Severe hypotension
 Cardiac dilatation
 Tricuspid regurgitation
 RESP
 Pulmonary hypertension
 RENAL
 Oliguria
 Water and electrolyte imbalance
MULTI-ORGAN EFFECTS
 Liver
 Hyperammonemia
 Coagulopathy
 NEC
 Hematology
 Polycythemia
 Thrombocytopenia
 Neutrophilia and neutropenia
 Haematoma in Posterior cranial fossa
(cardio-respiratory depression)
 INVESTIGATIONS

 BLOOD TESTS  IMAGING TESTS*

 This modality can only be done at
 Arterial blood gas
facilities with a neonatal intensive
 FBC
care unit (i.e. MRI)
 Electrolytes Na+,K+ &
Ca2+
 Echo
 Others
 MANAGEMENT
PREVENTIVE MEASURES
 Antenatal care= early identification and monitoring of all at risk
pregnancies with early referral when expertise lacking.

 During labour= early identification, monitoring and swift action

on all problematic deliveries(i.e. prolonged labour, foetal
distress, etc.)
NB: Multi-disciplinary teams are sometimes required for some
at risk pregnancies were available.
 MANAGEMENT CONT’
AT BIRTH
 Resuscitation as per Zambian algorithm
Determine the level of encephalopathy (refer all cases of
encephalopathy and all neonates with APGAR<7 after 5mins to a
NICU)
 Treat and prevent the 4 H + S.
• Hypoxia- give oxygen via nasal prongs or CPAP
• Hypoglycaemia- monitor RBS or give prophylactic bolus
@3ml/kg
• Hypotension- monitor PR,CRT and urine output give
inotropes when necessary
 MANAGEMENT CONT’
 Treat and prevent 4H+S CONT’
 Hypothermia- keep the neonates temperature within normal but
avoid overheating

 Seizures- detect and treat all seizures with appropriate anti-

epileptic medications (treat all possible causes of seizures and avoid
diazepam in neonates)

 1st line anti- convulsant- Phenobarbitol @ 20mls/kg

 MANAGEMENT CONT’
 Fluids & feeds
 Restrict total fluid intake to 2/3 of daily required
or give (40mls/kg at day-1 of life)
(should we advise NPO? Hypoglycaemia)

NB: Use appropriate fluids

 PROGNOSIS
In severe HIE, mortality is 25-50%. Mostly in first few days of life
 Long term complications in 80%- CP, epilepsy, blindness,
deafness
 10-20% moderately serious disability
 10% are well
 Moderately severe HIE
 30 – 50 % serious
 10 – 20 % minor neurologic deficits
 PROGNOSIS CONT’
 Developmental outcome in acute hypoxic ischaemic injury is
spastic quadriplegia or dyskinetic cerebral palsy
 Other outcomes are related to other forms of brain injury

 Thompson score is a prognostic tool for predicting the long term

outcome
 Score of 10 or less in first 6days with 0 by D7 predicts good
outcome
 Score of 11-15 at any time / score> 0 on D7 predicts poor
outcome in 65%
 Score > 15 predicts poor outcome in 92%
 REFERENCES
 Gunn AJ, Wyatt JS, Whitelaw A et al. Therapeutic hypothermia
changes prognostic value of clinical evaluation of neonatal
encephalopathy. J Pediatr. 2008 Jan 152 (1) : 55- 8. [medline]

 Santina A Zanelli, Dharmeedra J Nimavat, Hypoxic ischemic

encephalopathy, Medscape

 Neonatal encephalopathy and neurologic outcome, second edition.

Report of the American College of Obstetricians and
Gynecologists' Task Force on Neonatal [Link]
Gynecol. 2014;123(4):896.
 REFERENCES CONT’
Rajiv Agarwall et al, post resuscitation management of asphyxiated
babies. All India institute of medical sciences
 Hellen Namusoke ,et al, Incidence and short term outcomes of
neonates with HIE in a peri urban teaching hospital , Uganda : a
prospective cohort study. Matern Health Neonatol Perinatol. 2018;
4:6.
 Yvonne Wu,Uptodate-clinical features , diagnosis and management
of neonatal encephalopathy, Feb 2020
THANK YOU FOR LISTENING

RemembeR “Time is bRain”

 NEONATAL
HYPOGLYCEMIA
 INTRODUCTION
Hypoglycaemia is the most common metabolic problem in
newborns.
 Major long-term sequelae include neurologic damage resulting in
mental retardation, recurrent seizure activity, developmental delay,
and personality disorders.
 Some evidence suggests that severe hypoglycemia may impair
cardiovascular function.
 DEFINITION
 Low blood glucose, the body’s main
source of energy.
 Glucose delivery or availability is

inadequate to meet glucose demand”

(Karlsen, 2006)
 WHAT IS THE NORMAL?
 Defining a normal glucose level remains controversial

 The normal range of blood glucose concentration in newborn

infants is 2.6 mmol/l to 7.0 mmol/l.

 Hypoglycemia <2.6 mmols/l

 Severe hypoglycaemia <1.5 mmols/l

 INCIDENCE OF HYPOGLYCEMIA
 Overall Incidence = 1- 5/1000 live births
 Normal newborns – 10% if feeding is delayed for 3-6 hours
after birth
 At-Risk Infants – 30%
 LGA – 8%
 Preterm – 15%
 SGA – 15%
 IDM – 20%
 INFANTS AT HIGHEST RISK
Low birth weight infants (either preterm or underweight for
gestational age)
 Wasted infants
 Infants where there is a delay in the onset of feeding (infants who
have not been fed)
 Hypoxic infants and infants who need active resuscitation at birth
 Exposure to certain medications
 INFANTS AT HIGHEST RISK
 Infected infants
 Infants with liver disease
 Infants with respiratory distress
 Hypothermic infants
 Infants of diabetic mothers
 Overweight for gestational age infants
 Polycythaemic infants
WHY IS HYPOGLYCEMIA A PROBLEM?
When the blood glucose concentration is low the cells of the body,
particularly the brain, do not receive enough glucose and cannot
produce energy for their metabolism.

 As a result the brain cells can be damaged or die, causing cerebral

palsy, mental retardation or death.
 WHEN ARE INFANTS AT RISK OF
DEVELOPING HYPOGLYCAEMIA?
 Infants are at an increased risk of developing hypoglycemia when:

 They have reduced energy stores.

 They have increased energy needs.

WHICH INFANTS HAVE
REDUCED ENERGY
STORES?
Which infants have increased energy needs?
 SIGNS & SYMPTOMS OF
HYPOGLYCEMIA
Jitteriness
 Irritability
 Hypotonia
 Lethargy
 High-pitched cry
 Hypothermia
 SIGNS & SYMPTOMS OF
HYPOGLYCEMIA CONT’
Poor suck
 Tachypnea
 Cyanosis
 Apnea
 Seizures
 Cardiac arrest
 NURSING MANAGEMENT

 Complete evaluation and review of systems

 Early breast or bottle feeding within 30 minutes

 Glucose monitoring within 1 hour

 Monitor pre-feeding levels thereafter

 MONITORING

Serum glucose level is the gold standard

 Bedside glucose levels are for screening

 Monitor at least hourly until glucose level has stabilized

 Know your hospital policy for monitoring infants at risk for

hypoglycemia
 TREATMENT
(REFER TO PROTOCOL)

 Oral feedings as tolerated

 If glucose is very low or the infant is not able to feed orally:
 3ml/kg of D10W IV bolus
 Follow up screenings within 30 minutes
 Repeat bolus if glucose is < 2.6mmol/l
 If unable to stabilize glucose, consider increasing IV rate or
glucose concentration
 PREVENTION

Increase awareness of conditions that predispose an infant to

hypoglycemia

 Early screening of at-risk infants

 Early and frequent feedings

 Maintain temperature
END OF PRESENTATION
 MANAGEMENT OF
INTRAVENOUS FLUIDS
 OBJECTIVES
When you have completed this unit you should be able to:

 Describe the fluid needs of infants

 Give maintenance intravenous fluid

 Feed preterm infants

 Feed sick infants

 Manage an infant with feeds intolerance

 FLUID REQUIREMENTS
 Planning fluid and energy requirements of an infant, you must
understand the role of fluid in the body

 The importance of maintaining a normal amount and composition

of the body fluid

 WHAT IS BODY FLUID?

About 70% of a term infant body weight fluids consists of:

 Water.

 Electrolytes (such as sodium, potassium, chloride and

bicarbonate).
 Proteins.

 Nutrients such as glucose, amino acids, fatty acids and vitamins.

WHAT IS BODY FLUID COMPOSED OF?
 Gases such as oxygen and carbon dioxide.
 Waste products such as urea and acids.

 Trace elements.

 ‘Messengers’ such as hormones.

NB: These substances are called the constituents of body fluid.

 WHERE DO YOU FIND BODY FLUID?
 Body fluid is found in different areas (body spaces) and is divided

into:
 Intracellular fluid which is present inside the cells of the body.

 Intercellular fluid which is present between the cells.

 Intravascular fluid which is present in the blood vessels.

 NOTE:
The concentration of the various constituents of
body fluid varies between these different areas.
Allowing continual movement of fluids, as water
tends to move to the area which has the highest
concentration of electrolytes and protein.
 WHAT IS THE FUNCTION OF BODY
FLUID?
 Intracellular fluid - maintaining cell health and movement of

body fluids constituents from one part of the cell to another

 Intercellular fluid - movement of constituents of body fluids

between the blood vessels and the cells

 Intravascular fluid (serum or plasma) - movement blood cells

and the constituents of body fluid from one area of the body to
another
 NOTE!!
Too much or too little body fluid, or an
imbalance in the amount or constituents of body
fluid between different areas, can prevent the
body from functioning normally and may even
result in death.
 DOES BODY FLUID NEED TO BE
REPLACED?
 YES.

 Water and all the constituents of body fluid are continually being

lost in the urine, stool and sweat, and, therefore, need to be

replaced. This can be done:
• By mouth (orally)

• By nasogastric tube

• By intravenous infusion
 WHAT DETERMINES AN INFANT’S
FLUID NEEDS?
 The daily fluid requirement of the infant depends on:
 The body weight. Fluid requirements are expressed in mls/kg

bwt.
• Term infants, therefore, need more fluid than a preterm infants.

 The age after delivery. Fluid requirements increase from

birth to day 5, then remain stable.

 INFANTS NEED MORE FLUID THAN
ADULTS
 Infants need more fluid per kg than adults because:

 They lose more fluid through insensible water loss.

 Their kidneys do not concentrate urine well and, therefore, need

more fluid to excrete waste products.

NB: All these ways of losing fluid are more exaggerated in preterm infants
HOW MUCH FLUID DO
MOST INFANTS NEED?
 TOTAL FLUID INTAKE (TFI) ml/Kg

WEIGHT DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

<1000g 90 110 130 140 150

1000-1200g 80 100 120 140 150

1201-1499g 70 90 110 130 150

1500g and above 60 80 100 120 150

 NOTE
The Total fluid intake (TFI) is
increased by 20ml/kg /day
HOW MUCH FLUID DO MOST INFANTS
NEED?
 Note that the fluid requirements are given in mls/kg/bwt, increase
gradually from day 1 to day 5

 As the infant’s weight increases after day 5, total amount of fluids

(TFI) remain constant at 150ml/kg

 The fluid requirements after birth per day is a guide as some infants
may need more than others.
 WHY DO THE DAILY FLUID NEEDS
INCREASE DURING THE FIRST 5 DAYS?
 For the first few days after delivery the mother’s breasts do not

produce a lot of milk

 To prevent dehydration, the kidneys of the newborn infant produce

little urine during this period

 The infant also has an additional store of extracellular fluid at birth

 WHY DO THE DAILY FLUID NEEDS
INCREASE DURING THE FIRST 5 DAYS?
 Infants does not need a lot of fluids initially as its adapting to

surviving while the mother is still establishing feeds.

 The infant’s fluid needs gradually increase from day 1 to 5, the

kidneys are functional and passing a lot of urine.

 Giving 150 ml/kg in the 1st 4 days of life may result in over

hydration and oedema

 WHY DO INFANTS LOSE WEIGHT
AFTER BIRTH?
 Because the fluid intake is reduced for the first few days

 Increased insensible looses

 This weight loss is normal as long as it is not greater than 10% of

the birth weight

WHICH INFANTS NEED EXTRA FLUID?
 Infants that need more fluids are:
Infants weighing <1500 g
 Infants under radiant warmer, 25 ml/kg/bwt/day replacing

additional fluid lost through the skin.

 Infants receiving phototherapy do not usually need extra fluid if

their temperature remains normal

WHICH INFANTS NEED EXTRA FLUID?
 Infants with diarrhoea or vomiting.

 Some preterm infants need between 150 and 180 ml/kg to

obtain enough energy for growth.

NOTE
 Weighing the infant daily is the best method of assessing
whether enough fluid is being given.
If an infant looses more than 10% of their birth weight, then
the daily fluid intake must be increased
 Very small infants, weighing less than 1000 g, need even
more extra fluid during the first 4 days
 WHAT ARE THE ENERGY NEEDS OF
AN INFANT?
 Feeds of 150 ml/kg/day of breast milk or standard formula
provide the infant with approximately 440 kJ/kg/day (105
kcal/kg/day) adequate energy growth

 Some preterm infants, however, need up to 500 kJ/kg/day before

they gain weight

 WHAT ARE THE ENERGY NEEDS OF
AN INFANT?
 This requires milk feeds of up to 180 ml/kg/day of breast milk or
a standard formula and 170/ml/day of special preterm formula

 Instead of increasing the volume of the feeds, however, extra energy can be

added to the milk (by giving 1 ml medium-chained triglyceride oil giving

38 kJ or fortification of breastmilk) before each feed.
END OF PRESENTATION
 WHAT IS JAUNDICE?
 Jaundice - yellow discoloration of skin &
sclerae due to bilirubin deposits
 Jaundice - a clinical sign & not a laboratory

measurement

 Skin discoloration - used to detect neonatal

jaundice as sclerae may be difficult to see

 BILIRUBIN METABOLISM
Destruction of red blood produces heme + globin

 Heme is eventually changed into a yellow pigment called bilirubin

Unconjugated bilirubin - carried by albumin in blood stream to

liver where it is first conjugated & then excreted in bile

 Significantly high levels (hyperbilirubinaemia) will cause jaundice

 WHAT IS HYPERBILIRUBINAEMIA?
 Hyperbilirubinaemia - concentration of total serum bilirubin (TSB)
higher than normal range

 Normally TSB is low at birth - <35 µmol/l

 Levels rise steadily for first few days, before returning to

<35 µmol/l by 2 weeks

 TSB in term infants usually does not rise > 200 µmol/l (12 mg/dl)
 TYPES OF BILIRUBIN
Unconjugated (indirect)
 Bound to albumin in blood (transport to liver)
 Not water soluble
 Can cross blood brain barrier
 Dangerous at high levels
 Conjugated (Direct)
 Bound to glucuronic acid
 Water soluble
 Doesn’t cross blood brain barrier
 HOW IS BILIRUBIN MEASURED?
 Difficult & inaccurate to assess TSB levels by clinical examination of
jaundice, especially in an infant with dark skin

 Important to measure bilirubin levels if an infant is jaundiced

 Importance of doing both TSB & direct bilirubin levels

 WHAT ARE THE CAUSES OF
JAUNDICE?
 Main causes of jaundice in newborns:

 Increased production of bilirubin

 Slow bilirubin conjugation in the liver

 Decreased excretion of bile

 WHAT ARE CAUSES OF INCREASED
PRODUCTION OF BILIRUBIN?
 Cephalohaematoma or bruising

 Polycythaemia

 Infection

 Haemolytic disease of the newborn

 Blood group incompatibilities

 WHAT CAUSES DECREASED
EXCRETION OF BILIRUBIN?
 Hepatitis due to septicaemia, viral infection or syphilis

 Biliary atresia - destruction of bile ducts caused by a viral

infection during first weeks of life

 Choledochal cysts

 Type of jaundice?
 CHARACTERISTICS OF TYPES
OF HYPERBILIRUBINAEMIA

 UNCONJUGATED  CONJUGATED
 Yellow stools
 Pale stools

 Yellow skin discoloration

 Greenish tinge
 More common
 Less common
 INVESTIGATIONS
 Bloods

 Imaging

 Biopsy if indicated
 HOW IS BILIRUBIN EXCRETED IN THE
FETUS
 Fetus is unable to excrete conjugated bilirubin via the
stool as it usually does not pass meconium and also lacks
bacteria in the intestines to convert bilirubin into
stercobilin.

 Instead, fetal bilirubin, is excreted by the placenta into the

mother’s blood.

 However, the placenta can only remove fat soluble, unconjugated

bilirubin and not water soluble, conjugated bilirubin.
 IS JAUNDICE DANGEROUS?
 Dangerous when concentration of unconjugated bilirubin becomes
very high

 Unconjugated bilirubin may enter the brain & cause bilirubin

encephalopathy (kernicterus)

 Conjugated bilirubin - not toxic to the brain- may cause liver

damage

 In clinical practice TSB is used to assess whether the bilirubin is

reaching dangerous concentrations
 RISK OF BILIRUBIN ENCEPHALOPATHY
 Total serum bilirubin concentration
 The higher the TSB, the greater the chance of brain cells damage

 Gestational age
 The more preterm the infant the higher the risk due to an
immature blood brain barrier

 Postnatal age
 A high TSB in first few days has a greater chance of increasing to
dangerous levels than the same TSB at a week of age
 RISK OF BILIRUBIN ENCEPHALOPATHY
 Factors that may make the blood brain barrier more permeable
to bilirubin
 Hypoxia

 Hypothermia

 Hypoglycaemia

 Infection
 CONSEQUENCES OF BILIRUBIN
ENCEPHALOPATHY
Death

 Cerebral palsy

 Dysfunctional families
 CLINICAL APPLICATION
How to examine

 How to investigate
 HOW CAN YOU PREVENT BILIRUBIN
ENCEPHALOPATHY?
 Phototherapy

 Phototherapy

 Phototherapy

 Phototherapy
 WHO GETS PHOTOTHERAPY
 Either therapeutically or prophylactically
 Therapeutic phototherapy: whenever TSB is above the normal range
and approaches dangerous levels.
 Administration of therapeutic phototherapy guided by chart (figure
below)
 If newborn’s TSB reaches the phototherapy line, start treatment
 Use of Kramer grading
 WHO GETS PHOTOTHERAPY CONT’
 Phototherapy usually started earlier in preterm or sick infants.
 Avoid phototherapy in term infants with TSB below the
phototherapy line.
 Infants born to women blood group O should have TSB measured
at 6 hrs of life. TSB> 80 µg/dl =phototherapy
 Phototherapy done appropriately may negate need for exchange
transfusions.
 CAUTIONS ABOUT PHOTOTHERAPY
 Dehydration: breastfeed/EBM or IV fluids where indicated

 Dermatitis: Appropriate distance

 Blindness: eye shields

 Diarrhea

 Lethargy
WHY DO NEWBORN BABIES DEVELOP
JAUNDICE
 Physiological jaundice

 Self-limiting

 Ends within a week

 Benign
 FOLLOW UP
 Long term follow up for neurological assessment for all neonates
that develop jaundice

 This begins with a neurological assessment at week 6 of life.

 CONCLUSION
 Do thorough examination of newborn

 Teach mothers about jaundice

 Encourage mothers to return immediately if jaundice is noticed in

newborn

 Most importantly: do not tell mothers to place babies under

sunlight
THANK YOU
 NEONATAL PRE -
REFERRAL STABILISATION
/ TRANSPORT / TRANSFER
 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Cardiac
 Asymptomatic heart murmur
 Heart murmur with non-life threatening symptoms
 Respiratory
 Meconium aspiration requiring oxygen
 Respiratory distress: grunting, tachypnea, nasal flaring, chest in
drawing, cyanosis
 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Musculoskeletal
 Birth Injury (Mechanical injuries not affecting cardiorespiratory
status)
 Absent digits or limbs
 Congenital hip problem (can be seen non urgently at tertiary level)
Congenital foot problem (can be seen non urgently at tertiary level)
 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Neurological
 Microcephaly
 Gastrointestinal
 Sustained feeding difficulties in a newborn not related to
gestational age
Poor weight gain
 Genitourinary
 Undescended testes
 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Maternal conditions
 Stable infant of a mother with history of substance or alcohol
misuse/dependence in this pregnancy

 Infant of mother with diabetes (apparently normal)

 Intrauterine infection (RPR, Hep B, Hep C)

 Maternal medication with risk to baby (carbimazole,

antipsychotics, antidepressants, anticonvulsants)

 Maternal/family history with risk factors for baby

 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Growth and feeding
 Dehydration or >10% weight loss since birth

 Small for gestation age

 Low birth weight: 1.5kg to 2.5kg Metabolic and others

 Excessive irritability

 Hypothermia/hyperthermia
 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Surgical:
 Spina Bifida (non urgent referral)

 Cleft palate (non urgent referral)

 Protruding abdominal viscera (exomphalos Gastroschisis)

 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Surgical:
 Hydrocephalus (non urgent referral)

 Encephalocele (brain protrusion through the skull)

 Urethra malposition (Hypospadias, Epispadias) {non urgent

referral}
 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Genetic, metabolic and others
 Septicemia requiring 3rd line antibiotics not stocked at first level
e.g.
imipenem

 Bilirubin levels above 400 micromol/L or requiring exchange

transfusion (see age
appropriate charts).

 Persistent hypoglycaemia not responsive to dextrose infusions

 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Genetic, metabolic and others
 Late jaundice: visible or >150 micromole / l from 2 weeks in term
infant and 3 weeks in preterm infant.

 Jaundice associated with pale or gray colored stools.

 Familial bleeding tendency

 REFERRAL ADMISSION CRITERIA
FROM A LOWER TO HIGHER LEVEL
 Dermatological (skin)
 Life threatening skin conditions (blistering of the whole or
significant parts of the body).

NOTE:
 For emergencies, provide appropriate resuscitative care before
referring the patient
 STEPS FOR PRE-REFERRAL
STABILISATION MANAGEMENT OF
COMMON NEONATAL CONDITIONS
 Transfer of a sick baby requires stabilisation, and the ABCDE
should be done for all these Babies
 A-Airway; ensure the airway is clear (suction only if secretions
present).

 B-Breathing; the baby is put on respiratory support during

transfer if in respiratory distress (nasal prong oxygen or CPAP if
available on transfer).
 STEPS FOR PRE-REFERRAL
STABILISATION MANAGEMENT OF
COMMON NEONATAL CONDITIONS CONT’
 C-Circulation; Insert IV access peripherally with a size 24/26G
cannula or umbilical catheter (can use a size 5/6 NGT) if peripheral
access fails and one is skilled enough in inserting umbilical catheter.

 D- Dextrose bolus of 5 ml/kg should be given PO/IV. In transit,

give continued dextrose boluses calculated based on the baby’s
weight. NGT for feeds should be inserted in babies that are not
breast feeding (feeds should be calculated based on the weight as in
the chart below).
 STEPS FOR PRE-REFERRAL
STABILISATION MANAGEMENT OF
COMMON NEONATAL CONDITIONS CONT’

E-Exposure; keep the baby warm (put a hat and socks transfer
skin to skin with the mother or use a plastic bag before covering with
a blanket if mum is not available). Aim for temperature 36.5oC to
37.5c.

NOTE:
For purposes of transfer, all hypothermic babies regardless of weight
should be put skin to skin or in a plastic bag
 ASPHYXIATED /CONVULSING BABY
 Insert cannular or Umbilical catheter if peripheral access is not
available

 Give a bolus of 10% dextrose at3-5 ml/kg if low sugar or if

dextrose Stix are not available)

 If convulsions persist after the dextrose bolus, give Phenobarbitone

at 20 mg/kg IV stat dose ( a second dose can be given but beware of
respiratory depression)
 ASPHYXIATED /CONVULSING BABY

 Calculate the Dextrose boluses at 40ml/kg/day (asphyxiated

babies require initial fluid restriction)
 Put hat and socks on

 Baby should be transferred at a temperature of 36.5o C to 37.5oC

 Transfer on oxygen
 PRESUMED SEPSIS
/JAUNDICE/PNEUMONIA
 Insert peripheral IV access (Do not put an Umbilical catheter
especially if there’s evidence
of umbilical sepsis)

 Give a bolus of dextrose at 3-5 ml/kg (if evidence of

hypoglycaemia or if dextrose Stix are
not available)-bolus dextrose can be given orally if no IV access
 PRESUMED SEPSIS
/JAUNDICE/PNEUMONIA
 If no fits detected, no abdominal distension and no vomiting, insert
an NGT and give
a cup to mother to express feeds depending on the baby’s weight
(refer to the section
above)
 Give stat doses of X-pen (50,000IU per Kg and gentamicin 5
mg/kg)

 Transfer on oxygen/CPAP if baby needs it

 PRE-REFERRAL STABILIZATION AND
TRANSPORT
 AMBULANCE SERVICES
 A neonatal dedicated ambulance should be kept at
designated commanding post close to health centers

 Communication system which must be functional

 The skilled accompanying health care provider should

sit close to the patient while being transferred

 The ambulance should only be used for purposes of

transporting patients.
IDEAL AMBULANCE FOR ZAMBIAN
TERRAIN PACKED AT MWANDI
MISSION HOSPITAL
 PRE-REFERRAL STABILIZATION AND
CARE IN TRANSIT

Neonates may need to move to a unit other than where they were
born for specialist care that is not provided in their local unit and
may need Transport Service.

 Care of the patients should continue in transit

 RESOURCES REQUIRED DURING
TRANSFER
 Main stretcher
 Self loading trolley
 I.V. fluid mounting
 Transport incubator system (incubator + ventilator + monitor +
battery+ oxygen cylinders 5-10 liters) in a secure way
 Stationary oxygen
 Appropriate intravenous fluids
 RESOURCES REQUIRED DURING
TRANSFER CONT’
 Syringes with volume of 2, 5, 10, 20, 50 ml;
 Fluid giving sets;
 Canulae size G24, G25
 Blankets;
 Thermometers (if no monitor);
 Emergency drugs.
 EMPLOY SBAR APPROACH BEFORE
TRANSFER
 After the baby is stabilized there is need to undertake SBAR
S - Situation

 B - Background

 A - Assessment

 R - Recommendation
 REFERENCE

 Zambia National Maternal and Neonatal Referral guidelines-MoH

2018

 National Neonatal Transport Services –NHS England-2015

 SA Neonatal Guidelines Final CHeRP 2007

END PRESENTATION – THANK YOU
FOR LISTENING