Management of sick neonates
Doug Simkiss
Associate Professor of Child Health
Warwick Medical School
Introduction
• Revise the danger signs in neonates and
young infants
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Often non-specific
Unable to breast feed
Convulsions
Drowsy or unconscious
Respiratory rate < 20 / minute
Danger signs in neonates and young
infants
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Bleeding
Central cyanosis (blueness)
Hypothermia
Hyperthermia
Hypoglycaemia
Dehydration
Danger signs in neonates and young
infants
– Apnoea (cessation of breathing for > 15
seconds)
– Respiratory rate > 60 / minute
– Grunting
– Severe chest indrawing
– Central cyanosis
– Deep jaundice
– Severe abdominal distension
Emergency management
• Give oxygen 0.5 l / minute by nasal prongs
or catheter if infant is cyanosed or in severe
respiratory distress
• Give bag and mask ventilation with oxygen
(or room air if oxygen is not available) if
respiratory rate is too slow (< 20 / minute)
• Give ampicillin (or penicillin) and
gentamicin
Emergency management
• If drowsy, unconscious or convulsing, check
blood glucose
– If glucose < 1.1 mmol/l (<20mg/100ml), give
i.v. glucose
– If glucose 1.1 – 2.2 mmol/l (20-40mg/100ml)
feed immediately and increase feeding
frequency
Emergency management
– If you cannot check blood glucose quickly,
assume hypoglycaemia and give glucose i.v. If
you cannot insert an i.v. drip, give expressed
breast milk or glucose through a nasogastric
tube
• Give phenobarbital if convulsing (I dose of
20mg / kg). If fits continue for 30 minutes
give 10 mg / kg. If needed continue with
phenobarbital 5mg/kg once daily
Emergency management
• Admit or refer urgently if treatment is not
available locally
• Give vitamin K (if not given before)
• Monitor the baby frequently
• If baby is from a malarious area and has
fever, take blood film to check for malaria
also. Neonatal malaria is very rare. If
confirmed treat with quinine
Supportive care for the sick infant
• Thermal environment
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Keep the infant dry and well wrapped
Use a bonnet to reduce heat loss
Keep the room warm (> 25°C)
Keeping the young infant in close skin to skin
contact with the mother for 24 hours a day is
as effective as using an incubator or external
heating device to avoid chilling
Supportive care for the sick infant
– Pay special attention to avoid chilling the
infant during examination or investigation
– Regularly check that the infants temperature is
maintained in the range 36.5-37.5°C rectal or
36.0-37.0°C axillary.
Supportive care for the sick infant
• Fluid management
– Encourage the mother to breast feed
frequently to prevent hypoglycaemia. If unable
to feed, give expressed breast milk by
nasogastric tube
– Withhold oral feeding if there is bowel
obstruction, necrotising enterocolotis or the
feeds are not tolerated (indicated by increasing
abdominal distension or vomiting)
Supportive care for the sick infant
– Withhold oral feeding in the acute phase in
babies who are lethargic or unconscious , or
having frequent seizures
– If i.v. fluids are given, reduce the iv fluid rates
as the volume of milk feeds increases
– Babies who are suckling well but need an i.v.
drip for antibiotics should be on minimal i.v.
fluids to avoid fluid overload, or flush cannula
with 0.5ml of 0.9% saline and cap
Supportive care for the sick infant
– Increase the total amount of fluid (oral and i.v.)
over the first 3-5 days
• Day 1
• Day 2
• Day 3
• Then increase to
60ml/kg/day
90ml/kg/day
120ml/kg/day
150ml/kg/day
– When babies are tolerating oral feeds well, this
can be increased to 180ml/kg/day after some
days.
Supportive care for the sick infant
– Be careful with parenteral fluids which can
quickly overhydrate a baby. Do not exceed
180ml/kg.day i.v. unless the baby is
dehydrated or under phototherapy or a radiant
heater.
– Remember to include oral intake when
calculating the i.v. fluid intake a baby needs
– Give more fluid if under a radiant heater (1.21.5 times more)
Supportive care for the sick infant
– Do not use i.v. glucose and water (without
sodium) after the first 3 days of life. Babies
over 3 days need some sodium (e.g. 0.18%
saline / 5% glucose).
– Monitor the i.v. infusion very carefully
• Use a monitoring sheet
• Calculate the drip rate
• Check drip rate and volume infused very hour
• Weigh baby daily
Supportive care for the sick infant
• Watch for facial swelling; if this occurs reduce the
i.v. fluid to minimal levels or take out the i.v.
• Introduce milk feeds by nasogastric tube or breast
feeding as soon as it is safe to do so.
Supportive care for the sick infant
• Oxygen therapy
– Give oxygen to infants with any of
• Central cyanosis
• Grunting with every breath
• Difficulty in feeding due to respiratory distress
• Severe lower chest wall indrawing
• Head nodding - indicates severe respiratory distress
Supportive care for the sick infant
– Pulse oximetry, use if available and give oxygen
if saturation < 90%. Aim for 92-95% saturation
levels. Stop oxygen if baby can maintain
oxygen saturations above 90% in air .
– Nasal prongs is preferred method for oxygen
delivery. Use flow of 0.5 litre / minute. Use
suction to remove thick secretions from nose
and throat if baby is too weak to clear them.
Supportive care for the sick infant
• High fever
– Assess the cause
– If signs of infection, treat with appropriate
antibiotics
– Do not use antipyretic medication like
paracetamol for controlling fever in young
infants. Control the environment. If necessary,
undress the baby.