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

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

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

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

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

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

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

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

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

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

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

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

14. Supportive care for the sick infant –Increase the total amount of fluid (oral and i.v.) over the first 3-5 days Day 1 60ml/kg/day Day 290ml/kg/day Day 3120ml/kg/day Then increase to 150ml/kg/day –When babies are tolerating oral feeds well, this can be increased to 180ml/kg/day after some days.

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

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

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

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

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

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