10.3 Care of the sick newborn

10.3.1 Danger signs

Routinely check all newborns for danger signs at birth and during their stay in the maternity hospital. Danger signs indicate severe infection and require immediate care.

Danger signs

Temperature

> 38°C: hyperthermia
< 35.5°C: hypothermia

Neurological signs

Seizures (including subtle* or “abnormal” movements)
Bulging fontanelle
Inability to suckle effectively
Lethargy or coma
Hypotonia

Respiration

Apnoea (respiratory pause > 20 seconds or combined with bradycardia)
Bradypnoea (respiratory rate < 30/minute)
Tachypnoea (respiratory rate > 60/minute)
Grunting respirations
Chest indrawing

Abdomen

Severe abdominal distension

Skin colour

Generalised cyanosis (blue colouring)
Extreme pallor

Skin

Umbilicus red or oozing blood or pus
Numerous or large pustules

Joints

Swollen, painful joint (irritability when moved) with reduced joint movement

Blood glucose

Recurrent hypoglycaemia (> 2 episodes)

* Subtle movements: sucking or chewing, blinking or disorganised eye movements, disordered arm or leg movements (pedalling).

10.3.2 Management of life-threatening emergencies

Cyanosis and/or respiratory distress

– Position the head to open the airway.
– Administer oxygen with an appropriate nasal cannula, at a maximum flow rate of 2 litres/minute, monitoring with a pulse oxymeter. The oxygen saturation in full-term or premature infants should be 90 to 95%.
Use an appropriate paediatric flow splitter so that the oxygen flow can be adjusted correctly when there are several infants on the same oxygen concentrator.
– Place a gastric tube for feeding (Appendix 5).

Apnoea or bradypnoea

– Perform bag-mask ventilation (add oxygen if the ventilation lasts more than 1 to 2 minutes).

Impaired consciousness and/or seizures

– Check the blood glucose or, if that is not possible, treat hypoglycaemia (Section 10.3.5).
– Administer phenobarbital in case of seizures (Section 10.2.2).
– Place a gastric tube for feeding (Appendix 5).

10.3.3 Management of symptomatic neonatal infections

A neonatal infection is likely and an antibiotic therapy and transfer to neonate unit are required:

In presence of one of these danger signs

– Hyperthermia
– Seizures
– Bulging fontanelle
– Apnoea
– Severe abdominal distension
– Generalised cyanosis
– Umbilicus red or oozing blood or pus
– Numerous or large pustules
– Swollen, painful joint with reduced joint movement
– Recurrent hypoglycaemia (> 2 episodes)

OR

In presence of two of these danger signs
or
If one these danger signs persist for more than one hour

– Hypothermia
– Inability to suckle effectively
– Lethargy or coma
– Hypotony
– Bradypnoea
– Tachypnoea
– Grunting respirations
– Chest indrawing
– Extreme pallor


– The first-line treatment is the combination ampicillin IV + gentamicin IM.
The ampicillin is preferably used IV; the IM route is an option if the context does not permit proper IV administration. To avoid multiple IM injections, however, it may be better to use procaine benzylpenicillin IM1 + gentamicin IM or, as a last resort (if procaine benzylpenicillin is not available) ceftriaxone2  IM + gentamicin IM.
– If meningitis is suspected, do not use procaine benzylpenicillin.– If the infection is cutaneous in origin, replace the ampicillin with cloxacillin IV3 .

Symptomatic neonatal infections are treated for a total of 10 to 14 days. This may be shorted to 7 days if there is complete recovery in the first 24 hours. It should never be less than 7 days and never given orally. Gentamicin should usually be stopped after 5 days of treatment.

Premature and low birth weight infants are at greater risk of serious infection.

Table 10.5 - Antibiotic dosages for newborns less than 7 days old

Antibacterial

Birth weight

≤ 2000 g

> 2000 g

ampicillin
IV/IM injection

100 mg/kg/day in 2 divided doses

If meningitis:
200 mg/kg/day in 3 divided doses

150 mg/kg/day in 3 divided doses

If meningitis:
300 mg/kg/day in 3 divided doses

gentamicin
IM injection

3 mg/kg once daily

5 mg/kg once daily

procaine benzylpenicilline1

IM injection

50 000 IU/kg once daily

If meningitis: do not administer.

ceftriaxone
IV/IM injection

50 mg/kg once daily

If meningitis:
100 mg/kg once daily

cloxacillin
IV infusion

50 mg/kg/day in 2 divided doses

75 mg/kg/day in 3 divided doses


In all cases, while awaiting the transfer in neonatal intensive care unit:

– Start antibiotic therapy.
– Ensure routine newborn care (Section 10.1).
– Keep the infant warm in a 25°C room, wrapped in a survival blanket or under a warming lamp if possible, and cover the head with a cap.
– Closely monitor temperature, respiratory rate and oxygen saturation.

10.3.4 Management of asymptomatic newborns at risk of neonatal infection

In asymptomatic newborns (no danger signs), neonatal infection should nevertheless be suspected if any of the risk factors below are present.

Major risk factors (RF)

– Peripartum maternal fever (To ≥ 38°C before delivery or during labour)
– Chorioamnionitis (foul-smelling, cloudy amniotic fluid)
– Prolonged rupture of membranes lasting > 18 hours before delivery

Minor risk factors

– Birth weight < 2000 g
– Resuscitation at birth with manual ventilation
– Meconium-stained amniotic fluid: this is a risk factor for neonatal infection, but not in itself an indication for antibiotic therapy. Meconium-stained amniotic fluid is also a risk factor for pneumothorax and aspiration pneumonia.

Criteria for suspecting asymptomatic neonatal infection

1 major RF if the mother did not receive antibiotics during labour (or received less than 2 doses4 )
or
1 major RF and birth weight < 2000 g, whether the mother received antibiotics during labour or not
or
≥ 2 major RFs, whether the mother received antibiotics during labour or not
or
1 major and ≥ 2 minor RFs, whether the mother received antibiotics during labour or not
or
≥ 3 minor RFs, whether the mother received antibiotics during labour or not

Management of suspected asymptomatic neonatal infection

(one of the criteria above)

– Administer antibiotics for 48 hours3: ampicillin IV + gentamicin IM or fortified penicillin procaine IM + gentamicin IM. See Table 10.5 for dosage.
– Monitor for danger signs (Section 10.3.1). If the infant presents at least one danger sign, see Section 10.3.3.
– If the infant has not presented any of the danger signs during the first 48 hours, stop the antibiotics and keep under observation for an additional 48 hours.
– If the infant has not presented any of the danger signs during the observation period or at the discharge clinical examination (preferably done by a doctor): send home. In this case, tell the parents which signs require immediate consultation.

Management for all other asymptomatic newborns

(none of the criteria above)

– Keep under observation in the maternity hospital for 24 hours.
– Monitor for danger signs (Section 10.3.1). If the infant presents at least one danger sign, see Section 10.3.3.
– If the infant did not present any danger signs during observation: send home. In that case, tell the parents which signs require immediate consultation.

10.3.5 Management of hypoglycaemia

Criteria defining newborns at risk for hypoglycaemia

– Presence of at least one of the following signs:
• Hypothermia (axillary temperature < 35.5°C)
• Irritability or trembling
• Bradypnoea or apnoea or cyanosis
• Difficulty breastfeeding (difficulty attaching to the breast, difficulty sucking, inadequate milk production)
• Hypotony or poor response to stimulation (impaired consciousness)
• Seizures

– Birth weight < 2500 g or > 4000 g

– Maternal diabetes

– Mother treated with labetalol

Always check blood glucose5 if at least one of the above criteria is present.

Management

If the blood glucose is normal (> 2.5 mmol/l or > 45 mg/dl):
– Breastfeeding every 3 hours (add 10% glucose PO if breastfeeding is insufficient).
– Keep the infant warm.
– Check the blood glucose before each meal until there are 3 consecutive normal results.

If the hypoglycaemia is moderate (2 to 2.5 mmol/l or 35 to 45 mg/dl) and it is the first episode of hypoglycaemia:
– Put to the breast and give 5 ml/kg of 10% glucose over 5-10 minutes PO or by gastric tube, or
– Administer 2 ml/kg of 10% glucose by IV infusion as below, if an IV line is already in place and if the newborn is symptomatic.
– Check the blood glucose after 30 minutes; administer IV glucose if blood glucose is < 2.5 mmol/l (< 45 mg/dl).
– Check the blood glucose before each meal until there are 3 consecutive normal results.

If the hypoglycaemia is severe (< 2 mmol/l or < 35 mg/dl) or recurrent:
– Place an IV line and administer 2 ml/kg of 10% glucose.
– If not feasible, administer 10 ml/kg of 10% glucose by gastric tube.
– Then start a continuous infusion of glucose 10%: 80 ml/kg/day for at least 24 hours, if conditions permit.
– Check the blood glucose after 30 minutes and then before each meal until there are 3 consecutive normal results.

The use of 50% glucose (1 ml/kg) sublingually is recommended only if it is impossible to do an infusion or place a gastric tube.

10.3.6 Management of jaundice

Severe jaundice can cause acute encephalopathy, potentially leading to neurological sequelae and death.

Diagnosis

Jaundice is yellow colouring of the skin and mucous membranes due to hyperbilirubinaemia.
It appears first on the face, and then moves to the chest and then the extremities.
The examination should be done in day light. It is done by pressing the infant’s skin and looking to see if it is yellow immediately after the pressure is removed.

Jaundice can be physiologic, with a yellowish skin colour, without the criteria for pathological jaundice below.
Physiologic jaundice is a diagnosis of exclusion in an infant in excellent general condition who is feeding well and whose neurological examination is normal.

Pathological jaundice starts the first day of life (the second day of life if < 35 weeks), and lasts more than 14 days in full-term infants or more than 21 days in premature infants.
It is an intense colour that affects the palms of the hands and soles of the feet, and may be associated with a neonatal infection.

In cases of jaundice, consider septicaemia or congenital malaria.

Management

Infants presenting criteria of severity (early onset jaundice, extensive jaundice, low birth weight, or specific risk) should be referred.

Table 10.6 - Criteria for transferring newborns with jaundice to neonatal unit

Time of onset

Criteria for transfer

Day 0

– All newborns, regardless of birth weight

Day 1

Newborns < 1500 g
Newborns > 1500 g with extensive jaundice: head, chest, abdomen, upper arms and thighs

Day 2 or later

Newborns < 1500 g with very extensive jaundice (head, chest, abdomen, upper arm and forearm, thigh and lower leg)

Newborns > 1500 g with:

  • very extensive jaundice (head, chest, abdomen, upper arm and forearm, thigh and lower leg)
    AND
  • at least one of the following risk factors: ABO or Rh incompatibility, G6PD deficiency, inadequate breastfeeding, infection, hypothermia, asphyxia, cephalohaematoma or maternal diabetes

Newborns > 1500 g with no risk factors but extreme jaundice also affecting the palms of the hands and soles of the feet

If there are no criteria of severity or while awaiting the transfer:
– Maintain good hydration (breastfeeding), if necessary use infant formula and a gastric tube.
– Begin treatment for infection, if present.
– Sun exposure is not an effective treatment for severe jaundice. However, if there are no other options, expose the bare newborn to the sun for 10 minutes 4 times a day, in the morning and late afternoon, when the sun is not too strong.
Cover the infant’s eyes.



Footnotes
Ref Notes
1

Procaine benzylpenicillin may be replaced by fortified penicillin procaine (PPF), same doses. These two penicillins SHOULD NEVER BE USED IN TRAVENOUSLY.

[ a b ]
2

Ceftriaxone is contra-indicated in newborns with jaundice.

3

Due to the risk of local necrosis, cloxacillin should be administered by IV infusion in 5% glucose or 0.9% sodium chloride over 30 to 60 minutes (or if i mpossible, by slow IV injection over at least 5 minutes).

4

Antibiotics during labour when there is a prolonged rupture of membranes (Chapter 4, Section 4.9.3) reduces risk of septicaemia in the newborn. Coverage is considered effective if at least 2 doses have been administered 4 hours apart during labour.

5

Blood glucose is measured on a sample of capillary blood taken from the lateral aspect of the heel using a lancet or 24G needle. This technique is used for other tests like HemoCue haemoglobin measurement.