10.3 Care of the sick newborn

10.3.1 Danger signs

Danger signs may present at delivery or develop within hours or days after birth.
All neonates should be examined for danger signs at birth, during their stay in maternity or at the first post-natal visit if born at home. 
If any of the following signs are present, treat immediately (Section 10.3.2) and transfer to a neonatal care unit.

Danger signs

Temperature

• Hyperthermia (axillary temperature > 38 °C)
• Hypothermia (axillary temperature < 35.5 °C)

Neurological signs

• Bulging fontanelle
• Hypotonia

• Lethargy or coma
• Unable to breastfeed
• Seizures including subtle or abnormal movements:
– deviation of the eyes with or without spasms, eyelid blinking
– sucking, smacking or other mouth movements 
– swimming or pedalling movements

Respiration

• Apnoea or bradypnoea (RR < 30/minute)
• Tachypnoea (RR > 60/minute)
• Severe chest indrawing
• Grunting

Heart

• Tachycardia (HR > 180/minute)

• Prolonged capillary refill time (> 2 seconds)

Abdomen

Severe abdominal distension

Skin colour

• Generalised cyanosis (blue colouring)
• Extreme pallor
• Extensive jaundice (yellow colouring)

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 (blood glucose level < 2.5 mmol/litre or < 45 mg/dl on more than 2 episodes)

10.3.2 General management

– Stabilise the neonate before transfer to the neonatal unit:
• Position the head to open the airway.
• Administer oxygen with an appropriate nasal cannula, at a maximum flow rate of 2 litres/minute (aim for SpO2 90-95%).
• In the case of apnoea or if RR < 20/minute: perform bag and mask ventilation (Section 10.2.1).
• Check blood glucose and/or treat for hypoglycaemia (Section 10.3.4).

– While awaiting transfer:
• Keep neonate warm in a room at 23-25 °C wrapped in a blanket or under an infant warmer, and cover the head with a cap.
• Closely monitor temperature, respiratory rate and SpO2.
• Start treatment for neonatal infection (Section 10.3.3).
• Ensure routine neonatal care (Section 10.1).
• Start or continue feeding (Appendix 4). Only if necessary, compliment feeds with a nasogastric tube and/or IV fluids (Appendix 5).

 In the case of severe respiratory distress, abdominal distension, or coma, do not feed the neonate by mouth. Start IV fluids if possible (Appendix 5).

10.3.3 Neonatal infection

Neonates suspected to have severe neonatal infection

Danger signs may indicate an underlying severe infection which requires transfer to a neonatal unit and antibiotic therapy. 

While awaiting transfer to a neonatal unit, start antibiotic therapy: 
– The first line treatment is the combination of ampicillin IV + gentamicin IM. 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 IM + gentamicin IM. 
– If meningitis is suspected, do not use procaine benzylpenicillin.

– If the infection is cutaneous in origin, replace the ampicillin with cloxacillin IV.1
– Total treatment duration is
 7 to 10 days according to clinical response. Gentamicin should be stopped after 5 days of treatment. 

Table 10.5 - Antibiotic dosages 


Antibacterial

Birth weight

≤ 2000 g

> 2000 g

ampicillin
IV/IM injection

50 mg/kg every 12 hours

If meningitis:
100 mg/kg every 12 hours

50 mg/kg every 8 hours

If meningitis:
100 mg/kg every 8 hours

gentamicin
IM injection

3 mg/kg every 24 hours

5 mg/kg every 24 hours

procaine benzylpenicilline2

IM injection

50 000 IU/kg every 24 hours

If meningitis: do not administer.

cloxacillin
IV infusion

25 mg/kg every 12 hours

25 mg/kg every 8 hours

Prophylactic treatment for asymptomatic neonates with risk factors for infection

In asymptomatic neonates (absence of danger signs) in whom the assessment for risk factors for neonatal infection at birth was positive (Section 10.1.1, Clinical examination and assessment of risk factors):
– Administer antibiotics for 48 hours3ampicillin IV + gentamicin IM or procaine benzylpenicillin IM + gentamicin IM. See Table 10.5 for dosage.
– Monitor for danger signs (
Section 10.3.1). If the neonate presents at least one danger sign, treat as suspected severe infection as below.
– If the neonate has not presented any of the danger signs during the first 48 hours, stop the antibiotics and keep under observation for 24 to 48 hours.
– If the neonate has not presented any of the danger signs during the observation period or during clinical examination for discharge: send home. In this case, tell the parents which signs require immediate consultation.

Note: neonates born at home, seen for the first time after 72 hours of age and present no signs of infection, do not need prophylactic antibiotics even if a maternal risk factor is identified.

10.3.4 Hypoglycaemia

Hypoglycaemia is common in neonates but often asymptomatic or presents with non-specific signs. Recurrent or persistent hypoglycaemia can lead to neurological sequelae.

Diagnosis

– Blood glucose < 2.5 mmol/l or < 45 mg/dl.
– Blood glucose is measured on a sample of capillary blood taken from the lateral aspect of the heel using a lancet or 24G needle. 

Always check blood glucose:  
–  In neonates at risk of hypoglycaemia (Section 10.1.1, Clinical examination and assessment of risk factors
–  In neonates presenting with one of these signs: 
 • Hypothermia 
 • Irritability or tremors 
 • Bradypnoea or apnoea or cyanosis 
 • Hypotonia or poor response to stimulation or impaired consciousness
 • Seizures

Management

Moderate hypoglycaemia (2 to 2.4 mmol/litre or 35 to 44 mg/dl) and asymptomatic:
– Feed neonate immediately (preferably breast milk).
– If no milk is available, give 5 ml/kg of 10% glucose PO over 5 to 10 minutes.
– Check blood glucose after 30 minutes:
• If it is normal (≥ 2.5 mmol/litre or ≥ 45 mg/dl), ensure the neonate feeds regularly and check blood glucose again before each feed until there are 3 consecutive normal results. 
• If it remains < 2.5 mmol/litre or < 45 mg/dl), treat as recurrent hypoglycaemia.

Severe hypoglycaemia (< 2 mmol/litre or < 35 mg/dl) or symptomatic or recurrent:
– Give 5 ml/kg of 10% glucose PO or via gastric tube over 5 to 10 minutes, or if IV line already in place, give 2 ml/kg of 10% glucose slow IV (2 to 3 minutes). 
– Check blood glucose after 30 minutes: 
• If it is normal (≥ 2.5 mmol/litre or ≥ 45 mg/dl), ensure the neonate feeds regularly, recheck blood glucose after 30 minutes and then before each feed until there are 3 consecutive normal results.

• If it is < 2.5 mmol/litre or < 45 mg/dl, or the neonate is still symptomatic, give a second dose of 10% glucose (5 ml/kg PO or 2 ml/kg IV) and transfer to a neonatal unit. While awaiting transfer, start a continuous infusion of 10% glucose (80 ml/kg/24 hours) if possible and continue to monitor blood glucose.

Note: only if it is impossible to give an infusion or place a gastric tube, 1 ml/kg of 50% glucose can be administered sublingually.

10.3.5 Jaundice

Neonatal jaundice is generally harmless, but severe jaundice can cause acute encephalopathy, potentially leading to neurological sequelae and death.

Diagnosis

– Yellow colouring of the skin and sclerae due to increased levels of bilirubin in the blood. 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 neonate's skin and looking to see if it is yellow immediately after the pressure is removed.
– Assess criteria for transfer to a neonatal care unit:

Table 10.6 - Criteria for transferring neonates with severe jaundice to neonatal unit.

Age

Criteria for transfer

Day 1

Any visible jaundice

Day 2

< 1500 g or risk factors*: any visible jaundice
> 1500 g: moderate jaundice (head, chest, lower body, thighs)

Day 3 or later

< 1500 g or risk factors*: extensive jaundice (head, chest, lower body, arms, thighs, lower leg)
> 1500 g: very extensive jaundice (head, chest, lower body, arms, thighs, lower leg, hands and feet)

* Risk factors include:
  • ABO or Rh factor incompatibility between mother and neonate.
  • Inadequate milk intake (dehydration, weight loss).
  • G6PD deficiency: consider if severe jaundice in family history or in prevalent regions (sub-Saharan Africa, Arabic peninsula and parts of Asia/Mediterranean).
  • Neonatal infection
  • Cephalohaematoma/bruising

Management

Neonate does not have criteria for transfer
– Put neonate on breast 8 to 12 times per day.
– Monitor extent of jaundice for 12 to 18 hours.
– If all well the neonate can be discharged. Give mother routine discharge advice (Section 10.6) and specific advice regarding the jaundice: to return if stools become pale and urine becomes dark or jaundice prolonged beyond 2 weeks.

Neonate needs to be transferred
– Put neonate on breast 8 to 12 times per day for first few days if able to breastfeed. Supplement with expressed breast milk or infant formula if necessary. Use gastric tube if oral intake is not possible.
– Begin treatment for infection, if present (Section 10.3.3).

10.3.6 Seizures

Seizures in neonates are often subtle, featured as any unusual repetitive or stereotypic movement (Section 10.3.1).
– Check blood glucose and/or treat for hypoglycaemia (Section 10.3.4).
– Treat with phenobarbital IV if the seizure lasts more than 3 minutes, or recurs (> 2 to 3 episodes in one hour), or is associated with cardiorespiratory disturbance:
• First dose: 20 mg/kg by slow IV infusion over 30 minutes. Phenobarbital should never be administered as a rapid direct IV injection. Phenobarbital may be given IM (undiluted) if there is no IV access.
• If seizures persist 30 minutes after, administer a second dose of phenobarbital 10 mg/kg by slow IV infusion over 30 minutes. If still no IV access, give the second dose of phenobarbital 10 mg/kg (undiluted) IM at least 60 minutes after the first IM dose. 
Do not give more than 40 mg/kg in total.
– Any neonate that required treatment with phenobarbital should be transferred to a neonatal care unit.
– Monitor the neonate closely while awaiting transfer. Ensure ventilation equipment is available as there is a risk of respiratory depression.



Footnotes
Ref Notes
1

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 not possible, by slow IV injection over at least 5 minutes).

2

Do not administer procaine benzylpenicillin by IV route.