Neonatal care
Dr Jenny Woodruff
[email protected]
Global Links Volunteer Paediatrician
Tuesday 24th March 2015
Neonatal care in a nutshell...
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What do babies die of?
Preterm babies and feeding regimes
Hypothermia
A few specific conditions: NEC, neonatal sepsis
A few things you DON’T need to worry about!
Birth asphyxia
Resuscitation – principles
What do babies die of in Uganda?
Neonatal
deaths =
within
first 28
days of
life
When do babies die?
• Biggest risk is first hour of life
• Next highest risk is within 24 hours (25 – 45% of
neonatal mortality)
• 75% neonatal mortality occurs during first week
• First month of life has a 30 times higher mortality
than older babies
— Lawn et al, 4 million neonatal deaths: when? Where? Why?
Lancet 2005, 365:891-900.
— Zupan et al, Perinatal Mortality for the Year 2000: Estimates Developed by
WHO. 2005.
What is prematurity?
• Premature means less than 37 weeks’
gestation
• Extremely preterm <28weeks’ gestation
(around 6 and a half months’)
• Very preterm 28 weeks – 32 weeks (6 and a
half months to 7 and a half months’ gestation)
• Moderate to late preterm 32 weeks to <37
weeks
What is prematurity?
• Premature means less than 37 weeks’ gestation
• Extremely preterm <28weeks’ gestation (around
6 and a half months’)
– Mortality >90% in low income countries, <10% in high
income settings
• Very preterm 28 weeks – 32 weeks (6 and a half
months to 7 and a half months’ gestation)
• Moderate to late preterm 32 weeks to <37 weeks
– Mortality at 32 weeks (7 months) gestation: 50%
mortality in low income countries, nearly all survive in
high income settings
What about low birth weight?
• Low Birth weight <2.5kg
– Incidence of 14% of live births in Uganda in 2006
– This is double that of the UK (7%)
• Very low birth weight <1.5kg
• Extremely low birth weight <1kg
Unicef country profile,
Uganda 2010
Low birth weight vs prematurity
• Similar difficulties in temperature control
• A term baby who has a low birth weight will
have better developed lungs and suck than a
preterm infant of the same weight, so is likely
to be ready for discharge earlier
• How can we tell if mother doesn’t know her
dates?
“Ballard score”
Higher score = more mature
Higher score = more mature
Physical maturity:
So what do we need to consider for
premature / low birth weight babies?
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Fluid management / establishing feeds
High risk of hypoglycaemia
Temperature control
High risk of sepsis
Jaundice – higher risk of kernicterus
Breathing difficulties (respiratory distress
syndrome and apnoeas)
Longterm: risk of
• Necrotising Enterocolitis
neurodevelopmental
problems including cerebral
• Patent ductus arteriosus
palsy due to bleeding in the
brain and also blindness
Day zero = 60ml/kg/day
Day 8 until 4 weeks post term
180ml/kg/day
Feeding regimes – red, yellow, green
• Red: Do not feed. Give IV fluids
• Yellow: Feed after 24 hours of IV 10% dextrose
• Green: Feed immediately
– 10% dextrose is IV fluid of choice until day 3 when
need to add electrolytes
– From day 3 give: 2/3rds of the volume as 10%
dextrose and 1/3rd of the volume as R/L or N/S (use
R/L if dehydrated)
Eg. A 3 day old septic premature with
distended abdomen
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Weighs 1.2kg
So for day 3 we need 100ml/kg/day
= 120mls in 24 hours
= 10mls every 2 hours
• Give 2/3rds as 10% dex i.e. 7mls/2hrs
• Give 1/3rd as N/S or R/L i.e. 3mls/2hrs
How do we feed prematures / low
birth weight babies?
“But my baby can suck! They don’t need a tube! “
• May have some suckling reflex from 28 weeks (approx 1kg)
• BUT ability to do suck-swallow-breathe starts at the earliest at 32 – 33 weeks
(approx 1.8kg)
• Expect baby to have a coordinated suck-swallow-breathe from 34 weeks
(approx 2.1kg)
• Expect baby to be able to breastfeed effectively to get all the milk they need
from about 35 – 36 weeks. (approx 2.5kg)
Options for feeding...
Uses: If baby unable to
suck as too premature
eg <1kg, or too sleepy
e.g. birth asphyxia, or
too small and unstable
and needs to stay in
incubator.
If baby stable and able
to suck but not able to
get all the milk needed
from the breast i.e.
<2.5kg or <35 weeks
gestation
NB: Tricky to do with
Kangaroo Mother Care!
Can use in
combination with
other methods – but
be careful, prems can
get tired!
Feeding preterm babies
• For babies <1.5kg need to gradually increase
feeds to ensure they are tolerated and reduce the
risk of NEC
• Can start milk at 25ml/kg/day (this would be day
2 of life). Normally would advise to increase daily
by 25ml/kg/day
• This means by day 6 they would be on full milk
feeds
• Due to the difficulty of giving IV fluids regularly, I
believe it is better in our setting to increase the
milk feeds more quickly if the baby tolerates
them, so that baby does not need IV fluids after
day 3 or 4 of life.
Prematurity – risk of sepsis
• Premature infants have a much higher risk of
sepsis
• Therefore we give them prophylactic antibiotics
• Definitely give antibiotics if any other risk factors
for sepsis, or if Very Low Birthweight (i.e. <1.5kg)
or if Very premature (<32 weeks=7.5months)
• If >1.5kg and >32 weeks, no risk factors and well,
it is reasonable to withhold antibiotics
• If clinically well and just giving antibiotics due to
prematurity, 5 days is sufficient
• If clinically unwell or multiple septic risk factors
should give 7 – 10 days
Prematurity – breathing troubles
• Respiratory distress syndrome – due to lack of
surfactant
• Affects infants <34 weeks
• Higher risk if <31 weeks
• Risk reduced if mother
given antenatal
dexamethasone
Prematurity – breathing troubles
• Apnoeas of prematurity – baby forgets to
breathe for 20 secs or more, or breathes
shallowly, and develops reduced oxygen sp02
/ low heart rate (bradycardia)
• Incidence of apnoea of prematurity
– >85% at below 28 weeks
– 50% at 30-31 weeks
• Tend to resolve around 34-35 weeks gestation
• Treat with aminophylline
What is hypothermia?
• Normal temperature is 36.5 to 37.5oC
• Temperature less than 36.5 oC is hypothermic
in a newborn
When do babies become
hypothermic?
• In utero, temperature is 38oC. Then…..
Hypothermia - why does it matter?
• It is common: 80% of 300 newborns in St Francis Hospital,
Nsambya, were hypothermic within 90 minutes of delivery
• More likely if no skin-to-skin or bathed within 1 hour of birth
• 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
• In 2006 in SCU in Mulago hospital, Kampala, 29% of newborn deaths
were associated with hypothermia
Arch Pediatr Adolesc Med. 2010 Jul;164(7):650-6. Risk of mortality associated with
neonatal hypothermia in southern Nepal. Mullany et al.
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
• In 2006 in SCU in Mulago hospital, Kampala, 29% of newborn deaths
were associated with hypothermia
Arch Pediatr Adolesc Med. 2010 Jul;164(7):650-6. Risk
of mortality associated with neonatal hypothermia in
southern Nepal. Mullany et al.
How can we prevent hypothermia?
Delivery room minimum 25oC
Dry, cover, hat
Skin to skin 1 – 2 hours
Breastfeeding within 1 hr
Bathing > 6 hrs (day 2/3 is best)
1 – 2 more layers than adults
Benefits of Kangaroo Mother Care
(KMC)
• At discharge or 40 – 41 weeks’ corrected age:
– Reduction in mortality (Risk Ratio 0.6)
– Reduction in sepsis (RR 0.42)
– Reduction in hypothermia (RR 0.23)
– Reduction in length of admission (mean 2.4 days)
• KMC was also found to increase some
measures of infant growth, breastfeeding, and
mother-infant attachment
Kangaroo care – effect on observations
KMC – how much to advise?
• We normally ask mothers to do KMC for 2
hours, 4 times a day as a minimum (once the
baby is stable)
• If stable but temp 35.9 or less, should do KMC
immediately.
• If unstable / on oxygen, they should do KMC if
temperature is 35.4oC or less.
Dress with hat, nappy
and socks
Expressing / giving cup / NGT feeds can be tricky
on KMC (but not impossible!)
New innovation in SCU
• In Charge Temperature Champion Mother of
the Week
• Mothers monitor the babies’ temperatures
themselves, 4x a day
Maternal Temperature Record Chart. Please record your baby’s temperature below.
There is a Temperature Champion Mother of the Week who has the thermometer
and pen for you to use and can help you to record your baby’s temperatures.
Baby’s name....................................................
Baby’s date of birth.........................................
Date
Temp at 06:00am
Temp at 12:00midday
Temp at 06.00pm
Temp at midnight
Temperature ranges and action needed
37.6oC or higher: The baby is too hot. Remove one blanket, and if baby is in incubator lift up the side of the incubator so cold air can reach baby. Recheck
temp in 1 hour. If still high, tell nurse (may need antibiotics)
36.5 – 37.5: Well done. This is the best temperature for the baby to grow and survive
36.0 – 36.4: The baby is cold. If in incubator: add one thick blanket or 2 thin blankets, and also add a hat. Ensure the side of the incubator is DOWN so no
cold air can reach baby. If on phototherapy, add one thick blanket over the baby’s legs. Recheck temp in 1 hour: if not improving, ensure incubator lightbulb
is ON (use dial on side of incubator), and the incubator tray has water in it, and the side of the incubator is DOWN so no cold air can reach baby.
35.5 - 35.9: The baby is VERY cold and must be warmed up. Use Kangaroo (even if the baby is on phototherapy, Kangaroo is better for baby than
phototherapy when baby is so cold). Do Kangaroo with a hat for at least 2 hours. Then recheck temperature. Only remove from Kangaroo when temp is 36.0
or above. If the baby is on oxygen / too unwell for Kangaroo, ensure incubator lightbulb is ON (use dial on side of incubator), and the incubator tray has
water in it, and the side of the incubator is DOWN so no cold air can reach baby.
35.4 or lower: The baby is DANGEROUSLY COLD and must be warmed up urgently. Use Kangaroo (even if baby is very unwell or needing oxygen, Kangaroo
is best for the baby when he is so cold). Do Kangaroo with a hat and at least 2 thick blankets on top of mum and baby, for at least 2 hours. Then recheck
temperature. Only remove from Kangaroo when temperature is 36.0 or above – then ensure incubator is prepared and warm before transferring baby.
NEC – necrotizing enterocolitis
• Inflammation of the gut, can lead to necrosis
• Most common in <1.5kg babies
• 90% occurs in preterm babies (mean gest age
30 – 32 and 12 days old). 10% in term babies.
NEC – how does it present?
• Intramural
gas
• Gas in portal
system
Treatment of NEC
• Medical:
• Nil per os (for at least 3 days, and depending
on symptoms may need 10 - 14 days NPO)
• Triple antibiotics: ampicillin / gent / metro
• NGT on free drainage
• Surgical:
• If has perforated (may see on lateral decubitas
Xray) can be lifesaving.
Moving on from prematures...
Neonatal sepsis: Risk factors
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Maternal fever >38.0
Foul smelling vaginal discharge
Foul smelling amniotic fluid
Maternal Urinary Tract Infection
Prolonged rupture membranes >18 hrs
<37 weeks’ gestation
Low birthweight
Fetal tachycardia in utero
Maternal tachycardia in labour
Late sepsis:
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Failure of breast feeding
Disruption of skin integrity with needle pricks
Poor umbilical cord care
Poor hand hygiene in hospitals
Signs of neonatal sepsis
• Temperature (axillary) ≥37.5°C or <35.5°C
• History of feeding difficulty
• History of convulsions
• Change in level of activity
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Fast breathing/respiratory rate ≥60 bpm
Severe chest indrawing
Grunting
Cyanosis
Which antibiotics?
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Ampicillin/Gentamicin first line
Ceftriaxone / cloxa second line / meningitis
7 – 10 days sepsis
10 – 14 days meningitis
5 days - only if giving Abx due to prematurity
and baby well without other risk factors
A quick aside: Cord care – WHO
recommends:
Newborns who are born at home in settings with high neonatal
mortality (30 or more neonatal deaths per 1000 live births):
Daily chlorhexidine application to the umbilical cord stump
during the first week of life is recommended
Newborns born in health facilities and at home in low neonatal
mortality settings: Clean, dry cord care is recommended.
Use of chlorhexidine in these situations may be considered only
to replace application of a harmful traditional substance, such
as cow dung, to the cord stump.
A few things you DON’T need to worry
about
• Bloody /
brown vomits
/ aspirates
within first 3
days of life –
likely
swallowed
maternal
blood (after
this age can be
due to cracked
nipples)
• BUT check has
had vit K
A few things you DON’T need to worry
about
• Blood in nappy passed vaginally from baby girl
– common around age 5 days due to
withdrawal from mum’s hormones
• Breast buds, including leaking milk
• Pimply rash in a well baby
• Hiccupping
• Sneezing
• Startle reflex
Birth asphyxia
• Due to low levels of oxygen around the time
of birth
• Can cause permanent brain damage
• Apgar scores <7 at 5 mins – at increased risk.
Apgar score less than or equal to 5 at 10 mins
(or still needing resuscitation at 10 mins) –
very high risk
• Lower apgar score at 10 mins (e.g. 0/1/2)
gives higher risk long term disability / death
Apgar score
Birth asphyxia
• Baby likely to not breathe, may be grey and
floppy at birth
• Often develop convulsions within the first 24
hours of life
• Severe cases are in a deep coma with
laboured breathing
• May make full recovery but may suffer long
term effects
Birth asphyxia – treatment
• If convulsion lasts >3mins or multiple shorter convulsions
in succession…. TREAT with:
– Test / treat for hypoglycaemia – 2 to 5mls/kg 10% dextrose
– Firstline drug is phenobarbitone
• Eg phenobarb 20mg/kg loading, followed at 30 minute intervals with
10mg/kg and 10mg/kg to maximum daily total of 40mg/kg.
Maintenance of 5mg/kg od (IV or po)
– Secondline drug is diazepam but need to give it SLOWLY to
reduce risk of respiratory depression
• Diazepam 0.2 – 0.3mg/kg given over 10 mins slow IV push , can repeat
max of 3 times
– Consider treating for meningitis if has signs of it (or do LP if
possible)
• Nutrition – give IV fluids initially then once stable (i.e. not
having convulsions) can give expressed breastmilk by
nasogastric tube
How big is the need for resuscitation?
• 26% of neonatal mortality is due to birth
asphyxia
• Around 10% require some help to breathe at
birth
• Less than 1% require extensive resuscitation at
birth
• Good resuscitation skills leads to lower rates
of stillbirths and birth asphyxia / brain damage
Does this baby need help?
Does this baby need help?
• See video
How can we help?
• Helping Babies Breathe
• The Golden Minute: Within one minute of
birth, a baby should be breathing well or
should be ventilated with a bag and mask.
• First, let’s watch the summary video...
Hold head in
neutral
position
Resus 13
Placing the mask on the face
Grip on the mask, push down on face whilst
using 3rd/4th/5th fingers to push jaw up
With the mask in place
• Breath for the baby at a rate of 40 breaths per
minute by squeezing the bag
Chest compressions
• In babies who are not breathing well by one
minute, priority should be given to ventilation
rather than chest compressions.
• For this reason, chest compressions are not
taught in HBB.
• BUT! Chest compressions are part of advanced
resuscitation with 2 or more health professionals
if good chest rise for 3 -5 mins yet heart rate
remains slow <100.
How to do chest compressions
• Should compress the
chest by a third of the
depth of the body
• Press at a rate of 120
beats per minute (2 per
second)
• Give three chest
compressions for every 1
breath
• Video of chest compressions...
When to stop resuscitating
• In babies who have no spontaneous heart rate
after 10 minutes, resuscitation should be
stopped.
• In babies who have a heart rate < 60 beats per
minute and no spontaneous breathing after
20 minutes of resuscitation, intervention
should be stopped.
Summary
• Biggest killers of neonates in Uganda are
sepsis, prematurity and birth asphyxia
• Premature infants need extra support in
temperature control and nutrition.
• Resuscitation saves lives and prevents brain
damage.
• HBB gives us clear guidance – the golden
minute to ensure breathing or start BVM
ventilation
• Chest compressions if 2 trained medical staff
• Any questions?
• My email is [email protected] if you
want me to email you the presentation