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4

Emergency management of infants

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Contents

Objectives

Introduction

4-1 What is the emergency management of a newborn infant?

Some newborn infants develop serious problems which often cannot be managed in a level 1 clinic or hospital where only primary care is available. These infants need to be carefully assessed and stabilised before they can be moved to a level 2 (special care unit) or level 3 (intensive care unit) hospital that has the staff and facilities to provide the care needed. Emergency management is the care that must be given to these infants in a level 1 hospital or clinic before they are transferred. Staff working in level 1 hospitals and clinics must be able to give emergency care.

4-2 Which infants need emergency management?

The management of hypothermia

4-3 How do you measure an infant’s temperature?

The infant’s skin temperature, rather than the oral or rectal temperature, is usually used. The axillary or abdominal skin temperature should be measured.

Skin temperature can be measured with either:

4-4 What is the normal range of body temperature?

This depends on the site where the temperature is measured:

  1. The normal axillary temperature is 36.5–37 °C.
  2. The normal abdominal skin temperature is 36–36.5 °C.

4-5 What is hypothermia?

Hypothermia (low body temperature) is defined as an axillary temperature below 36.5 °C or an abdominal skin temperature below 36 °C.

4-6 Which infants are at high risk of hypothermia?

  1. Infants who are not dried well after birth
  2. Infants in a cold room or cool incubator
  3. Low-birth-weight infants
  4. Infants lying near cold windows
  5. Infants who are not fed

4-7 How do you recognise an infant with hypothermia?

Hypothermic infants present with the following signs:

  1. They are cold to the touch.
  2. They are lethargic, hypotonic, feed poorly and have a feeble cry.
  3. Their hands and feet are usually pale or blue, but their tongue and cheeks are often pink. The pink cheeks may incorrectly suggest that the infant is well.
  4. Peripheral oedema or sclerema (a woody or plastic feel to the skin).
  5. Shallow, slow respiration or signs of respiratory distress.
  6. Bleeding from the mouth, nose or needle punctures.

4-8 What problems are common in hypothermic infants?

  1. Hypoglycaemia. This is a common cause of death in cold infants and the most important complication of hypothermia. Cold infants use a lot of energy in an attempt to warm themselves. As a result they use up all their energy stores, resulting in hypoglycaemia.
  2. Hypoxia. The infant’s haemoglobin does not carry oxygen normally when the red blood cells are very cold.
  3. Haemorrhage. When infants are very cold their blood does not clot normally and they commonly bleed.

Hypothermic infants may die of hypoglycaemia.

4-9 How do you treat hypothermia?

  1. Warm the infant in a closed incubator, overhead radiant warmer or warm room. The incubator temperature should be set at 37 °C until the skin temperature returns to normal. If these are not available, place the infant naked against the mother’s skin and wrap both in a blanket to give skin-to-skin care.
  2. Provide energy while the infant is being warmed. Hypoglycaemia may occur during warming. Energy can be given as oral or nasogastric milk, or intravenous maintenance fluid containing 10% dextrose water (e.g. Neonatalyte).
  3. Provide oxygen. Give 30% oxygen by headbox while the infant is being warmed, even if the infant is pink.
  4. Notify the referral level 1 or 2 unit as this infant may need to be transported. Discuss the management of the infant with the staff of the referral hospital.
  5. Observations. Monitor and record the infant’s temperature, pulse, respiration, skin colour and blood glucose concentration until they are normal and stable.
  6. Keep the infant warm once a normal body temperature is reached. It is very important to keep the infant warm during transport.

4-10 How should you keep an infant warm during transport?

Infants should be kept warm during transport by nursing them in a transport incubator or by skin-to-skin care. If the mother cannot be moved, a nurse, doctor or ambulance attendant can give skin-to-skin care. Warm infants can also be dressed and then wrapped in a silver swaddler or tin foil. The infant must be warm before transport.

The management of hypoglycaemia

4-11 What is glucose?

Glucose is an important type of sugar. Many forms of food (e.g. milk formula) contain glucose. Infants also get glucose from lactose in breast milk and from the breakdown of starch when solids are added to the diet. Glucose is an essential source of energy to many cells of the body, especially the brain. Glucose is stored as glycogen in the liver. Glucose can also be stored as fat and protein. The liver can change stores of glycogen, fat and protein back into glucose.

The amount of glucose available to the cells can be assessed by measuring the concentration of glucose in the blood.

4-12 How is blood glucose measured in the nursery?

The quickest, cheapest and easiest method to measure the blood glucose concentration in the nursery is to use a reagent strip such as Haemo-Glukotest, Glucotrend or Dextrostix. However, a far more accurate method to screen for hypoglycaemia is to read the colour of the reagent strip with a glucose meter such as a Reflolux meter. It is important to carefully read the instructions which are packed with the reagent strips as the correct method must be used.

4-13 What is the normal concentration of glucose in the blood?

The normal concentration of glucose in the blood of newborn infants is 2.0 mmol/l to 7.0 mmol/l.

4-14 What is hypoglycaemia?

Hypoglycaemia is defined as a blood glucose concentration below 2.0 mmol/l. Mild hypoglycaemia is defined as a blood glucose concentration between 1.5 to 2.0 mmol/l in an infant without any abnormal neurological signs. Severe hypoglycaemia is defined as a blood glucose concentration of less than 1.5 mmol/l or hypoglycaemia with abnormal neurological signs.

Hypoglycaemia is defined as a blood glucose concentration below 2.0 mmol/l.

4-15 What are the dangers of hypoglycaemia?

Hypoglycaemia is extremely dangerous, especially when the blood glucose concentration is below 1.5 mmol/l and the infant has abnormal neurological signs. When the blood glucose concentration is low the cells of the body, particularly the brain, do not receive enough glucose and as a result cannot produce energy for their metabolism. With severe hypoglycaemia the brain cells can be damaged or die, causing cerebral palsy, mental retardation or death. Mild hypoglycaemia is important as it may rapidly progress to severe hypoglycaemia. Every effort must therefore be made to treat mild hypoglycaemia promptly.

Hypoglycaemia may cause brain damage.

4-16 Which infants are at risk of developing hypoglycaemia?

Infants that have reduced energy stores, reduced energy intake (feed poorly) or increased energy needs are at risk of hypoglycaemia.

Hypothermia causes hypoglycaemia.

4-17 What are the clinical signs of hypoglycaemia?

Hypoglycaemia may produce no clinical signs or present with only non-specific signs. This makes the clinical diagnosis of hypoglycaemia very difficult. When present, the clinical signs of hypoglycaemia are:

  1. The infant may be lethargic and hypotonic, feed poorly, have a weak cry, apnoea, cyanosis or an absent Moro reflex.
  2. The infant may be jittery with a high-pitched cry, a fixed stare and fisting, have abnormal eye movements or convulsions.
  3. Excessive sweating. This sign may not be present, however, especially in preterm infants.

Often an infant has both signs of decreased brain function, such as lethargy and poor feeding, as well as signs of excessive brain function, such as jitteriness and convulsions. The clinical presentation of hypoglycaemia is very variable which makes the clinical diagnosis of hypoglycaemia difficult. Therefore, the diagnosis of hypoglycaemia can be easily missed.

Hypoglycaemic infants may have no abnormal clinical signs.

4-18 How can you diagnose hypoglycaemia?

As the clinical diagnosis is difficult and often missed, it is essential that all infants at risk of hypoglycaemia, and infants with clinical signs that may be caused by hypoglycaemia, be screened with reagent strips. Whenever possible, use a glucose meter rather than reading the reagent strip by eye. Ideally a diagnosis of hypoglycaemia made with reagent strips should be confirmed with a laboratory blood glucose measurement.

4-19 How can you prevent hypoglycaemia?

Every effort must be taken to prevent hypoglycaemia by:

  1. Identifying all infants at high risk of developing hypoglycaemia.
  2. Monitoring the blood glucose concentration of these infants with reagent strips.
  3. Feeding all infants as soon as possible after delivery, especially low-birth-weight infants and infants of diabetic women.
  4. Whenever possible, milk feeds should be given. Both clear feeds and dextrose feeds should not be used in newborn infants as they are low in energy and may result in hypoglycaemia.
  5. If milk feeds cannot be given, then an intravenous infusion of 10% glucose (e.g. Neonatalyte) should be started.
  6. Prevent hypothermia.

With a policy of breastfeeding as soon as possible after delivery, most cases of hypoglycaemia can be prevented.

Early breastfeeding can usually prevent hypoglycaemia.

4-20 How should you treat an infant with mild hypoglycaemia?

Infants with a blood glucose concentration between 1.5 mmol/l and 2.0 mmol/l and no clinical signs of hypoglycaemia usually need milk feeds urgently to prevent severe hypoglycaemia:

  1. If they tolerate oral or nasogastric feeds, give 10 ml/kg breast milk or milk formula immediately. Do not give 5% or 10% dextrose orally as the energy content is less than that of breast milk or milk formula.
  2. Repeat the reagent strip reading 30 minutes after the feed to determine whether the blood glucose concentration has returned to the normal range. If it is still in the mild hypoglycaemia range, repeat the feed with an added 5 g sugar (1 teaspoon) per 30 ml milk and repeat the reagent strip measurement after another 30 minutes.
  3. When the blood glucose concentration has returned to normal, continue with regular milk feeds and continue to monitor with reagent strips hourly for 3 hours.
  4. If the blood glucose concentration falls below 1.5 mmol/l then treat as for severe hypoglycaemia.
  5. If the infant is too small or too ill to tolerate milk feeds, start an intravenous infusion of 10% glucose (e.g. Neonatalyte) and transfer to a level 2 or 3 hospital.

Most infants with mild hypoglycaemia respond well to milk feeds and do not need to be transferred. Establish breastfeeding as soon as possible to prevent hypoglycaemia recurring.

4-21 How should you treat an infant with severe hypoglycaemia?

All infants with a blood glucose concentration below 1.5 mmol/l, or hypoglycaemia with abnormal clinical signs, have severe hypoglycaemia. This is a medical emergency and must be treated immediately. The management of severe hypoglycaemia consists of the following steps:

  1. The treatment of choice is to start an intravenous infusion of 10% glucose (e.g. Neonatalyte) at a drip rate calculated to give 100 ml/kg in the first 24 hours. Give a bolus of 2 ml/kg of the 10% glucose over 5 minutes at the start of the infusion.
  2. If you cannot rapidly put up a peripheral intravenous line, insert an umbilical vein catheter.
  3. Repeat the reagent strip measurement after 15 minutes. If the blood glucose concentration has not returned to normal, dilute 5 ml of 50% dextrose with 5 ml of the 10% dextrose infusion fluid to give a 30% glucose solution. Inject 5 ml of this 30% glucose solution over 5 minutes into the plastic bulb of the infusion set. It is not advisable to inject 50% dextrose, as it is extremely hypertonic.
  4. If the blood glucose concentration still has not returned to normal within a further 15 minutes phone your referral hospital. They may ask you to give 5 mg hydrocortisone intravenously or glucagon 0.3 mg/kg intramuscularly.
  5. In an emergency, if you are unable to give intravenous dextrose, give the infant 10 ml/kg breast milk or formula (or sweetened cows’ milk if neither is available) by mouth or via a nasogastric tube. You can add 5 g (a teaspoon) of sugar or 5 ml of 50% dextrose per 10 ml feed to increase the glucose concentration. Do not give pure 50% dextrose orally, as it will cause vomiting.
  6. Keep the infant warm. &. The infant now needs to be referred urgently to the referral hospital. It is very important that the infant’s blood glucose remains normal during transport.

4-22 How frequently should you measure the blood glucose concentration?

  1. In most infants at high risk of hypoglycaemia, the blood glucose concentration should be measured hourly with reagent strips for the first 3 hours, then 3-hourly until 100 ml/kg/day milk feeds have been established, which is usually within 24 to 48 hours.
  2. Infants with mild hypoglycaemia should be monitored every 30 minutes until the blood glucose concentration has returned to the normal range. Readings should then be made hourly for 3 hours to ensure that the blood glucose concentration does not fall again. Thereafter, measure the blood glucose concentration 3-hourly until milk feeds are established.
  3. Infants with severe hypoglycaemia should have their blood glucose concentration measured every 15 minutes until it has increased above 1.5 mmol/l. Then measure the blood glucose concentration hourly until the infant arrives at the referral unit.

4-23 What is the prognosis after hypoglycaemia?

The risk of brain damage depends on the severity, duration and number of hypoglycaemic attacks. The prognosis is worst if the hypoglycaemia has produced clinical signs, especially convulsions.

Management of respiratory distress

4-24 What is respiratory distress?

Respiratory distress is a collection of clinical signs, which indicate that the infant has difficulty breathing. The 4 most important clinical signs of respiratory distress are:

  1. Tachypnoea. A respiratory (breathing) rate of 60 or more breaths per minute (normal respiratory rate is about 40).
  2. Central cyanosis. A blue tongue in room air.
  3. Recession. The in-drawing of the ribs and sternum during inspiration (also called retraction).
  4. Grunting. A snoring noise made in the throat during expiration.

If an infant has central cyanosis plus 1 or more of the above clinical signs, the infant is said to have respiratory distress.

4-25 What are the important causes of respiratory distress?

Respiratory distress in newborn infants is usually caused by one of the following conditions:

  1. Hyaline membrane disease
  2. Wet lung syndrome
  3. Meconium aspiration
  4. Pneumonia

Other less common causes of respiratory distress include hypothermia and anaemia.

There are many different causes of respiratory distress.

4-26 What is hyaline membrane disease (HMD)?

At term the fetal lungs are mature and ready to be filled with air after delivery. The alveoli (air sacs) of these mature lungs secrete a substance called surfactant that prevents them collapsing at the end of expiration. This allows the infant to breathe air in and out with very little physical effort.

In contrast, many preterm infants have immature lungs, which do not have adequate amounts of surfactant at birth. As a result the alveoli collapse with expiration and the infant is unable to expand them again during inspiration. Collapsed alveoli due to the lack of surfactant result in respiratory distress. This condition is known as hyaline membrane disease (HMD).

Hyaline membrane disease is caused by too little surfactant in immature lungs.

4-27 What is the shake test?

The amount of surfactant in the fetal lung can be determined after birth by doing a shake test on a sample of gastric aspirate obtained within 30 minutes after delivery. A positive shake test indicates that adequate surfactant is present in the lungs of the newborn infant. A negative test indicates inadequate surfactant and strongly suggests that the infant has hyaline membrane disease.

It is important to pass a nasogastric tube and aspirate the stomach of all preterm infants soon after birth. The sample should be sent in a syringe or test tube with the infant when it is referred to a level 2 or 3 unit so that the shake test can be done at the referral hospital. The result is very useful in managing an infant with respiratory distress.

The gastric aspirate can also be used to help diagnose congenital pneumonia when pus cells and bacteria can often be seen under the microscope.

4-28 How do you diagnose hyaline membrane disease?

  1. The infant is preterm.
  2. The infant develops respiratory distress at or soon after delivery. The signs of respiratory distress gradually become worse.
  3. The infant usually moves very little and commonly develops peripheral oedema.
  4. The shake test on gastric aspirate is negative, indicating inadequate surfactant.

4-29 What is the clinical course in hyaline membrane disease?

The degree of respiratory distress gets worse during the first 48 hours after birth and the concentration of inspired oxygen, needed to keep the infant pink, increases for the first 2 to 3 days (48 to 72 hours). During this time some infants will die of hyaline membrane disease. Otherwise the respiratory distress starts to improve. As the respiratory distress can be expected to get worse during the first few days, it is important the infant be transferred to a level 2 or 3 unit as soon as possible.

Hyaline membrane disease gets worse before it gets better.

4-30 What is wet lung syndrome?

Before delivery the fetal lungs are not collapsed but filled with lung fluid. At vaginal delivery, most of this fluid is squeezed out of the lungs as the chest is compressed in the birth canal. After birth the remaining fluid is coughed up or is absorbed within a few minutes. In some infants this rapid removal of fetal lung fluid does not take place, resulting in wet lung syndrome which presents after delivery as respiratory distress. Wet lung syndrome is the commonest cause of respiratory distress. It is also important because during the first day of life it can easily be confused with hyaline membrane disease.

Wet lung syndrome is usually seen in term infants, especially after fetal distress, maternal sedation, Caesarean section and polyhydramnios. In these infants the normal clearance of lung fluid is often delayed for many hours resulting in wet lung syndrome.

4-31 How can you diagnose wet lung syndrome?

  1. These infants are usually born at term.
  2. They develop respiratory distress from delivery.
  3. They have a typical clinical course.
  4. The shake test on the gastric aspirate is positive, which excludes hyaline membrane disease.

Wet lung syndrome is the commonest cause of respiratory distress.

4-32 What is the clinical course of wet lung syndrome?

The respiratory distress in infants with wet lung syndrome gradually improves during the first 24 hours and usually recovers by 72 hours. Oxygen is needed for a few hours to 3 days only. Usually less than 40% oxygen is required.The clinical course of wet lung syndrome, therefore, is very different from that of hyaline membrane disease.

Wet lung syndrome is important because it can be confused with hyaline membrane disease.

4-33 What is meconium aspiration syndrome?

If the fetus is hypoxic in utero it may become distressed, pass meconium, and make gasping movements, which suck the meconium-stained liquor into the larynx and trachea. If the airways are not well suctioned after the infant’s head is delivered, the meconium can be inhaled into the smaller airways and alveoli with the onset of breathing. This results in meconium aspiration syndrome. Many cases of severe meconium aspiration syndrome can be prevented by carefully suctioning the upper airways of meconium-stained infants before they breathe at birth. The risk of meconium aspiration syndrome is particularly high if the meconium is very thick.

The airways of all meconium-stained infants should be well suctioned before delivering the shoulders.

4-34 How do you diagnose meconium aspiration syndrome?

  1. The infant is usually born at term or post-term but only rarely preterm.
  2. The liquor is meconium stained.
  3. Meconium may be suctioned from the mouth and upper airways at birth and the infant is usually meconium stained.
  4. Respiratory distress is present and the chest usually appears hyperinflated (over expanded).

4-35 What is the clinical course of meconium aspiration syndrome?

From birth, the meconium-stained infant has respiratory distress which, in severe cases, gets progressively worse and may kill the infant. Milder cases will gradually recover over days or weeks. Infants who survive severe meconium aspiration often have damaged lungs that may take months to recover.

4-36 What are the common causes of pneumonia?

An infant may be born with pneumonia (congenital pneumonia) as a complication of chorioamnionitis. Other infants may develop pneumonia in the days or weeks after delivery, due to the spread of bacteria in a nursery. Preterm infants are at an increased risk of pneumonia.

4-37 How can you diagnose pneumonia?

  1. The infant develops signs of respiratory distress and also appears clinically ill.
  2. The diagnosis of congenital pneumonia complicating chorioamnionitis is suggested by seeing pus cells and bacteria in a Gram stain of the gastric aspirate after delivery.

4-38 How should you manage an infant with respiratory distress?

The principles of care are the same, irrespective of the cause of the respiratory distress. Therefore, all infants with respiratory distress should receive the same general management:

  1. Keep the infant warm, preferably in an incubator.
  2. Handle the infant as little as possible, because stimulating the infant often increases the oxygen requirements. There is no need to routinely suction the airways.
  3. Provide energy to prevent hypoglycaemia. Preferably give an infusion of 10% glucose (e.g. Neonatalyte). Milk feeds by nasogastric tube can be given to infants with mild respiratory distress.
  4. Treat central cyanosis by giving oxygen. Give oxygen therapy correctly.
  5. Record the following important observations every hour and note any deterioration:
    • respiratory rate
    • presence or absence of recession and grunting
    • presence or absence of cyanosis
    • percentage of oxygen given
    • heart rate
    • both the skin and incubator temperature
  6. Consult the staff of the nearest level 2 or 3 hospital, as the infant may need to be transferred. This is particularly important in hyaline membrane disease where early transport is best. A chest X-ray at the referral hospital will help decide the cause of the respiratory distress.
  7. If the infant develops recurrent apnoea, or if oxygen fails to keep the infant pink, then mask-and-bag ventilation should be started.
  8. Parenteral antibiotics must be given if pneumonia is diagnosed. Either ceftriaxone 50 mg/kg daily by IM or IV injection or a combination of daily benzyl penicillin 50 000 units/kg/day IV plus gentamicin 7.5 mg/kg IM daily.
  9. Unfortunately there is no specific treatment for the infant with respiratory distress caused by meconium aspiration.
  10. Transfer is not as urgent in infants with wet lung syndrome as they usually improve after the first few hours and rarely need more than 40% oxygen.
  11. Infants who do not need to be transferred should be nursed in an incubator and given oxygen as required. 3-hourly feeds by nasogastric tube, rather than an intravenous infusion, can usually be given to these infants.

The correct use of oxygen therapy

4-39 Why does the body need oxygen?

Oxygen is needed by all the cells of the body. Without enough oxygen the cells, especially of the brain, will be damaged or die. However, too much oxygen is also dangerous and can damage cells. In the body, oxygen is carried by red blood cells from the lungs to all the other organs. When loaded with oxygen the red blood cells are red in colour. With too little oxygen they are blue.

Too little oxygen can cause brain damage.

4-40 How do you measure the amount of oxygen in the blood?

  1. This can be roughly assessed clinically as the infant appears peripherally and centrally cyanosed if there is not enough oxygen in the red cells. This clinical method may be inaccurate and should, whenever possible, be confirmed by measuring the oxygen saturation.
  2. At the bedside the oxygen saturation can be measured with a saturation monitor (i.e. pulse oximeter), which simply clips onto the infant’s hand or foot and measures the oxygen saturation through the skin. The oxygen saturation is given as a percentage. It indicates the amount of oxygen being carried by the red cells.
  3. In a laboratory the amount of oxygen in the blood can also be measured accurately in a sample of arterial blood.

4-41 How much oxygen is needed by the normal infant?

The normal oxygen saturation in a newborn infant is 86 to 92%. This indicates that the infant is breathing the correct amount of oxygen. If the saturation is less than 86% the infant is not getting enough oxygen while a saturation above 92% indicates that the infant may be getting too much oxygen. A saturation monitor is very useful to assess whether a newborn infant with respiratory distress is getting the correct amount of oxygen.

The normal saturation of oxygen in the blood is 86 to 92%.

4-42 When does an infant need extra oxygen?

An infant needs extra oxygen if it becomes centrally cyanosed or if the saturation of oxygen falls below 86%.

4-43 Can you give too much oxygen?

Yes. If too much oxygen is given the oxygen saturation will rise above 92%. Preterm infants, especially infants below 34 weeks gestation, are at risk of oxygen damage to the eyes (known as retinopathy of prematurity) if excessive amounts of oxygen are given. The damage to the retina is caused by too much oxygen in the blood, and not by the direct effect on the infant’s eyes of oxygen in the headbox.

At resuscitation it is probably safe to use oxygen for a short period only until the infant is pink and breathing well.

Too much oxygen is dangerous as it may cause blindness.

4-44 When should you give an infant extra oxygen?

  1. During resuscitation, if the infant does not respond rapidly to mask ventilation with room air
  2. When there is respiratory distress
  3. When the infant has central cyanosis
  4. When the oxygen saturation is less than 86%

4-45 Which infants do not need extra oxygen?

  1. Infants with normal Apgar scores at birth
  2. Infants with peripheral but not central cyanosis. If there is peripheral cyanosis only, the cause is usually cold hands and feet with poor perfusion, rather than hypoxia.
  3. Preterm infants with a normal oxygen saturation

4-46 What methods can you use to administer oxygen?

  1. Oxygen is most commonly given into a perspex head box. This is the best method of administering oxygen in a level 1 unit, as it is simple, cheap and highly effective.
  2. At resuscitation oxygen is given via a mask and bag.
  3. In a level 2 or 3 unit, oxygen is sometimes given via nasal prongs to infants with respiratory distress syndrome. Other infants may need to be intubated and ventilated.

Oxygen should not be given directly into a closed incubator as this method is wasteful, high concentrations cannot be reached and the concentration of oxygen drops every time an incubator port is opened. Giving 100% oxygen via a cardboard cup is extremely dangerous, especially if used over a long period of time, as it is almost impossible to control the percentage of oxygen accurately.

4-47 How can you measure the amount of extra oxygen given?

There is 21% oxygen in room air. Piped oxygen or oxygen from cylinders provides 100%. More and more oxygen can be added to room air until 100% oxygen is reached. It is very important to know how much extra oxygen the infant is receiving.

The amount of oxygen being given in a headbox can be measured with an oxygen monitor. The probe of the oxygen monitor is placed in the headbox and the display on the monitor box shows the amount of oxygen that the infant is breathing.

4-48 How much oxygen should you give?

The percentage of oxygen given in the headbox should be increased until:

  1. Central cyanosis is corrected (the tongue is pink).
  2. The oxygen saturation is 86–92%.

The required percentage of oxygen given to keep different infants pink may vary from 21 to 100%. For example, an infant with severe hyaline membrane disease may need 90% oxygen while another infant with mild wet lung syndrome may need only 25% to achieve a normal oxygen saturation. Do not confuse the percentage of oxygen given in a headbox with the oxygen saturation in the infant’s blood.

4-49 How can you control the amount of oxygen given?

As there are dangers in giving too much or too little oxygen, it is important to give oxygen correctly.

In a level 1 hospital or clinic, oxygen is usually given by headbox. Whenever possible, an air/oxygen blender should be used so that the percentage of oxygen in the headbox can be accurately controlled. If a blender is not available, a venturi can be used. The venturi is a plastic gauge, which controls the amount of air and oxygen being mixed. Some venturis mix pure oxygen with room air to give any required percentage of oxygen while others only give a fixed percentage.

Whenever possible, an oxygen monitor should be used to accurately measure the percentage of oxygen in the headbox. It is very dangerous to attempt to control the percentage of oxygen given into a head box by simply altering the flow rate.

Always give headbox oxygen via a blender or venturi.

4-50 Should you humidify oxygen?

Yes. Oxygen should always be humidified, as oxygen from a cylinder is very dry. Dry oxygen irritates the airways. Usually it is not needed to warm oxygen if it is given by a headbox.

4-51 What flow rate of oxygen should you use?

When oxygen is given into a headbox, either directly or via a blender or venturi, the flow should be 5 litres per minute. A high flow rate wastes oxygen and cools the infant.

Transferring a newborn infant

4-52 Why should newborn infants be transferred?

If pregnant women are correctly categorised into low-risk and high-risk groups during pregnancy and labour, low-risk infants can be delivered at level 1 hospitals and clinics with the necessary staff and equipment to care for them. However, when maternal categorisation is incorrect, when unexpected problems present during or after delivery, or when a mother with a complicated pregnancy or labour arrives in advanced labour at a level 1 hospital or clinic, then the infant may need to be transferred to a hospital with a level 2 or 3 unit.

If possible, it is better for the infant to be transferred before delivery than after birth. The mother is the best incubator during transfer.

It is better to transfer the mother before delivery than to transfer the infant after birth.

4-53 What is the aim of care during transfer?

The aim is to keep the infant in the best possible clinical condition while it is being moved from the clinic to the hospital. This is achieved by providing the following:

  1. A warm environment
  2. An adequate supply of oxygen
  3. A source of energy
  4. Careful observations

This greatly increases the infant’s chance of survival without brain damage.

4-54 Which infants should be transferred to a level 2 or 3 hospital?

All infants that need management which cannot be provided at a level 1 hospital or clinic must be referred to the nearest level 2 hospital with a special care unit or a level 3 hospital with an intensive care unit. The following infants should be transferred:

  1. Preterm infants, especially infants less than 36 weeks gestation
  2. Infants with a birth weight under 1800 g. Most infants between 1800 g and 2500 g do not need to be referred and can be sent home.
  3. Infants with poor breathing at birth that require ventilation during resuscitation
  4. Infants who need emergency management for hypothermia, hypoglycaemia or respiratory distress
  5. Infants with problems such as severe infection, marked jaundice, trauma or bleeding
  6. Infants with major congenital abnormalities, especially if urgent surgery is needed

Any infant needing possible referral must first be discussed with the staff at the referral hospital. Each region should establish its own referral criteria so that the staff knows which infants need to be transferred.

Each region must draw up its own referral criteria.

4-55 Why should the infant be resuscitated and stabilised before being transferred?

It is very important that the infant is fully resuscitated and stabilised before being transferred. The infant must be warm, well oxygenated and given a supply of energy before being moved. Transferring a collapsed infant will often kill the infant. The clinic staff and the transfer personnel should together assess the infant and ensure that the infant is in the best possible condition to be moved.

4-56 How should the transfer be arranged?

If possible, the hospital staff that will receive the infant should make the transfer arrangements. The hospital staff can then advise on management during transfer and be ready to receive the infant in the nursery. The unexpected arrival of an infant at the hospital must be avoided. The clinical notes and a referral letter must be sent with the infant. A sample of gastric aspirate, collected soon after delivery for microscopy and the shake test is very helpful, especially in preterm infants, infants with respiratory distress and infants with suspected congenital pneumonia. Consent for surgery should also be sent if a surgical problem is diagnosed.

4-57 What are the greatest dangers during transfer?

  1. Hypothermia: Infants must be kept warm during transfer and their skin temperature should be regularly measured. A transport incubator is the best way to keep the body temperature normal. If an incubator is not available, hypothermia can be prevented by using skin-to-skin care or by dressing the infant and then wrapping the infant in a silver swaddler (space blanket) or heavy gauge tin foil.
  2. Hypoglycaemia: Some supply of energy must be provided during transfer. Either milk feeds or intravenous fluids should be given. The blood glucose concentration should be regularly measured with reagent strips.
  3. Hypoxia: It is essential that infants receive oxygen during transfer if this is needed. All the equipment required for the safe administration of oxygen should be available. Infants who do not need extra oxygen must not be given oxygen routinely while being transferred. Some infants with respiratory distress or apnoea need ventilation during transfer.

4-58 Who should transfer a sick infant?

Vehicles to transfer infants must be provided by the local authority in each region. Ideally an ambulance should be used. If possible, ambulance personnel should be trained to care for infants during transfer. When this service is not available, the referral hospital should provide nursing or medical staff to care for the infant while it is being moved from the clinic to the hospital. A transport incubator, oxygen supply and emergency box of essential resuscitation equipment should always be available at the referral hospital for use in transferring newborn infants. Only as a last resort should the clinic provide a vehicle and staff to transfer a sick infant to hospital.

4-59 Should the mother also be transferred to hospital?

Yes, whenever possible, the mother should be transferred to hospital with her infant.

Case study 1

A 1500 g infant is brought to an outlying clinic on a cold winter’s day. The mother delivered 30 minutes before and has remained at home. The infant’s axillary temperature is 34.5 °C but the infant appears active. The clinic does not have an incubator.

1. What error was made in the management of this infant?

The infant should have been kept warm. Skin-to-skin care is very effective in keeping an infant warm after delivery. An infant should never be allowed to get cold after delivery.

2. How can you warm this infant in the clinic?

You can use an incubator or a warm room to correct the infant’s temperature. The staff can also give skin-to-skin care themselves.

3. When should the infant be moved to hospital?

If possible, it is best to warm the infant first before moving it to hospital.

4. How can the infant be kept warm in the ambulance?

If possible, a transport incubator should be used. If this is not available, use skin-to-skin care. Otherwise, the infant should be warmly dressed and wrapped in a blanket. A thermal blanket (or aluminium foil) can also be used. Remember that the infant must be warmed before it is placed in a thermal blanket.

Case study 2

A term infant is brought to a rural clinic after having been born at home. The infant is cold and wasted but otherwise appears well. A Haemo-Glukotest reagent strip, read by naked eye, gives a reading between 1.5 and 2 mmol/l.

1. What is your interpretation of the blood glucose concentration?

The infant has mild hypoglycaemia.

2. What is the danger of mild hypoglycaemia?

The infant is at high risk of developing severe hypoglycaemia.

3. Why does this term infant have a low blood glucose concentration?

Because the infant is cold. Hypothermic infants often become hypoglycaemic as they rapidly use up all their energy stores such as glycogen and fat. In addition this infant is wasted and therefore was born with reduced energy stores.

4. What are the clinical signs of hypoglycaemia?

Often there are no clinical signs. Severe hypoglycaemia may cause neurological signs such as lethargy, decreased tone, poor feeding, a weak cry, absent Moro, jitteriness and convulsions.

5. How would you treat this infant at the clinic?

Give the infant a feed of breast milk or formula. If neither is available, sweetened cows’ milk may be used. The infant must also be warmed. The blood glucose concentration should have returned to normal in 15 minutes. If not, repeat the feed and arrange urgent transport to the nearest hospital. If the infant develops severe hypoglycaemia an infusion 10% dextrose (e.g. Neonatalyte) must be started. It is very important to start treatment before referring the infant to hospital.

Case study 3

A male infant is born at 32 weeks gestation in a level 1 hospital. Soon after delivery his respiratory rate is 80 breaths per minute with recession and expiratory grunting. The infant’s tongue is blue in room air. A gastric aspirate is collected 10 minutes after delivery.

1. Which clinical signs indicate that the infant has respiratory distress?

Tachypnoea, recession, grunting and central cyanosis in room air.

2. What is the probable cause of the respiratory distress?

The infant probably has hyaline membrane disease due to immature lungs. Hyaline membrane disease is common in infants born preterm.

3. What is the value of collecting a sample of gastric aspirate?

Diagnosing the cause of the respiratory distress is often helped if a sample of gastric aspirate is collected soon after delivery. The diagnosis of hyaline membrane disease is supported by a negative shake test, which indicates immature lungs. A Gram stain showing pus cells suggests that the infant has congenital pneumonia as a complication of chorioamnionitis.

4. Should this infant remain at the level 1 hospital?

No, he should be moved as soon as possible to a level 2 or 3 hospital with staff and facilities to care for sick infants. Hyaline membrane disease deteriorates for 2 to 3 days before improving. Therefore, this infant should be transferred as soon as possible.

5. How would you manage this infant before transfer to a larger hospital?

Keep the infant warm and give just enough oxygen via a head box to keep the tongue pink. If a saturation monitor is available, keep the oxygen saturation between 86 and 92%. Handle the infant as little as possible after starting an intravenous infusion of 10% dextrose (e.g. Neonatalyte). Carefully observe his respiration rate and pattern, colour, heart rate and temperature. Ventilate with a bag and mask if the infant develops apnoea or remains cyanosed in 100% oxygen.

6. How should the amount of oxygen in the infant’s blood be measured?

With a saturation monitor.

Case study 4

A 3-day-old term infant has pneumonia in a level 1 hospital and is nursed in an incubator. The infant is cyanosed in room air and needs oxygen therapy.

1. What equipment should be used to administer the oxygen?

The best method to give this infant oxygen would be a perspex head box. Giving oxygen directly into the incubator is unsatisfactory as it wastes a lot of oxygen. In addition, high concentrations of oxygen cannot be given and the amount of oxygen in the incubator drops when a porthole is opened.

2. How should you measure the amount of oxygen given?

The concentration of oxygen in the head box should be measured with an oxygen monitor. The amount of oxygen given must not be measured in litres per minute with a flow meter, as this is an extremely inaccurate method of estimating the amount of oxygen being given.

3. How should you control the percentage of oxygen given?

With an oxygen/air blender or a venturi.

4. Why should the oxygen be humidified?

Because unhumidified gas is very dry and will irritate the linings of the nose, throat and airways.

5. What flow rate of oxygen should be given into the head box?

A flow rate of 5 litres per minute is best. This is measured on the flow meter.

Case study 5

A 1700 g infant is born in a rural clinic. The clinic staff call for an ambulance to take the infant to the nearest hospital. The hospital is not contacted. The infant, which appears well, is wrapped in a blanket and not given a feed. The note to the hospital reads ‘Please take over the management of this small infant’.

1. How should the transfer of this infant have been arranged?

The clinic staff should have contacted the referral hospital and discussed the problem with them. The hospital staff should have advised the clinic staff as to further management. Only then should the infant have been transferred.

2. What was wrong with the management of the infant at the clinic?

The infant should have been fed before referral. A transport incubator or silver swaddler should have been used to prevent hypothermia on the way to hospital. Skin-to-skin care could also have been used.

3. Why was the referral note inadequate?

The referral letter should give all the necessary details of the pregnancy, the delivery and the infant’s clinical condition.