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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.
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:
This depends on the site where the temperature is measured:
Hypothermia (low body temperature) is defined as an axillary temperature below 36.5 °C or an abdominal skin temperature below 36 °C.
Hypothermic infants present with the following signs:
Hypothermic infants may die of hypoglycaemia.
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.
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.
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.
The normal concentration of glucose in the blood of newborn infants is 2.0 mmol/l to 7.0 mmol/l.
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.
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.
Infants that have reduced energy stores, reduced energy intake (feed poorly) or increased energy needs are at risk of hypoglycaemia.
Hypothermia causes 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:
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.
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.
Every effort must be taken to prevent hypoglycaemia by:
With a policy of breastfeeding as soon as possible after delivery, most cases of hypoglycaemia can be prevented.
Early breastfeeding can usually prevent 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:
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.
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:
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.
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:
If an infant has central cyanosis plus 1 or more of the above clinical signs, the infant is said to have respiratory distress.
Respiratory distress in newborn infants is usually caused by one of the following conditions:
Other less common causes of respiratory distress include hypothermia and anaemia.
There are many different causes of respiratory distress.
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.
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.
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.
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.
Wet lung syndrome is the commonest cause of respiratory distress.
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.
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.
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.
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.
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:
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.
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%.
An infant needs extra oxygen if it becomes centrally cyanosed or if the saturation of oxygen falls below 86%.
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.
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.
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.
The percentage of oxygen given in the headbox should be increased until:
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.
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.
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.
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.
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.
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:
This greatly increases the infant’s chance of survival without brain damage.
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:
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.
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.
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.
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.
Yes, whenever possible, the mother should be transferred to hospital with her infant.
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.
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.
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.
If possible, it is best to warm the infant first before moving it to hospital.
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.
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.
The infant has mild hypoglycaemia.
The infant is at high risk of developing severe hypoglycaemia.
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.
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.
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.
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.
Tachypnoea, recession, grunting and central cyanosis in room air.
The infant probably has hyaline membrane disease due to immature lungs. Hyaline membrane disease is common in infants born preterm.
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.
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.
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.
With a saturation monitor.
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.
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.
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.
With an oxygen/air blender or a venturi.
Because unhumidified gas is very dry and will irritate the linings of the nose, throat and airways.
A flow rate of 5 litres per minute is best. This is measured on the flow meter.
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’.
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.
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.
The referral letter should give all the necessary details of the pregnancy, the delivery and the infant’s clinical condition.