Care of sick and small neonates

Z76.2

DESCRIPTION

Neonates can become ill very rapidly and signs of disease are often not readily appreciated unless specifically looked for. Neonates should be referred urgently.
Neonates < 2.5kg are at higher risk of feeding and growth problems and need careful follow-up.

Urgently manage and refer neonates with a possible serious bacterial infection and jaundice:

  • Convulsions
  • Passing blood per rectum
  • Lethargic/ unconscious
  • Pallor
  • Bulging fontanelle
  • Jaundice in 1st 24 hours of life
  • Apnoea(< 30 breaths/min)
  • Diarrhoea
  • Severe chest indrawing
  • Many or severe skin pustules
  • Nasal flaring or grunting
  • Fast breathing (> 60 breaths/min)
  • Swollen eyes - pus draining from eye
  • Vomiting everything/bile-stained vomitus
  • Low or high temperature
  • Only moves when stimulated
  • Not able to feed
  • Umbilical redness extending to the skin and draining pus

GENERAL MEASURES

  • Keep the neonate warm (skin-to-skin/kangaroo mother care or in an incubator), the axillary temperature should be 36.5–37°C.
  • Check blood glucose and treat if low (< 2.6mmol/L). Repeat glucose in 15 minutes. If normal, feed 2-3 hourly. If still low, treat as severe hypoglycaemia.
  • Check mother able to successfully establish breastfeeding in the small neonate and check health and weight gain more frequently.

MEDICINE TREATMENT

If grunting or severe chest indrawing P22.0-1/P22.8-9

  • Oxygen, using nasal catheter at 1 L/minute.

If infection is suspected and jaundice has been excluded Z29.2

Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose.

CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN

  • If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if jaundiced.
  • Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:
    • If ≤ 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone administered.
    • If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after.
    • Preferably administer IV fluids without calcium contents.
  • Always include the dose and route of administration of ceftriaxone in the referral letter.

If blood glucose < 2.6 mmol/L and baby able to suckle or take orally:

  • Breastfeed or give expressed breastmilk (only if breastfeeding is not possible, give replacement milk feed 10 mL/kg)
  • If unable to take orally consider nasogastric tube feeding. Repeat glucose in 15 minutes. If still < 2.6 mmol/L, manage as below.

If blood glucose < 1.4 mmol/L or remains < 2.6 mmol/L after an oral feed:

  • Dextrose 10% IV, 2 mL/kg as a bolus.

AND

LoEIII [36]

  • Dextrose 10%, IV, 3 mL/kg/hour.
    • Repeat in 15 minutes.
    • If blood glucose still low, repeat dextrose bolus.

REFERRAL

Urgent

  • All neonates with a possible serious bacterial infection.
  • All neonates with jaundice on the first day of life, with pallor or with poor feeding.
  • All other neonates with increasing, deep or persistent (> 10 days) jaundice should be referred as soon as possible.
  • All small neonates (< 2.5kg) not able to feed.
  • Persistent hypoglycaemia despite treatment.

(If possible, always send mother with the neonate as well as any clinical notes).