2 5408876251152646501

Neonatal
Neonatal Guidelines 2015–17

Neonatal Guidelines
2015-17
Guidelines
This book has been compiled as an aide-memoire for all staff
concerned with the management of neonates, towards a more
uniform standard of care across the Staffordshire, Shropshire and
Black Country Newborn and Maternity Network hospitals and
2015–17
Southern West Midlands Maternity and Newborn Network hospitals.
These guidelines are advisory, not mandatory
Every effort has been made to ensure accuracy
The authors cannot accept any responsibility for adverse outcomes
Published by the Staffordshire, Shropshire &

Black Country Newborn and Maternity Network
The Bedside Clinical Guidelines Partnership
Further copies are available to purchase from the
http://www.networks.nhs.uk/nhs-networks/staffordshire- in association with the
shropshire-and-black-country-newborn/neonatal-guidelines
Staffordshire, Shropshire & Black Country
Copyright © Copyright Holder
Newborn and Maternity Network
ISBN 978-0-9557058-7-8 Southern West Midlands Maternity and

Issue 6
Newborn Network
Printed by Sherwin Rivers Ltd.

Waterloo Road, Cobridge, Stoke on Trent ST6 3HR
Tel: 01782 212024 Email: sales@sherwin-rivers.co.uk 9 780955 705878
@pediatric_books
This copy belongs to
Name...........................................................................................................
Further copies can be purchased from Staffordshire, Shropshire & Black
Country Newborn and Maternity Network Administrator:
Email: sarah.carnwell@nhs.net
Published by the Bedside Clinical Guidelines Partnership,

Staffordshire, Shropshire & Black Country Newborn and Maternity
Network and Southern West Midlands Maternity and Newborn Network
NOT TO BE REPRODUCED WITHOUT PERMISSION
Staffordshire, Shropshire & Black Country Newborn and Maternity Network comprises:
The Dudley Group NHS Foundation Trust
The Royal Wolverhampton NHS Trust
The Shrewsbury and Telford Hospital NHS Trust
University Hospitals of North Midlands NHS Trust
Walsall Healthcare NHS Trust
Southern West Midlands Maternity and Newborn Network comprises:

Birmingham Women’s NHS Foundation Trust
Heart of England NHS Foundation Trust
Sandwell and West Birmingham Hospitals NHS Trust
Worcestershire Acute Hospitals NHS Trust
Wye Valley NHS Trust
Birmingham Children’s Hospital NHS Foundation Trust
The Bedside Clinical Guidelines Partnership comprises:

Ashford & St Peter’s Hospitals NHS Trust
Barnet and Chase Farm Hospitals NHS Trust
Basildon and Thurrock University Hospital NHS Foundation Trust
Burton Hospitals NHS Foundation Trust
East Cheshire NHS Trust
George Eliot Hospital NHS Trust
The Hillingdon Hospital NHS Foundation Trust
Mid Cheshire Hospitals NHS Trust
North Cumbria University Hospitals NHS Trust
The Pennine Acute Hospitals NHS Trust
The Royal Wolverhampton Hospitals NHS Trust
University Hospitals Birmingham NHS Foundation Trust
University Hospitals North Midlands NHS Trust
University Hospitals of Morecambe Bay NHS Trust
Wrightington, Wigan and Leigh NHS Foundation Trust
CONTENTS • 1/4
Page
ADMISSION AND DISCHARGE

Admission to neonatal unit (NNU) .........................................................................…17
Death and seriously ill babies ................................................................................…79
Discharge from neonatal unit ................................................................................…86
Follow up of babies discharged from the neonatal unit ...................................…111
Labour ward calls ..................................................................................................…197
Transport and retrieval ..........................................................................................…321
CARDIOVASCULAR
Cardiac murmurs .....................................................................................................…46
Congenital heart disease duct-dependent lesions
[Including hypoplastic left heart syndrome (HLHS) and left-sided
outflow tract obstructions] ..............................................................................…60
ECG abnormalities ...................................................................................................…90
Heart failure ............................................................................................................…124
Hypotension ...........................................................................................................…151
Patent ductus arteriosus (PDA)............................................................................…251
Pericardiocentesis .................................................................................................…254
Vascular spasm and thrombosis .........................................................................…340
CRITICAL CARE
Extreme prematurity ..............................................................................................…109
Golden hour – preterm babies <28 weeks’ gestation ........................................…119
Hydrops fetalis New guideline ............................................................................…133
Hypothermia ...........................................................................................................…154
Pain assessment and management .....................................................................…238
Resuscitation .........................................................................................................…277
Sudden unexpected postnatal collapse in first week of life .............................…298
DEVELOPMENTAL CARE
Developmental care .................................................................................................…82
Environment and noise ...........................................................................................…94
Kangaroo care ...........................................................................................................195
Non-nutritive sucking (NNS) .................................................................................…221
Positioning .............................................................................................................…260
ENDOCRINE/METABOLISM
Hyperglycaemia......................................................................................................…135
Hyperkalaemia ........................................................................................................…137
Hypernatraemic dehydration ................................................................................…139
Issue 6
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Issued: December 2015
Expires: November 2017
CONTENTS • 2/4
Hypoglycaemia .......................................................................................................…143
Hypokalaemia New guideline ................................................................................…149
Hypothyroidism .....................................................................................................…156
Intravenous fluid therapy ......................................................................................…181
Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCADD)
– early management of babies with family history .........................................206
Metabolic bone disease New guideline ...............................................................…207
Thyroid disease (maternal) ...................................................................................…311
GASTROENTEROLOGY
Bottle feeding in the neonatal unit ........................................................................…34
Breastfeeding ...........................................................................................................…36
Breast milk expression ...........................................................................................…38
Breast milk handling and storage ..........................................................................…40
Gastro-oesophageal reflux (GOR) ........................................................................…113
Jaundice..................................................................................................................…192
Liver dysfunction in preterm babies ....................................................................…198
Nasogastric tube – administration of feed, fluid or medication ...........................211
Necrotising enterocolitis (NEC) ............................................................................…217
Nutrition and enteral feeding ................................................................................…222
Parenteral nutrition ................................................................................................…246
HAEMATOLOGY
Blood group incompatibilities ................................................................................…31
Coagulopathy ...........................................................................................................…57
Polycythaemia ........................................................................................................…258
Thrombocytopenia ................................................................................................…306
Transfusion of red blood cells .............................................................................…317
Vitamin K ................................................................................................................…354
INFECTION
BCG immunisation...................................................................................................…28
CMV ...........................................................................................................................…55
Conjunctivitis ...........................................................................................................…64
Hepatitis B and C ...................................................................................................…127
Herpes simplex ......................................................................................................…129
Human immunodeficiency virus (HIV) .................................................................…131
Immunisations ........................................................................................................…163
Infection in first 72 hours of life ...........................................................................…166
Infection – late onset ............................................................................................…169
Multi-drug resistant organism colonisation (MRSA, ESBL etc.) ........................…209
Palivizumab ............................................................................................................…244
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CONTENTS • 3/4
Syphilis – babies born to mothers with positive serology ...............................…303
TB (investigation and management following exposure in pregnancy) ...........…324
Varicella ..................................................................................................................…337
NEUROLOGY
Abstinence syndrome..............................................................................................…13
Cooling in non-cooling centres .............................................................................…73
Hypoxic ischaemic encephalopathy (HIE) ..........................................................…159
Seizures ..................................................................................................................…286
Upper limb birth injuries including brachial plexus injury ................................…333
PRACTICAL PROCEDURES
Arterial line insertion ...............................................................................................…24
Arterial line sampling ..............................................................................................…26
Cannulation ..............................................................................................................…45
Chest drain insertion ...............................................................................................…47
Chest drain insertion – Seldinger technique New guideline ...............................…49
Consent ....................................................................................................................…65
Endotracheal tube suctioning New guideline .......................................................…92
Exchange transfusion............................................................................................…100
Extravasation injuries............................................................................................…106
Long line insertion (peripherally sited) ...............................................................…202
Nasogastric tube insertion....................................................................................…213
Prostaglandin infusion ..........................................................................................…263
Skin biopsy for inborn errors of metabolism .....................................................…290
Skin care .................................................................................................................…292
Transillumination of the chest ..............................................................................…320
Umbilical artery catheterisation and removal .....................................................…326
Umbilical venous catheterisation and removal ..................................................…330
Venepuncture .........................................................................................................…342
RENAL
Renal failure............................................................................................................…274
Urinary tract abnormalities on antenatal scan ...................................................…334
RESPIRATORY
Apnoea and bradycardia .........................................................................................…22
Chest physiotherapy ...............................................................................................…51
Chronic lung disease...............................................................................................…53
Continuous positive airway pressure (CPAP) .......................................................…69
High-flow nasal cannulae (HFNC) respiratory support .....................................…130
Intubation ................................................................................................................…186
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CONTENTS • 4/4
Intubation – difficult ...............................................................................................…189
Nitric oxide ..............................................................................................................…220
Oxygen on discharge .............................................................................................…234
Oxygen saturation targets .....................................................................................…236
Persistent pulmonary hypertension of the newborn (PPHN) .............................…255
Pulmonary haemorrhage .......................................................................................…265
Surfactant replacement therapy ...........................................................................…301
Transcutaneous CO2 and O2 .................................................................................…314
Ventilation (conventional) ......................................................................................…343
Ventilation high frequency oscillatory .................................................................…347
Ventilation synchronous positive pressure (SIPPV) ...........................................…350
Ventilation (volume guarantee/targeted tidal volume) ........................................…353
SCREENING
Antenatal ultrasound abnormalities .......................................................................…21
Bloodspot screening ................................................................................................…33
Cranial ultrasound scans ........................................................................................…76
Developmental dysplasia of the hip New guideline ..............................................…84
Disorders of sexual development ...........................................................................…88
Examination of the newborn ...................................................................................…96
Hearing screening...................................................................................................…122
Pulse-oximetry (universal) screening ..................................................................…267
Retinopathy of prematurity (ROP) .......................................................................…283
Sacral dimple New guideline .................................................................................…285
SURGICAL GUIDELINES
Ano-rectal malformation ..........................................................................................…19
Broviac line insertion ...............................................................................................…42
Exomphalos – initial management ........................................................................…103
Gastroschisis ..........................................................................................................…115
Inguinal hernia ........................................................................................................…174
Intra-abdominal cysts ............................................................................................…179
Oesophageal atresia/Replogle tubes ...................................................................…231
Rectal washout .......................................................................................................…270
Recycling stoma losses .........................................................................................…272
Stoma management (gastrointestinal) ................................................................…294
Index ........................................................................................................................…356
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ACKNOWLEDGEMENTS • 1/2
We would like to thank the following for their assistance in producing this edition of the
Neonatal Guidelines on behalf of the Bedside Clinical Guidelines Partnership and
Staffordshire, Shropshire and Black Country Newborn and Maternity Network
Contributors Bashir Muhammad

Lee Abbott Vel Murugan
S. Arul Robert Negrine
Ruth Andrassy-Newton Kate Palmer
Meena Bankhakavi Katy Parnell
Alison Bedford Russell Alex Philpot
Pat Bloor Tilly Pillay
Lucilla Butler Vishna Rasiah
Fiona Chambers Bernadette Reda
Sara Clarke Cathryn Seagrave
Joanne Cookson Shiva Shankar
Sarah Cormack Phillip Simmons
Cheryl Curson Anju Singh
Sanjeev Deshpande Jaideep Singh
Amber Evans S. Sivakumar
Andy Ewer Jacqueline Stretton
Emma Foulerton Pinki Surana
V. Ganesan Arumugavelu Thirumurugan
Vidya Garikapati Wendy Tyler
Oliver Gee Julia Uffindell
Jo Gregory Vikranth Venugopalan
Kalyana Gurusamy Suresh Vijay
Helen Haley Viviana Weckemann
Lindsay Halpern Ali White
Julie Harcourt Louise Whitticase
Liza Harry
Kate Harvey
Louise Hirons
Michael James
Andrea Jester
Asok Kumar
Anna Kotas
Laura Johnson
Sally Lennon
Nick Makwana
Paddy McMaster
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ACKNOWLEDGEMENTS • 2/2
Neonatal Editors
Robert Negrine
Alyson Skinner
Bedside Clinical Guidelines

Partnership
Kathryn McCarron
Marian Kerr
Naveed Mustfa
Kate Palmer
Stephen Parton
Mathew Stone
Staffordshire, Shropshire &

Black Country Newborn and
Maternity Network
Sarah Carnwell
Ruth Moore
Kate Palmer
Julie Ebrey
Southern West Midlands

Maternity and Newborn Network
Sonia Saxon
Teresa Meredith
S. Sivakumar
The editors would like to thank the

following people/organisations for
allowing us to use/adapt their guidelines:
Birmingham Children’s Hospital –
Skin biopsy guideline
Dr Carl Kuschel
Auckland District Health Board
Auckland, New Zealand –
Ventilation guideline
Birmingham Women's Hospital Neonatal
Unit – Extravasation injuries guideline
Guy’s and St Thomas’ NHS Trust –
Transcutaneous monitoring guideline
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COMMONLY USED ABBREVIATIONS • 1/2
ACTH Adrenocorticotrophic hormone GGT Gamma-glutamyl transaminase
aEEG Cerebral function monitoring GLUT 1 Glucose transporter defect
ALT Alanine aminotransferase GOR Gastro-oesophageal reflux
APTT Activated partial thromboplastin time HCG Human chorionic gonadotropin
ASD Atrial septal defect Hct Haematocrit
AST Aspartate aminotransferase HCV Hepatitis C virus
AVSD Atrioventricular septal defect HFNC High flow nasal cannulae
BAPM British Association of Perinatal HFOV High frequency oscillatory ventilation
Medicine HIE Hypoxic ischaemic encephalopathy
BCG Bacille Calmette-Guerin HIV Human immunodeficiency virus
BiPAP Biphasic CPAP HLHS Hypoplastic left heart syndrome
BPD Bronchopulmonary dysplasia HSV Herpes simplex virus
CAMT Congenital amegakaryocytic HTLV Human T-cell lymphotropic virus
thrombocytopenia
ICCP Integrated comfort care pathway
CCAM Congenital cystic adenomatoid
malformation IMD Inherited metabolic disorders
CDH Congenital dislocation of hips or IUGR Intrauterine growth retardation
congenital diaphragmatic hernia iNO Inhaled nitric oxide
CH Congenital hypothyroidism IPPV Intermittent positive pressure
CHD Congenital heart disease ventilation
CLD Chronic lung disease IUT In-utero blood transfusion or
in-utero transfer
CMPI Cow’s milk protein intolerance
IVC Inferior vena cava
CMV Cytomegalovirus
IVH Intraventricular haemorrhage
CNS Central nervous system
IVIG Intravenous immunoglobin
CoNS Coagulase-negative staphylococcus
LHRH Luteinizing hormone releasing
CPAP Continuous positive airway pressure hormone
CRP C-reaction protein LV Left ventricular
CVS Cardiovascular LVOT Left ventricular outflow tract
DCT Direct Coombs’ test MAP Mean airway pressure or mean
DDH Developmental dysplasia of the hip arterial pressure
DEBM Donor expressed breast milk MCADD Medium chain acyl co-A
DHEA Dihydroepiandrostenedione dehydrogenase deficiency
dHT Dihydrotestosterone MDT Multidisciplinary team
DIC Disseminated intravascular MEBM Mother’s expressed breast milk

coagulation MSUD Maple syrup urine disease
DSD Disorders of sexual development NAIT Neonatal allo-immune
EBM Expressed breast milk thrombocytopenia
ECG Electrocardiogram NEC Necrotising enterocolitis
EDD Expected date of delivery NGT Nasogastric tube
EFM Electronic fetal monitoring NHSP Newborn Hearing Screening

Programme
ETT Endotracheal tube
NKHG Non-ketotic hyperglycinaemia
EUT Extrauterine transfer
NICU Neonatal intensive care unit
FFP Fresh frozen plasma
NNU Neonatal unit
GBS Group B streptococcus
NPSA National Patient Safety Agency
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COMMONLY USED ABBREVIATIONS • 2/2
NTS Neonatal Transport Service UVC Umbilical vein catheter
OI Oxygenation index VSD Ventricular septal defect
OPS Oropharyngeal secretions VLBW Very low birth weight
PAT Pain assessment tool Vt Tidal volume
PCOS Polycystic ovary syndrome VZIG Varicella Zoster immune globulin
PCR Polymerase chain reaction VZV Varicella-zoster virus
PDA Patent ductus arteriosus WCC White cell count
PEEP Positive end expiratory pressure
PFO Patent foramen ovale
PIH Pregnancy-induced hypertension
PIP Peak inspiratory pressure
PIPP Premature infant pain profile
PKU Phenylketonuria
PN Parenteral nutrition
PPHN Persistent pulmonary hypertension
of the newborn
PROM Pre-labour rupture of membranes
PT Prothrombin time
PTV Patient triggered ventilation
PVL Periventricular Leukomalacia
PVR Pulmonary venous return
RDS Respiratory distress syndrome
ROP Retinopathy of prematurity
RVH Right ventricular hypertrophy
SANDS Stillbirth and Neonatal Death Society
SaO2/SpO2 Arterial/peripheral oxygen
saturation
SGA Small for gestational age
SIMV Simultaneous intermittent
mandatory ventilation
SPA Supra-pubic aspiration
SSRI Selective serotonin reuptake inhibitor
SVC Superior vena cava
SVT Supraventricular tachycardia
TAR Thrombocytopenia Absent Radii
Te Expiratory time
TEW Transepidermal water
TGA Transposition of the great arteries
THAM Trometamol
Ti Inspiratory time
TTV Targeted tidal volume
TPN Total parenteral nutrition
UAC Umbilical artery catheter
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PREFACE • 1/2
This book has been compiled as an aide-memoire for all staff concerned with the
management of neonates, to work towards a more uniform standard of care across the
Staffordshire, Shropshire and Black Country and Southern West Midlands Newborn and
Maternity Networks’ hospitals. Further copies of the book are available to purchase from
the Staffordshire, Shropshire and Black Country Newborn and Maternity Network at:
http://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country-
newborn/neonatal-guidelines
These guidelines have been drafted with reference to published medical literature and
amended after extensive consultation. Wherever possible, the recommendations made
are evidence based. Where no clear evidence has been identified from published
literature the advice given represents a consensus of the expert authors and their
peers and is based on their practical experience.
No guideline will apply to every patient, even where the diagnosis is clear-cut; there
will always be exceptions. These guidelines are not intended as a substitute for logical
thought and must be tempered by clinical judgement in the individual patient and
advice from senior colleagues.
The guidelines are advisory, NOT mandatory
Prescribing regimens and nomograms

The administration of certain drugs, especially those given intravenously, requires
great care if hazardous errors are to be avoided. These guidelines do not include
comprehensive guidance on the indications, contraindications, dosage and
administration for all drugs. Please refer to the Neonatal Unit’s preferred formulary;
either the Neonatal Formulary: Drug Use in Pregnancy and the First Year of Life,
7th Edition 2014, or the BNF for Children September 2015 available at:
http://www.medicinescomplete.com/mc/bnfc/current/ Adjust doses as necessary for
renal or hepatic impairment.
Practical procedures
DO NOT attempt to carry out any of these procedures unless you have been trained to
do so and have demonstrated your competence.
Legal advice
How to keep out of court:
Write the patient’s name and unit number on the top of each side of paper
Time and date each entry
Sign and write your name legibly after every entry
Document acknowledgement of results of all investigations (including radiology)
Document all interactions including discussions with parents (and who was present)
Supporting information
Where possible the guidelines are based on evidence from published literature. It is
intended that evidence relating to statements made in the guidelines and its quality will
be made explicit.
Where supporting evidence has been identified it is graded I to V according to standard
criteria of validity and methodological quality as detailed in the table below. A summary of
the evidence supporting each statement is available, with the original sources referenced
(intranet/internet only). The evidence summaries are developed on a rolling programme
which will be updated as the guideline is reviewed.
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PREFACE • 2/2
Level of evidence Strength of evidence

Strong evidence from at least one systematic review of multiple well-
I
designed randomised controlled trials
Strong evidence from at least one properly designed randomised controlled
II
trial of appropriate size
Evidence from well-designed trials without randomisation, single group pre-
III
post, cohort, time series or matched case-control studies
IV Evidence from well-designed non-experimental studies from more than one

centre or research group
V Opinions of respected authorities, based on clinical evidence, descriptive

studies or reports of expert committees
JA Muir-Gray from Evidence Based Healthcare, Churchill Livingstone London 1997
Evaluation of the evidence-base of these guidelines involves review of existing literature

then periodical review of anything else that has been published since the last review.
The editors encourage you to challenge the evidence provided in this document. If you
know of evidence that contradicts, or additional evidence in support of the advice given
in these guidelines, please forward it to the Clinical Guidelines Developer/Co-ordinator,
bedsideclinicalguidelines@uhns.nhs.uk or Dr Kate Palmer (Kate.palmer@uhns.nhs.uk).
Evidence-based developments for which funding is being sought

As new treatments prove more effective than existing ones, the onus falls upon those
practising evidence-based healthcare to adopt best practice. New treatments are
usually, but not always, more expensive. Within the finite resources of each Trust and
of the NHS as a whole, adoption of these treatments has to be justified in terms of the
improvements they will bring to the quality or cost-effectiveness of care. The priorities
for funding new areas of treatment and patient care will be determined at Trust level.
Feedback and new guidelines
The Bedside Clinical Guidelines Partnership, the Staffordshire, Shropshire and Black
Country and Southern West Midlands Newborn and Maternity Networks have provided
the logistical, financial and editorial expertise to produce the guidelines. These
guidelines have been developed by clinicians for practice based on best available
evidence and opinion. Any deviation in practice should be recorded in the patient’s
notes with reasons for deviation. The editors acknowledge the time and trouble taken
by numerous colleagues in the drafting and amending of the text. The accuracy of the
detailed advice given has been subject to exhaustive checks. However, any errors or
omissions that become apparent should be drawn to the notice of the editors, via the
Clinical Guidelines Developer/Co-ordinator, bedsideclinicalguidelines@uhns.nhs.uk or
Dr Kate Palmer (Kate.palmer@uhns.nhs.uk), so that these can be amended in the next
review, or, if necessary, be brought to the urgent attention of users. Constructive
comments or suggestions would also be welcome.
There are still many areas of neonatal care which are not included: please submit new
guidelines as soon as possible for editorial comment.
For brevity, where the word ‘parent(s)’ is read, this means mothers, fathers, guardians
or others with parental care responsibilities for babies.
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ABSTINENCE SYNDROME • 1/4
Inability to co-ordinate sucking,
RECOGNITION AND necessitating introduction of tube
ASSESSMENT feeding
Definition Baby inconsolable after 2 consecutive
feeds
Neonatal AIMS
withdrawal/abstinence
syndrome To identify withdrawal symptoms
following birth
Symptoms evident in babies born to
opiate-dependent mothers and To give effective medical treatment
mothers on other drugs associated where necessary
with withdrawal symptoms (generally To promote bonding and facilitate good
milder with other drugs) parenting skills
To support and keep baby comfortable
Timescale of withdrawal during withdrawal period
Signs of withdrawal from opiates To optimise feeding and growth
(misused drugs, such as heroin) can To identify social issues and refer to
occur <24 hr after birth appropriate agencies
Signs of withdrawal from opioids
(prescribed drugs, such as methadone) ANTENATAL ISSUES
can occur 3–4 days after birth,
Check maternal hepatitis B, hepatitis C
occasionally up to 2 wk after birth
and HIV status and decide on
Multiple drug use can delay, confuse management plan for baby
and intensify withdrawal signs in the
first weeks of life Check maternal healthcare record for
case conference recommendations
Minor signs and discuss care plan for discharge
with drug liaison midwife
Tremors when disturbed
Tachypnoea (>60/min)
Management of labour
Pyrexia
Sweating Make sure you know:
Yawning type and amount of drug(s) exposure
Sneezing route of administration
Nasal stuffiness when last dose was taken
Poor feeding Neonatal team are not required to be

present at delivery unless clinical
Regurgitation situation dictates
Loose stools
Sleeping <3 hr after feed (NB: usual
IMMEDIATE TREATMENT
among breastfed babies) Delivery
Major signs Do not give naloxone (can
exacerbate withdrawal symptoms)
Convulsions
Profuse vomiting or diarrhoea
Issue 6
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Care of baby is as for any other baby, For babies with minor signs, use non-
including encouragement of skin-to- pharmacological management (e.g.
skin contact and initiation of early swaddling)
breastfeeding, if this is mother's choice Start pharmacological treatment (after
– see Breastfeeding guideline other causes excluded) if there is:
After delivery recurrent vomiting
profuse watery diarrhoea
Transfer to postnatal ward/transitional
care and commence normal care poor feeding requiring tube feeds
Admit to neonatal unit only if there are inconsolability after 2 consecutive feeds
clinical indications seizures
Keep babies who are not withdrawing, The assessment chart (see below)
feeding well and have no child aims to reduce subjectivity associated
protection issues with their mothers in with scoring systems
postnatal ward/transitional care When mother has been using an opiate
Babies who are symptomatic enough or opioid, a morphine derivative is the
to require pharmacological treatment most effective way to relieve symptoms
usually require admission to neonatal When there has been multiple drug
unit usage, phenobarbital may be more
Start case notes effective
Take a detailed history, including:
Opioids
social history, to facilitate discharge
planning If authorised by experienced
maternal hepatitis B, hepatitis C and doctor/ANNP start morphine
HIV status 40 microgram/kg oral 4-hrly. In rare
cases, and after discussion with
Ensure postnatal baby check and daily
consultant, it may be necessary to
review by paediatrician
increase dose by 10 microgram/kg
As symptoms of withdrawal can be increments
delayed, keep baby in hospital for at If baby feeding well and settling
least 4 days between feeds, consider doubling
dose interval and, after 48 hr, reducing
SUBSEQUENT MANAGEMENT dose by 10 microgram/kg every 48 hr.
If major signs continue, discuss with
Aims of managing a baby at risk of experienced doctor/ANNP
neonatal drug withdrawal are to: Consider need for other medication
maintain normal temperature (e.g. phenobarbital)
reduce hyperactivity
Phenobarbital
reduce excessive crying
reduce motor instability For treatment of seizures and for
babies of mothers who are dependent
ensure adequate weight gain and
on other drugs in addition to opiates
sleep pattern
and are suffering serious withdrawal
identify significant withdrawal requiring symptoms, give phenobarbital
pharmacological treatment 20 mg/kg IV loading dose over 20 min,
Ensure baby reviewed daily by then maintenance 4 mg/kg oral daily
neonatal staff
Issue 6
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Unless ongoing seizures, give a short
4–6 day course
Infections
For treatment of seizures, see Follow relevant guidelines for specific
Seizures guideline situations, such as HIV, hepatitis B or
hepatitis C positive mothers – see HIV
Chlorpromazine guideline and Hepatitis B and C
guideline
For babies of mothers who use
benzodiazepines, give chlorpromazine Give BCG immunisation where
1 mg/kg oral 8-hrly if showing signs of indicated – see BCG immunisation
withdrawal guideline
remember chlorpromazine can reduce ASSESSMENT CHART
seizure threshold
Chart available for download from
Breastfeeding Staffordshire, Shropshire and Black
Country Newborn Network website:
Unless other contraindications co-exist http://www.networks.nhs.uk/nhs-
or baby going for adoption, strongly
networks/staffordshire-shropshire-and-
recommend breastfeeding – see
black-country-
Breastfeeding guideline
newborn/documents/Abstinence%20A
Support mother in her choice of SSESSMENT_CHART.pdf/view?searc
feeding method hterm=abstinence
Give mother all information she needs Local severity assessment/score
to make an informed choice about charts may be used
breastfeeding
Aim of treatment is to reduce distress
Drugs of misuse do not, in general, and control potentially dangerous
pass into breast milk in sufficient signs
quantities to have a major effect in
Minor signs (e.g. jitters, sweating,
newborn baby
yawning) do not require treatment
Breastfeeding will certainly support
mother in feeling she is positively
comforting her baby, should he/she be Has baby been inconsolable with
harder to settle standard comfort measures (cuddling,
swaddling, or non-nutritive sucking)
since last feed, had profuse vomiting
or loose stools, had an unco-
ordinated suck requiring tube feeds or
had seizures?
Place a tick in yes or no box (do not indicate any other signs in boxes)
Date
Time 04:00 08:00 12:00 16:00 20:00 24:00
Yes
No
Issue 6
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DISCHARGE AND FOLLOW-UP
Babies who required Babies who did not require

treatment treatment
Ensure discharge planning involving: If no signs of withdrawal, discharge at
social worker (may not be needed if day 5
prescribed for pain relief and no other Arrange follow-up by GP and health
concerns) visitor and advise referral to hospital if
health visitor there are concerns
community neonatal team if treated at Clarify the need for any ongoing social
home after discharge services involvement
drug rehabilitation team for mother

If seizures occurred or treatment was
required, arrange follow-up in named
consultant's clinic or as per local
protocol
Issue 6
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ADMISSION TO NEONATAL UNIT (NNU) • 1/2
There should be good clinical reasons
for admission to NNU
Procedure
Avoid unnecessary separation of mother Deal with any immediate life-threatening
and baby as it affects maternal bonding clinical problems (e.g. airway, breathing,
circulation and seizures)
Please ensure that all babies born
have NIPE (Newborn Infant Physical Show baby to parents and explain
Examination) between 6–72 hr of birth reason for admission to NNU
Inform NNU nursing staff that you wish
to admit a baby, reason for admission
CRITERIA FOR ADMISSION
and clinical condition of baby
FROM LABOUR WARD OR
POSTNATAL WARD Inform middle grade doctor and/or
consultant
Discuss need for admission with Ensure baby name labels present
senior medical staff Document relevant history and
examination
Clinical condition requiring constant
monitoring, <34 weeks’ gestation or Complete problem sheets and
investigation charts (follow local
birth weight <1800 g
guidelines)
Unwell baby:
Measure and plot birth weight and
poor condition at birth requiring head circumference on growth chart
prolonged resuscitation for >10 min
and/or cord pH<7.0 (a low cord pH Measure admission temperature
may not in itself necessitate an Measure blood pressure using non-
admission to NNU) invasive cuff
respiratory distress or cyanosis Institute appropriate monitoring and
apnoeic or cyanotic attacks treatment in conjunction with nursing
signs of encephalopathy and senior medical colleagues
jaundice needing intensive Investigations
phototherapy or exchange transfusion
major congenital abnormality likely to For babies admitted to the NNU,
threaten immediate survival obtain 1 bloodspot on newborn
seizures bloodspot screening (Guthrie) card
inability to tolerate enteral feeds with
vomiting and/or abdominal distension Babies <32 weeks/1500 g
and/or hypoglycaemia (blood glucose weight/unwell/ventilated
<2.6 mmol/L)
FBC
symptomatic hypoglycaemia or
hypoglycaemia not responding to Blood glucose
treatment – see Hypoglycaemia Blood gases
guideline Clotting screen if clinically indicated -
Neonatal abstinence syndrome see Coagulopathy guideline
requiring treatment – see Abstinence routine clotting screens in all babies
syndrome guideline <30 weeks’ gestation is not
Mother admitted to ITU recommended
If respiratory symptoms or support,
chest X-ray
Issue 6
17
ADMISSION TO NEONATAL UNIT (NNU) • 2/2
If umbilical lines in place, abdominal
X-ray
MONITORING
If suspicion of sepsis, blood culture
and CRP before starting antibiotics Use minimal handling
and consider lumbar puncture (see Cardiorespiratory monitoring through
Infection in the first 72 hours skin electrodes. Do not use in babies
guideline) <26 weeks’ gestation
Other babies Pulse oximetry. Maintain SpO2 as per
gestation target values (see Oxygen
Decision depends on initial assessment saturation targets guideline)
and suspected clinical problem (e.g.
Transcutaneous probe for
infection, jaundice, hypoglycaemia etc.)
TcPO2/TcPCO2, if available
see relevant guidelines
Temperature
IMMEDIATE MANAGEMENT
Blood glucose
Evaluation of baby, including full If ventilated, umbilical arterial
clinical examination catheterisation/peripheral arterial line
Define appropriate management plan for monitoring arterial blood pressure
and procedures in consultation with and arterial blood gas – see
middle grade doctor and perform as appropriate guideline in Practical
efficiently as possible to ensure baby procedures section
is not disturbed unnecessarily
CRITERIA FOR ADMISSION
Aim for examination and procedures to TO TRANSITIONAL CARE
be completed within 1 hr of admission
UNIT
If no contraindications, unless already
administered, give Vitamin K – see The following are common indications for
Vitamin K guideline admitting babies to transitional care unit
(if available locally), refer to local
If antibiotics appropriate, give within 1 hr
guidelines for local variations
Senior clinician to update parents as
Small for gestational age 1.7–2 kg and
soon as possible (certainly within 24
no other clinical concerns
hr) and document discussion in notes
Preterm 34–36 weeks’ gestation and
Respiratory support no other clinical concerns
Minor congenital abnormalities likely to
If required, this takes priority over
affect feeding, e.g. cleft lip and palate
other procedures
Requiring support with feeding
include incubator oxygen, high-flow
humidified oxygen, continuous positive Babies of substance abusing mothers
airway pressure (CPAP) or mechanical (observe for signs of withdrawal)
ventilation Receiving IV antibiotics
Intravenous access
If required, IV cannulation and/or
umbilical venous catheterisation (UVC)
– see appropriate guidelines in
Practical procedures section
Issue 6
18
ANORECTAL MALFORMATION IN NNU BEFORE
TRANSFER TO SURGICAL CENTRE • 1/2
INTRODUCTION rarely (in girls): cloaca [1 opening in
the perineum instead of 3 (urethra,
Incidence of anorectal malformation
vagina and anus)]
(ARM) is 1 in 5,000 neonates. More
common in boys. It can be associated
with the other abnormalities including the
VACTERL association, chromosomal
abnormalities and duodenal atresia
Symptoms and signs
ARM is present when either:
anus is not present (Figure 1)
bowel opens in the wrong position in
the perineum (a fistula) (Figure 2)
Figure 2: Fistula opening onto scrotal

raphe
Caution
The presence of meconium in the
nappy does not exclude an ARM, as a
neonate may still pass meconium
through a fistula
Always clean the perineum and
establish that a normally sited anus is
Figure 1: Anus is absent present
One or more of the following features

may be present:
abnormal looking perineum
delayed or no passage of meconium
abdominal distension
bilious vomiting
drooling of saliva (if coexistent
oesophageal atresia)
Examination
Full physical examination. Look for:
Figure 3: ARM with a fistula to the
dysmorphic features urinary tract
cardiac anomalies
limb anomalies
absence of anus (Figure 1)
abnormal position of bowel opening
(Figure 2). In girls, an abnormal
opening may be seen at the vestibule
Issue 6
19
ANO-RECTAL MALFORMATION IN NNU BEFORE
TRANSFER TO SURGICAL CENTRE • 2/2
MANAGEMENT Referral
Nil-by-mouth Refer to paediatric surgical team
Insert a size 8 Fr nasogastric tube Obtain a sample of mother’s blood for
(NGT) and fix securely (see crossmatch. Handwrite form,
Nasogastric tube insertion completing all relevant sections and
guideline). Successful passage of an indicating this is the mother of the
NGT excludes diagnosis of baby being transferred. Include baby’s
oesophageal atresia name
Empty stomach by aspirating NGT Complete nursing and medical
4-hrly with a 5 mL syringe. Place NGT documentation for transfer and
on free drainage by connecting to a arrange electronic transfer of any
bile bag X-rays taken. Ensure you have
Insert an IV cannula and obtain blood mother’s name and telephone contact
for FBC, U&E, glucose and blood details (including ward details if she is
cultures still an in-patient). Surgeon will require
verbal telephone consent if operation
Start maintenance IV fluids (see IV is required and a parent is not able to
fluid therapy guideline) attend surgical unit at appropriate time
Give broad spectrum antibiotics Inform surgical unit staff when baby is
Give vitamin K IM (see Vitamin K ready for transfer. Have available:
guideline) name, gestational age, weight,
Collect pre-transfusion bloodspot and ventilatory and oxygen requirements (if
send with baby to surgical centre applicable) and mother’s name and
ward (if admitted)
Replace nasogastric losses mL-for-mL
using sodium chloride 0.9% with Useful Information
10 mmol potassium chloride in 500 mL
http://www.bch.nhs.uk/content/neonatal-
IV
surgery
Chest X-ray to confirm position of NGT
http://www.bch.nhs.uk/find-us/maps-
and:
directions
vertebral anomalies
abnormal cardiac outline
Supine abdominal X-ray looking for:
dilated bowel/associated bowel atresia
vertebral anomalies
A combined chest and abdominal
X-ray is suitable as an alternative
Take photographs for parents
Issue 6
20
ANTENATAL ULTRASOUND ABNORMALITIES
• 1/1
DEFINITION Congenital diaphragmatic
Any lesion identified antenatally in the hernia
fetus (e.g. renal pelvic dilatation, Obstetric team to refer all cases to
hypoplastic left heart) tertiary fetal medicine team
Any maternal factor identified (Birmingham or Liverpool) who will
antenatally that could affect the baby counsel, monitor and arrange delivery
after delivery (e.g. anhydramnios from
preterm prolonged rupture of
MANAGEMENT AFTER
membranes) DELIVERY
For minor lesions, such as renal pelvic
COUNSELLING BEFORE dilatation, follow appropriate guideline
DELIVERY and inform senior staff and parents
All affected pregnancies will have For other lesions, follow written plan
detailed individualised plans for made by senior staff before delivery,
management of baby by consultant including need to contact seniors and
neonatologist, including place of specialist staff in regional referral
delivery centre before and after delivery
As some lesions are progressive (e.g. Communicate any new information
hypoplastic left heart syndrome, obtained after birth to consultant as
gastroschisis), the situation can this may change the plan of care
change and information from the required
obstetric team can alter over time.
Maintain regular contact with specialist
Discuss all affected pregnancies at the
teams as indicated by them
combined fetomaternal meeting until
delivery Arrange postnatal transfer if required
when bed available
Offer neonatal counselling to all
women whose pregnancy has been Keep parents informed of actions
affected by major lesions, to discuss taken, and contact from specialist
the impact of the identified lesion on teams
quality of life, including possible Consider syndrome for babies with >1
disabilities, investigations and surgery, lesion, discuss with senior staff as
and post-delivery plan soon as possible
Cleft lip and/or palate When available and if not issued

antenatally, provide written information
Obstetric team to refer to regional from 'Contact a family' book or
multidisciplinary cleft palate team, who www.cafamily.org.uk/
will counsel parents, communicate
plans for delivery and provide Specific lesions
postnatal support for baby
See Urinary tract abnormalities on
Hypoplastic left heart ultrasound scan, Gastroschisis, and
syndrome or other presumed Congenital heart disease: duct
dependent lesions guidelines
duct-dependent lesions
Obstetric team to refer to regional
cardiac team, who will counsel parents
and, where appropriate, confirm
diagnosis and provide a plan of action
Issue 6
21
APNOEA AND BRADYCARDIA • 1/2
Consider causes other than apnoea of
RECOGNITION AND prematurity if occurs:
ASSESSMENT
in term or near-term baby (>34 weeks’
Apnoea gestation)
on first day after birth in preterm baby
Pause(s) in breathing for >20 seconds
(or less, when associated with onset of apnoea after 7 days of age in
bradycardia or cyanosis) a preterm baby
Bradycardia Causes
Heart rate <100/min, associated with Infection

desaturation
septicaemia
Types necrotising enterocolitis
meningitis
Central
caused by poorly developed Respiratory
neurological control
inadequate respiratory support
respiratory movements absent
upper airway obstruction
Obstructive surfactant deficiency
caused by upper airway obstruction,
CNS
usually at pharyngeal level
intracranial haemorrhage
respiratory movements continue
initially but then stop seizure
congenital malformations
Mixed
initially central, followed by obstructive CVS
apnoea patent ductus arteriosus
Significance anaemia
Most babies born <34 weeks’ GI

gestation have primary apnoea of
gastro-oesophageal reflux
prematurity (PAP). Hence babies born
<34 weeks should have SpO2
Other
monitoring until at least 34 weeks post
conceptional age (PCA) metabolic abnormalities, especially
hypoglycaemia
multiple aetiologic factors can
exacerbate apnoea in preterm babies haematological: anaemia
sudden increase in frequency warrants inherited metabolic disorders e.g. non-

immediate action ketotic hyperglycinaemia
Issue 6
22
APNOEA AND BRADYCARDIA • 2/2
MANAGEMENT Pharmacological treatment

Terminate episode Caffeine citrate 20 mg/kg loading dose
oral/IV (over 30 min) followed, after
If apnoea not self-limiting, perform the 24 hr, by maintenance dose of 5 mg/kg
following in sequence to try to oral/IV (over 10 min) once daily,
terminate episode: increasing to 10 mg/kg if required until
ensure head in neutral position 34 weeks PCA
stimulate baby by tickling feet or may continue beyond 34 weeks PCA if

stroking abdomen desaturations and bradycardias
persist. If so review need for treatment
if aspiration or secretions in pharynx regularly
suspected, apply brief oropharyngeal
suction This dosing regime is recommended
by BNF-C. Higher doses have been
face mask ventilation used with evidence that it reduces risk
emergency intubation of failure of extubation in preterm
babies
Once stable, perform thorough clinical
examination to confirm/evaluate cause
Non-pharmacological
Screen for sepsis treatment
If apnoea or bradycardia increasingly CPAP, SiPAP/BiPAP – see CPAP

frequent or severe, screen for sepsis guideline
as apnoea and bradycardia can be If above fails, intubate and ventilate
sole presenting sign
TREATMENT
Treat specific cause, if present

Primary apnoea of prematurity is a
diagnosis of exclusion and may not
require treatment unless pauses are:
frequent (>8 in 12 hr) or
severe (>2 episodes/day requiring
positive pressure ventilation)
Issue 6
23
ARTERIAL LINE INSERTION • 1/2
Splint
PERIPHERAL ARTERIAL
LINES Sodium chloride 0.9% flush in 2 mL
syringe, primed through T-connector
INDICATIONS Transillumination fibre-optic light
source
Frequent monitoring of blood gases
3-way tap
Direct monitoring of arterial blood
pressure PROCEDURE USING RADIAL
Premature removal (or failure to site) ARTERY
an umbilical artery catheter (UAC)
Preparation
Exchange transfusion (peripheral
venous and arterial catheters Wash hands
‘continuous’ technique) or partial
exchange transfusion Check patency of ipsilateral ulnar
artery and proceed only if patent
CONTRAINDICATIONS Put on gloves
Extend baby’s wrist with palm of hand
Bleeding disorder
upwards
Inadequate patency of ulnar artery on
Transilluminate radial artery with fibre-
transillumination or failed Allen’s test (if
optic light source behind baby’s wrist
cannulating radial artery) or vice-versa
OR palpate pulse
Pre-existing evidence of circulatory
Allen’s test – for patency of ulnar artery
insufficiency in limb
Clean skin with antiseptic cleaning
Local skin infection
solution
Malformation of upper extremity for
radial arterial cannulation Procedure
Possible sites of arterial Enter artery with 24-gauge cannula just
entry proximal to wrist crease at 25–30º angle
Remove stylet from cannula and
Radial (most commonly used): the advance cannula into artery
only procedure discussed in this
guideline Connect cannula to T-connector
primed with sodium chloride 0.9%, and
Posterior tibial flush gently
Dorsalis pedis Secure cannula with tape, ensuring
Ulnar (usually only if ipsilateral radial fingers are visible for frequent
artery cannulation has not been inspection, and apply splint
attempted) Connect T-connector to infusion line
(sodium chloride 0.9% with heparin
EQUIPMENT
1 unit/mL), with 3-way tap in situ for
Gloves blood sampling
Cleaning solution as per unit policy Documentation
24-gauge cannula
Document clearly in notes all attempts
T-connector with Luer lock
at cannulation, including those that are
Adhesive tape unsuccessful
Issue 6
24
ARTERIAL LINE INSERTION • 2/2
AFTERCARE COMPLICATIONS
Monitor Thromboembolism/vasospasm/
thrombosis
Inspect distal digits regularly for
Blanching and partial loss of digits
circulatory status: if blanching does not
(radial artery)
recover after 5 min, remove line
Necrosis
Avoid excessive hyperextension of
wrist, as this can result in occlusion of Skin ulceration
artery Reversible occlusion of artery
Ensure a continuous pressure Extravasation of sodium chloride
waveform tracing is displayed on infusate
monitor screen at all times: if flushing Infection (rarely associated with line
line does not restore lost tracing, infection)
change position of limb/dressing
Haematoma
Usage Haemorrhage
Do not administer rapid boluses of Air embolism
fluid as this can lead to retrograde
embolisation of clot or air: use minimal
volume when flushing after sampling
and inject slowly
Use cannula only for sampling or
removal of blood during exchange
transfusion, and infuse only sodium
chloride 0.9% with heparin 1 unit/mL
Remove cannula as soon as no longer
required
Removal
Aseptic removal of arterial line: apply
pressure for at least 5 min (longer if
coagulopathy/low platelets) until no
bleeding or bruising
dressings do not prevent bleeding or
bruising
do not send tip for culture routinely
Issue 6
25
ARTERIAL LINE SAMPLING • 1/2
INDICATIONS Inaccuracy of blood gas

results
Blood gas analysis
Analyse sample immediately. After
Biochemical/and haematological blood is withdrawn from an artery, it
investigations
continues to consume oxygen
CONTRAINDICATIONS Excess heparin in syringe can result in
a falsely low pH and PaCO2. Remove
Blood drawn from an arterial line may excess heparin from syringe before
not be suitable for clotting studies (see obtaining sample
Coagulopathy guideline and
Bloodspot screening guideline) Do not use if air bubbles in sample:
take fresh specimen
COMPLICATIONS
EQUIPMENT
Haemorrhage Gloves
Ensure all connections are secure, Paper towel

Luer locks tight and 3-way taps Alcohol swabs x 2
appropriately adjusted
Syringes
Infection 2 mL syringe (A) for clearing line
2 mL syringe (B) for other blood
Maintain sterile technique during
samples as necessary
sampling to reduce risk of infection
1 mL syringe (C) pre-heparinised for
Artery spasm blood gas analysis
Limb appears blanched. Stop 2 mL syringe (D) containing 0.5–1 mL

procedure and allow time for recovery. of sodium chloride 0.9%
Warming of opposite limb can elicit Appropriate blood sample bottles and
reflex vasodilatation request forms
Thromboembolism PREPARATION AND

PROCEDURE
Flush catheter with 0.5 mL sodium
Preparation
chloride 0.9% each time sample taken.
If catheter not sampling, clot formation
Record SpO2 and TcCO2 at time of
may be in progress. Request urgent
taking blood to allow comparison with
middle grade review of arterial line for
blood gas if performed
a prompt decision about removal
Wash hands and put on gloves
Place paper towel beneath 3-way tap
collection port (maintain asepsis by
non-touch technique rather than sterile
gloves and towel)
Ensure 3-way tap closed to port hole
Issue 6
26
ARTERIAL LINE SAMPLING • 2/2
Turn 3-way tap so it is closed to
Procedure syringe, remove syringe (D), swab port
hole with alcohol wipe and cover with
Remove Luer lock cap, clean with
Luer lock cap
alcohol swab and allow to dry, or
prepare bioconnector Record amount of blood removed and
volume of flush on baby’s daily fluid
Connect 2 mL syringe (A)
record
Turn 3-way tap so it is closed to
infusion and open to syringe and AFTERCARE
arterial catheter
Ensure all connections tight and 3-way
Withdraw 2 mL blood slowly. It must
tap turned off to syringe port to prevent
clear the dead space
haemorrhage
If bioconnector not being used, turn
If sampling from umbilical arterial
3-way tap so it is closed to arterial
catheter (UAC), ensure lower limbs
catheter to prevent blood loss from
are pink and well perfused on
baby
completion of procedure
if bioconnector used, do not turn 3-way
If sampling from peripheral arterial
tap until end of procedure
line, check colour and perfusion of line
Attach appropriate syringe (B/C) site and limb housing arterial line
needed for required blood sample
Ensure line patency by recommencing
If bioconnector not being used, turn infusion pump
3-way tap to open to syringe and
Before leaving baby, ensure arterial
arterial catheter and withdraw required
wave form present and all alarms set
amount of blood for blood samples.
Do not withdraw more than required
amount
3-way tap off to arterial catheter in
between syringes B and C if both
required, after taking required samples
with syringes
Reattach syringe (A)
Clear the connection of air
Slowly return to baby any blood in line
not required for samples
3-way tap off to arterial catheter
Attach syringe (D) of heparinised
sodium chloride 0.9%
3-way tap so it is open to syringe and
arterial line, clear line of air and slowly
flush line to clear it of blood
Issue 6
27
BCG IMMUNISATION • 1/3
See also Tuberculosis (Investigation and management
following exposure in pregnancy) guideline
INDICATIONS
Born or living in an area where the notification rate of TB is >40/100,000 (including UK)
A parent or grandparent born in a country where the notification rate of TB is
≥40/100,000
Family history of TB in previous 5 yr
Local policy to give BCG to all neonates in that area
Countries with incidence of TB >40/100,000

Afghanistan Central African Guatemala Libya Nigeria Sudan
Algeria Republic Guinea Lithuania Pakistan South Sudan
Angola Chad Guinea-Bissau Macao Panama Suriname
Armenia China Guyana Madagascar Papua New Swaziland
Azerbaijan Congo Haiti Malawi Guinea Tajikistan
Bangladesh Congo DR Honduras Malaysia Paraguay Tanzania
Belarus Côte d'Ivoire Hong Kong Maldives Peru Thailand
Belize Djibouti India Mali Philippines Timor-Leste
Benin Dominican Indonesia Marshall Qatar Togo
Republic Islands Romania
Bhutan Iraq Turkmenistan
Ecuador Mauritania Russia
Bolivia Kazakhstan Tuvalu
Equatorial Micronesia Rwanda
Bosnia & Kenya Uganda
Guinea
Herzegovina Kiribati Moldova Saudi Arabia Ukraine
Eritrea
Botswana Korea DPR Mongolia Senegal Uzbekistan
Ethiopia
Brazil Korea Morocco Sierra Leone Vanuatu
Gabon
Brunei (Rep. of) Mozambique Singapore Vietnam
Gambia
Burkina Faso Kyrgyzstan Myanmar Solomon Yemen
Georgia Islands
Burundi Lao PDR Namibia Zambia
Ghana Somalia
Cambodia Latvia Nauru Zimbabwe
Greenland South Africa
Cameroon Lesotho Nepal
Guam Sri Lanka
Cape Verde Liberia Niger
https://www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people
Parts of UK with incidence of TB >40/100,000

Brent Harlow Luton Tower Hamlets
Ealing Hillingdon Newham Waltham Forrest
Greenwich Hounslow Redbridge
Haringey Leicester Slough
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/358226/TB_Official_St
atistics_230914.pdf
Tuberculin testing not necessary <6 yr old unless baby has been in recent contact
with tuberculosis or has resided in high-incidence country for >3 months
Issue 6
28
CONTRAINDICATIONS EQUIPMENT
Temperature >38ºC Alcohol hand gel
Severe eczema (give at suitable Injection tray
lesion-free site) 1 mL syringe
Neonate in household where an active Brown needle (26 FG 0.45 x 10 mm)
TB case suspected or confirmed, see to administer immunisation
Tuberculosis (Investigation and Green needle 21 FG 1 inch (to draw up
management following exposure in diluents and mix with vaccine powder)
pregnancy) guideline Cotton wool balls
Immunodeficient or on high-dose Foil dish for cotton wool balls
corticosteroids Non-woven gauze
defer BCG until 3 months after stopping Sharps container
corticosteroids if given prednisolone Bags for clinical waste
1 mg/kg/day for >3 weeks, 2 mg/kg/day
BCG vaccine
for 1 week, (or equivalent doses of
another corticosteroid, e.g. BCG vials are kept in fridge
dexamethasone 0.2 mg = prednisolone consist of 2 vials
1 mg) make up brown vial with entire
HIV positive, living in UK contents of clear vial
if mother HIV positive and exclusively invert vial 1–2 times to mix, do not shake
formula feeding, give vaccine only available for use for 4 hr after
after baby has had negative test for reconstitution
HIV after 3 months of age dose: 0.05 mL (note: vial contains 20
if high risk of TB exposure and doses)
maternal HIV viral load <50 copies/mL Document that BCG has been given,
after 36 weeks gestation, BCG can be site, dose and batch number
given at birth
PROCEDURE
encourage maternal HIV testing but do
not withhold BCG if mother declines Consent
testing unless mother from sub-
Saharan Africa in which case refer to Midwife to record at booking if risk
HIV team for counselling about testing factor present
Postnatal check for risk factor
SPECIAL CASES Ensure baby within inclusion group
No need to delay routine vaccinations Give mother information on vaccine
Give appropriate language leaflet TB,
BCG can be given simultaneously with
BCG vaccine and your baby,
other vaccines [including palivizumab
available from
(Synagis)] but not in same arm
https://www.gov.uk/government/publica
no further immunisation should be tions/tb-bcg-and-your-baby-leaflet
given in the arm used for BCG order line: 0300 123 1002 or
immunisation for at least 3 months due https://www.orderline.dh.gov.uk/ecom_
to risk of regional lymphadenitis dh/public/home.jsf
if not given at same time, leave 4 DH guidelines state written consent is
weeks before giving other live vaccines not required but follow local practice
Issue 6
29
skin
subcutaneous
tissue
muscle
sometimes, this ulcerates and can ooze

Injection
site need not be protected from water
Only staff trained to give intradermal do not cover with an impervious
injections to give BCG dressing
Hold arm at 45º to body can take several months to heal
At insertion of deltoid muscle near occasionally persists as keloid
middle of left upper arm (particularly if given superior to
If skin is clean, no further cleaning is insertion of deltoid)
necessary
Adenitis:
If skin is visibly dirty, clean with soap
and water a minor degree of adenitis can occur
in the weeks following BCG
Stretch skin between thumb and
forefinger no treatment indicated
Introduce needle bevel upwards about
Rare sequelae:
3 mm into superficial layers of dermis
almost parallel to skin local abscess
If considerable resistance not felt, chronic suppurative lymphadenopathy
remove needle and reinsert before disseminated disease, if
giving more vaccine immunocompromised
Correctly given intradermal injection osteitis, refer to infectious diseases
results a tense blanched bleb specialist
DOCUMENTATION Refer to paediatric
Complete ‘Unscheduled vaccine form’ TB team if
or letter with batch number, vaccine
Severe local reactions
name and site of immunisation
abscesses or drainage at the injection
Send to local TB service/Public Health
site
Department
Keep a local record or
Enter in Red book on relevant page regional suppurative lymphadenitis
with draining sinuses
SEQUELAE
Refer disseminated BCG infection to
Scar paediatric TB specialist
within 2–6 wk a small papule will appear
Issue 6
30
BLOOD GROUP INCOMPATIBILITIES
(including Rhesus disease) • 1/2
Aim to avoid kernicterus and discuss progress regularly with middle-
severe anaemia grade or consultant
Keep consultant in charge informed Decide whether baby needs
phototherapy or exchange transfusion
as determined by the gestational age-
POSTNATAL MONITORING specific charts
Babies at risk If baby has negative DCT and had no
IUT, no further action required; baby is
Those with mothers with known blood not affected
group antibodies including:
D (Rhesus), c, C, s, E, e, Duffy Management of babies with
Kell: causes bone marrow suppression haemolysis diagnosed or
in addition to haemolysis suspected postnatally
Management of babies at Babies with:
risk of haemolysis blood group incompatibility with a
positive DCT, manage as above
Antenatally: prepare a plan based on red cell enzyme defect, inform on-
antibody titres, middle cerebral artery service consultant
Dopplers and evidence of hydrops
in severely affected cases, order blood PHOTOTHERAPY
in advance for exchange transfusion
Indications/treatment
Send cord blood urgently for Hb,
blood group, direct Coombs’ test
thresholds
(DCT) and bilirubin
Refer to NICE jaundice
in all babies who have had an in-utero
guideline table and
blood transfusion (IUT), send cord
blood also for a Kleihauer test treatment charts
chase results Prophylactic phototherapy
If pale with abnormal cardiorespiratory (e.g. from birth) is not beneficial
signs (e.g. tachycardia), admit to
Neonatal Unit (NNU) DO NOT subtract the
If baby has positive DCT or had an IUT direct/conjugated bilirubin value
(regardless of DCT and blood group): from the total
discuss with middle-grade or
consultant Inform middle-grade when a baby
requires phototherapy
if cord bloods not available, check
baby’s blood immediately for bilirubin, Management
Hb and DCT
monitor serum bilirubin, usually at 6-hrly Plot bilirubin values on the appropriate
intervals until the level is both gestation NICE treatment chart
stable/falling and 2 consecutive values Administer phototherapy – see
are >50 umol/L below the treatment Jaundice guideline
threshold Check bilirubin 6 hr after onset of
plot bilirubin values on the NICE phototherapy and at least 6-hrly until
gestational age-specific charts: the level is both stable/falling and 2
http://www.nice.org.uk/guidance/CG98 consecutive values of >50 umol/L
keep parents informed below the treatment threshold
Issue 6
31
BLOOD GROUP INCOMPATIBILITIES
(including Rhesus disease) • 2/2
INTRAVENOUS IMMUNOGLOBULIN (IVIG)
Always discuss indications with consultant
Indications for IVIG use in isoimmune haemolytic anaemia

Indication Bilirubin levels
IVIG indication for rapidly rising >8.5 micromol/L per hour despite intensive
bilirubin level as recommended phototherapy (4 light sources used at correct
by NICE 2010 distance – see Table in Jaundice guideline)
Second dose of IVIG If bilirubin continues to rise rapidly as above (see
Table in Jaundice guideline), a single repeat
dose of IVIG can be given 12 hr+ later
Dose and administration

Complete immunoglobulin request form for babies who had IUT, IVIG or
(this is a red indication for use; please exchange transfusion, follow-up with
tick relevant box on the form) Hb check every 2 weeks initially, and
500 mg/kg over 4 hr (see Neonatal until 3 months of age; thereafter
Formulary) arrange developmental follow-up (see
below)
EXCHANGE TRANSFUSION for all other babies who had Coombs’
(ET) tests more than weakly positive, review
with Hb check at 2 and 6 weeks; once
Always discuss indications with Hb stable discharge from follow-up and
consultant discontinue folic acid if this has been
prescribed
See Exchange transfusion guideline
Indication for top-up
BEFORE DISCHARGE transfusion for late anaemia
Check discharge Hb and bilirubin Symptomatic anaemia
FOLLOW-UP AND Hb <75 g/dL
TREATMENT OF LATE Ongoing neuro-
ANAEMIA developmental follow-up
and hearing test
All babies with haemolytic
anaemia Arrange for any baby:
with definite red cell anomalies
Arrange Hb check and review at 2
weeks of age who has undergone an exchange
transfusion
Discuss results urgently with neonatal
consultant who has had an IUT
dependent on rate of fall of Hb from who required IVIG
discharge Hb, frequency of Hb checks with serum bilirubin at or above
planned (may need to be as frequent exchange transfusion threshold
as weekly)
Issue 6
32
BLOODSPOT SCREENING • 1/1
Depending on circumstances,
INTRODUCTION screening laboratory will request
Screen babies on day 5 of age (date repeat bloodspot
of birth = day 0) for the following
conditions:
No transfusions before day 5
sickle cell disease Collect routine bloodspot card at day 5
phenylketonuria (PKU) fill 4 circles and send to West Midlands
congenital hypothyroidism (CHT) screening centre via courier service
after validation check, irrespective of
cystic fibrosis (phased implementation)
milk feeds or gestational age
medium chain acyl co-A
dehydrogenase (MCADD) deficiency Preterm babies <32 weeks
maple syrup urine disease (MSUD) (≤31 weeks and 6 days) will require
repeat sample at 28 days or
isovaleric acidaemia (IVA) discharge home, whichever is the
glutaric aciduria type 1 (GA1) sooner for CHT
homocystinuria (HCU)
CONSENT AND
Obtain pre-transfusion bloodspot
samples as previous blood INFORMATION
transfusions can falsify results
Person undertaking procedure must:
explain pre-transfusion screening
TIMING procedure to parent(s)
If transfused before day 5 provide national pre-screening leaflet
It is mandatory to include baby’s NHS
Collect first bloodspot card before number on the bloodspot card
transfusion
fill one circle Further Information
mark card ‘pre-transfusion’ Detailed information available from UK
Newborn screening programme centre
Collect second bloodspot card at 5–8
website:
days of age and at least 72 hr after
blood transfusion http://newbornbloodspot.screening.nhs
.uk/
fill 4 circles
record whether plasma or red cells
transfused
Staple pre-transfusion and second
bloodspot card together and send to
West Midlands screening centre via
courier service after validation check
Multiple transfusions
between 5 and 8 days of age
Collect 4 bloodspots within this
window. Complete with as much time-
lapse as possible from any transfusion
Issue 6
33
BOTTLE FEEDING IN THE NEONATAL UNIT •
1/2
INTRODUCTION CONTRAINDICATIONS
It is rare for babies to be developmentally Mother has chosen to breastfeed
ready for bottle feeding before 34 weeks Baby has a medical condition and
AIM specialist assessment indicates bottle
Recognition of baby’s feeding skills feeding contraindicated
and cues by neonatal staff and parents
Special precautions/cautions
Sensitive and safe bottle feeding
To prevent long-term aversive behaviour Medical condition indicates oral motor
and pharyngeal skills may be
INDICATIONS compromised/delayed, impacting
safety of baby’s swallow (e.g. extreme
Breastfeeding is the preferred feeding
prematurity, chronic lung disease, cleft
method for the majority of babies
palate, certain syndromes and
except if:
neurological dysfunction), take special
mother unable to breastfeed for medical care in introducing bottle feeds. Refer
reasons (maternal HIV, HTLV) or on to speech and language therapist
treatment making breast milk unsafe
parental choice – discuss merits of
breastfeeding, including bottle feeding
expressed breast milk
baby’s medical condition makes full
breastfeeding impractical or unsafe
PROCEDURE
Action Reason
Parents/carers to be available for feeds Benefits for baby:
consistency
bonding and attachment
Plan care activities in relation to Care activities before feeds will cause:
feeding fatigue
depleted energy
reduced capacity to feed orally
Observe baby’s behaviour before Risks of feeding baby or no feeding
feeding, looking for signs of: cues:
alertness aspiration
rooting long-term feeding aversion
physiologically stable
Ensure quiet environment Sensitive babies will show signs of
stress and instability
In preterm babies begin feeds with a Consider length, shape and flow of
slow-flow teat teat in relation to:
baby’s size
oral structures
strength
texture of liquid
Issue 6
34
BOTTLE FEEDING IN THE NEONATAL UNIT •
2/2
PROCEDURE (cont.)
Action Reason
Warm milk to room or body Benefits:
temperature before feeding comfort
easier to digest
All premature babies benefit from a Benefits:
swaddled, elevated side-lying feeding comfort
position to support bottle feeding skills, safety
especially at the beginning of their bottle facilitates postural support
feeding journey. This position will require supports pacing and co-ordination
nursing team education and training
If baby does not tolerate an elevated Benefits:
side-lying feeding position, revert to an supports flexed position and grasp reflex
upright feeding position: maintains firm muscle tone to suck and
swaddle swallow safely
provide back support able to observe stress cues
ensure baby’s hands are free to grasp
If baby is not actively sucking, avoid Stimulation is distracting and indicates
stimulation to the mouth area baby not able to continue with bottle feed
Pace baby during bottle feed to help To pace:

regulate sucking, swallowing and adjust milk flow by lowering angle of teat
breathing if baby continues to suck and not
breathe, remove teat from mouth
Bottle feed should take 20–30 min Long bottle feeds will:
cause fatigue
impact on weight gain
increase risk of feeding aversion
Introduce cue-based feeding Benefits:
baby in control
improved milk volumes orally
reduced risk of feeding aversion
reduced aspiration risk
Teach parents to mix feeds following Unhygienic and incorrectly constituted
infection control guidelines feeds can cause poor growth and illness
Parents to room-in and demand-feed To ensure parent and baby confidence

baby before discharge
Table adapted from ‘A guide to infant development in the newborn nursery 2010’ 5th Edition Inga
Warren and Cherry Bond, Winnicott Baby Unit, St. Mary’s Hospital, Paddington (with permission)
Issue 6
35
BREASTFEEDING • 1/2
PRETERM BABIES CONTRAINDICATIONS TO

BREASTFEEDING
Rationale
Breast milk feeding, even partial, Babies with galactosaemia should not
reduces risk of necrotising enterocolitis receive breast milk
(NEC) and improves cognitive
outcomes in preterm babies HIV in UK
Human milk is important in Always check maternal HIV status
establishing enteral nutrition before breastfeeding
Any amount of mother’s fresh breast breastfeeding absolutely
milk is better than none contraindicated in UK
Physician advocacy has a strong if you are concerned that mother
influence on intention to feed intends to breastfeed, ensure an HIV
specialist explains the risk to baby
Parent information
HIV in developing countries
Offer parents the following fact sheets,
available from: If returning to a developing country
http://www.bliss.org.uk/Shop/the-best- where there is no access to clean
start-a-guide-to-expressing-and- water, exclusive breastfeeding is safer
breastfeeding-your-premature-baby than mixed
Small Wonders DVD Maternal medications
IMPLEMENTATION
The risk of the medication to baby is
In pregnancy at high risk of premature dependent on the gestation, age and
delivery, discuss feeding during clinical condition of baby
antenatal period
Antimetabolites or cytotoxic drugs
Discuss value/benefits during mother’s
Radioisotope investigation (until
first visit to neonatal unit
isotope clears)
Document discussion in maternal
See Neonatal Formulary, BNF or
healthcare record
‘Medications and mother’s milk’ by
Separate decision to provide a few T W Hale
weeks’ pumped breast milk from the
commitment to long-term, exclusive A current, reliable reference for drugs
breastfeeding and breastfeeding must be available
on the neonatal unit
Praise efforts to provide expressed
breast milk
Ensure adequate discussion and BREASTFEEDING WITH
provision of written information on SPECIAL PRECAUTIONS
hand-expression, and on mode and
frequency of pump use Tuberculosis
See Nutrition and enteral feeding Maternal sputum-positive TB is not a
guideline re: establishing contraindication to breastfeeding
breastfeeding If mother on isoniazid, give prophylactic
pyridoxine to mother and baby
Issue 6
36
BREASTFEEDING • 2/2
Refer to Tuberculosis – careful hand hygiene essential
Investigation and management affected side – cover, pump and
following exposure in pregnancy discard milk (no breastfeeding) until
guideline for further advice lesions are clear
Cytomegalovirus (CMV) unaffected side – can breastfeed and
use EBM
Mothers who have a primary CMV
infection or a reactivation may be Phenylketonuria (PKU)
infective. Take senior microbiological
Breastfeeding not contraindicated in
advice on testing and feeding
babies with PKU
Pasteurisation of milk inactivates CMV
Screening service will contact
Hepatitis B paediatric dietitians directly
Careful dietetic management
Risk of transmission can be almost necessary
totally eliminated by a combination of
All babies should be under the care of
active and passive immunisation paediatric dietitians and inherited
Breastfeeding is not contraindicated metabolic diseases team
See Hepatitis B and C guideline
Radioactive diagnostic
Hepatitis C agents
Transmission by breastfeeding Women receiving radioactive diagnostic
theoretically possible but has not been agents should pump and discard
documented although most agents have very short
Breastfeeding not contraindicated but plasma half-lives, seek advice from
inform mother that risks are unknown hospital nuclear medicine department
– consider avoiding breastfeeding if as to how long to discard milk for
nipples cracked as increased risk of
infection Medications
Varicella-zoster virus (VZV) For medications that require caution

with breastfeeding, see Maternal
Babies of mothers with active VZV can medications above
reduce the risk by avoiding
breastfeeding until mother is no longer Social drugs
infectious (5 days from onset of rash)
Alcohol
Premature babies born <1 kg or <28 discourage more than limited
weeks are considered high-risk and consumption
should be given Varicella-zoster
immunoglobulin VZIG (see Varicella Nicotine
guideline) nicotine concentration in breast milk
increases immediately after smoking
Herpes simplex type 1 discourage mothers from smoking
directly before breastfeeding or
Omit breastfeeding or feeding EBM
from affected side in women with expressing breast milk
herpetic lesions on breast until lesions
have healed
cover active lesions elsewhere
Issue 6
37
BREAST MILK EXPRESSION • 1/2
Electric breast pumps used in hospital Encourage simultaneous (double)
should have the following pumping of both breasts
characteristics: Ensure mother has a properly fitting
easy to assemble and disassemble breast shield (funnel), size is
with all parts able to withstand determined by comfort
sterilisation methods
TECHNIQUE
fully automatic, with a cyclic suction
rhythm that mimics baby suckling Ensure mother seated in comfortable
vacuum strength not exceeding straight-backed chair and keep
250 mmHg, and easily regulated clothing away from breast while
separate drive and suction system to expressing milk
ensure no contamination from milk Support breast from underneath with
spillage can enter pump fingers flat on ribs and index finger at
collection system enabling milk to be junction of breast and ribs with nipple
pumped directly into storage container positioned centrally in shield (funnel)
with universal thread, to avoid need to Adjust suction control for comfort
transfer milk to another container for Use light pressure to obtain patent
storage or administration seal between breast and shield. Firm
pressure will inhibit milk flow by
GENERAL compressing ducts
Advise mothers to: Empty breasts as thoroughly as
bath or shower daily possible since fat content increases as
breast is drained
wash hands thoroughly with soap and
running water before expressing If using a single pump, switch to
second breast when milk flow slows
gently massage breast and stimulate
nipple to trigger milk ejection reflex Use a new bottle for each expression
before milk expression Leave a space of 1–2 cm at the top of
complete expressing log each bottle to allow for expansion
during freezing
MILK COLLECTION Following expression, wash equipment
in hot soapy water with a bottle brush
Sterilise milk collection utensils before before sterilisation
use
Encourage mothers to practice
Commence milk collection as soon as ‘kangaroo care’ also known as skin-to-
possible following delivery (preferably
skin holding (see Kangaroo care
within 6 hr)
guideline)
Frequency of expression should be
Encourage mothers to express where
8–12 times/24 hr (not leaving a gap of
they feel most comfortable; either
longer than 6 hr overnight)
close to baby or with baby
Teach all mothers hand expression picture/memento
Use hand expression to express Complete at least 4 formal expressing
colostrum and collect the milk obtained assessments in the first 2 weeks
via a syringe (optimise milk production and address
When milk obtained is sufficient to flow any issues related to expressing)
easily into a storage container, teach
mothers to use an electric breast pump
Issue 6
38
BREAST MILK EXPRESSION • 2/2
Problems related to milk

expression
Sore nipples
Centre milk expression shield
Try a variety of shield sizes
Check pump vacuum
Stop pump before removing shields
Do not use plastic-backed breast pads
Change breast pads frequently
Too little milk

Increase kangaroo care (skin-to-skin)
Express close to baby’s cot
Check frequency and duration of
pumping
Check shield (funnel) size
Encourage breast compression during
expression
Increase frequency of expression
sessions
Consider enhancing prolactin secretion
using domperidone
Praise provision of expressed milk, no
matter how small
Parent information
Offer parents the following fact sheets,
available from:
http://www.bliss.org.uk/Shop/the-best-
start-a-guide-to-expressing-and-
breastfeeding-your-premature-baby
Small Wonders DVD
Issue 6
39
BREAST MILK HANDLING AND STORAGE • 1/2
Improperly collected or stored Clearly label milk from individual
breast milk can become mothers in individual patient labelled
contaminated and cause sepsis containers and store separately in fridge
(individual containers must not hold
Staff must adhere to local policies
bottles from more than one mother)
on collection of human milk and
hand washing Blood and other pigments can
discolour milk causing appearance to
vary considerably
ADMINISTRATION
unless it appears rancid and smells
Ensure there is a dedicated fridge and
offensive, the appearance of milk is of
freezer for milk storage on ward
no clinical concern and it can be safely
Add date and time bottles removed fed to baby
from freezer/opened to bottle label
STORAGE
ADVICE TO MOTHERS
Where
See Breast milk expression guideline
Store in refrigerator at 4ºC. Freshly
Advise mothers to bath or shower daily expressed breast milk can be stored
do not wash breasts with bactericidal for 48 hr before freezing
detergent or soap Breast milk can be stored for 3 months
Before expressing milk, it is essential to in freezer at -18ºC without a defrost
wash hands thoroughly with soap and cycle (in hospital)
water and dry with a disposable towel if freezer has defrost cycle and milk
Wipe breast pump with disinfectant appears frothy but does not smell
wipe before use rancid, it is safe to use
Give all breastfeeding mothers: Monitor fridge and freezer temperature
daily using maximum/minimum
fact sheet available from
http://www.bliss.org.uk thermometer that is calibrated every 6
months. This temperature should be
and ‘Small Wonders’ DVD recorded – date/time and temperature
Emphasise to mothers the importance
of washing all breast milk collecting How
equipment properly before disinfection Place milk in sterile container with
wash equipment with detergent and hot airtight lid
water using bottle brush (not shared) Ensure bottles labelled appropriately –
and rinse well before disinfection see Record keeping
discard bottle brushes on discharge Store labelled bottles in separate
containers in fridge/freezer (individual
COLLECTION OF BREAST containers must not hold bottles from
MILK more than one mother)
Give mother sterile collection kit Wash containers stored in fridge daily
Provide parents with patient in warm soapy water, rinse well and
identification stickers to label milk. dry thoroughly
Before giving a mother the patient Clean containers between each use
identification stickers positive Shake milk container to mix milk
identification must be made at the before use
cotside/bedside
refrigerated milk separates with hind
milk forming top layer
Issue 6
40
BREAST MILK HANDLING AND STORAGE • 2/2
Hospital-to-hospital
DEFROSTING
use rigid container for easy cleaning
Use frozen milk in sequence of (e.g. cool box) and fill empty space
storage until enteral feeds are with bubble wrap
established use coolant block to maintain
Thaw frozen milk in waterless warmer temperature and transfer to fridge as
or in fridge (if warmer is not available) soon as possible on arrival in
NNU/ward
If frozen milk needs to be thawed
quickly (and warmer is not available),
PRECAUTIONS
hold bottle under cold or tepid water.
Shake frequently and do not allow Wash hands thoroughly
water to enter bottle via cap
Cover cuts and abrasions and wear
Discard thawed milk (stored in a gloves if necessary
refrigerator at 4ºC) after 24 hr
RECORD KEEPING
USE
Label all bottles with baby’s printed
Once removed from fridge, fresh or hospital label containing:
defrosted milk must be used within 4 hr
name and hospital number
Fresh milk is preferable to thawed milk
(when on full feeds) date and time of expression
Change continuous tube feeding If mother is expressing milk at home,
(tubing between nasogastric tube and provide supply of printed hospital
pump) every 4 hr labels
To minimise fat loss, position syringe Before giving breast milk, 2 members
delivering feed in semi-upright position of staff must check label and cross-
reference with baby’s identity bracelet
Bolus, feeds – warm milk before giving to ensure milk is not given to wrong
using waterless warmer if available (to child
minimise fat loss)
If freezing MEBM label date and time
Additives should be added to breast frozen and date time of defrosting
milk as close to feed time as possible
See Breastfeeding guideline
Only warm volume of milk required for
feed. Store remainder in refrigerator STORAGE FOLLOWING
DISCHARGE
TRANSPORTATION OF MILK
Ensure parents take home all EBM in
Milk is often transported from:
the refrigerator or freezer. If mother’s
Mother's home to hospital EBM remains on unit and is in date,
transport in an insulated container that transfer from refrigerator to freezer
can be easily cleaned immediately – inform parents to collect
as soon as possible
encourage mothers to use coolant
block to maintain stable temperature Discard milk stored in neonatal unit
freezer one month after discharge
Issue 6
41
BROVIAC LINE INSERTION • 1/3
INDICATIONS bleeding/bruising
Long-term central venous access line dislodgement/break/blockage
necessary (3–4 weeks) and all sites wound problems (especially vascuports)
for peripherally inserted central pneumothorax (uncommon)
catheters (PICC) line insertion have haemothorax (uncommon)
been exhausted
pericardial effusion (uncommon)
Referring neonatologist must balance
cardiac arrhythmias (uncommon)
the risks of the procedure/transfer
against the benefits Inform parents the surgeon inserting
the line will meet with them before the
CONTRAINDICATIONS procedure to discuss their concerns
Pyrexial or septic baby. Remove any and complete formal consent form
other lines e.g. PICC and administer if parents are not able to attend surgical
antibiotics until apyrexial for at least centre on day of procedure, formal
48 hr before insertion of Broviac line ‘delegated consent’ must be gained by
local neonatal team and completed
Consent and communication
consent form must accompany baby to
with parents surgical centre. File a copy in baby’s
Before transferring to surgical centre, healthcare record. This should be
explain procedure to parents and discussed with the surgical team
discuss risks including: Document all discussions with parents
infection in baby’s healthcare record
Complications Problems in Causes of line blockage

of insertion established lines Difficult to aspirate and flush
Infection
line
Pneumothorax cuff Tip of line in wrong place
skin
endocarditis
Lumen blocked
Haemothorax Breakage blood clot or
PN/drug concretion
Bleeding/haematoma Blockage Fibrin sheath over end of line
Thrombus at the tip of line
Cardiac tamponade Displacement
Blood clot or vegetations
Line tip pressed against
vessel wall
Malposition Thrombus on tip of line
heart valve
atrial wall
Line partially pulled out
Extravasation Venous occlusion
tip no longer in vessel
Tip eroded through vessel wall and
Venous occlusion
lying outside lumen
Damage to line or lumen
Issue 6
42
INSERTION clamp catheter immediately following
instillation of heparin
Inserted using an ultrasound guided
percutaneous approach under general to use a heplocked line, aspirate the
anaesthetic at a paediatric surgical lumen until blood is withdrawn and
centre discard the aspirated solution
Blood transfusions due to bleeding as REMOVAL
a complication of surgery are very
rarely required and usually occur due Neonatal consultant will decide when
to an underlying condition line to be removed, often following
discussion with surgeons
Referral
Indications
Refer urgently to on-call paediatric
surgeon at planned place of surgery. Line no longer needed
Arrangements will be made on an Line blocked or damaged
individual basis depending on degree Cuff dislodged so that it is visible
of urgency and clinical need outside the skin
Once procedure date set, liaise with Central line infection, not controlled by
the transport team antibiotics
Ensure a transfer letter is ready to Evidence of sepsis with no obvious
accompany baby, together with recent cause, not controlled by antibiotics
FBC, clotting screen and U&E results
Repeated (>2) episodes of Broviac line
Prepare baby for transfer. Follow pre- related sepsis
operative fasting instructions from the
surgical team Preparation for removal
Discuss with surgical team or surgical
Post-operative care
outreach nurse
All lines will be imaged in theatre
Discuss procedure, benefits and risks
unless otherwise specified
with parents and document discussion
Line will be looped on the chest under in baby’s healthcare record
an IV3000 dressing +/- a biopatch
Most Broviac line removals are
biopatch used for babies >26 weeks performed at the neonatal surgical
and >7 days old centre on an elective basis according
avoid excessive pressure over the to the degree of urgency and other
patch (risk of skin necrosis) clinical needs (occasionally a
consultant surgeon may perform the
Change dressing weekly for 3 weeks
procedure at the neonatal unit)
2.7 Fr line: continuous infusion at
≥1 mL/hr to prevent blockage Once a date is agreed, inform
transport team
4.2 Fr line: when not in use:
Ensure transfer letter is ready to
heplock twice weekly with prescribed accompany baby, together with results
heparin 0.4 mL (10 iu/ml) of recent FBC, clotting screen and U&E
**please note this is a reduction in Prepare baby for transfer. Follow pre-
heparin concentration from previous operative fasting instructions from the
guidelines** surgical team
use aseptic technique
Issue 6
43
Equipment required if Embolised line
surgeon removing line on Very rare but occasionally line will
neonatal unit break causing the tip to embolise into
Surgical consent form the right atrium or pulmonary artery
Trolley If line stops working, perform chest
X-ray
Sterile dressings pack
Requires retrieval by interventional
Cut-down pack (e.g. insertion of a
cardiologist at paediatric surgical
UVC or a chest drain)
centre. Liaise with either on-call
Local anaesthetic (lidocaine 1% or paediatric surgeon or vascular access
marcaine 0.25%) team at planned place of surgery
Sterile pot to send tip to microbiology
Useful Information
Sterile gauze
Cleaning fluid i.e. chlorhexidine etc. surgery
Steristrips http://www.bch.nhs.uk/find-us/maps-
Mepore dressing directions
Potential complications of
line removal
Bleeding – usually oozes from exit site
that will settle with pressure
pressure may need to be applied to
neck, just above clavicle (venous
puncture site)
Infection
Line breaking during removal
(embolisation) – very rare but line tip
may require removal
Wound problems
Issue 6
44
CANNULATION – PERIPHERAL VENOUS • 1/1
It can be helpful to flush cannula with
CANNULATION sodium chloride 0.9% to assist in
INDICATIONS identification of point at which cannula
enters vein. If blood samples taken at
Access for intravenous infusion and time of cannula insertion, do not flush
medications cannula as this will contaminate
sample for analysis
CONTRAINDICATIONS Wash hands and put on gloves
Sore or broken skin
Insertion
EQUIPMENT Apply hand pressure around limb to
distend vein
Cleaning solution (see your Trust’s
policy) Place thumb on skin slightly distal to
proposed puncture site
Appropriately labelled blood bottles
and request cards Hold cannula at 10–20º angle and
puncture skin
Non-sterile disposable gloves
24 gauge cannula Advance cannula toward vein
T-piece connected to a syringe of resistance may diminish slightly as it

sodium chloride 0.9%, flushed and enters vein and a speck of blood may
ready be seen in hub of needle (this is easier
to see if cannula has been flushed
Tape and splint to secure cannula with sodium chloride 0.9%). Do not
3-way tap if necessary advance needle further as it can pierce
back wall of vein
EMLA cream is not used in neonates
When this occurs, hold needle steady
and advance cannula a short distance
PROCEDURE within vein
Withdraw needle from cannula
Preparation
Connect T-piece and flush cannula
Identify suitable site: gently with 0.5 mL sodium chloride
preferably back of hand or foot 0.9% to confirm it is in the vein
save long saphenous and antecubital Secure cannula with clear dressing
fossa veins for long line insertion (e.g. Tegaderm/Opsite) to ensure IV
site visible at all times, and connect to
scalp: shave area if using scalp vein infusion
(do not use as first priority site)
inform parents before procedure if Documentation
possible
Record date, time and site of cannula
Identify suitable vein, which should be insertion in notes with identification and
clearly visible. Unlike in adults, signature of person carrying out
neonatal veins are rarely palpable procedure (use local sticker if available)
When baby likely to need numerous Record date and time of removal of
cannulations, avoid using potential cannula
long line veins Use visual phlebitis scoring for
ongoing monitoring of cannula,
according to local Trust policy
Issue 6
45
CARDIAC MURMURS • 1/1
Failed oximetry: Cardiac murmur detected on routine postnatal examination
See Pulse-oximetry
screening guideline
Lower limb SpO2 <95% Thorough cardiovascular examination
Pre and post- ductal Pre and post ductal saturations
difference of >2% Senior paediatric review
Any of the following Any of the following All of the following Grades of cardiac
Failed oximetry Loud murmur Asymptomatic well murmur
Weak or absent (>2/6 intensity) baby Grade 1 – barely
femoral pulses Pansystolic/ No signs of heart audible
Symptoms of heart diastolic/continuous failure Grade 2 – soft but
failure Heave Normal pulses easily audible
Signs of heart Location other Normal saturations Grade 3 – moderately
failure than LSE Soft systolic loud, no thrill
Cardiovascular Murmur plus murmur (<2/6) Grade 4 – louder,
shock dysmorphic features with thrill
Grade 5 – audible
with stethoscope
barely on chest
Significant congenital Possible congenital Likely innocent heart Grade 6 – audible with
heart disease heart disease murmur stethoscope off chest
URGENT SOON ROUTINE Signs and

Admit to NNU Senior review Echo before symptoms of heart
+/- ECG, chest X- ECG +/- echo discharge if failure:
ray, four-limb BP before discharge available or Lethargy, not
and blood gas if available Review in waking up for
analysis Review by paediatrician out- feeds
Hyperoxia test +/- paediatrician with patient clinic within Poor feeding
Prostin (see echocardiography 2–6 weeks Not completing
Congenital heart skills or paediatric Advise parents to feeds
disease:duct cardiologist within watch for signs of Fast or abnormal
dependent 2–3 weeks heart failure breathing
lesions and Advise parents to Inform GP Chest recessions
Prostaglandin watch for signs of Sweaty during
infusion heart failure feeds
guidelines) Inform GP Colour changes
Echo (performed
locally, if available) Poor weight gain
Liaise with regional
cardiologist
Issue 6
46
CHEST DRAIN INSERTION –
TRADITIONAL • 1/2
INDICATIONS PROCEDURE
Treatment of pneumothorax or pleural Preparation and position
effusion of baby
EQUIPMENT Inform parents and obtain verbal
consent as recommended by BAPM
Sterile dressing pack
(unless emergency procedure)
Cleaning solution as per unit policy
Use 10–12 FG pleural catheter (small
and wash off with sodium chloride
babies may need 8 FG)
0.9% once dried for babies <26 weeks’
gestation Position baby supine and flat with
affected side slightly tilted up (for
Lidocaine 1%, with syringe and needle
example, by using a folded blanket)
for preparation and injection
Prepare skin with full aseptic technique
Chest drains size FG 8,10,12 (use
largest possible depending on size of Infiltrate with lidocaine 1%, even in
baby) babies being given systemic
analgesia
Low pressure suction unit
Scalpel and fine straight blade (size Insertion of tube
11) Make small incision in skin with scalpel
Fine blunt forceps at lower edge of intercostal space to
Underwater seal chest drainage bottle avoid injury to intercostal vessels
and tubing or flutter (Heimlich) valve Dissect bluntly with fine forceps
Steristrips and transparent dressing through intercostal muscle and pleura
(e.g. Opsite/Tegaderm) Use fine forceps to gently advance tip
of catheter
SITES
Push and twist tube gently through
Site of insertion depends on position of incision into pleural space
pneumothorax
Insert chest drain 2–3 cm for small
preferred site is in anterior axillary line, preterm and 3 cm for term babies
between fourth and sixth intercostal
Use of trocar not generally
space, to conceal subsequent scarring
recommended. If used (in bigger
and avoid interference with breast
baby), protect lung by clamping artery
development
forceps onto trocar 1 cm from the tip
alternative site is just lateral to
Connect tube to prepared underwater
midclavicular line, in second or third
seal or flutter (Heimlich) valve
intercostal space
(according to local practice)
if pneumothorax does not drain
Manipulate tube gently so that tip lies
satisfactorily, it may be necessary to
anteriorly in thoracic cavity for
insert more than one drain
pneumothorax, and posteriorly for
for pleural effusion, use midaxillary line effusion
between fourth and fifth intercostal
Secure tube with Steristrips, and cover
spaces, and direct drain posteriorly
with gauze dressing. A suture may be
required; do not use purse-string
suture
Secure tube to chest wall using
suitable tape (Opsite/Tegaderm)
Issue 6
47
TRADITIONAL • 2/2
AFTERCARE REMOVAL OF CHEST DRAIN
Check bubbling or oscillation of water Remove tubing when no bubbling or
column seen with every inspiration oscillation of water column has
Check tube position with chest X-ray occurred for 24 hr
(consider lateral X-ray to confirm Clamp chest drain for 12 hr and repeat
position) chest X-ray before removal. While
removing drain, ask an assistant to
Suction hold wound edges close together
If bubbling poor and X-ray confirms After removing drain, close wound with
drain is in correct position but steristrips, a suture is seldom
pneumothorax not fully draining on X- necessary
ray or cold light, apply continuous
suction of 5–10 cm of water. Thoracic Close clinical observation after
removal of drain is sufficient to
suction is better suited for this purpose
diagnose re-accumulation of the air
than routine wall suction. Occasionally,
leak, routine chest X-ray not generally
a second drain may be necessary
warranted
Flutter valve
As an alternative to underwater chest
drain system, especially during
transport, a flutter valve can be used
Document
Record presence of bubbling
(continuous/intermittent/none) on
nursing care chart
Record with nursing observations,
bubbling and/or oscillation of water
column, or fluttering of valve seen with
every inspiration
Issue 6
48
SELDINGER TECHNIQUE • 1/2
INDICATIONS
Treatment of pneumothorax or pleural effusion
EQUIPMENT
Introducer needle
Chest drain
Guide wire
Dilator
3-way tap, connector
Extension
Flutter valve
PROCEDURE
Step 1: Analgesia Step 3: Insert needle
Ensure baby has adequate analgesia
if ventilated – use morphine bolus
if non-ventilated – use low-dose
fentanyl (watch for chest wall rigidity)
lidocaine locally
Step 2: Aseptic technique
Select location for chest drain –

usually 5th intercostal space, anterior
axillary line
Insert needle whilst aspirating syringe
Stop advancing once air aspirated
(<1 cm)
Use sterile gloves and gown

Identify site
Clean skin according to local policy
Issue 6
49
SELDINGER TECHNIQUE • 2/2
Step 4: Insert wire Step 7: Add the flutter valve or
connect to underwater seal
Assemble drainage equipment
extension
3-way tap
connector and flutter valve or
underwater seal and suction
if connected to underwater seal use
5–8 cm water pressure suction
Pass wire through needle to mark on
wire
Holding wire still, remove needle
Take care to keep equipment sterile

at all times. This may require an
assistant to ‘control’ wire
Attach valve/underwater drain to end
of drain (as above)
Step 5: Dilate the skin Chest X-ray to confirm position and
monitor progress/resolution in
pneumothorax or pleural effusion
Step 8: Secure the drain

Carefully secure the drain
DO NOT use a purse string suture
Pass dilator along wire
suture can be placed through skin and
Push dilator through skin about 1 cm, knotted to drain
angling anteriorly
secure chest drain with steristrips and
Skin may require small incision tegaderm
Following dilation, dilator can be
removed HOW TO REMOVE
At all times wire must be held still, Wear personal protective equipment,
not advanced or withdrawn i.e. gloves, eye protection
Remove sutures and tegaderm
Step 6: Insert the drain Gently pull drain – pigtail will uncurl
Beware of splashing body fluids – as
drain comes out of skin, pigtail
catheter will spring back
Advance drain over wire (this often

needs an assistant)
Advance drain through skin so holes
are inside baby
Wire can now be removed
Issue 6
50
CHEST PHYSIOTHERAPY • 1/2
INTRODUCTION Intraventricular haemorrhage (IVH)
The neonatal toolkit recommends that within 48 hr
all units caring for babies requiring Extreme prematurity (<1500 g/<26
intensive and high dependency care weeks’ gestation) in first week of life
who provide a chest clearance should Platelet count <50 x 109/L and/or
have access to a paediatric/neonatal prolonged clotting and/or active bleeding
specialised respiratory physiotherapist
Precautions
All staff undertaking percussion must
be competent and seek advice where Poor skin integrity
required Platelet count <100 x 109/L
Contact a respiratory physiotherapist Avoid chest drain sites and Broviac
to review babies with difficulties lines/proximity of wounds/stomas
clearing secretions Effectiveness reduced in chest wall
oedema
PERCUSSION
Distended abdomen
Definition
Rhythmic patting over chest wall using PROCEDURE
a palm cup percussor to generate Always assess cardiorespiratory status
pressure changes stimulating mucous before intervention
clearance by ciliary stimulation Ensure nesting and developmental
Indications care support throughout procedure
(see Developmental care guideline
Tenacious secretions not cleared and Positioning guideline)
effectively with suction +/- sodium
chloride 0.9% Plan treatment episodes pre-feed or
more than 30 min post-feed
Signs of respiratory compromise
changes in ventilation suggestive of Positioning
secretion retention (e.g. tidal volumes, See Positioning guideline
peak pressures) Do not disconnect baby from the
decreased SpO2/PaO2 ventilator for a turn
increased PaCO2 Different positions can be used to
target specific areas of collapse and/or
Auscultation findings
consolidation
Chest X-ray changes e.g. focal
collapse/consolidation Ventilation/perfusion mismatch may
necessitate increasing oxygen delivery
Consider neuromuscular pathologies
resulting in poor airway protection, and Variety in positions is important but
very frequent position changes are
respiratory conditions such as cystic
discouraged. Do not leave baby for
fibrosis (CF). These conditions may
prolonged periods – dependant (lower)
require prophylactic physiotherapy and
lung can retain secretions/collapse, as
parental training before discharge –
well as risk of pressure areas
refer to physiotherapist
Never use head-down tilt due to risk of
Contraindications IVH/reflux/respiratory compromise
Cardiovascular instability
Percussion
Undrained pneumothorax/bullae
Stabilise head with one hand at all times
Pulmonary interstitial emphysema (PIE)
Ensure whole circumference of the
Acute pulmonary haemorrhage percussor makes contact with baby’s
Metabolic bone disease/fractured ribs chest, ideally directly on baby’s skin.
Issue 6
51
CHEST PHYSIOTHERAPY • 2/2
If not practical, a layer of vest is should not exceed 100 mmHg/13 kPa
acceptable. The pressure should not apply on withdrawal only
cause any movement of baby/skin Oral suction must follow to clear
reaction secretions from around ETT – use a
Ideal rate approximately 3/sec catheter no larger than 10 FG
Use short percussion episodes When not in use, turn suction off to
according to baby’s reduce noise
stability/tolerance/gestational age
Other considerations
generally maximum of 1–2 min (up to
2–3 min for more robust self- Sodium chloride 0.9% to mobilise
ventilating babies) tenacious secretions/mucus plug(s)
Address signs of stress by pacing do not use routinely
baby or giving time-out/comfort holding instil 0.2–0.3 mL (up to 0.5 mL in term
Treat only when clinically indicated baby) via ETT before suction
and a maximum of 4-hrly, except when warm unopened ampoules in incubator
an acute deterioration necessitates High frequency oscillatory
additional treatments ventilation (HFOV)
Use a maximum of 2 positions after suction, increase mean airway
Suction following percussion pressure by 1 cm H2O to recruit lung
Keep percussor in the incubator. Wash at the discretion of medical staff
with soap and warm water and Alco wipe Mucoactives
Risks of percussion may be helpful for viscous secretions
with persistent collapse/consolidation.
Vigorous percussion in vulnerable Discuss with medical team
extremely preterm babies and poor Non–ventilated babies
use of supportive developmental oral suction with size 8 or 10 catheter.
care techniques have previously Always position in side lying for
been linked with IVH and suction. This reduces risk of
periventricular leucomalacia aspiration if baby vomits
Suction AFTERCARE
Endotracheal tube (ETT) suctioning – Assess and document effectiveness of
see Endotracheal tube suctioning interventions
guideline If baby shows no improvement, or is
Suction only when indicated, not worse, seek advice from MDT and
routinely refer to physiotherapist
Maintain normal saturation range for Assess indication for percussion at
gestational age by titrated pre/post- each episode and discontinue when
oxygenation. Avoid hyperoxia desired outcomes achieved
Catheter for open suction must be Ensure timely and detailed
graduated and have a Mülly tip (larger documentation including time,
end hole and 2 opposite pressure indications, intervention and outcomes
relieving side-eyes) and be no larger Further information
than two-thirds diameter of ETT
For babies with difficulty clearing
Use measured suction to minimise secretions and for individual/group
cardiovascular instability and trauma
training, contact a neonatal respiratory
Suction pressures physiotherapist
Issue 6
52
CHRONIC LUNG DISEASE • 1/2
RECOGNITION AND ASSESSMENT
Definition
Gestational age
<32 weeks ≥32 weeks
36 weeks CGA >28 days, but <56 days
Time of assessment or discharge postnatal age or discharge
Treatment with oxygen ≥28 days ≥28 days
Bronchopulmonary dysplasia
In air at 36 weeks CGA In air by 56 days
Mild or discharge postnatal age or discharge
<30% oxygen at 36 weeks CGA <30% oxygen at 56 days

Moderate or discharge postnatal age or discharge
>30% oxygen +/- CPAP or >30% oxygen +/- CPAP or
Severe ventilation at 36 weeks CGA ventilation at 56 days
or discharge postnatal age or discharge
Target saturations ≥95% at 36 weeks CGA (see Oxygen saturation guideline for details)
Investigations at time of Optimise nutrition

assessment (see above) Ensure adequate calorie intake (at
Blood gas least 120 Kcal/kg/day) because of
increased work of breathing
Chest X-ray: homogenous
opacification of lung fields developing If growth unsatisfactory, involve
after first week of life (Type 1) or dietitian
coarse streaky opacities with cystic Avoid fluid overload
translucencies in lung fields (Type 2)
Echocardiography to rule out Corticosteroids
pulmonary hypertension or structural If ventilator-dependent and requiring
pathology increasing or persistently high oxygen
intake, consider using corticosteroids
Electrocardiography (ECG) to rule out
pulmonary hypertension Treatment with corticosteroids is a
consultant led decision
Overnight oximetry study (see Oxygen
on discharge guideline) Inform parents of potential short-term
and long-term adverse effects
TREATMENT Obtain oral consent and record in
Optimise ventilation notes
strategies Give BLISS information leaflet Going
Use lowest possible ventilator home on oxygen
pressures to deliver appropriate tidal http://www.bliss.org.uk/shop
volumes to minimise barotrauma and
volutrauma. Volume-targeted/volume-
guarantee ventilation may be helpful if
available
Issue 6
53
CHRONIC LUNG DISEASE • 2/2
Short-term side effects of SUBSEQUENT MANAGEMENT
corticosteroids Monitoring treatment
Risk of infection
Continuous
Poor growth
Aim for SpO2 of 91–95% until 36
Reversible ventricular hypertrophy weeks corrected gestational age
Gastrointestinal perforation and After 36 weeks gestational age,
bleeding maintain SpO2 ≥95% to prevent
Adrenal suppression pulmonary hypertension
Glucose intolerance Warm and humidify supplemental
oxygen unless on low-flow oxygen
Long-term side effects of
Monitor weight and head growth
corticosteroids
Assess for gastro-oesophageal reflux
Increased risk of neurodisability
(see Gastro-oesophageal reflux
Doses guideline)
Use Neonatal Formulary for Aim to stop diuretic therapy before
dexamethasone dosage regimen discharge (consultant decision)
(consultant decision on DART versus
minidex regimen) DISCHARGE AND FOLLOW-UP
If still oxygen-dependent at time of
If respiratory status worsens after
discharge (see Oxygen at discharge
initial improvement consider repeating
guideline)
course of corticosteroids (consultant
led decision) Long-term neuro-developmental and
respiratory follow-up
Monitoring while on
corticosteroids
Daily BP and urinary glucose
Diuretics
Use of diuretics to improve lung
function (consultant decision).
Diuretics of choice are chlorothiazide
and spironolactone (use of
spironolactone can be guided by
serum potassium). Avoid amiloride
due to its lung fluid retaining properties
Side-effects include hyponatraemia,
hypo/hyperkalaemia, hypercalciuria
(leading to nephrocalcinosis) and
metabolic alkalosis
If no improvement on diuretics stop
after 1 week
Issue 6
54
CMV • 1/2
In utero transmission of CMV can occur Investigation results
during primary maternal infection,
CMV IgM positive
reactivation, or reinfection of seropositive
mothers CMV PCR urine positive
Haemolytic anaemia
MATERNAL TESTS
Thrombocytopenia
CMV serology (IgG and IgM)
Conjugated hyperbilirubinaemia
and viral loads
Raised liver enzymes
Both IgG and IgM negative: unlikely to
be CMV infection HIV antibody test
IgG positive, IgM negative: past If CMV positive, continue with
maternal infection further investigations
IgG positive, IgM positive: check CMV FURTHER INVESTIGATIONS
IgG avidity – if low likely to be acute
maternal CMV infection. High CMV Blood and urine CMV viral load
viral load in maternal blood indicative Ophthalmology: chorioretinitis
of acute maternal CMV infection
Audiology: formal hearing test (not just
Antenatal ultrasound screening ABR) sensorineural hearing
loss
Features include:
Head ultrasound: hydrocephalus, cysts
IUGR
Hydrocephalus (ventricular dilatation), CT scan of brain
intracranial calcification, microcephaly Intracranial calcification
Ascites, hydrops fetalis Ventriculomegaly
Pleural or pericardial effusions Cerebral atrophy
Oligo- or polyhydramnios
TREATMENT
Hepatomegaly
Asymptomatic
Abdominal calcification
(CMV IgM or PCR positive +/-
Pseudomeconium ileus
thrombocytopenia)
Thickened placenta
Treatment not indicated
NEONATAL FEATURES Symptoms other than
Main clinical signs neurological
Small for gestational age Seek expert advice from paediatric
infectious disease specialist regarding
Petechiae/purpura
offering valganciclovir
Hepatosplenomegaly
Jaundice
Pneumonia
Issue 6
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CMV • 2/2
Neurologically symptomatic FEEDING
Ganciclovir [prepared by pharmacy Do not discourage infected women
(cytotoxic)] 6 mg/kg IV over 1 hr from breastfeeding their own
12-hrly for 6 weeks or valganciclovir uninfected, term babies (CMV can be
16 mg/kg oral 12-hrly for 6 months transmitted via breastfeeding, but
Discuss side effects vs benefits with benefits of feeding outweigh risks
parents: posed by breastfeeding as a source of
transmission)
advantages: potential reduced risk of
deafness and developmental delay Avoid breastfeeding of premature
neonates if mother is positive and
disadvantages: during treatment baby asymptomatic
reversible blood dyscrasia; long-term
unknown risk to fertility and FOLLOW-UP
malignancy
Enter on European Congenital CMV
Monitor for neutropenia, Initiative register www.ecci.ac.uk if
thrombocytopenia, hepatic and renal treated
function throughout: may need dose
Annual hearing and ophthalmology
reduction
assessment for both asymptomatic
discuss with specialist in paediatric and symptomatic congenitally infected
infectious diseases babies
Start treatment as soon as possible; if MRI brain discuss with radiology
diagnosis delayed, treatment can be
started up to 1 month of age
Issue 6
56
COAGULOPATHY • 1/3
Haemostasis is immature during the Liver dysfunction or conjugated jaundice
neonatal period and does not attain full Babies undergoing surgery or tissue
function until 6 months of age biopsy who have had previous
prolonged prothrombin time (PT) and bleeding problems
activated partial thromboplastin time Family history of inherited bleeding
(APTT) are associated with disorder (after discussion with
intraventricular haemorrhage (IVH) in consultant haematologist)
unstable (e.g. hypotensive or hypoxic)
Thrombocytopenia – see
or bruised extremely preterm babies
Thrombocytopenia guideline
75% of cases of IVH occur within first
24 hr of life and 90% within first 7 days Sampling
prophylactic fresh frozen plasma (FFP) Ensure sample from a free-flowing
does not prevent IVH in preterm baby vein (peripheral or umbilical) or from
without evidence of coagulopathy an arterial line before heparinising
Use appropriate coagulation tubes as
INVESTIGATIONS per local policy
Check clotting in: Fill exactly to black mark on tube
Any bruised or bleeding baby (e.g. (usually 1.3 mL)
IVH, pulmonary haemorrhage, If sample clots (this does not confirm
gastrointestinal bleeding, suspected normal coagulation), take another
haemorrhagic disease of newborn etc.)
If sampling from arterial line with
Preterm <30 weeks’ gestation (due to heparin infusion, take larger volume
IVH risk) if clinical concerns about from dead-space (e.g. 2.5 mL), see
bleeding Arterial line sampling guideline
Moderate-to-severe encephalopathy
(e.g. babies who are being cooled) Request
Septicaemia PT
Necrotising enterocolitis (NEC) APTT
Sick or unstable baby (e.g. ventilated, Fibrinogen
inotropic support etc.) If features of DIC (e.g. bruising,
Metabolic disease: urea cycle disorder, bleeding, sepsis), request:
galactosaemia, tyrosinaemia, organic fibrin degradation products and
acidaemia D-dimer (if available)
Acceptable reference values

Value
Clotting Ratio
Gestation (laboratory control PT 11–14 sec
parameter INR
and APTT 30–33 sec)
Term 1–1.6 10–16 sec
PT
Preterm (<37 weeks) 1–2 11–22 sec
Term 1–1.6 31–55 sec

APTT
Preterm (<37 weeks) 1–2 28–70 sec
Term 1.7–4.0
Fibrinogen
Preterm (<37 weeks) 1.5–3.7
Issue 6
57
IMMEDIATE TREATMENT In case of persistently prolonged INR
or liver disorder/conjugated jaundice,
If INR alone is prolonged, check
give regular doses of vitamin K
whether clotting samples were
performed before first dose of vitamin In persistently prolonged APTT, give
K. If so, repeat clotting screen further doses of FFP (or
cryoprecipitate – see below)
If prolonged INR (see thresholds
below) and normal APTT in stable Use of FFP and
term baby (e.g. clotting screen
cryoprecipitate
performed as part of conjugated
jaundice screen), give repeat dose of Do not use FFP or cryoprecipitate
vitamin K 100 micrograms/kg (up to 1 purely for volume replacement or
mg) IV. If repeat INR not improving polycythaemia without coagulopathy
after 6 hr, discuss with
senior/haematologist to explore other
Treatment thresholds for
causes and the need for FFP or
regular vitamin K use of FFP
In preterm baby <30 weeks (with risk If PT or APTT below treatment
of IVH) or unwell with prolonged INR, thresholds:
repeat vitamin K 1 mg IV with FFP FFP 10–20 mL/kg over 30–60 min
If APTT beyond upper limit of
reference range, give FFP (see below)
Unstable*,
significant**,
Clotting
Gestation Stable baby bleeding or
parameter
invasive
procedure***
Ratio (INR) ≥1.6 or Ratio (INR) ≥1.5 or

Term
Value ≥16 sec Value ≥15 sec
PT
Ratio (INR) ≥2 or Ratio (INR) ≥1.8 or
Preterm (<37 weeks)
Ratio (INR) ≥1.6 or Ratio (INR) ≥1.5 or

Term
APTT
Ratio (INR) ≥2 or Ratio (INR) ≥1.8 or
Preterm (<37 weeks)
* Unstable (e.g. DIC, significant sepsis, In inherited clotting factor deficiencies,

NEC, ventilated, hypotensive etc.) use FFP only when pathogen
** Significant bleeding (e.g. significant inactivated factor unavailable. Discuss
bruising, IVH, gastrointestinaI with consultant haematologist before
bleeding, pulmonary haemorrhage giving FFP
etc.) If APTT ratio still ≥1.8 after giving FFP
*** Invasive procedures (e.g. lumbar (especially if fibrinogen <1.2), consider
puncture, umbilical lines, long lines, cryoprecipitate (5–10 mL/kg over
chest drain, exchange transfusion 30–60 min) after discussion with on-call
etc.) consultant and haematologist
Issue 6
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MONITORING
Repeat coagulation profile 2–4 hr after
FFP/cryoprecipitate or every 12–24 hr
Look for and treat causes of abnormal
coagulation:
sepsis
shock
haemorrhage
severe hypothermia
hypoxia
If abnormal coagulation persists for
>24 hr in the absence of any
precipitating factors, seek advice from
paediatric haematologist about factor
assays and 50:50 mixture correction
test
Issue 6
59
CONGENITAL HEART DISEASE:
DUCT-DEPENDENT LESIONS
[Including hypoplastic left heart syndrome (HLHS)
and left-sided outflow tract obstructions] • 1/4
INTRODUCTION
Duct-dependent congenital heart disease can be broadly divided into 3 categories
1 Mixing lesions e.g. transposition of great arteries Usually presents as cyanosis (‘blue baby’)
2 Obstruction to pulmonary circulation e.g.
pulmonary or tricuspid atresia, Fallot’s Usually presents as cyanosis (‘blue baby’)
tetralogy, critical pulmonary stenosis
3 Obstruction to systemic circulation e.g.
hypoplastic left heart syndrome (HLHS), critical
Usually presents as poor perfusion (shock)
aortic stenosis, coarctation of aorta, interrupted
aortic arch
Differential diagnosis of Other rare causes of central

central cyanosis ('blue baby') cyanosis
or persistently low SpO2 Methaemoglobinemia
(<95%)
Differential diagnosis of
Cyanosis is the abnormal blue babies presenting with poor
discoloration of skin and mucous
perfusion (shock)
membranes
Cardiac causes of shock
Without echocardiography, clinical
Duct-dependent lesion (see above)
distinction between significant
persistent pulmonary hypertension Other cardiac causes e.g. arrhythmias
(PPHN) and a duct-dependent (supraventricular/ventricular
pulmonary circulation can be tachycardia) cardiomyopathy etc.
extremely challenging Other causes of shock
If duct-dependent lesion, discuss
commencing prostaglandin with a Sepsis, bleeding, dehydration,
senior even if in doubt about cause metabolic
RECOGNITION AND
Cardiac causes of central ASSESSMENT OF DUCT-
cyanosis DEPENDENT LESIONS
Duct-dependent lesions (see above) In-utero (antenatal) diagnosis
Other cardiac conditions e.g. anomalous If diagnosed in-utero, see
pulmonary venous drainage, Fallot’s management plan in mother’s
tetralogy, truncus arteriosus etc. healthcare record
Respiratory causes of central Deliver at local neonatal unit (NNU) or
cyanosis neonatal intensive care unit (NICU)
equipped for serious congenital heart
Persistent pulmonary hypertension disease. Stabilise before non-urgent
Other respiratory conditions, e.g. transfer to regional paediatric cardiac
congenital pneumonia, pneumothorax, centre for full cardiology assessment
meconium aspiration, congenital
diaphragmatic hernia, respiratory tract
obstruction
Issue 6
60
If urgent septostomy anticipated for Investigations
closed or small (restrictive) atrial
Chest X-ray
septum, cardiologists may recommend
delivery at regional NICU – liaise with oligaemia/plethora/congenital anomaly
cardiologist at tertiary centre prior to ‘classic’ appearance (e.g. ‘boot
delivery shaped’ heart) is unusual
Neonatal team meet parent(s) pre- Blood gas including lactate
delivery Echocardiogram if available
In some cases of HLHS or complex Blood pressure in right upper limb and
congenital heart disease, comfort care a lower limb (>20 mmHg difference
plan may be in place antenatally – between upper and lower limb is
clarify with cardiac team and parents abnormal)
before delivery
Pre-ductal (right upper limb) and post-
When delivery expected, notify on-call ductal (lower limb) saturations (SpO2
neonatal consultant, NNU and
of <95% in both limbs or >3%
paediatric cardiology team at local
difference is significant) – see Pulse-
referral centre
oximetry screening guideline
Postnatal Modified hyperoxia test (carries risk of
Some babies, particularly if left heart duct closure: discuss with consultant
lesion developed later in gestation, will first) to differentiate between
present when duct closes respiratory (parenchymal) and cardiac
cause of cyanosis including baseline
can happen any time during neonatal
saturation (and blood gas if arterial line
period and early infancy
in situ)
baby is often asymptomatic before
place baby in 100% ambient oxygen
duct closes
for 10 min
A baby presenting with cyanosis or if there is respiratory pathology, SpO2
shock is a neonatal emergency usually rise to ≥95%
requiring senior input. These babies
can deteriorate very quickly IMMEDIATE MANAGEMENT
A suspected cardiac baby presenting
Symptoms and signs of duct- collapsed, shocked and/or cyanosed is
dependent cardiac disease a challenging neonatal emergency,
Central cyanosis and/or SpO2 <95% discuss commencement of
prostaglandin infusion urgently with a
Poor perfusion and shock senior.
Weak or absent femoral pulses Discuss urgently with cardiac centre
Usually limited signs of respiratory
distress Immediate post-delivery and
Murmur (in some) – see Cardiac resuscitation
murmurs guideline If antenatally diagnosed duct-dependent
Hepatomegaly or other signs of lesion, neonatal team (junior and middle
cardiac failure grade) should be present at delivery
Issue 6
61
If baby requires resuscitation do not Discuss management with cardiac team
delay – see Resuscitation guideline at regional paediatric cardiac centre
Check SpO2 using pulse oximetry Echocardiogram if available
Once stable, transfer baby to NNU Monitor
immediately in transport incubator (if
SpO2
on saturation monitor, SpO2 75–85%
should be acceptable) Heart rate and ECG
Blood gases (including lactate) and
Stable babies with normal breathing avoid acidosis
and SpO2 ≥75% may not require Blood pressure (preferably using a
intubation peripheral arterial cannula – avoid
umbilical lines)
Management in NNU
Avoid hypothermia
Aim to maintain patency of (or open a
closed) ductus arteriosus, and Ventilation (see also
optimise systemic perfusion Ventilation guideline)
Commence prostaglandin infusion (as Indications
per antenatal plan if known) through If intubation not needed as emergency,
peripheral IV line, or long line (see discuss with paediatric intensive care
Prostaglandin infusion guideline) unit (PICU)/cardiac team
Unless access extremely difficult, Severe hypoxaemia, acidosis and
avoid umbilical venous line (cardiac cardiorespiratory failure
unit may need UVC for septostomy)
Apnoea after starting prostaglandin
Use dinoprostone (prostaglandin E2, infusion
prostin E2) – see Prostaglandin dose >20 nanogram/kg/min (review
infusion guideline need for such a high dosage in stable
start IV infusion at baby)
5–15 nanogram/kg/min as indicated Features of high pulmonary flow in
dose may be increased up to case of HLHS
50 nanogram/kg/min if no response
Elective ventilation, if preferred by
within 1 hr paediatric cardiologist or retrieval team
oral Dinoprostin used temporarily on lead
very rare occasions when IV access is
Technique
extremely difficult – see Neonatal
Formulary Use sedation/muscle relaxants as
needed
if dinoprostone not available, use
prostaglandin E1 (Alprostadil); see Avoid hyperventilation, which can
Neonatal Formulary increase pulmonary blood flow
Make fresh solution every 24 hr Use supplemental oxygen judiciously if
SpO2 <75%
Be vigilant: if apnoea occurs
secondary to a prostaglandin infusion, Initial settings: PEEP 4–5 cm H2O, low
intubate baby but do not reduce mean airway pressure, tidal volume
infusion dose (see Intubation 4–6 mL/kg and FiO2 0.21, adjusted
guideline) accordingly
Issue 6
62
Aim for: High pulmonary blood flow
PaCO2 5–7 kPa (especially in left-sided lesions
PaO2 4–6 kPa
such as HLHS)
pH 7.35–7.40 Presentation
SpO2 75–85% (although many will run If there is too much pulmonary blood
higher in room air) flow due to pulmonary ‘steal’
phenomenon, baby may have:
Inotropes high or near normal saturations
If signs of peripheral under-perfusion, metabolic acidosis with a rising lactate
discuss using fluid boluses and
inotropes (e.g. dobutamine, milrinone low blood pressure (especially low
etc.) with cardiac centre diastolic)
Arrange local echocardiography (if cool peripheries
available) to assess contractility tachycardia
Restrictive atrial septum Management

Signs: Aim is to improve perfusion and
severe cyanosis acidosis by balancing systemic versus
pulmonary circulation
cool peripheries
Discuss urgently with cardiac centre
pallor
Intubate and ventilate (technique as
respiratory distress above)
X-ray signs of pulmonary oedema with Fluid boluses and inotropes as needed
relatively normal heart size. In
contrast, if atrial septum is non-
restrictive, pulmonary congestion with
cardiomegaly and prominent right
heart border is likely
May require balloon atrial septostomy
as an urgent procedure. If too unstable
for transfer or no beds at cardiac
centre, cardiac team may perform as
emergency outreach procedure in
NNU
Issue 6
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CONJUNCTIVITIS • 1/1
Chlamydia swab (specific for
Conjunctivitis is a potentially blinding
chlamydia PCR)
condition with associated systemic
manifestations Treat both eyes with:
frequent eye toilet as necessary
RECOGNITION AND chloramphenicol 0.5% eye drops
ASSESSMENT
fusidic acid 1% eye drops for
Conjunctival redness staphylococcus
Swelling of conjunctiva and eyelids Presentation within first 24 hr suggests
Purulent discharge gonococcal infection – inform senior
paediatrician
Differential diagnosis
Sticky eye with blocked tear duct in SUBSEQUENT MANAGEMENT
which there is no inflammation of
In severe non-resolving cases
conjunctiva
Take throat and eye swabs for viral PCR
Congenital glaucoma in which there is
corneal opacity If herpes suspected, look for other
signs of herpetic infection
AETIOLOGY Treat suspected herpes with IV and
Bacterial topical aciclovir for 14 days
Staphylococcus aureus and epidemidis Refer to ophthalmology
Haemophilus influenzae
Streptococcus pneumoniae
Neisseria gonorrhoeae
suspected
Serratia spp, E Coli, Pseudomonas spp
Request urgent Gram stain and culture
Neisseria gonorrhoeae – typical onset
0–5 days of age – mild inflammation Assess baby for septicaemia
with sero-sanguineous discharge to
Neisseria gonorrhoeae
thick, purulent discharge with tense
oedema of eyelids confirmed
Chlamydia trachomatis – typical onset Give single dose cefotaxime
5–14 days of age: mild-to-severe 100 mg/kg IV stat
swelling with purulent discharge (may For severe cases, frequent sodium
be blood-stained) chloride 0.9% irrigation of the eyes and
continue treatment with IV cefotaxime
Viral for up to 5 days (consultant decision)
Herpes simplex virus (HSV) Refer to ophthalmology
MANAGEMENT If due to N gonorrhoea or chlamydia
Sticky eye/blocked tear duct discuss referral to the genitourinary
medicine services
4–6 hrly eye toilet using sodium
chloride 0.9% Chlamydia result positive
Conjunctivitis Treat with erythromycin 12.5 mg/kg
(see signs above) 6-hrly for 14 days
Swab all for: Gonococcal or chlamydia
Gram stain and bacterial culture and infection detected
sensitivities Refer mother and partner to genito-
if other suspicions of HSV (e.g. urinary medicine for immediate
vesicles etc.), viral swab for HSV PCR treatment
Issue 6
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CONSENT • 1/4
FOR COMMON NEONATAL Witness consent wherever possible,
INVESTIGATIONS, and record name of witness
INTERVENTIONS AND In neonatal practice, there are frequent
TREATMENTS occasions when no one is available to
provide valid consent and treatment is
The following guidance is taken from
initiated in its absence (e.g.
'Good practice framework for consent in
emergency ABC resuscitation,
neonatal clinical care' produced by the
stabilisation, chest drainage or
British Association of Perinatal Medicine
exchange transfusion when delayed
(BAPM)
treatment would not be in the baby’s
It is a legal and ethical requirement to best interests, or following maternal
gain valid consent before examining general anaesthetic when mother is
and initiating any investigation or unmarried to baby’s father). It should
treatment for any patient always be possible later to justify the
Consent is obtained from someone action to the parents and to reassure
with parental responsibilities: them that it was in the baby’s best
if married, parents interests
if not married, mother but not father, GOOD PRACTICE

unless father has acquired parental Give parents of babies admitted to
responsibility via a court order, being neonatal unit written information
registered on birth certificate or (BLISS booklet
parental responsibility agreement http://www.bliss.org.uk/information-for-
a legally appointed guardian parents/) describing low-risk
a local authority designated in a care procedures such as venesection, for
order or holding an emergency which explicit consent is not normally
protection order sought
Consent is valid only when information Give parents information leaflet for
has been understood by the parent(s) data collection, allowing them to opt
and explains why the intervention is out
recommended, its risks and Written explicit consent
implications, and other options should
consent be withheld Purpose and risks of an intervention are
formally explained and consent obtained
Documentation of information and recorded before the intervention
given and parent(s) understanding
and agreement to proceed is the
most important validation of consent.
A signature does not in itself confirm
informed consent
Issue 6
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CONSENT • 2/4
Table 1: Explicit consent (recorded in patient notes, and supported by a

signature) is required for:
Investigation/intervention
Clinical photographs and video-recordings Use consent form specific for this purpose
Any biopsy or aspiration For example: skin, liver, bone marrow
Exchange transfusion
Treatment for retinopathy Obtained by ophthalmologist
Consent taken by surgical team. If

telephone consent required and mother
Surgical procedures
still an in-patient, midwife on postnatal
ward or neonatal team to act as witness
See Death guideline and use specific form.

Post-mortem Usually obtained through consultant or
senior middle grade staff
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CONSENT • 3/4
Table 2: Explicit oral consent
Explicit consent as defined above, documented, but not supported by a signature,
required for the following:
Explicit oral consent

Investigations Screening baby and/or mother in high-risk situations
with no knowledge of maternal status (e.g. HIV,
substance misuse)
Genetic testing
Gut imaging involving contrast
MR/CT imaging
Practical procedures Therapeutic lumbar puncture (LP) or ventricular tap in
absence of reservoir*
Peripherally-placed long lines*
Brachial or femoral arterial line
Chest drain insertion/replacement*
Abdominal drainage for perforation or ascites*
Irrigation following extravasation*
Hearing screening
Immunisations See Immunisations guideline
Treatments Vitamin K for normal term babies

Nitric oxide
Postnatal steroids for chronic lung disease
Use of donor breast milk
Transport Emergency transfers
Routine transfers for out-patients or back-transfers
NB: Initiation of cooling for neuroprotection does not
require explicit consent, but transfer to another unit for
formal cooling does
* It is accepted that, in some circumstances, these procedures are performed in an

emergency in baby’s best interests and may be performed without oral consent;
owing to risks associated with procedures or conditions in which they are necessary,
it is considered best practice to inform parents as soon as possible and to document
this in baby’s notes
Others: Implicit consent
Where the nature and risk of the procedure is such that a less formal transfer of
information is considered sufficient, and is often retrospective
List of investigations, procedures and treatments is long, see Table 3
If unsure, seek senior advice
Explain all investigations, procedures and treatments

to parents at earliest opportunity
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CONSENT • 4/4
Table 3: Implicit consent
Implicit consent
Examination and Examining and assessing baby
investigations Routine blood sampling
Septic screen
Diagnostic LP (possible infectious or metabolic illness)
Suprapubic aspiration of urine
Screening for infection in response to positive results of
maternal screening (e.g. known maternal HIV or substance
abuse)
CMV, toxoplasmosis, rubella and herpes screening
X-ray and ultrasound
ECG
Retinopathy of prematurity (ROP) screening
Practical procedures Umbilical line insertion
Percutaneous arterial lines (radial, posterior tibial only)
Peripheral venous lines
Nasogastric tube insertion
Tracheal intubation
Ventilation/CPAP
Urethral catheterisation
Treatments: Blood transfusion
blood products Use of pooled blood products e.g. FFP
Partial exchange transfusion
Treatments: drugs Antibiotics
Vitamins/minerals
Surfactant
Anticonvulsants
Sedation for intubation and ventilation
Inotropes
Indometacin or ibuprofen for patent ductus arteriosus (PDA)
Prophylactic indometacin
Postnatal dexamethasone for laryngeal oedema
Nutrition/fluids Breast milk fortification
Intravenous fluids
Parenteral nutrition
DOCUMENTATION
Documentation, supported by a signature for written explicit consent
Documentation of oral explicit consent
Provide parents with information sheets
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CONTINUOUS POSITIVE AIRWAY PRESSURE
(CPAP) • 1/4
DEFINITION When in doubt about CPAP indications
Non-invasive respiratory support or contraindications, discuss with
utilising continuous distending pressure consultant
during inspiration and expiration in
spontaneously breathing babies TYPES OF CPAP
Benefits (exact CPAP device will vary
from unit to unit)
Improves oxygenation
1. Standard CPAP
Reduces work of breathing
2. Two-level CPAP
Maintains lung volume
3. Bubble CPAP
Lowers upper airway resistance
Conserves surfactant 1. STANDARD CPAP
INDICATIONS Equipment
Early onset respiratory distress in Short binasal prongs and/or nasal
preterm babies mask
Respiratory support following extubation Circuit
Respiratory support in preterm babies Humidification
with evolving chronic lung disease CPAP generating device with gas
Recurrent apnoea (in preterm babies) mixing and pressure monitoring
Atelectasis All require high gas flow (usual starting
rate 8 L/min)
Tracheomalacia
Fixing nasal CPAP device:
CPAP following extubation
short binasal prongs
Consider in babies of <32 weeks’ (preferred)
gestation
To avoid loss of pressure, use largest
CONTRAINDICATIONS prongs that fit nostrils comfortably
Any baby fulfilling the criteria for Ensure device is straight and not
ventilation pressed hard against nasal septum or
Irregular respirations lateral walls of nostrils. Excessive
pressure can cause tissue damage
Pneumothorax without chest drain
Nasal trauma/deformity that might be Nasal mask
exacerbated by use of nasal prongs Fit securely over nose
Larger, more mature babies often do consider alternating mask with prongs,
not tolerate the application of CPAP particularly if baby developing
devices well excoriation or erosion of nasal septum.
Congenital anomalies: Masks can also result in trauma,
usually at the junction between the
diaphragmatic hernia
nasal septum and philtrum
choanal atresia
Masks can give a poor seal and can
tracheo-oesophageal fistula obstruct
gastroschisis
Issue 6
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(CPAP) • 2/4
Procedure Checks
Position baby Before accepting apparent CPAP
'failure' exclude:
Prone position is preferable
pneumothorax
Avoid excessive flexion, extension or
rotation of the head insufficient pressure
insufficient circuit flow
Set up equipment
(see specific manufacturer inappropriate prong size or placement
instructions) airway obstruction from secretions
Connect humidification to CPAP open mouth
Connect CPAP circuit with prongs to Complications
CPAP device
Erosion of nasal septum: reduce risk
Place CPAP hat on baby by careful prong placement and
Turn on CPAP flow and set pressure regular reassessment
Attach CPAP circuit to CPAP hat and Gastric distension: benign, reduce by
apply prongs/mask maintaining open nasogastric tube
Pressure range Weaning CPAP

Start at 5–6 cm H2O initially and When
increase by 1 cm H2O increments Start when baby consistently requiring
Optimum pressure depends on illness FiO2 <0.30, pressure 5 cmH2O and
type and severity – watch baby and stable clinical condition
use lowest pressure required to If nasal tissue damage significant,
improve work of breathing consider earlier weaning
High pressures (≥10 cm H2O) may How: 'Pressure reduction' or
restrict pulmonary blood flow, 'Time off'
increase air leak risk and cause over- Pressure reduction
distension
more physiological approach although
CPAP ‘failure’ can increase the work of breathing if
pressure is too low. Has been shown
'Failure of CPAP' implies a need for to be quicker than ‘time off’ mode
ventilation. Consider intubation and
surfactant for preterm babies on CPAP wean pressures in steps of 1 cm H2O
as initial therapy if: every 12–24 hr. If no deterioration
discontinue CPAP after 24 hr of
early chest X-ray demonstrates RDS
4–5 cm H2O and minimal oxygen
and if any of the following apply:
requirement
- FiO2 consistently >0.5
Time off CPAP
- marked respiratory distress
plan using 2 x 12 or 3 x 8 hr time
- persistent respiratory acidosis periods
- recurrent significant apnoea The following regimen of cycling CPAP
- irregular breathing can be adapted to individual situations
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(CPAP) • 3/4
Day 1 1 hr off twice a day (1 off, 11 on) Specific modes of two-level
Day 2 2 hr off twice a day (2 off, 10 on) CPAP (specific names vary
Day 3 3 hr off twice a day (3 off, 9 on) with manufacturer)
Day 4 4 hr off twice a day (4 off, 8 on)
Day 5 6 hr off twice a day (6 off, 6 on)
CPAP and apnoea
Day 6 Off CPAP CPAP with added advantage of
apnoea monitoring via a sensor
Note: High-flow humidified attached to abdomen
oxygen therapy Apnoea alarm is triggered when no
Increasingly used as non-invasive breaths are detected within set time-
respiratory support out period
Offers theoretical advantages over
Biphasic
CPAP in ventilating upper airway
spaces and producing less nasal Bi-level pressure respiratory support
tissue damage with or without apnoea monitoring
When weaning CPAP, consider using Higher level pressure rise above
5–6 L/min of high-flow humidified baseline CPAP that is delivered
oxygen (e.g. Vapotherm or Optiflow) intermittently at pressure, rate and
rather than low-flow nasal cannulae inspiratory time set by clinician
oxygen or lower pressure CPAP Not synchronised with respiratory effort
Failure of weaning Biphasic trigger (tr)
Increased oxygen requirement, Bi-level pressure respiratory support
increasing respiratory distress and/or with inbuilt apnoea monitoring
worsening respiratory acidosis during
Higher level pressure rise above
weaning should necessitate a review
baseline CPAP at rate determined by,
and consider escalation of support
and in synchrony with, baby’s
2. TWO-LEVEL CPAP respiratory effort sensed through an
abdominal sensor
Two-level CPAP at a rate set by
clinician (biphasic) or triggered by baby Pressure, inspiratory time and back-up
using an abdominal sensor (biphasic rate set by clinician
trigger or Infant Flow® SiPAP)
Clinical use
Inspiratory time, pressures and
apnoea alarm limit set by clinician
Biphasic
Begin with CPAP pressure of 5–6 cm
Indications/contraindications as CPAP
H 2O
and can be used when baby’s clinical
condition is not improving despite CPAP Set peak inspiratory pressure (PIP)
at 3–4 cm H2O above CPAP and rate
Theoretical advantages over 30 breaths/min
CPAP
Keep Ti and apnoea alarm delay at
Improved thoraco-abdominal default setting
synchrony
If CO2 retention occurs, review baby
Better chest wall stabilisation
and consider increase in rate and/or PIP
Reduced upper airway resistance
Avoid over-distension and keep PIP to a
Reduced work of breathing minimum for optimum chest expansion
Issue 6
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(CPAP) • 4/4
Weaning Procedure
By rate and pressure Connect bubble CPAP system to baby
If rate >30 bpm, wean to 30 bpm as per manufacturer’s instructions
Reduce MAP, by reducing PIP by 1 cm Ensure appropriate size nasal prongs
H2O every 12–24 hr used
Bubble CPAP nasal prongs are
When baby breathing above 30 bpm
designed not to rest on nasal
change to biphasic tr mode
septum. Ensure prongs are not resting
When MAP 5–6 cm H2O, change to on the philtrum nor twisted to cause
CPAP lateral pressure on septum, and allow a
small gap between septum and prongs
Biphasic trigger
Commence at pressures of 5 cm H2O
Begin with CPAP pressure of 5–6 cm
H2O with PIP at 3–4 cm H2O Bubble CPAP failure
Keep Ti and apnoea alarm delay at See CPAP failure in 1. STANDARD
default setting CPAP
Set back-up rate at 30 bpm
Before inferring bubble
Weaning CPAP failure
Reduce MAP by reducing PIP by 1 cm Ensure baby has been receiving bubble
H2O every 12–24 hr CPAP appropriately by checking for
continuous bubbling in CPAP generator,
Once MAP 5–6 cm H2O, change to
lack of bubbling can result from
standard CPAP pressure leaks in the circuit or baby
If deterioration occurs during weaning
process, assess baby and consider
returning to biphasic mode
3. BUBBLE CPAP
This is an alternative method of CPAP
that may reduce work of breathing
through facilitated diffusion
Equipment
Fisher & Paykel bubble CPAP system:
delivery system: humidifier chamber,
pressure manifold, heated circuit,
CPAP generator
patient interface: nasal tubing, nasal
prongs, baby bonnet, chin strap
Issue 6
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COOLING IN NON-COOLING CENTRES
REFERRAL AND PREPARATION OF ELIGIBLE
INFANTS FOR ACTIVE COOLING • 1/3
ASSESSMENT Request midwives save placenta for
Babies ≥36 weeks gestation, meeting histological examination
criteria A and B and aged ≤6 hr are Passive cooling
eligible for treatment with cooling
As soon as decision made to refer for
Infants 35+0–35+6 weeks’ gestation but cooling, referring unit telephones cooling
meeting criteria A and B and are aged centre and begins passive cooling
≤6 hr, discuss with a cooling centre as
document this time as ‘age when
they may be suitable for treatment passive cooling commenced’ on TOBY
If in doubt about the suitability of any cooling form (see Stabilisation phase
baby for cooling, discuss with a below)
cooling centre
document baby’s temperature at this
Criterion A one or more of time
Apgar score ≤5 at 10 min after birth begin passive cooling by switching off
Continued need for resuscitation, any overhead heater and active
including endotracheal or mask heating in a transport incubator
ventilation at 10 min after birth Nurse baby in an open Babytherm cot
Acidosis within 60 min of birth (defined with heater switched off
as umbilical cord, arterial or capillary If baby nursed in an incubator, open
pH <7.00) portholes
Base deficit ≥16 mmol/L in umbilical Nurse baby naked apart from a nappy
cord or any blood sample (arterial,
Continuous rectal
venous or capillary) within 60 min of
birth
temperature monitoring
Insert a rectal thermometer to 6 cm
Criterion B and commence continuous rectal
Seizures OR moderate-to-severe temperature monitoring. If rectal
encephalopathy, consisting of: temperature monitoring unavailable,
altered state of consciousness perform axillary temperature
(reduced or absent response to monitoring every 15 min
stimulation) and Target rectal temperature 33–34ºC
abnormal tone (focal or general Regular communication between
hypotonia, or flaccid) and referring unit and cooling centre is vital
abnormal primitive reflexes (weak or
absent suck or Moro response) Once baby accepted by a cooling
centre, contact neonatal transport
REFERRAL team to arrange transport of baby
Consent Discuss methods of cooling with cooling
Discuss option of cooling treatment centre, before arrival of neonatal
with parents as soon as practically transport team. Use fans or gloves filled
possible. It is not necessary to wait for with cold water only if continuous rectal
formal consent before starting passive temperature monitoring is in place
cooling
Never use ice filled gloves to cool a
Document discussions in baby’s notes
baby as this can bring the temperature
In addition down to dangerously low and
Request cord gases (if not already uncontrolled levels
obtained)
Issue 6
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STABILISATION PHASE Take blood for blood culture, FBC,
arterial blood gas, lactate, electrolytes,
Passive cooling urea and creatinine, calcium,
Use the referral form from the website: magnesium, prothrombin time, APTT,
glucose and LFT
http://www.networks.nhs.uk/nhs-
black-country-newborn/care-pathways
Ensure baby’s temperature does

not fall below 33ºC. Document every
15 min
Follow Passive cooling protocol
flowchart
Care continues in referring unit with
advice from cooling centre
If not already intubated at delivery,
electively intubate and ventilate baby
for transfer (see Intubation guideline)
If possible, insert umbilical arterial and
venous catheters and monitor arterial
blood pressure – see Umbilical artery
catheterisation and Umbilical
venous catheterisation guidelines.
Check position of lines on X-ray
Aim to maintain arterial PaCO2 of
6–8 kPa
Sedate baby using either morphine at
an infusion rate of 20 microgram/kg/hr
or alternative sedation as per local
guidelines. Aim for heart rate of 100
bpm. Faster rates may be a sign of
distress, in which case increase
sedation
Maintain mean arterial blood pressure
at >45 mmHg. See Hypotension
guideline
Restrict total fluids to 40 mL/kg/day
initially
Keep glucose within normal range –
use higher glucose concentration
infusion if necessary. See
Hypoglycaemia guideline
Issue 6
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Passive cooling protocol
Commence continuous rectal temperature

monitoring
Document initial temperature
(axilla if rectal thermometer not available)
Turn incubator off, open portholes,

document rectal/axilla temperature every
15 min
Wait 30 min
Temperature falling?
YES
YES Baby temperature

>33ºC
NO
Add 1 blanket
Baby temperature NO
>34ºC
YES
Remove blanket if present
Consider using a fan, contact
transport consultant for advice*
*Do not use ice packs for cooling as severe hypothermia can result
Do not use active cooling (e.g. fan) unless rectal temperature is monitored
Issue 6
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CRANIAL ULTRASOUND SCANS • 1/3
PURPOSE
To detect brain injury in at-risk babies in order to provide appropriate medical
management
To detect lesions associated with long-term adverse neuro-developmental outcome
ROUTINE SCANNING PROTOCOL FOR PRETERM BABIES
Scan preterm babies according to the following minimum regimen
Scan babies of ≥33 weeks’ gestation only if clinically indicated
Gestation
36 weeks
<30 weeks 0–3 days 6–10 days 14–16 days CGA or
at discharge
36 weeks
30–32
3–7 days CGA or
weeks
at discharge
Additional scans Multiple congenital abnormalities

(except trisomy 21)
If routine scans show a significant
abnormality, discuss serial scanning Unexplained poor feeding at term
with consultant Unexplained hypoglycaemia, looking
Perform additional scans as clinically for pituitary and midline structures
indicated or following a significant Meningitis
clinical event:
Congenital viral infection
necrotising enterocolitis
Metabolic disorders
major collapse
Suspected brain malformations
repeated severe episodes of apnoea
Consider further imaging e.g. MRI scan
and bradycardia
or, if ultrasound abnormal, CT scan of
unexplained sharp fall in haemoglobin brain
change in neurological status Significant maternal alcohol intake
abnormal head growth during pregnancy
pre- and post-operatively Seizures
Follow-up In term babies with seizures, perform
cranial ultrasound on admission and at
If scan abnormal at 6 weeks, discuss
2 and 7 days while waiting for an MRI
the need for further imaging with
scan to be performed. MRI scan is the
consultant
preferred imaging modality
INDICATIONS FOR SCANNING
Neonatal encephalopathy
TERM/NEAR TERM BABIES
Initial scan within 24 hr
Neonatal encephalopathy/ischaemic
brain injury 2nd scan 3–4 days
Neonatal seizures 3rd scan 7–14 days
Abnormal neurological signs (e.g.
floppy child, large head)
Issue 6
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In encephalopathic babies with Record minimum set of sagittal (5+
significant birth trauma and low images):
haematocrit, request non-contrast CT midline through 3rd ventricle, septum
scan to exclude extra-axial bleed cavum pellucidum, cerebellum with 4th
For babies with moderate-to-severe ventricle and foramen magnum
encephalopathy, MRI scan through each lateral ventricle showing
recommended between 7–14 days of anterior and posterior horns, with
life caudothalamic notch imaged if
PROCEDURE possible
through each hemisphere lateral to the
Operator must achieve an acceptable ventricle for deep white matter
level of competence before performing
Supplemental oblique, surface and
and reporting scans independently
axial images may be necessary to
record pathology
Record minimum set of coronal (6+
images): For detection of cerebellar lesions,
scanning through posterior fontanelle
anterior to frontal horns of lateral
ventricles (junction of lambdoid and sagittal
sutures) and mastoid fontanelle
at anterior horns of lateral ventricles (junction of posterior parietal, temporal
and Sylvian fissures and occipital bones) can be useful
at 3rd ventricle and thalami
SCAN REPORTING
at posterior horns of lateral ventricles
(with choroids) Appropriately trained staff must
interpret cranial ultrasound scans
posterior to choroids (posterior brain
substance) Scans must be reported using
categories/terminology in Table below
if lateral ventricules are dilatated,
measure the ventricular index at the
level of 3rd ventricle at the foramina of
Munro (ventricular index) and plot on
appropriate chart
None
Intraventricular Localised IVH without dilatation (germinal matrix
haemorrhage haemorrhage, subependymal haemorrhage)
IVH with ventricular dilatation
Large IVH with parenchymal infarction
Normal
Ventricular size
Enlarged (measure and plot ventricular index)
None
Periventricular flare
Parenchymal lesions
Cystic lesions
single large porencephalic cyst
multiple cysts (cystic periventricular leukomalacia)
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COMMUNICATION DOCUMENTATION
Any member of neonatal team may Documentation is extremely important.
communicate a normal result to Archive digital copies of scans for
parents but note that a normal scan future review – each image must
does not equate to normal contain patient identifiers
development and follow-up is essential Record following information on
Discuss an abnormal result with investigation chart:
neonatal consultant before discussion date scan requested
with parents – an abnormal scan does
not equate to abnormal development, date scan carried out
follow-up is essential Record ultrasound result (or file a
written report) in baby’s notes
Offer parents the BLISS hydrocephalus
information leaflet available for (neonatal staff)
download from Complete Cranial ultrasound ad hoc
http://www.bliss.org.uk/factsheets form in BadgerNet
Record a plan for performing future
scans
Record in notes any discussion with
parents, especially of abnormal scans
Include results of all scans in discharge
summary, even if normal
If eligible baby transferred to another
hospital before scanning, communicate
need for scan in transfer summary
Issue 6
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DEATH AND SERIOUSLY ILL BABIES • 1/3
Consultant must be involved Further support

immediately in the care of a If parents do not accept second clinical
seriously ill baby assessment:
discuss with medical director or deputy
GUIDANCE
discuss with parents the option of a
Preparation further opinion from consultant
Most neonatal deaths are anticipated neonatologist from another unit in
and often occur following withdrawal of neonatal network
intensive care. The neonatal staff in Consultant may wish to seek advice
conjunction with the parents should from Trust’s legal advisers via medico-
plan the care of the baby around death legal department or on-call manager
If baby’s condition deteriorates Timescale for events in individual
seriously, discuss immediately with on- babies may vary from under 24 hr to
call consultant over 1–2 weeks
On-call consultant will assess the
Good documentation is essential
situation with nursing and medical
team, ensuring thorough
documentation Saying goodbye
Parents may request a blessing or
Discussion with parents naming ceremony by a religious
If death is inevitable, consultant will representative
discuss with parents
Ensure all family members are allowed
ensure baby’s nurse is present and time and privacy with baby
document discussion
Consider an appropriate place of care
Ask parents if they wish a religious or for baby, including transfer to a
spiritual person to be involved hospice if available/appropriate and
Use the BLISS booklet ‘Making Critical parents desire this
Care Decisions’ as appropriate Ensure parents have had opportunity
Complete the Midlands Newborn to take photographs of their baby
Network Integrated Comfort Care if local transport facility unavailable,
Pathway (ICCP). This document: contact regional transport team to
acts as a record of events and a guide facilitate this
for palliative care Provide a keep-sake box that can
contains useful links for further include photos, hand and foot prints,
information lock of hair, cot card, etc.
if transfer home or to a hospice If parental ethnicity and religious
complete the Advanced Care Pathway beliefs allow, offer parents opportunity
West Midlands, as dictated by local to wash, dress and prepare baby
team/hospice A small toy or other memento may
accompany baby to mortuary
Second opinion
If there is disagreement amongst the
multidisciplinary team or between the
team and the parents, consultant to
seek second opinion from a colleague
Issue 6
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DEATH if you are unable to issue death
certificate, a senior clinician must
When a baby dies, there are
report the death to the Coroner for a
formalities to be completed. These
Coroner’s post-mortem
should be handled as sensitively as
possible to minimise emotional trauma If death certificate can be issued:
to parents, whose wishes should be parents make an appointment with
respected and who should be guided Registrar of births and deaths to
carefully through the necessary deliver death certificate, unless
procedures Coroner’s officer recommends
Following notification of baby’s death otherwise
from attending nurse, a doctor or Registrar of births and deaths will
ANNP should confirm the death and issue certificate of authority for burial
make a suitable entry in the case or cremation, which should be given
notes with date and time of to:
confirmation of death
hospital general office, if hospital is
If the death was sudden and burying baby
unexpected (e.g. resuscitation failure
funeral director handling burial, if
in delivery suite or in the A&E soon
parents are making their own
after arrival):
arrangements
if no radiological confirmation of
position of endotracheal tube (ET), Post-mortem
another practitioner must verify Request a post-mortem in all babies
position on direct laryngoscopy before not requiring investigation by the
removal, and the depth of insertion coroner. It is parents’ right to have this
(from lips or nostril) should be choice
recorded. A post mortem X-ray is not
give parents an information leaflet to
necessary for such confirmation
assist their choice
similarly, leave all central vascular
if case required Coroner investigation,
catheters and drains in situ after
Coroner determines need for post-
cutting short and covered with
mortem and parents cannot choose
dressing
The post-mortem request must come
Ensure baby’s correct registered name from a middle grade doctor and a
appears on all documentation witness must sign the fully completed
consent form
Formal arrangements send original form to mortuary with

baby, place copies in baby’s hospital
Neonatal staff will offer advice about notes together with copy of death
registration and funeral arrangements certificate
with back-up support from hospital
general office/bereavement office death summary must be completed by
middle grade doctor within 24 hr of
Involve bereavement midwife early if death
available
copy of death summary must be sent
In some areas, all deaths must be to mortuary to accompany baby having
discussed with Coroner’s officer. Check a post-mortem
the requirements of your local Coroner
before issuing death certificate and
requesting post-mortem consent
Issue 6
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Baby transfer
Special arrangements will be made to
transport baby to mortuary according to
local hospital policy allow parents to
accompany baby if they wish
some may prefer to see their baby on
the neonatal unit if possible or chapel
of rest
Parents may take baby’s body directly
from the neonatal unit, once
appropriate documentation has been
completed (see SANDS website).
Where babies are taken will depend
upon religious belief of parents or
designated funeral director. In all cases
strict adherence of local hospital policy
must apply
Parent support
Offer bereavement support information
(e.g. SANDS; Child bereavement UK,
ACT) or counsellor
consultant will offer bereavement
counselling at 6–8 weeks, or following
final post-mortem result
arrange an appointment with trained
bereavement nurse/midwife specialist if
available
Communication
Inform named obstetrician and
neonatology consultants at referring
hospital (if appropriate), GP, health
visitor, and community midwife that
death has occurred
Document this in notes or on local
checklists
Ensure any pending appointments or
referrals are cancelled
follow local guidelines for notifying child
death and completion of form A and B
for death reviews (legal requirement)
Use local bereavement checklist
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DEVELOPMENTAL CARE • 1/2
INTRODUCTION Reduced stress and pain
Developmental needs are an integral Appropriate sensory experience
part of care planning; these differ Protection of postural development
according to gestational age, postnatal
Improved sleep patterns
age and health status. Assess
developmental needs and plan care Improved feeding
responsive to baby’s stress threshold Confident parenting and attachment
and sleep/wake pattern Staff satisfaction
Key concepts Improved neuro-developmental
Promoting organised neuro- outcomes
behavioural and physiological function OBSERVATION AND
Altering the physical environment to RECOGNISING BEHAVIOURAL
protect vulnerable developing sensory CUES
systems
Recognition of signs that baby may be
Family-centred care experiencing stress is vital. Babies will
display different cues at different stages
Goals
of development according to their
Improved physiological stability behavioural state (wake/sleep state)
Defensive/avoidance behaviour Coping/approach behaviour

Any of the following indicate baby may The following may indicate how well
need help or some time out: baby is able to settle itself, cope with
respiratory pauses, tachypnoea, gasping interventions and to interact
yawning, sighing able to regulate colour and breathing
gagging, posseting pattern
hiccoughing reduction of tremors, twitches and
sneezing autonomic stress cues
coughing smooth well-modulated posture and
straining normal tone
flaccidity (limp posture) trunk, limbs, face, smooth movements
mouth hand and foot clasping
hypertonicity with hyperextension (stiff grasping
posture) hand-to-mouth activity
arching hand holding
finger splays, ‘high guard hands’, hands to midline
‘saluting’ rooting/sucking
hand-on-face, fisting defined sleep states
facial grimace focused, shiny-eyed alertness or
Frantic diffuse motor activity: animated facial expression
squirming ‘ooh’ face
disorganised transition between and rapid cooing
changes of behavioural state attentional smiling
fussing or irritability easily consoled
staring or gaze averting
hyper alertness
crying/whimpering
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DEVELOPMENTAL CARE • 2/2
CARE-GIVING AND delay in development of normal
INTERVENTIONS movement and posture
Handling and invasive procedures may diminished parental confidence and
cause: competence
destabilisation of blood flow, cardiac Whenever possible all care-giving and
regulation, oxygenation and digestive intervention should be carried out by
functions two people, one person performs the
discomfort, pain and iatrogenic injury intervention; the other provides the
poor thermo-regulation baby with comfort and support
disrupted growth
altered sleep patterns with disordered
transition between states
Aim Method
Plan and deliver Closely observe baby’s physiological, motor and
individualised care and behavioural cues. Plan, adapt and pace care-giving
interventions (nursing and and interventions in response
medical), in accordance Have all necessary equipment ready before starting
with baby’s cues, promoting Approach baby carefully, using soft voice and
physiological stability and gentle touch, allowing time to adjust before
self-calming behaviours beginning
Protect baby’s sleep and Keep lighting and noise levels low
ability to self-regulate Support and comfort baby throughout:
Avoid pain, distress and administer appropriate analgesia including sucrose
iatrogenic injury and MEBM
Protect developing avoid totally exposing baby
musculoskeletal systems by facilitate baby’s self-calming strategies according to
promoting midline postures behavioural cues e.g. non-nutritive sucking,
and symmetry grasping, hand-to-mouth and foot bracing
Increase parents’ use swaddling and containment (hands/nest/soft
confidence and competence blanket or clothing) to provide support during care
or procedure
allow baby ‘time out’ to recover if cues indicate
stress. Recommence when baby is calm
Use side-lying position for cares, including nappy
changes. Promote a flexed position with limbs
tucked in. Do not lift baby’s legs, place soles of feet
together and roll side-to-side instead
Use containment and swaddling for transfers
into/out of incubator/cot, weighing, and bathing.
Move baby slowly, in flexed, side-lying position,
close to carer’s body
Promote positive touch and active parental role
Promote kangaroo care as soon as possible (see
Kangaroo care guideline)
Ensure baby is settled, comfortable and stable
before leaving the bedside
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DEVELOPMENTAL DYSPLASIA OF THE HIP
(DDH) • 1/2
INTRODUCTION examination will include Ortolani and
DDH ranges from mild acetabular Barlow tests. Ortolani and Barlow tests
dysplasia with a stable hip through will detect an unstable hip or a hip that
more severe forms of dysplasia, often is dislocated or subluxed but reducible.
associated with neonatal hip instability, They will not detect an irreducible hip
to established hip dysplasia with or which is best detected by identifying
without later subluxation or dislocation limited abduction of the flexed hip
Delayed diagnosis requires more ULTRASOUND SCREENING
complex treatment and has a less Selective ultrasound examination for
successful outcome than dysplasia babies with specific risk factors is
diagnosed early recommended
Screening for DDH is part of the A hip ultrasound should be
Newborn and Infant Physical performed if:
Examination (NIPE)
there is a first degree family history
DDH IS MORE COMMON IN of hip problems in early life, unless
BABIES WITH DDH has definitely been excluded in
that relative
Family history of first degree relative
with DDH breech presentation
Breech presentation during pregnancy - at or after 36 completed weeks of
pregnancy, irrespective of
Hip abnormality on clinical examination
presentation at delivery or mode of
Structural foot abnormality – delivery, or
congenital calcaneovalgus, fixed
- at delivery if this is earlier than 36
talipes equinovarus
weeks
Significant intrauterine moulding –
- in the case of a multiple birth, if any
congenital torticollis, congenital
of the babies falls into either of
plagiocephaly
these categories, all the babies in
Birth weight >5 kg this pregnancy should have an
Oligohydramnios ultrasound examination
Multiple pregnancy structural foot deformity
Prematurity - congenital calcaneovalgus, fixed
Neuromuscular disorders talipes equinovarus
significant moulding
SCREENING FOR DDH
- congenital torticollis, congenital
All babies are offered a NIPE and it must
plagiocephaly
have been completed by 72 hr of age
clicky but stable hips
The NIPE must include questions to
the parents in order to find risk factors - clicks should be distinguished from
for DDH and a thorough examination ‘clunks’ during examination. Most
looking for hip abnormalities clicks are benign and result from
soft tissue movement
parents should be asked “Is there
anyone in the baby’s close family, i.e Urgent referral and urgent hip
mother, father, brother or sister, who ultrasound should be performed if:
has had a hip problem that started abnormal hip examination
when they were a baby or young child - positive Ortolani or Barlow test or
and that needed treatment with a limited hip abduction (<60º when hip
splint, harness or operation?” is flexed to 90º)
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DEVELOPMENTAL DYSPLASIA OF THE HIP
(DDH) • 2/2
PROCESS arrange further paediatric orthopaedic
review
No risk factors on history
and normal examination Babies need an expert consultation* by
4 weeks
No further intervention needed
Check local policy regarding referring
Inform parents and document findings to physiotherapy/orthopaedic team and
These babies will be rechecked at their urgent ultrasound. A service may be
6–8 week check provided locally or a referral to a
tertiary centre paediatric orthopaedic
Specific risk factor
team may be required
(as detailed above) on
* Expert consultation is defined as ‘seen
history and/or examination
by a clinician who is able to diagnose
Inform parents of findings and plan for and initiate treatment for this particular
further investigation condition’. In some trusts this service is
Document findings and plan run jointly by the physiotherapy and
Request outpatient hip ultrasound to be orthopaedic teams
performed by 6 weeks
HIP EXAMINATION
preterm babies should be scanned at (SEE DIAGRAM)
term +4 weeks
Barlow test (left) and Ortolani test (right).
Departments need to have a system in In the Barlow test (baby’s right hip), the
place to review all hip scan results and hip is adducted and flexed to 90º; the
inform parents as they are reported examiner holds the distal thigh and
babies with a normal hip scan require pushes posteriorly on the hip joint. The
no further action and will be retest is positive when the femoral head is
examined at their 6-8 week check felt to slide posteriorly as it dislocates. In
babies with an abnormal hip scan require the Ortolani test (baby’s left hip), the
an expert consultation* by 8 weeks pelvis is stabilised by the examiner and
each hip examined separately. In a baby
Dislocated/dislocatable/ with limited hip abduction in flexion, the
unstable hip – positive hip is flexed to 90º and gently abducted
Ortolani or Barlow test or while the examiner’s finger lifts the greater
limited hip abduction trochanter. In a positive test the femoral
Review by middle grade or consultant head is felt to locate into the acetabulum
to confirm diagnosis
Inform parents of findings and plan for
further investigation and management
Document findings and plan
Urgent referral to the paediatric
physiotherapist/orthopaedic team
Physiotherapist/orthopaedic team will
see the patient as soon as possible
Physiotherapist/orthopaedic team will
assess the baby
fit a pelvic harness if needed
request an urgent hip ultrasound to be
performed within 2 weeks
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DISCHARGE FROM NEONATAL UNIT • 1/2
DECISION TO DISCHARGE Follow local policy for breast pump
loan and/or return
Only consultant or middle grade may
discharge: check local practice Ensure parents have information
regarding local breastfeeding groups
Medical and nursing staff to agree
for ongoing support, and BLISS
discharge date with parents or persons
support group meeting
with parental responsibility
Ensure parents have up-to-date safety
Nursing team perform majority of
information
discharge requirements
if transporting in a car, use suitable car
DISCHARGE CHECKLIST seat
Where appropriate, the following must be If transferring to another unit, ensure
achieved before discharge: parents understand reason for transfer.
Provide information about receiving
Parental competencies unit
Administration of medications when
Ensure remaining breast milk in
required
hospital fridge/freezer given to take
Baby cares (e.g. nappy changes, top home
and tailing, bathing etc.)
Feeding
Parent information
Local unit discharge pack
Nasogastric tube feeding where
necessary Offer parents the following information,
available from:
Stoma care (surgical babies)
http://www.bliss.org.uk/Shop/going-home-
Parent education (according the-next-big-step
to local practice)
Procedures/investigations
In addition to above, it is best practice
to offer parents education on: Newborn bloodspot – see Bloodspot
screening guideline
basic neonatal resuscitation (practical
demonstration or leaflet/DVD etc.) for babies <32 weeks’ gestation,
repeat on day 28 or the day of
respiratory syncytial virus (give BLISS
discharge if sooner
leaflet,
http://www.bliss.org.uk/Shop/common- When immunisation (2, 3 and 4 month)
winter-illnesses) not complete in preterm babies, inform
GP and health visitor
immunisations, if not already received
(give national leaflet) Give BCG immunisation if required –
see BCG immunisation guideline
Parent communication Complete audiology screening – see
Check home and discharge addresses Hearing screening guideline
and confirm name of GP with parents Where required, confirm
Complete Red book (include ophthalmology appointment date – see
immunisations given and dates) and Retinopathy of prematurity (ROP)
give to parents screening guideline
Give parents copy of discharge If going home on oxygen, follow
summary and time to ask questions appropriate guidelines
after they have read it
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DISCHARGE FROM NEONATAL UNIT • 2/2
Professional communication FOLLOW-UP
Complete admission book entries Appointments
Inform: Ensure these are written on discharge
health visitor of discharge summary and in Red book
community midwife if baby <10 days Likely appointments could include:
old neonatal/paediatric consultant out-
if safeguarding concerns and baby <28 patient clinic
days old, notify community midwife ophthalmology screening
GP audiology referral
community neonatal or paediatric team cranial ultrasound
as required locally
brain US/MR scan
Multidisciplinary (MDT) physiotherapy
review/discharge planning hip or renal ultrasound
meeting dietitian
Babies with safeguarding concerns (to community paediatrician
formulate child protection plan)
child development centre
Babies with complex needs
BCG immunisation or palivizumab
Other appropriate babies
planned future admission (e.g. for
Medical team immunisations)
Complete discharge summary by date planned future review for blood taking,
of discharge wound review
Complete neonatal dataset by date of tertiary consultant out-patients
discharge Open access to children’s wards
Answer parents’ questions after they where available and appropriate
have read discharge summary See also Follow-up of babies
Ensure all follow-up appointments discharged from the Neonatal Unit
made – see Follow-up guideline
Perform and record discharge
examination
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DISORDERS OF SEXUAL DEVELOPMENT • 1/2
RECOGNITION AND PRINCIPLES OF
ASSESSMENT MANAGEMENT
Definition This is a medical emergency: involve
consultant immediately
New nomenclature: disorders of sexual
development (DSD) known formerly as Avoid gender assignment before
ambiguous genitalia expert evaluation
Congenital conditions in which Consultant to discuss with parents
development of chromosomal, gonadal
always use the term ‘baby’ and avoid
or anatomical sex is atypical, most
using ‘he’, ‘she’ or, most importantly, ‘it’
commonly:
advise parents about delaying
congenital adrenal hyperplasia registration and informing wider family
gonadal dysgenesis and friends until gender assignment
complete
partial androgen insensitivity
liaise with laboratory to enable
For DSD classification, see evaluation without indicating gender in
Supporting information lab request forms
Factors suggesting DSD Link with expert centre for appropriate
evaluation
Overt genital ambiguity (e.g. cloacal
Communicate openly with family
extrophy)
Respect family concerns and culture
Apparent female genitalia with
enlarged clitoris, posterior labial fusion DSD is not shameful
or inguinal/labial masses potential for well-adjusted individual
and a functioning member of society
Apparent male genitalia with bilateral
undescended testes, isolated perineal best course of action may not be clear
hypospadias, mild hypospadias with initially
undescended testis parents need time to understand
Family history of DSD e.g. complete sexual development
androgen insensitivity syndrome (CAIS)
First line investigations
Discordance between genital Blood pressure
appearance and antenatal karyotype
Karyotype (urgent)
Pseudo-ambiguity (atrophic vulva and Imaging
clitoral oedema) in growth-restricted or
preterm female babies abdominal and pelvic ultrasound by an
experienced paediatric sonographer
17-OHP (delay until day 4–5 to allow
maternal hormonal effects to decline)
Testosterone and oestradiol
LH, FSH
U&E and glucose
Cortisol
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DISORDERS OF SEXUAL DEVELOPMENT • 2/2
Further investigations
(locally and/or in conjunction
with specialist advice)
dHT (dihydrotestosterone)
DHEA (dihydroepiandrosterone)
Androstenedione
Urine steroid analysis
ACTH
LHRH and hCG stimulation
ACTH stimulation test
AMH (anti-mullerian hormone) imaging
studies
Biopsy of gonad
Molecular genetic studies (e.g. for CAIS)
TREATMENT
Avoid unnecessary admission to the
neonatal unit
Check serum electrolytes and plasma
glucose
Involves a multidisciplinary team with
an identified person (usually consultant
neonatologist) acting as primary
contact with family
Specific treatment dependent on many
factors and the diagnosis
discuss with specialists
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ECG ABNORMALITIES • 1/2
SINUS TACHYCARDIA In a regular sinus rhythm at a normal rate,
a P wave occurring before next expected
Recognition and assessment
P wave is a premature atrial beat
Sinus rhythm (P wave precedes every
QRS complex) with a heart rate above Most premature atrial beats are benign
normal limit for age and gestation Investigations
Causes 12-lead ECG
Fever PREMATURE
Infection VENTRICULAR BEAT
Low haemoglobin Recognition and assessment
Pain Premature abnormal QRS complex not
Prematurity preceded by a premature P wave
Hypovolaemia
Investigations
Hyperthyroidism
12-lead ECG
Myocarditis
Measure QTc interval on ECG during
Drugs (e.g. caffeine and salbutamol) period of sinus rhythm
Management Echocardiogram to rule out structural
Treat the cause abnormality of heart
SINUS BRADYCARDIA Immediate treatment

Seek advice from paediatric cardiologist
Sinus rhythm (P wave precedes every SUPRAVENTRICULAR
QRS complex) with a heart rate below TACHYCARDIA
normal limit for age and gestation
Differential diagnosis Rapid regular tachyarrhythmia
Hypoxia (most likely cause) Heart rate >230/min
Vagal stimulation ECG:
Post-intubation P waves commonly absent. When
Hypovolaemia present they almost always have an
Hypothermia abnormal morphology
Metabolic derangement narrow QRS complex
in fast sinus tachycardia, P waves can
Immediate management be very difficult to see
Manage airway and breathing look for delta waves consistent with
If intubation required, optimise ET Wolff-Parkinson-White syndrome as
position this can affect the choice of anti-
If bradycardia occurs post-intubation, arrhythmic agent used
use atropine (see Neonatal Formulary)
Symptoms and signs
Correct hypovolaemia
Persistent SVT can cause
Correct metabolic derangement haemodynamic compromise
If persistent, obtain 12-lead ECG
Investigations
PREMATURE ATRIAL BEAT 12-lead ECG to document SVT: if not
Recognition and assessment definite SVT, treat for cause of sinus
Most common form of arrhythmia tachycardia (e.g. fluid for hypovolaemia)
Issue 6
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ECG ABNORMALITIES • 2/2
Immediate management Discuss with paediatric cardiologist for
Assess airway, breathing and circulation further management (or earlier if
necessary)
Check for signs of cardiac failure
Vagal manoeuvre such as applying ice VENTRICULAR
pack to face TACHYCARDIA
Adenosine IV bolus Recognition and assessment
use central venous access or IV access Heart rate >200/min
in a bigger vein (antecubital fossa) Wide QRS complexes
connect 3-way connector to end of
Immediate management
cannula/catheter
Manage airway and breathing
establish patency of IV access
Correct hypoxia
connect syringe with adenosine to one
Correct electrolyte disturbance
port and sodium chloride 0.9% flush to
another port Discuss with paediatric cardiology centre
run ECG strip Consider synchronised cardioversion
(in very fast heart rates, defibrillators
give adenosine as a quick bolus and cannot synchronise with the patient
push the bolus of sodium chloride and unsynchronised will be required) if
0.9% at the end quickly intubated, with analgesia
document change in cardiac rhythm on Amiodarone 5 mg/kg over 30 min IV
ECG (repeat if necessary)
Adenosine dosage If no response, lidocaine 0.5–1 mg/kg
Start with 150 microgram/kg IV bolus IV. May be repeated after 5 min.
Maximum cumulative dose 3 mg/kg
if no response, increase by
50 microgram/kg TACHYARRHYTHMIA
Repeat every 1–2 min True heart rate?
maximum dose 300 microgram/kg Is baby crying/in pain?
if no response, discuss DC shock with Check airway and breathing
paediatric cardiologist Check saturation
Consider arterial/capillary gas
Subsequent management
Check perfusion
Echocardiogram to assess ventricular
function and presence of congenital Check blood pressure
heart disease Manage airway and breathing
Correct electrolyte and metabolic Correct hypoxia
imbalance, if present Correct electrolyte disturbance
12-lead ECG
Narrow QRS complex Broad QRS complex

Absent/abnormal P wave Abnormal P wave
vagal manoeuvres
discuss with paediatric cardiologist
adenosine
discuss with paediatric cardiologist synchronised cardioversion
consider synchronised cardioversion
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ENDOTRACHEAL TUBE SUCTIONING • 1/2
This procedure guideline is applicable to will be within 0.5 cm and 1 cm of the
ventilated babies where a closed suction end of the endotracheal tube
catheter system is used. Endotracheal Note the nearest coloured band to the
tube suctioning is necessary to clear irrigation port window. Coloured bands
secretions and to maintain airway patency, allow for easy visualisation on
and to optimise oxygenation and subsequent suction procedures
ventilation in an intubated patient. The goal
of endotracheal tube suctioning should be
to maximise the amount of secretions
Irrigation port window
removed with minimal adverse effects
INDICATIONS
End of cut
ET tube
To maintain airway patency

5 cm
To remove respiratory secretions or

aspirated fluid from within the
endotracheal tube
To obtain secretions for culture analysis Method 2
EQUIPMENT Stabilise the Y adaptor with one hand
Non-sterile disposable gloves Advance the catheter until the printed
Disposable apron depth numbers on the catheter align
with the same numbers printed on the
PROCEDURE endotracheal tube
Preparation The catheter tip will be within 0.5 cm
and 1 cm of the end of the
Wash hands and put on gloves and
endotracheal tube
apron
Auscultate chest before suctioning Performing suctioning
Ensure full monitoring of heart rate Ensure the suction catheter is correctly
and SpO2 in place advanced using either of methods 1 or
2 (above)
Ensure baby is adequately
oxygenated; consider increasing FiO2 Depress thumb control valve and hold
by up to 0.1 before procedure while withdrawing the catheter slowly
Ensure closed suction device is When the tip of the suction catheter
unlocked reaches the dome, release thumb
control valve and stop withdrawing
Measuring catheter Procedure should take ≤10 seconds
advancement and the duration of negative
Method 1 pressure should be ≤5 seconds
Note the printed number on the cut Repeat procedure if necessary
endotracheal tube Do not use a sodium chloride flush
Add 5 cm to this to give the total distance routinely. A sodium chloride 0.9% flush
of suction catheter advancement may be used if secretions are thick
and tenacious and cannot be extracted
Stabilise the Y adaptor with one hand by suctioning alone
and advance the catheter until
calculated length is visible in the
irrigation port window. The catheter tip
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ENDOTRACHEAL TUBE SUCTIONING • 2/2
DOCUMENTATION COMPLICATIONS
Record procedure in nursing Hypoxaemia
documentation, noting the distance the Atelectasis
tube was passed and the colour of the
band on the catheter tube closest to Bradycardia
this measured distance Tachycardia
Blood pressure fluctuations
AFTERCARE
Decreased tidal volume
Equipment
Airway mucosal trauma
Leave thumb valve in locked position
Dislodgement of the endotracheal tube
when not in use to prevent inadvertent
activation Extubation
Leave catheter tip in dome between use Pneumothorax
Device is single use only and replace Pneumomediastinum
every 24 hr as per manufacturer’s Bacteraemia
guidance Pneumonia
Monitoring Fluctuations in intracranial pressure
Ensure monitoring of heart rate and and cerebral blood flow velocity
SpO2 continues after procedure
FURTHER INFORMATION
Auscultate baby’s chest after procedure Further details on endotracheal tube
and document any changes observed closed suction can be found in the
If FiO2 was adjusted before procedure, manufacturer’s guidance
return to original settings, or ensure
that baby’s target oxygen saturations
are maintained
Reporting adverse events

Report adverse incidents using local
risk management procedure
Issue 6
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ENVIRONMENT AND NOISE • 1/2
ENVIRONMENT
Lighting
Excessive and rapid changes in light levels may cause physiological instability,
disturbed sleep and interfere with visual development. The thin eyelids of preterm
babies may allow significant light to penetrate even if eyes closed
Aim Method
Provide flexible lighting to Keep lighting levels around 200–300 lux (moderate
meet individual room lighting)
developmental needs and Monitor and audit light levels in nursery and baby’s
caregiver’s needs immediate environment regularly
Ensure sufficient lighting for Daylight is preferable to artificial lighting. Protect
observation and care babies from direct sunlight
delivery
Avoid direct bright light during feeding
Promote optimal extra-
uterine development and Use dimmer switches and avoid sudden changes in
physiological stability light levels
Reduce stress Use incubator covers or canopies for preterm, sick

or neurologically compromised babies
Protect sleep
keep a corner/flap up to allow safe observation
Development of normal
circadian rhythms Protect babies in open cots from bright light until
near term (37–40 weeks)
Use night lights for development of day–night cycle
Use individual task lighting for care and procedures.
Shade baby’s eyes throughout
Protect babies from phototherapy and bright lights
in other bed spaces
Promote appropriate visual interactions with
parents/carers
Protect babies from bright light for a minimum of
18 hr following ROP screening
NOISE
High levels of sound may cause:
baby distress
sleep disturbance
damage to hearing
impaired language and speech development
A noisy environment affects behaviour and well-being of adults present, with impact on
confidentiality, communication, stress levels and the ability to concentrate, make
decisions and perform fine motor tasks
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ENVIRONMENT AND NOISE • 2/2
Aim Method
Promote optimal extra- Monitor noise levels in nursery and within baby’s
uterine development and immediate environment
physiological stability Maintain ambient noise levels at 45 dB, with
Protect sleep occasional peaks of 70 dB
Maintain confidentiality and Observe baby’s cues to ensure noise levels do not
privacy indicate stress
Promote normal speech Open packaging outside incubator
and language development Keep monitor alarms and telephone ring tones at
Provide appropriate working quiet but safe audible levels
environment silence alarms quickly
Empty ‘rainout’ from ventilator tubing as soon as
possible
Turn off suction when not in use
Close incubator doors and bins gently
Cover incubators of preterm, sick and neurologically
compromised babies
Keep conversations away from babies and speak
quietly
Encourage parents/carers to speak softly to their
babies
Maintain quiet environment during oral feeding
Only use radios, portable music devices, musical
toys etc. when clinically indicated and ensure other
babies are not disturbed
Promote at least one ‘rest time’ per day. Lower light
and noise levels and suspend all routine
procedures/ward rounds. Leave babies undisturbed
to facilitate sleep. Encourage parents to view this
as a quiet time to spend with baby
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EXAMINATION OF THE NEWBORN • 1/4
INDICATIONS identify pregnancy complications,
blood tests, ultrasound scans,
Routine discharge check admissions to hospital
A thorough physical examination of every
identify maternal blood group,
newborn baby is good practice and forms
presence of antibodies, serology
a core item of the UK Child Health
results for sexually transmitted
Surveillance programme
diseases
Ideally performed >24 hr after birth
duration of labour, type of delivery,
many babies are discharged before duration of rupture of membranes,
24 hr of age. Follow local policy on condition of liquor
timing of discharge
Apgar scores and whether
confirm apparent normality resuscitation required
detect abnormalities/anomalies birth weight, gestational age, head
provide plan of care circumference
provide reassurance to parents and Consent and preparation
opportunity for discussion
Introduce yourself to mother and gain
EQUIPMENT oral consent. Ask about particular
concerns
Maternal and baby notes
Keep baby warm and examine in quiet
Stethoscope
environment
Ophthalmoscope
Measuring tape PROCEDURE
Skin examination
AIMS
Hydration
Identify congenital malformations
Rashes: including erythema toxicum,
Identify common neonatal problems milia, miliaria, staphylococcal skin
and initiate management infection, candida
Continue with screening, begun Pigmented lesions: naevi, Mongolian
antenatally, to identify need for specific blue spots, birth marks, café au lait
interventions (e.g. immunisation) spots
PRE-PROCEDURE Bruises: traumatic lesions, petechiae
Before undertaking clinical Cutis aplasia
examination, familiarise yourself with Tufts of hair not on head
maternal history and pregnancy
records, including: Vascular lesions: haemangioma, port
wine stain, simple naevus
maternal medical, obstetric and social
history Colour:
pink/cyanosis/jaundice/pallor/plethora
paternal medical history, if appropriate
Acrocyanosis
family health, history of congenital
diseases Cutis marmorata
identify drugs mother may have taken Facial examination

during pregnancy and in labour General facial appearance to identify
health of siblings common syndromes
Issue 6
96
Eyes Neck
Shape Swellings
Slant Movement
Size Webbing
Position Traumatic lesions from forceps
Strabismus delivery
Nystagmus Clavicles
Red reflex For fracture
Presence of colobomata
Arms and legs
Discharges
Position and symmetry of movement
Nose Swelling and bruising
Nasal flaring
Hands and feet
Patency
Extra digits (polydactyly)
Ears Syndactyly, clinodactyly
Shape Palmer creases
Position Skin tags
Tags or pits Position and configuration of feet
looking for fixed/positional talipes
Mouth
Overlapping toes
Size
Cleft lip Hips
Symmetry of movement Developmental dysplasia using
Ortolani’s and Barlow’s manoeuvres.
Swellings, Epstein’s pearls, ranula,
See Development dysplasia of the
tongue tie (for parental reassurance)
hip guideline
Teeth
Cleft palate, hard/soft palate, (by both Spine
inspection and palpation) Curvatures
Sucking Dimples
Sacrococcygeal pits
Skull
Hairy patches/naevi
Palpate:
Hairy tuft on spine
skull for sutures and shape/cranio-
synostosis Systems
swellings on scalp, especially crossing Examine (inspection, palpation,
suture lines, cephalhaematoma auscultation) each system
signs of trauma associated with birth
(e.g. chignon from vacuum extraction)
sutures for ridging or undue separation
Issue 6
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Respiratory system Genito-urinary system
Respiratory rate Ask mother if baby has passed urine,
grunting and how frequently
nasal flaring
Inspect appearance of genitalia:
Chest shape, asymmetry of rib cage, ambiguous?
swellings
nipple position, Male genito-urinary system
swelling/discharge/extra nipples Penis size (>1 cm)
Chest movement Position of urethral meatus. Look for
presence/absence of recession hypospadias
Auscultate for breath sounds Inguinal hernia
Chordee
Cardiovascular system
Urinary stream
Skin colour/cyanosis
Scrotum for colour
Palpate:
Palpate scrotum for presence of two
precordium for thrills testes and presence of hydrocoele
peripheral and femoral pulses for rate
and volume Female genito-urinary system
central perfusion Presence of vaginal discharge (reassure
parents about pseudomenstruation)
Auscultate for heart sounds,
murmur(s), rate, rhythm Skin tags
pulse oximetry of right arm and either Inguinal hernia
leg (<3% difference in SpO2 normal) Proximity of genitalia to anal sphincter
Routine palpation of kidneys is not
Gastrointestinal tract always necessary as antenatal scans
Ask mother how well baby is will have assessed presence
feeding, whether baby has vomited
Neurological system
and, if so, colour of vomit
Bilious vomiting may have a Before beginning examination,
surgical cause and needs prompt observe baby’s posture
stabilisation and referral Assess:
muscle tone, grasp, responses to
Abdominal shape stimulation
Presence of distension
behaviour
Cord stump for discharge or
ability to suck
inflammation/umbilical hernia
limb movements
Presence and position of anus and
patency cry
Stools passed head size in relation to body weight
Palpate abdomen for tenderness, spine, presence of sacral pits, midline
masses and palpable liver spinal skin lesions/tufts of hair
Auscultation is not routinely undertaken If neurological concerns, initiate Moro
unless there are abdominal concerns and stepping reflexes
Issue 6
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Responses to passive movements:
pull-to-sit
ventral suspension
Palpate anterior fontanelle size (<3 cm
x 3 cm) and tone
OUTCOME
Documentation
Complete neonatal examination record
in medical notes and sign and date it.
Also complete child health record (Red
book) or in NIPE Smart if used
Record any discussion or advice given
to parents
Normal examination
If no concerns raised, reassure
parents of apparent normality and
advise to seek advice if concerns arise
at home
GP will re-examine baby when 6
weeks old
Abnormal examination
In first instance, seek advice from
neonatal registrar/consultant
Refer to postnatal ward guidelines for
ongoing management
Refer abnormalities to relevant senior
doctor
Issue 6
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EXCHANGE TRANSFUSION • 1/3
Exchange transfusion replaces withdrawn COMPLICATIONS
baby blood with an equal volume of Cardiac arrhythmias
donor blood
Air embolism
Discuss all cases with neonatal Necrotising enterocolitis
consultant Coagulopathy
Apnoeas and bradycardia
INDICATIONS
Sepsis
Haemolytic anaemia Electrolyte disturbances
A newborn who has not had an in-utero Acidosis owing to non-fresh blood
transfusion (IUT) with a cord Hb <120
Thrombocytopenia
g/L and is haemolysing, may require
urgent exchange transfusion to remove Late hyporegenerative anaemia
antibodies and correct anaemia: PROCEDURE
if Hb <100 g/L, discuss urgently with Prepare
consultant and proceed to exchange
Ensure full intensive care space and
transfusion; avoid simple packed cell
equipment available and ready
transfusions
Allocate one doctor/practitioner and one
if Hb 100–120 g/L, obtain 6-hrly other member of nursing staff, both
bilirubin values and, if rapidly rising or experienced in exchange transfusion, to
close to exchange transfusion level, care for each baby during procedure;
see Table in Jaundice guideline, use document their names in baby’s notes
intravenous immunoglobin (IVIG)
Obtain written consent when possible,
A newborn who has had IUTs and and document in baby’s notes
whose Kleihauer test (this test may not
Phototherapy can usually be
be available in your hospital)
interrupted during exchange
demonstrates a predominance of adult
Hb, anaemia can be managed using a Calculate volume of blood to be
top-up transfusion of irradiated, CMV- exchanged: 160 mL/kg (double blood
negative blood volume) removes 90% of baby red
cells and 50% of available
Hyperbilirubinaemia intravascular bilirubin
Discuss promptly with consultant. If Order appropriate volume (usually 2
bilirubin values approaching guidance units) of blood from blood bank,
below; senior decision is required: stipulating that it must be:
guidance as determined by exchange crossmatched against mother’s blood
transfusion line on gestation-specific group and antibody status, and (if
NICE jaundice chart – see Table in requested by your blood bank) baby’s
Jaundice guideline blood group
if bilirubin rises faster than CMV-negative
8.5 micromol/L/hr despite irradiated (shelf-life 24 hr) for any baby
phototherapy, anticipate need for who has had an in-utero blood
exchange transfusion transfusion
as fresh as possible, and certainly no
Other indications more than 4 days old
Chronic feto-maternal transfusion plasma reduced red cells for ‘exchange
Disseminated intravascular transfusion’ (haematocrit 0.5–0.6), not
coagulation (DIC) SAG-M blood and not packed cells
Issue 6
100
Prepare baby Or
Empty stomach using nasogastric tube Insert UVC (‘in route’) and UAC (‘out
(see Nasogastric tube insertion route’) and confirm position. Use
guideline) umbilical venous and arterial
‘continuous’ technique below for
Start intravenous infusion and allow
exchange
nil-by-mouth
Pay attention to thermoregulation, UVC ‘push-pull’ technique
particularly if procedure to be Connect catheter bag (using Vygon
performed under radiant heater connector) and donor blood to 4-way
Commence continuous cardiac, tap and 4-way tap to UVC
temperature and saturation monitoring Remove 10 mL baby blood from UVC
using syringe
Monitor and document
Send first sample for serum bilirubin,
Blood pressure and heart rate every
full blood count, blood culture, blood
15 min throughout exchange
glucose, calcium, electrolytes,
If any change in baby’s coagulation and liver function tests
cardiorespiratory status, pause when exchange performed for reasons
exchange by priming catheter with other than known blood group
donor blood that will not clot. Discuss antibodies, send blood for G6PD
with consultant screening and viral serology
Replace precise volume removed with
Prepare blood donor blood, slowly using a syringe
Set up blood warmer early (aim for 37ºC) Each out-in cycle should replace no
Check blood units as per hospital policy more than 8.5 mL/kg and take at least
Connect donor blood to filter and 5 min; start with smaller aliquots
prime blood giving set (10 mL) and increase to 20 mL (if baby
stable and weight allows) only after
Connect to 4-way (if using UVC) or 3-
30 min. As a guide:
way tap (outside the warmer) as
indicated birth weight <1000 g: use 5 mL aliquots
Ensure donor blood well mixed before birth weight 1000–2000 g: use 10 mL
and throughout exchange aliquots
birth weight >2000 g: use 20 mL
Technique aliquots
Ensure working area sterile Discard ‘out’ baby blood into catheter
Either bag
Insert UVC (see Umbilical venous Continue out-in cycles every 5 min
catheterisation guideline) and confirm (maximum aliquot with each cycle)
position. Use UVC ‘push-pull’ until complete
technique below for exchange Send last ‘out’ baby blood sample for
Or serum bilirubin, full blood count, blood
culture, blood glucose, calcium and
Insert peripheral venous (‘in route’)
electrolytes
and arterial (‘out route’) catheters. Use
peripheral venous and arterial
catheters ‘continuous’ technique
below for exchange
Issue 6
101
Peripheral venous and UVC and UAC continuous
arterial catheters technique
‘continuous’ technique Use UVC as ‘in’ line and UAC as ‘out’
Connect catheter bag, using Vygon line and proceed as with Peripheral
connector, to 3-way tap attached to venous and arterial ‘continuous’
arterial line extension technique
Never leave arterial line open to AFTERCARE

catheter bag Immediate
Connect donor blood to venous catheter When Hb and bilirubin in final ‘out’
sample known, check with consultant
Remove 10 mL of baby’s blood from
before removing all lines
arterial line and send for tests as listed
above under UVC ‘push-pull’ Complete documentation (volumes
technique in/out, and all observations)
Start venous infusion at rate to match Recommence phototherapy
withdrawal rate e.g. 120 mL/hr for a Recommence feeds 4–6 hr after
10 mL volume withdrawal every 5 min completion
Remove ‘out’ aliquots of baby’s blood Monitor blood sugar 4-hrly until
from arterial line every 5 min to match acceptable on 2 consecutive occasions
volume of donor blood being infused
Update parents
into venous line
Observe limb distal to arterial line at all Intermediate
times and document appearance. If In babies receiving antibiotics, a
concerned, pause exchange and repeat dose may be required: discuss
discuss with consultant with consultant
Continue steps as above but note that Delayed Guthrie spot collection will be
continuous ‘in’ cycle requires removal indicated, as directed by regional centre
of ‘out’ aliquots only every 5 min
If exchange stopped for >2–3 min,
Follow-up
discontinue procedure and ensure all Neuro-developmental follow-up in all
lines are flushed babies who have undergone exchange
transfusion
Equipment diagram for ‘Push-Pull’
Exchange Transfusion Repeat full blood count at intervals
(likely 1–2 weekly but to be
From the determined individually) for up to at
Blood Warmer
least 6 weeks, to detect anaemia
secondary to ongoing haemolysis
Two 3-way taps
connected together
To Waste Bag
Issue 6
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EXOMPHALOS – INITIAL MANAGEMENT • 1/3
DEFINITION
Congenital anterior abdominal wall defect, resulting in herniation of the abdominal
contents through the umbilicus. Herniated viscera are covered by a sac
Exomphalos minor: defect diameter <5 cm with no liver in sac
Exomphalos major: defect diameter >5 cm. Sac usually contains liver (see photograph)
Small bowel loops
Umbilical cord
Liver
Key issues to be aware of: Give parents information leaflet

rupture or damage to protective sac Aim to deliver in appropriate neonatal
association with other major unit (NNU) with either postnatal
abnormalities (cardiac or chromosomal) transfer to paediatric surgical unit or
management by paediatric surgical
Depending, on individual patient factors, outreach team at the NNU
an exomphalos can be managed either
by: Pre-delivery
early surgical closure of the defect (as Liaise with on-call team at the
a neonate) paediatric surgical centre before making
delayed surgical closure, after arrangements for elective delivery
epithelisation of the sac using dressings
Delivery
Diagnosis and antenatal care Experienced paediatrician/ANNP to
Majority diagnosed antenatally attend delivery
Often associated with chromosomal Clamp umbilical cord only after careful
and other abnormalities assessment of the umbilical defect (to
avoid any bowel present at base of cord)
Multi-professional discussions needed
to carefully plan antenatal and Use plastic cord clamp (not artery
postnatal care forceps) on umbilical cord at least 10
cm away from where normal umbilical
If suspected antenatally cord starts to avoid bowel injury
refer to fetal medicine department for Dry baby
further assessment
Provide resuscitation, as required.
refer to paediatric surgery for antenatal Avoid prolonged mask ventilation
counselling
Issue 6
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Nurse in supine position Administer fluid boluses as indicated by
Pass a size 8 Fr nasogastric tube baby’s condition
(NGT) and fix securely with tape (see Start maintenance IV fluids (see IV
Nasogastric tube insertion guideline) fluid therapy guideline)
Empty stomach by aspirating NGT with Give vitamin K (see Vitamin K
10–20 mL syringe. If <20 mL fluid guideline)
aspirated, check position of tube. Place Leave NGT, on free drainage and
tube on free drainage by connecting to aspirate NGT 4-hrly with a 20 mL
a bile bag enteral syringe
Put nappy on baby, taking care to fold Replace nasogastric losses mL-for-mL
it down under the defect using IV sodium chloride 0.9% with
Place baby’s legs and trunk, feet first, potassium chloride 10 mmol in 500 mL
into a sterile plastic bag, to protect the bag
defect and reduce fluid loss. Pull the Start broad spectrum antibiotics
draw-string under the arms, so that both including metronidazole
arms are outside the top of the bag
Monitor blood glucose 4–6 hrly
Show baby to parents and transfer to
NNU Swab sac and send for culture and
sensitivity
In NNU Take a photograph of the exomphalos,
Careful physical examination by with parent’s consent
experienced neonatal practitioner. If Remove bowel bag and protect the sac
baby has a major lethal congenital by covering with a non-adhesive
abnormality, local consultant to decide dressing (Jelonet) and sterile gauze,
whether referral for management is until assessed by the paediatric
appropriate. May require discussion surgical outreach team
with on-call consultant surgeon. If the
Discuss baby’s condition and treatment
decision is not to transfer, inform
plan with parents and ensure they have
surgical unit
seen the baby before transfer. Take
Nurse in supine position photographs for parents
Insert IV cannula. Avoid vein which could
be used for long line e.g. antecubital
Referral
fossa, long saphenous or scalp Refer baby to planned paediatric
surgical unit e.g. BCH. This may
Avoid umbilical lines
require a conference call with the on-
Take blood for: call surgeon to discuss urgency of
culture transfer; an emergency surgical
FBC, CRP and clotting screen, procedure is normally not indicated
including fibrinogen Some babies may not require transfer
U&E to the paediatric surgical unit and can
sometimes be managed at a NNU
blood glucose and venous blood gas
for BCH this may include transfer to
Crossmatch sample will be taken at BWH for the Neonatal Surgical
surgical centre Outreach Service
Send 1 bloodspot on neonatal
screening card marked as 'pre-
transfusion' (for sickle cell screening)
with baby to surgical centre
Issue 6
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Obtain a sample of mother’s blood for Transfer to surgical unit
crossmatch. Handwrite form,
Place baby in transport incubator
completing all relevant sections and
indicating this is the mother of the baby Take baby to parents (if not yet seen)
being transferred. Include baby’s name in the transport incubator, en-route to
the ambulance
Complete nursing and medical
documentation for transfer and obtain Ensure mother’s blood, baby’s pre-
copies of X-rays if taken. Ensure you transfusion bloodspots, letters for
have mother’s contact details (ward surgical team and all documentation
telephone number or home/mobile accompanies baby
number if she has been discharged). Ensure documentation includes whether
Surgeon will obtain verbal telephone vitamin K given, the referring consultant,
consent if operation is required and a whether parents had antenatal
parent is not able to attend surgical unit counselling, mother’s contact details
at appropriate time Make and document all the usual
If the neonatal surgical decision is to observations during transport and on
perform a delayed closure of the arrival at the surgical unit
exomphalos, the recommended
dressing is Manuka honey gel covered Useful Information
with a honey net dressing, sterile http://www.bch.nhs.uk/content/neonatal-
gauze and crepe bandage surgery
If exomphalos is to be managed with http://www.bch.nhs.uk/find-us/maps-
dressings on NNU then this will be directions
supported by the Surgical Neonatal Parent information/support organisation
Outreach Service http://www.geeps.co.uk/ (GEEPS –
While awaiting transfer exomphalos page)
Reassess hourly for further fluid

boluses and, if necessary, give
10 mL/kg of either sodium chloride
0.9% or human albumin solution (HAS)
4.5%
If evidence of a coagulopathy, treat
appropriately (see Coagulopathy
guidelines)
Aspirate NGT 4-hrly
Replace nasogastric losses mL-for-mL
with sodium chloride 0.9% IV with
potassium chloride 10 mmol in 500 mL
bag. Leave NGT on free drainage
Issue 6
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EXTRAVASATION INJURIES • 1/3
BACKGROUND The degree of tissue damage due to
extravasation is dependent upon:
Approximately 4% of babies develop
skin necrosis as a result of volume of infusate, its pH and osmolality
extravasation of an IV infusion the dissociation constant and
A small proportion of these babies pharmacological action of any drug(s)
develop long-term cosmetic or being infused
functional compromise
Wound dressings
Extravasation may be due to:
When choosing wound dressing,
cannula piercing the vessel wall or consider the need to prevent:
from distal venous occlusion causing further trauma
backpressure and increased vascular
epidermal water loss
permeability
contractures by allowing a full range of
Cochrane review shows that centrally
limb movements
placed catheters may cause
extravasation as often as peripheral Dressings must be:
cannula easy to apply to small body surface areas
Extravasation can lead to both short sterile
and long-term complications suitable for use in humidified/incubator
Use this guideline to define the grading, environments
and management, of subcutaneous
extravasation injuries in babies, either Most commonly used
from peripheral or central lines dressings
Limiting the IV pump cycle to 1 hr may Hydrocolloid 9 (e.g. Duoderm) or
minimise the extent of tissue damage hydrogel (e.g. Intrasite gel, Intrasite
from extravasation providing the entry conformable)
site is observed concurrently if in doubt, seek advice from tissue
viability nurse
ASSESSMENT
Table 1: Grading of extravasation injuries
Grade 1 Grade 2 Grade 3 Grade 4
IV device flushes Pain at infusion site Pain at infusion site Pain at infusion site
with difficulty Mild swelling Marked swelling Very marked swelling
Pain at infusion site Redness Skin blanching Skin blanching
No skin blanching Cool blanched area Cool blanched area
No swelling or
redness Normal distal Normal distal Reduced capillary refill
capillary refill and capillary refill and +/- arterial occlusion
pulsation pulsation +/- blistering/skin
breakdown/necrosis
Investigations
No specific investigations required. However, if wound appears infected:
wound swab
FBC
CRP
blood culture
start appropriate antibiotics – see Infection (late onset) guideline
Issue 6
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ACUTE MANAGEMENT
Table 2
Grade 1 and 2 Grade 3 Grade 4
Stop infusion immediately Stop infusion immediately Stop infusion immediately
Remove cannula and Remove constricting tapes Remove constricting tapes
splints/tapes Leave cannula in situ until Leave cannula in situ until
Elevate limb review by doctor/ANNP review by doctor/ANNP
Withdraw as much of the Withdraw as much of the
drug/fluid as possible via drug/fluid as possible via the
the cannula cannula
Consider irrigation of Photograph lesion – provided
affected area no delay in further treatment
Elevate limb Irrigate affected area
Inform tissue viability nurse Elevate limb
Inform tissue viability
nurse/registrar/consultant +/-
plastic surgery team
Most extravasation injuries are of Other considerations

Grades 1 and 2 and do not require Family-centred care – inform parents
extensive intervention of extravasation injury and
Grade 3 and 4 injuries have a greater management plan
potential for skin necrosis,
compartment syndrome and need for Special considerations
future plastic surgery, depending on Infection control – observe standard
type of solution extravasated infection control procedures
Complete an incident report for Grade
FURTHER ASSESSMENT 3 and 4 extravasations
Following irrigation treatment, review all
injuries within 24 hr of extravasation IRRIGATION OF
occurring EXTRAVASATION INJURIES
Irrigation of major grades of Procedure
extravasation has been used to prevent Withdraw as much of the drug and or
extensive skin loss and need for plastic fluid as possible via cannula or catheter
surgery and skin grafting. However, the Infiltrate the site with lidocaine 1%
evidence for the use of irrigation in 0.3 mL before to reduce pain
preventing long-term injury is limited
Using a scalpel, make 4 small incisions
Documentation around periphery of extravasated site
Document extent and management of Insert blunt Verres needle, or pink
the injury in medical record cannula with needle removed, into
each incision in turn, and irrigate
FOLLOW-UP AND REVIEW damaged tissue with hyaluronidase*
Determined by grade of extravasation followed by sodium chloride 0.9%. It
neonatal medical staff review minor should flow freely out of other incisions
grades after 24 hr Massage out any excess fluid using
neonatal/plastic surgery staff/tissue gentle manipulation
viability nurse review Grades 3 and 4 Cover with paraffin gauze for 24–48 hr
within 24 hr to assess degree of tissue
damage and outcome of irrigation
procedure if performed
Issue 6
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*Preparation of hyaluronidase
Reconstitute a 1500 unit vial of
hyaluronidase with 3 mL of water for
injection
Use 1-2 mL shared between each
incision then irrigate with sodium
chloride 0.9%
When irrigating with sodium chloride
0.9%, use discretion depending on
baby’s weight
Documentation
Person performing procedure must
document in baby’s medical record
Issue 6
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EXTREME PREMATURITY • 1/2
INTRODUCTION <24 weeks’ gestation
Outcomes for premature babies at Discuss with parents national and local
borderline viability generally improve statistical evidence for survival in
with each additional week of babies with range of disabilities found
gestational age. See EPICure studies in this age group
http://www.epicure.ac.uk/ explain that statistics indicate most
If ultrasound scan performed within a babies born <24 weeks’ gestation are
week before delivery, an estimated likely to die and a significant proportion
fetal weight of <500 g at any gestation of survivors are likely to have some
between 22+0 and 25+6 weeks is form of neurological impairment
associated with a very poor outcome;
MANAGEMENT AT SPECIFIC
Draper charts demonstrate predicted
survival of a fetus alive at the onset of GESTATIONS
labour weighing 250–500 g at 22, 23, Between 24+0 and 24+6
24, 25 and 26 weeks are 2,4,5,7, and weeks’ gestation
8% respectively
Provide full, invasive, intensive care
Estimation of gestational age by and support from birth and admit to
ultrasound when carried out in first NICU unless parents and clinicians
trimester of pregnancy is most reliable: agree that, in view of baby’s condition
if fetal heart heard during labour, call (or likely condition) intensive care is
paediatric team to attend delivery not in his/her best interests
once baby delivered, further Between 23+0 and 23+6
resuscitation and management
decisions should be made in baby’s
weeks’ gestation
best interests, taking into account Give precedence to parents’ wishes
clinical condition at birth e.g. heart rate, regarding resuscitation and invasive
breathing, weight, severity of bruising intensive care treatment. However,
to skin etc.; obtain urgent senior advice when condition at birth indicates that
baby will not survive for long, clinicians
Discussion with parents before birth, if
are not legally obliged to proceed with
possible, should precede any action,
treatment that is wholly contrary to
preferably by obstetric and paediatric
their clinical judgement, if they
teams jointly
consider treatment would be futile
Document all discussions in case records
as a first step, determine whether baby
MANAGEMENT is suffering, whether any suffering can
be alleviated, and likely burden placed
An experienced neonatologist to be
on baby by intensive care treatment
present at delivery of extremely
premature babies (<27 completed where parents would prefer clinical team
weeks’ gestation) and make to make decision about initiation of
confirmatory assessment of gestational intensive care, clinicians must determine
age and condition of baby what constitutes appropriate care
where it has not been possible to
≥24 weeks’ gestation discuss a baby’s treatment with mother
Unless baby has a severe abnormality and, where appropriate, her partner,
incompatible with any significant period before the birth, clinical team should
of survival, initiate intensive care and consider offering full invasive intensive
admit to neonatal intensive care unit care until baby’s condition and treatment
(NICU) can be discussed with parents
Issue 6
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EXTREME PREMATURITY • 2/2
If baby is born in good condition, Parent information
initiate resuscitation using IPPV (via
‘Information for parents of extremely
ETT or facemask if good chest
premature babies’ leaflet available to
movement obtained)
download from
if baby does not improve and heart www.epicure.ac.uk/index.php/download_file
rate remains low at 10 min after /view/150/
effective ventilatory support, withhold
further resuscitation
response of heart rate to ventilation is
critical in deciding whether to continue
or stop. Counsel parents with sensitivity
that further interventions are futile
Between 22+0 and 22+6

weeks’ gestation
Standard practice should be not to
resuscitate a baby and this would
normally not be considered or
proposed
If parents request resuscitation, and
reiterate this request, discuss risks and
long-term outcomes with an
experienced neonatologist before
attempting resuscitation and offering
intensive care
Treating clinicians must all agree that
this is an exceptional case where
resuscitation is in a baby’s best
interests
<22 weeks’ gestation

Resuscitation should never occur in
routine clinical practice
any attempt to resuscitate babies born
at this gestational age should take
place only within the context of an
approved research study
When intensive care not given,

clinical team must provide palliative
care until baby dies. Refer to BAPM
guidelines for counselling
Issue 6
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FOLLOW-UP OF BABIES DISCHARGED FROM
THE NEONATAL UNIT • 1/2
INDICATIONS or serum bilirubin >10 x gestational
Birth weight <1501 g age (weeks) in preterm infants
Gestation <32 weeks Major congenital anomalies (consider
early referral to general paediatrician)
Requiring IPPV or CPAP for more than
a few hours Persistent hypoglycaemia
Significant cranial ultrasound Consultant discretion
abnormality on final scan on NNU Babies who have undergone surgery
Acute neonatal encephalopathy grade for congenital heart disease in early
2 or 3 neonatal period
Seizures (of whatever cause) PROCEDURE
Neonatal meningitis Refer to neonatal follow-up clinic
Abnormal neurological examination at
Follow-up timetables
discharge
These tables are a guide to usual
Neonatal abstinence syndrome
number of appointments according to
requiring treatment (see Abstinence
each neonatal condition
syndrome guideline)
Adjust follow-up to individual needs
Exchange transfusion for any
reason/immunoglobulin for Follow local policy to book appointments
hyperbilirubinaemia/in-utero transfusion with relevant professionals
High risk preterm babies born <32 weeks or <1501 g

1st follow- 2nd 3rd 4th 5th 6th
Indications/criteria up from from from from from from
discharge EDD EDD EDD EDD EDD
Prematurity 6 weeks 4 months 8 months 12 months 18 months 2 years
<32 weeks or <1501 g Height, weight, OFC; neurological, medical and developmental assessment
≥32 weeks and >1500 g with severe neonatal illness

1st follow- 2nd 3rd 4th 5th 6th
Indications/criteria up from from from from from from
discharge EDD EDD EDD EDD EDD
Nitric oxide/ECMO or
HIE grade 2/3/therapeutic
cooling or intracranial 4–6
6–8 weeks 12 months 18 months 2 years
bleeds/infarcts months
cystic PVL/significant
IVH/ventricular dilatation
32–33+6 weeks and
>1500 g well premature
babies or meningitis or
abnormal neurological 4–6
examination, seizures or 6–8 weeks 12 months
months
treated neonatal
abstinence or
severe jaundice needing
exchange/immunoglobulin
Term ventilation/CPAP/
culture-positive sepsis/ 6–8 weeks
persistent hypoglycaemia
Issue 6
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FOLLOW-UP OF BABIES DISCHARGED FROM
THE NEONATAL UNIT • 2/2
Two-year neuro- Babies with problems
developmental follow-up identifiable early
Babies born <32 weeks or weighing For babies with Down's syndrome,
<1501 g or with moderate to severe severe hypoxic ischaemic
encephalopathy/therapeutic cooling or encephalopathy or at consultant
who required nitric oxide/ECMO, carry discretion, involve patch consultant
out structured neuro-developmental community paediatrician and pre-
assessment (Bayley’s/SOGS/Griffith’s) school therapy team early, before
at 2–2.5 yr corrected age discharge if appropriate
For babies with concurrent medical
Babies ≥34 weeks with
problems (e.g. cardiac problem,
transient problems chronic lung disease), arrange co-
(e.g. mild jaundice, feeding ordinated follow-up (decided on
problems, hypoglycaemia, individual basis following discussion
culture-negative sepsis etc.) between community and neonatal
May require specific advice to consultants)
community team/general practitioner Refer children with impaired vision
about monitoring/follow-up, but usually and/or hearing to consultant
do not need neonatal follow-up community paediatrician
See relevant guideline for follow-up for
other conditions e.g. syphilis, HIV,
hepatitis, cardiac murmurs etc.
FURTHER MANAGEMENT
AT CLINIC
Neuro-developmental
problems identified
Refer to child development centre
and/or specialist services e.g.
physiotherapist, speech and language
therapist and dietitian according to
baby’s individual needs
Refer to patch consultant community
paediatrician
referral may be made at time the
problem is identified or later if more
appropriate for the family
For complex medical problems, e.g.
ongoing cardiac or respiratory disease,
shared neonatal follow-up
Issue 6
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GASTRO-OESOPHAGEAL REFLUX (GOR) • 1/2
INTRODUCTION INVESTIGATIONS
There is very little evidence to support a 24 hr pH monitoring is of limited value
causal relationship between GOR and its in preterm babies. Consider in cases
assumed consequences such as where repeated apnoea/bradycardia is
apnoeas, respiratory distress and failure resistant to other measures
to thrive, especially in preterm babies. The following investigations to be
Therefore, avoid widespread use of anti- considered after discussion with
reflux medications consultant:
RECOGNITION AND if repeated apnoea/bradycardia,
ASSESSMENT consider 24 hr pulse oximetry
recordings to assess extent of problem
Symptoms and relationship to feeding
Frequent vomiting after feeds in an if apnoeas/bradycardia persist at term-
otherwise healthy baby equivalent, consider a video
Recurrent desaturation and/or apnoea fluoroscopic assessment of sucking-
Recurrent desaturations in ventilated swallowing co-ordination and GOR
babies [exclude bronchopulmonary MANAGEMENT
dysplasia (BPD) spells]
Position
Chronic lung disease of prematurity
may be worsened by recurrent Head upwards, at an angle of 30º
aspiration caused by GOR Nurse baby prone or in left lateral
position if monitored
Risk factors
Immaturity of the lower oesophageal Feeding
sphincter Frequent low volume feeds
Chronic relaxation of the sphincter Avoid overfeeding
Increased abdominal pressure Gaviscon Infant (1 dose = half dual
Gastric distension sachet):
Hiatus hernia breastfed: give during or after a feed
(add 5 mL sterile water/milk to make a
Malrotation
paste, then add another 5–10 mL and
Oesophageal dysmotility give with a spoon)
Neuro-developmental abnormalities bottle fed: add to at least 115 mL milk
Differential diagnosis nasogastric tube (NGT) fed: make up
with 5 mL water and give 1 mL per
Suspect cow’s milk protein intolerance 25 mL of feed
(CMPI) in babies who are formula milk
fed or have fortifier added to maternal Caution: Gaviscon Infant contains
breast milk, and have recurrent 0.92 mmol of sodium per dose
vomiting/irritability/apnoeas despite
appropriate management of GOR.
Platelet count may be raised and is
consistent with, though not diagnostic
of, CMPI
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GASTRO-OESOPHAGEAL REFLUX (GOR) • 2/2
If symptoms persist, consider change Drugs (see Neonatal
to Instant Carobel (will thicken with Formulary)
cold or hand-warm milk). Add 2 scoops
In severe cases with no improvement
to 100 mL, shake well and leave for
after above measures and after
3–4 min to thicken. Shake feed again
discussion with senior or specialist,
and give immediately. Take care that
use only with caution:
thickened liquid does not block fine
bore NGT ranitidine (licensed) or omeprazole
(non licensed)
Do not give Gaviscon Infant and
Carobel together as this will cause the There is no evidence to support use
milk to become too thick of drugs in GOR
H2 receptor antagonists such as
Other measures ranitidine may increase risk of sepsis
If symptoms persist, consider other or necrotising enterocolitis
measures after discussion with Erythromycin may facilitate bacterial
consultant e.g: resistance and is not recommended
dairy free diet for a breastfeeding
mother or trial of cow’s milk protein- Parent information
free formula (in artificially fed babies)
Offer parents the following information,
some babies with suspected CMPI are available from:
also allergic to hydrolysate and will
respond to an amino acid-based http://www.bliss.org.uk/reflux
formula. Some can also be allergic to
the lipid in Neocate
if trial commenced, continue for a
minimum period of 2 weeks with
careful symptom monitoring
assessment by speech and language
therapy team as poor suck-swallow
co-ordination can result in aspiration
during feeds if unable to protect
airway; can also occur following an
episode of GOR
Issue 6
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GASTROSCHISIS • 1/4
DEFINITION DELIVERY
Congenital defect of the anterior Neonatal middle grade and junior
abdominal wall resulting in herniation of grade or ANNP attend delivery
bowel. The herniated viscera are not Take a size 8 Fr nasogastric tube
covered by any surrounding membranes (NGT) and a gastroschisis bag (often
and are exposed to amniotic fluid during labelled as a bowel bag). This is a
pregnancy and air following delivery large sterile bag which can be closed
around baby’s chest with a draw-string
DIAGNOSIS
Babies become cold very quickly and
Majority of cases diagnosed on
experience fluid loss from the exposed
antenatal ultrasound scan
bowel. Perform the following, as
Refer mothers to a fetal medicine rapidly as possible:
department
clamp cord with plastic clamp (not
Refer parents to paediatric surgery for artery forceps) placed approximately
antenatal counselling 5 cm from baby’s abdomen, checking
Give parents gastroschisis information cord clamp is securely fastened. If in
leaflet. Offer them the opportunity to doubt, apply a second plastic cord
visit the neonatal intensive care unit clamp adjacent to the first
(NICU) where the baby will be delivered dry upper part of baby quickly
PRE-DELIVERY initiate resuscitation as required. Avoid
prolonged mask ventilation, if
Gastroschisis is a surgical emergency,
resuscitation prolonged, intubate
delivery should be planned in
appropriate level neonatal unit aiming pass NGT and fix securely
to transfer to paediatric surgical unit empty baby’s stomach by aspirating
within 4 hr of birth NGT with a 10 or 20 mL syringe.
Antenatal and postnatal care must be If <20 mL of fluid aspirated, check
carefully planned. Communication position of tube
between groups of professionals and place tube on free drainage by
the parents is essential connecting to a bile bag
Prior to delivery the case should be If stomach protruding through defect
discussed with the local paediatric (Image 1), ensure it is decompressed
surgery unit
If no surgical cot is available there and
delivery cannot be postponed, then the
neonatal team will need to identify a
potential cot at the nearest alternative
paediatric surgical centre
Once baby is induced or mother is in
labour, inform transport team or
retrieval team as appropriate
Issue 6
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Image 1
Right Left
Branches of gastroepiploic vessel

Umbilical cord
Umbilical defect
Gastroschisis bowel
Gastroepiploic vessel is a longitudinal
vessel running along the greater
curvature of the stomach and helps
identify the stomach from the bowel
Image 1
If stomach cannot be decompressed, call surgical registrar for further advice. Failure
to decompress the stomach can cause pressure on the bowel mesentery resulting in
bowel ischaemia
Aspirate NGT gently. If the stomach fails to decompress, gently manipulate to
facilitate this, whilst aspirating the NGT
Take great care not to cause reflux of stomach contents up the oesophagus around
the tube but simply aid drainage
Assess colour and alignment of bowel
Using sterile gloves handle the bowel carefully to ensure it is not twisted or kinked
and there is no traction on the mesentery (Image 2)
Image 2 To head
Stomach
Umbilical cord
Normally aligned
small bowel
mesentery
without kink
To legs
Issue 6
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Place baby onto the same side as the Monitor central perfusion, using central
defect (usually right) and support capillary refill time, at least every
bowel on a folded nappy placed 15 min. Give further fluid boluses as
slightly under baby required to maintain a normal CRT
Check perfusion of bowel. If vascular <2 sec. Babies with gastroschisis
compromise suspected, call consultant have a high fluid requirement until the
neonatologist herniated bowel is replaced in the
abdomen
if compromise persists, inform surgical
team immediately Start IV antibiotics (benzyl penicillin,
gentamicin and metronidazole) use
Place baby’s legs and trunk into Neonatal Formulary
gastroschisis bag, feet first, and pull
draw-string under baby’s arms so both Give IM vitamin K (see Vitamin K
arms are outside of the bag guideline)
Alternatively, cover and support Discuss baby's condition and treatment
intestines with cling film from upper plan with parents and ensure they have
chest to lower abdomen, holding seen the baby before transfer. Take
intestines in central position photographs for parents
ensure intestines are visible Inform staff at the surgical unit, that baby
is ready for transfer. Have available:
do not wrap cling film tightly as this will
reduce perfusion name
Show baby to parents and transfer to gestational age
NNU weight
Check global perfusion using central ventilatory and oxygen requirements
capillary refill time mother’s name and ward (if mother
Check perfusion of bowel again admitted) – including contact number if
immediately before transfer to NNU possible (for consent)
and at least every 15 min thereafter
Blood samples
IN NNU Baby
Inform transport co-ordination team
Blood culture
immediately as this is a time critical
transfer (aim <4 hr from delivery) FBC and clotting studies, including
fibrinogen
Monitor perfusion and alignment of
bowel at least every 15 min U&E
Insert IV cannula, avoid potential long Blood glucose
line veins Capillary/venous blood gas
Avoid umbilical lines Check with surgical unit if sample from
Infuse 20 mL/kg either sodium chloride baby for group & save, Coombs’ or
0.9% or human albumin solution crossmatch required (e.g. Birmingham
(HAS) 4.5% over 1 hr and start routine Children’s Hospital do not need these
IV maintenance fluids – see IV fluid before transfer as these are done at
therapy guideline surgical unit)
Aspirate NGT again and record Send 1 bloodspot on neonatal
volume. Replace NG losses mL-for-mL screening card marked as 'pre-
with sodium chloride 0.9% + 10 mmol transfusion' (for sickle cell screening)
potassium chloride/500 mL IV with the baby to surgical unit
Issue 6
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Mother TRANSFER TO SURGICAL
Obtain sample of mother’s blood for UNIT
crossmatch Inform surgical unit that transfer is
handwrite form, completing all relevant underway
sections fully. Indicate this is the mother Place baby in transport incubator,
of baby being transferred and include taking care to transfer bowel and
baby’s name. This information will be mesentery in a supported, non-kinked
required by surgical unit blood bank position. Keep stomach empty
AWAITING TRANSFER TO place baby on side of defect and
support bowel on a folded nappy just
SURGICAL UNIT
slightly under baby. Check bowel
Continue to assess bowel perfusion perfusion immediately and at least
and alignment every 15 min every 15 min
Reassess baby’s fluid requirements ensure mother’s blood, baby’s pre-
hourly. If fluid boluses required, give transfusion bloodspots, letters for
10 mL/kg sodium chloride 0.9% IV surgical team and all documentation
If evidence of a coagulopathy, treat accompanies baby
with fresh frozen plasma (FFP) or
cryoprecipitate, as appropriate – see During transport
Coagulopathy guideline Carry out and document usual
Aspirate NGT hourly and replace observations, include bowel perfusion
aspirate volume, mL-for-mL with and alter its position if necessary
sodium chloride 0.9% with 10 mmol
Arrival at surgical unit
potassium chloride/500 mL IV
Record bowel perfusion and alignment
Leave the NGT on free drainage
Useful information
DOCUMENTATION
Complete nursing and medical surgery
documentation for transfer.
Electronically transfer any X-rays to http://www.bch.nhs.uk/find-us/maps-
the surgical unit (or obtain copies of X- directions
rays) Parent information/support organisation
Ensure mother’s details are included (GEEPS – gastroschisis page)
(including ward phone number if an in- http://www.geeps.co.uk/gastroschisis.htm
patient and own number if discharged) NHS Fetal Anomaly Screening
as if operation necessary and a parent Programme gastroschisis guideline
unable to attend surgical unit, surgeon
will require verbal telephone consent
Ensure baby’s documentation
includes:
whether vitamin K has been given
name of referring consultant
whether parents received antenatal
counselling
mother’s name, ward (if admitted) and
her contact details
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GOLDEN HOUR
Preterm babies <28 weeks’ gestation • 1/3
INTRODUCTION AIM
The care preterm babies receive within To stabilise and perform all procedures
the first few hours and days of life has a required by the baby within the first hour
significant impact on their long-term of life
outcomes. The CESDI 27–28 study
highlighted the importance of good early
care for preterm babies with particular
reference to effective resuscitation (see
Resuscitation guideline)
BEFORE DELIVERY
Nurses Doctors/ANNPs
Identify nurse responsible for admission Registrar or experienced ANNP is
and redistribute existing babies responsible for early care of babies
Ensure incubator set up and pre- <28 weeks’ gestation
warmed with humidity set at maximum counsel parents appropriate to
Check monitor and appropriate gestation
connections <26 weeks, discuss delivery with
Set oxygen saturation limits at 91–95% consultant, who will attend whenever
possible
Ensure ventilator and NeopuffTM
plugged in and checked Prescribe infusions for UAC and UVC
Ensure appropriate size face masks Check resuscitaire in delivery suite
available ensure overhead heater switched on
Prepare suction and catheters and set to maximum
Ensure transport incubator pre-warmed set peak inspiratory pressure (PIP) at
and cylinders full 20 cmH2O and FiO2 at 0.21
Ensure endotracheal tube (ETT) sizes check saturation monitor and probe
2.5 and 3.0 are available available
Set up trolley for umbilical arterial Prepare plastic bag
catheter (UAC) and umbilical venous
catheter (UVC) beside incubator
Prepare infusion fluids for UAC and
UVC
Take resuscitation bag and saturation
monitor to delivery
Issue 6
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GOLDEN HOUR
AFTER DELIVERY
Keep baby warm with plastic Competent practitioner, ANNP or middle grade
bag and hat doctor to attend
Assist with resuscitation If normal delivery and baby breathing, delay
clamping of cord for up to 2 min providing baby
Accurate time-keeping including
can be kept warm
resuscitation and procedures
If operative or instrumental delivery, cut cord
Attach oxygen saturation probe immediately and take baby to resuscitaire
to right hand
Place baby in plastic bag
Assist with ETT fixation Cover baby’s head with appropriate size warmed
Set up transport incubator and hat
transfer baby to it Assess colour tone, heart rate and breathing
Ensure baby labels in place If baby breathing regularly, commence CPAP at
before transport 5 cmH2O
Ensure midwives have taken If baby not breathing regularly, give 5 inflation
cord gases breaths at 20–25 cmH2O using T piece and face
Transfer baby to neonatal unit mask
(NNU) monitor response: check heart rate, colour and
respiratory effort
if baby does not start to breath, give ventilation
breaths with pressure of 20/5 and rate of
40–60/min
if heart rate not above 100 bpm or falls, observe
chest movement and if poor, increase pressures
to 25/5
observe chest movement throughout and
consider reducing inspiratory pressure if
necessary (e.g. to 16–18)
when heart rate >100 bpm or chest movement
seen, check saturation monitor and adjust FiO2
aiming to bring saturations close to NLS guidance
If continued IPPV necessary, intubate
If unit policy is to give surfactant on labour ward,
ensure appropriate ETT position and fix securely
before administering surfactant
Review baby once placed in transport incubator:
air entry
colour
heart rate
saturation
Complete joint resuscitation record and obtain
signature from maternity team
Show baby to parents
Senior member of staff to talk briefly to parents
Transfer baby to NNU
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GOLDEN HOUR
FIRST HOUR ON NNU
Aim for at least 1:1 nursing care Reassess ABC
for first hour Split tasks between doctors/ANNPs
Transfer to incubator in plastic
bag Doctor/ANNP A
Prescribe weight-dependent drugs and
Weigh baby in plastic bag
infusions and vitamin K
Leave baby in plastic bag until Write blood test forms and prepare blood bottles
incubator reaches adequate
Start admission notes (BadgerNet)
humidity
Attach baby to ventilator or Doctor/ANNP B
CPAP driver and reassess ABC Check ETT position clinically and administer
If ventilated, pre-warm surfactant if not previously given on labour ward
surfactant and prepare Check ventilation – review tidal volume and
surfactant administration chest movement
equipment (e.g. TrachCare if tidal volume >5 mL/kg or vigorous chest
MacTM) movement, reduce PIP without waiting for first
Monitor heart rate and gas
saturation check saturations and adjust FiO2 to keep
Record blood pressure + saturation 91–95%
baseline observations Insert UAC and UVC through hole in plastic bag
Do not use ECG leads on commence infusions as soon as line secured
babies <26 weeks’ gestation
Take blood for:
Measure axillary temperature
on arrival FBC
clotting if clinically indicated
Insert nasogastric tube (NGT)
group and DCT
Assist doctor/ANNP with lines
blood culture
Give vitamin K blood glucose
Give first dose of antibiotics pre-transfusion bloodspot
Take a photograph for parents arterial gas
Defer peripheral IV cannula insertion unless
unable to gain umbilical access
Once lines inserted, request X-rays
Document
ETT position
NGT length
UAC and UVC positions at time X-ray taken
Write X-ray report in notes
Update parents and document in notes
Once baby set up – minimise handling

Hands off – Eyes on
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HEARING SCREENING • 1/2
INTRODUCTION How
Early intervention improves the Oto-Acoustic Emissions (OAE) +/-
outcome for babies with a congenital Automated Auditory Brainstem
hearing deficit Response (AABR) according to
Screening for congenital deafness is national ‘Well baby’ or ‘NICU’ protocols
undertaken through the NHS Newborn neonatal staff must inform screeners if
Hearing Screening Programme baby has ever spent >48 hr on NNU
(NHSP) by trained screeners so that NICU protocol can be used
according to national guidelines. They babies on transitional care are
are automatically informed of all births screened using the ‘Well baby’
and will ensure babies are screened protocol (unless previously on NNU for
Neonatal staff must understand how >48 hr)
their local programme is organised,
the risk factors for congenital deafness When
and know how to work with the Screen only when baby has reached
screeners 34 weeks (corrected age)
INDICATIONS Where
Who Well babies
All babies are eligible for screening, Screening is performed as an inpatient
unless they have previously been before discharge or in the community.
diagnosed with bacterial meningitis or See Table 1 for local details
their ear canal is not patent on one or
both sides NNU babies
neonatal staff must refer babies with Arrange screening as close to
meningitis to audiology for an urgent discharge as possible, when baby is
assessment (NHSP referral to be well enough to test and preferably
completed and handed to the once major medical treatment, ototoxic
screeners who will book a diagnostic or other drug treatment complete
appointment) Do not screen babies transferring to
screeners will refer babies with non- another NNU
patent canal for urgent diagnostic Complete screening of babies on NNU
assessment >48 hr by 44 weeks (corrected age)
PROCEDURE FOLLOW-UP
Consent Neonatal team must ensure all babies
diagnosed with bacterial meningitis are
Screening can only be performed with
parental consent referred for an urgent audiology
assessment and are not screened
screeners will obtain verbal consent
from parents (if present) before Screeners will arrange routine follow-
screening up according to screening results and
presence of other specific risk factors
if baby on neonatal unit (NNU) and
parents absent, screeners will leave
an explanatory leaflet and gain verbal
consent from parents during their visit
to NNU or over the telephone
Issue 6
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HEARING SCREENING • 2/2
Risk factors Babies with the following risk factors
are not followed up by audiology, but
Neonatal staff must inform the screener
data is collected for audit purposes:
of the following risk factors in order that
the appropriate follow-up at 7–9 months severe jaundice (at exchange level)
can be arranged: multiple abnormalities with
proven or possible congenital infection neurodegenerative/neuro-
(CMV, rubella, toxoplasmosis) developmental disorder
cranio-facial anomalies, cleft palate, mechanical ventilation >5 days
deformed pinnae (not simple ear tags)
Screener will determine presence of
syndromes associated with hearing other risk factors before screening:
loss (Down’s, Waardenburg, Alport,
Usher etc.) family history of permanent hearing
loss in childhood
baby has been treated with ECMO
those with first-degree relative will be
followed up in audiology
FURTHER INFORMATION
Detailed information available from NHSP website:
https://www.gov.uk/topic/population-screening-programmes/newborn-hearing
Table 1: Local details
Alexandra Hospital, Redditch

Russells Hall Hospital, Dudley Usually performed by trained staff in the
Shrewsbury & Telford Hospitals community
New Cross Hospital, Babies on NNU usually screened before
Wolverhampton discharge
Worcester Royal Hospital
Hereford County Hospital
Birmingham City Hospital

Birmingham Heartlands Hospital
Birmingham Women’s Hospital Screening for all babies usually
performed while still an in-patient,
Good Hope Hospital, Sutton usually at bedside
Coldfield
Manor Hospital, Walsall
Royal Stoke University Hospital
Sandwell Hospital MLU Screening performed as an out-patient

Solihull Hospital MLU unless baby transferred into a main
maternity/neonatal unit
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HEART FAILURE • 1/3
DEFINITION SYMPTOMS AND SIGNS OF
Congestive cardiac failure occurs CARDIAC FAILURE
when heart is unable to pump Tachycardia
sufficient blood to meet metabolic
Tachypnoea
demands of body tissues
Hepatomegaly
underlying cause may be cardiac or
non-cardiac Excessive weight gain
Hypotension
Causes
Murmur
Non-cardiac Abnormal femoral pulses
Sepsis
in obstructive left heart lesions,
Hypoxia femoral pulses may not be absent if
Anaemia duct still patent
Polycythaemia weak femoral pulses are significant
Fluid overload INVESTIGATIONS
AV malformation Blood gas including lactate
Pulmonary hypertension Chest X-ray
Cardiac look for cardiomegaly and pulmonary
oedema
Left ventricular outflow tract (LVOT)
obstruction (see below) Echocardiogram
Left-to-right shunt (see Increased left- BP – check in right arm and one of the
to-right shunt below) legs (a difference of >20 mmHg
between an upper and lower limb is
Arrhythmia
significant)
TGA
Pre- and postductal saturations
Left ventricular outflow postductal saturations can be
tract obstruction considerably lower than preductal in
Hypoplastic left heart syndrome aortic arch defects (a difference of
>2% is significant)
Critical aortic stenosis
Coarctation TREATMENT OF CARDIAC
Interrupted aortic arch FAILURE DUE TO
OBSTRUCTIVE HEART
Clinical differentiation between an DISEASE
obstructed systemic circulation and
severe sepsis is extremely difficult as If left-sided obstructive lesion
a murmur and weak pulses can be suspected, treat with inotropes and
common to both. use diuretics cautiously
For baby in extremis, presence of
abnormal pulses alone is sufficient Resuscitation
indication to start a prostaglandin
Airway
infusion until a cardiac lesion has
been excluded by echocardiography – Intubate and ventilate babies presenting
see Prostaglandin infusion guideline collapsed or with obvious cyanosis in
association with cardiac failure
Issue 6
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Routine intubation not indicated When cardiac output low:
If apnoea occurs secondary to a ensure adequate intravascular volume
prostaglandin infusion, intubate baby correct anaemia
but do not alter infusion dobutamine may be required for poor
Breathing perfusion
See Ventilation – conventional SUBSEQUENT MANAGEMENT

guideline – TRANSFER
Ventilate with PEEP 5–6 cm
Baby must be kept warm and
Adjust ventilation to maintain: normoglycaemic
PaCO2 5–6 kPa
Discuss further management and
pH >7.25 transfer with regional cardiac centre
Circulation Babies who respond to a
prostaglandin infusion may not need
Vascular access with 2 IV cannulae or transferring out-of-hours
umbilical venous catheter (UVC) – see
Appropriately skilled medical and
Umbilical venous catheterisation
nursing staff are necessary for transfer
guideline
Intubation
Presence of cyanosis and a murmur
suggest baby likely to respond to An intubated baby requires a cardiac
prostaglandin infusion centre ITU bed: do not intubate
routinely for transfer
Prostaglandin infusion to maintain
ductal patency (see Prostaglandin Intubate if:
infusion guideline) continuing metabolic acidosis and poor
open duct with dinoprostone perfusion
(prostaglandin E2, prostin E2), see long-distance transfer necessary
Neonatal Formulary. Start at 5–10 inotropic support needed
nanogram/kg/min, may be increased to
apnoea occurring
50 nanogram/kg/min, but only on
cardiologist advice recommended by cardiac team
Monitor blood pressure invasively DISCHARGE FROM
[ideally using a peripheral arterial CARDIAC CENTRE
cannula rather than an umbilical Baby may go home or return to a
arterial catheter (UAC)] paediatric ward or neonatal unit, possibly
Cardiac output on a prostaglandin infusion whilst awaiting
surgery or for continuing care after a
Assess cardiac output, it is likely to be palliative procedure (e.g. septostomy)
low when:
tachycardia persists Management plan
BP remains low Regardless of outcome, obtain a
management plan from cardiac centre,
acidosis persists defining:
high lactate acceptable vital signs (e.g. saturations)
peripheral perfusion poor medication, including dosage
ensure prostaglandin infusion adequate follow-up arrangements
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INCREASED LEFT-TO-RIGHT SHUNT
RECOGNITION AND Investigations

ASSESSMENT Chest X-ray looking for fluid overload
Definition Echocardiogram
Any lesion causing increased MANAGEMENT
pulmonary blood flow
If in cardiac failure, give immediate
Usually presents when pulmonary dose of diuretic
resistance falls after 48 hr
May require maintenance diuretics
Size and type of lesion will influence (discuss with cardiologist)
time of presentation
usually furosemide 1 mg/kg twice daily
Differential diagnosis and amiloride 100 microgram/kg twice
daily orally
AVSD
Discuss with cardiac centre for
Partial AVSD
definitive management and follow-up
VSD
Truncus arteriosus
PDA
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HEPATITIS B and C • 1/2
HEPATITIS B Labour
Check mother’s hepatitis B status before When an HBsAg +ve mother arrives in
birth labour or for caesarean section, labour
ward must inform on-call neonatal team
Antenatal
Midwife to inform obstetrician, Postnatal
neonatologist, public health team and For all newborns, check screening
GP of plan to immunise results of mother’s antenatal tests
Hepatitis B immunoglobulin (HBIG) If antenatal testing not done, request
issued by Public Health England (PHE) urgent maternal HBsAg test
via local consultant microbiologist. Mother may breastfeed
Order well in advance of birth
IMMEDIATE POSTNATAL TREATMENT OF BABY

To which babies
Immunoglobulin
Maternal status Vaccine
(HBIG)
required by baby
required by baby
HBsAg positive, HbeAg positive Y Y
HBsAg positive, HBeAg negative, HBe
Y Y
antibody (anti-HBe) negative
HBsAg positive where e markers have
Y Y
not been determined
Acute hepatitis B during pregnancy Y Y
HBsAg positive and baby <1.5 kg Y Y
HBsAg positive, anti-HBe positive Y N
HBsAg positive and >106 iu/mL
Y Y
Hepatitis B DNA in antenatal sample
Other high risk group Y N
Give low-birth-weight and premature What

babies full neonatal dose hepatitis B
Give hepatitis B vaccine 0.5 mL IM.
vaccine
Caution: brands have different doses
Give HBIG and hepatitis B vaccine to [e.g. Engerix-B® 10 microgram
babies with birth weight <1.5 kg born to (recommended), HBVaxPro Paediatric®
mother with hepatitis B, regardless of 5 microgram]
mother’s HBeAg status
HBIG 200 units additionally given to
Give hepatitis B vaccine to HIV babies of highly infectious mothers
exposed/infected babies (see Table above)
When Monitor infants born <28 weeks’
gestation for 72 hr after HBIG
Give within 24 hr of birth, ideally as
soon as possible after delivery
Issue 6
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HEPATITIS B AND C • 2/2
How with close family contacts known to be
Use two separate injection sites for HBsAg positive
hepatitis B vaccine and HBIG, in who intend to live in a country with high
anterolateral thighs (not buttocks) prevalence of hepatitis B (Africa, Asia,
Give hepatitis B vaccine IM, except in Eastern Europe, Northern Canada,
bleeding disorder where it may be Alaska)
given deep subcutaneously
Dose regimen
Relationship to other If mother HBsAg +ve, 1st dose within
immunisations 24 hr, 2nd dose at 1 month, 3rd at 2
No need to delay BCG following HBIG months, 4th at 12 months and pre-
Hepatitis B vaccine may be given with school booster
other vaccines, but use separate site. If mother HBsAg –ve, 1st dose before
If same limb used, give vaccines discharge, 2nd at 1 month, 3rd at 6
>2.5 cm apart months and pre-school booster
Documentation Advise GP of schedule or give in
Record immunisation in red book hospital
SUBSEQUENT MANAGEMENT HEPATITIS C
Further doses Antenatal
2nd dose at 1 month High-risk groups:
3rd dose at 2 months intravenous drug users (or women with
4th dose at 12 months partners who are IVDU)
Give appointment for next dose or from a country of high prevalence [e.g.
ensure agreement to give vaccine at North Africa (particularly Egypt),
GP practice or immunisation team Middle East]
1 year follow-up Discuss baby testing with mothers who
Book 1 year hospital blood test before had hepatitis C during antenatal period
neonatal discharge If maternal HCV RNA -ve, baby not at
Check child’s HBsAg status at one risk
year old
Postnatal
if HBsAb, refer to infectious disease or
liver team for further management Hepatitis C antibody testing after 18
months (serum, clotted specimen)
ROUTINE HEPATITIS
If antibody +ve or if HIV co-infected,
IMMUNISATION test for HCV RNA (EDTA)
To whom If RNA +ve, check ALT and refer to
Hepatitis B immunisation recommended regional hepatitis unit
with other routine immunisations for
high-risk babies born to mothers: Documentation
with partners who are hepatitis B Document hepatitis C follow-up visits
surface antigen (HBsAg) positive in Red book to ensure health visitor
with partners who are intravenous aware and baby followed up
drug users (even if HBsAg negative)
Breastfeeding
who change sexual partners frequently
(e.g. commercial sex workers) Mother may breastfeed
Issue 6
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HERPES SIMPLEX • 1/1
MOTHER WITH GENITAL MOTHER WITH NO HISTORY
LESIONS, SUSPECTED HSV OF GENITAL HERPES
Strict infection control for mother and BEFORE PREGNANCY
baby (PRIMARY HSV)
Recommend breastfeeding unless Swab nasopharynx, conjunctiva,
herpetic lesions around nipple mouth and rectum in viral transport
medium for HSV PCR
Vaginal delivery or
Check infant’s ALT and send blood for
Rupture of membranes >6 hr or
HSV PCR
Fetal scalp electrode or other
Start aciclovir 20 mg/kg IVI over
instrumentation
1 hr 8-hrly. If ALT abnormal or other
Mother signs of infection send CSF for HSV
PCR
Swab lesions in viral transport medium
for HSV PCR Stop aciclovir if neonatal HSV PCR -ve
Infant TREATMENT
Within 24 hr of delivery swab Duration aciclovir
nasopharynx, conjunctiva, mouth and if CSF HSV -ve and ALT normal give
rectum 10 days IV aciclovir
in viral transport medium for HSV PCR if ALT raised and CSF -ve give 14 days
Send EDTA blood for HSV PCR aciclovir IV
if skin, eye or mouth lesions give
MOTHER WITH HISTORY OF 10 days aciclovir IV
GENITAL HERPES BEFORE
if CSF HSV +ve, repeat LP at 14 days
PREGNANCY (PREVIOUS HSV
and if -ve stop at 21 days
INFECTION) BUT NO ACTIVE
LESIONS OR DELIVERY BY If HSV disease give aciclovir
300 mg/m2 oral 8-hrly for 6 months
CAESAREAN SECTION
No swabs or treatment
Good hand hygiene
Advise to seek medical help if skin,
eye or mucous membrane lesions,
lethargy/irritability, poor feeding
Issue 6
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HIGH-FLOW NASAL CANNULAE (HFNC)
RESPIRATORY SUPPORT • 1/1
DEFINITION SETTING AND FLOW RATE
Delivery of humidified, heated and Set operating temperature at 36–38ºC
blended oxygen/air at flow rates between Start at flow rate of 4–6 L/min (flow
1–8 L/min via nasal cannula rates >6 L/min in babies <1 kg –
discuss with on-call consultant)
INDICATIONS
Use up to 8 L/min in babies >1 kg,
Treating or preventing apnoea of
unless baby requires FiO2 >0.4 or has
prematurity
CO2 retention, acidosis or apnoea, in
Respiratory support for babies with:
which case consider alternative support
Respiratory distress syndrome (RDS)
– first-line or post extubation Ensure there is leak around the prongs
chronic lung disease MONITORING

meconium aspiration Continually
pulmonary oedema Heart rate
pulmonary hypoplasia Respiratory rate
pneumonia SpO2
Babies slow to wean off nasal CPAP If on supplemental oxygen or on
Babies with nasal trauma from nasal clinical grounds – blood gases
CPAP Prescribe supplemental oxygen on
drug chart
WEANING FLOW RATES

FiO2 >0.3 May not be possible to wean flow rate
FiO2 <0.25 in baby >1.5 kg Attempt to reduce by 1.0 L/min 24-hrly
FiO2 <0.25 in baby <1.5 kg Attempt to reduce by 1.0 L/min 48-hrly
FiO2 0.25–0.3 Attempt to reduce by 1.0 L/min 48-hrly
Requiring ≤2.0 L/min Attempt to stop (baby in air does not require nasal
prong oxygen)
If baby in oxygen, put in 0.2 L/min of nasal prong
oxygen initially
Clinical instability
Increased work of breathing Consider pneumothorax (rare)
Significant increase in FiO2
CONTRAINDICATIONS
Upper airway abnormalities
Ventilatory failure
Severe cardiovascular instability
Frequent apnoeas (despite caffeine in preterms)
Issue 6
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HUMAN IMMUNODEFICIENCY VIRUS (HIV) • 1/2
Maternal to child transmission of Low risk group
HIV can be prevented only if maternal Maternal viral load <50 copies/mL
HIV status known Give baby zidovudine for 4 weeks
ANTENATAL High risk group

Check latest version of care plan and Mother’s viral load >50 copies/mL or
last maternal HIV viral load not known
If mother is to have IV zidovudine, Give baby zidovudine, lamivudine and
prescribe it antenatally nevirapine
Confirm labour ward has the If maternal resistance and viral load
antiretrovirals indicated for this baby >50, follow individualised plan
Recommend formula feeding; provide If mother diagnosed postpartum, start
bottles/steriliser if necessary baby on triple therapy immediately if
if mother wishes to breastfeed, refer to <72 hr old
HIV team TREATMENT OF BABY
absolutely avoid mixed feeding with Do not delay treatment for blood tests
bottle and breast or any other reason
Maternal blood tests Start as soon as possible after birth,
Check every mother’s HIV results definitely within 4 hr
if no result, recommend mother tested

urgently (point of care if available)
if declined, offer baby testing (urgent
HIV antibody)
if declined and from sub-Saharan
Africa, refer to specialist midwife or
HIV team
Zidovudine 4 week dosing schedule

>34 weeks and feeding 4 mg/kg oral 12-hrly
>34 weeks and not tolerating feeds 1.5 mg/kg IV over 30 min 6-hrly
30–34 weeks and on feeds 2 mg/kg oral/NG 12-hrly for first 2 weeks THEN
2 mg/kg oral/NG 8-hrly for second 2 weeks
<30 weeks and on feeds 2 mg/kg oral/NG 12-hrly
<34 weeks and not tolerating feeds 1.5 mg/kg IV over 30 min 12-hrly
Lamivudine 2 mg/kg oral 12-hrly for 4 If medication cannot be given orally,

weeks give IV zidovudine
Nevirapine 2 mg/kg oral daily for 1 if high risk, change to oral zidovudine
week then 4 mg/kg daily for 1 week, for 4 weeks as soon as medication can
then stop be given orally and add oral lamivudine
if mother on nevirapine >3 days, give for 4 weeks and nevirapine for 2 weeks
baby 4 mg/kg daily for 2 weeks then
stop
Issue 6
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HUMAN IMMUNODEFICIENCY VIRUS (HIV) • 2/2
If maternal viral load >50 copies/mL and Notify lead consultant for HIV who will
antiretroviral resistance, discuss with notify British Paediatric Surveillance
lead consultant for HIV perinatal care Unit (BPSU)
Advice available (24 hr) from regional Follow-up appointment with lead
hub [e.g. Birmingham Heartlands consultant for HIV at 6 weeks
Hospital (0121 424 2000), North Ensure all involved have record of
Manchester (0161 624 0420), London: perinatal care: mother, paediatrician,
St Mary’s (0207 886 6666) or St obstetrician, infectious diseases
George’s (0208 725 3262)] consultant
TESTING OF BABY SUBSEQUENT MANAGEMENT
HIV RNA PCR (viral load 2 mL EDTA) Investigations
at local virology laboratory if agreed
policy HIV RNA (or DNA) PCR at 6 weeks
and 3 months
Otherwise HIV DNA PCR (1.3 mL
EDTA) sent to PHE at Colindale with HIV antibody at 2 yr if laboratory only
paired sample from mother (complete using combined antibody/antigen test,
Reference Test form, available to (or 18 months if earlier generation
download from antibody test used)
https://www.gov.uk/government/upload PCP prophylaxis
s/system/uploads/attachment_data/file/
344580/S3_HIV_Reference_Test.pdf If maternal viral load >1000 copies/mL
or unknown, give baby co-trimoxazole
Day 1 (or within 48 hr after birth if 120 mg babies >2 kg; babies <2 kg
weekend/bank holiday)
900 mg/m2 or 24 mg/kg
DISCHARGE AND FOLLOW-UP once daily 3 times a week (Monday,
Advise postnatal staff not to Wednesday, Friday)
recommend breastfeeding start at 4 weeks
Give mother cabergoline to suppress stop if HIV PCR still negative at
milk 3 months
If mother does breastfeed, monthly
Immunisations
HIV RNA PCR testing for mother and
baby Unless high risk of TB and last
maternal viral load <50 copies/mL, and
If baby vomits within 30 min of taking
exclusively formula fed, delay BCG
medicines, or if medicine is seen in the
vaccination of baby until results of
vomit, give the dose again
3 month PCR tests negative
Bring next dose forward up to 6 hr
Recommend all other vaccinations as
after last dose for mother to give at a
per routine schedule (including MMR)
convenient time
Round dose up to nearest easily
measurable volume
Dose does not need to be changed
with baby’s weight gain
Ensure mother confident to give
antiretrovirals to baby
Dispense 4 weeks’ supply on discharge
Issue 6
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HYDROPS FETALIS • 1/2
DEFINITION SYMPTOMS AND SIGNS
Abnormal accumulation of fluid in two Hydrops fetalis is diagnosed antenatally
or more compartments of the fetus (a
Refer all antenatally diagnosed
compartment can be skin, pleura,
hydrops fetalis to a regional fetal
pericardium, placenta, peritoneum or
medicine centre for further
amniotic fluid)
assessment and management
Two recognised types – immune and
non-immune INVESTIGATIONS
immune hydrops fetalis occurs when Refer to fetal medicine team to
maternal allo-immune antibodies are investigate both mother and baby to
produced against fetal red cells determine the cause. (Investigations
causing haemolysis carried out by the fetal medicine team
non-immune hydrops fetalis occurs in are beyond the scope of this guideline)
the absence of maternal antibodies Due to the extensive list of causes of
hydrops fetalis, investigations should
Mortality is high – between 56% and
78.2% in developed countries be directed according to clinical history
and presentation. Initial investigations
to consider include:
Further investigations
to be considered if
Cause Initial investigations
underlying cause is not
ascertained
Anaemia Full blood count (including Red cell enzyme deficiency
blood film) (e.g. G6PD deficiency)
Group and Direct Coombs’ test Red cell membrane defects
Maternal Kleihauer test (e.g. hereditary spherocytosis)
Haemoglobinopathies (e.g.
thalassaemia)
Biochemistry Liver function tests including If pleural/ascitic tap done –
albumin send for fluid MC+S and
Urea, creatinine and electrolytes biochemistry
Cardiac ECG to exclude cardiac
dysrhythmias
Echocardiography to exclude
structural heart defects
Placenta Send to pathologist
Genetic testing Chromosomes Investigate for congenital
Microarray metabolic conditions
Infection Toxoplasma, rubella, CMV, parvo
virus, herpes simplex virus
Radiology Chest X-ray Further investigations to be
Abdominal X-ray guided by clinical picture
Cranial ultrasound scan
15–25% of babies diagnosed have no clearly discernible cause
Issue 6
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HYDROPS FETALIS • 2/2
TREATMENT Cardiovascular system
Antenatal treatment Use inotropes to support heart and
blood pressure
For immune hydrops the fetal
medicine team may carry out If intravascular fluid depletion give
intrauterine blood transfusions colloid
Further intensive monitoring is also Strict fluid balance
provided (discussion of this is beyond If severe compromise may require
the scope of this guideline) further pleural and ascitic taps
Immediate neonatal Immune hydrops may require
management exchange transfusion. See Jaundice
An expert team, including a neonatal and Exchange transfusion guidelines
consultant must attend delivery of a Even with optimal management,
baby diagnosed with having hydrops the mortality rate is high. Consider a
fetalis as resuscitation and stabilisation post mortem in the event of a death
can be difficult
Manage according to Neonatal Life
Support (NLS)
Consider concurrent pleural/ascitic

drains to facilitate resuscitation
In cases of severe anaemia, give
urgent O negative blood transfusions.
Baby may need further grouped and
cross matched blood transfusions in
the neonatal unit
Give only CMV negative and

irradiated blood
SUBSEQUENT MANAGEMENT
Ventilation
Ensure adequate oxygenation and
ventilation
May require high frequency oscillatory
ventilation (see HFOV guideline) and
muscle relaxation
If pulmonary hypertension present may
require nitric oxide (see Nitric oxide
guideline)
Issue 6
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HYPERGLYCAEMIA • 1/2
DEFINITION with severe unexpected dehydration or
metabolic acidosis
There is no established definition of
hyperglycaemia. However, treat if: with poor weight gain while receiving
>120 kcal/kg/day
two blood sugars are ≥14 on 2
occasions measured at least 2 hr apart Babies treated with
or
corticosteroids
blood sugars ≥12 on 2 occasions
Check urine for glycosuria daily
measured at least 2 hr apart with
evidence of significant glycosuria (++ Check blood glucose if ≥2+ glucose in
on the urine dipstick) urine
Do not take sample from an infusion line TREATMENT

that has glucose running through it If possible, discontinue or decrease
medications that worsen
CLINICAL FEATURES hyperglycaemia
Osmotic diuresis leading to dehydration Suspected infection/NEC
Poor weight gain Hyperglycaemia in baby with previously
stable blood glucose may be an early
Risk factors
indicator of infection or NEC
Immaturity of pancreatic function (e.g.
extremely premature infants and small- Assess baby clinically
for-gestational-age) After taking appropriate cultures, treat
empirically
Insulin resistance
Glucose overload (e.g. equipment Fluids
failure, administrator error) If blood glucose ≥12 mmol/L, check
Stress (e.g. infection, pain) urine for glycosuria (of ≥2+) and
Side effects of a medication (e.g. assess clinical hydration and fluid
glucocorticoid treatment) input/output. Check for fluid
administration errors
MONITORING Calculate amount of glucose baby is
Twice-daily receiving (as mg/kg/min) using the
formula:
Check blood glucose at least 6–8 hrly
in: Glucose infusion rate (mg/kg/min) =
unstable or acutely ill babies % glucose x fluid rate (mL/kg/day)
[respiratory distress syndrome (RDS), 144
septicaemia, necrotising enterocolitis If glucose delivery rate >10 mg/kg/min,
(NEC)] decrease glucose in increments to
Most blood gas machines provide 6–10 mg/kg/min. If on TPN,
blood glucose measurements 8–10 mg/kg/min is acceptable
If glycosuria and hyperglycaemia
Daily >12 mmol/L persists despite an
Check blood glucose at least once a appropriate glucose infusion rate,
day in stable babies: consider treating with insulin
<32 weeks’ gestation for first week
receiving TPN
Issue 6
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HYPERGLYCAEMIA • 2/2
Insulin ADMINISTRATION OF
Commence insulin therapy at 0.05 ACTRAPID INSULIN
units/kg/hr and titrate according to (SOLUBLE INSULIN)
response – see Administration of Follow instructions in Neonatal
Actrapid insulin below Formulary for making up insulin
Check blood glucose 1 hr from starting infusion
and hourly until target reached Administer Actrapid insulin infusion via
Increase by 0.02 units/kg/hr until blood a central line or a dedicated peripheral
glucose decreasing by at least cannula
1 mmol/L between blood samples Before starting infusion, prime all IV
Target blood glucose while on insulin connecting and extension sets and T-
is 6–8 mmol/L connectors with insulin infusion fluid.
Once blood glucose is stable, decide Check manufacturer’s guide on lumen
frequency of checking glucose capacity for priming volumes
clinically
When a baby is on insulin it is very
important to prevent hypoglycaemia –
see below
Preventing hypoglycaemia
Blood sugar Action
6–8 mmol/L and Maintain insulin infusion
stable rate
Reduce insulin infusion
6–8 mmol/L and
rate to 50% of present
decreasing
rate
<6 mmol/L Stop infusion
Re-check blood glucose 1 hr after

reducing dose, then 1–2 hrly until
stable
If unable to wean off insulin after 1
week, transient neonatal diabetes is
likely; consult paediatric
endocrinologist
Early introduction of PN and early
trophic enteral feeding will help reduce
incidence of hyperglycaemia requiring
insulin
Issue 6
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HYPERKALAEMIA • 1/2
RECOGNITION AND INVESTIGATIONS
ASSESSMENT If sample haemolysed, repeat and send
Plasma potassium >6 mmol/L (normal free-flowing venous or arterial sample
3.0–5.5 lithium heparin specimen) If potassium >6.0 mmol/L, connect to
Babies often tolerate concentrations up cardiac monitor
to 7.5–8.0 mmol/L without ECG changes
IMMEDIATE TREATMENT
SYMPTOMS AND SIGNS Serum potassium
Cardiac arrest >6.0 mmol/L
ECG abnormalities (see below): (stable with normal ECG)
tall peaked T waves Stop all K+ IV solutions, oral
widened QRS complex supplements and potassium-sparing
diuretics
sine waves (widened QRS complex
merging with T wave) Reconfirm hyperkalaemia
prolonged PR interval, bradycardia, Institute continuous ECG monitoring
absent P wave
Serum potassium
>7.0 mmol/L without ECG
changes
As above
Give salbutamol 4 microgram/kg IV in
glucose 10% over 5–10 min: effect
evident within 30 min but sustained
Tall, peaked T wave, widening of QRS benefit may require repeat infusion
after at least 2 hr
if IV access difficult, give nebulized
salbutamol 2.5 mg as a single dose
(difficult to administer if ventilated and
not formally evaluated in babies) and
repeat if necessary
Sine wave QRS complex (before cardiac arrest)
give furosemide 1 mg/kg IV
CAUSES If serum potassium still >7.0 mmol/L,
Renal failure: secondary to hypoxic give insulin 0.5 units/kg IV in glucose
ischaemic encephalopathy (HIE), 10% (made up to 2.5 mL and given
sepsis and hypotension, or structural over 30 min): very effective and has an
abnormalities additive effect with salbutamol
Cellular injury with potassium release Repeat U&E

e.g. large intraventricular Repeat insulin infusion as necessary
haemorrhage, haemolysis until K+ <7 mmol/L
Very low-birth-weight babies without Monitor blood glucose every 15 min
renal failure (non-oliguric for first 2 hr during and after infusion
hyperkalaemia) in first 12–48 hr aim for blood glucose 4–7 mmol/L
Excess K+ in IV solutions
Endocrine (congenital adrenal
hyperplasia)
Issue 6
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HYPERKALAEMIA • 2/2
Serum potassium SUBSEQUENT MANAGEMENT
>7.5 mmol/L with ECG Recheck serum K+ 4–6 hrly; when
changes arrhythmias present with renal failure,
As above, but first institute monitor hourly
emergency measures below: Monitor urine output and maintain
give 10% calcium gluconate 0.5 mL/kg good fluid balance
IV over 5–10 min If urine output <1 mL/kg/hr, unless
flush line with sodium chloride 0.9% or baby volume depleted, give
preferably use a different line furosemide 1 mg/kg IV until volume
corrected
give IV sodium bicarbonate (1 mmol/kg
over 2 min) this is effective even in Treat any underlying cause (e.g. renal
babies who are not acidotic (2 mL of failure)
sodium bicarbonate 4.2% = 1 mmol)
Further treatments: discuss
with consultant
A cation-exchange resin, such as
calcium resonium (500 mg/kg rectally,
with removal by colonic irrigation
8–12 hrly, repeat every 12 hr. Dose
can be doubled at least once to 1 g/kg
in severe hyperkalaemia). Useful for
sustained reduction in serum
potassium but takes many hours to act
and is best avoided in sick preterms
who are at risk of necrotising
enterocolitis (NEC)
If severe hyperkalaemia persists
despite above measures in term
babies with otherwise good prognosis,
contact renal team for consideration of
dialysis
Exchange transfusion using fresh
blood or washed red blood cells is
another strategy for sustained and
reliable reduction in serum K+
concentration – see Exchange
transfusion guideline
Issue 6
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HYPERNATRAEMIC DEHYDRATION • 1/4
DEFINITION Maternal breast abnormalities (flat,
inverted nipples)/surgery
Serum sodium >145 mmol/L
Maternal illness, haemorrhage
mild: 146–149 mmol/L
Maternal obesity
moderate: 150–160 mmol/L
Maternal diabetes
severe: >160 mmol/L
Polycystic ovary syndrome (PCOS)
Most common cause is failure to Skin conditions that increase
establish adequate oral intake while insensible water loss
attempting breastfeeding
Action
AIM Identify babies at risk
To prevent/treat hypernatraemic Immediate skin-to-skin contact at birth
dehydration while encouraging and breastfeed within 1 hr of life
breastfeeding
Offer breastfeeding assistance within
Other causes of 6 hr of life
hypernatraemia Assess baby to ensure feeding
Diarrhoea/vomiting adequate
Infection and poor feeding Ensure baby feeds at least 6 times
within 24 hr
Renal dysplasia
If baby reluctant to feed, express
Obstructive uropathy breast milk (see Breast milk
Diuretic phase following acute kidney expression guideline) and offer by
injury cup or syringe
Osmotic diuresis Calculate required volume of feeds
Diabetes insipidus using local guidelines
Idiopathic causes Avoid bottle feeding as far as possible
and avoid dummies
Sodium bicarbonate or sodium
chloride administration Assess feeding, number of wet
nappies and stools using Table
Excessive insensible losses in
extremely premature babies Avoid early discharge of at-risk babies
Improperly prepared formula Early re-weighing of at risk babies (at
72–96 hr) with breastfeeding support
PREVENTION can reduce severity of hypernatremic
Babies at high risk dehydration
Preterm <37 weeks
Born to primiparous women
Maternal prolonged second stage of
labour >1 hr
Use of labour medications
Caesarean section with delayed
initiation of feeding
Cleft lip and/or palate
Issue 6
139
Day Wet nappies Stool
1–2 ≥2/day >1/day
3–4 ≥3/day ≥2/day, changing in colour and consistency
5–6 ≥5/day ≥2/day, yellow in colour
Weigh between 72 and 96 hr
Refer all who have lost >10% weight
weight loss % = weight loss (g)/birth weight (g) x 100
Symptoms and signs Cognitive and motor deficits

Irritability/high pitched cry: unsettled Hearing impairment – may be transient
during breastfeeding Hypertension
Prolonged feeding >45 min Cerebral infarction
Demanding <6 feeds in 24 hr Renal failure
Reduced urinary frequency Death
Delayed change from meconium to Long term developmental delay
transitional stools
Weight loss Investigations
Fever U&E
Jaundice Calcium
Lethargy/altered level of consciousness Total bilirubin
Tremor Blood glucose
Increased tone CRP
Doughy skin Blood culture
Seizures (usually during rehydration) Paired urinary electrolytes
Physical examination may be

unremarkable
Usual signs of dehydration (sunken
fontanelle, reduced skin turgor) may
be absent
Complications
Venous and arterial thrombosis
Subdural and cerebral haemorrhage
Cerebral oedema (especially during
rehydration)
Seizures (especially following
rehydration)
Apnoea and bradycardia
Issue 6
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MANAGEMENT
Signs or symptoms of dehydration or

clinical suspicion of hypernatraemia
Moderate or severe
hypernatraemia – discuss
Send blood for U&E
with seniors.
Follow algorithm on next page
Mild hypernatraemia
Manage in postnatal ward

Put baby to the breast and encourage mother to express breast milk (EBM), see
Breast milk expression guideline
Top up baby with EBM/formula milk 100 mL/kg/day by cup or syringe
Check U&E and calcium after 12 hr
Monitor blood glucose as per Hypoglycaemia guideline
Aim to establish breastfeeding and reduce top-up once sufficient EBM
If Na+ returns to normal before sufficient EBM, liberalise feeds calculated according
to local guidance
Oral feeds not tolerated Baby improving:

Baby unwell continue routine postnatal care
Repeat U&E shows worsening repeat U&E
hypernatraemia, moderate or severe
hypernatraemia
Associated hypocalcaemia Routine postnatal examination
Follow-up with GP and community
midwife
Admit to neonatal unit
Issue 6
141
Baby admitted to neonatal unit
Examine and exclude other cause of hypernatraemia
Moderate or severe hypernatraemia Mild hypernatraemia
Unwell baby Well baby Put baby to breast

Top up with EBM/formula at
No 100 mL/kg/day via cup or syringe
Signs of shock? Tolerate enteral
feed If cup and syringe feeds not
Yes tolerated, pass nasogastric tube
Yes
and administer feeds (breast milk
Resuscitate with and/or formula milk)
10 mL/kg No If total enteral feeds not tolerated,
sodium chloride 0.9% give IV fluids to make up deficit
Start IV fluids at 100 mL/kg/day

Initially use sodium chloride 0.45% and Wean off formula feeds or IV
glucose 5% or 10% (or use 10% glucose and fluids on to breast or EBM as
add extra sodium) tolerated by baby
Subtract resuscitation fluid from calculated
maintenance fluid
Enteral rehydration is safe and effective if baby is clinically stable and should be used
in preference to IV
Repeat U&E 4-hrly
Aim for rate of fall in Na+ of 0.5 mmol/L/hr. If Na+ falling any faster, reduce rate of
rehydration or change fluids to sodium chloride 0.9% with glucose
If severe hypernatraemia, contact consultant
If low blood glucose, see Hypoglycaemia guideline
If in renal failure, suspected renal cause or Na+ >170 mmol/L, discuss with paediatric
nephrologist – may need dialysis
Monitor:
temperature
heart rate
blood pressure
Keep strict fluid balance chart
Monitor weight once or twice daily
Aim to correct dehydration over 48–72 hr or slower in severe cases
Do not correct hyperglycaemia with insulin, this can reduce plasma osmolality
rapidly and precipitate cerebral oedema
Once sufficient EBM available, aim to establish breastfeeding and reduce top-up
Neuro-developmental follow-up for all babies with moderate and severe hypernatraemia
Issue 6
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HYPOGLYCAEMIA • 1/6
DEFINITION
There is no agreed definition of hypoglycaemia in babies. Thresholds are therefore,
chosen as pragmatic approaches prompting clinical interventions if blood glucose falls
below certain levels (Table 1)
Table 1: Blood glucose thresholds for initiating treatment
Symptomatic and preterm babies <2.6 mmol/L
<2.0 mmol/L (no simple correlation between
Asymptomatic term babies
blood glucose levels and neuroglycopaenia)
PREVENTION
Dry baby and keep warm with skin-to-skin contact after birth
Encourage breastfeeding in accordance with ‘Baby Friendly’ guidelines
baby should feed within 1–2 hr after birth and continue breastfeeding at regular intervals
(3–4 hrly as a minimum)
it is particularly important that mothers of babies who are at risk of hypoglycaemia are
encouraged to breastfeed as colostrum and breast milk contain metabolites thought to
help babies cope with the physiological drop in blood glucose
if baby not able to suck effectively, use mother’s expressed breast milk (EBM)
Do not offer formula milk to breast-fed babies (unless it is mother’s informed choice)
Identify babies at risk of hypoglycaemia (Table 2) and initiate blood glucose
monitoring as soon as possible after birth
Table 2: Babies with risk factors for hypoglycaemia
Maternal conditions Neonatal conditions
Diabetes during pregnancy IUGR and SGA (<10th centile on WHO
Drug treatment (beta blocker/or growth chart or clinically wasted)
hypoglycaemic agents) Preterm (<37 weeks)
Hypothermia
Unwell baby
Suspected endocrine condition (e.g.
CAH)
Haemolytic disease of baby
Severe fluid restriction
Obvious syndromes (e.g. midline defects
Bethwith-Weidemann syndrome)
Screening for metabolic disorders (e.g.
family history of MCADD)
Babies on IV fluids or PN
TESTING BLOOD GLUCOSE

Obtain glucose using a ward-based glucometer (e.g. Medisense®) or a blood gas
analyser. Ensure equipment is calibrated regularly according to manufacturer’s
instructions
Record results as ‘blood glucose’ or ‘BG’ (not BM) in baby’s medical record
Issue 6
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Who to test When to test blood glucose
Babies at risk of hypoglycaemia (see Babies with risk factors for
Table 2) compromised metabolic
Babies with signs and symptoms adaptation (Table 2)
suggestive of hypoglycaemia Initial screening before the second
feeding poorly (despite support) feed, usually around 3–4 hr of age
hypothermia Subsequently:
hypotonia, limpness in first 24 hr of life before each feed,
lethargy or sleepy 3–4 hrly
seizures in second 24 hr of life 4–6 hrly
changes in levels of consciousness then as necessary
(e.g. irritability, drowsy, stupor or coma) As glucose is most likely to be low in
apnoeic or cyanotic spells first 24 hr, discontinue screening after
this time if baby is feeding well, or
If symptomatic hypoglycaemia, before if glucose levels ≥2 mmol/L (or
call urgently an advanced neonatal ≥2.6 for preterm) on 4 consecutive
nurse practitioner (ANNP) or a occasions
paediatric doctor for assessment If concerns persist, continue pre-feed
and immediate treatment checks
Babies on PN: measure blood
When to perform glucose at least daily
hypoglycaemia screen MANAGEMENT –
(investigations for underlying see flow chart
cause – see below)
Asymptomatic
All these babies are hypoglycaemia
managed in NNU
Feeding
Symptomatic hypoglycaemia
Correct hypothermia (see
Hypoglycaemia without risk factors
Hypothermia guideline)
Persistent or recurrent hypoglycaemia
If baby is feeding, increase frequency
Symptoms cannot be attributed and/or volume of milk
to hypoglycaemia if they persist In breast-fed, not able to suck
with normoglycaemia within 30 min. effectively, feeding can be
Jitteriness is rarely associated supplemented by mother’s expressed
with hypoglycaemia in term babies breast milk (EBM)
Glucose
Who NOT to test blood Repeat blood glucose measurement
glucose within 1 hr, if still low check laboratory
Healthy term babies born following blood glucose
normal pregnancy and delivery Give IV glucose if:
feeds not tolerated
intensive feeding does not normalise
or improve blood glucose
Issue 6
144
Give glucose 10% by infusion Recheck blood glucose in 30 min;
6 mg/kg/min (90 mL/kg/day) if still low, increase the infusion rate to
once normoglycaemia achieved, 8 mg/kg/min by increasing volume
reduce infusion as feeds tolerated (120 mg/kg/day) or increase the
concentration (glucose up to 12.5% via
If blood glucose on 2 consecutive peripheral venous line) depending on
blood glucose results <2.0 mmol/L baby’s daily requirement
(<2.6 for preterm) despite extra
feeding, support and interventions, If baby able to take some enteral feed
admit to NNU or TCU for more but cannot cope with the increased
intensive feeding regimen (e.g. volume, give remaining volume as IV
nasogastric tube feeding and/or a glucose
glucose infusion) Repeat blood glucose in 1 hr; if still low,
If baby symptomatic or if blood glucose increase glucose infusion rate to
is profoundly low (<1.5 mmol/L), 10 mg/kg/min either through increasing
follow guidance for Symptomatic or the volume to 150 mL/kg/day or if this is
profound hypoglycaemia (below) not possible increase concentration to
immediately 15% and then to 20%
Continue enteral feeding during If >12.5% of glucose concentration is
glucose IV and increase as tolerated required, give centrally through a long
line or an umbilical venous catheter
Symptomatic or profound (UVC), ensuring the tip is not in the
hypoglycaemia liver – see Long line insertion
guideline and Umbilical venous
Therapeutic goal of intervention is catheterisation guideline
different to thresholds to initiate
treatment. Glucose infusion in mg/kg/min =
Symptomatic babies and babies % glucose x fluid volume in mL/kg/day
with suspected hyperinsulinemia 144
are at higher risk of complications, If blood glucose still low, give Glucagon
therapeutic goal is to restore 200 microgram/kg IM, IV or SC
glucose to >3.3 mmol/L. (maximum 1 mg repeated only once if
For all other babies, aim is to needed)
restore ≥2.6 mmol/L
Check blood glucose 30 min after
Check laboratory blood glucose but do administration of Glucagon and hourly
not delay treatment after that until stable
Give 2.5–5 mL/kg glucose 10% IV at Do not use glucose concentration
1 mL/min. Always follow with glucose >20% in babies unless advised by
10% infusion of 6 mg/kg/min endocrinologist
(90 mL/kg/day). If necessary this can
be increased to up to one day ahead If symptomatic hypoglycaemia,
of daily requirement always verify blood glucose by
Feeds may continue if clinical situation sending sample for laboratory
allows and if tolerated glucose estimation
Aim for blood glucose >3.3 mmol/L
Step-down
and record baby’s response. Once
normoglycaemic, clinical signs of Once blood glucose normal and stable,
hypoglycaemia should disappear wean baby onto milk feeds slowly
within 30 min aiming to establish 3-hrly feeding
Issue 6
145
Other strategies SEVERE, PERSISTENT OR
Hypostop RECURRENT
HYPOGLYCAEMIA
Although hypostop has been shown to
cause slight increase in blood glucose Discuss with paediatric
when given to babies, the WHO expert endocrine/metabolic team.
panel found there was insufficient If hyperinsulinism suspected,
evidence to recommend its use in this discuss with national centre
situation for hyperinsulinism at
Preterm formula Manchester Children’s
Although preterm formula milk may Hospital
have a higher calorific content than Causes
breast milk, there is no evidence to
Hyperinsulinism
support its use in place of breast milk
during the management of Endocrine deficiency, especially
asymptomatic neonatal hypoglycaemia. panhypopituitarism
Breast milk has many other advantages Disorder of:
Routine additions of fatty acid metabolism
polymers (e.g. Maxijul) carbohydrate metabolism
Not recommended. If felt necessary, amino acid metabolism
discuss with neonatal dietitian and Rate of glucose infusion required is a
beware risk of necrotising enterocolitis good guide to likely cause
(NEC)
Substrate or endocrine deficiency <5 mL/kg/hr of glucose 10% (<8 mg/kg/min)

Hyperinsulinism >6 mL/kg/hr of glucose 10% (>10 mg/kg/min)
Investigations When to investigate further

(hypoglycaemia screen) Persistent recurrent hypoglycaemia,
Paired insulin and glucose estimations especially in low-risk baby
while hypoglycaemic (hyperinsulinism Unexpectedly profound hypoglycaemia
confirmed if insulin >10 picomole/L in a well baby
when glucose <2 mmol/L or
Hypoglycaemia in association with
glucose:insulin ratio <0.3)
metabolic acidosis and/or abnormal
LFT, TFT neurological signs
Blood gas Hypoglycaemia in association with
Urinary ketones and organic acids other abnormalities:
Serum C-peptide midline defects
Plasma cortisol and growth hormone micropenis
Plasma amino acids exomphalos
Plasma acylcarnitine erratic temperature control
Free and total carnitines Family history of SIDS, Reye’s
syndrome, or developmental delay
Fatty acids and beta hydroxybuturate
Galactosaemia screen
Issue 6
146
Documentation
Neonatal hypoglycaemia may be an early sign of other significant disease processes
requiring further investigation
Accurate contemporaneous documentation of events must be made in baby’s
medical record, including:
time hypoglycaemia noted
baby’s clinical condition when hypoglycaemia noted
blood glucose concentration and method by which it was measured
nature of treatment
nature and timing of clinical response to treatment
confirmation of improvement in blood glucose
Issue 6
147
Flowchart: Neonatal hypoglycaemia
Monitor at risk groups (see Table 2)
Keep warm and skin-to-skin contact

Feed within 1–2 hr of birth, breastfeeding recommended, aim for 2–3 hrly
Measure blood glucose (BG) before 2nd feed using ward glucometer or gas machine
Asymptomatic
BG BG
Term ≥2 mmol/L Term 1.5–1.9 mmol/L
Preterm ≥2.6 mmol/L Preterm 1.5–2.5 mmol/L
Continue feeding 2–3 hrly Feed immediately

Monitor pre–feed BGs Increase feed volume and frequency
Stay on postnatal ward if
appropriate
Repeat BG in 1 hr
BG ≥2.6 mmol/L BG 1.5–2.5 mmol/L Symptomatic and/or

BG <1.5 mmol/L
Continue feeding 2–3 hrly

Monitor pre–feed BGs
Urgent Review
Take lab sample glucose
and other tests as
4 consecutive BGs indicated
≥2.6 mmol/L Give IV bolus
Check lab BG and 2.5-5 mL/kg 10% glucose
other tests as indicated Admit to NNU
Admit to NNU for IV 10% glucose infusion
intensive feeding and/or Ensure symptoms
Stop BG checks IVI 10% glucose resolved
If ward glucometers give value of <X.X, assume BG <1.5 and check both gas
machine and lab BG to confirm
If anytime baby symptomatic or BG <1.5, give bolus 10% glucose and admit to
NNU for IV infusion
Threshold for initiating treatment is different from therapeutic goal for intervention
(most babies, BG therapeutic goal ≥2.6)
Therapeutic goal for symptomatic babies and suspected hyperinsulinism is BG >3.3
Issue 6
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HYPOKALAEMIA • 1/2
RECOGNITION AND CAUSES
ASSESSMENT Low intake/K+ concentration in IV fluids
Plasma potassium level less than Alkalosis (approximately 0.4 mmol/L
3.5 mmol/L or below normal level fall in K+ for every 0.1 unit rise in pH)
defined by local laboratory
Insulin administration
Symptoms may occur if potassium
level <3 mmol/L Diarrhoea (Note: K+ content of lower
GI losses is >upper GI losses)
Late sign of potassium depletion as
plasma/serum potassium maintained by Renal losses – diuretics, bicarbonate
administration or renal tubular acidosis
mobilizing intracellular potassium stores
Increased mineralocorticoid activity –
SYMPTOMS AND SIGNS as in hypovolaemia, 11 beta-
Muscle weakness and paralysis hydroxylase deficiency, (rarer form of
CAH – presents with virilization,
ECG changes
hypertension, and hypokalemia)
increased amplitude and width of
P wave INVESTIGATIONS
prolongation of PR interval Value confirmed on venous lab sample
T wave flattening and inversion (Note: ‘normal’ value on capillary
sample may be falsely reassuring if
ST depression sample has haemolysed and true
prominent U waves (best seen in value is lower)
precordial leads)
ECG
apparent long QT interval due to Cardiac monitor if ECG changes present
fusion of T and U waves
No investigations needed if
hypokalaemia is mild (serum level
3–3.5 mmol/L) and there is a reason
for baby to be hypokalaemic
Significant hypokalaemia (serum level
<3 mmol/L) and no obvious cause
check:
acid/base balance and bicarbonate
T wave inversion and prominent U wave level on blood gas
urinary K+ level. Level >20 mmol/L
suggest excess renal K+ losses
if baby is hypertensive plasma renin
and aldosterone
If hypokalaemia is not responding well
to replacement check magnesium level
Apparently long QT interval (actually T-U IMMEDIATE MANAGEMENT
fusion)
Normal maintenance K+ requirement is
Arrhythmias (premature atrial and 2 mmol/kg/day. Higher amounts will be
ventricular beats, sinus bradycardia, needed to correct hypokalaemia
paroxysmal atrial or junctional
tachycardia, atrioventricular block, and If baby is on insulin infusion, consider
ventricular tachycardia or fibrillation) stopping
Issue 6
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HYPOKALAEMIA • 2/2
Symptomatic babies SUBSEQUENT MANAGEMENT
Give rapid K+ supplementation Monitor potassium levels according to
Strong potassium clinical need
contains 20 mmol/10 mL Well babies receiving oral K+ check
level 1–2 weekly
must be diluted at least 50-fold with
sodium chloride 0.9% or a mixture of Babies on IV fluids or PN with mild
sodium chloride 0.9% in glucose prior hypokalaemia (potassium
to administration 3–3.5 mmol/L) check daily
maximal peripheral concentration Check more frequently in significant
40 mmol/L (1 mmol in 25 mL) hypokalaemia (serum level <3 mmol/L),
symptomatic hypokalaemia or if
maximal central concentration concentrations of potassium
80 mmol/L (1 mmol in 12.5 mL) >5 mmol/kg/day are being given
rate 0.2 mmol/kg/hr (maximum Once plasma/serum potassium level is
0.5 mmol/kg/hr if severe K+ depletion) normal, continue potassium
Monitor of K+ levels and cardiac supplementation for a further week if
monitoring necessary baby is orally fed to allow
Recheck potassium at 2–4 hr and replenishment of total body potassium
assess continuing need for infusion (intracellular) stores, or reduce
potassium down to 2 mmol/kg/day if
Asymptomatic babies baby is on IV fluids/TPN
Potassium replacement given Re-check the potassium level following
according to how baby is being fed this to ensure hypokalaemia does not
orally fed babies recur
- oral supplementation should be given
e.g. potassium chloride 1 mmol/kg
12–hrly dose – increased/titrated
according to response
babies on intravenous fluids
- potassium chloride 3–5 mmol/kg/day,
depending on electrolyte levels, may
be added to intravenous fluid
babies receiving parenteral nutrition
(PN)
- increase K+ concentration in the PN
to 3–5 mmol/kg/day
- if modified PN not available run K+
infusion 3–5 mmol/kg/day to run
alongside current PN
Issue 6
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HYPOTENSION • 1/3
Hypovolaemia is an uncommon cause Poor myocardial contractility (very-low-
of hypotension in the preterm newborn. birth-weight, hypoxia, cardiomyopathy
or hypocalcaemia)
Excessive volume expansion can
increase mortality Polyuria secondary to glucosuria
Third spacing (surgical causes –
DEFINITION NEC/perforation/malrotation/obstruction)
Thresholds for intervention High positive intrathoracic pressure
(high MAP on conventional/HFOV)
Aim to maintain mean arterial BP
≥ gestational age in weeks Severe acidosis (pH <7)
Aim for even higher mean arterial Drugs (morphine, muscle relaxants
blood pressure in case of persistent and anti-hypertensives)
pulmonary hypertension of the
IMMEDIATE TREATMENT
newborn – see PPHN guideline
Aim is to treat cause and improve organ
RECOGNITION AND perfusion, not to correct a ‘BP reading’
ASSESSMENT
Seek senior advice throughout
Assessment of BP
Measure mean arterial pressure Transilluminate chest to exclude
(MAP): pneumothorax – see Transillumination
by direct intra-arterial BP [umbilical of the chest guideline
arterial catheter (see Umbilical artery Fluid
catheterisation guideline) or
peripheral arterial line] Give if hypovolaemic (not >10 mL/kg
unless there is evidence of fluid/blood
automated oscillometry (Dinamap) has loss). Otherwise, start inotropes first
limited accuracy in hypotensive (see below)
preterm babies; usually over-reads BP
in the lower ranges If clinical condition poor, BP very low,
or mother has been treated with IV
Assess as many of the following antihypertensive agent, give inotrope
indices of tissue perfusion as possible after fluid bolus
(thresholds for abnormality in
brackets): Which fluid?
capillary refill time (>3 sec) Use sodium chloride 0.9% 10 mL/kg
toe-core temperature difference (>2ºC) over 10–15 min EXCEPT when there
is:
urine output (<1 mL/kg/hr)
coagulopathy with bruising: give fresh
blood lactate (>2.5 mmol/L) frozen plasma 10 mL/kg over 30 min
Causes of hypotension (see Coagulopathy guideline)
Sepsis Acute blood loss: give packed cells
10 mL/kg over 30 min
Extreme prematurity
Tension pneumothorax Reassess clinically within
10 min of bolus
Blood loss
Large patent ductus arteriosus (PDA) If hypotension persists, start inotropes
– see Patent ductus arteriosus – seek senior advice
guideline
Issue 6
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HYPOTENSION • 2/3
Inotropes Refractory hypotension
Evidence for the best choice of Seek senior advice before starting
inotropes is lacking and thus this adrenaline infusion. Depending on
guideline is suggested from the best individual circumstances, discuss
possible evidence and the safety of alternative agents (e.g. noradrenaline,
the commonly used inotropes vasopressin)
Use of adrenaline in <26 weeks’
Start dopamine at 5 microgram/kg/min gestation should only occur after
Reassess every 15–20 min discussion with consultant and used
only as a temporary measure and
If still hypotensive, increase dopamine
to 10 microgram/kg/min withdrawn as quickly as possible
if still hypotensive, add dobutamine at If acidotic with severe

10 microgram/kg/min hypotension, but not
if still hypotensive, increase hypovolaemic
dobutamine up to 20
Give adrenaline 100–1000
microgram/kg/min
nanogram/kg/min (see BNFc for
if still hypotensive, increase dopamine instructions on making up solution).
up to 20 microgram/kg/min If baby requires more than 1000
give hydrocortisone 2.5 mg/kg IV (over nanograms/kg/min, consider other
3–4 min) followed by 2.5 mg/kg IV inotropes
6–8 hrly for 2–3 days as necessary Monitor limb perfusion and urine
output
Do not use >20 microgram/kg/min
of dopamine (alpha effect causes
If cooling for hypoxic ischaemic
vasoconstriction)
encephalopathy (HIE) – refer to
In babies with poor cardiac function, Cooling guideline.
consider starting dobutamine first (also Vaso-constrictive agents can
discuss with cardiologist) reduce peripheral perfusion
In term babies requiring inotropes for
pulmonary hypertension an infusion of MONITORING
noradrenaline or adrenaline may be BP via arterial line (peripheral or UAC)
required (see PPHN guideline) – see Umbilical artery
catheterisation guideline
How
Check effective delivery of drugs:
Inotropes ideally given via central line
record volume in syringe hourly
When peripheral line used during
emergency (see BNFc for dilutions), check for leaks
monitor site carefully for extravasation ensure correct position of UVC or long
injury (see Extravasation injuries line delivering inotropes
guideline) Chest X-ray:
Continuing hypotension if intubated
Echocardiogram where possible to urgent, if respiratory status worsening
assess myocardial look for air leak or over-inflation
dysfunction/congenital heart disease
Issue 6
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HYPOTENSION • 3/3
Signs of tissue perfusion:
blood gases including lactate
urine output
capillary refill
heart rate
Echocardiogram, where possible to
assess function and structure
If already on morphine and muscle
relaxant infusion, reduce dosage if
possible
If ventilated, try to reduce mean airway
pressure without compromising chest
inflation and oxygenation
If baby acidotic and not responding to
treatment, consider sodium bicarbonate
Weaning inotropes if
hypotension improves
Wean inotropes (dopamine or
dobutamine) in 5 microgram/kg/min
decrements and adrenaline in
100 nanogram/kg/min decrements) as
tolerated and directed by senior advice
Issue 6
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HYPOTHERMIA • 1/2
DEFINITION Babies <32 weeks
Axillary temperature <36.0ºC Dry head and put on hat
Do not dry remainder of baby
ASSESSMENT
Place in polythene bag feet first
Babies at risk immediately and keep inside bag until
Preterm <30 weeks’ gestation placed in pre-heated pre-humidified
Low-birth-weight incubator. Do not cover the polythene
bag during transfer
Sick baby
Small for dates Other babies
Use pre-warmed towel, dry
Consequences (<36.0ºC)
immediately after delivery
Hypoglycaemia
Discard towel and wrap in another pre-
Metabolic acidosis warmed towel and blanket
Hypoxia with increased oxygen Ensure room warm enough to enable
demands skin-to-skin contact and early
Increased metabolic rate breastfeeding
Clotting disorders Cover exposed skin with warm blanket
Shock Avoid giving bath immediately after birth
Apnoea Neonatal unit
Intraventricular haemorrhage Keep at 24–25ºC to avoid cooling from
Persistent pulmonary hypertension radiant heat loss, and ‘misting’
Decreased surfactant production and (condensation) in incubators
function Keep incubators and cots away from
windows to prevent radiation heat loss
Causes of heat loss
Nurse babies requiring intensive care
Radiation: heat lost to cooler objects in in pre-warmed incubator
the room
For very premature babies, use
in cold environment, whether in humidification
incubator or not, excessive heat may
be lost
in excessively hot environment or in Incubator temperature during first
direct sunlight, baby could overheat in 3 days
incubator Incubator
Birth weight (g)
Conduction: heat lost to cooler temperature (ºC)
surfaces on which baby is placed 1000 35
Convection: heat lost due to drafts 1500 34
Evaporation: heat lost through water 2000 33.5
evaporating from skin 2500 33.2
PREVENTION 3000 33
4000 32.5
Delivery suite
Keep room 23–28ºC and free from
draughts, especially when babies are
due to be delivered
Issue 6
154
HYPOTHERMIA • 2/2
Babies <1000 g may require even REWARMING OF
higher temperatures, occasionally HYPOTHERMIC BABIES
>37ºC
Rewarm in incubator
If baby’s temperature remains within
>1200 g, rewarm at 1ºC/hr
normal limits for 24 hr, reduce
incubator temperature according to <1200 g, rewarm more slowly
baby’s needs
Take care not to overheat babies.
When baby’s weight reaches about Aim for 36.5–37.5ºC
1600 g, or according to local practice,
transfer to open cot
Rainout may occur if the difference

between temperature in incubator
and room temperature is >5ºC:
ensure room temperature kept at
locally agreed level
Babies not at risk of

hypothermia
If not requiring observation of
respiratory status or excessive
invasive procedures, babies may be:
dressed
kept wrapped
placed in a cot
Mild hypothermia can be managed

with the addition of:
hats
cot lids
heated mattresses
If baby’s temperature <36.0ºC
consider:
use of incubator, if available
increasing humidity, if appropriate for
gestational age
bubble wrap
skin-to-skin
Recheck temperature in 1 hr
Issue 6
155
HYPOTHYROIDISM • 1/3
SCREENING Consultant meeting
Congenital hypothyroidism (CHT) is Consultant to arrange to meet parents
included in routine neonatal blood spot on same or next day to:
screening at age 5–8 days explain abnormal result
In preterm babies of ≤31+6 weeks’ examine baby using screening
gestation, repeat at 28 days of age or laboratory proforma as an aide-mémoire
at discharge, whichever is sooner
look for other abnormalities (10% in
Screening relies on measurement of
CHT versus 3% in baby without CHT),
raised blood spot TSH
congenital heart disease (pulmonary
Reporting of screening result stenosis, ASD and VSD) is
Initial TSH concentration of: commonest anomaly
<10 mU/L: negative result – CHT not commence treatment
suspected stress importance of daily and life-long
≥20 mU/L: positive result – CHT treatment
suspected provide parent information leaflet
If CHT suspected, newborn screening (available from
laboratory will notify designated http://www.gosh.nhs.uk/medical-
consultant or on-call consultant information/search-medical-
≥10 mU/L but <20 mU/L: borderline conditions/congenital-hypothyroidism)
result Document discussion and
Newborn screening laboratory will management plan and follow-up and
arrange a repeat sample to be collected send to GP and parents
and tested. If repeat sample result is: Complete and return data form to
<10 mU/L: negative result – CHT not clinical biochemist at screening
suspected laboratory
≥10 mU/L: positive result – CHT Obtain further diagnostic
suspected
tests
IMMEDIATE MANAGEMENT Baby
Informing diagnosis 1 mL venous blood in heparinised
If screening test result indicates container for FT4 and TSH
congenital hypothyroidism, a well- send repeat dried blood spot card to
informed healthcare professional screening laboratory
(community midwife, neonatal
1 mL venous blood for serum
outreach nurse, health visitor or GP)
thyroglobulin
must inform parents face-to-face
do not communicate an abnormal ultrasound or radionuclide scan of
result on Friday, Saturday or just thyroid, the latter preferably within
before a weekend if consultant meeting 5 days of starting levothyroxine;
cannot be arranged within next 24 hr ultrasound can be performed at any age
provide parents with information leaflet Mother
‘congenital hypothyroidism suspected’ take 3 mL venous blood from mother
(available from into a heparinised container for FT4,
https://www.gov.uk/government/uploads/
TSH and thyroid antibodies
system/uploads/attachment_data/file/
396288/CHT_is_suspected_LR.pdf
Issue 6
156
TREATMENT do not add to bottle of formula
Start treatment with levothyroxine after suspensions not advised due to
obtaining confirmatory blood tests. variable bioavailability
Do not wait for results unless transient repeat dose if baby vomits or
hypothyroidism suspected. Treatment regurgitates immediately
must start before 18 days of age, and
Record date treatment commenced
preferably by 14 days. For those
detected on repeat sampling, treatment Provide parents with 28 day
should ideally commence by 21 days prescription for levothyroxine
and certainly before 24 days Arrange continued prescription with
after discussion with paediatric GP, emphasising need to avoid
endocrinologist, consultant may suspensions
withhold treatment if transient
FOLLOW–UP
hypothyroidism suspected
Arrange follow-up after
Starting dose levothyroxine
commencement of hormone
10–15 microgram/kg/day with a
replacement therapy as follows:
maximum daily dose of 50 microgram.
Aim to maintain serum FT4 in upper 2 weeks, 4 weeks, 8 weeks, 3 months,
half of normal range by 2 weeks 6 months, 9 months, 1 yr, 18 months,
treatment and for normalisation of TSH 2 yr, 30 months, 3 yr, yearly thereafter
by 4 weeks At each clinic visit:
Adjustment required depending on physical examination, including height,
thyroid function test results weight and head circumference
Tablets are 25 microgram strength developmental progress
it is not necessary to divide tablets for blood sample for thyroid function test
intermediate dose; administer (FT4, FT3 and TSH, just before usual
intermediate dose, such as daily medication dose)
37.5 microgram, as 25 and request as FT4 priority, then TSH
50 microgram on alternate days
Crush required levothyroxine dose
using tablet crusher (if tablet crusher
not available, between 2 metal
spoons) and mix with a little milk or
water, using teaspoon or syringe
Interpretation of thyroid function test results

Analyte Age Concentration
0–5 days 17–52
FT4 (pmol/L) 5–14 days 12–30
14 days–2 yr 12–25
0–14 days 1–10
TSH (mU/L)
15 days–2 yr 3.6–8.5
Check reference ranges with your laboratory’s assay
Issue 6
157
Aim for FT4 towards upper limit of AFTERCARE
normal range Reassure parents that baby will grow
at higher concentrations of FT4, normal into healthy adult with normal
concentrations of T3 (produced by intelligence
peripheral conversion) are achieved Stress importance of regular treatment.
if FT44 concentration satisfactory but As half-life is long, it is not
necessary to give an extra tablet
with significantly raised TSH, consider
next day if a day's treatment missed
non-compliance
Give details of:
TSH concentration does not always
normalise under 6 months and may be British Thyroid Foundation, 2nd floor,
slightly raised up to 3 yr of age in 3 Devonshire Place,
absence of non-compliance, probably Harrogate HG1 4AA
due to reset feedback mechanism 01423 709707/709448
http://www.bsped.org.uk
Overtreatment may induce tachycardia,
nervousness and disturbed sleep
patterns, and can produce premature
fusion of cranial sutures and
epiphyses. If symptoms of
overtreatment or very suppressed TSH,
reduce dose of levothyroxine
Issue 6
158
HYPOXIC ISCHAEMIC ENCEPHALOPATHY
(HIE) • 1/4
RECOGNITION AND INVESTIGATIONS
ASSESSMENT Bloods
Risk factors FBC
History of non-reassuring Blood culture
cardiotocography (CTG) Clotting screen
Fetal heart rate abnormalities during Renal and liver profile, calcium,
labour magnesium
Low Apgar score Glucose
Acidotic umbilical arterial or venous Blood gas including lactate
gas Urine dipsticks
Need for prolonged resuscitation Cranial ultrasound
SYMPTOMS AND SIGNS Generalised increase in echogenicity,
indistinct sulci and narrow ventricles
Acute neonatal
After 2–3 days of age, increased
encephalopathy echogenicity of thalami and
Altered state of consciousness parenchymal echodensities
(irritability, unresponsiveness to After 1 week, parenchymal cysts,
stimulation) ventriculomegaly and cortical atrophy
Abnormal tone (hypo/hypertonia, Cerebral Doppler used early, but does
abnormal posturing, decerebrate not affect management
rigidity, extensor response to painful relative increase of end-diastolic blood
stimulus) flow velocity compared to peak systolic
Seizures blood flow velocity (Resistive Index
Weak (or no) suck <0.55) in anterior cerebral artery predicts
poor outcome (repeat after 24 hr)
Hypo/hyperventilation
MR scan of brain between
Other signs and symptoms
days 10–14 of life
related to effects on other
organ systems For baby with moderate and severe
encephalopathy (see Table) and in baby
Renal failure with seizures due to encephalopathy
Respiratory distress syndrome, Hypodense areas in thalamus, basal
particularly if preterm ganglia and internal capsule indicate
Pulmonary haemorrhage poor prognosis
Persistent pulmonary hypertension of Cerebral function monitoring
the newborn
(aEEG)
Myocardial ischaemia and hypotension Normal trace upper margin above
Hepatic failure 10 microvolts and lower margin above
Necrotising enterocolitis 5 microvolts
Hypoglycaemia Moderately abnormal trace upper
margin above 10 microvolts and lower
Fluid retention margin below 5 microvolts
Disseminated intravascular Severely abnormal upper margin
coagulation (DIC) below 10 microvolts and lower margin
below 5 microvolts
Issue 6
159
(HIE) • 2/4
EEG Criterion A
Normal EEG during first 3 days has Babies ≥36 completed weeks’
good prognosis gestation admitted to neonatal unit
with at least one of the following:
Lack of normal background activity is Apgar score ≤5 at 10 min after birth
associated with a poor outcome
continued need for resuscitation,
IMMEDIATE TREATMENT including endotracheal or mask
Prompt and effective resuscitation ventilation, at 10 min after birth
Maintain body temperature, avoid acidosis within 60 min of birth (defined
hyperthermia as umbilical cord, arterial or capillary
pH <7.00)
In babies ≥36 weeks’ gestation requiring
continued resuscitation at 10 min after base deficit ≥16 mmol/L in umbilical cord
birth, institute passive cooling by or any blood sample (arterial, venous or
switching off overhead warmer capillary) within 60 min of birth
IV access For babies meeting criterion A, assess
whether they meet neurological
Isotonic glucose-containing IV fluids at abnormality entry criteria (B) with at
40 mL/kg/day. See Intravenous fluid least one of the following:
therapy guideline
Criterion B
WHEN TO CONSIDER
Seizures or moderate-to-severe
TREATMENT WITH TOTAL
encephalopathy comprising:
BODY COOLING
altered state of consciousness (reduced
Treatment criteria or absent response to stimulation) and
Babies meeting criteria A and B for abnormal tone (focal or general
treatment with cooling – see Cooling hypotonia, or flaccid) and
guideline
abnormal primitive reflexes (weak or
absent suck or Moro response)
Criteria for defining moderate and severe encephalopathy

Parameter Moderate Severe
encephalopathy encephalopathy
Level of consciousness Reduced response to Absent response to
stimulation stimulation
Spontaneous activity Decreased activity No activity
Distal flexion, complete
Posture Decerebrate
extension
Hypotonia
Tone Flaccid
(focal or general)
Suck Weak Absent
Moro Incomplete Absent
Pupils Constricted Constricted
Heart rate Bradycardia Variable
Respiration Periodic breathing Apnoea
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(HIE) • 3/4
SUBSEQUENT MANAGEMENT Further fluid restriction if serum
sodium falls and weight gain/failure to
If decision made to treat baby lose weight
with total body cooling, If in renal failure, follow Renal failure
see Cooling guideline guideline
This should always be a
consultant decision Acidosis
Will normally correct itself once adequate
If not using total body cooling, respiratory and circulatory support
continue with management below
provided (correction occasionally
Oxygen required during initial resuscitation)
Avoid hypoxaemia. Maintain PaO2 Sodium bicarbonate correction is rarely
required post resuscitation and it is
10–12 kPa and SpO2 >94%
better to allow spontaneous correction
Episodes of hypoxaemia (possibly
associated with convulsions) are an Glucose
indication for IPPV Regular blood glucose monitoring
Carbon dioxide Target >2.6 mmol/L
Maintain PaCO2 5.0–7.0 kPa Fluid restriction may require use of
higher concentrations of glucose to
Hypoventilation leading to hypercapnia maintain satisfactory blood glucose
(>7 kPa) is an indication for IPPV
Avoid hyperglycaemia (>8 mmol/L)
Hyperventilation is contraindicated but,
if baby spontaneously hyperventilating, Calcium
mechanical ventilation, with or without Asphyxiated babies are at increased
paralysis, may be necessary to control risk of hypocalcaemia
PaCO2
Treat with calcium gluconate when
Circulatory support serum corrected calcium <1.7 mmol/L
or if ionized calcium <0.8
Maintain mean arterial blood pressure
at ≥40 mmHg for term babies Convulsions
If cardiac output poor (e.g. poor Prophylactic anticonvulsants not
perfusion: blood pressure is a poor indicated
predictor of cardiac output) use
In muscle-relaxed baby, abrupt
inotropes
changes in blood pressure, SpO2 and
Avoid volume replacement unless heart rate can indicate convulsions
evidence of hypovolaemia
Treat persistent (>3/hr) or prolonged
Fluid balance and renal convulsions (>3 min, recur >3 times/hr)
function – see Seizures guideline
Start fluids at 40 mL/kg/day. See give phenobarbital
Intravenous fluid therapy guideline if ineffective or contraindicated, give
Some babies develop inappropriate phenytoin. If no response, give
ADH secretion at 3–4 days (suggested clonazepam or midazolam – see
by hypo-osmolar serum with low Seizures guideline
serum sodium associated with an Convulsions associated with HIE can
inappropriately high urine sodium and be notoriously difficult to control
osmolality) (preventing every twitch is unrealistic)
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(HIE) • 4/4
Regular fits causing respiratory evidence of severe asphyxia
insufficiency are an indication for IPPV multi-organ failure
Once baby stable for 2–3 days, intractable seizures
anticonvulsants can usually be
withdrawn although phenobarbital can coma
be continued for a little longer (duration very abnormal cranial ultrasound scan
can vary depending on individual abnormal Doppler cerebral blood flow
practice and clinical severity of seizures) velocities
Avoid corticosteroids and mannitol persistent burst suppression pattern on
Thermal control cerebral function monitoring and/or EEG
Maintain normal body temperature Decision to withdraw care requires
(36.5–37.2ºC). Avoid hyperthermia discussion with parents, and other
nursing and medical staff. Such
Gastrointestinal system decisions are frequently reached, by
Term babies who suffer a severe baby’s consultant, after a series of
asphyxial insult are at risk of developing discussions
necrotising enterocolitis – see It helps if the same staff speak to
Necrotising enterocolitis guideline parents on each occasion
In other babies, gastric motility can be The best interests of the child are
reduced: introduce enteral feeds slowly paramount
PROGNOSIS Record a summary of discussion in notes
Risk of long-term problems increases DISCHARGE AND FOLLOW-UP
with the degree of encephalopathy
Arrange clinic follow-up in 4–6 weeks
Overall risk of death or significant
for babies discharged
handicap is negligible for mild HIE,
26% for moderate and almost 100% Repeat cranial ultrasound scan before
for severe HIE discharge
Prolonged encephalopathy (e.g. Arrange hearing screen – see Hearing
moderate HIE lasting >6 days) also screening guideline
associated with poor outcome For babies with moderate and severe
Persistent oliguria is associated with encephalopathy (see Table) and in
poor outcome in 90% those with seizures due to
Prognostic factors indicative of worse encephalopathy, arrange MR scan as
outcome: an out-patient (if not already
performed as an in-patient), preferably
prolonged duration of ventilation
7–14 days of life
prolonged need for anticonvulsants
time taken to establish oral feeding Information for parents
Offer parents information on HIE,
DISCONTINUING INTENSIVE available from:
CARE
http://www.bliss.org.uk/Shop/hie-hypoxic-
When prognosis very poor, discuss ischaemic-encephalopathy-information-
withdrawing intensive care support and for-parents/
consider palliative care
Very poor prognostic factors include:
need for prolonged resuscitation at birth
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IMMUNISATIONS • 1/3
ROUTINE IMMUNISATIONS Administer by IM injection into thigh
FOR ALL BABIES Dose for all primary immunisations
Plan to achieve immunity to diphtheria, (DTaP/IPV/Hib, meningococcal C,
tetanus, pertussis, (DTaP), polio, pneumococcal) is 0.5 mL
haemophilus (Hib), meningococcus B, Give meningococcal C and
meningococcus C and pneumococcus pneumococcal (Prevenar 13) vaccine
within 4 months of birth (see also BCG into separate injection sites in other
immunisation guideline) thigh
Rotavirus vaccine must NOT be injected
Do not delay immunisation in
and preferably NOT given via an NGT
preterm babies because of
prematurity or low body weight Meningitis B vaccine is administered
0.5 mL IM
CONTRAINDICATIONS can be given with DTaP/IPV/Hib
Cardiorespiratory events (apnoeas, if given on the same limb, give
bradycardia and desaturations) are not ≥2.5 cm apart
contraindications to immunisation, but DOCUMENTATION
continue to monitor for a further 72 hr
following immunisation After immunisation, document the
following in case notes as well as in
See Precautions with rotavirus Child Health Record (Red book):
vaccine below
consent gained from parents
PROCEDURE vaccine given and reasons for any
Consent omissions
Inform parents of process, benefits site of injection(s) in case of
and risks reactions
For further information refer parents to batch number of product(s)
www.nhs.uk/Conditions/vaccinations expiry date of product(s)
Offer parents opportunity to ask legible signature of doctor
questions administering immunisations
Informed consent (can be written or adverse reactions
oral) must be obtained and recorded in Sign treatment sheet
notes at time of each immunisation
Complete immunisation form in
Complete ‘unscheduled immunisation BadgerNet system. Document all
form’ before immunisation and send to information on discharge summary and
local Child Health Information medical case notes including
Prescription recommendations for future
immunisations and need for any
Use immunisation listed in Schedule special vaccinations, such as
below influenza, palivizumab, etc.
Keep strictly to schedule to avoid delay
Order vaccines in advance unless held MONITORING
as stock on neonatal unit (NNU) Babies born <28 weeks may have an
impaired immune response. Check
Prescribe on treatment sheet
functional antibodies 1 month after
ADMINISTRATION booster at 1 year old, if needed
DTaP/IPV/Hib (Pediacel) is a 5-in-1
preparation
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Babies <28 weeks’ gestation at birth, Precautions with rotavirus
who are in hospital, respiratory vaccination
monitoring for 48–72 hr when given
Postpone administration of rotavirus
first routine immunisations
vaccine in infants suffering from:
If baby has apnoea, bradycardias or
acute severe febrile illness
desaturations after first routine
immunisations, second immunisation acute diarrhoea or vomiting
should ideally be given in hospital with Do not administer Rotarix® to infants
respiratory monitoring for 48–72 hr with:
ADVERSE REACTIONS confirmed anaphylactic reaction to
a previous dose of rotavirus vaccine
Local:
confirmed anaphylactic reaction to
extensive area of redness or swelling
any components of the vaccine
General:
history of intussusception
fever >39.5ºC within 48 hr
≥24+0 weeks of age
anaphylaxis
severe combined immunodeficiency
bronchospasm (SCID) disorder
laryngeal oedema malformation of the gastrointestinal
generalised collapse tract that could predispose them to
intussusception
episodes of severe apnoea
diarrhoea rare hereditary problems of fructose
intolerance, glucose-galactose
irritability malabsorption or sucrase-
vomiting isomaltase insufficiency
flatulence
ADDITIONAL
loss of appetite IMMUNISATIONS
regurgitation Influenza
Specific notes for rotavirus (in autumn and winter only)
vaccination Indications
Do not give Rotarix® to infants Chronic lung disease (on, or has
<6 weeks of age recently had, oxygen)
minimum age for first dose of Congenital heart disease, renal, liver
Rotarix® is 6+0 weeks or neurological disease
maximum age for first dose is Immunodeficiency
14+6 weeks
Recommendations
Do not vaccinate with Rotarix® in
infants aged ≥15+0 weeks. Infants who Recommend vaccination to close
have received their first dose of family members of these babies
vaccine under 15+0 weeks of age Give babies >6 months–2 yr of age
should receive their second dose of 0.25 mL, 2 doses 4–6 weeks apart, IM
Rotarix® after a minimum interval of 4 injection
weeks and by 23+6 weeks of age Note: intranasal flu vaccine is now
Do not give Rotarix® vaccine to infants routinely recommended for children
who are ≥24+0 weeks of age aged 2, 3 and 4 yr
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Palivizumab Routine immunisations including
See Palivizumab guideline rotavirus vaccine not contraindicated
Generally do not offer BCG at birth, wait
BCG for 3 months and HIV PCR negative
See BCG immunisation guideline However, BHIVA guidelines indicate
Hepatitis B that babies considered low risk of HIV
transmission (maternal viral load
See Hepatitis B guidelines
<50 HIV RNA copies/mL at or after
HIV 36 weeks’ gestation) but with a high
Babies who are HIV infected, or HIV risk of tuberculosis exposure BCG may
exposed (born to HIV positive mother) be given at birth
and status not yet known:
UK 2015 Immunisation Schedule
AGE Immunisation (vaccine given)
5-in-1 (DTaP/IPV/Hib) vaccine – this single jab contains vaccines
to protect against 5 separate diseases: diphtheria, tetanus,
whooping cough (pertussis), polio and Haemophilus influenzae
type b (known as Hib – a bacterial infection that can cause
2 months severe pneumonia or meningitis in young children)
Pneumococcal (PCV) vaccine
Rotavirus vaccine
Men B vaccine
5-in-1 (DTaP/IPV/Hib) vaccine, second dose
3 months Men C vaccine
Rotavirus vaccine, second dose
5-in-1 (DTaP/IPV/Hib) vaccine, third dose
4 months Pneumococcal (PCV) vaccine, second dose
Men B vaccine second dose
Hib/Men C booster, given as a single jab containing meningitis C
(second dose) and Hib (fourth dose)
12–13 months Measles, mumps and rubella (MMR) vaccine, given as a single jab
Pneumococcal (PCV) vaccine, third dose
Men B vaccine third dose
2, 3 and 4 years Children's flu vaccine (annual) – nasal spray
Measles, mumps and rubella (MMR) vaccine, second dose
3 years and four 4-in-1 (DTaP/IPV) pre-school booster, given as a single jab
months – 5 yr containing vaccines against diphtheria, tetanus, whooping cough
(pertussis) and polio
Around 12–13 yr HPV vaccine, which protects against cervical cancer – two
(girls) injections given between six months and two years apart
3-in-1 (Td/IPV) teenage booster, given as a single jab and
Around 13–18 contains vaccines against diphtheria, tetanus and polio
years
Men ACWY vaccine
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INFECTION IN FIRST 72 HOURS OF LIFE • 1/3
Based on NICE CG149 Antibiotics for early onset
neonatal infection
RISK FACTORS FOR Metabolic acidosis (BE ≥10)

INFECTION Local signs of infection e.g. skin, eyes
Pre-labour rupture of membranes Confirmed or suspected sepsis in a
Preterm birth (<37 weeks), especially co-twin red flag
with pre-labour rupture of membranes
Red flag signs suggestive of
Confirmed or suspected neonatal infection
chorioamnioitis (e.g. intrapartum fever)
Systemic antibiotics given to mother
Invasive group B streptococcal (GBS) for suspected bacterial infection
infection in a previous baby within 24 hr of birth
Antibiotic treatment given to mother for Seizures
confirmed or suspected invasive Signs of shock
bacterial infection 24 hr before, during,
Need for mechanical ventilation in a
or post labour
term baby
CLINICAL INDICATORS Suspected or confirmed infection in
SUGGESTIVE OF INFECTION a co-twin
Altered behaviour or responsiveness
ACTIONS
Altered muscle tone
Any red flags or no red flags but ≥2
Feeding difficulties (e.g. feed refusal) risk factors or clinical indicators
Feed intolerance (e.g. abdominal perform investigations, including blood
distension, vomiting) cultures, and start antibiotics
Altered heart rate No red flag or clinical indicators but
one risk factor or no red flag or risk
Signs of respiratory distress
factors but 1 clinical indicator
Oxygen desaturation
use clinical judgement and consider
Apnoea withholding antibiotics
Signs of perinatal asphyxia or hypoxic monitor baby for clinical indicators of
ischaemia possible infection, including vital signs
Seizures red flag monitor for at least 12 hr from birth (at
Need for mechanical ventilation 1 hr, 2 hr and then 2-hrly for 10 hr)
(especially term baby) red flag If further clinical concerns, perform
PPHN investigations including blood cultures
and start antibiotics
Temperature abnormality not explained
by environment if decision made to give antibiotics,
aim to start within 30 min and always
Signs of shock red flag within 1 hr of decision
Unexplained bleeding disorder (e.g.
thrombocytopenia, INR >2)
Oliguria
Hypo/hyperglycaemia
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neonatal infection
INVESTIGATIONS BEFORE INVESTIGATIONS DURING
STARTING ANTIBIOTICS ANTIBIOTIC TREATMENT
Blood culture (in all) CRP: measure before starting
Measure CRP and FBC at presentation antibiotics and 18–24 hr after
and 18–24 hr after presentation
If strong clinical suspicion of infection Consider LP if:
or signs/symptoms of meningitis, CRP >10 mg/L
perform lumbar puncture (LP), if
thought safe to do positive blood culture
if performing LP will delay antibiotics, baby does not respond satisfactorily to
give antibiotics first antibiotics
Do not carry out urine MC&S Asymptomatic babies on postnatal
ward/TC unit with CRP ≤60 do not
Take skin swabs only if clinical signs of
require a routine LP but should be
localised infection
reviewed by a middle grade doctor
If purulent eye discharge (may indicate
serious infection e.g. chlamydia or DURATION OF ANTIBIOTIC
gonococcus): TREATMENT
collect eye swabs for urgent MC&S, Stop at 36 hr if:
especially looking for chlamydia or
gonococcus initial clinical suspicion of infection was
not strong
start systemic antibiotics while awaiting
results and
If signs of umbilical infection, including CRP <10 mg/L on both tests
purulent discharge or periumbilical and
cellulitis, perform a blood culture and
negative blood culture
start IV flucloxacillin and gentamicin
and
Choice of antibiotics
baby is well with no clinical indicators
Use benzylpenicillin and gentamicin as of possible infection
first choice for empirical treatment
Treat for 7 days if:
Benzylpenicillin strong clinical suggestion of infection
25 mg/kg 12-hrly
continued clinical concerns about
If baby appears very ill, give 25 mg/kg infection at 36 hr
8-hrly
CRP >10 mg/L on either measurement
Gentamicin positive blood culture
Follow local guideline or: If baby not fully recovered at 7 days,
5 mg/kg continue antibiotics
if a second dose to be given (see this is advisable based on blood culture
below), give 36 hr after first dose result and expert microbiological advice
interval may be shortened based on if necessary
clinical judgement e.g. for Gram-negative
infection or if baby appears very ill
Monitoring of gentamicin – see below
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neonatal infection
Meningitis Therapeutic monitoring of
If meningitis suspected but Gram stain gentamicin
is uninformative, use amoxicillin and Follow local guidelines or:
cefotaxime
Trough concentrations:
Review treatment decisions taking CSF
results into account if second dose to be given, measure
before administering
If CSF Gram stain suggests GBS, give
benzylpenicillin 50 mg/kg 12-hrly and review level before giving third dose
gentamicin 5 mg/kg every 36 hr monitor before every third dose, or
more frequently if necessary (e.g.
If CSF culture confirms GBS, continue
concern about previous level or renal
benzylpenicillin for at least 14 days and
impairment)
gentamicin for 5 days
adjust dose interval aiming to achieve
If CSF culture or Gram stain confirms
level of <2 mg/L
Gram-negative infection, stop
amoxicillin and treat with cefotaxime if course lasts >3 doses, level of
alone <1 mg/L is advisable
If blood culture or CSF culture is if a trough level is not available, do not
positive for listeria, consider stopping withhold next dose of gentamicin
cefotaxime and treating with amoxicillin
Peak concentrations:
and gentamicin
measure in selected babies e.g.
If CSF Gram stain or culture suggests
any organism other than GBS, use an - with oedema
antibiotic regimen based on local - with macrosomia (birth weight >4.5 kg)
expert microbiological advice
- who do not respond to treatment
Measure 1 hr after starting gentamicin
infusion
If peak is <8 mg/L, increase dose
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INFECTION (LATE ONSET) • 1/5
DEFINITION Meticulous regimen for changing drips
and 3-way taps
Infection after first 72 hr of life
Initiate enteral feeds with maternal
Late onset Group B streptococcus
breast milk within 24 hr of birth
(GBS) infection: after first 6 days of life
When acquired in hospital – most PRESENTATION
commonly Gram-positive organisms. Can be vague and non-specific
Coagulase-negative staphylococci
account for approximately 50% of all Symptoms
late onset infections Respiratory distress – increase in
Gram-negative bacteria accounts for oxygen requirement/respiratory support
20–40% and these are increasingly Apnoea/bradycardia
resistant to gentamicin
(Klebsiella>Serratia>Enterobacter> Cyanosis or poor colour
Pseudomonas>E.coli and Poor perfusion (CRT >3 sec; toe-core
Acinetobacter) temperature gap >2ºC; mottling)
Hypotension
Risk factors
Tachycardia
Risk of infection is inversely related to
gestational age and birth weight and Temperature instability (high or low)
directly related to severity of illness at Glucose instability
birth, reflecting need for invasive Hypotonia
interventions e.g. prolonged ventilation,
central venous access and parenteral Irritability
nutrition Lethargy/inactivity
Delayed introduction of enteral feeds is Poor feeding and poor suck
associated with higher infection rates Jaundice
Increased risk of sepsis after gut Seizures
surgery especially if enteral feeds slow
Vomiting
to establish e.g. post-gastroschisis or
necrotising enterocolitis (NEC) with Abdominal distension
stoma Nursing staff may describe babies with
a mixture of these symptoms as having
PREVENTION ’gone off’
Strict hand washing and alcohol
hand rubs: Signs
to the elbow with particular attention Look for
between digits Systemic signs of sepsis such as
on entering the unit and between each tachycardia, poor perfusion, reduced
patient tone, quiet, lethargy
Unless absolutely essential, avoid Tachypnoea and intercostal and/or
entering incubators or touching any subcostal recession
part of cots Bulging of the fontanelle suggesting
Do not lean on incubators or other raised intracranial pressure
patient equipment not always detectable in babies with
Wear apron and gloves when carrying neonatal meningitis
out any procedure e.g. heel prick,
resiting IV cannula
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Abdominal distension and tenderness Generally a delay of 24 hr between
auscultate for bowel sounds; reduced onset of symptoms and rise in serum
or absent with infection (as a result of CRP
septic ileus) or NEC Take sample at presentation and further
inspect stool for visible blood sample 18–24 hr after first CRP sample
petechiae, bleeding diathesis a rise may support diagnosis of infection
but failure to rise does not exclude it
Septic spots in eyes, umbilicus, nails where other findings are supportive
and skin
if blood culture negative and clinical
Reluctance to move or tenderness in condition satisfactory, failure of CRP to
joints and limbs suggestive of rise during first 48 hr is a useful indicator
osteomyelitis or septic arthritis that antibiotics may be safely stopped
INVESTIGATIONS (perform Urine microscopy, culture
before starting antibiotics) and sensitivity
Swabs for culture Clean-catch or supra-pubic aspiration
Swab any suspicious lesion (e.g. skin, (SPA). Use ultrasound scan to check
umbilicus or nails) urine in bladder before SPA
Routine rectal swabs may detect do not send urine collected in a bag
resistant Gram-negative bacteria that for culture
require treatment with an alternative
antibiotic e.g. meropenem, or MRSA Lumbar puncture (LP)
which requires treatment with If baby unstable, deranged clotting or
vancomycin. Otherwise swabs are not thrombocytopenia, discuss advisability
diagnostically useful with consultant
May be performed later but cultures
Blood cultures
often negative
From a peripheral vein, using a closed
system, non-touch, aseptic technique Send CSF for urgent Gram-stain and
culture (MC&S), protein and glucose
Full blood count In critically ill baby, consider PCR for
A neutrophil count <2 or >15 x 109/L HSV, especially term babies
(supportive but not diagnostic, and
marginally more sensitive than a total
Others
white cell count) Chest X-ray
Platelet count of <100 x 109/L If abdominal distension noted,
abdominal X-ray
Toxic granulation in neutrophils [or if
measured: an immature:total (I:T) Documentation
neutrophil ratio >0.2]
Always contemporaneously document
Clotting profile symptoms and signs of infection at the
time of taking blood culture and all
If evidence of bleeding diathesis or in
blood and CSF cultures (and
severe infection/septicaemia
abdominal radiographs) on BadgerNet
CRP ad-hoc reporting field
Acute phase protein synthesised in the
liver in response to inflammatory
cytokines
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EMPIRICAL TREATMENT Remove indwelling catheters for all
infections except CONS (unless
Do not use oral antibiotics to treat access is a major issue). Line removal
infection in babies should be a considered decision
Consult local microbiology department If line ‘precious’ and baby responding
for current recommendations. to treatment, consider infusing
These may differ between units vancomycin down long line and
according to local resident flora leaving it to dwell for 1 hr before
flushing. Ensure therapeutic trough
Late onset sepsis levels
Antibiotics If meningitis diagnosed or strongly
First line: empirical flucloxacillin and suspected clinically, treat with high
gentamicin unless microbiology dose cefotaxime 50 mg/kg/dose
isolates dictate otherwise (see If baby has improved clinically and
Neonatal Formulary for dose bacteriological cultures are negative so
intervals) far, stop antibiotics after 48 hr
Second line: vancomycin plus treat for at least 7 days, or for 5 days
gentamicin or tazocin after clinical response
Third line or if cultures dictate:
meropenem plus vancomycin SPECIFIC INFECTIONS
When course of antibiotic prolonged Discharging eyes
>1 week, babies are very preterm and See Conjunctivitis guideline
post-gut surgery, consider
commencing fungal prophylaxis with Umbilicus sepsis (omphalitis)
either oral and topical nystatin or Systemic antibiotics required only if
IV/oral fluconazole. Steroid therapy local induration or surrounding
also associated with increased risk of reddening of the skin
fungal infection
Do not use vancomycin routinely: Meningitis
(consult local policy)
For all babies with a positive blood
for babies with indwelling catheters culture, other than CONS, consider
and on parenteral nutrition, unless LP. This must be discussed with an
they are very unwell experienced clinician. Organisms such
to treat endotracheal secretion as Group B streptococcus and E. coli
colonisation with coagulase-negative penetrate the CSF readily
staphylococci (CONS)
Maintain vancomycin trough levels Empirical treatment whilst
between 10–15 µg/mL, as bactericidal CSF results pending
activity is related to trough
CSF visually clear, give first line
concentration (or, if using continuous
antibiotics as per guidance for late-
infusion vancomycin, as per local
onset sepsis
guidance)
CSF cloudy or high clinical suspicion
When culture results available, always
of meningitis, give high-dose
change to narrowest spectrum
cefotaxime
antibiotic, or stop antibiotics if negative
cultures, inflammatory markers not
raised and no clinical signs of infection
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Table of normal CSF values
Gestation White cell count Protein (g/L) Glucose (mmol/L)
(count/mm3)
Preterm <28 days 9 (0–30) 1.0 (0.5–2.5) 3.0 (1.5–5.5)
Term <28 days 6 (0–21) 0.6 (0.3–2.0) 3 (1.5–5.5)
Values are mean (range) If low clinical suspicion of meningitis,

Note: protein levels are higher in first stop antibiotics after 48 hr if:
week of life and depend on RBC CSF glucose >2/3 simultaneous blood
count. WBC of >21/mm3 with a protein glucose and
of >1.0 g/L with <1000 RBCs is CSF protein <1 g/L
suspicious of meningitis
cultures negative and baby remains well
If traumatic LP and strong suspicion of
meningitis, repeat LP after 24–48 hr Urinary tract infection (UTI)
Manage baby as if he/she has Usually occurs as late-onset infection
meningitis. None of the ‘correcting’ Start IV empiric antibiotic treatment, as
formulae are reliable above, immediately after appropriate
urine collection (not bag urine)
Subsequent management
Continue IV empiric antibiotics until
Meningitis confirmed when organisms
culture results available
seen on urgent Gram stain and/or
grown from subsequent culture once stable, treat with oral antibiotics
according to sensitivities
Cultures often negative, especially if
CSF taken after baby given antibiotics Exclude obstruction by renal
or if mother given intrapartum antibiotics ultrasound scan as soon as available
No other single CSF value can reliably Subsequent management
diagnose meningitis. However,
Prophylaxis: single night-time dose of
meningitis is suggested by:
oral trimethoprim 2 mg/kg/dose for all
low CSF glucose: <2/3 simultaneous babies with confirmed UTI, while
blood glucose completing investigations to identify
high CSF protein: >1 g/L predisposing factors
Send CSF for herpes PCR and start For further information on
empiric treatment with IV aciclovir until management of UTI in babies – see
results available if: Urinary tract infection guideline in
neonatal herpes encephalitis suggested Partners in Paediatrics guidelines
by symptoms and signs of infection, Necrotising enterocolitis
which may or may not include seizures
and CSF showing monocytosis or See Necrotising enterocolitis guideline
lymphocytosis, increased protein and Fungal infection
decreased glucose
Mostly late onset
If bacterial meningitis confirmed on
culture or high clinical suspicion of Incidence in UK up to 1.2% in very-low-
meningitis, treat with high-dose birth-weight (VLBW) babies and 2.6%
cefotaxime for 14–21 days, depending in extremely-low-birth-weight (ELBW)
on organism. Seek advice from babies (versus up to 28% in the USA),
microbiologist hence no routine prophylaxis in the UK
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Risk factors Treatment
<1500 g First choice
Parenteral nutrition Standard amphotericin starting at
Indwelling catheter 1 mg/kg. Can increase dose as
tolerated to 1.5 g/kg. In renal failure
No enteral feeds
can use liposomal amphotericin at
Ventilation 1–2 mg/kg, increasing to a maximum of
H2 antagonists 6 mg/kg (see Neonatal Formulary for
doses and intervals)
Exposure to broad spectrum
antibiotics, especially cephalosporins Alternative is fluconazole – see local
formulary
Abdominal surgery
Peritoneal dialysis ADJUNCTIVE THERAPY
No substantive trials to date show
Symptoms and signs
benefit of IV immunoglobulin,
Non-specific recombinant cytokines etc.
as for late onset infection
Additional investigations
If fungal infection suspected or
diagnosed, end-organ evaluation to
include:
abdominal ultrasound
cerebral ultrasound
lumbar puncture
fundoscopy
echocardiogram
blood cultures 24–48 hrly to confirm
clearance
suprapubic or catheter specimen of
urine
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INGUINAL HERNIA • 1/1
INTRODUCTION Incarcerated inguinal hernia
Incidence: 0.5–1% in term babies and Stabilise baby
5–10% in premature babies Administer analgesia (IV morphine),
Right-sided in 50% of cases, left-sided then gently try to reduce hernia
in 10% and both sides in 40% If fully reduced, arrange elective
Most cases can be managed with inguinal herniotomy before discharge.
elective surgery at time of discharge Refer to paediatric surgical team for
from neonatal unit (NNU) elective review
Manage incarcerated hernia as a If not reducible, request urgent help
surgical emergency from on-call paediatrician/neonatologist
CLINICAL FEATURES Keep child nil-by-mouth

Insert large bore nasogastric tube,
Visible swelling or bulge in inguino-
empty stomach and leave on free
scrotal region in boys, inguino-labial
drainage (see Nasogastric tube
region in girls. May be constant or
insertion guideline)
intermittent, becoming more prominent
with crying or straining Obtain IV access and send blood for
FBC and U&E
Simple inguinal hernia
Start maintenance IV fluids
Usually painless
Aspirate nasogastric tube 4-hrly in
Incarcerated inguinal hernia addition to free drainage and replace
the aspirate volume, mL-for-mL with
Generally presents with a tender firm sodium chloride 0.9% with 10 mmol
mass in the inguinal canal or scrotum
potassium chloride in 500 mL IV. Leave
Baby may be fussy, unwilling to feed nasogastric tube on free drainage
and crying inconsolably
If hernia remains irreducible, refer
Overlying skin may be oedematous, urgently for surgical assessment
erythematous and discoloured
Complete detailed transfer letter, using
May be associated abdominal distension BadgerNet system. Ensure parental
with or without bilious vomiting details and telephone contact numbers
Arrange emergency surgical referral included
If possible, ask parents to travel to
MANAGEMENT AND planned place of surgery to meet with
REFERRAL surgical team
Reducible inguinal hernia
WHILE AWAITING TRANSFER
If asymptomatic, refer by letter to TO SURGICAL UNIT
surgeon. Include likely date of
discharge and parents’ contact details Reassess baby regularly
Inform parents of the risk of hernia Monitor fluid balance, blood gases,
becoming incarcerated glucose and consider need for fluid
resuscitation
if baby develops a tense, painful
swelling and is in obvious pain, parents Useful information
should seek immediate medical advice
if swelling not reduced within 2 hr, surgery
serious complications may arise
directions
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INHERITED METABOLIC DISORDERS (IMD)
• 1/4
RECOGNITION
Early recognition of IMD and prompt management are essential to prevent death or
neurodisability
diagnosis of IMD in babies is often delayed owing to non-specific nature of clinical
presentation and unfamiliarity with diagnostic tests
seek early advice from the regional clinical IMD team
Consider IMD at the same time as common acquired conditions, such as sepsis
Differential diagnosis (the lists below are not comprehensive, discuss with
clinical IMD team)
Presentation Common conditions
Encephalopathy without metabolic Urea cycle disorders
acidosis Maple syrup urine disease (MSUD)
Encephalopathy with metabolic acidosis Organic acidaemias (e.g. propionic,
methylmalonic, isovaleric, glutaric
aciduria Type I)
Congenital lactic acidosis
Liver dysfunction including jaundice, Galactosaemia
particularly conjugated Tyrosinaemia
Neonatal haemochromatosis
α1-antitrypsin deficiency
Citrin deficiency
Niemann-Pick disease type C
Mitochondrial disease
Congenital disorders of glycosylation –
CDG 1b (uncommon)
Hypoglycaemia Hyperinsulinism
Fatty acid oxidation disorders
Glycogen storage disorders
Gluconeogenesis defects
Metabolic acidosis Organic acidaemias
Congenital lactic acidosis
Non-immune hydrops Lysosomal storage disorders, including:
Mucopolysaccharidoses
I-Cell disease
Gaucher disease
Niemann-Pick disease type A, B or C
Severe neonatal hypotonia Zellweger’s syndrome
Non-ketotic hyperglycinaemia (NKHG)
Cataracts Galactosaemia
Zellweger’s syndrome
Lowe’s syndrome
Dislocated lens Homocystinuria
Sulphite oxidase deficiency
Issue 6
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• 2/4
Presentation Common conditions
Congenital anomalies
if developmental delay or neurological
signs present with dysmorphism,
consider IMD
Apnoea or periodic breathing in term NKHG (also likely to have hypotonia,
baby epileptic encephalopathy)
Hiccoughing MSUD
Respiratory alkalosis in a tachypnoeic baby Hyperammonaemia
Cyclical vomiting Hyperammonaemia
Intractable neonatal seizures Pyridoxine and pyridoxal phosphate –
responsive seizures
Peroxisomal biogenesis disorders
Neurotransmitter disorders
Glucose transporter defect (GLUT 1)
NKHG
Sulphite oxidase deficiency and
molybdenum cofactor deficiency
Specific indicators
Clinical context
Unexplained and mysterious Changes in muscle tone:
deterioration of baby (can be as short
axial hypotonia with limb hypertonia
as 12 hr but more commonly after a
symptom-free interval of 24 hr–14 days) ‘normal’ tone in comatose baby
Abnormal movements:
Family history
Known metabolic disorders myoclonic or boxing movements
Unexplained neonatal or infant deaths tongue thrusting

Parental consanguinity lip smacking
unexplained seizures/burst
Obstetric history suppression/hypsarrythmia
Acute fatty liver of pregnancy and
seizures are uncommon or occur late
HELLP syndrome in index pregnancy
in babies with metabolic
may point towards long chain fatty acid
encephalopathy compared to hypoxic-
oxidation defect in baby
ischaemic encephalopathy
Non-specific indicators
INITIAL INVESTIGATIONS
suggestive of metabolic
disorder in an Whenever IMD suspected, perform
encephalopathic baby required investigations without delay
Encephalopathy in low-risk baby, or Seek early advice about appropriate

onset after period of normality investigations and management from
IMD team at tertiary metabolic centre
Fluctuating consciousness and muscle
tone
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• 3/4
Urine Unexplained/prolonged
Smell jaundice or liver synthetic
dysfunction
Ketostix: presence of large amounts of
urinary ketones is usually abnormal in Jaundice
babies and could suggest IMD,
Skin (and liver) biopsy after discussion
especially organic acidaemias
with metabolic team
Reducing substances: use Clinitest –
urinary dipsticks are specific for Blood
glucose and miss galactose in babies Galactosaemia screen (urinary reducing
with galactosaemia substances can be negative after short
a negative Clinitest does not exclude period of galactose exclusion)
galactosaemia Blood spot – succinyl acetone
Freeze 15–20 mL urine for amino and Ferritin
organic acid analysis
Very long chain fatty acids
Amino acids
α1-antitrypsin (quantitative)
Blood 7-dehydrocholesterol
FBC, U&E, infection screen Transferrin isoelectric focusing
Glucose Consider Niemann-Pick disease type C-
chitotriosidase, DNA- mutation analysis
Blood gas (calculate anion gap)
Ammonia Urine
Lactate Succinylacetone
Total and conjugated bilirubin, liver Encephalopathy
function tests including clotting studies
Paired blood and CSF glycine
Acylcarnitines, including free and total
CSF lactate
carnitine
Very long chain fatty acid profile
Uric acid
Urine for orotic acid
Galactosaemia screen
(GALIPUT/Beutler test) Urine: Sulfitest for sulphite oxidase
deficiency
Red blood cell galactose-1-phosphate
if transfused in previous 90 days Hypoglycaemia
(most informative when obtained at
Imaging
time of hypoglycaemia)
Cranial ultrasound scan
Plasma non-esterified fatty acids
Ophthalmic examination β-hydroxybutyrate
SPECIFIC INVESTIGATIONS Insulin and C-peptide
Acylcarnitine profile, free and total
Discuss with clinical IMD team as not carnitine
all tests may be indicated in all babies
with similar presentation Cortisol, growth hormone
Urine for organic acids
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• 4/4
Post-mortem SPECIFIC MANAGEMENT
(plan how best to use these precious Must be led by IMD team
samples in consultation with IMD team) Use following as guide to general
Plasma (2–5 mL), urine (10–20 mL) principles of management
and CSF (1 mL) frozen at -20ºC
Red cells: blood (5 mL) in lithium Neonatal hyperammonaemia
heparin stored at 4ºC (fridge) A medical emergency requiring prompt
Blood (5 mL) in EDTA: stored at 4ºC intervention to lower ammonia
for DNA analysis concentration
Tissue biopsies Renal replacement therapy
(haemofiltration more efficient than
skin: store in viral culture medium or
peritoneal dialysis)
sodium chloride 0.9% at 4ºC (fridge)
Sodium benzoate
muscle and liver: take within 1 hr of
death, snap freeze in liquid nitrogen Sodium phenylbutyrate
Post-mortem examination L-arginine
Bile for acylcarnitine analysis – stable
Organic acidaemia
for longer than other body fluids
Reduce/stop protein intake
IMMEDIATE MANAGEMENT
Glucose 10% infusion +/- insulin
Commence emergency management L-carnitine
of suspected IMD while awaiting results
of initial investigations and discuss with Fatty acid oxidation
IMD team as early as possible disorders
Attend to Airway, Breathing and Avoid prolonged fast
Circulation; ventilate if necessary Specific management guide by IMD
Omit all protein, fat and team
galactose/lactose (milk) intake,
including TPN and lipid
Lactic acidosis
Commence glucose 10% IV infusion to Dichloroacetate
provide 6–8 mg glucose kg/min Biotin
start insulin infusion if hyperglycaemic L-carnitine
(>15 mmol/L) or catabolic, under
Thiamine
guidance from IMD team
if hypertonic (concentration of glucose Galactosaemia
>10%) infusion necessary, insert Dietary exclusion of galactose
central line
Correct dehydration, acid-base and For further information on IMD,
electrolyte disturbances www.bimdg.org.uk/guidelines.asp,
Emergency protocols and follow through
Cover for infection
Control seizures (avoid sodium valproate)
LOCAL CONTACT
When stable and appropriate, consider
early transfer to tertiary metabolic centre Birmingham Children’s Hospital
metabolic team (0121 333 9999)
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INTRA-ABDOMINAL CYSTS • 1/2
INTRODUCTION Meconium pseudocyst
This guideline does not apply to cystic If suspected antenatally, do not feed
structures which may be arising from baby at birth
the urinary tract Insert a size 8 Fr nasogastric tube
Antenatally detected intra-abdominal (NGT) immediately after birth and fix
cysts include: securely with tape – see Nasogastric
ovarian tube insertion guideline
intestinal duplication Empty stomach by aspirating NGT with

a 10 or 20 mL syringe
mesenteric
if <20 mL aspirated, check position of
vitello-intestinal tube
SYMPTOMS AND SIGNS Place NGT on free drainage by
connecting to a bile bag
Most cysts will be asymptomatic but
the following can be present: Replace nasogastric losses, mL-for-mL,
using sodium chloride 0.9% with
abdominal pain
potassium chloride 10 mmol/500 mL IV
vomiting
Once stabilised, admit baby to neonatal
abdominal distension unit (NNU)
respiratory compromise Commence intravenous maintenance
rectal bleeding fluids – see IV fluid therapy guideline
Meconium pseudocyst may also be On day of birth, refer to on-call surgical
detected on an antenatal ultrasound. team at planned place of surgery
They will nearly always cause vomiting
and abdominal distension and may be
Other types of intra-
associated with an underlying abdominal cysts
diagnosis of cystic fibrosis Unless significant abdominal distension
present following birth, allow baby to
MANAGEMENT feed normally and observe in the
Antenatal postnatal ward for at least 48 hr
Refer to/discuss appropriate place for If baby well after 48 hr with no
delivery with a fetal medicine unit abdominal symptoms and feeding
normally then discharge
Refer to paediatric surgeon for
antenatal counselling Arrange an out-patient abdominal
ultrasound scan within 1 week of birth
Delivery
In the majority of cases, obstetric
management will not alter
Postnatal
Resuscitate baby as normal
Once stable, perform full postnatal
physical examination – see
Examination of the newborn
guideline
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INTRA-ABDOMINAL CYSTS • 2/2
SURGICAL REFERRAL
Urgency will depend on clinical
situation
Meconium pseudocyst:
manage as above and refer to surgeon
on day of birth
Symptomatic cyst:
stabilise on NNU and refer to on-call
surgical team on day of presentation
Asymptomatic cyst:
abdominal ultrasound within 1 week of
birth
when result known, written out-patient
referral to consultant paediatric surgeon
Resolved cyst:
ultrasound within 1 week of birth, even
if cyst appears to have resolved during
pregnancy. Arrange out-patient surgical
referral
Useful information
surgery
directions
Issue 6
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INTRAVENOUS FLUID THERAPY • 1/5
PRINCIPLES
Postnatal physiological weight loss is admission electrolytes reflect maternal
approximately 5–10% in first week of status: need not be acted upon but
life help to interpret trends
Preterm babies have more total body serum urea not useful in monitoring
water and may lose 10–15% of their fluid balance: reflects nutritional status
weight in first week of life and nitrogen load
Postnatal diuresis is delayed in
Serum creatinine
respiratory distress syndrome (RDS)
and in babies who had significant Daily for intensive care babies
intrapartum stress Reflects renal function over longer
Preterm babies have limited capacity term
to excrete sodium in first 48 hr trend is most useful
Sodium chloride 0.9% contributes a tends to rise over first 2–3 days
significant chloride (Cl-) load which gradually falls over subsequent weeks
can exacerbate metabolic acidosis
absence of postnatal drop is significant
Liberal sodium and water intake before
onset of natural diuresis is associated Urine output
with increased incidence of patent Review 8-hrly for intensive care babies
ductus arteriosus (PDA), necrotising
2–4 mL/kg/hr normal hydration
enterocolitis (NEC) and chronic lung
disease (CLD) <1 mL/kg/hr requires investigation
except in first 24 hr of life
After diuresis, a positive sodium
balance is necessary for tissue growth >6–7 mL/kg/hr suggests impaired
concentrating ability or excess fluids
Preterm babies, especially if born <29
weeks’ gestation, lose excessive NORMAL REQUIREMENTS
sodium through immature kidneys
Humidification
Babies <28 weeks have significant
transepidermal water loss (TEW) If <29 weeks, humidify incubator to at
least 60%
TEW loss leads to hypothermia, loss
of calories and dehydration, and If ventilated or on CPAP ventilator, set
causes excessive weight loss and humidifier at 39ºC negative 2 to
hypernatraemia ensure maximal humidification of
inspired gas
MONITORING
Normal fluid volume requirements
Weigh
On admission Fluid volume (mL/kg/day)
Daily for intensive care babies: twice Day of life <1000 g ≥1000 g
daily if fluid balance is a problem 1 90 60
use in-line scales if available
2 120 90
Serum sodium 3 150 120
Daily for intensive care babies 4 150 150
If electrolyte problems or ≤26 weeks,
measure twice daily
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Day 1 excessive IV fluids
glucose 10% inappropriate secretion of ADH in
if birth weight <1000 g start parenteral babies following major cerebral insults,
nutrition (PN) (with potassium or with severe lung disease
2 mmol/kg daily) treatment with indometacin or ibuprofen
Day 2 Excessive losses
glucose 10% and potassium 10 mmol prematurity (most common cause after
in 500 mL (depending on electrolyte 48 hr of age)
results) or PN adrenal insufficiency
use sodium chloride 0.45% in arterial GI losses
line fluids
diuretic therapy (older babies)
add sodium only when there is diuresis,
or weight loss >6% of birth weight inherited renal tubular disorders
Day 3 Inadequate intake
glucose 10%, sodium chloride 0.18% preterm breast fed babies aged >7 days
and potassium 10 mmol in 500 mL Management depends on cause
or PN (with potassium 2 mmol/kg/day
and sodium 4 mmol/kg/day)
Excessive IV fluids and
After day 4 failure to excrete fetal ECF
glucose 10% (with maintenance Management
electrolytes adjusted according to daily
Reduce fluid intake to 75% of expected
U&E) or PN
Fluid volume requirements are a guide Inappropriate ADH
and can be increased faster or slower Clinical features
depending on serum sodium values,
urine output and changes in weight Weight gain, oedema, poor urine output
Babies receiving phototherapy may Serum osmolality low (<275 mOsm/kg)
require extra fluids depending on type with urine not maximally dilute
of phototherapy (osmolality >100 mOsm/kg)
HYPONATRAEMIA Management
(<130 mmol/L) Reduce fluid intake to 75% of expected
Response to treatment should be Consider sodium infusion only if serum
proportionate to degree of hyponatraemia sodium <120 mmol/L
Causes Risk of accidental hypernatraemia

when using 30% sodium chloride.
Excessive free water
Use with caution and always dilute
reflection of maternal electrolyte status before use
in first 24 hr
failure to excrete fetal extracellular Acute renal failure
fluid will lead to oedema without Management
weight gain
Reduce intake to match insensible
water overload: diagnose clinically by losses + urine output
oedema and weight gain
Seek advice from senior colleague
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Excessive renal sodium losses Management
Management Give increased sodium supplementation
If taking diuretics, stop or reduce dose
If possible, stop medication (diuretics,
caffeine) that causes excess losses Excessive sodium intake
Check urinary electrolytes
leading to water retention
Calculate fractional excretion of Clinical features
sodium (FE Na+ %): Inappropriate weight gain
FE Na+ = [(urine Na x plasma Management
creatinine)/(urine creatinine x plasma
Na)] x 100 Reduce sodium intake
normally <1% but in sick preterm HYPERNATRAEMIA

babies can be up to 10% (>145 mmol/L)
affected by sodium intake: increased Prevention
intake leads to increased fractional
clearance Prevent high transepidermal water loss
use plastic wrap to cover babies of
if >1%, give sodium supplements
<32 weeks’ gestation at birth
Calculate sodium deficit
nurse in high ambient humidity >80%
= (135 – plasma sodium) x 0.6 x
weight in kg use bubble wrap
minimise interventions
replace over 24 hr unless sodium
<120 mmol/L or symptomatic (apnoea, humidify ventilator gases
fits, irritability)
Causes
initial treatment should bring serum
sodium up to about 125 mmol/L Water loss (most commonly)
Use sodium chloride 30% (5 mmol/mL) TEW

diluted in maintenance fluids. Ensure glycosuria
bag is mixed well before administration Excessive sodium intake
Adrenal insufficiency sodium bicarbonate
Clinical features repeated boluses of sodium chloride

Hyperkalaemia congenital hyperaldosteronism/diabetes
insipidus (very rare)
Excessive weight loss
Virilisation of females Management depends on cause
Increased pigmentation of both sexes
Hypernatraemia resulting
Ambiguous genitalia
from water loss
Management Clinical features
Seek consultant advice Leads to weight-loss with
hypernatraemia
Inadequate intake
Clinical features Management
Poor weight gain and decreased Increase fluid intake and monitor
urinary sodium serum sodium
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Osmotic diuresis USING SYRINGE OR
Management VOLUMATIC PUMP TO
ADMINISTER IV FLUIDS
Treat hyperglycaemia with an insulin
infusion (see Hyperglycaemia Do not leave bag of fluid connected
guideline) (blood components excepted)
Rehydrate with sodium chloride 0.9% Nurse to check hourly:
infusion rate
Hypernatraemia resulting
from excessive intake infusion equipment
Management site of infusion
If acidosis requires treatment, use Before removing giving set, close all
THAM instead of sodium bicarbonate clamps and switch off pump
Reduce sodium intake IV FLUIDS: some useful
Change arterial line fluid to sodium information
chloride 0.45%
Percentage solution = grams in 100 mL
Minimise number and volume of (e.g. glucose 10% = 10 g in 100 mL)
flushes of IA and IV lines
One millimole = molecular weight in
milligrams
Compositions of commonly available solutions

FLUID Na K Cl Energy
mmol/L mmol/L mmol/L kCal/L
Sodium chloride 0.9% 150 – 150 –
Glucose 10% – – – 400
Glucose 10%/sodium
30 – 30 400
chloride 0.18%
Albumin 4.5% 150 1 – –
Sodium chloride 0.45% 75 – 75 –
Useful figures Osmolality

Sodium chloride 30% = Serum osmolality = 2(Na + K) +
5.13 mmol/mL each of Na and Cl glucose + urea (normally
Sodium chloride 0.9% = 285–295 mOsmol/kg)
0.154 mmol/mL each of Na and Cl Anion gap = (Na+ + K+) - (Cl– + HCO3–)
Potassium chloride 15% = normally 7–17 mmol/L
2 mmol/mL each of K and Cl Normal urine: osmolality
Calcium gluconate 10% = 100–300 mOsmol/kg, specific gravity
0.225 mmol/mL of Ca 1004–1015
Sodium bicarbonate 8.4% = Babies can dilute urine up to
1 mmol/mL each of Na and bicarbonate 100 mOsmol/kg, but can concentrate
only up to 700 mOsmol/kg
Sodium chloride 0.9% 1 mL/hr
= 3.7 mmol Na in 24 hr
Issue 6
184
Glucose
To make glucose 12.5%, add 30 mL of
glucose 50% to 470 mL of glucose 10%
To make glucose 15%, add 60 mL of
glucose 50% to 440 mL of glucose 10%
Glucose 20% is commercially available
Glucose 10% with sodium chloride
0.18% and 10 mmol potassium
chloride is not commercially available
but can be made up using 3 mL
sodium chloride 30% and a 500 mL
bag of glucose 10% with 10 mmol
potassium chloride
Issue 6
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INTUBATION • 1/3
See also Intubation – difficult Check you have the correct ETT size
guideline and attachments to secure ETT
Insert ETT introducer into ETT ensuring
This procedure must be undertaken or
it does not protrude past the end of the
supervised by an experienced person
ETT
Do not attempt to carry out this
procedure unsupervised unless you Ensure all drugs drawn up, checked,
have demonstrated your competence labelled and ready to give
Check no contraindications to drugs
ELECTIVE INTUBATION Ensure monitoring equipment attached
Use pre-medication as appropriate for and working reliably
your unit If nasogastric tube (NGT) in place,
aspirate stomach (particularly important
Equipment if baby has been given enteral feeds)
Suction Check IV line working
Oxygen with pressure limiting device Ensure back-up plan in case intubation
and T-piece or 500 mL bag and does not work (see Intubation –
appropriate size face mask difficult guideline)
Endotracheal tubes (ETT); non cuffed;
3 sizes (diameter in mm): Premedication
Use blended oxygen to pre-oxygenate
Weight of baby (g) ETT for 2 min prior to drug administration
<1000–1250 2.5 start with room air and increase FiO2
1250–3000 3.0 to get SpO2 to target range
appropriate for gestational age – see
>3000 3.5–4
Oxygen saturation target guideline.
Endotracheal tube introducer/stylet Avoid hyperoxia in preterm baby
Syringe and needles for drawing up Continue to pre-oxygenate until
premedication laryngoscopy and between attempts if
more than one attempt necessary
Neonatal stethoscope
Hat for baby to secure tube, ETT fixing Drugs
device, forceps and scissors
Choice of drugs depends on local
Laryngoscope handle and Miller practice
blades sizes 0 and 00, stethoscope, Analgesia and muscle relaxation can
oropharyngeal airway improve likelihood of successful
Pedicap® end tidal CO2 detector intubation
Oxygen blender
Muscle relaxants
Preparation Administer muscle relaxants only if
Ensure cannula in place and working you are confident that the team can
Ensure laryngoscope is working, correct intubate baby quickly
sized blades are available and T-piece Do not use a muscle relaxant unless
system is working. Set pressure limits – adequate analgesia has been given
30 cm H2O for term babies and Do not use muscle relaxant for
20–25 cm H2O in preterm babies INSURE (in-and-out surfactant
replacement)
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INTUBATION • 2/3
PROCEDURE
Give premedication Insert ETT
Use mask ventilation in neutral Advance ETT to desired length at the
position, a shoulder roll may help lips
Place laryngoscope in right side of General recommendation is to advance
mouth, lift up tongue and jaw to view ETT no further than end of black mark
cords and larynx. Lift laryngoscope: do at end of tube (2.5 cm beyond cords),
not tilt but this length is far too long for
Avoid trauma to gums extremely preterm babies
Cricoid pressure: by person intubating See Table: Length of ETT for where
or an assistant approximate markings of the ETT
should be at the lips
Suction secretions only if they are
blocking the view as this can stimulate
the vagal nerve and cause a
bradycardia and vocal cord spasm
Table: Length of ETT
Gestation of baby Actual weight Length of ETT (cm)
of baby (kg) at lips
23–24 0.5–0.6 5.5
25–26 0.7–0.8 6.0
27–29 0.9–1.0 6.5
30–32 1.1–1.4 7.0
33–34 1.5–1.8 7.5
35–37 1.9–2.4 8.0
38–40 2.5–3.1 8.5
41–43 3.2–4.2 9.0
Remove stylet if used and check to position (colour change is dependant

ensure it is intact before proceeding on circulation and an adequate volume
If stylet not intact, remove ETT of gas exchange)
immediately and prepare to reintubate Auscultate both axillae and stomach.
Breath sounds should be similar on
Confirming position of ETT each side and not be heard over the
View ETT passing through larynx stomach. This may be difficult to
Observe for chest movements with assess in very immature infants. In
ventilation breaths some special circumstances (e.g.
Use an end tidal CO2 detector pneumothorax diaphragmatic hernia)
attached to ETT for verification of there may be asymmetrical breath
correct tube placement sounds
may be of limited value in the very if breath sounds unequal and louder
small baby or in the presence of on right, withdraw ETT by 0.5 cm and
cardiovascular collapse. In these listen again, repeat until breath sounds
cases lack of colour change may not equal bilaterally
always mean tube is not in the correct
Issue 6
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INTUBATION • 3/3
If ETT tip in the trachea, and you are Record keeping
using a clear ETT, mist may condense
Indication for intubation
on the inside of the endotracheal tube
during expiration Whether oral or nasal
ETT size and position at cords and
Do not leave baby with nares/lips
unequal air entry
Radiological position of tip of ETT and
stabilise tube using ETT fixation any adjustments following to X-ray
method in accordance with unit Medication chart completed
practice
Baby’s tolerance of procedure and any
request chest X-ray: adjust ETT length adverse events
so that tip is at level of T2–3 vertebrae
and document on nursing chart and in
baby’s hospital notes
Intubation failure
Definition: Unable to intubate
within 30 seconds
If intubation unsuccessful, seek help
from someone more experienced
If there is a risk of aspiration, maintain
cricoid pressure
Continue mask ventilation until
successful intubation achieved
Limit hypoxia by:
limiting the intubation attempt to
prevent excess fall in oxygen saturation
and/or heart rate – a supportive team
member should be available to
determine when the attempt should
cease and re-oxygenation be
implemented
providing appropriate ventilation before
and between intubation attempts
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INTUBATION – DIFFICULT • 1/3
BACKGROUND
In most babies, direct laryngoscopy results in a clear view of the larynx. The laryngeal
view is classified by Cormack and Lehane as follows:
Grade 1 Grade 2 Grade 3 Grade 4
Visualisation of entire laryngeal aperture

Grade 1
There should be no difficulty in intubation
Visualisation of just the posterior portion of the laryngeal aperture
Grade 2 May be slight difficulty
Cricoid pressure should improve visualisation
Visualisation of only the epiglottis
Grade 3
Can result in severe difficulty; cricoid pressure may be helpful
Visualisation of soft palate only, not even the epiglottis is visible
Grade 4 Always difficult and usually accompanies obvious pathology but may also
occur totally unexpectedly. Senior support may be required
MANAGEMENT PLAN Straight bladed laryngoscopes for big

and small baby
Difficult neonatal intubation may occur
at or after delivery and may be: Forceps
anticipated (e.g. Pierre Robin sequence, Laryngeal mask airways (size 1)
Treacher–Collins, cleft lip and palate, Size 2.5–4.5 endotracheal bougies for
Goldenhar syndrome, Apert/Crouzon railroading ETT
syndrome, Down’s syndrome) or
Video laryngoscope and blades if
unanticipated (e.g. subglottic stenosis, available on your unit
laryngeal atresia, laryngeal or tracheal
CO2 detector e.g. Pedicap®
webs, glottic oedema post extubation)
Where difficult intubation is anticipated, Can ventilate, cannot intubate
ensure senior help is available before
(Good chest excursion and
commencing (senior experienced
middle grade, consultant or, if rising/good heart rate but
indicated, ENT consultant/anaesthetist) baby still needs intubation)
No more than 4 attempts at intubation
Difficult airway pack (2 per individual resuscitator), to avoid
Infant oropharyngeal airways (Guedel, laryngeal oedema and convert this into
sizes 000, 00, 0) a ‘cannot intubate, cannot ventilate’
ETT size 2–4.5 with stylet for intubation scenario
ETT size 2–4.5 with scissors, to cut ventilate between attempts at intubation
short for use as nasopharyngeal airway maximum 30 seconds per attempt to
support limit hypoxia
ETT fixation equipment Call for senior help
Issue 6
189
If intubation attempts fail, stop. When senior help arrives:
Continue either bag and mask
re-attempt intubation
ventilation or laryngeal mask airway
ventilation until senior help available use a small towel roll under baby’s
shoulder to improve vision
it is safer to maintain ventilation with
mask ventilation with adequate chest use indirect laryngoscopy with video
expansion until help arrives, as baby is laryngoscope if available
less likely to survive repeated Call ENT or anaesthetist for support
unsuccessful ETT attempts (ENT for rigid bronchoscopy or surgical
Two further attempts by senior tracheostomy, or anaesthetist for flexible
trainee/neonatologist fibrescope assisted intubation as above,
depending on your hospital’s availability)
Try indirect laryngoscopy using video
laryngoscope if available. If this fails, Use end tidal CO2 detector (e.g.
call for ENT support for rigid Pedicap®) to confirm tracheal intubation
bronchoscopy or surgical tracheostomy,
or ENT/anaesthetist for flexible Prevent/anticipate difficult
fibrescope assisted intubation intubation/re-intubation
depending on your hospital’s availability
For ventilated babies due for
Use end tidal CO2 detectors (e.g. extubation, risk of difficult re-intubation
Pedicap®) to confirm tracheal intubation can be reduced by pre-extubation
dexamethasone to reduce cord
Cannot ventilate, cannot oedema, especially in babies who had
intubate difficult initial intubations or chronic
ventilatory course
Reconfirm the following, and call for
senior help: if ETT leak <10–15%, consider
dexamethasone
neutral head position (overextension
can limit vision)
correct size face mask being used,
create a tight seal
use correct size oropharyngeal airway
(Guedel airway): too big may cause
laryngospasm and too small may
worsen obstruction (tip of the Guedel
airway should reach the angle of the jaw
when aligned with lip on side of face)
For specific conditions (e.g. Pierre
Robin sequence, micrognathia)
nasopharyngeal airway may be useful.
To make, take an ETT and shorten it by
measuring distance between nasal tip
and ear tragus. Choose a size that
does not blanch the nares completely
when inserted
Laryngeal mask ventilation (smallest size
= size 1, suitable for babies >1.5 kg)
Issue 6
190
Common problems with intubation
Problem Action
Oesophageal intubation – blade placed Retry with shallow blade insertion and
too deep, cords not visualised use cricoid pressure
Sweep tongue to left side using blade
Tongue obscures vision Use a more anterior lift
Use straight blade (Miller)
Ensure head not hyper-extended
Cannot see cords Use small towel roll under baby’s
shoulders
Do not panic
Calmly maintain chest excursions
through bag or T-piece/face or laryngeal
Cannot intubate mask ventilation until help arrives
Use Guedel oral airway if necessary
Call for senior help
See senior support in the Surgical tracheostomy: not

following situations undertaken by neonatal consultants –
seek ENT support
Blind intubation: in small baby where
poor visualisation due to size NB: Prolonged procedure: additional
dose of muscle relaxant can be used
Laryngeal mask airway (size 1): can
under senior guidance
be inserted by juniors while awaiting
senior support if trained ensure venous access obtained
Video laryngoscope: if available, to support cardiac system with IV fluid
guide intubation through the cords boluses as required
Railroad technique: if laryngeal use inotropic agents as required,
aperture narrow, insertion of stylet based on perfusion and blood pressure
through cords, and railroading ETT Keep baby warm using techniques
over it: supported by your local unit e.g.
usually a two-person procedure and transwarmer, bubble wrap
can be carried out under direct Empty stomach contents regularly
vision/blind, depending on visual field while on face mask/T-piece ventilation
and equipment
carefully insert a bougie through vocal
cords, not more than 2 cm beyond
aperture opening
keep bougie steady while colleague
threads ETT over top end of stylet and
into trachea. Note: using a stylet from
the ETT pack carries risk of
oesophageal/tracheal perforation
Ultra-small fibre-optic bronchoscopy
(if available locally): with railroading via
bronchoscope
Issue 6
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JAUNDICE (Based on NICE CG98 Jaundice in
newborn babies under 28 days) • 1/3
RECOGNITION AND Persistent jaundice after

ASSESSMENT 14 days of age – see Liver
Risk factors for dysfunction guideline
hyperbilirubinaemia Breast milk jaundice
Hypothyroidism
<38 weeks’ gestation
Liver disease (e.g. extra hepatic biliary
Previous sibling required treatment for atresia and neonatal hepatitis)
jaundice α1-antitrypsin deficiency
Mother intends to exclusively breastfeed Galactosaemia
Visible jaundice in baby aged <24 hr TPN-induced cholestasis
Risk factors for kernicterus Investigations
High bilirubin level (>340 micromol/L in Assessment of jaundice
term baby) Babies <72 hr old at every opportunity
(risk factors and visual inspection)
Rapidly rising bilirubin level
(>8.5 micromol/L/hr) Babies with suspected or obvious
jaundice, measure and record bilirubin
Clinical features of bilirubin level urgently
encephalopathy
<24 hr, within 2 hr
Symptoms and signs ≥24 hr, within 6 hr
Yellow colouration of skin in a pale- If serum bilirubin >100 micromol/L in
skinned baby observed in natural light first 24 hr
repeat measurement in 6–12 hr
Yellow conjunctivae in dark-skinned
interpret result in accordance with
babies
baby’s age and gestation – see Table
Assess urgent medical review as soon as
possible (and within 6 hr)
Pallor (haemolysis)
Interpret bilirubin result in accordance
Poor feeding, drowsiness (neurotoxicity) with baby’s gestational and postnatal
Hepatosplenomegaly (blood-group age according to Table
incompatibility or cytomegalovirus)
Jaundice requiring treatment
Splenomegaly (spherocytosis) Total bilirubin
Causes Baby’s blood group and Direct Coombs’
test (interpret result taking into account
Physiological
strength of reaction and whether
Prematurity mother received prophylactic anti-D
Increased bilirubin load: immunoglobulin during pregnancy)
blood group incompatibility (Rhesus or Mother’s blood group and antibody
ABO) status (should be available from
maternal healthcare record)
G6PD deficiency and other red cell
PCV
enzyme deficiencies
congenital spherocytosis Plus (if clinically indicated)
Full infection screen (in an ill baby)
cephalhaematoma, bruising
G6PD level and activity (if indicated by
Rarely infection (e.g. UTI, congenital ethnic origin: Mediterranean, Middle
infection) Eastern, South East Asian)
Metabolic disorder FBC and film
Issue 6
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Persistent jaundice Use continuous multiple phototherapy

>14 days term baby; for babies who:
>21 days preterm baby fail to respond to conventional
(see Liver dysfunction guideline) phototherapy (bilirubin does not fall
within 6 hr of starting treatment)
Total and conjugated bilirubin
have a rapid rise in bilirubin
Examine stool colour
(>8.5 micromol/L/hr)
FBC
have a bilirubin level at which
Baby’s blood group and Direct Coombs’ exchange transfusion is indicated
test (interpret result taking into account
strength of reaction and whether Babies <38 weeks’ gestation
mother received prophylactic anti-D Use fibre optic or conventional blue
immunoglobulin during pregnancy) light as 1st line treatment
Ensure routine metabolic screening based on gestational age and
performed (including screening for postnatal age, use Threshold graphs
hypothyroidism) (http://www.nice.org.uk/guidance/CG98
Urine culture under ‘Tools and resources’ then
‘CG98 Neonatal Jaundice: treatment
Baby with conjugated bilirubin threshold graphs’) to determine
>25 micromol/L, refer urgently to a threshold for phototherapy
specialist centre
Indications for multiple phototherapy
2nd line investigations as term babies
(not in NICE guideline) Management during
Liver function tests (ALT, AST, albumin, phototherapy
GGT)
Offer parents information on procedure
Coagulation profile (BLISS ‘Neonatal Jaundice factsheet’
G6PD screen in African, Asian or available at
Mediterranean babies http://www.bliss.org.uk/factsheets)
Thyroid function tests: ask for ‘FT4 Unless other clinical conditions
priority and then TSH’ prevent, place baby in supine position
Congenital infection screen Ensure treatment applied to maximum
area of skin
Urine for CMV PCR, toxoplasma
ISAGA-IgM and throat swab for HSV Monitor baby’s temperature
culture/PCR Use eye protection and give routine
Metabolic investigations e.g: eye care
blood galactose-1-phosphate Provided bilirubin not significantly
elevated, encourage breaks of up to
urine for reducing substances 30 min for breastfeeding, nappy
α1-antitrypsin change and cuddles
Do not give additional fluids routinely
TREATMENT <7 DAYS
During multiple phototherapy:
Babies ≥38 weeks’ gestation
do not interrupt for feeds
Use conventional blue light
phototherapy (not fibre optic) as monitor hydration by weighing baby
treatment of choice daily and assessing wet nappies
Issue 6
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Monitoring during DISCHARGE AND FOLLOW-UP

phototherapy GP follow-up with routine examination
Repeat serum bilirubin 4–6 hr after at 6–8 weeks
starting treatment If exchange transfusion necessary or
Repeat serum bilirubin 6–12 hrly when considered, request developmental
bilirubin stable or falling follow-up and hearing test
Stop phototherapy once serum bilirubin In babies with more than weakly positive
has fallen to at least 50 micromol/L Coombs’ test who require phototherapy:
below threshold check haemoglobin at 2 and 4 weeks of
Check for rebound jaundice with age due to risk of continuing haemolysis
repeat serum bilirubin 12–18 hr after give folic acid 1 mg daily
stopping phototherapy
Table: Limits for phototherapy and exchange transfusion for babies ≥38 weeks’
gestation
Age (hours) Serum bilirubin Serum bilirubin Serum bilirubin Serum bilirubin
(micromol/L) (micromol/L) (micromol/L) (micromol/L)
0 >100 >100
6 >100 >112 >125 >150
12 >100 >125 >150 >200
18 >100 >137 >175 >250
24 >100 >150 >200 >300
30 >112 >162 >212 >350
36 >125 >175 >225 >400
42 >137 >187 >237 >450
48 >150 >200 >250 >450
54 >162 >212 >262 >450
60 >175 >225 >275 >450
66 >187 >237 >287 >450
72 >200 >250 >300 >450
78 – >262 >312 >450
84 – >275 >325 >450
90 – >287 >337 >450
96+ – >300 >350 >450
Repeat Consider Start Perform
transcutaneous phototherapy phototherapy exchange
bilirubin/serum (repeat transfusion
ACTION bilirubin (6–12 hr) transcutaneous
bilirubin/serum
bilirubin in 6 hr)
Source: http://www.nice.org.uk/guidance/CG98
Treatment graphs giving the phototherapy and exchange transfusion limits for each
gestational age can be printed from http://www.nice.org.uk/guidance/CG98 under
‘Tools and resources’ then ‘CG98 Neonatal Jaundice: treatment threshold graphs’
Issue 6
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KANGAROO CARE (KC) • 1/2
DEFINITION CONTRAINDICATIONS
Method of holding preterm and/or sick Umbilical lines in situ
baby skin-to-skin in an upright position
between mother’s breasts or against Consider
carer’s chest (fathers and siblings can Baby’s condition and dependency
also be Kangaroo carers) Maintenance of neutral thermal
KC can be offered to parents of environment and humidity
medically stable babies Activity in the room: quiet, calm
environment is preferable
Benefits of Kangaroo care
Inform parents about the benefits of Support available from colleagues
KC (use BLISS ‘Skin-to-skin and Ensure
Kangaroo Care’ information
http://www.bliss.org.uk/skin-to-skin- Access to oxygen and suction
and-kangaroo-care or locally approved PARENT PREPARATION
information leaflets):
Ensure parents are aware that baby
helps promote physiological stability: may be briefly unstable during transfer
regulates baby’s temperature, heart from/to incubator/cot
rate, breathing and oxygen saturation
Suggest parents do not smoke
associated with fewer episodes of immediately before KC time
apnoea and bradycardia
Choose a mutually convenient time for
increases time in quiet sleep parents and baby
longer alert states and less crying Provide privacy for parents to prepare
analgesic effect during painful clothing – suggest parents wear a
procedures clean loose fitting, front fastening shirt
promotes growth and earlier discharge Provide comfortable chair and foot rest
improves lactation and breastfeeding if appropriate
success – duration and exclusivity Offer a hand-held mirror – to enable
promotes parent–baby attachment and parent to see baby’s face
family-centred care Advise parents to bring a drink and go
positive effect on parenting – reduces to toilet before KC time
stress and depression, triggers healing
Nurse transfer
process, increases confidence
Recommended initial transfer method.
INDICATIONS
Use this method until parents feel
Medically stable baby – including confident
those on CPAP with a stable oxygen
requirement Parent to sit slightly reclined in a
Medically stable ventilated babies after comfortable chair. Ensure clothing
discussion with MDT open and ready to receive baby
Ventilated babies receiving palliative Contain baby’s limbs and move gently
care – use ‘snuggle up’ nest if appropriate
Place baby on parent’s chest, prone
If concerns regarding stability of with head to parent’s sternum
baby, discuss with senior member of
medical and nursing team Parent to support baby’s head and
body with baby’s legs flexed
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KANGAROO CARE (KC) • 2/2
Turn baby’s head to side to protect Duration of KC
airway
When baby settled, remove
Use parent’s clothing and a screens/curtains – be guided by
wrap/blanket for warmth and support parental preference
If appropriate, place hat on baby Aim to provide KC for a minimum of 1 hr
Parent transfer Monitor baby’s position and vital signs
Parent to stand at side of incubator Babies may have nasogastric tube
(NGT) feeds during KC time
Place forearm gently under ‘snuggle
up’ nest or sheet, cup baby’s head Discontinue KC if:
with other hand baby shows signs of distress
Gently lift baby from incubator and has a prolonged increase in oxygen
onto chest, resting baby’s head requirement of 10–20%
against sternum while supporting at parent’s request
baby’s back and bottom with forearm
Parent gently moves back to sit in Breast milk
chair, guided by nurse Encourage mother to express breast
Nurse to check baby’s position as milk following KC time. See Breast
before milk expression guideline
Issue 6
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LABOUR WARD CALLS • 1/1
Encourage obstetric team to warn The following factors may
neonatal team of expected problems require neonatal team to
well in advance attend birth or assess baby
Decide who should attend (e.g. Tier 1, soon after birth (see antenatal
2 or 3 staff), and degree of urgency plan in maternal notes)
Neonatal team should attend Maternal illness likely to affect baby:
the following deliveries diabetes mellitus
Non-reassuring electronic fetal thyroid disease
monitoring (EFM) trace, as assessed systemic lupus erythematosus
by obstetric team
myasthenia gravis
Significant fresh meconium in liquor
myotonic dystrophy
Caesarean section under general
anaesthesia (see below) hepatitis B carriage
Major congenital abnormalities (minor HIV
abnormalities will wait until working HELLP syndrome
hours)
Maternal medications that may affect
Vacuum extraction or instrumental
baby e.g. antidepressants
deliveries performed for fetal reasons
(see below)
Neonatal alerts:
Preterm delivery <36 weeks’ gestation
abnormal antenatal scans
Severe pre-eclampsia with seizures
low birth weight baby <2.5 kg
Antepartum haemorrhage
Moderate-to-severe Rhesus disease Pregnancy and past history
Unexpected breech delivery prolonged rupture of membranes
polyhydramnios
It is not necessary for neonatal team to
previous baby/perinatal death
attend the following deliveries:
family history of genetic or metabolic
Elective caesarean section under abnormalities
regional anaesthesia
Meconium staining of liquor
Breech delivery (including caesarean
section under regional anaesthesia)
Twins (>36 weeks)
Pre-eclampsia without seizures
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LIVER DYSFUNCTION IN PRETERM BABIES •
1/4
DEFINITION CAUSES
Cholestasis: conjugated Not all liver dysfunction in preterm
hyperbilirubinaemia ≥25 micromol/L babies is caused by parenteral
and/or ≥20% of total bilirubin nutrition. Extra-hepatic biliary atresia
Acute liver failure with raised does occur and must be diagnosed
transaminase and coagulopathy and managed in a timely fashion
unresponsive to vitamin K
Biliary tract disorders Neonatal hepatitis Metabolic
Extra-hepatic biliary Isolated α1-antitrypsin deficiency
atresia Associated with: Cystic fibrosis
Bile duct stricture parenteral nutrition Galactosaemia
Choledochal cyst maternal diabetes Dubin-Johnson syndrome
Alagille syndrome hydrops fetalis Bile acid disorder
Non-syndromic bile duct trisomy 21 Haemochromatosis
paucity
Infection Endocrine Toxins/injury
Cytomegalovirus Hypopituitarism Parenteral nutrition

Toxoplasmosis Hypothyroidism Multifactorial preterm
Sepsis Haemolytic disease
Hypoxia
Discuss all term babies with liver First-line investigations

dysfunction urgently with liver unit team Complete the following as soon as
To exclude extra-hepatic biliary atresia, possible:
admit to liver unit coagulation screen
transaminases, bilirubin (total and
SYMPTOMS AND SIGNS
conjugated), albumin, gamma GT, and
Pale or acholic stools alkaline phosphatase
Prolonged jaundice (defined as visible galactosaemia and tyrosinaemia screen
jaundice at day 14 in term and day 21
α1-antitrypsin concentration and
or older in preterm babies)
phenotype
Bleeding, including intraventricular
haemorrhage from vitamin K deficiency serum cortisol, T4 and TSH
Green jaundice on any day of life stool in opaque pot for consultant review
Acute collapse with liver failure urine for MC&S
Failure to thrive abdominal ultrasound scan, after 4 hr
fast if possible, to include liver and
INVESTIGATIONS gallbladder examination
Aim to diagnose causes of liver if clinical suspicion high, toxoplasma
dysfunction that will benefit from serology, CMV IgM or PCR or urine
early diagnosis while avoiding PCR for CMV, syphilis serology, viral
unnecessary transfer and culture from swabs of any vesicles for
investigation of small sick babies herpes simplex, hepatitis E serology
Issue 6
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2/4
if metabolic disorder suspected, Preterm babies with diagnoses
plasma lactate, plasma and urine requiring surgery (e.g. Kasai
amino acids, and urine organic acids procedure for biliary atresia) need to
be more than term-corrected age or
As they become available, discuss weigh at least 2 kg before surgery
results of liver function, coagulation, considered
stool colour, weight gain and abdominal
ultrasound with liver unit team Early isotope scanning not widely
available and of limited value, many
babies can be investigated without this
FURTHER INVESTIGATIONS procedure
Standard aggressive protocol used to Assessment of stool colour can
investigate term babies is inappropriate determine which babies with
in preterm babies because of: cholestasis require urgent further
insufficient blood volume for blanket investigation, as shown below:
testing
poor temperature control when
attending for isotope scans
limited size increases risk of liver
biopsy
Transfer to specialist centre often not
possible owing to need for ongoing
respiratory support and neonatal
nursing care
Pigmented Pale stools or

Acholic stools
stools not seen
USS
(4 hr fast)
Isotope excretion scan

organised by liver team
Gallbladder Gallbladder
when ≥2 kg
normal small or
absent
Ongoing medical Excretion No excretion

assessment with liver
team, nutritional
management, vitamin
supplementation and Urgent liver biopsy may be
ursodeoxycholic acid deferred until weight ≥2 kg
Issue 6
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3/4
Investigations for ongoing Prescribe vitamins during cholestasis
liver dysfunction and for 3 months following resolution
of jaundice; doses will require
Preterm babies with persistent liver
monitoring and adjustment if still
dysfunction but initially normal
required after discharge (co-ordinated
gallbladder size or an excreting
by liver team):
isotope scan can be further
investigated locally, discuss with liver vitamin K 1 mg oral daily: monitor PT
team and APTT
If indicated by results of first-line vitamin A 5,000 units daily: monitor
investigations or progressive serum vitamin A
dysfunction, consider: vitamin E 50 mg daily: monitor serum
ophthalmic review (other than for vitamin E
retinopathy of prematurity) alfacalcidol 20 nanogram/kg daily:
micro-array for dysmorphism given as 100 nanogram (1 drop) every
2–3 days dependent on weight (it is
very long-chain fatty acids for
not possible to measure a smaller
neurological abnormality
dose). Monitor bone biochemistry
urinary bile salts
isotope scan, liver biopsy or bone
Ursodeoxycholic acid
marrow aspirate BNFc dose 5–10 mg/kg three times
daily but liver team will normally
MANAGEMENT OF recommend 20–30 mg/kg/day in
CHOLESTASIS divided doses for most preterm babies
Surgical correction, if appropriate (e.g. until jaundice resolves, and to
Kasai, choledochal cyst), usually when stimulate bile flow in babies and
≥2 kg or term-corrected age, discuss children with cystic fibrosis
individual cases with liver team
Parenteral nutrition (PN)
Nutrition to overcome malabsorption of
Wherever possible, feed enterally, as
long-chain fat and fat-soluble vitamins
even small amounts have trophic
if breastfeeding, continue unless effects on gut, reduce bacterial
weight gain or linear growth colonisation and promote bile flow
inadequate
Bolus feeds promote bile flow more
if breastfeeding not available or failing readily than continuous feeds, but the
to thrive, provide high-calorie diet latter may be better absorbed
aiming for 120–150% of estimated
Discontinue PN as soon as possible in
average with increased percentage of
all preterm babies with cholestasis
fat as medium-chain triglycerides
(such as Pepti-Junior) or supplement Specific treatments
breast milk with medium-chain
Babies with cystic fibrosis,
triglyceride fat additives, seek advice
galactosaemia, tyrosinaemia type 1,
from liver unit team
hypopituitarism, hypothyroidism or bile
if individually prescribed modular feed acid disorders require additional
required: co-ordinated by liver unit targeted management and life-long
dietitians while baby is in-patient on follow-up shared by local teams and
liver unit or attending their out-patient appropriate specialists
clinic
Issue 6
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4/4
FOLLOW-UP
For babies with persistent cholestasis,
arrange out-patient follow-up with liver
team after discharge from neonatal unit
If liver dysfunction has resolved, no
follow-up with liver team necessary
For all others with a specific diagnosis,
follow-up will be directed by liver team,
appropriate specialists and local
consultant
Long-term hepatic outcome for
multifactorial preterm or neonatal
hepatitis excellent, majority resolve
within first year
Issue 6
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LONG LINE INSERTION (PERIPHERALLY
SITED) • 1/4
Central venous catheters allow sterile towels/sheets
administration of infusions that, if given non-toothed forceps
peripherally, may cause damage to the
vein and surrounding skin, or be less 5–10 mL syringe
effective. These benefits must be Steristrips
weighed against the risks of line sepsis, sterile scissors
thrombosis, embolism, and pleural and
clear dressing (e.g. Tegaderm/Opsite)
pericardial effusion. Units which use
central line catheters should have a PROCEDURE
formal training package for insertion of
catheters which should include Must be performed or directly
assessment of technical competence and supervised by an individual competent
awareness of potential complications in the insertion of these devices
INDICATIONS Consent and preparation

Total/partial parenteral nutrition Inform parents and obtain verbal
Concentrated (>12.5%) glucose consent as recommended by BAPM
infusions Discuss timing of procedure with
Infusions of glucose >5% + calcium nurses
gluconate Keep baby warm. Work through
Inotrope infusions portholes
Prolonged drug or fluid administration Identify site of insertion

where peripheral access difficult typically long saphenous at ankle or
medial/lateral antecubital vein at elbow
CONTRAINDICATIONS
where access difficult, other large
Infection at proposed insertion site peripheral veins or scalp veins anterior
Systemic sepsis: defer until sepsis to ear may be used
treatment commenced and blood Measure distance, aiming to insert tip
cultures negative of catheter into superior or inferior
Tissue perfusion concerns vena cava (to xiphisternum for lower
limb insertion, to upper sternum for
EQUIPMENT upper limb insertion)
Sterile gown and sterile gloves
Developmental care
Unless contraindicated, give sucrose
Sodium chloride 0.9% for injection or breast milk and non-nutritive
Tape measure sucking
Overhead light Shield baby’s eyes from bright light
Neonatal long line – appropriate for Second person to provide containment
size of baby and expected rate of holding – see Pain assessment and
infusion management guideline
Decide whether double or single
Aseptic insertion
lumen line required
Maintain strict asepsis throughout
Long line insertion pack or, if not
available, individual items to include: Prime catheter and cut small piece of
gauze for under hub
dressing pack with swabs and plastic
dish
Issue 6
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SITED) • 2/4
Clean site and allow to dry. Ensure use X-ray magnification, contrast
that cleaning fluid does not pool adjustment and inversion to aid
beneath baby process
Puncture site with needle from pack use of contrast medium can help
and follow instructions for that catheter if using contrast medium, refer to local
Avoid use of cannulae for long line policy
insertion If inserted in upper limb, ensure arm is
When blood flows back through the at 90º angle to thorax during X-ray
needle, insert line using non-toothed Determine satisfactory position
forceps
Upper limb catheter tip should
If appropriately placed, the line will preferably be in superior vena cava
pass easily beyond the tip of the (SVC). Lower limb catheter should be
needle in inferior vena cava (IVC) above L4–5
Release tourniquet if used and outside heart. Other large veins
There may be some resistance when e.g. innominate, subclavian, common
the line passes joints, such as knee, iliac are acceptable
and gentle repositioning of baby’s limb Catheter tips in axillary, cephalic and
may help femoral veins are acceptable if the
Should catheter advancement become benefit outweighs increased risks of
difficult, infuse a little fluid whilst reinsertion
simultaneously advancing catheter Monitor site closely
Never withdraw catheter back through If catheter tip beyond desired location,
needle using aseptic technique, remove
When in place, withdraw needle as dressing and, withdraw catheter the
stated in catheter instructions measured distance. Redress with new
sterile dressing and confirm new
Catheter should allow free aspiration position by X-ray
of blood in the final position
Catheter tip must not lie within heart
Securing catheter in correct (risk of perforation and tamponade)
position
When haemostasis achieved, fix with Failure of insertion
Steristrips. Place small piece of gauze If second operator is required following
under hub, and cover with an unsuccessful attempt at placement,
Tegaderm/Opsite, making sure that all use fresh equipment
dressing and site is covered, but not
encircling the limb tightly. Ensure line DOCUMENTATION
insertion site is visible through clear Record in case notes:
dressing
date and time of insertion
Connect a sterile 5 mL syringe
success of insertion and number of
containing sodium chloride 0.9% and
attempts
infuse at 0.5 mL/hr, while awaiting
X-ray, to ensure that the line does not type and gauge of catheter
clot off site and length of insertion
X-ray to determine position X-ray position and alterations
Small gauge neonatal long lines can Insert tracking stickers from all packs
be difficult to see on plain X-ray
Issue 6
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SITED) • 3/4
AFTERCARE Avoid the use of alcohol or acetone to
clean the catheter as this may result in
Dressings and site care
catheter damage
Routine dressing changes are
Limit line breaks as above
unnecessary
Replace aseptically only if dressings Do not exceed the pressure limits
lift or catheter visibly kinked or given by the manufacturer because of
becomes insecure the risk of damage to the line
Observe site every shift for bleeding, Catheter-related sepsis

leaking of infusate and signs of Commonest complication
infection (redness, swelling)
See Infection (late onset) guideline
Line management and
medication Extravasation of fluids
Minimise number of line breaks Into pleural, peritoneal, pericardial
Intermittent medications only given via (above) and subcutaneous
this route in extreme circumstances. compartments
(This is a senior medical decision). Seek immediate advice from senior
Plan timing to match infusion changes colleagues and follow Extravasation
When breaking into line, observe hand injuries guideline
hygiene, wear sterile gloves and clean
Suspected/proven pericardial
connection as per local infection
control policy
tamponade
Suspect if any of the following
Change tubing used to give blood
symptoms:
products immediately after transfusion
(use to give blood product only if it is acute or refractory hypotension
difficult to insert alternative IV line) acute respiratory deterioration
Position maintenance arrhythmias
Repeat X-ray weekly to detect line tachycardia
migration unexplained metabolic acidosis
Never routinely resite a line Confirm by X-ray (widened
Review continued need on daily ward mediastinum, enlarged cardiac
rounds and remove as soon as possible shadow) or by presence of pericardial
fluid on echocardiogram
COMPLICATIONS
Drain pericardial fluid (see
Clinical deterioration of a baby in whom Pericardiocentesis guideline) and
a central venous catheter is present remove catheter
should raise the question of catheter
related complications; particularly Embolisation of catheter
infection, extravasation and tamponade fragments
Prevention Lines can snap if anchored within a
Do not give blood products and thrombus
medications routinely through long line If undue resistance encountered
Avoid the use of small syringes <2 mL during removal, do not force
for bolus injections as they generate Inform consultant: if accessible it may
high pressures which may result in need surgical removal
catheter damage
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SITED) • 4/4
REMOVAL
Indications
Clinical use is no longer justified
Remove 24 hr after stopping
parenteral nutrition total (TPN) to
ensure tolerance to full enteral feeds,
running glucose 10% through line at
0.5 mL/hr to maintain patency
Complications – see Complications
Technique
Using aseptic technique:
remove adhesive dressing very
carefully
pull line out slowly, using gentle
traction in the direction of the vein,
grasping line not hub
ensure catheter complete
if clinical suspicion of line infection,
send tip for culture and sensitivity
apply pressure to achieve haemostasis
document removal in notes
Issue 6
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MEDIUM-CHAIN ACYL-COA DEHYDROGENASE
DEFICIENCY (MCADD) • 1/1
Early management of babies with family history
DEFINITION DNA mutation analysis (in most cases,

genotype will be known for the index
A rare autosomal recessive inherited
case)
metabolic disease where the body
cannot metabolise fat properly Discuss testing with metabolic
laboratory at Birmingham Children’s
With regular intake of food, individuals
Hospital and mark request ‘family
can lead a normal healthy life but
history of MCADD’
prolonged fasting or illness with
vomiting can lead to encephalopathy, Continue special feeding regimen until
coma or sudden death results available
Affects 1:10,000 babies in UK. 1:80 MANAGEMENT
healthy people are carriers
High index of suspicion antenatally
Bloodspot screening at day 5 includes
MCADD (see Bloodspot screening Refer those with family history of
guideline) MCADD for genetic counselling
antenatally
Newborn babies with MCADD are
especially vulnerable in first few days Advise parents baby will require
of life before breast milk supply and specialist feeding regimen from birth
regular feeding pattern established and rapid testing at 24–48 hr old
Babies with a family history of MCADD Institute specialist feeding regimen

require a special feeding regimen and from birth
observation from birth Ensure regular milk intake
term baby 4-hrly feeds
SYMPTOMS
preterm baby 3-hrly feeds
Often non-specific
Breast fed babies are at a particular
hypothermia
risk in first 72 hr. Give formula top-ups
jitteriness until good maternal milk supply
irritability established
drowsiness if baby not taking adequate oral feeds,
start nasogastric tube feeding
reluctance to feed
If enteral feeds not tolerated,
lethargy
commence IV fluid – glucose 10%,
rapid breathing sodium chloride 0.18%
seizures Complete bloodspot screening as
coma normal on day 5
sudden death LOCAL CONTACT
Hypoglycaemia occurs late For specialist advice, consult
DIAGNOSIS Birmingham Children’s Hospital
metabolic on-call consultant (0121 333
When mother admitted in labour, inform 9999)
neonatal team
Test baby between 24-48 hr old FURTHER INFORMATION
bloodspot acylcarnitines http://www.bimdg.org.uk/guidelines.asp
urine organic acids
Issue 6
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METABOLIC BONE DISEASE • 1/2
RECOGNITION AND Poor weight gain or faltering growth
ASSESSMENT Respiratory difﬁculties
Definition failure to wean off ventilator due to
Decreased mineralisation of bones due excessive chest wall compliance
to deficient phosphate (PO4), calcium Fractures with minor or no trauma;
(Ca) or vitamin D in preterm babies may manifest as pain on handling
Also known as osteopenia of prematurity Jitteriness in hypocalcaemia
Craniotabes (softening of skull bones)
Causes
Low bone density on X-rays (rachitic
Inadequate postnatal intake or changes, cortical thinning, periosteal
absorption to support intrauterine elevation)
mineral accretion rate
Later clinical consequences
Risk factors
Marked dolicocephaly (long and
<32 weeks’ gestation narrow skull)
<1500 g birth-weight Myopia of prematurity
Male gender Reduced linear growth
Inadequate nutrition
INVESTIGATIONS
suboptimal intake
Measure serum Ca, PO4 and alkaline
enteral feeds with low mineral
content/bioavailability [unfortified phosphatase (ALP) levels weekly from
expressed breast milk (EBM), term third week of life in high risk babies
formula] low serum PO4 (<1.8 mmol/L) with
Phosphorus deficiency (primary elevated ALP (>900 IU/L) is 100%
nutritional reason) sensitive and 70% speciﬁc for
diagnosing low bone mineral density.
Vitamin D deficiency Low serum PO4 concentrations
Prolonged total parenteral nutrition (<1.8 mmol/L) have 96% specificity but
Chronic use of drugs that increase only 50% sensitivity
mineral excretion (diuretics, serum Ca levels may remain normal
dexamethasone, sodium bicarbonate) until late in the disease
Lack of mechanical stimulation e.g. Measure urinary Ca and PO4. Urinary
sedation/paralysis excretion of Ca >1.2 mmol/L and PO4
Bronchopulmonary dysplasia >0.4 mmol/L signifies slight surplus of
Cholestatic jaundice supply and correlates with highest
bone mineral accretion rate
Short gut syndrome (malabsorption of
vitamin D and Ca) phospaturia can occur due to
aminoglycoside, indomethacin and
Symptoms and signs dexamethasone therapy
Up to 6 weeks, most babies are calciuria can occur due to diuretics,
asymptomatic and normal on dexamethasone and theophylline
examination
Usually presents between 6–12 weeks
of age
Issue 6
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METABOLIC BONE DISEASE • 2/2
Babies on unfortified human milk are If PO4 deficient (<1.8 mmol/L) –
relatively phosphate deficient and have: supplement PO4 at 1–2 mmol/kg/day
normal serum Ca, low serum PO4 and in divided doses
high serum ALP If Ca deficient (<1.6 mmol/L) –
urinary PO4 excretion is very low or supplement Ca at 1–3 mmol/kg/day in
absent and urinary Ca excretion divided doses
increases as serum PO4 concentration do not give Ca and PO4 at the same
decreases time because they may precipitate; so
normal serum vitamin D and give at alternate feeds
parathormone levels Ca supplementation can cause intestinal
Formula-fed preterm babies have a obstruction and hypercalcinosis
low calcium absorption rate and Consider other nutritional deficiencies
therefore a very low urinary Ca and e.g. zinc, in a baby with faltering growth
PO4 concentrations with evidence of significant bone
disease
X-rays can demonstrate
demineralised, thin bones, signs of MONITORING AND
rickets and thoracic cage and
FOLLOW-UP
extremity fractures
Weekly monitoring of serum Ca, PO4
Dual-energy X-ray absorptiometry
(DXA) and ALP along with urinary Ca and PO4
Continue treatment until biochemical
PREVENTION indices are normal and radiographic
Aggressive nutritional care of preterm evidence of healing, usually until term
babies corrected gestation
initiate early parenteral nutrition with
optimised Ca and PO4 content [at
least 12 mmol/L each of Ca and PO4
(= 1.8 mmol/kg/day of Ca and PO4 at
150 mL/kg/day)]
early enteral feeds
use of breast milk fortifier or preterm
formula
Early phosphate supplementation in
high risk babies
Gentle passive physiotherapy
TREATMENT
Ensure an adequate intake of Ca
(2.5–4 mmol/kg/day) and PO4
(1.9–2.9 mmol/kg/d) by using fortified
breast milk or preterm formula
Ensure a daily intake of at least 800 IU
vitamin D per day
Issue 6
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MULTI DRUG RESISTANT ORGANISM
COLONISATION (MRSA, ESBL ETC) • 1/2
Use this guideline in conjunction with mother has other risk factor: high BMI
your local Trust policy or is a healthcare worker with patient
contact
This guideline describes the screening mother or household member has a
and follow-up action for the following history of skin/soft tissue infection
organisms abscess or recurrent skin infections in
Meticillin-resistant Staphylococcus the last 12 months
aureus (MRSA) If none of these risk factors present,
Multi-resistant Gram-negative bacilli screening contacts is not necessary
(MGNB) including: unless advised by consultant
Extended spectrum beta lactamase microbiologist
(ESBL)
Contacts on NICU
Carbapenemase-producing
enterobacteriaceae (CPE) Screen babies who have been in NICU
>2 weeks
other carbapenemase-producing GNB
Those who have been in close proximity
SCREENING of the index case (i.e. in the same room)
Babies transferred from Others (potentially all) following a risk
other hospitals assessment and discussion with
Screen on arrival. Include babies who consultant of the week, co-ordinator
attend other hospitals for invasive day and consultant microbiologist
case procedures (e.g. PDA ligation) Healthy babies about to be discharged
MRSA: home do not require screening unless
advised by consultant microbiologist
swab nose and perineum plus
umbilicus if still moist, and any skin Decolonisation of carriers
lesion (e.g. indwelling vascular line)
Discharge term healthy babies without
urine if long-term urinary catheter treatment
present
Smaller babies with indwelling lines or
MGNB: CPAP probes are more at risk and
rectal swab should be treated
if unable to obtain rectal swab send mupirocin (Bactroban Nasal®)
stool sample instead with reason stated ointment applied to inner surface of
Barrier nurse until swabs confirmed each nostril 3 times daily for 5 days; if
negative at 48 hr MRSA reported as high level resistant
to mupirocin, then discuss with
MANAGEMENT OF consultant microbiologist
INCIDENTAL FINDINGS
wash daily with antimicrobial wash, e.g.
MRSA chlorhexidine or octenidine, for 5 days
Mother Repeat screening swabs 48 hr after all
Screen mother with nasal, perineal, antibiotic treatment has finished and if
wound and skin lesion swabs, if: baby not about to be discharged
delivery by caesarean section Successful eradication can be
mother had recent admission to assumed if 3 consecutive swabs taken
hospital before delivery at 3–7 day intervals are negative. Do
not attempt to decolonise more than
mother has chronic health problem
twice during any one admission
(e.g. diabetes, asthma)
Issue 6
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MULTI DRUG RESISTANT ORGANISM
COLONISATION (MRSA, ESBL ETC) • 2/2
MGNB MGNB
Do not attempt decolonisation. Two or more babies with same strain of
Colonisation is in the gut. Drugs are MGNB constitutes an outbreak
ineffective, may severely damage the For CPE two or more babies with the
gut flora and encourage development same carbapenemase gene (OXA-48,
of resistant organisms KPC, VIM, NDM-1 etc.) irrespective of
Some babies may naturally eradicate organism if associated in time and
the colonisation over several months or space constitutes an outbreak
years Other MGNB isolates from different
Babies colonisation with CPE and other babies are considered ‘the same’ if
carbapenemase producing GNB should they have been sent by microbiology to
be deemed colonised for at least 5 a reference lab for typing and have
years after the last positive swab been reported by reference lab as
irrespective of the screening results ‘indistinguishable’
MANAGEMENT OF OUTBREAK Action

MRSA As MRSA
Two or more babies with same strain of
MRSA constitutes an outbreak
MRSA from different babies are
considered ‘the same’ if they have been
sent by microbiology to a reference lab
for typing and have been reported by
reference lab as ‘indistinguishable’
Action
Screen all babies in neonatal unit
(swabs as above)
Optimise infection control measures:
see local infection control policy
If further cases of the same strain occur:
arrange incident meeting to discuss
further measures, e.g. swabs from all
staff on unit
screening is co-ordinated by infection
control team (ICT) in collaboration with
occupational health (OH) department at
an outbreak meeting
results are sent to OH and ICT but not
to the unit
Issue 6
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NASOGASTRIC TUBE ADMINISTRATION OF
FEED, FLUID OR MEDICATION • 1/2
Procedure is the same for nasogastric Checking pH
and orogastric tubes. As nasogastric
Check pH before every feed/use of
tubes (NGT) are more commonly used in
tube according to NPSA guidelines –
babies, the term nasogastric will be used
see Nasogastric tube insertion
throughout this guideline
guideline
INDICATIONS if pH 0–5.5, commence feed and
Contraindications to oral feeding, or document pH
baby unable to take full requirements if pH ≥6, do not commence feed.
orally Repeat aspiration and retest
Nasogastric or orogastric tube in place If repeated test ≥6, seek advice from
senior clinician and undertake risk
EQUIPMENT assessment following NPSA algorithm
Enteral syringes (see NPSA alert 19 – see Nasogastric tube insertion
http://www.nrls.npsa.nhs.uk/resources/? guideline. Document decision made
entryid45=59808) and rationale
pH testing strips If no aspirate obtained, do not feed.
Follow procedure outlined in NPSA
Gravity/bolus feeding set
guideline
Feed/fluids/medication according to
prescription Feeding
Prescription chart (for medication) Avoid rigid feeding patterns (e.g. 1
bottle/2 tube, alternate bottle/tube etc.)
PROCEDURE
When handling tubes, ensure clean
Preparation technique. Pay careful attention to feed
See Nasogastric tube insertion preparation and administration
guideline Administer feed by gravity
Discuss procedure with parents/carer Remove plunger, connect to tube, pour
Wash hands and prepare equipment small volume of feed into barrel, raise
level of barrel above baby’s stomach.
Bring milk to room temperature by Control speed of administration by
removing from fridge. Never deliver raising or lowering barrel
fridge-cold milk directly via nasogastric
or orogastric tube. See Nutrition and Do not plunge feed
enteral feeding guideline Ensure tube feed takes approximately
the same time as a suckling feed e.g.:
Position of baby for feeding
20 min for full feed volume requirement
Baby need not be lying down. It is
acceptable to feed if baby receiving 10 min for 50% volume
Kangaroo care or positioned in baby 5 min for 25% volume
chair
If lying flat in a cot:
elevate mattress to 30º before feeding
and return to flat position within 1 hr
Issue 6
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NASOGASTRIC TUBE ADMINISTRATION OF
FEED, FLUID OR MEDICATION • 2/2
Monitoring FURTHER INFORMATION
Observe baby throughout feed for Nasogastric tube insertion guideline
signs of deterioration or distress Further details available from
(change in colour, cyanosis, apnoea, www.nrls.npsa.nhs.uk/resources/?entryid
bradycardia, vomiting, straining, 45=59794
squirming, grimacing and other
avoidance behaviour)
Observe for abdominal distension
following a feed
If appropriate developmental
stage/capabilities, offer small drops of
milk to mouth to taste, but avoid in
babies with no swallow mechanism
Consider offering baby mother’s breast
for nuzzling or non-nutritive sucking
during tube feed – see Non-nutritive
sucking guideline
On completion of feed, instil small
amount of air into tube (0.5–1 mL)
DOCUMENTATION
Document feed details:
pH
type
volume
time
behaviour/response during feed
adverse reactions (vomiting etc.)
Ensure medication chart is signed
FURTHER MANAGEMENT
For administration of medication,
remember to check baby identity and
prescription. Follow Trust policy for
administration of medicines and British
Association of Parenteral and Enteral
Nutrition (BAPEN) guidance
Flushing of nasogastric tubes is not
routine in babies. To avoid medication
remaining in NG tube try to give
medications pre-feed. Where this is not
possible 1 mL of feed can be used to
flush tube after inserting medication
Issue 6
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NASOGASTRIC TUBE INSERTION • 1/4
The procedure is the same for both PROCEDURE
nasogastric and orogastric tubes. As
nasogastric tubes (NGT) are more
Preparation
commonly used in babies, the term Discuss procedure with parents/carer
nasogastric will be used throughout this To prevent risk of aspiration, pass
guideline NGT before a feed
INDICATIONS Wash hands and prepare equipment
To keep stomach deflated or to instil Administer sucrose – see Pain
enteral feeds when full oral feeding not assessment and management
possible guideline
Administration of medications when To reduce risk of epidermal stripping,
unable to use oral route apply Duoderm to skin of face as an
attachment for adhesive tape
Orogastric tubes are used
predominantly in babies in respiratory Determine length of tube to be
distress or with structural abnormality inserted by measuring
of nasal cavity where full bottle feeds nose>ear>xiphisternum measurement.
are contraindicated Note the cm mark on the tube or keep
your fingers on the point measured
NGT are used short-term for all other
babies until full oral feeding achievable For orogastric tube, measure as NGT
but start from the centre of the bottom
An NGT is preferred over an orogastric lip rather than the nose
tube with a few exceptions, such as a
structural abnormality (e.g. choanal
atresia, cleft lip and palate) and some
respiratory distress. It may still be
possible to use an NGT if baby is
receiving nasal mask CPAP or nasal
prong oxygen
EQUIPMENT
Smallest sized NPSA compliant NGT
that will pass: 4 FG, 5 FG or 6 FG to
reduce risk of nasal abrasions and Insertion
ensure baby comfort
With clean hands, put on gloves and
Exceptions – surgical patient in pass tube into nose or mouth slowly
specific clinical circumstances and steadily until required pre-
Enteral syringe (see NPSA alert 19) measured depth reached
pH testing strips Use of a dummy (with parents
Extra-thin hydrocolloid dressing (e.g. permission) may help tube passage
Duoderm, Convatec) Observe baby throughout procedure
Soft adhesive tape (e.g. Hypafix, for colour change, vomiting, respiratory
Tegaderm, Mefix) distress or resistance
Non-sterile disposable gloves if any of these features, or distress
occurs, stop and remove tube and try
a different angle or nostril. If resistance
felt, abandon procedure – Do NOT
force the tube
Issue 6
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Checking position of
nasogastric feeding tube
Neonatal units and carers in the
community should use pH indicator
strips or paper
Do NOT use radiography ‘routinely’
but, if baby being X-rayed for another
reason, use X-ray to confirm position
is satisfactory by noting position of
tube on film
Do NOT use ‘Whoosh test’
(auscultation of injected air entering
the stomach) to determine position of
NGT as it is unreliable
Checking position using pH

Aspirate stomach contents with enteral
syringe and test for acid response
using pH testing strips
pH ≤5.5 indicates correct gastric
placement
if pH ≥6, do not commence feed.
Repeat aspiration and retest
if repeated test ≥6, seek advice from
senior clinician and undertake risk
assessment
Following factors can contribute to
high gastric pH ≥6
presence of amniotic fluid in baby <48 hr
milk in baby’s stomach, particularly if
1–2 hrly feeds
use of medication to reduce stomach
acid
tube positioned in jejunum or duodenum
tube positioned in lungs
Multidisciplinary care team should then
discuss possible actions, balancing the
risk of feeding (with a possibility of the
tube being in the lungs) and not
feeding the baby in the short-term, and
record how they reached their decision
Ensure you work through the NPSA
flowchart below and record findings
before making any decisions
Issue 6
214
NPSA flowchart: A basis for decision-making when checking position of
naso- and orogastric feeding tube in babies on neonatal units
1. If not initial insertion, check for signs of tube

displacement Aspirate obtained
(0.2–1 mL)
2. If not initial insertion, reposition or repass tube
3. Aspirate using a syringe and gentle pressure
Aspirate not obtained
DO NOT FEED
Aspirate obtained
1. Turn baby onto his/her side, if possible
(0.2–1 mL)
2. Re-aspirate
Aspirate not obtained
DO NOT FEED Aspirate

Test pH strip
1. Inject 1–2 mL of air into tube using syringe obtained
or paper
2. Re-aspirate (0.2–1 mL)
Aspirate not obtained pH <6
pH ≥6
DO NOT FEED DOCUMENT
1. If initial insertion, advance 1. Length of tube, if initial insertion
or retract tube 1–2 cm, any 2. pH of aspirate
resistance – STOP 3. Length of any tube
2. Re-aspirate advancement/retraction, if done
Aspirate not obtained Proceed to feed
CAUTION DO NOT FEED CAUTION DO NOT FEED

1. If initial insertion, 1. Consider waiting 15–30 min, then re-aspirate
consider replacing or 2. Consider replacing or re-passing tube and re-aspirating
re-passing tube 3. If pH still ≥6, seek senior advice – ask about:
2. If tube in situ, seek medication
senior advice the tube – is it the same as that documented
3. Only consider chest and on last X-ray and is length the same?
abdominal X-ray if timely feeding history
4. Document decisions and balancing risks
rationale 4. Only consider X-ray if timely
5. Document decisions and rationale
Issue 6
215
Securing tube Changing NGT
Once correct tube position ascertained, Follow manufacturer’s
secure to face with soft adhesive tape recommendations
(e.g. Hypafix or Mefix) over Duoderm Ensure safe and gentle removal of
tape using water, applied with cotton
DOCUMENTATION
bud to soften adhesive tape. Never be
Record procedure in nursing tempted to rip tape directly from the
documentation, noting type and size of skin
tube, length passed, position, pH, date
passed and due for changing Pass new NGT via opposite nostril
wherever possible
FURTHER MANAGEMENT Document removal/replacement in
Monitoring baby’s medical record
Check integrity of skin around nostril at Reporting misplaced tube
frequent intervals for signs of incidents
deterioration
Report all misplaced feeding tube
if signs of pressure appear, reposition incidents using local risk management
tube and/or tape, or re-pass NGT via procedure
opposite nostril, or use orogastric
route if necessary FURTHER INFORMATION
Check NGT position by measuring pH Further details on determining correct
of aspirate. Follow NPSA flowchart position of oro-/nasogastric tubes in
on previous page: babies are available from
after initial insertion and subsequent www.nrls.npsa.nhs.uk/resources/?entryid
reinsertions 45=59794
before administering each feed
before giving medication
after vomiting, retching or coughing
(absence of coughing does not rule
out misplacement or migration)
if evidence of tube displacement (e.g.
if tape loose or visible tube appears
longer or kinked)
when chest X-ray taken for another
reason
If receiving continuous feeds, use
appropriate giving set and check pH
when changing set
when continuous feeding has stopped,
wait 15–30 min to allow stomach to
empty of milk and for aspirate pH to fall
Issue 6
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NECROTISING ENTEROCOLITIS (NEC) • 1/3
RECOGNITION AND Radiological signs: significant intestinal
ASSESSMENT dilatation, pneumatosis intestinalis,
portal vein gas, +/- ascites, persistently
Definition abnormal gas pattern (e.g. localised
Acute inflammatory disease in newborn dilated loop of bowel seen on serial
intestine characterised by haemorrhagic X-rays or gasless abdomen)
necrosis, which may lead to perforation
and destruction of the gut. Clinical Stage 3: Advanced NEC:
presentation usually comprises triad of severely ill, bowel intact or
abdominal distension, gastrointestinal perforated
bleeding and pneumatosis intestinalis (air Systemic signs: see Stage 2 +
in bowel wall on abdominal X-ray) hypotension, bradycardia, severe
apnoea, combined respiratory and
Modified Bell’s criteria
metabolic acidosis, DIC, neutropenia
Stage 1: Suspected NEC: Intestinal signs: see Stage 2 + signs of
clinical signs suggestive but generalised peritonitis, marked
X-ray non-diagnostic tenderness, distension of abdomen
Systemic signs: Radiological signs: see Stage 2 +
temperature instability pneumoperitoneum +/- ascites
apnoea Risk factors
bradycardia Prematurity
lethargy Intrauterine growth restriction
Intestinal signs: Absent or reversed end-diastolic flow
increased gastric residuals on umbilical arterial Doppler
antenatally
Perinatal asphyxia
vomiting
Low systemic blood flow during
blood in stools
neonatal period (including duct-
Radiological signs: dependent congenital heart disease)
normal or mild intestinal dilatation Significant patent ductus arteriosus
thickened bowel loops Exchange transfusion
Stage 2: Definite NEC: mild- Formula milk

to-moderately ill – abdominal No antenatal corticosteroids
X-ray demonstrates Infections with: klebsiella,
pneumatosis intestinalis enterobacter, anaerobes
Systemic signs: see Stage 1 +/- mild
metabolic acidosis, mild
thrombocytopenia, raised CRP Sepsis with ileus
Intestinal signs: see Stage 1 + absent Bowel obstruction
bowel sounds, +/- localised abdominal Volvulus
tenderness, abdominal cellulitis or right
Malrotation
lower quadrant mass, bright red blood
and/or mucus from rectum (exclude
local pathology)
Issue 6
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Spontaneous intestinal perforation: IMMEDIATE TREATMENT
associated with early postnatal Always discuss management with
corticosteroids or indomethacin senior neonatologist
abdominal X-ray demonstrates
pneumoperitoneum but does not show In all stages
evidence of pneumatosis intestinalis Nil-by-mouth
Systemic candidiasis: Transfer baby to neonatal intensive
care and nurse in incubator to avoid
clinical signs can mimic NEC with
cross infection
abdominal distension, metabolic
disturbances, hypotension and If respiratory failure and worsening
thrombocytopenia acidosis, intubate and ventilate
Gastric decompression
INVESTIGATIONS
Free drainage with large nasogastric
Abdominal X-ray tube (size 8)
Supine antero-posterior view NEC often associated with significant
third spacing of fluid into peritoneum
If perforation suspected but not clear
on supine view, left lateral view Triple antibiotics: penicillin/amoxicillin
and gentamicin and metronidazole
Not all babies will have IV fluids/PN: total volume ≤150 mL/kg
radiological findings associated Long line when stable and
with NEC (Stage 1) bacteraemia/septicaemia excluded
Pain relief, consider
Blood tests
morphine/diamorphine infusion (see
FBC: anaemia, neutropenia and Pain assessment and management
thrombocytopenia often present; early guideline)
return to normal carries good prognosis
Stage 2: Proven NEC
Blood film: evidence of haemolysis
(confirmed radiologically)
and toxic changes (e.g. spherocytes,
vacuolation and toxic granulation of If breathing supported by nasal CPAP,
neutrophils, cell fragments, elective intubation to provide bowel
polychromatic cells) decompression (see Intubation
guideline)
CRP, but a normal value will not be
helpful in initial phase Give IV fluid resuscitation 10 mL/kg
sodium chloride 0.9% for shock and
Urea and electrolytes repeat as necessary. Shock is most
Blood gas: evidence of metabolic common cause of hypotension in
acidosis (base deficit worse than -10), babies with NEC (see Hypotension
raised lactate guideline)
If coagulation abnormal, give FFP (see
Coagulation screen
Coagulopathy guideline)
Blood cultures
If thrombocytopenia and/or anaemia
occur, transfuse (see
Thrombocytopenia guideline)
Discuss with surgical team: may need
transfer to surgical centre
Issue 6
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Stage 3 : Advanced NEC MONITORING TREATMENT
(fulminant NEC with or Observe general condition closely and
without intestinal review at least 12-hrly
perforation) Daily:
Treat as for Stage 2 and refer to acid-base
surgical team: may need laparotomy
fluid balance (twice daily if condition
or resection of bowel in surgical centre
unstable)
If baby unstable for transfer to surgical
electrolytes (twice daily if condition
centre, discuss abdominal
unstable)
paracentesis with surgical team
FBC and coagulation (twice daily if
SUBSEQUENT MANAGEMENT condition unstable)
In recovery phase repeat X-ray daily or twice daily until
In Stage 1: if improvement after 48 hr, condition stable. Discuss with
consider restarting feeds slowly (see consultant/surgeons
Nutrition and enteral feeding LONG-TERM MANAGEMENT
guideline) and stopping antibiotics
Advise parents about signs of bowel
In Stage 2: if abdominal examination obstruction
normal after 7–10 days, consider
restarting feeds Medical +/- surgical follow-up after
discharge
some may need longer period of total
gut rest Contrast studies if clinically indicated
for strictures
stop antibiotics after 7–10 days
Appropriate developmental follow-up
In Stage 3: discuss with surgeon and
dietitian before restarting feeds Parent information
Late complications Offer parents information on NEC,
available from
Recurrence (in about 10%) http://www.bliss.org.uk/factsheets
Strictures (in about 10% non-surgical
cases)
Short bowel syndrome and problems
related to gut resection
Neuro-developmental problems
Issue 6
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NITRIC OXIDE • 1/1
INDICATIONS Definition of response to NO
Persistent pulmonary hypertension of Either increase in postductal SpO2
the newborn in term babies, proven on >20% or increase in postductal PaO2
clinical grounds or by echocardiography >3 kPa occurring within 15 min of
– see Persistent pulmonary starting NO and while ventilator
hypertension of the newborn (PPHN) settings constant
guideline
Oxygen index >20 Weaning
Initiate treatment with nitric oxide (NO) If NO has been administered for ≥4 hr,
only after discussion with on-call wean gradually to prevent rebound
consultant in ‘responders’, once FiO2 <0.5, attempt
Babies requiring NO should be referred to reduce dose
to a NICU for ongoing management, in reduce NO to 5 ppm in decrements of
accordance with Toolkit principles 5 ppm every 1–2 hr. Then reduce by
1 ppm every 1–2 hr and finally to
CAUTIONS 0.5 ppm for at least 1 hr before stopping.
Preterm baby (not routinely Reverse any reduction that causes SpO2
recommended following Cochrane
to drop persistently by >5%
review 2007)
some babies will require low dose
Grade 4 intraventricular haemorrhage
(<0.5 ppm) for some time (up to 24 hr)
(IVH)
during weaning
Recent pulmonary haemorrhage
If sustained and significant fall in SpO2
Platelets <50 x 109/L occurs following reduction in dosage,
Contraindications increase dosage to previous level and
Congenital heart disease continue to wean at half previous rate
Once discontinued, wait at least 6 hr
DOSE AND ADMINISTRATION before removing NO circuit from
Starting nitric oxide ventilator
Preparation MONITORING
Ensure ventilation optimal and that Use SpO2 to monitor response
other aspects of the PPHN guideline
have been followed Blood gases 4-hrly
A sustained inflation immediately before Monitor methaemoglobin before
starting NO can enhance response starting NO, 1 hr after starting and
then 12-hrly. Maximum proportion of
Administration total haemoglobin is reached after 8 hr
Document FiO2 and SpO2 immediately normal <1%
before starting NO 2–3% is acceptable
Start NO at 10 ppm 4% requires action: reduce NO and
If no response (see below), increase to repeat in 1 hr
maximum of 20 ppm - if still >4%, stop NO
If still no response at 20 ppm, discontinue - if >6%, treat with methylthioninium
NO can be stopped abruptly without chloride (methylene blue) 1 mg/kg IV
weaning if given for <4 hr over 1 hr
Once responding, wean to 5 ppm as NO inhibits platelet function and can
soon as possible, and within 2–24 hr trigger bleeding if baby has bleeding
of starting treatment problem or thrombocytopenia. Check
FBC daily while baby receiving NO
Issue 6
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NON-NUTRITIVE SUCKING (NNS) • 1/1
INDICATIONS CAUTIONS
Actively promoted for: As baby begins to take more enteral
feeds (at around 33 weeks), NNS is no
comfort
longer appropriate as it may mask
pain relief feeding cues
maximising nasal CPAP delivery. Can
be used for short period to assist in
CONSENT
acquisition of an effective seal Before commencing, ensure parents
receive written information on suitable
developing the sucking reflex and
use of NNS on neonatal unit
assisting transition from tube to full
breast or bottle feeding A signed informed consent form must
be held in baby’s medical record
normal peristalsis helping to alleviate
gastro-oesophageal reflux
Encourage preterm babies not mature
enough to suck at feed times to suck
on a non-nutritive device during a tube
feed
Form of non-pharmacological pain
relief during painful procedures
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NUTRITION AND ENTERAL FEEDING • 1/9
AIMS Manage feeding on an individual basis
dependent upon gastrointestinal
To achieve growth and nutrient tolerance and availability of breast milk
accretion similar to intrauterine rates
There is robust evidence that feeding
To achieve best possible neuro- maternal breast milk is protective for
developmental outcome
necrotising enterocolitis (NEC) when
To prevent specific nutritional compared to formula milk
deficiencies
The evidence base for how fast to
increase feeds is limited and meta-
PRINCIPLES
analyses are inconclusive regarding
Early enteral feeds promote normal implications for practice
gastrointestinal structure and function,
motility and enzymatic activity Enteral feeding may be a risk factor for
NEC, especially in premature babies,
Delayed nutrition can result in growth those with IUGR and absent or
restriction with long-term complications reversed end-diastolic flow on
of short stature, poor organ growth umbilical artery Doppler
and poorer neurological function
Delayed introduction of minimal enteral
Target population
expressed breast milk/colostrum in ‘sick’ Preterm babies, especially birth weight
infants, of any gestation, is seldom <1500 g
beneficial but may be appropriate in
Small-for-gestational age = birth
some. Decision to start enteral feeding
weight <10th centile
should be made on daily ward round
NUTRITIONAL REQUIREMENTS
Daily recommended intake of nutrients for stable/growing preterm babies
Preterm baby Preterm baby

Nutrient Term baby <1000 g 1000–1800 g
(Tsang/ESPGHAN) (Tsang/ESPGHAN)
Energy (kcal/kg) 95–115 130–150 110–135
Protein (g/kg) 2 3.8–4.5 3.4–4.2
Sodium (mmol/kg) 1.5 3–5 3–5
Potassium (mmol/kg) 3.4 2–3 2–3.5
Calcium (mmol/kg) 3.8 2.5–5.5 2.5–5.5
Phosphate (mmol/kg) 2.1 2–4.5 1.9–4.5
Vitamin A (ug RE/kg) 59 400–1000 400–1000
Vitamin D (ug/d) 8.5 10–25 10–25
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Nutrient composition of breast milk per 100 mL
Fortified
Mature
Preterm breast milk
breast milk Donor EBM
breast milk (Nutriprem
(>2 wk)
BMF)
Energy (kcal) 70 69 66 85
Protein (g) 1.8 1.3 0.9 2.6
Sodium (mmol) 1.3 0.7 Not specified 2.2
Calcium (mmol) 0.55 0.55 Not specified 2.2
Phosphorus (mmol) 0.5 0.5 Not specified 1.9
Vitamin A (ug) 83 57 Not specified 188
Vitamin D (ug) 0.18 0.05 Not specified 7.65
Nutrient composition of preterm formulas per 100 mL
SMA Gold SMA Gold

Nutriprem 1
Prem 1 Prem Pro
Energy (kcal) 80 82 80
Protein (g) 2.6 2.2 2.9
Sodium (mmol) 3.0 1.9 2.2
Calcium (mmol) 2.4 2.5 2.9
Phosphorus (mmol) 2.0 2.0 2.5
Vitamin A (ug) 180 189 370
Vitamin D (ug) 3 3.4 3.7
(Based on 2014 datacards)
FEEDING GUIDE
Route of administration
Babies <34 weeks cannot co-ordinate sucking, swallowing and breathing effectively
and must be tube fed
use gastric feeding with either nasogastric (NGT) or orogastric (OGT) tube
Issue 6
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Initiating and advancing enteral feeds
Make every effort to use mother’s expressed colostrum and breast milk
Commence feeding as soon after birth as possible
following individual clinical assessment
High risk Gestation Gestation ≥34

of NEC* 29+1–33+6 weeks
Step 1 10–20 mL/kg/day 20–30 mL/kg/day 30–60 mL/kg/day

First day of feeding trophic feeds 1–2 hrly feeds 3-hrly feeds
Maintain trophic feeds as

long as clinically indicated
Step 2 10–20 mL/kg in

20 mL/kg in 24 hr 30 mL/kg/day
Advance as 24 hr as hourly
as 1–2 hrly feeds as 3-hrly feeds
indicated feeds
Continue to
Continue to increase at this rate until
Step 3 increase by
full enteral volume achieved
10 mL/kg twice in
24 hr as hourly
feeds until
150–180 mL/kg
Only increase
beyond
180 mL/kg after
growth
assessment
Babies can move between risk categories following

individual clinical assessment
*High risk definition:
<29 weeks’ gestation or <1200 g birth weight
Absent or reversed end diastolic flow in <34 weeks or <1501 g birth weight
Re-establishment of feeds following NEC
Post-surgery for congenital gut abnormality or abdominal wall defects
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Caution when increasing Feeds to a minimum volume of
feeds in the following 150 mL/kg increasing to 180 mL/kg as
(consider minimal trophic full feeds
enteral feeds of expressed Increase up to 200 mL/kg as indicated
breast milk) by weight gain and volume tolerance
Ibuprofen (during treatment) or Donor expressed breast milk

surgical ligation for patent ductus (DEBM)
arteriosus
In the absence of a mother’s own
Complex congenital cardiac disease expressed breast milk, consider donor
Dexamethasone treatment milk as the next milk of choice for
babies at higher risk of NEC
Unstable/hypotensive ventilated babies
Indication for use:
Perinatal hypoxia-ischaemia with
mother’s milk unavailable and
significant organ dysfunction
gestational age <29 weeks or birth
Requiring full or partial exchange weight <1200 g or
transfusion
previous proven NEC
Which milk to use Due to poor nutritional profile of donor
milk it is wise to restrict use to
Mother’s expressed breast establishing feeds in high risk babies
milk (MEBM) with the gradual introduction of
Wherever possible, use expressed alternative feeds one week after full
breast milk for initiation of enteral volumes achieved (see Slow change
feeds. Breast milk remains the ideal to a different type of milk feed)
milk for term and preterm babies and
should be strongly recommended Breast milk fortifier (BMF)
(Nutriprem BMF/SMA BMF)
Breast milk is more protective against
NEC than formula milk. Encourage All preterm infants <33+6 weeks fed on
mothers to express breast milk as D/MEBM require addition of BMF to
soon as possible after delivery (WHO meet protein requirements as
standard within 6 hr) and to continue recommended by ESPGHAN 2010
to express breast milk 8–12 times When MEBM/DEBM tolerated at
every 24 hr – see Breast milk 150 mL/kg for 48 hr and >10 days old,
expression guideline add breast milk fortifier (BMF)
If decision to breastfeed/use MEBM is Observe for signs of feed intolerance
made when starting feeds, use only (abdominal distension, vomiting,
breast milk enterally as available. It increased aspirates, change in stool
may not be possible to follow frequency) for next 24 hr
schedules below until sufficient breast Thereafter, gradually increase volume
milk is being produced of milk to 180–200 mL/kg/day
If mother’s own expressed breast milk
not available, consider donor milk in Protein Supplement
appropriate babies (see below). (Nutriprem Protein
If donor milk not appropriate use Supplement)
preterm formula Use under direction of neonatal or
Provide support to all mothers in the paediatric dietitian
feeding method of their choice
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Formulated to provide extra protein to All ‘specialised’ term formulas
meet the requirements of ELBW infants
These formulas do not provide
Extensively hydrolysed protein alone – adequate nutrition for preterm babies
NO micronutrients or energy at standard dilution and will require
Calculate energy and protein intake modification to ensure individual
and compare to requirements prior to requirements are met. Use specialised
addition of protein supplement formulas only where absolutely
necessary and always under the
Check blood urea if normal ranges do
direction of a paediatric or neonatal
not add protein supplement – discuss
dietitian
with neonatal or paediatric dietitian
Add to D/MEBM alongside BMF or Slow change to different
directly to preterm formula to enhance type of milk feed
protein intake Occasionally, it may be necessary to
1 g sachet = 0.82 g protein change from one type of milk feed to
Monitor blood urea nitrogen twice weekly another, mostly from DEBM/MEBM to
in all infants on protein supplement preterm formula. Do this slowly to
ensure baby tolerates the change in
Preterm milk formula feed
(Nutriprem 1/SMA Gold Prem 1) Day 1: 75% feeds with current milk,
Indicated for babies born <1800–2000 g 25% with new milk (i.e. 3 old feeds:
and <34 weeks’ gestation 1 new feed)
Initially increase feeds to 150 Day 2: 50% feeds with current milk,
mL/kg/day 50% with new milk (i.e. 2 old feeds:
If necessary, increase to 180 2 new feeds)
mL/kg/day as indicated by weight gain Day 3: 75% feeds with new milk, 25%
with current milk (i.e. 1 old feed:
Specialised preterm formulas 3 new feeds)
(Hydrolysed Nutriprem 1/SMA Day 4: 100% new milk
Gold Prem Pro)
It is also acceptable practice during
Hydrolysed Nutriprem 1 – extensively the slow change to mix the milks
hydrolysed protein preterm formula together rather than using separately
SMA Gold Prem Pro – hydrolysed (NB: BMF should not be added to
protein preterm formula (indicated formula so omit during slow change if
especially babies <1000 g) feeds are being mixed)
See company information for Nutrient additives
nutritional breakdown
Exclusively breastfed babies <34 weeks’
these formulas may be suitable for gestation and/or <1500 g (no BMF)
babies who fail to tolerate/progress on
standard preterm formula, OR have a once 50% enteral feeds established
family history of CMPI (Hydrolysed 0.6 mL Abidec (NB: contains peanut oil)
Nutriprem 1 only), OR require MCT fat Joulie’s phosphate (infants <30 weeks
(SMA Gold Prem Pro only), but only or 1500 g) 0.5 mmol/kg 8-hrly adjusted
when absolutely necessary and according to serum phosphate and
always under the direction of a alkaline phosphatase levels, and
paediatric or neonatal dietitian urinary reabsorption of phosphate
Issue 6
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check plasma and urinary sodium. MONITORING
Breast milk sodium concentration is
Monitoring of gastrointestinal tolerance,
inversely proportional to the amount
growth and biochemical balance is critical
expressed. May need to supplement
in nutritional management of preterm
with sodium
babies
folic acid (if used) 50 microgram daily
until discharge unless prescribed Clinical monitoring
breast milk fortifier Daily assessment of gastrointestinal
Fortified breast milk tolerance:
<2 kg 0.3 mL Abidec multivitamin gastric residues
>2 kg no vitamins stool frequency
may need Joulie’s phosphate if PO4 abdominal examination as appropriate
<1.8 mmol
Feeding intolerance
no folic acid
Intolerance to feeding is common
Infants <34 weeks’ gestation fed among small preterm babies and some
preterm formula, tolerating at least 50% will have episodes requiring either
enteral feeds temporary discontinuation of feeding or
0.3 mL Abidec (NB: contains peanut oil) delay in advancing feeds
Seek advice early from a neonatal or
Iron paediatric dietitian if failure to progress
At 28 days of age and only for feeds continues
exclusively breastfed (+/- BMF) babies
Carefully observe for signs of NEC
<34 weeks’ gestation and/or 1500 g, including abdominal distension,
start sodium feredetate (e.g. Sytron) discolouration, blood in stools,
once daily: metabolic acidosis – see Necrotising
<1500 g, 0.5 mL enterocolitis guideline
≥1500 g, 1 mL
ASPIRATES AND WHEN TO
Babies on term formula 1 mL Sytron STOP FEEDS
Babies fed preterm formula or preterm Aspirate 4-hrly, then:
discharge formula do not need iron
supplements if aspirate <50% total of previous 4 hr
feed volume and not bile stained,
CHANGEOVER OF MILK ON replace and continue feeds whilst
REACHING 2 kg observing baby closely
If feeding on fortified EBM and baby if aspirate ≥50% of the total of the
has been gaining 15–20 g/kg/day, stop previous 4 hr feed volume and not
fortifier and monitor weight closely bilious, replace prescribed hourly
volume, discard the rest and omit next
If feeding on fortified EBM and gaining
feed
<15 g/kg/day, refer to dietitian
Stop feeds and seek medical review if:
If feeding on preterm milk and gaining
15–20 g/kg/day, change to a nutrient aspirates heavily bile stained and
enriched post-discharge formula (e.g. >50% of the total of the previous 4 hr
Nutriprem 2 or SMA Gold Prem 2) feed volume, consider withholding
feeds on that occasion, and assess for
If feeding on a preterm milk and
any signs of NEC
gaining <15 g/kg/day, refer to dietitian
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blood or mucus per rectum Biochemical monitoring
abnormal abdominal examination (e.g. In sick or very premature babies,
abdominal distension, discolouration, measure plasma urea, electrolytes,
tenderness, poor bowel sounds, not calcium, phosphate and albumin twice
passing stools >48 hr) daily for initial few days. Reduce
frequency depending on clinical stability
FREQUENCY OF FEEDS
Monitor glucose closely in initial few days
Dependent on maturity and condition
of baby once clinical stability and full enteral
feeds achieved, carry out these tests at
In extremely premature baby, initial least once a week in very low birth
1–2 hrly feeds are appropriate weight (VLBW) babies
Once baby tolerating full feeds, Check urine weekly for excretion of
increase feed interval to 3-hrly – but do sodium and phosphate
not give 4-hrly feed to preterm baby
(<40 weeks) COMMON PROBLEMS
ROUTE OF FEEDING Poor growth
Babies with weight gain <15 g/kg/day
In most premature babies: via
require further assessment
nasogastric or orogastric tube
Ensure baby receiving adequate nutrition
Once baby more mature and able to
(energy intake >120 kcal/kg/day; protein
suck offer feeds by breast (see
3.3 g/100 kcal). Calculate energy and
Progression to Oral Feeding below),
protein intake per kg/day
cup or bottle
Check for following factors, that may
Encourage mothers who wish to affect growth:
breastfeed by starting skin-to-skin time
clinical illness (e.g. UTI)
Anthropometry medications (diuretics)
Monitor weight daily for first few days steroid treatment can delay growth for
to assist with fluid management – see up to 3–4 weeks after stopping
Intravenous fluid therapy guideline
increased energy requirement resulting
once clinically stable, measure weight from respiratory/cardiac disorders
twice weekly hyponatraemia (serum Na should be
weight gain of 15–20 g/kg/day is ≥132 mmol/L) and urine sodium
adequate in growing phase >20 mmol/L
25–30 g/day is adequate weight gain if hypophosphatemia (maintain serum
weight >2.0 kg PO4 at 2 mmol/L)
Measure head circumference weekly to anaemia
assess cerebral growth
Measure length on admission and then
Excessive weight gain
monthly Babies with weight gain >25 g/kg/day
require further assessment
Document weight, length and head
circumference regularly on RCPCH- Ensure measurement not spurious and
WHO growth chart not related to catch-up growth after a
period of poor weight gain
Evaluate for fluid retention and its causes
consider diuretics in presence of
oedema
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If receiving >150 kcal/kg/day, reduce increase breastfeeds gradually from a
energy intake few minutes at the breast to one full
if applicable, change feed under feed per day, in response to baby’s
direction of paediatric dietitian, or demands
decrease volume of feeds See Breastfeeding and Bottle feeding
guidelines for further information
Patent ductus arteriosus (PDA)
Preterm babies with PDA have Maternal milk supply
decreased blood-flow in descending Ensure sufficient maternal breast milk
aorta and increased risk of NEC. and good lactation
Ibuprofen is also associated with should fulfil baby’s total 24 hr
decreased gastrointestinal blood-flow. requirement by 72 hr postnatal
Observe closely for feeding intolerance
and signs of NEC Process
As increased IV fluid rates are Skin-to-skin contact for extended
associated with PDA, avoid any periods as long as mother and baby
increase >150 mL/kg/day can tolerate
Cautiously increase feeds while Non-nutritive sucking at a fully
receiving ibuprofen expressed breast, on a clean or gloved
See Patent ductus arteriosus guideline finger or with a dummy
Positioning at breast should ensure
PROGRESSION TO ORAL mother is comfortable, can see baby’s
FEEDING face and is able to provide good support
Aim for baby’s head, neck and shoulders
e.g. cross-cradle or underarm position
Safe progression to oral feeding
Attachment – may need temporary use
Principles of premature nipple shields
Reaching a specific gestational age or If baby awake, alert and demonstrating
body weight is not an indication for feeding/approach cues, offer breast
transition from NGT feeding to oral support mother to assess a feed based
feeding but baby should be at least on duration at the breast and features
32–34 weeks’ gestation of effective latch, sucking rhythm,
Initiation of oral feeds should follow depth and behaviour following a feed,
observations of baby’s behaviour e.g.: to determine need for supplementation
tolerating bolus feeds feeds <10 min at the breast, not
swallowing secretions rhythmic or well co-ordinated, usually
require a top-up of at least 50% volume
physiologically stable
of NGT feed
stable respirations (>70 breaths/min
if baby not waking naturally at least 8
will inhibit oral response)
times per 24 hr (or more) it is likely to
demonstrating rooting and feeding cues require supplements until more
able to demonstrate rhythmic non- established on the breast
nutritive sucking for approximately 5 min Optimise milk transfer – offer the breast
Early oral feeding attempts are gradual with the best flow first. Stimulate the
and not expected to result in full ‘let-down’ reflex before putting baby to
feeding immediately breast e.g. hand or mechanical
expression
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Progression to demand Follow-on preterm formula
feeding Consider post-discharge follow-on
Gradual progress from NGT/enteral preterm milk (e.g. Nutriprem 2, SMA
feeds to exclusive breastfeeding by Gold Prem 2) in premature babies with:
responding to baby’s behavioural cues chronic lung disease
before, during and after breastfeeds
restricted intake (e.g. congenital heart
ensures nutritional needs are met and
disease)
prevents baby from becoming overtired
poor growth
Before withdrawal of NGT, ensure baby
can wake sufficiently frequently and Give multivitamin (Abidec) 0.3 mL until
breastfeed effectively 12 months old
Weight gain of 10–15 g/kg/day must be Continue post discharge formula until
achieved before changing to full 6 months CGA if growth velocity
breastfeeds appropriate
Monitor wet and dirty nappies, weight, For term babies with increased energy
length and head circumference demands or reduced intake, liaise with
regularly to assess nutritional status dietitian regarding use of a higher
and adequacy of feeding energy formula
If poor weight gain, feed volume can Department of Health Guidelines state
be increased to a maximum of all children aged 6 month-5 yr receive
200 mL/kg/day, if tolerated, or breast vitamin supplementation unless
milk fortifier may be added receiving >500 mL/day formula milk
POST-DISCHARGE NUTRITION
Nutrients vitamins and iron
Breast milk
Babies <34 weeks’ gestation and/or
<1500 g, give multivitamins (Abidec)
0.6 mL until 12 months corrected
gestational age (CGA)
Give sodium feredetate (e.g. Sytron)
once daily:
≥1.5 kg = 1 mL
discontinue once mixed feeding
established
Term formulas
Babies <34 weeks gestation and/or
<1500 g, give multivitamin (Abidec)
0.6 mL until 12 months CGA
Give sodium feredetate (e.g. Sytron)
once daily: ≥1500 g = 1 mL
discontinue once mixed feeding
established
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OESOPHAGEAL ATRESIA • 1/3
DEFINITION do not use force (may lead to
oesophageal perforation)
Congenital anomaly with blind ending
oesophagus which may be associated AP X-ray of whole chest and abdomen
with a fistula between the abnormal diagnosis confirmed if NGT curled in
oesophagus and the trachea upper oesophagus
DIAGNOSIS gastric air bubble/bowel gas confirms
presence of fistula between trachea
Suspect antenatally if scans show
and distal oesophagus
polyhydramnios +/- absent stomach
bubble Do not attempt a contrast
oesophagogram
refer to fetal medicine specialist
plan appropriate place of delivery MANAGEMENT ON
parents should meet paediatric NEONATAL UNIT
surgeon antenatally If respiratory support required or
Most cases present shortly after birth. abdominal distension, contact surgical
Suspect if: unit and transfer team immediately
(time critical transfer)
history of polyhydramnios +/- absent
stomach bubble Nurse 30º head-up with head turned to
side to facilitate drainage of secretions
frothing at mouth
Pass 10 Fr Replogle tube into
respiratory symptoms on feeding oesophageal pouch (see Insertion
difficulty in passing NG tube (NGT) and management of Replogle tube)
anorectal malformation – see if Replogle tube unavailable, place 10
Anorectal malformation guideline Fr NG tube into pouch, aspirating
every 15 min
DELIVERY
an NG tube cannot be placed on
If diagnosis suspected antenatally, suction so needs regular, intermittent
avoid: aspiration
any positive pressure ventilation Insert until resistance is met, then
(including mask ventilation, Optiflow, withdraw by 1 cm
CPAP and ETT): pouch distension may
lead to respiratory compromise and/or Tape securely to face. Usually
aspiration via a distal pouch fistula 10–12 cm at nostril in a term baby
If intubation indicated, site place mittens on baby to prevent tube
endotracheal tube (ETT) tip as close to being pulled out
carina as possible to minimise gas flow attach tapered end of tube to
through a fistula. Ventilatory pressures continuous suction. Start pressure at
should be as low as possible 5 kPa aiming for continuous flow of
If any significant respiratory secretions from upper oesophagus.
compromise, instigate a time critical Maximum pressure 10 kPa
transfer to surgical unit do not share suction with other drains
e.g. chest drain
Confirmation of diagnosis
Baby should be relaxed and pink with
Experienced operator to place radio- no respiratory distress or secretions in
opaque 8 Fr NGT. Typically resistance the mouth
is felt 10–12 cm from nostril in term
baby Keep nil-by-mouth
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Flush Replogle tube with 0.5 mL Discuss baby’s condition and
sodium chloride 0.9% via the sidearm treatment plan with parents and
every 15 min. More frequently if visible ensure they have seen baby before
oral secretions transfer. Take photographs for parents
If using an enteral tube to drain saliva, Contact surgical centre to arrange
aspirate every 15 min, more frequently transfer as soon as possible
if visible oral secretions or respiratory Obtain sample of mother’s blood for
difficulty evident crossmatch. Handwrite form,
If no movement of secretions in completing all relevant sections and
Replogle tube after flushing with 0.5 mL indicating this is the mother of the baby
sodium chloride 0.9% via the sidearm, being transferred. Include baby’s name
change tube Complete nursing and medical
Do not leave syringe attached to documentation for transfer and send
sidearm as this will prevent the tube copies of X-rays by PACS. Ensure you
working effectively have mother’s contact details (ward
change tube every 10 days or daily if telephone number or home/mobile
viscous secretions number if she has been discharged).
Surgeon will obtain verbal telephone
Samples consent if operation is required and a
Obtain IV access parent is not able to attend surgical
unit at appropriate time
Take blood for FBC, clotting, U&E,
blood glucose and blood culture Inform surgical unit staff when baby is
ready for transfer. Have available:
Birmingham Children’s Hospital do not name, gestational age, weight,
require a baby crossmatch sample ventilatory and oxygen requirements (if
before transfer applicable) and mother’s name and
Send 1 bloodspot on neonatal ward (if admitted)
screening card to surgical unit with
baby for sickle cell screening (mark Useful information
card ‘pre-transfusion’) http://www.bch.nhs.uk/content/neonatal-
surgery
Fluids and medication
Commence maintenance IV fluids (see directions
Intravenous fluid therapy guideline)
http://www.tofs.org.uk
Give vitamin K IM (see Vitamin K
guideline) http://www.networks.nhs.uk/nhs-
Start broad spectrum antibiotics black-country-newborn/documents/
Referral
Examine baby for other associated
abnormalities (e.g. cardiac murmur,
anorectal abnormalities). If major
congenital abnormality detected,
discuss with consultant before
arranging transfer for management of
oesophageal atresia as this may not
be appropriate
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Insertion and management of Replogle tube
Connect to Pass Replogle

low-flow suction tube, ideally
5–10 kPa nasally, into upper
pouch until
resistance felt,
Flush tube to
(approximately
prevent blocking
10–12 cm from
of lumen:
nostril in a term
instil 0.5 mL baby), withdraw
sodium chloride slightly and fix with
0.9% into blue Elastoplast®
sidearm and
remove syringe
immediately
observe flow of
sodium chloride
0.9% along tube
AIM Blocked tube

To prevent aspiration of secretions by Suspect if:
continuous drainage of upper no continuous flow of secretions along
oesophageal pouch tube
Equipment visible oral secretions
Replogle tube size 10 Fr + 1 spare to baby in distress
keep at bedside Clear airway with high-flow
Low-flow suction oropharyngeal suction
Regular suction Increase low-flow suction and flush
Replogle tube with air, observing flow
2 mL IV syringe
of saliva along tube
Sodium chloride 0.9%
If patency not restored, replace with
Duoderm dressing and Elastoplast® new Replogle tube and return low-flow
Lubricant suction to previous level
Monitoring If blocked, alternate nostrils
Check Replogle tube several times an

hour and flush to prevent blocking of
lumen by instilling 0.5 mL sodium
chloride 0.9% into blue sidearm,
removing syringe immediately and
observing the flow of secretions along
the tube. Monitor oxygen saturation,
respiratory status and heart rate
continuously
For long-term Replogle use, monitor
electrolytes and consider replacement
therapy
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OXYGEN ON DISCHARGE • 1/2
OBJECTIVE PREPARATION FOR
To put an effective plan in place to DISCHARGE
allow oxygen-dependent babies to be Make arrangements with
cared for safely at home parents
INDICATIONS FOR HOME Discuss need for home oxygen with
OXYGEN THERAPY parents
Chronic lung disease with ongoing Obtain consent for home oxygen
demand for additional inspired oxygen supply and for sharing information with
oxygen supplier. This is obligatory
Criteria before supplier can be contacted with
Clinically stable on oxygen therapy via patient details
nasal cannulae for ≥2 weeks Arrange multidisciplinary meeting one
SpO2 ≥95% after 36 weeks’ gestation week before discharge with
on <0.5 L/min oxygen (if >0.5 L/min parents/carers, community nurse,
oxygen requirement at term then refer health visitor and member of neonatal
to paediatric respiratory team) unit (NNU)
Cyanotic congenital heart disease: a Arrange discharge plan – see
lower value may be appropriate, set Discharge guideline
threshold on an individual basis (liaise Parent training
with paediatric cardiologists)
Resuscitation techniques (2 adults)
Overnight pulse oximetry study when
on stable oxygen for one week before No smoking in the house or anywhere
discharge in baby’s environment
mean SpO2 should be ≥93% without Recognition of baby’s breathing
pattern, colour and movements
frequent periods of desaturations
Use of oxygen equipment (2 adults)
SpO2 should not fall below 90% for >5%
of the artefact-free recording period Competence in tape application for
nasal prongs and skin care (water
If using <0.5 L/min ensure baby able to based emollients)
cope with short periods in air in case
their nasal cannulae become dislodged What to do in case of emergency:
Routine continuous oxygen monitoring contact numbers
discontinued including at feeding, direct admission policy
awake and sleeping times, apart from fire safety and insurance advice (car
checks at 4-hrly intervals twice weekly and home)
before discharge
discuss Disability Living Allowance
Thermo-control well established (DLA)/blue badge advantage
Feeding orally 3–4 hrly and gaining Give parents information leaflet
weight available to download from
some babies may require tube http://www.bliss.org.uk/shop
feeding, if all other criteria are met,
this should not hinder discharge
Final decision on suitability for
discharge lies with consultant
Issue 6
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OXYGEN ON DISCHARGE • 2/2
Organise oxygen AFTERCARE
Prescribing clinician to complete Home As oxygen dependent babies (e.g.
Oxygen Order Form (HOOF). Do not chronic lung disease) are at increased
send home on less than 0.1 L (even if risk of contracting respiratory syncytial
on <0.1 L in NNU. See BTS guidelines) virus (RSV), give palivizumab and
fax completed form to appropriate influenza vaccine (see Immunisations
supplier guideline and Palivizumab guideline)
file original in babies notes Refer to local guidelines for follow-up
Discharge checklist
Discharge plan implemented – see
Discharge guideline
Plan discharge for beginning of week
to ensure staff available in event of
problems
Oxygen supply and equipment installed
in the home
Baby will go home on prescribed
amount of oxygen; this may be altered
on direction of medical or nursing staff,
or in event of emergency
GP and other relevant professionals
(also fire and electricity companies,
although oxygen supplier usually does
this) informed of date and time of
discharge
Community team briefed to arrange
home visit well in advance of discharge
to ensure conditions suitable and
equipment correctly installed
Parents/carers trained to care for baby
safely at home and have support
contact numbers
Open access to paediatric ward
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OXYGEN SATURATION TARGETS • 1/2
Maintaining oxygen PRINCIPLES
saturation within target Usual unit target range SpO2 91–95%
range for preterm babies <36 weeks
Use this guideline for preterm babies corrected gestational age who are
<36 weeks corrected gestational age breathing on supplemental oxygen
Alternative saturation targets or If different target range, see right-hand
strategy may be specified for babies column of table below
with congenital heart disease or those Prescribe oxygen on baby’s drug chart
at risk of PPHN specifying target range
Setting alarm limits

If currently ≥36 weeks corrected age
If currently <36 weeks corrected age –
OR born ≥34 weeks – Target
Target range SpO2 91–95%
SpO2 ≥95%
Babies breathing supplemental oxygen Babies breathing supplemental oxygen
Low alarm at 89% and high alarm at 96% Low alarm at 94% and high alarm at 99%
Babies breathing air Babies breathing air

Low alarm at 89% and high alarm at 100% Low alarm at 94% and high alarm at 100%
RESPONDING TO OXYGEN small frequent tweaking of inspired

SATURATION ALARMS oxygen by 1–3% between 40–50%
oxygen is much better than
General principles intermittently swinging between
30–80% oxygen to achieve same
Monitor
target range
Assess monitor trace and baby before
increasing inspired oxygen. In If it is necessary to increase
particular, assess: inspired oxygen by >5–10%, or to
introduce (or change)
baby’s position
CPAP or ventilation, discuss with
presence of secretions that may need doctor or ANNP immediately
to be removed
position of endotracheal tube or other Specific circumstances
device for delivering oxygen High alarm
Adjust inspired oxygen silence alarm and observe for an

alarm cycle (3 min)
Change inspired oxygen in increments
of 1–3% at a time except before if alarm still sounding after a cycle,
procedures or with significant decrease inspired oxygen by 1–3%
desaturations below 70%. In these continue reducing inspired oxygen by
circumstances, see below 1–3% every alarm cycle until
Avoid titrating target saturation with saturation stable in desired range
large and frequent increases and
decreases in inspired oxygen
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OXYGEN SATURATION TARGETS • 2/2
Low alarm
silence alarm and observe
assess waveform and heart rate
baby: check position of endotracheal
tube or other oxygen delivery device
e.g. nasal prongs or mask, and
consider suction or repositioning
If desaturation persists after above
checks, increase inspired oxygen by
1–3% for moderate desaturation
(SpO2 >70%)
significant desaturations (SpO2 <70%),
double baseline inspired oxygen
(increase by at least 20%) until SpO2
increases to 90%, then wean rapidly to
within 3% of baseline inspired oxygen
Handling or procedures
If history of significant desaturation
with handling or procedures, increase
inspired oxygen by 5–10% before
handling or procedure
increase PEEP (or PIP if CO2 rising)
by 1–2 cm for a few minutes
After procedure, once SpO2 stabilises,
wean inspired oxygen rapidly to
baseline
Labile cases
Some sick babies will be particularly
labile and it is challenging to maintain
SpO2 in target range. It is important to
remain patient and continue to follow
guidance above
In rare cases, individualised
adjustments to alarm settings may be
necessary after discussion with
medical team
Issue 6
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PAIN ASSESSMENT AND MANAGEMENT • 1/6
INTRODUCTION Key recommendations
Discomfort, pain or stress can be Routine assessments to detect pain
associated with routine care and using a validated assessment tool
invasive procedures. Babies are unable Reduce number of painful procedures
to report pain, use observational skills
and clinical judgment Prevent/reduce acute pain from invasive
procedures using non-pharmacological
and pharmacological methods
Anticipate and treat post-operative pain
Types of pain
Acute pain Skin-breaking procedures or tissue injury caused by
diagnostic or therapeutic interventions
Established pain Occurs after surgery, localised inflammatory conditions,
birth-related trauma
Prolonged/chronic pain Results from severe diseases e.g. NEC, meningitis.
Pathological pain state persisting beyond normal tissue
healing time
Symptoms and signs

Lack of behavioural responses does not exclude pain
Physiological Behavioural Anatomical Body
changes changes changes movements
Increase in: Change in facial Dilated pupils Fisting
heart rate expression: Sweating Tremulousness
blood pressure grimace Flushing Thrashing limbs
respiratory rate brow bulge Pallor Limb withdrawal
oxygen eye squeeze Writhing
consumption deepening naso- Arching back
mean airway labial furrow Head banging
pressure nasal flaring Finger splaying
muscle tone tongue curving or Cycling
intracranial quivering
pressure Crying
skin blood flow Whimpering
Decrease in: ‘Silent’ cry
oxygen saturation (intubated babies)
and Decreased sleep
transcutaneous Heightened
oxygen levels responses
Apnoea
shallow breathing
fixed heart rate
Sudden pain and distress may indicate acute deterioration e.g. bowel perforation
Physiological changes cannot be sustained long-term
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PAIN ASSESSMENT Pain assessment tools
Assess within 1 hr of admission Separate tools may be needed to
Frequency of further assessments will assess acute and prolonged pain
depend on baby’s clinical condition, Use validated pain assessment tools
underlying diagnosis and pain score – [Pain Assessment Tool (PAT) and
see Frequency of assessment Premature Infant Pain Profile (PIPP)]
See Abstinence syndrome guideline
for assessment of babies with neonatal
abstinence syndrome
Pain assessment not indicated/unsuitable
Not indicated Unsuitable
Pharmacologically paralysed babies; Distress is expected but easily relieved
provide appropriate pain relief (e.g. ventilated baby requiring suction)
For simple, routine procedures e.g.
capillary blood sampling
second person (parent, nurse or
healthcare practitioner to provide
support and comfort baby)
Use of pain assessment tool Intensive care: Within 1 hr of

admission. Hourly with observations
Note gestational age
High dependency: Within 1 hr of
Observe baby’s behaviour for
admission and 4-hrly or if signs of
15–30 sec then gently touch baby’s
distress/discomfort
limb to determine muscle tone/tension
(can be done during routine handling) Special care: Within 1 hr of admission
and subsequently if signs of
Note:
distress/discomfort
physiological conditions that may
influence score (in cyanotic heart Post-operatively: Hourly for first 8 hr,
then 4-hrly until 48 hr post-operatively
disease, baby’s colour may score
(more frequently if signs of
normal unless there is a change in the
distress/discomfort)
intensity of the cyanosis or duskiness
due to pain) PAIN MANAGEMENT
medications that may affect behaviour
Indications
or physiological responses
Birth trauma
environmental triggers (sudden bright
lights, noise, activity) may cause a Iatrogenic injury
stress response. Document on chart or Before, during and after any painful
in notes at time of score procedure
When score is above tool’s Severe illness e.g. NEC, meningitis
recommended thresholds, initiate To aid ventilation
comfort measures or analgesia
Babies undergoing therapeutic
Frequency of assessment hypothermia
Score generated will dictate the Post-operatively
frequency of assessment End-of-life care
Issue 6
239
Formal assessment indicates pain Reassess after 30 min
If appropriate, begin with non- If pain score in upper range, institute
pharmacological techniques. If comfort measures and administer
moderate-severe pain evident prescribed analgesia/seek medical
(exceptions include post-surgery, review
severe illness, major injury, congenital
If score continues to rise, consider
malformations and palliative care),
increasing dose of analgesia and
progress to pharmacological agents
reassess after 30 min
Non-pharmacological pain if clinical concerns – medical review
relief If score constantly below baseline and
Gently repositioning baby analgesia is maintained, reduce
dosage
Light swaddling (blanket/nest)
prolonged, restrictive swaddling may Record effectiveness of pain
be associated with increased risk of management in care plan
developmental hip dysplasia
Sucrose
Comfort/containment holding
Sucrose 24% solution and breast milk
Reducing light, noise, and activity provide a quick, short-term analgesic
around baby effect
Soothing voice Non-nutritive sucking increases
Nappy change effectiveness
Non-nutritive sucking (dummy or Use in conjunction with environmental
gloved finger) – see Non-nutritive and behavioural measures to relieve
sucking guideline pain (e.g. positioning, swaddling,
Kangaroo care – see Kangaroo care containment holding, Kangaroo care)
guideline may be given to ventilated babies with
Breastfeed – see Breastfeeding care
guideline ineffective if not given orally. Consider
Sucrose MEBM as an alternative
Mother’s expressed breast milk
(MEBM) – no additives
Contraindications to sucrose
Do not use May not be effective
<28 weeks’ gestation – use MEBM Baby with neonatal abstinence
High risk of NEC – use MEBM syndrome
Nil-by-mouth (if due to surgical Baby just been fed
problem, sucrose may be appropriate, Exposed to chronic in-utero stress
discuss with surgeon) >6 months
Sedated or on other pain medications
Diabetic mother (until blood glucose
stabilised)
Known carbohydrate malabsorption or
enzyme deficiency
Issue 6
240
Administration
Use commercially available sucrose 24% solution and follow manufacturer’s
guidelines re storage and use
Maximum 8 doses in 24 hr
Avoid risk of choking/aspiration – ensure baby is awake
Drop dose onto tongue, buccal membrane, or dummy and wait 2 min before starting
procedure
For procedures lasting >5 min, repeat dose (maximum 2 further doses)
Continue environmental and behavioural management strategies during procedure
Observe baby's cues and allow ‘time out’ to recover
Document administration of sucrose as per local policy
Gestation Dose of sucrose 24%

28+0–30+6 weeks 0.1 mL (max 0.3 mL per procedure)
≥31+0 weeks and 1000–2000 g 0.2 mL (max 0.6 mL per procedure)
>2000 g 0.5 mL (max 1.5 mL per procedure)
Management of procedural pain
Painful procedure
Assess situation and context
Initiate comfort measures

Swaddling
Containment holding
Kangaroo care
See Sucrose
Sucrose
Breast milk
Dummy (non-nutritive sucking)
Breastfeeding
Assess if pharmacological See Pharmacological

treatment is necessary pain management
Baby settled
Document response and

perform procedure
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Management of prolonged or chronic pain
Baseline pain assessment score using validated tool

(intervals as detailed or if condition changes)
Pain score ≥ baseline Pain score below baseline
Investigate Consider decreasing analgesia
Comfort measures Consider increasing analgesia
Reassess pain score
Improvement No improvement
Document response Seek medical review
Pharmacological pain management

Give medication in conjunction with non-pharmacological measures
The following drugs may be useful
diamorphine
fentanyl
morphine
paracetamol
Details of these drugs can be found in local neonatal formulary
Issue 6
242
Suggested medication for procedures

Specific situations
Non-urgent Laser
Mechanical Chest drain CT/MR Therapeutic
endotracheal therapy
ventilation insertion imaging hypothermia
intubation for ROP
Fentanyl Morphine/ Morphine/ Sedation Morphine/diamorphine
Atropine diamorphine diamorphine may be continuous infusion
continuous IV unnecessary
Suxamethonium infusion if baby fed
Lidocaine SC
and
swaddled
Chloral
hydrate
Midazolam
IV/buccal/
intranasal
Simple surgical procedures

Wound Application of
Abdominal drain Broviac line
dressing/drain silo bag for
insertion removal
removal gastroschisis
Morphine/ Paracetamol Paracetamol Paracetamol rectal
diamorphine oral/rectal oral/rectal
continuous infusion Lidocaine SC Sucrose
Lidocaine SC Sucrose
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PALIVIZUMAB • 1/2
INDICATIONS Infants with respiratory disease who
are not necessarily preterm but who
Lung disease
remain on oxygen on 1st October are
Moderate or severe BPD in preterm considered to be at higher risk. This
infants defined as: may include those with conditions
preterm infants with compatible X-ray including:
changes who continue to receive pulmonary hypoplasia due to
supplemental oxygen or respiratory congenital diaphragmatic hernia
support at 36 weeks post-menstrual other congenital lung abnormalities
age and (sometimes involving heart disease or
in the shaded area in Table 1 (age on lung malformation)
1st October) interstitial lung disease
long-term ventilation
Table 1: Chronological age cut off for palivizumab in lung disease
Gestational age at birth (whole weeks)

Chronological age 24+1 to 26+1 to 28+1 to 30+1 to 32+1 to
≤24+0 >34+1
(months) 26+0 28+0 30+0 32+0 34+0
<1.5
1.5 to <3
3 to <6
6 to <9
≥9
Congenital heart disease (CHD)

Preterm infants with haemodynamically significant, acyanotic CHD at the
chronological ages on 1st October and gestational ages covered by the shaded area
in Table 2
Cyanotic or acyanotic CHD plus significant co-morbidities (particularly if multiple
organ systems are involved)
Table 2: Chronological age cut off for palivizumab in CHD
Gestational age at birth (whole weeks)

Chronological age 24+1 to 26+1 to 28+1 to 30+1 to
≤24+0 32+1
(months) 26+0 28+0 30+0 32+0
<1.5
1.5 to <3
3 to <6
≥6
Children under the age of 24 months who have severe combined
immunodeficiency syndrome (SCID) until immune reconstituted
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PALIVIZUMAB • 2/2
Other conditions DOCUMENTATION
Only patients meeting the criteria listed After immunisation, document the
above will routinely be eligible for following in case notes as well as in
funding for palivizumab Child Health Record (Red book):
If a consultant feels that a baby consent gained from parents
outside of these criteria should be vaccine given and reasons for any
treated an application for approval omissions
should be made through the regional site of injection(s) in case of any
IFR process reactions
PROCEDURE batch number of product(s)
expiry date of product(s)
Consultant neonatologist will identify
patient and sign accompanying letter legible signature of person
to GP administering immunisations
5 doses monthly in RSV season at the adverse reactions
beginning of October, November, Sign treatment sheet
December, January and February
Update problem sheet with date and
give appointment for subsequent immunisations given
doses at palivizumab clinic (if held)
Document all information on discharge
where possible, administer 1st dose summary and medical case notes
before start of RSV season including recommendations for future
15 mg/kg by IM injection into antero- immunisations and need for any
lateral aspect of thigh special vaccinations, such as
influenza, palivizumab, etc.
Order palivizumab injection from local
community or hospital pharmacy (this
can take some days)
Palivizumab must be stored at 2–8ºC.
Full administration instructions are
provided in the ‘Summary of product
characteristics’ (SPC)
Split between 2 sites if >1 mL (final
concentration when reconstituted
100 mg/mL)
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PARENTERAL NUTRITION • 1/5
DEFINITION Indicated if full enteral feeds likely to
be obtained relatively soon
Parenteral nutrition (PN) is the
intravenous infusion of some or all temporary option for some post-
nutrients for tissue maintenance, surgical babies
metabolic requirements and growth short episodes of feeding intolerance
promotion in babies unable to tolerate full or suspected NEC until central line
enteral feeds inserted
Seek advice from your local PN Central PN
pharmacist
Requires placement of a central
catheter (see Long line insertion
INDICATIONS FOR PN guideline) with tip in either superior
Short-term supply of vena cava or inferior vena cava
nutrients
Central PN [long lines and umbilical
Extremely low birth weight (<1000 g) venous catheters (UVC)] can
and/or gestation <30 weeks introduce infection and septicaemia
Very low birth weight (<1500 g) AND
clinically unstable, absent/reversed PN prescription
end-diastolic flow or full enteral feeds Most units have specific PN bags that
seem unachievable by day 5 are used to allow nutrients to be
Necrotising enterocolitis (10–14 days) increased to meet full nutritional
requirements over 4 days. These may
Temporary feeding intolerance
be added to (but nothing may be
Prolonged non-use of removed) by discussing with PN
gastrointestinal (GI) tract pharmacist and obtaining consultant
signature to confirm
>2 weeks
Modify PN infusion according to
Usually commenced in surgical centre
requirements and tolerance of each
before transfer back to neonatal unit
baby and taper as enteral feeding
(NNU):
becomes established
relapsing or complicated necrotising
enterocolitis (NEC)
surgical GI disorders (e.g.
gastroschisis, large omphalocoele)
short bowel syndrome
PRESCRIBING PARENTERAL
NUTRITION (PN)
Peripheral PN
Limited by glucose concentration
[usually no more than 10–12%
(dependent upon local practice)].
Osmolality needs to be considered if
large quantities of electrolytes are
added
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Daily requirements
Birth weight <2.5 kg
<2.5 kg Day 1 Day 2 Day 3 Day 4 Comment
Protein
2 3 3.5 3.5
(g/kg/day)
6–15
Carbohydrate (based on
↑ by 2 each day
(g/kg/day) maintenance
fluid volume)
Fat (g/kg/day) 1 2 3 3
Birth weight 2.5–5 kg
2.5–5 kg Day 1 Day 2 Day 3 Day 4 Comment

Protein
1 2 2.5 2.5
(g/kg/day)
6–14
↑ by If possible calculate
Carbohydrate (based on
2 each 14 14 day 1 glucose from
(g/kg/day) maintenance)
day maintenance infusion
fluid volume
Fat (g/kg/day) 1 2 3 3
Maintenance electrolyte and other nutrient requirements
Birth weight <2.5 kg Birth weight 2.5–5 kg

Na (mmol/kg/day) 3 (range 3–5)† 3 (range 3–5)
K (mmol/kg/day) 2.5 2.5
Ca (mmol/kg/day) 1 1
PO4 (mmol/kg/day) 1.5 1
Mg (mmol/kg/day) 0.2 0.2
Peditrace (mL/kg/day) 0.5 (day 1) 0.5 (day 1)
1 (day 2 onwards) 1 (day 2 onwards)
Vitilipid (infant) 4 mL/kg/day 10 mL daily (total)
† Do not add supplemental sodium on days 1–2 if <32 weeks until naturesis
has occurred (measure urine Na levels daily). May not require potassium on
days 1–2
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Glucose – maximum Fat (provides 9 kcal/mL)
concentration Fat of 3–3.5 g/kg/day is usually sufficient
Peripheral PN 10–12% ≥4 g/kg/day only in very preterm with
Central PN up to 20–25% (may rise normal triglycerides not septic, not on
occasionally) phototherapy
Volume fat should ideally provide 35–40% of
Volume may be up to 150 mL/kg/day non-protein nitrogen calories
(see Intravenous fluid therapy To minimise essential fatty acid
guideline for fluid requirement) maximal deficiency, hyperlipidaemia, bilirubin
fluid volume varies with individual displacement, and respiratory
management, although adequate compromise, lipid infusion rates
nutrition may be provided in less volume ≤0.15 g/kg/hr are recommended to
Remember to account for volume, run throughout 24 hr
electrolyte and glucose content of other in babies, maximal removal capacity of
infusions (e.g. UAC/UVC fluid, inotropes, plasma lipids is 0.3 g/kg/hr
drugs). Giving adequate nutrition may
require a more concentrated solution of Energy
PN if part of the total daily fluid volume is Carbohydrate (glucose) and fat (lipid
used for other purposes emulsions) provide necessary energy
to meet the demands and, when
Calories
provided in adequate amounts, spare
Healthy preterm requires 50 kcal/kg/day
protein (amino acids) to support cell
for basal energy expenditure (not
maturation, remodelling, growth,
growth) and 1–1.5 g protein to preserve
activity of enzymes and transport
endogenous protein stores; more is
proteins for all body organs
required for growth, particularly if unwell
60 kcal/kg/day will meet energy PN requirement for growth
requirements during sepsis 90–120 kcal/kg/day
90 kcal/kg/day and 2.7–3.5 g protein Electrolytes
will support growth and positive Sodium, potassium, and chloride
nitrogen balance dependent on obligatory losses,
120 kcal/kg/day may be required for a abnormal losses and amounts
rapidly growing preterm baby necessary for growth, and can be
adjusted daily
NUTRITIONAL SOURCES
If baby <32 weeks, do not add sodium
Glucose (provides 3.4 kcal/g)
until they have started their naturesis,
Initiated at endogenous hepatic
monitored by daily urine Na+
glucose production and utilisation rate
of 4–6 mg/kg/min; [8–10 mg/kg/min in Babies given electrolytes solely as
extremely low-birth-weight (ELBW) chloride salts can develop
babies]. Osmolality of glucose limits its hyperchloraemic metabolic acidosis
concentration (consider adding acetate to PN, where
available)
Protein (provides 3.6 kcal/g)
Monitor serum phosphate twice weekly.
At least 1 g/kg/day in preterm and Aim to maintain at around 2 mmol/L
2 g/kg/day in ELBW decrease
catabolism Vitamins
3–3.5 g protein/kg/day and adequate Vitamin and mineral added according
non-protein energy meets to best estimates based on limited
requirements for anabolism data (ESPGHAN guidelines 2005)
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SPECIAL NEEDS consult dietitian and/or pharmacist
regarding prescribing information
Hyperglycaemia
If hyperglycaemia severe or persistent, permissible concentrations depend on
start insulin infusion – see amino acid and glucose concentrations
Administration of actrapid insulin in PN solution
(soluble insulin) in Hyperglycaemia
Metabolic acidosis
guideline
For management of metabolic acidosis,
Osteopenia add acetate as Na or K salt if available:
If baby at risk of, or has established consult pharmacist
osteopenia, give higher than usual choice of salt(s) will depend on serum
intakes of calcium and phosphate. (see electrolytes
Metabolic bone disease guideline)
MONITORING
Daily Fluid input
Fluid output
Energy intake
Protein
Non-protein nitrogen
Calories
Daily Urine glucose
Blood glucose (if urine glucose positive)
Twice weekly* Urine electrolytes
Weight
Weekly Length
Head circumference
Twice weekly* FBC
Na
K
Glucose
Urea
Creatinine
Albumin
Bone chemistry
Bilirubin**
Blood gas (arterial or venous)
Weekly Serum triglycerides**
Magnesium
Zinc**
* Initially daily and decrease frequency once stable unless indicated for other birth
weight or gestation-specific guidance – see Intravenous fluid therapy guideline
** In prolonged PN >2 weeks, consider giving SMOFlipid
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COMPLICATIONS if the conjugated component is
persistently >100 or if stools acholic
Catheter-related: (see Long (putty grey) or very pale, refer urgently
line insertion guideline) to liver unit to discuss investigations
Peripheral catheters: extravasations and further management
and skin sloughs if failure to progress with enteral
Septicaemia feeding in a timely fashion, seek advice
from a paediatric gastroenterologist
Electrolyte abnormalities
Electrolyte and acid-base disturbances WEANING PN
When advancing enteral feedings,
Metabolic reduce rate of PN administration to
Hyper/hypoglycaemia, osmotic diuresis achieve desired total fluid volume
Metabolic bone disease: mineral Decrease the aqueous and fat portions
abnormalities (Ca/PO4/Mg) see by 90% and 10% respectively for each
Metabolic bone disease guideline volume of PN reduced e.g. if reducing
PN by 1 mL/hr, reduce Vamin by
Hyperlipidaemia and
0.9 mL and Intralipid by 0.1 mL
hypercholesterolaemia
Assess nutrient intake from both PN
Conjugated hyperbilirubinaemia
and enteral feed in relation to overall
PN-associated cholestatic nutrition goals
hepatitis
Can occur with prolonged PN
(>10–14 days)
probably due to combination of PN
hepato-toxicity, sepsis and reduced oral
feeding
often transient
usually manifests as rising serum
bilirubin (with increased conjugated
component) and mildly elevated
transaminases
leads to deficiencies of fatty acids and
trace minerals in enterally fed babies
even small enteral feeds will limit or
prevent this problem and therefore
trophic feeds should be given to all
babies on PN unless there are
contraindications such as acute clinical
instability or NEC
consider other causes of
hyperbilirubinaemia (PN-induced
cholestasis is diagnosis of exclusion)
e.g. CMV, hypothyroidism
ensure trace minerals are added to PN
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PATENT DUCTUS ARTERIOSUS • 1/3
RECOGNITION AND low-pitched systolic or continuous
ASSESSMENT murmur over left upper sternal edge
(absence of a murmur does not
Definition exclude significant PDA)
Persistent patency of the ductus signs of cardiac failure (tachypnoea,
arteriosus (PDA) is a failure of tachycardia, hepatomegaly, pulmonary
functional ductal closure by 48 hr or oedema, generalised oedema etc.)
anatomical closure by 3 weeks of age
poor perfusion (hypotension, poor
Factors associated with capillary refill, mottled skin and
delayed closure persistent acidosis)
Prematurity (significant PDA affects increased or persistent ventilatory

approximately 30% of very-low-birth- requirements
weight babies)
Lack of antenatal corticosteroid
Other cardiac pathology (e.g.
prophylaxis
congenital heart disease, including
Surfactant-deficient lung disease duct-dependent lesions, arrhythmias or
Hypoxaemia cardiomyopathy)
Volume overload Sepsis
Adverse effects of PDA INVESTIGATIONS

Haemodynamic consequences of left- SpO2 monitoring
to-right shunt in preterm babies can Chest X-ray (cardiomegaly?
prolong ventilatory support and are pulmonary plethora?)
associated with mortality and morbidity
(chronic lung disease, pulmonary Echocardiography is advisable as
haemorrhage, intraventricular duct-dependent cardiac lesions, or
haemorrhage, necrotising enterocolitis other cardiac pathologies, can be
and retinopathy of prematurity) difficult to detect clinically and is
important if considering treatment with
Increased pulmonary blood flow prostaglandin inhibitor
(leading to increased work of breathing
and respiratory deterioration) Echocardiographic assessment of
significant PDA includes:
Reduced systemic blood flow (leading
to acidosis and hypotension) size of PDA (>1.5 mm)
volume loading of left atrium (LA/aorta
Symptoms and signs ratio >1.5)
Can be absent even in the presence of volume loading of left ventricle
a significant duct in first 7 days of life
velocity and flow pattern of ductal flow
A significant left-to-right shunt is
suggested by:
bounding pulses and wide pulse
pressure (i.e. >25 mmHg)
hyperdynamic precordium (excessive
movement of precordium)
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IMMEDIATE TREATMENT Contraindications to
General measures ibuprofen
Duct-dependent cardiac lesion
Optimise oxygenation by appropriate
ventilatory management Significant renal impairment: urine
output <1 mL/kg/hr or creatinine
Use of a higher PEEP (i.e. ≥5 cmH2O)
>120 micromol/L
can help minimise effects of pulmonary
oedema and risk of pulmonary Significant thrombocytopenia, i.e.,
haemorrhage platelet count <50 x 109/L (course
started or next dose given only after
Treat anaemia – maintain Hb ≥100 g/L
platelet transfusion)
with blood transfusion (consider
concurrent dose of IV furosemide) Suspected or definite necrotising
enterocolitis
Before starting medication, restrict fluid
intake to 60–80% (e.g. from Active phase of significant bleeding
150 mL/kg/day to 90–120 mL/kg/day) (gastrointestinal or severe intracranial)
– treat coagulopathy before starting
If fluid overload or pulmonary oedema,
course – see Coagulopathy guideline
give one IV dose of furosemide in
accordance with Neonatal Formulary Dose
Specific measures Calculate carefully and prescribe
individually on single dose part of
Aim to convert haemodynamically
prescription chart so that
significant PDA into insignificant PDA
contraindications checked before each
as complete duct closure may take
dose
weeks or months
Administer in accordance with
Pharmacological treatment Neonatal Formulary
with prostaglandin inhibitor Ibuprofen has similar efficacy to
to initiate closure indometacin but fewer renal side
Ibuprofen is the drug of choice for this effects (can be used in babies with
purpose. Indometacin is not currently mild or previous renal dysfunction)
available in the UK
Pharmacological treatment is best
used within 2 weeks of age but can be Monitoring pharmacological
effective up to 6 weeks treatment
Check before each dose:
Indications
creatinine (maintained <120 micromol/L)
Babies born <34 weeks’ gestation with
significant PDA – on clinical and/or urine output (maintained >1 mL/kg/hr)
echocardiographic assessment
platelet count (kept ≥50 x 109/L with
Includes ventilatory/CPAP dependent platelet infusions if needed)
babies or PDA with haemodynamic
concomitant nephrotoxic drug e.g.
effects (i.e. cardiac failure or poor gentamicin/vancomycin (monitor levels
perfusion) carefully OR use alternative non-
Monitor babies with non-significant PDA nephrotoxic drug)
carefully and treat if becomes significant
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Feed tolerance (feeds cautiously If PDA still significant and baby
initiated or continued during treatment – ventilatory or CPAP dependent, discuss
briefly stopped during actual infusion) with cardiac centre for surgical ligation
when:
Clinical signs of PDA and baby’s
progress prostaglandin inhibitor contraindicated
Echocardiography (if clinically prostaglandin inhibitor not indicated
indicated), repeated after 2–3 days of (≥34 weeks with cardiac failure not
completion controlled by diuretics)
Fluid gradually liberalised after prostaglandin inhibitor ineffective
treatment based on: (usually after giving second course)
daily weight (weight gain suggests fluid Discuss further cardiac assessment
retention) and surgical ligation of PDA with
cardiologist at regional cardiac centre
serum sodium (dilutional
and transport team – follow local care
hyponatraemia common)
pathway (e.g. West Midlands PDA
Persistence or recurrence of Ligation Referral Pathway)
asymptomatic PDA After surgical ligation, keep baby nil-by-
mouth for 24 hr before gradually
Persistence of murmur does not
building up feeds (because of risk of
necessarily indicate return of PDA
necrotising enterocolitis)
Echocardiogram sometimes
demonstrates physiological branch DISCHARGE POLICY FOR
pulmonary stenosis PERSISTENT PDA
If baby with asymptomatic murmur is If PDA persistent clinically or
making progress, plan echocardiographically at discharge or
echocardiography before discharge to at 6 weeks follow-up, arrange further
decide follow-up follow-ups in cardiac clinic (locally or at
cardiac centre depending on local
Persistent significant PDA practice)
and surgical referral
If PDA reviewed locally still persistent
If PDA significant after 48 hr of at 1 yr of age or if clinically significant
completion of first course of during follow-up (cardiac failure or
prostaglandin inhibitor, use second failure to thrive), refer to paediatric
course of ibuprofen cardiologist at regional cardiac centre
If PDA still significant but baby making to consider closure (first option is
progress (i.e., can be extubated or usually catheter closure)
come off CPAP):
commence regular diuretics
(furosemide + amiloride/spironolactone)
to help control haemodynamic effects –
in accordance with Neonatal
Formulary
monitor closely
Issue 6
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PERICARDIOCENTESIS • 1/1
INDICATION PROCEDURE
Drain a pericardial effusion only if there Consent and preparation
is cardiovascular compromise. If time
If time allows, inform parents and
allows, discuss with paediatric
obtain consent (verbal or written)
cardiologist before drainage
If skilled operator available, perform
PERICARDIAL EFFUSION under ultrasound guidance
Causes In an emergency situation, the most
experienced person present performs
Neonatal hydrops
procedure without delay and without
Extravasation of PN from migrated ultrasound guidance
long lines
Ensure baby has adequate analgesia
Complication of central venous with intravenous morphine and local
catheters lidocaine instillation
Clinical signs Drainage
Sudden collapse in baby with long line Maintain strict aseptic technique
or umbilical venous catheter in situ – throughout
always consider pericardial tamponade
Clean skin around xiphisternum and
Tachycardia allow to dry
Poor perfusion Attach needle to syringe and insert just
Soft/muffled heart sounds below xiphisternum at 30º to skin and
Increasing cardiomegaly aiming toward left shoulder
Decreasing oxygen SpO2 Continuously aspirate syringe with
gentle pressure as needle is inserted.
Arrhythmias As needle enters pericardial space
there will be a gush of fluid, blood or air
Investigations
Send aspirated fluid for microbiological
Chest X-ray: widened mediastinum
and biochemical analysis
and enlarged cardiac shadow
Withdraw needle
Echocardiogram (if available)
EQUIPMENT AFTERCARE
Cover entry site with clear dressing
Sterile gown and gloves
(e.g. Tegaderm/Opsite)
Sterile drapes
Discuss further management with
Dressing pack with swabs and plastic paediatric cardiologist
dish
22/24 gauge cannula
5–10 mL syringe with 3-way tap
attached
Lidocaine
Issue 6
254
PERSISTENT PULMONARY HYPERTENSION
OF THE NEWBORN (PPHN) • 1/3
RECOGNITION AND CLINICAL FEATURES
ASSESSMENT Usually present in first
Definition 12 hr of life
Failure of normal postnatal fall in SpO2 <95% or hypoxia (PaO2 <6 kPa)
pulmonary vascular resistance
Mimics cyanotic heart disease
Leads to right-to-left shunting and
subsequent hypoxia CVS: tricuspid regurgitant murmur,
right ventricular heave, loud second
Can be primary (idiopathic) or heart sound and systemic hypotension
secondary
Idiopathic PPHN: respiratory signs
Severe hypoxaemia (PaO2 <6 kPa) in mild or absent
FiO2 1.0
Secondary PPHN: features of
Complex condition with varied causes underlying disease
and degrees of severity
INVESTIGATIONS
Idiopathic Blood gas shows hypoxaemia (PaO2
Degree of hypoxia disproportionate to <6 kPa) with oxygenation index >20
degree of hypercarbia (underlying disease will produce a
mixed picture)
Mild lung disease (in primary/idiopathic
PPHN) SpO2 >5% difference in pre- and post-
Echocardiogram: structurally normal ductal saturations (pre > post)
heart (may show right ventricular Hyperoxia test (100% oxygen for 5 min)
hypertrophy), right-to-left or
SpO2 may improve to ≥95% in early
bidirectional shunt at PFO and/or
patent ductus arteriosus (PDA) stage or may not respond, i.e., staying
<95% in established PPHN (as in
Secondary: cyanotic heart disease)
may be associated with: Chest X-ray: variable findings
Severe lung disease [e.g. meconium depending on underling diagnosis
aspiration (MAS), surfactant deficiency] (normal or minimal changes in
idiopathic PPHN)
Perinatal asphyxia
Electrocardiograph – often normal.
Infection [e.g. Group B streptococcal Can sometimes show tall P waves in
(GBS) pneumonia] lead 2/V1/V2 or features of RVH (i.e.
Structural abnormalities: pulmonary tall R waves V1/V2, right axis deviation
hypoplasia, congenital diaphragmatic or upright T waves in V1/V2)
hernia, A-V malformations, Congenital
Cystic Adenomatoid Malformation
(CCAM)
Maternal drugs: aspirin, non-steroidal
anti-inflammatory drugs, SSRIs
Issue 6
255
Echocardiogram (although not If perfusion poor, fluid bolus (10 mL/kg
mandatory) is useful: sodium chloride 0.9% or if
coagulopathy, fresh frozen plasma –
to exclude cyanotic heart disease
see Coagulopathy guideline)
to assess pulmonary pressure
Once PaCO2 in acceptable range (i.e.
to evaluate ventricular function <6 kPa), correct metabolic acidosis to
one or more of the following confirm maintain pH 7.35–7.45 using full
PPHN in presence of normal cardiac correction with sodium bicarbonate
structures: over 1 hr. If repeat correction
necessary, slow bicarbonate infusion
a) significant tricuspid regurgitation of calculated dose can be given over
b) dilated right side of heart 6–12 hr (see Neonatal Formulary)
c) right-to-left shunting across PFO Ventilation
and/or PDA
Use conventional ventilation to start
d) pulmonary regurgitation with (targeted tidal volume 5–6 mL/kg)
MANAGEMENT Use sedation and muscle relaxation in
babies with high ventilatory and oxygen
Once PPHN suspected, involve
requirements and/or ventilator
consultant neonatologist immediately
asynchrony
Aims of management are to:
PaCO2 4.5-5.5 kPa (accept up to
decrease pulmonary vascular resistance 6 kPa in parenchymal lung disease).
increase systemic blood pressure Avoid hypocarbia
to treat any underlying condition start at FiO2 1.0 (=100% oxygen) and
reduce as tolerated. Maintain SpO2 at
Babies with PPHN should be referred
96–100% and PaO2 at
to a NICU for on-going management
10–12 kPa
General measures High frequency oscillatory ventilation
Minimal handling, nurse in quiet (HFOV) may further improve
environment oxygenation (see High frequency
oscillatory ventilation guideline)
Secure arterial and central venous
access, see Arterial line insertion Monitor oxygenation index (OI)
guideline or Umbilical artery
catheterisation and Umbilical OI = mean airway pressure (cmH2O) x
venous catheterisation guidelines FiO2 x 100
Maintain normal temperature, postductal PaO2 (kPa) x 7.5
biochemistry and fluid balance
Keep Hb ≥120 g/L
Give antibiotics (sepsis, particularly
GBS, is difficult to exclude)
Surfactant may be beneficial in MAS or
GBS sepsis – discuss with consultant
Issue 6
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Inotropes – Exclusion criteria
see Hypotension guideline (if in doubt, discuss with
Use inotropes early ECMO team)
In significant PPHN, adrenaline or Major intracranial haemorrhage
noradrenaline can be useful in Irreversible lung injury or mechanical
increasing systemic blood pressure ventilation >10 days
without increasing pulmonary vascular
Lethal congenital or chromosomal
resistance
anomalies
Maintain systemic mean BP
Severe encephalopathy
45–55 mmHg in term baby and
systemic systolic BP 60–70 mmHg or Major cardiac malformation
above estimated pulmonary pressures
A baby accepted for transfer to
(if available by echo)
ECMO centre will be retrieved by
Pulmonary vasodilatation ECMO or PICU team
If OI >20 or needs 100% oxygen or ECMO centre will need:
significant PPHN on echo, use inhaled
nitric oxide (NO) as a selective a cranial ultrasound scan
pulmonary vasodilator (see Nitric maternal blood for group and
oxide guideline) crossmatching (check with ECMO
centre)
Severe and resistant PPHN
a referral letter
not responding to
copies of hospital notes/chest X-rays
conventional management
Outreach ECMO
May benefit from ECMO or other
specialist treatment ECMO team may decide to start
outreach ECMO in neonatal unit before
Discuss with KIDS team in West
transfer to ECMO unit. Check with
Midlands or nearest ECMO centre
ECMO team regarding diathermy unit
Criteria for considering ECMO and number of packed cell units
needed for procedure
Baby born ≥34 weeks or ≥2 kg with
PPHN Referral for ECMO
not responding or OI >30 despite NO, Contact KIDS team on 03002001100 (for
inotropes and/or HFOV OR West Midlands) or
unable to maintain BP with inotropes or
ECMO co-ordinator/fellow at nearest
persistent need for
ECMO Centre:
adrenaline/noradrenaline infusion OR
no significant progression after 3 days Glenfield Hospital, Leicester
0116 287 1471
Criteria for ECMO Great Ormond Street Hospital, London
Baby born ≥34 weeks or ≥2 kg with 0207 829 8652
PPHN
Freeman Hospital, Newcastle
Oxygenation index >40 0191 223 1016
Reversible lung disease (<10 days high
Yorkhill Hospital, Glasgow
pressure ventilation)
0141 201 0000
No lethal congenital malformation
Issue 6
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POLYCYTHAEMIA • 1/2
RECOGNITION AND Clinical consequences
ASSESSMENT Hyperviscosity
Definition Decreased blood flow and impaired
tissue perfusion
Peripheral venous haematocrit (Hct)
Thrombus formation
>65%
Symptoms rarely occur with peripheral Complications
Hct of <70% Cerebral micro-infarction and adverse
neuro-developmental outcome
Hct peaks at 2 hr after birth and then
decreases with significant changes Renal vein thrombosis
occurring by 6 hr Necrotising enterocolitis (NEC)
Causes
Intra-uterine increased erythropoiesis Erythrocyte transfusion
Placental insufficiency (SGA) Maternal-fetal
Postmaturity Twin-to-twin transfusion
Maternal diabetes Delayed cord clamping
Maternal smoking Unattended delivery
Chromosomal abnormalities: trisomy 21, 18, 13
Beckwith–Wiedemann syndrome
Congenital adrenal hyperplasia
Neonatal thryotoxicosis
Congenital hypothyroidism
Symptoms and signs

Commonly plethoric but asymptomatic
Cardiorespiratory Respiratory distress
Persistent pulmonary hypertension of the newborn (PPHN)
Congestive cardiac failure
CNS Lethargy, hypotonia within 6 hr
Difficult arousal, irritability
Jittery
Easily startled
Seizures
GIT Poor feeding
Vomiting
NEC
Metabolic Hypoglycaemia
Hypocalcaemia
Jaundice
Haematological Thrombocytopenia
Renal Renal vein thrombosis
Renal failure
Issue 6
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POLYCYTHAEMIA • 2/2
INVESTIGATIONS Treatment
In all unwell babies and at-risk babies Dilutional exchange transfusion.
who look plethoric (as mentioned above) Discuss with consultant
FBC/Hct explain to parents need for exchange
and possible risks before performing
If Hct >65%, repeat a free-flowing
dilutional exchange transfusion. Partial
venous sample or obtain arterial Hct
exchange transfusion increases risk of
If polycythaemic, check blood glucose NEC
and serum calcium
use sodium chloride 0.9% – see
IMMEDIATE TREATMENT Exchange transfusion guideline
Ensure babies at risk have liberal fluid Volume to be exchanged = 20 mL/kg

intake one day ahead see Perform exchange via peripheral
Intravenous fluid therapy guideline arterial and IV lines or via umbilical
venous catheter (UVC)
Asymptomatic babies with
Hct >70% Take 5–10 mL aliquots and complete
procedure over 15–20 min
Repeat venous Hct after 6 hr
if still high, discuss with consultant
(current evidence does not show any Babies who required dilutional
benefit in treating asymptomatic exchange transfusion require long-
babies) term neuro-developmental follow-up
Symptomatic babies with Otherwise, follow-up will be dependent

on background problem
Hct >65%
Possible symptoms: fits and excessive
jitteriness, with neurological signs and
refractory hypoglycaemia
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POSITIONING • 1/3
FOR COMFORT AND
DEVELOPMENT
Poor positioning may cause: poor thermo-regulation
discomfort compromised skin integrity
disturbed sleep flattened elongated head shape and
postural deformities
physiological instability
inability to interact socially
impaired cerebral blood flow
poor parental perception of baby
increased intracranial pressure
The positions described below aim to
increased gastro-oesophageal reflux
minimise these effects
(GOR)
Positions
Consider for all, including ventilated babies. See also Kangaroo care guideline
Position Use for Method

Prone Respiratory compromise Tuck limbs with arms forward and hands near
GOR to face for self-calming
Unsettled babies Provide head support
Older babies to encourage Place small, soft roll under baby from head to
physical development – active umbilicus to allow a rounded, flexed posture
neck extension, head control (prevents flattening of trunk and shoulder
and subsequent gross motor retraction – ‘W’ position)
skills. When awake/alert only, Support with good boundaries to prevent
in response to cues excessive hip abduction (‘frog’ position)
Lifting Avoid neck hyperextension
If baby not monitored, do not place in
prone position. Give parents/carers
information about The Lullaby Trust
(formerly FSID) recommendations before
discharge
Supine Some surgical and medical Provide supportive boundary to allow hands-
conditions to-face/mouth for self-calming and prevent
Older babies ready for interaction shoulder retraction (‘W’ position)
Intubated babies where midline Provide head support
head support necessary (e.g. for Avoid excessive neck rotation (impairs
cooling) cerebral blood flow)
Most difficult position for babies If required, neck roll must be small and soft to
to work against gravity for self- avoid restricting cerebellar blood flow
calming and development of
movement
Safest sleeping position for
babies not monitored – promote
supine sleeping and feet-foot
position before discharge
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POSITIONING • 2/3
Position Use for Method

Side-lying Most babies Provide back support. Gently curl back, flex
Best position for self-regulation hips and knees. Avoid excessive flexion
and calming behaviours which may impair respiration and digestion
Left side-lying reduces GOR Position with feet against boundary to
Lifting facilitate foot bracing
Use elevated side-lying position Keep head in midline
for preterm, hypotonic or babies Keep upper shoulder slightly flexed to prevent
with chronic lung disease or baby falling backwards
neurological impairment when Support arms in midline, with hands close to
learning to bottle-feed face – use straps of nest/soft sheet. Give
May be appropriate for other baby small soft toy/roll to ‘cuddle’ to support
medical conditions where upper arm
increased risk of aspiration
Sitting Near term ready for more Use reclining baby seat
interaction/stimulation Maintain midline position – use blanket rolls
GOR to prevent slumping, asymmetry and
Encourages midline position, plagiocephaly
chin tuck, eye/hand co-ordination Keep hips in middle of seat
Place padding behind back (from shoulder
level) to allow head to rest in line with body
Tuck rolls under shoulders to bring arms
forward
Avoid over-stimulation. Do not place objects
too close to baby’s face
Car seats Small and preterm babies are at Fasten straps before tucking blankets around
(Information risk of breathing difficulties baby
for parents) while travelling in car seats Use inserts only if recommended/approved by
car seat manufacturer
Advise parents to refer to RoSPa website
www.rospa.org.uk/roadsafety before purchasing
car seat
Advise parents to keep time baby spends in car
seat to a minimum and observe closely during
journey
Issue 6
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POSITIONING • 3/3
Comfort score
Observational tool to assess positioning as a guide to promote comfort and minimise
postural deformity
Least comfortable Most comfortable

1 Aah! Baby looks uncomfortable (include 0 1 2 3 4 5 Baby looks relaxed,
Factor facial expression and colour) – you comfortable, cosy, content
feel you want to do something about it
2 Head Trunk arched/rotated or curved with 0 1 2 3 4 5 Head and trunk in line, with
and a) Head extended or head in midline or three-
trunk b) Chin on chest or quarters toward side of head
c) Head flat to side with twisted neck (neck not fully twisted)
3 Arms Flaccid or stiff, and stretched out or: 0 1 2 3 4 5 All the following:
a) ‘W’ position with shoulders a) Shoulders forward
retracted (pushed back) or b) Arms flexed or relaxed
b) Twisted/trapped under body or c) Possibility to reach mouth
between body and bedding or or face with ease
immobilised
4 Hands a) Fingers splayed or 0 1 2 3 4 5 One or more of the following:
b) Hands tightly fisted or a) Hands relaxed, open, or
c) Immobilised or restricted by fingers softly folded
clothing b) Hands together or clasped
c) Touching head/face/
mouth/own body
d) Holding/grasping onto
something
5 Legs a) Flaccid, with straight or ‘frog-like’ 0 1 2 3 4 5 In all positions:
and feet posture (abducted and externally a) Flexed legs with feet
rotated at hips) with feet pointing touching each other, or
outwards or resting against other leg
b) Stiff, straight legs with toes and
splayed or curled tight, and/or b) Able to reach boundary to
pushing hard on bedding, turning brace feet
outwards In prone position, knees
should be tucked under body,
feet angled towards each
other (not turning out)
6 Arousal a) Agitated, jerky, jittery movements 0 1 2 3 4 5 a) Sleeping restfully or
and/or quietly awake
b) Fussing or crying b) Minimal or smooth
c) Unconscious movement
Total (Max score = 30)
Reproduced with permission (Inga Warren, consultant occupational therapist, Winnicott baby unit)
Issue 6
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PROSTAGLANDIN INFUSION • 1/2
DOSAGE Desired response
Ranges from 5–50 nanogram/kg/min Suspected left-sided obstruction:
(higher doses may be used on the aim for palpable pulses, normal pH
recommendation of a tertiary specialist) and normal lactate
Antenatal diagnosis of duct dependent Suspected right-sided obstruction:
lesion:
aim for SpO2 75–85% and normal
start at 5 nanogram/kg/min lactate
Cyanotic baby or with poorly palpable
Suspected or known transposition of
pulses who is otherwise well and non-
the great arteries (TGA) or hypoplastic
acidotic:
left or right heart syndrome with SpO2
start at 5–15 nanogram/kg/min <70% or worsening lactates
Acidotic or unwell baby with suspected liaise urgently with cardiology and/or
duct dependent lesion: intensive care/retrieval team (e.g.
start at 10–20 nanogram/kg/min. If no KIDS) as rapid assessment and atrial
response within first hour, consider an septostomy may be necessary
increase of up to 50 nanogram/kg/min
PREPARATIONS
Dinoprostone (Prostaglandin E2) is the recommended prostaglandin*
Dinoprostone infusion Other information

Standard dinoprostone infusion: Stability:
Make a solution of 500 microgram in syringe stable for 24 hr
500 mL by adding 0.5 mL of Compatibility:
dinoprostone 1 mg in 1 mL to a 500 mL infuse dinoprostone via separate line
bag of suitable diluent (glucose 5% or Flush:
10% or sodium chloride 0.45% and
sodium chloride 0.9% at same rate as
0.9%)
infusion
Transfer 50 mL of this solution into a Administration:
50 mL Luer lock syringe and label
continuously (short half-life). Ensure 2
Discard the 500 mL bag immediately working points of IV access at all times
into clinical waste – single patient and infusions can be given via long line,
single dose use only UVC or peripherally
Infusion rate: 0.3 mL/kg/hr = extravasation can cause necrosis – use
5 nanogram/kg/min central access if available
* If IV Dinoprostone not available, use Alprostadil (Prostaglandin E1) IV as alternative

(see Neonatal Formulary)
Issue 6
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PROSTAGLANDIN INFUSION • 2/2
Oral Dinoprostone MONITOR
(see Neonatal Formulary) Heart rate
Used temporarily on very rare Blood pressure
occasions when IV access is
Respiratory rate
extremely difficult
Temperature
Discuss with cardiac centre before
using Oxygen saturations
Use Dinoprostone injection orally Blood gases
May not be as effective as IV Blood glucose and lactate
prostaglandin
TRANSFER OF BABY
SIDE EFFECTS RECEIVING PROSTAGLANDIN
Common INFUSION
Apnoea – tends to occur in first hour Contact local retrieval team for
after starting prostaglandin or when transport of babies to cardiac centre
dose increased. Consider ventilation (e.g. for Birmingham Children’s
Hospital – contact KIDS team on 0300
Hypotension – due to systemic 200 1100)
vasodilatation. Consider sodium
chloride 0.9% bolus 10 mL/kg Keep baby nil-by-mouth for transfer
Fever For well babies on

≤10 nanogram/kg/min prostaglandin,
Tachycardia risk of apnoea is low
Hypoglycaemia
Uncommon
Hypothermia
Bradycardia
Convulsions
Cardiac arrest
Diarrhoea
Disseminated intravascular
coagulation (DIC)
Gastric outlet obstruction
Cortical hyperostosis
Gastric hyperplasia (prolonged use)
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PULMONARY HAEMORRHAGE • 1/2
RECOGNITION AND IMMEDIATE TREATMENT
ASSESSMENT Basic resuscitation
Definition
Respiratory
Acute onset of bleeding from
endotracheal tube (ETT) associated Intubate and ventilate
with cardiorespiratory deterioration and Sedate and give muscle relaxant
changes on chest X-ray
PEEP 6–8 cm, even higher PEEP of
Significant pulmonary haemorrhage is 10–12 cm of water sometimes
most likely to represent haemorrhagic required to control haemorrhage
pulmonary oedema. Differentiate from
minor traumatic haemorrhage following PIP to be guided by chest expansion
endotracheal suction and blood gases
Long inspiratory times (0.5 sec may be
Risk factors needed)
Preterm babies Endotracheal suction (try to avoid but
Respiratory distress syndrome (RDS) consider in extreme cases to reduce
Large patent ductus arteriosus (PDA) risk of ETT blockage)
Excessive use of volume (>20 mL/kg) Ensure adequate humidification
in first 24–48 hr in babies ≤28 weeks’ Avoid chest physiotherapy
gestation
Establish arterial access
Coagulopathy
Sepsis Fluid management
IUGR If hypovolaemic, restore circulating
Grade 3 hypoxic ischaemic volume over 30 min with 10 mL/kg
encephalopathy (HIE) sodium chloride 0.9% or O-negative
packed cells if crystalloid bolus already
Symptoms and signs given. Beware of overloading (added
Apnoeas, gasping respirations, volume can be detrimental to LV failure)
desaturations If not hypovolaemic and evidence of
Tachycardia >160/min, bradycardia, left ventricular failure, give furosemide
hypotension, shock, PDA, signs of 1 mg/kg IV
heart failure Correct acidosis (see Neonatal
Widespread crepitations, reduced air Formulary)
entry
If PDA present, restrict fluids to
Pink/red frothy expectorate, or frank 60–80 mL/kg/24 hr in acute phase
blood from oropharynx or ETT if
Further blood transfusion, vitamin K
intubated
administration and FFP to be guided
Investigations by haemoglobin concentration, PT and
APTT (see Transfusion of red blood
Blood gas (expect hypoxia and
cells guideline and Coagulopathy
hypercarbia with mixed acidosis)
guideline)
FBC, clotting
Chest X-ray (usually shows classic
white-out with only air bronchogram
visible but may be less striking and
resemble RDS)
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PULMONARY HAEMORRHAGE • 2/2
Hypotension/cardiac
dysfunction
If still hypotensive or evidence of
cardiac dysfunction after fluid
resuscitation, treat hypotension with
inotropes (see Hypotension guideline)
Infection
If infection suspected, request septic
screen and start antibiotics
Once baby stable
Inform on-call consultant
Speak to parents
Document event in case notes
Consider single extra dose of natural
surfactant in babies with severe
hypoxaemia or oxygenation index >20
If PDA suspected, arrange
echocardiogram (see Patent ductus
arteriosus guideline)
Perform cranial ultrasound scan to
exclude intracranial haemorrhage as
this may influence management – see
Cranial ultrasound scans guideline
Issue 6
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PULSE-OXIMETRY (UNIVERSAL) SCREENING
• 1/3
INTRODUCTION
Used in some maternity units following results and recommendation of pulse-oximetry
study to detect serious congenital heart disease for babies born ≥34 weeks’ gestation
along with clinical examination
Flowchart 1: Pulse-oximetry screening test
Apparently well newborn in postnatal nursery

Pre-discharge pulse-oximetry screening at 4–48 hr (depending on local circumstances)
Right-hand (pre-ductal) and either foot (post-ductal) saturations

measured until consistent reading obtained
Both readings >94% Reading 90–94% Reading <90%

and or or
difference <3% >2% difference symptomatic
If asymptomatic,
repeat test in 1–2 hr
Reading 90–94%
or
>2% difference
If asymptomatic
repeat test in 1–2 hr
Test negative Reading <95% Test positive

No further action or Urgent paediatric
Routine care >2% difference assessment
Comprehensive evaluation for causes of hypoxaemia

(see next section and Flowchart 2).
In the absence of non-cardiac findings to explain hypoxaemia,
refer for diagnostic echocardiogram
Issue 6
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• 2/3
POSITIVE PULSE-OXIMETRY MANAGEMENT OF TEST-
SCREEN (ABNORMAL TEST) POSITIVE BABY
Initial assessment of Any test-positive baby
test-positive baby See Flowchart 2
Assess cardiac and Seen by appropriately trained
respiratory systems paediatric staff
Is baby symptomatic? Seek advice from most experienced
quiet, less responsive member of paediatric team
temperature instability Admission

tachypnoea with RR ≥60 min Admit to NNU for assessment if:
respiratory distress abnormal examination findings or
grunting respirations pulse-oximetry screening positive on 3
nasal flaring occasions (see Flowchart 2)
chest wall recession Investigations
apnoea If respiratory/infective condition
suspected from history/examination
Examination
and saturations improve with oxygen
Abnormal breath sounds
FBC/CRP/blood culture/chest X-ray as
Heart murmur appropriate
Weak or absent femoral pulse
Echocardiogram
Response to oxygen therapy
Indicated if any of the following:
History CVS examination abnormal
Previous cardiac defect or congenital no respiratory signs
infection?
no response to oxygen
Suspicion of congenital abnormality on
low saturations persist
antenatal scan?
no satisfactory explanation
Maternal illness during pregnancy,
including diabetes? If echo unavailable, contact senior
regarding Prostaglandin E2
Drug ingestion during pregnancy
(anticonvulsants)? infusion/paediatric cardiology input –
see Congenital heart disease
PROM guideline and Prostaglandin infusion
Positive maternal culture guideline
Maternal fever or raised inflammatory
markers
Foul-smelling liquor
Mode of delivery
Need for resuscitation (Apgar score)
Issue 6
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• 3/3
Flowchart 2: Positive pulse-oximetry screen (abnormal test)
Positive pulse-oximetry screen

Pre or post-ductal SpO2 <90%
SpO2 90-–94% or >2% pre-and post-ductal difference on 3 measurements
Symptomatic or abnormal examination findings
Admit to NNU
Assessment by or discussion with senior paediatrician
CONTINOUS PRE- AND POST-DUCTAL SATURATION MONITORING
Asymptomatic Respiratory/infective Minimal respiratory

and symptoms symptoms
Repeat pre and post- and/or and/or
ductal SpO2 >94% in air Repeat pre and post- Abnormal CVS examination
ductal SpO2 >94% with and/or
oxygen Repeat pre or post-ductal
SpO2 <95% with oxygen
Urgent in-house echo

or
Discuss with paediatric
If concerned, consider Investigate and treat cardiologist
further observation on respiratory or infective Consider prostaglandin
NNU illness infusion
Repeat pre and post-ductal SpO2 Repeat pre or post-ductal SpO2

>94% in air <95% with oxygen
and or
Repeat CVS examination normal Diagnosis not established
and or
No concerns Echo abnormal
Discharge Refer to cardiac centre
Issue 6
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RECTAL WASHOUT USING SYRINGE
METHOD • 1/2
INDICATIONS Rectal washout solution (sodium
chloride 0.9%) warmed to room
Suspected or confirmed Hirschsprung’s temperature
disease
Plastic apron
Suspected meconium plugs
Gloves
BENEFITS Protective sheet
Bowel decompression
Receptacle to collect effluent
Establishment of feeding
Container for clean rectal washout
Weight gain solution
Reduced risk of colitis Blanket to wrap baby
CONTRAINDICATIONS Preparation
Rectal biopsies taken in preceding 24 hr Place all equipment at cot side
Rectal bleeding (relative Sedation is not necessary
contraindication)
Second person to comfort infant using
Severe anal stenosis dummy and breast milk/sucrose – see
Pain assessment and management
Anus not clearly identified
guideline
Known surgical patient (without
discussion with surgical team) Wash hands, put on gloves and apron
Position baby supine with legs raised
ADVERSE REACTIONS
Keep baby warm
Bleeding from anus or rectum
Perforation of bowel; this is very rare
PROCEDURE
Inspect and palpate abdomen – note
Electrolyte imbalance if inappropriate
distension or presence of lumps
fluid used or retained
Draw up 60 mL solution into syringe
Vomiting
and keep on one side
Hypothermia
Insert lubricated catheter into rectum
Distress to baby and parent [up to approximately 10 cm (in a term
baby) or until resistance felt] noting any
Consent flatus or faecal fluid drained
Explain procedure to parents/carer and Massage abdomen in a clockwise
obtain verbal consent direction to release flatus
Equipment Attach syringe containing solution to
tube in rectum and gently instil fluid:
Tube size 6–10 Fr (recommended:
Conveen easicath pre-lubricated Weight ≤2 kg 5–10 mL
catheter)
Weight >2 kg 20 mL
Lubricating gel (if catheter not lubricated)
Bladder tip syringe no smaller than Disconnect syringe from tube and drain
60 mL effluent into receptacle
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RECTAL WASHOUT USING SYRINGE
METHOD • 2/2
Repeat procedure until drained solution
becomes clearer, up to a maximum of
3 times
If solution does not drain out, manipulate
tube in and out and massage abdomen
If no faeces are passed or all the
solution is retained, seek medical help
Re-examine abdomen and note any
differences
Wash, dress and comfort baby
Preparation for discharge

For discharge, baby should require no
more than 2 rectal washouts a day
Order equipment via paediatric
community nurse
Ward will supply 5 days’ equipment
Discharge letter for GP detailing
equipment required
Arrange home visit with clinical nurse
specialist in stoma care if available
locally
Ensure parents competent to perform
rectal washout and can describe signs
of colitis
complete rectal washout parent
competency sheet if available locally
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RE-CYCLING OF STOMA LOSSES VIA A
MUCUS FISTULA • 1/2
INDICATIONS Before commencing
Stoma output >30 mL/kg/day term Discuss with surgical team and
baby (>20 mL/kg/day for preterm baby) confirm they agree with procedure
Discrepancy in proximal and distal whether a distal contrast study is
bowel calibre required before re-cycling
Inability to absorb increasing enteral
feeds Consent
Failure to thrive Explain procedure and potential
adverse reactions to parents and
Developing cholestasis
obtain verbal consent
BENEFITS
Equipment
Maximise nutrition for sustained weight
gain and decrease in parenteral Tube (enteral or Foley catheter) size 6
nutrition or 8 Fr
Stimulation of gut hormones and Lubricating gel (if catheter not
enzymes lubricated)
Increases absorption of water, Enteral syringe (60 mL)
electrolytes and nutrients by utilising Stoma pot to collect stoma effluent
distal bowel
Extension tubing
Digestive tract matures and increases
in length and diameter with use Syringe pump (enteral pump if available)
Adaptation is driven by enteral feed in Plastic apron and gloves
distal bowel
Tape and dressing
Preparation of distal bowel for closure
Baby can, in some circumstances, be Documentation
managed at home Record name of surgeon requesting
procedure in baby’s notes (when
CONTRAINDICATIONS commencing)
Diseased or compromised distal bowel Record condition of peri-stomal skin
Rectal bleeding (not absolute but pre-procedure
discuss with surgical team)
Anal stenosis or imperforate anus Preparation
Signs of systemic infection Place all necessary equipment at cot
side
Effluent too thick to infuse
Wash hands and put on gloves and
ADVERSE REACTIONS apron
Bleeding from distal stoma Position baby in supine position and
Perforation of bowel by catheter (rare) keep warm
Leakage of stoma effluent onto
peristomal skin may result in
excoriation of the skin
Distress to baby and parent
Sepsis due to translocation
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RE-CYCLING OF STOMA LOSSES VIA A
MUCUS FISTULA • 2/2
PROCEDURE Preparation for home
Confirm which visible stoma is the Liaise with neonatal surgical nurse
mucus fistula – operation note or
Teach parents the procedure
surgical team
Order equipment via paediatric
Pass lubricated catheter into mucus community nurse
fistula up to 2 cm past end holes
Ward will supply 5 days’ equipment
If using a Foley catheter put only
0.5 mL water into balloon Discharge letter for GP detailing
equipment required
Secure catheter to the abdomen with
duoderm, tape and leave in situ Arrange home visit with clinical nurse
specialist in stoma care if available
Cover mucus fistula with paraffin gauze
locally
dressing (e.g. Jelonet)
Inform surgical team before discharge
Collect stoma fluid from acting stoma
into enteral syringe, connect to catheter
via extension tube and start re-cycling
using syringe pump
Aim to infuse stoma loss over a few
hours, but no more than 4 hr. Discard
any effluent older than 4 hr
If stoma loss <5 mL, re-cycle by
syringe as a slow bolus over a few
minutes
Re-cycling should result in bowel
actions per rectum of a consistency
thicker than the stoma loss
If bowel actions per rectum are watery
and/or frequent, send samples for
culture and sensitivity, virology and
detection of fat globules and reducing
substances. Discuss with surgical team
If baby develops signs suggestive of
sepsis, stop procedure and perform
septic screen as per unit policy.
Discuss with surgical team
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RENAL FAILURE • 1/3
DEFINITION Other
Failure of the kidneys to maintain Renal vein thrombosis
metabolic stability in relation to fluid Renal artery thrombosis
balance, electrolyte balance and
excretion of nitrogenous waste DIAGNOSIS
MAIN CAUSES Renal abnormalities (prenatal)
Risk factors (i.e. severe
Congenital asphyxia/sepsis/hypotension/
Usually affects term babies congenital heart disease)
Often diagnosed antenatally with renal Oliguria (<1 mL/kg/hr)
abnormality/hydrops
Hypovolaemia
Most commonly an obstructive
Electrolyte disturbance (particularly
uropathy
raised potassium)
posterior urethral valves
Rising creatinine after 48 hr
bilateral pelvi-ureteric junction (PUJ) postpartum
obstruction
Non-obstructive cause PREVENTION
renal agenesis This is the most important approach in
the preterm baby
polycystic kidneys (autosomal
recessive) Ensure adequate fluid intake
particularly in very preterm babies with
secondary to congenital heart disease excessive transepidermal water loss
hypoperfusion (see Fluid balance below)
severe acidosis Extra care required when using radiant
heaters in contrast to high
Asphyxia humidification in incubator (see
Occurs in severe hypoxic ischaemic Hypothermia guideline)
encephalopathy Maintain a safe blood pressure (see
direct hypoxic effect or secondary to Hypotension guideline)
hypoperfusion
INVESTIGATIONS
usually transient
poor prognosis for intact survival when
Monitor
severe Weigh 12-hrly
BP 12-hrly
Prematurity
Cardiac monitor to detect arrhythmias
Normally caused by poor renal
perfusion secondary to: Urine
hypovolaemia Dipstick (proteinuria; sediment, such
hypotension as blood, casts, tubular debris,
indicate intrinsic problem; WBC and
hypoxaemia
nitrites suggest infection)
sepsis
Microscopy and culture
Inappropriate ADH in ventilated babies
Electrolytes, urea, creatinine,
causes transient oliguria
osmolality
will correct spontaneously as lung
compliance improves
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Blood Consider trial of furosemide, if there
are signs of fluid overload
U&E, creatinine 8-hrly
In the majority of cases the kidneys
Blood gas, pH 4–8 hrly
will recover in 24–48 hr
Blood cultures, CRP
Glucose 4-hrly Supportive
Calcium, phosphate, magnesium, Assess fluid balance when problem
albumin recognised
Blood count (film and platelets) Signs of
Typical biochemical changes in acute depletion/hypovolaemia
renal failure (ARF) Cold peripheries
Increased urea, creatinine, K+, PO42- Delayed capillary refill
Reduced Na+, Ca2+, HCO -, pH 3 Tachycardic
Oliguric (<1 mL/kg/hr) or anuric
Imaging
If umbilical artery catheter (UAC) in Signs of overload
place, abdominal X-ray to check position Tachypnoeic
confirm UAC tip does not sit at L1 Oedema
Renal ultrasound scan Excessive weight gain
to detect congenital causes, post-renal Raised blood pressure
causes, pyelonephritis and renal vein Gallop rhythm
thrombosis
Hepatomegaly
TREAMENT
Fluid balance
Correct underlying cause If baby hypovolaemic/hypotensive, it is
Surgical approach to uropathy unless important to correct this before
prognosis hopeless (e.g. Potter’s instituting fluid restriction (see above)
syndrome) Strictly monitor all intake and output
Correct hypovolaemia, but avoid over- Restrict fluid intake to minimal
hydration in established renal failure maintenance fluids
sodium chloride 0.9% 10–20 mL/kg IV Calculate maintenance fluid:
if blood loss known or suspected, give maintenance fluid = insensible losses
10–20 mL/kg packed red cells + urine output + GIT losses
If hypotensive in absence of fluid insensible losses:
depletion: <1500 g (at birth) = 50–80 mL/kg/day
start inotrope infusion: (see >1500 g (at birth) = 15–35 mL/kg/day
Hypotension guideline) for babies in well-humidified incubator
Open duct in duct-dependent or receiving humidified respiratory
circulation in congenital heart disease support, use lower figure
(see Cardiovascular guidelines) Replace maintenance fluid as
Antibiotics for sepsis glucose10–20% (electrolyte-free)
Stop all nephrotoxic drugs (e.g. Electrolytes will be required if
aminoglycosides, vancomycin, electrolyte losses ongoing (e.g.
furosemide) if possible diarrhoea, fistula)
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Weigh twice daily MONITORING
best guide to change in hydration is Most useful variable is urine output
change in body weight
In newborn renal failure, anuria/oliguria
stable weight indicates overhydration is the normal situation and increasing
and need to reduce fluid intake further urine output indicates recovery
aim to achieve 1% loss of body weight Creatinine estimation is often
daily misleading in first few days:
Hyperkalaemia in utero, creatinine is cleared by the
placenta
See Hyperkalaemia guideline
after delivery, creatinine production by
Acidosis muscles is not stable and can be
Monitor pH 8-hrly influenced heavily by muscle damage
resulting from delivery/hypoxia/sepsis
if metabolic acidosis is present with
pH <7.2, give sodium bicarbonate after 48–72 hr, it can be used, but the
trend is much more valuable than the
Hyponatraemia absolute concentration
Low sodium is more likely to indicate Urea estimation is misleading
fluid overload than a deficit in body it is influenced by tissue breakdown
sodium (e.g. bruises/swallowed blood)
Unless evidence of dehydration, conversely, little is produced when
treatment should be fluid restriction protein intake is compromised
with maintenance sodium intake of
2–3 mmol/kg/day CONCLUSION
If severe (Na <120 mmol/L) and In the newborn baby, the vast majority of
associated with neurological cases of renal failure will recover if the
symptoms, such as seizures: underlying cause is addressed and
can use hypertonic saline (sodium supportive management provided to
chloride 3%) 4 mL/kg over a minimum maintain fluid and electrolyte balance
of 15 min; check serum sodium until recovery takes place, normally over
immediately after completion of 24–48 hr. If there is no improvement,
infusion discuss with paediatric nephrologist
If baby still fitting, dose can be
repeated after assessing serum
sodium concentration
During recovery phase, babies rarely
become polyuric, when sodium chloride
0.45% is typically required, although
this will depend on a measurement of
urinary sodium concentration
Dialysis
Hardly ever used in this population
because of technical difficulty and poor
prognosis
only applicable to term babies with a
treatable renal problem
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RESUSCITATION • 1/6
Check equipment daily, and before CHECK AIRWAY
resuscitation
For baby to breathe effectively,
Follow Resuscitation Council UK
Guidelines airway must be open
https://www.resus.org.uk/resuscitation- To open airway, place baby supine
guidelines/ with head in ‘neutral position’
CORD CLAMPING If very floppy, give chin support or jaw
Uncompromised term and preterm thrust while maintaining the neutral
infants delay cord clamping for at least position
1 min from complete delivery of baby
IMMEDIATE TREATMENT
Stripping (milking) of the cord is not
recommended Airway
If immediate resuscitation is required, Keep head in neutral position
clamp cord as soon as possible Use T-piece and soft round face mask,
extending from nasal bridge to chin
DRY AND COVER
Give 5 inflation breaths, sustaining
≥32 weeks’ gestation, dry baby,
inflation pressure (Table 1) for 2–3 sec
remove wet towels and cover baby
for each breath
with dry towels
Give PEEP of 5 cm H2O
<32 weeks’ gestation, do not dry body
but place baby in plastic bag feet first, Inflation breaths:
dry head only and put on hat term start in air
Aim to maintain body temperature preterm use low oxygen concentration
36.5ºC–37.5ºC (unless decision taken (≤30%)
to start therapeutic hypothermia)
Look for chest movement
Preterm <32 weeks’ gestation may
require additional interventions to Table 1: Inflation pressure (avoid using
maintain target temperature: pressure higher than recommended)
warmed humidified respiratory gases
Term baby 30 cm of water
thermal mattress alone
increased room temperature (≥26ºC) Preterm baby 20–25 cm of water
plus plastic wrapping of head and
body plus thermal mattress No chest movement
ASSESS Ask yourself:
Assess colour, tone, breathing and Is head in neutral position?
heart rate Is a jaw thrust required?
If baby very floppy and heart rate slow, Do you need a second person to help
assist breathing immediately with airway to perform a jaw thrust?
Is there an obstruction and do you
Reassess heart rate, breathing and
need to look with a laryngoscope and
chest movement every 30 sec
suck with a large-bore device?
throughout resuscitation process
If help required, request immediately
If baby not breathing adequately by
90 sec, assist breathing
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Consider placing oropharyngeal if not breathing adequately give 5
(Guedel) airway under direct vision inflation breaths, preferably using air
using laryngoscope at pressures in Table 1
Is inflation time long enough? Heart rate should rapidly increase as
if no chest movement occurs after oxygenated blood reaches heart
alternative airway procedures above
Do not move onto ventilation breaths
have been tried (volume given is a
unless you have a heart rate response
function of time and pressure), a larger
OR you have seen chest movement
volume can be delivered if necessary
by inflating for a longer time (3–4 sec)
Review assessment after
Attach saturation monitor to right hand
– see Saturation monitoring for inflation breaths
guidance on SpO2 targets Is there a rise in heart rate?
Is there chest movement with the
Endotracheal intubation breaths you are giving?
Nasal CPAP rather than routine intubation If no spontaneous breathing provided
may be used to provide initial respiratory the heart rate has increased and chest
support of all spontaneously breathing movement has been obtained, perform
preterm infants with respiratory distress 30 sec of ventilation breaths, given
Indications at a rate of 30 breaths/min (1 sec
inspiration)
Severe hypoxia (e.g. terminal apnoea
or fresh stillbirth) If baby is floppy with slow heart rate
and there is chest movement, start
Stabilisation of airway
cardiac compressions with ventilation
Congenital diaphragmatic hernia breaths immediately after inflation
breaths
Safe insertion of endotracheal tube
requires skill and experience Increase inspired oxygen
concentration every 30 sec by 30%
If you cannot insert a tracheal tube
e.g. 30–60–90% depending on
within 30 sec, revert to mask
response – see Saturation chart
ventilation
Capnography can help to assess Chest compression
endotracheal tube placement Use if heart rate approximately
<60 beats/min (do not try to count
Breathing accurately as this will waste time)
Most babies have a good heart rate Start chest compression only after
after birth and establish breathing by
successful inflation of lungs
90 sec
Table 2: Outcome after 30 sec of ventilation breaths

Heart rate Breathing Action
Increases Not started breathing Provide 30–40 breaths/min
Where available, use PEEP at 5 cm
water with T-piece system
<60 Obvious chest Start chest compressions (see
movement overleaf)
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Figure 1
Figure 2
Pictures taken from NLS manual and Resuscitation Council (UK) and reproduced with their permission
Ideal hold (figure 1/figure 2) Action

Circle chest with both hands so that Compress chest quickly and firmly to
thumbs can press on the sternum just reduce the antero-posterior diameter
below an imaginary line joining the of the chest by about one-third,
nipples with fingers over baby’s spine followed by full re-expansion to allow
ventricles to refill
Alternative hold
remember to relax grip on the chest
(less effective) during IPPV, and feel for chest
Compress lower sternum with fingers movement during ventilation breaths,
while supporting baby’s back. The as it is easy to lose neutral position
alternative hand position for cardiac when cardiac compressions are started
compressions can be used when
access to the umbilicus for UVC Co-ordinate compression and
catheterisation is required, as hands ventilation to avoid competition.
around the chest may be awkward Aim for 3:1 ratio of compressions
to ventilations and 90 compressions
and 30 breaths (120 ‘events’) per min
Issue 6
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Blood If mother has been given pethidine
within 2–4 hr of delivery, give IM
If there is evidence of fetal haemorrhage
naloxone:
and hypovolaemia, consider giving O
negative emergency blood 100 microgram (0.25 mL) for small
preterm babies
Resuscitation drugs 200 microgram (0.5 mL) for all other
Always ask about drugs taken recently babies
by, or given to mother
Give drugs only if there is an
WHEN TO STOP
undetectable or slow heartbeat despite If no sign of life after 10 min, outlook is
effective lung inflation and effective poor with few survivors, majority will
chest compression have cerebral palsy and learning
difficulties
Umbilical venous catheter (UVC) is the
preferred route for urgent venous Continue resuscitation until a senior
access member of staff advises stopping
Recommence cardiac compressions
and ventilation breaths ratio 3:1 after MONITORING
each drug administration and re-
assess after 30 sec
Saturation monitoring
Oxygen monitoring is activated when
If no heart rate increase, progress onto
next drug paediatrician/2nd pair of hands arrives.
In the meantime, the person initiating
Adrenaline 1:10,000 resuscitation carries out all the usual
steps in resuscitation
0.1 mL/kg (10 microgram/kg)
1:10,000 IV Do not stop resuscitation for a
saturation probe to be attached
Repeat dose 0.3 mL/kg
(30 microgram/kg) 1:10,000 IV Attach saturation probe to the right
hand and connect to the monitor once
Administration via endotracheal tube
use only when IV access not available; 5 inflation breaths have been given
dose is 0.5–1.0 mL/kg SpO2 should spontaneously improve
(50–100 microgram/kg) 1:10,000 as Table 3
Sodium bicarbonate 4.2% Table 3

1–2 mmol/kg (2–4 mL/kg) IV (never Time Acceptable pre-ductal
give via ET tube) (min) SpO2 (%)
Glucose 10% 2 60
2.5 mL/kg IV slowly over 5 min 3 70
4 80
Sodium chloride 0.9% 5 85
10 mL/kg IV 10 90
Naloxone
Give only after ventilation by mask or
ETT has been established with chest
movement seen and heart beat
>100 beats/min
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Heart rate monitoring Preterm deliveries
Best by listening with stethoscope Nasal CPAP rather than routine
Pulse-oximetry intubation may be used to provide
initial respiratory support of all
ECG monitoring, if available, can give spontaneously breathing preterm
rapid accurate and continuous heart babies with respiratory distress. Give
rate reading. However it does not PEEP at 5 cm H20 via mask ventilation
indicate the presence of a cardiac
with oxygen supplementation as
output and should not be the sole
appropriate on the resuscitaire
means of monitoring
continuing PEEP support on transfer to
Air to oxygen NICU
If inflation breaths produce a response If respiratory effort is poor, at any
and SpO2 monitoring is available with point, or baby’s condition deteriorates,
intubate and ventilate
a reliable trace, target saturations as in
Table 3 DOCUMENTATION
If inflation breaths have been Make accurate written record of facts
successful and chest movement seen (not opinions) as soon as possible
but colour/SpO2 (if available) not after the event
improved, increase oxygen to 30%
Record:
If no response, increase by increments
when you were called, by whom and
of 30% every 30 sec i.e.:
why
Term air: 30–60–90/100%
condition of baby on arrival
Preterm air: 30–60–90%
what you did and when you did it
If chest compressions are required
timing and detail of any response by
following chest movement with inflation
baby
breaths, increase oxygen to 90%
date and time of writing your entry
If SpO2 above levels in Table 3 or
>95% at 10 min of life, reduce oxygen a legible signature
Meconium deliveries COMMUNICATION

Inform parents what has happened
Do not attempt to suction nose and
(the facts)
mouth whilst head is on perineum
If thick particulate meconium and baby
not breathing inspect airway under
direct vision before delivering inflation
breaths but aim to inflate lungs within
1st min
Only intubate if suspected tracheal
obstruction, routine intubation is not
necessary
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Newborn life support algorithm
(Antenatal counselling)
Team briefing and equipment check
AT
Birth
Dry baby
Maintain normal temperature
Start clock or note time ALL
60
sec
Assess (tone), breathing, heart rate
If gasping or not breathing

TIMES
MAINTAIN TEMPERATURE
Open airway
Give 5 inflation breaths
Consider SpO2 ± ECG monitoring
ASK:
Re-assess
If no increase in heart rate, look for chest movement
during inflation
Acceptable
Pre-ductal SpO2
If chest not moving
Re-check head position 2 min 60%
Consider 2-person airway control and other 3 min 70%
airway manoeuvres 4 min 80%
Repeat inflation breaths 5 min 85%
SpO2 ± ECG monitoring 10 min 90%
Look for a response
(guided by oximetry if available)
No increase in heart rate

DO
Increase oxygen
Look for chest movement
When chest moving

If heart rate not detectable or very slow
(<60/min),start chest compressions YOU
3 compressions to each breath
NEED
Re-assess heart rate
Every 30 sec
If heart rate not detectable or very slow (<60/min),
consider venous access and drugs
HELP?
Update parents and debrief team
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RETINOPATHY OF PREMATURITY (ROP) • 1/2
INDICATIONS
All babies either ≤1500 g birth weight or <32 completed weeks’ gestation
PROCEDURE
When to screen
Indication When to start screen
Born <27 weeks’ gestation 30–31 weeks post-conceptual age
Born 27–32 weeks’ gestation or ≤1500 g 4–5 weeks postnatal age
If baby to be discharged before How to screen

screening due, bring eye examination
forward to be seen before discharge Arrange screening with ophthalmologist
How often to screen Preparation for screening

Prescribe eye drops for night before
Determined by ophthalmologist but
screening on drug chart
minimum recommendations are:
Give cyclopentolate 0.5% and
weekly for vessels ending in zone I or
phenylephrine 2.5%
posterior zone II; or any plus or pre-
plus disease; or any stage 3 disease in 1 drop into each eye. Give 2 doses,
any zone 15 min apart, 30 min before
examination
every 2 weeks in all other
circumstances until criteria for if in any doubt whether drop has gone
discontinuing screening are met (see into eye, give another drop immediately
below) (pupil must be fully dilated)
When to stop screening close eyelids after instillation of eye

drops, wipe off any excess
In babies without ROP, when
vascularisation has extended into zone Care during procedure
III, usually after 36 completed weeks A competent doctor/ANNP available
postnatal age during eye examinations
In babies with ROP, when the following Use comfort care techniques (nesting,
are seen on at least 2 separate swaddling +/- dummy)
occasions:
Consider oral sucrose – see Pain
lack of increase in severity assessment and management
partial resolution progressing toward guideline before examination
complete resolution (maximum 3 doses)
change in colour of the ridge from If eyelid speculum or indentor to be
salmon-pink to white used, topical anaesthesia
(proxymetacaine 0.5% eye drops)
transgression of vessels through administered before examination
demarcation line
Avoid bright light and cover
commencement of process of incubator/cot for 4–6 hr after
replacement of active ROP lesions by
examination
scar tissue
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RETINOPATHY OF PREMATURITY (ROP) • 2/2
AFTERCARE
Complete ad hoc ROP form in
BadgerNet documentation
Eye examination results and
recommendations for further screening
must be included in transfer letter,
together with ophthalmological status,
future recommendations for screening
intervals and out-patient follow-up
arrangements
Subsequent examinations must be
documented by ophthalmologist in
baby’s medical notes
Parent information
http://www.bliss.org.uk/factsheets
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SACRAL DIMPLE • 1/1
‘TYPICAL’ ‘ATYPICAL’
All the following Any of the following ‘Typical’ or
features present: features present ‘Atypical’ sacral
<5 mm in size >5 mm in size dimple with
Situated within Situated >2.5 cm abnormal
2.5 cm of anus from anus neurology2
In midline Not in midline
Normal neurology Cutaneous markers
present1
Ultrasound scan of
lumbosacral spine
Normal Abnormal
MRI scan of spine
Reassure parents Consider neurosurgical referral
Notes
1. Cutaneous markers e.g. pigmentation, hairy patch, abnormal skin texture, lipoma,
cyst, skin tag, haemangioma and swelling
2. Check for neurological signs in lower limbs – tone, deep tendon reflexes, presence
of patulous anus etc.
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SEIZURES • 1/4
Neonatal seizures are a manifestation of Focal (one extremity) or multifocal
neurological dysfunction. Seizures occur (several body parts)
in 1–3% of term newborn babies and in a Perform a detailed physical
greater proportion of preterm babies. examination and neurological
They can be subtle, clonic, myoclonic or assessment
tonic
RECOGNITION AND
Jitteriness: tremulous, jerky, stimulus-
ASSESSMENT provoked and ceasing with passive
Physical signs flexion
In addition to obvious convulsive Benign sleep myoclonus: focal or
movements, look for: generalised, myoclonic limb jerks that
Eyes: staring, blinking, horizontal do not involve face, occurring when
deviation the child is going to or waking up from
sleep; EEG normal; resolves by
Oral: mouthing, chewing, sucking,
4–6 months of age
tongue thrusting, lip smacking
Differentiation between jitteriness and
Limbs: boxing, cycling, pedalling
seizures
Autonomic: apnoea, tachycardia,
unstable blood pressure
Sign Jitteriness Seizure

Stimulus provoked Yes No
Predominant movement Rapid, oscillatory, tremor Clonic, tonic
Movements cease when limb is held Yes No
Conscious state Awake or asleep Altered
Eye deviation No Yes
Investigations Cranial ultrasound scan (to exclude

intracranial haemorrhage)
First line
EEG (to identify electrographic seizures
Blood glucose
and to monitor response to therapy).
Serum electrolytes including calcium, Consider cerebral function monitor
magnesium (CFM–aEEG)
FBC coagulation (if stroke suspected,
thrombophilia screen) Second line
Congenital infection screen (TORCH
Blood gas
screen)
Blood culture
MRI scan
CRP
Screen for maternal substance abuse
LFT
Serum acylcarnitine, biotinidase,
Serum ammonia, amino acids VLCFA, uric acid, sulphocysteine, total
Urine amino acids, organic acids and free homocysteine
Lumbar puncture (LP) – CSF CSF: lactate, glucose, glycine (paired
microscopy and culture (bacterial and with bloods, carried out before LP).
viral) Freeze spare sample
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SEIZURES • 2/4
Trial of pyridoxine treatment, preferably Maintenance and duration
during EEG monitoring, may be of treatment
diagnostic as well as therapeutic
Keep duration of treatment as short as
Contact metabolic team for further possible. This will depend on diagnosis
advice and the likelihood of recurrence
TREATMENT May not require maintenance therapy
after loading dose
Ensure ABC
If maintenance therapy is required:
Treat underlying cause
(hypoglycaemia, electrolyte monitor serum levels
abnormalities, infection) develop emergency seizure
hypoglycaemia: give glucose 10% management plan, including, if
2.5–5 mL/kg IV bolus, followed by required, a plan for buccal/intranasal
maintenance infusion. Wherever midazolam
possible, obtain ‘hypoglycaemia
screen’ (see Hypoglycaemia
Stopping treatment
guideline) before the administration of Consider:
glucose bolus seizures have ceased and neurological
hypocalcaemia (total Ca <1.7 mmol/L examination is normal or
or ionized Ca <0.64 mmol/L): give abnormal neurological examination
calcium gluconate 10% 0.5 mL/kg IV with normal EEG
over 5–10 min with ECG monitoring
(risk of tissue damage if extravasation) DISCHARGE AND FOLLOW-UP
hypomagnesaemia (<0.68 mmol/L): Discharge
give magnesium sulphate 100 mg/kg Ensure parents are provided with
IV or deep IM (also use for refractory appropriate discharge documentation
hypocalcaemic fit)
seizure emergency management plan
Pyridoxine (50–100 mg IV) can be
given to babies unresponsive to copy of discharge summary, including:
types of seizures,
conventional anticonvulsants or seek
medications/anticonvulsants
neurologist opinion
administered
Initiation of anticonvulsants
Follow-up
(for immediate management
follow Flowchart) Follow-up will depend on cause of
seizures and response to treatment
Start anticonvulsant drugs when:
Consider: specialist follow-up for
prolonged: >2–3 min babies discharged on anticonvulsant
frequent: >2–3/hr drugs or as per local unit guideline
disruption of ventilation and/or blood
Further information for
pressure
patients
Administration www.bcmj.org/sites/default/files/HN_
Intravenously to achieve rapid onset of Seizures-newborns.pdf
action and predictable blood levels
To maximum dosage before
introducing a second drug
Issue 6
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SEIZURES • 3/4
Anticonvulsant drug therapy schedule
Drug Loading dose Maintenance dose

Phenobarbital 20 mg/kg IV – administer over 2.5–5 mg/kg IV or oral once
20 min daily beginning 12–24 hr after
Optional additional doses of loading dose
10 mg/kg each until seizures
cease or total dose of
40 mg/kg can be given
Phenytoin 20 mg/kg IV – maximum 2.5–5 mg/kg IV or oral 12-hrly
infusion rate of 1 mg/kg/min Measure trough levels 48 hr
Monitor cardiac rate and after IV loading dose
rhythm and blood pressure for
hypotension
Midazolam Give 200 microgram/kg IV
(if no over 5 min followed by
response to continuous infusion
above drugs) 60–300 microgram/kg/hr
Reconstitution and dilution:
Dilute 15 mg/kg of midazolam
up to a total of 50 mL with
sodium chloride 0.9%, glucose
5% or glucose 10% 0.1 mL/hr
= 30 microgram/kg/hr
may cause significant
respiratory depression and
hypotension if injected rapidly,
or used in conjunction with
narcotics
Clonazepam 100 microgram/kg IV push
(if midazolam over 2 min
not available) repeat dose after 24 hr if
necessary
concurrent treatment with
phenytoin reduces the half-life
of clonazepam
Lidocaine 2 mg/kg IV over 10 min, then Exercise caution with phenytoin

(if above commence infusion as concurrent intravenous
medications 6 mg/kg/hr for 6 hr, then infusion of both these drugs has
ineffective) 4 mg/kg/hr for 12 hr, then a cardiac depressant action
2 mg/kg/hr for 12 hr
Issue 6
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SEIZURES • 4/4
Flowchart: Immediate management
Suspected seizures
Monitor
Heart rate, respiratory effort,
Assess ABC
SpO2, BP
Observe and document seizures
Correct cardiorespiratory
compromise Initiate ongoing communication with parent(s)
Clinical assessment
Perinatal history
Physical and neurological Is there an
examination underlying treatable
Investigate cause (hypoglycaemia,
Infective screen: electrolyte abnormalities,
FBC, CRP, blood culture CSF infection)
microscopy and culture including
herpes and enterovirus PCR Yes
No
Metabolic screen:
Blood glucose, Ca, Mg, urea and Treatment:
electrolytes, gas Loading dose phenobarbitone
Structural screen: 20 mg/kg IV
Cranial ultrasound scan, and/or Continue cardiorespiratory and
MRI scan, EEG blood pressure monitoring and
support as required
Consider stopping oral feeds
Treatment
Additional doses of 10 mg/kg
phenobarbital (up to
40mg/kg)
Treat underlying cause as indicated
If seizure activity continues
Phenytoin 20 mg/kg Continue
Consider No Yes monitoring
Seizure activity
Midazolam Consider stopping
ceased?
200 microgram/kg IV over anticonvulsants if:
5 min or seizures controlled
Clonazepam and neurology
100 microgram/kg IV normal or
Lidocaine 2 mg/kg and neurology
follow with IV infusion abnormal but EEG
Maintenance therapy normal
May be required for babies
with difficult to control or
prolonged seizures or Transfer as required
abnormal EEG Investigations as required
Arrange follow-up
Issue 6
289
SKIN BIOPSY FOR INBORN ERRORS OF
METABOLISM • 1/2
INDICATIONS SAMPLE REQUIREMENTS
Diagnosis of inherited metabolic At least 1 mm x 1 mm of skin (ideally
disorders 2 mm x 2 mm) from preferred site (e.g.
Wherever possible, discuss biopsy and inner side of forearm or posterior
arrangements with Department of aspect just above elbow)
Newborn Screening and Biochemical choose site carefully as even a small
Genetics, Birmingham Children's scar on coloured skin will be very
Hospital 0121 333 9942 obvious
this should include discussion about if post-mortem, take skin from over
which specimen bottles and transport scapula as this leaves less obvious
medium to use damage (see Post-mortem
confirm instructions for storage and specimens)
transport to laboratory with your local
PROCEDURE
laboratory
Consent
Skin biopsy is often collected for
Inform parents of reason for biopsy,
histological analysis. Contact your explain procedure and risks including:
local histopathology department for
advice on sample handling healing and scarring
possibility of contamination
EQUIPMENT poor growth
Forceps: fine non-bend watchmaker’s Obtain and record consent
or dissecting
Cotton wool balls and gallipots Technique
Dressing towel Maintain strict asepsis using
Plastic apron ‘no touch’ technique
Size 15 scalpel blade and no. 3 handle Wash hands and put on apron and
25 gauge needle (orange top) sterile gloves
23 gauge needle (blue top) Cleanse site
21 gauge needle (green top) for ensure cleaning fluid does not pool
drawing up lidocaine beneath baby
2 mL syringe Sedation if appropriate
Cleaning solution as per unit policy Inject lidocaine 1%, a little
Lidocaine 1% intradermally and remainder
subcutaneously to anaesthetise an
Bottles of culture medium
area 1.5 x 1 cm
Sterile gloves
Wait 5 min to ensure site
Steristrips anaesthetised
Dressings: Cleanse again, wipe off and dry using
1 small transparent dressing (e.g. sterile cotton wool or gauze swabs
Tegaderm/Opsite)
gauze swabs
elasticated cotton or other bandage
Issue 6
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SKIN BIOPSY FOR INBORN ERRORS OF
METABOLISM • 2/2
Method A POST-MORTEM SPECIMENS
Using fine forceps, grip a fold of skin In accordance with Human Tissue Act,
between blades so that a length of post-mortem samples must be taken
skin 3 mm x 2 mm protrudes only on licensed premises (or satellites
slice off in one stroke by running thereof). Check with your pathology
scalpel blade along upper edge of laboratory manager
forceps blades
Specimens taken after death present a
if skin too thick or oedematous to grip, high risk of infection and possible
proceed to Method B failure of culture. Follow strict aseptic
technique
Method B
Pierce skin with 23 or 21 gauge Take 2 biopsies from over scapula (as
needle and lift to produce ‘tenting’ this leaves less obvious damage), as
cut off tip of tent to produce a round soon as possible after death, ideally
‘O’ shaped piece of skin approximately before 48 hr have elapsed
2 mm Send sample to Inherited Metabolic
Place into culture medium bottle Disease Laboratory immediately, or
immediately (lid of bottle removed by store at +4ºC before dispatch for
assistant for shortest possible time) maximum of 12 hr, do not freeze
Complete request form with: Include clinical details, date and time
of sampling, and date and time of
clinical details
death on request form
date and time of sampling
Dressing wound
Although it may bleed freely, wound is
usually partial thickness and should
not require stitching
apply pressure to stanch bleeding
apply Steristrips and sterile dressing,
bandage if necessary
Remove bandage after a few hours,
but leave dressing for several days
Reassure parents that scar, when
visible, will be seen as a fine line
Transport
Once sample taken, send to Inherited
Metabolic Diseases Laboratory as
soon as possible
if unable to arrange transport
immediately, store sample at +4ºC for
maximum of 12 hr before despatch, do
not freeze sample
Issue 6
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SKIN CARE • 1/2
INTRODUCTION Check all substances that come into
contact with baby’s skin. Avoid using
Neonatal skin care is very important,
those with potential percutaneous
especially if baby is premature and/or in a
absorption
critical condition. Special emphasis is
placed on skin barrier properties, Protect areas of skin from friction
transcutaneous absorption, transepidermal injury with soft bedding and supporting
water loss and maintaining skin integrity blanket rolls
Use pressure-relief mattresses (e.g.
PURPOSE
Spenco)
To maintain integrity of the skin
Change nappy 4–6 hrly as condition
Prevent/minimise skin damage dictates. Wash nappy area with warm
Minimise water loss and heat loss water and dry well
Protect against absorption of toxic Nurse baby, especially extremely low
materials and drugs birth weight, in humidity of 60–90% to
protect skin, maintain body
Treat skin damage
temperature and prevent water loss
Ensure optimal healing of wounds
Do not use ECG leads on babies
RISK FACTORS <26 weeks’ gestation
Prematurity Disinfectants
Birth weight <1000 g Disinfect skin surfaces before invasive
Oedema procedures such as intravenous
Immobility cannulation, umbilical vessel
catheterisation, chest drain insertion,
Congenital skin problems intravenous puncture or heel pricks for
Invasive procedures laboratory samples
Use disinfectant pre-injection as per
Birth weight <1250 g
unit policy
Careful handling
Most serious injuries can occur in first
Adhesives
hours and days after birth when baby In all newborns, use adhesives
often requires intensive care monitoring sparingly to secure life support,
monitoring and other devices
Frequent bathing changes skin pH,
Wherever possible, use Duoderm under
disrupts protective acid mantle and is
adhesive tape. Duoderm adheres to
not recommended
skin without the use of adhesive and
will prevent epidermal stripping
Preventing/minimising risk of
skin injury/infection in all Remove adhesives carefully with warm
water on a cotton wool ball. Alcohol is
babies
very drying, is easily absorbed and
Ensure adequate hand hygiene to should be avoided
protect baby’s skin from cutaneous
infection e.g. Staphylococcus aureus
Change baby’s position 4–6 hrly as
condition dictates and place
intravenous lines and monitoring leads
away from skin
Issue 6
292
SKIN CARE • 2/2
CORD CARE Treat significant skin
Immediate excoriation
Clean cord and surrounding skin Identify and treat underlying cause
surface as needed with cleanser used Protect injured skin with thick application
for initial or routine bathing and rinse of barrier containing zinc oxide
thoroughly or cleanse with sterile water
Presence of red satellite
Clean umbilical cord with warm water
and cotton wool and keep dry
lesions/culture indicates
Candida albicans nappy rash
Ongoing Rash will become more intense if
Keep cord area clean and dry. If cord covered by occlusive ointments.
becomes soiled with urine or stool, Treatment includes antifungal ointments
cleanse area with water or cream and exposure to air and light
Educate staff and families about Do not use powders in treatment of
normal mechanism of cord healing nappy dermatitis
Teach parents or care-givers to keep Avoid use of antibiotic ointments
area clean and dry, avoid
contamination with urine and stool,
keep nappy folded away from area
and wash hands before handling
baby’s umbilical cord area
NAPPY DERMATITIS
To maintain optimal skin
environment
Change nappy frequently
Use nappy made from absorbent gel
materials
Use cotton wool and warm water.
Do not use commercially available
baby wipes
Encourage/support breastfeeding
throughout infancy
Prevention strategies for

babies at risk
Use petrolatum-based lubricants or
barriers containing zinc oxide
Avoid use of products not currently
recommended for newborns (e.g.
polymer barrier films)
Issue 6
293
STOMA MANAGEMENT
(GASTROINTESTINAL) • 1/4
TYPES OF STOMA Loop stoma
Split stoma and mucus fistula Formed by suturing a loop of bowel to
the abdominal wall and making an
Bowel is divided and both ends brought
opening into bowel, which remains in
out through abdominal wall separately
continuity
Proximal end is the functioning stoma
and the distal end is the mucus fistula
Operation note should make it clear
where the stoma and mucus fistula are
situated on the abdomen
Stoma and mucus fistula may
sometimes be fashioned side-by-side
without a skin bridge. The wound is
closed with dissolvable sutures
Fig. 3: Loop stoma (slightly prolapsed)
MANAGEMENT
Application of stoma bag
Before stoma starts working, fit an
appropriately sized stoma bag and
empty 4–6 hrly
In a split stoma and mucus fistula, fit
the stoma bag on the proximal stoma
only, where possible, and leave mucus
fistula exposed and dressed with a
paraffin gauze dressing (e.g. Jelonet)
Fig. 1: Split stoma and mucus fistula
or Vaseline® and non-sterile gauze
End stoma without mucus dressing
fistula Change bag every 1–3 days
Proximal bowel end is brought out (maximum) or if it leaks
through abdominal wall as stoma and Remove using a stoma adhesive
distal end is closed and left within the remover wipe
abdominal cavity Clean skin around stoma with warm tap
water and dry with non-sterile gauze
Monitoring
Examine baby’s abdomen and stoma
daily
Look for:
dehydration
wound infection or breakdown
Fig. 2: End stoma without mucus fistula
peri-stomal skin excoriation
granulation tissue formation
stomal bleeding
Issue 6
294
STOMA MANAGEMENT
discolouration of stoma or mucus Sodium supplements usually required
fistula in babies with a small bowel stoma
stomal prolapse or retraction until the stoma closed
stoma bag leakage If urinary sodium is <20 mmol/L or ratio
of concentration of urinary sodium to
rectal discharge potassium is <3:1, increase sodium
If stoma becomes dusky or black, call intake
the surgical team
NUTRITION
If skin surrounding the stoma is
excoriated, identify cause and treat Total parenteral nutrition
and no enteral feeds
Weight
Check surgical discharge letter and
Measure and record weight daily. operation notes for instructions on
Inadequate weight gain or weight loss starting enteral feeds
may be secondary to:
Introduce enteral feeds slowly and
insufficient calorie intake increase gradually in accordance with
malabsorption local unit feeding regimen
dehydration (high stoma output) Useful indicators of potential feed
electrolyte abnormalities (high stoma intolerance are:
output) vomiting and abdominal distension
Stoma effluent bile in nasogastric aspirates
Maintain a regularly updated fluid large nasogastric losses
balance chart and record: low stoma losses – indicating
fluid intake and stoma losses dysmotility/obstruction
colour and consistency of stoma high stoma losses – indicating

effluent malabsorption
reducing substances or fat globules in
Serum electrolytes the stool/stoma effluent
Measure at least every 2 days in the
first 7 post-operative days Combination of parenteral
nutrition and enteral feeds
Urinary electrolytes (sodium Increase enteral feeds gradually in
and potassium) accordance with local unit’s feeding
Monitoring is extremely important for regimen
nutrition and growth It is not possible to predict how much
Measure weekly enteral feed baby will be able to
Babies with stomata (especially small tolerate. As a general rule, the more
bowel stomata) are at risk of losing a distal the stoma, the better the
significant amount of sodium into the absorption of feeds
effluent. They will often fail to gain The amount of stoma effluent and
weight if total body sodium is depleted. presence/absence of reducing
Serum sodium is an unreliable indicator substances in the stoma effluent
of total body sodium should guide the advancement of
Urinary sodium and Na+:K+ ratio are enteral feeds
better indicators
Issue 6
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STOMA MANAGEMENT
Full enteral feeds Surgical team will review and advise if
recycling may start
Tolerance of enteral feeds can fluctuate
with time and babies with stomata are If baby not thriving, consider parenteral
at high risk of life-threatening nutrition (see Parenteral nutrition
dehydration and electrolyte guideline)
abnormalities as a result of
gastroenteritis. There should be a low Increasing enteral feeds in a baby with
threshold for readmission to hospital poor weight gain and a high output
and appropriate resuscitation stoma, will worsen the situation
COMPLICATIONS If none of the above measures are

effective, stop enteral feeds, start
High stoma output parenteral nutrition and consult surgical
Daily output >20 mL/kg/day in team to discuss surgical options
premature or low-birth-weight babies
and 30 mL/kg/day in term babies Stomal stenosis
Measure serum and urinary electrolytes May be present if:
Replace stoma losses (when stomal output reduces or stoma stops
>20 mL/kg/day) mL-for-mL using functioning
sodium chloride 0.9% with potassium stoma effluent becomes watery
chloride 10 mmol in 500 mL IV Call surgical team for advice
Consider either reducing or stopping
enteral feeds until losses decrease, Prolapse
liaison with surgical team is encouraged Call surgical team for advice. If stoma
Test stoma effluent for reducing is discoloured, emergency action is
substances and fat globules required
If reducing substances are positive or STOMA CLOSURE
fat globules present, consider reduction
Often aimed to be performed when
of enteral feed or changing type of
baby is well and thriving, which may
enteral feed after consultation with a
be after discharge from hospital
surgeon, specialist surgical outreach
nurse or dietitian Indications for early closure are:
Perform blood gas; (stoma effluent may failure to achieve full enteral feeds
be rich in bicarbonate and metabolic recurrent stomal prolapse with or
acidosis may be present; consider without stomal discolouration
sodium bicarbonate supplementation)
stomal stenosis
Mucus fistula high stoma output not responding to
If present, consider recycling of stoma measures outlined above
effluent (see Recycling stoma losses
via a mucus fistula guideline). Before
recycling, consult surgical team to
decide whether a contrast study
through the mucus fistula is required
If a contrast study advised, make
arrangements with surgical unit and
inform surgical team when the study
will take place
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STOMA MANAGEMENT
DISCHARGE PLANNING AND
PARENTAL TEACHING
Discharge when baby well, tolerating
feeds and thriving
It is the responsibility of the ward/unit
nurse to teach parents stoma care
When discharge planned, inform:
secretary of surgical consultant who
fashioned the stoma, to arrange out-
patient follow-up
stoma care specialist
Bernadette Reda – surgical outreach
service (if involved in care)
Who to call when you
need help?
Surgical team
Call team of consultant surgeon who
performed the surgery
In an emergency out-of-hours, contact
on-call surgical registrar
Stoma care specialist e.g. Gail
Fitzpatrick at BCH (mobile 07557
001653) for management of stoma-
related complications and parent and
staff training
Bernadette Reda, surgical outreach
service will visit neonatal units and
provide advice, support and training on
surgical management
Useful information
surgery
directions
Issue 6
297
SUDDEN UNEXPECTED POSTNATAL
COLLAPSE IN FIRST WEEK OF LIFE • 1/3
Based on recommendations from a Professional Group on
Sudden Unexpected Postnatal Collapse March 2011 (British
Association of Perinatal Medicine)
Sudden unexpected postnatal collapse Labour and birth

(SUPC) in apparently well term babies, in (from consultant obstetrician
the first week of life is rare or senior trainee)
Summary of BAPM SUPC Maternal medication
recommendations Markers of fetal wellbeing
Increased risk of congenital anomaly or scalp pH
metabolic disease
cord pH
Need comprehensive investigation to
determine underlying cause electronic fetal monitoring (EFM)
Involve interdisciplinary liaison to passage of meconium
maximise diagnostic yield requirement for resuscitation
Senior doctor to obtain detailed family
history and situational events Health of baby until collapse
Notify coroner of all babies who die Growth and feeding
from such collapse
Other information
For all babies who die, post-mortem to
be performed by a perinatal pathologist Circumstances surrounding collapse
Safeguarding issues must be who was present?
considered, if collapse happened after was baby feeding?
the baby left hospital
position of baby (from staff and family
Detailed multiprofessional case review present at time of collapse)
should follow investigation of
It is also important to collect information
unexpected baby death
from other agencies who may have
Information after the event been involved with the family e.g.
primary care, social care and police
Collect the following as soon as possible
after presentation Full resuscitation details
Parental medical history Investigations whilst baby

Full parental drug, alcohol and nicotine alive
history Carry out a full examination
Three-generation family tree noting egg Liaison with local and regional
donation, sperm donation (where laboratories is mandatory to ensure
available) optimal collection and timing of samples.
Use your judgment about which tests to
Obstetric history (from
prioritise to ensure optimal diagnostic
consultant obstetrician or yield with least intervention
senior trainee)
If baby sufficiently stable, consider
Infection transfer to a specialist unit for imaging
Fetal growth
Suspected fetal anomalies
Fetal movements
Liquor volume
Issue 6
298
Neonatal Cerebrospinal Surface Nasophyngeal Other
Issue 6
Urine Imaging
blood fluid swabs aspirate investigations
FBC Biochemistry Bacteriology Bacteriology Bacteriology Skeletal survey Ophthalmoscopy/
Coagulation Glucose (paired and virology Virology Cranial ultrasound Retcam

Blood gas with plasma scan Skin biopsy for
Toxicology
Renal and liver glucose) fibroblast culture
Organic acids MRI brain scan
biochemistry
Culture including orotic Renal/adrenal If unable to
Glucose exclude
Virology acid ultrasound scan
Lactate neuromuscular or
Calcium Lactate Amino acids Electrocardiogram mitochondrial
Magnesium Amino acids including Echocardiogram disorder, muscle
Ammonia including glycine, urinary biopsy
sulphocysteine
Beta- storage Electro-
hydroxybutyrate Retain urine encephalogram
Amino acids for storage
Genetics
Insulin assessment and
Free fatty acids clinical
Acyl carnitines photographs
profile
Urates
Uric acid
(British Association of Perinatal Medicine)
Cortisol (3
samples at
different times)
Culture
sudden unexpected postnatal collapse March 2011
Viral titres
Bloodspot for
cardiolipin analysis
Specific genetics:
Based on recommendations from a Professional group on
DNA
chromosomes
microarray
retained bloodspot
299
Based on recommendations from a Professional group on
sudden unexpected postnatal collapse March 2011
(British Association of Perinatal Medicine)
If there is suspicion that the event may virology
have been due to unrecognised
lactate
hypoventilation/apnoea, send DNA
sample for phox2b gene abnormalities amino acids including glycine, freeze
(commonly implicated in congenital and store
central hypoventilation syndrome) Skin biopsy (if possible locally) for
Consider testing for mutations and culture and storage of fibroblasts:
copy number variation in mecp2 gene. 3 x 2 mm full thickness using aseptic
This may present as newborn technique into culture or viral transport
encephalopathy and/or apnoeas and medium or gauze soaked in sodium
respiratory collapse chloride 0.9%. Send promptly to
cytogenetics laboratory (see Skin
Array-based comparative genomic biopsy guideline)
hybridisation is a useful investigation
(will replace conventional karyotyping Muscle biopsy (if locally possible) for
for detecting causative chromosomal electron microscopy, histopathology
deletions and duplications) and enzymology. Wrap in aluminium
foil, snap freeze and store at -70ºC.
Investigations before Contact metabolic physician or
post-mortem pathologist before sample collection
If it has not been possible to take If difficulty in obtaining necessary kit for
samples during life, take samples investigations, most labour wards have
(where feasible) while awaiting post- a ‘still birth kit’ which will contain much,
mortem to prevent degradation of if not all, of what is needed
material and loss of important
diagnostic information. Where possible, Safeguarding issues
discuss and agree baseline samples Must be considered in all cases of out
with a pathologist and, where indicated, of hospital collapses
a biochemist
The process of investigation for
Throat and nose swabs for bacterial unexpected child deaths sometimes
and viral culture needs following even if the baby survives
Blood culture This involves the rapid response team
Blood and urine for metabolic studies from the district who need to undertake
a home visit to gather additional
glucose, acylcarnitine, organic and information regarding the critical event
amino acids including orotic acid and
sulphocysteine, freeze urine for storage For documentation and investigation
Blood for DNA, chromosomes and check list for SUPC, use appendices
dried bloodspots on several cards from full BAPM guidelines –
www.bapm.org/publications/documents/gu
CSF obtained by lumbar puncture or
idelines/SUPC_Booklet.pdf
ventricular tap – biochemistry
glucose
culture
Issue 6
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SURFACTANT REPLACEMENT THERAPY • 1/2
Early administration of natural Early rescue treatment
surfactant decreases the risk of acute Babies born <26 weeks’
pulmonary injury and neonatal mortality gestation
Early CPAP and selective administration If intubation for respiratory distress
of surfactant is preferable to routine required and need FiO2 >0.30, give
intubation and prophylactic surfactant surfactant
Natural surfactant preparations are Babies born ≥26 weeks’
superior to protein-free synthetic
gestation
preparations containing only
If requiring intubation and needing FiO2
phospholipids for reducing mortality
and air leaks >0.40, give surfactant
Poractant alfa at 200 mg/kg shows Other babies that can be
survival advantage compared to considered for surfactant
beractant or poractant alpha in a dose therapy (after discussion with
of 100 mg/kg consultant)
Multiple rescue doses result in greater Ventilated babies with meconium
improvements in oxygenation and aspiration syndrome (may need repeat
ventilatory requirements, a decreased dose after 6–8 hr)
risk of pneumothorax and a trend Term babies with pneumonia and stiff
toward improved survival lungs
Use of INSURE
EQUIPMENT
(Intubate–Surfactant–Extubate to
CPAP) technique for early surfactant Natural surfactant, Poractant alfa
administration reduces the need for (Curosurf®) 200 mg/kg (2.5 mL/kg)
ventilation and improves survival round to the nearest whole vial
(prophylaxis and rescue doses can
INDICATIONS differ, check dose with local policy) or
Prophylaxis (administration beractant (Survanta®) 100 mg/kg
(4 mL/kg)
within 15 min of birth)
Sterile gloves
Babies born <28 weeks’
TrachCare Mac catheter [do not cut
gestation
nasogastric tube (NGT)]
Routine intubation of these babies
solely for the purpose of PROCEDURE
administration of surfactant is not Preparation
necessary, and a policy of early
Calculate dose of surfactant required
CPAP with selective surfactant
and warm to room temperature
administration is preferred
Ensure correct endotracheal tube
If requiring intubation for respiratory
(ETT) position
support during resuscitation or whose
mothers have not had antenatal check ETT length at lips
steroids, give surfactant as prophylaxis listen for bilateral air entry and look for
Otherwise, institute early CPAP and chest movement
administer surfactant selectively as per if in doubt, ensure ETT in trachea
Early rescue treatment using laryngoscope and adjust to
ensure bilateral equal air entry
chest X-ray not necessary before first
dose
Issue 6
301
SURFACTANT REPLACEMENT THERAPY • 2/2
Refer to manufacturer’s guidelines and DOCUMENTATION
Neonatal Formulary
For every dose given, document in
Invert surfactant vial gently several case notes:
times, without shaking, to re-suspend
indication for surfactant use
the material
time of administration
Draw up required dose
dose given
Administer via TrachCare Mac device
– note: it is no longer acceptable to condition of baby pre-administration,
administer surfactant via an NGT as including measurement of blood gas
this contravenes European conformity unless on labour ward when SpO2
(CE marking) and NPSA guidance should be noted
response to surfactant, including
Instillation measurement of post-administration
With baby supine, instil prescribed blood gas and SpO2
dose down tracheal tube; administer
beractant in 2–3 aliquots reasons why second dose not given, if
applicable
Wait for recovery of air entry/chest
movement and oxygenation between reason(s) for giving third dose if
boluses administered
Prescribe surfactant on drug chart
Post-instillation care
Do not suction ETT for 8 hr (suction is Information for parents
contraindicated in Surfactant- http://www.bliss.org.uk/factsheets
deficiency Disease for 48 hr)
Be ready to adjust ventilator/oxygen
settings in response to changes in
chest movement, tidal volume and
oxygen saturation. Use of volume-
target ventilation can facilitate
responsiveness to rapid changes in
lung compliance following surfactant
instillation. Be ready to reduce FiO2
soon after administration of surfactant
to avoid hyperoxia
Take an arterial/capillary blood gas
within 30 min
If baby remains ventilated at FiO2 >0.3
with a mean airway pressure of
>7 cm H2O, give further dose of
surfactant 6–12 hr after the first dose
Third dose should be given only at the
request of the attending consultant
Issue 6
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SYPHILIS • 1/3
BABIES BORN TO MOTHERS WITH POSITIVE SEROLOGY
INTRODUCTION Ocular or neurological involvement

If untreated, 40% of early syphilis will Haemolysis
result in stillbirth/spontaneous Thrombocytopenia
abortion/perinatal loss. Risk is
dependent upon maternal stage of ASSESSMENT OF MATERNAL
infection and spirochete blood load TREATMENT
Untreated babies >2 yr may present Maternal treatment is adequate if:
with: treated with full course of penicillin: 3
CNS (VIII nerve deafness) injections over 3 week >4 week
bone and joint (frontal bossing, saddle before delivery AND there is a
nose and Clutton joints) documented four-fold decrease in
VDRL titres
teeth (Hutchinson incisors and
mulberry molars) INVESTIGATIONS
eye (interstitial keratitis 5–20 yr) Diagnostic serology
involvement
Baby may have positive serology
RECOGNITION AND depending on timing of maternal infection,
therefore mother must be screened
ASSESSMENT
simultaneously for titre comparison.
Clarify maternal treatment and post- DO NOT USE CORD BLOOD
treatment titres if possible
Discuss management plan with Non-treponemal tests
parents before birth if possible Venereal disease research laboratory
All parents are seen by specialist (VDRL) test:
midwife antenatally to discuss 4 x decrease in titre = effective
management of baby treatment
Follow Management flowchart 4 x increase after treatment = relapse
or re-infection
CLINICAL FEATURES
May be false negative in babies who
Clinical evidence of early acquire congenital syphilis in late
congenital syphilis pregnancy or have extremely high
Rash antibody titres before dilution (prozone
phenomenon)
Infectious snuffles (copious nasal
secretions) May be false positive in viral
infections (Epstein-Barr, varicella
Haemorrhagic rhinitis
zoster, hepatitis, measles),
Osteochondritis tuberculosis, endocarditis, malaria,
Periostitis lymphoma, connective tissue disease,
pregnancy, intravenous drug use
Pseudo-paralysis
Mucocutaneous patches Treponemal tests
Peri-oral fissures IgM
Hepatosplenomegaly Treponema. pallidum particle
Lymphadenopthy agglutination test (TPPA)
Oedema Treponema. pallidum
haemagglutination assay (TPHA)
Glomerulonephritis
Fluorescent treponemal antibody
Issue 6
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SYPHILIS • 2/3
absorption test (FTA-ABS) TREATMENT
Tests may also be positive in other Possible congenital syphilis:
spirochetal disease e.g. yaws, pinta, benzylpenicillin 50 mg/kg IV 12-hrly for
leptospirosis, and Lyme disease. 7 days and 8-hrly for next 3 days
There is poor correlation of titres with
If delay in results, offer single dose IM
disease activity benzathine penicillin while awaiting
Interpretation of syphilis results
serology of baby 50,000 units/kg as a single dose by IM
injection within 24 hr of decision to
Syphilis serology is positive in baby if:
treat. Reconstitute vial with the solvent
anti-treponemal antibody IgM positive provided (WFI) to produce a solution
baby’s TPPA is four-times greater than containing 300,000 units/mL
repeated maternal TPPA titre at delivery Example: 2 kg baby: Dose = 50,000
units x 2 = 100,000 units – volume to
Example of positive TPPA
inject = 100,000/300,000 = 0.33 mL. If
Maternal titres 1:1040 >24 hr of therapy is missed, restart
Baby serology 1:4160 (i.e. baby four- entire course
times greater than mother)
FOLLOW-UP
Baby’s VDRL titre is four-times greater
than repeated maternal VDRL titre at If IgM test is negative, other tests are
delivery reactive with titres <four-fold higher
than mother’s with no signs of
Example of positive VDRL congenital syphilis, repeat reactive
Maternal titres 1:64 tests at 3, 6 and 12 months or until all
tests (VDRL, TPPA and IgM) become
Baby serology 1:256 (i.e. baby four- negative (usually by 6 months)
times greater than mother)
If baby’s serum negative on screening,
CSF and no signs of congenital infection,
CSF investigations require at least no further testing is necessary
0.5 mL of CSF. A CSF is classed as If any doubt regarding test
positive if: interpretation/follow-up, discuss with
increased WCC and protein local expert in neonatal
infection/microbiology
reactive TPPA and VDRL (a negative
VDRL does not exclude neurosyphillis) If Neurosyphilis, CSF at 6 months
Remember to suspect other causes of
elevated values when evaluating baby
for congenital syphilis
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SYPHILIS • 3/3
Management flowchart: Baby born to mother with positive syphilis serology
(IgM/VDRL or TPPA reactive)
Clarify maternal treatment and post-treatment titres if possible

Discuss management plan with parents before birth if possible
Clinical examination of baby

Assess adequacy of maternal treatment (see Assessment of maternal treatment)
Baby syphilis serology IgM, VDRL+TPPA (paired sample with mother must be taken and sent
at same time)
Physical examination abnormal If examination is normal, mother Physical

OR has had adequate treatment but examination
Inadequate maternal treatment no documented reduction in normal
(including non-penicillin regimen) titres post treatment AND
OR Negative baby
Results from paired samples show serology (VDRL,
positive baby serology (see If results expected quickly, TPPA and IgM
send child home and chase negative)
associated text)
results of paired serology AND
Warn parents baby may have Adequate maternal
Possible congenital syphilis to return for treatment if treatment
serology positive
Evaluate: (including follow-
If delay in results, offer single up testing to
FBC and differential
dose IM benzathine penicillin* confirm successful
CSF cell count, protein, VDRL and while awaiting results
TPPA treatment)
Other tests as clinically indicated:
chest X-ray, X-ray femur + Serology (see - (IgM negative,
LFT associated text) VDRL and/or TPPA
cranial ultrasound <4 x paired maternal
ophthalmology review titres)
auditory brain stem responses
Congenital syphilis
unlikely
Treat
No treatment
Benzylpenicillin 50 mg/kg IV 12-hrly for
7 days and 8-hrly for next 3 days
Follow-up Discharge
Clinic review at 3, 6 and 12 months If any uncertainty about
Repeat serology at 3, 6 and 12 months or until completeness of antenatal follow-
VDRL, TPPA and IgM all non-reactive up or neonatal serology, further
If Neurosyphilis, CSF at 6 months review with serology
recommended at 3 and 6 months
*Benzathine penicillin:
Dose: 50,000 units/kg as a single dose by IM injection within 24 hr of decision to treat
Reconstitution: reconstitute vial with the solvent provided (WFI) to produce a solution containing
300,000 units/mL
Example: 2 kg baby: Dose = 50,000 units x 2 = 100,000 units – volume to inject =
100,000/300,000 = 0.33 mL
Issue 6
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THROMBOCYTOPENIA • 1/5
DEFINITION
Platelet count <150 x 109/L
mild (platelet count 100–150 x 109/L) and moderate (50–100 x 109/L)
thrombocytopenia occur frequently in preterm babies who are ill, and in those born
to women with pregnancy-induced hypertension (PIH)
severe thrombocytopenia (<50 x 109/L) is uncommon, particularly in apparently
healthy term babies and raises the possibility of neonatal allo-immune
thrombocytopenia (NAIT; see below)
ensure results are not spurious, if in doubt repeat venous sample
CAUSES
WELL ILL
Common Placental insufficiency Infection
Intrauterine growth retardation Necrotising enterocolitis (NEC)
(IUGR) Disseminated intravascular
Maternal diabetes coagulation (DIC)
Immune mediated Hypoxic Ischaemic
Allo-immune thrombocytopenia Encephalopathy
(NAIT) Congenital infections
Auto-immune (maternal ITP, Thrombosis (renal, aortic)
SLE) Congenital leukaemia or
Trisomies (13, 18, 21) neuroblastoma
Rare Inherited disorders Metabolic disorders (propionic
Thrombocytopenia Absent Radii and methymalonic acidemia)
(TAR) syndrome
Congenital amegakaryocytic
thrombocytopenia (CAMT)
Cavernous haemangioma
(Kasabach-Merritt syndrome)
Severe thrombocytopenia in an otherwise healthy term newborn baby is
NAIT until proved otherwise
INVESTIGATIONS Look for presence of active bleeding or
Evaluation of early-onset (<72 hr after visible petechiae
birth) thrombocytopenia (see Flowchart) If features suggestive of congenital
in preterm babies with early-onset mild- infection (e.g. abnormal LFTs, rashes,
to-moderate thrombocytopenia in whom maternal history etc.) or if persistent or
there is good evidence of placental unexplained thrombocytopenia, perform
insufficiency, further investigations are congenital infection i.e. CMV and
not warranted unless platelet count does toxoplasma serology; check maternal
not recover within 10–14 days status for syphilis, rubella and HIV;
herpes simplex and enteroviral screen
in preterm babies without placental
insufficiency, investigate first for sepsis Obstetric history, particularly maternal
platelet count, drugs, pre-eclampsia.
in term babies, investigate for sepsis
Family history of bleeding disorders
and NAIT
Careful examination, include other
If severe thrombocytopenia, perform
associated features (e.g. trisomies and
clotting screen
inherited syndromes)
Issue 6
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Flowchart
Early thrombocytopenia
(platelet count <150 x 109/L)
Platelet count 50–150 x 109/L Platelet count

<50 x 109/L, or active bleeding
with platelet count 50–100 x 109/L
Maternal PIH or
placental insufficiency
NO
YES
Check coagulation
Baby Infection
Baby unwell workup/antibiotics
clinically well
Check coagulation
Consider antibiotics
Exclude sepsis and/or DIC
Monitor platelet
count closely Sepsis likely Sepsis
and platelets unlikely and
normalised platelets still
after low Exclude immune thrombocytopenia
treatment (NAIT, ITP, SLE)
Platelet count
at 10 days
No further Exclude congenital infections (CMV,

action toxo, check maternal status)
Diagnosis made?
≥150 x 109/L <150 x 109/L
YES NO
No further
action
No further Seek
evaluation specialist
advice
Evaluation of late onset thrombocytopenia

Thrombocytopenia presenting in baby after first 3 days of life, presume underlying
sepsis or NEC until proved otherwise
these babies are at significant risk of haemorrhage, though the benefit of platelet
transfusion is not clear-cut
Issue 6
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MANAGEMENT planned surgery, exchange transfusion
or invasive procedure (central line
General insertion, lumbar puncture, chest drain,
Avoid etc.)
Heel prick and IM injections, use platelet count falling and likely to fall
venepuncture and IV injections below 30
Invasive procedure (central line, lumbar NAIT if previously affected sibling with
puncture, chest drain etc). If any of intracranial bleed
above are unavoidable: PDA treated with indomethacin or
discuss with on-call consultant ibuprofen
give platelet transfusion if platelet count Platelet count <100 x 109/L
<50 x 109/L before the procedure (if If major bleeding or major surgery (e.g.
semi-elective e.g. LP, central lines) OR neurosurgery), give platelet transfusion
during/soon after the procedure (if
emergency like chest drain) Type of platelets
give particular attention to haemostasis NAIT: HPA compatible platelets
wherever possible
Platelet transfusion
All others: blood group-compatible
Only available immediate and specific cytomegalovirus (CMV) negative
therapy for thrombocytopenia but carries
a risk of transfusion-related infections and Irradiation of platelets is not routinely
transfusion reactions and only after required but consider for babies with
discussion with senior definite or suspected immunodeficiency
or those who have undergone
Indications for platelet intrauterine transfusions
transfusion (term and
Volume of platelets
preterm babies)
10–20 mL/kg (10 mL/kg usually raise
Main objective is to prevent the platelet count by >50 x 109/L). Babies
consequences of severe
with suspected NAIT will require higher
thrombocytopenia, significant risk of
dose 20 mL/kg
acute intracerebral haemorrhage and
neuromorbidity ADMINISTRATION OF
Platelet count <30 x 109/L
PLATELETS
In otherwise well baby, including NAIT, Never administer platelets through an
if no evidence of bleeding and no family arterial line or UAC
history of intracranial haemorrhage
Use platelets as soon as they arrive on
Platelet count <50 x 109/L ward (ensure IV access before
In baby with: requesting platelets from blood bank)
clinical instability Keep platelets at room temperature
concurrent coagulopathy To minimise loss, draw contents of pack
birth weight <1000 g and age <1 week into 50 mL syringe through a special
platelet or fresh blood transfusion set
previous major bleeding e.g.
with a 170–200 micrometre filter and
intraventricular haemorrhage (IVH)
infuse, using a narrow bore extension
current minor bleeding (e.g. petechiae, set linked to IV line, primed with sodium
venepuncture oozing) chloride 0.9%
Issue 6
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Transfuse platelets over 30–60 min, Obtain blood from mother, baby and
mixing syringe from time to time to father for platelet typing and
avoid platelets settling down antibodies. Liaise with haematology
There is no need for routine use of department about appropriate samples
diuretic after platelet transfusion Arrange cranial ultrasound scan (see
Check platelet count within 12 hr after Cranial ultrasound scans guideline)
transfusion
Treatment
NEONATAL ALLO-IMMUNE In 30% of cases, maternal antibody
THROMBOCYTOPENIA (NAIT) may not be found and can be detected
later
This is analogous to Rhesus
haemolytic disease and is caused by Transfuse baby with suspected NAIT
transplacental passage of maternal with accredited HPA-1 antigen-
alloantibodies directed against fetal negative platelets if:
platelet antigens, inherited from father bleeding or
but absent in mother
platelet count <30 x 109/L
Majority caused by antibodies against
National Blood Transfusion Service
platelet antigens, HPA-1a (80%) and
has a pool of suitable donors, and
HPA-5b (10–15%)
platelets are available at short notice
NAIT can affect first pregnancy and from blood bank
has a 10% risk of severe intracranial
if accredited HPA-1a negative platelets
haemorrhage; 20% of survivors exhibit
not available, administer random donor
significant neuro-developmental
platelets
sequelae
Recognition Inform blood bank and consultant

haematologist as soon as NAIT
For HPA-1a antigen-negative women, suspected.
complete a neonatal alert form
Do not delay transfusion for
Petechiae, purpura, excessive bleeding investigations
and severe thrombocytopenia in an
otherwise healthy term newborn baby If thrombocytopenia severe (<50 x
indicate NAIT until proved otherwise 109/L), or haemorrhage persists
NAIT can also present with: despite transfusion of antigen-negative
platelets, administer intravenous
fetal intracranial haemorrhage or human immunoglobulin (IVIG)
unexplained hydrocephalus 1 g/kg/day once daily (give one full
postnatal intracranial haemorrhage in 2.5 g vial maximum for babies
term baby ≥2.5 kg) for 1-3 days (may require
additional doses 2–4 weeks later)
If NAIT suspected, involve consultant
neonatologist immediately Aim to keep platelet count >30 x 109/L
for first week of life, or as long as
active bleeding continues
Assessment
Report newly diagnosed babies with
Check baby’s platelet count daily until
NAIT to fetal medicine consultant for
>100 x 109/L
counselling for future pregnancies
Check mother’s platelet count (may
already be in maternal healthcare
record)
Issue 6
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NEONATAL AUTO-IMMUNE
THROMBOCYTOPENIA
Clinical features
Caused by transplacental passage of
autoantibodies in women with ITP or
SLE, and affecting about 10% of
babies born to such women
Severity generally related to severity of
maternal disease
Risk of intracranial haemorrhage in
baby <1%
Management
Report all women with
thrombocytopenia and those
splenectomised through Neonatal Alert
System, and instigate plan of
management
Send cord blood for platelet count
Check baby’s platelet count 24 hr later,
irrespective of cord blood result
If baby thrombocytopenic, check
platelet count daily for first 3–4 days or
until >100 x 109/L
If platelet count <30 x 109/L, whether
bleeding or not, treat with IVIG (dose
as in NAIT) +/- steroids
Discharge baby when platelet count
>100 x 109/L
For babies requiring IVIG, recheck
platelet count 2 weeks later. A few may
require another course of IVIG at this
time because of persistence of
maternal antibodies
Issue 6
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THYROID DISEASE
(MANAGEMENT OF BABIES BORN TO
MOTHERS WITH THYROID DISEASE) • 1/3
RECOGNITION AND Head and neck
ASSESSMENT goitre, periorbital oedema, exophthalmos
Obstetric team should inform neonatal Central nervous system (CNS)
team after delivery of a baby with
irritability, jitteriness, poor sleeping,
maternal history of hyperthyroidism microcephaly
(Graves’ disease) or hypothyroidism
Cardiovascular system (CVS)
MATERNAL tachycardia, arrhythmias, flushing,
HYPERTHYROIDISM sweating, hypertension
Common Gastrointestinal (GI)
Maternal Graves’ disease (autoimmune diarrhoea, vomiting, excess weight
hyperthyroidism) loss, hepatosplenomegaly
IgG thyroid stimulating antibodies cross Others
from mother with Graves’ disease to fetus
towards the end of 12.5% of pregnancies bruising, petechiae due to
thrombocytopenia, jaundice
half-life of thyroid stimulating antibodies
is approximately 12 days and resolution It is not sufficient to judge risk based
of fetal thyrotoxicosis corresponds to on current maternal thyroid function as
their degradation over 3–12 weeks mothers on antithyroid medication or
Rare who have received thyroid ablative
therapy (surgery or radioactive iodine)
Maternal Hashimoto’s thyroiditis may be euthyroid or hypothyroid yet
producing thyroid stimulating antibodies still have high thyroid antibody titres
Activating mutations of TSH receptor
(family history of hyperthyroidism in Management
first degree relatives)
Follow Management flowchart
Babies at high risk Examine high risk babies after delivery
Mother has high levels of thyroid note maternal antibody titres and
antibodies (Thyroid Stimulating evidence of fetal thyrotoxicosis
Immunoglobulin, TSI or Thyroid (tachycardia and goitre)
Receptor Antibody, TRAb) – refer to
maternal healthcare record Observe baby for 48 hr and take
bloods for FT4 and TSH at 48 hr
Maternal thyroid antibody status unknown
Mother clinically hyperthyroid or receiving if well with normal TFTs, (see
antithyroid drugs in third trimester Hypothyroidism guideline for normal
values) discharge
Mother previously treated with
radioactive iodine or surgery or with Explain signs of hyperthyroidism to
previously affected infants parents and advise to seek medical
advice if concerned
Evidence of fetal hyperthyroidism
Arrange review at 10–14 days to
Family history of TSH receptor mutation
repeat TFTs and clinical assessment
Clinical features of fetal if clinically or biochemically
hyperthyroidism hyperthyroid, discuss with paediatric
Usually present by 24–48 hr of age but endocrine team
can be delayed up to 10 days. Disorder
is self-limiting over 3–12 weeks
Issue 6
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THYROID DISEASE
Flowchart: Management of babies at risk for congenital hyperthyroidism
Examine high-risk babies soon after delivery

Note maternal antibody titres and evidence of fetal
thyrotoxicosis (tachycardia and goitre)
Observe baby for 48 hr and take bloods

for FT4 and TSH at 48 hr
Add TSI if mother has not had TSI/TRAb levels
tested in pregnancy
If well with normal TFTs, discharge
Explain signs of hyperthyroidism to parents
and advise to seek medical advice if concerned
Inform GP
If clinically or biochemically hyperthyroid, discuss
with paediatric endocrine team
If high risk*, repeat FT4, TSH and examination

age 2–7 days
In all babies, repeat FT4, TSH and examination

age 10–14 days
Result of thyroid function from any of the above
Normal Hypothyroid Hyperthyroid

No treatment Repeat FT4 and TSH If clinically or biochemically
If confirmed, treat hyperthyroid, discuss with paediatric
with thyroxine endocrine team
Consider treatment with
propylthiouracil/carbimozole
+/– iodide
+/– propranolol
* see text
Issue 6
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THYROID DISEASE
MATERNAL HYPOTHYROIDISM
Physiology Management
After onset of fetal thyroid secretion at Hashimoto’s thyroiditis (autoimmune)
mid-gestation, maternal transfer of T4 occurs in approximately 2.5% of
continues to contribute to fetal serum women and is associated with thyroid
T4, protecting neurodevelopment until inhibiting or, rarely, thyroid stimulating
birth. Prompt treatment of maternal antibodies. Baby may develop transient
hypothyroidism should mitigate hypo or, rarely, hyperthyroidism. These
negative effects on baby’s babies should be reviewed at 10-14
neurodevelopment days and have their T4/TSH checked
Babies born to mothers with congenital
Risks associated with
hypothyroidism (aplasia/hypoplasia)
maternal hypothyroidism and treated with levothyroxine do not
Preterm delivery require routine thyroid function testing
Intrauterine growth restriction (IUGR) Mothers who have been treated for
Postpartum bleeding Grave’s disease (surgery or radioactive
iodine) may be euthyroid or
Untreated severe hypothyroidism in
hypothyroid but may still have high
mother can lead to impaired brain
thyroid antibody. Treat as high risk for
development in baby
neonatal hyperthyroidism and follow
guideline for maternal hyperthyroidism
Breastfeeding
Encourage for all babies even if mother
currently taking carbimazole,
propylthiouracil or levothyroxine
Contraindication
Radioactive iodine treatment
Issue 6
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TRANSCUTANEOUS CO2 AND O2 • 1/3
(Adapted with permission, Guy’s and St Thomas’ NHS Trust
nursing guideline)
INTRODUCTION Probe placement and

In babies requiring assisted ventilation, application of fixation rings
it is essential to monitor arterial partial Preferred sites:
pressure of oxygen (PaO2) and carbon
if baby nursed prone: the back
dioxide (PaCO2) to ensure adequate
gas exchange if baby nursed supine: the chest
Transcutaneous monitoring allows Avoid bony surfaces: use soft tissues

continuous measurement (TcCO2 and (e.g. abdomen, buttock, thigh) and
avoid placing over liver as this can
TcO2)
prevent accurate clinical assessment
Use this guideline to set up and safely of liver size
use transcutaneous monitoring Ensure chosen site is clean and dry
equipment
Peel adhesive protection layer off ring
Clinical indications Place ring on chosen site pressing
Monitoring adequacy of arterial gently on centre of ring before running
oxygenation and/or ventilation finger around outside. Ensure effective
seal as this will affect accuracy of
Nursing critically ill or unstable baby
measurement
Advantages Place three drops of contact fluid in
Reduction in number of blood gas centre of ring
measurements Remove transducer from module into
Immediate recognition of need for ring and turn one-quarter clockwise to
ventilation adjustment secure
Potential problems CARE AND MONITORING

Tissue injury (e.g. erythema, blisters, Temperature setting
burns, and skin tears) as a result of Keep transducer setting at 44ºC for all
failure to change site frequently babies. There is good correlation of
enough (2–3 hrly) according to local TcO2 with heat settings of 44ºC but
protocol lower settings will result with under-
Inadequate measurement resulting reading of TcO2 and difference is
from incorrect set-up larger with increasing TcO2
EQUIPMENT Alarm settings

Transducer: insert at end position of PPHN
rack for easy accessibility
Exact limits will depend on specific
Membranes pathology but, for guidance, in term
Electrolyte solution babies with PPHN:
Adhesive fixation rings TcO2 upper 10.0 lower 5.5
Recalibration machine TcCO2 upper 7.0 lower 5.0
Issue 6
314
nursing guideline)
Blood gas sampling Changing transducer

Take blood gas 20 min after membranes – see Figure 6–10
commencing transcutaneous All staff responsible for ventilated
monitoring to allow comparison babies can change transducer
between transcutaneous values and membranes
arterial partial pressures of O2 and
CO2 levels, as discrepancy can occur Indications
If transcutaneous monitoring values When using a new transducer or if
change suddenly, check contact is in transducer has dried out
place before making ventilator For each new baby
changes. If any doubt about accuracy
When membrane crinkled, scratched
of values, check blood gas before
or damaged
making ventilator changes
After 5 days continuous use
Changing measurement site
Babies <29 weeks: change 2-hrly
Procedure
Wash and dry hands
Babies ≥29 weeks: change 3-hrly
To remove O-rings, unscrew protective
Unscrew transducer before removing
cap from transducer and hook O-ring
fixation rings
remover under them
Remove fixation rings when
Remove both clear plastic membranes
repositioning baby from supine to
with your fingers
prone and vice-versa to avoid
pressure sore from lying on rings To ensure correct values, clean
transducer head, including grove and
Remove rings 12-hrly on babies
rim, with absorbent paper to remove
<29 weeks and 24-hrly on babies
all old electrolyte solution
≥29 weeks
Apply approximately two drops of
Calibration of membrane electrolyte solution to transducer head
See Figure 1–5 Press transducer head downward into
an unused membrane replacer until
Indications replacer reacts as far as it can and a
Transducer membrane has been click is heard
replaced
Monitor displays ‘calibration required’
Measurement values in doubt
Applying to a new baby
Changing measurement site
Ensure calibrator is turned off

after use. Do not dispose of
connecting tube.
Contact technicians when
calibrating gas empty
Issue 6
315
nursing guideline)
Figure: 1–5: Figure: 6–10

Calibration of membrane; Changing transducer membranes
Issue 6
316
TRANSFUSION OF RED BLOOD CELLS • 1/3
INDICATIONS
Acute blood loss with haemodynamic compromise or ≥10% blood volume loss
(e.g. significant feto-maternal transfusion or pulmonary haemorrhage)
in emergency, use O negative blood
transfuse 10 mL/kg over 30 min
further transfusion based on haemoglobin (Hb)
Top-up blood transfusion, if Hb below threshold levels quoted in the following situations
Postnatal age Suggested transfusion threshold Hb (g/L)

Ventilated Other respiratory No respiratory support
support
(CPAP/ BIPAP
HFNC/O2)
Week 1 (days 1–7) <120 <100
Week 2 (days 8–14) <100 <95 <85 if symptoms of anaemia
(e.g. poor weight gain or
significant apnoeas) or poor
reticulocyte response (<4% or
count <100 x 109/L)
≥Week 3 (day 15 <85 <75 if asymptomatic and
onwards) good reticulocyte response
(≥4% or reticulocyte count
≥100 x 109/L)
Adapted from British Committee for Standards in Haematology recommendations
PRE-TRANSFUSION Direct Coombs’ testing

Communication The laboratory will perform Direct
Coombs’ test (DCT) on maternal serum
If clinical condition permits before
for any atypical antibodies
transfusion, inform parents that baby
will receive blood transfusion If maternal DCT negative, blood issued
will be crossmatched once against
document discussion
maternal serum. No further maternal
If parents refuse transfusion (e.g. blood samples are necessary for
Jehovah’s Witness) follow local policy repeat top-up transfusions
Crossmatch If maternal DCT positive, crossmatching
of donor red blood cells against
For top-up transfusions in well baby,
maternal serum is required every time
arrange with blood bank during normal
working hours Multiple transfusions
Crossmatch against maternal serum (or In babies <29 weeks who may need
neonatal serum if maternal serum not multiple transfusions, use paediatric
available) satellite packs (‘Paedipacks’) from one
For first transfusion, send samples of donor (if available) to reduce multiple
baby’s and mother's blood donor exposure
Issue 6
317
When to use irradiated blood Exchange transfusion
It is preferred practice for all blood See Exchange transfusion guideline
given to babies to be irradiated.
However, irradiated blood MUST TRANSFUSION
always be given for those: Volume of transfusion
who have received intra-uterine Give 15–20 mL/kg of red cell transfusion
transfusion irrespective of pre-transfusion Hb
with suspected or proven
A paediatric pack contains
immunodeficiency
approximately 50 mL blood.
receiving blood from a first- or second- Use one pack if possible
degree relative, or an HLA-selected
donor Rate of administration
Administer blood at 15 mL/kg over 3 hr
When to use CMV-free blood or 20 mL/kg over 4 hr (5 mL/kg/hr)
As CMV seronegativity cannot be Increase rate in presence of active
guaranteed in untested blood, use haemorrhage with shock
only CMV-seronegative blood for
neonatal transfusions Via peripheral venous or umbilical
venous line (not via long line or
Blood products in use in the UK are arterial line)
leuco-depleted to <5 x 106
leucocytes/unit at point of manufacture Use of furosemide
Routine use not recommended
Special considerations
Consider soon after blood transfusion
Iron supplements for babies:
Premature babies receiving breast milk with chronic lung disease
or with Hb <100 g/L, commence oral
iron supplementation at 4 weeks of with haemodynamically significant PDA
age – see Nutrition and enteral in heart failure
feeding guideline with oedema or fluid overload
Withholding feeds during DOCUMENTATION AND
transfusion GOOD PRACTICE
Some units withhold enteral feeds Clearly document indication for
during the 3–4 hr duration of transfusion transfusion
Babies with necrotising After transfusion, record benefit (or
lack thereof)
enterocolitis (NEC)
Document pre- and post-transfusion
Transfuse using red cells in sodium
Hb levels
chloride 0.9%, adenine, glucose and
mannitol (SAG-M), preferably, as it is Ensure blood transfusion volume and
relatively plasma-free. This may not be rate is prescribed in appropriate
available in all units. Investigate any infusion chart
unexpected haemolysis associated Observations, including:
with transfusion in a baby with NEC for continuous ECG
T-cell activation in consultation with
local haematology department and SpO2
with close involvement of consultant hourly temperature and BP (recorded
neonatologist before, during and after transfusion)
Issue 6
318
Ensure positive identification of baby
using accessible identification
Appropriate labelling of syringes to
ensure compliance with current best
practice
Unless clinically urgent, avoid
transfusion out-of-hours
To reduce need for blood transfusion,
minimise blood sampling in babies
(micro-techniques, non-invasive
monitoring) and avoid unnecessary
testing
Ensure donor exposure is minimised by
using satellite packs from same donor
Hazards of transfusion
Most important are:
infections – bacterial or viral
hypocalcaemia
volume overload
citrate toxicity
rebound hypoglycaemia (following high
glucose levels in additive solutions)
thrombocytopenia after exchange
transfusion
Issue 6
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TRANSILLUMINATION OF THE CHEST • 1/1
INDICATION DIAGNOSIS
Suspected pneumothorax (e.g. any Pneumothorax confirmed if chest
deterioration in clinical condition, fluoresces bright red
particularly if ventilated) Compare both sides of chest (babies
can have bilateral pneumothoraces)
EQUIPMENT
Compare degree of fluorescence with
Cold light source
that seen over liver
Black drapes to cover incubator
liver and lung without pneumothorax,
PROCEDURE shine dull dark red
Dim lights
Caution – false positive diagnoses
Expose baby’s chest and abdomen may be made in extremely preterm
Remove all non-essential monitoring babies and those with pulmonary
leads interstitial emphysema
Cover outside of incubator with black Transillumination may be unreliable in
drapes babies with increased thickness of the
chest wall (macrosomic term infants
Place cold light tip perpendicular to and
and those with chest wall oedema)
touching baby’s skin
Shine light from the side, in the 5 ACTION
positions shown in diagram, comparing
right side with left (5th position shines Once pneumothorax is confirmed in a
through the liver and is used as a ventilated or unstable baby, perform
control) immediate needle thoracocentesis in
2nd intercostal space, mid-clavicular
Clean cold light tip with an alcohol wipe line on the side of the chest that
after use fluoresced brightly. Do not wait for a
chest X-ray
1. Right side just below axilla

2. Left side just below axilla
3. Right side approximately
5th/6th intercostal space
4. Left side approximately
5th/6th intercostal space
5. Right side just below
diaphragm (liver)
Issue 6
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TRANSPORT AND RETRIEVAL • 1/3
[West Midlands Neonatal Transport Service (WMNTS) guideline]
INTRODUCTION Clinical care

The aim of a safe transfer policy is to Preparation for transport begins as soon
ensure the highest standard, streamlined as decision is made to transfer the baby
care. In the majority of cases, transfer will
be performed by a dedicated transfer
Airway/breathing
team but, in certain cases, the referring If baby unstable or on CPAP with FiO2
team may perform the transfer. In all >0.4, intubate and ventilate (intermittent
cases, the ACCEPT model (Table 1) can mandatory ventilation modality most
be used used in transport ventilators)
Adjust ETT and lines depending on
INDICATIONS FOR TRANSFER chest X-ray position; document all
Uplift for services not provided at positions and adjustments
referring unit (including diagnostic and If indicated, give surfactant (see
drive-through transfers) Surfactant replacement therapy
Repatriation guideline)
Resources/capacity If present, connect chest drains to a
flutter valve device
Table 1: ACCEPT model Check appropriate type of ventilator
A Assessment support is available for transfer (e.g.
high-flow/BiPAP/SiPAP may not be
C Control
provided in transport)
C Communication
Circulation
E Evaluation If baby dependent on drug infusions
P Preparation and packaging (e.g. inotropes, prostaglandin), two
reliable points of venous access must
T Transportation be inserted
ASSESSMENT Check whether receiving unit will
accept central lines
Referring team decides on
if ventilated with FiO2 >0.4, UVC and
urgency of transfer and who
umbilical artery catheter (UAC)
will perform it
necessary, decide whether a double
Key questions are: lumen UVC is required
what is the problem? ensure catheters are secured with
what is being done? suture and tape
what effect is it having? check all access is patent and visible
what is needed now? optimise blood pressure (see
Hypotension guideline)
Control
Drugs
Following initial assessment control the
Antibiotics – see Infection in first 72 hr
situation:
of life guideline and Infection (late
who is the team leader? onset) guideline
what tasks need to be done (clinical Decide whether infusions need to be
care/equipment and resources)? concentrated
who will do them (allocated by team Check IM vitamin K has been given
leader)? Decide whether sedation needed for
who will transfer the baby (if relevant)? transfer
Issue 6
321
Environment state type of, and time limit for, transfer

Monitor temperature throughout provide clinical details to transfer team
stabilisation – in the extreme preterm - name, weight and gestation
baby, chemical gel mattress may be
required - history and clinical details
Cooling babies – see Cooling in non- - interventions, investigations and results

cooling centres (referral and - medications
preparation of babies eligible for Document advice given/received
active cooling) guideline
Prepare transfer information/discharge
Fluids summary and arrange for images to be
reviewed at receiving hospital
Ensure all fluids and infusions are in
50 mL syringes and are labelled Obtain a sample of mother’s blood (if
required)
Volume as per IV fluid therapy
guideline Identify whether a parent is suitable for
transfer with baby (see WMNTS policy
Monitor intake and output
for details)
Parents
Receiving centre
Update with plan of care
Ensure consultant and nurse co-
Establish how parents will get to unit; if ordinator accept referral and agree with
mother is an inpatient, check with advice given
maternity liaison
Clarify method of feeding EVALUATION
Referring clinician, transfer team and
COMMUNICATION receiving team evaluate urgency of the
Referring centre transfer and decide who will do it
Make decision to transfer with parents’ Neonatal transfers are classified as:
agreement time critical (e.g. gastroschisis,
Locate neonatal intensive care unit ventilated tracheoesophageal fistula,
(NICU)/paediatric intensive care unit intestinal perforation, duct-dependent
(PICU)/speciality bed cardiac lesion not responding to
prostaglandin infusion and other
for BCH PICU bed, call KIDS on 0300
unstable conditions)
200 1100
to be performed within 1 hr
for speciality or other PICU bed, call
receiving clinician to be performed within 24 hr
for neonatal cot, call cot locator (0121 to be performed after 24 hr
626 4571) during office hours In the event of a transfer team being
(0900–1700 hr) or contact units directly unable to respond within an appropriate
out-of-hours (use cot availability chart time period, referring unit may decide to
on website) perform the transfer themselves in the
Once cot is available (and KIDS not co- best interests of the baby
ordinating) contact WMNTS:
07929 053730 (mobile). If your call is
not answered, leave a message
Issue 6
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PREPARATION AND On arrival at ambulance

PACKAGING Ensure incubator and equipment are
Three components: securely fastened/stowed in
accordance with CEN standards
clinical care (see above)
Plug in gases and electrical
location and checking of equipment connections
allocation of team
Ensure temperature in ambulance is
Transport equipment must not be used suitable
for any other purpose
Check all staff are aware of destination
Team undertaking the transfer must be
Discuss mode of progression to
trained in use of all equipment and
hospital (e.g. blue lights)
drugs and be competent to perform
any necessary procedures en-route Ensure all staff are wearing seatbelts
before vehicle moves
Ensure air and oxygen cylinders are
full before departure During road transit
ETT and lines must be secured before Record vital signs
transferring baby to the transport
incubator If baby requires clinical intervention,
stop ambulance in a safe place before
Baby must be secured in the transport staff leave their seats
incubator
Make receiving team aware of any
TRANSPORT major changes in clinical condition
Before leaving the On arrival at receiving

referring unit hospital
Change to transport incubator gases Follow the ACCEPT structure
(check cylinders are full)
Handover to receiving team then
Check blood gas 10 min after changing transfer baby to the unit’s equipment
to transport ventilator. Make any
necessary changes transfer and receiving teams to agree
order in which transfer happens
Check lines and tubes are not tangled;
check infusions are running After transfer, dispose of any partially
used drugs and infusions before
Record vital signs returning to ambulance
Allow parents to see baby
Contact receiving hospital to confirm
cot is still available
Only leave referring unit when

team leader is confident that baby is
stable for transfer
Issue 6
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TUBERCULOSIS
(INVESTIGATION AND MANAGEMENT
FOLLOWING EXPOSURE IN PREGNANCY) • 1/2
Usually the result of:
maternal history of TB in pregnancy
baby exposed to a close (usually household) contact with sputum positive TB
Mother with TB treatment Mother incompletely treated by time of delivery

completed in pregnancy,
or past history of TB
Investigate baby
Three consecutive early morning pre-feed gastric
BCG washings, collected in alkali medium (arrange with
microbiologist) for TB culture and AFB
Follow-up as required Chest X-ray
for general condition +/- CSF
Additional investigation
Asymptomatic +/- maternal endometrial sample for TB culture and AFB
Isoniazid (INH) prophylaxis for 3 months Symptomatic
Mantoux and/or
Interferon Gamma Release Assay (IGRA), also known as IGT,
TB Elispot or T Spot Elispot
Negative (<6 mm)
Continue INH. Repeat Mantoux

and/or IGRA 6 weeks later
Positive
If Mantoux and/or IGRA negative

Is this infection Is this infection
i.e. well baby? i.e. ill baby?
Stop INH
Give further Full TB treatment.

Give BCG 72 hr later 3 months’ INH Refer to TB team or
infectious diseases
(ID) physician
Consultant (ID physician or paediatrician with infectious disease interest)

follow-up for all these processes
Issue 6
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TUBERCULOSIS
(INVESTIGATION AND MANAGEMENT
FOLLOWING EXPOSURE IN PREGNANCY) • 2/2
Important points to consider IGRA and Mantoux skin tests define

infection but cannot distinguish
As clearance of mycobacteria from between infection and disease
pregnant mother’s sputum is not clearly
defined, treat newborns of any If IGRA (also known as IGT, TB Elispot
incompletely treated mother as at risk or T Spot) not available, Mantoux skin
for acquiring TB infection/disease test is sufficient provided baby has not
had BCG. IGRA takes 72 hr to be
Baby may acquire mycobacteria from completed and cannot be carried out at
an incompletely treated mother either
weekend. This must be arranged with
in-utero, intrapartum or postpartum.
microbiology/immunology laboratory
Gastric washing samples taken pre-
feed (usually early morning) are useful,
as any potential mycobacteria caught
by baby’s innate mucociliary escalator
will be washed into trachea, bronchi
and upwards, swallowed and present in
the relatively less acidic neonatal
stomach. Using an alkali solution as
the transport medium for the gastric
aspirate keeps the mycobacteria alive
until plated in the laboratory
Issue 6
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UMBILICAL ARTERY CATHETERISATION
AND REMOVAL • 1/4
Risks include sepsis and thrombosis
procedure unsupervised unless you See Consent guideline
have been trained to do so and have
demonstrated your competence Non-sterile preparation
Monitor baby’s vital signs during
INDICATIONS procedure
Frequent blood gas analysis: Estimate length of catheter to be
ventilated babies (most babies treated inserted using formula: (weight in kg x
with CPAP can be managed with 3) + 9 cm
capillary gases) alternative method for UAC length is
Continuous monitoring of arterial blood twice distance from umbilicus to mid-
pressure (if poor circulation or need for inguinal point, plus distance from
accurate BP) umbilicus to xiphisternum
Exchange transfusion add length of cord stump to give final

length
CONTRAINDICATIONS prefer high catheter position i.e. tip
Umbilical sepsis above diaphragm (T6–T10 vertebral
bodies)
Necrotising enterocolitis (NEC)
Inspect lower limbs and buttocks for
Evidence of vascular compromise in
discolouration
legs or buttocks
Tie an umbilical tape loosely around
Congenital abnormality of the
base of cord
umbilicus (e.g. exomphalos or
gastroschisis) Sterile preparation
EQUIPMENT Scrub up, put on gown and gloves
using aseptic technique
Umbilical artery catheterisation pack
Ask assistant (if available) to gently
Umbilical catheter (<2 kg use size
hold baby’s legs and arms away from
3.5 FG, >2 kg use size up to 5 FG)
umbilical site
3-way tap
Clean cord stump and surrounding
Sterile gown, gloves and drape skin with cleaning solution
Infusion pump Attach 3-way tap to catheter and flush
Sodium chloride 0.9% or 0.45% all parts with sodium chloride 0.9%
infusion containing heparin 1 unit/mL leaving syringe attached
Umbilical tape Place all equipment to be used on a
sterile towel covering a sterile trolley
Place sterile drape with a hole in the
Zinc oxide tape or Elastoplast® centre over the umbilical stump. Pull
the stump through the hole ready for
PROCEDURE
catheter insertion
Consent
Wherever possible inform parents of
need and associated risks before
procedure; if an emergency, delay
explanation until after insertion
Issue 6
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AND REMOVAL • 2/4
Insertion of arterial catheter Place 2 sutures into cord, one on
either side of catheter, allowing suture
Clamp across cord with artery forceps ends to be at least 5 cm long beyond
Apply gentle upward traction cut surface of the cord. Sandwich
catheter and ends of the 2 sutures
Cut along underside of forceps with a
scalpel blade to reveal either the cut between zinc oxide or Elastoplast®
surface of the whole cord, or use a tape as close to cord as possible
side-on approach cut part way through without touching cord (like a flag).
the artery at a 45º angle The sutures should be separate from
the catheter on either side as this
Leave a 2–3 cm stump; remember to allows easy adjustment of catheter
measure length of cord stump and add length, should this be necessary. Top
to calculated placement to give final edge of sutures can be tied together
advancement distance above flag for extra security after
Identify vessels, single thin-walled vein confirming X-ray position
and two small thick-walled arteries that If catheter requires adjustment, cut
can protrude from the cut surface zinc oxide or Elastoplast® tape
Support cord with artery forceps between catheter and the 2 suture
placed near to chosen artery ends, pull back catheter to desired
length and retape; never advance
Dilate lumen using either dilator or fine once tape applied as this is not sterile
forceps
Connect catheter to infusion of
Insert catheter with 3-way tap closed heparinised sodium chloride 0.9% or
to catheter. If resistance felt, apply 0.45% at 0.5 mL/hr
gentle steady pressure for 30–60 sec
Confirm position of catheter by X-ray:
Advance catheter to the calculated unlike a UVC, a UAC will go down
distance before it goes up
Open 3-way tap to check for easy a high position tip (above diaphragm
withdrawal of blood and for pulsation but below T6) is preferred
of blood in the catheter
if catheter below the diaphragm resite
at L3–L4 (low position)
If catheter will not advance beyond
4–5 cm and blood cannot be if catheter position too high, withdraw
withdrawn, it is likely that a false to appropriate length
passage has been created. if catheter length adjusted, repeat X-ray
Remove catheter and seek advice
from a more experienced person
Securing catheter
If an umbilical venous catheter (UVC)
is also to be inserted, site both
catheters before securing either.
Secure each catheter separately as
below to allow independent removal
Issue 6
327
AND REMOVAL • 3/4
Acceptable UAC tip positions
Acceptable or
Tip position Precautions/adjustments
unacceptable
T6–T10 vertebra Acceptable Ideal high UAC position
L3–L4 Acceptable Low UAC position
T11 Can be used with caution Monitor blood sugar
L5 Can be used with caution Monitor leg perfusion
Risk of bowel or renal ischemia, pull
T12–L2 Not acceptable
back to L3–L4
Above T6 Not acceptable Pull back to T6–T10
Risk of leg ischemia, replace with
Femoral artery Not acceptable
new UAC
Do not infuse any other solution

Avoid L1, the origin of the renal
through UAC. Glucose or drugs may
arteries
be administered through UAC only in
Never attempt to advance a catheter exceptional situations, on the authority
after it has been secured; either of a consultant
withdraw it to the low position or
remove it and insert a new one COMPLICATIONS
Bleeding following accidental
DOCUMENTATION
disconnection
Record details of procedure in baby’s
Vasospasm: if blanching of the lower
notes, including catheter position on
limb occurs and does not resolve,
X-ray and whether any adjustments
remove catheter
were made
Embolisation from blood clot or air in
Always label umbilical arterial and
the infusion system
venous catheters using the
appropriately coloured and labelled Thrombosis involving:
stickers femoral artery, resulting in limb
Place traceability sticker from ischaemia
catheter/insertion pack into notes renal artery, resulting in haematuria,
renal failure and hypertension
AFTERCARE
mesenteric artery, resulting in
Nurse baby in a position where UAC
necrotising enterocolitis (NEC)
can be observed
Infection: prophylactic antibiotics are
Monitor circulation in lower limbs and
not required
buttocks while catheter is in situ
Leave cord stump exposed to air
Infuse heparinised sodium chloride
0.9% or 0.45% 0.5 mL/hr heparin/mL
Issue 6
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AND REMOVAL • 4/4
REMOVAL AFTERCARE
Nurse baby supine for 4 hr following
removal, and observe for bleeding
procedure unsupervised unless you
have been trained to do so and have COMPLICATIONS
demonstrated your competence
Bleeding
INDICATIONS Catheter tip inadvertently left in blood
vessel
Catheter no longer required
No longer patent
Suspected infection
Complications (e.g. NEC, vascular
compromise to the lower limbs)
EQUIPMENT
Sterile stitch cutter
Sterile blade
Umbilical tape
PROCEDURE
Wash hands and put on sterile gloves
Clean cord stump with cleaning
solution
if umbilical tissue adherent to catheter,
loosen by soaking cord stump with
gauze swab soaked in sodium chloride
0.9%
Ensure an umbilical tape is loosely
secured around base of umbilicus
Turn infusion pump off and clamp
infusion line
Withdraw catheter slowly over 2–3 min
taking particular care with last 2–3 cm
If bleeding noted, tighten umbilical tape
Do not cover umbilicus with large
absorbent pad, a small piece of cotton
gauze should suffice
Confirm catheter is intact
Issue 6
329
UMBILICAL VENOUS CATHETERISATION
AND REMOVAL • 1/3
Estimate length of catheter to be
inserted: use formula (weight in kg x
procedure unsupervised unless you
1.5) + 5.5 cm but note that this formula
have been trained to do so and have
aims to site the catheter in the right
demonstrated your competence under
atrium which is now considered
appropriate supervision
potentially unsafe
INDICATIONS Alternatively, measure distance from
All babies <1000 g umbilicus to xiphisternum for length of
UVC
Babies >1000 g ventilated or unwell
(e.g. HIE) (a double lumen catheter high catheter placement preferred: at
may be indicated if baby requires T8–9 but not in heart
significant support) if tip in liver, pull back to lower border
Exchange transfusion of liver (acceptable lower position) and
check whether catheter is still
Administration of hypertonic solutions
sampling freely before use
(e.g. glucose >12.5%, parenteral
nutrition or inotropes) Remember to add length of cord
stump to give final distance catheter
CONTRAINDICATIONS needs to be advanced
Umbilical sepsis Tie umbilical tape loosely around base
Necrotising enterocolitis (NEC) of cord
Gastroschisis/exomphalos Sterile preparation
EQUIPMENT Scrub up, and put on gown and gloves
Umbilical vein catheterisation pack Use sterile technique
Umbilical venous catheter Clean cord stump and surrounding
skin with cleaning solution
3-way tap
Attach 3-way tap to catheter and flush
Gown and gloves
all parts with sodium chloride 0.9%.
Sterile drape Leave syringe attached
Infusion pump Place all equipment to be used on
Sodium chloride 0.9% infusion sterile towel covering sterile trolley
Umbilical tape Drape umbilical stump with sterile towels
Cleaning solution as per unit policy Place sterile sheet with a hole in the
Zinc oxide tape or Elastoplast® centre over the cord. Pull the cord
through the hole
PROCEDURE
Insertion of umbilical catheter
Consent
Clamp across cord with artery forceps
Wherever possible inform parents of
need and associated risks before Apply gentle upward traction
procedure; if an emergency, delay Cut along underside of forceps with
explanation until after insertion scalpel blade cleanly to leave 2–3 cm
stump or, if also placing an umbilical
Risks include sepsis and thrombosis
arterial catheter (UAC) and you have
See Consent guideline been trained in this procedure, consider
Non-sterile preparation using side-on technique (see Umbilical
artery catheterisation guideline)
Monitor all vital signs during procedure
Issue 6
330
AND REMOVAL • 2/3
If catheter requires adjustment, cut
Remember to measure length of
zinc oxide or Elastoplast® tape
cord stump and add to calculated
between catheter and 2 suture ends,
placement distance to give final
pull back catheter to desired length
length catheter needs to be advanced
and retape; never advance once tape
Identify vessels: has been applied as it is not sterile
single thin-walled vein Connect catheter to infusion
2 small thick-walled arteries that can Confirm position of catheter in IVC by
protrude from cut surface X-ray. A UVC goes straight up
Support cord with artery forceps if catheter found to be in right atrium,
placed near to vein withdraw it to avoid risk of cardiac
Locate lumen of vein using either a tamponade or cardiac arrhythmia
dilator or fine forceps if catheter in liver, withdraw it to lower
Insert catheter (3.5 F for babies with border of liver so that it lies in IVC, or
birth weight <1500 g and 5 F for those remove it and insert replacement
>1500 g) with 3-way tap closed to if catheter length adjusted, repeat X-ray
catheter; if resistance felt, apply gentle
steady pressure for 30–60 sec Acceptable UVC tip
Advance catheter to desired distance, positions
and open 3-way tap to check for easy High position – at T8–9 but not within
withdrawal of blood cardiac shadow on X-ray
If catheter will not advance beyond Low position – at the lower border of
4–5 cm and blood cannot be liver and not inside the liver shadow
withdrawn, it is likely that a false (short-term use only)
passage has been created. Remove
catheter and seek advice from a more
DOCUMENTATION
experienced senior person Record in notes details of procedure,
including catheter position on X-ray
Securing catheter and whether any adjustments were
If a UAC is also to be inserted, site made
both catheters before securing either. Always label umbilical arterial and
Secure each catheter separately as venous catheters, using the
below to allow independent removal appropriately coloured and labelled
Place 2 sutures into cord, one on either stickers
side of the catheter, allowing suture Place traceability sticker from
ends to be at least 5 cm long beyond catheter/insertion pack into notes
cut surface of cord. Bend the catheter
in a loop then sandwich it and ends of AFTERCARE
the 2 sutures between zinc oxide or Monitor circulation in lower limbs and
Elastoplast® tape as close to the cord buttocks whilst catheter is in situ
as possible without touching cord (like
Leave cord stump exposed to air
a flag). The sutures should be separate
from the catheter on either side as this The catheter may remain in place for
allows easy adjustment of catheter up to 7–10 days (longer at consultant
length, should this be necessary. Top request). There is a risk of infection if
edge of sutures can be tied together left longer than 7 days
above flag for extra security after Any infusions must be connected to
confirming X-ray position UVC using aseptic technique
Issue 6
331
AND REMOVAL • 3/3
Catheters below T10 have increased REMOVAL
risk of extravasation. They can be
used in the short term but should be Do not attempt to carry out this
replaced at the earliest opportunity procedure unsupervised unless
you have been trained to do so and
COMPLICATIONS
have demonstrated your competence
Air embolism under appropriate supervision
Bleeding resulting from accidental
disconnection INDICATIONS
Refractory hypoglycaemia due to Central venous access no longer
malpositioning of catheter required
Infection: prophylactic antibiotics not Concerns regarding sepsis
required
Remove after a maximum of 10 days
Thrombus formation
Cardiac tamponade (see below) EQUIPMENT
Any deterioration in a baby in whom a Sterile stitch cutter
central venous catheter is present Sterile blade
should raise the question of catheter Cleaning solution as per unit policy
related complications; particularly
infection, extravasation and Gown and gloves
tamponade PROCEDURE
Cardiac tamponade Wash hands and put on gown and
gloves
Suspect in presence of:
tachycardia Clean cord stump with cleaning
solution
poor perfusion
Turn infusion pump off and clamp
soft heart sounds infusion line
increasing cardiomegaly Ensure umbilical tape secured loosely
decreasing oxygen saturation around base of umbilicus
arrhythmias Withdraw catheter slowly
Confirm diagnosis by: If any bleeding noted, tighten umbilical
chest X-ray: widened mediastinum and tape
enlarged cardiac shadow Confirm catheter is intact
echocardiogram (if available)
AFTERCARE
If there is cardiovascular compromise,
Nurse baby supine for 4 hr following
consider drainage (see
removal and observe for bleeding
Pericardiocentesis guideline)
COMPLICATIONS
Bleeding
Loss of UVC tip
Infection
Issue 6
332
UPPER LIMB BIRTH INJURIES INCLUDING
BRACHIAL PLEXUS PALSY • 1/1
DEFINITION Paralysis of the arm, which is
completely resolved within a few days
Brachial plexus palsy may be
does not need to be referred but if
congenital occurring in-utero or
there is any doubt, all babies will be
acquired due to injury to brachial
seen in the regular weekly hand
plexus nerves sustained due to
trauma clinic so that a specialist
stretching of nerves during delivery
assessment can be made and the
Fractures to humerus or clavicle parents can be given appropriate
Isolated radial nerve palsy of the information
newborn
BIRMINGHAM CHILDREN’S
ASSESSMENT OF ALL HAND and UPPER LIMB
BABIES WITH REDUCED SERVICE:
UPPER LIMB MOVEMENT Fax referral proforma to: 0121 333
Examine the arm and neck for 8131. Form available for download
swelling, bruising, tone, posture and from http://www.networks.nhs.uk/nhs-
degree of movement networks/staffordshire-shropshire-and-
black-country-newborn/neonatal-
Assess for breathing difficulties and guidelines/neurology-1
Horner’s syndrome
Email secretary: Brenda Riley or
Document findings clearly in case Parvinder.Sahota2@bch.nhs.uk
notes
Tel: 0121 333 8136/8285
Explain to parents that recovery
probable but may not be complete Email for advice:
andrea.jester@bch.nhs.uk
Inform consultant obstetrician and
paediatrician Write to Mrs Jester, Consultant
Plastic/Hand Surgeon,
MANAGEMENT Birmingham Children’s Hand and
Upper Limb Service,
X-ray humerus/clavicle to exclude
fracture Birmingham Children’s Hospital,
Steelhouse Lane
if fracture of clavicle clearly seen, Birmingham B4 6NH
reassure parents and review baby at 3
weeks when movement should be
returning
if fracture of humerus is clearly seen,
offer strapping of arm to chest for
comfort and review baby at 3 weeks
when movement should be returning
and baby becoming more comfortable
if uncertain, refer to Children’s Hand
and Upper Limb Service at BCH
Classical ‘Waiter’s tip position’ –
refer to Children’s Hand and Upper
Limb Service at BCH as soon as
possible
initiate referral to local physiotherapists
Issue 6
333
URINARY TRACT ABNORMALITIES IN
ANTENATAL SCANS • 1/3
ANTENATAL ASSESSMENT moderate: RPD 10–14 mm. If bilateral,
suspect critical obstruction
Fetal diagnostic scans are undertaken at
18–20 weeks and may be repeated at severe: RPD ≥15 mm. Suspect critical
32–34 weeks obstruction
calyceal dilatation: often indicates
18–20 week scan severity; may suggest obstruction
Possible urinary tract Unilateral/bilateral dilated ureter(s) –
abnormalities include: suspect obstruction or vesico-ureteric
Kidneys reflux (VUR)
Renal agenesis +/- oligohydramnios – Thick-walled bladder, suspect outlet

Potter sequence obstruction
Multi-cystic dysplastic kidney (MCDK), Dilated bladder, suspect poor emptying

check other kidney for normal Ureterocoele, suspect duplex system
appearance on that side
Solitary kidney
Communication
Abnormal position (e.g. pelvic) or
Provide mother with an information
shape (e.g. horseshoe)
leaflet, if available in your hospital,
Kidneys with echo-bright parenchyma about this antenatal anomaly and
(suspect cystic diseases) proposed plan of management after
birth
Collecting system/tubes
Unilateral or bilateral renal pelvic POSTNATAL MANAGEMENT
dilatation (RPD)/pelviectasis Indications for intervention
Measured in antero-posterior diameter Urgent
(APD)
Bilateral RPD ≥10 mm +/- thick-walled
mild: RPD 5–9 mm bladder: suspect posterior urethral
moderate: RPD 10–14 mm valve (boys)
severe: RPD ≥15 mm Unilateral RPD ≥15 mm, suspect pelvi-
ureteric junction (PUJ) obstruction
Unilateral or bilateral dilated calyces or
ureter Significant abnormalities of
kidney(s)/urinary tract – if risk of renal
Bladder insufficiency
(dilated or thick-walled; check serum potassium, blood gas for
ureterocoele in bladder) metabolic acidosis and serum
creatinine
32–34 week scan
To clarify urinary tract abnormalities Non-urgent
found in early fetal scans All other abnormalities of urinary tract
Assess severity of RPD/pelviectasis: in the antenatal scan
normal: RPD <7 mm

mild: RPD 7–9 mm
Issue 6
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URINARY TRACT ABNORMALITIES ON
ANTENATAL SCAN • 2/3
IMMEDIATE MANAGEMENT SUBSEQUENT MANAGEMENT
For urgent indications Subsequent management depends
on findings of ultrasound scan at
If posterior urethral valve (PUV)/PUJ
2–6 weeks
obstruction suspected, check urine
output/stream and monitor weight trend Severe pelviectasis
Arrange urgent KUB ultrasound (RPD ≥15 mm)
scan within 24–48 hr (minimal milk
Arrange MAG3 scan – timing depends
intake may underestimate the size of
on severity of obstruction – as soon as
renal pelvis, but do not delay if there
possible if RPD ≥20 mm
is gross dilatation)
if MAG 3 scan shows obstructed
If postnatal scan raises suspicion of pattern, discuss with paediatric
posterior urethral valve (dilated ureters
urologist
+ thick walled bladder)
Repeat ultrasound scan at 3–6 months
check serum creatinine of age (depending on cause of
arrange urgent micturating cysto- dilatation, a complete obstruction
urethrogram (MCUG) requires closer monitoring)
after confirmation by MCUG, refer Continue antibiotic prophylaxis until
baby urgently to paediatric urologist advised otherwise by urologist
If unilateral RPD ≥20 mm (suggestive
Moderate unilateral
of PUJ obstruction) discuss with
urologist and arrange MAG3 renogram pelviectasis (RPD 10–14 mm)
as soon as possible/as advised by the and/or ureteric dilatation
urologist Presumed mild obstruction or VUR
Significant abnormalities of If RPD increases beyond 15 mm,
kidney(s)/urinary tract – if risk of renal arrange MAG3 scan
insufficiency:
Continue prophylaxis for VUR ≥grade
check serum potassium, blood gas for 4 (marked dilatation of ureter and
metabolic acidosis and serum calyces) until child is continent (out of
creatinine nappies)
start trimethoprim 2 mg/kg as single Repeat scan every 6 months until RPD
night-time dose <10 mm, then follow advice below
Discuss with consultant before
Normal or mild isolated
discharge
pelviectasis (RPD <10 mm)
For non-urgent indications Stop antibiotic prophylaxis
Renal ultrasound scan at 2–6 weeks of Repeat scan after 6 months
age
if 6 month scan normal or shows no
Consultant review with results change and there have been no
urinary tract infections (UTIs),
Antibiotic prophylaxis discharge
For RPD ≥10 mm, give trimethoprim
If unwell, especially pyrexial without
2 mg/kg as single night-time dose until
obvious cause, advise urine collection
criteria for stopping are met (see
below)
Issue 6
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URINARY TRACT ABNORMALITIES ON
ANTENATAL SCAN • 3/3
Multi-cystic dysplastic kidney Renal parenchymal problem
(MCDK) requiring nephrology review
DMSA to clarify nil function of MCDK Bright kidneys
and normal uptake pattern of other Multiple cysts
kidney
Repeat ultrasound scan 6–12 monthly Other conditions
to observe involution of kidney (may Single renal artery in cord
take several years)
increased risk of renal abnormality but
Beware of 20% risk of vesico-ureteric postnatal ultrasound scan only if
reflux (VUR) in ‘normal’ kidney, advise antenatal scan missed or abnormal
parents to recognise
UTI/pyelonephritis (especially if fever Ear abnormalities: ultrasound
is without obvious focus) examination only if associated with:
MCUG or prophylaxis until continent syndrome
ONLY if dilated pelvis or ureter in other malformations
good kidney
maternal/gestational diabetes
Annual blood pressure check until
kidney involuted family history of deafness
If cysts persist > 5 yrs, enlarging or

hypertension, refer to urology
Ureterocoele
(often occurs with duplex
kidney)
MCUG (if VUR or PUV suspected)
MAG3 to check function and drainage
from both moieties of the duplex
system
Prophylaxis until problem resolved
Urology referral – sooner if obstruction
suspected
Solitary kidney/unilateral
renal agenesis
Kidney ultrasound at 6 weeks to
confirm antenatal findings and rule out
other urogenital structure
abnormalities
DMSA to confirm absence of one
kidney + normal uptake pattern by the
single kidney
Issue 6
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VARICELLA • 1/3
RECOGNITION AND Management
ASSESSMENT Management is supportive and requires
Definition long-term multidisciplinary follow-up.
Varicella zoster immunoglobulin (VZIG)
There are 2 separate presentations
or aciclovir have no role in the
depending on timing of infection:
management of these babies
fetal varicella syndrome: maternal
chickenpox infection before 20 weeks’ NEONATAL VARICELLA (NV)
gestation Neonatal varicella is a serious illness
neonatal varicella: maternal infection in with high mortality (approximately 30%).
perinatal period or close contact with It most commonly occurs in babies born
chickenpox or shingles in first 7 days to mothers with chickenpox or close
after birth contact with chickenpox or zoster within
7 days of birth
FETAL VARICELLA
SYNDROME (FVS) Management of exposure to
chickenpox/zoster
Symptoms and signs
Requires VZIG
Limb hypoplasia
obtain VZIG from microbiology
Scarring of skin in a dermatomal
department
distribution
Cortical atrophy, microcephaly, bowel Management of baby born to
and bladder sphincter dysfunction, mother who develops
vocal cord paralysis chickenpox rash (but not
Chorioretinitis, cataracts and zoster) within 7 days before
microphthalmia birth, or 7 days after birth
Intra-uterine growth restriction (IUGR) Give VZIG 250 mg (1 vial approx.
1.7 mL) IM (not IV)
Investigations
antenatal chickenpox: give as soon as
Maternal possible after delivery (must be within
If no history of chickenpox, check 72 hr)
maternal VZ IgG at time of contact postnatal chickenpox: give as soon as
If mother develops chickenpox rash, possible and within 10 days after initial
send a swab from the base of the exposure
vesicle in viral transport media for consider giving in different sites in
varicella zoster PCR small babies
Neonatal can be given without antibody testing
of baby
≤7 days VZ IgM (can be done on cord
blood), or of no benefit once neonatal
chickenpox has developed
>7 days VZ IgG (even if VZ IgM
negative at birth) not needed for babies born after
7 days of appearance of maternal
If vesicles are present send a swab
chickenpox, or where mother has
from the base of the vesicle in viral
zoster, as these babies should have
transport media for varicella zoster
transplacental antibodies
PCR
may not prevent neonatal varicella, but
can make the illness milder
Issue 6
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VARICELLA • 2/3
If VZIG not available or IM injection VZ antibody-negative babies of any
contraindicated, give IVIG 0.2 g/kg age, exposed to chickenpox or herpes
(less effective) zoster while still requiring intensive or
prolonged special care nursing
Management of baby
for babies exposed postnatally,
exposed after birth to regardless of maternal chickenpox
chickenpox from history, who:
non-maternal source
- weighed <1 kg at birth, or
(see Decision pathway)
- were ≤28 weeks’ gestation at birth, or
Significant exposure: household, face-
to-face for 5 min, in same room for - are >60 days old, or
>15 min - have had repeated blood sampling
a case of chickenpox or disseminated with replacement by packed cell
zoster is infectious between 48 hr infusions perform VZ IgG assay and,
before onset of rash until crusting of if negative, give VZIG (because they
lesions are at risk of not having received or
retained sufficient maternal VZ IgG)
Give VZIG in the following cases of
postnatal exposure to varicella:
varicella antibody-negative babies (this
can be determined by testing mother
for varicella antibodies) exposed to
chickenpox or herpes zoster from any
other contact other than mother, in first
7 days of life (see Decision pathway)
Decision pathway for VZV contact
Exposure
28 weeks or <1 kg at delivery or >28 weeks or 1 kg at delivery

>60 days old or multiple blood
transfusions
Previous maternal chickenpox
Baby VZ IgG assay,

regardless of
maternal status Yes No or uncertain
No VZIG Urgent maternal serology

(VZ IgG)
Seronegative give Seropositive Seronegative

baby VZIG
No VZIG VZIG if within 10 days
of exposure
Issue 6
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VARICELLA • 3/3
Symptoms and signs of Staff
neonatal varicella Exposed staff with no history of
Mild: vesicular rash chickenpox, VZ vaccination or of
unknown VZ IgG status should have
Severe: pneumonitis, pulmonary
VZ IgG measured by occupational
necrosis, fulminant hepatitis
health
mortality 30% without varicella-zoster
if VZ IgG negative, immunise with
immunoglobulin (VZIG)
varicella vaccine
TREATMENT remove from clinical duties during
Aciclovir days 7–21 following exposure
if in high risk group for complications
Indications (immunocompromised), offer VZIG
Babies with signs and symptoms of
neonatal varicella MONITORING TREATMENT
Babies with postnatal exposure for Aciclovir
whom VZIG was indicated (as above) ensure good hydration
but not given within 24 hr of exposure
stop once clinical improvement occurs
Chickenpox in baby currently treated or when all lesions crusted
with corticosteroids or born
prematurely or immunocompromised DISCHARGE AND FOLLOW-UP
Dosage Maternal infection
20 mg/kg IV (over 1 hr) 8-hrly, diluted After baby has had VZIG, discharge
to 5 mg/mL Monitor baby for signs of infection,
For renal impairment, refer to especially if onset of maternal
Neonatal Formulary chickenpox occurred 4 days before to
2 days after delivery
Treat for at least 7 days, up to 21 days
if severe Advise mother to seek medical help if
baby develops chickenpox, preferably
SUBSEQUENT MANAGEMENT via an open-access policy where
available
Where
Advise GP and midwife to recommend
On postnatal ward, unless baby
admission to isolation cubicle if rash
requires neonatal intensive care
develops
support:
isolate mother and baby together in Fetal infection
separate room until 5 days after onset Diagnosed with positive VZ IgM or
of rash and all lesions crusted over positive VZV PCR
if baby already exposed, breastfeeding ophthalmic examination
can continue but explain to mother
cranial ultrasound
possible risk of transmission
developmental follow-up
Issue 6
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VASCULAR SPASM AND THROMBOSIS • 1/2
Vascular spasm Management of
Blanching or cyanosis of extremity thromboembolism
following insertion or manipulation of Controversial
peripheral or umbilical arterial catheter
Inadequate controlled trials
(UAC)
Inform consultant
Remove catheter
Liaise with plastic surgeons,
unless absolutely essential haematologists and other specialists
as needed
Elicit reflex vasodilation
Treatment options
reflex vasospasm on insertion of UAC
can occasionally be corrected by reflex Conservative
vasodilation by warming contralateral Observe closely with no intervention
limb e.g. unilateral renal vein thrombosis
Volume expansion Anticoagulation and
if appropriate, give 10 mL/kg sodium thrombolysis
chloride 0.9% as volume expander No controlled neonatal trials
GTN patch Use only under guidance from
haematologist and/or plastic surgeon
use can be considered to improve
perfusion but not trialled or licensed for
use in babies. Discuss with consultant
Liaise with plastic surgeons,

haematologists and other specialists
as needed
Issue 6
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VASCULAR SPASM AND THROMBOSIS • 2/2
Vascular thrombosis
Clinical features suggesting vascular thrombosis
Site Clinical signs Diagnostic imaging

Pallor Doppler scan for large
Cold arm/foot vessel thrombus (sensitivity
and specificity uncertain in
Weak or absent peripheral the neonatal period)
pulse
Peripheral or central Real-time two-dimensional
Discolouration ultrasound
(aorta or iliac) arterial
thrombosis Gangrene CT scan with contrast
Difficulty establishing a Contrast angiography (at
proper pulse oximetry trace specialised centre)
Delayed capillary refill time
on affected limb
Systemic hypertension
Renal artery/aortic Haematuria
thrombosis Oliguria
Renal failure
Flank mass
Renal vein Haematuria
thrombosis Hypertension
Thrombocytopenia
Cool lower limbs

Inferior vena cava
Cyanosis
thrombosis
Oedema
Swelling of upper limbs and
Superior vena cava head
thrombosis
Chylothorax
High pressures on long line

SVC obstruction
Central venous line
Chylothorax
thrombus
Swelling
Discolouration of extremity
Heart failure Echo
Right atrial thrombus
Embolic phenomenon
Pulmonary Respiratory failure Lung perfusion scan (at

thromboembolism specialised centre)
Issue 6
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VENEPUNCTURE • 1/1
INDICATIONS Insertion and sampling
Blood sampling in a baby without Apply hand pressure around limb to
indwelling arterial line, or when distend vein
sampling from arterial line or capillary Clean the puncture site then do not
sampling is inappropriate touch again
EQUIPMENT Place thumb on skin slightly distal to
proposed puncture site
Cleaning solution or cleaning swab –
follow local infection control policy Hold needle at a 10–20º angle and
puncture skin
Appropriately labelled blood bottles
and request cards Advance needle toward vein.
Resistance may diminish slightly as
Non-sterile gloves
needle enters vein and blood will be
23 gauge blood sampling needle or seen to flow
needle-safe cannula
Collect required volume taking care to
Do not use a broken needle mix but not shake blood
Sterile gauze/cotton wool to apply to When sampling complete, place
wound post-procedure gauze/cotton wool over insertion point
and withdraw needle
PROCEDURE
Maintain pressure on site until
Preparation bleeding ceases
Wash hands and wear gloves
Keep track of all needles used and
Second person employs containment dispose of them in sharps container
holding and gives sucrose – see Pain
Label all samples and investigation
assessment and management
forms at cot side
guideline
Arrange for transfer of samples to
Identify suitable vein (typically back of laboratory
hand or foot)
Avoid sampling from potential IV DIFFICULT VENEPUNCTURE
infusion site or long-line vein (e.g. If small quantities of blood required
cubital fossa or long saphenous) (<1 mL), use heel prick, but remember
whenever possible that squeezing can cause haemolysis
Place paper towels under limb to avoid and elevate serum potassium
blood dripping onto bed linen Defer to a more experienced operator
Transillumination of limb can help
identify suitable vein
Issue 6
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VENTILATION – CONVENTIONAL • 1/4
INTRODUCTION Rate
Oxygenation Fast-rate (≥60/min) ventilation is
associated with fewer air leaks and
Increase oxygenation by increasing:
asynchrony compared to slow
FiO2 (20–40/min) rates
peak end expiratory pressure (PEEP) If rate >70/min required, HFOV may
peak inspiratory pressure (PIP) be a more appropriate option – see
High frequency oscillatory
inspiratory time (Tinsp)
ventilation guideline
CO2 Flow
Reduced by: Flow of 5–8 L/min is generally sufficient
increased PIP Consider higher flows at faster
increased rate ventilatory rates or shorter inspiratory
occasionally by reducing excessive times
PEEP (beware of effect on oxygenation) SLE ventilator has a fixed flow (5 L/min)
that cannot be altered
VENTILATOR PARAMETERS
Tidal volume (Vt)
Peak inspiratory pressure
(PIP) Target is 4–6 mL/kg
Use lowest possible PIP to achieve SETTING UP VENTILATOR
visible chest expansion and adequate
gas exchange on blood gas analysis Switch on humidifier and follow
manufacturer’s recommended settings
To minimise lung injury from for optimum temperature and humidity
barotrauma and inadvertent over-
distension, avoid excessive PIP Setting 1
Need for higher pressures [e.g. mean When an admission of a preterm baby
airway pressure (MAP) >12 cm] should requiring ventilatory support (for
lead to consideration of high frequency recurrent apnoea, see Setting 2)
oscillatory ventilation (HFOV) – see rate 60/min
High frequency oscillatory
ventilation guideline PIP 16–18 cmH2O
PEEP 4 cmH2O
Peak end expiratory pressure
(PEEP) Tinsp 0.3–0.4 sec
Use a PEEP of at least 3 cm and FiO2 0.4–0.6

increase incrementally up to 8 cm for flow 6–8 L/min (not applicable to SLE)
improving oxygenation but
Adjust ventilatory settings depending
when PEEP >6 cm is necessary, take on chest movement, SpO2, and
senior advice measured Vt
Inspiratory time (Tinsp) Sample blood gas within 30 min of
commencing ventilatory support
Usually between 0.3–0.4 sec
Avoid Tinsp >0.5 sec except in term
babies with parenchymal lung disease
where a Tinsp up to 1 sec may be used
Issue 6
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Setting 2 Altering ventilatory settings
For babies with normal lungs requiring according to blood gases
supportive ventilation such as term If blood gases are outside the targets,
babies with respiratory depression first check the following:
(asphyxia or drugs), babies with
Reliability of blood gas:
neuromuscular disorders or, in the
post-operative period, and preterm is the blood gas result reliable?
babies with recurrent apnoea, set has there been a sudden unexpected
ventilator at following settings: change from previous blood gas
rate 20–40/min values?
PIP/PEEP 10–12/3 cmH2O did sample contain an air bubble?
was it obtained from a poorly perfused
Tinsp 0.35–0.4 sec
site?
FiO2 0.21–0.3
Baby’s status:
ADJUSTING VENTILATORY is baby’s chest moving adequately?
SETTINGS how is the air entry?
Adjusting FiO2 Ventilator and tubing
Oxygen is a drug and should be is there an air leak? (transilluminate to
prescribed as with other medications. exclude – see Transillumination of
This should be done by specifying the the chest guideline)
intended target range of SpO2 on what is the Vt?
baby’s drug chart are the measured ventilatory values
Suggested target SpO2 ranges (see markedly different to the set ones?
Oxygen saturation guideline) is there a large (>40%) endotracheal
preterm babies: 91–95% tube (ETT) leak?
term babies with PPHN: 96–100%
Remember to exclude airway
problems (blocked/displaced ETT)
and air leaks in case of deterioration
of blood gases. If available, use
pedi-cap or end-tidal CO2 monitoring
to exclude ETT malposition
Small frequent changes are more

appropriate than large infrequent ones
Issue 6
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Blood gas scenario Recommended action in order of preference

Exclude airleak/displaced ETT/overinflation
Increase FiO2
Increase PEEP
Increase PIP (but be aware of effect on PaCO2)
Low PaO2/SpO2 Increase Tinsp (but ensure adequate Texp, especially at fast rates)
Consider further surfactant (see Surfactant replacement
guideline)
If above measures unsuccessful, discuss with consultant (may
need HFOV/iNO)
Decrease FiO2 (unless already in air)
High PaO2 Decrease PEEP (if >5 cm)
Decrease PIP (especially if PaCO2 is also low)
Exclude airleak/displaced or blocked ETT

Increase PIP
High PaCO2 Increase rate
Decrease PEEP (only if oxygenation adequate and PEEP >6 cm)
after taking senior advice
Decrease PIP
Low PaCO2
Decrease rate
Exclude displaced/blocked ETT
Exclude air leak
Low PaO2/SpO2 and high Increase PIP
PaCO2 Consider further surfactant
If no response, consider HFOV – see High frequency
oscillatory ventilation guideline
All ventilator changes must be prescribed and signed for on the intensive care chart
Load all babies <30 weeks’ gestation with caffeine on day 0 with maintenance doses
thereafter. Do not delay loading until the weaning stage
WEANING Extubation
While weaning baby off ventilator: Extubate babies of <30 weeks’
reduce PIP (usually by 1–2 cm) until gestation onto nasal CPAP – for mode,
MAP of ≤7 cm reached see CPAP guideline
thereafter, reduce rate to 20/min, more mature babies with no significant
usually in decrements of chest recessions can be extubated
5–10 breaths/min directly into incubator oxygen
Issue 6
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BABIES FIGHTING
VENTILATOR
If baby in asynchrony with
the ventilator (fighting)
Ensure baby is not hypoxic or under-
ventilated
Exclude blocked ETT
Look for obvious pain e.g. necrotising
enterocolitis (NEC)
If possible, change to synchronised form
of ventilation (SIPPV/PTV/Assist
Control/SIMV) – see Ventilation:
synchronous positive pressure
guideline
Ensure adequate sedation. Usually
intravenous infusion of morphine
(10–20 microgram/kg/hr). Muscle
relaxation is seldom necessary and
used only if morphine infusion has
already commenced
CARE OF VENTILATED BABY

Ventilated babies should have:
Continuous electronic monitoring of
heart rate, ECG, respiratory rate, SpO2
and temperature
Blood pressure
continuous measurement of arterial
blood pressure in babies ≤28 weeks’
gestation, and those >28 weeks
needing FiO2 >0.6
cuff measurement 4-hrly in acute phase
At least 6-hrly blood gas (arterial or
capillary) measurement during acute
phase of disease
Hourly measurement of colour, and
measured ventilatory parameters. If
sudden drop in Vt, check air entry
Daily monitoring of intake, output and
weight
Parent information
Offer parents the following information,
available from:
http://www.bliss.org.uk/ventilation
Issue 6
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VENTILATION: HIGH FREQUENCY
OSCILLATORY (HFOV) • 1/3
Decision to initiate HFOV must be made by a consultant. Do not start HFOV unless
you have been trained to do so and have demonstrated your competence
INDICATIONS
Rescue following failure of conventional ventilation (e.g. PPHN, MAS)
To reduce barotrauma when conventional ventilator settings are high
Airleak (pneumothorax, PIE)
Less effective in non-homogenous lung disease
Terminology
Frequency High frequency ventilation rate (Hz, cycles per second)
MAP Mean airway pressure (cmH2O)
Amplitude Delta P or power is the variation around the MAP
Mechanism
Oxygenation and CO2 elimination are independent
Oxygenation is MAP provides constant distending pressure equivalent to CPAP, inflating
dependent on MAP the lung to constant and optimal lung volume, maximising area for gas
and FiO2 exchange and preventing alveolar collapse in the expiratory phase
Ventilation (CO2 removal) The wobble superimposed around the MAP achieves alveolar
dependent on amplitude ventilation and CO2 removal
MANAGEMENT
Preparation for HFOV
If there is significant leakage around Invasive blood pressure monitoring if
the ET tube (ETT), insert a larger one possible
Optimise blood pressure and perfusion, Correct metabolic acidosis
complete any necessary volume Ensure adequate sedation
replacement and start inotropes, if
Muscle relaxants are not necessary
necessary, before starting HFOV
unless already in use
Initial settings on HFOV

MAP
Optimal (high) If changing from conventional ventilation, set MAP 2–4 cmH2O
lung volume strategy above MAP on conventional ventilation
(aim to maximise recruitment If starting immediately on HFOV, start with MAP of 8 cmH O and
2
of alveoli) increase in 1–2 cmH2O increments until optimal SpO2 achieved
Set frequency to 10 Hz
Low volume strategy Set MAP equal to MAP on conventional ventilation
(aim to minimise lung trauma) Set frequency to 10 Hz
Optimal (high) volume strategy preferred but consider low volume strategy when air
leaks are present
Issue 6
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Amplitude (delta P on SLE ventilator)
Gradually increase amplitude until chest seen to wobble well
Obtain early blood gas (within 20 min) and adjust settings as appropriate
Change frequency only after discussion with consultant
Making adjustments once HFOV established

Poor Over- Under- Over-
oxygenation oxygenation ventilation ventilation
Decrease MAP
Adjust MAP Increase Decrease
Either (1–2 cmH2O)
(+/- 1–2 cmH2O)* amplitude amplitude
when FiO2 <0.4
Or Increase FiO2 Decrease FiO2
* both over and under inflation can result in hypoxia. If in doubt, perform chest X-ray
MONITORING increase FiO2 following suctioning

Amplitude maximal when chest procedure
‘wobbling’, minimal when movement MAP can be temporarily increased by
imperceptible 2–3 cmH2O until oxygenation improves
Frequent blood gas monitoring (every
30–60 min) in early stages of Low PaO2
treatment as PaO2 and PaCO2 can Suboptimal lung recruitment
change rapidly increase MAP
If available, transcutaneous TcPCO2 consider chest X-ray
Chest X-ray Over-inflated lung
Within 1 hr to determine baseline lung reduce MAP: does oxygenation

volume on HFOV (aim for 8 ribs at improve? Check blood pressure
midclavicular line) consider chest X-ray
if condition changes acutely and/or ETT patency
daily to assess expansion/ETT check head position and exclude kinks
position, repeat chest X-ray in tube
TROUBLESHOOTING ON check for chest movement and breath
HFOV sounds
check there is no water in ETT/T piece
Chest wall movement
Air leak/pneumothorax
Suction indicated for diminished chest
wall movement indicating airway or transillumination – see
ETT obstruction Transillumination of the chest
guideline
Always use an in-line suction device to
maintain PEEP urgent chest X-ray
Issue 6
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High PaCO2
ETT patency and air leaks (as above)
Increase amplitude, does chest wall
movement increase?
Increased airway resistance (MAS or
BPD) or non-homogenous lung
disease, is HFOV appropriate?
Persisting
acidosis/hypotension
Over-distension
Exclude air leaks; consider chest X-ray
reduce MAP: does oxygenation
improve?
Spontaneous breathing
Usually not a problem but can indicate
suboptimal ventilation (e.g. kinking of
ETT, build-up of secretions) or
metabolic acidosis
WEANING
Reduce FiO2 to <0.4 before weaning
MAP (except when over-inflation
evident)
When chest X-ray shows evidence of
over-inflation (>9 ribs), reduce MAP
Reduce MAP in 1–2 cm decrements to
8–9 cm 1–2 hrly or as tolerated
If oxygenation lost during weaning,
increase MAP by 3–4 cm and begin
weaning again more gradually. When
MAP is very low, amplitude may need
increasing
In air leak syndromes (using low
volume strategy), reducing MAP takes
priority over weaning the FiO2
Wean the amplitude in small increments
(5–15%) depending upon PCO2
Do not wean the frequency
When MAP <8 cmH2O, amplitude

20–25 and blood gases satisfactory,
consider switching to conventional
ventilation or extubation to CPAP
Issue 6
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VENTILATION: SYNCHRONOUS POSITIVE
PRESSURE (SIPPV) • 1/3
DEFINITION Set back-up rate of 35–40/min
A form of synchronous ventilation in Peak inspiratory pressure (PIP)
which baby triggers/initiates the breath 16–18 cm H2O
while ventilator does the work of
Peak end expiratory pressure (PEEP)
breathing. In other words, rate of 5 cm H2O
ventilation is determined by baby while
pressures are determined by operator via FiO2: 0.4–0.6
ventilator
Software allows compensation for a
SETTING UP TRIGGER leak of 10–50%
VENTILATION Observe tidal volume settings to
confirm between 4–6 mL/kg
Set humidifier temperature at 39ºC
(negative 2) to achieve airway Baby
temperature of 37ºC
If gestation <34 weeks, load baby with
Set up Babylog (Drager) caffeine citrate (20 mg/kg) IV if not
already started
Flow 6–10 L/min
Discontinue sedation
Select SIPPV mode
Select highest trigger sensitivity (1: bar INITIATING TRIGGER
is all unshaded) VENTILATION
Select Tinsp (inspiratory time) between Once baby connected to ventilator:
0.3–0.4 sec check SpO2 (see Oxygen saturation
Adjust Texp (expiratory time) to achieve targets guideline) and adjust FiO2
back-up rate of 35–40/min accordingly
Peak inspiratory pressure (PIP) check baby’s chest moving
16–18 cm H2O adequately, and measured tidal
volume (Vt). Chest expansion should
Peak end expiratory pressure (PEEP)
be just visible, and Vt should be
5 cm H2O
between 4–6 mL/kg. If not, adjust
FiO2: 0.4–0.6 PIP/PEEP to maintain adequate
oxygenation and ventilation
Set up SLE 5000 using
check ventilator triggering in synchrony
version 4.3 software upgrade with baby. Assess by listening to
Flow is fixed in SLE at 5 L/min ventilator while watching baby’s
Select PTV (patient triggered respiratory effort
ventilation) mode
Most likely cause of baby ‘fighting’
Select highest trigger sensitivity ventilator is asynchrony (see
(0.4 L/min for ≤28 weeks’ gestation, Management of asynchrony)
0.6–0.8 L/min for >28 weeks’
gestation). Look at baby to confirm
triggering adequately by observing
baby generated breaths are triggering
ventilator support
Select Ti (inspiratory time) for back-up
breaths between 0.3–0.4 sec
Issue 6
350
SUBSEQUENT Do not use muscle relaxants at any
ADJUSTMENTS ON SIPPV stage unless, despite carrying out above
Check blood gas within 30 min of checks, baby cannot be ventilated.
initiation of SIPPV If muscle relaxants necessary, revert to
conventional ventilation (see
Aim for PaO2 between 6–10 kPa,
Ventilation - conventional guideline)
PaCO2 between 5–7 kPa and pH >7.25
NURSING OBSERVATIONS
To improve oxygenation
While baby on SIPPV,
Increase FiO2
hourly observations
Rule out pneumothorax Back-up rate set
Increase PIP and/or PEEP Baby’s own respiratory rate
Increase Tinsp (not more than 0.4 sec) Tidal volume (Vt in mL)
Minute ventilation (MV in 1/min)
To decrease PaCO2
If alarm goes off, check
Rule out pneumothorax
Synchrony between baby and ventilator
Increase PIP Excessive water droplets in ventilator
Check if baby triggering adequately. tubing
If not, try shortening Tinsp, or Flow graph for evidence of blocked
increasing back-up rate tube or excessive Tinsp
Disconnection
Low PaCO2
Decrease PIP
MANAGEMENT OF
ASYNCHRONY
Decrease back-up rate if >35/min
Checklist
In a vigorous hypocapnic baby, transfer
Is endotracheal tube (ETT) patent
to SIMV (synchronised intermittent
(look at flow graph and Vt)
mandatory ventilation) at a rate of at
least 20/min Is Tinsp too long? (is baby exhaling
against ventilator?), if so shorten Tinsp
GENERAL SUPPORT to 0.24–0.3 sec
Monitor SpO2 continuously Is back-up rate too high? If so, consider
dropping to 30–35 breaths/min
Check arterial blood gases at least
4–6 hrly depending on stage of disease Is there water condensation in
ventilator tubing?
In babies successfully ventilated in
If all above fails, consider morphine
SIPPV mode, sedation is unnecessary
bolus (100 microgram/kg) over 3–5 min
Remember, most common cause of If baby still continues to ‘fight’ ventilator,
baby fighting ventilator is asynchrony. use continuous sedation and revert to
Always carry out checks and SIMV (see Ventilation - conventional
adjustments (see Management of guideline)
asynchrony)
Issue 6
351
AUTOCYCLING WEANING FROM SIPPV
(FALSE TRIGGERING) Once baby stable (triggering above set
False triggering occurs when ventilator rate, saturating in FiO2 <0.3), wean by:
delivers a mechanical breath
decreasing PIP by 1–2 cm H2O each
artifactually when baby not actually
time (in SIPPV/PTV mode, weaning
initiating a spontaneous respiration
rate in a baby who is already triggering
Usually results from presence of water above it is useless)
droplets in ventilatory circuit, or an
check baby breathing regularly and
excessive ETT leak
effortlessly (no chest recessions), and
If baby’s trigger rate appears to be in blood gases and oximetry are
excess of 80/min, ensure this is actual acceptable
rate by observing baby’s own
once PIP between 14–16 cm H2O
respiratory movements. If not:
(depending on size of baby), consider
check ventilatory circuit for excessive extubation
water condensation and empty if
necessary assess need for nasal CPAP by
checking for chest recessions,
decrease trigger sensitivity spontaneous minute ventilation, and
look for amount of ETT leak on regularity of breathing
Babylog display. If in excess of 50%, During weaning PaCO2 can rise above
consider changing to slightly wider ETT
7 kPa and Vt may fall below 4 mL/kg
provided baby triggering well, is not
visibly tired, and pH >7.25, no action
required
if poor triggering, visibly tired or
abnormal pH, increase PIP, and later
back-up rate
Issue 6
352
VENTILATION - VOLUME TARGETED
(Volume guarantee/targeted tidal volume) • 1/1
DEFINITION PEAK PRESSURES
In volume-targeted ventilation (VTV) Start PIP limit (Pmax) of ~25–30 cm
primary gas delivery target is tidal volume H 2O
(Vt) while the peak inspiratory pressure
Adjust Pmax to 5–6 cm H2O above
may vary depending on underlying lung
compliance. Available as volume average PIP needed to deliver set tidal
guarantee (VG) on Draeger babylog and volume
targeted tidal volume (TTV) on SLE 5000 If PIP progressively increases or is
persistently high or if set Vt not
Benefits delivered, re-assess baby
Compared with pressure-controlled PEEP set at 4–6 cm water
ventilation, VTV can reduce:
mortality VENTILATOR RATE
bronchopulmonary dysplasia In baby with poor respiratory drive, use
rates of 50–60 bpm
pneumothorax
Lower back-up rates of 30–40 bpm can
hypocarbia
be used with good respiratory drive
severe cranial ultrasound abnormalities
Use Ti (inspiratory time) of
INDICATION 0.3–0.4 sec; in PSV mode, set
maximum Ti at 0.5–0.6 sec – actual Ti
Primarily used in preterm babies with
is adjusted by the ventilator
surfactant-deficient lung disease
requiring ventilation WEANING
May be useful in other situations In assist-control or PSV, wean by
requiring ventilation reducing Vt in steps of 0.5 mL/kg
TIDAL VOLUMES TO USE Pressure weans automatically as lung
Expired tidal volume (Vte) used as compliance improves
less influenced by ETT leaks Avoid tidal volumes <3.5 mL/kg
Vt 4–6 mL/kg In SIMV, rate reduced as well as Vt
Vt >8 mL/kg associated with Attempt extubation when:
volutrauma MAP falls consistently <8 cm
5 mL/kg reasonable starting volume baby has good respiratory drive and
Adjustments can be made in steps of satisfactory gases
0.5 mL/kg
Avoid Vt <3.5 mL/kg
MODE
VG/TTV combined with assist control
(PTV) or pressure-support ventilation
(PSV) preferred – these modes
support all spontaneous breaths
If used in SIMV mode, need a set rate
of at least 40/min
PSV has the additional advantage of
synchronising expiration
Issue 6
353
VITAMIN K • 1/2
INDICATIONS Two doses of oral vitamin K 2 mg
should be given in the first week, the
Prophylaxis first at birth and the second at 4–7
Babies are relatively deficient in days. For exclusively breastfed babies,
vitamin K (phytomenadione) and those a third dose of 2 mg is given at 1
who do not receive supplements are at month of age; the third dose is omitted
risk of bleeding (vitamin K deficiency in formula-fed babies because formula
bleeding, formerly known as feeds contain adequate vitamin K
haemorrhagic disease of the newborn)
If parents refuse prophylaxis, ask
All babies should be given vitamin K senior neonatologist to see and record
with parental consent discussion in notes
Therapy IM use
After blood has been taken for clotting Do not dilute or mix with other
studies, vitamin K can also be used to parenteral injections
treat any baby with active bleeding
that might have resulted from vitamin Oral use
K deficiency Break open ampoule and withdraw
a prolonged prothrombin time (INR 0.2 mL (2 mg) into the oral dispenser
≥3.5) that falls within 1 hr of treatment, provided. Drop contents directly into
with normal platelet count and baby's mouth by pressing plunger
fibrinogen concentration suggest the
diagnosis. However, as INR is a poor
indicator of vitamin K deficiency,
PIVKAII is a better investigation if
available
ADMINISTRATION
Prophylaxis
Vitamin K (Konakion MM Paediatric)
as a single IM dose (see Table below
for dosage schedule)
avoid IV administration for prophylaxis
as it does not provide the same
sustained protection as IM
Give in accordance with
manufacturer’s instructions in order to
ensure clinical effectiveness
If parents decline IM route, offer oral
vitamin K as second line option (safety
fears of parenteral vitamin K appear to
be unfounded)
Issue 6
354
VITAMIN K • 2/2
Prophylaxis dosage Konakion MM Paediatric
Healthy babies of ≥36 weeks First line
1 mg IM at birth or soon after
Second line
2 mg oral at birth, then
2 mg oral at 4–7 days, then
2 mg oral at 1 month if exclusively
breastfed
Term babies at special risk
Instrumental delivery, caesarean
section 1 mg IM at birth or soon after
Maternal treatment with enzyme-
inducing anticonvulsants
Do not offer oral vitamin K
(carbamazepine, phenobarbital,
phenytoin), rifampicin or warfarin
Requiring admission to neonatal unit
Babies with cholestatic disease where
oral absorption likely to be impaired
Preterm babies <36 weeks but ≥2500 g 1 mg IM at birth or soon after

All babies <2500 g 400 microgram/kg (0.04 mL/kg) IM shortly
after birth (maximum dose 1 mg)
Do not exceed this parenteral dose
The frequency of further doses should
depend on coagulation status
Babies who have or may have Factor VIII Unless results of Factor assays normal,
or Factor IX deficiency or other give orally – consult with local
coagulation deficiency haematologist
For babies with birth weight Therapy dosage

≥2500 g If not already given IM, give vitamin K
Administer Konakion MM Paediatric 100 microgram/kg IV up to 1 mg
1 mg (0.1 mL) IM maximum dose
this is approximately half of the ampoule Further doses as required, depending on
volume and should be drawn up using clinical picture and coagulation status
the syringe supplied with the ampoule may need to be accompanied by a more
immediately effective treatment such as
For babies with birth weight transfusion of fresh frozen plasma
<2500 g
Administer 400 microgram/kg (0.04 mL) IV administration
with a maximum of 1 mg (0.1 mL) of If necessary, dilute. For IV
Konakion MM Paediatric IM administration, dilution in glucose is not
round up the dose to nearest hundredth recommended due to reactions with
[e.g. 300 microgram (0.03 mL), syringes but the drug can be added to
500 microgram (0.05 mL) etc.] a lower port of a syringe giving set
draw up the dose using the syringe administering glucose 5% at rate not
supplied with the ampoule less than 0.7 mL/hr
Issue 6
355
INDEX • 1/4
A Chickenpox 337-339
Abstinence syndrome 13 Chlamydia 64, 167
Aciclovir 64, 129, 172, 337, 339 Chloral hydrate 243
Activated Partial Thromboplastin Chloramphenicol 64
Time (APTT) 57-58, 74, 200, 265 Chlorpromazine 15
Actrapid 136, 249 Chronic lung disease 53
Admission to neonatal unit (NNU) 17 Cleft lip/palate 18, 21, 97, 139, 189, 213
Ambiguous genitalia 88, 183 Clonazepam 161, 288-289
Anaphylaxis 164 CMV 55
Ano-rectal malformation 19 CO2 and O2
Antenatal ultrasound abnormalities 21 transcutaneous monitoring 314-315
Apgar score 73, 96, 159-160, 268 Coagulopathy 57
Apnoea and bradycardia 22 Collapse (sudden postnatal) 298
APTT 57-58, 74, 200, 265 Congenital heart disease
Arterial line insertion 24 including HLHS 60
Arterial line sampling 26 Congenital spherocytosis 192
Atelectasis 69, 93 Conjunctivitis 64
Consent 65
B Conventional ventilation 343
Bag and mask ventilation 190 Convulsions 13, 161, 264
BCG immunisation 28 Cooling 73
Blood gas analysis 26, 48, 326, 343 Coombs’ positive babies 32, 194
Blood group incompatibilities 31 Cord care 293
Bloodspot screening 33 CPAP 69
Blood transfusion 317 Cranial ultrasound scans 76
Blue baby 60 Curosurf® 301
Bottle feeding 34
Brachial plexus injury 333 D
Breastfeeding 36 Death and seriously ill babies 79
Breast milk expression 38 Decolonisation 209-210
Breast milk handling and storage 40 Dehydration (hypernatraemic) 139
Broviac line insertion 42 Developmental care 82
Developmental dysplasia of the hip 84
C Dexamethasone 29, 54, 68, 139, 190,
Calcium resonium 138 207, 225
Cannulation 45 Dialysis 138, 142, 173, 178, 276
Cardiac arrhythmias 42, 60, 100, 138, 149, Diamorphine 218, 242, 243
204, 251, 254, 332 Difficult intubation 189
Cardiac murmurs 46 Direct Coombs’ test 31, 133,
Cephalhaematoma 97, 192 192, 193, 317
Chest drain insertion 47 Discharge from the neonatal unit 86
Chest drain insertion – Disorders of sexual development 88
Seldinger technique 49 Domperidone 39
Chest physiotherapy 51 Drug withdrawal 14
Issue 6
356
INDEX • 2/4
E Hepatosplenomegaly 55, 192, 303, 311
EBM 37, 41, 83, 141-144, Herpes simplex 129
207, 223, 225-227, 240 HFOV 347
ECG abnormalities 90 High flow nasal cannulae (HFNC) 130
ECMO 111-112, 123, 257 HIV 131
Eczema 29 HLHS 60-63
Endocrine deficiency 146 Hydrolysate 114
Endotracheal tube suctioning 92 Hydrops fetalis 133
Enteral feeding 222-330 Hyperglycaemia 135
Environment and noise 94 Hyperinsulinism 146, 148, 175
Erythromycin 64, 114 Hyperkalaemia 137
ESBL 209-210 Hypernatraemic dehydration 139
Examination of the newborn 96 Hyperoxia 46, 52, 61, 186, 255, 302
Exchange transfusion 100 Hypoglycaemia 143
Exomphalus major 103 Hypokalaemia 149
Extravasation injuries 106 Hyponatraemia 54, 182, 228, 253, 276
Extreme prematurity 109 Hypoplastic left heart syndrome
(HLHS) 60
F Hypotension 151
Feeding Hypothermia 154
– Enteral 222 Hypothyroidism 156
– PN 246 Hypoxic-ischaemic
Fluid restriction 143, 161, 275-276 encephalopathy (HIE) 159
Fluid therapy IV 181
Follow up of babies I
discharged from NNU 111 Immunisations 163
Inborn errors of metabolism 290-291
G Infection in first 72 hours of life 166
Gastro-oesophageal reflux (GOR) 113 Infection (late onset) 169
Gastroschisis 115 Inguinal hernia 174
Glucosuria 151 Insertion of arterial lines 24
Golden hour 119 Insertion of chest drain 47, 49
Gonococcus 167 Insertion of long lines 202
Gram-negative organisms 167-170, 209 Intra-abdominal cysts 179
Gram stain 64, 168, 170, 172 Intubation 186
Intubation – difficult 189
H Isoniazid 36, 324
HCV 128 IUT 31-32, 100
Hearing screening 122 Intravenous fluid therapy 181
Heart failure 124
Heart murmur 46, 268 J
Heel prick 169, 292, 308, 342 Jaundice 192
Hepatitis B and C 127
Issue 6
357
INDEX • 3/4
K Non-nutritive sucking 221
Kangaroo care 195 Nutrition and enteral feeding 222
Kleihauer test 31, 100, 133
Konakion 354-355 O
Oesophageal atresia/replogle tubes 231
L O2 and CO2 transcutaneous monitoring 314
Labour ward calls 197 Oxygen on discharge 234
Liver disease 192 Oxygen (saturation) 236
Liver dysfunction in preterm babies 198
Long line insertion 202 P
Lumbar puncture 18, 58, 67, 167, 170, Pain assessment and management 238
173, 286, 300, 308 Palivizumab 244
Lung disease (chronic) 53 Paracetamol 242
Parenteral nutrition 246
M Patent ductus arteriosus (PDA) 251
Maternal diabetes 139, 198, 258, 306 Pelviectasis 334-335
Maternal thyroid disease 311 Pericardial tamponade 204, 254
Maxijul 146 Pericardiocentesis 254
Meconium aspiration syndrome 301 Persistent pulmonary
Meconium staining 197 hypertension (PPHN) 255
Medium-chain Acyl-coa Dehydrogenase Phenytoin 161, 288-289, 355
Deficiency (MCADD) 206 Phytomenadione 354
Metabolic bone disease 207 PKU 33, 37
Meningococcus B 163 Polycystic kidneys 274
Meningococcus C 163 Polycythaemia 258
Metabolic disorders 22, 76, 143, Poractant 301
175-178, 290, 306 Positioning and positioning aids 260
Morphine sedation 49, 74, 151, 153, 174, Preterm care 119
218, 243, 346, 351
Prostaglandin infusion 263
MRSA 170, 209-210
Prothrombin time (PT) 57, 74
Multi-drug resistant
Pulmonary haemorrhage 265
organism colonisation 209
Pulse-oximetry screening (universal) 267
Multiple transfusions 33, 317
Myasthenia gravis 197
Q
Quiet time 95
N
Nappy dermatitis 293
Nasogastric tube administration
R
of feed, fluid or medication 211 Radioisotope 36
Nasogastric tube insertion 213 Rectal washout 270
Necrotising enterocolitis (NEC) 317 Recycling stoma losses 272
Neonatal abstinence 13 Renal abnormalities on
Newborn examination 96 ultrasound scan 334
Nitric oxide 220 Renal failure 274
Issue 6
358
INDEX • 4/4
Replogle tubes 231 U
Respiratory distress syndrome Umbilical arterial catheterisation
130, 135, 159, 181, 265 and removal 326
Resuscitation 277 Umbilical venous catheterisation
Retinopathy of prematurity (ROP) 283 and removal 330
Rhesus disease 31, 197 Universal pulse-oximetry screening 264
Upper limb birth injuries including
brachial plexus injury 333
S Urinary tract abnormalities
on antenatal scan 334
Sacral dimple 285
Salbutamol 90, 137
Seizures 286 V
Sexual development (disorders of) 88 Vaccination (BCG) 132
SIPPV 350 Varicella 337
Skin biopsy 290 Vascular spasm and thrombosis 340
Skin care 292 Vasospasm 25, 328, 340
Skin excoriation 293, 294 VDRL 303-305
Stoma management Venepuncture 342
(gastrointestinal) 294 Ventilation conventional 343
Sucrose 83, 202, 213, 240-241, 243, Ventilation high frequency oscillatory 347
270, 283, 342 Ventilation synchronous
Sudden unexpected postnatal positive pressure (SIPPV) 350
collapse in first week of life 298 Ventilation (volume guarantee/
Surfactant replacement therapy 301 targeted tidal volume) 353
Synagis® (palivizumab) 29 Vitamin K 354
Synchronous intermittent positive VZV 37, 338-339
pressure ventilation (SIPPV) 350
Syphilis 303 W
Systemic lupus erythematosus 197 Warfarin 355
T Z
TB (investigation and management Zidovudine 131
following exposure in pregnancy) 324
Tetanus pertussis 163
Thrombocytopenia 306
Thromboembolism 25-26, 340, 341
Thyroid disease (maternal) 311
Transcutaneous CO2 and O2
monitoring 314
Transfusion of red blood cells 317
Transillumination of the chest 320
Transport and retrieval 321
Trimethoprim 172, 335
Tuberculin 28
Issue 6
359
NOTES
Issue 6
360
NOTES
Issue 6
361
NOTES
Issue 6
362
This copy belongs to
Name...........................................................................................................
Further copies can be purchased from Staffordshire, Shropshire & Black
Country Newborn and Maternity Network Administrator:
Email: sarah.carnwell@nhs.net
Published by the Bedside Clinical Guidelines Partnership,

Staffordshire, Shropshire & Black Country Newborn and Maternity
Network and Southern West Midlands Maternity and Newborn Network
NOT TO BE REPRODUCED WITHOUT PERMISSION
Staffordshire, Shropshire & Black Country Newborn and Maternity Network comprises:
The Royal Wolverhampton NHS Trust
University Hospitals of North Midlands NHS Trust
Southern West Midlands Maternity and Newborn Network comprises:

Birmingham Women’s NHS Foundation Trust
Heart of England NHS Foundation Trust
Sandwell and West Birmingham Hospitals NHS Trust
Worcestershire Acute Hospitals NHS Trust
Birmingham Children’s Hospital NHS Foundation Trust
The Bedside Clinical Guidelines Partnership comprises:

Ashford & St Peter’s Hospitals NHS Trust
Barnet and Chase Farm Hospitals NHS Trust
Basildon and Thurrock University Hospital NHS Foundation Trust
Burton Hospitals NHS Foundation Trust
East Cheshire NHS Trust
George Eliot Hospital NHS Trust
The Hillingdon Hospital NHS Foundation Trust
Mid Cheshire Hospitals NHS Trust
North Cumbria University Hospitals NHS Trust
The Pennine Acute Hospitals NHS Trust
The Royal Wolverhampton Hospitals NHS Trust
University Hospitals Birmingham NHS Foundation Trust
University Hospitals North Midlands NHS Trust
University Hospitals of Morecambe Bay NHS Trust
Wrightington, Wigan and Leigh NHS Foundation Trust
Neonatal
Neonatal Guidelines 2015–17

Neonatal Guidelines
2015-17
Guidelines
This book has been compiled as an aide-memoire for all staff
concerned with the management of neonates, towards a more
uniform standard of care across the Staffordshire, Shropshire and
Black Country Newborn and Maternity Network hospitals and
2015–17
Southern West Midlands Maternity and Newborn Network hospitals.
These guidelines are advisory, not mandatory
Every effort has been made to ensure accuracy
The authors cannot accept any responsibility for adverse outcomes
Published by the Staffordshire, Shropshire &

Black Country Newborn and Maternity Network
The Bedside Clinical Guidelines Partnership
Further copies are available to purchase from the
http://www.networks.nhs.uk/nhs-networks/staffordshire- in association with the
shropshire-and-black-country-newborn/neonatal-guidelines
Staffordshire, Shropshire & Black Country
Copyright © Copyright Holder
Newborn and Maternity Network
ISBN 978-0-9557058-7-8 Southern West Midlands Maternity and

Issue 6
Newborn Network
Printed by Sherwin Rivers Ltd.

Waterloo Road, Cobridge, Stoke on Trent ST6 3HR
Tel: 01782 212024 Email: sales@sherwin-rivers.co.uk 9 780955 705878

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Neonatal

Neonatal Guidelines 2015–17

These guidelines are advisory, not mandatory

Every effort has been made to ensure accuracy

The authors cannot accept any responsibility for adverse outcomes

Published by the Staffordshire, Shropshire &

ISBN 978-0-9557058-7-8 Southern West Midlands Maternity and

Printed by Sherwin Rivers Ltd.

Published by the Bedside Clinical Guidelines Partnership,

Southern West Midlands Maternity and Newborn Network comprises:

The Bedside Clinical Guidelines Partnership comprises:

ADMISSION AND DISCHARGE

Contributors Bashir Muhammad

Bedside Clinical Guidelines

Staffordshire, Shropshire &

Southern West Midlands

The editors would like to thank the

dHT Dihydrotestosterone MDT Multidisciplinary team

DIC Disseminated intravascular MEBM Mother’s expressed breast milk

ECG Electrocardiogram NEC Necrotising enterocolitis

EDD Expected date of delivery NGT Nasogastric tube

EFM Electronic fetal monitoring NHSP Newborn Hearing Screening

Prescribing regimens and nomograms

Level of evidence Strength of evidence

IV Evidence from well-designed non-experimental studies from more than one

V Opinions of respected authorities, based on clinical evidence, descriptive

Evaluation of the evidence-base of these guidelines involves review of existing literature

Evidence-based developments for which funding is being sought

Yawning type and amount of drug(s) exposure

Sneezing route of administration

Nasal stuffiness when last dose was taken

Poor feeding Neonatal team are not required to be

Babies who required Babies who did not require

drug rehabilitation team for mother

Figure 2: Fistula opening onto scrotal

One or more of the following features

Cleft lip and/or palate When available and if not issued

Heart rate <100/min, associated with Infection

Most babies born <34 weeks’ GI

sudden increase in frequency warrants inherited metabolic disorders e.g. non-

MANAGEMENT Pharmacological treatment

stimulate baby by tickling feet or may continue beyond 34 weeks PCA if

If apnoea or bradycardia increasingly CPAP, SiPAP/BiPAP – see CPAP

Treat specific cause, if present

INDICATIONS Inaccuracy of blood gas

Ensure all connections are secure, Paper towel

Limb appears blanched. Stop 2 mL syringe (D) containing 0.5–1 mL

Thromboembolism PREPARATION AND

Countries with incidence of TB >40/100,000

Parts of UK with incidence of TB >40/100,000

sometimes, this ulcerates and can ooze

Always discuss indications with consultant

Indications for IVIG use in isoimmune haemolytic anaemia

Dose and administration

Pace baby during bottle feed to help To pace:

Parents to room-in and demand-feed To ensure parent and baby confidence

PRETERM BABIES CONTRAINDICATIONS TO

Varicella-zoster virus (VZV) For medications that require caution

Problems related to milk

Too little milk

Complications Problems in Causes of line blockage

T-piece connected to a syringe of resistance may diminish slightly as it

URGENT SOON ROUTINE Signs and