Neonatal Guidlines

Neonatal Guideline Valid till .31st January 2017

Postnatal v2015.1

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NEONATAL GUIDELINES

Postnatal

Version 2015.1

Archive of relevant ratified guidelines

Specialty: Neonatal Medicine

Revision date: January 2015

Revised by: Sujoy Banerjee

Edited by : Sujoy Banerjee

Approved by: Quality and Safety Group, W&CH, ABMU in

line with changes made to neonatal guidelines

Date for Review: 31st January 2017

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CONTENTS

Topics Page number

___________________________________________________________________

Disclaimer 4

Admission criteria for NNU 5

Hand washing and aseptic technique 6

Postnatal Examination 7

Postnatal Follow up 11

Prescription Charts 11

Collapse in the postnatal period 13

Neonatal resuscitation 13

Clinical observation of babies in the postnatal period 20

Common Postnatal Problems 23

Management of birth injuries 30

Meconium stained liquor 40

Heart Murmur in the newborn 41

Routine pulse oximetry in the newborn 42

Absent femoral pulse / Cyanosis 44

Siblings with history of Congenital Heart disease 45

Ectopic beats in neonates 46

Hip abnormalities /Clubfoot 47

Chicken pox exposure in the peripartum period 53

Management of infection 54

Antibiotic Policy 57

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Herpes Simplex Infection in neonate 62

PROM guidelines 67

Group B streptococcal guidelines 68

Sepsis prophylaxis flow chart 72

Hepatitis C 75

Hepatitis B 79

Management of infants with maternal retroviral infection 86

Diagnosis and management of infants at risk of congenital syphilis 89

Management of weight loss in healthy breast fed babies 93

Management of hypoglycemia 97

Neonatal jaundice 103

Conjugated hyperbilirubinaemia 106

Phototherapy 107

Management of incidentally detected extremely high bilirubin 110

Management of suspected haemolytic disease of newborn 111

Management of deliveries to Rh D negative women 114

Prolonged jaundice 117

Guidelines on use of Tc Bilirubinometer 120

Neonatal Polycythaemia 122

Discharge medications 125

Neonatal abstinence syndrome 128

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Disclaimer

These guidelines are intended to assist decision making process for common neonatal

problems in the postnatal period either in hospital or in the community.. For more

complex problems refer to the full neonatal guidelines on the unit or take advice from a

senior neonatologist.

The guidelines are frequently updated. You will be informed if there has been a

significant change and it is your responsibility to familiarise yourself with the current

guidelines.

Guidelines are not meant to replace discussion. If you feel uncertain please ask! Your

questions may help us to modify our practices to provide better care for our babies.

Don’t be afraid to challenge!

For dosage of drugs please refer initially to the Northern Neonatal Network Formulary

Formulary 5th edition. If the information is not available in the formulary then consult the

unit drug folder.

These guidelines are intended only for use within ABMU Health Board and may need to

be adapted for different sites. No responsibility or liability is accepted for the use or

misuse of these protocols and guidelines outside of this Health Board.

NB: These GUIDELINES are only valid until the date stated at the

footer of each section. DO NOT follow protocol if the ‘valid until’ date

has passed; consult an up-to-date version.

Please note that these files are ‘read only’ copies. Any comments /

proposed changes to the guideline must be directed to Dr. Sujoy

Banerjee. Such changes will be discussed in our team meeting and

you will be notified if an amendment is made.

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Who needs admission to NNU?

1. Infants less than 35 weeks gestation

2. Infants less than 1800g birth weight

3. Infants of a diabetic mother whose weights are >90th percentile (macrosomic) or

<10th percentile

4. Any infant with an episode of apnea or seizure

5. Tachypnoea, grunting or any oxygen requirement or requirement for CPAP or

ventilation.

6. Infants with suspected or confirmed severe congenital abnormalities such as

cyanotic congenital heart disease, TOF, exomphalos, gastroschisis

7. Infants with withdrawal signs from maternal drugs

8. Any baby who requires prolonged resuscitation including cardiac compressions or

adrenaline or Apgars <5 @5 min, or any baby who is in secondary apnea

9. Infants with suspected metabolic disease

10. Infants requiring exchange transfusion or with severe jaundice or hemolytic

disease

11. Hypoglycemia that has not responded to tube feeds or glucose <1.6 mmmol/l

12. Infants who have vomited bile or have abdominal distension

13. Other babies at the discretion of the paediatrician

No baby should be admitted to the neonatal unit after discharge home except for those

with severe hyperbilirubinaemia with potential for exchange transfusion. Always discuss

with the neonatal consultant or the sister in charge for NNU if you are not sure (Working

draft policy – Changed March 2011).

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Hand washing and aseptic technique

Newborn babies are vulnerable to infection. This can be transmitted via improper

handwashing. Before examining each baby, please ensure that all your jewellery, e.g.

rings, watches etc, are removed, your sleeves are well rolled up and you have carefully

and thoroughly washed your hands.

You can only use the gel in order to disinfect hands, which are already clean.

Please ensure that everyone on the unit follows this policy at all times

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Postnatal examination:

After a baby is born parents are naturally anxious to know if their baby is all right. A

thorough physical examination of every newborn is accepted as good practice and forms

a core item of the child health surveillance programme in the UK. Up to 12% of babies

may have some detectable abnormality at birth but not all will impact on health or require

action. All newborn babies should be examined within preferably within 24 hours of birth

and always within the first 72 hours. They will need to be reviewed again only if any new

problems are identified during their stay.

The aims of the newborn examination are:

Diagnosis of congenital malformations

Diagnosis of common neonatal problems with advice about management or

appropriate reassurance if no intervention is indicated

Identify babies who should be offered specific intervention e.g. Hepatitis B

vaccination

Health education advice (cot death prevention, breast feeding, safe transport in

cars)

General parental reassurance

If a significant problem is identified an experienced paediatrician needs to explain the

situation to the parents.

Remember the newborn / postnatal period is an emotional time for parents and for

mothers in particular. They are tired and trying to establish feeding and have hormonal

changes occurring. At such a time what appears to be a small problem to yourself may

be perceived as a big upset for them. This is particularly for procedures that involve

separating mothers from their babies eg: going under a phototherapy light or being

admitted to the neonatal unit. Please be as positive, supportive and reassuring in your

approach as you can.

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Midwives & Nursery Nurses

It is important to respect their knowledge and experience of normal newborns. Listen to

them, you can learn a lot about aspects of newborns and their care. If there is a

disagreement regarding the management of a baby always listen first then explain your

viewpoint. If the difference is still not resolved consult your SCBU Registrar/Consultant.

Newborn examination checklist:

The findings of these examinations should be clearly documented in the notes. Any

plans for further screening or investigations should be clearly documented and

appropriate follow up arrangement made.

The ophthalmoscope and the auroscope now stay on a trolley on the NNU and need to

be returned to NNU and plugged in for charging after the postnatal checks are over

This checklist is a reminder

Wash hands thoroughly immediately before every examination (3 mins for initial wash).

Introduce yourself and offer congratulations.

Initial Details:

Obtain any relevant past obstetric history, past medical history, pregnancy details

(drugs/illness) and details of the labour, delivery and infant’s condition at birth and

progress following birth.

Check feeding and adequacy of intake.

Note urinary output (Meconium is usually passed in the first 24hrs and in 90-95%

of babies and urine is passed in the first 48hrs).

Verify infant’s identification.

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Examination (in mother’s presence)

Is the infant well?

Observe colour (should be uniformly pink but blueness of hands and feet is not

abnormal, blueness of face ・} facial petechiae is common from cord around the

neck/rapid second stage),

Look for alertness, appearance, posture, and movements. Note cry

? Any congenital anomalies or unusual facial appearance

Auscultate heart for heart rate (normal 120-150/min) rhythm, heart sounds and

murmurs. Palpate precordium and apex and check pulses (brachial, femoral).

Check oxygen saturation as per specific guidance see page 42. This is not

currently undertaken for babies born at home.

Undress infant completely at this point

Examine Chest: note respiratory rate (normal 40-60/min)? any sternal and/or

subcostal recession

Auscultate the chest and the heart

“Head to toe technique” Examine head and scalp, measure head circumference

(2-3 measurements & take the largest; microcephaly is < 32.5cm at term). Look at

head shape, palpate anterior fontanelle, suture lines and posterior fontanelle

(cephalhaematoma is confined to suture lines)

Inspect ears (shape, size and position), mouth, jaw (micrognathia) and nose.

Look specifically for cleft palate – This examination must be done in every

baby during the newborn baby check and in every baby on the neonatal unit

during the discharge examination.

1. You will need

a. An assistant, either the baby’s parent or a midwife, to gently hold the

baby’s head still

b. A torch or flashlight

c. A clean disposable wooden spatula/ tongue depressor.

2. Explain to the parent that this is like examining a small child with a sore throat,

and that it is the best way to ensure there is no cleft of the palate.

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3. Directly visualize the hard and soft palate as far back as the uvula. You will need

to apply gentle pressure with the spatula, to depress the anterior portion of the

tongue just enough to allow you to see the whole palate.

4. Palpate the hard palate to rule out sub mucous clefts

Neck (look for branchial & thyroglossal cysts & swellings, neonatal goitre – all

rare) palpate clavicles for fractures. Low hairline is seen in Turner Syndrome

Examine arms (fractures or Erb’s palsy) and hands – finger length, clinodactyly

{5th finger} and palmar creases, grasp reflex.

Examine abdomen – shape, umbilical vessels

Palpate for liver (1-2cm below costal margin), spleen, kidneys and bladder.

Examine genitalia (boys: testes descended, hypospadias; girls: normal female

external genitalia – hymenal skin tags, mucoid vaginal discharge and vaginal

bleeding (small amt) are common and regress in the first few daysweeks &

nothing needs to be done). Examine anus (should be patent & normally

situated). (Urates in the urine can cause a pinkish-red stain in the nappy which

may be confused with haematuria)

Examine Hips – Observe for symmetry of skin creases and leg length. Abduct hips

– abduction should reach 80-90° if not – Is the hip dislocated? Perform the Barlow

and Ortolani test as appropriate. See hip examination flow chart later(see “hippy”

doll for demonstration and practice). Babies with risk factors for DDH should

have a routine USS scan of hips arranged (see section on hips)

Examine legs and feet (Talipes).

Examine eyes for pupil size and shape, clearness of cornea and check red reflex

(subconjunctival haemorrhages are not uncommon).

Pull to sit, observe head control and tone, grasp and moro reflex (presence and

symmetry)

Suspend prone, observe tone and head position, examine back (run finger down

the back) and sacral region.

Examine skin for rashes (E. toxicum, Staph infection) & petechiae

Reassure and advise (parents appreciate being told the examination is normal

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Postnatal follow up:

Please arrange follow up only if there is a good indication.

Infants to be booked into the baby clinic of the consultant on for NICU for the week,

unless otherwise indicated.

Please ensure a referral letter is dictated, typed and inserted in the notes prior to

discharge on any baby being followed up. Give one copy to the neonatal secretaries for

attention of the consultant.

Parents must be given an explanation of the condition and reason for referral

before their baby is discharged.

Please note – the baby notes are sent home with baby. If a summary is not done prior

to discharge, it cannot be done until after the clinic appointment. If parents forget to

bring the notes to clinic with them, we will have no idea why they are there unless there

is a summary in the ‘system’. This is therefore very important and it also keeps the GP

informed.

Prescription charts:

Prescribe clearly, IN CAPITALS, and use the approved name of the drug.

CHECK – the dose, route and frequency:

 Beware of excessive precision! Only prescribe doses which can be

measured.

 Always re-check doses

 Beware of the potential for confusion with dosage units – do not abbreviate

 Keep up to date with weight (ensure on chart) and age based dosage.

 Decimal places should be avoided where possible, e.g. write 500 mg not

0.5 g. If decimal has to be used, write 0.5 mg not .5 mg.

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Specify details regarding ‘PRN’ or ‘duration of therapy’ where appropriate. Do not

only write as required. It is important to indicate a maximum cumulative daily (24

hours) dose.

Write micrograms not μg.

SIGN and DATE the prescription.

Make sure the times are specified.

CANCELLATIONS – draw a horizontal line through the name of the drug and the

date and then date and initial the ‘date discontinued’ space. Stop dates for short

course treatments (such as antibiotics) can often be recorded on the medicine

chart when first prescribed.

Any mistakes in dosages should be reported immediately to the doctor in charge

and recorded on a risk assessment form.

Note writing:

There must be an entry written by the medical staff in baby’s notes whenever a baby is

examined or management altered. All entries must be signed, followed by a printed

name and designation (SHO, Reg., etc.) and GMC number. The nurses and midwives

also write in the notes.

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Common causes of collapse in the postnatal period are –

a) Sepsis

b) Duct dependent congenital heart disease

c) Aspiration / feeding incordination

d) Seizures

e) Hypoglycaemia

Rare causes will include –

a) Congenital adrenal hyperplasia (salt loosing type)

b) Inborn errors of metabolism

When a baby collapses in the postnatal period, seek help early. Take the baby to

the nearest resuscitaire as quickly as possible, if available or a flat surface if in

the community

What to do at resuscitation?

Term or Near Term Baby:

Note the time, wrap the baby in a warm, dry towel and place a hat on the baby’s head.

Ensure that the baby is kept warm.

Listen with a stethoscope for heart rate. It is not necessary to count this exactly but you

should note whether the heart rate is absent, <100 or, >100/min. Assess the condition

of the infant –tone, colour, breathing and heart rate.

When to start resuscitation?

The indications for positive pressure ventilation include:-

1. Apnoea or ineffective respiratory effort

2. Heart rate less than 100/minute.

3. Persistent central cyanosis in facemask oxygen and a low heart rate

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Airway and breathing:

Transfer to a neonatal resuscitaire if available. Otherwise use a firm flat surface for

resuscitation. If the baby is not breathing perform airway-opening manoeuvres, place the

appropriate size mask on the baby’s face over the nose and mouth, and ventilate via the

bag or T piece (neopuff). The baby’s head should be in the neutral position. In a

newborn, give the initial five breathes as inflation breaths (even if the lung does not

contain fluids it is likely to be atlectatic), 30/5, each lasting 2-3 seconds in order to

expand the alveoli and establish resting lung volume. The circuit must include a

pressure relief valve. Start resuscitation in air where available and increase amount of

FiO2 guided by improvement in heart rate and saturation monitor if available. If oxygen

is the only gas available gas, start resuscitation in 100% oxygen.

Reassess after the inflation breaths by auscultating the heart rate. If the heart rate has

improved you can assume that you have inflated the lung and therefore proceed to

ventilation breaths. If the heart rate does not respond to inflation breaths the only way to

check that the lungs have been inflated successfully is to see chest move in response to

your inflation breaths. Therefore if there is no increase in heart rate check for chest

movement.

If you do not see a heart rate response and there is no chest movement with the inflation

breaths assess the need for the following in a systematic manner –Reposition – ensure neutral position of baby’s head. It is very easy to over

extend the neck during resuscitation!!

Ensure you have gas flow (at least 6 litres / min).

Re-evaluate the size of the mask and ensure appropriate seal.

Apply single or double jaw thrust. If you have help it may be easier to use the two

person jaw thrust technique.

Ensure you have inflation pressure of at least 30cm of water and you are

delivering long inspiratory times of 2-3 seconds.

Assess the need for a laryngeal mask airway I-gel

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Assess the need to suction the airway under direct vision.

Assess the need for an oropharyngeal (Guedel) airway?

Assess the need for higher pressures? Do you need to use a self inflating bag

valve mask device?

At all times evaluate the need for further help.

Attach the baby to a oxygen saturation monitor if available

If there is good response to these manoeuvres with an increase in HR then proceed to

ventilation breaths. A rate of 30 ventilation breaths per minute is sufficient. You may

need to reduce your inflation pressures appropriately. Watch for the baby’s chest

movement, colour, tone, breathing and heart rate and keep on assessing the situation

every 30 seconds.

Recently concerns has been expressed that the peak pressure delivered by a Laerdal

bag may be far too large and lead to over distension of the lungs, which may contribute

to chronic lung disease. Also the PEEP is variable. PEEP is required to establish a

functional residual capacity. You will need to watch the expansion of the chest during

each ventilation to gage whether or not the pressures are optimal. Ideally we should

measure tidal volumes delivered but this is not yet possible on the delivery unit using

existing equipment. With experience you should be able to gauge whether the chest

movement is optimal.

Discontinue ventilation when baby has adequate respiratory effort and able to maintain

colour and heart rate. Evaluate clinical background, degree of resuscitation and

response, work of breathing, colour and tone to ascertain the need to admit to neonatal

unit.

Absolute indications for endotracheal intubation are:-

i) Failure of effective ventilation with a face mask,

ii) Infant with suspected diaphragmatic hernia

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If intubation is required ensure that a good view of the larynx is obtained. The

commonest problem is overextension of the neck and deviation from midline. This

should be avoided as this gives a distorted view of the upper airway. The baby should

be intubated effectively within 30 seconds. If this is not successful you should go back

to mask resuscitation until the baby is pink. Do not allow the baby to become hypoxic

during an attempt to intubate. In a baby who is preterm and intubated give surfactant as

soon as intubation is achieved successfully and tube secured.

If you do not see a good HR response despite good chest movement proceed to chest

compression.

Cardiac compression:

Cardiac compressions should be commenced once 5 effective inflation breaths have

been given with adequate chest movement but has not resulted in an improvement in

the heart rate (i.e. HR still <60/min). If HR is rising, another 30 seconds of ventilation

breaths can be continued before starting chest compressions.

Chest compression necessitates the involvement of a second pair of hands. The chest

should be encircled in both hands with the thumbs placed on the lower third of the

sternum and the fingers over the spine. The land mark to place your thumbs is 1 cm

below the imaginary line joining the nipples. Alternatively locate the xiphisternum and go

1 cm up centrally on the sternum. The depth of cardiac compression should be about

1/3 of the “depth of the chest”. Cardiac massage should be done at about 90/minute

along with ventilation breaths of 30/minute at a ration of 3:1. Allow sufficient relaxation

time as the coronary arteries are perfused in diastole. The person doing cardiac

massage should give their sole attention to this task.

In a very small pre-term baby cardiac massage can be done with two fingers with the

back of the baby well supported.

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Reassess every 30 seconds or so, stop for 5 seconds and listen for the heart rate. Do

not stop cardiac massage until the heart rate is consistently > 60/minute and rising.

Drugs:

If the heart rate fails to improve after 30 seconds of good quality cardiac compression,

drugs should be considered. The intravenous route is preferred but if the baby is

intubated consider intratracheal adrenaline at the dose of 0.5-1ml/Kg of 1in 10,000

solution.

Obtain central venous promptly by catheterising the umbilical vein if access is still

possible. Prime the UVC with saline or hepsal prior to insertion to prevent air embolus.

Remember this is an emergency CLEAN procedure but not a sterile procedure – so

don’t waste time gowning up!! . Take some blood for a gas and blood sugar when you

insert the catheter. If umbilical venous access cannot be obtained or fails, intraosseus

route is an alternative for drug administration in neonatal resuscitation.

IV Adrenaline can then be given in a dose of 0.1 mls per kilo of 1:10,000 (first dose). If

there is no response give Sodium Bicarbonate 4.2% intravenously in a dose of 2 mmols

per Kg (4 mls per Kg) slowly over 1 minute. This should be followed by 0.3 mls/kg

1:10,000 adrenaline IV after 3 minutes or so. After each drug flush the line with 1-2 mls

of 0.9% saline.

If hypovolaemia is suspected give volume e.g. 10 mls per kilo of normal saline. Correct

hypoglycaemia if blood sugar less than 2.6mmol / litre by giving 2.5mls/kg of 10%

dextrose. Avoid giving IV dextrose routinely as hyperglycaemia is known to be

associated with poor outcome during a hypoxic ischemic insult.

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Ensure that adequate ventilation and cardiac massage are continued throughout these

procedures and that the baby is kept as warm as possible. Spare a thought and word

for the parents who will probably be extremely frightened and listening to everything that

is going on.

Any baby who needs unexpected resuscitation on the postnatal ward will need

admission to the corresponding newborn unit at Singleton Hospital or POW hospital in

Bridgend as appropriate.

Please note that for the birthing centre at NPT, contact 999 ambulance and transfer to

Singleton Hospital. The baby should be resuscitated using equipment in the box

available at the birthing centre and transported on a transport blanket with the midwife in

attendance.

For resuscitation in the community / home, further evaluation should be undertaken in

PAU/ Paeds A&E at Morriston Hospital.

Always inform NICU / PAU prior to transfer

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Clinical observations of babies in the postnatal period

Midwives are practitioners in their own right and are able to work autonomously when caring

for normal well term babies

Low-risk term babies born in good condition:

These are babies who are unlikely to have problems based on risk factors.

During the first hour of life:

a. Mother and baby should not be separated

b. Skin to skin contact should be encouraged

c. Breastfeeding should be initiated

After 1 hour, record baby’s head circumference, body temperature and weight

Healthy babies should have normal colour for their ethnicity, maintain a stable body

temperature (measure only if clinical concern) and pass urine and stools at regular intervals.

They initiate feeds, suck well on the breast (or bottle) and settle between feeds. They are not

excessively irritable, tense, sleepy or floppy. They should not breathe fast or demonstrate

excessive work of breathing (Respiratory rate 30-60/min, no nasal flaring, grunting or chest

recessions).

At every postnatal contact with the mother, general well being of the baby should be

assessed and documented along these lines.

When a Problem is identified with a baby

a) Observations of respiratory rate, heart rate and temperature should be clearly recorded in

the baby notes.

b) There should be clear documentation of what the midwives concerns are.

c) The paediatrician should be asked to review and the time of request clearly documented in

the notes.

d) The time that the paediatrician attends should be clearly documented in the notes.

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Paediatric Responsibility:

a) The paediatrician who has reviewed the baby should clearly document a plan of care.

b) This plan should identify what observations are to be recorded and the frequency and

length of time these observations are required.

c) Any further tests need to be documented.

d) When further review is to be undertaken.

High-risk babies:

These are babies who although well at birth are thought to be at higher risk of developing

neonatal problems based on risk factors. Skin to skin contact and breastfeeding should be

encouraged as normal unless clinical condition demands intervention

These babies will need specific observations. Alert paediatrician if abnormal at any stage

Box 1:

The following are guidelines for more well defined risk factors. However babies who do not fit

in any of these categories should be discussed with the paediatrician and an individualised

care plan agreed.

General well being

Chest movements and nasal flare

Skin colour (Test capillary refill – <2 sec)

Feeding

Muscle tone

Temperature (normally 36-37C)

Respiration (normally 30-60/min)

Heart rate if any of the above abnormal

(Normally 100-160/min)

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1) Meconium stained liquor:

a) Light meconium stained liquor– Hourly observation for first two hours.

b) Thick meconium stained liquor- (Dark green or black amniotic fluid that is

thick or tenacious, or any meconium stained fluid containing lumps of

meconium)

Hourly observations for first two hours and then two hourly until baby 12 hours old. If

normal discontinue specific observations.

If observations abnormal at any stage alert paediatrician

2) Prelabour rupture of membranes at term (PROM) >24 hours – Defined as interval

from rupture of membrane to onset of labour (Not birth)

a) No other risk factors – No bloods or antibiotics required. Need to stay in at

least for 12 hours, preferably 24 hours. Hourly observations for 2 hours followed

by 2 hourly observations until 12 hours old. Discontinue specific observations if

all normal at 12 hours

b) Associated risk factors (see guidelines on PROM) – These babies will have

undergone partial septic screen and started on intravenous antibiotics. They will

need similar observations as above for the first 12 hours and then 4 hourly until

24 hours old. Discontinue specific observations if all normal at 24 hours. These

babies should be reviewed daily by the paediatrician until antibiotics are

stopped.

3) Known maternal Group B streptococcal guidelines: Observations will be similar to

that of PROM depending on risk factors and if baby is on antibiotics.

4) Babies on the hypoglycaemia pathway

These babies should have specific observations at 1 hour and then before every blood sugar

measurement until off hypoglycaemia pathway. Alert paediatrician if observation abnormal.

Reference:

1. Intrapartum care: NICE Guideline September 2007

2. Routine Postnatal care of women and their babies: NICE Guideline July 2006

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Common Postnatal Problems

Skin Rashes:

1. Erythema Toxicum:

Multiple small yellow spots surrounded by halo of red skin. The yellow spots are firm,

the cheesy material contains eosinophils and is not an indication of infection. These

spots tend to occur in crops, and have a tendency to “come and go”. They can appear

upto 14 days of age. It is very common (50% of newborns have it) and requires no

treatment. Reassure parents.

2. Small “white-heads” (not on nose)

These are usually staphylococcal infection. Unless multiple no treatment required. If

decide to treat – oral Flucloxacillin 25mg/kg 12 hourly for 5 days – can be discharged if

well infant.

3. Yellow lax blisters

Surrounded by inflammation are often staphylococcal. These should be swabbed to

confirm organism. Mother and baby should be isolated to prevent cross infection.

Perform a partial septic screen and treat systemically with IV Flucloxacillin and

gentamicin for at least 48 hours. A 5 day course of treatment could be completed with

oral flucloxacillin at home if baby responds to treatment and blood culture results do

not indicate a different organism. If baby is unwell, admit to unit and complete a full

septic screen

Birthmarks

1. Strawberry naevus

Usually very small and raised. Rarely present at birth and usually appears in the first few

weeks. Reassure patients. Explain will gradually increase in size but will then start

involuting towards the end of first year and usually disappear before 5 years of age.

Lesions obstructing vision will need urgent referral to ophthalmologist. Other lesions which

may need referral to a dermatologist and intervention are perioral and perineal lesions that

interferes with care and prone to bleeding, infection and ulceration.

2. Port-wine stain

These do not disappear. Parents need reassurance that laser treatment is available.

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Refer to Dr Blackford (Dermatology). (Who should midwives at NPTH and POW refer to)

Facial port-wine stains can be associated with focal fits specially if involving forehead and

eyelid (Distribution of the ophthalmic division of the trigeminal nerve (Sturge-Weber). If the

lesion involves the eyelid the child has increased risk glaucoma and needs referral to Mr.

Laws. Inform Consultant ( who do we refer to in POW /NPTH) on for the week on the

neonatal unit.

“Unusual facial features”

Request an experienced paediatric review, either middle-grade or consultant, before

embarking on investigation e.g. chromosomes. Ask if the baby looks like anyone in the

family. Explain to parents that a senior paediatrician will be coming but focus on non-specific

findings e.g. floppiness in Downs syndrome, clicky hip, etc. Please be careful and sensitive

about what you say.

External ear anomalies:

For minor anomalies such as skin tags, preauricular sinuses, misshapen pinna routine renal

ultrasonography is not indicated unless accompanied by other systemic malformation.

Minor auricular deformities could be corrected through remoulding treatment if instituted early.

If parents are willing such treatment could be offered by referring to Dr. Nick Wilson Jones,

Consultant Plastic Surgeon at Morriston Hospital.

Hypospadias

The site of the meatus, severity of chordee and any accompanying abnormalities e.g. inguinal

hernia, cryptochidism should be identified.

Check the antenatal notes for any renal ultrasound abnormalities. Babies with glandular

hypospadius only do not need routine renal ultrasound scan. Babies with more severe forms

of hypospadius require a postnatal renal scan, but the timing depends on the antenatal scan

result and the severity of the abnormality. Perineal and penoscrotal hypospadias will need a

more senior review before discharge.

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Advice against circumcision as the prepucial skin may be required for repair. Refer to Mr.

Wilson Jones, plastic surgeon at Morriston, as a routine referral with a copy to the GP. They

are not usually repaired before 2 years of age and the surgical team will send an appointment

at an appropriate time. Don’t forget to consider ambiguous genitalia – bilateral

cryptochidism with hypospadias requires urgent investigation, and consultant

involvement at an early stage as this is a very difficult and complex problem.

Undescended Testis

Unilateral cryptorchidism is present in 2-3% of term male infants. Follow-up should be by the

GP and referral to surgeons directly (Mr. Paul Jones – Consultant Urologist – Swansea) if the

testis has not come down by 1 year of age

Consider ambiguous genitalia if bilateral cryptorchidism and hypospadias.

Inguinal Hernias in Newborn Infants or Pre-term Babies

Refer these to paediatric surgeons at Cardiff on the same day, but only after discussing with

consultant paediatrician in Swansea or POW. There may be local arrangements for operating

on these infants in future.

Hydroceles

Hydroceles resolve spontaneously over several months – no F/U required.

Single Umbilical Artery

There is a 2-4% associated risk of minor renal abnormalities. If possible send a piece of the

cord for histology for confirmation. Check that the antenatal scans showed no abnormalities.

In the absence of any additional clinical abnormality no further investigation is required.

Umbilical Hernias

Even large umbilical hernias usually resolve. Reassure mother. No follow-up required.

Tongue-tie

No intervention is required if the baby is feeding well. Reassure and discharge. If there are

feeding problems in a breast fed baby refer to the breast feeding coordinator

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Cleft Lip and Palate

Contact the Cleft Lip & Palate Team on: 01792 703810. This phone number will be

answered either by one of the Cleft Lip & Palate Specialist Nurses or the Team

Coordinator; if no one answers please leave a message. There is an on-call rota and

the messages are picked up several times every day including weekends and bank

holidays.

One of the Specialist Nurses will visit the family on post natal ward (PNW), and give

advice on feeding and follow up.

Notify consultant of the week.

Daily review on PNW, to ensure no concerns with feeding or breathing. Discuss with

Specialist Nurses, SpR or consultant if any concerns, as baby may need admission to

SCBU.

Letter to Dr Maha Mansour for clinic follow-up in 4 – 6 weeks, with copy to Mr. David

Drake (Cleft Lip & Palate Surgeon at Morrsiton). All babies will have cardiovascular

assessment in outpatients, but may require this prior to discharge if there are clinical

concerns.

Some babies may require other investigations, especially if there are associated

anomalies; these are usually arranged during outpatient follow up.

Sticky Umbilicus

An umbilicus becomes colonised with organisms such as Staphylococcus aureus,

epidermidis, and diphtheroids etc within a few days of birth. The umbilical cord separates

through a process of aseptic necrosis and can look ‘sticky’. This does not usually require any

treatment. Treatment with antiseptic agents or antibiotic powders is not indicated.

If pus is present or there is prominent umbilical flare, then after swabbing and partial septic

screen intravenous systemic antibiotic treatment with flucloxacillin and gentamicin is

indicated. The treatment can then be completed orally with flucloxacillin based on clinical

response and culture results.

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Natal Teeth:

Usually at site of lower incisors. If loose consider extraction prior to discharge as there is

small risk of aspiration. Contact Facio-maxillary team at Morriston

Breast enlargement

Occurs at 7-10 days in both sexes from surge in prolactin / oestrogen following birth

Skin tags and accessory digits:

Do NOT tie off skin tags with silk. Refer to plastic surgeons.

Extra digits

Define as pre-axial (radial side of hand and medial toes) axial (midline) or post-axial (ulnar

side of hand and lateral side of toes) There is often a strong family history in post-axial extra

digits. Pre-axial extra digits have a higher association with other anomalies

Do NOT tie off extra digits with silk – it is possible to tie off the wrong digit in this way and

often leaves unsightly tags. Complications: tender or unacceptable nubbins

Spinal abnormalities:

Blind ending, sacrococcygeal pits below S2 are normal and do not need referral.

Occult spinal dysraphism may be suggested by abnormalities of the skin and subcutaneous

tissues overlying the spine. If in doubt, ask the consultant on take to review the baby.

Cutaneous lesions associated with occult spinal dysraphism (OSD):

Imaging Indicated Imaging uncertain Imaging not required

Subcutaneous mass or lipoma Hyperpigmented patches Simple dimples (<5 mm, <25

mm from anal verge)

Hairy patch Deviation of the gluteal fold Coccygeal pits

Dermal sinus

Atypical dimples (deep, >5

mm, >25 mm from anal

verge)

Vascular lesion, e.g.

haemangioma/ telangiectasia

Skin appendages or polypoid

lesions, e.g. skin tags, taillike

appendages

Scar like lesions

Infants and children with OSD may develop symptoms as they grow due to distortion of

the spinal cord and nerve roots. This results in neurological sequelae in the lower

limbs, urinary and bowel symptoms.

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A combination of two or more skin lesions is the highest indicator of OSD

Ultrasound can identify spinal abnormalities but should ideally be performed within the

first 3 months of life

Magnetic resonance imaging is the modality of choice for evaluating the CNS but is

expensive and requires sedation or general anaesthesia in young children.

Ref: Helen Williams. Spinal sinuses, dimples, pits and patches: what lies beneath? Archives

of Disease in Childhood – Education and Practice 2006;91: ep75-ep80

Midline defects

Midline spinal haemangiomas should have a spine X-ray and USS and be referred if any

abnormality.

Bilious vomiting

Admit all babies with a history of one bilious vomit. They should be examined thoroughly, kept

nil by mouth, started on NG decompression. They should also have a partial septic screen

and started on first line antibiotics. Urgent abdominal X-ray should be arranged. If there are

any abnormalities on clinical examination and investigation the baby should be transferred to

a surgical unit for further evaluation (usually upper GI contrast) principally to rule out

malrotation. For stable babies with normal X-ray and examination surgical advice should be

taken with regards to further course of management.

Failure to pass urine

98% of babies have passed urine by 48hrs old. Failure to do so may be renal but more often

than not it is due to failure to notice urine rather than failure to pass it.

In a well baby, it is much more likely to be post-renal. In boys, the single most important

diagnosis to consider is posterior urethral valves. Failure to pass urine or a continual dribble

of incontinence in a boy should be considered due to this until proven otherwise.

The underlying cause may be renal / prerenal but most babies with such underlying causes

are very ill and already in SCBU. In girls the problems are very rare.

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Examination and history should establish the following:-

History of oligohyramnios (renal dysgenesis)

History of asphyxia

Kidneys palpable

Bladder palpable

Genitalia normal

F/H of renal problems

Bloods for U&E should be taken and a urinary catheter can be passed to determine if

there is urine in the bladder. In boys failing to pass urine in 48hrs, it is probably best to

arrange a renal USS.

Failure to pass meconium within 24 hours:

First check that the baby has not passed meconium at delivery!! (sometimes not recorded).

Recheck patency of anus, signs of intestinal obstruction (bilious vomiting, abdominal

distension). If a term baby has not passed meconium within 24 hours further investigations

such as referral to surgeons for rectal biopsy (rule out Hirschprung’s disease) or testing for

CF may be required.

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Management of Birth Injuries

(Section author – Sian Foulkes and Jean Matthes)

Examine carefully babies at increased risk of birth injuries

Macrosomic infants

Instrumental deliveries

Shoulder dystocia

Vaginal breech deliveries

Any other history of difficult delivery

General principles

The neonatal consultant should be informed immediately about any baby with

significant birth trauma including fractures, brachial plexus palsies, suspected

subgaleal haematomas and severe lacerations. The baby should then be put under

his/her care and this should be documented in the notes.

Examination should be thorough and include a detailed neurological examination

including recording of the deep tendon reflexes (except in the case of a fractured limb)

If pain is a possibility, then analgesia should be prescribed. Prescribe analgesia

regularly (not PRN) if the injury appears severe e.g. a fracture. Analgesia should be

prescribed when the baby goes home if there is an injury expected to result in pain.

Regular observations should be requested. Specify in the notes if these are to be

done more frequently than or beyond our standard times of 1, 2, 4, 8 and 12 hours.

The baby should be reviewed regularly by the medical team with documentation in

notes.

Medical photography of injuries may be helpful as part of the medical record

Soft tissue injuries

Babies with extensive bruising are at increased risk of jaundice

Most lacerations/abrasions are superficial. These require cleaning with sterile saline. A

few may require steri-strip closure.

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Petechiae on presenting part occur often and are of no concern if present from birth.

Babies with a spreading petechial rash or other signs of bleeding should have their

platelets and coagulation screens checked.

Head and face

Injuries to the head are commonly seen following instrumental delivery. Most are benign and

self limiting. Diagnosis has important implications regarding management

Caput Succedaneum: oedematous swelling above periosteum caused by prolonged

pressure on presenting part. Resolves spontaneously within 24-48 hours. Reassure

parents.

Cephalhaematoma: bleeding between periosteum and skull – limited by suture lines.

This generally resolves spontaneously over a few weeks, but is occasionally

complicated by calcification causing bony swelling. Reassure.

Sub-galeal haematoma: bleeding between the periosteum and aponeurosis. Can be

associated with substantial haemorrhage, shock, anaemia, hypotonia, seizures and

has a significant mortality. All babies with suspected sub-galeal haematoma should be

admitted promptly to the neonatal unit. Ensure vitamin K has been given, arrange

cross match, FBC and coagulation screen. To try to identify this problem early it is

important that all babies born by ventouse or forceps deliveries have frequent

observations for the first 12 hours of life which includes regular inspection of the head

for site and size of any swelling

How to differentiate between caput, cephalhaematoma and sub-galeal haematoma

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From uptodate.com/contents/neontatal-birth-injuries (originally modified from Volpe JJ) Neurology of the

Newborn, 4th ed, WB Saunders, Philadelphia 2001

Intracranial haemorrhage

Consider intracranial bleeding in any neonate with a history of traumatic delivery and any

abnormal neurology, tone, apnoea or lethargy. It may develop in an apparently well neonate

hours to days after delivery. Perform a coagulation screen and check the platelets and FBC.

Subarachnoid haemorrhage

These are usually asymptomatic but seizures and other complications rarely occur

Subdural

Presents shortly after birth with stupor, seizures, a full fontanelle, unresponsive pupils and

coma

Caput Cephalhaematoma Sub-galeal haematoma

Associated with

instrumental delivery?

No Yes Yes

Present at birth? Yes

Outlined but swelling

develops over first few

hours

Yes

Expands in size? No Rarely Yes

On palpation Firm Soft, not displaceable

Boggy/fluctuant-may

move/spread dependent on

gravity

Crosses suture lines? Yes No Yes

Localisation and spread

Poorly defined

but localised to

scalp

Localised swelling with

well defined outline

Poorly defined, may spread,

obliterate normal neck

contour and cause periauricular

and peri-orbital

oedema. May have crepitus

or fluid waves

Pain/Irritable cry

No

Possibly

Yes

Shock No No Possibly severe

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Intracerebral haemorrhage

All the above best diagnosed on CT /MRI scanning when the clinical condition of the baby

permits

Skull fractures

Skull fractures can be linear or depressed. They can be associated with instrumental delivery

or occur spontaneously. Fractures at the base of the skull can result in shock. Senior review

should be sought if skull fracture is suspected. Examine fully including OFC and fontanelle

and request regular observations (including neurological). A CT scan is useful to confirm or

rule out intracranial haemorrhage.

Injuries to the eyes

Subconjunctival haemorrhage is commonly seen due to elevated venous pressure in

head and neck due to delivery and resolves within 7-10 days. Reassure parents.

Any other eye injury e.g. corneal damage from forceps blades, hyphema (blood in

anterior chamber) orbital fracture, vitreous/orbital haemorrhage (presents with

proptosis) requires urgent ophthalmological review.

Nasal septum dislocation

Nasal septum dislocation presents as stridor and / or cyanosis. It requires reduction by ENT

specialists. Differentiate from a positional deformity by depressing tip of nose-dislocation

present when nares collapse and do not return to normal position with release of pressure

Trunk and Limbs

Fractures

Clavicular fracture: most common fracture seen in the neonate.

Often asymptomatic if non-displaced. Look for swelling, bruising, asymmetry or lack of

movement on one side. Palpate for any swelling/displaced bone or crepitus. Elicit any

signs of pain on passive movement of arm.

Diagnosis confirmed by x-ray (including chest and upper limbs-for other differential

diagnosis).

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Most heal spontaneously with no long term sequelae. Reassure parents, advise gentle

handling and analgesia. Immobilisation may also help with pain control by positioning

of arm to chest with elbow flexed at 90 degrees e.g. in a sling.

The most important consideration is to examine carefully for any associated brachial

plexus injury (see below).

Fractured humerus is the most common long bone fracture arising from birth trauma

Look for localised swelling/bruising, decreased movement of arm and decreased Moro

reflex on affected side. Observe for any pain on palpation or movement of arm.

Diagnosis confirmed by x-ray.

Treat by immobilisation of affected arm with elbow in 90 degrees of flexion. Most heal

well-reassure parents.

Often associated with brachial plexus injuries-examine carefully to exclude.

Inform paediatric orthopaedic consultant – Mr Paul Williams, or Mr Neil Price (based at

Morriston – contact via secretaries)

Fractured femur is less common with risk factors as above plus twin pregnancy and

prematurity.

Examine as above for humeral fracture but may it may be asymptomatic in the

immediate postnatal period

Confirm with x-ray. Often a spiral fracture

Contact paediatric orthopaedic consultant as above. This will require treatment with a

spica cast or Pavlik harness. However outcome is normally good and parents can be

reassured.

Rib fractures are exceedingly uncommon but can occur following extremely difficult

deliveries. There may be other obvious birth injuries especially fractured clavicles and

brachial plexus palsies which co – exist.

If it is suspected that there may have been a fracture caused by the delivery it is best to get

the X- ray done as soon as possible after birth.

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If the injury is known to be caused at birth because birth was traumatic, the x-ray was done

soon after birth confirming the fractures etc then NAI need not be considered.

In all other cases NAI must be considered. These fractures may best be considered as

‘unexplained’ necessitating social services referral in most cases.

Rib fractures –

May present with tachypnoea, crepitus, “clicking ribs” or pain on handling.

X-ray may be performed although fractures may not become apparent until there is

callus formation two weeks later. Obtain a report from a paediatric radiologist.

If there is doubt it can be helpful to perform another CXR exactly 2 weeks after birth. If

it was a birth injury callous will have appeared. If there is no callous it probably

occurred after birth.

Resolve spontaneously with no intervention.

As with all fractures it is important to document the presence carefully as otherwise

may be confused with child protection issues later.

Bear in mind that rib fractures are much more commonly caused by NAI than birth

trauma and birth trauma must be severe to cause these.

(Rib fractures may also be seen in preterm babies with osteopenia of prematurity and

chronic lung disease).

Epiphyseal separations

These can present as a pseudoparalysis of the shoulder or hip caused by injury to the

growth plate. The infant does not move the limb because of pain

They can be missed on X-ray and are best diagnosed by ultrasound.

Orthopaedic referral is essential

Nerve injuries

Assess by observing movements looking for symmetry, quantity and quality. Most common is

brachial plexus injury. You must record in the notes whether the deep tendon reflexes are

present or absent, as well as the grasp and Moro reflex

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Erb’s palsy (upper brachial plexus): damage to nerve roots C5- C6 and occasionally C7

causing weakness of shoulder muscles, elbow flexors and forearm supinators.

Clinical examination shows the affected arm hanging down, internally rotated,

extended and pronated. If C7 is also involved there flexion of the wrist and the fingers

curl up i.e. “waiter’s tip position”. If C4 is involved, the diaphragm will be paralysed on

that side.

Clinical examination reveals weakened, asymmetric or absent Moro reflex on that side.

The grasp reflex is intact, deep tendon reflexes will be absent (biceps C5, supinator

C6, triceps C7)

Check there are no associated clavicular or humeral fractures, and check respiratory

rate (some have phrenic nerve palsy too-see below)

Reassure parents – most recover to have good function. C5, C6 injury 90% chance of

full recovery by 3 months, C5, C6,C7 65 % chance of full recovery

Klumpke’s palsy (lower brachial plexus): involves C7- C8 and T1, causing weakness of

triceps (C7), forearm supinators and wrist flexors (C8,T1).

This lesion is rare – 2.5% of brachial plexus injuries

Clinical examination shows a paralysed “clawed hand” but with retained function of

shoulder and elbow.

Check for associated Horner’s syndrome (constricted pupil and ptosis) on affected side

secondary to cervical sympathetic nerve injury

Signs of absent grasp reflex (C8, T1).

Recovery < 50%, minimal if Horner’s syndrome apparent

Complete palsy C5-T1

Accounts for 20% of brachial plexus palsies

Arm is flail and paralysed with total sensory and motor deficit and absent reflexes

No Horner’s syndrome – approximately 50% recovery

With associated Horner syndrome will require surgery.

Urgent referral to paediatric orthopaedic surgeons in Morriston (?Possible referral to

Royal National Orthopaedic Hospital, Stanmore (Mr Carlstedt – leave this to our

orthopaedic surgeons to sort out)

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General care

Gentle handling of the limb.

Full clinical examination including for Horner’s, respiration (phrenic nerve palsy),

hoarseness (laryngeal nerve palsy), sucking (cranial nerve 12), and other injuries

X ray of limb and clavicle to rule out associated fractures

Parent information leaflet www.erbspalsygroup.co.uk

Ensure baby is seen by the consultant in neonatology

Refer to physiotherapy

Refer to paediatric orthopaedic surgeons

Facial palsy: usually caused by compression of facial nerve, usually with forceps/rotation but

can occur during delivery or in-uteri

Upper motor neurone lesion:

Affects the contralateral lower two thirds of the face (sparing the forehead)

Lower motor neurone lesion:

Affects the whole of the ipsilateral side of the face

LMN lesion – Reassure parents-prognosis is good with some improvement within days

and full recovery in most cases within a few weeks or months.

Protect the open eye. Use a patch and lubricating eye drops if necessary and inform

the ophthalmologists. Ensure feeding is effective

Inform senior for review

OPD follow-up in 6-8 weeks

Not to be confused with an asymmetric crying face: This affects mouth only, not eye or

nasolabial fold. Demonstrate to parents that it only occurs when crying-reassure, no

action is required

Phrenic nerve injury: causing paralysis of diaphragm

May be temporary or permanent

Presents at birth with symptoms of tachypnoea, cyanosis and asymmetric chest

movement.

Admit to neonatal unit.

CXR may show a raised hemidiaphragm. Screen the diaphragm to see its movements

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Laryngeal nerve injury:

May cause vocal cord paralysis and may be unilateral or bilateral

Presents at birth with stridor, hoarse, faint or absent cry, respiratory distress,

dysphagia and aspiration

Refer to senior neonatologist. Will need ENT referral. If unilateral treatment may be

conservative but will need monitoring for aspiration and/or treatment for reflux. SALT

may also be helpful. Bilateral cases may require surgical intervention

Spinal cord injury: very rare.

May occur without fracture of spinal column. Symptoms and presentation depend on

level of injury.

Abdominal injuries:

Are uncommon. Mainly consist of rupture or subcapsular haemorrhage into liver,

spleen or adrenal gland

Non-specific presentation: symptoms of pallor, abdominal distension/mass,

unexplained anaemia or shock

Rupture may present suddenly whilst subcapsular haematoma may have a more

insiduous onset including poor feeding, lethargy anaemia and jaundice.

An unusual presentation of adrenal haemorrhage is swelling and/or discolouration of

the scrotum if blood has leaked from peritoneal cavity via a patent processus vaginalis.

May mimic testicular torsion

Admit to neonatal unit urgently for fluid resuscitation and further management as

appropriate

Ensure vitamin K was given at birth

References.

1. Adapted from postnatal ward guidelines 2011 v0911

2. www.uptodate.com/contents/neonatal-birth-injuries

3. Leslie A. Parker. Part 1: Early Recognition and Treatment of Birth Trauma: Injuries to

the Head and Face. Advances in Neonatal Care, Vol 5, no. 6 December 2005 pp 288-

297

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4. Leslie A. Parker Part 2: Birth Trauma: Injuries to the Intraabdominal Organs, Peripheral

Nerves and Skeletal System.Advances in Neonatal Care, Vol 6, no.1 February 2006 pp

7-14

5. Seamus Morris; Noelle Cassidy; Michael Stephens; Damian McCormack and Frank

McMAnnus. Birth-associated Femoral Fractures: Incidence and Outcome. Journal of

paediatric orthopaedics. 22(1)2002;27-30

6. Kathleen Benjamin. Part 2. Distinguishing Physical Characteristics and Management of

Brachial Plexus Injuries. Advances in Neonatal Care, Vol 5, no. 5 October 2005 pp

240-251

7. Rick R. van Rijn; Rob A. C. Bilo & Simon G. F. Robben. Birth-related mid-posterior rib

fractures in neonates: a report of three cases (and a possible fourth case) and a review

of the literature. Pediatr Radiol (2009) 39:30-34

8. H. Carty. Clicking ribs-a clinical sign of rib fracture. Letter. Archives of Diseases in

Childhood. (2002)86:67

9. B Bulloch et al Cause and clinical characteristics of rib fractures in infants

Pediatrics 2000;105:e48

10. DJ Davis Neonatal subgaleal haemorrhage: diagnosis and management JAMC

2001;164:1452-1453

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Meconium Stained Liquor

Well babies with no additional risk factors born through light meconium stained liquor and

not requiring resuscitation at birth will need hourly observation (See Box 1) for the first two

hours by midwifes and neonatal review requested if they are abnormal. If the initial

observations are normal, there are no contraindications to early discharge.

The management of babies with other risk factors will be guided by that risk factor

Babies born through significant meconium stained liquor (Thick and particulate – seek

obstetrician’s advice) and requiring significant resuscitation at birth should be admitted

to the neonatal unit and observed closely. These babies are at risk of developing HIE and

PPHN

Babies born in good condition through thick meconium stained liquor should have

hourly observations for the first 2 hours followed by 2 hourly observations until 12

hours old. In the absence of other risk factors they could be discharged if asymptomatic at

12 hours of age.

Box 1: Observations required in a baby born through any meconium stained liquor

If further observations are required there must be a clear plan documented in the notes by the

paediatrician.

General well being

Chest movements and nasal flare

Skin colour (Test capillary refill)

Feeding

Muscle tone

Temperature

Heart rate and respiration

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Management of Newborn with Heart murmur

Heart murmur is very common in the first 48 hours of life. (1.4 -1.6% of all newborns) This is

mostly due to physiological circulatory changes at birth i.e. closing PDA, transient TR. A

small proportion of babies will have significant congenital heart disease that may or

may not have a heart murmur. Therefore it is the associated symptoms and signs that

dictate the course of management in these babies

Ref: Valmari et al: Arch Dis Child 2007; 92: F219-224 ; Farrer KFM et al: Arch Dis Child 2003; 88:F147

Heart Murmur

Assess quality of murmur

Femoral pulses, Perfusion

4 limb BP

Sats – pre + post ductal

Signs of CCF

Symptomatic

Harsh murmur ・} Thrill

Weak pulses, poor perfusion

Cyanosis, Sats <95%

Pre and post ductal sats difference ≥3%

Abnormal 4 limb BP

Inform neonatal consultant

Admit to NNU

Arrange urgent Echocardiogram

Asymptomatic

All other assessments

normal

Reassess after 24 hours

Repeat all initial

assessments

Review by

registrar/consultant

No murmur

All assessment normal

Reassure and

Discharge

Persistent murmur /

No murmur

Assessment Abnormal

Arrange echo if possible (Do not guarantee). Contact Sheryl in Singleton (Bleep 5902).

In POW: Dr Tony Goodwin is available most Wednesdays and Thursdays (secretary, Rhian

Rawlings, ext 2290)

If Echo unavailable -Information leaflet or documented communication of symptoms of heart disease

(Heart failure / duct dependant lesion). Complete referral form ( See useful forms section on

sharepoint) + give to secretaries for urgent attention of Dr. Mansour / Dr. Morris

FU Singleton: Preferably with Dr. Morris or Dr. Mansour. Failing this book in any other consultant’s

clinic within 3 weeks

FU POW (Bridgend): Refer to Dr. Goodwin’s murmur clinic (send request form to Rhian).

Persistent murmur AND

Assessment normal

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Pulse Oximetry screening in the postnatal period

Use the portable saturation monitor.

Clean the probe with a disinfectant wipe prior to use

Explain to the mother that this is part of the routine ‘baby check’.

Saturation measurement

Ensure that peripheries are warm, and well perfused before readings are taken.

Apply the saturation probe to either of the infant’s feet, to measure the postductal

saturation. If the postductal measurement is greater than 95% no further

measurement is necessary

If the postductal saturation is less than 95% – Apply the saturation probe to the

infant’s right hand, to measure the preductal saturation.

Ensure probe applied adequately, and wait until flashing lights on both sides of the

LED screen have reached the highest level they will go, before recording the saturation

reading.

Normal saturation readings

Normal postductal saturation readings should be equal to or above 95%. The pre and

postductal saturation difference when measured should not be greater than 2%.

Abnormal readings

1. In a well baby, with an otherwise normal examination:

If any saturation measurement is less than 95% or

If the difference between the two sites is 3% or more

Repeat both saturation measurements in 1 hour

Explain to mother you will return to re assess baby & saturation readings.

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Normal readings should be equal to or above 95%, with a difference of no more than

2% between pre and postductal saturation. Once achieved, baby may be discharged.

2. If on the repeat assessment, the saturation readings are still abnormal

Inform your senior colleague

Reassess baby

o Look for respiratory distress

o Repeat full cardiovascular examination

o General exam looking for signs of sepsis

o Are there any risk factors for PPHN

If on re-assessment baby is unwell, arrange admission, or transfer to NICU.

If all other findings are normal, arrange echo within the next 24 hours. Baby

must have an echo before discharge from hospital, unless in the meantime

the saturations normalise on a 3rd reading.

On weekends, the consultant on call must be informed and a decision made

about discussion with the on call Cardiologist at UHW.

3. A baby, whose saturation readings are below 92%, should be urgently

admitted to the neonatal unit for further assessment & management. Ensure

the senior staff nurse on NICU is made aware of the imminent admission, and

ensure safe transfer procedures are followed.

References

1. Impact of pulse oximetry screening on the detection of duct dependent

congenital heart disease: a Swedish prospective screening study in 39 821

newborns. De-Wahl Granelli, A, et al. BMJ 2009;338:145 – 149

2. Routine pulse oximetry in the asymptomatic newborn. Richmond, S, et al.

Arch Dis Child Fetal Neonatal Ed 2002;87:F83 – F88

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Babies Presenting with Absent Femoral Pulses in the postnatal period

a. Symptomatic babies should be admitted to the Neonatal Unit for urgent

management.

b. Asymptomatic babies should have their upper limb pulses palpated and

4 limb blood pressures measured along with pre and post ductal

saturations and be urgently reviewed by the neonatal middle grade or

consultant. If absent pulse is confirmed, they should have urgent

investigations including echocardiogram arranged. If in doubt, the infant

should be admitted to the neonatal unit until all investigations are

completed. Under no circumstances, such infants should be discharged

home until a definitive diagnosis is reached or structural defects ruled

out following investigations.

Blue babies:

If ever in doubt check pre and post ductal satuartion. If cyanosis is confirmed admit to

NNU to ascertain underlying cause –respiratory/ cardiac

Slow Heart Rate:

A few well term babies will have HR below 100/min, particularly when they are in

deep sleep. Most of these babies will spontaneously increase their HR >100/min

when they are awake and stimulated. HR below 90/min is outside 2SD (Task Force

of the European Society of Cardiology). Therefore, a persistent HR <90/minute in a

well baby should be investigated with a 12 lead ECG to rule out heart block.

If heart block is present –

Inform consultant

Seek cardiology opinion

Check mother’s blood for anti-Ro and anti-La antibodies

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Siblings of children with complex congenital heart disease

If one sibling in a family is affected the risks of another child in a family being affected

is in the order of 1-3% (the risk to offspring of a parent with congenital heart disease

is greater than the risk to the siblings of an affected child).

If there is a family history of congenital heart disease in previous siblings or offspring

a) All babies should have thorough clinical examination and & pre/post

ductal saturation measurements as normal

b) If examination & saturations are normal, and fetal echo was normal,

arrange non-urgent review & echo in OPD (unless parents very anxious)

i.e. complete referral forms (murmur) and give it to secretaries for attention

of Dr. Morris / Mansour or Dr. Goodwin at POW

c) If examination and saturations are normal, and fetal echo was not done,

arrange clinic within the fist week of life i.e. complete referral as above

d) If examination and /or saturations are normal but fetal echo showed

abnormalities, or if exam & saturations are not normal – then management

should be guided by the findings.

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Ectopic beats in neonates

In most cases the finding of “extra beats” in newborn babies is not significant. They

represent a developmental phenomenon and the vast majority disappear without any

consequence in early infancy. A small proportion (<1-2%) may go on to develop

significant arrhythmias such as SVT. In general these extra beats are premature

atrial complexes (PACs) but in a small number they are premature ventricular

complexes (PVCs).

In a small proportion of cases there is an underlying problem with the baby and the

following should be considered:

Hypoxia

Metabolic disturbance – acidosis / K+, Ca++ and glucose levels

Renal failure

Infection

Left atrial mass, very rarely

A careful assessment of the baby needs to be undertaken:

History including maternal drug history

Examination

Bloods electrolytes, renal function, glucose

Baseline ECG, with calculation of QTc

If the baby is otherwise well:

The neonatal/midwifery team should observe for symptoms for 2 days.

If the baby remains well and a repeat ECG on Day 2 or 3 of life shows

occasional PACs or PVCs, the baby can be discharged with arrangements in place

for ward or clinic review and repeat ECG in 1 week.

At the 1 week review, if PACs/PVCs persist, the baby should be referred to the

paediatric cardiology outpatient clinic on semi-urgent priority (2-4 weeks). An urgent

24 hour Holter should be arranged by the referring team.

If the baby becomes symptomatic / unwell at any point, an urgent referral for

paediatric cardiac assessment, including echocardiography, should be made.

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Neonatal Hip Examination and Screening by Ultrasound

All babies should have a clinical examination of their hips. If the clinical examination

suggests developmental dysplasia of hips (DDH), the infant should be referred to an

orthopaedic surgeon (see below). Universal ultrasound examination is not

recommended, but selective screening ultrasound examination is recommended for

babies with one or more of the following risk factors, irrespective of the clinical

findings.

1) A first degree family history of hip problems in early life as defined by a positive

response to the question, Is there anyone in the baby’s close family, i.e. mother,

father, brother or sister, who has had a hip problem that started when they

were a baby or young child that needed treatment with a splint, harness or

operation?”

If the answer to this question is ‘yes’, an ultrasound examination should be arranged,

unless DDH has been definitely excluded in that relative. If there is any doubt, an

ultrasound examination should be performed.

2) A breech presentation:-

a) at or after 36 completed weeks of pregnancy, irrespective of presentation at

delivery or mode of delivery, or

b) at delivery if this is earlier than 36 weeks.

In the case of a multiple birth, if any of the babies falls into either of these categories,

all babies in this pregnancy should have an ultrasound examination. Unless a history

of breech presentation at these times has already been handed over from the

midwifery staff, or is evident from the maternal notes, the mother should be asked

Was your baby in the breech position after 36 weeks of pregnancy or born in

the breech position?”

3) Abnormalities suggesting restriction of fetal movement/development in utero or

neuromuscular disorders. These include torticollis, arthrogryposis and fixed foot

deformities.

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NB: Many foot “deformities“ identified at birth represent “positional” or “physiological”

talipes. This is NOT an indication for a screening ultrasound examination. If the foot

can be easily moved into the anatomical position on clinical assessment, parents of

these babies should be reassured that this is a normal finding and no further action is

needed.

Ultrasound should be arranged as an outpatient in all the above categories as long

as there are no abnormal clinical signs related to hip examination. Please fill in the

clinical indication clearly when writing the form, specifying on the request form

the exact indication for the scan. This is to facilitate accurate assessment and

audit. Forms with inadequate clinical information may be returned to the referring

clinician.

Clinical Examination of Hips:

1. Note limb length discrepancy by comparing the distance between the anterior

superior iliac spine and the medial malleolus on both sides.

2. Galleazzi sign also helps in detecting unilateral dislocation (see below).

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3. Barlow manoeuvre is easily performed by adducting and flexing the hip

(bringing the thigh towards the midline) while applying light pressure on the

knee, directing the force posteriorly. If the hip is dislocatable; i.e. if the hip can

be popped out of socket with this manoeuvre-the test is considered positive.

4. Ortolani manoeuvre is performed by first flexing the hips and knees of a

supine infant to 90 degrees, then with the examiner’s index fingers placing

anterior pressure on the greater trochanters, gently and smoothly abducting

the infant’s legs using the examiner’s thumbs. A positive sign is a distinctive

‘clunk’ which can be heard and felt as the femoral head relocates anteriorly

into the acetabulum. Specifically, this tests for relocation of a posteriorly

dislocated hip. It usually becomes negative after 2 months of age.

Hence clinically abnormal hips fall into three basic groups:

1. Frankly dislocated but relocatable – i.e. there is a leg length discrepancy with

the dislocated side being short. On Ortolani’s test there is a clunk as the hip reenters

the socket. In this situation the hip is dislocated as the child lies on the

couch but relocates with abduction. These are the hips that should be referred

early. Confirm with an urgent hip scan as soon as possible (preferably as an

inpatient) and make a telephone call to Phillips Parade Orthopaedic Clinic on

01792 703010 or #6195. Mr N. Price or Mr P Williams, Paediatric Orthopaedic

Consultants will try to see the baby immediately.

2. Frankly dislocated hips but irreducible– Here there is a leg length

discrepancy but the Ortolani’s test is negative, though there is usually restriction

of abduction. Arrange an urgent hip scan (preferably as an inpatient) and

telephone Phillips Parade on 01792 703010 or #6195 to arrange for the baby to

be seen in the next available Paediatric Orthopaedic Clinic by Mr Price or Mr

Williams.

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3. Hips which are located but dislocatable – i.e. leg length equal but Barlow test

positive. The most likely cause for this situation is physiological instability of the

hip rather than frank dislocation. 90% of these cases settle within six weeks.

Provided one is happy about the physical signs these babies should be treated in

double nappies and an ultrasound scan performed within three weeks. Refer to

Mr. Price or Mr Williams (phone Phillips Parade on 01792 703010 or #6195) who

will then see them at Phillips Parade and decide about the need for splintage.

Neonatal Hip Protocol – Clinically Abnormal Hips

What happens after the Ultrasound is performed?

When the ultrasound scan is performed, a report is sent both to the referring

consultant and to the orthopaedic clinic at Phillips parade . No further action or

involvement from the neonatologist is required, and abnormal hips are managed by

the orthopaedic clinic, as in Appendix 1.

Abnormal Neonatal Clinical

Frankly

Dislocated

Located

Relocatabl

e Ortolani

+ve

Irreducible

Ortolani

-ve

Dislocatable

i.e. Barlow + ve

? Physiological

Urgent hip scan (preferably as inpatient),

urgent referral to Phillips Parade Childrens

Orthopaedic Clinic 01792 703010 or #6195

Double nappies

US scan within 3 weeks

Mr. Price/ Williams in

clinic at 3 wks – decide

on splintage

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Appendix 1 (Only relevant for radiologists / ultrasound technicians and

orthopaedic team

Most USS will be performed for the first time at around 2 weeks of age.

Result of USS Action to be taken

Grade 1 Discharged with a letter/information leaflet (see Appendix 2) and

the report to go back to the referrer.

Grade 2 Repeat scan 4 weeks later:

i) If reverted to Grade 1 then currently the plan is that they

are seen in the standard Paeds Orthopaedic clinic at

around 4-6 months of age for an AP X-Ray of the Pelvis.

ii) If remains Type 2 then to be treated with a Pavlik Harness

and to have continued USS surveillance in the abnormal

USS clinic.

Grades 3 & 4 Treatment in the Pavlik Harness if the hip relocates and will then

need serial surveillance in the harness in the abnormal USS

clinic until they revert to normal or a change in management is

initiated.

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Appendix 2:

Dear Parent/Guardian,

RE:

Your baby was examined in the hospital/clinic. An ultrasound examination of the hips

was organised, and I am pleased to say that this was normal.

However, you still need to attend the routine baby clinic appointments with your GP

and Health Visitor, as DDH can still rarely present at a later age. Please find

enclosed an information leaflet for this condition.

Yours sincerely

MRS O. BIZBY

CLINICAL SPECIALIST/TEAM LEADER

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Chickenpox (Varicella)

If at all possible, delivery should be delayed, until after 7 days from onset of maternal

rash, to allow maternal VZV immunoglobulin to be transferred across the placenta to

the fetus before birth.

If delivery occurs from 7 days before to 7 days after the onset of the maternal rash

(highest risk if 5 days before to 2 days after), there is a risk of developing severe

neonatal chicken pox. In this situation, mother and baby should be nursed in a

separate cubicle on the labour or postnatal ward. Breast-feeding is not

contraindicated. Management of the infant should follow the chart below.

Note:

VZIG 250 mg deep IM injection. Acyclovir is an infusion and needs to be given on

NICU.

Chicken pox exposure in the first week of life on the post-natal wards or in the

community:

A well newborn whose mother has no immunity to VZV (history of not having had

chicken pox in the past), may develop neonatal infection if exposed to chicken pox in

the first 7 days of life. It is recommended that these babies receive VZIG, and if any

signs of chicken pox develop, they should receive a course of IV acyclovir.

In postnatally acquired chickenpox the rash begins 10-28 days after birth. The illness

is generally mild and no treatment is needed.

In complicated cases discuss with infection control, virologist and the public health

consultant

Maternal chicken pox rash onset:

5 days before to 2 days after

delivery

Give VZIG

Monitor for at least 48hrs for signs

of chicken pox

Give Acyclovir at earliest suspicion

Maternal chicken pox rash onset:

7days before to 7 days after

delivery

Monitor for at least 48hrs for signs

of chicken pox

Give Acyclovir at earliest suspicion

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Guideline for the management of infection in the Newborn

Background:

Infection is a major cause of morbidity and mortality in the neonatal period. The reported

incidence of culture-proven infection is 1-8 per 1000 live births. The mortality rate from

neonatal infection is 13-30% with a higher rate in premature and VLBW infants. The

combination of immature immune system, non-specific symptoms and signs together with

ever changing infective pathogens leads to greater incidence of infection and consequent

mortality and morbidity. Traditionally, neonatal infection is divided into congenital and

acquired or early & late onset infection. The mortality rate for early-onset infection is 15%

and for late-onset infection is 9%. The incidence of late infection is now about 20 times that

of early infection in VLBW babies (<1.5Kg)

Early-onset infection occurs in the first 72 hours. The organisms involved are

usually acquired from the mother. This may be due to haematogenous spread, or

more commonly due to ascending infection from the vagina. The organisms

responsible could be both Gram positive and Gram negative bacteria that include

GBS, E Coli, H Influenzi, Listeria etc.

Common risk factors are maternal pyrexia (Temp >38oC), premature rupture of

membranes, preterm labour, chorioamnionitis, maternal UTI or bacteriuria and GBS

colonisation.

Late-onset infection occurs after 72 hours. The organisms are usually acquired from

the hospital environment or nosocomial infection. However, occasionally some of the

organisms acquired from the birth may also be responsible. The usual organisms

include CONS, Staph aureus, Enterococcus, E Coli, Enterobacter, Klebsiella, GBS,

Pseudomonas and Candida species.

Approach to management of Neonatal Infection:

History

Literature review shows that the consequences of delays in recognising and treating infected

babies could be very serious including death and serious morbidity. The symptoms and signs

of neonatal infection are usually non-specific. Table 1 and Table 2 should be used to identify

‘risk factors’ and ‘clinical indicators’ to identify and mange early onset neonatal infection. A

high degree of suspicion is necessary to treat neonatal sepsis effectively.

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In each case, it is important to review the maternal notes to see if mother had received any

antibiotics recently and in particular, during labour. Any known isolates on culture from blood,

urine or vaginal swabs should be noted. Any other markers of maternal infection such as

raised CRP, WCC should also be considered in the decision making process. Intra-partum

antibiotic prophylaxis (IAP) may prevent the isolation of organism from the baby even though

the baby may be infected.

Examination:

Any baby at risk or suspected of infection should be examined fully without delay including

assessment of vital signs (See Table 2).

Management:

In babies with any red flag, or with two or more non-red flag risk factors or

clinical indicators, perform investigations and start antibiotic treatment. Do not

wait for the blood results to come back before starting the treatment.

In babies without red flag and only one risk factor or clinical indicator, consider

whether it is safe to withhold antibiotics and monitor vital signs as per our unit’s

observation schedule (see page 71) in babies on the sepsis prophylaxis pathway.

Each set of observation should be undertaken for 12 hours ( hourly for first 2 hours

and then 2 hourly for the next 10 hours)

Table 1: Risk factors for early onset neonatal infection

Invasive early group B streptococcal infection in a previous baby

Maternal group B streptococcal colonisation, bacteriuria or infection in the current

pregnancy

Prelabour rupture of membranes

Preterm birth following spontaneous labour (< 37 weeks gestation)

Suspected or confirmed rupture of membranes > 18 hours in a preterm birth

Intrapartum fever > 38 degree C, confirmed or suspected chorioamnionitis

Parenteral antibiotic treatment given to the woman for confirmed/suspected

invasive bacterial infection during labour or 24 hour before and after birth. This

does not include routine intrapartum prophylaxis for known Group B

streptococcal colonisation only without risk factors.

Suspected/confirmed infection in another baby in the case of multiple pregnancy

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Table 2 Clinical indicators of possible early onset neonatal infection

Altered behaviour or responsiveness

Altered muscle tone ( for example floppiness)

Feeding difficulties (for example feed refusal)

Feed intolerance ( vomiting, excessive gastric aspirates, abdominal distension)

Abnormal heart rate (bradycardia or tachycardia)

Signs of respiratory distress

Respiratory distress starting >4 hours after birth

Hypoxia (central cyanosis, reduced oxygen saturation)

Jaundice < 24 hours of birth

Apnoea

Signs of neonatal encephalopathy

Seizures

Need for cardiopulmonary resuscitation

Need for mechanical ventilation in a preterm baby

Need for mechanical ventilation in a term baby

Persistent pulmonary hypertension

Temperature abnormality (<36 degree C or > 38 degree C)

Signs of shock

Unexplained excessive bleeding, thrombocytopenia, abnormal coagulation

Oliguria persisting beyond 24 hours after birth

Altered glucose homeostasis (hypoglycaemia or hyperglycemia)

Metabolic acidosis ( base deficit of 10 mmol/l or more)

Local signs of infection (for example eye, skin)

In babies being observed for possible sepsis, if clinical concern increases consider

performing essential investigations and commence antibiotics. However, if there are

no further concerns during the period of observation then baby should be discharged

home.

If there have been any concerns about early-onset neonatal infection before a baby is

discharged, advise the parents and carers verbally and in writing that they should

seek medical advice (for example, from NHS Direct, their general practice, or an

accident and emergency department) if they are concerned that the baby:

a) showing abnormal behaviour (for example, inconsolable crying or

listlessness) or

b) is unusually floppy, or

c) has developed difficulties with feeding or with tolerating feeds, or

d) has an abnormal temperature unexplained by environmental factors

(lower than 36°C or higher than 38°C), or

e) has rapid breathing, or

f) has a change in skin colour

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Investigations:

 Partial septic work-up should include a FBC (+ differentials and a blood film), CRP

and a blood culture. Do not forget the blood glucose.

 Chest X-Ray may be indicated if symptoms refer to the respiratory system.

 Lumbar puncture should be performed initially if –

1. there is a strong clinical suspicion of infection and not just risk factors

2. there are clinical symptoms and signs suggesting meningitis

3. If blood culture is positive

If lumbar puncture would delay the start of antibiotics, then it should be

performed as soon as possible after starting antibiotics.

 Urine culture is not routinely indicated in early onset sepsis but should be undertaken

in late-onset sepsis. The diagnosis of UTI is made only on a SPA or catheter urine

specimen.

 Strict aseptic technique should be employed when collecting culture specimens to

prevent the occurrence of false positive results – contaminant.

 The ideal volume of blood for culture is 1ml. If it is difficult to collect this amount from

the baby it is important to state the volume collected on the request form

 Skin swabs are only performed if there are signs of localized infection. Routine skin

swabs are misleading.

 Swabs should be taken if there is conjunctivitis with purulent eye discharge to

identify Chlamydia or Gonococcus.

 When a line infection is suspected, blood specimens should be collected both from

the line (only through Hickman Line) and a peripheral vein.

Antibiotic Policy:

Babies with suspected early onset neonatal sepsis should be treated as soon as

possible and definitely within 1 hour of the decision to treat.

Explain to the parents where possible the reason for treatment, observation and

investigations needed and likely duration of treatment. Treatment and care should

take into account the needs and preferences of parents and carers, as appropriate.

Parents and carers whose babies are at risk of or have an early-onset neonatal

infection should have the opportunity to make informed decisions about their baby’s

care and treatment, in partnership with their healthcare professionals. Where parents

cannot be contacted, continue management without delay.

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Prior to starting (or changing) antibiotic treatment, every baby should have blood

culture. The results should be chased at 36 hours and the choice and need to

continue antibiotics may need to be reviewed based on results and antibiotic

sensitivities.

Please remember to discuss with the obstetricians and the laboratory staff the results

of any swabs or cultures taken from the mother, particularly if the mother has

received antibiotics prior to delivery. Maternal antibiotics can reduce the isolation of

organisms from the baby even though the baby is infected.

First Line Antibiotics:

These are usually used within the first 72 hours or after birth for a presumed or suspected

early onset sepsis

Benzyl Penicillin – 60mg/kg/dose

Use one dose 12 hourly in the first week.

One dose 8 hourly in babies 1-4 weeks and

One dose 6 hourly in babies of 4 weeks or more

The dosage interval should be increased in renal failure

AND

Gentamicin – The dose is as follows

Babies less than 1 week old – 5mg/Kg every 36 hourly

Babies greater than 1 week old – 5mg/Kg every 24 hourly

Babies > 28 days old – 7mg/Kg every 24 hourly

The interval may be shortened, based on clinical judgement, for example if the baby appears

very ill or the blood culture shows a Gram-negative infection. Increase interval between

dosages in renal failure. If drug levels are not available do not withhold gentamicin unless

there is suspicion of renal dysfunction (anuria / raised Creatinine)

Amoxicillin and Gentamicin should be used if Listeria is considered on clinical grounds

Maternal pyrexia and flu-like symptoms prior to delivery

Meconium-stained liquor in a preterm infant

Macular rash or other signs of sepsis

Flucloxacilin and gentamicin is recommended if there are signs of umbilical infection (

purulent discharge or periumbilical cellulitis)

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Initial choice and modification of antibiotics in babies with suspected

meningitis:

If causative organism not known Treat with Amoxicillin and Cefotaxime

Therapeutic drug level monitoring of Gentamicin:

Generally only trough levels are required. Check trough levels 4-6 hours before the 3rd

dose, if Gentamicin needs to be continued beyond the 36 hours. If more than 3 doses of

Gentamicin are used, check trough levels every 3rd dose.

Trough (pre-dose) <2 mg/L

If trough levels >2 mg/L increase interval by 12 hours

If adjustment are needed please recheck the levels after the 6th dose. If renal

function is compromised, Gentamicin may need to be withheld until trough levels are

back to normal.

If more than 3 doses of Gentamicin are to be given then trough level of < 1mg/ L is

advised.

Consider measuring peak blood gentamicin concentrations in selected babies

oedema

macrosomia (birth weight more than 4.5 kg)

an unsatisfactory response to treatment

proven Gram-negative infection.

Measure peak concentrations 60 minutes after gentamicin administration, if given by bolus or

infusion.

If a baby has a Gram-negative or staphylococcal infection, consider increasing the

dose of gentamicin if the peak concentration is less than 8 mg/litre (such babies should

normally be on the neonatal unit).

How to write up 36 hourly Gentamicin?

When an infant needs Gentamicin to be prescribed 36 hourly, this needs to be written as

below:

1. Write on the ‘once only and pre-anaesthetic medical’ area of the prescription chart.

2. Each dose must be written separately and the date & time for each dose to be clear.

3. Write on the regular medications side of the prescription chart –‘GENTAMICIN’ –please see once only’.

4. As for all medications, print clearly and sign.

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Prescription writing

Drug dosage given in the Neonatal Formulary is used unless stated otherwise in our

protocols

Observe the principles of safe prescribing

Give the first dose immediately and always within 1 hour of the decision to treat.

Prescribe in a realistic manner – an easily measurable amount of the drug. It is

pointless prescribing volumes to an accuracy of one thousandth of a ml (e.g.

prescribe Gentamicin to the nearest 100 microgram and Benzyl Penicillin to the

nearest milligram)

• In renal failure check the pre-dose before giving any further doses.

How to decide the duration of the antibiotic treatment?

Prolonged and unnecessary use of antibiotics leads to the development of drug

resistance and should be avoided. Review the need for antibiotics daily on the

consultant ward round using the antibiotic prescription folder. If needed, discuss with

the microbiologist

During antibiotic treatment, measure CRP 24 hours after presentation.

Lumbar puncture should be considered in a baby on antibiotics who did not have this

investigation at presentation if blood culture is positive or who is not responding to the

treatment either clinically or through persistent rise of inflammatory markers.

The duration of antibiotic treatment should be determined by whether or not infection

is confirmed on bacteriological culture, the nature of the infecting organism and the

focus of infection.

NICE recommends having a system in hospitals that can provide blood culture results

36 hours after starting antibiotics to support timely antibiotic discontinuation and

hospital discharge.

If cultures are negative after 36 hours, CRP levels are normal and the baby is well

with no signs of infection, antibiotics may be discontinued. IF IN DOUBT – DISCUSS.

Remember that all drugs have side effects, and it is not good practice to continue

antibiotics without a good reason.

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The following are “best practice” guide on antibiotic treatment duration in different

clinical scenarios.

References and further reading:

1. NICE clinical guideline 149: Antibiotics for the prevention and treatment of early-onset

neonatal infection – guidance.nice.org.uk/cg149

2. Janet M Rennie Ed. Roberton’s Textbook of Neonatology (4ed). USA. Elsevier Churchill

Livingstone 2005. p1011-1092

3. Khadilkar V, Tudehope D, Fraser S. A prospective study of nosocomial infection in a neonatal

intensive care unit. Journal of Paediatrics and Child Health 1995; 31:387-391

4. Isaacs D, Barfield C, Clothier T, et al. Late-onset infections of infants in neonatal units. Journal

of Paediatrics and Child Health 1996; 32: 158-161

5. Escobar GJ, Zukin T Usatin MS, et al. Early discontinuation of antibiotic treatment in newborns

admitted to rule out sepsis: a decision rule. Pediatric Infectious Disease Journal 1994; 13:

860-866

6. Hodge D, Puntis JWL. Diagnosis, prevention, and management of catheter related

bloodstream infection during long-term parenteral nutrition. Archives of Disease in Childhood.

Fetal & Neonatal Ed 2002; 87: F21-F24

7. Hristeva L, Bowle I, Booy R, et al. Value of cerebrospinal fluid examination in the diagnosis of

meningitis in the newborn. Archives of Disease in Childhood 1993; 69: 514-51

Scenario Duration

Low suspicion / well baby / Negative culture

/ No rise in CRP > 10 on 2 samples 24

hours apart

Stop at 36 hours if blood culture still negative.

Strong suspicion of infection with rise in

CRP and WBC, Good clinical and

laboratory response to treatment / Negative

blood culture

5-7 days. Use clinicians discretion and review

after 5 days

Pneumonia with negative blood culture

5 days

Gram positive organisms in blood culture

without meninigitis including Group B

streptococcus and coagulase negative

staphylococcus in preterms

Usually 7-10 Days. If in doubt discuss with

microbiologist

Gram negative organisms in blood culture Usually 14 days – If in doubt discuss with

microbiologist

Group B streptococcal meningitis confirmed

on CSF culture

At least 14 days of Benzyl penicillin. Stop

Gentamicin after 5 days

Gram negative meningitis confirmed on

CSF culture

At least 3 weeks

Necrotising Enterocolitis 7-10 days. Review clinically and using

biochemical markers

Systemic Staphylococcal infection At least 2 weeks

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Neonatal Herpes infection

Neonatal herpes infection is rare in the UK – 1 in 60000 live births (BPSU 1986-91).

However, with modern diagnostic methods the incidence is likely to be higher. We

are currently waiting for the findings of a recent BPSU survey on neonatal herpes.

Neonatal herpes infection can be caused be both HSV type 2(70-75%) and HSV type

1 (25-30%). Unfortunately most babies who become seriously ill with neonatal herpes

are not delivered to women with an obvious symptoms or signs of the disease.

Routes of transmission:

 85% via infected maternal genital tract

? Ascending infection

En route

 10% postpartum*

 5% (or less) – intrauterine infection

* Uncommon but infection from a nipple lesion during breast feeding and from cold

sores have been reported

Factors influencing transmission:

Type of maternal infection (primary/recurrent)

Maternal antibody status

Duration of rupture of membranes

Integrity of mucocutaneous barriers

Mode of delivery (C-section/vaginal)

Risk of transmission:

The risk of transmission with vaginal delivery

 50% risk: Primary infection near delivery

 30% risk: First episode, non-primary infection (New infection with a second

serotype of herpes virus)

 1 to 3% risk: Recurrent infection

 0.4%: Recurrent infection but no active lesion in labour

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Risk of transmission is very low with elective caesarean section with intact

membranes.

Clinical presentations & outcome:

Four types of clinical presentations occur –

Localised (skin, ocular & mouth) – 45%

Meningo-encephalitis (Localised CNS) – 30-35%

Disseminated infection -20-25%

Congenital – rare

Skin Eye Mouth Disease (SEM):

 Approximately . of all HSV infections

 1st-2nd week presentation

 Limited to skin, eye, mouth / mucous membranes

 Untreated – 60-70% progress to CNS /disseminated disease

Disseminated Neonatal Herpes Infection

 Approximately 20% of all infections

Hepatitis

Pneumonitis

DIC

 Presents usually at 5-11 days of age, but as late as 4 weeks. However, infant

may be ill on first day of life

 10-50% will not develop skin lesions during the course of their illness.

 Encephalitis in 60 to 75%.

Isolated CNS disease:

 Encephalitis without visceral involvement, mainly involving the temporal lobes

 Early to 3rd week of life presentation

 Skin lesions may appear late, if at all

 35% of all cases

 If untreated – only 2-5% survive normally

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Table 1: Presentation and prognosis

Diagnosis:

Surface swabs should be taken at 48 hours or earlier if symptomatic. Isolation of

herpes virus after 48 hours indicates active replication.

 Surface cultures

Mouth (40-50%)

Eyes (25%)

Rectum

Skin

 Other Cultures

Stool

Urine

Vesicles

CSF >100 WBC/Inc. Pro

 PCR – CSF and blood if facility available: PCR detects minute amounts of

DNA, RNA. This is positive in 93% of disseminated disease, 76% of CNS

disease and 24% of SEM. False negative may occur if CSF is obtained “too

early”. Repeat if suspicion persists

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Approach to management of at risk infants:

Flow chart 1:

*** For C-section in advanced labour or with rupture of membranes > 4 hours

treat as vaginal delivery. Discuss with consult for all atypical clinical profile

For Treatment and further information: See full neonatal guidelines

Infection control measures:

Contact precautions

Hand washing before and after care of infants

Mother with lesions on hands: hand hygiene and gloves

BF is allowed: if no lesions on the breast or if active lesions could be covered

Mother with herpes labialis or stomatitis should wear disposable masks

References:

1. Kimberlin DW. Clinical microbiology reviews 2004;17:1–13

Vaginal Delivery Elective C-section

with intact

membranes **

Primary / Non

primary infection

No lesions

present in

labour

Recurrent

infection

Lesions

present

in labour

Screen and treat

prophylactically

Screen at 48

hours

Treat if positive

or symptomatic

No Screening

Educate parents

Treat if

symptomatic

Primary / Non

primary infection

Screen at 48

hours

Treat if positive

or symptomatic

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2. Toltzis, P. Current issues in neonatal herpes simplex virus infection. Clin.

Perinatol. 1991;18:193-208

3. Arvin, A.M., Yeager, A.S., Bruhn, F.W., Grossman, M. Neonatal herpes

simplex infection in the absence of mucocutaneous lesions. J.Pediatr. 1982;

100:715-721

4. Whitley, R.J., Nahmias, A.J., Soong, S., Galasso, G.G., Fleming, C.L., Alford,

C.A. Vidarabine therapy of neonatal herpes simplex virus infection.

Pediatrics1980; 66: 495-501

5. Brown, Z.A., Benedetti, J., Ashley, R., Burchett, S., Selke, S., Berry, S.,

Vontver, L.A., Corey, L. Neonatal herpes simplex virus infection in relation to

asymptomatic maternal infection at the time of labor. N.Engl.J.Med.1991;

324:1247-1252

6. Kimberlin, D.W., et al. Safety and efficacy of high-dose intravenous acyclovir

in the management of neonatal herpes virus infections. Pediatrics

2001;108:230-238

7. Rudnick CM, Hoekzima GS. Management of neonatal herpes infection. Am

Fam Physician 2002;65:1138-43

8. Management of genital herpes in pregnancy – RCOG green top guideline

9. Tookey P, Peckham CS. Neonatal herpes simplex virus infection in the British

Isles. Paediatric and Perinatal Epidemiology 1996; 10: 432-442

10. Can J Infect Dis. 2003 Jul–Aug; 14(4): 197–200.

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Guidelines on management of the neonate born following Prelabour Rupture of

Membranes (PROM)

Any breach to the integrity of the amniotic sac will lead to loss of liquor and risk of

ascending infection of the amniotic cavity and fetus by the vaginal organisms. The

resultant oligohydramnios may lead to mechanical deformation of the fetus or

pulmonary hypoplasia depending on the stage of pregnancy. The pregnant woman is

also at risk of developing chorioamnionitis and premature labour. The time between

the rupture of membranes and delivery of the baby can also be prolonged.

Prelabour rupture of membranes (PROM) is significant if the time interval between

the rupture of membrane and onset of labour exceeds 24hrs. Prolonged rupture of

membranes is associated with increased incidence of neonatal sepsis. However, this

increased risk should be balanced with the risk of prematurity if there is plan to

deliver the fetus immediately following the membrane rupture. A recent meta-analysis

of the trial of prophylactic antibiotics in preterm prolonged rupture of membranes

showed some benefits in reducing neonatal sepsis.

Terminologies

Prelabour rupture of membranes (PROM) – is membrane rupture before the onset of

labour

Preterm, premature rupture of membranes (PPROM) – rupture of membranes before

the onset of labour at <37weeks

Babies born to mothers with prolonged pre-labour rupture of membranes should be

managed according to the sepsis prophylaxis flow chart 1 on page 72-73. Remember

to consider maternal GBS colonisation as one of the risk factors. In complicated

cases, discuss with the neonatal registrar/ consultant

Duration of antibiotics: – duration of antibiotic treatment will depend on the severity

of clinical presentation and would usually be decided by a consultant or a senior

registrar. Antibiotics may need to be altered in light of the culture result

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Guideline for the prevention of early-onset neonatal GBS disease (EOGBSD)

Background:

GBS septicaemia is the commonest cause of early onset sepsis in the neonatal

period. The incidence is 0.5/1000 births in the UK & Ireland. The mortality from

EOGBSD in the UK is 6% (2-3% for term infants and 18% for preterm infants. The

carriage rate of GBS in pregnant women is between 25-33% and in the absence of

any intervention approximately 1% of babies born vaginally to these women develop

EOGBSD. The predisposing factors to the development of disease include –

intrapartum pyrexia, prematurity, PROM (>18-24hrs), chorioamnionitis, previous

affected sibling, GBS bacteriuria (104 colony count) and incidental GBS carriage in

present pregnancy.

Prevention of vertical transmission of EOGBSD has been achieved through the

administration of Intrapartum antibiotic prophylaxis (IAP) using Penicillin or

Cefazolin /Clindamycin (for women allergic to Penicillin). Identification of eligible

women had traditionally employed two approaches – bacteriological screening (at 35-

37wks) and risk-based approach. A third approach advocated by the Canadian

authorities is a combination of the two approaches. The bacteriological approach is

said to be superior to the risk-based approach with reduction of the incidence of

EOGBSD by 86% and 50-68.8% respectively. The third approach leads to an

incidence reduction of 51%. However, the number of women given IAP is 31.7% with

bacteriological screening, 25% with the risk-based approach and 3.4% with the

Canadian option. Despite concerns about emerging resistance, GBS continue to be

susceptible to Penicillin, although isolates with increased minimum inhibitory

concentration (MIC) to the drug has been reported. Increase in the number of earlyonset

neonatal sepsis caused by Gram-negative bacteria has been reported but the

trend is not consistent. Maternal anaphylaxis associated with GBS IAP occurs but is

sufficiently rare.

Vertical transmission prevention practices vary widely in the UK and there is currently

no national screening programme. However, best-practice guidelines by the RCOG,

Health protection agency (HPA), GBS support group (GBSS) are available. The

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Centre for Disease Control (CDC) has published a new and revised guideline for

prevention of EOGBSD in November 2010. This guideline is derived from a literature

review of the above documents.

Antenatal GBS Fact-sheet:

1. Routine screening (either bacteriological or risk-based) for antenatal GBS

carriage is not recommended by the RCOG in the UK.

2. If bacteriological swabs need to be taken for clinical reasons this should

include a combined low vaginal and rectal swab. GBS detected on HVS and

non selective media increases the risk of transmission to the neonate.

3. IAP does not prevent late-onset GBS disease

4. If GBS is detected incidentally, antenatal treatment with oral Penicillin is not

recommended as it does not reduce the likelihood of GBS colonisation at the

time of delivery.

5. IAP should be considered if GBS is detected incidentally

6. IAP should be offered to women with GBS bacteriuria who should also be

treated appropriately at the time of diagnosis

7. IAP should be offered to women with a previous baby with neonatal GBS

disease

8. EOGBSD risk is increased if GBS is isolated from a HVS and non-enriched

medium but reduced if obtained at an earlier stage of pregnancy

9. Where GBS carriage status in the current pregnancy is unknown, there is no

good evidence to support the use of routine IAP in women solely based on

GBS carriage in previous pregnancy

10. In the absence of labour in women with intact membranes undergoing

elective C/S, IAP is not needed regardless of their GBS colonisation status

11. If started, specific GBS prophylaxis should be discontinued within 48 hours in

women with preterm ROM, unless they are in established labour.

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Delivery care:

1. Broad spectrum antibiotic including an agent active against GBS should be

given in place of IAP if chorioamnionitis is suspected

2. Women with other risk factors – Intrapartum pyrexia (Fever>380C once or

>37.50C on two occasions taken 2 hours apart), prematurity, PROM (>24hrs),

should be considered for IAP especially in the presence of two or more factors

3. Penicillin or / Clindamycin as appropriate (in Penicillin allergy) should be given

as soon as labour is established. To optimise the efficacy of IAP, the first dose

should be given at least 4 hours prior to delivery – ‘Adequate IAP’.

Penicillin G – 3g (5Megaunits) IV stat, then 1.5g (2.5Megaunits) 4hrly until

delivery

In Penicillin allergic patients – guided by specific requests for antibiotic

sensitivity

Clindamycin – 900mg IV 8hrly until delivery

Neonatal Care for infants at risk of EOGBS infection:

1. Infants with signs of sepsis – whether term or preterm should be admitted to

the NICU, undergo full septic screen (Blood culture, FBC, CRP, Chest X-ray

and lumbar puncture) and treated promptly with antibiotics.

2. Infants born to mothers with frank chorioamnionitis should undergo partial

septic screen and intravenous antibiotic therapy as per neonatal guidelines

irrespective of gestation and IAP status, Need for further investigations should

be guided by clinical progress and initial results.

3. Well appearing term infants without risk factors and adequate IAP (Low

risk) do not need laboratory evaluations and postnatal antibiotic treatment.

They should be observed for 24 hours in hospital.

4. Well appearing preterm infants of 35-36 weeks gestation without

additional risk factors who received adequate IAP should be observed in

hospital for at least 48 hours without the need for any laboratory evaluation.

5. Well appearing term infants with an indication for GBS prophylaxis who

received no / inadequate IAP may be observed clinically in hospital for 24

hours without intervention if they have no additional risk factors

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6. Well term infant with multiple risk factors irrespective of IAP status

should undergo partial septic screen (Blood culture, FBC, CRP) and

presumptively treated with antibiotics for 48 hours until culture results are

known (Pragmatic decision)

7. Preterm infants of 35-36 weeks gestation with no or inadequate IAP or

those with additional risk factors irrespective of IAP status should undergo

partial septic screen and treated presumptively with antibiotics for 48hours

pending culture results.

8. In infants with previous affected sibling, observe for 24hrs if adequate IAP

was given. If IAP inadequate or additional risk factors perform partial septic

screen and commence post-natal antibiotics

9. Treat all infants of multiple pregnancies if one is diagnosed with

possible GBS disease.

10. Surface swab is not warranted in the neonatal preventive strategy for

EOGBSD as they are not indicators of infection.

11. Mothers with known GBS colonisation who refuse intrapartum antibiotics

should be advised hospital based observation of the neonate for 24 hours

irrespective of her choice of place of delivery. This should be documented in

the clinical notes.

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Sepsis prophylaxis in the newborn

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The following observation schedule should be observed in all babies on the sepsis

prophylaxis pathway

Follow up:

A. When a baby who has had a confirmed GBS infection is discharged from hospital

advise the woman that if she becomes pregnant again (document in notes):

o there will be an increased risk of early-onset neonatal infection

o she should inform her maternity care team that a previous baby has had a GBS infection

o antibiotics in labour will be recommended

inform the woman’s GP in writing that there is a risk of:

o recurrence of GBS infection in the baby, and

o GBS infection in babies in future pregnancies.

B. If the woman has had group B streptococcal colonisation in the pregnancy but without infection

in the baby, inform her that if she becomes pregnant again, this will not affect the management

of the birth in the next pregnancy

Observe for first 12 hours at 1hour, 2hour and 2

hourly for 10 hours. Thereafter observations should

continue 4 hourly if indicated.

General well being

Chest movements and nasal flare

Skin colour (Test capillary refill – <2 sec)

Feeding

Muscle tone

Temperature (Normally 36-37C)

Respiration ( Normally 30-60 breaths/min)

Heart rate if any of the above abnormal

(Normally 100-160/min)

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Further Reading:

1. Centers for Disease Control and Prevention. Prevention of Perinatal Group B Streptococcal disease: Revised

guidelines from CDC 2010]. MMWR 2010; 59(No. RR-10): 1-31

2. Smail E. Intrapartum antibiotics for group B streptococcal colonisation. Cochrane Database Syst Rev 2002:

CD000115

3. Scrag SJ, Zell ER, Lynfield R, et al. A population-based comparison of strategies to prevent early onset group

B streptococcal disease in neonates. N Engl J Med 2002; 347: 233-9

4. Prevention of early onset neonatal group B streptococcal disease – RCOG Guideline No. 36 (Nov 2003)

5. Interim “best practice” recommendations for the prevention of early onset neonatal Group B streptococcal

(GBS) infection in UK –Health Protection Agency (March 2004)

6. Group B streptococcus: The Facts. GBSS 2006.

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Hepatitis C infection in pregnancy and the newborn period

Introduction

Hepatitis C virus (HCV) is a small single stranded RNA virus of the family flavivirus. In the UK, the

carriage of Hepatitis C is approximately 0.4% of the population and about 1 per 1,400 healthy

adult blood donors. The virus may be transmitted perinatally or by blood transfusion. Blood

products have been screened since 1991 but a small risk remains that the virus may be

transmitted by blood transfusion in the immediate post infective period prior to the development of

antibodies

Hepatitis C is the main cause of sporadic Non A Non B hepatitis. The average incubation period is

6 weeks with a range of 2 weeks to 6 months. Only a minority of patients experience symptoms

during the acute stage with fever, malaise, jaundice and abdominal discomfort. Mean time from

infection to presentation, usually with the complications of cirrhosis is 10-15 years. Chronic

infection with the virus occurs in over 80% of cases. Hepatitis C accounts for 50% of cases of

chronic hepatitis. It is a risk factor for hepatocellular carcinoma and is the principle indicator for

liver transplant. With chronic disease, autoimmune complications are common e.g. arthritis, serum

sickness and erythema multiforme.

Perinatal Transmission:

HCV infection is not screened routinely in the antenatal population, unless there are specific

maternal risk factors. The risk of vertical transmission from an infected mother to her baby is low,

only around 5%. Vertical transmission is almost always confined to women who have detectable

HCV RNA. Factors which increase the transmission rate are maternal IV drug use, concurrent HIV

infection (risk increased to upto 48%) and a lack of Anti-C 100 antibodies. Most pregnant women

who are Hepatitis C positive have sub-clinical liver disease and remain well throughout pregnancy,

with no deterioration in their liver function. There is no increased risk of obstetric complications or

prematurity although there may be a fall in ALT and a rise in Hepatitis C virus RNA in the last

trimester. There is no increased risk with vaginal delivery and there is no data to suggest that

breast-feeding infants born to Hepatitis C-infected mothers affects the transmission rates.

Mothers who should be offered antenatal screening include:

IV drug abusers(60-80% will be positive) or those with past history of drug misuse

Those with HIV or Hepatitis B

Those who have received haemodialysis (10-50% will be positive).

Women whose partners are known to be Hep C positive

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50% of the infected populations have no identifiable risk factor.

What to do if a mother is found to be antibody positive?

If a mother is found to be antibody positive in pregnancy then hepatitis C PCR for circulating viral

RNA is needed to determine infectivity, together with liver function and coagulation studies. If

hepatitis C PCR is positive, indicating a chronic infection as opposed to a previous infection then

the mother should be referred to Dr Chinl’ye Chin if from Swansea and Dr. Tom Yapp if booked in

POW for further assessment and possible treatment following pregnancy

How to manage an infant born to an infected mother?

Hepatitis C infection is usually relatively silent in the new born period and throughout childhood.

HCV serology is not reliable during infancy because passively transferred maternal antibody may

persist up to 18 months and sometimes beyond. Majority will be seronegative by 12 months of

age. Earlier diagnosis of HCV infection is very unlikely to alter management. In view of parental

anxiety and concerns on part of health care professional that infant may be lost to follow-up, it is

reasonable to check HCV RNA PCR at 3 months in high risk cases.

Infants born to mothers with previously documented Hepatitis C infection but with NO viraemia

should have a blood test for the presence of anti HCV and HCV RNA PCR at 14 months of age. If

anti HCV is positive, but PCR is negative, then repeat in 6 months. If PCR is positive, then it needs

urgent referral to paediatric gastroenterologist Dr M Cosgrove or Dr S El-Hadi at POW

In case of infants born to mothers infected with HCV and with detectable HCV RNA PCR or

unknown viraemia status, the infant should be tested for HCV RNA PCR at 3 months of age. If it is

positive, perform a repeat sample and if again positive then refer to Dr Cosgrove or Dr. S El Hadi

at POW. . If negative then, perform anti HCV at 18 months. Persistent infection develops in around

85% of infected neonates even in the absence of biochemical evidence of liver disease.

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The following is a suggestion for follow up and investigation:

Refer to Neonatal Consultant of the week. In POW refer to the paediatric consultant of the

week. Needs regular follow up as per above flowchart.

If PCR positive, measure LFTs.

NB: Antibody tests may be negative in infants who are immunocompromised.

Every effort should be made to provide and complete Hepatitis B vaccination

Diagnosis is confirmed by positive HCV RNA PCR on two samples

OR

Anti HCV Elisa antibody test positive after 18-24 months of age

Treatment:

Treatment of adults is possible with interferon but there are unpleasant side effects and some

patients do not comply with the full course of therapy.

If infection is confirmed baby will be referred in Swansea to Dr. Mike Cosgrove and at POW to Dr.

Sarah El Hadi. Referral to a liver centre for liver biopsy is of value in staging histological disease

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and determining response to therapy (less likely to respond if there is cirrhosis). This is usually

undertaken at around 2 years of age.

Children respond well to therapy for chronic hepatitis C infection with Ribavarin and Pegylated

Interferon α. Outcomes are better for genotypes 2 and 3 than for 1 or 4. Treatment is generally

better tolerated in children than adults.

Infants who have confirmed hep C infection should be vaccinated against hepatitis B and against

Hepatitis A once aged 2 years.

References:

1. Perinatal hepatitis C virus infection: diagnosis and management. Davison SM et al. Arch

Dis Child 2006; 91:781-785.

2. Treatment of chronic viral hepatitis C in children and adolescents: UK experience. Abdel-

Hady M et al. Arch dis child 2014; 99:505-10.

3. Excluding hepatitis C virus (HCV) infection by serology in young infants of HCV-infected

mothers. England K, Pembrey L, et al. European Paediatric HCV Network. Acta Pediatr

2005.

4. http://www.cps.ca/documents/position/vertical-transmission-of-hepatitis-C

5. Vertical HCV infection – Standards Unit, Evaluation and Standards laboratory, HPA , VSOP

8Ii, Nov 2007

6. Hepatitis C virus infection. American Academy of Pediatrics Committee of Infectious

diseases. Pediatrics 1998; 101: 481-485

7. EASL International Consensus Conference on Hepatitis C, Paris 1999. Consensus

statement J Hepatology 1999; 30:956-61

8. The silent infection: should we be testing for perinatal hepatitis C and, if so, how? W

Hardiker, EJ Elliott et al MJA 2006;184(2) 54-55

9. Treating viral hepatitis c: Efficacy, side effects and complications MP Manns, H Wedmeyer

Gut 2006;1350-135

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Hepatitis B

Routine antenatal testing is currently undertaken for hepatitis B as part of the All Wales screening

program. Occasionally women are not screened due to non attendance at antenatal clinic or

refusal to allow blood tests. In these cases please ask the obstetric or midwifery staff to send

blood from the woman urgently and ring virology to request fast tracking and let us know the

results urgently.

Mother’s Hepatitis B surface antigen status and Hepatitis B e antigen status must be known. If

the mother has hepatitis B the baby will acquire infection at delivery in 100 % of cases unless

vaccinated. Of these babies 95 % will fail to clear the virus and become chronic carriers. Infection

can be prevented by vaccination in 95 % of cases. Infants who have hepatitis B stand an

increased risk of dying prematurely from cirrhosis and hepatocellular carcinoma. Hence

completion of the vaccination schedule is extremely important.

After obtaining parental consent, immunisation of babies of infected mothers should be

commenced as soon as possible after birth. The immunisation regime consists of four doses of

vaccine with the first dose given as soon as possible after birth, further doses at one and two

months of age and a booster dose at twelve months. The vaccine should be given intramuscularly.

Hepatitis B immunoglobulin, if required (see table in care pathway), is given in a dose

of 200 international units to the newborn at the time of the first vaccination. It should be given at a

different site from the hepatitis B vaccination. If mothers who are hep b positive refuse the

vaccination of their infants then this becomes an immediate child protection issue.

We also strongly recommend the vaccination of babies of mothers who are Hep B negative but

who use IV drugs or whose partners use IV also using the same regime as above. We give the

first dose as soon as possible after birth and to advise the mother that it is advisable to bring the

baby to clinic in 1 month for the second vaccination. If the mother refuses this advice we should

document this in the infant’s notes and note in any report for social services. However we cannot

enforce the administration.

For babies at Singleton, an appointment should be made for the baby to attend Dr Matthes’ clinic

for vaccination at the age of 1 month and at the required intervals thereafter. The baby will also be

seen at 14 months for clinical examination, HBV antibodies and liver function tests. Poor

responders should receive a booster dose and non-responders should receive a repeat course of

vaccination. In Bridgend area all this is undertaken by the GP.

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No contra-indication to breast-feeding.

References:

1) Global challenges in liver disease Roger Williams Hepatology 2006; 521-526

2) A treatment algorithm for the management of Chronic hepatitis B infection in the United States:

an update. EB Keeffe, DT Dieterich et al Clinical gastroenterology and hepatology 2006;4:

936-962

3) Current management of chronic hepatitis B GV Papatheodoridis, SJ Hadziyannis Alimant

Pharmacol Ther 2004; 19(1) 25-37

4) Antibody levels and protection after hepatitis B vaccination; results of a 15-year follow up BJ

McMahon, DL Bruden Ann Intern Med 2005;142:333-341

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CARE PATHWAY SINGLETON (Mothers who are hepatitis B positive).

For POW see separate document available locally

Responsibility

Date and

Signature

At diagnosis

Please give woman information sheet “Information for

pregnant women who are hepatitis B positive” –available

from Antenatal Screening Wales website.

Please notify Helen Bartlett (the Vaccination Coordinator,

Central Clinic) of names and dates of births of other

children and father of baby. She will notify the GP and

undertake contact tracing if necessary. It is the GP’s

responsibility to vaccinate these individuals and any other

household contacts.

If other children are in care midwife please notify Dr Peter

Barnes, Consultant Community Child Health giving names

and dates of births of the children and placement if known.

If mother is Hepatitis B positive and e Ag positive or no e

markers or e Ab negative, viral load to be measured. If

there is acute hepatitis B during pregnancy, viral load is to

be measured.

Consultant Microbiologist/Virologist to be notified of result

and will write to Dr Matthes, and Consultant Obstetrician

with advice.

With mother’s consent mother is referred to Dr Chin Lye

Ch’ng stating EDD and results of tests including viral load.

If high viral load mother will be treated with Lamivudine in

last trimester.

If gamma globulin is indicated order form to be completed

by midwife and sent to Pharmacy so that the gamma

globulin is available in Labour Ward fridge prior to delivery

of baby. Order forms available in antenatal clinic. Further

supplies from Katherine Wilson (Pharmacy) .

Midwife to ensure gamma globulin is ordered and in labour

ward fridge. One spare dose of Gamma globulin to be kept

in labour ward fridge in case of emergency. (There is also 1

spare vial in Pharmacy emergency cupboard).

Midwife

Midwife

Midwife

Viral Laboratory

Viral

Laboratory/Consultant

Microbiologist

Midwife/Consultant

Obstetrician

Midwife

Midwife

Labour Ward Lead

Mother’s Label Baby’s Label

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Responsibility

Information must be given to the mother in advance in case

she delivers elsewhere.

In an unbooked woman at the time of delivery organise an

urgent hepatitis B test.

At delivery

Mother given sheet to be put in baby’s red book and asked

to sign vaccination consent for HBIG (if indicated) and first

vaccination.

Baby given hepatitis B gamma globulin (HBIG) if indicated

as soon as possible after birth. Aim to give 100% within a few

hours of birth. Need written consent from parent. Record

batch no. etc in notes. The dose is 200 units given

intramuscularly. Note if using an adult vial of 500 units you

will need to draw up 2/5 of the volume of the vial. The

volume is variable but is stated on the vial. Fill in form

accompanying the HBIG and return to Pharmacy C/O

Katherine Wilson.

Paediatrician to

explain and take

consent

Midwife/Paediatrician

Indications for Hepatitis B Immunoglobulin

All babies with any of the following:

a) Mothers with high viral load even if treated

with Lamivudine.

b) Low birth weight < 2.5 kg

c) Pre-term < 37 weeks

d) Mothers with acute hepatitis B during pregnancy.

For other babies please follow the table.

Maternal status

sAg

Surface Antigen

eAg

eAb

Anti-HBV

immunoglobulin

200 iu within 12h

HBV vaccine

+ + – Yes Yes

+ – + No Yes

+ – – Yes Yes

+ + + No Yes

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Responsibility

Date and

Signature

Baby given 1st hepatitis B vaccination (Hep B Vaxpro) as

soon as possible after birth (aim to give 100% within a few

hours of birth). This includes extremely pre-term infants.

Need written consent from parent. Dose is 0.5 ml (5 ug)

given IM. (Also kept in Labour Ward fridge).

Vaccinations to be recorded in Red book and hospital

notes. Also notify Central Clinic register (Mrs Andrea

Evans) of vaccination and batch number.

Paediatrician to explain to mother the need to complete all

4 vaccinations and for testing at 14 months of age. This is

done at newborn examination. Conversation is to be

recorded in notes and mother’s queries answered.

Midwife/Paediatrician/

Neonatal Nurse

Neonatal SHO

Neonatal SHO or

Consultant

Neonatologist (usually

J Matthes)

Arrangements for 1 month appointment (Ext: 5811)

made prior to discharge and mother given appointment for

Dr Jean Matthes’ Clinic (Monday pm til April 2007, Friday

am after April 2007) by midwife.

Midwife/Receptionist

Paediatrician to write referral form and summary letter,

stating indication for hepatitis B program and giving

mother’s serology results.

Dr Matthes will give subsequent vaccinations in clinic.

Failure to attend subsequent visits or comply with

vaccination policy:

* Notify health visitor, GP and practice nurse

immediately.

* Notify Helen Bartlett.

* Notify CP coordinator immediately.

* Notify Social Services.

Further doses of vaccine are required at 1 month, 2 months

and 1 year.

Baby needs blood test at 14 months to confirm immunity

and lack of infection.

Neonatal SHO

J Matthes

J Matthes

J Matthes

J Matthes

This pathway was drawn up by the following health care professionals of the

Dr J Matthes (Consultant Neonatologist)

Dr N Berry & Dr Ann Lewis (Consultant Microbiologists)

Dr Chin Lye Ch-ng (Consultant Gastroenterologist with special interest in liver disease)

Ms Wendy Sunderland-Evans (Midwife with responsibility for antenatal care pathway)

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Helen Bartlett (Vaccination Coordinator)

Dr Mike Isaac (Biomedical Scientist, Level 3, Virology Lab)

Katherine Wilson (Pharmacy)

Cristine Koukos, Acting Clinical Service Manager, Central Clinic

Mr Marsham Moselhi (Consultant Obstetrician)

Dr Peter Barnes (Consultant in Community Paediatrics)

Protecting the Baby

Information for women who are positive for Hepatitis B

Women who are hepatitis B positive can pass on the virus to the baby at the time of birth. Virus in

the blood and vaginal fluids during the birth process readily expose the baby to the virus.

Newborn babies are especially vulnerable to hepatitis B infection because their immune systems

are immature.

Administration of hepatitis B immunoglobulin and a course of hepatitis B vaccinations will protect

most babies against infection. The baby must complete the hepatitis B vaccine programme to be

fully protected.

The vaccination program consists of a hepatitis B vaccination at birth, and then at 1 month,

another at 2 months and another at 12 months of age. At around 14 months of age the baby

should have a blood test to make sure that he or she is adequately protected against the virus.

Sometimes a fifth vaccination is required.

If the proper procedures are followed your baby will stand a very high chance (95%) of being

protected against hepatitis B and will have lifelong immunity. If however the proper procedures

are not followed then the baby will have a 90% chance of developing hepatitis B infection. This

will mean your baby will be a carrier of hepatitis B and face a high risk of developing liver cancer

and liver cirrhosis in later life.

Please make sure your baby receives the complete course of vaccination to ensure complete

protection. Remember there is no second chance to protect your newborn baby. There are no

known complications to the hepatitis B vaccination. In many countries all newborns are given

hepatitis B vaccination and these programs have been very successful.

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Please make sure you are given an appointment for the second vaccination before you leave

hospital. Ask your midwife to do this for you. Your baby’s appointment will be in the Baby Clinic at

Singleton Hospital (Dr Jean Matthes) and Dr Matthes will oversee your baby’s course of

vaccinations.

Can I breast feed my baby if I have hepatitis B?

The benefits of breast feeding outweigh the potential risk of infection from breast milk which is very

tiny indeed.

What about my other children?

If your other children and your partner/husband have not been vaccinated please inform your

midwife. They will be checked for infection and vaccinated also.

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Infant of mother with retroviral disease

Please also read the extended protocol on infants of mothers with HIV infection which is on

the neonatal unit

To manage a child correctly detailed and accurate information on maternal retroviral disease

status, treatment other associated infections are required. This can be collected on the following

data sheet that could also be used as a discharge summary and referral letter to Prof. Morgan

(See useful forms section on sharepoint). In most cases a well established individualised plan is

available in the medical notes.

Gestation:

Birth weight:

Head circumference:

Gender:

Mode of delivery:

Duration of rupture of membranes before birth:

Date of Mother’s diagnosis:

Mother’s treatment: ………………………………………………………………………

Most recent maternal Retroviral load and CD4 count:

Date Gestation Viral load (IU/ml) CD4 count (%)

Maternal serology:

Hepatitis B Status: Rubella Titres:

Hepatitis C PCR: CMV Titres:

Toxoplasma Titres: Blood group:

Hepatitis B and C comments: ……………………………………………………….

Medication commenced on at birth for the infant: …………………..

Advice given regarding exclusive formula feeding? Yes / No

Advice given regarding immunisation? Yes / No

Baby’s blood result’s (FBC, LFTs and CD4 count): …………………………………

…………………………………………………………………………………………………………………………………………

……………………………………………………

Pneumocystis Carinii Pneumonia (PCP) Prophylaxis required: Yes / No

Affix Identification Label of Baby

Affix Identification Label of Mother

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Plan for Baby:

Send blood from baby for FBC and CD4 count (purple topped EDTA bottle), and LFTs. Cord blood

is NOT adequate

If CD4 count is <1500 on blood, repeat on baby’s peripheral blood.

Start treatment AS SOON AS POSSIBLE after birth. Usually AZT 4mg/kg bd for4weeks, orally,

preferably strictly 12 hourly.

In those babies where oral medication cannot be given i.e. preterm / sick babies AZT 1.5 mg/kg

qds IV (as long as mother does not have a resistant strain of virus in which case she herself will be

on treatment other than AZT- Further specialist advise will be required. Discuss with consultant

immediately and refer to the extended guidelines)

Pneumocystis Carinii Pneumonia (PCP) Prophylaxis:

Required if CD4 count (on baby’s own blood) <1.5 x 10/9 per L.

Beware G6PD – test baby for this if from area of high prevalence.

Cotrimoxazole displaces bound bilirubin – leads to increased risk of kernicterus.

Cotrimoxazole dose 60 mg/kg oral bd on Mondays, Wednesdays, Fridays.

Hepatitis B and Hepatitis C – Follow Ward Protocols.

Baby must be bottle-fed.

Do NOT give BCG at birth.

At Discharge:

If mother is asylum seeker/refugee, please liaise with Mrs Jean Saunders (Health Visitor for

Asylum Seekers and Ethnic Minorities). Tel 01792 517882. This service is currently not

available at POW

The full discharge summary should be typed and placed in infant’s folder.

Follow up FBC, LFT at 2 weeks. Prof. Morgan is generally happy to do these bloods in his

clinic. Please discuss with him

Follow up Prof Morgan’s outpatient clinic.

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Appointments to be given to mother prior to her leaving hospital.

At delivery protective wear will be given to paediatric team by midwifery team – gown, goggles,

gloves, etc. Please use these and dispose off as instructed. The infant does not need to be

admitted to NICU because of mother’s HIV status, but obviously if there is another reason e.g.,

TTN, will need admission. In the event of needle stick injury, please attend casualty.

If the mother is known to have resistant virus, Dr Yoganathan (HIV Consultant) should be

contacted for Swansea booked mothers. GU Medicine contact no: extension 5096, 5095. Out of

hours, please contact switchboard. For POW booked mothers the GU consultant is usually Dr.

A.N. Abdullah based at the GU clinic in Royal Glamorgan.

There is an extended protocol on the unit which should be referred to in complicated cases

if there is no prospective plan or circumstances have changed since such plan.

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Approach to diagnosis and management of newborns at risk of congenital

syphilis

(Section author – Dr. Malini Ketty, Dr. Rachel Morris R, Dr. Jean Matthes, Prof. Gareth Morgan, Dr.

Sujoy Banerjee

Background

Cases of syphilis declined in the late 1980’s and early 1990’s1 followed by a resurgence in recent

years worldwide. As a result, cases of congenital syphilis have re-emerged.

Syphilis is caused by the spirochete bacterium Treponema pallidum. It can be transmitted

vertically from mother to baby if the mother is infected and not treated adequately. Incidence of

vertical transmission is 50% in both primary and secondary syphilis. The guideline addresses the

approach to early diagnosis and management in newborn infants born to mothers with recent or

previous history of Syphilis and adapted from The British association for sexual health and HIV

(BASHH) guidelines published in 20083.

Complications in pregnancy

Maternal syphilis before and during pregnancy can pose a significant threat to the pregnancy and

the fetus. Vertical transmission can occur at any time during pregnancy and at any stage of

syphilis. Pregnancies complicated by syphilis may result in spontaneous abortion in up to 50% of

pregnancies, intrauterine growth restriction, non-immune hydrops fetalis, stillbirth, and preterm

delivery. There are often other risk factors related to lifestyle issues.

Symptoms in babies

If not treated, surviving infants develop early-stage and late-stage symptoms of syphilis.

Early-stage symptoms include irritability, failure to thrive, non-specific fever, rash and condyloma

lata on the borders of the mouth, anus, and genitalia. A small percentage of infants have sniffles

(watery nasal discharge) and destruction of the cartilage of the nasal septum (a saddle nose).

Bone lesions are common, especially in the upper arm (humerus).

Later signs appear as tooth abnormalities (Hutchinson teeth), bone changes (sabre shins),

neurological involvement, blindness, and deafness2.

Diagnosis of Congenital Syphilis

Direct demonstration of T. pallidum by dark ground microscopy and/or PCR of exudates

from suspicious lesions, or body fluids (e.g., nasal discharge),

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Serological tests performed on symptomatic and asymptomatic infants.

Note|: Serological tests must be performed on infant’s blood and not cord blood

Screening serology: (See flow chart for approach to diagnosis & management of at-risk

infant on page 60 )

EIA (Enzyme immunoassay) – IgM and IgG

TPHA (Treponema pallidum haemagglutination)

VDRL / RPR (Rapid plasma reagin)

If mother is around, paired blood for serology should be undertaken as above on both the

infant and mother soon after birth.

If the infant’s serum is negative for IgG and IgM on screening, and there are no signs of

congenital infection, no further testing is necessary. This is very unlikely if the mother has

positive IgG serology and the bloods are taken soon after birth.

Positive serum IgM is indicative of congenital infection.

Serological tests detecting IgG may be positive due to passive transfer of maternal

antibodies whether or not the infant is infected.

If the IgM test is negative, infants with positive IgG titres less than four-fold higher than

those of the mother and without clinical signs of congenital syphilis should be followed up

by repeat of the positive tests at three, six and twelve months of age or until all tests

become negative (usually by six months). IgM should be repeated at three months in

case the infant’s response is delayed or suppressed.

A positive IgM EIA test and/or a sustained four -fold or higher titres in the infant (VDRL/RPR

or TPPA IgG) when compared to a paired sample from the mother (confirmed on testing a

second specimen from the infant) indicates a diagnosis of congenital infection.

Further investigations required in congenital infection:

Blood: full blood count, liver function, electrolytes

CSF: cells, protein, serological tests

X-rays of long bones

Ophthalmic assessment as indicated

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Management of Infants

All infants to have serial serological tests for syphilis as detailed in the section ‘Diagnosis of

Congenital Syphilis’ and have a thorough physical examination for signs of congenital

syphilis; where these signs are suspected further investigations are indicated as detailed in

the section above.

Further investigations as detailed in the section above and treatment as detailed below are

indicated for infants in the following categories:

Infants with clinical signs of congenital syphilis or those where mother had no,

inadequate or uncertain treatment or was treated less than 4 weeks before delivery

should be treated as congenital syphilis with Penicillin (see below)

For infants born to mothers treated with a penicillin-based regimen more than four

weeks prior to delivery with no evidence of re-infection or relapse, and where infant’s

titres are less than 4 fold than maternal titres monitoring using serology as detailed

above is indicated. If follow up is unlikely – treat as for congenital syphilis.

For infants born to mothers treated for syphilis prior to pregnancy with serofast titres

(no change in the antibody titres), monitoring of the infants as detailed in the section

‘Diagnosis of Congenital Syphilis’ is indicated.

Babies born to mothers treated antenatally for syphilis should be managed jointly with

pediatricians.

Older siblings should be screened for congenital syphilis if not done earlier.

Congenital syphilis diagnosed in an older child or in adulthood should be managed as for

late syphilis but the parents, all siblings and any sexual partner(s) should be screened for

syphilis.

Congenital Syphilis definitive treatment

1. Benzyl penicillin sodium 30 mg/kg BD intravenously (IV) in the first 7 days of life and 30mg

/Kg 8 hourly if older than 7 days. The total duration of treatment is 10 days

References:

1. CDSC. Sexually transmitted diseases quarterly report: syphilis – national and international epidemiology.

Communicable Disease Report 1999;9(5):38–9.

2. Oswal S, Lyons G. Syphilis in Pregnancy: Congenital Syphilis. Available at http://www.medscape.com/

3. UK National Guidelines on the Management of Syphilis 2008. International Journal of STD & AIDS 2008: 19: 729-

740

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Management of infants at risk of Congenital Syphilis

References

Symptomatic

Infant

Treat as Congenital

Syphilis

Asymptomatic

Infant

Paired Maternal and infant blood **

EIA – IgG and IgM, TPHA, RPR

Mother

treated prior

to pregnancy

with no

changes in

titres of

serology test

Mother treated > 4

weeks prior to

delivery in this

pregnancy

Treated with

Penicillin based

regimen

No evidence of

relapse

Mother inadequately treated or not

treated or treatment uncertain

Mother treated < 4 weeks prior to

delivery

Treated with Non-penicillin regimen

Infant titres 4 fold higher than maternal

titres or EIA IgM POSITIVE (Where

available)

Follow up of infant uncertain with

above

Treat as Congenital

Syphilis

Serology Follow

up – 0, 3, 6, 12

months or until

negative.

Treat as

congenital

syphilis if rising

titre or

symptomatic

Treat as

congenital

syphilis if follow

Serology Follow

up

Treat as

congenital

syphilis if rising

titre or

symptomatic

** If maternal sample not available –decide management course based on risk profile

using timing and adequacy of maternal treatment and if these are low risk based

investigations and serial serology titres. It is better to treat when information is

inadequate or sketchy.

Further investigations:

FBC, U&E, LFT, CSF for cells,

protein and serology

Bone radiology

Ophthalmic assessment

History of Maternal

Syphilis

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Guidelines for managing newborn weight loss in healthy

breast fed term baby

Rationale:

Growth has a long tradition of being used as a measurement of young children’s health and

wellbeing; weight is one component of this. These guidelines are produce in order to support

Health professionals to provide evidence based care that will enhance the health and well being of

the newborn baby and develop the parents confidence and ability in their parenting skills.

The Baby is to be weighed at 72 hours of age (or as close as reasonable) and again on day 5-

7. If weight loss < 8% of birth weight, care should continue as per protocol. However if

weight loss is > 8% please follow guidelines below. Please document care as per trust

policy.

8% – 10%

1. Check positioning and attachment satisfactory

2. Observe a feed.

3. Note sucking pattern. Is it effective?

4. Baby should demand at least 8 feeds in 24

hours.

5. If baby excessively sleepy, Mum must be

encouraged to wake baby.

6. If baby remains uninterested mum to express

and offer EBM via cup.

7. Note amount of wet nappies in 24 hrs (6 in

24hrs)

8. Observe stool. Note colour and amount. (2-3 in

24hrs. Yellow loose stool by day 5)

9. If 1-8 satisfied, could be discharged to

community if follow up ensured

10. Re-weigh in 48 hours in community. If baby has

not gained 50g please discuss / refer to

Breastfeeding coordinator or Support group

(Contact No: ext5697 /6688 or bleep 5223)

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10% – 12%

Milk Supplementation for poor/slow weight gain in a breast fed baby

All Supplements given should be expressed breast milk. However if insufficient breast milk

obtained formula milk should be considered. Please develop care plan with infant feeding

coordinator.

INFANT WEIGHT

Kg (lb)

TOTAL DAILY

INTAKE

150-200

ml/kg/day

DAILY

SUPPLEMENT

50 ml/kg/day

FEEDING

SUPPLEMENT

6-8 TIMES A

DAY

ml per feeding

>2.5 Kg 375-500 mls 125 mls 15-20 mls

>3 Kg 450-600 mls 150 mls 20-30 mls

>4 Kg 600-800 mls 200 mls 25-35 mls

1. Follow points 1 to 8 above.

2. Reassure mum. It is vital that anxiety is not

caused.

3. Do not discharge these babies from postnatal

ward

4. Do not encourage mum to feed every 3hrs. As

long as the baby demands 8 feeds in 24 hrs it

will be sufficient to stimulate and maintain milk

supply.

5. Re weigh in 24 hrs. Weight increase should be

between: –

10% loss: 25 – 100g

12% loss: 90– 200g

6. If expected weight gain achieved discharge with

appropriate follow up in community

7. If expected weight gain not achieved, is static or

falls further; the baby needs to be referred

immediately to the Pediatrician and the

Breastfeeding Coordinator.

8. Supplementation should start with EBM if

available (See chart below)

9. If EBM insufficient consider formula milk

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Failure of conservative management (weight loss >12% and failure to gain weight on earlier

management plan as above)

This should prompt an immediate assessment by the paediatrician.

Evaluation should include a clinical assessment of hydration and well being of the child

particularly for sepsis. These babies will need U&E, blood sugar, bilirubin and sepsis screen

if clinically indicated.

Babies with serum sodium >150mmol/litre will need careful rehydration

These babies should be rehydrated slowly and preferably by the enteral route (Cup, syringe

or NG tube in that order depending on the alertness and ability of the baby)

In most cases a total intake 150mls/ kg /day of milk will rehydrate the baby over a few days

and bring serum sodium to normal gradually. Breast feeding should continue as before and

should be encouraged.

Babies should have daily weight until a trend of steady weight gain is established. If serum

sodium is less than 150mmol/litre accompanied by weight gain no further electrolyte

measurement is necessary.

The supplements should be reduced appropriately as breast milk supply increases.

Involve the breast feeding support group in this process at all times

Rarely babies who are vomiting and unable to tolerate NG feeds should be admitted to the

neonatal unit for IV rehydration.

IV rehydration should be slow giving only maintenance fluid requirement initially with 10%

dextrose with added NaCl concentration of at least 75mmol/litre initially. This may need to

be adjusted depending on repeat Serum Na levels.

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Serum Na levels should not fall by more than 5 mmol / litre/day.

Reintroduce enteral feeds as soon as possible and cut back on IV supplementation

Bibliography

1. Illingworth. R.S. (1996) Normal child. Churchill Livingston, London.

2. Gwos, et al : Reference data on gains in weight and length during the first two years of life,

J. Pediatrics, 119:355, 1991.

3. Wright.C. et al: New chart to evaluate weight faltering. Archives Diseases in childhood,

78:40, 1998.

4. Hoekelman. R.A., et al (2001) Primary pediatric care, 4th ed. Mosby. London.

5. Mohrbacher.N, Stock. J (2003) The Breastfeeding Answer book. 3rd ed. La Leche league

international. Illinois.

6. Riordan.J.(2005) Breastfeeding and Human Lactation 3rd ed. Jones and Bartlett

Publishers. London

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Management of Neonatal Hypoglycaemia

(Section author: Carol Sullivan, Kate Richards)

Definitions:

Neonatal hypoglycaemia is diagnosed on the basis of blood glucose concentration, clinical signs

or a combination of both.

Whole blood glucose (laboratory) < 2.6 mmol/l

Precision machine <2.6mmol/l.

Precision machine is used to measure glucose on the postnatal wards

Healthy asymptomatic term babies:

There is a transient fall in blood glucose once the cord is clamped. During the first few days in

healthy term babies there are physiological changes resulting in an increase in counter regulatory

hormones such as glucagon, adrenaline, GH and cortisol thereby increasing endogenous glucose

production.

Healthy term infants can utilise other cerebral fuels such as ketone bodies and lactate and are well

adapted to withstand periods of low blood glucose. Therefore operational thresholds for

hypoglycaemia may not be applicable to healthy term babies if they remain asymptomatic. There

is evidence to suggest that healthy breast fed babies have lower blood glucose concentrations

than those fed artificial formula, but no reason to suppose this is detrimental to outcome.

Healthy asymptomatic term infants should not be screened for hypoglycaemia.

High Risk Babies:

Identify a baby`s risk category at birth and manage accordingly

In ill high-risk babies hypoglycaemia may be a feature of illness and the baby may not be able to

mount a counter regulatory hormonal response. Hence these babies may sustain neurological

damage if the hypoglycaemia is not recognized and corrected

Follow Hypoglycaemia Care Pathway 1 for babies:

Mother on β-Blockers

Weight <2.5 kg

Gestation <37 wks

Infant of diabetic mother

Temperature < 35.50 C

Paediatric request for any ill baby

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Follow Hypoglycaemia Care Pathway 2 for babies:

Cord gas pH < 7 or base deficit < -16

Any baby who requires prolonged resuscitation e.g. Apgar < 5 at 5 min

Any baby with “symptoms” of hypoglycemia

Any baby with diagnosis of HIE.

Symptoms of Hypoglycaemia

Hypoglycaemia may result in:

Jitteriness

Increased sweating

Reduced loss of consciousness and /or seizures.

As consciousness drops:

Cry changes

Movements decrease

Feeding becomes poor

Long respiratory pauses/apnoea

For symptoms to be attributed to hypoglycaemia they should resolve with the maintenance of

normoglycaemia.

Jitteriness is defined as excessive repetitive movements of one or more limbs, which are

unprovoked and usually relatively fast. It is important to be sure that this movement is not simply a

response to stimuli.”

All symptomatic baby should be immediately admitted to the neonatal unit and further

management initiated

See observations on High-risk babies on Postnatal Ward guidelines

Management: There are 2 pathways to follow for different risk groups –

Management pathway 1; For high-risk babies on postnatal ward

Management pathway 2: For severely asphyxiated babies

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Care related issues:

At each step mothers should be encouraged continuously to breastfeed and skin to skin

contact is recommended to facilitate this. This should be continued throughout the pathway.

At each step mothers are encouraged to express milk and then this is given in the first

instance assuming a satisfactory blood glucose reading. Should this be insufficient to

maintain / improve blood glucose levels, then formula milk at 10mls / kg can be offered

At all stages adequate temperature of the baby should be maintained

Breastfed babies show great variation in the frequency of feeds in the first 48 hrs after

delivery. Following the Reluctant Feeder Guidelines and feeding any expressed colostrum

via cup/syringe will help to improve feeding technique and maintain blood glucose level

If baby is well but the feeding pattern is causing concern a policy of “FEED- CHECKREVIEW”

is recommended

For high-risk babies follow Hypoglycaemia Pathway 1 and 2 respectively according to

indications above. This protocol has been devised to prevent harm to infants with

hypoglycaemia on the postnatal wards

Blood sugars to be checked on Precision machine.

Dextrose gel use should be administered as described below

Blood sugar of <1.6mmol/l at any stage of the pathway warrants admission to the NNU

Blood sugar should be checked around the age of 3 hours usually before 2nd feed

Encourage breast feeds even if supplementation is required due to medical reason

Other babies at risk such as those with inborn errors of metabolism, hyperinsulinemia and

hypopituitarism are difficult to diagnose. Therefore, any baby with symptoms suggestive of

hypoglycaemia should have their blood glucose measured immediately and a review by

neonatal team should be requested

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Dextrose Gel Use

The Sugar Babies Study (2013) was a randomised double-blind, placebo controlled trial from a

single centre tertiary unit in Hamilton, New Zealand. They demonstrated treatment with

concentrated buccal Dextrose gel was more effective than treatment with feeding alone, for the

reversal of neonatal hypoglycaemia in the at-risk late preterm and term baby, in the first 48 hours

following birth. Additionally it appeared to support breast feeding, partly by reducing the use of

formula milk.

We are now incorporating this into our Hypoglycaemia pathway 1 in the following way.

1. The dextrose gel we will be using is stored in the medicine cabinet. The concentration is

10g glucose in 25g which is conveniently to be written as ‘40% dextrose gel’.

2. The ‘40% dextrose gel’ is to be written up on the ‘As Required Medicines’ side of the

medication chart by the neonatal SHO/ANNP when the baby is identified as needing to

follow the Hypoglycaemia Pathway 1. The dose is 0.5 mls/kg.

3. If the baby fulfils the criteria for dextrose gel on the hypoglycaemia pathway 1 this should

be given by the Midwife/nursery nurse. There is no need to inform the neonatal SHO/ANNP

at that time unless under step 3A (Red) when the blood glucose is < 2mmol/L.

How to administer dextrose gel:

1. The Midwife/Nursery Nurse should dry the baby’s mouth with sterile gauze

2. The dextrose gel 40% should be squeezed into a galliput

3. The dextrose gel 0.5mls/kg should be drawn up into a syringe from the galliput (no needle

required)

4. Massage the gel into the buccal mucosa

5. Thereafter the baby should be encouraged to feed

All treatment/ care given must be documented as per Trust and departmental policy

Further Reading:

Harris HL, Weston PJ, Signal M, Chase GJ, Harding JE. Dextrose gel for neonatal hypoglycaemia

(the Sugar Babies Study) a randomised, double-blind, placebo-controlled trial. The Lancet 2013;

382: 2077-2083

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Hypoglycaemia Pathway 1 (Indication * ……………………………)

Step One – At birth

Step Two (Temp + blood sugar at 3 hrs)

*Care Pathway 1Risk factors: B-Blockers, Weight< 2.5 kg , Gestation <37 wks, Infant of diabetic mother , Temp <35.5c , Paediatric request

*Care Pathway 2 Risk factors: Cord gas Ph<7 or base deficit < -16, Apgar score <5 at 5 mins, Symptoms of Hypoglycemia , Diagnosis of HIE

If blood sugar <1.6 mmol/l or if the baby is symptomatic with hypoglycaemia at any stage of the pathway should be admitted to NNU

Dry baby, keep warm, & initiate skin to skin contact. Initiate breast feeding within 30 minutes, definitely by one hour (time…………….). If effective

proceed to Step 2. If baby not interested or breast feeding appears ineffective top up with available EBM cup/syringe or 10mls/kg Similac

Step 3A (Red)

Blood Sugar<2.0mmol/L

Midwife to give 40% dextrose gel 0.5 ml/kg

Step 3B (Amber)

Blood sugar 2.0 – 2.5 mmol/L

Midwife to give 40% dextrose gel 0.5 ml/kg

Step 3C (Green)

Blood sugar ≥2.6 mmol/L

Review by SHO & send lab

glucose

Admit if

symptomatic

If baby is well, consider

3ml/kg hourly feeds

EBM / Similac by NGT

Continue breastfeeding /available

EBM or top up 6 ml/kg Similac 2

hourly

Recheck blood sugar in 2 hours

< 2.0 mmol/l

Go to step 3A

≥ 2.0 mmol/l

Midwife to give dextrose

gel 0.5 ml/kg

Recheck blood sugar after 3 hrs

………mmol/l

<2.6.mmol/l

Go to

step3B

≥ 2.6 mmol/l

Continue breast feeding /EBM via cup /

syringe 2-3hrly. If no EBM top up Similac

10ml/kg 3 hrly.

Recheck blood sugar in

2hrs………mmol

If not tolerating

feeds or blood

sugar <2.0

discuss with

NNU/ admit

If blood sugar > 2 but <

2.6 mmol/l repeat

dextrose gel 0.5 ml/kg &

continue hourly feeds of

3ml/kg EBM/ Similac via

NGT for 6 hours with a

pre-blood sugar on

2nd…….. 4th……..and

Continue breastfeeding/available EBM or top up

6 ml/kg Similac 2 hourly until 3 pre feed sugars≥

2.6

1st………….2nd…………..& 3rd……………..mmol

Continue breast feeding or

available EBM or Similac 10 ml/kg 3

hourly until 1 further pre-feed sugar

≥2.6 mmol/l

Inform SHO if Blood sugar <2.0mmol/l

If blood sugar is ≥2.0 mmol/l, follow Step 3B or

C

Review by SHO & lab glu if the 3rd pre-feed sugar

< 2.6. mmol/l

If ≥ 2.6 mmol/L, Follow Step 3C

Continue regular (minimum 3 hrly)

feeds for 24hrs. Breastfeeding /

EBM / normal formula

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Pathway 2 for Hypoglycaemia

a) Cord gas pH < 7 or base deficit < -16.

b) Any baby who requires prolonged resuscitation e.g. Apgar score < 5 at 5

mins.

c) Any baby with diagnosis of HIE.

d) Any baby with “symptoms” of hypoglycaemia.

These babies should have blood glucose measured as soon as possible after birth.

Any blood glucose < 2.6 mmol/l baby to have bolus of IV 10% Dextrose at 2.5 mls /kg

followed by an infusion to maintain a steady state.

Glucose to be checked 30 minutes later and if still low the bolus is to be repeated.

Infusion of Dextrose to be increased to achieve a rise of glucose infusion of at least

2mg/kg/min

When blood glucose is > 2.6 mmol/l continue with infusion and recheck glucose 3 –4

hourly until there have been a total of 3 normal glucose results.

Evidence:

Babies born with umbilical arterial pH < 7 who subsequently developed

hypoglycaemia were 6 times more likely to have an abnormal neurological outcome

than babies who had normal blood glucose.

Reference:

Paediatrics 2004; Vol 114, 361 – 366. Salhab et al.

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Neonatal jaundice

Jaundice is caused by increased haem breakdown (haemolysis), interference with

hepatic conjugation (e.g. hepatitis), or impairment of bile excretion (e.g. biliary

atresia).

In normal newborn infants, due to their high intrauterine Hb concentration, there is

increased destruction of RBCs postnatally. Babies also have immature liver

pathways. It is normal or “physiological” for babies to have mild hyperbilirubinaemia.

High levels of unconjugated bilirubin (lipid soluble, and easily crosses blood brain

barrier) can cause acute bilirubin encephalopathy with the following manifestations:

lethargy, hypotonia and poor suck, followed by irritability and hypertonia, in

association with fever, high pitched cry. The hypertonia may alternate with

drowsiness and hypotonia, but there is some evidence that an exchange transfusion

even at this apparently late stage may reverse the CNS changes. Left untreated, this

may be fatal. In the chronic form of the condition, known as kernicterus, features

include high frequency deafness, choreo-athetoid cerebral palsy and severe learning

problems. Kernicterus is the name given to the yellow staining of the basal ganglia

found at post-mortem in bilirubin toxicity. Hopefully it should never be seen!

Intervention aims to prevent these problems.

Two-thirds of normal term babies develop visible jaundice in the first week of life.

However, neonatal jaundice is not always harmless. The level of unconjugated

bilirubin which can be considered safe depends on gestational age and also on the

general condition of the infant. Acidosis and hypoxia displace bound bilirubin

from albumin, allowing more bilirubin to cross the blood-brain-barrier, thus lowering

the threshold for treatment. Hypoalbuminaemia results in more unbound bilirubin,

thus more toxicity.

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Risk factors for developing kernicterus include

a. Serum bilirubin > 340micromole/L in term babies.

b. Rapidly rising bilirubin of > 8.5 micromole/L/hour.

c. Clinical features of bilirubin encephalopathy.

In the well term infant, problems are rarely seen below 340 micromols/l. In the preterm

infant the blood brain barrier is less developed and bilirubin can be pathological

at lower levels. See section 8.4.1

8.1 Assessing jaundice:

Identifying babies more likely to develop significant hyperbilirubinaemia:

gestational age under 38 weeks

a previous sibling with neonatal jaundice requiring phototherapy

mother’s intention to breastfeed exclusively

visible jaundice in the first 24 hours of life.

If a child is visually jaundiced:

1. For babies less than 24 hour old and under 35 weeks gestation – send lab

serum bilirubin urgently

2. For babies over 35 weeks gestation and greater than 24 hours old

a. Assess formally using a Transcutaneous bilirubinometer if available

b. If transcutaneous bilirubinometer is not available, have a low threshold

for measuring serum bilirubin.

Beware of visually underestimating jaundice in Asian or Afro-Caribbean infants. Preterm

infants often need treatment when little jaundice is visible. Also, beware the

baby who has been under phototherapy; the skin may look clear but the blood or

tissue bilirubin could still be high.

Definition of PATHOLOGICAL JAUNDICE:

Visible in first 24 hours (suggests haemolysis and needs urgent investigation

and treatment)

Baby is “unwell”

Total bilirubin >340 mmol/l (term infants)

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Conjugated jaundice (see definition in section 8.2.2)Conjugated

hyperbilirubinemia is defined by a serum conjugated bilirubin concentration of

 greater than 17 micromol/L if the total bilirubin is <85 micromol/L

OR

 more than 20% of the total bilirubin if the total bilirubin is >85

micromol/L.)

Prolonged jaundice

 > 14 days in term babies

 > 21 days in preterm babies

Jaundice which recurs having cleared

If any of these criteria are met, the cause(s) for the jaundice should be sought, and

the baby managed accordingly. See section 8.2.1.

8.2.1 Causes of unconjugated hyperbilirubinaemia:

a. Physiological Jaundice

b. Acute intravascular haemolysis

Haemolytic disease e.g. Rhesus, ABO, Kell

Red cell abnormalities e.g. G6PD, hereditary spherocytosis

Viral infections e.g. CMV, Herpes, Toxoplasmosis

Bacterial infection e.g. sepsis or urinary infection

c. Sequestered blood

Excessive bruising, cephalhaematoma

Intraventricular haemorrhage

Haemangioma

d. Decreased conjugation

Sepsis

Criglar-Najjar syndrome (deficiency of glucuronyl transferase enzyme)

e. Increased enterohepatic circulation due to decreased gut movement

Delayed feeding

Constipation or bowel obstruction

f. Breast milk jaundice

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8.2.2 Causes of conjugated hyperbilirubinaemia:

Conjugated hyperbilirubinemia is defined by a serum conjugated bilirubin

concentration of

 greater than 17 micromol/L if the total bilirubin is <85 micromol/L

OR

 more than 20% of the total bilirubin if the total bilirubin is >85

micromol/L.)

Definition from North American Society for Pediatric Gastroenterology, Hepatology, and

Nutrition (NASPGHAN)

Neonatal hepatitis

Hepatitis A, B or C

Other viral hepatitis

Congenital viral infections: rubella, CMV, Herpes

Galactosaemia

Other causes of conjugated hyperbilirubinaemia:

Cystic fibrosis

Endocrine causes (hypothyroidism, hypopitutarism)

Prolonged TPN

Biliary atresia

Alagille syndrome

Choledocal cyst

• α1 antitrypsin deficiency

Inspissated bile syndrome

Inborn errors of metabolism

Many more

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8.3 How to investigate a jaundiced baby:

8.3.1 Baseline for all jaundiced babies:

Baby more than 24 hours old and born at 35 weeks or more assess degree of

jaundice with transcutaneous bilirubinometer if available (see later in the chapter)

If Tc B measures Bili > 250 send SBR to lab

Baby less than 24 hours old or born at less than 35 weeks send SBR to lab

History & full examination, e.g. the spleen is often palpable in haemolysis or

sepsis

8.3.2 Additional investigations as suggested by history

FBC and film and reticulocyte count

Group and Coombs (interpreted in relation to mum’s blood group & whether or not

she received prophylactic anti-D antenatally)

Split direct & indirect bilirubin requested when baby > 6 days old

Septic screen (blood, urine, CSF)

Liver function tests, including coagulation screen

G6PDH screen

More investigations are dictated by suspected cause

8.4 Management of jaundice:

Phototherapy is the main treatment for unconjugated hyperbilirubinaemia, enabling

the effective and relatively rapid reduction of high bilirubin levels, facilitating the

prevention of kernicterus. (Overhead blue light phototherapy is recommended as first

line for term babies and overhead blue light or fibreoptic light is recommended for

preterm babies.)

8.4.1 Indication for phototherapy:

NICE jaundice charts should be used to plot a baby’s bilirubin level, to decide on

phototherapy. These can be found on our sharepoint site ‘Home Neonatology’

(Chapter 8) or as printed copies on the neonatal unit and postnatal ward.

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Note:

If the infant is sick (e.g. HIE, hypoxia, acidosis, hypoglycaemia, infection) lower

thresholds for treatment are necessary.

If the infant has Rhesus disease or suspected haemolysis, phototherapy needs

to be started immediately and exchange level is dependent on the rate of rise

rather than absolute level as per guideline for management of jaundice in first

24 hours – see section 8.6 below.

A. If serum bilirubin is not rising rapidly (> 8.5 micromole/L/hour) or the level is not

within 50 micromole/L for the threshold for exchange transfusion start single

phototherapy.

1. Short breaks for breast feeding can be allowed. Use clinical judgement.

2. Repeat bilirubin 4-6 hours after starting phototherapy. Then every 6-12

hours if level stable or falling.

3. Switch to continuous multiple phototherapy if level is not stable or

falling. Monitor hydration by daily weighing of babies and checking for

wet nappies.

B. If serum bilirubin is rising rapidly (> 8.5 micromole/L/hour) or the level is within 50

micromole/L for the threshold for exchange transfusion start on continuous multiple

phototherapy .

1. Do not interrupt for feeding. Intravenous or NGT enteral feeding can continue.

Monitor hydration.

2. Repeat bilirubin 4-6 hours after starting phototherapy. Then every 6-12 hours

if level stable or falling.

8.4.2 When to discontinue Rx:

Stop phototherapy once serum bilirubin has fallen to a level at least 50

micromol/litre below the phototherapy threshold

Check bilirubin for rebound 12-18 hours after stopping phototherapy.

Babies do not necessarily remain in hospital for this.

8.4.3 Managing a baby requiring phototherapy:

Check ‘baseline’ bloods –see 8.3.1.

*When deciding on intervention it is not usually necessary to perform a split

bilirubin (i.e. measurement of direct/indirect bilirubin) unless the conjugated

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level is suspected to be high, as in the case of some congenital infections, or if

the baby is older than 6 days old, or has clinical features of obstructive

jaundice (pale coloured stool, greenish tinge to jaundice, features of liver

disease).

It is important to clinically assess the need for a split bilirubin, as phototherapy

should not be given to a baby who has conjugated jaundice, as this would

result in a dark bronze discolouration of the skin.

The baby should have as much skin exposed as possible, so lay the baby on

an open nappy with no hat (unless ventilated).

The baby will probably need an incubator or overhead heater to keep warm.

The temperature should be measured 4-hourly.

Explain fully to the mother before starting. The mother should be allowed to

handle the baby for feeding, changing and cuddling the baby out of the

phototherapy with eyes uncovered, as long as there is no immediate risk of

having to do an exchange transfusion. However, baby should not be out of the

phototherapy for prolonged periods.

Phototherapy itself does not increase fluid requirements; however dehydrated

babies often have more severe jaundice and an assessment of hydration

should be made. If the SBR is particularly high, then electrolytes should be

checked and if dehydration is suspected, NG feeds or IVI considered.

8.4.4 Pre Discharge from post-natal ward (PNW)

Babies will be reviewed at home by the midwifery team, who will keep an eye on any

recurrence of jaundice, and manage accordingly. Babies especially at risk of

significant jaundice post discharge are:

Near term, i.e. GA 35 – 36/40 at birth

Cephalhaematoma / bruising

Exclusively breast fed, if concerns re the breast feeding / weight loss observed

Already received phototherapy on PNW

Sibling with history of neonatal jaundice requiring phototherapy

Presence of pathological jaundice, e.g. haemolytic

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For these babies, parents need to be advised to ensure adequate feeding, and to

seek professional help early (i.e. contact midwife) should they be concerned re

feeding or increasing jaundice. And midwifery team need to ensure early and regular

home visits following discharge.

8.5 Baby incidentally detected to have extremely high bilirubin:

In the event of first presentation of bilirubin level near exchange level:

Inform consultant on call.

Explain urgency of situation to parents, as baby would require admission to

NICU.

Take history of: age at onset of jaundice, feeding, stools, antenatal concerns,

maternal blood group.

Assess for CNS signs, signs of sepsis, hepatosplenomegaly, pallor.

Admit to NICU.

Start double / triple phototherapy.

Check FBC, DCT & Group, LFT (as it is also important to have normal albumin

level), conjugated bilirubin level, blood gas and PcX glucose. Request urgent

processing of these from the lab technicians.

Ensure adequate hydration, either enteral / parenteral.

o Keep nil by mouth if plan to perform exchange transfusion, or baby

unwell.

Contact blood bank re blood for exchange transfusion if bilirubin >420μmol/L

in a term baby, or > 340μmol/L in baby < 38/40, or an unwell baby.

Insert lines in preparation for exchange transfusion.

If necessary, perform full septic screen and start antibiotics.

Repeat bilirubin 2 – 4 hourly initially.

Once downward trend is seen, and if baby does not have haemolytic disease

of newborn, may check bilirubin 6 – 8 hourly.

If diagnosis of haemolytic disease of newborn – treat according to protocol

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8.6 Management of the infant with suspected haemolytic disease or who

develops jaundice in the first 24 hours

Haemolytic disease may be suspected if the mother is known to have antibodies, e.g.

Rhesus (see section on Rhesus), but there may be non-Rhesus antibodies that

cause severe haemolysis, if mother has had a previously-affected infant, or if the

baby is found to be anaemic, jaundiced or hydropic at birth. Usually, the

obstetricians will be aware of the problem and will let us know in advance.

If the obstetricians are aware of a high risk fetus, please let the blood bank know as

soon as possible so that they can cross-match blood against the mother’s serum and

have blood available for the infant at short notice. Blood used for exchange

transfusion is of a lower PCV than packs for ordinary transfusions. It needs to be

specially prepared and has a shorter shelf life.

Enquire about the history in previous infants – in Rhesus disease; it tends to be more

severe with each subsequent affected infant. At delivery, following adequate

resuscitation, examine the baby for anaemia, signs of heart failure, oedema and

hepatosplenomegaly.

8.6.1 – What to do in the first 24 hours:-

Cord blood urgently sent for:

Hb and blood film

Coombs test

Blood group (+ cross-matched if indicated)

Serum bilirubin

Clotting screen

If at birth, Hb <12 g/dl or SBR >85 micromols/l, the baby will need an early exchange

transfusion. Admit the baby, start double phototherapy, and discuss with the on call

consultant as a matter of urgency.

If at birth, Hb >12 g/dl and SBR > 85 micromols/l, the baby should have double

phototherapy making sure the baby is as fully exposed as possible (no hats or

nappies!). Check SBR 4-6 hourly in the first 24 – 48 hours, and calculate the rate of

rise. (The baby may still need an exchange transfusion.)

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Bilirubin rising at a level of greater than 8.5 micromols/ hour, is an indication for

an exchange transfusion. If the rate of rise is below this, but there is evidence of

haemolysis (Coombs test strongly positive or Hb dropping) the baby may continue to

be managed with double phototherapy, but a rapid drop in Hb is also an indication for

an exchange transfusion.

Bilirubin Level for exchange transfusion – in haemolytic disease:

As a rough rule of thumb the level at which an exchange transfusion should be

undertaken in a well baby is post conceptional age in weeks x 10

However, exchange transfusions are usually undertaken before this level is reached,

as the rate of rise of bilirubin is calculated, and exchange level is anticipated.

Procedure for exchange transfusion: See clinical procedure Section 12

8.6.1 Exchange transfusion.

– Counsel parents and get informed consent.

– Conduct double volume exchange transfusion with appropriate blood as per unit

guidelines. Liaise with the blood bank. Use blood warmer.

– Monitor baby during procedure and watch for adverse effects. Maintain input and

output records during procedure.

– Monitor bilirubin, Hb, U&E and Ca.

– Continue multiple phototherapy following exchange transfusion and check

bilirubin 2 hours after exchange. Manage according to threshold charts and graphs.

8.6.2 IVIG (Intravenous immunoglobulin)

Recommended for

– Babies on multiple phototherapy whose bilirubin levels remain above the

threshold for exchange transfusion and/or have signs of acute bilirubin

encephalopathy while preparing for exchange transfusion.

– Babies with Rhesus or ABO haemolytic disease if serum bilirubin level rises

> 8.5 micromole/L/hour.

Dosage recommended: 500 mg/kg over 4 hours.

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8.6.3 LATE ANAEMIA – in babies with haemolytic disease of the newborn

All babies with a haemolytic process can have a chronic low grade haemolysis, and

are at risk of developing severe anaemia requiring top-up transfusions. Therefore:

Check haemoglobin level measured prior to discharge

Only babies with documented haemolysis or Coomb’s test >2+ should be

commenced on folic acid supplements (500 microgram /Kg/dose – single daily

dose)

Fill in the referral template on postnatal guidelines and give it to the neonatal

secretaries on the same day and request consultant appointment. ; if the

baby has a discharge summary from the unit, this should be attached to the

template.

Organise blood tests in 2 weeks in PAU for FBC, film, reticulocyte count and

bilirubin .

Further follow up is decided based on these result

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8.7 Management of deliveries to Rh D negative mothers

Introduction:

Each year in England and Wales, there is approximately 105,000 births to RhD

negative women, almost 17% of all births. 59% of these babies are RhD positive;

they represent about 10% of all births.

Haemolytic Disease of the Newborn (HDN) may present as severe hydrops and fetal

demise, severe jaundice and anaemia of the newborn or simply as a positive DCT

with no clinical concerns. Prior to 1970, HDN was a significant cause of morbidity and

mortality. By 1990, mortality rate was reduced from 1.2 per 1000 births to 0.02 per

1000 births following the use of immunoprophylaxis with anti-D. With this treatment, it

was noted that RhD negative mothers were showing much lower rates of

sensitisation, and that these could be lowered even further with prophylaxis in the

third trimester. This led to the recommendation for routine antenatal anti-D

prophylaxis (RAADP).

Recent changes:

In April 2008, RAADP was introduced into the ABM trust West Division. This means

that all RhD negative pregnant mothers would be offered a single injection of anti-D

at 28 weeks, in addition to any other doses that are clinically indicated for potentially

sensitising events, e.g. following amniocentesis. This is in accordance with advice

from the British Committee for Standards in Haematology and NICE. Following

RAADP, the cord blood direct antibody test (DAT, DCT) may be falsely positive,

(although this is likely to be weakly positive), due to the presence of the circulating

anti-D administered to the mother. Therefore, a positive DCT will no longer be

exclusively indicative of a possible haemolysis. Because of this, and to avoid

confusion and unnecessary testing, Blood Bank will no longer be performing routine

DCT on all cord blood from RhD negative mothers.

Blood Bank will continue to check the baby’s RhD blood group on the cord blood

from all RhD negative mothers to guide the medical team on post partum

administration of anti D to the mother. If the baby is RhD positive, the mother will be

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offered further anti-D, but this would not be necessary following the birth of an RhD

negative baby.

8.7.1 Management of babies born to Rh D negative mothers

In all deliveries of RhD negative mothers: midwife will send cord blood for baby’s

blood group, and for other bloods as necessary –see below.

Check mother’s notes for antenatal blood group serology, i.e. presence of blood

group antibodies. (Specifically presence of any anti-D antibodies / rising titres)

8.7.2. If there are antenatally detected maternal antibodies or rising titres:

(NB this guideline should also be followed in the presence of other antenatally

detected blood group antibodies, as severe jaundice and anaemia and

possibility of exchange transfusion need to be ruled out)

Antenatal management depends on the antibody titre, and the blood bank will give an

estimate of likely severity. Antenatal detection of anaemia and treatment with

intrauterine transfusion (IUT) is available in some fetal medicine department (nearest:

UHW & Bristol). Babies who have received this may not require exchange

transfusion but will usually continue to have haemolytic anaemia and therefore

require follow up (see section on Late Anaemia). Any baby who receives IUT, must

have irradiated blood for any transfusion during the first year of life.

8.7.3 If the prediction is for moderate or high-risk of haemolytic disease –

• Fresh blood suitable for exchange transfusion should be ordered, and delivery of

the baby should not take place until this blood is ready in blood bank at Singleton,

(POW) except in extreme emergency.

• The neonatal team should be made aware of imminent delivery

• Cord bloods should be sent urgently for DCT, bilirubin and Hb, and results should

be chased ASAP to confirm/exclude HDN

• Baby should be examined immediately after delivery, looking for jaundice or pallor,

hepatosplenomegaly, other signs of hydrops

• Admission to the neonatal unit for double phototherapy.

• Neonatal consultant on-call should be informed prior to the baby’s birth, or as soon

as the team becomes aware of the baby’s birth

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• Calculate rate of rise of bilirubin, and manage accordingly – see Section 8.6.1

8.7.4 If the prediction is of mild HDN –

• The neonatal team should be made aware of imminent delivery

• Cord bloods should be sent urgently for DCT, bilirubin and Hb, and results should

be chased ASAP to confirm/exclude HDN

• Baby should be examined soon after delivery, looking for jaundice or pallor,

hepatosplenomegaly, other signs of hydrops

• Prophylactic phototherapy should be started on postnatal ward or on admission to

the neonatal unit

• Neonatal consultant on-call should be informed prior to the baby’s birth, or as soon

as the team becomes aware of the baby’s birth

Calculate rate of rise of bilirubin, and manage accordingly –see Section 8.6.1

8.7.5 In the absence of antenatally detected maternal antibodies:

There is no increased risk of haemolysis therefore manage baby as per normal. It

does not make a difference if the baby’s blood group is Rh D positive or negative

Remember that any baby, regardless of maternal blood group, who appears

jaundiced in the first 24 hours, requires a paediatric review and blood tests to

check bilirubin, Haemoglobin and DCT.

8.8 ABO and minor Blood Group incompatibilities:

These are more common but less severe than Rhesus problems. The most likely

risk of high SBR levels is if mother is group O and baby is group A. If mother is AB

there is no risk of ABO incompatibility.

ABO incompatibility usually comes to attention either because of early jaundice or

because the cord Coombs test is positive. Babies may have only a weakly positive

Coombs test in ABO incompatibility. In ABO incompatibility, the jaundice is usually

manageable by phototherapy.

If Coombs is positive and baby has shown signs of haemolysis in neonatal period

anaemia may occur late. Follow guideline for Late Anaemia.

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“Minor” blood groups i.e. E & c of the Rh system, Kell, Duffy, Lewis, Kidd, M, S,

can rarely cause isoimmune haemolytic disease. They tend to come to attention

because of antenatally detected antibodies. Again, the laboratory will give an

estimate of risk of HDN, and the management is as for Rhesus D isoimmunisation.

8.9 Prolonged jaundice

Defined as jaundice persisting beyond 14 days in term and 21 days in preterm babies

8.9.1 Causes of prolonged jaundice:

Persistence of unconjugated jaundice from early neonatal period:

Haemolytic jaundice (of any aetiology)

Infection, including UTI

Rare causes of unconjugated jaundice:

Inborn errors of metabolism (Galactosaemia, tyrosinaemia, lipid-storage disorders,

and others)

Hypothyroidism

Drugs

Crigler-Najjar

Gilbert’s

Intestinal obstruction

Cystic fibrosis

Conjugated jaundice – for list of causes see above:

Breast milk jaundice

8.9.2 Investigation of prolonged jaundice:

History & examination to elicit cause.,

Look for pale, chalky stool or urine that stains the nappy dark.

Base line investigations:

Split SBR (total and direct SBR) – the direct SBR is the conjugated fraction –

Conjugated hyperbilirubinemia is defined by a serum conjugated bilirubin

concentration greater than 17 micromol/L if the total bilirubin is <85 micromol/L;

or more than 20% of the total bilirubin if the total bilirubin is >85 micromol/L.

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Definition from North American Society for Pediatric Gastroenterology,

Hepatology, and Nutrition (NASPGHAN)

FBC. Group and Coomb’s. Blood film.

LFT & coagulation screen

TFTs

Urine culture

Further septic screen, if unwell

Urine for reducing substances

8.9.3 Prolonged Conjugated jaundice:

This is usually picked up because of prolonged jaundice with a high direct fraction.

There may be a history of pale stools and dark urine, which should ring alarm bells

for biliary atresia and other causes of obstructive jaundice. Do base line bloods/urine

and discuss with the consultant.

Further investigations in case of conjugated jaundice:

Hepatitis A, B and C

Gal-1-put

• α1 antitrypsin phenotype. (NB, since α1 antitrypsin is an acute phase reactant, it

may be raised in any intercurrent illness and may be normal even if there is a

deficiency. Hence the need for the typing.)

TORCH screen

Serum amino acids and urine organic acids, and urine organic acids

X-ray spine (hemivertebra in Alagille syndrome)

Liver USS (to exclude choledochal cyst, and look for signs of biliary atresia).

Please fast the baby for at least 4 hours prior to the USS. If no gall bladder is

visualised in the fasted USS refer to a specialised unit for further investigations

HIDA scan (radio-isotope scan of the liver to detect biliary atresia)

Eye examination (posterior embryotoxin)

8.9.4 Breast milk jaundice:

This is a diagnosis of exclusion. Excessive investigations may cause anxiety to

parents, and lead mother to stop breast feeding. Jaundice is not a reason to stop

breast-feeding but fluids may need to be increased.

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If the baby is well and is normal to examine, and has normally pigmented stools,

check the baseline investigations (see above).

If these are normal, no further investigations are needed unless the clinical picture

changes or the jaundice clinically becomes darker, in which case, a further split SBR

should be checked. If the jaundice does not resolve in a week, then the split SBR

should again be repeated, but if it remains unconjugated and the baby is well, no

further tests are needed.

Further Reading:

.

1. NICE clinical guideline 98. Neonatal Jaundice. Issue date: May 2010

2. Janet M Rennie, Arvind Seghal, Ambelika De, Giles S Kendall and Tim J Cole.

Range of UK practice regarding thresholds for phototherapy and exchange

transfusion in neonatal hyperbilirubinaemia. Arch. Dis. Child. Fetal Neonatal

Ed. published online 10 Nov 2008.

3. Subcommitte on Hyperbilirubinaemia, AAP. Management of

Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.

Pediatrics 2004. 114; (1):297-316.

4. Guidance on the Use of Routine Antenatal AntiD Prophylaxis for RhD

Negative Women. NICE 2002.

5. British Committee for Standards in Haematology – Guidelines for the Use of

Prophylactic Anti-D Immunoglobulin, 2004.

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Guideline for the use of JM 103 (Draegar) transcutaneous bilirubinometer

(Based on NICE guideline)

Transcutaneous bilirubinometer is a device used for non invasive estimation of serum

bilirubin in neonates. The gold standard for estimation of serum bilirubin is a

laboratory estimation of bilirubin. This guideline is designed for using the

transcutaneous bilirubinometer in the postnatal ward and NICU in Singleton hospital

during the trial of JM103 transcutaneous bilirubinometer from Draegar.

Who can use the bilirubinometer?

Currently use is restricted to doctors and ANNPs in the neonatal team who have

been trained in the use of the device.

Which babies are eligible to have their bilirubin levels assessed using

trancutaneous bilirubinometer?

1. Term and near-term babies more than 35 weeks gestation with visible

jaundice.

2. Babies more than 24 hours of age.

3. Babies who have not received phototherapy.

4. Babies in whom the transcutaneous bilirubinometer reading is less than 250

micromol/L.

The bilirubinometer can be used in babies with any skin tone (Caucasian, African,

Asian etc)

A blood sample to estimate lab serum bilirubin should be sent for any baby

who

1. Is less than 24 hours of age with suspected jaundice.

2. Has a transcutaneous bilirubinometer reading more than 250 micromol/L.

3. Has a transcutaneous bilirubinometer reading high enough to require

phototherapy. (Phototherapy can be started following the high bilirubinometer

reading pending lab results)

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Which babies should not have bilirubin estimated using transcutaneous

bilirubinometer?

1. Babies < 35 weeks gestation.

2. Babies < 24 hours old.

3. Babies who have received or is receiving phototherapy.

4. Babies with transcutaneous bilirubinometer reading > 250 micromol/L.

Method of use:

The bilirubinometer should be adequately charged. When not in use it should be

docked in the docking station in the doctor’s office in NICU. The doctor/ANNP using it

should ‘sign out’ in the log book when taking it out of the docking station and ‘sign in’

when returning it.

1. Switch device on. Wait for green light indicating device is ready.

2. Ensure that device is set to be in units ‘micromol/L’ and is set to measure

average of 3 values. (This is the default setting).

3. Clean the tip using an alcohol wipe.

4. Keep tip perpendicular to the sternum of the baby and press gently until a red

light flashes at the tip. Direct contact with skin is needed. Repeat process 3

times. If the red light does not flash wait a few seconds and try again.

5. Take the reading from the screen in micromol/L after the 3rd flash.

6. Record the actual reading on the patient’s notes and plot it and record against

the charts for assessing neonatal jaundice in the neonatal protocol. Take

appropriate action based on the chart. If baby requires phototherapy commence

phototherapy and send a blood sample to lab for serum bilirubin estimation. (Be

aware that transcutaneous bilirubinometer reading could have an error of +/- 50

micromol /L from the actual lab value.)

References:

1. NICE clinical guideline 98. Neonatal Jaundice. Issue date: May 2010.

2. Evaluation of a new transcutaneous bilirubinometer. Maisels MJ, Ostrea EM

Jr, Touch S, Clune SE, Cepeda E, Kring E, Gracey K, Jackson C, Talbot D,

Huang R. Pediatrics. 2004 Jun;113(6):1628-35

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Polycythaemia (PCT)

Polycythaemia can be defined as a central venous haematocrit (Hct) >65% for both

term and preterm infants.

Causes / risk factors for PCT include IUGR, maternal diabetes, maternal

hypertension, maternal smoking, delayed cord clamping, cord stripping, twin-twin

transfusion, maternal-fetal transfusion, Beckwith-Wiedeman syndrome, hypo- and

hyperthyroidism, perinatal asphyxia and trisomies.

When dealing with an infant with PCT always consider whether the cause needs

investigation +/- treatment

Symptoms:

Not present at birth, but usually become evident within first 24 to 48 hours.

They include lethargy, hypotonia, vomiting, irritability, poor response to light,

tremulousness.

Complications:

Neurological:

Seizures

Stroke

Developmental delay

Reduced IQ.

Cardiopulmonary:

Respiratory distress,

Pleural effusions,

Pulmonary hypertension.

Metabolic:

Hypoglycaemia,

Hypocalcaemia,

Others:

Necrotizing enterocolitis,

Renal vein thrombosis,

Proteinuria, renal tubular damage,

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Hyperbilirubinemia,

Thrombocytopenia

Treatment:

Always discuss with consultant before treating

Capillary Hct >65%

Confirm with venous Hct, exclude dehydration

(check weight loss)

Treat dehydration if present

PET (see below)

Hct 65-75%

Hct >75% and not decreasing

Maintain hydration, watch for

symptoms

Consider PET

Asymptomatic

Symptomatic

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Technique for Partial Exchange Transfusion (PET)

Fluid: Normal saline

Volume: 20 ml per kg

Infuse saline by peripheral cannula at rate of 40 ml/kg/hour and withdraw 20 ml/kg of

blood from the umbilical venous cannula at the same rate. Aim to complete exchange

over 30 minutes. Do not allow the infant to get cold, and check blood glucose after

the procedure. Stop feeds for 2-4 hours.

Section Author: Geraint Morris

Edited by: Sujoy Banerjee

Audiological screening

All newborn babies should have a routine audiological screening as part of the

National Newborn Hearing Screening Programme

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Discharge medication

Prescriptions should be done in good time as per the recommendations in the

guideline. For vitamin and mineral supplementation follow the guide as outlined

below

For preterm infants

Notes:

All preterm infants will need to be assessed for consideration of vitamin and

mineral supplementation depending on their gestation and type of enteral

feeds

Vitamin and minerals are supplemented in TPN and therefore consider

supplementation as soon as the infant is on full enteral feeds

Routine Iron supplementation starts at 28 days of life

The guidance is based on an average intake of 180mls/Kg/d of milk at preterm

gestation and 150mls/Kg for near term infants

It ensures an approximate daily intake of at least 400IU of Vit D, 400gg of Vit

A & 2mg/Kg/d of elemental iron without reaching toxic levels of other

elements.

For mixed feeding – change supplementation only if > 75% of feed volume on

the new allocation

When this specific guidance ends – consider for all children until their 5th

birthday – the DoH guidance on multivitamin supplementation ( see below).

For details – see flow chart – ‘Vitamin and Minerals supplementation policy 2014 for

preterm infants’ (page 21)

Easy to remember guide: The dose of Abidec is 0.3 mls for formula fed babies to be

discontinued 1 month post discharge. The dose of Abidec is 0.6 mls for breast fed babies not

on fortifiers.

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Term Infants:

The Department of Health recommends that all babies and young children

aged six months to five years should take a daily supplement containing

vitamin D.

Term formula milk contains supplemental vitamins and should be sufficient as

long as the infant has an average milk intake of 500 mls / day.

Breast fed infants whose mothers did not receive Vitamin D supplements

during pregnancy should also receive multivitamin supplements from 1 months

of age. The GP should take care of this during routine check ups.

However, the following infants are at particular risk of vitamin deficiencies and should

be prescribed Vitamin supplements from birth with advice given to GP to continue

this throughout childhood.

Infants in Asian households and other non-white ethnic groups are prone to

Vitamin D deficiency

Breast-fed term infants whose mothers are on restricted diets e.g. vegetarians.

These groups should also receive Abidec 0.6 mls per day until one year of age or

until they are on a well balanced diet. Infants of vegans who are breast-fed also need

Vitamin B12 supplements.

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Multivitamins and Mineral Supplementation Policy for preterm infants

Consider vitamin and mineral supplementation when infant on full enteral feeds

Start Sytron at 28 days of life

The guidance is based on an average intake of 180mls/Kg/d of milk at preterm gestation and 150mls/Kg at term

Aims to ensure an approximate daily intake of at least 400IU of Vit D, 400Vg of Vit A & 2mg/Kg/d of elemental iron without reaching toxic levels of other elements.

For mixed feeding – change supplementation only if > 75% of feed volume on the new allocation

When this specific guidance ends – consider for all children until their 5th birthday – the DoH guidance on multivitamin supplementation.

Gestation at birth

< 34 wks

34-37

wks

Breast milk

only

Breast milk +

fortifier

Nutriprem

1

Nutriprem 2 Term equivalent

formula e.g.

Peptijunior /

Nutramigen etc.

Breast milk

only

Term formula

Type of milk feed

Abidec 0.6 ml OD

Sytron 1ml OD

Abidec 0.6 ml OD

Sytron 1ml OD

Sytron 1ml

OD

Abidec 0.3 ml

OD

Abidec 0.3 ml

OD

Abidec 0.3 ml OD

Sytron 1ml OD

Abidec 0.3 ml OD

Sytron 1ml OD

Continue until

the 1st birthday

Continue until off

fortifier & then

follow guidance for

breast milk only

Continue until

off Nutriprem 1

Continue for

4 weeks after

discharge

Continue Abidec

for 4 weeks after

discharge

Sytron until 1st

birthday

Continue until

the1st birthday

Continue Abidec

for 4 weeks after

discharge

Sytron until 1st

birthday

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Neonatal abstinence syndrome in infants of substance abusing

mothers

Definition:

A constellation of signs and symptoms which result from the abrupt cessation of a

drug to which the fetus/neonate has become physiologically dependent

The risks to a fetus from maternal drug abuse include:

1. Teratogenic effects of the drug (cocaine, benzodiazepines)

2. Increased complications of pregnancy (abruption etc)

3. Fetal anoxia if there is maternal overdose

4. Poor fetal growth (especially amphetamines, cocaine and opiates)

5. Fetal addiction and withdrawal

6. Preterm labour

7. Increased risk of infection e.g. HIV, hepatitis B, C, syphilis etc

The process of fetal addiction:

Drugs readily cross the placenta. Once inside the fetus the drug may become tissue

bound or converted to a metabolite which does not cross the placental barrier as

easily as the parent compound (e.g. heroin is converted to morphine, and cocaine is

metabolised to norcocaine). These metabolites are pharmacologically active resulting

in a greater exposure and risk of addiction for the fetus than for the mother.

Procedure for infants at risk:

Admit the infant to the postnatal ward with the mother, as long as the baby is not

actively withdrawing, in which case admit to Neonatal unit. If the mother wishes to

breast feed this may be encouraged unless she is on crack cocaine, or is known to

be HIV positive. For other drugs please refer to Infant Feeding and Maternal

Substance Use Guideline for Professionals.

The baby should be observed carefully for signs of withdrawal by using the modified

Finnegan Score (See Table 1 for when and for how long to monitor with individual

substance use). Babies whose mothers have stopped using drugs before pregnancy

or used only occasional cannabis or cocaine do not routinely need to be started on

withdrawal score but social circumstances need to be evaluated prior to discharge.

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Table 1: FINNEGAN SCORING – when to administer and how long?

IN EACH CASE, PLEASE REFER TO THE CARE PLAN IN THE WOMAN’S NOTES

Useful Numbers: Substance Misuse Specialist, Midwife Ann Saunders

07891485872 Substance Misuse Specialist Nurse CDAT (Swansea)

Nicola Cook 01792 654630 or (POWH) Kerry Collier 07966352040

Drug/Medication Effects Time Scoring

Required

Breastfeeding

Recommended

Anti-Depressants/

SSRI’s : e.g

Citalopram 60mgs or

under daily

Sertraline 250mgs or

under daily

Fluoxitine 100mgs or

under daily

These dosages

have little or no

effect on neonate

None Yes

Alcohol Irritability, features of

Fetal Alcohol

Syndrome

48 hours No

Amphetamines and

Antipsychotic drugs

Irritability,

hyperstimulated,

difficulty controlling

temperature, over

feeder

5 days No

Benzodiazepines e.g.

Valium (diazepam),

Mitrazepine

Hypotonia,

hypothermia, slow to

feed

5 days No

Cannabis No physical effects None Yes

Cocaine Irritability,

hyperstimulated,

Poor feeder

5 days No

Methadone

(Opiate)

Neonatal Abstinence

Syndrome (NAS)

5 DAYS Yes

MCAT

Meow Meow

Bonsai

See amphetamines 5 days No

Subutex

(Buprenorphine)

Opiate

Neonatal Abstinence

Syndrome (NAS)

5 days Yes

Codeine Delayed onset of

NAS when mixed

with opiates

See effects of

cocaine

48 hours Yes

Heroin NAS (see

methadone)

5 DAYS No

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Withdrawal symptoms may start immediately (e.g. heroin) or infrequently may be

delayed for up to two weeks (e.g. methadone or barbiturates). Send urine from the

baby for a drug screen as soon as possible after birth (results may take up to two

weeks). Always assess social situation early.

A recent audit in our hospital looking at data from 2003-2007 has shown that more

than 95% of babies will have their peak withdrawal symptoms by day 5 of life.

Therefore babies with opiate use should be OBSERVED IN HOSPITAL FOR

MINIMUM 5 DAYS but may need to stay longer. Babies scoring 4 on the

Modified Finnegan score in the preceding 24 hours should not be sent home but

observed longer. In some cases babies could go home earlier after full review of

clinical and social circumstances and only following joint discussion with the

neonatal consultant and Lead Midwife for Vulnerable Adult / Child.

Drugs causing withdrawal (See Appendix 1 for more information on individual

drugs)

a) Opiates (heroine, methadone, morphine, fentanyl)

b) Barbiturates

c) Benzodiazepines

d) Alcohol

e) Cocaine has been linked to neurobehaviour problems in the newborn

but no withdrawal has been described.

f) SSRI

Signs of Withdrawal – remember the mnemonic “WITHDRAWAL”

Wakefulness

Irritability

Tremulous, Temp unstable, Tachypnoeic

Hyperactive, High Pitch Cry, Hypertonic, Hyperacusis

Diarrhoea, Diaphoresis

Rhinorrhoea, Rub Marks

Apnoea, Autonomic Dysfunction

Weight Loss

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Alkalosis

Lacrimation

Also: hiccups, yawning, sneezing, seizures (2-11%)

Management Goals:

Alleviate signs/ symptoms of withdrawal

Reduce serious morbidity

Maintain optimal nutrition and development

Facilitate positive caregiver-infant interaction & bonding

Ongoing parental education and support until symptoms are resolved

Initial actions:

a) No Narcan in the delivery room! Withdrawal may be precipitated

immediately!

b) Obtain urine and drug screens with first void /elimination

c) Evaluate risk for hepatitis B, C, HIV and syphilis

d) Check maternal notes for reports on cause for concern

e) If signs above (at least 2) are present, use abstinence scoring

system

Non pharmacologic Treatment:

Swaddle

Quiet, dim lighting

Gentle handling and holding

Vertical rocking +swing

Frequent small volume feeding, high caloric requirement (>+150

kcal/k/d). They often have disorganised suck and prolonged sucking

bursts

Engage and support caregiver

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Pharmacologic Treatment:

All babies requiring pharmacologic treatment should be admitted to NNU

Withdrawal score >8 on three occasions indicate significant withdrawal

signs which may require starting or advancing pharmacologic

treatment. (Appendix 2)

While up to 90% of newborns exposed to narcotics in fetal life have

some symptoms, only 70-75% requires treatment. Many require no

pharmacologic treatment. Infants with confirmed drug exposure who do

not have signs of withdrawal do not need therapy.

Other potential causes of these symptoms (infection, hypocalcaemia,

hypoglycaemia, CNS haemorrhage and rarely thyrotoxicosis)

should be considered before initiating drug therapy. Jitteriness,

hyperreflexia, irritability or sneezing alone is not an indication for drug

treatment.

General principle of drug treatment1

Opiate withdrawal – Best treated with morphine

Non narcotic withdrawal and polydrug use – better treated with phenobarbitone

The general principle with drug treatment is to achieve symptom control by rapidly

going up on to the desired dose as required, obtaining stability for 72 hours and then

try and wean slowly off the medication. The rate of withdrawal will be guided by

duration of treatment and recurrence of symptoms at each step of reduction but could

be tried initially every 24-48 hours by 10-20% of the total daily dose.

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Maternal Drug

Time to

Onset

Primary Rx

Optional Rx

Heroin/Narcotics

Methadone

48 -72 hours

May be

delayed

several weeks

Morphine Solution PO

Available in 100micrograms

/ml solution

Dose: 0.04mg/kg every 4

hours with feedings. Dose

may be increased by

0.04mg/kg every 4 hours as

needed to control

withdrawal. After withdrawal

signs are controlled for 3-5

days, the dosage should be

gradually reduced while

maintaining the q4hr

administration.

Do NOT use PAREGORIC.

Barbiturates 4-7 days

Phenobarbitone

Loading dose: 20 mg/kg

PO/IV

Maintenance dose: 3-5

mg/kg/day po or IV. May

need to go up to 10mg/kg/d.

Obtain a Phenobarbital level

five days after giving

Starting Dose

After condition stabilises,

dosage may be gradually

reduced.

SSRI Within 48

hours Phenobarbitone

Benzodiazepines May be as

late as 12 –21

days

Lorazepam

Dosing: Consult clinical

pharmacist.

Phenobarbitone

Multiple drugs

abuse

Variable

Phenobarbitone

Dosing: Same as under

‘Barbiturates’.

Morphine

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Morphine dosing of the vomiting baby11:

Ensure that the infant is not being overfed and that the infant is being appropriately

postured during and after feeding. Give the morphine before the feed.

If baby has a large vomit after being given morphine:

if vomits within 10 minutes of dose, re-dose

if vomits after 10 minutes, give . dose

if baby vomits after feed, do not give further morphine (always err on side of

caution)

Withdrawal following neonatal narcotic administration for pain is more common with

higher doses, continuous infusion, shorter acting agents (fentanyl) and longer

duration of use. This is likely to be less that we have now a restricted policy of using

morphine for premature babies

Suggestions for management of neonatal narcotic tapering (Table 2):

Duration of Morphine

Use:

Suggested Tapering Approach:

< 7 Day (Taper only required if

frequent doses)

Calculate the total daily dose (TDD) of

narcotic given over the 24 hours before taper

started. Order scheduled (not PRN) narcotic

= TDD divided into 3-4 doses. Decrease

TDD 25-50% of starting TDD each day as

tolerated. If withdrawal symptoms occur,

return to previous day’s TDD and proceed

more slowly with taper.

> 7 Days

Calculate the total daily dose (TDD) of

narcotic given over the 24 hours before taper

started. Order scheduled (not PRN) narcotic

= TDD divided into 3-4 doses. Reduce TDD

20% of starting TDD over the first 24 hours

and then 10% every 24 hours as tolerated. If

withdrawal symptoms occur, return to

previous day’s TDD and proceed more slowly

Once child is off medication, observe NAS scoring until scores <4 for 72 hours

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Special infection risks:

Scrutinize mother’s notes for her VDRL, Hepatitis B, Hepatitis C and HIV status, and

record clearly in the baby notes. Please refer to specific guidelines on Hep B and

Hep C (later). If mother is hepatitis C positive, send blood from the infant for Hep C

PCR.

OTHER ISSUES:

Notify the Lead Midwife for Vulnerable Adult / Child

Please discuss all these infants with the consultant as child protection issues may

need to be considered. There should be a discharge plan in place which will have

been arranged in the antenatal period according to Substance Misuse Guidelines for

Pregnant Women. Sometimes it is necessary to hold a discharge planning meeting

involving other health professionals, drug agencies and social services. At

discharge, send a summary to the GP and community paediatrician stating clearly if

there is a need for further HEP B vaccinations (1, 2 and 12 months) and book

appointment for Dr Matthes’s Clinic for hepatitis B vaccination. For POW write to the

GP requesting this

Cranial USS:

Literature review do not support mandatory cranial USS in babies exposed to

cocaine as the pick up rate of abnormalities is small. However, it may be good

practice to perform a USS on those with history of heavy use or polydrug use

including cocaine, head circumference less than 10th centile, and abnormal

neurology.

Infants should not be discharged if:

Absolute:

Excessive weight loss (>10% of birth weight)

Before day 5 of life if methadone use is suspected / known

For SSRI use observe for at least 48 hours

Suspected infant neglect or abuse

Suspected home violence

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Relative:

Poor mothercraft ability of mother, and inadequate home support or

acceptance of assistance

Erratic behaviours or continued intravenous and illicit drug use

Polydrug use

Inability of team to monitor welfare of infant. Mothers on high doses of

methadone or other drugs should be discouraged from going home early,

since their babies could withdraw at home. If such mothers insist on going

home they have a legal right to do so. Inform the Neonatal consultant

immediately as this may put the infant at risk and further

Follow up:

Babies requiring pharmacologic treatment should be given a follow up appointment in

4 weeks

Appendix 1: Information on different drugs

Opiates/Narcotics: Neonatal abstinence syndrome from maternal opiate use is

present in 42-68% of infants of heroin users, and 68-85% of methadone exposed

newborns. Dihydrocodeine (DF118) is also in common use. A sub acute withdrawal

state from opiates may persist for 4-6 months. Seizures have been documented in

8% of infants born to mothers on methadone and 1% of infants born to mothers using

heroin.2 Term babies have more severe symptoms, a higher incidence of withdrawal,

and longer duration of NAS than pre-term infants. Seizures occur in 8% of term,

and 3%.of preterm infants of mothers on methadone. The risk of Sudden Infant

Death Syndrome is higher in babies of mothers who use opiates (X4) and appears

highest for those using methadone.

Polydrug use: Users of illicit drugs frequently use more than one drug. Metaanalysis

of studies suggests that polydrug users have an increased risk of abnormal

pregnancy outcomes and the infants of polydrug users also have an increased risk of

SIDS (Increase in Relative risk – 95% CI: 1-10)3

Amphetamines: Infants born to mothers using low dose therapeutic amphetamines

usually do not have any abnormalities. IV amphetamine use however appears to be

on the increase. Decreased head circumference, length, birth weight, increased rates

of abruption, prematurity and growth restriction have been reported in pregnancies of

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mothers abusing amphetamines.4 In-utero amphetamine exposure may lead to

intracranial lesions including haemorrhage, infarction and cavitatory lesions.5

Cocaine and derivatives: The use of cocaine is often associated with the heavy use

of other abuse drugs. Adverse pregnancy and neonatal outcomes have been

reported in mothers using cocaine during pregnancy.6 It is clear that women who use

cocaine during pregnancy are at significant risk for shorter gestations, premature

delivery, spontaneous abortions, placental abruption and death. Bowel atresias have

been observed in newborn infants possibly secondary to intrauterine bowel

infarctions. A meta-analysis of studies examining the effect of cocaine use in

pregnancy on pregnancy outcomes found that the independent effect of cocaine on

adverse outcomes was small, and that similar effects were seen in polydrug users

whether or not they used cocaine.

Marijuana: Use of marijuana in pregnancy does not appear to increase the risks of

obstetric complications.3 It has been associated with reduced birth length and low

birth weight. No consistent morphological abnormality has been found in infants of

mothers who use marijuana. Subtle neuro-behavioural abnormalities have been

described in infants whose mothers are heavy users of marijuana although the

relationship remains unproven.

Benzodiazepines: The use of benzodiazepines during pregnancy, especially during

the last weeks, may cause body temperature problems, breathing problems,

irritability, difficulty in feeding, drowsiness, or muscle weakness in the newborn infant.

Continuous use during pregnancy may be associated with neonatal withdrawal.

Benzodiazepines have also been associated with IUGR (lower birth weights lengths

and head circumferences).7

Methadone: Up to 90% of babies of mothers on methadone experience some

withdrawal; only 50-75% will require treatment. Studies have found conflicting results

in their ability to relate methadone dose and severity of withdrawal.8 Withdrawal

appears to be greater in infants born to

mothers on higher doses of opiates however other factors such as the infant’s

metabolism may be important 8. Withdrawal is less severe in infants of mothers

taking less than 20mg methadone a day.9 Withdrawal from heroin usually occurs

earlier (within 12-24 hrs of birth – shorter half-life). Methadone causes more severe

withdrawal symptoms and usually occurs 2-3 days after birth but can occur on day 1

and up to day 7).4

SSRI: When taken by pregnant women, selective serotonin reuptake inhibitors

(SSRIs) cross the placenta and have the potential to affect newborns. Although

SSRIs have not been associated with congenital malformations, some evidence

suggests that they are associated with neonatal complications such as neonatal

abstinence syndrome (NAS) and persistent pulmonary hypertension (PPH). Two

studies point to such risks.

Researchers in Israel10 assessed NAS in 60 full-term newborns whose mothers had

taken SSRIs (mostly paroxetine) during the third semester and in 60 unexposed

control infants matched for birth weight, gender, and gestational age. Among the 60

exposed infants, 18 (30%) exhibited NAS (based on the Finnegan score for

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evaluating neonatal narcotic withdrawal). Eight of the exposed newborns (13%) had

severe NAS symptoms; symptoms peaked during the first 2 days of life in most

infants but lasted until 4 days in others. None of the 60 control infants had NAS. A

dose-response relation was observed between SSRI dose and NAS symptoms in

paroxetine-exposed newborns. Subgroups were too small to compare risks for NAS

associated with individual SSRIs. They suggested observation for at least 48 hours

prior to discharge.

In a nested case-control study drawn from a study of infants with birth defects,

researchers in California compared SSRI use in 377 women whose infants had PPH

and 836 matched controls. SSRI use after the 20th week of gestation was

significantly associated with neonatal PPH (14 exposed infants developed PPH, vs. 6

controls; adjusted odds ratio, 6.1). Neither use of SSRIs before the 20th week of

gestation nor use of other antidepressants any time during pregnancy was associated

with PPHN

In ABMU over the last 4 years, we have not seen any significant NAS symptoms in

babies born to mothers with history of being on SSRI. On balance, if social condition

permits and the mother is on relatively low dose of SSRIs, these babies may be

discharged home without hospital observation on the Finnegan scale.

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Score infants 30 minutes to 1 hour after feeds

Infants at risk will score from each of the three sections in the scoring sheet

Designed for term babies who are fed 4 hourly

Appropriate allowance need to be given to preterm babies * Record Time

Patient Label

Modified Finnegan Score

Alert Pediatrician if there are two scores >8 in last 24 hours or any score >12

Date:

Signature

* see main guidelines

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* Modification for prematurity – mainly necessary in the sections on sleeping and feeding. A

baby on 3 hourly feeds can sleep at most 2 3/4 hours. Scoring should therefore be 1 if a baby

sleeps less than 2 hours, 2 if sleeps less than 1 hour, and 3 if it does not sleep between

feeds. Many premature babies require tube feeding. Babies should not be scored for poor

feeding if tube feeding is expected at their gestation.

Reference:

1. Neonatal Drug Withdrawal. AAP committee on drugs. Pediatrics 1998;101:1079-88

2. Naeye RL, Ladis B, Drage JS. Sudden infant death syndrome. A prospective study. Am J

Dis Child. 130: 1207-10, 1976.

3. Briggs G, Freeman R, Yaffe S. Drugs in Pregnancy & Lactation 6th edition Lippincott

Williams & Wilkins 2002

4. Bell GL, Lau K. Perinatal and neonatal issues of substance abuse. Pediatr Clin North Am.

1995 Apr; 42(2): 261-281.

5. Dixon SD, Bejar RJ. Echoencephalographic findings in neonates associated with maternal

cocaine and methamphetamine use: incidence and clinical correlates. Pediatr. 1989;

115(5 Pt 1): 770-778.

6. Oro AS, Dixon SD. Perinatal cocaine and methamphetamine exposure: maternal and

neonatal correlates.J Pediatr. 1987; 111(4): 571-588.

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