Welcome

Hello.  This blog is an information dump I found useful to my first neonatal rotation.  I've posted some information that I think may be useful for someone who has no experience in neonates (say a GP trainee or ST1) and has a rotation coming up soon.

Its not at all comprehensive, but more of a pointer to things that hopefully will make the first few days a little less stressful - such as prescribing fluids and infusions, or what key topics to focus on.

Don't take this as gospel -  you should of course check with your seniors, local protocols and national guidelines.  Please do give feedback as to whether this is useful.

MD Marikar, East of England Paediatric Trainee
Follow @MDMarikar


My Tutorials

Common Terms
Common Conditions/Presentations
Neonatal Resuscitation
The importance of looking at cord gases
Admitting a neonate - simple cases
Calculating Fluids and Electrolytes 
Emergency Calculations and Key Procedure Calculations  (Intubation, Resuscitation, UAC and UVC)
Neonatal Infusions - how to calculate the hourly rate

Key Links

Dummies Guide To Neonatal Ventilation - a short guide to the basics
UK Neonatal Guidelines (Staffordshire, Shropshire and Black Country Newborn and Maternity Network) - Great guidelines from a UK neonatal network on just about everything
Cranial Ultrasound
Auckland District Neonatal Guidelines - lots of guidelines on pretty much everything, including ventilation
The Epicure Study A key study of outcomes in premature neonates - essential for counselling parents
Stanford Neonatal Photo Library - this is an excellent resource of common presentations to consult

NICE Guidelines

Neonatal Jaundice - the quick reference guide is especially useful, as are the jaundice threshold graphs for phototherapy
Antibiotics for early-onset Neonatal Infection

Neonatal Calculators

http://www.paediatrics.co.uk/nicu/ Has useful calculators for jaundice, drugs and procedures

Common Conditions/Presentations

Here is my recommendation of the main topics you should become focus on; the rest can follow.  Hopefully you will have a nice local guideline for each of these things!  I've included a web link of a reasonable guideline for some of these topics.

• Respiratory Distress
• Hypoglycaemia
• Jaundice
• NEC (Necrotising Enterocolitis)
• Early Onset Neonatal Sepsis/Group B Strep
• Hypotension
• HIE (Hypoxic Ischaemic Encephalopathy)
• PDA (Patent Ductus Arteriosus)
• NAS (Neonatal Abstinence Syndrome)

Prescribing fluids with electrolytes – how to do it

Prescribing Fluids

• What to give?
• Start with 10% dextrose
• How much to give?
• Babies considered at risk of HIE or having HIE give 40ml/kg/day iv
• Other babies
• start at 60ml/kg/day on day 1
• 90ml/kg on day 2,
• 120ml/kg on day 3
• 150ml/kg from day 4 onwards.
• Then calculate the rate in ml/hr
• Simple: divide the calculated amount in ml/kg/day by 24 to give an hourly rate! 

 Prescribing electrolytes with your fluids

• On day 1 you generally do not add electrolytes
• Electrolytes (Sodium and Potassium) are usually prescribed from day 2 onwards with reference to daily U+Es
• Assuming normal U+Es prescribe both Sodium Chloride and Potassium Chloride at 2mmol/kg/day as additives to dextrose (or whatever your local protocol says)
• Consult your senior if you have any queries regarding prescription in relation to the latest U+Es.  Beware of omitting Sodium supplementation in hypernatraemia – it is most likely due to dehydration rather than excess sodium.

When prescribing electrolytes with your fluids bear in mind that when you calculate electrolyte requirements based on the baby weight in mmol/kg/day this amount relates to your baby’s fluid requirement for the day.  For example a 3kg baby on 90ml/kg/day of 10% dextrose on day 2 of life with Sodium and Potassium additives at 2mmol/kg/day needs 6 mmol of Sodium and 6mmol of Potassium in 270ml of 10% dextrose over 24 hours.

But since we are putting our additives into a 500ml bag of dextrose rather than the baby’s exact fluid requirement (270ml), we need to adjust the amount of electrolytes to ensure that baby gets the correct amount of electrolytes per day. (In this case 500/270x6 = 11.1mmol of Sodium and Potassium for your 500ml bag)

The simplest formula for calculating the amount of Sodium or Potassium to add to a 500ml bag of dextrose is as follows:

No. of mmols to add to bag =          Volume of bag (always 500ml)    x   mmol/kg/day requirement

                                                             Fluid requirement in ml/kg

Worked example – sodium chloride

Baby on 120 ml/kg/day.  Normal U+Es

Additive: Sodium Chloride at 2mmol/kg/day

mmols of sodium  to add to 500ml bag =  (500/120)  x 2 = 8.3 mmol Sodium Chloride

                                                                               

Follow the same steps to add Potassium Chloride

Admitting a baby

Here is a little scheme for a simple neonatal admission for a baby over 30 weeks gestation who does not appear to be very sick (at least not yet) - your bread and butter case.    When admitting a neonate your first priority is to stabilise the baby.  Do a quick ABCD assessment.  If for example, the baby is showing continuing signs of respiratory distress you will need an oxygen saturation and a capillary gas.  The baby will also likely need a cannula to perform a partial septic screen, and prescribe iv antibiotics and likely iv fluids as well.  This is expected to be performed within one hour of admission to the unit.  To achieve this it would be best to do the aforementioned actions first, working alongside the nurses, before doing the detailed admission examination and paperwork.
 

Ensure the midwives give you the neonatal notes (with maternal booking blood results filled in) and maternity notes in a timely fashion for you to complete you admission clerking.  

One of the most important pieces of information is to know the babies gestational age; sometimes it can be useful to verify this with a gestational age calculator if you know the Last Menstrual Period and/or Estimated Date of Delivery


Airway and Breathing

• Is the baby in respiratory distess?  Assess the baby in terms of respiratory rate, nasal flaring, subcostal, intercostal and sternal recession.  Order a chest X-Ray if it hasn't settled.
• Determine heart rate and oxygen saturations on pulse oximetry, and get a capillary gas.  
• Sternal recession can be impressive in premature babies, and if you are concerned get senior help - while waiting you can ask to put the baby on CPAP while getting observations and a capillary gas.  If the baby is desaturating in air adjust the fractional inspired oxygen concentration (Fio2) to aim for for oxygen saturations of  91-95%.   Don't put Term babies on CPAP without senior advice - you could precipitate a pneumothorax.
• All premature neonates of 28 weeks gestation or less should have an iv loading dose of caffeine followed by daily maintenance dose 24 hours later. 
  
• If your baby is having significant desaturations, increase the oxygen concentration.  Speed up the radiographer for the Chest X-Ray.  Consider using a cold light; if the whole side chest lights up when pressed to the babys chest this is indicative of pneumothorax (but note this test is not particularly sensitive).
• I've said it three times now - a neonate with respiratory distress must have a chest X ray
• Neonatal capillary gases:
• ph ranges from 7.25-7.35, other values can be considered as for paediatric gas values. 
• A high pco2 with a metabolic acidosis is more concerning than a high pc02 alone. 
• Look at the trend of values.  A compensated high pco2 is often found in neonates with chronic lung disease, eg in a stable preterm on CPAP transferred in to your unit.
• This in combination with the other clinical parameters can help determine whether baby needs non-invasive (such as CPAP) or invasive ventilation
• This basic guide wont give guidance on neonates requiring intubation and ventilation (this link is a good place to start), except to introduce you early on to the very useful mnemonic DOPE to approach problems in the ventilated baby:
• Displacement – is the ET tube still in the right position?
• Obstruction – Does the tube need suctioning?* 
• Pneumothorax
• Equipment – is there equipment failure?  If this is suspected consider manual ventilation off the ventilator to determine if there is a problem

*Caution: If a nurse reports blood in the ET tube take this very seriously – it could herald a pulmonary haemorrhage  - uncommon but often fatal.  In this case you should get a senior opinion immediately and not disconnect the tube to perform suction.

Circulation

A simple rule of thumb with determining whether a baby is hypotensive is to look at the mean arterial pressure; if it is less than the gestational age then the baby is considered hypotensive (assuming a correct reading).  Assess this in the context of clinical evidence of poor perfusion – eg. Pallor and abnormal gases, and the possible cause, eg sepsis.  Giving a 10ml/kg 0.9% saline is the first line option if you have clinical concerns - but inform your registrar asap to assess.   Consult your local hypotension guidelines to determine further management in terms of how many fluid bolus to give and when to start inotropes.

Common Medication

Use your local neonatal iv guide to prescribe medication. 

• Benzylpenicillin (50mg/kg) and gentamycin (4-5mg/kg) are the antibiotics invariably used for presumed sepsis; your local iv antibiotics guideline is an excellent place to find out all you need to know.
  
• Vitamin K
• If the midwives have not given it in the delivery room, the dose is 1mg for babies weighing 2.5kg, or 0.4mg/kg for babies less than 2.5kg
  
• Remember when prescribing medication later on that the birthweight is always used in weight based medication calculations until the baby exceeds it’s birthweight

Feeding

• If a baby is in respiratory distress, it is best for baby to be on iv fluids initially
• What is the risk of NEC?
• If a baby is not in respiratory distress it is very important to consult the NEC care bundle to check if a baby is at risk of NEC – ask the nursing staff for the local protocol (which is likely a regional protocol).  This is a tool that stratifies baby into low, moderate and high risk of NEC.  Essentially, the higher the risk of NEC, the more slowly enteral feeds should be introduced.  For example in my hospital, a neonate of 35 weeks or older whose weight is lower than the 0.4^th centile is at high risk of NEC and should be started initially on iv fluids, which enteral feeds slowly introduced.  This is why it is very important to plot your babies admission weight centile.
• What to give?
• If needing IV fluids
• Always give dextrose
• Always start with 10% dextrose
• Its always a 500ml bag 
• TPN may be started early - but this is beyond the scope of this guide

• Enteral feeding
• Determine maternal preference for breast or formula milk
• In preterms DBM is preferred if mother consents
• Discuss with nursing staff route of administration – bottle or tube feeding
• How much to give?
• Babies considered at risk of HIE should have 40ml/kg/day iv 10% dextrose
• Other babies (enteral or iv or combination of both as per NEC care bundle)
• start at 60ml/kg/day on day 1
• 90ml/kg on day 2,
• 120ml/kg on day 3
• 150ml/kg from day 4 onwards.
• clearly enteral feeds need to be divided into 1,2, or 3 hourly amounts - discuss with seniors and nurses as to what is best, based on gestation and hypoglycaemia risk

• What if the baby becomes hypoglycaemic?
• There is controversy regarding the definition of neonatal hypoglycaemia and when to intervene – this article by Jane Hawdon is important to read
• A commonly used definition of hypoglycaemia is a blood sugar < 2.6 mmol/L - but when to intervene is dependent on whether your neonate is symptomatic or in a group at risk of hypoglycaemia - so make sure you know your local hypoglycaemia protocol well!
• Severe hypoglycaemia (Blood glucose < 1 mmol/L or symptomatic) requires an iv dextrose bolus - 2.5ml/kg of 10% dextrose
• In less severe cases, as a rule of thumb you can increase the feeds to the next day’s amount (ie from 60ml/kg to 90ml/kg on day 1, or 90ml/kg to 120ml/kg on day 2 and so on) but no more
• If hypoglycaemia persists, if you have not swapped enteral feeds for full iv 10% dextrose, you should do so now
• If hypoglycaemia persists, increase the concentration of dextrose to 12.5% (maximum safe concentration to give through a peripheral line) but keep the amount the same – you should urgently bleep your registrar to discuss this at this point.
• Persistent or severe hypoglycaemia
• is defined as hypoglycaemia requiring 10mg/kg/minute of glucose.  A neonate with such requirements needs urgent review and investigation
• You can calculate the glucose requirement using a formula, but as a rule of thumb beware if your neonate is hypoglycaemic despite being on more than the above fluid regime:

10mg/kg/min = 144ml/kg/day of 10% dextrose = 115.2 ml/kg/day 12.5% dextrose

 

The importance of checking cord gases – even when a baby is in good condition

The importance of checking cord gases – even when a baby is in good condition

• Even if a baby is clinically well, in a situation where there has been evidence of fetal distress, whether via CTG or an abnormal gas on fetal scalp blood sampling, it is essential that cord gases (ie umbilical artery and vein) should be analysed.  The rationale for this is that poor cord gases can be associated with fetal asphyxia occurred during delivery which could result in subsequent HIE (hypoxic ischaemic encephalopathy)
• A well looking baby with a cord gas with an arterial or venous a cord pH of ≤ 7.0 or cord gas base deficit more than 15 mmol/L may require admission.  Discuss the case with your registrar as soon as possible.
• If you need to leave and the cord gases are being processed make sure you hand over to the midwives that they should contact you with abnormal cord gas results.

Attending Neonatal Deliveries And Performing Resuscitation – some notes

If you are in any doubt about your neonatal resuscitation technique or using the Resuscitaire during the initial induction training, please ensure you let your team know, and ask your registrar if he can come with you when you are called to your first delivery.   

It is recommended to attend the NLS (Neonatal Life Support) course – forms available from the resuscitation officer.  Click here for the basic NLS protocol

Pre-delivery

To state the obvious, gestation really matters; here's an example protocol of who should be there with you at a delivery:

• 28 weeks or less
• The full neonatal team is needed at delivery - your registrar and experienced neonatal nurse(s). 
• Baby should be immediately placed into a food grade plastic bag without drying after birth under radiant heater. 
• Neonatal nurse should bring the ‘grab bag’ (transparent bag containing intubation equipment and umbilical lines) and saturation monitor to the delivery room. 
• Neonate should be transported from delivery room to NICU in a transport incubator 

• 28 – 31 week 
• Inform registrar and senior neonatal nurse and discuss whether steps above needed based on history
• You should have registrar in attendance until confident 

• 32 weeks plus 
• if no complicating issues you should be able to manage these neonates on your own with increasing experience

Cardiotocographs (CTG)

You will be often called to a delivery because of a "pathological CTG".  More often than not, your baby will respond well to drying.  But beware of talk of prolonged bradycardia, prolonged decelerations, late deceletations or a sinusoidal pattern.  If this is coupled with the presence of thick meconium, beware even more.  This CTG Guide may be useful for some basic understanding.

At delivery

The NLS Algorithm should be known; some notes to the algorithm above:

• Know your resuscitaire well.  Ensure you know how to set PIP and PEEP; in term babies PIP is set to 30 cm H20 and your PEEP to 5cm H20 before delivery.  Ensure you know how to adjust these settings and how to test it (don’t assume it will be set up for you - occasionally you will find the PEEP set too high or to 0).  Note that in many hospitals the T-Piece provided as standards may not have a PEEP valve 
• Make sure you have a size 0 face mask available for preterm neonates 32 weeks or less (default is size 1).  PIP is typically 20-25cm H20.  
•  Always remember to start the clock once the baby is delivered (ideally when the cord is cut).  It can be easily forgotten and is crucial in helping you decide when you need help.  Ensure the warmer is set too 
• Assuming the baby is older than 30 weeks, first ensure the baby is dried well and the wet towel removed (Neonates of  30 weeks or less should be immediately placed into a food grade plastic bag without drying after birth under a radiant heater).  The only exception to this is floppy apnoeic babies born in thick meconium - see below
• It sounds obvious, but when you are picking up the baby to get the wet towel removed, remember to support the baby's head with one of your hands! As I have learnt, rushing to pick up the baby with its head lolling around does not breed confidence in those around you.
•  Remember to check for tone in addition to breathing and heart rate – it is a crucial part of the assessment.  The easiest way to do this is to pick up an arm and drop it 
• Don’t rely on cord pulsation to check the heart rate
• Remember to give adequate time for your inflation breaths – 2 to 3 seconds.  Look to see if the chest is rising and look at your airway pressure meter while giving breaths to see that 30cm H20 is reached 
• If a baby delivered through meconium is floppy and apnoeic, then you should consider rapidly inspecting the laryngo-pharynx using laryngoscope and suction catheter to remove obstructions before applying inflation breaths.  Call for help early if you are in any doubt that your efforts are working.
• Chest compressions should be rarely needed; if heart rate is not responding to your 5 inflation breaths and you are not sure that the chest is rising, reposition your away and consider using a 2 person ventilation technique with jaw-thrust; do not move to CPR if the chest is not rising.  If the heart rate is responding by increasing then you know your inflation breaths are effective even if the chest rise intially might not be that great.  Call for help early if you are in any doubt that your efforts are working. 
• If a baby is making active respiratory effort but showing signs of respiratory distress, you can attempt to give a short period PEEP (if your T-Piece has a PEEP valve) via the facial mask – apply the face mask without occluding the T piece.  However, there is evidence to suggest that in term babies, this may increase the risk of pneumothorax.