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