Primary Newborn Care

Primary

Newborn Care
A learning
programme for
professionals

Developed by the
Perinatal Education Programme
Primary
Newborn Care
A learning programme
for professionals

Developed by the
Perinatal Education Programme
www.ebwhealthcare.com
VERY IMPORTANT
We have taken every care to ensure that drug
dosages and related medical advice in this book
are accurate. However, drug dosages can change
and are updated often, so always double-check
dosages and procedures against a reliable,
up-to-date formulary and the given drug‘s
documentation before administering it.
Primary Newborn Care: A learning programme

for professionals
Version 1.0.0
First published by Electric Book Works in 2008
Text © Perinatal Education Programme 2008
Getup © Electric Book Works 2008
ISBN (paperback): 978-1-920218-14-0
ISBN (PDF ebook): 978-1-920218-59-1
All text in this book excluding the tests and
answers is published under the Creative Commons
Attribution Non-Commercial No Derivatives
License. You can read up about this license at http://
creativecommons.org/licenses/by-nc-nd/3.0/.
The multiple-choice tests and answers in this
publication may not be reproduced, stored in a
retrieval system, or transmitted in any form or by
any means without the prior permission of Electric
Book Works, 87 Station Road, Observatory, Cape
Town, 7925.
Visit our websites at www.electricbookworks.com
and www.ebwhealthcare.com
Contents
Acknowledgements 5 Resuscitation 20
Management of the meconium-
Introduction 7 stained infant 25
Aim of the Perinatal Education Case study 1 26
Programme 7 Case study 2 26
Perinatal education 7 Case study 3 27
Perinatal Education Programme books 7 Case study 4 28
Book 1: Maternal Care 8
Book 2: Newborn Care 8 2 Care of normal infants 29
Book 3: Perinatal HIV/AIDS 8 Caring for normal infants 29
Book 4: Primary Newborn Care 8 Feeding the normal infant 33
Book 5: Mother and Baby Friendly Care 9 The baby friendly approach 40
Book 6: Saving Mothers and Babies 9 Discharging a normal infant 41
Book 7: Birth Defects 9 Case study 1 41
Book 8: Primary Maternal Care 9 Case study 2 42
Format of the Perinatal Education Case study 3 42
Programme 9 Case study 4 43
Study groups 10
The importance of a caring and 3 Care of low birth weight infants 44
questioning attitude 11 Prevention of hypothermia 48
Copyright 11 Prevention of hypoglycaemia 49
Final assessment 11 Recurrent apnoea 51
Obtaining an exam code 11 Feeding low birth weight infants 51
Managing your own course Anaemia 53
step-by-step 11 Kangaroo mother care (KMC) 53
Updating of the programme 13 Keeping good patient notes 54
Using the book as a work manual 13 Assessing patient care 56
Perinatal Education Trust 13 Case study 1 58
Further information 13 Case study 2 58
Comments and suggestions 13 Case study 3 59
Case study 4 59
1 Care of infants at birth 15 Case study 5 60
Management of a normal infant at
birth 15 4 Emergency management of infants 61
Management of the infant with The management of hypothermia 61
neonatal asphyxia 17 The management of hypoglycaemia 63
Management of respiratory distress 65
The correct use of oxygen therapy 69 Tests 92
Transferring a newborn infant 71
Case study 1 72
Case study 2 73
Case study 3 73
Case study 4 74
Case study 5 75
5 Management of important problems 76

Management of an infant with jaundice 77
Infection in the newborn infant 81
Trauma in the newborn infant 86
The management of bleeding in the
newborn infant 87
Management of convulsions (fits) 88
Congenital abnormalities 88
Case study 1 89
Case study 2 89
Case study 3 90
Case study 4 91
Acknowledgements
We acknowledge all the participants of Editor of Primary Newborn Care:

Primary Newborn Care courses who have
Prof D L Woods
made suggestions and offered constructive
criticism. It is only through constant feedback Contributors to Primary Newborn Care:
from colleagues and participants that the
Dr D Greenfield, Prof G Theron,
content of Perinatal Education Programme
Prof H de Groot, Ms H Louw
courses can be improved.
Editor-in-chief of the Perinatal Education
Programme: Prof D L Woods
Introduction
Aim of the Perinatal rural areas usually have the least continuing
education as they are furthest away from
Education Programme the training hospitals in urban centres. It
is not possible to send teachers to all these
The aim of the Perinatal Education rural areas for long periods of time while
Programme (PEP) is to improve the care of staff shortages and domestic reasons make
pregnant women and their newborn infants in it impractical to transfer large numbers
all communities, especially in poor periurban of doctors and nurses from primary- and
and rural districts of southern Africa. secondary-care centres to centralised tertiary
Although the Programme was written as a hospitals for training.
distance-learning course for both midwives
Ideally all medical and nursing staff should
and doctors in district and regional health
have regular training to improve and update
care facilities, it is also used in the training of
their theoretical knowledge and practical skills.
medical and nursing students.
One way of meeting these needs in continuing
The authors of the Perinatal Education education is with a self-help, outreach
Programme consist of nurses, obstetricians and educational programme. This decentralised
paediatricians from South Africa. This ensures method allows health care workers to take
a balanced, practical and up-to-date approach responsibility for their own learning and
to common and important clinical problems. professional growth. They can study at a time
Many colleagues in South African universities and place that suits them. Participants in the
and health services were also consulted with a programme can also study at their own pace.
view to reaching consensus on the management The education programme should be cheap
of most perinatal problems. and, if possible, not require a tutor.
Perinatal education Perinatal Education

Programme books
If all three levels of perinatal care are to
be efficiently provided within a perinatal
Initially the Perinatal Education Programme
health care region, continuous education and
was presented as two books only. The first PEP
training of all professional staff is essential.
book, Maternal Care, deals with problems
Unfortunately this often is achieved in the
experienced by women during and after
large, centralised tertiary-care hospitals only
pregnancy while the second PEP book,
and not in the rural secondary- or primary-
Newborn Care, deals with problems in the
care centres. The providers of primary care in
newborn infant. Both books should be studied
primar y newborn care
to improve your knowledge of all aspects of blood glucose concentration, insertion of

perinatal care. an umbilical catheter, phototherapy, apnoea
monitors and oxygen therapy.
Now six additional, supplementary books have
been prepared to address further common and
important problems related to both pregnant
women and their newborn infants. Book 3: Perinatal HIV/
AIDS
Book 1: Maternal Care The HIV epidemic is spreading at an
alarming pace through many developing
This book addresses all the common and countries, increasing the maternal and infant
important problems that occur during mortality rates, and adding to the financial
pregnancy, labour and delivery, and the burden of providing health services to all
puerperium. It includes booking for antenatal communities. Nowhere is the devastating
care, problems during the antenatal period, effect of this infection more obvious than in
monitoring and managing the mother, fetus the transmission of HIV from mothers to
and progress during labour, medical problems their infants. In order to decrease this risk, all
during pregnancy, problems during the health care workers dealing with HIV positive
three stages of labour and the puerperium, mothers and infants will need to receive
family planning after pregnancy, and additional training. Perinatal HIV/AIDS was
regionalised perinatal care. Skills workshops written to address this challenge.
teach the general examination, abdominal
This book will enable midwives, nurses and
and vaginal examination in pregnancy and
doctors to care for pregnant women and their
labour, screening for syphilis and HIV,
infants in communities where HIV infection
use of an antenatal card and partogram,
is present. Special emphasis has been placed
measuring blood pressure and proteinuria,
on the prevention the mother-to-infant
and performing and repairing an episiotomy.
transmission of HIV.
Maternal Care is aimed at professional health
care workers in level 1 hospitals or clinics. Chapters have been written on HIV infection,
antenatal, intrapartum and infant care, and
counselling. Colleagues from a number of
Book 2: Newborn Care hospitals and universities in South Africa were
invited to review and comment on the draft
Newborn Care was written for health document in order to achieve a well balanced
professionals providing special care for infants text. It is hoped that this training opportunity
in regional hospitals. It covers resuscitation will help to stem the tide of HIV infection in
at birth, assessing infant size and gestational our children.
age, routine care and feeding of both normal
and high risk infants, the prevention,
diagnosis and management of hypothermia, Book 4: Primary
hypoglycaemia, jaundice, respiratory distress, Newborn Care
infection, trauma, bleeding, and congenital
abnormalities, as well as communication
This book was written specifically for nurses
with parents. Skills workshops address
and doctors who provide primary care
resuscitation, size and gestational age
for newborn infants in level 1 clinics and
measurement, history, examination and
hospitals. Primary Newborn Care addresses the
clinical notes, nasogastric feeds, intravenous
care of infants at birth, care of normal infants,
infusions, use of incubators, measuring
care of low birth weight infants, neonatal
introduction
emergencies, and important problems in are at increased risk of giving birth to an

newborn infants. infant with a birth defect. Special attention
is given to modes of inheritance, medical
genetic counselling, and birth defects due
Book 5: Mother and to chromosomal abnormalities, single
gene defects, teratogens and multifactorial
Baby Friendly Care inheritance. This book is being used in the
Genetics Education Programme which has
With the recent technological advances in been developed to train health care workers in
modern medicine, the caring and humane genetic counselling in South Africa.
aspects of looking after mothers and infants
are often forgotten. This book describes better,
gentler, kinder, more natural, evidence-based Book 8: Primary
ways that care should be given to women
during pregnancy, labour and delivery. It Maternal Care
similarly looks at improved methods of
providing infant care with an emphasis This book addresses the needs of health care
on kangaroo mother care and exclusive workers who provide both antenatal and
breastfeeding. A number of medical and postnatal care but do not conduct deliveries.
nursing colleagues in South Africa contributed The content of these chapters is largely taken
to this book. from the relevant chapters in Maternal Care. It
contains theory chapters and skills workshops.
This book is ideal for staff providing primary
Book 6: Saving Mothers maternal care in level 1 district hospitals and
clinics.
and Babies
Saving Mothers and Babies was developed in Format of the Perinatal
response to the high maternal and perinatal
mortality rates found in most developing Education Programme
countries. Learning material used in the
book is based on the results of the annual Throughout this Programme the participant
confidential enquiries into maternal deaths takes full responsibility for his or her own
and the Saving Mothers and Saving Babies progress. This method teaches participants to
reports published in South Africa. It addresses become self-reliant and confident.
the basic principles of mortality audit,
maternal mortality, perinatal mortality, 1. The objectives
managing mortality meetings, and ways of
reducing maternal and perinatal mortality At the start of each chapter the learning
rates. This book should be used together objectives are clearly stated. They help the
with the Perinatal Problem Identification participant to identify and understand the
Programme (PPIP). important lessons to be learned.
2. Questions and answers

Book 7: Birth Defects Theoretical knowledge is taught by a
problem solving method which encourages
This book was written for health care the participant to actively participate in the
workers who look after individuals with learning process. An important question is
birth defects, their families, and women who asked, or problem posed, followed by the
correct answer or explanation. In this way,
10 primar y newborn care
the participant is led step by step through 4. Multiple-choice questions

the definitions, causes, diagnosis, prevention,
An in-course assessment is made at the
dangers and management of a particular
beginning and end of each chapter in the
problem.
form of a test consisting of 20 multiple-choice
It is suggested that the participant cover the questions. This helps participants manage their
answer for a few minutes with a piece of paper own course and monitor their own progress
or card while thinking about the correct reply by determining how much they know before
to the question. This method helps learning. starting a chapter, and how much they have
Simplified flow diagrams are also used, where learned at the end of the chapter. The results
necessary, to indicate the correct approach to will help the participant decide whether
diagnosing or managing a particular problem. they have successfully learned the important
Copies of these flow diagrams may be of value facts in that chapter and will also draw the
in the labour ward or nursery. participant’s attention to the areas where their
knowledge is inadequate.
Different forms of text are used to identify
particular sections of the Programme: In the multiple-choice tests the participant
is asked to choose the single, most correct
Each question is written in bold, like this, answer to each question or statement from
and is identified with the number of the four possible answers. A separate loose sheet
chapter, followed by the number of the should be used to record the test answers
question, e.g. 5-23. before (pre-test) and after (post-test) the
chapter is studied. The list of correct answers
also indicates which section should be
Important practical lessons are emphasized by restudied for each incorrect post-test answer.
placing them in a box like this.
On the website, the multiple-choice questions
are only made available to participants who
note Additional, non-essential information is
provided for interest and given in notes like this. wish to complete a PEP course and have
These facts are not used in the case studies or obtained an exam code (more on this below).
included in the multiple-choice questions.
3. Case problems Study groups

A number of clinical presentations in story-
It is strongly advised that the Programme
form are given at the end of each chapter so
courses are studied by a group of participants
that the participant can apply his/her newly
and not by individuals alone. Each group of
learned knowledge to solve some common
5 to 10 participants should be managed by a
clinical problems. This exercise also gives the
local co-ordinator who is usually a member of
participant an opportunity to see the problem
the group, if a formal trainer is not available.
as it usually presents itself in the clinic or
The local co-ordinator arranges the time and
hospital. A brief history and/or summary of
venue of the group meetings (usually once
the clinical examination is given, followed by
every three weeks). At the meeting the chapter
a series of questions. The participant should
just studied is discussed and the pre-tests
attempt to answer each question before reading
and post-tests are done. The skills workshops
the correct answer. The knowledge presented
should also be demonstrated and practiced at
in the cases is the same as that covered earlier
the meetings. In this way the group manages
in the chapter. The cases, therefore, serve to
all aspects of their course. The principles of
consolidate the participant’s knowledge.
peer tuition and co-operative learning play a
large part in the success of PEP.
introduction 11
The importance successfully completed that course. Credit for

completing the course will only be given if
of a caring and the final examination is successfully passed. A
questioning attitude separate examination is available for each book
and a certificate will be given to participants
who pass each final examination. A mark of
A caring and questioning attitude is
80% is needed to pass the final examinations.
encouraged. The welfare of the patient is of
Any official recognition for completing a PEP
the greatest importance, while an enquiring
course will have to be negotiated with your
mind is essential if participants are to continue
local health care authority.
improving their knowledge and skills. The
participant is also taught to solve practical To write the examination on the website, a
problems and to form a simple, logical participant first has to obtain an exam code,
approach to common perinatal problems. which can be obtained through the course
website.
Copyright
Obtaining an exam code
To be most effective, the Perinatal Educational
Programme course should be used under To obtain an exam code, visit this website:
the supervision of a co-ordinator. Using part
www.ebwhealthcare.com
of the Programme out of context will be of
limited value only, while changing part of the An exam code is a unique number for one
Programme may even be detrimental to the participant and one course. An exam code
participant’s perinatal knowledge. Therefore, enables a participant to test their knowledge
copyright on all PEP materials means that and write the final examination online. The fee
no portion of the Programme can be altered. and how to pay for exam codes is explained on
However, for teaching and management the website.
purposes only, parts or all of the Programme
may be photocopied provided that recognition
to the Programme is acknowledged. If the Managing your own
routine care in your clinic or hospital differs
from that given in the Programme, you should course step-by-step
discuss it with your staff.
1
Final assessment Before you start each chapter, take the test for
that chapter at the back of the book. Do the
On completion of each book, participants test by yourself even if you are studying with
may apply to write a formal multiple-choice a group of colleagues. Choose the best answer
examination on the course website – www. for each multiple-choice question and note
ebwhealthcare.com – to assess the amount your answers on a piece of loose paper. This is
of knowledge that they have acquired. All called your ‘pre-test’ for that chapter. There is
the questions will be taken from the tests an answer sheet that you should use to mark
at the end of each chapter. The content of your completed pre-test. Record your pre-test
the skills workshops will not be included in mark out of a possible 20.
the examination. Successful examination
candidates will be able to print their own
certificate which states that they have
2 www.ebwhealthcare.com. To write the final

examination you will need to have an exam
Now work through the chapter. Read each
code. This is a unique number that entitles
question and answer, and make sure you
you to write the examination for a course. If
understand it. Pay particular attention to
you don’t have one yet, you or your group can
the facts in grey boxes as these are the main
buy exam codes. The fee and how to pay is
messages. Read the case studies to check
described on the website. This exam code will
whether you have learned and understand the
only work once for one examination.
important information.
You will be able to write the examination,
3 consisting of 75 multiple-choice questions,
on the website. You will only have a limited
If you are part of a study group, use this time to answer each question and you will
opportunity to discuss with your colleagues not be able to go back and check previous
any difficulties you may have experienced. questions. Set aside at least an hour to
Talking about what you have read is a very write the examination. When you write the
important part of the learning process. If examination, do not use the book to look up
the book includes skills workshops, these the correct answers. Remember, you are your
should be conducted at the time of the group own teacher, so be strict with yourself!
meetings. Invite an experienced colleague who
can help you master the particular skill.
7
4 Your examination answers will automatically

be marked as soon as you have completed
When you have learned all the knowledge in the last question. If you get 80% or better you
that chapter, take the same test again. This have passed and will be able to print your
second test is called your ‘post-test’. Now own certificate which states that you have
mark the post-test and compare your pre-test successfully completed the course. However,
and post-test marks. Your marks should have if you have failed to achieve 80%, you can
improved considerably. In the answers section purchase another exam code to write the
of the book, opposite each correct answer, is examination again.
the number of the section where the question
was taken from. Re-read and learn the sections
Tips
for any post-test answers you got incorrect.
Now you are ready to move on to the next • Work through the course with a group of
chapter. friends or colleagues.
• One person in your group (your co-
5 ordinator or ‘convenor’) should take
responsibility for organising meetings to
Repeat steps 1 to 4 for each chapter as you discuss each chapter before you write the
work your way through the book. This enables post-test.
you to obtain the knowledge, monitor your • Set yourself targets, such as ‘two units a
progress, and measure how much you are month’.
learning. Most people will take about 2 to 4 • Keep your book with you to read whenever
weeks per chapter. you have a chance.
• Write the examination only when you feel
6 ready.
Once you are confident that you have
mastered all the main lessons in the book,
you can write the final examination online at
introduction 13
Updating of the funded and managed on a non-profit basis by

the Perinatal Education Trust.
programme
Based on the comments and suggestions Further information
made by participants and other authorities,
the chapters and skills workshops of the Further information on the Perinatal
Programme will be regularly edited to make Education Programme can be obtained in the
them more appropriate to the needs of following ways:
perinatal care and to keep the Programme
up to date with new ideas and developments.
By post
Everyone studying the Programme is invited
to write to the editor-in-chief with suggestions The Editor-in-Chief, Perinatal Education
as to how the books could be improved. You Programme, P O Box 34502, Groote Schuur,
can also send your comments on parts of the Observatory 7937, South Africa
books on the website www.ebwhealthcare.com.
By fax
• 021 671 8030 (from South Africa)
Using the book as a • +27 21 671 8030 (from outside South
work manual Africa)
It is hoped that as many participants as By phone

possible will use these books as work manuals
From within South Africa:
after they have completed the course. The
flow diagrams should be most useful in • 021 671 8030 (PEP Distribution Manager)
managing difficult problems and for planning • 021 786 5369 (Editor-in-Chief)
management. A further benefit of the books
will be to standardise the documentation and By email
management of certain clinical problems. [email protected]
This is particularly useful when patients are
referred within or between health care regions. Online
It is further hoped that all those who use these
books will enjoy learning about new and better www.ebwhealthcare.com
methods of caring for mothers and newborn www.pepcourse.co.za
infants. Every opportunity to share knowledge
with both patients and colleagues should be
used. By doing this you will find your career
more fulfilling and you will help to improve
Comments and
the perinatal care in your region. suggestions
The Perinatal Education Programme has been
Perinatal Education produced by a group of perinatal specialists
in South Africa, after wide consultation with
Trust colleagues who practice in both rural and
urban settings, in an attempt to reach consensus
Books developed by the Perinatal Education on the care of mothers and newborn infants.
Programme are provided as cheaply as possible. The Programme is designed so that it can be
Writing and updating the Programme is both improved and altered to keep pace with current
developments in health care. Participants using
books developed by the Programme can make to the contents. Details of alternative or better
an important contribution to its continual forms of management would be particularly
improvement by reporting factual or language appreciated. Please send any comments or
errors, by identifying sections that are difficult suggestions to the Editor-in-Chief at the above
to understand, and by suggesting improvements address.
1
Care of infants
at birth
5. A quick physical examination should be

Objectives done to assess the infant for size, serious
congenital abnormalities or other obvious
When you have completed this unit you clinical problems.
should be able to: 6. When the above have been completed, give
• Manage a normal infant at birth. the infant to the mother.
• Promote early bonding between mother
and infant. 1-2 When is the best time to clamp the
• Diagnose neonatal asphyxia at birth. umbilical cord?
• Assess an Apgar score. It is best to allow the infant to cry well a few
• Prepare for resuscitation. times before clamping the cord. Therefore, dry
• Resuscitate an infant. the infant well first and only then clamp the
• Prevent meconium aspiration. cord with surgical forceps. Drying the infant
usually stimulates crying.
Delaying clamping the cord, until the infant
Management of a breathes well, allows the infant to receive
normal infant at birth some extra blood from the placenta. This
extra blood may help prevent iron deficiency
anaemia later in the first year of life. Before
1-1 What care should you give a normal clamping the cord, keep the infant on the bed
infant immediately after delivery? at the same level as the mother.
1. Dry the infant, especially the head, with The umbilical cord must be clamped or tied
a warm towel. Then wrap the infant in a about 3 to 4 cm from the infant’s abdomen.
second warm, dry towel. This will help to Once the infant has been dried and assessed,
prevent the infant from getting cold after the surgical forceps can be replaced with a
delivery. sterile, disposable cord clamp or a sterile
2. It is not necessary to suction the nose and cord tie.
mouth of a normal infant who is breathing
well. If the infant has a lot of secretions, turn 1-3 When should you give the infant to the
the infant onto the side for a few minutes. mother?
3. Clamp the umbilical cord. It is important for the mother to see and hold
4. Assess the Apgar score at 1 minute. her infant as soon as possible after delivery. If
the infant appears to be normal and healthy, This will keep the infant warm. Skin-to-skin
the infant can be given to the mother after the care (kangaroo mother care) is important
1 minute Apgar score has been assessed and to promote bonding and breast feeding. The
the initial examination made. After delivery, infant must not be left alone in a cot.
both the infant and mother are in an alert
state. The infant’s eyes are usually open and 1-6 When do you identify the infant?
looking around.
Once the parents have had a chance to
The mother will usually hold the infant so meet and inspect their new infant, formal
that she can look at its face. She will talk to identification by the mother and staff must
her infant and touch the face and hands. This be done. Labels with the mother’s name and
initial contact between a mother and her folder number, together with the infant’s sex,
infant is an important stage in BONDING. date and time of birth are then attached to
Bonding is the emotional attachment that the infant’s wrist and ankle. Twins must be
develops between mother and child, and is an labelled ‘A’ and ‘B’. Once correctly identified,
important step towards good parenting later. other routine care can then be given.
Where possible, it is important that the father
also be present at the delivery so that he can 1-7 Should all infants be given vitamin K?
be part of this important phase of the bonding
process. Yes. It is important that all infants be given
1 mg of vitamin K1 (0.1 ml of Konakion) by
1-4 When should the normal infant be put intramuscular injection into the anterolateral
to the breast? aspect of the mid-thigh after delivery. Never
give the Konakion into the buttock as it may
If possible the mother should put the infant damage nerves or blood vessels that are just
to her breast within minutes after delivery under the skin in infants. Konakion will
because: prevent haemorrhagic disease of the newborn.
1. Studies have shown that the sooner the Be very careful not to give the infant the
infant is put to the breast, the greater is the mother’s oxytocin (Syntocinon) in error.
chance that the mother will successfully To avoid this mistake, some hospitals give
breast feed. Konakion in the nursery and not in the labour
2. Nipple stimulation, by putting the infant ward. Do not use oral Konakion.
to the breast, may speed up the third stage
of labour by stimulating the release of All infants must be given vitamin K after delivery.
maternal oxytocin.
3. It reassures the mother that her infant is
healthy and helps to promote bonding. 1-8 Should antibiotic ointment be placed in
Some women want to hold and look at the infant’s eyes?
their infants but do not want to breast feed Yes, it is advisable to place chloromycetin
soon after delivery. Their wishes should be ointment routinely into both eyes to prevent
respected. During a complicated third stage, Gonococcal conjunctivitis as an infant’s
or during the repair of an episiotomy, some eyes may become infected when the infant
mothers would rather not hold their infants. passes through the cervix and vagina. This
is particularly important if gonorrhoea is
1-5 How should the mother keep her infant common in that community. Many women
warm? with Gonococcal infection have no symptoms.
When the infant is given to the mother, she
should hold the infant, skin-to-skin, against
her chest and cover the infant with the towel.
care of infants at bir th 17
1-9 Should all infants be weighed and 1-12 Should the infant be bathed after
measured? delivery?
Yes, it is important to measure the infant’s There is no need to bath an infant immediately
weight and head circumference after birth. after delivery. It is much better if the infant
The parents are usually anxious to know the stays with the mother and only be bathed later.
infant’s weight. The infant’s length is usually Vernix protects the infant’s skin and helps to
not recorded, as it is very difficult to measure prevent skin infection.
accurately. Weighing all infants helps to
identify low birth weight infants (less than
2500g) who may need special care. Management of the
1-10 What care and management should
infant with neonatal
be documented? asphyxia
Accurate notes should be made after the
infant has been delivered. It is important to 1-13 When does a normal infant start
document the following observations and breathing after delivery?
procedures:
The normal, healthy newborn infant usually
1. Apgar score starts to breathe immediately after birth.
2. Any action taken to resuscitate the infant Sometimes gentle stimulation, such as drying,
3. Any abnormality or clinical problem is needed before the infant breathes well. By
noticed 1 minute after delivery the infants should be
4. Identification of the infant breathing well or crying.
5. Whether the infant is male or female
6. Administration of Konakion
1-14 What is neonatal asphyxia?
7. Whether prophylactic eye ointment was
given If an infant does not breathe well by 1 minute
8. Birth weight and head circumference after birth, the infant is said to have neonatal
asphyxia (asphyxia neonatorum).
1-11 Should the infant stay with the
mother after delivery?
Neonatal asphyxia is defined as the failure to
Yes. If the mother and infant are well, they breathe well within one minute after delivery.
should not be separated. The infant should be
kept skin-to-skin on the mother’s chest, as this
is the best way to keep an infant warm. The 1-15 What important clinical signs should
infant can stay with the mother in the labour be looked for in the infant after delivery?
ward and should be transferred with her to
There are 5 important clinical signs, which
the postnatal ward. If the infant is cared for
should be present after birth. These are called
by the mother, the staff will be relieved of this
vital signs:
additional duty.
1. Breathing
2. Heart rate
The mother and infant should remain together 3. Colour
after delivery, if both are well. 4. Tone
5. Response
1-16 What is the Apgar score? heart beat is present but the rate is slower than
100 per minute, while a score of 0 is given if no
The Apgar score uses the 5 vital signs at
heart beat can be heard or umbilical pulse felt.
birth to give a score, which is very useful in
assessing an infant’s condition after delivery.
It also helps to decide which infants need 1-20 How should you assess an infant’s
resuscitation. The famous Apgar score is colour after birth?
named after Virginia Apgar, who described the Look at the infant’s tongue and also at the hands
score in 1953. and feet. The tongue should always be pink. It
is not helpful to look at the colour of the lips
1-17 How is the Apgar score measured? or mucus membranes. If the tongue is blue the
infant has central cyanosis. This shows that
Each of the 5 vital signs is given a score of
important organs like the brain are not getting
0, 1 or 2. If the sign is normal a score of 2
enough oxygen. Almost all newborn infants
is given. Mildly abnormal signs are given a
have peripheral cyanosis with blue hands and
score of 1. If the vital sign is very abnormal a
feet immediately after delivery. This is normal
score of 0 is given.
and within minutes the hands and feet should
The scores for each vital sign are then added become pink. A pink tongue indicates that
together to give the Apgar score out of 10. enough oxygen is reaching the brain.
The best possible Apgar score is 10 and the
If the hands and feet are pink a score of 2 is
worst is 0.
given. If the tongue is pink,but the hands and
feet are still blue, a score of 1 is given. When
1-18 How should you assess an infant’s the tongue, hands and feet are all blue a score
breathing after birth? of 0 is given.
Look at the infant’s chest movements. Both
sides of the chest should move well when the 1-21 How should you assess an infant’s
infant breathes. A normal infant will cry or tone after birth?
take at least 40 breaths a minute.
Normal infants should have good muscle tone
If the infant breathes well or cries a score of 2 at birth and move their arms and legs actively.
is given. If there is poor or irregular breathing, They should not lie still. Normally the arms
or the infant only gives an occasional gasp, a and legs are flexed and held above the body,
score of 1 is given. A score of 0 is given if the with the knees held together, in a term infant.
infant makes no attempt to breathe.
If the infant moves well a score of 2 is given.
If there is only some movement, and the arms
1-19 How should you count an infant’s and legs are not pulled up against the body or
heart rate after birth? lifted off the surface, a score of 1 is given. A
Feel the base of the umbilical cord or listen to score of 0 is given if the infant is completely
the infant’s heart with a stethoscope to count limp and does not move at all.
the heart (pulse) rate. It often is very difficult
to feel peripheral pulses immediately after 1-22 How should you assess an infant’s
birth. The normal infant has a heart rate of 140 response to stimulation after birth?
(120 to 160) beats per minute. It saves time to
If you handle or gently stimulate the infant
count the heart rate for 30 seconds and then
there should be a good response. Usually the
multiply the rate by 2 to give the heart rate per
infant moves a lot or cries. The best method
minute. A wall clock is useful when counting
of stimulation is to dry the infant well with a
the heart rate.
towel. Smacking the infant or flicking the feet
If the heart rate is above 100 per minute a are not recommended.
score of 2 is given. A score of 1 is given if a
If the infant responds1well to stimulation

MINUTE 5 MINUTES
and cries or moves a lot a score of 2 is given.
Heart rate None 0 None 0
If there is only some response a score of 1 is
per minute Less than 100 1 Less than 100 1
given while a score of 0 is given if the infant
More than 100 2 More than 100 2
does not respond to stimulation at all.
Respiratory rate Absent 0 Absent 0
Weak
See the table ‘Calculating anor irregular
Apgar score’. 1 Weak or irregular 1
Good or cries 2 Good or cries 2
Colour Centrally cyanosed 0 Centrally cyanosed 0
Peripherally cyanosed 1 Peripherally cyanosed 1
Peripherally pink 2 Peripherally pink 2
Muscle tone Limp 0 Limp 0
Some flexion 1 Some flexion 1
Active and well flexed 2 Active and well flexed 2
Response to None 0 None 0
stimulation Some response 1 Some response 1
Good response 2 Good response 2
TOTAL SCORE: /10 /10
Table 1: Calculating an Apgar score
1-23 When should the Apgar score be birth, a 1 minute Apgar score of 10 is rare.
measured? The Apgar score at 5 minutes, and thereafter,
should be 7 or more.
All infants should have their Apgar score
measured at 1 minute after delivery. The 1 A 1 minute Apgar score of 4 to 6 indicates
minute Apgar score is a good method of moderate asphyxia while a score of 0 to 3
measuring the infant’s general condition after indicates severe neonatal asphyxia.
birth and is one of the best ways of deciding A low 5 minute Apgar score is worrying as it
whether the infant needs resuscitation. If the suggests that the infant is not responding well
Apgar score is normal, the score usually does to resuscitation. The longer the score remains
not need to be repeated. However, in many low, the greater is the risk of death or brain
clinics and hospitals the Apgar score is still damage.
repeated routinely at 5 minutes. Unfortunately
many of these normal infants are needlessly
removed from their mother’s skin-to-skin care The Apgar score should be 7 or more at 1 minute.
to have the 5 minute Apgar score determined.
However, if the 1 minute Apgar score is low, 1-25 What are the important causes of a
the score must be repeated every 5 minutes low Apgar score?
while the infant is being resuscitated. This
1. Fetal hypoxia
gives a very good assessment of the success or
2. Maternal general anaesthesia
failure of the attempts at resuscitation. With
3. Maternal sedation or analgesia with
successful resuscitation the Apgar score will
pethidine or morphine given within the
increase to normal.
last 4 hours
4. Excessive suctioning of the infant’s mouth
1-24 What is a normal Apgar score? and throat
The Apgar score at 1 minute should be 7 or 5. Delivery of a low birth weight infant
more out of a possible 10. As almost all infants 6. Difficult or traumatic delivery
have blue hands and feet immediately after 7. Severe respiratory distress
1-26 What is hypoxia? 1-30 How is neonatal asphyxia managed?

Hypoxia is defined as too little oxygen in the cells Neonatal asphyxia is corrected by resuscitating
of the body. If the infant failures to breathe well the newborn infant. Only about 5% of
after delivery the infant will develop hypoxia. newborn infants have asphyxia and, therefore,
As a result of hypoxia, the infant’s heart need resuscitation.
rate falls, breathing is poor, central cyanosis
develops and the infant becomes hypotonic
(floppy) and unresponsive. Neonatal asphyxia, Resuscitation
if not correctly managed, will lead to hypoxia
and possible brain damage or death.
1-31 What is resuscitation?
1-27 What is fetal hypoxia? Resuscitation is a series of actions taken to
If the placenta fails to provide the fetus with establish normal breathing, heart rate, colour,
enough oxygen, fetal hypoxia will result. Fetal tone and response in an infant with abnormal
hypoxia presents with meconium stained vital signs, i.e. a low Apgar score.
liquor and late fetal heart rate decelerations
or bradycardia. These are the signs of fetal 1-32 Which infants need resuscitation?
distress (or more accurately, stress). Therefore,
All infants who do not breathe well by 1
fetal hypoxia results in fetal distress. As
minute after delivery, or have a 1 minute
hypoxia may damage or kill the fetus, it is very
Apgar score below 7, need resuscitation. The
important that each infant is well monitored
lower the Apgar score the more resuscitation
during labour so that any signs of fetal distress
is usually needed. Any infant who stops
can be detected, as soon as possible, so that the
breathing or has abnormal vital signs at any
correct management can be given.
time after delivery or in the nursery also
Fetal hypoxia is an important cause of requires resuscitation.
neonatal asphyxia.
All infants with neonatal asphyxia, or a 1 minute
1-28 Are neonatal asphyxia and fetal
Apgar score below 7, require resuscitation.
hypoxia the same condition?
No. Neonatal asphyxia and fetal hypoxia are not
the same although severe fetal hypoxia usually 1-33 Can you anticipate which infants will
results in neonatal asphyxia after delivery. Some need resuscitation at birth?
infants with mild fetal hypoxia breathe well
Yes. Any of the conditions which cause
after birth and do not have neonatal asphyxia.
neonatal asphyxia may result in the infant
There are also many causes of neonatal asphyxia
needing resuscitation. However, neonatal
other than fetal hypoxia. Therefore, some
asphyxia cannot always be predicted before
infants have neonatal asphyxia even though
delivery. Remember that any infant can be
they have not had fetal hypoxia.
born with neonatal asphyxia without any
previous warning. It is essential, therefore, to
1-29 Can neonatal asphyxia be prevented? be prepared to resuscitate all newborn infants.
Good management during labour and the Everyone who delivers an infant must be able
early detection of fetal distress are the best to perform resuscitation.
methods of preventing neonatal asphyxia.
However, some cases of neonatal asphyxia Any infant can have neonatal asphyxia at birth
cannot be predicted nor prevented.
without warning signs during labour and
delivery.
1-34 What is needed to resuscitate a HIV if the secretions get into the mouth of
newborn infant? the person suctioning the infant.
2. Oxygen: Whenever possible, a cylinder
1. A suitable, warm area with good lighting
or wall source of 100% oxygen should be
2. The correct, clean and functioning
available. However, oxygen is not essential
equipment
for resuscitation.
3. The knowledge and skills
3. Self-inflating bag and mask: A simple
neonatal self-inflating bag and mask, e.g.
1-35 What is a suitable resuscitation area? Samson, Laerdal, Ambu, Penlon or Cardiff
A warm area with good light and a working resuscitator, must be available to provide
surface at a comfortable height is needed. In mask ventilation. Direct mouth-to-mouth
a clinic or hospital, some source of oxygen resuscitation is dangerous due to the risk of
and suction should be available together with becoming infected with HIV.
storage space for the equipment. Make sure 4. Naloxone: Ampoules of naloxone (Narcan
there is no draught. The temperature of the 0.4 mg in 1 ml). Small syringes and needles
resuscitation area should be at least 25 °C. will be needed to administer the drug.
Neonatal Narcan is no longer used, as the
A warm, well lit corner of the delivery room is concentration of drug is too small.
ideal for resuscitation. A heat source, such as 5. Wall clock or watch: To time the
an overhead radiant warmer or wall heater, is assessment of the Apgar score.
needed to keep the infant warm. A good light,
such as an angle-poise lamp, is essential so Although not essential for basic resuscitation,
that the infant can be closely observed during it is very useful to have an infant laryngoscope
resuscitation. A firm, flat surface at waist height and endotracheal tubes so that infants with
is best for resuscitating an infant. There is no severe neonatal asphyxia can be intubated, if
need to have the infant lying head down, and bag and mask ventilation is not adequate. If
the neck must not be overextended. It is very possible, everyone who regularly resuscitates
useful to have warm towels to dry the infant. newborn infants should learn how to intubate
them.
1-36 What equipment do you need for
infant resuscitation? 1-37 How should you stimulate respiration
immediately after birth?
It is essential that you have all the equipment
needed for basic infant resuscitation. The After birth, all infants must be quickly dried
equipment must be clean, in working order in a warm towel and then placed in a second
and immediately available. The equipment warm, dry towel. This must also be done to
must be checked daily. infants with neonatal asphyxia, before starting
resuscitation. Drying the infant prevents rapid
The following essential equipment must be heat loss due to evaporation. Handling and
available in the delivery room: rubbing the newborn infant with a dry towel
1. Suction apparatus: An electric or wall is usually all that is needed to stimulate the
vacuum suction apparatus is ideal but the onset of breathing. Stimulation alone will start
vacuum pressure should not exceed 200 cm breathing in most infants.
water. Soft F 10 end-hole suction catheters
are needed. A simple mouth suction 1-38 Should all infants be routinely
apparatus (mucus extractor) can also be suctioned after delivery?
used. It consists of a 2 soft plastic catheters
No. Infants who breathe well at delivery
attached to a 20 ml plastic container.
should not have their mouth and throat
Although it is effective, there is a small risk
routinely suctioned, as suctioning sometimes
that the staff could become infected with
causes apnoea. Infants born by caesarean It is very helpful to have an assistant during
section also need not be routinely suctioned. resuscitation.
It is not necessary to routinely suction the mouth 1-43 How do you resuscitate an infant?
and nose of infants after delivery. There are 4 main steps in the basic
resuscitation of a newborn infant. They can be
easily remembered by thinking of the first 4
1-39 Which infants should be suctioned letters of the alphabet, ‘ABCD’:
after delivery?
1. Airway
1. Infants who do not breathe well after 2. Breathing
stimulation 3. Circulation
2. Meconium-stained infants 4. Drugs
Step 1: Clear the airway
1-40 When should you start to resuscitate
an infant? Gently clear the throat. The infant may be
unable to breathe because the airway is
If the infant does not breathe well and fails blocked by mucus or blood. Therefore, if the
to respond to stimulation after drying and infant fails to breathe after stimulation, gently
clamping the umbilical cord, then the infant suction the back of the mouth and throat with
must be actively resuscitated. Drying and a soft F 10 catheter. Too much suctioning,
clamping the cord usually takes about 1 especially if too deep in the region of the vocal
minute. These infants will have a low 1 minute cords, may result in apnoea and bradycardia.
Apgar score. Although resuscitation usually This can be prevented by holding the catheter
starts after 1 minute, if the infant obviously has 5 cm from the tip when suctioning the infant’s
severe neonatal asphyxia, resuscitation should throat. There is no need to suction the nose.
be started sooner. Simply turning the infant onto the side will
often clear the airway.
1-41 Can resuscitation of an infant with
severe neonatal asphyxia result in survival If wall suction or a suction machine are not
with brain damage? available, a mucus extractor can be used to
suction the infant’s mouth and throat. Because
Some people are worried that resuscitation of the small risk of HIV infection, wall suction
may result in a live, but brain damaged infant, or a suction machine is best.
who would have died without resuscitation.
This is very uncommon. Not all infants with Correctly position the head. The upper
severe neonatal asphyxia die. Therefore, it is airway (pharynx) can be opened by placing
better to give good resuscitation early to all the infant’s head in the correct position.
infants with neonatal asphyxia and reduce With the infant lying on its back on a flat
the risk of brain damage that may occur if no surface, slightly extend the neck so that the
resuscitation is given. The only infants who face is pointing towards the ceiling. Do not
may not be offered resuscitation are those overextend the neck.
with a lethal congenital abnormality, such as If the infant is not breathing well after the
anencephaly. airway have been suctioned and the head
correctly positioned, stop suctioning and
1-42 Who should resuscitate the infant? move to step 2.
The most experienced person, irrespective of
Step 2: Start the infant breathing
rank, should resuscitate the infant. However,
everyone who conducts deliveries must have If stimulation and suctioning and correct
the skills and equipment to resuscitate infants. position of the head fail to start breathing,
mask and bag ventilation must be started. 1-44 How do you give oxygen to an infant?
Giving mask oxygen alone often does not help.
Oxygen is given if the infant is centrally
Keep the infant’s neck slightly extended and
cyanosed. Usually wall oxygen is used.
hold the mask firmly over the infant’s face.
Otherwise an oxygen cylinder or an oxygen
Most infants can be adequately ventilated
concentrator is needed. Oxygen is best given
with a neonatal bag and mask, such as a
by mask and bag ventilation. It is safer to only
Samson, Laerdal, Ambu, Penlon or Cardiff
use room air for resuscitation and only give
resuscitator. Ventilation is the most important
oxygen if the central cyanosis is not corrected
part of resuscitation. Usually mask and bag
by mask ventilation.
ventilation is given with room air.
Room air is safer than oxygen for most

Ventilation is more important than oxygen.
resuscitations.
Respiratory stimulants, such as Vandid, must
not be used, as they are dangerous and do not 1-45 How should you use a self-inflating
help. bag and mask to ventilate an infant?
Step 3: Obtain a good circulation 1. The position of the infant: The infant
must lie face up on a flat surface. The
If the heart rate remains below 80 beats per infant’s neck should be slightly extended.
minute after effective ventilation has been Do not over extend the neck. The infant’s
started, apply external cardiac massage at face should look towards the ceiling.
about 120 times a minute. Infants should be kept in a warm towel
during resuscitation.
Step 4: Drugs to reverse pethidine and 2. The apparatus: A number of bag and
morphine mask sets are suitable, such as the Samson,
If the mother has received either pethidine Laerdal, or Ambu resuscitators. Make
or morphine during the 4 hour period before sure that both the bag and mask are
delivery, the infant’s poor breathing may be designed for newborn infants. If required,
due to drug depression. If so, the respiratory the bag should be attached to an oxygen
depression caused by the analgesic can be source providing 5 litres per minute. It
rapidly reversed with Narcan (a 1 ml ampoule is important that the correct size mask is
contains 0.4 mg naloxone). Narcan 0.1 mg/kg used to cover the nose and mouth.
(i.e. 0.25 ml/kg) can be given by intramuscular 3. The position of the mask: The mask must
injection into the anterolateral aspect of the be placed over the infant’s mouth, nose and
thigh. Intramuscular Narcan takes a few chin. Hold the mask tightly against the face
minutes before it starts to act. Do not use so that there are no air leaks.
Neonatal Narcan, as this preparation requires 4. Using the self-inflation bag: The mask
too big a volume. should be held in place with the left hand
while the bag is squeezed at about 40
Narcan will not help resuscitate an infant
breaths per minute with the right hand. If
if the mother has not received a narcotic
the little and ring finger of the left hand are
analgesic during labour, or has received a
placed under the angle of the jaw, the jaw
non-opioid general anaesthetic, barbiturates
can be gently pulled upwards to keep the
or other sedatives.
tongue from falling back. The position of
the mask is the same with all types of bag.
Mask and bag ventilation is the most important When giving mask and bag ventilation,
step in resuscitating an infant. watch the movement of the chest. Squeeze
the bag hard enough to move the chest
with each inspiration. Continue giving that the infant did not suffer severe hypoxia
mask and bag ventilation at about 40 before delivery.
breaths per minute until the infant starts to
cry or breathes well. A small percentage of 1-48 When is further resuscitation
infants with severe neonatal asphyxia will hopeless?
not respond to mask ventilation and need
intubation and ventilation. Every effort should be made to resuscitate all
infants that show any sign of life at delivery.
The Apgar scores at 1 and 5 minutes are
1-46 How do you give cardiac massage?
not good indicators of the likelihood of
Place the infant on its back with the head hypoxic brain damage or death. If the Apgar
towards you. Place both hands under the score remains low after 5 minutes, efforts at
infant’s back and press on the lower half of resuscitation should be continued. However,
the sternum with both your thumbs. This if the infant has not started to breathe, or
will depress the sternum by about 2 cm. only gives occasional gasps, by 10 minutes
Push down on the sternum about 100 times the chance of death or brain damage is high.
a minute. Pressing on the sternum squeezes Resuscitation is usually stopped if the Apgar
blood out of the heart and causes blood to score at 20 minutes is still low with no regular
circulate to the lungs and body. breathing. It is best if an experienced person
decides when to abandon further attempts at
It takes 2 people to both mask ventilate and
resuscitation.
give cardiac massage. An assistant should
ventilate the infant while you give cardiac Resuscitation will not save all infants with
massage. After every third push on the neonatal asphyxia, but it will help most.
sternum the assistant should squeeze the
bag to give 1 breath after every 3 heart beats. 1-49 What post resuscitation care is
Continue cardiac massage until the infant’s needed?
heart rate increases to 100 or more beats per
minute. If you are resuscitating an infant on All infants that require resuscitation with
your own, good mask ventilation is more bag and mask ventilation must be carefully
important that cardiac massage. observed for at least 12 hours. Their
temperature, pulse and respiratory rate,
colour and activity should be recorded and
1-47 How can you assess whether the
their blood glucose concentration measured.
resuscitation has been successful?
Keep these infants warm and provide fluid
The 4 steps in resuscitation are followed step and energy, either intravenously or orally.
by step until the 3 most important vital signs Usually these infants are observed in a closed
of the Apgar score have returned to normal: incubator. Do not bath the infant until the
infant has fully recovered.
1. A pulse rate above 100 beats per minute.
Easily assessed by palpating the base of Careful notes must be made describing the
the umbilical cord or listening to the chest infant’s condition at birth, the resuscitation
with a stethoscope. needed and the probable cause of the neonatal
2. A good cry or good breathing efforts. asphyxia.
This assures adequate breathing.
3. A pink tongue. This indicates a good 1-50 What about the mother during
oxygen supply to the brain. Do not rely on resuscitation?
the colour of the lips.
It is very frightening for a mother to know that
With good resuscitation the Apgar score at 5 her infant needs resuscitation. Therefore, it is
minutes should be 7 or more. This suggests important to tell the mother that her infant
needs some help and to explain to her what is
being done to the infant. Remember that the Meconium aspiration results in respiratory
mother may start bleeding while the staff are distress after delivery.
busy resuscitating the infant.
Meconium often burns the infant’s skin and
digests away the infant’s eye lashes! Therefore,
1-51 How is the resuscitation equipment imagine the damage meconium can cause to
cleaned? the delicate lining of the lungs.
It is imporant that all the resuscitation
equipment is kept clean and in good working 1-54 How can you prevent meconium
order. After a resuscitation all the equipment aspiration at delivery?
must be cleaned to prevent the spread of
Before delivery of all meconium stained
infection. The masks and mucus extractors
infants, a suction apparatus and an F 10 end
must be washed with water and soap or
hole catheter must be ready at the bedside. If
detergent and rinsed. The self-inflating bags,
possible, the person conducting the delivery
e.g. Laerdal, Ambu and Penlon must be
should have an assistant to suction the infant’s
sterilised.
mouth when the head delivers.
After delivery of the head, the shoulders
Management of the should be held back and the mother asked
to breathe fast and not to push. This should
meconium-stained prevent delivery of the trunk. The infant’s face
infant is then turned to the side so that the mouth
and throat can be well suctioned. The nose can
be suctioned after the mouth and throat. The
1-52 Does the meconium stained infant infant should be completely delivered only
need special care? when no more meconium can be cleared from
the mouth and throat.
Yes. All infants that are meconium stained
at birth need special care to reduce the risk If the infant cries well after delivery, no
of severe meconium aspiration. Whenever further resuscitation or suctioning is needed.
possible, all these at-risk infants should be However, some infants develop apnoea and
identified before delivery by noting that the bradycardia as a result fetal hypoxia of the
liquor is meconium stained. suctioning and, therefore, need ventilation
after delivery. If a meconium stained infant
1-53 Why does the meconium stained needs ventilation, the throat should again be
infant need special care? suctioned before ventilation is started.
As a result of fetal hypoxia, the fetus may make This aggressive method of suctioning is very
gasping movements and pass meconium. Before successful in preventing severe meconium
delivery, meconium in the amniotic fluid can aspiration in meconium stained infants.
be sucked into the upper airways. Fortunately
most of the meconium is unable to reach the The mouth and throat of all meconium stained
fluid filled lungs of the fetus. Only after delivery, infants must be suctioned before the shoulders
when the infant inhales air, does meconium
are delivered.
usually enter the lungs.
Meconium contains enzymes from the fetal When a meconium stained infant is delivered
pancreas that can cause severe lung damage by caesarean section, the mouth and throat
and even death if inhaled into the lungs at must similarly be suctioned with a F10
delivery. Meconium also obstructs the airways. end-hole catheter, before the shoulders are
delivered from the uterus. After complete
delivery, move the infant immediately to brief examination indicates that the infant is
the resuscitation table. If the infant does not a normal, healthy term infant. The mothers
breathe well, further suctioning is needed should give skin-to-skin care of her infant after
before stimulating respiration or starting birth. The infant should not be left in a cot.
ventilation. The father should also be present to share this
exciting moment.
1-55 What care should you give to
meconium stained infants after birth? 2. When should the mother be encouraged
to put the infant to her breast?
All meconium stained infants should be
observed for a few hours after delivery as they As soon as she wants to. This is usually after
may show signs of meconium aspiration. Most she has had a chance to have a good look at
meconium stained infants have also swallowed her infant. There are advantages to putting the
meconium before delivery. Meconium is a infant to the breast soon after delivery.
very irritant substance and causes meconium
gastritis. This results in repeated vomits of 3. Should the vernix be washed off
meconium stained mucus. immediately after delivery?
Meconium gastritis may be prevented by Infants should not be bathed straight after
washing out the stomach with 2% sodium delivery, as they often get cold, while vernix
bicarbonate (mix 4% sodium bicarbonate should not be removed as it helps protect the
with an equal volume of sterile water). Five infant’s skin from infection. It would be better
ml of 2% sodium bicarbonate is repeatedly to bath the infant later, in the mother’s presence,
injected into the stomach via a nasogastric when most of the vernix will have cleared.
tube and then aspirated until the gastric
aspirate is clear. This should be followed by 4. Do you agree that this well infant does
a feed of colostrum. Only heavily meconium not need chloromycetin eye ointment?
stained infants should have a stomach washout
on arrival in the nursery. Routine stomach No. All infants should be given chloromycetin
washouts in infants with mildly meconium eye ointment, especially if gonorrhoea is
stained liquor are not needed. common in the community. Gonococcal
infection may be asymptomatic in the mother.
Case study 1 5. Should the infant stay with the mother

after delivery?
An infant is delivered by spontaneous vertex Yes, if possible the mother and her infant
delivery at term. Immediately after birth the should not be separated after delivery.
infant cries well and appears normal. The cord
is clamped and cut and the infant is dried.
The infant has a lot of vernix. As the infant Case study 2
appears healthy and the mother has no vaginal
discharge, chloromycetin ointment is not put
After a normal pregnancy, an infant is born
in the infant’s eyes. The infant is placed in a cot
by spontaneous vertex delivery. There are
beside the mother.
no signs of fetal distress during labour. The
mother received pethidine 2 hours before
1. When should the infant be given to the delivery. Immediately after delivery the infant
mother? is dried and placed under an overhead radiant
As soon as the infant is dried, the cord cut, warmer. At 1 minute after birth the infant
the 1 minute Apgar score determined and a has a heart rate of 80 beats per minute, gives
irregular gasps, has blue hands and feet but a
pink tongue, has some muscle tone but does 6. What is this infant’s Apgar score at 5
not respond to stimulation. At 5 minutes the minutes?
infant has a heart rate of 120 beats per minute
The Apgar score at 5 minutes is 9: heart rate=2,
and is breathing well. The tongue is pink but
breathing=2, colour=1, tone=2, response=2.
the hands and feet are still blue. The infant
This indicates that the infant has responded
moves actively and cries well.
well to resuscitation.
1. What is the infant’s Apgar score at 1

7. Why is this infant very unlikely to have
minute?
suffered brain damage due to hypoxia?
The Apgar score at 1 minute is 4: heart rate=1,
Because there is no history of fetal distress
respiration=1, colour=1, tone=1, response=0.
to indicate that this infant had been hypoxic
before delivery.
2. Does this infant have neonatal asphyxia?
Give your reasons.
8. What should be the management of this
Yes, the infant has neonatal asphyxia because infant after resuscitation?
the infant failed to establish adequate,
The infant should be kept warm and be
sustained respiration by 1 minute. The
transferred to the nursery for observation. As
diagnosis of neonatal asphyxia is supported by
soon as the infant is active and sucking well it
the low Apgar score at 1 minute.
should given to the mother to breast feed.
3. What is the probable cause of the

neonatal asphyxia?
Case study 3
Sedation due to the maternal pethidine given
2 hours before delivery. These sedated infants A woman with an abruptio placentae delivers
usually respond rapidly to resuscitation. If not, at 32 weeks in a clinic. Before delivery the
Narcan can be given to reverse the sedative fetal heart rate was only 80 beats per minute.
effect of the pethidine. The infant has a 1 minute Apgar score of 1
and is ventilated with bag and mask. Cardiac
4. What should be the first 2 steps in massage is also given. With further efforts at
resuscitating this infant? resuscitation, the Apgar score at 5 minutes is 5
and at 10 minutes is 9.
If respiration cannot be stimulated by drying
the infant then the following 2 steps must be
taken: 1. What is the probable cause of neonatal
asphyxia in this infant?
1. Clear the airway by gently suctioning the
throat. Fetal distress caused by hypoxia. Abruptio
2. Breathing must be started with mask and placentae (placental separation before
bag ventilation. delivery) is a common cause of fetal distress.
5. Should oxygen be given? 2. What is the significance of the Apgar

scores at 5 and 10 minutes?
Room air is usually adequate for resuscitation
unless the infant remains centrally cyanosed. The good responds indicates that the
resuscitation is successful. If the Apgar score is
still low at 5 minutes it is important to repeat
the score every 5 minutes. The normal score
at 10 minutes indicates the infant’s response to
the resuscitation.
3. Is this child at high risk of brain damage 2. What mistake was made with the
due to hypoxia? management of this infant?
The good response to resuscitation suggests The infant’s mouth and throat should have
that this infant will not have brain damage due been well suctioned before the shoulders were
to fetal hypoxia. delivered. This should reduce the risk of severe
meconium aspiration as the airway is cleared of
4. When should all attempts at meconium before the infant starts to breathe.
resuscitation be abandoned?
3. What size catheter would you have used
If the Apgar score remains low at 20 minutes,
to suction this infant’s mouth and throat?
attempts at resuscitation may be stopped.
A large catheter (F 10) must be used as a small
catheter will block with meconium.
Case study 4
4. Should this infant be given a bath and
After fetal distress has been diagnosed, an stomach washout in labour ward after it
infant is delivered vaginally after a long starts to breathe spontaneously?
second stage of labour. At delivery the infant No. These should not be done until the infant
is covered with thick meconium. The infant has been stable for a number of hours in the
starts to gasp before 1 minute. Only then are nursery.
the mouth and throat suctioned for the first
time. The Apgar score at 1 minute is 3. By 5
5. What 2 complications is this infant at
minutes the Apgar score is 6.
high risk of?
1. What are the probable causes of the low This infant may develop meconium aspiration
1 minute Apgar score? syndrome as it probably inhaled meconium
into its lungs after birth. It may also suffer
Fetal distress, as indicated by the passage of brain damage due to hypoxia causing fetal
meconium before delivery. The prolonged distress during labour. The poor response to
second stage may have caused fetal hypoxia. resuscitation suggests that some brain damage
Inhaled meconium may have blocked the may be present. It would be important to
airway and prevented the infant from breathing. repeat the Apgar score every 5 minutes until
20 minutes after delivery.
2
Care of normal
infants
Normal infants are at low risk of developing

Objectives problems in the newborn period and,
therefore, require primary care only. About
When you have completed this unit you 80% of all newborn infants are normal.
should be able to:
• Manage normal newborn infants. Normal newborn infants are at low risk of develop
• Diagnose and treat common minor ing problems and require only primary care.
problems.
• Manage breast feeding.
• Promote baby friendly care. 2-2 Should all normal infants be kept with
• Discharge a normal infant. their mothers?
Yes, all normal infants should stay with their
mothers and not get cared for in the nursery.
Caring for normal This is called rooming-in. The infant is either
nursed in a cot next to the mother’s bed or
infants is given skin-to-skin care (Kangaroo Mother
Care or KMC). The advantages of infants
2-1 What is a normal infant? staying with their mothers are:
A normal infant has the following 1. The mother remains close to her infant all
characteristics: the times and gets used to caring for her
infant. This strengthens bonding.
1. The infant is born at term (37 to 42 weeks 2. It encourages breast feeding.
gestation). 3. It builds up the mother’s confidence in her
2. The 1 minute Apgar score is 7 or more and ability to handle her infant.
no resuscitation is needed after birth. 4. It prevents the infant being exposed to the
3. The infant weighs between 2500 g and infections commonly present in a nursery.
4000 g at birth. 5. It reduces the number of staff needed to
4. On physical examination the infant care for infants.
appears healthy with no congenital
abnormalities or abnormal clinical signs. The father should be present at the delivery to
5. The infant feeds well. share this exciting moment.
6. There have been no problems with the
infant since delivery.
them from dehydration at a time when many

Mothers and infants should stay together.
mothers produce only small amounts of milk.
2-3 When should the infant receive the first 2-6 What routine cord care is needed?
bath? The umbilical cord stump is soft and wet after
There is no need to routinely bath all infants delivery and this dead tissue is an ideal site for
after delivery to remove the vernix. Vernix bacteria to grow. The cord should, therefore, be
will not harm the infant and disappears kept clean. It should also be dried out as soon
spontaneously after a day or two. Vernix as possible by 6 hourly applications of surgical
protects the skin and kills bacteria. Many spirits (alcohol). It is important to apply enough
infants also get cold if they are bathed soon spirits to run into all the folds around the base
after delivery. The only indication for an infant of the cord. There is no need to use antibiotic
to be washed or bathed soon after birth is powders. If the cord remains soft after 24
severe meconium staining or contamination hours, or becomes wet and smells offensively,
with maternal blood or stool. then the cord should be treated with surgical
spirits every 3 hours. Do not cover the cord
It is, however, important that all primiparous with a bandage. Usually the cord will come off
mothers learn how to bath their infants between 1 and 2 weeks after delivery.
before they go home. If these infants have
to be bathed on the first day of life, it is
preferable that this be delayed until they are a Good cord care with surgical spirits is important.
few hours old.
2-4 What is the appearance of a newborn 2-7 Can a vaginal discharge be normal in
infant’s stool? an infant?
For the first few days the infant will pass Yes. Many female infants have a white, mucoid
meconium, which is dark green and sticky. vaginal discharge at birth, which may continue
By day 5 the stools should change from green for a few weeks. Less commonly the discharge
to yellow, and by the end of the first week may be bloody. Both are normal and caused by
the stools should have the appearance of the secretion of oestrogen by the infant before
scrambled egg. The stools of breast fed infants and after delivery.
may also be soft and yellow-green but should
not smell offensive. 2-8 May normal infants have enlarged
breasts?
Some infants will pass a stool after every feed
while others may not pass a stool for a number Yes. Many infants, both male and female, have
of days. As long as the stool is not hard, the enlarged breasts at birth due to the secretion
frequency of stools is not important. of oestrogen. The breasts may enlarge further
after birth. Breast enlargement is normal and
2-5 How many wet nappies should an the breasts may remain enlarged for a few
infant have a day? months after delivery. Some enlarged breasts
may secrete milk. It is very important that
A normal infant should have at least 6 wet these breasts are not squeezed as this may
nappies a day. If the infant has fewer than 6 introduce infection resulting in mastitis or a
wet nappies a day, you should suspect that the breast abscess.
infant is not getting enough milk. However,
during the first 5 days, infants may have 2-9 Which birth marks are normal?
fewer wet nappies as infants normally pass
little urine in the first few days. This protects 1. A blue patch over the sacrum is very
common and is called a ‘mongolian spot’.
care of normal infants 31
It is seen in normal infants and is due to the tongue out fully and, therefore, is said to
the delayed migration of pigment cells into have ‘tongue tie’. This does not interfere with
other areas of the skin. It is not a sign of sucking and usually corrects itself with time.
Down syndrome (mongolism). Sometimes Do not cut the membrane as this may cause
similar patches are seen over the back, severe bleeding. Refer the child to a surgeon if
arms and legs and may look like bruises. the tongue does not appear normal by 2 years.
They need no treatment and disappear
during the first few years of life. 2-13 Does an umbilical hernia need
2. It is common for an infant to have a few treatment?
small pink or brown marks on the skin at
birth. These are normal and disappear in a Infants commonly develop a small umbilical
few weeks. hernia after the cord has separated. This does
3. Many infants also have pink areas on the not cause problems and usually disappears
upper eyelid, the bridge of the nose and without treatment when the infant starts to
back of the neck that become more obvious walk. If the hernia is still present at 5 years the
when the infant cries. These marks are child should be referred for possible surgical
called ‘angel’s kisses’ and ‘stork bites’. They correction.
are also normal and usually disappear
within a few years. 2-14 Do normal infants commonly have a
4. Some infants develop one or more raised blocked nose?
red lumps on their skin during the first Yes, a blocked nose is common due to the small
few weeks. These ‘strawberry patches’ size of the nose in a newborn infant. Normal
grow for a few months and take a few infants also sneeze. Usually a blocked nose does
years to disappear. They are best left alone not need treatment. However, some infants may
and not treated. develop breathing difficulties or apnoea if both
nostrils are completely blocked. Nose drops
2-10 Are cysts on the gum or palate containing drugs can be dangerous as they are
normal? absorbed into the blood stream and can cause
Small cysts on the infant’s gum or palate are a rapid heart rate. Sodium bicarbonate 2% or
common and almost always normal. They do saline nose drops can be used. The blocked nose
not need treatment and disappear with time. is usually not caused by a cold.
They must not be opened with a pin or needle
as this may introduce infection. 2-15 Are wide fontanelles and sutures
common?
2-11 Can infants be born with teeth? Many normal infants have wide fontanelles and
Yes, some infants are born with teeth. These sutures. This is particularly common in low
are either primary teeth or extra teeth. birth weight infants. The anterior fontanelle
Primary teeth are firmly attached and should may also pulsate. If the anterior fontanelle
not be removed. Extra teeth are very small and bulges and the infant’s head appears too big, the
usually very loose. A tooth that is very loose, infant must be referred to a level 2 or 3 hospital
and is only attached by a thread of tissue, can as hydrocephaly is probably present. If you
be pulled out. It will be replaced later by a are uncertain, repeat the head circumference
primary tooth. measurement in 2 weeks. It should not increase
by more than 0.5 cm per week.
2-12 Should ‘tongue tie’ be treated?
2-16 Are extra fingers or toes normal?
Many infants have a web of mucous
membrane under the tongue that continues to Extra fingers that are attached by a thread of
the tip. As a result the infant is not able to stick skin are common and occur in normal infants.
There is often a family history of extra digits. cotton vest and a gown that ties at the back or a
Extra fingers or toes should be tied off as close ‘baby grow’. A disposable or washable nappy is
to the hand or foot as possible with a piece of worn. If the room is cold, a woollen cap should
surgical silk. If the extra digit contains cartilage be worn. Woollen booties are sometimes also
or bone and is well attached with a broad base, worn. It is important that the clothing is not too
it must not be tired off. These infants have a tight. Infants should be dressed so that they are
high risk of other abnormalities and, therefore, comfortable and warm. Usually a single woollen
should be referred to a level 2 or 3 hospital. blanket is adequate.
2-17 Should an infant’s nails be cut? 2-21 Must the birth be notified?
If an infant’s fingernails become long they may The birth of every infant must be notified by
scratch the face. Long nails should, therefore, be the hospital, clinic or midwife. The parents
cut straight across with a sharp pair of scissors. later must register the infant’s name with the
Do not cut the nails too short. Never bite or tear local authority.
the nails. Nail clippers are dangerous.
2-22 Should all infants receive a Road-to-
2-18 Should the foreskin of an infant’s Health Card?
penis be pulled back?
Yes. All newborn infants must be given a
No. The foreskin is usually attached to the Road-to-Health Card (preschool card), as
underlying skin and, therefore, should not be this is one of the most important advances
pulled back to clean the glans. All newborn, in improving the health care of children. The
male infants have erections of the penis. They relevant information must be entered at birth.
also have larger testes than older infants. These Mothers should be told the importance of the
signs usually disappear within a few months card. Explain the idea of the Road-to-Health
and are due to the secretion of male hormones. Card to her. She must present the card every
time the infant is seen by a health care worker.
2-19 When should the normal infant be It is essential that all immunisations be entered
fully examined? on the card. A record of the infant’s weight gain
is also very important as poor weight gain or
Weighing and examining all newborn infants weight loss indicates that a child is not thriving.
are important parts of primary care. A full
examination should be done after the mother
and infant have recovered from the delivery, All newborn infants must be given a Road-to-
which usually takes about 2 hours. The infant Health Card.
must be examined in front of the mother so
that she is reassured that the infant is normal.
It also gives her a chance to ask questions 2-23 Should newborn infants be
about her infant. The infant is also briefly immunized?
examined immediately after birth to identify The schedule of immunisations varies slightly
any gross abnormalities. in different areas but most newborn infants are
given B.C.G. and polio drops within 5 days of
All newborn infants should be weighed and delivery. It is safe to give polio drops to infants
examined. of HIV positive mothers. However, their
B.G.G. immunisation is often delayed until
it can be established that they are not HIV
2-20 How should the infant be dressed? infected. Sick and preterm infants are usually
It is important that the infant does not get given B.C.G. and polio drops when they are
too hot or too cold. Usually an infant wears a ready to be discharged home.
Feeding the normal Benefits to the mother
infant 1. Breast feeding is much cheaper than

buying formula feeds.
2. Breast milk is instantly available at all
2-24 What milk can be given to a normal times. No sterilising of bottles and teats,
infant? and preparation of formula is needed.
3. It is emotionally satisfying for the mother
• Breast milk. Human breast milk meets to successfully breast feed her infant and
all the nutritional needs of a healthy term helps to form a strong bond between
infant. mother and infant.
• Formula feeds. These powdered feeds are 4. Breast feeding helps the involution of the
made from cow’s milk or soya bean and are uterus and reduces the amount of bleeding
modified to have similar constituents to during the puerperium.
breast milk. 5. Breast feeding helps the mother to lose
excessive weight gained during pregnancy.
Whenever possible mothers should breast feed Pregnancy, not breast feeding, alters the
their infants. breast shape of a primiparous woman.
Breast feeding is cheap and ensures an adequate,

2-25 What are the benefits of breast
safe supply of food. It, therefore, decreases the
feeding?
incidence of malnutrition.
Breast feeding provides many benefits to both
the infant and mother. The main benefits are: Breast feeding may increase the risk of HIV
transmission from mother to infant. This must
Benefits to the infant be taken into account when discussing breast
1. Breast milk is the ideal feed for term feeding with a mother.
infants as it provides all the nutrients in the
correct amount and proportion for normal 2-26 Why do some mothers not breast feed
growth and development. successfully?
2. Breast milk is easily digested and absorbed.
Breast feeding is not always easy, as the
3. Breast milk is clean and warm, and avoids
‘natural art of breast feeding’ has to be learned.
the dangers of a contaminated water
Some mothers do not breast feed or fail to
supply, inadequately sterilised bottles and
breast feed successfully because:
teats, and lack of refrigeration facilities.
4. Breast milk avoids the danger of diluted or 1. They believe that they do not have enough
concentrated formula. milk because it takes a number of days
5. Breast milk contains many anti-infective before the supply of milk increases.
factors and decreases the risk of infections, 2. They do not know the advantages of breast
especially gastroenteritis, a major cause of feeding.
death of infants in poor communities. 3. They think that their milk is too thin, or
6. Breast milk decreases the risk of allergy their breasts too large or too small.
in the infant, especially if there is a strong 4. They develop cracked nipples or engorged
family history of allergy. breasts due to an incorrect method of
feeding.
5. They want to return to work and do not
Breast feeding decreases the incidence of realise that many working mothers can
gastroenteritis and lowers the infant mortality continue to breast feed successfully.
rate in poor communities. 6. They are afraid of breast feeding.
7. They have flat or inverted nipples. 2-28 How can breast feeding be
8. Traditional beliefs may result in encouraged in hospitals and clinics?
unsuccessful breast feeding, e.g. incorrect
Staff should be convinced that breast feeding
beliefs that colostrum is not good for the
has many benefits for the mother and
infant, intercourse spoils the milk, and
infant, they should feel comfortable and
delayed feeding causes the milk to become
not embarrassed when speaking to patients
sour in the breast.
about breast feeding, and they must have
9. Poor sleeping or excessive crying by the
the knowledge and skills to teach mothers
infant is blamed on the quality or supply of
how to breast feed. Mothers must be helped
the breast milk.
individually with kindness and patience.
10. They are HIV positive and elect not to
breast feed. Facilities for rooming-in must be provided,
and the mother allowed unlimited access to
2-27 How can breast feeding be promoted? her infant to demand feed. The national baby
friendly hospital initiative encourages breast
Breast feeding should be promoted as the feeding.
normal, natural method of feeding an infant.
This can be achieved by:
2-29 What is the value of a local breast
1. Encouraging a positive attitude towards feeding support group?
breast feeding in the home during
Often the best person to advise and help a
childhood and adolescence by seeing other
breast feeding mother is someone who has
infants being breast fed.
successfully breast fed herself. A number of
2. Teaching the advantages of breast feeding
mothers who have breast fed and are interested
in schools.
in helping others to breast feed can form a
3. Promoting breast feeding in the media
local support group. With help and training by
(radio, TV, books).
midwives and doctors they can provide a very
4. Teaching the advantages and method of
helpful service.
breast feeding in all antenatal clinics.
5. Starting breast feeding groups run by
mothers who have themselves breast fed. 2-30 What preparation does a mother need
6. Encouraging breast feeding and practice for breast feeding?
kangaroo mother care in hospitals and 1. The decision to breast feed should be
clinics. taken before her infant is born. If she is
7. Discouraging bottle feeding in hospital. still undecided at delivery, she should be
Rather use cups for expressed breast milk encouraged to breast feed.
or formula feeding. 2. No routine preparation of breasts and
Further information on breast feeding in nipples before delivery is necessary.
South Africa can be obtained from a local 3. A good, supportive bra should be worn.
breast feeding support group or local branches Breast size is no indication of a woman’s
of the Breastfeeding Association, La Leche ability to breast feed.
League, and National Childbirth Education
and Parenting Association. 2-31 How can you treat flat or inverted
nipples?
Breast is best. If a woman’s’ nipples appear flat or inverted

during pregnancy, they can be corrected by the
infant sucking after delivery.
2-32 Should the infant be put to the breast 2-35 How should an infant fix at the breast?
immediately after delivery?
One of the commonest mistakes made when
Yes, the mother should breast feed her infant breast feeding is that the infant is not held
as soon as possible after delivery as the infant’s and fixed correctly (latched) at the breast.
sucking drive is usually strongest in the first The infant must take the whole nipple and
hour after birth. Early suckling promotes most of the pigmented areola into the mouth.
bonding between the mother and infant. It also Sucking or chewing on the nipple causes pain
stimulates milk production and encourages and damages the nipple. The mother should
successful breast feeding. The small amount let her nipple touch the infant’s cheek, so that
of colostrum in the first few days satisfies the the infant will turn towards the breast with an
infant and is very rich in antibodies. open mouth to take the nipple. Make sure that
the infant’s nose is not covered by the breast.
2-33 Should clear feeds be given during the
first few days? The infant must take the whole nipple and most
Sterile water or dextrose water should not be of the areola into the mouth when fixing at the
given before starting breast or formula feeds mother’s breast.
on day 1. A breast fed infant does not need
additional clear feeds. If the mother wants to
breast feed, no bottle feeds should be given to 2-36 Should infants be demand fed?
the infant as a teat can confuse the infant and
Yes. Whenever possible infants should be
cause it to reject the nipple.
demand fed. This means that the infant is
Unlike a bottle fed infant, that sucks the milk put to the breast whenever hungry. A normal
out of the teat, a breast fed infant holds the breast fed infant will usually feed every 2 to 4
nipple against the hard palate and compresses hours during the day for the first few weeks.
the milk ducts in the areola with the gums. Demand feeding prevents engorged breasts.
The breast fed infant, therefore, makes a
chewing movement while feeding (suckling). 2-37 What is the let down reflex?
When an infant is put to the breast, the
Routine clear feeds are not needed on day 1. pituitary gland in the mother’s brain responds
by producing the hormones prolactin and
oxytocin. Prolactin stimulates the breast to
2-34 What is the best position to hold an secrete milk while oxytocin produces the ‘let
infant while feeding? down reflex’. This reflex produces a tingling
The correct position of the infant while feeling in the breast, and results in milk
feeding is important. The mother should be being pumped into the infant’s mouth by the
warm and comfortable. Usually she sits up and contraction of muscle cells that surround
holds her infant across her body in front of the milk ducts under the areola. Milk may
her. The infant is held in one arm, and should leak from the other nipple during feeds. The
lie on its side with its mouth facing the nipple. release of oxytocin helps the uterus to involute
The breast is held in the other hand to offer the by causing the uterus to contract. It may
nipple to the infant. also produce abdominal pain during feeding
for the first few days after delivery. Tension,
Mothers should be encouraged to try different anxiety and a lack of sleep may inhibit the let
feeding positions in order to find which is down reflex.
most comfortable. Some mothers prefer to lie
down while they feed. Other mothers prefer to
tuck the infant under an arm like a rugby ball.
2-38 How do you manage leaking breasts? 1. Her breasts do not feel full before feeds
after day 5.
Milk leaking from the breasts is common
2. The infant continues to lose weight after
in the first few weeks of feeding. Leaking of
day 5.
the opposite breast during feeding can be
3. The infant loses more than 10% of its birth
stopped by pressing on that nipple. Cotton
weight.
handkerchiefs or pads can be used for leaking
4. The infant is not gaining weight by 2 weeks.
between feeds. They should be changed
5. The infant does not wet 6 or more nappies
frequently as dampness may cause sore nipples.
in 24 hours (after day 5), is very restless
and appears hungry.
2-39 Can a mother’s milk be too strong or
too weak? If you are worried that an infant is not getting
enough milk, then the infant can be test
No, but the appearance of breast milk varies. weighed before and after a feed. After the first
There are 3 different types of breast milk: week of life, most term infants will gain about
1. Colostrum. This is a milky fluid produced 25 g per day. Weight gain is best determined
in small quantities for the first few days over a few days.
after delivery. However, it contains a lot
of protein and provides all the infant’s 2-41 Is it normal for an infant to lose weight
nutritional needs. After 3 to 5 days the after birth?
milk supply suddenly increases and
Yes. Most breast fed infants will lose weight
the breasts feel full. This is due to the
for the first few days after birth due to the
production of mature milk, which consists
small volume of breast milk being produced.
of foremilk and hind milk.
Colostrum, however, will meet the infant’s
2. Foremilk. This is produced at the start of
nutritional needs. Once the milk ‘comes in’,
each feed. It appears very weak and thin
between days 3 and 5, the infant will start to
as it consists mainly of water with little
gain weight. Most breast fed infants regain
fat. On a hot day a thirsty infant will take
their birth weight by day 7. This weight loss
frequent, small feeds of foremilk.
is normal and does not cause the infant any
3. Hindmilk. This is only produced towards
harm. The normal infant does not usually lose
the end of a feed. It looks thick and
more than 10% of the birth weight. Marked
rich, and contains a lot of fat. A hungry
weight loss suggests that the infant is ill or not
infant will empty the breast to obtain the
getting enough milk.
hindmilk.
2-42 Is it necessary to weigh a normal

2-40 Do all mothers produce enough
infant every day?
breast milk?
No. The normal infant should be weighed
Most mothers produce enough milk for their
at delivery and again on days 3 and 5 if still
infant if breast feeding is managed correctly.
in hospital. Weight at discharge must be
Unfortunately many mothers stop breast
recorded. At every clinic visit the infant’s
feeding during the first 5 days because they
weight should be measured and recorded. Ill
are incorrectly advised that they do not have
infants should be weighed every day until well.
enough milk or because the infant is losing
weight. Milk supply is normally best in the
morning and poorest in the late afternoon and 2-43 How can you improve a mother’s milk
early evening. supply?
The mother is probably not producing enough 1. Reassurance, support and encouragement
milk if: that she will be able to breast feed. Also
ensure that she is getting enough sleep and
is not under too much stress, as anxiety 2-46 What should you do if an infant
is a major cause of poor milk production. refuses the breast?
Anxiety also inhibits the let down reflex.
Some infants may reject the breast and refuse
Many mothers are more relaxed in their
to fix on the nipple and suck. Common causes
own homes.
are a sore mouth due to thrush, the infant
2. Make sure that she is fixing the infant
being ill or upset, or the milk flow being too
correctly to the breast and that the infant is
fast. These problems should be looked for and
sucking correctly.
treated.
3. Put the infant to the breast frequently
during the day until a good milk supply Do not hold the infant’s head too tightly or
is established. If the infant is not demand push the face towards the breast, as the infant
feeding 3 to 4 hourly, it should be woken will turn towards your hand instead of the
for feeds. The best stimulus to milk nipple. It may help to squeeze a little breast
production is the infant sucking frequently milk onto the nipple before placing it in the
and for prolonged periods. infant’s mouth.
4. The mother should rest for a while in the
afternoon and drink adequate fluids. 2-47 What may causes an infant to choke
5. Stop any bottle feeds. while feeding?
During the first few weeks the mother may
The best stimulus for milk production is frequent have a lot of milk and the milk may flow too
feeding. fast causing the infant to choke or gag when
feeding. As a result the infant may refuse to
feed or overfeed and become restless. It may
2-44 Should infants be routinely test help for the mother to lie back at the start of
weighed? the feed with the infant across her chest so that
the milk has to flow upwards against gravity.
No, there is no need to test weigh all infants.
The mother may have to express a bit before
The amount of milk an infant takes varies
starting the feed, or feed the infant more
widely between feeds. A small feed, which
frequently. Too much milk and milk that flows
is common in the afternoon or when the
too quickly settles with time.
mother is tired, may cause maternal anxiety.
Test weighing may be useful to assess a
mother’s milk production if the infant does 2-48 How should you manage swollen or
not gain weight. painful breasts?
A normal, full breast feels tense and heavy, but
2-45 Should the infant always feed on both is not painful and any discomfort is relieved
breasts? by feeding. Breasts that are swollen, tender,
hard, lumpy and painful are caused by either
It is best to empty one breast first before
engorgement or mastitis.
putting the infant to the opposite breast. This
ensures that the infant gets the rich hind milk. Both engorgement and mastitis result from an
Start each feed on alternate breasts. However, obstruction in milk flow:
for the first few days it is useful to allow the
infant to feed on both breasts to stimulate the
milk production. 1. Engorged breasts
Both breasts are swollen, hard and painful but
the mother does not feel ill. The milk does not
flow freely. Engorged breasts usually occur
between days 3 and 5 when the mother’s milk
suddenly ‘comes in’. Engorged breasts are
common if the infant does not room-in and if It is important that the infant is correctly
the mother does not demand feed. fixed at the breast so that the nipple is not
chewed. When removing the infant from the
Treatment consists of emptying the breast by
breast, the mother should insert her little
expressing or allowing the infant to suck. The
finger into the corner of the infant’s mouth to
infant should be fed on the most painful breast
break the suction.
first. Sponging the breasts with warm water
or standing under a warm shower relieves
the discomfort, while a mild analgesic like Correct fixing of the infant at the breast will help
paracetamol (Panado) is helpful. Often the to prevent painful nipples.
infant is not able to fix correctly if the breast
is engorged as the nipples become flattened
by the swelling. If some milk is first expressed 2-50 How should you treat painful nipples?
from the breast, the infant will usually fix well.
Nipples are often painful during the first few
Breast engorgement should be prevented by
days of breast feeding, especially if the infant
frequent feeds.
is very hungry or is not fixing on the breast
2. Mastitis (milk fever) correctly. Do not let the infant sleep at the
nipple until the nipples have toughened.
Mastitis is an inflammation of the breast due
to infection in blocked milk ducts. It causes Cracked nipples are very painful and should
a swollen, painful, red area of one breast. The be prevented by correctly fixing the infant to
mother feels ill and may have a temperature. the breast and avoiding engorged breasts. Treat
cracked nipples with colostrum or hind milk
Treat with rest, warm compresses and a and mild analgesics. Alter the position of the
mild analgesic. It is most important that infant on the nipple so that it does not suck
the infant continues to suck frequently on on the tender area. It may be necessary to stop
the affected breast, as this will help the milk feeding on that side for 24 hours and express
to flow. Altering the feeding position often the breast instead. Frequent short feeds
helps to drain the affected area. Mastitis is when the infant is not hungry are preferable.
not dangerous for the infant. If the signs and Reassure the mother that painful nipples heal
symptoms do not improve within 24 hours very quickly. Mothers with painful nipples
an antibiotic (penicillin or cloxacillin) should need a lot of support if they are to continue
be prescribed for 5 days. If a fluctuant mass breast feeding.
develops then a breast abscess has formed.
This should be surgically drained. Due to the 2-51 Do breast fed infants need
pain of a breast abscess, feeding may have to complementary feeds?
be stopped on that breast for a few days. If
possible, feeding can be continued however. Most breast fed infants do not need
complementary (additional) feeds of formula.
2-49 How do you prevent painful nipples? Complementary feeds may decrease the
production of breast milk and the teat may
The nipples should be kept dry between feeds. confuse the infant. Only if an infant fails to
Instead of protecting the nipples with lanolin gain weight, after management to improve the
cream, petroleum jelly (Vaseline) or masse mother’s milk supply has been tried, should
cream, it is suggested that a little colostrum complementary feeds be used. Some mothers
or hind milk be left to dry on the nipples will give complementary feeds if they have to
after each feed. The milk has anti-infective leave their infant for more than a few hours.
properties and the fat protects the nipples. Do However, expressing milk into a bottle for the
not use alcohol on the nipples. Avoid vigorous missed feed would be preferable. Expressed
washing or soap on the nipples. breast milk can be safely stored up to 6 hours
in a cool place or for 48 hours in a fridge. 1, SMA). They are very similar and, therefore,
Breast milk can be safely frozen and stored the milk available at the local clinic or the
for 2 weeks in a fridge freezer or 6 months in cheapest milk should be bought. Unaltered
a deep freeze. Frozen milk should be thawed cows milk, evaporated milk and skimmed
slowly by placing the container in warm (not milk are not suitable for infants under 6
hot) water. months of age. Milk creamers must never be
used to feed infants.
2-52 Can working mothers continue to Bottle fed infants should be fed on demand. If
breast feed? fed according to a schedule, most infants will
Yes. Mothers can continue to breast feed for need to be fed 6 times a day, at 06:00, 10:00,
many months while working. Breast milk 14:00, 18:00, 22:00 and 02:00. After the first
can be expressed at work and this or formula few weeks the 02:00 feed can be missed. Most
is given to the infant during the day. When term infants will take about 100 ml per feed
at home the mother breast feeds frequently. after the first week.
Ideally it should be possible to take the infant
to work or leave the infant in a creche at or 2-56 How is formula made up?
near the place of work.
If a mother decides to formula feed her infant,
it is very important that she knows how to mix
2-53 Do drugs cross into the breast milk? formula correctly. She must also have a source
Almost all drugs that the mother takes by of clean water and know how to clean a cup or
mouth will cross into the breast milk in very bottle and teat.
small quantities that will not affect the infant. A level scoop of milk powder (scraped level
Breast feeding mothers should only take with a knife and not packed down) is added
medication that is necessary. to 25 ml of clean water in a feeding bottle. The
water should have been boiled beforehand
2-54 When should an infant not be breast and allowed to cool. The bottle and teat must
fed? have been cleaned and sterilised by boiling
1. If, after counselling, the mother has decided or standing in a disinfecting agent (Milton or
that she definitely does not want to breast half-diluted Jik). Shake the bottle well to mix
feed, then the infant should be fed formula. the feed. Bottles should not be used if they
2. If a mother is unable to breast feed because cannot be cleaned properly.
she is separated from her infant, she should One of the great dangers of formula feeds
express her milk, manually or with a breast is to make the mixture too strong or too
pump, for the infant to be cup fed. weak. If too much milk powder is added,
3. If the mother has an inadequate milk the infant may receive too much salt which
supply despite advice and support, and if can be dangerous. If too little milk powder is
the infant is not gaining wait by 2 weeks, added, the infant may become malnourished.
then complementary feeds should be Another danger is gastroenteritis caused by
started to ensure normal growth. infected water or dirty bottles and teats. These
4. If the mother is very ill. and other problems of formula feeds can be
5. If the mother is HIV positive and decides, avoided by breast feeding.
after counselling, to formula feed her infant.
Formula fed infants should be offered a few
clear feeds daily if the weather is very hot.
2-55 What formula feed should be used for Bottle fed infants must be held while feeding.
a term infant? The bottle should not be propped.
A number of formula feeds are available for
term infants (NAN 1, S26, Similac, Lactogen
Many of the dangers of infection when using months of age. Thereafter, milk alone is not
bottles and teats can be avoided if cup feeds enough and solids should be introduced. If
are used instead. possible, an infant should be entirely breast
fed for 6 months. Even if the mother can only
2-57 What are the advantages of cup breast feed for a few weeks or months, this
feeding over bottle feeding? will be of benefit to both her and her infant.
Introducing solids reduces the anti-infectious
If an infant cannot be breast fed it is better properties of breast milk.
to cup feed than to bottle feed. The greatest
advantage of cup feeding is that a cup can Some mothers continue to partially breast
be easily cleaned with soap and water. A cup feed up to 2 years. It is best to continue breast
also dries easily, especially if placed in the feeding after solids have been introduced.
sun, which helps to sterilise the cup. This is This practice is particularly important in poor
most important when clean or boiling water is communities as breast milk provides the infant
not available for washing bottles. A cup feed with a good source of protein and helps reduce
usually takes less time than a bottle feed. It is the risk of pregnancy in the mother. Weaning
also easier to wean a preterm infant from tube should be done over a few weeks by dropping
feeds onto cup feeds than onto bottle feeds as one feed per week.
many infants can swallow well before being
able to suck. Any small plastic cup or dish can Whenever possible infants should be entirely
be used to feed an infant. Breast milk can be
breast fed for 6 months.
expressed directly into the cup before a feed is
given to a preterm infant. Mothers who do not
breast feed should be shown how to cup feed
before they are discharged home after delivery. The baby friendly
In some infants bottle feeding may cause approach
problems with breast feeding as the
mechanism of sucking from a bottle is
different from feeding at a breast. This is often 2-60 What is a baby friendly hospital?
called ‘nipple confusion’.
The idea of a ‘Baby Friendly Hospital’ or
clinic was introduced by the World Health
2-58 Iron and vitamin supplements
Organisation to promote the advantages
needed?
of breast feeding. An agency is available to
A normal term infant born to a healthy mother registers hospitals as baby friendly. To become
on a good, mixed diet and regularly exposed to registered as a Baby Friendly Hospital all the
sunlight does not need supplements in the first ‘Ten steps to successful breast feeding’ have to
6 months of life. Additional iron and vitamin be implemented.
supplements may, however, be of benefit in
poor communities when iron drops 0.3 ml (or 2-61 What are the ten steps to successful
syrup 5 ml) and multivitamin drops 0.3 ml (or breast feeding?
syrup 5 ml) can be given daily. Supplements
given to well term infants are not harmful. 1. Have a written breast feeding policy that is
Remember that all preterm infants need more frequently communicated to all the health
supplements (0.6 ml). care staff.
2. Train all the health care staff in the skills
needed to implement successful breast
2-59 When should solids be introduced?
feeding.
Normally breast milk or formula feeds will 3. Inform all pregnant women about the
meet all the infant’s nutritional needs until 6 benefits of breast feeding.
4. Help mothers to start breast feeding within 1. Does the infant appear normal, active and
30 minutes of delivery. healthy?
5. Show mothers how to breast feed and teach 2. Does the infant feed well?
them how to maintain lactation even if 3. Can the mother feed and care for her infant?
they are separated from their infants. 4. Does the infant weigh 1800 g or more?
6. Do not give newborn infants formula or
If the answer to any of these questions is ‘No’
water feeds unless this is indicated for
the infant should not be discharged.
medical reasons.
7. Allow mothers and their infants to remain
together all the time from delivery to 2-64 What advice should the mother be
discharge. given about an infant at discharge?
8. Encourage demand feeding. Before discharge all mothers must be advised
9. Discourage the use of dummies, teats and about:
nipple shields.
10. Promote the formation of breast feeding 1. Feeding their infant.
support groups and refer mothers to these 2. Bathing and dressing their infant.
groups on discharge from hospital or clinic. 3. Follow-up appointments and arrangements.
4. Reporting immediately if the infant
appears ill or behaves abnormally.
2-62 What are the advantages of the baby
5. The importance of the Road-to-Health
friendly approach to the care of infants?
Card (preschool card).
It promotes exclusive breast feeding and
bonding between mother and infant. This 2-65 Should normal infants be followed up
is particularly important in communities after discharge?
where malnutrition, gastroenteritis and child
abuse are common. The baby friendly way of If the infant is discharged before 7 days of age,
infant care is also kinder, gentler, cheaper and the infant should be seen at home or at a clinic
better. Every effort must be made to make all on days 2 and 5 to assess whether:
hospitals and clinics baby friendly. 1. The infant appears healthy or sick.
If HIV positive mothers decide to breast feed, 2. The infant is feeding well and receiving
then exclusive breast feeding may reduce the enough milk.
risk of mother to child transmission of HIV. 3. The mother is managing to care for her
If they decide to formula feed, many of the infant.
practices which encourage bonding can still be 4. The cord is clean and dry.
practised. 5. The infant is jaundiced.
6. The mother has any problems with her
infant.
Discharging a normal After the age of one week, the normal infant
should be followed at the local ‘well baby’
infant clinic to assess the infant’s weight gain and
general development, and to receive the
required immunisations. These details must be
2-63 When can an infant be discharged
noted on the Road-to-Health Card.
from the hospital or clinic?
Most normal newborn infants can be
discharged 6 hours after delivery. Before Case study 1
discharging an infant from either a hospital or
clinic, you should ask yourself the following An infant is delivered by spontaneous vertex
questions: delivery at term. Immediately after birth
the cord is clamped and cut and the infant Case study 2
is dried. The infant cries well and appears
normal. The infant has a lot of vernix and a
Starch powder is sprinkled onto the umbilical
blue mark is noticed over the lower back. The
cord of a newborn infant twice a day to hasten
infant passes urine after delivery but does not
drying. The cord is then covered with a linen
pass urine again for 24 hours.
binder. The mother is worried that the infant
has enlarged breasts. As the ward is cold at
1. When should the infant be given to the night, she puts the infant into her bed.
mother?
As soon as the infant is dried, the cord cut, 1. What do you think of the method of cord
the Apgar score determined and a brief care in this infant?
examination indicates that the infant is a
The cord should be dried with surgical spirits
normal, healthy term infant. The father should
and not covered with starch powder. Covering
also be present to share this exciting moment.
the umbilical cord with a binder is incorrect as
it prevents the cord drying out.
2. What is the blue mark over the infant’s
back?
2. What treatment is needed for the infant’s
A ‘mongolian spot’, which is normal. It is enlarged breasts?
important to explain to the mother that it is
No treatment is needed and the mother must
not a bruise. It disappears over a few years.
not squeeze the breasts. The mother must be
reassured that breast enlargement resolves
3. Should the vernix be washed off spontaneously in a few months.
immediately after delivery?
Infants should not be bathed straight after 3. What would you advise the mother
delivery, as they often get cold, while vernix about sleeping with her infant?
should not be removed as it helps protect the
If the ward is cold and there is no simple way
infant’s skin from infection. It would be better
of keeping the infant warm, then the infant
to bath the infant the following day, in the
should sleep with the mother. It is important
mother’s presence, when most of the vernix
that infants do not get cold. Kangaroo mother
will have cleared.
care is a very effective method of keeping the
infant warm.
4. Should the infant stay with the mother
after delivery?
Yes, if possible the mother and her infant Case study 3
should not be separated after delivery.
A normal infant weighs 3000 g at birth. By
5. Does it matter if the infant only passes day 4 the infant appears well but the weight
urine once in the first 24 hours? has dropped to 2850 and it is suggested that
formula be started. The next day the mother
No. During the first few days a normal infant
has painful, engorged breasts. The policy in
often does not pass urine frequently. However,
the hospital is to keep all normal infants in
after day 5, an infant should have at least 6 wet
the nursery where the mothers can visit at
nappies a day.
feeding time.
1. Is the weight loss of 150 g normal for this 2. Why should the infant not be sent
infant? immediately to the nursery?
Yes. An infant may normally lose up to 10% of It is important for the mother to hold her
the birth weight in the first 5 days after delivery. infant after the delivery. This promotes breast
feeding and bonding. It is best if mother and
2. Should formula feeds be started? infant be kept together.
No. Within a day or two the mother should
3. Why is it incorrect to advise formula
have enough milk and the infant will start to
feeds if the breast milk appears to be
gain weight.
weak?
3. How should the mother’s engorged Both foremilk and colostrum often appear
breasts be managed? weak. This is normal and never an indication
for formula feeds.
Stop formula feeds and allow the infant to
breast feed frequently.
4. What are the dangers of a poor rural
woman giving bottle feeds?
4. What do you think of normal infants
being kept in the nursery? She may not be able to clean the bottle and teat
correctly. Cup feeds would be safer if formula
Normal infants should room-in with their is used as a cup is easier to clean. This mother
mothers. should be encouraged to breast feed.
5. Why is it important that this woman

Case study 4 breast feed her infant?
A well newborn infant is given clear feeds of 5% She will not be able to buy formula as she
dextrose for the first day. As the mother is tired is poor and probably does not live close to
after the delivery, the infant is immediately sent a shop. As a result the infant is at high risk
to the nursery. On day 3 the mother is advised of gastroenteritis and malnutrition. These
to bottle feed as her milk appears to be too problems can usually be prevented by breast
weak. She is a poor women who plans to return feeding.
to a rural district. It is suggested that the infant
starts solids at 1 month. 6. When should the infant be given solids?
This mother should breast feed for as long as
1. Should clear feeds be used in a healthy possible. It would probably be best if solids
newborn infant? were only started at 6 months.
No. Feeds should be started with breast milk
or full strength formula.
3
Care of low
birth weight
infants
care. All low birth weight infants must be
Objectives carefully assessed after birth.
When you have completed this unit you Low birth weight infants are at an increased risk
should be able to: of problems and may need special care.
• Identify and manage low birth weight
infants.
• Define preterm and underweight for 3-3 Why are some infants born with a low
gestational age infants. birth weight?
• List the complications of low birth
weight infants. Most infants weigh between 2500 and 4000g at
• Prevent hypothermia and hypoglycaemia. birth. However, some infants have a low birth
• Prevent recurrent apnoea. weight (less than 2500g) as a result of one or
• Manage anaemia of prematurity. both of the following 2 important problems
• Provide kangaroo mother care (KMC). during pregnancy:
• Keep good patient notes. • They are born too soon.
• Assess patient care. • They weigh less than expected for the
duration of pregnancy (i.e. they are
underweight for their gestational age).
3-1 What is a low birth weight infant?
A low birth weight (LBW) infant is an infant 3-4 Which infants are born too soon?
that weighs less than 2500g at birth. The weight The gestational age of an infant is measured
of all infants must be measured at birth so that from the first day of the mother’s last normal
low birth weight infants can be identified. menstrual period to the day of delivery. The
average gestational age is 40 weeks (280 days)
with a range of 37 weeks (259 days) to 42
It is important to weigh all infants after delivery.
weeks (293 days). Infants with a gestational
age between 37 and 42 weeks are called term
3-2 Why is it important to identify all low infants. Preterm infants are born before 37
birth weight infants? weeks while post term infants are born after
42 weeks.
Because these infants are at an increased risk
of problems and may need more than primary
care of low bir th weight infants 45
Any infant born before 37 weeks (i.e. preterm) helps to identify those infants who are growth
is regarded as being born too soon. About 5% restricted (grown too slowly).
of all infants are born preterm in a wealthy
In poor communities the commonest cause of
community and often more than 20% in a
low birth weight is slow fetal growth.
poor community.
Growth restricted infants have a head circum

Preterm infants are born before 37 weeks.
ference below the 10th centile.
3-5 What is an underweight for gestational

3-7 Which infants have lost weight during
age infant?
the last weeks of pregnancy?
Infants with a birth weight which is less than
Some infants lose weight in the last few weeks
expected for their gestational age are called
of pregnancy because the placenta is not
underweight for gestational age infants. When
supplying them with enough food from the
plotted on a birth weight for gestational age
mother. As a result of the weight lost, these
chart (a ‘fetal growth chart’), underweight
infants have loose, dry, peeling skin and
for gestational age infants have a birth weight
thin arms and legs at birth. They look as if
which falls below the 10th centile. Normally
they have been starved and are called wasted
grown infants (appropriate for their gestational
infants. Post term infants are often wasted.
age) have a birth weight between the 10th and
Weight loss (wasting) during the last weeks
90th centiles.
of pregnancy can, therefore, be identified by
examining the infant.
Underweight for gestational age infants have a
If only the infant’s weight, but not head
birth weight below the 10th centile. circumference, is below the 10th centile then
the infant is wasted but not growth restricted.
Infants may be underweight for gestational age Therefore, they are thin and underweight for
because of one or both of the following: their size.
• They have grown too slowly during Some infants have a low birth weight because
pregnancy. of 2 or more of these fetal problems, e.g. they
• They have lost weight during the last weeks may be born too soon (preterm) and also have
of pregnancy. grown too slowly (growth restricted). Other
low birth weight infants may have grown too
3-6 Which infants have grown too slowly
slowly and then lost weight in the last few
during pregnancy?
weeks of pregnancy (wasted).
Infants that have been growing too slowly
Infants are no longer described as premature,
during pregnancy, have a birth weight, length
post mature or dysmature as these descriptions
and head circumference that fall below the 10th
are difficult to define and only cause confusion.
centile (length is not routinely recorded as it
is difficult to measure accurately). Therefore,
all their measurements are less than would be 3-8 How do you assess the gestational age
expected for their gestational age. of an infant?
These small infants are called growth restricted 1. If possible the gestational age should
(or growth retarded) infants as they have be determined before delivery from the
suffered fetal growth restriction (intrauterine mother’s menstrual history and clinical
growth retardation). It is very useful to (or ultrasound) examination in early
measure the head circumference of all pregnancy.
underweight for gestational infants because it
2. If the duration of pregnancy is unknown 3. Problems with the pregnancy such as

or uncertain, the gestational age can be placenta praevia, placental abruption or
roughly estimated by simply observing cervical incompetence.
the newborn infant’s appearance and 4. Multiple pregnancy or polyhydramnios.
behaviour.
3. The Ballard method can be used to score 3-11 What are the common complications
an infant’s gestational age. This scoring of preterm infants?
method is based on the infant’s physical
appearance and behaviour. These infants have immature organs
because they are born too soon. Most of the
3-9 What are the clinical features of complications in preterm infants are because
preterm infants? of organ immaturity. They are also small and
fragile and can, therefore, be easily damaged
1. They have decreased muscle tone and,
during labour and delivery.
therefore, lie flat with straight arms and
legs or in a frog position. The common neonatal complications in
2. If their arms are gently pulled into an infants born preterm are:
extended position and then released, they
• Asphyxia (breathing poorly at birth)
do not immediately flex back at the elbow
• Hypothermia
into a bent position.
• Hypoglycaemia
3. They suck poorly.
• Recurrent apnoea
4. Their skin is thin and blood vessels can be
• Poor feeding
seen through their skin.
• Respiratory distress
5. They have few creases on the soles of their
• Jaundice
feet.
• Anaemia
6. They have no or small nipple nodules.
• Separation from parents
7. Boys have undescended testes and girls
have poorly formed labia majora. Less common complications are infection,
periventricular haemorrhage in the brain,
3-10 What are the common causes of an bruising and patent ductus arteriosus.
infant being born preterm? Preterm infants are, therefore, at high risk
1. The mother may develop preterm labour or of many complications after birth and need
prelabour rupture of the membranes. This special care. Many preterm infants die as a
is usually due to chorioamnionitis, which result of these complications, especially if they
is a bacterial infection of the amnion and are not correctly managed.
chorion cause by the spread of vaginal
bacteria through the cervical canal. Many Preterm infants often have immature organs.
of these women do not have the clinical
signs of severe chorioamnionitis (i.e. fever,
abdominal tenderness or an offensive 3-12 What are the clinical features of
vaginal discharge) and there is no obvious underweight for gestational age infants?
cause of the preterm labour or prelabour
rupture of the membranes. Most of these 1. Their weight is less than that expected
women have mild chorioamnionitis. for their gestational age (i.e. their weight
The reason why some women develop falls below the 10th centile on a weight for
chorioamnionitis is not understood. gestational age chart.
2. Maternal illness such as hypertension, 2. Infants who have been growing slower than
diabetes or heart disease. Many of these expected during pregnancy, will also with a
women have an induced labour or head circumference below the 10th centile.
caesarean section before term.
3. Infants who have lost weight during the gestational age infants commonly have the
last few weeks of pregnancy will be wasted following complications:
with loose, dry, peeling skin and thin
1. Asphyxia
arms and legs.
2. Organ damage due to lack of oxygen before
4. They are often meconium stained,
delivery (fetal hypoxia)
especially if born at term or post term.
3. Meconium aspiration
4. Hypothermia
3-13 What are the causes of infants being 5. Hypoglycaemia
born underweight for gestational age?
There are both maternal and fetal causes, 3-15 Why is it important to decide whether
which may result in the birth of an a low birth weight infant is born preterm or
underweight for gestational age infant: underweight for gestational age?
Because the causes and the complications
1. Maternal causes
of these two conditions may be different.
1. Low maternal weight Therefore, they often have different clinical
2. Poverty and manual labour problems, which need different forms of
3. Smoking management. However, some complications,
4. Excess alcohol intake such as asphyxia, hypothermia and
5. Hypertension or pre-eclampsia hypoglycaemia, are common in both preterm
and underweight for gestational age infants.
2. Fetal causes
1. Multiple pregnancy 3-16 What is the management of a low
2. Chromosomal abnormalities, e.g. Down birth weight infant?
syndrome
3. Severe congenital abnormalities 1. Good resuscitation if the infant has
4. Chronic intra-uterine infections, e.g. asphyxia.
syphilis 2. Prevent hypothermia.
5. Post term delivery 3. Prevent hypoglycaemia.
4. Start early feeds or an intravenous 10%
However, in many cases no obvious cause dextrose infusion.
can be found. Maternal height and race alone 5. Prevent apnoea.
probably have little effect on fetal growth. An 6. Monitor the infant carefully and treat any
abnormal placenta is rarely the primary cause of the common complications of low birth
of slow fetal growth or wasting. weight infants.
7. Keep the mother and infant together and
Pregnant women should not smoke or drink promote bonding.
alcohol. 8. Decide whether the infant needs to be
transferred to a level 2 or 3 unit.
Unless the infant is extremely small with fused
3-14 What are the common complications eyes, it should be regarded as possibly viable
of an underweight for gestational age and actively managed. With good emergency
infant? management and good transport many very
All underweight for gestational age infants, small infants can survive without long term
whether they have grown too slowly or are complications.
wasted or both, are at an increased risk during
the first weeks of life because they have often
received too little food and oxygen during
pregnancy. As a result, underweight for
Prevention of • Keep the room warm.

• Never nurse an infant near a cold
hypothermia window.
• Have curtains in the nursery.
• Never bath small or sick infants.
3-17 What is hypothermia? 4. Insulate the infant. Dress the infant
The normal temperature of a newborn infants and use a woollen cap. The naked head
is 36.0 °C to 36.5 °C, if the abdominal skin of a newborn infant loses a lot of heat. A
temperature is taken, and 36.5 °C to 37.0 woollen cap is particularly important if an
°C, if a digital (or low reading mercury) infant is receiving headbox oxygen. Infants
thermometer is placed in the axilla (armpit). in incubators should wear a woollen cap.
If either temperature is lower than the normal 5. All wet infants must be dried immediately
range (36.0 °C for skin temperature or 36.5 and then wrapped in another, warm, dry
°C for axillary temperature) the infant has towel. Do not leave an infant in a wet
hypothermia. A body temperature below towel. Remember to dry the infant’s head.
35 °C is particularly dangerous. It is very 6. Monitor the temperature in all infants who
important to prevent hypothermia, which are at an increased risk of hypothermia.
causes many clinical problems and can kill the It is essential to detect any drop in skin
infant if it is severe. temperature as soon as possible.
3-18 Which infants are at an increased risk A woollen cap prevents heat loss from an infant’s
of hypothermia? head.
1. All low birth weight infants
2. Infants who are not dried well after birth
3. Infants in a cold room or cool incubator 3-20 What is the best environmental
4. Infants lying near cold windows temperature?
5. Starved infants The best environmental (room or incubator)
temperature depends on:
3-19 How can you prevent hypothermia?
1. The weight and gestational age of the
1. Identify all infants at high risk of infant. The lower the weight and the
hypothermia. earlier the gestational age, the higher is
2. Provide energy (calories) by giving milk the required environmental temperature.
feeds or intravenous fluids. This is very Small, preterm infants need a very warm
important in low birth weight infants environment.
who are born with little body fat. Early 2. The postnatal age of the infant. The lower
feeding with breast milk or undiluted the postnatal age, the higher is the required
formula feeds helps to reduce the risk of environmental temperature, i.e. a younger
hypothermia by providing the infant with infant needs a warmer environmental
energy needed to produce heat. temperature.
3. Provide a warm environment for all 3. Illness. Sick infants need a higher
infants. The smaller the infant, the warmer environmental temperature.
the required environment. Most infants
The environmental temperature for each infant
under 1800 g need an incubator or skin-
should be adjusted in order to give a normal
to-skin care (kangaroo mother care). You
abdominal skin or axillary temperature. This
should:
can be achieved automatically if a servo-
• Never place an infant in a cold
controlled incubator is used. Skin-to-skin
incubator.
care will also provide the infant with the
• Keep the incubator ports closed.
correct temperature. Infants of 1500 g need an
incubator temperature of about 35.0 ºC during blanket, silver swaddler or heavy gauge
the first few days after delivery. aluminium foil normally used for cooking.
This is an effective method of preventing
The infant’s energy and oxygen needs are
heat loss during transport if the mother
lowest when the skin temperature is normal
cannot give skin-to-skin care and a
and the infant is nursed at the correct
transport incubator is not available. The
environmental temperature. Both energy
infant must be warm and dry before being
and oxygen needs increase if the infant’s skin
wrapped in a thermal blanket. Never put a
temperature is either above or below normal.
cold infant into a thermal blanket or use a
thermal blanket in an incubator.
The environmental temperature should be
adjusted to give a skin temperature of 36–36.5 ºC. A woollen cap and perspex heat shield reduces
heat loss when infants are nursed in an incubator.
3-21 How can you keep an infant warm?
The most appropriate method should be
There are a number of ways to keep an infant chosen for each individual. There is no excuse
warm: for an infant ever becoming hypothermic
1. A warm room. Most healthy, infants because hypothermia is preventable.
above 1800 g can be nursed in a cot in a
warm nursery, ward or home. The room
Hypothermia can be prevented by skin-to-skin
temperature should be about 20 ºC. The
care.
infant should be dressed in a nappy, jacket,
woollen hat and booties to prevent heat
loss. A woollen cap is most important.
Most infants below 1800 g can be kept Prevention of
warm in a cot if they are nursed in a room
where the temperature is kept at 25–30 ºC.
hypoglycaemia
The smaller the infant, the higher the
required room temperature will be. Do not 3-22 What is the normal concentration of
let the infant get too hot. glucose in the blood?
2. A closed incubator (or radiant warmer).
This is the way most small or sick infants The normal concentration of glucose in the
are nursed in hospital as the temperature blood of newborn infants is 2.0 mmol/l to 7.0
can be carefully controlled. Often infants mmol/l. (These levels are less than those for
in closed incubators are also dressed. A serum glucose). It is best to keep the blood
transparent perspex shield can be placed glucose concentration above 2.5 mmol/l.
over an infant in an incubator to help
reduce heat loss. 3-23 What is hypoglycaemia?
3. Maternal skin-to-skin care (kangaroo
A blood glucose concentration below 2.0
mother care). Many low birth weight
mmol/l (or serum glucose concentration
infants can be kept warm by placing
below 2.5 mmol/l) is abnormal and, therefore,
them naked against the mother’s naked
defined as hypoglycaemia.
breasts. This method is very successful and
particularly useful when closed incubators
are not available. The mother’s skin will Hypoglycaemia is defined as a blood glucose
become warmer or cooler to keep the concentration below 2.0 mmol/l.
infant’s temperature normal.
4. Thermal blanket. An infant can be kept
warm for hours if wrapped in a thermal
3-24 How is blood glucose measured in the 2. Hypothermic infants. These infants
nursery? use large amounts of glucose to produce
heat in an attempt to correct their body
The quickest, cheapest and easiest method
temperature.
to measure the blood glucose concentration
3. Infants of diabetic mothers. Before
in the nursery is to use reagent strips such as
delivery these infants get used to receiving
Haemoglukotest, Glucotrend or Dextrostix.
large amounts of glucose across the
Only a drop of blood is needed for a reagent
placenta, especially if the maternal diabetes
strip. After a minute it is either wiped off with
is poorly controlled. Often the fetus
cotton wool or washed off with water and then
becomes obese. At delivery the supply of
blotted dry, depending on the regent strip used.
glucose from the mother suddenly stops
The colour of the reagent strip is then compared
when the umbilical cord is clamped. As
to the colour range on the bottle to determine
a result, these infants commonly develop
the blood glucose concentration. A far more
hypoglycaemia because their high energy
accurate method to screen for hypoglycaemia
needs are no longer being provided for.
is to read the colour of the reagent strip with a
glucose meter such as reading Haemoglukotest
strips with a Reflolux meter. Hypothermia causes hypoglycaemia.
3-25 Which infants are at an increased risk

of developing hypoglycaemia? 3-26 How can you prevent hypoglycaemia?
Infants that have reduced energy stores or The following steps must be taken to prevent
reduced intake and infants with increased hypoglycaemia:
energy needs are at risk of hypoglycaemia. 1. Identify all infants at high risk of
Infants with reduced energy stores of glycogen developing hypoglycaemia, e.g. low birth
in the liver, protein in muscles, and fat under weight infants as they have little fat, muscle
the skin include: and glycogen stores.
2. Monitor the blood glucose concentration
1. Preterm infants. They are born too soon of these infants with reagent strips so that
before adequate amounts of glycogen, a falling blood glucose can be detected
protein and fat are stored in the tissues. before hypoglycaemic levels are reached.
The fetus gets most of its energy stores 3. Feed all infants as soon as possible after
from the mother in the last 6 weeks of delivery, especially low birth weight infants
pregnancy. and infants of diabetic women. If possible,
2. Underweight for gestational age or feed the infant within the first hour.
wasted infants. They have used up most 4. Whenever possible, milk feeds should
of their own energy stores before delivery be given. Sometimes nasogastric feeds
because they have not been getting enough may be needed. Both clear feeds and oral
glucose from their mother. 5% dextrose feeds should not be used in
3. Starved infants. Infants that are not fed, newborn infants as they have less energy
either orally or intravenously soon after than milk.
delivery, rapidly use up their energy stores. 5. If milk feeds cannot be given, then an
Infants with increased energy needs include: intravenous infusion of 10% glucose
(Neonatalyte) should be started.
1. Infants with respiratory distress. Their 6. Prevent hypothermia.
respiratory muscles require a lot of
glucose to provide the energy needed for
respiration. Early feeding with milk usually prevents
hypoglycaemia.
Recurrent apnoea a level 2 or 3 hospital for investigation. They

may need mask and bag ventilation before
being transported.
3-27 What is apnoea? It is dangerous to give head box oxygen to
Apnoea is the stopping of respiration for long infants with apnoea of immaturity, as they do
enough to cause bradycardia together with not need oxygen.
cyanosis or pallor. Usually apnoea for 20
seconds or longer is needed to produce these
clinical signs. The infant may have a single Feeding low birth
apnoeic attack but usually the episodes of
apnoea are repeated.
weight infants
In some preterm infants the respiratory
centre in the brain is immature and this 3-29 What determines an infant’s fluid
results in repeated attacks of apnoea. This is needs?
called apnoea of immaturity. These infants The daily fluid requirements of an infant
are usually less than 34 weeks of gestation. depends on:
Less commonly, apnoea may be caused
by respiratory distress, infection, hypoxia, 1. The body weight. Fluid requirements are
hypothermia, hypoglycaemia or convulsions. expressed in ml per kg of body weight.
Heavy infants, therefore, need more fluid
Apnoea should not be confused with periodic than do light infants.
breathing, which is a normal pattern of 2. The age after delivery. Fluid requirements
breathing in preterm infants. Infants with increase gradually from birth to 5 days and
periodic breathing frequently stop breathing for then remain stable.
less than 20 seconds, which is not long enough
to cause bradycardia, cyanosis or pallor.
3-30 How much fluid do most infants need?
Apnoea can be detected with the aid of an
Most infants need:
apnoea monitor, which is usually set to trigger
if the infant does not breathe for 20 seconds. • 60 ml/kg on day 1
• 75 ml/kg on day 2
3-28 How should you manage apnoea of • 100 ml/kg on day 3
immaturity? • 125 ml/kg on day 4
• 150 ml/kg on day 5 and thereafter.
Apnoea of immaturity can be largely prevented
and treated with the use of oral theophylline Note that the fluid requirements are given in
or caffeine. Theophylline is usually given ml per kg body weight, and that they increase
via a nasogastric tube as Nuelin liquid. A gradually from day 1 to day 5. After day 5
loading dose of 4 mg/kg is given, followed by a there is no further increase in the daily fluid
maintenance dose of 2 mg/kg every 12 hours. needs per kg body weight. As the infant’s
Prophylactic theophylline is given routinely to weight increases, so the total amount of fluid a
all infants born before 34 weeks of gestation day will increase although the amount of fluid
and can usually be stopped at 35 weeks. per kg remains constant at 150 ml/kg. Only
An overdose of theophylline presents with rarely do infants need more than 150 m/kg if
tachycardia, vomiting or convulsions. they are kept warm and well dressed.
During an attack of apnoea, breathing can be These daily fluid volumes meet the need of
restarted in most cases by simply stimulating both normal and low birth weight infants.
the infant. Infants with repeated apnoea, in They are used when infants receive either
spite of theophylline, should be referred to oral or intravenous fluids. The fluid volumes
needed by breast feeding infants do not 3-33 What route should be used to feed a
need to be calculated as they are met by the low birth weight infant?
increasing milk production by the mother
Most preterm infants born after 35 weeks are
during the first few days after delivery.
able to suck well and, therefore, take all their
feeds by mouth. If possible, they should be
The fluid requirements per day increase from 60 breast fed. A cup rather than a bottle should be
ml/kg on day 1 to 150 ml/kg on day 5. used to give feeds if expressed breast milk or
formula is used.
Preterm infants that are not able to suck
3-31 Why do the daily fluid needs increase should be fed via a nasogastric tube. They
during the first 5 days? usually start to suck between 32 and 34 weeks.
For the first few days after delivery the If the infant is fed via a nasogastric tube,
mother’s breasts do not produce a lot of milk. the mother must manually express her milk
To prevent dehydration, the kidneys of the every 4 hours during the day. A breast pump,
newborn infant, therefore, produce little urine if available, can also be used. The milk can
during this period. As a result the infant does be safely stored for 48 hours in a household
not need a lot of fluid in the first few days of fridge. It should stand at room temperature for
life. However, the infant’s fluid needs gradually 15 minutes to warm before feeding.
increase from day 1 to 5. By day 5 the kidneys
are functioning well and a lot of urine is
3-34 How often should a low birth weight
passed. Giving 150 ml/kg during the first 4
infant be fed?
days to infants may result in overhydration.
1. If below 1500 g: feed every 2 hours (i.e. 12
3-32 What milk feeds should be given to a feeds a day).
low birth weight infant? 2. If 1500–1800 g: feed every 3 hours (i.e. 8
feeds a day).
Whenever possible, every effort should be 3. If above 1800 g: feed every 4 hours (i.e. 6
made to feed a low birth weight infant with feeds a day).
breast milk. Infection, especially in preterm
infants, can be largely prevented by using Infants below 1500 g or sick infants may need
breast milk. intravenous fluids for the first few days before
milk feeds are started.
If breast milk is not available, then formula
(powdered milk) should be used. Infants
3-35 What are the dangers of milk feeds in
weighing 1500 g or more can be given a
low birth weight infants?
standard newborn formula such as Nan 1 or
S26. However, infants weighing less than 1500 Giving too big a feed may cause:
g should be given a special preterm formula
1. Vomiting
such as Prenan or S26 LBW. Cows milk is not
2. Abdominal distension
suitable for newborn infants.
3. Aspiration of the feed
If the correct volume of breast milk or formula
It is best to nurse infants on their backs as
is given, the infant will receive the correct
this lowers the risk of ‘cot deaths’. Raising the
amount of nutrients and energy. Diluted feeds
mattress below the head of the infant and
are not used.
giving smaller, more frequent feeds usually
Healthy term infants of normal birth weight prevents vomiting. Any infant that continues
should be demand fed at the breast. to vomit or develops a distended abdomen
should be referred as it may be infected.
3-36 What supplements are needed by low preterm infants after a few weeks of age may
birth weight infants? have a PCV below 30% and a Hb below 10 g/dl.
This condition is called anaemia of prematurity
Infants who have a gestational age below 37
as it caused by an immature bone marrow,
weeks are often deficient of both vitamins and
which does not produce enough red blood cells.
iron and should receive the following:
1. Multivitamin drops 0.6 ml daily should be 3-39 How should you manage anaemia of
started when the infant reaches 150 ml/kg prematurity?
milk feeds. This should be continued until
the infant is 6 months old. Vitamin drops There is no simple, cheap way of preventing
can be given into the infant’s mouth with anaemia of prematurity. Giving oral iron to
breast feeding or into the formula feed. The preterm infants does not help prevent or treat
extra vitamins prevent vitamin deficiencies anaemia of prematurity. These infants should
such as rickets. be discussed with the referral hospital, as they
2. Iron drops 0.3 ml daily should be started may need a blood transfusion, especially if
when the infant is old enough to suck the PCV falls to below 25% and the Hb below
well. When the infants is discharged from 8g/dl or they stop gaining weight. Most infants
hospital, the dose should be increased to with anaemia of prematurity recover after a
0.6 ml daily. This should be continued until few weeks without any treatment.
the infant is 6 months old. The added iron
prevents iron deficiency anaemia.
Kangaroo mother care
Low birth weight infants born at term usually
do not need any nutritional supplements. (KMC)
Anaemia 3-40 What is kangaroo mother care (KMC)?

Kangaroo mother care is a method of nursing
infants skin-to-skin against the mother’s chest.
3-37 What is anaemia? The infant, who is kept naked except for a
Anaemia is defined as a haemoglobin concen woollen cap and nappy, is placed vertically
tration (Hb) or packed cell volume (PCV) between the mother’s bare breasts. The
which is below the normal range. The normal infant is then covered with a blanket, towel
PCV at birth is 45–65% and the Hb 15–25 g/dl. or the mother’s clothing. The mother can
After delivery the PCV and Hb fall slowly until wear a belt, or tuck her vest, shirt, T-shirt or
about 8 weeks of age and then slowly increase blouse into her trousers, to prevent the infant
again. The Hb should not fall below 10g/dl and from falling. Special clothes are not needed
the PCV below 30%. If the Hb and PCV fall although a KMC baby carrier can be used.
below these levels the infant has anaemia. Other members of the family should also be
encouraged to give the infant KMC. This is
The commonest cause of anaemia in newborn particularly important for the father.
infants is anaemia of prematurity. Less
common causes are bleeding, infection and
3-41 Which infants should receive KMC?
haemolytic disease of the newborn.
1. Small infants in incubators who are still
3-38 What is anaemia of prematurity? too immature to be nursed in a cot. The
parents can give KMC while they visit
The PCV and Hb of the preterm infant are the infant in the nursery. Even very small
normal at birth but fall faster and to lower infants can be safely given KMC once their
levels than those in the term infant. Therefore, condition is stable.
2. Continuous KMC should be given to small Therefore, they should be written in an

infants when they reach about 1600 g and orderly, logical way so that all staff members
start to breast feed. They are taken out of can understand them.
the incubator and the mother provides
Whenever notes are written, it is important
KMC day and night. These mothers and
to give the date and the time that the record
infants should be cared for in a special
is made. It is then possible to know when the
KMC ward. The mother and infant can be
care was given.
discharged home when the infant breast
feeds well and the mother is confident to Every time you write clinical notes you should
manage her infant. These infants should sign your name. The rest of the health team
continue to be given KMC at home until then knows who wrote the notes.
they weigh 2000 g.
3. KMC can also be given to normal infants. 3-44 What is the SOAP method of writing
notes?
3-42 What are the advantages of KMC?
When an infant is examined for the first time
1. It keeps the infant warm. the clinical notes should include:
2. It allows the mother (and father) to play a
1. The Story
major role in caring for the infant.
2. The Observations
3. It promotes breast feeding.
3. The Assessment
4. It reduces the risk of infection in the infant.
4. The Plan
5. It allows the mother and infant to be
discharged home earlier. In order to remember these important steps
6. It reduces the work load of the nursing staff. in writing clinical notes, remember the word
7. It improves weight gain. SOAP. The letters in SOAP stand for Story,
Observations, Assessment, Plan.
Many studies have shown that the infant’s
temperature, respiration and heart rate remain
very stable with KMC. Apnoea is reduced. 3-45 What is the story?
Serious infection in hospital is uncommon as Good notes should always start with the story
the infant is colonised with bacteria from the (i.e. the history of the pregnancy, labour,
mother’s skin and breast milk rather than by delivery and events after delivery). A history
with dangerous nursery bacteria which are should always be taken before examining
often resistant to many antibiotics. KMC is an infant. Include any problems recorded
safe and should be widely practised. during the pregnancy, labour and delivery, the
Apgar score and any resuscitation needed, the
antenatal assessment of the gestational age and
KMC is one of the most important recent
any problems that occurred since delivery.
advances in infant care.
3-46 What are the observations?
The observations include the findings of
Keeping good patient the physical examination and the results
notes of any additional investigations done, e.g.
temperature or blood glucose measurement.
An assessment of the gestational age should be
3-43 What are good clinical notes? made in all low birth weight infants.
Good clinical notes, which form the patient
record, should be accurate, brief and easy to
read. In addition, they must be systematic.
3-47 What is the assessment? management, each item on the problem list
must be considered.
Once you have recorded the results of the
history, the physical examination and the
investigations, you must make an assessment 3-50 An example of good SOAP notes.
of the infant’s condition. For example, you 14 January 2008. 10:30.
should ask yourself:
1. Is the infant sick or well? Is it normal or S
abnormal? 18 year old primip. Booked.
Spontaneous preterm labour. 35
2. Is the infant at high risk or low risk for
weeks by dates and palpation.
clinical problems?
No signs of fetal distress. NVD
3. What clinical problems does the infant at 06:15. Apgar scores 4 and 9.
have at present? Intubation and ventilation needed
The assessment must not be forgotten, as a for 3 minutes. Thereafter infant
moved to nursery.
carefully recorded history and examination are
of little value if you are unable to assess what
O
this information means. The management Male infant. Weight 2000g.
depends on an accurate assessment of the Assessed gestational age 36 weeks.
infant’s problems. If you cannot identify Active.
the problems, you will not be able to plan Skin temperature 36 °C.
the correct treatment. Assessing an infant’s RS Respiratory distress with
problems correctly takes a lot of practice. Once recession and a respiratory rate of
the assessment is made, it is very helpful to 65 breaths per minute. Infant needs
compile a problem list. 50% head box oxygen to remain pink.
CVS Heart rate 150/min.
GIT Abdomen normal.
3-48 What is a problem list? CNS Appears normal. Fontanelle flat.
Each clinical problem that you identify from the Blood glucose 3.0 mmol/l. PCV 60%.
story and observations must be listed separately.
A
A typical problem list looks like this:
1. Preterm delivery.
1. Unmarried, teenage mother. 2. Asphyxia.
2. Preterm delivery. 3. Respiratory distress.
3. Jaundice.
P
You now have a good idea of the clinical 1. Incubator.
problems that require management. 2. Neonatalyte IVI at 4 dpm.
3. Nasogastric tube. Nil per
mouth.
3-49 How should the plan of management 4. Routine observations.
be decided? 5. Head box oxygen.
6. Speak to parents.
Once the history, examination, investigations 7. Arrange transfer to level 2
and assessment have been completed, the hospital.
plan of management must be decided. The
management consists of the nursing care, the Signed: Sr. Mowtana
observations needed, the medical treatment,
and the management of the parents. It may These brief notes give all the important
be important to discuss the patient with the information in a simple and systematic
referral hospital and decide whether transfer manner. Try to write your notes using the
is needed. When deciding on the plan of SOAP method.
Assessing patient care The legal definition of stillbirth in South Africa

is an infant born dead after ‘6 months of intra-
uterine life’ (i.e. 28 weeks since the start of the
3-51 Why should patient care be assessed? last period or 1000 g, if the gestational age is
not known). Therefore, only legally defined
It is very important to regularly assess the stillborn infants require a stillbirth certificate
range of problems seen in a level 1 unit and and must be buried or cremated. However,
evaluate the standard of care provided. This is for the collection of information on perinatal
the best method of ensuring that the highest mortality, the international definition of
standard of practice is maintained. Usually stillbirth is used.
the low birth weight rate, stillbirth rate, early
neonatal mortality (death) rate and perinatal
3-55 What is the early neonatal mortality
mortality rate of each service are recorded.
rate?
Infants weighing less than 500 g (about 22
An early neonatal death occurs if a liveborn
weeks) at birth are regarded as miscarriages
infant dies during the first 7 days after delivery.
and, therefore, are not included in these rates.
Therefore, the early neonatal mortality rate is
Perinatal information (data) is usually divided
the number of infants that die in the first week
into 500 g categories.
of life per 1000 liveborn deliveries. A liveborn
infant is defined as an infant that shows any
3-52 What is the low birth weight rate? sign of life at birth (i.e. breathes or moves).
The low birth weight rate is the number of However, liveborn infants below 500 g at birth
liveborn infants weighing less than 2500 g are usually regarded as abortions. The early
at birth per 1000 liveborn deliveries. The neonatal mortality rate in a developed country
low birth weight rate is often expressed as a is usually about 5 per 1000. In a developing
percentage, e.g. 15%. country the early neonatal mortality rate is
usually more than 10 per 1000.
3-53 How many infants are born with a low
birth weight? 3-56 What is the perinatal mortality rate?
In a wealthy community about 5 % of infants The perinatal mortality rate is the number of
are low birth weight. However, in poor stillbirths plus the number of early neonatal
communities up to 40% of all infants may deaths per 1000 total deliveries (i.e. both
have a low birth weight. The percentage of stillborn and liveborn). The perinatal mortality
low birth weight infants in a community can rate is about the same as the stillbirth rate
be used to assess the socioeconomic status of plus the early neonatal mortality rate. Most
that community. developed countries have a perinatal mortality
rate of about 10/1000 while most developing
3-54 What is the stillbirth rate? countries have a perinatal mortality rate of
more than 30/1000.
The stillbirth rate is the number of stillborn
infants per 1000 total deliveries (i.e. liveborn Note that the low birth weight rate and early
and stillborn). The international definition of neonatal mortality rate are expressed per
stillbirth, used for collecting information on 1000 live births while the stillbirth rate and
perinatal mortality, is an infant that is born perinatal mortality rate are expressed per 1000
dead and weighs 500 g or more. In a developed total births (i.e. live births plus stillbirths).
country the stillbirth rate is about 5 per 1000.
In a developing country, however, the stillbirth
rate is usually more than 20 per 1000.
3-57 What is the value of knowing these 3-59 What is a perinatal mortality and
rates? morbidity meeting?
It is very important to know the low birth This is a regular meeting of staff to discuss
weight, stillbirth, neonatal and perinatal all stillbirths and early neonatal deaths at
mortality rates in your service as these rates that clinic or hospital. Clinic deaths must
reflect the living conditions, standard of include infants who died after transfer to a
health, and quality of perinatal health care level 2 or 3 hospital as the cause of death may
services in that region. It is far more important be the management received at the clinic.
to know the mortality rate for the region than Management problems with sick infants who
simply the rates for one clinic or hospital in survived can also be discussed.
the region.
Perinatal mortality meetings are held weekly
Increased low birth weight and stillbirth or monthly. The aim of a perinatal mortality
rates suggest a low standard of living with meeting is, not only to establish the cause
many socio-economic problems, such as of death, but also to identify problems in
undernutrition, poor maternal education, hard the service and, thereby, to improve the
physical activity, poor housing and low income management of mothers and infants. Care must
in the community. An increased early neonatal be taken to review the management so that
mortality rate, especially if the rate of low birth lessons can be learned rather than to use the
weight infants is not high, usually indicates meeting to blame individuals for poor care. The
poor perinatal health services. Both a poor disciplining of staff should be done privately
standard of living and poor health services will and never at a perinatal mortality meeting.
increase the perinatal mortality rate.
Avoidable factors should be looked for
whenever there is a stillbirth or neonatal
An increased low birth rate reflects poor socio- death. The avoidable factors may be divided
economic conditions while a high early neonatal into problems with:
mortality rate indicates poor perinatal health 1. The mother, e.g. failure to attend antenatal
services. clinic
2. The staff, e.g. the fetal heart was not
monitored during labour
3-58 What are the main causes of perinatal 3. The service, e.g. there was no transport
death?
Some causes of death are avoidable (e.g.
In a developing country, the main causes of hypothermia) while others are not avoidable
perinatal death are: (e.g. abruptio placentae). By identifying
1. Preterm labour avoidable factors plans can be made to
2. Abruptio placentae improve the perinatal care provided.
3. Syphilis
4. Fetal (intra-uterine) growth restriction 3-60 Should referred infants also be
5. Bacterial infection after delivery discussed?
Many of these causes are preventable with Every infant referred from a level 1 clinic
good perinatal care in level 1 hospitals and or hospital to a level 2 or 3 hospital must
clinics. It is essential that you determine the be recorded and reviewed. The infant’s
common causes of perinatal death in your weight, age and reason for referral must be
area. The avoidable causes of perinatal death known as well as the outcome at the referral
should then be identified and steps taken to hospital. The adequacy of resuscitation and
correct these causes. management before transfer is important.
Comment on the management and condition
of the infant on arrival at the referral hospital 5. Why is it important to identify this infant
is very useful. With this information, problems as being underweight for gestational age
with management and transport can be and wasted?
identified, protocols improved and plans made
Because it indicates that the infant is at
for appropriate training.
high risk of asphyxia, meconium aspiration,
It is very helpful if staff from the referral hypothermia and hypoglycaemia. The infant
hospital can be involved in perinatal mortality may also have organ damage due to the lack of
and morbidity meetings. oxygen before delivery (fetal hypoxia).
6. What is the probable cause of this infant

Case study 1 being underweight for gestational age?
The mother’s heavy smoking.
A female infant weighs 2200 g at birth. The
mother is unbooked and does not know the
date of her last menstrual period. She smokes
20 cigarettes a day. The infant has loose,
Case study 2
wrinkled, dry skin and scores at 40.5 weeks.
When plotted on a weight for gestational age A 5 day old term infant is bathed in a cold
chart, the infant falls below the 10th centile. ward. Afterwards the infant appears well but
feels cold. A reading in the axilla with a digital
thermometer gives a result of 34.5 ºC. The
1. What is the explanation for the
infant, who weighed 2400 g at birth and is
appearance of this infant’s skin?
clinically wasted, is rapidly warmed by placing
The loose, wrinkled, dry skin suggests wasting it next to a wall heater.
due to a poor supply of food to the fetus
during the last weeks of pregnancy. 1. What is your diagnosis?
Hypothermia because the infant’s axillary
2. Why was it important to score the
temperature was below 36.5 ºC.
gestational age of this infant?
Because the infant weighed less than 2500 g 2. Give probable reasons why this infant
and the patient did not know the duration of became hypothermic.
pregnancy.
The infant is underweight for gestational age
and wasted. This may cause hypothermia as
3. How would you classify this infant by
the infant has little fat. In addition the infant
gestational age alone?
probably became cold after the bath because of
The scored age of 40.5 weeks indicates that the the cold room.
infant was born at term.
3. What important complication may result
4. How would you classify this infant by from the hypothermia?
weight for gestational age?
Hypoglycaemia. A cold infant uses a lot of
This infant is underweight for gestational age energy in an attempt to keep warm. This may
as the birth weight falls below the 10th centile. use up the infant’s energy stores and result in
hypoglycaemia.
4. When should this infant be fed? 5. Do all hypoglycaemic infants present

with abnormal neurological signs?
This infant should be fed as soon as possible.
This will help to prevent hypoglycaemia. Feeds No. Often hypoglycaemia is asymptomatic and
will also provide the infant with energy to can only be diagnosed with blood screening.
produce heat.
5. How should the infant be kept warm Case study 4

during the next few days?
The infant should be dressed and given a A 1900 g, healthy preterm infant is born
woollen cap. If the room becomes cold at by normal vertex delivery after a 34 week
night, the infant can be kept warm with skin- gestation.
to-skin care in the mother’s bed.
1. What method should be used to feed this
infant?
Case study 3 Tube feeds should be started after delivery.
There is no indication to give intravenous
A preterm infant of 1700 g is born in a level fluids. In a week or two, when the infant starts
1 hospital. The infant is nursed in a closed to suck, breast or cup feeds can be introduced.
incubator but no feed is given for 2 hours.
At 1 hour after birth the Haemoglukotest 2. What type of feed would you choose?
reading with a Reflolux meter is normal but
at 2 hours after birth the reading indicates Breast milk should be used if possible. If this
hypoglycaemia. is not available, then a standard infant formula
(e.g. NAN 1) should be given.
1. What is the definition of hypoglycaemia?
3. What volume of feed will be needed on
A blood glucose concentration below 2 mmol/l. day 1?
60 ml/kg = 60 × 1.9 = 114 ml over 24 hours.
2. Why is this infant hypoglycaemic?
Thereafter the volume will be increased daily
The infant is preterm and, therefore, has little until 150 ml/kg is reached on day 5.
energy store. In addition, the infant has not
been fed for 2 hours after birth. The infant had 4. How often should feeds be given to this
energy stores to last 1 but not 2 hours. infant?
4 hourly (i.e. 6 feeds a day). Therefore, the
3. How could the hypoglycaemia have been
volume of each feed will be 114/6 = 19 ml.
prevented?
Breast or formula feeds should have been 5. What supplements does this infant need?
started within an hour of delivery.
A multivitamin liquid 0.6 ml daily should
be started on day 5, while iron drops 0.3 ml
4. Are 5% dextrose feeds better than milk
should be started when the infant feeds orally.
feeds at preventing hypoglycaemia?
Both should be continued for 6 months. The
No. Milk feeds contain more energy than 5% dose should be increased to 0.6 ml per day on
dextrose feeds. discharge.
Case study 5 early neonatal mortality rate was 25/1950 ×

1000 = 12.8 per 1000.
It is decided to determine the perinatal health
and care status of a region. Therefore, all 6. What is the expected early neonatal
the birth weights, together with the number mortality rate for a developing country?
of live births and perinatal deaths, in the Above 10/1000. Therefore, the rate of
hospitals, clinics and home deliveries in that 12.8/1000 is what you would expect in a
region are recorded for a year. Only infants developing country.
with a birth weight of 500 g or more are
included in the survey. Of the 2000 births, 6. What was the perinatal mortality rate for
50 infants were stillborn and 1950 were born this region?
alive. Of the live born infants, 25 infants died
in the first week of life. One hundred and There were 50 stillbirths and 25 early neonatal
twenty infants liveborn infants weighed less deaths with 2000 total deliveries. Therefore,
than 2500 g at birth. the perinatal mortality rate was 50 + 25/2000 ×
1000 = 37.5 per 1000.
1. Why were infants between 500 g and
1000 g not also excluded? 7. What is the low birth weight rate for this
region?
Because some of these infants may live if they
are given emergency management and then Of the 1950 infants born alive during the
transferred to a level 2 or 3 hospital. Therefore, year, 120 weighed less than 2500 g at delivery.
all infants with a birth weight of 500 g or more Therefore, the low birth weight rate was
must be included in a perinatal survey. 120/1950 × 1000 = 61.5 per 1000 or 6.15%.
2. What was the stillbirth rate for this 8. Is the low birth weight rate typical of a
region? developing country?
There were 50 stillbirths and 2000 total births. No. Most developing countries have a low
Therefore, the stillbirth rate was 50/2000 × birth weight rate of more than 100/1000 or
1000 = 25 per 1000. 10%.
3. Is this stillbirth rate typical of a 9. How do you interpret the finding of a

developed or developing country? high perinatal mortality rate with a low
birth weight rate of only 6.15%?
It is typical of a developing country, which
usually has a stillbirth rate above 20/1000. In It suggests that the living conditions of the
contrast, a developed country usually has a mothers in the study region are satisfactory
stillbirth rate of about 5/1000. but the perinatal services are poor. Every
effort must be made, therefore, to improve
4. What was the early neonatal mortality these services.
rate?
Of the 1950 infants who were born alive, 25
died during the first week of life. Therefore, the
4
Emergency
management
of infants
The management of
Objectives
hypothermia
When you have completed this unit you
should be able to: 4-3 How do you measure an infant’s
• Manage hypothermia. temperature?
• Manage hypoglycaemia.
• Manage respiratory distress. An infant’s skin temperature, rather than its
• Use oxygen correctly. oral or rectal temperature, is usually used. The
• Transfer an infant. axillary or abdominal skin temperature should
be measured.
4-1 What is the emergency management of Skin temperature can be measured with either:
a newborn infant?
1. A low reading mercury thermometer.
Some newborn infants develop serious The thermometer is placed in the infant’s
problems which often cannot be managed in axilla (armpit) for 2 minutes before the
a level 1 clinic or hospital where only primary reading is taken. Thermometer should be
care is available. These infants need to be stored dry when not in use to prevent cross
carefully assessed and stabilised before they infection. Make sure it is a low reading
can be moved to a level 2 (special care unit) thermometer.
or level 3 (intensive care unit) hospital that 2. A telethermometer. This is an electrical
has the staff and facilities to provide the care thermometer. The probe is placed on
needed. Emergency management is the care the skin over the left, lower abdomen or
that must be given to these infants in a level 1 the lower back. Avoid the right, upper
hospital or clinic before they are transferred. abdomen as the liver produces a lot of heat
Staff working in level 1 hospitals and clinics and this may give too high a reading.
must be able to give emergency care.
4-4 What is the normal range of body
temperature?
4-2 Which infants need emergency
management? This depends on the site where the temperature
is measured:
1. Infants with hypothermia.
2. Infants with hypoglycaemia. 1. The normal axillary temperature is 36.5–
3. Infants with respiratory distress. 37 ºC.
2. The normal abdominal skin temperature is 3. Haemorrhage. When infants are very cold
36–36.5 ºC. their blood does not clot normally and
they commonly bleed.
4-5 What is hypothermia?
Hypothermia (low body temperature) is defined Hypothermic infants may die of hypoglycaemia.
as an axillary temperature below 36.5 ºC or an
abdominal skin temperature below 36 ºC.
4-9 How do you treat hypothermia?
4-6 Which infants are at high risk of 1. Warm the infant in a closed incubator,
hypothermia? overhead radiant warmer or warm room.
1. Infants who are not dried well after birth The incubator temperature should be set
2. Infants in a cold room or cool incubator at 37 ºC until the skin temperature returns
3. Low birth weight infants to normal. If these are not available, place
4. Infants lying near cold windows the infant naked against the mother’s skin
5. Infants who are not fed and wrap both in a blanket to give skin-
to-skin care.
2. Provide energy while the infant is being
4-7 How do you recognise an infant with
warmed. Hypoglycaemia may occur
hypothermia?
during warming. Energy can be given as
Hypothermic infants present with the oral or nasogastric milk, or intravenous
following signs: maintenance fluid containing 10% dextrose
water (e.g. Neonatalyte).
1. They are cold to the touch.
3. Provide oxygen. Give 30% oxygen by
2. They are lethargic, hypotonic, feed poorly
headbox while the infant is being warmed,
and have a feeble cry.
even if the infant is pink.
3. Their hands and feet are usually pale or
4. Notify the referral level 1 or 2 unit as this
blue, but their tongue and cheeks are often
infant may need to be transported. Discuss
pink. The pink cheeks may incorrectly
the management of the infant with the staff
suggest that the infant is well.
of the referral hospital.
4. Peripheral oedema or sclerema (a woody
5. Observations. Monitor and record the
or plastic feel to the skin).
infant’s temperature, pulse, respiration, skin
5. Shallow, slow respiration or signs of
colour and blood glucose concentration
respiratory distress.
until they are normal and stable.
6. Bleeding from the mouth, nose or needle
6. Keep the infant warm once a normal body
punctures.
temperature is reached. It is very important
to keep the infant warm during transport.
4-8 What problems are common in
hypothermic infants?
4-10 How should you keep an infant warm
1. Hypoglycaemia. This is a common cause during transport?
of death in cold infants and the most
Infants should be kept warm during transport
important complication of hypothermia.
by nursing them in a transport incubator or
Cold infants use a lot of energy in an
keeping them warm by skin-to-skin care. If
attempt to warm themselves. As a result
the mother cannot be moved, a nurse, doctor
they use up all their energy stores, resulting
or ambulance attendant can give skin-to-skin
in hypoglycaemia.
care. Warm infants can also be dressed and
2. Hypoxia. The infant’s haemoglobin does
then wrapped in a silver swaddler or tin foil.
not carry oxygen normally when the red
The infant must be warm before transport.
blood cells are very cold.
emergenc y management of infants 63
The management of signs. Severe hypoglycaemia is defined as a

blood glucose concentration of less than 1.5
hypoglycaemia mmol/l or hypoglycaemia with abnormal
neurological signs.
4-11 What is glucose?
Hypoglycaemia is defined as a blood glucose
Glucose is an important type of sugar. Many
concentration below 2.0 mmol/l.
forms of food (e.g. milk formula) contain
glucose. Infants also get glucose from lactose
in breast milk and from the breakdown of
4-15 What are the dangers of
starch when solids are added to the diet.
hypoglycaemia?
Glucose is an essential source of energy to
many cells of the body, especially the brain. Hypoglycaemia is extremely dangerous,
Glucose is stored as glycogen in the liver. especially when the blood glucose
Glucose can also be stored as fat and protein. concentration is below 1.5 mmol/l and the
The liver can change stores of glycogen, fat and infant has abnormal neurological signs. When
protein back into glucose. the blood glucose concentration is low the
cells of the body, particularly the brain, do not
The amount of glucose available to the cells can
receive enough glucose and as a result cannot
be assessed by measuring the concentration of
produce energy for their metabolism. With
glucose in the blood.
severe hypoglycaemia the brain cells can be
damaged or die, causing cerebral palsy, mental
4-12 How is blood glucose measured in the retardation or death. Mild hypoglycaemia is
nursery? important as it may rapidly progress to severe
The quickest, cheapest and easiest method to hypoglycaemia. Every effort must , therefore,
measure the blood glucose concentration in be made to treat mild hypoglycaemia
the nursery is to use a reagent strip such as promptly.
Haemoglukotest, Glucotrend or Dextrostix.
However, a far more accurate method to screen Hypoglycaemia may cause brain damage.
for hypoglycaemia is to read the colour of
the reagent strip with a glucose meter such as
reading Haemoglukotest strips with a Reflolux 4-16 Which infants are at risk of developing
meter. It is important to carefully read the hypoglycaemia?
instructions which are packed with the reagent Infants that have reduced energy stores,
strips as the correct method must be used. reduced energy intake (feed poorly) or
increased energy needs are at risk of
4-13 What is the normal concentration of hypoglycaemia.
glucose in the blood?
The normal concentration of glucose in the Hypothermia causes hypoglycaemia.
blood of newborn infants is 2.0 mmol/l to
7.0 mmol/l.
4-17 What are the clinical signs of
4-14 What is hypoglycaemia? hypoglycaemia?
Hypoglycaemia is defined as a blood glucose Hypoglycaemia may produce no clinical signs
concentration below 2.0 mmol/l. Mild or present with only non-specific signs. This
hypoglycaemia is defined as a blood glucose makes the clinical diagnosis of hypoglycaemia
concentration between 1.5 to 2.0 mmol/l in very difficult. When present, the clinical signs
an infant without any abnormal neurological of hypoglycaemia are:
1. The infant may be lethargic and hypotonic, 4. Whenever possible, milk feeds should be
feed poorly, have a weak cry, apnoea, given. Both clear feeds and dextrose feeds
cyanosis or an absent Moro reflex. should not be used in newborn infants as
2. The infant may be jittery with a high they are low in energy and may result in
pitched cry, a fixed stare and fisting, have hypoglycaemia.
abnormal eye movements or convulsions. 5. If milk feeds cannot be given, then an
3. Excessive sweating. This sign may not be intravenous infusion of 10% glucose (e.g.
present, however, especially in preterm Neonatalyte) should be started.
infants. 6. Prevent hypothermia.
Often an infant has both signs of decreased With a policy of breast feeding as soon
brain function, such as lethargy and poor as possible after delivery, most cases of
feeding, as well as signs of excessive brain hypoglycaemia can be prevented.
function, such as jitteriness and convulsions.
The clinical presentation of hypoglycaemia
is very variable which makes the clinical
Early breast feeding can usually prevent
diagnosis of hypoglycaemia difficult. hypoglycaemia.
Therefore, the diagnosis of hypoglycaemia can
be easily missed.
4-20 How should you treat an infant with
mild hypoglycaemia?
Hypoglycaemic infants may have no abnormal
Infants with a blood glucose concentration
clinical signs. between 1.5 mmol/l and 2.0 mmol/l and
no clinical signs of hypoglycaemia usually
need milk feeds urgently to prevent severe
4-18 How can you diagnose
hypoglycaemia:
hypoglycaemia?
1. If they tolerate oral or nasogastric feeds,
As the clinical diagnosis is difficult and often
give 10 ml/kg breast milk or milk formula
missed, it is essential that all infants at risk
immediately. Do not give 5% or 10%
of hypoglycaemia, and infants with clinical
dextrose orally as the energy content is less
signs that may be caused by hypoglycaemia,
than that of breast milk or milk formula.
be screened with reagent strips. Whenever
2. Repeat the reagent strip reading 30 minutes
possible, use a glucose meter rather than
after the feed to determine whether the
reading the reagent strip by eye. Ideally a
blood glucose concentration has returned
diagnosis of hypoglycaemia made with reagent
to the normal range. If it is still in the
strips should be confirmed with a laboratory
mild hypoglycaemia range, repeat the feed
blood glucose measurement.
with an added 5 g sugar (1 teaspoon) per
30 ml milk and repeat the reagent strip
4-19 How can you prevent hypoglycaemia? measurement after another 30 minutes.
Every effort must be taken to prevent 3. When the blood glucose concentration has
hypoglycaemia by: returned to normal, continue with regular
milk feeds and continue to monitor with
1. Identifying all infants at high risk of reagent strips hourly for 3 hours.
developing hypoglycaemia. 4. If the blood glucose concentration falls
2. Monitoring the blood glucose concentration below 1.5 mmol/l then treat as for severe
of these infants with reagent strips. hypoglycaemia.
3. Feeding all infants as soon as possible after 5. If the infant is too small or too ill to
delivery, especially low birth weight infants tolerate milk feeds, start an intravenous
and infants of diabetic women. infusion of 10% glucose (e.g. Neonatalyte)
and transfer to a level 2 or 3 hospital.
Most infants with mild hypoglycaemia respond 6. Keep the infant warm.
well to milk feeds and do not need to be 7. The infant now needs to be referred
transferred. Establish breast feeding as soon as urgently to the referral hospital. It is very
possible to prevent hypoglycaemia recurring. important that the infant’s blood glucose
remains normal during transport.
4-21 How should you treat an infant with
4-22 How frequently should you measure
severe hypoglycaemia?
the blood glucose concentration?
All infants with a blood glucose concentration
1. In most infants at high risk of
below 1.5 mmol/l, or hypoglycaemia
hypoglycaemia, the blood glucose
with abnormal clinical signs, have severe
concentration should be measured hourly
hypoglycaemia. This is a medical emergency
with reagent strips for the first 3 hours,
and must be treated immediately. The
then 3 hourly until 100 ml/kg/day milk
management of severe hypoglycaemia consists
feeds have been established which is
of the following steps:
usually in 24 to 48 hours.
1. The treatment of choice is to start an 2. Infants with mild hypoglycaemia should
intravenous infusion of 10% glucose (e.g. be monitored every 30 minutes until the
Neonatalyte) at a drip rate calculated to blood glucose concentration has returned
give 100 ml/kg in the first 24 hours. Give a to the normal range. Readings should then
bolus of 2 ml/kg of the 10% glucose over 5 be made hourly for 3 hours to ensure that
minutes at the start of the infusion. the blood glucose concentration does not
2. If you cannot rapidly put up a peripheral fall again. Thereafter, measure the blood
intravenous line, insert an umbilical vein glucose concentration 3 hourly until milk
catheter. feeds are established.
3. Repeat the reagent strip measurement 3. Infants with severe hypoglycaemia should
after 15 minutes. If the blood glucose have their blood glucose concentration
concentration has not returned to normal, measured every 15 minutes until it has
dilute 5 ml of 50% dextrose with 5 ml of increased above 1.5 mmol/l. Then measure
the 10% dextrose infusion fluid to give a the blood glucose concentration hourly
30% glucose solution. Inject 5 ml of this until the infant arrives at the referral unit.
30% glucose solution over 5 minutes into
the plastic bulb of the infusion set. It is not 4-23 What is the prognosis after
advisable to inject 50% dextrose, as it is hypoglycaemia?
extremely hypertonic.
4. If the blood glucose concentration still has The risk of brain damage depends on
not returned to normal within a further 15 the severity, duration and number of
minutes phone your referral hospital. They hypoglycaemic attacks. The prognosis is worst
may ask you to give 5 mg hydrocortisone if the hypoglycaemia has produced clinical
intravenously or glucagon 0.3 mg/kg signs, especially convulsions.
intramuscularly.
5. In an emergency, if you are unable to give
intravenous dextrose, give the infant 10 Management of
ml/kg breast milk or formula (or sweetened respiratory distress
cow’s milk if neither is available) by mouth
or via a nasogastric tube. You can add 5 g (a
teaspoon) of sugar or 5 ml of 50% dextrose 4-24 What is respiratory distress?
per 10 ml feed to increase the glucose
concentration. Do not give pure 50% Respiratory distress is a collection of clinical
dextrose orally, as it will cause vomiting. signs, which indicate that the infant has
difficulty breathing. The 4 most important infant is unable to expand them again during
clinical signs of respiratory distress are: inspiration. Collapsed alveoli, due to the lack
of surfactant, result in respiratory distress.
1. Tachypnoea. A respiratory (breathing) rate
This condition is known as hyaline membrane
of 60 or more breaths per minute (normal
disease (HMD).
respiratory rate is about 40).
2. Central cyanosis. A blue tongue in room
air. Hyaline membrane disease is caused by too little
3. Recession. The in-drawing of the ribs and surfactant in immature lungs.
sternum during inspiration (also called
retraction).
4. Grunting. A snoring noise made in the 4-27 What is the shake test?
throat during expiration.
The amount of surfactant in the fetal lung can
If an infant has central cyanosis plus 1 or more be determined after birth by doing a shake test
of the above clinical signs, the infant is said to on a sample of gastric aspirate obtained within
have respiratory distress. 30 minutes after delivery. A positive shake test
indicates that adequate surfactant is present
4-25 What are the important causes of in the lungs of the newborn infant. A negative
respiratory distress? test indicates inadequate surfactant and
strongly suggests that the infant has hyaline
Respiratory distress in newborn infants
membrane disease.
is usually caused by one of the following
conditions: It is important to pass a nasogastric tube and
aspirate the stomach of all preterm infants
1. Hyaline membrane disease
soon after birth. The sample should be sent
2. Wet lung syndrome
in a syringe or test tube with the infant when
3. Meconium aspiration
it is referred to a level 2 or 3 unit so that the
4. Pneumonia
shake test can be done at the referral hospital.
Other less common causes of respiratory The result is very useful in managing an infant
distress include hypothermia and anaemia. with respiratory distress.
The gastric aspirate can also be used to help
There are many different causes of respiratory diagnose congenital pneumonia when pus
distress. cells and bacteria can often be seen under the
microscope.
4-26 What is hyaline membrane disease 4-28 How do you diagnose hyaline
(HMD)? membrane disease?
At term the fetal lungs are mature and ready to 1. The infant is preterm.
be filled with air after delivery. The alveoli (air 2. The infant develops respiratory distress at or
sacs) of these mature lungs secrete a substance soon after delivery. The signs of respiratory
called surfactant that prevents them collapsing distress gradually become worse.
at the end of expiration. This allows the 3. The infant usually moves very little and
infant to breathe air in and out with very little commonly develops peripheral oedema.
physical effort. 4. The shake test on gastric aspirate is
negative indicating inadequate surfactant.
In contrast, many preterm infants have
immature lungs, which do not have adequate
amounts of surfactant at birth. As a result
the alveoli collapse with expiration and the
4-29 What is the clinical course in hyaline 4. The shake test on the gastric aspirate
membrane disease? is positive, which excludes hyaline
membrane disease.
The degree of respiratory distress gets worse
during the first 48 hours after birth and the
concentration of inspired oxygen, needed to The wet lung syndrome is the commonest cause
keep the infant pink, increases for the first 2 to of respiratory distress.
3 days (48 to 72 hours). During this time some
infants will die of hyaline membrane disease.
Otherwise the respiratory distress starts to 4-32 What is the clinical course of the wet
improve. As the respiratory distress can be lung syndrome?
expected to get worse during the first few days,
The respiratory distress in infants with the wet
it is important the infant be transferred to a
lung syndrome gradually improves during the
level 2 or 3 unit as soon as possible.
first 24 hours and usually recovers by 72 hours.
Oxygen is needed for a few hours to 3 days
Hyaline membrane disease gets worse before it only. Usually less than 40% oxygen is required.
gets better. The clinical course of the wet lung syndrome,
therefore, is very different from that of hyaline
membrane disease.
4-30 What is the wet lung syndrome?
Before delivery the fetal lungs are not The wet lung syndrome is important because it
collapsed but filled with lung fluid. At vaginal can be confused with hyaline membrane disease.
delivery, most of this fluid is squeezed out of
the lungs as the chest is compressed in the
birth canal. After birth the remaining fluid 4-33 What is the meconium aspiration
is coughed up or is absorbed within a few syndrome?
minutes. In some infants this rapid removal
If the fetus is hypoxic in utero it may become
of fetal lung fluid does not take place resulting
distressed, pass meconium, and make gasping
in the wet lung syndrome which presents
movements, which suck the meconium
after delivery as respiratory distress. The
stained liquor into the larynx and trachea. If
wet lung syndrome is the commonest cause
the airways are not well suctioned after the
of respiratory distress. It is also important
infant’s head is delivered, the meconium can
because during the first day of life it can easily
be inhaled into the smaller airways and alveoli
be confused with hyaline membrane disease.
with the onset of breathing. This results in the
The wet lung syndrome is usually seen in meconium aspiration syndrome. Many cases
term infants, especially after fetal distress, of severe meconium aspiration syndrome
maternal sedation, caesarean section and can be prevented by carefully suctioning the
polyhydramnios. In these infants the normal upper airways of meconium stained infants
clearance of lung fluid is often delayed before they breathe at birth. The risk of the
for many hours resulting in the wet lung meconium aspiration syndrome is particularly
syndrome. high if the meconium is very thick.
4-31 How can you diagnose the wet lung

The airways of all meconium stained infants
syndrome?
should be well suctioned before delivering the
1. These infants are usually born at term. shoulders.
2. They develop respiratory distress from
delivery.
3. They have a typical clinical course.
4-34 How do you diagnose the meconium 1. Keep the infant warm, preferably in an
aspiration syndrome? incubator.
2. Handle the infant as little as possible,
1. The infant is usually born at term or post
because stimulating the infant often
term but only rarely preterm.
increases the oxygen requirements. There
2. The liquor is meconium stained.
is no need to routinely suction the airways.
3. Meconium may be suctioned from the
3. Provide energy, to prevent hypoglycaemia.
mouth and upper airways at birth and the
Preferably give an infusion of 10%
infant is usually meconium stained.
glucose (e.g. Neonatalyte). Milk feeds by
4. Respiratory distress is present and the
nasogastric tube can be given to infants
chest usually appears hyperinflated (over
with mild respiratory distress.
expanded).
4. Treat central cyanosis by giving oxygen.
Give oxygen therapy correctly.
4-35 What is the clinical course of the 5. Record the following important
meconium aspiration syndrome? observations every hour and note any
From birth the meconium stained infant has deterioration:
respiratory distress which, in severe cases, • respiratory rate
gets progressively worse and may kill the • presence or absence of recession and
infant. Milder cases will gradually recover grunting
over days or weeks. Infants who survive severe • presence or absence of cyanosis
meconium aspiration often have damaged • percentage of oxygen given
lungs that may take months to recover. • heart rate
• both the skin and incubator
4-36 What are the common causes of temperature
pneumonia? 6. Consult the staff of the nearest level 2 or
3 hospital, as the infant may need to be
An infant may be born with pneumonia transferred. This is particularly important
(congenital pneumonia) as a complication in hyaline membrane disease where early
of chorioamnionitis. Other infants may transport is best. A chest X ray at the
develop pneumonia in the days or weeks after referral hospital will help decide the cause
delivery, due to the spread of bacteria in a of the respiratory distress.
nursery. Preterm infants are at an increased 7. If the infant develops recurrent apnoea, or
risk of pneumonia. if oxygen fails to keep the infant pink, then
mask and bag ventilation should be started.
4-37 How can you diagnose pneumonia? 8. Parenteral antibiotics must be given
if pneumonia is diagnosed. Either
1. The infant develops signs of respiratory
ceftriaxone 50mg/kg daily by IM or IV
distress and also appears clinically ill.
injection or a combination of daily benzyl
2. The diagnosis of congenital pneumonia
penicillin 50 000 units/kg/day IV plus
complicating chorioamnionitis is suggested
gentamicin 7.5 mg/kg IM daily.
by seeing pus cells and bacteria in a Gram
9. Unfortunately there is no specific
stain of the gastric aspirate after delivery.
treatment for the infant with respiratory
distress caused by meconium aspiration.
4-38 How should you manage an infant 10. Transfer is not as urgent in infants with
with respiratory distress? wet lung syndrome as they usually improve
The principles of care are the same, irrespective after the first few hours and rarely need
of the cause of the respiratory distress. more than 40% oxygen.
Therefore, all infants with respiratory distress 11. Infants who do not need to be transferred
should receive the same general management: should be nursed in an incubator and
given oxygen as required. Three hourly
feeds by nasogastric tube, rather than an 4-41 How much oxygen is needed by the
intravenous infusion, can usually be given normal infant?
to these infants.
The normal oxygen saturation in a newborn
infant is 86 to 92%. This indicates that the
infant is breathing the correct amount of
The correct use of oxygen. If the saturation is less than 86% the
oxygen therapy infant is not getting enough oxygen while a
saturation above 92% indicates that the infant
may be getting too much oxygen. A saturation
4-39 Why does the body need oxygen? monitor is very useful to assess whether a
newborn infant with respiratory distress is
Oxygen is needed by all the cells of the body.
getting the correct amount of oxygen.
Without enough oxygen the cells, especially
of the brain, will be damaged or die. However,
too much oxygen is also dangerous and can The normal saturation of oxygen in the blood is
damage cells. In the body, oxygen is carried 86 to 92%.
by red blood cells from the lungs to all the
other organs. When loaded with oxygen the
red blood cells are red in colour. With too little 4-42 When does an infant need extra
oxygen they are blue. oxygen?
An infant needs extra oxygen if it becomes
Too little oxygen can cause brain damage. centrally cyanosed or if the saturation of
oxygen falls below 86%.
4-40 How do you measure the amount of 4-43 Can you give too much oxygen?
oxygen in the blood?
Yes. If too much oxygen is given the oxygen
1. This can be roughly assessed clinically saturation will rise above 92%. Preterm infants,
as the infant appears peripherally and especially infants below 34 weeks gestation, are
centrally cyanosed if there is not enough at risk of oxygen damage to the eyes (known
oxygen in the red cells. This clinical as retinopathy of prematurity) if excessive
method may be inaccurate and should, amounts of oxygen are given. The damage to
whenever possible, be confirmed by the retina is done by too much oxygen in the
measuring the oxygen saturation. blood and not due to the direct effect on the
2. At the bedside the oxygen saturation can infant’s eyes of oxygen in the headbox.
be measured with a saturation monitor (i.e.
pulse oximeter), which simply clips onto At resuscitation it is probably safe to use
the infant’s hand or foot and measures the oxygen for a short period only until the infant
oxygen saturation through the skin. The is pink and breathing well.
oxygen saturation is given as a percentage.
It indicates the amount of oxygen being Too much oxygen is dangerous as it may cause
carried by the red cells. blindness.
3. In a laboratory the amount of oxygen in
the blood can also be measured accurately
in a sample of arterial blood. 4-44 When should you give an infant extra
oxygen?
1. During resuscitation if the infant does not
respond rapidly to mask ventilation with
room air
2. When there is respiratory distress The amount of oxygen being given in a

3. When the infant has central cyanosis headbox can be measured with an oxygen
4. When the oxygen saturation is less than monitor. The probe of the oxygen monitor is
86% placed in the headbox and the display on the
monitor box shows the amount of oxygen that
4-45 Which infants do not need extra the infant is breathing.
oxygen?
4-48 How much oxygen should you give?
1. Infants with normal Apgar scores at birth
2. Infants with peripheral but not central The percentage of oxygen given in the headbox
cyanosis. If there is peripheral cyanosis should be increased until:
only, the cause is usually cold hands and
1. Central cyanosis is corrected (the tongue
feet with poor perfusion, rather than
is pink).
hypoxia.
2. The oxygen saturation is 86–92%.
3. Preterm infants with a normal oxygen
saturations The required percentage of oxygen given to
keep different infants pink may vary from 21
4-46 What methods can you use to to 100%. For example, an infant with severe
administer oxygen? hyaline membrane disease may need 90%
oxygen while another infant with mild wet
1. Oxygen is most commonly given into a lung syndrome may need only 25% to achieve a
perspex head box. This is the best method normal oxygen saturation. Do not confuse the
of administering oxygen in a level 1 unit, percentage of oxygen given in a headbox with
as it is a simple, cheap and highly effective the oxygen saturation in the infant’s blood.
method.
2. At resuscitation oxygen is given via a mask
4-49 How can you control the amount of
and bag.
oxygen given?
3. In a level 2 or 3 unit, oxygen is sometimes
given via nasal prongs to infants with As there are dangers in giving too much or
respiratory distress syndrome. Other infants too little oxygen, it is important to give oxygen
may need to be intubated and ventilated. correctly.
Oxygen should not be given directly into a In a level 1 hospital or clinic, oxygen is usually
closed incubator as this method is wasteful, given by headbox. Whenever possible, an
high concentrations cannot be reached and air/oxygen blender should be used so that
the concentration of oxygen drops every time the percentage of oxygen in the headbox can
an incubator port is opened. Giving 100% be accurately controlled. If a blender is not
oxygen via a cardboard cup is extremely available, a venturi can be used. The venturi
dangerous, especially if used for a long time, is a plastic gauge, which controls the amount
as it is almost impossible to control the of air and oxygen being mixed. Some venturis
percentage of oxygen accurately. mix pure oxygen with room air to give any
required percentage of oxygen while others
4-47 How can you measure the amount of only give a fixed percentage.
extra oxygen given? Whenever possible, an oxygen monitor should
There is 21% oxygen in room air. Piped oxygen be used to accurately measure the percentage
or oxygen from cylinders provides 100%. of oxygen in the headbox. It is very dangerous
More and more oxygen can be added to room to attempt to control the percentage of oxygen
air until 100% oxygen is reached. It is very given into a head box by simply altering the
important to know how much extra oxygen flow rate.
the infant is receiving.
Always give headbox oxygen via a blender or 4-53 What is the aim of care during
transfer?
venturi.
The aim is to keep the infant in the best
possible clinical condition while it is being
4-50 Should you humidify oxygen? moved from the clinic to the hospital. This is
achieved by providing the following:
Yes. Oxygen should always be humidified, as
oxygen from a cylinder is very dry. Dry oxygen 1. A warm environment
irritates the airways. Usually it is not needed to 2. An adequate supply of oxygen
warm oxygen if it is given by a headbox. 3. A source of energy
4. Careful observations
4-51 What flow rate of oxygen should you This greatly increases the infant’s chance of
use? survival without brain damage.
When oxygen is given into a headbox, either
directly or via a blender or venturi, the flow 4-54 Which infants should be transferred to
should be 5 litres per minute. A high flow rate a level 2 or 3 hospital?
wastes oxygen and cools the infant.
All infants that need management, which
cannot be provided at a level 1 hospital or
clinic, must be referred to the nearest level
Transferring a 2 hospital with a special care unit or a level
newborn infant 3 hospital with an intensive care unit. The
following infants should be transferred:
1. Preterm infants, especially infants less than
4-52 Why should newborn infants be
36 weeks gestation
transferred?
2. Infants with a birth weight under 1800 g.
If pregnant women are correctly categorised Most infants between 1800 g and 2500 g
into low risk and high risk groups during do not need to be referred and can be sent
pregnancy and labour, low risk infants can home.
be delivered at level 1 hospitals and clinics 3. Infants with asphyxia that require
with the necessary staff and equipment to ventilation during resuscitation
care for them. However, when maternal 4. Infants who need emergency management
categorisation is incorrect, when unexpected for hypothermia, hypoglycaemia or
problems present during or after delivery, or respiratory distress
when a mother with a complicated pregnancy 5. Infants with problems such as severe
or labour arrives in advanced labour at a level infection, marked jaundice, trauma or
1 hospital or clinic, then the infant may need bleeding
to be transferred to a hospital with a level 2 6. Infants with major congenital abnormalities,
or 3 unit. especially if urgent surgery is needed
If possible, it is better for the infant to be Any infant needing possible referral must
transferred before delivery than after birth. The first be discussed with the staff at the referral
mother is the best incubator during transfer. hospital. Each region should establish its own
referral criteria so that the staff knows which
infants need to be transferred.
It is better to transfer the mother before delivery
than to transfer the infant after birth.
Each region must draw up its own referral criteria.
4-55 Why should the infant be resuscitated 3. Hypoxia: It is essential that infants receive
and stabilized before being transreffed? oxygen during transfer if this is needed.
All the equipment required for the safe
It is very important that the infant is fully
administration of oxygen should be
resuscitated and stabilised before being
available. Infants who do not need extra
transferred. The infant must be warm, well
oxygen must not be given oxygen routinely
oxygenated and given a supply of energy
while being transferred. Some infants
before being moved. Transferring a collapsed
with respiratory distress or apnoea need
infant will often kill the infant. The clinic staff
ventilation during transfer.
and the transfer personnel should together
assess the infant and ensure that the infant is
in the best possible condition to be moved. 4-58 Who should transfer a sick infant?
Vehicles to transfer infants must be provided
4-56 How should the transfer be arranged? by the local authority in each region. Ideally
an ambulance should be used. If possible,
If possible, the hospital staff that will
ambulance personnel should be trained to care
receive the infant should make the transfer
for infants during transfer. When this service
arrangements. The hospital staff can then
is not available, the referral hospital should
advise on management during transfer and be
provide nursing or medical staff to care for
ready to receive the infant in the nursery. The
the infant while it is being moved from the
unexpected arrival of an infant at the hospital
clinic to the hospital. A transport incubator,
must be avoided. The clinical notes and a
oxygen supply and emergency box of essential
referral letter must be sent with the infant.
resuscitation equipment should always be
A sample of gastric aspirate, collected soon
available at the referral hospital for use in
after delivery for microscopy and the shake
transferring newborn infants. Only as a last
test, is very helpful, especially in preterm
resort should the clinic provide a vehicle and
infants, infants with respiratory distress and
staff to transfer a sick infant to hospital.
infants with suspected congenital pneumonia.
Consent for surgery should also be sent if a
surgical problem is diagnosed. 4-59 Should the mother also be transferred
to hospital?
4-57 What are the greatest dangers during Yes, whenever possible, the mother should be
transfer? transferred to hospital with her infant.
1. Hypothermia: Infants must be kept warm
during transfer and their skin temperature
should be regularly measured. A transport Case study 1
incubator is the best way to keep the body
temperature normal. If an incubator is not A 1500 g infant is brought to an outlying clinic
available, hypothermia can be prevented on a cold winters day. The mother delivered 30
by using skin-to-skin care or by dressing minutes before and has remained at home. The
the infant and then wrapping the infant in infant’s axillary temperature is 34.5 ºC but the
a silver swaddler (space blanket) or heavy infant appears active. The clinic does not have
gauge tin foil. an incubator.
2. Hypoglycaemia: Some supply of energy
must be provided during transfer. Either 1. What error was made in the management
milk feeds or intravenous fluids should be of this infant?
given. The blood glucose concentration
The infant should have been kept warm. Skin-
should be regularly measured with
to-skin care is very effective in keeping an
reagent strips.
infant warm after delivery. An infant should 3. Why does this term infant have a low
never be allowed to get cold after delivery. blood glucose concentration?
Because the infant is cold. Hypothermic
2. How can you warm this infant in the infants often become hypoglycaemic as they
clinic? rapidly use up all their energy stores such as
You can use an incubator or a warm room to glycogen and fat. In addition this infant is
correct the infant’s temperature. The staff can wasted and, therefore, was born with reduced
also give skin-to-skin care themselves. energy stores.
3. When should the infant be moved to 4. What are the clinical signs of
hospital? hypoglycaemia?
If possible, it is best to warm the infant first Often there are no clinical signs. Severe
before moving it to hospital. hypoglycaemia may cause neurological signs
such as lethargy, decreased tone, poor feeding,
4. How can the infant be kept warm in the a weak cry, absent Moro, jitteriness and
ambulance? convulsions.
If possible, a transport incubator should be 5. How would you treat this infant at the
used. If this is not available, use skin-to-skin clinic?
care. Otherwise, the infant should be warmly
dressed and wrapped in a blanket. A thermal Give the infant a feed of breast milk or
blanket (or aluminium foil) can also be used. formula. If neither is available, sweetened
Remember that the infant must be warmed cow’s milk may be used. The infant must also
before it is placed in a thermal blanket. be warmed. The blood glucose concentration
should have returned to normal in 15 minutes.
If not, repeat the feed and arrange urgent
Case study 2 transport to the nearest hospital. If the infant
develops severe hypoglycaemia an infusion
10% dextrose (e.g. Neonatalyte) must be
A term infant is brought to a rural clinic after
started. It is very important to start treatment
having been born at home. The infant is cold
before referring the infant to hospital.
and wasted but otherwise appears well. A
Haemoglukotest reagent strip, read by naked
eye, gives a reading between 1.5 and 2 mmol/l.
Case study 3
1. What is your interpretation of the blood
glucose concentration? A male infant is born at 32 weeks gestation
in a level 1 hospital. Soon after delivery his
The infant has mild hypoglycaemia. respiratory rate is 80 breaths per minute with
recession and expiratory grunting. The infant’s
2. What is the danger of mild tongue is blue in room air. A gastric aspirate is
hypoglycaemia? collected 10 minutes after delivery.
The infant is at high risk of developing severe
hypoglycaemia. 1. Which clinical signs indicate that the
infant has respiratory distress?
Tachypnoea, recession, grunting and central
cyanosis in room air.
2. What is the probable cause of the Case study 4

respiratory distress?
The infant probably has hyaline membrane A 3 day old, term infant has pneumonia in a
disease due to immature lungs. Hyaline level 1 hospital and is nursed in an incubator.
membrane disease is common in infants born The infant is cyanosed in room air and needs
preterm. oxygen therapy.
3. What is the value of collecting a sample 1. What equipment should be used to

of gastric aspirate? administer the oxygen?
Diagnosing the cause of the respiratory The best method to give this infant oxygen
distress is often helped if a sample of gastric would be a perspex head box. Giving oxygen
aspirate is collected soon after delivery. The directly into the incubator is unsatisfactory
diagnosis of hyaline membrane disease is as it uses a lot of oxygen. In addition, high
supported by a negative shake test, which concentrations of oxygen cannot be given and
indicates immature lungs. A Gram stain the amount of oxygen in the incubator drops if
showing pus cells suggests that the infant has a porthole is opened.
congenital pneumonia as a complication of
chorioamnionitis. 2. How should you measure the amount of
oxygen given?
4. Should this infant remain at the level 1
The concentration of oxygen in the head
hospital?
box should be measured with an oxygen
No, he should be moved as soon as possible to monitor. The amount of oxygen given must
a level 2 or 3 hospital with staff and facilities not be measured in litres per minute with a
to care for sick infants. Hyaline membrane flow meter, as this is an extremely inaccurate
disease deteriorates for 2 to 3 days before method of estimating the amount of oxygen
improving. Therefore, this infant should be being given.
transferred as soon as possible.
3. How should you control the percentage
5. How would you manage this infant of oxygen given?
before transfer to a larger hospital?
With an oxygen-air blender or a venturi.
Keep the infant warm and give just enough
oxygen via a head box to keep the tongue 4. Why should the oxygen be humidified?
pink. If a saturation monitor is available,
keep the oxygen saturation between 86 and Because unhumidified gas is very dry and
92%. Handle the infant as little as possible will irritate the linings of the nose, throat and
after starting an intravenous infusion of 10% airways.
dextrose (e.g. Neonatalyte). Carefully observe
his respiration rate and pattern, colour, heart 5. What flow rate of oxygen should be
rate and temperature. Ventilate with a bag and given into the head box?
mask if the infant develops apnoea or remains A flow rate of 5 litres per minute is best. This is
cyanosed in 100% oxygen. measured on the flow meter.
6. How should the amount of oxygen in the

infant’s blood be measured?
With a saturation monitor.
Case study 5 management. Only then should the infant

have been transferred.
A 1700 g infant is born in a rural clinic. The
clinic staff call for an ambulance to take the 2. What was wrong with the management
infant to the nearest hospital. The hospital is of the infant at the clinic?
not contacted. The infant, which appears well, The infant should have been fed before
is wrapped in a blanket and not given a feed. referral. A transport incubator or silver
The note to the hospital reads ‘Please take over swaddler should have been used to prevent
the management of this small infant’. hypothermia on the way to hospital. Skin-to-
skin care could also have been used.
1. How should the transfer of this infant
have been arranged? 3. Why was the referral note inadequate?
The clinic staff should have contacted the The referral letter should give all the necessary
referral hospital and discussed the problem details of the pregnancy, the delivery and the
with them. The hospital staff should infant’s clinical condition.
have advised the clinic staff as to further
5
Management
of important
problems
5-2 Can these complications be prevented?
Objectives Many of these complications can be
prevented with good antenatal and labour
When you have completed this unit you care, together with good care of the infant
should be able to: after delivery. Whenever possible, women
• Manage a jaundiced infant. who are at risk of delivering an infant with
• Manage an infant with infection. complications should be identified before
• Manage an infant with trauma. delivery. These women can then be referred
• Manage a bleeding infant. for delivery at a level 2 or 3 hospital where
• Manage an infant with convulsions. special care for the infant is available.
• List the common congenital
abnormalities. 5-3 What is the management of these
complications if the infant is born in a level
1 clinic or hospital?
5-1 What are the important complications
1. They should be prevented antenatally if
of infants born in a level 1 clinic or
possible.
hospital?
2. The mother should be transferred to a level
1. Asphyxia 2 or 3 hospital before delivery if possible.
2. Hypothermia 3. The condition should be prevented after
3. Hypoglycaemia birth if possible.
4. Respiratory distress 4. The condition should be diagnosed as soon
5. Jaundice as possible after delivery.
6. Infection 5. Emergency management must be given.
7. Trauma 6. The infant should be discussed with the
8. Bleeding staff of the referral hospital.
9. Convulsion 7. A decision must be made as to whether the
10. Congenital abnormalities infant should be transferred or continue to
It is important that the nursing and medical be managed at the level 1 clinic or hospital.
staff at these clinics and hospitals are able to 8. Infants kept at the level 1 clinic or hospital
prevent, diagnose and manage these conditions. must be correctly managed.
management of impor tant problems 77
Management of an bilirubin increases in the serum and the

newborn infant may become jaundiced as the
infant with jaundice excess bilirubin is deposited in the skin. After
a few days the rate of conjugation in the liver
increases and much more bilirubin is excreted.
5-4 What is jaundice? As a result, the amount of bilirubin in the
Jaundice is a yellow colour of the skin caused serum slowly returns to the normal adult
by deposits of bilirubin in the skin. Jaundice is a range and any jaundice disappears.
clinical sign and not a laboratory measurement. Some of the bilirubin that is conjugated and
excreted by the liver in the first weeks of life is
5-5 What is bilirubin? often broken down (uncongugated) by another
Red cells in the blood contain a red pigment enzyme in the intestine. This bilirubin is then
called haemoglobin, which carries oxygen. reabsorbed back into the blood stream, adding
Red cells live for a few months only. Therefore, to the hyperbilirubinaemia. The reabsorption
the body is continually forming new red cells of bilirubin from the intestine is greater in
in the bone marrow and destroying old red starved and breast fed infants.
cells in the liver and spleen. The haemoglobin
in old red cells is broken down into a yellow 5-8 How is bilirubin measured?
pigment called bilirubin. As newborn It is both difficult and inaccurate to assess
infants normally have a high haemoglobin the concentration of bilirubin in the serum
concentration, they produce a lot of bilirubin. by clinical examination of the degree of
jaundice, especially in an infant with a dark
5-6 What is hyperbilirubinaemia? skin. Therefore, it is important to measure
Hyperbilirubinaemia is defined as a the bilirubin concentration of the serum if
concentration of total serum bilirubin that is an infant is very jaundiced. Usually a sample
higher than the normal range. Normally the of blood is collected into a capillary tube and
bilirubin concentration in the serum is low spun down to separate the serum from the
at birth, as it has been rapidly removed by red cells. The total serum bilirubin (TSB) is
the placenta during pregnancy. The bilirubin then measured with a bilirubinometer and
concentration climbs steadily for the first few expressed in µmol/l.
days after delivery, before returning to an adult
level by 2 weeks. The total serum bilirubin (TSB) cannot be
estimated accurately by assessing the degree of
5-7 How is bilirubin excreted? jaundice in the skin.
After birth, bilirubin is carried by the
blood stream to the liver where a special
enzyme changes the bilirubin into a water 5-9 What is physiological jaundice?
soluble form. This chemical process is called This is the mild jaundice that is seen in up to
conjugation. Only when the bilirubin is water 50% of all healthy, term infants during the first
soluble (i.e. conjugated) can the liver cells 2 weeks of life. Many of these infants are breast
excrete it into the small bile ducts. From here fed. These infants are well and do not need any
the conjugated bilirubin is carried in the bile treatment. Physiological jaundice in newborn
to the small intestine, where it is broken down infants is the result of:
further by bacteria and is excreted in the stool.
1. The normally high haemoglobin
During the first weeks of life the enzyme concentration which results in a lot of
system, that conjugates bilirubin in the liver, bilirubin being produced.
functions slowly. Therefore, the amount of
2. The slow rate of conjugation of bilirubin 3. When the infant has hepatitis due to:
by the liver, which results in only small, • Congenital syphilis.
amounts being excreted. • Septicaemia.
3. The reabsorption of bilirubin from the 4. When too much bilirubin is reabsorbed
intestines during the first few weeks after from the intestines:
birth. • Starved infants.
• Some breast fed infants.
All these factors usually disappear by 2 weeks
and the jaundice disappears. It is not uncommon for otherwise healthy
breast fed infants to remain jaundiced for
more than 2 weeks.
Many healthy infants have mild jaundice.
All these conditions may cause an abnormally
high TSB and a very jaundiced infant.
5-10 When is jaundice abnormal?
1. If the TSB increases above the upper limit 5-12 What is haemolytic disease of the
of the normal range or the infant looks newborn?
severely jaundiced. The phototherapy line Haemolytic disease of the newborn is a
shown in Figure 1 is the upper limit of condition where antibodies from the mother
normal for TSB. Jaundice of the palms and cross the placenta into the fetal blood stream.
soles suggests severe jaundice. Here these antibodies destroy the fetal red
2. If the infant appears jaundiced in the first cells (i.e. haemolysis), causing anaemia and
24 hours. an increased production of bilirubin in
3. If the infant is still jaundiced after 1 month. the fetus and newborn infant. The 2 most
4. If the infant is clinically sick or anaemic. important causes of haemolytic disease of the
It is very important to decide whether the newborn are:
jaundice is physiological or abnormal. 1. ABO haemolytic disease.
2. Rhesus haemolytic disease.
5-11 What causes jaundice which is
In haemolytic diseases of the newborn the
abnormal and not physiological?
blood group of the infant is different to that of
1. When too much bilirubin is produced the mother as it is inherited from the father.
from haemoglobin because:
• The concentration of haemoglobin is
very high (i.e. polycythaemia). 5-13 What is ABO haemolytic disease?
• Bilirubin is absorbed from a Red cells have blood group proteins on their
cephalhaematoma or area of bruising. surface. A, B, O and D (Rhesus) are the
• There is a very rapid break down of red most important blood group proteins. ABO
blood cells (i.e. haemolysis). haemolytic disease occurs when the mother
2. When the excretion of bilirubin is too slow: is blood group O and her fetus is blood group
• Preterm infants who have an immature A or B. For reasons unknown, some group
liver. O mothers start producing antibodies to the
• About 10% of clinically healthy, term A or B proteins. These antibodies cross the
infants have slower conjugation than placenta and cause haemolysis in the fetus
normal. by damaging the fetal red cells. With ABO
• Congenital hypothyroidism. Due to haemolytic disease, the haemolysis is not
the absence of a thyroid gland and low severe enough to cause anaemia in the fetus
concentrations of thyroid hormone, but may cause severe jaundice and anaemia
the enzymes in the liver function very in the newborn infant.
slowly.
The haemolysis results in anaemia (low

All women must have their blood group identified
haemoglobin concentration and low packed
during pregnancy and all Rhesus negative mothers
cell volume) and jaundice in the newborn
infant. An infant with ABO haemolytic must receive anti-d immunoglobulin after delivery.
disease usually appears normal at delivery
but becomes jaundiced within the first 24
5-16 When is jaundice dangerous?
hours. The TSB may increase rapidly and
reach dangerous levels. Due to the haemolysis, Jaundice can become dangerous when the
the infant may also become anaemic. ABO concentration of bilirubin in the blood
haemolytic disease cannot be prevented. becomes very high. Bilirubin may now
enter the brain of the newborn infant
and cause bilirubin encephalopathy (also
Jaundice on day 1 suggests haemolytic disease.
called kernicterus). The risk of bilirubin
encephalopathy depends on the severity of
the hyperbilirubinaemia. In well, term infants
5-14 What is Rhesus haemolytic disease?
the TSB becomes dangerous and may cause
Rhesus haemolytic disease is a form of bilirubin encephalopathy above 350 µmol/l
haemolytic disease of the newborn, which may while in preterm infants the TSB becomes
occur when the mother is Rhesus negative dangerous above 250 µmol/l.
(she has no D protein on her red cells) and
her fetus is Rhesus positive (it has D protein
on its red cells). Rhesus haemolytic disease is A high serum concentration of bilirubin can
caused by maternal antibodies to the D (i.e. damage the brain.
Rhesus or Rh) protein on the red cells of the
fetus. Only if fetal red cells accidentally cross Bilirubin encephalopathy presents with
the placenta, and enter the mother’ s blood lethargy, a high pitched cry and convulsions.
stream, will she produce antibodies to the D
protein of her fetus. This process is known as 5-17 How can bilirubin encephalopathy be
sensitisation and may occur in a Rhesus (Rh) prevented?
negative woman during a delivery, miscarriage
or placental abruption. Rhesus haemolytic By not allowing the TSB to reach dangerous
disease is more severe than ABO haemolytic levels. A number of methods can be used to
disease. Therefore, the fetus may develop reduce the TSB:
severe anaemia and die before birth. If born 1. Give early milk feeds (to reduce bilirubin
alive, the newborn infant rapidly becomes reabsoption from the intestine).
jaundiced and anaemic. 2. Prevent preterm delivery.
3. Give anti-D immunoglobulin to all
5-15 How can you prevent Rhesus Rhesus negative mothers after delivery, a
haemolytic disease? miscarriage or abruptio placentae.
4. Give phototherapy when the TSB
All pregnant women must have their blood approaches dangerous levels.
group tested at the start of antenatal care. 5. Do an exchange transfusion when
All Rhesus negative women must be given phototherapy cannot keep the TSB below
100 µg (4 ml) of anti-D immunoglobulin by dangerous levels.
intramuscular injection within 72 hours of
delivery, miscarriage or placental abruption.
This prevents sensitisation. Early milk feeds help lower the total serum
bilirubin.
5-18 What is phototherapy? 5-20 When should you give phototherapy?

Phototherapy uses white or blue light to Whenever the TSB is above the normal range
change bilirubin in the skin into a water and approaches dangerous levels, or if the
soluble form of bilirubin. This water soluble infant appears very jaundiced. In practice a
bilirubin is then carried in the blood to the simple chart is used to decide when to give
liver, from where it can be excreted without phototherapy. If the TSB concentration
having to be conjugated. Phototherapy is, reaches the phototherapy line, treatment
therefore, able to lower the TSB. should be started. The phototherapy line is
the same as the upper limit of normal for the
5-19 What equipment is used to give TSB and increases from birth to day 4 then
phototherapy? levels off. Phototherapy is usually started
earlier in preterm or sick infants. It is not
Phototherapy is usually given with a necessary to give phototherapy to healthy,
phototherapy unit, which consists of a row of term infants who are jaundiced with a TSB
fluorescent tubes. Daylight tubes, white tubes below the phototherapy line. Therefore,
or blue tubes are used. They should be changed phototherapy should not be given to well
after being used for 1000 hours because their infants with physiological jaundice. It is very
effectiveness decreases with time, even if they difficult to use phototherapy safely if the TSB
still appear bright. A perspex (clear plastic) cannot be measured.
sheet must be placed below the tubes to
reduce heat and filter out any ultraviolet light. See Figure 1 for a phototherapy chart showing
A perspex sheet also protects the infant if a the phototherapy line for term infants.
fluorescent tube breaks or comes loose. Prophylactic phototherapy is given when the
Although exposure to sunlight also lowers the TSB is still below the phototherapy line but
TSB, an infant placed in the sun may rapidly either the TSB is expected to increase rapidly
become too hot. Therefore, this form of or the infant is at an increased risk of bilirubin
phototherapy must be used with great caution. encephalopathy. Therefore, prophylactic
phototherapy is started immediately after
birth if haemolytic disease of the newborn
is suspected or diagnosed. Prophylactic
TSB µmol/1
350
300
250
200
150
100
50
0
0 1 2 3 4 5 6 7
Age in days
Figure I: Phototherapy chart showing the phototherapy line for term infants.
phototherapy is often given to preterm infants 2. The infant may pass large, loose, green
when their TSB gets near the phototherapy line. stools.
3. The infant’s eyes pads may cover its nose or
5-21 How do you give phototherapy? prevent conjunctivitis being noticed.
4. Phototherapy may interfere with maternal
1. Switch on the phototherapy unit and make bonding if the infant is separated from the
sure the tubes are all working. Check mother.
the age of the tubes and ensure that the 5. The clinical jaundice may disappear even
perspex sheet is in position. though the TSB remains high.
2. Place the infant naked in an incubator or 6. Skin rashes are common.
bassinet so that the infant is about 40 cm
from the phototherapy tubes. The infant
must not wear a cap or nappy. Instead, a The total serum bilirubin should be measured in
nappy can be placed under the infant. all infants receiving phototherapy.
3. Cover the infant’s eyes with pads as the
bright light often worries the infant. If the TSB cannot be measured at the level 1
Remove the eye pads during feeding so clinic or hospital, a heparinized capillary tube
that the eyes can be checked for infection of blood should be sealed at both ends with
and to allow the infant and mother to see plasticine and placed in a box to keep light
each other. away. It must be sent to the nearest laboratory,
4. Turn the infant over every hour. Frequent which should phone the result to the clinic or
turning will make the phototherapy more hospital, as soon as it is available. While waiting
effective as more skin is exposed to the light. for the result, phototherapy should be started.
5. Feed the infant milk, at least every 3 to 4
hours. Breast feed if possible. 5-24 When should an infant with jaundice
6. Monitor the infant’s skin temperature be tranferred?
hourly, weigh daily and measure TSB
daily or more frequently if it approaches 1. Whenever there are any signs of abnormal
dangerous levels. jaundice, such as jaundice in the first 24
7. Allow the mother unrestricted visiting. hours, severe jaundice or jaundice in an
If possible, the infant should be given ill infant, ie. when the jaundice is not
phototherapy next to the mother in the physiological.
postnatal ward. 2. If the TSB is more than 100 µmol/l above
the phototherapy line.
It is difficult to give phototherapy safely if the 3. If the TSB is above 350 µmol/l.
TSB cannot be measured.
These infants should be discussed with the
5-22 For how long should you give staff of the referral hospital before transfer.
phototherapy?
Continue phototherapy until the TSB has been Infection in the
under the phototherapy line for 24 hours.
Sometimes the TSB rises above the line again newborn infant
after the phototherapy has been stopped. If so,
the phototherapy should be restarted.
5-25 What infections are important in
newborn infants?
5-23 What are the problems with
phototherapy? 1. Conjunctivitis
2. Umbilical cord infection
1. The infant may become too hot or too cold.
3. Skin infection
4. Oral thrush
5. Septicaemia prevents conjunctivitis resulting from

6. Congenital syphilis infection with Gonococcus during delivery.
7. HIV infection 7. If formula feeds are being used, the aseptic
preparation of formula feeds, and the
5-26 Why is infection common in newborn boiling of cups, bottles and teats is essential
infants? to prevent contaminated feeds. Use a cup
rather than a bottle to give formula feeds.
Because they have an immature immune 8. Stethoscopes and other instruments
system and are exposed to infectious should be sprayed with an antiseptic spray
organisms during pregnancy, delivery and before an infant is examined.
in the nursery. The risk of infection in the 9. Immunization of all pregnant women
newborn infant is much higher than in older with tetanus toxoid prevents neonatal
children or adults. Infection is important as tetanus complicating cord infection.
it is one of the commonest causes of death in 10. Avoid overcrowding in nurseries by
infants during the first few months of life. keeping normal infants with their mothers
whenever possible.
Infection is a common cause of death in young
infants. Breast milk protects against infections.
It is not necessary to restrict visits of parents

5-27 How can you prevent infection in
and family in the nursery provided that strict
newborn infants?
hand washing and hand spraying is enforced.
There are many simple ways in which infections There is no need for visitors to wear masks
can be prevented in the newborn infant: or gowns. If possible, family and staff with
1. Do not separate mothers and their infants coughs, colds and ‘flu should not handle
unless absolutely necessary. Use skin-to- infants. Herpes infection (fever blisters) can
skin care. cause a very serious infection. Infants should
2. Breast feeding. Breast milk contains cells not be kissed.
and antibodies, which help to protect the
infant from infections. 5-28 What are the signs of conjunctivitis?
3. Vernix has antibacterial properties Conjunctivitis presents with:
and, therefore, should not be washed
off routinely after delivery. It is rapidly 1. A discharge from the eyes (mucous or pus).
absorbed by the skin. 2. Redness of the conjunctivae.
4. Hand spraying or hand washing before 3. Oedema of the eyelids.
touching an infant is the most important The degree of conjunctivitis can be divided
method of preventing the spread of clinically into mild, moderate and severe:
infection in the nursery. Before handling
an infant spray your hands with an 1. Mild conjunctivitis consists of a slight
antiseptic spray (e.g. D-germ). There is no discharge. The eyelashes tend to stick
evidence that gowns or masks reduce cross together.
infection. In the home, the family must 2. Moderate conjunctivitis presents with
wash their hands well after using the toilet. redness of the conjunctivae with an
5. Routine care of the umbilical stump with obvious discharge. Pus is present in the eye
alcohol (surgical spirits) helps prevent when the lids are separated.
infection. 3. Severe conjunctivitis has a marked
6. Routine prophylactic eye care after discharge with oedema of the eyelids. Pus
delivery with chloromycetin ointment spurts from the eye and runs down the
cheeks when the eyelids are opened. In
the most severe cases, it is not possible to alone are inadequate for treating severe
separate the eyelids due to the swelling. The conjunctivitis as the infection may have
pus may soften the cornea and cause it to already spread to involve the whole eye.
perforate (burst), severly damaging the eye. Start this treatment before referring the
infant urgently to a level 2 or 3 hospital
Conjunctivitis is usually mild. It is difficult
for further management.
to clinically identify the organism causing
conjunctivitis although severe conjunctivitis
is usually caused by Gonococcus from the Gonococcus causes severe conjunctivitis which
mother’s cervix and vagina. Therefore, the may result in blindness.
management depends on the severity rather
than the cause.
5-30 What are the signs of an infected
5-29 What is the management of umbilical cord?
conjunctivitis? A healthy umbilical cord stump is white
1. Mild conjunctivitis can usually be treated and soft at delivery. With good cord care it
by cleaning the eye with saline or warm becomes dark brown and dehydrated within
water at feeding times or when the lashes a few days, and at no stage does it smell
become sticky. A local antibiotic is usually offensive or produce pus. The aim of good
not needed. cord care is to dry the cord and keep it clean.
2. Moderate conjunctivitis should be treated Infection of the umbilical cord (omphalitis)
by cleaning the eye and then putting in presents with:
chloromycetin ointment 3 hourly or more
frequently if needed. 1. An offensive (smelly) cord with a discharge
3. Severe conjunctivitis is a medical of pus.
emergency as it can lead to blindness if 2. Failure of the cord to become dehydrated
not promptly and efficiently treated. The (i.e. the cord remains wet and soft).
infection is usually due to the Gonococcus 3. Redness of the skin around the base of the
and treatment consists of irrigating the eye cord (a flare).
and giving parenteral penicillin: The commonest site of infection is at the base
• The pus must be washed out of where the cord meets the skin. When the
the eye with saline, warm water or infection is localised to the cord only, there is
penicillin drops. This must be started no oedema of the skin around the base of the
immediately and repeated frequently cord and the infant is generally well. Umbilical
enough to keep the eye clear of pus. cord infection may spread to the anterior
The simplest way of irrigating the eye is abdominal wall from where it may cause
to use a vacolitre of normal saline and a peritonitis or septicaemia. Signs that the
an administration set. Penicillin drops infection of the umbilical cord has extended to
can also be used. They can be made up the abdominal wall are:
in the nursery by adding 1 ml of benzyl
penicillin to 50 ml sterile water or 1. Redness and oedema of the skin around
normal saline. The mixture must not be the base of the cord and spreading onto the
kept for more than 24 hours. abdomen (cellulitis).
• Benzyl penicillin intravenously 2. Abdominal distension often with decreased
6 hourly or procaine penicillin bowel sounds and vomiting (peritonitis).
intramuscularly 12 hourly must be 3. The infant is generally unwell with the
given for 3 days. The dose of both features of septicaemia.
benzyl and procaine penicillin is 50 000 Cellulitis, peritonitis and septicaemia are
units/kg per day. Penicillin eye drops serious infections and the infant may die if
not treated immediately with intramuscular 5-33 How do you manage tetanus?
or intravenous antibiotics. Infection of the
Tetanus can be prevented by:
umbilical cord may also cause tetanus in the
newborn infant. 1. Good cord care.
2. Immunising all pregnant women with
5-31 How do you treat umbilical cord tetanus toxoid if tetanus is common in
infection? the region. All children should be fully
immunised.
With good preventative cord care, infection of
the umbilical cord should not occur. Prevention The emergency treatment of tetanus consists of:
consists of routine applications of alcohol 1. Keeping the airway clear and giving oxygen.
(surgical spirits) to the cord every 6 hours until 2. Not stimulating the infant.
it is dehydrated. Antibiotic powder is not used. 3. Stopping spasms with 1 mg diazepam
Do not put aspirin or other home remedies on (Valium) rectally. This may have to be
the cord. Never cover the cord with the nappy repeated until the spasms stop. You may
or a bandage as this keeps it moist. have to mask and bag ventilate the infant.
If the infection is localised to the umbilical 4. Transferring the infant urgently to the
cord, and there are no signs of cellulitis, nearest level 2 and 3 hospital.
peritonitis, septicaemia or tetanus, then
treatment consists simply of cleaning the 5-34 What are the signs and causes of skin
cord with surgical spirits every 3 hours to infection?
clear the infection and hasten dehydration.
The 2 commonest forms of skin infection in
Neither local nor systemic antibiotics are
the newborn infant are:
needed. Special attention must be paid to the
folds around the base of the cord, which often 1. Impetigo caused by Staphylococcus,
remain moist. Within 24 hours the infection which presents as pus filled blisters
should have cleared. Keep a careful watch usually seen around the umbilicus or in
for signs that the infection may have spread the nappy area.
beyond the umbilicus. 2. A monilial rash caused by a fungus
(Candida or Monilia). This almost always
5-32 What is tetanus? occurs in the nappy area and presents as
a red, slightly raised, ‘velvety’ rash which
Tetanus in the newborn infant (tetanus is most marked in the skin creases. In
neonatorum) is caused by bacteria, which contrast, a nappy rash due to irritation of
infect dead tissues such as the umbilical cord. the skin by stool and urine usually affects
Tetanus bacteria usually occurs in soil and the exposed areas of the skin and not the
faeces, which may be placed on the cord or creases.
other wounds as a traditional practice. They
produces a powerful toxin that affects the A sweat rash, due to excessive sweating, may
nervous system. look like an infection. It presents as small, clear
blisters on the forehead or a fine red rash on the
Tetanus presents with: neck and trunk. Treat, by washing the infant to
1. Increased muscle tone (spasm), especially remove the sweat, and prevent overheating.
of the jaw muscles and abdomen.
2. Generalised muscle spasms and 5-35 How do you treat skin infections?
convulsions, often precipitated by
Pay strict attention to hand washing and
stimulation such as handling or loud noises.
spraying, and do not routinely wash off vernix.
3. Respiratory failure and death in untreated
Then skin infection should not be a problem
infants, due to spasm of the respiratory
in a nursery.
muscles.
1. Impetigo is treated by washing the infant prevent bacterial contamination of bottles but
in chlorhexidine (e.g. Bioscrub) or a red may not kill Candida. Dummies should be
soap (e.g. Lifebouy) twice a day for 5 days. boiled or thrown away.
If the infant should become unwell and
show any signs of septicaemia, then urgent 5-37 What are the signs of septicaemia?
treatment with parenteral antibiotics is
indicated. The clinical signs of septicaemia are often
2. A monilial rash should be treated with non-specific, making the early diagnosis of
topical mycostatin (Nystatin) cream and septicaemia difficult. The common clinical
the area should not be covered. Allow the signs are:
infant to sleep on a nappy and keep the 1. Lethargy and appearing generally unwell.
infected area of skin exposed to the air. A 2. Poor feeding. The infant may also fail to
little sunshine will also help but do not let gain or even lose weight.
the infant get too hot or sunburned. 3. Abdominal distension and vomiting.
4. Pallor (appear pale), jaundice and purpura
5-36 What are the clinical signs and (small red or blue spots due to bleeding
management oral thrush? into the skin).
5. Recurrent apnoea.
Oral thrush is caused by a fungus (Candida
6. Hypothermia.
or Monilia). It presents as a patchy, white
7. Oedema or sclerema (a woody feel to the
coating on the tongue and mucus membrane
skin).
of the mouth. Unlike a deposit of milk curds,
sometime seen after a feed, thrush can not be The infant may also have signs of pneumonia,
easily wiped away. Mild thrush is very common, meningitis or necrotising enterocolitis.
especially in breast fed infants and usually
requires no treatment. In contrast, with severe 5-38 How should you treat septicaemia?
thrush the tongue and mucus membrane are
red and covered with a thick white layer of Management of septicaemia consists of:
fungus. The infant feeds poorly due to a painful 1. General supportive care of a sick infant (i.e.
mouth. The infant appears miserable and may keep the infant warm, monitor the vital
lose weight or even become dehydrated. signs, give oxygen and intravenous fluids if
Severe thrush should be treated with 1 ml necessary).
mycostatin drops (Nystatin) into the mouth 2. Antibiotics. Usually ceftriaxone or
after each feed. Mycostatin ointment can also cefotaxime 100 mg/kg/day IM alone, or
be used and should be wiped onto the oral benzyl penicillin 50 000 units/kg/day IM
mucus membrane with a swab or clean finger. or IV plus gentamicin 7.5 mg/kg/day IM or
Treatment should be continued for a week. IV. Intramuscular ceftriaxone, gentamicin
Gentian violet can be used on the thrush if and benzathine penicillin are given daily,
mycostatin is not available. In a breast fed while intravenous benzyl penicillin and
infant the source usually is monilial infection cefotaxime are given 8-hourly.
of the mother’s nipples. Mycostatin ointment 3. Discuss the infant urgently with the
should be smeared on the nipple and areolae referral hospital and arrange transfer.
after each feed. If the mother has a monilial
vaginal discharge, this should be treated 5-39 What are the signs of congenital
with mycostatin vaginal cream to reduce the syphilis?
amount of Candida on the mother’s skin. In An infant born with congenital syphilis may
bottle fed infants, the bottles and teats must have one or more of the following signs:
be boiled after the feed. Disinfectant solutions
such as Milton and Jik are very useful to 1. Low birth weight
2. Blisters and peeling of the hands and feet
3. A distended abdomen due to an enlarged infected with HIV usually appear healthy.
liver and spleen Weeks to months or even years later they will
4. Pallor due to anaemia develop signs of HIV infection.
5. Purpura (petechiae) due to too few
The risk of HIV infection in the infant is greatly
platelets
reduced with antiretroviral prophylaxis. All
6. Jaundice due to hepatitis
HIV-exposed infants must be identified at birth
7. Respiratory distress due to pneumonia
and correctly managed.
8. A heavy, pale placenta weighing more than
a fifth of the weight of the infant
Some infants that have recently acquired Trauma in the newborn
congenital syphilis may have no clinical signs
yet. If untreated, most of these asymptomatic infant
infants will develop clinical signs of syphilis
within a few months. Infants with congenital
5-42 What are the important types of
syphilis will have a positive VDRL or RPR test.
trauma in the newborn infant?
5-40 How do you treat congenital syphilis? 1. Cephalhaematoma
2. Brachial plexus injury (Erb’s palsy)
The method of treatment depends on whether 3. Bruising
the infant has or has not clinical signs of
congenital syphilis:
5-43 What is a cephalhaematoma?
1. If the infant has clinical signs of syphilis
A cephalhaematoma is a collection of blood
give 50 000 units/kg of procaine penicillin
under the periosteum of the parietal bone of
daily by intramuscular injection for 10
the skull. It is common, appears within hours
days. These infants are often very sick and
of delivery as a soft swelling on the side of
need good general supportive care in a
the head, and may be on one or both sides.
level 2 hospital.
A cephalhaematoma is caused by damage
2. If the mother has untreated syphilis or has
to capillaries under the periosteum and,
not received a full course of treatment (3
therefore, never extends beyond the edges
weekly doses of benzathine penicillin), and
of the bone. Cephalhaematomas are usually
the infant has no clinical signs of syphilis,
small and need no treatment. The absorption
then the infant can be treated with a single
of blood may cause jaundice, however, which
intramuscular dose of 50 000 units/kg of
may require treatment by phototherapy.
benzathine penicillin.
It can take up to 3 months before the
3. If the mother has received a full course
cephalhaematoma disappears. Never aspirate
of penicillin and the infant has no signs
a cephalhaematoma as it may result in further
of syphilis, then the infant requires no
bleeding or infection.
treatment.
5-41 Can an infant get AIDS? Never aspirate or drain a cephalhaematoma.

Yes. If a woman with HIV infection falls
pregnant, or gets infected with HIV during In contrast, a subaponeurotic haemorrhage
pregnancy or while still breast feeding, the is a collection of blood under the scalp.
infant may also become infected with HIV. If Fortunately a subaponeurotic haemorrhage is
the mother is HIV positive, the risk of infection not common as it rapidly results in shock due
in the infant is about 25%. HIV transmission to blood loss.
from mother to infant usually takes place
during labour and delivery. At birth infants
5-44 What is a brachial plexus injury? The management

A brachial plexus injury (or Erb’s palsy) is of bleeding in the
caused by excessive pulling on the head and
neck during delivery. The infant is usually large newborn infant
and born at term with difficulty delivering the
shoulders. Brachial palsy may also complicate
a poorly managed breech delivery. By over 5-46 What is the commonest cause of
stretching the neck, the brachial plexus of bleeding?
nerves in the infant’s neck is damaged. Bleeding from the cut umbilical cord due to
Immediately after birth it is noticed that the a slipped cord clamp or cord tie. Therefore, it
infant does not move one arm due to weakness is very important to make sure that the cord
at the shoulder and elbow. The arm remains is clamped or tied correctly, or the infant may
fully extended and held beside the body. The bleed severely.
infant is unable to flex that arm at the elbow or
lift the arm off the bed. Movement of the hand 5-47 What is haemorrhagic disease of the
and fingers is normal, however. The infant newborn?
also has a markedly asymmetrical Moro reflex. Haemorrhagic disease of the newborn is
Unless there is an associated fracture, there is bleeding due to a lack of vitamin K, which
no tenderness, pain or swelling of the arm. is needed by the infant to produce clotting
Usually the weakness is much better by a week factors in the liver. During pregnancy the fetus
and full movement and power return by a does not get much vitamin K from the mother
month. If the weakness is not much improved and there is not much vitamin K in breast
by a week, refer the infant to a level 2 or 3 milk.
hospital for assessment. Keeping the arm Infants with haemorrhagic disease of the
above the head will not help recovery. newborn usually bleed from their umbilical
A facial palsy presenting with weakness of one cord, vomit blood or have blood in their
side of the face after delivery is not common stools during the first week of life. If severe,
and usually recovers within a few days. the infants can bleed to death. Any infant
presenting with bleeding must be given 1 mg
5-45 What causes bruising? of Konakion (vitamin K) and urgently referred
to a level 2 or 3 unit. If very pale and shocked,
Bruising is common after difficult deliveries, the infant must first be resuscitated and given
especially breech delivery in a preterm infant. intravenous fluid.
The bruise is due to bleeding into the skin. A
tight umbilical cord around the neck commonly 5-48 How do you prevent haemorrhagic
causes severe congestion and bruising of the disease of the newborn?
face. The bruise fades after a week or two and
needs no treatment. The absorbed blood may By giving all infants 1 mg (0.1 ml) of Konakion
cause jaundice, requiring phototherapy. by intramuscular injection after delivery. This
is best given into the lateral thigh (NOT into
Rarely, fractures of the clavicle (collar bone), the buttock).
humerus or even femur occur after a very
difficult delivery. These fractures usually heal
well without splinting. Paracetamol (Panado All babies must be given intramuscular konakion
syrup 2.5 ml) should be given for pain relief in after delivery.
all fractures.
Oral Konakion should not be used, as it addition, jitteriness can be stopped by holding
cannot be relied on to prevent haemorrhagic that limb.
disease unless it is given repeatedly.
5-51 What are the important causes of
5-49 What is purpura? convulsions?
Purpura (or petechiae) are small bleeds under The important causes of convulsions in the
the skin presenting as pink or blue spots. newborn infant are:
Purpura usually only occurs over part of the
1. Fetal hypoxia (hypoxia during labour)
body and is caused by pulling and squeezing
2. Hypoglycaemia
of the arms or legs during a difficult delivery.
3. Meningitis
It disappears after a few days. If purpura
occurs over the whole body there is probably Convulsions in the first few days of life are
some abnormality with the infant’s platelets. usually due to hypoxia during labour.
These infants must be urgently referred to
a level 2 or 3 hospital for investigation and 5-52 How do you treat a convulsion?
treatment. Do not confuse purpura with the
blue patches (Mongolian spots) commonly 1. Clear the mouth and throat by suction
seen over the back. and remove any vomited milk. Then
give oxygen by face mask. Mask and bag
ventilation will be needed if the infant is
not breathing or has central cyanosis.
Management of 2. Empty the stomach by a nasogastric tube
convulsions (fits) to prevent vomiting.
3. Stop the convulsion with phenobarbitone
20 mg/kg given intravenously, if possible,
5-50 How can you recognise a convulsion or by intramuscular injection. If the fit
in a newborn infant? does not stop in 15 minutes, diazepam
(Valium) 0.5 mg/kg can be given rectally
A convulsion (fit) may present as:
with a syringe and nasogastric tube.
1. Twitching of part of the body (e.g. a hand), 4. Measure the blood glucose concentration
one side of the body, or the whole body (a and treat hypoglycaemia, if present, before
generalised fit). transferring the infant.
2. Extension (spasm) of part of the body (e.g. 5. All infants that have had a fit must
an arm) or the whole body. transferred urgently to a level 2 or 3
3. Abnormal movements (e.g. mouthing hospital for investigation and treatment.
movements, turning the eyes to one side or
cycling movements of the legs).
4. Apnoea alone. Congenital
It is often very difficult to recognise a abnormalities
convulsion in a newborn infant as infants
usually do not have a grand mal fit (generalised
extension followed by jerking movements) as 5-53 What are the common congenital
seen in older children and adults. abnormalities?
Jitteriness and the movements normal infants 1. Extra fingers: These are usually attached
make while asleep must not be confused with by a thin thread and can be tied off with
convulsions. Unlike convulsions, jitteriness suture material. One of the parents often
can be stimulated by handling the infant. In has also had extra fingers at birth.
2. Hypospadias in boys: The underside of
the foreskin is missing, the penis is bent
down and the opening of the urethra is 2. Why does the infant not have jaundice
not at the end of the penis. These infants caused by ABO or Rhesus haemolytic
should be referred, as should infants with disease?
undescended testes at term. Infants with
Because both the mother and infant have the
abnormal genitalia and uncertain gender
same ABO and Rhesus blood groups.
must be referred urgently.
3. Birth marks: Blue marks over the lower
back (Mongolian spots) are common and 3. Does this infant have hyper
disappear in a few years. Bright red, raised bilirubinaemia? Give reasons for your
strawberry spots appear in the first few answer.
weeks. They enlarge for a few months and No, this infant does not have
then disappear by 5 years. hyperbilirubinaemia because the TSB falls
4. Clubbed feet: They cannot be twisted back within the normal range for day 3.
into a normal position unlike feet that
are simple squashed by too little amniotic 4. What is the correct management of this
fluid. The infant must be referred for infant?
treatment.
5. Cleft lip or palate: These infants may need The infant should be managed as for a healthy,
to be fed by tube or cup for the first few normal infant except that the TSB should be
days. They must be referred for treatment. repeated daily until it starts to fall.
6. Bowel abnormalities: Infants who dribble
or choke because they cannot swallow 5. Should this infant receive phototherapy?
must be transferred urgently as must
No. There is no reason for phototherapy.
infants who vomit bile, develop a distended
abdomen or have no anus.
7. Infants with an abnormal face: Infants 6. Should the mother stop breast feeding?
with Down syndrome and fetal alcohol Explain your answer.
syndrome can be recognised at birth by No, she should continue to breast feed.
experienced staff. They have an abnormal Although breast feeding may result in a
appearance to their face and may have slightly higher TSB, it is not necessary to stop
other abnormalities. They must be referred breast feeding.
for a specialist opinion.
Case study 1 Case study 2

The mother delivers a 2000 g infant at home.
A well, breast fed, term infant develops
On day 2 the infant develops bilateral purulent
jaundice on day 3. The TSB (total serum
conjunctivitis. When he is brought to the local
bilirubin) is 120 µmol/l, which falls into the
clinic his eyelids are swollen. Otherwise the
normal range for day 3. Both the mother and
infant is well with no other abnormal signs.
infant are blood group 0 positive.
However, it is noticed that the mother was
VDRL positive during her pregnancy and was
1. What is the probable cause of this not treated.
infant’s jaundice?
This infant probably has physiological jaundice
caused by slow bilirubin conjugation by the
liver and increased bilirubin reabsorption by
the intestines.
1. What is the probable cause of the 7. What is the treatment if the infant
conjunctivitis? appears well but the mother has untreated
syphilis?
Gonococcus. This is the commonest cause of
severe conjunctivitis. The infant was probably If the infant has no clinical signs of syphilis
infected during delivery. the treatment is a single intramuscular dose
of 50 000 units/kg benzathine penicillin.
2. How could the conjunctivitis have been If the infant had clinical signs of syphilis
prevented? the treatment would be procaine penicillin
50 000 units/kg IM daily for 10 days.
By placing chloromycetin ointment into the
infant’s eyes after delivery.
Case study 3
3. Why should you call this severe
conjunctivitus?
An infant weighing 5000 g is born in a level
Because the eyelids are swollen and the eyes 2 hospital. The shoulders are delivered with
are filled with pus. great difficulty. After birth it is noticed that the
infant does not move her right arm much and
4. What is the danger of severe has an asymmetrical Moro reflex.
conjunctivitis?
1. What do you think is wrong with her arm?
The cornea may become soft and perforate,
causing blindness. She probably has a brachial plexus injury
(Erb’s palsy) caused by excessive downward
5. What is the correct treatment of severe traction (pulling) on the neck during the
conjunctivitis? difficult delivery of the shoulders.
The eyes must be washed out with saline
2. How would you confirm this diagnosis?
or water. They should then be washed out
or irrigated repeatedly until the pus stops The infant will have weakness of the shoulder
forming. In addition, procaine penicillin 100 and elbow and will be unable to lift her arm
000 units must be given by intramuscular off the bed or flex the elbow against gravity.
injection daily for 3 days. Only when the eyes Movement and power in the hand will be
are clean and the first dose of penicillin has normal. Unless there is a fracture, there should
been given should the infant be referred to be no tenderness.
hospital for further treatment.
3. Will the weakness recover?
6. Why is it important to know that the
Usually the weakness is much improved by a
mother had a positive VDRL test during
week.
pregnancy?
Because it indicates that she probably has 4. What is the correct treatment?
syphilis. If the mother has not been fully
treated, the infant must be treated as he may If the weakness is not much better after a
have asymptomatic syphilis infection. week, the infant must be referred to a level 2 or
3 hospital for further management.
Case study 4 3. What is Konakion?

Vitamin K1. This must be given to all infants
A preterm infant weighing 1500 g is born at at birth by intramuscular injection into the
home. The infant is transferred to hospital but thigh.
the staff forget to give Konakion. On day 5 the
infant passes a lot of fresh blood in the stool, 4. What is the correct management of this
has a small dark brown vomit and appears pale. infant?
Give 1 mg Konakion immediately. Start an
1. Why does this infant have blood in the
intravenous infusion if the infant appears pale
vomitus and stool?
and shocked. Discuss the infant with the staff
The infant probably has haemorrhagic disease at the referral hospital and transfer the infant
of the newborn. as soon as possible.
2. Is this condition preventable?

Yes. Haemorrhagic disease of the newborn
should not be seen if Konakion is given
routinely to all infants.
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Primary Newborn Care: A learning programme

5 Management of important problems 76

We acknowledge all the participants of Editor of Primary Newborn Care:

Perinatal education Perinatal Education

to improve your knowledge of all aspects of blood glucose concentration, insertion of

emergencies, and important problems in are at increased risk of giving birth to an

2. Questions and answers

the participant is led step by step through 4. Multiple-choice questions

3. Case problems Study groups

The importance successfully completed that course. Credit for

2 www.ebwhealthcare.com. To write the final

4 Your examination answers will automatically

Updating of the funded and managed on a non-profit basis by

It is hoped that as many participants as By phone

5. A quick physical examination should be

If the infant responds1well to stimulation

1-26 What is hypoxia? 1-30 How is neonatal asphyxia managed?

Room air is safer than oxygen for most

Case study 1 5. Should the infant stay with the mother

1. What is the infant’s Apgar score at 1

3. What is the probable cause of the

5. Should oxygen be given? 2. What is the significance of the Apgar

Normal infants are at low risk of developing

them from dehydration at a time when many

Feeding the normal Benefits to the mother

infant 1. Breast feeding is much cheaper than

Breast feeding is cheap and ensures an adequate,

Breast is best. If a woman’s’ nipples appear flat or inverted

2-42 Is it necessary to weigh a normal

5. Why is it important that this woman

Growth restricted infants have a head circum­

3-5 What is an underweight for gestational

2. If the duration of pregnancy is unknown 3. Problems with the pregnancy such as

Prevention of • Keep the room warm.

3-25 Which infants are at an increased risk

Recurrent apnoea a level 2 or 3 hospital for investigation. They

Anaemia 3-40 What is kangaroo mother care (KMC)?

2. Continuous KMC should be given to small Therefore, they should be written in an

Assessing patient care The legal definition of stillbirth in South Africa

6. What is the probable cause of this infant

4. When should this infant be fed? 5. Do all hypoglycaemic infants present

5. How should the infant be kept warm Case study 4

Case study 5 early neonatal mortality rate was 25/1950 ×

3. Is this stillbirth rate typical of a 9. How do you interpret the finding of a

The management of signs. Severe hypoglycaemia is defined as a

4-31 How can you diagnose the wet lung

2. When there is respiratory distress The amount of oxygen being given in a

2. What is the probable cause of the Case study 4

3. What is the value of collecting a sample 1. What equipment should be used to

6. How should the amount of oxygen in the

Case study 5 management. Only then should the infant

Management of an bilirubin increases in the serum and the

The haemolysis results in anaemia (low

5-18 What is phototherapy? 5-20 When should you give phototherapy?

5. Septicaemia prevents conjunctivitis resulting from

It is not necessary to restrict visits of parents

5-41 Can an infant get AIDS? Never aspirate or drain a cephalhaematoma.

5-44 What is a brachial plexus injury? The management

Case study 1 Case study 2

Growth restricted infants have a head circum