pediatric

1. CARE FOR THE
NEWBORN BABY
1

2. Session objective
At the end of this session student will be able to:
• Identify cause of neonatal death
• Discuss the Essential Newborn Care
• Demonstrate Basic steps in Newborn Resuscitation
• Assessing the degree of asphyxia
• Demonstrate Resuscitation for Asphyxiated newborn
• Evaluate the baby during ventilation
• Identify Danger signs in newborns
2

3. CARE FOR THE NEWBORN BABY AT THE
TIME OF BIRTH
 Most neonates die mainly from three causes:
a) Neonatal infection: Sepsis, Tetanus, Diarrhea and
pneumonia
b) preterm delivery/ Low birth weight
c) Birth Asphyxia
• In Ethiopia, infection is considered to be the prime cause
of newborn death. It accounts 47% of the ND (sepsis
37%, Diarrhea 3%, and tetanus 7%) next to infection are
Asphyxia 23% and preterm/low birth weight 17%.
3

4. When do newborn die?
• 50 and 75 % of the newborn mortality take place
in the first 24 hrs and first week after birth
respectively
• Special attention should be provided to those
babies who are < one week of life, particularly at
the time of birth
• Provision of Essential Newborn Care and
Neonatal Basic Life Support to all babies
immediately after birth is the corner stone of
neonatal care that will certainly have a significant
impact on neonatal outcomes
4

5. • Therefore, Early recognition of signs of fetal
hypoxia by clinical monitoring and prompt
measures to deliver the necessary life support
to newborns with speed and safety are of
paramount importance and should be a
mandatory practice in all delivery rooms of all
hospitals and health centers
5

6. Cont…
To save the life of thousands of newborns dying
every year in Ethiopia, we should mainly focus on
the triads of activities that should be carried out
routinely:
1. Ensure the provision of Essential newborn care to
all babies
2. Early detection and management of common
newborn problems particularly birth asphyxia, and
neonatal infection.
3. Provision of extra care and creation of an
environment of thermal comfort to all preterm and
low birth weight babies
6

7. Essential Newborn Care:
• 90% of newly born babies make the transition from
intrauterine to extra-uterine life without difficulty
• They require little to no assistance to begin
spontaneous and regular respirations
• Approximately 10% of newborns require some
assistance to begin breathing at birth
• Only about 1% need extensive resuscitative
measures to survive
• Therefore, most babies breath and cry at birth with
only the provision of essential newborn care
• The care you give immediately after birth is simple
but important 7

8. Cont…
• Remember that the baby has just come out from the
most comfortable uterine environment
• It was warm and quiet in the uterus and the amniotic
fluid and walls of the uterus gently touched the baby
• You too should be gentle, observant and vigilant with
the baby when you handle them and also keep them
always warm
8

9. Basic steps in Resuscitation
• The diagram below illustrates the relationship
between resuscitation procedures and the
number of newly born babies who need them.
• At the top are the procedures needed by all
newborns.
• At the bottom are procedures needed by very
few.
9

10. 10

11. Essential Equipments
The following equipments and drugs should be
available and checked for proper function before
delivery.
• Radiant warmer/room heater, sterile sheets
• Suction catheter number 5,8,10, Fr
• Suction machine
• Infant resuscitation bag. If possible bag with
pressure release valve and reservoir. (Self inflating
bag have become popular and is preferred).
• Face mask size 00 and 01
• Oxygen with flow meter and tubing
• Laryngoscope with blade No 0 and 1 11

12. Cont….
• Endotracheal tube size: 2.5, 3.0, 3.5, and 4.0 mm
with connectors
• Scissors, adhesive tape, gloves and stethoscope
• Syringe: 2cc, 5cc,10cc, 20cc
• Needles No 24 and 21
• Alcohol and Iodine
• Umbilical catheters: No5 and 8 FR
• Feeding tubes: No 5 and 8 FR
• Iv cannula: 24 gauge and three way stop cocks
• In addition, specific equipments may be required
for specific situation as mentioned earlier.
12

13. Drugs to be used during resuscitation
• Currently the use of drugs during neonatal
resuscitation, particularly, sodium bicarbonate and
epinephrine are not routinely recommended.
• But in desperate situation, one may consider the
following drugs as a last resort.
• Epinephrine1:1000
• Sodium bicarbonate 7.5%
• Distilled water
• 10% Dextrose
• Normal saline
• Nalaxone and 10% calcium gluconate
13

14. 14

15. Steps of Essential Newborn Care
 Deliver baby onto mothers abdomen
 Dry baby with a warm and clean towel
 Remove the wet towel and wrap the baby with dry towel
and for preterm babies you wrap them with double towels
 Assess the baby’s breathing while drying
- make sure that there is not second baby
 Clamp and cut the umbilical cord
 Put the baby between mothers breasts for skin-to skin-care
 Cover mother and baby with warm cloth
 Place and identity label on baby
 Put a hat on the baby’s head and put socks also
 Start breastfeeding within one hour of life.
15

16. Before you start resuscitation
Before you apply any form of resuscitation, make sure that:
• The baby is alive?: 1st listen to its chest with a
stethoscope.
• You graded the extent of asphyxia: If the heartbeat is
less than 60 beats/minute, apply heart massage first, then
ventilate alternately on and off, till the HB is above 60
beats/minute
• The baby is not deeply meconium stained: If the baby’s
skin is stained with meconium, or the oral and nasal
cavities are filled with meconium stained you should not
resuscitate before suctioning the oral, nasal and
pharyngeal areas.
• Ventilation will aggravate the baby’s breathing problem
because it will force the meconium-stained fluid deep into
the baby’s lungs, where it will block the gas exchange. 16

17. A baby who is not breathing (no signs of chest or nose
movement) and with meconium stained all over its body.
17

18. Assessing the degree of asphyxia
• Moderate to severely asphyxiated babies usually
require intensive resuscitation.
• Within no more than 5 seconds after the birth, you
should make a very rapid assessment for alive baby to
assess the degree of asphyxia.
• A severely asphyxiated baby may not breathe at all,
there may be no movement of its limbs (arms and legs),
and the skin colour may be deeply blue or deeply
white.
18

19. Assessing the degree of asphyxia
Signs No asphyxia Mild asphyxia
Moderate
asphyxia
Severe
asphyxia
Heart rate
Above 100
beats/minute
Above 100
beats/minute
Above 60
beats/minute
Below 60
beats/minute
Skin colour Pink Mild blue Moderately blue Deeply blue
Breathing
pattern
Crying Crying
Breathing but not
strong
Not breathing, or
gasping type
Limb movement Moving well Weakly moving Floppy Floppy
Meconium-
stained
No No Maybe Usually
Resuscitation No need Fast response Good response
Takes a long time
to respond 19

20. Cont….
IF RESUSCITATION IS NECESSARY:
o Change your gloves
o Tie and cut the cord first
o Tell the mother that her baby is having difficulty to
breath and that you are going to help him. Tell her
quickly but calmly.
o Lightly wrap the baby in a warm dry towel or cloth.
o Leave the face and upper chest free for observation
o If necessary, transfer the baby to a newborn corner
which is warm, clean and dry surface, under an over
head heat source .
20

21. Checking the newborn’s heart rate
• The apical heartbeat (or AHB) is just another name for
the heartbeat heard through a stethoscope over the area
of the heart on the left side of the chest
• The newborn’s heartbeats can also be counted by
feeling the pulse at the base of the umbilical cord.
21

22. The initial actions
Actions you should take for all newborns in the sequence
shown, irrespective of the degree of asphyxia:
1. Fast drying
2. Keeping the baby warm.
3. Clearing the mouth and nose
4. Apply gentle tactile stimulation to initiate or enhance
breathing.
5. Simultaneously assessing the degree of asphyxia as
shown earlier.
6. Positioning the baby for resuscitation if there are signs
of asphyxia
22

23. Dry the baby quickly and keep it warm
23

24. Clearing the mouth and nose
24

25. Apply gentle tactile stimulation to initiate or enhance
breathing
25

26. Resuscitation of Asphyxiated newborn
 If the baby is not breathing, gasping or breathing <30/
minute and if drying the baby does not stimulate him to
breathe, the first step of resuscitation should be started
immediately.
• CALL FOR HELP!
• Cut cord quickly, transfer to a firm, warm surface [under
an over head heater source]
• Inform the mother that baby has difficulty breathing and
you will help the baby to breathe
• Start newborn resuscitation
26

27. Opening the airway
• POSITIONING
• Lay the baby on its back on a hard warm surface
• Position the baby’s head so that is slightly extended
• Place a folded piece of cloth under the baby’s
shoulders
27

28. SUCTION
• Routine suctioning may not be required. Do it when
there is Meconium stained liquor
Clear the mouth first and then the nose.
• gently introduce the suction tube into the mouth 5 cms
from the lips
• suck while withdrawing the tube
• Then introduce the suction tube 3 cms into each nostril
• suck while withdrawing the tube
• Repeat mouth and nose suction if needed , but no more
than twice.
 Spend no longer than 20 seconds doing suction
28

29. Clearing the mouth and nose
29

30. Ventilating the baby
• If the baby is still not breathing, VENTILATE.
• Use the CORRECT size face mask, Fitting a face mask:
• A correct sized mask covers: The nose, The mouth &
The tip of the chin
How to ventilate
• Squeeze bag with 2 fingers and a thumb or if needed
whole hand, 2-3 times
• Observe for rise of chest.
• IF CHEST IS NOT RISING:
– reposition the head
– check mask seal
• Squeeze bag harder with whole hand when necessary in a
stiff lung 30

31. Cont…
• Once good seal and chest rising, ventilate at 40
squeezes per minute
• Observe the chest while ventilating:
– is it moving with the ventilation?
– Is it moving symmetrically
– is baby breathing spontaneously?
• Observe for color change (the baby who was blue
becomes pink
31

32. The correct position for newborn resuscitation using an
ambu-bag
32

33. Ventilation: using a hand-operated pump called an ambu-bag
which pumps air into the baby’s lungs through a mask fitted over
its nose and mouth.
33

34. When to stop ventilating?
• If breathing or crying: STOP VENTILATING
– count breaths per minute
– look for chest in-drawing
• If breathing >30/min, and regular:
– Stop ventilating
–put the baby in skin-to-skin contact on mother’s
chest and continue care
– monitor every 15 minutes for breathing and
warmth
– tell the mother the baby will probably be well
• Encourage the mother to start breastfeeding as soon as
possible. 34

35. When to continue ventilating?
• If the baby:
– is breathing <30/min,
– is gasping/breathing irregularly
– has severe chest in-drawing
• ARRANGE FOR IMMEDIATE REFERRAL to a pediatrician
• Explain to the mother what happened, that her baby
needs help with breathing
• Ventilate during the referral
• Record the event on a referral form and labour record.
• If the baby is NOT breathing (stop ventilating at 20
minutes).
35

36. CPR
• If the apical heart beat is < (less than) 60
beats/minute:
• Apply heart massage and ventilate alternately
(on and off ventilation) with the ambu-bag.
• 3c:1r
• Thumb or finger methods
• Do it 2-3 round then if not give medication
36

37. Heart massage: pressing on the baby’s chest in a
rhythmic way to stimulate the heartbeat
37

38. APGAR SCORE
• APGAR score is not used to initiate or make decision about
resuscitative measures. However, it is useful for assessing the
effectiveness of resuscitation efforts.
38

39. Cont…
• One minute Apgar score, generally correlates with
umbilical cord blood PH and is an index of intra-
partum asphyxia.
• Normal Apgar score is >7 out of ten.
• babies with a score of 0 to 4 have been shown to
have significant acidosis and higher Pco2 value than
those with normal Apgar score.
• Beyond one minute, APGAR score reflects the
neonates changing condition and adequacy of the
resuscitative efforts.
• When 5 minute Apgar score is < 7 additional scores
should be obtained every 5 minutes up to 20 minutes
of age unless two successive scores are ≥ 8.
39

40. Care after resuscitation
 Place baby in skin-to-skin contact with mother
 Keep the baby warm
 Monitor every 15 minutes for the first 3 hours and if
baby remains ok, monitor every one hour for 24 hours.
 Start breastfeeding as soon as possible
 If breast feeding could not be started because of
medical reasons for more than one hour , give glucose
10%,2ml/kg stat and accordingly if BF is to be delayed
consider maintenance IVF therapy
 Discuss what has happened with the parents - be
positive!
 Do not separate the mother and baby unless the baby
has more difficulty breathing
40

41. 41

42. 42

43. Evaluate the baby during ventilation
• The best sign of good ventilation and improvement in the
baby’s condition is an increase in heart rate to more than
100 beats/minute.
• You would expect to see the baby’s skin colour change
from bluish or very pale, to pinkish colour.
• You may also see the baby begin to move a little bit,
beginning to flex its limbs and look less floppy.
• When you stop ventilating for a moment, is the baby
capable of spontaneous breathing or crying? These are
good signs.
• Many babies recover very quickly after a short period of
ventilation, but keep closely monitoring the baby until
you are sure it is breathing well on its own.
43

44. If chest compression and ventilation do not raise the heart
rate above 80 with in 30 minutes, with in 30 seconds
medication is needed.
Medications
• Adrenaline 0.1 to 0.3ml/kg sc (may be repeated every 5
minutes).
• Epinephrine 1:10,000 dilution Iv.
• Normal saline ringer lactate or blood 10- 20 ml/ kg in
case of hypo-volemia, history of blood loss or poor
response to resuscitation.
• Sodium bicarbonate ( 1-2 meg/ kg) in case of metabolic
acidosis.
• Dopamine ( 5-20 mg/kg/min) & fluids
44

45. • If the baby remains weak or is having irregular
breathing after 30 minutes of resuscitation, refer the
mother and baby urgently to hospital where they have
facilities to help babies who are having difficulty
breathing.
• Go with them and keep ventilating the baby all the
way.
• Make sure it is kept warm at all times.
• Newborns easily lose heat and this could be fatal in a
baby that can’t breathe adequately on its own.
45

46. ROUTINE CARE OF THE NEWBORN BABY
• The postnatal environment
• Breastfeeding care
• Keep the baby warm
• Giving cord care
• Hygiene
46

47. DANGER SIGNS IN NEWBORNS
• Neonates often present with non-specific symptoms and
signs which indicate severe illness. Signs include:
• Unable to breastfeed (Unable to suck or poorly)
• Convulsions
• Drowsy or unconscious
• apnea (cessation of breathing for >20 secs)
• Breathing ≤ 30 or ≥ 60 breaths per minute, grunting,
severe chest in drawing, blue tongue & lips, or gasping
• Grunting
47

48. Cont…
• Severe chest in drawing
• Central cyanosis
• Feels cold to touch or axillary temperature < 35°C
• Feels hot to touch or axillary temperature ≥ 37.5°C
• Red swollen eyelids and pus discharge from the eyes
• Jaundice /yellow skin — at age < 24 hours or > 2 weeks
— Involving soles and palms
• Pallor, bleeding from any site
• Repeated Vomiting, swollen abdomen, no stool after 24
hour
48

49. Emergency management of danger signs:
• All babies with danger and unable to feed should be put
on daily maintenance fluid therapy
• Give oxygen by nasal prongs or nasal catheter if the young
infant is cyanosed or in severe respiratory distress.
• Give bag and mask ventilation, with oxygen (or room air
if oxygen is not available) if RR too slow (<20).
• If drowsy, unconscious or convulsing, check blood
glucose.
• If glucose <20 mg/100 ml), give glucose IV. 10% ,2ml/kg
• If glucose 20–40 mg/100 ml), feed immediately and
increase feeding frequency.
49

50. Cont…
• If you cannot check blood glucose quickly, assume
hypoglycemia and give glucose IV. If you cannot
insert an IV drip, give expressed breast milk or
glucose through a nasogastric tube.
• if convulsing Give Phenobarbital 15mg/kg
• Give vitamin K (if not given before).
• After doing all these , refer the baby to pediatrician or
any available child health clinician in the hospital
50

51. Signs of Serious bacterial infection
Risk factors for serious bacterial infections are:
 Maternal fever (temperature >37.9 °C before delivery or during
labour)
 Membranes ruptured more than 24 hours before delivery
 Foul smelling amniotic fluid
 All of the DANGER SIGNS are signs of serious bacterial
infection, but there are:
 Deep jaundice
 Severe abdominal distension
 Localizing signs of infection are: Signs of septic arthritis :
Painful joints, joint swelling, reduced movement, and
irritability if these parts are handled
 Umbilical redness extending to the periumbilical
 skin orumbilicus draining pus.
 Bulging fontanelle
51

52. Prevention of neonatal infections
Many early neonatal infections can be prevented by:
 Ensuring clean and safe delivery always ;Good basic
hygiene and cleanliness during delivery of the baby
 Make sure the delivery room is clean and delivery
equipments are sterile or at least clean
 Special attention to cord care and Eye care
 Many late neonatal infections are acquired in hospitals.
These can be prevented by: Exclusive breastfeeding
and Strict procedures for hand washing for all staff and
for families before and After handling babies
52

53. Fluid management
• Encourage the mother to breastfeed frequently to
prevent hypoglycemia.
• If Unable to feed, give expressed breast milk by
nasogastric tube
The type of fluid and the amount in the first 24 hours
of life:
• 10% dextrose for Term babies, 60ml/kg/24hrs
• 5% dextrose for Preterm babies, 60ml/kg/24hrs
• Increase the daily requirement of fluid by 20ml/kg /day
every day until it reaches 150ml/kg/day
53

54. ROUTINE NEWBORN FOLLOW-UP
• Provide four postnatal visits, at 6-24 hours, 3 days,
7 days and 6 weeks.
54

55. Cont…
55

56. Summery
1. Why is neonatal resuscitation important?
Birth asphyxia is responsible for approximately 1 million
neonatal deaths each year worldwide. Successful neonatal
resuscitation can significantly improve the outcome for these
infants.
2. What percentage of newborns requires resuscitation at
birth? 10 % of newborns require some assistance to begin
breathing at birth. 1 % require extensive resuscitation and
neonatal intensive care to survive.
3. What is asphyxia? Asphyxia can be defined as significant
and progressive hypoxemia, hypercapnia, and metabolic
acidemia that can affect the function of vital organs and lead
to permanent brain damage and death
56

57. Cont…
4. What are the ABCDs of resuscitation? The ABCDs of
resuscitation are the same for neonates and adults:
• Airway-position and clear the airway
• Breathing-establish adequate ventilation, whether
spontaneous or assisted
• Circulation-assess heart rate and skin color
• Drugs-give medication
5. What are the four basic steps to resuscitation?
• Establish an airway.
• Establish breathing.
• Assist circulation.
• Give drugs.
57

58. Cont…
6. What are the initial steps of neonatal
resuscitation?
• Neonatal resuscitation differs from pediatric and
adult resuscitation in that preventing heat loss is a
vital part of the process. The initial steps are:
• Position the head and clear the airway as necessary.
• Stimulate the baby to breathe.
• Evaluate respirations, heart rate, and skin color;
give oxygen as necessary.
• Provide warmth by drying the infant thoroughly
and placing under a radiant warmer. 58

59. Cont…
7. At what heart rate do you start chest compressions? Chest
compressions are started at 60 beats per minute (bpm). Administer
with positive-pressure ventilation.
8. What is the ratio of chest compressions to ventilation in
newborns? 3:1 ratio (three compressions followed by a pause for
one ventilation). Simultaneous chest compressions and lung
inflation may impede effective ventilation.
9. What heart rate usually indicates that resuscitative measures
can be stopped? 100 bpm
10. When is epinephrine indicated during neonatal resuscitation?
If the heart rate is below 60 bpm after receiving 30 seconds of
assisted ventilation and 30 seconds of chest compressions with
ventilation. Epinephrine is not indicated if you have not established
adequate ventilation.
59

60. Cont…
11. What is the dose of epinephrine? The recommended
dose of epinephrine in neonates is 1:10,000
concentration given endotracheally or intravenously at
0.1-0.3 mg/kg.
12. What is the Apgar score? Virginia Apgar was an
anesthesiologist who developed the Apgar scoring
system to quantify the newborn's response to the
extrauterine environment and to resuscitation. The Apgar
score is assigned at 1 and 5 minutes after birth. When the
5-minute score is < 7, additional scores should be given
every 5 minutes for up to 20 minutes.
60

61. Cont…
13. Should the Apgar score be used to determine if
resuscitation is needed? No. It is not acceptable to
use the Apgar score to determine the appropriateness
of resuscitative actions, nor should intervention for a
depressed infant be delayed until the 1-minute
assessment.
61

62. Cont…
14. When should endotracheal intubation be
considered?
• When meconium is present and the infant is not vigorous
• When there is prolonged or ineffective bag and mask
ventilation
• If chest compression is needed to improve cardiovascular
status
• To administer epinephrine if required for persistent
bradycardia
• Known history of diaphragmatic hernia (These infants
should not receive prolonged bag and mask ventilation
and should be intubated immediately to avoid distention
of the intestinal contents in the chest.)
62