1. This document provides guidance on stabilizing newborns, including maintaining normal blood glucose levels, temperature, airway management, blood pressure, and common lab tests. It outlines risks for hypoglycemia and hypothermia and treatments. 2. Details are given on ventilation settings, intubation size, analgesia options, and managing respiratory conditions like transient tachypnea of the newborn, pulmonary hypertension, and congenital diaphragmatic hernia. 3. Factors contributing to shock, sepsis screening, and fluid resuscitation are reviewed. Blood pressure support may include fluids and dopamine. Common lab tests include complete blood count, blood culture, blood glucose, and blood gas analysis.

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STABLE Course Notes
1. Sugar & Safe Care
Aim for 2.8-6.0 mmol/L
Avoid enteral feeding – insert IVC or UVC
Risks for hypoglycaemia:
1. Prem (<37/40 gestation)
2. SGA
3. LGA
4. IDM
5. Stressed/sick
6. Some meds given to mother
a. β -symps
b. β -blockers
c. Chlorpropamide
d. Benzthiazides
e. TCAs during 3rd
trimester
Foetal glucose is approx 70-80% of maternal value
3rd
trimester = ↑ glycogen storage in liver
Factors affecting BGL after birth:
1. ↓ glycogen stores
2. Hyperinsulinaemia
3. ↑ glucose utilisation
Affecting:
1. Prem, SGA (@ term = 25% risk, prem SGA = ↑ risk) stressed/sick
2. IDM (insulin does not cross placenta. Foetus creates own insulin in response to mother glucose level.
Cutting cord  glucose stopped. May result in ↑insulin  ↓ BGL), LGA (↑ insulin can be cause of
LGA)
3. Prem, SGA, infection/shock/hypothermia/hypoxia (anaerobic metabolism; ↑ glucose consumption
for ↓ ATP output)/cardiac or respiratory disease
Screening:
15-30 min intervals until > 2.8mmol/L on at least 2 consecutive tests
S&S of Hypoglycaemia:
 ASYMPTOMATIC
 Twitching
 Jitteriness
 Irritability
 Hypotonia
 Lethargy
 High pitched cry
 Tachypnoea
 Cyanosis
 Poor suck
 Hypothermia
 Apnoea/irregular resps
Rate x conc x 0.167 = mg/kg/min
Weight
OR
100ml/kg/day = 10g/kg/day
10g / 1.44 =
mg/kg/min

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 Seizures
Treatment
1. D10W @ 80ml/kg/day via infusion pump (approx 5.5mg/kg/min)
a. Central line for D15W and above
b. Weight x 80ml / 24 = ml/hr
2. Bolus of 2ml/kg of D10W @ 1ml/min
3. Rpt if no improvement
4. Repeat & increase to 100ml/120ml/kg/day (or increase glucose concentration if pt not candidate for
↑ fluids)
NB prem may need ↑ fluids due to loss through thinner skin, radiant warmer, phototherapy lights etc.
Watch for ↑ BGL due to immature endocrine sys (i.e. may need ↑ fluids but ↓ glucose concentration)
UVC/UAC
UVC
 Rapid IV access
 Difficulty gaining Peripheral IV
 More than 1 IVC needed
 CVC access for D12.5W+
 Tip @ RA/IVC junction
 Preterm never more than 5cm; term never more than 7cm. Emergency placement – 3cm you’re in!
UAC
 Continuous ABGs
 ABP monitoring
 NO MEDS – NaCl only to maintain patency
 AP CXR – T6-T9 (high line - preferred); L3-L4 (low line)
 Monitor for arterial spasm/emboli (discolouration of feet/abdo/buttocks/legs/groin)
NB In life threatening emergency – IO access (tibial) 18G
Heparin
0.5-1.0 unit/ml of fluid IV. CUMH – 0.5u/ml
NB Comes in different concentrations! Check packaging first!
Volvulus
Green coloured emesis. Never assume to be normal! Rule out malrotation.
 Pain
 Bloody stool Ischaemia
 Shock & metabolic acidosis
Peripheral IVC
24G or 28G scalp needle

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STABLE Course Notes
2. Temperature
Maintain whether patient well or unwell
1. EARLY Prem & SGA at ↑ risk of hypothermia
a. ↑ surface area v body mass
b. Less insulating fat
c. Thinner immature skin
d. Little if any brown fat (5% of mass – back/spine/shoulder)
2. SMALL BW <1500g – problem accentuated
3. SICK Infants who require resuscitation or are acutely unwell
a. Hypoxic
b. Hypotonic (unable to flex/↓ activity  ↓ heat generation)
NB Core temp = 36.5°C – 37.5°C
Mild 36-36.4°C
Moderate 32-35.9°C Grades of hypothermia
Severe <32°C
NB Hypothermia is an independent risk factor for mortality
Normal response to cold stress
Peripheral vasoconstriction, ↑ flexion & activity, metabolism of brown fat  ↑ metabolic rate  ↑
utilisation of O2 & glucose
 Prem, SGA & hypoglycaemia are at increased risk of hypothermia
Decreasing heat loss
1. Pre-warm objects before contact (mattress, hands, steth, XR plates, blankets)
2. Insulation between baby & surfaces
3. Clothing, hats (not always practical)
4. Chemical thermal mattress with cover
5. Pre-heat room to 25-28°C
6. Cover chin-to-feet with polyethylene covering (may not be useful >1500g BW)
7. Closed, pre-warmed incubator
8. Heat O2 & humidify
9. Radiant warmer – do not obstruct during resus
10. Quickly dry infant
11. Do not bathe unstable infants – PPHN
12. Minimise air turbulence
13. Warm any IV solutions
14. Thermal shades over windows
15. Move infant away from windows & walls
16. Radiant bed – SERVO-CONTROL MODE!
a. Temp sensor on RUQ

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Physiological response to hypothermia (term infants)
Cold stress
Hypothalamus stimulated
Norepinephrine released Pulmonary vasoconstriction
Brown fat
metabolism ↑ activity, flexion R-L shunting
(aerobic) ↑ O2 consumption
↑ glucose utilisation
HYPOGLYCAEMIA HYPOXIA HYPOXAEMIA
Physiological response to hypothermia (pre-term infants)
Cold stress
Hypothalamus stimulated
Norepinephrine released Pulmonary vasoconstriction
Brown fat
metabolism ↑ activity & flexion
↑ O2 consumption
Limited glucose stores
HYPOGLYCAEMIA HYPOXIA
Right – left shunting  hypoxemia
Hypoxemia  Hypoxia  Anaerobic metabolism  ↑ lactic acid  ↓pH
Hypothermia
S&S of worsening Hypoglycaemia due to Hypothermia
 Respiratory distress
 ↓ LOC

5. 5 | P a g e
 ↓ resp rate
 ↑ sepsis risk
 DIC
 ARF
NB For re-warming, incubator is best choice. Set to air temperature mode. Set 1-1.5°C above core temp.
Closely monitor – avoid sudden vasodilation & hypotension
 Core temperature
 HR
 ECG
 BP Continuously monitor
 Resp rate & effort
 SpO2 > 90%
 ABB
 BGL
NB Baby can lose 150ml/day in non-sensible, uncontrolled fluid loss through evaporative heat loss. 1ml of
fluid loss = 4 cal energy loss
Prolonged resus – turn off radiant warmer. Possible candidate for therapeutic hypothermia / passive cooling
(33-34°C)
Rewarming – ½°C/hour

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STABLE Course Notes
3. Airway
Arterial Blood Gases (CUMH)
pH 7.30-7.45 (7.26 acceptable)
pCO2 35-45mmHg (4.5-6 kPa)
pO2 50-80mmHg (6.5-10 kPa)
HCO3- 19-26 mEq/L (18-24)
BE -4 to +4 (-6 to +6)
NB Temperature when taken should be input in order to give accurate results!
Respiratory Distress
 Mild - ↑RR
 Moderate - ↑RR, cyanosis, abnormal ABG
 Severe – central cyanosis, struggling, abnormal ABG
NB N = 30-60 r/min; < 30 = laboured; gasping = pre-arrest (BVM/tube/PPV)
Tachypnoea & ↓ pCO2 (non-respiratory cause)
 Congenital heart disease
 Metabolic acidosis
 Cerebral disorder (meningitis, oedema, haemorrhage)
Tachypnoea & ↑ pCO2 (respiratory cause)
 RDS (surfactant deficiency in immature infant)
 Pneumonia (give ABx until proven otherwise!)
 TTN (retained foetal lung fluid) (↑risk in pre-labour section)
 Aspiration
 Pulmonary haemorrhage
 Airway obstruction
 Chest mass, diaphragmatic hernia, pneumothorax (CXR for definitive Dx)
 Penicillin is cheap, safe & effective – use it!
Gas exchange
Resp  Breathe in  pO2 in alveoli ↑  O2 diffuses into plasma  Diffuses into RBC  O2 binds
to Hb  Hb saturated with O2  Heart  pumped to body  releases O2 to cells  O2 diffuses
into cells  CO2 diffuses from cells into plasma  lungs  CO2 removed
High  Low gradient

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pO2 blood > pO2 tissues
100mmHg > 23mmHg
↑ HCO3- = compensating respiratory acidosis
↓pCO2 = compensating metabolic acidosis
Metabolic Acidosis (lactic)
 Shock
 Poor perfusion
 Anaerobic metabolism
 Sepsis
 Hypothermia
 Congenital heart disease
 TRAUMA – accidental & intentional
Treatment of Metabolic Acidosis
 Treat the cause!
 ↑ O2
Respiratory Acidosis
 Lung disease
 Pneumothorax
 Airway obstruction
 ↓ resp effort
 Neurological injury
 Apnoea
 Mechanical interference
Treatment of Respiratory Acidosis
 CPAP
 PPV
NB Deterioration with PPV in neonate – consider diaphragmatic hernia.
Intubation
Weight (in kg) + 6 = tube mark @ lips
Ventilation
 Time-cycled mode
 Start low, work up
VLBW LBW Term
Rate 30-60 30-60 20-50
Insp time ≥0.25 Match GA < 0.45

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PIP 14-22 18-24 20-28
PEEP 3-4 4-5 4-5
↑ PIP = ↑ TV = ↓ pCO2
↑ PEEP = ↓TV (unless ↑ PIP) = ↑pCO2
NB Adjust PEEP first, then PIP, then insp. time
Analgesia
Morphine – ref NEOPAIN study
 0.05-0.1mg/kg per dose
 IV/IM/SC
 15-30 min admin time
Fentanyl
 1-2mg/kg per dose
 IV
 15-30 min admin time
Sucrose
 12-24% solution
 Term – 0.5-2.0ml
 Pre-term – 0.1-0.4ml
NB Sedatives ≠ Analgesia
Needle Aspiration of Pneumothorax
1. Turn 45°, pneumo side up
2. 4th
/5th
IC space
3. Mid-axillary or anterior axillary
CDH
 8/40 gestation – diaphragm develops. Mortality 40-60% with CDH
 Recognition
o Cyanosis
o Resp distress
o Scaphoid/sunken abdomen
 Risk of pneumothorax with PPV
NB DO NOT PPV if CDH – intubate!
Stabilisation of CDH
 Blow-by O2
 10F OG tube

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 CXR
 Pre & post-ductal SpO2% - observe for PPHN. Greater than 10% difference = R-L shunting
 Vitals
 Volume boluses
 Dopamine
 Observe for pneumothorax
 Analgesia
PPHN
PDA &/ FO remain open
3 main causes
1. ↑ muscularisation
2. Vasospasm – acidosis, hypoxia, hypothermia, sepsis
3. ↓ lung size – pulm hypoplasia, CDH
CPAP
Indications
1. Needs support but not intubation
2. ↑ severity/frequency of apnoea
3. ↑ work of breathing
4. ↑ O2 requirement
5. CO2 retention, acidosis (mild)
6. Atelectasis
7. Tracheobronchomalacia (flaccidity of tracheal cartilage)
Contra-indications
1. Progressive respiratory failure
2. ↑pCO2
3. ↑ acidosis
4. Hypoxemia
5. CDH, TEF, choanal atresia, cleft palate, cardiovascular instability, ↓ resp drive

10. 10 | P a g e
STABLE Course Notes
4. Blood Pressure
Hypovolemic, cardiogenic & septic shock
HR x SV = CO
Fluids
10ml/kg/dose over 15-30 mins (NaCl or Ringers)
Whole blood – over 30mins-2hrs
Sodium Bicarbonate
 4.2% solution
 For tx of severe metabolic acidosis (pH < 7.15)
 1-2mEq/kg/dose over 30-60 mins
 IV
Dopamine
 5-20mcg/kg/min
 IV
Group B Strep – risk factors
 Temp > 38.5°C
 Labour > 18hrs
 UTI / Previous delivery
Double penicillin to treat meningitis.
Ref HIP trial

11. 11 | P a g e
STABLE Course Notes
5. Lab Work
Blood count
Blood culture The 4 B’s
Blood glucose
Blood gas
Risk of infection
 PROM
 POL
 Chorioamnionitis (inflammation of foetal membranes)
 Increased risk of infection with
o Maternal infection
o Maternal fever
o Maternal GU tract infection
o ROM > 18hrs
o Instrumentation use
o Intubation/cannulation etc.
Neutrophils
Mature – Poly, Seg, Neut, PMNs
Immature – Metas, Bands, Stabs
 Immature-to-total (I/T) ratio is important
 Absolute Neutrophil Count (ANC) in important (↓ ANC = ↑ RIP risk in presence of sepsis)
NB ANC ≤ 1800 in term / pre-term is abnormal!
ANC = Segs + Bands + Metas
I/T > 0.25 (25%) – suspect that the infant is fighting infection.
(Meta +band) Immature = I/T Ratio
(Segs + meta + band) Total
NB I/T > 0.8 = ↑ risk of death from sepsis

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Platelets
100-150k Abnormal
<100k Definitely abnormal, investigate for bleeding
<25k Dangerously low
VLBW (<1.5kg) 275k +/- 60k
LBW (<2.5kg) 290k +/- 70k Normal platelet values
Term 310k +/- 68k
NB NEVER withhold antibiotic therapy on basis of N FBC!
Time between onset of infection & FBC changes can be 4-12 hours!
Antibiotics
Ampicillin
 100mg/kg/dose
 Give over 3-5 mins
 Every 12 hours
Gentamicin
 2.5mg/kg/dose
 Give over 30 mins
 Every 12-24 hours
APGAR
<3 critical
4-6 low
7-10 normal
How Ready Is This Child?
HR, RR, Irritability, Tone, Colour
APGAR
Appearance, Pulse, Grimace, Activity, Respiration

13. 13 | P a g e
IVC & SVC
AORTA
PA
PDA
PFO
RT Subclavian
(pre-ductal)