Emergency Care of the Newborn

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Emergency Care of the Newborn

• Tina M. Slusher, MD
• Associate Professor of Pediatrics
• University of Minnesota
• tslusher_at_umn.edu

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Neonatal Mortality WHO Data 2005
Danny Dorling
Center for Global Pediatrics
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The 3 leading recognized causes of neonatal death
world wide are

• Prematurity, infection, congenital anomalies
• Prematurity, infection, asphyxia
• Diarrheal diseases, asphyxia, prematurity
• Prematurity, infection, neonatal tetanus

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World Preterm 28 Infections 26 Asphyxia
23 Congenital anomalies 8 Tetanus 7 Other
7 Diarrheal 3
USA Preterm 23 Congenital anomalies
22 Sepsis 4 Asphyxia/Hypoxia 3
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Daily Risk of Neonatal Death
Lawn et al. Lancet, 2005.
Center for Global Pediatrics
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• Newborn resuscitation/ Respiratory distress
• Delayed umbilical clamping
• Umbilical cord antisepsis
• Hypothermia prevention management/Kangaroo
  Care
• Hypoglycemia prevention and management
• Breastfeeding
• Sepsis (Pneumonia)?
• Hyperbilirubemia screening
• Traditional birth attendant (TBA)/CHW training

Postnatal Interventions

• Vit K prophylaxis
• Hepatitis B vaccination
• Neonatal Vit A supplementation
• Topical Emollient therapy
• Prevention treatment of ophthalmia neonatorum

Community Based interventions Zulfiqar et al
Pediatrics 2005115519-617
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Percentage of Neonatal Resuscitation Doable at
most hospitals/clinics in the developing world

• lt50
• gt90
• lt70
• gt70

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• Appropriate neonatal resuscitation is easily
  adjusted to the resources available!!!!!

• 95 of resuscitation as taught by NRCP
  guidelines is doable at most hospitals many
  clinics in the developing world!!!

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Basic Resuscitation Equipment

• Warm delivery room (w/out draft - w/ fans off)
• Two pieces of cloth used to dry and wrap newborn
  to prevent heat loss
• Mucous extractor or DeLee Aspirator
• Positive Pressure Bag (Ambu bag) and mask or
  device to give positive pressure ventilation
  (mouth-to-mouth may be appropriate in some
  situations)

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What is most important in neonatal resuscitation

• Oxygen
• Ventilation
• Epinephrine
• Sodium Bicarbonate
• Meconium aspirator

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Neonatal Resuscitation

• Birth asphyxia is characterized by absent or
  depressed breathing at birth.
• Proper ventilation of the newborn is the most
  important aspect of resuscitation.

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Warm, Dry, Position Suction, Stimulate
20-30 seconds ONLY!!
Is my baby breathing? Is my baby breathing
well? IF no to either
Postive Pressure Ventilation Maybe Intubation
Decreasing success
Room Air or Supplemental Oxygen Okay
Only after 30 seconds of PPV with a HR lt 60
Definitely okay to start with room air !!! IF
oxygen available can give if infant stays
cyanotic
Chest Compressions
Meds
Mostly NRP/ PALS
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Saugstad
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Emphasize Time

• Remember first block warm, dry, position,
  suction, stimulate should be accomplished in NO
  MORE than 20-30 seconds
• By 30 seconds you should be positive pressure
  ventilating any infant who is not breathing or
  not breathing well

Suction Mouth First then Nose, Stimulate
Appropriately
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Heart Rate

• ?HR is the 1 sign of improved ventilation
  during neonatal resuscitation
• In community based resuscitation focus on
  ventilationmost resusciatatable infants
  resuscitated with ventilation NOT chest
  compressions and drugs
• Some programs teaching family members to do mouth
  to mouth secondary to concerns about infections
  in places where positive pressure bags not an
  option

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Respiratory Distress

• Keep oxygen flow in preemie low- aim for pink
  infant or O2 sats 87-95 (minimize risk of eye
  damage limit oxygen toxicity).
• In term infants at risk for pulmonary
  hypertension keep oxygen high.

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• Respiratory distress gt 1st hr of life always
  think sepsis/pneumonia Rx accordingly.
• Apnea of prematurity is treated w/ aminophylline.
  Dilute IV form w/ clean water and give po/ngt if
  solution not available. (Caffeine OK too)
• Aminophylline
• Load 5-6 mg/kg IV or po
• Maintenance 1-2 mg/kg/dose q 6-8-12h IV/po
• Continuous Positive Airway Pressure (CPAP) may
  be useful in mild-moderate respiratory distress
  or apnea without a ventilator

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Bubble CPAP
Can also be done with modified NC
Depth of tube In water determines CPAP delivered
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Delayed umbilical clamping

• May increase newborn infants iron stores and
  reduce incidence of iron deficiency anaemia in
  infancy-important public health importance.
• (BMJ 1996312136-137, Grajeda et al Am J Clin
  Nutr. 199765425-431)?

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Maintenance of Body Temperature

• Hypothermia occurs when body temp (axillary)
  drops below 36.5C (97.7F).
• Neonatal cold injuries are common worldwide.

• Ethiopian hospital - 67 of LBW and high-risk
  infants admitted to NICU from outside were cold.
• India - mortality rate of hypothermic infants was
  twice that of infants without hypothermia.

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• Cold infants are more difficult to resuscitate.
• Hypothermia clearly ? morbidity/ mortality in
  newborns.
• Skin-to-skin contact immediately upon delivery
  in nursery greatly ? risk of hypothermia or cold
  injury.
• Exception is asphyxiated infant---data NOT
  complete so can not yet recommend cooling but
  absolutely should NOT overheat asphyxiated
  infants!!

Kangaroo Care Works!
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Doable
Dependable
Isolettes
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Hypoglycemia

• Defined as lt40-45 mg/dL
• IF possible confirm strips w/ blood glucose
• Major cause of morbidity especially in groups
  such as premies, SGA, and IDM
• Most cost effective strategy for preventing
  hypoglycemia is early frequent breast feeding
  (cup spoon or NGT if not able to feed _at_breast)

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Hypoglycemia cont.

• IF breast feeding not possible ? glucose can be
  treated in mild group w/ 5 glucose by mouth
  4-8cc/kg
• IF glucose lt25mg/dL treat w/IV D10W 2-4cc/kg (not
  D25 or D50)

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EXCLUSIVE BREAST FEEDING IS BEST
ASK A RHINO or a COW
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• Exclusive is KEY!
• Especially if mother is HIV

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Sepsis

• Sepsis is major cause of death world-wide in
  neonates
• Think about early cover broadly until able to
  rule-out
• REMEMBER-Any deviation from normal can be sepsis
  ??temperature, ??WBC, lethargy, ??glucose,
  vomiting, diarrhoea, any feeding intolerance,
  respiratory distress beyond 1st hour, etc, etc,

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Sepsis continued

• Amp/Gent reasonable choices
• Consider cloxacillin if staph likely in your
  nursery.
• Cefotaxime good choice for resistant gram neg
  organisms or meningitis if available
• DO NOT use Ceftriaxone in Neonates!

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Hyperbilirubemia

• May be largest unrecognized or silent cause of
  neonatal morbidity/mortality in the developing
  world
• Need to think about it, look for it, and when
  severe treat it---all huge challenges in most of
  the developing world.

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Traditional birth attendant (TBA)/CHW training

• Most babies in developing world (60-80) still
  born at homehalf without access to skilled
  care)?
• Trained TBAs do a better job of taking care of
  newborns than untrained TBAs!
• Continued training important as it is for all of
  us

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Thanks
The End
Reference list included-bulk from Bhutta et al,
Pediatric 2005115519-617)?