NEONATOLOGY

UNIT
PAEDIATRIC DEPARTMENT
HOSPITAL SULTAN HAJI AHMAD SHAH
TEMERLOH

GUIDELINES OF COMMON NEONATAL PROBLEMS

FOR HOUSE OFFICERS AND JUNIOR MEDICAL
OFFICERS

Prepared by:
Dr Lim Ee Tang Dr Suryati Adnan
Paediatrician Consultant, Paediatric Infectious Disease
Neonatal Intensive Care Unit & Head of Department
Hospital Sultan Haji Ahmad Shah Hospital Sultan Haji Ahmad Shah
October 2009

Updated by:

Dr Tan Hooi Kheng

June 2016
rd
(adapted from Neonatology Unit HKL guidelines and Paediatric Protocol, 3 Edition)
rd
For details reading please kindly refer to Paediatric Protocols For Malaysian Hospitals 3 Edition

1

GENERAL DUTIES FOR HOUSE OFFICERS IN NEONATOLOGY ROTATION

1) Make sure you get this copy of General Duties For House Officers on your first day of reporting from the
ward sister.
2) Read through the guidelines.
3) All new house officers must tag in SCN, Labour Room and OT until 11pm for at least 2weeks before
starting on-call.
4) Inform the ward sister if you are not NRP trained. Buy the Neonatal Resuscitation Programme book from
the sister.
5) All new house officers must be orientated by the ward sister on your first day of reporting.
6) All new house officers must report to the specialist in-charge of SCN/NICU on your first day of reporting.
7) SCN must NEVER be left unattended by house officers at any time of the day. At least 2 House Officers
must be in SCN at all times. Take turn to go to Hospital CMEs of House Officers Teachings. Make sure you
are contactable at all times if you are in-charge of SCN.
8) Do morning rounds and afternoon rounds with medical officers and specialist.
9) Clerk and manage new cases admitted. All new cases must be reviewed by the medical officer. Document
the date and time of every review of patients.
10) Take blood and set venofix for babies. KEEP THE PROCEDURE ROOM TIDY!
11) Trace serum bilirubin and other blood investigations taken in the morning before afternoon round.
12) BE PROACTIVE, if there is a neonatal resuscitation in labour room, OT, or NICU please come and observe
and volunteer to help.
13) If there is an exchange transfusion on that particular day, make sure you come and observe, even if its at
3am in the morning
14) All DISCHARGE SUMMARIES need to be done in 72 hours of discharge

2

 BASIC NEONATOLOGY

Fluid requirement (ml/kg/day)

Term Preterm
Day 1 60 Day 1 60
Day 2 90 Day 2 80
Day 3 120 Day 3 100
Day 4 150 Day 4 120
Day >4 150 Day >4 140

(1) Feeding policies
Generally, the rate of increment of feed is about 20mls/kg/day
The increment of feeding may be more if decide by the MO or specialist
Babies should be observed for feeding intolerance or abdominal distension before the next feeding
Feed should not be increased if aspirate is >30% of total volume given in the last feeding. Any
aspirate >10ml is considered excessive and need to inform your MO

(2) Target weight gain/Supplements
Target weight gain should be around 15g/kg/day (range 10-25g/kg/day). Less than this suggests that
calories need to be increase and need to work up for poor weight gain.
In preterm babies, increase feed accordingly to 180ml/kg/day
If baby on EBM, add HMF (human milk fortifier) when reach 75ml/kg/day
Babies that require high calories due to increase energy expenditure, e.g. chronic lung disease,
congenital heart disease, should consider adding MCT oil and polycose
Vitamins: add oral multivitamin 0.5mls to 1ml daily and oral folic acid 0.5mls to 1 ml daily after day 14
of life, when on feeding 150ml/kg/day
Iron: add oral FAC (ferric ammonium citrate) elemental iron 6mg/kg (1cc FAC equal to 16mg
elemental iron, order in mls) daily at day 28 of life

3

Admission to SCN from LABOUR ROOM/OT

1. Prem 35 weeks to <37weeks

2. Birth weight <2kg
3. Birth weight >4kg
4. Respiratory distress:
a. Grunting
b. Respiratory rate >60 breaths/min
c. Chest recessions
d. Cyanosis
5. Infant of diabetic mother on Insulin
6. Infant of substance abuse mother
7. Infant of mother with RVD positive
8. Infant of mother with VDRL positive
9. Infant with risk of sepsis (refer the sepsis protocol)
10. Birth trauma Subaponeurotic Haemorrhage, Erbs Palsy, extensive bruises
11. Concern about condition after initial resuscitation (eg: poor perfusion, grunting or pale) with Apgar score
< 6 at 5 minuates of life
12. Infant of Rhesus negative mother
13. Baby with G6PD
14. Infant of previous siblings diagnosed/suspected Inborn Errors of Metabolism (IEM)
a. Previous siblings usually have follow-up under genetic and metabolic team HKL
b. Please ask mother whether any plan of delivery discussed with her by the genetic and metabolic
team for this current pregnancy. Usually this already been planned.
15. All babies whose mother has significant illness
a. Dengue fever
b. SLE
c. Myasthenia gravis
16. All babies with major congenital malformation
17. All down syndrome babies
18. MMSL/TMSL

4

Admission to SCN from POSTNATAL WARDS

1. Babies who cannot maintain temperature (hypothermia)

2. Babies who cannot maintain blood sugar, eg: infant of Diabetic Mother on Diet Control who developed
hypoglycemia in ward
3. Neonatal Jaundice
a. Onset of jaundice <24hours (pathological jaundice)
b. Babies who developed jaundice in ward while awaiting mother who had caesarean section
4. Babies who are unwell at post-natal ward
a. Poor feeding
b. Lethargy
a. Vomiting
b. Abdominal distension
c. Babies who do not pass urine by 24hours
d. Babies who do not pass motion by 24-48hours

Admission to POSTNATAL WARD (Review Upon Call)

Infant with single mother (booking done with negative infection screening)
Infant with 1 risk of sepsis (maternal UTI)
GDM with diet control
Infant of Hepatitis B carrier mother
Sacral dimple
Ear abnormalities
If uncertain at any time, please do not hesitate to ask the Specialist

Cases For MO Paediatrics To Standby During Deliveries

1. All cases of emergency caesarean section/ instrumental deliveries / spontaneous vertex deliveries with
FETAL DISTRESS
2. All deliveries with MECONIUM STAINED LIQUOR
3. All prematurity deliveries < 35 weeks or less than 1.8kg
4. Cases with per vaginal bleeding secondary to abruptio placenta/ placental praevia
5. Multiple pregnancies
6. Cord prolapsed
7. Hydrops fetalis
8. Severe malformation diagnosed antenatally

Cases that can consider to allow HO Paediatrics to standby with MO Paediatrics knowledge:

1. Elective caesarean section for fetal macrosomia/ breech/ unstable lie/ GDM on insulin
2. Emergency caesarean section for fetal macrosomia/ breech/ unstable lie/ GDM on insulin with CTG
REACTIVE
3. Emergency caesarean section for poor progress with CLEAR LIQUOR & CTG REACTIVE

* Gestation of 35 weeks to 37 weeks + 6 days will depend on individual cases, with/ without maternal risk
factors, estimated fetal weight etc

5

GUIDELINES FOR COMMON ADMISSION TO SCN

(ALL NEW ADMISSION MUST BE REVIEWED BY MEDICAL OFFICER)

SEPSIS PROTOCOL

Risk factors for early onset neonatal sepsis

1. Spontaneous onset of preterm labour (<37weeks gestation)

2. Amniotic membrane rupture (PPROM or PROM) >18hours
3. Intrapartum temperature >38C
4. Chroamnionitis
a. Maternal fever > 38 degree celcius and 2 or more following criteria
b. Maternal tachycardiac > 100bpm, Maternal leukocytosis > 15, Maternal positive blood culture,
Uterine tenderness, Foul smelling of amniotic fluid, Fetal tachy > 160
5. Maternal GBS
6. GBS bacteruria during pregnancy
7. Previous history of infant with GBS disease
8. Recurrent UTI ( 2 or more episodes) after 30weeks of gestation
9. Suspected or confirmed infection in another baby in the case of multiple pregnancy

Clinical signs for sepsis

Respiratory distress
Apnea
Marked increase or decrease in heart rate
Unexplained hypotension
Hypothermia (axillary temperature persistently <36.5C that does not respond to environmental
measures) or fever
Pale, mottled skin colour, poor capillary refill
Poor feeding
Hypoglycaemia/hyperglycaemia
Lethargy, decreased tone or irritability
Abdominal distension, vomiting
Seizure
Severe jaundice

6

 YES
Admit SCN
Sign of neonatal sepsis

Septic work-up
CXR (if presence of respiratory signs)
Start antibiotic therapy within 1 hour

NO
Admit SCN
YES
Septic work-up
Maternal chorioamnionitis

CXR (if presence of respiratory signs)

Start antibiotic therapy within 1 hour
NO
NO

Presence of IAP indicated for GBS Routine clinical care
prophylaxis?

YES YES Admit SCN
Observation for 48 hours
Mother received 4 hours of IV If 2 risk factors excluding GBS, then

penicillin, ampicillin or cefazolin septic work-up and start antibiotic

before deliver? therapy within 1 hour

NO
YES Admit SCN

Mother with previous history of infant Septic work-up
with GBS disease
Start antibiotic therapy within 1 hour

NO Admit SCN

YES Septic work-up
Observation for 48 hours
Premature < 37 weeks

If 2 risk factors, admit SCN, septic work-
NO up and observation for 48 hours
YES If 3 risk factors, admit SCN, septic work-
Other risk factors as listed up and start antibiotic therapy

7

Septic Workup

Septic workup include blood culture and FBC at birth, CRP at 12 hours
of life
Chest X ray is indicated if respiratory abnormality presence
Lumbar puncture is indicated in any infant with a positive blood
culture or in whom sepsis is highly suspected on the basis of clinical
signs, response to treatment and laboratory result
Infant with IAP indications, gastric larvage need to be taken for
culture, ear swab is not indicated

IAP indications for prophylaxis

Mother GBS positive

Spontaneous preterm delivery less than 37 weeks
Rupture of membrane > 18 hours
Maternal pyrexia
GBS bacteriuria during pregnancy
Previous history of infant with GBS disease

What to do if FBC and CRP abnormal?

1. If the first FBC abnormal (WCC < 5 or >25, platlet < 150) to start antibiotics or continue
antibiotics, repeat FBC at 48 hours
a. If repeated FBC normal, child asymptomatic, CRP normal, allow discharged
b. If repeated FBC abnormal or child symptomatic to consult your specialist
2. If CRP > 10mg/dL, child asymptomatic, continue antibiotics at least 5 days, trace the blood
culture and consult the specialist
* The specialist should be consulted to guide further management if unsure or situation that not stated
in the protocol

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INFANT WITH RESPIRATORY DISTRESS

Clinical sign of respiratory distress

Tachypnea > 60bpm

Grunting brathing against closed glottis
Vhest retraction and recession
Nasal flaring
Cyanosis
Saturation less than 95%

1. Admit to SCN
2. Keep NBM
3. IVD full maintenance
4. Head box oxygen 5L/min or nasal prong oxygen 2L/min (nasal prong air for premature baby)
5. Put baby on continuous SPO2 monitoring for first hour then if stable 4 hourly
6. Maintain saturation at 95% to 98%
7. Dextrostix stat and 4 hourly
8. Keep baby warm put under warmer
9. Review after 2 to 4 hours
10. Investigations:
FBC
CRP at 12 hours
Blood culture
VBG/ABG
Chest x-ray
11. Babies with risk of sepsis, start
IV C-Penicillin 100,000 units/kg BD
IV Gentamicin 4mg/kg daily (term), for prem refer drug database
12. If baby becomes more tachypnoeic, cyanosed, grunting, SPO2 <95%, to inform MO stat

9

INFANT WITH HYPOGYCAEMIA

Definition of hypoglycaemia
st
BG < 2.6mmol/L after 1 4 hours of life

*From birth to 4 hours, glucose level above 1.5mmol/L is acceptable if the infant is asymptomatic

Risk factors for hypoglycaemia

1. Infants of diabetic mothers

2. Large gestational age
3. Small gestational age
4. Premature babies
5. Babies with polycythemia

Clinical signs of hypoglycaemia

Major: Apnea, convulsions and coma. Rarely prolonged hypoglycaemia may cause congestive heart failure
or persistent pulmonary hypertension
Minor: Jitteriness, irritability, tremors, apathy, cyanotic spells and temperature instability

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 Hypogycaemia blood glucose < 2.6

Blood glucose < 1.5 or symptomatic BG 1.5 - < 2.6 and asymptomatic
(0 4 hours of life)

IV D10% 2-3mls/kg bolus Give supplement as soon as possible

IV D10% at 60 -90mls/kg/day If refuse feed, IV D1)% 60cc/kg/hour

Repeat BG in 30 minuates

If still hyoglycaemia:

Re-evaluate
Increase concenetration to D12.5% or D15% (need central line for D15% and above)

Repeat BG in 30 minuates

If still hypoglycaemia:

Re-evaluate
Increase volume by 30cc/kg/day
If BG < 1.5, give D10% 2-3mls/kg bolus then porceed flow chart

Repeat BG in 30 minuates

If glucose delivery > 8mg/kg/min and persistent hypoglycaemia:

IV Glucagon 40mcg/kg stat then 10-50mcg/kg/hr (not fot SGA or adrenal insufficiency
IV Hydrocortisone 2.5-5mg/kg/dose esp in SGA
PO Diazoxide 10-25mg/kg/day in 3 divided doses (in hyperinsulin, not in SGA)
SC Octreotide 2-10mcg/kg/day 2-3 times/day or infusion

Consider further workup if:

Failure to maintain normal BG despite glucose infusion rate of 15mg/kg/min

When stabilised is not achieved in 7 days of life

Once BG > 2.6mmol/L for 2 readings, monitor hourly x 2 then 2 hourly x 2 then 4 to 6 hourly
11

 1. Always check for the cause of hypoglycaemia and risk factor of hypoglycaemia
2. If the child on IV drip, ensure the line is secure
3. If persistent hypoglycaemia, need to inform your superior for further workup
4. The above flow chart is especially for newborn, should the child already few days of life without
hypoglycaemia and suddenly DXT < 2.6mmol/L, need urgent evaluation for possibility of sepsis, hence
need to discuss further with your superior for further management


Calculate glucose requirement: D% x drip rate (ml/hour)
mg/kg/min
Weight (kg) x 6

If glucose requirement > 12mg/kg/min, consider hyperinsulinism/inborn error of metabolism

During episodes of hypoglycemia (when glucose requirement > 15mg/kg/min), do

RBS
Ammonia
Lactate
VBG
Plasma amino acid
Acylcarnitine
Urine organic acid
Serum ketones
Serum cortisol
Serum insulin
Serum growth hormones

12

NEONATAL JAUNDICE

Please refer to CPG management of neonatal jaundice (second edition) for photo level

1. Admit the child if following:

TSB above photo level
Pathological jaundice, onset of jaundice less than 24 hours of life
2. Start phototherapy as soon as possible
3. Investigations for intensive photo and ET level:
TSB
Babys blood group
Maternal blood group
FBC with retic count
Coombs test (if suspected hemolytic jaundice)
Blood culture/UFEME/Urine culture (if suspected infection)
4. For TSB at single phototherapy
Repeat TSB stat and coming morning
Allow breastfeeding or oral feeding
Allow discharge if TSB below photo level
5. For intensive photo
Start intensive photo (double photo)
Look for the possible causes of high jaundice e.g infection, UTI, ABO, G6PD, polycythemia etc
Repeat TSB 4 to 6 hourly
Allow full/demand feeding or breast feeding
6. For ET level or near ET level
Prepare for ET
Take consent for ET
Call and infrom blood bank there is a possibilities of ET and need fresh whole blood (less than 5 days
to 7 days blood) and prepare GXM
Insert UVC
For ET if
o Baby shows sign of acute bilirubin encephalopathy
o TSB 85micromol/L above ET levels
o TSB rises to ET level despite intensive photo
o TSB remains above ET level despite intensive photo
7. For evidence of ABO incompatibility eg, early onset jaundice, high retic counts, coombs positive consider
early IVIG (to discuss with specialist)
8. Discharge plan
Repeat TSB in KK next morning
Need TCA Paediatric clinic and formal hearing assessment if peak TSB > 340micromol/L

13

EXCHANGE TRANSFUSION: refer Paediatric protocol

IVIG administration: 0.5gm to 1gm/kg over 4 hours

15 minuates: 0.5cc/kg/hour
15 minuates: 1cc/kg/hour
15 minuates: 2cc/kg/hour
15 minuates: 3cc/kg/hour
Remaining: over 1 to 3 hours

INFANT WITH POST PPV

1. After resussitation, if the child completely well then admit SCN

2. If no signs of asphyxia, can allow full feeding
3. Need to review back after 2 hours of post resusitation
4. May discharge to mother after 12 hours of observation

INFANT WITH MECONIUM STAINED LIQOUR

1. Admit SCN
2. If tachypnea
Do chest x ray
NP Oxygen 2L/min
NBM
3. If not tachypnea
Allow full feeding
Observe for 6 to 12 hours then allow discharge
4. Need to review child again within 6 hours of life, if not tachypnea, chest x ray clear, may off oxygen and
start feeding

PRETERM <37WEEKS

1. Admit HDU if less than 34 weeks, if more than 34 weeks can admit SCN
2. Put baby under warmer, monitor temperature 4 hourly
3. Inform if hypothermia <36.5C
4. If weight <1.5kg, place baby inside incubator
5. Dextrostix stat, if stable, do hourly dextrostix x 2, if stable, then 2hourly x 2, if stable, then 4 hourly
dextrostix monitoring
6. Start oral feeding if no contraindication start slow (eg: 3ml/3hourly) and step up accordingly (not more
than 20mls/kg/day)
* There is no consensus about ideal feeding practices; every individual has the unique tailored feeding
regime based on the presence of risk factors each individual has and specialist clinical decision
7. Allow breast feeding if no contraindication
8. Discharge criteria
Temperature and dextrostix stable after 24 hours
At least CGA 35 weeks

14

BIRTH WEIGHT<2KG (TERM SGA)

1. Put baby under warmer. Monitor temperature

2. If <1.5kg, put baby inside incubator
3. Dextrostix stat, if stable, do hourly dextrostix x 2, if stable, then 2hourly x 2, if stable, then 4 hourly
dextrostix monitoring
4. Take FBC for polycythemia
5. Allow feeding if no contraindication
6. Identified causes of small for gestational age eg maternal PIH etc
7. If causes not identified, check for evidence of intrauterine infection (red reflex, hepatosplenomegaly and
ultrasound cranium for calcification)
8. Do not routinely take TORCHES if no signs of intrauterine infection
9. Discharge if dextrostix stable, feeding well, BO and PU after 24hours
10. Discharge weight need to be > 1.8kg

INFANT OF DIABETIC MOTHER ON INSULIN

1. Dextrostix after 30 minuates of feeding

2. If stable, do hourly dextrostix x 2, if stable, then 2hourly x 2, if stable, then 4 hourly dextrostix monitoring
for 24hours
3. Allow breastfeeding if no contraindication
4. If mother not around, to give oral feeding demand feeding within 1 hour of life
rd
5. If hypoglycemia, refer to hypoglycemia flow chart (Paediatrics protocol for Malaysian Hospital 3 edition)

INFANT OF DIABETIC MOTHER ON DIET CONTROL

1. Admit to postnatal ward

2. If stable, do hourly dextrostix x 2, if stable, then 2hourly x 2, if stable, then 4 hourly dextrostix monitoring
for 12hours (mother discharge after 12 hours)
3. To admit SCN at any point of time if the dextrostix is less than 3mmol/L

BIRTH WEIGHT >4KG

1. Dextrostix stat, if stable, do hourly dextrostix x 2, if stable, then 2hourly x 2, if stable, then 4 hourly
dextrostix monitoring
2. Evaluate carefully for birth injuries
3. Allow feeding if no contraindication. Start feeding with at least 60ml/kg/day. Then call mother for
breastfeeding
4. Discharge if dextrostix stable, feeding well, BO and PU after 24hours

15

INFANT WITH SUBAPONEUROTIC HEMORRHAGE

1. Common in instrumental delivery

2. The first few hours are extremely important
3. Baby may develop hypovolemic shock due to acute blood loss
4. Assess haemodynamic status of baby
Blood pressure stat, inform if MAP <45mmhg
Inform if heart rate >160bpm
5. Measure head circumference stat, then do hourly x 4, if stable, then 4 hourly for the first 24hours
6. BP/HR monitoring hourly x 4, if stable, then 4 hourly for the first 24hours
7. Inform MO stat if rapid increment of head circumference or baby becomes pale
8. Blood investigations (must be sent urgent and trace within 1 hour)
FBC
PT/APTT/INR
GXM of mother and baby
9. All babies with SAH must be reviewed by MO within 30minutes of admission
10. If haemodynamically unstable,transfer to NICU/HDU

INFANT WITH CEPHALOHEMATOMA

1. Discharged to mother if baby well

2. Ensured SAH is not being missed before discharge to mother
3. Watch out for jaundice in postnatal ward

INFANT BORN TO RHESUS NEGATIVE MOTHER

1. Please go through antenatal red book to check whether indirect Coombs test has been done or not,
usually this would have been done.
2. Note whether any Rhogam was given to mother antenatally
3. If indirect Coombs test is negative, can be discharged to mother
4. If indirect Coombs test is positive, please ask O&G to send cord blood for:
FBC & reticulocyte count
ABO Group and Rhesus
Direct coombs test
Serum bilirubin
* The blood should be taken at birth if cord blood was not done
5. Trace the result urgently
6. Monitor for pathological jaundice in ward and treat accordingly

16

INFANT OF G6PD ENZYME DEFICIENCY

1. Admit to SCN
2. Observed for jaundice
3. Ideally to keep until day 5 of life, however if ward is full and child is well with no clinical jaundice (TSB <
160 micromol/L) the child can be discharged earlier at day 4 of life
4. Do not rely on visual inspection alone
5. TSB need to be taken before discharge and discharged according to the photo level
6. Before discharge
Advise the parents to check the TSB at nearest clinic until 1 week after birth
Educate the parents about G6PD and give the G6PD card to the parents
Advise the mother to avoid using mothballs, drugs and herbal

INFANT OF RETROVIRAL (RVD) POSITIVE MOTHER

1. Admit SCN
2. STRICTLY NO BREASTFEEDING IS ALLOWED
Breastfeeding confers an additional 14% risk of transmission
3. Start oral Zidovudine (AZT) within 6 hours of life as prophylaxis (total 6weeks)
Term: 4mg/kg BD
Prem: 1.5mg/kg BD for 2weeks, then 2mg/kg TDS for the next 4 weeks
4. If the mother is not adequately treated or high viral load or not treated, need to add Nivirapine 8mg/dose
nd
(BW < 2kg) 12mg/dose (BW > 2kg) for 3 doses: at birth, 48hours later and 96 hours after 2 dose
rd
Refer to Paediatric Protocol for Malaysian Hospital 3 Edition
5. Feed with fomula milk if no contraindication
6. Check mothers other infectious status VDRL, Hepatitis B
7. Investigations:
FBC
HIV DNA PCR
8. Educate parents regarding compliance of Zidovudine
9. Get clinic appointment 2weeks on discharge
10. BCG and Hepatitis B immunization after thorough cleaning off maternal liqour and vermix

17

INFANT OF MOTHER WITH VDRL POSITIVE

1. Must find out from antenatal red book whether mother is adequately treated or not
2. Criteria for adequate treatment:
Mother must be diagnosed/treated antenatally
Mother must be treated adequately with 3 doses of IM Benzathine Penicillin (treatment with
erythromycin is inadequate)
Mother must have completed treatment at least 1 month before delivery
Mothers VDRL titre must decrease 4 fold after treatment
3. If all 4 criteria are fulfilled, baby aymptomatic to treat with IM Benzathine Penicillin 50,000 units/kg 1
dose
4. If either one of the above criteria is not fulfilled, to treat as presumed congenital syphilis with:
IV C-penicillin 50,000 unites/kg/dose 12hourly for first 7 days, then 8 hourly for 10-14 days
5. Investigations:
Ask O&G to send for cord blood VDRL upon delivery
If not done, then immediately send babys blood for VDRL after delivery (to be done urgently)
FBC
Lumbar puncture send CSF for biochemistry, FEME, C&S , VDRL
6. Refer parents to STD clinic management if not already done
rd
*Refer to Paediatric Protocols for Malaysian Hospital 3 edition

INFANT OF MOTHER WITH HBsAG POSITIVE

1. No need to admit if baby is well

2. Make sure baby is given passive immunization on delivery, i.e. IM Hepatitis B Immunoglobulin 100 units
st
(0,5ml) and 1 dose of IM Hepatitis B Vaccination 1ml at contralateral thigh (active immunization)
3. Counsel mother regarding small risk of transmission (esp in HbeAg positive)
4. Allow breastfeeding after both passive and active immunization given
5. To complete primary immunization at nearest clinic
6. TCA infectious clinic at 8 months old
7. 1 month before TCA to take HbsAg and anti-HBS

INFANT OF HEPATITIS C MOTHER

1. Can be discharged to mother after delivery

2. To review the child in postnatal ward
3. Discuss with mother regarding feeding
4. No absolute contraindication for breast feeding, however if mother has cracked nipple, breastfeeding may
stop temporarily
* Transmission from breast milk has not been documented, although virus RNA can be found in breast
milk, however there is no recommendations concerning breastfeeding by HCV positive mothers
5. Give TCA in clinic at 18 months
6. To take anti-HCV 1 month prior to TCA

18

INFANT OF SUBSTANCES ABUSE MOTHER

1. Check the maternal history for what substance in used

2. Check any infectious screening done in antenatal book, if not done follow the unbooked unknown
infectious status protocol
3. Admit the child
4. Do Finnegan score
5. If Finnegan score more than 8 admit to HDU and may need to start oral morphine
6. Refer to NICU protocol for further management
7. If Finnegan score less than 8 admit to SCN
8. Refer to hospital social welfare (JKSP)
9. Baby can only be discharged after mother and baby have been reviewed by hospital social welfare

INFANT OF MOTHER WITH VARICELLA ZOSTER INFECTION

1. Infant born to mothers who develop varicella between 7 days antenatally and 14 days postnatally should
be admitted to SCN and nurse in isolation room
2. These babies should receive
i. 125 Zoster Immunoglobulin (VZIG) as soon as possible.
ii. If VZIG not available, give IVIG 400mg/kg and IV Acyclovir 15mg/kg/dose over 1 hour 8
hourly for 5 days
iii. If vesicles develop, to give Acyclovir 15mg/kg over 1 hour every 8 hourly for 7 days to 10
days
3. Mothers with varicella at time of delivery should be isolated from their newborns, breastfeeding is
contraindicated. Mothers should express breast milk in the meantime and commence breastfeeding when
all lesions have crusted
4. Neonates with varicella lesions should be isolated from other infants but not from their mothers

INFANT OF SINGLE, UNBOOKED, UNKNOWN INFECTIOUS STATUS MOTHER

1. Check whether mothers rapid test has been performed by labor room
2. If rapid test is negative, allow breastfeeding on demand
3. Counsel mother that baby needs to be screened for HIV, Hep B, Hep C, VDRL and please document in our
SCN notes
4. Refer to hospital social welfare (JKSP)
5. Baby can only be discharged after mother and baby have been reviewed by hospital social welfare
6. Must have formal documentation by social welfare in our SCN notes regarding the future care of the
baby before discharge
7. Verbal order from social welfare or documentation in O&G notes that baby can be discharged to mother
or adopted parents CANNOT BE ACCEPTED

19

INFANTS WITH BORN BEFORE ARRIVAL

1. Check maternal history and umbilical cord cut

2. If mother is booked case with no high risk behaviour and cord cut in sterile manner
3. Check FBC for polycythemia
If HCT is less than 60 may allow discharged to mother
If HCT is more than 60 admit to SCN
4. If unbooked and unscreen, admit to SCN
Check for FBC, HIV, Hep B, Hep C, VDRL
5. If unsteril cord cut
Admit SCN
Check FBC, CRP, Blood culture
Start antibiotic therapy
Give baby IM tetanus Immunoglobulin (TIG)

INFANT WITH SACRAL DIMPLES

1. Scaral dimples with any of these characteristics need to screen for neural tube defect
Multiple dimples
Dimple diameter > 5mm
Greater than 2.5cm above anal verge
Cutaneous stigmata (hair tufts, hemagioma, appendages)
Gluteal cleft abnormalities
Any midline skin lesions or more than one skin marking anywhere along the spine
2. Do x ray of the spine
3. Order ultrasound spine (the ultrasound should not be done later than 3 months old)
4. Give TCA Paediatrics clinic on the day of ultrasound
5. Inform the parents the possibilities of neural tube defect

INFANTS WITH EAR ANOMALIES

1. A renal ultrasound should be performed in patients with isolated preauricular pits, cup ears, or any other
ear anomaly accompanied 1 or more of the following
Other dysmorphisc features
Family history of deafness, auricular or renal malformations
2. All infants with an external ear anomaly should have an audiology evaluation to screen for hearing loss
3. Discharged to mother, give TCA clinic same date with ultrasound KUB

SALT THERAPY FOR UMBILICAL GRANULOMA

1. Apply small pinch of cooking salt onto the granuloma

2. Cover the area with gauze dressing swab and hold in for 10 to 30 minuates
3. Then clean the site using a clean gauze dressing soaked in warm boiled water
4. Repeat the procedure twice per day for at least 2 days
5. Watch out for infection
6. If not reponsed may need silver nitrate treatment

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