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● Clinical Guidelines are listed alphabetically.


❍ Titles without an underline are not yet available online, or have been withdrawn.

● If you are looking for a specific topic and cannot find it in the list below, click here to open the search page.

● Paediatric Resources (Starship)


● aA Ratio ● Gestation-Based Flow Sheet (intranet only)
● AaDO2 calculator (now only available via NICU ● Parenteral nutrition
database) ● Parenteral nutrition worksheet
● Abbreviations in use in Newborn ● Gestational Age Calculator
for individualised solutions
Services ● Glucose calculator
Granulocyte transfusion
● Parent Infant Nursery
● Acute Fatty Liver of Pregnancy - ●
● Parvovirus
Investigation of Infants
● Patent ductus arteriosus
● Admission Rates to NICU and
● Percutaneous Central Venous
Respiratory Support
Catheter Insertion
Requirements
● Perinatal asphyxia
● Admissions & Discharges from
(links to the Neonatal
NICU/SCBU encephalopathy guideline)
● Admissions from Home ● Periventricular leukomalacia
● Adoption procedure ● Persistent Pulmonary Hypertension
(intranet link to ADHB policy) of the Newborn (PPHN)
● Albumin ● Phototherapy
❍ Albumex TM4
● Chest physiotherapy
❍ Albumex TM20
● Haematological Disorders in the ● Physiotherapy
● Alcohol in Pregnancy ● Plasma
Neonate
● Ambiguous Genitalia ● Plastic wrap of babies <30 weeks
● Haematology values
● Anaesthetic and Self Inflating Bags ● Platelets
- Laerdal ● Handling small babies
❍ Platelet concentrates
● Analgesia for Simple Procedures ● Head Cooling following ● Pneumothorax and Underwater
● Ankyloglossia Perinatal Asphyxia Sealed Drainage
● Antenatal Doppler ● Head ultrasound scans
● Postnatal ward care
● Antenatally Diagnosed Congenital ● HELLP Syndrome - ● Postnatal ward obstetric care
Heart Disease Investigation of Infants ● Prevention of hypothermia in infants
● Antenatally Diagnosed Renal Tract Hepatitis B Vaccination
● <30 weeks gestation
Anomalies Hepatitis C
● ● Prolonged and Late-Onset Jaundice
● Anticonvulsant use in pregnancy
❍ Hepatitis C - Nursing
● Antimicrobial therapy
Care
● Apnoea monitoring (Home)
● Apnoea monitoring and caffeine
● High Frequency Ventilation
● Assignment of Consultant in Charge ● High Risk Deliveries
of Infants ● Human Immunodeficiency Virus
● Auditory testing ❍ HIV - Nursing Care of

Babies
● Humidification
● Hydrops
● Hyperglycaemia
● Hyperkalaemia
● Hypertension
● Hypoglycaemia ● Radiology Requirements in
● Hypospadias NICU
● Baby Safety ● Hypotension ● Red Blood Cell Transfusions
● Back to Sleep ● Hypotonia ● Renal Tract Anomalies
(intranet only) ● Hypoxic Ischaemic ● Respiratory Indices Calculator
● Bilious vomiting Encephalopathy ● Reticulocytes
● Blood Products ● Retinopathy of Prematurity
❍ Red Cells ● ROP Screening Form
❍ Immunoglobulin (Intranet only)
❍ Platelets ● Rotavirus
❍ Albumin (TM4 and TM20)

❍ FFP
❍ Buffy Coat
❍ Cryoprecipitate

● Blood Pressure
❍ Hypotension ● Immunisations
❍ Hypertension Immunisation of Preterm Infants
Immunoglobulin ● SARS
● Blood sampling ●

Infant of Diabetic Mothers (Severe Acute Respiratory


● Borderline viability ●

INIS Study Syndrome)


● Breast milk additives and ●

Intracranial Haemorrhage ● Seizures


handling of formula ●

Intravascular catheters ● Sepsis


● BRM2 Monitor ●

Intravenous cannulation ● Single Umbilical Artery


● Budesonide ●

● Buffy Coat Concentrates ● Intravenous and Medication ● Skeletal Surveys


Certification ● Skin Care ELBW (<1000g)
● Intravenous Drug Compatibility and VLBW (<1500g) Babies
● Small-for-Gestational Age
● Intravenous Nutrition
Infants
● Intravenous nutrition -
● Solid foods for Premature Infants
individualised prescription
(58KB pdf file)
worksheet
● Caloric Calculator ● Specialist Responsibilities
● Intraventricular haemorrhage
● Capillary Blood Sampling ● Spina bifida and
● Intubation
● Care map for infants <32 weeks meningomyelocoele
● Isolation
gestation ● Sucrose Analgesia
● Chickenpox ● Suctioning
● Child Development Services ● Surfactant
❍ Surfactant on Level 2
(Community)
This link opens the fax referral ● Surgical Guidelines
form. For information on criteria for ● Surgical Neonates
referral, click here ● Survival statistics
● Child Development Unit (borderline viability guideline)
● Cleft Lip and Palate
● CLD review
Chronic Lung Disease Discharge ● Jaundice
❍ Jaundice on the
● Collapsed ventilated baby
● Complementary and alternative Postnatal Ward
medicine (CAM) ● Jehovah's Witnesses and Blood
● Congenital Heart Disease
(Antenatally Diagnosed)
● Congenital Heart Disease -
Screening of First Degree
Relatives
● Congenital infection
● Conjugated hyperbilirubinaemia ● Laboratory tests ● Thermal environment
● Conjunctivitis ● Large-for-Gestational Age ● Thrombocytopenia
● Consent Infants (see also Neonatal Alloimmune
● Continuous Positive Airway ● Life Support Withdrawal Thrombocytopenia)
Pressure (CPAP) ● Longline Insertion ● Thyroid disorders (maternal)
● Coroner's Act 1951 ● Tongue-Tie
● Cranial ultrasound scans ● Top up transfusion readmissions
● CRP (C-Reactive Protein) ● TORCH infections
● Cryoprecipitate ● Trainee interns
● Cytogenetics ● Transfer of Infants to the
● Cytomegalovirus ● Meconium stained liquor Postnatal Ward after Brief
● Metoclopramide (Maxolon) and Admission to NICU
Breastfeeding ● Transfers
● Metabolic Bone Disease ● Transfusion Handbook
● Metabolic disorders ● Transport and retrieval
● Metabolic screening Transports
● Milk - Drugs in Breast milk
(links to MedSafe website)
● Multiple Birth Association

● Death on NICU
● Ultrasound scans (cranial)
● Delivery attendance
● Umbilical Catheter Insertion
● Developmental care
● Urinary Catheterisation of the
● Developmental paediatric
Newborn
service
● Urine Measurement & Urinalysis
● Developmental Therapists
● Urine sampling
● Dexamethasone for CLD
● Dietitian referral
● Discharge summaries
● Documentation on NICU
● Domperidone as a Galactogogue
(Domperidone and
Breastfeeding)
● Down Syndrome
● Drug dependant mothers

● Narcotic depression ● Vaccinations


● Nappy rash ● Vascular Malformation Clinic
● Neonatal Alloimmune ● Ventricular Reservoirs
Thrombocytopenia ● Visiting therapy
(NAIT) ● Vitamin K
● Neonatal Encephalopathy
● Neonatal Nutrition
(links to ADHB Nutrition Services
● ECG
Intranet site)
● ECMO
● Nephrocalcinosis
(Extracorporeal Membrane
● Neural Tube Defects
Oxygenation)
● Newborn Examination ● Weighing Babies
● Environmental and
● NICU Nutrition Guidelines ● Weight Conversion Calculator
Developmental Care
● Nitric Oxide (Kilos-to-Pounds and Pounds-to-
● Exchange transfusion
Kilos)
● Withholding feeds

● Feeding
● Feeding and Nutritional
guidelines ● Operating Room Issues for
Neonatal Staff ● Zinc deficiency
● Feeding on postnatal wards
● Fetal Alcohol Syndrome ● Orthopaedic problems
Alcohol in Pregnancy ● Osteopenia of prematurity
● Fluid and electrolytes ● Oxygen therapy and monitoring
● Fluid and electrolyte calculator ● Oxygen therapy standing orders
● Follow-up ● Oxygen Saturation Targets
● Forms (intranet only) ● Oxygen - low flow calculator
❍ Exchange transfusion results ● Home oxygen
❍ Exchange transfusion record ● Oxygenation Index Calculator
❍ Telephone advice sheet
● Formula Handling and Breast
Milk Additives
● Fractional Excretion of Sodium
● Fresh Frozen Plasma
Home | Contact Us | Phone Directory | Search

● Drugs are indexed alphabetically by their generic name. Trade names are included for user reference.
● Some of the drugs listed below do not have protocols available. This is either because they have been withdrawn (in
which case, hard copies are available through Carl Kuschel) or because protocols are currently under construction.
Those without protocols are not underlined.

Generic Trade Generic Trade Generic Trade

Acyclovir Zovirax IV Erythromycin EES Pancuronium Pancuronium


sodium ethylsuccinate bromide bromide
Adenosine Adenocor Erythromycin Erythromycin DBL Paracetamol Panadol,
lactobionate Pamol
Adrenaline Adrenaline Erythropoietin Recormon , Paraldehyde Paraldehyde
hydrochloride (Recombinant Exprex, Epoetin
Human)
Amikacin Amikin Phenobarbitone Gardenal
sulphate sodium sodium
Amiloride Midamor Fentanyl citrate Sublimaze Phenylephrine Metaoxedrine
hydrochloride
Aminophylline Aminophylline Ferrous gluconate Fergon Phenytoin sodium Dilantin
Amiodarone Cordarone X Ferrous sulphate Ferro-liquid Phytomenadione Vitamin K,
hydrochloride Konakion
Amoxycillin Ibiamox Flucloxacillin Floxapen, Piperacillin sodium Pipril
sodium Flucloxin
Amphotericin B Fungizone Fluconazole Diflucan Poractant alpha Curosurf
Atropine Atropine Flucytosine Alcobon Potassium chloride Potassium
sulphate
Frusemide Frusemide DBL, Propranolol Inderal
Lasix hydrochloride
Benzylpenicillin Crystapen, Prostaglandin E1 Paediatric
Penicillin (Alprostadil) Prostin VR
Sodium
Biochemie
Beractant Survanta Gaviscon Gaviscon Pyridoxine Vitamin B6
hydrochloride
Budesonide Pulmicort Gentamicin Gentamicin DBL
sulphate
Glucagon Glucagen hypokit Ranitidine Zantac
hydrochloride
Caffeine Caffeine Rifampicin Rifampin
Calcium Calcium Heparin sodium Heparin
gluconate gluconate
Carbamazepine Tegretol Hydrochlorothiazide Hydrochlorothiazide Salbutamol Ventolin,
Respax
Cefaclor Ceclor Hydrocortisone Solu-cortef Sodium bicarbonate Sodium
sodium succinate bicarbonate
Cefotaxime Claforan Sodium Chloride Sodium
sodium Infusion Chloride
(links to fluid
guideline)
Cefoxitin Mefoxin Ibuprofen Brufen Sodium Intal
sodium cromoglycate
Ceftazadime Fortum Imipenem / Primaxin Sodium nitroprusside Nipride
pentahydrate Cilastatin sodium dihydrate (DBL)
Ceftriaxone Rocephin Indomethacin Indocid Sodium polystyrene Resonium A
disodium sulphonate
Cefuroxime Zinacef Insulin (neutral) Actrapid penfill Sotalol hydrochloride Sotacor
sodium
Cephalothin Keflin Intralipid 20% Intralipid Spironolactone Aldactone
Chloral Hydrate Ipratropium Atrovent Sucrose 66.7% Syrup BP
bromide (Medical Guideline)
Chloramphenicol Chloromycetin Isoprenaline Isoproterenol, Suxamethonium Ethicholine
sodium hydrochloride Isuprel chloride
succinate
Chlorothiazide Chlorothiazide
Chlorpromazine Largactil Lignocaine Xylocaine Thiopentone sodium Pentothal
hydrochloride
Cisapride Prepulsid Ticarcillin disodium Tarcil
Clonazepam Rivotril Magnesium Magnesium Tolazoline Priscoline
sulphate hydrochloride
Cotrimoxazole Meropenem Merrem Trichloroacetaldehyde Chloral hydrate
(links to HIV hydrate
guideline)
Cyclopentolate Cyclogyl Metoclopramide Maxolon Tromethamine THAM
hydrochloride hydrochloride
Metronidazole Metronidazole
(Baxter)
Dexamethasone Dexamethasone Miconazole Daktarin Urokinase Ukidan
sodium DBL,
phosphate Decadron
Diazepam Valium Midazolam Hypnovel
Diazoxide Hyperstat Morphine Morphine Vancomycin Vancocin CP
hydrochloride hydrochloride
(Oral)
Digoxin Lanoxin Morphine sulphate Morphine Vitadol C Vitadol C
(IV)
Dobutamine Dobutrex Vitamin K Konakion
hydrochloride (Phytomenadione)
Dopamine Dopamin Naloxone Narcan
hydrochloride hydrochloride
Doxapram Dopram Neostigmine Neostigmine
methylsulphate
Nestargel Nestargel
Netilmicin sulphate Netromycin
Nitric oxide Nitric oxide
Nitroprusside Nipride
Noradrenaline Levophed
Nystatin Mycostatin, Nilstat
Last edited Monday, 09 January 2006
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday, May 21,
2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Respiratory Indices Calculator


Reviewed by Carl Kuschel

Oxygenation Index (OI)


Ventilation Index (VI)
September
Arterial Alveolar Ratio (aA Ratio) 2005
Alveolar Arterial Oxygen Difference (AaDO2)

Respiratory indices have two main uses:

● Eligibility for determining a eligibility for a treatment (for example, OI for ECMO) or research
intervention (for example, AaDO2 for the LessMAS trial)
● Research or audit purposes when evaluating the amount of respiratory support required for
individual babies, particularly when making comparisons between differing levels of support
that an infant may require.

● All calculations are performed using mmHg.


Blood If you choose kPa, the values will be converted to
gas units: -Choose- mmHg

% 100
%
inspired
oxygen
PaO2

PaCO2

Ventilation Choose ventilation


mode

Calculate Reset
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Abbreviations in Use in Newborn Services Reviewed by Charge Nurse -


Newborn and Carl Kuschel

July
2004

Introduction

● The following list is an accepted list of abbreviations that can be used in


documentation within the Newborn Service at National Women’s Health.

A-M N-Z
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

AB Apex beat N10 Newborn intravenous


nutrition 10% dextrose

ABG Arterial blood gas Na+ Sodium


AGA Appropriate for gestational NaHCO3 Sodium bicarbonate
age
AMSIS Auckland Maternity Service NBF Neville Barnes forceps
Information System
APH Antepartum haemorrhage NBM Nil by mouth
ARM Artificial rupture of NEC Necrotising enterocolitis
membranes
ASD Atrial septal defect NG Nasogastric
AXR Abdominal x-ray NICU Newborn intensive care unit
BE Base excess NIF National Women’s infant
formula
BP Blood pressure NO Nitric oxide
BPD Bronchopulmonary dysplasia NO2 Nitrogen dioxide
BW Birthweight NND Neonatal death
Ca++ Calcium NP Nasophargyneal
CCN Clinical Charge Nurse N.PR Nasal prongs
CDH Congenital diahragmatic NSA Normal serum albumin
hernia
CHD Congenital heart disease NVD Normal vaginal delivery
CLD Chronic lung disease OA On admission
CMV Cytomegalovirus OG Orogastric
CNC Clinical Nurse Consultant OT Operating theatre
CO2 Carbon dioxide OTT Orotracheal tube
CPAP Continuous positive airway P5 Premature baby intravenous
pressure nutrition 5% dextrose
CVL Central venous line P7.5 Premature baby intravenous
nutrition 7.5% dextrose
CVP Central venous pressure P10 Premature baby intravenous
nutrition 10% dextrose
CXR Chest x-ray PaCO2 Partial pressure arterial
carbon dioxide
D5W Dextrose 5% in water PaO2 Partial pressure arterial
oxygen
D10W Dextrose 10% in water Paw Mean airway pressure
DDH Developmental dysplasia of PDA Patent ductus arteriosus
the hips
DIC Disseminated intravascular PEEP Positive end expiratory
coagulation pressure
DU Delivery unit PIE Pulmonary interstitial
emphysema
EBM Expressed Breast Milk PIN Parent Infant Nursery
ECG Electrocardiogram PIP Peak inspiratory pressure
EDD Estimated date of delivery PINSP Peak inspiratory pressure
EEG Electro-encephalogram PPH Postpartum haemorrhage
ELBW Extremely low birthweight PPHN Persistent pulmonary
hypertension of the newborn
ET Expiratory time PPROM Prelabour premature rupture
of the membranes

ETA Estimated time of arrival PROM Prolonged rupture of


membranes
ETT Endotracheal tube PSV Pressure support ventilation
FAS Fetal alcohol syndrome PTU Phototherapy unit
FEBM Fortified expressed breast PVH Periventricular haemorrhage
milk
FDP Freeze dried plasma PVL or Periventricular leucomalacia
PVLM
FFP Fresh frozen plasma RDS Respiratory distress
syndrome
FH Fetal heart Resp Respiration
FiO2 Fraction of inspired oxygen RHT Radiant heat table
FLN Family Liaison Nurse ROP Retinopathy of prematurity
FLP Fresh lyophilised plasma RSV Respiratory synctival virus
FRC Functional residual capacity RV Residual volume
GPH Gestational proteinuria & SpO2 Oxygen saturation
hypertension
HFOV High frequency oscillatory SBR Serum bilirubin
ventilation
HIE Hypoxic ischaemic SGA Small for gestational age
encephalopathy
HMD Hyaline membrane disease SIMV Synchronised IMV

HPU Has passed urine SIPPV Synchronised IPPV


HR Heart rate SFD Small for dates
IA Intra-arterial SLE Systemic lupus erythematosis
ICP Intracranial pressure SRM Spontaneous rupture of
membranes
IDM Infant of diabetic mother SVD Spontaneous vaginal delivery
IDDM Insulin dependent diabetes T or Temp Temperature
mellitus
IE Ratio Inspiratory/expiratory ratio TAPVD Total anomalous pulmonary
venous drainage
IFD Intermediate fetal death TBW Total body water
IMV Intermittent mandatory TCM Transcutaneous monitoring
ventilation
Inc Incubator TE Expiratory Time
IPPV Intermittent positive pressure TGA Transposition of the great
ventilation vessels
IT Inspiratory time TI Inspiratory Time
IUCD Intrauterine contraceptive TLC Total lung capacity
device
IUD Intrauterine death Tet Tetralogy of Fallot
IUGR Intrauterine growth restriction TOF Tracheal oesophageal fistula
IV Intravenous TTN Transient tachypnoea of the
newborn
IVH Intraventricular haemorrhage TV Tidal volume
IVN Intravenous nutrition UAC Umbilical arterial catheter
IWL Insensible water loss UVC Umbilical venous catheter
K+ Potassium VC Vital capacity
KCL Potassium chloride VG Volume Guarantee
LBW Low birthweight VLBW Very low birthweight
LFT Liver function test V/Q Ventilation perfusion
LGA Large for gestational age VSD Ventricular septal defect
LMP Last menstrual period VT Tidal Volume
LP Lumbar puncture Vx Vertex
LSCS Lower segment caesarean ZIG Zoster immune globulin
section
MAP Mean arterial pressure
MAS Meconium aspiration
syndrome
Mec Meconium
Mv Minute volume
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Investigation of Infants born to Mothers with HELLP Reviewed by Carl Kuschel,


Syndrome and Acute Fatty Liver of Pregnancy Callum Wilson (Metabolic
Paediatrician), and Dianne
Webster (National Testing Centre)

August
2001

Introduction

An association has been demonstrated between long chain 3-hydroxyacyl-CoA-


dehydrogenase (LCHAD) deficiency and maternal HELLP (Haemolysis, Elevated Liver
enzymes, Low Platelets) and AFLP (Acute Fatty Liver of Pregnancy). This inherited,
autosomal recessive abnormality of fatty acid oxidation can result in significant morbidity
and mortality in infants if untreated. Treatment with dietary manipulation is possible.

Approximately 80% of infants with LCHAD diagnosed in childhood have been born after
pregnancies complicated by AFLP or HELLP. However, what is not known is how many
pregnancies complicated by AFLP or HELLP result in infants with LCHAD deficiency.

In view of the association, and the implications of detecting this condition early and
providing appropriate dietary and genetic advice, we recommend the following:

Guidelines for Screening

In pregnancies complicated by the HELLP syndrome or AFLP,

● Take the Newborn Screening Card at the usual time


● Send a specific lab form request with the screening card requesting Acylcarnitine
levels for detection of possible LCHAD deficiency.
● This will be processed by the National Testing Centre laboratory

A thorough family history is important. Infants should be observed for hypoglycaemia in


the early newborn period.

● If babies are symptomatic and LCHAD is considered a likely diagnosis, requests


should be marked as urgent.
Discuss with Dr Callum Wilson, Metabolic Paediatrician, if there are any clinical concerns.

References

1 Ibdah JA, Yang Z, Bennett MJ. Liver disease in pregnancy and fetal fatty acid oxidation defects. Molecular
Genetics and Metabolism 2000; 71:182-9.
2 Ibdah JA, Bennett MJ, Rinaldo P, et al. A fetal fatty-acid oxidation disorder as a cause of liver disease in
pregnant women. N Engl J Med 1999; 340:1723-31.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday, May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Admission Rates to NICU and Type of Respiratory Support Reviewed by David Knight and Carl
Required Kuschel

April
2003

Admission Rates and Support for all Babies Admission Rates and Support for babies 35-42 weeks

This guideline provides some data regarding admission rates by gestation, as well as the level of
respiratory support required.

● This information may be valuable when discussing anticipated neonatal care with parents who are
expecting a baby.
● Note that the figures include all babies, including those known before birth to have problems.
● Refer also to the Borderline Viability Guideline for information on infants 30 weeks gestation and
below.

Summary data are presented for the years 1999 and 2000. Further data will be added as available.

NICU Admission Rates and Respiratory Support for All Babies Born at NWH

NICU Admission Rates and Respiratory Support for Infants 35-42 weeks
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for Admissions to NICU, and Discharges Reviewed by Carl Kuschel


and Transfers from NICU

December
2005

Discharge of Low Transfers to and from Level


Admissions Discharge Documentation
Birthweight Infants 2 and PIN

Admissions

Guidelines for Admission to 1. Birthweight less than 1250g.


Level 3 2. Gestation less than 30 weeks. Some infants born
at 30-32 weeks may be admitted to Level 3
because of staffing acuity.
3. Requirement for intermittent positive pressure
ventilation.
4. Requirement for an exchange transfusion.
5. Any other baby whose clinical condition is such
that they cannot be appropriately cared for in
Level 2.

Guidelines for Admission to 1. Low Birthweight - under 2500g.


Level 2 Some babies between 2000 and 2500g may be
able to go directly to the postnatal ward.
This will depend upon the clinical assessment of
the baby and whether the postnatal ward is
deemed likely to provide an appropriate level of
care or not.
2. Prematurity - 36 weeks gestation or less.
For babies between 35 and 36 weeks gestation,
criteria as in (1) apply.
3. Infection - suspicion of infection together with
clinical concern.
4. Respiratory problems
(a) Apnoea or cyanotic episodes.
(b) Any respiratory distress causing concern.
(c) Persisting signs of respiratory distress for more
than one hour.
5. Gastrointestinal problems
(a) Feeding problems severe enough to cause
clinical concern.
(b) Bile stained vomiting, or other signs
suggesting bowel obstruction.
6. Metabolic problems
Inability to maintain a serum glucose
concentration greater than or equal to 2.6mmol/L
despite adequate feeding.
7. CNS problems
(a) Convulsion.
(b) Moderate birth asphyxia, which may require
monitoring for an initial period to ensure problems
do not ensue.
8. Malformations
Congenital anomalies that may require
intervention unavailable on the postnatal wards, or
an initial period of observation, eg Pierre Robin
Syndrome.
9. Cardiovascular
Problems requiring monitoring or intervention
unavailable on the postnatal wards.
10. Miscellaneous
Any baby that is causing concern to such a
degree that the attending doctor or NS-ANP feels
that the baby requires observation or treatment in
Level 2. It is better for a baby to be admitted
unnecessarily than for a baby requiring admission
to be left on the ward.
11. Social issues/terminal care
Such babies ideally be nursed on the ward with
parents, or at home. On occasions (after
multidisciplinary consultation) circumstances
dictate that these babies require a period of care
on Level 2.

Discharge of Low Birthweight Infants

Infants that have been born at very low birthweight or low birthweight, represent an at risk
group of children. Increasingly they are being discharged home at a weight less than
2.5kg. The following guidelines are suggested when considering discharge of such infants.

1. The baby has to be gaining weight - it doesn't have to have reached any
particular weight, however, as long as there is weight gain.
2. The baby has to be sucking all feeds.
If breast feeding is being established, it is not a prerequisite that the baby is on full
breast feeding prior to discharge, provided we are happy that the baby is able to
suck strongly.
However we must be sure that the mothers are aware of the need to continue to
monitor progress once further feeding changes are made at home, i.e. a switch
from complementing to fully breast feeding etc.
3. The baby must be able to maintain his or her temperature in a cot in a normal
household environmental temperature.
This is particularly important when discharging low birthweight babies home in the
winter.
4. Parents must be willing and happy to take the baby home and to have
demonstrated that they have adequate parenting skills.
This may be self-evident, particularly when there have been other children in the
family, although not always.
5. Some basic information should be known about the home environment and the
community to which the infant is going, i.e. if they are living in a remote area in a
caravan, then one would be less likely to effect a discharge home at a low
birthweight.
6. There should be adequate community follow up services available.
It may be appropriate to contact the general practitioner by telephone to discuss
follow up.
In remote areas details should be known about the availability of a Well Child
Service visiting.
The neonatal home care nurses will be able to provide some initial support and
follow up and to provide liaison for ongoing community follow up.

Transfers & Discharges from NICU and PIN

Transfers from Level 3

● For transfers from Level 3 to Level 2 or PIN a formal transfer should occur
between Level 3 Registrar or NS-ANP and the appropriate registrar or NS-ANP.
● Ideally the parents would have been told a few days in advance to accustom to the
transfer and possibly have looked around Level 2 or PIN.
● A transfer letter should be in the notes (and should also be sent to the LMC/GP).
● The problem list should be up-to-date (as should happen when a discharge/
transfer summary is prepared)

For infants discharged from Level 2

● Babies transferred to PIN need a formal letter if they have had a complicated
course whilst in Level 2. If they have had a recent transfer summary from Level 3
to Level 2, this may not be necessary.
❍ Babies who are transferred to PIN should have an up-to-date problem

summary in the notes.


● Babies transferred to other hospitals must not go without a registrar or NS-ANP
letter.
● Babies being transferred to towns outside the Auckland area should have a formal
letter prior to discharge.
Discharge Documentation

All patients discharged from hospital must have:

● A full examination record on the appropriate form (include age in days, weight,
length, head circumference).
● A plan for follow up clearly documented in the case notes.
● A record of any prescribed therapy.

Discharge Letters

● No baby is to be discharged from Level 3, Level 2, or PIN without a letter.


● For babies who are being discharged to the postnatal wards and where there are
going to be delays in generating a discharge letter, the baby can be discharged
with out a letter being available. However, it is the responsibility of the resident
team (registrar or NS-ANP) to ensure that a letter is completed as soon as
possible and is filed in the notes of the baby.
● PLEASE ENSURE that the discharge letter contains the correct information.
❍ The database can only use the information available within it.

❍ It provides a structure for the letter, and makes an attempt at providing a

letter that is nearly complete. You need to check the letter you have
produced and edit it in Word.
● The quality of the letters you sign your name to reflects on your abilities as well as
the quality of the care that the baby has received in NICU. PLEASE CHECK AND
EDIT THE LETTERS BEFORE YOU SIGN THEM AND SEND THEM OFF.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines on Admission to NICU from Home Reviewed by Simon Rowley


(Home Delivery or Early Discharge)

December
2000

The following guidelines cover admissions to the Neonatal Unit for babies who have been
delivered at home, have been discharged early or recently from NICU/PIN, and in whom
problems arise.

The general principles are:

1 Ideally babies admitted should be isolated, nursed in incubators or single room.


2 All home births under 48 hours of age can be considered for admission.
3 Some home births, early discharges and recent NICU/PIN discharges between
48 hours and 1 week, can be considered.
4 Few babies over 1 week of age, or discharged home > 1 week, would qualify for
admission.
a: Those needing specific neonatal expertise, e.g.:

● Low birthweight (including recent NICU/PIN discharge).


● Birth asphyxia, or convulsions in first 48 hours.
● Early onset respiratory distress (48 hours).
● Meconium aspiration syndrome.
● Jaundice requiring phototherapy or exchange transfusion.

b: Those infants requiring expertise likely to be more appropriately managed at


other institutions, should be referred accordingly, eg:

● Congenital heart disease or severe cyanosis in the absence of other


respiratory symptoms – Green Lane Hospital.
● Congenital malformations requiring assessment – Starship Hospital.
● Obvious surgical problems – Starship Hospital.
c: Infants with problems that appear infectious and particularly in which isolation
will be a priority, should be directed to Starship Hospital, e.g. respiratory viral
infections, apnoea – bronchiolitis, gastro-enteritis and Herpes virus infection.
d: Infants less than 1 week of age with feeding difficulties. In this situation having
mother and baby together is a priority and therefore the options should be:

● Mother and baby admitted to a postnatal ward at National Women’s


Hospital (baby sounds well).
● Admission to Starship Hospital where mothercraft can be facilitated
(sounds like sepsis or other pathology likely)

A yellow card (detailing perinatal history) is preferred.


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Albumex TM4 Authorised by Charge Nurse -


Newborn

April
2006

Albumex TM4 Parental Consent Prescribing Dose


Checking, Administration,
Ordering Storage Monitoring and Adverse Reactions
Documentation

Albumex TM4

● Available in two sizes - 500ml and 50ml.


❍ In NICU we usually use the 50ml size.

● 4% albumin is free of risk of transmission of known viral diseases (heat


inactivated).

Parental Consent

● Informed consent required.


● Parent signs on Agreement to Treatment Forms (CR0111).

Prescribing of Albumex TM4

● Prescribed on the blood transfusion/IV fluid chart (CR5541).

Dose

● 10-20mls/kg.

Ordering

● On NZBS requisition form (111F01802)

Storage
● Once opened use immediately as the product contains no antimicrobial
agent.
● Should be straw colour. Should not be cloudy.

Checking, Administration, Monitoring, and Documentation

● As for blood and blood products.


● Checking
● Administration
● Monitoring
● Documentation

Adverse Reactions

● See Transfusion Reactions.


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Albumex TM20 Authorised by Charge Nurse -


Newborn

April
2006

Albumex TM20 Parental Consent Prescribing Ordering


Checking, Administration,
Monitoring and Adverse Reactions
Documentation

Albumex TM20

● Albumex TM20 is free of the risk of infectious disease as it is heat inactivated.


● Albumex TM20 comes in two sizes - 10ml and 100ml and is made from large pools
of New Zealand donor plasma. It is used for babies with low protein and oedema.
● Request 100ml volume as 10ml ampoule is too small to filter using blood filter
giving set.
● Can be utilised 2 ways:
❍ As a volume expander like TM4.

Must be diluted - 1 part to 4 parts of 0.9% sodium chloride.


❍ To draw fluid out of the tissues.

Albumex TM20 draws 4 volumes of fluid from the extra cellular fluid into the
circulation.
Thus, 20ml of Albumex TM20 results in approximately 80ml increase in the
circulating volume.
This can cause volume overload, particularly in the presence of renal failure.
It should be given undiluted over 1 hour (approximately). 2gm in 10ml is
equal to 40ml Albumex TM4.
● Once the bottle is opened it must be used straight away.

Parental Consent

● Informed consent required.


● Parent signs on Agreement to Treatment Forms (CR0111).

Prescribing of Albumex TM20


● Prescribed on the blood transfusion/IV fluid cart (CR5541).

Ordering

● On NZBS requisition form (111F01802).

Checking, Administration, Monitoring and Documentation

● As for blood and blood products.


● Checking
● Administration
● Monitoring
● Documentation

Adverse Reactions

● See Transfusion Reactions


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Alcohol in Pregnancy Reviewed by Simon Rowley

December
2000

Management of the Neonate whose Mother has been Using or Abusing


Alcohol During Pregnancy

1. These infants are at risk of Fetal Alcohol Syndrome or Fetal Alcohol Effect.
Fetal Alcohol Syndrome is difficult to diagnose in the newborn period.
2. They are also at risk of withdrawal particularly if the mothers are drinking alcohol
during labour and delivery.
3. There is also the risk of respiratory depression in these circumstances.

● Paediatric attendance is recommended at delivery. The initial assessment should


include careful head, length and body weight measurements and any dysmorphic
features should be noted. The baby would normally be able to go to the postnatal
ward with the mother.
● Urine toxicology is recommended (there may be polydrug abuse).
● Consider using a drug withdrawal nursing chart as for narcotic withdrawal.
● Paediatric Consultant review should be arranged non-urgently.
❍ Drs Simon Rowley and Carl Kuschel are the specialists who primarily

evaluate these infants in the newborn period.

Follow Up Arrangements

These may need to be in conjunction with Social Services if already involved. Social work
evaluation is usually required to look at child protection issues. Referral of mother to a
detoxification programme may be appropriate.

● Paediatric Clinic at four months of age and at one year.


● Parents should be made aware of potential late effects of alcohol, e.g. attention
difficulties and where to seek help if concerned.
More protracted follow up although desirable, is probably not practical.

If neurodevelopmental problems are evident, then appropriate referral to Child


Development Services should be made.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Ambiguous Genitalia in the Newborn Reviewed by Carl Kuschel and


Initial Assessment and Investigation Wayne Cutfield (Paediatric
Endocrinology)

July
2003

Aetiology History Physical Examination Investigations Management

The neonate presenting with ambiguous genitalia should be treated as an emergency as


underlying causes, such as Congenital Adrenal Hyperplasia (CAH) can be life-
threatening. In addition, determination of gender is a primary concern for parents.

Aetiology

Virilised Females Feminised Males


Congenital Adrenal Hyperplasia Congenital Adrenal Hyperplasia

● 21-hydroxylase deficiency ● 3β-hydroxylase deficiency


● 11-hydroxylase deficiency
● 3β-hydroxylase deficiency

Chromosomal Abnormalities Partial Androgen Resistance


Syndromes
● XO/XY
● XX/XY ● 5 α-reductase deficiency
● Variants ● Partial androgen receptor
defects
Maternal Virilisation Defect in Testicular
Development
● Drug-induced
● Excessive androgen
production by mother

True Hermaphroditism True Hermaphroditism


Idiopathic Idiopathic

● Isolated ● Isolated
● Associated with midline ● Associated with midline
congenital anomalies congenital anomalies

History

● Drug ingestion during pregnancy?


● Any recent androgenic changes in the mother suggesting androgen excess?
● Are there few (or no) male offspring in families on mother's side?
● Any siblings dying in the newborn period?
● Any siblings with over-virilisation or precocious puberty?
● Any history of infection or exposure to teratogens?

Physical Examination

Although physical examination is useful, a diagnosis should not be made solely on


examination findings. However, the following information is useful in determining what
investigations are required.

● Are gonads palpable?


❍ 25% of infants with undescending testes and hypospadias have an intersex

disorder
❍ Gonads palpable in the perineum almost always indicate a male karyotype

● Is the penile length normal?


❍ Measure stretched length with a spatula from the symphysis pubis to the

stretched tip (not foreskin) of the penis


❍ Normal stretched length >3cm at term

❍ <2.5cm at term indicates a microphallus

❍ Is there reasonable penile girth on palpation?

❍ Is the phallus straight or is there chordee present?

● Where is the urethral opening?


● How fused are the labioscrotal folds?
● Is the scrotum hypoplastic?
● Is the anus normally sited?
● Are there any other physical abnormalities?
Investigations

● Chromosome analysis

● Pelvic/abdominal ultrasound scan to determine pelvic structures and the presence


or absence of gonads.
Uterine tissue excludes the presence of any testicular tissue in early gestation.

● 17-hydroxyprogesterone (newborn screening card for urgent 17OHP)

● Serum for Testosterone

● Serum electrolytes and glucose

Management

● Be careful with discussions with parents. Discuss with the specialist on call before
discussing specifics with parents.
❍ It is important to say that the baby has "unfinished genitalia" rather than to

talk about a penis or clitoris.


❍ Parents should be advised not to name the baby until the gender is known.

❍ Parents may choose to delay a birth notice and may wish to restrict visitors

until the gender has been assigned.


❍ Gender assignment is not dependent on what structures are present alone,

nor the karyotypic gender.


● Early referral to the Paediatric Endocrine Service after initial clinical evaluation.
❍ Surgical service involvement will be at the discretion of the Paediatric

Endocrine Service.
● Specific investigations and management will depend on the underlying cause.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Sucrose Analgesia for Simple Neonatal Procedures Created by Dr Mike Fernando


Reviewed by Dr Karen Munro,
Karen Anderson-Hawke, Bronwyn
Jones, Diane Saint, and Brenda
Hughes
Amended March 2004
(Consent guidelines changed)

Aim Criteria Administration Contraindications


Supporting Information Storage References

Aim

Neonates feel pain as intensely as adults. Oral Sucrose has been shown to be an
effective and safe treatment for reducing the pain response of neonates. A neonatal
admission will typically involve between 2 and several hundred painful procedures. The
aim is to reduce the discomfort caused by these procedures.

Criteria

Prior to any invasive procedure consideration should be made on how to minimize any
resulting pain. Painful procedures include but are not limited to venepuncture, peripheral
venous line placement, heel prick, arterial stab, and peripheral arterial line placement.
Ways to reduce pain can be through the use of pharmacological and non-
pharmacological measures. Non pharmacological measures include ensuring, where
possible, that the baby is calm, relaxed, warm, fed and that all necessary equipment for
the procedure is at hand. Once non-pharmacological measures have been implemented,
oral sucrose analgesia may be used in babies in Level II NICU and the Parent Infant
Nursery. Oral sucrose will not always eliminate all crying, but is known to significantly
reduce the physiological stress of pain.

Administration

● Dose: 0.2ml of a 66.7% Sucrose Solution (Syrup BP, 0.667g/ml).


● No more than 4 oral sucrose doses are to be administered in any 24 hour period.
● There is no minimum interval time between doses of oral sucrose.

Contraindications
● Neonates with known fructose intolerance.
● Neonates <1500g and <31 weeks postconceptional age.
● Lack of parental consent.

Supporting Information

● Parents should be advised that this procedure is to be used in hospital only. An


information leaflet is available.
● Consent is no longer required but information should be given to parents about the
use of sucrose, and this should be documented on the nursing care map.

Storage

● Oral Sucrose Solution (Syrup BP) should be stored in the refrigerator and
discarded one week after the bottle has been opened.

References

1 Stevens B, Yamada J, Ohlsson A. Sucrose analgesia in newborn infants undergoing painful procedures.
Cochrane Database of Systematic Reviews Issue 2, 2002.
2 Haouari N, Wood C, Griffiths G, Levene M.. The analgesic effect of sucrose in full term infants: a
randomized controlled trial. BMJ 1995; 310: 1498-1500.
3 Johnston CC, Filion F, Snider L,et al. Routine sucrose analgesia during the first week of life in neonates
younger than 31 weeks’ postconceptional age. Pediatrics 2002;110:523-528.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Ankyloglossia (Tongue-Tie) Reviewed by Simon Rowley, Carl


Kuschel, Lynley Nichols (Lactation
Consultant NICU), and Stuart
Ferguson (Paediatric Surgery)
December
2005

Diagnosis of Clinically Significant


Definition Incidence
Tongue-Tie
Assessment Management References

Definition

● The bottom of the tongue is tethered to the floor of the mouth by a membrane
(frenulum).
● This restricts the range of movements of the tongue.
● If the frenulum is too restrictive (tongue-tie, ankyloglossia), it may impact feeding,
speech, swallowing, and associated oral development problems.

Incidence

● Most reports give an incidence of 3-5%, although an incidence of up to 10% has


also been cited.
❍ Males are more commonly reported to be affected than females (1.5:1 to

2.6:1 ratio)
● Fewer than half of those infants identified as having a tongue-tie will require
intervention for symptoms.

Diagnosis of Clinically Significant Tongue-Tie

● Based on a combination of anatomical appearance and functional disturbance

Anatomical ● Type 1: Frenulum attaches to tip of


tongue in front of alveolar ridge in
low lip sulcus
● Type 2: Attaches 2-4mm behind
tongue tip and attaches on alveolar
ridge

● Type 3: Attaches to mid-tongue and


middle of floor of the mouth, usually
tighter and less elastic. The tip of
the tongue may appear “heart-
shaped”

● Type 4: Attaches against base of


tongue, is shiny, and is very inelastic

Functional disturbance ● Feeding difficulties


● Cannot initiate tongue grooving, cupping or depression
❍ Interferes with front-to-back peristalsis as well

as tongue palate synchronisation in breast


feeding
❍ May also adversely affect bottle feeding (rare)

● Older children may have difficulties with feeding (for


example, licking ice creams) or speech

Assessment

● There is no single reliable tool for assessment that adequately predicts the degree
of problems an individual infant will have. Staff familiar with the Hazelbaker
Assessment Tool For Lingual Frenulum Function (ATLFF) may wish to use this.

Physical examination ● Rule out thrush, clefts, and other defects including
neuromuscular conditions
● Range of motion of tongue and degree of extension
beyond lower dental ridge and lip
● Elevation to palate with mouth wide open
● Transverse movement of tongue without twisting of
the tongue
Maternal assessment ● Document degree of maternal nipple pain and nipple
skin erosion
● Painful breasts
● Low milk supply
● Plugged ducts
● Mastitis
● Untimely weaning
● Candida

Infant assessment ● Adequacy of latch and milk transfer


● Efficiency of bolus handling
● “Clicking” during feed due to loss of latch
● Sliding off breast
● Fatigue
● Irritability during/after feeding
● Poor weight gain (serial test weighs, supervised by a
senior team member, may be helpful)

Management

● Not all infants with tongue-tie will need any intervention other than good lactation
support.
● Assessment should be performed by a lactation consultant and/or speech
language therapist. If it is determined that the baby is likely to benefit from a
frenulotomy, this should be discussed with the specialist looking after the baby.
● Frenulotomy has been shown in prospective studies to improve feeding outcomes
and maternal symptoms in infants with significant ankyloglossia.
❍ Whilst some institutions undertake frenulotomy using sucrose analgesia,

local practice is to refer to a paediatric surgeon. Other institutions may


instead refer to ORL or plastic surgical services.
❍ Contact the paediatric surgical registrar on call and indicate that the infant

has a significant tongue-tie that is interfering with feeding.


❍ Frenulotomy should be performed within a few days of the referral being
made. The procedure will usually be performed under a light general
anaesthetic, using diathermy.
● All babies should have had Vitamin K administered at birth or at least 1 day prior to
the procedure.
● Post-operatively, babies will require a period of observation for at least 4 hours.
❍ Ex-premature infants should have a longer observation period in view of the

increased risk of apnoea.


● Paracetamol may be given as needed.
● If mothers are Hepatitis C positive, breast feeding should be postponed until the
wound has healed.
● Complications (such as excessive bleeding) are rare and should be documented
carefully.

References
1 Hall DMB, Renfrew MJ. Tongue tie. Arch Dis Child 2005;90;1211-5.
2 Messner AH. Lalakea ML. Aby J. Macmahon J. Bair E. Ankyloglossia: incidence and associated feeding
difficulties. Archives of Otolaryngology -- Head & Neck Surgery 2000;126:36-9.
3 Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the
breastfeeding dyad. Pediatrics 2002;110:e63.
4 Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-
feeding. J Am Board of Family Practice 2005;18:1-7.
5 Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF): use in a lactation consultant
private practice [thesis]. Pasadena (CA): Pacific Oaks College; 1993
6 Amir LH, James JP, Beatty J. Review of tongue-tie release at a tertiary maternity hospital. J Paediatr Child
Health 2005;41:243-5.
7 Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with
feeding problems. J Paediatr Child Health 2005;41:246-50.
8 Maternity and Neonatal Services, Women's Health Division, Canterbury DHB. Recognition, assessment
and ankyloglossia release and its impact on breastfeeding outcome: a quality-team initiative.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday, May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Doppler Studies in High Risk Pregnancies Reviewed by Associate Professor Lesley


McCowan (High Risk Maternity Service,
NWH)

February
2001

Background

Doppler ultrasound detects frequency shifts from moving targets (red blood cells). The flow velocity waveform
(FVW) which is produced is unique to the vessel being studied.

Flow velocity waveforms are analysed mathematically by creating a ratio of the systolic to diastolic frequencies.
The most common index in use at NWH is the resistance index (see figure 1).

Figure 1: Maximum frequency envelope of Doppler flow velocity waveform showing peak systolic frequency shift
(S) and end-diastolic frequency shift (D).

Umbilical Artery

In normal pregnancy, there is a progressive increase in end-diastolic velocity due to growth and dilatation of the
umbilical circulation. The resistance index therefore falls. A resistance index > 0.72 is outside the normal limits
from 26 weeks gestation onwards. In some pregnancies with fetal growth restriction and/or preeclampsia, there is
a reduction in the diastolic velocity and in severe cases as in c) and d) below, there is absent or reversed end
diastolic velocity.
Figure 2: Umbilical Doppler waveforms in healthy pregnancy and in pregnancies with fetal growth restriction.

These abnormal waveforms are associated with histological evidence of reduced numbers of small placental blood
vessels and therefore reflect "placental insufficiency". In pregnancies with reduced, absent or reversed end-
diastolic velocity, there is an increased risk of stillbirth, asphyxia, chromosomal and congenital abnormality.
Abnormal umbilical Doppler waveforms can be present for weeks before there is evidence of fetal compromise
and therefore are a marker of a high risk situation and should not normally be used in isolation as an indication for
delivery. However, most obstetricians would consider delivering a fetus with absent end-diastolic velocity from
about thirty two weeks gestation following administration of corticosteroids. In many instances, fetuses with absent
end-diastolic velocity would present much earlier in pregnancy and may require extremely preterm delivery.

Umbilical artery Doppler studies have been well evaluated in randomised controlled trials and use of umbilical
artery Doppler studies in small for gestation age pregnancies and in pregnancies with the preeclampsia is
associated with a 30% reduction in perinatal mortality (Cochrane Library 2000). The likely reason for the reduced
perinatal mortality is that the abnormal Doppler waveform highlights the at risk fetus who is then subject to more
frequent surveillance ultimately resulting in timely preterm delivery.

About two thirds of small gestational age fetuses have normal umbilical artery Doppler studies and are unlikely to
have histologic evidence of abnormal placental vascular development . These fetuses have a very low risk of
antenatal fetal compromise, have a low perinatal mortality, and do not normally require preterm delivery.

Uterine Artery Doppler Studies

Uterine artery Doppler studies reflect the resistance in the utero-placental circulation and have not been proven to
reduce perinatal morbidity or mortality. In conditions such as preeclampsia and fetal growth restriction abnormal
uterine artery Doppler studies indicate inadequate placentation and have been correlated with histological
evidence of defective replacement of spiral arteries by maternal trophoblast.

Figure 3:
Normal Uterine Artery Doppler Abnormal Uterine Artery Doppler

Abnormal uterine artery Doppler studies in the context of a growth restricted pregnancy suggest a maternal cause
for the growth restriction where as normal uterine artery Doppler studies suggest that a fetal cause of growth
restriction needs to be considered.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Antenatally Diagnosed Major Congenital Heart


Reviewed by Carl Kuschel, Tom
Disease Gentles (PCCS), and John Beca
Management at Delivery and in NICU (PICU)

May
2004

Immediate Delivery Room


Management in Labour Immediate Management in NICU
Management
Duct-dependent for Systemic Blood
Duct-dependent Cyanotic Lesions Rhythm Disturbances
Flow

See also the guideline on screening First Degree Relatives


See also the S.T.A.B.L.E. Cardiac module

National Women's Health acts as the primary delivery unit nationally for infants with an
antenatal diagnosis of major congenital heart disease who are likely to need surgical
intervention in the newborn period. A fetal cardiology service is provided by the Starship
Paediatric and Congenital Cardiology Service and in most instances the anatomical and
physiological lesion is able to be identified accurately prior to delivery.

The major cardiac lesions diagnosed antenatally can be generally divided into three
groups:

● Duct-dependent for systemic blood flow (e.g. Hypoplastic Left Heart Syndrome,
critical aortic stenosis, interrupted aortic arch).
● Duct-dependent cyanotic lesions (e.g. pulmonary atresia, transposition of the great
arteries)
● Rhythm disturbances (e.g. congenital heart block, fetal supraventricular
tachycardia)

Management in Labour

● A copy of the fetal echocardiography report(s), and Fetal Medicine Panel report if
applicable, should be obtained so accurate information is available.
● The obstetric service should notify the Level 3 neonatal registrar or NS-ANP
(pager 93-5535) that delivery is anticipated. The registrar or NS-ANP should
inform the neonatal unit clinical charge nurse and the neonatal specialist on duty
or on call.
● The paediatric cardiologist on call should be informed during normal working hours
if the mother is in labour or is going to be induced or electively delivered by
caesarean section.
● The paediatric cardiologist has usually already met with the parents to explain
what is planned post-delivery.

Immediate Delivery Room Management

● Most infants with major congenital heart disease will not require additional
resuscitation at birth and will be asymptomatic of their cardiac disease for hours or
days postnatally.
❍ An infant who is cyanosed and bradycardic at birth requires effective

resuscitation, and the cause of the cyanosis and bradycardia should


be assumed to be respiratory and not cardiac.
❍ Resuscitation measures may include the administration of oxygen and

positive pressure ventilation.


● Cardiac lesions that are responsible for an infant being in poor condition at birth
are rare (e.g. severe Ebstein's anomaly, or other cardiac conditions such as
arrhythmia, particularly if accompanied by fetal hydrops).
● Following resuscitation and assessment, the infant should be transferred to NICU
as soon as practical. The parents should be given the opportunity to hold their
baby if the baby's condition allows this.

Initial Management in NICU

Initial management will depend on the underlying cardiac lesion and the anticipated
neonatal problems.

● Infants should be admitted to Level 3 NICU.


● Cardiorespiratory and oxygen saturation monitoring should be commenced as
soon as possible.
● If the infant is unwell or requiring significant support, take blood cultures and
commence antibiotics.
● Intravenous access
❍ If the infant requires significant ventilatory support, arterial and venous

access should be obtained.


❍ Infants with lesions dependent on the duct for systemic blood flow, a double

lumen umbilical venous cather should be inserted.


❍ For infants with other lesions it is not necessary to insert umbilical catheters

if the baby is otherwise well.

Duct-dependent for Systemic Blood Flow

With severe left-sided obstructive lesions systemic blood flow is dependent on right-to-left
flow through a patent ductus arteriosus, so these babies are duct-dependent. Examples:
Hypoplastic Left Heart Syndrome, critical aortic stenosis, interrupted aortic arch.
● Insert a double lumen umbilical venous catheter
● Commence a prostaglandin infusion at an initial dose of 10 nanograms/kg/min.
● Do not over-oxygenate the infant (over-oxygenation will result in increased
pulmonary blood flow and reduced systemic blood flow).
● Accept oxygen saturations of 75% or above. Reduce inspired oxygen if
saturations >85%.
● Contact the paediatric cardiologist on call.
● The baby is to remain nil by mouth.
● If the infant requires assisted ventilation, ensure that the baby is not over-
ventilated. The aim should be to initially ventilate to keep a low-normal arterial
pH. Sedation, muscle relaxation, and controlled hypoventilation to further reduce
arterial pH may be necessary if there is excessive pulmonary blood flow and
reduced systemic blood flow (oxygen saturations >85%, low MAP, tachycardia,
cool peripheries).

Duct-dependent Cyanotic Lesions

These lesions are duct-dependent either to ensure adequate pulmonary blood flow (e.g.
pulmonary atresia, critical pulmonary stenosis) or to ensure adequate mixing between the
systemic and pulmonary circulations (transposition of the great arteries).

● Commence a prostaglandin infusion at an initial dose of 10 nanograms/kg/min.


● Ensure that at least one extra IV leur is available in the event that the PGE1
infusion tissues.
● If the systemic oxygen saturation is below 75%, call the paediatric cardiologist on
call.
● If the infant develops apnoea or the systemic oxygen saturation is below 75%
despite prostaglandin, they should be ventilated.
● If the infant develops apnoea but has a systemic oxygen saturation of 75% or
above, the dose of prostaglandin can be reduced (but not below 5 nanograms/kg/
min). If apnoea continues, the infant should be ventilated.
● If the infant is delivered after midnight but is stable, the paediatric cardiologist
should be contacted in the morning by 0700 hours. If unstable, contact the
paediatric cardiologist on call.

Rhythm Disturbances

Many infants are asymptomatic despite rhythm disturbances which have been detected
antenatally or postnatally. Some infants may require significant resuscitation, particularly
if they are hydropic. Hydropic infants require the attendance of a neonatal specialist.
Severely hydropic infants may require emergency insertion of intercostal and/or
abdominal drains at delivery.

Congenital Heart Block

● In the case of complete heart block with fetal hydrops, delivery should be planned
in consultation with the paediatric cardiologist and/or paediatric cardiac surgeon on
call as urgent pacing may be necessary.
● Transfer to NICU as quickly as possible.
● Intravenous access should be obtained.
● It is preferable but not essential to obtain a 12-lead ECG soon after admission to
NICU.
● If the heart rate is above 55bpm and the infant is stable, contact the paediatric
cardiologist non-urgently.
● If the heart rate is below 55bpm, contact the paediatric cardiologist on call.
● Do not commence chronotropic agents (e.g. isoprenaline) without first discussing
management with the paediatric cardiologist.

Tachyarrhythmias

● Be aware that some pregnant mothers are treated with one or more anti-
arrhythmic medications when the fetus has SVT, in order to treat the fetus, thus
the baby may have anti-arrhythmic medication(s) on board at delivery.
● If the tachycardia is still present after delivery, transfer to NICU as quickly as
possible
● Intravenous access should be obtained.
● Obtain a 12-lead ECG soon after admission to NICU. During normal working hours
contact the ECG technicians; after-hours, medical or nursing staff will need to
perform the ECG.
● Contact the paediatric cardiologist on call to discuss further management.
● If the tachycardia has resolved by delivery and the infant is stable, the baby can be
admitted to the postnatal ward under paediatric care. The baby should have Q4H
observations initially. Arrange review by the neonatal specialist on call the
following morning with a 12 lead ECG available.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday, May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Postnatal Management of Antenatally Diagnosed Renal Disorders Reviewed by Rita Teele, Carl Kuschel,
William Wong (Paediatric Nephrologist),
Max Morris (Paediatric Nephrologist), and
Vipul Upadhyay (Paediatric Surgeon)
October
2004

Background Information Indications for Scans References

Background

● Kidneys in the fetus can usually be identified on ultrasonography after 16 weeks gestational age.
● Single umbilical artery may be associated with anomalies, among them renal.
● Oligohydramnios may be a consequence of renal abnormality and poor urinary output by the fetus.
● Many of the aneuploidies and syndromes are associated with renal anomaly.
● Dilatation of the collecting system can involve calyces, renal pelvis and ureter(s).
● Dilatation may be due to obstruction, reflux, dysplasia.
● The definition of hydronephrosis varies between authors of publications.
● A normal antenatal scan rules out neither reflux nor the possibility of obstruction.

Information

Anatomy does not equal physiology; it is common for the fetal renal collecting system to fluctuate in size during an
antenatal scan. We also know that most babies and children ‘outgrow’ reflux. However it would be prudent to
identify those newborns who are at risk of renal infection because of reflux and those who have significant
obstruction. Because screening ultrasonography is generally done at 18 weeks, a ‘normal’ scan at this gestational
age does not rule out subsequent, severe dilatation associated with obstruction. Therefore, any comment as to
normal or abnormal prenatal ultrasonography has to include the gestational age at which the scans were obtained.

If one uses a transverse pelvic measurement of ≥ 4mm at any time during intrauterine life, as a definition of
dilatation, 13% of those neonates would be expected to have primary vesicoureteric reflux in neonatal life (based
on Christchurch study of primarily Caucasian babies). There is no difference in the prevalence of reflux between
fetuses who have anywhere from 4-9mm of measured renal pelvic diameter. Although unproven, it is likely that this
same prevalence of reflux also occurs amongst those with 0-3mm pelvic measurement. As mentioned, obstructive
hydronephrosis (e.g pelviureteric junction obstruction), may become apparent only later in pregnancy or after birth.
A ‘normal’ scan rules out neither future obstruction nor ongoing reflux.

Because of the difficulties of screening for urinary tract abnormality in the prenatal population, the following
guidelines are given as a compromise solution.

Indications for Scan

1. Remember: Any antenatally detected renal tract abnormality needs to be confirmed with postnatal imaging.
2. Postnatal renal ultrasonography can be requested at any time if there is concern regarding pulmonary
hypoplasia, other anomalies, a renal mass etc.

Antenatal Findings

The table below is to guide referral patterns rather than to state definitive neonatal clinical management.

Note: PUT clinic = Paediatric Urinary Tract Clinic. This is a multidisciplinary clinic with paediatric nephrologists,
urology, and paediatric surgical services. There is close liaison with the Radiology service.
Antenatal Ultrasound Postnatal Prophylactic Other Comments Refer to:
Findings Imaging Antibiotics Investigations

Bilateral renal pelvis Postnatal scan Ceclor from ● Blood In a male, ● Surgeon
dilatation ≥10mm Day 1 (or as birth pressure admit to on call
soon as ● Creatinine - NICU and ● If the baby
● Bilateral PUJ possible after repeat Day catheterise does not
obstruction delivery) 5 if abnormal after delivery have
● Bilateral VUJ (i.e. this posterior
obstruction represents urethral
● Posterior urethral posterior valves,
valves (in males) urethral refer to
● Prune Belly valves till PUT clinic.
Syndrome (in proven
males) otherwise).
If normal, repeat None if Refer to PUT
Day 5-7 normal clinic
Unilateral renal pelvis Renal Ceclor from See
dilatation ≥10mm ultrasound scan birth comments
Day 5 below about
● Unilateral PUJ If abnormal Continue VUR Refer to PUT
obstruction prophylactic clinic for further
● Unilateral VUJ ceclor investigation
obstruction Refer to PUT clinic
If normal Stop Celcor
● VUR

● Follow-
up USS
at 2-3
months

Unilateral or bilateral Renal Do not start See


renal pelvis transverse ultrasound scan at birth - wait comments
diameter ≥4mm and Day 5 for USS below about
VUR
<10mm If abnormal Prophylactic Refer to PUT
ceclor clinic for further
● PUJ obstruction investigation
● VUJ obstruction
If normal No ceclor Refer to PUT
● VUR
clinic or arrange
● Follow- GP follow-up
up USS
at 2-3
months

Unilateral "Cystic" Renal Ceclor if Refer to PUT


Kidney ultrasound scan confirmed as clinic
Day 5 obstruction
● Multicystic
Dysplastic Kidney
● Severe
hydronephrosis
Single Kidney Renal None May have Refer to Renal
ultrasound scan further Clinic, Starship
Day 5 investigations
as indicated
by
ultrasound
and
arranged by
the renal
service
Obstructed Ureterocoele Renal Ceclor from Refer to surgeon
ultrasound scan birth on call if
Day 1 obstruction
confirmed
Family history of Renal Ceclor if The Refer to PUT
Vesicoureteric Reflux ultrasound scan abnormal incidence of clinic for
Day 5 if family VUR is consideration of
wish higher (20- further
investigations 40%) in investigations
siblings of
children with
known VUR
than in the
general
population.
The
incidence is
also higher
(40-60%) in
offspring
born to
mothers with
VUR.
Horseshoe Kidney Renal Ceclor if May not be Refer to PUT
ultrasound scan evidence of detected clinic
Day 5 dilatation antenatally

References

1 Chertin B, Puri P. Familial vesicoureteral reflux. Journal of Urology 2003; 169(5):1804-8.


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for Babies of Mothers on Anticonvulsants


Reviewed by Salim Aftimos

October 2002

Most studies have shown a 2-4 fold increase in the incidence of malformations and /or
developmental disorders in infants of epileptic mothers on anticonvulsants as compared
to epileptic mothers not taking drugs. Some malformations are more common in
association with certain drugs.( Neural tube defects with valproate and carbamazepine.
Oral clefts with phenytoin. Skeletal defects with valproate). As well, dysmorphic findings
particularly midface hypoplasia may be seen in some infants. The incidence of
developmental delay as well as behavioural problems varies in between studies as well
as between the type of drug or combination of drugs used.

There is insufficient information at present on the teratogenicity of the newer


anticonvulsant drugs (gabapentin, lamotrigine, topiramate)

Neonatal withdrawal symptoms such as irritability, jitteriness, hypertonia, tachypnoea,


exaggerated startle reflex and vomiting have been reported in some infants, particularly in
infants of mothers on valproate, phenytoin, or polytherapy. Asymptomatic neonatal
hypoglycaemia has also been reported in infants of mothers on valproate.

In view of the above, infants of mothers on anticonvulsants should:

a. be admitted to the postnatal ward (or NICU, if appropriate for other reasons) under
paediatric care and observed for symptoms of withdrawal. For infants of mothers
on valproate, ensure early and adequate feeding. Monitor glucose as per the
infants at risk for hypoglycaemia guidelines.
b. receive a thorough physical examination by a paediatric registrar / consultant.
Assess facial dysmorphism particularly evidence of mid-facial hypoplasia. Look for
hypoplastic nails or distal phalangeal hypoplasia
c. be reviewed by the consultant at an outpatient clinic in 6-9 months to check for
developmental problems. It is possible that such problems may not emerge until a
later date. The parents could be informed and encouraged to seek medical
attention should such problems emerge.
● Please ensure that the baby has received the standard dose of Vitamin K at birth.

If an infant is identified with a problem secondary to maternal anticonvulsant, then the


parents should be informed of an increased risk of recurrence with subsequent
pregnancies. Quantification of the risk is difficult and advice could be obtained from the
genetic service. Periconceptual folic acid supplementation may be offered to the mother
keeping in mind that there is no good evidence for protection at least with the standard
0.4 mg dose.

Infants of mothers who received anticonvulsants in the first /second trimester then had
their medication stopped should still be admitted under paediatric care.

References

Ardinger H. et al; Verification of the fetal valproate syndrome phenotype. Am J Med Genet 1988;29:171-
1
185.
Jones K. et al; Pattern of malformations in the children of women treated with carbamazepine during
2
pregnancy. NEJM 1989;230:1661-1666
Thisted E. & Ebbesen F; Malformations, withdrawal manifestations and hypoglycemia after exposure to
3
valproate in utero. Arch Dis Child 1993;69:288-291
Nulman I et al; Findings in children exposed in utero to phenytoin and carbamazepine monotherapy:
4
Independent effects of epilepsy and medications. Am J Med Genet 1997;68:18-24.
Ebbesen F et al; Neonatal hypoglycemia and withdrawal symptoms after exposure in utero to valproate.
5
Arch Dis Child Fet Neonat Ed 2000. 83:F124-F129.
Moore S et al; A clinical study of 57 children with fetal anticonvulsant syndromes. J Med Genet
6
2000;37:489-497.
Dean J et al; Long term health and neurodevelopment in children exposed to antiepileptic drugs before
7
birth; J Med Genet 2001;39:251-259
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Antibiotics for Neonatal Sepsis Reviewed by Carl Kuschel

August
2003

Classification Indications for Antibiotics Risk factors for Sepsis Signs of Sepsis
Antibiotic Use Duration of Treatment References

● Bacterial sepsis is a major problem in the newborn unit. Approximately 10% of all
neonates admitted to NICU are treated with antibiotics for suspected sepsis.
● A bacterial cause is found in less than 10% of these infants (1-5 per 1000 live
births).
● The incidence of sepsis is higher in preterm infants, especially the very low
birthweight infant (<1500g).
● Common organisms identified are Coagulase negative Staphylococci (28%*),
Staphylococcus aureus (19%*), Streptococcus agalactiae (10%*) and Escherichia
coli (5%*).
● Other important pathogens include Listeria monocytogenes, Streptococcus
pneumoniae, Haemophilus influenza and other gram-negative organisms (total of
20%*).
● The clinical presentation of sepsis in the newborn is often non-specific; there may
however be an acute deterioration.

* Figures for blood stream infections within NICU at NWH 1998.

Classification of Neonatal Sepsis

Early Onset Sepsis Late onset sepsis


(infection occurring in the first 5 (infection occurring after 5 days of
days of life) age)
Exposure to bacteria can occur: Usually due to

● Before delivery due to ● Nosocomial infection,


infected amniotic fluid or organisms acquired from
occasionally following the environment
maternal sepsis ● Coagulase negative
● During delivery when staphylococci are the most
contact with organisms in common causative
the vagina can occur organisms
● After delivery following ● VLBW infants with
exposure to organisms in indwelling catheters,
the infants environment. central lines, chest drains
etc are at particular risk.

When should Antibiotics be Given?

● Antibiotics should be considered in any baby with signs of sepsis, particularly in


the presence of risk factors.
● Risk factors may be an indication for investigation - particularly a full blood count -
but are not in themselves an indication for antibiotics if the baby is born at term
and is clinically well.
● This is not a complete list and if there are any doubts a more senior member of
staff should be consulted.

Risk Factors for Sepsis

● Prolonged rupture of membranes (>24 hours).


● Prematurity (especially in association with PROM).
● Preterm labour with no adequate explanation
● Fetal distress without adequate explanation (fetal heart rate abnormalities
especially fetal tachycardia, passage of meconium).
● Maternal fever or other evidence of infection.
● Foul smelling amniotic fluid or malodorous baby
● Indwelling vascular catheter

Signs of Sepsis in the Newborn

● Fever, hypothermia and/or temperature instability.


● Respiratory distress.
● Apnoea and bradycardia
● Cyanotic episodes
● Lethargy, irritability, poor feeding.
● Unexplained high/low or unstable blood sugars
● Abdominal distension and bile stained aspirates
● Unexplained jaundice
● Umbilical flare, skin rashes
What Investigations should be Perfomed?

● Full blood count.


● Differential white cell count (Normal WBC 10-30,000 x 109/L) and percentage left
shift (immature neutrophils/total neutrophil count).
❍ If >20% this is moderately predictive of sepsis.

❍ A low WCC especially with neutropenia is also suspicious of sepsis.

● Blood cultures.
● Chest radiograph
● A C-Reactive Protein may be indicated.
● On occasion skin/wound swabs and gastric aspirate (at birth only).
● CSF may be needed in some cases - discuss with specialist.

The following investigations may need to be considered depending on the


organism isolated.

Late onset sepsis: In addition to the above consider

● Blood culture taken through central line.


● Lumbar puncture and CSF for microbiology/biochemistry.
● Urine by suprapubic aspirate (preferable) or catheter.

Antibiotic Use in Suspected Sepsis

First five days After first five days


Start amoxycillin and gentamicin Start flucloxacillin and amikacin
for all VLBW neonates and any in all babies
infant who
● Almost all Coag negative
● Appears septic or is sicker Staphylococcus is
than would be usually sensitive to amikacin but
anticipated. resistant to gentamicin.
● Has any vascular catheter ● Flucloxacillin being used
(UVC/UAC, percutaneous at present because of an
long lines or surgically increased number of
placed central venous lines) Staphylococcus aureus
isolates within the unit.
Start amoxycillin and cefoxitin in all
other babies. Add amoxycillin if specific cover
for Enterococci, Strep fecaelis
(suspected NEC), Listeria or
Group B Streptococcus is
needed.

● Review clinical progress and microbiology results at 48 hours.


❍ If cultures negative consider stopping therapy.
❍ Cultures positive/sepsis very likely or confirmed continue therapy.
● Add metronidazole if suspicion of anaerobic infection.
● Consider vancomycin for coagulase negative Staphylococci sepsis, especially if
infant unwell or central line infection with line staying in. Discuss with specialist
first.
● Change to cefotaxime if neonatal meningitis. Discuss with specialist first.

Duration of Treatment

Infection type Duration (days) of


therapy
Pneumonia 5-7
Septicaemia 7-10
Urinary Tract Infection 7-10
Meningitis 14-21
(depending on organism
isolated)

Skin conditions 5
Conjunctivitis 5-7
Oral thrush 7-10

References

1 Neonatal sepsis and meningitis. Philip AGS. GK Hall Medical Publishers. Boston 1985. ISBN 0-8161-2253-
9.
2 Neonatal Sepsis; progress in diagnosis and management. St Geme III JW. Polin RA. New Ethicals 1989;
25(6); 133-41(part 1) and 25(7); 109-31(part 2).
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Apnoea Monitoring on Discharge from NICU Reviewed by Carolyn Dakin and


Simon Rowley

December
2001

The following are practical guidelines for apnoea monitoring of neonates being
discharged from National Women’s Hospital.

1. There is no evidence that monitoring of infants is of value in saving lives.


2. Apnoea monitors are not designed to detect obstructive apnoea, and will fail to
detect obstructive apnoea.
Infants with respiratory obstruction (e.g. Pierre-Robin sequence, upper airway
anomalies, and infants with abnormalities of tone contributing to feeding and
swallowing difficulties) should be treated appropriately as indicated by the
underlying problem.
3. Low birthweight (LBW, VLBW, ELBW) in itself is not an indication for home
monitoring.
4. It is not clear that polygraphic studies identify infants at particularly high risk of
SIDS. However, they may be useful in individual cases.
5. Monitoring does not preclude the need in may cases to fully investigate and treat
causes of apnoea.
6. Some weeks prior to discharge all infants should be nursed in the supine position
unless clinical condition indicates otherwise.
7. Reduction of risk factors for SIDS should be emphasised:
❍ supine sleep position

❍ no bedding around the head (including no cot bumpers)

❍ no overwrapping

❍ avoidance of cigarette smoke

❍ it is preferable that co-bedding is avoided and the infant is breastfed.

With these points in mind, the following infants should be considered for home apnoea
monitoring:

1. Preterm infants with chronic lung disease discharged on home oxygen, or having
recently (within the last two weeks) come off oxygen.
2. Where practicable, preterm infants of narcotic and polydrug abusers. Infants
exposed to opioids in utero have a higher risk of SIDS. Preterm infants may be at
increased risk and should be considered for home apnoea monitoring. Reduction
of risk factors for SIDS should be emphasised (that is, supine sleep position,
breast feeding, avoidance of cigarette smoke and co-bedding).
3. Infants who have an Apparent Life Threatening Event (ALTE) in Hospital, with no
remediable cause identified.
4. Infants with respiratory obstruction, e.g, infants with Pierre Robin Syndrome, other
upper airways anomalies and with abnormalities of tone contributing to feeding
and swallowing difficulties.
5. Some infants with apnoea continuing beyond the normal period of prematurity, e.g
beyond 36 weeks gestation. These infants should be considered for further
investigation (e.g polygraphic and EEG studies) to determine the cause of apnoea,
and some will require monitoring.
6. Siblings of infants with SIDS who have additional risk factors such as prematurity,
apnoeas, or chronic lung disease.
❍ Parents of a previous SIDS victim should be referred, preferably in early

pregnancy to the Cot Death Society for counselling. Infants when born can
be referred for polygraphic studies but monitoring would not routinely be
indicated for these infants.
7. Infants of parents in a state of extreme anxiety where there are contributory
factors, e.g. poor obstetric history.

These recommendations are according to the NIH Consensus Development


Statement (1986) that monitoring is medically indicated for symptomatic but
not asymptomatic preterm infants. This was reiterated by the CHIME study
(JAMA 2001; 285:2199).

Practical Points

1. Polygraphic monitoring may be provided by consultation with Starship Respiratory


Team, Dr Carolyn Dakin, in response to Consultant referral. A referral sheet
should be completed and placed in the infant’s notes at the same time as the
phone call. The monitoring will usually be done at the Starship. The Respiratory
Department anticipates having full sleep monitoring available in the future but
currently performs Edentrace respiratory monitoring.
2. The Neonatal Homecare Nursing Service supervise the supply and use of the
monitors available for infants discharged from the Neonatal Unit who fit the above
criteria. Referral should be made after discussion with the Consultant and parents.
The Cot Death Society also has monitors, most of which are supplied to infants
who have had an ALTE after discharge home. For some anxious parents whose
infant does not fit the above criteria and for whom a Hospital monitor cannot be
made available, hiring of a monitor from certain Pharmacies may be a satisfactory
alternative.
3. All parents should attend the cardio-pulmonary resuscitation talks given by
Neonatal Homecare Nurses on the unit prior to discharge.

Click here to read the Information Sheet for Parents of infants on home
apnoea monitoring
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Caffeine Treatment and Apnoea Monitoring Reviewed by David Knight

January
2001

A baby having apnoea needs a full assessment. The various causes of apnoea
need to be considered and excluded.

● Initial treatment is usually by caffeine.


● CPAP is sometimes necessary (the baby may already be on this if weaned from
ventilation or recovering from respiratory distress).
● If the baby remains unstable on CPAP and caffeine, consider IMV.
● There are no fixed guidelines on the initiation of any of these treatments, as the
assessment of apnoea tends to be subjective, and each baby needs individual
assessment.
● In general, exercise caution in giving caffeine to babies with acute respiratory
problems; apnoea often indicates respiratory deterioration needing respiratory
support, not caffeine.

Monitoring the Baby

● Babies with apnoea severe enough to consider treatment should be monitored by


a cardio-respiratory monitor and pulse oximeter.
● Once the baby becomes more stable, discuss changing to an apnoea mattress on
the ward round.
❍ Usually this is at >32 weeks gestation.

❍ Apnoea mattresses are less sensitive at picking up apnoeas and do not

detect bradycardias or desaturations.

Monitoring Caffeine

● It is not necessary to do routine levels on stable babies.


● Serum concentrations should be obtained either if toxicity is suspected or if a baby
continues to have apnoea and has not previously had an optimal level
documented.
❍ Note that the assay is not very accurate and has a coefficient of variation of
15%, so that a reported level of 165 mmol/L has a 95% chance of being
between 115 and 215 mmol/L.
❍ Levels should not be checked within 6 hours of previous dose.
❍ Order levels the day before assay is to be done (clearly dated with the next
day’s date). Levels to be done at 0830 hours.
❍ Therapeutic range is: 135-200 m mol/L, toxicity is unlikely at <400 m mol/L.

Discontinuing

When

● In most babies, caffeine can be stopped between 32 and 34 weeks gestation, as


apnoea ceases to be an ongoing problem. At the latest, it should be discontinued
several days before the baby goes home.

How

● Continue apnoea monitoring for several days after stopping caffeine. Depending
on the clinical situation, this can be either by an apnoea mattress or cardio-
respiratory monitor plus pulse oximetry.
● For babies about to go home, monitoring is usually for 4 days, with a further day
off an apnoea monitor before discharge.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Assignment of Consultants In Charge of Infants Reviewed by Simon Rowley

December
2000

● Infants admitted to NICU are generally admitted under the Consultant on service
rostered for that day's admissions.
● All infants admitted to NICU are automatically under public care regardless of
whether they have been seen or assessed privately.
● If the delivery or baby being admitted has been attended by a private Consultant,
then the infant will be assigned to the Consultant who arranged the admission, but
looked after by the Team of the day. As such the Resident/Consultant on call
assumes responsibility for acute problems.
● All day to day management is directed by the Team and Consultant on service that
the infant is currently under, NOT by the private admitting Consultant (unless that
Consultant is also on service).
● The parents are informed by the private Consultant admitting their infant, that their
baby is under the Team Care for daily decisions and management, but that at
discharge follow up will be by the private Paediatrician who admitted them.
● Babies seen at North Shore and Waitakere Hospitals by Paediatricians are always
admitted under the Team Consultant on service.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Auditory Testing Reviewed by Simon Rowley

December
2000

Identifying Infants at Risk of Hearing Loss

Generally speaking all those infants admitted to Level 3 and some in Level 2 are at high
risk of future hearing impairment. The Newborn Hearing Screening Committee of United
States of America, which includes a panel of Otolaryngologists, Audiologists and
Paediatricians suggest that 9 groups of high risk should be followed up with hearing tests.
These are as follows:

1. Familial (member of family deaf. In Auckland this comprises the largest group of
children with hearing defects).
2. CMV, rubella (or other congenital infections).
3. Immaturity (birthweight <1500g).
4. Malformation (of cranium or face, e.g. cleft palate, auricular deformity, not pre-
auricular tags alone).
5. Hyperbilirubinaemia (>340μmol/L).
6. Meningitis.
7. Asphyxia.
8. Therapy with ototoxic drugs (where toxic levels reached, particularly loop diuretics
and aminoglycosides in combination).
9. Prolonged mechanical ventilation (> 5 days).

Follow up of the above children will detect 50% of all deaf children in any community and
give a greater yield of abnormal hearing testing. Therefore in New Zealand it is general
strategy to screen all the above children within the first few months of life. A newborn
hearing screening programme is being developed at National Women's Hospital.

Practically speaking this is accomplished as follows:

Referral BEFORE or AT discharge to:


1. Starship Hospital Audiology
2. Middlemore Hospital if the family are in the South Auckland
catchment area (south of Otahuhu, east of Panmure)
or
3. National Audiology Centre
98 Remuera Road
Auckland
Ph: 520 4009 Fax: 522 1622

● Please include parent's telephone number with referral as the appointments are
frequently phoned.
● The testing in neonates is generally using auditory brain stem response
audiometry which is an EEG based test. It does, however, have a relatively high
false positive rate and re-testing will be needed in some cases.
● Otoacoustic emissions may be added to testing. A pilot otoacoustic emission
screening programme is being developed at National Women's Hospital.

Suggested Plan for National Women's Health

Babies admitted to NICU are at high risk of hearing impairment.

● All infants under 1500g, those who have suffered birth asphyxia or any of the other
risk factors mentioned above, should be referred AT or PRIOR to discharge.
● In cases of hyperbilirubinaemia, referral is suggested if the serum bilirubin was
>340μmol /L.
❍ Premature babies will be at greater risk with lower levels, but will be

included under other categories, e.g. <1500g).

Once follow up has been organised, this fact should be recorded

● in the front sheet of the notes,


● on the discharge letter to the General Practitioner, and
● at an appropriate place in the Health and Development Book, which is given to the
parents and in which details are supervised by Plunket Society personnel.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
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guideline.

Withholding Feeds in the NICU


Carl Kuschel, Barbara Cormack
Assessment of Bilious Aspirates and Vomiting (Dietitian), and Phil Morreau
(Paediatric Surgery)

July 2005

Background Indications to Withhold Feeds Indicative Colour Chart of Aspirates


Investigation of Bilious Aspirates or
Management References
Vomiting

Background

Withholding feeds is a significant decision for infants in the NICU, particularly extremely
low birth weight infants. An audit of practice in NICU identified that withholding feeds was
1
a significant contributor to poor growth in infants. Calories and nutrients can be more
safely and more easily delivered by enteral feeds than by intravenous nutrition, without
increased cost and increased risks of complications.

However, some infants with feed intolerance may have significant intra-abdominal or
other problems.

Indications to Withhold Feeds

Absolute indications to ● Clear abdominal pathology


withhold feeds ❍ Suspected or proven NEC

❍ Significant abdominal distension or

discolouration
❍ Other suspected or proven bowel

pathologies
❍ Blood in stool

● Heavily bile-stained or large gastric residuals or


vomiting ("avocado" or "spinach" in the reference
chart below)
Relative indications to ● Feed intolerance
withhold feeds ❍ If <25% of 6-hour total feed volume - return

aspirate and give full feed


❍ 25-50% of 6-hour total feed volume - return

aspirate and miss feed


■ Check aspirate next feed. If

significant aspirate next feed, then


withhold feed and notify registrar or
NS-ANP
❍ >50% of 6-hour total feed volume - withhold

feed and notify registrar or NS-ANP


● Unstable condition causing clinical concern
❍ This may include infants with significant

cardiorespiratory instability or presumed


sepsis
● Infants about to undergo surgical or anaesthetic
procedures
❍ Refer to the preoperative surgical guideline

Indicative Colour Chart for Assessing Aspirate Colour

Milk Lemon Mustard Wasabi Lime Avocado Spinach

● Note that colostrum may appear yellow in colour.


● Some infants will have bilious aspirates that are bright yellow in colour in the initial
phases.

Investigation of Bilious Aspirates or Vomiting

Feed intolerance is common in preterm infants. However, it is less common in term


infants. In term infants, especially those with bile-stained vomiting or bilious aspirates,
gastrointestinal pathology needs to be investigated and early surgical consultation
should be considered.

Causes of bilious aspirates/vomiting include (but are not limited to):

● Proximal bowel obstruction (yet distal to the duodenum).


2
❍ It is particularly important to consider intestinal malrotation. Radiographs
and abdominal examination may be normal in infants with malrotation,
particularly in the early stage of the condition or if the obstruction is
intermittent. If malrotation is considered a possible diagnosis, an upper GI
contrast study should be considered. A recent report of infants presenting
to a surgical NICU with bilious vomiting demonstrated that 22% had an
3
intestinal malrotation.
● Other bowel obstruction
❍ Distal obstruction may result in bilious vomiting or aspirates.

❍ An abdominal radiograph may indicate intra-abdominal pathology, with air-

fluid levels
● Necrotising enterocolitis
● Paralytic ileus associated with generalised sepsis
❍ This usually presents with a silent abdomen in an infant with signs of

generalised sepsis.
● In some infants, no cause will be found despite thorough investigation.3

Management

1. The baby should be examined for signs of generalised sepsis or instability. Close
attention should be paid to the abdomen, paying particular attention to signs of
tenderness, erythema, or guarding.
2. The baby should be placed nil by mouth.
3. An abdominal series (AP supine and lateral decubitus with the left side down)
should be ordered.
❍ It may be appropriate to repeat the radiographs in 4-8 hours to evaluate any

change in bowel gas pattern or any evolution in radiographic features.


4. Antibiotics after an appropriate sepsis screen should be considered.
❍ If intra-abdominal pathology is suspected, the antibiotics of first choice are

amikacin, amoxycillin, and metronidazole.


❍ If sepsis is considered likely but an intra-abdominal source is not thought to

be the primary source, then the antibiotics of first choice are amikacin and
flucloxacillin.
5. Surgical consultation should be considered early.
6. Reintroduction of feeding will depend on the underlying condition and the
individual preferences of the supervising specialist.

References

1 Cormack BE, Bloomfield FH. An audit of feeding practices in babies <1200g or 30 weeks gestation during
the first month of life. Perinatal Society of Australia and New Zealand 9th Annual Congress, Adelaide,
2005. A42.
2 Strouse PJ. Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol 2004;34:837-51.
3 Foster JK, Mills JF. Neonatal bilious emesis: when does it matter? Perinatal Society of Australia and New
Zealand 9th Annual Congress, Adelaide, 2005. P61.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for Red Cell Transfusion Reviewed by Jane Harding

December
2003

Causes of Anaemia Indications for Transfusion Consent Ordering Multipacks


Transfusion Volume Other Related Documents References

Common Causes of Neonatal Anaemia

● Preterm delivery before establishment of normal red cell and iron stores in last
trimester.
● Blood loss for Laboratory testing.
● Expansion of blood volume with growth.
● Physiological cessation of red cell synthesis in the first 6 weeks after birth.

Although these factors combine to result in the ‘normal’ fall in haemoglobin concentration
in the first 6-9 weeks after birth, this is accompanied by improved oxygen unloading
capacity as 2,3-DPG levels rise, so that tissue oxygen delivery may improve despite
reduced oxygen carrying capacity. Thus the possible benefits of transfusion need to be
balanced against the known (and unknown) risks for each individual baby.

Indications for Transfusion

1. Shock due to blood loss.


2. Babies with cardiorespiratory disease.
Transfuse if haematocrit:
❍ <40 if unwell (ventilated, <1000g, ongoing problems)

❍ < 35 if moderate lung disease (O requirement > 30%, significant apnoeas


2
and bradycardia)
❍ < 30 if mild residual lung disease (CPAP or low rate ventilation in ≤ 30%
O2).
3. Stable growing babies < 6 weeks old.
❍ Transfuse if haematocrit < 30 and baby symptomatic (recurrent apnoea and

bradycardia, failure of weight gain).


❍ Baby for surgery.
4. Stable growing babies > 6 weeks old.
❍ Transfuse only if haematocrit < 25 and baby symptomatic. Transfusion at

this age will inhibit the normal onset of erythropoiesis and should usually be
discussed with a Specialist. Oral iron supplements should be started at 4
weeks of age.

Consent

● Informed consent must be obtained unless the situation is life threatening.


● Consent is documented on a consent form (Agreement to Treatment CR111).
● However, verbal consent by a parent is acceptable provided it is documented in
baby’s chart, until written consent is obtained.

Ordering Multipacks

● For infants who are under 1000g and less than 10 days old, or infants who are
likely to need multiple transfusions within the first few weeks, order a mulitpack.
This will provide 4 paediatric packs of red cells from a single donor, thereby
reducing donor exposure.

Transfusion Volume

● Small babies (<1500g) in the first week of life: 10ml/kg over 2h.

● Larger babies and older babies: 15ml/kg over 2h to maximise haemoglobin rise
while minimising numbers of transfusions required. Consider frusemide 1mg/kg
half way through the transfusion to minimise volume load.

References

1 Stefano JL and Bhutani VK. Role of furosemide therapy after booster-packed erythrocyte transfusions in
infants with bronchopulmonary dysplasia. J Pediatr 1990;117, 965-8.
2 Stute H, Greiner B, Linderkamp O. Effect of blood transfusion on cardiorespiratory abnormalities in preterm
infants. Arch Dis Child 1995; 72: F194-6.
3 Yu VYH and Gan TE. Red cell transfusion in the preterm infant. J Pediatr Child Health 1994; 30;301-9.

4 Fetus & Newborn Committee, Canadian Paediatric Society. Guidelines for transfusion of erythrocytes to
neonates and premature infants. Can Med Assoc J 1992; 147: 1781-6.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Administration of Immunoglobulin (IVIG)


Reviewed by

Complications/
IVIG Indications Ordering
Problems
Other Related Documents References

The Product

● IVIG 3g in 50ml (6% solution) l0ml aliquots available for neonatal use.
● Contains antibodies to normal range of infections in New Zealand.
● Prepared by cold ethanol fractionation and is free of HIV, and Hepatitis B and C
virus transmission risks.
● pH 4 for IV use only.

Complications/Problems

● Adults sometime react to IVIG with fall in blood pressure. Baby should be watched
carefully particularly at the start of the infusion.
● Most patients have no side effects at all.
● Low pH should be considered in sick babies with acid/base problems. Undiluted it
is hyperosmolar. Should be given over 1 hour or longer.
❍ If high osmolarity or low pH are a potential problem may be given diluted

with equal volumes of saline, ½ normal saline or 5% dextrose.

Indications

1. Sepsis in Compromised Neonates


❍ IVIG 750mg/kg = 12.5ml/kg infused over 2 -3 hours.

❍ May be repeated after 3 -5 days if inadequate response./li>

2. Treatment of Immune Thrombocytopenia


❍ IVIG 2g/kg in divided doses over 4 days, i.e, 0.5g/kg/day = 8.3ml/kg given

over a 3 hour period each day.


Ordering

● After consultation with ARBC Medical Officer, write Blood Products request form
with patient's name, number, date of birth, birthweight and present weight.

References

1 Muratt et at, Vox Sang 51: suppl 2, 22-29 (1986).

2 Sidiropoulos et at: Peds, 109:3; 505-508 (1986)

3 Hill. Pediatr Infect Dis J, 1993, 12:549-59

For further details see the Big Blue Blood Bank Book.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Platelet Concentrates Authorised by Charge Nurse -


Newborn

April
2006

Platelet Concentrates Indications Consent Prescribing


Ordering Dose Shelf Life
Checking, Administration,
Monitoring, and Adverse Reactions
Documentation

Platelet Concentrates

● Single random platelet concentrates are made from individual units of CMV
negative whole blood.
● These platelet concentrates are resuspended in 50 - 60mls of plasma with each
concentrate containing at least 5.5 x 1010 platelets, 1-2 x 108 lymphocytes and
some granulocytes and a small number of red cells.

Indications

Vary for individuals but below are guidelines:

● Thrombocytopenia (platelets reduced)


● Thrombasthaenia (platelets not functioning)

Click here to link to the Thrombocytopenia guideline for guidelines on what levels to
transfuse at.

Parental Consent

● Informed consent required.


● Parent signs on Agreement to Treatment Forms (CR0111).

Prescribing of Platelets
● Prescribed on the blood transfusion/IV fluid chart (CR5541).

Ordering

● One unit of platelet concentrate can be ordered over 24 hours for one baby without
contacting the NZBS Medical Officer. However, for longer, or daily concentrates,
please discuss with the NZBS Medical Officer.
● Remembering that every effort must be made to reduce exposure of neonatal
patients to blood products and separate blood donations.

Dose

● Usually 10-15ml/kg.
● Usually given 30-60 minutes.

Shelf Life

● Shelf Life of 5 days only.

Checking, Administration, Monitoring and Documentation

● As for blood and blood products.


● Checking
● Administration
● Monitoring
● Documentation

Adverse Reactions

● See Transfusion Reactions.


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Plasma Authorised by Charge Nurse -


Fresh Frozen Plasma (FFP) Newborn

April
2006

Fresh Frozen Plasma (FFP) Consent Prescribing Ordering


Checking, Administration,
Storage Monitoring and Adverse Reactions
Documentation

Fresh Frozen Plasma

● Fresh frozen plasma (FFP) is processed from a single donor blood donation either
prepared from a whole blood unit or from a plasmapheresis donor.
● It is prepared within 8 hours of collection. This method ensures the preservation of
labile coagulation factors.
● The plasma is stored at -30°C and thawed under controlled conditions at the
Bloodbank.
● Neonatal packs take 15-20 minutes to thaw in the Bloodbank.

Parental Consent

● Informed consent required.


● Parent signs Agreement to Treatment form (CR0111).

Prescribing of Fresh Frozen Plasma

● Prescribed on the blood transfusion/IV fluid chart (CR5541).

Ordering

● On NZBS requisition form (111F01802).

Storage
● Shelf life once thawed is 4 hours, when stored in blood fridge.
● FFP pack will have a yellow expiratory sticker, stating ‘date’ and ‘time’ of expiry.
● When pack arrives in Newborn Services it must be used within 2 hours.
● Once plasma is partially transfused it should never be returned to the fridge for
reuse at a later time because of the risk of contamination.
● For neonatal transfusions AB Plasma is used (compatible to all blood
groups).

Checking, Administration, Monitoring, and Documentation

● As for blood and blood products.


● Checking
● Administration
● Monitoring
● Documentation

Adverse Reactions

● See Transfusion Reactions


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Buffy Coat Concentrate Authorised by Charge Nurse -


Newborn

February
2003

Buffy Coat Concentrate Ordering Indications


Checking, Administration, Monitoring,
Adverse Reactions Other related documents
and Documentation

Buffy Coat Concentrate

● This is a concentrate of the white cells and platelets obtained from a freshly
centrifuged unit of whole blood. The buffy coat separates out as a layer which can
then be removed and if necessary buffy coats from different donors can be pooled
for the treatment of a single patient. The blood unit must be fresh and the buffy
coat separated under sterile conditions. Buffy coats must be used within 12 hours
of preparation to get maximal effect of the leucocytes.
● Buffy coat preparations are sometimes used in the treatment of overwhelming
gram negative septicaemia in young neonates. Multiple doses of buffy coats are
required to produce a clinical effect. Because of the relatively small dose of
leucocytes obtained by this method the procedure is not suitable for treatment of
adults who require granulocytes. Buffy coat preparations are not often used as
leucopheresis is the preferred option.
● Caution: Hyperviscosity Syndrome may be induced by transfusing babies to a
haemoglobin of greater than 160g/L. Partial exchange transfusion may be
needed. Red cell compatibility is needed for granulocyte transfusion.
● Neonates are given granulocytes from an O Rh(D) negative, usually CMV negative
donor. If granulocytes from an O Rh(D) negative donor are not available, they
may be made from a donor of a different group compatible with the baby.
● ‘Buffy coat’ one unit blood collected in the morning is spun hard and the buffy coat
and upper layer of red cells harvested into a variable volume of 20-50ml.
● This will have perhaps 80% of the total white blood cells in that 450ml of donor
blood and is also a packed red cell preparation. Should ideally be irradiated prior
to use.
● N.B.: This is prepared only on special request.

Ordering
● Prior to ordering buffy coat concentrate it must be discussed with Medical
Officer of NZBS.
● Granulocytes last only 12 hours once made up.
● Kept at room temperature. Should not be refrigerated.

Indications

1. Septic neutropenic baby with neutrophils 0.5 or less.


2. Septic baby with poorly functioning neutrophils, e.g. chronic Granulomatous
Disease.

Checking, Administration, Monitoring and Documentation

● As for blood and blood products.


● Checking
● Administration
● Monitoring
● Documentation

Adverse Reactions

● See Transfusion Reactions.


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Cryoprecipitate Authorised by Charge Nurse -


Newborn

February
2003

Cryoprecipitate Indications Dosage Storage


Checking, Administration,
Monitoring, and Adverse Reactions
Documentation

Cryoprecipitate

● Cryoprecipitate is prepared by freezing and then thawing plasma at which time a


cryoprecipitate occurs which contains a high concentration of factor VIII fibrinogen,
fibronectin and factor XIII.
● Cryoprecipitate (Lyophilised) is prepared from a single donation of apheresis
plasma obtained from NZ volunteer donors. It is processed within 6 hours of
collection. It is suspended in buffer under sterile conditions and then lyophilised
and heat treated.
● Cryoprecipitate should be ABO compatible wherever possible.

Indications

● Cryoprecipitate is now mainly used as a source of fibrinogen.


● Cryoprecipitate is sometimes used for the treatment of haemophilia A, where there
is a demonstrated deficiency of activity of the plasma clotting factor (AHF Factor
VIII). However the product of choice is Recombinant Factor 8 (synthetic derived
product).
● Can be used for the treatment of patients with fibrin stabilising factor (Factor XIII
deficiency).
The reconstituted product will contain approximately 200 units of Factor XIII).
● Von-Willebrands Syndrome.

Dosage

● 10 – 20ml/kg.
● Cryoprecipitate does not contain an antimicrobial preservative and is therefore
readily susceptible to contamination.

Storage

● Frozen cryoprecipitate is stable for one year at -30


● Shelf life is 6 hours when stored in Blood Fridge. When unit arrives in Newborn
Services it must be used within 2 hours.
● Must be transfused within 6 hours of thawing. It will have a yellow
expiratory sticker on stating date and time of expiry. Do not refrigerate after
thawing as otherwise insoluble cryoprecipitate may reform.

Checking, Administration, Monitoring, and Documentation

● As for blood and blood products.


● Checking
● Administration
● Monitoring
● Documentation

Adverse Reactions

● See Transfusion Reactions.


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Hypotension Reviewed by David Knight

December
2000

Importance of Low Blood Fluctuation in Blood


Normal Blood Pressure Blood Pressure to Aim For
Pressure Pressure
Treatment of Low Blood
Blood Pressure in PPHN References
Pressure

Normal Blood Pressure

Blood pressure increases over the first hours, then days after birth. Very low birth weight
babies often have a low blood pressure, especially on the first day. Infants with low Apgar
scores or requiring assisted ventilation tend to have lower BPs, while those whose
mothers were hypertensive or who received antenatal steroids have higher BPs. There
are poor relationships between blood pressure and either cardiac output or blood volume
1 2
in preterm infants , . Systemic vascular resistance is of great importance.

In very low birth weight infants, patent ductus arteriosus may contribute to low blood
3 4 5
pressure, even in the first few days, and its closure may result in an increase in BP , , .

Importance of Low Blood Pressure

There is controversy as to how active to be in treating a low blood pressure in a small sick
baby. There are several publications linking low BP with poor outcome. There may be
reporting bias in these publications. No-one has shown that treating low blood pressure
improves outcome.

6 7
Some have found a correlation between periods of hypotension and IVH , . Miall-Allen
8
also showed an association between MBP <30 and IVH, ischaemic lesions or death .
Low found a relationship between low BP and hypoxaemia and a poor neuro-
9
developmental outcome . The association between a low BP and IVH was not
10
supported by D’Souza .
Blood Pressure to Aim For

8
Miall-Allen used a mean BP of 30mm as her cut off irrespective of size or gestational
6
age. Watkins used his 10th centiles, which were:

For very low birth weight infants, a good rule of thumb is to aim for the baby’s gestational
age as the desired minimum mean blood pressure.

Fluctuation in blood pressure

Blood pressure fluctuation may be as important as its absolute value in the development
of cerebral lesions and the long term outcome of infants. Blood pressure variability should
be minimised as much as possible in the first days of life in very preterm infants. This
involves strategies of minimal handling, careful and gradual management changes and
avoiding interventions that can cause changes in catecholamine levels and blood
pressure.

Blood pressure in Persistent Pulmonary Hypertension

PPHN is associated with poor cardiac function. The ductus arteriosus is often patent so
that, with supra-systemic pulmonary artery pressure there is R-L ductal shunting. If
systemic pressure can be increased without a corresponding increase in pulmonary
pressure, the shunt will lessen and oxygenation improve. There is not much information
on the effect of inotropes on pulmonary vascular resistance in sick newborn infants. What
there is suggests that dopamine does not produce a selective increase in systemic
11
pressure.

However,

● Attempt to keep systemic blood pressure high.


● Treat initially with volume (judicious) and then with inotropic support.
● See the PPHN guidelines.
Treatment of low blood pressure

Normal Saline ● Give one to two boluses of 10-15ml/kg over 20 minutes.


● Equal response to 5% albumin infusion but fewer repeat doses
of volume were needed and a lower weight gain was seen over
12
48 hours, with no difference in serum [Na+] in the one trial .
13
● Saline similar to albumin/FFP in effect .
● Volume (albumin in the published paper) is less consistent at
increasing BP than dopamine and starting dopamine should not
14
be delayed if hypotension persists .

Dopamine ● Start at 5mcg/kg/min and increase incrementally to a maximum


of 20mcg/kg/min.
● Increases BP. More consistent response, at a lower dose with a
15, 16
bigger increase in BP than dobutamine .

Dobutamine ● Start at 5mcg/kg/min and increase incrementally to a maximum


of 20mcg/kg/min.
● Dobutamine is added to dopamine in persistently hypotensive
infants, when the dopamine dose has been increased to 10-
20mcg/kg/min.

4% Albumin ● This is an alternative to Normal saline.


● There is no data on the relative merits of each in babies outside
the immediate newborn period (first couple of days) so use
albumin rather than saline in these babies as it is the ‘more
established’ treatment.

Blood ● Use ‘whole’ blood as volume support if the baby is also


relatively anaemic.
● If volume expansion is desired, do not give frusemide with the
blood.

Hydrocortisone ● 2.5mg/kg IV 4hrly x 2 then 6hrly x 48 hrs then 0.125mg/kg 6hrly


x 48 hrs, then 0.0625 mg/kg 6hrly x 48 hrs.
● Increases BP a little less consistently but to a greater extent
1
than with dopamine 7 .

Dexamethasone ● 0.1-0.25mg/kg/dose. Studies of dexamethasone for ventilator


dependence shows a fairly rapid increase in BP and ability to
1
wean off inotropes 18, 9 .
Noradrenaline ● 0.05-0.5mcg/kg/min, incrementally.
● Primarily raises systemic vascular resistance.
● It may produce a reflex reduction in cardiac output and can
produce coronary artery changes.
● Very little (if anything) published on its use in the newborn. Use
with caution and only after a decision by a specialist 20 .

References

1 Bauer. Arch Dis Child 1993; 69:521-2

2 Kluckow J Pediatr 1996;129:506-12

3 Knight Early Hum Dev 1992;29:287-92

4 Evans Arch Dis Child 1992; 67:1169-73

5 Evans Arch Dis Child 1993; 68:584-7

6 Watkins. Early Hum Dev 1989;19:103-10

7 Moise Pediatrics 1995;95:845-50

8 Miall-Allen Arch Dis Child 1987;62:1068-9

9 Low Acta Paediatr 1993; 82:433-7)

10 D’Souza (Arch Dis Child 1995; 72:162-7).

11 Feltes. Pediatr Pharmacol.1986;5:261-71

12 So. Arch Dis Child 1997;76:43-7

13 Wright. unpublished

14 Gill. Arch Dis Child 1993;69:284-7

15 Klarr. J Pediatr 1994;125:117-22,

16 Greenough Eur J Pediatr 1993;152:925-7

17 Bourchier Arch Dis Child 1997;76:174-8

18 Fauser. Eur J Pediatr. 1992;152:354-6.

19 Yeh. J Pediatr 1990;117:273-82

20 Martinez. J Dev Physiol. 1990;13:141-6.

21 Bolande. Exp Mol Pathol. 1996;63:87-100


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Neonatal Hypertension Reviewed by Carl Kuschel, Jon


Skinner (Cardiology, Starship
Hospital), and William Wong
(Nephrology, Starship)
February
2003

Definition Normal Data Causes


Investigations Treatment References

Definition

Hypertension is not commonly diagnosed in newborn infants. The incidence in infants


discharged from neonatal units ranges from 0.7% to 2.0%

Hypertension is defined by a systolic blood pressure in a neonate which is ≥95th


percentile for age and sex on 3 separate occasions.

The gold standard for blood pressure measurement is an appropriately calibrated intra-
arterial catheter. However, for babies who do not have or require invasive monitoring, the
most frequently used technique is via an oscillometric manometer (e.g Dinamap). Blood
pressure should be taken when babies are quiet and not feeding (systolic BP is 5mmHg
lower in sleeping babies) with an appropriate sized cuff.

Hypertension detected on oscillometry (Dinamap) must be confirmed with another


modality such as Doppler sphygmomanometry

1
Normal Data

Gestation Age Systolic Blood Pressure


95th % 97th%
Term Day 1 96
Day 8-30 104
Term Day 4 95
6 weeks 113 (awake)
Term Day 1 82
Day 10 111

24 weeks Day 1 57
Day 10 71
28 weeks Day 1 62
Day 10 83
32 weeks Day 1 67
Day 10 94
36 weeks Day 1 74
Day 10 104

Causes

1. Renal
❍ Renal artery thrombosis (particularly if a UAC has been in place)
❍ Renal vein thrombosis
❍ Renal artery stenosis or compression (e.g. from tumour)

❍ Parenchymal renal disease

❍ Severely obstructed urinary tract

2. Cardiovascular
❍ Coarctation of the aorta

❍ Interrupted aortic arch

❍ Distal aortic thrombosis (particularly if a UAC has been in place)

❍ Fluid overload

3. Endocrine
❍ Congenital Adrenal Hyperplasia

❍ Hyperaldosteronism

❍ Hyperthyroidism

❍ Adrenal haemorrhage

❍ Hypercalcaemia

4. Neonatal Chronic Lung Disease


❍ May manifest late after discharge from NICU

5. Drugs
❍ Dexamethasone

❍ Adrenergic agents

❍ Caffeine

6. Neurological
❍ Pain

❍ Seizures

❍ Intracranial hypertension

❍ Drug Withdrawal

Investigations

First Line Investigations:


1. Repeat your clinical examination:
❍ Are there any abdominal masses? Can you feel the kidneys?

❍ Feel the pulses! Are the femoral pulses the same as the brachial pulses?

❍ Are the fontanelle and sutures normal?

2. 4-limb blood pressures


❍ Note: Dinamap BP can be normal in the lower limbs in a baby with

coarctation in.
❍ Do not rely on four limb Dinamap BP measurement to exclude coarctation -

use fingers or ideally Doppler sphygmomanometry


3. Electrolytes, urea, and creatinine
4. Urinalysis
5. Renal ultrasound scan
6. Chest radiograph (if cardiac murmur or signs of congestive cardiac failure)

Second Line Investigations (when history suggests):

1. Echocardiogram to exclude coarctation or interrupted aortic arch.


❍ Also useful to assess cardiovascular function and complications in long-

standing or severe hypertension.


2. Plasma renin activity
❍ Renin levels are higher in newborn infants than in older children and adults

and an elevated PRA may not indicate underlying renal disease


3. Plasma cortisol, aldosterone, or thyroxine (as indicated)
4. Cranial ultrasound or MRI if any suspicion of an intracranial cause
5. Renal radionucleotide study

Treatment

1. Treatment will depend on the underlying cause and should be commenced only
after discussion with either a paediatric nephrologist or a paediatric cardiologist
(depending on underlying cause).
❍ In general, Labetalol is the first-line treatment of hypertension severe

enough to require treatment (once coarctation is excluded).


❍ Second line agents include calcium channel blockers (however, not

Nifedipine) or Hydrallazine.

References

1 Watkinson M. Hypertension in the newborn baby. Arch Dis Child Fetal Neonatal Ed 2002; 86:F78-F81
Task force on blood pressure control in children. Report of the Second Task Force on Blood Pressure
2
Control in Children - 1987. Pediatrics, 1987; 79:1-25
3 Flynn JT. Neonatal hypertension: diagnosis and management. Pediatr Nephrol 2000;14(4):332-4.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Blood Sampling in NICU Reviewed by Joy Reilly (RN)


Laboratory Specimen Requirements
November
2005

NICU Radiometer Gas


Arterial gas Biochemistry Haematology
Machine
Drug Levels Blood Bank Other Tests Capillary Sampling Devices

Tests Volume Container


Arterial gas 0.3ml BD A-line
syringe
● Includes:Na, K, Glucose, Hb, Hct, MetHb.
● NICU Radiometer machine also measures
bilirubin and lactate

NICU Radiometer Gas Machine

● Capillary gas - includes: 95 uL Gaslyte


Na, K, Glucose, Bilirubin, Hb, Hct, MetHb,
lactate

● Glucose only 35 uL Small capillary


tube
● Bilirubin only 35 uL Small capillary
tube
Laboratory Gas

● Capillary gas - includes: 0.2 ml A full capillary


Na, K, Glucose gas tube

Biochemistry Laboratory
● SBR (total) only 0.3 ml Green top
(heparinised)
● Total & Direct SBR 0.4ml Green top
(heparinised)
N.B.: Full Biochemistry including all or any 0.7ml Green top
combination (heparinised)

● Electrolytes, Ca, Gluc, Creat, Urea, LFT,


SBR, Mg, PO4

● When collecting 3 – 4 tests 0.5-0.6ml

● LFT – Liver Function Tests


Medical Staff required to complete laboratory form stating specific tests required –
as this determines the amount of blood required. Routine tests will be bilirubin,
AST, ALT, GGT, and ALP.

Thyroid Function Tests


● TSH, Free T3 & T4 - use 2 tubes 860 uL blood Yellow top
(‘plain tube’ = no
anticoagulant)
● Free T3 & T4 500 uL

● Free T4 & TSH 600 uL

● These are minimum amounts, if the PCV is higher than 0.5, then more blood is
required
● When the laboratory requests SERUM approximately double the amount of
BLOOD is needed to obtain adequate serum for processing.
● Consult Medical Staff re tests required as this determines the amount of blood
required

CRP (C-Reactive Protein) 0.3 – 0.5 ml Green top


(depending on (heparinised)
PCV)

Haematology

Full Blood Count 0.3 ml Purple top


(EDTA)
Coagulation Screen 1.0 ml Blue top micro-
Venous / Arterial container
● N.B. – NICU stock – if not available obtain
from PICU – ( not Lab. incorrect size tube for
neonates, larger volume required)

Ferritin – (NOT routinely processed on Public Hols. 0.3 ml Green or Yellow


or Weekends) top
Whole Blood PR/INR &/or APTT Contact Lab Special container
G6PD 0.3 ml Purple top
(EDTA)

Drug Levels

● Amikacin All of these Green top


● Gentamicin drug levels container
● Vancomycin require 0.3ml
● Phenobarbitone
● Phenytoin
● Theophylline

● Caffeine (Lab. to be notified by medical staff 0.4 ml Yellow or Green


24 hours prior to collect) top

Vitamin A ● All samples taken 0.3 ml Yellow top


for vitamin levels (plain tube = no
Vitamin D must be wrapped 0.2 ml anticoagulant)
in tinfoil
Vitamin E 0.4 ml

Blood Bank
Will only accept ‘REQUEST FOR BLOOD COMPONENTS OR PRODUCTS’ Form for
blood samples – not Laboratory Form – complete ‘TESTS REQUIRED’ section

Blood Bank require their BLOOD SAMPLES to be legibly HAND LABELLED using the
specific labels, with:

● patient’s first & last names


● NHI number
● DOB
● date & time of collection
● signature/initials of collector

Group & Coombs 0.3 ml Purple top


(EDTA)
Neonatal Crossmatch 0.7 ml Purple top
(EDTA)

Other Tests

Neonatal Zinc Level 1.5 ml 2 x green top


Arterial or containers AND
● Samples to lab Monday to Friday, but not Venous sample 1 x empty
weekends or public holidays. container
● Samples are processed Monday,
Wednesday, and Friday.
● 1 empty container is required for control test
to detect zinc level in the containers.
Therefore THEY MUST BE THE SAME
BATCH NUMBERS - USE CONTAINERS
FROM AN INTACT PACKET FROM the
Cupboard in the RADIOMETER ROOM (or
use NAVY BLUE TOP container – adult
trace metal tube – obtain from lab.)

Lactate 0.6 ml Yellow top


Albumin 0.5 ml Green top
Cholesterol
● Level only 0.3 ml Yellow or Green
top
● Hg/etc 1.0 ml Yellow top

TORCH Screen 0.6ml Yellow top


Hepatitis screen 0.6ml Yellow top
Karyotype 1-2ml arterial or Green top
venous

Note:

● Other tests requested which are not routinely required for NICU infants –
PLEASE consult the Laboratory staff for information on the amount of blood
required and the appropriate container to use for the particular MICRO-
COLLECT, also state for NEONATE.

● For infants with a high PCV (often new admissions) when the blood clots
easily causing difficulty in obtaining a result via the Radiometer Gas
Machine, we have a supply of 55uL glass capillary tubes containing extra
Heparin which may ensure you obtain a result – please ask the CCN for
these capillary tubes when required.

Capillary Blood Sampling Devices


Tenderfoot– Micro- Blue
preemie For infants up to 1000
grams
Quikheel - Preemie Mauve ● Depth 0.85mm
Lancet For infants 1005-1500 ● Length 1.75mm
grams ● May also be used for a
small collect of 35mL
ONLY = glucose only or
bilirubin only via
Radiometer Gas Machine.

Quikheel - Infant Lancet Teal ● Depth 1.00mm


For infants >1500 grams ● Length 2.50mm
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday, May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Management of Pregnancies at Borderline Viability


Reviewed by Jane Harding

December 2005

Less than 23 weeks 23+0 to 23+6 weeks 24 weeks and more


Survival Rates Long-term Disability

All discussions regarding management of such pregnancies should involve the parents and members of both
Neonatal and Obstetric services. Members of these services are available to discuss cases by telephone at any
time.

● Click here to open the guideline on Admission Rates to NICU and the degree of Respiratory Support
required.

≤23 weeks 0 days

Standard Practice ● Do not refer to National Women’s Health.


● No fetal monitoring.
● No Paediatrician present at delivery.
● Obstetric staff will usually provide antenatal counselling regarding
outcomes.

23 weeks 0 days to 23 weeks 6 days

Usual Practice ● No fetal monitoring and therefore no caesarean section for fetal distress.
● Consider referral to National Women’s Health<.
● No attendance by paediatric staff.

If parents make a ● Consider steroids if delivery thought to be imminent or gestation of 23


decision for active weeks, 5 days plus.
treatment after informed ● Paediatrician called for delivery.
discussion with ● If birthweight >500g and gestation appears appropriate start resuscitation.
neonatal and obstetric ❍ Stop early if response poor.

specialists

≥24 weeks 0 days

Standard Practice ● Definite referral to National Women’s Health.


● Antenatal steroids.
● Fetal monitoring, consider caesarean section for fetal distress.
● Paediatrician called for delivery.
❍ If birthweight <500g discontinue resuscitation.
At parental discretion ● If <26 weeks, parents may elect after discussion for no fetal monitoring, no
caesarean section and no Paediatrician at delivery.

Survival Rates of Extremely Preterm Infants

● Survival for preterm infants has been increasing steadily over time. National Women's survival data by
birthweight are shown below. These birthweight data are only for infants admitted to the NICU.

Data collated by Associate Professor Ross Howie and Dr David Knight.

● Although birthweight is easy to measure and is an important determinant of survival, gestation is a better
predictor of outcome. The gestation-based survival figures of all infants born at National Women's
Health are:
● The outcomes above include all infants presenting in utero at National Women's
❍ It includes intrauterine deaths, stillbirths, and infants who were born alive but were

unable to be resuscitated.
❍ Admission to the neonatal unit results in higher survival rates as this is a more

selected group of infants.


● For the graphs below, subgroups are shown for gestations 30 weeks and below.
❍ Note that the numbers of infants in some gestational groups (for example, 23 and

24 week infants) or by some analyses (for example, outborn infants) are relatively
small.

Click on the link to the left to look at survival figures for all infants between 22 and 30 weeks gestation who were born
alive at National Women's 1996-2004.

Click on the link to the left to look at survival figures for all admissions to NICU for inborn infants at National Women's
1996-2004.

Click on the link to the left to look at survival figures for all admissions (inborn and outborn) to NICU 1996-2004.

Click on the link to the left to look at survival figures for outborn infants (infants born in other institutions) admitted to
NICU 1996-2004.

Click on the link to the left to look at overall survival for liveborn infants 24-30 weeks gestation at National Women's
Health between 1996 and 2004. Infants born at 23 weeks have been excluded, due to the relatively low numbers of
infants.

These data have largely been collected by Dr David Knight as part of ongoing audit for the Annual Report.
Long-Term Outcomes

● Disability rates are approximately 20% in extremely low birthweight (<1000g) survivors at any gestation.
❍ The rate of cerebral palsy is relatively constant at around 10%.

❍ Severe disability rates are approximately 10%.

❍ Disability rates are higher in infants below 25 weeks.

❍ Around 50% of surviving infants at 23 weeks have moderate or severe disability.

❍ At 24 weeks, approximately 40% of surviving infants have moderate or severe disability.

● Disability includes cerebral palsy, developmental delay, visual and hearing impairment.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Handling Powdered Formula and Breast Milk with Reviewed by Barbara Cormack
Additives (Dietitian) and Carl Kuschel

May
2005

Recommendations for Handling of


Background References
Enteral Nutrition Preparations

Background

This guideline should apply to all infants in a neonatal unit, maternity ward, or children's
hospital ward. It should also be applied to all healthy term infants for the first two months
of life.

There has been recent concern about the role of powdered formula preparations in the
development of Enterobacter sakazakii infection in neonates. Previously known as "yellow
pigmented" Enterobacter cloacae, it was renamed Enterobacter sakazakii in 1980. It has
been known to cause meningitis, septicaemia, and necrotising enterocolitis in neonates,
with reported mortality rates of up to 80%.

The incidence of E.sakazakii infection is low. In a report describing infection rates from
over 10,000 VLBW infants, only one case was identified from over 6,000 blood cultures
1
taken after the third day of life. Case reports and outbreaks of E.sakazakii infection
2-9
have variably been associated with the use of powdered formula. In 2002, the FDA
released a statement indicating that neonatal units should take steps to minimise the risk
10,11
associated with powdered formula and additives. In New Zealand, an investigation
into a case of E.sakazakii from a New Zealand neonatal unit led to local
12
recommendations from the Ministry of Health.

It is important to appreciate that powdered formulas and milk preparations are not sterile
and can provide a medium for bacteria to proliferate. Appropriate preparation and
handling of nutritional products is necessary to reduce the risk of milk becoming a source
13
of nosocomial infection. Breast feeding - apart from providing immunity through other
means - reduces the risk of infection associated with formula preparation and storage,
although care needs to be taken with breast milk which has been modified with additives.

Recommendations for Handling of Enteral Nutrition Preparations

Recommendation Comments

Encourage the use of sterile liquid "ready to ● Liquid formula is sterile.


feed" formula for both healthy newborn infants ● Although powdered formula is
in maternity wards, infants in NICU, and infants pasteurised, it is not sterile. Bacteria
in the wards of Starship Children's Health present in the formula, the preparation
equipment or the containers may
contaminate the preparation.

If formula needs to be prepared in advance, it ● Refrigerate feeds on delivery to the


should be prepared on a daily basis and should patient care room.
be kept at 4°C or below for not more than 30 ● Ensure that fridges are kept at ≤4°C
hours and are monitored.
● New feeds are to be delivered by every
24 hours.
❍ Only enough feed for 24 hours

should be delivered at one time.


● A “use by” date and time is to be visible
on every feed label.

Prepare only a small amount of reconstituted ● This is not practical for most areas in
formula for each feed to reduce the quantity the hospitals, hence the move to a
and time that formula is held at room liquid formula.
temperature for consumption ● This does apply to human milk fortifier
and other food additives.
❍ Make up no more than 50ml

(unless the infant's feed is a


greater volume than this)

Minimise the "hang-time" of formula feeds (or ● "Hang-times" should be recorded and
breast milk with additives) monitored.
● No "hang-time" should exceed 4 hours.

There should be surveillance of formula for ● ADHB Nutrition Services undertakes


possible contamination random sampling with specimens
analysed by an external laboratory.

Health professionals should investigate and ● The Ministry of Health has indicated
report sources and vehicles (including that Enterobacter sakazakii is a
powdered infant formula) of infection by E. notifiable disease.
sakazakii and other Enterobacteriaceae
References

1 Stoll BJ, Hansen N, Fanaroff AA, et al. Enterobacter sakazakii is a rare cause of neonatal septicaemia or
meningitis in VLBW infants. J Pediatr 2004;133:821-3.
2 Muytjens HL, Zanen HC, Sonderkamp HJ, Kollée LA, Wachsmuth IK, Farmer JJ 3rd. Analysis of eight
cases of neonatal meningitis and sepsis due to Enterobacter sakazakii. J Clin Microbiol 1983;18:115-20.
3 Biering G, Karlsson S, Clark NC, Jónsdóttir KE, Lúdvígsson P, Steingrímsson O. Three cases of neonatal
meningitis caused by Enterobacter sakazakii in powdered milk. J Clin Microbiol 1989;27:2054-56.
4 Muytjens HL. Kollee LA. Enterobacter sakazakii meningitis in neonates: causative role of formula? Pediatr
Infect Dis J 1990;9:372-3.
5 Jaspar AH. Muytjens HL. Kollee LA. Neonatal meningitis caused by Enterobacter sakazakii: milk powder is
not sterile and bacteria like milk too! Tijdschr Kindergeneeskd 1990;58:151-5.
6 Clark NC, Hill BC, O'Hara CM, Steingrimsson O, Cooksey RC. Epidemiologic typing of Enterobacter
sakazakii in two neonatal nosocomial outbreaks. Diagn Microbiol Infect Dis 1990;13:467-72.
7 Bar-Oz B, Preminger A, Peleg O, Block C, Arad I. Enterobacter sakazakii infection in the newborn. Acta
Paediatr 2001;90:356-8
8 Block C, Peleg O, Minster N, et al. Cluster of neonatal infections in Jerusalem due to unusual biochemical
variant of Enterobacter sakazakii. Eur J Clin Microbiol Infect Dis 2002;21:613-6.
9 van Acker J, de Smet F, Muyldermans G, Bougatef A, Naessens A, Lauwers S. Outbreak of necrotizing
enterocolitis associated with Enterobacter sakazakii in powdered milk formula. J Clinical Microbiology
2001;39:293-7
10 Anonymous. Enterobacter sakazakii infections associated with the use of powdered infant formula--
Tennessee, 2001. MMWR - Morbidity & Mortality Weekly Report Apr 12 2002;51(14):297-300
11 Anonymous. From the Centers for Disease Control and Prevention. Enterobacter sakazakii infections
associated with the use of powdered infant formula--Tennessee, 2001. JAMA. 2002;287:2204-5.
12 Ministry of Health, New Zealand. Inquiry into Actions of Sector Agencies in Relation to Contamination of
Infant Formula with Enterobacter Sakazakii. March 2005. Available online at http://www.moh.govt.nz
13 Agostoni C, Axelsson I, Goulet O, et al. Preparation and Handling of Powdered Infant Formula: A
Commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2004;39:320-2.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

BRM2 Monitor Reviewed by Angela Warren


(CCN), Robin Gardner (CCN),
Malcolm Battin and Carl Kuschel

September
2005

Indications Application Start the Monitor Log on


Enter Patient Details Check Contact Quality Mark Events Turn Off

The following policy/recommended best practice outlines practice applies to all Medical
and Nursing staff working in Newborn Services.

Indications

The following infants should be considered for Brainz BRM2 monitoring.

Infants ≥34/40 with:

● Definite or questionable seizures


● Muscle relaxed infants at risk of seizures that may not be clinically apparent
● Moderate perinatal asphyxia (neonatal encephalopathy)
● Unexplained apnoea

Monitoring should not be commenced unless directed by a specialist.

Application

Electrodes to be applied by newborn Medical and Nursing staff who have undertaken
BrainZ BRM2 training.

Equipment required:

● BrainZ sensor set


● BrainZ sensor positioning strip
● Marker pen
● Skin prep gel (NuPrep®)
● Wrap hat
● Water / gauze/ cotton tips

Step Action
1 Position infant supine
2 Using sensor positioning strip,
measure from the sagittal suture to the
tragus of the ear. Align so each end
point has the same letter (A,B etc)

3 Mark the site for electrode placement.

4 Clean the marked areas with water and gauze, parting the hair in a line towards
the top of the head
5 Gently pat dry with gauze maintaining the part in the hair
6 Using cotton tips clean the area with a
very small amount of NuPrep®

7 Using gauze and water clean off the NuPrep®, continuing to maintain the
parting.
8 Pat dry the area.
9 Site electrodes in the following manner.

● All leads to be directed to the


top of the head
● Black electrode placed at the
back
● White electrode placed in front
● Ensure electrodes do not touch

10 Gently turn infants head over and


repeat process.

11 Apply head wrap with adequate tension to support electrodes.


12 Site the green reference electrode,
either on the neck, shoulder, or back.

13 Plug blue connector into the data


acquisition unit (DAU)

14 Note: If electrodes lift, reapply using a small drop of sterile water. Do Not stop
the machine. Continue monitoring, making a note on the trace, of the event.

Start the Monitor

Step Action
1 Plug monitor into wall power supply.
2 Ensure power cable and serial cable is connected from monitor to the isolation
unit.
3 Connect the data cable from the isolation unit to the DAU.
4 Turn on the AC power switch (at back of monitor).
5 Check that the green light on the DAU comes on.

Log on

Step Action
1 Touch the white field next to ‘user name’ to display the onscreen keypad.
2 Type in the word NICU, press enter.
3 Touch the white field next to ‘password’ to display the on- screen keypad.
4 Type in the word NICU, press enter.
5 Once both user and password are entered touch the ‘login button’ to display
the main menu screen.

Enter Patient Details

Data must be entered before monitoring commences. Once monitoring, patient data can
not be altered.

Step Action
1 On main menu screen touch the ‘assess patient’ button to display the new
patient screen.
2 Touch the first white field to display the on-screen keypad.
3 Typing the appropriate data, touch enter at the end of each entry.
4 Touch the appropriate check box to select the gender.
5 Use arrows to adjust birth weight / current weight.
6 Touch appropriate date on calendar to enter birth date.

Check Contact Quality

Contact impedance is displayed on the ‘signal status screen’.

Step Action
1 On main menu screen touch the ‘check signal’ button.
2 All 4 dots displayed on the graphics should be green.
3 If dots are yellow or red check the corresponding electrode.
4 Once all dots are green press the ‘OK’ button.

Mark Events

During monitoring Mark events i.e. suctioning, cares, observation of seizure-like


movements, administration of anticonvulsants

Step Action
1 Touch ‘mark events’ button.
2 Touch white description area to display the onscreen keypad.
3 Enter a brief note
4 Touch enter, then OK
5 A green line and number will appear on the aEEG graphics. To recall the event
data touch the green line on the screen.

Turn Monitor Off

Step Action
1 On main menu screen touch ‘shutdown’ button.
2 On confirmation screen touch yes.
3 Once screen says shutdown complete, turn AC power off.
4 Remove sensors by dampening the gel with water.
References

1 BrainZ BRM2 Brain monitor reference manual


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Caloric Calculator © Carl Kuschel

February
2006

● This calculator provides an estimate of caloric intake.


● This may be useful when considering caloric intakes in infants who are
hyperglycaemic, where the use of insulin may be considered.
● It may also be used in those infants in whom referral to a dietitian for ongoing
nutritional management is being considered.

Working Weight: g

Current Fluid and Nutritional Intakes

Enteral Feeds

0 ml per hour
● Please
divide the 2- 0 ml/kg/day
or 3-hourly
feed amount
to work out
the hourly
0 kcal/kg/day
amount

Intravenous Nutrition

Amino Acid
0 ml per hour 0 ml/kg/day
Solution:
20% Intralipid: 0 ml per hour 0 ml/kg/day
0 g/kg/day 0 kcal/kg/day

Other Intravenous Fluids


● Do not count solutions in saline or half-normal saline (for example, arterial line fluids or infusions that
are not in dextrose).

● Do not count insulin infusions.

Infusion 1: 0 ml/hour 10 % dextrose 0 ml/kg/day


Calculate Reset
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Care Map for Infants <32 Weeks Gestation Reviewed by Jean Bertram, Frank
Bloomfield, Robyn Wilkinson,
Bronwyn Jones, and Carl Kuschel.

March
2006

Prior to Admission On Admission Ongoing Care

Prior to Admission

● CPAP incubator to DU/OT for delivery.

Admission

● Appropriate respiratory support (optimal CPAP).


● Baseline observations / monitor
❍ HR

❍ Respirations

❍ SaO as per oxygen saturation targets (range 85 – 92% with O2


2
requirement / alarm limits set appropriately)
❍ BP (mean blood pressure ≥ gestational age)

❍ Temperature (monitor skin temperature initially)

● Commence incubator humidity 50% (discontinue 3 weeks of age or 32 weeks


gestation, whichever comes first)
● IV 10% Dextrose 60-90mls/kg per day.
● FBC.
● Blood cultures if risk factors for sepsis or baby unwell.
❍ Commence antibiotics if indicated.

● Blood glucose.
● Capillary gas.
● Commence urine weighs.

Ongoing Care

● May need 1-2 hourly cuff BP measurement initially,


then 4 hourly,
then minimum 8 hourly till stable.
❍ Discuss frequency on ward round.
❍ Report hypotension or fluctuations in blood pressure to medical staff.

● Continue:
❍ urine weighs.

❍ urine testing for glucose, blood, and protein.

Test 8-hourly initially then discuss frequency on ward round.


❍ blood glucoses as indicated.

❍ capillary gases/electrolytes/SBR as indicated.

● Careful observation / assessment / documentation of respiratory status


❍ Report changes to medical staff.

❍ Have a low threshold for restarting babies back on CPAP if they are being

trialled off and become symptomatic with increasing tachypnoea,


desaturations, oxygen requirement, or apnoea.
● Discuss and assist mother with expressing.
● Demonstrate and encourage parents’ safe handling of baby
❍ nappy changes

❍ top and tail

❍ positioning / settling

❍ Kangaroo care

■ <30 weeks not in first 5 days

■ ≥30 weeks consider stability

■ Monitor infant's physiological status carefully.

■ Discuss on ward round if unsure.

NB: Read appropriate parts of Developmental Care Protocol


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Chickenpox Exposure in NICU


Reviewed by Dr Liz Wilson and
Judy Gilmour (Infection Control)

May 2005

● An individual with chickenpox (varicella) is infectious from 2 days prior to the


appearance of lesions to 5 days after or until the lesions are dry and crusted
(whichever is longer).
● Determine true diagnosis in index case / call infection control
● Susceptible contacts will require VZIG. VZIG needs to be given within 72 hours of
exposure and no later than 96 hours. See VZIG information.
● Note that VZIG costs $360 per vial and must be approved by the Medical Officer or
the "on call" transfusion specialist.
● Exposed individuals that are non-immune become potentially infectious from 8
days following initial contact until 21 days following the last contact with the index
case. See Chickenpox information.
● For isolation see Chickenpox - Infectious precautions.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

The Child Development Unit (CDU)


Reviewed by Anne Dezoete
Information for Parents

December
2000

See also CDU site

This follow up programme is available for children in the groups listed below who received
special care in the Neonatal Intensive Care Unit at National Women's Health. It is
provided as a service to parents and children, and to the hospital to give information on
how some of the children cared for progress in the years after they go home.

The Developmental Psychologist will check you child's development (mental, motor and
behavioural). This service is in addition to periodic medical checks by your Paediatrician.

At present the Child Development Unit service is offered to the following groups of children

1. BABIES WHO WEIGHED LESS THAN 1000 GRAMS AT BIRTH:


These are seen at the ages of nine and eighteen months and thereafter as
considered necessary.
2. BABIES OF 1000-1500 GRAMS:
These are seen ordinarily at eighteen months, earlier on special request, and later
as considered necessary.
3. OTHER INFANTS REFERRED BY THE CONSULTANT PAEDIATRICIAN:
These are seen as considered necessary.

This service is intended to benefit parents, children and the hospital. Parents and children
have the advantage of regular assessments, so that any problem may be identified at an
early age and appropriate help arranged. The hospital needs to know how infants from its
neonatal care units are progressing, which will help the staff of the Unit to take better care
of babies who need special care in the future.

Telephone contact: (09) 3074949 Ext.25364


See also CDU site
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Cleft Lip and Palate Guidelines Reviewed by Maeve Morrison


(SLT, Middlemore Hospital) and
Carl Kuschel

November
2003

Incidence Immediate Management Feeding Guidelines


Timing of Surgery Other Issues Followup

Incidence

● Bifid uvula 2%. This may indicate underlying submucous cleft.


● 1:800-1,000 cleft lip and palate.
● 1:2,000 isolated cleft palate.

Immediate Management

1. Paediatric assessment (SHO, NS-ANP, Registrar, or Consultant). In particular


examination for other abnormalities, airway and breathing difficulties.
2. Paediatric staff will refer to the Middlemore Hospital Plastics Team Clinic.
❍ Fax: 276 0004

Referral will be acknowledged by Clinic Manager by return fax Monday


to Friday
❍ Plastic Surgical Registrar can be contacted after hours or on the weekend if

urgent acknowledgement is required.


3. Referral to the Lactation Consultant, National Women’s Hospital.
4. Referral to the Speech Language Therapist, Middlemore Hospital
❍ Phone 263 0792 Ext.3245

❍ Locator 93 8155

❍ Plus written referral by fax 263 0539 to SLT.

5. Cleft Lip and Palate Support: The information pack is the Blue Book which is
available on NICU and is given to and discussed with the parents (available from
the Cleft Lip & Palate Support Group and available online (downloadable in Adobe
Acrobat format)). A visit can be arranged if parents request via the email address
in the Blue Book.

Feeding Guidelines
● Click here to open the Feeding Guidelines

Timing of Surgery

Surgical priorities are:

● speech
● appearances
● dental occlusion

● Lip and primary palate is usually repaired at around 5 months of age.


● Soft palate repair is usually around nine months of age.

Other Issues

● Children with Pierre Robin Syndrome or severe micrognathia are at high risk of
airway obstruction and may need to be nursed prone so that the tongue falls
forward and they may need tube feeding and saturation monitoring. The relative
mandibular under-development and glossoptosis usually disappears by early teens.
● Cleft lip and palate may be part of dysmorphic syndromes. Up to 40% will have
associated malformations. Investigations may include:
❍ A detailed family history is important.

❍ Chromosomes.

❍ Consider velocardiofacial syndrome, chromosome 22q syndrome or Di

George Syndrome – cytogenetics.


❍ Ultrasound scans of head, heart and kidneys. Radiographs of spine.

❍ Referral to the Geneticist for counselling.

Follow Up

The Middlemore Hospital Cleft Lip and Palate Team Plastic Surgeon and Speech-
Language Therapist try to see the newborn baby within a few days after birth. The team
will then assess the child in clinic within 6 weeks. The surgeon will outline and
individualise management for that child. The team includes:

● Plastic surgeon
● Orthodontist
● Speech-Language Therapist
● Plastic Surgery Nurse
● ENT Surgeon

If other anomalies are present then the Specialist will need to follow up as appropriate, e.
g. Paediatric Cardiology at Starship Hospital. A National Women’s newborn service
appointment may be offered for three months to ensure that all is progressing normally in
terms of follow up arrangements, feeding, growth and early development.
Parents are not always aware that the management of cleft lip and palate is long term and
follow up may be into the child’s twenties before orthodontics is completed. Rhinoplasty,
jaw and further lip surgery may also need to be scheduled at this late stage. We should
endeavour to inform the parents with the help of literature that the immediate repair is
only the beginning of a long term relationship with the Plastic Surgical Team.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Paediatric Respiratory Service Review of Infants on Reviewed by Innes Asher


NICU

May
1992

Dr Innes Asher, the Respiratory Registrar and Rhonda Akroyd, Dietitian, Auckland
Children's Hospital.

Visit starts 8.50am, NICU (or SCBU if previously notified) and lasts until l0am, on the
designated Monday.

Recommended information available on each patient:

To be received ONE WEEK before visit:

● Written medical summary, and copy of growth charts

Available on the Day:

● Problem list (up to date).


● Drug list.

Investigations:

● All chest radiographs displayed on viewing boxes. Chest radiograph within last four weeks.
First, worst, best and latest are of greatest interest.
● All ECGs including one within last four weeks. Reports available if possible.
● Blood gases, especially those within last two weeks.
● Any other relevant investigations if done, e.g. barium swallow, immunoglobulins,
echocardiograph, viral titres.
● Records of pulse oximetry in the last week including print out of oximetry over 24 hours.
Note duration of feeding, sleeping, activity etc on the printout.

Nutrition
● Charts up to date (up to the day of visit) for: weight, length, head circumference.
● Calculated 24 hour ml/kg and cal/kg intake
● Information on feeding methods and any problems.

Very important to have access to a nurse who currently knows the child well, and the Paediatric
Registrar who knows the child best.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

The Collapsed Ventilated Infant Reviewed by Simon Rowley


Aids to Diagnosis and Treatment

December
2000

Situation

You are called to see the small ventilated premature baby with RDS. The baby has
suddenly collapsed, is cyanosed, pale, with a falling BP, falling HR. How does one deal
with this situation?

Strategy

● Have a systematic checklist to rapidly ascertain the problem and then treat it
appropriately.
● Aim to achieve adequate oxygenation. If any delay in diagnosis or management
remember to maintain CPR basics.
● Don't hesitate in calling the consultant if you anticipate major problems that require
expertise beyond your abilities.

PROBLEM ACTION
● Delivery System fault, i.e. ● Reconnect or change to
interruption of gas adequate gas supply.
supply to ventilator.
Loss of desired ● Check ventilator settings and
ventilation from tubing circuit integrity.
machine to ETT.
● ET Tube Extubation ● Remove ETT, bag, reintubate.
Problems
● poor chest
movement, poor
air entry
‘blowing
bubbles’.

Tube Placement ● Directly visualise ET tube and


check position.
● e.g. right main ● Withdraw 0.5-1cm.
bronchus ● Check CXR.

Blockage ● Remove ETT, bag, reintubate.

● poor chest
movement, poor
air entry,
copious
secretions,
difficulty passing
suction catheter.

● Ectopic Air Pneumothorax ● Aspirate with fine gauge


butterfly needle, 3-way tap and
● decreased chest syringe.
movement and/ ● If free air proceed to insertion
or decreased air of intercostal drain.
entry, that may
transilluminate
with a cold light.

Pneumopericardium ● Aspirate with fine gauge


butterfly needle, 3-way tap and
● present on syringe via subxiphisternal
previous CXR space.
● signs of ● If air recollects consider drain
tamponade – insertion.
loss of cardiac
output with no
heart sounds
heard but
normal
complexes on
ECG.
● In both situations, consider obtaining a chest
radiograph if time allows to confirm diagnosis

● Acute Blood Revealed ● Control bleeding if possible.


Loss ● Give volume, FFP, blood
● From arterial promptly.
line, umbilical ● Check clotting.
vessels, GI
tract, renal tract
or up ETT.

Concealed ● Give volume , FFP, blood


promptly.
● Pulmonary, GI ● Check clotting.
tract bleeds and ● Arrange CXRs, cerebral USS.
also IVH/PVH.

● Neurological Convulsions ● Administer anticonvulsant –


Phenobarbitone 20-25 mg/kg
● associated load is usual.
abnormal limb ● Correct any predisposing
truncal, facial factors.
movements ● Arrange cerebral USS.

● Other Septicaemia ● Maintain optimal


occasional cardiovascular support with
causes of colloid and inotropic agents.
acute cardio- ● Obtain microbiological samples
respiratory if stable.
collapse. ● Check FBC, clotting.
● Commence on antibiotics.

Metabolic disturbances ● Administer 2ml/kg of 10%


e.g. Hypoglycaemia Dextrose as bolus, increase
rate of maintenance Dextrose
infusion and recheck blood
glucose in 30 minutes.

Hypocalcaemia ● Administer 1ml/kg of 10%


Calcium Gluconate, increase
maintenance infusion and
recheck serum calcium in 30
minutes.
Hyperkalaemia ● Administer 1ml/kg of 10%
Calcium Gluconate and
consider further treatment
depending on degree of
hyperkalaemia. e.g. Resonium,
Dextrose and Insulin.

Congenital Cardiac ● Maintain optimal oxygenation


Disease and cardiac output.
● Arrange urgent CXR, ECG and
With heart failure ECHO.
commonest lesions ● Treatment dependent on
presenting in first week diagnosis and in consultation
of life: with Paediatric Cardiologist.
● In the absence of a rapidly
accessible Echocardiogram or
● Hypoplasia of
Cardiology assessment, a
the left heart
prostaglandin infusion may be
● Coarctation of
the aorta life-saving.
syndrome.

With severe cyanosis:

● Transposition of
the great
arteries.
● Pulmonary
atresia or
severe
pulmonary valve
stenosis.

Pulmonary ● Keep optimal oxygenation.


Hypertension: ● Keep pH high using base +/-
hyperventilation.
● Maintain adequate systemic
● Commonly a
blood pressure with colloid and
problem in
inotropes.
known term
● Consider inhaled Nitric Oxide.
baby with PPHN.
● However,
significant R to L
shunting may
cause acute
collapse in the
ventilated
premature baby.
● Pulmonary
vasculature is
PO2 and pH
sensitive.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

The Use of Complementary and Alternative Medicine Reviewed by Carl Kuschel


(CAM) in NICU with advice from ADHB Legal
Services

March
2005

Background Summary References

Background

Having a baby in the NICU is a stressful experience for parents. For some parents,
conventional medicine may not fit well with their framework of personal, health, and
spiritual beliefs. Occasionally, parents will request that their infant receives
complementary and alternative medicine (CAM) care (for example, naturopathy,
osteopathy, or homeopathy).

1
The prevalence of CAM in NICUs is not widely reported. Some interventions that have
previously been regarded as “complementary” 2 (for example, kangaroo care, and music
therapy) have moved more into mainstream “conventional” care within the bounds of
some developmental care practices. For older children, there is evidence that CAM use
3
is relatively prevalent. In an Australian paediatric gastroenterology outpatient setting,
36% of children were using or had recently used CAM, and 78% of their parents indicated
4
that they would use CAM if they thought it would be beneficial. Similarly, 18% of
children were receiving CAM treatments at the time of hospitalisation for acute illness in a
New Zealand paediatric inpatient unit. 5 Many parents of children in a paediatric ICU
suggested that they would appreciate the opportunity to provide CAM therapies, and
those that were using CAM were reluctant to discuss this with conventional medicine
6
providers.

The Health and Disability Code of Rights states that “every consumer has the right to be
provided with services that take into account the needs, values, and beliefs of different
7
cultural, religious, social, and ethnic groups”. Whilst the code is geared more for adults
who are able to make autonomous decisions, there is potential conflict where parental
beliefs may conceivably place their infant at risk by not providing appropriate conventional
care or by exposing the infant to risk from untested or dangerous therapies (particularly
medications that may interact with conventional medicines). The legal position of the
Auckland District Health Board is that Newborn Services is responsible for the care of
infants in NICU and under paediatric care in the postnatal wards.

Summary

● If parents wish their infant to receive homeopathic or naturopathic treatments, or


treatments specific to a particular cultural or religious background, this needs to be
fully discussed with the specialist who is looking after the baby.
❍ The safety of the infant is paramount, although the needs of the family to

make a contribution to the health of their child should be considered.


❍ The use of CAM should not be a substitute for nor interfere with effective

conventional medical care.


❍ If CAM is used within NICU, it is the choice of the infant’s guardian and it is

not prescribed by, recommended or endorsed by Newborn Service staff.


❍ Any treatment which involves ingestion or topical application needs to be

considered in the context of possible interactions with conventional


medicines and the potential for significant absorption of the constituents of
complementary medicines through skin. However, information may not be
available pharmacology and interactions for complementary medicines.
● External health care providers are not able to administer complementary or
alternative care which involves direct patient contact within ADHB facilities, without
the approval of the NICU specialist and ADHB management. This is only an
option in exceptional circumstances.

References

1 Mark JD, Barton LL. Integrating complementary and alternative medicine with allopathic care in the
neonatal intensive care unit. Alternative Therapies in Health and Medicine;2001;7:134-6.
2 Jones JE, Kassity N. Varieties of alternative experience: complementary care in the neonatal intensive
care unit. Clin Obstetr Gynecol 2001;44:750-68.
3 Ernst E. Prevalence of complementary/alternative medicine for children: a systematic review. Eur J
Pediatr 1999;158:7-11.
4 Day AS. Use of complementary and alternative therapies and probiotic agents by children attending
gastroenterology outpatient clinics. J Paediatr Child Health 2002;38:343-6
5 Armishaw J, Grant CC. Use of complementary treatment by those hospitalised with acute illness. Arch Dis
Child 1999;81:133-7.
6 Moenkhoff M. Baenziger O, Fischer J, Fonconi S. Parental attitude towards alternative medicine in the
paediatric intensive care unit. Eur J Pediatr 1999;158:12-7.
7 The HDC Code of Health and Disability Services Consumers' Rights Regulation 1996.Clause 2, Code 1.
Available online at http://www.hdc.org.nz
8 Cohen MH, Kemper KJ. Complementary therapies in pediatrics: a legal perspective. Pediatrics 2005;115
(3):774-80.
9 Anonymous. Guidelines on complementary, alternative or unconventional Medicine. Medical Council of
New Zealand.April 1999. Available online at http://www.mcnz.org.nz/portals/1/Guidance/guidelines%20on
%20complmentary%20medicine.pdf
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Screening for Congenital Heart Disease in First Reviewed by Salim Aftimos and
Degree Relatives Tom Gentles (PCCS)

February
2004

The baseline prevalence of congenital heart disease (excluding PDA in preterm infants,
mitral valve prolapse, and biscuspid aortic valves) is approximately 0.5-0.8% of all live-
births.

The recurrence risk for siblings of children with congenital cardiac malformations have
been variably estimated in the region between 1% and 4%, provided there is no strong
family history of that particular malformation. The risk is higher in first degree relative
where the lesion is Hypoplastic Left Heart Syndrome (HLHS, 19.3%) and coarctation of
1
the aorta (9.4%). The most common finding in relatives was of a bicuspid aortic valve,
but some individuals had significant left-sided obstructive lesions including HLHS and
coarctation.

If a neonate is born who has a first degree relative (parent or sibling) who has been
diagnosed with these conditions:

● The baby requires a complete cardiovascular examination, ideally on the first day
but also later in the first week.
● Infants with symptoms or signs of congenital heart disease should be assessed as
indicated.
● Those infants with a normal examination should be referred to the Paediatric and
Congenital Cardiac Service outpatient clinic at Starship Hospital for assessment,
preferably within the first few weeks of life when sedation for an echocardiogram
should not be necessary.

See also the management of antentally diagnosed congenital heart disease

1 Loffredo CA, Chokkalingam A, Sill AM, Boughman JA, Clark EB, Scheel J, Brenner JI. Prevalence of
congenital cardiovascular malformations among relatives of infants with hypoplastic left heart, coarctation
of the aorta, and d-transposition of the great arteries. Am J Med Genet 2004 Jan 30;124A(3):225-30.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Congenital Infection Reviewed by Dr Liz Wilson and Dr


Guidelines for Investigation of Suspected Cases MC Croxson

December
2000

Infection of the fetus can result in embryonic death, stillbirth, prematurity, intrauterine
growth retardation, developmental abnormalities or congenital disease.

Clinical findings are rarely disease specific but include:

● Low birthweight for ● Purpura ● Jaundice


gestational age. ● Chronic rash ● Anaemia
● Prematurity. ● Cerebral calcification ● Hepatosplenomegaly
● Seizures ● Micro-ophthalmia ● Pneumonitis
● Chorio-retinitis
● Cataracts

Toxoplasmosis Rubella Cytomegalovirus Herpes Simplex Virus Syphilis

See also: Hepatitis C and HIV

Toxoplasmosis

● 85% of congenitally infected infants appear normal at birth.


● Only 75% of congenitally infected children will produce detectable specific IgM.
● Maternal infection in first trimester less likely to infect fetus (10%) but if it does the
damage is more severe. Mid or late trimester infection more likely to infect fetus
(30-50%) but the effects are milder.

Investigation of babies born to Toxoplasma IgM positive mothers

The following samples will enable search for toxoplasma DNA (by PCR) in baby's blood,
placenta and amniotic fluid.
The newborn blood and maternal blood will allow direct comparison of maternal/fetal
antibody levels, i.e, is there any evidence of fetal infection as revealed by fetal antibody
production? Cord blood is proving unreliable for antibody titration.

● Cord blood - label clearly 'cord blood'.


● Plain (red top) blood 5ml.
● CPD (yellow top) blood 5ml.

● Placenta - 100g placenta (fetal side near umbilical cord): place sterilely in sterile
disposable plastic container. Keep chilled.
● Amniotic fluid - please collect where available as this may be very informative -
10ml in sterile plastic container.
● Newborn serum - 1ml plain blood (red top) for toxoplasma IgG and IgM. Label
clearly 'newborn serum - not cord blood'.

All these samples should be sent to:

● Department of Virology & Immunology


● Level 2, Building 31
● LabPlus

If suspected after delivery:

● Maternal serum for toxoplasma IgG and IgM


● Infant serum (red top) for toxoplasma IgG, IgM and infant blood (CPD or EDTA
tube) for PCR
● Head ultrasound
● CSF for M, C and S, protein, glucose and toxoplasma PCR

Refer to Paediatric Infectious Diseases Team for treatment and follow up.

Rubella

● Infection of the fetus is CHRONIC, so congenitally infected infants will shed virus
at high titre for many months.

Investigations

● Mother
❍ Check antenatal serology and perform if result not available (mother may

have IgG from infection very early in pregnancy, so documented


seropositivity from a previous pregnancy is more reliable)
● Baby: • Urine +/- CSF for rubella virus PCR.
❍ • White blood cells (cord blood or infant blood) for rubella PCR (EDTA or

CPD tube).
❍ • Serum (cord or infant blood) for rubella IgM.
Isolation

● Contact isolation required: consider infectious for first year of life


● Only those known to be immune should care for the baby in hospital and pregnant
visitors at home should be warned.

Cytomegalovirus

● There may be a history of maternal 'mono'-like illness.


● Most infected infants are asymptomatic but may have later deafness or learning
disability.
● Approximately 15% of infants born after primary infection of mothers will have one
or more sequelae of intrauterine infection.
● CMV infection may show marked liver involvement than congenital toxoplasmosis
with hepatosplenomegaly and jaundice.

Investigations

● Urine culture for CMV (must be in first two weeks of life to confirm congenital
infection). Urine must be chilled and transported immediately to the lab on melting
ice.
● Cord or infant blood for CMV PCR (EDTA or CPD tube).
● Head ultrasound.
● Long term: serial audiology and developmental assessment, head circumference,
ophthalmology.

Click here to link to Nursing Care of Infants who are CMV positive

Herpes Simplex Virus

● Only 30% of mothers whose infants have neonatal herpes have a history of
symptomatic genital herpes.
● Most infections are acquired at birth. Intrapartum/post natal infection can become
manifested up to 4-6 weeks, disseminated infection usually in first two weeks,
localised CNS or SEM (skin, eye, mucous membrane) during second and third
week.
● The risk of HSV infection in an infant born vaginally to a mother with a first episode
or primary genital infection is 33-50% (hence caesarean section usually
performed) and such infants may warrant Acyclovir treatment once cultures have
been taken. Alternatively cultures can be taken at 24-48 hours if the infant is
asymptomatic and acyclovir only initiated if HSV is identified.
● The risk from recurrent genital HSV infection is 3-5% at most and empiric therapy
is not recommended.
● Scalp electrodes must be avoided wherever there is suspicion of active HSV in the
mother.

Investigations
● Skin vesicles: swab for viral culture and HSV PCR.
● Swabs from eyes, mouth/nasopharynx for HSV culture.
● WBCs (CPD or EDTA tube) for HSV PCR.
● CSF - cells, protein, glucose, culture, viral culture and HSV PCR.
● Head CT/EEG may localise disease but not essential.
● Subtype specific (HSV1 and 2) serology may be useful on mother and baby.
● Ophthalmic consultation.

Consult Paediatric Infectious Disease Team

Isolation

● Contact isolation required, especially if skin lesions present.


● Isolate infants born vaginally to mothers with active genital infection for four weeks.
Room-in with mother in isolation if possible. Advise mother re handwashing.

Observation/Surveillance

● Known exposed infants require careful observation.


● Take eye, mouth, nasopharyngeal +/- skin swabs at 24-48 hours
● The family must be educated regarding the symptoms and signs of neonatal HSV.

Syphilis

● Trans-placental infection can occur at any stage of pregnancy, during any stage of
maternal disease.
● NB: Testing of cord blood/infant serum is not adequate for screening because
these tests may be non-reactive when mother is positive. Therefore mother's
serology must be reviewed/performed in all suspected cases.

Evaluation of newborn for syphilis is indicated if:

● Maternal syphilis not or inadequately treated or treated with inadequate follow up.
● Syphilis in pregnancy treated with non-penicillin regime (e.g. erythromycin).
● Syphilis treated within one month prior to delivery.

Or if any of the following clinical features present:

● Osteochondritis/periostitis.
● Snuffles, haemorrhagic rhinitis.
● Condylomata lata.
● Bullous lesions, palmar/plantar rash.
● Mucous patches.
● Hepatomegaly/splenomegaly.
● Jaundice.
● Non immune hydrops fetalis (NB: check for parvovirus).
● Generalised lymph adenopathy.
● CNS signs, elevated cell count or protein in CSF.
● Haemolytic anaemia, DIC, thrombocytopenia.
● Pneumonitis.
● Nephrotic syndrome.
● Unexplained enlarged placenta.
● IUGR; failure to thrive.

Investigations

● FBC, LFTs and syphilis serology on infant blood.


● Maternal syphilis serology.
● CSF for VDRL, cells protein and glucose.
● Long bone radiographs.
● Darkfield microscopy of skin lesions, nasal discharge, placental tissue or amniotic
fluid may show spirochaetes (but majority of cases have none of these).

Refer to Paediatric Infectious Disease Team for treatment and follow up.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Conjugated Hyperbilirubinaemia Reviewed by Carl Kuschel and


Simon Chin

January
2001

Background 1st Line Investigations 2nd Line Investigations Other Investigations

Background

Conjugated hyperbilirubinaemia is relatively common occurrence in neonates. Generally,


the direct (conjugated) fraction of bilirubin should not be greater than 20mcmol/L, or more
than 10% of the total bilirubin if the bilirubin is greater than 200mcmol/L. Most commonly
it is seen in extremely immature infants who are recovering from their immediate neonatal
illnesses, and who have had prolonged parenteral nutrition.

The list of possible causes is extensive and a decision to investigate will depend on the
clinical circumstances. Investigations should be targeted towards either

a. confirming a clinically suspected diagnosis, or


b. excluding a condition for which there is an available treatment.

Therefore, the form below is a template for investigation - this is not an exhaustive list and
other investigations may be warranted. In general, first line investigations should be
performed prior to discussing the case with the Paediatric Gastroenterology Service.
Other investigations should be performed as indicated.

Referral to the Paediatric Gastroenterology service should be considered early if:

a. there is progression of liver disease or liver failure


b. no clear cause is identified

● This page can be printed out by clicking on the "Print" button on the toolbar at the
top of the browser window, or by clicking on the print icon on the banner at the
bottom of the page. This page can be filed in the baby's notes and filled out
according to which investigations are ordered.
Remember: Identifying one possible cause does not exclude co-existent pathology. For
example, it is entirely possible to have both CMV and biliary atresia as dual pathologies.

First Line Investigations

● These should be done prior to consulting the Gastroenterology Service.

Test Date taken Result


Full Blood Count
and film

Total
and conjugated
bilirubin
Liver function tests -
specify:
AST
ALT
GGT
ALP
Blood gas
Albumin
Often low in preterm
infants.
If assessing synthetic
function, consider a
coagulation screen

Blood group and


Coombs
Liver ultrasound
scan

Ferritin
Thyroid function
tests
α1 Antitrypsin
(including phenotype)

Urine CMV
Maternal
toxoplasma serology
Maternal/congenital
infection Maternal Syphilis
(can be obtained from the
obstetric record as
status
necessary)
Maternal Rubella
status
Maternal Hepatitis B
status
bacterial culture
Urine sample
reducing substances

Second Line Investigations

● Second line investigations that are relatively easy to obtain and may be considered
early are:

Test Date taken Result


Coagulation screen

HIDA scan
Urine organic acids
Urine amino acids
Serum amino acids
Plasma ammonia
Plasma Lactate and
Pyruvate
Herpes simplex PCR
(if clinically suspected)

Other Investigations

● These should only be ordered after discussion with a specialist from the Paediatric
Gastroenterology service and include:

Test Date Taken Result


Hepatitis A Virus IgM
Adenovirus serology
Epstein Barr Virus
serology
Other acquired and Stool Enterovirus
congenital infections (ECHO, coxsackie)

Parvovirus PCR
HHV6 PCR
HCV
(very uncommon cause in
the initial perinatal period)

HIV
Triglycerides and
Cholesterol
Carnitine
Urine bile acids
(bile acid synthetic defects)

Very long chain fatty


acids
(peroxisomal disorders)

White Blood Cell


enzymes or
Bone Marrow
aspirate
(storage disorders)

Karyotype
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday, May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Neonatal Conjunctivitis Reviewed by Simon Rowley and Lesley


Voss

December
2000

Demographics Diagnosis Causes References Antibiotics

Incidence

● 2-12% of newborns develop conjunctivitis in the first 28 days of life.

Presentation

● Conjunctival erythema
● Purulent discharge
● Lid oedema
● Look for involvement of any other system, e.g. herpes vesicles, infected scalp pH site.

History

Maternal history

● sexually transmitted diseases or exposure.


● results of high vaginal, cervical and urethral swabs in pregnancy
● length of labour and duration of membrane rupture.

Diagnosis

Bacterial culture ● dry swab for gram stain.


● wet swab for culture (eye swabs received on
● Do this first unless Chlamydia is strongly an infant <4 weeks of age routinely cultured
suspected for N. gonorrhoeae).
● if Gram stain finds Gram -ve bacilli, seriously
consider Pseudomonas and consider sepsis
screen and parenteral anti-Pseudomonal
antibiotics
Chlamydia ● Conjunctival scrapping - done with cotton-
tipped wire swab applied vigorously to the
lower palpebral conjunctiva.
● Purple swab.
● detection of C.trachomatis by EIA
(processed 5 days/week), PCR available on
request (more expensive, performed 3x/
week).
● Generally don’t look for this earlier than 5
days of age.

HSV ● Green viral culture swab (processed 5 days/


week).

NB: Transport all specimens ASAP to Microbiology Laboratory, LabPlus.

Causes

Non- ● Silver Nitrate drops


Infectious ● Corneal abrasion following trauma at delivery.
● Glaucoma (watch for corneal clouding or proptosis, is associated with portwine
stains in the ophthalmic region).
● Foreign body.
● Nasolacrimal duct obstruction may cause ‘sticky’ eyes.

Infectious Organism Age of Onset Clinical Therapy


Features
Staphylococcus 2-5 days Unilateral, Topical
aureus crusted purulent soframycin
discharge drops
Neisseria 3 days to 3 Bilateral, Ceftriaxone
# weeks hyperaemic, 50mg/kg IV/IM
gonorrhoeae
chemosis, as a single
copious thick dose
white discharge (maximum
125mg),

Saline
irrigations
hourly until
exudate
resolves.

Streptococcus 2 days Mild purulent Topical


pneumoniae, conjunctivitis soframycin
Haemophilus drops
spp, Enterococci
Pseudomonas 5-18 days Oedema and IV anti-
+ erthyema of lid, pseudomonal
aeruginosa
purulent antibiotics.
discharge.
Topical
polymyxin.
Chlamydia 2-20 weeks Unilateral or PO
* bilateral, mild erythromycin
trachomatis
conjunctivitis, 50mg/kg/day x
copious purulent 14d (bid or qid).
discharge.
Herpes simplex Conjunctivitis Acyclovir 30mg/
with vesicles kg/day IV tid x
elsewhere 14-21d.

Topical
acyclovir.

Isolation.

# Uncommon, potential for serious consequences - severe keratitis and endophthalmitis.


Requires early recognition and treatment. Needs blood and CSF culture. Consider
concomitant chlamydial infection if poor response to cephalosporin. Parents require
investigation and screening.

+ Risk of rapid progression from purulent discharge to denuding of corneal epithelium, and
perforation of cornea. The anterior chamber can fill with fibrinous exudate, iris can adhere to
cornea and later blood vessel invasion. The late ophthalmic complications can be followed by
bacteraemia and septic foci.

* Most common pathogen, 20-50% of exposed infants will develop chlamydia conjunctivitis,
10-20% will develop pneumonia. If relapse occurs repeat course of erythromycin for further
14 days. Parents require treatment.
NB: Chloramphenicol in topical therapy can obscure results of tests for chlamydia.

References

1 Tsang B, Infectious conjunctivitis in childhood. New Ethics Nov 1994, 1-8.

2 Remington and Klein. Infectious diseases of the fetus and newborn. 4th Ed. 1995.

Antibiotic Eye Preparations

Generic Name Trade Name Usual susceptibility Potential


and Staphylococci Steptococci Gram Pseudomonas Adverse
Preparation negative Effects
bacilli
Chloramphenicol Chlomin + + + - May obscure
drops, results of
ointment tests for
Chloromycetin Chlamydia;
drops, rarely
ointment marrow
Chloroptic aplasia.
drops,
ointment
Chlorsig
drops,
ointment
Minims drops
Chloramphenicol/ Chloromyxin + + + + May obscure
polymyxin B drops, results of
ointment tests for
Chlamydia;
rarely
ototoxicity or
marrow
aplasia.

Framycetin Soframycin + - + - Sensitisation;


drops, development
ointment of resistant
organisms.

Fusidic acid Fucithalmic + + - - Rarely


drops transient
stinging.

Gentamicin Genoptic + - + + Sensitisation;


drops development
Minims drops of resistant
organisms.

Gramicidin/ Neosporin + + + + Sensitisation;


neomycin drops development
polymyxin B of resistant
organisms;
rarely
ototoxicity.

Sulphacetamide Acetopt drops + + + - Inactivated


Bleph by pus and
Liquifilm drops tissue
Minims drops breakdown
products.
Tetracycline Achromycin + + + -
ointment
Tobramycin Tobrex drops, + - + + Sensitisation;
ointment development
of resistant
organisms.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for Consent in Newborn Care Reviewed by David Knight and


Sarah Devine

April
2002

National and ADHB


Written or Signed Consent Verbal Consent Procedures
Guidelines

National and ADHB Guidelines

1. The national guidelines are the Code of Health and Disability Services Consumer’s
Rights (http://www.hdc.org.nz/keyword/codetop.html ). The code states:

‘Services may be provided to a consumer only if that consumer (the parent or


guardian on NICU) makes an informed choice and gives informed consent (Right
7.1).’

‘Where a consumer is not competent … and no person entitled to consent on


behalf of the consumer is available, the provider may provide services where (a) it
is in the best interest of the consumer; and (b) reasonable steps have been taken
to ascertain the views of the consumer; and (c) either, - (i) If the consumer’s views
have been ascertained, … that the provider believes that the provision of services
in consistent with (those views); or (ii) if the consumer’s views have not been
ascertained, the views of other persons who are interested in the welfare of the
consumer are taken into account. (Right 7.4)’

Right 4 states that every consumer has the right to have services provided with
reasonable care and skill. The services must comply with legal, professional,
ethical, and other relevant standards. They must be provided in a manner
consistent with his or her needs. They must be provided in a manner that
minimises the potential harm to, and optimises the quality of life of, that consumer.
2. The Crimes Act (1961) Section 151 states that everyone who has charge of any
other person unable by reason of age, sickness or any other cause to provide
himself with the necessities of life, is under a legal duty to supply that person with
the necessities of life, and is criminally responsible for omitting without lawful
excuse to perform such a duty if the death of that person is caused, or if his life is
endangered or his health permanently injured, by such omission.
3. The ADHB generic guidelines on Informed Consent are available via the intranet.

Written or Signed Consent must be obtained for:

1. All surgical procedures i.e. those requiring a general anaesthetic. Use standard
Hospital Agreement to Treat form (CR0111). Usually the surgeon and anaesthetist
get this consent, unless they are unable to meet the parents pre-operatively.
2. Blood products e.g. red cells, platelets, plasma, granulocytes, immunoglobulin.
See the Blood and Blood Products folder for further information. Use the standard
hospital Agreement to Treat form (CR0111).
3. Exchange transfusion (may be combined with consent for other blood products).
Use the standard Hospital Agreement to Treat form (CR0111).
4. Immunisation:
For hepatitis B at birth i.e. carrier mother, use the special form (HNN2). For routine
6 week and 3 month vaccinations (DTP and hepatitis B) prescribe on the ordinary
drug chart and ask the parents to countersign the prescription.
5. Autopsy:
Use the ADHB form ‘Consent for autopsy’. Specific consent must be obtained for
any organs that are to be retained. Coroner’s autopsies are not subject to consent,
but provide a general explanation of the procedure. See separate ADHB
guidelines.
6. Special radiological procedures requiring use of intravenous contrast e.g. IVP, CT
& MR scan. Use the standard Hospital Agreement to Treat form (CR0111).
7. Guthrie card: Record on the Blue Card the parent’s consent (their signature is not
required) for the blood test and to retain the blood-spot card.
8. Vitamin K: Record the parent’s consent on the Blue Card (their signature not
required).
9. Any procedure or treatment that is considered to be innovative.
10. All research. Use the consent form approved by the Ethics Committee for that
project.

Verbal consent and information for parents:

Neonatal intensive care often involves a prolonged stay with the parents not present for
much of the time. However, we encourage parents to be involved in both the care of their
baby and the decisions on treatment.

Parents must be informed of the condition of their infant and the treatment that is to be/
being used. Such information sharing is usually considered to be adequate consent for
ongoing intensive care.

If possible, parents should be seen before delivery and likely treatment explained. This is
usually only possible for parents of some very low birth weight infants.

At delivery, the baby’s condition and the initial treatment that is necessary should be
explained. Often the father accompanies the baby to NICU, and can receive further
explanation and information.
For ongoing problems and treatment, the parents should be informed as the baby’s
condition changes and the new treatments are introduced. Ideally this can be done before
the treatment. However, on some occasions this is not possible (parents may not be
readily available, the treatment may be urgent or there may not be time because the unit
is busy). In such situations the doctor or nurse should inform the parents as soon as is
practicable.

Some treatments and investigations can be anticipated, and discussed before they occur.
Examples are ultrasounds, long lines, phototherapy, treatment of PDA etc.

Discussions with parents on treatment are done by all staff. The FLNs have an important
role in keeping parents informed of ongoing treatment. Written information (pamphlets
and the ‘baby book’ etc) is particularly useful. Medical staff and NS-ANPs need to ensure
that parents are adequately informed on the specifics for their baby.

Discussions with parents should be recorded in the clinical record. It is not practical to
record every discussion with parents, but those involving significant new or changes in
treatment should be.

Occasionally, parents have very little involvement in the care of their baby on NICU and
are difficult to contact. The need for ongoing changes in treatment should be discussed
with such parents when they are present or are in contact.

Postnatal dexamethasone should be discussed in detail and consent obtained, because


of the uncertainties surrounding its use. Such discussion should be recorded in the
clinical record.

Note: Urgent treatment should never be withheld or delayed until the parents have
been informed. However the treatment must be discussed with the parents
afterwards.

Procedures that parents should be informed about include:

Blood samples Oxygen and CPAP Phototherapy


Antibiotics Ventilation Type of feeding
Other drugs X-rays Milk used
IV fluids Ultrasounds Tube feeds
IVN PDA treatment LPs
Umbilical lines Vitamin K Guthrie card
Long lines
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Continuous Positive Airway Pressure Reviewed by Charge Nurse


Overview Newborn

May
2004

Overview Other Related Documents

● Bubble CPAP delivered


by binasal prongs is the
preferred mode of initial
ventilatory support in
infants with respiratory
distress.
● It was initially introduced
into the NICU at
National Women's
Hospital in 1997.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Coroner's Act 1951 Reviewed by David Knight

December
2000

Back to Guideline on Deaths in NICU

How to contact the Coroner

5. WHEN CORONER TO HOLD INQUEST

1. A Coroner shall hold an inquest in each case where he is informed that a person is
dead and there is reasonable cause to suspect that the person:

a) Has died either a violent or an unnatural death or

b) Has died while [in the legal custody of the Superintendent of a penal
institution]; or

c) Has died in such a place or under such circumstances that, in


accordance with the provisions of any enactment other than this Act, an
Inquest is required to be held.

2. A Coroner shall hold an Inquest where he is informed that any person has died a
sudden death of which the cause is unknown;

Provided that in any such case the Coroner may decide, in


accordance with section 6 of this Act, not to hold an Inquest.

3. Where a Coroner is informed that a person has died while (a committed patient or a
special patient within the meaning of the Mental Health Act 1969), or while committed to
the care of the Superintendent of Child Welfare under the Child Welfare Act 1925, or
while an inmate of a children's home under Part 1 of the Child Welfare Amendment Act
1927, or while an inmate of an Intebrates Home or a Reformatory Home under the
Reformatory Institutions Act 1909, or while in such a place or in such circumstances that,
in accordance with the provisions of any enactment other than this Act, notice of the
death is required to be given to a Coroner, the Coroner shall hold an Inquest if he
considers an inquest to be necessary or desirable:

Provided that nothing in this subsection shall be deemed to authorise a


Coroner to dispense with an Inquest in any case to which subsection (1) or
subsection (2) of this section applies.

4. It shall be the duty of any person finding a person lying dead, or having knowledge of
the death of any person in any of the circumstances set forth in the foregoing provisions
of this section, to report the death to a constable, who shall thereupon report the death to
a Coroner.

5. After a constable has reported the death to a Coroner in accordance with subsection
(4) of this section, the police shall make such inquiries as may be necessary for the
purposes of this Act or as may be directed by the Coroner.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday, May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Head Ultrasound Scans


Detection of Germinal Matrix-Intraventricular Haemorrhage Reviewed by Carl Kuschel

and Periventricular Leukomalacia


June
2005

Associated Risk Factors Timing of IVH Diagnosis


Indications for USS Grading System Other Information

Intracranial
haemorrhage
(ICH) can
affect
newborns of
all gestational
ages and
often is
clinically
‘silent’.
Germinal
matrix
haemorrhage
and
intraventricular
haemorrhage
(GM-IVH) is
most common
in the
premature
population.

Estimates of
frequency
have
changed over
the last 20
years.
Currently,
large series
report a 15%
prevalence in
infants <32
weeks.

National
Women's
data for the
period 2001-
2003
indicates an
incidence of
10.0% for GM-
IVH in
infants<32
weeks.
Those most
at risk were
infants <28
weeks
gestation.
Grade 3 and
4 GM-IVH
was seen in
2.9% of
infants<32
weeks, with a
higher
incidence
(15.5%) in
infants <26
weeks
gestation.

The incidence
of
periventricular
leukomalacia
(PVLM) in
infants <32
weeks at
National
Women's
over the
same period
of time was
1%.

Routine
screening for
GM-IVH is
performed in
infants <30
weeks or
<1250g at
birth.

Associated Risk Factors

● SGA status of newborn ● Outborn infant


● Maternal pre-eclampsia ● Antepartum haemorrhage
● Asphyxia ● Base deficit >10
● Male gender
Timing of IVH

● Most haemorrhage occurs within the first three days of life.


● "Late" haemorrhage (i.e., after three days of age) may be associated with pneumothorax and its
restriction of venous return to the heart.

Diagnosis

● GM-IVH is reliably diagnosed with ultrasonography.


● Parenchymal injury (ischaemia, petechial haemorrhage, haemorrhagic infarct) can be diagnosed
with ultrasonography, but with less sensitivity.
● Parenchymal ischaemia, without haemorrhage, may not be evident even with transducers of high
frequency and very good equipment.
● MRI is more sensitive but currently impractical as a routine investigation in preterm infants.
● CT scanning is more sensitive than ultrasonography in cases where extra axial (subdural,
subarachnoid) or posterior fossa haemorrhage is suspected.

Indications for Cerebral Ultrasound Scan

● Routine screening for GM-IVH should be performed in infants <30 weeks or <1250g at birth.
❍ Some more mature or larger infants will have cranial ultrasound scans performed because

of clinical suspicion of GM-IVH.


❍ The first scan should be performed at 4-5 days of age, by which time most cases of GM-

IVH will have occurred.


❍ Discussion with parent(s) regarding prognosis/follow up can be conducted by the admitting

team.
● Ultrasonograms can always be obtained when clinical signs and/or symptoms suggest that
intracranial haemorrhage has occurred, regardless of the baby’s age.
● A second ultrasound scan should be done at one month of age, looking at resolution of previous
GM-IVH, evidence of parenchymal injury, and for evidence of periventricular leukomalacia (PVLM).
● A "discharge" head ultrasound scan should be done at "term" (36 weeks is often chosen as the
most appropriate time) or at discharge from the nursery.
❍ In infants <30 weeks, this should be done at the same time as the screening renal

ultrasound scan for nephrocalcinosis.


● Be aware that ultrasound is not a sensitive method of detecting cortical or brainstem injury as
seen with neonatal encephalopathy, or for detecting evidence of cerebrovascular events or
collections outside the brain.
❍ In infants suspected of other pathologies, MRI or CT should be considered.

Grading Systems

GM-IVH

I Germinal layer (subependymal haemorrhage)


II Intraventricular haemorrhage - no dilatation (<97th percentile)
III Intraventricular haemorrhage with dilatation
IV Intraparenchymal haemorrhage

Periventricular Leucomalacia

without cysts echogenic periventricular margins (flare)


cystic multiple small periventricular cysts
porencephaly large intraparenchymal cysts

Other Information

● Research protocols may require variations on a grading system; grading should follow the
requirement of the protocols.
● The ultrasonographers describe abnormalities in detail on their reports.
● Be aware that transverse measurements of lateral ventricles from the midline will be influenced by
the size of the cavum septum pellucidum, a normal midline structure in preterm infants. Scans
should be reviewed with the Radiologist at conferences in NICU.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

C-Reactive Protein (CRP) Reviewed by Alan Groves


Indications and Interpretation

February
2003

● C-Reactive protein should NOT be checked as a routine part of a septic screen in


neonates.
● It may be helpful in excluding infection in some cases of sepsis if normal levels are
obtained 24-48 hours after the onset of symptoms. It should therefore be
considered in cases in which diagnosis of sepsis is unclear, and where negative
cultures may not give sufficient reassurance to discontinue antibiotics. Common
examples may include when maternal intrapartum IV antibiotics were given, and in
late onset sepsis where lumbar puncture specimens were unobtainable or blood-
stained.
● A level of greater than 10mg/litre is abnormal
❍ Less than 10 is normal and makes sepsis much less likely (see Background

and Applications).
● Judicious use of CRP to enable earlier discontinuation of antibiotics in some
instances may be cost-effective, decrease the possibility of resistance and in some
cases may decrease duration of hospital stay.

Sample

● The laboratory requires 0.10-0.15 ml of SERUM, therefore 0.3-0.5ml (depending


on haematocrit) of whole blood will be required, in a lithium heparin (green top)
tube.

Background

● CRP is an acute phase protein synthesised in the liver in response to inflammatory


cytokines. Its levels may increase up to a thousand-fold during an acute phase
response. Its short half-life (19hours) means levels should fall rapidly after
1
elimination of the (often microbial) source.
● There is generally a delay of up to 24 hours between onset of symptoms of
infection and a rise in serum CRP. Sensitivity of the test at presentation is only
40% - that is, 60% of subsequently proven sepsis episodes will have a normal
2
initial CRP (compared to 80% sensitivity of immature to total neutrophil ratio).
● With this in mind CRP level should not be checked at birth or at initial presentation
with symptoms suggestive of sepsis.

Applications

● The value of CRP is in its reliability in the 24-48 hours after birth/onset of infection.
● In early onset sepsis (before 72 hours old), a single CRP 24 hours into illness has
3
a 93% sensitivity for "probable" sepsis. 2 measures 24 hours apart are even
better. A more intuitive measure is the Bayesian ratio (likelihood ratio) - for a single
normal CRP the ratio for probable sepsis was 0.10. In effect this means that
having obtained a normal CRP one can assume probable sepsis to be 10 times
less likely. For 2 measures the ratios is 0.03, making probable sepsis 30 times less
likely.
● In late onset sepsis the reliability of the test is similarly high. A single CRP has a
sensitivity of 85%, with likelihood ratio of 0.19 (sepsis 5 times less likely given
normal result), and 2 separate measures have a likelihood ratio 0.07 (sepsis 14
times less likely).
● The positive predictive value for a raised CRP is poor so a positive test is poorly
predictive of sepsis. False positives arise from intraventricular haemorrhage,
meconium aspiration, NEC, pneumothorax, surgery and immunisation.
● Reassuringly, false positives don’t tend to occur with birth asphyxia, prolonged
rupture of membranes, respiratory distress syndrome and viral illnesses (except
invasive HSV).
● False negative results generally only occur early in infective episodes, though also
in UTI. False negatives don’t appear to occur in either infection with coagulase
2
negative staphylococcus or childhood meningitis, though there have been few
45
studies focussed on neonatal meningitis. ,
● A level of 10mg/litre has consistently been shown to be the most reliable cut-off to
indicate sepsis. There is a link between the level of elevation of the CRP and the
risk of sepsis, with positive predictive value steadily increasing up to CRP >100.
● Judicious use of CRP to enable earlier discontinuation of antibiotics in such
instances would be cost-effective, decrease the possibility of resistance and in
some cases may decrease duration of stay.

References

1 Ehl, S., et al. C-reactive protein is a useful marker for guiding duration of antibiotic therapy in suspected
neonatal bacterial infection. Pediatrics, 1997; 99:216-21.
2 Franz, A.R., et al. Reduction of unnecessary antibiotic therapy in newborn infants using interleukin-8 and
C-reactive protein as markers of bacterial infections. Pediatrics 1999. 104:447-53.
3 Benitz, W.E., et al., Serial serum C-reactive protein levels in the diagnosis of neonatal infection. Pediatrics
1998;102:E41.
4 Gerdes, L.U., et al., C-reactive protein and bacterial meningitis: a meta-analysis. Scand J Clin Lab Invest
1998; 58:383-93.
5 Tatara, R. and H. Imai, Serum C-reactive protein in the differential diagnosis of childhood meningitis.
Pediatr Int 2000; 42:541-6.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Chronic Lung Disease Discharge Planning


Reviewed by Simon Rowley and
Lynley Nichols

June 2003

Criteria for Referral to


Pre-referral assessment Discharge Planning Follow-Up
Respiratory Service
Recommended Saturations
Weaning
at Home

Criteria for Referral to the Respiratory Service

The Respiratory Service are keen to be involved where at discharge:

a. Severe clinical disease (marked respiratory effort, indraw etc).


b. Severe chronic lung disease on chest radiograph.
c. Requiring more than 250ml/min of oxygen.
d. Right ventricular hypertrophy on ECG
❍ R wave in V1 and V2 >20mm

❍ RSR’ pattern in V1 with R > R’

❍ Positive T wave in V1

❍ Right axis deviation

e. Babies without these criteria and who are expected to require home O2 briefly,
need not be referred.

Pre-referral Assessment For Infants Going Home on Oxygen

a. Overnight oximetry with printout, preferably current but also two weeks prior to
establish trend.
b. ECG.
c. Early morning capillary gas.
d. Current chest radiograph.
e. Growth chart.
f. Social Work/Homecare or Family Liaison Nurse assessment, usually including a
home visit.
g. Interim summary of neonatal course.
Discharge Planning

a. There will usually be a pre-discharge planning meeting approximately two weeks


prior to discharge in order to set a discharge date.
b. This meeting should include an invitation to the Respiratory Nurse Specialist,
General Practitioner, the Consultant Respiratory Paediatrician, Dietitian, other
NICU staff including the Neonatal Consultant, Family Liaison Nurse, Visiting
Therapist, Social Worker etc as appropriate.
c. The Respiratory Consultant may choose not to attend or become involved at this
stage if the risk factors for severity are not present (that is, if we anticipate the
baby will have minimal problems and come off oxygen relatively quickly following
discharge).
d. Infants will be not be considered for discharge if they have poor feeding, poor
growth, frequent desaturations, instability with feeding.
e. Infants being considered for discharge should have had 10 days stability on NICU
or PIN.
f. Infants who have just come off oxygen should also fulfil these criteria if being
discharged.

Outpatient Follow-Up for the Infant on Oxygen

a. Neonatal paediatrician
b. Respiratory Paediatrician for severely affected infants or other infants whose
progress is not as expected once discharged
c. The Homecare Nurses will visit weekly or according to need.

Recommended Best Practice For Home Oxygen

Saturation Level Proportion of Study


96-100% 80-90%
90-95% 10-20%
<90% None

This is different from the inpatient NICU Oxygen Saturation Targets, which are lower at
around 90-95%. Babies at home are not continuously monitored, and therefore their
discharge and home saturations are targeted higher.

Weaning

a. No changes should be made for the first two weeks on home oxygen.
b. If 90% of the time saturations are >95%, weaning can be initiated.
c. Minimum flow rate at home 0.1L/min.
d. Weaning should consist of periods during the day off oxygen initially 2-4 hours,
then 8 hours, finally off oxygen at night.
e. Following each change, day-time oximetry ± overnight oximetry should be carried
out.
f. Overnight oximetry needs to be carried out following discontinuing oxygen.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Cytogenetic Studies in the Neonatal Period Reviewed by Julie McGaughran

January
2001

Note: Given the increasing concerns around genetic testing without informed consent,
only tests for diagnostic or management reasons should be carried out in the neonatal
period.

● Consultation with the Northern Regional Genetic Service is recommended when


further advice is needed (Ext. 5530 AKH)

Cord Blood ● Confirmation of suspected chromosomal disorder following


abnormal antenatal ultrasound undertaken late in pregnancy or
where further investigation declined during in the pregnancy.
● Chromosome mosaicism found at CVS, amniocentesis or
cordocentesis (where indicated)
● DNA studies. Cord blood confirmation of single gene disorder
suspected on ultrasound findings eg achondroplasia
Testing for late onset disorders should not be undertaken
● Confirmation of biochemistry where prenatal diagnosis of a
known condition undertaken (requested by testing lab)

Neonatal ● Blood
Testing
i. Clinical features consistent with known
chromosomal abnormality.
ii. Multiple congenital anomalies consistent with
possible chromosomal abnormality
iii. FISH; where range of clinical features suggests a
specific microdeletion syndrome, specific FISH
test should be requested.
iv. Ambiguous genitalia.

● Solid Tissues
i. Products of conception.
ii. Post mortem - (1) - (4) as above.

Guidelines for ● Features of a single gene disorder/syndrome (for diagnostic


DNA Studies in purposes) e.g. hypotonia
the Neonatal ● Mitochondrial myopathy syndrome.
Period ● Features of possible single gene disorder where infant may die
and genetic testing may later become available (DNA storage)

Blood Collection Tubes

● DNA studies - EDTA (1 tube)


● Chromosomes + FISH - Lithium heparin (2ml)
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Death of an Infant on NICU Reviewed by Simon Rowley and


Jane Harding

March
1998

See also ADHB guidelines on referral to the Coroner

See also Deceased Baby Forms (intranet only)

These guidelines are not necessarily to be followed exactly. Each situation will be
different and will need to be handled accordingly.

On intensive care usually the death of a child will be anticipated and there will be time for
both parents to be present. Where possible they should have the situation clearly outlined
and the likely course of events (and mode of death) explained. This is especially
important in the event of' turning off the ventilator support so that the parents are not
unduly frightened by the prospect of an imagined horrible spectacle.

Parents should be encouraged but not forced to be present and to ask any family,
including the child's siblings or close friends to come in for support. Opportunities for
photography should be offered and efforts should be made to enable them to cuddle and
hold the child before, during and after death. One needs to gauge their feelings about this
at the time and not force them to do anything against their inclination. Similarly after
death, time should be allowed for the parents to be alone with the child if they wish but
someone should be popping in and out of the room to provide support if necessary .Once
the child has been laid out peacefully and if possible with some flowers, a photograph can
be taken which can be given to the parents. This may be more comforting than previous
photographs which have included intensive care apparatus etc. They may also wish to
return to see the child several times.

The parents are seen as soon as possible afterwards by a Paediatrician who must have
enough time to fully discuss the cause of death. Post mortem is offered as a final
examination to reveal any other factors relevant to counselling, genetic or otherwise.

Although most parents are keen to know about whether the same circumstances might
occur with the next child, a few parents may not initially see the relevance of post mortem
results and it is therefore the doctor's (preferably the registrar's) duty to impart this
information. One can usually explain that not only will it help other children in the future
with similar problems if we know as much as possible about the particular condition
causing death, but also that it is important from their own point of view if they wish to have
children in the future. (It is our experience that in the past when parents have been
several weeks afterwards who have not consented to a post mortem, invariably express
regret for having made that decision at the time). If the parents object to a post-mortem it
should be assumed that further discussion would be best carried out by another doctor
and that one should not persevere to get consent. At this point the Consultant should be
approached to decide whether further discussions with the parents is appropriate.

Post-mortem consent should always be requested in a proper manner and should be fully
informed. In Maori families particularly and with young parents, it should be suggested
that the parents ask their elders or relatives to participate in the discussion and have
more family involvement if this is appropriate. This may avoid the distress which can
occur when young Maori parents consent to post mortem but the grandparents and Maori
elders object for spiritual and cultural reasons.

In cases which are to be referred to the Coroner (if in doubt the Coroner is happy to be
telephoned at any time, day or night to discuss the desirability of a Coroner's autopsy),
the consent of the parents is not sought. It is important to explain to the parents the
reasons for the need for a Coroner's autopsy. The attached Coronial Autopsy Clinical
Summary form must be completed. Please note that all IV lines, catheters, NG tubes are
to be left in-situ but if being viewed by the parents before autopsy, tubes, lines etc, can be
cut short and covered with a dressing.

Many people need to be informed as soon as possible and the following check list should
be completed:

1.Paediatrician.
2.Obstetrician or other Consultant involved.
3.General Practitioner and Plunket Nurse.
4.Referring Consultant if applicable.
5.Social Worker if applicable.
6.Death certificate.
7.Post mortem consent.
8.A note for Pathologist if there are any specific questions to be answered at post
mortem.
9. The Perinatal Mortality Summary sheet should be completed at the same time as
the Death Certificate.
10. A clinical discharge letter should be dictated before the notes leave the nursery if
at all possible, even if final arrangements, post-mortem results etc are not known.
These can always be added later.
11. A follow up appointment should be made after discussion with the specialist
involved. This is initially 6 -8 weeks after the death and preferably after the
relevant Perinatal Morbidity Meeting discussion. An appropriate appointment letter
is available with the Secretaries if desired.
NB: There is also a booklet 'Neonatal Death' in NICU which can be used as a reference
relating to responsibilities of nursing and medical staff after an infant dies.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for Paediatric Presence at Delivery Reviewed by Carl Kuschel

April
2004

See also Attendance at High Risk Deliveries

Paediatric resident medical staff and NS-ANP’s are available to attend at risk deliveries
and compromised fetuses. Referrals should be made by the LMC attending the mother. In
emergencies or situations of urgency, messages can be relayed through clerical staff.
Paediatric staff often have to prioritise calls, so accurate information is needed.

In most situations the 1st call locator (usually a paediatric SHO, registrar, or NS-ANP)
should be called. Except in the situations set out below when 2nd call registrar or NS-ANP
should attend, the 1st call person is responsible for informing other paediatric staff if he/
she wants them to attend as well. The registrar/NS-ANP will attend deliveries with a
house surgeon at the beginning of a run, until the house surgeon is competent at
resuscitation.

The paediatric registrar/NS-ANP will contact the specialist if his/her presence is indicated,
unless there is a prior arrangement.

The paediatric service should be informed of labours likely to produce babies needing
paediatric care. This communication would normally be to Paediatric Medical Staff.
Referrals requesting paediatric input to the management of pregnancy/labour should be
to specialists.

1st Call
Level 2 Level 3
Registrar-
Registrar- Registrar-
NS-ANP-
NS-ANP NS-ANP Specialist
SHO
Locator Locator
Locator
93 5536 93 5535
93 5537
Meconium staining No
light, no fetal distress
light + fetal distress Yes
Thick Yes
Fetal distress Yes if severe
Preterm 34-36 weeks Yes

Preterm < 34 weeks Yes

Preterm < 31 weeks Yes Yes Discuss


prior to
labour/
delivery
Severe IUGR Yes
IUGR Post
delivery
Suspected fetal infection Yes

Maternal diabetes mellitus Post


delivery
Multiple pregnancy Yes Yes
LSCS Yes
Immediate LSCS Yes Yes

Low forceps No
High forceps Yes
Low ventouse delivery, no No
fetal concerns
Ventouse delivery with Yes
fetal distress, meconium,
or obstetric concerns
Breech delivery Yes
Drug dependent mother Post
delivery
Fetal abnormality likely to No Yes Possibly Discuss
affect condition at delivery prior to
labour/
delivery
Fetal abnormality other After Discuss
than above delivery prior to
labour/
delivery
Haemolytic disease Pre/post Discuss Possibly Discuss
delivery prior to prior to
labour/ labour/
delivery delivery

There may be other situations when a paediatric resident should be called. Any baby who
has problems or is unwell should be referred to the paediatric service. Private doctors
(GP or specialist) or independent midwives should either refer to the paediatric service
when appropriate, or to a private paediatric specialist.

All three resident paediatric staff answer 777 emergency calls. The 777 call does not go
to the specialist on call - a request for specialist attendance will need to be directed
through the operator. If a specialist is required urgently, then contact them via their pager
(and append with "*777") or their cell phone.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Developmental Care
Reviewed by Charge Nurse -
Newborn

December 2004

Scope Background Related Documents References

Scope

● Applies to all nurses employed in the Newborn Service.

Background

● Developmental support integrates the developmental needs of the infant in NICU


within the framework of medical care.
● Key concepts for delivery of developmental care include promoting organised
infant neurobehavioral and physiological function and tailoring the physical
environment, such as light and sound, to protect vulnerable developing sensory
systems, all within a context of family centred care.
● When providing developmental care for infants two overriding principles need to be
considered:
❍ First, that infants are unique and can display a wide variety of behaviours.

❍ Second, that the physiological condition of infants differs widely. For

example, a baby born at term who becomes critically ill will have different
developmental needs to an infant who is term but born prematurely.
● Hence these recommendations are a guide not a rigid prescription for every baby.
Assessment of infant cues remains central in the provision of developmental care.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Referral to Community-Based Child Development Reviewed by Carl Kuschel and


Services Rosemary Marks

April
2002

Many infants admitted to NICU are at risk of developmental problems in childhood. For
many infants, developmental problems do not surface until after discharge. However,
some infants require referral for developmental follow-up prior to discharge.

Note: National Women’s Newborn Services have a Child Development Unit (CDU) which
is distinct from the community-based Child Development Services (CDS). Please do not
confuse the two when making a referral.

● All infants <1500g are automatically referred to NWH CDU to have


their developmental progress assessed at the age of 18 months and
4 years (infants <1000g are also seen at 9 months). See also the
CDU guideline.
● Infants referred to the community-based Child Developmental
Services (CDS) generally require ongoing surveillance and/or
intervention for developmental concerns (e.g. motor delay, feeding
problems). Click here to open a referral form.

In addition, NICU has a developmental therapist service that performs inpatient


developmental assessments and intervention. A referral should be made for infants who
are going to require community developmental follow-up and who will be in-patients in
NICU for more than a few days.

Generally, there are two situations where developmental follow-up should be arranged
prior to discharge.
Infants expected to ● Early referral to the appropriate Developmental
have developmental Paediatrician within the family’s catchment area.
problems ● The referring doctor needs to provide sufficient
information about the baby’s condition, what clinical
● This includes course is expected, and what information the parents
infants with have been given.
severe birth ❍ It may be most appropriate for this to be done

asphyxia with at a specialist-to-specialist level.


persisting ● It is important to specify if a referral has already been
neurological made to the appropriate CDS.
abnormalities, ● Early referral (2-3 week prior to discharge) to the
infants with appropriate Child Developmental Service within the
significant brain family’s catchment area.
lesions (e.g. major ● It is important to specify which paediatricians are
intracranial involved or to whom referrals have been sent.
haemorrhage, ● Need to provide sufficient information (including social
periventricular circumstances, if appropriate) for the CDS to be able
leukomalacia), to prioritise the needs of the baby and family.
and infants with ● Provide a name and contact number so further
syndromes known information can be provided if necessary.
to involve
developmental
delay (e.g. Down
Syndrome).

Infants at risk of ● An early referral (2-3 weeks prior to discharge) to the


developmental appropriate Child Development Service is preferred
problems but is not always possible.
● Staff need to specify what follow-up arrangements
● This may include have been made (for example, NWH Paediatrician vs.
preterm or term Starship Paediatrician vs. other paediatrician).
infants where ● Sufficient information needs to be provided for the
developmental CDS to be able to prioritise the needs of the baby and
concerns are family.
raised prior to ● Provide a name and contact number so further
discharge, but information can be provided if necessary
referral to a
Developmental
Paediatrician is
not indicated at
this point
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Referral to NICU Developmental Therapists


Reviewed by Gaela Kilgour,
Inpatient Neurodevelopmental Assessment and Lynette Eaton, and Simon Rowley
Intervention

May
2002

● Designated time for this service is Wednesday morning each week with capacity to
respond to urgent referrals within 48 hours as necessary.
● A developmental assessment and intervention service is provided by an
occupational therapist and physiotherapist for infants who meet the following
criteria:

● Less than 1000 gms birthweight


These referrals are automatic via FLN

The following four criteria are via medical team referral:


● Infants with clearly defined special needs e.g. neuromuscular disease and
chromosomal abnormalities
● Infants having suffered perinatal asphyxia with HIE
● Preterm infants with extra risk factors e.g. grade IV IVH, PVL, difficult or
complex course
● Long stay infants e.g. 3 months or more with developmental needs

● This service may apply to infants described in the "expected" and "at risk" groups
outlined in the Community Child Development Service guideline.
● Other specific interventions such as splinting or strapping with known diagnoses
will occur following discussion with the medical team.
● If a child is referred to Community Child Development Services, the developmental
therapists will liaise with the appropriate agency and will forward appropriate
reports.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday,
May 21, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Referral to Dietitian - Neonatal Nutritional Risk Reviewed by Barbara Cormack


Screening Criteria (Dietitian) and Carl Kuschel

November
2005

● Children meeting these criteria may have special nutritional requirements and
should be considered for referral to a dietitian.

Over 2 weeks of age ● <2/3 expected caloric requirement


❍ Fluid restriction ≤160 ml/kg/day

❍ <100ml/kg/day P10 or N10 after Day 4 of life

❍ <180ml/kg/day enteral feeds in a preterm infant

❍ <150ml/kg/day enteral feeds in a term infant

● <10 g/kg/day weight gain for >5days (<38 weeks CGA)


<20 g per day weight gain for >7days (>38 weeks CGA)
● Significant obstructive jaundice
● Serum phosphorus <1.3mmol/L
● Intolerance to preterm formula or breast milk fortifier
● Intake >200ml/kg/day of preterm formula or breast milk
fortifier

Any infant with ● NEC where elemental formula is being considered


● Short bowel syndrome
● Malabsorption
● Chronic lung disease where growth impairment is likely
● Congenital heart disease where growth impairment is likely
● Gastrointestinal anomaly
● Metabolic disorder
● Chylothorax
● Renal failure
● Osteopenia requiring additional calcium and phosphate
● Possible zinc deficiency
● Breastfed baby where there are concerns about maternal nutrition
Note: All infants with a birth weight of <1.8 kg should be receiving fortified breast
milk or preterm formula until 2.5kg or they reach term or are fully breast fed.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Review and Recording Notes on NICU Babies Reviewed by David Knight

January
2001

New or Unstable Babies More Stable Babies Very Stable Babies Review
Procedures Weekly Plan Weekend Plan

This gives a guideline for reviewing and writing notes on NICU babies to ensure that
babies are appropriately assessed and residents use their time efficiently.

New/Unstable Babies

● Assess twice daily.


● Write notes twice daily
● Examine Acute problem list
● Assessment Progress in last day
● Observations and assessment
● Plan, reasons and interpretation

More Stable Babies

● Once in detail (as above). During the day except at weekends.


● Once in brief: Either in the day or at night. At weekends, split these assessments
between day and night staff.

Very Stable Babies

● Review daily during the week.


● At weekends, review daily in brief, often on the ward round. Write in notes.

Review

● If asked to review a baby, record appropriate observations and interpretations at


the time. Do not wait until the next routine review
Procedures

It is important to document significant procedures undertaken, whether successful or


unsuccessful. Procedures which should be clearly documented (with date and time)
include:

● Intubation/reintubation
● Extubation
● Intercostal drain insertion
● Umbilical venous and arterial catheterisation
● Peripheral artery catheterisation
● Longline insertion
● Urinary catheterisation
● Lumbar puncture
● Ventricular tap
● Exchange transfusion
● Institution of non-routine medications should also be clearly documented.

Weekly Plan

For stable babies, ensure that there is a weekly plan. Avoid duplication (of full
assessments and of tests etc.).

● Investigations: Blood tests: day, tick when ordered


● Scans/X-rays/Other
● Drugs: List once weekly or if changed.
● Record levels, date, change, plan.
● Growth/Nutrition: Measure at least weekly.
● Plot growth weekly.
● Respiratory: Part of daily review. Summarise overall course weekly.

Weekend Plan

● Write a weekend plan including blood tests.


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.

Any printed version can not be assumed to be current. Printed copies of this document are valid for

Monday, May 22, 2006.

The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this

guideline.

Domperidone (Motilium) as a Galactogogue Reviewed by Carol Thomas and

(Domperidone and Breast Feeding) Carl Kuschel

October

2002

Rationale Efficacy Dosage Precautions Recommendations References

● Domperidone has replaced Metoclopramide as the Galactogogue of choice

in NICU

Rationale

Domperidone is a peripheral dopamine-receptor antagonist used in the treatment of

dyspepsia, reflux oesophagitis, and nausea and vomiting. One of its side effects is an

1 2
increase in prolactin levels , .

Unlike metoclopramide that works centrally, domperidone works on peripheral dopamine

1
receptors in the GI wall and CTZ centre of the brainstem . Its effects on prolactin
secretion occurs at the pituitary level (outside the blood-brain barrier) 2. Domperidone is

less lipid soluble, has a larger molecular weight (426), and is highly protein bound (93%)

1, as compared to metochlopramide. Combined with the peripheral action this results in

2
fewer central side effects such as anxiety, depression and extrapyramidal symptoms

and less medication crossing through into breastmilk. Because domperidone crosses less

freely into breastmilk (compared with metoclopramide) the possible risks to the infant are

also reduced 3. There has been some concern of the possible effect of dopamine

antagonists on the functional maturation of central dopamine mechanisms in newborns

4
(identified in experiments on rats) .

Da Silva showed a milk domperidone concentration of 1.2ng/ml, after a dose of 10mg

2
three times per day, measured on day 5 from randomly selected samples . This is

compared with 125.7ng/ml of maxalon from milk samples taken 2 hours after a dose of

10mg of metoclopramide 4

Efficacy

Domperidone has been approved by the American Academy of Pediatrics (AAP) for use

in breastfeeding 1 and is currently the only galactogogue that has been scientifically

evaluated through a randomised, double-blind placebo-controlled trial 3. This trial by da

Silva et al 2 showed milk volume increased by 44.5% in the domperidone group

compared with 16% in the placebo group (p<0.05). There was a steady increase in milk

volume commencing 48 hours after initiation of treatment up until day 7, which was the

last day of medication. This correlated with a rise in serum prolactin in the domperidone

group, rising from 12.9 trial μ /L [SD7.7], measured as baseline, to 119.3 [SD97.3] μ/L

of a randomly sampled blood test on day 5. The serum prolactin levels returned to
baseline 3 days after treatment was ceased.

Dosage

● 10-20mgs, orally, 3-4 times per day

● A prescription for 2 weeks should be given initially and may be repeated if

necessary. The medication may need to be continued for up to 8 weeks, however

the long-term use of domeperidone has not been studied 1.

● There is little evidence to guide practice as regard to when to start, how long to

continue and how to wean from domperidone.

Precautions, Interactions, and Adverse Effects

● Prescribers should be aware of maternal conditions or medications that may be

affected by Domperidone

● Dosage should be reduced if there are underlying maternal renal or hepatic

conditions.

● Domperidone use should be avoided with antacids and antisecretory agents.

● Medications that inhibit the Cytochrome P450 enzyme system (e.g. azole

antifungals, macrolide antibiotics, HIV protease inhibitors, and nefazodone) may

increase Domperidone levels.

● Rare adverse effects include headache, dizziness, abdominal cramps, dry mouth,

drowsiness, and allergic reactions.

Recommendations

● Domperidone therapy to enhance lactation does not replace expressing and may
not work in some cases. It should only be given if the mother has been expressing

at least 6 times in 24 hours for at least 3 days. She must have had specific

teaching in effective expressing techniques and positioning of the baby at the

breast if possible.

● If the mother is still under obstetric or medical care, she should discuss the

possible use of domperidone with her medical adviser(s).

● To ensure that adequate assistance is given to the mother, it is advisable that the

mother is referred to a Lactation Consultant and or the charge nurse, or her LMC

before therapy is commenced.

References

1 Hale. Domperidone. Medications and Mothers’ Milk 2002: 10th Edition;230-231

2 da Silva et al. Effect of domperidone on milk production in mothers of premature newborns: a randomized,

double-blind, placebo-controlled trial. CMJ 2001;164(1):17-21.

3 Gabay. Galactogogues: Medications that induce lactation. J Hum Lact 2002;18(3):274-279.

4 Hofmeyr et al. Domperidone: secretion in breast milk and effect on puerperal prolactin levels. Br J Obs

Gynae 1985; 92:141-144.

5 New Ethicals Catalogue. Adis International. May-Nov 2002; 256


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Management of Down Syndrome Babies at NWH Reviewed by Salim Aftimos

November
2002

1. A Specialist Paediatrician discusses the diagnosis with the parents. He/she may
ask the Family Liason Nurse, NICU Charge Nurse, or the involved midwife on the
ward to attend this meeting. The meeting should normally be held in a private
place with both parents present.
2. The Specialist Paediatrician will notify the GP and/or Obstetrician and obtain
information or advice that may help with the counselling of parents.
3. The parents should be given the time they need to absorb the news. Repeat visits
may be necessary to deal with questions and distress.
4. In consultation with the Family Liaison Nurse, Charge Nurse/or Midwife and
parents, a decision is made on the need and timing of referral to the Hospital
Social Worker, Home Care Nurse, Physiotherapist, Chaplain etc.
5. The Paediatrician will consult with the parents and Family Liaison Nurse/Charge
Nurse/Midwife/Social Worker on the timing of introduction of books/pamphlets on
Down Syndrome and referral to the Down Syndrome Association.
6. A referral is made to the Developmental Therapist and a separate referral is made
to the Early Intervention Team. If the baby resides in Central Auckland or the North
Shore, Dr Rosie Marks should be contacted to offer her the chance of meeting the
parents before discharge.
7. Cardiac assessment -ECG, CXR. Echo at GLH.
8. Thyroid function testing. Ensure the Guthrie card has been sent.
9. Obtain an FBC as a screen for polycythemia and transient myeloproliferative
disorder.
10. Anticipate feeding difficulties and if required arrange for Lactation Consultant and/
or Speech-Language Therapist input
Newborn Services Clinical Guideline

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Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Infants Born to Drug Dependent Mothers Reviewed by Carl Kuschel

July
2004

Medical and Nursing Treatment of The Unsettled Irritable


Universal Precautions Points of Interest
Care on the Ward Withdrawal Baby

Guidelines

● The pregnancy will be managed by a Specialist Obstetric Team with the Midwife
being the key person. The aim is to ensure continuity of care for mother and her
partner. The Team meets regularly.

The team is as follows:


❍ Obstetrician: Dr Harilal.

❍ Midwives: Marian Cornwell (Midwife), and midwifery staff of Ward 32.

❍ Paediatricians: Dr Carl Kuschel and Dr Simon Rowley.

❍ Social Workers: ADAPT team social workers, or NICU Social Workers if

baby in NICU.
● The baby is expected to be normal in all respects other than smaller than average
for gestation.
● Maternal drug use alone is not an indication for delivery attendance - delivery will
be attended by neonatal staff only if there are other fetal or maternal reasons for
attendance. If NICU admission is necessary and there are no complications (e.g
asphyxia, LBW) the baby may spend time with the parents before transfer.
Naloxone should be avoided if possible because of the likelihood of precipitating
and intensifying withdrawal symptoms.
● The baby will be admitted to Ward 32 for observation. This will generally be for a
minimum of 7-10 days but may be for several weeks if medication is needed
because of drug withdrawal.
● Breastfeeding is encouraged, regardless of the drugs that have been taken by the
mother.
● Parents are expected and will be encouraged to spend as much time as possible
with their baby.

● Drug dependency care may include:


❍ Methadone maintenance during pregnancy.
❍ Methadone detoxification /benzodiazepine detoxification.
❍ Attendance at counselling agencies or therapeutic communities.

❍ Alcohol use.

❍ Other drugs including antipsychotic tranquillisers (prescribed or not).

● A file will be kept on Ward 32, including care plans and letters from Paediatricians
which will also be filed in the maternal notes. These files are kept in strict
confidence in the Charge Midwife office.
● Exclusions from the plan to send babies direct to Ward 32 (i.e. indications for
being nursed on the Newborn Intensive Care Unit)
❍ Low birthweight, premature or unwell as for normal indications for

admission to NICU.
❍ Polydrug abuse should be considered, particularly if there are confounding

social factors but the methadone dose alone is not an exclusion criteria.
❍ Maternal and other social complicating factors.

● There is a need to ensure confidentiality for parents. A single room should be


allocated if possible. The baby's history must not be discussed in front of other
parents. The case notes and drug charts are to be kept in the office at all times.
The baby's condition or reason for admission or length of stay is not to be
discussed with anyone other than the parents. This includes grandparents.
● Visiting is the same as for all postnatal wards.

Medical and Nursing Care on the Ward

● There are a small group of primary midwives that will be dealing with the mother
and baby.
● It is important during the baby's stay in hospital that the mother has consistency in
management, deals with as few staff as possible, i.e., one consultant or delegated
junior staff member and one senior nursing staff member to be the information
providers.
● Score sheets are to be kept in the office and maintained regularly.
● It is not routine to send a urine sample for toxicology if the mother is well known to
the ADAPT team and drug use is well documented.
❍ If a toxicology screen is required, the first urine from the baby is to be sent

for toxicology.
❍ Meconium samples (which will give an indication of drug use over recent

weeks rather than days) can be sent if indicated but need to be negotiated
on an individual basis with Toxicology at LabPlus.
● The Paediatric Consultant on service for the ADAPT team will visit as indicated
and communicate with the parents and nursing staff. If the baby is on medication,
then this will be daily.
● The Paediatric House Surgeon or Registrar should be called for any fever,
vomiting, feeding problems or unstable temperature which may be the signs of a
sick baby other than drug withdrawal.
● If the baby scores 8 or higher on the score chart then the Paediatric Registrar
should be informed.
● 75% of mothers on the methadone programme are Hepatitis C positive. The infant
will need antibody and RNA virus testing at 4-6 months, 12 months and 2 years. A
cord sample should be sent at birth for PCR, although there is a risk that this may
be falsely positive if contaminated by maternal blood in which case a repeat
sample should be taken on the baby.

Universal Precautions

● Gloves should be used for all nappy changes or for nursing staff changing the
babies - and handling baby before initial bath.

Treatment of Withdrawal

● This is managed by the Paediatric Consultant in conjunction with the Registrar and
Charge Midwife and parents. Medications are started when the baby has several
scores of >8 and after adequate consultation.
● The medication may only be changed by a Paediatric Consultant or Registrar.
● The drug used is neonatal morphine solution 1mg/ml.
❍ Start at 0.5mg/kg/day in 4 divided doses (that is, 6-hourly) and reduce by

10-15% of the original dose every 2-3 days if possible. The infant may need
increasing doses for stabilisation in the first few days.
● Medication must be given strictly as charted given directly into baby's mouth by
syringe. The drug must be given by a Registered Nurse/Midwife who checks the
drug - not a parent.
● Medication times are not to be changed to fit in with baby's feeds times. This
interferes with the withdrawal regime. Do not draw up milk into the syringe
because dead space can lead to overdose of morphine.
● If the medication time falls between feeds it is not necessary to wake the infant
completely. It has been noted on past experience that babies take the medication
well if the syringe is slipped into the mouth and medication is taken without any
problems. The baby is then tucked back to sleep.
● It is always a help if identification is on the left as this disturbs the baby less when
noting identification.
● An alternative treatment is chlorpromazine 2.2mg/kg/24 hours given in four divided
doses either orally or by injection. Full dosage should be given for two to four days
then tried to decrease at two day intervals if baby's condition, according to the
clinical score, permits.

Management of an Unsettled, Irritable Baby

● Check baby has dry napkin.


● Baby may be hungry. These babies will often take extra feeds but may be difficult
or sloppy feeders. They should not be tube fed unless there are other indications
such as hypoglycaemia or scores are approaching treatment levels and being
unduly influenced by symptoms of hunger. Dummies are very useful. Deep water
bathing and massage often help relax the baby if needed. Many babies will settle
well in the swinging cradle sling. A disposable napkin or incontinent pad must be
used when nursing baby in the sling to protect the sling cover.
● Frequent cuddling, walking with front pack, may be soothing music or quietness
rather than loud music (individual variation).
● When baby is stable, mother may take baby for a walk within the unit, if on NICU,
or outside the ward if on Ward 32. This is arranged between mother/charge
midwife/nurse - times to be specific so that all staff are aware. The day nursery
may be used. Later on, following negotiation with charge midwife, mother may take
baby for a walk in the grounds. This is subject to permission on each occasion and
excludes the Nurses Home.
● Midwives and nurses need to know the routine lines of communication when:
❍ threatened with violence

❍ parents are uplifting baby against medical advice

❍ there is inappropriate behaviour from parents and/or visitors

Discharge Planning

● A meeting may be organised prior to discharge. The following people may be


asked to attend:
❍ Paediatrician

❍ Charge Midwife/Nurse

❍ Public Health Nurse or Plunket Nurse,

❍ GP (if possible)

❍ Parents

❍ Liaison Midwife

❍ Counsellor Methadone Services/CADS Unit

❍ ADAPT S/W.

● For short stay infants who have not had withdrawal symptoms, e.g. less than 10
days there should be adequate communication between GP, Paediatrician,
Charge Midwife/Nurse with phone contact with other parties.
● Babies are not followed up by Neonatal Homecare unless they have other
problems such as prematurity or low birthweight, that would normally be referred.
● Medical follow up will be by the Paediatrician at clinic in 3-4 months or as
necessary and we will offer a follow up appointment at one year. This is
particularly important if mothers are Hepatitis C positive.
● These infants have a higher incidence of Sudden Infant Death Syndrome and
although this does not justify the use of monitors, the various community support
networks must be alerted. Advice about reduction of risk factors (supine sleeping
position, breast feeding, discouraging smoking, discouraging co-bedding) should
be given. Monitors may be indicated for preterm infants.
● Mother should attend teaching sessions for:
❍ Home environment/clothing/when baby is sick.

❍ Infant resuscitation classes.

❍ Deep warm bathing.

❍ Car seat needed.

❍ The Ward Clerk makes Paediatric appointment at 3-4 months for Outpatient

follow up. For infants discharged home from NICU, the Paediatric
Registrar will dictate a discharge letter with a copy to the General
Practitioner. Include follow up of HCV testing. NB: Note the privacy act and
confidentiality.

Points of Interest

● 70% of babies born to mothers taking heroin or methadone will manifest signs of
withdrawal. Some are only mildly affected. Babies born to methadone addicts
show more frequent and severe signs than heroin addicted mothers.
● The likelihood of the baby being affected is related to maternal consumption and
the length of time addicted. However some babies born to heavily affected
mothers may show no signs, while those born to 'light' users may show significant
signs of withdrawal.
● Although 70% will show signs of withdrawal, only about half of these will have
signs severe enough to require treatment. 90% of these showing signs will start to
have them within 48 hours. Initial signs of withdrawal are rare after 10 days of age.
● About half of affected infants requiring treatment need it for 10 - 20 days and one
third for up to 49 days after birth.
● Mortality is said to be about 3% but with treatment should be virtually nil.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

The Neonatal Electrocardiograph Reviewed by David Knight and


Clare O'Donnell

October
1998

Normal Values Interpretation Conditions with Specific ECGs

● Report the rate, rhythm, conduction, p waves, frontal plane axis, QRS complex.
● Comment on T waves over R chest. Look at QT interval
● Rate = 1500 / number of little squares or
= 300 / number of big squares

● Frontal plane QRS axis

Normal Values

SV1+ R+S
Ht QRS PR QIII RSV RV RV6 V4
QV6 RV1 SV1 1 6 SV6 R/S V6
Rate vector interval
Age
mm
o mm mm mm mm sec mm mm
/min sec sec mm

+59 to 4.5 2 5-26 0-23 0.1- ? 0-11 0-9.5 0.1 - ? 28 52.5


93- -163 0.08-.16 (14) (8) (2.2) (4) (3) (2.0)
<1
154 (137)
day (0.11)
(123)
91- +64 to 6.5 2.5 5-27 0-21 0.1 - ? 0-12 0-9.5 0.1 - ? 29 52
0.08-.14
1-2 159 -161 (14) (9) (2.0) (4.5) (3) (2.5)
(0.11)
days (123) (134)

91- +77 to 0.07-.14 5.5 3 3-24 0-17 0.2 - ? 0.5-12 0-10 0.1 -? 24.5 49
3-6 166 -163 (0.10) (13) (7) (2.7) (5) (3.5) (2.2)
days (129) (132)

107- +65 to 0.07-.14 6 3 3-21 0-11 1.0- ? 2.5- 0-10 0.1 - ? 21 49


1-3 182 -161 (0.01) (11) (4) (2.9) 16.5 (3.5) (3.3)
weeks (148) (110) (7.5)

(mean), ? = undefined

Interpretation

P waves Peaked (>3mm) = RA hypertrophy

Broad or biphasic = LA hypertrophy

Right Ventricular Pure RV1 >10mm (no SV1)


Hypertrophy
RV1 >25 (SV1 present)
Upright TV1 after 3 days (RV strain)
Right axis deviation >+180°
Left Ventricular RV6 >17mm in 1st week (>25mm in 1st month)
Hypertrophy
SV1 >20mm
SV1 + RV6 >45mm
QV5 or V6 >5mm with tall symmetric T
Asymmetric T inversion = LV strain
ST depression = LV strain
Biventricular Hypertrophy Abnormal voltages over R and L chest leads
Prominent mid-precordial voltages
AV Block 1° Prolonged P-R interval
2° Mobitz Type 1 Progressive increase in P-R
(Wenkebach) then dropped beat
2° Mobitz Type 2 Dropped beats without P-R
prolongation
3° Complete heart block
Tachycardias Atrial flutter - atrial rate 300-400, and regular saw-tooth
pattern of P waves in LI and LIII.
Ventricular rate depends on degree of A-V block.
Atrial fibrillation (rare in newborn). Often associated with
cardiac abnormalities, especialy if LA enlargement.
Atrial tachycardia.
AV re-entry tachycardia.
WPW: Short P-R paroxysmal tachycardias. Wide QRS
with ∆ wave re-entry through accessory pathway.
AV Nodal re-entry tachycardia
Sinus tachycardia
Ventricular Tachycardia >5 ventricular ectopics in rapid succession
Identify independent atrial activity
Direct
Indirect (Capture, atrial capture
beats with narrow complexes
(Fusion, supraventricular
beat with ventricular
complex)
Regular, broad complex tachycardia
Concordant pattern over chest leads
Ventricular Fibrillation

Prolonged Q-T

Ectopic Beats Common: 21-31% of healthy preterm and up to 23% of


term infants

Conditions with Specific ECGs

Preterm Infant Shorter QRS duration, shorter PR and QT interval


Less RV dominance than term infant at birth
AV Canal QRS -30 to -90°
RA enlargement
Prolonged PR
Ebstein's Anomaly QRS low voltage or RBBB or ventricular pre-excitation
PR prolonged, RA enlargement
Hypoplastic Right Heart Variable.
Absent or diminished RV voltages
Transposition of the Often normal
Great Arteries

Tricuspid atresia RA hypertrophy


Left axis deviation
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for Consideration of ECMO Reviewed by John Beca (PICU)


(ExtraCorporeal Membrane Oxygenation) and Carl Kuschel

July
2002

Eligibility Criteria Contraindications Pre-ECMO Investigations


Optimal Pre-ECMO Tubes and Lines Consideration of ECMO

ECMO is proven treatment for life-threatening respiratory and/or cardiac failure in


neonates. Overall survival rates are approximately 80% in infants with a predicted survival
of 20%.

Eligibility Criteria

ANY of the following AND underlying disease process which is likely to be reversible

1. OI ≥30 - 60 for 0.5 - OI = (MAP x FiO2 x 100) / PaO2 (mmHg) (click here to open
6 hours the OI calculator)
Standard criteria: OI ≥40 on conventional ventilation
OI ≥50-60 for HFOV
2. PaO2 <5.3kPa Despite maximal ventilatory support
(40mmHg) for >2
hours
3. Acidosis and Shock pH <7.25 due to metabolic acidosis
Raised lactate
Intractable hypotension

Contraindications to ECMO

Absolute

● Gestational age <34 weeks


● Birth weight <2kg
● >Grade 1 intracranial haemorrhage
● Severe and irreversible brain injury (as best as can be judged by
consultant neonatologist)

Lethal malformations or congenital anomalies

● Significant non-treatable congenital heart disease


● Severe and irreversible lung, liver or kidney disease

Relative

● > 10-14 days of mechanical ventilation


● Uncontrolled bleeding or coagulopathy
● IVH Grade 1
● Congenital Diaphragmatic Hernia if PaO2 never > 9.3kPa (70mmHg)
or PaCO2 never < 10.7–13.3kPa (80–100mmHg)

Pre ECMO Investigations

Investigation Responsibility
CXR NICU
FBC and Differential NICU
INR, APPT, Fibrinogen NICU
Electrolytes NICU
Urea and Creatinine
LFTs
Head Ultrasound Scan NICU
Cardiac Echo NICU but should have repeat
study performed by Paediatric
Cardiologist prior to cannulation
Crossmatch (2 adult units) NICU

Optimal Pre ECMO Tubes and Lines

Item Responsibility Comments


Nasal ETT NICU ● If very unstable, the
risks of electively
changing an oral ETT
to a nasal ETT need to
be considered carefully.
● Otherwise change to
nasal ETT after
cannulation

Peripheral arterial line NICU ● Ideally, this should be


pre-ductal (right radial
or brachial) but if
unsuccessful a
functioning UAC is
satisfactory.

Double lumen femoral PICU


venous catheter
Urinary catheter NICU

Consideration of ECMO

With the advent of HFOV and nitric oxide, patients being referred for ECMO will generally
be sicker than previously with little or no reserve. As a treatment with a proven survival
benefit, ECMO should be considered for any neonate with severe cardio-respiratory
failure and discussed early to facilitate timely transfers.

As many as possible of the pre-ECMO investigations, tubes and lines should be done
prior to transfer to allow for rapid initiation of ECMO if it is required.

Consider and discuss ECMO in any near-term neonate with:

● PaO2 <6.7kPa (50 mmHg)


● FiO2 1.0
● PIP >35cm H2O

● OI >30 on conventional ventilation


● OI >40 on HFOV
● Failure to improve with HFOV over 2-12 hours is also a very poor prognostic sign

● In the first instance discussion should be with either Dr John Beca or Dr David
Buckley
❍ If neither is available, contact the PICU Specialist on call with the

switchboard.
If a decision is made to transfer to PICU:

1. Ensure that 2 adult units of red cells have been cross matched
2. The transfer will be performed by either a Consultant Neonatologist or Senior
Fellow
3. PICU nursing staff will liaise with NICU nursing staff to determine current drug
infusions and doses
4. Initial ventilator settings and drug infusions at PICU will be as per the most recent
NICU settings
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Exchange Transfusion Reviewed by David Knight

March
2004

Technique Procedure Partial Exchange Transfusion


Other Related Documents References

Technique

● There are a variety of techniques for exchange transfusion. That chosen will
depend on the vascular access available and the choice of the specialist
supervising the exchange.
● The exchange equipment is usually set up by nursing staff, but the specialist
responsible for the exchange must check the set-up prior to commencing the
exchange.
❍ This set-up is a joint responsibility between medical and nursing staff, but

the specialist doing the exchange has overall responsibility for the
procedure.

1. Isovolumetric Exchange

● Remove blood from an artery while infusing through a vein at the same rate.

In Out
Umbilical vein Peripheral artery
or Umbilical vein 2
Umbilical artery
1
or Peripheral vein Peripheral artery
or Peripheral vein Umbilical artery

2. Push-pull

● This can be done through an umbilical venous catheter. 3 Exceptionally, an


umbilical artery catheter can be used.
● Ideally, the tip of the UVC should be in the IVC/right atrium (at or just above the
diaphragm) but can be used if it is in the portal sinus. For ‘high’ UVC placement,
position should be checked by an X-ray. This is not always necessary for a low
position. A low positioned catheter is usually removed after each exchange.

<1000gms Use 5ml aliquots


1000-2000gm 10ml
3 15ml
>2000gm

● Withdraw blood over 2 minutes, infuse slightly faster. Aim to exchange 180 ml/kg
over 1½ -2 hours.
● If using a 2-catheter push-pull method, withdraw the blood at the same time that
blood is given.

3. Infusion Method

● The choice of method is that of the specialist supervising.


● The choice of infusion method is a syringe or an infusion pump.
● Blood removal is by syringe.
● With the isovolumetric method and syringes, the doctors/NS-ANPs involved infuse
and withdraw at the same rate.
● REFER TO THE OTHER RELATED DOCUMENTS FOR LINKS TO THE
DIAGRAMS OF THE SET-UPS.

Volume

● Usually use two blood volumes (180 ml/kg).


❍ One blood volume removes 65% of baby’s red cells.

❍ Two blood volumes removes 88%.

3
● Thereafter the gain is small.

Procedure

● There must be at least one doctor/NS-ANP and one nurse exclusively involved in
the exchange throughout its progress.
● Meticulous care must be taken throughout, especially with volume balance, the
rate of the exchange, the vital signs and any signs of air in the lines.
● A doctor/NS-ANP must be present throughout the exchange. He/she may leave
the room briefly to get blood results, but if called away, the exchange is stopped
and the lines flushed.
● All exchanges are to be conducted in NICU Level 3.
● It may be necessary for another doctor/NS-ANP to cover the rest of the unit during
the exchange.
● IF THERE ARE ANY DOUBTS ABOUT THE SET-UP OR THE METHOD OF
DOING THE EXCHANGE TRANSFUSION, THEY MUST BE IMMEDIATELY
REFERRED TO SENIOR MEDICAL OR NURSING STAFF AND THE EXCHANGE
INTERRUPTED UNTIL THEY ARE ANSWERED SATISFACTORILY.

3
Partial Exchange Transfusion

● To correct severe anaemia without hypovolaemia or polycythaemia.

Polycythaemia

Blood Volume x (PCV initial - PCV desired)


Volume exchanged (ml) =
PCV initial

Anaemia

Blood Volume (ml) x (Hb desired - Hb


Volume exchanged (ml) = initial)
(Hb Donor - Hb Initial)

● Blood volume = 70-90 ml/kg for term and 85-110 ml/kg for preterm infants.

References

1 Fok TF. So LY. Leung KW. Wong W. Feng CS. Tsang SS. Use of peripheral vessels for exchange
transfusion. Arch Dis Child. 1990 65(7 Spec No):676-8
2 Martin JR. A double catheter technique for exchange transfusion in the newborn infant. NZMJ 1973; 77
(490):167-9
3 Edwards. chapter 41 in Atlas of procedures in neonatology. 2nd ed. Lippincott. 1993
4 Ramirez AM. Woodfield DG. Scott R. McLachlan J. High potassium levels in stored irradiated blood.
Transfusion 1987; 27(5):444-5
5 Ramirez. Unpublished. Potassium in blood for exchange transfusion. 1986.

6 Schuerger G. Robertson A. Ertel I. Effects of agitation of donor blood on neonatal exchange transfusions.
Clinical Pediatrics 1970; 9(12):715-8
7 Peterec SM. Management of Neonatal Rh Disease. Clinics in Perinatology 1995;22:561-92
Newborn Services Feeding Policy Reviewed by Charge Nurse -
Newborn

December
2004

Introduction Purpose Scope Associated Documents


Breastfeeding Policy Artificial Feeding Policy Other Related Documents

Introduction

The Newborn Service at National Women’s Health promotes breast milk and
breastfeeding as the optimum nutrition for infants as it provides many benefits. Benefits
apply to both the mother and the infant and include nutritional, immunological, psycho-
social and financial components.

The cultural, personal and/or physical factors affecting infant feeding are to be respected
and staff are to support and assist women in their choice of infant feeding.

This document details the policies and recommended best practices to support
breastfeeding the preterm or sick infant within the Newborn Service. It also provides
policies and recommended best practice for alternative methods of infant feeding
including bottle feeding and gastric tube feeding.

Purpose

The purpose of this policy is to ensure that Newborn Service health professionals protect,
promote and support breastfeeding during all stages of the infants association with the
service. This policy also seeks to provide information and skills on safe infant feeding
regardless of the method used.

Scope

This policy applies to all Newborn Service health professionals and employees who
provide care for, or have contact with, women and infants within Newborn Services. This
also applies to both inpatient and outpatient services.

The policies reflect the Global Criteria of WHO/UNICEF to meet accreditation for a Baby
Friendly Hospital.

Associated Documents

The table below indicates other documents associated with this policy.
Type Document Title(s)
Infection Control Manual ● Decontamination. Standard Precautions

Board Policy ● Informed Consent

NW Policy & Procedure ● Infant Feeding

Supporting ● Global Strategy for Infant and Young


literature regarding Child Feeding. WHO/UNICEF 2003
breastfeeding: ● Breastfeeding: A Guide to Action. MOH
2002.
● Baby Friendly Hospital NZ
Breastfeeding Authority 2000
● Food and Nutrition Guidelines for
Healthy Infants and Toddlers (aged 0-
2years) MOH 1999 PHC
● Interim Statement on HIV and
Breastfeeding WHO Sept. 1999.
● Infant Feeding – Guidelines for NZ
Health Workers MOH 1997 PHC
● Ten Steps To Successful
Breastfeeding WHO/UNICEF 1989

Pamphlets ● Breast Massage and Hand Expressing


regarding breastfeeding Breastmilk.
● Mastitis/plugged Ducts 2004 NW
Lactation Consultant
● Guidelines for Expressing Breastmilk
2004
● Storage and Transport of Expressed
Breast Milk 2003
● Use of Breast Pumps in Newborn
Services 2003
● Breastfeeding the Preterm infant: Hints
for Going Home 2004 (Newborn
Services Lactation Consultant)
Publications ● Global Strategy for Infant and Young
Regarding Artificial Feeding Child Feeding. WHO/UNICEF 2003
● Food and Nutrition Guidelines for
Healthy Infants and Toddlers (aged 0-
2years). MOH 1999 PHC
● Infant Feeding – Guidelines for NZ
Health Workers. MOH 1997 PHC
● Guidelines for Interpretation of the
WHO International Code of Marketing
of Breastmilk Substitutes in N.Z. MOH
PHC 1995.
● International Code of Marketing of
Breastmilk Substitutes. WHO 1981.

Pamphlet regarding artificial ● Information about Bottle feeding Your


feeding Baby (NW Lactation Consultant &
Nutrition Services 2000)

Breastfeeding Policy

Responsibility of the Health Professional

Health professionals are to give current, accurate and consistent, non-judgmental


breastfeeding information and supportive encouragement to enhance successful
breastfeeding. It is essential that feeding of preterm or sick infants is managed in a safe
and professional manner that enhances success for the infant, whatever the feeding
method.

The respect of, and sensitivity to each woman’s personal and psychosexual dignity is to
be upheld when assisting her to breastfeed. It is expected that touching the woman’s
breast will be minimised and the health professional will seek each woman’s permission
before touching and/or gentle handling of her breasts.

The health professionals breastfeeding practice will be in accordance with the WHO/
UNICEF Ten Steps to Successful Breastfeeding (1989), New Zealand College of
Midwives Handbook (1992), and the NZ Breastfeeding Authority Incorporated Baby
Friendly Hospital Initiative, particularly Part Two: Hospital Level Implementation for
Aotearoa New Zealand (2002), and the NWH Breastfeeding Policy (2003).

In order to maintain health professionals’ breastfeeding knowledge and skills, ongoing


review of practice is expected and will include annual updates of breastfeeding
knowledge in accordance with BFHI Aotearoa, 2002.

Feeding challenges and /or difficulties identified


Breastfeeding challenges and/or difficulties are to be identified early and documented in
the clinical records with a management plan.

● If breastfeeding difficulties are unresolved consult with the Clinical Charge Nurse
or Nurse Specialist. Appropriate referral will be made to the Speech and Language
Therapist or Lactation Consultant, Newborn Services.
● The Newborn Services Lactation Consultant is available to provide education to
both staff and mothers.

Discharge Planning

Discharge planning is to incorporate written breastfeeding information and referral to


appropriate services in the community resources to support continued breastfeeding
success.

Artificial Feeding Policy

Responsibility of the Health Professional

The health professional has a responsibility to meet the WHO Recommendations for
Infant Feeding, Article 4:2.

The health professional's responsibilities to women who choose to artificially feed their
babies are to:

● Ensure they have made an informed choice and are aware of the benefits of
breastmilk/breastfeeding.
● Ensure they are aware of the financial costs for providing feeding equipment and
providing formula until the infant is 12 months old.
● Document in the infant’s clinical records the feeding choice of the mother.
● Initiate a documented feeding plan that includes the appropriate volume and
frequency of feeds for age and weight of the baby.
● Provide one on one education on the safe administration of artificial feeding
including the correct preparation of formula, safe storage, sterilisation techniques,
and how to bottle-feed.
● The opportunity exists for the mother to provide her own feeding equipment for the
infant.
● No feeding equipment or formula is to be given to a mother or family unless it is
specialised and or prescribed.

Feeding challenges and/or difficulties identified

● Bottle feeding challenges and/or difficulties are to be identified early and


documented in the clinical records with a management plan.
● Consult with the Clinical Charge Nurse or Family Liaison Nurse. Appropriate
referral will be made to the Speech and Language Therapist or Lactation
Consultant, Newborn Services.
● Ongoing bottle feeding challenges will require referral to appropriate community
resources including Community Speech and Language Therapist.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Neonatal Nutrition Guideline Reviewed by Barbara Cormack


(Dietitian) and Carl Kuschel

February
2006

Born at less than 32 weeks OR Born at 32+ weeks AND birthweight


Additional Notes
birthweight <1800g 1800+g

● These guidelines have been developed based on the current RDIs


(Recommended Daily Intakes) for low birthweight infants and the specific nutrient
composition of Nutricia low birthweight feeds and fortifier.
● The guidelines do not apply to other feeds, which may have different nutrient
levels.
● If at any time growth is inadequate, consider referral to a dietitian.

Born at At any time if


growth is Preparation
<32 weeks Transition Stable At
inadequate, for
OR consider referral to Oral Feed Growing Discharge
Discharge
birthweight to dietitian
<1800g IVN then, When full feeds Stop Breast Milk Breast milk or
Breast milk or reached add Fortifier or term formula
term formula Breast Milk change from
Fortifier preterm formula
Karicare BMF 1 to term formula
pkt per 50ml when
Feed breast milk approaching
or discharge
change to or
Preterm approximately 40
Formula weeks or 2500g,
(Nutriprem) whichever occurs
earliest.
Begin at 1ml 2- Grade up to 3- Beginning 3- to 4-hourly or
hourly or as hourly feeds as sucking feeds. on demand
tolerated tolerated
Grade up as (approximately
tolerated 1500g) If the baby is
Usually increase going to be
Frequency feed volume by breast fed, then
1ml, every 12 to the first feeds
24 hours. offered should be
Increase more breast feeds.
rapidly once
tolerated.

Increase to 180ml/kg/day Usual volume is Demand volumes


180ml/kg/day 180ml/kg/day.
Increase to
Feed Volume Increase to 200ml/kg/day if
200ml/kg/day if poor growth.
poor growth.

Start Vitadol C Continue Vitadol Start Vitadol C Prescribe 0.3ml


0.30ml per day C only until 0.3ml per day. (10 drops) per
when tolerating tolerating 180ml/ day Vitadol C and
1/3 enteral feeds kg/day, then stop. 0.5ml/kg/day
or >50ml/kg/day Start 0.5ml/kg/ Ferrous sulphate
Supplements day Ferrous
elixir once 4
If volume taken sulphate elixir weeks of age or
is <180ml/kg/ once 4 weeks of on discharge,
day, add Vitadol age. whichever comes
C 0.15ml per day
earlier.

Note:

● The recommended daily neonatal intake of Vitamin D is 10μg or


400iU. This is provided by ≥180ml/kg/day of fortified EBM or
preterm formula because breastmilk fortifier and preterm formula
have higher levels of vitamins and minerals.
● Babies having lower volumes of FEBM or preterm formula need
Vitadol C 0.15ml daily to meet the recommended Vitamin D intake.
● Babies on all other feeds (e.g. unfortified EBM, term or hydrolysed
formula, which have much lower levels of vitamins and minerals)
need Vitamin D 0.3ml daily.

Born at 32 At any time if


growth is Preparation
+ weeks Transition Stable At
inadequate, for
AND consider referral to Oral Feed Growing Discharge
Discharge
birthweight to dietitian
1800+g Breast milk or Breast milk or Breast milk or Breast milk or
Feed term formula term formula term formula term formula
3-hourly unless 3-hourly feeds 3-hourly feeds or Demand
risk of on demand
hypoglycaemia

If the baby is
Frequency going to be
breast fed, then
the first feeds
offered should be
breast feeds.

Day 1 60-90 ml/ 180 ml/kg/day Increase to 200 Demand volumes


kg/day ml/kg/day if poor
Day 2 90-120 ml/ growth or on
kg/day Increase to demand
Feed Volume Day 3 120-150 200ml/kg/day or
ml/kg/day more if poor
Up to 180 ml/kg/ growth
day

Nil Nil Nil Nil


Supplements (see notes
below)

Additional ● Some infants with a gestation at birth ≥32 weeks and


Notes: birthweight ≥1800g may require fortifier or preterm formula for
growth.
● Some infants who are demand feeding will take volumes in
excess of 200ml/kg/day of expressed breast milk or term
formula.
● Iron (ferrous sulphate) should be commenced at 4 weeks of age
in eligible infants.
❍ Usual starting dose 3mg/kg/day of elemental iron (0.5ml/

kg/day) but increase dose to 6mg/kg/day in iron-deficient


infants.
❍ Infants receiving treatment with erythropoietin require

iron supplementation on commencement.


● Vitamin and iron supplements should be continued till the infant
is well established on a balanced diet of solids.
❍ Some groups recommend that infants should be

supplemented until 12 months of age.


● Iron and/or vitamins may be commenced in some infants who
do not fit the above criteria. These may include:
❍ Infants at risk of nutritional deficiency, for example –

malabsorptive diseases, long term parenteral nutrition,


fluid restriction (<160ml/kg/day), gastrointestinal tract
losses, and infants of mothers who are known to have or
are at risk of nutritional deficiencies.
❍ Babies at high-risk of iron deficiency.

● Note that a small number of infants who do not fulfil the criteria
above for iron supplementation may nevertheless develop iron
deficiency anaemia within the first few months of life. A FBC
and iron studies should be undertaken to confirm the diagnosis,
and supplementation should be instituted.
References

1 Franz AR, Mihatsch WA, Sander S, Kron M, Pohlandt F. Prospective randomized trial of early versus late
enteral iron supplementation in infants with a birth weight of less than 1301 grams. Pediatrics 2000;106
(4):700-6.
2 Klein CJ. Nutrient requirements for preterm infant formulas. J Nutr 2002;132(6 Suppl 1):1395S-577S.
3 Hay WW Jr, Lucas A, Heird WC, et al. Workshop summary: nutrition of the extremely low birth weight
infant. Pediatrics 1999;104;1360-1368.
4 Rao R, Georgieff MK. Neonatal iron nutrition. Semin Neonatol 2001;6:425-35.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Feeding Newborn Babies on Postnatal Wards Reviewed by Salim Aftimos and


Carol Thomas

January
2001

1. The main aim of these guidelines is promotion of successful breastfeeding.


2. Mothers should be encouraged to breastfeed their babies soon after birth.
❍ Newborns should be nursed whenever they show signs of hunger, such as

increased alertness or activity, mouthing or rooting.


❍ Ideally, they should be nursed frequently, 8-12 times per 24 hours until

baby is satisfied, usually 10-15 minutes of effective sucking on each breast.


❍ Milk delivery time varies between mothers. Some babies may be satisfied

with less frequent feeds.


❍ When breastfeeding is well established, feeding frequency gradually

decreases and most babies will be satisfied with around 6 feeds per day.
3. Healthy term babies do not require supplements (water/formula). See section on
indications for supplementation of breastfeeding.
4. Premature Babies
❍ Well premature babies usually at 35-36 gestation are often admitted to

postnatal wards with their mothers.


❍ These babies should be offered the breast as soon as possible after birth

and then demand up to 3 hourly.


❍ For those who latch and suck well on the breast, there is no need for

supplementation.
❍ Serum glucose may be checked if there is uncertainty about feeding

success or if there are risk factors (e.g., hypothermia).


❍ On the other hand if the baby does not show interest in feeding, is having

difficulties latching, or does not suckle for long, a supplementary feed will
be required.
❍ A feeding plan needs to be individualised.

❍ Feeding volumes should follow the recommended standards.

❍ Expressed breast milk is the food of choice, but if this is not available in

sufficient quantity, infant formula may be offered. Advice may be sought


from a Lactation Consultant.
5. Supplementation
❍ Supplementation of breastfeeding is usually requested when there is

concern that baby is at risk for hypoglycaemia. In that context consider the
following:
❍ Expressed breast milk is preferable to formula.
❍ Birth asphyxia
■ Significant birth asphyxia may be a risk factor for hypoglycaemia.

■ Such babies remain unwell after the initial resuscitation and are

admitted to NICU.
■ Term babies, depressed at birth, but responding quickly and fully to

resuscitation and are judged well enough to go to the postnatal


ward, should be considered well babies and encouraged to proceed
with normal breastfeeding.
❍ Small for gestational age babies.
■ Keep in mind that babies below the 10th centile in birthweight are

not necessarily SGA.


■ Consider such factors as ethnic background, parity and maternal

height which may influence birthweight.


■ Asymmetrically small babies with disparity between head

circumference and weight are more at risk for hypoglycaemia.


❍ Infants of Diabetic Mothers
■ These babies who are clinically macrosomic are at a greater risk for

hypoglycaemia.
■ Babies with adequate weight for gestational age are at a lower risk.

■ Should these babies require supplementation for initial

hypoglycaemia, attempt to expedite transfer to full breastfeeding.


(See nursing management of infants of diabetic mothers of postnatal
wards separate guideline).
❍ Large for Gestational Age Infants
■ Currently the NWH guidelines advise checking glucose levels in

babies above 4500g.


■ Hypoglycaemia is typically early in such babies and is rare beyond 8

hours of age.
■ Early feeding should be stressed again and any supplementation

should be limited to the initial few feeds, with attempts to expedite


full breastfeeding.
❍ Occasionally babies are seen on postnatal wards who may have been
receiving suboptimal quantity of breast milk, appear clinically dehydrated,
may have had significant weight loss from birthweight (7-10% below
birthweight), may have elevated temperature and show excessive sucking
activity.
■ These babies need to be supplemented with EBM/formula until they

are clinically well.


■ To support breast feeding, always offer breast feeds first and

supplement after this.


❍ Phototherapy
■ Phototherapy causes an increase in insensible water loss and in

stool water contents, equivalent to 15-25ml/kg/day.


■ This should be balanced by increased demand for breast milk in a

well term baby who has established breastfeeding.


■ Thus routine supplementation of babies under phototherapy is not

recommended.
■ If breastfeeding is not well established or baby appears clinically
under-hydrated, then formula supplementation is advised.

References

1 Breastfeeding and the use of Human Milk. American Academy of Pediatrics Policy Statement. Pediatrics
100; 1035-1039, 1997.
2 Hypoglycaemia of the Newborn. WHO Report 1997.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Fluid and Electrolyte Requirements Reviewed by Carl Kuschel

July
2004

Volume Recommended Electrolytes Arterial Line Fluids Glucose Intake


Insensible Water Loss GI Obstruction Chest and Peritoneal Drains Renal Impairment
Hyponatraemia Hypernatraemia References

Click here to link to the fluid and electrolytes calculator

Volume (ml/kg/day) Recommended

Day1 Day 2-3 Day 4-5 Day 6-7 Day >7

<1000g 60-90 120 140 150 180


>1000g 60 90 120 150 180

1. Start on 10% dextrose. Monitor blood glucose.


2. If under a radiant warmer, add 20 (mature) to 40 (immature) ml/kg/day.
3. If under phototherapy, add 20 ml/kg/day

Volume given will depend on the clinical condition of the infant, with fluid restriction
indicated with asphyxia, renal impairment or PDA.

Very preterm infants with immature skins can lose large amounts of fluid transcutaneously
over the first few days. This is monitored by serial serum Na+ measurements and by
change in weight. Fluid intake may have to increase to 200 ml/kg/day.

Electrolytes

Day 1 None routinely


Add electrolytes:

Na+ 3 mmol/kg/day (very preterm


infants may need more)
K+ 2 mmol/kg/day
Ca ++ 1 mmol/kg/day
Day 2 onwards

● Do not add Ca++ routinely in relatively well


infants only likely to be on short term IV
fluids. (This is most babies as the sicker,
longer term babies will be on IVN)

Additive Concentration Requirement Formula


4 Molar 3 mmol/kg/day 500 x weight x 0.75
Na+
(4mmol/ml) (0.75ml/kg/day) 24 hour total fluids
1 Molar 2 mmol/kg/day 500 x weight x 2
K+
(1mmol/ml) (2ml/kg/day) 24 hour total fluids
10% Ca
1 mmol/kg/day 500 x weight x 4.5
Ca2+ gluconate
(4.5ml/kg/day) 24 hour total fluids
(0.22mmol/ml)

Notes:

● Assumes that additives are added to a 500ml bag of fluid


● Add Heparin 250units/500ml to central venous (including long) line fluids.
● If daily requirements are increased or decreased, these formulations need to be
recalculated
● This system does not take into account the amount of sodium in arterial fluids or
other infusions and calculations need to be adjusted accordingly.

Arterial Line Fluids

<1000gms ● Initially 0.5ml/hr of 0.45% NaCl (= 0.9 mmol/


day Na+)
● Change to 0.9% NaCl as soon as Serum [Na
+] is stable. (= 1.8 mmol/day Na+)

>1000 gms ● Initially 0.5 ml/hr of 0.9% NaCl (= 1.8 mmol/


day Na+)
● Increase to 1 ml/hr as fluid intake increases.
(= 3.6 mmol/day Na+)
● Add Heparin 250units/500 ml to arterial fluids

Glucose Intake

● The neonatal liver normally puts out 6 - 8 mg/kg/min of glucose. This is


approximately the basal requirement of a newborn infant. Hypoglycaemia is severe
if it persists despite an intake of >10 mg/kg/min. Calculate the glucose intake:

% Dextrose x Volume (ml/


Glucose intake (mg/kg/min)
kg/day)
=
144
See also the Glucose
or
Calculator
Glucose intake (mg/kg/min) % Dextrose x Hourly Rate
= Weight (Kg) x 6

Intake 5% Dextrose 10% Dextrose 12.5% Dextrose


(ml/kg/day) mg/kg/min of dextrose
60 2.1 4.2 5.2
90 3.1 6.25 7.8
120 4.2 8.3 10.4
150 5.2 10.4 13.0
180 6.25 12.5 15.6

To get concentrated glucose solutions: See also the Fluid and Electrolytes calculator

Solution 10% Dextrose 50% Dextrose


12.5% 450 ml 30 ml
15 % 420 ml 60 ml
20 % 400 ml 135 ml
Solution 5% Dextrose 50% Dextrose
7.5% 450ml 30ml

● Dextrose solutions of >10% are best administered through central venous lines.
❍ Peripheral IVs do not last long, and extravasation can result in tissue

damage.

Insensible Water Loss

● This varies greatly with gestation and depends on the thermal environment. It
decreases markedly over the first few days.
❍ A 26 week baby under a radiant warmer on day 1 may lose over 150ml/kg/
day. Mature babies will lose <30ml/kg/day.
● Very preterm infants should be placed in humidified incubators in a neutral
thermal environment as soon as practical after birth.

IWL ml/kg/day
750-1000gm 64-82
1001-1250 56
1251-1500 38-46
>1500 20-26

GI Obstruction

● If there are significant gastric aspirates, replace these ml for ml with 0.9% NaCl
plus 10mmolKCl/500ml.

Chest and/or Peritoneal Drains

● If there are significant fluid losses from these, measure the volume and replace
with 4% albumin as indicated.
● Monitor serum albumin concentrations.
● Monitor the composition of the fluid being lost as this may assist with calculating
requirements

Renal Impairment

● Restrict intake to insensible water loss + urine output.


● Monitor fluid balance, serum electrolytes and weight carefully.

● In early Acute Tubular Necrosis, consider a pre-renal cause. Fractional Excretion


of Sodium will help sort this out.
❍ FE Na ≥2.5% in term infants suggests renal failure.
+
+
❍ FE Na <2.5% in term infants suggests pre-renal failure.

+
❍ FE Na is high in preterm infants because of tubular immaturity.

Urine [Na] x Serum


Creatinine
FE Na+ = x 100%
Serum [Na+] x Urine
Creatinine

Hyponatraemia

● Commonest Causes
❍ Prematurity

+
■ Renal Na loss from glomerulo-tubular imbalance
❍ Inadequate Na+ intake
❍ Excessive water intake.
❍ Diuretic therapy, especially loop diuretics.
❍ Acute tubular necrosis (tubular Na+ loss)
❍ Indomethacin
■ Reduces free water clearance and fractional excretion of sodium,

with the lower free water clearance leading to hyponatraemia.


❍ SIADH
■ ADH has a limited ability to concentrate the urine in the newborn,

and acts primarily as a vasopressor.


❍ Excess Na+ loss
■ Diarrhoea, Gastric, pleural, CSF, 17-OH progesterone deficiency.

If a concentrated solution of Sodium chloride is required for treatment of


hyponatraemia due to increased losses, refer to the sodium infusion calculator.

Hypernatraemia

● Commonest causes
❍ Excessive water loss

■ Very preterm insensible loss

■ Diarrhoea

■ Polyuria

+
❍ Excess Na intake.

References

1 Cloherty JP and Stark AR. (Ed) Manual of Neonatal Care. 3rd Ed. Little Brown. 1991.
2 Gomella TL (Ed). Neonatology 2nd Ed. Appleton & Lange. 1992.
3 Roberton NCR. A manual of Neonatal Intensive Care. 2nd Ed. Churchill Livingston. 1986
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Fluid and Electrolyte Calculator


© Carl Kuschel

August 2004

Click here to open the Glucose calculator to determine glucose intake

● Do not add electrolytes on Day 1.


● Do not add Ca++ routinely in relatively well infants only likely to be on short term IV fluids.
(This is most babies as the sicker, longer term babies will be on IVN)

Weight grams
Total Fluid Intake ml/kg/day
Dextrose concentration 10 %
● Usual requirement 3mmol/kg/day
Sodium 3 mmol/kg/day
● Usual requirement 2mmol/kg/day
Potassium 2 mmol/kg/day
● Add 1mmol/kg/day if required
Calcium 0 mmol/kg/day

Calculate Reset
Home | Contact Us | Careers | Phone Directory | Search

The Paediatricians at National Women's Health Newborn Services provide a follow-up service for babies
who have been cared for by the service. A timetable is included below. Registrars and house officers are
welcome to sit in with the specialists during their clinic sessions.

The focus of the clinic is surveillance. If problems are identified, babies will generally be referred to
another service (such as general paediatrics).

Infants who have been back-transferred to another neonatal unit - even in Auckland - will be followed by
paediatric services at that hospital, rather than at National Women's Health.

Criteria for Follow-Up at National Women's Health

● Preterm infants
❍ All infants with a birthweight <1500g

Ministry of Health ❍ Infants <32 weeks

NZ Government ● Infants <3rd% for birthweight who have been admitted to NICU
● Infants with at risk of neurological or developmental problems
❍ Infants who were ventilated in the newborn period and where there are concerns about the

degree of illness and the risk of subsequent growth or developmental problems


©Copyright ❍ Infants with seizures in the newborn period, unless referred to another follow-up service

Published: 11/01/2006 ❍ Infants who had meningitis, unless referred to another follow-up service

❍ Infants who were neurologically abnormal on discharge and who are not being followed by

other services
❍ Note that most term infants who have identified neurological problems at discharge will be

followed by their local developmental paediatric or neurology services


● Infants in research studies (e.g. selective head cooling). These may be followed up by the
researcher involved
● Infants born to mothers on the methadone programme or mothers using significant quantities of
alcohol in their pregnancy (these infants will generally see Dr Kuschel or Dr Rowley)
● Some infants with congenital anomalies or other problems (for example, infants with an Erb's palsy)
who are not being followed by another service
● Families of infants who have died whilst on NICU will be offered an appointment to discuss events
surrounding the baby's admission and death
● Some infants who do not qualify for routine neonatal follow-up but are being followed by neonatal
home care services may be referred following discharge if there are clinical concerns

Timing of Follow-Up

● The need for and time of follow-up should be discussed with the specialist concerned or the
specialist on service responsible for the care of the infant in NICU
● The timing of the first follow-up is for 3 months following discharge
❍ Professor Harding and Dr Bloomfield prefer to see the infants 4 months after going home

● Infants are generally seen intermittently until the age of around 18 months
● Appointments can be requested by neonatal staff via the request an appointment link

Timetable

Specialist Day and Time


Battin Every Wednesday at 1:30pm
Bloomfield 3rd Tuesday of the month at 1:30pm
Harding 1st Tuesday of the month at 1:30pm
Knight 2nd and 4th Tuesdays of the month at 1:30pm
Kuschel Every Tuesday at 1:30pm
Rowley Every Friday at 10:00am
Revised May 2005
David Knight and Carl Kuschel
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Fractional Excretion of Sodium (FENa


+) © Carl Kuschel

August 2003

Serum Sodium mmol/L


Urine Sodium mmol/L
Serum Creatinine mmol/L
Urine Creatinine mmol/L
Reset

The Fractional Excretion of Sodium is %.


FENa+ >2.5% in term infants suggests renal failure. FENa+ <2.5% in term infants suggests pre-renal failure.

This value in a term infant suggests .


● The Fractional Excretion of Sodium is higher in preterm infants because of renal
immaturity.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Gestation Calculator
© Carl Kuschel

May 2004

First day of - -Choose-


LMP -Choose-

EDD by - -Choose-
scan or
dates -Choose-

Calculate 1 January
the
gestation at 2000

Calculate Reset
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Used with permission from www.nicutools.


Glucose Calculator org

with subsequent modifications by Carl


Kuschel

Enter infant Weight: kg

Rate Fluid Volume Sugar Load


Enter infant nutrition: Dextrose
(ml/hour) (ml/kg/day) (mg/kg/min)

IV fluid #1: %

IV fluid #2: %

Milk: - Select an option -

Polycal: %

Reset Totals --- ---

This calculator determines how much sugar (in mg/kg/min) an infant is receiving.

Enter the infant’s weight, then specify the various inputs – dextrose percentage and flow rate for one or two
infusions, and type of milk and hourly milk volumes, and use of polycal (a sugar) in terms of specifying how
many grams are added to each 100 ml of milk.

Assumptions:
● Breast milk sugar content 7.1 g / 100 ml
● Term formula sugar content 7.1 g / 100 ml
● Pre-term formula sugar content 8.5 g / 100 ml
● Assumption made that all enteral feeds are absorbed

● Any infant requiring a glucose load of 10 mg/kg/minute to maintain normoglycaemia should be


investigated for hyperinsulinism.

Contact this calculator's developers


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Granulocyte Concentrate
Reviewed by

The Product

● "Buffy Coat" 1 unit blood collected in the morning is spun hard and the buffy coat
and upper layer of red cells harvested into a variable volume of 20-50 ml.
● This will have perhaps 80% of the total white blood cells in that 450ml of donor
blood and is also a packed red cell preparation.
● Should ideally be irradiated prior to use.

Indications

● Septic neutropenic baby (neutrophils <3 x 109/L in first week or <1 x 109/L
subsequently).
● Septic baby with poorly functioning neutrophils (e.g chronic granulomatous
disease).

Complications

● As for other blood cell products -infections, allergy, leucocyte antibodies, red cell
antibody problems and volume overload.
● Raising red cell count too much causing hyperviscosity syndrome.
● Potential GVH (Graft versus Host) disease if not irradiated.
● Potential source of CMV infection UNLESS from Anti-CMV negative donor -
Please Request.

Administration

● Granulocytes last only a few hours and survive best at room temperature.
❍ The preparation should be infused as soon as received and should NOT be

refrigerated.
● Draw up via a 170u blood filter.
● Transfuse over 2-3 hours maximum.
● It would be hard to give too many granulocytes to a septic neutropenic baby by
infusing even a whole buffy coat preparation.
❍ Volume that can be given is usually dictated by volume that baby can

receive.
● NOTE the high Hb content of the product. Be very careful not to raise the baby's
Hb too high or hyperviscosity problems and serious consequences may occur.

For further details, see the Big Blue Blood Bank Book
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Investigation of Possible Haematological Disorders Reviewed by Carl Kuschel,


in Neonates George Chan (Haematology) and
Paul Harper (Haematology)

February
2004

Introduction Thrombocytopenia Haemophilia and Comments von Willebrand Disease


Protein C/S/Antithrombin
Factor V Leiden Mutation Thalassaemia Intravascular Haemolysis
DeficiencyI
Vitamin K Deficiency
G6PD References
Bleeding

Introduction

"Bleeding problems" or a tendency to bruise or bleed are common problems. There may
be a family history of specific haematological diagnoses, or there may be more general
notes about bleeding tendencies in the maternal history.

Thrombocytopenia

See the Thrombocytopenia guideline.

Haemophilia

There are a number of coagulation factor defects that fall under the general heading of
haemophilia. The two most common are Factor VIII Deficiency and Factor IX Deficiency.
von Willebrand Disease is also classified as a haemophilia although it is clinically less
severe than Factor VIII and IX Deficiencies.

Factor VIII Deficiency (Haemophilia A)

This is the "classical" haemophilia, inherited as an X-linked recessive gene (affecting


males), and causes approximately 75% of all significant inborn coagulopathies. There
may be a family history of affected males on the maternal side. The incidence is
approximately 1:10,000 male births. The underlying abnormality is a defect in factor VIII.
It may present as severe bleeding after procedures (including intramuscular injection of
vitamin K), or even intracranial bleeding.

Investigations ● If male infant, urgent (<3 hours) Factor VIII assay from
cord blood or the baby (avoid heel prick samples)
❍ Normal neonatal ranges are the same as adult

ranges, so low values are pathologic


● If urgent factor VIII assay is not available, do a coagulation
screen (avoid heel prick samples)
❍ Activated Partial Thromboplastin Time will be

prolonged (neonatal upper limit of normal 36


seconds)

Newborn ● Avoid intramuscular injections


Management ● Discuss with a paediatric haematologist
● See other comments

Factor IX Deficiency (Haemophilia B, Christmas Disease)

This accounts for about 12% of all patients with haemophilia, is sex-linked (affecting
males), and is clinically indistinguishable from Factor VIII Deficiency (that is, it may
present with significant bleeding in the newborn period)

Investigations ● If male infant, urgent (<3 hours) Factor IX assay from cord
blood or the baby (avoid heel prick samples)
❍ The normal neonatal ranges are decreased

compared with adults, so diagnosis of a mild


deficiency can be difficult
● If urgent factor IX assay is not available, do a coagulation
screen (avoid heel prick samples)
❍ Activated Partial Thromboplastin Time will be

prolonged (neonatal upper limit of normal 36


seconds)

Newborn ● Avoid intramuscular injections


Management ● Discuss with a paediatric haematologist
● See other comments

Other comments about Haemophilia A and B

If factor assay indicates a severe (<1%) or moderate (1-4%) factor VIII or IX deficiency,

● The result should be sensitively communicated to the parents by experienced staff


● Take a further factor VIII/IX level
● Follow the neonate closely for a minimum of 7 days after birth through daily phone
contact from the Haemophilia Centre or GP, and frequent midwife visits.
● Educate parents regarding the symptoms and signs of intracranial haemorrhage
(poor feeding, irritability, listlessness, full fontanelle, pallor, convulsions)
❍ Do a CT (In preference to ultrasound) if there is suspicion of an intracranial

haemorrhage.
● Suggest that Factor VIII/IX levels are done on females born to carrier mothers to
detect the occasional carrier female with low levels at risk of symptomatic bleeding.

von Willebrand Disease (VWD)

This is most commonly inherited as an autosomal dominant trait with a mild to moderate
bleeding tendency. There is variable clinical and laboratory expression of platelet
dysfunction and factor VIII deficiency. The basic defect in vWD is an abnormality of von
Willebrand factor (vWF) which promotes platelet adhesion and transports factor VIII by
the factor VIII-vWF complex. There are different recognised types of vWD, depending on
qualitative or quantitative abnormalities of vWF.

There are very few reports of newborn infants with bleeding secondary to vWD. The most
common manifestations in children and adults are nosebleeds and easy bruising, with
more severe bleeding problems being rare. Bleeding after dental extractions can be
serious in some individuals. The diagnosis is made by platelet function analysis (PFA)
and specific tests for vW antigen and activity. Bleeding times are rarely performed.

Investigations ● No investigations are necessary


● Levels of vWF are physiologically increased in the neonatal
period

Newborn ● No special precautions unless clinically significant bleeding


Management ● Referral to paediatric haematology

Factor V Leiden Mutation

This may be found because of investigations performed on mothers with a history or pre-
eclampsia or recurrent miscarraige. It is generally associated with an increased lifetime
risk of thrombosis, although most individuals with Factor V Leiden mutation will remain
well. A severe neonatal form has been described.

Investigations ● No investigations are indicated at birth or in the neonatal


period.

Newborn ● No specific investigations


Management
Protein C, Protein S, and Antithrombin Deficiency

These are conditions which predispose to thrombosis. The classic presentation of Protein
C deficiency is purpura fulminans occurring within hours or days of birth. Infants with
homozygous Protein C deficiency often have significant in utero thrombotic events
(cerebral or ophthalmic) and severe DIC and large vein thromboses . Heterozygous
Protein C deficiency has been associated with neonatal thrombotic events. Coagulation
screens are usually normal but may show an elevated platelet count and increased fibrin
degradation products. Protein S deficiency has been very rarely reported in neonates.
Antithrombin deficiency most commonly presents in adulthood, although there are reports
of neonates with significant thromboses.

The ranges for protein C and protein S in normal neonates may be as low as 20-30% of
the normal adult value.

Investigations ● Discuss with a paediatric haematologist

Newborn ● Avoid indwelling central intravenous or intra-arterial


Management catheters
● Fresh frozen plasma or replacement products (Protein C or
Antithrombin concentrates) as symptomatically indicated
after discussion with a paediatric haematologist.

Thalassaemias

These are hereditary conditions with decreased or absent synthesis of at least one globin
chain. α- and β- thalassaemia refer to deficiencies of the α and β chains, respectively.

α-thalassaemia conditions are usually due to deletion of the α-globin gene. There are 4
copies of the α-globin gene. Deletion of one or two α-globin genes leads to α-
thalassaemia trait. The red cell changes are mild and may not be detected clinically or
may present with mild microcytic anaemia that should be differentiated from iron
deficiency. Deletion of three α-globin genes results in HbH Disease with chronic mild to
moderate anaemia but the patient is not transfusion dependent. The most severe form of
α-thalassaemia condition is Hb Bart's hydrops foetalis. All the four α-globin genes are
absent, and the condition is lethal with the affected baby dying in utero or soon after birth.

β-globin production is controlled by a pair of β-globin gene. β-thalassaemia conditions


arise from different genetic defects not limited to deletion. Defect of one β-globin gene
leads to β-thalassemia trait, which can be asymptomatic or more usually associated with
mild microcytic anaemia. When both β-globin genes are defective then there is no or very
little β-globin produced. This leads to β-thalassaemia major. Usually this presents as a
transfusion dependent chronic anaemia, but the severity of disease is dependent on the
interaction of a number of complex genetic factors, and some patients are not transfusion
dependent even though they have a moderate anaemia.
At birth the predominant circulating haemoglobin is Hb F (α2γ2). Adult haemoglobin, Hb A
(α2β2), becomes the predominant haemoglobin after birth. Therefore, infants with α-chain
abnormalities tend to be symptomatic at birth (or before) whereas those with β-chain
problems develop symptoms usually after 4-6 months. The cord blood red cells from
infants with either α-thalassaemia trait or HbH Disease are microcytic, and the level of Hb
Bart's (an abnormal haemoglobin composed of only γ-chains) in the cord blood is raised.

Investigations ● Cord blood for haemoglobin electrophoresis, particularly Hb


Bart's quantitation if α-thalassaemia is suspected
● Venous blood for haemoglobinopathy study.
❍ If β-globin defect is suspected the specimen should

usually be taken at 3 months at the earliest.


● FBC (may be normal in thalassaemia traits)

Newborn ● Haematology follow-up as indicated by particular


Management haemoglobinopathy

Intravascular Haemolysis

This is relatively common in neonates. It may be due to a variety of causes including


infection, AV malformations, alloimmune haemolysis (such as ABO incompatibility),
exposure to toxins (including bacterial toxins) and oxidant drugs, haemoglobinopathies,
red cell enzyme and membrane abnormalities. Often, no specific underlying cause is
found, as in the transient Infantile Pyknocytosis often seen 4-6 weeks after birth. Vitamin
E deficiency should be rare nowadays but also needs to be considered in some cases,
particularly very premature infants. It is important to look at the blood film for evidence of
haemolysis (spherocytes, cell fragment, polychromatic cells) or infection. There may be
prolonged or exaggerated jaundice.

Investigations ● Group and Direct Antiglobulin test


● Reticulocyte count
● Pyruvate Kinase screen
● Glucose-6-Phosphate Dehydrogenase screen
● Haemoglobinopathy study
● Vitamin E level
● Blood from both parents for Haemoglobin and blood film (to
evaluate red cell morphology)
● Exclude infection

Newborn ● Red Cell Transfusions as required to maintain a normal


Management haemoglobin
● Monitor and treat neonatal jaundice as indicated
● Discuss with a paediatric haematologist.
If no apparent cause is found, then further testing (such as investigations for red cell
membrane defects or unusual haemoglobinopathies) should be discussed with the on-call
paediatric haematologist.

Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD)

This is a relatively common abnormality of red cell metabolic enzymes, inherited as a sex-
linked disorder in males (although females can sometimes also be affected). G6PD is
required to protect the haemoglobin and the red cell membrane from oxidative damage.
The clinical presentation of G6PD deficiency varies. The severe forms can lead to severe
haemolysis, which can be spontaneous or after exposure to drugs or chemicals (including
fava bean and moth balls or naphthalene used as insect repellents in closets). Infection
can also precipitate haemolysis. It commonly manifests as severe jaundice in affected
male babies. G6PD is ubiquitous but is most common in South East Asia, the Indian
subcontinent, the Mediterranean area, and in tropical and subtropical Africa. Infants from
these ethnic groups who develop jaundice severe enough to require phototherapy should
be investigated.

Investigations ● G6PD screen and/or G6PD assay


❍ As red cell G6PD levels depend on the age of the

red cell, the result of the G6PD assay can be


equivocal or even normal during acute haemolysis.
If clinically appropriate, consider repeating the
G6PD study when the acute haemolysis has settled.
● FBC may show evidence of haemolysis with red cell
fragments, spherocytes, and "bite" cells

Newborn ● If confirmed to be affected, advise regarding medications


Management and other factors which may precipitate acute haemolysis
including foods.
● Advise parents of early recognition of symptoms and signs
of acute haemolysis, which can be a haematological
emergency.

Vitamin K Deficiency Bleeding (VKDB, Haemorrhagic Disease of the


Newborn)

See the Vitamin K Guideline.

This diagnosis should be considered in infants who appear to bleed excessively easily,
particularly if there is major evidence of haemorrhage (e.g. gastrointestinal or cerebral)
and it is not clear that the baby received adequate vitamin K supplementation at birth.
Investigations ● INR (Prothrombin Ratio)
❍ This is prolonged and corrects with the

administration of vitamin K.

Newborn ● Intramuscular Vitamin K 1mg.


Management

References

1 Christensen RD (Ed). Hematological problems of the neonate (1st ed). WB Saunders Co, Philadelphia. 2000
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22,
2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Normal Haematological Values


Reviewed by

Normal Haematologic Values During the First Two Weeks of Life in the Term Infant

Value Cord Blood Day 1 Day 3 Day 7 Day 14


Hb (gm/100ml) 16.8 18.4 17.8 17.0 16.8
Haematocrit (%) 53.0 58.0 55.0 54.0 52.0
Red cells (cu.mm. x 106) 5.25 5.8 5.6 5.2 5.1
MCV (m 3) 107 108 99.0 98.0 96.0
MCH (yy) 34 35 33 32.5 31.5
MCHC (%) 31.7 32.5 33 33 33
Reticulocytes (%) 3-7 3-7 1-3 0-1 0-1
Nuc RBC (cu.mm) 500 200 0-5 0 0
Platelets (1000’s/cu.mm) 290 192 213 248 252

● MCV = mean corpuscular volume


MCH = mean corpuscular haemoglobin
MCHC = mean corpuscular haemoglobin concentration

The White Blood Cell Count and the Differential Count During the First Two Weeks of
1
Life

Age Leukocytes Neutrophils Eosinophils Basophils Lymphyocytes Monocytes


Total Seg Band
Birth
Mean 18.100 11,000 9,400 1,600 400 100 5,500 1,050
Range 9.0-30.0 6.0-26 20-850 0-640 2.0-11.0 0.4-3.1
Mean - 61 52 9 2.2 0.6 31 5.8
%
7 Days
Mean 12,200 5,500 4,700 830 500 50 5,000 1,100
Range 5.0-21.0 1.5- 70-1100 0-250 2.0-17.0 0.3-2.7
10.0
Mean - 45 39 6 4.1 0.4 41 9.1
%
14 Days
Mean 11,400 4,500 3,900 630 350 50 5,500 1,000
Range 5.0-20.0 1.0-0.5 70-1000 0-230 2.0-17.0 0.2-2.4
Mean - 40 34 5.5 3.1 0.4 48 8.8
%

Haematologic Values in Low Birthweight Infants

Age of Infant
Determination 1-3 Days 4-7 Days 2 Weeks 4 Weeks 6 Weeks 8 Weeks
Birthweight less than 1200g
Haemoglobin 15.6 16.4 15.5 11.3 8.5 7.8
Reticulocytes as % of 8.4 3.9 1.9 4.1 5.4 6.1
RBC
Platelets 148,000 163,000 162,000 158,000 210,000 212,000
± 61,000 ± 69,000
Leukocytes 14,800 12,200 15,800 13,200 10,800 9,900
± 10,200 ± 7,000
Segmented 46 32 41 28 23 23
neutrophils
Band neutrophils 10.7 9.7 8.0 5.9 5.8 4.4
Juvenile neutrophils 2.0 3.9 5.3 3.6 2.6 2.0
Lymphocytes 32 43 39 55 61 65
Monocytes 5 7 5 4 6 3
Eosinophils 0.4 6.2 1.0 3.7 2.0 3.8
Nucleated RBC as % 16.7 1.1 0.1 1.0 2.7 2.0
of total RBC
Birthweight 1200-1500g
Haemoglobin 20.0 18.0 17.1 12.0 9.1 8.3
Reticulocytes as % of 2.7 1.2 0.9 1.0 2.2 2.7
RBC
Platelets 151,000 134,000 153,000 189,000 212,000 244,000
± 35,000 ± 49,000
Leukocytes 10,800 8,900 14,300 11,000 10,500 9,100
± 4,000 ± 2,900
Segmented 47 31 33 26 20 25
neutrophils
Band neutrophils 11.9 10.5 5.9 3.0 1.4 2.1
Juvenile neutrophils 5.1 2.4 2.7 1.8 1.7 1.6
Lymphocytes 34 48 52 59 69 64
Monocytes 3 6 3 4 5 5
Eosinophils 1.3 2.2 2.5 5.1 2.6 2.3
Nucleated RBC as % 19.8 0.8 0 0.4 1.4 1.0
of total RBC

References

1 From Altman, P.L and Dittmer, D.S: Blood and Other Body Fluids. Federation of American Societies for Experimental
Biology, Washington, D.C, 1961.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Handling of Small Babies Reviewed by Bronwyn Jones (NS-


ANP), Angela Warren (CCN), and
Carl Kuschel

April 2005

Introduction Scope Babies Most at Risk


Timing of IVH Haemodynamic Instability Kangaroo Care
Infant Postioning, Weighing and
Blood Pressure Management Related Documents
Optimal Haemodynamic Stability

Introduction

● Germinal Matrix - Intraventricular Haemorrhage (GM-IVH) is one of the most


frequently encountered neurological problems of the premature neonate. This
document outlines information and recommended best practice for assessing the
risks and subsequent nursing care of the infant <30 weeks gestation.

Scope

● Applies to all Nurses caring for ELBW and VLBW babies in the Newborn Service.

Babies Most At Risk

● Infants between 23 and 32 week gestation are at risk, with infants under 30 weeks
gestation being most at risk. There are, however, exceptions to this.

Timing of GM-IVH

● 0-90% of bleeds in the first 3 days.


● 7-20% in the next 4 days until <5% after 7 days.

Haemodynamic Instability

● All haemorrhages seem to start in the germinal matrix as the thin walled blood
vessels are vulnerable to damage due to disturbances in perfusion, caused by an
increase, decrease or fluctuating blood pressure. Changes in blood pressure may
occur as a result of handling, for example movement, crying, feeding, intubation,
suctioning and stimulation.
● Hypotension/hypertension is often a recurring and difficult problem exacerbated by
the fact that normal ranges for blood pressure in infants that are VLBW/ELBW has
not been firmly established.
● In very low birthweight infants during the first 48-96 hours blood pressure is
influenced by birthweight and gestational age.

Kangaroo Care

● Infants <30 weeks should not be offered cuddles or kangaroo care in the first 5
days of life.
❍ Discuss at ward round if appropriate for family to be offered cuddles to

infant >3 days old, stable and over 30 weeks gestational age.
❍ Infants that are 30 weeks and over should have their stability and disease

process considered prior to offering cuddles.


● An infant that is not expected to survive may also be an exception to these
guidelines.

Infant Positioning, Weighing and Optimal Haemodynamic Stability

Try to cluster cares to allow long rest periods particularly between stressful interventions.
The frequency and duration of handling during intensive care have been shown to
influence the occurrence and severity of hypoxaemia which can increase the risk of GM-
IVH in VLBW/ELBW infants. Disruptive tactile stimulation can precipitate a negative
physiologic chain of events and lead to intracranial pressure or cause haemodynamic
fluctuations. Excessive handling can also initiate hypoxaemia.

When changing nappies care can be taken by sliding the nappy under to avoid raising
legs as increase to intracranial pressure occurs when infants legs are lifted, especially if
above the head. Position with the head midline and the head of the bed slightly elevated.
Intracranial pressure is lowest when the head of the bed is elevated. Side lying with head
in midline to avoid twisting of the infants body also reduces the risk of increasing
intracranial pressure.

Blood Pressure Management

Monitor blood pressure diligently

1. Infants <32/40 with arterial lines have their BP monitored continuously and
recorded hourly on observation sheet.
2. VLBW/ELBW babies and sick infants i.e. <32/40 weeks ventilated, Hudson CPAP,
O2 requirement, without arterial lines may need 1-2 hourly cuff BP measurement
initially. Discuss frequency with NS-ANP/medical staff.
3. The optimal mean is decided by NS-ANP/medical staff. BP should be equal to or
greater than the gestational age in the first 24 hours.
4. Alarm limits on HP monitors should always be on and set at appropriate levels i.e.
upper level slightly above recommended mean BP and lower alarm level set at
slightly lower than desired mean BP.
5. Report fluctuations in BP, hypotension and hypertension to medical staff/NS-ANP.
6. Consider allowing recovery periods to avoid rapid BP fluctuations during handling.

Reduce fluctuations in blood pressure

1. Minimal handling and cluster cares to allow rest periods. Handle gently.
2. Refer to Suction Policy regarding babies on Hudson CPAP and IPPV. Pre-
oxygenate as indicated and allow time for SpO2 to recover between suctions.
3. ELBW infants ideally should only be warm weighed with two people to facilitate
procedure.
❍ Infants <30 weeks are not to be weighed in the first 5 days unless

requested by the medical staff or NS-ANP.


4. To avoid fluid overload, use accurate checking under RBP of rate of IV pumps.
❍ Rate of intermittent infusions e.g. blood plasma, via Graseby or IVAC pump

is also checked by two RNs and signed.


❍ Volume limit on IV pumps to be set within 10% of limit.

5. Nurse infant flat or head of bed slightly raised, not head down. Head needs to be
in line with body, not twisted so as not to increase intracranial blood flow and
pressure.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Hepatitis B Vaccination
Authorised by:
Charge Nurse Newborn

July 2002

Positive Mothers and those Hib-HepB (Comvax) 2-in-1


Information Other Related Documents
with Unknown Status Vaccine

Hepatitis B - Information

Information ● Spread through close physical contact with body fluids of


an infected person.
● The most infectious period is from several weeks before
symptoms appear until several weeks or months later.
● Carriers have the virus in their blood and can remain
infectious for many years.
● The younger a person is when Hep B infection occurs the
more likely they are to become a chronic carrier.
● Babies born to carrier mothers are at greater risk of
catching Hep B virus during birth. Baby can be protected
from Hepatitis B by having extra injections of Hep B
vaccine and Immunoglobulin (HBIG) at birth. If the
recommended immunisations are completed the baby’s risk
of becoming infected is reduced by about 95%.

Hepatitis B ● Is prepared from plasmas that contain high levels of


Immunoglobulin antibody to the surface antigen of the Hepatitis B virus. It
(HBIg) is given to all babies (including premature infants) whose
mothers are Hepatitis B antigen positive.

Storage of ● See Cold Chain Management


vaccine-

Hepatitis B - Mothers Antigen Positive and Status Unknown


Parental consent/ ● See flow chart for parental consent and vaccinations to
prescribing of give.

Hep B vaccine.
Mothers Hepatitis ● See flow chart for process – consent vaccinations and
B antigen Hep B Immunoglobulin (HBIG).
(HBsAg) status
unknown

Efficacy ● 85-95% and virtually complete protection in those who


develop antibody levels of greater than or equal to 10mlU/
ml (the protection level). At least 95% in children after 3
doses.
● The red form HNN2 then goes into the multidisciplinary
notes. Later one copy goes to the Medical Officer of
Health, Community Health.

Ordering of Hep B ● On the request form for Human Plasma Protein Products
Immunoglobulin (S405). Send to Blood Bank by chute plus a phone call.

Hepatitis B - Nursing Care of Baby whose Mother is Hep B Antigen Positive or


Status Unknown

Nursing care of ● The Nurse will ensure the following steps are carried out
baby in the nursing care for baby whose mother is Hepatitis B
antigen positive or status unknown.

Step Action
1 Strict handwashing.
2 Gloves for all cares, where contact with body fluid is anticipated.
3 Baby may have breast milk.
4 Babies greater than 32 weeks gestation bath as soon as possible, if condition
stable, using chlorhexidine surgical scrub 4%:

● Have bath water and towels on hand.


● Nurse wears long sleeve gown and gloves.

● Nurse wets hands, pours some chlorhexidine surgical


scrub 4% into hands, lathers up solution. Then using
hands cover all of baby's skin-hair (avoiding eyes and
ears)
● Place baby in bath water and rinse off the chlorhexidine.
● Dry baby.

Hib-Hep B (Comvax) 2 in 1 Vaccine - Information

This is a 2 in 1 vaccine for Haemophilus Influenza Type B (Hib) and Hepatitis B.


Haemophilus ● Haemophilus Influenzae Type B bacterium is a gram
Influenzae Type B negative coccobacillus.
(Hib) ● Hib causes meningitis, pneumonia, epiglottitis, septic,
arthritis, bacteraemia, cellulitis and empyema in infants and
young children. Mortality rate is 5% despite antibiotics and
medical care. Survivors of Hib meningitis may have a 30-
40% risk of long term neurological development impairment.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Hepatitis C Virus Reviewed by Kitty Croxson


Maternal Infection and Vertical Transmission (Virology), Lesley Voss (Paediatric
ID), Simon Rowley, and Carl
Kuschel

September
2003

Hepatitis C Virus Epidemiology Vertical Transmission Tests


Management of Pregnant Management of Infants born
Other related Documents References
Women to HCV Positive Mothers

Hepatitis C Virus

● Single-stranded negative sense RNA virus.


● Cytopathic virus, replicating in liver cells and spilling over into blood stream during
active infection.
● Damage to liver leads to steatosis, fibrosis, cirrhosis and in some cases
hepatocellular carcinoma.
● Major reason for liver transplantation world-wide.
● USA – 0.2% seroprevalence of HCV for children under 12 years of age.

Epidemiology

● Currently no tissue culture infectivity assay, so information on distribution of virus


based largely on detection of viral RNA.
● Transmission still incompletely understood. Up to 40% of infected individuals may
have no identifiable risk factors.
● >95% of infections thought to be parenteral, with injection of infectious blood the
most at risk procedure eg injecting drug users, and (pre-transfusion service
screening), haemophiliacs, transfusion recipients.
● In Western communities, < 5% of infections linked to sexual transmission or
household exposure.
● Antibodies not protective against re-infection.
● Currently no vaccine available.

Vertical Transmission

● Infrequent (as opposed to vertical transmission of Hepatitis B in the pre-vaccine


era).
● Rate approximately 6% in HCV viraemic, non-HIV infected mothers. May increase
to ~ 15% in HIV positive mothers.
● Majority of infant infections probably acquired during exposure to infectious blood
at delivery (infants not viraemic until several weeks post-delivery). However, there
are no convincing studies at this time demonstrating that Caesarean section
should be recommended.
● Transmission from breast milk has not been documented, although virus RNA can
be found in breast milk. Currently there are no recommendations concerning
breast feeding by HCV positive mothers. This should be discussed with the women
but breast feeding is not contraindicated.

Tests

● Antibody to HCV. Indicates past infection, or passive acquisition of maternal


antibody (infants).
● HCV RNA. Detects specific HCV genetic sequences by RT-PCV. Usually applied
to blood (serum). If positive, indicates ongoing active infection.
● Currently there is no reliable HCV antigen test.

Management of Pregnant Women

● Offer testing to all pregnant women at risk of HCV (eg on the methadone
programme or attending clinic for substance abuse).
● Ensure that the laboratory request is annotated " HCV screening in pregnancy."
● All antibody positive women must have HCV RNA tested.
● If positive, HIV testing must be offered also. (Note. This may become redundant
with the introduction of widespread screening for HIV in pregnancy).

Management of Infants Born to HCV Positive Women

● Since essentially no infected infants have been found viraemic at birth, testing of
cord blood is not necessary.

At 4-6 months:-

● Test for HCV RNA (HCV PCR), HCV antibody plus liver function
tests.
❍ Note: in many instances, maternal antibody will be detectable

for >12 months.

● If HCV RNA positive, refer to Paediatric Gastroenterology Clinic.


● If HCV RNA negative and HCV antibody positive, repeat antibody
test at 18 months to document clearance of antibody (and therefore
absence of infection).
● If HCV RNA and HCV antibody negative, no further follow-up is
required.
Index of ● Nursing Care of Infants Born to Hepatitis C Positive Mothers
Other
Related
Documents

References

1 Croxson M et al. Vertical transmission of Hepatitis C virus in New Zealand. NZMJ, 9 May 1997, Vol 110,
No 1043:165-7.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Hepatitis C
Nursing Care of a Baby whose Mother is HCV Authorised by:
Positive Charge Nurse Newborn

February 2006

Nursing Care of Baby

Step Action
1 Strict hand-washing and universal precautions.
2 Gloves worn for all cares where contact with body fluid is anticipated.
3 Babies greater than 32 weeks gestation if condition stable, are to be bathed
on admission (using baby soap).

4 Baby can have mother's breast milk provided the mother does not have co-
infection (e.g. with HIV) or severe liver failure but Doctor/NS-ANP need to
discuss with mother the theoretical risks.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

High Frequency Ventilation Reviewed by Malcolm Battin


(HFV)

January
2001

Making Adjustments once


Background Terminology Initial Settings on HFV
Established on HFV
Chest Radiographs Weaning Other Related Documents References

Background

High frequency ventilation (HFV) is defined by the ‘high frequency’ (2.5-15 Hz) and low
tidal volume (0.5-5 mL/kg). The tidal volume is barely greater than the dead space hence
1
alternative mechanisms of gas transport are required to explain the effect of HFV .

Indications for high frequency ventilation include

23
1. Rescue following failure of conventional ventilation (PPHN, Meconium). ,
4
2. Air leak syndromes (pneumothorax, pulmonary interstitial emphysema)
3. To reduce barotrauma when conventional ventilator settings are high.

HFV is not as yet proven to be of benefit in the elective treatment of respiratory distress
5
syndrome . Furthermore, caution is needed when HFV is used as high airway pressures
may result in impaired cardiac output causing a low BP requiring inotropic support or
volume expansion. Also some infants poorly tolerate the extra handling involved in
switching ventilators or may not respond to HFV. If no improvement with HFV consider
reverting to conventional ventilation.

Terminology

Frequency ● High frequency ventilation rate (Hz, cycles per second)


MAP ● Mean airway pressure (cmH2O)

Amplitude ● delta P or power is the variation around the MAP

Oxygenation is ● MAP provides a constant distending pressure equivalent to


dependent on MAP CPAP. This inflates the lung to a constant and optimal lung
and FiO2 volume maximising the area for gas exchange and
preventing alveolar collapse in the expiratory phase.
● Ventilation is dependent on amplitude and to lesser degree
frequency. Thus when using HFV CO2 elimination and
oxygenation are independent.

Initial settings on HFV

If you are using HFOV on the Babylog 8000plus, click here.

Optimal lung ● Set MAP 2-3 cmH2O above the MAP on conventional
volume strategy ventilation
(aim to maximise ● MAP in 1-2 cmH2O steps until oxygenation improves
recruitment of
alveoli). ● Set frequency to 10 Hz

Low volume ● Set MAP equal to the MAP on conventional ventilation


strategy ● Set frequency to 10 Hz
(aim to minimise lung ● Adjust amplitude to get an adequate chest wall vibration.
trauma)

● Obtain an early blood gas and adjust settings as appropriate.

● Changes in frequency should only be made in discussion with attending


Neonatologist.

Making adjustments once established on HFV

Poor Over
Under Ventilation Over Ventilation
Oxygenation Oxygenation

Increase FiO2 Decrease FiO2 Increase Decrease


Amplitude Amplitude
Decrease Increase
Increase MAP Decrease MAP Frequency Frequency
(1-2cmH2O) (1-2cmH2O) (1-2Hz) (1-2Hz)
if Amplitude if Amplitude
Maximal Minimal
Chest Radiograph

● Initial x-ray at 1-2 hrs to determine the baseline lung volume on HFV (aim for 7-8
ribs).
● A follow-up chest x-ray in 4-6 hours is recommended to assess the expansion.
● Thereafter repeat chest x-ray with acute changes in patient condition.

Weaning

● Reduce FiO2 to <40% before weaning MAP (except when over-inflation is evident).
● Reduce MAP when chest x-ray shows evidence of over-inflation (>9 ribs).
● Reduce MAP in 1-2cm increments to 8-9.
● In air leak syndromes (low volume strategy), reducing MAP takes priority over
weaning the FiO2.
● Wean the amplitude in 4cm H2O increments.
● Do not wean the frequency

● Consider switching to conventional ventilation when MAP <10cm H2O, Amplitude


20-25 and blood gases satisfactory.

● Suction is indicated for diminished chest wall movement indicating airway or ET


tube obstruction or if there are visible/audible secretions in the airway.
● Avoid in the first 24 hours of HFV, unless clinically indicated.
● Avoid hand-bagging during the suctioning procedure
❍ use PEEP protector and continue with patient on the ventilator.

❍ increase FiO following the suctioning procedure.


2
❍ MAP may be temporarily increased 2-3cm H2O until oxygenation improves.

References

1 Chang H K. Mechanisms of gas transport during ventilation by HFO. J Appl Physiol 1984 ; 56: 553-63

2 Clark RH et al. Prospective, randomized comparison of HFO and conventional ventilation in candidates for
ECMO. J Pediatr.1994;124: 447-54
3 Kohe et D, et al. High-frequency oscillation in the rescue of infants with persistent pulmonary hypertension.
Crit Care Med. 1988; 16: 510-6
4 Clark RH et al. Pulmonary interstitial emphysema treated by HFOV. Crit Care Med 1986; 14: 926-30

5 Bhuta T, Henderson-Smart D. Elective high frequency oscillatory ventilation vs conventional ventilation in


preterm infants with acute pulmonary dysfunction. (Cochrane Review) In: The Cochrane Library, Issue 2.
Oxford: Update Software; 1998. Updated quarterly
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guideline for Attendance at High Risk Deliveries by a Reviewed by Carl Kuschel


Specialist Neonatologist

April
2004

The need for a specialist Neonatologist to attend a delivery depends on:

1. The experience of the registrar, fellow, or NS-ANP "on call".


2. The level of concern of the obstetric staff.
3. The clinical scenario.

There should be good communication between the neonatologist and both the resident
neonatal staff and the obstetric service. During office hours a "high risk" case should be
discussed with the neonatologist "on duty" for level 3 and out of hours with the
neonatologist "on call".

If an obstetrician has concerns regarding a potential delivery and wishes a specialist


neonatologist to attend that delivery the specialist obstetrician should speak directly to
the neonatologist.

It is envisaged that:

a. Deliveries <28/40 should be discussed so the neonatologist has the option of


attending the delivery.
b. Deliveries of infants <26 weeks must be attended by a staff member with
appropriate neonatal expertise (that is, an experienced senior registrar, NS-ANP,
or specialist). This should be discussed with the neonatologist in advance. If in
doubt, the neonatologist should always be called.
c. Deliveries of infants with fetal hydrops or life-threatening congenital anomalies (e.
g. diaphragmatic hernia or other conditions) requiring immediate decisions
regarding resuscitation should be attended by a neonatologist.
d. For any case in which the infant resuscitation was unexpectedly complex or where
there is a poor response to resuscitation the attending neonatologist should be
called urgently.
The attending neonatologist should be notified shortly before or as soon as
practicable following the admission of infants to level 3 care who are:

1. <28/40, or <1000 g or ventilated or have significant respiratory disease.


2. Any sick baby causing concern for medical or senior nursing staff.
3. Any circumstance where the resident staff are inexperienced or not confident in
undertaking a treatment or procedure required.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for Paediatric Management of Infants Reviewed by Simon Rowley,


Born to HIV+ Pregnant Women Lesley Voss (Paediatric ID), and
Kitty Croxson (Lab Plus)

October
2004

Prenatal Period Post-Delivery Testing Treatment


Follow Up People to Contact Other Related Documents References

Prenatal Period

1. A paediatric consultant (Dr Rowley or Dr Kuschel) should aim to see the parent
and discuss the postnatal management of the infant with her. A Blue team
obstetrician and Obstetric Physician will usually monitor the pregnancy.
2. Maternal blood specimen should be taken for HIV PCR prior to AZT being
commenced.
If not an established patient here, send to be processed by Auckland City Hospital
Department of Virology and Immunology, LabPlus, Building 31, Auckland Hospital
(3x EDTA tubes). This will confirm that the mother's virus is detectable by PCR in
the Auckland system.
3. Confirm that AZT syrup is available at the Auckland City Hospital Pharmacy. This
will ensure availability if there is premature delivery. Liaise with paediatric
pharmacist (Brenda Hughes) 93-4136.
4. Obtain details of maternal antiretroviral treatment during pregnancy and current
HIV viral load prior to delivery.

Post Delivery

1. Vitamin K should be given intramuscularly once the baby has been bathed. The
baby is to be admitted to the postnatal ward, and the number of paediatric staff
involved in the care of the baby should be kept to a minimum.
2. Breastfeeding is contraindicated (as there is an increased risk of HIV transmission
to babies)

Testing
● Code for all lab forms: 4 letter, 6 number code - first 2 letters of the last name, first
letter of the Christian name (B if the baby is unnamed) and sex (M or F), followed
by the 6 figure birth date.

Tests
HIV Clinical
Time T Cell Antibody FBC
PCR Review
Subsets (Western
Blot)
Day 1 No longer required from cord + +
(Cord blood) blood (Pre-AZT)
Week 1 + + + + +
Week 4-8 + + + + +
(Post-AZT)
4-6 months + + +
12 months + +
18 months + +
(if still seropositive at
12 months)

● Any positive PCR test must be confirmed by repeat test to confirm


infection.

Treatment

Antiretrovirals

1. Zidovudine: start within 8 hours of delivery, and give for 6 weeks.


Term Infants 4mg/kg/dose q12h

There is no need to adjust the dose with


increasing weight.

Preterm Infants <30 1.5mg/kg/dose q12h IV


weeks GA at birth
1 or
2mg/kg/dose q12h orally

After 4 weeks, reduce dosing interval to


8-hourly
Preterm Infants ≥30 1.5mg/kg/dose q12h IV
weeks GA at birth
1 or
2mg/kg/dose q12h orally

After 2 weeks, reduce dosing interval to


8-hourly
❍ Recommend FBC prior to starting AZT and repeat at 6 weeks, if abnormal

at 6 weeks repeat at 12 weeks.


❍ Indications to stop AZT treatment include jaundice requiring phototherapy, a

neutrophil count of <750/mm3, Hb <80g/L or a platelet count <50,000/mm3.


❍ Zidovudine has special exemption under Pharmac CEC regulations to allow

the Auckland City Hospital pharmacy to dispense the discharge


medications.
2. Nevirapine if indicated 2mg/kg, single dose to be given ASAP within 3 days of
birth.
3. Lamivudine (3TC, 10mg/ml) 2mg/kg/dose b.d to start within 8 hours of delivery.
Use will be decided on by Paediatric ID team along with Neonatologist.

Prophylaxis

● If the initial PCR is positive, start Co-Trimoxazole 0.5mls/kg, daily at 6 weeks.


Stop when testing at 4 months confirms absence of HIV infection

Immunisations

● No BCG vaccination or other live vaccines should be given until it is clear that the
infant is HIV negative.

Follow Up

● Dr Rowley or Dr Kuschel will follow these babies at the Neonatal Outpatient Clinic
until 18 months, unless they are infected when care will be transferred to Dr L
Voss, Starship Children’s Hospital.

People to be contacted

● Neonatologists – Dr Simon Rowley, Dr Carl Kuschel


● Paediatric Infectious Disease Team (Dr L Voss, 93-4636 if available).
Phone as well as written consultation form should be sent.
● Virologist - Dr K Croxson, Department of Virology and Immunology, LabPlus
Building 31, Auckland Hospital, ext 6130, loc 93-4197, should be informed that the
bloods are being sent.
Index of ● Nursing Care of Infants born to HIV Positive Mothers
Related
Documents

References

1 Capparelli EV, Mirochnick M, Dankner WM, et al. Pharmacokinetics and tolerance of zidovudine in
preterm infants. J Pediatr 2003; 142:47-52.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Human Immunodeficiency Virus (HIV)


Nursing Care of Infants born to HIV Positive Mothers Authorised by:
Charge Nurse Newborn

July 2002

Nursing Care of Baby whose Mother is HIV Positive

Step Action
1 Use standard precautions.
2 Babies greater than 32 weeks gestation if condition stable, after birth bath
using chlorhexidine surgical scrub 4%:

● Have bath water and towels on hand.


● Nurse wears long sleeve gown and gloves.

● Nurse wets hands, pours some


chlorhexidine surgical scrub 4% into
hands, lathers up solution. Then using
hands cover all of baby's skin-hair
(avoiding eyes and ears) with the
chlorhexidine surgical scrub 4%.
● Place baby in bath water and rinse off the
chlorhexidine.
● Dry baby.

3 After baby bathed Vitamin K given IM in right leg (Parent consent needed).
4 Baby is not given breast milk or breastfed (as there is increased risk of HIV
transmission to baby).
5 Sample of baby’s urine sent to laboratory to test for cytomegalovirus (CMV).
6 No BCG vaccination or other live vaccines should be given until baby’s
status is clear.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Non-Immune Hydrops Reviewed by David Knight

December
2000

Fluid in two body cavities or one cavity plus oedema at birth. The prognosis depends on associated prematurity, the
underlying cause, the severity of any associated pulmonary hypoplasia and the severity of the ongoing post-natal
1
fluid accumulation (with problems of infection and malnutrition). Mortality is still up to 70%.

Resuscitation

Resuscitation and stabilisation is often difficult. It may be necessary to drain pleural effusions in the delivery room,
at the same time as resuscitating the baby. Find out about the size of pleural effusions and severity of the hydrops
2-3
from obstetric staff before delivery. It is important to prepare equipment before delivery .

Click here to see images of hydropic infants.

● The level III specialist should be informed and may well need to attend the delivery. A senior neonatal nurse
should also attend.

Associations with Non-Immune Hydrops

Cardiovascular Gastrointestinal Lymphatic Skeletal


● SVT ● Jejunal atresia ● Chylothorax ● Osteogenesis
● Heart block ● Midgut volvolus ● Congenital imperfecta
● Truncus arteriosus ● Meconium lymphangectasia ● Asphyxiating thoracic
● Coxsackie peritonitis ● Cystic hygroma of dystrophy
myocarditis ● Hepatitic fibrosis neck ● Thanatophoric
● Hypoplastic Left ● Hepatic vascular ● Noonan's dwarfism
Heart Syndrome malformations Syndrome ● Achondrogenesis
● Endocardial ● Familial cirrhosis ● Hyperphosphatasia
fibroelastosis and portal ● Saldino-Noonan
● VSD/AV canal hypertension Infective dwarfism
● Premature closure ● Parvovirus
of foramen ovale ● CMV
● Premature closure ● Toxoplasma Tumours
of PDA ● Syphilis ● Teratoma
● Tumours ● Leptospirosis ● Neuroblastoma
(rhabdomyomas) ● Chagas Disease ● Haemangioma
● Arterial calcification Genitourinary ● Congenital hepatitis
● Cardiomyopathy (e. ● Rubella
g. carnitine ● Herpes simplex Placental/Umbilical
deficiency) ● Varicella ● True knot
● AV malformations ● UV thrombosis
● Any cause of heart ● Placental
failure chorioangioma
Respiratory ● UA aneurysm

Maternal
● Congenital ● Diaphragmatic ● Diabetes
nephrotic hernia ● Preeclampsia
Chromosomal
syndrome ● Cystic ● Drugs (i.e.
● Trisomy 21 ● Urethral adenomatoid indomethacin)
● Triploidy obstruction and malformation
● 45XO (Turner's) renal dysplasia ● Hamartoma
● Many others ● Polycystic kidneys ● Tracheo- Metabolic
reported ● Renal vein oesophageal fistula ● Gaucher's Disease
obstruction ● Atresia of right ● GM1 gangliosidosis
● Vaginal and main bronchus ● Hurler's Syndrome
Dysmorphic Syndromes
uterine ● Sequestration (MP 1H)
abnormalities ● Pulmonary ● Morquio (MP IVb)
Neurological lymphangiectasia ● MP type VII
● Mediastinal ● Mucolipidosis type I
● Encephalocoele teratoma and II
● Agenesis of the Haematological ● Sialic acid storage
corpus callosum ● Twin-twin disease
● Tuberous sclerosis transfusion Other ● Galactosialidosis
● Vein of Galen ● Rhesus ● Retroperitoneal
aneurysm isoimmunisation fibrosis
● Arthrogryposis ● Feto-maternal
haemorrhage
● α-thalassaemia
(homozygous)
● Fetal anaemia or
blood loss
● G6PD deficiency
● Pyruvate kinase
deficiency

This list is not comprehensive! Also it does not give an idea of how common conditions may be.

Investigations

Many of these may have been done antenatally. Particular clinical findings may indicate other investigations for
aetiology. Target investigations at clinical features. Collect cord blood EDTA and clotted samples. Up to 50% of non-
immune hydrops remain unexplained after full investigation.

Anaemia ● Evidence of fetal anaemia.


● Maternal blood group and antibodies.
● Baby blood group and Coombs.
● Early haemoglobin/PCV.
● Maternal Kleihauer

Biochemistry ● Liver function including albumin/protein


● Renal function.

Cardiac rhythm in ● Evidence from ultrasound scans and CTGs.


utero ● Post-natal ECG + monitoring.

Fluid examination ● Protein and albumin


● Cell cytology (commonly finding marked lymphocytosis).
● Triglyceride levels after feeding started.

Placenta ● Macroscopic examination, histology and Toxoplasma PCR.


Ultrasound ● Head, heart, chest, abdomen.

X-rays ● Chest, abdomen and long bones (skeletal abnormalities and congenital infection).
● Further CT/MRI as indicated by clinical course and other results.

Infections ● Maternal or baby evidence of infections listed above.

Chromosomes
Hb electrophoresis
Metabolic testing ● Use family history as a guide.
● Look for features of possible conditions before launching into investigations for
specific conditions.

Infective causes

Parvovirus ● Fetal anaemia that may have recovered


● PCR, IgG and IgM titres
● Send baby/cord serum.

CMV ● Urine culture/PCR.


● Serum for CMV PCR.

Toxoplasma ● Maternal and baby blood, placenta and amniotic fluid PCR
● Baby/cord IgM.

Syphilis ● Maternal serology (VDRL)


● Baby/cord serology.

Congenital hepatitis ● Maternal hepatitis B serology


● Baby LFTs and liver US.

Rubella ● Maternal serology before pregnancy


● Urine ± CSF PCR.
● WBC for rubella PCR
● Serum IgM.

Herpes simplex ● WBC PCR.

Varicella ● Other features of congenital varicella.

Look for supportive evidence with long bone X-rays, cerebral US/CT and ophthalmic exam.

References

1 Fraser SH. Non-immune hydrops: no longer an automatic death sentence. Australia and NZ Perinatal Society. Perth 1997.
2 Stephenson T et al. Diagnosis and management of non-immune hydrops. Arch Dis Child 1994; 70: F151-4
3 Jones DC. Diagnosis and management of nonimmune hydrops. P452-61
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Hyperglycaemia Reviewed by Jane Harding

January
2001

Complications Criteria for Insulin Exceptions to Insulin Management of Insulin References

Complications of Hyperglycaemia

1. Undernutrition leading to growth failure


2. Osmotic diuresis leading to dehydration
3. Association with periventricular haemorrhage
4. Exacerbation of hypoxic ischemic brain injury

Criteria for use of Insulin

Link to Insulin protocol

Persistent glycosuria ≥ 2+
Tolerating <100 calories/kg/day
AND or
(see below for caloric calculations)
Blood glucose ≥ 10mmols

Exceptions to Insulin Use

i. First 72 hours of life


ii. Acute transient stress e.g. post surgery, acute sepsis etc.

Management of Insulin Infusion

i. Administer in same line as intravenous fluids, so if there are any interruptions, both
are interrupted together
ii. Starting dose usually 0.05units/kg/hr, then adjusted according to requirements
iii. Do not include insulin in the total daily fluid intake - it should be titrated on top of
the prescribed fluid intake
iv. Monitor blood glucose, initially 2 hourly, and once stable at least 8 hourly
v. Aim for blood glucose ≥4mmol with glycosuria ≤1+

Calorie Intakes

● 150ml/kg of P10 with 1g lipid gives 81 calories/kg/day


● 150ml/kg of P10 with 3g lipid gives 99 calories/kg/day
● 180ml/kg of P10 with 1g lipid gives 95 calories/kg/day
● 180ml/kg of P10 with 3g lipid gives 113 calories/kg/day

Thus a baby who is not tolerating 150ml/kg of P10 with 3g lipid, or 180ml/kg of P10 with
1g lipid would qualify for insulin infusion.

References

1 Binder ND, Raschko PK, Benda GI, Reynolds JW. Insulin infusion with parenteral nutrition in extremely low
birth weight infants with hyperglycemia. J Pediatr 1989; 114: 273-80.
2 Collins JW, Hoppe M, Brown K, Edidin DV, Padbury J, Ogata ES. A controlled trial of insulin infusion and
parenteral nutrition in extremely low birth weight infants with glucose intolerance. J Pediatr 1991; 118: 921-
7.
3 Pildes RS. Neonatal hyperglycaemia. J Pediatr 1986; 109: 905-7
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Hyperkalaemia Reviewed by Carl Kuschel

May
2003

Definition and
Aetiology Complications Treatment References
Diagnosis

Definition and Diagnosis

● Hyperkalaemia is defined as a serum potassium concentration greater than 7mmol/


l.
● Unfortunately, this is relatively common when capillary blood samples are
haemolysed. The first step should be to confirm a high serum potassium with a
non-haemolysed venous or arterial sample.
● ECG changes (peaked T waves, or arrhythmias) indicate severe hyperkalaemia
and require urgent treatment.

Aetiology

● The most important cause to investigate is oliguric renal failure.


● However, extremely premature babies may develop hyperkalaemia without
significant renal impairment due to release of potassium from catabolised cells, as
well as shift of intracellular potassium to the extracellular spaces. This may be
exacerbated by dehydration.

Complications

● In general, elevated potassium levels even above 7mmol/l are tolerated well by
neonates.
● The main complication is arrhythmia, with the most common arrhythmias being
ventricular tachycardia and sinus bradycardia.

Treatment

1. Remove K from IV (i.e. hang 10% dextrose with Na+)


2. 10% Calcium Gluconate 0.5ml/kg IV (0.1mmol/kg)
3. Sodium bicarbonate 2mmols/kg IV given over 30 minutes.
4. IV 20% - 50% dextrose so blood glucose >12mmol/L.
Then Insulin 0.3 unit/gram of glucose.
5. Resonium 0.5 - 1g/kg rectally.
3
6. Salbutamol 4micrograms/kg IV over 10 minutes . May be repeated after 2 hours.
7. Peritoneal dialysis.

References

1 Avery GB, Fletcher MA, MacDonald MG (eds). Neonatology: pathophysiology and management of the
newborn. 4th Ed. JB Lippincott Co, 1994.
2 Mildenberger E. Versmold HT. Pathogenesis and therapy of non-oliguric hyperkalaemia of the premature
infant. Eur J Pediatr, 2002; 161:415-22
3 The Northern Neonatal Network. Neonatal Formulary (3rd Ed), BMJ Publishing 2000.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for the Management of Hypoglycaemia Reviewed by Jane Harding

July
2004

Definition Diagnosis Treatment


Continuing Therapy References

Also see guideline on investigation of severe hypoglycaemia

Click here for the Glucose calculator

Hypoglycaemia is important because:

1. It is a common, readily diagnosed and readily treated problem.


2. If untreated, it may cause permanent brain damage.

Definition

Serum glucose <2.6mM. This is based on the following:

1. Glucose levels within the ‘normal’ range are not necessarily optimal.
2. There is no physiological reason why brain glucose requirements should differ
between term and preterm infants, or between the first and subsequent days of life.
3. The aim is to define a level which is safe for all babies, rather than is adequate for
most.
4. Altered electrophysiological measurements and poor long-term neurological
outcome have been reported in infants with recurrent serum glucose levels
<2.6mM.

Diagnosis

1. Monitor at-risk infants


❍ All infants <10th centile or >95th centile on customised centile charts

❍ If customised centiles are not available, all infants or birthweight < 2.5kg or

>4.5kg.
Infants of diabetic mothers

❍ Stressed infants - i.e. those with birth asphyxia, sepsis, haemolytic disease,

respiratory distress or congenital heart disease


❍ Infants with possible symptoms

2. When to monitor
❍ Measure plasma glucose at 1-2 hours of age, 4 hours, and then 4 hourly,

preferably before feeds.


3. How long to monitor
❍ If feeding well At least 12 hours
❍ Any recorded hypoglycaemia At least 12 hours after last low level

Click here to link to the flowchart for management of infants at risk of hypoglycaemia

Treatment

1. All at risk infants (see above) should receive milk feedings (either breastfeed or
formula - maternal preference) or intravenous dextrose as soon as feasible, and
always within the first 2 hours of life.
2. If glucose below 2.2mM on first testing (1-2 hours)
or 2.2-2.6mM after first 2 hours
feed immediately and recheck glucose within 1 hour.
3. If glucose below 2.2mM after first 2 hours
or below 2.6mM on more than 2 occasions
or feeds not tolerated
❍ start IV dextrose 10% at 60ml/kg/day (= 4.2mg/kg/min glucose)

❍ continue feeds if possible

❍ consider a bolus of 1-2ml/kg 10% dextrose IV

❍ recheck glucose within 1 hour

4. Recurrent or persistent hypoglycaemia not responding to above measures -


increase IV dextrose concentration or volume e.g. 12.5 or 15% dextrose and
continue feeding if tolerated.
5. For small- or large-for-gestational age infants or infants of diabetic mothers on
postnatal wards, see separate guidelines.

Continuing Therapy

Continue to monitor glucoses while IV dextrose is being gradually reduced. Rapid


reductions in glucose infusion are likely to cause rebound hypoglycaemia.

● Click here to link to the flowchart for weaning of infants receiving dextrose for
hypoglycaemia

Persistent or severe hypoglycaemia (requiring more than 10mg/kg/min of glucose or


lasting longer than 1 week) may require further investigation and management, e.g. with
glucagon, diazoxide, steroids or surgery.
Click here for the Glucose calculator
In an emergency, particularly if there is difficulty in starting intravenous glucose infusion,
glucagon 100 to 300ug/kg intramuscularly will stabilise blood glucose in most babies for
one to two hours. The dose can be repeated, but subsequent doses are much less likely
to be effective. (Glucagon mobilises glycogen stores. After the first dose, stores will
probably be depleted).

References

1 Koh THHG, Aynsley-Green A, Tarbit M, Eyre JA; Neural dysfunction during hypoglycaemia. Arch Dis Child
1988; 63: 1353-1358.
2 Koh THHG, Eyre JA, Aynsley-Green A; Neonatal hypoglycaemia - the controversy regarding definition.
Arch Dis Child 1988; 63:1386-1398
3 LaFranchi S; Hypoglycaemia of infancy and childhood. Pediatric Clin N Amer 1987; 34(4): 961-80.

4 Lubchenco LO, Bard H; Incidence of hypoglycemia in newborn infants classified by birth weight and
gestational age. Pediatrics 1971; 47: 831-8.
5 Lucas A, Morley R, Cole TJ; Adverse neurodevelopmental outcome of moderate neonatal hypoglycaemia.
Br Med J 1971; 297: 1304-8.
6 Senior B, Sadeghi-Nejad A; Hypoglycemia: A pathophysiologic approach. Acta Paediatr Scand Suppl
1989; 352: 1-27.
7 Glaser B, Thornton P, Otonkoski T, Junien C. Genetics of neonatal hyperinsulinism. Arch Dis Child Fetal
Neonatal Ed 2000; 82:F79-F86.
8 Shepherd RM, Cosgrove KE, O'Brien RE, et al. Hyperinsulinism of infancy: towards an understanding of
unregulated insulin release. Arch Dis Child Fetal Neonatal Ed 2000; 82:F87-F97.
9 Aynsley-Green A, Hussain K, Hall J, et al. Practical management of hyperinsulinism in infancy. Arch Dis
Child Fetal Neonatal Ed 2000; 82:F98-F107.
10 Rahier J, Guiot Y, Sempoux C. Persistent hyperinsulinaemic hypoglycaemia of infancy: a heterogenous
syndrome unrelated to nesidioblastosis. Arch Dis Child Fetal Neonatal Ed 2000; 82:F108-F112.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday,
May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Hypospadias Reviewed by Carl Kuschel and


James Hamill (Paediatric Surgery,
Starship Hospital)

May
2005

Incidence Definition and Description Investigations


Surgical Management Referrals References

Incidence

● Hypospadias is a very common congenital anomaly (1 in 300 male births). It is most


1
often an isolated finding but may be associated with other abnormalities.
● The incidence is increased if first degree relatives are affected. Up to 26% of male
offspring of an affected father may have hypospadias, and the risk in subsequent
2
siblings is 12%.
● It is more common in male infants who are growth restricted and premature. Other
3
risk factors include parental subfertility.

Definition and Description

Hypospadias (hypo =
below; spadon = a
fissure or a ‘hole’)
consists of some or all
of the following
features:

● Ventral
displacement of
the urethral
meatus
(hypospadias).
● Incomplete
formation of the
prepuce (dorsal
'hooding')
● Ventral
curvature
(chordee).

Urethral meatal
openings are generally
described as being:

● Anterior – where
the meatus is
near the tip of
the penis
● Middle – where
the meatus is
along the shaft
of the penis
● Posterior –
where the
meatus is near
the base of the
penis or in the
scrotum

● Early
recognition and
paediatric
urological
referral is useful
for counselling
and planning
timing of
surgery

Investigations

● The baby requires a complete examination to determine whether other external


abnormalities are present.
● Penile length should be determined
❍ Normal stretched penile length at term >2.5cm

❍ If penile length <2.5cm, refer to the Paediatric Endocrinology service for

assessment. Testosterone may be indicated.


● Renal ultrasound is not indicated for simple anterior or middle hypospadias unless
there are other features of concern (for example, dysmorphic features).
❍ Other conditions, such as an enlarged utricle, may be present particularly with

posterior hypospadias
❍ Renal abnormalities are more common with more posterior hypospadias.

Renal ultrasound is the investigation of choice initially.


● Posterior hypospadias – particularly in the absence of palpable gonads – should be
regarded as an intersex disorder and investigated appropriately.
Surgical Management

● Parents should be reassured that hypospadias is a common condition which can be


corrected with surgery.
● Surgery is performed by the Paediatric Urologists at Starship Children’s Hospital.
● Surgery is usually undertaken between 6 and 18 months, although timing will depend
on the surgeon and other factors. Often more than one procedure is required and it is
preferable to complete all stages in early childhood.
● It is critical that parents are told that circumcision should not be performed as the
foreskin remnant is required for surgical repair.
● The surgical principles are:
❍ To reposition the meatus on to the head of the penis (meatoplasty and

glanduloplasty)
❍ To straighten the chordee (othoplasty)

❍ To correct the hooded foreskin (by circumcision)

❍ To achieve all of this with an aesthetically acceptable result

Referrals

● Babies should be referred on discharge to the paediatric surgical service at Starship


Children’s Hospital.
● Send referrals to the Department of Paediatric Surgery – Fax 307 8952
● Alternatively contact a paediatric urologist directly.

References

1 Kulkarni BK, Oak SN, Patel MP, Merchant S, Borwankar SS. Developmental anomalies associated with
hypospadias. J Postgrad Med 1991;37:140-3
2 Bauer SB, Retik AB, Colodny AH. Genetic aspects of hypospadias. Urol Clin North Am 1981;8:559-64.
3 Manson JM, Carr MC. Molecular Epidemiology of Hypospadias: Review of Genetic and Environmental Risk
Factors. Birth Defects Research 2003;67(Part A):825– 36.
4 Smith EP, Wacksman J. Evaluation of severe hypospadias. J Pediatr 1997;131:344-6.
5 Shukla AR, Patel RP, Canning DA. Hypospadias. Urol Clin North Am 2004 Aug;31(3):445-60. (This entire
issue is devoted to hypospadias)
6 Anonymous. Timing of elective surgery on the genitalia of male children with particular reference to the risks,
benefits and psychological effects of surgery and anesthesia. Pediatics 1996;97(4):590-4.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Reviewed by Nicky Webster, Carl


Neonatal Hypotonia Kuschel, Salim Aftimos
(Genetics), and Melinda Nolan
(Neurology)
December
2004

Aetiology History Physical Examination Investigations References

Congenital hypotonia is a relatively common diagnosis in the newborn period. It is defined


as a subjective decrease of resistance to passive range of motion in a newborn and can
be due to a defect at any level of the nervous system.

Aetiology

Causes include (but are not limited to):

Central ● Hypoxic ischaemic encephalopathy


(most common) ● Intracranial haemorrhage
● Cerebral malformations
● Chromosomal abnormalities (e.g.
Trisomy 21, Prader-Willi syndrome)
● Congenital infections (TORCH)
● Acquired infections
● Peroxisomal disorders
● Drug effects (e.g. benzodiazepines)

Spinal cord ● Birth trauma (especially Breech


delivery)
● Syringomyelia

Anterior Horn Cell ● Spinal Muscular Atrophy


● Pompe’s disease (acid maltase
deficiency)
Neuromuscular ● Myasthenia gravis (transient/
junction congenital)
● Infantile botulism

Muscle ● Muscular dystrophies (inc. congenital


myotonic dystrophy)
● Congenital myopathies (e.g. central
core disease)

Peripheral nerves ● Hereditary motor and sensory


neuropathies

Metabolic ● Acid maltase deficiency


myopathies ● Carnitine deficiency
● Cytochrome-c-oxidase deficiency

The first goal in diagnosing the source of neonatal hypotonia is to ascertain if it is central
(upper motor neuron) or peripheral (lower motor neuron). Central causes are the most
common. This delineation will determine the investigations most likely to yield a
diagnosis.

History

● Any significant family history – affected parents or siblings, consanguinity,


stillbirths, childhood deaths
● Maternal disease – diabetes, epilepsy, myotonic dystrophy (may not be
recognised)
● Pregnancy and delivery history – drug or teratogen exposure
● Decreased fetal movements
● Abnormal presentation
● Polyhydramnios/ oligohydramnios
● Apgar scores
● Resuscitation requirements
● Cord gases
● History since delivery
❍ Respiratory effort

❍ Ability to feed

❍ Level of alertness

❍ Level of spontaneous activity

❍ Character of cry

Physical Examination

A detailed physical examination should be performed, assessing muscle tone, any


asymmetry, the infant’s strength, deep tendon reflexes (DTR), and any dysmorphic or
unusual features.

Anterior Neuromuscular
Central Nerve Muscle
Horn Cell Junction

weakness,
normal generalised weakness, weakness,
face/ eyes/
strength weakness distal>proximal proximal>distal
bulbar
normal/
decreased/ decreased/ decreased
increased normal DTRs
absent DTRs absent DTRs DTRs
DTRs +
+/-
+/-seizures fasciculations no fasciculations
fasciculations
+/- often
dysmorphic described as
features alert

+ At times babies with profound central hypotonia may have absent DTR,
therefore absent DTR at least in the first few days of life would not rule out
a central cause for the hypotonia

* Note that the presence of profound weakness as well as hypotonia


suggests a disorder of the lower motor neuron. A sign of this may be a
weak cry. Weakness is uncommon in central hypotonia except in the acute
stages.

Arthrogryposis (the fixation of joints at birth) may be associated with neonatal hypotonia,
more commonly with lower motor neuron unit or multisystem abnormalities.

Additional clues which may direct to a specific diagnosis:

● Hepatosplenomegaly – storage disorders, congenital infections


● Renal cysts, high forehead, wide fontanelles – Zellweger’s syndrome
● Hepatomegaly, retinitis pigmentosa – neonatal adrenoleukodystrophy
● Congenital cataracts, glaucoma – oculocerebrorenal (Lowe) syndrome
● Abnormal odour – metabolic disorders
● Hypopigmentation, undesceded testes – Prader Willi

Examination of the mother is also important in suspected cases of congenital myotonic


dystrophy or myasthenia gravis.

Most studies have found that central causes account for 60-80% of cases and that the
diagnosis can usually be made by a careful history and examination. However, there may
be a mixed picture. Infants with a peripheral cause for their hypotonia may be at
increased risk for problems during labour, delivery and resuscitation and develop hypoxic
ischaemic encephalopathy.
Investigations

Further investigation needs to be guided by history and examination.

● If the infant is hypotonic but has a degree of strength, a central cause is most
likely and investigations should be directed toward this.
● If the infant is hypotonic and weak a peripheral cause is possible and an early
review by the neurology service is warranted.

Central causes ● Neuroimaging


❍ Ultrasound scan in the first instance.

❍ MRI may be indicated if a structural abnormality

of brain development is suspected and to


exclude other abnormalities (for example,
evidence of HIE)
● EEG: prognostic information as to brain function, useful
clinically if seizures suspected
● Genetics review if any dysmorphic features present
● Karyotype (if dysmorphic features)
● TORCH screen
● DNA methylation studies or FISH for Prader-Willi
syndrome (if clinically indicated after a genetics review)
● Metabolic workup

Peripheral causes ● Neurology services review


● Cervical myelopathies are an infrequent cause of
hypotonia. The diagnosis is made by history and
examination. Diagnostic studies are of limited value.
● Molecular genetics – CTG repeats, deletions in SMN
gene
● Creatine kinase (levels need to be interpreted with
caution in the newborn, as levels tend to be high at
birth and increase in the first 24 hours, they also
increase with acidosis). If elevated in an early sample,
repeat after a few days.
● Nerve conduction studies and muscle biopsy
(Depending on clinical situation, may be delayed until
around 6 months of age as neonatal results are difficult
to interpret)

References

1 Fenichel GM. Neonatal Neurology 3rd edition. Churchill Livingston Inc. 1990

2 Paro-Panjan D, Neubauer D. Congenital hypotonia: is there an algorithm? Journal of Child Neurology;


Jun2004, Vol.19 (6): 439-43
3 Prasad AN, Prasad C. The floppy infant: contribution of genetic and metabolic disorders. Brain and
Development; Oct 2003, Vol.25(7): 457-76
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Neonatal Encephalopathy Reviewed by Malcolm Battin


(NE)

November
2004

Long Term Follow-Up


Background Initial Management Ongoing Management References
and NWH Audit

See also: Seizure guideline Head cooling Metabolic Disease

Background

Neonatal Encephalopathy (NE) is “a clinically defined syndrome of disturbed neurological


function in the earliest days of life in the term infant, manifested by difficulty with initiating
and maintaining respiration, depression of tone and reflexes, sub normal level of
consciousness and often seizures” 1. NE occurs in approximately 3.5 - 6/1000 live births
and usually affects the full term infant. The terminology NE is preferred to Hypoxic
Ischemic Encephalopathy (HIE) as it is not always possible to document a significant
hypoxic-ischemic insult 2and there are potentially several other aetiologies 3, 4.
Specifically, it is important to exclude metabolic disease, infection, drug exposure,
nervous system malformation and neonatal stroke as possible causes of the
encephalopathy. The requirement for investigation to exclude these possibilities will
depend on the presentation, history and clinical features of the individual case.

Three clinical stages of encephalopathy are described.

Stage 1 ● Duration < 24 hours with hyperalertness


● Uninhibited Moro and stretch reflexes
● Sympathetic effects
● Normal electroencephalogram.
Stage 2 ● Obtundation
● Hypotonia
● Decreased spontaneous movements with or
without seizures.

Stage 3 ● Stupor
● Flaccidity
● Seizures
● Suppressed brain stem and autonomic functions
● The EEG may be isopotential or have infrequent
periodic discharges.

● Stage 3 or persistence of stage 2 for more than seven days or failure of the EEG
to revert to normal is associated with neurodevelopmental impairment or death 5.
● Full-term infants who develop long-term neurologic sequelae from intrapartum
asphyxia may not have low Apgar scores but will demonstrate neurological
dysfunction within 48 hours.

Initial Management

1. Adequate resuscitation should be promptly instituted at birth. Aim to keep oxygen


saturation > 95% in term infants.
2. Cord gases should be collected
3. Apgar scores : a low Apgar score indicates an abnormal condition at birth but it is
not exclusive to asphyxia and drug exposure, trauma, hypovolemia, infection, or
congenital anomalies should be excluded.
4. A note should be made of
❍ the time for respiration to be established, and

❍ the return of tone as this may help indicate the severity of the insult.

❍ Also slow recovery of the heart rate despite adequate resuscitation may

indicate a severe insult and meconium staining of umbilical cord and skin
suggests prolonged exposure to meconium (> 3 hrs).

Ongoing Management

Once oxygenation is established management is supportive.


Note: If the clincal course is not typical of a hypoxic-ischaemic insult, consider other
causes (possible other causes include [but are not limited to] metabolic disease, infection,
drug exposure, CNS malformation, or neonatal stroke)

1. Monitor blood gases, glucose, urea & electrolytes, creatinine and fluid balance.
2. If metabolic acidosis is severe or persistent then sodium bicarbonate may be used
but caution is advised as rapid infusion increases serum osmolality and
alkalisation may decrease cerebral blood flow.
3. Inotropes and volume expansion may be cautiously used to maintain blood
pressure and renal blood flow. Hypotension and low cerebral flow may be
associated with adverse neurologic outcome but the loss of cerebral
autoregulation makes hypertension equally hazardous.
4. Acute tubular necrosis or the presence of inappropriate ADH secretion affect fluid
output and thus fluid overload is a distinct but avoidable hazard. Urine output must
be carefully measured and urinary cateterisation should be considered.
5. Other organ impairments such as persistent fetal circulation require specific
measures. Echocardiogram will help to rule out structural cardiac disease and will
assist with assessment of cardiac function.
6. Seizures require prompt treatment as cerebral oxygen use is increased almost
fivefold during a seizure.
7. The use of mannitol or steroids for either the early cerebral oedema or increased
intracerebral pressure is not supported by any controlled studies.
8. All infants should have serial clinical neurologic assessment.
9. For infants with Stage 2 or Stage 3 NE, further investigations should be performed
to assist with prognosis. Every attempt should be made to co-ordinate
appointments.
❍ Where possible an EEG should be performed at approximately 7 days of

age (Auckland Hospital ext. 7524).


❍ Imaging
6 should be performed to assist with exclusion of haemorrhage
and other intracerebral abnormalities.
❍ Cerebral ultrasound scans provide little additional information regarding

prognosis. Doppler studies suggest that a resistive index of less than 0.5-
0.6 is consistent with the diagnosis of HIE.
❍ CT scanning may be useful to exclude haemorrhage and may assist with

prognosis. Ring Starship Hospital CT scanning on ext. 25132.


❍ MRI may provide prognostic information. Abnormalities of the thalami and

basal ganglia are associated with an increased risk of subsequent abnormal


developmental outcome. Discuss with the on-duty paediatric radiologist
at Starship Hospital.
■ Because MR demonstrates findings similar to CT and has greater

inter-observer agreement, it appears that MR is a superior test to CT


in determining brain abnormalities in the term neonate 7.
■ Furthermore, since MR eliminates the use of ionizing radiation, a

putative cause of malignancy, it should be the standard in neonatal


brain imaging.
10. Recruitment to the Selective Head Cooling Study has now been completed and
results are awaited.

Long term follow up and audit of Perinatal Asphyxia outcome of at NWH

Full term infants who suffer from Grade 2 or 3 encephalopathy are known to have a high
incidence of neurologic damage. A systematic follow up of these infants born at NWH is
necessary to feed back to those involved with the initial care. In order to obtain this
information ALL TERM AND POST TERM INFANTS WITH CLINICAL SEIZURES OR
STAGE 3 encephalopathy should have a psychometric assessment at 18 months in the
Child Development Unit at NWH.
This definition is clear cut and has the advantage of simplicity. Most of the infants with
seizures will have had moderate-to-severe NE. Seizures due to metabolic problems or
meningitis are rare - but these infants also frequently have an adverse outcome.

The parents of all term infants who have had clinical seizures should have a follow up
process defined, preferably at a discharge planning meeting. Dependent on the clinical
state and consultant decision these infants should have a psychometric assessment at 18
months of age, in the Child Development Unit at NWH. Referrals should be sent to Dr A
Dezoete after the discharge planning meeting, with the name, address and telephone
number of the infant's parents and a contact person (usually grandparent). If the
paediatrician following these infants is not from NWH they should be notified of the
provision of such an assessment and be told that this is done for audit purposes.

A neurological examination should be done at 12 months of age, either by the


paediatrician who provided care in the neonatal period or the paediatrician providing care
at 12 months of age. A copy of this neurologic examination should be sent to the Director
of the Child Development Unit for inclusion in the annual report.

References

1 Nelson KB, Leviton A. How much of neonatal encephalopathy is due to birth asphyxia? Am J Dis Child
1991;145(11):1325-31.
2 Edwards AD, Nelson KB. Neonatal encephalopathies. Time to reconsider the cause of encephalopathies.
[comment]. BMJ 1998;317(7172):1537-8.
3 Badawi N, Kurinczuk JJ, et al. Antepartum risk factors for newborn encephalopathy: the Western
Australian case-control study.[comment]. BMJ 1998;317(7172):1549-53.
4 Badawi N, Kurinczuk JJ, et al. Intrapartum risk factors for newborn encephalopathy: the Western
Australian case-control study.[comment]. BMJ 1998;317(7172):1554-8.
5 Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and
electroencephalographic study. Arch Neurol 1976;33:696-705
6 Ment LR, Bada HS, Barnes P, et al. Report of the Quality Standards Subcommittee of the American
Acedemy of Neurology and the Practice Committee of the Child Neurology Society. Practice Parameter:
Neuroimaging of the neonate. Neurology 2002; 58:1726-38.
7 Robertson RL, Robson CD, Zurakowski D, Antiles S, Strauss K, Mulkern RV. CT versus MR in neonatal
brain imaging at term. Pediatr Radiol 2003 Jul;33(7):442-9. Epub 2003 May 13
8 JJ Volpe. Hypoxic-ischemic encephalopathy. In Volpe Neurology of the Newborn.

9 Levene MI. Management of the asphyxiated full term infant. Arch Dis Child 1993;68:612-6
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Vaccinations
Authorised by:
Charge Nurse Newborn

July 2002

Introduction Index of Related Documents

This Document

● This document covers the following topics relating to the administration of


immunisations and nursing care for baby’s exposed to infections.

Introduction

Purpose The following policy/recommended best practices outline the way


in which immunisations are administered to ensure safety and
best outcome.
Scope Applies to all Nurses who:

1. Are required to administer Hepatitis B vaccination and Hep


B Immunoglobulin after birth.
2. Have completed the Vaccination Programme Training to
administer immunisations to infants at six weeks and three
months in Newborn Services.
3. BCG immunisations can only be given by gazetted nurse.
See page 24.
4. Care for infants with infections (or contact with infections in
Newborn Services).

Parental consent As outlined in each individual RBP.


and prescribing
Newborn Services Clinical Guideline

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Any printed version can not be assumed to be current. Printed copies of this document are valid for
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The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Vaccination Schedule Authorised by Charge Nurse


Newborn and Dr Liz Wilson,
Paediatric Infectious Diseases

August 2005

Hepatitis B Vaccine and Hepatitis B Vaccine Routine Vaccination BCG


Hepatitis B Immunoglobulin Schedule
at Birth
Guideline for GPs - Infants Infants with Chronic Lung Siblings References
<1000g or <29 weeks Disease or Congenital Heart
Disease

Hepatitis B Vaccine and Hep B Immunoglobulin (HBIG) at Birth


Hepatitis B Vaccine

a. Mother HbsAg positive


i. Infant should receive HBIG (<12 hours but some effect up to 72 hours),
dose 100iU (0.5ml) IM given in right leg.
ii. Vaccinate as soon as possible after birth.
Dose 5.0mcg = 0.5ml IM in left leg.
iii. Recommend follow up serology in 3-6 months to confirm status as vaccine/
HBIG only 95% effective at preventing transmission.
iv. Need consent signed in two places on the National Hepatitis B
immunisation programme form
(a) for the Hep B vaccine
(b) for the Hep B immunoglobulin
then chart on drug sheet.
b. Mother's status unknown
i. Infant should receive HBIG (<12 hours but some effect up to 72 hours),
dose 100iU (0.5ml) IM given in right leg.
ii. Vaccinate as soon as possible after birth
Dose 5.0mcg = 0.5ml IM in left leg.
iii. Need consent signed in two places on the National Hepatitis B
immunisation programme form
(a) for the Hep B vaccine
(b) for the Hep B immunoglobulin
then chart on drug sheet.
c. Mother HbsAg negative
i. Vaccinate at 6 weeks, 3 months, 5 months if weight >= 2000g at time of
dose, 2.5mcg = 0.25ml IM.
d. Follow-up doses for infants who are born to mothers who are Hepatitis B positive
or of unknown status

i. At 6 weeks - Hib-HepB (Convax) 0.5ml IM given in left leg


ii. At 3 months - Hib-HepB (Convax) 0.5ml IM given in left leg
iii. At 5 months - HepB II 2.5mcg IM given in left leg.

Routine Schedule for All Infants

Age Vaccine Dose Site


DTaP - IPV 0.5ml Right Leg
Hib - Hep B 0.5ml Left Leg
6 Weeks
2 days after above
MeNZB 0.5ml
vaccines
DTaP - IPV 0.5ml Right Leg
Hib - Hep B 0.5ml Left Leg
3 Months
2 days after above
MeNZB 0.5ml
vaccines
● After discussion with Registrar/NS-ANP, Parent to countersign on Stat page of
Medication Chart
● The 6 week and 3 month vaccinations are only administered by a Vaccination
Team member and ideally checked by another Vaccination Team member.
Vaccinations will be done ideally Mon – Fri between 1000 and 1530 hours.
● Paracetamol will not be given routinely. However, if the baby develops a
temperature >37.5° C, inform the Registrar/NS-ANP and a stat dose of
paracetamol may be charted. Dose 10mgs/kg.

BCG ● If the baby meets criteria and is over 2000grams, BCG


consent form is signed by parent
● Doctor charts on stat page of medication chart – BCG
0.05mls Intradermally.
● Will be given by Gazetted Nurse.

● Current recommendation is that neonatal BCG will be


offered to those infants at increased risk of tuberculosis, i.e:

a. Will be living in a household containing a


person who has arrived in New Zealand
within the previous five years from any
country with a high incidence of tuberculosis
(this includes most countries outside North
America, Australia and Western Europe or
where there will be visitors to the household
from high risk countries).
b. Will be living in a household containing a
person with either current TB or history of TB.
c. Will be living in a high incidence area of NZ
where all neonates are offered BCG.

● These infants need to be identified prior to discharge and


ideally vaccination given in hospital or arrangements made
for referral to a Public Health Nurse Community BCG clinic.
● * Contraindications
❍ Sick infants.

❍ Infants < 2000g.

❍ Infants where an immuno-deficiency is suspected.

● Baby must weigh ≥2000g.


● Dose 0.05ml intradermally
NOTE: 1. See below Guidelines for GPs Immunisation Schedule for
Babies <1000 grams or <29 weeks.
2. See further information – Individual Policy – Nurses
Immunisation/Infection Policy.
3. For further information see MOH Immunisation Handbook.

Guidelines for General Practitioners - Immunisation Schedule for Babies


<1000 grams or <29 weeks

● If babies are >1000 grams AND ≥29 weeks routine schedules apply.

Age Vaccine Dose Due Date Date Given


DTaP – IPV 0.5mls IM Right Leg
6 Weeks
Hib – Hep B 0.5mls IM Left Leg
DTaP – IPV 0.5mls IM Right Leg
3 Months
Hib – Hep B 0.5mls IM Left Leg
DTaP – IPV 0.5mls IM Right Leg
5 Months
Hib – Hep B 0.5mls IM Left Leg
And Blood test (micro red top tube) to check sero conversion antibody levels of Hep B
>10mIU/ml (the protective level)

If sero conversion is not found give the following


6 Months Hepatitis B 5mcg IM Left Leg
7 Months Hepatitis B 5mcg IM Left Leg
8 Months Repeat blood test on baby and advise parents of result.

For Babies with Chronic Lung Disease or Cardiac Anomalies

At least 6
months
old and
Influenza Vaccine
prior to the
Influenza
season
1 month
Influenza Vaccine
later
Then annually
N.B.: This differs from routine schedule in offering an extra Hib dose at 5 months
to allow for poorer sero conversion to Hib in premature babies.

Siblings

● Note that the vaccination status of siblings should be checked.


● Siblings should be fully vaccinated, particularly for pertussis.
● For infants with Chronic Lung Disease who are receiving the Influenza vaccination,
siblings should also be considered for Influenza vaccination (although the family
may have to pay for this unless the siblings have a chronic medical condition)

References

1 NZ Immunisation Handbook, Ministry of Health 1996

2 1997 Red Book, Report of the Committee on Infectious Diseases


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Management of Infants of Diabetic Mothers on the Reviewed by Simon Rowley


Postnatal Ward

July
2004

See also Guideline on Management of Hypoglycaemia

See also Hypoglycaemia on the Postnatal Ward

● These babies are at risk of hypoglycaemia.


● Routine blood glucose measurement should have been requested by the LMC or
paediatrician within the first hour following birth and 4-hourly or pre-feed thereafter
(whichever comes first).
● All blood glucose measurements should be performed by the Laboratory.
● Bedside testing methods (BM-stix, Precision-G monitors) are not reliable at
detecting hypoglycaemia.
● Baby should be closely observed for signs of hypoglycaemia, e.g. jitteriness.
● Feeding should be commenced early; first feed within one hour of delivery and
thereafter at least 3 hourly.
● Either breast or formula feeds (maternal preference) can be given.
● Complementary feeds are not necessary unless the baby's blood glucose falls to
<2.6mmol/L.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

INIS (International Neonatal Immunotherapy Study) Reviewed by Ana Kennedy and


Study Information Malcolm Battin

February
2006

Eligibility Consent Prescribing Pre-administration Checks


Administration of the Study
Monitoring Complications or Problems Storage
Drug

Eligibility

Proven, or suspected, serious infection

AND

<1500grams
OR
Positive Blood Culture, CSF or usually sterile body
fluid
OR
on a ventilator

AND

On Antibiotics

Consent

● Informed consent required.


● Parent signs Agreement for INIS Study.

Prescribing of INIS Study Drug

● Order INIS Study Drug 8.3 ml/kg over 4 hours (may be slowed to 6 hours if
reactions occur).
❍ Weight should be written on the drug chart so that the dose can be checked.

● Second dose is to be given 48 hours after start of 1st dose (can be as early as 36
hours if required).
● After consultation with New Zealand Blood Service (
Cellphone and Fax Details ), fax a copy of Drug Administration
Record to NZBS.
● With larger babies and older babies consider Frusemide 1 mg/kg half way through
transfusion.
● INIS Study Drug is prescribed on the drug administration record on the single dose
section. Both doses are to be charted at the same time.
● It is also recorded in patient’s multidisciplinary clinical records.

Preadministration Checking

● INIS Study Drug for INIS patient comes in pre-primed BD syringe and
infusion set, the entire amount is to be given.

Step Action
1 The study drug must be checked by two Registered Nurses with current IV
certificates.
2 Check consent for INIS Study is signed by parent.
3 Baby’s identity - the baby’s identification band is checked against study drug
syringe label.
4 Check prescription order and amount to be given.

Administration of Study Drug

For specific information on the immunoglobulin preparation which may be used, click here.

Step Action
1 Should not be filtered.
2 Needs dedicated line; double lumen UVC OK.
Do not put through a long line as it may clot line.
3 Syringe pump to be lower than level of baby
4 If baby is charted Frusemide give via the injection port. (Flush with saline
before and after giving Frusemide.)

Monitoring

Step Action
1 Before commencement of study drug, baseline recordings of temperature,
heart rate, respirations and blood pressure will be taken and then repeated 15
minutes after commencement of study drug.
2 Temperature, heart rate and BP will be recorded hourly.
3 Record on normal observation chart if space allows. If not enough space then
record on blood transfusion record and make a note on the bedside
observation chart that you have recorded the vital signs on the blood
transfusion record.

Complications/Problems

● Adults sometime react to IVIG with fall in blood pressure. Baby should be watched
carefully particularly at the start of the infusion.
● Most patients have no side effects at all.
● Low pH should be considered in sick babies with acid/base problems.

Adverse Most patients have no side effects.


Reactions
Symptoms The following symptoms may occur.

● Hypotension, facial flushing or pallor, dyspnoea, non-urticarial


skin rash, itching, vomiting.
● May get delayed adverse reactions to Intragam P after the
infusion has stopped but usually within 24 hours.
● The low pH of IVIG should be considered in any sick babies
with acid/base problems.
● Undiluted, it is hyperosmolar. If the baby has high osmolarity or
low pH, there is a potential problem.

Follow the steps below to ensure best outcome for the infant.

Step Action
1 If any reaction to INIS study drug, it tends to be related to the infusion rate and
is most likely to occur in the first hour of infusion.
2 Stop the infusion temporarily.
3 Inform Doctor/NS-ANP.
4 Wait until infant has improved clinically (5-10 minutes).
5 Doctor/NS-ANP orders INIS Study Drug to be recommenced at a slower rate.
6 All adverse reactions should be reported to Dr Malcolm Battin, Prof. Jane
Harding, Dr Frank Bloomfield, or Ana Kennedy.

Storage
● In medication refrigerator in NICU for 24 hours (syringe will have expiration date
and time).
● Protect from light.
● Refrigerate at 2° to 8°C. Do not freeze.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Intravascular Catheters
Authorised by:
Charge Nurse - Newborn

November 2003

Purpose Scope Other Related Documents Associated Documents

Purpose

To ensure the best outcome for babies in the Newborn Service.

● The insertion and use of all lines


● Standard fluid regimes and practices
● Standard infusion lines
● Drug administration
● Monitoring procedures
● Blood sampling, including blood gases
● Possible complications of fluid/line therapies

Scope

Applies to all nurses working in Newborn Services.

Associated Documents

Type Document Title(s)


NW Nursing & ● Skin Care of the VLBW Infant
Midwifery Practice ● Baby Safety RBP
Manual
References ● Skinner J, Milligan C, Hunter S, Hey E (1992). Central
venous pressure in the ventilated neonate. Arch Dis
Child. Vol 67, Pages 374-377.
● Chair H, Kuhn M, Baum V (1994). Inferior vena caval
pressure reliability predicts right atrial pressure in
paediatric surgical patients. Critical Care Medicine. Vol
22, No 2, Page 219.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Intravenous Cannulation
Overview Authorised by:
Charge Nurse - Newborn

April 2006

Purpose Scope Criteria for Certification Maintenance of Certification

Purpose

● The following policy/RBP outlines the criteria for certification of nurses undertaking
IV cannulation within Newborn Services to ensure safety and best outcome.

Scope

● Applies to all Nurses applying to do IV cannulation within Newborn Services

Criteria for Certification

1. Must have worked within the newborn service at least 12 months and have
completed the Level III Care Competency booklet.
2. View DVD/video on ‘Intravenous Cannulation Insertion’.
3. Read teaching package and pass written test.
4. IV insertion to be demonstrated by a staff member on the IV Certification list.
5. Nurse is to be supervised/instructed for IV insertions by a certified IV cannulation
nurse. Three successful IV insertions are to be witnessed and signed off by the
supervising nurse.
6. IV cannulation certificate issued.

Maintenance of Certification

On a 2 yearly basis

1. Show proof of attendance at an education session on IV therapy.


2. Complete a competency review test.
3. Show documentation of recent IV insertion signed off by IV certified nurse.
Newborn Services Clinical Guideline

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Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Intravenous/Medication Certification
Authorised by:
Charge Nurse - Newborn

July 2004

Purpose IV Update Process Associated Documents

Purpose

● To ensure all staff have attained competency for checking/giving IV fluids and
medications and have an understanding of medications commonly used in the
service.

IV Update Process

Stage Description
1 Clinical Nurse Educators ensure all nursing staff have an understanding of
common medication (IV and oral) and IV therapy use in the Newborn service.
2 Coaching is provided for all new staff on IV and oral medications and IV
therapy.
3 Extra coaching and support is provided for staff having problems or when
errors are made with IV therapy or medication.
4 Staff must complete and pass successfully:

● an IV/medication level II test within four weeks of starting in Newborn


Service.
● a level III IV/medication test within four weeks of completing level III part
1 orientation.
● an annual IV/medication update test.
5 ● Clinical Nurse Educators and Senior Nursing staff assist with updates of
the Drug Protocols as required.
● IV/Medication tests are updated as required to ensure all staff are skilled
in current drugs or therapies used in the Newborn Service.

Associated Documents

Type Document Title(s)


Board Policy ● IV Medication Information
● Newborn Drug Protocols
● IV/Medication Test

Hospital Policy ● N/A


Newborn Services Drug Protocol

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Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Compatibilities for IV Y-site Administration Prepared by Brenda Hughes


Clinical Pharmacist,
Dept. Of Pharmacy, Auckland Healthcare

May 1999

● The compatibility data in the chart apply to drug concentrations as used in the protocols of Newborn
Services, National Women's Hospital.
● Where greater concentrations are used, contact the Pharmacy for compatibility advice

Compatible (at Y-site only) X Incompatible ? Unknown

Numbers below refer to references. Symbols are explained immediately below the table.

Caffeine Fentanyl Heparin Morphine NaHCO3 IVN


Aminophylline Dobutamine Dopamine Indomethacin Prostaglandin Intralipid
pH 2.0- pH 4.0- pH 5.5- pH 2.5- pH 7.0- pH
pH 8.8-10.0 pH 2.5-5.5 pH 2.5-4.5 pH 6.0-7.5 E1 pH 5.5
3.0 7.55 8.0 6.0 8.5 5.5-6.5

Aminophylline X X X
pH 8.8-10.0
? ? ? ?
1 1 +++ 1 12 ++ 10 + 21 13

Caffeine X X
pH 2.0-3.0
? ? ? ? ? ? ? ? X
2 4

Dobutamine X ? X X
pH 2.5-5.5
? ? ? ?
1 1 *** 11 5 1 20

Dopamine X X
pH 2.5-4.5
? ? ?
1 1 1 11 1 + 10 1, 3 20

Fentanyl
pH 4.0-7.55
? ? ? ? ? ? ? ? ?
1 20

Heparin
pH 5.5-8.0
? ? ? ? ?
+++ 1 1 1 *6 + 10 #1

Indomethacin X X X X X X X
pH 6.0-7.5
? ? ? ?
2 11 11 8, 9 11 11 8, 9

Morphine X ?
pH 2.5-6.0
? ?
12 5 1 *6 8, 9 + 10 1, 18 20 **15

Prostaglandin X
E1
? ? ? ? ? ?
++ 10 + + 10 + 10 + 10 7

NaHCO3 X X X
? ? ? ? ? ? X
pH 7.0-8.5 1 1, 3 11 1, 18

IVN X X X
pH 5.5-6.5
? ? ? ?
21 4 20 20 20 11 20

Intralipid X X ? X
pH 5.5
X ? ? ? X ?
13 #1 8, 9 ** 15 7
IVN = Intravenous Nutrition
+ = these drugs have a negligible effect on alprostadil (PGE 1), but the reverse not studied.
++ = in sodium chloride 0.9%
+++ = in glucose 5%
* = morphine ≤5mg/ml
** No conclusive data
*** conflicting results in studies (16, 19)
# destabilisation of fat emulsion has been noted at heparin 5 iU/ml (14) & 0.5 iU./ml (17) when co-infused
with TPN containing Ca++

Concentrations of Drugs used in NICU

Drug Concentration Used in NICU


Aminophylline 5mg per mL
Caffeine base 10mg per ml (Caffeine citrate 20mg per
mL)
Dobutamine 0.05 to 3.5 mg per mL
Dopamine 0.05 to 3.5 mg per mL
Fentanyl 1.0 to 15.0 mcg per mL
Heparin 0.5 to 2.0 units per mL
Indomethacin 0.5 to 1.0 mg per mL
Morphine 0.01 to 2.0 mg per mL
Prostaglandin (PGE1) 3.0 to 6.0 mcg per mL
Sodium bicarbonate 0.5 mmol per mL
Parenteral Nutrition
Intralipid 20%

References

1 Trissel LA, (ed). Handbook on Injectable Drugs (7th ed.). Bethesda: American Society of Hospital Pharmacists,1992.
2 Indocid P.D.A. Data Sheet. Auckland: Merck Sharp & Dohme (NZ) Ltd., 1997.

3 Dopamine data sheet. Victoria: F.H.Faulding & Co.Ltd,1992.

4 Roiall V. (Personal Correspondence). McGaw Biomed, August 1997.

5 Hasegawa G, Eder J. Visual compatibility of dobutamine HCl with other injectable drugs. Am J Hosp Pharm 1984;41: 949-51.

6 Baker DE,Yost GS et al. Compatibility of heparin sodium & morphine sulphate. Am J Hosp Pharm 1985;42:1352-5.

7 Little H. (Personal correspondence). Baxter Healthcare Ltd. 17 July 1996.

8 Indomethacin data sheet. West Point: Merck&Co.Inc,1994.

9 Reynolds JF, (ed). Martindale - The Extra Pharmacopoeia(30th ed). London: The Pharmaceutical Press,1993 .
10 Saunders J. (Personal correspondence) .Pharmacia & Upjohn.Aug.1996

11 Ishisaka D, Van Vleet J, et al. Visual compatibility of indomethacin sodium trihydrate with drugs given to neonates by
continuous infusion. Am J Hosp Pharm 1991; 48: 2442-3
12 Dasta JF, Hale KN et al. Comparison of visual and turbidimetric methods for determining short-term compatibility of
intravenous critical -care drugs. Am J Hosp Pharm.1988; 45:2361-6.
13 Gillies IR. Physical stability of Intralipid following drug addition. Aust J Hosp Pharm 1980; 10(3):118-120.

14 Johnson O, Washington C, et al. The destabilization of parenteral feeding emulsions by heparin. Int. J of Pharmaceutics.
1989;53: 237-240.
15 Little H. (Personal correspondence). Baxter Healthcare Ltd. June 1996.

16 Schilling CG. (Correspondence). Compatibility of drugs with a heparin-containing neonatal total parenteral nutrient solution. Am
J Hosp Pharm 1988; 45:313-4
17 Raup P, Von Kries R. et al. Incompatibility between fat emulsion and calcium plus heparin in parenteral nutrition of premature
babies. Lancet 1988; 1:700.
18 Zenk KE. Y-Site compatibility of drugs commonly used in the NICU. Neonatal Pharmacology Quarterly 1992; 1(2): 13-22.

19 Hasegawa GR, Eder JF. Dobutamine-heparin mixture inadvisable. Am J Hosp Pharm 1984; 41:2590-1.

20 Veltri M, Lee C. Compatibility of neonatal parenteral nutrient solutions with selected intravenous drugs. Am J Health-Syst
Pharm 1996; 53:2611-3.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Parenteral Nutrition Guidelines Reviewed by Carl Kuschel

July
2004

Composition of
Indications Lipid Emulsions Parenteral Vitamins References
Solutions

See also the Individualised Solution Worksheet for calculating individualised IVN
solutions.

● When enteral feedings are not possible, the use of parenteral nutrition is essential
for the care of the sick newborn.
● The goals of parenteral nutrition are several-fold:

1. to promote nitrogen retention and protein sparing,


2. to provide energy for metabolic processes, and
3. to establish growth and maturation during the critical postnatal
period.

● The premature newborn has limited glycogen and fat stores, which become rapidly
depleted with starvation.
● Sick premature and term newborns generally require more than 70kcal/kg/day and
2.5 to 3.5g/kg/day of amino acids to support growth and nitrogen retention as
compared with the intrauterine rate.

Indications for Parenteral Nutrition

● The premature infant who weighs less than 1500g and who has respiratory
distress or other contraindications to enteral feedings should be started on
intravenous glucose during the first hours of life.
● Electrolyte and calcium supplementation should begin by 12 to 24 hours after birth
and amino acids should be started by 2 days of age.
● Trace elements are automatically added to all standard solutions (P10, N10,
P7.5) but need to be specifically requested for individualised solutions ("special"
solutions).
● Heparin is added to all intravenous nutrition solutions but can be omitted on
specialist orders if felt to be contraindicated.
● Larger premature and sick term newborns may be maintained on only glucose and
electrolyte solutions, if is anticipated that full enteral feedings will be tolerated by 5
to 7 days of age.

Parenteral Lipid Emulsion

● Since VLBW prematures develop biochemical evidence of essential fatty acid


insufficiency within 3 days of fat-free nutrition, low doses (1g/kg/day) of
intravenous lipid should be started within 3 days of starting parenteral nutrition,
even if hyperbilirubinaemia requiring phototherapy is present.
❍ If the serum bilirubin is >50% of the level requiring exchange transfusion,

lipid should be restricted to 1g/kg/day.


● Intralipid is highly susceptible to oxidation causing lipid hydroperoxides which are
cytotoxic. Elevated levels can be formed during clinical use in ambient light,
especially when intralipid infusion is combined with phototherapy.
❍ This may be prevented by covering the intralipid by aluminium foil during

1
light exposure.
● 20% Intralipid emulsion 1 to 3g/kg/day - over 24 hours (1g provides 10Kcal)
● Syringes of intralipid will be stored in the fridge in NICU.

Parenteral Vitamins

● To maintain vitamin A and E levels near to recommended values, multivitamin


Paediatric solution 2ml/kg/day, is added to the intralipid and infused over the 24
hour period. 2
● Consultant advice should be obtained as to when oral multivitamins may be given
instead of parenteral. In most cases this should be done when the baby is
tolerating at least 30% of the feed orally.

Composition of Standard IVN Solutions

Reformulated as of Preterm Infants Term


November 2004 Infants
P5 P7.5 P10 N10
Protein g/L 10 15 20 20
Nitrogen g/L 1.6 2.4 3.3 3.3
Amino acid g/L 11 16 21 21
Glucose g/L 50 75 100 100
Sodium mmol/L 15 20 29 15
Potassium mmol/L 15 20 30 15
Chloride mmol/L 14 19 30 14
Gluconate mmol/L 20 24 28 24
Acetate mmol/L 15 23 20 24
Calcium mmol/L 10 12 14 12
Magnesium mmol/L 1.0 1.0 1.2 1.2
Phosphate mmol/L 10 12 14 12
Trace elements ml/L 6.7 6.7 6.7 6.7
Heparin U/L 500 500 500 500
Non protein energy 170 255 340 340
kcal/L
Non protein energy 714 1071 1428 1428
kJ/L
Total energy kcal/L 211 315 422 421
Total energy kJ/L 885 1324 1771 1770
Osmolality mOsm/kg 429 623 817 779

● In exceptional circumstances special solutions may be necessary.


❍ See also the Individualised Solution Worksheet for calculating and

prescribing individualised IVN solutions.


❍ Special solutions require prospective approval by a specialist and

should be countersigned by them each day.


❍ They cost substantially more than standard solutions and have not been

shown to have any advantage over appropriately formulated standard


solutions in the majority of infants . 3
❍ There may be alternative methods of changing nutrient and electrolyte

intake, such as a simultaneous infusion of sodium, potassium, or glucose.

References

1 Neuzil J, Darlow BA, Inder TE, et al. Oxidation of parenteral lipid emulsion by ambient and phototherapy
lights: potential toxicity of routine parenteral feeding. J Pediatr 1995; 126:785-90.
2 Inder TE, Carr AC, Winterbourn CC, Austin NC, Darlow BA. Vitamin A and E status in very low birthweight
infants: development of an improved parenteral delivery system. J Pediatr 1995;126:128-31.
3 Yeung MY, Smyth JP, Maheshwari R, Shah S. Evaluation of standardized versus individualized total
parenteral nutrition regime for neonates less than 33 weeks gestation. J Paediatr Child Health 2003;39:613-
7.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Parenteral Nutrition
Individual Solution Worksheet © Carl Kuschel

October 2005

Note: ● Individualised IVN is not to be ordered without approval from the specialist on duty.
● Standardised solutions should be used in preference to individualised solutions, except in
circumstances where nutritional needs cannot be met with the available IVN preparations.
❍ If the only difference between a standard solution and the requested individualised solution is

that more sodium is required, consider using a standardised solution and run in a separate
infusion of sodium chloride.
● This worksheet is designed to provide a prescription for individually prescribed IVN.
● Some features are built in to the calculator including a limit on protein, glucose and lipid intakes, and
limits on sodium, potassium, calcium and phosphate.
● The prescriber takes responsibility for the IVN prescription.
● Press the button at the bottom of the page to view and print out your prescription

Patient Details

Surname Hospital Prescriber


Number Name
Weight for Date of Default values have been assigned to protein,
calculations g Day Month Year
lipid and fluid intakes on the basis of this baby's
Birth age.
Default values will change when you alter the
age of the baby until you choose to alter or
accept any one of these 3 values.

Fluid Calculations

Fluid Volumes Lipid Prescription

Total Daily Fluid Lipid


g/kg/day
Intake intake
(This includes all fluids - ml/kg/day ml/day
Recommended maximum 3g/kg/day
IVN, lipid, infusions, and
feeds)
Current Infusions
Arterial fluids 0.0 ml/hour ml/day

ml/kg/day
Drug infusions 0.0 ml/hour ml/day
(do not count lipid)

ml/kg/day

Feeds 0 ml/day ml/kg/day

Amino Acid and Glucose Solution


Amino Acid and ml/day Caloric Calculations
Glucose Solution
ml/kg/
day Protein
ml/hour Glucose
Protein g/kg/day g/day Lipid
Recommended 2.5-3.5g/kg/day
g/L Enteral
g/kg/
Glucose 10 % dextrose
day
Recommended 12-18g/kg/day
Total

mg/kg/ Non-nitrogenous calories per gram of protein


min
g/L This ratio is calculated as if no enteral nutrition is
mmol/ being given
Sodium 3 mmol/kg/day A ratio of 24-32 is thought to optimise anabolism
day
Recommended 2-3mmol/kg/day
Preterm infants may need more mmol/L
mmol/
Potassium 2 mmol/kg/day
day
Recommended 1-2mmol/kg/day
Preterm infants may need more
mmol/L

Anion -Choose anion-

mmol/
Calcium 1.5 mmol/kg/day
day
Recommended 1.5-2.5mmol/kg/day
The maximum you can give is 2.5mmol/kg/day mmol/L
mmol/
Phosphate 1.5 mmol/kg/day
day
This will give the same amount as for calcium
mmol/L
mmol/
Magnesium 0.20 mmol/kg/day
day
Recommended 0.15-0.25mmol/kg/day
mmol/L
Trace will be added at a concentration of 1ml/150ml to all
elements solutions
Heparin will be added at a concentration of 500U/L to all solutions
Days to Days Volume to supply
Supply ml
Clicking on this button will perform a check of all data.
Click Here to Produce Your IVN Prescription
If all calculations are correct, a window will open with your IVN prescription

Reset All Values


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Premedication for Intubation Reviewed by Carl Kuschel

December
2000

Most intubations occur at the time of delivery in the process of resuscitation, or semi-
electively in infants with either poor respiratory effort or with severe immediate respiratory
distress in the immediate newborn period. Intubation medications are therefore not
usually given. However, once the infant is in the NICU environment and IV access is
obtained, the use of intubation agents for elective or semi-elective intubations should be
considered, particularly in large vigorous infants.

Contraindications and Precautions

1. Intubation drugs should not be used ● if there is a known allergy to any of


the agents

2. Suxamethonium should not be used ● if there is a family history of


malignant hyperthermia
● if there is a suspicion of muscular
dystrophy, or
● if there is significant hyperkalaemia

3.Suxamethonium should be used with ● if there is concern that the infant has
caution abnormal upper airway anatomy (for
example, severe micrognathia) and
that intubation may be technically
extremely difficult.
❍ In this situation, a consultant

(and potentially an ENT


surgeon) should also be
present.

Preparation and Equipment


1. Consider intubation drug use in all elective or semi-elective intubations where IV
access is available or can easily be obtained.
2. Premedication should be strongly considered for all vigorous term infants.
3. Equipment must be ready, especially the bag-mask circuit and laryngoscope. The
infant will have no spontaneous respiratory effort once muscle relaxing agents (or
Fentanyl) have been given.
4. Suxamethonium should not be given if there is significant hyperkalaemia.
5. If Fentanyl is given, Suxamethonium should be ready to be given if chest-wall
rigidity occurs.
6. Medications should be administered in the order of:

See Intubation Quick Reference Guide.


Atropine 20mcg/kg IV
Anticholinergic
(if given)

Give slowly (30 seconds)


Fentanyl 4mcg/kg IV to avoid muscle rigidity
Sedation
Allow at least 30 seconds
for sedation

Suxamethonium 2mg/kg
Muscle relaxation IV
(if given)

If Morphine is used instead of Fentanyl, drugs should be administered in the order


of

Morphine, then Atropine, then Suxamethonium

7. The infant should have bag-mask ventilation during the administration of Fentanyl
and Suxamethonium, or prior to this if respiratory effort is poor.
8. Laryngoscopy should commence once spontaneous respiratory movements have
ceased.
9. Muscle fasciculation from Suxamethonium administration does not occur in
neonates and should not be relied upon as a sign of successful neuromuscular
blockade.
10. If bradycardia occurs in the presence of hypoxaemia, a second dose of Atropine
should not be given. The bradycardia is due to inadequate oxygenation and/or
ventilation.
11. If the intubation is unsuccessful, Suxamethonium can be re-administered but
Atropine and Fentanyl should not be repeated.

To view a literature review and rationale for this protocol, click here
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Isolation Guidelines
Reviewed by

Antibiotic resistant ● Until cleared


organisms
+ contacts
CMV * ● ubiquitious but pregnant staff not asked to nurse -
not a danger to other infants.

Diarrhoea ● until cultures negative and asymptomatic.


+ contacts
Enterovirus + contacts ● until asymptomatic and cultures negative.

Gonococcal ophthalmia ● until treated ? 24 hours.

Hepatitis A ● mother: 3 weeks from onset of jaundice.


● baby remain with mother in isolation - no treatment.

Hepatitis B ● clinical - mother isolated in hospital.


● carrier mother - syringe needle isolation
● infant - see immunisation schedule

Herpes simplex* ● until proven negative.


+ contacts
Outborn infants except ● until cultures negative.
from other delivery suites ● Infants from home -postnatal ward
Staphylococcal sepsis ● until negative and/or treated.
+ contacts
Necrotising enterocolitis * ● desirable to isolate.

Rubella * ● single room only because of danger to pregnant


nurses

Toxoplasmosis ● isolation not necessary.

Varicella-Zoster ● mother and infant -until lesions crusted.

* Isolation may not be possible except for known highly contagious disease, but barrier
nursing with gloves is indicated.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Management of Neonatal Jaundice Reviewed by Peter Nobbs

May
2001

Assessment Management (including Atypical Jaundice Related Documents


graphs)

See also Neonatal Jaundice on the Postnatal Ward.

● Jaundice (SBR >50 μmol /L) is one of the most common physical signs observed
during the neonatal period.
● Approximately 50-60% of newborn infants will become jaundiced during the first
week of life.
● For many newborn infants the jaundice may be regarded as a manifestation of
their ongoing adaptation to the extra uterine environment.
● Although most jaundice is mild and physiological in origin, it cannot safely be
automatically assumed to be either.
● Jaundice may be a sign of pathology and demands evaluation and rational
management.
● Atypical presentation of jaundice (early onset, rapid rise in SBR, prolonged
jaundice, and/or late onset jaundice) is likely to reflect pathology.
● Furthermore, it is important to appreciate that an infant's symptoms may be
attributed to its jaundice when in fact they are due to other pathology.

Assessment

The evaluation of the jaundiced newborn infant must include a thorough history and
physical examination, with particular emphasis on the state of hydration and consideration
of the possibility of an acute haemolytic process and/or infection.

● The following approach to the evaluation of neonatal jaundice is recommended:-

1. Review maternal blood group.


2. Request infant's blood group and Coomb’s test if mother's blood
group is O.
3. Check SBR (note that a direct SBR very rarely indicated within the
first 5 days of life).
4. Haemoglobin, WBC and differential, and reticulocytes if suspicion/
evidence of haemolysis.
5. Urine for microscopy and a culture only if clinical suspicion of a
urinary tract infection.
6. If galactosaemia is suspected, then discuss an urgent serum assay
through the National Testing Laboratory. Urine samples for reducing
substances are not reliable nor specific.

● Other investigations may be necessary depending upon the specific clinical


situation.
● The significance of any SBR estimation depends upon the maturity and postnatal
age of the infant, the clinical status of the infant (hypoxaemia, acidaemia,
hypoalbuminaemia, and/or hypothermia) and the aetiology of the jaundice.
● Serial SBR estimations are an essential component of the continuing assessment
and management of the jaundiced newborn infant. Graphs are available to aid the
interpretation of SBR estimations.

Management

● Treatment Guidelines for Term


Infants without Haemolysis
❍ Click on the picture on the right

● Treatment Guidelines for Preterm


Infants or Infants with Haemolysis
❍ Click on the picture on the right

● It is important to maintain normal hydration and nutrition of the jaundiced newborn


infant. This may be achieved by the encouragement of breastfeeding, the provision
of additional oral fluids or may require the intravenous administration of fluid.
There is no evidence to support the administration of excessive quantities of fluid
and most infants will not need extra fluids.
● Phototherapy causes photodegradation of bilirubin in the infant's skin.
❍ This form of physical therapy has been shown to be an efficient method of

lowering the SBR and is usually effective.


❍ Complications of phototherapy are generally mild and include increased

insensible water losses, loose green stools, skin rashes, overheating and/or
chilling.
❍ The levels of SBR at which phototherapy is recommended in various

situations are indicated in the accompanying graphs.


2
❍ An inadequate quantum of phototherapy (<4 mcw/nm/cm ) is ineffective.

Recommended range for phototherapy is 5-10 mcw/nm/cm2. Increasing


phototherapy about 9-10 mcw/nm/cm2 is unlikely to provide any additional
benefit.
● Infants receiving phototherapy should be under paediatric supervision.
● An exchange transfusion is indicated for any infant in whom the degree of
hyperbilirubinaemia cannot be adequately controlled by phototherapy alone.
❍ Discuss the indications for exchange transfusion with the appropriate

specialist.
❍ Note that infants with jaundice due to a haemolytic disorder usually benefit

from phototherapy but may also require an exchange transfusion.


❍ With appropriate management, exchange transfusion should rarely be

required.

Atypical Jaundice

● Separate guidelines are available for the evaluation and management of late onset
jaundice (7-10 days or later) and prolonged jaundice (SBR >200 μmol /L after 7-
10 days of age).
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Neonatal Jaundice on the Postnatal Ward Reviewed by Peter Nobbs

May
2001

Significance of Jaundice Indications for Paediatric Referral Management

See also Neonatal Jaundice, which contains graphs indicating treatment levels.

The Significance of Jaundice

● Although 50-60% of newborn infants develop jaundice it cannot be assumed it is


either mild or "physiological" unless conscious evaluation, examination and
investigation has taken place.
● The significance of any serum bilirubin estimation depends upon the maturity and
postnatal age of the infant, the clinical status of the infant and the aetiology of the
jaundice.
● Jaundice is important because in itself it may cause kernicterus and because it
may be a presenting sign of an apparently unrelated condition. For example,
Chinese boys with jaundice may have G6PD deficiency.

Indications for Paediatric Referral

● Jaundice requires paediatric evaluation in the following situations and whenever


there is a possibility that hyperbilirubinaemia may indicate or cause pathology.

1. Clinically present before 24hrs of age.


2. Whenever other symptoms and/or signs of illness are present. When
SBR >200 μmol/L on the second day of life.
3. When SBR >250 μmol/L
4. When jaundice is of late onset (7-10 days or later) or is prolonged
with SBR >200 μmol/L after 7-10 days of life.

Management of Neonatal Jaundice

● Management is dictated both by the bilirubin level and by the underlying condition.
For example, a significant haemolytic condition may indicate earlier or longer
treatment.

● Treatment may consist of both ensuring adequate hydration, and encouraging


photo-degradation of unconjugated bilirubin in the skin by the provision of
phototherapy. This may prevent serum bilirubin levels rising to levels where
exchange transfusion would be necessary. Phototherapy is very effective at
preventing the need for an exchange transfusion.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Blood Product Transfusion for Jehovah's Witnesses Reviewed by David Knight

March
2004

Urgent Transfusions Less Urgent Transfusions The Law in NZ Court Wardship

Jehovah's witnesses do not agree with blood transfusions. Our policy is to try to avoid
transfusion, but always to have the best interests of the infant as the foremost aim. Blood
tests should be kept to the safe minimum. Erythropoietin is used early and should be
considered even if the baby has received a transfusion.

Transfusion needs to be discussed with the parents. Consider inviting a Jehovah's


Witness Elder to such meetings, with the parent's consent. We have had a lot of contact
with Elders of the Church over the years and, although they disagree with transfusion,
these discussions have been helpful, particularly for the Witness parents.

Click here to open the contact details for the Witness's Hospital Liaison Committee
(intranet only)

For Urgent Transfusions

● We need to ask for consent.


● If consent is withheld, we can transfuse if it is thought that the transfusion is
needed to save life or prevent permanent injury or prolonged and avoidable pain
and suffering.
● This decision is made by a specialist and must be recorded in the clinical record.
● Unless impracticable the specialist should consult with a colleague before
proceeding.
● If further transfusions are likely to be needed, there should be discussion with
ADHB legal counsel.

For Less Urgent Transfusions (or if the need for transfusion is anticipated)

● We need to discuss with the parents.


● If consent is withheld, tell them that we will be consulting legal counsel and
seeking guardianship.
● In these circumstances, guardianship will only apply to blood transfusion.

Anticipated transfusion need: Unwell ELBW infants, babies <26 weeks, anaemic VLBW
infants, significant haemolytic disease, very sick term infants (although many of these
would fit the urgent transfusion criteria).

The law in New Zealand

The law in New Zealand covering transfusion to minors is as follows:

'Section 126B of the Health Act 1956: This section protects medical practitioners from
civil or criminal proceedings for administering blood transfusions without consent to any
person under the age of 20 years as long as the judge is satisfied that:

1. The transfusion was (in the reasonable opinion of the person administering the
transfusion) necessary to save life, or to prevent permanent injury or prolonged
and avoidable pain and suffering; and
2. There were reasonable attempts to obtain consent, or it was impracticable to
obtain consent given urgency; and
3. In all the circumstances, administering the transfusion is reasonable

Note: 16 to 19 year olds have the right to consent to medical treatment and their informed
refusal of blood products should be respected.

Court Wardship

In Re J [1996] 2 NZLR 134 Ellis J had made a three-year-old boy, whom doctors
considered in need of a blood transfusion after a severe nose bleed, a ward of the Court
and appointed a medical specialist to act as agent of the court to consent to any medical
treatment involving blood transfusion, over the objection of the boy's Jehovah’s Witness
parents. The Court of Appeal dismissed the parents’ appeal, noting that the parents’ right
to practise their religion cannot extend to imperil the life or health of the child.

The Court confirmed that S126B of the Health Act 1956 does not provide an exclusive
statutory mechanism, and that an application to place the child under the guardianship of
the Court and seek prior consent to a blood transfusion, may be brought where time and
circumstances permit. Before the Court, as guardian, authorises a transfusion to a child in
the face of parental opposition: there must be real or substantial risk that the patient's
condition will in the course of medical care be such as, on accepted medical practice,
would call for blood transfusion and that in the event that condition develops a blood
transfusion will be necessary.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Laboratory Testing Reviewed by Carl Kuschel

May
2002

Collecting Ordering Tests New Admissions Babies on the Neonatal Unit


Jaundice Respiratory Distress Infection Screen Drug Monitoring

Collecting

On NICU and PIN nurses do capillary and arterial line collects. Doctors and NS-ANPs do
the venous collects. These can be ordered at any time although it is better to stick to
‘standard times’.

On Postnatal Wards, there is collecting round at 0900. At other times inform the
laboratory (3051) that a collect is necessary. Group the collections at 1300, 1600 or 1700,
2100, 0100 and 0500. For serial glucoses, write the times on the first glucose form and
the rest will be done.

Ordering tests

● Order laboratory tests when clinically indicated. Think of the use the test will be
and what information you will get from the result.
● Avoid unnecessary tests: they are unpleasant for the baby and expensive.
● Do not order tests more that a day ahead as clinical situations change at old
orders may no longer be relevant.

What tests to order

● This list is a guide. It is not exhaustive or exclusive.

New Admissions

● No routine tests. Admitting doctor or NS-ANP to decide what is warranted for that
baby.
Preterm, IUGR, ● Blood glucose monitoring 2, 4, 8, 12 hours and after that as
Unwell, >4kg, IDM indicated
● See hypoglycaemia guideline
● FBC

Respiratory ● Surface swabs and gastric aspirate


distress or ● Blood culture
possible infection ● FBC
● Glucose monitoring
● Consider LP
● Urine if >24 hours old

Unwell, asphyxia, ● Consider blood gas (arterial or capillary)


respiratory distress ● FBC

IUGR ● Consider congenital infection screen:


● Urine CMV, rubella/toxo serology ± IgM.
● Get maternal information

Babies on the Neonatal Units

<1000gms for 1st ● Regular blood gases include Na+, K+, ICa++ and glucoses.
few days These do not need to be done separately.
● Blood gases as indicated by baby’s condition.
● Daily FBC, urea and creatinine.
● SBR in first day and as indicated thereafter.
● If no regular gases, glucoses 4 hourly initially, decreasing
frequenct if stable. Electrolytes 8-12 hourly initially

<1500gms for 1st ● Very dependant on clinical condition


few days ● Glucoses serially initially.
● Electrolytes daily. Urea and creatinine daily initially.
● FBC initially and daily if unwell.
● Gases as indicated.
● SBR if any sign of jaundice.

Babies on IV ● Glucoses 4-8 hourly until stable then daily.


therapy ● Electrolytes, urea and creatinine daily initially.

Babies on IVN ● Initially daily urea, electrolytes, blood gas, glucose, FBC.
● When stable, 2 x weekly bloods. More frequent glucoses.
Preterm babies ● Weekly electrolytes if indicated.
after first few days ● FBC if symptoms and/or signs of anaemia.

Babies <1000gms, ● Ca2+, PO43-, and ALP as indicated clinically.


or on IVN for >2
weeks, or diuretics/
steroids for chronic
lung disease

Jaundice

● SBR regularly. Frequency a severity, age, rate of change. Rarely >1 daily in well
term infants.
● Direct SBR if prolonged (>2 weeks term or >3 weeks preterm) or if atypical, or
unwell baby or before an exchange.
● Group & Coombs, FBC (look at film result). Consider reducing substances, urgent
Guthrie, Consider the cause and investigate if indicated.

Respiratory Distress

● Blood gases (capillary or arterial). Individualise frequency. Are repeated gases


clinically useful in that baby?
● FBC as indicated.
● If chest drain, regular protein and albumin.

Infection screen

● FBC, blood culture


● Urine (SPA or catheter if possible) if > 24 hours old.
● CSF in 1st 24 hours if baby unwell and may be septicaemic, provided baby stable
enough for an LP.
● CSF after 24 hours of age unless treating respiratory deterioration only.
● CXR if chest infection likely.

Drug monitoring

● Gentamicin/netilmicin/vancomycin: Trough and peak after 1st dose or after change


in dose and repeat every 3-5 days.
● Caffeine: In a baby with no signs of toxicity and controlled apnoeas, NO DRUG
LEVELS ARE NEEDED.
Any suspicions of toxicity: check level
Persisting apnoea: check level.
DISCUSS WITH THE LABORATORY PRIOR TO SENDING AS CAFFEINE
SAMPLES ARE FORWARDED TO EXTERNAL LABORATORIES
● Phenobarbitone/phenytoin: 12-24 hours after 1st dose and thereafter at intervals.
● Digoxin: 10-12 hours after last loading dose and repeat at intervals, including after
change in dose.
10-12 hours post dose.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Management of Small- or Large-for Gestational Age Reviewed by Jane Harding


Infants on the Postnatal Ward

July
2004

See also Guideline on Management of Hypoglycaemia

See also Hypoglycaemia on the Postnatal Ward

This guideline refers to term or near-term babies who are:

● <10th or >95th centile by customised centile charts, or


● <2.5kg or >4.5kg if customised centiles are not available

These babies are at risk of:

● hypoglycaemia
● hypothermia
● jaundice secondary to polycythaemia

1. Temperature should be monitored before feeds for 12 hours or until stable


2. Baby should be closely observed for signs of hypoglycaemia or hypothermia (e.g
jitteriness, pallor, lethargy).
3. Routine blood glucose measurement should have been requested by the LMC or
Paediatrician within the first hour following birth and 4-hourly or pre-feed thereafter
(whichever comes first).
❍ All blood glucose measurements should be performed by the Laboratory.

❍ That is, bedside testing methods (BM-stix, Precision-G monitors) are not

reliable at detecting hypoglycaemia.


4. Feeding should be commenced early; first feed within one hour of delivery and
thereafter at least 3 hourly.
❍ Either breast or formula feeds (maternal preference) can be given.

❍ Complement feeds are not necessary unless the babies blood glucose falls

to <2.6mmol/L.
5. The baby should be watched for jaundice and bilirubin levels measured as
indicated.
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guideline.

Withdrawal of Life Support Treatment


Refusal to Consent

Ethical Issues

1. The Welfare of the Child and best interests of the Child are Paramount

Interpreted with respect to what a reasonable adult would choose for themselves.

2. The Role of the Parent; its Scope and Limitations

The Guardianship Act: parent's ability to consent to treatment of a child.

(a) Parents cannot choose against the best interests of the child where these are clear e.
g. refusal of blood transfusion by Jehovah Witness parents.

(b) Discretionary role where parents are competent and the best interests of the child are
in doubt.

(c) Parents cannot insist on treatment that is not in the child's best interests

(i) Futile treatment: where it would not produce an outcome beneficial to


the child.

(ii) Treatment contrary to the child's best interests e.g. epidermolysis


bullosa (Lethalis).

3. The Role of Medical Practitioners

Whether providing for or withholding treatment is in child's "best interests: physicians


have a responsibility to prevent undue suffering including that from inhumane treatments
and in the case of a dying child, allow "death with dignity" .

(a) There is no legal duty to provide futile treatment.

(b) Courts will not order treatment against clinical judgement if there is medical diagnostic
and prognostic certainty.

(c) Courts will not lightly overrule parents.

(d) Family, clinical and ethical consensus is desirable.

(e) Clinicians/parental disagreement equals "alarm". In these cases, review legal issues
by legal advisers and ethical issues by the Hospital Ethics Committee is recommended. It
may be appropriate to obtain a Court Order approving the decision to withdraw.

References

1 Annas GJ. Asking the Courts to set the standards of emergency are -the case of Baby K. N Engl J Med
1994; 330: 1542-5.
2 Biachi DW, van Mater LJ. An approach to ventilator dependent neonates with arthrogryposis. Paediatrics
1994; 94: 682-6.

These guidelines were initially developed by Dr Andrew Howie, Ms Jane Bowden, and Associate Professor Tania Gunn
- September 1997
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guideline.

Percutaneous Central Venous Catheter (Longline) Reviewed by Malcolm Battin,


Insertion Bernadette Page, and David Odd

February
2002

Indications Contraindications Sites


Procedure Other Related Documents

Indications

● The insertion of a longline


should not be considered a routine. However, infants who are VLBW, likely to be
slow to reach full enteral feeds, have IV access problems or long term IV nutrition
needs (NEC, major surgical problems etc.) may require line placement.
● Infants to have longlines inserted should be discussed on ward round and/or with a
Specialist at the time of presentation.
● In babies <1000g insertion of an umbilical venous catheter on admission is the
preferred option. In those who are very small, sick or have respiratory distress an
umbilical artery catheter should be considered at the same time. In sick term
babies a double lumen UVC should be used as they may require several infusions.
● Where ever possible discuss the risks of the procedure with the family.

Contraindications

● Skin sepsis at insertion site


● Bacteraemia or septicaemia

Sites

● Large vein in antecubital fossa, long saphenous vein or posterior tibial vein

Procedure
Important: Use a full sterile technique.
DO NOT ATTEMPT THIS PROCEDURE THROUGH THE PORTHOLES

Insertion ● For longlines inserted via the leg, measure from insertion site
Distance to xiphisternum.
● For longlines inserted via the arm, measure from insertion site
to the sternal notch.

Equipment ● Open longline


Required pack onto trolley and add:
❍ 20 gauge cannula

❍ Longline

set
❍ Scalpel blade

❍ 5ml syringe

❍ 0.9% NaCl 5ml ampoule

❍ Heparinised saline 10 unit/ml

❍ Skin wash

■ Either Chlorhexidine 0.5% in 70% alcohol or

0.2% for infants <1000gms. <2 weeks old.


❍ Steristrips

❍ Duoderm dressing

❍ Tegaderm or Opsite dressing

Procedure ● Don mask, gown, and gloves.


● Flush the longline
with 0.9% NaCl leaving syringe attached
● Cut round the IV cannula at the hub leaving cannula on the
introducer
● Position the infant maximising access i.e. open the incubator
door, slide tray out and use overhead heater. Secure limbs if
necessary

● If an assistant is required they must wear a gown and sterile


gloves
● Clean the skin with the chlorhexidine solution appropriate for
the infant’s gestation.
❍ Wait about 1 minute until it dries otherwise it will

not be an effective skin prep.

● Create a sterile field with sterile guards


● Apply tourniquet above site

● Position line, syringe and forceps on sterile field


● Insert cannula, advance cannula off the introducer and
withdraw introducer
● Insert longline
with forceps and feed to premeasured distance releasing
tourniquet when catheter is through the cannula
● Withdraw cannula over the longline ensuring the longline is
stable by using pressure on the limb above the cannula
● Detach longline at blue connection, remove cannula and
reattach connection, ensuring air is not introduced. The black
marker that lies over the metal insert must not be visible.
● Flush longline with 0.5ml of heparinised saline (10U/ml)

Securing the ● Coil longline next to site without crossing longline.


Line ❍ Steristrips should be used to anchor the line preventing

inward movement and may also help to keep the


longline coiled.
● Place a small piece of Duoderm on skin under connection and
secure everything with Tegaderm.

Confirm the ● Wrap syringe in sterile guard until position confirmed by x-ray
position ❍ The Department of Health (UK) has recently reviewed

four cases of neonatal death due to pericardial


tamponade associated with the presence of a central
venous percutaneous line. The recommendation from
this group was that the line tip is placed OUTSIDE the
heart.
● X-ray with contrast medium prior to connecting fluids. This
must be done using sterile technique
● Record in the clinical notes the date, insertion site and length of
catheter. Enter the procedure in the neonatal database.

❍ It is also important that we note the catheter tip position


in the clinical record
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guideline.

Meconium-stained Liquor and Meconium Aspiration Reviewed by David Knight

October
2004

Delivery Room Management Further Management Criteria for Admission to NICU


Management of the Symptomatic
Complications of Meconium Aspiration References
Infant

Delivery Room Management

1. The Paediatric Resident (SHO, Registrar, or NS-ANP) should be called if there is


thick meconium staining or light meconium plus fetal distress.
2. There is no advantage in oral and pharyngeal suction as the head delivers and this
1
is no longer indicated.
Suctioning does not alter the chance of developing respiratory distress or
symptomatic meconium aspiration syndrome, even in sub-groups with thick
meconium, fetal distress or delivered by Caesarean section.
3. If the baby is apparently vigorous at birth (heart rate >100, spontaneous
respiration, reasonable tone), intubation and tracheal suction is not indicated,
unless the baby subsequently has poor respiratory effort or early respiratory
distress. 2
Intubation of vigorous babies does not improve respiratory outcomes and can
result in trauma to the infant.
4. Intubation and tracheal suction should be performed if the baby has moderate or
thick meconium and depression at birth.

● Laryngoscope and suction the pharynx under direct vision. Intubate


and suction the trachea with a meconium aspirator tube, applying
suction as it is withdrawn. Use a pressure of -100mm Hg or -13Kpa
2
for 1-5 seconds, with withdrawal of the tube .
● If meconium is present in the trachea, consider repeating ET suction.
● Resuscitate infant appropriately. If the heart rate is low, the infant
should be ventilated after the first intubation (bag and mask) or on
the second intubation.
5. Assess the infant.
Arrange for cord blood gas (arterial if possible) to be taken from a double clamped
section of cord.

Further Management

● All infants with meconium stained liquor must be well observed. For most babies
this is with their mothers.
● If there is thick meconium or any worrying clinical features, the paediatric resident
staff should review the baby at an hour of age.
● All babies should have AC temperature and respiration recordings with instructions
to call the paediatric resident if there is any respiratory distress. 3

Criteria for Admission to NICU

● Symptomatic meconium aspiration syndrome.


● Meconium in trachea with significant asphyxia
(> 10 minutes to establish spontaneous ventilation or cord pH < 7.2).
● Other significant risk factors for infection.

Management of the Symptomatic Infant

● Assess the infant.


● Give enough oxygen to maintain SpO2 >95% initially. Put on CPAP to deliver
oxygen.
● CXR if significant respiratory distress or tachypnoea persists.
● Consider antibiotics:
I. if unwell
II. if persistent symptoms
III. if other risk factors for infection
● Take blood culture if treating with antibiotics.

Complications of Meconium Aspiration

1. Infection: Uncommon unless sepsis was the stimulus to make the infant pass
meconium. Consider LISTERIA, especially if preterm. Meconium is a good culture
medium so secondary infection may occur.
2. Pneumothorax: May occur at any stage (MAS is an air-trapping disease). So
consider this any time from resuscitation onwards if there is unexpected
deterioration or significant disease.
3. Respiratory Failure: Can occur because of respiratory obstruction, inflammation,
infection or shunting.
4. Persistent Pulmonary Hypertension: Is common in severe MAS and can be very
difficult to treat. Early assessment and avoidance of hypoxaemia, hypothermia,
hypoglycaemia are important to avert PPHN.

References
1 Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their
shoulders: multicentre, randomised controlled trial. Vane NE, Szyld EG, et al. Lancet 2004: 364: 597-602
2 Delivery room management of the apparently vigorous meconium-stained neonate: results of the
multicenter, international collaborative trial. Wiswell TE, Gannon CM, Jacob J, et al. Pediatrics 2000;
105:1-7.
3 Clinical audit of babies delivered through meconium stained liquor. Ashton M. NWH 2001
Newborn Services Clinical Guideline

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Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
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guideline.

Metoclopramide (Maxolon) and Breastfeeding Reviewed by Carl Kuschel

October
2002

Rationale Recommendations References

● Domperidone has replaced Metoclopramide as the galactogogue of choice in


NICU.

Rationale

Metoclopramide (Maxolon) is an anti-dopaminergic agent which has been shown to


significantly increase milk yields in mothers with lactational deficiency.

A placebo controlled double blind study of metoclopramide started on the first day post
partum and continued for eight days, showed a 50% greater milk yield in the
1
metoclopramide treated group .

In a placebo controlled study of mothers 4-20 weeks post partum metoclopramide 10mg
tds for three weeks caused a significant increase in milk yield and in serum prolactin
levels. There was no change in the serum concentration of TSH or free thyroxine of either
mothers or infants and there was no rise in the prolactin levels in the infants in either
group. This study showed no effect on the hypothalamo-hypophyseal axis of the neonate
2
.

Metoclopramide taken orally by the mother is transferred to the breast milk. However it
3
was detected in the plasma from only one of the five neonates studied . Exposure of the
infant to metoclopramide was 6-24mcg/kg/day compared to the therapeutic dose of
500mcg/kg/day, i.e, less than 5%. Metoclopramide has been used successfully to treat
preterm infants with persistent functional feeding intolerance in a dose of 300mcg/kg/day
4
and no side effects were noted .

Maternal side effects are mild, uncommon and non-specific, e.g. tiredness. Extra
pyramidal dystonia has been reported and parents need to be aware of the possibility.

Recommendations

● Maxolon (metoclopramide) should only be given after the mother has been
expressing at least six times in 24 hours for three days. She must have had
teaching in effective expressing techniques and positioning of the baby at the
breast if possible.
● If the mother is still under obstetric or medical care, she should discuss the
possible use of metoclopramide with her medical adviser(s). The RMO may then
give the mother a prescription for Maxolon 10mg tds orally for two weeks. This
prescription may be repeated as necessary.
● Discuss with the Paediatric Consultant or Lactation Consultant and/or primary
charge nurse before starting therapy, to ensure that adequate assistance is in
place.

References

1 De Gezelle et al. Metoclopramide and breast milk. Euro J Obst Gynec Reprod Biol 1983; 15:31-6.
2 Kauppila et al. Metoclopramide and breastfeeding: Efficacy and anterior pituitary responses of the mother
and child. Euro J Obstet Gynec Reprod biol 1985; 19: 19-22.
3 Kauppila et al. Metoclopramide and breastfeeding: Transfer into milk and the newborn. Euro J Clin Pharm
1983; 25: 819-23.
4 Sankaran K et al. Use of metoclopramide in preterm infants. Devel Pharm & Therap 1982; 5: 114-9.
Newborn Services Clinical Guideline

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Monday, May 22, 2006.
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guideline.

Metabolic Bone Disease/Osteopenia of Prematurity Reviewed by Barbara Cormack


(Dietitian)

June
2005

Risk Factors Treatment References

Risk Factors

● <30 weeks gestation.


● <1000g birthweight.
● Delayed establishment of full enteral feeds/prolonged parenteral nutrition.
● Enteral feeds with low mineral content or bioavailability (unfortified EBM, standard
term formula).
● Chronic use of medications that increase mineral excretion (diuretics,
dexamethasone, sodium bicarbonate).
● Cholestatic jaundice.

When an infant is identified to be at risk of osteopenia, measurement of urinary


mineral excretion and serum 25-OH D should be considered.

Guidelines for the Treatment of Osteopenia of Prematurity

1. Prescribe elemental calcium 2.5mmol/kg/day and elemental phosphate 1.6mmol/


kg/day to be given in divided doses, four times daily.
Calcium and phosphate must not be given at the same time, so in practice
should be given at alternate feeds.
For example,
0600hr Calcium 1.25mmol/kg/dose
Phosphate 0.8mmol/kg/
1200hr
dose
1800hr Calcium 1.25mmol/kg/dose
Phosphate 0.8mmol/kg/
2400hr
dose

As intestinal obstruction has been associated with calcium supplementation of


enteral feeds, incremental advancement of calcium and phosphate supplements is
recommended starting at 50% of the target dose recommended above.
Contact the Newborn Unit Pharmacist for directions.

2. Ensure an adequate intake of calcium and phosphate from feeds:


❍ If <3.5kg Fortified EBM or Preterm formula

❍ If >3.5kg Unfortified EBM or Term formula (not Soy)

❍ N.B. This is different from the usual recommendation of 2.5kg.

3. Ensure a daily intake of 400IU Vitamin D per day.


❍ If on Fortified EBM or Preterm formula - Vitadol C 0.15ml/day (note this is

different to usual recommendations)


❍ If on Unfortified EBM or term formula - Vitadol C 0.3ml/day

4. Weekly monitoring in infants being treated with additional calcium, phosphate, or


vitamin D:
❍ serum calcium.

❍ serum phosphate.

❍ sodium.

❍ potassium.

❍ creatinine.

❍ acid/base balance.

5. Treatment is continued until biochemical indices are normal and radiographic


evidence of healing is present.
6. Consider other nutritional deficiencies (for example zinc) in an infant who is failing
to thrive with evidence of significant bone disease.

Caution: ● Infants on chronic diuretic therapy with loop diuretics (frusemide) are at
risk of increased urinary calcium excretion. High urinary calcium
increases the risk of nephrocalcinosis.

References

1 Groh-Wargo S, Thompson M, Hovasi Cox J, Hartline J. Nutritional Care for High-Risk Newborns, 3rd
Edition, Illinois, Precept Press, 2000
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Investigation and Treatment of Suspected Metabolic Reviewed by Callum Wilson


Disease

January
2001

General Guidelines Post-Mortem Samples and Analysis Emergency Management

General Guidelines

● Any sick baby where metabolic disease is part of the differential diagnosis. Please
discuss with the consultant acutely - many of the presentations can present rapid
demise.
● Important - you will get the best out of these tests if you contact the laboratory
when you suspect metabolic disease. Some of these tests have long turn-around
times - if you don’t tell the lab you have a problem they can’t do the tests urgently
for you.
❍ Auckland site - Claire de Luen (Biochemical Genetics, LabPlus, can be

contacted for all the tests re sample and destination Ext 6678).

Blood

● Glucose
● Gases
● U&E
● LFT’s
● Ketones (β-Hydroxybutyrate, acetoacetate)
● Lactate
● Acylcarnitine profile (plasma or blood spot on Guthrie card)
● Ammonia
● Alanine
● Free Fatty Acids

Urine

● Ketones - β-Hydroxybutyrate, acetoacetate)


● Organic acids screen
● Amino acid screen
● Glycoaminoglycan screen (if lysosomal disorder suspected)

General Notes

● Ask the lab not to discard specimens until you have an alternative diagnosis.

1. Obtain bloods BEFORE treatment is commenced.


2. Lactate: fluoride tube, grey top 0.5ml minimum
All other tests need green top (Li. Heparin) 2-5 mls.
3. If hypoglycaemia a prominent feature check growth hormone, insulin and cortisol.
4. If serum ammonia high check urinary orotic acid and plasma amino acids.

Any child who dies without a diagnosis, SIDS:

Information for post-mortem studies

● Blood (cardiac if not otherwise available) on filter paper


● Blood (separate if possible and freeze red cells and plasma separately) as soon as
possible post-mortem.
● Bile - freeze
● Urine - freeze
● Skin biopsy -fibroblast line
● Liver/kidney/muscle (small sugar cube size wrap in tinfoil, and snap frozen, -70°C,
use liquid nitrogen or dry ice if possible. Samples are best taken as soon after
death as possible. Consider a needle biopsy if it might take some time to get the
post-mortem samples).
● Hold samples. Await histology. Remember to ask for fat stains as important
indicators of metabolic disease (e.g.. fatty acid oxidation defects).

Remember Guthrie cards are kept by National Testing Centre for organic acid analysis
etc. (via Tandem Mass Spec. Also possible to do DNA studies [e.g.. MCAD] when a likely
diagnosis is found).

Emergency protocol for presumed metabolic disease

General

Contact expert help - Dr Callum Wilson is the local metabolic paediatrician. He can be
contacted through the Starship Operator.

● Treat hypoxia, infection, dehydration vigorously


● Fluids: 150-175%of maintenance
● Carbohydrate: maintenance of at 10-16% dextrose (pyruvate dehydrogenase
deficiency or electron transport chain defect patients worsen with high
carbohydrate load)
● Lipid: 2-3 g/kg per day (not in suspected fatty acid oxidation defects)
● Amino acids: to meet minimal RDA requirements (monitor amino acids)

Acidosis

● Severe metabolic acidosis in neonatal period is often fatal.


● Consider sodium bicarbonate when HCO3 <15. May need huge amounts to
correct acidosis in organic acidaemias (beware hyperammonaemia)
● Megadoses of vitamin co-factors are recommended by some authors.
❍ Thiamine B1 50-150mg/day (MSUD,PDH)

❍ Cobalamin B12 1-2mg/day (MMA)

❍ Biotin 10-20mg/day (Propionic aciduria, multiple carboxylase)

❍ Riboflavin 20-40mg/kg

❍ Coenzyme Q 4mg/kg (Resp. chain)

❍ Carnitine 100-200mg/kg (FAOD’s organic acidemias, urea cycle)

❍ Vitamin C 250-1000mg/kg

❍ Vitamin B6(pyridoxine dependent convulsions)

Hyperammonaemia

● Sodium benzoate, Sodium phenylacetate or sodium phenylbutyrate: 250mg/kg


loading dose (over 90 minutes) then 250mg/kg /day slow infusion.
● IV L-carnitine 100-200mg/kg /day
● L-arginine 400mg/kg /day (or citrulline)
● Consider testosterone/growth hormone/insulin infusion (0.2-0.3u/kg/hr) (decrease
catabolism)
● Early consideration of peritoneal dialysis or haemodialysis. Peritoneal dialysis: 40-
50ml/kg dialysate via peritoneal catheter, one hour cycles for 24-36 hrs. Careful
fluid balance, blood glucose, electrolyte measurements, All neonatal patients with
severe hyperammonaemia (plasma levels greater than 10 times normal) should be
haemodialysed.
● Contact expert help early
Newborn Services Clinical Guideline

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Monday, May 22, 2006.
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guideline.

Guidelines for Metabolic Screening of Newborn Reviewed by Callum Wilson and


Infants Dianne Webster

January
2001

The National Testing Centre (NTC) performs approximately 60,000 screening tests per
year for the following conditions (NZ incidence noted). Diagnostic tests are available for
the conditions marked "*", and therapeutic monitoring is available for PKU and MSUD.

● Cystic Fibrosis
1:3,500

● Congenital Hypothyroidism
1:4,800

● Phenylketonuria *
1:20,500

● Congenital Adrenal
Hyperplasia 1:25,000

● Biotinidase Deficiency *
1:83,000

● Galactosemia *
1:128,000

● Maple Syrup Urine Disease *


1:189,500

Diagnostic tests are also offered in conditions where the diagnosis can be made on the
basis of abnormal amino acid levels in physiological samples. About 30 such samples are
tested annually. Colleagues, primarily those in Australia provide invaluable support for
this service.

For infants with suspected metabolic problems, Dr Callum Wilson should be contacted via
Starship Hospital.
● Newborn screening samples on the Guthrie card should be collected after at least
48 hours of protein feeding in all newborn infants. The Ward Clerk should label a
Guthrie card for each infant born in another Hospital.
● For babies in NICU and PIN a Guthrie card should be put on the incubator by the
Ward Clerk and blood collected 4 days after birth on all infants regardless of
feeding regime and health status. If this is not done conditions such as congenital
hypothyroidism will have a delayed diagnosis and treatment. If the baby is not
tolerating full feeds, this first sample should be labelled stating, "Baby is not fully
orally feed".
● The Nurse (or laboratory staff) are responsible for documenting the collection of
the blood sample in the chart of the baby.
● The National Testing Centre will send a report of the original sample with a further
sample card and reminder for the retest. This is important because they are then
able to link subsequent samples with the original one.
● When these infants are taking full oral feeds for 48 hours, this further sample
should be taken and sent to the National Testing Centre.
Prescriber Update Articles
Drug Safety in Lactation
Website: May 2001
Prescriber Update No.21:10-23

Sharon Gardiner, Drug Information Pharmacist, Christchurch Hospital and Evan


Begg, Clinical Pharmacologist, Christchurch School of Medicine.

Many mothers are required to use drugs during breastfeeding. Almost all drugs transfer into
breast milk and this may carry a risk to a breastfed infant. Factors such as the dose received
via breast milk, and the pharmacokinetics and effect of the drug in the infant need to be taken
into consideration. Problems should not be overstated however, as many drugs are considered
'safe' during breastfeeding.

Transfer of drugs into breast milk is influenced by protein binding, lipid solubility and ionisation
Calculation of infant exposure to drugs can be used to help guide safe use
Infants have lower drug clearance than adults
Minimise risk to the breastfed infant by reducing drug exposure
Safety assessment of some frequently used drugs
Tabulated summary of drug distribution into breast milk
Primary sources

Transfer of drugs into breast milk is influenced by protein binding, lipid solubility and
ionisation<//h4>

Nearly all drugs transfer into breast milk to some extent. Notable exceptions are heparin and insulin
which are too large to cross biological membranes. The infant almost invariably receives no benefit
from this form of exposure and is considered to be an 'innocent bystander'. Drug transfer from
maternal plasma to milk is, with rare exceptions, by passive diffusion across biological membranes.
Transfer is greatest in the presence of low maternal plasma protein binding and high lipid solubility.
In addition, milk is slightly more acidic than plasma (pH of milk is approximately 7.2 and plasma is
7.4) allowing weakly basic drugs to transfer more readily into breast milk and become trapped
secondary to ionisation. Milk composition varies within and between feeds and this may also affect
transfer of drugs into breast milk. For example, milk at the end of a feed (hindmilk) contains
considerably more fat than foremilk and may concentrate fat-soluble drugs.
Transfer of drugs into breast milk is most commonly described quantitatively using the milk to
plasma (M/P) concentration ratio. The accuracy of this value is improved if it is based on the area
under the concentration-time curves (AUC) of the drug in maternal milk and plasma (M/PAUC).

Calculation of infant exposure to drugs can be used to help guide safe use

The infant's dose (Dinfant) received via milk can be calculated using the maternal plasma
concentration (Cmaternal), M/PAUC ratio and the volume of milk ingested by the infant (Vinfant):

Dinfant (mg/kg/day) = Cmaternal (mg/L) x M/PAUC x Vinfant (L/kg/day)

The volume of milk ingested by infants is commonly estimated as 0.15L/kg/day. The infant dose (mg/
kg) can then be expressed as a percentage of the maternal dose (mg/kg). An arbitrary cut-off of 10%
has been selected as a guide to the safe use of drugs during lactation. Drugs such as lithium (infant
dose as high as 80% of the weight-adjusted maternal dose) and amiodarone (infant dose up to 50%)
should be avoided due to high infant exposure and potential for significant toxicity. For drugs with
greater inherent toxicity such as cytotoxic agents, ergotamine, gold salts, immunosuppressives and
isotretinoin, the cut-off of 10% is too high and breastfeeding is contraindicated.

As a general rule, maternal use of topical preparations such as creams, nasal sprays or inhalers would
be expected to carry less risk to a breastfed infant than systemically administered drugs. This is due
to lower maternal concentrations and therefore lower transfer into breast milk. However, the risk to
the infant must be considered in relation to the toxicity of the drug used, the dosage regimen and the
area of application. For example, use of corticosteroids nasal sprays or inhalers in standard doses
would be considered compatible with breastfeeding.

Other factors to consider in conjunction with the infant's dose include the pharmacokinetics of the
drug in the infant. Generally, drugs that are poorly absorbed or have high first-pass metabolism are
less likely to be problematical during breastfeeding. For example, gentamicin is highly hydrophilic
and is very poorly absorbed when administered orally. Should any gentamicin be ingested via breast
milk, it is unlikely to be absorbed.

Infants have lower drug clearance than adults

Drug clearance in the infant is a particularly important consideration and premature infants have a
severely limited ability to clear drugs. Within a few days of delivery, term infants have glomerular
filtration rates approximately one-third of adult values after adjusting for difference in body surface
area, and premature infants have even more impaired clearance (see Table 1). Generally, adult
glomerular filtration rates (adjusted for the difference in surface area) are attained by five to six
months of age. Metabolic processes such as phase 1 oxidation and phase 2 glucuronidation are also
impaired in the neonate. Drugs subject to high first-pass metabolism may have higher oral availability
in premature or term infants due to impaired ability to metabolise on first-pass. Adult metabolic
capacity is attained towards the latter part of the infant's first year of life. The following table is
useful for estimating infant clearance.

Table 1: Approximate clearance values at different ages

Clearance of drug
Post-conceptual age
(compared with adults)
24-28 weeks 5%
28-34 weeks 10%
34-40 weeks 33%
40-44 weeks 50%
44-68 weeks 66%
> 68 weeks 100%

Minimise risk to the breastfed infant by reducing drug exposure

The overall risk of a drug to a breastfed infant depends on the concentration in the infant's blood and
the effects of the drug in the infant. If, after assessment of the risks and benefits, the decision is made
to breastfeed while the mother is using a drug, the infant should be monitored for adverse effects such
as failure to thrive, irritability and sedation. However, it is difficult to identify adverse reactions
occurring in neonates. Feeding immediately prior to a dose may help to minimise infant exposure as
concentrations in milk are likely to be lowest towards the end of a dosing interval. However, for some
drugs, milk concentrations lag behind plasma concentrations.

For drugs that have an infant dose greater than the arbitrary cut-off of 10% of the weight-adjusted
maternal dose, it may be reasonable to reduce infant exposure by alternating breast and bottle-
feeding. For drugs that are not considered safe in breastfeeding, breast milk may be expressed and
discarded for the treatment duration. Breastfeeding may be resumed after the drug has been
eliminated from the maternal blood stream. A period of approximately four half-lives will reduce
maternal concentrations to around 10% of steady-state concentrations.

Safety assessment of some frequently used drugs

A discussion of the safety of the more commonly used drugs is provided below. The data must be
assessed in conjunction with information on the maternal dose and therefore probable maternal
concentrations, the age of the infant and their likely ability to eliminate the drug. In general, if the
infant dose as a percentage of the maternal dose (corrected for weight) is close to 1%, the drug can be
considered 'safe' regardless of infant age. For drugs where the weight-adjusted dose is closer to 10%,
the infant clearance should also be taken into account (see Table 1). For example, if the weight-
adjusted infant dose is 10% but the infant is premature, the lower clearance will mean that the infant
concentrations may be well above those expected.

Analgesics:
Analgesics such as paracetamol, ibuprofen, naproxen and codeine are considered to be 'safe', due to
low transfer into breast milk and few problems with extensive usage. Transfer of aspirin into breast
milk appears to be low but it is best avoided due to the theoretical risk of Reye's syndrome.
Sumatriptan has a short half-life of approximately two hours and infant exposure can be almost
completely avoided by expressing and discarding breast milk for approximately eight hours after
dosing. Limited data on tramadol suggest low transfer into breast milk although where possible, it
would be preferable to use agents which are more established such as codeine and paracetamol.
Morphine is usually considered 'safe' because of low transfer into milk, and high first-pass
metabolism.

Anthelminthics:
There does not appear to be any data on the transfer of mebendazole or pyrantel embonate into
human breast milk although these agents are generally considered to be 'safe' due to poor absorption
from the gastrointestinal tract.

Antibiotics:
Antibiotics such as penicillins, cephalosporins and macrolides are considered to be compatible with
breastfeeding although there are theoretical risks of alterations to infant bowel flora and allergic
sensitisation.

The safety of metronidazole is controversial due to the possibility of high transfer into breast milk.
The weight-adjusted infant dose may be as high as 36% of the maternal dose indicating that infant
exposure may be higher than the arbitrary cut-off of 10%. Techniques that may be considered for
minimising infant exposure include choosing an alternative antibiotic such as amoxycillin/clavulanic
acid (if appropriate), alternating breast and bottle feeding, or withholding breastfeeding during the
treatment course. If breastfeeding is to be withheld, the mother should be encouraged to continue to
express breast milk while on the antibiotic course but to discard the milk. This will help to maintain
lactation and enable the mother to resume breastfeeding at the end of the course.

The transfer of tetracyclines into breast milk is low but they are usually avoided due to the possible
risks of inhibiting bone growth or causing dental staining. Fluoroquinolones should also be avoided
in breastfeeding as they have been reported to cause arthropathies in immature animals.
Sulphonamides such as sulphamethoxazole are unlikely to be problematical in most situations but are
best avoided in infants with hyperbilirubinaemia or glucose-6-phosphate dehydrogenase deficiency.

Anticoagulants:
Heparins (unfractionated and low molecular weight) are considered 'safe' since these agents have a
large molecular weight and do not cross into breast milk to a significant extent. They are also poorly
absorbed. Warfarin is also considered to be compatible with breastfeeding as transfer is low, and
adverse effects and changes in prothrombin time have not been detected in breastfed infants.
However, it would be prudent to monitor the infant's prothrombin time during treatment.

Anticonvulsants:
Carbamazepine, phenytoin and sodium valproate are generally considered to be compatible with
breastfeeding although the infant should be observed for evidence of central nervous system
depression. Available data on the safety of lamotrigine in breastfeeding suggest that transfer into
breast milk may be considerable and therapeutic concentrations have been detected in breastfed
infants. There are insufficient published data to comment on the safety of gabapentin in breastfeeding.

Antidepressants:
Selective serotonin reuptake inhibitors (SSRIs) transfer into breast milk to varying extents.
Paroxetine is reported to have the lowest transfer into breast milk (weight-adjusted infant dose 1-3%).
Fluoxetine transfers to a greater extent (weight-adjusted infant dose ≤ 14%) and its active metabolite,
norfluoxetine, has a long half-life of one to two weeks and may accumulate in a breastfed infant. Data
on citalopram (weight-adjusted infant dose approximately 5%) suggest that the relative infant dose of
citalopram is intermediate between paroxetine and fluoxetine. Based on these data, paroxetine is the
preferred SSRI in breastfeeding women.

Most tricyclic antidepressants are considered to be compatible with breastfeeding due to low transfer
into breast milk and this is supported by extensive usage data. Moclobemide has low-transfer into
breast milk and is considered compatible with breastfeeding.

Antihistamines:
Agents such as promethazine, dexchlorpheniramine and diphenhydramine are considered to be safe
through extensive usage, although it would be prudent to monitor for evidence of sedation or
irritability in the infant. There is less data on the non-sedating antihistamines, although loratadine and
fexofenadine are likely to be safe due to low transfer into milk.

Benzodiazepines:
Sporadic use of benzodiazepines with a short plasma half-life such as midazolam and temazepam is
unlikely to be problematical due to low quantities transferred into breast milk. Agents with a long
half-life such as diazepam may accumulate in the infant with prolonged exposure and may be
associated with lethargy, poor suckling and reduced weight gain.

Decongestants:
A short course of pseudoephedrine (weight-adjusted dose < 4%) is unlikely to be problematical.
However, topical decongestant nasal sprays or drops are usually preferred due to lower infant
exposure.

Social drugs:
These have particular problems because the dose and pattern of usage are uncontrolled. In addition
most have relatively high infant doses. Infant exposure following maternal ethanol ingestion may be
as high as 20% and has been associated with impaired psychomotor development. Alcohol
consumption should be minimised during lactation (e.g. by withholding breastfeeding for about two
hours after ingestion of a standard alcoholic drink).

Caffeine exposure may be as high as 34% of the weight-adjusted maternal dose and side effects such
as restlessness and irritability have been reported in infants exposed via breast milk.

Nicotine has been detected in the plasma of breastfed infants, and smoking is best avoided by
breastfeeding mothers. The use of nicotine replacement therapy (e.g. transdermal delivery systems) in
breastfeeding mothers should be considered in terms of risks and benefits. However, as a general
rule, the short-term use of nicotine replacement therapy is far preferable than continued smoking.

Drugs affecting milk:


Drugs can affect milk secretion or composition by affecting factors such as mammary gland
development, milk secretion and hormonal regulation of lactation. Prolactin is necessary for human
milk secretion and may be affected by drug use. Dopamine agonists such as cabergoline reduce
prolactin and are sometimes used therapeutically to stop lactation. Dopamine antagonists such as
metoclopramide and most antipsychotics may increase prolactin (see article on Hyperprolactinaemia
With Antipsychotics) and milk production. Other drugs that have been associated with causing
hyperprolactinaemia include SSRIs and opioids.

Tabulated summary of drug distribution into breast milk

Table 2 shows published M/P ratios from the literature and provides an estimate of the weight-
adjusted infant dose. Interpretation of these requires an understanding of the limitations associated
with published data, such as the availability of only single pairs of plasma and milk concentrations.
Infant clearance (related to post-conceptual age) should always be considered.

Table 2: Summary of distribution of drugs into breast milk

ID = insufficient data

Drug M/PAUC % maternal dose Comments


Acid-suppressants:
Avoid in favour of safer alternatives with
Cimetidine 1.7-5.8 5.4-6.7 lower potential for side effects. May
accumulate in milk due to active transport.
Famotidine 1.5 1.6 Probably safe.
Probably safe when restricted to sporadic
Ranitidine 2.8 5.0-7.8 doses or a single dose at night-time. May
accumulate in milk due to active transport.
Analgesics:
Avoid due to possible association with
Aspirin 0.06 3.2
Reye’s syndrome.
Codeine 2.16 6.8 Considered safe.
Ibuprofen 0 < 0.6 Considered safe. Not detected in milk.
Considered safe. One case of seizures
Indomethacin 0.37 < 1.0
(causality questionable).
Mefenamic acid ID 0.3 Probably safe.
Considered safe in methadone maintenance
as 60% of infants born to mothers in
Methadone 0.47 2.2
maintenance programmes develop
symptoms of withdrawal.
Morphine 2.46 0.4 Considered safe.
Probably safe.
Naproxen ID 1.1

Nefopam ID 0.4 Probably safe.


Use a NSAID with a shorter half-life where
Piroxicam ID 5-10
possible.
Paracetamol 0.8 2.9-7.9 Considered safe.
Exposure limited by low oral availability in
Sumatriptan 4.1-5.7 0.3-6.7 term infants. Expressing for 8 hours post-
dose will almost completely avoid exposure.
Antibiotics:
Aminoglycosides
Considered compatible with breastfeeding
Gentamicin 0.17 2.2
due to low transfer and low oral availability.

Cephalosporins

Cefaclor ID 0.7
Considered safe. Low transfer into
milk. Third generation cephalosporins
Cefalexin 0.09 0.5-1.2
have greater potential to alter bowel
flora.
Cefotaxime ID 0.3

Ceftriaxone 0.04 0.7-4.7

Fluoroquinolones
Avoid fluoroquinolones due to theoretical
Ciprofloxacin 2.17 4.8
risk of arthropathies.

Macrolides

Clarithromycin 0.25 1.8 Considered safe. May alter bowel flora.

Erythromycin 0.41 2.1

Penicillins
Considered safe. Note: although
Amoxycillin ID 0.7 amoxycillin/clavulanic acid combination
is used extensively in lactation, there are
Benzylpenicillin 0.37 0.8 no published data on the safety of
clavulanic acid.
Phenoxymethyl-penicillin ID 0.25

Tetracyclines
Avoid tetracyclines where feasible due
to the possible risks of dental staining
Minocycline ID 3.6
and adverse effects on bone
development.
Tetracycline 0.58 4.8

Others
Considered safe. No adverse effects noted
Aciclovir ID 1.1-1.2
in breastfed infants.
Potential for accumulation particularly in
Fluconazole 0.75 11
premature infants.
Controversial as exposure may be high.
Metronidazole 0.9-1.1 0.1-36.0 With high doses consider expressing and
discarding milk.
Avoid in G6PD-deficient infants (due to
Nitrofurantoin ID 0.6-6.0
the risk of haemolysis).
Sulphamethoxazole &
0.1 2-2.5 Avoid suphaemethoxazole in infants with
Trimethoprim
1.26 3.8-5.5 hyperbilirubinaemia and G6PD deficiency.
(i.e. co-trimoxazole)
Anticoagulants
Probably safe. No changes in prothrombin
Warfarin 0 < 4.4 times detected in breastfeeding infants.
Monitor prothrombin time.
Anticonvulsants:
Considered safe. Monitor for sedation,
Carbamazepine 0.36-0.39 2.8-7.3
poor suckling.
Concentrations in breastfed infants have
Lamotrigine ID 10-22 been consistent with those expected to
produce clinical effect. Best to avoid.
Phenobarbitone ID 23-156 Avoid due to high infant exposure.
Considered safe. Observe for sedation, poor
suckling. One report of
Pheyntoin 0.13-0.18 3.0-7.2
methaemoglobinaemia, poor suckling and
sedation.
Considered safe at low doses. High doses
Sodium valproate 0.05 1.8
may increase the risk of hepatitis.
Vigabatrin ID <1% Avoid until further data are available.
Antidepressants:

Tricyclics:

Amitriptyline 0.83 0.6-0.9

Desipramine ID 0.5-1.0

Probably safe. Negligible or no


Dothiepin 0.8-1.6 0.2-1.5 concentrations detected in breastfed
infants.

Doxepin ID 0.01

Imipramine ID 0.13

Nortriptyline ID 0.53

SSRIs
See text
Others
Moclobemide 0.72 1.6 Probably safe.
Antiemetics:
Domperidone ID 0.05 Probably safe. May increase milk secretion.
Low dose or sporadic use probably safe.
Metoclopramide ID 4.7-11.3
May increase milk secretion.
Antihistamines:
Probably safe. No adverse effects reported
Loratadine 1.2 0.7
in infants.
Triprolidine 0.53 0.9 Considered safe.
Antipsychotics:

Chlorpromazine ID 0.2 Probably safe. May increase milk


secretion. Monitor infant for sedation,
Flupenthixol ID 0.5-0.8 irritability etc.

Haloperidol ID 0.15-2.0

Cardiovascular:
Amiodarone ID 37 Avoid in breastfeeding.
Avoid in favour of antihypertensives with
Atenolol 2.3-4.5 5.7-19.2
lower infant exposure.
Captopril 0.03 0.014 Considered safe.
Digoxin 0.6-0.9 2.3-5.6 Considered safe.
Unlikely to be problematical in
Diltiazem 0.98 0.9
breastfeeding.
Enalapril 0.02 < 0.1 Considered safe.
Metoprolol 2.8-3.6 1.7-3.3 Probably safe.
Consider choosing a beta-blocker with a
Nadolol 4.6 5.1
lower infant dose, if feasible.
Propranolol 0.32-0.76 0.2-0.9 Probably safe.
Quinapril 0.12 1.6 Considered safe.
Verapamil 0.6 0.14-0.84 Considered safe.
Sedatives/hypnotics:
Short-term use of low doses is probably
Clonazepam ID 1.5-3.0
safe.
Reasonable to breastfeed after a low single
dose but potential for accumulation with
Diazepam 0.16 2.0-2.3
prolonged use. Sedation has been reported
in breastfed infants.
Short-term use of low doses is probably
Lorazepam ID 2.2
safe.
Short-term use of low doses is probably
Midazolam 0.16 0.7
safe.
Short-term use of low doses is probably
Nitrazepam ID ID safe. Potential for accumulation with
prolonged administration.
Short-term use of low doses is probably
Zopiclone 0.5 4.1
safe.
Social Drugs:
Cannabis (THC) ID ID Avoid as long-term effects are unknown.
Low intake probably safe. Restlessness
Caffeine 0.5-0.8 0.6-21.0 and irritability documented. Prolonged
half-life (80-100 hours) in neonates.
Occasional low usage probably safe.
Chronic intake may be associated with
Ethanol 0.9 3-4 impairment of psychomotor development.
Consider withholding breastfeeding for 1-2
hours per standard drink.
Cigarette smoking should be avoided due
to health hazards associated with smoking.
Use of nicotine patches may be considered
Nicotine 2.92 ID
compatible with breastfeeding and is
favoured over smoking.

Miscellaneous:
Ethinyloestradiol ID 0.3 May suppress lactation.
Levonorgestrel ID 1.1 Considered safe.
Medroxyprogesterone ID-0.72 3.4-5.0 Considered safe.
Norethisterone ID-0.26 0.02-1.9 Considered safe.
Short courses of low doses (≤ 20mg daily)
are probably safe. Note: there are
Prednisone ID 0.26 insufficient data on other systemic
corticosteroids (e.g. betamethasone,
dexamethasone).
Pseudoephedrine 2.5 4.0 Low doses or sporadic use probably safe.
Avoid in infants with hyperbilirubinaemia
Sulphasalazine ID 1.2-7.0
or G6PD deficiency.

Correspondence to Sharon Gardiner, Department of Clinical Pharmacology, Christchurch Hospital,


Private Bag 4710, Christchurch. E-mail: sharon.gardiner@cdhb.govt.nz

Primary sources

Atkinson HC, Begg EJ, Darlow BA. Drugs in human milk. Clinical pharmacokinetic considerations.
Clinical Pharmacokinetics 1988;14:217-40.
Bennett PN and the WHO Working Group, editors. Drugs and human lactation. 2nd edition.
Amsterdam: Elsevier, 1997.

Ilett KF, Kristensen JH, Begg EJ. Drug distribution in human milk. Australian Prescriber 1997;20
(2):35-40.

Speight TM, Holford NHG, editors. Avery's Drug Treatment. 4th edition. Auckland: Adis
International Ltd, 1997.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Narcotic Depression in the Newborn Infant Reviewed by David Knight

January
2001

Treatment of Narcotic Depression Observation and Documentation References

● This is manifest either at delivery when a baby needs resuscitation, or following


delivery with behavioural changes in the infant.
● Narcotics given to the mother in labour can contribute to depression in an
asphyxiated infant, or can result in depression without asphyxia. In this latter case,
the baby usually has a normal heart rate initially, but depressed respiration.

Treatment of Narcotic Depression

1. When indicated, resuscitation must be instituted without delay, usually before


naloxone administration.
2. Treat narcotic depression with naloxone (Narcan) intramuscularly.

a. Dose 0.1-0.2mg/kg per dose, IM.


b. Naloxone comes in ampoules containing 0.4mg/ml.
c. Intramuscular administration is preferable. The onset
of action is almost as rapid as with IV administration,
but the duration of action is much longer.

See Naloxone Drug Protocol for more details.

● DO NOT GIVE NALOXONE TO INFANTS AT RISK OF DRUG WITHDRAWAL,


WHOSE MOTHERS HAVE BEEN TAKING OPIOID DRUGS.

Observation and Documentation

● The half life of intravenous naloxone is very short, and there is the potential its
action will wear off before that of the opioid causing the depression. This appears
not to be a problem with large intramuscular doses of naloxone (as recommended
here).
● There appears to be a depot effect of the IM injection. Measurable effects of
naloxone have been seen up to 48 hours after the dose.
● Babies needing resuscitation and/or naloxone at birth need observation
afterwards. This need not necessarily be on NICU but can be with the mother in
the delivery unit or post natal ward.
● When administered in the delivery room, naloxone will often be given on the verbal
order of the doctor or NS-ANP. This order should be written on the ‘blue card’ by
the doctor/NS-ANP after the resuscitation.

References

1 Committee on Drugs. American Academy of Pediatrics. Pediatrics 1989;83:803.

2 Wiener PC et al. Br Med J 1977;2:228-31.

3 Brice JEH et al. Arch Dis Child. 1979;54:356-61


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Nappy Rash
Reviewed by Robyn Wilkinson,
Brenda Hughes, and Carl Kuschel

December 2003

Treatment of an Excoriated
Prevention Candida Nappy Rash Severe Nappy Rash
Bottom

Prevention

● Wash bottom with water/soap free solution and dry thoroughly.


● Apply petroleum jelly -a must for infants on Nutriprem or fortified milk.
❍ Petroleum jelly does not need to be prescribed on the drug chart.

Treatment of an Excoriated Bottom

● If Candida is not suspected, apply zinc oxide ointment (Karicare ointment) at


nappy changes.
❍ Zinc oxide ointment does not need to be prescribed on the drug chart.

● If bowel motions are frequent


❍ Change nappies and apply zinc oxide ointment more often.

❍ Exposing buttocks to air may not be effective.

❍ There is no evidence to suggest any benefit from using heat lamps.

● If there is no improvement after 2 days of treatment


❍ Consider sending a skin swab for Candida (Candida may not always

display a typical appearance).

Treatment of Candidiasis

● Take a skin swab


❍ It is a clinical decision as to whether you await the result or commence

treatment immediately.
● Apply nystatin (Mycostatin, Nilstat ) cream four times a day (prescribed on drug
chart).
● Continue to apply zinc ointment (after Nystatin application) to treat
excoriation.
● Treatment should extend for at least 3 days after rash has healed.
● Infant should also be treated with Oral Nystatin 0.5ml-1.0ml QID.

Severe Nappy Rash

● For example, in Short Bowel Syndrome, malabsorption, opiate withdrawal,


infectious diarrhoea, or Cystic Fibrosis.
● SECURA Extra Protective Cream cream (prescribed on drug chart) must be
applied to prevent excoriation after each nappy change.

References

1 Lund C, Kuller J, Lane A, Lott JW, Raines DA. Neonatal skin care: the scientific basis for practice. J Obstet
Gynecol Neonatal Nurs 1999; 28(3):241-54.
2 Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA. Neonatal skin care: clinical outcomes of the
AWHONN/NANN evidence-based clinical practice guideline. Association of Women's Health, Obstetric and
Neonatal Nurses and the National Association of Neonatal Nurses. J Obstet Gynecol Neonatal Nurs 2001;
30(1):41-51.
3 Bowring AR, Mackay D, Taylor FR. The treatment of napkin dermatitis: a double-blind comparison of two
steroid-antibiotic combinations. Pharmatherapeutica 1984; 3(9):613-7
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Neonatal Alloimmune Thrombocytopenia Reviewed by Alan Groves and


(NAIT) Carl Kuschel

April
2003

Background Presentation Differential Diagnosis Investigation


Management References Index of Related Documents

● Low platelet count in an otherwise healthy term newborn is due to NAIT


until proven otherwise.
● Urgent matched platelet transfusion should be discussed with specialist
on call at all times.

Background

● Neonatal Alloimmune Thrombocytopenia (NAIT) is a disorder caused by


fetomaternal platelet incompatibility analogous to that in Rhesus Haemolytic
Disease, with maternal anti-platelet antibodies crossing the placenta and
destroying fetal platelets.
● The majority of cases are caused by antibodies directed against Human Platelet
Antigen-1a (HPA-1a) and HPA-5b, but many rarer reactions have been reported.
1
● Prospective studies have shown incidence to be 1:1,100 live births, but the
2
condition is under-reported.
● Mortality is around 10% of presenting cases, with neurological sequelae, including
intracranial haemorrhage and subsequent neurodevelopmental delay in up to
3
25%.

Presentation

The commonest mode of presentation is probably the well neonate with bruises or
petechiae. However the spectrum of disease ranges from sub-clinical moderate
thrombocytopenia to catastrophic intracranial hemorrhage (ICH) and death. A high index
of suspicion is essential in all cases of active bleeding, but also in asymptomatic
laboratory diagnosed thrombocytopenia. A history of thrombocytopenia in a previous
sibling makes the diagnosis almost certain.

Modes of ● Previously affected sibling


presentation ● Recurrent fetal loss
● Antenatal ICH/hydrocephalus
● Stillbirth
● Bruising/bleeding neonate
● Excessive haematoma at injection site
● Disseminated intravascular coagulopathy
● Postnatal ICH (silent or presenting with seizures, etc)

Differential Diagnosis

Also see Neonatal Thrombocytopenia protocol

● Sepsis
● NEC
● DIC
● Placental insufficiency
● Congenital infection
● Asphyxia
● Artefact - clotted FBC sample
● Autoimmune thrombocytopenia (maternal ITP)

Investigation

FBC to confirm platelet count


Maternal FBC likely to have been performed during pregnancy. Maternal platelet
count is normal in NAIT.
● Definitive diagnosis of NAIT depends on parental testing.
● In most cases the lab prefers to do this prior to platelet transfusion, but discussion
with haematologist on call is necessary to arrange urgent testing.

● FURTHER TESTING SHOULD NOT DELAY PLATELET TRANSFUSION IF


REQUIRED URGENTLY

Maternal blood 3 x CPD (yellow) and 1x plain (red) tubes for anti-platelet antibodies
samples and genotyping.
Paternal blood 3 x CPD (yellow) tubes for genotyping.
samples If no paternal blood available, send 1 x infant plain tube for platelet
grouping.

● Direct crossmatch between parents will also be performed.


● Maternal antibody levels fall towards term, so repeat testing 6 weeks post-partum
is required in some cases.
● Phone laboratory with specimen queries (523 5731).

Management

Platelet Count
Action
(x109)
<30 Transfuse
30-49 Transfuse if any bleeding
50-99 Transfuse if major bleeding
>99 Do not transfuse

● If the infant’s platelet count is <30x109/L and the maternal count is normal, the
treatment of choice is urgent transfusion of 10ml/kg of matched platelets.
● In most cases these will be HPA-1a negative, but Maori and Asian mothers are
more likely to have antibodies other than anti HPA-1a.

● Infuse platelets over 30-60 minutes (see platelet protocol), and recheck platelet
count after one hour.
● Antigen-negative platelets should be given urgently, as infants are at significant
risk of ICH in the first days of life
● If antigen negative platelets are not available, intravenous immunoglobulin (IVIG)
1g/kg/day for 2 days may be effective.
❍ There is often a delay of 24-48 hours prior to response, leaving a window of

risk for ICH.


● If the platelet count fails to rise in response to matched platelets consider
alternative diagnoses, and check for rarer maternal antibody types.
● Affected infants should have a FBC checked daily until platelet count is stable over
100x109/L. Need for platelet transfusion at moderately low platelet counts (30-100
x 109/L) is not clear.
● It is essential that parental investigation is initiated prior to discharge and adequate
follow up arrangements made.
❍ The risk of a subsequent pregnancy being affected is 100% if the father is

4
homozygous for the reacting antigen, and 50% if heterozygous.
❍ In general, subsequent pregnancies are at least as severely affected as the
first.
❍ Antenatal therapy in subsequent pregnancies remains contentious, but
options include intrauterine platelet transfusion, maternal immunoglobulin
5
and steroids.

References

1 Williamson, L.M., et al., The natural history of fetomaternal alloimmunization to the platelet-specific antigen
HPA-1a (PlA1, Zwa) as determined by antenatal screening. Blood, 1998. 92(7): p. 2280-7.
2 Murphy, M.F., S. Verjee, and M. Greaves, Inadequacies in the postnatal management of fetomaternal
alloimmune thrombocytopenia (FMAIT). Br J Haematol, 1999. 105(1): p. 123-6.
3 Management of alloimmune neonatal thrombocytopenia. Lancet, 1989. 1(8630): p. 137-8.
4 Bussel, J.B., et al., Fetal alloimmune thrombocytopenia. N Engl J Med, 1997. 337(1): p. 22-6.
5 Roberts, I.A. and N.A. Murray, Thrombocytopenia in the newborn. Curr Opin Pediatr, 2003. 15(1): p. 17-23.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Screening for Nephrocalcinosis Reviewed by Carl Kuschel, Rita Teele


(Paediatric Radiology), and William Wong
(Paediatric Nephrology)

April
2005

Background Screening Policy Ultrasound Appearances


Follow-Up References

Background

The incidence of nephrocalcinosis (NC) in ex-premature infants is reported to be high. Although the overall
incidence of NC in VLBW infants is reported to be around 20%, 1 the incidence may approach 50% in infants
<750g at birth. 1 Local data from a group of infants who received dexamethasone for treatment of evolving
chronic lung disease showed an incidence of 83%. 2

NC may be a consequence of neonatal treatments such as diuretics and steroids, 1 or may just be a marker
of neonatal illness. Nutritional factors are thought to contribute, particularly high intakes of calcium in the diet
which may not necessarily be absorbed and instead are excreted in urine.

Although the natural history of NC is that 66% of infants will have resolution by 15 months of age and 85% by
30 months, 3 some infants will develop renal calculi. Renal function does not appear to be adversely affected
into childhood. 3

Screening Policy

● In view of the potential clinical significance of NC, infants who are <30 weeks at birth should be
screened for NC.
● These infants should have a renal ultrasound scan at the same time as their pre-discharge head
ultrasound scans (that is, around 36 weeks corrected gestational age, or earlier if ready for discharge
prior to this time).

Ultrasound Appearances of Nephrocalcinosis


More marked changes may be seen, with significant calcium deposition in the collecting systems, as below.

Follow-Up

● If significant NC is demonstrated, a referral should be sent to Dr William Wong for follow-up in the
Renal Clinic at Starship Hospital

References

1 Saarela T, Vaarala A, Lanning P, Koivisto M. Incidence, ultrasonic patterns and resolution of nephrocalcinosis in very low
birthweight infants. Acta Pædiatr 1999; 88: 655–60.
2 Cranefield DF, Odd D, Harding JE, Teele RL. The high incidence of nephrocalcinosis in a preterm neonatal population receiving
steroids. European Society for Pediatric Radiology, Genoa, 2003.
3 Schell-Feith EA, Kist-van Holthe·JE, van Zwieten PHT, et al. Preterm neonates with nephrocalcinosis: natural course and renal
function. Pediatr Nephrol 2003;18:1102–8.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Management of Infants with Myelomeningocoele Reviewed by Colette Muir, Carl


Kuschel, Andrew Law (Paediatric
Neurosurgery, Starship Hospital),
Raewyn Gavin (General
Paediatrics, Starship Hospital),
Bobby Tsang (General
Paediatrician, Waitemata District
Health Board)
October 2005

Definition Aetiology Incidence Antenatal Issues


Place and Mode of Delivery Postnatal Management Postoperative Care Prognosis

Definition

● The neural tube usually closes between 15 and 28 days post-conception. Failure
of normal closure results in a neural tube defect (NTD). 90% of NTDs are spina
bifida or anencephaly.
❍ Anencephaly is caused by a defect in the closure of the anterior portion of

the neural groove. This results in an unfused partially developed forebrain


and incompletely developed calvarium. This condition is always lethal.
❍ Spina bifida is caused by failure of closure of the posterior portion of the

neural tube.
❍ A meningomyelocoele (MM), the most common type of spina bifida, is a sac

like structure which protrudes through a defect in the vertebral arches,


containing meninges, CSF and spinal cord and /or nerve roots.
❍ Meningocoeles are rare. The structure contains meninges and CSF only.

❍ Spina bifida occulta is a common anomaly consisting of a midline defect of

the vertebral bodies without protrusion of spinal cord or meninges. The


incidence is reported to be between 5% and 40%. Most often it is
asymptomatic and of no consequence, but it can be associated with
developmental abnormalities or tethering of the spinal cord.
● Both meningomyelocoeles and meningocoeles may occur anywhere along the
spinal cord but are most common in the lumbar and sacral area.

Thoracolumbar junction 45%


Lumbar 20%
Lumbosacral 20%
Sacral 10%
Other (high) lesions 5%

● The degree of neurological impairment depends on the position and extent of the
lesion. There will usually be loss of sensation in corresponding dermatome,
complete or partial paralysis of skeletal muscles and often bladder and/or anal
sphincter paralysis.
● The Chiari II malformation (herniation of the cerebellar vermis through the foramen
Magnum, with dislocation of the fourth ventricle towards the neural canal, and
downward displacement of the tentorium) is present in 95% of children with
myelomeningocoele. This is associated with obstructive hydrocephalus.
❍ Other abnormalities of CNS development (e.g. polymicrogyria, heterotopias,

aqueduct stenosis) may co-exist.


● Orthopaedic abnormalities related to disrupted innervation of muscles (i.e.
dislocated hips, club feet) are common.
● There may be an associated spinal deformity (scoliosis or kyphosis).
● Other major abnormalities of other organ systems are unusual.

Aetiology

● The aetiology is felt to be multifactorial. However, risk factors include:


❍ previous pregnancies have been affected with NTDs

❍ some anticonvulsants such as carbamazepine and sodium valproate

❍ pregnancies complicated by diabetes at conception

● 10% of infants may have an associated chromosomal defect (e.g. trisomy 18,
triploidy, or single gene disorders). A referral to the genetic service should be
arranged, and karyotype considered as indicated.

Incidence

● The true incidence of NTDs appears to be decreasing in most parts of the world.
● Estimates of rate approximate 0.2-0.4 per 1000 livebirths.
● In 1999 in New Zealand, the prevalence of neural tube defects was 0.5 per 1000
live births. Many pregnancies complicated by NTDs result in termination –
therefore the incidence increases to 0.91 per 1,000 total births and terminations.

Antenatal Issues

● Periconceptional folate supplementation has been shown to reduce the incidence


of NTDs, with data suggesting that a daily intake of 0.4mg of folic acid reduces the
risk of 1st neural tube defects by up to 70%.
● Current New Zealand recomendations are for women to take 800 micrograms of
folic acid 4 weeks prior to and 12 weeks after conception. Women at high risk
require 5mg daily.
● Problems exist in that a real proportion of NZ pregnancies are not planned and
preconceptual folate is not taken.
Screening and Detection

● Alpha feto protein (AFP) from amniotic fluid is very reliable except when the defect
is closed.
● Maternal serum AFP is less reliable, detecting between 50-90% of open
anomalies, but is falsely positive in 5%.

● USS: Diagnosis often made at 16-18 week Coronal view of


USS. Often seen as lateral displacement of
the spinal pedicles, but the sac may also be
visualised.
❍ An axial cross section through the fetal

skull may demonstrate a “lemon head” spine


shape, with a depression of the
metopic suture in the frontal region.
❍ Visualisation of the posterior fossa

may demonstrate a “banana sign”,


observed at the level of the cerebellum
and cistern magna. It is caused by
herniation of the cerebellar vermis Sagittal view of spine
through the foramen magnum, giving
the cerebellum the appearance of a
banana.
❍ USS should evaluate for other

structural abnormalities of limbs, brain,


kidneys, and other organs.
"Lemon" shaped skull

Counselling

● Parents will usually have seen the neurosurgeon prior to delivery to discuss
treatment options and prognosis.
● Genetic counselling – 2-4% recurrence risk.

Place and mode of delivery

● Tertiary institution with access to neurosurgical services.


❍ Delivery by elective lower segment Caesarean section (LSCS) prior to the

onset of labour may result in better motor function than vaginal delivery or
LSCS after a trial of labour.

Postnatal Management

● The goal is for neurosurgical closure within 24 hours.


● Some parents may opt, after discussions with the neurosurgeon, for palliative care
or conservative management.
General Cares 1. Avoid latex products (use latex-free gloves for all
handling).

Clinical 1. Careful clinical assessment.


Assessment ❍ It is unusual, however, for other abnormalities to be

present.
2. Place the infant prone and evaluate the size, position, and
appearance of the lesion.
3. Palpate the fontanelle and sutures for evidence of raised
intracranial pressure.
4. Measure the head circumference.
5. Evaluate spontaneous movements (note that any
stimulation to promote movements should be confined to
the upper body, as reflex movements may occur in
response to stimulation of paralysed lower limbs and trunk).
6. Evaluate the level of sensation. This can be determined
using an open nappy pin (not a hypodermic needle).
7. Assess anal tone.
8. Urine output.
❍ Is there dribbling of urine?

❍ Is the bladder palpable?

Infection Risk 1. Antibiotics should be administered as per the Newborn


Services policy.
2. Blood and other cultures are not required unless the baby
is clinically unwell.

Fluids/Electrolytes 1. Remain NBM.


2. 10% dextrose as per Newborn Services Fluids and
Electrolytes policy.
3. Infants with urinary retention will require urinary
catheterisation.

Neurosurgical 1. Inform the neurosurgical team at the Starship Hospital.


Referral They will arrange for early transfer and repair of the lesion.

Imaging 1. Cranial ultrasound scan of brain to evaluate ventricular


size and to assess other malformations.
2. A CT scan or MRI is commonly obtained peri-operatively
but will be organised by or on the instruction of the
neurosurgical team.
3. Renal imaging (renal ultrasound scan and MCUG) should
be performed in the postoperative period.
Dressings 1. The baby should be nursed in the prone position.
2. The sac must be kept covered and moist prior to closure.
3. Exposure of the tissue to trauma or drying out can lead to
a “shock-like” state of the spinal cord.
4. This needs to be a strictly aseptic technique.
a. Apply saline soaked Telfa over the sac.
b. Obtain a Butterfly infusion needle, and remove the
needle.
c. Insert the Butterfly tubing on the layers of Telfa with
a second Telfa.
d. Seal the entire dressing with Tegaderm.
e. The wound can be irrigated hourly using the fine
Butterfly tubing, with small amounts of warmed
saline.

Parental Support 1. Referral to Paediatric Neurosurgical Social Worker will be


arranged following surgery.
2. A Child Disability Allowance form should be filled out.
3. Useful information for parents can be accessed from the
Australian Spina Bifida and Hydrocephalus Association
(www.asbha.org.au)

Postoperative Care

1. Will usually be undertaken on the Neurosurgical and Neurology ward (26A) at


Starship Hospital.
2. A urinary catheter usually remains in situ postoperatively (preferably until renal
imaging has been undertaken).

Prognosis

● Children require multidisciplinary follow-up including the neurosurgical team, a


developmental or general paediatrician, urologists, orthopaedic surgeons, and
physiotherapists. There should be a supervising “overviewing” paediatrician.
❍ Children with spina bifida from West and North are seen by Dr Bobby

Tsang, Paediatrician at Wilson Centre. Those from Central and South are
seen by Dr Raewyn Gavin, Paediatrician at Greenlane Clinical Centre.
● Hydrocephalus is a common occurrence after surgery but may not develop for
some weeks. However most become evident in the first 10 days post closure.
❍ The baby should be watched with serial head circumference measures and

ultrasound imaging.
❍ A shunt should be inserted if there is clear evidence of progressive

ventriculomegaly or increasing head circumference.


❍ Shunt infections and revisions are common throughout childhood.

● In the absence of treatment, the mortality of myelomeningocoele is approximately


50%.
● Normal intellect should be assumed in the absence of significant hydrocephalus or
dysmorphism.
● Children with MM have a lifetime increased risk of latex sensitivity and therefore
need to be cared for in a latex-free environment.
● Urological and orthopaedic referral will be organised by the neurology/
neurosurgery services.

References

1 Improving folate intake in New Zealand: Policy Implications: Ministry Of Health, 2003.
Folic acid and neural tube defects: the current evidence and implications for prevention. Ciba foundation
2
Symposium 181:192-208
3 Volpe JJ. Neurology of the newborn 4th ed. WB Saunders Co, Philadelphia 2001
Levene MI, Chervanek FA, Whittle MJ (eds). Fetal and neonatal neurology and neurosurgery, 3rd Ed.
4
Churchill Livingstone, London 2001.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Recommendations for Newborn Examination of All Reviewed by David Knight


Babies

December
2000

Early Examination

On the first day, all babies should have a full clinical examination.

The examiner should have full knowledge of the perinatal history and relevant family and
social history. No baby should be left in the sole care of its parents before having a full
clinical examination. The examination should include:

● Weight + percentile
● Length + percentile
● Head circumference + percentile

A general examination including looking for dysmorphic features, checking for cardio-
respiratory problems and checking the palate, hips, genitalia and anus. Eyes can be
difficult to see soon after birth; if so, this should be noted for the later examination.

Late Examination

At the end of the first week (4-10 days) the check should include the following:

● Weight (relate to birth weight)


● Head circumference (relate to birth head circumference)
● Length (relate to birth length)
● Feeding
● Meconium passage in first day
● Vomiting (especially bile stained)
● Colour, especially Cyanosis & Jaundice
● Respiratory distress (including respiratory rate)
● Heart murmur. Femoral pulses
● Eye check: Eyes open; Pupil size, shape, equal and Cornea clear, Red Reflex.
● Hips
● Cord
● Tone and activity
● Newborn screening done
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Nitric Oxide
Authorised by:
Charge Nurse - Newborn

October 2003

Introduction Purpose Scope Prescribing of Nitric Oxide


Dose Index of Related Documents

Introduction

● Nitric oxide is a colourless, odourless toxic and non-inflammable gas that can be
administered via the ventilator circuit as an additional therapy in Newborn Services.
● Nitric oxide is used to treat persistent pulmonary hypertension.

Purpose

● The following policy outlines the way in which Nitric Oxide is administered in
Newborn Services to ensure safety and best outcome.

Scope

● Applies to Level 3/Level 4 nurses in Newborn Services who have completed a NO


training session and are involved in the administration of Nitric Oxide.

Prescribing of Nitric Oxide

● Treatment initiated only on Consultant's orders.


● Charted and signed by Registrar/Nurse Specialist - Advanced Neonatal Practice
(NS-ANP) on Level 3 Nursing Chart in parts per million (ppm) including all changes
in concentration.

Dose

● Refer to the Nitric Oxide drug protocol


Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Process Issues for Neonatal Staff Attending Reviewed by Anne Wroe, CNE,
Deliveries in Operating Rooms Operating Rooms

May
2004

Welcome to NWH Caesarean Section Theatres

The theatres that deal with all Obstetric cases are Theatres 1 & 2, although occasionally
Theatres 3 or 4 may be used for an emergency case. Theatre 1 is dedicated to all acutes
and multiple births and Theatre 2 is used for elective cases, but sometimes it is also used
in the event of an emergency.

When you are required to come to the OR, in most cases you will not be required to
scrub. However, as you are entering a sterile field it is important that you maintain a level
of sterility and be absolutely aware of the sterile field.

The recommendations are:

● All persons receiving the baby from the surgeon must wear a mask. These masks
are located on the wall outside the scrub bay door (in the theatre corridor).
● All persons receiving the baby from the surgeon must wash their hands before
donning a pair of sterile gloves. It is not acceptable to wear unsterile gloves when
receiving the baby.
● Once you have put your sterile gloves on, you are not permitted to touch anything
else. Please stand with your hands clasped together out in front of you and wait
until the scrub nurse can drape a sterile guard over your arms and chest.
● Please ensure that you don’t stand too close to the sterile instrument trolley when
the nurse does drape you with the guard; sterile instrument trolley’s have been
contaminated during this process.
● All persons receiving the baby must be draped in a sterile guard, which the scrub
nurse will drape you with.
● It is not acceptable to reach onto the sterile scrub trolley and lift this guard up
yourself, even though you are wearing sterile gloves.
❍ The reason for this is that more often that not, your arms are uncovered and

you skin will shed onto the sterile field.


● You are only permitted to touch the sterile field if you have performed the correct
surgical scrub, & are wearing sterile gloves and a sterile gown.

As neonatal staff, the need to scrub and don sterile gloves & gowns is not usually a
requirement, but there are some instances where this may be necessary:

● In the event of multiple births. It is preferable if both neonatal staff members


present scrub and don sterile gloves and gowns.
● If there is evidence of meconium and the baby will require suctioning on the
operating field.
● If any baby suctioning is required in the acute case (placenta previa, placental
abruption etc) it is preferable for the neonatal staff member to scrub.
❍ The scrub nurse’s priority will be to deal with the mothers bleeding,

instruments etc and will not be able to tend to any needs of the baby on the
sterile field.
● Please consider a complete sterile scrub for all acute cases where it may be
necessary for the baby to require immediate suctioning.

There is an ADHB policy governing the practices of the surgical scrub, as well as a policy
governing the practice of donning surgical gloves and gowns. These policies are available
to read and is the responsibility of all staff who work for the ADHB to become familiar with
them. Please be aware that not all hospitals have the same policies and scrubbing
practices, but it is important that you become familiar with each hospitals different policy.
The ADHB requires you to follow their Recommended Best practices and Policies whilst
working here.

● There is also a Nurse Educator available to assist you and teach you with
scrubbing, gowning & gloving. The Nurse educator is available on Locator 93 4390
should you need help. Please call up in advance to set up a time to teach you
these practices.

If you are bringing a Trainee Intern with you to the OR to assist, please ensure that they
adopt the appropriate practices.

If you have any problems at all, please don’t hesitate to contact the Nurse Educator.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Orthopaedic Problems Reviewed by Starship


Orthopaedic Service

March
2003

Talipes
Congenital Dislocation Abnormalities of
Talipes Equinovarus Calcaneovalgus and Arthrogryposes
of the Hips Hands, Feet and Digits
Vertical Talus

There is a Paediatric Orthopaedic Team at Starship Hospital. Referral to an Orthopaedic


Surgeon should not be carried out before a baby has been seen by a Consultant
Paediatrician.

● Referral is done by faxing a referral consultation sheet to the Paediatric


Orthopaedic Clinic (internal 5906, External 307 8906) and phoning through to
extension 6116 as well.
❍ More urgent referrals should also be telephone through to the on-call

Orthopaedic Registrar at Starship Hospital.

They will either visit National Women's Hospital within the first week to 10 days of life, or
request that the infant be given an appointment to their weekly outpatient clinic at
Starship Children's Hospital.

Congenital Dislocation of the Hips

The term encompasses a spectrum of abnormalities ranging from severely dysplastic or


teratogenic hip to one which is barely subluxatable. The treatment modality is according
to the classification (e.g. frankly dislocatable hips need treatment from the first week,
whereas subluxable hips may only need to be seen with radiographs at 4 months by an
Orthopaedic Surgeon).

The Starship Orthopaedic Surgeons would like to have referred:

1. Babies who fall into the at risk category


a. breech deliveries
b. family history of hip problems, particularly congenital
dislocation
c. babies where there are other orthopaedic abnormalities or
neuromuscular problems
2. Any baby in whom, at any stage, there has been a query about their
hips regardless of the experience of the examiner.

It is not generally useful to see babies with unstable hips before the age of 5- 7 days of
life, so that they would normally be seen at the end of the first week and then again at the
age of 4 months with radiographs. The question of using double nappies as an interim
measure for subluxable hips depends upon the individual Orthopaedic Consultant

Note: If a baby has not been assessed by an Orthopaedic Surgeon at the time of
discharge from hospital it must be quite clear from the details given on the referral form
whether the hip is one which needs to be seen urgently or at 4 months of age. In addition
adequate arrangements must be made to maximise the probability of families with
transport or financial problems being able to attend.

Talipes Equinovarus

Talipes equinovarus referrals should be sent to the Paediatric Orthopaedic Department at


Starship Hospital as soon as possible.

Talipes Calcaneovalgus and Vertical Talus

These may need to be x-rayed and it is recommended that specialist Orthopaedic


Radiology be performed at Starship Hospital. This would normally be arranged after
consultation with the Orthopaedic Surgeon.

Abnormalities of Hands, Feet and Digits (Syndactyly, Amputations, and


Duplications)

Although this is in the field of both plastic and orthopaedic surgery it has been our
practise to refer cases to the orthopaedic team at Starship Hospital. However an
alternative source of referral for hand anomalies would be Middlemore Hospital.

Arthrogryposes

This is a complex group of disorders which may result from intrauterine compression or
underlying neuromuscular disorder. This should be considered when making assessment
and referral, particularly where neurological problems are suspected.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Oxygen Therapy and Monitoring Reviewed by David Knight

August
2002

● Supplemental oxygen must always be monitored.


● There are risks of too little or too much oxygen.
❍ Preterm infants are at risk of ROP with high levels.

❍ Term infants are at risk of pulmonary hypertension if hypoxaemic.

❍ Babies with chronic lung disease are at risk of pulmonary vascular disease

if hypoxic.

See the list of related documents

Monitoring

Pulse Oximetry (SpO2)

● Any baby receiving oxygen therapy (except chronic babies prior to discharge)
should have continuous pulse oximeter monitoring. These are very useful and
easy to use.
● Accuracy is about ± 2%. The therapeutic range is small. Remember the oxygen
dissociation curve in interpreting the result.

Moves to the Left Moves to the Right


● Fetal Hb ● Adult Hb
(SpO2 higher for given (SaO2 lower for a
PaO2) given PaO2)
● Alkalosis ● Acidosis
● Low temperature ● High temperature
● Low PaCO2 ● High PaCO2
● Low 2-3 DPG ● Low 2-3 DPG
Umbilical Artery Catheter

● Use in preference to peripheral in VLBW or babies likely to have prolonged or


difficult course.
❍ Use size 3.5 FG <1000 gms, 5 FG >1000 gms.

● Preferably, use a high catheter position (T6-T10) rather than the low position (L3-
L4).

Peripheral Artery (Radial, Ulnar or Posterior Tibial)

● For Radial/Ulnar, check patency of other artery by transillumination. (Allen test is


unreliable.)
● Do not use if other artery is not patent.

Arterial Stabs

● These are seldom necessary as oxygenation can be determined by SpO2 and CO2
is often inaccurate with a stab on an unsettled baby.

Transcutaneous Monitor (TcPO2 and TcPCO2)

● These may be useful in complementing SpO2 monitoring, but are less reliable and
more difficult to use.

Capillary Blood Gas

● This gives an indication of pH and PCO2 only and is not accurate.


● They are NOT useful for PO2 assessment.
● Interpret results with caution.
● Check with an arterial blood gas if necessary.
● Interpret in the whole clinical context (i.e. look at the baby).
● The result tells you that the true pH and PCO2 are probably no worse (well not
much) than the capillary result.
● Do not repeat an imprecise and not very useful test too often!

Tissue Oxygenation

● This is dependent on the tissues need (utilisation or uptake) and oxygen delivery.
● O2 delivery varies with blood flow and O2 content, in turn a product of haemoglobin
and saturation.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Oxygen Therapy: Standing Orders for Nursing Staff Reviewed by David Knight

July
2001

● Oxygenation and oxygen therapy must be closely monitored.


● Appropriate use is life saving but inappropriate use has dangers: i.e. high levels
contributing to retinopathy of prematurity and low levels to pulmonary hypertension.
● In unwell infants, oxygen needs are continually changing and the nurse should
vary the inspired oxygen concentration within these guidelines.

1. A cyanosed baby or one with a low saturation (SpO2) should be given enough
oxygen to become pink or saturated. It may be necessary to initiate other
resuscitative procedures. Call medical staff for urgent assistance.
2. Babies receiving supplemental oxygen, or those likely to need it should be
monitored by continuous pulse oximetry, (with the exception of babies close to
being discharged on oxygen). If an arterial line is in situ, regular blood gases
should be done. The frequency of these varies with the clinical situation (discuss
this with medical staff or NS-ANPs).
3. The following are the recommended values. Any different range for an individual
baby should be noted and signed on the nursing chart by Dr/NS-ANP.
Click here to open the saturation targets
4. The nurse should alter the inspired oxygen to maintain the appropriate SpO2/
PaO2. Remember that babies having apnoeas need to breath to oxygenate: it may
be more appropriate to stimulate, bag or change ventilation settings rather than
increase FiO2.
5. If there is a sustained change in FiO2 of more than 0.1 (10%), inform medical staff.
6. Be careful to decrease FiO2 after a desaturation and avoid overshooting to
high SpO2 levels.
7. With Persistent Pulmonary Hypertension of the Newborn, FiO2 is not to be
decreased except on (signed) medical orders.
8. In some babies with complex cardiac conditions, a low saturation is desirable to
help prevent ductus closure and excessive pulmonary blood flow. In these babies,
the medical staff will determine the desired saturation range.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Oxygen Saturations and Targeting Reviewed by David Knight, Simon


Rowley, and Carl Kuschel

May
2004

Oxygen Saturation Targeting in Infants

Infants PaO2 (kPa) Saturation Range


VLBW (<1500g) 6.5-9.0 85-92%
VLBW >4 weeks old 8.0-10.0 90-95%
LBW 8.0-10.0 90-95%
90-100%
Term/post-term 8.0-12.0 In the first 24
hours, 95-100%
CLD AND 36 weeks
8.0-10.0 90-95%
PMA

Overnight Saturation Run Guidelines

● For infants who are in air and do no need supplemental oxygen,


saturations which are mostly above 90% are regarded as
satisfactory.
● For babies who are in oxygen, saturations should be targeting the
following values:

Saturation Level Proportion of Study


90-95% 80-90%
<90% 10-20%

Reference: Askie LM, Henderson-Smart DJ, Irwig L, Simpson JM. Oxygen-saturation targets and outcomes in
extremely preterm infants. N Engl J Med 2003;349:959-67.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Low Flow Oxygen FiO2 Calculator


Page developer: http://www.nicutools.org/ with
modifications by Dr Michael Hewson, NICU, Wellington
Hospital

● Use this calculator to estimate the effective FiO2 that low flow oxygen delivers.

Weight: Kg

Respiratory rate: breaths/min

Gas flow: ml/Min

Blender Oxygen: 100 %

Actual Inspired O2:

● Simply input the child's weight (in kg), his or her respiratory rate, the current O2 flow rate and percent O2 at the blender.
● The algorithm uses a method validated by Finer et al, Pediatr Pulmonol 1996;21(1):48-51. Finer’s formula has been modified to allow for the
use of an O2 blender. A tidal volume of 5.5mL/kg is assumed.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for the Parent-Infant Nursery Reviewed by Moira Malarkey, Carl


(PIN) Kuschel, and Simon Rowley

April
2006

Medical and Nursing


Purpose Admission Criteria Handover Discharge
Staffing

Back to the Parent-Infant Nursery (PIN)


See also the PIN Registrar Guideline

Purpose

● The PIN environment should be quiet, intimate, and provide privacy and comfort
but also provide company for parents to support each other.
● There is an expectation that parents will actively participate in the discharge
planning process.
● Staff in the Newborn Service are there to support parenting with the emphasis on
encouraging the family/whanau to stay and carry out many of the baby’s cares.
● An important aim is to be able to "demedicalise" the baby before discharge home
in an environment that is safe.

Admission Criteria

● PIN is not an observation unit for acute babies. Babies will not be admitted
directly to the Neonatal Service via PIN, unless transferred in from another
neonatal unit and requiring only the level of care provided in PIN.

Absolute Admission Criteria:

● >1200g (and preferably >1400g)


● ≥32 weeks gestation (corrected)
● on full oral feeds

Relative Criteria for Admission to PIN:


Infants who have "greater than usual" medical needs can still be considered for PIN (if
staffing allows):

● On low flow oxygen


● On antibiotics
● Long line antibiotics (if staffing appropriate)
● Top up transfusions (if staffing appropriate)

Contraindications to Admission to PIN:

● ADAPT babies. These babies should either be nursed on the postnatal wards with
the mother, or on NICU.
● Babies who are expected to be in PIN for less than 48 hours and whose mother is
still on the postnatal ward should not be admitted as they may directly to the ward

Medical and Nursing Staffing

● The infants will be under the Level 2 Specialist Team.


● A Registrar will be assigned to spend one week on PIN.

● Click here to access the PIN Registrar guidelines


● The specialist is available to review babies or meet with parents as
requested by the Registrar/FLN or family/whanau on other days.

● There will be a Family Liaison Nurse in PIN Monday to Friday. The FLN will co-
ordinate discharge planning with the multidisciplinary team.
● When patient numbers are high it is important to try to maintain the special
purpose and ambience of PIN.

Handover

● There will be a list on the whiteboard in NICU of babies coming up to readiness for
transfer to PIN. The decision is made by the Specialist, FLN and CCN each day.
● It is expected that all babies being transferred will have a handover written in the
case notes pending the letter.
❍ Complicated infants who are transferred directly from Level 3 require a

formal transfer letter and a consultant handover.


❍ Infants who have been in Level 2 following an admission to Level 3 do not

require a further letter if they have had an uncomplicated course and a


letter of transfer from Level 3 to Level 2.
❍ Complicated infants who have been cared for primarily in Level 2 also

require a formal transfer letter.

Discharge Criteria

In general, an infant is ready for discharge when


● They are able to maintain their temperature in a cot,
● They have had 24 hours of full sucking feeds OR 3-4 breast feeds during the day,
● They are medically stable, and
● The family/whanau are adequately prepared for discharge and follow-up through
Newborn Home Care Nursing service or transfer to a well health provider has been
arranged.
● Most babies will achieve these criteria at 36 weeks corrected gestational age or
greater.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Parvovirus Infection and the Fetus


Availability of Testing in Auckland Reviewed by

One available test involves using a DNA probe to identify the virus. This means that this
test needs to be done during the acute phase as basically one is looking for virus particles
in the blood.

IgM, IgG and DNA testing for parvovirus are available in Auckland. Thus active parvovirus
infection can be identified locally by the IgM/IgG (just need 1-2ml plain serum) and
parvovirus viraemia can also be identified if this is an issue, also (2ml plain serum). In
many instances the viraemia will have cleared by the time the rash is apparent, so
serology is a useful option for the acute (as well as the not quite so acute) diagnosis.

In regard to fetal hydrops, there is little data on finding parvovirus in the amniotic fluid
when the fetus is infected, but it would seem reasonable to assume it would be there. We
could certainly assay for parvovirus DNA in amniotic fluid. The same goes for any/all
tissues, including placenta – direct assay for parvovirus DNA would be the most useful
thing to do. A small quantity of tissue (not in formalin) in a sterile disposable plastic
container, put on ice and sent to the Virology Laboratory.

If parvovirus is suspected in a fetus or young infant, examination of mother’s serology


may be helpful diagnostically.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Patent Ductus Arteriosus Reviewed by David Knight

December
2000

Incidence Diagnosis Investigations


Management Other Related Documents

Incidence

● PDA is a problem in ventilated very low birth weight infants. About 40% of these
will have a large PDA at 3 days of age.

Diagnosis

● Early: Mostly silent, with no murmur. BP may be low (systolic, diastolic and mean)
with normal pulse pressure.
● Late: Murmur. Hyperactive precordium.
● Increased pulses. Wide pulse pressure. These are not reliable signs in the first
few days.
● Congestive Heart Failure
❍ Cardiomegaly.

❍ Hepatomegaly.

❍ Pulmonary congestion/oedema/plethora.

● Clinical respiratory deterioration.


● Rising PaCO2.

Usually diagnosed late. Most babies treated before this stage.

Investigations
Echocardiogram ● Rules out (most) congenital heart disease. Important to rule
out duct dependent lesions.
Click here to see some still ● Establishes duct patency and size.
images of ducts ● Indicates size of shunt. (ductus shunt best assessed by its
physical size, then by descending aortic flow pattern, then
by LA and LV size).
● Assesses atrial shunt and size.

Chest X-ray ● To look at heart size and lung fields.

ECG ● Usually normal. Do if ‘atypical’, PDA persists or suspicion


on congenital heart disease.

Management

<1000gms and ● Echocardiogram at 3 days.


on IPPV or ● Significant PDA: Consider indomethacin.
CPAP
Other babies ● Investigate if clinical suspicion.
on IPPV
Indomethacin ● See drug protocol.
● Monitor creatinine, electrolytes, urine output & platelets before
and at least daily.
● Review baby and results before each dose.
● Contraindications:
Thrombocytopenia
NEC
Bleeding diathesis
Poor renal function
Pulmonary haemorrhage (note: may occur because there
is a PDA)

Fluid restriction ● While on indomethacin, reduce by 20-40ml/kg/day.


● There is no evidence that fluid restriction per se results in
closure of the duct but there are studies suggesting that early,
liberal fluid intakes are associated with a higher incidence of
PDA.

Surgery ● If PDA is still clinically significant after indomethacin, or if


indomethacin is contraindicated. Surgery will usually be
performed on NICU.
● Note that a increase in respiratory support is often required
immediately after surgery.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Persistent Pulmonary Hypertension of the Newborn Reviewed by Simon Rowley and


(PPHN) Carl Kuschel

January
2001

Pathogenesis Diagnosis Investigations


Management Aims Specific Therapies References

Infants with Persistent Pulmonary Hypertension of the Newborn (PPHN) are exceptionally
unstable and difficult to manage. After initial resuscitation the management should always
be discussed with the consultant on call.

Pulmonary hypertension of the newborn with right to left shunt occurs in a variety of
clinical situations. These include Meconium Aspiration Syndrome, hypoplastic lungs,
transient tachypnoea of the newborn, congenital pneumonia and hyaline membrane
disease. Secondary disturbances such as polycythaemia and myocardial failure are
contributory. There is frequently a history of chronic in utero hypoxia, but some cases
remain idiopathic.

Pathogenesis

● Pulmonary vasoconstriction is exacerbated by hypoxia, acidosis, and


hypercapnia (?secondary to changes in pH). Meconium may trigger vasoactive
process to exacerbate this.
● Anatomic abnormality of the pulmonary vascular bed (e.g. pulmonary hypoplasia
with pulmonary arteriolar smooth muscle hypertrophy) or chronic in-utero
hypotension following chronic intrauterine hypoxia may also play a role.
● Birth asphyxia with hypoxia, acidosis and shock is clinically associated with
increased responsivity of the pulmonary vascular bed.
● Group B streptococcal sepsis via Strep polysaccharide toxins.
● Polycythaemia, hyaline membrane disease, hypocalcaemia and hypoglycaemia
may contribute similarly.
● Structural lung abnormalities (e.g. congenital diaphragmatic hernia, CCAM, ...) are
frequently associated with PPHN.

Diagnosis
● This is essentially one of exclusion of significant cyanotic congenital heart disease
and severe parenchymal lung disease. However, PPHN may coexist with
significant parenchymal lung disease.
● Have a high index of suspicion for the 'at risk' group in a term baby with respiratory
distress and cyanosis, particularly if there has been a history of intrauterine
hypoxia and meconium exposure or birth asphyxia.

Investigations

Necessary investigations include

● chest radiograph
● serial arterial blood gases (simultaneous pre- and post-ductal samples may be
helpful)
● full blood count
● blood cultures
● blood glucose
● calcium
● Echocardiogram.
This is crucial to exclude cyanotic congenital heart disease (particularly
transposition of the great arteries, and totally anomalous pulmonary venous
return). In the presence of significant parenchymal lung disease, cardiac
assessment is less urgent.
Echocardiography is also useful to
1. assess myocardial function, which is often severely affected
2. assess the severity of PPHN, and assess responses to treatment.
■ Tricuspid regurgitation - allows indirect measurement of the RV

pressure and therefore severity


■ Ductual shunting

■ Shunting through the foramen ovale

3. Click here to see echocardiographic images of PPHN


● The hyperoxic test may play a role in diagnosis if 2D echocardiography is not
available. However, severe PPHN is likely to produce a similar result to cyanotic
CHD.

Aims of Management

1. Lower pulmonary vascular resistance.


2. Maintain systemic blood pressure.
3. Reverse right-to-left shunting.
4. Improve arteriolar oxygen saturation and oxygen delivery to the tissues.
5. Minimise barotrauma.

Specific Therapies
1. Oxygen and a. 100% O2
ventilation Always start with 100% oxygen and reduce the FiO2, rather
than starting on 25% and increasing. In the short term
there is no risk to a term baby using such measures.
b. Normo-ventilation i.e. pO2 7-12 kpa is acceptable if baby
stable
c. pCO2 5-7 kpa if this can be achieved
d. Use of HFOV, particularly in combination with inhaled Nitric
Oxide, has been shown to reduce the need for ECMO.

2. Normotension a. Myocardial function is frequently poor, despite reasonable


blood pressures.
b. Aim to keep the mean arterial pressures above 50mm Hg
in term infants
c. Use volume (initially normal saline) and dopamine -starting
with 5-10 mcg/kg/min and/or dobutamine 5-10 mcg/kg/min
if systemic pressure raises and pulmonary pressure stays
the same, R-L shunt will diminish .
d. Adrenaline infusions may be indicated if there is severe
myocardial dysfunction

3. Avoid a. Aim to keep the PCV between 0.40 and 0.45.


polycythaemia

4. Alkalosis a. Establish the critical pH- preferably 7.45 but may be


higher. If there is no dramatic improvement in PaO2 at a
pH >7.6, the infant can be deemed to be "pH
unresponsive".
b. Use small boluses of bicarbonate (1-2 mmol/kg) or a
continuous infusion (0.5mmol/kg/hour initially). Liberal
bicarbonate use may result in hypernatraemia and
hypokalaemia.

5. Sedation a. Many babies are very unstable.


b. Consider early use of narcotic infusions.

6. Muscle a. This may be necessary to gain initial control in very


Relaxation vigorous babies who are not adequately sedated with
narcotics and are fighting the ventilator to their detriment.
b. Use pancuronium 100micrograms/kg/dose PRN preferably
for 24 hours or less.
7. Pulmonary a. Inhaled nitric oxide (iNO) is the vasodilator of choice.
vasodilators iNO should be started at 20ppm and reduced to 5ppm as
able, according to response and to stability.
Methaemoglobin levels should be monitored (these are
measured automatically on blood gases).
Nitrogen dioxide (NO2) levels should be monitored and
kept below 1ppm.
b. Magnesium sulphate may be used in refractory cases. The
use of MgSO4 is controversial but may be indicated in
selected instances.
c. Prostacyclin may also be used in severe and refractory
cases, although it is difficult to obtain and its use is
controversial.
d. Tolazoline is no longer used at NWH. It is a non-registered
medication. It has an unpredictable effect and frequently
results in systemic hypotension and collapse.

8. Hyperventilation a. Inducing alkalosis by hyperventilation often creates as


many problems as it solves and is best avoided. There can
be an improvement in PO2.

9. ECMO a. This is essentially prolonged cardio-pulmonary bypass and is provided via


PICU at Starship Hospital.
b. Usual criteria are infants who have an Oxygenation Index (OI) >40 but it may
be appropriate to discuss infants who may potentially require ECMO with the
PICU specialist early rather than when ECMO or death are imminent. This will
be done specialist-to-specialist. The neurological status of the infant may be
an important factor in determining if ECMO is offered.

Click here to open the OI


OI = MAP x100 x FiO2
calculator
PaO2 (mmHg)

where MAP is Mean Airway Pressure,


PaO2 is the arterial oxygen tension in mmHg (1kPa
= 7.5mmHg), and
FiO2 is the fraction of inspired oxygen (100% = 1.0,
air = 0.21)

10. Weaning a. Weaning such babies is invariably difficult. Steps should be


taken one at a time and by small increments once lability
appears to have stabilised.

Other

● Pay careful attention to maintaining normal electrolytes, blood glucose, calcium


and nutrition.
● In babies on long term ventilation, particularly if they are growth retarded from the
outset, intravenous nutrition may be required.

References

1 Drummond WH. Persistent pulmonary hypertension of the neonate (Persistent fetal circulation syndrome).
1984, Year Book Medical Publishers, In. pg 61-85.
2 Fox WW, Duara S. Persistent pulmonary hypertension in the neonate: Diagnosis and management. J
Pediatr 1983; Vol 103:4 pg 505-514.
3 Drummond WH, Gregory GA, et al. The independent effects of hyperventilation, tolazoline, and dopamine
on infants with persistent pulmonary hypertension. J Pediatr 1981; 9(4): 603-611
4 Wung J, James LS, et al. Management of infants with severe respiratory failure and persistence of the fetal
circulation, without hyper- ventilation. Pediatrics 1985; 76:4, pg488-494.
5 Hansen and Corlet from "Diseases of the Newborn" : Disorders of the transition. Taeusch Ballard Avery 6th
edition -Chapter VIII.
6 Finer NN, Barrington KJ. Nitric oxide for respiratory failure in infants born at or near term. Cochrane
Database of Systematic Reviews 2000; Issue 2. Update Software.
7 UK Collaborative ECMO Trial Group. UK collaborative randomised trial of neonatal extracorporeal
membrane oxygenation. Lancet 1996; 348:75-82.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Administration and Monitoring of Phototherapy Reviewed by Charge Nurse -


Newborn

June
2005

Purpose Medela Phototherapy Lamp Ohmeda Biliblanket Phototherapy Lite Meter

Purpose The following policy/recommended best practice outlines the use of


phototherapy lights and the Ohmeda Biliblanket to ensure the best
outcomes for babies in the Newborn Service.
Scope Applies to all Nurses who work in Newborn Services

Associated Operating manuals for:


Documents
● Medela Phototherapy Lamp (Instructions for Use)
● Minolta/Airshields Fluoro-Lite Meter (Model 451)
● Biliblanket Plus Phototherapy System (Operation, Maintenance
and Service Manual)

Medela Phototherapy Lamp

● Follow the steps below to ensure that phototherapy is delivered safely

Step Action
1 Position phototherapy unit 25-30cm from baby in a cot or 2cm above the top of
the incubator.
2 Baby is nursed naked.
3 Use appropriate sized eye shields to protect eyes.
4 Use the phototherapy lite meter to check the unit’s light output each duty.
Output should be over 10mcw/nm/cm2.
5 To avoid the possibility of burns do not use baby lotions or creams on baby’s
skin.
Ohmeda Biliblanket

● Follow the steps below for using the biliblanket.


● Use in conjunction with Medela Phototherapy lamp when SBR level high/rising.

Step Action
1 Insert the fibreoptic pad into, disposable cover.
Secure the cover around the protruding cable with the self-adhesive tabs.
Do not use without disposable cover.
2 Set the brightness selector switch to high.
3 Place covered pad directly under baby with the white illuminating side facing up.
4 Use appropriate sized eye shields to protect eyes.
5 Ensure the air circulation vents on the top and bottom of the illuminator are
unobstructed at all times and that the blocked air circulation indicator is not on

Minolta/Airshields Fluoro-Lite Meter 451

● Follow the steps below.

Step Action
1 Place cap firmly over the receptor head dome.
2 Set the on/off switch to on. The letters ‘Cal’ should appear in the display
window.
3 The ‘Cal’ display will be followed by a zero level display. This indicates that the
meter is calibrated.
If the display window is blank, or three decimal points (…) appear, this indicates
a weak battery.
4 Hold receptor level with the upper surface of baby. Read the digits displayed. If
<10mcw/nm/cm2 remove the phototherapy unit and send to electronics for
evaluation
5 If no measurement is recording, press the hold/run measuring switch. This will
allow the measurement to be displayed
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Guidelines for the Use of Chest Physiotherapy


Reviewed by David Knight

November 2000

1. Chest physiotherapy is no longer used at National Women’s Hospital on newborn


babies. It is not available. However, it is possible that a baby with a particular
problem may need chest physiotherapy at some time in the future and that this
may be organised with paediatric physiotherapists in another Auckland Hospital.
Therefore, this guideline is still in the file.
2. Babies under 1500g, less than a month of age should not be treated with chest
physiotherapy.
3. Chest physiotherapy should only be commenced when specifically ordered by the
Specialist.
4. Chest physiotherapy should be discussed by a doctor/NS-ANP with the parents
before starting.
5. The physiotherapist will decide on the method of physiotherapy to be given. For
percussion, the baby’s head must be held during physiotherapy.
6. Chest physiotherapy is given by physiotherapists only.
7. The need for ongoing chest physiotherapy should be reviewed daily and recorded
in the medical notes, unless an order for long term chest physiotherapy is made
and recorded.
8. Head ultrasounds should be done at least two weeks after ceasing physiotherapy.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Plasma Administration
Reviewed by

FDP Complications Administration Volume to Transfuse Ordering

Fresh Lyophilised (Freeze dried) Plasma (FDP)

Platelet poor plasma separated from single unit of donor blood within 6 hours of its
collection and therefore rich in all coagulation factors, freeze dried in 50ml volume. This
contains approximately 80% of clotting factors present in fresh normal plasma.

Fresh frozen plasma is also available, but is usually only indicated for:

1. Cl esterase inhibitor deficiency.


2. Some cases of Von Willebrand's for factor deficiency

Complications

1. Infections with HBV, HIV, bacterial contamination etc. as for red cell transfusion.
2. Volume overload.
3. Allergic reactions.
4. Antibody mediated reactions, e.g. if group A plasma (containing Anti-B) is given to
a group B baby, haemolysis may occur. Leucocyte antibodies may be present in
donor blood and could cause reactions.
5. May contribute to rise in blood viscosity.

Administration

1. Reconstitute over 10 minutes swirling gently. Use immediately.


2. As for red cells, draw into syringe through a new 170u blood group filter and infuse
generally over not more than 2 hours.

Volume to Transfuse
● FDP contains around 80% of clotting factors found in fresh normal plasma.
● Bleeding and abnormal clotting may occur when one or more clotting factors fall
below 30%.
● Baby's plasma volume will be approximately 50ml/kg

Therefore: 50 x 0.3 = 18.75ml/kg of FDP containing 80% clotting factors


should correct bleeding if clotting factor levels are 0%.

● Where volume overload is a problem, double or triple strength plasma can be


made by reducing the volume of reconstituting fluid to 1/2 or 1/3 - this solution will
be hypertonic and should be infused SLOWLY over at least 1 hour if possible.

Ordering

For individual patients order on green blood product request form (S407) through Blood
Bank.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Monday, May
22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Prevention of Hypothermia in Infants <30 weeks Reviewed by Bronwyn Jones (NNP)


Gestation and Malcom Battin

August
2005

Introduction Which Babies When and How to Apply In the Operating Theatre
In Delivery Unit When CPAP is Required When to Remove the Wrap References

Introduction

● Hypothermia in the premature newborn is associated with increased mortality and


morbidity. 1
● In infants <1500g, temperatures on admission to the neonatal unit are on average <35.5°
C.
● Polyethylene wraps have been shown to be an effective intervention in improving core
temperature on admission to neonatal units. 2

Which Babies

● This guideline applies to infants born at <30 weeks gestation at National Women’s Health
in either delivery unit or theatre and - if practical - elsewhere in Auckland City Hospital (e.
g. antenatal wards, WAU or ED).

When and How to Apply

● Plastic wrap should be pre-warmed.


● Note that the infant is not dried prior to being placed in the wrap.
a. Baby wrapped
without drying
wrapping the
head first.

b. Sides
wrapped in
similar fashion
as one would
when using a
towel.
c. Infant is
resuscitated in
plastic wrap.

d. Heart-rate can
be
auscultated
through
plastic.

e. A SaO2 probe should be applied to the right arm/hand as soon as possible following
delivery via the bottom of the wrapped infant.
f. Vitamin K should be given in the Newborn Unit. (Note this should be prescribed on the
stat dose side of the drug sheet).
g. Temperature should be taken immediately on arrival in the NICU and again at 1 hour.

In the Operating Theatre

● In theatre the infant is transferred to the radiant warmer and placed on a plastic wrap that
has been pre-warmed.
● Plastic wrap pre-
warmed on heat
table.

In Delivery Unit

● In the Delivery Unit the infant is wrapped in warmed plastic wrap directly at mother’s
bedside in the same manner as outlined above.
● The infant is then transferred to the radiant warmer for immediate management.

When CPAP is Required

● If CPAP is required the babies head should be dried and CPAP bonnet applied in the
usual way keeping the babies body wrapped in plastic.

When to Remove Wrap

● When the infant is stabilised in the neonatal unit in either a humidified incubator or heat
table the plastic can be removed.
● Drying the infant is not necessary.
● Admission temperature and temperature at 1 hour should be recorded and care must be
taken not to overheat the infant.

References

1 Costeloe K, Hennessy E, Gibson A, Marlow N, Wilkinson A. The EPICure Study: Outcomes to discharge from
hospital for infants born at the threshold of viability. Pediatrics 2000;106(4):659
2 McCall E, Alderdice F, Halliday H, Jenkins J, Vohra S. Interventions to prevent hypothermia at birth in preterm and/
or low birthweight babies. The Cochrane Database of Systematic Reviews 2005.
Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for
Monday, May 22, 2006.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this
guideline.

Pneumothorax Reviewed by Charge Nurse


Overview Newborn

April
2004

Overview Other Related Documents

See also the radiology pages on air leak syndromes

Overview

Purpose ● This document details the policies and recommended best practices
of air leak syndromes and chest drain management in Newborn
Services.

Scope ● Applies to all Nurses in Newborn Services caring for baby requiring
chest drain management.

Associated Type Document Title(s)


Documents
Newborn ● All policies/RBP associated with the care/treatment
Services of baby while in Newborn Services
R