ESSENTIAL NEWBORN

CARE
DR. PAVITHRA
DNB PAEDIATRICS
• Introduction
• Promotion of newborn and young infant health and prevention of newborn and
young infant illnesses
1. Care of the newborn immediately after birth
2. Postnatal care
3. Newborn immunization
• Management of newborn and young infant illnesses
4. Newborn resuscitation
5. Management of suspected neonatal sepsis
6. Care of the preterm and low-birth-weight newborn
7. Care of the newborn of an HIV-infected mother
8. Management of other severe conditions
— Neonatal seizures
— Neonatal jaundice
— Necrotizing enterocolitis
— Congenital syphilis
— Ophthalmia neonatorum
INTRODUCTION:
• What health interventions should the newborn and young infants < 2
months of age receive and when to receive it?
• What health behaviours should a mother/caregiver practise (or not
practise)?
Care of the newborn immediately after birth:
Immediate drying and additional stimulation

Delayed cord clamping

Skin to skin contact

Initiate breastfeeding

Vitamin K prophylaxis
 Nasal/
oral
suction
- babies born through clear
amniotic fluid & who do not
start breathing
- Mouth full of secretions
- neonates born through
meconium do not
spontaneously breathe
Tracheal
suction
- Routine suction: babies
born through clear amniotic
fluid & who start
spontaneous breathing
- Intrapartum suction : at
delivery of head in neonates
born through meconium &
spontaneously breathing
- Tracheal suction : born
through meconium and
spontaneously breathing
Post natal care
1. Timing of discharge from the health facility- at least 24 hours after
birth
2. Timing and number of postnatal contacts

day 3
day 7– 6
all (48–72 all all
14 weeks
hours)

3. Home visits in the first week of life

4. Assessment of the newborn

stopped feeding well

any jaundice in first

24 hours of life, or history of
yellow palms and convulsions
soles at any age.

temperature
fast breathing
>37.5oC or <35.5oC

no spontaneous severe chest in-

movement drawing
5. Exclusive breastfeeding
6. Cord care
7. Keeping the newborn warm
Newborn immunization
Hepatitis B
as soon as possible after
birth, preferably within 24
hours
Oral polio
BCG vaccine
vaccine
The birth dose should
be administered at
birth, or as soon as a single dose
possible after birth
Other care:
 Communication and play should be encouraged.
 Preterm and low-birth-weight babies - special care.
Management of newborn and young infant
illnesses

4. NEWBORN RESUSCITATION

Immediate care after birth

• Delayed cord clamp.
• Early cord clamp
Positive-pressure ventilation

PPV within one minute after birth.

In term or preterm (>32 weeks gestation) , ventilation should be initiated with air.

self-inflating bag and mask

face-mask interface.

adequacy of ventilation should be assessed by measurement of the heart rate after 60 seconds of ventilation with visible chest
movements.

priority should be given to providing adequate ventilation rather than to chest compressions.
 no detectable heart rate
Stopping resuscitation after 10 minutes of effective
ventilation, resuscitation
should be stopped.

Those who continue to have

a heart rate < 60/min and no
spontaneous breathing after
20 minutes of resuscitation,
resuscitation should be
stopped

Post resuscitation care

Head or whole body cooling should not be done outside
well-resourced, tertiary neonatal intensive care units,
because there is potential for harm from this therapy in
low-resource settings
5. MANAGEMENT OF SUSPECTED
NEONATAL SEPSIS
Prophylactic antibiotics
for prevention of sepsis
A neonate with risk factors for infection
• membranes ruptured >18 hours before delivery,
• mother had fever > 38 ºC before delivery or
during labour
• amniotic fluid was foul smelling or purulent

After 2 days, the neonate should

be reassessed and treatment
ampicillin and gentamicin (IM
continued only if there are signs
/IV) for at least 2 days.
of sepsis or a positive blood
culture.
Empirical antibiotics for suspected neonatal
sepsis

Ampicillin and gentamicin If there is no improvement

Blood cultures should be
(IM /IV) - first line If staphylococcus infection in 2–3 days- change of
obtained before starting
treatment x at least 10 is suspected antibiotic/ referred for
antibiotics.
days. higher centre

extensive skin pustules/

abscess/ omphalitis in
addition to signs of
sepsis- cloxacillin and
gentamicin
Managing serious bacterial infection in young
infants when referral is not feasible :
-counsel families on recognition of
danger signs
Community health workers and
-assess young infants for danger
home visits for postnatal care
signs of illness
-promote appropriate care seeking

Infants 0–6 days with fast breathing as the only sign of illness :
• should be referred to hospital. If families do not accept or cannot access referral care,
• oral amoxicillin, 50 mg/kg per dose twice daily for 7 days

Infants 7–59 days with fast breathing as the only sign of illness :
• oral amoxicillin, 50 mg/kg per dose twice daily for seven days
• These infants do not need referral.
Young infants 0–59 days old with clinical severe infection
• whose families do not accept or cannot access referral care should be
managed in outpatient settings :
• Option 1: IM gentamicin 5–7.5 mg/kg (for low-birth-weight infants gentamicin
3–4 mg/kg) once daily for 7days and twice daily oral amoxicillin, 50 mg/kg per
dose for 7days.
• Option 2: IM gentamicin 5–7.5 mg/kg once daily for 2 days and twice daily oral
amoxicillin,50 mg/kg per dose for 7 days.
• A careful assessment on day 4 is mandatory.
• Close follow-up is essential.

Young infants 0–59 days old with critical illness

• any sign of critical illness (at presentation or developed during treatment of
clinical severe infection) should be hospitalized after pre referral treatment.
6. CARE OF THE PRETERM AND LOW-BIRTH-WEIGHT
NEWBORN
Prevention of hypothermia immediately
after birth :
• LBW neonates >1200g - with no complications &
clinically stable
• skin-to-skin contact - to prevent neonatal
hypothermia
Kangaroo Mother Care and Thermal care for preterm/low birth
weight newborns
• 2000 g or less at birth, and should be initiated in health-care
facilities as soon as the newborns are clinically stable.
• Intermittent Kangaroo mother care at least if continuous Kangaroo
mother care is not possible
• newborns who cannot be given KMC should be cared for in a
thermo-neutral environment either under radiant warmers or in
incubators.
• There is insufficient evidence on the effectiveness of plastic
bags/wraps in providing thermal care for preterm newborns
immediately after birth.
 Oxygen therapy and
concentration for preterm
newborns
• During ventilation of
preterm babies born at or
before 32 weeks of
gestation, start with 30%
oxygen or air (if blended
oxygen is not available),
rather than with 100%
oxygen.
• higher concentrations of
oxygen -considered if their
heart rate is less than 60
/min after 30 seconds of
adequate ventilation with
30% oxygen or air.
Continuous positive airway
pressure for newborns with
respiratory distress syndrome
• started as soon as the
diagnosis is made.
Surfactant administration for
newborns with respiratory
distress syndrome
• Surfactant replacement
therapy - for intubated and
ventilated newborns with
respiratory distress
syndrome.
• within the first 2 hours after
birth(rescue therapy)
• Either animal-derived or
protein-containing synthetic
surfactants can be used for
surfactant replacement
• prophylactic administration
in preterm newborns is not
recommended
Feeding of Low-birth-weight (LBW) infants:
mother’s own milk.
LBW infants, including
those with very low birth
human-milk weight (VLBW), who
fortifiers, preferably cannot be fed mother’s
own milk should be fed
those that are donor human milk
human milk based
LBW infants, including
those with VLBW, who
need not be given cannot be fed mother’s
bovine milk-based own milk or donor human
milk should be fed
human-milk standard infant formula.
fortifier.
VLBW infants who cannot be
fed mother’s own milk or
donor human milk should be
Continued from the given preterm infant formula
time of discharge if they fail to gain weight
despite adequate feeding
until 6 months of with standard infant formula
age.
 Routine zinc supplementation -
not recommended

VLBW infants should be given

fed based on infants’ hunger 10ml/kg per day of enteral
cues, except when the infant feeds, preferably expressed
remains asleep beyond 3 hours breast milk, starting from the
since the last feed. first day of life, with the
remaining by intravenous fluids

the intragastric tube may be

LBW infants should be
placed - oral or nasal route,
exclusively breastfed until 6
depending upon the
months of age.
preferences

VLBW infants requiring

alternative oral feeding method
intragastric tube feeding should
by cup (or palladai which is a cup
be given bolus intermittent
with a beak) or spoon.
feeds.
7. CARE OF THE NEWBORN OF AN HIV-
INFECTED MOTHER

Timing of testing
• At birth, nucleic acid testing (NAT) + existing early
infant diagnosis (EID) testing approaches
• Rapid diagnostic tests (RDTs) :
 in infants < 4 months of age. HIV-exposure status in
infants and children 4–18 months of age can be
HIV Diagnosis ascertained by HIV serological testing in the mother
 At 9 months to rule out HIV infection in asymptomatic
HIV-exposed infants
 to diagnose HIV infection in children >18 months
following the national testing strategy
Infant prophylaxis

HIV infected mother- Infants at high risk of acquiring HIV2

dual prophylaxis :
• AZT (twice daily)
• NVP (once daily) x first 6 weeks of life

additional 6 weeks (total of 12 weeks of infant prophylaxis) using

either AZT (twice daily) and NVP (once daily) or NVP alone
Infant feeding
• The duration of breastfeeding by mothers living with HIV
• at least 12 months and continue up to 24 months
+
ART adherence
HIV-infected Mothers - exclusively breastfeed their HIV uninfected
infants or infants whose HIV status unknown for the first 6 months
In settings where national authorities promote and
support HIV-infected women to avoid all breastfeeding:

only commercial infant formula milk as a replacement feed

- Assured safe water and sanitation at household level and community level

- If able to provide sufficient infant formula to support normal growth and development

- If mother can prepare it cleanly and frequently enough- so as to prevent diarrohea & malnutrition

- If mother can give exclusively infant formula milk- 6 months

- the family is supportive of this practice

- If access for child health services available.

MANAGEMENT OF OTHER SEVERE
CONDITIONS

• Clinically apparent seizures – lasting for >3 minutes /brief serial seizures-
should be treated.
• all electrical seizures, even in the absence of clinically apparent seizures with
continuous EEG monitoring- should be treated.

Neonatal • hypoglycaemia should be ruled out.

• If clinical signs s/o sepsis or meningitis- R/O CNS infection- lumbar puncture,
seizures and treated with appropriate antibiotics
• If facilities for LP are not available - empirical treatment with antibiotics
• In all neonates with seizures- serum calcium measured and treated if
hypocalcaemia is present.
• In the absence of obvious structural causes- pyridoxine.
Neonatal seizures
Phenobarbital -
first-line agent

midazolam or
lidocaine -
• Abrupt
discontinuation
second-line
without any tapering agent
– if seizure controlled
with single drug

When to stop seizure-free for

If normal
>72 hours
antiepileptic? - can be
neurological
examination
reinstituted if and/or normal
recurrence of EEG consider
seizures

• drugs may be stopped one by one, with phenobarbital being the last drug to be withdrawn
• all clinical seizures in the neonatal period - confirmed by EEG if available.
• Radiological investigations (USG/CT/MRI)
Neonatal jaundice :
Monitoring jaundice and serum bilirubin
• all newborns – routinely monitored , serum bilirubin should be
measured in those at risk:
in all babies if jaundice on day 1
in preterm babies (<35 wks) if jaundice on day 2
in all babies if palms and soles are yellow at any age
Serum bilirubin cut-offs for phototherapy and exchange transfusion:
Necrotizing enterocolitis
Antibiotics- IV or IM ampicillin and gentamicin – 1st line 10 days.
Congenital syphilis
Symptomatic or high risk infants
• confirmed congenital syphilis or
• clinically normal infants, but mothers –untreated/ inadequately
treated syphilis/treatment within 30 days of delivery /treated with
non-penicillin regimens
• WHO guideline - aqueous benzyl penicillin procaine penicillin.

100 000–150 000 U/kg/day 50 000 U/kg/day single dose

IV for 10–15 days IM for 10–15 day
Asymptomatic or low risk infants:
• clinically normal infants and whose mothers had syphilis that was adequately treated with no signs of reinfection- close
monitoring

Ophthalmia neonatorum:
• gonococcal conjunctivitis:

— ceftriaxone 50 mg/kg (maximum 150 mg) IM as a single dose

— kanamycin 25 mg/kg (maximum 75 mg) IM as a single dose

— spectinomycin 25 mg/kg (maximum 75 mg) IM as a single dose.

• chlamydial conjunctivitis,

-- azithromycin 20 mg/kg/day orally one dose daily for 3 days over erythromycin 50 mg/ kg/ day orally in
4 divided doses daily for 14 days.
Prevention of ophthalmia neonatorum
topical prophylaxis for the prevention of gonococcal and chlamydial
ophthalmia neonatorum

— tetracycline hydrochloride 1% eye ointment

— erythromycin 0.5% eye ointment
— povidone iodine 2.5% solution (water-based)
— silver nitrate 1% solution
— chloramphenicol 1% eye ointment.