Cardiac murmur 2011-13 management guide

Cardiac murmur 2011-13
Symptomatic or
>grade 3*
murmur or signs
Normal
Cardiac murmur detected at routine postnatal examination
In grade 1–3* systolic murmurs only, asymptomatic
24–36 hr after examination
Oximetry on right arm and leg
Check femoral pulses
SpO2 ≥95% SpO2 <95%
Review in 18–24 hr
Check femorals again
No murmur
and normal
femorals
Murmur persists and normal
femorals
Before discharge:
Pulse oximetry
Check femorals
Inform parents to watch for poor feeding, poor weight gain,
breathing difficulties, colour change
Paediatric follow-up in 2 weeks
Murmur persisting but
asymptomatic, keep under review
Transfer to NNU for
ECG, CXR and echo (if
available). Contact
cardiologist
Abnormal
Absent femorals
Discharge
Symptomatic or >grade 3*
refer to paediatric cardiologist
Repeat oximetry
Symptoms
• Tachypnoea or abnormal
breathing pattern
• Not taking feeds •
Slow to feed (>30 min)
• Sweaty or tachypnoeic
during feeds
• Colour change
Signs of congenital heart
disease
• Central cyanosis
• Tachypnoea •
Other respiratory
distress •
Tachycardia •
Hyperdynamic
precordium •
Abnormal volume or
character of pulse •
Hepatomegaly •
Abnormal heart sounds
• Heart murmur •
Absence of femoral
pulses
CARDIAC MURMURS
* Grade 1 – barely audible
Grade 2 – soft but easily audible
Grade 3 – moderately loud, no thrill
Grade 4 – louder, with thrill
Grade 5 – audible with stethoscope barely on the chest
Grade 6 – audible with stethoscope off the chest
Dr. Zuhair Aldajani
zuhair_dajani@hotmail.com
Neonatal Guidelines NHS 2011-2013

Cyanotic 2011-13
CYANOTIC CONGENITAL HEART DISEASE
INCLUDING HYPOPLASTIC LEFT HEART SYNDROME (HLHS)
(AND OTHER DUCT-DEPENDENT LESIONS DIAGNOSED
ANTENATALLY)
DEFINITION
‛Blue’ refers to central cyanosis (e.g. colour of tongue and gums). It is very difficult to see with
the naked eye before the ductus arteriosus reaches a critical closing point
Any baby presenting as blue has a critically small or closed duct and is a neonatal
emergency requiring consultant input. These babies can deteriorate very quickly
Differential diagnosis
Without echocardiography, clinical distinction between persistent pulmonary hypertension
(PPHN) and a duct-dependent pulmonary circulation can be extremely challenging
Lungs
• Persistent pulmonary hypertension of newborn
• Congenital diaphragmatic hernia
• Congenital lung lesions (e.g. pulmonary lymphangiectasia)
Heart
• Obstruction of blood flow from heart to lungs
• Obstruction of blood flow from lungs to heart
• Mixing oxygenated and deoxygenated blood
• Total disconnection of pulmonary and systemic circulations
SYMPTOMS AND SIGNS IN CARDIAC DISEASE
• Central cyanosis
• Usually limited signs of respiratory distress
• Murmur, in the minority
• Hepatomegaly
• Poor perfusion
INVESTIGATIONS
• Chest X-ray
• oligaemia/plethora/congenital anomaly
• ‘classic’ appearance (e.g. ‛boot shaped’ heart) is unusual
• Blood gas including lactate
• Echocardiogram
• 4-limb BP (>20 mmHg difference between an upper and lower limb is abnormal)
• Pre- and postductal saturations (saturation of <95% in both limbs or >3% difference is
significant)
• Nitrogen washout test (carries risk of duct closure: discuss with consultant first) to
differentiate between respiratory (parenchymal) and cardiac cause of cyanosis including
PPHN
• baseline saturation (and blood gas if arterial line in-situ)
• place baby in 100% ambient oxygen for 10 min
• if there is respiratory pathology, saturations should rise to >95%
IMMEDIATE MANAGEMENT
Resuscitation
Call consultant
A cardiac baby presenting collapsed and/or cyanosed is a challenging neonatal
emergency

Cyanotic 2011-13
Airway
• Intubate and ventilate all babies presenting profoundly cyanosed or collapsed
• If apnoea occurs secondary to a prostaglandin infusion, intubate baby but do not alter
infusion
Maintain ductal patency
• Open duct with dinoprostone (prostaglandin E2, prostin E2)
• Start at 5 nanogram/kg/min, may be increased to 40 nanogram/kg/min on advice of
cardiologist
• if dinoprostone not available, use prostaglandin E1 (Alprostadil); see local formulary
• Make fresh solution every 24 hr
• Be vigilant: 10% will develop apnoeas on this low dose regimen
Ventilation
Indications
• Significant apnoeas
• Congestive cardiac failure
• Respiratory failure
Technique
• Avoid hyperventilation, which can increase pulmonary blood flow
• initial settings: PEEP 4–5 cm H2O and FiO2 0.21, adjusted accordingly
• Aim for:
• PaCO2 5–7 KPa
• PaO2 4–6 KPa
• pH 7.35–7.40
• SpO2 75–90%, although many will run higher in room air
Inotropes
• If signs of peripheral underperfusion persist, arrange local echocardiography (if available)
to assess contractility
• if confirmed, start dobutamine 5–10 microgram/kg/min by continuous IV infusion
• if no improvement to peripheral circulation, consider nitroprusside 0.5–8
microgram/kg/min by continuous IV infusion after discussion with cardiac team
Monitor
• Monitor blood pressure invasively using a peripheral arterial cannula, not UAC
• Titrate infusion to keep to SpO2 >75–90%
• need to balance pulmonary and systemic circulations:
too high an SpO2 compromises LV output and worsens hypotension
• Assess cardiac output, likely to be low when:
• tachycardia persists
• BP remains low
• acidosis persists
• lactate elevated or rising
• poor peripheral perfusion
• When cardiac output low:
• ensure prostaglandin infusion adequate
• ensure adequate intravascular volume
• correct anaemia
• inotropes (dobutamine) may be required for tissue oxygen delivery and hypotension (as
usually started for elevated lactate and reduced perfusion long before hypotension arises)
SUBSEQUENT MANAGEMENT
TRANSFER
It is imperative that baby is kept warm and normoglycaemic

Cyanotic 2011-13
• Discuss further management and transfer with regional cardiac centre
• Babies who respond to a prostaglandin infusion do not need to be transferred out-of-
hours
• Appropriately skilled medical and nursing staff are necessary for transfer
Intubation
Do not intubate routinely for transfer
An intubated baby requires a cardiac centre ITU bed
• Intubate if:
• continuing metabolic acidosis and poor perfusion
• long-distance transfer necessary
• significant inotropic support in sick baby needed
• apnoea
• recommended by cardiac team
DISCHARGE FROM CARDIAC CENTRE
Patient may go home or return to a paediatric ward or neonatal unit
Management plan
• Regardless of outcome, obtain a management plan from cardiac centre, defining:
• medication, including dosage
• acceptable vital signs (e.g. saturations)
• follow-up arrangements
HYPOPLASTIC LEFT HEART SYNDROME (HLHS)
(AND OTHER DUCT-DEPENDENT LESIONS DIAGNOSED
ANTENATALLY)
BACKGROUND
• Malformation affecting left ventricle, aorta and valves
• Degree of hypoplasia varies considerably and, in many cases, lesion is dynamic with
progression during pregnancy
• Recently palliative/corrective surgery (Norwood procedure and its modifications) has
become increasingly successful in prolonging survival with a view to later heart
transplantation
ANTENATAL MANAGEMENT
• Record management plan in mother’s notes and in antenatal counselling letter (with
additional copy of both on neonatal unit)
• After delivery and stabilisation at local maternity unit, arrange non-urgent transfer to
regional cardiac surgery centre for full cardiology assessment
• If closed or small (restrictive) atrial septum puts fetus at risk of severe pulmonary
congestion and hypoxaemia shortly after birth, urgent septostomy immediately after
delivery at maternity unit may be recommended, despite a generally poor outcome
Postnatal diagnosis
• Some babies will present when duct closes, anytime during neonatal period and early
infancy, particularly where a left heart lesion has developed later in gestation
It is important to consider diagnosis of HLHS in any baby presenting with ‛shock’

Cyanotic 2011-13
MANAGEMENT
Aim to maintain patency of (or open a closed) ductus arteriosus, and optimise
systemic perfusion
• In HLHS, single right ventricle supplies blood to systemic and pulmonary circulations .
Excess flow in one circulation will lead to a significant decrease in blood supplied to other
circulation
• Greatest risk is excessive blood flow through pulmonary circulation with systemic
underperfusion, presenting with:
• tachypnoea;
• poor peripheral perfusion; and
• metabolic acidosis
• Poor peripheral perfusion can lead to cerebral injury and necrotising enterocolitis (NEC)
Resuscitation
• Neonatal team must be present at delivery to ensure baby establishes effective
respirations and becomes pink
• Although no increased requirement for resuscitation, it is extremely important to avoid
hypoxia and hyperoxia
• If stable, allow short cuddle with parents before transfer to neonatal unit, but keep warm
to avoid hypothermia
• Admit to unit for routine monitoring and investigations including blood gases and avoid
acidosis
FURTHER MANAGEMENT
See Cyanotic congenital heart disease section of this guideline

ECG abnormalities 2011-13
ECG ABNORMALITIES
SINUS TACHYCARDIA
Recognition and assessment
• Sinus rhythm (P wave precedes every QRS complex) with a heart rate above normal limit
for age and gestation
Causes
• Fever
• Infection
• Low haemoglobin
• Pain
• Hypovolaemia
• Hyperthyroidism
• Myocarditis
• Drugs (e.g. caffeine and salbutamol)
Management
• Treat the cause
SINUS BRADYCARDIA
• Sinus rhythm (P wave precedes every QRS complex) with a heart rate below normal limit
for age and gestation
• Hypoxia (most likely cause)
• Vagal stimulation (ET tube touching carina)
• Post-intubation
• Hypovolaemia
• Hypothermia
• Metabolic derangement
Immediate management
• Manage airway and breathing
• Adjust ET position, if too low
• If post-intubation, use atropine (see Neonatal Formulary)
• Correct hypovolaemia
• Correct metabolic derangement
• If persistent, obtain 12-lead ECG
PREMATURE ATRIAL BEAT
• Most common form of arrhythmia
• In a regular sinus rhythm at a normal rate, a P wave occurring before next expected P
wave is a premature atrial beat
• Most premature atrial beats are benign
Investigations
• 12-lead ECG
PREMATURE VENTRICULAR BEAT
• Premature abnormal QRS complex not preceded by a premature P wave

Investigations
• 12-lead ECG
• Measure QTc interval on ECG during period of sinus rhythm
• Echocardiogram to rule out structural abnormality of heart
Immediate treatment
• Seek advice from paediatric cardiologist
SUPRAVENTRICULAR TACHYCARDIA
• Rapid regular tachyarrhythmia
• Heart rate >230/min
• ECG:
• P waves commonly absent. When present, almost always have a different morphology
• narrow QRS complex
• in fast sinus tachycardia, P waves can be very difficult to see
• look for delta waves consistent with Wolff-Parkinson-White syndrome as this affects the
choice of anti-arrhythmic agent used by cardiologists at Birmingham Children’s Hospital
(BCH)
Symptoms and signs
• Persistent SVT can cause haemodynamic compromise
Investigations
• 12-lead ECG to document SVT: if not definite SVT, treat for cause of sinus tachycardia
(e.g. fluid for hypovolaemia)
• Assess airway, breathing and circulation
• Check for signs of cardiac failure
• Vagal manoeuvre such as applying ice pack to face
• Adenosine IV bolus
• use central venous access or IV access in a bigger vein (antecubital fossa)
• connect 3-way connector to end of cannula/catheter
• establish patency of IV access
• connect syringe with adenosine to one port and sodium chloride 0.9% flush to another
port
• run ECG strip
• give adenosine as a quick bolus and push the bolus of sodium chloride 0.9% at the end
quickly
• document change in cardiac rhythm on ECG
Adenosine dosage
• Start with 150 microgram/kg IV bolus
• if no response, increase by 50 microgram/kg
• Repeat every 1–2 min
• maximum dose 300 microgram/kg
• If no response, discuss with BCH cardiologists regarding DC shock
Subsequent management
• Echocardiogram to assess ventricular function and presence of congenital heart disease
• Correct electrolyte and metabolic imbalance, if present
• Discuss with paediatric cardiology centre for further management or earlier if necessary
VENTRICULAR TACHYCARDIA
• Heart rate >200/min

• Wide QRS complexes
• Correct hypoxia
• Correct electrolyte disturbance
• Discuss with paediatric cardiology centre
• Consider synchronised cardioversion (in very fast heart rates, defibrillators cannot
synchronise with the patient and unsynchronised will be required) if intubated, with
analgesia
• Amiodarone 5 mg/kg over 30 min IV (repeat if necessary)
• If no response, lidocaine 0.5–1 mg/kg IV. May be repeated after 5 min
TACHYARRHYTHMIA
• True heart rate?
• Is baby crying/in pain?
• Check airway and breathing
• Check saturation
• Consider arterial/capillary gas
• Check perfusion
• Check blood pressure
• Correct hypoxia
• Correct electrolyte disturbance
12 lead ECG12-lead ECG
• Narrow QRS complex
• Absent/abnormal P wave
• vagal manoeuvres
• adenosine
• discuss with paediatric cardiologist
• consider synchronised cardioversion
• Broad QRS complex
• Abnormal P wave
• discuss with paediatric cardiologist
• synchronised cardioversion

Heart failure 2011-13
HEART FAILURE
DEFINITION
• Congestive cardiac failure occurs when heart unable to pump sufficient blood to meet
metabolic demands of body tissues
• cause may be cardiac or non-cardiac
Causes
Non-cardiac
• Sepsis
• Asphyxia
• Anaemia
• Polycythaemia
• Fluid overload
• AV malformation
• Bronchopulmonary dysplasia (BPD)
Cardiac
• Left ventricular outflow tract (LVOT) obstruction
• Left-to-right shunt (see Increased left to right shunt below)
• Arrhythmia
Left ventricular outflow tract obstruction (LVOT)
• Hypoplastic left heart syndrome
• Critical aortic stenosis
• Coarctation
• Interrupted aortic arch
SYMPTOMS AND SIGNS OF CARDIAC FAILURE
• Tachycardia
• Tachypnoea
• Hepatomegaly
• Excessive weight gain
• Hypotension
• Murmur
• Abnormal femoral pulses
• in obstructive left heart lesions, femoral pulses may not be absent if duct still patent
• weak femoral pulses are significant
INVESTIGATIONS
• Blood gas including lactate
• Chest X-ray
• cardiomegaly and pulmonary oedema
• Echocardiogram
• Four-limb BP (a difference of >20 mmHg between an upper and lower limb is significant)
• Pre- and postductal saturations
• postductal saturations can be considerably lower than preductal in aortic arch defects (a
difference of >3% is significant)
IMMEDIATE TREATMENT
Clinical differentiation between an obstructed systemic circulation and severe sepsis is
extremely difficult as a murmur and weak pulses can be common to both.
In infant in extremis, presence of abnormal pulses alone is sufficient indication to start a
prostaglandin infusion until a cardiac lesion has been excluded by echocardiography
If left sided obstructive lesion suspected, treat with inotropes and use diuretics
cautiously

Resuscitation
Airway
• Intubate and ventilate babies presenting collapsed or with obvious cyanosis in association
with cardiac failure
• Routine intubation not indicated
• If apnoea occurs secondary to a prostaglandin infusion, intubate baby but do not alter
infusion
Breathing
• See Ventilation guideline
• Ventilate with PEEP 5–6 cm
• Adjust ventilation to maintain:
• PaCO2 5–6 kPa
• pH ≤7.4
Circulation
• Vascular access with 2 IV cannulae or umbilical venous catheter (UVC) – See Umbilical
venous catheterisation guideline
Presence of cyanosis and a murmur suggest baby likely to respond to prostaglandin
infusion
• Prostaglandin infusion to maintain ductal patency
• open duct with dinoprostone (prostaglandin E2, prostin E2), see Neonatal Formulary. Start
at 5 nanogram/kg/min, may be increased to 40 nanogram/kg/min, but only on advice of
cardiologist
• alprostadil (prostaglandin E1 can also be used. Start at 5 nanogram/kg/min, may be
increased but only on advice of cardiologist
• Monitor blood pressure invasively using a peripheral arterial cannula, not umbilical arterial
catheter (UAC)
• need to balance pulmonary and systemic circulations: too high an SpO2 compromises LV
output and worsens hypotension – seek advice from cardiologist
Cardiac output
• Assess cardiac output, it is likely to be low when:
• tachycardia persists
• BP remains low
• acidosis persists
• high lactate
• peripheral perfusion poor
• ensure prostaglandin infusion adequate
• When cardiac output low:
• ensure adequate intravascular volume
• correct anaemia
• dobutamine will be required for poor perfusion
SUBSEQUENT MANAGEMENT – TRANSFER
Baby must be kept warm and normoglycaemic
• Discuss further management and transfer with regional cardiac centre
• Babies who respond to a prostaglandin infusion do not need transferring out-of-hours
• Appropriately skilled medical and nursing staff are necessary for transfer
Intubation
An intubated baby requires a cardiac centre ITU bed: do not intubate routinely for
transfer

• Intubate if:
• continuing metabolic acidosis and poor perfusion
• long-distance transfer necessary
• inotropic support needed
• apnoea occurring
• recommended by cardiac team
DISCHARGE FROM CARDIAC CENTRE
Patient may go home or return to a paediatric ward or neonatal unit, possibly on a
prostaglandin infusion whilst awaiting surgery or for continuing care after a palliative
procedure (e.g. septostomy)
Management plan
• Regardless of outcome, obtain a management plan from cardiac centre, defining:
• acceptable vital signs (e.g. saturations)
• medication, including dosage
• follow-up arrangements
INCREASED LEFT TO RIGHT SHUNT
RECOGNITION AND ASSESSMENT
Definition
• Any lesion causing increased pulmonary blood flow
• Usually presents when pulmonary resistance falls after 48 hr
• Size and type of lesion will influence time of presentation
• AVSD
• Partial AVSD
• VSD
• Truncus arteriosus
Investigations
• Chest X-ray looking for fluid overload
• Echocardiogram
MANAGEMENT
• If in cardiac failure, give immediate dose of diuretic
• May require maintenance diuretics (discuss with cardiologist)
• usually furosemide 1 mg/kg and amiloride 100 microgram/kg orally
• Discuss with cardiac centre for definitive management and follow-up

Hypotension 2011-13
HYPOTENSION
Hypovolaemia is an uncommon cause of hypotension in the preterm newborn.
Excessive volume expansion can increase mortality
DEFINITION
Thresholds for intervention
• Aim to maintain mean arterial BP >gestational age in weeks
• If mean BP unavailable or pulse pressure wide (e.g. PDA), aim to maintain systolic BP
>gestational age in weeks in first 24 hr, and >30 mmHg thereafter
• Aim for even higher mean arterial blood pressure in case of persistent pulmonary
hypertension of newborn – see PPHN guideline
Assessment of BP
• Measure mean arterial pressure (MAP):
• by direct intra-arterial BP [umbilical arterial catheter (see Umbilical artery
catheterisation guideline) or peripheral arterial line if trace satisfactory]
• automated oscillometry (Dinamap) has limited accuracy in hypotensive preterm neonates;
usually over-reads BP in the lower ranges
• Assess as many of the following indices of tissue perfusion as possible (thresholds for
abnormality in brackets):
• toe-core temperature difference (>2o
C)
• urine output (<1 mL/kg/hr)
• blood lactate (>2.5 mmol/L)
Causes of hypotension or poor perfusion
• Cardiac dysfunction or hypovolaemia owing to:
• extreme immaturity
• hypoxia
• pneumothorax
• hypothermia
• morphine analgesia
• bleeding
• polyuria secondary to glucosuria
• Sepsis
IMMEDIATE TREATMENT
Aim of treatment is to improve organ perfusion, not to correct a ‘BP reading’
Seek senior advice throughout
Transilluminate chest to exclude pneumothorax
Fluid
• Not >10 mL/kg unless there is evidence of fluid/blood loss and hypovolaemia
• If clinical condition poor, BP very low, or mother has been treated with IV antihypertensive
agent, give inotrope (see below) after fluid bolus
Which fluid?
• Use sodium chloride 0.9% 10 mL/kg over 30 min EXCEPT when there is:
• coagulopathy with bruising: give fresh frozen plasma 10 mL/kg over 30 min (see
Coagulopathy guideline )
• Acute blood loss: give packed cells 10 mL/kg over 30 min
Reassess clinically within 30 min of each bolus

Hypotension 2011-13
• If hypotension persists after fluid bolus, seek senior advice
• start inotropes
Inotropes
• If evidence of poor perfusion, give dobutamine as initial agent commencing at
10 microgram/kg/min. If no response after 20 min, increase to 15 microgram/kg/min
Always use dobutamine as first inotrope for pulmonary hypertension
• Dobutamine will have now improved organ perfusion, but if mean BP remains low,
commence dopamine at 5 microgram/kg/min, increasing by 5 microgram/kg/min
increments in 30 min intervals to a maximum of 20 microgram/kg/min
• where possible, perform echocardiogram to assess response to dopamine at doses >10
microgram/kg/min
• If hypotensive but peripheral perfusion good or bounding, as in sepsis, consider
dopamine as initial inotrope after fluid bolus, as this will cause vasoconstriction that will
help alleviate poor vascular tone seen with sepsis
How
• Dopamine must be given centrally because:
• can cause tissue injury if given into liver or extravasation injury if given peripherally
• Dobutamine is best given centrally, although can be given peripherally
Continuing hypotension
• If hypotension persists despite these measures:
• give hydrocortisone 1 mg/kg IV followed by 1 mg/kg IV 8–12 hrly for 2–3 days as
necessary
• seek senior advice throughout
Refractive hypotension
Seek senior advice before starting adrenaline infusion. Depending on individual
circumstances, discuss alternative agents (e.g. noradrenaline, vasopressin)
If acidotic with severe hypotension, but not hypovolaemic
• Give adrenaline 100–300 nanogram/kg/min (see Neonatal Formulary for instructions on
making up solution)
• Monitor limb perfusion and urine output
If cooling, refer to Cooling guideline and avoid vasoconstrictive agents which further
reduce peripheral perfusion
DO NOT USE ADRENALINE in cooled infants
MONITORING
• If pneumothorax suspected, transilluminate
• Chest X-ray:
• if intubated
• urgent, if respiratory status worsening
• look for air leak or overinflation
• Blood gases
• Check effective delivery of drugs:
• record volume in syringe hourly
• check for leaks
• ensure correct position of umbilical venous catheter (UVC) delivering inotropes
• If being given morphine, reduce dose if possible

Hypotension 2011-13
• If ventilated, try to reduce mean airway pressure without compromising chest inflation and
oxygenation
• If poor response to above measures:
• echocardiogram to assess for myocardial dysfunction/congenital heart disease
Weaning inotropes
• Wean dopamine or dobutamine in 5 microgram/kg/min decrements as tolerated and
directed by senior advice

PDA 2011-13
PATENT DUCTUS ARTERIOSUS
Definition
• Patent ductus arteriosus (PDA) is the continuation of blood flow through the duct following
birth
• Persistent PDA is failure of functional closure of duct by 48 hr or of anatomical closure by
3 weeks
Factors associated with delayed closure
• Early gestation
• Lack of antenatal corticosteroid prophylaxis where indicated
• Surfactant-deficient lung disease
• Hypoxaemia
• Volume overload
Adverse effects of PDA
• Can become manifest in first 48 hr
• Significant right-to-left shunt and hypoxia until pulmonary pressure falls
• Reduced systemic blood flow leading to acidosis and hypotension
• Increased pulmonary blood flow leading to increased work of breathing
• Pulmonary haemorrhage
• Intraventricular haemorrhage and cerebral ischaemia (steal)
Symptoms and signs
• Can be absent in a clinically significant duct for first 7 days of life
• Significant left-to-right shunt suggested by:
• active praecordium
• full pulses
• wide pulse pressure
• murmur
• hypotension
• hepatomegaly
• oedema
• Significant right-to-left shunt suggested by:
• hypoxia
• Other cardiac pathology
• physiological left pulmonary branch stenosis
• ventricular septal defect
• atrial septal defect/patent foramen ovale
• Sepsis
• Right-sided cardiac pathology secondary to lung disease
INVESTIGATIONS
• Palpation of femoral pulses
• Pre and post ductal SpO2 monitoring
• Chest X-ray:
• cardiomegaly
• pulmonary plethora
• Echocardiography
• not essential but advisable because duct-dependent cardiac lesion can be difficult to
detect clinically
• important, if considering treatment with prostaglandin inhibitor, to assess cardiac anatomy
and ductal status

PDA 2011-13
IMMEDIATE TREATMENT
• Restrict fluid intake to <150 mL/kg/day
Prostaglandin inhibitor to initiate ductal closure
• Indometacin or ibuprofen
• follow your unit’s practice
Contraindications to indometacin or ibuprofen
• Renal impairment
• Urine output <1 mL/kg/hr
• Platelet count <50 × 109
/L
• Suspected necrotising enterocolitis
Dose
• If not contraindicated, give loading dose of indometacin 100 microgram/kg IV over 20–30
min or ibuprofen 10 mg/kg IV administered in accordance with Neonatal Formulary
• Check renal function and platelets before each dose
• Repeat echocardiogram after completing the course
• Feeds can be initiated and continued at a routine rate
Monitoring pharmacological treatment
• Check:
• urine output >1 mL/kg/day
• feed tolerance
• FBC platelets >50 × 109
/L
• renal profile: an increase in urea and creatinine can be expected after administration of
indometacin/ibuprofen but urine output is of more clinical value. Discuss with senior
colleague
Persistence or recurrence of murmur
• Does not necessarily indicate return of PDA
• Echocardiogram sometimes demonstrates a physiological left branch pulmonary stenosis:
common after ductal closure and not clinically significant
Surgical referral
• Consider surgical ligation if:
• pharmacological closure contraindicated or ineffective
• obvious cardiac compromise
• it is not possible to extubate baby or there has been post-extubation failure
• there have been pulmonary haemorrhages or other symptoms suggestive of ductal steal
DISCHARGE POLICY FOR PERSISTENT PDA
• If duct does not close but baby can be extubated:
• monitor duct clinically
• Refer to cardiologist for further management if there is:
• evidence of cardiac failure
• failure to thrive
• persistent oxygen requirement
• If PDA still present echocardiographically or clinically by age 6 wks, refer to paediatric
cardiology service

Pericardial 2011-13
PERICARDIOCENTESIS
INDICATION
Consider drainage of a pericardial effusion only if there is cardiovascular compromise
PERICARDIAL EFFUSION
Causes
• Neonatal hydrops
• Extravasation of TPN from migrated long lines
• Complication of central venous catheters
Clinical signs
• Tachycardia
• Poor perfusion
• Soft heart sounds
• Increasing cardiomegaly
• Decreasing oxygen saturation
• Arrhythmias
• Sudden collapse in baby with long line or umbilical venous catheter (UVC) in situ
Investigations
• Chest X-ray: widened mediastinum and enlarged cardiac shadow
• Echocardiogram (if available)
EQUIPMENT
• Sterile gown and gloves
• Sterile drapes
• Dressing pack with swabs and plastic dish
• 22/24 gauge cannula
• 5–10 mL syringe with 3-way tap attached
• Cleaning solution as per unit policy - suggest aqueous chlorhexidine 0.5%/isopropyl
alcohol 70% (Hydrex), diluted 50:50 with Normasol for infants <26 weeks’ gestation
PROCEDURE
Consent and preparation
• If time allows, inform parents and obtain consent (verbal or written)
• If skilled operator available, perform under ultrasound guidance
• In an emergency situation, the most experienced person present performs procedure
without delay and without ultrasound guidance
• Ensure baby has adequate analgesia
Drainage
• Maintain strict aseptic technique throughout
• Clean skin around xiphisternum and allow to dry
• Attach needle to syringe and insert just below xiphisternum at 30° to skin and aiming
towards left shoulder
• Continuously aspirate syringe with gentle pressure as needle inserted. As needle enters
pericardial space there will be a gush of blood or air
• Send aspirated fluid for microbiological and biochemical analysis
• Withdraw needle
AFTERCARE
• Cover entry site with clear dressing (e.g. Tegaderm/Opsite)

Extreme prematurity 2011-13
EXTREME PREMATURITY
INTRODUCTION
• Outcomes for premature babies at borderline of viability generally improve with each
additional week of gestational age
• estimation of gestational age confirmed by ultrasound when carried out in first trimester of
pregnancy is generally reliable
• Discussion with parents, before birth if possible, should precede any action
MANAGEMENT
• An experienced paediatrician to be present at delivery of extremely premature babies (<28
completed weeks’ gestation) and make confirmatory assessment of gestational age and
condition of baby
≥24 weeks gestation
• Unless baby has a severe abnormality incompatible with any significant period of survival,
initiate intensive care and admit to neonatal intensive care unit
<24 weeks gestation
• Discuss with parents national and local statistical evidence for survival in babies with range of
disabilities found in this age group
• explain that statistics indicate most babies born <24 weeks’ gestation will die
Between 24 weeks, 0 days and 24 weeks, 6 days’ gestation
• Unless parents and clinicians agree that, in view of baby’s condition (or likely condition) it is
not in his/her best interests to start intensive care, provide full, invasive, intensive care and
support from birth and admit to neonatal intensive care unit
Between 23 weeks, 0 days and 23 weeks, 6 days’ gestation
• Give precedence to parents’ wishes regarding resuscitation and invasive intensive care
treatment. However, when condition indicates baby will not survive for long, clinicians are not
legally obliged to proceed with treatment that is wholly contrary to their clinical judgement, if
they consider treatment would be futile
• as a first step, determine whether baby is suffering, whether any suffering can be alleviated,
and likely burden placed on baby by intensive care treatment
• where parents would prefer clinical team to make decision about initiation of intensive care,
clinicians must determine what constitutes appropriate care
• where it has not been possible to discuss a baby’s treatment with mother and, where
appropriate, her partner, before the birth, clinical team should consider offering full invasive
intensive care until baby’s condition and treatment can be discussed with parents
Between 22 weeks, 0 days and 22 weeks, 6 days gestation
• Standard practice should be not to resuscitate a baby and this would normally not be
considered or proposed
• If parents request resuscitation, and reiterate this request, discuss risks and long-term
outcomes with an experienced neonatologist before attempting resuscitation and offering
intensive care
• Treating clinicians must all agree that this is an exceptional case where resuscitation is in a
baby’s best interests
Below 22 weeks gestation
• Resuscitation should never occur in routine clinical practice
• any attempt to resuscitate babies born at this gestational age should take place only within
the context of an approved research study
When intensive care not given, clinical team must provide palliative care until baby dies

EXTREME PREMATURITY
Supporting information
Most babies born <24 weeks gestation are expected to die, but outcome improves with
each additional week of gestational age?
A retrospective, 5 year case-control review of 237 infants with gestational ages < 27 weeks
(Genzel-Boroviczeny, 2010) found that, despite successful resuscitation, infants between 23
and 26 weeks had a very poor prognosis for survival when presenting with bradycardia,
cyanosis and no respiratory efforts (1-min Apgar=1) at birth. Initiating active treatment for an
infant at 23 weeks with bradycardia and apnoea was almost always unsuccessful (with a 1-
min Apgar score of 1, a male infant at 23 weeks and 500g had a mortality rate of 92%),
whereas by 26 weeks gestation, the chances of survival were higher than the probability of
death.
.nhs.uk
Genzel-Boroviczeny O, Hempelman J, Zoppelli L, et al. Predictive value of the 1-min Apgar
score for survival at 23-26 weeks gestational age. Acta Paediatr 2010;99:1790-4
Evidence Level: III
Last amended January 2011
Not found an answer to your question? Contact bedsideclinicalguidelines@uhns.nhs.uk

Golden hour 2011-13
GOLDEN HOUR
Preterm infants <28 weeks’ gestation
INTRODUCTION
The care preterm babies receive within the first few hours and days of life has a significant
impact on their long-term outcomes. The CESDI 27–28 study highlighted the importance of
good early care for preterm babies with particular reference to effective resuscitation (see
Resuscitation guideline)
AIM
To stabilise and perform all procedures required by the baby within the first hour of life
BEFORE DELIVERY
Nurses Doctors/ANNPs
• Identify nurse responsible for admission
and redistribute existing babies
• Ensure incubator set up and pre-warmed
with humidity set at maximum
• Check monitor and appropriate
connections
• Set oxygen saturation limits at 92–95%
• Ensure ventilator and NeopuffTM
plugged
in and checked
• Ensure appropriate size face masks
available
• Prepare suction and catheters
• Ensure transport incubator pre-warmed
and cylinders full
• Ensure endotracheal tube (ETT) sizes 2.5
and 3.0 are available
• Set up trolley for umbilical arterial
catheter (UAC) and umbilical venous
catheter (UVC) beside incubator
• Prepare infusion fluids for UAC and UVC
• Take resuscitation bag and saturation
monitor to delivery
• Registrar or experienced ANNP is
responsible for early care of babies
<28 weeks’ gestation
• counsel parents appropriate to gestation
• <26 weeks, discuss delivery with
consultant, who will attend whenever
possible
• Prescribe infusions for UAC and UVC
• Check resuscitaire in delivery suite
• ensure overhead heater switched on and
set to maximum
• set peak inspiratory pressure (PIP) at 20
cmH2O and FiO2 at 0.21
• check saturation monitor and probe
available
• Prepare plastic bag

Golden hour 2011-13
AFTER DELIVERY
• Keep baby warm with plastic bag and
hat
• Assist with resuscitation
• Accurate time-keeping including
resuscitation and procedures
• Attach oxygen saturation probe to right
hand
• Assist with ETT fixation
• Set up transport incubator and transfer
baby to it
• Ensure baby labels in place before
transport
• Ensure midwives have taken cord
gases
• Transfer baby to neonatal unit (NNU)
• Competent practitioner, ANNP or
middle grade doctor to attend
• If normal delivery and baby breathing,
delay clamping of cord for 1–2 min
providing baby can be kept warm
• If operative or instrumental delivery, cut
cord immediately and take baby to
resuscitaire
• Place baby in plastic bag
• Cover baby’s head with appropriate size
warmed hat
• Assess colour tone, heart rate and
breathing
• If baby is breathing regularly,
commence CPAP at 5 cmH2O
• If baby is not breathing regularly, give 5
inflation breaths at 20–25 cmH20 using
T piece and face mask
• monitor response by checking colour,
breathing and heart rate
• if baby does not start to breath, ventilate
at 20/5
• if heart rate not above 100 bpm or falls,
observe chest movement and if poor,
increase pressures to 25/5
• observe chest movement throughout
and, if obvious and heart rate good,
reduce pressures
• when heart rate >100 bpm or chest
movement seen, check saturation
monitor and adjust FiO2 aiming to bring
saturations close to NLS guidance
• If continued IPPV necessary, intubate
• If unit policy is to give surfactant on
labour ward ensure that ETT is not
inserted too far and is securely fixed
before administering surfactant
• Check baby once placed in transport
incubator and review
• air entry
• colour
• heart rate
• saturation
• Complete joint resuscitation record and
obtain signature from maternity team
• Show baby to parents
• Senior member of staff to talk briefly to
parents
• Transfer baby to NNU

Golden hour 2011-13
FIRST HOUR ON NNU
• Aim for at least 1:1 nursing care for first
hour
• Transfer to incubator in plastic bag
• Weigh baby in plastic bag
• Leave baby in plastic bag until incubator
reaches adequate humidity
• Attach baby to ventilator or CPAP driver
and reassess ABC
• If ventilated, pre-warm surfactant and
prepare Mac TachCare
• Monitor heart rate and saturation
• Record blood pressure
• Do not use ECG leads on babies
<26 weeks’ gestation
• Measure axillary temperature on arrival
• Insert nasogastric (NG) tube
• Assist doctor/ANNP with lines
• Give Vitamin K
• Give first dose of antibiotics
• Take a photograph for parents
• Reassess ABC
• Split tasks between doctors/ANNP
Doctor/ANNP A
• Prescribe weight dependent drugs and
infusions and Vitamin K
• Write blood test forms and prepare
blood bottles
• Start admission notes (Badger)
Doctor/ANNP B
• Check ETT position clinically and
administer surfactant if not previously
given on labour ward
• Check ventilation – Review tidal volume
and chest movement
• if tidal volume >5 mL/kg or vigorous
chest movement, reduce PIP without
waiting for first gas
• check saturations and adjust FiO2 to
keep saturation 92–95%
• Insert UAC and UVC through hole in
plastic bag
• commence infusions as soon as line
secured
• Take blood for:
• FBC
• clotting
• group and DCT
• blood culture
• blood glucose
• pre-transfusion bloodspots
• arterial gas
• Defer peripheral IV cannula insertion
unless unable to get umbilical lines
• Once lines inserted, request X-rays
• Document
• ETT position
• NG length
• UAC and UVC positions at time X-ray
taken
• Write X-ray report in notes
• Update parents and document in notes
Once baby set up – minimise handling
Hands off – Eyes on

Hypothermia 2011-13
HYPOTHERMIA
DEFINITION
• Skin temperature <36.0O
C on admission from delivery suite
ASSESSMENT
Babies at risk
• Preterm <30 weeks’ gestation
• Low birth weight <1500 g
• Sick baby
• Small for dates
Consequences (<36.0O
C)
• Hypoglycaemia
• Metabolic acidosis
• Hypoxia with increased oxygen demands
Consequences (<35.5O
C)
• Increased metabolic rate
• Clotting disorders
• Shock
• Apnoea
• Intraventricular haemorrhage
• Persistent fetal circulation
• Decreased surfactant production and function
Causes of heat loss
• Radiation: heat lost to cooler objects in the room
• in cold environment, whether in incubator or not, excessive heat may be lost
• in excessively hot environment or in direct sunlight, baby could overheat in incubator
• Conduction: heat lost to cooler surfaces on which baby is placed
• Convection: heat lost due to drafts
• Evaporation: heat lost through water evaporating from skin
PREVENTION
Delivery suite
• Keep room 23–28O
C and free from draughts, especially when babies are due to be delivered
Babies <30 weeks
• Dry head and put on hat
• Do not dry remainder of baby
• Place in polythene bag immediately and keep inside bag until placed in pre-heated pre-
humidified incubator. Do not cover the polythene bag during transfer
Other babies
• Use pre-warmed towel, dry immediately after delivery
• Discard towel and wrap in another pre-warmed towel and blanket
• Ensure room warm enough to enable skin-to-skin contact and early breastfeeding
• Cover exposed skin with warm blanket
Neonatal unit
• Keep at 24–25O
C to avoid cooling from radiant heat loss, and ‛misting’ (condensation) in
incubators
• Keep incubators and cots away from windows to prevent radiation heat loss
• Nurse babies requiring intensive care in pre-warmed incubator

Hypothermia 2011-13
• Babies <29 weeks must have humidification >60% for first 2 weeks
Incubator temperature during first 3 days
Birth weight (g) Incubator temperature (O
C)
1000 35
1500 34
2000 33.5
2500 33.2
3000 33
4000 32.5
• Babies <1000 g require even higher temperatures, occasionally >37O
C
• If baby’s temperature remains within normal limits for 24 hrs, reduce incubator temperature
by 1O
C according to baby’s needs
• When baby’s weight reaches about 1600 g, or according to local practice, transfer to open cot
Rainout may occur if the difference between temperature in incubator and room
temperature is >5O
C: ensure room temperature kept at locally agreed level
Babies not at risk of hypothermia
• If not requiring observation of respiratory status or excessive invasive procedures, babies
may be:
• dressed
• kept wrapped
• placed in a cot
• Mild hypothermia can be managed with the addition of:
• hats
• cot lids
• heated mattresses
• If baby’s temperature <36.0O
C consider:
• use of incubator, if available
• increasing humidity, if appropriate for gestational age
• bubble wrap
REWARMING OF HYPOTHERMIC BABIES
• Rewarm in incubator
• >1200 g, rewarm at 1O
C per hour
• <1200 g, rewarm more slowly
Take care not to overheat babies. Aim for 36.5–37.2O
C

HYPOTHERMIA
Supporting Information
Placing the baby in a polythene bag prevents heat loss pending transfer to an
incubator?
A Cochrane systematic review (McCall, 2010) found that “Plastic wraps or bags were effective
in reducing heat losses in infants < 28 weeks' gestation (4 studies, n = 223; WMD 0.68 °C;
95% CI 0.45, 0.91), but not in infants between 28 to 31 week's gestation.”
McCall EM, Alderdice F, Halliday HL, et al. Interventions to prevent hypothermia at birth in
preterm and/or low birthweight infants. Cochrane Database of Systematic Reviews 2010,
Issue 3. Art. No.: CD004210
Evidence Level: I
Heated mattresses are useful in the treatment of mild hypothermia?
A retrospective review (Ibrahim, 2010) studied the occurrence of hypothermia in 105 babies
born before, and 124 born after the introduction of heated gel mattresses. Four (3.3%) babies
were hypothermic (temperature <36 degrees C) at admission when the mattresses were
used, compared to 21 (22.6%) babies during the period it was not (p < 0.001). Hyperthermia
(temperature >37 degrees C) rose from 30.1% prior to use of gel mattresses to 49.6% when
they were used (p = 0.004).
Ibrahim CP, Yoxall CW. Use of self-heating gel mattresses eliminates admission hypothermia
in infants born below 28 weeks gestation. Eur J Pediatr 2010;169:795-9
Evidence Level: IV
Last amended October 2010

PAIN AND STRESS
This guideline and supporting information has been prepared with reference to:
Anon. Prevention and management of pain in the neonate: an update. American Academy of
Pediatrics Committee on Fetus and Newborn and Section on Surgery; Canadian Paediatric
Society Fetus and Newborn Committee. Pediatrics 2006;118:2231-41
What is the evidence for the efficacy of non-pharmacological interventions?
A systematic literature review of 13 randomised trials and 2 meta-analyses (Cignacco, 2007)
looked at the effects of non-nutritive sucking, music, swaddling, positioning, olfactory and
multisensorial stimulation, kangaroo care and maternal touch. These had an observable positive
effect on pulse rate, respiration and oxygen saturation, reduction of motor activity and excitation
states following painful procedures. Validated pain assessment instruments were not employed in
these studies, however, and further research was called for.
A Cochrane systematic review of 11 trials (Shah, 2006) found that distress measured by heart
rate, crying time and three scoring systems (Premature Infant Pain Profile, Douleur Aigue
Nouveau-ne and Neonatal Facial Coding Score) was significantly reduced by breastfeeding or
breast milk supplementation during painful procedures.
A double-blind prospective trial in 110 infants (Thyr, 2007) found that infants given 2 mL of 30%
glucose after immunisation at 3, 5 and 12 months cried less than those given water (mean crying
time reduced by 22, 62 and 52% respectively).
“Additional research is needed to fully understand the mechanism of action, optimal dose, and
safety of repeated doses of oral sucrose in neonates” (Anon, 2006).
A meta-analysis of 20 RCTs involving 1380 infants and children between 1 month and 11 years of
age (Chambers, 2009) found that breathing exercises, child-directed distraction, nurse-led
distraction, and combined cognitive-behavioural interventions were effective in reducing the pain
and distress associated with routine childhood immunisations.
A Cochrane systematic review of 44 studies involving 3,496 infants (Stevens, 2010) found that
sucrose significantly reduced the duration of total crying time (seconds) [WMD -39.26 (95% CI -
44.29, -34.24), 88 neonates].
Anon. Prevention and management of pain in the neonate: an update. American Academy of Pediatrics
Committee on Fetus and Newborn and Section on Surgery; Canadian Paediatric Society Fetus and
Newborn Committee. Pediatrics 2006;118:2231-41
Chambers CT, Taddio A, Uman LS, et al. Psychological interventions for reducing pain and distress during
routine childhood immunizations: a systematic review. Clin Ther 2009;31(Suppl 2):S77-S103)
Cignacco E, Hamers JP, Stoffel L, et al. The efficacy of non-pharmacological interventions in the
management of procedural pain in preterm and term neonates. A systematic literature review. Eur J Pain
2007;11:139-52
Shah PS, Aliwalas LL, Shah V. Breastfeeding or breast milk for procedural pain in neonates. Cochrane
Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004950
Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful
procedures. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD001069
Thyr M, Sundholm A, Teeland L, et al. Oral glucose as an analgesic to reduce infant distress following
immunization at the age of 3, 5 and 12 months. Acta Paediatr 2007; 96:233-6
Evidence Level: I
Last amended May 2010

Pain and Stress 2011-13
PAIN AND STRESS
Symptoms and signs
• Distinguish signs of pain and stress from signs of life-threatening conditions, such as
hypoxia, seizures or CO2 retention, which require other forms of management
• Lack of behavioural responses (e.g. crying and movement) does not necessarily indicate
lack of pain
Sudden pain and distress is usually caused by serious condition e.g. bowel
perforation
Behavioural
• Crying, whimpering
• Facial expressions:
• brow bulge
• eye squeeze
• deepening of nasolabial folds
• Active movement and attempts to withdraw from painful stimulus:
• thrashing
• tremulousness
• limb withdrawal, flexion
• cycling movements
• arching
• Flexor reflexes; leg withdrawal
• Exaggerated reactivity
• Decreased sleep periods
Physiological
• Changes in heart rate and variability
• Respiratory rate and quality, including apnoea and tachypnoea
• Fluctuations in blood pressure, up or down
• Decreased transcutaneous oxygen and carbon dioxide levels
• Oxygen desaturation
• Pallor
• Flushing
Indications for pain management
• Before painful procedures:
• insertion of long lines
• intubation and IPPV
• lumbar puncture
• insertion of chest drain
• venous sampling/access
• In response to behavioural changes
• To aid ventilation in:
• term infants with pulmonary hypertension
• stabilisation of congenital diaphragmatic hernia
• preterm babies only if local unit policy
• To assist with management of cooling in infants treated for encephalopathy
NON-PHARMACOLOGICAL PAIN MANAGEMENT
• Non-nutritive sucking
• Swaddling
• Calming
• Tactile stimulation

• Rocking
• Expressed breast milk
• Skin-to-skin care
PRINCIPLES OF ANALGESIA
• Prophylactic or symptomatic
• Use stepwise approach with agents of increasing potency
ANALGESIA FOR NON-VENTILATED INFANTS
Sucrose
Activates opioid systems that provide natural analgesia and is recognised as an appropriate
analgesia for newborn babies during some painful procedures
Contraindicated in unstable babies, sedated intubated babies, NEC, GI obstruction and
paralysed babies
Indications
• Heel pricks for blood sampling
• Cannulation and venous sampling
• Ventricular tap
• Lumbar puncture
• Insertion of long lines
• Eye examination
• IM injection
• Tape removal
• Nasogastric tube insertion
Use
• Use sucrose in conjunction with other non-pharmacological methods such as:
• dummy
• hands-on comforting
• swaddling
• performing procedure in a quiet environment
• Use sucrose solution (e.g. Sweet-Ease 24%)
• preterm baby: 0.1–0.5 mL repeated as necessary
• term baby: 2 mL in repeated doses as necessary at 5 min intervals to a maximum of 3
doses per procedure
• maximum doses per 24 hr – see Table 1
Table 1: Maximum doses of sucrose per 24 hr
Gestational age
(weeks)
Maximum oral dose of sucrose (24%)
24–26 0.2 mL (max 1 mL in 24 hr)
27–31 0.5 mL (max 2.5 mL in 24 hr)
32–36 1 mL (max 5 mL in 24 hr)
>36 weeks 2 mL (max 10 mL in 24 hr)
Give a maximum of 5 doses only in one 24 hr period
• Give first dose 2 min before procedure by one of the following methods:
• dip cotton bud into solution and wipe around baby’s mouth
• dip dummy into solution and give to baby (each dip is 0.2 mL)
• via syringe
Topical pain relief
• Lidocaine (plain, not with adrenaline) 1% 0.3 mL/kg maximum per dose effective as a
topical anaesthesia

Indications
• Insertion of a chest drain
• Insertion of a peritoneal drain
Paracetamol
• Orally or rectally: absorbed more quickly if given via oral route
Table 2
Route Gestation Loading
dose
Maintenance Maximum daily dose
Oral >32 weeks 24 mg/kg 12 mg/kg 4-hrly 60 mg/kg
<32 weeks 24 mg/kg 12 mg/kg 8-hrly 30 mg/kg
Rectal >32 weeks 30 mg/kg 20 mg/kg 8-hrly 60 mg/kg
<32 weeks 20 mg/kg 15 mg/kg 12-hrly 30 mg/kg
Morphine sulphate oral liquid (Oramorph)
• Particularly useful for chronic pain relief and for terminal care
• Large doses such as 100 microgram/kg 6-hrly can cause hypotension and respiratory
depression
ANALGESIA FOR VENTILATED INFANTS
• It is essential that ventilated babies have adequate pain control
• may be achieved using diamorphine or morphine in addition to agents used for non-
ventilated Infants
• Manage any asynchrony using alternative ventilation modes (see Ventilation guideline)
• Loading doses for maintenance of analgesia for ventilation are lower than formulary
recommends for painful procedures
Diamorphine
• Loading dose for ventilated babies in serious pain, 180 microgram/kg IV over 30 min
• Maintenance 15 microgram/kg/hr IV infusion
• Larger doses than this are no more effective but are associated with more adverse effects
• Effects can be reversed by naloxone 100 microgram/kg IV
Morphine
• Loading dose for sedation whilst ventilated 120 microgram/kg IV over 5 min; for severe
pain 240 microgram/kg
• Maintenance 10–20 microgram/kg/hr IV
• Can cause hypotension, bradycardia and respiratory depression
• Half-life between 1 and 6 hr: increases with decreasing gestational age
• Effects can be reversed by naloxone 100 microgram/kg IV as a bolus
SEDATION
Sedation has no analgesic effect. Always use in conjunction with appropriate analgesia
Chloral hydrate
• Can be useful in irritable fatigued child/cerebral irritation
• Has long half life and can accumulate, leading to hypotension and respiratory depression
• single dose treatment: 45 mg/kg orally (75 mg/kg for term infants for single procedure,
e.g. CT)
• sustained sedation: 30 mg/kg 6-hrly orally
• if used regularly, review after 1–2 days
Avoid EMLA cream: evidence of efficacy in neonate is inconsistent

PRETERM CARE (“GOLDEN HOUR”)
Evidence pertinent to this guideline may be found in the supporting information for the
following Neonatal Guidelines:
• Resuscitation
• Hypothermia
• Ventilation
• Cannulation
• Infection

RESUSCITATION
This guideline and supporting information has been prepared with reference to the
following:
Anon. Ethical guidelines on resuscitation of newborns: FIGO Committee for the Ethical Aspects of Human
Reproduction and Women’s Health. Int J Gynecol Obstet 2006;94:169-71
Kattwinkel J, Perlman JM, Aziz K, et al. Neonatal resuscitation: 2010 American Heart Association guidelines
for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics 2010;126:e1400-13
Resuscitation Council (UK). Newborn life support. 2010 http://www.resus.org.uk/pages/nls.pdf
Naloxone should not be administered to infants whose mothers abuse narcotics?
A single case study (Gibbs, 1989) recorded generalised convulsions unresponsive to diazepam in
a naloxone-treated baby born to a heroin user maintained throughout her pregnancy on
methadone. The authors concluded that, as convulsions due to neonatal abstinence syndrome do
not appear until at least 48 hours after birth, the symptoms in this case were due to naloxone
administration.
Gibbs J, Newson T, Williams J, et al. Naloxone hazard in infant of opioid abuser. Lancet. 1989;2:159–60
Evidence Level: V
Should resuscitation be carried out with 21% or 100% oxygen?
Guidelines from the Resuscitation Council (see above) give no direction on this question. A
systematic review and meta-analysis of 10 studies in a total of 2,133 infants (Saugstad, 2008)
found that those given 21% oxygen (n=1,082) had reduced mortality compared to those
(n=1,051) given 100% oxygen (RR 0.69; 95% CI 0.54 – 0.88).
A systematic review of 2,011 infants from 7 controlled trials (Rabi, 2007) found a statistically
significant reduction in mortality in the room air group at 1 week (OR 0.70, 95% CI 0.50 - 0.98)
and at 1 month (OR 0.63, 95% CI 0.42 - 0.94).
A randomised study in 44 preterm infants (Ezaki, 2009) found reduced oxidative stress in the
group given 21% oxygen, compared to the group given 100% oxygen.
Ezaki S, Suzuki K, Kurishima C, et al. Resuscitation of preterm infants with reduced oxygen results in less
oxidative stress than resuscitation with 100% oxygen. J Clin Biochem Nutr 2009;44:111-8
Rabi Y, Rabi D, Yee W. Room air resuscitation of the depressed newborn: a systematic review and
metaanalysis. Resuscitation 2007;72:353–63
Saugstad OD, Ramji S, Soll RF, et al. Resuscitation of newborn infants with 21% or 100% oxygen: an
updated systematic review and meta-analysis. Neonatology 2008;94:176-82
Evidence Level: I
Last amended September 2011

Resuscitation 2011-13
RESUSCITATION
• Check equipment daily, and before resuscitation
• Follow Resuscitation Council UK Guidelines www.resus.org.uk
DRY AND COVER
• Cord clamping – see Cord clamping below
• >28 weeks’ gestation, dry baby, remove wet towels and cover baby with dry towels
• <28 weeks’ gestation, do not dry body but place in plastic bag, dry head only and put on hat
Cord clamping
• It is current NLS recommendation that cord is not clamped immediately
• In uncompromised infants a delay in cord clamping of at least one minute is recommended
• After discussion in Staffordshire, Shropshire & Black Country resuscitation group it has been
decided any time a neonatologist is called for fetal reasons, do not delay cord clamping
ASSESS
• Assess colour, tone, breathing and heart rate
If baby very floppy and heart rate slow, assist breathing immediately
• Reassess every 30 sec throughout resuscitation process
• If help required, request immediately
If baby not breathing adequately by 90 sec, assist breathing
CHECK AIRWAY
For baby to breathe effectively, airway must be open
• To open airway, place baby supine with head in ‛neutral position’
• If very floppy, consider chin support or jaw thrust while maintaining the neutral position
IMMEDIATE TREATMENT
Airway
• Keep head in neutral position
• Use T-piece and soft round face mask, extending from nasal bridge to chin
• Give 5 inflation breaths, sustaining inflation pressure (Table 1) for 2–3 sec for each breath
• Give PEEP of 5 cm H2O
• Begin inflation breaths in air
Table 1: Inflation pressure (avoid using pressure higher than recommended)
Term infant 30 cm of water
Preterm infant 20–25 cm of water
No chest movement
Ask yourself:
• Is head in neutral position?
• Is a jaw thrust required?
• Do you need a second person to help with airway to perform a jaw thrust?

• Is there an obstruction and do you need to look with a laryngoscope and suck with a large-
bore device?
• Consider placing oro-pharyngeal (Guedel) airway under direct vision using laryngoscope
• Is inflation time long enough?
• if no chest movement occurs after alternative airway procedures above have been tried
(volume given is a function of time and pressure), a larger volume can be delivered if
necessary by inflating for a longer time (3–4 sec)
• Attach saturation monitor to right hand – see Saturation monitoring for guidance on
saturation targets
Endotracheal intubation
Indications
• Severe hypoxia (e.g. terminal apnoea or fresh stillbirth)
• Stabilisation of airway
• Extreme prematurity
• Congenital diaphragmatic hernia
Breathing
• Most babies have a good heart rate after birth and establish breathing by 90 sec
• if not breathing adequately give 5 inflation breaths, preferably using air at pressures in
Table 1
• heart rate should rapidly increase as oxygenated blood reaches heart
Do not move onto ventilation breaths unless you have a heart rate response OR you have
seen chest movement
Review assessment after inflation breaths
• Is there a rise in heart rate?
• Is there chest movement with the breaths you are giving?
• If no spontaneous breathing, but chest movement has been obtained, perform 30 sec of
ventilation breaths, given at a rate of 30 breaths per min (1 sec inspiration)
Table 2: Outcome after 30 sec of ventilation breaths
Heart rate Breathing Action
Increases Not started breathing • Provide 30–40 breaths/min
• Where available, use PEEP
at 5 cm water with T-piece
system
<60 Obvious chest
movement
• Start chest compressions –
See below
• If baby is floppy with slow heart rate and there is chest movement, start cardiac compressions
with ventilation breaths immediately after inflation breaths
• Increase inspired oxygen concentration every 30 sec by 30% e.g. 30–60–90% depending on
response – see Saturation chart
Safe insertion of tracheal tube requires skill and experience
If you cannot insert a tracheal tube within 30 sec, revert to mask ventilation

Chest compression
• Use if heart rate approximately <60 beats/min (do not try and count accurately as this will
waste time)
Figure 1 Figure 2
Pictures taken from NLS manual and Resuscitation Council (UK) and reproduced with their permission
Ideal hold (figure1/figure 2)
• Circle chest with both hands so that thumbs of both hands can press on the sternum just
below an imaginary line joining the nipples with fingers over baby’s spine
Alternative hold (less effective)
• Compress lower sternum with fingers whilst supporting baby’s back. The alternative hand
position for cardiac compressions can be used when access to the umbilicus for UVC
catheterisation is required, as hands around the chest may be awkward
Start chest compression only after successful
inflation of lungs

Action
• Compress chest quickly and firmly to reduce the antero-posterior diameter of the chest by
about one-third, followed by full re-expansion to allow ventricles to refill
• remember to relax grip during IPPV, and feel for chest movement during ventilation breaths,
as it is easy to lose neutral position when cardiac compressions are started
Co-ordinate compression and ventilation to avoid competition.
Aim for 3:1 ratio of compressions to ventilations,
and 90 compressions and 30 breaths (120 ‛events’) per min
Blood
• If there is evidence of fetal haemorrhage, consider giving O negative emergency blood
Resuscitation drugs
• Always ask about drugs taken recently by, or given to mother
• Consider drugs only if there is an undetectable or slow heartbeat despite effective lung
inflation and effective chest compression
• Umbilical venous catheter (UVC) preferred venous access
Adrenaline 1:10,000
• 10 microgram/kg (0.1 mL/kg) IV
• If this dose is not effective, consider giving 30 microgram/kg (0.3 mL/kg) after sodium
bicarbonate has been given
• Adrenaline should only be given via the ET tube if venous access is taking time to achieve; it
should not delay intravenous access and treatment; the dose is 0.5–1.0 mL/kg of 1 in 10,000.
Sodium bicarbonate 4.2%
• 1–2 mmol/kg (2–4 mL/kg) IV (never give via ET tube)
Glucose 10%
• 2.5 mL/kg IV slowly over 5 min
Sodium chloride 0.9%
• 10 mL/kg IV
Naloxone
• Consider only after ventilation by mask or endotracheal tube has been established with chest
movement seen and heart beat >100 beats/min
• If mother has been given pethidine within 2–4 hr of delivery, give IM naloxone:
• 100 microgram (0.25 mL) for small prem babies
• 200 microgram (0.5 mL) for all other babies
Do not give naloxone to babies born to mothers who abuse narcotics
WHEN TO STOP
• If no sign of life present after 10 min of continuous good quality resuscitation, outlook is poor
with few survivors, majority will have cerebral palsy and learning difficulties
• If no sustained spontaneous breathing 30 min after a heart rate has been established,
majority also have poor prognosis
Continue resuscitation until a senior neonatologist advises stopping

MONITORING
Saturation monitoring
• Oxygen monitoring is activated when paediatrician/2nd
pair of hands arrives. In the meantime,
the person initiating resuscitation carries out all the usual steps in resuscitation
• Do not stop resuscitation for a saturation probe to be attached
• Attach saturation monitor to the right hand once five inflation breaths have been given
• Saturations should spontaneously improve as Table 3
Table 3
Time (min) Acceptable pre-ductal
saturations (%)
2 60
3 70
4 80
5 85
10 90
Air to oxygen
• If inflation breaths have been successful and chest movement seen but heart rate and/or
colour/saturations (if available) not improved:
• in term babies – increase oxygen to 30%
• in preterm babies – increase oxygen to 30%
• If no response, increase by increments of 30% every 30 sec i.e.:
Term air
30–60–90/100%
Preterm air
30– 60–90/100%
• Reduce oxygen if saturation levels as per Boost recommendations when oxygen saturation
levels at 91–95% for preterm <30 weeks or >95% for term at 10 min of life (otherwise Resus
Council target sats should be followed to stop babies being too pink too early on and being at
risk of O2 toxicity)
Preterm deliveries
• >26 weeks’ gestation do not require routine intubation if respiratory effort good
• these babies can receive PEEP 5cm H20 via mask ventilation with oxygen supplementation
as appropriate on the resuscitaire and PEEP support on transfer to NICU
• If respiratory effort is poor, at any point, or baby’s condition deteriorates, intubate and
ventilate as per BAPM guidance
DOCUMENTATION
• Make accurate written record of facts (not opinions) as soon as possible after the event
• Record
• when you were called, by whom and why
• condition of baby on arrival
• what you did and when you did it
• timing and detail of any response by baby
• date and time of writing your entry
• a legible signature
COMMUNICATION
• Inform parents what has happened (the facts)

Newborn life support algorithm
Dry baby
Remove wet towels and cover
Start clock or note time
Assess
tone, breathing and heart rate
If gasping or not breathing
Open airway
Give 5 inflation breaths
Consider SpO2 monitoring
Re-assess
If no increase in heart rate, look
for chest movement
If chest not moving
Re-check head position
Consider 2-person airway
control and other airway
manoeuvres
Repeat inflation breaths
Consider SpO2 monitoring
Look for a response
No increase in heart rate –
Look for chest movement
When chest moving
If heart rate not detectable or
slow (<60/min),
start chest compressions
3 compressions to each breath
Re-assess heart rate
Every 30 sec
If heart rate not detectable or
slow (<60/min), consider
venous access and drugs
Birth
60
sec
30
sec
AT
ALL
STAGES
ASK:
DO
YOU
NEED
HELP?
Acceptable
Pre-ductal SpO2
2 min 60%
3 min 70%
4 min 80%
5 min 85%
10 min 90%

Hyperglycaemia including insulin 2011-13
HYPERGLYCAEMIA
DEFINITION
• Blood glucose >12 mmol/L, and/or presence of >2+ glycosuria on dipstick testing
Do not take sample from an infusion line that has glucose running through it

CLINICAL FEATURES
• Dehydration
• Acidosis
• ketoacidosis does not occur in babies
• Poor weight gain

Babies at high risk
• Ill, unstable
• Preterm (especially <28 weeks)
• Small for gestational age (<3rd
centile)
• Receiving total parenteral nutrition (TPN)
• Receiving corticosteroids, caffeine
MONITORING
Twice-daily monitoring
• Check blood glucose at least twice a day in:
• unstable or acutely ill babies (RDS, septicaemia, NEC)
Daily monitoring
• Check blood glucose at least once a day in babies:
• <32 weeks’ gestation for first week
• receiving TPN
• with severe unexpected dehydration or metabolic acidosis
• with poor weight gain while receiving >120 kcal/kg/day
Babies treated with corticosteroids
• Check urine for glycosuria daily
• Check blood glucose if >2+ glucose in urine

TREATMENT
• Discontinue or decrease medications that worsen hyperglycaemia
Suspected infection
• Hyperglycaemia in baby with previously stable blood glucose may be early indicator of
infection
• After taking appropriate cultures, treat empirically
Fluids
• Correct dehydration by increasing daily fluid intake: use sodium chloride 0.9%
• If baby receiving >6 mg glucose/kg/min, decrease concentration of glucose infused or
replace some of the glucose intake with sodium chloride 0.9% using following formula:
• glucose infusion rate (mg/kg/min) = % glucose × fluid volume (mL/kg/day) divided by 144
• these measures often bring blood glucose down substantially
• hypoglycaemia can occur following overzealous glucose restriction
Insulin
• Consider if:
• baby remains hyperglycaemic (blood glucose >12 mmol/L), and/or
• presence of >2+ glycosuria on dipstick testing and
• when control not obtained with above methods or
• a higher carbohydrate intake than infant will tolerate is necessary for nutritional reasons

Hyperglycaemia including insulin 2011-13
• Seek senior advice about commencing insulin therapy
• See Administration of Actrapid insulin below
• Follow Neonatal Formulary for insulin infusion rates
• Check blood glucose concentrations regularly during insulin infusion. Treating clinician
to decide on frequency, based on stability of glycaemia
• If unable to wean off insulin after 2 weeks, transient neonatal diabetes is likely; consult a
paediatric endocrinologist
ADMINISTRATION OF ACTRAPID INSULIN (SOLUBLE
INSULIN)
• To avoid delay in administration of Actrapid insulin infusion caused by lumen capacity of
IV extension sets and cannula T-connections, administer via a peripheral cannula used
only for this purpose
• Before starting infusion, prime T-connector of cannula with a 0.5 mL bolus of infusion
fluid
• Provided an octopus or IV extension set is not used, the infusion can also be
administered directly connected to the lumen of an umbilical venous catheter (UVC). In
this instance, the recommended priming volume is 0.26 mL
• If it is not possible to deliver the Actrapid infusion in either of these ways, and the use of
an extension set or octopus is unavoidable, be aware of lumen capacity of the extension
set used and the delay it may cause. Inform medical team when assessing effectiveness
of treatment
• Calculate delays by using the information below and the infusion rate
Example
Actrapid insulin to be infused at 0.1 mL/hr through a peripheral cannula (including a ‘T’
adapter) + octopus extension set
Total lumen capacity: 0.5 mL + 0.34 mL = 0.84 mL
Time delay: 0.84 mL/0.1 mL/hr = 8.4 hr*
Lumen capacity of IV sets**
IV product Product
manufacturer
Product code Priming volume
(lumen capacity)
Extension set with ‘T’ adapter
SL
Venisytems F89805014 0.5 mL
Ready set Vygon 836.201 0.85 mL
Double lumen umbilical
catheter
Vygon 1274.14 0.26 mL
Triple lumen extension tube
with Bionector (octopus)
Vygon 841.364 0.34 mL (per lumen)
*It may be possible to reduce delay by priming some or all of the IV assembly with infusion
fluid, if safe from interactions with drugs infused simultaneously through same extension set
and with permission of the medical team i.e. SpR or consultant only
**Information above was obtained from the manufacturers of the IV sets currently in use. If a
new product is introduced or a new manufacturer used for an existing product, priming
volume may require updating

HYPERGLYCAEMIA
Hyperglycaemia increases mortality risk in premature infants?
A prospective chart study of 93 extremely low birth-weight infants (Hays, 2006) found that more
than 50% of the infants had persistent blood glucose concentrations of >150 mg/dL during the
first week of life. Twenty-two of these infants (44%) had an early adverse outcome, defined as
death or intra-ventricular haemorrhage of grade 3 or 4 before the 10th
day of life.
Another prospective study in 252 premature infants weighing </=1500 g (Heimann, 2007) found a
significant increase in mortality (p<0.0001) with increasing median blood glucose level and
repeated (>/=4) incidents of blood glucose levels >/=150 mg/dL associated with low gestational
age (<27 weeks).
Retrospective analysis of a prospective cohort study of 201 ELBW infants (Kao, 2006) found the
odds ratio for either dying or developing a late infection was 5.07 (95% CI 1.06 – 24.3) in those
babies with persistent severe hyperglycaemia (>/=180 mg/dL).
A review of the literature (Ogilvy-Stuart, 2010) concluded that hyperglycaemia “is associated with
increased morbidity and mortality in preterm infants, but what should be considered optimal
glucose control, and how best to achieve it, has yet to be defined in these infants”.
Hays SP, O’Brian Smith E, Sunehag AL. Hyperglycemia is a risk factor for early death and morbidity in
extremely low birth-weight infants. Pediatrics 2006;118:1811-18
Heimann K, Peschgens T, Kwiecien R, et al. Are recurrent hyperglycemic episodes and median blood
glucose level a prognostic factor for increased morbidity and mortality in premature infants </=1500 g? J
Perinat Med 2007;35:245-8
Kao LS, Morris BH, Lally KP, et al. Hyperglycemia and morbidity and mortality in extremely low birth weight
infants. J Perinatol 2006;26:730-6
Ogilvy-Stuart AL, Beardsall K. Management of hyperglycaemia in the preterm infant. Arch Dis Child Fetal
Neonat Ed 2010;95:F126-31
Evidence Level: IV
Treating hyperglycaemia has a beneficial effect on mortality and morbidity?
A Cochrane Systematic Review of 2 trials in 47 infants (Bottino, 2009) found the evidence was
insufficient to answer this question and called for more and larger trials to be conducted.
Bottino M, Cowett RM, Sinclair JC. Interventions for treatment of neonatal hyperglycemia in very low birth
weight infants. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD007453
Evidence Level: I
Last amended June 2010

Hyperkalaemia 2011-13
HYPERKALAEMIA
• Plasma potassium >6 mmol/L (normal 3.0–5.5 lithium heparin specimen)
• Neonates often tolerate concentrations up to 7.5–8.0 mmol/L without ECG changes
SYMPTOMS AND SIGNS
• Cardiac arrest
• ECG abnormalities (see below):
• tall peaked T waves
• widened QRS complex
• sine waves (widened QRS complex merging with T wave)
• prolonged PR interval, bradycardia, absent P wave
Tall, peaked T wave, widening of QRS
Sine wave QRS complex (before cardiac arrest)
CAUSES
• Renal failure: secondary to hypoxic ischaemic encephalopathy (HIE), sepsis and
hypotension, or structural abnormalities
• Cellular injury with potassium release e.g. large intraventricular haemorrhage
• Very low-birth-weight babies without renal failure (non-oliguric hyperkalaemia) in first 12–
48 hr
• Excess K
+
in IV solutions
• Endocrine (congenital adrenal hyperplasia)
INVESTIGATIONS
• If sample haemolysed, repeat and send free-flowing venous sample or arterial sample
• If potassium >6.0 mmol/L, connect to cardiac monitor
IMMEDIATE TREATMENT
Serum potassium >6.0 mmol/L (stable with normal ECG)
• Stop all K
+
IV solutions or oral supplements
• Reconfirm hyperkalaemia
• Institute continuous ECG monitoring

Hyperkalaemia 2011-13
Serum potassium >7.0 mmol/L without ECG changes
• As above
• Give salbutamol 4 microgram/kg IV in glucose 10% over 5–10 min: effect evident within
30 min but sustained benefit may require a repeat infusion after at least 2 hr
• if IV access difficult, give nebulized salbutamol 2.5 mg as a single dose (difficult to
administer if ventilated and not formally evaluated in neonates) and repeat if necessary
• Give intravenous insulin 0.5 units/kg in glucose 10% (made up to 2.5 mL and given over
30 min): very effective and has an additive effect with salbutamol
• Repeat U&E
• Repeat insulin infusion as necessary until K
+
<7 mmol/L
• Monitor blood glucose every 15 min for first 2 hr during and after infusion
• aim for blood glucose 4–7 mmol/L
Serum potassium >7.5 mmol/L with ECG changes
• As above, but first institute emergency measures below:
• give 10% calcium gluconate 2 mL/kg IV over 5–10 min
• flush line with sodium chloride 0.9% or preferably use a different line
• give IV sodium bicarbonate (1 mmol/kg over 2 min) this is effective even in patients who
are not acidotic (2 mL of 4.2 % sodium bicarbonate = 1 mmol)
Further treatments: discuss with consultant
• A cation-exchange resin, such as calcium resonium (500 mg/kg rectally, with removal by
colonic irrigation 8–12 hrly, repeat every 12 hr. Dose can be doubled at least once to
1 g/kg in severe hyperkalaemia). Useful for sustained reduction in serum potassium but
takes many hours to act and is best avoided in sick preterms who are at risk of
necrotising enterocolitis (NEC)
• If severe hyperkalaemia persists despite above measures in term babies with otherwise
good prognosis, contact renal team for consideration of dialysis
• Exchange transfusion using fresh blood or washed red blood cells provides another
strategy for sustained and reliable reduction in serum K
+
concentration – see Exchange
transfusion guideline
• Recheck serum K
+
4–6 hrly; when arrhythmias present with renal failure, monitor hourly
• Monitor urine output and maintain good fluid balance
• If urine output <1 mL/kg/hr, unless baby volume depleted, give IV furosemide 1 mg/kg
until volume corrected
• Treat any underlying cause (e.g. renal failure)

HYPERKALAEMIA
What is the evidence for the use of salbutamol, and is it superior to insulin as a treatment
for hyperkalaemia? Has nebulised salbutamol been evaluated?
Intravenous administration of insulin (together with glucose) effectively manages hyperkalaemia
in neonates (Ditzenberger, 1999), but the response is unpredictable, and carries the risk of
hypoglycaemia, hyperosmolarity, and volume overload (Helfrich, 2001). No good, randomised
trials for its use in neonates have been identified.
Intravenous salbutamol is rapidly effective and side effects, including elevated heart rate, mild
vasomotor flushing and mild tremor are all short-lasting (Helfrich, 2001; Kemper, 1996; Murdoch,
1991). One prospective, randomised, placebo-controlled double-blind trial of nebulised
salbutamol, in 19 neonates <2000g, has been identified (Singh, 2002). Serum potassium levels
fell rapidly (from 7.06 +/- 0.23 mmol/L to 6.34 +/- 0.24 mmol/L, P=.003) in the first 4 hours in the
treatment group (n=8) in response to 400 mcg given by nebuliser. No significant change was
seen in the placebo group (n=11) (6.88 +/- 0.18 mmol/L to 6.85 +/- 0.24 mmol/L).
Ditzenberger GR, Collins SD, Binder N. Continuous insulin intravenous infusion therapy for VLBW infants. J
Perinat Neonat Nurs 1999;13:70-82
Helfrich E, de Vries TW, van Roon EN. Salbutamol for hyperkalaemia in children. Acta Paediatr
2001;90:1213-6
Kemper MJ, Harps E, Hellwege HH, et al. Effective treatment of acute hyperkalaemia in childhood by short-
term infusion of salbutamol. Eur J Pediatr 1996;155:495-7
Murdoch IA, Dos Angos R, Haycock GB. Treatment of hyperkalaemia with intravenous salbutamol. Arch Dis
Child 1991;66:527-8
Singh BS, Sadiq HF, Noguchi A, et al. Efficacy of albuterol inhalation in treatment of hyperkalemia in
premature neonates. J Pediatr 2002;141:16-20
Evidence Level: II (for inhaled salbutamol)
Is rectal calcium resonium a safe treatment in neonates?
Intestinal perforation has been reported in infants treated with exchange resin enemas
(Grammatikopoulos, 2003; Bennett, 1996), although these may have been spontaneous rather
than as a result of the treatment.
Nausea and vomiting are common side effects of oral administration, but changing to the rectal
route is “less effective” (Helfrich, 2001).
Only one randomised trial of resins in the treatment of hyperkalaemia in neonates has been
identified (Hu, 1999). 40 VLBW infants were randomised to receive either glucose/insulin infusion
(n=20) or kayexalate resin enema (n=20). Duration of hyperkalaemia was significantly shorter
(26.4 +/- 14.9 vs 38.6 +/-13.3 hours) in the insulin group.
An appropriately-sized randomised trial is necessary to evaluate the risks and benefits of this
treatment in premature infants (Grammatikopoulos, 2003).
Bennett LN, Myers TF, Lambert GH. Cecal perforation associated with sodium polystyrene sulfonate-sorbitol
enemas in a 650 gram infant with hyperkalemia. Am J Perinatol 1996;13:167-70
Grammatikopoulos T, Greenough A, Pallidis C, et al. Benefits and risks of calcium resonium therapy in
hyperkalaemic preterm infants. Acta Paediatr 2003;92:118-27
Helfrich E, de Vries TW, van Roon EN. Salbutamol for hyperkalaemia in children. Acta Paediatr
2001;90:1213-6
Hu PS, Su BH, Peng CT, et al. Glucose and insulin infusion versus kayexalate for the early treatment of
non-oliguric hyperkalaemia in very-low-birth-weight infants. Acta Paediatr Taiwan 1999;40:314-8
Evidence Level: II (For no evidence of benefit of resins over glucose/insulin)
Evidence Level: V (For case report evidence of harm from resins)

Do some VLBW infants without renal failure suffer from hyperkalaemia?
Both renal and non-renal causes of neonatal hyperkalaemia have been suggested (Singh, 2002),
and the cause of the condition is generally held to be multi-factorial (Ditzenberger, 1999). One
study of 48 infants (Fukuda, 1989) implicated metabolic acidosis and catabolic state, but another,
in 33 infants (Stefano, 1993), found no difference in muscle protein catabolism between 12
infants with hyperkalaemia and 21 without.
In a study of 18 VLBW infants (Gruskay, 1988) no differences in renal glomerular function were
noted in 8 who developed hyperkalaemia and 10 who did not.
Inability to regulate potassium balance, as a result of immature distal tubule function, may result
in hyperkalaemia in the absence of renal failure (Mildenberger, 2002; Lorenz, 1997; Matsuo,
1995; Sato, 1995).
Fukuda Y, Kojima T, Ono, A, et al. Factors causing hyperkalemia in premature infants. Am J Perinatol
1989;6:76-9
Gruskay J, Costarino AT, Polin RA, et al. Nonoliguric hyperkalemia in the premature infant weighing less
than 1000 grams. J Pediatr 1988;113:381-6
Lorenz JM, Kleinmann LI, Markarian K. Potassium metabolism in extremely low birth weight infants in the
first week of life. J Pediatr 1997;131:81-6
Matsuo Y, Hasegawa K, Doi Y, et al. Erythrocyte sodium-potassium transport in hyperkalaemic and
normokalaemic infants. Eur J Pediatr 1995;154:571-6
Mildenberger E, Versmold HT. Pathogenesis and therapy of non-oliguric hyperkalaemia of the premature
infant. Eur J Pediatr 2002;161:415-22
Sato K, Kondo T, Iwao H, et al. Internal potassium shift in premature infants: cause of nonoliguric
hyperkalemia. J Pediatr 1995;126:109-13
Stefano JL, Norman ME. Nitrogen balance in extremely low birth weight infants with nonoliguric
hyperkalemia. J Pediatr 1993;123:632-5
Evidence Level: IV
What level of hyperkalaemia should prompt treatment?
The criteria on which to treat hyperkalaemia have ranged from 6.8 to 7.5 mmol/L, but 6.5 mmol/L
may be a better level at which to begin treatment, as rhythm disturbances are to be expected
above 7.0 mmol/L (Grammatikopoulos, 2003). If treatment is not initiated until symptoms appear
(or the serum level exceeds 7.0 mmol/L), the potential for success is reduced (Ditzenberger,
1999). Mortality rates may be as high as 80% once arrhythmias have appeared (Singh, 2002).
Grammatikopoulos T, Greenough A, Pallidis C, et al. Benefits and risks of calcium resonium therapy in
hyperkalaemic preterm infants. Acta Paediatr 2003;92:118-27
Evidence Level: V
Last amended September 2007

Hypernatraemia 2011-13

HYPERNATRAEMIC DEHYDRATION
DEFINITION
In breast fed babies
• Serum sodium >145 mmol/L
• mild: 146–149 mmol/L
• moderate: 150–169 mmol/L
• severe: >170 mmol/L
AIM
To prevent/treat hypernatraemic dehydration while encouraging breastfeeding
Other causes of hypernatraemia
• Diarrhoea
• Excessive perspiration
• Renal dysplasia
• Obstructive uropathy
• Osmotic diuresis
• Diabetes insipidus
• Idiopathic causes
• Infection (meningitis, encephalitis)
• Improperly mixed formula
• Sodium bicarbonate or sodium chloride administration
PREVENTION
Babies at high risk
• Born to primiparous women
• Maternal prolonged second stage of labour >1 hr
• Caesarean section with delayed initiation of feeding
• Maternal breast abnormalities (flat, inverted nipples)/surgery
• Use of labour medications
• Maternal illness, haemorrhage
• Preterm <37 weeks
• Maternal obesity
• Maternal diabetes
Action
• Identify babies at risk
• Immediate skin-to-skin contact at birth and breastfeed within 1 hr of life
• Offer breastfeeding assistance within 6 hr of life
• Ensure babies feed at least 6 times within 24 hr
• If baby reluctant to feed, express breast milk (see Breast milk expression guideline) and
offer by cup or syringe
• Calculate required volume of feeds using local guidelines
• Avoid bottle feeding and dummies
• Avoid early discharge in at-risk babies
• Assess baby to ensure feeding adequate
• assess feeding, number of wet nappies and stools using following table


Day Wet nappies Stool
1–2 >2/day >1/day
3–4 >3/day >2 /day, changing in colour and consistency
5–6 >5/day >2/day, yellow in colour
• Weigh between 72 and 96 hr
• Refer all who have lost more than 10% weight
• weight loss % = weight loss (g)/birth weight (g) × 100
Symptoms and signs
• Lethargy
• Irritability: fussy or unsettled during breastfeeding
• Prolonged feeding >45 min
• Delayed change from meconium to transitional stools
• Demanding <6 feeds in 24 hr
• Reduced urinary frequency
• Weight loss
• Jaundice
• Tremor
• Increased tone
• Fever
• Doughy skin
• Seizures (usually during rehydration)
• Fullness of anterior fontanelle
• Physical examination can be unremarkable
• usual signs (sunken fontanelle, reduced skin turgor) of dehydration can be absent
Complications
• Venous and arterial thrombosis
• Subdural and capillary haemorrhage
• Cerebral oedema
• Seizures (especially following rehydration)
• Apnoea and bradycardia
• Cognitive and motor deficits
• Hypertension
• Cerebral infarction
• Death
Investigations
• U&E
• Calcium
• Total bilirubin
• Blood glucose
• CRP
• Blood culture


MANAGEMENT

Signs or symptoms of dehydration or
clinical suspicion of hypernatraemia
Send blood for U&E
Mild hypernatraemia
• Manage in postnatal ward
• Put baby to the breast and encourage mother to express breast milk (EMB), see Breast milk expression
guideline
• Top up baby with EBM/formula milk 100 mL/kg/day by cup or syringe
• Check U&E and calcium after 12 hr
• Monitor blood glucose as per Hypoglycaemia guideline
• Aim to establish breastfeeding and reduce top-up once sufficient EMB
• If Na+ returns to normal before sufficient EBM, liberalise feeds calculated according to local guidance
• Oral feeds not tolerated
• Baby unwell
• Repeat U&E shows worsening
hypernatraemia, moderate or severe
hypernatraemia
• Associated hypocalcaemia
• Baby improving
• continue routine postnatal care
• Routine postnatal examination
• Follow-up with GP and community midwife
Admit to neonatal unit


Yes
Baby admitted to neonatal unit
Examine and exclude other cause of hypernatraemia
Moderate or severe hypernatraemia Mild hypernatraemia
Unwell baby • Put baby to breast
• Top up with EBM/formula at 100 mL/kg/day
via cup or syringe
• If cup and syringe feeds not tolerated, pass
NG tube and administer feeds (breast milk
and/or formula milk)
• If total enteral feeds not tolerated, give IV
fluids to make up deficit
Well baby
Signs of shock?
Resuscitate with
10 mL/kg
sodium chloride 0.9%
Tolerate enteral
feed
• Start IV fluids 100 mL/kg/day
• If blood glucose >2.5 mmol, use sodium
chloride 0.9%
• If blood glucose <2.5 mmol, use sodium
chloride 0.45% and glucose 5% or 10%
• Subtract resuscitation fluid from calculated
maintenance fluid
Wean off formula feeds or IV fluids on
to breast or EBM as tolerated by baby
• U&E and blood glucose 4-hrly
• Aim for rate of fall in Na
+
of 0.5 mmol/L/hr. If Na
+
falling any faster, reduce rate of rehydration
• If severe hypernatraemia, contact consultant
• If low blood glucose, see Hypoglycaemia guideline
• If renal failure or Na
+
>170 mmol/L, discuss with paediatric nephrologist
• Monitor 4-hrly:
• temperature
• heart rate
• blood pressure
• Keep strict fluid balance chart
• Monitor weight daily
• Aim to correct dehydration over 48–72 hr or slower in severe cases
• Do not correct hyperglycaemia with insulin, this can reduce plasma osmolality rapidly and
precipitate cerebral oedema
• Once sufficient EBM, aim to establish breastfeeding and reduce top-up
• Neurodevelopmental follow-up for all babies with moderate and severe hypernatraemia
• Encourage mother to continue expressing breast milk in addition to breastfeeding
No
No

HYPERNATRAEMIC DEHYDRATION
Infants losing more than 10% of birth weight should be referred?
A prospective cohort study in 2,788 term newborns (Konetzny, 2009) found that weight loss of
>/= 10% of birth weight was an early indicator for hypernatraemic dehydration of sufficient
severity to cause possible convulsions, permanent brain damage, or death. Sixty-seven
(2.4%) newborns had a weight loss >/ = 10% of birth weight; 24 (36%) of these had moderate
and 18 (27%) severe hypernatraemia. Infants born by caesarean section had a 3.4 times
higher risk for hypernatraemia than those born vaginally. All newborns regained weight 24 h
after additional fluids.
Konetzny G, Bucher HU, Arlettaz R. Prevention of hypernatraemic dehydration in breastfed newborn
infants by daily weighing. Eur J Pediatr 2009;168:815-8
Evidence Level: III
Weighing babies early (72-96 hrs after birth) helps to prevent hypernatraemic
dehydration?
A study of outcomes pre- and post- the introduction of a policy of weighing newborns at 72-96
hrs after birth (Iyer, 2008) found 60 cases of hypernatraemic dehydration: 23 before and 37
after introduction of the policy. After the policy, there was earlier recognition (median 3 vs 6
days), lower percentage weight loss (11% vs 15%), smaller increase in sodium (147 vs 150
mmol/l), and higher breastfeeding rate at discharge (73% vs 22%) and 8 weeks (57% vs
22%). All the differences were significant (p<0.01). There was one death in the pre-policy
group, and none in the post-policy group.
Iyer NP, Srinivasan R, Evans K, et al. Impact of an early weighing policy on neonatal hypernatraemic
dehydration and breast feeding. Arch Dis Child 2008;93:297-9
Evidence Level: IV
Last amended January 2011

Hypoglycaemia 2011-13
HYPOGLYCAEMIA
DEFINITION
Asymptomatic hypoglycaemia
• Low blood glucose concentrations are common in preterm and small-for-gestational-age
infants
• No simple correlation between blood glucose concentration and neuroglycopenia
• Blood glucose >2.0 mmol/L is safe
Symptomatic hypoglycaemia
• Blood glucose <2.6 mmol/L and any of the following symptoms, provided these resolve
once hypoglycaemia has been corrected:
• convulsions
• abnormal neurological behaviour, including hypotonia and poor response to stimulation
• apnoea
Symptoms cannot be attributed to hypoglycaemia if they persist after adequate
treatment. Jitteriness alone does not constitute symptomatic hypoglycaemia
PREVENTION
• Keep all infants warm
• Feed all high-risk infants within 2 hr of birth if possible
• In all starved high-risk infants, institute IV infusion of glucose 10% (see below)
At-risk infants
Perform blood glucose estimation in:
• Small for dates
• Preterm
• Any ill infant
• Infant of diabetic mother
• Beckwith-Wiedemann syndrome
• Haemolytic disease of the newborn
• Severe fluid restriction
Monitor all at-risk infants using near-patient monitoring
• First 24 hr, 3–4 hrly
• Second 24 hr, 4–6 hrly
• Then as necessary
• Babies requiring TPN, at least daily
• Babies fed enterally, immediately before feeds
Always verify a low near-patient test result (<2.6 mmol/L) in a symptomatic baby by
sending a sample for laboratory blood glucose estimation
MANAGEMENT
Never use concentrated (>20%) glucose solutions in babies
Asymptomatic hypoglycaemia in at-risk infant
• Correct hypothermia (see Hypothermia guideline)
Feeding
• Increase frequency and/or volume of feeds
• milk is more beneficial than glucose 10% as it is more energy dense (70 kcal/100 mL –vs-
40 kcal/100 mL) and contains fats that promote ketoneogenesis and glucose uptake
• Calculate exact amount of milk baby needs and ensure calculated amount given

• seek advice from breastfeeding advisor, if available
• if baby not taking full amount, top-up with nasogastric feeding
• If breast milk not adequate, top-up feeding via cup with term formula first, then, if next blood
glucose still <2.6, preterm formula
IV glucose
• Give IV glucose if:
• unable to increase/tolerate feed frequency or volume or
• intensive feeding does not produce normoglycaemia
• Give glucose 6 mg/kg/min (glucose 10% at 90 mL/kg/day) by IV infusion
• Continue enteral feeding during IV infusion
• Once normoglycaemia achieved, wean from infusion as tolerated
Monitor
• Repeat glucose measurement after 1 hr. If low, check laboratory blood glucose
• If infant develops symptoms or becomes profoundly hypoglycaemic (<1.1 mmol/L), follow
Symptomatic hypoglycaemia protocol (below) immediately
Symptomatic hypoglycaemia
• Aim for blood glucose >2.6 mmol/L
IV glucose
• Give glucose 10% 2.5 mL/kg by IV bolus over 5 min into peripheral vein and follow with an
infusion of at least 90 mL/kg/day (~6 mg/kg/min), that may be increased if necessary
• Continue enteral feeds
Monitor and adjust
• Record whether symptoms respond to treatment within 30 min: very important for definitive
diagnosis of symptomatic hypoglycaemia
• Re-check blood glucose after 30 min. If still low, give another 2.5 mL/kg bolus and increase
infusion rate to 120 mL/kg/day (8.3 mg/kg/min) except on day 1 when increase glucose
concentration of infusion
• Record response and repeat glucose measurement in 1 hr. If still low, check blood glucose
by laboratory estimation and, if hypoglycaemia confirmed, increase delivered glucose
content by increasing either volume (to 150 mL/kg/day), or concentration (12.5–20%).
Glucose 20% is commercially available but please follow local policy (Table 1)
Give glucose 12.5–20% centrally as extremely hypertonic.
If UVC used, ensure tip not near liver
Failure to respond
• If >12 mg/kg/min of glucose required to achieve normoglycaemia, hyperinsulinaemic state is
very likely. Obtain blood sample at time of hypoglycaemia for simultaneous measurement
of:
• blood glucose
• plasma insulin and serum C-peptide
• free fatty acids
• ketones
• cortisol
• growth hormone
• acylcarnitines
• collect next passed urine for organic acid analysis
• Administer glucagon 200 microgram/kg (maximum 1 mg) IM, SC, or IV. Check blood
glucose within 30 min of glucagon administration, and houly thereafter until stable
• If persistent hyperinsulinism suspected, seek advice from paediatric
endocrinologist/metabolic paediatrician, and consider early transfer to a unit specialising in
the management of such infants

Routine addition of glucose polymers (e.g. Maxijul) not recommended.
If decision made to use Maxijul, discuss with paediatric dietitian.
Beware risk of necrotising enterocolitis
Table 1: Prescription to make up 50 mL of varying concentrations of glucose solution
Infusion concentration (%) Volume of 10% glucose (mL) Volume of 50% glucose (mL)
12 47.5 2.5
15 44.0 6.0
17 41.0 9.0
20 37.5 12.5
Step down
• Once blood glucose normal, wean infant on to milk feeds either continuously or by hourly
boluses, followed by normalising to 3-hrly feeds when blood glucose stable
MONITORING
• Hypoglycaemic patients:
• if symptomatic, every 30 min
• if asymptomatic, every hour
• continue until normoglycaemic
• Once normoglycaemic, 3–4 hrly until 24 hr has elapsed since last hypoglycaemic episode
SEVERE PERSISTENT OR RECURRENT HYPOGLYCAEMIA
Causes of recurrent, persistent neonatal hypoglycaemia
• Hyperinsulinism
• Endocrine deficiency, especially panhypopituitarism
• Disorder of fatty acid metabolism
• Disorder of carbohydrate metabolism
• Disorder of amino acid metabolism
• Rate of glucose infusion required is good guide to likely cause
Substrate or endocrine deficiency <5 mL/kg/hr of glucose 10% required (<8 mg/kg/min)
Hyperinsulinism >6 mL/kg/hr of glucose 10% required (>10 mg/kg/min)
When to investigate further
• Persistent recurrent hypoglycaemia, especially in ‛low-risk’ baby
• Unexpectedly profound hypoglycaemia in a well baby
• Hypoglycaemia in association with metabolic acidosis
• Hypoglycaemia in association with other abnormalities:
• midline defects
• micropenis
• exomphalos
• erratic temperature control
• Family history of SIDS, Reye’s syndrome, or developmental delay
Investigations
• Paired insulin and glucose estimations while hypoglycaemic (hyperinsulinism confirmed if
insulin >10 picomol/L when glucose <2 mmol/L or glucose/:insulin ratio <0.3)
• Urinary ketones and organic acids
• Serum C-peptide
• Plasma cortisol and growth hormone
• Plasma amino acids
• Plasma acylcarnitine
• Free and total carnitines

• Free fatty acids and betahydroxybuturate
• Galactosaemia screen

Management of glycaemic status in at-risk infants
YES
YES
YES
NO
NO
Symptomatic
Cord blood
glucose not
available
Check cord
blood glucose
• Admit to neonatal unit
• Start IV glucose (10%)
90 mL/kg/day – See Symptomatic
hypoglycaemia
<2.6
mmol/L
• Do not admit to neonatal unit
unless otherwise indicated
• Initiate feeding as soon as possible
• Breastfeeding recommended but
support mother’s choice
• Check blood glucose before 2
nd
feed – See Asymptomatic
hypoglycaemia
>2.0
mmol/L
Symptomatic
Asymptomatic
• Continue feeding
• Check blood glucose before 4
th
feed
>2.6
mmol/L
• Continue feeding
• No more blood glucose monitoring
necessary unless symptomatic
• Increase volume and
frequency of feeds
• Check blood glucose
before 4th
feed
• Increase volume and/or
concentration of IV glucose
• Consider glucagon after
senior advice
• Investigate
>2.60
mmol/L
• Check blood glucose
1 hr later
• Continue IV fluids
• Commence and increase enteral
feeds as tolerated
• Monitor pre-feed blood glucose and
decrease IV fluids gradually
NO
Asymptomatic

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