Sick Newborn

Ask

If first visit

• How old is the baby? Where was the baby born?
• Who delivered the baby? Check infant record for risk factors
• What was birth weight? LBW? Preterm?Twin?
• Any problem at birth? Breech? Difficult birth? Was resuscitation done?

Ask the mother

• Has the baby had any convulsions?
• Does the baby have frequent heavy vomiting?
• How is the baby feeding? Any feeding problems?
• How many times has baby breastfed in last 24 hours?
• Is baby satisfied with feeds? Have you fed baby any other food or drinks?
• Has baby breastfed in previous hour?
• How do your breasts feel?
• Do you have any other concerns?

Look, listen feel

• Assess breathing (baby must be calm)
• Count breaths (normal: 30-60/min)
• Assess for grunting/chest in-drawing
• Check SpO2 if available
• Look at the movements: normal and symmetrical?
• Look at the presenting part for swelling or bruises
• Check abdomen for pallor and distention
• Look for malformations
• Feel the tone: normal?
• Feel for warmth and check temperature
• Weigh the baby
• Observe a breastfeed: Is the baby able to attach? Suckling effectively? Well-positioned?
• Look for ulcers and white patches in the mouth (thrush)

SIGNS

CLASSIFY

TREAT

Any of the following

• Respiratory rate > 60 or < 30 or grunting or gasping
• Severe chest indrawing or cyanosis
• Not feeding well
• Convulsions
• Abdominal overdistension
• Heart rate constantly > 180 beats per minutes
• Floppy or stiff body or no spontaneous movements
• Temperature > 37.5°C or < 35.5°C after warming
• Umbilicus draining pus, redness/ swelling extended to skin
• Skin pustules >10 or bullae or skin swelling and hardness
• Bleeding from stump or cut
• Pallor

Possible Serious Illness (see sections neonatal sepsis, meningitis, tetanus)

• Give ampicillin 50 mg/kg IM every 12 hours plus gentamicin 5 mg/kg every 24 hours (4 mg/kg if preterm)
• Refer baby to hospital
• If referral not possible continue treatment for 7 days
• Keep baby warm
• Clean infected umbilicus and pustules and apply Gentian Violet
• If risk of staphylococcus infection, give cloxacillin 50 mg/Kg IV/IM every 6 hours and gentamicin 5-7 mg/Kg every 24 hours

SIGNS

CLASSIFY

MANAGE BY/ADVISE ON

• Feeding well (suckling effectively >8 times in 24 hours)
• Weight >2,500 g or small baby but eating and gaining weight well
• No danger signs
• No special treatment needs

Well Baby

• Continue exclusive breastfeeding on demand
• Ensure warmth, cord care, hygiene, other baby care
• Routine visit at age 3-7 days
• Next immunization at 6 weeks
• When to return if danger signs
• Record on home-based record

If first visit (baby not delivered in health facilities) give

• Vitamin K 1 mg IM
• Tetracycline eye ointment

• Receiving other foods/drinks or given pacifier
• Breastfeeding <8 times/ 24 hours
• Not well attached/not suckling well
• Thrush
• Poor weight gain

Feeding Problem

• Stop other food/drinks
• Feed more frequently, day and night. Reassure mother she has enough milk
• Ensure correct positioning/ attachment
• If thrush: teach how to treat at home (apply gentian violet paint 4 times daily for 7 days with clean hands, use a soft cloth)
• FOLLOW UP visit in 2 days, re-check weight
• If no improvement: Refer for breastfeeding counselling

• Preterm
• Low birth weight (LBW) 1,500–2,500g
• Twin

Small Baby

• Provide as close to continuous Kangaroo mother care as possible to prevent hypothermia
• Give special support to breastfeed small baby/twins
• Teach mother how to care for a small baby
• Teach alternative feeding method (cup feeding)
• Assess daily (if admitted) or every 2 days (if outpatient) until feeding and growing well
• If twins, discharge them only when both are fit to go home

• Very Low Birth weight < 1,500g
• Very preterm (< 32 weeks)

Very Small Baby

• Refer urgently to hospital for special care
• Ensure extra warmth during referral

• Mother very ill/ receiving special treatments
• Mother transferred

Mother Unable to Take Care of Baby

• Help mother to express breastmilk (to maintain lactation)
• Consider other feeding methods until mother can breastfeed
• Ensure warmth using other methods
• Cord care and hygiene
• Monitor daily

Ask (check records)

• Has the mother had (within 2 days of delivery) fever> 38°C and/or infection treated with antibiotic?
• Did the mother have membrane ruptured > 18 hours before delivery?
• Has the mother tested RPR positive?
• Has the mother started TB treatment < 2 months ago?
• Is the mother HIV positive? is she on ARVs?
• Has anything been applied to the umbilicus?

Look Listen and feel

• Eyes: Swollen and draining pus?
• Umbilicus: Red and draining pus?
• Skin: Many or severe pustules? Swelling, hardness or large bullae?
• Jaundice: check face if baby < 24 hours, check palms and soles if > 24 hours
• Movements: Less than normal? Limbs moving symmetrically?
• Presenting part (head or buttocks): Swelling, bruising?
• Any malformation?

SIGNS

CLASSIFY

MANAGE BY/ADVISE ON

• Baby < 1 day old and membrane ruptured > 18 hours
• Mother with fever and/or on antibiotics

Risk of Bacterial Infection

• Give ampicillin 50 mg/kg every 12 hours plus gentamicin 5 mg/kg (4 mg if pre-term) once daily for 5 days
• Assess baby daily

• Mother tested RPR positive

Risk of Congenital Syphilis

• Give baby single dose benzathine penicillin 50,000 IU/ kg IM
• Ensure mother and partner are treated (see Syphilis)
• FOLLOW UP every 2 weeks

• Mother started TB treatment <2 months before delivery

Risk of TB

• Give baby prophylaxis with isoniazid 5 mg/kg daily for 6 months
• Vaccinate with BCG only after treatment completed
• Reassure breastfeeding is safe
• FOLLOW UP every 2 weeks

• Mother known HIV positive

Risk of HIV

• Give ARV prophylaxis as per national guidelines (see HIV infection and AIDS)
• Counsel on infant feeding
• Special counselling if mother breastfeeding
• FOLLOW UP every 2 weeks

• Eyes swollen, draining pus

Gonococcal Eye Infection

(Possible Chlamydia Coinfection - See Section)

• Give ceftriaxone 125 mg IM stat plus azithromycin syrup 20 mg/kg daily for 3 days
• Teach mother how to treat eye infection at home (clean eyes with clean wet cloth and apply tetracycline ointment 3 times day)
• Assess and treat mother and partner for possible gonorrhoea and chlamydia (see Sexually transmitted Infections)
• FOLLOW UP in 2 days

• Red umbilicus

Local Umbilical Infection

• Teach mother how to treat at home (wash crust and pus with boiled cooled water, dry and apply Gentian Violet 0.5% 3 times a day)
• FOLLOW UP in 2 days
• If not improved, reclassify and treat or refer

• <10 pustules

Local Skin Infection

• Teach mother to how to treat infection at home (wash crust and pus with boiled cooled water, dry and apply Gentian Violet 0.5% 3 times a day)
• Reassess after 2 days
• If not improved, reclassify and treat or refer

• Yellow face (<24 hours old) or
• Yellow palms and soles (>24 hours old)

Severe Jaundice

Refer urgently to hospital

• Encourage breastfeeding
• If breastfeeding problem, give expressed milk by cup

• Bruises or swelling on buttocks
• Swollen head - bump on one or both sides
• Abnormal position of legs after breech presentation
• Asymmetrical arm movement or arm does not move

Birth Injury

• Explain to parents that it does not hurt the baby and it will disappear in 1 or 2 weeks by itself
• DO NOT force the leg into a different position
• Gently handle the limb that is not moving, do not pull

• Club foot
• Cleft palate or lip
• Odd looking, unusual appearance
• Open tissue on the head/ abdomen/ back/ perineum or genitalia

Malformation

•  Refer for special evaluation and treatment
• Help mother breastfeed or teach mother alternative method if not possible
• Cover open tissue with sterile gauze soaked in sterile saline solution before referral