Chapter 3.10 Supportive care for sick neonates

Chapter 3.10.1 thermal environment

  • Keep the young infant dry and well wrapped.
  • A hat can reduce heat loss. Keep the room warm (at least 25°C).  Keeping a young infant in close skin-to-skin contact with the mother (Kangaroo Mother Care) for 24 h/day is an effective way of keeping the infant warm.  An external heating device may be needed when the mother is asleep or too ill
  • Pay special attention to avoid chilling the infant during an examination or investigation
  • Check regularly that the infant's temperature is maintained in the range 36.5-37.5°C (97.7 - 99.5°F) rectal or 36.0 - 37.0°C (96.8 - 98.6°F) axillary.  Use a low-reading thermometer to ensure detection of hypothermia.

Chapter 3.10.2 fluid management

Encourage the mother to breastfeed frequently to prevent hypoglycaemia. If the infant is unable to feed, give expressed breast milk by nasogastric tube.

  • Withhold oral feeding if there is bowel obstruction, necrotizing enterocolitis, or the feeds are not tolerated, indicated e.g. by increasing abdominal distension or vomiting everything.
  • Withhold oral feeding in the acute phase in infants who are lethargic, unconscious or having frequent convulsions.
  • If IV fluids are given, reduce the rate as the volume of oral or gastric milk feeds increases. IV fluids should ideally be given with an in-line burette to ensure the exact doses of fluids prescribed.

Increase the amount of fluid given over the first 3–5 days (total amount, oral plus IV).

Day 1 60 ml/kg per day
Day 2 90 ml/kg per day
Day 3 120 ml/kg per day

Then increase to   150 ml/kg per day

When the infant tolerates oral feeds well, the amount of fluid might be increased to 180 ml/kg per day after some days. Be careful in giving parenteral IV fluids, which can quickly overhydrate a child. Do not exceed 100 ml/kg per day of IV fluids, unless the infant is dehydrated or under phototherapy or a radiant heater. This amount is the total fluid intake an infant needs, and oral intake must be taken into account when calculating IV rates.

  • Give more fluid if the infant is under a radiant heater (1.2–1.5 times).
  • During the first 2 days of life give 10% glucose infusion IV. Do not use IV glucose without sodium after the first 2 days of life. Suitable alternative IV fluids after the first 2 days are half normal saline and 5% dextrose.

Monitor the IV infusion very carefully (ideally through an in-line burette).

  • Use a monitoring sheet.
  • Calculate the drip rate.
  • Check the drip rate and volume infused every hour.
  • Weigh the infant daily.
  • Watch for facial swelling: if this occurs, reduce the IV fluid to a minimum or take out the IV line. Introduce breastfeeding or milk feeding by orogastric or nasogastric tube as soon as it is safe to do so.

Chapter 3.10.3 oxygen therapy

Give oxygen to neonates or young infants with any of the following: 

  • central cyanosis or gasping
  • grunting with every breath
  • difficulty in feeding due to respiratory distress
  • severe lower chest wall indrawing
  • head nodding (i.e. a nodding movement of the head, synchronous with the respiration and indicating severe respiratory distress)

Use a pulse oximeter to guide oxygen therapy. Oxygen should be given if the oxygen saturation is < 90%, and the oxygen flow should be regulated to maintain saturation of > 90%. Oxygen can be discontinued once the infant can maintain saturation > 90% in room air.

Nasal prongs are the preferred method for delivering oxygen to this age group, with a flow rate of 0.5–1 litre/min, increased to 2 litres/min in severe respiratory distress to achieve oxygen saturation > 90%. Thick secretions should be cleared from the throat by intermittent suction under direct observation, if they are obstructing the airway and the infant is too weak to clear them. Oxygen should be stopped when the infant’s general condition improves and the above signs are no longer present.

Chapter 3.10.4 high fever

Do not use antipyretic agents such as paracetamol to control fever in young infants; instead, control the environment. If necessary, undress the child.