NEONATES (we have abbreviated the NICU or neonatal site in italics)

•  Nepean Neonatal Intensive Care Unit  (Nepean) 

• NETS

• Royal Hospital for Women Neonatal Medical Guidelines (RHW)

•  Neonatal ehandbook Victorian Health (NEB)

• RPAH intranet policies

• Liverpool NICU intranet policies

• ASID management of perinatal infections

• Cochrane Database on neonatal care

• NICU tools 

MANAGEMENT OF BABIES WITH RESPIRATORY DISTRESS IN A SPECIAL CARE NURSERY

Neonates may exhibit signs of persistent respiratory distress following their delivery. The lower the gestational age, the higher the proportion of neonates that are born with surfactant deficiency, or respiratory distress syndrome (aka hyaline membrane disease).

In a neonate respiratory distress may be observed with the following features: tachypnoea (respiratory rate >60 mildly concerning, >80 ongoing is quite concerning), tracheal tug (with head bobbing), intercostal and subcostal recession, nasal flare and expiratory grunting (grunting noise heard consistently with each exhalation).

WHEN IS RESPIRATORY SUPPORT NEEDED?

·   IF ONGOING RESPIRATORY DISTRESS AND/ OR LOW OXYGEN LEVELS (TARGET O2 SATs of 91-95%)

By 10 minutes of age, a neonate, who is transitioning from foetal circulation to neonatal circulation, on average, should have SaO2 saturations > 90% with no (or minimal) observed respiratory distress.

Neonates with persistent respiratory distress, and/ or an oxygen requirement should have a paediatric registrar (or medical) review and be admitted to Special Care Nursery for observation. Note following caesarean section the risk of transient tachypnoea of newborn is higher, so particular attention following C-section birth and routine monitoring of O2 is saturations recommended.

NURSING IN SPECIAL CARE

Once in the a nursery the baby with respiratory distress will be placed under a resuscitaire. Upper and lower limb O2 saturations should be checked. Sometime just warming the baby up, nursing prone may improve ventilation, and reduce respiratory distress. A blood sugar is checked and consideration of capillary blood gas by the ISTAT machine.

REGISTRAR REVIEW

If the nurse confirms ongoing respiratory distress, the registrar must perform a thorough review including history and examination.

Premature baby:   In a premature infant, especially those babies < 34 week gestation,  with persistent respiratory distress, the likelihood of prompt spontaneous resolution of respiratory distress is lower than in a term infant. Consideration should be given to early administration of nasal CPAP and oxygen (see CPAP document).

Term baby:            In a term infant who is stable with no significant respiratory distress, who has mild hypoxaemia, i.e. requiring only small amounts of supplemental oxygen to maintain normal O2saturations (e.g. FiO2 < 0.25-0.3 ), clinicians may elect to wait for one hour to see if the respiratory system stabilises, prior to commencing CPAP.

INITIATING CPAP: WHEN SHOULD CPAP BE STARTED?

If the baby has ongoing respiratory distress +/- hypoxaemia then consideration for commencing CPAP after the registrar reaching agreement with the nurse in charge.

Bubble CPAP is commenced usually at 5-6 cm H20. If there is disagreement then the team discusses management with the consultant on call.

For the technical aspects of CPAP treatment, if you are working in NSW Health  please refer to Western LHD document on CPAP.

Note whilst awaiting our nursing staff to see up the bubble CPAP, a doctor (or nurse) can hold the Neopuff over the baby's face (nose and mouth  should be covered) , as this will give CPAP earlier.

PLACING AN INTRAVENOUS CANNULA AND INTRAVENOUS FLUIDS

If the baby has ongoing respiratory distress it will most likely benefit from an intravenous cannula and 10% dextrose intravenous fluids at 60ml/kg/day.

Or   2.5 x (body weight in kg)  ml per hour eg 4kg is:  4x 2.5 = 10ml per hour

VENTING THE STOMACH ON CPAP: If the baby is on CPAP an orogastric tube (ideally a size 8f) should be inserted and left on free drainage.

GLUCOSE

Check the blood glucose level is > 2.6mmol and treat as per hypoglycaemia protocol

WHAT INVESTIGATIONS ARE DONE IN THE EARLY PHASES OF TREATMENT of BABIES WITH RESPIRATORY DISTRESS ON CPAP?

(< 4 hours?)

·   Venous blood gas or capillary blood gas:

a) if the PCO2 > 70  and pH < 7.1 on CPAP on 1-2 occasions, then call consultant and consider preparing for intubation and ventilation

b) if the PCO2 is >60 and pH < 7.25 this merits immediate discussion with consultant on call.

c) if the PCO is 45-60 and pH is 7.25 to 7.34 – repeat in one hour on CPAP

d) if the PCO2 is < 45 repeat as clinical needs indicate- e.g. worsening respiratory distress

·   Full blood count- looking for low haemoglobin (from haemolysis or blood loss), white cell count elevation neutrophils > 20 or neutropaenia <1.0 (in particular < 0.5 is of concern), thrombocytopaenia (may be seen in sepsis)

·   Blood culture: inserting a cannula under aseptic conditions and inserting 1-2ml of blood into a blood culture bottle

SHOULD THE BABY BE STARTED ON INTRAVENOUS ANTIBIOTICS (IVABs)?

IF SO WHEN?

·   Risk factors for neonatal sepsis on history and examination need to be considered by the team.

·   If there is a history of prolonged rupture of membranes > 18 hours, maternal fever > 38c in labour, Group B strep positive (especially if found in maternal urine), malodorous placenta (possible chorioamniitis), previous child with GBS sepsis, unexplained pre-term labour

·   Examination findings which would concerning for neonatal sepsis: persistent respiratory distress, temperature instability (temperature < 36c or > 37.5c consistently), poor perfusion (central capillary return on forehead or chest > 3 seconds), lethargic, hypoglycaemia.

·   If there are risk factors for sepsis and ongoing respiratory distress, following blood culture collection, then start IVABs- see RPA guidelines and drug folder

·   If the baby was born via a "cold" caesarean section (i.e no onset of labour) , with no risk factors, has a normal examination and responds well to CPAP with no respiratory distress and the presumed diagnosis is TTN, then discuss with the consultant about postponing IVABs.

·   Babies who need more than 4 hours of CPAP, even with normal examination etc there is a strong case for IVABs

WHEN SHOULD A CHEST X-RAY BE DONE?

There is no one recommendation for all patients, so for babies on CPAP discuss case with a consultant.

·   All babies with ongoing respiratory distress on CPAP and/or oxygen requirement after 4 hours need a CXR for diagnostic reasons.

·   If a baby responds well to CPAP, has no respiratory distress, no oxygen requirement then a discussion with the consultant can be had about not doing a CXR.

·   If a baby is moderately sick with RR > 80 and /or FIO 2 > 50% oxygen, or focal respiratory clinical signs (eg poor chest movement on one side or reduced air entry on one side, a CXR should be run immediately, whilst preparing for possible pneumothorax treatment.

·   Note check the orogastric tube placement on the CXR to ensure it is beyond the diaphragm and not in the oesophagus.

DISCUSSING PATIENTS WITH PERISTING RESPIRATORY DISTRESS ON CPAP

If the respiratory distress persists on CPAP 6 cm H20, and/or the FiO2increases to above 30%, then the registrar should discuss management with the consultant on call.  Please refer to Dubbo Base Hospital CPG on CPAP and respiratory distress syndrome and surfactant.

SUDDEN CHANGE IN RESPIRATORY STATUS

If the SaO2    falls suddenly and the FiO2  needed for targeted O2  increases by 10% or more, or there is a sudden change in respiratory distress status (e.g. RR suddenly increased from <60 to >75-80 with significant recession then team needs to:

•       ensure nasal cannulae or the nares are not blocked;

•       ensure the circuit is intact;

•       consider the need for suctioning as nasal secretions, as they may block nasal air flow

•       exclude a pneumothorax by transillumination and/or CXR supine and or lateral

•       Notify consultant on call.

SHOULD SURFACTANT BE GIVEN?     (Consider MIST if trained to do so)

Consider surfactant in those babies with typical history and chest x-ray findings of RDS and:

·   in a baby on CPAP in the first 24-48 hours of life with FIO2 > 0.3, to maintain SaO2 91-95%

·       If respiratory distress persists and if CPAP is at the upper limit 8cm H2O

·       pH less than 7.25 on two occasions

·       CO2 greater than 60 on two occasions

·       Also consider surfactant in a baby with persistent marked respiratory distress on CPAP

ESCALATING CARE in the NURSERY

·   If the FIO2 > 0.4 the team discusses with NETS and the neonatologist regarding treatments planned in the hours to follow and likely transfer to Sydney

·   If the FIO2> 0.6, PCO > 60 on two samples, pH < 7.25 on two samples consistently there is a high chance of requiring intubation and ventilation. The consultant on call is called to attend the baby in the nursery.

·   The plan for ventilatory support is implemented (see intubation and ventilation guideline)

SHOULD I START ENTERAL FEEDS?

·   Feeding the baby may be difficult if there is significant respiratory distress after 1 hour of life. If the respiratory rate is > 60-70 bpm, there are other persisting features of respiratory distress and/ or the FiO2 on CPAP is >25%, then enteral feeds are not recommended.

·   If the FiO2 is < 25% on CPAP and there is no significant respiratory distress, orogastric feeds may be considered after discussion with consultant on call for SCN.

LATER CONSIDER MORE BLOOD INVESTIGATIONS

·   CRP- the CRP is a marker of infection, and may done by a heel prick

The CRP takes time to rise. It is best deferred until the baby is older than 6 hours. When used in conjunction with the FBC, blood culture and the infant’s clinical condition, the CRP may assist in determining when to cease antibiotics. Two normal CRP tests, taken 8-24 hours after birth, and 24 hours later makes the chances of neonatal sepsis extremely unlikely. The negative predictive accuracy is 99.7%.

·   Electrolytes- at birth this reflects maternal electrolytes, so this is best deferred until 12 to 24 hours of age. Sodium and potassium may be obtained from the venous blood gas, upon request.

Enteral Feeding

Overview

This feeding protocol is a guide to assist clinicians in supporting grading up of feeds in babies  born in. It is principally aimed at grading up of feeds in babies requiring admission to a Nursery.

3.1 What milk and what volume?

a) First choice milk: Maternal expressed breast milk (EBM). This should be supplemented with FM85 human milk fortifier to 26calories/30ml when the baby is tolerating 150ml/kg/day (approximately day 7 of life) in babies born before 35 weeks gestation and/or who are less than 2.0kg

b) Normal term formula in babies born after 32 weeks, after tolerating 120-150ml/kg/day

c)   What volume?

Day 1- 60 mls/kg/day  divided in into feeds every 3 to 4 hours (on day 1 a range of 60-90ml/kg/day e.g. hypoglycaemic infants)

Day 2- 80 mls/kg

Day 3- 100 mls/kg

Day 4- 120 mls/kg

Day 5- 140 mls/kg

Day 6- 160 mls/kg

Day 7- and beyond – as per MO’s order

3.2 When should milk be started?

·   Babies born after 32 weeks (33 weeks and over) who are normally grown (>10th centile) can be started immediately on intermittent nasogastric bolus milk feeds according to usual fluid requirements feeding being given every 2 hours. In mothers who wish to breast feed, we should discuss with them the transitional use of formula milk while we await sufficient supply of EBM.

·   Babies born between 30 and 32 weeks who are well (e.g not on respiratory support) should have a peripheral IV inserted to allow slow increase in enteral milk feeds starting at 1ml/hr on day 1 or as maternal breast milk becomes available.

·   Babies born before 30 weeks and babies born from 30 weeks onwards who have respiratory problems (e.g.  or other complications should start minimal enteric feeds at 1 ml every 4 hours as soon as mother’s breast milk is available.

3.3 How quickly should milk feeds be increased?

·       In preterm babies born after 27 weeks (e.g. 28 weeks onwards), who commence on IV fluids at birth: The rate of increase needs to be individualised however the Cochrane review would suggest that in uncomplicated preterm babies, feeds can be advanced up to 30 to 35 ml/kg per day if tolerated without adverse effect.14 In babies born after 31 weeks who start on IV fluids, it may be reasonable to increase feeds faster than that.

·       How should the rate of increase be individualised? In terms of the hourly bolus feeds, this can range from an increase of 1ml/hr every 4 hours to 1ml/hr every 24 hours or even longer in some babies and should be titrated against maturity, feed tolerance and other abdominal signs.

3.4 What should be the final feed volume?

·       In babies born before 33 weeks or 33 and 34 weeks and less than 10th centile (33w <1600g; 34 weeks <1800g), the target total feed volume should be 180 ml/kg/day. This should be achieved by:

·       Increasing hourly bolus feeds with unfortified EBM, DBM or preterm formula to 150-160 ml/kg/day as described above.

·       After 24-48 hours of tolerance with unfortified EBM or DBM at 150-160 ml/kg/day, add FM85 to 26 cals/30ml.

·       After 48-72 hours of tolerance of fortified EBM, DBM or preterm formula, increase to 180 ml/kg/day in three daily steps of 10 ml/kg. Consider going faster than this in more mature babies.

·       In babies born after 32 weeks and birth weight above than 10th centile (33w >1600g; 34 weeks >1800g), the target total feed volume should be 150-160 ml/kg/day; this may well increase to 180ml/kg/day and at times up to 200ml/kg/day.

3.5 What babies need further nutritional supplementation of milk?

·       In babies born before 35 weeks who are less than 2.5kg

·        If tolerating 180ml/kg/day of FM85 fortified EBM or LBW formula: Nutritional and vitamin requirements are met with the possible exception of Vitamin D. Our view is that the evidence is not strong enough to support routine supplementation of Vitamin D above that provided by FM85.

·       Add Pentavite 0.45ml/day when baby is tolerating 150 ml/kg/day (this is approximately on day 7 of life). This may be omitted in formula feed infants.

·       Add Iron as Ferrous Sulphate (6mg elemental iron per ml) from 28 days of age at 1.2mg elemental iron/kg/day (0.2ml/kg/day) in one dose. (1ml per day is a reasonable approximate dose)

3.6    When to stop FM-85 or LBW formula and post-discharge nutrition?

·   Once a baby is feeding at the breast there are practical limitations to providing nutritional supplementation and not enough evidence to support routine supplementation. This will need individualising in babies not growing adequately.

·   Prior to establishment of sucking feeds at breast or bottle, we will stop breast milk fortification or change low birth weight formula to normal term formula when:

·   Weight is more than 2.2kg or:

·   Has taken at least three suck feeds a day on two consecutive days and:

·   Is appropriately grown (>10th centile) and is gaining weight adequately (>15g/kg/day).

3.7 Which babies should get post-discharge iron and vitamin supplement?

·   Post-discharge iron and vitamin supplementation should be recommended for all babies who are born before 35 weeks (e.g 34 weeks and less) with birth weight less than 2.5 kg. Supplementation can be considered on an individual basis for babies born after 34 weeks if they are very growth restricted.

• Regimen: Pentavite 0.45ml/day and Ferrous Sulphate (6mg elemental iron per ml) at 1.0ml/day both as a once daily dose to be started when stopping breast milk fortification or changing from LBW to term formula in the smaller babies.

4. Main Guideline

4.1 Introduction

4.2 Which Milk?  Breast milk and formulas

4.3 How should the milk be given?

4.4 When should milk be started?

4.1 Introduction

The goal of nutrition for the preterm infants is to achieve as near to normal weight gain and growth as possible. It is difficult to deliver adequate calories with parenteral nutrition so the aim should be to introduce enteral milk feeds as early as a baby can safely tolerate them.

Nutritional Needs of Preterm Babies: The enteral calorie requirement of a preterm baby will range between 110 and 135 kcal/kg/day and this would usually be administered in milk volumes ranging between 135 and 200 ml/kg/day with most babies’ routine feed volumes between 150 and 180 ml/kg/day.1

Overall adequacy of nutritional intake in any baby is measured by growth, particularly weight gain. In a preterm baby, the target weight gain when a baby is on full enteral feeds is between 10 and 25 grams/kg/day with an average of around ­­15g/kg/day.2 Weight gains in excess of 25g/kg/day should raise concerns about fluid retention.

Table 1 shows the range of nutrient intakes as recommended by ESPGHAN in 2010 comparing breast milk and different strengths of fortified breast milk.

4.2 Which Milk?

Breast Milk

Expressed Breast Milk (EBM): Breast milk expressed by the baby’s own mother remains the first choice of feed for the preterm infant. Numerous short and long term benefits have been demonstrated including better feed tolerance, reduced risk of NEC and late onset sepsis and,

Donor Breast Milk (DBM): In babies at high risk of NEC where the mother is not able to express adequate breast milk, donor breast milk collected in accordance with the RPA donor breast milk policy can be considered. Although pasteurisation modifies some of the anti-infective constituents of breast milk there is evidence from systematic review, that DBM still confers a protective effect against NEC when compared to formula milk.4

The decision to use DBM should be made by senior medical staff on an individual case basis but babies in whom it should be considered include the very premature (born before 30 weeks), or born after 30 weeks and with severe intrauterine growth restriction and absent or reversed end-diastolic umbilical artery flow on fetal Doppler.

Nutritional limitations of Breast Milk for Preterm Babies: In light of the long-term health outcome advantages of expressed maternal breast milk together with probable short-term immunological advantages, this has to be the milk of choice. However breast milk does have limitations in addressing the nutritional needs of the very preterm infant

• It does not have enough calories to ensure optimal early growth at 20 kcal/30ml, particularly it does not have enough protein.3

Nutritional limitations of Breast Milk for Preterm Babies:

It does not have enough sodium to compensate for the high renal sodium losses of the very preterm infant.

It does not have enough calcium or phosphate. Historically, osteopenia of prematurity was a problem in breast milk fed babies and those on prolonged parenteral nutrition.

Breast milk has low concentrations of vitamins and iron relative to the needs of a preterm infant who will have missed out on the last trimester placental vitamin transfer.(see vitamins and minerals below).

The Cochrane review concludes that multicomponent human milk fortification results in better short term weight gain and linear and head circumference growth. There is no evidence of longer term growth advantage.6

At RPAH, we routinely supplement EBM with FM 85 human milk fortifier up to 26kcal/30ml in babies born before 33 weeks (e.g. 32 weeks and less) and in babies born at 33 and 34 weeks with birth below the approximate 10th centile (see table below).

Gestation

Add FM85 if less than:

33 weeks and 1600g

34 weeks and 1800g

FM85 provides adequate extra calories, vitamins, sodium, calcium, phosphate and iron but is still deficient in some vitamins particularly D and A. See table 1

When to start FM85? There are no standards or evidence around when breast milk fortifier should be started. Within the clinical trials of breast milk fortifiers, there was considerable variation as to when it was added with some trials waiting for enteral tolerance of full total fluid requirement with unfortified breast milk and other trials adding it earlier, e.g. from when 100 ml/kg/day is tolerated. More research is needed to confirm the safety of early addition of human milk fortifiers.

At RPAH, we add FM85 to expressed maternal or donor breast milk in babies born before 33 weeks and in babies born at 33 and 34 weeks with birth weight below the approximate 10th centile (see table), once they’ve been tolerating 150 ml/kg/day for 48 hours.

Babies who do not tolerate FM85 fortification of EBM/DBM should be supplemented with mineral

Formula Milks

Low Birth Weight Formula: Sometimes it will be necessary to use formula milk in preterm babies whose mothers cannot (or do not wish) to express adequate quantities of breast milk.

There are low birth weight formulas adapted to the nutritional needs of very preterm babies and the randomised study of Lucas et al7 showed that babies less than 1750g at birth fed preterm compared to normal formula thrived significantly better. The main difference between the commercial low birth weight formulas is whether the protein is partially hydrolysed. Comparative trials have shown little difference between partially hydrolysed and non-hydrolysed in terms of feed tolerance or growth.8,9

The current LBW formula at Dubbo SCN is Prenan.

Extensively Hydrolysed Elemental Formula:. An extensively hydrolysed elemental formula, such as Neocate may be trialed in infants with recurrent feed intolerance, colitis (visible blood in stools) or lactose malabsorption where there is recurrent intolerance to a standard LBW formula or breast milk. As well as including extensively hydrolysed protein, Neocate is lactose free and has added medium chain triglycerides. (See RPAH feeding guideline for issues around Neocate in the longer term).

.

Summary of recommendations on which milk:

First choice milk: Maternal expressed breast milk. This should be supplemented with FM85 breast milk fortifier to 26 calories/30ml when the baby is tolerating 150ml/kg/day in babies less than 35 weeks gestation and less than 2.0kg.

Second choice milk: Low birth weight formula in babies born less than 35 weeks gestation and less than 2.0kg.

4.3 How should the milk be given?

As preferential nose breathers, a nasogastric tube has a significant space occupying effect on the airway of a preterm baby.10 Nasogastric tubes are also not possible when babies are receiving nasal CPAP. In view of this, gastric tubes at RPAH are passed via the oro-gastric route.

The controversy remains as to whether feeds should be given by continuous infusion or intermittent bolus. Continuous infusion was hypothesised to reduce respiratory effects of a bolus of milk in the stomach, although there is not much evidence to support this hypothesis. The Cochrane systematic review of trials comparing these two approaches concluded that the evidence did not show any clear advantage of one approach over the other.11

At RPAH, routine feeding is administered by intermittent bolus with the feed interval individualised according to the baby’s age and feed tolerance.

4.4 When should milk be started?

There is no evidence that delayed commencement of feeds protects against NEC in high risk infants (eg growth restricted babies with abnormal antenatal umbilical artery Doppler flows).13 However there is good empiric reason in such babies to use breast milk and avoid any early use of formula milk.

Summary of recommendations on when to start:

Babies born after 32 weeks (33 weeks and over) who are normally grown (>10th centile)

Can be started immediately on intermittent bolus milk feeds according to usual fluid requirements. In mothers who wish to breast feed, we should discuss with them about the transitional use of formula milk, while we await sufficient supply of breast milk.

Babies born between 30 and 32 weeks who are well (e.g not on respiratory support) should have a peripheral IV inserted to allow slow increase in enteral milk feeds starting at 1ml/hr on day 1.

 Babies born before 30 weeks and babies born from 30 weeks onwards who have respiratory problems or other complications should start minimal enteric feeds at 1 ml every 4 hours as soon as mother’s breast milk is available, via a size 8 orogastric tube and the tube vented.

• In all babies:

o Mother’s lactation should be supported from birth.

o Where breast milk is not available by 72 hours, consideration of alternative feeding regimens should be considered in consultation with the mother.

o Delayed commencement of enteral feeds may need to be considered in unusually sick or complicated babies on an individualised basis.

4.4 How quickly should feeds be increased?

• In preterm babies born after 27 weeks (e.g 28 weeks onwards), who commence on IV fluids at birth: The rate of increase needs to be individualised however the Cochrane review would suggest that in uncomplicated preterm babies, feeds can be advanced up to 30 to 35 ml/kg per day if tolerated without adverse effect.14 In babies born after 31 weeks who start on IV fluids, it may be reasonable to increase feeds faster than that.

• How should the rate of increase be individualised? In terms of the hourly bolus feeds, this can range from an increase of 1ml/hr every 4 hours to 1ml/hr every 24 hours or even longer in some babies. The following factors should be considered in individualising the rate of feed increase:

Gestation and weight of the baby.

How sick the baby is or has been

How well the milk is being tolerated (vomits or large residuals)

Any abdominal signs e.g. distension.

Bile stained aspirates, though these are common and it may be reasonable to continue to increase if aspirates are small and only lightly bile stained.

Special situations (see below).

4.5 What should be the final feed volume?

In babies receiving total fluid volume via enteral feeding:

As a guide, feeds should be increased as shown:

o Day 1- 60 mls/kg (on day 1 a range of 60-90ml/kg/day eg hypoglycaemic infants)

o Day 2- 80 mls/kg

o Day 3- 100 mls/kg

o Day 4- 120 mls/kg

o Day 5- 140 mls/kg

o Day 6- 160 mls/kg

o Day 7- and beyond – as per MO’s order

A reasonable approach is to have the baby graded up to 150-160ml/kg/day and the lowest value above this, to achieve good weight gain, is a reasonable final target volume. Beyond this a baby will demand feed and self-determine the volumes taken in.

At the upper range of feed volumes is 200ml/kg/day may be complicated by over-feeding problems such as worsening of gastro-oesophageal reflux and excessive weight gain. The important message is that clinicians need to individualise final feed volumes to the baby by titrating against the weight gain (15-25g/kg/day) and history of feed intolerance.

.

Summary of recommendations on final feed volume:

In IUGR babies born eg babies less than 2.0kg and less than 35 weeks gestation the target total feed volume should be 180 ml/kg/day. This should be achieved by:

1. Increasing hourly bolus feeds with unfortified EBM, DBM or preterm formula to 150 ml/kg/day as described above.

2. After 24-48 hours of tolerance with unfortified EBM or DBM at 150 ml/kg/day, add FM85 to 26cals/30ml.

3. After 48-72 hours of tolerance of fortified EBM or preterm formula, increase to 180 ml/kg/day in three daily steps of 10 ml/kg. Consider going faster than this in more mature babies.

In babies born above 2.0kg and above 35 weeks gestation the target total feed volume should be 150-160 ml/kg/day.

In all babies, the final feed volume should be titrated against weight gain and feed tolerance

Weight gain once on full feeds should be about 15g/kg/day (range 10-25g/kg/day). Less than this suggests calories need increasing by increasing volume or calorie content of the milk. Weight gain more than 25g/kg/day should raise the possibility of fluid retention particularly in babies with chronic lung disease.

4.6 Vitamin Supplementation.

The last trimester is an important time for transfer of vitamins to the fetus. The preterm infant misses out on this transfer and because breast milk has low vitamin concentrations, the vitamins contained in breast milk fortifier are important. As can be seen from table 1, fortified EBM at 180 ml/kg/day largely meets vitamin requirements with the exception of vitamin D and vitamin A.

Vitamin D: Vitamin D is important for supporting a range of physiological processes, particularly bone mineralization and calcium absorption from the GI tract. The study of Bronner et al18 suggested that preterm infant calcium absorption was largely independent of Vitamin D level, however two more recent studies have questioned this, both showing better calcium absorption rates in preterm babies supplemented with 1200 IU of Vitamin D a day.19,20

Because of these findings the ESPGHAN recommendations are that Vitamin D should be supplemented in preterm babies to 800-1000IU per day (note not per kg/day) during the first months of life.

Vitamin A: Vitamin A is a group of fat soluble compounds used by the body for regulation and promotion of growth and differentiation of many cells, including cells in the retina of the eye and the cells that line the lung. Preterm infants have low vitamin A levels at birth. This may contribute to an increased risk of developing chronic lung disease.

Cochrane review of trials of vitamin A supplementation in preterm babies showed reduced incidence of oxygen requirement at 36 weeks corrected age and an insignificant trend to less retinopathy of prematurity.21 The intervention in the included trials involved intramuscular injections of vitamin A. In the one trial where vitamin A was used orally, the dose was 1500 μg/day. ESPGHAN highlights the risk of potentially toxic levels of vitamin A at doses above 1200 μg/day thus they recommend a dose between 400 and 1000 μg/kg/day.

Vitamin A and D in TPN: The TPN regimen at RPAH provides 160 IU/kg/day of Vitamin D and 276 mcg/kg/day (920 IU/kg/day) of Vitamin A at 3gms/kg/day of lipid infusion.

Vitamin A and D in EBM fully fortified with FM85 at 180 ml/kg/day will deliver about 290 IU of Vitamin D and 756 μg of Vitamin A.

Vitamin A and D in S26 low birth weight formula at 180 ml/kg/day will deliver about 240 IU of Vitamin D and 333 μg of Vitamin A.

4.7 Mineral Supplementation

Sodium: Most of a preterm baby’s mineral and trace element requirements will be met using 180 ml/kg of fortified breast milk or low birth weight formula. The exception will be sodium where the intake will be at the lower end of the recommended range. Sodium chloride supplementation should be titrated to the serum sodium level, starting at 2 mmol/kg (46 mg/kg).

Calcium and Phosphate: Requirements for these minerals will be met at 180 ml/kg/day of fortified EBM/DBM or low birth weight formula but these will need monitoring with blood tests as detailed in the ‘Metabolic Bone Disease’ guideline. High risk babies for deficiency in these minerals will include:

 -Babies with delayed feed tolerance requiring prolonged TPN.

-Babies who do not tolerate FM85.

.-Babies who are fed with extensively hydrolysed formula such as Neocate.

Babies with blood test evidence of calcium or phosphate deficiency will need supplementing as detailed in the ‘Metabolic Bone Disease’ guideline.

Iron: Total body iron in a newborn is approximately 75mg/kg with most of this within the blood volume thus the smaller a baby, the lower their iron stores. Risk of iron deficiency is compounded by losses due to blood tests and low iron content of EBM. On the other hand there are risks of excessive iron supplementation including increased infection risk, poor growth and disturbance of absorption of other minerals. There is also the potential risk of free oxygen radical formation increasing the risk of ROP.22 For these reasons, we’ve traditionally delayed administration of enteral iron for 6-8 weeks.

However two trials of early supplementation (when tolerating 100ml/kg) vs no enteral iron supplements have shown no adverse effects of early iron administration and one trial showed less early iron deficiency and lower transfusion rates.23,24 Further an RCT of an iron fortified HMF (commenced when tolerating 100ml/kg) showed no adverse effects and a lower transfusion rate with iron fortification of HMF.

Summary of recommendations for mineral and vitamin supplementation:

In babies <33 weeks or 33 and 34 weeks and birth weight <10th centile.

• If tolerating 180ml/kg/day of fortified EBM or LBW formula: Nutritional and vitamin requirements are met with the possible exception of Vitamin D. Our view is that the evidence supporting the ESGHAN Vitamin D recommendation is not strong enough to support routine supplementation of Vitamin D above that provided by FM85.

• If baby is not tolerating FM85 in EBM or has been changed to Neocate:

o Add 1.5 mmol/kg/day of calcium and 1.0 mmol/kg day of phosphate

o Add Pentavite 0.45ml/day when baby is tolerating 150 ml/kg/day.

o Add Iron as Ferrous Sulphate (6mg elemental iron per ml) from 28 days of age at 1.2mg elemental iron/kg/day (0.2ml/kg/day) in one dose.

4.8 When to stop FM85 supplementation of human milk or LBW formula and post-discharge nutrition.

Supplementation of human milk with multicomponent fortifiers is associated with short term increases in weight gain, linear and head growth.26 For almost all studies, fortification ceased at a specified weight (generally 1800 to 2000g) or at discharge.26 Limited available data do not provide convincing evidence that feeding preterm infants with multi-nutrient fortified breast milk compared with unfortified breast milk following hospital discharge affects important outcomes including growth rates during infancy.27 However, there is substantial heterogeneity between trials. One trial of multicomponent fortification of half human milk feeds for 12 weeks post discharge reported increased weight, head circumference, bone mineral density and visual acuity in fortified infants.28-30 A second trial in which fortifier was given once daily mixed in 20 mL to 50 mL of milk reported no significant influence on growth parameters at 1 year of age compared with unfortified mother's milk.31 These trials did not enrol infants with postnatal growth failure or chronic lung disease.

The available data (7 trials, 631 infants) do not provide strong evidence that feeding preterm infants following hospital discharge with nutrient-enriched formula compared with standard term

formula affects growth rates or development up to 18 months post-term.32 There are no data from randomised controlled trials to determine whether feeding preterm infants following hospital discharge with nutrient-enriched formula milk versus human breast milk affects growth and development.33 Again, These trials did not enrol infants with postnatal growth failure or chronic lung disease.

A single trial in infants with bronchopulmonary dysplasia comparing an isocaloric protein and mineral enriched formula to a standard formula reported greater linear growth, lean and bone mass in the enriched formula group.34 ESPGHAN notes that infants discharged with a subnormal weight for postconceptional age are at increased risk of long-term growth failure, and recommends the human milk they consume be supplemented with a human milk fortifier to provide an adequate nutrient supply.

Summary of recommendations on when to change LBW formula to term formula or when to stop fortifying EBM:

Once a baby is feeding at the breast there are practical limitations to providing nutritional supplementation and not enough evidence to support routine supplementation. This will need individualising in babies not growing adequately.

Prior to establishment of sucking feeds at breast or bottle, we will stop breast milk fortification or change low birth weight formula to normal term formula in:

1. AGA infants with normal growth velocity (≥15g/kg/day) may cease multicomponent fortification when they reach 2200g.

2. AGA infants with normal growth velocity who have achieved 3 sucking feeds for 2 consecutive days may cease multicomponent fortification between 1800g to 2200g.

3. Continued fortification, at least until a post-conceptional age of 40 weeks, and possibly until about 52 weeks post-conceptional age, should be considered in the following groups of babies:35

• Infants with postnatal growth failure (weight percentile <10th),

• Infants with low growth velocity (weight gain <15g/kg/day), and

• Infants with increased energy requirements including those infants with chronic lung disease with increased work of breathing.

4.9 Post-discharge iron and vitamins supplementation:

Iron: The recent trial of Berglund et al36 suggested that all babies, breast and formula fed, born less than 2.5kg would benefit from early iron supplementation. This randomised controlled trial enrolled 285 babies birth weight between 2 - 2.5kg to one of three arms; placebo, iron at 1mg/kg/day and at 2mg/kg/day from 6 weeks to 6 months. The main outcome was the iron deficiency anaemia rate at 6 months. This was 10% with placebo, 2.7% with 1mg/kg/day and 0% with 2mg/kg/day. Benefits were greatest in babies exclusively breast fed and preterm.

Pentavite: There is little evidence on this though it is apparent that breast milk does not have adequate vitamins for preterm babies in the post discharge period. Vitamins are added to infant formula but it is less clear whether these standard formulas contain adequate vitamins for preterm babies. Table 3 below shows vitamin intake at 150ml/kg of S26 gold compared to the ESPGHAN recommendations. It can be seen that A and D are low and the others are in the lower end of the recommended range.

Recommendation: That for consistency we provide routine post-discharge iron and vitamin supplementation to all babies who are born before 35 weeks (e.g 34 weeks and less) with birth weight less than 2.5 kg. Supplementation can be considered on an individual basis for babies born after 34 weeks if they are very growth restricted.

Regimen: Pentavite 0.45ml/day and Ferrous Sulphate (6mg elemental iron per ml) at 1.0ml/day both as a once daily dose to be started when stopping breast milk fortification or changing from LBW to Term formula in the smaller babies.

If babies of 33 and 34 weeks >10th centile (e.g babies not getting fortified BM or LBW formula) are slow in establishing sucking feeds then Pentavite and Ferrous Sulfate should be started in day 28 at the latest.

4.10 Special Situations.

Preterm and growth restricted babies with absent or reversed end-diastolic flows on antenatal Doppler studies,

• Insert a peripheral IV after birth to allow slow introduction of feeds, and watch for signs of NEC

Initially use only EBM as it becomes available.

Signs of Feed Intolerance  

Bilious Aspirate and bilious vomiting (green vomiting)

Bile can be a sign of a poorly positioned feeding tube, an ileus or obstruction and therefore should be investigated. However, green-coloured aspirates are not associated with any increase in NEC in the absence of any other clinical manifestation. (Mihatsch et al, 2002)

For bilious (green) vomiting, feeds may be stopped for 24 hours and supine abdominal Xray taken and should this worsen, there may be investigation for infection required. The decision whether the feeds should be ceased OR continued but not upgraded will be at the discretion of the MO. Recurrent green vomiting is a bowel obstruction until proven otherwise.

Vomiting

Vomiting may be the result of an over distended stomach, poorly positioned feeding tube, reflux, or may be more sinister – infection, obstruction or other disorders and significant vomiting should always prompt a clinical review.

Abdominal distension

Distension with or without visible loops can be due to poor gastric motility, ileus, constipation or ‘gas’. If the abdomen remains soft and/or non-tender it may resolve with prone positioning. A tense abdomen with or without visible loops of bowel is abnormal and requires investigation for obstruction, infection or NEC.

Feed intolerance management

Deciding whether feeds should be continued, reduced or stopped is at the discretion of the MO. Feeds are usually stopped if there is significant vomiting and/or abdominal distension, abdominal tenderness or discoloration and/or blood in the stools. Investigations should be carried out and a re-assessment on enteral feeds made after 24 hours. Feeds can generally be restarted when the infant has stabilised and has had a 12 to 24 hour absence of any significant clinical signs of feed intolerance and after consultation with the medical officer.

If the baby has less prominent, non-bilious vomiting and the baby does not have concerning features as listed above, then feed frequency may be reduced down to q2 hourly and then, if still vomiting down to q1 hourly feeds. If this is not tolerated, then consideration could be given to continuous feeds as per John Hunter Hospital Neonatal Guideline (essentially giving EBM/ formula every 2 hours by continuous infusion). The baby requires ongoing clinical review for medical and surgical causes of vomiting and feed intolerance.

If it is anticipated that full feeds will be not be reached for various reasons by day 5 (typical reasons might be baby on CPAP or low Apgar scores requiring resuscitation), then consideration for early administration of peripheral total parenteral nutrition (TPN) be given after discussion with consultant and, if appropriate, a neonatologist.

How do I increase feeds?

When increasing total fluid requirement, the feeds should be graded in increments according to size and gestation of the infant, as well as level of tolerance.

How do I grade feeds from hourly to 2nd hourly, 2nd hourly to 3rd hourly etc?

When grading up the time between each feed, the feeds should be immediately graded in increments according to the size and gestation of the infant.

Dubbo SCN Clinical Admission Sheet

Date of birth:                             Time of birth:

Gestation:                                   EDD:  / /    (based on USG… Trimester / based on dates of LMP)

Birth weight:              g (… centile)     HC  cm (…centile)        L   cm (…centile)

Booked at:                  Transfer

Mother:                      Age:    G…P…              Blood group… Rh…                                     Antibody screen… (if +ve- cord DAT needs running and chasing by registrar)

Father’s name:         

Smoker: Yes/No        Alcohol: Yes/No            Recreational Drugs:

Relevant Medical and general History:

Relevant Obstetrics History:

Relevant medications:

Mother’s feeding intention:                  mother consents to formula if baby hypoglycaemic and EBM unavailable… (y/n)

Pregnancy:

Rubella (immune/non-immune)                        VDRL (+ve / -ve)                                              Hep B ( +ve /  –ve)   GBS ( +ve/-ve)

OGTT:…

Intrapartum fever > 38 c (yes/no)

Duration of rupture of membranes:

Antenatal steroids:   …doses; 2nd dose given at … rescue steroids…

Labour:                       None/ Spontaneous/ Induced

                                      Meconium stained liquor:  yes/no        if yes – thick/thin

CTG:                             Foetal distress

Antepartum/ intrapartum antibiotics :             were antibiotics given > 4 hours prior to delivery?

Maternal medications: Morphine/fentanyl (yes/no)  if yes time of morphine… Epidural (yes/no) Spinal (y/n) GA…

Delivery: NVD/ breech Vag/ LSCS emergency / LSCS elective / forceps / Ventouse

Reason for mode of delivery if not NVD…..

Apgars                         …/1     …/5   …/10 …/

Cord gas:                    arterial/venous  pH… pCO2… BE… Lactate…

Resuscitation at delivery:        Suction yes/no O2 yes/no Neopuff IPPV

                                                       Cardiac massage… Adrenaline …

                                                       Time to establish respiration

Transfer to nursery:                 Peak FIO2 … this achieved right hand SaO2 …..

                                                       Transferred on CPAP of …cm H20

Progress from labour ward/ theatres

In nursery at … minutes of age

On CPAP/ not on CPAP

SaO2 right hand…       PR…. RR….  Temp… Glucose

Blood pressure (make sure cuff is correct size)

Colour pink/cyanosed/ pale

Increased Work of breathing ( none/ mild/moderate/severe) grunting (y/n)

Capillary venous return on sternum (<3seconds/> 3 seconds)

Alert- fixing on faces (yes/no)

Vigorous and moving arms and legs symmetrically (y/n)

General examination

·       Scalp:    normal (y/n) moulding (y/n)  caput (y/n)  sutures felt: overriding (yes/no)

                          Fontanelles felt anterior (y/n) posterior (y/n)

·       Face: symmetrical or asymmetrical (check of asymmetrical cry)

·       Eyeball: Left eye present                        right eyeball present

·       Nares:   left patent                                   right patent

·       Mouth: hard palate felt or visualised  soft palate felt or visualised

·       Ears: left and right symmetry meatus open skin tag (y/n)

·       Neck: moves freely

·       Chest: symmetrical and moves symmetrically Nipples           breast tissue palpable

·       Abdomen:      soft   masses felt (y/n)

Cord vessels: two or three

·       Upper Limbs: right and left equal length (y/n)

                          Digits: Right …digits    left …digits

                          Creases (y/n)              Webbing (y/n)

·       Lower limbs: Right and left     Equal length  DDH examination done (y/n)    

Feet right : … digits left … digits

Creases or webbing

§  Spine: palpate and visualised : midline lesions (y/n)

§  Sacral area: checked  dimple (y/s) hairy patch (y/s)

Plan for admission

Respiratory support (none/CPAP and O2)

IV dextrose  or enteral feeds

Suck feeds/ nasogastric feeds

IV antibiotics or not

Any antenatal issues for post natal review eg abnormal ultrasound

Notify consultant

Notify family of progress

Many babies can be treated with high doses of enteral feeds within the first 24 hours of life.

Glucogel 0.5ml /kg can be rubbed in frequently until IV access is obtained

Place a nasogastric tube and start feeds at 90ml/kg/day given at hourly intervals , this can go up to 100mg/kg/day but may be complicated by feed intolerance and vomiting

Neofeed can give the feed volume over 40 minutes even up to 60 minutes as a slow infusion

If vomiting occurs- call the consultant

Consider a umbilical venous catheter in large for gestational age babies 

Ambiguous genitalia  (Victoria Neonatal Handbook)

Apnoea ( quick summary and list of causes of breath holding  from Neonatal E Handbook)

Apnoea  and caffeine dosing  (NOTE 2mg caffeine citrate = 1mg caffeine base )

Bleeding conditions ( different disorders presenting with bleeding in neonates  has management suggestions with dosages NEB)

Blood gas interpretation  (NEB)

Blood pressure disorder (hypotension and hypertension from NEB)

Bowel obstruction in a neonate ( general conditions and their presentation NEB)

Breast feeding in neonates ( good general information on breast feeding, how to stimulate milk production, contraindications NEB)

Chronic lung disease ( good simple approach to  CLD & feeding issues, diuretics, air challenge, going home on O2 NEB)

Cleft lip and palate in neonates ( NEB)

Cooling for HIE and asphyxia (NEP)

Cooling for HIE in Special Care Nursery (NEB)

Congenital adrenal hyperplasia (NEB)

Congenital diaphragmatic hernia (NEB)

Cyanosed infant ( works through differentials : cardiac , respiratory , sepsis. Hyperoxic test NEB)

Cytomegalovirus in neonates

Developmental dysplasia of the hip  (NEB)

Diabetic mother - infant care (NEB)

Down syndrome and neonates (NEB)

Dysmorphology examination (NEB) (A dysmorphology assessment of a newborn focuses on aspects of history, physical examination and investigations that may lead to a syndrome diagnosis ) 

Early pulse oximetry screening   ( foot O2 sats should be more than 95% within 6 hours of age)

Electrolyte abnormalities in neonates (low and high sodium is a specialised area in neonates, discuss with consultant and neonatologist- this is a guide on same)

Encephalopathy in neonates (NEB) information on assessment and cooling

Endotracheal tube suctioning (NNICU)

Enteral feeding (NEB) general information

Exchange Transfusion    (giving and taking blood for severe jaundice )

Exomphalos (NEB) (An exomphalos (also known as omphalocele) is the herniation of abdominal organs through a central abdominal wall defect )

Extreme prematurity (NEB) (Obstetric and neonatal decision making for births at 22+0 to 24+6 weeks’ gestation presents clinical and ethical challenges )

Gasto-oesophageal reflux  (NEB) (general features and treatments- NOTE: recommendation on Randitine in now out of date , we would use PPIs eg omperazole 1-3mg/kg/day)

Gastroschisis (NEB)

Glucose-6 phoshphate dehydrogenase deficiency (NEB) (a possible cause of severe jaundice and haemolysis in neonates)

Group B streptococcus (GBS) - screening and management  (NEB)

Hearing screening in Victoria (NEB)

Herpes 1 and 2 (NEB)- (simple, fairly comprehensive document on HSV in the neonate; includes photos of vesicular rash and treatment guide)

Herpes simplex  1 and 2 (ASID guide, no direct link possible- need to scroll into PDF book , but good information once there cold sores and genital herpes)

Home oxygen

HIV  (ASID- need to scroll in PDF book)

HIV (NeB) direct link

Hydronephrosis  (NEB) 

Hypoglycaemia (Western LHD)

Hypospadias (NEB) a abnormality of the penis of varying severity

Hypothermia for Hypoxic Ischaemic Encephalopathy in Special Care Nursery (NEB)

Hypothyroidism (NEB)

Iron replacement- RCH

Iron dosing 

Immunisation schedule (National Immunisation Program )

Immunisation of preterm infants (NEB)

Incubator to cot transfer (NEB)

Inguinal hernia (NEB)

Intrauterine growth retardation (IUGR)

Intraosseous needle for a neonate (NEB)

Intravenous electrolyte correction for neonates (NEB) (hyponatraemia, hypocalcaemia , hypomagnasaemia, metabolic acidosis- bicarbonate therapy)

Intravenous infusions for neonates (NEB)- a simple, quick outline on IV fluids, when to check UEC, and when to consider TPN)

Jaundice - neonatal jaundice > 32 weeks gestation

Jaundice - late preterm infant 34 to 37 week gestation

Limb problems in neonates (NEB) has information on Erb's palsy, Klumpke, syndactyly 

Lumbar puncture (NEB)- note get a 25 Gauge LP  needle if possible- this could reduce the chance a blood-stained tap

Meconium

Meconium (NEB) This is a simple, practical guide as to what a clinician should after delivery.

Metabolic diseases in neonates (NEB) and approach to a variety of metabolic conditions

Metabolic diseases in neonates ( Vademecum metabolicum excellent , practical guide to  metabolic clinical scenarios and their treatments  eg encephalophatic baby, lactic acidosis, hypoglycaemia , hyperammonaemia and the clinical differential diagnoses- recommended by metabolic fellows from SCHN in 2019)

Osteopaenia of prematurity  (Better Safe)

Minimally invasive surfactant therapy or Less invasive surfactant therapy   MIST or LISA (includes excellent Aukland video)

Necrotising enterocolitis (NEB) 

Neural tube defects  (NEB)

Newborn screening (website on SCHN internet link- lists conditions currently screened for in NSW)

Non-invasive ventilation ( CPAP and weaning to high flow- from RPAH)

Normal laboratory values (NEB)

Oesophageal atresia (NEB)

Osteopaenia of prematurity (NEB)

Oxygen saturation screening for congenital heart disease

Oxygen screening for congenital heart disease (NEB)

Oxygen screening single page algorithm (NEB)

Patent Ductus Arteriosus

Peripheral arterial line in neonate (NEB)

Peripheral intravenous cannula (NEB)

Persistent Pulmonary Hypertension ( Victorian Neonatal E-Book)

Pneumothorax (from RPAH this is the same technique for Dubbo)

Polycythaemia in neonates (NEB) indications for partial exchange and volumes in same

Postmortem service NSW

Renal Pelvic Dilatation (see also hydronephrosis)

Respiratory distress syndrome ( clinical features, CPAP, criteria for surfactant and calling  NETS)

Respiratory distress syndrome (Victoria E-Book- excellent overview)

Rubella in neonate (NEB)

Sepsis in neonates (NEB) presenting clinical features, blood test interpretation and treatment

Shock in neonates (NEB) 

Single umbilical artery (NEB)

Small for gestational age (NEB) or intrauterine growth retardation (IUGR)

Stridor (noisy breathing in) (NEB)

Sucrose (for procedural pain relief) (NEB)

Supplementation for preterm infants (NEB) ( Vitamin D,E iron etc)

Supraventricular tachycardia ("SVT") (NEB)

Surfactant drug information

Surfactant MIST

Syphilis in neonates (NEB) (note if mother's RPR or VDRL positive it will be very hard to avoid 10 days of IV penicillin for baby unless maternal treatment confirmed. TPHA will remain positive for life in mother)

Thrombocytopaenia in neonates (NEB)

Thrombosis in neonates (NEB)

Thyroid function testing (NEB)  covers maternal Graves and neonatal hyperthyroidism and see also hypothyroidism

Transfusions for neonates (NEB)

Tuberculosis in neonates (NEB)

Umbilical venous catheters ( UVC- emergency venous access to belly button from RPAH)

Umbilical venous catheters (UVC document with good images on xrays)

Varicella zoster in neonates (NEB)

Vitamin D supplementation (NEB)

Vitamin supplementation (NEB)

Vomiting in neonates (NEB) see also bilious vomiting

Abdominal wall defects ( NETS)

Alprostadil (also known as Prostin VR) ( NETS) 

Ambiguous genitalia  (Victoria Neonatal Handbook)

Anti-depressants in pregnancy and post natally with lactation (RHW)

Apnoea ( quick summary and list of causes of breath holding  from Neonatal E Handbook)

Apnoea  and caffeine dosing  (NOTE 2mg caffeine citrate = 1mg caffeine base )

Apnoea in neonates  (Nepean)

Arterial catheter management in neonates (Grace)

Bacterial infection (early and late onset) (RRAH)

Bilious vomiting (green vomiting means a surgical problem needs consideration  RPAH)  Also see video of meconium ileus with visible peristalsis NELJ via CIAP

Bilious vomiting in neonate , see also : Vomiting in neonates (NEB) concise document 

Bleeding conditions ( different disorders presenting with bleeding in neonates  has management suggestions with dosages NEB)

Blood gas interpretation  (NEB)

Blood pressure disorder (hypotension and hypertension from NEB)
Blood tranfusions in neonates ( emergencies and elective) (Liverpool) 

Blood transfusion in neonates ( Nepean)

Bowel obstruction in a neonate ( general conditions and their presentation NEB)

Breast feeding in neonates ( good general information on breast feeding, how to stimulate milk production,  grading up domperidone and  side effects, and contraindications (NEB)

Breast feeding promotion and support (RCH)

Chickenpox see Varicella zoster in neonates (NEB)

Chronic lung disease ( good simple approach to  CLD & feeding issues, diuretics, air challenge, going home on O2 NEB)

Cleft lip and palate in neonates ( NEB)

Cooling for HIE and asphyxia (NEP)

Cooling for HIE in Special Care Nursery (NEB)

Cooling for Hypoxic ischaemic encephalopathy ( NETS)

Congenital adrenal hyperplasia (NEB)

Congenital diaphragmatic hernia (NEB)

Cord clamping - see delayed cord clamping ( Westmead NICU)

Coroner's case (Nepean)

COVID exposure and/or infection in neonates ( RHW)

C-MAC the video-laryngoscope maintenance (RHW)

CPAP via Drager (Nepean)

Cyanosed infant ( works through differentials : cardiac , respiratory , sepsis. Hyperoxic test NEB)

Cytomegalovirus in neonates

Death of a Neonate (Nepean)

Defibrillation in neonates ( Nepean) 

Delayed cord clamping ( Nepean) 

Department of Communities and Justice - assisting with an AOC ( DCJ) 

Developmental dysplasia of the hip  (NEB)

Diabetic mother - infant care (NEB)

Domperidone - a medication (galactogogue to improve breast milk production)

Donor human milk (RPAH)

Donor human Milk Bank and Australian Red Cross NSW pasteurised service

Down syndrome and neonates (NEB)

Dysmorphology examination (NEB) (A dysmorphology assessment of a newborn focuses on aspects of history, physical examination and investigations that may lead to a syndrome diagnosis ) 

Early pulse oximetry screening   ( foot O2 sats should be more than 95% within 6 hours of age)

Electrolyte abnormalities in neonates (low and high sodium is a specialised area in neonates, discuss with consultant and neonatologist- this is a guide on same)

Encephalopathy in neonates (NEB) information on assessment and cooling

Endotracheal tube suctioning (Nepean)

Enteral tube insertion ( Nasogastric tube and orogastric tube insertion)  ( Nepean)
Enteral tube feeding (Nepean)

Enteral feeding (NEB) general information

Exchange Transfusion    (giving and taking blood for severe jaundice ) (Nepean)

Exomphalos (NEB) (An exomphalos (also known as omphalocele) is the herniation of abdominal organs through a central abdominal wall defect )

Extravasation injury management - a cannula has tissued an infused under skin (Nepean) 

Extremely low birth weight- NETS retrieval 

Extreme prematurity (NEB) (Obstetric and neonatal decision making for births at 22+0 to 24+6 weeks’ gestation presents clinical and ethical challenges )

Extubation (Nepean)

Eye examination - newborn check for ROP etc (RCH)

Eye care for watery and sticky eye : naso-lacrimal duct cares (RHW)

Feeding plan for premature infants (RPAH)

Gasto-oesophageal reflux  (NEB) (general features and treatments- NOTE: recommendation on Randitine in now out of date , we would use PPIs eg omperazole 1-3mg/kg/day)

Gastroschisis (NEB)

Gastroschisis ( NETS) ( also under Abdominal Wall Defects)

General Movements Assessments (a physio assessment to help predict risk of cerebral palsy)  (Nepean)

Glucose or Glucogel 40% standing order (Nepean) 

Glucose-6 phoshphate dehydrogenase deficiency (NEB) (a possible cause of severe jaundice and haemolysis in neonates)

Group B streptococcus (GBS) - screening and management  (NEB)

Hearing check in NSW "SWISH"

Hearing screening in Victoria (NEB)

Hepatitis B (RPAH)

Hepatitis C- see Perinatal infections with ASID

Herpes 1 and 2 (NEB)- (simple, fairly comprehensive document on HSV in the neonate; includes photos of vesicular rash and treatment guide)

Herpes simplex  1 and 2 (ASID guide, no direct link possible- need to scroll into PDF book , but good information once there cold sores and genital herpes)

Hirschprung's disease pre and postoperative care in Grace Nursery 

Home tube feeding 

Home oxygen

HIV-  Human immunodeficiency virus in pregnancy: prevention of mother to child transmission (RHW)

Home oxygen (RPAH)

Humavant ( Nepean)

Humidified High Flow Nasal Cannula Oxygen using Fisher & Paykel Delivery System (Nepean)

Humidified Low Flow Oxygen for Neonatal Patients Using AIRVOTM  (Nepean)

Hydronephrosis  (NEB) 

Hyperglycaemia

Hypoglycaemia (Dubbo guideline) and 

Hypoglycaemia (Nepean)   Hypoglycaemia   (NETS )

Hypospadias (NEB) a abnormality of the penis of varying severity

Hypothermia for Hypoxic Ischaemic Encephalopathy in Special Care Nursery (NEB)

Hypothermia (systemic hypothermic for HIE) 

Hypothyroidism (NEB)

Hypoxic ischaemic encephalopathy ( RHW)

Hypoxic ischaemic encephalopathy ( ACI)   same document : Hypoxic ischaemic encephalopathy in newborns - recognition, monitoring and early management (Nepean)

Iron replacement ( ANF- has information on drug dosing post transfusion etc) NOTE: Dose is 0.5ml/kg/day up to 1ml/kg/day of Ferro-Liquid 6mg/ml )

Immune Oral Supportive Care (Nepean)

Immunisation schedule (National Immunisation Program )

Immunisation of preterm infants (NEB)
Immunisation of newborn (Nepean) 

Incubator to cot transfer (NEB)
Induced systemic hypothermia for hypoxic ischaemic encephalopathy (Nepean)

Inguinal hernia (NEB)

Instrumental delivery - surveillance for subgaleal injuries after birth (Nepean)

Intrauterine growth retardation (IUGR)

Intraosseous needle for a neonate (NEB)

Intravenous electrolyte correction for neonates (NEB) (hyponatraemia, hypocalcaemia , hypomagnasaemia, metabolic acidosis- bicarbonate therapy)

Intravenous infusions for neonates (NEB)- a simple, quick outline on IV fluids, when to check UEC, and when to consider TPN)

Intubation  including pre-medication (Nepean)

Intubation (RCH)

Jaundice - neonatal jaundice > 32 weeks gestation  (Neonatal Ebook)

Jaundice in neonates ( RCH)

Jaundice in early infancy (has NSW Health  age specific jaundice charts in awkward format)

Jitteriness in babies

Kangaroo care in NICU (Nepean)

Late preterm infant (management on the ward)

Limb problems in neonates (NEB) has information on Erb's palsy, Klumpke, syndactyly 

Lumbar puncture (NEB)- note get a 25 Gauge LP  needle if possible- this could reduce the chance a blood-stained tap

Lumbar puncture (Nepean)

Maternal mental health issues

Meconium aspiration syndrome

Meconium (NEB) This is a simple, practical guide as to what a clinician should after delivery.

Metabolic diseases in neonates (NEB) and approach to a variety of metabolic conditions

Metabolic diseases in neonates ( Vademecum metabolicum excellent , practical guide to  metabolic clinical scenarios and their treatments  eg encephalophatic baby, lactic acidosis, hypoglycaemia , hyperammonaemia and the clinical differential diagnoses- recommended by metabolic fellows from SCHN in 2019)

Metabolic bone disease (from RPAH) (see also osteopaenia of prematurity a simpler document )

Minimally invasive surfactant therapy or Less invasive surfactant therapy   MIST or LISA (includes excellent Aukland video)

Minimally invasive surfactant  (Liverpool)

Minimally invasive surfactant therapy ( Nepean)

Perinatal Mental Wellbeing

See also:

• Psychotropic Drug Use in Perinatal Mental Health

• Psychotropic Medicine Profiles in Pregnancy and Breastfeeding

Red flags

• Organic causes of severe mental health symptoms, e.g. delirium

• Suicidality or risk of harm to self, risk of harm to the child, or others

• Severe mood symptoms or puerperal psychosis

Background

About perinatal mental health

About perinatal mental health

Mental health problems in the perinatal period (pregnancy and the first two years after birth) can increase difficulties in mother-baby attachment. If this is serious and persistent it can have an adverse impact on the baby’s emotional and behavioural development.

• In Australia, up to 10% of women experience depression antenatally and up to 16% postnatally. The prevalence of perinatal anxiety is even greater (up to 20%). Mental health symptoms in the pregnancy partner may have a similar prevalence.1

• Women with a history of:

  • mood and anxiety disorders are at increased risk of relapse.

  • severe depression and bipolar disorder who cease medication in pregnancy have a greatly increased risk of relapse in the perinatal period (as high as 70 to 80%).

  • bipolar disorder have a 1 in 3 chance of a postnatal psychosis, while for those with a prior postnatal psychosis it is 1 in 2.

• The risk of postnatal psychosis in the general population is 1 to 2 in 1,000.

Assessment

1. Undertake assessment based on the point of contact in perinatal period:

   • In the antenatal period

   • In the antenatal period

     • Screen for vulnerability to and/or symptoms of a mental illness.

     • Screen for vulnerability to and/or symptoms of mental illness

     • Enquire about:

       • current and past mental health issues and treatment.

       • family history of mental illness, particularly perinatal.

       • intellectual disability or cognitive impairment.

     • Assess for risk to self, others and the baby.

     • Consider psychosocial risk factors.

     • Consider psychosocial risk factors

     • Enquire about:

       • Current stressors e.g. relationship issues, financial stress, living arrangements

       • Domestic and family violence – 20% of domestic violence starts during a pregnancy

       • Grief and loss

       • Substance use

       • Homelessness or unsuitable living arrangements

       • Lack of support (practical and emotional)

       • History of trauma, including past traumatic births or loss of pregnancy

       • Age of mother

       • Cultural and/or social isolation

     • Consider using a tool to assess psychosocial risk. See COPE – Antenatal (Psychosocial) Risk Questionnaire (ANRQ) Clinician Information and Scoring Template.

     • Perform a mental state exam to review appearance, behaviour, mood, affect, speech, thought form and content, perceptual disturbance, cognition, and orientation.

     • Screen for substance use, including tobacco and alcohol.

     • Consider the patient's participation in antenatal care, and feelings about pregnancy.

   • In the postnatal period

   • In the postnatal period

     • Screen for vulnerability to and/or symptoms of a mental illness.

     • Assess for risk to self, others, and the baby.

     • Consider psychosocial risk factors.

     • Assess mother and infant interaction.

     • Carer‑infant interaction

     • Consider:

       • Attachment

       • Carer’s attentiveness and responsiveness to the baby

       • Difficulty with breastfeeding and associated distress

       • Carer prioritising safety of the infant

       • Empathy for and ability to reflect the infant’s feelings

       • Sensitivity to the infant through immediate and appropriate responses

       • The carer’s response is paced to infant cues

       • Some eye contact between the carer and infant

       • The infant is able to communicate their needs to the carer

     • Behaviours of concern:

       • Carer unreliable, inconsistent, or inappropriate in responding to the infant’s cues.

       • Carer afraid of the baby.

       • Inappropriate carer representations e.g., experiences the infant as rejecting or manipulative.

       • Frightening or frightened carer behaviour e.g., dissociation, threatening expressions or voices, rough or intrusive handling, seductive or sexualised behaviour.

     • Assess wellbeing of infant.

     • Assess wellbeing of infant

     • Consider:

       • Infant is interactive, cries when distressed and settles when comforted.

       • Hygiene and grooming.

       • Nutrition, weight, and growth, and any difficulties feeding and settling.

       • Infant meeting developmental milestones.

       • Infant responds appropriately to mother's presence.

       • Infant displays appropriate level of wariness or friendliness with strangers.

     • Screen for substance use.

     • Consider the patient's participation in postnatal care.

2. Screen all women in the perinatal period with the Edinburgh Postnatal Depression Scale (EPDS) as this supports the assessment of perinatal risk and emotional distress.

3. The Edinburgh Postnatal Depression Scale (EPDS)

4. The EPDS is a 10‑item self-report measure designed to screen women for symptoms of emotional distress during pregnancy and the postnatal period.

   • Complete the first antenatal screening as early as practical in pregnancy, and repeat screening at least once later in pregnancy.

   • Complete the first postnatal screening 6 to 12 weeks after birth, and repeat screening at least once in the first postnatal year.

   • Take care with scoring:

     • Question 1, 2 and 4 are scored in reverse.

     • A score of 1, 2, or 3 for question 10 (which relates to self‑harm) requires further risk assessment.

5. See also Edinburgh Postnatal Depression Scale – PDF or online.

6. Consider specific diagnostic categories where signs of mental illness are present:

   • Minor mood disturbance (postnatal blues or "baby blues")

   • Minor mood disturbance

     • Common but transient emotional lability during the first week after birth.

     • Symptoms develop within 2 to 3 days after childbirth, peak on the fifth day, and resolve within 2 weeks.

     • Affects 30% to 80% of women following childbirth.

     • Mood swings ranging from elation to sadness, insomnia, tearfulness, crying spells, irritability, anxiety, and decreased concentration.

     • Care of the baby is not impaired, hopelessness and worthlessness are not prominent, and patients do not feel suicidal.

     • Usually self-limiting.

   • Perinatal depression

   • Perinatal depression

   • Symptoms begin within 12 months after delivery and may include:

     • Depressed mood or irritability

     • Diminished interest in activities

     • Significant weight or appetite change

     • Sleeping problems that are not related to the normal demands of caring for a young child

     • Fatigue

     • Feelings of worthlessness or guilt

     • Inability to think clearly or concentrate

     • Recurrent thoughts of death and/or suicide

     • Psychomotor agitation and/or retardation

   • Perinatal anxiety

   • Perinatal anxiety

     • Anxiety disorder is very common in the perinatal period, affecting around 1 in 5 women in both the antenatal and postnatal periods.

     • Symptoms include:

       • Anxiety and worry most days over a number of events or activities that is difficult to control

       • Restlessness or feeling keyed up or on edge

       • Easily fatigued

       • Difficulty concentrating

       • Irritability

       • Muscle tension

       • Sleep disturbance

   • PTSD in the perinatal period

   • PTSD in the perinatal period

     • Persistently re-experiencing thoughts and/or dreams.

     • Flashbacks which are accompanied by intense distress.

     • Persistently avoiding thoughts, feelings, and situations associated with the traumatic event.

     • Persistent state of arousal, irritability, hyper-vigilance, exaggerated startle response, difficulty getting to or staying asleep.

     • Feeling detached from others.

     • Some women experience birth, or pregnancy-specific events, as traumatic.

   • Puerperal psychosis

   • Puerperal psychosis

     • Symptoms usually start within 48 hours to 2 weeks, although can present up to 12 weeks postpartum.

     • Onset of symptoms is sudden and can include:

       • Mania

       • Depression

       • Delusions or beliefs that people are trying to harm the baby

       • Bizarre behaviour

       • Mood lability and/or irritability

       • Perceptual disturbance such as hallucinations

       • Disorganised thinking and confusion

     • Can be related to an underlying mental health disorder (e.g. bipolar disorder, schizophrenia) but not always.

     • Puerperal psychosis is a medical emergency – there is a risk of self-harm or harm to the infant.

   • Relapse of major mental illness e.g. OCD, bipolar disorder, schizophrenia, personality disorders, eating disorders.

   • Major mental illness

     • This can occur in the perinatal period as a result of women ceasing medications during pregnancy and/or increased emotional distress.

     • Women with existing diagnosis are at a higher risk of relapse in the postnatal period.

7. Seek corroborative information from family and friends.

8. Enquire about pre-existing physical health conditions.

9. Conduct routine examination and investigations, including FBC, LFTs, EUC, thyroid, iron, MSU.

10. Review current medication use, including over the counter, complementary, and alternative medications.

11. Current medication use, including over the counter, complementary, and alternative medications

    • Check:

      • which medications the patient has taken previously, and when they ceased.

      • current medications, dose, and when started

      • if the patient was taking medication when conception occurred.

    • If a pregnant patient has taken psychotropic medications with known teratogenic risk at any time in the first trimester:

      • offer screening for fetal abnormalities,

      • make arrangements for additional monitoring,

      • consider outcomes of ceasing or continuing medication, and

      • seek specialist advice.

    • See also Psychotropic Drug Use in Perinatal Mental Health.

Management

Practice point

Use family-centred collaborative care

Collaborative care planning including the patient, family (where appropriate) and other clinicians involved, ensures continuity of care and is regarded as best practice.

1. If red flags are present or there is immediate risk to self or others, phone 000 to arrange transfer to the emergency department for acute mental health assessment:

2. Red flags

   • Organic causes of severe mental health symptoms, e.g. delirium

   • Suicidality or risk of harm to self, risk of harm to the child, or others

   • Severe mood symptoms or puerperal psychosis

   • Be aware you may be required to enact a schedule under the Mental Health Act.

   • When determining treatment approach, use clinical judgement and consider patient participation in care, their vulnerabilities, and psychosocial supports.

3. If concerned about the safety and wellbeing of children or an unborn baby, follow mandatory reporting processes. If there is immediate risk of harm to a child or young person, phone Family and Community Services on 132‑111.

4. Treat any underlying medical causes, e.g. iron deficiency, thyroid disorder.

5. Undertake further risk assessment if the patient scores 1, 2, or 3 on question 10 (which relates to risk of self-harm) of the EPDS.

6. Determine severity of symptoms, and if the patient:

   • can be managed in primary care, or

   • has indicators for specialist care.

   • Indicators for specialist care

     • Score of 13 or higher on the EPDS

     • Past history of major mental illness

     • Observed difficulties with the mother-infant interaction

     • Patient requests specialist support

     • Major psychosocial stressors e.g. adolescent pregnancy, poverty, domestic or family violence, substance misuse

7. If EPDS score is:

   • 10 to 12, repeat within 2 to 4 weeks, and consider a GP Mental Health Care Plan.

   • 13 or higher, do a GP Mental Health Care Plan, and refer for mental health assessment.

8. For all patients, take a family-centred approach. 

9. Family-centred approach

   • Managing the mother and infant together is recommended (where appropriate) as maternal mental health difficulties can disturb the mother-infant relationship.

   • Consider impact on partner and other family members involved, and link with support services as required:

     • Mental Health Family and Carer Support

     • Closing the Gap service providers 

     • Parenting Support Programs

     • Drug and Alcohol Community Support

     • Housing and Financial Support

     • Domestic and Family Abuse and Violence (DFAV) Referrals

   • Provide education and information to the family to build their capacity to support the patient:

     • Beyond Blue:

       • Information for Partners, Family and Friends

       • Dadvice

     • PANDA – Caring for Someone with Perinatal Anxiety and Depression

     • Raising Children – Postnatal Depression and Your Partner: How to Help

10. Discuss treatment options and provide support:

    • Severe mental health symptoms

    • Severe mental health symptoms

      • Facilitate collaborative care planning including the patient, family (where appropriate), and other clinicians involved, which ensures continuity of care and is regarded as best practice.

      • Ensure patient safety and consider risk to self, baby, and others.

      • Undertake urgent intensive management. Consider:

        • medication.

        • outpatient care – general practitioner, psychiatry, psychological support.

        • inpatient care:

          • consult with on-call obstetric physician, or

          • consult with Mental Health Line on 1800‑011‑511, or

          • arrange transfer to the emergency department for mental health assessment.

      • Refer to Parent and Infant Mental Health for assessment of people in the acute phase of mental illness via 1800‑011‑511.

    • Moderate mental health symptoms (EPDS > 13)

    • Moderate mental health symptoms (EPDS > 13)

      • Facilitate collaborative care planning including the patient, family (where appropriate), and other clinicians involved, which ensures continuity of care and is regarded as best practice.

      • Provide psychoeducation e.g. information about depression or anxiety. Encourage and empower the patient to ask for support, and validate the importance of taking time for themselves for self-care.

      • Provide lifestyle advice e.g. diet, physical activity, sleep, smoking and alcohol cessation. See Get Healthy in Pregnancy.

      • Offer referral to parenting support services and provide practical support e.g. for parenting, sleep deprivation, unsettled baby.

      • If further mental health assessment or psychological intervention is required, offer referral to appropriate psychological services, (a GP Mental Health Care plan is required to access some of these services).

      • Consider medication.

      • If further clinical advice is required, consider seeking mental health advice from a psychiatrist (e.g. Statewide Outreach Perinatal Service) or referring to a private psychiatrist.

    • Mild mental health symptoms with or without psychosocial risk factors (EPDS < 13) 

    • Mild mental health symptoms with or without psychosocial risk factors (EPDS < 13)

      • Ensure routine antenatal/postnatal care and opportunistic reassessment.

      • Ask the patient if they would like help with identified psychosocial risk factors.

      • Facilitate family-centred collaborative care planning including the patient, family (where appropriate), and other clinicians involved, which ensures continuity of care and is regarded as best practice.

      • Provide lifestyle advice e.g. diet, physical activity, sleep, smoking and alcohol cessation. See Get Healthy in Pregnancy.

      • Offer referral to parenting support services and provide practical support e.g. for parenting, sleep deprivation, unsettled baby.

      • Provide psychoeducation e.g. information about depression or anxiety. Encourage and empower the patient to ask for support, and validate the importance of taking time for themselves for self-care.

      • Offer referral to appropriate community support services and counselling and consider need for GP Mental Health Care plan.

      • If Aboriginal and Torres Strait Islander patient, consider referral to an Aboriginal and Torres Strait Islander mother and infant health service. 

11. Manage concerns about substance abuse during pregnancy:

    • In the first instance, request drug and alcohol assessment.

    • For patients with sustained high daily alcohol intake, prescribe high dose folic acid 5 mg daily.

    • Consider prescribing vitamin B complex twice a day. If there are symptoms of deficiency, use a higher dose.

12. Monitor during pregnancy and postpartum:

    • If the patient is no longer on antidepressant medication, proactively manage risk of relapse (70 to 80%).

    • Screen for risk of harm to self, others, and the fetus or baby.

    • Look for warning signs of possible mental health stresses that may not have been obvious at first review.

    • Warning signs

      • Ambivalent feelings about the pregnancy

      • A stressful, difficult, or complicated pregnancy

      • Poor or absent partner or family support, or close friendships

      • Financial stress

      • Problems adjusting to change in routine

      • High expectations of “being the perfect parent”

      • Emotional dysregulation

    • Ensure good communication between antenatal care team, mental health services, and early childhood services.

13. Coordinate follow-up and engage patient in relapse prevention planning. Frequency of appointments will depend on severity of symptoms.

14. Consider phoning the Statewide Outreach Perinatal Service for Mental Health (SwOPS-mh) for advice on (02) 8890‑3617 (business hours).

Referral

• If red flags are present or there is immediate risk to self or others, phone 000 to arrange transfer to emergency department for acute mental health assessment. You may be required to enact a schedule under the Mental Health Act.

• If there is immediate risk of harm to a child or young person, phone Family and Community Services on 132‑111.

• If severe:

  • Consider the need for inpatient care.

    • Consult with on-call obstetric physician, or

    • Consult with Mental Health Line on 1800-011-511, or

    • Arrange transfer to the emergency department for mental health assessment.

  • Refer to Parent and Infant Mental Health for assessment of people in the acute phase of mental illness via 1800‑011‑511.

• Consider phoning the Statewide Outreach Perinatal Service for Mental Health (SwOPS-mh) for advice on (02) 8890‑3617 (business hours).

• Refer according to symptom severity:

  • Mild symptoms referral

  • Moderate symptoms referral

• If moderate mental health symptoms and further clinical advice is required, consider seeking mental health advice from a psychiatrist (e.g. Statewide Outreach Perinatal Service) or referring to a private psychiatrist.

• Refer to other community supports as required:

  • Mental Health Family and Carer Support

  • Closing the Gap service providers 

  • Parenting Support Programs

  • Drug and Alcohol Community Support

  • Housing and Financial Support

  • Domestic and Family Abuse and Violence (DFAV) Referrals

• If Aboriginal and Torres Strait Islander patient, consider referral to an Aboriginal and Torres Strait Islander mother and infant health service.

• Request drug and alcohol assessment if concerns about substance abuse during pregnancy.

 eReferral is the recommended referral method. Read more...

Information

Nappy rash (Nepean)

Nasopharyngeal tube (RCH ) for small upper airway eg Pierre Robin sequence

Nausea and vomiting (RCH in chemotherapy cases 

Necrotising enterocolitis ("NEC" serious gut complication in babies from RPAH)

Necrotising enterocolitis (NEB) 

Needle stick injury (Victorian)

Neonatal abstinence syndrome ( drug withdrawal from illicit drugs , from Nepean)

Neonatal apnoea  (Nepean) 

Neonatal blood transfusion ( Nepean)

Neonatal oxygen saturations (RCH) 

Neonatal Ventilation ( NETS) 

Neopuff set up (Nepean )

Neural tube defects  (NEB)

Newborn screening test (SCHN) 

Newborn screening (website on SCHN internet link- lists conditions currently screened for in NSW)

Nirsevimab ( RSV monoclonal antibody given at birth x 1 dose only 0.5ml=50mg) 

Non-invasive ventilation ( CPAP and weaning to high flow- from RPAH)

Normal laboratory values (NEB)

Oesophageal atresia (NEB) and Oesophageal atresia - intermittent suctioning with Replogle tube (RCH)

Osteopaenia of prematurity (NEB)

Oxygen saturation screening for congenital heart disease (RPAH)

Oxygen saturation targets in neonates (RCH) Neonatal oxygen saturations (RCH) 

Oxygen screening for congenital heart disease (NEB)

Oxygen screening single page algorithm (NEB)

Oxygen therapy  Low flow O2 ( from Nepean) 

Oxygen therapy , home oxygen checklist (Nepean)

Pain management in neonates (Grace NICU)

Pain assessment in neonates (RCH) mPAT

Pain management in neonates (Nepean)

Partial exchange in neonates (Nepean)

Peripheral arterial line in neonate (NEB)

Peripheral intravenous cannula (NEB)

Peripheral cannula ( Nepean) 

Persistent Pulmonary Hypertension ( Victorian Neonatal E-Book)

Persistent pulmonary hypertension ( NETS)

Pneumothorax video of insertion of Safe-T-Centesis in mannequin 

Pneumothorax drainage with Safe-t-centesis ( RHW)

Pneumothorax - chest drain set up ( RHW)

Pneumothorax treatment (includes needle thorocostomy) (Nepean)

Polycythaemia in neonates (NEB) indications for partial exchange and volumes in same

Postmortem service NSW

Prostin ( NETS) 

Pulse oximetry screening for congenital heart disease (Nepean)

Psychotropic Drug Use in Perinatal Mental Health

See also:

• Perinatal Mental Wellbeing

• Medications in Pregnancy and Breastfeeding

• Psychotropic Medicine Profiles in Pregnancy and Breastfeeding

Assessment

Practice point

Consider risks and benefits

In severe mental illness, including bipolar, depression, or anxiety, the risk of not treating with psychotropic medications far outweighs the risk of treating, for both mother and infant. In mild depression or anxiety, there may be alternatives to prescribing psychotropic medications.

1. Consider patient factors:

   • Personal preference

   • Ability to cope with untreated or sub-threshold symptoms

   • Co-morbid mental health disorders including panic disorder

   • Risk of relapse

   • Risk of relapse

   • The risk of relapse is related to:

     • severity of index episode.

     • severity and frequency of any past episodes.

     • whether the symptoms are currently well controlled, and if so for how long.

     • past and present response to medication.

     • whether there have been any previous attempts to withdraw medication, and the outcome of any attempts.

2. Compare the risks and benefits of not prescribing psychotropic medications during pregnancy and breastfeeding against the risks and benefits of prescribing. The decision to prescribe will involve balancing:

   • risks of untreated mental illness.

   • Risks of untreated mental illness

     • Untreated antenatal mental illness is associated with:

       • relapse or worsening of psychiatric illness which may include suicide or self-harm, family or relationship deterioration, and “self-medicating” with less safe alternatives such as alcohol, cigarettes, and illicit drugs.

       • poor maternal nutrition, poor antenatal attendance.

       • obstetric complications.

       • Obstetric complications

         • Spontaneous abortion

         • Pre‑eclampsia

         • Increased uterine artery resistance

         • Intrauterine growth retardation

         • Pre‑term delivery

         • Low birth‑weight babies

       • increased risk of infant abuse and neglect.

     • Neonates born to depressed or anxious mothers tend to have smaller head circumferences, lower Apgar scores, higher cortisol levels at birth, and an increased need for neonatal admission due to medical complication.

     • There is a greater likelihood that a woman with untreated antenatal depression and anxiety will go on to develop post-natal depression (PND), which can have detrimental effects on both the mother and the infant.

   • potential adverse effects of psychotropic medication on the infant.

   • Potential adverse effects of psychotropic medication

     • Pregnancy:

       • All psychotropic medications carry the risk of:

         • withdrawal or toxicity in neonates, however in most cases the effects are mild and self-limiting, and can be alleviated by early, frequent breastfeeding.

         • long-term neurodevelopmental effects and congenital abnormalities. When discussing particular medications, remember that the incidence of non-drug related spontaneous abnormalities in Australia is 2 to 4% of live births.1

       • Symptoms may include hypotonia, irritability, excessive crying, sleeping difficulties, and mild respiratory distress. Observation of the neonate is needed for a few days post-delivery.

     • Breastfeeding:

       • Continue antenatal antidepressant regimen whilst breastfeeding.

       • If antidepressants are commenced postpartum, breastfeeding is still recommended. Advise parents and caregivers to monitor the baby for drowsiness, irritability, poor feeding, and restlessness, and notify their neonatal care provider immediately if these occur.

3. Consider prescribing psychotropic medication in pregnancy and breastfeeding for the following indications:

   • Moderate-to-severe depressive symptoms, including vegetative symptoms, psychomotor agitation or retardation, and suicidal ideation or actual attempts

   • Co-morbid panic or anxiety disorder, or co-morbid psychotic symptoms

   • Significant impairment in functioning e.g., inability to work, relationship breakdown

   • History of recurrent depression with hospitalisations

4. Consider TGA category but do not use as sole basis for decision-making.

5. TGA category2

6. The TGA pregnancy category:

   • does not provide information about the balance of harms and benefits for a particular patient.

   • does not indicate the stage(s) of fetal development that might be affected by drug exposure

   • may not reflect the most up-to-date information about the drug's use in pregnancy.

7. Consult the patient’s specialist or drug information service for advice if required.

8. See also TGA – Prescribing Medicines in Pregnancy Database.

Management

1. If the patient is already on a psychotropic medication regimen, consult a specialist prior to ceasing or changing their treatment.

2. Optimise non-pharmacological interventions. If mild depression or anxiety always consider non-pharmacological interventions as first-line.

3. For patients with moderate-to-severe mental illness, consider:

   • recommendations for commencing psychotropic medications in pregnancy and breastfeeding.

   • Psychotropic medications

   • Psychotropic drug recommendations for depression, anxiety, and bipolar disorder in pregnancy and breastfeeding:

     • Depression – for both pregnancy and breastfeeding:

       • First-line therapy – SSRIs:

         • Sertraline – initiate with 25 mg daily to minimise side-effects and increase to 50 mg daily after a few days

         • Citalopram – initiate with 10 mg daily to minimise side-effects and increase to 20 mg daily after a few days

       • Second-line therapy – TCAs:

         • Nortriptyline 25 mg daily

         • Amitriptyline 75 mg daily in divided doses

     • Anxiety – for both pregnancy and breastfeeding:

       • First-line therapy – SSRIs:

         • Sertraline – initiate with 25 mg daily to minimise side-effects and increase to 50 mg daily after a few days

         • Citalopram – initiate with 10 mg daily to minimise side-effects and increase to 20 mg daily

       • Second-line therapy – TCAs:

         • Nortriptyline 25 mg daily

         • Amitriptyline 75 mg daily in divided doses

       • Short‑ or medium‑acting benzodiazepines may be required while awaiting onset of action of SSRIs:

         • Oxazepam 7.5 to 15 mg three to four times daily

         • Lorazepam 2 to 3 mg daily in divided doses

     • Avoid long-acting benzodiazepines e.g., diazepam.

     • Bipolar:

       • Pregnancy:

         • Manage with a psychiatrist.

         • If using mood stabilisers, ensure 5 mg folic acid daily.

       • Breastfeeding – Manage with a psychiatrist.

   • other relevant information about psychotropic medications in pregnancy and breastfeeding:

     • Anticonvulsants

     • Anticonvulsants

     • Always manage in consultation with a psychiatrist or mental health service.

     • Prescribe folate 5 mg daily, as several anticonvulsants are folate antagonists and are associated with an increased risk of major malformations.

       • Sodium valproate:

         • Valproate has a high teratogenic potential and children exposed in-utero have a high risk for congenital malformations and neurodevelopmental disorders. Avoid prescribing in women of childbearing age unless other treatments are ineffective or not tolerated.

         • If the patient is already pregnant, arrange urgent psychiatric review for further management advice:

           • If in Newcastle, phone the Newcastle Mental Health Centre Mater Campus PECC Unit on (02) 4033‑5900.

           • If in other areas, refer to the emergency department for MHEC-RAP assessment.

         • If the patient is breastfeeding and there is no effective alternative, ensure optimal contraception (depot contraception is recommended).

       • There is some data to suggest that carbamazepine increases the risk of major malformations.

       • Lamotrigine is probably not associated with significant risks of structural teratogenicity.

     • Closely monitor breastfed infants for adverse effects, ideally in consultation with a neonatologist, as the risk of anticonvulsants used by breastfeeding mothers is uncertain.

     • For further information about anticonvulsant use in pregnancy, see Epilepsy in Women and Pregnancy or contact a Drug Information Service.

     • Antidepressants

     • Antidepressants

       • Medication is only recommended for patients with moderate‑to‑severe depression or anxiety.

       • In milder depression or anxiety, or where depressive or anxiety symptoms have been well controlled for > 6 months, consider a cautious withdrawal of medication.

       • If a patient is already established on an antidepressant and is responding well, continue. Switching antidepressants may not reduce fetal or baby exposure and may lead to relapse.

       • If initiating antidepressants in pregnancy, use SSRIs first-line. In general, use sertraline first-line and citalopram second-line.

       • For patients on higher doses of citalopram or escitalopram, consider an ECG to check for prolonged QT syndrome.

       • Consider risks to the unborn baby:

         • Antidepressants may have a small effect on some pregnancy outcomes (gestational age, Apgar score), though it is uncertain if this is clinically significant.

         • SSRIs:

           • Use in late pregnancy may be associated with self-limited withdrawal effects (e.g. irritability, altered muscle tone). Decreasing the SSRI dose in the weeks before delivery may reduce neonatal withdrawal or toxic effects, however supporting evidence is lacking and some patients may require increased doses due to pharmacokinetic changes in late pregnancy.

           • Do not appear to be associated with an increased risk of malformations. Recent evidence suggests that paroxetine is not associated with an increased risk of heart defects.3

           • May be associated with premature delivery.

           • May be associated with an increased risk of postpartum haemorrhage, but the magnitude and clinical significance of this risk is uncertain.

           • Although the risk of persistent pulmonary hypertension in babies exposed in-utero to SSRIs is increased, the absolute risk is low and likely to be outweighed by the potential benefits of treatment.4

           • 10% to 30% of neonates of mothers taking SSRIs in late pregnancy will have poor neonatal adaptation syndrome in the first week postpartum (depending on medication's half‑life). All SSRIs appear to carry the same risk of the syndrome. Patients may be required to stay in hospital longer after birth for monitoring – usually 72 hours.

           • Poor neonatal adaptation syndrome

             • Signs and symptoms include:

               • central nervous system reactivity – irritability, restlessness, tremor, hyperreflexia, myoclonus, and occasionally seizures.

               • gastrointestinal disturbance e.g., feeding difficulties.

               • respiratory difficulties.

               • low Apgar scores.

             • Almost all cases remit within 2 weeks with no apparent residual problems.

           • Use of SSRIs during pregnancy does not appear to be associated with reduced IQ or increased risk of behavioural problems in children aged 3 to 6 years

       • Consider risks to the breastfeeding infant:

         • Note there is no current evidence of long‑term risk to the developing baby from exposure to small amounts of antidepressants in breast milk.

         • If the patient has responded well to antidepressant therapy during pregnancy, continue the antidepressant postpartum.

         • Avoid starting doxepin postpartum as it may cause respiratory depression in the infant. Mianserin, mirtazapine, irreversible non-selective MAOIs, and reboxetine have not been adequately studied.

         • SSRIs:

           • Sertraline has the lowest excretion of the SSRIs into breast milk.

           • Avoid fluoxetine due to very long half-life and risk of accumulation in breast milk, unless the patient is currently stabilised on fluoxetine and risks of switching antidepressants outweigh the benefits.

           • SSRIs stay in the body for a sufficient length of time that it is not possible to alter the dosing so that the SSRI is not excreted in the breast milk.

     • Antipsychotics

     • Antipsychotics

       • Always manage in consultation with a psychiatrist or mental health service.

       • Be aware that:

         • there is little evidence to recommend a particular antipsychotic over another one.

         • second‑generation antipsychotics are preferred over first‑generation.

         • in general, the use of antipsychotics in pregnancy does not appear to be associated with adverse pregnancy or neonatal outcomes, though there may be a small increased risk of malformations with in-utero exposure to risperidone.

         • quetiapine has a relatively low rate of placental passage.

         • in pregnancy, switching from one antipsychotic to another puts the patient at risk of relapse and of potential adverse effects to the fetus from exposure to multiple drugs.

         • breastfeeding on clozapine is contraindicated.

       • Consider using the antipsychotic that has worked best for the patient in the past, after discussion of benefits and risks.

       • Regularly monitor women on antipsychotics, and manage for excessive weight gain and increased risk of gestational diabetes.

       • Consider decreasing dose in the weeks prior to delivery to minimise effects on the newborn.

     • Benzodiazepines and other hypnotics

     • Benzodiazepines and other hypnotics

       • Do not regularly use benzodiazepines long‑term in the management of anxiety disorders – they are associated with high risk of abuse, accidental overdose, and other significant side‑effects.

       • Be aware that the use of benzodiazepines in pregnancy has not been associated with increased risk of major malformations in the newborn, and their short‑term use may be appropriate in patients with severe symptoms of anxiety.

       • Be cautious if using long‑acting benzodiazepines around the time of birth, as they are associated with an increased risk of respiratory difficulty and poor neonatal adaptation syndrome.

       • Consider doxylamine (antihistamine – category A) first-line for moderate to severe insomnia in pregnancy.

       • Use the non-benzodiazepine hypnotics zopiclone, zolpidem, and zaleplon (Z‑drugs) with caution during pregnancy.

       • Avoid use if possible in the third trimester (particularly large doses, regular use and benzodiazepines with long half-lives) due to risk of neonatal withdrawal syndrome.

       • Closely monitor babies of breastfeeding mothers taking these medications, as hypnotics and anxiolytics cross into breast milk

     • Lithium

     • Lithium

       • Always manage in consultation with a psychiatrist or mental health service.

       • If the medication is continued during pregnancy, closely monitor blood levels as requirements increase with the advancing pregnancy.

       • Use only in consultation with treating psychiatrist in breastfeeding mothers, as there is high passage into breast milk and risk of toxicity for the baby. Maternal lithium levels do not correlate with infant serum levels. Monitor infant for adverse effects.

       • Be aware of limits of current data about effects of lithium:

         • Due to the small volume of data, existing evidence cannot exclude an effect of lithium on overall malformation rate, or cardiovascular anomalies in particular. However, if a risk exists, it is likely to be small.

         • Too little is known about the effects of lithium on spontaneous abortion, birth weight, and gestational length to draw any conclusions.

         • There is no systematic data regarding neonatal effects of lithium exposure.

         • There is limited data to suggest that there are no effects of lithium on neurodevelopment.

4. See also Psychotropic Medicine Profiles in Pregnancy and Breastfeeding.

5. If medication is considered necessary:

   • discuss the possible benefits and side-effects with the patient, and document this in the medical record.

   • prescribe the lowest effective dose. Higher doses may be required due to physiological changes for some women, particularly in late pregnancy.

6. For breastfeeding mothers taking:

   • antidepressants, prescribe once a day dosing and avoid sustained release preparations of antidepressants whenever possible.

   • anticonvulsants, consult with a specialist or drug information service about pharmacokinetics to determine optimal dosing schedule.

   • any psychotropic medication, monitor infants for side-effects, including:

     • excessive crying or irritability.

     • hypoactivity.

     • sleep disturbance.

     • feeding difficulties or gastrointestinal symptoms e.g., bloating, diarrhoea, vomiting, constipation.

7. For advice, consider contacting:

   • the Statewide Outreach Perinatal Service for Mental Health (SwOPS-mh) for advice if required on (02) 8890‑3617 (business hours).

   • a Drug Information Service.

Referral

• For advice, consider contacting:

  • the Statewide Outreach Perinatal Service for Mental Health (SwOPS-mh) for advice if required on (02) 8890‑3617 (business hours).

  • a Drug Information Service.

• Always manage anticonvulsants, antipsychotics, and lithium in consultation with a psychiatrist or specialist mental health service.

• If the patient is already pregnant and taking sodium valproate without pre-conception planning, arrange urgent psychiatric review for further management advice:

  • If in Newcastle, phone the Newcastle Mental Health Centre Mater Campus PECC Unit on (02) 4033‑5900.

  • If in other areas, refer to the emergency department for MHEC-RAP assessment.

Information

For health professionals

Further information

• Australian Journal of General Practice – Critical Caveats in Using Product Information/Pregnancy Categories for Pregnant or Breastfeeding Patients

• Centre of Perinatal Excellence (COPE) – Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline (October 2017)

Recognition of the seriously ill neonate (PIC)

Renal Pelvic Dilatation (see also hydronephrosis)

Renal Pelvic Dilatation see also Antenatal Urinary Tract Dilatation (PIC)

Respiratory distress syndrome ( clinical features, CPAP, criteria for surfactant and calling  NETS)

Respiratory distress syndrome (Victoria E-Book- excellent overview)

Respiratory support in neonates (Grace) summary on LMA/CPAP/HHFO2/Ventilation

Retinopathy of prematurity ( Nepean)

Retrieval of the extremely low birth weight baby (NETS)

RSV vaccination ( nirsevimab " Beyfortus") 

Rubella in neonate (NEB)

Sacral dimple (lumbosacral dimple) ( RHW)  

Seizures in a neonate (NEB)

Sepsis in neonates (NEB) presenting clinical features, blood test interpretation and treatment

Sepsis in neonate (Nepean)

Shock in neonates (NEB) 

Single umbilical artery (NEB)

Skin to skin care (RCH) also called Kangaroo care

Small for gestational age (NEB) or intrauterine growth retardation (IUGR)

Stridor (noisy breathing in) (NEB)

Subgaleal haemorrhage (Liverpool)

Subgaleal monitoring after instrumental deliveries ( Nepean)

Sucrose (for procedural pain relief) (NEB)

Supplementation for preterm infants (NEB) ( Vitamin D,E iron etc)

Supraventricular tachycardia ("SVT") (NEB)

Surfactant: endotracheal surfactant administration ( NETS)

Surfactant administration ( Nepean) 

Surfactant MIST

Surfactant by laryngeal mask (Liverpool NICU guideline)

Surfactant general information on administration etc (RCH)

Syphilis in neonates (NEB) (note if mother's RPR or VDRL positive it will be very hard to avoid 10 days of IV penicillin for baby unless maternal treatment confirmed. TPHA will remain positive for life in mother)

Thermoregulation ( Nepean)

Thrombocytopaenia in neonates (NEB)

Thrombosis in neonates (NEB)

Thyroid function testing (NEB)  covers maternal Graves and neonatal hyperthyroidism and see also hypothyroidism

Tongue-tie (RHW)

Transfusions for neonates (NEB)

Tuberculosis in neonates (NEB)

Umbilical venous catheters (UVC document with good images on xrays)

Umbilical venous catheters (NETS UVC insertion with Vycon complete disposable set - Nepean has this set too)

Urinary catheterisations in neonates (Nepean)

Urinary tract dilatation ( PIC)

TIP: If using heparin/saline for UVC or UAV read the following:

Intravenous Unfractionated Heparin A common cause of fatal heparin induced bleeding is accidental overdose, especially in neonates. The most common cause of this is drug error, with 5,000 Units/mL or similar concentration vials being erroneously selected instead of 50 Units/mL vials 

Varicella zoster in neonates (NEB)

Ventilation ( Neonatal Ventilation) (NETS)

Ventilation with Hamilton Ventilator - Emergency Department ( Nepean)

Vitamin D supplementation (NEB)

Vitamin supplementation (NEB)

Vomiting in neonates (NEB) see also bilious vomiting

MINIMALLY-INVASIVE SURFACTANT THERAPY (MIST)

Minimally invasive surfactant therapy (MIST) is now being adopted at some special care nurseries, both in Australia and overseas. It is estimated that about 1 in 4 nurseries in Sydney utilise MIST including: Liverpool, RPAH, RNSH and RHW.

We note our referral hospital Nepean has reservations about MIST, citing concerns about the lack of analgesia, and suboptimal delivery of surfactant to both lungs (compared to ventilator assisted distribution) with the additional issue of refluxing of surfactant up the airway. As such Nepean NICU is not yet utilising the MIST, but rather prefers the INSURE method.

A general anecdotal comment is that the closer a baby is to term, and the bigger and stronger it may be, the harder perhaps for the paediatrician to perform laryngoscopy and view the cords. So it might be appropriate to consider the 32 to 37 week gestation and 37 and 40 gestation as separate categories, the latter may be better done with INSURE.

However, the potential gains are considerable for Dubbo Special Care Nursery (DSCN) in adopting MIST as its preferred practice in those babies on CPAP who fail to respond adequately. The potential reduction in transfer of babies to NICU elsewhere in NSW and a reduced risk of apnoea in those children who do not receive opioids. This higher safety profile (if there is reduced risk of apnoeas) is highly desirable in a remote location, where once a baby is ventilated it is more difficult to withdraw this ventilation safely. MIST offers the possibility of avoiding ventilation altogether, which is desirable.

If Dubbo clinicians look to other NICUs for clinical practice guidelines on MIST, the NICU potentially most closely aligned with DSCN (i.e. a bubble CPAP system, and if required followed by MIST) is the Royal Hospital for Women. Their MIST protocol may be found on their website. (RHW MIST Guideline)

INTRODUCTION

Preterm infants are increasingly being supported with nasal continuous positive airway pressure (nCPAP) at birth and are not routinely intubated. However, many of these infants have significant surfactant deficiency. New techniques of minimally-invasive surfactant therapy (MIST) have been developed, whereby exogenous surfactant can be administered to spontaneously breathing infants on non-invasive respiratory support without the need for intubation. Our LOP at the Royal Hospital for Women is based on the “Hobart method”1, which involves the administration of surfactant via a semi-rigid catheter briefly passed into the trachea.

1. AIM

To safely administer surfactant to spontaneously breathing infants on non-invasive respiratory support

2. PATIENT

Neonates

3. STAFF

Medical and nursing staff

4. EQUIPMENT

Hudson CPAP prongs [Sizes 1 (10fr) – 4 (16fr)]

o 700-1250 grams 1 (10fr)

o 1250-2000 grams 2 (12.5fr)

o 2000-3000 grams 3 (15fr)

o >3000 grams 4 (16fr)

Oral sucrose

Atropine 600 mcg/ml

Layngoscope handle and blade – Miller 0 or 00

BD Angiocath 16G, 1.7 x 133 mm

Surfcath- see photo

Surfactant

3ml or 5ml syringe

Vial access cannula

C-MAC laryngoscope

5. CLINICAL PRACTICE

Preparation

1. Ensure that the infant is suitable for administration of surfactant via MIST. This should always be at the discretion of the neonatologist. In general, MIST should be used in infants that are clinically stable on nCPAP where it is felt that the infant does not require invasive respiratory support but would benefit from surfactant administration.

2. Do not use this technique in an infant that is rapidly deteriorating, haemodynamically unstable or in situations where escalation to invasive ventilation is imminent or likely. MIST should be used with caution in infants who have congenital airway anomalies or other respiratory conditions (eg. pulmonary hypoplasia) contributing to their respiratory status.

3. Assemble necessary equipment to perform the procedure. Importantly, the Hudson CPAP prongs and catheters used for this procedure are not routinely ordered NCC stock and should be located prior to considering giving surfactant via MIST.

4. Ensure intubation trolley and all necessary equipment required for invasive ventilation is readily available if required.

5. Change the infant’s CPAP midline nasal tubing with prongs or mask to Hudson CPAP prongs using the existing CPAP circuit. It is very difficult to manipulate the laryngoscope blade and position the catheter with the CPAP nasal tubing in a midline position. If Hudson CPAP prongs are not available, it is an option to set up a high flow circuit and place the infant on high flow (8L/min) for the procedure.

6. Prepare the 16G Angiocath by making a slight anterior curve in the catheter so that the distance from the bend to the tip of the catheter matches the desired insertion distance below the vocal cords. This helps with positioning the catheter in the trachea and positioning the tip appropriately to ensure even distribution of surfactant to both lungs.

The required depth should be based on the infant’s size:

o <1000 grams – 1.5 cm

o 1000-2000 grams – 2.0 cm

o 2000-3000 grams – 2.5 cm

o >3000 grams – 3 cm

7. Draw up surfactant (Curosurf™, Chiesi Farmaceutici, Parma, Italy) in a 3 or 5 mL syringe. The surfactant dose is 200 mg/kg (2.5 mL/kg). Draw up an additional 0.5 mL of air into the syringe, which allows for the dead space in the instillation catheter (~0.3 mL).

Procedure

1. Continue cardiorespiratory monitoring throughout the procedure.

2. Swaddle the infant and administer oral sucrose. It is optional to also give atropine (10 microg/kg) intravenously at fellow/consultant discretion.

3. Position the infant as for a standard intubation procedure.

4. Perform direct laryngoscopy using a standard laryngoscope blade. If possible, the laryngoscopy and tracheal cannulation should be performed with the CPAP prongs remaining in situ. The NCC has a video laryngoscope that can be used to ensure correct placement of the catheter.

5. Insert the Angiocath orally and pass it through the vocal cords to the desired depth, and hold it in position at the lips. The laryngoscope blade should then be removed. C

Closing the mouth to maintain the CPAP is now done.

(Note:the small catheter does partially obstruct the airway and the time of surfactant pushed through, if delayed, also contributes the relative hypoventilation during the administration).

Check observations are stable, and check position of the angiocath with the CO2 detector. 

NB. If an Angiocath is not available, it is possible to insert an “old” intragastric tube (CH 05) nasally and use Magill’s forceps to guide the tube into position.

6. Connect the surfactant syringe to the catheter hub and instil the surfactant in 2-4 boluses over 15-30 seconds. If catheterisation of the trachea is not possible within 20–30 seconds, remove the laryngoscope and allow recovery on nCPAP before attempting tracheal catheterisation again. Consider abandoning the procedure after three unsuccessful attempts.

·   Flush the remaining surfactant through the iv tubing and angiocath with some air. The dead space is 0.2ml for the angiocath plus - in this case - 1ml for iv tubing.

·       Remove the angiocath once the surfactant has been given and maintain CPAP.

Post-procedure

Remain with infant until heart rate, oxygen saturations and respiratory effort are close to baseline values.

·   Be prepared to give positive pressure ventilation if clinically indicated, such as apnoea, chest not moving, or bradycardia.

1. Restore the infant to their previous position and change the infant’s Hudson CPAP prongs back to the midline nasal tubing with prongs or mask on the same settings as prior to the procedure.

2. Document the details of the procedure in the integrated clinical notes and record the procedure in the infant’s observation chart.

6. DOCUMENTATION

Integrated Clinical Notes

Observation Chart

NOTE

If the procedure is poorly tolerated by the baby, as it is resisting the laryngoscope and so the visualisation of the larynx is not possible then consider mild sedation for the procedure

Options would include

1)     Remifentanil (this may cause apnoea and chest wall rigidity so the clinician needs to be ready for a need for intubation and ventilation). Naloxone should be given after procedure if successful MIST

2)     Propofol- this is less analgesic and may be associated with hypotension

In the event that clinician is unable to achieve successful MIST, then proceeding to intubation, ventilation and transfer is likely be needed (given anticipated difficulties at supporting the airway)

7. EDUCATIONAL NOTES

Preterm infants who have respiratory distress syndrome have for many years been managed with a combination of early intubation and exogenous surfactant therapy. With the increasing use of nCPAP as primary therapy for preterm infants, many of whom have significant surfactant deficiency, there is growing interest in developing new techniques to administer surfactant without the need for intubation.2

From a number of potential techniques, methods involving brief tracheal catheterization have been most extensively studied. These generally involve surfactant administration using either a flexible feeding tube or a semi-rigid vascular catheter. There are a considerable number of different techniques described under the banner of MIST, none of which have been directly compared. It is likely that there is little difference between them in the ultimate effect of the instilled surfactant.2

In clinical trials surfactant delivery via a feeding tube was found to reduce the need for subsequent intubation and ventilation and to improve short-term respiratory outcomes. Further randomized controlled trials of surfactant administration via tracheal catheterization are underway or planned, and they will help clarify the place of this therapeutic approach.3-5

Not all preterm infants managed on nCPAP stand to benefit from MIST. Many infants will be well supported by CPAP alone and, conversely, many infants with severe surfactant deficiency will require invasive respiratory support.2

Infants who develop severe respiratory distress syndrome (RDS) should ideally receive surfactant early to gain the most advantage, however, in practice it can be very difficult to predict which infants will require surfactant. Currently, it is felt that consideration of MIST should be coupled with early selection of infants who have significant RDS.2

Published studies of MIST with the use of direct laryngoscopy and tracheal catheterization have used different approaches to premedication but all avoid narcotic medications. The avoidance of narcotic medications does not seem to have been associated with any major deleterious effects in the short term. There is also a theoretical benefit of more effective distribution of surfactant with spontaneous breathing during the MIST procedure, which may be ameliorated by the use of narcotic medications.2

Surfactant dosage in published studies has been either 100 or 200 mg/kg. We have chosen the higher dose of 200 mg/kg as reflux of surfactant into the pharynx around the thin catheter is common. It is also reported that 200 mg/kg is associated with a more prolonged effect.2

Infiltration is generally benign but a large volume of infiltrate can cause a compartment syndrome, compressing nerves and compromising circulation.2

A video of the MIST procedure from Aukland Starship can be seen on their website Aukland Starship MIST Guideline

Dubbo surfactant document

Respiratory distress syndrome management

Escalating treatments when CPAP management is ineffective

(This document assumes a pneumothorax has been excluded clinically and radiologically)

Exogenous surfactant is a treatment modality used in the treatment of premature newborns experiencing respiratory distress syndrome (RDS). In preterm infants at risk for or with established RDS without respiratory failure, nasal CPAP is the initial preferred intervention versus intubation, surfactant administration and ventilation.

The decision to administer surfactant should be made as per local operating protocols and in consultation with NETS.

Criteria for surfactant administration:

· FiO2 greater than 0.3 to maintain SPO2 91-95% in right hand

· CPAP is at the upper limit of 8cm H2O

· pH less than 7.25 on two occasions

· CO2 greater than 60 on two occasions

· X-ray showing RDS changes

There are 3 main options when babies on CPAP fail to respond to treatment in Dubbo Special Care Nursery (DSCN)

1)      Intubate /surfactant administration/ ventilate/transfer (“ISVT”)  i.e. transfer to NICU

2)      INSURE: intubate, wean ventilator settings, consult with neonatologist (NETS or Nepean), and extubate to CPAP.

3)      MIST therapy: as per RHW document (summary of this below). In short this includes laryngoscopy

This document will focus on the INSURE and MIST options intubation/surfactant/ventilation/transfer (ISVT).

INSURE method

Historically in DSCN this has not been done successfully.

The main obstacles to safely performing INSURE are the apnoea and chest wall rigidity following sedation with intravenous morphine. This drug is typically administered prior to potentially painful laryngoscopy and intubation. Apnoea poses safety issues as registrars on duty may have no NICU experience, and nursing staff experience is variable for intermittent positive pressure ventilation (IPPV), in an apnoeic baby. Historically apnoea has led to reintubation and transfer, and as such, no improvement in the medical service to the baby from the attempted INSURE (compared to if the endotracheal tube was left in position).

The other difficulties following IV morphine are the variable and unpredictable onset of analgesia and apnoea. The analgesic properties may take 20-30 minutes to take effect (note NETS suggests 5 minutes, but this may not be long enough). However seldom do clinicians wait this long, prior to attempting intubation.

Whilst awaiting for the analgesic effects to take effect, the baby is at risk of hypoventilation and apnoea. The onset of apnoea is unpredictable and make occur within minutes or make take effect 12-24 hours after the dose of morphine. That being said, apnoea following morphine would be rare after 12 hours.

As such, if morphine has been given, and there is consideration being given to extubate the baby following INSURE, then appropriate skills will need to be arranged on site. The main challenge for Dubbo SCN to manage is this apnoea associated with morphine, after the removal of the endotracheal tube (ETT).

1)      In view of this risk of apnoea,  attempts of INSURE with extubation would need to be done in daylight hours 0800 to 2000, and consultant staff would be fresher and able to remain in close proximity to the nursery. Consideration for consultants sleeping on site, is unlikely to be popular as there is no consultant bed for the nursery (this could be negotiated with maternity).

2)      Consideration for Naloxone (as a drug antagonist to be given once extubation has taken place. Naloxone can be re-administered in a (?) 4-6 hours if apnoea continues.

3)      Consideration for different medication options other than then regular morphine dose

4)      As there will be a “learning curve” for consultant paediatricians weaning the ventilator settings, prior to extubation to CPAP, this could be supported by Telehealth Video consultation with a neonatologist. Eg WALLIE computer could be linked with Nepean neonatologist on call.

Other medication options for INSURE

https://www.slhd.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/tube.pdf

1)      Reduce the dose of morphine from the NETs dose of 0.1mg/kg (100mcg/kg) to 0.05mg/kg (50mcg/kg)

2)      Remifentanil hydrochloride (remifentanil). This is a synthetic opioid with a rapid onset of action and short half-life. So whilst there is still a risk of apnoea and chest wall rigidity, it is of shorter duration and for Dubbo nursery this would potentially improve our safety profile.

The main challenges with a simple transition from morphine to remifentanil is complexity in drawing up the drug doses. It is a complicated drawing up procedure with more potential errors to made.

Drawing up procedures for remifentanil:

Powder for reconstitution: First draw up 1mL of sodium chloride

0.9% and add to vial containing 1mg powder for reconstitution.

Shake well to dissolve.

Further dilution is required, follow directions

below according to indication.

For tracheal intubation IV intermittent dose – infuse via

syringe driver (see administration section):

Two step dilution

Step 1: Add 1mL of reconstituted solution to 4mL of sodium chloride

0.9% to make 5mL of 0.2mg/mL solution. Solution should be clear

and colourless.

Step 2: Take 0.25mL of 0.2mg/mL solution and make up to 50mL

using sodium chloride 0.9% to obtain a final concentration of

1microgram/mL

DOSE

A) For tracheal intubation IV intermittent dose – infuse via syringe driver

Initial dose:                  1-2 microgram/kg.

Repeat dose(s):                         1 microgram/kg/dose may be used after 2-3 minutes if required. Maximum of 2 repeat doses may be used.

OTHER MEDICATION OPTIONS

3)      Propofol. This is a medication more used by our anaesthetic colleagues, nevertheless it is also is being used by our neonatal colleagues. (https://fn.bmj.com/content/105/5/489)

This drug is mostly a hypnotic drug, but does have some mild analgesic effects. The advantage for DSCN would it rarely causes apnoea in contrast the traditional opioid drugs used in intubation.

The dose is 1.0-2.0mg/kg and the main problem is one of hypotension, which may need treatment. It is not known if cerebral perfusion pressures are altered by this hypotension which would be the main clinical concern.

4)      Fentanyl- this like morphine has risks of apnoea but is an excellent analgesic. RPA uses this drug with intubation and

5)      Ketamine may cause laryngospasm and respiratory depression if given too quickly. Apnoea is not generally seen with this medication. May cause raised ICP, which is of concerns in neonates. This is not a mainstream neonatal intubation but is used.