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ADVANCED

NEONATAL CARE

CLINICAL & THERAPEUTIC GUIDELINE

MSF OCG (INTERNAL USE)

Updated version:

Version - Janvier 2015

2 3 Case management (CM) of sick neonates needs to approach not only ante-natal care and

obstetrical emergencies, per natal resuscitation (Part II), mother to child transmitted diseases (Part

III), and main neonatal diseases (Part IV) but also to be capable having a specific regard on Low Birth Weight, Very Low Birth Weight and Extremely Low Birth Weight babies (Parts V & VI).

Newborns in tropical countries and poor settings were neglected for too long time in the past

decades, so now it is time to urgently act in order to decrease the 40% of under five years old children mortality due to neonatal deaths (Part I). This protocol can apply in all MSF CH programs were there are newborns that means Mobile Clinics, OPD, IPD, Obstetrics etc... according to the skills of the health staff. A large part of recommendations and treatments were agreed by the Pediatrics Working Group and it has largely participated to the writing.

This protocol is integrative part of the BibOp and will be regularly updated according to the

capitalization of collected field experiences (your feedback), the scientific evolution (literature) and

the WHO recommendations. Be vigilant and use uniquely the most recent version.

Some adaptations might be discussed according to the countries in order to follow a specific

national protocol or in order to better cope with specific conditions. Nevertheless any change and/or adaptation should be communicated to the cell and validated by the medical department before use. I would like to sincerely thank you the pediatricians from the different MSF Operational Centers (OC), whose have participated to the writing of this protocol. A special attention is given to the MSF International Pediatrics Working Group Members, Isabel

Zuniga,

Isabel.zuniga@brussels.msf.org, Nicolas Peyraud, Nicolas.peyraud@geneva.msf.org, Harriet Roggeveen, Harriet.roggeveen@amsterdam.msf.org, Roberta Petrucci, Roberta.petrucci@geneva.msf.org, Anne Pittet, Anne.pittet@geneva.msf.org, Daniel Martinez, Daniel.martinez@barcelona.msf.org, Pascual Caballero, Pascual.caballero@msf.org, Maura PEDRINI, Maura.pedrini@msf.org, Elisabeth Canisius, Elisabeth.canisius@geneva.msf.org,, Belen Caminoa , Belen.caminoa@msf.org, Marianne Sutton, mariannebsutton@gmail.com and to the Medical Director attached to this Working Group at the moment this guideline was written, Dr Eric

Comte,

Eric.comte@geneva.msf.org, for his implication in its realization. We reniew all our best thanks to them.

We also would like to thanks for their contribution the pediatricians Dr Dina-Maria Jakob,

dina.jakob@gmail.com, Teresa Gadsden Hevia, teregads@gmail.com, Marco Olla , Marco.olla@msf.org, Laurent HIFFLER, Laurent.hiffler@msf.org, Ante Liesbeth Wind, antewind@gmail.com as well as the Pediatrics Tropical Group of the French Society of Paediatrics.

I hope this tool will really help you. I am now looking forward to hear from you, remarks,

comments, suggestions and questions. They will be welcomed and source of progress for everyone. Marie-Claude Bottineau, Paediatrics and Neonatology MSF International Working Group Leader,

Marie-claude.bottineau@geneva.msf.org

CONTENT of TABLE

ADVANCED NEONATAL CARE ....................................................................................................... 1

ACRONYMS ....................................................................................................................................... 6

PART I .................................................................................................................................................... 9

EPIDEMIOLOGY & NEONATAL CONTEXT In the DEVELOPING WORLD............................ 9

PART II................................................................................................................................................. 15

NEONATAL VITAL EVALUATION & NEONATAL RESUSCITATION ................................... 16

1. PREPARATION for DELIVERY ............................................................................................. 17

2. APGAR SCORE (VITAL EVALUATION) at 1, 5 and 10 minutes after birth (Total =

10) .................................................................................................................................................. 19

3. RESUSCITATION AT BIRTH ................................................................................................. 20

4. NEONATAL RESUSCITATION in PRACTICE ..................................................................... 23

TRAINING MATERIALS AVAILABLE in MSF ....................................................................... 32

5. DANGER SIGNS & NEONATAL TRANSFER ...................................................................... 34

6. NEONATAL IMMEDIATE POST-PARTUM ROUTINE / ESSENTIAL CARE IN

DELIVERY ROOM....................................................................................................................... 36

7. IDENTIFICATION OF NEONATES AT RISK FOR SEPSIS OR HYPOGLYCEMIA

8. POST PARTUM MATERNAL & NEONATAL CARE IN THE MATERNITY .................... 44

PART III ............................................................................................................................................... 48

MATERNAL TO CHILD TRANSMITTED DISEASES ................................................................. 48

1. Infant Born from Mother with GONORRHEA or CHLAMYDIA ........................................... 49

2. Infant Born from Mother with CYTOMEGALOVIRUS (CMV) INFECTION ....................... 51

3. Infant Born from Mother with ACTIVE HEPATITIS B ........................................................... 52

4. Infant Born from Mother with HERPES SIMPLEX VIRUS (HSV) ......................................... 54

5. Infant Born from Mother with HIV* ......................................................................................... 57

6. CONGENITAL & NEONATAL MALARIA ........................................................................... 69

7. CONGENITAL RUBELLA ...................................................................................................... 75

8. CONGENITAL SYPHILIS ....................................................................................................... 76

9. CONGENITAL TOXOPLASMOSIS ........................................................................................ 80

10. Infant Born from Mother with ACTIVE TUBERCULOSIS ................................................... 83

11. Infant born from Mother with Diabetes

12. SUMMARY TABLE of CASES MANAGEMENT

PART IV ............................................................................................................................................... 87

UNIT FOR SICK NEWBORNS MAIN NEONATAL DISEASES.................................................. 90

1. PERINATAL ASPHYXIA & SEIZURES due to HYPOXIC / ISCHEMIC

ENCEPHALOPATHY (HIE) ........................................................................................................ 91

2. NEONATAL SEIZURES due to OTHER CAUSES than HIE ................................................. 94

3. NEONATAL RESPIRATORY DISTRESS SYNDROME (RDS) - MANAGEMENT

& MAIN ETIOLOGIES - NEONATAL APNOEAS ................................................................... 97

4. NEONATAL CYANOSIS ....................................................................................................... 102

5. TRANSIENT TACHYPNOEA OF THE NEWBORN (TTN) ................................................ 105

6. HYALINE MEMBRANE DISEASE (HMD) ......................................................................... 107

7. SEVERE DESHYDRATIONS HYPOVOLEMIC & HEMORRHAGIC SHOCKS /

SEPTIC SHOCKS ....................................................................................................................... 110

8. BLOOD TRANSFUSION IN NEONATOLOGY................................................................... 118

9. OMPHALITIS ......................................................................................................................... 125

10. NEONATAL INFECTION: RISK OF SEPSIS, SEPSIS AND BACTERIAL

NEONATAL MENINGITIS

11. NECROTIZING ENTEROCOLITIS (NEC) ......................................................................... 138

12. NEONATAL SKIN CANDIDIASIS ("DIAPER RASH").................................................... 144

13. NEONATAL TETANUS....................................................................................................... 146

14. MANAGEMENT of NEWBORN with HIGH FEVER ........................................................ 151

15. MANAGEMENT of NEWBORN with HYPOTHERMIA ................................................... 152

16. MANAGEMENT of NEWBORN with HYPOGLYCEMIA OR RISK OF

HYPOGLYCEMIA...................................................................................................................... 155

17. MANAGEMENT of HYPOCALCEMIA

18. MANAGEMENT of NEWBORN with JAUNDICE ............................................................ 160

19. MANAGEMENT of a NEWBORN with GASTROINTESTINAL BLEEDING from

the UPPER TRACT ..................................................................................................................... 141

20. MANAGEMENT of a NEWBORN with GASTROINTESTINAL BEEDING from

the LOWER TRACT ................................................................................................................... 144

21. MANAGEMENT of NEONATAL PAIN ............................................................................. 147

22. MANAGEMENT of TALIPES CLUB-FOOTED NEWBORNS ......................................... 149

23. SURVEILLANCE & MONITORING FORM FOR SICK NEWBORN UNIT (NCU) ....... 150

PART V ............................................................................................................................................... 152

KANGAROO CARE UNIT NOT SICK LBW - VLBW - ELBW & IUGR ................................. 152

1. EVALUATION OF GESTATIONAL AGE (GA) .................................................................. 153

2. LBW - VLBW - ELBW - IUGR: CAUSES & CONSEQUENCES ...................................... 155

3. GENERAL PRINCIPLES MANAGING LBW, VLBW & ELBW ........................................ 157

4. KANGAROO MOTHER CARE (KMC) ................................................................................ 158

5. APNOEAS of the PREMATURITY ....................................................................................... 162

6. PHYSIOLOGIC ANAEMIA in LBW, VLBW and ELBW BABIES DIAGNOSIS -

PREVENTION & CORRECTION .............................................................................................. 165

7. SURVEILLANCE & MONITORING FORM for KMCU ..................................................... 167

PART VI ............................................................................................................................................. 169

FEEDING & INFUSIONS MANAGEMENT................................................................................. 169

1. FEEDING/HYDRATION OF THE NEWBORN...........................

2. BASIC PRINCIPLES TO UNDERSTAND THE CHOICE OF FEEDING THE

NEWBORNS (ACCORDING TO WEIGHT AND HEALTH CONDITION)................

2.1 DAILY AMOUNTS REQUIRED FOR THE ENTERAL FEEDING ONLY

2.2 DAILY AMOUNTS REQUIRED FOR IV AND ENTERAL FEEDING

3. PLACING AN ORO / NASOGASTRIC TUBE

4. ENCOURAGEMENT TO EXCLUSIVE BREASTFEED

5. EXTRA CONSIDERATIONS ABOUT FEEDING IN CERTAIN SPECIFIC

CONDITION

6. MEDICAL SPECIALITED FORMULA for NEONATES ..................................................... 200

PART VII ............................................................................................................................................ 202

NEONATAL PROCEDURES & VITAL NORMS ........................................................................ 202

1. OXYGEN THERAPY ............................................................................................................. 203

2. ORO / NASO GASTRIC TUBE (OGT / NGT) INSERTION ................................................ 206

3. INTRA OSSEOUS INFUSION (IO) ....................................................................................... 209

4. LUMBAR PUNCTURE (LP) .................................................................................................. 212

5. TAKING CAPILLARY BLOOD SAMPLE (HEEL PRICK) - From WHO

MANAGING NEWBORN PROBLEMS .................................................................................... 214

6. Making an IM INJECTION in neonates and premature babies ............................................... 216

7. USING Nasal Continuous Positive Airways Pressure (NCPAP) in NEONATES .................. 219

8. ELECTRIC INFUSION PUMP in NEONATES ..................................................................... 223

9. CLEANING OF INCUBATORS ............................................................................................ 224

10. LABORATORY REFERENCE VALUES............................................................................ 225

PART VIII .......................................................................................................................................... 227

CASE DEFINITIONS for the DATABASE.................................................................................... 227

CHECKLISTS

CONCLUSION .................................................................................................................................. 244

REFERENCES ................................................................................................................................... 245

NEONATAL BIBOP 2015 ......................................................................................................................

ACRONYMS

AGE Acute Gastro - Enteritis

ANC Ante Natal Care

ARV AntiRétroViral (treatment)

ART AntiRétroViral Treatment

ASA Acetylic Salicylic Acid

ATB Antibiotic

BP Blood Pressure

BPM / bpm Beating Per Minute

BS Blood Slide

CC Chest Compression

CM Case Management

CMV Cyto Megalo Virus

CPAP Continuous Positive Airways Pressure

CSN Central Nervous System

CRT Capillary Refill Time

CSF Cerebral Spinal Fluid

D1, 2, 3... Day 1, 2, 3...

D5%, 10%, 20%, 50% Dextrose 5%, 10%, 20%, 50%

DBS Dry Bloot Spot

DC Developing Country

DIVC Disseminated Intra-Vascular Coagulation

ELBW Extremely Low Birth Weight

ECMO Extra Corporeal Membrane Oxygenation

EID Early Infant Diagnosis

EPI Enlarged Program of Immunization

FUO Fever of Unexplicated Origin

GA Gestational Age

GBS Group B Streptococci

G6PD Glucose6 Phosphate Deshydrogenase

Hb Haemoglobin

HBP High Blood Pressure

HIE Hypoxic Ischemic Encephalopathy

HMD Hyaline Membrane Disease

HSV Herpes Simplex Virus

HIV / AIDS Human Immunodeficiency Virus / Acquired Immune Deficiency

Syndrome

HR / RR Heart Rate / Respiratory Rate

IOI Intra-Osseous Infusion

IDM Infant born from a Diabetic Mother

Ig Immunoglobulins

IM / IV / SIV Intra-Muscular / Intra-Venous / Slow Intra-Venous

IUGR Intra Uterine Growth Retardation

IVeH Intra Ventricular (Cranial) Hemorrhage

KMCU Kangaroo Mother Care Unit

LBW Low Birth Weight

LGA Large for Gestational Age / Macrosomic baby

LP Lumbar Puncture

LRTI Low Respiratory Tract Infection

MD Medical Doctor

MSF Médecins Sans Frontières,

MTCTD Mother To Child Transmitted Disease

NCU Neonatal Care Unit

NEC Necrotizing Enterocolitis

NGT Naso-Gastric Tube

NICU Neonatal Intensive Care Unit

NS Normal Saline

NTT Neonatal Tetanus (TT - Tetanus; TTV - Tetanus Toxoid Vaccine)

OA Orally Administered

OPV Oral Polio Virus Vaccine

OGT Oro-Gastric Tube

PDA Patent Ductus Arteriosus

PF Plasmodium Falciparum

PM Placental Malaria

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