OBJECTIVES When you have completed this unit you should be able to: Manage hypothermia. Manage hypoglycaemia. Manage respiratory distress. Use oxygen correctly. Transfer an infant.

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All rights reserved. No part of this Perinatal Education Programme may be altered in any way, nor may copies of the complete Programme be made, without the written permission of the editorial board of the Perinatal Education Trust. To facilitate the improvement of perinatal care in Southern Africa, however, parts of the Programme may be reproduced for teaching purposes provided due acknowledgement is given and the material is not sold for financial profit. While the advice and information in the Programme are believed to be accurate, the editorial board cannot accept responsibility or liability for any errors or omissions that may have been made.

39-1 WHAT IS THE EMERGENCY MANAGEMENT OF A NEWBORN INFANT?

Some newborn infants develop serious problems which often cannot be managed in a level I clinic or hospital where only primary care is available. These infants need to be carefully assessed and stabilised before they can be moved to a level II (special care unit) or III (intensive care unit) hospital that has the staff and facilities to provide the care needed. Emergency management is the care that must be given to these infants in a level I hospital or clinic before they can be transferred. Staff working in level I hospitals and clinics must be able to give emergency care.

39-2 WHICH INFANTS NEED EMERGENCY MANAGEMENT?

1. Infants with hypothermia.
2. Infants with hypoglycaemia.
3. Infants with respiratory distress.

THE MANAGEMENT OF HYPOTHERMIA

39-3 HOW DO YOU MEASURE AN INFANT'S TEMPERATURE?

An infant's skin temperature, rather than its oral or rectal temperature, is usually used. The axillary or abdominal skin temperature should be measured.

Skin temperature can be measured with either:

1. A LOW READING MERCURY THERMOMETER. The thermometer is placed in the infant's axilla (armpit) for 2 minutes before the reading is taken. Thermometer should be stored dry when not in use to prevent cross infection. Make sure it is a low reading thermometer.
2. A TELETHERMOMETER. This is an electrical thermometer. The probe is placed on the skin over the left, lower abdomen or the lower back. Avoid the right, upper abdomen as the liver produces a lot of heat and this may give too high a reading.

The correct use of a telethermometer is described in Skills Workshop 26 of the Newborn Care manual of PEP.

39-4 WHAT IS THE NORMAL RANGE OF BODY TEMPERATURE?

This depends on the site where the temperature is measured:

1. The normal axillary temperature is 36,5 - 37șC.
2. The normal abdominal skin temperature is 36 - 36,5șC.

39-5 WHAT IS HYPOTHERMIA?

Hypothermia (low body temperature) is defined as an axillary or abdominal skin temperature below 35șC.

39-6 WHICH INFANTS ARE AT HIGH RISK OF HYPOTHERMIA?

1. Infants who are not dried well after birth.
2. Infants in a cold room or cool incubator.
3. Low birth weight infants.
4. Infants lying near cold windows.
5. Starved infants.

39-7 HOW DO YOU RECOGNISE AN INFANT WITH HYPOTHERMIA?

Hypothermic infants present with the following signs:

1. They are cold to the touch.
2. They are lethargic, hypotonic, feed poorly and have a feeble cry.
3. Their hands and feet are usually pale or blue, but their tongue and cheeks are often pink. The pink cheeks may incorrectly suggest that the infant is well.
4. Peripheral oedema or sclerema (a woody or plastic feel to the skin).
5. Shallow, slow respiration or signs of respiratory distress.
6. Bleeding from the mouth, nose or needle punctures.

39-8 WHAT PROBLEMS ARE COMMON IN HYPOTHERMIC INFANTS?

1. HYPOGLYCAEMIA. This is a common cause of death in cold infants and the most important complication of hypothermia. Cold infants use a lot of energy in an attempt to warm themselves. As a result they use up all their energy stores, resulting in hypoglycaemia.
2. HYPOXIA. The infant's haemoglobin does not carry oxygen normally when the red blood cells are very cold.
3. HAEMORRAHGE. When infants are very cold their blood does not clot normally and they commonly bleed.

HYPOTHERMIC INFANTS MAY DIE OF HYPOGLYCAEMIA

39-9 HOW DO YOU TREAT HYPOTHERMIA?

1. WARM THE INFANT in a closed incubator, overhead radiant warmer or warm room. The incubator temperature should be set at 37șC until the skin temperature returns to normal. If these are not available, place the infant naked against the mother's skin and wrap both in a blanket to give skin-to-skin care.
2. PROVIDE ENERGY while the infant is being warmed. Hypoglycaemia may occur during warming. Energy can be given as oral or nasogastric milk, or intravenous maintenance fluid containing 10% dextrose water (e.g. Neonatalyte).
3. PROVIDE OXYGEN. Give 30% oxygen by headbox while the infant is being warmed, even if the infant is pink.
4. NOTIFY the referral level I or II unit as this infant may need to be transported. Discuss the management of the infant with the staff of the referral hospital.
5. OBSERVATIONS. Monitor and record the infant's temperature, pulse, respiration, skin colour and blood glucose concentration until they are normal and stable.
6. Keep the infant warm once a normal body temperature is reached. It is very important to keep the infant warm during transport.

39-10 HOW SHOULD YOU KEEP AN INFANT WARM DURING TRANSPORT?

The infant should be kept warm during transport by nursing it in a transport incubator or keeping it warm by skin-to-skin care. If the mother cannot be moved, a nurse, doctor are ambulance attendant can give skin-to-skin care. Warm infants can also be dressed and then wrapped in a silver swaddler or tin foil. The infant must be warm before transport.

THE MANAGEMENT OF HYPOGLYCAEMIA

39-11 WHAT IS GLUCOSE?

Glucose is an important type of sugar. Many forms of food (e.g. milk formula) contain glucose. Infants also get glucose from lactose in breast milk and from the breakdown of starch when solids are added to the diet. Glucose is an essential source of energy to many cells of the body, especially the brain. Glucose is stored as glycogen in the liver. Glucose can also be stored as fat and protein. The liver can change stores of glycogen, fat and protein back into glucose.

The amount of glucose available to the cells can be assessed by measuring the concentration of glucose in the blood.

39-12 HOW IS BLOOD GLUCOSE MEASURED IN THE NURSERY?

The quickest, cheapest and easiest method to measure the blood glucose concentration in the nursery is to use a reagent strip such as Haemoglukotest, Glucotrend or Dextrostix. A drop of blood is placed on the reagent strip. After a minute it is either wiped off with cotton wool or washed off with water and then blotted dry depending on the regent strip used. The colour of the reagent strip is then compared to the colour range on the bottle to determine the blood glucose concentration. A far more accurate method to screen for hypoglycaemia is to read the colour of the reagent strip with a glucose meter such as reading Haemoglukotest strips with a Reflolux meter. It is important to carefully read the instructions which are packed with the reagent strips as the correct method must be used.

The method of measuring blood glucose with a reagent strip is described in Skills Workshop 23 in the Newborn Care manual of PEP

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