Care of Sick and Small Neonates

Description

General measures

Medicine treatment

Referral

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DESCRIPTION

Neonates can become ill very rapidly and signs of disease are often not readily appreciated unless specifically looked for. Neonates should be referred urgently. Neonates < 2.5 kg are at higher risk of feeding and growth problems and need careful follow-up.

Urgently manage and refer neonates with any of the following signs of possible serious bacterial infection and/or jaundice:

• Convulsions
• Passing blood per rectum
• Lethargic/ unconscious
• Pallor
• Bulging fontanelle
• Jaundice in 1^st 24 hours of life
• Apnoea (< 30 breaths/min)
• Diarrhoea
• Severe chest indrawing
• Many or severe skin pustules
• Nasal flaring or grunting
• Fast breathing (> 60 breaths/min)
• Swollen eyes; pus draining from eye
• Vomiting everything/bile-stained vomitus
• Low or high temperature
• Only moves when stimulated
• Not able to feed
• Umbilical redness extending to the skin and draining pus

GENERAL MEASURES

• Keep the neonate warm (skin-to-skin/kangaroo mother care or in an incubator), the axillary temperature should be 36.5–37^oC.
• Check blood glucose concentration and treat if low (< 2.6 mmol/L). Check blood glucose concentration again after 15 minutes. If normal, feed 2-3 hourly. If still low, treat as severe hypoglycaemia (see below).
• Check mother able to successfully establish breastfeeding in the small neonate and check health and weight gain more frequently.

MEDICINE TREATMENT

If grunting or severe chest indrawing
P22.0-1/P22.8-9

• Oxygen, using nasal catheter at 1 L/minute.

If infection is suspected and jaundice has been excluded
Z29.2

• Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose.
  • Administer into the lateral thigh.
  • Do not inject more than 1 g at one injection site.

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CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN
- If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if jaundiced.
- Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:
- If ≤ 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone administered.
- If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after.
- Preferably administer IV fluids without calcium contents.
- Always include the dose and route of administration of ceftriaxone in the referral letter.

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If blood glucose < 2.6 mmol/L and baby able to suckle or take orally:

• Breastfeed or give expressed breastmilk (only if breastfeeding is not possible, give replacement milk feed 10 mL/kg)
• If unable to take orally consider nasogastric tube feeding. Check blood glucose concentration again after 15 minutes. If normal, feed 2-3 hourly. If still < 2.6 mmol/L, manage as below.

If blood glucose < 1.4 mmol/L or remains < 2.6 mmol/L after an oral feed:

• Dextrose 10%, IV, 2 mL/kg as a bolus.

AND

• Dextrose 10%, IV, 3 mL/kg/hour.
  • Repeat in 15 minutes.
  • If blood glucose still low, repeat dextrose bolus.

LoE:IVb³⁶

REFERRAL

Urgent

• All neonates with a possible serious bacterial infection.
• All neonates with jaundice on the first day of life, with pallor or with poor feeding.
• All other neonates with increasing, deep or persistent (> 10 days) jaundice should be referred as soon as possible.
• All small neonates (< 2.5 kg) not able to feed.
• Persistent hypoglycaemia despite treatment.

(If possible, always send mother with the neonate as well as any clinical notes).

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2025-9_Version 1.0_26 March 2026

Chapter 6: Obstetrics and Gynaecology_6.6.3 Care of Sick and Small Neonates