What to do for Admission, Discharge and Follow-up
Admissions Care of babies <900g birth weight Eye checks for retinopathy of prematurity Discharge Summaries and stats meetings Neonatal follow-up (NNFU) Postnatal wards Admissions Which patients to admit: Usually it is obvious if a baby needs admission. Some of the grey areas are: Low birth weight but baby otherwise well. All babies of birth weight < 1800g should be admitted Mild respir
Care of babies <900g birth weight
Eye checks for retinopathy of prematurity
Admissions
Which patients to admit:
Usually it is obvious if a baby needs admission. Some of the grey areas are:
- Low birth weight but baby otherwise well. All babies of birth weight < 1800g should be admitted
- Mild respiratory distress in term babies may be transient tachypnoea of newborn (TTN). This often settles rapidly, so these babies may be observed for no longer than 4 hours to see if it settles. Do not delay admission if the baby is deteriorating, or if there is reason to suspect another diagnosis e.g. pneumonia or meconium aspiration syndrome (MAS). All babies admitted for respiratory distress should be started on Penicillin G/Ampicillin and an aminoglycoside (e.g. Gentamicin)
- “Asymptomatic” hypoglycaemia (see section hypoglycaemia): Any “symptomatic” hypoglycaemia requires admission. Even if the baby is “asymptomatic”, more than one episode of a dextrostix <2.5mmol/l while on adequate oral feeds usually requires admission
What to do on admission:
- Bloods: FBC, blood culture as indicated, unless baby well and wt >1500g (bloods can be done on D2). Please do not request a differential count or CRP or U&E at birth. Do an arterial blood gas (ABG) if there was perinatal asphyxia or the baby is in respiratory distress
- Fluids and feeds: start on IVI Potassium-free (Non-K+) solution (see Fluids section). If the baby is >1500g and generally well oral feeds can be started
- Medications: If respiratory distress is present or suspected sepsis, start Penicillin G/Ampicillin and Gentamicin. In addition, if weight <1500g or gestation < 32 weeks, start caffeine
- NB: Fill out the neonatal admission pack and RedCap admission forms
- All Low birth weight babies (<2500g) should have a gestational age assessed using the modified Ballard Score
- If needing supplemental oxygen, request a blender
- Enter patient details into the mortality and morbidity book in NICU, if it is necessary to discuss the case with the obstetrics department
Care of babies <900g birth weight
Although we don’t ventilate babies < 900g (except under exceptional circumstances), we do give them all the other care they require (and + 1/3rd survive). Babies weighing 700-749g are eligible for NCPAP in ward 16b and babies > 750g are eligible for NCPAP in NICU. Please discuss all ELBW infants with your seniors as even an infant weighing < 700g may be eligible for NCPAP if resources are available.
Initial Management:
- Penicillin G/Ampicillin, Gentamicin and Caffeine
- NPO (start feeds on D2)
- 5% dextrose water @ 100ml/kg/day
- Oxygen with a blender to keep O2 Sats between 90% and 94%
- Warm baby: incubator, hat, plastic sheet
- Additional blood tests: Day 2: U&E, SBR, CRP
- Watch for hyperglycaemia, hypothermia and dehydration
- Babies ≥700g are eligible for NCPAP ± surfactant
- Babies < 700g discuss with senior if eligible for NCPAP
Eye checks for retinopathy of prematurity
Who:
- All babies gestation < 32 weeks or <1500 g at birth
When:
- If gestation <28 weeks then first check at 31 weeks corrected age Gestation 28-32 weeks first check after 4 weeks
- Repeat eye check every week or fortnight as requested by the ophthalmologist
How:
- Identify babies for check on Fridays. Complete the ROP forms as well as the eye-drop forms (cyclomydril) and ensure drops are instilled early on Friday morning
- Attach the forms to the front of the crib/ incubator. Call the ophthalmologist to confirm numbers of patients. Leave list on the notice board in Ward 16B
If babies have not had an eye check by the time of discharge, they should be referred to the Helen Joseph Hospital Eye Clinic on a Monday at 08:00 (a booking is not necessary).
Discharge
When to discharge:
- VLBW (<1500g) infants must have gained weight to at least 1650g. If birthweight <1800g to have regained to birth weight.
- Taking full feeds from breast (preferably) or cup for 24 hours
- Maintaining temperature in crib for 24 hours
- Other therapy stopped except in special cases
- Coping in room air (except babies being discharged on home oxygen)
The following babies do not need follow-up:
- BW >1800g and no significant medical or social problems
- Term baby with brief admission to “rule out” sepsis which was negative
- Term or near-term babies with a diagnosis of TTN or congenital pneumonia
- Birth asphyxia with no hypoxic ischaemic encephalopathy (HIE) or mild Neonatal Encephalopathy (HIE 1)
- Term or near-term babies with ‘simple’ neonatal jaundice
Neonatal follow-up date:
- For general and development check @ 4-6 weeks after discharge
- Sooner in specific cases e.g. for haemolytic jaundice: anaemia check in 1-2 weeks
Eye check for ROP:
- If eye check required, and not done during admission, refer according to guidelines in section on eye checks
Cranial ultrasound:
All babies of BW<1500g or <32 weeks, or with suspected neurological problems, should have cranial ultrasounds. This should include a late ultrasound at 36 weeks corrected age/discharge to exclude periventricular leukomalacia. Sonars should be performed more regularly if evolving pathology is suspected. Please ensure that a late ultrasound is done prior to discharge. These are done by the neonatal consultants.
Vitamin and other Supplements:
Continue Abidec, vitamin D and iron supplements on discharge.
Summaries and stats meetings
The discharge summary as well as the RedCap form gets updated and completed at discharge or when a baby is transferred to general paeds (ward 1) or to another facility. Please note the discharge weight on the discharge summary as well as outstanding blood results with barcodes. The RedCap forms (from discharges) are checked every afternoon by the intern and consultant assigned to stats and then handed to our data-capturer to enter on the neonatal database. A PPIP form (and the RedCap form) must be completed for every death and handed to the consultant in the unit. Neonatal stats and deaths get discussed at the neonatal M&M meeting every 3rd Tuesday of the month.
Neonatal follow-up (NNFU)
Consultant/Reg to see if there is a high likelihood of neuro-developmental delay e.g.:
- All ventilated babies
- Moderate to severe neonatal encephalopathy
- IVH grade 3 or 4
- Peri-ventricular leukomalacia (PVL)
- BW<1200g
- Symptomatic hypoglycaemia
- Neonatal convulsions
Consultant to see other unusual cases e.g. uncommon dysmorphic syndromes, obstructive jaundice, baby on home O2 etc.
Developmental assessment (physiotherapist or occupational therapist):
All babies with a high risk of neuro-developmental problems (as above) should be referred early for neuro- developmental assessment. Other babies with developmental delay (for corrected age) or abnormal neurological signs should be referred to a physiotherapist or occupational therapist for developmental assessment.
Hearing test:
Required for most babies, as per referral form – usually booked from NNFU.
Growth:
Plot growth charts. In the first few months of life preterm infants should gain weight at 150-250g/week and the head circumference should grow by about 0.5-1 cm/week.
Supplements:
Please continue Abidec, Vit D and Iron supplements up to at least 6-12 months of life.
Postnatal wards
Routine baby checks are done by the midwives. However, it is our responsibility to check any baby they are concerned about, in addition to the babies we see for complicated births (instrumental deliveries, caesareans, premature births etc.). We can expect to be called for all:
- Babies of Rh negative mothers. Cord blood should have been sent for Blood Group and Coombs by the obstetric or nursing staff. If not please do bloods
- Babies of RPR positive mothers
- Babies with low dextrostix
- Jaundiced infants. Ensure the SBR result is always obtained within a few hours. If jaundice looks severe, start phototherapy immediately while awaiting result
- Problems they think need a paediatric review
- LBW (<2500g) babies should be observed for 48-72 hours. Make sure they are establishing feeds, maintaining temperature, glucose and are not jaundiced
Rahima Moosa Mother and Child Hospital - Neonatal Care Handbook 2023; What to do for admission, discharge and follow-up; Admissions, Care of babies <900g birth weight, Eye checks for retinopathy of prematurity, Discharge, Summaries and stats meeting, Neonatal follow-up (NNFU), Postnatal wards
Last checked for updates: January 2024