Chapter 1: Organisation of neonatal care
Web-based resources written by: HEATHER MAXWELL & LISA KAISER

Case Study 1: The 27-week infant in a LNU

You have just commenced your shift at your unit, which is a level 2 local neonatal unit (LNU). Dylan, the baby you have been allocated today, was born only 2 hours before at 27 weeks gestation, weighing 1085grams. He was delivered via emergency C-section due to concerns about foetal wellbeing. Having received surfactant in the delivery room, he is now stable on CPAP with acceptable blood gases. His other parameters are satisfactory. Dylan is receiving parenteral nutrition (PN) via an umbilical venous catheter.

Question 1

Which care category does Dylan fall under in accordance with BAPM guidelines? Is it suitable for him to be cared for on your unit in the longer term – what is the rationale behind your answer?

Intensive Care (IC). It is unlikely that he can be cared for in the LNU longer term – Dylan will quite probably require non-invasive respiratory support for a number of days and establishment of enteral feeds will be slow, meaning he has a continued need for PN. This is therefore not considered ‘short-term’ IC, which would be appropriate for a level 2 LNU.

Question 2

What does the nurse in charge have to consider with regards to distribution of the workload amongst staff, and whom she allocates to look after Dylan?

Dylan should be cared for by one nurse with no other responsibilities, and this nurse has to be qualified-in specialty (QIS), or be supervised by a QIS nurse while working towards this qualification.

The decision is made for Dylan to be transferred to a level 3 Neonatal Intensive Care Unit (NICU) for his ongoing care.

Question 3

How would you prepare for Dylan’s transfer? Who needs to be contacted to facilitate this happening?

On an organisational level, the regional level 3 NICU needs to be contacted, to establish whether there is cot and staffing capacity for Dylan’s ongoing care. Once a cot has been identified, Dylan needs to be referred to the neonatal transfer team. Dylan’s parents need to be kept fully up to date with any change in his care. They should, ideally, have been made aware of the possibility that he may require care in a NICU antenatally. It is particularly crucial to keep them closely informed of any events around the transfer, i.e. arrival of the team; and to ensure that both parents have an opportunity to see and touch Dylan prior to his departure. Liaise closely with the midwifery team for this purpose. From an administrative perspective, the relevant nursing and medical documentation, such as discharge letters, photocopies of drug charts etc., needs to be prepared ready for Dylan’s transfer. See also the information for Chapter 22 on neonatal transportation.

Case Study 2: The journey of an extremely preterm infant transferred ex utero

Pavneet was born unexpectedly at 23+2 weeks gestation without having received antenatal corticosteroids. The level 1 Special care Unit (SCU) at her mother Rashmi’s booking hospital stabilised Pavneet and had her transferred to the regional level 3 NICU.

Question 1

Could anything have been done to prevent Pavneet being delivered in an inappropriate setting for her care requirements?

Unlikely in this case, as it sounds as though Rashmi’s labour was too advanced for her to be safely transferred to a hospital with a level 3 NICU. However, the aim is for all infants to be born in settings appropriate for their care needs. Individuals of the neonatal team can contribute towards this happening by liaising closely with the obstetric team, so that discussions with a tertiary centre can take place early, and transfer organised if possible. Refer to the NICE Quality statement on neonatal specialist care for benchmarking indicators including transfer and parental involvement in decision-making.

Pavneet is now nine weeks old and has multiple problems: she is still requiring humidified high-flow nasal cannula (HHFNC) oxygen, has suffered significant intraventricular haemorrhages likely to affect her long-term neurodevelopment, and is failing to thrive with her current weight on the 0.4th percentile. However, as Pavneet is now stable, there is a plan to transfer her back to the SCU at her booking hospital. Rashmi and her husband Manjunath are feeling extremely anxious about this and expresses a wish for Pavneet to remain on the NICU instead.

Question 2

In your opinion, is it appropriate for Pavneet to be repatriated to her local SCU, considering the level of care she is now receiving?

Pavneet is receiving HD care by definition, and SCUs would not routinely provide longer-term HD care. Also, Pavneet belongs to a very vulnerable patient group and is at risk of developing further complications throughout her NNU stay, such as infections, which may result in clinical deterioration. While some SCUs in the UK may look after babies like Pavneet, these factors need to be considered and contingency plans put in place, should she go on to again require a higher level of care.

Question 3

How would you approach a conversation with Rashmi? Do you think it would be feasible for Pavneet to be discharged from the NICU instead of her booking hospital’s SCU?

Rashmi’s feelings are shared by many parents whose babies have required IC. The transition from one NNU to another is often very difficult for families, as they must leave behind an environment they have grown used to, with staff they have got to know and trust. Sadly, as there are usually very high demands on level 3 NICUs within neonatal networks, it is rarely feasible for parents to make the choice of their baby remaining there. There are also practical aspects to be considered: often, the NICU may be many miles from a family’s home, so that it really would not be feasible for the NICU graduate to receive their follow-up and ongoing care there. Pavneet may very well still require oxygen following discharge home and will therefore need to be supported by her local community services. Should she become unwell at home, she will be looked after within the paediatric services at her local hospital. All these factors mean that it is not only sensible for her to spend time in her booking hospital’s SCU prior to discharge home, but it will be very useful for her local medical and nursing teams to be able to familiarise themselves with Pavneet’s history and establish a relationship of trust with her parents.

All this needs to be explained to Rashmi and Manjunath in a sensitive manner, as often parents express feelings of ‘being abandoned’ by the NICU team in these situations. Conversations about this should start early, so that the proposal of a repatriation does not come as a shock to Pavneet’s family. Facilitating a visit to the local unit so families can get to know the staff and environment prior to the baby being transferred back can help with this.

Question 4

What are your considerations for Pavneet’s ongoing care? Which members of the multidisciplinary team will most likely need to be involved?

Pavneet will likely benefit from input from physiotherapists, speech and language therapists and dietetics. Ideally this should continue once she is back at her local hospital. Rashmi and her husband will undoubtedly require psychological support to cope with the transition from the NICU to the SCU, as well as post-traumatic stress symptoms they may experience as a result of their and Pavneet’s NICU journey. There are still inequalities with regards to neonatal care provision, so it is important to ensure each baby has access to the facilities and specialties he or she requires.

Chapter 2: Assessment of the neonate
Chapter written by: LINDA MCDONALD & LISA KAISER
Web-based resources written by: LINDA MCDONALD

Case study 1: Term baby with respiratory distress

Archie has been admitted from the postnatal ward with tachypnoea and grunting. You are asked to undertake an initial assessment.

Question 1

What are your immediate steps, and which investigations would you like to do?

Commence assessment using the look - listen - feel approach.
Look for: work of breathing including recessions, rate of respiration, heart rate, saturations etc.
Listen for: Air entry in upper and lower lung lobes. Is it bilateral or unequal? Airway noises such as crepitations/crackles/stridor/grunting etc. and note where and when these take place (on inhalation or exhalation). Grunting is heard on exhalation.
Feel: central and peripheral temperature. Consider the metabolic triangle and remember that hypothermia may exacerbate respiratory distress. Hyperthermia may be environmental or a sign of infection.
Investigations: Undertake and compare vital signs to the parameters listed in the chapter of this book documenting any anomalies. Consider taking a blood gas and blood sugar. Further investigations including a CXR and laboratory bloods (full blood count, CRP, blood culture).

Question 2

What would you like to know about Archie’s history?

Gestational age, weight, concerns during labour (e.g. decelerations on CTG), mode of delivery, presentation at birth, condition at birth, need for resuscitation, any underlying conditions or pathologies noted antenatally; information about general wellbeing/behaviour since birth, feeding history, observations if done; risk factors for infection.

Question 3

Can you think of any aspects of Archie’s Mum’s history that may be important to know?

Age, weight, culture, previous pregnancies, medical conditions, medications, substance misuse, blood group, social concerns, health during pregnancy, type of labour, drugs given during labour and/or delivery, placental complications etc.

Question 4

What could be the possible causes for Archie’s presentation?

Differential diagnosis may include TTN (transient tachypnoea of the newborn), RDS (Respiratory Distress Syndrome), infection, anatomical anomalies e.g. diaphragmatic hernia, oesophageal atresia, meconium aspiration, shoulder dystocia resulting in a hypoxic-ischaemic event, air leak, congenital cardiac anomaly, hypothermia.

Case study 2: Distended abdomen

Amy was born at 27 weeks and is now 3 days old. She developed a distended abdomen today.

Question 1

What information would you like to know from Amy’s history?

Maternal history? Reason for preterm delivery? Any physical anomalies on antenatal scans? Type of delivery? Condition at birth? Resuscitation required? Any asphyxia? Any other problems aside from prematurity e.g. hypotension/hypoglycaemia/respiratory distress. Previous treatment required such as ventilation, medications, antibiotics, blood transfusions?

Question 2

What information would you like to know about Amy’s current care?

Current problems using systems assessment and current treatment such as ventilation, medications, antibiotics. Consider nutrition: has she been fed and if so what type of milk and how much? Any vomiting or gastric aspirates such as amount and colour (bile stained?). Has she passed urine and had her bowels open and if so any blood in the stool? Has she had an abdominal X-ray? Blood gases including raised lactate? Blood results including urea, creatinine and infection markers such as CRP, platelet count and/or raised white cell count.

Question 3

Using the vital signs parameters and a look, listen and feel approach, how would you undertake a physical assessment of Amy?

Vital signs assessment: are they within normal limits, are there variations outside the normal range, particularly considering signs of infection such as temperature instability/toe core gap/ desaturations or apnoeas/ blood pressure. Is the baby appropriately active or unresponsive.
Look: Begin by looking at abdomen appearance, size (swollen or bloated?), colour (pink, pale, dark, mottled, shiny, visible loops?) Look at other abnormal signs such as increased work of breathing or pain.
Listen: air entry/ heart sounds (murmurs)/ can active bowel sounds be heard?
Feel: Temperature (hot, cold, warm), capillary refill time (CRT) ideally <2-3 seconds, to assess for perfusion. If the abdomen is large does it feel tense or is it soft and non-tender? What is Amy’s response to be handled? Is it well tolerated or a source of pain or apnoeas?

Question 4

Reviewing the information you have collected, list possible causes (differential diagnoses) for Amy's distended abdomen?

Physical anomaly: e.g. duodenal atresia, imperforate anus, Hirschsprung’s disease, meconium ileus.
Viral or Bacterial infection: Necrotising enterocolitis or early onset infection commonly caused by E. coli or group B streptococcus (GBS).
Cardiac: e.g. Patent Ductus Arteriosus (PDA) may affect adequate blood flow to the gut, as may hypotension.
Respiratory illness: may influence oxygen delivery to the premature, underdeveloped gut which limits normal function including peristalsis.

Chapter 3: The premature and low birthweight infant
Web-based resources written by: LISA KAISER & JULIA PETTY

Case Study 1: Impending birth of a preterm infant

Labour ward has contacted your unit to alert them to a new admission. Leonora is a 26-year-old primigravida who is 27 weeks pregnant and has attended the assessment unit with ruptured membranes and tightenings.

Question 1

What else would you like to know at this stage?

Has she received antenatal steroids? Has she been commenced on magnesium sulphate (MgSO4) and antibiotics? Are there any other health concerns at present (infection, PET…)? Have there been any concerns about the baby during her pregnancy? Has Leonora got anybody with her for support?

Question 2

Leonora is not able to attend the NNU for a look around, so you go and speak to her on labour ward. What information does Leonora require at this stage? Is there anything in particular you would like to discuss with her?

Discuss the actual delivery – the number of staff likely to be present, that her baby will likely be transferred to the resuscitaire quickly; potential modes of respiratory support required, and that she will get to see her baby prior to transfer to the neonatal unit (NNU).

Prepare Leonora for the ITU/HDU environment, consider talking about respiratory support, intravenous feeding, lines, antibiotics, monitoring. Discuss the vital importance of expressing breastmilk, even if breastfeeding is not Leonora’s primary feeding choice, and why this is important.

It is likely that you will be accompanying a senior member of the medical team for an antenatal counselling scenario such as this. However, it is good for you to consider important points to be covered, and you can add some valuable information for the parents from a nursing perspective; such as explaining your local visiting policy, encouraging parents to visit their baby, process of expressing breastmilk/donor breastmilk depending on your unit policy, etc. Bear in mind that all this information will be a lot for them to take in, so it may be necessary to keep the conversation short and aim for a repeat visit at another time, if possible. Try to be reassuring.

Leonora’s labour is progressing rapidly. She is expected to deliver within the next 30 minutes but has only received one dose of corticosteroids 2 hours ago. Magnesium sulphate was commenced soon after admission.

Question 3

Consider the prematurity-associated problems Leonora’s baby is likely to encounter, both based on gestation and antenatal events. How can you contribute to their early recognition and minimisation of their impact on outcomes in the short term and long term?

  • Hypothermia – adequate management of the delivery environment (temperature) and measures to avoid hypothermia (transwarmer, plastic bag/wrap, radiant heat). Transfer to NNU under a radiant heat source, or in a transport incubator.
  • RDS (respiratory distress syndrome = surfactant insufficiency) – depending on baby’s condition and respiratory effort at birth, he or she may receive surfactant in the delivery room or not. If managed on non-invasive ventilation, ensure very close observation for signs of RDS – blood gases, work of breathing, O2 requirements, with timely intervention if signs of deterioration present.
  • Observe for necrotising enterocolitis (NEC) – not in the very early period, but once enteral feeds are introduced, this needs to be very closely monitored for. Enteral feeds should be commenced as early as possible following birth, so that Leonora should have been counselled on expressing antenatally, to start this as soon as possible. Formula milk should be avoided. Signs of NEC/feed intolerance – abdominal distension, green aspirates, increased apnoeas/bradycardias/desaturations, abnormal colour (pallor/mottling)
  • Intraventricular haemorrhage (IVH) – Close monitoring of all parameters. Prompt response to hypotension (request medical review), action blood gases, oxygenation. Cord milking/delayed clamping at delivery
  • Infection – Particularly while Leonora’s baby has indwelling central lines whilst establishing full enteral feeds, he or she will be at increased risk of infection. Signs of infection are largely the same as those for NEC – see chapter 18 information on neonatal infection.
  • Retinopathy of prematurity (ROP): This condition is most common in infants born under 28-32 weeks gestation and a birthweight of <1.5 kg who have received oxygen therapy in their early life. Certain criteria are in place for screening for ROP which will identify the presence of the disease according to 5 stages: see the RCPCH Guidance.  For a clear overview including illustrations, see the RNIB webpage on ROP. It is important to keep oxygen to a minimum for premature infants and avoid sudden swings in oxygenation. The first ROP screening examination should be undertaken between 4 to 5 weeks (i.e. 28-35 days) postnatal age. Treatment and outcomes will depend on the grade of ROP and the zone in which it occurs. Again refer to the guidance here and in further resources.
  • Consider other conditions of prematurity: Apnoea of prematurity, Anaemia of prematurity, and refer to other chapters of the book and web-site that deal with other conditions in greater depth.

Case study 2: Management of an IUGR infant

Sarah is a 34-week gestation infant born via normal vaginal delivery with a birth weight of 1.1kg. Her mother Angela had been well throughout her pregnancy with the exception of pregnancy-induced hypertension (PIH) from 26 weeks’ gestation, for which she was treated with labetalol. Foetal growth began to slow from 28 weeks’ gestation. This was noted to be static in the week prior to delivery, with normal diastolic flow noted on ultrasound. There were no risk factors for sepsis identified. Sarah’s mother wishes to breast feed.

Question 1

What could be potential causes for Sarah’s poor growth?

Most likely the PIH, but other possibilities need to be considered – is Mum a smoker? Are there any underlying genetic abnormalities affecting Sarah’s growth? TORCH infections? Constitutional (size of Sarah’s parents)?

Question 2

How would Sarah’s care differ from infants at 34 weeks who are born at an appropriate weight for gestational age?

Sarah’s care needs to be addressed more like that of a preterm rather than that of a term baby – consider thermoregulation, metabolic adaptation, immature behaviour (i.e. feeding) – so will likely require an incubator/hot cot, close blood glucose monitoring, NGT feeds with good breastfeeding support to ensure adequacy of her latch suck etc.

Question 3

What are your thoughts about Angela’s wish to exclusively breastfeed Sarah? Will this be feasible?

Breastmilk would be an appropriate feeding choice for Sarah, however Angela’s expectations need to be managed with regards to Sarah’s immediate ability to breastfeed. This will take time to establish. Furthermore, Sarah has a requirement for catch-up growth – she may even require PN based on her birthweight and depending on how well she tolerates enteral feeds. Breastmilk fortification may also be required, and depending on her growth velocity postnatally, her nutrition may have to be actively managed – consider dietetic input if any concerns are identified.

Case study 3: At the borderline of viability

Alice is a 42-year-old woman who was admitted to labour ward with abdominal pain at 22+5 weeks gestation. She is a ‘gravida 4, para 0+2’, having had 2 early miscarriages and 2 extremely preterm babies, both of whom survived less than 24 hours. This pregnancy is the result of in vitro fertilisation using a donor egg. On admission Alice is assessed to be in established labour. Alice and her partner Liam agree that they would like the neonatal team to attempt full resuscitation following delivery.

Question 1

What are your thoughts about Alice’s and Liam’s wishes? Do you think this is in the best interest of their baby?

This is an ethical dilemma. On the one hand, the parents’ views should be respected, and they must be listened to / involved in the decision-making about the best course of action for their baby. On the other hand, the baby's best interests must also be closely considered in view of their gestation & extreme immaturity and potential outcome / chances of significant long-term problems. The question of administering prolonged, invasive procedures on a baby so immature must also be factored into the decision-making and discussions about their best interest as to whether this would cause the baby to suffer; hence futile. There is no right or wrong with such a case and this will be viewed on an individual basis depending, in the first instance, on the baby’s condition at birth. Refer to Chapter 9: Legal and Ethical issues in neonatal care.

Question 2

Using one or more available prognostic tools, try and establish their baby’s prognosis for survival and long-term outcomes. How would you counsel Alice and Liam?

Specific factors are associated with improved outcomes in premature infants such as surfactant administration, antenatal steroids, magnesium sulphate in the perinatal period. In relation to factors associated with poor outcomes, early gestational age and birth weight are significant predictors of poor long-term neurological outcome. Structural changes of the brain, infection, male gender and neonatal intensive care unit course are also important factors affecting eventual outcome. Other complex biological and socio-economic factors, which extend from prenatal through postnatal periods, also affect the trajectory of brain development in preterm infants. See the paper by Glass et al (2015) for a summary of factors affecting outcome.

Prognostic tools have been researched – i.e. refer to specific papers in the Further resources and the Epicure study / web-site- such work has looked at data collected from large, multicenter studies / audits. The lead consultant will lead the discussion with parents about future outcomes, but nurses should be part of the meeting and be there to advocate and support the parents and to reinforce any information during and after any meeting with them. The parents can be shown outcome figures and survival data as long as this does not dominate the discussion and their views are taken on board compassionately and empathically.

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Open-access articles

Benzies, K. M., Magill-Evans, J. E., Hayden, K. A., & Ballantyne, M. (2013). Key components of early intervention programs for preterm infants and their parents: a systematic review and meta-analysis BMC pregnancy and childbirth, 13 Suppl 1(Suppl 1), S10. doi:10.1186/1471-2393-13-S1-S10

Chollat, C., Sentilhes, L., & Marret, S. (2018). Fetal Neuroprotection by Magnesium Sulfate: From Translational Research to Clinical Application Frontiers in Neurology, 9, 247. doi:10.3389/fneur.2018.00247

Dal’Assta et al (2017) Early onset fetal growth restriction Maternal Health, Neonatology and Perinatology2017 3:2 

Daly, M (2019) Parental perspective on neonatal outcomes. BMJ Paediatics Open.

Eichenwald, EC (2016) Apnea of Prematurity. Pediatrics, 31, 1

Glass, H. C., Costarino, A. T., Stayer, S. A., Brett, C. M., Cladis, F., & Davis, P. J. (2015). Outcomes for extremely premature infants Anesthesia and analgesia, 120(6), 1337–1351. doi:10.1213/ANE.0000000000000705

Sharma, D., Shastri, S., & Sharma, P. (2016). Intrauterine Growth Restriction: Antenatal and Postnatal Aspects. Clinical medicine insights. Pediatrics, 10, 67–83. doi:10.4137/CMPed.S40070

Strauss R. G. (2010). Anaemia of prematurity: pathophysiology and treatment Blood Reviews, 24(6), 221–225. doi:10.1016/j.blre.2010.08.001

Wen J. Ge, MSc,a,b Lucia Mirea, PhD,a,b Junmin Yang, MSc,a Kate L. Bassil, PhD,a,b Shoo K. Lee, MD, PhD,a,c and Prakeshkumar S. Shah, MD, MSc,a,c on behalf of the Canadian Neonatal Network (2013). Prediction of Neonatal Outcomes in Extremely
Preterm Neonates. Pediatrics. 132(4), e876-e885

Wolf HT, Huusom L, Weber T and the EPICE Research Group, et al
Use of magnesium sulfate before 32 weeks of gestation: a European population-based cohort study. BMJ Open 2017;7:e013952. doi: 10.1136/bmjopen-2016-013952

Zhao, J., Gonzalez, F., & Mu, D. (2011). Apnea of prematurity: from cause to treatment. European Journal of Pediatrics, 170(9), 1097–1105. doi:10.1007/s00431-011-1409-6

Web-based resources

Chapter 4: Nurturing supportive family and infant relationships in the neonatal environment
Chapter written by: LIZ CRATHERN
Web-based resources written by: JULIA PETTY AND LIZ CRATHERN

Case study 1: Addressing family challenges

Olive has been delivered at 26 weeks gestation by vaginal delivery, first baby to a young mother Eve who is 18 years old. Eve’s partner, Tom, is away on military duties as he is in the army and is not returning home for another 3 weeks. Eve’s mother is present with her. Olive is admitted to intensive care and placed within an incubator onto bi-level continuous positive airway pressure after a brief period of ventilation but remains unstable and her oxygen requirement is 50%. She is currently 20 hours old.

With reference to the key points within the chapter, consider the following questions:

Question 1

What are the possible challenges and emotions that Eve and her mother are likely to be experiencing?

Anxiety, worry, feeling scared and stressed about the early and unexpected birth of the baby and how unwell / unstable she is. Discomfort and stress caused by separation from barriers to bonding and the unfamiliar neonatal environment. Eve’s partner is away so no support is available from him.

Question 2

What early nursing interventions are required so that Eve can experience bonding with her daughter?

Encourage Eve to touch her baby, ensure she is able to stay with her baby next to the incubator, encourage closeness / proximity, skin-to-skin. These open access papers by Flacking et al (2012) and Flacking et al (2016) outline the importance of ensuring emotional closeness. Give clear and timely information about the baby and the care that is required. Communication is essential with parents in the neonatal unit to ensure their experience is a more positive one as highlighted in these open access papers by van de Vijver and Evans (2015) and Wigert et al (2014).

When Olive is 2 weeks old, she develops a suspected bowel obstruction and experiences complications with her respiratory status requiring referral and transfer to a tertiary centre for further management

Question 3

How will this situation impact on the emotional well-being of Olive and her family?

Further emotions are likely to be exhibited, as described previously. The uncertain outcome will now be an additional and significant source of stress and anxiety. The upheaval is further added to by transfer of the baby to another hospital leading to increased unfamiliarity and uncertainty.

Question 4

Again, what strategies can be employed to enhance the well-being of Olive and Eve, including psycho-emotional and practical considerations?

Open and honest communication, regular updates, inclusion and encouragement of participation in care and decision-making, involvement of the wider family, referral to support / peer groups and other members of the multi-disciplinary team such as feeding specialist, psychologists if available. Provision of skin to skin and support with expressing breast milk. Provision of practical and financial support and advice. Read these open access papers for more information on key strategies to enhance emotional wellbeing: Fowler et al (2019)O’Brien et al (2013).

After a 3-week period in the receiving neonatal unit, Olive is transferred back to her referring unit and plans are commenced to work towards discharge home.

Question 5

What factors need to be considered when planning discharge for this family and what strategies are needed for the transition home to go smoothly?

Early planning for discharge and sign-posting to support networks and groups as appropriate. Education of Eve and her mother regarding caring for Olive at home – skills based (e.g. feeding, oxygen therapy if appropriate), liaison with community health professionals / outreach / health visitors to ensure communication is filtered to all essential members of staff who will support the family.

Case study 2: Cultural considerations

Amar and Fatima are married parents who have recently arrived in the UK from Pakistan with their three children, all girls aged 18 months, three and eight years old. They speak Bengali and only Amar has some very basic, rudimentary English. Soon after arrival to the country, Fatima went into premature labour at 23 weeks + 5 days and delivered a baby boy called Asif. He is currently 6 hours old and is fully ventilated with a high oxygen requirement. Fatima suffered an antepartum bleed during labour and is still in the delivery suite. Amar has just arrived at the neonatal unit to visit his son and is very distressed. They have no other family in the UK and are practicing Muslims.

With reference to the key points within the chapter, consider the following questions:

Question 1

What are the immediate challenges faced by these parents?

The parents are new to the country and so unfamiliar with the language and the care setting plus the early, sudden delivery of their baby is an unexpected situation. Fatima is also unwell and unable to be with her baby on admission leaving Amar to cope with seeing his baby born so early and small. There are also other children in the family to support and care for.

Question 2

What strategies should be put in place to reduce the father’s anxiety?

Give him essential information about his baby and enable him to be at the bedside. Explanations using an interpreter if available. Contact the family’s Imam to provide support and / or the hospital chaplaincy staff.

Fatima finally is able to visit Asif later that day.

Question 3

What strategies should be put in place to enable her to bond with her son?

Assist Fatima to touch or hold her baby as appropriate and provide early support for expressing her breast-milk if she wishes to. Support her to provide care as tolerated for her baby such as mouth care.

Question 4

What cultural issues need considering? How would you integrate these into your care?

Ensure any cultural and spiritual considerations relevant to the Muslim faith are factored into care planning and provision. Enable parents to leave any religious symbols with the baby. Liaise with the Imam and chaplaincy. Ensure information is clear and able to be understood / translated as appropriate. Overall, ensure culturally appropriate / competent care.

Question 5

How can the staff support the whole family during this time?

Provision of family- centered and/or family integrated care depending on the family’s wishes. Fatima may need to be at home after her own discharge with the other children and so may not be able to stay on the neonatal unit for the entire duration of Asif’s stay - consider this in relation to her involvement. Encourage siblings to visit and involve them in information giving.

Case study 3: A father’s story

Read the extract below about a father’s experience and with reference to the key points within the chapter and consider the task that follows.

Jack was twenty-two years old and lived with his partner Rose at his parents’ home whilst they were decorating their new home in preparation for the new arrival. They were both first time parents. Jack worked full time. He had no prior experience of hospitals. Jack is now the father of a baby boy called Henry who was born 5 weeks early at 35 weeks gestation by normal delivery weighing 2.75 kgs. The experience of transition to fatherhood in this situation was very traumatic for Jack, it was not a nice experience, an unanticipated event and not what he was expecting or prepared for; consequently, this was a major disruption in his life. His newborn son Henry was whisked away to the neonatal unit immediately, the neonatal staff briefly telling Jack and Rose that their baby was fine. Having had no communication from the midwifery or neonatal staff for three hours he spent his time during and after the delivery in a kind of limbo, a not knowing period. This was very stressful for Jack, a first-time father, as he tried to be a comfort and support for Rose. He was concerned about revealing his emotions to Rose and at the same time he says he felt "scared as hell" inside, worrying about his son Henry, trying not to think the worst but also trying to prepare for the fact that he might die. No one had told him where he could find his son and not knowing the hospital layout this was an additional stress. He described the whole labour experience as “going from the best day to the worst day of my life in hours”.

Going to visit Henry in NICU was equally traumatic, walking into the room and seeing tubes, wires and machinery around his infant son was scary. He said the next few hours were all a blur and he couldn’t remember anything the staff had told him. He does remember feeling angry at that point, feeling helpless, willing the staff to do something to save his son.


Identify the key issues and strategies you would employ in this situation. What potential situations may occur that might mean you will need to revise your plan?

It is well documented that fathers may not receive the same attention and support as mothers and are not included in care as much. Ensure that psychological support is offered, and that Jack is involved in his baby’s care, giving him clear explanations about progress and outcomes along with any interventions that are required by Henry. Encourage him to meet other parents / fathers for peer support. Reassure him that the feelings he is experiencing are normal and to be expected. Involve him in care and decision-making ensuring his voice is heard / considered by the care team.

Use the words in the list below to complete the sentence





staff education and support

parent education

Neonatal unit environment

psychological support

Family Integrated Care programme

post traumatic stress disorders






Open access articles

Flacking, R., Thomson, G., & Axelin, A. (2016). Pathways to emotional closeness in neonatal units - a cross-national qualitative study. BMC Pregnancy and Childbirth16(1), 170. doi:10.1186/s12884-016-0955-3

Fowler, C, Green, J, Elliot, D, Whiting, L and Petty, J (2019). The forgotten mothers of extremely preterm babies: need for increased psychosocial support. Journal of Clinical Nursing.

O’Brien, K., Bracht, M., Macdonell, K., McBride, T., Robson, K., O’Leary, L., ... & Lee, S. K. (2013). A pilot cohort analytic study of Family Integrated Care in a Canadian neonatal intensive care unit. BMC Pregnancy and Childbirth13(1), S12.

Petty, J, Whiting, L., Green, J., Fowler, C., Rossiter, C. & Elliott, D. (2018). Parents’ views on preparation to care for extremely premature infants at home. Nursing Children and Young People. 30(4), 22-27  

Russell, G. M., Sawyer, A., Rabe, H., Abbott, J., Gyte, G., Duley, L., Ayers, S. and Very Preterm Birth Qualitative Collaborative Group. (2014). Parents' views on care of their very premature babies in neonatal intensive care units: a qualitative study. BMC Pediatrics, 14(1), 230

Stefana A, Lavelli M (2017). Parental engagement and early interactions with preterm infants during the stay in the neonatal intensive care unit: protocol of a mixed-method and longitudinal study BMJ Open 2017;7:e013824. doi: 10.1136/bmjopen-2016-013824

Wigert, H., Blom, M. D., & Bry, K. (2014). Parents’ experiences of communication with
neonatal intensive-care unit staff: an interview study. BMC Pediatrics, 14(1), 304.

Web-based resources

BLISS offers support for premature and sick babies across the UK. The website includes a specific section for parents including information about local support groups; downloadable information leaflets relating to specific conditions and treatment; a message board for parents’ questions; parents stories. There is also a helpline available for parents. Parent stories are also available BLISS Parent stories   

Contact a family This charity offers, via its website, advice,
information and support to families of disabled children. This includes a free helpline,
understanding the benefits system and accessing the right educational support.

SCOPE SCOPE will offer support and advice for families with a child with cerebral palsy, helping to identify and address barriers to inclusion.

The Fatherhood Institute This is a charity aiming to engage fathers in the lives of children, to promote an inclusive approach to family policies through the encouragement of father-focused research. The website includes help and advice for all fathers and provides specific information, for example, for young fathers, parenting education, vulnerable families, Muslim fathers.

Stories from the Neonatal Unit- a website that focuses on digital stories from the narratives of parents

Chapter 5: Developmentally Focused Nursing Care
Chapter updated by: ALISON O’DOHERTY
Web-based resources written by: JULIA PETTY

Case study 1: Two-day old premature baby

Jacob is a 2-day old baby boy born at 24 weeks gestation. Following a traumatic delivery requiring resuscitation, he is fully ventilated within a humidified incubator and is also being monitored by ECG, pulse oximetry and arterial line blood gas analysis. He also has an intravenous long-line in-situ for nutrition and drugs.

Question 1

Firstly, consider the foetal environment: the consistent temperature, gravitational support and containment, attenuated light and sound, and nutritional, hormonal and psychological influences. Now consider the postnatal environment that Jacob was born into and his early care in the first few hours. How has this affected him and how would you manage the neonatal environment?

The postnatal surroundings pose a harsher and less protective environment to an infant who is born too soon and therefore more vulnerable to stressors such as loud noises, light, cold air and other disturbances. Small, preterm babies can show stress signs in such an environment. High levels of sound in the neonatal unit may lead to sleep disturbance, and induce physiological instability in infants, including fluctuations in heart rate, blood pressure, perfusion and oxygen saturation, increases in intracranial pressure, and alterations in corticosteroid level. One study also reports on the impact on oral feeding. Optimum environmental care should be undertaken which includes provision of a quiet, dimmed and calm room and the avoidance of stress – read a summary of management here.

As someone who is looking after Jacob and his parents, you watch him for a while and note the following…...You note an infant in light sleep who, upon handling, immediately becomes hyper-alert and agitated with extensor postures and ‘panicked’ facial expression. You also note the difficulty in achieving a quiet, alert state with responsive and animated facial expression. You have the additional problem of being unable to detect distinct states due to the infant’s immature behaviours and the environment in which the infant is nursed in. With reference to the key points within the chapter, consider the following questions:

Question 2

What do you notice about Jacob’s behaviour?

This is a picture of infant stress; what is noticed are key ‘cues’ of behaviour. Preterm infants born early with immature neurological functioning may live in the neonatal intensive care unit (NICU) for an extended period of time. From birth on, these infants face a series of challenges in various areas of development. One of the major challenges in the first months of life is state organisation, the development of integrated and coordinated patterns of sleep-wake states. Read a summary of behavioural state development in the preterm infant.

Question 3

How would you explain this to the parents and how would you work with the parents to address the behaviours?

It is vital to perform ‘cue-based’ care. Read the paper by Altimier and Phillips (2016) for an excellent summary of how to integrate the parents/ family into delivering optimum developmental care. This demonstrates how family-integrated, neuroprotective, developmentally supportive care includes creating a healing environment that manages stress and pain while offering a calming and soothing approach that keeps the whole family involved in the infant's care and development.

Question 4

What developmental care strategies could parents employ with your support, in this case, and why?

Developmental care is a broad category of interventions designed to minimise the stress of the neonatal unit environment. These interventions may include one or more elements such as control of external stimuli (vestibular, auditory, visual, tactile), clustering of nursing care activities, and positioning or swaddling of the preterm infant. Individual strategies have also been combined to form programs, such as the 'Neonatal Individualized Developmental Care and Assessment Program' (NIDCAP) The effects of light and sound (noise) levels on preterm infants have been studied extensively. It is generally accepted that a dimmer, quieter environment is important for the developing brain and modification of the environment could minimise the iatrogenic effects. Cue-based care is highlighted above as an important strategy for comfort and feeding. Minimal handling and responding to pain and stress signs is essential. The preterm infant should also be positioned appropriately with head in the midline and cushioned / nested so that boundaries are maintained, and the baby can use their immature limbs to push against. This will also facilitate optimum ventilation. Consideration of many factors is important.

Case Study 2: Three-week old premature twin boys

Sebastian and Paulo are 3-week-old twins who were born at 25 weeks gestation to Italian parents, visiting the UK on holiday. Sebastian has suffered a grade 2 bleed (IVH) on his left side but regardless of this, he has progressed well and has been taken off all forms of ventilatory support just requiring some low flow oxygen in the special care unit. Paulo however, has not progressed so well, had become septic and was re-ventilated after being on high flow oxygen therapy, currently being nursed in the intensive care unit. He has been diagnosed with a grade 2 and 3 bleed on the right and left sides respectively.

With reference to the key points within the chapter, consider the following questions:

Question 1

How would you work with the parents to manage this situation?

The same principles as highlighted for Care Study 2 apply here except this time, it is for both babies. Developmental care interventions should be individualised for each of the twins depending on their own cues and responses to stimulation / handling / interventions. Sebastian will be more able to tolerate stimulation than Paulo who still requires ventilatory support and is more unstable- however, key principles of family-integrated developmental care must be provided for both. The parents can be supported to work with their babies’ cues and can also be encouraged to provide positive touch and skin-to-skin contact if the conditions allow.

Question 2

What strategies are required for both infants to optimise their well-being and prevent any longer-term development problems?

Managing the environment is essential to avoid unnecessary stressors and supportive strategies such as optimum positioning and providing certain positive sensory experiences have been linked to improved outcomes for both infant and family. This integrative review by Pineda et al (2016) summarises many of the strategies that have been documented in recent research. This Summary Table is particularly useful. Finally, a comprehensive paper of core measures for developmental supportive care is provided by Coughlin et al (2009).

Question 3

What members of the neonatal multidisciplinary team should you involve to also work with the parents?

Neonatal nurses, medical staff, developmental care specialist if available, physiotherapist, occupational therapist, speech and language therapist, feeding support specialist, counsellor / family support.

Case Study 3: Eight-week old premature baby on a developmental care programme

Baby Callum was born at 23 weeks and is now 8 weeks old. After a very unstable few weeks, he is starting to show progress in all areas but remains oxygen dependent with difficulty tolerating his feeds. He has been reviewed by a developmental care specialist who is trained in ‘NIDCAP’. Along with the parents, they explain to you about the importance of observing the reactions of Callum in different environmental conditions. They also note the circumstance which supports his efforts to quieten and relax or reach alertness. They observe his behaviour during periods of high activity and note the stress responses as well as comparing their state system stability in relation to the environment of care.

With reference to the key points within the chapter, consider the following questions:

Question 1

What do these observations and explanations mean to you and why are they important for the infant and family?

These observations are important as part of NIDCAP which is the Newborn Individualised Developmental Care and Assessment Programme.As reported by Als and McNulty (2011), NIDCAP aims to prevent the iatrogenic sequelae of intensive care and to maintain the intimate connection between parent and infant. NIDCAP embeds the infant in the natural parent niche, avoids over-stimulation, stress, pain, and isolation while it supports self-regulation, competence, and goal orientation. Research demonstrates that NIDCAP improves brain development, functional competence, health, and life quality.

Question 2

How can you support the family during this current time in line with these types of observations?

Ensure that the principles of NIDCAP are applied to the care of infant and family and that any intervention is based on the assessment of the individual baby discussed and agreed with the family.

Question 3

What interventions are required, working towards discharge home, to minimise adverse outcomes?

Kangaroo care / skin-to-skin care, positive touch, optimum positioning, individualised cue-based care and feeding, appropriate sensory stimulation, minimal handling, involvement of the multidisciplinary team- refer to the strategies highlighted in Case Studies 1 and 2.

To start a quiz hover over it and click 'Launch'.
Once completed click to take the next quiz. Click Feedback to get an explanation of the answer (where applicable).

Fill in the Blanks - Use the words in the list below to complete the sentence





cue-based care


mental health

stress response




minimal handling





Open access articles

Als, H., & McAnulty, G. B. (2011). The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) with Kangaroo Mother Care (KMC): Comprehensive Care for Preterm Infants. Current Women's Health Reviews7(3), 288–301. doi:10.2174/157340411796355216

Als, H., Duffy, F. H., McAnulty, G., Butler, S. C., Lightbody, L., Kosta, S., … Warfield, S. K. (2012). NIDCAP improves brain function and structure in preterm infants with severe intrauterine growth restriction. Journal of Perinatology : official journal of the California Perinatal Association32(10), 797–803. doi:10.1038/jp.2011.201

Altimier, L., & Phillips, R. (2016). The neonatal integrative developmental care model: Advanced clinical applications of the seven core measures for neuroprotective family-centered developmental care. Newborn and infant nursing reviews16(4), 230-244.

Craig, J. W., Glick, C., Phillips, R., Hall, S. L., Smith, J., & Browne, J. (2015). Recommendations for involving the family in developmental care of the NICU baby. Journal of Perinatology35(S1), S5.

Coughlin, M., Gibbins, S., & Hoath, S. (2009). Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice. Journal of Advanced Nursing65(10), 2239–2248. doi:10.1111/j.1365-2648.2009.05052.x

Madlinger-Lewis, L., Reynolds, L., Zarem, C., Crapnell, T., Inder, T., & Pineda, R. (2013). The effects of alternative positioning on preterm infants in the neonatal intensive care unit: a randomized clinical trial. Research in Developmental Disabilities35(2), 490–497. doi:10.1016/j.ridd.2013.11.019

Pineda, R., Guth, R., Herring, A., Reynolds, L., Oberle, S., & Smith, J. (2016). Enhancing sensory experiences for very preterm infants in the NICU: an integrative review. Journal of Perinatology: 37(4), 323–332. doi:10.1038/jp.2016.179

Spittle A, Orton J, Anderson PJ, Boyd R, Doyle LW Spittle A, Orton J, Anderson PJ, Boyd R, Doyle LW. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database of Systematic Reviews 2015, Issue 11. Art. No.: CD005495. DOI: 10.1002/14651858.CD005495.pub4

Williams, K. G., Patel, K. T., Stausmire, J. M., Bridges, C., Mathis, M. W., & Barkin, J. L. (2018). The Neonatal Intensive Care Unit: Environmental Stressors and Supports. International journal of environmental research and public health15(1), 60. doi:10.3390/ijerph15010060

Web-based resources

Developmental Care in Newborn Intensive and Special Care

Positioning the preterm infant

NIDCAP website

NIDCAP programme – Developmental care

Chapter 6: Management of pain and stress in the neonatal unit
Chapter written by: KAYE SPENCE
Web-based resources written by: KAYE SPENCE & JULIA PETTY

Case Study 1: Neonatal stress

Naomi has been in the NICU for four weeks now. She was delivered by Caesarean section at 28 weeks gestation as her mother went into labour with ruptured membranes. Naomi was on mechanical ventilation for two weeks and now is receiving respiratory support with CPAP. She has started small volumes of expressed breastmilk down her gastric tube. You have been assigned to care for Naomi for your shift.

Question 1

On receiving handover from your colleague how would you determine if Naomi is comfortable?

Ensure she has a dry nappy, check her position and any supports in her bedding, check her immediate environment for any unnecessary noise or direct light into her bed, ensure her limbs are not restricted, has she had periods of restful sleep during the preceding shift.

Question 2

What signs of stress would you be looking for when you are undertaking care-giving for Naomi?

Facial expression – should be peaceful with no frowning or crying. Breathing pattern – calm and effortless, no straining, tachypnea or apnoea. Tone in her limbs – normal tone, no tension or flaccidity. Hand and foot activity – relaxed, hands on face, grasping objects, no flaccidity or clenched fists or finger or toe splay (spread). Level of activity – lying calmly either awake or asleep, no signs of persistent restlessness or looking exhausted.

Question 3

How may you determine if Naomi has been experiencing stressful events either on the past shift or during your shift?

Consider the number of stressful interventions that have occurred. Use the NISS to guide you to measure the volume of stress and to relay this to the rest of the health care team. Read the resource: Newnham, CA., Inder, T., Milgrom, J. (2009) Measuring preterm cumulative stressors within the NICU: The neonatal infant stressor scale. Early Human Development 85, 9: 549-555. The abstract is here. Using the scale in the article review Naomi’s history. You may choose to do this on a baby you have cared for to get a feel of what are considered stressful interventions.

Question 4

What are some of the detrimental effects of stress for neonates in the NICU?

It is well-known that high levels of pain-related stress exposure in very premature infants are associated with a cohort of alterations in cerebral, physiological, and behavioural development during childhood and adulthood, heightening the risk of behavioural and affective difficulties later in life. It is significantly associated with reduced white matter and subcortical grey matter maturation.
An excellent, open access paper by Cong et al (2018) summarises the potential effects of stress on neonatal outcomes.

Case Study 2: Pain assessment

Angus was born at 34 weeks gestation and he is now five days of age. On his mother’s antenatal scan, he was diagnosed with a congenital heart defect. He had surgery on the second day of life for a narrowing of his aortic arch. He was ventilated in the post-operative period for three days and was receiving a fentanyl infusion for his pain. On the medical round the team has asked that his fentanyl be reduced in preparation for extubation.

Question 1

How would you assess Angus’ readiness for a reduction in his analgesia?

Check his heart rate and blood pressure for stability. Check to see his breathing is above the ventilator rate as an indicator of respiratory effort. Check his awakeness so that he will be able to breathe on his own when extubated.

Question 2

You have been asked what the trends in his pain score are, prior to reducing the analgesia.

Scoring Instructions
Step 1 Observe the infant for 15 seconds at rest and assess vital sign indicators
Step 2 Observe the infant for 30 seconds after proceedure and assess change in vital sign indicators (maximal HR, lowest O2 SAT and duration of facial actions observed).
If infant requires an increase in oxygen at any point before or during procedure, they receive a score of 3 for the O2 SAT indicator
Step 3 Score for corrected gestational age (GA) and behavioural states (BS) if the sub-total score > 0.
Step 4 Calculate total score by adding Sub-total Score + BS Score

Using a suitable pain assessment scale check the algorithm to gauge the scores that would be suitable for weaning the analgesia.

Each pain scale has an algorithm to guide interpretation. As an example, the PIPP_R (Gibbons et al. 2014) has several components so look at each and work out how to calculate taking into consideration the gestational age and the behavioural state of the infant. Use the chart here

Infant indicator Indicator Score Infant indicator Score
0 +1 +2 +3
Change in Heart Rate (bpm)
Baseline: _____
0 - 4 5 - 14 15 - 24 >24
Decrease in Oxygen Saturation (%)
Baseline: _____
0 - 2 3 - 5 6 - 8 >8 or increase in O2
Brow Bulge
Eye Squeeze
Naso-Labial Furrow
*Sub-total Score:
Gestational Age
(Wks + Days)
>36 wks 32 wks - 35 wks, 6d 28 wks - 31 wks, 6d <28 wks
Behavioural State
Active and Awake Quiet and Awake Active and Asleep Quiet and Asleep
**Total Score:

Question 3

You have been assigned a new staff member to work with you in caring for Angus. As part of your mentorship you decide to teach them about how to assess a baby’s pain. What do you need to consider in explaining how to assess a baby’s pain using a pain scale?

Before undertaking a pain assessment, a guideline should be followed to ensure consistency and reliability in the assessment so that when handing over the patient at the end of a shift, the criteria used are similar and the context is the same:

  • Familiarise yourself with the components of the assessment tool and the recommended actions from the score obtained.
  • Stand where you can clearly see the baby’s face and all of the body.
  • Note the gestational age of the neonate.
  • Observe the neonate’s behavioural state for 30 seconds and take into consideration during your assessment.
  • At conclusion of the observation, gently touch neonate’s limb to determine muscle tone/tension.
  • Complete the physiological and behavioural parameters.

During the score consider:

  • Physiological conditions that may influence the score. For example, neonates with cyanotic heart disease would score their colour as normal unless there is a change in the intensity of the cyanosis or duskiness in response to pain.
  • Medications the neonate is receiving or has recently received that may affect behaviour or physiological responses.
  • Other environmental issues that may contribute to an elicited response from the neonate. For example, sudden bright lights, noise, activity around the bedspace.
  • Document these potential distracters on the chart or in the notes at the time of the score.

When to do the assessment and score:

  • At the commencement of your shift – think of pain assessment as a vital sign and a priority in assessment.
  • Prior to and at the completion of a painful intervention.
  • At least once per nursing shift (every four to six hours) and continue as long as analgesia is being used for pain relief.
  • When analgesia is being weaned continue to score when the analgesia has been completed for a further 48 hours.

Action to be taken on the results of the pain assessment score:

  • Depending on the assessment tool being used and the recommended thresholds, institute comfort measures or analgesia when the score is above baseline.
  • Reassess one to two hours after administering analgesia or comfort measures.
  • If the score continues to rise, then consider increasing dose of analgesia.
  • Reassess after one to two hours.
  • If score constantly at 0 and analgesia maintained, consider reducing the analgesia according to the guidelines.

Ensuring the reliability of staff in using a pain assessment score

Each health professional needs to be able to demonstrate their reliability in their assessment of a neonate’s pain using a pain score. To assess the reliability of all staff and to teach new staff the following criteria for pain assessment skill is recommended:

  • Health professional in groups of two or three observe the neonate as described above and each health professional scores the neonate’s pain separately.
  • Compare scores and see where differences occur.
  • Re-observe neonate or a different neonate until consensus is reached for each parameter of the assessment tool.
  • This test and retest should occur on a regular basis for all staff.

For a clear summary of neonatal pain assessment and management, see this open access paper by Witt et al (2016)

Case study 3: Pain management

George is 26-week gestation infant weighing 875 grams. He delivered by emergency Caesarean section following maternal antepartum haemorrhage. His mother did not receive antenatal steroids. He was born in fair condition and was intubated and given surfactant immediately after delivery. Following stabilisation, he is transferred to the neonatal intensive care unit, where he continues to require mechanical ventilation. Umbilical arterial and venous lines are sited for monitoring and intravenous therapy and medication.

Question 1

Does George need any pain relief given that he is so premature? Please qualify your answer.

Yes, prematurity is not a reason to withhold analgesia. Studies have shown that morphine is a safe analgesia for premature infants at 10 micrograms/kg/hour by continuous infusion. An 8-year follow-up study found there were no adverse events associated with morphine use in the NICU- read this open access paper by Attarian et al (2015) on neonatal pain and the long-term effects of morphine use.

Question 2

What drugs could be used in this situation?

Morphine is a safe drug when administered to preterm infants. However there does need to be vigilance in observation to ensure the dose is set appropriately and to monitor the infant’s response to the drug and dose. Some infants may display signs of toxicity and need the dose reduced.

Question 3

Are there any non-pharmacological strategies you could employ to keep George comfortable?

Yes, firstly reducing environmental stress of noise, light and activity around the bed. Restful sleep is important for brain growth and plasticity. Other strategies for George could include positioning him in a comfortable position which may include offering boundaries for his attempts at self-regulation.  As he is ventilated using facilitated tucking during potentially painful procedures such as ETT suctioning, turning and nappy changes. This open access paper addresses non-pharmacological approaches to neonatal pain relief: Mangat et al (2018).

Question 4

How would you assess whether the pain-relieving strategies were effective?

His heart rate and blood pressure would be normal for age. He would appear comfortable in his behavioural signs. Regular pain assessments every 2-3 hours would yield a consistent trend below the intervention level on the algorithm..

Question 5

What pharmacological interventions would be appropriate for procedural pain?

Sucrose for interventions such as replacement of gastric tube or any skin breaking procedure. Prematurity is not a reason for not using sucrose. It is absorbed by the buccal route and not swallowed. There have been no studies to indicate a contraindication to using sucrose. There has been some controversy about its use and effectiveness. It does not have analgesic properties, it is the sweetness that turns on the endogens in the brain. Sucrose does not replace morphine for severe or ongoing pain. Paracetamol can also be considered for neonatal use.

Open-access articles

Bellieni C. V. (2012). Pain assessment in human fetus and infants. The AAPS journal, 14(3), 456–461. doi:10.1208/s12248-012-9354-5

Cong, X., Wu, J., Vittner, D., Xu, W., Hussain, N., Galvin, S., ... & Henderson, W. A. (2017). The impact of cumulative pain/stress on neurobehavioral development of preterm infants in the NICU. Early Human Development, 108, 9-16.

Hall, R. W., & Anand, K. J. (2014). Pain management in newborns. Clinics in Perinatology41(4), 895–924. doi:10.1016/j.clp.2014.08.010

Johnston  C, Campbell‐Yeo  M, Fernandes  A, Inglis  D, Streiner  D, Zee  R. Skin‐to‐skin care for procedural pain in neonates. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD008435. DOI: 10.1002/14651858.CD008435.pub2.

Lago, P., Garetti, E., Merazzi, D., Pieragostini, L., Ancora, G., Pirelli, A., … Pain Study Group of the Italian Society of Neonatology (2009). Guidelines for procedural pain in the newborn. Acta Paediatrica (Oslo, Norway : 1992), 98(6), 932–939. doi:10.1111/j.1651-2227.2009.01291.x

Latimer, M., Jackson, P., Johnston, C., & Vine, J. (2011). Examining nurse empathy for infant procedural pain: Testing a new video measure. Pain research & Management16(4), 228–233.

Mangat, A. K., Oei, J. L., Chen, K., Quah-Smith, I., & Schmölzer, G. M. (2018). A Review of Non-Pharmacological Treatments for Pain Management in Newborn Infants. Children, 5(10), 130. doi:10.3390/children5100130

Moultrie, F, Slater, R, Hartley, (2017). Improving the treatment of infant pain. Current Opinion in Supportive and Palliative Care: 11(2),  p 112–117

Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD001069. DOI: 10.1002/14651858.CD001069.pub5

Walker S. M. (2013). Neonatal pain. Paediatric Anaesthesia24(1), 39–48. doi:10.1111/pan.12293

Witt, N., Coynor, S., Edwards, C., & Bradshaw, H. (2016). A Guide to Pain Assessment and Management in the Neonate. Current Emergency and Hospital Medicine reports4, 1–10. doi:10.1007/s40138-016-0089-y

Web-based resources

Prevention and management of pain and stress in the neonate
An Open access, full-text  Chapter that provides an overview of methods used to assess neonatal pain, followed by a summary of the evidence supporting breastfeeding, skin-to-skin care, and sweet solutions for procedural pain reduction with a discussion about barriers and facilitators to using these strategies in the clinical setting. Finally, a review of recommendations included in current neonatal pain guidelines is presented.

Parent education- reducing your baby’s pain during procedures
An example of an intervention is a publicly accessible YouTube video, targeted at parents of infants, showing three scenarios; a mother BF, a mother holding her infant in SSC during heel lance, and an infant being given sucrose with non-nutritive sucking during a venipuncture procedure. The effectiveness of this YouTube video and other interventions disseminated via social media are potentially promising methods to widely disseminate knowledge.

How do babies feel pain?
Useful short video with graphics as a revision on how babies feel pain the current research into this field.

Improving the treatment of neonatal pain
Overview of research at Oxford University reported by Rebeccah Slater

Chapter 7: Neonatal Palliative care
Chapter written by: SHARON NURSE
Web-based resources written by: JULIA PETTY

For each of these cases below...

  • Q.1. What are the key issues and care considerations for these infants and families?
  • Q.2. How would you plan palliative care?
  • Q.3. What are the reasons for your answers?
  • Q.4. What potential situations may occur that might mean you will need to revise your plan?

Case study 1: The infant with a congenital syndrome

Jacob was born at term and has Edwards Syndrome, which was diagnosed postnatally. His parents are polish and have lived in the UK for the past two years. They have two other children; Marcos who is four and Katrina who is eight years old. Jacob is now a week old and following discussion with the neonatal MDT, the decision is made for Jacob to be discharged home for palliative care. The family live in a two-bedroom, third floor flat.

This condition has a short life expectancy, usually less than a year. It is vital to undertake a needs assessment which includes pain and symptom management, the provision of accurate and relevant information, discuss with the family where they wished palliative care to take place, provide emotional, psychological and spiritual support. The family’s wishes around end of life care should be discussed and planned well in advance.  Evidence that has explored parents’ views highlights these are important factors to consider. It is also important to inform Jacobs siblings of the situation and involve them as much as appropriate.  Signpost to the relevant support organisations such as ‘Together for Short Lives’ (see other open access resources for this chapter and chapter 7).  Be open to parents wishing to transfer to hospice care if they find the home situation difficult.  Consider pastoral and religious support as appropriate. Overall, refer to recent TfSL evidence-based guidance for palliative care in the community, home or hospice setting and / or the NICE guidance. It is essential that culturally sensitive palliative care is given to all families as summarised here in this paper by Brooks et al (2018).

Case study 2: The infant with severe hypoxia at birth

Devinder is a post-term baby, now 4 days old, who suffered severe hypoxia at birth during a prolonged and difficult labour and has a diagnosis of severe hypoxic-ischaemic encephalopathy. Therapeutic cooling has been undertaken but this did not result in any improvement in his condition and he has no spontaneous effort to breathe. Devinder’s parents are Sikhs and have three older children aged 2, 5 and 14 years old respectively. The nursing team has discussed the situation with the parents and they understand that a plan of palliative care is now the next step in their son’s care.

Devinder may not survive for very long after being taken off the ventilator and if so, palliative care is likely to take place in the hospital setting.  Careful and timely explanations are essential, so the parents understand the situation and the reasons behind any care decisions.  Consider / offer involvement of the family’s religious figures to support them at this difficult time. Respect any specific religious observances relating to death and refer to current guidance on Faith at End-of-life if required. It has been found that parents prefer multiple options for the personal care of their infant at the end of life including a need for guidance by the neonatal team, memory making and feeling cared for and respected by staff (Shelkovitz et al, 2015). Overall, refer to recent, evidence-based guidance for palliative care in the neonatal unit

Case study 3: The preterm infant with devastating necrotising enterocolitis

Eve was born at 24 weeks gestation to parents, Brigit and Patrick, after a sudden delivery 20 minutes after presenting in labour ward. After an unstable period of ventilation, she had stabilised at age 10 days and was on bi-level continuous positive airway pressure. Early feeding had started via a nasogastric tube and this was being increased slowly. However, Eve developed necrotising enterocolitis on day 11 of life which showed no improvement after medical management. She went to theatre but unfortunately, her bowel was so damaged that none of it was viable, requiring the difficult decision to return her to the neonatal unit for palliative care. Parents are Irish catholic and have one other boy, Daniel who is 18 months old.

As above, Eve may not survive for very long after being taken off her respiratory support and palliative care is likely to take place in the hospital setting.  Again, careful and timely explanations are essential, so the parents understand the situation which may be unexpected and the reasons behind the need for palliative care.  Consider / offer involvement of the family’s priest to support them at this difficult time. Respect any specific religious observances relating to death, again by consulting guidance as needed. Overall once again, as for Case 2, refer to recent, evidence-based guidance for palliative care in the neonatal unit.

Use the words in the list below to complete the sentence

life limiting














Open-access articles

Balaguer, A., Martín-Ancel, A., Ortigoza-Escobar, D., Escribano, J., & Argemi, J. (2012). The model of Palliative Care in the perinatal setting: a review of the literature. BMC Pediatrics, 12, 25. doi:10.1186/1471-2431-12-25

Brooks, L. A., Bloomer, M. J., & Manias, E. (2018). Culturally sensitive communication at the end-of-life in the intensive care unit: A systematic review. Australian Critical Care. Online

Carter B. S. (2018). Pediatric Palliative Care in Infants and Neonates. Children, 5(2), 21. doi:10.3390/children5020021

Kilcullen, M., & Ireland, S. (2017). Palliative care in the neonatal unit: neonatal nursing staff perceptions of facilitators and barriers in a regional tertiary nursery. BMC Palliative care, 16(1), 32.

Sorin, G., Vialet, R., & Tosello, B. (2018). Formal procedure to facilitate the decision to withhold or withdraw life-sustaining interventions in a neonatal intensive care unit: a seven-year retrospective study. BMC palliative care, 17(1), 76. doi:10.1186/s12904-018-0329-x

Xafis, V., Wilkinson, D., & Sullivan, J. (2015). What information do parents need when facing end-of-life decisions for their child? A meta-synthesis of parental feedback. BMC palliative care, 14, 19. doi:10.1186/s12904-015-0024-0

Web-based resources

Mancini et al (2014). Practical guidance for the management of palliative care on neonatal units.

Together for Short Lives – Perinatal palliative care pathway

A perinatal pathway for babies with palliative care needs – full document

A Guide to children’s palliative care 2018

NICE Guidance on ‘End of life care for infants, children and young people with life-limiting conditions: planning and management’

Chapter 8: Neonatal bereavement care
Chapter written by: JO COOKSON
Web-based resources written by: JO COOKSON, LISA KAISER & JULIA PETTY

Case study 1 - Organ donation

Dale and Chloe have given birth to a daughter, Ellie, at 39 weeks gestation. Chloe presented to the maternity services with a heavy vaginal bleed and was immediately taken for an emergency caesarean section because of placental abruption. Ellie was born in poor condition and no heart rate was noted at birth. She had advanced resuscitation by the attending neonatal team including intubation, cardiac compressions and resuscitation drugs. A heart rate was first heard at 10 minutes of age. Ellie fulfilled the criteria for therapeutic hypothermia. After a period of 3 days of cooling, she remained neurologically compromised and did not demonstrate any spontaneous respiratory effort. On examination, she had fixed dilated pupils and absent gag and deep tendon reflexes.

Magnetic resonance imaging (MRI) was undertaken on day 5 and demonstrated extensive changes in the white matter and basal ganglia, suggestive of severe hypoxic-ischaemic brain damage. The neonatal team agree that further intensive care is futile and are considering re-orienting Ellie’s care to palliation. Throughout Ellie’s stay on the NNU Dale and Chloe have been made aware of how critical her status was and have ‘prepared themselves for the worst’ prior to her MRI. Once the results are discussed with the parents, they express a wish to donate Ellie’s organs following her death.

Would Ellie be eligible for organ donation?

It is imperative that collaborative discussions are facilitated between the clinical team and the SNOD (Specialist Nurses for Organ Donation) to plan the most effective and supportive approach to the family. Certain aspects of Ellie’s care such as medication management may render Ellie not suitable for organ and tissue donation. This should never be assumed though. Close liaison with the SNOD team will be able to guide the clinical team as to the appropriateness of raising initial discussions with Ellie’s family. The SNOD will also be present for any initial discussions with Ellie’s family.

Always consider contacting the NHS Blood and Transplant service to discuss individual cases. You will be able to speak to a Specialist Nurse for Organ Donation & Transplantation. 24hr Referral Line: 03000 20 30 40.

Case study 2 – Planning holistic bereavement care

Tyler was born at 24 weeks and doing well initially, but sadly deteriorated with fulminant necrotising enterocolitis at 10 days of age. He is too unstable for an operation, and within a few hours it becomes evident that Tyler will not survive for much longer. His parents, Matilda and Jamil, have two other children, Daisy aged 7, and Jackson aged 4 years. Jamil was raised in the Muslim faith but is not practicing this as part of his adult life or raising his children in accordance with it.

Question 1

What are your immediate considerations with regards to planning Tyler’s care around his death?

Tyler is deteriorating rapidly, so his parents are likely to struggle with several aspects: coming to terms with what is happening with Tyler and the thought of losing him; ensuring their other children are looked after so they can focus on spending time with Tyler.

They may well appreciate suggestions with regards to memory making and how to spend Tyler’s last moments with him. They will be in shock and therefore likely ‘not able to think straight’, to consider their wishes and preferences. In this first instance therefore, the nurse looking after them can gently guide them by making them aware as to all available options (cuddles/skin to skin as Tyler is dying; foot prints, hand prints, locks of hair if available, washing and dressing Tyler, placing teddies with him, photography, filming; inviting extended family to spend time with him). Once they are aware of their options, however, give them time to consider and get back to you. You may need to go over it again.

Question 2

Given that Jamil is not a practicing Muslim, would you address religious aspects as part of the family’s bereavement care?

Yes, you need to speak to both parents about their religious beliefs and wishes. Many people who are not practicing their denominated faith, may still wish to do so in the case of a death. It is therefore important to speak to both parents about this, as Matilda may also have wishes with regards to this. Make the parents aware that they can have a religious/naming ceremony for Tyler before or after his death, and that religious officials are available to attend the unit if requested. It is essential that culturally sensitive care is given to all families as summarised here in this paper by Brooks et al (2018).

Question 3

Which points would you like to discuss with Matilda and Jamil with regards to their other children?

The importance of involving siblings in bereavement care to improve their long term psychological wellbeing has been discussed. Matilda and Jamil may feel unsure about whether this would be good for their other children, or how to facilitate this. Therefore, the subject needs to be discussed with them sensitively, and possibilities explored as to how Daisy and Jackson can accompany Tyler in the moment of his death, and how they can be supported through this. Point them towards Child Bereavement UK.

Use the words in the list below to complete the sentence











empathy and kindness






Open-access articles

Banerjee, J., Kaur, C., Ramaiah, S., Roy, R., & Aladangady, N. (2016). Factors influencing the uptake of neonatal bereavement support services - Findings from two tertiary neonatal centres in the UK. BMC palliative care, 15, 54. doi:10.1186/s12904-016-0126-3

Brooks, L. A., Bloomer, M. J., & Manias, E. (2018). Culturally sensitive communication at the end-of-life in the intensive care unit: A systematic review. Australian Critical Care.

Jones, E., Lattof, S. R., & Coast, E. (2017). Interventions to provide culturally-appropriate maternity care services: factors affecting implementation. BMC Pregnancy and Childbirth, 17(1), 267.

Redshaw, M., Rowe, R., & Henderson, J. (2014). Listening to parents after stillbirth or the death of their baby after birth. National Perinatal Epidemiology Unit.

Redshaw M, Henderson J (2018) Mothers’ experience of maternity and neonatal care when babies die: A quantitative study. PLoS ONE 13(12): e0208134.

Shelkowitz, E., Vessella, S. L., O’Reilly, P., Tucker, R., & Lechner, B. E. (2015). Counseling for personal care options at neonatal end of life: a quantitative and qualitative parent survey. BMC Palliative Care, 14(1), 70.

Web-based resources

The National Bereavement Care Pathway for pregnancy and baby loss

Neonatal Death Bereavement Care Pathway

Child Bereavement Charity  The CBC exists to support all those affected when a baby or child dies. Its website includes helping families organise practicalities following a baby’s death, family stories and links to articles and leaflets relating to all aspects of child bereavement from each family member’s perspective.

SANDS support anyone affected by the death of a baby by offering practical information for families as well as emotional support and understanding. Its website includes, for example, how and when to talking about emotions and feelings, a useful publications list, and stories of personal experiences from bereaved parents.

SPRING SPRING offers a counselling service providing support to parents and relatives who have suffered the loss of a baby before or around birth including miscarriage, still birth and termination for foetal anomaly. Paediatric Subgroup of the National Organ Donation Committee (2019) Uk Paediatric and Neonatal Deceased Donation. A Strategic Plan. NHS Blood and Transplant.

RCPCH (2015)
The diagnosis of Death by Neurological Criteria in Infants Less Than Two Months Old.

Chapter 9: Legal and ethical issues in the neonatal unit

For each of these cases below...

  • Q.1. What are the key legal and ethical issues in these three cases?
  • Q.2. What would you consider in line with the ‘best interest’ principle?
  • Q.3. What are vital considerations for supporting the parents / family in these cases?
  • Q.4.Can you identify the areas of conflict in decision-making in these cases and possible ways to resolve this?
  • Q.5. What are the reasons for your answers?

Case study 1: An ethical dilemma in delivery suite

Faye was born very prematurely and because her mum, Freda, had not had any antenatal care, the exact estimated date of delivery was uncertain. An assessment by the neonatal team came to the decision that she presented like a baby born at 22-23 weeks. Faye required prolonged resuscitation after delivery and her heart rate remained low with very little spontaneous breathing. Freda wanted full resuscitation to continue and for Faye to be admitted to the neonatal unit for full intensive care. She was estranged from her partner; Faye’s father Pete and they had separated when she was in the early stages of pregnancy. They were unmarried with no other children. Pete did not wish Faye to receive full intensive care as he felt it was not in her best interest.

The key legal and ethical issues in this case are regarding the resuscitation and continued care of a very premature baby showing signs of a very poor prognosis. There is the question of viability- legally, at 22-23 weeks, she does not meet the criteria to be regarded as such, as she was born before 24 weeks, the legal age of viability. The British Pregnancy advisory service explains this complex issue very clearly. The best interest of the child needs considering in relation to whether prolonged resuscitation and care in the neonatal unit is appropriate or whether this is futile, causing further suffering to this very immature baby.Read here for the Nuffield Council guidance on ‘best interest’ in neonatal care: ‘Critical care decisions in fetal and neonatal medicine: ethical issues’. The considerations in supporting the family relate to being mindful of their involvement in decision-making- this has been shown to be a very important requirement. Key themes from research that has explored parents views of being part of ethical decision making included the need for parent involvement in decision making, recognition of the parental role, necessity of good information, need for communication, desire for hope and compassion conveyed by providers, decision making satisfaction, and trust in caregiving team. Conflict has arisen here between the parents as they both want very different things. It is important to address any conflicts that arise and come to some resolution, again ensuring the best interests of the child is upheld.

Case study 2: A child protection dilemma

Tim is a very growth restricted baby boy, born at 37 weeks gestation to Linda, a known drug user (heroine). Linda lives in a hostel run by a local charity and has been on a methadone programme although the compliance with this is erratic. Her two other children are in temporary foster care. There is also a history of domestic abuse from Linda’s ex-partner and he is aware that Tim has been born although he is not permitted to visit the neonatal unit. Following birth, Tim shows withdrawal signs and is very irritable, inconsolable with an episode of fitting. He is placed onto methadone.

The legal and ethical issues here relate to safeguarding the baby born to a mother who is a drug user, particularly given the social circumstances surrounding the family. An excellent summary of important issues relating to drug misuse in pregnancy and the effects on the baby as well as a list to sign-post you to other resources on this topic, can be found on the Best Beginnings webpage- Helping vulnerable families- Parents who use drugs.

The best interests of the baby must be upheld, and the aim would be to keep both mum and baby together and support them both as a unit. However, it is vital for the multi-disciplinary team including social workers and the substance-abuse midwife, to assess the risks posed in such a case as this, to the baby.  Conflict may arise in ensuring that mothers and their babies are kept together but also that the baby is not put at risk after discharge. A paper by Povey (2018) provides a concise summary of such a conflict and the difficult ethical challenge around ensuring best interests of both mother and baby.

Case study 3: Ethical and legal issues in the older infant

Rosemary was born at term and spent a period of 10 weeks being very unstable requiring respiratory support and displaying symptoms of hypotonia, muscle weakness, pneumonia, and swallowing and feeding difficulties. After a recent extubation, she required re-ventilation and a diagnosis returned of spinal muscular atrophy. Her respiratory drive continued to worsen, eventually diminishing completely and she was unable to tolerate any enteral feeding. Her parents Precious and Zane, who had four other children all healthy, wanted full ventilation support to continue. The consultant had spoken to them about Rosemary’s poor prognosis and the fact that she would be unable to breathe without this support.

The legal / ethical issues here relate to decision making about the continuation of intensive intervention that may be deemed inappropriate or invasive and not in the baby’s best interest. Read the paper by Kirkbridge (2013) for a clear summary of complex ethical decision making and the use of an ethical framework in such cases. Larcher et al (2015) also provide a detailed summary of a framework for practice to guide in decisions about such a complex and difficult dilemma and an overview of situations where it may be ethically permissible to withhold or withdraw life-sustaining treatments. The parents in this case want treatment to continue and so their wishes must be respected, and full, open discussion should be continued on a regular basis with them. Should any conflict arise between what parents want and what the healthcare team deem should happen must be managed carefully.  Referring to the legal system is very much a last resort and hopefully will not be necessary when there is shared decision-making and good communication. As reported by Eden and Callister (2010), establishing good relationships and clear communication between the health-care team and parents builds trust and eases stress placed on parents making decisions about the care of their infant. Nurses play a critical role in assisting parents surrounding life support decisions (Kavanaugh et al (2010)

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Chapter 10: Early Care of the newborn
Chapter updated by: SARAH FITCHETT
Web-based resources written by: SARAH FITCHETT

Case study 1: Delivery of an extremely preterm infant

Ava is 24+3 weeks gestation and was delivered by Claire, a primi-gravida mother, after early onset of labour.

Question 1

How would you prepare the equipment and environment prior to the birth of Ava?

Heat loss through evaporation, convection, conduction and radiation must be prevented by preparing the environment and equipment appropriately. Environmental temperature at 26oC. Turn off fans, close doors and windows, ensuring a draught free environment.

Check resuscitaire, neopuff, suction and all equipment are working correctly. Full air and oxygen cylinders on the resuscitaire. Available heat and light source and a supply of warm towels and a plastic bag. Availability of intubation equipment including a hat. Resuscitation trolley and drugs – all checked and in date.

Transport incubator, monitoring equipment (saturation probe, ECG leads, thermometer) and neonatal squad bag all checked and stocked ready for use at the delivery. Surfactant and a surfactant administration kit.

Question 2

Which members of the multidisciplinary team need to be informed of the impending delivery?

Neonatal Unit Co-ordinator, Shift Lead, Room Lead for admissions room, Consultant Neonatologist / Consultant Paediatrician..

Question 3

How could Ava’s parents Claire and Richard best be prepared for her birth?

Neonatal Nurse / Sister to attend with Neonatal Consultant to introduce the team and to speak with both parents on the antenatal ward or delivery suite where Claire is being cared for and provide effective counselling. Good communication is essential, and parents should be informed about local, national and unit statistics and outcomes (Epicure, 1995, 2006, 2012; MBRACE, 2018). They have the right to be involved in the discussions leading to decision making and remain updated (NICE, 2017; POPPY Report, 2012) and allow parents to ask questions. Decision making re intervention and resuscitation. Informing parents of what baby might look like and what interventions and equipment may be used to stabilise baby following delivery. Information needs to be given in a format that parents can understand and revisit when necessary. A tour of the NICU prior to delivery to ensure that parents are orientated to the environment prior to delivery. Meeting parents allows for discussions to enhance history taking..

Question 4

Explain how you would use the Apgar score to assess Ava’s condition at birth.

The APGAR score is the initial clinical assessment at birth and includes; heart rate, respiratory effort, colour and tone which is the basis of the APGAR score. This APGAR score provides the team with an easy and convenient way to assess and convey the condition of the baby following birth. As the baby is born the clock should be started and the APGAR is assessed at 1, 5 and 10 minutes.

At birth Ava’s colour is pink with gasping breaths, no cry, hypotonic, heart rate is 100bpm and rising.

Question 5

What are your initial management priorities following delivery? Discuss the care for Ava in relation to the components of the Golden Hour.

Ava would be delivered in to a plastic bag, head and face dried off using a warm towel and an appropriately sized hat applied to the head. Ava would be then assessed on the resuscitaire – heart rate auscultated and head placed in neutral using a chin lift manoeuvre. The mask will be sized and neopuff pressures set at 20cm H2O PIP and 5cm H2O PEEP and 5 inflation breaths would be given. Reassessment of heart rate following these inflations breaths. Refer to the latest Newborn Resuscitation guidance.

Case study 2: Term baby compromised at delivery

Amy gave birth to her first baby Jack in the delivery suite. When Jack was born his colour was blue, heart rate was slow, he had reduced tone and after stimulation he grimaced and gasped but made no further attempts to breathe.

Question 1

What are your immediate assessments?

Initial assessment includes appearance, grimace, heart rate, respiratory effort.

Question 2

What are the initial actions that you would take to resuscitate Jack?

Airway management: head placed in the neutral position and 5 inflation sustained over 2-3 seconds.

Question 3

How would you size a face mask for Jack?

The mask should be sized to fit over the nose and mouth, without occluding the orbital ridges and provide a good seal.

Question 4

How would you hand over the resuscitation situation using the SBAR tool?

Using the SBAR communication tool information is given succinctly in the areas of
Situation: Jack requires resuscitation following delivery by (Type of delivery) and time of birth. APGARS if any are available at this time.
Background: Gestation, gravida and parity. Maternal history and any pregnancy problems. Jack has been stimulated, dried and wrapped, hat applied, head place in neutral and 5 inflation breaths given.
Assessment: Jack’s colour remains blue, heart rate slow, reduced tone and after stimulation he grimaced and gasped, but has made no further attempts to breathe. Chest wall movement seen / not seen. Currently in the process of resuscitation.
Recommendation: Jack needs to have resuscitation continued, need to put out the emergency call for the neonatal team and come back and inform me that this has been done.
Ref. The NHS Institute for Innovation and Improvement (NHSII) (2008) and The UK Resuscitation Council (2016).

Question 5

What are the ongoing observations following resuscitation? What assessment tool would be used on the postnatal ward?

Continuing observation is necessary for any infant who has required resuscitation and has any need for ongoing support. Observations include temperature, respiratory rate, heart rate, +/- oxygen saturations, blood glucose. Colour, tone, neurological and feeding assessment – e.g. waking for feeds. A multidisciplinary team (MDT) approach is adopted and frequency of observations are determined. The Newborn Early Warning Sore (NEWS) is used on the postnatal ward.

Short Answer Questions

Question 1

What are the key aims of successful resuscitation?

To establish and maintain a clear airway by ventilation and oxygenation, ensure effective circulation, correct acidosis, prevent hypothermia and hypoglycaemia.

Question 2

What equipment and supplies are needed to perform neonatal resuscitation?

  • Radiant Warmer – flat surface, heat source, light source, timer/clock
  • Stethoscope
  • Warm Towels
  • Suction unit with tubing, yankeur and various sizes of suction catheters
  • Blended air / oxygen supply with flow regulation and adjustable pressures
  • Pulse Oximetry
  • T-piece e.g. neopuff
  • Self-inflating bag
  • Assorted face mask sizes
  • Oropharyngeal (Guedel) airways – various sizes for preterm and term babies
  • Plastic Bags / Wrap for preterm babies.

Question 3

What maternal, obstetric, and foetal (or neonatal) factors indicate a high probability of needing advanced neonatal resuscitation?

  • Maternal disease, e.g. pre-eclampsia
  • Maternal infection, e.g. chorioamnionitis
  • Maternal substance misuse
  • Foetal abnormality, e.g. diaphragmatic hernia; intrauterine growth restriction
  • Ante or intra partum haemorrhage
  • Prolonged rupture of membranes
  • Foetal compromise indicated by foetal heart rate
  • Preterm labour
  • Induction of labour
  • Meconium stained amniotic fluid
  • Prolonged labour
  • Maternal sedation
  • Instrumental and operative delivery
  • Obstetric emergency e.g. cord prolapse and shoulder dystocia).

Question 4

What are the steps in initial resuscitation of the newborn?

Airway management: head in neutral position. Breathing: inflation breaths x5 sustained over 2-3 seconds; only moving on to ventilations breaths when there is chest wall movement with inflation breaths, or a rise in heart rate demonstrating aeration of the lungs.

Question 5

What are the indications for oxygen administration and how should it be administered?

Consider oxygen if there is a failure of the heart rate to respond to successful lung inflation or in response to pulse oximetry readings.

Question 6

When and how should assisted respiration (ventilation) be administered to the newborn?

Assisted respiration (ventilation) is administered to the neonate following the delivery of x5 sustained inflation breaths and the assessment of successful aeration of the lungs; this is demonstrated in a rising heart rate or visible chest wall movement with inflation breaths. Ventilation breaths are then delivered at a rate of 30 breaths per minute or 15 breaths in 30 seconds.

Question 7

When and how should chest compressions be performed during neonatal resuscitation?

Chest compressions are performed following the delivery of five successful inflation breaths (demonstrated by chest movement), and on reassessment the heart rate has not increased and remains at a rate of less than 60 beats per minute. One cycle of ventilation breaths should then be given at a rate of 30 per minute, reassessing after 30 seconds and if the heart rate still has not increased then chest compressions are commenced at a 3:1 ratio giving 120 cycles per minute, for example, 90 cardiac compressions to 30 breaths.

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Chapter 11: Management of neonatal thermal stability
Chapter updated by: TRACEY JONES
Web-based resources written by: JULIA PETTY

Case study 1: Thermal care in a premature infant

Simona arrived in the emergency department in early labour and within ten minutes delivered Jasmine at 26 weeks gestation by precipitous vaginal delivery while she was in the toilet. The A&E staff attended to both Jasmine and Simona and fortunately, the neonatal team are called quickly and a resuscitaire bought to the scene.

With reference to the key points within the chapter, consider the following questions:

Question 1

What are the ways this infant will lose heat?

Evaporation; heat loss through immature skin. Convection due to cool circulating air currents. Radiation of body heat towards a cool surface. Conduction by direct contact with cool surfaces. See this summary of neonatal thermoregulation.

Question 2

What are the physiological factors that may lead to poor thermal control?

Immature hypothalamus, large surface area to body weight ratio, reduced amounts of adipose tissue (brown fat), reduced subcutaneous fat, immature thermogenesis mechanisms. See here, a summary of thermal control and related care.

Question 3

What factors / strategies need to be considered in the thermal care of this infant?

Use of plastic bags at delivery, place baby in / under a heat source, put on a hat to limit heat loss from the head, transfer straight into humidity (80-85%) within a pre-warmed incubator set and adjust  according to the appropriate neutral-thermal environment. Refer to Open access guideline that includes for a summary of strategies.

Case study 2: Cold stress in the term infant

A term infant, Jake, has just arrived from delivery suite with an admission core temperature of 35.70C. The infant had to be given inflation breaths in delivery suite with a bag-valve mask system for poor respiratory effort at birth. The resuscitaire had malfunctioned.

With reference to the key points within the chapter, consider the following questions:

Question 1

What are the potential effects of this infant being so cold?

Hypothermia can lead to many adverse consequences such as hypoxia, hypoglycaemia, impaired surfactant release and efficacy, abnormal blood gases.

Question 2

What is the physiological basis of your answer for Q.1

See this resource here for a summary of the metabolic triangle and how hypothermia can lead to these above effects in line with thermal care as a whole. All elements of the triangle, hypothermia, hypoglycaemia and hypoxia, are interlinked.

Question 3

In line with cold stress, what interventions are needed for this infant?

Further information can be viewed here in a summary of thermoregulation and related strategies along with the above cited articles too. A Cochrane review also summarises recent evidence based strategies for effective thermal control in neonates.

Case study 3: Transition to going home

Premature twins born at 25 weeks are now 10 weeks old (35 weeks corrected) and have come off all respiratory support except for low flow oxygen. Time has arrived to prepare them towards discharge home, but they are still being nursed in incubators. What factors now require consideration for both the infants’ thermal care and that of the family needs moving towards going home?

Ensure that the twins are able to maintain their central temperature, and this is stable. Once they are a certain weight, transfer can be considered if not before depending on local guidance to ascertain readiness for transfer. Follow guidance for transfer to an open cot from an incubator. A Cochrane review has explored this in relation to weight. Ensure the twins are dressed and covered and wearing hats after the transition to an open cot. Consider heated mattresses as an option if they do find it difficult to maintain their own temperature. Keep the twins comfortable and well oxygenated. Ensure they are well nourished and receiving sufficient glucose. When the twins are discharged home, give advice regarding the prevention of overheating and refer to the guideline for the prevention of cot death. This paper also summarise this topic as a whole.

Chapter 12: Management of neonatal respiratory disorders
Chapter updated by: BREIDGE BOYLE
Web-based resources written by: JULIA PETTY

For the three case studies below, consider the following questions:

  • Q.1. Considering the current literature and guidelines on neonatal respiratory management, what are the strategies required for these three case studies below?
  • Q.2. What are your reasons for your answer to Q.1, for each case study?
  • Q.3. What factors will benefit these infants' outcomes and why?
  • Q.4. What are the risks associated with respiratory management in these cases and how can these be minimised?

Case study 1: Ventilatory management of the premature infant

Thomas is 27+3 weeks’ gestation and weighs 810g. He was delivered by lower segment Caesarean section for maternal pregnancy-induced hypertension. His mother is a primigravida and received a full course of antenatal steroids prior to delivery. At birth, Thomas had a heart rate over 100 but had a very weak respiratory effort. His cord blood gas at 10 minutes old was pH = 7.16, PaCO2 = 8.6kpa PaO2 = 2.4kpa. Bicarbonate 14 mmol/L Base excess = -7

This baby has a mixed acidosis and so the respiratory and metabolic components need addressing as well as management of the provisional diagnosis of respiratory distress syndrome (RDS). It is important to refer to the NICE guidance – this states the following- Administer Surfactant preferably via a minimally invasive mode (no prolonged intubation). If ventilation is required; use volume-targeted ventilation (VTV) in combination with synchronised ventilation as the primary mode of respiratory support. If this is not effective, consider high-frequency oscillatory ventilation (HFOV). If VTV and HFOV are not available or not suitable, consider synchronised intermittent mandatory ventilation (SIMV). If full ventilation is not required, use CPAP or high-flow oxygen therapy. These recommendations are based on key evidence such as Sweet et al (2017). Improved outcomes in RDS have been associated with administration of antenatal steroids, surfactant administration and minimal / protective ventilation strategies including limiting pressure, volume and oxygen which can be damaging to immature lungs. Careful thermal care, fluid administration and early care (the Golden hour) are also important areas of care to maintain: refer to the relevant chapters for more information on these aspects of care. Key nursing observation, management of stress and pain along with other vital areas of assessment must be continued to maximise the success of all respiratory interventions

Case study 2: Weaning from ventilation

Gabriella was born at 30 weeks gestation, birth weight 900g and required resuscitation at birth due to respiratory distress. She was diagnosed with an early onset infection and has required full ventilation as she did not tolerate CPAP. She has failed one previous attempt at extubation at 4 days old. She is now 7 days old and her blood gas is pH 7.49, PaCO2 = 3.4 kpa PaO2 = 10.5kpa. Bicarbonate 20 mmol/L Base excess = +3

This baby has a respiratory alkalosis indicating that she can be weaned from ventilation, so this would be the aim. Start on caffeine, wean down the set parameters plus oxygen as tolerated and place onto non-invasive mode of support after extubation- this can be high-flow oxygen or CPAP / BiPAP. Continue to monitor oxygen, blood gases, vital signs and ensure baby is as stress free as possible, well-nourished and kept warm and comfortable along with the family- this will all help to minimise any risks during this vulnerable period when respiratory requirements are being weaned down and the baby must take more spontaneous control of their own breathing.

Case study 3: Weaning from CPAP

Sanjeet, born at 26 weeks gestation, has chronic lung disease and has been on bi-level CPAP now for 5 weeks after an unstable period of ventilation. He has an oxygen requirement of 55%. He is now 9 weeks old and the decision is made to wean and discontinue the CPAP as soon as his condition allows. His blood gas is pH 7.33, PaCO2 = 9kpa PaO2 = 8.6kpa (in oxygen) Bicarbonate 30 mmol/L Base excess = +4

This baby has a compensated respiratory acidosis, typical of chronic lung disease. If his condition is now stable, he can be weaned from the bi-level pressure with the move towards breathing without pressure support. According to McMorrow and Millar (2012), CPAP should be weaned according to individual practice. Consider single level CPAP or high-flow oxygen therapy. Remember there are factors that may need addressing, that affect successful weaning such as previous intubation, anaemia, infection and gastro-esophageal reflux, all of which are associated with prolonged time from weaning (Shaili et al, 2015). Eventually, the baby should be weaned to low-flow nasal cannula oxygen which will continue for a certain period of time until he comes off completely either before discharge or after.

Chapter 13: Management of Cardiovascular Disorders
Web-based resources written by: KAREN HOOVER, NICKY MCCARTHY & JULIA PETTY

Case study 1: The term baby with failed pulse oximetry screening

Neil is a 6-hour old term baby who has failed pulse oximetry screening with both upper and lower saturation reading 78%. He is tachypnoeic but has no other signs of respiratory distress.

Question 1

What are the cyanotic defects presenting with failed pulse oximetry?

The cyanotic defects associated with failed pulse oximetry screening include defects with obstruction to pulmonary blood flow such as pulmonary atresia, critical pulmonary stenosis and tricuspid atresia. Transposition of the Great Arteries (TGA) will also result in failed pulse oximetry screening because the pulmonary artery is providing blood to the systemic circulation.

Question 2

What defect can present with higher post ductal saturations compared to preductal?

This occurs in TGA because the pulmonary artery is in the left ventricle and receives oxygenated blood from the lungs. This blood then enters the descending aorta via the ductus. Since the aorta leaves the right ventricle where the blood is de-oxygenated, the arteries supplying the right hand will have lower oxygen levels than that in the feet.

Neil is commenced on a prostaglandin infusion

Question 3

What is the aim of the prostaglandin infusion in this case?

Babies with duct-dependent pulmonary circulation such as pulmonary atresia, critical pulmonary stenosis and tricuspid atresia rely on the ductus arteriosus to perfuse the lungs via the aorta. Therefore, prostaglandin in this situation is lifesaving until surgery can be performed.

In TGA, survival depends on the degree of mixing of the systemic and pulmonary circulations through the foramen ovale unless a ventricular septal defect is present. Prostaglandin may help increase pulmonary blood flow, but it will not sustain life if there is a restrictive (small) foramen ovale and in these babies an urgent atrial septostomy will be necessary.

Question 4

What are the side effects of prostaglandin?

The most concerning side effect is apnoea, but this usually only occurs with higher doses above 15 nanograms/kg/minute. Babies on higher doses who are being transported to cardiac units may be intubated prior to transfer. Other side effects include hypotension and flushing because of vasodilation. Pyrexia and tachycardia can also occur.

Question 5

What particular nursing care does this baby need?

Once prostaglandin is commenced and the blood flow to the pulmonary circulation is restored, the main aim of nursing care is to monitor the peripheral or central venous site where the drug is being administered. The drug is life saving and should it become disconnected, the ductus arteriosus would start to constrict and the baby rapidly deteriorate as pulmonary blood flow is reduced. Remember to provide the parents with tailored information on this condition and support / reassure them throughout the care and forthcoming journey with their baby.

Case Study 2: The term baby with absent femoral pulses

Ryan is a 5-day old term baby who is completing a course of antibiotics for pneumonia on the postnatal ward. On his discharge examination, the femoral pulses cannot be felt. The baby is otherwise well and feeding normally.

Question 1

What congenital heart defect is most commonly associated with absent femoral pulses?

The most common CHD associated with absent femoral pulses is coarctation of the aorta.

Question 2

Is the pulmonary or systemic circulation affected?

The aorta leaves from the left ventricle and supplies blood to the systemic circulation via the ascending aorta to the head, and the descending aorta to the lower body.

Question 3

What could you do to provide more information regarding the possible diagnosis before the echocardiogram is performed?

4 limb blood pressures may show decreased pressures in the legs compared to the arms, and a difference of around 15mmHg is said to be significant indicating decreased blood flow to the lower limbs.

A prostaglandin infusion is commenced

Question 4

What is the aim of the prostaglandin infusion in this case?

Once the ductus arteriosus closes, babies with left heart obstruction have reduced perfusion to the systemic circulation. This results in metabolic acidosis, tachycardia, tachypnoea and poor perfusion. If the ductus is not re-opened with prostaglandin, the baby will continue to deteriorate and will die.

Question 5

What would you expect to happen once prostaglandin is commenced?

Once the ductus arteriosus re-opens, blood supply to the lower limbs via the descending aorta is re-established and the baby will have palpable femoral pulses. Metabolic acidosis and other signs of decreased systemic perfusion will also start to improve.

Case study 3: Hypotension in a preterm infant

Bryony is a 25-week gestation infant who is now 8 hours old. She has been stable since admission, minimally ventilated, has commenced parenteral nutrition and has umbilical lines in situ. You notice that for the past 10 minutes her Mean arterial blood pressure (MABP) has been reading 22 – 24mmHg.

Question 1

What are your first steps to verify if this is a true reflection of Bryony’s BP? What else would your clinical assessment include?

Ensure transducer zeroed and positioned correctly. You could attempt a cuff BP, but this is likely to be lower.
Undertake a clinical assessment of Bryony – hydration status, CRT, toe-core gap, urine output, tachycardia? Remember:
Skin and superficial tissue perfusion: In low cardiac output states, blood supply to the skin is diverted to vital organs. Skin perfusion can be assessed by timing capillary refill and measuring central-peripheral temperature gap.
Metabolic acidosis: tissue hypoxia leads to anaerobic metabolism and lactate production Reduced urine output: a urine output <1ml/kg/hour is indicative of inadequate kidney perfusion.
Reduced conscious level: with severe hypotension comes a loss of autoregulation of blood flow in the brain so that babies may become encephalopathic.

Question 2

What would the initial pharmacological management of her hypotension be?

Commonly volume replacement (10mL kg 0.9% sodium chloride), likely followed by a dopamine infusion.

Bryony has been commenced on a dopamine infusion. There is suboptimal response to this at 10mcg/kg/minute, so a dobutamine infusion is also started at initially 5mcg/kg/minute

Question 3

Other than the desired increase in BP, what other changes in Bryony’s parameters might you observe?

Tachycardia, increase in urine output; potential for increase in lactate due to peripheral vasoconstriction.

Question 4

In the case of a poor response, what other causes of hypotension would you need to consider? Which investigations could aid in the diagnosis of these?

Technical problem with BP measurement (Cuff size, zero transducer); prescription or administration error (check all infusions and doses); pneumothorax; pericardial tamponade; extreme hypovolemia; high mean airway pressure (especially on high frequency oscillatory ventilation); hidden blood loss (IVH or scalp, bowel, twin to twin transfusion or foeto-maternal haemorrhage)

For a summary of neonatal hypotension, this open access paper has some key points- Joynt and Cheung (2018).

Case Study 4: The baby with a VSD

Shelley is a 2-week-old term baby admitted for poor feeding and has been found to have a heart murmur due to a ventricular septal defect (VSD). Over the past few days she has become increasingly tachypnoeic and needing nasal cannula oxygen.

Question 1

What is happening and why?

As pulmonary vascular resistance falls in the first 2-6 weeks after birth, the pressure in the left side of the heart increases forcing blood through the VSD and into the pulmonary artery to the lungs. This results in increased pulmonary blood flow.

Question 2

What other signs would you expect to see?

The increased pulmonary blood flow will result in tachypnoea, and difficulty feeding. The increased blood volume results in hepatomegaly and a large weight gain.

Question 3

What medical treatment would you expect this baby to have?

The main aim is to reduce fluid overload and its effects on the heart and lungs. This is achieved by fluid restriction and diuretics. Medication such as captopril may be used to increase the pumping ability of the heart against a larger blood volume.

Question 4

What are the principles of nursing care for this baby?

Daily weighing allows monitoring for fluid overload, or too much weight loss. Either will require adjustment to fluid intake and diuretic dosage. For babies on restricted fluids, calorie intake must be maintained for growth and this can be achieved by high calorie feeds. Nasogastric feeds will reduce energy expenditure as will oxygen administration.

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Open-access resources

Dempsey, E. M., Barrington, K. J., Marlow, N., O'donnell, C. P., Miletin, J., Naulaers, G., ... & Van Laere, D. (2014). Management of hypotension in preterm infants (The HIP Trial): a randomised controlled trial of hypotension management in extremely low gestational age newborns. Neonatology, 105(4), 275-281.

Joynt, C., & Cheung, P. Y. (2018). Treating Hypotension in Preterm Neonates With Vasoactive Medications. Frontiers in Pediatrics6, 86. doi:10.3389/fped.2018.00086

Nickavar, A and Assadi, F (2014) Managing hypertension in newborn infants. International Journal of Preventative Medicine. 5(suppl 1), S39-S43

Osborn  DA, Paradisis  M, Evans  NJ. The effect of inotropes on morbidity and mortality in preterm infants with low systemic or organ blood flow. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD005090. DOI: 10.1002/14651858.CD005090.pub2.

Plana MN, Zamora J, Suresh G, Fernandez-Pineda L, Thangaratinam S, Ewer AK. Pulse oximetry screening for critical congenital heart defects. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD011912. DOI: 10.1002/14651858.CD011912.pub2

Sharma et al. (2015) Persistent Pulmonary Hypertension of the Newborn. Maternal Health, Neonatology, and Perinatology

Singh, Y., Katheria, A. C., & Vora, F. (2018). Advances in Diagnosis and Management of Hemodynamic Instability in Neonatal Shock. Frontiers in Pediatrics6, 2. doi:10.3389/fped.2018.00002

Subhedar NV, Shaw NJ. Dopamine versus dobutamine for hypotensive preterm infants. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD001242. DOI: 10.1002/14651858.CD001242

Taksande, A., Meshram, R., Lohakare, A., Purandare, S., Biyani, U., & Vagha, J. (2017). An update work of pulse oximetry screening for detecting critical congenital heart disease in the newborn. Images in Paediatric Cardiology, 19(3), 12–18.

Web-based resources

Children’s Heart federation: list of heart conditions with images / animations

Congenital heart defects- British Heart Foundation

Stanford Childrens Hospital Overview of congenital heart disease

American Heart Association- list of congenital heart defects with images A clearly illustrated depiction of the fetal circulation. An illustrated teaching session describing the transitional circulation following birth An illustrated teaching session giving the clear explanation of the foetal circulation Video describing fetal embryology using models Video describing the cardiac cycle and how each stage is represented on the ECG.  Video on foetal circulation and hypoplastic left heart syndrome

Chapter 14: Neonatal Brain Injury
Chapter updated by: DEBBIE WEBSTER
Web-based resources written by: JULIA PETTY

Case study 1: The infant with IVH

Kwame is a 25-week gestation infant born by precipitous vaginal delivery, weighing 720g. During pregnancy, there had been some intermittent vaginal bleeding at 12 – 16 weeks’ gestation and then again at 24 weeks. However, before Margaret his mother, could be transferred to a tertiary perinatal centre, she began to feel unwell with uterine tenderness and fever and on admission to her local hospital, Kwame was delivered. Margaret also experienced a significant antepartum haemorrhage. Kwame required resuscitation at birth including intubation and positive pressure ventilation and after being given a dose of surfactant, he was transferred to the neonatal intensive care unit (NICU). On admission to NICU, he was commenced on volume targeted ventilation and in the first 24 hours of life, his blood pressure was problematic requiring two doses of volume expansion followed by inotropic support. As his condition was very unstable, he was transferred to a level 3 neonatal intensive care unit, 26 miles from the local hospital. His parents are Margaret and Oko, a Ghanaian married couple with three other children.

Question 1

What antenatal factors placed Kwame at risk of brain injury?

Many factors place the fetus or neonate at risk of impaired brain development. In addition, the events during pregnancy and delivery impose risks such as maternal bleeding and infection. Chorioamnionitis is a major cause of preterm birth and brain injury. Bacterial invasion of the chorion and amnion, and/or the placenta, can lead to a foetal inflammatory response, which in turn has significant adverse consequences for the developing foetal brain. Accordingly, there is a strong causal link between chorioamnionitis, preterm brain injury and the pathogenesis of severe postnatal neurological deficits and cerebral palsy.

Question 2

What post-natal factors in the first few hours of life placed Kwame at further risk of brain injury?

A comprehensive summary of post-natal factors that increase the risk of brain injury is provided by Viaroli et al (2018). Among the factors, hypothermia, lower cerebral oxygen saturation during delivery room resuscitation and high tidal volumes delivered during respiratory support are associated with increased risk of severe neurologic injury.

On day three of life, Kwame became more hypotensive and a murmur presented on auscultation. A patent ductus arteriosus was confirmed on cardiac echo. On day 7, a head ultrasound scan identified evidence of intraventricular haemorrhage (IVH) with blood present in both right and left ventricles (grades 3 and 2 respectively). The right ventricle was also enlarged.

Question 3

Describe the mechanisms for injury that were present in this situation.

According to Ballabh (2014), pathogenesis of intraventricular hemorrhage (IVH) is attributed to intrinsic fragility of immature, germinal matrix blood vessels and to the fluctuation in the cerebral blood flow. Fluctuation in the cerebral blood flow results from a wide range of respiratory and haemodynamic instability associated with preterm infants. The immature vessels are damaged / ruptured leading to bleeding of varying grades 1 to 4, associated with potential adverse outcomes.

Question 4

What potential care-giving practices need addressing in the prevention and management of IVH?

The avoidance of stress (caused for example, by suctioning, interventions, movement and transfer, unstable ventilation and blood pressure) is to be maintained especially in the early hours of life (including the Golden Hour) – some strategies are summarised in this Table ‘Prevention of Intraventricular hemorrhage’ provided by Ballabh (2014). Ensure gentle, minimal handling and pain and stress relief at all times as well as appropriate positioning and other care practices that protect the immature, vulnerable brain as highlighted in this concise blog as well as this review of practices to prevent IVH.

Follow-up head ultrasound scan at 14 days of age revealed further bleeding on the left side and ventricles were slightly dilated. However, he was extubated to continuous positive airways pressure (CPAP) on day 15 and further regular ultrasounds were planned as the parents had been told there was a risk of post-haemorrhagic hydrocephalus. Successive scans did show progressive dilatation of the ventricles. He also remained on low-flow oxygen for chronic lung disease.

Question 5

How should the team prepare the parents, Margaret and Oko, for Kwame’s discharge and how can they all work together to optimize his outcome?

The parents need to be kept fully informed and require open, honest information about Kwame’s potential outcome based on the information and available evidence. Working together to ensure the appropriate professionals are involved in his follow-up and community care is essential as well as educating parents to observe for signs of neurological compromise, sign-posting them to relevant services as appropriate. Any specific treatments required in the future need to be explained in full; for example, this paper by Roostan et al (2012) highlight the need for parents to regularly updated and the need for time to show, and explain to parents their baby’s daily ultrasound head scans to ensure they have a good understanding of what is happening.

Question 6

What is Kwame’s likely long-term outcome?

High IVH grade is strongly correlated with adverse neurodevelopmental outcome. The impact of an increased head circumference highlights the need for early management. CSF biomarkers and new medical treatments such as antenatal magnesium sulphate have emerged and could predict and improve the prognosis of these newborns with PHH- see a summary paper by Gilard et al (2018).

Case study 2: The infant with HIE

Chloe is a 41+3-week gestation female infant born by emergency Caesarian section subsequent to her mother being admitted due to antepartum bleeding and foetal bradycardia presenting during prolonged second stage of labour. Chloe was born pale, floppy, with no respiratory effort, and a heart rate of less than 60. She required inflation breaths followed by bag and mask ventilation, chest compressions, intubation and adrenaline. A fluid bolus of 10ml/kg/dose of normal saline was given for poor perfusion. Her first spontaneous respiration was noted at 10 minutes of age. Apgar scores were 1, 1, 5 and 7 at 1, 5, 10 and 15 minutes respectively. On admission to NICU her breathing pattern was stabilising but she was irritable with abnormal posturing. On the first arterial gas obtained, her pH was 6.9 with a base deficit of 16mEq/L.

Question 1

Why is therapeutic cooling likely to be beneficial to Chloe and what are the initial actions that must be taken at this point?

According to Jacobs et al (2013), there is evidence that induced hypothermia (cooling) of newborn babies who may have suffered from a lack of oxygen at birth reduces death or disability, without increasing disability in survivors. This means that the parents should expect that cooling will decrease their baby's chance of dying, and that if their baby survives, cooling will decrease his/her chance of major disability. Initials actions will be to perform passive cooling (open incubator doors, exposure) and follow the process to refer for therapeutic hypothermia which will involve transportation to a cooling centre.

Question 2

Describe the reasons for this in line with the criteria for this treatment.

Chloe fits the criteria for treatment with therapeutic hypothermia as can be seen in the available guidance from the TOBY trial / NPEU She is likely to have hypoxic-ischaemic-encephalopathy (HIE)- which is classed as mild, moderate or severe according to the presenting signs. The guidance also outlines an encephalopathy score. Chloe at present is showing she is moderate to severe HIE. A paper by Martinello et al (2017) provides an excellent, comprehensive summary of HIE, presentation and management.

Question 3

What should be explained to the parents?

This information guide provides an excellent resource for parents explaining HIE. The Bebop website is also a useful resource for parents.

The aEEG initially showed a discontinuous pattern without sleep–wake cycling; however, at 18 hours of age she was noted to have repetitive jerky movements of her upper extremities with eye flickering lasting 45 seconds. She was given a loading dose of phenobarbital for recurrent episodes of jerking movements correlating to seizure activity on aEEG.

Question 4

Describe the significance of seizures including their nature and timing.

As reported in the above paper by Martinelli et al (2017), seizures are a common feature of HIE. Approx. 34% of neonatal seizures have clinical features that can be seen and over 70% of what are thought to be seizures are not associated with an epileptiform picture on amplitude-integrated electroencephalography (aEEG), highlighting the importance of neurophysiological monitoring (cerebral function monitoring; CFM). These seizures appear to be myoclonic in nature as summarised in a useful online chapter. In HIE, seizures usually occur on day 1, and those seen prior to 6 hours of age should raise suspicion of earlier in utero insult. Seizures increase cerebral metabolic demand, trigger release of excitatory neurotransmitter and cause cardiorespiratory instability, all exacerbating neuronal injury with an impact on potential outcome.

Question 5

Identify and explain care-giving practices required while Chloe is being cooled.

This article by Chirinian and Mann (2011) summarises what nurses need to know about caring for the baby receiving therapeutic hypothermia treatment. Other nursing guidelines exist such as this one here and includes passive and active cooling, temperature monitoring, cerebral function monitoring, skin integrity and comfort measures.

Over the next 12 hours her seizures stopped. She was re-warmed after 72 hours of cooling and was extubated to room air. Over the course of the next 10 days Chloe established breast feeding well.

Question 6

What is Chloe’s long-term outcome likely to be and what do the parents need to be told?

As stated above, a Cochrane review reports benefits to outcomes from cooling stating that the benefits of cooling on survival and neurodevelopment outweigh the short-term adverse effects. This review recommends that hypothermia should be instituted in term and late preterm infants with moderate-to-severe hypoxic ischaemic encephalopathy if identified before six hours of age.  Parents as stated above need to be kept informed about the available evidence and this must be continued on any follow-up. Refer / sign-post the parents to useful information about brain injury and future development.

Case study 3: The infant with uncertain neurological outcome

Andreas is one of triplets born at 25 weeks gestation and is now 12 weeks old. Following a long period of respiratory support and stabilisation, he is now progressing in the special care are of the neonatal unit along with the other triplets, Marcos and Paul who are due to go home in the next few days. Andreas however has been much slower to get this point and suffered periods of being much more unstable both from a ventilation and blood pressure perspective. He also has two periods of infection requiring antibiotics which set his progress back. Andreas’s mother Beth also showed signs of infection during her pregnancy. The last few head ultrasound scans show that there are bilateral white, cystic appearances around the ventricle areas of the brain. He is presenting with some abnormal neurological signs.

Question 1

What is the significance of the information presented here in relation to a possible diagnosis relating to the brain?

Given the predisposing factors, ultrasound appearance and neurological signs, this is a picture of white matter injury or periventricular leukomalacia (PVL).

Question 2

What factors leading up to this point have pre-disposed Andreas to neurological compromise?

The most common antenatal events associated with PVL are: antepartum haemorrhage, chorioamnionitis, maternal trauma or severe maternal illness, embolic phenomena from a dead twin, possible maternal drug abuse (rare). Postnatal events associated with PVL include: Any cause of profound hypotension or cardiovascular collapse and inadvertent hypocapnia (low CO2) due to hyperventilation.

Question 3

In relation to the ‘abnormal’ neurology mentioned above, what might this be in relation to your nursing assessment of this infant?

Assessing the neonate may highlight a number of signs, many of which do not present until some time after birth. The following symptoms may develop over time: apnoea, delayed motor development, vision problems, seizures, weakness or altered muscle tone, primarily in the lower extremities. In infants at risk of PVL, scans must be brain ultrasound scans must be done and repeated regularly. As PVL may take up to 6 weeks to appear, this is important.

Question 4

What is the potential long-term outcome for Andreas?

Once cysts on the brain ultrasound appear, the prognosis is variable and depends on the site of the lesion (occipito-parietal worse than frontal). The outlook for children born with periventricular leukomalacia also depends on the amount of brain tissue damaged – some children will have minimal problems, but others may have severe disabilities. Periventricular leukomalacia is not a progressive disease, that is, it will not get any worse as a child grows older. PVL often develops into cerebral palsy, (CP) described as ‘’a group of developmental disorders of movement and posture, causing activity restrictions or disability that are attributed to disturbances occurring in the foetal or infant brain. The motor impairment may be accompanied by a seizure disorder and by impairment of sensation, cognition, communication, and/or behavior” (Rosenbaum, cited by Hadders-Algra (2014). PVL is commonly associated with spastic diplegia because of involvement of the internal capsule (leg >arm).

Question 5

What should the parents be told about this situation and how will they be facilitated / supported to improve future outcome?

Parents need information and need to know that PVL often develops into cerebral palsy (CP). This leaflet on CP and other parent information is available for sign-posting. They will need to be supported in the community setting and referred to parent groups and the multi-disciplinary team for follow-up and developmental intervention at home into childhood.

Test Your Knowledge: Crossword

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Open-access articles

Ahya, K. P., & Suryawanshi, P. (2018). Neonatal periventricular leukomalacia: current perspectives. Research and Reports in Neonatology8, 1-8.

Ballabh P. (2010). Intraventricular hemorrhage in premature infants: mechanism of disease. Pediatric research67(1), 1–8. doi:10.1203/PDR.0b013e3181c1b176

Ballabh P. (2013). Pathogenesis and prevention of intraventricular hemorrhage. Clinics in Perinatology41(1), 47–67. doi:10.1016/j.clp.2013.09.007

Bouyssi-Kobar, M., du Plessis, A. J., McCarter, R., Brossard-Racine, M., Murnick, J., Tinkleman, L., ... & Limperopoulos, C. (2016). Third trimester brain growth in preterm infants compared with in utero healthy fetuses. Pediatrics138(5).

Chirinian, N., & Mann, N. (2011). Therapeutic hypothermia for management of neonatal asphyxia: What nurses need to know. Critical Care Nurse31(3), e1-e12.

Dixon, B., Reis, C., Ho, W., Tang, J., & Zhang, J. (2015). Neuroprotective strategies after neonatal hypoxic ischemic encephalopathy. International Journal of Molecular Sciences16(9), 22368-22401.

Gilard, V., Chadie, A., Ferracci, F. X., Brasseur-Daudruy, M., Proust, F., Marret, S., & Curey, S. (2018). Post hemorrhagic hydrocephalus and neurodevelopmental outcomes in a context of neonatal intraventricular hemorrhage: an institutional experience in 122 preterm children. BMC Pediatrics18(1), 288. doi:10.1186/s12887-018-1249-x

Glass, H. C., Kan, J., Bonifacio, S. L., & Ferriero, D. M. (2012). Neonatal seizures: treatment practices among term and preterm infants. Pediatric Neurology, 46(2), 111–115. doi:10.1016/j.pediatrneurol.2011.11.006

Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD003311. DOI: 10.1002/14651858.CD003311.pub3     

Martinello, K., Hart, A. R., Yap, S., Mitra, S., & Robertson, N. J. (2017). Management and investigation of neonatal encephalopathy: 2017 update. Archives of Disease in Childhood-Fetal and Neonatal Edition102(4), F346-F358.

Montaldo P, Lally PJ, Oliveira V, et al Therapeutic hypothermia initiated within 6 hours of birth is associated with reduced brain injury on MR biomarkers in mild hypoxic-ischaemic encephalopathy: a non-randomised cohort study, Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 13 November 2018. doi: 10.1136/archdischild-2018-316040
Rennie JM, de Vries LS, Blennow M, et al (2018). Characterisation of neonatal seizures and their treatment using continuous EEG monitoring: a multicentre experience. Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 24 November 2018. doi: 10.1136/archdischild-2018-315624

Shankaran S. (2012). Therapeutic hypothermia for neonatal encephalopathy. Current treatment options in neurology14(6), 608–619. doi:10.1007/s11940-012-0200-y
Viaroli, F., Cheung, P. Y., O'Reilly, M., Polglase, G. R., Pichler, G., & Schmölzer, G. M. (2018). Reducing Brain Injury of Preterm Infants in the Delivery Room. Frontiers in Pediatrics6, 290. doi:10.3389/fped.2018.00290

Web-based resources

Baby Brain protection website- Resources for Health Professionals

The TOBY trial – Protocol for Therapeutic Cooling UK (NPEU)

Neonatal Seizures, Chapter 5 in The Epilepsies: Seizures, Syndromes and Management.

Take a look at the full list of Cochrane reviews to see what systematic reviews have been undertaken on various aspects of neurological specific neonatal care.

Chapter 15: Management of Haematological Disorders
Web-based resources written by: JULIA PETTY

Case study 1: The infant with jaundice on day 3 of life

Amy is an infant girl born at 37 weeks gestation, birthweight 2.4kg, second child to parents Bob and Karen. She has developed hyperbilirubinemia on day 3 of life and is transferred to the special care unit for observation and investigation. She looks visibly jaundiced.

With reference to the key points within the chapter, consider the following questions:

Question 1

What type of jaundice is Amy presenting with and what are the potential causes?

Physiological jaundice. This type of jaundice typically presents on the second or third day of life, and results from the increased production of bilirubin formed from the haemolysis of red blood cells and the breakdown of haem  (owing to increased circulating red cell mass and a shortened red cell lifespan) and the decreased excretion of bilirubin (owing to low concentrations of the hepatocyte binding protein, low activity of glucuronosyl transferase, and altered enterohepatic circulation) that normally occur in newborn babies. Read the first part of the article by Woodgate and Jardine (2011) for a clear overview.

Question 2

What other types of jaundice are there and what is the associated physiology?

Pathological Jaundice- Bilirubin levels with a deviation from the normal range and requiring intervention from day 1 of life due to a disease process that causes increased haemolysis (breakdown) of red blood cells. This may be caused by Rh or AB0 incompatibility or infection. Prolonged jaundice is the presence of clinical jaundice for more than 2 weeks. A summary paper distinguishes jaundice related to unconjugated (indirect) or conjugated (direct) hyperbilirubinemia. A prolonged unconjugated hyperbilirubinemia may be related to breastfeeding or to some pathological conditions as hemolytic diseases (due to G6PD deficiency), congenital hypothyroidism, urinary infection, Crigler-Najjar or Gilbert syndromes. Conjugated hyperbilirubinemia (cholestatic jaundice) is never physiologic. It should be suspected in all jaundiced infants with light stools and dark urine. Breast Feeding and Breast Milk Jaundice- Exclusively infants with breastfeeding have a different physiological pattern for jaundice compared with artificially feed babies. Possible reasons include a decreased caloric intake and inhibition of hepatic bilirubin excretion. Higher bilirubin levels have been reported in these infants and it may take 10–14 days after birth or may reoccur during the breast-feeding period. For a very comprehensive summary of all types of jaundice including further key literature sources – see CKS Summary of neonatal jaundice.

Question 3

What management and nursing care does this infant require?

Observation of clinical jaundice and assessment of transcutaneous or serum bilirubin (SBR) levels. Plot bilirubin level on the appropriate graph. Monitor levels regularly and continue to plot to see if the threshold for treatment is reached and if so, give phototherapy. See NICE guidance and the interactive flow chart for further detail. Exchange transfusion will be required if levels rise very high and do not respond to phototherapy. During phototherapy, the baby will require comfort measures, eye protection, full skin exposure (free of any creams) and continuation of enteral feeding while under phototherapy. Discontinue when once serum bilirubin has fallen to a level at least 50 micromol/litre below the phototherapy threshold (see threshold table and the treatment threshold graphs from the CG98 full guideline).

Question 4

What information do you require from the parents and what do you need to explain to them?

You will need to know if the baby has been feeding well, by what method and if and when the parents themselves have noticed any yellow appearance in the skin or sclera of the eyes. They will need reassurance and clear explanations of what jaundice is and what treatment is required. For example; clear language is as follows: Jaundice is a yellow colour of the skin and is common in newborn babies. Babies become jaundiced when they have too much bilirubin in their blood. Bilirubin is a pigment produced as red blood cells break down. It is usually processed by the liver and excreted in the baby’s stool. When a baby has jaundice, either too much bilirubin is being produced or the liver does not get rid of it quickly enough. A newborn baby’s liver is not fully matured, so jaundice is common during a baby’s first few days of life. Parent information can be found here in Information for the public from NICE.

Case study 2: The infant with abnormal blood results

Hassan is a 6-day old premature infant born at 29 weeks gestation who has been very unstable in his first few days of life and continues to show a fluctuating oxygen requirement, metabolic acidosis, possible signs of infection. He has umbilical catheters in situ and is fully monitored. His blood results show a low haemoglobin, prolonged clotting time and a low level of platelets.

With reference to the key points within the chapter, consider the following questions:

Question 1

What possible conditions is Hassan presenting with here and what are the underlying reasons for these blood results?

Hassan has a low haemoglobin (Hb) showing he is anaemic. This is likely due to both physiological reasons when the foetal Hb is reducing in early life exacerbated by frequent blood sampling necessary as part of his management. He also has reduced clotting factors and platelets which could be due to disseminated intravascular coagulation as a consequence of infection, where the blood forms micro-thrombi which uses up existing clotting factors needed for normal blood coagulation leading potentially to a higher bleeding risk. Low platelets is also known as thrombocytopenia and can also be as a consequence of infection.

Question 2

What is the associated management and nursing care of this infant in relation to theses specific findings?

Blood products may be required to correct these disorders given by transfusion; whole blood for anaemia, fresh frozen plasma and cryoprecipitate for DIC and platelets for thrombocytopenia. Hassan must also be observed for vital signs associated with anaemia such as poor oxygenation, respiratory compromise and pallor. Close assessment for signs of bleeding must also be undertaken, for example, via IV sites, ngt, urine and stool.

Question 3

How would you explain this to parents to reassure them?

Parents should be advised of the blood results and potential risks plus the reasons for any blood product transfusions. They can also be encouraged to observe Hassan for any bleeding or changes to his appearance and be part of the assessment.

Case study 3: The infant who has a high red cell load

Thomas is a 35 weeks gestation infant with intra-uterine growth restriction who is 1 day old. His blood results show he has a high packed cell volume (PCV) of > 65% and is experiencing respiratory distress at present, grunting and tachypnoea. With reference to the key points within the chapter, consider the following questions:

Question 1

What condition is Thomas presenting with here and what could be the potential underlying reasons for this blood result?

Polycythaemia – This is defined as venous haematocrit over 65%. The incidence of Polycythaemia in newborns is increased in those who are small for gestational age. Most infants with Polycythaemia are asymptomatic but in some symptoms do give cause for concern. The symptoms are related to increased blood viscosity and decreased blood flow to various organs such as the lungs as seen in this case with the presenting respiratory distress. Cardiorespiratory and neurological signs can also result. Features include cyanosis, tachypnoea, heart murmurs, congestive heart failure and cardiomegaly.

Question 2

What is the appropriate management and nursing care of this infant?

Packed cell volume (PCV) (otherwise known as haematocrit) needs to be measured from day 1 and monitored to see if the high red cell load will reduce without intervention. The infant needs to be kept well-hydrated and signs and symptoms must be observed for. If the PCV does not reduce, then a dilutional exchange transfusion may be required.

Question 3

What are the associated risks with this condition and how would you explain this to parents to reassure them?

The risks include thrombus formation in the blood vessels preventing adequate blood flow to organs such as the lungs and resultant signs of compromise. Parents need clear information about the reasons for blood tests and potential need for an exchange transfusion should the situation arise.

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Chapter 16: Fluid and Electrolyte Balance
Web-based resources written by: ALISON MITCHELL, ELLA PORTER & JULIA PETTY

Case study 1: Assessment and monitoring of fluid balance

Alice has twelve months’ neonatal experience; she is providing the neonatal nursing care for Fenna today. Fenna was born at 26 weeks gestation and she is 20 hours old. Her birthweight is 750g. Her Mum, Sara, has received antenatal steroids 48 hours ago due to preterm labour. Sara has been well in her pregnancy.

Currently Fenna is…

  • Ventilated but stable.
  • Has lines in situ; a double lumen umbilical venous catheter, an umbilical arterial line and a percutaneous long line.
  • Is receiving ambient humidity at 90%.
  • Incubator temperature is set at  37.50C.
  • Central temperature 37.30C and peripheral 36.80C - temperatures are stable.
  • HR 140, RR 60, BP 55/30mmHg, SaO2 93%.
  • Electrolytes - Sodium 137mmol/L, potassium 3.8mmol/L, glucose 4.8mmol/L.
  • Clear fluids and maintenance parenteral nutrition is being given. Fenna is nil by mouth.
  • Her skin feels sticky and warm to touch.
  • Activity - she is flexed and appears comfortable.

Address the questions below:

Question 1

How will you assess Fenna’s fluid and electrolyte balance

  • Do I need senior help? / SBAR.
  • Set the alarm parameters and check all the equipment is working.
  • Ascertain if Fenna’s parameters are normal - seek senior advice from the senior nurse/coordinator if there are any concerns.
  • The current parameters are within normal limits but Fenna may become unstable & therefore requires close monitoring.
  • Monitor temperature / HR / BP /Saturations, colour, perfusion / CRT, glucose, incubator temperature.
  • Blood electrolyte values.
  • Maintain high ambient humidity in the incubator. 
  • Weigh daily, monitor and record hourly urine output, daily urinalysis, orogastric losses].

Question 2

How will you monitor her fluid intake and output and minimise her heat and water losses?

  • Identify the total fluid requirements Fenna needs today.
  • Calculate fluids on current weight or birthweight if this exceeds the current weight to ensure calorie intake.
  • Infuse fluids at the recommended volume for her age - 10% glucose &/or total parenteral nutrition.
  • Use a phlebitis or VIP score to ensure the intravenous lines remain patent and Fenna remains comfortable.
  • Ensure Fennas’ blood results are within a normal range.
  • Keep the incubator doors closed/ empty the ventilator tubes to prevent rainout and cooling. Promote minimal handling, cluster activities to allow Fenna to rest.
  • Maintain humidity of 80-90% or above for the next 24-48 hours. Reduce as unit policy dictates.
  • Sodium levels and other electrolytes may be unstable for a few days. Sodium follows water. If there are high insensible water losses, her weight will fall, the sodium level will increase. Sodium & other electrolytes are likely to be checked 8-12 hourly.  High levels of sodium can cause long term neurological problems.  Regularly monitor the laboratory /blood gases to guide amendments to the fluid & electrolyte regimes.
  • Record strict fluid balance- input & output.
  • Weigh all nappies (must be weighed naked) to ensure accuracy.
  • Note frequency of passing urine and opening bowels.
  • 12-24-hour urinalysis. Fenna may not be in the diuretic phase of her respiratory disease.
  • At risk of hypoglycaemia /hyperglycaemia. Consider also that Fenna has limited fat stores. The glucose levels in TPN may not be tolerated. As Fenna is sick, extremely premature and she is at risk of an osmotic diuresis (increased urine output)- N.B- normal output is 1mL/kg/hour at 20 hours of age and therefore watch for the risk of dehydration].

Question 3

Outline the observations you would undertake each hour.

  • Record temperature (central and peripheral if both are monitored- If so, the difference should be less than 1-2°C, which indicates good perfusion).
  • General wellbeing.
  • HR 110-180.
  • BP mean = gestational age.
  • Saturations 90-95%.
  • Colour/perfusion
  •  CRT-should ideally be less than 2 seconds.
  • Glucose 2.6 - 7mmol/l- indicates normoglycaemia.
  • Temperature and % humidity in the incubator and ventilator chamber.
  • Weigh daily.
  • Ensure Sara and her partner are updated about Fenna’s progress today].

Case study 2: The infant who is volume depleted

Molly has just been transferred back to her referring neonatal unit after a period in another unit where she has gone for stabilisation and respiratory management on day 1 of life. She was born at 25 weeks gestation and is now two weeks old. She is on parenteral nutrition and a small amount of enteral feed (breastmilk) via a nasogastric tube and is on nasal CPAP. Her intravenous long line appears to have ceased working properly and her peripheral cannula has tissued. Her gastric aspirates are larger than previously noted and she is not tolerating her milk. On assessment, it is noted that she looks ‘dry’, and Molly’s parents comment that she does not look right, particularly her skin colour.

Question 1

What assessment is required on Molly in relation to her fluid balance?

clinical appearance, assessment of input and output / balance, blood electrolyte values

Question 2

How will she present if she is fluid-depleted?

signs of dehydration are: reduced skin turgor, sunken fontanelle, sunken eyes, reduced urine output, high urine specific gravity, tachycardia. See NICE guidance section 1.2.7 Table 1. She may also present with high blood sodium should blood be taken for any reason

Question 3

What fluid management and nursing care will Molly need?

re-establishment of intravenous access for continued TPN / IV fluids, keep NBM currently and re-attempt small amount of enteral feed via a newly passed nasogastric tube once she is settled after her transfer and re-assess the gastric aspirates, assess heart rate and other vital signs, re-assess / evaluate regularly to ensure re-hydration

Question 4

What advice do the parents require?

They need to be informed that Molly is potentially dehydrated due to a period without fluids or feed and that she is to be re-hydrated and re-assessed. They can continue to observe their daughter to see if her colour improves. Mum should continue to be encouraged and supported to express her milk

The infant with fluid imbalance

Ali is a term infant admitted to the neonatal unit at birth with meconium aspiration. He has been very unwell with high oxygen and ventilatory requirements and on the ward round, Ali’s father comments that he looks very ‘puffy’ compared to the previous day. His chest X-ray shows a white appearance through both lungs, again different to previous.

Question 1

What do you think the reasons are for these observations?

There are signs of fluid leaking into the extracellular space because of Ali’s current condition / possible fluid overload

Question 2

Can you explain the physiology behind this picture?

Peripheral oedema and pulmonary oedema occurs due to fluid entering the interstitial space (from the intracellular spaces) during illness / hypoxia which affects the cell membrane permeability. There may also be a possibility of kidney compromise due to being so unwell / hypoxic

Question 3

What fluid management and nursing care will Ali need?

Assess urine output and vital signs (heart rate, blood pressure, oxygen saturations) and ensure these are stable / adequate- it is important to ensure that there is no compromise to the intravascular (blood) fluid volume. Ensure Ali is well oxygenated. Fluids may need to be restricted until fluid balance has stabilised

Question 4

How would you explain this to the parents?

The parents require explanations and reassurance that this is due to Ali being compromised at present along with the reasons given as to why this situation has occurred

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Open-access articles

Norwood, J,  Morgan, H and Gill, A. (2012). Principles of fluid management for paediatric patients. The Pharmaceutical Journal.

Abitbol, C. L., DeFreitas, M. J., & Strauss, J. (2016). Assessment of kidney function in preterm infants: lifelong implications. Pediatric Nephrology31(12), 2213-2222.

Rozance, P. J., & Hay, W. W. (2016). New approaches to management of neonatal hypoglycemia. Maternal health, neonatology and perinatology2(1), 3.

Modi (2004) Management of fluid balance in the very immature neonate. Archives Disease in Children Fetal and Neonatal edition

Web-based resources

Fluid management in infants and your children NICE guidance

Fluid and electrolyte management in the neonate


Fluid and Electrolytes: Everything You Need to Know!  (8.27 minutes)
Nurse Bass

Internal medicine: Hyperkalaemia by Dr Ben Schelem (3.14 mins)

Peritoneal dialysis by Sharon Su for OPEN pediatrics(15.58mins)

How do your kidneys work? Emma Bryce-  simple explanations (3.54 mins)

The kidney and the nephron. Renal system physiology Khan academy (Detailed physiology18.37 mins)

Hyponatremia explained with animation Hippocra TV (3.30mins)

Hyponatraemia EXPLAINED Hippocra TV (3.30 MINS)

Urine osmolality vs serum osmolality Hippocra TV (1.15 mins)

SIADH – Syndrome of Inappropriate Antidiuretic Hormone (1.15mins)

Chapter 17: Nutrition and feeding in the neonatal unit
Web-based resources written by: KAYE SPENCE AND ALEXANDRA CONNOLLY

Case study 1: Nutrition management for a preterm infant

oseph was born at 26 weeks’ gestation. He was the first child of a young married couple. At birth, Joseph breathed spontaneously and required minimal resuscitation. He was transferred to the NICU. His birth weight was 780g. An arterial blood gas and chest X-ray indicated respiratory distress syndrome and he was intubated, received surfactant and was ventilated. Joseph required assisted ventilation for the first two days then he was extubated and placed on CPAP. He was nursed in a double-walled incubator and was requiring supplemental oxygen of 25 per cent.  His weight at two weeks of age when plotted on the growth chart was less than the 3rd centile. Joseph’s mother was with him each day and was expressing good volumes of milk. She was keen to be able to eventually breastfeed. Her concern was for his future and that he would develop normally.

Question 1

What would be the most appropriate method to supply Joseph’s nutritional requirements for the first week of his life?

Preference would be for commencement of small volumes of his mother’s milk to help prime his gut and consider the intestinal flora. In addition, as he is preterm and below the 3rd centile at birth, it is important that adequate nutrients are provided due to the high energy demands of his brain and heart. Total Parenteral Nutrition (TPN) through a central venous catheter would be the best option].

Question 2

What risk factors may impact on Joseph commencing enteral feeds?

The potential limited ability of his mother to supply breast milk may be a risk factor due to stress. Therefore, supporting and helping her to express milk and to alleviate any stress she has is essential and to enable her to have a good supply. Consider ways to support Joseph’s mother. In addition, breastmilk alone may not provide the complete nutritional needs of Joseph for his growth and brain. Human milk fortification is supported by the evidence in relation to weight gain, growth in head circumference as well as neurodevelopmental outcomes.

Question 3

Once Joseph was to commence enteral feeds, what method would be appropriate for him?

As Joseph weighs only 780 grams, a gastric tube would be required. He remains on oxygen and in order to not compromise his breathing, the small-bore feeding tube would be placed orally. The position and guide for checking the tube would be carried out according to the NHS safety notice. After reading the safety notice, consider your own practice and if your NICU complies with this notice (or similar in another country).

Question 4

How would you reliably assess the outcome of Joseph’s nutritional goals?

The most readily accessible method is to measure his growth which includes weight, length and head circumference. The ponderal index, which is a calculation of body weight and length, gives an indication of the quality of the growth by relating the body weight to the overall length. (PI = weight (grams) /crown-heel-length (cm) x 100. If <2 =asymmetric IUGR, >2.5= health growth proportion).  Length and head circumference are important to measure as they are indices of skeletal and organ growth, whereas weight may change due to fluid balance changes and fat disposition. Growth is not linear and is characterised by growth spurts and stagnation making the interpretation of daily weights difficult. Accuracy is ensured by weighing at the same time each day, on the same scales, before feeds and have a second nurse check the weight.

Question 5

What are some strategies you could implement to improve Joseph’s growth?

Examine the five steps provided in table 17.2 in the book. Ensure all nutrients are delivered and received avoiding any prolonged delays or gaps in feeding, and if this occurs document any variances. Measure growth and consider using the z-scores to get an accurate indicator of Joseph’s growth during hospitalisation, particularly if he remains in hospital for a prolonged time due to his chronic lung disease. For more information on the use of z-scores, read the on-line resource of Riddle & DonLevy (2010).

Case study 2: Support for successful breast-feeding in the neonatal unit

Olga, mother of Francesca born at 26 weeks gestation, struggled to express her breast-milk in the early days of her baby’s life. After a significant amount of support and advice from various people and sources, she finally managed to produce enough breast milk to store in readiness for when Francesca started to feed enterally.

Question 1

What advice and support do you think was given to Olga to enable her to eventually produce and express sufficient qualities of breast milk?

Provision of facilities for her to express her milk, encouragement to express milk at least 8 times a day while lactation is being established, including overnight, ensuring she has access to the use of a breast pump. It would also be important to remind her that, to maintain her lactation, she will need to express regularly until the baby can start to feed. Provision of information is also helpful for parents from sources such as Unicef and / or the breast feeding network. It is also important for neonatal staff to be up-to-date by referring to key guidance to support feeding in the neonatal unit

Later when Francesca’s condition had improved, and she was 7 weeks old, Olga strongly wanted to breast feed her baby. However, again, she required assistance to successfully do this

Question 2

Which members of the neonatal multidisciplinary team would be required to assist her?

Preferably a feeding support specialist, if available, would be able to support her along with additional support from the neonatal nursing team. Some units have peer support / volunteers to also assist and advise with breast-feeding].

Question 3

How would Francesca’s readiness to feed be assessed?

According to Harding et al (2015), alertness, hunger signs and non-nutritive sucking competence can be assessed in combination with a review of successful weight gain, respiratory stability and general physiological stability before a tube feed or when suckling on an empty expressed breast nipple]. Parents/carers should be supported to identify readiness signs during early caregiving activities such as skin to skin, sensitive mouth cares and/or tube feeding. See IFDC app Chapter 14 (reference in web-based resources) Involve other members of the neonatal feeding team if readiness signs are not observed as expected. e.g. Speech and Language Therapist, Occupational Therapist

Question 4

How would this feeding assessment be integrated with the principles of developmental care outlined in chapter 5?

Case study 3: The very low birthweight infant

Tommy is a 36-week gestation baby with a very low birthweight; his weight is under the 3rd centile and this was due to placental problems during pregnancy leading to poor foetal growth. He required enteral feeding by nasogastric tube as well as orally when he was admitted to the neonatal unit as he lost a significant amount of weight in the first few days after delivery and had a very low blood sugar. His mum was not well and was in intensive care with pre-eclampsia, so breast milk was not available. A later problem was severe reflux which impacted on the time taken to reach an adequate weight and tolerate full feeding requirements.

Question 1

Why was it important that Tommy was enterally fed so early?

Enteral feeding was essential to address the low blood sugar and weight loss and ensure that there was no delay to receiving adequate nutrition in the early days. Delaying feeding can lead to problems with extra-uterine adaptation and lead to hypoglycaemia, jaundice, delayed gut stimulation

Question 2

Can you identify key strategies you would employ in this situation to ensure adequate nutrition and feeding tolerance, in line with both management of his growth restriction, poor weight gain and later, the gastroesophageal reflux?

Ensure regular feeding on demand as soon as possible to replace nasogastric route, weigh daily and monitor closely, encourage and support breast-feeding once mum’s condition has improved and she wishes to do so, liaise with dietician if required if weight gain does not improve, consider supplementation. For the later reflux, refer to guidelines on the management of gastro-oesophageal reflux disease.

Open-access articles

Dutta, S., Singh, B., Chessell, L., Wilson, J., Janes, M., McDonald, K., … Fusch, C. (2015). Guidelines for feeding very low birth weight infants. Nutrients7(1), 423–442. doi:10.3390/nu7010423

Hay W. W., Jr (2018). Nutritional Support Strategies for the Preterm Infant in the Neonatal Intensive Care Unit. Pediatric Gastroenterology, Hepatology & Nutrition21(4), 234–247. doi:10.5223/pghn.2018.21.4.234

Riddle, W.R., & DonLevy, S. C. (2010) Generating expected growth curves and Z-scores for premature infants. Journal of Perinatology 30, 741–750   This article provides detailed information about growth curves and how z-scores can be used.

Parker, L., Murgas Torrazza, R., Li, Y., Talaga, E., Shuster, J., Neu J. (2015) Aspiration and Evaluation of Gastric Residuals in the Neonatal Intensive Care Unit.  J Perinatal and Neonatal Nurs 29, 1:51–59    Read this article and think about the practice in your unit regarding gastric residuals. How are they managed?

Underwood M. A. (2012). Human milk for the premature infant. Pediatric Clinics of North America60(1), 189–207. doi:10.1016/j.pcl.2012.09.008

Visuthranukul, C., Abrams, S. A., Hawthorne, K. M., Hagan, J. L., & Hair, A. B. (2018). Premature small for gestational age infants fed an exclusive human milk-based diet achieve catch-up growth without metabolic consequences at 2 years of age. Archives of Disease in Childhood-Fetal and Neonatal Edition, fetalneonatal-2017.

White-Traut, R., Shapiro, N., Healy-Baker, E., Menchavez, L., Rankin, K., & Medoff-Cooper, B. (2013). Lack of feeding progression in a preterm infant: a case study. Advances in neonatal care : official journal of the National Association of Neonatal Nurses, 13(3), 175–180.

Web-based resources

European Standards for the care of newborn health: Nutrition

The UNICEF Baby Friendly Initiative: A worldwide programme to of the World Health Organization and UNICEF to support breastfeeding and parent-baby relationships.
Small Wonders: Best Beginnings: A series of 12 films by Best Beginnings that follow 14 families on their journey from birth to first contact with their baby, to one year on.
Cochrane Neonatal reviews  - scroll through the full list of reviews as there are numerous ones available on feeding methods, issues and supplementation such as; Greene  Z, O'Donnell  CPF, Walshe  M. Oral stimulation for promoting oral feeding in preterm infants. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD009720. DOI: 10.1002/14651858.CD009720.pub2. 

Reducing the harm caused by misplaced naso and orogastric feeding tubes in babies under the care of neonatal units. Reducing harm, confirming and checking tube placement. NHS.   Read these safety alerts and consider your own practice in terms of placement and checking gastric tubes. Do you comply? Are these resources available in your NICU?

Imperial College Healthcare NHS Trust 'Integrated Family Delivered Neonatal Care' IFDC app. Apple app store (2018) Use this app for detailed current information written specifically for parents by a neonatal multi-disciplinary team. The app can be used by parents on any neonatal unit or as a learning tool for any member of the neonatal team. Refer to Chapter 14 ‘The Journey to suck feeding’ for practical information and descriptions of supportive interventions carried out by both parents/carers and nurses.

Further Reading:

Rennie, J., Kendall, G. (2013). Part 3 – Nutrition and Electrolyte Balance in A Manual of Neonatal Intensive Care Fifth Edition. London: CRC Press. pp 79-112. This chapter provides a ready reference for the specific nutritional requirements for both preterm and term infants in the NICU. In addition, the section of Parenteral Nutrition provides useful information of the complications in providing PN using a variety of devices.

Chapter 18: Neonatal Infection
Chapter written by: LISA KAISER
Web-based resources written by: LISA KAISER & JULIA PETTY

Case Study 1: Early-onset infection in a term neonate

Esme is a term baby born vaginally to a second-time mother after 42 hours rupture of the membranes. She was admitted to the neonatal unit (NNU) as she developed severe respiratory distress in the delivery room and commenced on CPAP, requiring 35 – 40% oxygen to maintain normal saturations. She continues to have significant subcostal recession and is noted to be grunting, which worsens with handling. Following admission, Esme was started on benzylpenicillin and gentamicin following a partial septic screen, and she is NBM on IV fluids. Esme’s chest x-ray shows bilateral ‘ground-glass’ consolidation. After 2 hours her blood gases still show a respiratory acidosis, her oxygen-requirements are climbing, and her work of breathing is worsening. Her blood results show a raised white cell count (WCC), and her initial C-Reactive protein (CRP) is 27mg/L.

Question 1

What is Esme’s diagnosis likely to be? Can you think of a pathogen which typically presents like this?

While differential diagnoses such as transient tachypnoea of the newborn and respiratory distress syndrome need to be considered as they can present in a similar way, the likely diagnosis here is congenital infection based on the blood results. The CXR changes make a diagnosis of congenital pneumonia most likely. The probable pathogen is Streptococcus agalactiae (Group B Streptococcus), but as blood cultures are not very diagnostically sensitive, this may not be identified. Read the open access paper by Heath and Jardine (2014) to update your knowledge of Group B Streptococcal infection in the newborn.

Question 2

Do you think Esme’s condition is likely to improve over the next few hours? What other supportive treatment may be required in this case?

Whilst IV antibiotics start taking effect immediately, it may well be that Esme deteriorates further and will require ongoing respiratory support. She may even need to be ventilated and require surfactant administration. Esme needs to be closely monitored with respect to her other parameters. In overwhelming sepsis, neonates often require inotropic support, potentially blood product administration to address coagulopathy or thrombocytopenia, and intravenous nutrition. Read the open access paper by Edmond and Zaidi (2010) for an overview of treatments for neonatal infection.

Question 3

Which other investigations may need to be considered here?

Despite the fact that a likely diagnosis here is pneumonia, meningitis must be ruled out by performing a lumbar puncture, providing Esme is stable enough to tolerate the procedure. Read the open access paper by Morinis et al (2011) for some more case studies on babies with GBS infection and the associated care and management.

Case Study 2: The extremely preterm NICU resident

Harry is a 39-day old baby born at 24+6 weeks. He now weighs 984grams. He is currently stable on Optiflow 6L in 28 – 34% and on a combination of nasogastric feeds of maternal breastmilk and TPN through a CVC to aid his growth. This was inserted when he was a week old.

Question 1

What measures can you take to help prevent Harry developing CVC-related infection?

Most importantly, good hand hygiene; minimising the number of different healthcare professionals who touch Harry; good aseptic non-touch technique with any access to the line and minimising line breakages. Read the open access paper by Marchant et al (2013) for an overview of Coagulase- negative staphylococcal infection (CONS), a common pathogen / cause of late-onset neonatal infection in the NNU .

Question 2

Which changes in his observations would make you concerned that he may be septic?

Changes in behaviour such as poor tolerance of handling/lethargy; changes in his observations such as elevated heart rate and/or temperature, or temperature instability; increased episodes of apnoeas/desaturations/bradycardias; poor feed tolerance with increased vomits, abdominal distension or bilious aspirates; rely on Mum’s gut feeling here – if she thinks Harry ‘just isn’t himself’, listen to her!

Question 3

Is there anything you would like to discuss with the medical team on Harry’s ward round this morning?

Harry still weighs less than 1kg, so the benefits of continuing combination feeds of TPN and enteral feeds are important. However, bring to the medical team’s attention how long the CVC has been in situ, so that this is considered on a daily basis and regarded as a likely cause should Harry deteriorate with suspected infection..

Case Study 3: Unexpected admission from the postnatal ward

Baby Tariq, a term baby boy, is admitted to the NNU from the postnatal ward at age 2 hours of age following an episode of becoming cyanosed. On assessment, the midwife heard respiratory grunting and his breathing rate had become more rapid, with his colour looking pale and mottled.

Question 1

What do you think is going on here and what risk factors would you need to consider in relation to his birth, delivery and details about his mother’s health?

Infection is the most likely explanation for Tariq’s condition. Differential diagnosis may also be aspiration, presence of a heart defect and respiratory distress syndrome. The presenting signs can also fit the picture of early-onset infection due to a specific pathogen – read here about Early onset sepsis. You would need to consider any risk factors that may have been present during pregnancy and delivery such as maternal infection (fever, raised CRP, offensive liquor, other signs of generalised / viral infection), previous group B streptococcal infection. This open access paper provides a summary of risk factors for early-onset infection in the newborn.

Question 2

What nursing assessment would he require?

A septic screen is required which includes blood sampling for culture / microscopy, full blood count and inflammatory markers such as CRP (C-reactive protein), clinical assessment including colour, perfusion, signs of skin rash or jaundice and general appearance /behaviour along with vital signs / monitoring (especially central temperature, heart rate, respiratory rate & oxygen saturations). You should check a blood gas, to establish whether Tariq may require respiratory support. A lumbar puncture may also be necessary, depending on CRP findings. As Tariq presented with respiratory signs, a chest X-ray should be done – this could identify congenital pneumonia, transient tachypnoea of the newborn, or respiratory distress syndrome.

Consider signs and symptoms for all systems – respiratory, cardiovascular, gastrointestinal, hepatic, skin, renal / fluid status and neurological. As an example, infants with neonatal infection may have the following symptoms, across many body systems:

  • Body temperature changes
  • Respiratory distress (tachypnoea, dyspnoea such as recession/nasal flaring, apnoea)
  • Absence of bowel movements +/- abdominal distension and bile-stained aspirates/vomits secondary to a septic ileus
  • Low blood sugar
  • Reduced movements, poor tone, lethargy
  • Poor feeding
  • Seizures

Also, consider the previous two case studies for information on signs and symptoms of infection. The NICE guidance on neonatal infection can be read for a clear overview.

Question 3

What would you explain to the parents and how would they be supported at this time?

Honest and open information should be given to the parents as for all conditions presenting in neonatal care. They need to understand the reasons for admission and the treatment / care that their baby will require. NICE has written information for the public on neonatal infection which provides a clear summary of what to inform parents.

Knowledge Quiz

Question 1

Name 3 differences to do with the immune system which make neonates more susceptible to infections than adults?

placental transfer of IgG antibodies takes place in the third trimester, ineffective first line barriers (skin, mucosa), immaturity of T-Cells and B-Cells, reduced efficacy of phagocytes.

Question 2

What do you understand by ‘vertical’ as opposed to ‘horizontal’ transmission of infection?

Vertical transmission is transplacental or ascending vaginal infection; horizontal infection refers to nosocomial transmission..

Question 3

Which is the most common causative pathogen for EOS?

Streptococcus agalactiae (GBS).

Question 4

Name 3 risk factors for EOS!

Invasive group B streptococcal infection in a previous baby, maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy, prelabour rupture of membranes, preterm birth following spontaneous labour (before 37 weeks’ gestation), suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth, intrapartum fever higher than 38˚C, or confirmed or suspected chorioamnionitis.

Question 5

Which pathogen is highly associated with meconium-staining of the liquor?

Listeria monocytogenes.

Question 6

Which combination of antibiotics is the treatment of choice for EOS according to the NICE guidelines, and why?

Benzylpenicillin and gentamicin – in combination they provide synergistic cover for many gram positive and gram-negative pathogens.

Question 7

Name 5 risk factors for LOS?

Extreme prematurity, poor immune responses, prolonged hospitalisation, exposure to healthcare professionals, exposure to shared equipment, exposure to nosocomial pathogens, delay in enteral breast milk administration, prolonged presence of CVCs and administration of parenteral nutrition, prolonged ventilation.

Question 8

Can you name some considerations to be taken into account for infants treated with vancomycin?

Drug level monitoring as it is nephrotoxic and ototoxic, slow administration to avoid ‘red man syndrome’, significant association with emerging resistance.

Question 9

Can you name the signs commonly seen in infants born with a viral infection from the TORCH group?

Growth restriction, petechial rash, jaundice, hepatosplenomegaly, sometimes thrombocytopenia; may be systemically ill.

Question 10

What feeding advice would you give to a mother who is HIV positive?

In the UK, it is advised that HIV positive women should not breastfeed to minimise the risk of transmission..

Question 11

Name 10 signs of neonatal infection.

Choose from various examples such as…..respiratory (tachypnoea, dyspnea, apnoea, cyanosis, low oxygen saturations), thermal instability, skin (pallor, rashes, jaundice), cardiovascular (tachycardia, poor perfusion, slow capillary refill time), haematological (abnormal white cell count, high CRP, electrolyte inconsistencies), gastrointestinal (changes to stool, increased gastric aspirates, bowel changes, low blood sugar) and neurological signs (behaviour, tone and movement changes / signs).

Question 12

What do you understand by a partial septic screen?

Blood culture, full blood count, CRP.

Question 13

Name 5 ways in which neonatal nurses can contribute to infection prevention?

Hand hygiene education and monitoring, adherence to CVC care bundles (inc. aseptic techniques when access is required, partake in daily discussion of ongoing need, review of the insertion site), consideration of antifungal prophylaxis with antibiotic treatments, advocacy of early breast milk administration and supporting mothers with expressing their milk early on, judicious use of endotracheal suction..

Open-access articles

Camacho-Gonzalez, A., Spearman, P. W., & Stoll, B. J. (2013). Neonatal infectious diseases: evaluation of neonatal sepsis. Pediatric Clinics of North America, 60(2), 367–389. doi:10.1016/j.pcl.2012.12.003

Edmond, K., & Zaidi, A. (2010). New approaches to preventing, diagnosing, and treating neonatal sepsis. PLoS medicine, 7(3), e1000213. doi:10.1371/journal.pmed.1000213

Heath, P. T., & Jardine, L. A. (2014). Neonatal infections: group B streptococcus. BMJ Clinical Evidence, 2014, 0323.

Marchant, E. A., Boyce, G. K., Sadarangani, M., & Lavoie, P. M. (2013). Neonatal sepsis due to coagulase-negative staphylococci. Clinical & Developmental Immunology, 2013, 586076. doi:10.1155/2013/586076

Morinis, J., Shah, J., Murthy, P., & Fulford, M. (2011). Horizontal transmission of group B streptococcus in a neonatal intensive care unit. Paediatrics & Child Health, 16(6), e48–e50

Mukhopadhyay, S., & Puopolo, K. M. (2012). Risk assessment in neonatal early onset sepsis. Seminars in Perinatology, 36(6), 408–415. doi:10.1053/j.semperi.2012.06.002

Patras, K. A., & Nizet, V. (2018). Group B Streptococcal Maternal Colonization and Neonatal Disease: Molecular Mechanisms and Preventative Approaches. Frontiers in Pediatrics, 6, 27. doi:10.3389/fped.2018.00027

Ramasethu, J. (2017). Prevention and treatment of neonatal nosocomial infections.  Maternal Health, Neonatology and Perinatology 3(5)

Shah, B. A., & Padbury, J. F. (2013). Neonatal sepsis: an old problem with new insights. Virulence, 5(1), 170–178. doi:10.4161/viru.26906

Seale, A. C., & Agarwal, R. (2018). Improving management of neonatal infections. The Lancet, 392(10142), 100-102. doi:10.1016/S0140-6736(18)31432-6

Shane, A. L., Sánchez, P. J., & Stoll, B. J. (2017). Neonatal sepsis. The Lancet, 390(10104), 1770-1780.

Vergnano S, Menson E, Kennea N, et al (2011). Neonatal infections in England: the NeonIN surveillance network. Archives of Disease in Childhood - Fetal and Neonatal Edition. 96, F9-F14.

Web-based resources

Group B Strep Support (GBSS) Resources resources

Management of meningitis in infants less than 3 months

National Institute for Health and Clinical Excellence (2014a) Antibiotics for early-onset neonatal infection. NICE clinical guideline 149.

National Institute for Health and Clinical Excellence (2014b) Neonatal Infection.

National Institute for Health and Care Excellence. (2016). Sepsis: recognition, diagnosis and early management.

Chapter 19: Medication practice in the neonatal unit
Chapter written by: KAREN HOOVER
Web-based resources written by: KAREN HOOVER AND JULIA PETTY

Case Study 1: The preterm infant who has become unwell

Jonathan was born at 25 weeks gestation and is now 3 weeks old. He has developed signs of necrotising enterocolitis (NEC) and has been prescribed cefotaxime 6 hourly and metronidazole IV as a loading dose, followed by a maintenance dose after 24 hours.

Question 1

Why is cefotaxime prescribed 6 hourly for this baby?

The half-life is the period of time required for a drug’s concentration to be reduced by half and depends on how quickly a drug is eliminated. Half-life decreases as the baby gets older and kidney filtration improves. This is independent of gestational age at birth. At 3 weeks old, the half-life would necessitate the drug being given 6 hourly.

Question 2

How often would you expect it to be prescribed in a 1-day old baby?

In a one-day old baby the half-life of cefotaxime is 2-6 hours with the more premature baby having the longer time. Therefore, the drug needs to be given 12 hourly, or the levels will fall to sub therapeutic levels.

Question 3

Why does metronidazole need a loading dose?

A loading dose allows drugs with a long half-life such as metronidazole to achieve steady state where the amount of drug administered equals the amount eliminated. The loading dose ensures the desired effect is achieved more rapidly.

Question 4

Why is the next dose not given for 24 hours?

The next dose is not given for 24 hours because drugs with long half- lives mean they take longer to be eliminated, and if given sooner, would reach toxic levels.

Question 5

What drug(s) would you consider for pain management?

An opioid drug such as morphine would be needed. According to Hall et al (2014), Opioids provide the most effective therapy for moderate to severe pain. They produce both analgesia and sedation, have a wide therapeutic window, and also attenuate the physiologic stress responses of neonates. Later on, once the NEC has been addressed and no longer presents a problem, morphine can be weaned while paracetamol is added.

Jonathan becomes increasingly unwell and is intubated and ventilated, then is started on dopamine and dobutamine infusions for hypotension.

Question 6

Why are some drugs given by continuous infusion?

Drugs with very short half -lives such as dopamine need to be given by continuous infusion to allow adequate therapeutic levels to be achieved quickly and maintained at therapeutic levels.

Question 7

What factors predispose this baby to medication errors?

The factors that predispose this baby to medication errors are the same as for all neonates, although the smaller size and immaturity of the premature neonate make them even more vulnerable. These factors include: The widespread use of unlicensed and off label medications which increases the risk of dosing errors and the use of complex calculations and preparation, often using adult dosing vials when only small amounts of the drug are required.

Question 8

What are the potential side-effects of inotropes such as dopamine and dobutamine?

Dopamine is a cardiac stimulant which acts on beta1 receptors in cardiac muscle, and increases contractility with little effect on rate. The potential side effects include vasoconstriction, hypertension, dyspnoea. Dobutamine is also a cardiac stimulant which acts on beta1 receptors in cardiac muscle and increases contractility with similar side effects although hypertension is rare.

After a period of stabilisation, Jonathan improves and at the age of 5 weeks is being weaned from ventilation requirements. He is commenced on caffeine as part of this management.

Question 9

Why is caffeine given?

Caffeine is given as a respiratory stimulant. The pharmacological effects of caffeine in apnoea of prematurity include: (1) stimulation of the respiratory centre in the medulla; (2) increased sensitivity to carbon dioxide; (3) increased skeletal muscle tone; (4) enhanced diaphragmatic contractility; (5) increased minute ventilation; (6) increased metabolic rate; and (7) increased oxygen consumption. Caffeine also stimulates the central nervous and cardiovascular systems, enhances catecholamine secretion, has a diuretic effect, and alters glucose homeostasis.

Case Study 2: Medication during therapeutic hypothermia

Caroline is a 2-day old term baby undergoing therapeutic hypothermia (TH) for hypoxic-ischaemic encephalopathy (HIE). She was commenced on gentamicin after birth but has now developed renal failure. She is also receiving phenobarbital, a morphine infusion, and a dopamine infusion.

Question 1

How is drug metabolism affected by TH?

Many drugs are metabolised by liver enzymes and these are temperature dependant. Therefore, this can lead to a lack of action for some drugs and accumulation of others. Drug metabolism also changes during rewarming and some drugs such as fentanyl which have been dormant in peripheral tissues are recirculated increasing the risk of toxicity. See this review by Zanelli et al (2011).

Question 2

Does the gentamicin dosage need amending and why?

Hypothermia induces vasoconstriction which decreases glomerular filtration rate (GFR) and elimination of renally excreted drugs such as gentamicin. Renal impairment is common in neonates undergoing therapeutic hypothermia and so drugs excreted via the kidneys like gentamicin will require adjustment of dosage to prevent toxicity.

Question 3

What are the potential side-effects of morphine and phenobarbitone?

Potential side-effects of morphine include hypotension (with high doses); nausea (more common on initiation); respiratory depression (with high doses); skin reactions; urinary retention. Potential side-effects of phenobarbital include drowsiness and respiratory depression.

Case Study 3: The late preterm infant with multiple issues

A new mother of a 35-week gestation baby girl called Petra who is admitted to the neonatal unit with a low blood sugar and jaundice, wants to breast feed but is concerned about medication she is taking. The infant also develops an eye infection and thrush around the nappy area. What advice would you give to mum about breast-feeding, eye and skin care and how would this baby be managed?

The mother can be reassured that although most medications are excreted into breast milk, the amounts are small, and most are considered compatible with breast feeding. However, the BNFc should be consulted, or other breast-feeding references before offering advice on individual medications. This mother should also be advised about good hygiene during lactation and cleansing needs of the baby particularly in relation to keeping the eyes clean and observing the nappy area, ensuring regular nappy changes. Drops or ointment will be required to treat the eye infection and an anti-fungal cream for the thrush. Mum can be sign-posted to information such as that provided by Medicines for Children. See here for Eye Infection Treatment and here for fungal treatment. Also refer to NICE Clinical Knowledge summary on Nappy rash.

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Open-access articles

Allegaert, K., van de Velde, M., & van den Anker, J. (2013). Neonatal clinical pharmacology. Paediatric anaesthesia24(1), 30–38. doi:10.1111/pan.12176

Allegaert, K., & van den Anker, J. N. (2014). Clinical pharmacology in neonates: small size, huge variability. Neonatology105(4), 344-349.

Hsieh, E. M., Hornik, C. P., Clark, R. H., Laughon, M. M., Benjamin, D. K., Smith, P. B., & Best Pharmaceuticals for Children Act—Pediatric Trials Network (2013). Medication use in the neonatal intensive care unit. American Journal of Perinatology31(9), 811–821. doi:10.1055/s-0033-1361933

O'hara, K., Wright, I. M., Schneider, J. J., Jones, A. L., & Martin, J. H. (2015). Pharmacokinetics in neonatal prescribing: evidence base, paradigms and the future. British Journal of Clinical Pharmacology80(6), 1281-1288.

Clyman, R. I., Couto, J., & Murphy, G. M. (2012). Patent ductus arteriosus: are current neonatal treatment options better or worse than no treatment at all?. Seminars in Perinatology36(2), 123–129. doi:10.1053/j.semperi.2011.09.022

Web-based resources

NICE guidance on antibiotics

Paediatric Formulary Committee. British National Formulary for Children London: BMJ Publishing Group, Royal Pharmaceutical Society of Great Britain and RCPCH Publications  

National Patient Safety Agency (NPSA) Gentamicin bundle (safer use of gentamicin in neonates  

Breast feeding and maternal medications:

(USA) Drugs and lactation database Lact Med

(UK) Drugs in lactation advisory service

(UK) Breastfeeding network Drugs factsheets

Hale T.W. Medications and Mothers Milk (2012) A Manual of Lactational Pharmacology 15th Ed. Amarillo: Pharmasoft Publishing.

Take a look at the full list of Cochrane reviews to see what systematic reviews have been undertaken on various drugs in neonatal care.

Chapter 20: Neonatal Anaesthesia
Web-based resources written by: JULIA PETTY

Case study 1: The infant with congenital diaphragmatic hernia

Leo is a term infant who has suffered a respiratory arrest soon after delivery. There is a suspected diagnosis of congenital diaphragmatic hernia (CDH) due to his scaphoid abdomen and worsening respiratory distress.

Question 1

What is the nurse’s role in intubating and ventilating this infant for further management on the neonatal unit?

The nurse is a key member of the multidisciplinary team caring for this baby in the early hours of life during stabilisation. It is vital to minimise/avoid bag and mask ventilation. Sedation should be considered as soon as possible after birth to avoid any inhalation of air and distension of GI contents along with immediate intubation with large ET tube. A large bore NG tube (size 10F) should be passed and put on free drainage with regular aspiration. Monitor pre/post-ductal saturations. This will indicate if any ductal shunting is occurring. Temperature must be maintained during resuscitation and initial stabilisation as hypothermia can lead to pulmonary vasoconstriction and worsening of pulmonary hypertension. Early joint medical and surgical management is essential, hence the need for urgent transfer to a surgical centre. Surgery is to be considered when oxygen requirement is less than 50% and cardiovascular status is stable without inotropes.

Question 2

What pre-operative preparation will this infant and his parents require and who will be involved in this?

A detailed review of Congenital Diaphragmatic hernia by Chandrasekharan et al (2017) outlines all the necessary aspects of management prior to surgery for the baby particularly around stabilisation (see also the answer guide for Q1).  Specific aspects of pre-operative stabilisation including transport can be seen in this guideline on initial stabilisation of the infant with CDH. The parents will also need thorough preparation to reduce their anxiety and to ensure they are able to cope with the stress of this challenging situation. See the next question.

Question 3

What specific information will the parents need about the pending anaesthesia for their baby?

Take a look at this article by Hinton et al (2018) -  While some parents reported experiencing excellent communication and felt they were listened to and involved by the care team, this was not always the case. Dealing with large, complex medical and surgical teams could result in conflicting messages, uncertainty and distress. Parents wanted information but also described being overwhelmed and wanting to distance themselves to maintain hope. Information and support from other parents in hospital and online groups were highly valued. Listening to the experience of parents provides rich data to enhance clinical understandings on how to improve information and communication with parents and ameliorate the deep and lasting distress and anxiety that some parents feel when their infants face early surgery.

Case study 2: The preterm infant with a patent ductus arteriosus

Annie, a preterm infant (born 25 weeks), returned from theatre 2 hours ago to the neonatal unit following surgery to ligate a patent ductus arteriosus. She is ventilated, and it is noted that she is tachycardic with minimal spontaneous respiratory effort. Her blood gas shows a mixed acidosis.

Question 1

What are the possible reasons for these observations?

The situation is likely to be due to the effects of anaesthesia with the associated risks of hypoventilation; this would have affected the blood gas and raised the CO2 and potentially affected oxygen delivery. The preterm neonate is vulnerable due to immaturity of the physiological and anatomical systems and so there are many inherent reasons due to this. A detailed review of the physiological effects of anaesthesia and surgery is provided by Taneja et al (2012).

Question 2

What intra-operative information would be useful in managing this infant?

It would be useful to know how long the surgery took, if there were any adverse events or observations in the peri-operative phase such as hypotension or hypoxia and what the immediate recovery period presented.

Question 3

What do you need to explain to the parents?

As for Case Study 1, see the paper by Hinton et al (2018). Parents require timely and open information about the surgery, potential risks and effects of anaesthesia on their baby.

Case study 3: The premature infant undergoing bowel surgery

Holly is a 5-week old infant who was born at 26 weeks’ gestation. She required ventilation for 20 days and is still receiving nasal CPAP. Over the past 48 hours her condition has deteriorated with abdominal distension, increasing oxygen requirements and deranged blood-clotting indices. She has a diagnosis of necrotising enterocolitis and now requires a laparotomy at the regional paediatric surgical centre 40 miles away.

Question 1

What additional ventilatory support is likely to be required for transport of this infant?

If respiratory failure and worsening acidosis is present, she will need intubating and ventilating. As this is proven necrotising enterocolitis (NEC; confirmed radiologically) and breathing is supported by nasal CPAP, elective intubation is required to minimise gastric distension. Other areas of management include: Nil-by Mouth, gastric decompression and free drainage with a large nasogastric tube. NEC is often associated with significant third spacing of fluid into the mesentery needing fluid resuscitation. Triple antibiotics: usually penicillin, gentamicin and metronidazole; are given along with IV fluids/TPN. Maintenance fluid restriction is usually required. Long line when stable. Pain relief, consider morphine /diamorphine. Ensure adequate analgesia is given. Guidance is available for the stabilisation and transfer of infants with NEC].

Question 2

What blood products will need to be ordered prior to her going to theatre?

If coagulation abnormal, give fresh frozen plasma (FFP). If thrombocytopenia and/or anaemia occur, transfuse with appropriate blood product.; platelets or whole blood respectively.

Question 3

What are the challenges for the anaesthetist and the nursing team in the intra-operative management of this case?

The challenges are as for Case Study 2 in relation to the preterm neonate undergoing general anaesthesia and surgery. This baby however is likely to be much sicker and more unstable due to the nature of NEC and the impact on the baby’s respiratory and cardiovascular status plus the risk of a compromised bowel. Refer again to the issues covered in this thorough review by Taneja et al (2012).

Question 4

Is any special monitoring and nursing care required in the post-operative period?

The surgical and anaesthetic management of the baby with NEC is summarised clearly in an article by Sodhi and Fiset (2012). NEC babies may require large volumes of i.v. fluid along with appropriate maintenance fluids to maintain normoglycaemia. Frequently, severely ill infants with NEC require inotropic support to maintain adequate perfusion pressures. The assessment of intra-vascular blood volume and blood loss is a real challenge. A good urine output (>1-2 mL kg/hour) may reflect an adequate perfusion pressure. Blood loss needs to be replaced with blood, fresh-frozen plasma (FFP), and albumin. Coagulopathy requires platelets and FFP transfusion. Respiratory management and oxygenation must continue as required. Standard routine monitoring (pulse oximeter, ECG, blood pressure, blood gases, central temperature) must be used. Assessment of the abdomen and wound site / stoma if applicable should be done on a regular basis as well as gastric aspirates.

Question 5

What assessment and methods may be used to provide adequate pain relief in the post-operative period?

Preterm babies undergoing surgery show an increased neuroendocrine response so careful pain assessment and administration of continuous analgesia with opiate infusion is necessary remembering that the surgical stress response lasts longer in preterm infants than in full-term babies and adults. In addition, avoidance of any undue stress and / or prolonged handling should be kept in mind in the post-operative period during recovery.

Use the words in the list below to complete the sentence






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Chapter 21: Care of the surgical infant
Chapter written by: YVONNE COUSINS
Web-based resources written by: YVONNE COUSINS & JULIA PETTY

Case study 1: The deteriorating preterm infant

Alex is now 1-week old following delivery at 28 weeks gestation weighing 1.2kg. He is currently receiving full enteral feeds of expressed breast milk at 180mLkg/day. You notice on your shift that he is having frequent apnoeas and bradycardias associated with colour changes, and his mother expresses concerns that he is not himself. On assessment Alex is lethargic, pale and vomits his recent feed, which is slightly green in colour.

Question 1

What are your immediate actions?

This baby needs a surgical referral immediately. His feeds should be stopped, and the feeding tube removed. A wide, short nasogastric tube should then be passed and left on free drainage plus aspirated at intervals to remove any bilious aspirates and excess gas (decompression of the bowel). Intravenous access will be required to administer fluids and / or total parenteral nutrition (TPN). Antibiotics are very likely to be started, and Alex may require increased ventilatory support including oxygen administration. Pain management is essential from the outset. The parents will require reassurance and consistent, timely information about the changes to his condition and care, supported by reasons. Family centered care must continue in the care of the surgical neonate as highlighted in a paper by Gephart and McGrath (2013). In addition, for all these case studies, listen to the parent voice based on their experiences as highlighted in this video. See also Case Study 2 for more information on parents’ needs within this area of care.

Alex’s condition quickly deteriorates, and he needs to go to theatre as he has a perforation near the terminal ileum.

Question 2

How can you optimise his condition in preparation for theatre?

Ensure close assessment continues in the pre-operative period of all vital signs, monitoring and other investigations as well as of his clinical picture to ensure any deterioration is quickly noticed. His bowel should remain decompressed and he should be kept pain-free and comfortable. He must be kept well oxygenated and any blood abnormalities including Hb, blood gases and clotting are rectified prior to surgery.

It is now four weeks since Alex had his operation, during which he required partial bowel resection and formation of an ileostomy. He is receiving breast-milk feeds at 150mL/kg/day but is not gaining weight.

Question 3

What is your management strategy?

Alex will require referral for nutritional management via the dietician to ensure he is receiving optimum nutrition / supplementation as required. The stoma losses must be closely observed and measured to ensure optimum fluid balance and if necessary, replacement fluid may be required. The stoma itself must also be assessed regularly for appearance, perfusion, the output, consistency of stool and the appearance of the surrounding skin area. Support and advice needs to be sought also from the stoma nurse specialist if available. For a clear summary of ileostomy care in the neonate, see the open access paper by Kargl et al (2017).

Question 4

What are the potential future risks?

The risk of increased stoma losses is lack of absorption of essential nutrition and water and fluid imbalances. If weight loss continues, the infant may fail to thrive adequately. A risk of bowel surgery is the removal of surface area for adequate absorption of nutrients for growth in the future. This is particularly significant the more bowel is removed and those with a large resection may subsequently have short bowel syndrome. Read about this in the neonate in an open access paper by Amin et al (2013). All risks must be considered, and care directed to avoiding them by referral to key members of the multi-disciplinary team.

Case study 2: The term infant with delayed passage of meconium

Harry is admitted with a history of not having passed meconium since birth (30 hours ago). He also has a distended, tense abdomen.

Question 1

What could the diagnosis be?

Hirschsprung’s disease (HD), meconium ileus, meconium plug.

Question 2

What do you do?

  • Routine observations/monitoring
  • Full assessment including abdominal and rectal
  • Large bore NGT on free drainage and regularly aspirated
  • No enteral/oral feeds
  • IV access for nutrition/hydration, antibiotics and replacement fluids (mL per mL)
  • Administer rectal washouts as directed by surgical team

Question 3

What investigations will be required and at what stage will they take place?

Abdominal x-ray immediately, suction rectal biopsy to confirm diagnosis once abdomen decompressed.

Following rectal suction biopsy, Harry is diagnosed with Hirschsprung’s Disease.

Question 4

What specific information and support do the parents need?

If diagnosis confirmed as HD – how to perform rectal washouts, signs and symptoms of enterocolitis. Parent information is available from various sources including Bladder and Bowel Uk and Great Ormond street Hospital. Listen to parents speaking about their experiences of having a baby diagnosed with this condition. This open access paper by Hinton et al (2018) highlights that listening to the experiences of parents provides rich data to enhance clinical understanding on how to improve information and communication with parents and ameliorate the deep and lasting distress and anxiety that some parents feel when their infants face early surgery.

Case study 3: The term baby with bile-stained vomiting

Poppy was born at term and has been admitted from the postnatal ward with a history of bile-stained vomiting.

Question 1

What do you do?

Routine observations, pass large bore NGT, aspirate regularly and leave on free drainage (as for case study 1- this is essential for gastric decompression and to avoid bowel perforation), nil enterally, gain IV access for nutrition /hydration /antibiotics /replacement fluids (ml per ml). Observe the aspirates and vomit for colour. Timely management is essential to avoid potential bowel perforation. An open access paper on the bowel perforation in the neonate and potential causes can be seen here by Hyginus et al (2013).

Question 2

Her mother is very anxious – what explanations would you give her, what can she expect to happen next?

See case studies 1 and 2 for information and resources relating to care of parents in neonatal surgical care. This mother will need to know the reasons to be concerned about bile stained vomiting, necessary investigations, the process of surgical review.

Question 3

What information do you need?

General condition – signs of sepsis, birth history e.g. presence of meconium, actual colour of vomit- see above.

Question 4

What investigations are required?

Abdominal x-ray, upper gastrointestinal contrast study.

Question 5

Is this considered to be a surgical emergency? Why?

Yes, healthy term babies do not vomit bile, this could be malrotation. Risk of volvulus with delay in diagnosis, which could lead to necrotic bowel. Urgent management is required for a baby that presents with bile-stained vomiting and for an overview of this condition with potential causes and need for rapid diagnosis and care, see this paper here.

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Open-access articles

Amin, S. C., Pappas, C., Iyengar, H., & Maheshwari, A. (2013). Short bowel syndrome in the NICU. Clinics in Perinatology, 40(1), 53–68. doi:10.1016/j.clp.2012.12.003

Chandrasekharan et al. (2017). Congenital Diaphragmatic hernia – a review. Maternal Health, Neonatology, and Perinatology. 3:6 DOI 10.1186/s40748-017-0045-

Gephart, S. M., & McGrath, J. M. (2012). Family-Centered Care of the Surgical Neonate. Newborn and Infant Nursing Reviews : NAINR12(1), 5–7. doi:10.1053/j.nainr.2011.12.002

Gephart, S. M., McGrath, J. M., Effken, J. A., & Halpern, M. D. (2012). Necrotizing enterocolitis risk: state of the science. Advances in neonatal care : official journal of the National Association of Neonatal Nurses, 12(2), 77–89. doi:10.1097/ANC.0b013e31824cee94

Gregory, K. E., Deforge, C. E., Natale, K. M., Phillips, M., & Van Marter, L. J. (2011). Necrotizing enterocolitis in the premature infant: neonatal nursing assessment, disease pathogenesis, and clinical presentation. Advances in neonatal care : official journal of the National Association of Neonatal Nurses, 11(3), 155–166. doi:10.1097/ANC.0b013e31821baaf4

Hinton L, Locock L, Long A, et al (2018). What can make things better for parents when babies need abdominal surgery in their first year of life? A qualitative interview study in the UK BMJ Open 2018;8:e020921. doi: 10.1136/bmjopen-2017-020921

Hyginus, E. O., Jideoffor, U., Victor, M., & N, O. A. (2013). Gastrointestinal perforation in neonates: aetiology and risk factors. Journal of Neonatal Surgery, 2(3), 30.

Kargl, S., Wagner, O., & Pumberger, W. (2017). Ileostomy Complications in Infants less than 1500 grams - Frequent but Manageable. Journal of Neonatal Surgery6(1), 4. doi:10.21699/jns.v6i1.451

Kimura, K., & Loening-Baucke, V. (2000). Bilious vomiting in the newborn: rapid diagnosis of intestinal obstruction. American Family Physician, 61(9), 2791-2798.

Parolini, F., Bulotta, A. L., Battaglia, S., & Alberti, D. (2017). Preoperative management of children with esophageal atresia: current perspectives. Pediatric Health, Medicine and Therapeutics8, 1–7. doi:10.2147/PHMT.S106643

Pober, B. R., Russell, M. K., & Ackerman, K. G. (2010). Congenital diaphragmatic hernia overview. In GeneReviews®[Internet]. University of Washington, Seattle.

Sodhi and Fiset (2012) Necrotizing enterocolitis.  Continuing Education in Anaesthesia Critical Care & Pain, 12,1, ; 1–4

Zani, A., & Pierro, A. (2015). Necrotizing enterocolitis: controversies and challenges. F1000Research, 4, F1000 Faculty Rev-1373.

Web-based resources

YouTube video on Development of the GI system

HealthTalk online – Parents experiences of neonatal surgery   Listen to parents speak about their experiences of having a baby requiring neonatal surgery

Nucleus Medical Media (on YouTube): Here you can find videos about the following:

Gastro-oesophageal reflux disease – Clinical Knowledge Summary (NICE)

Parent information on a variety of conditions including neonatal surgery (Great Ormond Street)

Chapter 22: Neonatal transportation
Chapter written by: PATRICK TURTON
Web-based resources written by: JULIA PETTY

These three case studies below present different infants who all require transportation for further management of their conditions. For each case study, can you answer the following questions:

  • Q.1 Can you outline the nursing considerations when stabilising these infants for transfer?
  • Q.2 Can you identify the potential risks relating to the actual transfer and how will these be minimised?
  • Q.3 What are the specific challenges for the families of these infants?
  • Q.4 What specific care and information do the parents need?
  • Q.5 What information do the receiving units need about these infants?

Case study 1: Congenital cardiac lesion

Marcus is a term infant born with a congenital heart defect, diagnosed following a collapse on the postnatal ward in the first day of life. He requires transfer to a specialist cardiac centre which is > 40 miles away from the current neonatal unit. He has a duct dependent defect. Marcus’s mother is single, and the father is not present or contactable. She has her parents with her

Stabilisation is a key area prior to transfer during the referral process and important questions required by the receiving unit are…

  • Antenatal scans and family history
  • Labour, delivery, and resuscitation details
  • Time course of presentation including timing of cyanosis
  • Perfusion: Pulses and 4-limb blood pressure
  • Examination findings: Cardiac murmur, hepatomegaly, heart rate, respiratory rate o Blood gases and lactate levels o ECG / Echocardiogram findings
  • Chest x-ray
  • Other relevant findings e.g. evidence of sepsis.

It is important to refer to specific guidance. Preparation involves: Immediate management using an ABC approach o Consider immediate intubation and ventilation if severe respiratory failure. Monitor pre and post ductal saturations (right hand and either foot)

  • Consider immediate intubation and ventilation if severe respiratory failure. Monitor pre- and post ductal saturations (right hand and either foot)
  • Ensure at least 2 IV cannula / Consider Umbilical venous catheter
  • 4 limb BP, ECG, ECHO if possible
  • If hypotensive, give 10ml/kg 0.9% saline and consider further boluses if required and /or manage with inotropes
  • Commence Prostin to open and/or maintain ductal patency. Consider the potential side-effects of this drug: bradycardia, tachycardia, hypotension, seizure-like activity, hyperthermia, and apnoea.

Other risks are associated with the transport process itself such as temperature instability, dislodgement of tubes and lines, unstable blood gases. Parents need careful explanations of the process. Key information about the receiving unit and specific care aspects for this condition and reassured appropriately. A family-centered approach must be assured at all stages. Mum required support as she is on her own.

Case study 2: Surgical problem

Jeannie is a term infant who after delivery was found to experience problems with feeding when she went blue and encountered coughing. A nasogastric tube was passed but this coiled back up to the mouth and an oesophageal atresia is suspected. She is currently in a level 1, special care unit with no surgical care. Her parents have four other children.

This condition requires specific management as risks involve aspiration of milk / mucous into the lungs and babies can be unstable particularly during transfer to a surgical centre. Firstly, airway management is the main priority. It is vital to keep the oro-pharynx / upper pouch clear of secretions to prevent risk of aspiration of fluids into the lungs, by frequent suctioning.

  • Pass Replogle tube, place on low suction (5-10 kPa) flushing with 0.5ml saline every 15 minutes.
  • If not possible to use low suction, pass a size 10 Fr tube and aspirate every 5-10 minutes.
  • Mask ventilation should be avoided as this leads to upper pouch distension and gastric distension if a lower fistula is present, leading to respiratory compromise.  If the baby is spontaneously breathing with good oxygenation, intubation should be avoided.
  • If intubation is indicated for respiratory distress, ET tube should be positioned close to carina to avoid gas flow through any fistula.
  • Nil by mouth, on IV fluids.
  • Nurse supine in head up position (approximately 30–60 degrees)
  • Antibiotics if any evidence of aspiration pneumonia.
  • Examine to rule out any other anomalies.

The baby will need cardiac and renal scans and genetic testing by the local unit on a non-urgent basis. Again, parents require information and support and they will need to arrange care for their other children. They will need to be available for consent for their baby to go to urgent surgery on arrival at the receiving hospital.

Case study 3: Varying care levels in a set of twins

Aneesa and Jasmine are girl twins born at 27 weeks gestation. There was a diagnosis of twin to twin transfusion during pregnancy. Aneesa is the twin that received more blood in utero and although is experiencing some respiratory distress and a high packed cell volume, is being managed effectively and is stable. Jasmine however was born much smaller with a birthweight of <600g. She is very anaemic, hypovolaemic and is unstable with a high oxygen and ventilation requirement. She requires transfer to a level 3 neonatal unit for further management. The twins’ mother Meera is currently unwell with high blood pressure and remains in the postnatal ward. Father Ali is present in the neonatal unit. The extended family is caring for their other 2 older children at home.

For this case, it is important to refer to guidance on transfer of the preterm neonate. The referring unit will need to stabilise her on non-invasive (i.e. CPAP), or invasive ventilation (i.e. endotracheal tube [ETT]). Before transferring, stability must be ensured, and consideration given to expected duration of transfer. Prime consideration should be given to maintenance of airway security. ETTs should be positioned and fixed securely and supported within the transport incubator to allow minimal movement. It has been demonstrated that motion during transport may induce sufficient mechanical forces to result in extubation as well as cardiovascular and/or neurological instability. A nasogastric tube should be inserted, and gastric contents emptied, to reduce the risk of aspiration during the course of transfer. One of the most common adverse events is hypothermia and Jasmine with be susceptible due to high surface area: volume ratio, and poor skin integrity. This is a difficult situation for the family as the twins require separation and the family will need to be split between 2 hospitals. In addition, Meera (mum) is unwell and so will not be able to be transferred with Jasmine.

Use the words in the list below to complete the sentence





















Chapter 23: Exploring Evidence-based Practice (EBP) in Neonatal Care
Web-based resources written by: MARIE LINDSAY-SUTHERLAND

Case study 1: Producing an evidence-based guideline

You work on a neonatal unit where parents can visit any time, but extended family can only visit at set times which are limited to one-hour periods. You are aware that a family were upset that the grandparents were not allowed free access to their first grandchild. Staff have also expressed that it can be difficult with lots of visitors in the unit, especially when babies are very sick. You are asked to update the unit visiting guideline.

  • Q.1 Which sources would you use in order to provide the most evidence -based guidance?
  • Q.2 What are you expecting each source to add to the process?
  • Q.3 What obstacles do you envision occurring?
  • Q.4 How will you overcome these obstacles?

Local guideline - What needs updating - frame the question? Network guideline? National guideline? Literature review on effects of extended vs limited visiting on neonatal outcomes; Audit of parents? - What do parents want? Talk to a Bliss representative?Create a focus group of staff – Impact on care? / Benefits of change? Foreseen issues? Social Media contacts in other Trusts - Do other Trusts have guidelines? How were issues addressed? / How were issues overcome? Trust template including up to date references- validated for use. Motivated colleague to help drive guideline in practice. Launch with education for staff. Leaflets/ posters for parents/staff. Re-evaluate at set timeframe and update as necessary.

Case study 2: The expert vs. the novice approach

Jane is a midwifery student on her neonatal unit placement. Her mentor is an experienced neonatal nurse. They are caring for an extremely preterm infant who has redirection of care and dies shortly afterwards.

  • Q.1 What forms of knowledge will Jane use to provide care for the family at this time?
  • Q.2 What forms of knowledge will her mentor use to support the family?
  • Q.3 What forms of knowledge will her mentor use to support Jane?
  • Q.4 How will Jane use this experience in future practice?

Previous experience of end of life situations; Previous peer behaviour; Previous experience of neonatal death; Previous experience of mentoring; Parent information leaflets/Online information from support groups; Previous parental experience- lived experience; Reflection; Debrief.


Thinking again about the above two case studies as well as the other case studies featured throughout this book.

  • Q.1 Is there anything different you would do or anything you would have done differently, having now read this chapter?
  • Q.2 How will you apply the learning from this chapter to your practice? On your next shift? Next month? Next year?
  • Q.3. Are your literature searching skills up to date?
  • Q.4. Does your organisation provide training to improve EBP skills?
  • Q.5. Could you set up a journal club in your unit? Or could you support one that already exists?

Final Reflection

Think about your last day or week of work on the neonatal unit.

  • Q.1. What forms of evidence did you use to guide your clinical practice?
  • Q.2. How did you know these sources were up to date and reliable?
  • Q.3. Was your practice evidence- based?
  • Q.4 Were there any areas of care that are not supported by evidence or research or that require an update in knowledge?

Finally, can you identify any area of care that requires change or one that needs to be introduced into the clinical area? What further research and enquiry is required?

Guidelines/ Previous knowledge/ Previous experience/ Parental experience/ Audit/ Peer knowledge/ Neonatal courses.

Test Your Knowledge: Wordsearch

Download Wordsearch

Open-access articles

Brün C (2013) Finding the Evidence. A Key Step in the Information Production Process the Information Standard Guide. Available from: [Accessed 27 January 2019]

Nuytten, A., Behal, H., Duhamel, A., Jarreau, P. H., Mazela, J., Milligan, D., … EPICE (Effective Perinatal Intensive Care in Europe) Research Group (2017). Evidence-Based Neonatal Unit Practices and Determinants of Postnatal Corticosteroid-Use in Preterm Births below 30 Weeks GA in Europe. A Population-Based Cohort Study. PloS one12(1), e0170234. doi:10.1371/journal.pone.0170234

Zeitlin, J., Manktelow, B. N., Piedvache, A., Cuttini, M., Boyle, E., Van Heijst, A., ... & Schmidt, S. (2016). Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort. BMJ354, i2976.

Web-based resources

Cochrane Library

Cochrane Organisation (2018) Strategy To 2020. Available from:

Healthcare Quality Improvement Partnership (2015) A Guide to Quality Improvement Methods. Available from:

Imperial College London (2018) NDAU Neonatal Data Analysis Unit. How to Use the National Neonatal Research Database (NNRD) for Research, Audit and Quality Improvement. Available from:

Neonatal Research Database (NNRD) for Research, Audit and Quality Improvement. Available from:

Royal College of Paediatrics and Child Health (RCPCH) (2017 National Neonatal Audit Programme. Available from:

The National Institute for Health and Care Excellence (NICE). Available from:

World Medical Association (WMA) (2013) WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects. Available from:


Most of the below databases require OpenAthens access. This access is with either a personal login or through your hospital or university.


British Nursing Index






PubMed Central (can be accessed without OpenAthens account)

Databases can be accessed-

ViAnswer guide:-

ViAnswer guide:-

ViAnswer guide:-

YouTube Links

Qualitative research

Quantitative V qualitative research

Classifying quantitative research methods

How to use the PICO method to form a clinical question

Using PICO to structure a literature search

Critical appraisal of evidence

How to read a paper!

Example of a Literature Search

Define the clinical question using the PICO template

E.g., For a clinician question involving temperature control in neonates

P - Neonates born in the hospital
I - Taking a temperature at 30 minutes of age
C - Taking a temperature later than 30 minutes of age
O - Maintaining a temperature between 36.5 and 37.5 degrees

So, the PICO question is:-

Do neonates born in the hospital have a temperature noted between 36.5 and 37.5 degrees, if the temperature is checked at 30 minutes of age versus later?

Choose key words to apply to a suitable database

E.g., Neonat* (will get neonate/ neonates/ neonatal/ neonatology)
        “Temperature control”

These words are joined with “AND”

Using these key words in PubMed Central, gets 38 articles.

This search can be further limited to 5 years old-> 12 articles; and Humans-> 9 articles; full text-> 9 articles and English Language-> 9 articles.

Review the articles for relevance

E.g., The titles and abstracts of the 9 articles are reviewed for relevance

One article examines temperature control during transport so can be excluded, and two articles focus on therapeutic hypothermia which can also be excluded. A further article looks at a guideline for management of neonatal respiratory distress which may have some relevance that may be worth exploring further. Five articles fit the above criteria.

Review the remaining articles in more depth for validity and clinical relevance

Smita S, Amit G, Anjoo B and Sanjeev D (2014) Effect of very early skin to skin contact on success at breastfeeding and preventing early hypothermia in neonates Indian Journal of Public Health 58 (1): 22-26. Available from:

A RCT. Randomised to early skin to skin v not. Total participants = 298 women delivering their singletons in a tertiary unit over a two-year period. There were 122 cases and 118 controls after study losses/ exclusions. Form of randomisation was stated. Neonatal temperature was checked at less than 30 minutes and then again at 2 hours. All the case group (early skin to skin) had a normal temperature at 2 hours v 92% of the controls. Appropriate statistical tools were used on the data generated. There was better temperature gain in the case v controls when the first and second temperatures were compared (P < 0.0001). So, a statistically significant outcome was generated from robust methodology which sits at the top of the hierarchy of evidence.

The other articles can also then be assessed for validity and clinical relevance.

Application to clinical practice

E.g., in the case of the above article, whilst not directly reflecting early v later temperature monitoring, it shows the effect of neonatal temperature maintaining strategies which are informed through earlier and then later temperature monitoring. This had a statistically significant result which then needs to be assessed for clinical significance and a strategy for clinical application needs to be generated.

As a temperature maintaining strategy, early skin to skin is a cost effective, non-invasive and simple technique that could be easily applied to clinical practice with minimal effort. Engagement with peers, other professionals and service users could see this practice change applied within a short period of time. Clinical champions could train staff on the use of early skin to skin and the technique could be promoted among the birthing and wider public. A local audit of neonatal temperatures at less than 30 minutes and then at 2 hours of age could confirm the transferability of the above research to the local neonatal population.

Useful websites

General open access online resources in neonatal care

Stories from the Neonatal Unit – Parents’ stories  This site focuses on what health professionals can learn from the narratives of those who have experienced neonatal care; namely the parents of babies who were born prematurely and have spent their first days and weeks on a neonatal unit. Experience is represented here as a collection of digital stories aiming to provide an education resource for anyone working in this specialty.

Stories from the neonatal unit - Appreciation of the neonatal care experience through the eyes of student nurses - This site focuses on story telling from student nurses who have spent time on a clinical placement on a neonatal unit. Their narratives depict their experiences of neonatal care and an appreciation of key points for learning.

Neonatal Nursing- Knowledge to support learning in practice  - This site is hosted on the University of Hertfordshire website and serves as a repository of resources in key areas of neonatal care useful for anyone learning about this specialty or those who require an update of the specific learning points to apply to practice.

Knowledge for neonatal nursing practice: A self-directed learning programme - This site is an interactive, self-directed resource comprising a variety of units on various topics in neonatal care, both for the healthy baby and the neonate who requires admission to a neonatal unit. The different units provide information, fact sheets and interactive quizzes.

Patient - a collection of 1st person parent stories from neonatal care – This webpage is hosted on the main Patient Voice website and comprises a collection of stories spoken by parents who have had babies in neonatal care for a variety of reasons.

European Foundation for the Care of the Newborn Infant (EFCNI): Standards of Care for Newborn Health (ESCNH) - This site hosts a collection of excellent, evidence-based standards of care written by the EFCNI and associated experts in the field.

Cochrane Neonatal - This link takes you to the complete list to neonatal specific Cochrane reviews which are systematic reviews of available research in many specific areas of neonatal care.

National Perinatal Epidemiology Unit (NPEU) – All publications  - The NPEU undertake many vital research studies in perinatal and neonatal care and you can view the list of publications here. The main site also details the past and current research trials and other studies undertaken by this organisation.

National Institute for Health Research – Neonatal Research Studies  - This page contains links to all neonatal related research funded by the NIHR

NHS Networks: an example of a collection of evidence-based clinical guidelines on a range of topics

Stanford Newborn Nursery website and photo gallery: A useful US website comprising information / guidelines for health professionals but most importantly, is the Photo Gallery that contains a wide variety of images, audio clips and videos of various aspects of newborn assessment with supporting explanations.