Paediatrics

Neonatal sepsis: recognition, diagnosis, treatment and supportive care Neonatal sepsis is a systemic illness caused by invasive infection during the first 28 days of life. It may progress from subtle feeding difficulty to shock, meningitis, respiratory failure and death within hours. Early-onset disease is usually acquired before or during birth; late-onset disease is acquired after birth from the community, caregivers or healthcare environment. Because signs are non-specific, clinical risk assessment and repeated observation are as important as laboratory tests. A newborn with poor feeding, abnormal temperature, apnoea, respiratory distress, lethargy or colour change should be assessed for serious bacterial infection immediately. Learning objectives Differentiate early- and late-onset sepsis and identify maternal, neonatal and healthcare risks. Recognise subtle and advanced clinical signs, including meningitis and septic shock. Obtain appropriate cultures and interpret tests without delaying antibiotics. Start empiric antimicrobial therapy according to current local guidance, then narrow or stop safely. Provide thermoregulation, respiratory, circulatory, glucose, nutritional and family-centred supportive care. Plan monitoring, duration, discharge, prevention and follow-up. Definitions and timing Pattern Typical timing Common sources/risk Early-onset sepsis (EOS) First 72 hours, definitions vary Ascending maternal infection, chorioamnionitis, prolonged rupture of membranes, prematurity, maternal fever or GBS colonisation Late-onset sepsis (LOS) After 72 hours to 28 days Hospital equipment/lines, prolonged admission, prematurity, skin/gut flora, community exposure Very late/healthcare-associated Often after prolonged NICU stay Central lines, ventilation, surgery, resistant organisms, parenteral nutrition Definitions differ between surveillance systems; document the exact age and local definition. A newborn can have meningitis, urinary infection, pneumonia or omphalitis with or without positive blood culture. Pathogens and risk factors Likely organisms vary by setting and resistance pattern. Group B streptococcus, enteric gram-negative bacilli such as Escherichia coli, Klebsiella and other Enterobacterales, Staphylococcus aureus, coagulase-negative staphylococci, enterococci, and occasionally Listeria or fungi may occur. Obtain local antibiograms and follow Uganda guidance rather than assuming a textbook pattern. Prematurity, low birth weight, male sex and perinatal asphyxia. Maternal fever, suspected chorioamnionitis, untreated UTI, GBS risk, foul liquor or prolonged rupture of membranes. Unclean delivery, invasive procedures, umbilical/central catheters, ventilation, surgery and prolonged hospitalisation. Skin breakdown, parenteral nutrition, overcrowding, inadequate hand hygiene and antibiotic exposure. Clinical presentation Subtle early signs Poor or absent feeding, weak suck, vomiting, temperature instability, reduced activity, irritability, abnormal cry, pallor, mottling, jaundice, hypoglycaemia, abdominal distension, reduced urine and apnoea may be the only clues. Do not wait for fever: neonates may be hypothermic or normothermic. Respiratory and cardiovascular signs Tachypnoea, grunting, nasal flaring, indrawing, cyanosis, recurrent apnoea, oxygen requirement, bradycardia, tachycardia, prolonged capillary refill, weak pulses, hypotension, cold extremities and oliguria indicate severe illness or shock. Neurological signs Lethargy, altered consciousness, hypotonia, abnormal tone, bulging fontanelle, high-pitched cry, seizures, irritability, poor suck or temperature instability raise concern for meningitis or encephalopathy. Focal infection Umbilical redness/pus, skin pustules, cellulitis, conjunctivitis, pneumonia, abdominal tenderness/distension, necrotising enterocolitis, osteomyelitis or septic arthritis can accompany bacteraemia. Neonatal danger signs require urgent referral or inpatient treatment: inability to feed, convulsions, apnoea, severe respiratory distress, shock, lethargy/unconsciousness, hypothermia/fever, cyanosis, bulging fontanelle, severe jaundice or rapidly worsening condition. Initial assessment: ABCDE Airway: position, clear only visible obstruction, assess cry and protect airway. Breathing: respiratory rate/effort, saturation, blood gas when available; provide oxygen/CPAP/ventilation as indicated. Circulation: heart rate, pulses, capillary refill, blood pressure, temperature, urine output and lactate/perfusion. Disability: consciousness, tone, seizures and bedside glucose; treat hypoglycaemia immediately. Exposure: inspect cord/skin, assess abdomen, hydration, jaundice, weight and gestation while preventing heat loss. Investigations Blood culture: obtain adequate volume before antibiotics when this does not delay treatment; document site and time. Full blood count: anaemia, platelet count and leukocyte pattern may support severity but cannot rule sepsis in or out alone. CRP/procalcitonin: trends can support stopping or continuing therapy, but timing and local assay matter; do not delay treatment for them. Blood gas/lactate, glucose, electrolytes, renal/liver function: assess shock, metabolic complications and drug safety. Lumbar puncture: perform when safe in suspected meningitis, bacteraemia without focus, seizures or neurological signs; stabilise airway/breathing/circulation first. Send CSF cell count, glucose, protein, Gram stain, culture and PCR where available. Urine culture: obtain by catheterisation or suprapubic aspiration in late-onset/community infection where indicated; bag urine is unreliable for culture. Chest radiograph/ultrasound: targeted to respiratory disease, line position, focal infection, abdominal signs or NEC. Serial clinical examination is essential. A negative culture does not exclude sepsis after prior antibiotics or with low-volume sampling; a contaminant must be distinguished from true bacteraemia using clinical context and repeat cultures. Empiric antimicrobial treatment Suspected early-onset sepsis Use the current Uganda/neonatal-unit first-line combination (commonly a penicillin such as ampicillin/benzylpenicillin plus gentamicin) at weight-, gestation- and postnatal-age adjusted doses. Cover meningitis with the recommended regimen if neurological signs are present. Late-onset healthcare-associated sepsis Choose therapy according to local resistance, line exposure and unit antibiogram, often covering gram-positive line organisms and gram-negative bacilli. Involve microbiology for suspected MRSA, ESBL, carbapenem-resistant organisms or fungal infection. Focal infection/meningitis Adjust antibiotic choice and duration to site, CSF findings and culture. Ensure adequate CNS penetration for meningitis and obtain source-control input for abscess, infected line, NEC, bone or joint infection. Antibiotic stewardship Give the first dose promptly, review at 36–48 hours when cultures and clinical course are available, narrow to the narrowest effective agent, and stop when serious bacterial infection is unlikely. Dose-adjust for renal function and monitor gentamicin levels where available. Supportive care Thermoregulation: incubator/radiant warmer or skin-to-skin when stable; treat hypothermia and fever while investigating causes. Respiratory: oxygen titrated to target, CPAP or ventilation for failure; monitor for apnoea, PPHN and pneumothorax. Circulation: cautious isotonic fluid bolus only when indicated, reassess frequently, and use inotropes for persistent shock under specialist care. Glucose/electrolytes: check repeatedly, correct hypoglycaemia, calcium and sodium abnormalities, and avoid fluid overload. Nutrition: continue expressed breast milk when safe; withhold/modify feeds in shock, ileus or NEC risk, using tube or parenteral nutrition appropriately. Renal: strict input/output, daily weight, creatinine and urine monitoring; modify nephrotoxic drugs. Pain and developmental care: minimise procedures, support sleep, protect skin and involve parents. Specific complications Septic shock: oxygen, vascular access, glucose, cautious

Birth asphyxia and neonatal hypoxic-ischaemic injury Birth asphyxia describes failure to initiate and sustain breathing at birth. Hypoxic-ischaemic encephalopathy (HIE) is the neurological syndrome that may follow reduced oxygen and blood flow around birth. It is an emergency: effective ventilation, circulation, glucose, temperature and seizure management must begin immediately while the cause and severity are clarified. Do not wait for an Apgar score or cord-gas result before ventilating a newborn who is apnoeic, gasping or persistently bradycardic. Causes and risk factors Placental abruption, uterine rupture, cord prolapse/compression and severe maternal hypotension. Obstructed or prolonged labour, malpresentation, shoulder dystocia and difficult operative delivery. Maternal hypoxia, seizures, severe anaemia, infection, diabetes or sedative/opioid exposure. Prematurity, congenital anomaly, fetal growth restriction and severe meconium aspiration. Immediate assessment and resuscitation Warm, dry, position airway, stimulate and assess breathing and heart rate. If apnoeic/gasping or heart rate below 100/min, provide effective positive-pressure ventilation with a correctly fitted mask and observe chest movement. Reassess heart rate; correct mask seal, airway position and ventilation technique before escalating. If heart rate remains below 60/min despite effective ventilation, begin coordinated chest compressions with ventilation and follow the neonatal algorithm for oxygen, vascular access and adrenaline. After stabilisation, monitor oxygen saturation, temperature, glucose, perfusion, urine output and neurological status. Ventilation is the priority intervention. Suction is not routine; reserve it for obstruction. Do not delay ventilation for prolonged stimulation, Apgar scoring or diagnostic tests. Assessing HIE Look for altered consciousness, abnormal tone, weak or absent suck, poor feeding, abnormal posture, seizures, apnoea, unequal pupils and abnormal reflexes. Stage severity using a validated neurological examination (for example, Sarnat-based assessment) and repeat because signs evolve. Record cord pH/base deficit when available, but do not use one value alone to label injury. Investigations Blood glucose immediately and repeatedly; correct hypoglycaemia. Blood gas, lactate, electrolytes, calcium, magnesium, renal/liver function, full blood count and coagulation studies. Blood culture and sepsis evaluation when infection is possible; start antibiotics if clinically indicated. Amplitude-integrated EEG or conventional EEG for seizures and subclinical status. Neuroimaging: cranial ultrasound initially where available; MRI with diffusion when stable and timing is appropriate. Chest radiograph only when respiratory disease, aspiration or tube position needs evaluation. Supportive care Airway and breathing Maintain airway, oxygenate using monitored targets, use CPAP or ventilation for respiratory failure and avoid both hypoxia and hyperoxia. Confirm tube position clinically and radiographically when intubated. Circulation Assess perfusion, pulses, blood pressure, lactate and urine output. Treat hypovolaemia cautiously with appropriate fluids/blood; use inotropes for myocardial dysfunction or persistent shock under specialist guidance. Glucose, electrolytes and fluids Prevent hypoglycaemia, correct calcium/electrolyte abnormalities, avoid fluid overload and monitor renal function. Restrict or adjust fluids when renal injury or cerebral oedema is suspected. Seizures Check glucose, calcium, magnesium and infection. Treat clinically significant seizures promptly with the current neonatal protocol; use EEG to detect electrographic seizures and reassess treatment response. Therapeutic hypothermia For selected term or near-term infants with evidence of significant perinatal hypoxia and moderate/severe HIE, controlled therapeutic hypothermia started within the recommended early window may reduce disability and death. It must be delivered in an equipped unit with strict temperature, cardiorespiratory, glucose, coagulation and neurological monitoring. Do not improvise uncontrolled cooling; refer urgently to a centre with a protocol. Nutrition and developmental care Withhold oral feeds during instability or severe encephalopathy; provide safe expressed breast milk when ready, using tube/cup feeding if coordination is poor. Protect sleep, minimise painful stimulation, support skin-to-skin when stable and involve parents. Arrange hearing, vision, motor, feeding, seizure and developmental follow-up before discharge. Complications and prognosis Seizures, cerebral oedema, respiratory failure, pulmonary hypertension and myocardial dysfunction. Acute kidney injury, hepatic injury, coagulopathy, necrotising enterocolitis and hypoglycaemia. Long-term cerebral palsy, epilepsy, developmental delay, feeding/swallowing difficulty, hearing/vision impairment and behavioural problems. Prognosis depends on severity, duration, neurological course, EEG/MRI and multisystem injury; avoid deterministic counselling from Apgar alone. References SlideShare: Birth asphyxia. WHO: Perinatal asphyxia. Current neonatal resuscitation and HIE cooling protocols.

Neonatal respiratory distress and respiratory distress syndrome Respiratory distress is a clinical syndrome of tachypnoea, grunting, nasal flaring, retractions, cyanosis or oxygen requirement. Respiratory distress syndrome (RDS) is primarily surfactant deficiency in preterm lungs, but a distressed newborn may also have transient tachypnoea, pneumonia/sepsis, meconium aspiration, pneumothorax, pulmonary hypertension, congenital heart disease, airway obstruction or metabolic disease. Stabilise airway, breathing, oxygenation and temperature first; diagnose the cause in parallel. Recognition and severity Count respirations for a full minute when calm; note grunting, nasal flaring, chest indrawing, apnoea, cyanosis and fatigue. Check heart rate, perfusion, temperature, glucose and oxygen saturation with a good waveform. Assess feeding: tachypnoea, choking or exhaustion may require temporary tube/IV support. Use an objective respiratory score where available, but follow the clinical trajectory rather than a number alone. Immediate escalation: persistent central cyanosis, apnoea, severe retractions, gasping, exhaustion, shock, unequal breath sounds or sudden deterioration suggesting pneumothorax. Differential diagnosis Condition Clues Priority action RDS Preterm, early onset, grunting, diffuse reticulogranular pattern CPAP, oxygen titration, surfactant pathway Transient tachypnoea Term/late preterm, caesarean, early tachypnoea, improves within hours Support, exclude sepsis/heart disease Pneumonia/sepsis Risk factors, temperature instability, poor feeding, diffuse signs Cultures when feasible and prompt antibiotics Meconium aspiration Meconium-stained fluid, hypoxia, coarse breath sounds Respiratory support, pulmonary hypertension assessment Pneumothorax Sudden deterioration, asymmetry, shock, reduced air entry Urgent decompression if tension physiology PPHN/heart disease Disproportionate cyanosis, pre/postductal difference, murmur Oxygen, echo/referral and specialist management Initial stabilisation Warm, position airway and provide gentle stimulation. Use pulse oximetry, target oxygen according to gestational age and current protocol, and avoid hyperoxia. For spontaneous breathing with distress, commence nasal CPAP if available and appropriate; ensure a skilled team and backup ventilation. If apnoea, gasping or inadequate effort, provide positive-pressure ventilation and escalate to intubation if ineffective. Check glucose, blood gas, perfusion and temperature; treat hypoglycaemia and shock. Investigations Blood gas for ventilation, oxygenation, pH and lactate when moderate/severe distress. Chest radiograph for uncertain diagnosis, severe disease, suspected pneumothorax, tube position or persistent oxygen need. Full blood count, blood culture and inflammatory assessment when sepsis is possible; do not withhold antibiotics in an unstable high-risk infant. Glucose, electrolytes, calcium and haemoglobin according to severity. Echocardiography when cyanosis is disproportionate, oxygen response is poor, PPHN/heart disease is suspected or there is persistent pulmonary hypertension. RDS management Non-invasive support Early CPAP maintains functional residual capacity and reduces atelectasis. Use appropriately sized prongs/mask, humidification, gastric decompression when needed and frequent checks for leaks, nasal injury and worsening fatigue. Surfactant Give surfactant early to eligible preterm infants with worsening RDS or escalating oxygen/pressure requirements using the local INSURE/LISA or intubation protocol. Confirm airway expertise, dosing and monitoring; avoid delaying for a radiograph when clinical criteria are met. Mechanical ventilation Use lung-protective ventilation for failure of non-invasive support, recurrent apnoea, severe acidosis or exhaustion. Monitor gases, pressures, oxygen requirement and ventilator-associated injury; wean as the lung improves. Supportive care Thermoregulation, minimal handling, caffeine when indicated for prematurity/apnoea, safe nutrition, infection prevention, pain control and fluid/electrolyte monitoring are essential. Complications and reassessment Air-leak syndrome, pulmonary haemorrhage, PPHN, sepsis, atelectasis and ventilator-associated injury. Monitor work of breathing, oxygen requirement, blood gases, perfusion, urine output, abdominal distension and feeding tolerance. Sudden deterioration requires immediate check of airway, tube/circuit, pneumothorax, sepsis, hypoglycaemia and haemodynamic status. Discharge requires stable temperature, feeding, oxygenation, no significant apnoea and a follow-up plan. References SlideShare: Respiratory distress syndrome. WHO recommendations on care of preterm/low-birth-weight infants and newborn respiratory support. Current neonatal respiratory-support and surfactant protocols.

Neonatal apnoea: recognition, causes and management Apnoea is cessation of breathing for about 20 seconds or a shorter pause associated with bradycardia, cyanosis, pallor or marked hypotonia. Apnoea of prematurity reflects immature respiratory control, but apnoea in any newborn may signal sepsis, hypoglycaemia, seizures, airway obstruction, respiratory disease, anaemia, temperature disturbance or neurological injury. Treat the event immediately, then search for an underlying cause—“apnoea of prematurity” is a diagnosis of exclusion. Types and clinical patterns Central: absent respiratory effort and airflow. Obstructive: respiratory effort continues but airflow is blocked. Mixed: central pause followed by obstruction or the reverse; common in preterm infants. Periodic breathing: brief pauses separated by regular breaths, usually without colour change or bradycardia; distinguish from pathological apnoea. Immediate response Call for help, assess airway, breathing, heart rate, colour, oxygen saturation and perfusion. Position head neutrally, ensure airway patency and provide gentle tactile stimulation. If breathing does not resume promptly or bradycardia/cyanosis persists, begin positive-pressure ventilation with a correctly fitted mask. Escalate to CPAP, intubation and resuscitation protocol when ventilation is ineffective or recurrent. Check bedside glucose and temperature immediately; treat abnormalities. Do not shake, slap or aggressively suction the baby. Ineffective ventilation is the commonest preventable cause of prolonged bradycardia during an apnoeic event. Causes to exclude Cause Clues Evaluation/response Apnoea of prematurity Preterm, recurrent, otherwise stable, often mixed Monitor, stimulation, caffeine and respiratory support Sepsis/meningitis Temperature instability, poor feeding, lethargy, perfusion change Cultures and prompt antibiotics when indicated Hypoglycaemia/electrolyte disorder Jitteriness, seizures, poor feeding, instability Immediate glucose/electrolyte testing and correction Respiratory disease Grunting, retractions, oxygen need, abnormal gases Respiratory support and chest evaluation Seizure/neurological injury Abnormal movements, tone, consciousness or birth asphyxia Glucose, calcium, EEG and neurological assessment Airway obstruction/aspiration Choking, secretions, stridor, positional events Airway assessment, feeding review and imaging when indicated Assessment and investigations Document duration, colour change, heart rate, oxygen saturation, respiratory effort, context (feed/sleep/handling), intervention and recovery. Review gestation, birth history, maternal drugs, infection risks, feeding and previous events. Check glucose, temperature, blood gas, electrolytes, calcium, haemoglobin and sepsis tests according to presentation. Consider chest radiograph, ECG, cranial ultrasound/MRI, EEG, airway assessment or reflux/aspiration evaluation when clinically indicated. Continuous cardiorespiratory and saturation monitoring is required for recurrent or significant events. Apnoea of prematurity management Supportive measures Maintain neutral airway position, minimise handling, avoid excessive neck flexion, prevent hypothermia, treat infection, optimise oxygenation and provide safe feeding. Review medications and anaemia. Caffeine Caffeine citrate is standard therapy for clinically significant apnoea of prematurity. Use the current weight-based loading/maintenance regimen and monitor heart rate, feeding, seizures and response under neonatal protocol. CPAP/non-invasive support Use CPAP or other non-invasive support for recurrent apnoea, obstruction or oxygen/ventilation need. Check interface, pressure, gastric distension, nasal injury and work of breathing. Mechanical ventilation Intubate and ventilate for persistent apnoea with bradycardia, failure of non-invasive support, severe respiratory disease or inability to protect the airway. Feeding and discharge Pause oral feeds during severe or recurrent events, assess suck–swallow–breathe coordination and use expressed milk by a safe route. Before discharge, the infant should be clinically stable, maintaining temperature and feeding, with no significant untreated apnoea/bradycardia/desaturation for the unit’s protocol-defined observation period. Educate caregivers about safe sleep, CPR response where available and urgent return for colour change, pauses, poor feeding or lethargy. Home monitors are not a substitute for diagnosis and follow-up. References SlideShare: Neonatal apnoea. AAP review: Apnoea of prematurity. Current neonatal resuscitation and local neonatal-unit protocols.

Examination of the newborn: a systematic bedside assessment Newborn examination confirms transition to extrauterine life, identifies congenital anomalies, detects birth injury and infection, assesses feeding and establishes a baseline for follow-up. It must be performed after immediate stabilisation, in a warm environment, with the baby observed before handling and the mother involved. A sick newborn may deteriorate rapidly: check breathing, colour, tone, temperature, glucose and feeding before completing the full examination. Preparation and sequence Hand hygiene, warm room, good light, clean equipment and consent. Confirm identity, sex, birth time, gestation, birth weight, Apgar, resuscitation, maternal illness, drugs, blood group and infection risks. Observe posture, tone, colour, breathing, cry, activity, feeding and interaction before disturbing the baby. Perform general examination, measurements, head-to-toe examination, systems review, hips, spine, genitalia and neurological assessment. Rewarm, support feeding and document findings with a plan for follow-up. Urgent danger signs: apnoea, grunting, severe indrawing, central cyanosis, persistent pallor, shock, seizures, lethargy, temperature instability, bilious vomiting, abdominal distension, severe jaundice in the first day or inability to feed. Measurements and vital signs Measure Technique/interpretation Weight Calibrated scale, naked or dry nappy; classify low birth weight and plot against gestation Length Recumbent length board with two people where possible Head circumference Non-stretch tape above eyebrows and around occiput; repeat if abnormal Temperature Axillary measurement with validated device; hypothermia and fever are both significant Respiratory rate Count full minute when quiet; note grunting, nasal flaring, indrawing, pauses Heart rate/perfusion Count, assess femoral pulses, capillary refill, colour and blood pressure when indicated General inspection Assess maturity, size, proportionality, posture, tone, spontaneous movement, cry and consolability. Look for dysmorphic features, birth trauma, bruising, petechiae, pallor, jaundice, cyanosis, oedema, rash, dehydration, congenital anomalies and signs of infection. Note whether the baby is alert and feeding or unusually sleepy, irritable or floppy. Head and face Inspect scalp swelling: caput crosses sutures; cephalohaematoma is confined by sutures; subgaleal haemorrhage is diffuse, fluctuant and potentially rapidly fatal. Palpate sutures and fontanelles; tense fontanelle with illness may indicate raised intracranial pressure. Assess facial symmetry, eyes, red reflex, pupils, mouth, palate, tongue, suck, nostrils and ears. Look for choanal obstruction, cleft palate, micrognathia, macroglossia and cranial nerve abnormalities. Chest and cardiovascular system Inspect respiratory effort and symmetry. Auscultate both lungs for air entry, crackles, wheeze or asymmetry. Check precordium, apex, heart sounds, murmurs, femoral pulses, perfusion and signs of heart failure. A murmur may be transitional, but cyanosis, weak femoral pulses, poor feeding, tachypnoea or shock requires urgent evaluation for critical congenital heart disease. Abdomen, cord and genitourinary system Inspect distension, veins, hernias and cord vessels. Palpate liver, spleen, kidneys and masses. Bilious vomiting, absent bowel sounds, distension or failure to pass meconium suggests obstruction. Examine anus for patency. Inspect genitalia for sex-development variation, hypospadias, undescended testes, ambiguous genitalia and scrotal swelling; do not assign blame or make rushed assumptions. Musculoskeletal and neurological examination Inspect limbs, digits, clubfoot, fractures, brachial-plexus injury and movement symmetry. Perform Ortolani and Barlow manoeuvres gently when trained; assess risk factors for developmental dysplasia. Inspect spine and sacrum for dimples, tufts, masses and curvature. Assess tone, alertness, posture and primitive reflexes: rooting, sucking, Moro, grasp and stepping. Observe cry, consolability and response to handling; asymmetry or persistent hypotonia needs evaluation. Skin and jaundice Describe colour and lesions, blanching, distribution and timing. Jaundice in the first 24 hours, rapidly rising jaundice, pale stools, dark urine, anaemia, lethargy or poor feeding is urgent. Transcutaneous or serum bilirubin should guide management according to age in hours, gestation and risk factors; visual inspection alone is unreliable. Feeding assessment Observe latch, suck–swallow–breathe coordination, fatigue, choking, vomiting, urine output and stool passage. Ask about skin-to-skin, time to first feed, colostrum, maternal medications and breast anatomy. Poor feeding is a non-specific but important sign of sepsis, hypoglycaemia, respiratory disease, neurological illness or congenital anomaly. Documentation and discharge safety-net Record gestation, measurements, vital signs, examination positives and negatives, prophylaxis/immunisation, feeding plan and follow-up. Teach caregivers to return for difficulty breathing, fever or coldness, jaundice spreading to palms/soles, convulsions, lethargy, poor feeding, repeated vomiting, abdominal distension, bleeding or reduced urine. References SlideShare: Neonatal examination. WHO Essential Newborn Care and Pocket Book of Hospital Care for Children. Uganda newborn and neonatal-care protocols.

Apgar score: scoring, interpretation and limitations The Apgar score is a structured description of a newborn’s condition at 1 and 5 minutes after birth using Appearance, Pulse, Grimace, Activity and Respirations. Each item scores 0, 1 or 2, giving a maximum of 10. It communicates response to transition and resuscitation; it does not replace clinical assessment or determine whether resuscitation should begin. Start resuscitation according to breathing, heart rate and tone—never wait for the 1-minute Apgar score. Components and scoring Component 0 1 2 Appearance Blue/pale Body pink, extremities blue Completely pink Pulse Absent Below 100/min 100/min or more Grimace/reflex response No response Grimace Cough, sneeze or active response Activity/tone Limp Some flexion Active movement Respirations Absent Slow/irregular or weak cry Good breathing/cry When and how to score At one minute, score the infant’s condition and document any concurrent support. At five minutes, repeat. If below 7, continue scoring every five minutes up to 20 minutes while resuscitation/observation continues. Record each component separately, the total, gestational age, interventions and timing—not only the total. Use a preterm-appropriate clinical context: prematurity, maternal drugs, congenital anomalies, infection and hypothermia can lower scores. Interpretation 7–10: generally reassuring transition, but continue routine observation and assess any abnormal component. 4–6: moderately depressed; reassess airway, breathing, heart rate, temperature and glucose and provide indicated support. 0–3: severely depressed; immediate neonatal resuscitation and urgent escalation are required. A score can improve after ventilation, stimulation, oxygen or other interventions. A low score at one minute may reflect transition; persistent low scores at 5–10 minutes are concerning and require documentation and evaluation. Limitations: Apgar alone cannot diagnose birth asphyxia, hypoxic-ischaemic encephalopathy or predict an individual child’s neurological outcome. It must be interpreted with cord gases where available, neurological examination, resuscitation details and evidence of organ dysfunction. Relation to resuscitation Resuscitation follows the newborn algorithm: warmth, drying, positioning, stimulation, assessment of breathing and heart rate, effective ventilation when needed, and escalation according to response. Apgar scoring is performed while care continues. An infant receiving ventilation may have a low respiratory score despite appropriate treatment; document the intervention-modified score and the score that reflects the infant’s condition. Documentation example “Apgar 1 min: 5 (HR 1, respirations 1, tone 1, reflex 1, colour 1); positive-pressure ventilation initiated at 60 seconds. Apgar 5 min: 8 (HR 2, respirations 2, tone 2, reflex 1, colour 1). Continued observation; no seizures or respiratory distress.” This is more useful than “Apgar 5/8” alone. Common errors Using Apgar to decide whether to start resuscitation. Scoring colour without considering peripheral cyanosis in a normal transition. Failing to score after 5 minutes when the score remains low. Ignoring gestation, maternal sedation or congenital anomaly. Calling a low score “asphyxia” without neurological, metabolic and organ evidence. Exam pearls Apgar is Appearance, Pulse, Grimace, Activity, Respirations. Pulse below 100 scores 1; absent pulse scores 0. Resuscitation must not be delayed for scoring. Persistent low scores require escalation and documentation, not a single label. References SlideShare: Apgar score. American Academy of Pediatrics: The Apgar Score. Current neonatal resuscitation programme guidance.

Gestational-age assessment of the newborn Gestational age (GA) describes maturity at birth and guides respiratory support, feeding, thermoregulation, medication, jaundice thresholds and follow-up. The best estimate is based on reliable menstrual dates and early ultrasound; physical and neuromuscular examination is a complementary method when dates are uncertain. Record both the best obstetric estimate and the postnatal examination estimate, including the method and uncertainty. Definitions Category Completed gestation Clinical implications Preterm Less than 37+0 weeks Respiratory, thermal, feeding, infection and neurodevelopmental risks Very preterm Less than 32 weeks High need for specialised neonatal care Extremely preterm Less than 28 weeks Very high morbidity/mortality; specialist counselling Term 37+0 to 41+6 weeks Assess size, transition and post-term risks Post-term 42+0 weeks or more Meconium, macrosomia, placental insufficiency and birth injury risks Best dating information Use first-trimester ultrasound when available. Use a certain last menstrual period if cycles are regular and recall is reliable. Use assisted-reproduction dates when applicable. Correlate fundal height and fetal growth but do not use them alone to date a newborn. If no reliable date exists, perform a validated examination such as New Ballard or Dubowitz and document uncertainty. Physical maturity assessment Skin: transparency, colour, texture, peeling and cracking. Lanugo: fine hair distribution changes with maturity. Plantar creases: absent/sole smoothness progresses to deep creases. Breast tissue: areola and bud size. Eye/ear: eyelid opening, pinna cartilage and recoil. Genitalia: testicular descent/scrotal rugae or labial development. Neuromuscular maturity assessment Posture and resting flexion. Square-window angle at the wrist. Arm recoil after flexion. Popliteal angle. Scarf sign. Heel-to-ear manoeuvre. More flexion, stronger recoil, resistance to extension and limited heel-to-ear movement indicate greater maturity. Perform gently; pain, illness, hypoxia, neuromuscular disease, sedation and severe growth restriction can distort the estimate. Ballard/Dubowitz approach Validated scores assign points to physical and neuromuscular signs and convert the total to an estimated GA. New Ballard is practical at the bedside, especially when dates are unavailable, but precision is limited and accuracy is lower in extremely preterm infants or when examination is delayed. Use the score to guide care—not to overrule reliable early ultrasound. Do not confuse size with gestational age: a small-for-gestational-age term infant may look immature, while a growth-restricted infant can have mature physical signs. Plot birth weight against GA to classify SGA, AGA or LGA. Management implications Preterm babies need aggressive thermal protection, respiratory assessment, feeding support and infection vigilance. GA changes bilirubin treatment thresholds and risk interpretation. Medication doses, caffeine, antibiotics, fluids and nutrition depend on GA/postnatal age and organ function. Arrange hearing, eye, developmental, immunisation and growth follow-up appropriate to GA and birth weight. Explain uncertainty honestly to caregivers and update the estimate if better records become available. Exam pearls Early ultrasound is more reliable than late physical scoring. Neuromuscular signs are especially useful when dates are unknown. Illness and sedation can make a mature infant appear immature. Always interpret weight relative to gestational age. References SlideShare: Assessment of gestational age. WHO newborn and preterm-care guidance. New Ballard/Dubowitz clinical assessment principles.

Essential newborn care and low-birth-weight babies Essential newborn care is a package delivered to every baby from birth: thermal protection, breathing support when needed, skin-to-skin contact, early breastfeeding, infection prevention, cord and eye care according to policy, immunisation, danger-sign recognition and follow-up. Low birth weight (LBW) means birth weight below 2,500 g; it may reflect prematurity, fetal growth restriction or both. Mother and baby should remain together unless a valid medical reason requires separation; family participation is part of safe neonatal care. Immediate care at birth Prepare warm, clean equipment and skilled resuscitation support. Dry thoroughly, remove wet linen, assess breathing and tone, and provide stimulation/airway positioning. If breathing is absent/ineffective or heart rate is low, start neonatal resuscitation promptly according to the current algorithm. When stable, initiate skin-to-skin contact, delay cord clamping when appropriate and begin breastfeeding in the first hour. Record time of birth, sex, weight, gestation, Apgar, interventions and maternal/newborn risk factors. Urgent referral: apnoea, persistent respiratory distress, central cyanosis, shock, seizures, severe hypothermia, hypoglycaemia, inability to feed, suspected sepsis, major anomaly or rapidly worsening jaundice. Thermoregulation Newborns lose heat by evaporation, conduction, convection and radiation. Prevent loss with a warm room, immediate drying, hat, skin-to-skin contact, warm transport and delayed bathing. Measure temperature and treat hypothermia while searching for sepsis, hypoglycaemia and environmental causes. Preterm/LBW babies need additional incubator or radiant-warmer support while maintaining skin-to-skin whenever clinically feasible. Feeding and glucose Support early, frequent exclusive breast milk feeding; observe latch, suck–swallow–breathe coordination and urine/stool output. Small or preterm babies may require expressed breast milk by cup, spoon or tube according to ability and protocol. Check glucose in symptomatic, preterm, SGA, LGA, infant-of-diabetic-mother or sick babies; treat hypoglycaemia promptly. Do not give water, glucose water or unprescribed formula as a substitute for breast milk. Monitor weight, dehydration, vomiting, abdominal distension and feeding fatigue. Kangaroo mother care (KMC) KMC combines prolonged skin-to-skin contact, exclusive breast milk feeding, early discharge when safe and close follow-up. Position the baby upright between the breasts, head turned to one side with neck slightly extended, airway visible, hips flexed and securely supported. Initiate as early as possible for stable preterm/LBW newborns; provide cardiorespiratory support first when the baby is haemodynamically compromised or unable to breathe independently. KMC improves warmth, breastfeeding, bonding and survival. Infection prevention and early recognition Hand hygiene before every contact, clean cord care and aseptic procedures. Assess risk from prolonged rupture of membranes, maternal fever, chorioamnionitis, prematurity, invasive procedures and poor feeding. Signs may be subtle: temperature instability, lethargy, weak cry, apnoea, respiratory distress, abdominal distension, jaundice, vomiting or feeding difficulty. Investigate and treat suspected sepsis urgently according to local protocol; never wait for culture in a deteriorating newborn. LBW classification and care priorities Category Birth weight Priority Low birth weight Below 2,500 g Thermal care, feeding, infection and growth monitoring Very low birth weight Below 1,500 g Specialist neonatal support and close monitoring Extremely low birth weight Below 1,000 g Advanced neonatal intensive care and multidisciplinary follow-up Classify also by gestation and size for gestational age. A term SGA infant needs glucose and growth surveillance; a preterm AGA infant has respiratory and feeding immaturity even if weight is appropriate. Monitoring and discharge Monitor temperature, respiratory rate, oxygenation, heart rate, glucose when indicated, weight, feeds, urine, stool, jaundice, infection signs and apnoea. Before discharge confirm stable temperature, effective feeding, safe caregiver technique, weight/growth plan, immunisation/prophylaxis, transport and follow-up. Teach danger signs: poor feeding, fast breathing, chest indrawing, fever/coldness, convulsion, lethargy, jaundice to palms/soles, repeated vomiting or reduced urine. Follow-up and family-centred care Early postnatal review for LBW/preterm babies, then frequent growth, feeding, development, hearing and eye follow-up. Support maternal mental health, lactation and family confidence; address transport and cost barriers. Use corrected age for developmental assessment of preterm infants. Coordinate immunisation and prophylaxis with national policy and clinical stability. References SlideShare: Essential newborn care and LBW management. WHO Essential Newborn Care. WHO Kangaroo Mother Care clinical practice guide.

Taking a paediatric general history A paediatric history is a conversation with the child and caregiver, not a form to be completed mechanically. The child’s age, developmental level, communication ability and family context determine how questions are asked. A good history identifies the immediate syndrome, establishes baseline function, uncovers preventable risks and makes the caregiver a partner in care. Start with danger signs and sick appearance before completing a long history; a critically ill child must be stabilised while information is gathered. Learning objectives Conduct a respectful, age-adapted history from caregiver and child. Recognise general danger signs and prioritise urgent action. Cover presenting complaint, history of illness, background, development, nutrition, immunisation, family and social context. Use open questions, clarification, summarising and safety-netting. Present a concise problem representation and differential diagnosis. Preparation and first impression Wash hands, introduce yourself, confirm the child’s identity and obtain permission to talk/examine. Observe before questioning: alertness, interaction, consolability, breathing effort, colour, hydration, posture, voice/cry, seizure activity and caregiver–child interaction. Record exact age, sex, weight, length/height, temperature, oxygen saturation and triage category. Ask immediately about inability to drink/breastfeed, repeated vomiting, convulsion, lethargy/unconsciousness, severe breathing difficulty, shock and severe dehydration. Red flag: a quiet, floppy or poorly responsive child may be critically ill even without fever. Do not postpone ABCDE assessment for a complete history. Presenting complaint and history of presenting illness Begin with an open invitation: “Tell me what brought you and what worries you most.” Then establish onset, progression, severity and functional effect. Ask about the child’s normal baseline and what has changed. Symptom domain Questions that change diagnosis/urgency Fever Measured or felt? duration/pattern? rigors, rash, malaria exposure, immunisation, antipyretics and response? Breathing Cough, fast breathing, chest indrawing, stridor, wheeze, apnoea, cyanosis, feeding interruption or choking? Diarrhoea/vomiting Frequency, blood/mucus, bilious vomit, fluids tolerated, urine output, tears and dehydration signs? Neurology Convulsions, altered consciousness, headache, neck stiffness, weakness, regression or abnormal behaviour? Feeding/weight Breastfeeding or diet change, appetite, swallowing, weight loss, oedema, growth trend? Urinary Dysuria, frequency, loin pain, abnormal urine, reduced output, bedwetting or genital symptoms? Skin Rash onset, itch, pain, mucosal involvement, bruising, petechiae, exposure or medication? Past medical and birth history Pregnancy: antenatal care, maternal illness/infection, medicines, substance exposure and complications. Birth: gestational age, mode/place, birth weight, resuscitation, neonatal admission, jaundice, sepsis, feeding and discharge. Previous illnesses: admissions, pneumonia, malaria, diarrhoea, TB/HIV exposure, seizures, surgery, allergies and chronic disease. Medicines: prescribed, over-the-counter, traditional/herbal remedies, doses, adherence and adverse effects. Immunisation: card dates, birth vaccines, missed doses, adverse events and access barriers. Growth, nutrition and development Ask about breastfeeding, complementary foods, feeding frequency, appetite, food security, vomiting, diarrhoea, swallowing and special diets. Review weight/length/head-circumference trends rather than a single value. Ask milestone domains—gross motor, fine motor, language/hearing, social and adaptive skills—and whether any skill has been lost. For adolescents, ask about school, mood, sleep, substance use, sexual health and safety privately when appropriate. Family, social and safeguarding history Household composition, caregiver capacity, housing, water/sanitation, smoke exposure, pets, travel and sick contacts. Family history of asthma, seizures, sickle-cell disease, diabetes, TB, congenital disorders, sudden death, mental illness and consanguinity. School attendance, learning, bullying, disability support and psychosocial stress. Safeguarding: unexplained injuries, inconsistent accounts, fear, neglect, sexual abuse, exploitation, child marriage or unsafe discharge. Ask privately when possible and document the child’s words accurately. Follow local reporting pathways. Medication, allergy and exposure reconciliation Ask the caregiver to show medicines. Confirm name, concentration, amount, route, timing, last dose and whether the child vomited it. Clarify drug/food/latex reactions and the exact symptoms of “allergy.” Ask about accidental ingestion, pesticides, kerosene, batteries, traditional medicines and household hazards. Communication technique Use plain language and an interpreter when needed; avoid leading questions. Talk to the child directly, even when the caregiver answers. Validate concerns without assuming the diagnosis. Summarise and ask, “What have I missed?” Explain the next steps, expected warning signs, follow-up and how to return urgently. Case presentation and problem representation Present in one sentence: age, relevant background, duration, dominant syndrome, severity and key discriminating signs. Example: “A 14-month-old previously well child with three days of fever, cough and poor feeding, tachypnoea with lower-chest indrawing and oxygen saturation 88%, concerning for severe pneumonia with hypoxaemia.” List active problems, immediate threats, likely diagnoses, alternatives and missing information. OSCE checklist Introduces self, confirms identity, consent, privacy and caregiver relationship. Checks danger signs and stabilises before detailed questioning. Covers presenting illness, birth, past illness, medicines/allergy, immunisation, nutrition, growth/development, family/social and safeguarding. Uses age-appropriate communication and includes the child’s voice. Summarises, explains plan and safety-nets. References SlideShare: Paediatric clerkship. SlideShare: Clerkship history for paediatric patients. WHO/UNICEF IMCI assessment and referral guidance.

Performing a paediatric physical examination Paediatric examination is a planned assessment adapted to age, fear, developmental ability and illness severity. Observe first, examine the least frightening parts before invasive manoeuvres, keep the child warm and involve the caregiver. A complete examination includes general condition, growth and nutrition, vital signs, system examination and a targeted search for danger signs. Examine the child in the caregiver’s arms when possible; crying changes respiratory rate, heart rate, colour and lung findings. Learning objectives Prepare a safe, child-friendly examination environment. Perform an age-appropriate ABCDE and general examination. Measure and interpret growth, vital signs, hydration and nutritional status. Complete cardiovascular, respiratory, abdominal, neurological and developmental examinations. Document positive and important negative findings and recognise urgent referral signs. Preparation and sequence Hand hygiene, introduce yourself, confirm identity, consent and privacy. Have equipment ready: thermometer, paediatric cuff, pulse oximeter, scale, length board/stadiometer, measuring tape, penlight, otoscope, stethoscope, glucometer and reflex hammer. Observe from the doorway: posture, alertness, interaction, work of breathing, colour, hydration, nutrition and caregiver interaction. Examine while calm: hands/skin, face, chest and abdomen; leave ears, throat and painful areas until last unless urgent. Reassess vital signs after calming and after treatment if abnormal. Immediate escalation: central cyanosis, severe respiratory distress, apnoea, shock, convulsion, coma, severe dehydration, hypoglycaemia, severe malnutrition with complications or suspected abuse. General examination and vital signs Measure Technique Interpretation cautions Temperature Use a validated site/device; record method Fever thresholds vary by age; hypothermia is also dangerous in neonates Respiratory rate Count a full minute while calm; repeat if crying Age-specific tachypnoea; observe retractions, grunting, stridor and apnoea Heart rate Count a full minute, assess pulses and perfusion Crying/fever raise rate; bradycardia in a sick child is late danger Blood pressure Correct cuff width; arm at heart level Interpret by age, sex and height centiles; hypotension is late shock SpO₂ Warm, well-perfused finger/toe; verify waveform Motion, cold extremities, dyshemoglobins and probe position mislead Glucose Point-of-care test in altered, shocked, malnourished or very young child Treat severe hypoglycaemia immediately while confirming when appropriate Growth and nutrition examination Weigh with minimal clothing and plot weight-for-age. Measure length recumbent below two years and standing height in older children; plot length/height-for-age. Measure head circumference in infants and young children. Assess weight-for-length/height, mid-upper-arm circumference and bilateral pitting oedema where malnutrition is suspected. Look for wasting, muscle loss, pallor, hair/skin changes, oral lesions, rickets, dehydration and micronutrient deficiency. Assess feeding ability, suck, swallow, aspiration, oral-motor coordination and caregiver–child interaction. ABCDE assessment Airway Look for obstruction, drooling, stridor, muffled cry, facial trauma, foreign body and positioning. Maintain airway with age-appropriate manoeuvres and call for help early. Breathing Count rate, inspect chest movement, nasal flaring, grunting, indrawing, asymmetry and cyanosis. Auscultate for wheeze, crackles, reduced air entry and bronchial breathing. Assess speech/cry and fatigue. Circulation Assess mental state, pulse quality, capillary refill, skin temperature/colour, urine output and blood pressure. Look for dehydration, bleeding and signs of heart failure. Disability Use AVPU or paediatric GCS, check pupils, seizures, tone, posture and glucose. Compare with baseline and caregiver report. Exposure Expose only what is necessary while preserving warmth and dignity. Look for rash, petechiae, bruising, burns, oedema, jaundice, trauma, dehydration and safeguarding clues. System examination Respiratory Inspect shape and symmetry, palpate expansion and tactile fremitus, percuss when useful and auscultate systematically anteriorly, laterally and posteriorly. In infants, nasal obstruction and transmitted upper-airway sounds are common mimics. Cardiovascular Check pulses in all limbs when indicated, precordial activity, apex position, heart sounds, murmurs, gallop rhythm, hepatomegaly, oedema and signs of poor perfusion. Describe murmurs by timing, location, radiation, intensity and effect of position. Abdomen Inspect distension, veins, scars and hernias. Auscultate, then palpate gently for tenderness, masses, liver, spleen and kidneys. Check ascites, genitalia and anus when clinically indicated and with consent. Neurological Assess alertness, interaction, speech, cranial nerves, tone, power, reflexes, coordination, gait and sensation according to age. Examine infants for fontanelle, head control, symmetry, primitive reflexes and developmental milestones. Skin, lymph nodes and joints Describe lesions by morphology and distribution. Examine nodes, joints, range of motion, warmth, swelling and tenderness. Non-blanching rash with fever is an emergency until proven otherwise. Age-specific adaptations Newborn: temperature, breathing, colour, tone, feeding, cord, fontanelle, hips, reflexes, genitalia and congenital anomalies. Infant: examine on caregiver’s lap; observe feeding, attachment, head control, tone, fontanelle and growth. Toddler: use play, allow exploration and examine ears/throat last. School child: explain steps, offer choices, assess school and psychosocial function. Adolescent: ensure privacy, offer part of examination without caregiver and explain confidentiality limits. Documentation and reassessment Record appearance, vital signs with method, anthropometry and centiles, positive findings, relevant negatives, response to treatment and who was present. Document the child’s and caregiver’s words when safeguarding is relevant. A changing child needs repeated examination; a normal first assessment does not end observation when the trajectory is concerning. OSCE checklist Hand hygiene, introduction, consent, privacy and appropriate draping. Initial observation and danger-sign screen. Accurate age-appropriate vital signs and growth measures. Complete general and system examination without causing avoidable distress. Summarise findings, state differential, plan investigations/referral and safety-net. References SlideShare: Pediatric physical assessment. SlideShare: The paediatric history and physical examination. WHO IMCI and Pocket Book of Hospital Care for Children.