Neonatal Intensive
Care Nursing

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).

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.

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.

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.

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?

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.

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?

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.

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?

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)?

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.

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.

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.

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).

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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..

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.

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).

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

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.

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.

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.

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).

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.

Heat loss through evaporation, convection, conduction and radiation must be prevented by preparing the environment and equipment appropriately. Environmental temperature at 26^oC. 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.

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

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..

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.

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.

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

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

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

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).

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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

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

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).

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.

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

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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

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.

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.

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.

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

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.

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.

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).

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

• 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].

• 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].

• 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].

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

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

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

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

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

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

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

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

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].

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.

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).

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.

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).

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

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].

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

Adopting an integrated approach is essential that includes nutrition as a core component of family-centred, developmental care, as proposed by Altimier & Phillips (2016) ] Ensure also that the neonatal team understand the integral role parents/carers play during the assessment process. Parents should be viewed as partners providing valuable information regarding their perspective on the feeding experience].

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

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.

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.

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.

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.

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 .

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!

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..

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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).

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.

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.

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].

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

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).

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.

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.

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.

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.

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).

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.

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

• 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

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

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.

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).

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.

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

Abdominal x-ray, upper gastrointestinal contrast study.

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.