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NICU guideline identifier

Postnatal wards - management of infants under paediatric care

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Admission to Postnatal Ward from Delivery Suite or NICU

  • Birthweight = 2.0 kg
  • Gestational age = 35 weeks
  • Criteria for multiples dependent upon other factors e.g. co-twin/triplet BW, maternal wellbeing

NB: Infants = 2.5kg or 37 weeks gestation should remain under the paediatric service on the wards.

Tachypnoea

  • Infants with risk factors .e.g. meconium exposure, sepsis risk will have had AC temperature/respirations requested.
  • The normal respiratory rate 40-50/minute. If >60/minute refer to Paediatric registrar for assessment.
  • If Temperature >37.5°C on 2 occasions more than 1 hour apart, the infant should be examined and referred to the Paediatric Registrar

Infants of Diabetic Mothers

See Guidelines for the Management of hypoglycaemia

Prematurity

These infants must be referred to the Paediatric Registrar who may decide (especially >36 weeks) to leave them under obstetric care. Where there is doubt about gestation, refer to registrar for their opinion.

Temperature control

  • Hypothermia is a major problem with low birthweight and growth restricted infants. These infants should be suitably dressed (nappy if skin to skin, or singlet, stretch 'n grow, cardigan, hat, booties, bedding firmly tucked) and kept in a warm room with no drafts.
  • Temperatures of <36.5°C are abnormal. The infant should be placed skin to skin with mother with blanket over back keeping face clear and temperature repeated in an hour.
  • If the temperature remains low in the first 24 hours, the baby should be placed in a Cosytherm / incubator, and if not up above 36.8°C in 4 hours, refer to the Paediatric Registrar.
  • Temperature instability after the first day should be referred to the Paediatric Registrar.

Note: Hypothermia is often the first sign of sepsis and the possibility of major infection should always be considered.

Sepsis risk factors at delivery

  • Prolonged rupture of membranes
  • Gestation <37 weeks
  • Maternal pyrexia
  • Fetal tachycardia
  • Offensive liquor (meconium exposure)

Take swabs at delivery (ear/axilla/gastric aspirate) and ask for a differential on a full blood count. Request AC temperature and respiratory recordings.

If the white blood count shows a left shift (band forms and immature forms >20% of total neutrophils), if the respiratory rate is >60/minute or the temperature is >37.5°C, or swabs subsequently grow Group B Streptococcus refer to the Paediatric Registrar.

If two or more risk factors present, or the baby has symptoms other than the above, immediate referral is necessary.

Jaundice

see Jaundice on the Postnatal Ward

  • Jaundice requires Paediatric evaluation as per the link above .
  • If a jaundiced baby requires phototherapy then a Paediatric referral and assessment is mandatory.
  • At the time of Paediatric referral, a request should be made to blood bank for the baby's blood group and Coomb's results and FBC and film comment requested

Abnormal Pulse oximetry screening

  • The baby should be referred immediately to the Paediatric Registrar for a same day paediatric assessment. This may include full examination, CXR, ECG and echocardiogram. See pulse oximetry screening
  • Consider respiratory and metabolic causes of the hypoxaemic infant.

Heart Murmurs

Pulse oximetry should have already been carried out. Regardless of result, refer infant to Paediatric Registrar. If asymptomatic, further investigations such as ECG, CXR and echocardiogram may be carried out on the ward. Follow-up with Cardiology or Newborn service needs to be arranged.

Cord flare

  • This may indicate the presence of early omphalitis although commonly is due to cord-clamp irritation of abdominal skin.
  • If there are no other signs of sepsis (fever, tachycardia, paronychia, skin pustules elsewhere or induration), check FBC, do umbilical and groin swabs, and observe.
  • If other signs of sepsis are present, refer to Paediatric Registrar immediately for full septic screen and treatment.

Ventouse deliveries

These infants are at risk of sub-galeal haemorrhage. They need to be monitored. Discuss the level of surveillance with the Registrar within 30 minutes of delivery.

Feeding infants on Postnatal Wards

  • The main aim is promotion of successful, exclusive breast feeding
  • Weight loss >10% on day 3 needs referral to lactation consultant and paediatrician for consideration of adequacy of lactation and consideration of medical causes.

Healthy Term infants

Infants should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing or rooting -ideally 8-12 times per 24hours.

Milk delivery time varies between mothers -some infants may be satisfied with less frequent feeds.
Once breast feeding is established feeding frequency gradually decreases to around 6 feeds per day for most infants (usually post discharge).

Healthy term infants do not require supplements (water/formula). If there are risk factors for hypoglycaemia such as maternal diabetes/asphyxia etc. then blood glucose monitoring is required. See Management of hypoglycaemia

Late pre-term infants, SGA and LGA infants, other at risk infants.

see Management of hypoglycaemia

Place infant skin to skin with mother, offer breast feed as soon as possible after birth and demand feed up to 3 hourly.

For infants who latch and suck well on the breast there is no need for supplementation but mothers should be shown how, and encouraged to hand express after breast feeds to stimulate milk production.

For those infants who do not feed well e.g. difficulty latching, do not suckle for long- a blood glucose should be checked and a supplementary feed may be required (expressed breast milk or formula). Feed volumes will vary and individualised feeding plan can be discussed with the ward lactation consultant. The method of delivery may be via cup, syringe or bottle.

Orogastric or nasogastric tube feeds should only be instituted on the advice of the paediatric staff. See guidelines for supplementary feeding on the postnatal ward. See also Newborn services feeding policy

Glucose monitoring as per Management of hypoglycaemia guideline.

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Document Control

  • Date last published: 31 October 2016
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years