NEONATOLOGY

July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

NEONATAL TRANSPORT

INDICATIONS FOR TRANSPORT IN NEONATES

REFERRAL TO HIGHER CENTRE

Any newborn who is assessed by the Health Care Provider as sick and needs referral

NBCC/NBSU TO SNCU SNCU TO NICU

• Birth weight <1800 grams and/or gestational age • Birth weight <1000 grams and/or gestational
<34 weeks
age < 28 weeks
• Neonates with:
- Apnea or gasping • Neonates with:
- Respiratory distress with retractions or grunt, or - Respiratory distress requiring mechanical
not maintaining SpO2 with oxygen ventilation
- Persistent Hypothermia or Hyperthermia - Unresponsive shock
- Severe jaundice requiring intensive phototherapy
- Jaundice requiring exchange transfusion, if
- Vomiting or abdominal distention
- Central cyanosis facility is not available
- Need of positive pressure ventilation>60 seconds - Refractory seizures
at birth - Need for surgical intervention
- Non-passage of stool or urine for more than 24
- Birth asphyxia qualifying for therapeutic
hours after birth
- Shock (Cold periphery with CFT > 3 seconds, and hypothermia
weak/fast pulse) - Multiorgan failure
- Refusal to feed, less movement, abnormal - Refractory hypoglycemia
movements - Acute kidney injury needing dialysis
- Significant bleeding

PREPAREDNESS AND PRE-TRANSPORT STABILIZATION

• Identify and communicate with the referral facility • Enclose (1) Complete summary (2) All investigations
• Check availability of the services and bed in the referral (3) Mother’s blood sample
facility (e.g. Ventilator) • Identify the transport team with appropriate skilled
• Explain the condition of the patient, need for transport persons
to higher facility, the expected plan and prognosis to the • Ensure the logistics and the vehicle are organised
• If shock present - start treatment before transport
family
• All doses of antibiotics and drugs should be timed prior
• Discuss with parents the possible expenses to transport
• Take informed consent of the parents prior to transport • Check temperature and blood glucose prior to transport
• Share the contact numbers of both referring and the • Ensure clear airway, appropriate respiratory support and
receiving facility including the concerned doctor secure IV access

MONITORING AND MANAGEMENT DURING TRANSPORT

MONITORING DURING TRANSPORT MANAGEMENT DURING TRANSPORT

• Parameters to be monitored: Temperature, • Maintain temperature and warmth (incubator / clothing /
Heart rate, Respiratory rate, Air entry, SpO2, GI Kangaroo Mother Care)
Aspirates, Position of tubes (ET, OG, Catheter, ICD, • Position, clear the secretion and assess for need of
IV cannula), Ventilator/ Continuous positive intubation
• Assist with appropriate respiratory support (Oxygen, CPAP,
airway pressure (CPAP) settings
Neonatal ventilation). Stop the vehicle if needed for urgent
• Frequency of monitoring: Every 30 minutes
care, e.g. intubation
depending on the sickness of the baby • Manage shock by titrating the fluids and inotropes
• Communication: Parents and the receiving • Appropriate quantity, frequency and modality of feeding
doctor should be informed of any change in the should be followed during transport (preferably
condition of the baby by the transport team breastfeeding or expressed breastmilk)

TRANSFER (HANDING OVER) TO THE RECEIVING CENTER BY TRANSPORT TEAM

Transport team should assist the The recieving All the documents viz. discharge summary,
transfer of the baby to the SNCU/ doctor should have investigations, mothers’ samples, list of awaited
NICU in the receiving center a one to one investigations that will be intimated later etc.
discusssion with should be handed over
Once transferred to the SNCU/ the handing over
NICU bed, the baby should be team The family should be introduced to the new team
stabilized by both the teams in person

ABBREVIATIONS
CFT: Capillary filling time NBCC: Newborn care corner OG: Orogastric
ET: Endo tracheal NBSU: Newborn stabilization unit SNCU: Special Newborn care unit
ICD: Intercostal drain NICU: Neonatal Intensive care unit SpO2: Pulse Oxygen saturation

REFERENCE
1. Transport of a sick neonate. Evidence-based clinical practice guidelines. National Neonatology Forum India.
Available at www.nnfi.org/cpg

AVOID INVASIVE PROCEDURES DURING TRANSPORT

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

NEONATAL EMERGENCY TRIAGE ASSESSMENT AND MANAGEMENT

SICK OR AT-RISK NEONATE PRESENTING TO HEALTH FACILITY

• Place under radiant warmer

• Attach temperature probe and pulse oximeter
• Assess for emergency signs using TABCD
› Temperature

› Airway and Breathing

› Circulation (CFT, pulse, BP)

› Coma/Convulsions

› Dehydration

EMERGENCY SIGNS PRIORITY SIGNS NON-URGENT SIGNS

• Apnea or gasping • Weight < 1800 g or > 3.8 kg • Jaundice
• Severe respiratory distress (severe • Respiratory distress(RR>60, no retractions) • Transitional stools
retractions, grunt, RR>70) • Severe jaundice (onset < 24 h /palm or sole staining/
• Minor birth trauma
• Central cyanosis/oxygen satuation <91% duration > 2 weeks)
• Shock (Cold peripheries, mottled/grey • Severe pallor • Minor malformations
skin, CFT>3 sec, weak & fast pulse, low • Bleeding • Superficial infections
BP) • Major malformation (tracheo-esophageal fistula, • Breastfeeding
• HR > 200/min meningomyelocele, gastroschisis, anorectal malformation) difficulty
• Coma or convulsions • Abdominal distension
• Regurgitation
• Severe dehydration(in cases of • Irritable/Restless
diarrhoea) • Refusal to feed
• Severe Hypothermia (< 32oC) • Moderate (32-35.9oC) or mild (36-36.4oC) hypothermia

INITIATE EMERGENCY TREATMENT AND STABILIZE ASSESS AND ACT RAPIDLY ASSESS AND COUNSEL
• Resuscitation as per NRP • Maintain TABC • Assessment and
• Maintain TABC • Check SpO2 and start oxygen if < 91% treatment as per
• Check SpO2 and start oxygen if < 91% • Check blood glucose requirement
• Start CPAP if respiratory distress • Start IV fluids (if abdominal distension/GI • Explain danger
• Start IV fluids as per weight and postnatal malformation) or gavage feeds (Refer to signs
age (Refer to STW on Feeds & Fluids) STW on Feeds & Fluids) • Counsel for
• Check blood glucose, draw CBC and • Elicit perinatal risk factors for sepsis and breastfeeding
blood culture, and give first dose of evaluate if sepsis workup is needed (refer
antibiotics(Refer to STW on Sepsis in to STW on Sepsis in neonates)
neonates) • Investigations as per clinical findings

Follow specific STWs

A neonate may have more than one condition

SPECIFIC MANAGEMENT WORKFLOWS

• Provide warmth
SHOCK • IV NS 10mL/kg bolus over 30-60 min
• May repeat bolus if evidence of volume deficit
• Consider inotropes
• Urgent ECG-look for p waves
HR> 200/MIN • If SVT, consider ice-pack and IV adenosine
• Check for and correct hyperthermia if present
SEVERE DEHYDRATION • Provide warmth
(Diarrhoea plus any two of • IV 30 mL/kg of RL or NS in 1 hour followed by 70 mL/kg in next 5 hours (WHO plan C)
lethargy, very slow skin pinch • If IV not possible, give ORS at 20 mL/kg/h for 6 hours
and sunken eyes) • Assess 1-2 hourly and titrate the volume of fluids

HYPOTHERMIA • Mild (36-36.4oC): Warm environment, skin-to-skin contact, breastfeeding

(Refer to STW on thermal care • Moderate (32-35.9oC): Place under servo-controlled warmer; skin-to-skin contact till arranged
of newborn) • Severe( < 32oC): As for moderate hypothermia plus IV fluids and inj. vitamin K

HYPOGLYCEMIA • Blood glucose < 45mg/dL and asymptomatic : supervised breastfeeding or EBM
(Refer to STW on neonatal • Blood glucose < 20 mg/dL OR symptomatic : 2mL/kg 10% dextrose IV followed by infusion
hypoglycemia) @ 6mg/kg/min

JAUNDICE • Serious jaundice (onset at < 24 h of age, palm or sole staining, or signs of acute bilirubin
(Refer to STW on neonatal encephalopathy): Intensive phototherapy, consider IV fluids if suspicion of dehydration,
jaundice) prepare for exchange blood transfusion

• Maintain TABC
• Check blood glucose by glucometer: If < 45 mg/dL, 2mL/kg 10% dextrose IV followed by
SEIZURES infusion @ 6mg/kg/min
(Refer to STW on neonatal • If not controlled, 2 mL/kg 10% calcium gluconate IV, diluted 1:1 with D5, D10 or DW, over 10
seizures) min under cardiac monitoring
• If not controlled, Inj. Phenobarbitone 20 mg/kg IV over 15 mins. If seizures persist after 15
min. consider another bolus of 10mg/kg phenobarbitone over 10 min

• Cover any skin defects with warm saline sterile gauze

SURGICAL • Maintain hydration
• Consult surgeon

• Observe and look for proper positioning and attachment of baby during breastfeeding
BREASTFEEDING DIFFICULTY • Counsel mother

ABBREVIATIONS
CFT: Capillary filling time NRP: Neonatal resuscitation protocol SVT: Supraventricular tachycardia
CPAP: Continuous positive airway pressure NS: Normal saline STW: Standard treatment workflow
ECG: Electrocardiogram RL: Ringer lactate TABC: Temperature, airway, breathing, circulation
EBM: Expressed breastmilk SpO2: Pulse oxygen saturation
REFERENCE
1. Guideline for Paediatric emergency triage, assessment and treatment. World Health Organization 2016. Available at https://apps.who.int

IDENTIFICATION AND PROMPTKEEP A HIGH THRESHOLD

TREATMENT FOR AND
OF EMERGENCY INVASIVE
PRIORITY SIGNS IS THE KEY TO PREVENT MORTALITY
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

NEONATAL SEIZURES
ICD-10-P90

NEONATES AT RISK FOR SEIZURES

• Birth asphyxia • Small for gestational age
• Sepsis • Metabolic or electrolyte abnormalities
• Meningitis • Major bleeding
• Preterm
Sudden
alteration in IDENTIFICATION OF SEIZURES
motor, behavior Motor manifestations
or autonomic • Rhythmic jerks of limb(s) or facial part(s)
• Tonic contraction of limb(s)
activity, with or • Stereotypical movements of limbs, face, eyes
without ▶
Limbs: Pedalling, rowing, swimming, cycling, stepping
alteration of ▶
Oral: Pouting of lips, mouthing, repeated sucking
▶
Eyes: Vacant stare, transient eye deviation, nystagmoid movements,
consciousness repeated blinking
Behavioural manifestations
• Sudden change in consciousness or cry characteristic
Autonomic manifestations
• Fluctuations in heart rate, sudden change in BP, sudden appearance of
unexplained apneic episodes

HISTORY EXAMINATION INVESTIGATIONS

Antenatal: First trimester viral illness, PIH, Vital signs: Temp, BP, HR, RR, CFT, In all neonates: Blood glucose, Serum electrolytes,
diabetes, PROM/ chorioamnionitis, STDs, SpO2 hemogram, ionized calcium, blood urea/
drugs or substance abuse, decreased fetal General: pallor, icterus, rash, skin creatinine, liver function tests, blood gas analysis,
movements lesions cranial ultrasound
Intrapartum: Fetal distress, difficult Specific circumstances
Head to toe : Head circumference ,
delivery, cord complications, mode of Suspected sepsis: cerebrospinal fluid examination
bulging fontanelle, needle marks on
delivery, instrumentation Suspected TORCH infections : paired mother and
Postnatal: Resuscitation, other organ scalp, dysmorphism, malformations, baby serology (for toxoplasma, CMV, rubella),
system involvement, feeding history, petechie, ecchymoses body fluids for PCR (urine for CMV), CSF for
Seizure details: onset, duration, Systemic exam : Level of alertness, toxoplasma, CMV, herpes
description (review videos) cranial nerve and motor exam, Suspected intracranial bleed: Ultrasound or CT or
Family: Consanguinity, early neonatal examination of all systems MRI head, Platelet count and Coagulogram
deaths, mental retardation, epilepsy Fundus examination Electroencephalography

ACUTE MANAGEMENT OF SEIZURES

Neonate with seizure

Goal of the treatment is the total or Ensure TABC, IV access

near total elimination of seizures. Check blood glucose by
However, with higher doses and Glucometer
addition of more anti-epileptic drugs,
the neonate requires intensive
respiratory and cardiac monitoring. If
recurrent seizures, isolated twitches Yes 10% dextrose 2 mL/kg Follow STW on
BG < 45
may be just monitored mg/dL bolus, followed by Neonatal
infusion @ 6 mg/kg/min Hypoglycemia

No
If available, measure ionized Calcium 2 mL/kg 10% calcium gluconate IV, diluted 1:1 with D5,
(iCa). If iCa <1.0 mmol/L and seizures D10 or DW over 10 min under cardiac monitoring
persist, repeat Calcium dose
Seizures persist
Inj. Phenobarbitone 20 mg/kg IV over 15 mins. If seizures persist after 15 min. consider
another bolus of 10mg/kg phenobarbitone over 10 min. Assess seizure control after 15 min
Seizures persist
Consider referral.
Phenytoin or Fosphenytoin 20 mg/kg PE: infuse over 20 min Follow STW on
under cardiac monitoring. Assess seizure control after 30 min Neonatal Transport
Seizures persist
Give Lorazepam 0.05 mg/kg IV over 2-5 mins
Can repeat dose once if seizures persist
Seizures persist
• Midazolam 0.1 mg/kg IV bolus, followed by continuous infusion (1µg/kg/min) increasing by
0.5 to 1 µg/kg/min every 2 min until a favorable response or max. 18 µg/kg/min
• Levetiracetam 40 mg/kg IV bolus followed by 40-60 mg/kg/day IV or oral in 2-3 divided doses

DURATION OF ANTICONVULSANTS
• Maintenance therapy is not needed in case of a single brief seizure that needs only one loading dose of phenobarbitone
• If more than one loading dose OR more than one drug is needed to control seizures - start the maintenance dose 24 h after the
loading dose of the respective drugs. Prefer oral route if no contraindication
• After a seizure-free period of 72 h, stop all other anticonvulsants one by one, except phenobarbitone
• After one week or at discharge (whichever is earlier), stop phenobarbitone if neurological examination and EEG are normal. If the
neurological examination or EEG is abnormal (electrical seizure activity or a burst-suppression background): discharge on
maintenance therapy
• Review at monthly intervals and taper anticonvulsants if neurological examination and EEG become normal
• If anticonvulsants are required beyond 3 months, consult a neurologist and switch to other drugs
ABBREVIATIONS
BG: Blood glucose EEG: Electroencephalography SGA: Small for gestational age
BP: Blood pressure HR: Heart rate SPO2: Pulse oxygen saturation
CFT: Capillary filling time iCA: Ionised calcium STD: Sexually transmitted diseases
CSF: Cerebrospinal fluid PIH: Pregnancy induced hypertension TABC: Temperature, airway, breathing,
DW: Distilled water for injection RR: Respiratory rate circulation
REFERENCES
1. Guidelines on neonatal seizures . World Health Organization 2011. Available at https://apps.who.int
2. Management of Seizures in the Newborn. Evidence Based Clinical Practice Guidelines. National Neonatology Forum India 2011. Available at
www.nnfi.org/cpg
NEONATES WITH SEIZURES REQUIRE LONG TERM NEURODEVELOPMENTAL FOLLOW-UP AND HEARING ASSESSMENT
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

RESPIRATORY DISTRESS IN NEONATES
ICD-10-P22.0

ACTIONS
• Rapid assessment of TABC (temperature, airway, breathing, circulation) and stabilize
the baby
• Admit the baby in SNCU/NICU
• Nurse in a radiant warmer/incubator; monitor with continuous pulse oximetry
Presence of any one:
• Quantify the severity of RD using Silverman Anderson Score [SAS]
Tachypnea (RR >60 • Closely monitor RR, SAS, SpO2, and CFT
bpm), OR lower • Most neonates with RD can be fed enterally (by breastfeeding [if RR<70 bpm and not
chest retractions, on respiratory support] or orogastric tube). Those with severe distress or any
nasal flaring, contraindication to enteral feeding should be given IV fluids
grunting OR
cyanosis GOALS
• To alleviate the work of breathing by providing appropriate respiratory support
• To maintain oxygen saturations from 91% to 95%
• Identify and treat the underlying cause

RESPIRATORY SUPPORT
• SpO2< 91%: Oxygen by nasal prongs(NP) 0.5 -1.0 Lpm
(max. 2 Lpm)
• Gestation ≥ 32 weeks: CPAP if SAS 4 >, OR no
improvement with NP oxygen
• Gestation < 32 weeks: CPAP if SpO2< 91% OR SAS 1-3
• Those with severe RD (SAS of 5 >; FiO2 of more than
60-70%), unresponsive to CPAP, having shock or
repeated episodes of apnea, may require mechanical
ventilation and referral ( See STW on Transport)

SILVERMAN ANDERSON SCORE (SAS)

RESPIRATORY DISTRESS OR LOW SPO2 (<91%)

Start oxygen by nasal cannula @ 0.5-1 LPM*

SpO2 <91% SpO2 91-95%

Increase flow up to 2 LPM Monitor clinically and SpO2

Consider using oxygen hood if no
retractions/grunt
Clinical deterioration, SpO2 >95%: Wean
SpO2 <91% Oxygen flow
No improvement

*Consider early CPAP if gestation <32 weeks, AND SpO2 <91% OR

Consider CPAP
SAS 3 or more

ASSESS AND TREAT THE UNDERLYING CAUSE

• RESPIRATORY DISTRESS SYNDROME (RDS): Consider surfactant replacement therapy as per indication
• PNEUMONIA-SEPSIS: Treat with antibiotics as per unit’s protocol (refer to sepsis STW)

WHAT NOT TO DO
• DO NOT let SpO2 exceedc 95% while supplementing oxygen. High oxygen saturation is a risk factor for
retinopathy of prematurity
• DO NOT give unnecessary IV fluids, antibiotics, blood products or drugs
• DO NOT perform unnecessary investigations (CBC, CRP, routine ABG)
• DO NOT do routine chest X-ray in all neonates with RD. Perform chest X-ray if RD is persisting beyond 6
hours of age, there is worsening or a diagnostic dilemma

ABBREVIATIONS
BW: Birth weight GA: Gestational age RR: Respiratory rate
CPAP: Continuous positive airway pressure IV: Intravenous SAS: Silverman Anderson score
CFT: Capillary filling time RD: Respiratory distress

REFERENCES
1. Oxygen therapy in neonates, and Surfactant Replacement therapy in neonates. Evidence-based Clinical Practice Guidelines. National
Neonatology Forum India. Available at www.nnfi.org/cpg

PREVENT HYPOXIA AND HYPEROXIA

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

THERMAL CARE OF NEWBORN
ICD-10-P81.8

Delivery room - in the first STANDARD TECHNIQUE FOR MEASUREMENT OF

hour after delivery TEMPERATURE
• Use a standard digital thermometer
Temperature • Place the tip in the neonate’s axilla
Prior to and during transport keeping it parallel to the neonate’s trunk
measurement
• Read once the beep sound is heard
for neonates is
mandatory in At the time of admission
the given
settings to
Continuous monitoring for all
diagnose babies nursed in radiant
hypothermia warmer/ incubator >37.5 ºC
Hyperthermia

36.5 to 37.5 ºC
At-risk neonates staying with Normal
mother e.g. - LBW, preterms - 36.0-36.4 ºC
Mild hypothermia
every 4 hourly
32-35.9 ºC
Moderate Hypothermia

REGULARLY MONITOR TEMPERATURE AND DOCUMENT

<32.0ºC
Severe Hypothermia

NO Is it • Check for possible cause of hypothermia

YES
<36.5 °C? • Assess for risk factors & clinical features of sepsis (Refer to sepsis STW)
• Check room temperature

YES

MILD HYPOTHERMIA: 36 °C- 36.4 °C MODERATE HYPOTHERMIA: 32 °C- 35.9 °C SEVERE HYPOTHERMIA: <32 °C

• Ensure room temperature 25-28 °C • Nurse under radiant warmer in servo mode with • Manage as per moderate
• Provide skin-to-skin (STS) contact temperature probe attached to neonate hypothermia
• Continue breastfeeding • Continue skin-to-skin contact till warmer is
available ensuring mother-neonate dyad is • Make nil per oral
• If sick, nurse under radiant warmer covered with pre-warmed linen • Start IV fluids (refer to STW on
• Start O2 if SpO2<91% Feeds and fluids)
• RECHECK TEMPERATURE IN 1 HOUR: • Check blood sugar, if <45 mg/dL then follow STW
• Give Inj. Vitamin K
• If normal, wrap properly on Hypoglycemia
• Recheck temperature every 15 minutes till it • Refer to higher centre if develops
• If still <36.5 °C then treat as moderate
normalizes shock or respiratory failure (refer to
hypothermia • Continue feeding if stable and abdominal STW on Neonatal Transport)
examination is normal

PREVENTION OF HYPOTHERMIA- MAINTENANCE OF WARM CHAIN

DELIVERY ROOM (DR) POSTNATAL WARDS WARM CHAIN DURING TRANSPORT

• Radiant warmer is must in Neonatal Care Corner • Cover neonate adequately Without external heat source:
• Area should be air draught free • Practice rooming-in 24x7 • A fully wrapped neonate with cap can
be transported in an adult’s arms in a
• All DRs should have room thermometer • Avoid air draughts by closing
closed vehicle
• Maintain DR temperature >25 °C windows, doors, and switching • Neonate can be transported in
• Switch on radiant warmer 20-30 minutes before delivery off fans and air conditioners skin-to-skin contact
• Radiant warmer should be in manual mode with heater • Start Kangaroo Mother Care • Ensure that the neonate is in upright
output being 100% (KMC) as early as possible for position and covered snuggly with the
• Pre-warm two to three sterile towels by keeping them person’s clothes and a blanket
eligible neonate
under radiant warmer for 20 minutes • Promote exclusive breastfeeding With external heat source:
• Practice early skin-to-skin contact for stable neonates • Delay bath till after discharge • A thermal mattress or a transport
for 1 hour or at least till first breastfeeding • Remove wet clothes as early as incubator
• Dry newborn immediately after birth possible • Indigenous insulated boxes can be
• Remove wet linen immediately • Educate mother regarding used in resource-limited settings
• Weighing and checking temperature should be done • No neonate should be placed naked in
identification of hypothermia
after breastfeeding a trolley or bed without an external
using touch method heat source

Early skin-to-skin contact Adequate clothing & rooming-in Kangaroo Mother Care Radiant warmer
HYPERTHERMIA
• Neonates may become hyperthermic due to high environmental temperature and/ or overclothing
• Differentiate from sepsis: If both trunk & extremities are hot, an environmental cause is likely. If trunk is hot & extremities are cold, consider sepsis
• If baby is hyperthermic, move to cooler environment and decrease clothing. Ensure adequate breastfeeding and check weight loss
• If still hyperthermic, needs further evaluation

REFERENCES
1. World Health Organization. Maternal Health and Safe Motherhood Programme & Meeting of Technical Working Group on Thermal Control of the Newborn (1992
:Geneva, Switzerland). (1993). Thermal control of the newborn : a practical guide. World Health Organization. https://apps.who.int/iris/handle/10665/60042

HYPOTHERMIA IN NEWBORNS INCREASES MORTALITY. PREVENT HYPOTHERMIA - MAINTAIN WARM CHAIN

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

NEONATAL HYPOGLYCEMIA
ICD-10-P70.4

WHOM TO SCREEN FOR HYPOGLYCEMIA?

• Preterm infants (< 37 weeks gestational age)
• Low birth weight Infants (< 2500 g)
• Small for gestation age (SGA): birth weight < 10th percentile
• Large for gestation age (LGA): birth weight > 90th percentile
• Infant of diabetic mother (IDM)
• Sick infants (eg: sepsis, asphyxia, respiratory distress, shock,polycythemia, seizure)
• Post exchange blood transfusion
• Infants on intravenous fluids and parenteral nutrition
Do not monitor blood glucose routinely in term healthy AGA infants

SCHEDULE OF BLOOD GLUCOSE (BG) HOW TO MONITOR BLOOD GLUCOSE (BG)?

MONITORING (PREFEED)
• Use Glucose reagent strips along with a
CATEGORY TIME SCHEDULE
glucometer
At 2, 6, 12, 24, 48, 72 • Low value (< 45 mg/dL) – Send a blood
At-risk infants hours of life sample to the lab for confirmation
• Do not delay treatment
Infants on IV fluids/
Every 6-8 hours
parenteral nutrition

BLOOD GLUCOSE <45 mg/dL

LOOK FOR FOLLOWING SYMPTOMS AND SIGNS

• Stupor, lethargy, limpness
• Jitteriness, tremors, convulsions
• Episodes of cyanosis, apnea or tachypnea
• Weak and high-pitched cry
• Difficulty in feeding

ASYMPTOMATIC SYMPTOMATIC OR BG < 20mg/dL

• Immediate supervised feeding • IV bolus: 2 mL/kg 10% dextrose
• Breastfeeding or a measured volume of • Start IV infusion of dextrose at a
expressed breast milk (formula milk if EBM glucose infusion rate (GIR) of 6
not available) by paladai or gavage mg/kg/min

RE-CHECK BG AFTER 1 HOUR Re-check BG every 30 mins till 2 values

≥ 45 mg/dL & then every 6 hrs

If BG ≥ 45 mg/dL Start IV glucose

• Continue feeds infusion if:
• Continue BG BG < 45 despite one
BG < 45 mg/dL BG ≥ 45 mg/dL
monitoring attempt of feeding
every 6 hourly OR
for 24 hours Baby becomes
Increase GIR @ 2
symptomatic Euglycemic for 24
mg/kg/min till max GIR 12
hours on IV fluids
mg/kg/min
PREVENTION OF HYPOGLYCEMIA
• Support mother for early initiation and
regular breastfeeding • Wean @ 2 mg/kg/min
Refractory hypoglycemia:
• Maintain normothermia every 6 hourly
High (>12 mg/kg/min for 24
• Do not feed 5%, 10% or 25% dextrose as a • Increase oral feeds
hours) or persistent (> 7
substitute for breast milk • Monitor BG every 6
days) GIR requirement
hourly

PRACTICAL POINTS
Stop IV fluids when
• Avoid > 12.5-15% dextrose infusion through a CONSIDER DRUGS* AND REFER euglycemic on GIR 4
peripheral vein TO HIGHER CENTRE mg/kg/min
• Use a syringe/ infusion pump to deliver
glucose
• Avoid frequent dextrose boluses
*DRUGS FOR REFRACTORY HYPOGLYCEMIA
• Send blood in fluoride or oxalate vial for
laboratory glucose estimation • Hydrocortisone: 5 mg/kg/day IV in two
• Always search for an underlying cause - divided doses
polycythemia, sepsis, meningitis, • Diazoxide: 10-25 mg/kg/day PO in three
hypothermia, IUGR divided doses
• Do not give antibiotics unless sepsis is • Glucagon: 300 μg/kg SC or IM
suspected (refer to STW on sepsis) • Octreotide: 2-10 μg/kg/day SC

ABBREVIATIONS

AGA : Appropriate for Gestational Age IV : Intravenous PO : Per oral IUGR: Intra uterine growth retardation
EBM : Expressed breast milk IM: Intramuscular SC : Subcutaneous

SYMPTOMATIC AS WELL AS ASYMPTOMATIC HYPOGLYCEMIA CAN LEAD TO PERMANENT BRAIN DAMAGE

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

FEEDS & FLUIDS IN NEONATES
ICD-10-R63.3
PART A
Nutritional plan for infants not on enteral feeds at admission
IF ANY OF THE FOLLOWING ARE PRESENT

Gestation <35 wks and birth weight <3rd centile or Suspected GI

Gestation <35 wks & OR
NO REDF in antenatal USG
AEDF in antenatal USG, need for extensive resuscitation, OR malformation
HIE, 5 minute Apgar <7, has RED signs (Part B) or suspected NEC

NPO for 24 h → Re-assess → Abdomen Keep NPO for 6 h → Re-assess →

Keep NPO → Take
soft, no distension → Start feeds @ 10-20 Abdomen soft, no distension & recovery
pediatric surgery
ml/kg/d → If tolerates, increase @ half of from red signs → Start feeds as per
consultation*
weight/ gestation specific increments gestation/ weight specific protocol

GA <26 weeks* GA 26-27 weeks* GA 28-30 weeks GA >30 weeks

BW < 750 g BW 750-999 g BW 1000-1250 g BW >1250 g

NPO for 24 h NPO for 24 h

Trophic feeds @ Start feeds @ Start feeds @ All fluid as
10 ml/kg/d for 48 h 20 ml/kg/d 30 ml/kg/d feeds
Increase @ Increase @ Increase @ from D
10-15 ml/kg/d 15-20 ml/kg/d 30 ml/kg/d

• For total daily fluid requirement see table 1. Remaining fluid requirement after accounting for feed volume, should be given as
IV fluids and if feasible as PN in neonates born at less than 28 weeks or 1000 g*
• IV fluids can be stopped once infant is tolerating feeds @ 120 mL/kg/d, if blood glucose is maintained.
• Preferred mode of feeding: < 32 weeks: Oro-Gastric tube; 32-34 weeks: Spoon/Paladai; and ≥ 35weeks: Breast feeds
• Choice of milk in order of preference: Expressed breast milk (EBM) >> pasteurized donor human milk >> formula milk
• Frequency of feeds: q 2 h if PMA < 32 weeks/ weight <1500g and q 3 h if ≥ 32weeks/ weight >1500g
• Add supplements as per Table 2

*Indicates conditions which need admission/referral to tertiary care health facility

PART B
Nutritional plan for infants on partial or full enteral feeds at admission

ARE ANY OF THESE RED SIGNS PRESENT?

Significant Feed intolerance

Ongoing
respiratory Shock (abdominal distension
hypoxia or Ongoing Severe
distress needing with vomiting, bilious
moderate to seizures hypothermia
(Silverman/ inotropes or bloody gastric
severe apneas
Downe score>6) aspirates)

NO YES

Continue feeds Keep NPO and start IV fluids Every 12-24 h re-assess Restart at 50% of the
and advance as Consider PN if gestation < 28 weeks for readiness of feed by volume of feed being
given in flow or weight <1000 g* presence of soft tolerated before
chart in part A Take Pediaric surgery consultation if abdomen, no distension making NPO and
suspecting GI obstruction or and absence of red signs make increment as
peritonitis* per chart in part A

TABLE 1 TABLE 2
Maintenance volume (Enteral + IV, mL/kg/d) and type of IV fluids Supplements

BIRTH WEIGHT DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 • Start when infant is on 100ml/kg/day of enteral feeds
• Start Iron at 2 weeks of age
<1000 g or Weight <1800 gram or Gestation <35 weeks
Advance strictly as per clinical and lab
Gestation <28 80-100 • If on EBM Or Donor Milk: HMF + Iron + Vitamin D3
hydration status
weeks • If on Breastfeeds: Iron + Calcium + Phosphorus +
Multivitamins + Vitamin D3
1000-1250g • If on Preterm Formula: Iron and Vitamin D3
80 100 120 140 150 150-160 150-160
28 to 30 weeks Weight >=1800 gram and Gestation >=35 weeks
• Vitamin D 3 and Iron (only for gestation <37
>1250 g 60 80 100 120 140 150 150-160 weeks)
>30 weeks
Dose Duration
Iron: 2mg/kg/day Iron and Vit-D3: till 1 year
Type of IV Start with D10 Vit -D3: 400 IU to 800 Calcium and
fluids Titrate dextrose IU/day Phosphorus: till term
concentration as N/5 in D10 with KCl Calcium: 120mg/kg/day PMA
per blood glucose Phosphorus: 60mg/kg/day Multivitamins: till 6
months

• Table 1 is a general guide and daily increments may be based on daily weight change, urine output, serum sodium and
co-morbidities such as PDA or sepsis
• Daily increments of feed should be based on tolerance and weight gain.
• Monitor growth by regular measurement of weight and head circumference. Once full feeds have been achieved, preterm neonates
are expected to gain weight @ 10-20 g/kg/day. Plot the growth parameters on intergrowth 21st postnatal charts for preterm
neonates
• If not gaining weight adequately on exclusive enteral feeds, after 2 weeks of life, feed volume may be increased gradually upto
200-250 mL/kg/d as per tolerance
ABBREVIATIONS
AEDF: Absent end diastolic flow NEC: Necrotizing enterocolitis PN: Parenteral nutrition
HIE: Hypoxic ischemic encephalopathy PDA: Patent ductus arteriosus REDF: Reversed end diastolic flow
HMF: Human milk fortifiers PMA: Post menstrual age
EARLY AND AGGRESSIVE ENTERAL FEEDING BY BREASTMILK DECREASES MORTALITY AND MORBIDITY
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

NEONATAL JAUNDICE IN INFANTS ≥ 35 WEEKS
ICD-10-P59.9

VISUAL ASSESMENT

Examine the baby in bright LOOK FOR THESE RISK FACTORS

natural/ white fluorescent light • Gestation < 38 weeks
• Previous sibling requiring treatment for
Approach to Make sure the baby is naked and jaundice
neonatal no yellow/ off white background • Blood group incompatibility (ABO/Rh)
jaundice • High prevalence of G6PD deficiency
Examine blanched skin • Exclusively breast fed baby with weight loss
>3% per day; or >10% cumulative
• Total serum bilirubin (TSB) / Transcutaneous
Assess severity of jaundice bilirubin (TcB) value in the high/
high-intermediate risk zone

ASSESSMENT OF SEVERITY OF JAUNDICE

Clinical 1 KRAMER ZONES APPROX SERUM BILIRUBIN SERIOUS JAUNDICE

• Visible jaundice in first 24 hrs OR
examination 1 Face and neck 4 to 6 mg/dL ASSESS IF
• Yellow palms and soles anytime OR
every 12 hrs THE BABY • Signs of acute bilirubin
4 2 4 2 Chest and upper abdomen 8 to 10 mg/dL
during the HAS encephalopathy (ABE) like poor
5 5
initial 3 to 5 3 3 Lower abdomen and thighs 12 to 14 mg/dL SERIOUS suck/feeding, lethargy, hypotonia OR
days of life; 4 Legs and arms/ forearms 15 to 18 mg/dL JAUNDICE*? • Abnormal posturing such as arching,
use TcB if 4 4 retrocollis, opisthotonus, convulsion,
5 Palms and soles >15 to 20 mg/dL fever, high pitched cry
available 5 5

MANAGEMENT
Does the infant have serious jaundice?

YES NO

Start Intensive Phototherapy Does the infant require TSB measurement ?

• Document serum bilirubin simultaneously
• Jaundice in first 24 hrs ?
• Prepare for exchange blood transfusion (EBT) if signs of ABE
• Beyond 24 hrs: more than 12-14 mg/dL
are present
on visual assessment / TcB or near PT
cut-off ?
As per TSB, determine if baby requires • Unsure about visual assessment ?
YES
phototherapy/ EBT if TSB at/more than cut-off?

YES NO
Continue phototherapy/prepare for NO
Continue visual
EBT and determine the cause
assessment/TcB
Stop phototherapy (if available) every 12 to
Investigation:
· Blood type and DCT (if mother is 'O' or Rh -ve 24 hrs till discharge
· G6PD status
· Peipheral smear and reticulocyte count

Stop phototherapy
TSB falls below 13-14 mg/dL or 2 mg/dL below cut-off
ENSURING OPTIMAL EXCHANGE
ENSURING OPTIMAL PHOTOTHERAPY BLOOD TRANSFUSION (EBT) DISCHARGE ADVICE
· Keep the baby naked (only small nappy to cover the genitalia
and eye covers) · Immediate EBT is · Reinforce breastfeeding at
· Place the baby close to the lights recommended if infant shows discharge
· Phototherapy can be interrupted for feeding & clinical procedures signs of ABE or if TSB is above · If discharged before 72 hrs;
· Encourage frequent breastfeeding the recommended age and risk
· Monitor temperature regularly follow up at 48 to 72 hrs
specific cut off
· Maintain equipment as per manufacturer’s instructions after discharge
• Frequency of repeat TSB measurement depends on cause, · Exchange volume = Twice the
severity, age and gestation estimated blood volume of
• Hemolytic jaundice : 6 to 8 hourly during initial 24 to 48 hrs 80-100 mL/kg
• Non-hemolytic jaundice : 12-24 hourly

SOME IMPORTANT DO’S SOME IMPORTANT DON’TS

Encourage frequent breastfeeding Sunlight should not be used for treatment of hyperbilirubinemia
Avoid exposure to naphthalene balls Do not rely on visual assessment/ TcB while the baby is under phototherapy
Complete evaluation of newborn is important to
Do not give phenobarbitone for treatment of hyperbilirubinemia
evaluate for risk factors and underlying causes
Do pre-discharge risk assessment Do not stop breastfeeding
ABBREVIATIONS
ABE: Acute bilirubin encephalopathy EBT: Exchange blood transfusion TcB: Transcutaneous bilirubin
DCT: Direct coombs test G6PD: Glucose-6-phosphate dehydrogenase TSB: Total serum bilirubin

REFERENCES
1. Screening, Prevention and Management of Neonatal Hyperbilirubinemia. Clinical Practice Guidelines. National Neonatology Forum India 2020.
www.nnfi.org/cpg
2.Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. American Academy of Pediatrics Practice Guidelines .
www.cdc.gov

HYPERBILIRUBINEMIA IS A PREVENTABLE CAUSE OF BRAIN DAMAGE

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

POST-ASPHYXIAL MANAGEMENT OF NEONATES
ICD-10-P21.0

IMMEDIATE MANAGEMENT OF AN ASPHYXIATED NEONATE

Need for Positive pressure ventilation (PPV) at birth
OR
Referred with history of delayed cry at birth

• PPV for <60 seconds OR • PPV for 60 seconds or more OR

• Delayed cry and resuscitation • Needed intubation or medications OR
details not available • Cord pH <7.1 (if available)

At risk of hypoxic-ischemic
Assess 15 minutes after birth OR at admission encephalopathy (HIE)
1. Lethargy/coma or irritability?
2. Absent spontaneous movements? Yes
3. Absent Suck and Moro's reflex ? Check vitals and blood glucose If any value is
4. Abnormal movements ( limb jerks, cycling, • Temperature, heart rate, abnormal, follow
swimming, chewing, sucking movements respiratory rate, oxygen appropriate STW
saturation (SpO2), capillary refill for Neonatal Triage
which are persistent and monotonous) ?
time
5. Respiratory distress ? • Check blood glucose
6. Features of shock ?

Stabilization and Supportive Treatment

No • Secure airway
• If SpO2 <91%, start O2 by prongs/ hood
• If respiratory distress persists, follow STW for respiratory distress;
consider CPAP if chest retractions or persistent hypoxia
• Shift to mother’s side
• Start IV 10% dextrose at 60 mL/kg/day
• Initiate breastfeeding • Maintain normal temperature; avoid hyperthermia
• Skin-to-skin contact • Target blood glucose of 50-125 mg/dL
• Observe every 15 minutes for 1 hour • If infant has seizures, follow STW for seizure

• Initiate feeds once vitals are

Assess for moderate to severe HIE
stable No HIE or
• Switch to breastfeeding as early No Lethargic or comatose with ANY ONE of the
Mild HIE
as possible. following:
• Continue monitoring for 24hrs 1. Seizures
2. Decreased muscle tone
3. Absent /weak Suck or Moro's reflex
Needs further assessment; may Moderate or Yes
need therapeutic hypothermia severe HIE

NEONATE WITH MODERATE OR SEVERE HYPOXIC-ISCHEMIC ENCEPHALOPATHY

FULFILLS ALL OF THE FOLLOWING CRITERIA?
• ≥ 36 weeks gestational age NO
• ≥ 1800g birth weight PROVIDE SUPPORTIVE TREATMENT
• < 6 hrs old
• Admission temperature 36-37.4 0C • Secure airway
YES • If SpO2 <91%, start O2 by prongs/ hood

All of the following are fulfilled: • Start IV 10% dextrose at 60 mL/kg/day

• pH <7 or base excess ≥16 on cord or arterial blood gas • Maintain normal temperature; avoid
done within 1 h of life AND NO
• Apgar score< 5 at 10 minutes or at least 10 min of PPV hyperthermia
AND
• Target blood glucose of 50-125 mg/dL
• History of acute perinatal event (such as but not limited
to placental abruption, uterine rupture, cord prolapse) • If infant has seizures, follow STW for
YES seizures
NO
Moderate to Severe HIE
YES
NO
Written protocol and facility for therapeutic
REFER TO HIGHER CENTRE
hypothermia and level-3 intensive care available?
YES

Initiate whole body cooling using a servo-controlled mattress / phase-change material (PCM) based device / ice or gel packs.
• If using gel or ice packs/PCM - ensure presence of nurse in 1:1 ratio for the neonate being cooled
• Whatever the device used, the cooling targets and monitoring are similar:
o
Continuous rectal temperature monitoring is required from initiation until 8 hrs after rewarming
o
Target rectal temperature is 33-34 °C
o
Induction: aim to attain target temperature in the first 30 minutes
o
Maintenance: continue to maintain target temperature for 72 hrs after initiation
o
Rewarming: increase rectal temperature to 36.5 °C over 6-12 hrs, at a rate ≤ 0.5 °C per hour

ABBREVIATIONS
BE: Base excess CSF: Cerebrospinal fluid PPV: Positive pressure ventilation
CBC: Complete blood count HIE: Hypoxic-ischemic encephalopathy SNCU: Special newborn care unit
CRP: C reactive protein NICU: Neonatal intensive care unit
REFERENCES
1. NNF Working Group. Position Statement and Guidelines for Use of Therapeutic Hypothermia to treat Neonatal Hypoxic Ischemic Encephalopathy in India. New Delhi: National
Neonatology Forum, India; 2021 Oct.
2. Sarnat HB, Sarnat MS. Neonatal Encephalopathy Following Fetal Distress: A Clinical and Electroencephalographic Study. Arch Neurol-chicago. 1976; 33(10):696–705.
3. Abate BB, Bimerew M, Gebremichael B, Kassie AM, Kassaw M, Gebremeskel T, et al. Effects of therapeutic hypothermia on death among asphyxiated neonates with
hypoxic-ischemic encephalopathy: A systematic review and meta-analysis of randomized control trials. Plos One. 2021; 16(2):e0247229.

FREQUENT MULTI-SYSTEM MONITORING IS A MUST

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.
 July/ 2020

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW)

SEPSIS IN NEONATES
ICD-10-P36

RED FLAG SIGNS

Shock
Bleeding from multiple sites
Hardening of skin so that it
cannot be pinched off the
underlying tissue or bone Respiratory distress onset
Assess every neonate (look at cheeks and thighs) more than 6 hrs after birth
born in or brought
Respiratory distress
to a health facility needing intubation or If age of baby is less than 7 days
for presence of Silverman’s score >6 and mother has foul smelling
sepsis, at admission discharge or chorioamnionitis
and during hospital
stay, by looking for YELLOW FLAG SIGNS
red and yellow flag
signs and risk factors Refusal HR>160 persisting for Respiratory
Seizures one hour despite Floppiness
to feed normal temperature distress

Feed New or increased Fever or hypothermia not due

Lethargy to environmental temperature
intolerance apneic episodes
Any of the maternal risk factors: If age of baby is less than 7 days and mother has

Dai handling or Rupture of

unclean vaginal membranes pPROM Urinary tract Diarrhea Fever
examination ≥18 hrs infection

HIGH PROBABILITY OF SEPSIS AT-RISK/SUSPECT SEPSIS

Start treatment and investigate Observe
• Any RED flag sign is present • One YELLOW sign or maternal risk factor is present
• Two YELLOW signs/ maternal risk factors are present AND
• One YELLOW sign or maternal risk factor is present • Baby’s gestation at birth is >32 weeks
AND baby’s gestation at birth is ≤ 32 weeks

• Admit in the NICU/SNCU • Keep baby under close observation for 48-72 hrs
• Obtain blood sample for culture and sensitivity • Start antibiotics if another yellow/ red sign
• Start empirical antibiotics as per local/unit policy
pending reports appears during observation
• Provide supportive care and do appropriate laboratory • Obtain sample for blood culture and sensitivity
investigations as indicated clinically (Chest X-ray, CBC, before starting antibiotics
platelet count, RBS, serum electrolytes, renal • Perform LP for CSF analysis if starting antibiotics
functions) or if the blood culture is positive
• Perform lumbar puncture (LP) for CSF analysis when
baby is hemodynamically stable
REVIEW AT 48 HRS
SIGNS OF SEPSIS DISAPPEARED AND SIGNS OF SEPSIS IMPROVING BUT SIGNS OF SEPSIS WORSENED, OR A RED SIGN
CRP <12 MG/L STILL PRESENT APPEARED AFTER STARTING TREATMENT
• Stop antibiotics • Continue antibiotics • Upgrade antibiotics as per antibiotic
• Keep under observation till blood culture • Antibiotic duration based on blood local/unit policy
is reported as sterile after 48 hrs of culture and LP report • Antibiotic duration based on blood culture
incubation and LP report

If antibiotics are continued, review again at 5 days: If baby is now well from last 48 hrs, blood culture is sterile and CSF is normal: Stop antibiotics

If blood culture was not done, a negative CRP or Procalcitonin at 24-48 hrs after starting antibiotics, can help in early stopping of antibiotics

DURATION OF ANTIBIOTICS
CONDITION DURATION
Pneumonia 5-7 DAYS
Sepsis with CRP >12 mg/L AND sterile blood culture AND normal CSF analysis 5-7 DAYS
Blood culture positive 10-14 DAYS
CSF suggestive of meningitis 21 DAYS

REMEMBER
Do not start antibiotics without Main utility of both CRP and procalcitonin is
indication. Clinical features in neonates Believe a negative to rule-out sepsis. A positive test may also be
are non-specific. Looking for alternative blood culture report due to several non-infective conditions.
reasons for sickness and careful serial and stop antibiotics if Therefore, a positive CRP or procalcitonin
observations are important ways to avoid baby has recovered. should be interpreted carefully giving due
unnecessary use of antibiotics. weightage to clinical course of the baby.

ABBREVIATIONS
CBC: Complete blood count LP: Lumbar puncture RBS: Random blood sugar
CRP: C-reactive protein NICU: Neonatal intensive care unit SNCU: Special newborn care unit
CSF: Cerebrospinal fluid pPROM: Preterm premature rupture of membranes
REFERENCES
1. Sankar MJ, Agarwal R, Deorari AK, Paul VK. Sepsis in the newborn. Indian J Pediatrics. 2008; 75(3):261–6.
2. The Young Infants Clinical Signs Study Group. Clinical signs that predict severe illness in children under age 2 months: a multicentre study. Lancet. 2008; 371(9607):135–42.
3. Neonatal infection: antibiotics for prevention and treatment. London: National Institute for Health and Care Excellence (NICE); 2021 Apr 20. (NICE Guideline, No. 195.). Available from:
https://www.nice.org.uk/guidance/ng195 Last access on 20/04/2022

PREVENT SEPSIS BY ENSURING HAND HYGIENE, ASEPSIS DURING PROCEDURES AND DILIGENT HOUSEKEEPING
This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of DHR for more information: (stw.icmr.org.in) for more information.
©Department of Health Research, Ministry of Health & Family Welfare, Government of India.