MANAGEMENT OF SICK AND SMALL NEWBORNS

FACILITATOR GUIDE TO CLINICAL PRACTICE

2ND EDITION, JULY 2015

This work is licensed under a CC BY 4.0 International License.

Facilitator guide to Practical’s 2nd edition 1

FACILITATORS GUIDE TO CLINICAL PRACTICE ...... 3

PRACTICAL 1: WORKING IN THE NEONATAL UNIT, INFECTION PREVENTION AND A NEUROPROTECTIVE ENVIRONMENT...... 6

PRACTICAL 2 & 3: ASSESS AND CLASSIFY DEMONSTRATION AND PRACTISE ...... 9

PRACTICAL 4: Demonstrate and Practise Assess Risk Factors and special treatment needs ...... 11

PRACTICAL 5: Maintain normal body temperature ...... 13

Practical 6: Oxygen therapy ...... 15

Practical 7: Demonstration and practice of feeds and fluids calculations ...... 18

PRACTICAL 8: Ballard Score ...... 19

PRACTICAL 9: KMC PART 1: The KMC unit ...... 20

KMC 9: PART 2: Assisting mothers in placing babies in KMC ...... 22

PRACTICAL 10 KMC DAILY SCORE SHEET ...... 23

PRACTICAL 11: ASSESS WEIGHT GAIN IN LBW BABY ...... 26

PRACTICAL 12 JAUNDICE ...... 28

PRACTICAL 13 NEONATAL ENCEPHALOPATHY (HIE) ...... 29

PRACTICAL 15: CPAP ...... 30

PRACTICAL 18: CREATING A NEURODEVELOPMENTAL SENSITIVE NNU ENVIRONMENT FOR THE PRETERM INFANT ...... 34

PRACTICAL 19: INFANT MOTOR ASSESSMENT ...... 36

PRACTICAL 20: UMBILICAL VEIN LINE INSERTION ...... 37

PRACTICAL 21: X-RAY INTERPRETATION ...... 39

Still to be developed ...... 39

PRACTICAL 22: CLEANING AND STERILISING EQUIPMENT AND NEONATAL WARD ...... 40

PRACTICAL 23: ASSESSING AND ASSISTING WITH BREASTFEEDING ...... 41

PRACTICAL 24: EXPRESSING BREAST MILK AND CUP FEEDING ...... 43

2 Facilitator guide to Practical’s 2nd edition

FACILITATORS GUIDE TO CLINICAL PRACTICE Clinical practice is an essential part of this course that provides daily practice in using case management skills so participants can perform proficiently. Participants learn skills by reading modules. They practice in class by doing exercises or case studies and importantly, in clinical practice. They practice using their skills with newborns in the neonatal unit.

The table below provides an overview and of the practical sessions in the training courses.

Practical Training Module Module subsection Duration of practical Practical 1 Principles of Infection prevention in the neonatal unit, including 40 minutes treatment hand washing, and neuroprotection Practical 2 Assess and classify Demonstrate A&C 40 minutes Practical 3 Assess and classify A&C, Need for emergency signs and priority signs, 40 minutes injuries, abnormalities and local infection Practical 4 Assess and classify A&C risk factors and special treatment needs 40 minutes Practical 5 Principles of Maintain normal body temp: using a manual and 40 minutes treatment servo control incubator Practical 6 Principles of Oxygen therapy 40 minutes treatment Practical 7 Principles of Feeds and fluids 40 minutes treatment Practical 8 Specific treatment: Ballard score 40 minutes LBW Practical 9 Specific treatment: KMC, Skin-to-skin, managing and monitoring in 40 minutes LBW KMC Practical 10 Specific treatment: KMC, discharge use the tool and assess 40 minutes LBW Practical 11 Specific treatment: Assess weight gain 40 minutes LBW Practical 12 Specific treatment: Jaundice, check bilirubin, manage phototherapy 40 minutes Jaundice Practical 13 Neonatal Monitor and Manage infant with NE, 40 minutes encephalopathy Practical 14 HIV, TB, Syphilis HIV and syphilis 40 minutes Practical 15 CPAP CPAP – demonstrate use of CPAP VIDEO 40 minutes Practical 16 CPAP CPAP – assembling and setting up CPAP machine 40 minutes Practical 17 CPAP CPAP – initiating, monitoring and adjusting 40 minutes Practical 18 Development In development 40 minutes Assessment Practical 19 Infant Motor In development 40 minutes Assessment Practical 20 Umbilical Cord Drip In development 40 minutes Practical 21 XRay interpretation In development 40 minutes Practical 22 Principles of Cleaning and sterilising equipment and surfaces in 40 minutes treatment the NNU Practical 23 Routine care Assessing and assisting with breast feeding 40 minutes Practical 24 Routine care Expressing breast milk and cup feeding 40 minutes

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ROLE OF FACILITATORS DURING CLINICAL SESSIONS: Before clinical session begins the facilitator will visit the neonatal unit. The purpose of this is to introduce herself to the unit manager and doctor in charge of the neonatal unit and explain the nature of the clinical practice to be conducted until the end of the course.

In preparation for the 5 days clinical session the facilitator will:

• Visit the neonatal unit to identify sick babies

• Meet with neonatal staff and confirm all logistics

• Identify babies relevant for the clinical practice

• Assemble all relevant equipment for all clinical stations

• Give clear instruction to participants before clinical session

• Divide participants into groups of 4 - 6

SETTING AND PARTICIPANTS Clinical practicals are conducted in the neonatal unit with adequate number of sick neonates for participants to get an opportunity of identifying all relevant signs. There should be a participant ratio of 4 - 6 participants per facilitator. Ideally the total participants should range between 16 -18 per course with minimum of 3 facilitators. Participants will then be divided into small groups of 4-6. These groups will then rotate through all 3 stations in the clinical area and spend about 40 minutes at each station.

CLINICAL PRACTICE OBJECTIVES During clinical practice sessions participants will:

• Get an instruction on how clinical practice will be performed

• See demonstrations on how to assess babies

• See examples on how to practice the principles of newborn care as well as specific treatments

• Practices assess and classify of sick babies

• Practise the principles of care such as thermoneutral environment, oxygen and CPAP, KMC

• Observe and discuss how to prevent infections

• Learn how a neonatal unit functions

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PRACTICAL 1: WORKING IN THE NEONATAL UNIT AND INFECTION PREVENTION Duration 40 minutes

PURPOSE: To orientate participants to the neonatal unit, infection prevention, and ensuring a neuro-protective environment.

EQUIPMENT AND SUPPLIES NEEDED: Soap and paper towels

SPACE NEEDED: • Handwash area for demonstration and practice • Review of neonatal unit, isolation area, and process of cleaning and infection control in the unit • Space around an incubator for demonstration and practice – probably intermediate care area MATERIAL NEEDED: • Newborn care charts pg 45 • Hand- washing chart CLINICAL CASES NEEDED: • One baby in an incubator

PREPARATION:

1. ENSURE THAT THE HAND-WASHING AREA HAS THE FOLLOWING FOR YOUR DEMONSTRATION. o Basin with elbow tap o Soap/D-gem o Paper towel o Pedal bin o Wall poster guide 2. VISIT THE NEONATAL UNIT AND REVIEW THE PROCESS THAT THE NEONATAL UNIT USES FOR INFECTION CONTROL SO THAT YOU WILL BE ABLE TO DEMONSTRATE THE FOLLOWING • The isolation area • Hand washing areas • Cleaning of walls and floors • Cleaning of equipment • Cleaning of surfaces • Handling of nappies and linen • Handling of sharps 3. REVIEW THE NEURO-PROTECTIVE ENVIRONMENT FOR A BABY IN THE UNIT SO YOU CAN DEMONSTRATE ( SEE PRACTICAL 18) • A baby nested and protected in an incubator • Appropriate clothing for baby in an incuabator ( Hat, booties, nappy and clothes ) • Wall thermometer and temperature management • Lighting in the unit, and how babies can sleep. • Volume of alarms, and noise control

DEMONSTRATION

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HAND WASHING • Store bags and excess clothes and jewellery away from the clinical area • Go to hand-washing area • Demonstrate hand-washing • Have everyone wash their hands correctly – see chart.

INFECTION CONTROL Conduct a round of the ward and demonstrate the following to particiapnts

GUIDELINE ON PREVENTION AND CONTROL OF INFECTION ¨ There should be adequate space for each incubator or bassinette minimum space of 5m². ¨ Each neonatal unit must have hand washing basin with foot or elbow controls ¨ Personnel with air borne infections and skin infections should not work with patients directly until they are better. Personnel in NICU to receive annual influenza vaccine

ISOLATION ¨ Babies with minor infections that are not very contagious can be nursed in closed incubator at a distance of 2 meter, and strict hand washing protocols followed ¨ Babies with contagious conditions should ideally be in an isolation area of the neonatal unit. ¨ Babies born outside the hospital should be treated the same as hospital babies unless there is disease outbreak or nosocomial infection. ¨ Parents are free to visit in the unit as long as they have no respiratory infection and they should adhere to hand washing policy. CLEANING INSTRUCTIONS FOR NEONATAL UNIT ¨ Clean incubators and bassinet daily with pine gel and weekly with precept or chlorine ¨ Replace waterproof mattress when torn. Oxygen tubing and respiratory circuits, nasal prongs wash with sun light liquid soap and water then rinse and soak in cydex 10% isopropyl alcohol in 90mls water. if possible autoclave. ¨ Wash feeding cups with sun light liquid soap, Disinfect with chlorine or precept detergent after every meal. ¨ Discard disposable syringe after use if used for feeding. ¨ Stethoscope, tape measure, thermometer to be kept under incubator for single patient. ¨ Wipe stethoscope with webcol. Clean tape measure with soap and water.

FLOORS SURFACES AND WALLS ¨ Clean floor surfaces, pay attention to hidden corners using pine gel and water twice daily. ¨ Scrub floor surfaces with biocide weekly. ¨ Clean walls from top to bottom using detergent like precept 1 tablet in 90mls water or, chlorine 1 sachet in 90mls water weeklyUse separate mop specifically for NNU. ¨ Clean windows and blinds weekly using sunlight liquid soap ¨ Wash dustbins with pine gel and water daily, Change inside bag daily and if necessary. ¨ NB *Detergents like: Biocide, precept, chlorine are used in spillage of blood and body fluids also used for outbreak of micro - organisms as they destroy germs. ¨ Pine gel, handy Andy, sun light liquid, hibiscrub, are antiseptics used to prevent the spread of micro organisms ¨ Hibiscrub is used for hand washing ¨ D germ is for rubbing of hands between patients

SHARPS AND VIALS • Use puncture proof container for contaminated sharps. • Empty when ⅔ full.

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PRACTICAL 2 & 3: ASSESS AND CLASSIFY DEMONSTRATION AND PRACTISE Duration 80 minutes

PURPOSE: To give participants practise in using the Newborn Care Charts and the Initial Assessment Form how to “Assess and Classify Sick and Small Newborns.”

EQUIPMENT AND SUPPLIES NEEDED: None

SPACE NEEDED: Enough space around each patient for demonstrating

MATERIAL NEEDED: Initial assessment forms, 1 for each clinical case, and 4 per participant Clipboards, 1 per participant

CLINICAL CASES NEEDED: 10 clinical cases that demonstrate priority signs and signs of injuries, malformation and local infections

PREPARATION: v One facilitator goes to the neonatal unit to select and prepare clinical cases v Select 5 clinical cases for each group, if there are 16 participants select Select 8 cases for assessment. Do not use cases that are very ill or terminal. If these patients have important signs, you can quickly demonstrate these at the end, without subjecting the patient to the assessment process. v If there are other cases with signs not often seen, select these cases for demonstration at the end. v Ask permission from the mother and the ward staff to use the baby for the clinical assessment. v Prepare an Initial Assessment for each baby. Fill in the History of the Initial Assessment form and place this at the end of each incubator or bassinette. v Also ensure that the Admission form that provides information on the perinatal history is completed for each baby, so participants can use the front page to get the information they require to Assess for Risk factors. v If necessary, (perhaps the information is not all available) fill in a new Admission page, with simulated information, and let participants use this information. v Ensure that there is enough space between the babies for all participants to work. v Ensure that there is soap, hand towels and hand spray v Bring Clipboards and pencils for each student v Bring 4 copies of the Initial Assessment form for each participant. v Put up an A2 or A3 poster of the newborn care charts in the Neonatal unit, so you can use this to demonstrate to participants how to classify.

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ASSESS AND CLASSIFY NEWBORNS o Divide the group into groups of 4 - 6, with 1 facilitators per group o Give each participant a clipboard, and 4 Initial Assessment forms. o Ensure participants have the Newborn Care Chart Book with them o Find space for them to place their bags, jerseys etc.

INTRODUCTION (5 MINUTES) Introduce the purpose of the session Ø To demonstrate the process of Assessing and classifying newborns Ø To let participants practice Assessing and classifying newborns, up to the end of local infections Ø To demonstrate clinical signs to the groups

DEMONSTRATE ASSESS AND CLASSIFY TO END OF LOCAL INFECTIONS (15 MINUTES) Using one case, demonstrate to the participants how you Assess and Classify the Sick or Small Baby ¨ First quickly read the history given on the Assessment form ¨ Then QUICKLY Assess the need for emergency care. o Explain that this is a quick assessment to check if the baby may need emergency care, i.e. is he breathing well, is circulation good, and is his glucose normal. ¨ Fill in the recording form so participants can see how this is done. ¨ Write a simulated Glucose test strip result on the recording form, so you do not unnecessarily do a glucose on the baby. ¨ Get participants to help you classify the baby for emergency care ¨ If there is a need for emergency care ask participants to read to you from the charts how they will “ACT NOW”. o (If this is not a simulated need, please hand over patient to ward staff.) ¨ THEN demonstrate how to assess for Priority signs. Once you have done the Assessment, ask participants to help you Classify using their newborn care charts or a poster on the wall. o Do not at this stage discuss the management (ACT NOW) ¨ Then demonstrate the Assessment for Abnormalities and Local Infections and get participants to help you Classify o but don’t dwell on the treatment.

PRACTICE ASSESS AND CLASSIFY TO END OF LOCAL INFECTIONS (60 MINUTES) ü Assign one case to each participant. Allow them to work in pairs so that they each assess and classify two cases. Allow 10 minutes per case. ü Whilst participants are assessing the cases, move around and offer assistance where needed. ü After 20 minutes bring the participants together and get each person to quickly present the finding for each case. ü Praise participants for correct assessments, and if incorrect demonstrate the correct sign or classification ü Ensure that participants always use the charts to classify ü At the end of the session, collect participants recording forms and mark them (either 0 not done, 1 partially correct or 2 for correct) ü Fill in this assessment on your monitoring chart ü Give the forms back to each participant

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PRACTICAL 4: DEMONSTRATE AND PRACTISE ASSESS RISK FACTORS AND SPECIAL TREATMENT NEEDS PURPOSE: To give participants practise in Assessing and Classifying babies for risk factors and special treatment needs

EQUIPMENT AND SUPPLIES NEEDED: None

SPACE NEEDED: Enough space around each patient for demonstrating

MATERIAL NEEDED: Initial assessment forms, 1 for each clinical case, and 4 per participant Clipboards, 1 per participant

CLINICAL CASES NEEDED: 5 clinical cases that demonstrate risk factors and special treatment needs

PREPARATION: v One facilitator goes to the neonatal unit to select and prepare clinical cases v Select 5 clinical cases who have a risk factor or special treatment need. Select cases for demonstration that do not have emergency signs or many priority signs, but has risk factors. If there are not many cases with risk factors these can be simulated on a Newborn Admission form. Remember to tell participants that they are simulated. v If there are other cases with signs not often seen, select these cases for demonstration at the end. v Ask permission from the mother and the ward staff to use the baby for the clinical assessment. v Prepare an Initial Assessment for each baby. Fill in the History of the Initial Assessment form and place this at the end of each incubator or bassinette. v Also ensure that the Admission form that provides information on the perinatal history is completed for each baby, so participants can use the front page to get the information they require to Assess for Risk factors. v If necessary, (perhaps the information is not all available) fill in a new Admission page, with simulated information, and let participants use this information. v Ensure that there is enough space between the babies for all participants to work. v Ensure that there is soap, hand towels and hand spray v Bring Clipboards and pencils for each student v Bring 4 copies of the Initial Assessment form for each participant. v Put up an A2 or A3 poster of the newborn care charts in the Neonatal unit, so you can use this to demonstrate to participants how to classify.

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PRACTICAL 4: ASSESS AND CLASSIFY FOR RISK FACTORS AND SPECIAL TREATMENT NEEDS

INTRODUCTION: The purpose is to give you practise in Assessing and Classifying babies for risk factors and special treatment needs DEMONSTRATION ¨ Using one case, demonstrate to your participants how you Assess and Classify the Sick or Small Baby to the end of Risk Factors. ¨ First quickly read the history given on the Assessment form, ¨ Then QUICKLY demonstrate your assessment of the need for emergency care, priority signs and abnormalities and local infections. ¨ Fill in the recording form as you go so participants can see how you do this ¨ Then Assess for risk factors ad special treatment needs ¨ Demonstrate how you use the Newborn Admission record to get the information you require about the pregnancy, labour and birth to identify the risk factors. ¨ Get participants to help you classify the patient for Risk factors. Do not at this stage discuss the management

THEN ¨ Assign each participant a case as before and allow them to work in pairs. Each participant will present the case assigned to them ¨ Ensure that the Newborn Admission sheet or a simulated sheet is available to each participant so they do not have to page through the record or ask the mother questions. ¨ Whilst participants are assessing the cases, move around and offer assistance where needed. ¨ After 20 minutes bring the participants together and get each person to quickly present the finding for each case. ¨ Praise participants for correct assessments, and if incorrect demonstrate the correct sign or classification ¨ Ensure that participants always use the charts to classify ¨ At the end of the session, collect participants recording forms, so you can mark them (either 0 not done, 1 partially correct or 2 for correct) ¨ Fill in this assessment on your monitoring chart ¨ Give the forms back to each participant

DEMONSTRATE OTHER SIGNS ¨ At the end of each practical session, demonstrate to participants any signs that patients in the ward may have, that all participants may not have all seen. ¨ When back in the classroom get participants to sign there initials below the signs they have seen.

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PRACTICAL 5: MAINTAIN NORMAL BODY TEMPERATURE PURPOSE: To demonstrate to participants how to maintain normal body temperature, using an incubator, and to identify factors in the neonatal unit that promote or discourage maintenance of a thermo-neutral environment for the baby

EQUIPMENT AND SUPPLIES NEEDED: A servo-control incubator, a manual incubator and overhead radiant warmer. Incubators must be functioning correctly

SPACE NEEDED: Enough space around each patient A side ward to demonstrate incubators – if not possible then in an area of the ward

MATERIAL NEEDED: Chart books pg 35 - 37

CLINICAL CASES NEEDED: 3 babies who are receiving care in an incubator 1 baby who can be placed in intermittent skin to skin

PREPARATION: ü Prepare a side ward in the neonatal unit with a manual and servo control incubator ü Select 3 patients who are in an open servocontrol incubator, a closed servo control incubator and a closed manual incubator, and 1 or 2 who can be placed skin to skin ü Make a copy of the temperature monitoring for each patient for the last day

DEMONSTRATE USE OF INCUBATORS 20 MIN ¨ Demonstrate the use of incubators ¨ Discuss the positioning of incubators in the unit o Vertical to wall o Away from windows o Ideally 2m apart

DEMONSTRATE HOW TO CARE FOR A THE BABY IN SERVO INCUBATOR ¨ Review the advantages o control the temperature of the air in the incubator to keep the babies skin temperature normal o Uses temperature probes that are attached to baby’s skin & is calibrated in the incubator o The thermostat then automatically increases or decreases the temperature of the heating coil to keep the baby at the required temperature ¨ Review the Disadvantage of servo control incubators o If the skin probe is not attached to the baby, this will not function as servo o If the skin probe becomes loose the incubator will continue to warm up & the baby will become hyperthermia

DEMONSTRATION OF SERVO INCUBATORS o Wash hands before touching the baby o Explain the procedure to the mother if present o The baby should be dressed only with a nappy o Switch the control to manual (AIR) and preheat to 37°C o Place the baby in the incubator and attach the temperature probe to the baby’s skin

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o Make sure the cable from the baby’s skin is correctly plugged into the incubator o Switch the incubator control from manual (AIR) to servo-controlled (SKIN) o Set the required skin temperature to 36.5°C on the control panel o The actual skin temperature will be displayed on the panel o After 30 minutes check that the baby’s skin temperature is the same as the required temperature. If not then the skin probe is not correctly applied or the incubator is malfunctioning o Check the temperature of both baby and incubator every 1-3 hours

DEMONSTRATE THE MANUAL INCUBATOR ¨ Review the ADVANTAGES OF MANUAL INCUBATORS o Maintains constant temperature o Allows observation of the baby o Oxygen can be easily provided

¨ Review the DISADVANTAGES OF MANUAL INCUBATORS o Baby can become hyperthermia or hypothermic if temperature is not regulated o Baby can be easily colonized by bacteria o Incubators requires reliable source of electricity o Mother & baby are separated o The standard incubators requires manual setting of temperature & monitoring

¨ DEMONATRATION OF MANUAL INCUBATORS o Place the baby in a warm (37°C) clean incubator o Determine the recommended incubator temperature for your baby o Set the incubator to this temperature o Measure the incubator and baby’s temperature after 30 minutes and adjust the incubator temperature if the baby’s temperature is not normal (36.5 - 37.5°C), and review every 30 minutes until normal o Monitor the incubator and baby’s temperature 3 hourly as part of routine observations. Alter the incubator temperature whenever the baby’s temperature is outside the normal range.

Birth Days after delivery

weight 0 5 10 15 20 25 30

1000g 35.5 35.0 35.0 34.5 34.0 33.5 33.0 1500g 35.0 34.0 33.5 33.5 33.0 32.5 32.5 2000g 34.0 33.0 32.5 32.0 32.0 32.0 32.0 2500g 33.5 32.5 32.0 31.0 31.0 31.0 31.0 3000g 33.0 32.0 31.0 30.0 30.0 30.0 30.0

DEMONSTRATE SKIN TO SKIN CARE ¨ Find a baby that is ready and stable for skin to skin care, and a mother willing to start ¨ Demonstrate to participants how to place the baby skin to skin. ¨ Discuss the different ways you can secure the baby for intermittent skin to skin ¨ Discuss the benefits and importance of skin to skin

ASSESS THERMO NEUTRAL ENVIRONMENT OF BABIES ¨ Divide participants in pairs, and let them each assess the temperature management of one of the 3 babies selected. Ask participants to o review the appropriateness of the method used, o demonstrate the use of the incubator o to review the temperature control in the last 24 hours o to comment on factors that will affect the thermoneutral environment of the baby, pay attention to temperature of the environment, draughts, windows, heat shields, clothing etc. Facilitator guide to Practical’s 2nd edition 14

PRACTICAL 6: OXYGEN THERAPY DURATION: 40 MINUTES PREPARATION: The purpose of the practical is to demonstrate to participants the different oxygen delivery systems and assist them in selecting an appropriate delivery system and monitoring.

EQUIPMENT AND SUPPLIES NEEDED: ¨ Neonatal Nasal prongs ¨ Nasogastric tube FG 5/8 ¨ Oxygen flow meter ¨ Oxygen tubing ¨ Oxygen Air Blender ¨ Oxygen Headbox ¨ Oxycheck ¨ Set of Venturis ¨ Pulse oximeter ¨ Strapping

SPACE NEEDED: A side room or empty cubicle with a supply of oxygen

MATERIAL NEEDED: Initial assessment forms, 1 for each clinical case, and 4 per participant Clipboards, 1 per participant

CLINICAL CASES NEEDED: Select 3 patients who are receiving oxygen, preferably by nasal prong, nasal catheter and headbox,

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PART 1: DEMONSTRATE OXYGEN DELIVERY SYSTEMS

DEMONSTRATE DIFFERENT APPARATUS REQUIRED FOR ADMINISTRATION OF OXYGEN ¨ Discuss with participants the different delivery methods for oxygen o Headbox o Nasal prong o Nasal cannula o Nasal CPAP and Ventilation ¨ Remind participants that Nasal prongs and cannulas can only deliver around 30% oxygen even when pure oxygen is used ¨ A head box can deliver up to 80% oxygen dependent on the flow rates – that will be discussed later ¨ Nasal CPAP and Ventilation use a blender and delivery 21 – 100% oxygen

DEMONSTRATE NEONATAL NASAL PRONGS ¨ This method is ideal for babies with mild respiratory distress ¨ Place the prongs just below the baby s nostrils, use 1mm prongs for small babies and 2mm prongs for term babies ¨ Secure the prongs with tape ¨ Refer participants to new born care charts page 39 for advantages and disadvantages of nasal prongs ¨ Set the flow rate at 1 litre / minute ¨ Humidification is not necessary – if used there MUST be a sterile bottle replaced daily

DEMONSTRATE NASAL CANNULA ¨ Explain to participants that this method is appropriate for babies with mild respiratory distress ¨ Insert NG 5 or 8,2-3 cm into the nostril ¨ Secure with tape ¨ Refer to page 39 of new born care charts for advantages and disadvantages of this method ¨ Set the flow rate at 0,5litres per minute ¨ Humidification is not necessary – if used there MUST be a sterile bottle replaced daily

DEMONSTRATE HEAD BOX OXYGEN ¨ Use appropriate head box size for the baby; it must be well fitting to avoid air leak ¨ Place the head box over the baby ¨ Set the air/ oxygen at 5L/min, starting with 60% oxygen on blender or 60% venturi ¨ Monitor the oxygen saturation ¨ If the saturation is < 90% o increase the percentage oxygen if there is a blender o Increase the flow rate as below to achieve a greater oxygen percentage if there is no blender Fio2 80% 60% 40% 28% 24% 21% Flow 12 10 8 6 4 4

¨ If the saturation is > 94% o then decrease the oxygen percentage in the blender o Decrease the flow if there is not blender but never to less than 4l/minute o If the saturation is > 94% on 4l/minute, add a venture of lower percentage o If babies saturation is > 90% on 40% head box oxygen then try and change to nasal prong oxygen ¨ Using an oxycheck to demonsrate the % oxygen achieved in a headbox with various flow rates, and openings in the headbox. ¨ Never remove baby from head box, without ensuring the baby has nasal or face mask oxygen ¨ Feed baby while in headbox with Nasogastric tube ¨ Monitor the saturation with a PULSE OXIMETER continuously for 30 minutes after commencement on oxygen

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PART 2: ASSESS OXYGEN THERAPY ¨ Let participants divide into pairs, and each assess the oxygen therapy provided over 24 hours. They should review ¨ Appropriateness of the choice ¨ Correct application of the oxygen ¨ Monitoring over the last 24 hour

GUIDELINES FOR OXYGEN ADMINISTRATION ¨ Start nasal prong oxygen at 1L/MIN for all babies with RESPIRATORY DISTRESS ¨ Monitor the oxygen saturation with a PULSE OXIMETER continuously for 30 minutes after starting the oxygen, and then at least hourly ¨ A preterm baby’s oxygen saturation should be between 90% and 94% ¨ A term baby’s oxygen saturation should be between 92 and 94% ¨ If the baby is preterm and the saturation is low and the baby has severe respiratory distress, AND CPAP is available then start nasal CPAP ¨ If the baby is not preterm or is preterm but CPAP is not available, start headbox oxygen. Run 4 L/ min of oxygen into a headbox, with all its openings closed. ¨ If the baby remains distressed, blue, or the oxygen saturation remains < 90% then increase the flow to 6 -8 litres a minute ¨ If the baby does not cope on this then the baby will need to be transferred for ventilation if available ¨ When the baby is pink and comfortable (less grunting / chest in-drawing) and oxygen saturation is > 90%, in < 40% oxygen on head box, change to nasal prongs. ¨ When the baby is comfortable on nasal prongs and oxygen saturation is >90% then remove nasal prongs, and monitor saturation in next 3 hours.

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PRACTICAL 7: DEMONSTRATION AND PRACTICE OF FEEDS AND FLUIDS CALCULATIONS DURATION: 40 MINUTES PREPARATION: The purpose of the demonstration is to get participants to assess and work out feeds and fluid calculations on actual babies in the neonatal unit

EQUIPMENT AND SUPPLIES NEEDED: Babies records Weight, feeding and treatment summary sheets SPACE NEEDED: Space around the baby for participants to evaluate feeds and fluids

MATERIAL NEEDED: Chartbook, a piece of paper and calculator CLINICAL CASES NEEDED: Identify 4 babies in the unit that on intravenous and oral feeds as well as those that are on only oral. Check the feeding and fluids that have been given and if necessary update the weight, feeding and treatment summary sheets to make it easier for participants to determine the volume of feeds and fluids ordered, and demonstrate the value of filling in the chart

FACILITATOR INSTRUCTIONS FOR DEMONSTRATION ¨ Select a case for demonstration ¨ Review the babies weight, birth weight and age and condition ¨ Calculate their fluid/feeds requirement for that day ¨ Review the weight, feeding and treatment summary sheets ¨ Assess if the feeds/fluids that have been prescribed are appropriate ¨ Discuss the reason for any discrepancy

PARTICIPANTS PRACTICE FLUID PRESCRIPTION ¨ Assign patients to pairs of learners ¨ Each pair to calculate feeds and fluids for that day, and compare with what has been prescribed ¨ Review the 3 cases with the group and give guidance and feedback

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PRACTICAL 8: BALLARD SCORE PREPARATION: The purpose of the Ballard Score practical is for participants to observe a Ballard being done on a baby and to practice doing a Ballard score. If your province or facility uses an alternative scoring chart, then use that instead.

EQUIPMENT AND SUPPLIES NEEDED: Nil SPACE NEEDED: Enough space around each baby MATERIAL NEEDED: Newborn Care charts page 54 - 57 3 blank Ballard score charts per participant 3 Blank Growth and head circumference charts per person CLINICAL CASES NEEDED: Identify 4 babies for assessment of Ballard score, and do a Ballard Score on each baby so that there is a Gold Standard from which to assess the baby. ADDITIONAL PREPARATION If possible participants should watch the video of how to do the Ballard score before the practical Watch the video’s from www.ballardscore.com X 5 video’s total of 30 minutes

INSTRUCTION FOR DEMONSTRATION A facilitator who is experienced in doing the Ballard score should demonstrate the Ballard score. This is often a paediatrician or experienced medical officer ¨ Facilitator demonstrate each neurological and physical feature in the chart, and get participants to score each item ¨ Help participants tally the score and determine the gestational age ¨ Plot the weight, length and head circumference on the Growth and head circumference chart page 99

INSTRUCTION FOR PARTICIPANTS ¨ Assign babies to participants in pairs ¨ Allow participants to conduct Ballard score and fill in the weight and head circumference chart ¨ Go through all the cases with the participants and compare with the Gold Standard assessment.

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PRACTICAL 9: KMC PART 1: THE KMC UNIT EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED: KMC Unit

MATERIAL NEEDED: Nil CLINICAL CASES NEEDED: Mothers and babies

PRACTICAL: ¨ Ask the participants to evaluate the KMC Unit according to the guidelines in their manuals and to comment on the positive elements as well as those elements that leave room for improvement. ¨ Ask the participants to discuss how they would bring change e.g. fund raising, inviting community support, businesses to support, high schools etc. etc. ¨ Ask the participants how they will create a KMC awareness amongst the community of the referral catchment area, by involving the different local media sources e.g. radio, newspaper, etc. etc. ¨ Ask the participants how they will create a KMC / premature birth awareness amongst the high schools in the referral catchment area.

NOTES FOR PREPARATION

CREATING A MOTHER AND BABY FRIENDLY KMC ENVIRONMENT. • There should be a key person, preferably a nurse who is in charge of the KMC patients and the KMC ward at each facility providing KMC who is able to train others in his/her facility and community. • KMC is continuous skin to skin care practiced in a dedicated KMC • The mothers should be regarded as full members of the health care team, and not as patients, although for stable and continuous KMC, it is in fact the mother who will take up most of the health worker’s time in terms of support and motivation. Mothers require a considerable amount of practical and emotional support and this must be factored into any KMC protocol. Any enthusiastic staff member, (not necessarily a professional nurse), can provide this kind of support. • It is important that mothers in KMC are guided and empowered to be the primary caregiver of their baby. Responsible to take observations, change nappies, feed the baby and even administer oral medication. This will increase the mothers confidence in handling her tiny baby, and she will be able to identify abnormalities in breathing and temperature. • Daily programme Orientation of new mothers. Identify a Lodger mother “head girl” that orientates new mothers into the unit. • Mothers are educated on: o Managing baby o Washing o Feeding o Medication o Securing of baby o Danger signs o Do’ ’ s and Don’ts • Mom to keep baby in KMC position at all times except for a few minutes when she is bathing/washing • Hand washing after toileting & before feeding is very important • Mothers can walk around the ward & outside with babies strapped skin to skin on them, if weather conditions are favourable. They can even have meals outside during summer, under a tree/ shaded area where a table and chairs are placed as a relaxing/ eating area.

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• Involve the Allied Health Care workers to occupy the mothers. • Occupational therapists can teach mothers to crochet caps for babies, or to make wraps, or knit etc. • Dietician must be involved on breastfeeding education and introduction of solids as well as preparing nutritious family meals. • The social worker has to do an assessment of the living environment at home as well as support systems for the mother

LAYOUT OF THE UNIT AND EQUIPMENT NEEDED: • Building and furnishing • KMC ward should be warm & homely • No specialized equipment is required, but it is necessary to provide space for the mothers, as full boarders. However, any rooms with beds, ablution facilities and reasonable access to the Neonatal Unit will suffice. In future all neonatal units should be designed to include maternal accommodation.

As KMC is FAMILY CENTRED CARE, it is important that there is a visiting area with comfortable chairs for siblings, her spouse or partner to come and visit. RECREATIONAL NEEDS AND EQUIPMENT: Refrigeration facilities will be needed for mothers expressed breast milk. A microwave oven, kettle, refrigerator for snacks is an asset and supports the mother emotionally. In admitting mothers to continuous KMC it is useful to provide them with comfort and antidotes to boredom such as a lounge, TV, DVD for educational purposes as well, a radio, and reading material. It’s important to have a separate dining area where mothers can sit around a table and enjoy their meals. In summer this table can even be placed outside, under the trees or shaded area. Laundry facilities and a washing line are a bonus but much appreciated by mothers

Approach private businesses for sponsorship regarding all your needs for the KMC Unit. Funding can also be supported by fundraising efforts from within the staff for these essential comforts.

PHARMACY The following items should be available if indicated: • Galactogogues such as Metoclopramide may help to improve breast milk production. This is especially important for mothers who are only able to visit their babies infrequently. • Breast milk fortifiers, which increase calcium, phosphorus and caloric content in breast milk, for infants less than 1500g. • Multivitamin syrup • Vitamin D syrup • Iron syrup • Preterm formula for supplementation of breast milk ONLY if MEDICALLY indicated

HOUSEKEEPING Accommodating mothers will incur cleaning and catering costs, and a small increase in consumables. However these are minimal when set against the savings generated by KMC.

TRANSPORT It might be a proposition to invest in a dedicated baby transport bus/kombi in which stable infants in the KMC position can be transported back to the referral or step-down hospitals in the region without having to use the over-extended ambulance service. This requires further detailed investigation. Remember that babies are transported skin to skin in the KMC position.

SUPPORT Support visits at the mothers home after discharge, should be regarded as part of the continuous development of the KMC intervention and provision should be made for KMC to be incorporated into community health workers follow up visits.

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KMC 9: PART 2: ASSISTING MOTHERS IN PLACING BABIES IN KMC Preparation:

Equipment and supplies needed: KMC ties

Space needed: KMC unit

Material needed: Newborn care charts Clinical cases needed: Mothers and babies in KMC

HOW TO SECURE A BABY ONTO THE MOTHER USING DIFFERENT WRAPS, THARIS, ETC

The facilitator demonstrates putting baby on KMC position and making use of pouch or tari or mbeleko Emphasize the importance of continuous skin to skin KMC

Demonstrate to participants how to place the baby in the skin to skin position Discuss the different ways you can tie a baby in the skin to skin position. Allow participants to practice assisting mothers putting babies in the skin to skin position-you can assist mothers who are still doing intermittent KMC Discuss the benefits and importance of KMC during the post partum period. 4 weeks for a full term baby, 10 weeks for a preterm. Discuss when you should start skin to skin. ASAP

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PRACTICAL 10 KMC DAILY SCORE SHEET PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED: KMC Unit

MATERIAL NEEDED:

CLINICAL CASES NEEDED: Mothers in KMC

INTRODUCE PARTICIPANTS TO THE KMC TOOL ¨ This tool is used to monitor babies in KMC and assess readiness for discharge ¨ It is important to always have a health worker allocated in KMC unit to continuously monitor and observe mothers and babies in KMC. ¨ The applicability and acceptance of KMC will only be observed if there is continuous monitoring. ¨ To do this assessment the health worker needs to be present when the mothers breastfeed their babies. ¨ All the factors below in the table are incorporated into the daily score sheet. ¨ The evaluation of the daily score chart is done on day 1 of admission in KMC ward ¨ This score sheet is done daily by the nurse working in KMC, ¨ There are ten factors used to score both mother and baby. ¨ The score ranges from 0 to 2. ¨ 0 is the lowest score and 2 is the highest score. ¨ At the end of the evaluation the score that determines the mother and baby’s readiness to be discharged home should be above 19 if the mother is breastfeeding. ¨ If the mother is formula feeding the score should be above 15.

PRACTICAL: Each participant assess one patient using the KMC Daily score sheet, (or divide in pairs if there are not enough patients).

NOTES ON THE KMC DAILY SCORE CHART

MOTHER’S MILK PRODUCTION (BREASTFEEDING MOTHERS) If the mother is breastfeeding, observe the amount of milk she expresses during feeding time, if she expresses between 0-10 mls the score will be0, and if she expresses between 10 -20 mls the score will be 1 and if she expresses between 20- 30 mls the score will be 2.

POSITIONING AND ATTACHING BABY TO THE BREAST (BREASTFEEDING MOTHERS) If the mother is breastfeeding, observe how breastfeeding is going. The mother should be able to attach the baby to the breast. Observe four main points of good attachment. If the mother still need assistance to position and attach the baby to the breast the score will be 0 and if she occasionally need assistant then the score will be 1 and if she is able to position and attach the baby to the breast on he own the score will be 2.

BABY’S ABILITY TO SUCKLE FROM THE BREAST (BREASTFEEDING MOTHERS)

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As the baby may be still very small, she may not be able to suckle well from the breast. When the mother breastfeeds observe if the baby gets tired very quickly the score will be 0. If the baby gets infrequently tired the score will be 1 and if the baby is able to breastfeed on its own then the score will be 2.

SOCIO-ECONOMIC STATUS The mother is asked if she has support at home. This includes family support, financial support and access energy resources If the mother has family supports e.g. mother in law or her husband who support her both financially and emotionally then the score. It is important to observe if the mother have anybody visiting her while in hospital that will strengthen the point that the mother will be well supported after discharge. If the mother is having financial, family and material resources at home like water supply and electricity and can afford to care for both herself and baby at home the score. The evaluation of the economic status of the mother will benefit both mother and baby in determining if the mother comes from a very poor resourced background with no support can be kept longer in hospital and be discharged once baby’s weight is satisfactory. Discharging the baby early from poor socio-economic background too early may put the baby at risk.

CONFIDENCE IN HANDLING THE BABY Most mother’s may find it difficult to handle small babies, because they usually very fragile and slippery. Therefore, during procedures like napkin changing, feeding and bathing. If the mother always needs assistance the score will be 0 and if she occasionally needs assistant the score will be 1 and if she does not need assistance the score will be 2.

BABY’S WEIGHT GAIN PER DAY. It is important to weigh babies daily in KMC using electronic or digital scale. If the baby’s weight gain per day is between 0-10g the score will be 0. If the baby weighs between 10 -20g per day the score will be 1 and if the weight gain per day is between 20 -30g the score will be 2. All babies should have scored either 1 or 2 before discharge. If the baby is not gaining weight manage according to classification of INADEQUATE WEIGHT GAIN on page 11.

CONFIDENCE IN ADMINISTERING IRON DROPS/ORAL MEDICATION As low birth weight babies are routinely given iron according to guidelines on their management. Mother is supported and assisted while in hospital so as to be able to continue giving the iron drops at home. If the mother is not confident the score is 0, some confidence the score is 1 and fully confident the score will be 2.

KNOWLEDGE OF KMC Mother is given information on KMC so that she has full understanding of KMC. Information discussed with her includes benefits of KMC to her and the baby, how to care for the baby in hospital and at home. The mother should appreciate KMC and be willing to do KMC even at home. Evaluate daily the mother’s knowledge of KMC, if she has no knowledge the score will be 0 and if she shows to have some knowledge the score will be 1 and if she is knowledgeable the score will be 2.

ACCEPTANCE AND APPLICATION OF KMC The acceptance and application of KMC by mother’s follows after the information has been given to the mother about KMC. First teach mother skin- to skin position and how to put the baby in the KMC position. Inform the mother about the importance of continuous KMC. Observe if the mother is doing continuous KMC in the ward. If the mother is not putting the baby on continuous KMC on her own will show that she has not yet accepted KMC, the score will be 0. A mother who partly accept or sometimes put the baby on KMC position will be scored 1 and for the mother who is able to apply KMC on her own the score will be 2.

CONFIDENCE IN CARING FOR THE BABY AT HOME. The mother should be confident the way she cares for the baby in the hospital as well at home. The health worker will be able to evaluate this factor only if she spends most of the time with the mother while in hospital. If the mother does not feel confident that she will be able to care for the baby at home the score should be 0 , if she feels slightly confident the score should be 1 and if she feels confident that she will be able to care for the baby at home the should be 2.

24 Date of birth KMC Daily Score Sheet ……./….../…...

Based on the Intra-hospital KMC Training Programme in Bogota, Colombia Date → Name: Breastfeeding: Day 21 Date started 24 Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day hour KMC 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Hospital No: Formula: ……./….../…… Score Weight → Evaluation 0 1 2 Remarks Good Socio-economic No help or Occasional support support support help system Expresses 0 - Expresses Expresses Must score Mother's milk 10ml breast 10 - 20 ml 20 - 30 ml before discharge. production milk breast milk breast milk N/A for formula Positioning and Occasionally No Not applicable Always need attaching of baby needs assistance for formula assistance on to breast assistance needed feeding Baby's ability to Takes all Gets tires very Gets tired suckle at the breast feeding quickly infrequently / cup feed well Confidence in Occasionally No handling baby i.e. Always need needs assistance Feeding, bathing, assistance assistance needed changing Baby's weight gain Must score 1 or 2 0-10g 10-20g 20-30g per day before discharge Confidence in administering Some Fully No confidence vitamin and iron confidence confident drops Some Knowledge- Knowledge of KMC No knowledge knowledge able Partly Applies Applies KMC Acceptance & Does not accept accepts & KMC without having application of KMC or apply KMC applies KMC without to be told method Confidence in Feels slightly Does not feel Feels caring for baby at unsure and sure or able confident home unable TOTAL SCORE per day

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PRACTICAL 11: ASSESS WEIGHT GAIN IN LBW BABY PREPARATION: The purpose of the practical is to assist participants in determining the weight gain of low birth weight babies

EQUIPMENT AND SUPPLIES NEEDED: Babies records Weight, feeding and treatment summary sheets SPACE NEEDED: Space around the baby for participants to evaluate weight gain

MATERIAL NEEDED: Chartbook, Weight, feeding and treatment summary sheets Paper and calculator CLINICAL CASES NEEDED: Identify 4 babies in the unit that are growing premature babies. If necessary update the weight, feeding and treatment summary sheets to make it easier for participants to determine the weight gain. For each case work out the following o Birth weight o Time at maximal weight loss and % weight loss o Time to regain birth weight o Weight gain since regaining birth weight o Weight gain per day since regaining birth weight

CLINICAL DEMONSTRATION ON ASSESSING PERCENTAGE OF WEIGHT LOSS AND WEIGHT GAIN ¨ Select a baby ¨ With participants demonstrate the following on the weight summary chart o Birth weight o Time at maximal weight loss and % weight loss o Time to regain birth weight o Weight gain since regaining birth weight o Weight gain per day since regaining birth weight

PRACTICAL ON ASSESSING WEIGHT LOSS AND WEIGHT GAIN ¨ Assign babies to pairs ¨ Let each pair determine the following

o Birth weight o Time at maximal weight loss and % weight loss o Time to regain birth weight o Weight gain since regaining birth weight o Weight gain per day since regaining birth weight ¨ Go through each case with all participants and compare their answers with your prepared answers ¨ Discuss any discrepancies

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% WEIGHT LOSS FORMULA Birth weight-current weight × 100 Birth weight

Example 1: 1. Birth weight 1600g Day 4 weighs1410g

Calculation - 1, 6kg - 1,410kg ×100 1, 6 kg = 11, 9% inadequate weight gain

ASSESSING WEIGHT GAIN CALCULATION Formula current weight –previous weight Previous weight in kg X no days

Example 2. 14 days weighs 1020g 21 days weighs 1170g Day 21:- Calculation – 1170g -1020g 1, 02(kg) x7 days 150 g 1,02kg ×7 days 150g 7, 14kg/day =21g/kg/day

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PRACTICAL 12 JAUNDICE PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED: ¨ Bilicheck ¨ Phototherapy lights SPACE NEEDED: Space in which to demonstrate Jaundice MATERIAL NEEDED: ¨ Bilirubin charts CLINICAL CASES NEEDED: ¨ Babies with Jaundice who are receiving phototherapy ¨ Completed bilirubin graph for each baby

SCREENING FOR JAUNDICE ¨ In a newborn with jaundice, always determine the degree of jaundice by measuring the TSB and plotting this on a graph. ¨ The result of the TSB needs to be available within 1 hour from the laboratory ¨ Check the bilirubin of all babies at 6 hours of age, if there mothers are O positive or Rh negative ¨ Demonstrate to participants how to use a Bilicheck machine ¨ Calibrate by pressing the blue button ¨ Close the tip with bili– patch when calibrating ¨ Then put the tip on the forehead and press the blue button 5 times ¨ It will give the reading in seconds ¨ Discuss when you can rely on a bilicheck and when you need to take blood for bilirubin ¨ Let each participant measure the bilirubin with a bilicheck

DEMONSTRATE THE USE OF PHOTOTHERAPY ¨ Start phototherapy while waiting for the TSB result or if the Bilicheck result indicates the baby needs phototherapy ¨ The distance between the mattress and the light should be about 40 cm ¨ The baby should be naked ¨ Cover the baby’s eyes when under phototherapy (remove the cover for feeding) ¨ Turn the baby over every hour ¨ Do not cover the incubator, or cot, or phototherapy lights with blankets or sheets ¨ A biliblanket can be used instead of phototherapy lights – demonstrate the use. ¨ Ensure that the baby is getting an adequate fluid intake, as the baby will lose more fluid than normal ¨ Encourage breastfeeding, as it enhances the excretion of bilirubin. ¨ Repeat the bilirubin every day or more often if the bilirubin was very high ¨ Stop phototherapy when the TSB is 50 μmol/L lower than the line on graph , and repeat the TSB the next day

EXCHANGE TRANSFUSION ¨ Exchange transfusion is needed if the TSB is above the line ¨ on the exchange transfusion graph ¨ A baby should be referred for exchange transfusion: ¨ If the TSB level is close to, or is above, the exchange transfusion level ¨ If the TSB is rising at more than 17 μmol/L/hour ¨ Exchange transfusions should be discussed with, and if at all possible done at, the level 3 hospitals

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PRACTICAL 13 NEONATAL ENCEPHALOPATHY (HIE) PREPARATION: To demonstrate the use of the HIE score chart EQUIPMENT AND SUPPLIES NEEDED: Nil SPACE NEEDED: Space around the baby MATERIAL NEEDED:

CLINICAL CASES NEEDED: Babies who have HIE, Councel and get mothers permission. Completed HIE score charts for each baby selected

DEMONSTRATE TO PARTICIPANTS HIE SCORE ¨ The HIE scoring system is a simple clinical tool which helps to predict the infant's long term outcome. ¨ Demonstrate each of the 9 signs ¨ The baby should be scored every day ¨ According to research done by Thompson, infants with a maximum score of 10 or less, will almost certainly be neurologically normal. Those with a maximum score of 15 or more, and who are not sucking by day 7, will probably not be neurologically normal. ¨ If there are babies with HIE, allow participants to do the scoring. Advise participants not to counsel the mother

SCORE DAY 1 2 3 4 5 6 7 8 9 10 Sign 0 1 2 3 Date Tone normal Hyper hypo flaccid

Conscious normal hyper alert, stare lethargic comatose level

Fits none infrequent <3 frequent / day >3 / day

Posture normal fisting cycling strong decerebrate distal flexion

Moro normal partial absent

Grasp normal Poor absent

Suck normal Poor absent

Respiration normal Hyperventilation brief IPPV apnoea (apnoea)

Fontanel normal full - not tense tense

Total score per day

<11 mild HIE 11-14 moderate HIE >14 severe HIE

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PRACTICAL 15: CPAP PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED:

MATERIAL NEEDED:

CLINICAL CASES NEEDED:

Time: 80 - 120 minutes

PREPARATION: To enable participants to assemble the CPAP machine, to place the CPAP on the baby and to understand how to monitor and adjust the CPAP to meet the babies requirements.

EQUIPMENT AND SUPPLIES NEEDED: ü CPAP machines – any number ü Humidifier ü Circuits for CPAP – old or unsterilized for practice ü Generator set ü Nasal prongs for CPAP ü Stockinette for a hat ü Strapping ü Granuflex

SPACE NEEDED: Space where there is medical air and oxygen, and space to demonstrate and practice the use

MATERIAL NEEDED: Chart books

CLINICAL CASES NEEDED: 3 – 4 Patients on NCPAP for demonstration

ADDITIONAL MATERIAL Video https://www.youtube.com/watch?v=4o_hTeQzDWU

INTRODUCTION If time allows let participants watch the video before they

PART 1 DEMONSTRATE TO PARTICIPANTS HOW TO SET UP THE CPAP MACHINE ( 40 MINUTES) 30

¨ Explain that models vary, and that they need to follow the manufacturer’s instructions, and get the supplier to do demonstrations and training ¨ As a general rule 1. Connect the air and oxygen supply to the CPAP machine 2. Connect the air supply hose and oxygen supply hose to the central gas supply or oxygen canister and compressor 3. Insert the plug from the external power supply into the socket 4. Connect the suitable tube of the patient circuit to the flow outlet and the humidifier 5. Connect the other tube, normally the longer one to the humidifier 6. Connect the CPAP pressure line to the humidifier and to the patient connector

SECURE THE CPAP AND NASAL PRONG ¨ Select a headband or cap of appropriate size. ¨ Demonstrate how to make a hat o It is imperative that a well-fitting cap is used to attach the NCPAP to the baby. If it is too small it can cause oedema and discomfort for the baby. (Make sure the ears lie flat under the cap.) ¨ Position the Velcro strip over the forehead ¨ Use the transparent measuring tape to select the appropriate size prongs. o The best fitting size is taken, this is the biggest nasal prong that comfortably fits the nostril. It needs to snuggly fit into the nasal cavity and have appropriate inter nares distance. A tight one will cause pressure necrosis and a loose one will result in large air leaks. ¨ Applying granuflex under the nose and over the bridge of the nose can prevent necrosis. ¨ Moisten the prongs with saline before insertion. ¨ The bridge of the prongs should not abut the columella and must not cause blanching of the skin. o Periodically check the nasal mucosa for hyperaemia and the columella for blanching. ¨ Secure the nasal prongs with the bonnet and straps provided, and secure the circuit with the head gear provided. ¨ Make sure that the columella is not blanching.

PRACTICAL PARTICIPANTS ¨ Participants work in groups of 2 ¨ Set up the machine and do the wall connections, ¨ Set the flow and 02 %, and alarm limits ¨ Assemble the CPAP generator set ¨ Choose the correct size hat and nasal prongs ¨ Attach the baby / doll to the CPAP driver

PART 2: MANAGING THE BABY ON NCPAP

DISCUSS STARTING PRESSURE AND REGULATE THE PRESSURE

¨ For most conditions start the NCPAP at 5cm H2O. For apnoea of prematurity start at 4cm H2O. ¨ Chest retractions, grunting and lung inflation < 6 spaces on the X-ray are indications for increasing NCPAP pressure. ¨ After initiating NCPAP the decision to increase NCPAP should be based on clinical signs. o Presence of grunt, in-drawing, and tachypnoea are indications of inadequate support. ¨ SpO2 and blood gas are useful in decision making, don’t wait for X-ray to make the decision. ¨ FiO2 should be adjusted to keep the SpO2 in range of 90 – 94%. ¨ NCPAP pressure and FiO2 often go hand in hand. ¨ If there is a mismatch something may be wrong. Bring down the FiO2 and then the pressure.

DISCUSS SIGNS OF A POSITIVE RESPONSE TO BABIES ON NCPAP? ¨ The baby’s respiratory distress will improve: ¨ Reduction in respiratory rate ¨ Stabilisation or reduction in FiO2

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¨ Resolution of grunting ¨ Reduction in the degree of sternal and intercostal recession

DISCUSS MONITORED WHILE ON CPAP ¨ NCPAP system o tubes in the nose, o nasal airway clear o mouth closed o neck slightly extended ¨ Continuous pulse oximetry ¨ HR, RR, chest in-drawing, Grunting, Flaring ¨ Blood gas analysis* ¨ Regular inspection and assessment of ventilator circuit and equipment

FEEDING OF BABIES ¨ Babies are initially kept nil per mouth until stabilised. Thereafter commence feeds by using an orogastric tube.

WHAT ARE THE COMPLICATIONS TO LOOK OUT FOR? ¨ Pneumothorax ¨ Agitation ¨ Continued deterioration ¨ Nasal trauma

WHEN HAS THE NCPAP FAILED? ¨ An FiO2 rising to above 0.6 ¨ Respiratory Acidosis pH, 7.28 with a rising pa CO2 > 60mmHg* ¨ Development of recurrent apnoea requiring stimulation ¨ Worsening indrawing / grunting / tachypnoea ¨ Agitation not relieved by simple measures ¨ All of the above require immediate consultation with a paediatrician to discuss further management and retrieval if possible.

DISCUSS HOW DO I WEAN THE BABY OFF NCPAP? Criteria for weaning: ¨ Absence of significant episodes of apnoea ¨ Minimal work of breathing ¨ Decreasing oxygen requirements to less than 30% ¨ Once a baby’s respiratory rate falls below 70/min, the FiO2 is < 0.3 and the baby is breathing with less effort, the NCPAP should be reduced by 1cm H2O every 6 hours until at 5cm H2O. ¨ A trial off NCPAP is undertaken once the baby is stable for 6 – 12 hours on a NCPAP of 5 cm H2O in a FiO2 < 0.3 with a respiratory rate < 70. ¨ It is not uncommon to see a mild increase in respiratory rate as well as an increase in inspired oxygen concentration in the first hour after discontinuation of NCPAP.

CLINICAL DEMONSTRATION ¨ Conduct a ward round of 3 – 4 patients on NCPAP ¨ Demonstrate the following on a baby o Pressure o Fi02 and oxygen saturation o Clinical signs o Any complications o Discuss if adjustments are needed ¨ Get each pair of participants to answer the following about each patient o Pressure

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o Fi02 and oxygen saturation o Clinical signs o Any complications o Discuss if adjustments are needed

PART 3: CLEANING AND MAINTAINING CPAP AND CIRCUITS

HOW OFTEN DO I NEED TO CHANGE THE CIRCUIT? ¨ The circuits can stay on the same baby for a week. Only change the circuit every week. At district hospitals you will usually only have a baby on NCPAP for a few days. The circuits are not discarded, but are washed, sterilised and reused. HOW DO I REUSE AND CLEAN THE CIRCUITS, GENERATOR SETS AND NASAL PRONGS? Nasal prongs and generator sets ¨ Take out the nasal prongs from the generator set. Wash the prongs and generator set in clean soapy water to remove any secretions and dirt, rinse and dry. ¨ Pack and gas sterilise ¨ Alternately soak in cidex or ultracide for 10 minutes, rinse in sterile water and dry. ¨ If there has been contamination with nosocomial infection immerse for 10 hours, or discard. Nasal NCPAP circuits ¨ Clean any secretions or blood from the circuits ¨ Hang them to dry for 24 hours, or blow dry with air or oxygen until completely dry ¨ Gas sterilise Humidifier chamber ¨ Fill with sterile water. ¨ After each baby, wash with soapy water, rinse and gas sterilise.

The nasal prongs, generator set, and circuits can be reused many times as long as they are sterilised and still function well not producing any air leaks. If the plastic cracks or there are air leaks then discard.

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PRACTICAL 18: CREATING A NEURODEVELOPMENTAL SENSITIVE NNU ENVIRONMENT FOR THE PRETERM INFANT PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED:

MATERIAL NEEDED:

CLINICAL CASES NEEDED: None

Creating an NNU environment, similar to the intra-uterine environment that is conducive for the preterm infant is of utmost importance in protecting the pre-terms very sensitive and vulnerable brain. Due to the nature of the NICU environment (increased light and sound, painful invasive procedures, multiple care givers, lack of consistency, disruption of sleep/wake cycles, and other abnormal stimuli), the infant is deprived of his/her normal ante/postnatal developmental environment. Over time this overload of stressors can affect a baby’s ongoing growth and development and can lead to lifelong emotional and behavioural problems.

Mother and Family centred care The mother and family are an integral and vital part of optimal care of the neonate. They must be encouraged and facilitated in taking an active role in their babies care. Nappy changes, feeding, taking observations, giving oral medication. All of this happens under the supervision of the neonatal nurse Consider family needs when planning care and feed times. Bonding by implementing and practicing Kangaroo mother care (KMC) is the foundation of developmentally supportive care and must be supported and encouraged as soon as possible. This promotes necessary rest and sleep for the preterm. Parents form part of the support team and they need to be informed and consulted about their baby’s care and management

GENERAL GUIDELINES OF NEURO DEVELOPMENTALLY SENSITIVE ENVIRONMENT Approach the infant gently by speaking softly and resting a hand on the infant before moving the infant or beginning any care activity. Ensure feeding is a pleasurable, nurturing experience in a calm surrounding for the infant. Always position the baby skin to skin on the mothers’ chest during feeding times, with the baby’s mouth positioned on the mother’s nipple. Comfort the infant quickly and consistently when he/she is upset or uncomfortable during or between care giving activities

Protect the following senses of the baby: 1) Sight The premature eye has a decreased tolerance for light. The iris has a decreased ability to adjust to changes in light and frequently admits more light, which causes pain. ¨ Ensure dimmer capability for overhead room lights. ¨ Avoid direct light of preterm infant care space except for procedures. ¨ Allow babies to open their eyes and focus on mother’s face ¨ Decrease ambient light – turn off overhead lights by 13h00 ¨ Use individual lighting where possible ¨ Cover the baby’s eyes when under phototherapy ¨ Cover all closed incubators with a blanket to decrease light penetration. ¨ Ensure baby is nursed on a saturation monitor if not clearly visible

2) Hearing ¨ Decrease ambient noise ¨ Keep radio and voice levels low ¨ Silence monitor alarms as quickly as possible

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¨ Do not have conversations at the bedside ¨ Do not bang the incubator doors ¨ Do not place anything on top of the incubator ¨ Answer the telephone quickly

Reduce light and noise during feeding time to promote optimal maternal infant interaction.

3) Smell ¨ Let the preterm smell and taste the breastmilk even if he is receiving tube feeds. ¨ Prevent strong smells in front of the preterm’s face. ¨ Allow alcohol hand rub to dry on hands before putting them in the incubator.

4) Touch and Handling and Positioning ¨ Observe and teach mother to identify her baby’s behaviour and signals, and show her how to respond appropriately. ¨ Avoid stroking prems - they respond better to a firmer hold with one hand on their head and the other on their body. ¨ When the mother is not present, position the infant in the flexed intra uterine position with his hands in front of his face, knees pulled up and flexed when positioned in the incubator. ¨ Roll a nest around the preterm to mimic the uterine boundary

Preparation: Facilitator will visit neonatal unit and prepare the following: • Identify 4 babies for assessment.

INSTRUCTION TO FACILITATORS • Divide participants into 3 groups. Participants should be in small groups of 6 per facilitator

Task: Participants must identify environmental factors in the NNU that are influencing the physiological stability of the baby, and are therefore causing despair and stress to the baby

Participants must discuss what interventions/ changes they would implement to ensure that babies are protected in a neurodevelopmental sensitive environment

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PRACTICAL 19: INFANT MOTOR ASSESSMENT PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED:

MATERIAL NEEDED:

CLINICAL CASES NEEDED:

Still to be developed

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PRACTICAL 20: UMBILICAL VEIN LINE INSERTION PREPARATION:

If your require intravenous access especially in the emergency situation then the insertion of an Umbilical vein catheter can facilitate rapid access

INDICATIONS

• To administer a bolus of fluids for volume expansion • To administer adrenaline • To correct severe hypoglycaemia • If iv access is difficult • For an exchange transfusion

EQUIPMENT AND SUPPLIES NEEDED: Preferably a sterile pack containing

• Size 5FG sterile nasogastric tube or umbilical vein catheter • Sterile swabs • Sterile scalpel and Blade • Umbilical cord ties • Strapping • Normal Saline ampoule • 5ml syringe • Artery forceps

PROCEDURE

• This is a sterile procedure, put on a mask, wash hands thoroughly and put on sterile gloves. • Infant should be under a radiant warmer with good light • Attach the catheter / nasogastric tube to a syringe full of saline • Clean the umbilical cord area with spirits • Place a sterile towel around the umbilicus • Place the umbilical tape 1cm above the abdominal skin and tie loosely • Cut the cord 2cm above the skin • You will see the umbilical vein and two umbilical arteries, the vein is situated at the top (towards the babies head) and the two arteries below. • Insert the tip of the saline filled catheter or nasogastric tube into the vein. • Securely strap the umbilical catheter in place. Rugby post strapping works well. • You can replace the syringe with an intravenous giving set or 3 way tap if you need to give medications

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PRECAUTIONS

• Bleeding if the base of the cord is not secured tightly • Ensure not to allow air to be introduced into the catheter, this is why you fill the catheter with saline and leave the syringe attached. If you see air in the catheter, withdraw on the end until there is no air and replace syringe • Don’t give 50% glucose and 8% soda bicarbonate through the catheter • Portal vein thrombosis may complicate umbilical vein catheterization • Do not insert an umbilical vein catheter if it is possible to insert a peripheral vein infusion

Your facilitator will assist you with insertion of an umbilical vein catheter into a piece of umbilical cord.

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PRACTICAL 21: X-RAY INTERPRETATION PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED:

MATERIAL NEEDED:

CLINICAL CASES NEEDED:

STILL TO BE DEVELOPED

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PRACTICAL 22: CLEANING AND STERILISING EQUIPMENT AND NEONATAL WARD PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED:

MATERIAL NEEDED:

CLINICAL CASES NEEDED:

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PRACTICAL 23: ASSESSING AND ASSISTING WITH BREASTFEEDING PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED:

MATERIAL NEEDED:

CLINICAL CASES NEEDED:

INSTRUCTION FOR FACILITATORS

Apply listening and learning skills and building confidence skills when counseling mother about breastfeeding

TEACH CORRECT POSITIONING & ATTACHMENT FOR BREASTFEEDING

The mother must be seated comfortably

Show the mother how to hold her infant:

• With the infant’s head & body straight

• Facing her breast, with infant’s nose opposite her nipple

• With infant’s body close to her body

• Supporting infant’s whole body, not just neck & shoulders

Show her how to help the infant to attach. She should:

• Touch her infant’s lips with her nipple

• Wait until her infant’s mouth is opening wide

• Move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple

Look for signs of good attachment & effective suckling. If the attachment or suckling is not good, try again.

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GOOD ATTACHMENT POOR ATTACHMENT

SIGNS OF GOOD ATTACHMENT: SIGNS OF POOR ATTACHMENT:

• MORE AREOLA ABOVE BABY’S MOUTH • BABY SUCKING ON THE NIPPLE, NOT THE AREOLA

• MOUTH WIDE OPEN • RAPID SHALLOW SUCKS

• LOWER LIP TURNED OUTWARDS • SMACKING OR CLICKING SOUNDS

• CHIN TOUCHING BREAST • CHEEKS DRAWN IN

• SLOW, DEEP SUCKS AND SWALLOWING SOUNDS • CHIN NOT TOUCHING BREAST

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PRACTICAL 24: EXPRESSING BREAST MILK AND CUP FEEDING PREPARATION:

EQUIPMENT AND SUPPLIES NEEDED:

SPACE NEEDED:

MATERIAL NEEDED:

CLINICAL CASES NEEDED:

INTRODUCTION

INSTRUCTION FOR FACILIATORS

Visit neonatal unit and prepare the following:

• Equipment for cup feeding

• Formula feeding

• Pasteuration of milk

Equipment for cup feeding

• Cups for expressing and feeding

• Ideally a bigger cup is required for expressing

• Warm soapy water and Milton for sterilizing

• Container with a lead for soaking the cups

Prepare utensils for milk preparation in formula feeding babies

Prepare the following utensils for Pretoria Pateuration of BREAST milk:

• Electric kettle

• 1L aluminum pot

• Glass jar with a lead

• Feeding cups and bucket for soaking

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Divide participants into 3 groups of 6

Instruct them to take along newborn care charts and exercise book

INSTRUCTION ON CUP FEEDING

Facilitator will first demonstrate to participants on how to feed baby by cup

• Explain procedure to mother

• Wash hands

• Demonstrate to mother how to hold the bay during feeding

• Demonstrate expressed breast milk to mother and participants

o mother to sit comfortable with back supported

o Hold the bay in a upright position

o Hold the cup with milk and touch the lower lip and baby will automatically open the mouth

o Allow baby to drink from the cup, do not pour milk into the mouth

o Wait for the baby to swallow without forcing milk into the mouth

o When the baby has had enough will close the mouth

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DEMONSTRATION OF FORMULA FEEDING

Safe preparation of formula milk

1. Wash your hands with soap and water 1. before preparing a feed.

2. 2. Boil the water. If you are boiling the water in a pan, it must boil for three minutes. Put the pot’s lid on while the water cools down.

3. The water must still be hot when you mix the feed to kill germs that might be in the powder.

3. Carefully pour the amount of water 4 that will be needed in the marked cup. . Check if the water level is correct before adding the powder.

5. 4. Only use the scoop that was supplied with the formula. Fill the scoop loosely with powder and level it off with a sterilised knife or the scraper that was supplied with the formula.

Make sure you add 1 scoop of powder for 6. every 25 ml of water.

DEMONSTRATION OF PRETORIA PASTEURATION OF MILK

• Use only a 1 litre hart aluminum pot

• Instruct mother to wash hands with soap and water before expressing breast milk

• Express breast milk into a glass jar

• Put the lead on the jar and place it into the pot

• Boil water with a kettle, when vigorously bubbling pour into the pot

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• Put the milk jar with milk into the pot with boiling water

• Leave milk inside the pot for 25-30 minutes

• Guard against milk jar floating above the water, if milk small put heavy object on top of milk jar to avoid it floating

• Remove milk and feed baby by cup

• Wash utensils and soak in Milton

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