Clinical Monitoring of

Hospitalized New Born

Dr. L S DeshmukhMD,Dip.NB,DM (Neonatology)

Heinz Fellow, Royal College of Pediatrics &

Child Health, London,eMail :lsdesmukh@indiatimes.com

Importance of Neonatal Monitoring

• A neonate cannot complain• Adaptation to extrauterine life

may be difficult.• Illnesses quite common• If not detected in time, may be

fatal / brain damage• Adequate monitoring – first step

toward improved survival without morbidity

Objectives of neonatal monitoring• Evaluate the status of neonate at

birth• Categorize degree of risk to the

baby• Anticipate and detect early signs of

illness• Assess the progress of illness• Monitor adequacy of nutritional

intake and growth.

What should be monitored ?• Vital signs

• Signs and severity of illness• Biochemical and biophysical

monitoring depending upon the illness.

• Drug administration and side effects of drugs.

• Nutritional intake and growth• Effective functioning of the

equipment used in neonatal care.

Who should monitor ?• Trained nurse (Adequate number essential)

• Doctors (senior / junior)

• During transport, nurse / doctor• Role of mother - supportive

Frequency of clinical monitoring• Decided by degree of risk & of sickness• Continuous electronic monitoring for very high-risk NB• During first 8 – 12 hrs. in all babies

- Two hourly vital signs till stabilized - Note feed/fluid intake

• Low-risk baby- Vital signs 12 hrly.- Daily weight, feeding, bowel, urination.

• High-risk baby- Every 2 hrs. in first 24 hrs. (May be longer if unstable)- Every 4 hrs – on stabilization

• During transport- Every 15-30 min.

* Some monitoring for all neonates

* During first 8 hours (transition), in all babies.

* For longer period in high risk neonates.

Whom to monitor ?

Instruments to monitor

Open eyes Open ears

Warm hands Taste

Alert Brain

Instruments to monitor

“The eye of the master will do more work than both his hands”

- Benjamin Franklin

Eyes, ears, nose and palpating fingers are crucial for clinical monitoring with intact analytical brain, an essential attribute

Clinical Monitoring – Vital SignsTemperature :• Monitor environmental as well as baby’s

temperature.• Methods :

- Mercury –in- glass thermometer- Probe – Type electronic thermometer- Infrared thermometer

• Hand touch is most useful for monitoring at any level.

• Sites : Axillary, Rectal, Skin surface,- Aural / Esophageal, Sublingual

• Intermittent rather than continuous monitoring

Site for Temperature MonitoringSite Rate [°C] Application

Surface1. Abdomen 36.0-36.5 Servo control2. Axillary 36.5-37.0 Noninvasive

Approx of core temp

Core1. Sublingual 36.5-37.5 Quick reflection

ofbody change

2. Esophageal 36.5-37.5 Reliable reflection of

Changes3. Rectal 36.5-37.5 Slow reflection of

Changes

Core-Peripheral Temp. Gradient• Often used to assess state of peripheral perfusion

• Large gradient = hypo volemia• A gradient may indicate thermal stress• May be affected by thermal environment,

phototherapy.• Gradient > 3.2°C, may be a sign of sepsis (Bhandari et al, Indian Pediatr, 1992)

• Usually inaccurate in pre terms (immature autonomous control)

• Optimum sites & reference ranges not well studied.

Clinical Monitoring – Vital SignsHeart Rate :• Varies widely with state• Resting HR most consistent• Preterms have higher HR• Recorded by precordial

palpation, peripheral pulses• Easiest way by auscultation• Bradycardia < 100 bpm• Tachydardia > 160 bpm

Clinical Monitoring – Vital SignsRespiration :• RR must be counted for full one

minute in a quiet infant• RR x TV = MV• RR affected by various factors• RR slightly more on listening

with stethoscope than observation.

• Normal range – 30-60 BPM• In addition, look for retractions,

grunting / moaning, apnea

Clinical Monitoring – Vital SignsBlood Pressure

• Various techniques• Invasive / noninvasive• Flush blood pressure

- Gives mean pressure- Lower than direct

• Important elements for accuracy1. Quiet infant2. Proper cuff size (50-67% of arm length)

• Small cuff – BP higher, Large cuff – BP lower

Clinical Monitoring – Vital SignsBlood pressure (Contd..)• Note pulse pressure (25-30 mmHg in term,

15-25 mmHg in preterm).

• Limitations of flush method – Continuous monitoring not feasible, not practical, inaccurate, does not given systolic and diastolic BP.

• Normal values for BP vary with GA, PNA, method as well as site.

• For normal values, use Nomogram / chart.

Clinical Monitoring – Vital SignsColour :• Pink soles – indicate normal Hb,

PaO2, BP, Temp.• Pale (anaemia, shock)• Plethora – S/o polycythemia• Blue (cyanosis) – RS, CVS, Temp.• Yellow (Jaundice ) – Kramer’s

Icterometer

Capillary Refill Time (CRT)• Widely used as a guide to peripheral perfusion.

• Upper limit of normal less than 3 seconds.• Values from center of chest and forehead

more reliable (Strozik et al, Arch Dis Child, 1997).

• Limitations :- Large inter observer variation.- Fallacious on babies in incubators or radiant warmers.- Does not always correlate with BP/Cardiac index

Clinical Monitoring – Vital SignsActivity :• Good – reassuring• Lethargic / irritable – Search for

cause• Seizure activity – CNS disorderImportant : State of the baby and

feeding

Listen to the cry

Pulse Oximetry

• Considered as “Fifth vital sign”• Part of clinical monitoring• Normal range – 92+3% (room air)• Advantages :

- Noninvasive- No patient preparation- Rapid response time- Useful on different patient population.

• Limitations :- Decreased accuracy < 65%- Not sensitive for hyperoxemia- Affected by type of Hb (F/A)- Nor reliable with low pulse volume

Intake / Output Record• Record fluid intake ml to ml (including boluses & flushes)

• Record feed volume & type accurately

• Record accurately- Stool – frequency, type- Vomiting – frequency, color, content- Gastric residuals – volume, color, content.

• Urine – volume (accurately) or frequency (stable NB)

Stool- Normal pattern

Weight Monitoring• Most important parameter of growth

• Monitoring intake-output balance• Record with a sensitive weighing

scale• Check daily till weight gain stabilized• Plot daily weight on a chart• Monitor rate of weight gain / loss• In addition, record, length and head

circumference weekly.

Measure Wt. & Length accurately

Monitor & plot daily wt.

Record of identity

Role of Mother (In a Hospitalised Baby)• Nursing shortage – chronic problem

• An educated mother can monitor almost all vital signs (except HR and CRT)

• Monitor IV leakage, milk intake• Uneducated mother may be trained

to monitor• Need to supervised, educated and

monitored.

The Technology Should Supplement Rather Than Replace the Traditional Tools

Who is monitoring monitor?