Republic of Rwanda

MINISTRY OF HEALTH

NATIONAL NEONATAL CARE PROTOCOL

Prepare BEFORE delivery – Equipment, Warmth, Getting Help
Breathing should be started within 60 secs

If the baby has not taken a breath at all, think: Is there MECONIUM?

NO YES

Use warm cloth – dry and Before first breath and

stimulate; observe activity, color and before drying/stimulating: Suck/clean
breathing, wrap in a new warm cloth oro-pharynx under direct vision.
with chest exposed Do not do deep blind suction.

YES
Baby now active and taking breaths? Skin to skin with mother to keep warm
and observe; initiate breastfeeding
NO

A Check if airway is clear.

If obstructed use suction to clear;
put head in neutral position Baby stable

B YES
Is baby breathing normally? Keep warm, count rate of breathing and
heart rate. Give oxygen if continued
NO respiratory distress

ABC OK
Weak, gasping or absent respirations,
call for help
YES Continue with 30–50 breaths/min,
observe chest movement,
re-evaluate every 1–2 minutes

Start ventilation.
B Ensure the chest rises in the first breaths,
continue at about 30–50 breaths/min.
Check heart rate at 1 min.
Add O₂ if no improvement after 2 mins.

Give 1 EFFECTIVE breath for every

NO 3 chest compressions for 1 min.
C Is the heart rate
Reassess ABC every 1–2 min,
> 60 bpm?
stop compressions when HR > 60 bpm
and support breathing until OK
 Republic of Rwanda
MINISTRY OF HEALTH

NATIONAL NEONATAL CARE PROTOCOL

Hypothermia Management of Newborns (Temperature < 36°C)

Transfer to the Neonatal Unit

Ensure infant is dry, wearing a hat and close windows and curtains in room

Stable Unstable or < 1 kg

• If < 1 kg transfer to incubator

• Initiate Kangaroo Mother Care (incubator or
radiant warmer if caregiver unavailable) • If unstable or needs procedures transfer to
radiant warmer

Temperature 36.5–37.5°C? Improved after 24 hours and weight > 1 kg?

YES NO YES NO

Initiate KMC and

Continue KMC Transfer to
monitor; may Maintain
and monitoring incubator or
alternate KMC/ in incubator
as usual radiant warmer
incubator

Definition of Special Considerations for For Severe Hypothermia

Successful KMC Very Low Birth Weight Infants < 1.5 kg (Temperature < 35°C)
• Infant able to • Increased risk for hypothermia; immediate • Use radiant warmer for
maintain temperature intervention essential immediate rewarming
36.5 – 37.5°C • Unstable infants < 1.5 kg should remain in • Hold enteral feeds until
• Exam stable incubator until exam stable and weight temperature > 35°C; initiate IV
• After first week of life gain steady fluid if prolonged
steady weight gain, • Once goals achieved begin transition to • Recheck temperature every
> 15 grams/kg/day KMC. May increase KMC frequency and hour until > 36.5°C
duration daily as tolerated.
Republic of Rwanda
MINISTRY OF HEALTH NATIONAL NEONATAL CARE PROTOCOL
Treatment of Newborn with Respiratory Distress

Very Preterm < 33 weeks or Low Birth Weight < 2 kg with ANY
Term / Approaching Term ≥ 33 weeks | ≥ 2 kg
Respiratory Distress (Mild, Moderate, or Severe)

Order caffeine or aminophyline

Escalate CPAP Initiate CPAP Moderate or Severe Mild Respiratory Distress

Respiratory Distress • Mild grunting/flaring/
If respiratory If respiratory 1. Start CPAP at 6cm H₂O
distress & hypoxia: distress & no • Moderate or severe retractions
2. Measure Oxygen Saturation grunting/flaring/
hypoxia: • RR 50– 70
1. ↑ O₂ • If > 90% → room air retractions
concentrator 1. ↑ CPAP by • O₂ sat > 90%
Symptoms • If < 90% → O₂ • RR > 70 or < 30
to 4L/min 1– 2 cm H₂O to
worsen concentrator 2L/min • O₂ sat < 90%
2. ↑ CPAP by max of 10cm H₂O
1– 2 cm H₂O to RAM cannula/8cm 3. Place enteral tube
max of 10cm H₂O nasal prongs
*For severe distress/hypoxia, Initiate O₂ nasal cannula
RAM cannula/8cm escalate quickly
nasal prongs
3. Change to O₂ tank
at 4L/min
Symptoms Symptoms
resolved recur
Symptoms
improve

Wean CPAP Discontinue CPAP If respiratory support is required:

As respiratory exam improves: Respiratory symptoms resolve 1. Monitor vital signs every hour for
1. Change to O₂ concentrator for > 24 hrs: 3 hours, then a minimum of every
1. Discontinue CPAP 3 hours
2. ↓ O₂ to 2L/min
2. Evaluate for sepsis/pneumonia
3. Discontinue O₂ if tolerated 2. Apply alternative O₂
source if indicated 3. Make NPO, start IVF
4. ↓ CPAP pressure by 1cm H₂O/hour as (ex: nasal cannula) 4. Monitor glucose
tolerated to minimum 6cm H₂O RAM
cannula/4cm H₂O nasal prongs 5. Monitor temperature
6. Keep O₂ Sat 90– 95%
Republic of Rwanda
MINISTRY OF HEALTH

NATIONAL NEONATAL CARE PROTOCOL

Hyperbilirubinemia Assessment and Treatment

Assess for jaundice and start phototherapy if

Days < 35 wks gestation, Physical Examination –

of sepsis, hemolysis, poor ≥ 35 wks gestation, Assessment for Jaundice
Life feeding, < 2 kg no risk factors, ≥ 2 kg
• If visible scleral icterus and facial jaundice
0 Any visible jaundice* → estimate bilirubin ~ 5 mg/dL

1 170 µmol/L = 10 mg/dL 260 µmol/L = 15 mg/dL • If visible jaundice of palms and soles →
estimate bilirubin > 20 mg/dL
2+ 250 µmol/L = 15 mg/dL 310 µmol/L = 18 mg/dL
Bilirubin conversion: 1 mg/dL = 17.1 µmol/L.
*Or excessive bruising or anticipated prolonged NPO course in the VLBW. Source: Initiate Phototherapy
WHO 2013
1. Place newborn in bassinet or incubator
(if available or LBW)
2. Ensure wearing protective eyewear
3. Ensure naked except for diaper and
protective eyewear
4. Position distance of phototherapy source
based on machine specifications
5. Minimize interruptions
Discontinue Phototherapy
1. When total serum bilirubin level < treatment thresholds
2. Recheck total bilirubin level after 24 hours Monitor Phototherapy
3. If bilirubin is above the treatment threshold, restart 1. Check temperature every 3 hours
phototherapy (goal 36.5 – 37.5°C)
2. Monitor hydration status
3. Monitor feeding (7– 8 times/day or
If Bilirubin Rising Despite Phototherapy on IV fluids)
1. If > 340 µmol/L (20 mg/dL) take additional measures to 4. Monitor urine output (> 6 voids/day)
reduce bilirubin (see box below)
2. If > 425 µmol/L (25 mg/dL)
– Consider exchange transfusion Repeat Lab Testing:
– Apply below measures (see box below) Total and Direct Bilirubin
– Give 10– 20 mL/kg IV fluid bolus 1. If initial total bilirubin > 340 µmol/L
– Consider NG tube feeding until bilirubin level < 425 (20 mg/dL), repeat in 6 –12 hrs
µmol/L (25 mg/dL) 2. If initial total bilirubin < 340 µmol/L
– Ask mother to manually express breast milk (20 mg/dL) and NOT on ful volume feeds,
– If not orally feeding well, place NGT and give ~150 mL/ repeat in 12 hrs; if on full volume feeds,
kg/day of breastmilk/formula repeat in 24 hrs

Additional Measures to Reduce Bilirubin

• Conduct feedings under phototherapy lights • If not already receiving IV fluids, start IV and provide
• Ensure maximum skin exposed to light and cover incubator IV hydration to avoid hemoconcentration (additional
with white sheet to create reflective surface 20–40 mL/kg to total fluid intake)
• Continue enteral intake PO or NG to promote excretion of
metabolized bilirubin
 Republic of Rwanda
MINISTRY OF HEALTH

NATIONAL NEONATAL CARE PROTOCOL

APPENDIX  D  
IV  Fluid  Recipes  
IV Fluid Recipes
 
 
G10%  IV  fluid  from  G5%  and  G50%,  Use  premixed  G10%  if  available  
 
1. Remove  28  ml  from  250  ml  bag  of  G5%    
 
2. Add  28  ml  G50%  to  bag  in  step1  
 
3. Mix  bag  to  m ake  G10%  
 
 
  G10%  ¼  Ringers  Lactate  (RL)  from  G5%,  G50%  and  RL  
  1. Remove  95  ml  from  250  ml  bag  of  G5%    
  2. Add  35  ml  G50%  to  bag  in  step1  
  3. Add  60  ml  RL  to  bag  in  step  2  
  4. Mix  bag  to  m ake  G10%  ¼  Ringers  lactate  
 
  G10%  ¼  Ringers  Lactate  (RL)  from  G10%,  G50%  and  RL  
 
1. Remove  75  ml  from  250ml  bag  of  G10%    
 
2. Add  15  ml  G50%  to  bag  in  step1  
 
3. Add  60  ml  RL  to  bag  in  step  2  
 
4. Mix  bag  to  m ake  G10%  ¼  Ringers  lactate  
 
 
  G10%  ¼  Normal  Saline  (NS)  from  G5%,  G50%  and  N S  
  1. Remove  95  ml  from  250ml  bag  of  G5%    
  2. Add  35  ml  G50%  to  bag  in  step1  
  3. Add  60  ml  NS  to  bag  in  step  2  
  4. Mix  bag  to  m ake  G10%  ¼  Normal  saline  
 
   G10%  ¼  Normal  Saline  (NS)  from  G10%,  G50%  and  NS  
  1. Remove  75  ml  from  250ml  bag  of  G10%    
  2. Add  15  ml  G50%  to  bag  in  step1  
  3. Add  60  ml  NS  to  bag  in  step  2  
  4. Mix  bag  to  m ake  G10%  ¼  Normal  saline  
 
 
G12.5%  ¼  Ringers  Lactate  (RL)  from  G5%,  G50%  and  RL  
 
  1. Remove  108  ml  from  250ml  bag  of  G5%    
  2. Add  48  ml  G50%  to  bag  in  step1  
  3. Add  60  ml  NS  to  bag  in  step  2  
  4. Mix  bag  to  m ake  G12.5%  ¼  Ringers  Lactate  
 
G12.5%  ¼  Ringers  Lactate  (RL)  from  G10%,  G50%  and  RL  
 
 
1. Remove  90  ml  from  250  ml  bag  of  G10%    
APPENDIX  
2. Add  30  ml  EG  50%  to  bag  in  step1  
3. Add  60  ml  NS  to  bag  in  step  2  
 
4. Mix  bag  to  m ake  G12.5%  ¼  Ringers  Lactate  

72 National  Neonatal  Care  Protocol  

Republic of Rwanda
MINISTRY OF HEALTH

NATIONAL
APPENDIX  E  
NEONATAL CARE PROTOCOL
IV  and  Enteral  Fluid  Rates  for  Newborns    
in  Enteral
IV and Neonatal   Unit
Fluid Rates
  for Newborns in Neonatal Unit
Birth  Weight  <  1  kg  (ELBW)  
(Estimated  as  0.9  kg  for  calculation)  

IV   Enteral  
Total  Fluid:  IV+PO  
DOL   IV  Fluid   ml/kg/day   ml/kg/24hrs   ml/hr   ml/kg/24hrs   ml/3hrs  
0   G10%   80   80   3   0   0  

1   G10%   100   90   3   10   1  

2   G10%   120   90   3   30   3  

3   G10%   140   90   3   50   6  

4   G10%   150   80   3   70   8  

5   G10%   150   60   2   90   10  

6   G10%   150   40   2   110   12  

7   G10%   150   20   1   130   15  

8   n/a   160   0   0   150   17  

9   n/a   170   0   0   170   19  

10   n/a   180   0   0   180   20  

 
 
  Birth  Weight  1  –  1.5  kg  (VLBW)  
    Birth  Weight  
(Estimated   1  –k
as  1.25    1g  
.5   kg  c(alculation)  
for   VLBW)  
(Estimated  as  1.25  kg  for  calculation)  
IV   Enteral  
Total  Fluid:  IV+PO   IV   Enteral  
Total  Fluid:  IV+PO  
DOL   IV  Fluid   ml/kg/day   ml/kg/24hrs   ml/hr   ml/kg/24hrs   ml/3hrs  
DOL   IV  Fluid   ml/kg/day   ml/kg/24hrs   ml/hr   ml/kg/24hrs   ml/3hrs  
0   G10%   80   80   4   0   0  
0   G10%   80   80   4   0   0  
1   G10%   100   75   4   25   4  
1   G10%   100   75   4   25   4  
2   G10%   120   70   4   50   8  
2   G10%   120   70   4   50   8  
3   G10%   140   65   3   75   12  
3   G10%   140   65   3   75   12  
4   G10%   150   50   3   100   16  
4   G10%   150   50   3   100   16  
5   G10%   150   25   1   125   20  
5   G10%   150   25   1   125   20  
6   n/a   150   0   0   150   24  
6   n/a   150   0   0   150   24  
7   n/a   170   0   0   170   26  
7   n/a   170   0   0   170   26  
8   n/a   180   0   0   180   28  
8   n/a   180   0   0   180   28  
    National  Neonatal  Care  Protocol   73
     
 

Birth  Weight  1.5  –  2  kg  (LBW)  

Birth  Weight  1.5  –  2  kg  (LBW)  
(Estimated  as  1.75  kg  for  calculation)  
(Estimated  as  1.75  kg  for  calculation)  
IV   Enteral  
Total  Fluid:  IV+PO   IV   Enteral  
Total  Fluid:  IV+PO  
DOL   IV  Fluid   ml/kg/day   ml/kg/24hrs   ml/hr   ml/kg/24hrs   ml/3hrs  
DOL   IV  Fluid   ml/kg/day   ml/kg/24hrs   ml/hr   ml/kg/24hrs   ml/3hrs  
0   G10%   60   60   4   0   0  
0   G10%   60   60   4   0   0  
1   G10%   80   50   4   30   7  
1   G10%   80   50   4   30   7  
2   G10%   100   40   3   60   13  
2   G10%   100   40   3   60   13  
3   G10%   120   30   2   90   20  
3   G10%   120   30   2   90   20  
4   G10%   140   20   1   120   26  
4   G10%   140   20   1   120   26  
5   n/a   150   0   0   150   33  
5   n/a   150   0   0   150   33  
6   n/a   170   0   0   170   37  
6   n/a   170   0   0   170   37  
 
 
   
   
Republic of Rwanda
MINISTRY OF HEALTH

NATIONAL NEONATAL CARE PROTOCOL

IV and Enteral Fluid Rates for Newborns in Neonatal Unit

Birth  Weight    2  –  2.5  kg  unable  to  breastfeed  

(Estimated  as  2.25  kg  for  calculation)  

IV   Enteral  
Total  Fluid:  IV+PO  
DOL   IV  Fluid   ml/kg/day   ml/kg/24hrs   ml/hr   ml/kg/24hrs   ml/3hrs  
0   G10%   60   60   6   0   0  

1   G10%   90   50   5   40   11  

2   G10%   120   40   4   80   23  

3   G10%   150   30   3   120   34  

4   n/a   150   0   0   150   42  

 
 

Birth  Weight  2.5  –  3  kg  unable  to  breastfeed  

(Estimated  as  2.75  kg  for  calculation)  

IV   Enteral  
Total  Fluid:  IV+PO  
DOL   IV  Fluid   ml/kg/day   ml/kg/24hrs   ml/hr   ml/kg/24hrs   ml/3hrs  
0   G10%   60   60   7   0   0  

1   G10%   90   50   6   40   14  

2   G10%   120   40   5   80   28  

3   G10%   150   30   3   120   41  

4   n/a   150   0   0   150   52  

 
 

Birth  Weight  >  3  kg  unable  to  breastfeed  

(Estimated  as  3.5  kg  for  calculation)  

IV   Enteral  
Total  Fluid:  IV+PO  
DOL   IV  Fluid   ml/kg/day   ml/kg/24hrs   ml/hr   ml/kg/24hrs   ml/3hrs  
0   G10%   60   60   9   0   0  

1   G10%   90   40   6   50   22  

2   G10%   120   20   3   100   44  

3   n/a   150   0   0   150   66