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  1. 1. Introduction
    1. 1.0 Overview
    2. 1.1 What is the Purpose of the Field Guide
    3. 1.2 Who is the Field Guide intended for?
    4. 1.3 How is the Field Guide organized?
  2. 2. Background
    1. 2.0 Overview
    2. 2.1 Humanitarian Settings Across the Globe
      1. 2.1.1 Challenges to Newborn Health Service Delivery
    3. 2.2 Newborn Health: Epidemiology
      1. 2.2.1 Global burden of newborn mortality
      2. 2.2.2 Principal causes of neonatal deaths
  3. 3. Newborn Health Services
    1. 3.0 Overview
    2. 3.1 General Principles and Considerations
      1. 3.1.1 The Continuum of Care Across the Lifecourse
      2. 3.1.2 Levels of Care
    3. 3.2 Essential Newborn Care
    4. 3.3 Newborn Care at Household/Community Level
      1. 3.3.1 During the Antenatal Period
      2. 3.3.2 Intrapartum and essential newborn care
      3. 3.3.3 Postnatal care
    5. 3.4 Newborn Care at Primary Care Facilities
      1. 3.4.1 Antenatal care
      2. 3.4.2 Intrapartum and essential newborn care
      3. 3.4.3 Postnatal care
    6. 3.5 Newborn Care at Hospitals
      1. 3.5.1 Antenatal care
      2. 3.5.2 Intrapartum and essential newborn care
      3. 3.5.3 Postnatal care
    7. 3.6 Additional Considerations for Preventing and Managing Principal Causes of Neonatal Deaths
      1. 3.6.1 Prematurity/Low Birth Weight (LBW)
      2. 3.6.2 Newborn Infections
      3. 3.6.3 Intrapartum Complications
  4. 4. Strategic Considerations
    1. 4.0 Overview
    2. 4.1 Mainstreaming newborn health in humanitarian coordination
      1. 4.1.1 Incorporate questions about newborn health services within a rapid health assessment
      2. 4.1.2 Advocate for the inclusion and prioritisation of newborn health in humanitarian response plans
    3. 4.2 Conducting a situational analysis
      1. 4.2.1 Examine national policies and protocols relevant to newborn health
      2. 4.2.2 Examine existing clinical guidelines, key messages/ BCC materials, tools and training materials
      3. 4.2.3 Assess resource availability: facilities, supplies and staff
    4. 4.3 Developing an inclusive and unified response strategy
      1. 4.3.1 Prioritizing newborn interventions
      2. 4.3.2 Update and distribute clinical guidelines and protocols
      3. 4.3.3 Develop and collate needs based staff training materials
      4. 4.3.4 Procure and distribute essential medicines and supplies
      5. 4.3.5 Ensure quality improvement and respectful care
      6. 4.3.6 Develop proposals to secure additional funding
    5. 4.4 Developing and implementing a monitoring and evaluation (M&E) plan
      1. 4.4.1 Compromised data flow and routine information systems
  5. 5. Program Implementation Considerations
    1. 5.0 Overview
    2. 5.1 Developing and disseminating key messages/behavior change communication (BCC) materials
    3. 5.2 Developing a referral system
      1. 5.2.1 When referral is not feasible
    4. 5.3 Home visits for mothers and babies
    5. 5.4 Procuring newborn care supply kits
    6. 5.5 Managing newborn deaths in crisis settings
      1. 5.5.1 Support for neonatal loss
      2. 5.5.2 Documenting neonatal loss
  6. 6. Annexes
    1. 6.1 Annex 1: Newborn health services summary tables by levels of care
      1. 6.1.1 Annex 1A
      2. 6.1.2 Annex 1B
      3. 6.1.3 Annex 1C
    2. 6.2 Annex 2: Doses of Common Drugs for Neonates
    3. 6.3 Annex 3: Advanced Care for Very Sick Newborns
    4. 6.4 Annex 4: Tools to Support Neonatal Referrals
      1. 6.4.1 Annex 4A: When to Refer a Newborn to the Hospital
      2. 6.4.2 Annex 4B: Job Aid: Transporting the Sick Newborn
      3. 6.4.3 Annex 4C: Sample Referral Note
    5. 6.5 Annex 5: Newborn Kits for Humanitarian Settings
    6. 6.6 Annex 6: Indicators
      1. 6.6.1 Annex 6A: Newborn Health Indicators for Routine Data Systems
      2. 6.6.2 Annex 6B: List of Indicators and Questions to Measure Facility Capacity to Provide Key Newborn Health Services
Newborn Field Guide

6.4 Annex 4: Tools to Support Neonatal Referrals

Download as PDF

To ensure the safe, efficient transfer of newborns in humanitarian settings, use these simple tools:

Visit the Newborn Health in Humanitarian Settings Implementation Toolkit for more resources: www.healthynewbornnetwork.org.

6.4.1 Annex 4A: When to Refer a Newborn to the Hospital

For referrals from the household and primary health care (PHC) levels to the hospital.

Ask

  • Is the baby having difficulty feeding?
  • Has the baby had any convulsions (fits)?

Look, Listen, Feel

Count the breaths in one minute. Repeat the count if more than 60 breaths per minute.

  • Look for severe chest indrawing.
  • Measure axillary temperature.
  • Look at the umbilicus. Is it red or draining pus?
  • Look for skin pustules.
  • Look at the young infant’s movements.
  • If baby is sleeping, ask the mother to wake him/her. Does the baby move on his/her own?
  • If the baby is not moving, gently stimulate him/her. Does the baby not move at all?

Refer when Any of the Following Signs are Present

  • Not feeding well
  • Convulsions
  • Fast breathing (60 breaths per minute or more)
  • Severe chest indrawing
  • Fever (37.5°C[1] or above)
  • Low body temperature (less than 35.5oC*)
  • Movement only when stimulated or no movement at all

Action Before Transfer

  • Give first dose of intramuscular antibiotics
  • Treat to prevent low blood sugar (PHC level only)
  • Advise mother how to keep baby warm on the way to the hospital
  • Refer urgently

Ask

  • How much does the baby weigh?
  • How many weeks gestation was the pregnancy?

Refer when ANY of the Following Signs are Present

At household level:

  • <2.5 kg
  • <37 weeks gestation

At PHC level:

  • <2.5 kg plus another severe classification
  • <2.0 kg

Action Before Transfer

  • Place baby immediately in KMCabbreviation position with mother or surrogate
  • Refer urgently

Ask

Is the baby breathing normally, or is the baby gasping for breath?

Look, Listen, Feel

  • Look at the baby and observe the breathing.
  • Count the breaths in one minute.
  • Look to see if the baby’s tongue is blue.
  • Look to see if the baby is pale. Look at the tongue and palms.
  • Feel the pulse and count the heart rate in 1 minute.

Refer when Any of the Following Signs are Present

First follow the Newborn Resuscitation Flowchart (Figure 3.2). Then refer if:

  • Not breathing at all
  • Gasping
  • Respiration < 20 breaths per minute
  • Heart rate < 100 per minute
  • Tongue is blue

Action Before Transfer

  • Advise mother how to keep baby warm on the way to the hospital
  • Refer urgently

Ask

If jaundice is present, ask: when did the jaundice first appear?

Look, Listen, Feel

  • Look for jaundice (yellow eyes or skin)
  • Look at the baby’s palms and soles. Are they yellow?

Refer when Any of the Following Signs are Present

  • Any jaundice if age less than 24 hours
  • Yellow palms and soles at any age

Action Before Transfer

  • Treat to prevent low blood sugar (PHC level only)
  • Advise mother how to keep baby warm on the way to the hospital
  • Refer urgently

Ask

Does the baby have diarrhea?[2]

Look, Listen, Feel

  • Does the infant move on his/her own?
  • Does the infant not move even when stimulated but then stops?
  • Does the infant not move at all?
  • Is the infant restless and irritable?
  • Look for sunken eyes.
  • Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? or slowly?

Refer when Two of the Following Signs are Present

  • Movement only when stimulated or no movement at all
  • Sunken eyes
  • Skin pinch goes back very slowly

Action Before Transfer

  • Advise mother how to keep baby warm on the way to the hospital
  • Advise mother to continue breastfeeding
  • Refer urgently

PHC Level Only

If infant has no other severe classification:

  • Give fluid for severe dehydration

or If infant has another severe classification:

  • Refer urgently to hospital with mother giving frequent sips of ORS on the way
  • Advise mother to continue breastfeeding

6.4.2 Annex 4B: Job Aid: Transporting the Sick Newborn

Before transport

  • Stabilize baby to the extent possible.
    • Note that trained Community Health Workers (CHWs) can provide the initial dose of antibiotics, per protocol.
  • Call receiving facility to notify them of the referral.
  • Counsel family to explain why referral is necessary. Mother should accompany baby whenever possible.
  • Fill out referral note (see Annex 4C for sample) and give to the caregiver or health worker accompanying the baby to the receiving facility.
  • Record referred case in register.

On the way to the health facility

  • If the baby is able to breastfeed, feed the baby at least every two hours. Give only breast milk.
  • Keep the baby warm. Keeping the baby skin-to-skin is best. Ensure the baby is:
    • Naked except for a nappy, hat and socks
    • Placed between the mother’s breasts with the baby’s legs along her ribs and the head turned to the side
    • Secured with a cloth
  • If skin-to-skin care is not possible, wrap the baby well and keep her or him close to the mother.
  • Where feasible, the health worker accompanying the caregiver and baby can provide counseling on care during transport, such as thermal care and breastfeeding.

After referral

  • Where feasible, track counter-referral, including outcome of the referral and any follow-up actions required.
    • Trained CHWs can undertake follow-up visits for referred newborns.
  • Monitor and address barriers to the referral process.

6.4.3 Annex 4C: Sample Referral Note

Note that pictorial referral slips can be developed in settings where community health workers are preliterate. See the Newborn Health in Humanitarian Settings Implementation Toolkit for samples: www.healthynewbornnetwork.org.


Abbreviations

  1. These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately .5°C higher. ↩︎

  2. A newborn has diarrhea if the stools have changed from usual pattern and are many and watery (more water than fecal matter). The normally frequent or semi-solid stools of a breastfed baby are not diarrhea. ↩︎