Any neonate, less than 28 days old, presenting as unwell.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
Signs of serious illness in neonates may be non-specific.
All neonates require escalation as per local CERS protocol as soon as possible.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset of symptoms
- Pain assessment
- Feeding history, including pattern and behaviours, e.g. breast, bottle or mixed
- Fluid intake, i.e. mL or % of usual feeds
- Fluid output, i.e. number of wet nappies
- Pre-hospital treatment
- Past medical history, including birth and/or prenatal complications
- Group B streptococcal (GBS) status of the mother, including recent and previous pregnancies
- Suspected exposure to the herpes simplex virus (HSV)
- Maternal drug and medication use
- Current medications
- Immunisation history
- Current and birth weight
- Sick contacts
Signs and symptoms
- Irritable
- Lethargic
- High-pitched cry
- Poor or reduced tone
- Respiratory distress
- Pallor
- Jaundice
- Poor feeding
- Vomiting
- Poor urine output
- Pain or unable to settle
- Fever, 38° and over
- Rash
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Prematurity
- Low birth weight
- Slow weight gain, failure to thrive or unexpected weight loss
- High level of parental or carer concern
Clinical
- Seizure
- Abnormal posturing
- Floppy baby or decreased tone
- Lethargy or irritability
- Weak, high pitched or continuous cry
- Bulging fontanelle
- Apnoea
- Severe respiratory distress or grunting
- Bradycardia or hypotension, with weak or absent central or peripheral pulses – pre-terminal signs
- Persistent tachycardia
- Pallor
- Mottled
- Cyanotic
- Jaundice
- Cool to touch
- Bilious or projectile vomiting
- Distended abdomen
- Absent or infrequent bowel actions or bowel sounds
- Red currant/bloody stool
- Fever, 38° and over
- Hypothermia, less than 36.5°C
- Non-blanching rash
- Painful erythematous rash
Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
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Position
| Assessment | Signs of serious illness | Intervention |
|---|---|---|
General appearance/first impressions Observe position, including spontaneous movements and posture | Abnormal posturing Lethargy Floppy Weak, high pitched or continuous cry Irritability | Apply continuous cardiorespiratory monitoring Reduce stress, e.g. clustering of cares, as tolerated Use settling techniques Nurse in infant warmer, if available |
Airway
| Assessment | Signs of serious illness | Intervention |
|---|---|---|
Patency of airway | Stridor (new onset) | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
| Assessment | Signs of serious illness | Intervention |
|---|---|---|
Respiratory rate and work of breathing Consider cardiac causes for respiratory distress in the absence of coryzal symptoms Auscultate chest (breath sounds) | Grunting Tachypnoea Increased work of breathing Decreased air entry Crackles or wheeze | Minimal handling Consider superficial nasal suction Sodium chloride 0.9% nasal drops may be used to clear airway and support feeding Assist ventilation with positive end-expiratory pressure (PEEP), as clinically indicated |
Apnoea, 20 seconds and over Hypoventilation with desaturation | Provide tactile stimulation such as rubbing the soles of feet or gentle rubbing of the chest Position the airway in a neutral position If spontaneous respirations have not resumed:
| |
Oxygen saturation (SpO2) |
Signs of congenital heart disease may include:
| Complete pre and post-ductal oxygen saturations (right arm and either foot) Apply oxygen to maintain SpO2 95% and over (pre-ductal) Avoid hyperoxia in the newborn |
Circulation
| Assessment | Signs of serious illness | Intervention |
|---|---|---|
Perfusion (capillary refill, skin warmth and colour) Mucosa and skin turgor | Pallor Mottled skin Cyanosis Jaundice Cool or cold CRT 3 seconds and over | Assess circulation Palpate central pulses (compare the strength of brachial pulses with femoral pulses) Bradycardia is a late sign and may indicate cardiorespiratory collapse or raised intracranial pressure If the heart rate is below 60 beats per minute, commence basic life support |
Heart rate | Bradycardia Weak or absent central or peripheral pulses Persistent tachycardia | |
Blood pressure | Hypotension | |
Cardiac rhythm | Arrhythmia | Check cardiac rhythm and consider 12 lead ECG |
IVC and/or pathology | Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained | |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus If further fluid resuscitation is required, give 10 mL/kg sodium chloride 0.9% bolus IV/intraosseous |
Disability
| Assessment | Signs of serious illness | Intervention |
|---|---|---|
| AVPU | Floppy Bulging or sunken fontanelle | If AVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength |
GCS, pupillary response and limb strength | Poor tone Focal neurological signs or seizures | Consider head trauma, accidental and non-accidental Obtain baseline and repeat assessment as clinically indicated |
| Pain | Sudden onset of excessive crying and/or irritability | Assess for pain using modified pain assessment tool (mPAT) (appendix) |
Exposure
| Assessment | Signs of serious illness | Intervention |
|---|---|---|
| Temperature | 36°C and below or 38°C or above or subjective temperature at home, i.e. felt hot or cold | Measure temperature If the temperature is 34°C or below, warm rapidly:
If the temperature is 34°C or below and hypoglycaemic, 3 mmol/l and below:
Aim for temperature above 36°C and less than 38°C per axilla If the measured or reported temperature is 38°C or above, see pathology section |
Head-to-toe inspection, including posterior surfaces | Non-blanching rash Skin erythema and/or tenderness Vesicular rash Swelling of a limb or joint Not using a limb Bruising or unexplained injury | Remove clothing, including nappy, while maintaining normothermia Assess for signs of illness or pain, e.g. hair tourniquet, limb, skin and joint infection or injury Assess the umbilical stump for signs of infection Measure bare weight |
Fluids
| Assessment | Signs of serious illness | Intervention |
|---|---|---|
Hydration status | Poor feeding Reduced urine output | Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses |
| Nausea and/or vomiting | Bilious vomiting Projectile vomiting | |
| Gastrointestinal | Distended abdomen Absent or infrequent bowel actions or bowel sounds Red currant/bloody stool Irreducible inguinal hernia Jaundice | Check scrotum for mass, e.g. inguinal hernia |
Glucose
| Assessment | Intervention |
|---|---|
|
BGL |
Measure BGL If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):
If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:
Consider the need for ongoing glucose maintenance |
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Complete a neonatal focused assessment.
Precautions and notes
- Neonates should be 'warm, pink, sweet' (normoglycaemia) and calm.
- Signs of serious illness may be vague and non-specific, so complete a structured assessment and consider parental or carer concern.
- A period of observation and reassessment of A–G in neonates with unspecific symptoms is recommended to recognise a deteriorating or sick child.
- Respiratory distress without coryzal symptoms may indicate sepsis, congenital heart disease or metabolic conditions.
- Consider non-accidental injury in the persistently crying or irritable neonate.
Interventions and diagnostics
Specific treatment
- Ensure a bare weight is measured and documented.
- Recorded or reported temperature over 38°C: a full septic workup is required as soon as medical or nurse practitioner is available.
Glucose gel 40%
- Use an oral syringe and measure 200 mg/kg (0.5 mL/kg) of 40% glucose gel.
- With a gloved hand, dry both sides of the buccal mucosa, which includes the inside of the cheeks, inside of the lips and above the gum line, with gauze or a large swab.
- Apply the gel to the mucosa with a gloved finger, dividing the dose equally between the sides.
- Do not squirt the gel directly into the infant's mouth.
- Commence enteral feed if able.
Procedural analgesia
For pain relief required during procedures only, not used to replace appropriate analgesia.
Sucrose 24%
Less than 28 days old: give up to 0.5 mL orally per procedure. Maximum dose 5 mL in 24 hours.
Repeat as needed up to the maximum dose.
Non-pharmacological pain relief
Infants may benefit from non-pharmacological interventions such as:
- swaddling
- facilitated tucking and positioning
- breastfeeding or non-nutritive suckling (pacifier)
- skin-to-skin contact
- reduction of stimuli (light and sound)
- music therapy.
See non-pharmacological pain relief appendix.
Radiology
Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.
Pathology
- If practical: FBC, UEC, glucose, CRP, VBG, blood cultures
- Urinalysis: clean catch or catheter urine. Send for MC&S. Keep sample refrigerated if transport delayed.
- Home birth: retain placenta if available
Medications
The patient’s weight is mandatory for calculating fluid and medication doses.
The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
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| Drug | Dose | Route | Frequency |
|---|---|---|---|
| 500 microg | IM | Once only | |
2 mL/kg | Slow IV injection | Once only | |
Glucose 40% gel | 200 mg/kg (0.5 mL/kg) | Buccal | Repeat after 15 minutes if required |
0.25–15 L/min, device dependent | Inhalation | Continuous | |
10 mL/kg | IV/intraosseous | Bolus Repeat once if required | |
Up to 0.5 ml per procedure Maximum dose 5 mL in 24 hours | Oral | Used during procedures only Repeat if required to maximum dose |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Roberto Calzada, Adriana Yock-Corrales, Manuel Soto-Martínez. Management of Common Newborn Emergencies. Glob J of Ped & Neonatol Car. 2(3): 2020. GJPNC.MS.ID.000537. Available from: https://irispublishers.com/gjpnc/fulltext/management-of-common-newborn-emergencies.ID.000537.php
- Bolisetty S, Osborn D. Sucrose Oral Solution 24%. Australia Royal Hospital for Women; 2021 [cited 10 March 2023]. Available from: https://www.seslhd.health.nsw.gov.au/sites/default/files/groups/Royal_Hospital_for_Women/Neonatal/Neomed/Neomed21sucrose.pdf
- Clinical Resources. Australasian Neonatal Medicines Formulary. Australia: NSW Health; 2023 [cited 10 March 2023]. Available from: https://www.anmfonline.org/
- Department of Health and Aged Care. FLACC pain scale. Australia: Australian Government; 2013 [cited 23 Feb 2023]. Available from: https://www1.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-pain~triageqrg-FLACC
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- NSW Health. Australian Medicines Handbook Children's Dosing Companion Australia: Australian Government, NSW; 2023 [cited 28 Feb 2023]. Available from: https://childrens.amh.net.au.acs.hcn.com.au/?acc=36422
- The Royal Children's Hospital Melbourne. Recognition of the seriously unwell neonate and young infant. Australia: Victoria Health 2019 [cited 10 March 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Recognition_of_the_seriously_unwell_neonate_and_young_infant/
- The Royal Children's Hospital Melbourne. Unsettled or crying babies. Australia: Victoria Health 2019 [cited 10 March 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Crying_Baby_Infant_Distress/
- The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
| Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
| Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
| Currency | Due for review: Jan 2026. Based on a regular review cycle. |
| Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/recognition-unwell-neonate