Resuscitation of the Young Infant (Chapter 4)

See young infant resuscitation algorithm for an overview

Learning Objectives

After completion of this chapter the participant should be able to:

Demonstrate the resusciation or a sick young infant.

This chapter covers resuscitation of a young infant (resuscitation of a baby from 29 days to 60 days). There are a lot of similarities with neonatal resuscitation and the skills required are similar.
The resuscitation of the YI is very similar to the newborn, except for the initial steps and ratio of breathes to cardiac compressions.

This chapter also includes
The insertion of a guedel (oropharyngeal) airway

First make sure baby is warm and blood sugar is normal.

Temperature	Hypoglycaemia
All sick NYI are prone to hypothermia. Maintain thermal environment. Keep the infant dry and well wrapped. Hats help to reduce heat loss. Keep the room warm (at least 25⁰C). Keep the baby under a heated radiant warmer .	Check all infants presenting with emergency signs and all sick NYI for blood glucose. If you cannot measure blood glucose, give a bolus glucose dose.

Managing Airway and Breathing

The letters A and B in ABCCCD represent airway and breathing. To assess if the child has an airway or breathing problem you need to know:

Is the airway open?
Is the child breathing?
Is the child blue (centrally cyanosed)?
Does the child have severe respiratory distress?

A. Airway

Neutral position to open the airway in an infant.
Head tilt-chin lift manoeuvre for opening airway

The neck is very slightly extended, and the head is tilted by placing one hand onto the child’s forehead. Lift the mandible upwards (towards the ceiling) by placing the fingertips of the other hand under the chin.

Conscious	Unconscious
Inspect the mouth and remove secretions.	Open the airway with slight head tilt and chin lift.
Let the infant assume a position of maximum comfort.	Inspect the mouth and remove secretions.
Give oxygen.	Check if manoeuvre has improved air entry by looking at the chest.
Continue assessment.	If not, insert airway.

Insertion of an Oropharyngeal (Guedel) Airway

The oropharyngeal or Guedel airway can be used in an unconscious infant to improve airway opening. It may not be tolerated in a patient who is awake and may induce choking or vomiting. Guedel airways come in different sizes; an appropriately sized airway goes from the angle of the mouth to the angle of the jaw when laid on the face with the convex side up.

Insert an oropharyngeal airway in an infant, convex side up.

Select an appropriately sized airway.
Position the child to open the airway.
Insert the oropharyngeal airway the convex side up.
Re-check airway opening.
Use a different sized airway or reposition if necessary.

B. Breathing

Does the child have Severe Respiratory Distress?

Is there difficulty in breathing while breastfeeding? Is the baby breathing very fast, has severe lower chest wall in-drawing, or using the accessory muscles for breathing which cause the head to nod with every inspiration? Are there any abnormal noises heard when breathing? A short noise when breathing out in young infants is called grunting. Grunting is a sign of severe respiratory distress.

Signs of severe respiratory distress:

Grunting
Head nodding
Respiratory rate >60/min
Severe lower chest in-drawing
Apnoeic spells
Unable to feed due to respiratory distress
Cyanosis

Giving oxygen to a baby with respiratory distress.

A baby with severe respiratory distress should be allowed to take a comfortable position of his choice and should be given oxygen. Oxygen may be provided with a catheter or prongs. If the baby’s breathing difficulty worsens or the baby has central cyanosis while on catheter or prongs: add oxygen at a high flow rate via a face mask (4 litres/min), if available.

Management of airway in a child with gasping or who has just stopped breathing.

If the baby is not breathing, you need to manage the airway and support the breathing with a bag and mask.

Ventilate with bag and mask (BMV).

If the child is not breathing even after the above manoeuvres or spontaneous ventilation is inadequate (as judged by insufficient chest movements and inadequate breath sounds), ventilate with a self-inflating bag and mask.
During bag and mask ventilation, it may be necessary to move the baby’s head and neck gently through a range of positions to determine the optimum position for airway patency and effectiveness of ventilation. A neutral position without hyperextension of the neck is usually appropriate for infants.
Infants may need padding under the shoulders to prevent excessive flexion of the neck that occurs when their prominent occiput rests on the surface on which the child lies.

Padding for an infant to maintain a patent airway.

Neutral position to open the airway in an infant.

Call for help in any child who needs Bag and Mask Ventilation (BMV) since some of these infants may additionally need chest compression.

After five effective ventilations, check the pulse (femoral) for 10 seconds. If pulse is absent, the second person should start chest compression.

C. Chest Compressions (as in neonatal resuscitation)

Note: while it is often possible to resuscitate a baby who has stopped breathing but still has a good heart beat, i.e., a respiratory arrest, it is almost never possible to resuscitate a baby whose heart has stopped, i.e., a cardiorespiratory arrest.

Chest compressions are done as in neonates. One cycle will consist of 15 compressions plus 2 ventilation breaths.

Algorithm: Emergency assessment and management of NYI airway and breathing

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E 1 Suction Machine (Pump)

A suction machine is life-saving equipment which is often needed in resuscitation of the young infant. See the equipment chapter on suction machine for more information.