1. Clinical Monitoring of
Hospitalized New Born
Dr. L S Deshmukh
MD,Dip.NB,DM (Neonatology)
Heinz Fellow,
Royal College of Pediatrics &
Child Health, London,
eMail
:lsdesmukh@indiatimes.com

2. 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

3. 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.

4. 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.

5. Who should monitor ?
•
•
•
•
Trained nurse (Adequate number essential)
Doctors (senior / junior)
During transport, nurse / doctor
Role of mother - supportive

6. 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.

7. Whom to monitor ?
* Some monitoring for all
neonates
* During first 8 hours
(transition), in all babies.
* For longer period in high
risk neonates.

8. Instruments to monitor
Open eyes
Open ears
Alert
Brain
Warm hands
Taste

9. Instruments to monitor

10. “The eye of the master will do
more work than both his hands”
- Benjamin Franklin

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

12. Clinical Monitoring – Vital Signs
Temperature :
• 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

13. Site for Temperature Monitoring
Site
Surface
1. Abdomen
2. Axillary
Rate [°C]
Application
36.0-36.5
36.5-37.0
Servo control
Noninvasive
Approx of core temp
Core
1. Sublingual 36.5-37.5
2.
Esophageal 36.5-37.5
3.
Rectal
36.5-37.5
Quick reflection of
body change
Reliable reflection of
Changes
Slow reflection of
Changes

14. 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.

15. Clinical Monitoring – Vital Signs
Heart 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

16. Clinical Monitoring – Vital
Signs :
Respiration
•
•
•
•
•
•
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

17. Clinical Monitoring – Vital Signs
Blood Pressure
• Various techniques
• Invasive / noninvasive
• Flush blood pressure
- Gives mean pressure
- Lower than direct
• Important elements for accuracy
1. Quiet infant
2. Proper cuff size (50-67% of arm
length)
•
Small cuff – BP higher, Large cuff –
BP lower

18. Clinical Monitoring – Vital Signs
Blood 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.

19. Clinical Monitoring – Vital Signs
Colour :
• 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

20. 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

21. Clinical Monitoring – Vital Signs
Activity :
• Good – reassuring
• Lethargic / irritable – Search for cause
• Seizure activity – CNS disorder
Important : State of the baby and feeding

22. Listen to the cry

23. 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

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

26. Stool- Normal pattern

27. 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.

28. Measure Wt.
& Length
accurately

29. Monitor & plot daily wt.

30. Record of identity

31. 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.

32. The Technology Should
Supplement Rather Than
Replace the Traditional Tools

33. Who is monitoring monitor?