SARDAR PATEL COLLEGE OF NURSING,

LUCKNOW

SUB: CHILD HEALTH NURSING I & II

MODULE

ON

ESSENTIAL NEWBORN CARE (ENBC)

&

FACILITY BASED NEWBORN CARE (FBNC)

ENROLLMENT NO.

ROLL NO.

SUBJECT CO-ORDINATOR PRINCIPAL

 INTERNAL EXAMINER EXTERNAL EXAMINER

SARDAR PATEL COLLEGE OF NURSING,

LUCKNOW

SUB: CHILD HEALTH NURSING I & II

MODULE

ON

FACILITY BASED NEWBORN CARE (FBNC)

&

FACILITY BASED NEWBORN CARE (FBNC)

TOPIC:

ENROLLMENT NO.

SUBMITTED TO SUBMITTED BY
 SUBMITTED ON

Index
S.No. Content Page.no.
 Acknowledgment

I take this opportunity to express my sincere gratitude to all those who have contributed to the preparation
of this module on Essential Newborn Care (ENBC) and Facility Based Newborn Care (FBNC) for the
B.Sc. Nursing 6th Semester.

First and foremost, I am deeply thankful to the Indian Nursing Council (INC) for providing the guidelines
and curriculum framework that served as the foundation for developing this module. My heartfelt thanks
to the Principal, Mr. M Suresh and faculty members of the Sardar Patel College of Nursing, Lucknow for
their continuous guidance, encouragement, and valuable suggestions throughout the preparation process.

I extend my special appreciation to Ms. Anchal Yadav, Assistant Professor, Department of Child Health
Nursing, SPCON, Lucknow, for her academic support, expert inputs, and constructive feedback that
enriched the content of this module.

I am also grateful to my classmates and peers for their cooperation and motivation, which inspired me to
complete this work with dedication.

Lastly, I acknowledge the contribution of all reference books, journals, and online resources that provided
relevant information in developing a comprehensive and evidence-based module.

This module has been prepared with the objective of facilitating effective teaching and learning for
nursing students, and I sincerely hope it will serve as a valuable resource in enhancing my knowledge and
skills in newborn care.
Care Of At Risk
Neonates
 Introduction: Care of At-Risk Neonates

Neonatal care is a critical aspect of pediatric and maternal healthcare, especially when dealing with at-risk
neonates—newborns who face increased vulnerability due to factors such as prematurity, low birth
weight, congenital anomalies, birth asphyxia, or maternal health complications. These infants require
specialized and often intensive medical attention to survive and thrive during the first crucial days and
weeks of life.With advancements in neonatal medicine and technology, survival rates of at-risk neonates
have significantly improved; however, these gains demand not only technological support but also a
skilled, multidisciplinary team capable of providing individualized care. Early identification, continuous
monitoring, and prompt interventions are essential in preventing complications and improving long-term
outcomes.The care of at-risk neonates involves a holistic approach that addresses physiological stability,
nutritional needs, thermoregulation, infection prevention, and family-centered support. This introduction
sets the stage for exploring the principles, practices, and challenges involved in the care of these
vulnerable newborns.
LEARNING OBJECTIVES:

At the end of this session, participants will be able to:

 Teach the mother how to look after her baby and what to do if her baby has any health problems

 Identify and manage at-risk and sick neonates

CARE OF AT-RISK NEONATES

1. WHO IS AN 'AT-RISK' NEONATE?

An 'at-risk' neonate has one or more of the following features:
1. Weight 1500-2499g
2. Temperature (axillary) 36.0°C-36.4°C
3. Babies with moderate or severe hypothermia who respond to warming
4. Cried late (>1min) but within
5 minutes of birth
5. Sucking poor, but not absent
6. Depressed sensorium, but is arousable
7. Respiratory rate of over 60 per minute, but no chest retractions
8. Jaundice present, but no staining of palms/soles
9. Presence of any one of the following:
- Diarrhea or vomiting or abdominal distension
- Umbilicus draining pus or pustules on skin
- Fever
 Incidence Rate In India

Key statistics:
(Neonatal mortality rates for India, major states and groups of states, by urban (panel A) and rural (panel B) sub-populations,
1981 to 2011.)
1. Preterm births (prematurity)

 In 2019–21, approximately 12% of live births in india were preterm (born before 37 weeks), and
18% had low birth weight pmc.
 This reflects a sharp rise from around 2.1% in 2005–06 to 12.34% in 2019–21, based on nfhs
data springerlink.
 A who-linked report (2010 data) estimated that india had around 3.5 million preterm births
annually—roughly 1 in 10 births, contributing to one of the highest counts of preterm birth-
related deaths globally the hindumedical dialogues.

 A report from the times of india states that in 2020,(data is till 2011) india recorded over 3
million preterm births—about 9.9% of all births—i.e. Nearly 1 in 10 infants the times of india.

Summary: preterm birth in india ranges broadly from ~10% to 12% of live births, depending on the data
source and timeframe.
2. Small vulnerable newborns (svn)

This includes babies who are preterm, small for gestational age, or low birth weight. In one north-india
cohort study:

 48.4% of newborns fell under the svn category:

o 35.1% were term-sga
o 9.7% preterm-non-sga
o 3.6% preterm-sga pubmed
3. Low birth weight (lbw)

 Lbw prevalence was around 18% nationwide during 2019–21 pmc.

 In a specific study from northern india, the overall lbw incidence was 13.26% (ranged from ~11%
to ~14.5% over 2018–2020) lippincott journals.

4. Other key risks

 One hospital-based study in kerala (early 2000s) noted a neonatal hypoglycemia incidence of 41
per 1,000 live births (or 4.1%) pubmed.

At-Risk Neonate Incidence at a Glance

Risk factor Incience in india
 Preterm birth  ~10% to 12% of live births
 Low Birth Weight (LBW)  ~13% (some studies as high as 18%)
 Small Vulnerable Newborns (SVN)  ~48% (in one North-India cohort)
 Neonatal Hypoglycemia  ~4.1% (hospital-based data)

Context and takeaways

 Preterm births are a major concern, forming a significant portion of neonatal risk—studies show
wide-ranging prevalence, but generally around 1 in 10 births.
 Low birth weight is another pervasive risk factor, affecting around 1 in 8–9 newborns
nationally.
 The svn category, combining multiple risk indicators, shows nearly half of babies in high-risk
care settings are vulnerable, though this prevalence may be cohort-specific.
 Other conditions like neonatal hypoglycemia also add to the vulnerability landscape.

2. CARE OF AT-RISK NEONATES

2.1 Where should an at-risk neonate be managed?

 The care of 'at-risk' neonate should be initiated at the health facility itself under direct supervision.
After initial improvement, further care can be provided at home.

2.2 What care is provided to the at-risk baby at the health facility?

 The care of at-risk babies is outlined below:

2.2.1 Warmth

The steps are dependent up on the current temperature of the baby

 Temperature Management
Normal Prevent hypothermia
Temperature  Wrap the baby in layers of clothing
 Cover the head and limbs
 Place the baby in direct contact with mother
 In winter months, the room may have to be
warmed with heater, angeethi etc
Cold Stress Treat hypothermia
(Temperature Between 36.0°C And 36.4°C)  Wrap the baby with extra layers of clothing
 Cover the head and limbs
 Place the baby in close contact with the
mother, preferably skin-to-skin
 In winter months, heat the room with a heater,
angeethi etc.
Hypothermia  Requires immediate exposure to a radiant
(Temperature <36.0°C) heat source (such as radiant warmer) or
heater.
 Other measures same as for cold stress
 2.2.2. Stabilization

 Most of these babies do not require stabilization other than prevention for hypothermia as above. If there is
occasional apnea, physical stimulation may be provided.

2.2.3 Feeds

 Feeding of at-risk infants is explained in another module (Refer to the module on 'Feeding of normal and
low birth weight baby).
 The baby is started on direct breast feeding. If not sucking well, she is provided expressed breast milk by
spoon or paladai. Occasionally, expressed breast milk may have to be given by gavage feeding.

2.2.4 Specific therapy

 Some simple conditions can be readily treated at the health facility and later at home.

Condition Treatment
Umbilical Redness/Pus Discharge  Local application of 1% gentian violet and
syrup cotrimoxazole 1/3 tsf BDX5days
Skin Pustules  Local application of 1% gentian violet
Pneumonia (Respiratory  Syr Cotrimoxazole 1/3 tsf BD x 7 days (or
Rate >60/Min, No Chest syrup Amoxycillin 1.25ml TDSx7days)
Retractions)

2.2.5 Monitoring

 The following signs should be monitored every two hours:

Signs to be monitored
 Temperature  Convulsion
 Sucking  Bleeding
 Sensorium  Diarrhea
 Respiration  Vomiting
 Apnea  Abdominal distension
 Cyanosis

All the signs should be monitored 2 hourly

 2.2.6 Re-evaluation

 After stabilization and/or specific therapy, the baby has to be re-evaluated for improvement.
 The two cardinal signs of improvement are:
i. The temperature will become normal (36.5°C -37.5°C) and
ii. The baby will accept feeds well.
o Other signs such as rapid breathing, depressed sensorium, abdominal distention etc. will also start
improving. Such a baby can be sent home after advising the mother/family regarding care at home.
Prepare a brief note regarding baby's condition, treatment and advice.
o On the other hand, if the baby does not improve and exhibits signs indicative of sick state, he
should be referred to other hospital. The mother/family should be taken into confidence and the
physician should organize efficient and stable transport of the baby

2.2.7 Communication

o Communication with the family, especially the mother is very important during the management of
at-risk and sick neonates. Health workers should inform the mother frequently regarding the baby's
condition - whether it is improving or not. If the condition improves, the family has to be
reassured; mother should be explained about the care of the baby at home. A note has to be made
regarding the baby's condition and care
o Communication with the family, especially the mother is very important during the management of
at-risk and sick neonates. Health workers should inform the mother frequently regarding the baby's
condition - whether it is improving or not. If the condition improves, the family has to be
reassured; mother should be explained about the care of the baby at home. A note has to be made
regarding the baby's condition and care

Communication with the family

1. Reassure the mother and family.
2. Prepare a note regarding baby's condition and care.
3. If baby improves and is to be sent home, explain care of the baby at home.
4. If baby does not improve or worsens, explain the need for referral and care during transport
3. FOLLOW - UP

3.1 Advice about follow-up visits

 Mother has to be advised regarding the time of follow-up visit, whether the baby is referred or sent home
(See table).
 As we can see from the table, one visit by the health worker at home is a must after discharge. This
improves the relationship between the family and the health worker and also leads to better understanding
of the home environment

Condition Time of follow-up visit

If sent home Health worker: to visit next day
Mother (with the baby): to be called after two and
seven days
If referred Health worker: to visit one day after discharge from
hospital
Mother (with the baby): to be called after two and
seven days of discharge from hospital
3.2 What advice should you give to mother and family regarding home care?

3.2.1. Keep the baby warm

 Baby should be kept well clothed taking care to cover the head and limbs. He should be dried
quickly if urine or stool is passed. Maternal contact, preferably skin to skin should be practiced.
This not only provides warmth from mother's body, but also promotes lactation and close mother-
baby bonding. Warming of the room with heater or angeethi may be required in winter. Baby
should be bathed only when the weight of the baby is over 2000g and that also if the baby has no
other features that characterize him at-risk. Bathing an 'at-risk' baby may aggravate his condition
severely.
3.2.2. Provide exclusive breast milk feeding

 Baby should be provided only breast milk. Often an at-risk baby can suck adequately on the
breasts. Some babies, however, may not suck well for a few days. These babies may be provided
expressed breast milk by spoon/paladai. It should be emphasized that baby must be put on the
breast first, to provide stimulus for lactation. This should be followed by expression of breast milk
and assisted feeding with spoon or paladai. The mother should be explained the method of manual
expression of breast milk and feeding with spoon.

3.2.3. Continue the prescribed treatment

 If the baby has been advised local gentian violet application on the cord for umbilical sepsis or on
skin for pustules, that advice should be followed at home also. Babies prescribed oral
cotrimoxazole for mild pneumonia should be administered the medication regularly.

3.2.4. Observe progress of baby

 The mother / family should be explained that signs of well being of the 'at-risk' neonate are:
(i) the baby accepts feeds well and
(ii) (s)he has warm trunk, warm and pink soles and palms.
The baby should also be monitored for any danger signs described above.
In case any of these features are present or persistent or have reappeared, the baby should
be re-evaluated without delay.

3.2.5. Counsel and educate the mother and family

 The doctor & nurses team should explain the condition of the baby to the mother and the family.
They should be reassured and educated regarding the care at home. Emphasis should be laid on
keeping a careful vigil for signs of improvement and of worsening. It should be stressed upon them
that a baby may require re-evaluation any time if the progress is not satisfactory or if there is
worsening. Above all, the health care provider must encourage the mother/family to gain
confidence in looking after the baby.
 Understanding Risk Factors and Classifications

At-risk neonates can be classified based on a variety of risk factors that influence their health outcomes.
Common classifications include preterm neonates (born before 37 weeks of gestation), low birth weight
infants (weighing less than 2,500 grams), and neonates with intrauterine growth restriction (IUGR).
Additionally, maternal conditions such as diabetes, hypertension, infections, and substance abuse during
pregnancy can contribute to neonatal risk. Birth-related complications, including prolonged labor,
premature rupture of membranes, and birth asphyxia, also play a significant role. Early recognition of
these risk factors is crucial for initiating timely interventions and ensuring appropriate levels of care,
whether in a neonatal intensive care unit (NICU) or through enhanced monitoring in a postnatal ward.
3.2.6. Follow-up

 A home visit by the health worker one day after evaluation at hospital is desirable. Thereafter the
baby should be seen again after 2 and 7 days by health worker. At follow up baby's weight should
be taken. A gain of 10-15 g/kg per day is expected after 7 to 10 days of age. Immunization should
be provided as for other neonates.
 Summary

The care of an at-risk neonate involves early identification and close monitoring of newborns who are more likely
to develop complications due to maternal conditions (such as diabetes or infections), prematurity, low birth
weight, birth trauma, or perinatal distress. Immediate priorities include maintaining warmth, supporting airway,
breathing, and circulation, and monitoring vital signs, blood glucose, and feeding tolerance. These infants may
require specialized care in a neonatal intensive care unit (NICU), particularly if they have respiratory distress,
infections, or feeding issues. Preventing infection through hygiene, supporting breastfeeding, and involving
parents in care are essential. Discharge planning should ensure the neonate is stable, feeding well, gaining weight,
and scheduled for appropriate follow-up and immunizations
 Conclusion
In conclusion, the care of at-risk neonates requires prompt recognition, vigilant monitoring, and a
multidisciplinary approach to address their unique physiological vulnerabilities. Ensuring thermal
stability, adequate nutrition, respiratory support, and infection prevention are critical components of care.
Early intervention and parental involvement not only improve immediate outcomes but also contribute to
the long-term health and development of these vulnerable newborns.
 Bibliography

Books:
 Sharma rimple, “essential pediaric nursing” , 3rd edition, jaypee publication

New delhi, india page no. 48-56

 Sasmal swashri, “textbook of child health nursing 1st edition” , UHS publication

Raipur, page no. 41-59

 Vinod k paul, Arvind sumit, “essential pediartic 10th edition” CBS publication

And distribution private limited page no. 26-35

Websites:
https://www.aap.org
https://www.pediatrics.theclinics.com