Triage of Newborn

1. INTRODUCTION

• Definition: Triage is the process of rapidly screening sick newborns upon arrival to identify those with life-threatening conditions requiring immediate resuscitation versus those who can wait for detailed assessment.
• Goal: To prioritize treatment and reduce the "Golden Hour" delay, thereby decreasing neonatal mortality.
• Setting: Triage takes place in the Reception Area of the Special Care Newborn Unit (SCNU) immediately upon arrival.

2. STEPS OF TRIAGE (FBNC GUIDELINES)

The triage process follows a hierarchical approach: RAPID ASSESSMENT $\to$ CLASSIFICATION $\to$ IMMEDIATE MANAGEMENT.

Step 1: Rapid Assessment (The "ABCD" Approach)

Performed within seconds of arrival. Do not move to the next step until the previous one is cleared.

1. A & B (Airway & Breathing):
   • Is the baby breathing?
   • Is there gasping or apnea?
   • Is there central cyanosis?
   • Is there severe respiratory distress?
2. C (Circulation):
   • Are hands and feet cold?
   • Is Capillary Refill Time (CFT) > 3 seconds?
   • Is the pulse weak or fast (>160/min)?
3. C (Coma/Convulsions):
   • Is the baby convulsing now?
   • Is the baby lethargic or unconscious (no movement on stimulation)?
4. D (Dehydration):
   • Skin turgor, sunken eyes (mostly for older neonates/post-discharge).
5. T (Temperature):
   • Touch for Hypothermia (cold abdomen) or Fever.

Step 2: Classification

Based on the assessment, the newborn is classified into one of three categories:

3. DETAILED SIGNS & MANAGEMENT (FBNC/IMNCI)

A. CATEGORY I: EMERGENCY SIGNS (Requires Immediate Resuscitation)

If ANY of the following are present:

1. Gasping or Not Breathing:
   • Action: Position airway, suction (if needed), start Bag & Mask Ventilation (BMV).
2. Central Cyanosis:
   • Action: Administer free-flow oxygen; check SpO2.
3. Shock (Cold periphery + CFT >3s + Weak pulse):
   • Action: Provide warmth. Secure IV access. Normal Saline Bolus (10 mL/kg).
4. Hypothermia (Severe):
   • Action: Place under radiant warmer immediately.
5. Active Convulsions:
   • Action: Check Blood Glucose. Administer Phenobarbitone (20 mg/kg) or Dextrose (2 mL/kg of 10% D) if hypoglycemic.

B. CATEGORY II: PRIORITY SIGNS (Requires Urgent Assessment)

Admit and assess immediately after Emergency cases are stabilized.

1. Tiny Baby: Birth weight < 1500g or Preterm < 32 weeks.
2. Temperature Instability: Cold to touch (36–36.4°C) or Fever (> 37.5°C).
3. Respiratory Distress: RR > 60/min, Grunting, Chest Indrawing (without cyanosis/apnea).
4. Severe Jaundice: Visible on palms/soles or < 24 hours of age.
5. Bleeding: From any site (umbilical, GI, skin).
6. Abdominal Distension: Significant distension with vomiting.
7. Major Congenital Malformations: Meningomyelocele, Omphalocele, Gastroschisis.

C. ADMISSION CRITERIA (FBNC Guidelines)

While triage prioritizes, the following specific criteria mandate admission to SCNU:

1. Birth Weight < 1800g or Gestation < 34 weeks.
2. Severe Respiratory Distress (RR >60 + retractions/grunting).
3. Perinatal Asphyxia (Apgar <5 at 5 mins or need for PPV >1 min).
4. Sepsis: Symptomatic or high-risk screen.
5. Jaundice: Requiring phototherapy or exchange transfusion.
6. Major Malformations requiring surgical or medical support.
7. Refusal to Feed or inability to suck.

4. IMNCI INTEGRATION (THE "YOUNG INFANT" 0-2 MONTHS)

IMNCI guidelines are used for screening and referral. In the triage setting, "Pink/Red" classification confirms the need for admission.

7 Signs of POSSIBLE SERIOUS BACTERIAL INFECTION (PSBI):

1. Convulsions: History of or active.
2. Fast Breathing: RR $\ge$ 60 bpm.
3. Severe Chest Indrawing.
4. Nasal Flaring / Grunting.
5. Movement: No movement or movement only on stimulation.
6. Fever: Temp $\ge$ 37.5°C.
7. Hypothermia: Temp < 35.5°C.

• Umbilical Infection: Redness extending to skin.
• Skin Pustules: Many or severe.
• Feeding: Not able to feed or stopped feeding well.

IMNCI Color Coded Triage:

• PINK (Severe Disease): Any PSBI sign $\to$ Admit to SCNU.
• YELLOW (Local Infection): Pus from umbilicus/eyes $\to$ OPD management/Home care.
• GREEN (Not Sick): Routine care.

5. INITIAL STABILIZATION AT ADMISSION ("S.T.A.B.L.E.")

Once triaged and decision to admit is made, stabilize using the STABLE framework before shifting to the specific bed.

1. S - Sugar: Screen for hypoglycemia (< 45 mg/dL). Treat with 2 mL/kg 10% Dextrose if low.
2. T - Temperature: Place under radiant warmer. Goal: 36.5–37.5°C.
3. A - Airway: Position head, clear secretions, support breathing (O2/CPAP).
4. B - Blood Pressure (Perfusion): Check CFT. Give NS bolus if shock is present.
5. L - Lab work: Septic screen, Glucose, Calcium, Bilirubin.
6. E - Emotional Support: Inform parents about the condition and admission plan.

6. INFECTION CONTROL DURING TRIAGE

• Hand Hygiene: Essential before touching the baby.
• Isolation: Babies with obvious contagious infections (e.g., skin abscesses, diarrhea) should be triaged to the Isolation Room or designated septic area immediately to prevent cross-contamination.