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Referral and warning signs
When to refer
URGENT REFERRAL TO HOSPITAL for ANY newborn/young infant with ANY danger sign.
Red flags
- Any of the listed danger signs constitutes a red flag.
Signs and symptoms
- Danger Signs (Check ALL newborns/young infants):
- - History of Convulsions.
- - Frequent heavy vomiting.
- - Not feeding well / Stopped feeding well / Unable to breastfeed.
- - Respiratory rate < 30 or >= 60 breaths/minute.
- - Severe chest indrawing.
- - Grunting / Gasping / Cyanosis.
- - Fever (>37.5°C) or feels hot.
- - Hypothermia (<35.5°C) or feels cold (despite warming).
- - Movement only when stimulated or no movement at all (lethargy/unconscious).
- - Floppy or stiff body.
- - Bulging fontanelle.
- - Umbilicus draining pus WITH redness extending to skin.
- - Skin pustules >= 10 OR any bullae OR skin swelling/hardness.
- - Bleeding from stump or cut.
- - Signs of Tetanus (difficulty feeding, rigidity, spasms, lock jaw - see Infectious Diseases).
- - Pallor (severe).
- - Abdominal overdistension.
- - Heart rate constantly > 180 bpm.
Risk factors
- Prematurity / Low Birth Weight.
- Difficult delivery / Birth asphyxia.
- Maternal infection (chorioamnionitis, PROM >18h, maternal fever).
- Unclean delivery / Cord care practices.
- Lack of immunization (maternal tetanus).
Diagnosis
Clinical assessment
Based on asking about key symptoms (convulsions, feeding) and looking/listening/feeling for the listed danger signs. Any single danger sign classifies as Possible Serious Illness / Very Severe Disease.
Investigations
- Assess breathing (rate, effort).
- Assess temperature.
- Assess activity level/tone.
- Examine umbilicus, skin.
- Assess feeding.
- Further investigations at referral center (Blood culture, CRP, LP, CXR etc).
Diagnostic criteria
Presence of ANY listed danger sign in a newborn (0-7 days) or young infant (up to 2 months).
Management
Non-pharmacological management
- Immediate Actions:
- - Ensure Airway, Breathing, Circulation (Basic resuscitation if needed).
- - Keep baby warm (KMC, incubator, wrap well).
- - Prevent low blood sugar: Offer breastfeed if able; if not, give expressed breast milk (EBM) or sugar water (1 tsp sugar in 50ml water) via cup/NGT.
- - Position correctly if unconscious (recovery position).
- - Urgent Referral to Hospital. Advise mother on keeping baby warm during transport.
Pharmacological treatment
- Pre-referral Antibiotics (Give FIRST dose):
- - Ampicillin 50 mg/kg IM
- - PLUS Gentamicin:
- - Age < 7 days or preterm: 5 mg/kg IM once daily.
- - Age >= 7 days (term): 7.5 mg/kg IM once daily.
- - (Alternative at HC2 if Amp/Gent unavailable: Benzylpenicillin 50,000 IU/kg IM single dose).
- If referral not possible (Continue treatment for 7 days MINIMUM):
- - Ampicillin: Q12H if <7 days, Q8H if >7 days.
- - Gentamicin: Once daily as above.
- If Staphylococcal risk (multiple pustules, umbilical sepsis):
- - Cloxacillin 50 mg/kg IV/IM Q6H
- - PLUS Gentamicin (as above).
- If Convulsing: Rectal Diazepam 0.5 mg/kg (See Emergencies/Neurology).
Monitoring
Closely monitor vital signs, temperature, feeding, activity level pending referral or during treatment if referral impossible.
Complications
- Sepsis (See ID chapter)
- Meningitis (See ID chapter)
- Pneumonia (See Resp chapter)
- Neonatal Tetanus (See ID chapter)
- Death
- Long-term neurodevelopmental impairment.
Prevention
- Antenatal care.
- Clean delivery practices.
- Clean cord care.
- Maternal tetanus immunization.
- Early initiation of breastfeeding.
- Kangaroo Mother Care.
- Prompt recognition and treatment of maternal infections.
Patient education
- Teach mother/caregiver to recognize ALL danger signs.
- Emphasize the need for IMMEDIATE care seeking if any danger sign appears.
- Importance of keeping the baby warm.
- How to give expressed breast milk if needed.
- Importance of completing antibiotics if referral impossible.
Uganda-specific notes
Neonatal sepsis and meningitis are major causes of mortality. Early recognition of danger signs and prompt initiation of pre-referral antibiotics (Ampicillin + Gentamicin) is critical. Tetanus still occurs. Access to hospital-level neonatal care is limited in many areas.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.1.1 (Danger signs list), 17.2.1 (Classification/Treatment)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Sections 2.1.7.1 (Sepsis), 2.1.5.1 (Meningitis), 2.1.8.1 (Tetanus)