Cardiovascular

The cardiovascular chapter focuses on signs of shock—when cardiac output cannot meet the oxygen and energy requirements of vital organs—central cyanosis, and cardiac arrythmia. It identifies and prioritizes the need for immediate stabilization, cardiorespiratory support, and management. Stabilization includes clinical assessment of circulation, pulse oximetry, and determining whether cyanosis can respond to oxygen. The difference between cyanosis of cardiac and respiratory origins is explained and illustrated, along with implications for diagnosis and treatment. Anatomical abnormalities of the heart and abnormal heart rhythms are considered separately. Specific conditions are described and illustrated: hypoplastic left heart syndrome, coarctation of the aorta, persistent pulmonary hypertension of the newborn, cyanotic heart disease, transposition of the great arteries, tricuspid atresia, and total anomalous pulmonary venous return. Related procedures and treatment modalities (e.g., volume expansion, prostaglandin E1, transfusion, or intravenous antibiotics for suspected sepsis) are described. Three case scenarios highlight differences between shock and circulatory instability without shock.

Jaundice

The jaundice chapter illustrates how to stabilize newborns with hyperbilirubinemia—a common condition—and avoid their developing severe hyperbilirubinemia. Prevention is accomplished by transcutaneous bilirubin testing, total serum bilirubintests, and the use of nomograms to evaluate risk for hyperbilirubinemia and direct appropriate care. Specific risk factors for jaundice and hyperbilirubinemia, treatment thresholds for phototherapy treatment or exchange transfusion, and a bilirubin-induced neurological dysfunction scoring tool for assessing severity in acute bilirubin encephalopathy cases are included. Related procedures, such as the direct antiglobulin test, volume expansion, and intravenous immunoglobulin administration are described. Focal skills, such as plotting and interpreting the nomograms, are applied in the case scenario.

Transition

The transition chapter describes the physiological changes that occur during every newborn’s transition from intrauterine to extrauterine life. Understanding this complex and intensive process of adaptation in the human life cycle is essential for understanding ACoRN’s approach to stabilization. Transition is examined systemically—from respiratory, cardiovascular, neurobehavioural, feeding, glycemic, renal, hepatic, thermal, and immunological perspectives. Some aspects of transition occur at birth (e.g., the separation of the placenta, onset of breathing, and the switch from fetal to neonatal circulation). Cardiorespiratory, neurological, glycemic, and thermal adaptations occur within minutes, as extra-uterine life begins. Endocrine, metabolic, and immunological adaptations unfold over several hours and days. Signs and symptoms of problems during transition are discussed in ‘learning points’, along with clinical implications for stabilization. Review questions and answers are included.

Fluid and Glucose

The fluid and glucose chapter focuses primarily on unwell newborns who need early blood glucose monitoring for hypoglycemia and immediate stabilization with intravenous dextrose solution. But infants can be at risk for low blood glucose for many reasons, and they too need specific attention and care, even when they are not symptomatic. Oral doses of dextrose gel may help to raise blood glucose levels, which also depend on whether an infant cannot feed or should not be fed (for any reason) and response to supplementation or managed oral feeding. Guidance includes glucose thresholds to aim for, determined by postnatal age, and testing intervals to expedite the normalization of blood glucose values. How to assess, measure, and anticipate fluid requirements in at-risk infants is explained in detail, and risks for hypoglycaemia, dehydration, and overhydration are considered. Two case scenarios examine different hypoglycaemia risks.

Support

Support is the final ACoRN chapter because it is an overarching component of stabilization. The chapter emphasizes that infants experience stress and pain and discusses how to recognize signs of and provide strategies to relieve infant stress and pain. Supportive care begins at first contact with an infant and family and ends with a health care team debrief following difficult cases. Support includes recognizing, anticipating, and minimizing infant pain and stress, family-centred care, and team-based learning from experience. Environmental and developmentally supportive care strategies for newborns are described, along with approaches for supporting parents and transitioning from active to palliative care. Debriefing tools and a case scenario are included.

Infection

The infection chapter captures all the clinical indicators of possible neonatal infection that appear as Alerting Signs (marked with an asterisk [*]) in almost every ACoRN Sequence. Infection signs require appropriate response and follow-up, but these and associated risk factors for infection are now evaluated as ‘higher risk’ (red flags) or ‘lower risk’ (non-red flags) in the Infection Assessment Table. Care and treatment of suspected infections, including early antibiotics while awaiting cultures, are determined by the presence and number of red flags and non-red flags. The presence of two or more non-red flags heightens risk for sepsis in the newborn, an often subtle condition which impacts stabilization across multiple systems. Diagnostic tests to determine infection site and causative organism are described and evaluated. Close observation and frequent reassessment of infant status using the ACoRN Primary Survey and Sequences are recommended. Two case scenarios compare respiratory distress risk for infection.

Neurology

The neurology chapter examines mild, transient, and more serious, underlying neurological conditions that present in the newborn period. Abnormalities of tone, activity, alertness, and movements (i.e., seizures) can occur in many neonatal conditions, some of which require immediate intervention. Assessments include testing infant tone and reflexes, the Encephalopathy Assessment Table, distinguishing jitteriness from seizure activity, and identifying seizure characteristics. Early identification of infants with hypoxic ischemic encephalopathy—a primary cause of neonatal encephalopathy—is essential and should prompt either thermoregulatory management (strict normothermia) or therapeutic hypothermia, providing specific criteria are met. Symptomatic hypoglycemia can have long-term neurodevelopmental consequences and must be treated emergently with intravenous dextrose solution. Anticonvulsant therapy should be initiated for seizures, even when the underlying cause is not yet determined. Diagnostic testing and differential diagnoses, such as neonatal abstinence syndrome or neonatal opiate withdrawal are considered. Three case scenarios follow care pathways for two unwell infants.

Thermoregulation

The thermoregulation chapter focuses on care for infants in a controlled thermal environment while maintaining their body temperature within normal range. All newborns are at risk for temperature instability, and stabilization means providing an optimal neutral thermal care environment by minimizing and managing factors that cause cold and heat stress. The effect of infection on infant temperature is also considered. Axillary temperature thresholds, infant risk factors for hypothermia and hyperthermia, and specific strategies to prevent both heat loss and overheating are discussed. Recommendations for care of infants at risk for hypoxic ischemic encephalopathy, described in the neurology chapter and included in the Thermoregulation Sequence, determine whether therapeutic hypothermia or strict normothermia is the appropriate treatment course. Thermal management principles are applied in the case scenario.

Transport

The transport chapter focuses on factors that determine the decision to transport a sick infant for higher level care and preparing the infant for transfer. How the transport system works and the responsibilities of those involved are described. Specifically, the chapter describes the information needed by the receiving hospital and clarifies the roles of the sending hospital, the receiving physician, coordinating physician, and the transport team. Tools to aid decision-making (e.g., the Situation/Background/Assessment/Recommendation/Readback-Response communication tool) and process (the NICU telephone consultation form and a sample neonatal transfer record) are included. A case scenario, which rounds out the chapter, provides a scenario in which a decision whether or not to transport must be made.

The ACoRN Process

The ACoRN process chapter shows how ACoRN works, step by step. ACoRN’s goal is to identify and manage the unwell or at-risk newborn at, or very soon after, birth or resuscitation. Nine key steps in the ACoRN process are explained, assessing the requirement for resuscitation, followed by 8 systems-based chapters and Sequences (a system-based algorithm for care): respiratory, cardiovascular, neurology, surgical conditions, fluid and glucose, jaundice, thermoregulation, and infection. The ACoRN mnemonic determines the structure of the chapter: alerting signs, core steps, organization of care, response, next steps, and specific diagnosis and management. Essential components, such as the ACoRN Primary Survey, the Sequence, the prioritized Problem List, and the Level of Risk, are described. Diagrams and examples illustrate this process, and the first case scenario shows when and why stabilization should be initiated.