Patient selection: neonate > 35 weeks gestation
Parameters:
(1) body temperature in °C
(2) heart rate in beats per minute
(3) respiratory rate in breaths per minute
(4) respiratory distress
(5) consciousness
(6) pre-feed blood sugar in mmol/L
|
Parameter
|
Finding
|
Points
|
|
body temperature in °C
|
> 38.0°C
|
2
|
|
|
37.5 to 38.0
|
1
|
|
|
36.5 to 37.4
|
0
|
|
|
36.0 to 36.4
|
special
|
|
|
< 36°C
|
2
|
|
heart rate
|
>= 220 beats per minute
|
3
|
|
|
180 to 219
|
2
|
|
|
160 to 179
|
1
|
|
|
100 to 150
|
0
|
|
|
80 to 99
|
1
|
|
|
< 80 beats per minute
|
3
|
|
respiratory rate
|
> 70 breaths per minute
|
2
|
|
|
51 to 70
|
1
|
|
|
31 to 50
|
0
|
|
|
20 to 30
|
1
|
|
|
< 20 breaths per minute
|
3
|
|
respiratory distress
|
absent
|
0
|
|
|
present
|
3
|
|
consciousness
|
alert
|
0
|
|
|
sleeping
|
0
|
|
|
irritable or jittery
|
1
|
|
|
lethargic
|
1
|
|
|
unresponsive
|
3
|
|
pre-feed blood glucose
|
>= 6.0 mmol/L (>= 108 mg/dL)
|
1
|
|
|
2.0 to 5.9 (36 to 107.9 mg/dL)
|
0
|
|
|
1.1 to 1.9 (18.1 to 35.9 mg/dL)
|
1
|
|
|
<= 1 mmol/L (<= 18 mg/dL)
|
2
|
Temperature special: warm the baby, with skin-to-skin contact. Repeat temperature measurement in 1 hour.
total score =
= SUM(points for all 6 parameters)
Interpretation:
• minimum total score: 0
• maximum total score: 15
• If any parameter is scored 3 (“red zone”) then consider calling the rapid response team.
• A total score >=2 should prompt an urgent medical evaluation and possible admission to NICU.
• A total score of 1 should prompt a medical evaluation. Consider evaluating for sepsis.
• Monitoring and care is continued if the score is 0.
