Holme et al reported the neonatal trigger score (NTS) for neonates. This can help to guide monitoring of these patients and to trigger an early intervention. The authors are from Whittington Health, Northwick Park Hospital, and University College London.
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.
Purpose: To evaluate a neonate with the neonatal trigger score (NTS) of Holme et al.
Objective: other testing, complication detection
ICD-10: P00-P96,
