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05/01/2023
NEONATOLOGY PROTOCOLS
PRESENTED BY – DR NISHANT PRABHAKARMODERATOR - DR M. LAZARUS
05/01/2023
HYPERBILIRUBINEMIA Presence of one or more of following conditions would qualify a neonate to have
pathological jaundice – 1. Visible jaundice in first 24 hours of life. However slight jaundice on face at the end
of first day (say 18 to 24 hr) is common and can be considered physiological. 2. Presence of jaundice on arms and legs on day 2 3. Yellow palms and soles anytime 4. Serum bilirubin concentration increasing more than 0.2 mg/dL/hour or more than
5 mg/dL in 24 hours 5. If TSB concentration more than 95th centile as per age-specific bilirubin nomogram 6. Signs of acute bilirubin encephalopathy or kernicterus 7. Direct bilirubin more than 1.5 to 2 mg/dL at any age 8. Clinical jaundice persisting beyond 2 weeks in term and 3 weeks in preterm
neonates.
Avery’s Diseases of the Newborn 8th edn pp 1226-56.
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HYPERBILIRUBINEMIA• All the neonates should be visually inspected for jaundice
every 12 hours during initial 3-5 days of life.• The PT and BET recommendations for preterm infants <35
weeks of gestation
*Martin & Fanaroff. Neonatal-Perinatal Medicine, 8th Edition p1450
BIRTH WEIGHT
HEALTHY INFANT SICK INFANT
(GRAMS) PT ET PT ET
<1000 5-7 11-13 4-6 10-12
1000-1500 7-10 13-15 6-8 11-13
1501-2000 10-12 15-18 8-10 13-15
>2000 12-15 18-20 10-12 15-18
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HYPERBILIRUBINEMIA• American Academy of Paediatrics (AAP) criteria should be
used for making decision regarding phototherapy or exchange transfusion in infants of 35 weeks or more
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics
2004;114:297-316.
AGE AFTER BIRTH IN HOURS
LOW RISK1- ≥38 WEEKS & WELL
MEDIUM RISK1-35-37WKS & WELL2-≥38 WKS WITH RISK*
HIGH RISK1-35-37 WKS WITH RISK
PT ET PT ET PT ET
24 12 19 10 16 8 15
48 15 22 13 19 11 17
72 17 24 15 21 13 18
96 20 25 18 24 16 19
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HYPERBILIRUBINEMIA• Risk factors include presence of isoimmune hemolytic anemia,
G6PD deficiency, asphyxia, temperature instability, hypothermia, sepsis, significant lethargy, acidosis and hypoalbuminemia.
• AAP nomogram for phototherapy in hospitalized infants of 35 or more weeks’ gestation
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics
2004;114:297-316
05/01/2023
HYPERBILIRUBINEMIA• AAP nomogram for exchange transfusion in infants 35 or more
weeks’ gestation
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics
2004;114:297-316
8
APPROACH TO AN INFANT WITH JAUNDICE
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EXCHANGE TRANSFUSION• Double volume exchange transfusion (DVET) should be
performed if the TSB levels reach to age specific cut-off for exchange transfusion or the infant shows signs of bilirubin encephalopathy irrespective of TSB levels. In infants with Rh isoimmunization include: 1. Cord bilirubin is 5 mg/dL or more 2. Cord Hb is 10 g/dL or less
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COMMON CAUSES AND INVESTIGATIONS• Common causes.• Hemolysis: blood group incompatibility such as those of ABO, Rh and
minor groups, enzyme deficiencies such as G6PD deficiency, autoimmune hemolytic anemia.(baby & mother bld gp, G6PD,DCT, PSAT, Retic count)
• Decreased conjugation such as prematurity • Increased enterohepatic circulation such as lack of adequate enteral
feeding that includes insufficient breastfeeding or the infant not being fed because of illness, GI obstruction.(X-ray scout abd, USG abd)
• Extravasated blood: cephalhematoma, extensive bruising etc.• Septicemia: (CBC, TGBC, ANC, CRP, Blood CSt)• For prolonged/conjugated hyperbilirubinemia: LFT, T3, T4, TSH, TORCH
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NEONATAL SEIZURES• Clinical classification of seizures has limited diagnostic / prognostic value.• The common underlying etiologies for neonatal seizures are HIE, ICH,
intracranial infections and metabolic disturbances (in decreasing order of frequency). A detailed history and a complete clinical examination and neuroimaging will identify cause of seizures in most neonates.
• Investigations for neonatal seizures may be prioritized as follows:• First line (mandatory): Blood glucose, serum ionized/total calcium, serum sodium and
blood gas.• Add-on (situational): (a) Sick neonates with seizures: Investigations for sepsis (complete
hemogram & blood culture), intracranial infection (CSF studies for bacterial and viral etiology), intracranial hemorrhage (cranial ultrasonography & CT scan) and IEM (serum ammonia, lactate and pyruvate , urine and serum organic and amino acid analysis).
• A conventional EEG should be considered in all neonates for diagnosis, classification and for prognostic purposes.(as subtle seizures common)
• Neuroimaging: mandatory for persistent focal clonic or tonic seizures and to look for infarcts (arterial or venous). But the need for a neuroimaging has to be assessed on a case by case basis.
NNF Clinical Practice Guidelines
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HYPOGLYCEMIA• a blood glucose value of < 40mg/dL (plasma glucose < 45
mg/dL) should prompt intervention for hypoglycemia in all newborns.
• Screening for hypoglycemia is recommended in – Very low birth weight infants (<1500 grams) – Preterm infants (<35 weeks) – Small for gestational age infants (SGA) with birth weight <10th
percentile – Infant of diabetic mother (insulin dependent and gestational
diabetes) – Large for gestational age (LGA) infants with birth weight >90th
percentile.
AIIMS PROTOCOL 2015 PG 211-220
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HYPOGLYCEMIA– Infants with Rh-hemolytic disease – Infants born to mothers receiving therapy with terbutaline/propranolol/oral
hypoglycemic agents – Neonates with perinatal asphyxia, polycythemia, sepsis, shock, respiratory
distress, hypothermia – Infants with morphological growth retardation. This group includes neonates
with birth weight between 10th – 90th percentile with features of fetal under-nutrition in the form of skin peeling, loose skin folds and deficient buccal pad of fat.
– Infants on intravenous fluids and total parenteral nutrition• Time schedule for screening:
– In high-risk infants, screening for hypoglycemia should be done at 2, 6, 12, 24, 48 and 72 hours of age, prior to feeding
– Sick infants every 6-8 hours– Stable VLBW on TPN-1st 72 hrs every 6-8 hrs then every day.
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HYPOGLYCEMIA• Glucose Infusion rate = Fluid rate (mL/kg/day) x 0.007 x % of
dextrose infused (mg/kg/min) • Check blood glucose after 30 minutes of every change in
infusion rate.• Reduce glucose infusion rate , if last 2 blood glucose values
are>50 mg/dl• Oral feeding helps in better glycemic control and should be
initiated/continued along with intravenous therapy.• There is no role of drugs(like diazoxide & glucagon) in infants
with IUGR• Stop hydrocortisone in 3-5 days.
NNF Clinical Practice Guidelines
05/01/2023
HYPOGLYCEMIA
CAUSES OF RESISTANT HYPOGLYCEMIA
• Congenital hypopitutarism • Adrenal insufficiency • Hyperinsulinemic states • Galactosemia • Glycogen storage disorders • Maple syrup urine disease • Mitochondrial disorders • Fatty acid oxidation defect
INVESTIGATIONS• Serum insulin levels • Serum cortisol levels • Growth hormone levels • Blood ammonia • Blood lactate levels • Urine ketones and reducing
substances • Urine and sugar aminoacidogram • Free fatty acid levels • Galactose 1 phosphate uridyl
transferase levels
AIIMS PROTOCOL 2015 PG 211-220
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HYPOGLYCEMIA• Recurrent / resistant hypoglycemia
– This condition should be considered when infant fails to maintain normal BGL despite a GIR of 12 mg/kg/min or when stabilization is not achieved by 7 days of therapy .
– Hydrocortisone 5 mg/kg/day IV or PO in two divided doses for 24 to 48 hrs
– Diazoxide can be given orally 10-25 mg/kg/day in three divided doses .
– Glucagon 100µ g/kg subcutaneous or intramuscular (max 300 µg) – maximum of three doses .
– Octreotide (synthetic somatostatin in dose of 2-10 μg/kg/day subcutaneously two to three times a day
AIIMS PROTOCOL 2015 PG 211-220
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NEONATAL SEPSIS
• It encompasses various systemic infections of the newborn such as septicemia, meningitis, pneumonia, arthritis, osteomyelitis, and urinary tract infections.
• Early onset sepsis (EOS): It presents within the first 72 hours of life. 1. Low birth weight (<2500 grams) or prematurity 2. Febrile illness in the mother with evidence of bacterial
infection within 2 weeks prior to delivery 3. Foul smelling and/or meconium stained liquor
AIIMS PROTOCOL PG 163-173
05/01/2023
4. Rupture of membranes >24 hours 5. Single unclean or > 3 sterile vaginal examination(s) during labor 6. Prolonged labor (sum of 1st and 2nd stage of labor > 24 hrs) 7. Perinatal asphyxia (Apgar score <4 at 1 minute)
• Presence of foul smelling liquor or three of the above mentioned risk factors warrant initiation of antibiotic treatment.
• Late onset sepsis (LOS): It usually presents after 72 hours of age. The source of infection in LOS is either nosocomial (hospital-acquired) or community-acquired and neonates usually present with septicemia, pneumonia or meningitis
Gerdes JS, Polin R. Early diagnosis and treatment of neonatal sepsis. Indian J Pediatr 1998;65:63-78.
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Components Abnormal value Total leukocyte count <5000/mm3 Absolute neutrophil count Low counts as per Manroe chart for term and
Mouzinho’s chart for VLBW infants
Immature/total neutrophil >0.2
Micro-ESR >15 mm in 1st hour C reactive protein (CRP) >1 mg/dl
• SEPTIC SCREEN
• In situations of late onset sepsis, LP should be done in all infants prior to starting antibiotics.
Report of the National Neonatal Perinatal Database (National Neonatology Forum) 2002-03.
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Indications for starting antibiotics
• IN EOS(a) presence of >3 risk factors for early onset sepsis (see
above) (b) presence of foul smelling liquor (c) presence of >2 antenatal risk factor(s) and a positive
septic screen and (d) strong clinical suspicion of sepsis.
• IN LOS(a) positive septic screen and/or (b) strong clinical suspicion of sepsis.
NNF Clinical Practice Guidelines PG 155-171
05/01/2023
FOR MENINGITIS• Preterm infants:
– Treat if CSF WBC count ≥10 OR glucose <24 OR protein >170. – Do not treat if “CSF WBC count <25 AND glucose ≥25 AND
protein <170”. – For in-between results, clinical judgment will have to be used,
keeping in mind clinical features (seizures, degree of altered sensorium, fullness of fontanelles) and prematurity (the lower the gestation, lower should be the threshold for diagnosis).
• Term infants: – Treat if CSF WBC count >8 OR glucose <20 OR protein >120. – There is no safe cut-off at which one can recommend “do not
treat”. Clinical judgment as above would have to be used.
NNF Clinical Practice Guidelines PG 155-171
05/01/2023
ANTIBIOTIC THERAPY
• Every newborn unit must have its own antibiotic policy based on the local sensitivity patterns and the profile of pathogens.
• Apart from appropriate antibiotics, the survival of a sick septic newborn often depends upon aggressive supportive care.
• Empirical upgradation must be done if the expected clinical improvement with the ongoing line of antibiotics does not occur. At least 48-72 hours period of observation should be allowed before declaring the particular line as having failed.
NNF Clinical Practice Guidelines PG 155-171
05/01/2023
• In case the neonate is extremely sick or deteriorating very rapidly and the treating team feels that the neonate may not able to survive 48 hours in the absence of appropriate antibiotics, a decision may be taken to bypass the first line of antibiotics and start with the second-line of antibiotics.
NNF Clinical Practice Guidelines PG 155-171
05/01/2023
ANTIBIOTIC THERAPY ONCE CULTURE POSITIVE
• If the organism is sensitive to an antibiotic with a narrower spectrum or lower cost, therapy must be changed to such an antibiotic, even if the neonate was improving with the empirical antibiotics and/or the empirical antibiotics are reported sensitive.
• If possible, a single sensitive antibiotic must be used, the exception being Pseudomonas for which 2 sensitive antibiotics must be used.
NNF Clinical Practice Guidelines PG 155-171
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• If the empirical antibiotics are reported sensitive, but the neonate has worsened on these antibiotics, it may be a case of in vitro resistance. Antibiotics may be changed to an alternate sensitive antibiotic with the narrowest spectrum and lowest cost.
NNF Clinical Practice Guidelines PG 155-171
05/01/2023
• If the empirical antibiotics are reported resistant but the neonate has improved clinically, it may or may not be a case of in-vivo sensitivity. In such cases a careful assessment must be made before deciding on continuing with the empirical antibiotics.
• One must not continue with antibiotics with in vitro resistance in case of Pseudomonas, Klebsiella and MRSA; and in cases of CNS infections and deep-seated infections.
NNF Clinical Practice Guidelines PG 155-171
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• If no antibiotic has been reported sensitive, but one or more has been reported ‘moderately sensitive’, therapy must be changed to such antibiotics at the highest permissible dose. Use a combination, in such cases.
NNF Clinical Practice Guidelines PG 155-171
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• Proven bone or joint infections: Must be treated for at least 6 weeks.
• The currently available evidence does not support the use of IVIG.
• There is currently no evidence to support the use of colony stimulating factors either as a treatment modality or as a prophylaxis therapy.
• BET may be performed in a case of deteriorating sepsis with sclerema provided the general condition of the baby allows the procedure .
NNF Clinical Practice Guidelines PG 155-171
05/01/2023
OXYGEN THERAPY IN THE NEWBORN
• Oxygen should be supplemented in the neonates in the following clinical situations:– Hypoxemia (O2 saturation <87% and / or PaO2<50 mmHg in room
air) and – an acute situation with respiratory distress (respiratory rate
>60/min and/or intercostal retractions and / or grunt and / or cyanosis in room air).
• For the babies needing lower FiO2s (<40%), the most practical method of providing supplemental oxygen in neonates is by nasal cannula.
• Uncontrolled CPAP by using high flows through nasal cannulas is not recomended.
NNF Clinical Practice Guidelines PG 77-92
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OXYGEN THERAPY IN THE NEWBORN
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• Supplemental oxygen must always be monitored. In Level III NICU there should be facilities for ABG analysis and Pulse oxymetry. In Level II NICU, there should be facility for Pulse oxymetry and access to ABG if oxygen use is prolonged or in high concentration.
• When direct measurement of arterial blood is not available or accessible in a timely fashion, PtcO2 measurements may temporarily suffice.
NNF Clinical Practice Guidelines PG 77-92
05/01/2023 NNF Clinical Practice Guidelines PG 77-92
• OXYGEN SATURATION TARGETS
• Apart from keeping these saturation ranges it is very important to avoid excessive fluctuation in the saturation.
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SURFACTANT REPLACEMENT THERAPY
• Surfactant therapy has been divided in to – a) prophylactic – initial 15-30 min.– b) early rescue and – initial 2 hours– c) late rescue - >2 hours
• An INSURE approach is recommended for surfactant administration where intubation of the trachea is done only for administration of surfactant.
NNF Clinical Practice Guidelines PG 103-113
05/01/2023
SURFACTANT REPLACEMENT THERAPY
• Extremely preterm neonates (<28 weeks gestation) should also be initiated on early CPAP with selective early rescue surfactant.
• CPAP with surfactant is more effective than intubation and mechanical ventilation as early CPAP may by itself eliminate the need for surfactant.
• Natural surfactant extracts seem to be the more desirable choice when compared to currently available synthetic surfactants till cheaper, effective and safe synthetic surfactants are not available.
NNF Clinical Practice Guidelines PG 103-113
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SURFACTANT REPLACEMENT THERAPY
• This should be in two to four aliquots (as per the manufacturer’s recommendation), over a period of few minutes, with in between positive pressure breaths, with the neonate maintained in the supine position during the whole procedure.
• Surfactant therapy is part of the comprehensive intensive care for RDS that includes appropriate ventilator and fluid management, adequate nutrition and maintenance of asepsis etc(only in level ll or lll NICU).
NNF Clinical Practice Guidelines PG 103-113
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PROTOCOL FOR SRT
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HYPOCALCEMIA
• Definition of hypocalcemia
• Causes of early onset hypocalcaemia – Prematurity – Preeclampsia – Infant of diabetic mother – Perinatal stress/ asphyxia
AIIMS PROTOCOL PG 191-201
Gestation of infants Total serum calcium level Ionic serum calcium level Preterm <7 mg/dL (1.75 mmol/L) <4 mg/dL (1 mmol/L)
Term <8 mg/dL (2 mmol/L; total) <4.8 mg/dL (1.2 mmol/L)
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– Maternal intake of anticonvulsants (phenobarbitone, phenytoin sodium)
– Maternal hyperparathyroidism – Iatrogenic (alkalosis, use of blood products, diuretics,
phototherapy, lipid infusions etc).• This condition is fairly common and seen within
the first 3 to 4 days of life in these clinical settings. • 4 mL/kg/day of 10% calcium gluconate should be
given 6 hourly for 1st 3 days.
AIIMS PROTOCOL PG 191-201
HYPOCALCEMIA
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MANAGEMENT OF POLYCYTHEMIA
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VOLUME TO BE EXCHANGED
AIIMS PROTOCOL PG 201-211
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THANK YOU