Neonatal Care Essentials

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Normal Newborn: Definitions & Classification Newborn Period: First 4 weeks after birth (first week is early, next 3 weeks are late). Average Birth Weight (India): 2.9 kgs Low Birth Weight (LBW): $ Very Low Birth Weight (VLBW): $ Extremely Low Birth Weight (ELBW): $ Macrosomia: $> 4$ kgs at birth Birth Weight Interpretation Always interpreted with gestational age using intrauterine growth chart. Lower Reference Curve: $10^{th}$ percentile Upper Reference Curve: $90^{th}$ percentile Large for Gestational Age (LGA): $> 90^{th}$ percentile Appropriate for Gestational Age (AGA): $10^{th} - 90^{th}$ percentile Small for Gestational Age (SGA): $ Small for Gestational Age (SGA) Types: Normal variant/Constitutional SGA (more common) Abnormal variant: IUGR (Intrauterine Growth Restriction/Retardation) - always associated with pathology. Differentiating IUGR from Normal Variant SGA IUGR babies have loose skin folds ($\ge 3$). Placenta/umbilical cord appears thin. Head circumference $>>$ chest circumference (difference $> 3$ cm). Normal difference is $3$ cm. Types of IUGR Feature Maternal Cause (more common) Fetal Cause Causes Disorders of uteroplacental insufficiency (e.g., Gestational HTN) Genetic defects, anomalies Onset Late ($2^{nd}$ or $3^{rd}$ trimester) Early ($1^{st}$ trimester) Effect Brain sparing (blood supply directed towards brain). Head size normal, body small (asymmetric IUGR). No brain sparing (due to early onset). Every part undergoes growth restriction (symmetric IUGR). Ponderal Index (PI): $PI = \frac{\text{weight (g)}}{\text{length (cm)}^3} \times 100$ $PI > 2$: Symmetric IUGR $PI Large for Gestational Age (LGA) Birth Weight: $ > 90^{th}$ percentile Causes: Constitutional LGA/normal variant. Infant of Diabetic Mother (gestational diabetes). Sotos syndrome (cerebral gigantism): Intellectual disability, premature tooth eruption, developmental delay. Beckwith-Wiedemann syndrome: Macroglossia, anterior abdominal defects (Omphalocele, umbilical hernia), hemihypertrophy, increased risk for Wilms's tumor. Assessment of Maturity Newborns are divided into Pre-term, Term, and Post-term babies based on gestational age (GA). Pre-term: GA $ Term: GA $37$ weeks to $41$ weeks $+ 6$ days Post-term: GA $> 42$ weeks Gestational age is calculated from LMP (Last Menstrual Period). Postnatal Assessment of Gestational Age Done using Expanded New Ballard Score (ENBS). Criteria: Physical maturity Neuromuscular maturity Range of Gestation: $20$ weeks to $44$ weeks. Total Score Range: $-10$ to $+50$. Accurate to $\pm 1$ week. Points to Identify Post-Term Baby Meconium staining over nails, fingers & body. After $42$ weeks, anal sphincter opens. Overgrown fingernails. Wrinkling of skin (decrease in amniotic fluid). Routine Newborn Care 1. At Birth: 5 Cleans Clean hands & wear gloves. Clean surface (towel to receive babies should be clean and warm). Clean blade/scissors (for cutting umbilical cord). Clean cord clamp. Clean cord (should be kept dry). Delayed Cord Clamping Delayed clamping by $30-60$ seconds. Increases blood flow via placenta, decreasing risk of anemia. In preterm babies, it decreases risk of intraventricular hemorrhage. 2. Prevention of Hypothermia Delivery room temperature at $25^\circ C$. No free draft of air in the delivery room. Facilitate skin-to-skin contact of baby and mother. 3. Breastfeeding Should be started as early as possible after birth. 4. Rooming-in Keeps baby and mother together, facilitates bonding, and helps in breastfeeding. 5. Prophylaxis at Time of Birth Vitamin K: Activates clotting factors $II, VII, IX, X$. Given IM in anterolateral aspect of thigh. Dose: $1$ mg. If weight $ Prevents hemorrhagic disease of newborn. Normal Observation in Newborn Vital Signs Temperature: $36.5^\circ C$ to $37.5^\circ C$. Heart Rate: $110-160$/min. Respiratory Rate: $40-60$/min. Blood Pressure: $60/40$ mmHg. CFT (Capillary Filling Time): Measure of circulation, checked over bony prominence (preferred site: sternum). Normal: $ Normal Findings in Newborn: Skin and Mucosa Normal Skin Findings Erythema Toxicum/Neonatorum (most common) Pustular Melanosis Appearance Red and yellow papulo-pustular lesions. Appears after $24$ hours. Hyperpigmented patches + pustules. Appears within $24$ hours. Microscopy Eosinophils ++ Neutrophils ++ Treatment Reassurance Reassurance Other Normal Findings Effect of Maternal Estrogen: White discharge per vagina (mucus from cervix). Breast engorgement. Neonatal endometrial sloughing (due to withdrawal of maternal estrogen). Epithelial Inclusion Cyst/Retention Cyst (Appears white): Milia: Around the nose and face (milk spots). Gums: Bohn's nodules (white spots). Palate: Epstein pearls. Mongolian Spots: Hyperpigmented macules, very common in Indian and Asian people. Salmon Patch/Strawberry Angioma/Stork Bite/Nevus Flavus: Bright red colored lesion. Also seen on forehead and nape of neck. Small Subconjunctival/Retinal Hemorrhages: (While passing through birth canal). Hymenal Skin Tags: In female babies. Physiological Phimosis: In male babies. Reassurance is the only treatment required for all normal newborn findings. Head Swellings in Newborn Feature Caput Succedaneum (more common) Cephalohematoma Location Subcutaneous plane. Superficial swelling in scalp. Diffuse. Sub periosteum (common: Parietal bone). Deep swelling, localised (limited by sutures). Reason Prolonged labour $\to$ Congestion of scalp veins $\to$ Edema. Instrumental delivery $\to$ Trauma to skull. Content Fluid Blood Appearance At birth/soon after birth. Slowly increases over $12-24$ hours after birth. Disappearance $48-72$ hours $2$ weeks to $3$ months Associations Negative $5-25\%$ linear skull fractures, jaundice (from haem break down forming bilirubin). Subgaleal Hemorrhage (most severe) Beneath galea aponeurosis. Associated with vacuum assisted delivery. Diffuse accumulation of blood. Hypovolemia $\to$ shock. Pallor (due to decreased circulating volume). Jaundice (lysis of RBCs). Head Swellings Summary Type of Collection Condition Superficial, diffuse collection of fluid Caput succedaneum Superficial, diffuse collection of blood Subgaleal hemorrhage Deep, localized collection of blood Cephalohematoma Neonatal Reflexes (Primitive/Immature Reflexes) Primitive reflexes disappear after brain matures. Generally present during neonatal period but with few exceptions. Reflex Onset Fully Developed Duration Palmar grasp $28$ weeks of gestation $32$ weeks of gestation $2-3$ months after birth Rooting reflex (attachment & sucking while breast feeding) $28-32$ weeks of gestation $34-36$ weeks of gestation Less prominent, $1$ month after birth Moro reflex (seen only in term babies) $28-32$ weeks of gestation $37$ weeks of gestation (term) $5-6$ months after birth Asymmetric tonic neck $35^{th}$ week of gestation $1$ month after birth $6-7$ months after birth Parachute $7-8$ months (post natal) $10-11$ months Persists throughout life Components of Moro Reflex Extension & abduction followed by flexion & adduction $\pm$ cry. Abnormalities: Absent moro reflex: Anomalies like anencephaly, Hypoxic Ischemic Encephalopathy (HIE stage 3). Unilateral moro reflex: Nerve injury (brachial plexus injury e.g. Erb's palsy), bony injury like fracture/dislocation (m/c: shoulder, most common fracture at birth: clavicle). Persistent moro: Even after $6$ months indicates immaturity of brain (cerebral palsy). Asymmetric Tonic Neck Reflex If head is turned to one side, upper limb on same side extends, while other upper limb flexes. Rooting Reflex Stimulation of baby's mouth causes the mouth to turn in the direction of the stimulus. Reflexes Appearing After Birth/Infantile Reflex (mnemonic: SPL) Parachute Reflex: Protective extension reaction forward. Prevents head from falling down. Symmetric Tonic Neck Reflex (STNR) / Crawling Reflex: Neck extension $\to$ upper limb extension & lower limb flexion. Neck flexion $\to$ upper limb flexion & lower limb extension. Appears by $4-6$ months after birth. Duration: $8-12$ months after birth (helps in crawling). Landau Reflex: On horizontal suspension, flexion of neck $\to$ flexion of limbs. Extension of neck $\to$ extension of limbs. Appears: $3$ months after birth. Duration: $9$ months after birth. Management of LBW Babies Reasons for LBW Preterm babies (developed countries). IUGR/growth restriction (developing countries) $\to$ SGA babies. Most common problem faced by these babies: Hypothermia . Temperature Regulation in a Newborn Normal: $36.5-37.5^\circ C$. Site of measurement: Axilla (for precise recording, bulb of thermometer should be placed over roof of dry axilla for a minimum of $3$ minutes, while holding axilla close to baby's body). Modes of Heat Loss in a Newborn Conduction: Baby loses heat when placed on a cold surface. Evaporation: Evaporative heat loss (sweating). Convection: Air current or air flow around the baby, causing heat loss. Radiation: Heat from baby radiating to the roof/walls of the room. Most important mechanism of heat loss: Radiation heat loss. Most important site of heat loss: Head , because it has largest Body Surface Area (BSA). Hence, baby's head must be covered to prevent excessive heat loss. LBW Babies More Prone to Hypothermia than Normal Weight Babies Feature LBW Babies (Preterm) Normal Weight Babies (Term) Surface area of head Greater Lesser Posture Extension $\to$ more heat loss Flexion $\to$ protects from heat loss Brown fat Low More Body fat Less $\to$ less insulation $\to$ heat loss More Skin More permeable $\to$ heat loss Less permeable Sources of Heat Production Increased physical activity (crying/movements) $\to$ increased heat production. Cold exposure $\to$ Stress $\to$ Sympathetic surge (release of sympathetic hormones) $\to$ increased heat production through brown fat. Brown vs White Adipose Tissue Feature White/Usual Adipocyte Brown Adipocyte Fat vacuole One large Small Mitochondria Less More (brown structures) Vascularity Less More Nerve innervation Less More (sympathetic nerves) Brown fat cells: Specialized structures present in newborn which helps in heat production. Location of Brown Fat Nape/back side of neck (most common). Interscapular region. Axillar or groin region. Perirenal areas. Non-Shivering Thermogenesis Mechanism of heat generation in a newborn, without shivering, with the help of brown fat tissue. In a fat cell, oxidation of fatty acids takes place, followed by phosphorylation. Oxidation couples with phosphorylation (coupling reaction) to produce ATP. Exposure to cold $\to$ Stress $\to$ Sympathetic surge $\to$ Release of sympathetic hormones (Norepinephrine: most common) $\to$ Uncoupling reaction (oxidation inhibited from phosphorylation) $\to$ Diverts oxidation towards heat generation. Hypothermia ($ Normal Temperature: $36.5-37.5^\circ C$. Classification: Cold Stress ($36-36.4^\circ C$): Extremities become cold, trunk remains warm (initial stage). Moderate Hypothermia ($32-36^\circ C$): Entire body becomes cold. Severe Hypothermia ($ Entire body becomes cold. Prevention of Hypothermia (stable hemodynamically): Gently cover the baby (especially the head). If LBW/preterm, Kangaroo Mother Care (skin-to-skin contact with mother $\to$ Heat transfer from mother to baby $\to$ Protects baby from hypothermia). Kangaroo Mother Care (KMC) Position: Posture of baby: Vertical or upright. Position of baby's face: Turned to one side. Position of legs: Flexed at hip and knees (frog leg posture). Head of the baby covered additionally. Feeding: Exclusive breast feeding. Early discharge of baby: Due to better care of baby because of contact with mother. KMC Duration: Variable (can be up to $24$ hrs). Long duration: Most preferred. Short duration ($ KMC Can Be Stopped: When baby is of term gestation from birth (if premature). When baby weighs $> 2.5$ kg (if LBW). Unstable Hemodynamically (managed in NICU) Radiant Warmer (radiation type of heat exchange): Heat generated over the surface $\to$ Radiates down to the baby. Incubator (convection type of heat exchange): Closed chamber. Nutrition of LBW Babies Depends on gestational age: $ Total Parenteral Nutrition (TPN): IV fluids. No enteral feeding as gastrointestinal tract is not developed completely. Preferred IV fluids: $ $> 48$ hours: Isolyte-P. Amount of IV fluids to be given: Day 1: $60-80$ ml/kg/$24$ hours. Increase by $10-20$ ml/kg everyday. $150$ ml/kg/$24$ hours (maximum level) and maintain it. $28-32$ weeks of gestation: Only suckling burst seen (suckling + swallowing + breathing coordination not completely developed). Expressed Breast Milk (EBM) given by orogastric tube. Baby may aspirate EBM if given by mouth directly. Therefore EBM given through nasogastric tube/orogastric tube. Length of insertion of NG tube: Nose to ear lobule to midpoint between xiphoid sternum & umbilicus. Must be measured and marked then inserted. $32-34$ weeks of gestation (coordination better developed): EBM with a paladai or katori spoon. $> 34$ weeks (completely developed coordination): Direct breast feeding. Nutritional Supplements Weight Supplements All babies Vitamin D ($400$ IU/day: Orally for $1$ year). $1.5-2.5$ kg Vitamin D + Iron ($2$ mg/kg/day): From $6-8$ weeks after birth till $1$ year. (LBW babies have inadequate iron stores). $ Iron + HMF (Human Milk Fortifier). Nutritional sachets continued till baby reaches $40$ weeks of gestation after birth. Continue Iron + Vitamin D for $1$ year. HMF contains all micronutrients + minerals + vitamins, except iron. Therefore, iron supplements in addition. Problems Faced by LBW Babies (Preterm/IUGR Babies) Problem Preterm Babies IUGR Babies Neonatal asphyxia Increased risk Increased risk Hypothermia Increased risk Increased risk Low nutrient reserves Hypoglycemia (low glycogen reserves) Hypoglycemia (low glycogen reserves) Kernicterus (brain damage due to bilirubin) Increased risk. High levels of bilirubin $\to$ Easy passage into brain (blood brain barrier is more permeable in preterm babies). - Necrotizing enterocolitis (NEC) Increased risk - Patent Ductus Arteriosus (PDA) Increased risk - Hematological Anemia (low iron stores) Polycythemia. IUGR $\to$ Stress $\to$ Intrauterine hypoxia (chronic) $\to$ Release of EPO $\to$ Increase erythropoiesis $\to$ Polycythaemia. Problems Faced by Premature Babies due to Immaturity of Organ Systems Intraventricular Hemorrhage (IVH): $ Germinal matrix (group of fragile blood vessels around the ventricles) undergoes involution $> 34$ weeks. If baby $ Increased Risk of Apnea of Prematurity: (Absent breathing $> 20$ seconds or any duration + bradycardia or cyanosis). Treatment: Caffeine citrate. Increased Risk of Developing Sensorineural Hearing Loss (SNHL): Frequent screening tests done. Oto-Acoustic Emissions (OAE). Automated Auditory Brainstem Response (AABR): Most preferred. Increased Risk of Developing Retinopathy of Prematurity (ROP): Possibly leading to blindness. Either due to immaturity of retina. When exposed to high levels of oxygen therapy (hyperoxia). Prevented by limiting $\text{O}_2$ exposure: By continuously monitoring $\text{SpO}_2$ ($90-95\%$ maintenance). Respiratory Problems Respiratory Condition Cause Less surfactant causing Respiratory Distress Syndrome (RDS) Lack of mature surfactant in preterm babies. Meconium Aspiration Syndrome (MAS) IUGR $\to$ Stress $\to$ Release of motilin $\to$ Increased peristalsis of intestines $\to$ Passage of meconium in-utero $\to$ Aspirated by baby during delivery $\to$ MAS. Neonatal Resuscitation The guidelines for neonatal resuscitation are based on NRP $2021$. In newborn babies, the priority is respiration $>>$ temperature $>$ circulation. Resuscitation in newborns is not done under room air but under warmer air. Initial Assessment: 4 Pre-Birth Questions Gestational age of the baby. Amniotic fluid is clear or not. Additional risk factors. Umbilical cord management plan $\to$ Delayed cord clamping by $30-60$ seconds. Algorithm Initial assessment $\to$ no cry Initial steps $\to$ no cry Assess HR & respiratory effort Positive pressure ventilation $\to$ No response Chest compression (with ventilation) $\to$ Still no improvement & HR $ Adrenaline injection HR $ Initial Steps Temperature: Needs to be maintained by putting the baby into the warmer. Stimulate the baby by gentle tactile stimulation: Rubbing the back of the baby. Flicking the soles of the baby. Position the airway of the baby by slight extension/sniffing posture. Easily done by placing a rolled cotton towel behind the shoulder blades. Optional Step Suctioning of the secretions (mouth $\to$ then nose) to prevent aspiration (routine suctioning not recommended anymore). If the baby still doesn't cry after the initial steps, assess for heart rate (to check for hypoxia) and respiratory effort. Significant hypoxia is a decrease in heart rate: $ Resuscitation Flowchart Assess HR & respiratory effort HR $> 100$/min but inadequate/labored breathing $\to$ Oxygen supplementation ($\to$ Oxygen hood $\to$ nasal prongs) or CPAP (for preterm: $ HR $ Chest Compressions If still no response and heart rate $ 2 thumb technique: Site: Lower $1/3^{rd}$ of sternum. Avoid xiphisternum. $1/3^{rd}$ of the anterior-posterior diameter should be compressed. Chest compressions should be combined with ventilation in a newborn resuscitation. Ratio of compression:ventilation: $3:1 \to 90$ compressions $+ 30$ ventilation in $1$ minute. Ventilation is usually given by an alternate airway like ET ventilation. Cardiac monitor is necessary at this stage to monitor HR. Adrenaline Injection No response to chest compressions then, Adrenaline injection (epinephrine) at $1:10,000$ strength. Route: Umbilical vein (IV $>>$ intraosseous), Endotracheal route. Dose: IV/Intraosseous route: $0.2$ ml/kg or $0.02$ mg/kg. Endotracheal route: $1$ ml/kg or $0.1$ mg/kg. If even after adrenaline injection, there is no improvement $\to$ consider volume expansion: NS $10$ ml/kg (not a routine step, usually done as a last effort where definite history of blood loss (e.g. PPH etc.,) present. Maximum duration of neonatal resuscitation $\to 20$ minutes $\to$ call off resuscitation if all steps done & no HR. Timeline Timeline between the initial step to PPV is $1$ minute (golden minute of resuscitation). Timeline between PPV & chest compression initiation $\to 30$ seconds. Timeline between chest compression initiation & adrenaline injection $\to 30$ seconds. Bag & Mask Ventilation (BMV) Volume of bag for resuscitation: $240-750$ ml. Response: Increase in HR $> 100$/min. If no response $\to$ ventilation corrective steps: Mask readjustment. Reposition head. Suction. Open the mouth. Pressure to be increased. Alternate airway (ET). Rate of BMV: $40-60$/min. Pressure: First breath $30-40$ cm $\text{H}_2\text{O}$. Subsequent breaths $15-20$ cm $\text{H}_2\text{O}$ (always at lower pressure to prevent trauma to the alveoli). Recommended $\text{FiO}_2$: Babies born $\ge 35$ weeks: Room air ($21\%$ $\text{O}_2$). Babies born $ Further titration of oxygen depends on $\text{SpO}_2$ response. Target $\text{SpO}_2$ Time $\text{SpO}_2$ Target $1$ min $60-65\%$ $2$ min $65-70\%$ $3$ min $70-75\%$ $4$ min $75-80\%$ $5$ min $80-85\%$ $10$ min $85-90\%$ Endotracheal Intubation Before ET, laryngoscopy with straight blade ($0$ for preterm & $1$ for term babies) needs to be done to visualize glottic region. Uncuffed tubes are preferred in newborns (pressure induced tracheal stenosis can occur if cuffed ET is used). Inner diameter of ET: $ $1-2$ kg: $3$ mm. $> 2$ kg: $3.5$ mm. Length (cm) of insertion of ET: Depends on the age of the child. Length $= 6 +$ weight of child (kg). Best way to confirm position of ET: End tidal $\text{CO}_2$ with capnography. Infections in Neonates Types of Infections Superficial infections Systemic infections Superficial Infections Omphalitis (infection of the umbilical cord): Can present as redness/induration/pus discharge around umbilicus. If untreated, causes systemic infection (sepsis). Management depends on: Size of Induration Presence of Sepsis Treatment Less than $1$ cm No Topical $0.5\%$ gentian violet $4$ times a day More than $1$ cm Yes/No Systemic antibiotics (treat like sepsis) Oral Thrush: By candida species. Differentiated from Milk Curds: Difficulty in wiping the lesion. Presence of hemorrhagic spots after forceful removal. Treated with topical Nystatin or Clotrimazole $4$ times a day till all lesions are resolved. Conjunctivitis (ophthalmia neonatorum): Acquired during delivery of the baby along the infected birth canal. Feature Gonococci (Neisseria gonorrhoeae) Chlamydia (Chlamydia trachomatis) Time of presentation Day $3-7$ From $5^{th}$ day of delivery Discharge Copious and purulent Scanty Treatment IV Ceftriaxone/Cefotaxime for $7-10$ days Oral Azithromycin for $3$ days/Erythromycin for $14$ days Gonococcal conjunctivitis is treated as an emergency. Blindness and systemic infection can occur if untreated. $0.5\%$ Erythromycin eye ointment is used as prophylaxis against ophthalmia neonatorum. Systemic Infections Neonatal Sepsis (in the $1^{st}$ month of life) Most common cause of neonatal mortality after prematurity. Diagnosed by presence of clinical features of sepsis along with bacteremia (presence of bacteria in blood as detected by blood culture). Causative Organisms: India: Klebsiella $>$ Staphylococcus aureus $>$ E.coli Worldwide: Group B Streptococci Types Feature Early Onset Sepsis Late Onset Sepsis Onset Within $72$ hours of life After $72$ hours of life Source From the mother (in the uterus/passage via birth canal) Hospital acquired infection (Nosocomial) Risk Factors Chorioamnionitis (high fever in mother + foul smelling liquor), Duration of ROM $> 24$ hours ($ > 72$ hours: very high risk), PPROM (any duration), $\ge 3$ unclean vaginal examinations. Unclean hands of health personnel (most important preventable cause), Preterm/low birth weight babies, Absence of breast feeding. Type of infection Pneumonia Septicemia, meningitis Diagnosis of Neonatal Sepsis Any sick baby, suspect sepsis & start IV antibiotics. No single most important clinical feature is diagnostic. Early features: Altered feeding pattern, lethargic baby. Reliable feature: Hypothermia (more reliable in preterm babies than fever). Manifestations of affected organ system like respiratory distress, seizures etc. Management Gold standard: Blood culture (takes $48-72$ hours to get report). Start empirical antibiotics. Screen for sepsis using $5$ components (Presence of any one is significant): Components Abnormal Value Total leukocyte count $ Absolute neutrophil count $ Immature/total neutrophil ratio $\ge 20\%$ immature neutrophils or Ratio $\ge 0.2$ Micro ESR $\ge 15$ mm/hr CRP (C-Reactive Protein) $\ge 1$ mg/dl Sepsis screening has negative predictive value (helps rule out infection). If screening is negative: Absence of disease. If screening is positive: Do a blood culture to confirm sepsis. Role of C-Reactive Protein (CRP) CRP raises only $6-12$ hours after infection. Peaks at $24$ hours. Disadvantage: Negative in early infection. Newer and better marker of inflammation: Procalcitonin. Raises $4-6$ hours after infection and peaks at $24$ hours. Procalcitonin is not routinely used in sepsis screening. Other Investigations Chest X-ray (in case of suspected pneumonia). Lumbar puncture: In all symptomatic babies with suspected/confirmed sepsis. (Asymptomatic babies: Presence of risk factors - Lumbar puncture is not required). Management: Empirical Antibiotics Gram Positive Gram Negative Penicillin group: Ampicillin + Aminoglycoside: Amikacin/Gentamicin No response to treatment by $48$ hours/severe infection such as meningitis, septic shock $\to$ Add $3^{rd}$ generation cephalosporin (Ceftriaxone/Cefotaxime). Suspected staphylococcus aureus infection: Add Cloxacillin. In case of MRSA: Add vancomycin. In NICU with high incidence of resistant strains: Cefotaxime/PIPTAZ/Ciprofloxacin + Amikacin. Duration of Antibiotic Therapy in Neonatal Sepsis Diagnosis Duration Culture negative sepsis (screening positive and/or clinical course consistent with sepsis) $5-7$ days Blood culture positive without meningitis $14$ days Meningitis $3$ weeks Ventriculitis (Diagnosed using MRI) $4-6$ weeks Birth Asphyxia & Hypoxic Ischemic Encephalopathy (HIE) & Neonatal Seizures Perinatal Asphyxia Impaired gas exchange in the fetus during pregnancy or due to complications of labor. Leads to: Hypoxia. Hypercarbia. Lactic acidosis: Main feature to diagnose asphyxia. Umbilical arterial blood pH $ WHO Definition of Birth Asphyxia It is a condition that should be considered in any newborn baby wherein the baby fails to initiate breathing or not able to sustain breathing at the time of birth. Consequences of Birth Asphyxia (Due to Hypoxia) Organ Clinical Condition Brain Hypoxic Ischemic Encephalopathy (HIE). Multi organ failure: Kidney (m/c) after brain. Acute Tubular Necrosis (ATN) in proximal tubule (most sensitive). Anaerobic metabolism in tissues Lactic acidosis. Low APGAR score is seen in babies with birth asphyxia: $ Hypoxic Ischemic Encephalopathy (HIE) Hypoxia: Decreased oxygenation to tissues $\to$ Ischemia: Hypoperfusion: Inadequate bloody supply to tissues $\to$ Encephalopathy: Brain injury. Leading cause of neonatal brain injury worldwide. Associated with increased risk of neonatal mortality. Surviving babies may have neurodevelopmental sequelae like Cerebral Palsy (CP), intractable seizures, & low IQ. Sarnat & Sarnat Staging Features Stage I Stage II Stage III Consciousness Normal/hyperalert Lethargic Comatose Reflexes (moro, sucking) Easily elicitable (hyperactive) Sluggish Absent Seizures - +++ in first $24$ hours - (no brain activity) Autonomic involvement Sympathetic overactivity Parasympathetic overactivity Sympathetic overactivity Pupil size mydriasis miosis unequal: poorly/not reactive to light. Heart Rate Increased Decreased Variable Posture Normal Flexion Decerebrate EEG Normal Low voltage complexes. Seizure spikes seen. Burst suppression. Isoelectric pattern. Duration $ $24$ hours - $14$ days Several days to weeks Outcome $99\%$: Normal outcome. $80\%$: Good outcome. $20\%$: Sequelae. $50\%$: Die. $50\%$: Sequelae. Normal posture: Universal flexion resisting passive extension. Decerebrate posture: All limbs in extension. In stage $II$, $20\%$ of babies develop neurological sequelae, while in stage $III$, all surviving $50\%$ develop cerebral palsy as sequelae. Child will not always progress from stage I and can present in any stage. Sarnat & Sarnat staging is also indicative of the prognosis. HIE is the leading cause of neonatal seizures. Neurological Sequelae Depend on the area of brain affected by HIE. Factors that determine area affected: Blood supply of brain. Gestational age. Metabolic demands of different parts of the baby's brain. Parasagittal Infarct Brain injury in term babies due to asphyxia. Water shed area supplied between anterior & middle cerebral artery. Motor cortex & subcortical areas are affected. Initially, upper limbs are predominantly affected. All $4$ limbs will be eventually affected: Spastic quadriplegia, cerebral palsy (CP). Periventricular Leukomalacia Brain injury in preterm babies. Affects motor distribution of both lower limbs: Spastic diplegia. Other Patterns of Ischemic Brain Injury in Term Babies Focal Ischemic Necrosis: Refers to only one part of brain being affected. Associated with focal seizures & hemiparesis (upper & lower limbs on one side being affected). Selective Neuronal Necrosis: Particular areas of brain are commonly affected. Deep nuclei of brain: Putamen of basal ganglia (extrapyramidal symptoms), Hippocampus. Purkinje cells of cerebellum: Ataxia, vertigo. Many areas affected together: CP with low IQ. Neuroimaging Screening: Neurosonogram: Ultrasonogram through fontanelles. Only small part of brain is visualized. Main role: To rule out significant intracranial hemorrhages. Definitive: MRI of brain. In early stages: Diffusion weighted Imaging (DWI) shows abnormality (early changes) within few hours after birth. Treatment of HIE Cannot completely cure, only supportive management. Maintain blood sugar, temperature and administer adequate fluids. AEEG (Amplitude Integrated EEG): For continuous monitoring of seizure activity in a newborn. Only $1-2$ electrodes used (conventional EEG has $16$ electrodes). Conventional EEG needs expert evaluation. Facilitates continuous monitoring of seizure activity. Helps in detection of subclinical seizure activity in ICU. Screening test only. Diagnostic test: Conventional EEG. Treatment of seizures: Phenobarbitone (DOC). Therapeutic Hypothermia Inducing hypothermia by placing ice packs or cooling crystals around the baby's body: whole body cooling. Only around the head: Selective head cooling. Preferred: Whole body cooling $>$ selective body cooling. Whole body cooling offers uniform cooling & better outcomes. Temperature maintained: $33.5^\circ C$ ($33-34^\circ C$). Mechanism of action: Decreases neuronal injury by decreasing neuronal apoptosis. Decreases production of free radicals & nitric oxide. Decreases production of excitatory amino acid glutamate. Decreases incidence of seizures. Criteria for therapeutic hypothermia: Post menstrual age: $> 36$ weeks of gestation. Birth weight: $\ge 2$ kg. Stage II/Stage III HIE. Should be started within $6$ hours of birth. Duration: $72$ hours. Types and Etiology of Neonatal Seizures Types Subtle (m/c type in children): Minimal manifestations. Ocular movements (Example: Deviation of eye or continuous blinking of eyes for few seconds). Orofacial lingual movements (Example: Continuous chewing). Limbs (Example: cycling movement). Seizure generated impulse is not transmitted rapidly in the immature brain. Clonic: Focal clonic: Best prognosis. Tonic Myoclonic: Worst prognosis. Etiology HIE (m/c): $50-60\%$ within $12$ hours of $1^{st}$ day of life. Metabolic causes: Hypoglycemia. Hypocalcemia. Hypomagnesemia. Infections: Sepsis. TORCH infections. Intracranial hemorrhage: Preterm: Intraventricular hemorrhage. Term: Subdural hemorrhage (poor outcome). Developmental defects: Congenital anomalies (example anencephaly). Pyridoxine deficiency/dependent seizures: Rare cause of neonatal seizures. Typically manifests as refractory seizures. $\uparrow$ Glutamate $\xrightarrow{\text{GAD}}$ $\downarrow$ GABA (Inhibitory). $\downarrow$ Pyridoxine. Management of Neonatal Seizures TABC: Temperature, airway, breathing, circulation. Correction of hypoglycemia and hypocalcemia. Antiepileptic drug therapy: First line: Phenobarbitone IV. Second line: Phenytoin. Followed by Benzodiazepines. Refractory seizures: Trial of pyridoxine. Necrotizing Enterocolitis (NEC) Considered as a gastrointestinal emergency in a neonate. Characterized by inflammation due to bacterial colonization of the intestine, leading to necrosis of that part of the intestine, if left untreated. Parts of the intestine affected: Terminal ileum: Most common. Proximal colon (ascending colon). Risk Factors Prematurity. Top feeds (feeding with milk, other than breast milk: cow milk/formula milk). Breast milk is protective because it lowers the gastric pH, making it more acidic, which prevents bacteria colonization by pathogenic bacteria like E. coli, Klebsiella. It also promotes peristalsis of the intestine. It contains substances like lactoferrin, which protects against the growth of bacteria like E. coli. Increases normal gut flora. Birth Asphyxia. Maternal abuse of cocaine. Usage of $\text{H}_2$ blockers in the neonate. $\text{H}_2$ blockers $\to$ Decreases the HCl amount in stomach $\to$ Increases pH of gastric wall $\to$ No protection from bacterial colonization. Pathogenesis Prematurity $\to$ Immature GIT $\to$ Inflammation leading to necrosis. Top feeds $\to$ Bacterial Colonization $\to$ Inflammation leading to necrosis. Asphyxia $\to$ Vasoconstriction of the splanchnic vessels $\to$ predisposed to necrosis $\to$ NEC. Cocaine abuse $\to$ Vasoconstriction of the splanchnic vessels $\to$ predisposed to necrosis $\to$ NEC. Features of NEC: Modified Bell's Staging Stage Features Imaging Stage 1 (initial/beginning). NEC suspected. Non specific abdominal features (distension/vomiting). Systemic manifestations: Fever, bradycardia or apnea. Stage 1A: Occult blood in the stool. Stage 1B: Gross blood in the stool. Normal x-ray Stage 2. Definite NEC. Absent bowel sounds. X-ray abdomen: Pneumatosis intestinalis (air in the wall of the intestine). Stage 2B Bowel sounds (-) + Abdominal wall edema. Lab triad: Thrombocytopenia + Hyponatremia + Metabolic acidosis. X-ray abdomen: Pneumatosis portalis (air in the portal vein). Stage 3. Severe NEC: Complicated/Advanced NEC. Stage 3A: Definite evidence of peritonitis (erythema of the abdominal wall + induration + tenderness of the abdominal wall) + definite ascites. Stage 3B: Intestinal perforation (air collecting in the peritoneal cavity). Surgical Gastrointestinal Emergency of Neonates. X-ray abdomen: Pneumoperitoneum (air or gas under diaphragm). Management of NEC Stage Management Treatment Till Stage 3A Medical management (Since no bowel perforation) Nil Per Oral (NPO). TPN (Total Parenteral Nutrition): IV Fluids with Dextrose. IV antibiotics: Ampicillin, Gentamycin (aminoglycosides). Metronidazole (anaerobic coverage). Duration of Antibiotics: Stage 1A: 3 days. Stage 1B: 7-10 days. Stage 2A, 2B, 3A: 14 days. Stage 3B Surgical management. Stable $\to$ Laparotomy (Resection of necrotized part, followed by anastomoses). Unstable $\to$ Perform PPD (Primary Peritoneal Drainage). When stabilized, definitive surgical intervention. Prevention of NEC Antenatal steroids: Dexamethasone/Betamethasone. Help in maturity of lungs $\to$ Preventing RDS (Respiratory Distress Syndrome). Also help in maturity of GIT $\to$ Preventing bacterial colonization $\to$ Preventing NEC. Minimal Enteral Nutrition (MEN): Especially helpful in small, preterm babies. In babies $ Should be given small amounts of enteral feeds (MEN) like expressed breast milk, using nasogastric tubes ($10$ ml/kg/day). This MEN helps in promoting the maturation of the GIT, decreasing the risk of NEC. AKA Trophic Feeds (Trophic = Growth). Enterally fed probiotics. Normal gut flora like Lactobacillus/Bifidobacterium spp. Prevent colonization from the pathogens. Respiratory Distress in Newborn Features of Respiratory Distress Any of the following must be present: Respiratory rate $> 60$/min. Chest retractions/indrawing. Grunting & cyanosis: Grunting $\to$ Expiration in a partially closed glottis by the baby to prevent collapse of alveoli. Produces a positive end expiratory pressure that prevents alveolar collapse. Causes of Respiratory Distress Pulmonary (more common) Non-Pulmonary TTNB (Transient Tachypnea of Newborn) (m/c). Respiratory Distress Syndrome (RDS). Meconium Aspiration Syndrome (MAS). Air leaks (Pneumothorax). Pneumonia. Anomalies: Congenital Diaphragmatic Hernia (CDH). Cardiac failure due to certain congenital heart diseases. Metabolic: Hypoglycemia, Hypocalcemia. Monitoring of Respiratory Distress Important scoring systems: Silverman Anderson Score. Downe's Score. Silverman Anderson Score: Useful for monitoring preterm babies with respiratory distress. Silverman Anderson Score Symptom 0 1 2 Upper chest retractions Synchronized Chest lags during breathing (abdomen moving outwards during inspiration, chest only slightly moving outwards) See saw respiration (abdomen moving outwards, chest moving inwards: Severe) Lower chest retractions No Mild Marked Nares dilatation/nasal flaring No Mild Marked Xiphoid retractions No Mild Marked Grunting No Heard with stethoscope Naked ear Interpretation: Minimum score 0: Normal. Maximum score 10: Completely abnormal. Score Degree of Respiratory Distress $ Mild respiratory distress $5-7$ Moderate respiratory distress $> 7$ Severe respiratory distress. Impending respiratory failure that requires advanced forms of ventilatory support. Downe's Vidyasagar Score Symptoms 0 1 2 Respiratory Rate $ $60-80$/min $> 80$/min or apnea Cyanosis No In room air With $\text{O}_2$ support at $\text{FiO}_2 \ge 40\%$ Air entry Normal Decreased Barely audible Retractions No Mild Marked Grunting No Heard with stethoscope Naked ear Interpretation: $\ge 7$: Severe distress and impending respiratory failure. Monitoring of Oxygen Saturation $\text{SpO}_2 Oxygen challenge: Give $\text{O}_2$ and observe change in $\text{SpO}_2$. $\ge 20\%$ improvement $\to$ No change or $ Transient Tachypnea of Newborn (TTNB) Risk factors: Lower segment Caesarean section (LSCS) in term/late preterm ($35-36$ weeks). Diabetic mothers. Reason: Delayed clearance of lung fluids. Mechanisms: In normal vaginal delivery, baby is squeezed & compressed and then delivered. The fluid is squeezed out of the lungs and baby can breathe freely. But in LSCS, no squeezing causes remnant fluid in the lungs and leading to distress. During delivery: Increased expression of ENac & $\text{Na}^+\text{K}^+\text{ATPase}$ channels. Helps in sodium and water reabsorption, clearing lung fluid. In LSCS, impaired expression of these channels. Presentation: Breathing difficulty within $6$ hours after birth. Chest X-ray: Fluid in the lungs. Perihilar streaks/sun burst appearance: Fluid in the bronchopulmonary structures. Fluid in the interlobar fissure. Management: Transient condition lasts up to $72$ hours. Only supportive treatment with $\text{O}_2$ inhalation. New guidelines of TTNB: Salbutamol inhalation in early TTNB increases expression of ENAC and $\text{Na}^+\text{K}^+\text{ATPase}$ channels. Respiratory Distress Syndrome (RDS) Occurs in preterm ($ Pathology: Hyaline membrane Disease (HMD). Reason: Deficit or immature surfactant levels. Surfactant: Produced by Type II pneumocytes. Keeps the alveoli open by decreasing the surface tension and prevents its collapse. In RDS, Immature/deficit surfactant: Collapsed alveoli $\to$ hypoxia and respiratory distress. Presentation: $ Tests for Fetal Lung Maturity These can be done in amniotic fluid/gastric juice after birth but are obsolete. Lecithin:Sphingomyelin ratio (L:S): Normally $> 2:1$. Phospholipids that compose surfactant, Lecithin: is the mature form, sphingomyelin is the immature form. more lecithin, more mature surfactant. Exception: Infant of diabetic mother (IDM): should be $> 3.5:1$. Phosphatidyl glycerol test: Better and more sensitive. Lamellar body count: Storage form of surfactant in Type II pneumocytes. Some detected in amniotic fluid. mature lung: $> 50,000$/microlitre. Shake test: $0.5$ ml of gastric aspirate $+ 0.5$ ml $95\%$ ethyl alcohol. Shake it vigorously for $10-15$ min and leave it for another $10-15$ min. Full rim of bubbles indicate positive test for lung maturation. Management of Respiratory Distress Syndrome Delivery Room Preterm baby $ Start CPAP (Continuous Positive Airway Pressure): Keeps alveoli open & prevents its collapse. $ This strategy is termed as early delivery room cpap with selective surfactant. ICU: Depends on Silverman scoring RDS Management $ Start warm humidified $\text{O}_2$. Target $\text{SpO}_2$ levels: $90-95\%$. $\text{SpO}_2 > 95\%$: Excess $\text{O}_2 \to$ Retinopathy of prematurity leading to blindness. $5-7$: moderate RDS. Start CPAP. Initial Pressure: $5$ cm $\text{H}_2\text{O}$. Pressure and $\text{O}_2$ concentration can be adjusted according to the response in the baby. $> 7$: Severe RDS. Intubation + endotracheal surfactant therapy. Standard guideline for surfactant therapy: Insure technique. Intubation $\to$ Surfactant $\to$ Extubation. (Standard Guideline) Newer Techniques for Surfactant Therapy Non invasive/less invasive: MIST: Minimally Invasive Surfactant Therapy. LISA: Less Invasive Surfactant Administration. Done using a feeding tube/tracheal catheter. Early rescue surfactant therapy: moderate RDS $\to$ CPAP $\to$ No response ($\text{FiO}_2 > 40\%$) $\to$ Surfactant therapy $\to$ Decrease the need for mechanical ventilation. Indications for surfactant therapy: Severe RDS. Moderate RDS with no response to CPAP. Antenatal Prevention of RDS Corticosteroids: To mothers who deliver at $24-34$ weeks. Corticosteroids Dose Betamethasone $12$ mg/dose, $2$ doses $24$ hours apart Dexamethasone (common in India) $6$ mg/dose, $4$ doses $12$ hours apart Benefits: Decreases incidence of Respiratory distress syndrome. Necrotizing enterocolitis. Intra ventricular hemorrhage in preterm babies. Overall neonatal mortality. Bronchopulmonary Dysplasia (BPD) / Chronic Lung Disease of Newborn Risk factors: Preterm babies born at $ Babies on $\text{O}_2$ support for $> 4$ weeks after birth. When to assess: $36$ weeks of post menstrual age. BPD $\text{O}_2$ Requirement Mild BPD No $\text{O}_2$ required Moderate BPD $\text{FiO}_2 Severe BPD $\text{FiO}_2 > 30\%$ or any form of ventilatory assistance Congenital Diaphragmatic Hernia (CDH) Intestines herniating from the abdominal cavity into the thoracic cavity. Type of Hernia Location of Defect Bochdalek hernia (m/c type) Posterolateral and left side of diaphragm Morgagni hernia (rare) Anterior aspect and right side of diaphragm Features of CDH: Compression of lungs $\to$ Lung hypoplasia $\to$ Respiratory distress after birth. Heart sounds on the right side due to right shift of the thoracic contents. Sunken (scaphoid) abdomen. Diagnosis of CDH Antenatal: USG between $16-24$ weeks. After birth: Chest X-ray. Air shadows in thoracic cavity indicating intestinal shadows. No definite diaphragm border on the left indicating defect in the diaphragm. Heart shadow on the right side. Absent air shadows in the abdomen. Management of CDH Management Treatment Medical management (First $48$ hours after birth). Aim: Promote lung maturation, Stabilize pulmonary hypertension due to lung compression. $> 48$ hours of life. Lung tissue repair. Patch Repair (Polytetrafluoroethylene: GORE-TEX). Treatment: ventilation. Conventional ventilation $\to$ HFOV (High Frequency Oscillatory ventilation) $\to$ ECMO (Extra Corporeal membrane Oxygenation). Approach: Subcostal approach as it helps in better visualization. Poor Prognostic Factors of CDH Antenatal Factors Postnatal Factors USG: Lung head ratio $ Degree of pulmonary hypertension: most important prognostic factor. Size of the defect. Early onset of respiratory distress $ MRI: Derived Total Lung volume (TLV) $ - Meconium Aspiration Syndrome (MAS) Common in post term babies (or) term babies with IUGR. Intrauterine stress $\to$ Increased motilin $\to$ Increased peristalsis of GIT $\to$ Expulsion of meconium in utero into amniotic cavity $\to$ Swallowed and aspirated $\to$ MAS. Chemical Pneumonitis. Consequences of MAS: Partial block of a main airway: Obstructive emphysema $\to$ Air trapping during exhalation $\to$ Hyperinflation in CXR. Complete block of a small airway: Segmental atelectasis. Meconium in alveoli: Chemical pneumonitis. Diagnostic Criteria for MAS Diagnosis of exclusion: Meconium Stained Liquor (MSL) at birth + Respiratory distress. X-ray: Coarse, ill defined infiltrates. Exclude other known conditions. Complication of MAS Air leaks like Pneumothorax. Persistent Pulmonary Hypertension of Newborn (PPHN). Management Symptomatic management according to ventilatory requirements like $\text{O}_2$ therapy or CPAP. PPHN: Inhaled Nitric Oxide (INO). Neonatal Hypoglycemia Hypoglycemia definition (WHO): Blood glucose $ Hypoglycemia can also be asymptomatic. Screening for Neonatal Hypoglycemia: 'At Risk' Babies Low substrate (low glycogen): Preterm babies $ Relative hyperinsulinemia: Large for gestation babies, infant of diabetic mother, Rh incompatibility (transient insulin increase). Sick baby: Neonatal sepsis, birth asphyxia, hypothermia. Hypoglycemia is screened by dipstick measurement of heel prick sample. Schedule of Screening for At Risk Babies At $2, 6, 12, 24, 48$ and $72$ hours after birth. Features of Neonatal Hypoglycemia Earliest: Jitteriness/tremors. Other features: Lethargy, weak cry, poor feeding pattern. Can present with seizures. Autonomic changes include sudden changes in heart rate, sudden pallor or episodes of hypothermia (rare in a newborn compared to older child or adults). Jitteriness vs Seizures Feature Jitteriness Seizures Stimulus Stimulus sensitive Not stimulus sensitive Eye deviation Not seen Seen Autonomic changes Not seen Seen Management Depends on symptomatic or asymptomatic. Symptomatic hypoglycemia: Emergency: Treated immediately with IV bolus $10\%$ Dextrose ($2$ ml/kg) followed by IV $10\%$ Dextrose infusion at $6$ mg/kg/min. Asymptomatic hypoglycemia (detected while screening): $ $20-45$ mg/dl: Oral feeds. Feed once $\to$ Recheck after $30$ to $45$ minutes. If normal $\to$ continue breastfeeding every $2$ hourly or as per baby's requirement. If $ Infant of Diabetic Mother (IDM) Pedersen's hypothesis: maternal hyperglycemia $\to$ sugar crosses placenta $\to$ hyperglycemia in fetus $\to$ increased secretion of insulin in fetus $\to$ excess growth (anabolism) $\to$ macrosomia (large for gestational age). Complications of infant of diabetic mother: Delivery complications: Shoulder dystocia, brachial plexus injury i.e. Erb's palsy, fractures of clavicle. Asymmetrical interventricular septal hypertrophy (form of hypertrophic cardiomyopathy): Transient condition. Increased demand of oxygen $\to$ increased RBC production $\to$ polycythemia $\to$ predisposition to thromboembolic manifestations (hypercoagulable blood). Increased insulin $\to$ interferes with surfactant maturation $\to$ respiratory distress syndrome.