Identification, Management & Referral of a Sick Neonate

Dr.Mahesh Hiranandani M.D(PGI)

Mamta child health care centre

My Perspective

Your perspective

Who is a Pediatric Practioner ?Who is a Pediatric Practioner ? * One doing OPD & attends to occasional* One doing OPD & attends to occasional

sick newborn babies.sick newborn babies.

* Attached to a maternity home, attends * Attached to a maternity home, attends

RES calls & refers if sick .RES calls & refers if sick .

* Actively attends RES calls ,manages in * Actively attends RES calls ,manages in

a specialized unit rarely refers.a specialized unit rarely refers.

Load of sick neonates in the region

Crude birth rate 22.8/1000 (2007) Population 16 Lacs Total live birth 36000

* TBA/ANM/Dai delivered. * GH-16. * PGIMER. * GMCH. * GH Mohali & Pkl . * ESI hosp, Polyclinics. * Approx 50 private maternity centers.

* A max of 50 NICU beds to cater to a * A max of 50 NICU beds to cater to a population of 3 million. population of 3 million. * At best 4 high level-II(>150/yr) & 6 basic * At best 4 high level-II(>150/yr) & 6 basic level-II(<100/yr) NICU’s.level-II(<100/yr) NICU’s.* Ventilation facilities(15 vents) complete with * Ventilation facilities(15 vents) complete with

laboratory, radiology & central oxygen laboratory, radiology & central oxygen at at

4 units.4 units. * 15 Pediatricians trained in neonatology for* 15 Pediatricians trained in neonatology for 3-24 months provide this care. 3-24 months provide this care.

Current status of newborn care in Current status of newborn care in Tri-cityTri-city

A max of 50 NICU beds ( 2008)Up from 6-8 beds (1995)

4 high level-II & 6 basic level-II NICU’s

Ventilation facilities(15) complete withCentral O2,lab & radiology at 4 centers.

15 Pediatricians trained in Neonatology (3-24 mths)

Which one of them is really sick ??Which one of them is really sick ??

Sickness markers in a newbornSickness markers in a newborn Refusal to feed Difficulty waking upRefusal to feed Difficulty waking up

Labored breathing Abnormal jerks Labored breathing Abnormal jerks

Urine voiding <6 Fewer than 2 stoolsUrine voiding <6 Fewer than 2 stools

Yellow color Blue or pale skinYellow color Blue or pale skin

Distended abdomen Projectile vomitingDistended abdomen Projectile vomiting

Physical signs that denote troublePhysical signs that denote trouble

Tachypnoea Grunting Apnoea Tachypnoea Grunting Apnoea

Bradycardia Cyanosis MurmurBradycardia Cyanosis Murmur

Plethora Pallor JaundicePlethora Pallor Jaundice

Hypotension Petechiae Hypotonia Hypotension Petechiae Hypotonia

Signs of sicknessSigns of sickness

What is a desirable clinical signWhat is a desirable clinical sign

– Singly or in combination, must have modest PPVSingly or in combination, must have modest PPV

Should score over Should score over “looks unwell”, “gut feeling”“looks unwell”, “gut feeling”

– Must not be infrequentMust not be infrequent

– There should be 2 sets of signsThere should be 2 sets of signs

Predictors of sickness/sepsis , ie need for referralPredictors of sickness/sepsis , ie need for referral

Predictors of moratlityPredictors of moratlity

Signs in PGI NICUSigns in PGI NICU

0 10 20 30 40 50 60

Grunt

Abd dist

Aspirates

Tachycardia

Fever

Retractions

Lethargy

Apnea

Unwell look

Tachypnea

Not feeding

Temp<35.5

PPV Frequency

Singh, Dutta, Narang et al, J Trop Ped, 2003

These 7 signs had PPV >30%

How does that help my practice?How does that help my practice?

Good predictors of Good predictors of

sickness & sepsis:sickness & sepsis:

– Lethargy, Lethargy,

� ↓↓ feeding, feeding,

– fever, fever,

– retract’sretract’s

� ↓↓ movem’ts, movem’ts,

– abd distension, abd distension,

– tachypneatachypnea

• Good predictors of mortality

• Hypotension

• Hypothermia

• Hypoxemia

• Acidemia

• Multiple seizures

• Oliguria

• ELBW

• SGA

• Asphyxia

Commonest neonatal problemsCommonest neonatal problems

* Prematurity & low birth weight.* Prematurity & low birth weight.

* Suspected & manifest sepsis.* Suspected & manifest sepsis.

* Birth asphyxia.* Birth asphyxia.

* Respiratory problems.* Respiratory problems.

* Neonatal hyperbilirubinemia.* Neonatal hyperbilirubinemia.

* Metabolic problems: Hypoglycemia.* Metabolic problems: Hypoglycemia.

* Surgical problems. * Surgical problems.

* Congenital malformations.* Congenital malformations.

Care of newborn in a Maternity homeCare of newborn in a Maternity home

Myth-1: Providing primary care Myth-1: Providing primary care

to a newborn is expensive.to a newborn is expensive.

Myth-2: Highly qualified and Myth-2: Highly qualified and

trained nurses are essential.trained nurses are essential.

Myth-3: Pediatrician can be Myth-3: Pediatrician can be

called if the baby is born sick. called if the baby is born sick.

Fact: It is cheaper than Fact: It is cheaper than

creating a setup for D & C.creating a setup for D & C.

Fact: Unqualified staff & mothersFact: Unqualified staff & mothers

can be trained to look after a can be trained to look after a

sick baby under supervisionsick baby under supervision

Fact: Its all over… Asphyxia is a Fact: Its all over… Asphyxia is a

lethal game of 5 mins. lethal game of 5 mins.

Is the welfare of newborn responsibility of a Pediatrician alone

Lets lobby for the respectful survival of fetus

Integration of maternity & neonatal health care Services is the most desired need of the hour..

Good antenatal care Safe child birth

Good Resuscitation facility

Early & exclusive breast feeding

Compassionate nursing

Neonatal ResuscitationNeonatal Resuscitation* * “ Pediatrician On call ” concept must go .“ Pediatrician On call ” concept must go .

NRP GuidelineNRP Guideline

“ “ Well trained personnel must be present at Well trained personnel must be present at the site of Infant delivery. ”the site of Infant delivery. ”

Preparation & anticipation is the key. Preparation & anticipation is the key.

Identify & train the right personnel.Identify & train the right personnel.

What is the cost of creating a What is the cost of creating a Resuscitator ??? Resuscitator ???

Rs.30000/

Rs.3000/

Rs.15000/

Total costRs.50000/

Cost of a complete resuscitation trolley

??????

Things to avoid in Resuscitation

* Do not overdo the suction… its noxious.

* Donot panic if ET cant be put in… Bag & Mask

* Avoid high O2 conc to resuscitate a premmy.

•Be gentle on the Ambu… TV of 250 v/s 35 ml.

Things to avoid in Resuscitation

Sod bicarbonate is reserved for specific use.

Donot give volume expanders casually.

Do not focus heavily on cardiac resuscitation.

No role of steroids, Calcium, Coramine etc.

Birth AsphyxiaBirth Asphyxia

A baby born asphyxiatedA baby born asphyxiated

???? Guilt & FEAR ???? Guilt & FEAR

* 1-2 % incidence at best Delivery rooms.* 1-2 % incidence at best Delivery rooms.

* Term IDM’s , IUGR , Breech & Post date.* Term IDM’s , IUGR , Breech & Post date.

* Incorrect reporting of APGAR scores. * Incorrect reporting of APGAR scores.

Birth AsphyxiaBirth Asphyxia

Non Funct ioning Non Funct ioning equipment equipment

& & An An

I ncompet ent / Missing I ncompet ent / Missing Resuscit at orResuscit at or

Per f ect Recipe f or Per f ect Recipe f or long CPA bat t le long CPA bat t le

Organ dysfunction in AsphyxiaOrgan dysfunction in Asphyxia

BrainBrain : HIE manifests as gamut of signs.: HIE manifests as gamut of signs.(100%)(100%)

Seizures are seen in upto 50% cases.Seizures are seen in upto 50% cases.

Raised ICP indicates poor prognosis.Raised ICP indicates poor prognosis.

PulmonaryPulmonary : PPHN, MAS, Edema & RDS: PPHN, MAS, Edema & RDS(85%)(85%)

KidneyKidney : ATN seen in upto 70%: ATN seen in upto 70% OLIGURIA OLIGURIA

HeartHeart : TR, Poor LV function & PAH : TR, Poor LV function & PAH (60%)(60%)

GI Sys GI Sys : Bowel ischemia & NNEC : Bowel ischemia & NNEC (15%).(15%).

Hematologic & Hepatic effects Hematologic & Hepatic effects

Management of AsphyxiaManagement of Asphyxia

Identify & keep a close watch on all HRPs.Identify & keep a close watch on all HRPs. Involve the Pediatrician during ANP Involve the Pediatrician during ANP

Meticulous intrapartum monitoring.Meticulous intrapartum monitoring. Perinatal team on standby 24X7.Perinatal team on standby 24X7.

Management of AsphyxiaManagement of Asphyxia

At Birth At Birth : Prevent hypothermia by all means.: Prevent hypothermia by all means. Minimize hypoxia & assess acidosis.Minimize hypoxia & assess acidosis.

NICU NICU : Judicious FLUID …. Do not overload.: Judicious FLUID …. Do not overload. Smooth Ventilation & Oxygenation.Smooth Ventilation & Oxygenation. Seizure control using all modalities.Seizure control using all modalities. Phenobarbitone--Pheytoin--MidazolamPhenobarbitone--Pheytoin--Midazolam W/F : Raised ICP, Oliguria Cardiac dys & PPHN W/F : Raised ICP, Oliguria Cardiac dys & PPHN

Neonatal SepsisNeonatal Sepsis * Neonatal sepsis is a major killer. ( 52% mort)* Neonatal sepsis is a major killer. ( 52% mort)

SUSPECT DIAGNOSE MANAGESUSPECT DIAGNOSE MANAGE

Early onsetEarly onset Birth canal Birth canal Late onsetLate onset EnvironmentEnvironment

Risk factors: Risk factors: Prematurity,POL/PROM>24 hrsPrematurity,POL/PROM>24 hrs

Freq P/V, cervical sutures etcFreq P/V, cervical sutures etc

Maternal infections UTI,Diarrhoea. Maternal infections UTI,Diarrhoea.

Asphyxia & Meconium aspiration Asphyxia & Meconium aspiration

Late onsetLate onset Preterm,Prolonged IV/ AntibioticsPreterm,Prolonged IV/ Antibiotics CommunityCommunity acquiredacquired Poor hygiene, bottle feeding, overcrowdingPoor hygiene, bottle feeding, overcrowding

Neonatal SepsisNeonatal SepsisMicrobiology:Microbiology: How often do you identify the bug.How often do you identify the bug.

Manifestations:Manifestations:

Early signs are subtle noted by mother/nurse. Early signs are subtle noted by mother/nurse.

“ “Looking unwell”....... Looking unwell”....... Cold mottled limbs Cold mottled limbs

Resp dist,Poor feeding,Vomiting & Full abd Resp dist,Poor feeding,Vomiting & Full abd

Lethargy, Irritability & Temp instability.Lethargy, Irritability & Temp instability.

Fulminant sepsisFulminant sepsis

Cyanosis, Apnoea, Seizures, Bleeding &ScleremaCyanosis, Apnoea, Seizures, Bleeding &Sclerema

Vague symptoms Vague symptoms Low thresh hold for sepsis Low thresh hold for sepsis evaluationevaluation..

Sepsis EvaluationSepsis Evaluation ““No sure shot test to document sepsis”No sure shot test to document sepsis”

CBC :CBC : TLC <5000/TLC <5000/mm3mm3 ANC > 1750/ ANC > 1750/mm3mm3

I/T ratio ( >0.2) Band cells > 2000/I/T ratio ( >0.2) Band cells > 2000/mm3 mm3

Platelet count low in 25 % .Platelet count low in 25 % .

Blood culture : Blood culture : Gold standard for sepsisGold standard for sepsis

Ideal volumeIdeal volume 1 ML 1 ML (63-(63-98%) 98%)

Ideal timeIdeal time 48 hrs 48 hrs (97%)(97%)

Acute phase reactants : Acute phase reactants :

CRP is the most studied & reliable CRP is the most studied & reliable

Levels of more than 10mg/dl suggest sepsis.Levels of more than 10mg/dl suggest sepsis. Daily serial values are 80-90% sensitive Daily serial values are 80-90% sensitive Bentz 1998Bentz 1998

uESR in service for past 50 years.uESR in service for past 50 years.

Upper limit = Age in days + 3 mm/hr.Upper limit = Age in days + 3 mm/hr.

Poor & variable sensitivity of 30-70%. Poor & variable sensitivity of 30-70%. Sepsis screen is a combination of tests for rapid diagnosis of sepsisSepsis screen is a combination of tests for rapid diagnosis of sepsis

TLC/ANC, I/T ratio, CRP & uESRTLC/ANC, I/T ratio, CRP & uESR

11 rpt at 24 hrs 2 rpt at 24 hrs 295% sen 395% sen 3 Presume sepsis+ Presume sepsis+

Treatment of Neonatal SepsisTreatment of Neonatal Sepsis

Decision to Treat:Decision to Treat: Risk factors, Clinical signsRisk factors, Clinical signs

Results of sepsis screen.Results of sepsis screen.

Choice of Antibiotics : Choice of Antibiotics : ? Vanco ? Vanco ? Merop ? Merop Piper? Piper?

Is it fashionable to use newer antibiotics only?Is it fashionable to use newer antibiotics only?

Organism Sensitivity ExperienceOrganism Sensitivity Experience

Empirical therapyEmpirical therapy Ampicillin+ Aminogly / IIICephalo Ampicillin+ Aminogly / IIICephalo

IV & IV not IM IV & IV not IM Co-amoxy + III Cephalo Co-amoxy + III Cephalo

Duration of ABs: Duration of ABs: Level of suspicion of sepsisLevel of suspicion of sepsis Diagnostics & Cl course.Diagnostics & Cl course.

Treatment of Neonatal Sepsis

Decision to treat : Risk factors, Clinical picture Results of sepsis screen.

Choice of Antibiotics: ? Vanco ?Merop ? Piper

Organism Sensitivity Experience

Empirical therapy Ampicillin + AminoG/Cephalo III Coamoxyclav + Cephalo III

Duration of antibioticsLevel of suspicion of sepsis Diagnostics & Clinical course

JAUNDICE IN NEW BORN JAUNDICE IN NEW BORN BABIESBABIES

Yellow discolouration of skin ,eyes & mucosaYellow discolouration of skin ,eyes & mucosaAdults appear icteric at 2Mg & neonate at 7 mg% Adults appear icteric at 2Mg & neonate at 7 mg%

PHYSIOLOGICAL PATHOLOGICALPHYSIOLOGICAL PATHOLOGICAL * Almost 100% develop* Almost 100% develop. . * 10% develop.* 10% develop.

* Appears 48hrs,peaks 72hrs* Appears 48hrs,peaks 72hrs. . * Early onset, delayed peak* Early onset, delayed peak * Light staining * Light staining * Deeper staining* Deeper staining * No Rx needed* No Rx needed. . * Phototherapy/Exchange* Phototherapy/Exchange

Which baby Which baby is heading is heading towards pathological Jaundice ?towards pathological Jaundice ?

ASSESSMENT OF SEVERITY ASSESSMENT OF SEVERITY OF JAUNDICEOF JAUNDICE

Examine all babies every 36-48hrly till Day7.Examine all babies every 36-48hrly till Day7.

Assess Jaundice in good day light.Assess Jaundice in good day light.

Jaundice progresses in Cephalo-caudal direction.Jaundice progresses in Cephalo-caudal direction.

Staining below knee/Wrist corresponds to high TSBStaining below knee/Wrist corresponds to high TSB

Skin assessment could be fallacious after PT.Skin assessment could be fallacious after PT.

IS Physical Exam For Jaundice Reliable ?

When in Doubt …… Always ask for a TSBWhen in Doubt …… Always ask for a TSB

Bare minimum Lab analysisBare minimum Lab analysis

TSB, Blood group, Rh typing & Coombs*TSB, Blood group, Rh typing & Coombs*

Blood film, Reticulocyte, G6PD & PCV.Blood film, Reticulocyte, G6PD & PCV.

Prolonged Jaundice( >2weeks)Prolonged Jaundice( >2weeks)

Direct Bilirubin, thyroid functions, urine c/sDirect Bilirubin, thyroid functions, urine c/s

TORCH analysis, Metabolic screenTORCH analysis, Metabolic screen

Liver function test & Ultrasound abdomenLiver function test & Ultrasound abdomen

Neonatal HyperbilirubinemiaNeonatal Hyperbilirubinemia

Treatment of Neonatal Hyperbilirubinemia

Depends upon weight, gestation,TSB & level of sickness.

Phototherapy Effective modality to treat levels upto 20 mg%. Types: Double surface, CFL, LED, Biliblanket. Ideal distance 15-30cms Irradiance > 10uw/cm2. Tough to maintain temperature in winters. Skin assessment fallacious, repeat TSB 12 hrly. When to stop PT Term at 13 & preterm at 10mg. Maintain Hydration & nutrition for better results. Discourage Home PT ,Sun therapy & Luminal.

Exchange Transfusion For Jaundice

Exchange Transfusion in a term at TSB> 25mg%.

Fresh blood (<7ds), 160ml/kg in CPD used.

IV line secured for glucose, Calcium & other drugs.

Exchange aliquots <1.5kg--5ml 1-5 to 2-5kg--10ml

TSB & PCV done at 4Hrs, Intensive PT to continue.

W/F Hypocalcemia, hypoglycemia & hyperkalemia

Whats new For babies with Jaundice…

Oral Agar Effective in term breast/formula fed babies with TSB>15mg. Economical and shortens the duration of PT.High dose IVIg O.5-1gm/kg used in Iso immune hemolysis. Acts by coating the Fc rec.Metalloporphyrins Tin/Zinc porphy inhibit heme oxygenase used in ABO & Criggler najar synd.

Respiratory Distress SyndromeRespiratory Distress Syndrome

Commonest & most feared problem in NICUCommonest & most feared problem in NICU

“ “ Preterm boy born by LSCS to Diabetic mother Preterm boy born by LSCS to Diabetic mother developing Asphyxia”developing Asphyxia”

Prenatal DiagnosisPrenatal Diagnosis

* L/S ratio * Lamellar body count* L/S ratio * Lamellar body count

Antenatal steroids Antenatal steroids

Betamethasone(2) or Dexamethasone(4) to allBetamethasone(2) or Dexamethasone(4) to all

mothers between 24-34 wks with intact membsmothers between 24-34 wks with intact membs

Incidence falls by 50%, Mortality by 40%. Incidence falls by 50%, Mortality by 40%.

Respiratory SupportRespiratory Support

Most premmies with RDS need resp support.Most premmies with RDS need resp support.

Oxygen therapyOxygen therapy

* RR>60,retractions, Flare,grunting & low * RR>60,retractions, Flare,grunting & low spo2spo2

* Warm & humidified O2 to maintain * Warm & humidified O2 to maintain Spo2 90-95% Spo2 90-95%

* Head box, nasal prongs/catheter… * Head box, nasal prongs/catheter… WAFTINGWAFTING

* Warmidifiers & O2 concentrators* Warmidifiers & O2 concentratorsReliableReliable

Flow rates : Head box (3lit) Prongs( 1-2lit)Flow rates : Head box (3lit) Prongs( 1-2lit)

NP catheter (1lit) NP catheter (1lit)

Surfactant Replacement TherapySurfactant Replacement Therapy

Best studied therapy – Is almost a miracle Rx.Best studied therapy – Is almost a miracle Rx. Billions of bubbles created by SURF inflates the lungs.Billions of bubbles created by SURF inflates the lungs.

* Type : * Type : Natural preferred over syntheticNatural preferred over synthetic

* Timing : * Timing : Prophylactic- Given soon after birth.Prophylactic- Given soon after birth.

Early rescue- Given as distress sets Early rescue- Given as distress sets

* Dose : * Dose : 100mg/kg through an ET tube.100mg/kg through an ET tube.

* Effects : * Effects : Inflates lung & improves oxygenationInflates lung & improves oxygenation

Reduces risk of air leaks & early recoveryReduces risk of air leaks & early recovery

Respiratory SupportRespiratory Support How do you assess worsening RDS…. How do you assess worsening RDS….

Clinical scoring, Spo2, Blood gases, XrayClinical scoring, Spo2, Blood gases, Xray

FiO2 levelsFiO2 levels

Also look at Perfusion, BP & urine output.Also look at Perfusion, BP & urine output.

What can you do before this baby crashes…What can you do before this baby crashes…

CPAP CPAP

Halts progression, Less barotraumaHalts progression, Less barotrauma

Noninvasive, easy to use & avoids IMVNoninvasive, easy to use & avoids IMV

MethodMethod Nasal, Nasopharyngeal & ET Nasal, Nasopharyngeal & ET

Respiratory SupportRespiratory Support

CPAPCPAP Disadvantages Disadvantages * Doesnot improve ventilation infact worsens it. * Doesnot improve ventilation infact worsens it.

* Hypercarbia & impaired cardiac output .* Hypercarbia & impaired cardiac output .

* Maintaining it in a large child difficult.* Maintaining it in a large child difficult.

Mechanical VentilationMechanical Ventilation

* Amazing range of neonate specific ventilators.* Amazing range of neonate specific ventilators.

* Goal is to limit TV & Ti, avoid collapse & wean.* Goal is to limit TV & Ti, avoid collapse & wean.

* SIMV is the preferred mode of ventilation.* SIMV is the preferred mode of ventilation.

Meconium Aspiration SyndromeMeconium Aspiration Syndrome

* MSAF is seen in upto 10-15% live births* MSAF is seen in upto 10-15% live births

* Postmature, SGA, Presentation & CORD* Postmature, SGA, Presentation & CORD

Can MAS be prevented ?? Can MAS be prevented ??

Intrapartum monitoring AmnioinfusionIntrapartum monitoring Amnioinfusion

Should all infants be subjected to NP/TRAC SuctionShould all infants be subjected to NP/TRAC Suction

PPHN the most feared complication.PPHN the most feared complication.

Rx : Mag sulph, ??Oral viagra , HFV & iNORx : Mag sulph, ??Oral viagra , HFV & iNO

Prolonged O2 dependence is common.Prolonged O2 dependence is common.

Extremely Low birth weight baby ( < 1000grams)

Unique group , Fragile & sensitive to changes .

Standard management protocols ensures good results.

Collobrative efforts between HRP & Level 3 NICU teams. What is a viable Micropremmy ?????? > 23 weeks > 500 Grams

Never Ever Give Up On Them

How Invasive One should be while caring for a ELBW

Extremely Low Birth Weight Infant

Minimum procedures & handling is the key. Challenge to manage ROP in an ELBW baby. Course of stay always stormy & eventful.

Maintaining prolonged IV access a problem.

Morbidity Mortality Parental concern COST

26 weeks 475 gms Survived Intact Thriving

Minimum handling Bare essential tests Early trophic feeds Meticulous monitoring

Non invasive Neonatology

Nano Baljeet

ELBW – Standard Care Protocol

Prenatal Consultation Parental education & participation .

Resuscitation Define limits Minimize heat losses Early SRT & Resp suppt.

Ventilation strategy Low TV short Ti Avoid Hyperoxia & Hypocapnia

Fluid therapy Limit losses Restrict boluses Maintain Electrolytes I/O

Nutrition Early trophic feeds & TPN

Patent ductus arterious Avoid fluid overload Early medical Treatment

Infection Control Meticulous hand washing Limit invasive handling

Cost of careCost of care “ “ The average cost of treatment per baby per day The average cost of treatment per baby per day In a high level-II NICU is around Rs. 3000-5000/.In a high level-II NICU is around Rs. 3000-5000/.Additional cost for ventilation is around Rs. 3000/.”Additional cost for ventilation is around Rs. 3000/.”

* * Infrastructure * Equipment * Nursing care Infrastructure * Equipment * Nursing care

* Drugs & Disposables * Oxygen * Laboratory* Drugs & Disposables * Oxygen * Laboratory

* Biomedical waste * Power backup * Security* Biomedical waste * Power backup * Security

* Insurance * Staff * Repairs * Taxes * Insurance * Staff * Repairs * Taxes

Which baby may be referred?Which baby may be referred?

Who needs continuous electronic monitoringWho needs continuous electronic monitoring– HR, SpOHR, SpO2,2, BP, CVP BP, CVP

Who requires investigations that areWho requires investigations that are– Either too specialized (eg. metabolic, endocrine, etc)Either too specialized (eg. metabolic, endocrine, etc)– Or need physical presence of baby (neuro-imaging, EEG, Or need physical presence of baby (neuro-imaging, EEG,

advanced radiology, pathology etc)advanced radiology, pathology etc)

Who requires specialized evaluationWho requires specialized evaluation– Uncertain diagnosisUncertain diagnosis– Specialized opinion (Genetics, Hemat, Neuro, Cardiac etc)Specialized opinion (Genetics, Hemat, Neuro, Cardiac etc)

Who needs specialized interventionWho needs specialized intervention– TPNTPN– VentilationVentilation– InotropesInotropes– Invasive procedures (chest drain etc) Invasive procedures (chest drain etc)

Who should not be referred?Who should not be referred?

Babies >1500 g, but fairly problem-freeBabies >1500 g, but fairly problem-free

Birth asphyxia with no Stage II-III HIE or Birth asphyxia with no Stage II-III HIE or end-organ damageend-organ damage

All unconjugated jaundiceAll unconjugated jaundice– Exceptions: Rh isoimmunized or hydropic or Exceptions: Rh isoimmunized or hydropic or

kernicterickernicteric

Sepsis with no resp/hemodynamic/renal Sepsis with no resp/hemodynamic/renal compromise & no organ dysfunction compromise & no organ dysfunction

Things to do before referringThings to do before referring

Stabilize for transportStabilize for transport

Write a detailed referral summaryWrite a detailed referral summary

Talk to receiving consultantTalk to receiving consultant

Talk to familyTalk to family

StabilizationStabilizationS= SugarS= Sugar– Ensure BS is well above lower cut-offEnsure BS is well above lower cut-off

T= TemperatureT= Temperature– Euthermic. No cold stress.Euthermic. No cold stress.

A= Airway patentA= Airway patent– Clear secretions, ensure correct position, intubate if necessaryClear secretions, ensure correct position, intubate if necessary

B= Blood testsB= Blood tests– Ensure all reports, incl. Xrays attachedEnsure all reports, incl. Xrays attached

– Pending reports (eg. blood culture) mentionedPending reports (eg. blood culture) mentioned

L= Lines & tubes fastenedL= Lines & tubes fastened– IV canulas, OG tubes, ET tubes well fastenedIV canulas, OG tubes, ET tubes well fastened

– Write whether tubes repositioned after last XrayWrite whether tubes repositioned after last Xray

E= Emotional supportE= Emotional support

It is unfair to send a moribund patient to an institution just to get rid of the patient

before death

Talking to familyTalking to family

Do not give false hopesDo not give false hopes– जातेजाते हीही बेडबेड िमिलिमिल जाएगाजाएगा– जसैेजसैे हीही मिशीनमिशीन मिेमिे डालगेेडालगेे सबसब ठीकठीक होहो जाएगाजाएगा

Do not create impression that everything Do not create impression that everything is free & everyone can be made “poor is free & everyone can be made “poor free” in government hospitalsfree” in government hospitals

Give realistic idea of prognosisGive realistic idea of prognosis

Keep channels open for back referralKeep channels open for back referral

ConclusionsConclusions

Think before you referThink before you refer– A lot of problems can be tackled locallyA lot of problems can be tackled locally

Certain clinical signs are better predictors Certain clinical signs are better predictors of sickness & death than othersof sickness & death than others

Stabilize patients before referralStabilize patients before referral

Communicate with receiving consultant & Communicate with receiving consultant & with familywith family

Make comprehensive referral summaryMake comprehensive referral summary

My Special Thanks to

Dr. Sourabh Dutta Add Professor, Neonatology , PGIMER, Chandigarh Nestle Nutrition services .

My Staff at Mamta child health care centre

Cosmo Hospital Mohali

All the lil babies that we have cared for…………

Thanks for your attention

All Sickly newborns deserve an ambulance like this one.

Good resuscitation facility

VLBW babies with susp. sepsisVLBW babies with susp. sepsis

Fanaroff, PIDJ, 1998

0 20 40 60

Apneas*

GI problems

Increased O2*

Increased vent*

Feed intol.

Lethargy*

Temp instab

Hypotension*

Frequency

PPV

*= p<0.05

Transport of a sick Neonate “ The best transport incubator is the uterus” Within the city (upto 20 kms) Round the clock equipped & staffed ambulance avialable at Rs.2000/.

Outside the city (up to 50 kms) Facility available at Rs.5000/

“ Any takers for developing this facility a lil further”

Need for referral Need for referral

* Referrals are seldom made by the practioners.* Referrals are seldom made by the practioners.

* Lack of trust in the treating team ….* Lack of trust in the treating team ….

* More often financial compulsions.* More often financial compulsions.

* Surgical problem with medical presentation.* Surgical problem with medical presentation.

* Suspected cardiac lesion.* Suspected cardiac lesion.

Referral by the primary CaretakerReferral by the primary Caretaker * Communicate the need for transfer.* Communicate the need for transfer.

* Notify the referral hospital.* Notify the referral hospital.

* Arrange for safe transport.* Arrange for safe transport.

* Detailed referral note attached.* Detailed referral note attached.

* Follow up the progress of baby.* Follow up the progress of baby.

Referral against adviseReferral against advise * Liability of Rx details & transport.* Liability of Rx details & transport.

* Should clearance of bill be made an issue?* Should clearance of bill be made an issue?

PrematurityPrematurity * VLBW may survive HMD to get NEC at 5 weeks.* VLBW may survive HMD to get NEC at 5 weeks.

* To manage severe ROP in VLBW is a challenge.* To manage severe ROP in VLBW is a challenge.

* Minimum procedures, sampling & handling is the key.* Minimum procedures, sampling & handling is the key.

* Maintaining prolonged IV access is a problem. * Maintaining prolonged IV access is a problem.

Neonatal jaundiceNeonatal jaundice Exchange transfusion at TSB> 24mg%.Exchange transfusion at TSB> 24mg%.

CFL phototherapy is the most effective.CFL phototherapy is the most effective.

TSB at 24 hrs age a reliable indicator.TSB at 24 hrs age a reliable indicator.

Are you checking the photo irradiance ??. Are you checking the photo irradiance ??.

* A max of 50 NICU beds to cater to a * A max of 50 NICU beds to cater to a population of 3 million. population of 3 million. * At best 4 high level-II(>150/yr) & 6 basic * At best 4 high level-II(>150/yr) & 6 basic level-II(<100/yr) NICU’s.level-II(<100/yr) NICU’s.* Ventilation facilities(15 vents) complete with * Ventilation facilities(15 vents) complete with

laboratory, radiology & central oxygen laboratory, radiology & central oxygen at at

4 units.4 units. * 15 Pediatricians trained in neonatology for* 15 Pediatricians trained in neonatology for 3-24 months provide this care. 3-24 months provide this care.

Current status of newborn care in Current status of newborn care in Tri-cityTri-city

Transport of the sick neonateTransport of the sick neonate“ “ The best transport incubator is the uterus ”The best transport incubator is the uterus ”

Within the city( up to 20kms)Within the city( up to 20kms)

* Round the clock ambulances equipped * Round the clock ambulances equipped

and staffed available at Rs.2000/ (3).and staffed available at Rs.2000/ (3).

Outside the city( up to 50 kms) Outside the city( up to 50 kms)

* Facility available at Rs.5000/. * Facility available at Rs.5000/. Any takers for developing this facility a Any takers for developing this facility a

lil furtherlil further

Role of ObstetriciansRole of Obstetricians““Is welfare of a Newborn responsibility of Pediatrician Is welfare of a Newborn responsibility of Pediatrician

alone”alone” Lets lobby for the right of fetus for a respectful survivalLets lobby for the right of fetus for a respectful survival

All that it takes is :All that it takes is :

* Good antenatal care * Provision of asepsis* Good antenatal care * Provision of asepsis

* Adequate feeding * Adequate feeding

Integration & coordination of Maternity homes & Integration & coordination of Maternity homes & Level-II neonatal care is the most desired needLevel-II neonatal care is the most desired need

PHOTO LUX METER

It measures luminance of light. Reliable & inexpensive.

1uw/cm2/nm = 600 lux

Please appreciate the baby’s struggle inside a head box

Non contact Oxygen delivery Non contact Oxygen delivery

* Wafting : Aiming stream of O2 at the patient.* Wafting : Aiming stream of O2 at the patient.

to produce initial relief & enablingto produce initial relief & enabling

child to sleep hence allowing furtherchild to sleep hence allowing further

management.management.

* Efficacy of wafting O2 therapy not quantified.* Efficacy of wafting O2 therapy not quantified.

* Methods : Resuscitator bag, Baby face mask* Methods : Resuscitator bag, Baby face mask

standard green oxygen tubing. standard green oxygen tubing.

A novel & cost effective O2 delivery methodA novel & cost effective O2 delivery method

“ “ A twin holed feeding tube directing a streamA twin holed feeding tube directing a stream

of O2 at the nostrils is a very effective ,easy of O2 at the nostrils is a very effective ,easy

and affordable step down O2 delivery method”and affordable step down O2 delivery method”

Indications:Indications:

1. Prolonged O2 dependence as in MAS1. Prolonged O2 dependence as in MAS

Cong Pneumonias & HMD.Cong Pneumonias & HMD.

2. In children who do not tolerate mask, prongs 2. In children who do not tolerate mask, prongs

or even head box. or even head box.

“ “IT saves on the cost of Oxygen”IT saves on the cost of Oxygen”

Venous access in difficult situation

Focus a halogen lampOn cannulation site for3-5 mins to produce Warming & venodilatation.

Infusates & Antibiotics: Infusates & Antibiotics: Never use the top port for injections.Never use the top port for injections.

Antibiotics/Injections are diluted appropriately.Antibiotics/Injections are diluted appropriately.

“ “Reverse injections”Reverse injections”

Daily dose of antibiotics & other drugs Daily dose of antibiotics & other drugs

are injected through a 3- way connector are injected through a 3- way connector

in reverse direction towards the Pediatric in reverse direction towards the Pediatric

Infusion set and later drip is restarted. This Infusion set and later drip is restarted. This

ensures a uniform slow rate of antibioticensures a uniform slow rate of antibiotic

delivery thus preventing thrombophlebitis.delivery thus preventing thrombophlebitis.

This is why I do it… Thank youThis is why I do it… Thank you

Current status of Neonatal care in Current status of Neonatal care in regionregion

* Paradoxical situation of inadequate NSCU’s* Paradoxical situation of inadequate NSCU’s

in spite of growing enthusiasm about in spite of growing enthusiasm about neonatal care amongst the Pediatricians.neonatal care amongst the Pediatricians.

* *

Twin holed nasal catheter delivering direct stream of oxygen at nostrils is an ideal step down O2 delivery system.

It is well tolerated & allows feeding, bathing & handling of the baby .

It saves on the cost of O2.

TREATMENT OF NEONATAL TREATMENT OF NEONATAL JAUNDICEJAUNDICE

Depends upon weight, gestation, birth history & sicknessDepends upon weight, gestation, birth history & sickness TREATMENT MODALITIESTREATMENT MODALITIES Phototherapy Phototherapy

Effective modality to treat mod levels (upto 20 mg%).Effective modality to treat mod levels (upto 20 mg%).Types : Conventional, double surface ,Halogen, CFL & LEDTypes : Conventional, double surface ,Halogen, CFL & LEDEyes & male genitalia should be covered.Eyes & male genitalia should be covered.Hydration & nutrition should be adequately maintained.Hydration & nutrition should be adequately maintained.Bilirubin should be monitored at 12-24 hrly interval.Bilirubin should be monitored at 12-24 hrly interval.

Is Your PT machine good enough ??? Is Your PT machine good enough ???

Conclusions

• Think before you refer– A lot of problems can be tackled locally

• Certain clinical signs are better predictors of sickness & death than others

• Stabilize patients before referral

• Communicate with receiving consultant & with family

• Make comprehensive referral summary

Conclusions

• Think before you refer– A lot of problems can be tackled locally

• Certain clinical signs are better predictors of sickness & death than others

• Stabilize patients before referral

• Communicate with receiving consultant & with family

• Make comprehensive referral summary

Conclusions

• Think before you refer– A lot of problems can be tackled locally

• Certain clinical signs are better predictors of sickness & death than others

• Stabilize patients before referral

• Communicate with receiving consultant & with family

• Make comprehensive referral summary

Which baby may be referred?Which baby may be referred?

Who needs continuous electronic monitoringWho needs continuous electronic monitoring– HR, SpOHR, SpO2,2, BP, CVP BP, CVP

Who requires investigations that areWho requires investigations that are– Either too specialized (eg. metabolic, endocrine, etc)Either too specialized (eg. metabolic, endocrine, etc)– Or need physical presence of baby (neuro-imaging, EEG, Or need physical presence of baby (neuro-imaging, EEG,

advanced radiology, pathology etc)advanced radiology, pathology etc)

Who requires specialized evaluationWho requires specialized evaluation– Uncertain diagnosisUncertain diagnosis– Specialized opinion (Genetics, Hemat, Neuro, Cardiac etc)Specialized opinion (Genetics, Hemat, Neuro, Cardiac etc)

Who needs specialized interventionWho needs specialized intervention– TPNTPN– VentilationVentilation– InotropesInotropes– Invasive procedures (chest drain etc) Invasive procedures (chest drain etc)

Who should not be referred?Who should not be referred?

Babies >1500 g, but fairly problem-freeBabies >1500 g, but fairly problem-free

Birth asphyxia with no Stage II-III HIE or Birth asphyxia with no Stage II-III HIE or end-organ damageend-organ damage

All unconjugated jaundiceAll unconjugated jaundice– Exceptions: Rh isoimmunized or hydropic or Exceptions: Rh isoimmunized or hydropic or

kernicterickernicteric

Sepsis with no resp/hemodynamic/renal Sepsis with no resp/hemodynamic/renal compromise & no organ dysfunction compromise & no organ dysfunction

Things to do before referringThings to do before referring

Stabilize for transportStabilize for transport

Write a detailed referral summaryWrite a detailed referral summary

Talk to receiving consultantTalk to receiving consultant

Talk to familyTalk to family

StabilizationStabilizationS= SugarS= Sugar– Ensure BS is well above lower cut-offEnsure BS is well above lower cut-off

T= TemperatureT= Temperature– Euthermic. No cold stress.Euthermic. No cold stress.

A= Airway patentA= Airway patent– Clear secretions, ensure correct position, intubate if necessaryClear secretions, ensure correct position, intubate if necessary

B= Blood testsB= Blood tests– Ensure all reports, incl. Xrays attachedEnsure all reports, incl. Xrays attached

– Pending reports (eg. blood culture) mentionedPending reports (eg. blood culture) mentioned

L= Lines & tubes fastenedL= Lines & tubes fastened– IV canulas, OG tubes, ET tubes well fastenedIV canulas, OG tubes, ET tubes well fastened

– Write whether tubes repositioned after last XrayWrite whether tubes repositioned after last Xray

E= Emotional supportE= Emotional support

It is unfair to send a moribund patient to an institution just to get rid of the patient

before death

Talking to familyTalking to family

Do not give false hopesDo not give false hopes– जातेजाते हीही बेडबेड िमिलिमिल जाएगाजाएगा– जसैेजसैे हीही मिशीनमिशीन मिेमिे डालगेेडालगेे सबसब ठीकठीक होहो जाएगाजाएगा

Do not create impression that everything Do not create impression that everything is free & everyone can be made “poor is free & everyone can be made “poor free” in government hospitalsfree” in government hospitals

Give realistic idea of prognosisGive realistic idea of prognosis

Keep channels open for back referralKeep channels open for back referral

ConclusionsConclusions

Think before you referThink before you refer– A lot of problems can be tackled locallyA lot of problems can be tackled locally

Certain clinical signs are better predictors Certain clinical signs are better predictors of sickness & death than othersof sickness & death than others

Stabilize patients before referralStabilize patients before referral

Communicate with receiving consultant & Communicate with receiving consultant & with familywith family

Make comprehensive referral summaryMake comprehensive referral summary