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Section of Neonatology Department of PediatricsBaylor College of MedicineHouston, Texas
Arnold J. Rudolph, MMBCh (1918 - 1995)
Guidelines for Acute Care of the Neonate20th Edition, 2012–2013
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Guidelines for Acute Care of the Neonate20th Edition, 2012–2013
Editors
James M. Adams, M.D
Caraciolo J. Fernandes, M.D
Associate Editors
Steven A. Abrams, M.D.
Diane M. Anderson, Ph.D., R.D.
Catherine M. Gannon M.D.
Joseph A. Garcia-Prats, M.D.
Alfred Gest M.D.
Leslie L. Harris, M.D.
Timothy C. Lee M.D.
Tiffany M. McKee-Garrett, M.D.
Muralidhar Premkumar, M.D.Christopher J. Rhee, M.D.
Michael E. Speer, M.D.
Section of Neonatology
Department of Pediatrics
Baylor College of Medicine
Houston, Texas
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Copyright © 1981–2012 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine.
20th Edition, First printing July 2012
Published by
Guidelines for Acute Care of the Neonate
Section of Neonatology, Department of Pediatrics Baylor College of Medicine
6621 Fannin Suite W6104
Houston, TX 77030
All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed
in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Printed in the United
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Guidelines for Acute Care of the Neonate, 20 th Edition, 2012–13
Acknowledgments
Guidelines for Acute Care of the Neonate, 20th Edition, 2012–13
Clinical Review Committees
Care of Very Low Birth Weight Babies, Cardiopulmonary CareJames M. Adams, MD (Chair), Xanthi Couroucli, MD, Cecelia Torres-Day, MD, Daniella Dinu MD, Caraciolo J. Fernandes, MD, Jennifer
Gardner, PharmD, Al Gest MD, Ganga Gokulakrishnan, MD, Charleta Guillory, MD, Leslie L. Harris, MD, Karen E. Johnson, MD, Yvette R.
Johnson, MD MPH, Kimberly Le, PharmD, Krithika Lingappan, MD, George Mandy, MD, Alice Obuobi, MD, Jochen Profit, MD, ChristopherRhee MD, Danielle Rios, MD.
EndocrinologyCatherine M. Gannon MD (Chair), Joseph A. Garcia-Prats, MD, Leslie L. Harris, MD, Binoy Shivanna, MD, Mohan Pammi, MD
EnvironmentJames M. Adams, MD (Chair), Margo Cox, MD, Carol Turnage-Carrier MSN,RN, CNS, Caraciolo J. Fernandes, MD, Al Gest MD
GastroenterologySteven Abrams, MD (Chair), Amy Hair, MD, Madhulika Kulkarni, MD, Muraliadhar Premkumar, MD,
GeneticsMuralidhar Premkumar, MD (Co-Chair), Michael Speer, MD (Co-Chair), Gerardo Cabrera-Meza, MD, Caraciolo J. Fernandes, MD,
HematologyCaraciolo J. Fernandes, MD (Chair), S. Gwyn Geddie, MD, Adel A. ElHennawy, MD, Leslie L. Harris, MD, Yvette R. Johnson, MD,
Muraliadhar Prekumar, MD, Mohan Pammi, MD, Katherine Weiss, MD
Infectious Diseases, MedicationsMichael E. Speer, MD (Chair), Jennifer Gardner, PharmD, Charleta Guillory, MD, Amy Hair, MD, Leslie L. Harris, MD, Kimberly Le,
PharmD, Valerie Moore, MD, Frank X. Placencia, MD, Mohan Pammi, MD, Leonard E. Weisman, MD
NeurologyChristopher Rhee, MD (Chair), Daniela Dinu, MD, Yvette R. Johnson, MD MPH, Binoy Shivanna, MD,
Normal Newborn CareTiffany McKee-Garrett, MD (Chair), Gerardo Cabrera-Meza, MD, Lisa Fuller MD, Catherine M. Gannon, MD, Joseph A. Garcia-Prats, MD,
Jenelle Little, MD, Valarie Moore MD, Joanne Nguyen MD, Monica Patel MD, Lori A. Sielski, MD
Nutrition, Metabolic ManagementDiane M. Anderson, PhD, RD (chair), Saify Abbasi, MD, Steven A. Abrams, MD, Amy Carter, RD LD, Margo Cox, MD, Gerardo Cabrera-
Meza, MD, Ganga Gokulakrishnan, MD, Amy Hair, MD, Nancy Hurst RD, Madhulika Kulkami, MD, Tommy Leonard, MD, Krithika
Lingappan, MD, Adriana Massieu RD CNSD LD, Meghan McDonald, MD, Alice Obuobi, MD, Sundae Rich RD
SurgeryMichael E. Speer MD (Co-Chair), Tim Lee MD (C0-Chair), Daniella Dinu MD, Leslie L. Harris, MD,
End of Life Care, Grief & BereavementLeslie L. Harris, MD (Chair), Jennifer Arnold, MD, Marcia Berretta, LCSW, Torey Mack MD, Frank X. Placencia, MD, Alina Saldarriaga,
MD, Pamela Taylor D.Min, BCC, Tamara Thrasher-Cateni (Family Centered Care Specialist)
ContributorsEndocrinology chapter written with the advice of the Pediatric Endocrine and Metabolism Section, in particular, Drs. Lefki P. Karaviti, Luisa
M. Rodriguez, and Rona Yoffe. Environment chapter, in particular NICU Environment, written with the advice of Carol Turnage-Carrier, MSN
RN CNS. Infectious Disease chapter written with the advice of the Pediatric Infectious Disease Section, in particular, Doctors Carol J. Baker,
Judith R. Campbell, Morven S. Edwards, Mary Healy, and Flor Munoz-Rivas. Human Immunodeficiency Virus (HIV) section written with the
advice of the Allergy & Immunology Section. Genetics chapter written with the advice of Dr. James Craigen of the Department of Molecular
and Human Genetics. Neurology chapter written with the advice of the Neurology Section.
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ii Guidelines for Acute Care of the Neonate, 20th Edition, 2012–13
Section of Neonatology, Department of Pediatrics, Baylor College of Medicin
* Asterisk indicates information new to this edition.
Preface
Purpose
The purpose of these guidelines is to help neonatology fellows, pediatric house officers, and others with the usual routines followed in caring
for common problems encountered in the care of neonates. These guidelines were designed by the Section of Neonatology at Baylor College
of Medicine (BCM). Where appropriate, national guidelines or reference to peer-reviewed scientific investigations are cited to help in the
decision-making process. Also, regional traits unique to the southeast Texas patient population are used when appropriate. The guidelines are
reviewed and revised annually (or more frequently as necessary) as new recommendations for clinical care become available. Users should refer tothe most recent edition of these guidelines.
DedicationThese guidelines are dedicated to Dr. Arnold J. Rudolph (1918–1993), who taught the art of neonatology and whose life continues to touch us in
innumerable ways.
DisclaimerThese are guidelines only and may not be applicable to populations outside the BCM Affiliated Hospitals. These guidelines do not represent official
policy of Texas Children’s Hospital, Ben Taub General Hospital, BCM, or the BCM Department of Pediatrics, nor are they intended as practice
guidelines or standards of care. Specific circumstances often dictate deviations from these guidelines. Each new admission and all significant new
developments must be discussed with the fellow on call and with the attending neonatologist on rounds. All users of this material should be aware ofthe possibility of changes to this handbook and should use the most recently published guidelines.
Summary of major changes, 20th editionMinor changes were made in addition to the major content changes
detailed below.
Cardiopulmonary• Changes to Respiratory Distress – Goals of Management and
Modes of support
• New Ventilator Management - Use of Volume Guarantee
• Changes to Control of Breathing - Planning for Discharge
• Updates to Patent Ductus Arteriosus-treatment of PDA
• Updates to Exogenous Surfactant
• Updates to Respiratory Management of Congenital Diaphragmatic
Hernia
• Updates to Bronchopulmonary Dysplasia
Environment• Updates to Thermal Regulation
Metabolic
• Updates – Hypoglycemia, Management of Glucose Intolerance
Normal Newborn• Updates to Breast Feeding and Supplementation
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Guidelines for Acute Care of the Neonate, 20 th Edition, 2012–13 ii
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
* Asterisk indicates information new to this edition.
Contents
Chapter 1. Care of Very Low Birth Weight Babies . . 1General Care (babies < 1500 grams) . . . . . . . . . . . . . . . . 1
Example of Admission Orders . . . . . . . . . . . . . . . . . . 1
Indicate . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Monitoring Orders . . . . . . . . . . . . . . . . . . . . . 1
Metabolic Orders . . . . . . . . . . . . . . . . . . . . . . 1
Respiratory Orders . . . . . . . . . . . . . . . . . . . . . 1
Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . 1
Labs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Medication Orders . . . . . . . . . . . . . . . . . . . . . 1
Screens and Follow-up . . . . . . . . . . . . . . . . . . . 1
Suggested Lab Studies . . . . . . . . . . . . . . . . . . . . . . 1
Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Table 1–1. Admission labs . . . . . . . . . . . . . . . . . . . . 2
Table 1–2. Labs during early hospitalization. . . . . . . . . . . 2
Specialized Care (babies ≤ 26 weeks’ gestation) . . . . . . . . . . 2
Prompt Resuscitation and Stabilization . . . . . . . . . . . . . 2
Volume Expansion . . . . . . . . . . . . . . . . . . . . . . . . 2
Respiratory Care . . . . . . . . . . . . . . . . . . . . . . . . . 2
Vitamin A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Caffeine Citrate. . . . . . . . . . . . . . . . . . . . . . . . . . 3
Other Measure to Minimize Blood Pressure Fluctuations
or Venous Congestion . . . . . . . . . . . . . . . . . . . . 3
Umbilical Venous Catheters . . . . . . . . . . . . . . . . . . . . . 3
Multi-lumen . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Figure 1–1. Double-lumen system . . . . . . . . . . . . . . . . 3
Figure 1–2. Suggested catheter tip placement; anatomy of
the great arteries and veins . . . . . . . . . . . . . . . . . 3
Placing UVCs. . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Chapter 2. Cardiopulmonary Care . . . . . . . . . . 5Resuscitation and Stabilization . . . . . . . . . . . . . . . . . . . 5
Figure 2–1. Resuscitation—stabilization process: birth to
post-resuscitation care. . . . . . . . . . . . . . . . . . . . 5
Circulatory Disorders . . . . . . . . . . . . . . . . . . . . . . . . 5
Fetal Circulation . . . . . . . . . . . . . . . . . . . . . . . . . 5
Postnatal (Adult) Circulation. . . . . . . . . . . . . . . . . . . 5
Transitional Circulation . . . . . . . . . . . . . . . . . . . . . 5
Disturbances of the Transitional Circulation . . . . . . . . . . . 5
Parenchymal Pulmonary Disease . . . . . . . . . . . . . . 5
Persistent Pulmonary Hypertension of the Newborn . . . . 5
Congenital Heart Disease . . . . . . . . . . . . . . . . . . 6
Patent Ductus Arteriosus (PDA) . . . . . . . . . . . . . . 6
Figure 2–2. Fetal circulation . . . . . . . . . . . . . . . . . . . 6
Figure 2–3. Postnatal (adult) circulation . . . . . . . . . . . . . 6 Figure 2–4. Transitional circulation . . . . . . . . . . . . . . . 6
Circulatory Insufficiency . . . . . . . . . . . . . . . . . . . . . 6
Nonspecific Hypotension. . . . . . . . . . . . . . . . . . 6
Treatment . . . . . . . . . . . . . . . . . . . . . . . 6
Figure 2–5. Mean aortic blood pressure during the first
12 hours of life . . . . . . . . . . . . . . . . . . . . . . . 7
Hypovolemic Shock. . . . . . . . . . . . . . . . . . . . . 7
Etiologies . . . . . . . . . . . . . . . . . . . . . . . 7
Treatment . . . . . . . . . . . . . . . . . . . . . . . 7
Cardiogenic Shock . . . . . . . . . . . . . . . . . . . . . 7
Symptoms. . . . . . . . . . . . . . . . . . . . . . . . 7
Treatment . . . . . . . . . . . . . . . . . . . . . . . 7
Septic Shock. . . . . . . . . . . . . . . . . . . . . . . . . 8
Treatment . . . . . . . . . . . . . . . . . . . . . . . 8
Management of Respiratory Distress . . . . . . . . . . . . . . . . 8
Basic Strategies Infants 30 0/7 weeks’ gestation or less . . . . . . . . . . . . . . 8
Infants More Than 30 Weeks’ Gestation . . . . . . . . . . . . . 9
Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . 9
FiO2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Arterial Blood Gas Measurements . . . . . . . . . . . . . 9
Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . 9
Capillary Blood Gas Determination. . . . . . . . . . . . . 9
Nasal CPAP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Continuous Flow CPAP . . . . . . . . . . . . . . . . . . . 9
Bubble CPAP . . . . . . . . . . . . . . . . . . . . . . . . 9
Nasal Cannula (not recommended) . . . . . . . . . . . . . 9
Table 2–2a Calculation of effective FiO2
, Step 1 . . . . . . . . 10
Table 2–2b Calculation of effective FiO2, Step 2. . . . . . . . 10
Indications for Nasal CPAP . . . . . . . . . . . . . . . . . . 10
Apnea of Prematurity . . . . . . . . . . . . . . . . . . . 10
Maintenance of Lung Recruitment . . . . . . . . . . . . 10
Acute Lung Disease . . . . . . . . . . . . . . . . . . . . 11
Mechanical Ventilation. . . . . . . . . . . . . . . . . . . . . . . 11
Endotracheal Tube Positioning . . . . . . . . . . . . . . . . . 11
Importance of Adequate Lung Recruitment . . . . . . . . . . 11
Overview of mechanical Ventilation . . . . . . . . . . . . . . 11
Babies < 1500 g or < 32 weeks gestation . . . . . . . . . . . 11
Babies > 1500 g or 32 weeks and older infants . . . . . . . . 11
Infants with BPD requiring chronic MV . . . . . . . . . . . . 11
HFOV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Volume Guarantee . . . . . . . . . . . . . . . . . . . . . . . 11
Initial Ventilation . . . . . . . . . . . . . . . . . . . . . 11
Maintenance of VG Ventilation . . . . . . . . . . . . . . 11
Weaning VG Ventilation. . . . . . . . . . . . . . . . . . 12
Indications for potential extubation to NCPAP . . . . . . 12
Prolonged Mechanical Ventilation . . . . . . . . . . . . 12
VG References . . . . . . . . . . . . . . . . . . . . . . 12
Table 2–3. Ventilator manipulations to effect . . . . . . . . . 12
Synchronized Ventilation . . . . . . . . . . . . . . . . . . . . . 12
SIMV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Initial Ventilator Settings - SIMV Mode . . . . . . . . . 12
Subsequent Ventilator Adjustments . . . . . . . . . . . . 13
Assist-control (AC). . . . . . . . . . . . . . . . . . . . . . . 13
Pressure Support Ventilation . . . . . . . . . . . . . . . . . . 13
Chronic Mechanical Ventilation. . . . . . . . . . . . . . . . . . 13High-frequency Oscillatory Ventilation (HFOV) . . . . . . . . 14
Table 2–4. Useful Respiratory Equations . . . . . . . . . . . 14
Indications for Use . . . . . . . . . . . . . . . . . . . . . . . 14
Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
HFOV Management . . . . . . . . . . . . . . . . . . . . . . 15
Initial Settings. . . . . . . . . . . . . . . . . . . . . . . 15
Control of Ventilation (PCO2) . . . . . . . . . . . . . . . . . 15
Control of Oxygenation (PO2) . . . . . . . . . . . . . . . . . 15
Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Special Considerations . . . . . . . . . . . . . . . . . . . . . 15
Weaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
* Asterisk indicates information new to this edition.
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Contents Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Selection and Preparation for Home Ventilation. . . . . . . . . 15
Criteria for DC to Home Ventilation . . . . . . . . . . . . . . 16
Migration to Home Ventilator . . . . . . . . . . . . . . . . . 16
Monitoring and Equipment for Home Ventilation . . . . . . . 16
Special Issues . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Surfactant Replacement Therapy . . . . . . . . . . . . . . . . . 16
Prophylactic treatment . . . . . . . . . . . . . . . . . . . . . 16
Rescue treatment . . . . . . . . . . . . . . . . . . . . . . . . 16
Surfactant Product Selection and Administration . . . . . . . 17
Curosurf ® . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Survanta® . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Surfactant Replacement for Term Babies with Hypoxic
Respiratory Failure . . . . . . . . . . . . . . . . . . . . 17
Inhaled Nitric Oxide . . . . . . . . . . . . . . . . . . . . . . . . 17
Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . 17
Administration . . . . . . . . . . . . . . . . . . . . . . . . . 17
Weaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Patent Ductus Arteriosus . . . . . . . . . . . . . . . . . . . . . 18
Treatment of PDA . . . . . . . . . . . . . . . . . . . . . . . 18
Ibuprofen Treatment. . . . . . . . . . . . . . . . . . . . 18
Administration and Monitoring . . . . . . . . . . . . . . 18
Treatment Failure . . . . . . . . . . . . . . . . . . . . . 18
Indomethacin Treatment . . . . . . . . . . . . . . . . . . . . 18The Meconium Stained Infant . . . . . . . . . . . . . . . . . . . 18
After Delivery . . . . . . . . . . . . . . . . . . . . . . . . . 18
No Meconium Obtained. . . . . . . . . . . . . . . . . . 19
Mecomium Obtained . . . . . . . . . . . . . . . . . . . 19
Immediate Post-procedure Care . . . . . . . . . . . . . . . . 19
Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Respiratory Management of Congenital Diaphragmatic
Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Control of Breathing . . . . . . . . . . . . . . . . . . . . . . . . 20
Central Respiratory Drive . . . . . . . . . . . . . . . . . . . 20
Modifiers 20
Sleep State. . . . . . . . . . . . . . . . . . . . . . . . . 20
Temperature . . . . . . . . . . . . . . . . . . . . . . . . 20
Chemoreceptors . . . . . . . . . . . . . . . . . . . . . . 20 Circulatory Time . . . . . . . . . . . . . . . . . . . . . 20
Lung Volume . . . . . . . . . . . . . . . . . . . . . . . 20
Airway Patency and Receptors . . . . . . . . . . . . . . . . . 20
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Hypopharynx . . . . . . . . . . . . . . . . . . . . . . . 21
Larynx and Trachea . . . . . . . . . . . . . . . . . . . . 21
Respiratory Pump. . . . . . . . . . . . . . . . . . . . . . . . 21
Bony Thorax . . . . . . . . . . . . . . . . . . . . . . . 21
Intercostal Muscles . . . . . . . . . . . . . . . . . . . . 21
Diaphragm. . . . . . . . . . . . . . . . . . . . . . . . . 21
Management of Apnea . . . . . . . . . . . . . . . . . . . . . 21
General Measures . . . . . . . . . . . . . . . . . . . . . 21
Xanthines . . . . . . . . . . . . . . . . . . . . . . . . . 21
Nasal CPAP . . . . . . . . . . . . . . . . . . . . . . . . 22 Role of Anemia . . . . . . . . . . . . . . . . . . . . . . 22
Apnea of Prematurity: Preparation for Discharge . . . . . . . 22
Bronchopulmonary Dysplasia . . . . . . . . . . . . . . . . . . . 22
Etiology and Pathogenesis . . . . . . . . . . . . . . . . . . . 22
Clinical Course . . . . . . . . . . . . . . . . . . . . . . . . . 22
Classic BPD . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Acute Course and Diagnosis . . . . . . . . . . . . . . . 22
Course of Chronic Ventilator Dependency . . . . . . . . 23
Discharge Planning and Transition to Home Care . . . . 23
The “New” BPD . . . . . . . . . . . . . . . . . . . . . . . . 23
Cardiopulmonary Physiology . . . . . . . . . . . . . . . . . 23
Management. . . . . . . . . . . . . . . . . . . . . . . . 23
Supportive Care and Nutrition . . . . . . . . . . . . . . 24
Fluid Restriction. . . . . . . . . . . . . . . . . . . . . . 24
Diuretics . . . . . . . . . . . . . . . . . . . . . . . 24
Thiazides . . . . . . . . . . . . . . . . . . . . . . . . . 24
Furosemide . . . . . . . . . . . . . . . . . . . . . . . . 24
Chloride Supplements. . . . . . . . . . . . . . . . . . . 24
Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Chronic Mechanical Ventilation. . . . . . . . . . . . . . 24
Inhaled Medications . . . . . . . . . . . . . . . . . . . . . . 24
Short Acting Beta-Adrenergic Agents. . . . . . . . . . . 24
Inhaled Corticosteroids . . . . . . . . . . . . . . . . . . 25
Management of Acute Reactive Airway Disease . . . . . 25
Use of Systemic Steroids in Severe Chronic
Lung Disease. . . . . . . . . . . . . . . . . . . . . 25
Exacerbation of Lung Inflammation . . . . . . . . . . . . . . 26
Monitoring the BPD Patient . . . . . . . . . . . . . . . . . . 26
Nutritional Monitoring . . . . . . . . . . . . . . . . . . 26
Oxygen Monitoring . . . . . . . . . . . . . . . . . . . . 26
Echocardiograms . . . . . . . . . . . . . . . . . . . . . 26
Developmental Screening . . . . . . . . . . . . . . . . . 26
Goal Directed Multidisciplinary Care . . . . . . . . . . . . . 26
Discharge Planning . . . . . . . . . . . . . . . . . . . . 26 Prevention of Chronic Lung Disease . . . . . . . . . . . . . . 26
Use of Sodium Bicarbonate in Acute Cardiopulmonary Care. . . 26
Persistant Metabolic Acidosis . . . . . . . . . . . . . . . . . 26
Chapter 3. Endocrinology . . . . . . . . . . . . . . 29An Approach to the Management of Ambiguous Genitalia . . . . . 29
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Multidisciplinary Team Management of Disorders of Sexual
Evaluation of a Baby with Ambiguous Genitalia. . . . . . . . 29
History. . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Maternal . . . . . . . . . . . . . . . . . . . . . . . 29
Familial . . . . . . . . . . . . . . . . . . . . . . . 29
Figure 3–1. Sexual Differentiation . . . . . . . . . . . . . . . 29
Figure 3–2. Pathways of adrenal hormone synthesis. . . . . . 29 Physical examination . . . . . . . . . . . . . . . . . . . 29
General Examination . . . . . . . . . . . . . . . . 29
External Genitalia . . . . . . . . . . . . . . . . . . 30
Investigations . . . . . . . . . . . . . . . . . . . . . . . 30
Karyotype . . . . . . . . . . . . . . . . . . . . . . 30
Internal Genitalia . . . . . . . . . . . . . . . . . . 30
Figure 3–3. Approach to disorders of sexual differentiation . . 30
Hormonal Tests . . . . . . . . . . . . . . . . . . . 31
The Role of the Parent . . . . . . . . . . . . . . . . . . . . . 31
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . 31
Hypothyroxinemia of Prematurity . . . . . . . . . . . . . . . . 31
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Table 3–1. Thyroxine values according to gestational age . . . 31
Table 3–2. Thyroxine and thyrotropin levels according togestational age. . . . . . . . . . . . . . . . . . . . . . . 31
Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . 31
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Steroid Therapy for Adrenal Insufficiency . . . . . . . . . . . . 32
Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . 32
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Evaluation of Hypothalamic-Pituitary-Adrenal Axis
and Function. . . . . . . . . . . . . . . . . . . . . . . . 32
Laboratory Testing . . . . . . . . . . . . . . . . . . . . . . . 32
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Persistent Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . 33
Disorders of Insulin Secretion and Production . . . . . . . . . 33
Endocrine Abnormalities . . . . . . . . . . . . . . . . . . . . 33
Disorders of Ketogenesis and Fatty Acid Oxygenation . . . . 33
Defects in Amino Acid Metabolism . . . . . . . . . . . . . . 33
Inborn Errors of Glucose Production. . . . . . . . . . . . . . 33
Laboratory Evaluation for Presistent Hypoglycemia. . . . . . 33
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . 33
Chapter 4. Environment . . . . . . . . . . . . . . . 35NICU Environment. . . . . . . . . . . . . . . . . . . . . . . . . 35
Effects of Environment . . . . . . . . . . . . . . . . . . . . . 35
Therapeutic Handling and Positioning . . . . . . . . . . . . . 35
Handling. . . . . . . . . . . . . . . . . . . . . . . . . . 35
Positioning . . . . . . . . . . . . . . . . . . . . . . . . 35
Containment . . . . . . . . . . . . . . . . . . . . . 36
Correct Positioning . . . . . . . . . . . . . . . . . 36
Proper Positioning Techniques. . . . . . . . . . . . 36
Environmental Factors . . . . . . . . . . . . . . . . . . . . . 36 Tastes and Odors . . . . . . . . . . . . . . . . . . . . . 36
Sound . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Effects of Sound . . . . . . . . . . . . . . . . . . . 37
Interventions . . . . . . . . . . . . . . . . . . . . . 37
Light, Vision, and Biologic Rhythms . . . . . . . . . . . 37
Effects of Light . . . . . . . . . . . . . . . . . . . 37
Parents: The Natural Environment . . . . . . . . . . . . . . . 37
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Thermal Regulation . . . . . . . . . . . . . . . . . . . . . . . . 38
Table 4–1. Sources of heat loss in infants . . . . . . . . . . . 38
Thermal Stress . . . . . . . . . . . . . . . . . . . . . . . . . 38
Responses: Shivering . . . . . . . . . . . . . . . . . . . 38
Consequences . . . . . . . . . . . . . . . . . . . . . . . 38 Normal Temperature Ranges * . . . . . . . . . . . . . . 38
Management. . . . . . . . . . . . . . . . . . . . . . . . 38
Delivery Room. . . . . . . . . . . . . . . . . . . . 38
Transport . . . . . . . . . . . . . . . . . . . . . . . 38
Bed Selection * . . . . . . . . . . . . . . . . . . . 38
Incubators . . . . . . . . . . . . . . . . . . . . . . 38
Radiant Warmers. . . . . . . . . . . . . . . . . . . 39
Table 4–2. Neutral thermal environmental temperatures:
Suggested starting incubator air temperatures for clinical
approximation of a neutral thermal environment . . . . . 39
Figure 4–1. Effects of environmental temperature on oxygen
consumption and body temperature. . . . . . . . . . . . 39
Weaning from Servo to Manual Control * . . . . . . . . 40
Weaning from Manual Control to Open Crib * . . . . . . 40 Ancillary Measures . . . . . . . . . . . . . . . . . . . . 40
Weaning to Open Crib. . . . . . . . . . . . . . . . . . . 40
Chapter 5. Gastroenterology . . . . . . . . . . . . 41Necrotizing Enterocolitis (NEC). . . . . . . . . . . . . . . . . . 41
Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Gastroschisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Short Bowel Syndrome (SBS) . . . . . . . . . . . . . . . . . . . 41
Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Short-term Goals . . . . . . . . . . . . . . . . . . . . . 42
Long-term Goals . . . . . . . . . . . . . . . . . . . . . 42
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Cholestasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Omega-3 Fatty Acids (Omegaven) . . . . . . . . . . . . . . . . 43
Inclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . 43
Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . 43
Use of Omegaven. . . . . . . . . . . . . . . . . . . . . . . . 43
Duration of Treatment . . . . . . . . . . . . . . . . . . . . . 44
Home Use of Omegaven . . . . . . . . . . . . . . . . . . . . 44
Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Recognizing Underlying End-stage Liver Disease . . . . . . . 44
Gastroesophageal Reflux (GER). . . . . . . . . . . . . . . . . . 44
Erythromycin . . . . . . . . . . . . . . . . . . . . . . . . . . 44
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Chapter 6. Genetics. . . . . . . . . . . . . . . . . . 47Inborn Errors of Metabolism . . . . . . . . . . . . . . . . . . . 47
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Categories of Inborn Errors . . . . . . . . . . . . . . . . 47
Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Figure 6–1. Presentations of metabolic disorders . . . . . . . 48
Hyperammonemia. . . . . . . . . . . . . . . . . . . . . 48
Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . . 48
Disorders of Fatty Acid Oxidation . . . . . . . . . . . . 48
Fetal Hydrops . . . . . . . . . . . . . . . . . . . . . . . 48
Maternal-fetal Interactions . . . . . . . . . . . . . . . . 48
Table 6–1. Metabolic disorders, chromosomal abnormalities,
and syndromes associated with nonimmune fetal hydrops . 49 Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . 49
Neurologic Status . . . . . . . . . . . . . . . . . . . . . 49
Liver Disease . . . . . . . . . . . . . . . . . . . . . . . 49
Cardiac Disease . . . . . . . . . . . . . . . . . . . . . . 50
Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . 50
Online Resources. . . . . . . . . . . . . . . . . . . . . . . . 51
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Cystic Fibrosis * . . . . . . . . . . . . . . . . . . . . . 51
Prediagnosis treatment. . . . . . . . . . . . . . . . . . . 51
Galactosemia . . . . . . . . . . . . . . . . . . . . . . . 51
GSD1 . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
MSUD. . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Organic aciduria. . . . . . . . . . . . . . . . . . . . . . 51 PKU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Urea cycle disorders. . . . . . . . . . . . . . . . . . . . 52
Newborn Screening. . . . . . . . . . . . . . . . . . . . . . . 52
Chromosomal Abnormalities . . . . . . . . . . . . . . . . . . 52
Chromosomal Microarray (CMA) . . . . . . . . . . . . 52
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Table 6–2. Newborn Screening Program in Texas . . . . . . . 52
Chapter 7. Hematology . . . . . . . . . . . . . . . 53Approach to the Bleeding Neonate . . . . . . . . . . . . . . . . 53
Neonatal Hemostatic System. . . . . . . . . . . . . . . . . . 53
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Table 7–1. Differential diagnosis of bleeding in the neonate 53
Abnormal Bleeding. . . . . . . . . . . . . . . . . . . . . . . 53
Coagulation Disorders . . . . . . . . . . . . . . . . . . 53
Thrombocytopenias . . . . . . . . . . . . . . . . . . . . 54
Neonatal Alloimmune Thrombocytopenia (NAIT) . . . . 54
Table 7–2. Causes of neonatal thrombocytopenia . . . . 54
Figure 7–1. Guidelines for platelet transfusion in
the newborn . . . . . . . . . . . . . . . . . . . . . 54
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Blood Transfusion . . . . . . . . . . . . . . . . . . . . . . . . . 55
Trigger Levels . . . . . . . . . . . . . . . . . . . . . . . . . 55
Table 7–3. Risk factors for severe hyperbilirubinemia . . . . . 55
Transfusion and Risk of Necrotizing Enterocolitis. . . . . . . 56
Transfusion Volume . . . . . . . . . . . . . . . . . . . . . . 56
Erythropoietin . . . . . . . . . . . . . . . . . . . . . . . . . 56
Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Figure 7–2. Nomogram for designation of risk based on the
hour-specific serum bilirubin values . . . . . . . . . . . 56
Table 7–4. Hyperbilirubinemia: Age at discharge and
follow-up . . . . . . . . . . . . . . . . . . . . . . . . . 56
Risk Factors for Severe Hyperbilirubinemia . . . . . . . . . . 57
Differential Diagnosis of Jaundice . . . . . . . . . . . . . . . 57
Figure 7–3. Guidelines for phototherapy in hospitalized
infants of ≥35 weeks’ gestation . . . . . . . . . . . . . . 57 Jaundice Appearing on Day 1 of Life . . . . . . . . . . . 57
Jaundice Appearing Later in the First Week . . . . . . . 57
Jaundice Persisting or Appearing Past the First Week . . 57
Cholestatic Jaundice. . . . . . . . . . . . . . . . . . . . 57
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Figure 7–4. Guidelines for exchange transfusion in infants
35 or more weeks’ gestation. . . . . . . . . . . . . . . . 58
Follow-up of Healthy Term and Late-term Infants at
Risk for Hyperbilirubinemia . . . . . . . . . . . . . . . 58
Management . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Phototherapy . . . . . . . . . . . . . . . . . . . . . . . 58
Intravenous Immune globulin . . . . . . . . . . . . . . . 59
Indications for Exchange Transfusion . . . . . . . . . . 59
Management of Hyperbilirubinemia in Low Birth Weight Infants . . . . . . . . . . . . . . . . . . . . 59
Table 7–5. Guidelines for Management of Hyperbilirubinemia
in Low Birth Weight Infants. . . . . . . . . . . . . . . . 59
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Exchange Transfusion . . . . . . . . . . . . . . . . . . . . . . . 59
Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Before the Exchange . . . . . . . . . . . . . . . . . . . . . . 60
Important Points to Remember . . . . . . . . . . . . . . . . . 60
Exchange Procedure . . . . . . . . . . . . . . . . . . . . . . 60
After the Exchange . . . . . . . . . . . . . . . . . . . . . . . 60
Hypervolemia–polycythemia . . . . . . . . . . . . . . . . . . . 60
Etiologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Chapter 8. Infectious diseases . . . . . . . . . . . 61Bacterial Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
General Points . . . . . . . . . . . . . . . . . . . . . . . . . 61
Blood Cultures . . . . . . . . . . . . . . . . . . . . . . . . . 61
Age 0 to 72 Hours (early-onset, maternally acquired sepsis) . . 61
Indications for Evaluation. . . . . . . . . . . . . . . . . 61
Term Infants (infants > 37 weeks’ gestation) . . . . 61
Preterm Infants (infants < 37 weeks’ gestation) . . . 61
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 61
Term Infants . . . . . . . . . . . . . . . . . . . . . 61
Preterm Infants. . . . . . . . . . . . . . . . . . . . 61
Initial Empirical Therapy . . . . . . . . . . . . . . . . . 61
Duration of Therapy. . . . . . . . . . . . . . . . . . . . 61
Late-onset Infection . . . . . . . . . . . . . . . . . . . . . . 61
Indications for Evaluation. . . . . . . . . . . . . . . . . 62
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 62
Initial Empirical Therapy . . . . . . . . . . . . . . . . . 62
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Group B Streptococcus (GBS) . . . . . . . . . . . . . . . . . . . 62
Management of At-risk Infants . . . . . . . . . . . . . . . . . 62
Figure 8–1. Incidence of early-and late-onset group B
streptococcus . . . . . . . . . . . . . . . . . . . . . . . 62
Figure 8–2. Algorithms for the prevention of early-onset
group B streptococcus. . . . . . . . . . . . . . . . . . . 63
Figure 8–3. Time course of acute hepatitis B at term and
chronic neonatal infection. . . . . . . . . . . . . . . . . 64
Figure 8–4. Recommended immunization schedule for
persons age 0–6 years—United States, 2010 * . . . . . . 64
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Figure 8–5. Algorithm for screening for group B streptococcal
(GBS) colonization and use of intrapartum prophylaxis for
women with preterm* labor (PTL) . . . . . . . . . . . . 65 Figure 8–6. Algorithm for screening for group B streptococcal
(GBS) colonization and use of intrapartum prophylaxis for
women with preterm* premature rupture of membrane
(pPROM) . . . . . . . . . . . . . . . . . . . . . . . . . 65
Figure 8–7. Recommended regimens for intrapartum antibiotic
prophylaxis for prevention of early-onset group B
streptococcal (GBS) disease* premature rupture of
membrane (pPROM) . . . . . . . . . . . . . . . . . . . 66
Cytomegalovirus (CMV) . . . . . . . . . . . . . . . . . . . . . 66
General Points . . . . . . . . . . . . . . . . . . . . . . . . . 66
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Fungal Infection (Candida) . . . . . . . . . . . . . . . . . . . . 66
General Points . . . . . . . . . . . . . . . . . . . . . . . . . 66 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Chemoprophylaxis . . . . . . . . . . . . . . . . . . . . . . . 66
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Gonococcal Disease . . . . . . . . . . . . . . . . . . . . . . . . . 67
Managing Asymptomatic Infants. . . . . . . . . . . . . . . . 67
Managing Symptomatic Infants . . . . . . . . . . . . . . . . 67
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Vaccine Use in Neonates . . . . . . . . . . . . . . . . . . . . 67
Figure 8–8. Time course of acute hepatitis B at term and
chronic neonatal infection. . . . . . . . . . . . . . . . . 67
Maternal Screen Status . . . . . . . . . . . . . . . . . . . . . 67
Positive . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Unknown . . . . . . . . . . . . . . . . . . . . . . . . . 68
Routine Vaccination . . . . . . . . . . . . . . . . . . . . . . 68
Recommended Doses of Hepatitis B Virus Vaccines . . . 68
Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Hepatitis C Virus Infection . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Herpes Simplex Virus (HSV) . . . . . . . . . . . . . . . . . . . 68
Newborns of Mothers with Suspected HSV . . . . . . . . . . 68
A Careful History. . . . . . . . . . . . . . . . . . . . . . . . 69
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At-risk Infants . . . . . . . . . . . . . . . . . . . . . . . . . 69
Maternal . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Neonatal . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Management of At-risk Infants. . . . . . . . . . . . . . . . . 69
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Human Immunodeficiency Virus (HIV) . . . . . . . . . . . . . 69
Treatment of Newborn Infants . . . . . . . . . . . . . . . . . 69
Figure 8–9. Recommended immunization schedule for
persons aged 0-6 years—United States, 2012. . . . . . . 70
Dosage. . . . . . . . . . . . . . . . . . . . . . . . . . . 70
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Immunization Schedule for Hospitalized Infants . . . . . . . 70
Respiratory Syncytial Virus (RSV) . . . . . . . . . . . . . . . . 72
Infection Prophylaxis . . . . . . . . . . . . . . . . . . . . . . 72
Indications for Use of Palivizumab. . . . . . . . . . . . . . . 72
Dosage. . . . . . . . . . . . . . . . . . . . . . . . . . . 72
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Rotavirus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Syphilis, Congenital . . . . . . . . . . . . . . . . . . . . . . . . 72
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Figure 8–10. Algorithm for evaluation of positive
matermal RPR. . . . . . . . . . . . . . . . . . . . . . . 73
Table 8–1. Treponemal and non-treponemal serologic testsin infant and mother . . . . . . . . . . . . . . . . . . . . 73
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Symptomatic Infants or Infants Born to Symptomatic
Mothers . . . . . . . . . . . . . . . . . . . . . . . 73
Asymptomatic Infants. . . . . . . . . . . . . . . . . . . 73
Biologic False-positive RPR . . . . . . . . . . . . . . . 73
Evaluation for At-risk Infants . . . . . . . . . . . . . . . . . 73
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Dosing. . . . . . . . . . . . . . . . . . . . . . . . . . . 74
ID Consultation. . . . . . . . . . . . . . . . . . . . . . . . . 74
Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Newborns of PPD-positive Mothers . . . . . . . . . . . . . . 74 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Varicella-Zoster Virus (VZV) . . . . . . . . . . . . . . . . . . . 74
Exposure in Newborns . . . . . . . . . . . . . . . . . . . . . 74
Clinical Syndromes Varicella Embryopathy . . . . . . . 74
Perinatal Exposure . . . . . . . . . . . . . . . . . . . . 74
Varicella-Zoster Immune Globulin (VariZIG) and Intravenous
Immune Globulin (IVIG) . . . . . . . . . . . . . . . . . 74
Indications for VariZIG . . . . . . . . . . . . . . . . . . 74
Dosing . . . . . . . . . . . . . . . . . . . . . . . . 75
Where to Obtain VariZIG . . . . . . . . . . . . . . 75
Indications for IVIG. . . . . . . . . . . . . . . . . . . . 75
Isolation 67
Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Chapter 9. Medications . . . . . . . . . . . . . . . 77Medication Dosing . . . . . . . . . . . . . . . . . . . . . . . . . 77
Table 9–1. Usual dosing ranges . . . . . . . . . . . . . . . . 77
Managing Intravenous Infiltrations . . . . . . . . . . . . . . . . 77
Phentolamine mesylate . . . . . . . . . . . . . . . . . . . . . 77
Hyaluronidase . . . . . . . . . . . . . . . . . . . . . . . . . 78
Common Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . 78
Serum Antibiotic Level . . . . . . . . . . . . . . . . . . . . . 78
Table 9–2. Guidelines for initial antibiotic doses and
intervals based on categories of postconceptual age . . . 79
Table 9–3. Medication Infusion Chart . . . . . . . . . . . . . 80
Chapter 10. Metabolic Management . . . . . . . . . 81Fluid and Electrolyte Therapy. . . . . . . . . . . . . . . . . . . 81
Water Balances . . . . . . . . . . . . . . . . . . . . . . . . . 81
Table 10–1. Fluid (H2O) loss (mg/kg per day) in standard
incubators . . . . . . . . . . . . . . . . . . . . . . . . . 81
Table 10–2. Fluid requirements (mL/kg per day) . . . . . . . 81
Electrolyte Balance. . . . . . . . . . . . . . . . . . . . . . . 81
Table 10–3. Composition of GI fluids . . . . . . . . . . . . . 81
Short-term Intravascular Fluid Therapy (day 1 to 3) . . . . . 81
Fluid Composition . . . . . . . . . . . . . . . . . . . . . . . 81
Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . . . 81
Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Etiology of Hypoglycemia . . . . . . . . . . . . . . . . . . . 82
Evaluation and Intervention . . . . . . . . . . . . . . . . . . 82
Fluid and Venous Line Management . . . . . . . . . . . . . . 82
Glucose Calculations . . . . . . . . . . . . . . . . . . . . . . 82
Hyperglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Management . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Hyperkalemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Evaluation and Treatment . . . . . . . . . . . . . . . . . . . 84
Suspected Hyperkalemia . . . . . . . . . . . . . . . . . . . . 84Hyperkalemia with Cardiac Changes. . . . . . . . . . . . . . 84
Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Infant of Diabetic Mother (IDM) . . . . . . . . . . . . . . . . . 84
Metabolic Complications. . . . . . . . . . . . . . . . . . . . 84
Congenital Malformations . . . . . . . . . . . . . . . . . . . 84
Table 10–4. Common anomalies in infants of diabetic mothers. . 84
Admission Criteria for Newborn Nursery . . . . . . . . . . . 84
Protocol in Newborn Nursery . . . . . . . . . . . . . . . . . 84
Hypocalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Early Hypocalcemia . . . . . . . . . . . . . . . . . . . . . . 84
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Other Factors . . . . . . . . . . . . . . . . . . . . . . . 85
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 85
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Late Hypocalcemia . . . . . . . . . . . . . . . . . . . . . . . 85
Assesment and Management of Seizures due to Hypocalcemia
in Infants 3 to 10 Days of Age Born at Greater Than 34
Weeks’ Gestation . . . . . . . . . . . . . . . . . . . . . . . 85
Initial Assesment . . . . . . . . . . . . . . . . . . . . . . . . 85
Intravenous Medication Therapy . . . . . . . . . . . . . . . . 85
Oral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Hypercalcemia or Hyperphosphatemia * . . . . . . . . . . . . . 86
Use of Sodium Bicarbonate in Acute Cariopulmonary Care . . 86
Persistent Metabolic Acidosis . . . . . . . . . . . . . . . . . . . 87
Figure 10–1. Screening for and management of postnatal
glucose homeostasis in late-preterm (LPT 34-36 6/7
weeks) and term small-for-gestational age (SGA) infants
and infants born to mothers with diabetes (IDM)/large- for-gestational age (LGA) infants. . . . . . . . . . . . . 87
Chapter 11. Neurology . . . . . . . . . . . . . . . . 89Encephalopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Table 11–1. Sarnat stages of encephalopathy . . . . . . . . . 89
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Intervention/therapies. . . . . . . . . . . . . . . . . . . . . . 89
Treatment Criteria for Whole Body Cooling . . . . . . . . . . 89
TCH Total Body Cooling Protocol . . . . . . . . . . . . . . . 90
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
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Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . 90
Background and Pathogenesis . . . . . . . . . . . . . . . . . 90
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Initial Treatment. . . . . . . . . . . . . . . . . . . . . . 90
Table 11–2. Most Common Etiologies of Neonatal Seizures . . . 91
Outcome and Duration of Treatment . . . . . . . . . . . . . . 91
Cerebral Hemorrhage and Infarction. . . . . . . . . . . . . . . 91
Periventricular, Intraventricular Hemorrhage (PIVH) . . . . . 91
Periventricular Leukomalacia (PVL) . . . . . . . . . . . . . . 92
Perinatal and Neonatal Stroke (term and near term infant) . . 92
Traumatic Birth Injuries (Nervous System) . . . . . . . . . . . 93
Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Cephalohematoma. . . . . . . . . . . . . . . . . . . . . 93
Skull Fractures . . . . . . . . . . . . . . . . . . . . . . 93
Subgaleal hemorrhage. . . . . . . . . . . . . . . . . . . 93
Intracranial hemmorrhages . . . . . . . . . . . . . . . . 93
Brachial palsies and phrenic nerve injury. . . . . . . . . 93
Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . . . . 93
Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Neural Tube Defects. . . . . . . . . . . . . . . . . . . . . . . . . 93
Meningomyelocele . . . . . . . . . . . . . . . . . . . . . . . 93 Prenatal Surgery. . . . . . . . . . . . . . . . . . . . . . 93
Immediate Management. . . . . . . . . . . . . . . . . . 94
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 94
Discharge Planning . . . . . . . . . . . . . . . . . . . . 94
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Drug-exposed Infants. . . . . . . . . . . . . . . . . . . . . . . . 94
Nursery Admission . . . . . . . . . . . . . . . . . . . . . . . 94
Maternal Drug and Alcohol History . . . . . . . . . . . . . . 94
General. 83
Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Treatment of Withdrawal. . . . . . . . . . . . . . . . . . . . 94
Nonpharmacologic Measures . . . . . . . . . . . . . . . 94
Pharmacological Measures . . . . . . . . . . . . . . . . 94 Opioid Withdrawal Guidelines . . . . . . . . . . . . . . . . . 95
Opioid Weaning Options . . . . . . . . . . . . . . . . . 95
Additional Considerations . . . . . . . . . . . . . . . . . . . 95
Methadone. . . . . . . . . . . . . . . . . . . . . . . . . 95
Pain Assessment and Management . . . . . . . . . . . . . . . . 95
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Nonpharmacologic Pain Management . . . . . . . . . . . . . 96
Pharmacologic Pain Management . . . . . . . . . . . . . . . 96
Morphine Sulfate . . . . . . . . . . . . . . . . . . . . . 96
Table 11–3. Suggested management of procedural pain in
neonates at Baylor College of Medicine affiliated
hospital NICUs . . . . . . . . . . . . . . . . . . . . . . 96
Figure 11–1. Neonatal abstinence scoring system . . . . . . . 97
Fentanyl Citrate . . . . . . . . . . . . . . . . . . . . . . 98 Procedural Pain Management . . . . . . . . . . . . . . . . . 98
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Hypoxic-ischemic Encephalopathy . . . . . . . . . . . . . . 98
Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Drug-exposed Infants. . . . . . . . . . . . . . . . . . . . . . 98
Pain Assessment and Management . . . . . . . . . . . . . . . 99
Chapter 12. Normal Newborn . . . . . . . . . . . 101Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Transitional Period . . . . . . . . . . . . . . . . . . . . . . 101
Routine Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Bathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Cord Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Eye Care * . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Eye Prophylaxis and Vitamin K Administation . . . . . . . .101
Feeding, Breastfeeding . . . . . . . . . . . . . . . . . . . . .102
Lactation Consultants . . . . . . . . . . . . . . . . . . .102
Maternal Medications . . . . . . . . . . . . . . . . . . .102
Methods and Practices . . . . . . . . . . . . . . . . . .102
Assessment . . . . . . . . . . . . . . . . . . . . . . . .102
Ankyloglossia . . . . . . . . . . . . . . . . . . . . . . . . .102
Supplementation: Health Term Newborns . . . . . . . . . . .102
Indications for supplementation-infant issues . . . . . .102
Indications for supplementation-maternal issues . . . . .102
Supplementation: Vitamins and Iron . . . . . . . . . . . . . .102
Figure 12–1. Breastfed infant with > 8% weight loss
algorithm . . . . . . . . . . . . . . . . . . . . . . . . .103
Working Mothers . . . . . . . . . . . . . . . . . . . . .104
Contraindications to Breast Feeding . . . . . . . . . . .104
Maternal Medications . . . . . . . . . . . . . . . . . . .104
Feeding, Formula Feeding . . . . . . . . . . . . . . . . . . .104
Formula Preparations . . . . . . . . . . . . . . . . . . .104
Feeding During the First Weeks. . . . . . . . . . . . . .104
Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
Screening - Hearing . . . . . . . . . . . . . . . . . . . . . .104 Screening - Blood * . . . . . . . . . . . . . . . . . . . . . 105
Glucose Screening of at Risk Infants . . . . . . . . . . .105
State Newborn Screening . . . . . . . . . . . . . . . . .105
Ben Taub General Hospital (BTGH) . . . . . . . . . . .105
Texas Children’s Hospital (TCH) . . . . . . . . . . . . .105
Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Sleep Position. . . . . . . . . . . . . . . . . . . . . . . . . .105
Positional Plagiocephaly Without Synostosis (PWS). . .105
Urination and Bowel Movements . . . . . . . . . . . . . . .105
Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
Cardiac, Murmurs . . . . . . . . . . . . . . . . . . . . . . . . .106
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . .106
Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
Birthmarks . . . . . . . . . . . . . . . . . . . . . . . . . . .106
Dimples. . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
Cutaneous Markers Associated with Occult Spinal
Dysraphism . . . . . . . . . . . . . . . . . . . . .107
References . . . . . . . . . . . . . . . . . . . . . . . . . . .107
Ear Tags and Pits . . . . . . . . . . . . . . . . . . . . . . . .107
References . . . . . . . . . . . . . . . . . . . . . . . . . . .107
Forceps Marks . . . . . . . . . . . . . . . . . . . . . . . . .107
Lacerations . . . . . . . . . . . . . . . . . . . . . . . . . . .107
Nipples, Extra . . . . . . . . . . . . . . . . . . . . . . . . .107
Rashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Scalp Electrode Marks . . . . . . . . . . . . . . . . . . . . . 94 Subcutaneous Fat Necrosis . . . . . . . . . . . . . . . . . . .108
Extracranial Swelling . . . . . . . . . . . . . . . . . . . . . . . 108
Caput Succedaneum . . . . . . . . . . . . . . . . . . . . . .108
Cephalohematoma . . . . . . . . . . . . . . . . . . . . . . .108
Subgaleal Hemorrhage . . . . . . . . . . . . . . . . . . . . .108
Cause and Appearance . . . . . . . . . . . . . . . . . .108
Evaluation and Management . . . . . . . . . . . . . . .108
Table 12–1. Features of extracranial swelling . . . . . . . . 108
Hospital Discharge . . . . . . . . . . . . . . . . . . . . . . . . .108
Early Discharge. . . . . . . . . . . . . . . . . . . . . . . . .108
Criteria for Early Discharge . . . . . . . . . . . . . . . . . .109
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Contents Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Chapter 14. Surgery . . . . . . . . . . . . . . . . 129Perioperative Management . . . . . . . . . . . . . . . . . . . . 129
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
Blood Products . . . . . . . . . . . . . . . . . . . . . . . . .129
Complications . . . . . . . . . . . . . . . . . . . . . . . . .129
Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . .129
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . .129
Peripheral and Central Venous Access . . . . . . . . . . . . .129
Peripheral . . . . . . . . . . . . . . . . . . . . . . . . .129
Central. . . . . . . . . . . . . . . . . . . . . . . . . . .129
Stomas, Intestinal. . . . . . . . . . . . . . . . . . . . . . . .130
Specific Surgical Conditions . . . . . . . . . . . . . . . . . . . . 130
Bronchopulmonary Sequestration (BPS). . . . . . . . . . . .130
Chylothorax. . . . . . . . . . . . . . . . . . . . . . . . . . .130
Cloacal Malformations and Cloacal Exstrophy . . . . . . . .131
Congenital Cystic Adenomatoid Malformation (CCAM) . . .131
Congenital Diaphragmatic Hernia (CDH) . . . . . . . . . . .131
Congenital Lobar Emphysema (CLE) . . . . . . . . . . . . .132
Duodenal Atresia . . . . . . . . . . . . . . . . . . . . . . . .132
Esophageal Atresia and Tracheal Fistula . . . . . . . . . . . .132
Extracorporeal Life Support (ECLS). . . . . . . . . . . . . .133
Table 14–1. ECLS Criteria . . . . . . . . . . . . . . . . . . .133
ECLS Circuit . . . . . . . . . . . . . . . . . . . . . . .133
Cannulae . . . . . . . . . . . . . . . . . . . . . . .133 Physiology of ECLS . . . . . . . . . . . . . . . . . . .133
Venoarterial . . . . . . . . . . . . . . . . . . . . .133
Venovenous . . . . . . . . . . . . . . . . . . . . .133
Gastroschisis . . . . . . . . . . . . . . . . . . . . . . . . . .133
Hirschsprung Disease (HD) . . . . . . . . . . . . . . . . . .134
Imperforate Anus (IA) . . . . . . . . . . . . . . . . . . . . .134
Inguinal Hernia . . . . . . . . . . . . . . . . . . . . . . . . .134
Intestinal Atresia . . . . . . . . . . . . . . . . . . . . . . . .134
Malrotation and Midgut Volvulus . . . . . . . . . . . . . . .135
Meconium Ileus (MI). . . . . . . . . . . . . . . . . . . . . .135
Chapter 15. End of Life Care, Grief &Bereavement . . . . . . . . . . . . . . . . . . . . 137
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . .123Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . .137
Understanding and Communicating at the End of Life . . . . .137
Attachment in Pregnancy. . . . . . . . . . . . . . . . . . . .137
Professional and Societal Perceptions of Death and Grieving. . . 137
Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . .137
Determination of Limitation or Withdrawal of Care . . . . . .137
The Texas Advance Directives Act and its Application
to Minors. . . . . . . . . . . . . . . . . . . . . . .137
Special Circumstances Surrounding Delivery Room
Resuscitation. . . . . . . . . . . . . . . . . . . . .138
Developing Consensus between the Medical Team
and the Family . . . . . . . . . . . . . . . . . . . .138
Disagreement between the Medical Team and the Family. . 138
Bioethics Committee Consultation . . . . . . . . . . . .138 Patients in Child Protective Services Custody . . . . . .138
Imparting Difficult Information . . . . . . . . . . . . . .138
Documentation . . . . . . . . . . . . . . . . . . . . . .139
The Transition to Comfort Care . . . . . . . . . . . . . . . . . 140
Supporting the Family . . . . . . . . . . . . . . . . . . . . .140
Care of the Dying Infant . . . . . . . . . . . . . . . . . . . .140
Pharmacologic Management. . . . . . . . . . . . . . . . . . . .140
Narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . .140
Benzodiazepines * . . . . . . . . . . . . . . . . . . . . . . .141
Habituated Patients . . . . . . . . . . . . . . . . . . . . . . .141
* Asterisk indicates information new to this edition.
Oral Medications . . . . . . . . . . . . . . . . . . . . . . . .141
Adjunct Medications . . . . . . . . . . . . . . . . . . . . . .141
Death of the Infant . . . . . . . . . . . . . . . . . . . . . . . . .141
Transitioning to Conventional Ventilation, Decreasing
Ventilatory Support, and Removal of Endotracheal Tube . . 141
Pronouncing the Death . . . . . . . . . . . . . . . . . . . . .141
The Option of No Escalation of Care . . . . . . . . . . . . .141
Organ Donation. . . . . . . . . . . . . . . . . . . . . . . . .141
Medical Examine . . . . . . . . . . . . . . . . . . . . . . . .141
Autopsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . .141
Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142
Perinatal Hospice . . . . . . . . . . . . . . . . . . . . . . . .142
Funeral Homes . . . . . . . . . . . . . . . . . . . . . . . . .142
Nursing Bereavement Support Checklist. . . . . . . . . . . .142
Lactation Support. . . . . . . . . . . . . . . . . . . . . . . .142
Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . .142
Support of Hospital Team Members . . . . . . . . . . . . . .142
The Grief Process . . . . . . . . . . . . . . . . . . . . . . . . .142
Timing and Stages of Grief. . . . . . . . . . . . . . . . . . .142
Special Circumstances Relating to Fetal or Infant Death . . . 143
Religious and Cultural Differences Surrounding Death and
Grieving . . . . . . . . . . . . . . . . . . . . . . . . . .143
Self-Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
References . . . . . . . . . . . . . . . . . . . . . . . . . . .143 Figure 15–1. Fetal End of Life Algorithm . . . . . . . . . . .143
Figure 15–2. Neonatal End of Life Algorithm . . . . . . . . .144
Appendix. Overview of Nursery RoutinesCharting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
Lab Flow Sheets . . . . . . . . . . . . . . . . . . . . . . . .145
Problem Lists . . . . . . . . . . . . . . . . . . . . . . . . . .145
Procedure Notes . . . . . . . . . . . . . . . . . . . . . . . .145
Weight Charts and Weekly Patient FOCs and Lengths. . . . .145
Communicating with Parents . . . . . . . . . . . . . . . . . . .145
Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
Child Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Occupational and Physical Therapy . . . . . . . . . . . . . . . 145
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145Discharge or Transfer Documentation . . . . . . . . . . . . . . 145
Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
Note. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
At Ben Taub . . . . . . . . . . . . . . . . . . . . . . . . . .146
Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . .146
Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . .146
Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
Gowns . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
Stethoscopes . . . . . . . . . . . . . . . . . . . . . . . . . .146
Isolation Area. . . . . . . . . . . . . . . . . . . . . . . . . .146
Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146
Nutrition Support After Discharge . . . . . . . . . . . . . . . . 146
Parent Support Groups . . . . . . . . . . . . . . . . . . . . . .146ROP Screening . . . . . . . . . . . . . . . . . . . . . . . . . . .146
General Guidelines—Ben Taub General Hospital . . . . . . . .146
Triage of Admissions . . . . . . . . . . . . . . . . . . . . . .146
Daily Activities . . . . . . . . . . . . . . . . . . . . . . . . .146
Rounds . . . . . . . . . . . . . . . . . . . . . . . . . .146
Code Warmer Activities. . . . . . . . . . . . . . . . . .146
Neo Resuscitation Team Response . . . . . . . . .147
Scheduled Lectures . . . . . . . . . . . . . . . . . . . .147
Ordering Routine Studies. . . . . . . . . . . . . . . . . . . .147
Routine Scheduled Labs, X rays, etc . . . . . . . . . . .147
Ordering TPN and Other Fluids. . . . . . . . . . . . . .147
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Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Content
Cardiology Consultations. . . . . . . . . . . . . . . . . . . .147
Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . .147
Transfer and Off-service Note . . . . . . . . . . . . . . . . .147
Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . 147
Clinic Appointments Protocol at Ben Taub. . . . . . . . . . .147
Level 1 Clinics . . . . . . . . . . . . . . . . . . . . . .147
Level 2 Clinics . . . . . . . . . . . . . . . . . . . . . .148
General Guidelines—Texas Children’s Hospital. . . . . . . . . 148
Texas Children’s NICU Daily Activities . . . . . . . . . . . .148
Transfer and Off-service Notes. . . . . . . . . . . . . . . . .148
Texas Children’s Night Call Activities . . . . . . . . . . . . . 148
Neurodevelopmental Follow-up . . . . . . . . . . . . . . . .148
High-risk Developmental Follow-up Clinic. . . . . . . .148
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I-VI
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Contents Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
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Guidelines for Acute Care of the Neonate, 20 th Edition, 2012–13 1
General Care (babies < 1500 grams)
Example of Admission Orders
Each infant’s problems will be unique. Appropriate routines will vary bygestation and birth weight. Each order, including all medication doses
and IV rates, must be individualized. In current practice each infant has
a basic admission order set in the EMR. Additional orders are added per
individual indication. The following categories of orders are common in
VLBW infants.
Indicate• Unit of admission (eg, NICU) and diagnosis.
Order• A humidified convertible incubator/radiant warmer is preferred for
infants with BW less than 1250 grams or less than 32 weeks. If
servo-control mode of warmer or incubator is used, indicate servo
skin temperature set point (usually set at 36.5°C). Always useradiant warmer in servo-control mode.
• Use plastic wrap blanket to reduce evaporative water loss if on a
radiant warmer for babies who weigh 1250 grams or less.
Monitoring Orders• Cardio-respiratory monitor.
• Oximeter - oxygen saturation target 90-95% for premature infants
and term babies with acute respiratory distress (alarm limits 88-
96%).
• Vital signs (VS) and blood pressure (BP) by unit routines unless
increased frequency is indicated.
• Umbilical artery catheter (UAC) or peripheral arterial line to BP
monitor if invasive monitoring is done.
Metabolic Management Orders• I&O measurements.
• Type and volume of feeds or NPO.
• IV fluids or parenteral nutrition.
• If arterial line is in place, order heparinized NS at 0.5 mL per hour.
Respiratory Orders• If infant is intubated, order ET tube and size.
• Standard starting ventilator settings for infants with acute lung
disease:
Ventilator Orders should include mode and settings:
CPAP –Bubble CPAP, and level of end expiratory pressure
SIMV – rate, PIP, Ti, PEEP
A/C – PIP, Ti, PEEP, Back Up Rate
VG – Target Vt, Pmax (instead of PIP)
FiO2 – as needed to maintain target saturations
Diagnostic Imaging• Order appropriate radiographic studies.
• Order cranial US between 7 and 14 days of life.
Labs• Admission labs: CBC with differential and platelets, blood type,
Rh, Coombs, glucose
• Obtain results of maternal RPR, HIV, GBS and hepatitis screens.
• Order other routine labs.
• Order labs to manage specific conditions as needed (eg, electrolytes
at 12 to 24 hours of life).• Order newborn screen at 24 to 48 hours of age and DOL 14.
Medication OrdersMedication orders commonly include:
• vitamin K – 0.5 mg IM.
• eye prophylaxis – erythromycin ophthalmic ointment.
• Surfactant replacement (as indicated) – (indicate BW, product
and dose needed) (see Cardiopulmonary chapter).
• antibiotics – if infant is considered to be at risk for sepsis (see
Infectious Diseases chapter).
• Vitamin A (for infants with BW 1000 grams or less) – 5000 IU
intramuscularly every Monday, Wednesday, Friday for 4 weeks
(12 doses).• caffeine citrate (for infants BW 1250 grams or less) – 20 mg/kg
loading dose followed by 5 mg/kg/day given once daily. Initiate
therapy within first 10 days of life.
Screens and Follow-up• Order hearing screen before hospital discharge. Hearing screens
should be performed when the baby is medically stable, > 34 weeks
postmenstrual age and in an open crib.
• Order ophthalmology screening for ROP if:
» less than 1500 grams birth weight or 30 weeks’ gestation or less
or
» 1500 to 2000 grams birth weight or greater than 30 weeks’ gesta-
tion with unstable clinical course where physician believes infantis at risk for ROP.
• Before discharge,
» observe infant in car safety seat for evidence of apnea,
bradycardia, or oxygen desaturation,
» offer CPR training to parents,
» schedule high-risk follow-up clinic as recommended below,
» write orders for palivizumab as appropriate.
• Schedule other laboratory screening tests as recommended below.
Suggested Lab StudiesThese labs are appropriate for many VLBW admissions to NICU and
are provided as a general guideline. Many babies will not require this
volume of tests, others will require more. Review this list with the
Attending Neonatologist. Regularly review routine scheduled labs and
eliminate those no longer necessary. See Table 1–1 and Table 1–2.
Follow-upMany of these infants will require follow-up for CNS, cardiac, renal,
ophthalmologic, or otologic function. Additional follow-up of specific
conditions may be warranted as well.
Cranial ultrasounds (US)—Order US for infants less than 1500 grams
birth weight between 7 and 14 days of age. When the baby reaches term
or at discharge, another US is recommended to detect cystic periven-
tricular leukomalacia (PVL).
Care of Very Low
Birth Weight Babies1
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Chapter 1—Care of Very Low Birth Weight Babies Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Infants with US that demonstrates significant IVH require follow-up
ultrasounds (weekly, every other week, or monthly) to identify progres-
sion to hydrocephalus.
Screening for retinopathy of prematurity (ROP) – Initial and follow-
up eye exams by a pediatric ophthalmologist should be performed
at intervals recommended by the American Academy of Pediatrics
(Pediatrics 2006; 117:572–576). If hospital discharge or transfer
to another neonatal unit or hospital is contemplated before retinal
maturation into zone III has taken place or if the infant has been treated
by ablation for ROP and is not yet fully healed, the availability of
appropriate follow-up ophthalmologic examination must be ensured and
specific arrangements for that examination must be made before such
discharge or transfer occurs.
Development Clinic – TCH Infants who weigh less than 1501 grams
at birth should be scheduled for the Desmond Developmental Clinic
at four months adjusted age. Infants with HIE, Twin-Twin Transfusion
syndrome or those requiring ECMO should also be referred. Patients
in these categories should have an initial developmental consultation
and evaluation before discharge. Other infants whose clinical course
placing them at high risk will be scheduled on an individual basis. Clinic
appointments are made through the Neonatology office.
Hearing screen – Perform a pre-discharge hearing screen on all
infants admitted to a Level 2 or 3 nursery. Infants with congenital
cytomegalovirus (CMV), bronchopulmonary dysplasia (BPD), ormeningitis and infants treated with ECMO might have a normal screen
at discharge but later develop sensorineural hearing loss.
Monitoring for anemia – Laboratory testing (a hemoglobin/hematocrit
with a reticulocyte count, if indicated) to investigate the degree of
physiologic anemia of prematurity should be considered as needed based
on an infant’s clinical status, need for positive pressure/ oxygen support,
size, recent phlebotomies, and most recent hematocrit. Frequency
of such testing may vary from every 1 to 2 weeks in the sick, tiny
premature infant on positive pressure support to once a month or less in
a healthy, normally growing premature infant. Efforts should be made to
cluster such routine sampling with other laboratory tests.
Specialized Care
(babies ≤ 26 weeks’ gestation)The following care procedures are recommended initial management for
infants who are 26 or fewer weeks’ gestation.
Prompt Resuscitation and StabilizationInitiate prompt resuscitation and stabilization in the delivery room with
initiation of CPAP, or intubation and intermittent positive pressure venti-
lation (IPPV) and surfactant replacement if needed.
Volume ExpansionAvoid use of volume expanders. But if given, infuse volume expanders
over 30 to 60 minutes. Give blood transfusions over 1 to 2 hours.
A pressor agent such as dopamine is preferable to treat nonspecific
hypotension in babies without anemia, evidence of hypovolemia, or
acute blood loss.
Respiratory CareDetermination of the need for respiratory support in these infants after
delivery should include assessment of respiratory effort and degree of
distress. ELBW infants, whose mothers received antenatal steroids,
may be vigorous and have good respiratory effort at birth. Such a
patient can receive a trial of spontaneous breathing on NCPAP startingin the delivery room. If respiratory distress develops or pulmonary
function subsequently deteriorates, the infant should be intubated and
given early rescue surfactant (within first 2 hours). See Chapter 2 -
Cardiopulmonary Care. The goal of care is maintenance of adequate
inflation of the immature lung and early surfactant replacement in
those exhibiting respiratory distress to prevent progressive atelectasis.
Achieving adequate lung inflation and assuring correct ET tube position
before dosing are essential for uniform distribution of surfactant
within the lung (correct ET position may be assessed clinically or by
radiograph).
After initial surfactant treatment, some babies will exhibit a typical
course of respiratory distress and require continued ventilation.
However, many will have rapid improvement in lung compliance.
Rapid improvement in lung compliance necessitates close monitoring
and prompt reduction in ventilator PIP, FiO2, and rate. Initial reduction
in ventilator settings after surfactant should be determined by clinical
assessment (eg, adequacy of chest rise). Monitor clinically and obtain
blood gases within 30 minutes of dosing and frequently thereafter.
When ventilator support has been weaned to minimal levels, attempt
extubation and place infant on nasal CPAP. Minimal support includes:
• FiO2 30% or less
• PIP 20 cm or less
• Vt 3.6-4.5 ml/kg (VG)
• Rate less than 25/min (SIMV)
• PEEP 5-6 cm
Infants meeting these criteria may be extubated and placed on nasalCPAP. This often will require loading with caffeine.
Vitamin AMany extremely preterm infants have low plasma and tissue concen-
trations of vitamin A. A large randomized trial demonstrated that
supplemental vitamin A (5000 IU three times per week for 4 weeks)
in infants with BW 1000 grams or less requiring positive pressure at
birth is safe, and results in a small reduction in their risk of developing
bronchopulmonary dysplasia. All infants 1000 grams or less at birth on
positive pressure (CPAP or mechanical ventilation) should be started on
vitamin A (for dosing, see Medication Orders section in this chapter)
Table 1–2. Labs during early hospitalization, days 1 to 3
Electrolytes, glucose
BUN Every 12 to 24 hours (depends on infant’s size and
metabolic stability)
Calcium (ionized) 24 and 48 hours of age
TSB every 24 hours (depends on size, presence of
bruising, ABO-Rh status, pattern of jaundice)
Hematocrit every 24 to 48 hours (depends on size, previous
hematocrit, and ABO-Rh status)
Table 1–1. Admission labs
CBC, platelets at admission
Blood culture, ABG at admission, if appropriate
Glucose screening at 30 minutes of age
Electrolytes, glucose
BUN 12 or 24 hours of age (depends on infant’s size and
metabolic stability)
Calcium (ionized) at 24 and 48 hours of age
Total Serum Bilirubin at 24 hours of age or if visibly jaundiced (depends on size, presence of bruising, ABO-Rh status)
Newborn screens
First screen at 24 to 48 hours of age
Second screen Repeat newborn screen at
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