Professional Documents
Culture Documents
Handbook of Protocols
Fourth Edition
Newborr Unit
';(Department o · Pediatrics
Postgraduate Institute of Medical Education
and Research 1PGIMER)
Chandi 1arh
lndi.i
-
ii
Previous editions
1971 edited by Omkar Nath Bhakoo
1995 edited by Praveen Kumar
2003 edited by Kanya Mukhopadhyay
Printed by
Chandika Press Pvt. Ltd., 240, HSIIDC Ind. Estate, Barwala (Hry.) India
-
iii
( a. ,,II'~">I\ .
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c''{oV°' _7
iv
'
EDITORS
Sourabh Dutta
&
Praveen Kumar
CONTRIBUTORS
(in alphabetical order)
Anil Narang
Ashwini Kumar
Deepak Louis
Kanya \if ukhopadhyay
Neeraj Gupta
Praveer Kumar
S Giridhar
S Mangalabharti
S Venk1taseshan
Samir Sheikh
Shiv Sajan Saini
Sourabh Dutta
Sunil Aggarwal
Sunil SJi Kishore M
Swati C'hacham
Vandar. a Negi
FORl:WORD
Praveen Kumar
August 2010
viii
ix
PREJ'ACE
This Handbook, informally called The Blue Book, is an extensively
revised, updated, formatted and r '-organized edition of the popular
manual of PGIMER (formerly calkd "Protocols in Neonatology") . .The
current edition incorporates separate sections on investigations, drugs,
nomograms and telephone numbers, apart from the chapters on
management protocols. The chapters have been divided into numbered
sections. A large number of management algorithms and tables have
been added. The Blue Book is comprehensively cross-referenced and
indexed. It is the culmination of an elaborate exercise of systematically
reviewing the literature, grading the evidence and adapting it to Indian
conditions.
A book of this scale would not have seen the light of day without
exceptional teamwork. The team comprised of the DM fellows, faculty
and staff of Neonatology at PGIMER. While the contributions of all the
contributors is gratefully acknowledged, there are some whose assistance
was extraordinary and I must make special mention of them. Foremost
among them are Dr S Giridhar and Dr Samir Sheikh, who corrected all
the raw manuscripts. Dr Sunil Sai Kishore and Dr Shiv Sajan Saini
helped out with collecting data. Dr Mangalabharti collated information
about investigations. Dr Vandana Negi updated the drugs and
nomograms.
The care of newborn babies demands a rare combination of
knowledge, art, skill, compassion, hard work and patience. Hence, it is
no surprise that an impending posting in the NICU evokes the entire
spectrum of responses from resident doctors- ranging from excitement
and expectation to doubt and despair. Every effort has been taken to
make this handbook user-friendly so that it decreases the stress levels of
residents and fellows working in the NICU. Although targeted at the
doctors of PGIMER, it would immensely benefit everybody who deals
with newborn infants.
Despite our best efforts, some mistakes may have crept in. To err is
human- and to point out other people's errors is even more human! If you
happen to spot any errors, kindly bring them to the notice of the editors,
so that they can be rectified in future reprints.
I hope the Blue Book will help to improve the short-term and long-
term outcomes of both neonates and resident doctors in the neonatal unit.
Sourabh Dutta
August 2010
x
DISCLAIMERS
Care has been taken to verify the accuracy of all the information in
this handbook. However, the contributors and editors are not responsible
for errors or omissions or for any consequences from the application of
information provided in this handbook and give no guarantee with
respect to the completeness or accuracy of the contents. Application of
the information in a situation outside the Newborn Unit of PGlMER
Chandigarh remains the professional responsibility of the concerned
physician.
The editors and contributors have made great effort to ensure that
information related to drug doses, storage conditions, reconstimtion and
administration are according to currently accepted recommendations.
However, given the rapidity with which such infomtation changes, the
reader is urged to check the package insert of each drug before use,
particularly so for infrequently used drugs.
In a few places, brand names of medicines or devices are mentioned,
simply because these are currently in use in the unit. This docs not
constitute an endorsement of any particular brand. The contributors,
editors and faculty of the newborn unit of PGIMER have no affiliation to
any of these companies,
Fees for certain services and prices of items mentioned in the
handbook are liable to change with time. The editors take no
responsibility for any discrepancy in these figures.
Personal landline numbers and personal mobile numbers of
employees of PG!MER have not been mentioned in the handbook. Only
internal numbers have been mentioned. Phone numbers of people outside
PGIMER have been mentioned only if they were already in the public
domain or where the individuals concerned had no objection to their
inclusion.
1
Several instructions related to patients files, administrative issues
and investigations might be altered once the hospital computerization
project is fully implemented,
In the interest of brevity, references have been quoted selectively.
American spellings have been used
xi
COl'TENTS
Sections Page
How to use this handbook I
Abbreviations used in the handbook 3
PROTOCOLS
No. Title Page
I Pregnant mothers from ncor:atal perspective 9
2 Neonatal resuscitation 17
3 Admission, transfer and discharge 19
4 Medical records and admini ,trative issues 25
5 Stable term and late preterm babies 30
6 Monitoring under various circumstances~ 42
7 Temperature maintenance a 1d hypothennia 46
8 Fluid and electrolyte management -;;< 54
9 Enteral nutrition ? 68
10 Acid base disorders 83
II Hypoglycemia and hypergl.)cemia ;;/' 92
12 Perinatal asphyxia .,it !OT
13 Apnea 109
14 Acute respiratory diseases ;>t. 115
15 Inhaled nitric oxide 149
16 Bronchopulmonary dysplasia 157
17 Anemia 163
18 Polycythemia 171
19 Bleeding neonate
qp Jaundice
Intra-cranial bleeds & pcrivt:ntricular lcukomalacia i7
22
23
Seizures
Asepsis routines
~
217
24 Sepsis @§)
25 Epidemic of septicemia 240
26 TORCH infections 244
27 Human immunodeficiency virus (HIV) mfection 257
28 Congenital heart diseases 268
29 Shock 287
30 Patent ductus arteriosus of prematurity 293
31 Necrotizing coterocolitis 298
32 Parenteral nutrition
,kf' 33
~ 34
35
Inborn errors of metabolisn
Genetic/ syndromic illncssb
Surgical problems
~
327
xii
INVESTIGATIONS
No. Title Page
1-1 Sampling methods 391
1-2 Practical issues regarding sending blood samples 392
1-3 Tests to be done at bedside/ NJCU lab 393
1-4 Biochemical investigations 396
1-5 Hematological investigations 404
1-6 Microbiological investigations 409
1-7 Endocrinological investigations 416
1-8 Genetic and pathological investigations 418
1-9 Radiological and miscellaneous investigations 419
1-10 Uncommon investigations available with private 421
laboratories in Chandigarh
1-11 Selected laboratories outside Chandigarh 427
DRUGS
No. Title Page
DI - Drug information organized alphabetically 429
DJ33
RF.I Dose modification of antimicrobials in renal failure 481
RF.2 Dose modification of non-antimicrobials in renal 488
failure
NOMOGRAMS
No. Title Page
NI PGIMER Intra-uterine Growth Chart 491
N2 Lubchenco's Intrauterine Growth Charts 492
N3 Fenton's Chart For Intrauterine Growth & Initial JO 493
Wks Of Postnatal Age
xiii
INDEX 519
Cl Confidence interval
CLR Clean labor room
~ Comprehensive maintenance contract
' cMr Congenital malfonnation
CMV Cytomegalovirus
CNS Central nen oil!> system
CoA Coarctatmn of aona
CP Cerebral palsy
CPAP Conunuou:; pos1t1\'C airway pressure
CPDA Q!111~osphate-dextrosc-aoeninc
CPK-MB Crcatinc p-hospno1Ci1\ase - muscle, brain fraction
'"CR "lo. Central regtstratlon number
' CRD Central record departmeni
lCRP C-rcacti\c protcm
CRS Congenital rubella syndrome
csr Ccrcbro\pmal nu1d
CT Computenzed tomography
Card1othoracic and \ascular ::.urgery
@fCXR
\ dBllL
Ccntral venous catheter
Central venous pressure
Cardio vascular system
Chc>t X-ray
Decibel hearing Joss
DBP Diastolic blood pressure
OCT Direct Coomb's test
DIC Disscmmatcd mtravascular coagulat1on
D\,1SA Dimcrcaptosuccmic acid
DNA Dcoxynbonuclcic acid
DNS De>.trose 1'onnal Saline
DTPa Diphlhena. tetanus. pertussis (acellular)
DTPw Diphthena. tetanus. penussis (whole cell)
DVET Double volume exchange transfusion
EBM Expressed breast milk
EC Ex posurc code
ECF Extra-cellular tluid
ECG ElcctroeardJogram
Echo Echocardiogram
EDTA Ethylene diamim: tetra aceuc acid
EEG Electroencephalogram
ELBW fatremcly low binh weight
ELISA Enrymc linked immunosorbcnt assay
EMLA Eutectic mixture of local anesthetics
ENT Ear-nose-throat
EOS Early-<>nset ~cpsis
EPO Erythropo1etin
ET Endotrucheal
FcNa Fmcuonal excretion of sodium
FFP Fresh frozen plasma
FHR Fetal hcan rote
FlSll Fluorescent in-situ hybndi1.ahon
FiO: Fraction of inspired oxygen
G6PD Glucose 6 phosphate deh}drogenase
GA Gestational age
GALT Galact<>"e· l-pho,phatc undylyl traru.ferase
G-CSF Granulocytc colony stimulating factor
GER Ga·>tro e<;ophagcal renul(
GI! Growth hom1one
GIT Gastro mtcsunal traet
GM-CSF Grunulocyte macrophage colony sumuletmg factor
s
GYHD Graft versus host disease
H10 History of
Hb llcmoglobm
IIBig Hepauns-B 1mrnunoglob.:1lin
HBsAg Hepatitis-B surface antigen
HBV Hepautis-B virus
HCV Hepautis-C virus
llEV llepatttis-E virus
fHFOv High frequency cn.c11lato y ventilauo~
'11ib Hemophitus mfueniae t>re b
mE I lypoii:ic-ischemic enc~lopathy
HIV Human Lmmunodcfic1cn y virus
!ILi IS Hypoplasuc left bean S)' drom.iJ
~~?
Hyalinc membrane <tisca-.c
Human milk fortllier
'-f:PLC High performance hqu1d chromatography
WR I. Heart rate, 2. l~onia;ad + rifamp1cm
HRZ Ison111Zld • nfamp1cin nmtzmamide
HSV Herpes simpleJt virus
lit IIeight
IAP Indian academy of pcdrn rics
ICP lncracranial pressure
ICT Indirect Coomb's test
~~M Insulin dependent diabctt> mellnus
Infant ofd1abe11c mochcr
LllM Inborn errors ofmetabol m
IF lmmunofluorescence
~ lmmunoglobulm
l,!GDM Infant ofgestational diabetic mother
1\1 Intramuscular
l"lli lsoniazid
~
o Inhaled nitric oJtide
No In-born number
SURE lntubate-surfactant-eii:tufute
lntrapartum
IPPV Intermittent posmvc pre .sure vent1lat1011
~~
Injectable polio vaccine
Immature to total ratio
International unit
IUD lntra-utcnne death
IUGR Intrauterine growth retnJJ.ation
IUI lntrautcnnc infection(s)
IUT lntra-utenne tranSfusion
IV Intravenous
IVF Intravenous fluid(s)
lVH Intra-\ entrieular bC'lllO..i.age
JR Junior resident(s) .T
KUB Kidney ureter bladder
LAD Left axis deviation
LD'W Low bmh weight
LFT Liver function test(s)
l.GA Large for gestational ag
LL Lower limb(s)
LMWH
LOS
Low molecular weight
Late onset sepsis
'F°"
LP Lumbar puncture
LR Labor room
LSCS Lower segment cc:sllreall section
LV Left vcntnclc
6
~
co Nauonal AIDS control organi1ation
c 1'ieubauer's chamber
PAP 1'asal continuous pos1uvc airv.ay pressure
NLC 1\ecrolizing enterocolitis
NFC 1\conatal follow up clinic
,J:iG !'\asogastric
LNJCHD National institute of child health and human development
NICU Nconatru 111tens1vc care unit
NIMHANS :Sational institute of mental health and neurosc1enctl.
rNIPPV Nasal intcrminent positt\C pressure \COt1lation
~NF Nauonal nconatology forum
1'N'\ Neonatal nursery
NPO Nil per oral
~PV Negati"c predicuve value
NRP Neonatal resuscitation program
NS Normal saline
NSR Neonatology seminar room
~
ST Non-stress test
TD Neural tube dcfect(s)
NTZ Neutral thermal zone
VP Nevi rapine
OD Oneca day
OFC Occ1p110-frontal circumference
~
Oroga>tric
Oxygen mdeic
Outbom number
~
Osteopema of prcmaturit)·
Out-patient department
OPV Oral polio \·acc111e
OR Odds ratio
OT Operation theatre
~
Partu1l pressure of carboo-dio1tidc in arterial blood
Pulmonary ar1enal hypcncns1on
PAO.• Panial pressure of o.'tygen m alveolar ga.
PoQ, Par11al pressure of oxygen 1n ancrial blood
PBF Pulmonary blood llo"
PC Platelet concentrate
(g, Pediatnc cardiology clinic
PCR Polymerase cham reaction
PCV Packed cell volume
7
cil
Cl'?!rN)
'-::ppm
Post menstrual age
Post natal age
per oral
Per..i~tent pulmonary hyp:nension of newborn
Parts per million
PPV I Po>1tive predictive val 1c: 2. Posi1ive prosure ventilation
PRBC Packed red blood cells
PRP Platelet nch plasma
PS Pulmonary stenos1s
P>i Pa..-.cals per square inch
~ Peak systolic velocity
PT I. Prolhrombin ume; 2 fhotolherap)
PTI Prothrombin index
P\L Penvcntncular leukomalac1a
PVR Pulmonlll} vascular res1Jotancc
PWD Pulse wave Doppler
QID Four times ma da)
RAD Right axis deviation
RBC Red blood cell
RCT Randomized controlled 1:'1al
RDS Re;p1ratory distress syndrome
Rf Renal fa1 lure
ff;!:1 Recommended flow ratC'
Renal function test
RJ Res1suve mdex
RL Ringer's Lac1ate
RNA Ribonucleic acid
ROP Rcunopathy of prematur ty
RR Respiratory rate
RSV Respiratory syncytial v1 11s
RV Right ventncle
RVH Right ventricular hypcruophy
SD Systolic'd1astolic \
SAii Suba.rachnoid hcmorrllage
sao, 0'<ygcn saturallon of aB:nal blood
dru
SD
SERFT
Shop cum fla1
Shop cum office
Standard deviauon
Serum electrolytes and renal function test
SGA Smull for gestational ag.-
SGOT ~)·f Serurn glutarnic oxaloal ~lie transnminasc
SGPT !\'---.; Scrum glutamic pyruvic transaminase
SIADl l Syndrome ofinappropmtc ant1-diureuc hormone
8
~
Tuberculosis
Trans-cutaneous bilirubin
Tetanus, diphtheria, pertussis (acel\ular)
To Expiratory time
TEF T racheo-esophageal fistula
TG Triglyceride
TGA Transposition of great arteries
GD lnspiratory time
TID Thrice in a day
TLC Total leukocyte count
TMP/SMX Trimethoprim/ suphamethoxazo\e
TMS Tandem mass spectrometry
TOF Tetralogy ofFallot
TORCH Toxoplasma, others, rubella, CMV, herpes~
TPN Total parenteral nutrition
TR T ricuspid regurgitation
TSB Total serum bilirubin
TT Tetanus toxoid
TV Tidal volu1ne
U/L Unilateral
UA Umbilical artery
UAC Umbilical artery catheter
UL- Upper limb •
USG_ U\trasonogram
UT! Urinary tract infection
VDRL- Venereal disease research laboratory
VF Ventricular fibrillation
Vit Vitamin
VLBW Very low birth weight
VSD Ventricular septa! defect
VT Ventricular tachycardia
VUR Vcsico ureteric reflux:
VZIG Varicella zoster immunoglobulin
WBC White blood cell
wk(s) Week(s)
WFI Water for injection
WHO World health organization
Wt Weight
yr(s) Year(s)
µESR Micro erythrocyte sedimentation rate
System International (SI) units have been used for expressing
measurements. Standard abbreviations of SI units and acceptable
non-SI units are found in http://physics.nist.gov/cuu/Units/index.html.
Standard chemical abbreviations have been used.
9
1.2.2 BPP _ l
• Fetal breathing movement: \.. ~ I ~pisode of ~O s of sustained
breathing movement during 30 rninlobservatio~ penOd
• Fetal movement: ~2 discretegrnss body/limb movements in 30 min
observatioo...p~rioa -
• Fetal tone\.~ 1 episodes of limb notion from JJ_cxiQn to extension and
•
rapid return back to flexion.
Fetal reactivity: reactive NST c1iteria
_L J
• AFV: ~ I pocket of fluidmeasuring ~2 ems in 2 perpendicylar pJanes
Placental matunty is also judged. f- l
Presence of each of the above get a score of 2 points and absence a
score of 0 points.
Interpretation ofscores :J
• 8-10 is nonnal, unless there isfciligohydramnios
• 4-6 is suspicious of chronic hypo~ -
• 0-2 is strongly suspicious oTChiomc hypoxia. In case of score 0-2,
BPP testing time is usually extended to 120 nun.,..... -
Action based on BPP1 ~
The action lines based on the BPP stores are shown in Table 1.2
Modified BPP
A modified BPP, consisting of a l\ST and AFI, is widely used. If either
the NST or AFI are abnormal, a c~e BPPls performed.
1.2:nnlniottc'fluid index (AFI) ---
• AFf is a measure of the amour t of amniotic fluid and is an index of
fetal wellbeing .
• AFI is the score given to the a noun! of amniotic fluid (by adding up
centimeters of depth of four pockets of fluid), seen on USG. An AFI
12
~
• Reactive NST: presence of 2 or more acceleration of 15 beats or
more lasting for 15 s or more In a 20 mm tracmg.
• Non-reactive NST: no accelcrat1ons seen with movements; and there
maybe decelerations with movement. Long-tcnn variability is absent
and short-term variability is reduced.
• Equivocal VST: No movements in lQ._min with no accelerations or
decelerations suggest an equivocal N~_T. In such a case. the NST can
be done for..4!LJ:nlns (extended NST) before labeling it as non-
reactive.
• U11satisfactory VST: if the quality of the tracing is )!1!.,dsuate. for
~t<;IJ)_retation,
Implications
Risk of fetal demise within I wk after reactive NST - 3 1000
False negative results - 3.2/ 1000 (for antenatal death after correction for
congenital anomalies and unrelated causes) 3
1.2.6 Fetal Doppler studies
Umbilical artery: For interpretation of doppler indices sec Table 1.4
13
SD ratio SD*
RI )\)"\~../ (S-D)/S*
,,
Pl Pu.\)""'''
Mean of 23.3 at 18 wks
PSY ~~ V 1
emfs gestation; 64.4 at 40 wks
h estation
• dices d crease with advancing Gfl~
Any abnonnal u erine artery doppler findings is a significant predictor of
adverse neonatal outcome after controlling for occurrence of
preeclampsia (OR: 4.1, 95% CI, 2.2- '.5)4
MCA flow
The MCA is exammed close to its origin in the fi tfima] carotid arte~
(See Figure I. I). The risk of anem a is highest m etuses with a pre-
transfusion PSY :::: 1.5 times Multiple of median (MoMJ.
r eo
I ~..._~~~~~~-=--..r
l 40 .,___,_-=--..--
~ )() .......,.::;;;....~~---,~~
MCA PSV velocity > 1.5 MoM diagnoses fetal anemia with -JOO
sensitivity, - 90% specificity with NPV and PPV - 100% and -55-56%
respective!/.
14
1.2.7 Amniocentesis
Amniotic fluid can be analyzed for various compound including AFP,
Acetylcholine esterase and bilirubin. Increased level of AFP along with
the presence of Acetylcholine esterase identifies NTD with 98%
sensitivity. Increased level of bilirubin in amniotic fluid reflects
erythrocyte destruction as in isoimmune hemolysis. The relation of
bilirubin level with degree of hemolysis is interpreted according to
Liley's chart. MCA PSV is a more accurate indicator ofhemolysis and in
modem-day, practice has replaced Liley's chart as a predictor of fetal
anemia and hemolysis.
1.2.8 Chromosomal analysis
Fetal cells can be extracted from the amniotic fluid and analyzed for
chromosomes.
• 73% of clinically significant karyotype abnormalities related to one
of these 5 chromosomes (13, 18, and 21, X or Y) can be detected by
FISH with 90% sensitivity.
• DNA analysis: can be done with direct or indirect methods. Allows
diagnosis of alpha-thalassemia, cystic fibrosis, Duchene and Becker
muscular dystrophy, Phenylketonuria (PKU) etc.
1.2.9 Cordocentesis
Cordocentesis can be done under ultrasonic guidance from 2nd trimester
until term. It has diagnostic and therapeutic implications. It provides
diagnostic samples for cytogenetic, hematologic, immunologic and DNA
studies. It provides access for treatment in utero like IUT for fetal
anemia.
Risk for fetal loss with the procedure: 1-2%
Risk for preterm delivery: 5%
1.2.10 Cardiotocography
Parameters measured are as follows:
Baseline HR: normal between 110 and 160 beats/min. Baseline fetal
bradycardia, defined as <110/min, may result from congenital heart
block. Baseline tachycardia, defined as FHR > 160/min, results from
fetal dysrhythmia, hyperthyroidism, maternal fever or chorioamnionitis.
Beat to beat variability: Healthy awake term fetus varies the HR from
beat to beat by approximately 5-25 beats/min. Reduced variability
results from depression of fetal CNS due to immaturity, hypoxia, fetal
sleep, or specific maternal medications such as sedatives, narcotics, P-
blockers and IV magnesium sulphate. Accelerations of the FHR are
reassuring.
Decelerations: These may be benign or indicative of fetal compromise
depending on their characteristic shape and timing in relation to uterine
contractions.
15
REFERENCES
1. Vintzileos AM, et al. Am J Obstet Gynecol. 1987; 157: 627.
2. Wenstorm K D, et al. Am J Obst Gynecol 1999; 181: 887.
3. Freeman RK, et al. Am J Obstet Gynecol 1982; 143:778.
4. Mari G, et al. Semin Perinatal 2008; 32: 182.
5. Mari G, et al. Semin Perinatal 2008; 32: 253.
17
2. NEONATAL RESUSCITATION
.
'J .
"<·
Fetald~
Multiple birthi
.
.,' .
I lydrops fetalis
Antenatally diagnosed major £~
Whenever requested by the Ob tctricians •
------
18
REFERENCES
I. Neonatal Resuscitation, 51h edition, 2006. AM and AHA.
19
• Involve the public health nurse in the care of the baby very early
during the hospital course to build a good rapport with the family,
which will later help in assessment of the family environment, and to
plan the discharge.
3.2.2 Prerequisites for discharge of a healthy, term neonate
• Antepartum, IP and postpartum course for both mother and baby are
uncomplicated.
• Baby's vital signs documented within 12 h prior to discharge are
normal. Vital signs include RR <60 /min, HR I 00-160/min, axillary
temperature of 36.5°C to 37.4°C in an open cot with appropriate
clothing.
• Baby has urinated and has passed at least one normal stool.
• Baby has completed at least two successful breast feedings with
documentation of coordinated sucking, swallowing and breathing
while feeding.
• Physical examination reveals no abnormality that requires continued
hospitalization.
• The clinical significance of jaundice, if present before discharge, has
been determined and appropriate plan and place for follow up visits
has been decided. (See section 20.5; N19).
• Mother's knowledge, confidence and ability to provide adequate
care for her baby are documented by the fact that they have received
instructions on: breast feeding- nursing position, latching on,
adequacy of swallowing, normal urine and stool frequency, cord,
skin and genital care, recognition of illness and common problems
particularly jaundice.
• Family member or other support person(s) are available to the
mother.
• Vaccinations at birth have been administered as per PGIMER policy
(BCG, OPV & Hepatitis B). (see section 5.2.6)
• A local physician who can provide medical care after discharge has
to be identified especially if discharged <48 h of life and in that case
parents must be advised to meet this physician for examination of
the newborn within the next 48 h.
• Family, environmental and social risk factors are assessed and
resolved.
• Maternal and infant blood test results are available and have been
reviewed, which should include: Maternal syphilis and hepatitis B
surface antigen status; Cord or infant blood type and Direct Coombs
test (if clinically indicated).
Note: Early discharge (discharge within 48 h of life) may be considered
if delivery is vaginal & baby is singleton at 38-42 completed wks of
gestation and BW is appropriate for that GA as per intrauterine growth
curves, provided all the above criteria are met.
23
of the scheduled ROP screen in the discharge summary and the same
• - -
must be conveyed to the parents. Contact JR or SR Ophthalmology.
-
Metabolic screening: Premature neonates are prone for metabolic
bone disease, hypoalbuminemia and hyponatremia. Hence preterm
neonates who are > 3 wks old and sick neonates who had been on
IVFffPN should have their complete metabolic profile screened
before discharge.
Metabolic screening includes:
o Calcium, phosphorus and ALP
o Sodium
o Total proteins and albumin I globulin fraction
• PCV must be done to rule out anemia of prematurity (see section
17.4). -~~
3.3 IMMUNIZATIONS:
See section 5.2.6
25
sheets should be sent to CRD a.ong with the file. After completing
the formalities of no dues, give t ie file to sister on duty to be handed
over to ward aide.
• The Hospital Attendant is sent with the patient's attendant for "no
dues" to window no. 16 in the Reception during 9 am to 9 pm. After
9 pm, "no dues" are done in the Emergency Reception. The "no
dues" receipt is attached with the file.
• Discharge summary must be provided to patient at the time of
discharge. In rare cases, if the discharge summary is not ready it
should be posted to the address of the patient with a covering letter
attached.
S.t DEFINITIO!\S
Tenn: All babies~ 37 wks gestation
61
Late preterm (or near tcnn): 34 36 wks
Stable babies. Refers to well babies with no ad\erse health condition
a
SGA baby (-2 SD)
Single UA
Pol yhydramnios
Excessive drooling of saliva
• Abdomen Kote the shape of the abdomen. A nat abdomen signifies
abdominal contents in the chest (see section 35.2. I), or abnormali ties
in abdominal musculature. Note abdominal distension. Examine the
umbilical cord and count the vessels. Note color of the cord. Palpate
the liver and spleen. It may be normal for the liver to be about 2 cm
below the nght costal margin. The spleen 1s not usually palpable; if
the spleen is felt, be alert for congenital infection or cxtramedullary
31
Bathing
As a hospital policy, bathing of babies must not be done in PGlMER.
The only exception is a baby born to an HIV+ve mother. Daily sponging
of the baby must be done in the morning by the mother using clean
lukewarm water taking care to clean the flexural areas.
Care of diaper area
The mother should be counseled that the diaper area should be cleaned
gently with warm water and soaked cotton to remove stuck feces. The
bottom should be wiped from front to back to avoid fecal matter from
reaching the genitals. The area should then be dried by patting with a
towel to avoid any undue friction. Skin should then be exposed to air for
a few minutes. 8 Nappy rash can be prevented by reducing moisture by
the frequent changing of nappies or by using diapers using absorbent
gelling material. 9 Barrier pastes like Zinc oxide/petrolatum should be
applied on the area after each change for nappy rash.
10
Umbilical cord care
Keep the umbilical cord clean and dry. Antiseptics should not be used
routinely. The cord clamp should be removed once the cord becomes dry
and shriveled. Air exposure helps the cord stay dry and eventually fall
off, so keep diapers folded down below the cord.
Immunization
See section 5.2.6.
Jaundice:
Before discharge (especially so if discharged at <72 h) every newborn
should be assessed for the risk of developing severe hyperbilirubinemia
(see section 20.5). Measure the TSB and plot the results on the Bhutani
nomogram (sec section N 19). Infants in the high risk and high
intermediate risk zone should not be discharged early as they are prone
for hyperbilirubinemia. Others can be discharged if adequate follow up
can be ensured.
5.2.3 Problems with Near Term Infants
• The care of the healthy near-terrn infant deserves special
consideration because these babies often appear robust but may have
physiologic vulnerabilities and are prone to hypothermia.
hypoglycemia, jaundice, dehydration and breastfeeding problems.
• Such infants born must be monitored for 1-2 h in the CLR until their
vital signs are stable and then transferred to the mother. Needle
sticks may be avoided unless clinically indicated. They must be seen
37
Nails
Nail should be regularly cut and kert short and clean. Special nail cutters
for newborn babies or small scissor; may be used.
Ears
Routine cleaning of the inside of the ear canal is not advised. If done,
cotton swab soaked in warm water can be used to avoid injury to the
auditory canal. Oil must not be instilled into the ear.
Napkin changes and diaper care
• In general, nappies should be made of cotton cloth and should be
home laundered with mild detergents. If affording, parents may use
diapers and super-disposable diapers as they keep the skin relatively
dry, maintain pH and reduce the risk of rash. There are concerns that
the materials used in diapers are non-biodegradable and hence
environmentally unfriendly.
• Parents should forego tight-fitting diapers and consider a diaper
slightly larger than the infant to minimize the contact between skin
and urine or feces
• Wash hands well after each diaper change to prevent germs from
spreading.
5.2.6 lmrnunization:
• Term, healthy neonate: Recommendations of !AP have to be
followed. (see Table 5.3)
o OPV - soon after birth
o BCG intraderrnal - at birth but not later than 30 d of age
o Hepatitis B vaccine at birth or before discharge. Babies born to
HBSAg +ve mothers should receive hepatitis B vaccine at birth
irrespective of GA or BW along with HBIG.
• Pretenn neonate: Vaccines should be administered as per the
schedule for term infants. This should be according to chronological
age of the infant and not postconceptional age.
As far as possible, babies must be administered BCG, Hepatitis B and
OPV at least 1d prior to discharge to monitor for any adverse effects due
to immunization. Contact vaccinators for inborn babies in case of
emergency discharges. Babies discharged within 24 h should be advised
immunization at the earliest either at PGIMER (Room No. 2422, APC-
2D) or with a local practitioner, whichever is convenient.
DTPw-l I DTPa but the two have equal efficacy and the
-l cost of DTPa is inordinately high.
Hepatitis-B -2
Hib - I
IOwks OPV-2 + IPV-2 I
OPV -2
DTPw-2 I DTPa
-2
Hib-2
14 wks OPV-3 + IPV-3 I
OPV -3
DTPw-3 I DTPa
-3
Hepatitis-B -3
Hib - 3
9 mths Measles
15 - 18 OPV-4 + IPV-Bl OPV alone if IPV cannot be given
mths I OPV -4
DTPw-Booster l
I DTPa -Booster
l
MMR-l
Hib - Booster
2 yrs Tvohoid Revaccinate every 3-4 vrs
5 yrs OPV-5 Second dose of MMR vaccine can be
DTPw-Booster 2 given at any time 8 wks after the first dose
I DTPa -Booster
2
MMR-2
Vaccines that can be given a~er discussion with oarents
More than Pneumococcal 3 primary doses at 6, I 0, and 14 wks,
6 wks conjugate followed bv a booster at l 5-l 8 mths
More than Rotavirus vaccine 2 or 3 doses (depending on brand) at
6 wks 4-8 wks interval
After 15 Varicella Age less than l 3 yrs: one dose
mths Age more than l 3 yrs: 2 doses at 4-8
wks interval
After 18 Hepatitis A 2 doses at 6- l 2 mths interval
mths
This list is not exhaustive. Newer vaccines are constantly being
introduced.
41
REFERENCES:
I. Righard Let al. Lancet.1990;3:6:1105
2. Ransjii-Arvidson AB et al. Birt:1. 200 I ;28:5.
3. Gunther Met al. Lancet 1955;2\8:575.
4. Klaus MH et al. Obstet Gynecol Clin North Am. 1987;14:623.
5. De Carvalho Met al. Pediatrics 1983;72:307.
6. Breastfeeding Promotion Network of India.
http://www.bpni.org/breastfeed1ng.html
7. Baumer J H et al. Arch. Dis. Child. Ed. Pract. 2007;92:61.
8. Dhar S et al. Indian J Dermatol 2007;52: I.
9. Lane AT et al. AmJDisChild. 1990;144:315.
I 0. Zupan Jet al. Cochrane Database Syst Rev. 2004.
11. Stellwagen Let al. Pediatr Rev. 2006;27:89.
12. AAP, Subcommittee on Hyperbilirobinemia. Pediatrics
2004;114:297.
13. Mitchell EA et al. Arch Dis Child. 2007;92:155.
14. Association of Women's Health, Obstetric and Neonatal Nurses.
www .awhonn.org
15. Darmstadt GL ct al. Acta Paediatr.2002;91 :546.
16. !AP guide book on immunization, 2009.
42
6.1 MONITORING IN LR
6.1.1 Normal term neonates without risk factors:
HR, respiration, temperature, color, and CFT should be monitored once
after stabilization. Monitor these parameters once per nursing shift if the
baby remains stable.
6. 1.2 Late preterm babies:
They should be monitored 2 hourly for 6 h and then 12 hourly until
transfer.
6.1.3 High risk asymptomatic babies (except near term babies):
This group predominantly includes (but not limited to) preterm, SGA,
IDM, babies born through MSL, perinatal asphyxia (see Table 6.1)
All babies are evaluated for jaundice at transfer and at least 12 hourly.
baby is in cold stress. In hypothermia, both feet and abdomen are cold to
touch.
7.3.2 Thermometer
Mercury-in-glass thermometers o,. digital thermometers: Preferably,
use a low reading thermometer that can record temperature as low as
30°C. Disadvantage is single point determination.
Rectal temperature
Infants must be placed on their stomach and held securely in place. It is
recorded by inserting the greased bulb of the thermometer into the
rectum to a depth of3 cm in a term baby or 2 cm in a preterm baby. Keep
thermometer in place at least for 3 min. It is the best guide for core
temperature in cold (hypothermic) sick neonates.
Axillary temperature
It is recorded by placing the bulb of the thermometer against the roof of a
dry axilla perpendicular to the arm. Baby's arm is held close to the body
to keep thermometer in place. The temperature is read after 5 min (WHO
recommendation) 1. The recommendations are similar for term and
preterm babies. There is a wide variation across studies regarding the
agreement between axillary and rectal temperature although most studies
agree that the variation is less in pretcrrn infants.
7.3.3 Thermistor
Skin temperature is recorded by a thermistor. Site of attachment: supine -
right upper abdomen; prone position - flank. When possible
simultaneously measure temperatures over the abdomen and sole. Attach
probe to skin using a reflective thermal pad.
False high temperature recordings are due to:
o Probe over interscapular area (area of brown fat)
o Probe sandwiched between the mattress and the skin.
o Probe covered with a tight fitting cloth.
False low temperature record
o Low environmental relative humidity
o Probe over bony prominences
/
so
BW Environmental temoerature
(kg) 35°C 34 °C 33 °C 32 °C
1.0 - Forl"IOd After 10 d After 3 wks After 5 wks
1.5
1.5 - Forl"IOd After 10 d After4 wks
2.0
2.0 - For1"2d After 2 d After 3 wks
2.5
> 2.5 For1"2d After 2 d
l
Monitor skin temperature continuously. Record
axillary temperature Yi hourly till euthcrmic
REFERENCES
l. World Health Organization. Thermal protection of the newborn: a
practical guide. 1997.
2. McCall EM et al. Cochrane Database Syst Rev. 2008.
3. Hey E. Br Med Bull. 1975;3 I :69.
4. Christensson Ket al. Lancet. 1998;352:1115.
5. Kaplan Met al. J Pediatr. I 984; 105:470.
54
• Estimate losses over past 6-12 11. Replace urinary losses only if total
loss > 4 mL/kg/h in 6 h period. Replace the volume that is in excess
of 4 mL/kg/h- volume by volume- over next 6-12 h. Other losses are
replaced volume for volume every 6 h. In all VLBW babies, the
calculation oflosses and replacement should be done every 6 hourly.
• Type of fluid used for replacement:
o Vomiting, NG aspirations and excess urine output in polyuria
(>4 ml/kg/hour): replace "ith N/2 saline with+ 10 mEq/L KC!
(0.5 mL KCI added per eve1y I 00 mL offluid)
o Chest tube drainage and third space losses (approximate clinical
assessment) with NS
o Diarrheal losses (10-20 ml per stool) with 0.2 NS in D5 + 20
mEq/L KCI (I ml KC! added per every 100 ml offluid)
Hyponatrrmia
(Serum Na <13(1 mEq!L)
+
Inadequate Intake Excessive Loss
I
+
Decreased urine
output
•
Normal/ Increased urine
output
(Renal losses)
Diuretics
Prematurity
Renal tubular
(Extra renal losses)
GI losses
Third space Joss >1015 •
<1005
acidosis
CAH i
CCF Renal failure
Sepsis
SIADH
Muscle relaxants
*Factitious hyponatremia
Hyperlipidemia: Na~ decreases by 0.2 for every 100 mg/dL rise in total
lipids.
Hyperproteinemia: Na+ decreases by 0.25 for every g/dL rise in total
protein beyond a value of 8 g/dL.
Hyperglycemia: Na decreases by 1.6 mEq/L for each 100 mg/dL rise in
glucose
# FENa values may not be useful in <32 wks gestation
62
8.8.3 Hypernatremia
Definition: serum [Na+] >150 mEq/L
Causes: Hypcmatremia is secondary to negative water balance or excess
Na+ intake.
Hypernatremia with normal or deficient ECF volume
• Increased IWL- Hypematremia is often a problem in the l" wk of
life in summer months, particularly if the mother has poor milk
output.
• Skin sloughing- e.g. SSSS, epidermolysis
• ADH deficiency - IVH, meningitis, birth asphyxia. Note that
SJADH is more common in these conditions than ADH deficiency.
• Acute gastroenteritis
Hypernatremia with excess ECF volume
• Excessive administration of isotonic or hypertonic fluids
• Administration ofNaHC0 3 , other Na containing medications
• High solute formula feeding
Hypematremia may cause hyperexcitability and hyperreflexia. Severe
hypematremia (serum [Na+] >160 mEq/L) may cause permanent CNS
damage.
Management of hypernatremic dehydration
There are complex ways of calculating the exact fluid composition that
meets Na+ requirements, but the following guidelines are appropriate for
most circumstances.
Restore infravascular volume
NS: 20 mL/kg over 20 min (Repeat until intravascular volume restored)
Determine time.for correction based on initial sodium concentration
[Na]:J45-157 mEq/L: 24 h
[Na]: 158-170 mEq/L: 48 h
[Na]:\71-183 mEq/L: 72 h
[Na]:184-196 mEq/L: 84 h
Administer fluid at constant rate over time for correction
Typical fluid: D5 Y, NS (with 20 mEq/L KCI unless contraindicated)
Typical rate: 1.25-1.5 times maintenance
Follow serum sodium concentration to adjust fluid based on clinical
status and serum sodium concentration
Signs of volume depletion: administer NS (20 mL/kg)
Sodium decreases too rapidly- Increase sodium concentration of IVF, or
decrease rate of JVF
Sodium decreases too slowly- Decrease sodium concentration of IVF, or
increase rate of IVF
Replace ongoing losses as they occur
If hypernatremia is corrected too rapidly, brain edema, seizures, and
death can occur. Scrum Na should not drop by> 10 mEq/L/d. If seizures
63
occur during correction, they are us ially due to water intoxication. Treat
by giving 5 mL/kg of NS.
Peritoneal dialysis - If serum Na·: 180 mEq/L, rapid correction may be
done by putting 45 mL/kg of a dialysis solution containing 4.25%
glucose intra·peritoneally and withdrawing it one hour later. After a few
cycles as the serum sodium falls, subsequent dialysis may be carried out
using the normal PD solution with I .5% glucose.
8.8.4 Hypokalemia
Definition: Serum K' <3.5mmol/L
Common causes
• Inadequate intake
• Alkalosis (bicarbonate treatment or loss of acid from gastric
secretions). Metabolic alkalosis is more often associated with
hypokalemia than respiratory alkalosis.
• Renal losses · tubular defects
• GIT losses · Diarrhea, NG or ileostomy drainage
• Medications (diuretic therapy, sodium bicarbonate infusions,
salbutamol, amphotericin B and insulin)
ECG changes · Prolonged QT interval, U waves, ST depression,
depressed T waves
Treatment:
Treatment will depend on the underlying cause and the severity of the
hypokalemia. Caution: Consider delayed treatment or monitor carefully
if urine output is low or renal function is abnormal
• Reduce gastro-intestinal or renal losses & replace fluid losses
• Increase oral or parenteral potassium intake as needed.
• Oral potassium supplements· molar KC! supplements (I mL ~ 2
mmol KC!). Usually start at 2 mmol/kg/d KC! supplement.
• IV potassium supplementation-
o Maximum permissible is 40 mEq/L, i.e. 2 mL of 15% KCl/100
mL fluids, without ECG monitoring.
o With ECG monitoring, one can go up to 60-80 mEq/L, i.e. 3-4
mL KCI/ I 00 mL fluid.
• Monitor the serum K" carefully and adjust dose accordingly.
8.8.5 Hyperkalemia
Definition: serum potassium >6 mEqiL.
Causes (Shown in Table 8.4):
The most important cause to investigate is oliguric renal failure.
However, extremely premature babies may develop hyperkalemia
without significant renal impairment in the initial days of Ii fe. This is due
to relative aldosterone resistance and low glomerular filtration rate
(GFR).
64
+
Peritoneal dialysis
DVET with fresh whole blood I fresh PRBCs with FFP in dire
emergency if peritoneal dialysis is not possible, especially if
sepsis co-existent
*insulin dextrose infusion: Begin with a bolus of regular insulin 0.05 units/kg and 2 mUkg
of 10% dextrose. Follow it up with 10°/o dextrose infusion at the rate of2·4 mUkg/h along
with regular insulin 0.1 units/kg/h (10 units of insulin in 100 rnL of 10% dextrose@ l
mlJkg/h) (see section 070)
66
1 Itt
8.8.6 Hypocalcemia
Defined as total scrum calcium concentration of <7 mgidL or an ionized
calcium concentration of <4 mg. dL (i.e. 1 mEq L). Postnatal changes in
serum calcium: at birth, umbilical calcium level is 10-11 mg dL, which
decrease in healthy term newborns to reach a nadir of 7.5-8.5 mgldL for /7
the first 24-48 h. Thereafter. level rises to adult value. /
Classification: early onset (<3 d) and late onset(>3 d) / D..-//.,,7 1-~ "~
Causes: - _.J ]
Early onset: Prematurity, IDM. perinatal asphyxia, maternal. intake of
anticonvulsants, lUOR. If hypocalcemia docs not resolve within 72 h of
~hera~y investigate for causes of late onset hypocalcem1a.
Late onset:
• Increased phosphate load - Cow's milk, advanced repal insufficiency J
• rlypomagnesemia
• Vit D deficiency- Maternal vit D deficiency, Malagsorption, Renal
insuffic1eacy, Hepatobiliary disease
• Parathyroid hormone resistance- Transient neonatal
pseudohypoparathyroid1sm
• Hypoparathyroid1sm
• Metabolic Syndromes- Kenny-CafTey syndrome, Long-chain fatty
acyl coenzymc A (CoA) dehydrogenasc deficiency, Keams-Sayre
syndrome
• Iatrogenic - C1tmted blood products. Lipid infusions. Bicarbonate
therapy, Diuretics (loop diuretics), Glucocomco1ds, Phosphate
therapy, Alkalos1s, PT
C/i11ical manifestations: generally non-specific like apnca, irritability, ~
J
I
jittcrincss, increased extensor tone, seizures, clonus, hypcrreflex1a, and
stridor (due to layngospasm).
Monitor: VLBW babies or gestation :532 wks~h asphyxia (moderate
to severe), IDM, lUGR (<2SD), shock, sepsis with multi-organ
dysfunction syndrome (MODS), D1Georgc sequence, DVET - 24 hourly
for 48 h.
Diag110.\is: laboratory serum and ionized calcium values. ECG - Q0 Tc
>0.2 or QTc >0.45. A diagnosis of hypocalcemia based only on ECG
criteria 1s likely to yield a high false pos1t1vc rate. A simple formula to
evaluate hypocalcemia 1s: ·•if (number of small squares in Q0 T) squared >
(number of small squares m RR). that means Q0 Tc 1s prolonged.
lllvestigatio11s: Send serum calcium, magnesium, phosphate, pH, ionized
calcium fraction. Get Chest X-ray for thymic shadow if Di George's
syndrome suspected
Treatment
Maintenance: 4-6 mL kgld of Ca gluconatc IV (added in last 2 h of 6
hourly IVF) {~ec section D20)
67
REFERENCES
I. MacDonald M G. Avery's Neonatology. Pathophysiology and
management of newborn. Lippincott Williams & Wilkins 6th edition
2005; Chapter 21.
2. Dutta S. Acta Paediatr 2009; 98: 970.
3. Gaylord MS. J Perinatol 2001; 21: 438.
68
9. ENTERAL NUTRITION
9.1 INTRODUCTION
Nutrition is one of the most important aspects in the management of
neonates. especially for LBW babies. The objective of this chapter is
primarily to address the issues involved in the optimal feeding of the
LBW infant. For feeding of term & near term infants refer to section
5.2.2. The use of feeding bottles, pacifiers and pre-lacteal feeds is
prohibited in PGIMER.
• Relative contra-tndtcauon-
o Significant respiratory distress (Downe's score >4)
o Severe bemodynamic instability (requmng inotropes > 15
µg/kg/min)
9.11 SUPPLEMENTS:
9.11.1 Iron: The store of iron is low in preterm infants. Start iron at 2
wks of life. Babies <1000 g must be given 3-4 mg/kg/d and babies >1000
g 2-3 mg/kg/d of iron. Continue until 1 yr of age. For composition and
dosage of commonly used iron supplements in our unit see Table 9.3.
..
T a bl e 9 3 C omoos1"ti on & dosae:e of some iron sunn ements:
Commercially available Elemental Vit 812 Folic acid
brands iron m!!lmL) luP/mL) luPimL)
Tonoferon (lmL~20 droos) 25 5 200
Provive Fe drops 15 4 200
Hemsi drops 30 5 200
73
9. 12 Hl\fF:
As preterm mother's milk is inadequ 1te as the sole source of all the
nutrients, the use of multicomponent fortifier allows the infant to receive
a nutrient intake that meets the estim~ed needs. In infants <32 wks of
gestation, mu lticomponent fortifier leads to short-term increases in Wt
gain, linear growth, head growth and minerali1.:ation7. There appears to be
74
no efTect on growth beyond I yr of age. A study done in our unit had also
shown that HMF addition resulted in increased Wt, length and head
growth in pretcrm VLBW SGA rather than AGA infants, when compared
to no HMF supplcmentation. 8
9. 12.1 Using multicomponent fortifier:
Consider using HMF in babies with <32 wks of gestation who arc not on
direct breast feeds and are not gaining adequate Wt in spite of receiving
full feeds. Unfortunately, an optimum HMF is still not available in the
Indian market. The available one (Lactodex-HMF) does not have the
desired protcm content {sec Table 9.S below).
• If a decision to use HMF is taken, fortification must start once full
feeds are reached ( 180-200 mUkg/d.
• The manufacturer's recommendation is to add I sachet of HMF to
SO mL of milk under aseptic precautions, refrigerate the unused
human milk and use 1t within 8 h of preparation.
• If a mother expresses less than SO mL milk it poses certam practical
problems. One option is to press the HMF sachet such that the
contents arc layered uniformly inside. The sachet can be cut with a
sterile blade into 4 parts. These parts can be stored m a sterile
container The HMF powder does not generally spill out because it is
sticky. The contents of each cut part can be added to 12 mL of EBM.
• Dividing the HMF powder in the pharmacy into smaller sachets
contaimng the exact Wt of HMF required per feed sounds ideal.
However, multiple handlers may mcrease the risk of contamination;
the paper (1f absorbent) may deplete the fat; and it would be difficult
to constantly juggle wi th HMF quantities when the volume of EBM
feeds is rapidly graded up.
• Do not mix fortifier in fonnula mHk
• lrthe baby gets partly preterm formula and partly EBM, IIMF must
be added to the EBM feeds, unless the EBM constitutes <I/3rd of the
total volume or the absolute volume of each EBM feed is <12 ml.
This holds true for Lactodex-LBW as well as Dexolac Special Care.
• Continue fortifier until the baby reaches 2 kg or goes on to full
breast feed.
• When the fortifier is stopped. start supplements with calcium and
mult1v1tamms. Do not mtroduce these supplements as long as HMF
is given.
• HMF docs not contain iron. Hence iron supplementation must stan
as scheduled at 2 wks age.
• For those who can't afford HMF, addition of LBW formula 4 gt I 00
mL feed is an alternative option. This amounts to I g of powder
added to 2S mL EBM (an average feed volume). This option has
been found safe only in terms of osmolarity (390 mOsm/L), but not
been evaluated for clinical outcomes. Once the tin of pretem1
75
Table 9.6: Composition of prcterm-human milk and commercially available preterm formulas
for diaper changes. The mother can sleep with the baby in kangaroo
position in a semi-recumbent position, at an angle of 15-30 degrees.
• When the mother is not free, '·ther family members, including the
father or grandmothers can also provide KMC.
• The baby can be weaned from KMC when the corrected GA is about
40 wks, weight about 2500 g, when the baby wriggles, pulls her
limbs out, or cries whenever the mother tries to resume KMC. While
weaning the mother can provide occasional KMC, e.g. after giving
the baby a bath or on cold nights.
REFERENCES
1. Optimal feeding of low-birth-weight infants. WHO technical review,
2006.
2. Dhingra A. J Matern Fetal Neonatal Med. 2009;22: 198.
3. Kennedy KA. Cochrane Database Syst Rev.1998.
4. Tyson JE et al. Cochrane Database Syst Rev.2005.
5. Schanler RJ. Pediatrics 1999;103:1150.
6. Akintorin SM. Pediatrics 1997;100: e4.
7. Kuschel CA. Cochrane Database Syst Rev.2004.
8. Mukhopadhyay K. Indian Pediatr. 2007;44:286.
9. Hansen WF. Obstet Gynecol. 2005; 105:383.
10. daSilvaOPCMAJ.2001;164:17.
11. Darling J. Arch Dis Child Fetal Neonatal Ed. 2005;90:f359.
12. Tyson JE. N Engl J Med. 1999;340:1962.
13. Ng E. Cochrane Database Syst Rev. 2008.
83
JO.I INTRODUCTION
Maintenance of plasma pH within the range 7.35- 7.45 is an essential
requirement for life, because many metabolic processes (e.g. enzymatic
reactions) are exquisitely sensitive to changes in H+ concentration.
Buffers are the substances that attenuate changes in pH. Bicarbonate
buffers are the most effective buffers in the body. Non bicarbonate
buffers include proteins (albumin & Hb ). phosphate and bo11e.
~
Hypoxia <87
Sp02 87 - 95 Calculated
Hyperoxia >95
Table 10.2: Change in the hlood gas parameters over time stored at
Room temperatureI Ice:
Blood gas Room temperature Iced sample
parameter 15 min 30 min 15 min 30 min
Pa0 2 ! 5 mmHg ! 8 mmHg j 1 mmHg j 1 mmHg
Paco, j 0.8 mmHg i 1.3 mmHg j 0.6mmHg j 0.5 mmHg
pH ! 0.007 ! 0.016 ! 0.005 ! 0.004
..
T a ble 10 4 I nterpretation of meas•red vs. expect ed b'1carb onate
Respiratory acidosis with
Measured HC0 3 ~expected
appropriate compensation
Measured HC0 3 <expected, but Respiratory acidosis with
higher than normal range partial compensation
Respiratory acidosis with metabolic
Measured HC0 3 > expected
alkalosis (mixed disorder)
Respiratory and metabolic acidosis
Measured HC0 3 $normal range
(mixed disorder)
10.11.2 Etiology
Respiratory acidosis is seen in conditions like _CNS depression (e.g.
infection, birth trauma, hypoxic brain damage, drugs overdose, apnea,
anesthesia, raised ICP), neuromuscular disorders (e.g. diaphragmatic
paralysis, muscular dystrophies, spinal cord injury, medications like
paralytic agents and aminoglycosides), i:Y.eakness of respiratory muscles
(e.g. hypothyroidism, hypokalemia, hypophosphatemia), pulmonary
s!isease and upper airway obstruction.
10.11.3 Treatment --
The history and physical often point to a clear etiology.
In ventilated babies one should proceed in following fashion- (also see
section 14.12)
90
REFERENCES
I. Kelly AM. Emerg Med J 2001; 18: 340.
2. McLain BI. Arch Dis Child 1988; 63: 743.
3. Forsythe SM. Chest 2000; 117: 260.
92
HYPOGLYCEMIA
'
1
Hypoglycemia I
'
Ful! term AGA infant who is not at risk
but incidentally detected to have
hypoglycemia
_____, Take sample for
laboratory estimation
of plasma glucose
Blood glucosel
l
Blood Glucose
2 ml/kg of I 0% IV dextrose over 1 min
~ (don't treat with intennittent boluses, don't
>25 mg;dL I <25 mg/dL
give bolus with either 25% or SQl'/o dextrose)
Send first line investigations Start tapering down g]U<;osc rate by 2 mg/kg/min every 6
and start medications hour if BS.rate remain~ in euglycemic range for >6 h or
bl d glucose remains >I 00 mg/dL for 2 h.
95
11 .4.1 Medications (see sections I .7.3 and 11. 7.4 and figure 11 .2)
0
fl uids cg I 00 mL kg,d and increas the concentration of IV dextrose
infusion to provide glucose rate )f 6 mg/kg/min and IVF @ 60
mUkg/ min. Insert central line if lextrose concentration is > 12.5°10
through peripheral line.
If the baby is already on full eeds and develops symptomatic
hypoglycemia, reduce the feedSto 50% of the requirement and give rest
of the fluids rv @, 6 mglkg/nlin to bt]!n with. Continue monitoring and
if BS remains 10 euglycemtc range, tirrate fluids as well as feeds m above
mentioned manner
If a baby on TPN develops hypoglycc.mia, increase the daily fluids by 20
mL/kg/d. Prepare extra fluids in a way that the glucose rate increases by
2 mg/kg/min and continue monitoring.
98
l
I Hemod:rnamically uru;table
1
-
I Hemodynamically !>table I
If NPO, introduce feeds by increasing total intake
by .];O mUlc_fd O\er marntenance requirementJ>.
I
Minimal F.ntcral
Nutrition (MEN) ] -
Maximum limitJ> of increasing total intake before
abandoning this policy and reducing the t~
MEN are:
<I kg 20 mL /kg/day
-
I Euglycemia ~
by 2 mg/kg/min
- l
Observe for 3 feeds
-
to maintenance 40 mukg'd and rt.'duce glucol>C rate
l +
Increase feeds nnd reduce IV I Hypoglycemia I
fluid!> as well as Glucose rate
every 6 hourly +
Keep feeds @, 40 mllkg/d and increase glucose rate
lo pre"fous level by mcrcasmg dextrose
+
I Continue monitoring I concentration
+
I If glucose rate exceeds > 12 mg 'kg.'min I
!
Reduce feeds to ML:-! and give rest of the
I maintenance fluids as dex~e infu,ion I
99
11.11 MA1'AGEMENT:
• Decrease glucose rate to 4 mg/kg/min with monitoring of BS every I
hourly. Don't give less than 5% concentration of dextrose. Minimal
permissible glucose rate for term AGA babies is 3 mg/kg, min
• Initiate insulin therapy (see section D70) when osmotic diuresis
(urine output >4 mUkg/h) occurs (expect osmotic diuresis with BS
>215 mg/dL). Start insulin infusion: 10 units of regular insulin in
100 mL of maintenance fluid @ 0.01 to 0.2 unit/kg/hour if BS
remains >215 mg/dl for >6 h after decreasing glucose rate to
maintenance. Flush IV tubing with SO mL of insulin stock solution.
Monitor whole BS every 15 min for I" hour and then hourly.
Monitor serum potassium every 6 hourly.
• Taper insulin infusion if BS remains <200 mg/dL and omit insulin
infusion if BS < 150 mg/dL.
• If a neonate on TPN develops hyperglycemia, increase the
maintenance fluid by 20 mLJkg/d and use that fluid to prepare
insulin infusion to be gi\'en @ 0.10 to 0.2 unit of 1nsulin/kg/hour.
• Monitor BS every 15 min for 2 readings and then hourly for 6 h and
then every 6 hourly.
REFERENCES
l. Williams AF. Semin Fetal Neonatal Med. 2005; I0:363.
2. Mendiola J. Anesth Analg.1982;61 :32.
--
3. Stanley CA. Pediatr Cl in North Am l 997;44:363.
4. Aynslcy-Grcen A. Arch Dis Child Fetal Neonatal Ed. 2000;82:F98.
101
12.1 BACKGROUND
Perinatal asphyxia is an insult to the fi·tus or the newborn due to lack of
oxygen (hypoxia) and/or a lack o perfusion (1schemia). Perinatal
asphyxia is classified into moderate ~vxia (slow gasping breathing or
I min Apgar score of 4-6) and severe asph ia (no breathing or 1 min
Apgar score o - . v1dence of eta distress ts de me as e a
m>riormalit1es ± cord blood pH < 7 0. Immediate management
neonate with asphyxia is shown in Figl.re 12. I
I mm Apgar < 7
and/or e/o fetal distress
Parameter Frequency
HR
RR
Continuously
Sao,
Temperature
BP
Capillary-filling time
Every hourly
Color
Peripheral pulses
Neurological examination for signs of
6 hourly
HIE
Wt
Urine output 12 hourly
Abdominal girth
anterior fontanel tenseness
Daily
OFC
Other systemic examination As clinically indicated
Parameter Frequency
Serum calcium As clinically required
Sepsis screen and blood culture
and sensitivity In unexplained cases of asphyxia
REFERENCES
I. Levene ML. Early Hum Dev 1985; II: 21.
2. Samat HB. Arch Neural 1976; 33: 696.
3. Lantos ID. NeoReviews 2009; 10: e65.
4. Cochrane review, 2007
(}J.. ~fit.,. I ,., •JI 6 . [,.,
?rye,.'C!P'{E. '-" j; >~ ~
109
0
Often central component precedes Obstructive component.
Frequency according to the type: Mixed> Central> Obstructive.
eek
, Breathing effons pre~nt or not
Airway obstruction (11eck position. secretions)
Tactile stimulalton twice
l Gentle oropharyngca sucuon
Apne1c or
HR<60 Con11nuc
mon1111nng&
evaluate
Provide effective PPV x 30 s cause
HR < 60 l t HR > 60
HR< 60
I Administer Epinephrine•
S- Response - nonnal respiration, HR> 100. pink
•.Consider intubation
• One should attempt to get the drug levels if feasible (not routinely
done in PG!). The therapeutic It vels: 7-15 µg/mL.
• Once the baby is eligible for <·ral drug administration, shift to oral
theophylline (see section Dl23)
• Toxic effects- Tachycardia, jitteriness, irritability, seizures,
abdominal distension, feed intolerance, vomiting, GER,
hyperglycemia.
CPAP*
-r - I
Continued ;neas
(• Start with CPAP of 5 cm H20. One can consider increasing CPAP up to 6, if apneas
continue on 5 cm H 20, as optimal PEEP for splinting chest wall & airway can vary with
the babies).
REFERENCES:
I. Henderson-Smart DJ. Cochrane Database Syst Rev. 2001.
2. Comer AM. Paediatr Drugs. 200 l ;3 :61.
115
14.1 DEFINITIONS
Clues Diaenosis
Prematurity (<34 wks),
No. inadequate antenatal steroids,
APH, maternal DM, Rh
RDS
isoimmunization, a suggesti,·e
gastric aspirate shake test (see
section I-3)
Risk factors of EOS (see section
24.3), PMN in gastric aspirate (>5
Congenital pneumonia
per hofl
Evidence of fetal distress, decreased sphyx1al lung damage
fetal movements, abnormal FHR (Secondary surfactant
patterns (see section 1.2. l 0), MSL, c:eficiency/dysfunction). PPHN.
cord UA blood acidosis MAS
$evere RDS, congenital
Prolonged IPPV, need for high rneumonia, pleural effusion,
inspiratory pressures, difficult to pulmonary hypoplasia,
rise chest (immediate postpartum pneumothorax. airway
and in the first 24 h) ma! formations
PPV, asynchronous breathing
efforts, underlying disease causing
A 1r leak syndromes
air trapping (e.g. MAS), sudden
( ~neumothorax , PIE,
onset hypoxia and hypercarbia,
prleumopericardium)
chest hyperinnation, reduced air
entry II
116
Clues Dia~nosis
Polyhydramnios, single UA, Esophageal atresia with/without
excessive frothing from mouth, trachea-esophageal fistula (see
absent stomach bubble on AXR, section 35.2.2)
scanhoid abdomen
Oligohydramnios, Potter facies, Pulmonary hypoplasia
limb deformities
CDH, congenital cystic
Polyhydramnios, antenatal hydrops adenomatoid malformation,
fetal is pleural effusion (uni/BIL)
Scaphoid abdomen, heart sounds
over the right chest, bowel sounds CDH (See section 35.2.1)
over the thorax
Abnormal presentation (breech,
brow, face), difficult delivery (large
Diaphragmatic paralysis, pain
baby, shoulder dystocia, forceps
(due to brachia! plexus injury,
extraction) especially in a female
fracture humerus or clavicle)
neonate, asymmetric Moro's reflex
on clinical examination
Unexplained sibling death,
unexplained metabolic acidosis and
!EM (see section 33.4)
hypoglycemia, seizures, abnormal
odor (bodv/urinc)
Risk factor for breathing-
swallowing in-coordination such as
asphyxia, CNS malformations,
Aspiration pneurnonitis
gestation <34 wks, poor feeding
technique, anatomical defects (clef\
nalate, ~lossontosis)
Tachypnea, stridor, Upper airway pathologies
suprastemal/supraclavicular (laryngomalacia, vascular
recessions, little oxygen malformations, subglottic
reauirement stenosis)
Metabolic disease (hypoglycemia,
Isolated tachypnea (usually no
!EM), CNS disease, CHD
oxygen requirement)
Polvcvthemia, anemia, pain
Antenatal ACE inhibitors, post-
term, asphyxia, MAS, severe
cyanosis (not responding to 0 2),
PPHN
extreme !ability especially on
handling, tricuspid systolic murmur,
differential saturation
Post term infant, hyper inflated
Amniotic fluid aspiration
chest, other causes ruled out
117
Two important scoring systems available are the Downe's score and the
Silverman-Anderson retraction score
14.5.1 Downe's score: Shown in Table 14.2
14.5.2 Silverman-Anderson score: Shown in Table 14.3
118
- - - - - -
Parameter 0 1 2
lnterprerat10n:
• Normal range in a newborn: 5 - 15
• Abnormal: 15-40
• Definitely abnormal: >40
a/A ratio:
Ratio of Pa01 to PA02. Consider..d to be a better indicator of gas
exchange as the ratto is less affected oy changes in Fi0 2
Interpretation:
• Greater than 0.8: Nonna!
• Less than 0.6: need for 0 2 tberaty
• Less than 0. 15: severe hypoxem a
Oxyge11ation Index (OJ):
Recommended in babies who are rrechanically ventilated as this score
includes MAP
OJ = (MAP x Fi02) Pa02
Interpretation:
• 01 25 - 40: severe respiratory fa lure; monality risk is 50 60%
• 01 > 40: Mortality risk is >80%
-
-
- -
122
•
in the airflow and inadvertent uncontrolled PEEP delivery apart from
causing local airway injury
Use oxygen analyzer to check the Fi02 when 0 2 therapy is begun,
l
whenever a change in the oxygen now rate is made or a change in
the respiratory status of the neonate has occurred. ,;
14.8.4 How to administer appropriate oxygen concentration?
Air-Oxygen blender )
These mechanically blend pressurized oxygen and arr, and are the ideal
way to provide appropnate delivered Fi01 • 0 2 concentration and flow
rate are set as per the manufacturer's protocol.
Indigenous air-oxygen mixing.
• Mix oxygen and air at pre-decided flow rates using a ·y· piece to
achieve target Fi02 (see Table 14.6)
123
( i02
Landmar
(•/.)
ks for the RFR
(at an Complication Remarks/precautio
Type depth of (Lim
avera s ns
insertion in)
(in ems)
g
RFR)
Read the
product
insen for Short, binasal
Crusting,
Nasal prongs selection I -2 25 45 prongs are
erosion
of recommended
appropriate -
orong I
I RFR should be at
least 4 nmes that of
Oxygen hood -- 2-4 30~ --- the - minute
70_..o ventilation. Lesser
-ct
flow rates carry risk
-=-- ofC02 retentiOil-
Incubator 0 2
,- - - -- --
system - 7-v
1-
Note:
• Short binasal prongs are currendy available for 0 2 administration
alone which can be attached to the humidification system to provide
heated and humidified 0 2
• Oxygen hoods are available with occludable port holes in the sides.
Occlusion of these holes increases the 0 2 concentration by
preventing air entrainment. Apprdximate Fi02 delivered:
o With one port hole opened - J0-50%
o With both the port holes opened - 30-40%
o With both port holes closed - 80-90% (at 0 2 flow rate 10-1 5
L/min)
124
Table 14.6: Air and oxygen flow rates required to achieve desired
FiO' l
01 AIR (Umin)
(LI
mi 4 s 6 7 8 9 10
0 I 2 J
o)
0 • 10.8 20.8 20.K 20.8 20.8 20.8 20.~ 20.8 208 20.8
4 100 86 74 66 60 51 54 48.S 45 44 42
5 100 88 78 71 66 59 57 53 4Q.5 4R 46
Nasal canula1
Regression equation for estimating nasal cannula Fi02 at flO\\ rates of
I 3Lmm
Approximate Fi0 2= (02 flow x 0. 79) -t- [(0.21 x VF.) (VF .,, 100)]
Note: VE= minute ventilation (TV x RR), 0 2 flow - mL min
TV assumed: 5-6 mL kg; equation directly applicable for infants < 1500 g
from deve~op~d e
countries suggests a cut-off
cosl-effecttve in our set-up.
w~it
/
may nOl be
J
gently. Look for adequate chest rise & oxygenation "_)
14.9.3 Precautions:
• Do not heat the vial with artificial heating methods
• Do not suction the baby for at least 4 h after administering surfactant
• -
unless indicated by an emergency ...__
Do not leave the baby unattended after the procedure
14.9.4 Failure of response to surfactant: -
• Teclrnica/ flaws:
o ET tube displacement leading to inadvertent admm1stration into
the stomach
o ET tube too high or too low in the trachea
• Alternative pnmary diagnosis
• Complicated HMO: Pneumonia, PDA. sepsis. PPHN, air leak
syndromes (PIE, pneumothorax)
14.9.S Surfactant preparations available in India (as of 2009) (see
section D 120): Shown in Table 14.8
127
Figure 14.3: Algorithm for management around the time of
administering surfactant
Prctcrm mfant wuh re:.pmuory
diotIC"
14.10 CPAP:
Application of continuous distending pressure throughout the respiratory
J
cycle in a spontaneously breathing infant
14.10.1 Indications of CPAP ~
• Respiratory distress in pretenn neonates~ (early use reduces
mortali~ or oxygen therapy at 28 d even in neonates between 25
•
•
28 wks)
Post-cxtubation
,,-
C) Arl!Vle
Size Equivalent to Hudson size
Extra small Outer diam <Hudson 0 size
Small I
Large 3 l
14.10.4 How to start CPAP:
• lnitial pressure: Level of CPAP should be individualized to the
baby's disease. As a general guideline start CPAP at:
o Lung disease: 5 6 ems H20
o Central problems (apnea): 4 ;ms ~
.1 ,
1
7
130
Start on CPAP
!
Feature• of uodcrinfla11on
• Per;1Stent. wol"\Cned
w 'or grunt
retra<llOrt>
l
Features of adequate
inflation
,..__ _ _ _ _ ____.
l
Features of ovcrinOation
• Chest wall bypennOauon
- .....,
l
lncrea<c CPAP b> I cm 11,0
l D
Dccrc:bt CPAP by I cm 1120
incmncnL' decrements
Improved
Vote: CXR give:. a good indication of adequacy ofCPAP. Management doe~ nol depend on
CXR alone as it ma} not always be a\'ailable.
1
• CPAP: 5 ems 11 20 (or 4 ems, in case ofapnea) at an Fi02 :5 30%
• Clinically stable .;lo ,_ ~ ...
• Good respiratory efforts
• Apnea and bradycardia free in the rrevious 24 h
14.11 NIPPY:
N IPPV provides IPPV via a nasal or nasopharyngeal interface device. If
a ventilator is available, NIPPV is preferred over CPAP for the 3
indications mentioned bcloW.--- -=-
14.11.1 Indications
132
Intubate, check tube poo1tion. Atn:p1ne 20 µg.\g u\a I mm+ fentanyl 2 µg.lg
SC..'Ul'e anJ documem O\~ ~ aun (or I\' morphine 0.1 mg kg a. a •lo"'
bol'1-~) JO minutes pnor to intubation (except in
INSURE technique)
\fanuall> 'cnt1late to achie•e
adequate chc-t r1>e & detennme
the appropriate PIP
Ob>erve lnf11nrfor
• Chest "all mo\emc:nt - adeqwq
• lnterca,,tal rctract1on' - presence I worsening I
ab.cnce
• Inflation of the chest - signs ofo•erinflation
• Chmcal C)11""'L>
lfotch the monitor for
• Saturauon t;irgct M7-93'9
• lleart rate tachyciltd1a (fighting neonate),
bradycardta (hypoxia)
A u1cultate for
• Breath ;0und> (ad«juaC) & S)~try)
• Added sound~ (rhonch1 airway spasm)
Oxygenation u; madcquate
lncrca>e Fi(), by 5°'. increments 1111 Place arterial line (if not done>.
saturation is nonnalizcd Draw bk>ud for ASG
134
VR
PIP PEEP Flow
Disease Ti (s) (per
(cm H20) (cmH 20) (L/min)
min)
HMD 16 - 18 5-6 0.3-0.35 60 7-8
Pneumonia 14- 16 3-4 0.35-0.4 50-60 6-8
MAS 14- 16 3-4 0.35-0.4 40-50 5-7
Apnea 12 -14 3 0.35 20-30 5-6
Air leak 14 - 16 3 0.3-0.35 60 5-6
BPD 15-20 4-5 0.4-0.7 20-40 5-6
injury is the least and from where the infant can be safely taken off
ventilator support. This depends on the underlying disease for which the
infant was ventilated and the mode of ventilation from which he/she has
to be weaned off
14.12.9 Prerequisites for weaning from acute ventilation (up to 7 d of
ventilation):
• Clinically & hemodynamically stable
• Effective respiratory efforts
• Basic lung pathology I disease improving
• Associated illnesses are improving (e.g. active PDA)
• Optimum blood gases
• Complications due to ventilation are taken care of (air leak, collapse
etc.)
14.12.10 Prerequisites for weaning from chronic ventilation(> 7 d of
ventilation):
• All the above features for acute ventilation, plus
• Adequate and consistent Wt gain (over the last 5 d)
• Normal serum electrolytes (especially potassium)
• Acceptable blood Hb I PCV levels (PCV > 35%) (see section 17.6)
14.12.11 General principles of weaning:
• Decrease the most potentially harmful parameters first (PIP & Fi0 2)
• Limit changes to one parameter at a time
• Avoid changes ofa large magnitude
• Document the infant's response to each change in the ventilation
chart
14.12.12 Weaning from A IC mode:
• In NC mode, all the infant breaths are supported with the preset PIP
and hence weaning is different with this mode
• Weaning is done by reduction in the PIP and Fi0 2. As all the breaths
are supported, reduction in the ventilator rates will have no effect as
long as the spontaneous rates arc more than the control rate. As the
underlying disease process improves, spontaneous rates reduce,
thereby reducing the ventilator rates (auto weaning of the ventilator
rates)
• Alternatively, dependency on the ventilator breaths can be reduced
by decreasing the sensitivity of the trigger sensitivity function (assist
sensitivity in VIP-BIRD). This may help in the conditioning of
respiratory musculature
• While weaning, be careful to provide adequate TV, as the infant may
increase his/her RR to increase the minute ventilation which can lead
to autotriggering
14.12.13 Weaning from (S)IMV mode: Shown in Figure 14.6
139
I
Reduce PIP, PEEP and Fi02 by Minimum PIP:
alternating each other to reach 12- • <IOOOg-12
1613130% • I000-2000g- 14
• PIP by 1-2 cm H20 each time • >2000 g-16
• PEEP by 1cm H20 each time r-----+ Minimum PEEP
• Fi02 by 5o/o • <1500g-3
Correspondingly! rates by 5 till 30 • >1500 g- 4
I
I EXTUBATE I
Alternatively:
• At low rates (20-30), SIMV can be
combined with pressure support
(PSv)
• PSV provides moderate support to
the SIMV unsupported patient
breaths and thereby helps in
reduction of work of breathing
• CXR: Send call for CXR one<: the decision for starting HFOV is
taken. A check CXR immed 1ately after initiation of HFOV is
essential to know the adequacy of chest inflation. Further CXR's are
warranted in 4-6 hourly interv.ols until the optimal MAP has been
identified
• ABG: Every 2 h during the acute I titration phase; 4-6 hourly and
'SOS' once stabilized
• Spontaneous breathing should be encouraged even on HFOV.
Hence, routine sedation and neuromuscular paralysis is not
indicated. Nevertheless a fighting baby on a HFOV may make the
HFOV inefficient and hence may require sedation. Decide after
discussion with the consultant
14.13.4 Weaning and extubation from HFOV:
• Start weaning Fi0 2 first. Once Fi02 reaches 0.6, then reduce MAP in
I cm H20 decrements
• Reduce amplitude in 5% decrements simultaneously with MAP
based on the PaC0 2 and chest oscillations.
• Frequency is usually not adjusted during the weaning process
• Bigger babies whose lung pathology has resolved may be directly
extubated to a non-invasive mode of ventilation or even to hood
oxygen. A recent study showed that extubation of preterm infants at
MAP below 8 cm H 20 with an Fi0 2 below 0.30 is feasible during
HFOV, with a 90% success rate", showing that direct extubation can
also be done in preterm infants.
• Typical settings from which HFV can be discontinued:
o MAP 7-8 ems H20
o Amplitude 25-30%
o Fi0 2 25-30%
14.15 PPHN:
PPHN is dealt with as a special case because it poses many peculiar
challenges. It is characterized by persistent elevation of the PVR at birth.
It mimics the fetal circulation with suprasystemic pulmonary pressures
and right to left shunting through foramen ovale and I or PDA.
Pulmonary artery hypertension secondary to various systemic illnesses
like sepsis and pneumonia occurring beyond the transitional period of life
are not classified under PPHN; rather they are rightly termed as
secondary pulmonary artery hypertension (PAH)
14.15.1 Diagnosis:
• Clinical setting: A typical clinical setting is in a term/post-term
neonate born through MSL and is asphyxiated. Nevertheless, PPHN
should be a differential diagnosis in all centrally cyanotic neonates
irrespective of GA
• Physical examination:
o Prominent precordial impulse
o Single or a narrowly split and accentuated second heart sound
o Systolic murmur consistent with TR
• ABG: Simultaneous prcductal-postductal gradient of Pa0 2 of at least
20 mm Hg in the absence of a structural heart disease (Preductal-
right UL; postductal: LL)
• Pulse oximetry: Preductal-postductal Sp02 gradient of~ I 0% in the
absence of a structural heart disease
Note: Pa0 2 and Sp0 2 gradient is observed due to ductal right to left
shunting of blood. Absence of ductal shunting does not rule out PPHN as
145
• Ventilator support
o ~to create respiratory alkalosis (PaC0 2 <30
• mmHfil. is not recommended due to associa~
b3rotrauma as well as long term adverse effects due to
hypocarbia (poor neurodevelopment and hearing defects in term
infants)
• Si/denajil citrate: Start sildenafil if the strategies mentioned above
fail. 1 m_g!kg/dose evei:y 6 h; increase to]. mg_lk_gidnse every 6 h if
no improvement i~ Two smalt RCT's from resource
limited settings, in term and near term babies~at sildenafil
significantly increased oxygenation" (see section DI 14)
• iNO (see c ap er 5).
147
Figure 14.7: Management algorith o for PPHN
l'ion-aggressi\e \enlllatioo
Targets:
•
•
•
•
•
pH 2:7.25
Pa01: 50-70 mm Hg
PaCOi: 40-60 mm Hg
Rates : 40-60 breaths/min
PTP : Adequate chest rise
J Eligible for iNO
• Ti . 0.4-0.45 s Administer as
per 1\:i.Q_
protocol
High-frequency
(ifCMV fails)
ventilation~ No rei.por se by the next 12@ (ChaptCi'T5)
REFERENCES:
1. National Neonatology Forum of India. National Neonatal Perinatal
Database - Report for 2002-2003.
2. Finer NN. Pediatr Pulmonol. 1996;21 :48.
3. International Organization for Standardization. Respiratory tract
humidifiers for medical use -- Particular requirements for respiratory
humidification systems. ISO 8185, 2007.
4. Soll RF. Cochrane Database Syst Rev. 2001
5. Yost CC. Cochrane Database Syst Rev. 2000.
6. Stevens TP. Cochrane Database Syst Rev. 2007.
7. Soll R. Cochrane Database Syst Rev. 2009.
8. Ashwin S.MD Thesis. 2009
9. Morley CJ. N Engl J Med. 2008;358:700.
10. Sai Sunil Kishore M. Acta Paediatr. 2009; 98:1412.
11. Davis PG. Cochrane Database Syst Rev. 200 I.
12. Lemyre B. Cochrane Database Syst Rev. 2002.
13. Cools F. Cochrane Database Syst Rev. 2009.
14. van Velzen A. Pediatr Crit Care Med. 2009; I 0:71.
15. Henderson-Smart DJ. Cochrane Database Syst Rev. 2001.
16. Davis PG. Cochrane Database Syst Rev. 2001.
17. Flenady VJ. Cochrane Database Syst Rev. 2002.
18. Davies MW. Cochrane Database Syst Rev. 2002.
19. Shah PS. Cochrane Database Syst Rev. 2007.
149
The table above is for reference only. Factors such as the accuracy of the
ventilator flow, percent error in delivery apparatus, human error, and
accuracy of calibration of the NO may all affect the actual delivered
concentrations of NO and N0 2 •
15.7 TOXICITY
15.7.1 Methemoglobinemia:
• The binding of NO to hemoglobin results in the production of
methemoglobin. This is not in itself toxic, but methemoglobin is not
able to carry oxygen. Therefore high levels of methemoglobin will
reduce the oxygen carrying capacity of the blood
• With doses of iNO of less than 20 ppm you would not expect to see
methemoglobin levels in excess of 2%
• A level of 2% should be considered a warning level, and if
methemoglobin levels rise to 5% iNO dosage should be reduced and
the level rechecked after 1 hour. If the levels have not fallen
substantially, iNO administration should if possible be reduced
further.
154
; .:;· ·'""""
If Eligibility Criteria•
~1-T
Initial Clinical No Non Responders
•Echo mandatory to rule
out underlying
structural heart disease
• Poor lung recruitment
is the most common
cause of failure
• Continue at 20 ppm until Weaning STOP • Changing ventilator
Criteria••• met NITRIC
strategy will be more
•Wean from 20 to 5 ppm in 5 ppm steps q OXIDE beneficial
2-4 h
• Wean from 20 to 5 ppm within 24 h
Patient stable at
5 ppm?
No
Patient stable at I ppm?
OffiNO
should not be routinely used; rather, its use should be limited to patients
with supra systemic PVR after establishing optimal lung inflation and
demonstrating adequate LV performance.
15.8.2 Preterm neonates (<34 wks) with hypoxemic respiratory
failure: Recommendations for routine use of nitric oxide in pretenn
cannot be made based upon the available evidence 4 . It can be considered
in selected subgroups.
SENIOR RESIDENT
2.
3.
REFERENCES
I. The Neonatal Inhaled Nitric Oxide Study Group. NEJM 1997; 336:
597.
2. FinerNN. Pediatrics2001; 108: 949.
3. Neonatal Inhaled Nitric Oxide Study Group. Pediatrics 1997;
99:838.
4. Barrington K J. Cochrane Database Syst Rev 2007; 18.
157
16.1 DEFINITION
The term BPD rather than Chronic Lung Disease (CLD) should be used
as it is clearly distinct from the multiple CLDs oflater life. The definition
of BPD has been revised recently by NICHD 1 (See table 16.l)
REFERENCES
1. Jobe AH, Bancalari E.NICHD-NHLBIORD Workshop. Am J Resp
Crit Care Med 200 I; 163: 1723.
2. Khemani R G, Randolph A, Markovitz 8. Cochrane Database Syst
Rev 2009; 8
3. Baveja R, Christou H. Semin Perinatol 2006; 30: 209.
4. Doyle et al. Pediatrics 2006; 117: 75.
5. Panitch H et al. In: McConnell MS, Imaizumi SO (eds), Guidelines
for pediatric home health care. Am Acad Ped; 2002. p 323
6. Allen Jet al. Am J Resp Crit Care Med 2003; 168: 356
163
17.ANEMIA
17.1 DEFINITION
Anemia is defined as Hb or PCV value below the expected range for the
gestational and chronological age (see table 17.1 and 17.2).
l Hematocrit
Low
Bone marrow suppression
• Congenital syndromes /
• Acquired - parvo B 19
Positive
Immune hemolytic anemia
• ABO & Rh isoimmunization
• Minor blood group
MCV
Low
• Chronic blood loss
• Thalassemias
Normal Abnormal
• Blood loss • Spherocytosis
• Infection • Elliptocytosis
• RBC enzytne defkiency • G6PD deficiency
166
REFERENCES:
l. Stockman JA 3rd. Am J Dis. Child 1980; 134:945.
2. Shannon KM. US Multicenter Erythropoietin Study. Pediatrics.
1995;95: I ..
3. Lieberman P. American academy of allergy, asthma and
immunology guideline, 2005.
4. Aher SM. Cochrane Database Syst Rev. 2006.
.
171
18. POLYCYTHEMIA
18.1 DEFINITION
Polycythemia is defined as venous "'CV equal to or more than 65% (fur
both term and preterm newborns) or arterial PCV ~63% By default, the
worcr'PCV" refers to venous PCV mly and wheil'ineilsured by the spun
method, and not by automated cell counter because spun PCV is higher
than automated cell counter me1sured PCV and it shows better
correlation with viscosity in v'tro. 1 he capillary tub.f should be filled to
3/4~of its length and spun a 11 ,000 rpm for 5 mi!Vn a m1crocentri fuge
(see section 1-3). - - ·
18. J.I Dynamic definition of polycythemia:
The PCV shows a physiological change over time in the initia l hours of
life. Thus, the upper limit of venous PCV can be de fi ned as ~70% at 2 lt
of lif~~6~o/!.&§ h of life and ~G5% thereafter in neonatal lifer.
oidism /
Maternal use of propranolol /
Perinatal as h ia /
Suspected TORCH infection
Lookin lethoric I
-
and 12 h & as clinically indicatec.
172
18.4 SYMPTOMS
There are a large number of symptoms. Only those, which requires PET,
are mentioned here.
CNS:
Lethargy (14.5%) I
Hypotonia (7-9%) I
Irritability (13%) I
Tremors (7%) j
Seizures (1.2%)
Stroke
One or more CNS findings (27%)
Metabolic:
Hypoglycemia (11-40"/o)
Symptomatic hypocalcaemia (1-11%)
CVS:
Tachypnea (16-27%)
Respiratory distress (9%)
I
Tachycardia
Cyanosis (7-14.5%)
Apnea (4%)
Pleural effusion
CHF
GIT:
Poor feeding (7-20. 7%)
Feed intolerance (22%)
lieus
NEC (l-3.7%)
Renal:
Oliguria
ARF
Renal vein thrombosis
Hematologic:
Symptomatic Thrombocytopenia (1-30%)
Significant Hyperbilirubinemia (2-22%)
Misc:
Peripheral gangrene
18.5 TREATMENT
18.5.1 Hemodilution (by fluid supplementatio
d
Hemodilution must not be done as there is no vidence available in
literature to support fluid supplementation for asymptomatic moderate
(PCV 65-75%) polycythemia. An RCT done in our unit in asymptomatic
babies of"'.34 wks of gestation showed no difference in the need for PET
between the fluid supplemented and non-supplemented group. 2
173
18.5.2 PET:
Indications:
• All asymptomatic newborns witl PCV >75%
• All symptomatic newborns with PCV ~65%
Blood vessels used: (in order of preference)
Use radial artery, ulnar artery or po .erior tibial artery. Avoid UV as far
as possible because of tile risk ofNEr In polycythemia.
Fluid used: -
NS (Q.9% NP.9) 1s the preferred flud. There 1s no clinically important
difference among plasma, 5% alb1.~ NS, or Ringers solution in
reducing PC'{ NS IS cheai,readil) available, and does not carry the
potential risk of transfusion associated infection. Viscosity depends on
plasmayroteins which is higher in adult_plasma. Hence, after PET with
adult plasma, the PCV may fall but viscosity may still rema~n high.
Calculation offluid volume:
Exchange volume- <Observed PCV -. Desired PCV) x blood volume
Obser' ·ed PCV
Where desired PCV 1( 55% /
Calculation of blood volume:3 ShO\\.T in Fit,'Ure 18. 1
I
Figure 18.1 Blood volume according to weight (Reprinted from Journal of
Pediatrics. volume IOI, Rawlings JS, Penen ~ •• Wiswell Th, Clapper J, Estimated blood
volumes m poly9them1c neonates as a fuoe1 on of b1nh weigh~ page~ 594-9, copyright
1982, '~1th perr111ss1on from Elsevier)
110
~
lDO
Jf
>
-
::::,.
so
::::i
cO
"
...lu
E~
Monitoring
Monitor PCV 2 h after PET and then every 12 hourly for 48 h or as
clinically indicated.
18.5.3 Algorithm of management of polycythemia;.-Shown in Figure
18.2
i
Monitor as per schedule j
i
Symptomatic Polycythemia -+ Asymptomatic
J
l
PET
l
PCV>75% /
l
PCV<75% I
l
Monitor/
l
Nonna!PCV /
REFERENCES
I. Shohat M, Reisner S H, Mimour i F, Merl ob P. Pediatrics 1984; 73:
11.
2. Mangalabharathi, Dutta S. DM t11esis PGIMER; Chandigarh: 2009
3. Rowling JS et al. J Pediatr 1982: IOI: 594.
4. Michael S. Schimmel M S, Bromiker R, Soll RF. Clin Perinatol
2004; 31: 545.
176
19.3 INVESTIGATIONS:
Platelet count, coagulogram and peripheral smear must be done in all
cases and the rest of the investigations should be individualized.
19.3.1 Platelet count: Thrombocytopenia is defined as platelet count less
than l 50,000/mm 3 and severe thrombocytopenia as< 50,0001 mm 3.
177
. Clinical Diagnosis
Platelets PT
: condition
rsick
neonate N
N i Liver disease
N N Stress bleed
............'.......•........•..
Well Immune
neonate thrombocytopenia,
N N Kasabach-Meritt
syndrome, bone marrow
_hypojJlasia
Vit K deficiency ·
N i i bleeding
Hereditary clotting
N N i fact(}r~eficiencx ..
Swallowed blood,
trauma, qualitative
N N N
platelet defects, Factor
.......................................................x........m.... ~ei1cie11cy·............................. j
19.5 TREATMENT:
19.5.1 General principles of treatment of a bleeding neonate
• Give Vit K 1 mg IV if it has not already been given in the preceding
week.
• Keep cross matched blood ready for emergency transfusion and for
further transfusions.
• If there is hypovolemic shock/blood loss > I 0%, give equal volume
of whole blood and plasma expander.
• Look for the underlying cause and treat it.
19.5.2 Platelet transfusion
Indication for platelet transfusion: 3.4
• Count <50,000 µL in
o any preterm infant (<33 wks) in l" wk oflife
o clinically unstable term infants in l" wk oflife
o any neonate undergoing invasive procedure (e.g. ventricular tap)
179
o preterm neonate who h" to be started ibuprofen or
indomethacin or who has re<:ent-onset grade Ill/IV IVH
• Count <20,000 µL in all stable infants beyond l" wk of life without
active bleeding. There is evident e from pediatric oncologic literature
that a count> 10,000 µL is safe lor performing a LP in an otherwise
stable, non-bleeding infant.
• Count <100,000 µL in presence of allo-immune thrombocytopenia
(see section 19.7.1 for more details)
• Count <100,000 µLin presence of active major bleeding
• Qualitative platelet defect with bleeding with any platelet count.
Blood group for transfusion: Shown in Table 19.3. Platelets are less
antigenic than RBC's; hence more flexibility is available in terms of the
group.
0 0 A,B,AB
A A AB
B B AB
AB AB -
Instructions related to FFP transfusion
• Transfuse FFP l 0 mL/kg over 2-3 h. With active bleeding one may
need to raise the concentration of the clotting factors to 20% of the
normal. This can be done by repeating l 0 mL/kg.
• FFP/SDP can be stored temporarily in the freezer compartment of
the refrigerator for less than 12 h.
• Once thawed, transfuse immediately and do not refreeze.
19.6 Vitamin K deficiency bleeding: Shown in Table 19.5
19.8 DIC:
• Treat the underlying cause
• GiveVitKl-1 mg JV
• Platelets and FFP are given as needed to keep the platelet count
above 50,000/µL.
• Consider DVET, if bleeding persists.
• In case of thrombotic DIC, give heparin@ 30 U/kg IV stat, followed
by I 0 U/kg/h to keep APTT 1.5-2 times of the normal. LMWH is
preferred in neonates over unfractionated heparin'. If LMWH is
used, the dose is 1.5 mg/kg/d SIC q 12 hourly.
REFERENCES:
1. Andrew M. Blood. 1987;70:165.
2. AndrewM. Blood. 1988;72:1651.
3. D.J. Cassandra. Transfusion of neonates and pediatric patients. In:
Blood Banking and Transfusion Medicine: Basic Principles and
Practice Ed 2, 2007, 510.
4. Saxonhouse MA. Neoreviews, 2009.
5. Transfusion guidelines for neonates and older children. British
Committee for Standards in Haematology (BCSH). 2004.
183
Dermal Mean ± SD
zone (mg/dL)
I 5.9±0.3
2 8.9 :I: 1.7
3 11.8 ± 1.8
4 15 :I: 1.7
5 > 15
Mental
Severity Score Muscle tone Cry pattern
status
None 0 Nonna( Normal Normal
Sleepy,. Neck stiffn~ss,
High
Mild I poor mild
pitched
feeding JI hyper/hvootonia
Arching neck,
Lethargic,
Moderate 2 retrocollis, Shrill
irritable·
arching trunk ·
Semi-
coma, Bowing trunk,
Severe 3 Inconsolable
seizures. opisthotonus .
coma
,\ote: The 81?\D o;corc holds good for late wctenn and term infant>. Pretenn babies may
not ~ho" the abo~c evolution of ABE. -
History Relevance
Blood group incompatibility (Rh.
Previous sibling with neonatal ABO), G6PD deficiency,
jaundice or family h/o anemia, spherocytosis, Cnglcr-NnJjar.
~~~e~am~1 ___--------~~U~G~1~~~a~r\a~n~~~~~~~---'
186
History Relevance
Maternal illness with fever and
JUI
rash during pregnancy
Asphyxia, trauma, use of oxytocin,
Labor and delivery events
delayed cord clamping
Maternal drugs (sulfonamides, Hemolysis in a G6PD deficient
nitrofurantoin, antimalarials) infant
Galactosemia, a-1 antitrypsin
Liver disease in the family
deficiencv
Prolonged parenteral nutrition Cholestatic jaundice
20.6 TREATMENT
The two main treatment modalities arc
• PT
• DVET
188
20.9 PT
20.9.J Practical points
• Commo11/y used light sources are
o Special blue tube lights (Phalips TL52, 20W)
o Special blue CFL lamps (Philips l 8W or Osram 18 W)
o High intensity gallium nitride blue light emitting diodes (LED)
2
• Dose: Minimum of 15 µW/cm2/nm. Ideally 30 µW/cm /nm. The
higher the 1rradian~e. the bette· 1s the effect. Io increase the dose,
sc the following methods
Most importantly, measure the irradiance and if it is below 15
µ W 1cm2tnm. change the tubes.
Consider double surface PT (place lights both above and
below). Double surface and multiple PT should be used if:
• TSB rises rapidly (>0.5 mg dL h)
• TSB is within 3 mg/dL of the threshold for DVET
• TSB fails to respond t) single surface PT within 6 h (i.e.
e ot a or con mi..cs o n
lfTSB falls to a eve > m ~dL below the threshold for DVET.
step down to single surtacc 1 .
o Distance between tubes and baby can be decreased to 10-15 cm
o Add additional PT units see indications above, for double
surface PT)
o Sides of bassinet. incubator or warmer can be lined with
aluminum foil or white she ts taking care to sec that the hot air
vents arc not blocked.
• SR of each area should check irradiance of all the PT units
belonging to his her area every f >rtnightly (i.e. on I" & 16th of every
month) and ensure that the lights and protective covers are clean.
• While under PT, the baby's eye should be securely covered (put an
opaque paper in between layers pf bandage) w11hout undue pressure
on the face and nose. Commerc ally available PT goggles may also
be used. They generally come in 2 sizes- 2 cm x 9 cm and 3cm x 12
cm
• The mother should be encourag.!d to remove the baby from under
the lights, uncover the eyes and breastfeed every 2-3 h. During
breastfeeding, switch off the Pl unit. If the TSB is rising at >0.5
190
mg.dLh or the TSB is within 3 mgdL of the threshold for DVET,
the mother must be told to minimize the stoppages of PT as far as
possible.
20.9.2 Monitoring a baby receiving PT
• Clinical assessment of jaundice in babies under PT may be
fallacious. Hence, monitor TSB level every 4-12 hourly, depending
on proximity ofTSB to the cut-off value for DVET.
• Babies under PT may develop hyper or hypothermia. Monitor
axillary temperature every 2-4 hourly.
• Record Wt daily; ensure that baby passes adequate urine (6-8 times
per day).
• Some degree of loose green stools are fairly common during PT.
Sometimes, a skin rash may develop. Mother should be reassured
about the transient and benign nature of these conditions.
• Check skin color. PT if used in infants with conjugated
hyperbihrubmemta can cause bronze discoloration of skm.
20.9.3 Stopping PT
Stop PT once you obtain 2 TSB values at least 4 h apart that are at least 2
mg 'dL below the PT cut-ofT (see section N20. I). Take the natural course
of the cause of jaundice into account while stoppmg PT. Check for
rebound nse in TSB after 8-12 h in neonates with GA <35 wks, BW
<2000 g, G6PD deficiency or hemolytic diseases. In all others, check
rebound by TcB.
20.JO DVET
20.10.1 Indications for DVET:
• Hydrops: Perform DVET as soon as possible after birth, once the
baby is stabilized. (initially only PET may be done to increase PCV
if baby cannot tolerate double volume exchange)
• I-Vo previous sibs requiring DVET because of Rh isoimmunization
and the index patient 1s born with pallor, hejiaiOsplenomegaly and
positive OCT.
• Cord Hb < I 0 g/dL and/or ord TSB > 5 m dL
• Rate rise o SB > mg/ Uhour despite PT or rate of rise ofTSB
> 0.5 mgtdLhour despite PI 1f Hr>is between I 0-12 g dL -
• Any TSB > 12 mg/dL in first 12 h a"ffit any I SB 5 2umg, dL m the
neonatal period in the setting of hemolysis.
• Jn DVET zone as per modified AAP charts for near tc and term
babies (see section N20.2) ...- y
191
-
0
til\ .W
1."1~
f_
o
t1µ1d requirement). A simple brmula to calculate ' this 8-h fluid
requirement 1s. Fluid volume= [340 .f xm6, "h~e x 1s that day's
maintenance fluid requirement(e~pressed m ml.kg,d) and Wt IS
expressed m kg)
• lt may also work in hemolytic Jaundice and preterm neonates, but
evidence is still awaited. pie should consider giving fluid
suppl ementation in all cases of evere n~:J1emolytic Jaundice (TSB
> 18) and in Ifie waiting phase b fore DVE'T m cases w1lh hemolytic
J~
Figure 20.2~ Algorithm for fluid supplementatiot>
!
ls jaundice __N_o--t• ls newborn read Yes Any major nsk factor•
present'> for discharge? - - - - . . . . ANDagc <72 h
! Yes
• ls age <24 h
• Appears excessive for age
J No lYb
• Measure TSB
• Doubt about degree of
• Plot in nomogram &
jaundice decide funhcr
iv~
Measure TSB &
interpret by age in
hour
! Yes
• Evaluate cause • Can discharge'
• Stan PT • Advise to foll was m
• Repeat TSB in 4-12 h table 20.5
*Note: Major risk f1ctors
• Clinical Jaundice S 24 h
• Pre\ious sib received PT
• Cephalhcmatoma, subgaleal bleed or sign 1cant bruising
• Nonoptimal sucking/nursing
• Gestauonal age 35 to 36 wk
• su~nect hcmolvt1c d1sca.~c
196
Figure 20.4: Approach to a baby born to an Rh ~ve mother
Mother Rh negative
i
H/o previous sib involvement
Isoimmunized in this pregnancy
• Rising ICT titer+
• Hydrops fetalis
• Fetal anem1·a
Yes
SR to attend
No
Cord TSB/PCV/DCT
Is immediate DVET
No Monitor TSB/PCV 4 hrly
required? -------~ Start IVIG if features of
l
Do DVET
Yes
isoimminization
Start PT ifTSB
Give IVIG • Is in PT zone
Intensive PT • Rising by> 0.5 mg/dl/h
1 1
Do DVET ifTSB > 12 mg/dL in !' 24 h or> 20 mg/dL subsequently
Can repeat TVIG 12 hrly
Do conjugated TSB & subtract it from total only if> 50o/o of the total
197
Prolon;ed Jaundice
i
Direct & Total Bilirubin
I
+
Predominantly +
Conjugated
Unconjugated Evaluate for causes of cholestasis
i
History- hemolytic disease, jaundice
(see Figure 20.6)
i
If all work up negative & jaundice
persisting (>15 mg!dL), Give
phenobarbitone 5 mg/kg/day for 7 day
and re-evaluate (only after discussion
with consultant).
Give vitamins in
Conjugated hyperbilirubinemia - - - - . enhanced doses''!'
Do LFT, PT, INR
•
Liver biopsy if indicated
Urgency: Biliary
Atresla
Liver biopsy
1
"· Vit A (Aquasol-A) 50,000 IV IM monthly, Vit D (Arachitol) 40,000 JU IM monthly, Vit K 5 mg JM
monthly, Vit E 15-200 mg/d PO. Water soluble vitamins: twice the RDA. Continue fat soluble
vitamins for 3 mths after resolution of jaundice.
* fndividualize investigation,*'" surgery ifcholedochal cyst on USG
~ Stop milk feeds till galactosemia is ruled out
• may need bone marrow testing
REFERENCES
I. Subcommittee on Hyperbilirubinemia. Pediatrics 2004; 114: 297.
2. Cloherty J P, Eichenwald E C, Stark A R. Manual of neonatal care
2007. Lippincott Williams and Wilkins 61h edition; chapter 18.
3. Karthik B, Praveen K. M.D. Thesis PGIMER; Chandigarh: 2008.
4. Hammerman C. Acta Pediatr 1996; 85: 1351.
5. Kumar R. Indian Pediatr 2002; 39:945.
201
21. INTRA-CRANIAL HEMORRHAGE AND
PERIVENTRICULAR LEUCOMALACIA
l
Three vial test -ve
1
I Look for signs ofbrainstem herniaJion, do USG Head I
•
I ! l
Bleed with signs Bleed without
No Bleed of brain stem signs of brain
herniation stem herniation
'
1
l
Vitals.& ~NS
mon1tonng
I
•
Surgical
decompression
I
•
•
•
i
Medical management
Maintenance of cerebral perfusion- maintain
normal BP. Refer to Chapter 29.
Avoidance of fluctuating/raised BP, hyper-
osmolar solutions, rapid bolus
Trc-atment of acidosis, pneumothorax,
seizures, !CO, 10, (optimize ventilator
Monitor OFC and settings).
fontanelle daily, serial • Follow up USG scans (see section 21.8) .
USGq7d
204
21.8 PHH
21.8.1 Definition and diagnosis
PHH- is defined as IVH followed by progressive enlargement of cerebral
ventricles witil the ventricular width at the intraventricular foramen
exceeds 4 mm over the 97th centile for GA.' (see section N8) Ventricular
Index is the distance between midline and border of lateral ventricle in
the plane of third ventricle in coronal view. The incidence of PHH
increases with the severity of IVH- grades I & 2: 5-12%, grades 3 & 4:
PHH up to 75%. Ventricular Index is preferred over Ventriculo-
hemispheric ratio (VHR).
21.8.2 Management of PHH: Shown in Figure 21.2
21.8.3 Indication for therapeutic LP (See PGIMER video on neonatal
procedures):
LP is therapeutic only ifthe hydrocephalus is communicating. lfthere are
signs of raised ICP or the ventricles gradually enlarge beyond the 97th
centile +4 mm limit, LP is done to drain IO mL/kg of CSF (measured at
bedside with the help of sterile graduated disposable syringe) and sent for
analysis (see section NS). After LP and draining CSF USG is done to
find the ventricular width. If it crosses the 97th centile +4 mm limit, the
LP is repeated.
21.8.4 Pharmacological management of PHH:
Acetazolamide and frusemide (see sections DI and D55) are not
routinely recommended in the management of PHH. 6 Their role in other
forms of hydrocephalus is not clear.
21.8.5 Indications for Ventriculo-peritoneal (VP) shunt
• Progressive ventricular dilatation > 4 wks despite serial CSF taps.
• Rapidly progressive ventricular dilatation (head growth >2 ems/wk,
moderate or severe ventricular dilatation)
206
~
+
I No (65%) •
I Slow (30o/o) progression I
progression
I I
•
Cessation I Contd
J.
•
VP Shunt
Pediatric
If not possible-ventricular drainage,
should do from both sides.
Surgery
F/up
J. 1
Cessation of Contd
dilation dilation
•
Ventricular drainage
I
J.
Cessation of
dilation
l 1
Contd
dilation
Monthly observation for 3 months and then 2 monthly for I year VP Shunt
Pediatric
Surgery
F/up
Grade I
Grade II
Grade III sts
Grade IV
208
2
21.14 TIMING OF USG/MRI FOR PVL
• First USG at 7- 14 d
• Follow up with monthly USG for evolution
• USG at 40 wks PMA or prior to discharge
• Indications of doing MRI: Premature baby on follow up presenting
with cognitive, motor and/or sensory impairments.
REFERENCES:
I. Volpe JJ. Clin Perinatal. 1989;16:361.
2. Ment LR. Neurology. 2002;58: 1726.
3. Bellu R. Arch Dis Child Fetal Neonatal Ed. 2009 Jun 15. [Epub
ahead of print].
4. Cools F. Cochrane Database Syst Rev. 2005.
5. Levene MI. Arch Dis Child. 1981 ;56:905.
6. Whitelaw A. Cochrane Database Syst Rev. 200 I.
7. Larroque B. J Pediatr. 2003;143:477.
8. de Vries LS. Behav Brain Res. 1992;49: 1.
9. de Vries LS. Neuropediatrics. l 993;24:263.
209
22. SEIZURES
22.1 BACKGROUND
Seizures are the most common neur(•logical emergency in newborns. The
incidence of seizures in the neonatal period is greater than in any other
time of life. with most seizures occurring within the I" wk of life.
Ta ble 22.4: E.
tiolo"" of seizures bv a2e of onset
< 24 h 24-72 h 72 h-1 wk I wk-4wks
IVH in Bacterial/Fungal Bacterial/Fungal
HIE premature sepsis and sepsis and
newborns Meningitis Meningitis
Benign
SAH, Laceration Cerebral idiopathic Herpes simplex
oftentorium or contusion with neonatal encephalitis
falx SDHand SAH seizures (fifth
day fits)
Storage disorders
Scalp local Drug (rare): GMI
Bacterial sepsis
anesthetic withdrawal gangliosidosis
and meningitis
injection type I, Gaucher's
disease tvoe 2
Benign familial
IEM: Pyridoxine Tuberous
neonatal Kemicterus
dependency sclerosis (rare)
seizures
Rare: sepsis and IEM: Glycine
meningitis IUI, encephalopathy, IEM (rare): Organic acidemias, Urea-
Direct drug Urea-cycle cycle disturbances
effects disturbances
Others (rare):
Drug Others:
withdrawal, Intracerebral
incontinentia hemorrhage,
pigrnenti, Tuberous
Tuberous sclerosis
sclerosis
22.6 DIAGNOSIS
22.6.1 History and examination
• Maternal history- history that supports TORCH infection, maternal
PIH, fetal distress, maternal infection/chorioamnionitis.
• Delivery history for type of delivery, any use of local anaesthetics
for the mother and did they not take effect? (Suggesting perhaps not
injected into her but into baby), antecedent events, instrumentation,
Apgar score and cord pH.
• Postnatal history- Age of onset, feeding history, sleep and activity
prior to seizures. A h/o tremulousness may suggest drug withdrawal
or neonatal hypocalcemia. Lethargy and temperature instability may
suggest an infection. Hiccups may suggest nonketotic
hyperglycinemia.
212
22.7 MANAGEMENT (also see sections 020, D79, D99, OIOI, 078):
Shown in Figure 22.1
22.7.1 Practical points:
• During the initial management every seizure episode should be
treated. When seizures become unresponsive to maximal doses of
phenobarbitone and fosphenytoin only frequent (>3/hour) or
prolonged seizures (>3min) or those associated with clinically
significant changes in cardiovascular stability should be treated.
213
f-
(Avoid Hyperglycemia)
i BS>40
Do ioniled calcium b)' ABG If ionized calcium < 0.6 mm~IL!...,ond seizures
anal}'7er Give~alcium persist rpt Calci1Ii¥1 dose anctii' no response
gluconate ~ mUk,.; TV over 5-10
Sci7Ures persist.
Ca - "lormal
!
m1ns - .. l
give 50% Magnesium Sulphatc~IP mUkg IM ~
Se11.11rcs persist
Newborn on AED
l
Transient metabolic problem - stop AED.
If non-transient etiology, stop all AED
except Pb* when seizure controlled
Normal
l
Assess neurological Discharge on Pb.
status at discharge Repeat neurological
Abnormal
examination at 1 mth
Do EEG
Stop Pb
,I Abnormal
Abnormai '----~
Reassess at 3 mths of life Taper & stop Pb
Normal over 2 wks.
and repeat sequence.
Switch to
carbamazepine/valproate
Taper & stop Pb
over 2 wks
* Pb = Phenobarbitone
References
l. Volpe J J. Neurology of Newborn 5th edition 2008; Philadelphia
Elsevier: Chapter 5.
217
23.1 DEFINITIONS
The single most important intervention to reduce sepsis in a newborn unit
is hand hygiene. Hand hygiene is defined as any method that removes or
destroys microorganisms on hands. The following definitions are
relevant to hand hygiene:
• Hand hygiene: A general term that applies to hand washing,
antiseptic hand wash, antiseptic hand rub, or surgical hand
antisepsis.
• Hand washing: Washing hands with plain (i.e., non-antimicrobial)
soap and water.
• Plain soap: Refers to detergents that do not contain antimicrobial
agents or contain low concentrations of antimicrobial agents that are
effective solely as preservatives. They may be bar soaps or liquid
soaps.
• Antimicrobial soap: Soap (i.e .. detergent) containing an antiseptic
agent.
• Antiseptic hand wash: Washing hands with water and soap or other
detergents containing an antiseptic agent.
• Alcohol-based hand rub: An alcohol-containing preparation
designed for application to the hands for reducing the number of
viable microorganisms on the hands (usually contain 60%-95o/o
ethanol or isopropanol)
• Antiseptic agent: Antimicrobial substances that are applied to the
skin to reduce the number of microbial flora. E.g. alcohols,
chlorhexidine, chlorine, hexachlorophcne, iodine, chloroxylenol,
quaternary ammonium compoW1ds and triclosan.
• Antiseptic hand rub: Applying an antiseptic hand-rub product to all
surfaces of the hands to reduce the number of microorganisms
present.
• Decontaminate hands: To reduce bacterial counts on hands by
performing antiseptic hand rub or antiseptic hand washes.
• Visibly soiled hands: Hands showing visible dirt or visibly
contaminated with proteinaceous material, blood, or other body
fluids (e.g., fecal material or urine).
• Pyodenna
• External infected wounds
• Conjunctivitis
• Ear discharges
• Viral exanthems
Those with upper respiratory infections may work wearing a mask at all
times.
REFERENCES
I. O'Grady. MMWR 2002; 51: I
2. Shah PS. Cochrane 2009
226
24. SEPSIS
24. 1 DEFINITIONS
"Jeonatal sepsis 1s defined as the presence of generalized systemic
features of sepsis associated with pure growth of bacteria from one or
more sites.
Probable sepsis: clinical and laboratory findings consistent with bacterial
infection without a positive culture.
Severe Sepsis: Sepsis associated with organ dysfunction, hypoperfusion
abnormalities, or hypotens1on. Manifestations of hypoperfusion include
but are not limited to proloQged CFT, lactic acidosis, oliguna or an acute
.a!!,eration in scnsorium.
Septic Shock: Sepsis-induced hypotension despite fluid resuscitation (sec
chapter 29).
\fODS· Presence of altered organ functions in an acutely 111 patient such
that homeostasis cannot be maintamed without intervention.
o Those who are born with<. ur any of the known risk factors of
sepsis [preterm, pPROM, ~ROM > I 8 h, duration of labor > 24 h,
spontaneous pretenn onse1 of labor. clinical chorioammomus.
foul smelling liquor, uncl ·an vaginal exanunations. maternal
fever, maternal urinary or other systemic infections, frequent
(>3) per vaginal examina ions in labor, pennatal asphyxia].
AND r '
o Chest X-ray not suggestive .>fpneumonia AND
o Have alternative reasons to ·xplain the symptoms.
Note: contrary to popular practice in India, the corr ev1at1on
for 'preterm premature rupture of membranes' is pPROM and not
PTPROM. -
• Symptomatic neonates with any of the known risk factors listed or
who have a CXR suggestive c. f pneumonia or do not have any
alternate explanation for the sigas, must be immediately started on
antibiotics after drawing a bloo I culture. LP for CSF examination
must be performed m symptomatic neonates, with the exception of
premature neonates presenting \.\Ith respiratory distress at birth with
no risk factors for sepsis.4..s
24.3.2 Presence of risk factors for s psis in as)mptomatic babies
• All neonates. especially those who are premature. must be evaluated
for presence of risk factors of E)~k score was generated in
PGI and was later validated in RCT." All neonates <35 wks of
gestation, who remain asympton 1 ~ life}areassessed
for the risk of EOS using the following pennatal risk score.
r °"Kisk factor Seore
IP per vaginal examinations ?. 6
Clinical chorioammonitis• 6
BW < l.5kg 3
Male gender 3
Not received IP antibiotics•• 2
Gestation 5 30 wks 2
• mica! chorioamnionitis: JP ever (>37.8°C) with ~of the
following features: fetal tachycardia, uterine tenderness, malodorous
vaginal discharge, maternal leucocytosis (TLC > 15,000).
••Antibiotics started <4 h prior tD delivery also classified as "Not
-
received antibiotics" -
o Neonates with a score of C-6 must be carefully monitored_
clinically for a period of at teast'72 h for signs of sepsiS.-A score
0-6 is not a justification for I avmg the baby unmonitored with
the mother m the ward. Etern I vigilance is the pnce one has to
pay for a restrictive antibiotic policy. Sepsis screen and CSF
must not bc pertormed. Thos who remain asymptomatic until
72 h need not be actively mon torcd further, but the mother must
228
24.4 A PPROAC H TO LO
• Neonates who become symptomatic afler 72 h must be evaluated for
LOS. The clinical signs m section 24.2TCan be used as a guide.
Overall. 30°'0 neonates clinically suspected to have LOS in PGI
NJCU have culture proven LOS. 1
• A single episode or transient presence of one of the above signs may
not warrant any action. The more persistent the sign the more likely
ll 1s associated with LOS.~
• Based on clinical assessment the neonate must be categon1cd into
low probability of sepsis or high probability of sepsis. "Low
probability'' represents situations where the clinician woul~
Wliiii1gtc>\\1thhold antibioucs if the sepsis screen is negative
• Those with low probability of sepsis (e.g. single episode of apnea,
but otherwise well) should undergo a sepsis screen The purpose of
the sepsis screen is to rule out sepsis rather than to rule m sepsis. The
sepsis screen consists of: CRP. ANC. ITR and micro-erythrocyte
sedimentation rate (µ-ESR).
o CRP: It is done by quantitative ELISA or by a bedside semi-
quantitative latex agglutination kit. More than I 0 mg/L is
positive.
o ANC: It must be read off Manroc's charts, Schelonka 's chart or
Mouzinho's chart, depending on whether it is a tcnn baby or a
229
l
traumatic LP. Nothing much is gained by using the various formulas
for adjusting the WBC count m a traumatic CSF, based on the RBC
counts. Adjustment merely results in a loss of sensitivity with
14
marginal gam in specificity.
• The WBC cell count must be performed w1t!lm 30 mio of drawing
the sample, m the Neonatology lab by the lab technician during
office hours and by the JR (to be confirmed by the sRt'iift'Cr office
hours. CSF WBC and glucose rapidly fall- with time, g1\ ing spurious
results. 5 - -
24.6.1 Interpretation of CSF findings
• Apart from culture and gram stain, 4 parameters are commonly
evaluated: total WBC count (per µL), percentage neutrophil count,
glucose and protein. The traditionally used cut-offs are unacceptable
because they are based on 2 SD values of normal populations. T~ere
is surprisingly little data on the hospital-based mcidence of culture-
proven meningitis among cases of suspected sepsis in developing
countnes. Based on a hospital-based study from Bangladesh a
prevalence of 5°/o among cases of suspected nosocomial sepsis can
16
be assumed. Based on a multi-centric study from Asia, a
prevalence of 13% among cases of culture-proven EOS and 17%
7
among cases of culture-proven LOS can be assumed.
• Among preterm infants (<34 wks), none of the above CSF
parameters was shown to be satisfactory for the rapid diagnosis of
meningitis (n= 4,632 infants). 18 Similarly, none of the above CSF
parameters was shown to be satisfactory for the rawd diagnosis of
meningitis in infants 2:34 wks {n= 9111 infants). 9 However, for
want of a better alternative, these parameters arc still used.
231
Among neonates
Among neonates with
with blood culture
suspected sepsis
proven sepsis
Preterm babies
• WBC>25AND •WBC>lO
protein > 170 OR
OR • Glucose< 25
• WBC> 100 OR
Cut-off OR • Protein > 170
values to • Glucose < 25
diagnose Term babies
meningitis • WBC>21 • WBC>8
OR OR
• Glucose < 20 • Glucose < 20
OR
• Protein > 120
1Vote:
I. Have very low threshold for treating as meningitis in proven gram -ve LOS as the
prevalence is highest in this sub-group (-30o/o).
2. CSF parameters may not qualify for a diagnosis of meningitis when sepsis is initially
suspected, but the same parameters may qualify for a diagnosis of meningitis once
culture report becomes available (Table 24.l). In this case, switch over from anti-
meningitic to meningitic doses of antibiotics with plan to treat for 21 d.
3. There is no need to do a blood glucose
232
J
before decid ing on contin 1ing with the empirical antibioticso
One must not continue w1til antib1ot1cs with in vitro resistance
in case of Pseudomonas, K ebsiella and MRSA; and m cases of
CNS infections and deep-sc.ated infections.
o If no ant ibiotic has been re >orted sensitive, but one or more has
l
been reported 'moderately cnsitivc' , therapy must be changed
to such antibiotics at tht highest perrmssible dose. Use a
combination, in such cases.
24.8.4 Duration of antibiotics
• Culture positive sepsis: A sensi ive antibiotic for toLal duration of 14
d. Staphylococcus aureus se sis invariably requires 14 d of
antibiotics. In those neona cs who arc infected by non-
Staphylococcm aureus orgamsms. w1thout menmg1t1s or deep-seated
infections, and who rapidly be ome completely asymptomatic, one
may consider a shorter duratioc of antibiotics after discussing with
the consultant. 22 Qyantjtativ.e CRP assay (<10 mg/L) could be~)
as a guide to decide on stoppagL of antibiotics. 23 ~
• If the blood culture is rcpo11cd sterile at 48 h, the followmg
r
~ guidelines must be adhered to:
o Asymptomatic neonate at mk of EOS: stop antibiotics
234
a
•
eningitis suspected on CSF examination: give total of 21-d course
f parenteral antibiotics that cross uninflamed meninges. Anti-
eningitic doses must be used throughout the course.
o For culture-proven meningitis, only antibiotics with proven in
vitro sensitivity must be used. .._
o .... Morutonng protocol follo;fng diagnosis of meningitis:
• Twice weekly OFC
• Daily 110 m
.-
~~
liSG :F.xam
t i
NonnaI Abnonnal
t
II
! i l
<2 yr 2-5 yr
I I >S yr
MCU&
DMSA
MCU& DoDMSA No test
DMSA DoMCU
only if scar
on DMSAor
D\iSA not
possible
24
• Management of Septic Shock (see section 29.6)
Fluid resuscitation with isotonic boluses (up to 2 boluses of 10-20
mL kg over 20-30 min each) should be accomplished (see section
29.6). ln addition, hypoglycemia and hypocalcjmia should be
corrected. Hypocalcemia must be treated with slow IV
administration of calcium gluconate at a dose of 2 ml/kg (see
section O~f shock persists, central venous ancrartemrt'-access
should be obtained and vasoactive agents should be started, with
dopamine as a first-line ag~t (see section D45). If after the first
h our c1rcufati"on is not restored with further pressor support. concern
for adrenal insufficiency sh.ould be raised and hydrocortisone
therapy should be considered.
• Prolonged ET intubation
• Receipt of parenteral hyper alimcntation
• Presence ofCVCs
• Surgical procedures especially abdominal and cardiac
• Prolonged hospitalization
• Administration of corticosteroids and H2 receptor blocking agents
• Hyperglycemia
• NEC
24.11.2 Diagnosis
• Fungal sepsis must be suspected in sick newborns with any of the
above risk factors or any sick neonate who has received up to the
third line of empiric antibiotics or sepsis developing beyond 7 d of
life. A smoldering course with persistent thrombocytopenia or
unexplained hyperglycemia or high CRP is typical of fungal sepsis.
• Culture: Candida sp grows in routine blood culture media, but if
other fungi are suspected, a fungal culture medium should be used
(special biphasic media containing BHI broth with agar). Although it
is recommended that cultures should be monitored for 10 d to ensure
adequate growth of slower growing Candida species and other fungi,
results can be available as early as 72 h. For neonates with
indwelling central lines, samples must be obtained from both
catheter and venepuncture.
• CSF: CSF examination for cells, biochemistry, smear for fungal
elements and fungal culture must be performed because this affects
the choice and duration of antifungals. Culture of the CSF is
important in diagnosing fungal meningitis in VLBW infants since
CSF cell counts and chemistries may be normal.
• Suprapubic urine examination for fungal hyphae. Report is available
on the same day (call Mycology lab or Dr Arunaloke Chakrabarti).
• Microscopic examination of huffy coat by centrifugation of blood in
microhematocrit tubes can be used for rapid diagnosis of fungal
invasion in blood.
• If disseminated candidiasis is suspected based on clinical features or
if a positive fungal blood culture is obtained, perform the following:
o Indirect ophthalmoscopy - Endophthalmitis begins as a
chorioretinal lesion that gradually elevates and breaks free in the
vitreous, appearing as a white fluffy ball. These solitary or
multiple white lesions are most often seen in the posterior retina
(zone 1) and vitreous. Contact Ophthalmology JR or SR.
o Abdomen USG for renal mycetomas and hepato-splenic
abscesses
o Neuroimaging to look for ventriculitis or abscess
o Echo for fungal endocarditis
238
24.11.3 Treatment
Empirical treatment:
• First line: Fluconazole (see section D52)
• Second line: Plain Amphotericin B (see section D 11 ). This can be
started if there is no response after 5 d of fluconazole treatment.
Treatment ofproven fungal sepsis:
• If sensitivity report is available, follow the report. Use the simplest
and least expensive anti-fungal (in most cases Fluconazole).
• If sensitivity report is awaited, follow these guidelines:
o For uncomplicated systemic fungal infection, use Fluconazole
o For CNS fungal infection, use plain Arnphotericin B + 5-
flucytosine (see section D53)
o For hepato-splenic or pulmonary: use Amphotericin B Lipid
Complex
o For C glabrata: Use Voriconazole
o For':C parapsilo!tt-imd C tropicalis, use higher doses of
Amph~
o ~use Am~otericin B J
o For endocarditis or Candida refractory to fluconazole ~
Arnphotericin B: use Micafungin
The role for liposornal Amph~ very limited in neonatal fungal
sepsis. Oc21ls1onal c~esOfCNS f'ltilga1 infection may require j t - - - -
~4 Duration of anti-fungal treatment ----
Fluconazole: 7-10 d if uncomplicated, 10-14 d if funguria or mycetoma
(do not go by USG ffodings- they~ to disappear).
Arnphotericin B: Cumulative dose of 20-25 mg/kg. In neonates, there is
no need to give test dose or to build ~
REFERENCES
1. Singh S.A. J.Trop.Pediatr. 2003; 49: 235
2. Benitz W.E. Pediatrics 1998; 102: E41
3. Mahale R. Am.J.Perinatol. 2009;
4. Eldadah M. Pediatr.lnfect.Dis.J. 1987; 6: 243
5. Weiss M.G. J.Pediatr. 1991; I 19: 973
6. Dutta S. Arch.Dis.Child Fetal Neonatal Ed 2009;
7. Fielkow S. J.Pediatr. 1991; 119: 971
8. Kumar P. J.Paediatr.Child Health 1995; 31 : 8
9. Kudawla M. J.Trop.Pediatr. 2008; 54: 66
10. Mouzinho A. Pediatrics 1994; 94: 76
11. Schelonka R.L. J.Pediatr. 1994; 125: 603
12. Da Silva 0 . Pediatr.lnfcct.Dis.J. 1995; 14: 362
13. Fowlie P.W. Arch.Dis.Child Fetal Neonatal Ed 1998; 78: F92
14. Greenberg R.G. Pediatr.lnfect.Dis.J. 2008; 27: 1047
239
15. Rajesh N.T. Arch.Dis.Child Fetal Neonatal Ed 2009; Aug 10: Epub
ahead of print
16. Ahmed A.S. Indian Pediatr. 2002; 39: 1034
17. Tiskumara R. Arch Dis Child F & N Ed 2009; 94: F 144
18. Smith P.B. Am.J.Perinatol. 2008: 25: 421
19. Garges H.P. Pediatrics 2006; 1I7: 1094
20. DiGeronimo R.J. Pediatr.Infect.Dis.J. 1992; I I: 764
21. Tamim M.M. Pediatr.Infect.Dis.J. 2003; 22: 805
22. Chowdhary G. J.Trop.Pediatr. 2006; 52: 427
23. Couto R.C. Braz.I.Infect.Dis. 2007; 11: 240
24. Carcillo J.A. Crit Care Med. 2002; 30: 1365
25. Ohlsson A. Cochrane.Database.Syst.Rev. 2004; CD001239
26. Carr R. Cochrane.Database.Syst.Rev. 2003; CD003066
27. Sadana S. Indian Pediatr. 1997; 34: 20
240
25. I DEFINITION
Epidemic is defined as the occurrence of cases greater than the expected
number. Strictly speaking, for labeling as epidemic, baseline prevalence
is necessary and the unexpected rise has to be statistically proven.
Practically speaking, the investigation & control measures should be
initiated with any unexpected sharp increase of a specific infection.
25.2 MANAGEMENT
The steps are provided below:
25.2.1 Get organized:
• To get the services of the division of hospital infection control, meet
Dr. Manisha or Dr. Malkiat Singh. Microbiology has got a vital role
in the investigation of an epidemic. A multidisciplinary team should
quickly be constituted to handle the epidemic- consisting of unit
consultants, area SR, sister-in-charge of the area and hospital
infection control team.
• Additional support may be required from hospital administration,
sanitation and biomedical engineering after the initial investigation.
The consultant-in-charge must contact the relevant support staff.
• A formal meeting should be conducted in the unit to define the case
and plan the evaluation and management.
25.2.2 Defining a case:
• This should be formulated by the members of the team in the
meeting. The definition should include time, place and person. E.g.:
I. "any NICU baby who has grown MRSA from any body site after
l" Nov 2007." This allows the members of the unit to understand
what should be called as a 'case' and it ·can be used prospectively to
identify more cases.
25.2.3 Confirm the outbreak:
• Compare the past unit data, preferably of that season with the
infection rate of the presumed outbreak. The SR in charge of the area
should obtain the previous unit data for that specific infection.
25.2.4 Rapid identification of the existing cases:
• Send the cultures of all the babies admitted in that area. Do focused
clinical examinations. Keep low threshold for suspicion of sepsis
and investigation.
25.2.5 Prevent further spread:
• Strengthen the asepsis routine.< including hand hygiene and
housekeeping practices (see sections 23.2, 23.5). Area SR should
sensitize all the staff of the area (including sanitation staff) regarding
the outbreak and should take efforts to improve the compliance with
asepsis routines.
241
Use the information from the line listing for determining the type of
outbreak. If the outbreak is due to a point source, it will have one major
peak, and if it is propagating outbreak it will have multiple peaks.
25.2.8 Antibiotic policy
Check the sensitivity pattern of the implicated organism and consider a
change of antibiotic policy, if necessary (see section 24.8.1).
25.2.9 Other administrative measures
• Limit the new admissions into the area only for unavoidable
admissions.
• Involve the Obstetrics department and try to transfer waiting high
risk mothers to other hospitals for delivery.
• Avoid transfer of the residents from one area to another area in the
unit.
• Tackling the source:
o Point source- like drugs, !VF, formula feeds must be discarded.
If a particular batch no. of IVF is responsible then notify the
hospital administration.
o If the source is equipment like incubators, disinfect it. Do not
use until two consecutive cultures are negative.
o If the source is a health care personnel acting as persistent
carrier, treat the carrier state if treatment available. He/she is to
be allowed to participate in the care of the babies, only if two
consecutive cultures are negative. Persistent carriers may have
to be permanently shifted out "fthe area.
This chapter does not cover HIV. See chapter 27 for HIV.
26.1 SUSPECT AN IUI IN THE FOLLOWING SITUATIONS
• Maternal h/o contact with a known infected case or h/o non-
vesicular rash (Rubella, Parvovirus) or vesicular rash (Varicella and
Herpes) during pregnancy
• PDA in a near tenn/term infant
• Clinical stigmata (unexplained severe SFD, hepatosplenomegaly,
blue berry muffins, microcephaly)
• Late onset neonatal cholestasis
• H/o recurrent abortions in mother -- suspect syphilis
26.3 GENERAL MEASURES (modified from AAP Red book & CDC
guidelines)' ·2
• Contact isolation in a separate room in NNN. It is preferable but not
absolutely required to isolate incubator-confined patients. Also limit
transport and movement of patients outside of the room.
• Early discharge to be planned if isolation is not feasible.
• Wear a new gown at entry and thoroughly hand wash while entering
and leaving. Wear gloves while handling patient.
• Napkins, beddings and other materials that are exposed to the
infant's body fluids should be bagged and sterilized.
• Ensure that rooms of patients on contact precautions are prioritized
for freqiient cleaning and disinfection with a focus on frequently-
245
lgM/lgAIJgG -ve
Normal Suggestive
CT/ophthalmoscopy CT/ophthalmoscopy
·>
Send blood and urine to Parasitology
____, Dept for isolation of T gondii by
mice peritoneal inoculation after
discussion with Parasitology SR Normal
CT/ophthalmoscopy
Suggestive
+ve • Do 3 monthly ophthalmic evaluation
for appearance of retinitis and start
CT/ophthalmoscopy treatment if positive.
• Do follow up IgG every 6 weeks.
_I Treat as congenital
Start treatment if lgG titers are rising
I toxoplasmosis at 6 weeks
Note;
• Suggestive CT findings are periventricular white matter and basal
ganglia calcification and hydrocephalus.
• Suggestive ophthalmoscopic findings are focal necrotizing retinitis
with macular involvement
26.S.2 Diagnosis
• Presence of typical vesicular rash and maternal h/o peripartum
varicella is itself diagnostic.
• Antigen detection by indirect fluorescent antibody test: Obtain a
special slide for this test from the Virology department Room no
107, level I, Research A block. Take scrapings from the base of the
lesion and apply to the well of the slide (A dermatology consultation
can be sought for obtaining the skin scraping). Transport promptly to
lab. Results are available in 24 h.
• Infant 1-2 mL blood for Varicella zoster virus lgM: rarely required
248
26.8 RUBELLA
When rubella infection occurs during pregnancy, especially during the
first trimester, the risk of fetal infection may be as high as 90%. The most
common manifestations of CRS are sensorineural hearing loss, cataracts
and heart defects. PDA is the most common defect and may occur as the
sole manifestation of congenital rubella. Eye defects include cataracts
and a 'salt and pepper' retinopathy.
26.8.1 Diagnosis of CRS (any one positive test required)
• Demonstration of rubella-specific IgM antibody before 3 mths of
age. In some instances, IgM may not be detected until at least 1 mth
of age. So infants with symptoms consistent with CRS who test
negative shortly after birth should be retested at l mth of age.
• IgG that persists at a higher level (i.e., titer that does not drop at the
expected rate of a twofold dilution per month) and for a period of>
6 wks.
• PCR for Rubella DNA
Serology is available in PG! at room no 109, Dept of Virology. PCR is
currently not available in PG! but could be done in private labs and
should be done in infants with symptoms consistent with CRS who have
persistent lgM seronegativity. Ophthalmic testing and hearing assessment
should be done in all proven cases.
26.8.2 Treatment
Follow general measures stated in introduction. There is no specific
treatment. Non-immune pregnant staff members must be shifted to other
areas. The family must be told that non-immune pregnant family
members or well-wishers must be asked to stay away.
252
26.9 HEPATITIS B
The prevalence of HBsAg positivity in pregnant mothers in various
Indian studies ranges from 0.6%-5.0%. 70-90% of newborns born to
mothers who are HbsAg and HbeAg positive acquire infection during the
perinatal period and 90o/o of these newborns become chronic carriers. 5o/o
of newborns born to HbsAg +/ HbeAg - mothers become chronic carriers
5
26.9.1 Management of infant born to HbsAg +ve moth er : Sh own m .
Table 26.4
Maternal Intervention
status I
Gestation and
Wt ofbabv
HbsAg Administer Hepatitis B vaccine (see section 5.2.6) and
positive (Term HBIG (0.5 ml) lM at Sl2 h of birth (efficacious up to
baby of any 72 h) (see section D63). Administer at different
Wt) injection sites. Repeat vaccine doses at I and 6 mths
(85%--95% efficacy). If patient cannot afford HBIG
administer vaccine first dose Sl2 h of birth with repeat
doses at I and 6 mths (70-90% efficacv)
HbsAg Same as above. Initial vaccine dose (birth dose) should
positive not be counted as part of the vaccine series. 3
(pretenn baby additional doses of vaccine (for a total of 4 doses)
or< 2000 g of should be administered beginning when the infant
any gestation) reaches age I mth.
Mother with Ensure administration of vaccine at Sl2 h of birth. If
unknown mother turns out to be HbsAg positive later, administer
HBsAg status HBIG as soon as possible but no later than age 7 d
after birth.
26.10 HEPATITIS C
Approximately 5% of all infants born to HCV infected mothers become
infected. Risk factors for MTCT include maternal HIV co-infection, high
maternal HCV viremia, IV drug use.
26.10.1 Management
• Allow breastfeeding
• PCR tests for HCV-RNA at 2 mths or Anti-HCV testing at 12~
18 mths of life. These investigations are not currently available in
PG!.
• There is no specific management
26.11 HEPATITIS E
Studies have shown that Hepatitis E is responsible for 40-60% of acute
viral hepatitis in pregnancy. 20% of women can develop fulminant
hepatic failure. Preterm delivery rates are higher. Vertical transmission
rates up to 75% in various studies. Neonatal manifestations include
anicteric, icteric and fulminant hepatitis. Send blood for lgM anti-HEY
antibodies by ELISA assay and HEV-RNA to confirm diagnosis (the
latter is currently not available in PG!).
Give HR
prophylaxis for 9
mths ( 12 mths if Mantoux at 3 mths
Hrv positive) +ve ·Ve
26.13 SYPHILIS 6
26.13.1 Diagnosis
• If mother is seroreactive, evaluate baby with a quantitative non-
treponemal serologic test (VDRL). Conducting a treponemal test is
not necessary.
• Examine thoroughly for evidence of congenital syphilis (e.g.,
nonimmune hydrops, jaundice, hepatosplenomegaly, rhinitis, skin
rash, and/or pseudoparalysis of an extremity).
26.13.2 Management
Scenario I: Infant with an abnormal physical examination that is
consistent with congenital syphilis
Evaluation
• Do blood VDRL
• CSF analysis for VDRL, cell count, and protein
• CBC and differential and platelet count
• Other tests as clinically indicated (e.g., long-bone radiographs, chest
radiograph, liver-function tests, cranial USG, ophthalmologic
examination, and auditory brains tern response)
Treatment: Aqueous crystalline penicillin G 100,000-150,000 units/kg/ct
(see D98), administered as 50,000 units/kg/dose IV every 12 h during the
first 7 d of life and every 8 h thereafter for a total of 10 d (3 wks if CNS
involvement) or Procaine penicillin G 50,000 units/kg/dose IM in a
single daily dose for 10 d. lf>l d of therapy is missed, the entire course
should be restarted. Data are insufficient regarding the use of other
antimicrobial agents.
Scenario 2: Infants who have a normal physical examination and VDRL
titer the same or less than fourfold the maternal titer, and the
1. Mother was not treated, inadequately treated, or has no
documentation of having received treatment;
2. Mother was treated with nonpenicillin regimen; or
3. Mother received treatment <4 wks before delivery.
Evaluation
• CSF analysis for VDRL, cell count, and protein
• CBC and differential and platelet count
• Long-bone radiographs
Treatment
Crystalline penicillin G (see dose above, section D98) or Procaine
penicillin G (see dose above) or Benzathine penicillin G 50,000
units/kg/dose IM in a single dose (use latter only if evaluation is normal
and follow up is certain).
256
REFERENCES:
1. Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings 2007, CDC
2. Isolation Precautions. AAP Red Book 2009: 149-158.
3. Kimberlin DW. J Pediatr. 2003;143:16.
4. Kimberlin DW. J Infect Dis. 2008;197:836.
5. Hepatitis B treatment guidelines. CDC 2006
6. Evaluation and treatment of infants during the first month of life.
Congenital syphilis treatment guidelines. CDC 2006.
257
Counseling r
screening __..,..Re-counseling
Known HJV infection and HIV test positive HIV test negative
already receiving ART
+
Continue ART Determine ART
I eligibility* I
I
•
Eligible for ART*"' •
Not eligible for ART; requires
I I ARV prophylaxis I
+
Give one of the recommended 3-
drug ART regimes to mother in
•
Option A: Maternal
AZT prophylaxis
•
Option B: Triple
ARV prophylaxis
antenatal period** starting from 14 starting from 14
weeks of gestation weeks of gestation
•• + + +
I Continue ART in labor I Sd-NVP at the start
of labor and AZT +
Continue triple ARV
tve -ve
-ve
HIV HIV
confirmed reasonably HIV
excluded unlikely
ELISA at 18 mths, 2
times, different kits
HIV HIV
confirmed excluded
ls this source material blood, body fluid, other potentially infectious material
(OPIM) or an instrument contaminated '"'ith one of these substances?
No PEP relquired+----No
i yri
OPIM,
blood/bodv fluid
+
LP
Jntact skin Type of exposure?
Small volume
(few drops)
Large volume
(several drops/major
splash)/longer duration
(several minutes or more)
j
More severe (large bore
l
hollow needle, deep
Less severe (solid puncture, visible blood
needle, superficial or needle used in pt.
scratch) artery or vein)
EC 1 EC 2
+
EC2
EC 3
266
Source
HIV HIV status of the exposure
unknown
source
l l
negrve
11 +
Low titer High titer (advanced
(asymptomatic/ AIDS, primary HIV
high CD4 counts) infection/high viral load
or low CD4 counts)
1
HIV SC 2
HIV SC I
REFERENCES
I. Ministry of Health & Family Welfare, Government of India. ART
Guidelines for HIV-Infected Adults and Adolescents Including Post-
exposure Prophylaxis; May 20<l7.
2. The International Perinatal HIV Group. NEJM 1999; 340: 977.
3. Marina M de Paoli, Ntombizodumo B M, Richter L M, Rollins N.
Acta Pediatr 2008; 97: 1663.
4. Babat R, Moodley D, Coutsoudis A, Coovadia H. AIDS 1997; 11:
1627.
5. Thior I et al. JAMA 2006; 296:794.
6. Lewis DE et al. Clin Diagn Lab Imrnunol !995; 2: 87.
268
Innocent or nhvsiolo2ical
Physiological pulmonary Ejection systolic character, grade I to 2,
branch narrowing low pitched and extends till or just beyond
S2. Maximal in pulmonary area,
transmitted throughout the chest. Resolves
bv 6 mths.
TR Confused with VSD clinically. Resolves
as PVR falls by day 2 -3.
Transient systolic closing Audible at left upper sternal border on day
PDAmurmur I.
Patholo2ical murmurs
Obstructive lesions AS and PS
(producing turbulence in a
great artery)
Regurgitant valves Mitra! and tricusoid regurgitation
Shunting Small VSD and PDA
28.4 INVESTIGATIONS
28.4.t CXR: Shown in Table 28.2
28.4.2ECG
Ask for 13-lead electrocardiography - includes V3R or V4R. Normal
EXG findings are shown in Table 28.3
270
Table 28.3 Normal ECG findings (figures are ranges with means in
brackets)
Measure 0-1 d 1-3 d 3-7 d 7-30d
Term neonates 1
QRS axis + 59 to +64 t•l +77 to +65 to
+193 (135) +197 (134) +187 (132) +150(110)
PR interval (s) 0.08-0.16 0.08. 0.14 0.08- 0.14 0.07 - 0.14
(0.11) (0.11) (0.10) (0.10)
QRS duration 0.02 - 0.08 0.02 - 0.07 0.02 - 0.07 0.02 - 0.08
V5 (s) (0.05) (0.05) (0.05) (0.05)
RV! mm 6.5-23. 7 7.0-24.2 5.5-21.5 4.5-18.1
(13.5) (14.8) (12.8) (I 0.5)
SY! mm 1.0-18.5 1.5-19.0 1.0-15.0 0.5-9.7
(8.5) (9.5) 16.8) (4.0)
RV6mm 0.5-9.5 0.5-9.5 1.0-10.5 2.6-13.5
(4.5) (4.8) (5.1) (7.6)
SV6mm 0.2-7.9 0.2-7.6 0.2-8.0 0.2-3.2
(3.5) (3.2) (3. 7) (3.2)
Preterm neonates '
QRS axis +75 to +75 to +75 to +17 to
+194 (]27) +195(121) +165 (117) +171180)
PR interval (s) 0.09-0.10 0.09 -0.10 0.09 - 0.10 0.09- 0.10
(0.10) (0.10) (0.10) (0.10)
QRS duration 0.04 0.04 0.04 0.04
V5
RVl mm 2.0-12.6 2.6-14.9 3.8-16.9 6.2-21.6
(6.5) (7.4) (8.7) (13.0)
SY! mm 0.6-17.6 1.0-16.0 0.0-15.0 1.2-14.0
(6.8) (6.5) (6.8) (6.2)
RV6mm 3.5-21.3 5.0-20.8 4.0-20.5 8.3-21.0
(11.4) (11.9) (12.3) (15.0)
S V6mm 2.5-26.5 2.6-26.0 3.0-25.0 3.1-26.3
(15.0) (13.5) (14.0) (15.0)
IMaternal history, antenatal USG and physical findings like cardiomegaly, murmurs, clearly audible
bilateral breath sounds on auscultation and/or lack of respiratory distress suggest a cardiac cause
t
F;GEll
: RH>LL I I LL>RH I DoCXR [
l
Do CXR and Echo.
Echo confinns
PGEI [
I
· diagnosis of PPHN [ Start O!igemic non oligemic \
I and CXR confirms
lung field lung fields
associated lung
disease with PPHN
r Pulmonary outflow obstruction
TGV with either I
PPHN
Aortic arch abn
I
Complete mix.mg with I
unrestricted ASD
275
not present at this stage because the ductus usually is large. Room air
pulse oximetry in the lower extremities (postductal saturation) may be
helpful. A value above 96% Of •17% rules out a completely ductal-
dependent left heart obstruction ( hypoplastic left heart or interrupted
aortic arch).
1
I Detailed history
Infant of diabetic mother Asymmetric septa! hypertrophy and structural heart diseases; metabolic
causes (hypoglycemia and hypocalccmla) and polycythemia
Birth asphyxia Asphyxia! oardiac injury and metabolic causes
Pretenn neonate Fluid overload and PDA
Maternal rubella virus or Myocarditis and PDA respective! y
Parvovirus infection during
pregnancy
i
Clinical findings
I Hydrops Indicates antenatal cardiac failure· arrhythmias, myocarditis, severe
anaemia, Jarge AVM's
I Associated BPD Chronic right heart failure (cor pulmona!e)
Abnormal rhythm Arrhythmias
' Abnonnal bruits AVM's
I Rash, weak pulses, distant Viral myocarditis
heart sounds, gallop rhythm
Sepsis Seps1$ induced cardiac dysfunction
Cyanosis Common mixing lesions
I Presentation with shock and Left sided OOstructive lesions
collapse
IV Morphine
1 l
I Refer to arrhythmia flow chart I
IV Nitroglycerine
(caution with Dopamine 4-20 µg/kg/min
valvular stenosis) Adrenaline up to 0.05-2.5 µg/kg/min
Correct hypoglycemia, hypocalcemia
and acidosis
Improved
No improvement Improved 1
• Increase diuretic Taper medication BP still < 101h
dosage Switch to oral centile
• Low dose dopamine medications I
Oral
(2-4 µg/kg/min)
medications
• Dobutamine
Improved No improvement
l
Oral medications
l
I Consider I
Oral frusernide 2-3 Milrinone I
mg/kg/day
Oral digoxin (no need for
loading dose)
Consider ACE inhibitors
279
.J-~~A~-·~M+
..,. •1·~-IJ..~, .... ..,. •
• Atrial rate up to
500 in
newborns
VT • Often with AV
dissociation
11
• Capture" or
"fusion 11 beats
diagnostic.
VF • Chaotic rh thm
281
• Rapid and
irregular
rhythm
• ,~·,,J,,
• Regular R-R
intervals
~! = ,...
•&Yr
. . l-.a 0 • Regular P-P
intervals
• Atrial rate >
ventricular rate
't ,~--
L-'rl'& ... !
followed by a
blocked beat
• Usually
indicates block
in the AV node
Mobitz type II •No
characteristic
PR
1+'4'4
• =• prolongation as
seen in type I.
• Usually not
reversible with
medications.
Neonatal SVT
IV adenosine
I Vagal maneuvers I
l
DC Cardioversion 0.5-1 J!kg.
Double the dosage if no response
l !'-Jo response
Consider IV adenosine if no response
I IV amiodarone I
after 3 shocks
1 No response
Evaluate cardiac function
No response
IV Esmolol or Mctaprolol
IV Flecainide/propafenone/
procainamide
Method
• Consider intubation and ventilation before cardioversion
• Switch power on the defibrillator and turn the selector switch to
"defib".
• Select energy setting by using the up/down arrows.
• Apply a liberal amount of gel on both paddles or use gel patches.
• The sternal paddle is placed immediately to the right of the sternum
just below the clavicle and the apex paddle is placed between the tip
of the left scapula and the spine to place as much heart mass as
possible between the two paddles. The paddles should be applied
firmly against the chest wall to avoid arcing and skin burns.
• Press the charge button on the front panel or on the apex paddle
handle.
• When a tone appears clearly say "One, I'm clear' Two - you 're
clear! Three - everybody's clear!". Using the thumb simultaneously
press both the shock buttons on the paddle until energy is delivered.
• Repeat the above steps if needed.
• If conversion to sinus rhythm is not achieved after two attempts,
drug therapy should be initiated before attempting cardioversion
again.
283
1 VT/VF persists
Give Amiodarone 5 mg/kg and 4th shock 4J/kg
Consider lignocainc if amiodarone is not immediately
available. Also consider Magnesium 25-50 mg/kg slow
IV ifTorsadc de pointes
i
Continue giving shocks every 2 min. Give
adrenaline immediately before every other shock
until return of spontaneous circulation.
Yes I No
i 1
Echo to be done If murmur persists Periodically reassess baby
during hospital fix an appointment till I wk. In case of early
stay with PCC (Thur 2 It-- discharge, call to Children
pm, Advanced OPD at I wk for
Cardiac Centre). An reassessment
Echo will be decided
at follow up in PCC
28.11 COUNSELLING
Having a sibling with CHD confers a 2% risk on a subsequent child. A
mother with CHD has a 6% risk of having an affected offspring and a
father a 2% risk overall and if there are two affected first-degree
relatives, the recurrence rate ofCHD is 3% to 12% (Table 28.8).
If a neonate is born who has a first degree relative (parent or sibling) who
has been diagnosed with HLHS, coarctation, or bicuspid aortic valve do a
complete cardiovascular examination at birth and investigate
immediately if suspicious findings; and refer babies with a normal
examination to the PCC (Advanced Cardiac Centre, Block IC, Thur 2
pm) at 2 wks of life.
REFERENCES:
29.SHOCK
29.1 DEFINITION
Shock is a clinical state of acute circulatory dysfunction resulting in
insufficient 0 2 and nutrient deliv~ry to satisfy tissue requirements.
Hypotension, frequently but not always. accompanies shock.
Hypotension refers to a BP that is lower than the expected reference
range (see sections Nl4, Nl5, Nl6). During the first postnatal day, the
numerical value of mean arterial BP is approximately equal to the
numerical value of the patient's GA.
29.2 MEASUREMENT OF BP
29.2.I Noninvasive BP monitoring (oscillometric method): (See
PGIMER video on neonatal procedures, for NIBP measurement).
Oscillometry is the only reliable and accurate way of measuring BP
indirectly. To minimise errors the following guidelines are recommended
• Use appropriate cuff size. The width of the air bladder should be 45-
55% of the circumference or 125 -155% of diameter of the arm (or
calf). Three sizes of neonatal cuffs are available; size 1 (arm
circumference 3-6 cm), size 2 (arm circumference 4-8 cm) and size 3
(arm circumference 6-11 cm).
• Place the cuff so that the artery is aligned with the mark
• Wrap the cuff snugly around the infant's limb
• Obtain BP measurement during quiet or sleep state
• Obtain average of two or three measurements if making management
decisions
• Use MBP to monitor changes (less likely to be erroneous)
Fallacies with osci/lometric method
• Movement artefact
• May overestimate BP measurements in hypotensive pretenns
29.2.2 Invasive BP monitoring (See PGIMER video on neonatal
procedures for peripheral arterial line and UAC insertion): Considered
gold standard. Invasive BP monitoring must be done in all sick babies
requiring frequent BP monitoring even if there is no hypotension. To
minimise errors when using in-dwelling arterial lines, the following
factors should be noted
• Keep the transducer at the level of heart (mid-axillary line)
• Dicrotic notch must be clearly visible on the arterial waveform trace
• Air bubbles in the system results in excessive damping (decreases
SBP & increases DBP). If dicrotic notch becomes distorted or
absent, one should suspect overdarnping and look for the presence of
air bubbles in the catheter transducer system.
• Tubing should have low compliance and shortest possible length
(long length decreases both SBP, DBP)
288
29.5 INVESTIGATIONS
• pH, BE, lactate, PCV, BS, calcium, Na, K, urea, creatinine (in all
cases)
• Sepsis investigations, if sepsis 's suspected (see sections 24.4, 24.5)
• Serum cortisol for inotrope res.istant hypotension defined as
dopamine requirement 2: 20 µg/kg/min (cortisol < 5 mg/dL is
suggestive ofrelative adrenal insufficiency)
• ECG, CXR if cardiogenic cause suspected (may help in diagnosis)
• Echo: perform whenever cardiogenic cause suspected. Look for
cardiac contractility and ejection fraction. Also helpful in diagnosing
PDA (look for flow through PDA, Left atrium/ aorta (LA/Ao) ratio,
LV filling pattern - El A ratio and diastolic steal in peripheral arteries
like mesenteric, celiac, renal and MCA) and PPHN (look for TR jet,
pattern of flow through PDA and ventricular septa) position). It
should also be considered in inotrope resistant shock of any etiology
( doppler USG of peripheral arteries may be performed to have an
idea of peripheral resistance, presence or absence of PDA, superior
vena cava (SVC) flow and cardiac contractility parameters) to fine
tune the inotropic requirement. The LVO can be quantified to guide
the management ofhypotension (Table 29.2).
o If the LVO is normal or high and PDA is not evident, a
vasopressor (e.g. dopamine) can be instituted. If a
hemodynamically significant PDA is diagnosed, additional
treatment should be directed toward the PDA.
BW mL/min mL/kg/min
750-1249 275 ± 37 262 ± 31
1250-1749 388 ± 60 261±36
1750-2249 522 ± 92 259 ± 35
2250-2749 602 ± 85 244 ± 27
2750-3249 737 ± 128 247 ± 37
3250-3749 902± 120 257 ± 35
3750-4249 924 ± 119 229 ± 31
4250-4750 987 ± 67 221±15
with 0.1 mg/kg over 15-30 min Use only after discussion with
consultant.
29.6.7 Vasopressin: (Pitresin, CpreS<in®)
In a recent study', the authors concluded that vasopressin might be a
promising rescue therapy in catecholamine-resistant vasodilatory shock
in ELBW infants with acute renal injury. Dose: 0.3-2 mU/kg/min. Use
only after discussion with consultant.
Shock
(Poor tissue perfusion± low MBP)
No improvement
Improvement {.l- HR andt BP)
• Can repeat bolus in confirmed cases of
• Continue monitoring perfusion
hypovolemia
• Can repeat bolus if perfusion still
• When in doubt, establish CVP to help
impaired
decision making
• But do not v.aste time in inserting CVP line;
go to next step if required
REFERENCES
1. Walther F J. Pediatrics 1985; 76: 829. Pediatrics 1985; 76: 829
2. Meyer S, Loffler G, Polcher T, Gottschling S, Gartner L. Acta
Paediatr 2006; 95: 1309
293
30.I BACKGROUND:
The ductus arteriosus is patent in all newborns at the time of delivery.
Functional closure begins l 0-15 h after birth. It is closed functionally by
48 h after birth in almost all infants delivered at 0".40 wks gestation and
by 72 h after birth in 90% of infants delivered at 0".30 wks gestation. 25%
of infants with BWs 1,000-1,500 g will have a PDA at 72 h, and 70% of
these will require treatment. 65% of infants with BWs <I ,000 g will have
a PDA at 72 h, and 85% of these will require treatment.
o Feed intolerance
30.3. l Utility of 3 major clinical signs at different days of life '" '
Shown in Table 30.1
30.4 ECHOCARDIOGRAPHY
PDA is confirmed on color Doppler echocardiography. An Echo must be
performed on all ELBW babies within 24 h of life and in all other babies,
whenever clinically indicated. SRs are authorized to perform a basic
Echo but they must get the findings confirmed by a Pediatric
Cardiologist. The hemodynamic significance of the PDA must always be
assessed and reported.
30.4.1 Features of hemodynamic significance on echocardiography: 3
Shown in Table 30.2
Modality
Feature and
quantified position of
NoPDA Small Moderate Large
samole eate
Characteristics of ductus arteriosus
Transductal 2-D short
0 . <l.5 1.5-3 >3
diameter (mml axis view
PWDat
Ductal velocity
pulmonary 0 >2 1.5-2 <1.5
Vmax (emfs)
end of duct
PWDwithin
Antegrade PA left
diastolic flow pulmonary 0 <JO 30-50 >50
(cm/s) artery
Pulmonan overcirculation
M-mode
Left atrial/aortic long axis 1.13±0.23 <1.4:1 1.4-1.6: I >l.6:1
view
M-mode
Left
long axis 1.86±0.29 - 2.15±0.39 2.27±0.37
ventricular/aortic
view
transmitral
E/A <I <I 1-1.5 >1.5
Donn!er
PWD
between <35
!VRT (mis) <55 46-54 36-45
mitral and
aortic valve
M-modeof
LVSTI 0.34±0.09 - 0.26±0.03 0.24±0.07
aortic valve
S stemlc ffu,,_.,r erfusion
Retrograde CWDof
diastolic flow descending JO <30 30-50 >50
(%) aorta
PWOofLV
LVO >314
outflow 190-310
(mUkg/min)
tract
CWD- continuous wave Doppler, IVRT- Isovolumetnc relaxation ttme, LVSTI- Left
ventricular systolic time integral
30.5.3 Pharmacotherapy:
Pharmacotherapy is permissible if the age of the neonate is less than 3
wks, if the neonate has not already received 2 courses of medication and
if there is no risk of a ductus dependent disease. An Echo prior to starting
pharmacotherapy is desirable, but not mandatory. The situations in which
an Echo is mandatory are: gestation > 32 wks, absent femoral pulses.
shock, atypical location of the murmur, cyanosis that does not improve
on oxygen and malformations. Response to pharmacotherapy can be
monitored clinically. It is not essential to perform a check Echo.
296
Long course
0.1 mg/kg/dose IV/oral 24 hourly interval for 5-7 d
Contraindications - similar to Ibuprofen
30.5.4 Repeat course:
If ductus reopens after the first course, second course can be given (no
data to support superiority of prolonged second course versus short
second course). A maximum of 2 courses may be tried.
30.5.5 Surgical closure:
Surgical closure is indicated if
• There is a contraindication to medical therapy
• The patient has not responded to 2 courses of medical therapy
• The age of the patient is >3 wks and the disease is either clinically or
echocardiographically of hemodynamic significance.
The CTVS SR must be contacted if surgical closure is contemplated. A
detailed Echo by a Pediatric Cardiologist is mandatory before the patient
is operated.
Such patients should be followed up mly in the NFC (see section 42.2)
30.6.2 Patients who had PDA that was operated
Such patients should be followed Lp at least once in the CTVS OPD
(Advanced Cardiac Centre, ground f;oor) of the concerned consultant; in
the PCC, Thursday, 2 pm, Advanced Cardiac Centre, ground floor as
well as in the NFC.
30.6.3 Patients who had an echo confirmed PDA that was not
hemodynamically or clinically significant, but persisted at the time of
discharge
Such patients must be followed up in the PCC and in the NFC. They
must be monitored for signs of chronic CCF and episodes of pneumonia.
Surgery is indicated in such patients if
• Signs of CHF appear
• There is even a single episode of pneumonia
• Echo confirmed features of pulmonary artery hypertension
• PDA persists at age >!yr and Wt >8 kg
REFERENCES:
I. Skelton R. J Paediatr Child Health. I 994;30:406
2. Davis P. Arch Pediatr Adolesc Med. 1995;149:1136
3. Sehgal A. Eur J Pediatr. 2009; 168:907
298
31.4 MANAGEMENT
31.4.1 On suspicion of NEC
• Keep NPO
• Continuous gastric aspiration
• Antibiotics as per sepsis protocol after taking blood culture (see
section 24.8.1).
• Complete workup for sepsis (see sections 24.4, 24.5, 24.6)
• Platelet count
• Stool for occult blood (APC 3C Pediatric Biochemistry- 9 to 11 am,
except Sundays)
• Blood gas for acidosis
• Serum electrolytes
• AXR (supine as well as lateral decubitus)
• Remove umbilical catheters (arterial & venous)
• Pediatric surgery opinion if suspected perforation
• Attempt feeds once gastric aspirates are nil for at least 24 h with soft
abdomen and good bowel sounds/baby starts passing stools.
31.4.2 Supportive care:
• Treatment for shock (see section 29.6), DIC (see section 19.5),
electrolyte imbalance (see section 8.8), acidosis (see section I 0.9.3),
apnea (sec section 13.4).
• Because of third space loss, patient may require !VF up to 200
mL/kg/d or more. Guide fluid therapy depending on urine output.
serum Na & blood urea.
• Replace gastric aspirates with N/2 saline with KCl (I mL/100 mL
fluid) every 12 h.
31.4.3 Suspected stage 3 disease: Management is shown in Figure 31.1
• Do abdominal paracentesis and send fluid for smear and culture. If
fluid is bilious or exudative, insert flank drainage 2.
• Monitor flank drainage with pre-weighed surgical packs (replace at
least twice daily) or with urine collection bag attached to drain site.
Replace flank drainage with NS every 12 hourly.
• Remove flank drain if drain output is nil for 48 h with improvement
in the patient's intestinal condition. (consider blockage of drain if
drain output is nil but intestinal condition fails to improve). Consult
pediatric surgery before drain removal/replacement.
31.4.4 Monitor progression
Progression of disease is likely during first 72 h after onset, hence
aggressive monitoring is required during that time
• Abdominal girth - 6 hourly
• Hemodynamic monitoring - continuously
• Supine and lateral decubitus AXR- 12 hourly for first 72 h and
thereafter as only as clinically indicated (look for fixed intestinal
301
Suspected NEC
!
Nil oral. Continuous gastric aspiration.
Antibiotics. Complete workup for sepsis.
Platelet count
Stool for occult blood
Blood gas for acidosis
Serum electrolytes
AXR (supine as well as cross table lateral)
Remove umbilical catheters
!
Stage 3 disease
Yes
..
l
No
Pediatric surgery opinion and
abdominal paracentesis
+
Perforation
+
lank drainage
Laparotomy
REFERENCES
I. Deshpande et al. PSANZ conference, 2009
2. Moss R Let al. N Engl J Med 2006; 25; 354: 2225
303
32.1 INDICATIONS
TPN should be reserved for babies m whom significant enteral nutrition
(>60 Cal/kg/d) is not possible. In the PGIMER unit the indications for
starting TPN are
• All ELBW babies (consider staning on day I itself) who are kept nil
per oral.
• Babies with BW 1-1.5 kg & not expected to receive significant
enteral nutrition for more than 3 d.
• Babies with BW > 1.5 kg & not expected to receive significant
enteral nutrition for more than 5 d
• Neonates with NEC (see section 31.2.1), surgical abdominal
conditions (see section 35.3)
• Short bowel syndrome
32.3.2 Proteins
• Crystalline AA solutions provide the protein requirements. Two
types of preparations are available in market: Aminoven (6% &
!0%) and Primene (10%).
• Start from day I of life at 2 glkg/d, as much as possible depending
1
on fluid allowance and access.
• Advance by I glkg/d to a maximum of 3 g/kg/d in term infants and 4
mglkg/d in preterm infants.
• AA yields 4 Cal per g. Do not include protein in the Calorie count.
• A rise in blood urea is not an adverse effect or sign of toxicity; rather
it is a normal accompaniment of increased protein intake. More
often, it is because of fluid deficit and fluid therapy should be
optimized.
• Hyperammonemia and metabolic acidosis are uncommon with
present day AA solutions.
• Restrict protein intake to 0.5-1 g!kg/d when there is oliguria
associated with serum creatinine > 1.5 mg/dL.
32.3.3 Lipids
• Lipid emulsions serve as an energy dense substrate besides
preventing essential fatty acid deficiency. lntralipid (10% & 20%) is
the available brand. I 0% lipid has an energy density of I.I Cal per
mL and 20% lipid of 2 Cal per mL.
• Lipids are usually started at the rate of I g/kg/d beginning within 48
h of life. Gradually increase by I g/kg/d until a maximum of 3
g/kg/d.
• The total amount for the day is to be given as continuous infusion
over 24 h.
• Infusion rate should not exceed 150 mg/kg/h (i.e. 3.6 g/kg/d)
• 20% lipid emulsions is to preferred over I 0% emulsions as higher
phospholipids content in I 0% interferes with TG clearance leading
to higher TG and cholesterol values.
• Clearance is monitored by measuring plasma TG levels. Maximal
acceptable level ranges from 150 to 200 mg/dL. If the value is
between 150 to 200 do not increase the dose and if it is above 200
mg/dL stop it altogether.
• IV lipid emulsions in the recommended infusion rate ( :> 150
mg/kg/h) do not seem to affect platelet number or function and
bilirubin displacement from albumin sites. However, one should
monitor TG level in cases of jaundice nearing DVET level and
severe thrombocytopenia.
• Serum TG value should be checked once lipids of 3 g/kg/d is
reached and subsequently at weekly intervals. It should also be
305
• Administer a weekly dose of vii K (0.5-1 mL/kg J.M.) and vii B12
(10 µg/kg J.M.).
• About 80% of vit A and 30% of vit D and E are lost during
administration owing to adherence to tubings and photodegradation.
Photodegraded MVI increases urinary peroxides. Protect MVI
containing solutions from ambient light by wrapping with opaque
paper. By adding the vit preparation into fat emulsion instead of AA-
dextrose mixture, vit losses can be reduced.
NaCl)
307
32.9 COMPLICATIONS
Besides infection and catheter related complications, following are the
important metabolic complications of parenteral nutrition
• Hypoglycemia, hyperglycemia, glycosuria, hyperosmolality and
dehydration are related to low or excessive carbohydrate infusion.
309
REFERENCES:
I. Thureen PJ. Pcdiatr Res. 2003;53:24
2. Mermel LA. Clin Infect Dis. 2009;49: I
311
Peroxisomal disorders
312
3.3 PRESENTATION OF IEM IN NEONATAL PERIOD: Shown in
Figure 33.1
IEM
+
l
Obtain plasma NH 3 - - - - - - O b t a i n pH and CO,
High
Obtain pH and C0 2
No™'i 1 j
i High Anion gap
acidosis
Normal Anion gap
l
Normal Anion gap
acidosis
Hypoglycemia
!
Urine for non glucose reducing substances;
if strong suspicion, send GALT
Presentl lAbsent
Galactosemia Ketones
lHigh
Premature Full-term No
Acidosis
+
THAM PC
+ acidosis
Absent Plasma AA
f'"'"'
Urine orotic acid
citrun,.in_e_ _ _ _ _ _c_.irlnine
wj +
Citrulline Citrulline
moderately markedly
CPS OTC elevated ASA elevated ASA
deficiencv deficiencv prtent abtent
Argininosuccinic Citrullinemia
aciduria
315
1
Organic
acidemia
Abnormal +---------
Organic
acid
~
Dicarboxilic!
aciduria Normal
• Glycogen storage
disease type- I
• Fructose l,6-DP
deficiency,
+-- Present ...,.._ Hypoglycemia
• PEP carboxykinase
deficiency i
Absent
• Respiratory chain defects
• Pyruvate carboxylase
i
• PDH deficiency
deficiency
• Pyruvate carboxylase
deficiency
Refractory myoclonic
j
Vomiting, Dysmorphic facies,
seizures/opisthtonus hypoglycemia, hypotonia, seizures,
jaundice, hepatomegaly, blindness
posture
sepsis
l
Non ketotic l l
Peroxisomal
hyperglycinemia Galactosemia disorders
• Admit in NICU
• Establish IV access, arterial line
• Adequate respiratory support
• Correct hypothermia, hypoglycemia &
Supportive care dehydration
• Correction of acidosis with NaHC0 3 [when
pH <7.22 & HC0 3 <14 mEq/L]
• Monitor electrolytes & blood gases
• Start antibiotics if sepsis is suspected
Reduce load on the • Keep NPO [stops exogenous protein]
affected metabolic • Start JV dextrose at 6 mg/kg/min
pathway
• Ensure adequate hydration & adequate
urine output
• Peritoneal dialysis• indicated if
o oliguria/anuria
Removal of toxic
o serum sodium> 165 mEq/L
metabolites
o persistent metabolic acidosis
o hyperarnmonemia > 400 µmol/L
o if no decrease in ammonia after 4 h of IV
benzoatc
•Vitamins [JOO times the daily requirement]:
3 mL ofNcurobion JM, once daily. Split the
Co-factor
dose as volume is too high for neonates.
administration ..
•Oral cam1hne Syrup 100-200 mg/d
[5 mL ~ 250 mg] (see section D22)
*DVET has no role
() Sex unspecified
O==D Consanguinous mating
,0 ,0 Deceased individuals
db Dizygous twins
••D
Affected individuals
A Monozygous tw·ins
n
Pruband
~
m Individuals
and generations Abortus (remale)
Yes
•
Lab confirmation if possible
(Karyotypc, DNA analysis or en7ymalic
testing)
No
Recognized
+ No
Treat as per organ involvement.
34.7 COUNSELING:
For general issues refer to chapter on 'counseling'. The risk of recurrence
will depend on the diagnosis.
325
Trisomv 21 Translocation
I I
Recurrence risk I% Do karyotyping of parents
REFERENCES:
I. Judith G Hall. Handbook of physical measurements. 2"0 Ed, 2007,
Oxford University Press US.
2. Nayler JR. J. orPostgrad Medicine 2003; 49: 256
327
Preoperative management
• Keep baby in a prone positio11 or lateral head end up to prevent
aspiration.
• Place replogle sump tube on continuous suction (<5 cm H20) to drain
the blind pouch.
• Avoid bag and mask ventilation and nasal CPAP/IMV to prevent
over-distension of the stomach. If the baby needs respiratory
assistance, intubate the infant.
• If the baby has severe lung disease and a distal TEF, ventilation of
the lungs may be extremely difficult because of the low resistance
through the fistula into the stomach and bowel. Notify Pediatric
Surgery immediately as the baby may need immediate closure of the
fistula or an emergency gastrostomy with placement of a distal
esophageal balloon to facilitate adequate ventilation.
• Examine infant carefully for other anomalies associated with
VACTERL or CHARGE or evidence of Down syndrome.
Postoperative management
• If a chest tube is in place draining the area of the anastomosis, do not
connect negative suction without consulting with the attending
surgeon. The chest tube is usually in place for 7-10 d until x-ray
studies show no leak at the anastomosis.
• Do not extubate until the baby is extremely stable on very low
ventilatory settings, because positive pressure mask ventilation must
be avoided to prevent transmission of pressure to the esophagus,
which may rupture the anastomotic suture line.
• If the baby needs to be reintubated, the most experienced person
should do this. Faulty (i.e., esophageal) intubation could result in
injury to the anastomosis.
• Leave the OG or NG tube in place until x-ray studies show no leak
at the anastomotic site, and attending surgeon agrees to removal of
the tube. If the tube accidentally comes out, do not reinsert tube
without consulting with the attending surgeon, as you may damage
the anastomosis.
• X-ray contrast study should be done at approximately I 0 d
postoperatively to assess for leakage at the anastomotic site prior to
starting oral feedings.
• Gastrostomy tube feedings and NG tube feedings may be started
earlier.
330
i
Vomiting, abdominal distension
and failure to pass meconium
I
!
ileus,
Duplication Absent distelnsion
cyst anus
DoAXR
ARM
More vomiting
Less abdominal dist
j
Prominent abd
distension
i
Surgery
i ;=r·
Upper GI series Calcification
Do contrast
i enema
Meconium
peritonitis
l
Therapeutic for SCLS,
meconium plug and
simple meconium ileus;
Surgery in other cases
.
T a bl e 35 6 In d"1cat1ons of sur2erv 1n NTD
•Open defects with no/minimal neurological
Immediate deficit
surgery • With impending rupture
• Recent leak (onerate after 24 h of antibiotics)
• Good skin cover
Delayed surgery • Infected defects or defects leaking for > 24 h
with no neurological deficit
• Infected or leaking defects with neurological
Contraindications deficit
• Neurogenic bladder or gross hvdroceohalus
REFERENCES
I. Moya F R. Semin Perinatol 2005; 29: 112
2. Neonatal Inhaled Nitric Oxide Study Group. Pediatrics 1997; 99:838
3. Weaver LT. Arch Dis Child 1993; 68: 317
339
Only those issues unique to ELBW babies are mentioned. For more
details. refer to the respective protocols.
36.2 HYPOTENSION
Up to 45% of ELBW infants have hypotension. Risk of hypotension is
high due to
• High JWL
• Loss of auto regulation & vasodilatation, low systemic blood flow
• Fluid shift (due to capillary leak), PDA
• Low adrenal reserves & poor adrenal response to stress
36.2.1 Management
• Administer 0.9% saline I 0 mL/kg over 30 min period (once)
• If there is inadequate response within 30 min or response not
sustained for at least 30 min, start inotropes
340
36.3 THERMOREGULATION
• ELBW infants lose heat through all avenues especially by
evaporation. This high evaporative loss may be up to 6 times higher
per unit surface area in comparison to a term baby. Additional losses
occur due to adhesive trauma to the skin.
• Methods to reduce heat loss:
• Increase ambient relative humidity up to 70-80%.
• Use double walled incubator or a Perspex heat shield in a single
walled incubator (see section 7.8)
• Use caps and clothing, even in an incubator
• Use portholes instead of opening the incubator door for
handling or procedures
• Use an extra heat source like a mobile heating lamp during
procedures.
• Waterproof the baby: This can be done in various ways:
o Food grade plastic film wrapped around the baby
o Clean plastic film stuck edge to edge above the infant in a
open care system
o Application of vegetable oils (e.g. sunflower seed oil). Use
oil sparingly as evidence in hospital settings is lacking.
36.6ANEMIA
Low iron stores, multiple blood tests & associated blood loss and rapid
growth make anemia an unavoidable complication in these infants.
36.6.J Measures to reduce the severity of anemia
• Plan investigations: Group the investigations for the next 12 h [by
the SR] including the volume of blood required and the timing of
sampling. Morning's elective sampling has to be planned by the SR
on the previous evening. This has to be clubbed with the emergency
sampling decision taken by the on-duty SR. The amount sampled has
to be duly recorded in the nursing observation chart.
343
• Preferably use arterial lines for •ampling. Do not use central venous
lines for drawing blood.
• Venous sampling: l n babies without an arterial line, a fresh
peripheral vein can be used for drawing blood after thorough aseptic
preparation of the skin. Approximate volume of blood by drop
method should be calculated and specified in the nursing chart.
Roughly 16 drops correspond to 1 mL.
• Use noninvasive monitoring wherever possible (pulse-oximeter,
transcutaneous devices) especially after initial 7 d of life or after the
acute disease process has settled.
36.6.2 Measures to reduce transfusion-acquired infections (see
section 17.6)
An ELBW infant, on an average requires 6 PRBC transfusions during a
hospital stay of 6 wks. The requirement for transfusion usually starts
from 2"' wk onwards.
• Send a blood sample 3 working days prior to the first BT for blood
grouping & cross matching. The blood bank will reserve a dedicated
unit for that baby. Satellite bags of the request volume will be
prepared using sterile connecting device (see section 17.7.1 ).
• Irradiation of blood: Currently there is no data to support mandatory
irradiation of simple PRBC transfusions in neonates. Irradiation may
be considered in ELBW infants undergoing DVET & transfusion of
blood from biologic relatives (see section 17.7.3).
• Leukoreduction: ELBW infants are in an immunocornpromised
state. Hence, CMV negative blood products are preferred. Routine
CMV antibody screening is not done in PGIMER. Hence,
leukoreduction using 3"' generation fiber mesh filters (to which
leukocytes adhere) can be used (PAL filter-SQ40 costing - ~ 1000),
depending on affordability. The filtered product should have less
than 5 x!0 6 residual WBC's (3-log reduction~ 99.9 % reduction).
36.8 NUTRITION
Due to excessive catabolism postnatally, enteral nutrition alone can never
provide the Calories required (I 00-120 Cal/kg/d) for growth in these
infants. Parenteral nutrition (starting at 80-85 Cal/kg/d) is essential for
growth (see chapter 32).
• Start parenteral nutrition on day I of life in all ELBW infants who
are NPO.
• Start trophic feeds (I 0 - 20 mL/kg/d) once stable and transition to
nutritional feeds depending on the tolerance.
• To facilitate uninterrupted PN, place a dedicated PICC. Under
aseptic precautions, PICC does not increase risk of infection.
Resuscitation comer:
1) Personnel: at least 2; one of them SR
2) Additional equipments: Pulse-oximeter, infusion pump,
polythene wrap, surfactant
LR ___.,. Precautions:
1) LR temperature: 28-30°C
2) Wrap (plastic) may be considered
3) Gentle PPV; avoid excessive pressure on head
4) Maintain Sp02 : 87-93% (not>95%)
5) If transfer expected :S30 min to NICU - do not start IV lines;
If delay anticipated - start dextrose infusion at 6 mg/kg/min
6) Consider prophylactic surfactant & start early CPAP (as
indicated)
7) Always wash hands and use alcohol hand rub
Pre-transport:
1) Check STABLE* & vitals
Transport ~ 2) ET intubation if mechanical ventilation anticipated
3) Ensure adequate communication with NICU
During transport:
I) Avoid jerks (risk of IVH)
2) Care of airway (obstruction, accidental extubation)
REFERENCES
1. Stevens TP, Blennow M, Myers EH, Soll R. Cochrane Database of
Systematic Reviews 2007; 4.
2. Dani C. J Maternal Fetal Neonatal Med 2010; (epub)
3. Ikonen RS, Janas M 0, Koivikko M J, Laippala P, Kuusinen E J.
Acta Pediatr 2008; 81: 802.
4. Pak C Ng. Pediatrics 2008; 122: 873.
5. Skelton R, Evans N, Smythe J. J Pediatr Child Health 1994; 30: 406.
6. Ohlsson A, Walia R, Shah S S. Cochrane Database of Systematic
Reviews 2008; Issue 1.
347
REFERENCES:
I. The !CROP revisited. Arch Ophthalmol. 2005; 123:991.
2. Jalali S. Indian J Ophthalmol. 2003 Mar;5 l :89-99.
3. Good WV. Trans Am Ophthalmol Soc. 2004;102:233.
350
38.1 INTROOUCTIO"I
OOP 1s a metabolic bone disease associated with decreased bone mineral
content in preterm infants. Preterm babies are prone for OOP as two
thirds of skelernnmneralization occurs in the last trimester of pregnancy.
~itiorus accret on 1s ffie pnnc1pal et10log1cal factor m the
development of OOP. Rou I half of ELBW and one-fourth of VLBW
babies develop radiological sign ofosteopenia if untreated.
38.3 DIAGNOSIS
Diagnosis 1s suggested b~rnical4 radiolog!sal a~hnic~feature~
38.3.1 Biochemical - - -
j i
• Scrum lllorganic phosphate < 4.5 mg/dLl
• Scrum ALP > 450 IU/dL __.l
38.3.2 Other helpful markers in cases of ambiguity
• Urinary calcium/ creatinine ratio (spot sample) >0.5
• Tubular reabsorpt1on of phosphate (TRP)=
I- Urine PO~ x plasma creatinine x I 00 (>95% 1s abnormal) I ~O
Plasma P04 x urine creatinine - l
38.3.3 X ray
Osteopenic infants may manifest after 2-4 wks of postnatal life.
Diagnostic findlllg include fraying and widenin of mctaphyses; s -
.£i!riosteal bone~. a_ ~s. he rad1ograph1c mdmgs
may not be visible until bone mineralization is reduced bif4@ Get X-
ray \\-TISt'chest done if clinical or b1ochenucal signs of osteopcnia arc
present. X ray should be repeated after 4 wks of therapy to document
resolution.
38.3.4 Dual x-ray absorptiometry (DEXA)- used to measure bone
density. It can diagnose early demineralization accurately and 1s the gold
standard diagnostic modality. DEXA is available in PGIMER but cannot
be used in pretcrm babies as the appropriate software for prctcrms is
currently not available and there is lack of normati vc data.
351
38.S PREVENTION
• Babies on pretcnn fonnuJa feeds (e.g. Lactodex-LBW) at the rate of
180 mL/kg/d do not need suppl ~mentatton.
• Babies on EBM require supp emcntation as pretenn milk cannot
fulfill Ca, P04 requirements \ ithout supplementation. From EBM
babies get 45-50 mg/kg/d of calcium and 20-22 mg/kg/d of P04 (see
section 9.11.3, 9.12).
o Calcium ( 148-232 mg/kg/11) and phosphorus (75-120 mg/kg/d)
must be given to all premature breast-fed babies (<34 wks of
gestation) in a ratio of 1.8: to 2: I .
o Supplement vit 0 in a dose of 400 500 IU/d (see section 047).
• Requirements in babies on TP1' are-
a Calcium 60-75 mg/kgtd
o Phosphorus 35-50 mgikg1cl. Parenteral phosphorus preparations
arc not yet available in India. Hence OOP 1s almost universal in
Indian preterm mfants on long-term TPN
38.6 TREATMENT
• Calcium I phosphorus supplementation- should be started m the
same doses as above and esca ated to maximum perrrussible. Syrup
Ostocalcium provides 82 mg elemental Ca, 41 mg of elemental
phosphorus and 200 IU Vit 0 'er 5 mL. A sachet of Lactodex-HMF
has 50 mg of calcium, 25 mg C'f phosphorus and 250 JU Vit 0 3• (see
section 9. 12)
352
• Vit D 400 U/d-1600 U/d is required in all babies. Starting doses can
be hiked to 1600 U/d if there is no response to small doses (as
assessed by weekly ALP levels). There is no evidence that higher
doses are beneficial. Vit D deficiency states require doses up to 5000
U/d.
• Physiotherapy- There is weak evidence from a metanalysis 1 that
physical activity programs might promote moderate short-term Wt
gain and bone mineralization in pretenn infants. Gentle
physiotherapy should be done.
38.6.1 Duration of therapy
Continue until there is radiological healing of rickets or biochemical
parameters return to normal. Usually it takes 2-3 mths.
38.8 PROGNOSIS
Prognosis is good in most cases with the resolution of osteopenia by 6-9
mths. The long-term effects of OOP, including the effects on bone
mineralization and stature during adolescence as well as the effects on
the risks of osteoporosis in adult life, remain unknown. Peak ALP level
of >1200 lU has been shown to be associated with reduced Ht at 12
years 2 .
REFERENCES
1. Schulzke S. Cochrane Database of Systematic Reviews2009; Issue
4.
2. Mary SF. J Pediatr 2000; 137: 668.
353
REFERENCES:
I. Narang A. Indian Pediatr. 2005;42:989.
356
them in the clinic for the first t', me after the death, express feelings
such as you are saddened and di> appointed.
{'
No autopsy Autopsy to be done No autopsy Autopsy to be done
t i t t
• ~urse will send body to • Nurse wi II send body to • Nurse \Vil! send body to • Nurse \\'iii c>-.:n..! !;.,..!J ·~
mortuary with no certificate. mortuary with I carbon copy mortuary with no certificate. mortuary with carbon
• Will simultaneously give certificate with "Release body • Will give original certificate copy certificate with
original certificate to parents only atler autopsy" written to parents with "Dues cleared. "Release body only after
with "Dues cleared. Release behind. Relea'}e body" written behind autopsy'' written behind.
body" written behind. • Will give original certificate once dues is cleared. • Will give original certificate
• Parents will collect body from to parents with "Dues cleared. • Parents will collect body from to parents with "Dues
mortuary after showing Release body after autopsy" mortuary after showing cleared. Release body after
original certificate. written behind. original certificate. autopsy" written behind
• Parents will collect body from once dues are cleared.
mortuary after showing • Parents will collect body
original certificate after from mortuary after
autopsy is done. showing original certificate
after autopsy is done.
362
This chapter deals with problems other than ROP. For ROP see chapter
37.
41.1 VISUAL PROBLEMS:
41.1.1 Whom to screen?
• All preterm neonates, especially those who received therapy for
ROP (see section 37.5)
• Symptomatic neonatal hypoglycemia
• Any infant found to be neuro-developmentally abnormal (see section
43.4.3) or suspected to have abnormality of vision due to any cause
on follow-up.
41.1.2 What problems can occur?
• Significant refractory errors
o Hypermetropia of> +3 D (diopters) is regarded as significant.
o High myopia defined as <-3 D) and slight myopia as >--3 D and
<OD.
o Astigmatism of>! D and of>2 D regarded as "significant" and
"high", respectively.
o Anisometropia defined as the difference in the spherical
equivalent between the eyes of at least 1 diopter. "Moderate" is
defined as"> I D and <2 D" and "high" is defined as ">2 D".
• Strabismus
• Decreased visual acuity
• Cortical blindness
41.1.3 When to evaluate?
• <34 wks and/or <1750 g BW: at 6, 12, 24 & 36 mths of corrected
age and as per the abnormality thereafter.
• Late preterm babies (34-36 wks) should have at least one
ophthalmological examination including retinoscopy between 6-12
mths and one after 24 mths.
41.4 PREVENTION:
• Ideally, as proposed by the US Environmental Protection Agency, a
noise level exceeding 45 dB must be avoided in the neonatal unit.
• Maintain silence. Avoid discussions at bedside.
• Give ototoxic drugs like aminoglycosides always by slow IV
infusion.
• Avoid combination of ototoxic medications like aminoglycosides
with Vancomycin and loop diuretics as they have synergistic
ototoxic effects.
• No tapping or writing on the tops of incubators and hoods.
• Careful closing of incubator doors
• Set desired and individualized alarm limits.
• Careful maintenance of equipments to avoid false alanns.
REFERENCES:
I. AAP, Joint Committee on Infant Hearing. Pediatrics. 2007;120:898.
2. Deorari AK et al. Ind Pediatr. ! 989;26:981-6
365
42. FOLLOW-UP
42.1 NFC
• All discharges for which NFC follow up is required are to be entered
in a diary, which is kept in the NICU office. JR's must ring up the
Newborn Unit office to get an appointment date for the Wednesday
NFC. At the time of discharge the JR must consult the SR and write
"To make NFC file" on top of the discharge booklet if a file has to
be made during follow up. The JR must ask the parents to bring
along a photocopy of the discharge summary during the first follow-
up visit.
• NFC's are held on Wednesday and Friday from 2 pm to 4.30 pm in
the Pediatrics OPD, level 3, D Block, APC.
• Wednesday NFC is meant for routine follow up, nutrition and
growth monitoring of high-risk babies. Friday NFC is meant for
detailed evaluation of babies with neurodevelopment abnormalities
detected during follow up and also for high risk babies at 36 wks and
40 wks postmenstrual age for neurological assessment; and at 3, 6, 9
and 12 mth corrected age for neurological and development
evaluation. Babies should be called strictly on prior appointment on
both days. Appointments will be given by SR-in-charge of NFC
(Room no. 3413, APC). For the next appointment, ring up the SR-in-
charge on his/her PGJ mobile. Just mention approximately when the
next appointment is required- e.g. "after 2 mths". The SR-in-charge
will provide the date and will make an entry in the appointment
diary. The SR-in-charge is also responsible for allocating patients to
various doctors in the NFC. Given these additional administrative
responsibilities, the SR-in-charge must allocate fewer patients to
himself/herself.
• Parents who are unable to come on the scheduled date have to ring
the Newborn Unit office (0172-2755318) to get a fresh date.
• Plot Wt and OFC at all visits ac, ording to corrected age in the charts
provided.
• Important issues during folio" -up are feeding issues (chapter 9),
weaning, vitamin and mineral s11pplementation, Wt gain, OFC gain,
neurological problems (chapter 43), development, hearing deficits
(chapter 41), visual deficits, ROP (chapter 37), OOP (chapter 38),
hyponatremia of prematurity, anemia of prematurity (chapter 17).
• Sampling for PCV is done in room no. 2406.
• For getting appointments for BERA & EEG send to APC-5A. For
CT and MRI send to Radiology reception.
• Discourage visits without appointment.
42.4.1 Specific responsibilities during Friday NFC
• Do complete neurological and developmental evaluation as per pro
forma in the file (see sections 43.1, 43.2)
• Physiotherapy, occupational therapy and play therapy services are
available in APC ground floor, room no 2416
• Consider referral to PRAYAS. Parents should be counseled
regarding simultaneous follow up in NFC.
Subjects who satisfy the criteria for high-risk follow up (see chapter 42)
are all candidates for neurodevelopnjental assessment.
43.2.2 Denver-II
There are 4 sectors- personal-social, fine motor-adaptive, language, and
gross motor. Testing begins with items that fall completely to the left of
the child's age line and continues to the more difficult tasks to the right,
irrespective of the age of the child. At least three items in each sector to
the left of the child's age line should be tested. All items intersected by
the age line should also be administered. Testing continues with items to
the right until three failures are obtained in each sector. The child may be
given up to three trials to perform each item. Items are scored as "pass,"
"fail," "no opportunity," or "refusal." The four "test behavior" ratings are
scored after the completion of the test. The test behaviors rated are
compliance, interest in surroundings, fearfulness, and attention span.
Denver II determines child's relative "advances" and "delays" in
development. A child who passes one or more items that have
distribution bars to the right of his/her age line is relatively advanced on
that item. Scoring a "pass," "fail," or "refuse" on items having the age
line intersect between the 25th and 75th percentile is considered to be
well within the normal range. Failing or refusing items having the age
line intersect the bar between the 75th and 90th percentile is cause for
concern and is classified "caution." A child failing one or more items that
have distribution bars to the left of the age line is relatively slow in that
area of development. The more items a child fails that are totally to the
let1 of the child's age line, the greater the likelihood that the child is slow
in development.
43.2.3 Assessment of passive tone on follow-up
371
The normal ranges of angles used in the assessment of passive tone are
shown in Table 43.2
43.4 CP
43.4.t Classification
Two major categories are spastic (pyramidal) and extrapyramidal. The
spastic group is further subdivided based on the pattern of body
involvement: quadriplegic, diplegic, and hemiplegic. The subdivisions of
extrapyramidal group are based on the type of movement disorder which
predominates: rigidity, dystonia, choreoathetosis and ataxia. Around IOo/o
are classified as mixed, displaying prominent spastic and extrapyramidal
features.
The critical feature characterizing spasticity is velocity dependent
increase of tone. The faster the attempt to passively move the joint, the
greater the resistance. Rigidity is characterized by consistent increased
tone unrelated to speed of movement or joint position.
43.4.2 Diagnosis of CP
• The diagnosis of CP is made largely through clinical observations.
The major signs that collectively suggest a diagnosis of CP are
delayed motor milestones, abnormal neurologic examination,
persistence of primitive reflexes, and abnormal postural reactions. It
is important to remember that although no single abnormal physical
sign is diagnostic, clusters of symptoms or evolving abnormal
movement patterns may be indications of CP.
• When calculating any developmental quotient in the first 24 mths of
age, correction up to 40 wks should be given for prematurity. A
motor quotient of :S70 is classified as motor delay.
• Significant in the neurologic examination are abnormali6es in
muscle tone, weakness, brisk deep tendon reflexes, clonus persisting
beyond 12 mths of age, and asymmetries in muscle tone or
functional abillties.
• The persistent of primitive reflexes is often the earliest clue to the
diagnosis of CP. Primitive reflexes should gradually disappear over
the first 6 mths. Prominent fisting, obligate positive support reflex,
and obligate asymmetric tonic neck reflex are suggestive of spastic
CP. Prominent Moro and tonic labyrinthine reflexes, especially
when they persist past 6 mths, are early markers for extrapyramidal
forms.
• Failure to develop protective reflexes such as the parachute response
also may be seen.
• Serial examinations are important to monitor progress when there is
suspicion ofCP. The diagnosis Often is easier if there is known brain
damage documented by cranial USG, CT scan, or MRI.
373
1.
i
Confirm that the history and examination does not suggest a progressive or
degenerative CNS disorder
2. Classify the type ofCP (quadriplegia, ataxic, etc)
3. Screen for associated conditions including:
a. MR (52o/o)
b. Ophthalmologic (28o/o)/hcaring impairments (12%)
c. Speech and language delay (38o/o)
d. Epilepsy (45°/o), obtain EEG ifh/o suspected seizure
e. Feeding/swallowing dysfunction
1~ l~
No need for further Obtain neuroimaging study
diagnostic testing (MRI preferred over CT)
!
Nonual MRI
I. Determine ifneuroimaging
abnonualities in combination with
A. Evidence of deterioration or evidence history and examination establishes a
of metabolic decompensation specific etiology of CP
B. No etiology detenuined by medical 2. If developmental malformation is
evaluation present, consider genetic evaluation.
C. Family hlo childhood neurologic 3. If previous stroke, consider evaluation
disorder associated with CP for coagulopathy or other etiology
• Positioning techniques
• Use of splints to maintain stretch/position properly. Contact
physiotherapy.
• Oral medications (Diazepam, Baclofen and others) (see section D41)
o Improvement in mobility and reduction of spasm related pain
o Results in drooling or drowsiness but may improve fine motor
skills
• Botulin um toxin (contact Prof. Dr. Prabhakar, the Head, Dept of
Neurology)
o Muscle relaxation by blocking the release of acetylcholine
esterase
o Decreases focal muscle spasticity, increasing mobility or motor
function without the systemic effects of oral muscle relaxants
o Remember: effects lasts from 2 to 6 mths only
o Physical therapy, serial casting, or use of splints can maximize
the benefits of Botulinum toxin
o Botulinum toxin can be used in children > 1 yr age with spastic
CP
o Requires repeated treatments. May result in muscle weakness.
• Baclofen pump (contact Dr. Prabhakar, Neurology; pump available
with Medtronics company, cost - ~ 2,50,000)
o Baclofen delivered into the spinal cord via a pump implanted
surgically
o Less medication is required which results in fewer adverse
effects
o Risk for infection and mechanical failure
• Surgery options
Selective dorsal rhizotomy permanently decreases spasticity. Dorsal
or sensory nerve roots of the lumbar spinal cord are cut with the
reduction in spasticity often leading to improved motor function. For
children without potential for ambulation, this treatment option may
facilitate ease of care and decrease the risk of contractures. Long-
term benefits versus risks of surgery need to be considered for each
patient. Procedure is done in PGIMER, AIIMS, and NIMHANS-
more often in the latter two institutions.
Possible
Problems Management
mechanisms
• Poor oral motor • Accurate Wt, Ht, OFC,
skills skin fold thickness
• ineffective measurement at each visit
swallowing • Determine the possible
patterns mechanism in each case
• pain due to • Calculate intake (protein,
esophagi tis Calories)
(Gastro- • Calorie dense food
esophageal reflux • Gastrostomy tube feeding
disease (GERD) in difficult cases
• dental issues
Malnutrition &
Inadequate • chronic
constipation
growth
• lack of
independence in
feeding
• need for extra
Calories
(spasticity or
choreoathetoid
movements)
• inability to
request food or to
indicate hunger
• Inability of • Nursing care
Pressure sores
posture change • Proper fitting splints
Friction
• Tight feting • Gloves
erosions
splints/casts
Thickening of
skin • Commando
crawling
Nystagmus, Yearly eye examination by
strabismus, a pediatric ophthalmologist
Visual refractory errors,
abnormality hemianopsia,
dyskinetic eye
movements
Hearing • Sensorineural • Audiological evaluation
problems hearing loss • Adenoidectomy
Sleep apnea • Large tonsils, • Check tvmoanic
376
Possible
Problems Management
mechanisms
Otitis media adenoids membrane at each visit
• Inability to tell
about ear pain
• Increased • Oro-motor therapy to
secretion of saliva close lips & swallow
• Poor lip closure effectively (done in PG!
• Inadequate jaw physiotherapy and Prayas)
Drooling
closure • Glycopyrrolate (currently
• Postural problems not available in India)
• Scopolamine patch (not
yet available in India)
Dental evaluation
(Pedodentistry, room no
202, 1" floor, Dept of oral
Dental caries Poor oral hygiene
health sciences, Monday,
Wednesday and Saturday 9
am)
Recurrent Ineffective cough, • Thickening of feed
pneumonia weak respiratory • Maneuvers (chin tuck)
Chronic muscles, recurrent • Pneumococcal/influenza
bronchitis aspiration, spasticity vaccines
asthma of chest wall
Motility Slow gastric • Erythromycin
problems emptying • Formula with fibers
Constipation
Voiding Timed toileting
dysfunction
Scoliosis Splints & braces
Progressive hip
adduction and
Orthopaedic consultation
flexion leading to
Hip disorders (contact Dr. P. Sudesh,
deformity of
Wed, APC SD, 9 am)
femoral head,
dislocation
Osteoporosis No Wt bearing Phvsiotherapy, walking
Anti-convulsants
Epilepsy
Sedatives: Melatonin,
Sleep problems
clonidine, diphenhvdramine
Behavior/ Consult Dr P Malhi (APC
emotional 2D, room no. 2414)
problems
377
REFERENCES
1. Amiel-Tison C, Gosselin J. Neurological development from birth to
six years- guide for examination and evaluation. The John Hopkins
University press, London.
2. Amie!-Tison C. Curr Prob! Pediatr 1976; 7: 1.
378
44. PAIN
Procedure Mana!!ement
Heel lance •Consider use ofvenepuncture, ifftequent
sampling is not anticipated.
•Breast feeding and/or KMC, swaddling, do
not squeeze
•Oral olucose
V enepuncture •Breast feeding and/or KMC, swaddling,
facilitated tucking
•Oral glucose
•If sampling is not urgent, apply Prilox
cream 60 min. before venepuncture
Arterial puncture & arterial •Facilitated tucking, swaddling
line •Oral olucose
IM/SC injection •Preferably avoid IM/SC injection, use IV
route
•Breast feeding
•Oral olucose
PICC line •Swaddling, facilitated tucking
•Oral glucose
• Prilox cream 60 min. before the nrocedure
Nonemergent intubation •Atropine 20 µg/kg over I min+ fentanyl 2
(Excluding INSURE) "o/k" over 2 min.
LP •Oral glucose
•Prilox cream at the site 60 min. before the
nrocedure
Chest tube •SC lignocaine 0.3 mL/kg of 1% solution+
IV morphine 0.1 mg/kg
•Oral paracetamol 6-8 hourly while the tube
is in situ
!umbilical catheter •Facilitated tucking. Avoid sutures or
hemostat clamps on the skin around the
umbilicus
•Oral !!]ucose
ET suction •Swaddling, facilitated tucking
Suprapubic urinary tap •Oral glucose
• Prilox cream at the site 60 min. before the
orocedure
383
Procedure IM anae•ment
Adhesive tape removal •We the edges with NS swab and keep
wettmg the taoe while removing
ROP screening •Facilitated tucking, swaddling
•Screen l -2 h post feed
•Oral glucose
LASER for ROP •KMC, Facilitated tucking, swaddling
before the procedure
•Local anesthetic drops (0.5% Proparacaine
eye drops- I drop administered once about I
min before the orocedure)
In intubated & sick neonates: depend more on individualized developmental
care, reduce light & noise and use momhine boluses selectivelv.
REFERENCES:
1. Ng E. Intravenous midazolam infusion for sedation of infants in the
neonatal intensive care unit. Cochrane review 2003: CD002052.
2. Bellu R. Opioids for neonates receiving mechanical ventilation.
ADC F&N 2009; doi: 10.1136/adc.2008.150318
3. Menon G. How should we manage pain in ventilated neonates?
Neonatology 2008;93:316.
4. Lago P. Guidelines for procedural pain in the newborn. Acta Pediatr
2009;98:932.
5. AAP policy statement. Prevention and management of pain in the
neonate: An update. Pediatrics 2006;118:2231
384
45.t FIRE
45.1.1 Information regarding fire
• In case of fire, immediately give infonnation to fire control room
(6101, 6110, 85-8905, 85-9101). Also, give infonnation to the
central complaint office ( 6341 ), nearby security guard, security
control room (6100), and to electricity department (6343, 85-9343).
Give exact location of fire and identify yourself.
• Also, infonn the PG! central oxygen plant (5889), central air
conditioning (AC) plant (5867), in-charge AC manifold room 85-
8887. In case of major fire inform main fire station, sector 17 (tel no
IOI, 2702333) or fire brigade sector 11 (no 2747820) or chief fire
officer (2703236).
45. 1.2 Switching off electricity
• In case of electrical fire, immediately switch off the main switch
(panel) that supplies that area. In case of any type of fire in any area,
remember to switch off all electrical appliances in the area.
• SEE MAP OF PGIMER NEWBORN UNIT AND FAMILIARIZE
YOURSELF BEFOREHAND WITH ALL THE MAIN SWITCHES
(figure 45.1 ). Take a walk around the unit and see the locations.
o The UPS is designated "A". Panels from B through E are
located in the NICU complex and panels from F through L are
located in the NNN complex. See Table 45. I for panels to be
switched off according to area of fire.
• In case the panels themselves catch fire, switch off the controlling
panels as shown in Table 45.2
~JI()
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.
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11~ •• •• ............... •
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387
45.3 EARTHQUAKE
• Do not panic. Open all exits to facilitate evacuation. Reassure
people, to prevent stampede. Tell them intensity of earthquake is
maximum at the onset and reduces thereafter.
• If possible leave the building; otherwise take cover under tables or
beds and protect head, face and torso.
• !vlove away from large objects, which may fall.
• After the shaking stops, assess your immediate surroundings fire.
Put out small fires if possible.
• Do not light match or turn on electrical switch. Use torch light.
• Assist others and initiate rescue efforts if necessary. Do not re-enter
a severely damaged building.
• Check utilities (power, gas supplies) and shut off if necessary. Never
touch hanging power lines. Only shut off gas ifthere is leak.
389
INVESTIGATIONS
Clean the site by triple swab technique .. Wipe dry with sterile gauze.
Dryness is essential to avoid hemolysis by alcohol or water. Make
puncture with lancet with tip shorter than 2.0 mm. Wipe off first small
drop of blood with a sterile gauze .Avoid "milking" or massaging as this
causes hemolysis and admixture of interstitial/intracellular fluid with
blood. Hold the collecting tube in a nearly horizontal position and allow
it to be filled. Seal the capillary tubes with clay sealant (plasticene) at one
end after col1ection.
392
Investigation Sample & Container Lab Reporting Units Normal Special instructions
volume values for
(before neonates
3.30 pm/ (Microtech
after 3.30l lab stdl
Tenn: 4.6-7.4
Serum g/ dL
Albumin Preterm: 1.8-
3.0
Tenn: 2.5-3.4
Serum g/ dL -TOtaf P~Ot~i~ ---
Globulin minus
albumin
BUN, mg/ ·see·ai;~.;e -----
crealmine & dl
- ~~t:C-~ly_t~~ - - - -
Calcium mg/ · 3:24 ·11:9 a:· ---
(total) dL 10.6
24-48 h: 7.0-
12
4-7 d: 9.0-10.9
>7 d: .8-10.8
Inorganic mg/ · a=s Cf:-4.s=s.2· -
phosphorus dL >5 d: 3.8-6.5
Magnesium Whole Plain vial Microtech lab. Same day mg/ 0-6 d: 1.2-2.6 Plan on previous day.
blood (0.5 Not done on holidays. 4pm dL >6 d: l.6-2.6 Sample to be taken and
mL) sent by night duty JR by
8 am
CRP (Hioh Whole Plain vial Microtcch lab. Same day ml!/ 0.50-3.00 Cut-off for bacterial
400
Investigation Sample & Container Lab Reporting Units Normal Special instructions
volume values for
(before neonates
3.30 pm/ (Micro tech
atrer 3.30) lab std)
occult blood stool Not done on holidays. 4pm positive/negati
(Hemospot sample ve.
card method)
Urine Urine 0.5 Plain vial Microtech lab. Same day mEq/ FENa (o/o)
electrolytes mL Not done on holidays. 4pm L Pre term
1001-1500 g Plan on previous day.
1-2 d 2.0±3 Sample to be taken and
8-9 d 1.3±0.2 sent by night duty JR by
15-16d: 8am
0.7±0.1
1501-2000 g
1-2 d 2.2±0.5
8-9 d 0.9±0.2
15-16d
0.3±0.1
2001-2500 g
1-2 d 1.1±0.2
8-9 d 0.6±0.2
15-16 d
0.15±0.1
Term
1-2 d 0.3±0.l
8-9 d 0.5±0. l
15-16 d
0.25±0.1
403
Investigation Sample & Container Lab Reporting Units Normal Spe<:ial instructions
volume values for
(before neonates
3.30 pm/ (Microtech
after 3.30) Jab std)
Urine spot Urine I ml Plain vial Microtech lab. Same day mg/ Preterm (5-30
Protein Not done on holidays. 4pm dL d): 88-845
Tenn: 94-455
manual
PT, 1.8 ml whole Special Coagulation Same day Timings: Coagulation lab (Mon to Sat. 9
APTT(aPTn& blood- to be 3.2% lab 4pm am -12 noon. Not done on holiday)
PTI added to 0.2 Sodiwn Emergency Emergency hematology lab (Mon to Sat -
ml Sodium citrate test hematology 12 noon to 9 am next day. 24 hon Sunday
citrate. Ratio tube lab after 3 h & holiday)
9:1 (procure
from lab\
406
Blood bacterial 1-3 mL 40mL Clinical Plating is Indwelling arterial catheters not to be
culture & whole blood BACTEC bacteriology done only used for sampling. Skin over sampling site
sensitivity. culture lab. after to be cleaned with triple swab technique
bottle Emergency overnight before sampling.
CSF and other body fluids ---<:ulture & I mL CSF/ Sterile test micro lab. incubation. Sterile syringe to be used for collecting
sensitivity Body fluid tube I vial Overnight blood. Blood to be pushed into culture
culture bottle without opening its cap by poking it
Urine culture & 2 mL urine Sterile test reports - with needle of the syringe.
sensitivity collected by tube I vial 2 pm on the Separate requisition forms to be sent along
suprapubic day after with samples if sensitivity pattern for
puncture platting. se<:ond line drugs is required.
Pus 1-2 mL Sterile swab Final Ask for plating on anaerobic media if
ET aspirates /sterile report- after anaerobic infections are suspected
Broncho-alveolar lavage (BAL) container 5 d of
ConjunctivaVbuccal/ plating.
wound swabs Any growth
gram stain, in mean
culture & time will be
sensitivity informed
immediatel
v by !ah.
411
Blood for fungal culture & sensitivity I mL in each 2 Fungal Mycology lab. Culture In case of fungal gro'Nth sensitivity results
pediatric culture Emergency results: will be available in another 3 d against
fungal culture bottles- to micro lab First report Fluconazole,
bottle be procured after I wk. Kctoconazole,
from lab. Final report Amphotericin B
KOH Smear, gram stain & culture for I mL sample In sterile after 4 wks. 5 Flucytocine &
fungus in I swab container I Smear Nericonazole
Urine swab results:
CSF Same day
BAL 3pm
ET aspirates
Conjunctival/buccal'
wound swabs
Fungal serology against 1 ml whole Plain vial Mycology lab After I wk
Candida, Aspecgillus niger, flavus & blood - serology
fumigatus section
AFB staining for mycobacterium. Depending on Mycobacteriol Routine
Mycobacteria site ogylab cultures -
-Routine culture after 6 wks.
-BACTEC culture (on all samples except BACTEC
blood & urine) after 2 wks.
VDRL titers in 3mL Plain vial STD lab Processing VDRL titers< I :8 reported as negative.
Blood I CSF Blood I CSF done only Quantitative titers will be given for values
twice >1:8
weekly on
Mondays &
- ----- - ------ --------- ---- -- --------- --------------
412
CMV pp65 antigen detection by IF l ml Fresh EDTA vial Viral serology Same day 4
whole blood lab pm
(<6 hold)
Urine for CMV inclusion bodies Equal volume Special vial Viral serology Next day
of urine as with lab
that of alcohol- to
preservative be procured
from lab.
CMV IgM Serology - ELISA 2 mLwhole Plain vial Viral hepatitis ELISA.o; Contact the lab for probable date of
blood lab done only reporting.
when 6-10
samples
Rubella lgM -by ELISA 2mLwhole Plain vial Viral hepatitis accumulate.
blood lab But are
done at
least once
in I wk.
Serology for varicella zoster lmL Plain vial Viral serology Only when
Blood I CSF - Blood/CSF lab kit is
By ELISA available.
Serology for parvo B 19 Check
Blood I CSF- availability
By ELISA before
sampling.
414
Hepatitis B complete profile (HbsAg, 2mLwhole Plain vial Hepatology Done only
anti HbsAg, HbeAg, antiHBeAg, HBc blood lab on selected
Ag) days
depending
on number
of samples.
Contact the
lab for
probable
reporting
date.
Ioxoplasma I mL whole Plain vial Pardsitology Done once
IgM I IgG / lgA levels by blood I CSF lab in I wk on
ELISA Wednesday
Blood/ CSF sonly.
Reporting
on
Thursdays
Animal inoculation for toxoplasma Placental Tissue in Parasitology 1·2 wks
tissues sterile NS lab
Malarial parasite I mLwhole EDTA vial Parasitology Same day 3
Peripheral smear blood lab pm
Antigen by spot
QBC
416
GH
Insulin
ACTH
Cortisol
Testosterone
Estradiol
AFP levels 2 mL whole plain vial Immuno After I wk
blood
--------- ---------- -- --- -------------- pathology lab
------- - - -
6 Human chorionic gonadotropin (HCG) 2 mL whole
levels blood
FSH~ folltcle sttmulatmg hormone, LH~ lutem1zmg hormone
418
Investigation Sample & Container Lab Sample acceptance timings Reporting Special instructions
Quantity
Required
---------
·uf~OUlld (Em;rg-eO-cY)- ------ -w~;k~ys s·pm-10· 9·a-m: saturdays-2 pm ·1~-9 am· -
Level II emergency block Sundays - round the clock.
Nehru hosoital
Doppler sn.idies (on prior Requisition to be sent to APC Ultrasound. Weekdays 9 am to 4 pm
appointment ) Procedure done at main USG room. Saturday 9 am to 2 pm
Closed on holidays
MCU Radiology, APC Weekdays 9 am to 4 pm
GIT contrast studies (only on Saturday 9 am to 2 pm
orior "nnnintment ) Closed on holidavs
ECG ECG Room (call for portable) Round the clock
Note that situations keep changing. Many investigations that are currently not done in PGIMER may become available in due
course. Investigations that are available in PGIMER must not be done from private laboratories, unless there are exceptional
circumstances, in which case the consultant Neonatology must write down the justification in the file. Under no circumstances
must any representative of a private lab be allowed to come into the hospital premises. The sample must be handed over to the
parents for transportation to the lab.
I-10.1 Laboratories that provide special investigations in Chandigarh (list is not exhaustive)
DI. ACETAZOLAMIDE
Indications: Hydrocephalus. Not recommended for PHH.
Presentation: 250 mg tablets, to be made into sachets. Store at room
temperature.
Dosage: Start with I0 mg/kg/dose q 6-8 hourly. Increase to 25
mg/kg/dose
Duration: As indicated by underlying condition
Administration: Oral
Comments: Causes G.I irritation, drowsiness, hypokalemia & acidosis
D2. ACYCLOVIR
Indications: HSV and severe Varicella zoster infections (CNS &
pulmonary) & herpes simplex encephalitis
Presentation: IV: 250 mg vial of I0 mL. Store below 25°C.
Oral syrup: 200 mg/5 mL concentration. Store at room temperature
Dosage: 20 mg/kg/dose q 8h
Duration: Localized Herpes Simplex infections - 14 d
CNS or disseminated infections - 21 d
Reconstitution: Add IO mL of WFI or N/S to the vial to make a 250-
mg/l 0 mL solution. Discard after use. Reconstituted solution is stable in
room temperature for 12 h. Do not refrigerate.
Dilution: Dilute the contents of the reconstituted vial to 50 mL with N/S
or N/4 saline to make a 250 mg/50 mL solution (5 mg/I mL dilution). 2
mL/kg ~ I 0 mg/kg
Administration: Syringe driver infusion over l hour.
Comments: The drug is metabolized in liver & excreted by the kidney
and the dose interval may need to be adjusted if there is renal impairment
or hepatic failure. Normal hydratioo to avoid crystalluria and renal
tubular damage.
D3. ADENOSINE
Indications: SVT involving the A-V node (re-entrant type)
Presentation: 6 mg/2 mL vial. Store below 25°C. Do not refrigerate.
Dosage : 50 µglkg/dose, increasing by 50 µg/kg with each dose until
there is reversion to sinus rhythm or the maximum dose of 250 µg/kg is
reached. I - 2 min between doses.
Dilution: Dilute 0.33 mL (I mg)/kg from the vial to 20 mL with N/S to
make a 1000 µg/kg/20 mL solution. I mL ~ 50 µg/kg. Solution
compatibility: 5% D, NS
Administration: Rapid injection at proximal cannula site. Flush IV with
saline immediately
Comments: Higher doses required for patients on theophylline. May
430
D4. ADRENALINE
Indications: Hypotension and circulatory failure not responding to other
drugs. Acute cardiocirculatory arrest.
Presentation: I: 1000 ampoule (1000 µg/mL). Store below 25°C. Protect
from light. Always use as a 1:10000 concentration (100 µglmL) (class
III)
Dosage : Low dosage 0.05 - 0.1 µg/kglmin. High dosage 0.2 -
µglkglmin
Dilution: First dilute 1 mL of the adrenaline in 9 mL N/S to make
1:10,000 solution. For low dose infusion dilute 1.5 mL (150 µg)/kg from
the ampoule to 50 mL with 5% D or N/S to make a 3 µg/kglmL solution.
I mL/h ~ 0.05 µg/kglmin. For high dose infusion dilute 6 mL (600
µg)/kg from the ampoule to 50 mL with 5% D or N/S to make a 12
µg/kglmL solution. 1 mL/h ~ 0.2 µg/kg/min. Solution compatibility: 5%
D, 10%0, NS
Administration: Syringe pump infusion.
Comments: Ensure adequate circulating blood volume. Concurrent
vasodilator therapy is usually necessary if a high dose is used.
D5. AMIKACIN
Indications : Gram-negative bacillary infection resistant to other
aminoglycosides
Presentation: I 00 mgl2 mL vial. Store below 25°C. 1
Dosage : S l 500 g babies in the first 7 d oflife: 7. 5 mglkgldose q 241'.J
All others: 15 mg/kgld~h
Dilution: Dilute 0.6 mL (30 mg) from the vial to 10 mL of N/S or 5% D
to make a 30 mgllO mL
solution. 2.5 mL/kg ~ 7.5 mglkg.
Solution compatibility: 5% D, 10% D, NS
Incompatibility: Cloxacillin, amphotericin B, phenytoin, ampicillin
Administration: Syringe driver infusion over 1 hour.
Serum levels: Peak 20 - 30 mglL; Trough 2 - 5 mglL.
Storage: Store at 2-30 °C.
Comments: Ototoxic and nephrotoxic; avoid concurrent use of
frusemide, vancomycin. Excreted by the kidney and the dose interval
may need to be increased if there is renal impairment, significant
asphyxia, PDA, lndomcthacin therapy. May prolong the action of
neuromuscular blocking agents.
431
D6. AMILORIDE
Indication: Chronic lung disease
Preparation: See hydrochlorothiazide
Dose: See hydrochlorothiazide
Comments: Potassium sparing, hence can cause hyperkalemia
D7. AMINOPHYLLINE
Indications : Apnoea of prematurity, Weaning preterm infants from
intermittent mandatory ventilation, BPD, PGE 1 induced apnea
Presentation: 250 mg/2 mL ampoule (IO mL). Store below 25°C.
Protect from light.
Dosage: Loading 6-8 mg/kg. Mamtenance 1- 2 mg/kg/dose q Sh
Dilution: Dilute 0.4 mL (I 0 mg) from the ampoule to I 0 mL with 5% D
to make a I0 mg/lO mL
solution. I mL/kg ~ I mg/kg
Administration: The loading dose is given by syringe driver infusion
over I hour. The maintenance dose is given by syringe driver infusion
over 20 - 30 min. Rapid infusion has been associated with marked
hypotension, syncope and death.
Plasma levels: Blood is collected 1 hour pre-dose. Therapeutic levels are
7-12 µg/mL
Comments: Reduce the doses in liver disease and heart failure. Adverse
effects- tachycardia, GIT irritation, hyperglycemia, CNS irritability.
Toxicity: failure to gain Wt, vomiting, and seizures. Treatment:
Activated charcoal Jg/kg as slurry by gavage tube q2-4 h.
D8. AMIODARONE
Indication: Supra-ventricular & ventricular tachyarrhythmias
Presentation: Supplied: Injection 50 mg I mL ampoules. Ampoules
usually 150mg. Tablet 200 mg
Dosage:
IV (only in emergencies): 5 mg/kg JV over I min, followed by infusion
of 5 µg/kg/min; infusion may be increased up to I 0-20 µg/kg /min. IV
continuous infusion concentration for peripheral administration should
not exceed 2 mg/mL and must be diluted with 05 W.
2
Oral: Loading dose of JO mg/kg/d, or 800 mg/J.72m Id for JO d,
thereafter tapering to maintenance of 2.5 mg/kg/d.
Administration: PO, JV
Comments: Amiodarone reduces clearance of Digoxin, Flecainide,
Procainamide, Quinidine, Sildenafil, Theophylline and Warfarin.
Monitor ECG, electrolytes, liver enzymes, thyroid functions, Chest X-
ray. May cause worsening of preexisting arrhythmia with bradycardia
and A-V block. Protect patient from sunlight for up to 3 mths after
stopping treatment using a Zn or Ti based sun block.
432
09. AMOXICILLIN
Indications: L1steriosis, Prophylaxis for UTI, Otit1s media
Preparation : Suspension 125 mg;5 ml. After reconstitution the
suspension should be refngeratcd but that is not essential. It can be used
for 14 d at room temperature.
Dosage
50 mg,kg;dose q 12 hourly in first 7 d PO.
50 mg,ikg/dose q 8 hourly in 2nd to 3rd wk PO.
50 mg/kg/dose q 6 hourly in 4lh wk PO.
Comments: In case of hypersensitivity to penicillin 1t should be 8\01ded.
lt is more completely absorbed than ampicillin. Can cause diarrhea.
010. AMOXICILLIN-CLAVULANATE
Indications: Acute bacterial LRI (pneumonia), UTI, Skin & Soft tissue
infections.
Presentation: (7: I formulation)
lnJ Vial 250 mg. (Amox1c1lhn 200 mg ... Clarnlamc acid 50 mg)
Syrup (Amox1c11lin 200mg + Clavulamc acid 28.5 mg/5 mL}
Dosage: 30 mg; kg of Amoxicillin. (<3 mths of age)
Interval: 12 hourly.
Storage of injection: Unconstituted: Store at less than 30°C.
Reconstituted'. 24 hat room temp .. 5 d at 4°C
Comments: Causes Diarrhea, skin rash, Urticaria Must not come in
contact with an aminoglycoside. Each 3 1.25 mg of Potassium clavulanate
has 0.16 mFq ofK.
D12. AMPJCILLIN ·.
Indications: Ampicillin together with an aminoglycoside (genramicin)
may be used for the treatment of suspected community-acquired early-
onset bacterial sepsis. Ampicillin has a broader spectrum of activity than
penicillin. It is useful against GBS, Listeria, susceptible E coli.
Ampicillin is preferred to penicillin for the treatment of listeria
monocytogenes sepsis.
Presentation: 250 mg, 500 mg vial. Store below 25°C. Suspension 125
mg/5 mL
Dosa e: m d
,;7 d >7 d
100-200 200-400
The higher dose is recommended for meningitis.
Route: PO, IM, IV
Interval
j,;7d
I 12 h
1;:d
Reconstitution: Add 1.7 mL ofWFI to the vial to make a 250 mg/I mL
solution. 0.5 mL/kg ~ 125 mg/kg. 5% D, 10% D, NS are compatible.
Administration: Slow injection at proximal cannula site.
Storage of injection: Unconstitutcd: Keep at less than 30°C.
Reconstituted: 24 h at room temp, 5 d at 4 °C.
434
Dl3. AMRINONE
Indications: Post-cardiac surgery, cardiogenic shock
Presentation: Injection: 5 mg/mL in 20 mL vial .
Dosage: Loading dose~ 1-3 mg/kg IV over 30 min. Continuous infusion
~ 5-10 µg/kg/min
Reconstitution: Do not dilute with Dextrose containing solutions.
Comments: Onset of action 2-5 min with peak effect in 10 min. Not to
be infused with frusemide. Monitor for thrombocytopenia,
hepatotoxicity, GIT effects, fluid and electrolytes.
DIS. AZITHROMYCIN
Indication: Active against a broad spectrum of organisms, including
most g +ve organisms, Hemophilus, atypical organisms, such as
Ureaplasma. Mycoplasma, Chlamydia and S typhi
Preparation: Syrup I 00 mL/5 mL
Dose: 6 mg/kg/dose
Interval: 24 h •
Duration: 3 d
Comments: Can cause diarrhea. Less gastric irritation and hepatic
adverse effects than erythromycin.
D16. AZTREONAM
Indication: Sepsis due to major gram negative pathogens like £. coli,
Klebsiella species, H. influenzae, Serratia species and Pseudomonas
aeruginosa. Ineffective against gram positive.
435
DI7. BUDESONIDE
Indications : BPD
Presentation: Respules containing nebulising suspension 250, 500 µg, I
mg /2 mL. Store below 25°C.
Dosage: 100 µg/kg/dose. Maximum dose~ 400 µg/d
Interval: 12 h
Dilution: Dilute the prescribed dose with N/S to give a total fill volume
of4 mL.
Administration: Nebulise for I 0 min and discard the remainder.
Comments: The effect on growth and adrenal function has not been
studied in newborn infants, though there is a favourable topical to
systemic effect ratio. The drug can also be administered using a metered
dose inhaler, spacer or face mask. May cause pharyngitis, cough, and
epistaxis.
D21.CAPTOPRIL
Indications: Congestive cardiac failure. Neonatal hypertension including
that associated with coarctation of the aorta.
Presentation: Tablets of 12.5 mg. To be reconstituted into sachets. Store
below 25°C.
Dosage : Test 0.05 - 0.1 mg/kg. Use the smaller test dose when the
infant is receiving other vasoactive drugs or diuretics.
Maintenance 0.1--0.3 mg/kg/dose. Commence maintenance at 0.1
mg/kg/dose and increase each day by 0.1 mg/kg/dose to 0.3 mg/kg/dose
depending upon the desired hemodynamic effects.
437
Interval: 8 h
Administration: Orally before feeds
Comments: Use with caution in patients with low renal perfusion
pressure. Reduce dose with renal in1pairment and in sodium and water
depleted patients. May cause prott"inuria, neutropenia, hyponatremia.
May cause hyperkalemia as it spares potassium at renal level.
D22. CARNITINE
Indication: Fatty acid oxidation defects, camitine deficiency, dilated
cardiomyopathies
Presentation: 330 mg per tablet. Make sachets.
Dosage: Carnitine deficiency: initial 50 mg/kg/d, mcrease to I 00
mg/kg/d. Max dose 3 g/d
Cardiomyopathy: initial 100 mg/kg/d, increase to 200 mg/kg/d
Interval: 24 h
Administration: Oral
Comments: Causes transient diarrhea
D23. CEFOPERAZONE
Indication: Systemic infections based on sensitivity report. Covers
Pseudomonas.
Presentation: 250 mg per mL vials
Dosage: 30 - 40 mg/kg/dose. IV bolus: Over 3-5 min. IV infusion: Dilute
to 20 mL, infuse over 20-60 min
Interval: 8 hourly
Reconstitution: I g diluted to 5 mL and subsequently to 15-20 mL with
any diluent except RL. For injection the final concentration should be
maximum of I 00 mg/mL. Wait till foaming subsides before injection.
Straw yellow colour does not indicate loss of potency.
Storage: Unconstituted: Store at less than 25 'C. Reconstituted: 24 h at
room temp., 5 d at 4°C.
Comments: Extensively excreted in bile, use with caution in patients
with hepatic failure. Does not penetrate well into CSF. Sodium contenF
1.5 mEq/g
D24.CEFOT AXIME
Indications: Active against many Gram negative organisms but not
Pseudomonas species. Good CSF penetration and therefore the drug of
choice for Gram negative meningitis.
Presentation: 125, 250, 500 mg vial. Store below 25°C. Protect from
light.
438
~\ 1 . tGY"'·
Dosa /k Id
>7 d
~1 ~°'! \A.
:£7 d
100-150 l 50-200
The higher dose is recommended for meningitis.
Interval
Gestation $7 d >7 d
Preterm 12 h 8h
Term 8h 6h
Reconstitution: Add 4.8 mL of WFI to the vial to make a 500 mg/5 mL
solution. Stable for 24 h in the refrigerator. l mL/kg = l 00 mg/kg.
Colour can become yellow without loss of potency; however dark brown
colour implies loss of potency.
Storage: Unconstituted: Store at less than 30°C. Protect unconstituted
product from light. Reconstituted: 24 h at room temp, l 0 d at 4 °C.
Administration: Slow injection at proximal cannula site.
Comments: Blunting of peak aminoglycoside concentration if
administered< 2 h before/after cefotaxime. Sodium content: 2.2 mEq/g
D25.CEFTAZIDIME
Indications: Active against many Gram-negative organisms including
Pseudomonas species. Good CSF penetration and therefore the drug of
choice for Pseudomonas meningitis.
Presentation: lg vial. Store below 25°C.
Dose And Interval (mg/kg/dose)
Wt <:1200 g 1200-2000 g >2000 g
Age Any <: 7 d >7 d <: 7 d >7 d
Dose 50 50 50 50 50
Interval 12 h 12 h Sh 12 h Sh
Reconstitution
Add 10 mL of WFI to the vial to make a 90 mg/mL solution. Shake to
dissolve and wait until the solution is clear (l - 2 min). Stable for 7 d in
the refrigerator. l.l mL/kg = 100 mg/kg. Yellow, amber or dark colours
do not indicate loss in potency.
Storage: Unconstituted: Store at 15 - 30°C. Reconstituted: 24 hat room
temp., 7 d at 4 °C, 3 mths frozen. Carbon dioxide is released as
ceftazidime dissolves, generating pressure within the container. A vent
needle should be inserted after the drug has dissolved.
Administration: Slow injection over 3-5 min. at proximal cannula site.
Comments: Sodium content: 2.3 mEq/g. Must not come in contact with
aminoglycosides, vancomycin or bicarbonate.
439
D26. CEFTRIAXONE
Indications: Broad spectrum antibio ic.
Presentation: 1 vial with dry substa 1ce equivalent to 0.25 g or 0.5g or 1
g ceftriaxone. (contains 3.5 mEq Na;•)
Dosage:
Wt :01200 g 1200-2000 g >2000 g
Age Any :s 7 d >7 d <7d >7 d
Dose 50 50 50-75 50 50-75
Interval 24h 24 h 24 h 24 h 24 h
Severe mfechons: 80-100 mgikg/d m 2 d1v1ded doses
Reconstitution:
IV injection: For IV injection, ceftriaxone 0.$ ~dissolved in 5 mL, and
ceftriaxone 1 g in 10 mL, of SWFI. The IV administration should be
given over two to four min.
IV infusion: The infusion should last at least 30 min. For IV infusion,
0.5 g ceftriaxone are dissolved in 10 mL (I0-40 g/mL) of one of the
following calcium-free infusion solutions: sodium chloride 0.9%, sodium
chloride 0.45o/o + dextrose 2.5%, dextrose 5%, dextrose 1Oo/o infusions,
sterile WFI.
Storage: Reconstituted solutions retain their physical and chemical
stability for 6 h at room temperature (or 24 h at 2-8°C). Store below
25°C.
Comments: Coombs' test may rarely become false-positive. False
positive tests for galactosemia. Incompatible with vancomycin,
fluconazole and aminoglycosides. Ceftriaxone can displace bilirubin
from serum albumin. Should not be used in neonates at risk of
developing bilirubin encephalopathy. Can cause biliary sludging
D27.CHLORAL HYDRA TE
Indications : Sedation.
Presentation: 100 mg/mL syrup. Store below 25'C.
Dosage
Hypnotic 50 mg/kg/dose
Sedative 5 - I 0 mg/kg/dose
Sedation for medical imaging 50 mg/kg
I ntervaI: 6 - 8 h
Administration: Oral. 1
1
Comments: Use with caution in the~resence of hepatic dysfunction
since use has been associated 'th both indirect and direct
hyperbilirubinemia. Repeated dosing at frequent intervals causes
accumulation of toxic metabolites. Causes irritation of skin and mucous
membranes because of its high osmolarity. \Contraindicated in renal and
hepatic impairment. \~
440
D28. CHLOROQUINE
Indication: Acute malaria- congenital or transfusion related.
Presentation: Suspension 50 mg/5 mL. Inj 40 mg/mL ampoule.
Dosage: 10 mg/kg stat followed by 5 mg/kg 6 h later, and OD for 2 d.
Comments: Avoid in severe liver disease. Parenteral injection can cause
hypotension, respiratory depression.
D29. CIMETIDINE
Indications: Reflux esophagitis. Treatment of gastric ulceration and
gastritis secondary to stress or indomethacin.
Presentation: 200 mg tablet. To be reconstituted into sachets. Store
below 25°C.
Dosage : 5 - I 0 mg/kg/dose. Commence treatment with the lower dose.
Interval: 6 h
Dilution: For oral administration dissolve one tablet (200 mg) in I 0 mL
of sterile water to make a 200 mg/10 mL solution. 0.5 mL/kg ~ 10 mg/kg
Administration: Orally with feeds.
Comments: Use with caution when hepatic or renal function is impaired.
Reduce the dose of theophylline by 50 % if used concurrently. Routine
use has been associated with increased respiratory infections.
Neutropenia, cholestasis and elevated transaminases are the side effects.
D30. CIPROFLOXACIN
Indication: Active against gram-negative bacteria including
Pseudomonas. Also active against gram-positive bacteria like Staph
aureus, Staph epidermidis.
Presentation: IV 200 mg/100 mL bottle. Tablets- 100 mg, 250 mg, 500
mg.
Dosage: 10 mg/kg/dose. No difference in meningitis.
Interval: 12 h
Administration: Infuse over 30-60 min
Storage: Store IV preparation at less than 30 °C
Comments: Several reports are now available showing safety in
neonates. There are reports confirming successful use of Ciprofloxacin in
neonatal meningitis. Use with caution along with Aminophylline, as
serum levels of Aminophyllinc may rise and cause toxicity.
D31. CLINDAMYCIN
Indications : Gram-positive coccal and anaerobic sepsis. First-line drug
combined with an aminoglycoside (gentamicin) in the treatment of
proven anaerobic sepsis.
Presentation: 300 mg/2 mL vial. Store below 25°C.
Dosage & interval
(mg/kg/ dose)
441
Wt <1200 g 1200-2000 g >2000 e
Age Any <7d >7 d <7d >7 d
Dose 5 5 5 5 5-7.5
Interval 12 h 12 h 8h 8h 6h
D32. CLONAZEPAM
Indications: Seizures not controlled with phenobarbitone and phenytoin.
Presentation: I mg/mL ampoule (with diluent). After reconstitution I
mg/2mL. Tablets: 0.5 mg and 2 mg.
Dosage: Intermittent: 0.05 - 0.1 mg/dose; Maintenance: 0.05 - 0.1
mg/kg/d
Interval: 8 h
Storage: Store below 25°C.
Administration: IV & Oral; If IV, give as slow injection at proximal
cannula site.
Comments: The therapeutic plasma levels: 60 - 150 nmol/L; May cause
respiratory depression; May cause hypotonia.
D34. CLOXACILLIN
Indication: Septicaemia caused by gram-positive bacteria including
MSSA
Presentation: 250-mg/ vials; 125 mg/5 mL Syrup.
Dosage: 25- 30 mg/kg/dose
Interval: 6- 8 h.
Storage of injection: Unconstituted: Store at less than 30°C;
Reconstituted: 24 h at room temp. & 7 d at 4 °C
Comments: Sodium content of IV preparation: 2.5 mEq/g. Can cause
442
D35.COLISTIN
Indication: MDR bacterial infections. No data on efficacy & safety in
neonates.
Presentation: Colistimethate sodium in vials containing 150 mg colistin
base.
Dosage: 5 mg/kg/d
Interval: 8 hourly
Reconstitution: With 2 mL WFI to yield 75 mg/mL base. Gently swirl
to avoid frothing
Storage: Reconstituted solution at 2-8 'C for 24 h
Administration: IV slowly over 3-5 min
Comments: Nephrotoxic
D39. DEXAMETHASONE
Indications: The use of post-natal dexamethasone {irrespective of
indication & dose regime) is controversial, because of major concerns
regarding poor neuro-developmemal outcome. It should be sparingly
used, after seeking i'1formed parental consent.
Preterm infants with BPD.
ET intubation injury with upper airway oedema and obstruction resulting
in repeated extubation failures.
Presentation: 4 mg/mL ampoule; Tablets: 0.5 mg tablets to be
reconstituted in sachets
Dosage: BPD: 0.89 mg/kg of cumulative dose over IO d
Peri-extubation: 0.25mg/kg/dose q 8 hourly for 3 doses, I" dose at least
4 h prior to extubation
Reconstitution: Dilute 1 mL (4 mg) from the ampoule to 4 mL with N/S
to make a 1 mg/mL solution. 0.5 mL/kg ~ 0.5 mg/kg
Storage: Store below 25°C.
Administration: Slow injection at proximal cannula site. The IV route is
preferred but the oral route may be used after the first 3 - 6 d.
Comments: Hypertension, hyperglycemia, GIT bleeding or perforation
and hypertrophic obstructive cardiomyopathy may occur. May cause
adrenal suppression, lowered immunity.
D40. DIAZOXIDE
Indications: Hypoglycemia secondary to hyperinsulinism, Hypertension
444
D41. DIAZEPAM
Indication: Status epilepticus/continuous refractory seizures,
sedation/muscle relaxation, hyperglycinemia
Presentation: 1Omg/2 mL ampoules
Dosage: 0.1-0.3 mg/kg/dose.
Comments: To be injected slowly, not to be mixed with other solutions.
The vehicle of diazepam contains sodium benzoate, and it displaces
bilirubin from albumin binding site.
D42. DIGOXIN
Indications: Congestive cardiac failure, SVT, congenital atrial flutter
and fibrillation.
Presentation: 50 µg/2 mL ampoule for IV injection. 50 µg/mL elixir for
oral use.
Dosa e
Term
Di italisation 30
Maintenance d
Interval: For Digitalisation: Give one-half of the digitalising dose stat
and the other one-half in three divided doses at 6 - 8 h intervals. For
Maintenance: 12 h
Reconstitution: Dilute 1 mL from the ampoule to 5 mL with WFI or N/S
to make a 25 µg/5 mL solution. 1 mL/kg ~ 5 µg/kg
Storage: Store below 25°C.
Administration: lflV- Slow injection at proximal cannula site; Oral.
Comments: The therapeutic plasma concentration is 1 - 2 ng/mL
Digoxin toxicity is rare when the plasma level is <3.5 ng/mL. Cross
reactivity may result in spuriously high levels in newborn infants.
Toxicity causes arrhythmias (usually supra-ventricular), sinus
bradycardia, heart block, vomiting.
044. DOMPERIDONE
Indications: Upper GIT motility disorders
Presentation: I mg/mL syrup
Dose: 0.3 mg/kg/dose
Interval: q 8 - 12 hourly
Administration: Oral
Comments: Anticholinergic agents reduce its effect
045. DOPAMINE
Indications: Circulatory failure. Oliguric prerenal failure- this is
controversial, as it has no effect on mortality. PPHN- controversial, as it
is likely to increase pulmonary artery pressures as well.
Presentation: 200 mg/5 mL ampoule. Store below 25°C.
Dosage: Always by IV infusion. low: I - 5µg/kg/min, increases RBF
and urine output; Intermediate: 5-15µg/kg/min, increases RBF, CO, HR,
BP; High: >15µg/kg/min adrenergic effects. In neonates (particularly
preterrns) cut-offs may not be as clear-cut.
Reconstitution: Dilute 0. 75 mL (30 mg)/kg from an ampoule to 50 mL
with 5% D or N/S to make a 30 mg/kg/50 mL solution. 1 mL/h ~ IO
µg/kg/min; Max concentration 3200 µg/mL
Storage: protect from light, solution slightly darker than yellow should
not be used.
Administration: Administration in UA catheter not recommended.
Stable in D 5%, NS
Comments: Ensure adequate circulating blood volume. Inactivated by
sodium bicarbonate. Extravasation 1nay cause tissue necrosis. Peripheral
tissue ischemia can be treated with 2% glyceryl trinitrate ointment 4
mg/kg. Adverse effects similar to dobutamine, except that tachycardia &
tachyarrhythmias commoner with dopamine. Cardiac effect antagonized
by p - blockers.
446
D46. ENALAPRIL
Indications: Treatment of moderate to severe hypertension, after load
reduction in newborns with CCF, asymptomatic LV dysfunction.
Presentation: Tablets 2.5 mg, IV: 1.25 mg/mL (1 mL & 2 mL vials)
Dosage: Oral: 0.05-0.1 mg/kg/dose OD, Max 0.5mg/kg (i over 2 wks);
IV: 5-10 µg/kg/dose 8-24hrly
Reconstitution: Crush 2.5 mg tablets and dissolve in 12.5 mL of sterile
water to yield final concentration of 0.2 mg/mL. IV infusion mixed with
NS, D 5%, and DNS
Storage: Store vials below 30°C
Comments: May cause renal failure in preterm infants. Use within 6 h of
use of ~ blocker not recommended. Displaces bilirubin from albumin.
May cause hyperkalemia- monitor electrolytes. Can cause angioedema,
neutropcnia, and hypotension.
D47. ERGOCALCIFEROL
Indications: Hypocalcaemia secondary to hypoparathyroidism. Difficult
to treat OOP.
Presentation: 60,000 JU per sachet & 5000 IU/mL
Dosage: Adequate intake - 400 JU/ d
Nutritional rickets, OOP-1000 -5000 lU/d
Hypoparathyroidism: 1.25 - 5 mg/d (50,000-200000 JU)
Interval: 24 hourly
Administration: Oral (any time). Slow onset of action and long half-life.
Comments: Use with caution in patients with renal impairment, renal
calculi. Ensure adequate calcium intake. Plasma calcium, phosphorus and
ALP should be monitored closely. Each µg ~ 40 JU.
D48. ERYTHROMYCJN
Indications: Infections with Chlamydia trachomatis, Bordete/la
pertussis, Ureaplasma urea/yticum and Mycopla':lrna pneumonia; as a
pro-kinetic drug in preterm babies with GER.
Presentation: 200-mg/5 mL (ethyl succinate) and I 00 mg/mL as drops
(ethyl succinate): for oral use
D osage:
Postnatal <7d >7d
Age < 1200 g 1200- > 2000 g
2000 g
Dose 20 20 30 30-40
(mg/kg/d)
Interval 12 hrlv 12 hrlv 8 hourly 6-8 hourly
447
D49. ERYTHROPOEITIN
Indications: Anemia of prematurity, Anemia of chronic disease.
Presentation: Without preservative: 2000, 3000, 4000, 10000, 40000
U/mL (1 mL)
Dosage regimens: (i) 25-100 U/kg/dose- 3 times/wk (ii) 100 U/kg/dose-
5 times/wk (iii) 200 U/kg/dose every alternate day for IO doses. Decrease
dose when target range reached or Hb increase > 1 g/dL in any 2 wk
period. Increase dose when Hb doesn't rise by 2 g/dL after 8 wks of
treatment and Hb is below target range. Stop therapy when Hb > 13 g/dL.
Re-initiate therapy with 25% lower dose after Hb decreases to target or
12 g/dL
Stability: Refrigerate. Single dose vial doesn't contain any preservative.
Multidose vials - stable for 2 wks at room temperature, for 2ld
refrigerated.
Administration: Do not shake. SC preferred. IV dilution I: I with NS
and infuse over 1-3 mins
Comments: Iron 3-6 mg/kg should be given during EPO therapy. Can
cause hypertension, edema, seizures, rash, neutropenia, hypersensitivity
reaction. Potentiates effect of diuretic and hypotensive agents.
DSO. ETHAMBUTOL
Indication: Bacteriostatic anti-tubercular drug used in treatment of TB in
conjunction with other antitubercular drugs.
Presentation: 200mg/400mg/800mg tablets
Dosage & Interval: 15-20 mg/kg 24 hourly
Administration: Orally on empty stomach
Comments: Can cause optic neuritis, use with caution in neonates.
448
Maintenance
D52.FLUCONAZOLE
Indication: Mucosal and systemic candidiasis, Cryptococcal meningitis
and as prophylaxis during Candida! epidemics
Presentation: 200 mg per 100 mL reconstituted vial, 50,100,150 mg
capsules and 50, 100, 150 mg tablets
Dosage: 6 mg/kg/dose
Interval
GA < 29 wks 30-36 wks > 37 wks
Postnatal age <14d[>l4d < 14 d I > 14 d <7d I >7d
Dosing interval n h I 48 h 48 h I 24 h 48 h I 24 h
Administration: Oral (absorpt10n ts excellent). IV slow bolus over 30
mm
Comments: Inhibits fungal cytochrome P450 enzyme lanosterol 14
demethylase and thus impairs ergosterol synthesis. Side effects include
vomiting, rashes. Avoid giving to a patient getting Cisapride.
D53. 5-FLUOROCYTOSINE
Indications: May be used together with amphotericin in the treatment of
systemic Candida sepsis, particularly when there is CNS infection or
persistent candidemia.
Presentation: Capsule: Not easi/v available. IV: Currently not available
in India
Dosage:
Preterm ..................... 100 mg/kg/d
449
D54. FLUDROCORTISONE
Indication: Maintenance therapy for adrenocortical deficiency states,
e.g. salt-losing CAH
Presentation: Tablets: 0.1 mg. To be reconstituted into sachets.
Dosage & Interval: 0.05 -0.1 mgik:g/dose 24 hourly
Administration: Oral
Comments: A synthetic corticosteroid with predominant
mineralocorticoid action. Monitor BP, serum electrolytes. Contra-
indicated in the presence of CHF
DSS. FRUSEMIDE
Indications: Congestive cardiac failure (CCF), Prerenal failure (RF),
BPD (not routinely recommended).
Presentation: 20 mg/ mL ampoule. Store below 25°C. Protect from
light. Tablets 40 mg. Store below 8°C. Do not freeze.
Dosage
CCFandRF
Single 0.5 - 2 mg/kg
Maintenance 1 - 2 mg/kg/dose
BPD
I - 2 mg/kg/dose
Interval
CCF and RF 8 - 12 h
BPD 48 h
Reconstitution: Reconstitute with NS or sterile water
Administration: Slow injection at proximal cannula site.
Comments: May cause osteopenia, nephrolithiasis, cholelithiasis,
hypercalciuria (chronic use), hypokalemia, volume depletion, contraction
alkalosis, hyponatremia, and ototoxicity. May open the ductus arteriosus
in infants with HMD.
D56. GANCJCLOVIR
Indication: Life-threatening or sight-threatening congenital CMV
infection
450
Presentation: 500 mg vial, lyophilized powder for injection and 250 &
500 mg capsules
Dosage & Interval: 6 mg/kg/dose, JV 12 hourly (reduce dose by half for
significant neutropenia (<500/mm)
Duration: Minimum of 6 wks
Reconstitution & Storage: Add 10 mL WFJ to 1 vial (500 mg) of
ganciclovir to make 50 mg/mL. Shake to dissolve and use promptly;
discard if particulate matter is visible; after reconstitution stable for 12 h
in room temperature; do not refrigerate. Dilute I mL (50 mg) of
reconstituted vial to 10 mL to make 5 mg/l mL; can refrigerate for 24 h.
Solution is compatible also with NS and 5%D.
Administration: Infuse over I h through infusion pump.
Comments: Do CBC every 2-3 d for first 3 wks, weekly thereafter if
stable. Keep the patient well hydrated. As undiluted product of
ganciclovir is very caustic (pH 11) use gloves and goggles during
reconstitution. Use soap and water to wash accidental contact with skin.
D57. GENTAMICIN
Indications: Gram-negative sepsis with susceptible organism.
Presentation: 20 mg/2 mL vial.
Dosage & Interval: 4 mg/kg/dose 24 hourly
Reconstitution: Dilute 1 mL from the vial to I 0 mL with N/S or 5% D
to make a 10 mg/ I0 mL solution. 1 ml/kg~ I mg/kg
Storage: Store at 2 - 30 °C
Administration: Syringe driver infusion over 30 min.
Comments: Serum levels should be measured on the fourth dose, if the
drug is to be given for longer than 48 h. Peak serum level is 6 - 8 mg/L
and trough level is <2 mg/L. Ototoxic and nephrotoxic, particularly
when used in conjunction with frusemide. Must not come in contact with
P-lactam antibiotics. heparin, frusemide.
D58. G-CSF
Indication: Severe neutropenia due to sepsis (ANC<lOOO/mm'l, severe
neutropenia due to maternal PIH
Presentation: 30- MU/0.5 mL in a prefilled syringe. Store between 2-8°
C. Do not freeze.
Dosage: 5-10 MU/kg SC/IV OD for 5 d
Administration: SC
Comments: When used for sepsis, there is a rise in ANC noticed within
48 h of administration. There is no convincing impact on mortality.
D59. GM-CSF
Indication: Severe neutropenia due to sepsis (ANC<I 000/mm\ aplastic
anemia, severe neutropenia due to maternal hypertension
451
D60. GLUCAGON
Indications: Refractory hypoglycaemia
Presentation: Lyophilised powder 1 mg vial + syringe prefilled with
WFI. l IU= 1mg. Store below 25°C.
Dosage: 200 µg/kg/dose IV push or SC (max. 1mg). Infusion: 5 - 20
µg/kg/h (rise in BS should occur within I hour of starting the infusion)
Reconstitution: Add the accompanying diluent to the vial of freeze-
dried glucagon. Dilute the contents of the reconstituted vial to 50 mL
with 10% D to make a 1000 µg/50 mL solution. 0.5 mL/kg/h = IO
µg/kg/h.
Administration: Syringe pump infusion.
Comments: Can cause nausea, vomiting, tachycardia, hyponatremia and
thrombocytopenia.
Enoxaprin:
1.5 mg/kg/dose twice daily
Monitor for anti factor Xa level after 4-6 h of first dose
Theraoeutic level- 0.5-1.0 umts/mL anti"factor Xa
Adjustment of maintenance by Anti factor Xa
<0.35 U/mL t bv 25% After 4 h
0.35-0.49 U/mL t by 10% After 4 h
1.1-2 U/mL .j, by 20-30% 24 h
064. HYDROCHLOROTHIAZIDE
Indication: Maintenance diuretic therapy for BPD. Can be used in mild
to moderate edema and hypertension.
Presentation: 12.5mg and 25 mg tablets. To be reconstituted into
sachets.
Dosage & Interval: 1-2 mg/kg/dose 12 hourly
Administration: Oral
Comments: Electrolyte imbalance hyponatremia, hypokalemia,
hypomagnesemia, hyperglycemia, hyperuricemia. Contra-indicated in
renal failure and hyperkalemia.
D65. HYDROCORTISONE
Indications: preterm neonate with refractory shock, neonatal
hypoglycaemia, hypoadrenocorticism, adrenal crisis.
Presentation: I 00 mg vial. Protect from light. Tablets: 20 mg. To be
reconstituted into sachets.
Store below 25"C.
Dosaee:
Hypoglycaemia JO mg/kg/d
Physiological 7-9 mg! m2/d
Adrenal crisis 25 - 50 mg/m2/d
Maintenance for CAH 20 mg/m2/d
Preterm with refractory shock 25 - 30 mg/m2/d
066, IBUPROFEN
Indications: Treatment of PDA, treatment of fever/ inflammation
Presentation: Oral suspension 100 mg/5 mL.
Dosa2e:
I 0 mg/kg stat, followed by 5 mg/kg q 24 h for 2
PDA
doses
Fever/inflammation 5 mg/kg q 6 h
Comments: Used with caution m mfants with thrombocytopema,
receiving anticoagulants or decreased renal, hepatic functions.
Contraindicated in NEC, evolving IVH, duct dependent lesions.
067. IMIPENEM-CILASTATIN
Indications: Serious infections resistant to other antibiotics.
Presentation: 250 mg vial. Store below 25°C.
Dosage & Interval: 25 mg/kg/dose 12 hourly
Reconstitution: Add 5 mL of N/S from a 25 mL syringe to a 250 mg
vial to make 250 mg/5 mL. Light to deep yellow colour does not indicate
loss of potency. Brown colour indicates loss of potency. Add the contents
of the reconstituted vial to the remaining 20 mL of N/S in the 25 mL
syringe to make a 250 mg/25 mL solution. 2.5 mL/kg ~ 25 mg/kg.
Storage: Unconstituted: Store at less than 30 °C. Reconstituted: 10 h at
room temp., 48 h at 4 °C, do not freeze.
Administration: Syringe driver infusion over 30 min
Comments: May cause convulsions. CSF penetration is poor and
therefore best avoided in the treatment of meningitis. Sodium content:
3.2 mEq/g Induces B-lactamase production by Gram-negative organisms
thereby leading to resistance to B-lactam antibiotics. Physically
incompatible with Amikacin, Gentamicin, Fluconazole, sodium
bicarbonate, lorazepam.
068. IMMUNOGLOBULIN
Indications: Early in the course of Rh isoimmunisation. Alla-immune
thrombocytopenia. Life threatening bacterial sepsis not responding to
specific antimicrobial therapy (benefit is marginal, the cost-benefit ratio
is high and utility against Indian strains of bacteria is unproven).
Presentation: Gamma IV: 0.5 g, 2.5 g & 5 g per vial. Do not freeze.
Protect from light. I mL ~ 60 mg IgG. Pentaglobin: 10 mL, 50 mL, 100
455
D69. INDOMETHACIN
Indications: Symptomatic PDA in preterm infants.
Presentation: Oral: 25 mg capsule. IV: l mg vial. Store below 25°C.
Protect from light.
Dosa e:
Short course 0.2 mg/kg/dose for 3 doses
Prolonged course 0.1 mg/kg/dose for 6 doses
Interval:
rl~~-S_h_o_rt~co-ur~se~~~~~~~-q-1_2_h~~~~
D72. ISONIAZID
Indications: Prophylaxis against TB. Treatment of TB
Presentation: Syrup ( 100 mg/5 mL), Dispersible tablet (1 OOmg)
Dosage & Interval: 5 mg/kg/dose OD
Administration: Oral
Comments: For prophylaxis always combine with Rifampicin. Duration
of prophylaxis 6 mths Pyridoxine supplementation is not needed in
infancy.
D73. ISOPRENALINE
Indication: PPHN. Congenital heart block. Cardio-circulatory failure.
Bradycardia not responsive to atropine.
Presentation: 2000 µg/mL ampoule. Store below 8°C. Do not freeze.
Protect from light.
Dosage: 0.05 - I µg/kg/min
Reconstitution:
6 x desired dose (ug/kg/mL) x Wt (kg)= mg drug
desired rate (mL/h) I 00 mL fluid
Administration: Syringe pump infusion.
Comments: Efficacy limited by its propensity to cause tachycardia.
Ensure adequate circulating blood volume.
D74. ITRACONAZOLE
Indication: Systemic fungemia, which is resistant to fluconazole, and
where oral therapy possible
457
D75. LIGNOCAINE
Indication: Local infiltrative anat•sthesia, pre-procedural surface
anesthesia (EMLA), ventricular armythmias (premature ventricular
complexes, VT, VF), resistant status epilepticus
Pre•entation: Injection: Xylocaine: 1% solution (50 mL vial), Xylocard
2% solution (50 mL vial)
EMLA cream: I g cream containing 25 mg lignocaine and 25 mg
prilocaine
Dosage:
Local infiltrative anesthesia: 0.3 mL/kg of 1% solution.
EMLA: 0.5 g applied to skin 45-60 min before procedure.
Arrhythmia & seizure: Stat dose: 1-2 mg/kg (0.1 - 0.2 mL/kg of
adrenaline free I% solution) IV slow bolus over 5 min. Can be given
through ET tube if no IV access. May be repeated after 5-IO min as
needed. Maximum total dose 5 mg/kg. 5 mg/kg IM injection will give
effective blood concentration in 15 min. Infusion: I 0-50 mcg/kg/min.
Taper after 12-36 h of starting infusion.
Reconstitution:
Bolus dose: N/S or 5% D
Infusion: 5% D
Administration: SC, IV, IM, ET
Comments: Toxicity includes hypertension, seizures (treatment with
diazepam, DVET) respiratory arrest, and arrhythmias (usually
bradycardia). Warning: use with caution in hepatic and renal disease,
because of potential of accumulation. Contraindicated in WPW
syndrome, severe sino-atrial, AV or intraventricular block EMLA may
raise methemoglobin levels.
D76. LINEZOLID
Indications
Activity against S. Aureus, S. Epidermidis, Clostridium difficile and C.
Perfringens is equivalent to vancomycin. Linezolid is highly effective for
resistant streptococcus pneurnoniae. Active against all enterococcal
isolates and other gram-positive. Ineffective against most gram negative
pathogens.
Presentation: Tablets containing 600 mg. Injections of 100 mL and 300
mL containing 2mg/mL (linospan, linox IV). Oral suspension (20
mg/mL).
Dosage & Interval: I 0 mg/kg every 8- 12 h.
458
D77. LISINOPRIL
Indications: Maintenance therapy of congestive cardiac failure which
has been treated with Captopril.
Presentation: 2.5, 5 and 10 mg tablets.
Dosage & Interval: 0.1 mg/kg/dose q 24 h
Reconstitution: Dissolve a 5 mg tablet in 5 mL of water to make a 5
mg/5 mL solution. 0.3 mL/kg = 0.3 mg/kg. Discard reconstituted solution
after each dose.
Administration: Oral
Comments: BP should be monitored when commencing treatment.
Hyperkalemia may occur. Plasma potassium should be monitored when
commencing treatment, particularly in infants receiving potassium
supplements or spironolactone. Azotemia may occur.
D78. LORAZEPAM
Indications: Treatment of seizures, after phenobarbitone and phenytoin
have been used
Presentation: 2 mL ampoule, 2 mg/mL; tablets- 0.5mg, 1mg, 2mg.
Dosage: 0.05-0. l mg/kg slow bolus over 2-5 min
Interval: May be repeated twice at 15-20 min interval for acute
management
Administration: For IV use dilute with equal volume of NS or 5%D
and give as slow bolus. Do not exceed 2 mg/ min. Can be given IM.
Comments: Do not use if injection is discoloured or contains precipitate.
Protect from light. Refrigerate injectable form and oral solution. Injection
is stable at room temperature for 8 wks. Three times more potent than
diazepam. Onset of action is within 2-3 min. of infusion, and action lasts
for 24 h.
D80. MANNITOL
Indications: Raised symptomatic ICP
Presentation: 20% Mannitol in I 00 mL, 250 mL, 500 mL bottles
Dosage: I gikg (5 mL/kg). Subsequent doses may be lower.
Interval: May be repeated once or twice at intervals of 4-8 h
Administration: Over 10-20 min as IV infusion through filter to trap
small crystals
Comments: Co-existence of congestive cardiac failure is a contra-
indication. Babies with HIE often have associated cardiac dysfunction.
Impact on survival and long-term outcome is not established.
460
D81. MEROPENEM
Indication: Serious infections resistant to other antibiotics, but not
effective against MRSA and enterococci.
Presentation: 500 g/l 000 g vial.
Dose And Interval (/kg/dose)
Wt :01200 1200-2000 g >2000 g
Age ,; 4 wk ,; 7 d >7 d ,; 7 d >7 d
Dose 20mg 20mg 20mg 20 mg 20
mg
Interval 24 h 12 h 12 h 12 h 8
mg
D82. METOCLOPRAMIDE
Indications: Reduces symptoms of gastro-esophageal reflux. Facilitates
nasojejunal intubation. Useful for insufficient maternal lactation.
Presentation: I 0 mg/2 mL ampoule. 1 mg/mL syrup. 5 mg dispersible
tablet.
Dosage:
Infants 0.1 - 0.2 mg/kg/dose
(Lower end of dose range for preterms, higher for term infants)
Lactating women I 0 mg/dose
Interval:
Preterm infants 8h
Term infants 6h
Lactating women 8h
Dilution: For IV administration dilute 0.8 mL (4 mg) from the ampoule
to 20 ml with 5% D or N/S to make a 0.2 mg/ml solution. 0.5 ml/kg~
0.1 mg/kg
Storage: Store below 25"C. Protect from light.
Administration: Slow injection at proximal cannula site. Orally 15 - 30
min before feeds.
Comments: Extra-pyramidal side-effects caused by metoclopramide can
461
D83. METRONIDAWLE
Indications: Anaerobic sepsis owing to sensitive Bacteroides and
C/ostridia species.
Presentation: 100 mg/mL in 100 mL bottle.
Dosage:
Loading: 15 mg/kg
Maintenance·
Postnatal age <7d ,, 7 d
Birth wt (k~) < 1.2-2 >2 < 1.2-2 >2
Dose (mg/kg/dose) 7.5 7.5 7.5 15
Dosing interval 24h 12 h 12 h 12 h
Commence 24 h after the loadmg dose m term infants and 48 h after the
loading dose in preterm infants. Higher doses have been used for
meningitis.
Storage: Store below 25°C. Protect ftom light.
Administration: Syringe driver infus10n over 10- 15 min.
Comments: Apparently well tolerated by newborn infants. Effectively
penetrates into the CSF. Newborns demonstrate a diminished capacity to
eliminate metronidazole. The elimination half-life inversely relates to
GA.
D84. MIDAWLAM
Indications: Sedation during mechanical ventilation. Status epilepticus.
Presentation: 5 mg/ml ampoule.
Dosage:
Bolus 150 - 200 µg/kg
Infusion 1 - 5 µg/kg/min
Dilution: For bolus injection dilute 0.4 ml (2 mg)/kg from an ampoule
to 20 mL with 5% D or N/S to make a 2000 µg/kg/20 ml solution. 1 mL
~ 100 µg/kg. For infusion dilute 0.6 mL (3 mg)/kg ftom an ampoule to
50 mL with 5% D or N/S to make a 3 mg/kg/50 mL solution, 1 mL/h ~ 1
µg/kg/min.
Storage: Store below 25°C.
Administration: Slow injection at proximal cannula site. Syringe pump
infusion.
Comments: May cause respiratory depression and hypotension. Use may
be associated with dependence.
462
D85. MILRINONE
Indications: Reversing the low cardiac output frequently observed in
infants and children after cardiac surgery:
Vu in Septic Shock: No data available in neonates In addition to its use
after cardiac surgery. milrinone may also be beneficial in the
management of low cardiac output resulting from septic shock.
Presentation: Milrinone is available in a I mg/ml concentration in 10,
20. and 50 mL single-dose vials, 5 mg/5mL sterile cartridges, and in 200
mcg/mL premixed 100 and 200 mL bags.
Dosage: Recommended loading dose of milrinone is 50 mcg/kg given IV
over 15 to 30 min. The loading dose may be reduced to 25 mcg/kg or
omitted in patients at risk for hypotension. Immediately after the load, a
continuous infusion of 0.375 to 0.75 mcg/kg/min may be started.
Administration of milrinone within this range should produce serum
concentrations above the minimum desired concentration of 100 ng/mL.
The maintenance infusion rate should be titrated to patient response.
Reconstitution: The loading dose of milrinone may be given undiluted
or diluted to 10 to 20 mL. For infusion, milrinone should be diluted to a
concentration of 200 to 400 mcg/mL with 5% D, 0.9% sodium chloride,
0.45% sodium chloride, or lactated Ringer's solution.
Comments: Milrinone is considered 10-30 times more potent than it's
parent drug Amrinone . After IV injection half life is 0.8 h.
D87. MUPIROCIN
Indication: Bacterial infection of skin (furunculosis, impetigo,
folliculitis etc)
Presentation: 2o/o ointment
Dose: Apply to affected areas 3 times per day. For JO d (maximum)
Comments: It can cause burning sensation, itching, stinging and dryness.
D88. NALOXONE
Indications: Reversal of narcotic depression.
Presentation: 400 µg/ I mL ampoule.
Dosage: 100 µglkg/dose
Storage: Store below 25°C. Protect from light.
Administration: Rapid injection at proximal cannula site.
Comments: The dose may need to be repeated because the duration of
action of naloxone may be shorter than that of the narcotic.
Cardiorespiratory monitoring should be continued for at least 6 - 8 h
after the administration of naloxone.
D89. NEOSTIGMINE
Indications: Reverse non-depolarising muscle relaxant. Diagnostic test
for neonatal myasthenia gravis.
Presentation: 0.5 mg/mL ampoule.
Dosage: 50 µg/kg
Dilution: Dilute 1 mL (0.5 mg) from an ampoule to 5 mL with N/S to
make a 500 µg/5 mL solution. 0.5 mL!kg ~ 50 µg/kg
Storage: Store below 25°C. Protect from light.
Administration: Slow injection at proximal cannula site.
Comments: Atropine is usually required to reverse muscarinic effects.
D90. NETILMICIN
Indication: Susceptible gram-negative infections
Presentation: Ampoules I 0 mg/mL and 25 mg/mL
Dosa e:
Interval: 24 hourly
Reconstitution: To 2 mg/mL by diluting with NS/5% D/10% D
Storage: Stability of reconstituted product - 72 h in the refiigerator
Administration: Over 30-60 min by syringe driver
Comments: Ototoxicity at serum peak cone. > 12 µg/mL, nephrotoxicity
at serum peak cone. > 4 µg/mL. Ideally, draw serum levels around 4'"
464
maintenance dose and adjust dose. Monitor renal functions before and
during therapy and BERA after completion. Avoid simultaneous
treatment with Frusemide. Must not come in contact with 13-Iactam
antibiotics, heparin and frusemide.
D91. NEVIRAPINE
Indications: Mother-to-child transmission of HIV during labor and at
birth (prevention)
Presentation: 200 mg tablets. Oral Suspension: 50mg/5mL
Dosage: If the mother received NVP IP, then give the infant a single
dose of oral NVP (2 mg/kg) within 48 to 72 h after birth. If the mother
did not receive NVP IP, then give the infant a single dose of oral NVP (2
mg/kg) as soon as possible after birth.
Storage: Tablets and Oral Suspension should be stored at 15°-30°C
Comments: Adverse reactions arc hepatitis/hepatic failure, Stevens
Johnson syndrome, toxic epidermal necrolysis, and hypersensitivity
reactions, eosinophilia, granulocytopenia. Co-administration of
clarithromycin, rifampicin, fluconazole, ketoconazole may result in
decreased plasma concentrations of these drugs and attenuate their
therapeutic effects.
D93. NITROPRUSSIDE
Indications: Systemic arterial hype1tension. Congestive cardiac failure.
Presentation: 50 mg/mL vial.
Dosage: 0.5 - 8 µg/kg/min. Commence treatment at 0.5 µg/kg/min and
increase by 0.5 µg/kg/min every 15 - 20 min until there is a satisfactory
response, complications occur or the maximum dose of 8 µg/kg/rnin is
reached.
Reconstitution: Dissolve the powder with 3 mL of 5% D to make a 50
mg/3 mL solution. Dilute 0.18 mL (3 mg)/kg from the reconstituted vial
to 50 mL with 5% D to make a 3 mg/kg/50 mL solution. 1 mL/h ~ I
µg/kg/min
Storage: Store below 25°C. Protect from light.
Administration: Syringe pump infusion using black opaque infusion
tubing.
Comments: Measure thiocyanate levels if use is prolonged (>3 d).
Symptoms of toxicity (seizures, muscle spasms and vomiting) appear at
5-10 mg/dL. Treatment should be discontinued iflevels are >12 mg/dL.
Cover solution with aluminium foil to protect it from light. Discard after
24 h. May cause tachycardia. Ensure adequate circulating blood volume.
Concurrent use of an inotropic drug is recommended.
D94. NORADRENALINE
Indications: Cardiogenic shock following cardiac surgery.
Presentation: 1 mg/mL solution in 2 mL ampoule.
Dosage: 0.05 - 1 µg/kg/min
Reconstitution: Dilute 0.15 mL ( 150 µg)/kg from an ampoule to 50 mL
with 5% D to make a 150 µg/kg/50 mL solution. 1 mL/h ~ 0.05
µg/kg/min.
Administration: Syringe pump infusion.
Comments: No published data are available regarding use in newborn
infants. Ensure an adequate circulating blood volume. Concurrent use of
a vasodilator drug is usually necessary. Incompatible with sodium
bicarbonate.
D95. OCTREOTIDE
Indications: PHH!, Insulinoma, GVHD induced diarrhea, post- operative
chylothorax.
Presentation: IV: I mL ampoules in 3 strengths- 50 µg, 100 µg, 500 µg
Dosage:
PHH!: 1 - IO µg/kg/dose 12 to 24 hourly (IV/SC). Individualize dose
depending upon patient response with decreasing time interval (4-6
hourly). Maximum dose: 40 µg/kg/d.
466
GIT Bleed: I µg/kg bolus followed l µg/kg /hour infusion. Taper dose to
50% every 12 hour when no active bleeding for 24 hour. Discontinue
when dose is 25% of initial dose.
Chylothorax: 1 - 4 µg/kg /hour continuous IV infusion.
Storage: store in refrigerator, protect from light. Stable in NS for 4 d and
5% D for 24 hat room temperature. Not compatible with TPN solutions.
Comments: Can cause hypertension, CHF, bradycardia, arrhythmia,
seizures, hyperglycemia, hypothyroidism, fat malabsorption, elevated
liver enzymes, j CPK, biliary obstruction, cholecystitis, cholelithiasis.
Chronic use associated with ! vit B 12 levels and GH suppression.
D96. PANCURONIUM
Indications: Muscle relaxation for extremely difficult controlled
mechanical ventilation.
Presentation: 4 mg/2 mL ampoule.
Dosage:
Bolus ........................ 50 - 100 µg/kg
Infusion .................... 25 µg/kg/h
Reconstitution: For bolus injection dilute one ampoule (4 mg) to 8 mL
with WFI to make a 4 mg/8 mL solution. 0.1 mL/kg ~ 50 µg/kg. For
constant infusion dilute 0.625 mL ( l.25 mg)/kg from an ampoule to 50
mL with 5% D or N/S to make a 1.25 mg/kg/50 mL solution. I mL/h ~
25 µg/kg/h
Storage: Stable at 25°C for six wks. If stored in refrigerator may be kept
until the designated expiry date.
Administration: Slow injection at proximal cannula site. Syringe pump
infusion.
Comments: Monitor HR and BP. Infant may require increased Fi0 2
and/or ventilation. Fluid balance requires careful attention.
D97. PARACETAMOL
Indications: Postoperative analgesia in term and preterm infants. May be
used alone or combined with a narcotic analgesic
Presentation: 125-mg/5 mL oral syrup. 150 mg/mL oral drops. Rectal
suppository: 80 mg, 170 mg
Dosage;
467
098. PENICILLIN G
Indications: Many Gram positive organisms including Group 8 13-
haemolytic streptococcus, Streptococcus pneumoniae, Clostridium
welchii and non-j3-lactamase producing Staphylococcus aureus.
Penicillin (or ampicillin) and an aminoglycoside (gentamicin) is
recommended for the treatment of suspected EOS.
Presentation: 500,000 and 10,00,000 units per vial. Store below 25°C.
D osa2e:
Age <'. 7d
Age > 7d
D99. PH E1'0BARBITONE
Indications: Neonatal seizures, treatment of prolonged jaundice.
Presentation: 200 mg mL ampoule, 20 mg/0.5 mL ampoule. 20mgi5
~oral suspension. - - -
Dosage:
Anti conrnlsant· Loading - 20 mg leg for seizures, single dose. If seizures
are not controlled give additional 5mg/kg at 15-30 mm intervals till
seizures are controlled or max dose of 40 mg· kg achieved. Maintenance -
3-5 mg. kgti;l OD.J 2 h after loading dose.
Jaundice: Loading - I 0 mg/kg; Maintenance - 5 mg/kg/d OD for 4 d
Administration: Compatible with D5°10 and NS. The loading dose is
given by syrmge driver infusion over 20 - 30 min. Don't inject fas ter
than I mg/kg min with a maximum of 30mg/min. The maintenance dose
is given by slow injection at the proximal cannula site.
Storage: Store below 25°C. Protect from light. Not stable in aqueous
solution. Use only clear solution.
Comments: Plasma levels: 40 - 80 µmol/L Effect. Oral Onset of
action- 20-60mins. Durauon 6-10 h; IV Onset of action- 5 mins.
Duration - 4 -10 h
Comments: Adverse Effects - Hypotens1on. drowsiness. skin rash,
megaloblastic anemia. hepat1t1s, respiratory depression Decreases
concentration of lamotrigine. warfann, chloramphenicol, P-blocker,
theophylhne, conicosteroids. Levels increased by valpro1c acid and
chloramphemcol. CNS depression synergistic with bcnzodia7cpincs.
DJOt. PHENYTOIN
Indications: Sci?Ures not controlled with phenobarb1tone.
Pre entation: 100-mg:2 mL ampoule. 25 mg mL oral suspension.
Dosage: Loading dose. 15-20mg/k:g;dose single m dtvf<1Cd: Maintenance
dose: 12 hour aficr loadin'l_S mg kg/din 2 divided doses (max 8mg/kg/c!l
Dilution: Dilute 1 mL (50 mg) from an ampoule to, 0 mL with N S to
make a 50 mg/10 mL solution. 4 mL/kg = 20 mg/kg
Administration:
The loading dose 1s given by syringe driver infusion over 20 30 min.
The maintenance dose is given by slow injection at the prox imal cannula
469
site. IV infusion rate max 0.5mg/kg/m in IV injection to be followed by
NS flush.
Storage: Store below 25°C. Stability Use parenteral solution till not
hazy. Do not mix with other medicin<:s. Compatible with NS and RL.
Infusion should start within I hour of preparation. Diluted solution
should not be refrigerated. Discard 4 h after preparation.
Comments: Plasma levels: 40 - 80 µmol/L. Adverse Effects: Lethargy,
nystagmus. Arrhythmia, hypotension, bradycardia with IV route,
hirsuitism, coarse facial features, S-J syndrome, megaloblastic anemia,
blood dyscrasia. Hold feed 2 h prior and 2 h after drug. Avoid giving Ca
and Mg supplements with phenytoin, spacing by :0:2 h. The HR should be
monitored during IV administration.
0103. PREDNISOLONE
Indications: Chronic lung disease presenting like asthma, immune
thrombocytopenia
Presentation: Tablets: strength 5 mg, lO mg, 20 mg. Syrup 5 mg/5 mL
Dosage: 0.5-2 mg/kg/d
Interval: 6-8 hourly
Administration: Oral
Comments: Adverse effects are hyperglycemia, hypertension, gastritis.
DI04. PROPRANOLOL
Indications: Hypertension, PSVT, cyanotic spells
470
D107. PYRAZINAMIDE
Indications: Congenital/ neonatal TB
Presentation: Tablets 250 and 300 mg
Dosage: 30 mg/kg/dose
Interval: 24 h
Administration: Oral. During l" 2 mths of ATT
Comments: Monitor hepatotoxicity
Dl08. PYRIDOXINE
Indications: Therapeutic trial in neonatal seizures, which may be the
result of pyridoxine dependency.
Presentation: Tablets of 100 mg, 50 mg/mL ampoule.
Dosage: 50 - I 00 mg once daily
Storage: Store below 25°C. Protect from light.
Administration: Rapid injection at proximal cannula site, oral
Comments: The effect on seizures should be evaluated using EEG
monitoring. Seizures cease and the EEG becomes normal within minutes.
D109. PYRIMETHAMINE
Indications: Congenital toxoplasma infection
Presentation: 25 mg tablets
Dosa e
/dose) Interval
<6 mths 24 h
6-12 mths 48 h
Administration: Oral
Comments: Combine with Suphadiazine 100 mg/kg/d .. Give Folinic
Acid (Leucovorin) 5-10 mg three times a wk. Adverse effects include
leukopenia, thrombocytopenia, megaloblastic anemia, anorexia,
472
Dl 10.RANITIDINE
Indication: GERD, Upper GIT bleeding, Hypersecretory conditions
Presentation: Ampoules 25 mg/mL, Tablets 150 mg
Reconstitution: IV 2.5 mg/mL with NS/5% D/10% D. Stability at room
temp 48 h
Dose and Interval
IV : 1 mg/kg/dose q 6 h
PO: 1-2 mg/kg/dose q 12 h
Administration: Over 5 min
Comments: Increased colonization with pathogenic bacteria and yeast,
Constipation, sedation, tachycardia.
Dlll. RIFAMPICIN
Indications: Congenital/ neonatal TB
Presentation: Suspension I 00 mg/5 mL
Dosage: 10 mg/kg/dose
Interval: 24 h
Administration: Oral
Comments: Orange discoloration of body fluids. Hepatotoxicity,
vomiting, blood dyscrasias, eosinophilia, elevated BUN. renal failure.
Induces hepatic drug metabolising enzymes and reduces activity of
steroids, digoxin, opioid, phenytoin, Phenobarbital, theophylline.
D112. RESONIUM A
Indications: Hyperkalemia (plasma potassium >7.0 mmol/L).
Presentation: Powder. Store below 25°C.
Dosage: 1.0 g/kg
Interval: 4 - 6 h
Dilution: Dissolve the powder in 4 mL/kg of 10% D.
Administration: Retention enema.
Comments: May cause constipation. Nonselective cation DVET.
Therefore monitor plasma calcium and magnesium as well as potassium
and sodium.
Dll3. SALBUTAMOL
Indications: BPD (BPD) with reversible bronchospasm.
Presentation: Respirator solution 0.5% (5 mg/mL). Store below 25°C.
Dosage: 0.1 mg (0.02 mL)/kg/dose
Interval: 6 h
473
Dilution: Dilute the prescribed dose Hith N/S to give a total fill volume
of4 mL.
Administration: Nebulise for IO min ind discard the remainder.
Comments: There are limited data r"garding use in infants with BPD.
Can cause hypokalemia, tachycardia
Dll4. SILDENAFIL
Indications:
PPHN
Presentation: Tablets 25 mg 50 mg I 00 mg
Dosage: Initial dose should be 0.25-0.5 mg/kg/dose q 4-8 h. Increase by
0.25 mg per dose. Doses are titrated on response. Maximum dose is 2
mg/kg/dose every 4 h.
Storage: Store at l 5-30°C
Comments: May lead to a fall in systemic pressure. Medications, which
inhibit cytochrome 3A4, will enhance activity of sildenafil
(erythromycin, clarithromycin, ketoconazole and protease inhibitors)
Medications which induce the cytochromes 3A4 enzymes will or may
decrease activity of sildenafil. Rifampin, carbamazepine, fosphenytoin,
phenytoin, Phenobarbital.
Dll6. SOMATROPIN
Indications
Long term treatment of GH for lack or inadequate endogenous GH,
Prader Willi syndrome, SGA babies with failure to catch up growth by 2
yrs of age, Turner syndrome
Dosage: Check instruction leaflet provided with drug.
474
D117. SOTALOL
Indications: Refractory supraventricular tachyarrhythmia's (SVT, Atrial
flutter & fibrillation)
Presentation: Tablets of 40 and 80 mg. 80 mg/8 mL ampoule (currently
not available in India)
Dosage : Oral 2 - 4 mg/kg/d (gradually increase every 3-5 d if
needed; max.dose
4mg/kg/dose)
Infusion 0. 1 - 0.2 mg/kg/h
Commence treatment with the lower dosage.
Dilution: Dilute 0.5 mL (5 mg)/kg from an ampoule to 50 mL with 5%
Dor N/S to make a 5 mg/kg/50 mL solution (I mL/h ~ 0.1 mg/kg/h)
Interval: Oral 12 h
Administration: Orally before feeds; milk reduces absorption by 20-
30%
IV by syringe pump infusion.
Comments
Use with caution in the presence of heart failure; avoid in the presence of
hypokalemia and hypomagnesemia (due to the risk of torsades de
pointes)
Dl 18. SPIRONOLACTONE
Indications: Congestive cardiac failure & BPD
Presentation: Tablet: 25 mg and I 00 mg. Reconstitute into sachets.
Store below 25°C.
Dosage : I - 3 mg/kg/dose
Interval: 8 - 24 h
Administration: Oral.
Comments: Used with frusemide to facilitate diuresis and conserve
potassium. May prolong the half-life of digoxin. May cause
hyponatremia and hyperkalemia.
475
Dll9. SULPHADIAZINE
Indication: Congenital toxoplasmo&is
Presentation: Tablet 500 mg
Dosage: l 00 mg/kg/d
Interval: 6-l 2 hourly
Administration: Oral
Comments: Can cause rash, hepatitis, cytopenias, SJ syndrome
Dl20. SURFACTANT
Indications: Prophylaxis and therapy ofHMD, Acute respiratory
distress syndrome (ARDS) due to any cause, MAS, PPHN (still
experimental), Surfactant protein B deficiency (use Survanta)
Presentation:
Survanta: Vial containing 4 mL or 8 mL of suspension. Store below
s0 c.
Curosurf: Vial containing 1.5 mL of white creamy suspension.
Neosurf: Vial containing 3 mL or 5 mL of suspension. Store below 8 oc.
Dose
Survanta: 4 mL/kg
Curosurf: First dose 2.5 mL/kg; subsequent 1.25 mL/kg
Neosurf: 5 mL/kg
Reconstitution: Allow to warm to room temperature. Using an 18-G
needle and a I0 mL Luer-Lock syringe withdraw the required dose from
the vial.
Administration: Attach a 6-FG end-hole catheter cut to the same length
as the infant's ET tube to the surfactant syringe. Insert the catheter into
the ET tube and inject in two aliquots. Vials are for single use.
Comments: Adverse effects of surfactant include acute ET tube block,
pulmonary hemorrhage, opening of PDA.
Dl21. TEICOPLANIN
Indication: Serious infections caused by aerobic and anaerobic gram-
positive bacteria (esp. Staph aureus)
Presentation: 200mg/400 mg per vial. Wait till foaming subsides after
reconstitution.
Dosage: 16 mg/kg stat followed by 8 mg!kg/d
Administration: IV or IM
Interval: 12- 24 h
Storage: Unconstituted: Store at less than 30 °C. Reconstituted: Up to 24
hat 4 °C.
Comments: Can cause pain, phlebitis at site of injection. Slowly
eliminated in kidney with serum half-life of70-100 h.
476
Dl23. THEOPHYLLINE
Indications: Apnoea of prematurity, Weaning from mechanical
ventilation, BPD.
Presentation: 50 mg/5 mL syrup. Store below 25°C.
Dosage
Loading (optional) 5 mg/kg
Maintenance 2 mg/kg/dose
Interval: 6-8 h
Plasma levels: should be monitored
Therapeutic range: apnoea of prematurity 7-12 µg/mL
Bronchospasm 10-20 µg/mL
Tachycardia at 15-20 µg/mL, seizures >40 µg/mL
Comments: Side effects include vomiting, sinus tachycardia and SVT.
Dl24. THIAMINE
Indication: Thiamine-responsive Maple Syrup Urine Disease
Presentation: 100 mg/tablets, Inj. JOO mg/mL
Dosage: 10-25 mg/dose IV, 10-50 mg/dose PO
Dl25. THYROXINE
Indications: Hypothyroidism.
Presentation: 25, 50, 100 µg tablet. Store below 25°C. Make sachets.
Dosage : JOO µg!m2/d or 8 µg/kg/dose
The usual starting dose is 25 µg/d in a term infant and 12.5 µg/d in a
preterm infant.
If rapid correction is desired, one may start with 50 µg/d.
Interval: 24 h
Administration: Dissolve desired fraction of a tablet in a small amount
of WFI, water for irrigation or milk and give orally. Administer oral
doses on an empty stomach.
Comments: Monitor T4, T3 and TSH levels and clinical status at regular
intervals
477
D129. VANCOMYCIN
Indications: Sepsis from S. epidermidis and methicillin-resistant S.
aureus (MRSA).
Presentation: 500 mg vial. Store below 25°C.
Dosa2e and interval: lm!!lk!!ld)
Wt < 1500 g " >1500 g
Aqe ' <7d >7 d <7d >7 d
Dose 20 30 30 45
Interval 24h Sh 12 h Sh
Reconstitntion: Add 10 mL ofWFI to the vial to make a 500 mg/10 mL
solution.
Dilution: Dilute 2 mL ( 100 mg) of the reconstituted vial to I 0 mL with
5% D to make a 100 mg/10 mL solution. 1 mL/kg ~ 10 mg/kg
Administration: Syringe driver infusion over 1 hour.
Serum levels
Peak .......................... 25 - 40 mg/L.
Trough ...................... <12 mg/L.
Storage: Unconstituted: Store at less than 30 °C. Reconstituted: Up to 14
d at room temp., 3 m at 4 °C
Comments: Precipitation occurs if mixed with other drugs (particularly
ceftazidime, heparin, bicarbonate, steroids) or TPN. Rapid infusion can
cause an erythematous rash ('red man' syndrome). Potentially
nephrotoxic and ototoxic.
D130. VECURONIUM
Indications: Skeletal muscle paralysis in case of difficult ventilation &
PPHN. Adjunct to facilitate ET intubation.
Presentation: 4 mg/2 mL ampoule
Dosage: 0.03- O.OS mg/kg/dose
Comments: Can cause transient fall in BP, slight increase in HR,
reduction in GIT motility. Can cause malignant hyperthermia
D131. VIT K
Indications: Prophylaxis or therapy for Hemorrhagic disease of newborn
Presentation: 1.0 mg/0.5 mL ampoule. Store below 25°C. Protect from
light.
Dosage: 1.0 mg
Administration: Intra-muscular to all at birth
D132. ZIDOVUDINE
Indications: Infants born to HN positive mothers, Symptomatic and
asymptomatic HIV infected infants
Dosage
Term: 2 mg/kg/dose PO q 8 hourly
479
Amphotericin B choleteryl
? QD I No guidelines established
sulfate (Amphotec)
Amphotcricin B liquid
Renal 1% QD I No guidelines established
complex (Abelect)
Amphotericin B liposomal Renal
QD I No guidelines established
(AmBisome) '.010%
QI2-
Ampicillin Renal Q6hr I Q6hr Q6-l2hr
16hr
Renal 75%-
Aztreonam Q6-12hr D 50% 25%
(heoatic) 100%
Cefaclor Renal Q8-12hr D 100% 100% 50%
Q24-
Cefadroxil Renal Q12hr I QJ2hr QJ2-24hr
48hr
Ql2 h regimens:
Est Cr Cl
Dose
(mL/min)
Cefepime 50mg/kg/dose
Renal Q8-12hr DI 30-60
Q24hr
25mg/kg/dose
11-29
Q24hr
<JO 12.5mg/kg/dose
Q24hr
483
Q8hr regiments:
CrCl(mL/min)
Dose
30-50 50mg/kg/dosc
Ql2hr
10-30 50mg/kg/dose
Q24hr
<IO 50mg/kg/dose Q24-
48hr
Renal 75% (CrCI 50%(CrC
Cefiximc QI2-24hr D 100%
(hcoatic) 21-60) 1<20)
Ccfotaxime Renal Q6-12hr D 100% CrCI <20 ~ t dose by 50%
CrCI 30-50
Normal ~Q8-12hr Q24-
Cefoxitin Renal Q4-8hr I
Interval CrCI 10-30 48hr
~QI2-24hr
CrCl<30~Q2
Cefpodoxime proxctil Renal QJ2hr I Q12hr Q24hr
4hr
CrCI30-50 Q24-
~QI2hr 48hr
Ceftazidime Renal Q8-l 2hr I Q8-12hr
CrCI 10-30
~Q24hr
484
Q48-
Ceftizoxime Renal Q6-12hr I Q8-12hr Q36-48hr
72hr
CrCl 10-20=
Cefuroxime Renal Q8-12hr I Q8-12hr Q24hr
Ql2hr
Q\2-
Cephalexin Renal Q6hr I Q6hr Q8-12hr
24hr
50% (or
50-75%(or Ql8-
Renal
Ciprofloxacin Q8-12hr D,I 100% QI 8-24hr for 24hr for
(hepatic)
CrCI <30) CrCI
<30)
Cr Cl<30= t
dose by 50%
Renal/ No
C!arithromycin Ql2hr DI and ?
hepatic Change
administer
BID-QD
Sulfametho Cr CI
Ql2hr
Co-trimoxazole (sulfa- xazole: D No CrCI 15-30 <15=
methoxazole/trimethoprim) Hepatic Change =50% Not
(Renal) Recomm
485
Trimethopr -ended
im:
Renal
(hepatic)
Hepatic 50%-
Erythromycin Q6-8hr D 100% 100%
(renal) 75%
Renal Q48hr±L
Ethambutol 24hr I Q24hr Q24-36hr
(heoatic) dose
Fluconazole Renal Q24hr D 100% 25-50% 25%
Flucytosine Renal Q6h [ Q6h Q 12 h Q24H
!V:Dl IV: 50%-
25°10-50°!0
100% 25% and
IV: Ql2hr and Q24hr
and Q24hr
Ql2hr
Ganciclovir Renal
P0:50%
-100% 50%and 50%and
PO:T!D PO:DI
and-TID B!D-QD QD
Q24-
Gentamicin Renal Q8-12hr 1 Q8-12hr Ql2-18hr
48hr
50-100% 25%-50% 25% and
Imipcncm/cilastatin Renal Q6-8hr DI
and Q6- and Q8hr Ql2hr
486
8hr
Hepatic
Isoniazid Q24hr D 100% 100% 50%
(renal)
f. Mcropcncm
Methicillin
Renal
Renal
Q8hr
Q4-6hr
DI
1
JQQ:lli..
and Q8hr
Q4-6hr
50%-100%
and Ql2hr
Q6-8hr
50% and
24hr
Q8-12hr
Renal .
Metronidazole Q6-12hr D 100% 100% 50%
(hepatic)
Hepatic
Nortloxacin BID 1 BID QD-BID QD
(renal)
Ofloxacin Renal BID 1 BID QD QOD
Use
lower
Renal
Oxacillin Q4-12hr D 100% 100% range of
(liver)
normal
dose
Penicillin G-potassium/Na Renal 20%-
Q4-6hr D 100% 75%
+(IV) (hepatic) 50%
Renal CrCI 20- CrCl <20
Pipcracillin Q4-6hr 1 Q4-6hr
(hepatic) 40~Q8hr ~Ql2h
I /
488
_
491
NOMOC RA\.1S
s I·rth we1e:
· h t ·m e:rams
Gestation -2 SD - 1 so \1can + I SO +2 SD
27 185 473 861 1149 • 1407
28 666 914 1162 1410 1608
29 861 1088 1315 1542 1769
30 837 1139 1441 1743 2045
31 549 1058 1567 2076 2585
32 844 12.95 1746 2197 2648
3) 1210 1517 1824 2131 2438
34 1229 1670 2111 2552 2993
35 1438 1879 2320 2761 3200
36 1674 2117 2560 3003 3+t6
37 1918 23.39 2760 3181 3602
38 2020 2440 [2864 3286 3708
39 2095 25 17 [2939 ! 336J 3783
40 2178 2593 3008 3424 3838
41 2205 2678 3151 3624 4097
42 2130 2555 2980 3405 3856
>42 2079 2505 [2931 3367 3783
.
l
- \ -1 I
-
I \ -:rt
492
I I I I
.. .. .......
I
· - - - - _ , .,, .... Jll
I
I
,, ,, ·~
- .--
. I
,
,.,
,.,
.....
., v v
IJ
IJ
IJ
,,
. IJ
IJ
- ...
1-l~" v
IJ
....
~-
-....
'
--
v
~-i-
I ~---~
--· fil ,
,., v v
....
~-
y
f) (,
:;I I~
,, , '·' -..
lo-
L..
... r.;.
~ .....
-
"'
•
---
,, "l
' ' .......... '
/
493
h-+'--'.-1,f-+++-;-J+,..::::,.+c,:±-H'CT-b.
. . I. I •'i
":1 ·-1~i----~i -·!:·
V1 i ~ •• ' j'
·'-r-1 ' L i .'
l
t • j
1 ••
'°J
••
•M•• .-l<L-t-""1.L-T..f il
494
14 28 42 56 70 84 98
Postnatal Age (Days)
~4.2 Avera~e length versus postnatal age (Wks) for \'LBW infants
stratified by I 00-g BW intervals
495
N4.3 Average weekly OFC versus postnatal age (Wks) for VLBW
infants stratified by 100-g BW intervals
35
'
f 'j'
···'··· t .
30 j
i
i······-+-·-···~----;
. . !
i--··---L--.t----L-.
. j -+---.--~--·
. . i.. ___l_'
l..
20 - ·--·1
2 3 4 5 8 7 8 9 10 11 12 13 14 15 16 17
Postnatal Age (Weeks)
I
i i
8 ;
i .---------·!
. '
7
r:·:~~==~~f~~= :·--~:~::1
7'·r">' I ••• • ··1 ,.___ -
1
-+·---~~::~=_:._ __ . f. .--.=~
r-·-~···71°······,· .- T.:::~_.J _____ ~ ----~-----_:
6 "" i.
'
---· ..... t---- ._.,.. ___ .., __ _
$
·!· . .
r=r,1 , "*"'
.>.. • - · · · · · · - , · - · - -- •
2 3 4 5 6 7 8 9 10 ti 12 13 14 15 16 17
Postnatal Age (Weeks)
496
2000
1750
I
.!!! 1250
i
~ 1000
750
14 28 42 56 70 84 98
Postnatal Age (Days)
N4.6 Growth curves of SGA infants (Solid lines) and AGA (AGA)
infants (dashed lines). Infants are stratified by 200-g BW intervals.
I 1250
i
;;! 1000
14 26 42 56 70 98
Postnatal Age (Days)
497
·~~~~~~~~~~~~'fl"''~
.....
Borth
Weigh!
u ]-~-
·' !_.~,,._,_
3
>111-HCI
1 ' •...
,_·· ... --:i.;.·~+--
....................
O.>~~=F:f::+--!--+-J-1--1--~-J---!--+-J-l--l--k+-i
~'w~w"~"~~~"~~~n~u~~~~
POSTNATAL AGE (days)
~ lHl-1$00
t -1--1--Hriri-+-+-+~++++-t-cbf-"-H:-:i'--11001-tuo
501- l'l-1000.
501·7'0
N6. WHO GROWTH CHARTS (Reproduced from the open access site
http://www.who.int/childgrov.rth/standards/en/)
N6.I Wt for age (Girls) - Birth to 2 yrs (percentiles)
---(
'
~ ~~...:-"']
_-.
·a--··--~ .
~~
,......,.,.,,- ------
'i
WHOO.kl(;,_.,,.,~
501
N6.7 Wt for length (Boys) - Birth to 2 yrs
502
- ..
l
, 1......-
i-
2 ••
///........._
2 .- I
,., /]::
~
,.,v' .. / •• ....
, /-.!'-.
/
.--
2 4- I /
V)/ A ;.,. ......
I
... I/ / ,, ,..
2000
/ ,/
,_..-
,.v
/
/
I/
/1,... /
•'
,,.·
'°"
- - v v.
;_,...-'
........ I
24 6 2' n 3'I 36 31f «>-42
--
-t::-
.......... .........
2a·- / /
'"
.. vv v/
/
/
/ --... """'""
-
~
2 4~
v
-
i/
00
/
.. v l/
/v
I/
/
/
/ / ~.,,,...""'
/ / /
00
v _,.,,,. ..-
OA
_.... /
,..... /
!/-'
800
y""'
~
24 <:ti 30 2 34 ~6 38 4()- 2
2'
Weft of 0.lutluei
503
Venlrfculm'
Index (mm}
20.
11'
'
16 - ; '
14. -~.!.·
•..•.~ ..
'
• ;
12 -
' l '
10 ~ --"
-
8
21 28 30 32 34 38 31 40
Gettallon(-)
-
N9. BODY SURFACE AREA
_.,.,,
lg)
4000 ·-
S..rl~
fcmi)
2500 Crown-hetl
'""''
(cm)
55
3000 2000
50
45
1600 40
35
30
1000
,.
1000 20
500
"
10
so4 f I {(
""110. MANROE'S CHART FOR TERM § A~OF
NEONA TES (Rcpnnted from Journal of Pediatrics, \'Olum~ BL, Weinberg
AG, Rosenfeld CR. Browne R, The neonatal blood count m health and disease. I. Reference
values for neutroph1lic cells, pages 89-98, copynghl 1979. with pemuss1on from Elsevier)
TIAIE (hon!
1:- .~·~..;..
:l · .. - .
~·
.· :
1: ·:~·:! .::·t·....:
i ,:··:I • •
r.
•
.
••
5- :!!·.... ·.. ... . ::. ..... --··
1 ,··:, • :_ ·. '. ~.~.-- ·:
i - ~:.:-·.. ·:. ·-
- -:=::-::. ..·. .. s•• ••
00 • • • ~ '° ~ ......... 60
TIM(-
505
·-·--
the AAP)
·-·--....
n oo
"/
/
".
......
~ ...... Birth to
60 h of
life
.
i ....
l·- ·=·
. . ••...... ._,- .. .. .. ..
,_;,....
•• •
,.
I--.-~~~-~-~~~-~~
~
_.,........ ·····- 61 h to
28 dof
.. life
!',:
---- ,,
.. ·-. -- .
...... . -····- ····-
N12.2 5th and 95th centile values of neutrophils in I" 72 h (28-36 wks
gestation)
"'
507
N14
Macmi
Nt4.1
~
~UBROW'S) CHARTS
Zubrow's
FOR BP (Reprinted by pennission from
pubhshers Ltd: Journal of Perinatology; volume 15: pages 470479, © 1995)
charts for BP according to GA
l ~~1· ---
10
o 'r'...,.....,....,...,........,~...,......,...,-,-...,........,...,........,...,...
22 24 26 28 JO 32 34 J6 JS 40 42
Gestational age (weeks)
70
60
°'EE
I
50
Upper 95°t C.L.
-___ ... ---
c.. 40 ---
-- -- ---
Ill
.!::' JO
E 20
'
.~
• ---
---
Lower 95% C.L
0 10
0
22 24 26 28 JO J2 34 36 38 40 42
Gestational age (weeks)
508
Ol 80
-- ---- ---
I
E 70
E 60 ---- -- -
~
a. 50
--- -
• - -- -
a:i
Lower 95 %C. L.
-~ 40 --
Ci 30
~
"'>-
\fl 20
---
10
0 ' I I • . . I II I
I I . I
750 . 1.250 . 1.750 . 2.250 2.750 I 1250 ' 3750 I
1.000 1.500 2.000 2.500 3.000 3.100 4.000
Birth weight (kg)
Upper 95 % CL.
~ --- --- ---
t
E
SC·
~ -- ---- --- --- •
a. 40
r •
L
' --
al
v 30 - i I i • ---
0
VI 20
• --- --- ---
re
0 10 -- --- - - - Lower 95% C.L.
:;~o I1.iso
0
1.lSO I2J.so I2.iso I12so I3.i5o I
r
24 26 28 30 32 34 36 38 40 42 44 46
Post conceptional age (weeks)
100
Oi 90
I 80
E Upper 95% CL
E 70
--- --- -·
--- ---
~
c. 60
m
u 50
40
--- ---
0
.,
--- ---
0
"'
l'J
30
20 ___ - - - - - -
--- Lower 95% C.L.
10
0 '' I l
24 26 28 30 32 34 36 38 40· 42 44 46
Post conceptional age (weeks)
510
111[
;1~1r--5llT>
;tt----------=:
70
65
0 1 d 5 6 7 10 11 12
MONTHS
7'
-----95TH
-----90TH
-----
-----5CTH
012345S789101112
MONTHS
5:
Nlti. MEAN BP IN NEONATES \\'JTH GA 23-43 WKs (Reprinted &o
Clinic, in Perinatology, Volume 26, Nuntna Umit P, Yang W, Bada-Ellzey HS, Bloo
&om Elsevier)
pressure measurements in the newborn, pag,, 981-96, copyr;ght 1999, with P<miissio,
E~
gJ. 50
l!!
~- w .r------·-----
. . 33-36 Wk
----· -------------
- ------- 27-32""'
30
l
r·---- ---- ............. .. ------··.::~-:.::;.;..·.;.:.;. ..... -- ....... ~,:":'..
23-26 Wk
20
0 12
48
60 72
512
----
Nl 7. HEY'S CHARTS FOR._NTZ (Reprinted from Archives of Disease in Childhood, The optimum thennal env1rorunent for naked babies, Hey EN ,
Katz G, ~olume 45, pages 328-34, copYtighr1970, with pcm1iss ion from BMJ Publishing Group Ltd.)
Naked
24
0 10 20 30 0 10 20 30
jy 513
I
• '
I • I • • • I
....
,.. ~ c¢:::: 1~ etc: a;['.
> ·-· ... .. r ..
~ I ~
s_..
C• mJJ r.to. r. . f' ...
1<. Ana R<K. .
I ~. . {} {} 1}
140"-IW 11...... t> tO·llO•
'fr'<to'
......... ~ ~ . ct>
~-·'
2) ~
f ,~
(f:)
''°' ••. 1 ... ;~ 100' •••
5 ....... -ir -~ -& -~ _g -~
H "..r1111r..
ea l oS 1d9 , &9 I crl3 a:9'
-·- •• ••
/J •.... -........ ·~
.. j
--· ...,,.,..I),,...... . ,. •,. ,,... .,....
..._., •I
""°''
KJ• .._ ".. . I ......
.... 1-·-
J -
Gc.._tt. ....-Uf'lll ...U ..... ,......, ...........
....
t ---
I ......
-.... ,- -··-
I
.......
Clit9"I
--· 1.......
·-· .....
i -·
.....
~· _._....I .... I ' ....
514 CO;/)~'R )
N19. BHUTA~l'S PREDICTION NOMOGRAM FOR J-
HYPERBILTRUBI EMIA FOR WELL NE01'ATES OF~ 36 WKS
& ~ 2000 G. (Reproduced with pcnmss1onr om Pediatncs. vo110J. Page' 6-14.
Copyright 1999 by the AAP) rj C t) TS'[S
20 ~-+---+---+---+---+--+----lf---.+--.-+-
....--1-----1-~' ~ .( ~ I,_
)
I.E 10 -
~r
2
~+
~~ h~Y) ,,kQw~v-.J ·).~\,"7 ~
~ o -~-
N20 AAP GUIDELINES FOR J Al ' NOICE AGEMENT
(Rcpr~"ith pennisston from PedJatncs \ ol 114. Pages '.!97-316. Copynght C 2004
by the
'120 PT or neonates ~ 35 w_!<s g~ tation
-':;:::>'
'28
,.
. -· -·
--
3'2
. .
-·, ,_
.- ,
~ 257
.•
... ,,
,,
., ,
171
p
.....
·~ ~
5
,__ ~• • • • lnlanla a1 tow.r nsl( (l 38 wlc ndwel)
,.: :::: - - 1n1an1a 111 mlOQT\ ns« (l 38 flt + ns1111c101S"' 35-37 en on and .... -
-
0
'-- L _ _ - "'*'15 at h9llf r1lk (JS.37 " ' wlc ~ ,,. llelo<sJ ::+= 0
llinh 24 t({uj~ h 72h j 96h 5Dlys eo.ys 7 Daya
~
·u.--. DonoclLC!nel-'-*'Vor~lilfAOr\.
· ""*"'-
--·--1....i,tit-Ga'O~
.. l ..,,.,....__.~.-"'**"
- .-.i~(ll~
TSB-10tt--......., .. ,,_.,,,..,.
.....
•l'otwol-~el7""Cllt ..... l•M-11
....
---1111 -
--·-rsa-lbr..--•3SwlllMd•~~-..,--.,:11111
N20.2 Guidelines
_..~_,~.,r-··-·Till-2-3,...,.la-~
. . ,_. ...._
r~( DVET:Jlr neonate( > JS}Vks gestation
30 513
._,___ "T I I I I ~I I I I I I-'--
'-- ,___ •• - • lnlarits Ill lowef llsl< ~ 38 Wk lr1d - '--
,__ L - - - lnlanta 111....o..m ,,... p 31 v.lt • faaors cw 35-~7111 wl< ~ wel _._
lntlntsath4ghelnsk(35-3711/7W' +nsU1elots) _ ,_
..
'--L- -
I
'28
T .• -··
.... . - .. - -· - ... -
l
. .·., ,
- - I-
,, . _. I "
, ., .--. .
--
.. ,, -
:-11"
,, I I
257
7 i
. I
i
.
,_ l I I
. ..
i I I I I I
I I i
'" i
10 171
24h 48h 72h I 96h 5 Days
Pco 2 mm Ha
The sloping lines going across the chart represent HC0 3 values
517
N22. UMBILICAL ARTERY AND VEIN CATHETER LENGTH (Reprinted from Archives of Disease in ChHdhood, Localiza6on of the
umbilical catheter by post-mortem measurement, Dunn PM, volume 41, pages 69, copyright 1966, with pennission from BMJ Publishing Group Ltd.) The
shoulder to umbilicus distance is the perpendicular distance between parallel horizontal lines at the umbilicus and through the distal ends of the clavicles.
Umbilical Vein Umbilical Artery
10 11 12 13 14 1~ 16 17 18
"' ' "
" "
" "
,.,"' "
" 2S
" "
"
l&ttAtn1X11
"'2
"
"
~ "'
19
5 18
~ 17
~ ~:
"
"
"
"1D
'8
,' '
1'J 11 12 rn u 1s ,~ 11 1s
Length 1r001 Shrulderto Umbik:us \cm.1 Shouldar-Umbilicus Distance \cm}
518
INllEX
TELEPHONE NUMBERS
Only those telephone numbers that a ·e important from the perspective of
the Newborn Unit of PGIMER are I !sted below. For numbers not listed
here, see PGJMER telephone directm y or call enquiry 6565.
Newborn Unit
Name/ Area Landline Mobile
NICU 6236, 6237
NNN 6244 '
Other facultv
Dr. Akshav Saxena, Radiolorr" 6383 9383
Dr. K Sodhi, Radiolo11v 5634 8634
Dr. Malkiat Singh, Infection control 5153 8169
Dr. Manisha, Infection control 5151 8164
Dr. Pallab Ray, Microbio]ol!v 5157 8157
Dr. A Chakrabarti, Microbi0Jocn 1 5156 8156
Dr Vikas Gautam, Microbioloo-v 5152 8152
Dr. Ncelam Verma, HematoloP-v 5125 8125
Dr. Reena Dass, Hematology 5128,5566 8128
Dr Jasmina Ahluwalia, Hcmatolo "' 5129 8129
Dr. Prabhakar, Neuro\oav 6691 9691
Dr. P. Sudesh, Orthooedics - 9749
535
Name Landline Mobile
Dr Neelam Marwaha, Transfusion Medicine 6481 9481
Dr Suchet Sachdeva, Transfuion Medicine 6487 9487
Dr. B.R.Thana, Pediatric Gastrocnterolol!v 6607 9607
Dr. Manoi Rohit, Pediatric Cardiolol!V 6517 9517
Dr. Anish BhattachHrva, Nuclear Medicine 6726 9726
Dr. Raiendra Prasad, BiochemisTT\J 5178 8178
Dr MR Dogra, Qphthalmolocrv 6115 9115
Dr Rama Walia, EndocrinoloPv 6581 9872
Dr Ashim Das, HistonathoJogv 5139 8139
Dr Nandita Kakkar, Histonathology 5141 8141
Dr Kirti Guota, Histooathology 5135 8135
Dr Ashima Goval, Pediatric Dentistn. 1
6832 9836
Dr Raiendra Prasad. Biochemistrv 5178 8178
Non-Neonatolo!!v residents
Name/ Area Landline Mobile
Autopsy Resident Incharge
JR day 8614, JR
Night 8615, SR 8611
Blood Bank JR 6480 9480
Blood Bank SR 6486 9486
CTVSSR 5061, 5039 9549
Endocrinoloov SR 9584,9590
Hematolovv Lab SR - 8369
Hosnital Administration SR on call 6669 8687
Onhthalmoloo-y (Eve Bank) 6368 8711
<mbthahnoloo-v JR on call - 8710
Oohthalmolocrv ROP clinic 6111 -
Pediatric Cardiology SR - 8378
Pediatric Emereencv SR 5307,5327 8367, 8368
Pediatric GastroenteroloP'v SR 6211 9210
Pediatric Surl!erv SR - 8379
Virolo'"' SR - 8170
X-rav (Emere:encv) JR 6060 9060
Outside PGIMER
Chaitanya Hospital 2604613-x- Side 1 & 2, Sector 44-C;
NICU 311 - Chandigarh
Command hospital 2867658,
NICU 2867519 - Chandimandir
4692222-x-
Fortis Hospital NICU Phase 8, Mohali
6192
Dr Deepak
2665253-x- 3'd Floor, Block A, GMCH,
GMCHNICU Chawla
1108, 1300 Sector 32
9646121559
2768278, GMSH, Sector 16, Madhya
GMSH Nursery
2768277 - Marg, Chandil!arh
2543889,
Red Cross Bhawan, Madhya
Haryana Red Cross 2546330,
Marg, Sector 16, Chandigarh
2546328
Opposite Bal Bhawan, Sector
Missionaries of Charity 2705156 - 23-A,Chandil!arh
Sector-388, Dakshin Marg,
Prayas 2690872
n...-. Dainik Bhaskar
9779950037
2780827, Punjab Red Cross, Madhya
Punjab Red Cross (Mrs.
2548192 Marg, Sector-16, Chandigarh
K.aooor)
2na floor, Karuna Sadan
2744188,
UT Red Cross
2742000 - building, Sector 11-B,
Chandigarh
541
NOTES
542
NOTES
NOTES
544
NOTES
545
NOTES
546 r--1,· t_
J
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NOTES
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