Theory

BASIC TERMINOLOGIES IN NEWBORN

General
>> Neonatal period: First 28 days after birth
>> Early neonatal period: First 7 days of life
>> Late neonatal period: > 7th to 28 days of life

Gestational Age Related

Perinatal periodQ: From 22nd week of gestation (or over 500 grams of birth weight) to 7th day of life

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>> Term baby: A neonate born between 37 and <42 weeks (259-293 days) of gestation
>> Preterm neonate: A neonate born before 37 weeks (<259 days) of gestation

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>> Post-term neonate: A neonate born at a gestation age of 42 weeks or more (294 days or more)
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Extra edge
Newer terminologies (from Avery’s textbook of Neonatology)
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Fetal period
>> Early Fetal Period: up to 22 weeks of gestation
>> Intermediate Fetal Period: from 22 – 27 weeks of gestation
>> Late Fetal Period: from 27 weeks of gestation onwards

Birth Weight Related

>> Low birth weight (LBW): Birth weight <2500 g, irrespective of gestational age.
>> Very low birth weight (VLBW): Birth weight <1500 g, irrespective of gestational age.
>> Extremely low birth weight (ELBW): Birth weight <1000 g, irrespective of gestational age.
>> Small for gestational age (SGAQ) or Small for date (SFD): Birth weight < 10th percentile for that period of gestation.
>> Large for gestational age (LGA) or Large for date (LFD): Birth weight > 90th percentile for that period of gestation.
>> Appropriate for gestational age (AGA): Birth weight between 10th and 90th percentile for that period of gestation.
 Chapter 4  •  Neonatology
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SMALL FOR GESTATIONAL AGE VS INTRAUTERINE GROWTH RETARDATION

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>> SGA is a statistical definition used for neonates whose birth weight is < 10th percentile for that particular gestational age.
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>> IUGRQ is a clinical definition and includes neonates with clinical evidence of malnutrition (like loose skin folds, absence of
subcutaneous fat and skin peeling).
>> Almost all IUGR infants would also be SGA but not vice versa
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Types of IUGR
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Features Symmetric IUGR Asymmetric IUGR

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Incidence Less common (20%) More common (80%)

Onset Early (first) trimester of pregnancy Late (2nd and 3rd) trimesters
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Etiopathology • Congenital anomalies, genetic disorders • Uteroplacental insufficienyQ (e.g. maternal

• Decreased cell number hypertension)
• Decreased cell size
Clinical identification Uniformly small from head to foot Head size is normal; rest of body appears small
(due to ‘Brain sparing’Q effect)
Outcome Poor prognosis Good prognosis

Extra edge
Ponderal indexQ
•• Relates weight of a baby to its height
•• It attempts to distinguish between symmetric and asymmetric IUGR
•• Value < 2 is observed in Asymmetric IUGR and > 2 is seen in symmetric IUGR
•• Ponderal index = [weight (grams)/length (cm)3] × 100

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 Barker HypothesisQ in IUGR
>> Also called as ‘fetal origins’ hypothesis to explain the occurrence of adult disorders in relation to fetal nutrition/weight (i.e,
Complete Review of Pediatrics

adult sequelae of intrauterine growth restriction)

DIFFERENCES BETWEEN TERM AND PRETERM BASED ON PHYSICAL APPEARANCES

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Characteristics Preterm Term

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Appearance Limbs kept extended (due to decreased tone) Attitude of universal flexionQ (due to good tone)
Pinna Poorly developed ear cartilage; slow ear recoil Well developed ear cartilage; Fast ear recoil
Breast bud (nodule) < 5 mm Q
> 5 mmQ
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Hair Fuzzy hair Silky hair
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Sole creases Faint/absent sole creases Deep transverse creases on the soles
External genitalia-Male Smooth scrotum with absent rugae and not yet
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Well pigmented scrotum with rugae and fully
descended testis descended testes
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External genitalia-Female Equally prominent labia majora, minora and Labia majora covering clitoris and labia
clitoris minora
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Recent Advances
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Expanded New Ballard Scores (ENBS)

•• Commonly used scoring system for gestational ageQ assessment
•• Based on (i) physical characteristics and (ii) neuromuscular criteria
•• Has an accuracy of 1 weekQ
•• Minimum possible score is–10 (corresponds to gestational age of 20 weeks) and maximum possible score is 50 (corresponds to
gestational age of 44 weeks)

CARE OF A NORMAL NEWBORN

>> Aseptic precautions should be followed at birth, remembered as ‘five cleans’Q namely:

 Clean hands: Hand-hygiene and wear sterile gloves

 Clean surface: Use clean and sterile towel to dry and cover the baby
 Clean blade: The umbilical cord to be cut with a clean and sterile blade/scissor
 Clean tie: The cord should be clamped with a clean and sterile clamp or tie
 Clean cord: Nothing to be applied on the cord. Keep it dry
>> Delivery room temperature should be 25°C and hypothermia should be prevented (temperature regulation in newborn is discussed
below)
>> Umbilical cord should be clamped 30–60 secondsQ after birth and at 2–3 cm away from the abdomen

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>> Prophylactic vitamin KQ given intramuscularly to all babies (Dose of 0.5 mg for babies less than 1000 g and 1 mg for babies more
than 1000 g). It is preferable to administer the Kl preparation.
>> Breast feeding should be started as soon as possible after birth
>> Bathing the baby is recommended once the cord falls offQ

Chapter 4  •  Neonatology
Temperature Regulation in Newborn
>> Normal temperature in newborn is 36.5°C to 37.5°CQ
>> A low reading thermometer (which can measure up to 30°C) is recommended for measuring temperature in neonates
>> Axillary temperature recording is preferredQ in neonates (since it closely approximates the core temperature)
>> Thermometer is kept in roof of dry axilla for 3 minutesQ

Definitions
HypothermiaQ Axillary temperature less than 36.5°C
• Cold stress: 36.0-36.4°C
• Moderate hypothermia: 32-35.9°C
• Severe hypothermia: <32°C
Hyperthermia Axillary temperature more than 37.5°C

Sources of Heat LossQ in Newborn

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>> Radiation to surrounding environment not in direct contact with baby

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>> Convection to air flowing in surrounding of baby
>> Conduction to substances in direct contact with baby
>> Evaporation from baby’s skin to atmosphere
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Extra edge
(The most important source of heat loss is radiationQ from the head,
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since the head has the largest body surface area)

Non Shivering ThermogenesisQ

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>> A unique mechanism of heat generation in newborn mediated by brown fat

>> Brown fat is sympathetically innervated fat tissue located in interscapular area, nape of neckQ, axilla and perirenal/periadrenal
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areas. It is rich in mitochondriaQ

>> Hypothermia and stress results in norepinephrineQ discharge, which results in uncouplingQ of beta-oxidation from
phosphorylation and resultant heat production

Prevention of Hypothermia
Warm ChainQ
>> Refers to a set of ten steps aimed at decreasing heat loss and promoting heat gain

Ten steps of warm chain

Mnemonic
We Went in Summer but Brother and Mother Provided Water
Warm delivery room Bathing postponed
Warm resuscitation Appropriate clothing
Immediate drying Mother and baby together (‘Rooming in’)
Skin to skin contact (‘Kangaroo mother care’) Professional alertness
Breastfeeding Warm transportation

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 NORMAL NEWBORN CONDITIONS (WHICH REQUIRE NO TREATMENT)
Skin Changes
Complete Review of Pediatrics

• Erythema toxicum: • Bohn’s nodules:

ƒƒ Most common newborn rashQ seen after 24–48 hours of life ƒƒ Similar to Epstein pearls but seen over gingiva
ƒƒ Consists of erythematous popular, pustular lesions
ƒƒ Microscopy shows plenty of eosinophilsQ

• Pustular melanosis:
ƒƒ Consists of scattered pustular lesions with melanotic patches • Mongolian spots:

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ƒƒ Microscopy shows plenty of neutrophils (though it is a sterile
Q ƒƒ Greenish black slate like macules
lesion) ƒƒ Seen over lumbosacral region

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• Milia:
ƒƒ Keratin filled cysts seen in the face especially over and around
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the ose
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• Epstein pearlsQ:
ƒƒ White keratin filled cysts
ƒƒ Seen in palate and prepuce

Contd...

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Other conditions

• SubconjunctivalQ and retinal hemorrhages

Chapter 4  •  Neonatology
ƒƒ Commonly seen in babies delivered by vertex presentation
• Hymenal skin tag
• Skin peeling (more often seen in post-term and IUGR babies)
• Due to transplacentally transferred maternal estrogensQ:
ƒƒ Breast engorgement
ƒƒ Vaginal bleed/mucus discharge

NEONATAL REFLEXES
Reflex Onset Fully developed Duration
Palmar grasp 28 weeks gestation 32 weeks gestation 2–3 months postnatal Extra edge
Rooting 32 weeks gestation 36 weeks gestation Less prominent after Reflexes Appearing after BirthQ
1 month postnatal •• Symmetric tonic neck reflex
MoroQ 28–32 weeks 37 weeks gestation 5–6 months postnatal •• Parachute reflex

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gestation •• Landau reflex

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Asymmetric tonic 35 weeks gestation 1 month postnatal 6–7 months postnatal
neck
Parachute 7–8 months postnatal 10–11 months postnatal Remains throughout lifeQ

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Salient Points About Moro Reflex
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>> Most commonly elicited neonatal reflexQ

>> It is a vestibular reflex
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Components:
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>> Most common cause of absent Moro is CNS dysfunctionQ (HIE)

 Causes of asymmetrical Moro:

 Brachial plexus injury (Erb palsy)

 Fracture clavicle or humerus
 Congenital hemiplegia
>> Abnormal persistenceQ of Moro reflex beyond 6 monthsQ is an early sign of cerebral palsyQ
Moro reflex and HIEQ (in reference to Sarnat and Sarnat staging):
 Stage I – Strong Moro

 Stage II – Weak Moro

 Stage III – Absent Moro

(Please note that if the question asks about Moro reflex in HIE i.e., without mentioning the stage as described above – then the
answer should be absent Moro)

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 HEAD SWELLINGS IN A NEWBORN
Features Caput Succedaneum Cephalohematoma
Complete Review of Pediatrics

Appearance

Location (plane Subcutaneous plane Between skull and periosteum (usually over parietal
of swelling) bone)
Cause Prolonged/obstructed labor Traumatic deliveryQ (can be associated with fracture of
skull bone)
Contents Fluid Blood

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Onset Appears within few hours after birth Appears 3–5 days after birthQ
Clinical course Resolves within 2-3 days Takes 3 weeks to resolve; sometimes undergoes

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calcification
Characteristic Diffuse; crosses suture lineQ Limited by suturesQ; associated with prolongation of
findings/ physiological jaundice
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associations
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SUBGALEAL HEMORRHAGE
>>
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Most severeQ type of head swelling in newborn

>> Collection of blood beneath the galeal aponeurosis that covers the scalp
>> Often associated with vacuum-assisted delivery
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>> Bleeding occurs due to rupture of emissary veins

>> Complications: hypotension, anemia, jaundice, consumptive coagulopathy
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NEONATAL RESUSCITATION (2015) GUIDELINES

Chapter 4  •  Neonatology
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 Salient features of Neonatal Resuscitation
>> The 3 questions asked at the time of birth namely:
 Term gestation?
Complete Review of Pediatrics

 Breathing or crying and

 Good tone are collectively called as “INITIAL ASSESSMENT” Q at birth

>> The correct positioning of the neonate during resuscitation is “slight extension” Q of neck (also called as “Sniffing” position)–
achieved with a shoulder roll (only during this position, the airway is a straight line)

>> While clearing the airway of secretions, mouth is suctioned before noseQ (remember, ‘M’ before ‘N’) to ensure the infant does not
aspirate, if she should gasp when the nose is suctioned.
>> The only safe and appropriate methods of tactile stimulationQ are (i) flicking the soles and (ii) gentle rubbing of the back

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>> The first one minute of neonatal resuscitation (i.e., before the ventilation step) is called as “Golden MinuteQ”
>> Bradycardia (heart rate, HR < 100/min) is a sensitive indicator of profound hypoxemia, and establishing adequate ventilation is

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the most important step to correct itQ.
>> Positive pressure ventilation (PPV) is given by either bag and mask ventilation (BMV) or by endotracheal intubation viz., Invasive
positive pressure ventilation (IPPV). Rate of PPV is 40–60 breaths/ min
>> Term babies should be resuscitated with room air (21% oxygenQ). For preterm babies, upto 30% oxygen concentration can be
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used. However, whenever chest compressions are needed, 100% oxygen should be given.
>> Exhaled CO2 detection is the most reliable indicatorQ of endotracheal tube placement.
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>> The size of laryngoscope blade used for neonatal resuscitation is size ‘0’ for preterm babies and size ‘1’ for term babies

Appropriate Endotracheal Tube Size

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Inner diameter of tube (mm) Birth weight (Kg) Gestational age

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2.5 <1 < 28 weeks

3.0 1-2 28 – 34 weeks
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3.5 2-3 34 – 38 weeks

4.0 >3 > 38 weeks
>> A response to PPV is indicated by increase in HR to > 100/min. If no increase is observed, the ventilation corrective steps should be
taken, which is remembered by a mnemonic ‘MRSOPA’

Mnemonic
MRSOPA
M – Adjust Mask to assure good seal on the face
R – Reposition airway by adjusting head to "sniffing position"
S – Suction mouth and nose of secretions, if present
O – Open mouth slightly and move jaw forward
P – Increase Pressure to achieve chest rise
A – Consider Airway alternative (endotracheal intubation or laryngeal mask airway)

>> Two important heart rates to be remembered for exams:

 HR < 100/min is an indication for starting PPV
 HR < 60/min is an indication for starting chest compression

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>> Chest compression to ventilation ratio in a newborn is 3:1Q (hence in a minute, 90 compression and 30 ventilations are given)
>> The usual techniques for chest compression in a neonate are: (i) ‘Two thumb’ (preferred) technique or (ii) ‘Two finger’ technique
>> Persistently low HR (<60/min) even after chest compression is an indication for IV adrenaline (umbilical venous route is the
preferred route in neonates because of easily cannulation and availability)

Chapter 4  •  Neonatology
>> The usual dose of adrenaline is 0.1 – 0.3 mL/Kg/dose of 1: 10000 solutionQ (Normally available strength of adrenaline is 1:1000.
1:10000 solution is prepared by adding 9mL of water for injection to 1ml of 1:1000 solution of adrenaline thereby making 10 mL of
1:10000 solution from which the required dose is calculated)
>> The recommended products for treating hypovolemiaQ during neonatal resuscitation are:
 Normal (0.9%) saline

 O (–)ve packed RBCs (it should be noted that Ringer lactate is no longer recommended during neonatal resuscitation)

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Extra edge
Major changes in Neonatal resuscitation guidelines (2015)
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•• Delayed cord clamping (to 30–60 sec after birth)

•• Routine tracheal suction no longer recommended for NON-VIGOROUS babies with meconium stained fluid
•• Assess heart rate by auscultation only; use of pulse oximeter and cardiac monitor is encouraged
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•• Prophylactic CPAP in babies born at < 32 weeks of gestation

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APGAR SCORE
0 (Points) 1 2
Appearance Blue or pale all over Blue extremities, but torso pink Pink all over
Pulse None < 100 > 100
Grimace No response Weak grimace when stimulated Cries or pulls away when stimulated
Activity None Some flexion of arms Arms flexed, legs resist extension
Respirations None Weak, irregular or gasping Strong cry
0–3 Critically Low, 4–6 Fairly Low, 7–10 Generally Normal

>> Apgar score is done at 1 min, 5 min, 10 min and 20 min after birth
>> Maximum possible score is 10 and minimum possible score is 0
>> Persistently lowQ APGAR scores are a good predictor of neonatal deathQ

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 NEONATAL JAUNDICE
Bilirubin Metabolism
Complete Review of Pediatrics

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Reasons for Physiological Jaundice in Newborn s,
>> Increased RBC mass and shorter RBC life spanQ (compared to older children and adults)
>> Immature hepatic uptake (due to ↓ Y ligandin) and conjugation (due to ↓ UDP – GT levels)
>>
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Enterohepatic circulation
It should be noted that bilirubin levels should be at least 5mg% to be visible clinically

Visual Assessment of Level of Jaundice (Krammer’s Rule)

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>> Krammer’s rule is based on the concept that jaundice proceeds in a cephalocaudal direction (viz., from head downwards)
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>> This rule applies only to unconjugated hyperbilirubinemia

>> Yellow staining of palms and soles is a danger sign
>>
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This method of bilirubin assessment is unreliable once phototherapy is started

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 R E M E M B E R
Criteria for Pathological JaundiceQ

Chapter 4  •  Neonatology
•• Jaundice before 24 hours of life (Most cases are due to Rh incompatibility)
•• Rise in bilirubin >5 mg/dL/day
•• Peak bilirubin more than 15 mg% (palms and soles affected)
•• Persists more than 1 week (term)/2 weeks (preterm)
•• Conjugated jaundice (conjugated bilirubin >1mg% or > 20% of total bilirubin)

Important Causes of Prolonged Jaundice in Newborn

Unconjugated Hyperbilirubinemia • Sepsis or UTI
• G-6-PD deficiency
• Hemolytic disease of newborn
• Breast milk JaundiceQ
• HypothyroidismQ`
Conjugated Hyperbilirubinemia • Neonatal HepatitisQ Syndrome
• Biliary AtresiaQ
• Choledochal Cyst

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• Sepsis or UTI
• TORCH infections Q

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• Galactosemia or Alpha-1 antitrypsin deficiency

Breast Milk/Feeding and Jaundice

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Breast feeding jaundice Breast milk jaundice
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• Occurs due to inadequate breastfeeding Q
• Occurs during 3 week of life (usually presents as prolongation of
• Occurs during 1st week and disappears by 3rd week of life physiological jaundice)
• Treatment is to increase frequency and duration of • Occurs due to inhibitor (3 alpha 20 beta pregnanediolQ) in breast
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breastfeedingQ milk (inhibits bilirubin conjugation)

• Breastfeeding is NOT contraindicated Q (since it is not associated
with very high levels of jaundice)
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Treatment
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3 modalities are available namely:

1. Phototherapy (Most commonly used)
2. Exchange transfusion (used in severe/ refractory cases)
3. Drugs (used as adjunctive treatment)

Salient Points About Phototherapy

General • Mainstay of treating jaundice in neonatesQ
• Special blue lamps with a peak output at 425 to 475 nm are used
• Irradiance of phototherapy lights should be at least 30 micro W/cm2/nm
• Distance between baby and light should be 30 to 45 cm
• Baby should be lying naked except for diaper and eye patches
Mechanism • It acts by converting insoluble bilirubin (unconjugated) into soluble isomers that can be excreted outside
• Three major mechanisms are:
ƒƒ Structural isomerizationQ (Major mechanism): Here, bilirubin is converted into lumirubinQ
ƒƒ Configurational isomerization: Z-isomers of bilirubin are converted into E-isomers
ƒƒ Photo-oxidation (minor mechanism)
Side effects • ↑ Insensible water loss
• Watery diarrhea (due to ↑ bile salts and bilirubin in the stool)
• Low calcium levels
• Retinal damage (prevented by shielding eyes with eye patches)
Contd...
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 Contraindication • Direct (conjugated) hyperbilirubinemia (since indirect bilirubin levels are not usually high in these conditions and
because phototherapy may lead to the “bronze baby” syndromeQ – causing dark grey-brown pigmentation of skin,
mucous membrane and urine)
• Congenital erythropoietic porphyriaQ or family history of porphyriaQ (associated with severe blistering and
Complete Review of Pediatrics

photosensitivity during phototherapy)

Exchange Transfusion
>> Double-volume exchange transfusion is indicated when there is no response to phototherapy or initial value of bilirubin is above
the cut off for exchange transfusion
>> In a child with Rh isoimmunisation, indication include (i) Cord bilirubin > 5 mg/dl, (ii) Cord Hemoglobin <10 g/dl
>> Twice the volume of the baby’s blood (160 ml/Kg) is required for exchange transfusion
>> Type of blood required for transfusion: Rh-negative donorQ whose cells are compatible with both the infant’s and the mother’s sera.
(type O donor cells are generally usedQ, but cells of the infant’s ABO blood type may be used when the mother has the same type)

Drugs used in Neonatal Jaundice

>> Phenobarbitone (induces the levels of UDP–Glucuronyl transferase)
>> Oral agar (decreases enterohepatic circulation)
>> MetalloprotoporphyrinsQ (e.g., tin and zinc protoporphyrins)–act by inhibiting heme oxygenase enzyme, thereby decreasing the

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generation of bilirubin
>> Intravenous Immunoglobulin (used in Rh isoimmunization where it reduces the need for exchange transfusion)

Recent Advances
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Newer ways of administering phototherapy
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Type Remarks
• Fiberoptic blanket (‘Bili’blanket) phototherapy • Optical fiber based light therapy
• It avoids eye damage (allows phototherapy only on baby’s
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skin)
• Allows phototherapy while breastfeeding
• Portable and compact
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“Double” phototherapy: Two simultaneous light exposure

wherein, the infant lies on fiberoptic blanket with conventional
phototherapy overhead
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• LED (Light emitting diodes) phototherapy ƒƒ This delivers high intensity phototherapy 
ƒƒ Adjustable height
ƒƒ Low power consumption

Contd...

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 • “Spot” phototherapy ƒƒ Used for infants under radiant warmers
ƒƒ Phototherapy is given from above with “quartz
halide” white light having output in blue spectrum

Chapter 4  •  Neonatology
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Kernicterus: (Bilirubin Encephalopathy)
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>> Newer terminology is BINDQ–Bilirubin Induced Neurological Dysfunction
>> It occurs due to the deposition of unconjugated (indirect) bilirubin in the basal ganglia and brainstem nuclei
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Clinical Features
Acute form Chronic form
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• Phase 1 (1st 1-2 days): poor suck, stupor, hypotonia, seizures • “Tetrad” Q:
• Phase 2 (middle of 1st week): hypertonia of extensor muscles, ƒƒ Choreoathetosis
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opisthotonos, retrocollis, fever ƒƒ Deafness

• Phase 3 (after the 1st week): hypertonia ƒƒ Upward gaze palsy
ƒƒ Dental enamel hypoplasia
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Syndromic Associations of Jaundice

Conjugated hyperbilirubinemiaQ Dubin Johnson syndrome
Rotor syndrome
Unconjugated hyperbilirubinemia Crigler NajjarQ syndrome (Type I and II)
Gilbert syndrome
Crigler-Najjar type I is the most severe syndrome associated with jaundice in newborn

Inherited Jaundice (Syndromic Jaundice or Eponymal Jaundice)

>> Crigler-Najjar syndrome:
 Type 1: AR disorder, most severeQ type, presenting with very high unconjugated hyperbilirubinemia in newborn.

 Due to complete absenceQ of conjugating enzyme-UDP glucuronyl transferase (UGT1A1) activity

 Type 2: AD > AR, less severe type. Due to decreased activity of UGT1A1. May respond to Phenobarbitone

>> Gilbert syndrome:

 Most benign type; ADQ inheritance; characterized by intermittent, fluctuating jaundice.

 Due to decreased activity of UGT1A1 (levels more than that observed in Crigler-Najjar syndrome type 2).

 Lipofuscin accumulation in liver

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 >> Dubin Johnson syndrome:
 AR; accumulation of CONJUGATED bilirubin;

 Canalicular protein defect causing decreased secretion of conjugated bilirubin into bile

 Liver appears very dark (due to accumulation of melanin-like pigments)

Complete Review of Pediatrics

>> Rotor syndrome:

 AR; increase in conjugated bilirubin

 Liver appears normal (unlike in Dubin Johnson syndrome)

Features Dubin Johnson Syndrome Rotor Syndrome

Liver appearance Dark Normal
Gall bladder visualization (by oral Not Visualized Often visualized
cholecystogram)
Urine coproporphyrin content Normal with > 80% being isomer – 1* High with <70% being isomer – 1
*Normal urine contains more of isomer-3 than isomer-1

NEONATAL SEPSIS

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>> It is the second most common causeQ of neonatal mortality (the commonest cause being prematurityQ)
>> In India, the most common etiology is KlebsiellaQ followed by Staphylococcus (Worldwide and in developed countries, E.coliQ is the

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most common followed by Group B Streptococcus)

Early Onset Sepsis Late Onset Sepsis

• Occurs within 72 hours Q
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• Caused by organisms prevalent in the maternal genital tract • Caused by organisms in hospital (Nosocomial) or in
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environment (community acquired)
• Predisposing factors: LBW, foul smelling liquor, maternal fever • Often transmitted through the hands of the care-providers
• Commonly presents as pneumoniaQ • Commonly presents as meningitisQ
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Clinical Features
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>> Often nonspecific and requires high index of suspicion

>>
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Poor sucking, decreased cry, lethargy and hypothermia are common features
>> Fast breathing, chest retractions and grunt indicate pneumonia.
>> High-pitched crying, seizures, neck retraction or bulging anterior fontanel are suggestive of meningitisQ

Diagnosis and Treatment

>> Gold standard for diagnosis is Blood culture

Sepsis ScreenQ
Parameter Abnormal value
WBC count <5000/mm3
Absolute neutrophil count <1800/mm3
I:T Ratio (Immature: Total neutrophil ratio) Ratio more than 0.2 (or) Immature neutrophils > 20% of total neutrophils
Micro ESR > 15 mm in first hour
CRP > 1 mg/dL
• 2 or more abnormal valuesQ is taken as positive sepsis screen
• Two consecutive negative sepsis screen (taken 12 hours apart) rules out neonatal sepsis

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Duration of Antibiotic Treatment in Neonatal Sepsis
Diagnosis Duration

Chapter 4  •  Neonatology
Meningitis 21 daysQ
Blood culture positive but no meningitis 14 days
Blood culture negative (but sepsis screen positive and clinically consistent with sepsis) 5–7 days
• Usual first choice drug in a child with neonatal sepsis is ampicillin or penicillin with gentamicin
Q

• In cases of suspected meningitis, cefotaximeQ should be used along with an aminoglycoside.

Recent Advances
Procalcitonin in Neonatal Sepsis
•• A new biomarker that exhibits greater specificity than other markers
•• Levels become elevated within 2–4 hours after birth and peaks at 12–24 hours
•• Early decrease in procalcitonin levels are a reliable marker of appropriate antibiotic therapy

PERINATAL ASPHYXIA

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Definition

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All of the following should be present s,
Mnemonic
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“MAAN”
Multiorgan dysfunction
Acidosis (pH< 7.00) – Metabolic or mixed in umbilical cord
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Apgar scores 0-3 for longer than 5 minutes

Neurological sequelae (eg., seizures, hypotonia)
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Classification
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>> Moderate asphyxia: Apgar score of 4–6 at 1 minute of age

>> Severe asphyxia: Apgar score of 0–3 at 1 minute of age
>> Hypoxic ischemic encephalopathy (HIE) refers to the CNS dysfunction associated with perinatal asphyxia.
>> HIE is the most common cause of neonatal seizuresQ.

Levene’s Classification of HIE

Feature Mild Moderate Severe
Consciousness Irritable lethargy Comatose
Tone Hypotonia Marked hypotonia Q
Severe hypotonia
Seizures No Yes Prolonged
Sucking/ respiration Poor suck Unable to suck Q
Unable to sustain respiration
(mechanical ventilation needed)

Sarnat and Sarnat Staging of HIE

Stage I: Hyper alertQ + Strong moroQ + MydriasisQ
Stage II: Lethargic + weak moro reflex + MiosisQ + seizures
Stage III: ComaQ + absent moroQ + Unequal pupils, Poor light reflex + Decerebrate posturing

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 Treatment of HIE is basically maintenance of normal physiological functions of the newborn
Complete Review of Pediatrics

Recent Advances

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Therapeutic hypothermia in HIE
•• It can be given either as whole body (systemic) or selective cerebral (head cooling) therapeutic hypothermia
•• Usually done with servo-controlled cooling system (to minimize the chances of overcooling)
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•• Aim is to maintain a core (rectal) temperature of 33.5°CQ (92.3°F) within the 1st 6 hours after birth
•• The usual duration of therapeutic hypothermia is 72 hoursQ
•• This treatment modality reduces mortality or major neurodevelopmental impairment in term and near-term infants with HIE (it is
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usually avoided in preterm babies)
How does it work?
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RESPIRATORY DISTRESS
>> Tachypnea (Respiratory rate >60 per minQ) accompanied by chest retractions and or grunt is called as respiratory distress
>> It can be due to respiratory and non-respiratory causes

Major Causes of Respiratory Distress in Newborn

• Respiratory:
ƒƒ Medical disorders: Respiratory distress syndrome (RDS), Meconium aspiration syndrome (MAS), Transient tachypnea of newborn
(TTNB)
ƒƒ Surgical disorders: Tracheoesophageal fistula, diaphragmatic hernia, lobar emphysema
• Cardiac: Congestive heart failure
• Neurological: Asphyxia, cerebral edema, hemorrhage
• Metabolic: Hypoglycemia, hypocalcemia
• Chest wall disorders: Jeune’s Asphyxiating thoracic dystrophy, Werdnig-Hoffman disease

Scoring Systems for Respiratory Distress in Newborn

>> Downe scoring: (can be used for both term and preterm babies)

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 Score Cyanosis Respiratory rate Air entry Retractions Grunting
0 Nil <60/min Normal Nil None
1 In room air 60 – 80/ min Mild decrease Mild Audible with stethoscope

Chapter 4  •  Neonatology
2 In 40% FiO2 >80/min Marked decrease Moderate - severe Audible with naked ear

>> Silverman Anderson scoring (applicable only for preterm babies):

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4/
s,
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Comparison of 3 Major Causes of Respiratory Distress in Newborn

at

Characteristics Respiratory distress syndrome (RDS) Transient tachypnea of newborn Meconium aspiration
di

(TTNB) syndrome (MAS)

Occurrence Preterm (<36 weeksQ) babies Term babies born by caesarean section/ Post maturity or fetal distress
precipitous labor in antenatal period
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Pathophysiology Absent/decreased/Immature surfactant Retained lung fluid Aspirated meconium causing

leads to alveolar collapse
X-ray features • “Ground glass” Q appearance or
“white out” lung (occurs due to
alveolar collapse)
• “Air bronchogramQ” sign (depicted
in arrows below)
L
• “SunburstQ” appearance (prominent
perihilar pulmonary vascular
markings)
• Fluid in lung fissures (depicted in
arrow below)
airway obstruction
Complete obstruction: Collapse
of airway
Partial obstruction: Air
trapping
Non–specific (depends on the
type of obstruction caused by
meconium as described above)

Contd...

107
 Management • Warm humidified oxygen
• CPAP (Continuous positive airway
pressure)
• Mechanical ventilation
Complete Review of Pediatrics
• Supportive treatment • Supportive treatment
• Usually settles within 72 hours (Here, prognosis depends on
the extent of CNS injury from
asphyxia and the presence of

• Surfactant therapy (discussed below) associated problems such as

pulmonary hypertension)

Surfactant Therapy in Newborn

When to Administer?
>> Prophylactic surfactant therapy (administered at the time of delivery or within 15–20 minutes after birth, to infants at risk of RDS)
>> Early rescue therapy (administered within 2 hours of life, i.e., before the diagnosis of RDS)
>> Late Rescue therapy (Given after 2 hours of life, i.e., once the diagnosis of RDS is established)

How to Administer?
In SUREQ approach viz., Intubate, give SUR factant, then Extubate

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4/
s,
ric

Types of Surfactant?
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Natural surfactants (contains proteins SP-B & SP-C) Synthetic Surfactants (do not contain proteins) 
di

• Survanta (bovine lung extract) • Exocerf

• Infasurf (calf lung extract) • Surfaxin
• Curosurf (porcine lung extract) • Artificial surfactant (ALEC)
Pe

Benefits of Surfactant Therapy

>> Improvement in compliance, functional residual capacity, and oxygenation
>> ↓ incidence of air leaks (like pneumothorax)
>> ↓ neonatal mortality

Adverse Effects
>> Pulmonary haemorrhage (more common in ELBW babies and in babies with PDA)

Extra edge
Tests for Fetal Lung Maturity
•• L/S (Lecithin/ Sphingomyelin) ratioQ •• Generally L/S ratio >2 indicates lung maturity (Exception:
•• Lamellar bodyQ counts (measures phospholipids) Infant of diabetic mother where ratio >3.5 indicates maturity)
•• Amniotic fluid ‘shake test’ •• AMNIOSTAT test to detect phosphatidylglycerol and high
•• Foam stability index (FSI) concentrations of saturated phosphatidylcholine (SPC) also
•• TDx-FLM II (measures the surfactant to albumin ratio using indicate lung maturity
fluorescent polarization technology)

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CHRONIC LUNG DISEASE (CLD) OR BRONCHOPULMONARY DYSPLASLA (BPD)
>> Occurs in preterm infants who require respiratory support in the first few days of birth
>> BarotraumaQ and oxygen toxicityQ are two important factors in causation of this disorder

Chapter 4  •  Neonatology
>> It is defined as “oxygen dependency at 36 weeks postmenstrual age in a preterm, VLBW baby”

CONGENITAL DIAPHRAGMATIC HERNIA (CDH)

>> An important congenital anomaly associated with respiratory distress after birth
>> Herniation of abdominal contents into thoracic cavity occurs via the defect in diaphragm

Types
>> Bochdalek herniaQ (Most commonQ type; defect in posterlateralQ part of diaphragm on leftQ side)
>> Morgagni hernia (less common and less severe type; defect in the anterior part)

Clinical Features
>> Respiratory distress soon after birth; cyanosis in severe cases
>> ScaphoidQ abdomen

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>> Decreased or absent breath sounds (on the side of the hernia)
>> Displaced heart sounds (to the opposite side of the hernia)

4/
X-ray Findings
s,
>> Presence of bowel loops in the thoracic cavity and mediastinal shiftQ
ric
Management
>> During resuscitation, bag and mask ventilation is contraindicatedQ (enlarges the
at

stomach and small bowel and thus makes oxygenation more difficult)
>> Aggressive respiratory support in first 48 hours of life which includes
 Intubation and mechanical ventilation (permissive hypercapnia reduces lung
di

injury)
 Extracorporeal Membrane Oxygenation (ECMOQ)
 iNOQ (Inhaled nitric oxide)–reduces pulmonary pressures and results in improved oxygenation
Pe

>> Surgical repair: Ideally done after 48 hours of life

Poor Prognostic Factors

>> Herniation of bowel into chest from 1st trimester onwards
Extra edge
>> Presence of liver herniation Most common causes of mortalityQ in CDH
>> Prenatal Lung-to-head ratio (LHR) < 1Q are the underlying pulmonary hypoplasia
>> Presence of coexisting anomalies (especially cardiac) and pulmonary hypertension

Recent Advances Mnemonic

Newer treatment modalities in CDH: Mnemonic to remember features of Bochdalek hernia:
• Ex utero intrapartum treatment, or the EXIT procedure ‘BBBB’
• FETO (Fetal Endoscopic tracheal occlusion) B – Bochdalek hernia
B – Back side (viz., posterior aspect of diaphragm)
B – Big defect
B – Bad prognosis

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 HEMORRHAGIC DSEASE OF NEWBORN (HDN)
>> Occurs due to vitamin K deficiencyQ thereby causing a subsequent decrease in levels factors II, VII, IX, and X (since Vitamin K
facilitates posttranscriptional carboxylation of these clotting factors)
Complete Review of Pediatrics

>> Usually presents with gastrointestinal bleeding (other sites: intracranial, umbilicus, cephalhematoma)
>> Best diagnostic test: measurement of PIVKAQ (proteins induced in vitamin K absence)
>> Prevention: IntramuscularQ administration of 1 mg of vitamin K at the time of birth
>> Treatment: IntravenousQ vitamin K or FFPQ (fresh-frozen plasma) transfusion in severe cases

Types of HDN
Early HDN Classic HDN Late HDN
Age at presentation Day 1 of life Day 2 – 7 Day 7–6 months of age
Etiology/Risk factors Maternal drugs that
Q
• Exclusive breastfeeding Q
• Neonatal cholestasisQ
interfere with vitamin K (phenobarbital, phenytoin, • Vitamin K prophylaxis • Prolonged antibioticQ
warfarin, rifampicin, isoniazid) not given at birth administration

INFANT OF DIABETIC MOTHER (IDM)

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>> Usual pathological sequence:
Maternal hyperglycemia → fetal hyperglycemia → fetal hyperinsulinemia → complications

4/
>> Problems with ↑ frequency in affected infant:
 Macrosomia
 Congenital anomalies
s,
 Respiratory distress (due to decreased synthesis/delayed maturation of surfactant)
 Jaundice
ric
 Hypocalcemia; hypoglycemia
 Renal vein thrombosis
 Polycythemia
 Hairy pinna is a characteristic physical examination finding noted in these infants
at

Extra edge
di

Commonly asked one–liners on IDM

Pe

•• Most common congenital anomaly: ventricular septal defect (VSD)

•• Most specific congenital anomaly: Caudal regression syndrome
•• Reason for delayed passage of meconium in IDM: Small left colon syndrome

Common Metabolic Problems in Newborn

Hypoglycemia Hypocalcemia
• Definition: Blood glucose value < 40 mg/dL (or plasma glucose
Q
• DefinitionQ:
< 45 mg/dLQ) Total calcium Ionized calcium
• Risk factors/conditions:
ƒƒ SGA and LGA babies Term <8 mg/dL <4.8 mg/dL
ƒƒ Infant of diabetic mother Preterm <7 mg/dL <4 mg/dL
ƒƒ Prematurity (<35 weeks), twins
ƒƒ Sepsis, birth asphyxia
• Risk factors/conditions:
• Clinical features: seizures, lethargy, apnea or tachypnea; may be Early hypocalcemia (<72 hoursQ of life)
ƒƒ Infant of diabetic mother
asymptomatic also
ƒƒ Prematurity (<35 weeks)
• Treatment:
ƒƒ Perinatal asphyxia
Asymptomatic baby Trial of oral feeds Late hypocalcemia (>72 hoursQ of life)
Symptomatic baby I.V bolus of 2 mL/kgQ of 10% dextrose ƒƒ Vitamin D deficiency
followed by glucose infusion ƒƒ Hypoparathyroidism

Contd...
110
Hypoglycemia Hypocalcemia
• Clinical features: myoclonic jerks, jitteriness and seizures;
prolonged QT intervalQ in ECG; may be asymptomatic also

Chapter 4  •  Neonatology
(especially early onset variety)
• Treatment:
Asymptomatic baby 80 mg/kg/day of oral calcium for 48
hours followed by tapering
Symptomatic baby IV bolus of 2 ml/kg of 10% calcium
gluconate (diluted 1:1 with 5%
dextrose) followed by calcium infusion
of 80 mg/kg/day elemental calcium for
48 hours
Cardiac monitoring is a must while IV
calcium is being given

SALIENT FEATURES OF OTHER PROBLEMS EXCLUSIVELY SEEN IN PRETERM BABIES

Apnea of Prematurity

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>> Apnea is defined as cessation of respiration for > 20 secondsQ or any duration (if associated with bradycardia and/or cyanosisQ)

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>> Usually presents after 1-2 daysQ of life and within day 7Q of life
>> The most common pattern is Mixed apnea (consists of obstructed respiratory efforts usually following central pauses – due to
immaturity of CNS)
>> Most apneic spells respond to tactile stimulationQ.
s,
>> Recurrent apnea of prematurity may be treated with caffeine (preferred drugQ) or theophylline
>> This condition usually resolves by 37 weeks of postconceptional age
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Retinopathy of Prematurity (ROP)

at

>> Vasoproliferative disorder of the retina

>> The most important risk factors are (i) prematurityQ (< 32 weeks) and

Recent Advances
di

(ii) low birth weightQ (< 1500 g)

>> Excessive exposure to oxygen (hyperoxia) in the newborn period and
growth factors (especially VEGF) are responsible in pathogenesis BevacizumabQ (anti – VEGF) is a monoclonal antibody
Pe

>> Screening: First screening examination should be carried out at 31 administered as intravitreal injection in ROP
weeksQ of gestation (Postmenstrual age) or 4 weeks of ageQ, whichever
is later
>> Treatment: Cryotherapy or Laser photo-coagulationQ (treatment of choice)

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 Necrotizing Enterocolitis (NEC)
>> It is the most common serious surgical disorder postmenstrual age of the neonate
>> PrematurityPostmenstrual age (<32 weeks) is the single most important risk factor followed by feeding with bovine – milk
Complete Review of Pediatrics

>> Modified Bell’s Staging in NEC:

Classification Stage Clinical features Radiological signs

SUSPECT NEC IA Abdominal distension, vomiting, occult blood in stools Non-specific
IB Same as Stage IA+ gross bloodQ in stools Non-specific
DEFINITE NEC IIA Same as IB + absent bowel sounds Pneumatosis intestinalisQ (Air in the bowel
wall)
IIB Same as IIA + abdominal tenderness Pneumatosis intestinalis + gas in the portal
Systemic features likes mild metabolic acidosis + veinQ
thrombocytopenia
ADVANCED NEC IIIA Same as IIB + features of generalized peritonitis + Same as IIB
(Stage of intestinal severe metabolic acidosisQ and thrombocytopeniaQ
perforation)
IIIB Same as IIIA Same as IIB + PneumoperitoneumQ
>> Treatment:
 Nil per oral (NPO) with nasogastric drainage + intravenous antibiotics

e
 Surgical intervention in stage IIIBQ (for intestinal perforation)

4/
ROLE OF ANTENATAL CORTICOSTEROIDS s,
Guidelines:
>> Antenatal steroids are given to all pregnant women between 24 to 34 weeks of gestationQ who are at risk for preterm delivery within
ric
7 days
>> Schedule: 2 doses of 12 mg of betamethasoneQ IM 24 hours apart (preferred) (or) 4 doses of 6 mg of dexamethasoneQ IM 12 hours
apart
Benefits:
at

>> ↓ in neonatal mortalityQ by 40%

>> ↓ in respiratory distressQ by 50%
di

>> ↓ in intraventricular hemorrhageQ by 50%

>> ↓ in occurrence of patent ductus arteriosus, necrotizing enterocolitis and hemodynamic instability
Pe

Usefulness in other conditions:

>> Antenatal steroids (dexamethasone) when administered from 6 weeks of gestation can prevent the virilization of a female fetus
with CAH (congenital adrenal hyperplasia)
>> Antenatal steroids might reverse heart block occurring as a complication in neonatal lupus

Recent Advances
NICU scoring systems: (Abbreviations):
•• Clinical risk index for babies (CRIB)
•• Score for neonatal acute physiology (SNAP)
•• Neonatal mortality prognosis index (NMPI)

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