Management of Critical Neonates

in NICU Room

Rinawati Rohsiswatmo
 Terminology

Premature (WHO): Low Birth Weight:

Low Birth Weight <2500 g
All babies born within
Very Low Birth Weight: <1500 g
gestational age of <37 weeks Extremely Low Birth Weight: <1000 g
The highest ratio of weight gain in fetus are at week 26 to 36

Optimal growth for the premature is the growth

curve intra uterine, this requires the nutrients to be
digestible and absorbable
 Brain Development is Most Rapid in
The First 1000 Days of Life

BW BL Brain Weight Body calcium (TBV)

375 g 28000 mg
3500 g

50 cm
5600 mg
800 g 30 cm 75 g

25 40 25 40 25 40 25 40

Intrauterine Growth in The Last Trimester TBV at 2 years is ~ 83% of adult volume

A Structural MRI Study of Human Brain Development from Birth to 2 Years. J Neurosci. November 19, 2008 • 28(47):12176 –12182.
Early Childhood Brain Development. Todd Twogood, MD, FAAP
Brain Development

Belfort MB. Human Milk and Preterm Infant Brain Development. Breastfeeding Medicine. 2018 Apr;13(S1):S-23-S-25.
Kostović, I., Sedmak, G., & Judaš, M. (2018). Neural histology and neurogenesis of the human fetal and infant brain. NeuroImage. doi:10.1016/j.neuroimage.2018.12.043
Babies Born Early Can Have Brain Injury · Frontiers for Young Minds [Internet]. [cited 2020 Sep 30]. Available from: https://kids.frontiersin.org/article/10.3389/frym.2018.00020
The management
of premature
infants
I. At birth
Risk assessment, resuscitation preparation, and resuscitation
The Golden Minute: Assisted breathing/ventilation must be optimal within
1 minute.
The Golden Hour: STABLE must be achieved in 1 hour

Neonatal care in the first hour → Neonatal care in the first hour
significant impact on infant should focus on reducing Teamwork, consistent care, and evidence-
outcomes, especially in preterm complications: hypothermia, IVH, based practice application will enhance
infants CLD, and ROP neonatal care quality

Val Castrodale, MSN, RN, NNP-BC; Shannon Rinehart, RNC-NIC, BSN. The Golden Hour, improving the stabilization of the very low birth-weight infant. The national association of neonatal nurses. 2014Tin
W, Milligan DW, Pennefather P, Hey E. Pulse oximeter, severe retinopathy, and outcome at one year in babies of less than 28 weeks gestation. Arch Dis Child Fetal Neonatal Ed. 2001;84:F106-109-14
 “The Golden Minute”
● 60 second ➔ initial steps, re-evaluate, and initiate ventilation (if needed)
● The most important step for successful newborn resuscitation
● The decision to continue the initial steps is determined by simultaneous assessment:
○ Work of breathing (apnea, gasping, or respiratory effort)
○ Heart rate (< 100/min or > 100/min)

Wyckoff MH, Aziz K, Escobedo MB, Kapadia VS, Kattwinkel J, Perlman JM, et al. Part 13: neonatal resuscitation: 2015 american heart association guidelines update for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2015;132(suppl 2):S543-S560.
 When to Predict HIE and to start Passive
Cooling in the Delivery Room?

Mosalli R. Whole body cooling for infants with hypoxic-ischemic encephalopathy. J Clin Neonatol. 2012 Apr;1(2):101-6. doi: 10.4103/2249-4847.96777.
PMID: 24027701; PMCID: PMC3743149.
Hypoxic-Ischemic Encephalopathy
Assessment of encephalopathy severity (Sarnat scoring)

Queensland Clinical Guidelines. Hypoxic‐Ischaemic Encephalopathy (HIE). Encycl Diagnostic Imaging. 2008:932–932.
 Hypoxic-Ischemic Encephalopathy
Assessment of HIE (Thompson scoring)

Bhagwani DK, Sharma M, Dolker S, Kothapalli S. To Study the Correlation of Thompson Scoring in Predicting Early Neonatal Outcome in Post Asphyxiated Term Neonates. J Clin Diagn Res. 2016 Nov;10(11):SC16-
SC19. doi: 10.7860/JCDR/2016/22896.8882. Epub 2016 Nov 1. PMID: 28050462; PMCID: PMC5198415.
 VIDEO

2. Respiratory Support
Focus on lung development and safe oxygen administration.

Belfort MB. Human Milk and Preterm Infant Brain Development. Breastfeeding Medicine. 2018 Apr;13(S1):S-23-S-25.
Kostović, I., Sedmak, G., & Judaš, M. (2018). Neural histology and neurogenesis of the human fetal and infant brain. NeuroImage. doi:10.1016/j.neuroimage.2018.12.043
Babies Born Early Can Have Brain Injury · Frontiers for Young Minds [Internet]. [cited 2020 Sep 30]. Available from: https://kids.frontiersin.org/article/10.3389/frym.2018.00020
 VIDE
O

Gemelli 1 Gemelli 2
VIDE
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 2. Respiratory Support
Focus on lung development and safe oxygen administration.

• Monitoring with pulse oximetry

• Humidification if possible (for very
premature infants) Pulse oximetry

Neopuff dengan humidifier

Mixsafe dengan humidifier

 Oxygen Saturation Target

• There were 2 groups:

• Group of infants with 5th minute SpO2 ≥ 80%
• Group of infants with 5th minute SpO2 < 80%
• Premature infants who need breathing apparatus:
• Did not reach the target oxygen saturation of 80% at 5 minutes of age →
decreased oxygen saturation in the brain → cerebral hypoxia
• Heart rate was significantly lower at 3 and 4 minutes in the group with SpO2 80%
3. Nutrition Administration
Aggressive nutrition for very preterm babies

The highest rate of fetal weight gain occurs between weeks 26 and 36.

Objective:
The growth of premature infants should mimic that of fetuses in the
uterus at the same gestational age, which is approximately
15g/kg/day.

(American Academy of Pediatrics, 2015)

6th World Congress Perinatal Medicine In Developing Countries, Jakarta, March 9th, 2010
https://pedsinreview.aappublications.org/content/20/9/e56
 Revised TPN Guideline in Cipto Mangunkusumo Hospital for Preterm Infants
Day Fluid (mL/kg) GIR (mg/kg/minute) Protein (g/kg) Lipid (g/kg)
Birth weight 500 g-600 g or Gestational age 23 weeks
Double Wall Humidified Incubator Infant warmer
0 4 2-2.5 1.0
80 110—120
1-2 4—5
Up to 10**
3-5 o Can be increase up to 12 in Up to 4** Up to 3**
Can be increase up to 150 at 1 week*
hypoglycemia condition
o Close monitoring blood glucose level
Birth weight 601-800 g or Gestational age 24 weeks
Double Wall Humidified Incubator Infant warmer
0 4 2-2.5 1.0
80 100—110
1-2 4—5
Up to 10**
o Can be increase up to 12 in Up to 4** Up to 3**
Can be increase up to 150 at 1 week*
3-5 hypoglycemia condition
o Close monitoring blood glucose level
Birth weight 801-1000 g or Gestational age 25-27 weeks
Double Wall Humidified Incubator Infant warmer
0 4 2-2.5 1.0
80 80—100
1-2 4—5
Up to 10**
3-5 o Can be increase up to 12 in Up to 4** Up to 3**
Can be increase up to 150 at 1 week*
hypoglycemia condition
o Close monitoring blood glucose level

*Consider: fluid input, output, IWL, plasma sodium level

** include enteral feeding
 Revised TPN Guideline in Cipto Mangunkusumo Hospital for Preterm Infants
Day Fluid (mL/kg) GIR (mg/kg/minute) Protein (g/kg) Lipid (g/kg)
Birth weight 1000-1499 g or Gestational age 28-32 weeks
Double Wall Humidified
Infant warmer
Incubator
0 4—5 2.0-2.5 1.0
60—80 80—100
1-2 5—6
8—10
o Can be increase up to 12 in
hypoglycemia condition Up to 4** Up to 3**
3-5 Can be increase up to 150 at 1 week* o Should be adjust with enteral
feeding
o Close monitoring blood glucose
level
Birth weight 1500-2499 g or Gestational age 33-36 weeks
0 60
4—6
1- 2 60—80
6—8
o Can be increase up to 12 in Adjust with enteral Adjust with enteral
hypoglycemia condition feeding feeding
3-5 Can be increase up to 150 at 1 week* o Should be adjust with enteral
feeding
o Close monitoring blood glucose
level

*Consider: fluid input, output, IWL, plasma sodium level

** include enteral feeding
Choices of Enteral Feeding in RSCM
 Enteral Feeding Advancement

*Note:
Fast increment did not increase the risk of NEC, mortality or interruption of
feeds (Cochrane review, 2014)
Consider fortifying feeds when reaching 100 ml/kg/day
Consider removing parenteral nutrition lines after reaching enteral intake
120 ml/kg/day to minimize infection risk
Courtesy of dr Lily Rundjan SpA(K), presented in PICU NICU 2020
Pilling E, et al. Feeding Preterm Infant. Yorkshire and Humber neonatal ODN. 2011
Buku asuhan nutrisi bayi prematur, RSCM, 2016
REVISED Enteral and Parenteral Feeding Guideline in Preterm Infants
Modified by DRS, KY, RR, LR*

*Dalam proses pengajuan HAKI RSCM

 Contraindications to Enteral Feeding

Absolute Contraindication Relative Contraindication

• Hemodynamic instability: enteral nutrition in an ischemic • Severe feeding intolerance

small bowel can worsen the ischemia and lead to necrosis • Intestinal dysmotility
and bacterial overgrowth
• HS-PDA
• Significant gastrointestinal pathology (e.g NEC, mechanical
bowel obstruction, active gastrointestinal haemorrhage, • Severe GERD
intestinal perforation) • Diagnosed/ Suspected risk of aspiration
• HIE on cooling therapy • Under certain medications
• Respiratory failure or profound apneu with impending • Planned to undergo surgery/anaesthetic
intubation indication procedures
• Post gastro-intestinal surgery

Courtesy of dr Lily Rundjan SpA(K), presented in PICU NICU 2020

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3564561/#!po=15.7143
4. Infection Prevention

Enhancing aseptic
Environmental and antiseptic
Hand hygiene
cleaning techniques during
invasive procedures
 4. Infection Prevention

Performing proper care Appropriate use of

Safe feeding practice
procedures antibiotics

Pencegahan dan Pengendalian Infeksi di Ruang Perawatan Bayi. Courtesy of: Ns. Dian Anggur, S.Kep
5. Newborns should feel comfortbale

Day-night cycles are

established by dimming Avoiding coldness (room
Create a position similar to the
lights/covering the temperature 23°-25° C) Humidity
intrauterine position (nest)
maintained at 70%
incubator with cloth
and reducing noise.
Positioning
Floating
Solitude
Flexed position
Intrauterine

Many inappropriate Developmental

developmental Disorder
stimuli
Extrauterine
NIDCAP & Keperawatan Keluarga, courtesy of: Ns. Dian Anggur, S.Kep & dr. Lily Rundjan, Sp. A(K)
Positioning
• Regular use of positioning aids in the long
term helps motor development, calms the
baby, and ensures physiological stability.
• Create a position similar to the intrauterine
position, with boundaries → create a nest.

NIDCAP & Keperawatan Keluarga, courtesy of: Ns. Dian Anggur, S.Kep & dr. Lily Rundjan, Sp. A(K)
5. Newborns should feel comfortbale

Preparing the mother as

Pain free Kangaroo Mother Care close as possible to the baby

Administration of sucrose to
reduce pain

NIDCAP & Keperawatan Keluarga, courtesy of: Ns. Dian Anggur, S.Kep & dr. Lily Rundjan, Sp. A(K)
Summary of Japanese Neonatal Cardiopulmonary Resuscitation Guidelines 2015
 How to Minimalize Stress and Pain
Procedures → orogastric tube, skin-
Stress → cortisol level increases → limits
breaking procedures such as heel
neuron formation, interferes with memory
prick and venipuncture, even giving a
function and brain development
bath

• Swaddling
• Skin to skin contact or kangaroo mother care (KMC)
• Non-nutritive sucking (NNS)
• Reduce environmental stimuli (reduce exposure to light and
noise)
• Breastmilk
• Music therapy
• Oral sucrose
• Mother’s presence
Lago P, Garetti E, Pirelli A, Merazzi D, Bellieni CV, Levet PS, dkk. Non-
pharmacological intervention for neonatal pain control. Ital J Pediatr. 2014
Oct 9;40(Suppl 2):A52.
 How to Minimalize…continued
No sucrose given Oral sucrose given

Sucrose as analgesic, effective to reduce pain in

neonates even in preterms.
 Sucrose as Analgesic in CMH
Oral sucrose (33% sucrose) is given 2 minutes before minor
procedure and can be repeated every 2 minutes using 1 mL
syringe (needle must be removed first)

Maximum dose given Maximum dose given

Weight Dosage
per procedure per day
Fasting Feeding

< 1500 gram 0.05 – 0.1 ml 0.2 ml 0.5 ml 2.5 ml

≥ 1500 gram 0.1 – 0.25 ml 0.2 ml 1 ml 5 ml

Take Home Message

Critical management in the NICU involves

coordination and harmonization of the team.

The expected end result is not just survival but

certainly optimal quality of life.
ANY QUESTION?