Guidelines 2012 2013

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Section of Neonatology Department of PediatricsBaylor College of MedicineHouston, Texas

Arnold J. Rudolph, MMBCh (1918 - 1995)

Guidelines for Acute Care of the Neonate20th Edition, 2012–2013

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Guidelines for Acute Care of the Neonate20th Edition, 2012–2013

Editors

James M. Adams, M.D

Caraciolo J. Fernandes, M.D

Associate Editors

Steven A. Abrams, M.D.

Diane M. Anderson, Ph.D., R.D.

Catherine M. Gannon M.D.

Joseph A. Garcia-Prats, M.D.

Alfred Gest M.D.

Leslie L. Harris, M.D.

Timothy C. Lee M.D.

Tiffany M. McKee-Garrett, M.D.

Muralidhar Premkumar, M.D.Christopher J. Rhee, M.D.

Michael E. Speer, M.D.

Section of Neonatology

Department of Pediatrics

Baylor College of Medicine

Houston, Texas

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Copyright © 1981–2012 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine.

20th Edition, First printing July 2012

Published by

Guidelines for Acute Care of the Neonate

Section of Neonatology, Department of Pediatrics Baylor College of Medicine

6621 Fannin Suite W6104

Houston, TX 77030

All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed

in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Printed in the United

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Guidelines for Acute Care of the Neonate, 20 th Edition, 2012–13

Acknowledgments

Guidelines for Acute Care of the Neonate, 20th Edition, 2012–13

Clinical Review Committees

Care of Very Low Birth Weight Babies, Cardiopulmonary CareJames M. Adams, MD (Chair), Xanthi Couroucli, MD, Cecelia Torres-Day, MD, Daniella Dinu MD, Caraciolo J. Fernandes, MD, Jennifer

Gardner, PharmD, Al Gest MD, Ganga Gokulakrishnan, MD, Charleta Guillory, MD, Leslie L. Harris, MD, Karen E. Johnson, MD, Yvette R.

Johnson, MD MPH, Kimberly Le, PharmD, Krithika Lingappan, MD, George Mandy, MD, Alice Obuobi, MD, Jochen Profit, MD, ChristopherRhee MD, Danielle Rios, MD.

EndocrinologyCatherine M. Gannon MD (Chair), Joseph A. Garcia-Prats, MD, Leslie L. Harris, MD, Binoy Shivanna, MD, Mohan Pammi, MD

EnvironmentJames M. Adams, MD (Chair), Margo Cox, MD, Carol Turnage-Carrier MSN,RN, CNS, Caraciolo J. Fernandes, MD, Al Gest MD

GastroenterologySteven Abrams, MD (Chair), Amy Hair, MD, Madhulika Kulkarni, MD, Muraliadhar Premkumar, MD,

GeneticsMuralidhar Premkumar, MD (Co-Chair), Michael Speer, MD (Co-Chair), Gerardo Cabrera-Meza, MD, Caraciolo J. Fernandes, MD,

HematologyCaraciolo J. Fernandes, MD (Chair), S. Gwyn Geddie, MD, Adel A. ElHennawy, MD, Leslie L. Harris, MD, Yvette R. Johnson, MD,

Muraliadhar Prekumar, MD, Mohan Pammi, MD, Katherine Weiss, MD

Infectious Diseases, MedicationsMichael E. Speer, MD (Chair), Jennifer Gardner, PharmD, Charleta Guillory, MD, Amy Hair, MD, Leslie L. Harris, MD, Kimberly Le,

PharmD, Valerie Moore, MD, Frank X. Placencia, MD, Mohan Pammi, MD, Leonard E. Weisman, MD

NeurologyChristopher Rhee, MD (Chair), Daniela Dinu, MD, Yvette R. Johnson, MD MPH, Binoy Shivanna, MD,

Normal Newborn CareTiffany McKee-Garrett, MD (Chair), Gerardo Cabrera-Meza, MD, Lisa Fuller MD, Catherine M. Gannon, MD, Joseph A. Garcia-Prats, MD,

Jenelle Little, MD, Valarie Moore MD, Joanne Nguyen MD, Monica Patel MD, Lori A. Sielski, MD

Nutrition, Metabolic ManagementDiane M. Anderson, PhD, RD (chair), Saify Abbasi, MD, Steven A. Abrams, MD, Amy Carter, RD LD, Margo Cox, MD, Gerardo Cabrera-

Meza, MD, Ganga Gokulakrishnan, MD, Amy Hair, MD, Nancy Hurst RD, Madhulika Kulkami, MD, Tommy Leonard, MD, Krithika

Lingappan, MD, Adriana Massieu RD CNSD LD, Meghan McDonald, MD, Alice Obuobi, MD, Sundae Rich RD

SurgeryMichael E. Speer MD (Co-Chair), Tim Lee MD (C0-Chair), Daniella Dinu MD, Leslie L. Harris, MD,

End of Life Care, Grief & BereavementLeslie L. Harris, MD (Chair), Jennifer Arnold, MD, Marcia Berretta, LCSW, Torey Mack MD, Frank X. Placencia, MD, Alina Saldarriaga,

MD, Pamela Taylor D.Min, BCC, Tamara Thrasher-Cateni (Family Centered Care Specialist)

ContributorsEndocrinology chapter written with the advice of the Pediatric Endocrine and Metabolism Section, in particular, Drs. Lefki P. Karaviti, Luisa

M. Rodriguez, and Rona Yoffe. Environment chapter, in particular NICU Environment, written with the advice of Carol Turnage-Carrier, MSN

RN CNS. Infectious Disease chapter written with the advice of the Pediatric Infectious Disease Section, in particular, Doctors Carol J. Baker,

Judith R. Campbell, Morven S. Edwards, Mary Healy, and Flor Munoz-Rivas. Human Immunodeficiency Virus (HIV) section written with the

advice of the Allergy & Immunology Section. Genetics chapter written with the advice of Dr. James Craigen of the Department of Molecular

and Human Genetics. Neurology chapter written with the advice of the Neurology Section.

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ii Guidelines for Acute Care of the Neonate, 20th Edition, 2012–13

Section of Neonatology, Department of Pediatrics, Baylor College of Medicin

* Asterisk indicates information new to this edition.

Preface

Purpose

The purpose of these guidelines is to help neonatology fellows, pediatric house officers, and others with the usual routines followed in caring

for common problems encountered in the care of neonates. These guidelines were designed by the Section of Neonatology at Baylor College

of Medicine (BCM). Where appropriate, national guidelines or reference to peer-reviewed scientific investigations are cited to help in the

decision-making process. Also, regional traits unique to the southeast Texas patient population are used when appropriate. The guidelines are

reviewed and revised annually (or more frequently as necessary) as new recommendations for clinical care become available. Users should refer tothe most recent edition of these guidelines.

DedicationThese guidelines are dedicated to Dr. Arnold J. Rudolph (1918–1993), who taught the art of neonatology and whose life continues to touch us in

innumerable ways.

DisclaimerThese are guidelines only and may not be applicable to populations outside the BCM Affiliated Hospitals. These guidelines do not represent official

policy of Texas Children’s Hospital, Ben Taub General Hospital, BCM, or the BCM Department of Pediatrics, nor are they intended as practice

guidelines or standards of care. Specific circumstances often dictate deviations from these guidelines. Each new admission and all significant new

developments must be discussed with the fellow on call and with the attending neonatologist on rounds. All users of this material should be aware ofthe possibility of changes to this handbook and should use the most recently published guidelines.

Summary of major changes, 20th editionMinor changes were made in addition to the major content changes

detailed below.

Cardiopulmonary• Changes to Respiratory Distress – Goals of Management and

Modes of support

• New Ventilator Management - Use of Volume Guarantee

• Changes to Control of Breathing - Planning for Discharge

• Updates to Patent Ductus Arteriosus-treatment of PDA

• Updates to Exogenous Surfactant

• Updates to Respiratory Management of Congenital Diaphragmatic

Hernia

• Updates to Bronchopulmonary Dysplasia

Environment• Updates to Thermal Regulation

Metabolic

• Updates – Hypoglycemia, Management of Glucose Intolerance

Normal Newborn• Updates to Breast Feeding and Supplementation

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Guidelines for Acute Care of the Neonate, 20 th Edition, 2012–13 ii

Section of Neonatology, Department of Pediatrics, Baylor College of Medicine


Contents

Chapter 1. Care of Very Low Birth Weight Babies . . 1General Care (babies < 1500 grams) . . . . . . . . . . . . . . . . 1

Example of Admission Orders . . . . . . . . . . . . . . . . . . 1

Indicate . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Monitoring Orders . . . . . . . . . . . . . . . . . . . . . 1

Metabolic Orders . . . . . . . . . . . . . . . . . . . . . . 1

Respiratory Orders . . . . . . . . . . . . . . . . . . . . . 1

Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . 1

Labs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Medication Orders . . . . . . . . . . . . . . . . . . . . . 1

Screens and Follow-up . . . . . . . . . . . . . . . . . . . 1

Suggested Lab Studies . . . . . . . . . . . . . . . . . . . . . . 1

Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Table 1–1. Admission labs . . . . . . . . . . . . . . . . . . . . 2

Table 1–2. Labs during early hospitalization. . . . . . . . . . . 2

Specialized Care (babies ≤ 26 weeks’ gestation) . . . . . . . . . . 2

Prompt Resuscitation and Stabilization . . . . . . . . . . . . . 2

Volume Expansion . . . . . . . . . . . . . . . . . . . . . . . . 2

Respiratory Care . . . . . . . . . . . . . . . . . . . . . . . . . 2

Vitamin A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Caffeine Citrate. . . . . . . . . . . . . . . . . . . . . . . . . . 3

Other Measure to Minimize Blood Pressure Fluctuations

or Venous Congestion . . . . . . . . . . . . . . . . . . . . 3

Umbilical Venous Catheters . . . . . . . . . . . . . . . . . . . . . 3

Multi-lumen . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Figure 1–1. Double-lumen system . . . . . . . . . . . . . . . . 3

Figure 1–2. Suggested catheter tip placement; anatomy of

the great arteries and veins . . . . . . . . . . . . . . . . . 3

Placing UVCs. . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter 2. Cardiopulmonary Care . . . . . . . . . . 5Resuscitation and Stabilization . . . . . . . . . . . . . . . . . . . 5

Figure 2–1. Resuscitation—stabilization process: birth to

post-resuscitation care. . . . . . . . . . . . . . . . . . . . 5

Circulatory Disorders . . . . . . . . . . . . . . . . . . . . . . . . 5

Fetal Circulation . . . . . . . . . . . . . . . . . . . . . . . . . 5

Postnatal (Adult) Circulation. . . . . . . . . . . . . . . . . . . 5

Transitional Circulation . . . . . . . . . . . . . . . . . . . . . 5

Disturbances of the Transitional Circulation . . . . . . . . . . . 5

Parenchymal Pulmonary Disease . . . . . . . . . . . . . . 5

Persistent Pulmonary Hypertension of the Newborn . . . . 5

Congenital Heart Disease . . . . . . . . . . . . . . . . . . 6

Patent Ductus Arteriosus (PDA) . . . . . . . . . . . . . . 6

Figure 2–2. Fetal circulation . . . . . . . . . . . . . . . . . . . 6

Figure 2–3. Postnatal (adult) circulation . . . . . . . . . . . . . 6 Figure 2–4. Transitional circulation . . . . . . . . . . . . . . . 6

Circulatory Insufficiency . . . . . . . . . . . . . . . . . . . . . 6

Nonspecific Hypotension. . . . . . . . . . . . . . . . . . 6

Treatment . . . . . . . . . . . . . . . . . . . . . . . 6

Figure 2–5. Mean aortic blood pressure during the first

12 hours of life . . . . . . . . . . . . . . . . . . . . . . . 7

Hypovolemic Shock. . . . . . . . . . . . . . . . . . . . . 7

Etiologies . . . . . . . . . . . . . . . . . . . . . . . 7

Treatment . . . . . . . . . . . . . . . . . . . . . . . 7

Cardiogenic Shock . . . . . . . . . . . . . . . . . . . . . 7

Symptoms. . . . . . . . . . . . . . . . . . . . . . . . 7

Treatment . . . . . . . . . . . . . . . . . . . . . . . 7

Septic Shock. . . . . . . . . . . . . . . . . . . . . . . . . 8

Treatment . . . . . . . . . . . . . . . . . . . . . . . 8

Management of Respiratory Distress . . . . . . . . . . . . . . . . 8

Basic Strategies Infants 30 0/7 weeks’ gestation or less . . . . . . . . . . . . . . 8

Infants More Than 30 Weeks’ Gestation . . . . . . . . . . . . . 9

Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . 9

FiO2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Arterial Blood Gas Measurements . . . . . . . . . . . . . 9

Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . 9

Capillary Blood Gas Determination. . . . . . . . . . . . . 9

Nasal CPAP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Continuous Flow CPAP . . . . . . . . . . . . . . . . . . . 9

Bubble CPAP . . . . . . . . . . . . . . . . . . . . . . . . 9

Nasal Cannula (not recommended) . . . . . . . . . . . . . 9

Table 2–2a Calculation of effective FiO2

, Step 1 . . . . . . . . 10

Table 2–2b Calculation of effective FiO2, Step 2. . . . . . . . 10

Indications for Nasal CPAP . . . . . . . . . . . . . . . . . . 10

Apnea of Prematurity . . . . . . . . . . . . . . . . . . . 10

Maintenance of Lung Recruitment . . . . . . . . . . . . 10

Acute Lung Disease . . . . . . . . . . . . . . . . . . . . 11

Mechanical Ventilation. . . . . . . . . . . . . . . . . . . . . . . 11

Endotracheal Tube Positioning . . . . . . . . . . . . . . . . . 11

Importance of Adequate Lung Recruitment . . . . . . . . . . 11

Overview of mechanical Ventilation . . . . . . . . . . . . . . 11

Babies < 1500 g or < 32 weeks gestation . . . . . . . . . . . 11

Babies > 1500 g or 32 weeks and older infants . . . . . . . . 11

Infants with BPD requiring chronic MV . . . . . . . . . . . . 11

HFOV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Volume Guarantee . . . . . . . . . . . . . . . . . . . . . . . 11

Initial Ventilation . . . . . . . . . . . . . . . . . . . . . 11

Maintenance of VG Ventilation . . . . . . . . . . . . . . 11

Weaning VG Ventilation. . . . . . . . . . . . . . . . . . 12

Indications for potential extubation to NCPAP . . . . . . 12

Prolonged Mechanical Ventilation . . . . . . . . . . . . 12

VG References . . . . . . . . . . . . . . . . . . . . . . 12

Table 2–3. Ventilator manipulations to effect . . . . . . . . . 12

Synchronized Ventilation . . . . . . . . . . . . . . . . . . . . . 12

SIMV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Initial Ventilator Settings - SIMV Mode . . . . . . . . . 12

Subsequent Ventilator Adjustments . . . . . . . . . . . . 13

Assist-control (AC). . . . . . . . . . . . . . . . . . . . . . . 13

Pressure Support Ventilation . . . . . . . . . . . . . . . . . . 13

Chronic Mechanical Ventilation. . . . . . . . . . . . . . . . . . 13High-frequency Oscillatory Ventilation (HFOV) . . . . . . . . 14

Table 2–4. Useful Respiratory Equations . . . . . . . . . . . 14

Indications for Use . . . . . . . . . . . . . . . . . . . . . . . 14

Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

HFOV Management . . . . . . . . . . . . . . . . . . . . . . 15

Initial Settings. . . . . . . . . . . . . . . . . . . . . . . 15

Control of Ventilation (PCO2) . . . . . . . . . . . . . . . . . 15

Control of Oxygenation (PO2) . . . . . . . . . . . . . . . . . 15

Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Special Considerations . . . . . . . . . . . . . . . . . . . . . 15

Weaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15


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Contents Section of Neonatology, Department of Pediatrics, Baylor College of Medicine

Selection and Preparation for Home Ventilation. . . . . . . . . 15

Criteria for DC to Home Ventilation . . . . . . . . . . . . . . 16

Migration to Home Ventilator . . . . . . . . . . . . . . . . . 16

Monitoring and Equipment for Home Ventilation . . . . . . . 16

Special Issues . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Surfactant Replacement Therapy . . . . . . . . . . . . . . . . . 16

Prophylactic treatment . . . . . . . . . . . . . . . . . . . . . 16

Rescue treatment . . . . . . . . . . . . . . . . . . . . . . . . 16

Surfactant Product Selection and Administration . . . . . . . 17

Curosurf ® . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Survanta® . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Surfactant Replacement for Term Babies with Hypoxic

Respiratory Failure . . . . . . . . . . . . . . . . . . . . 17

Inhaled Nitric Oxide . . . . . . . . . . . . . . . . . . . . . . . . 17

Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . 17

Administration . . . . . . . . . . . . . . . . . . . . . . . . . 17

Weaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Patent Ductus Arteriosus . . . . . . . . . . . . . . . . . . . . . 18

Treatment of PDA . . . . . . . . . . . . . . . . . . . . . . . 18

Ibuprofen Treatment. . . . . . . . . . . . . . . . . . . . 18

Administration and Monitoring . . . . . . . . . . . . . . 18

Treatment Failure . . . . . . . . . . . . . . . . . . . . . 18

Indomethacin Treatment . . . . . . . . . . . . . . . . . . . . 18The Meconium Stained Infant . . . . . . . . . . . . . . . . . . . 18

After Delivery . . . . . . . . . . . . . . . . . . . . . . . . . 18

No Meconium Obtained. . . . . . . . . . . . . . . . . . 19

Mecomium Obtained . . . . . . . . . . . . . . . . . . . 19

Immediate Post-procedure Care . . . . . . . . . . . . . . . . 19

Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Respiratory Management of Congenital Diaphragmatic

Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Control of Breathing . . . . . . . . . . . . . . . . . . . . . . . . 20

Central Respiratory Drive . . . . . . . . . . . . . . . . . . . 20

Modifiers 20

Sleep State. . . . . . . . . . . . . . . . . . . . . . . . . 20

Temperature . . . . . . . . . . . . . . . . . . . . . . . . 20

Chemoreceptors . . . . . . . . . . . . . . . . . . . . . . 20 Circulatory Time . . . . . . . . . . . . . . . . . . . . . 20

Lung Volume . . . . . . . . . . . . . . . . . . . . . . . 20

Airway Patency and Receptors . . . . . . . . . . . . . . . . . 20

Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Hypopharynx . . . . . . . . . . . . . . . . . . . . . . . 21

Larynx and Trachea . . . . . . . . . . . . . . . . . . . . 21

Respiratory Pump. . . . . . . . . . . . . . . . . . . . . . . . 21

Bony Thorax . . . . . . . . . . . . . . . . . . . . . . . 21

Intercostal Muscles . . . . . . . . . . . . . . . . . . . . 21

Diaphragm. . . . . . . . . . . . . . . . . . . . . . . . . 21

Management of Apnea . . . . . . . . . . . . . . . . . . . . . 21

General Measures . . . . . . . . . . . . . . . . . . . . . 21

Xanthines . . . . . . . . . . . . . . . . . . . . . . . . . 21

Nasal CPAP . . . . . . . . . . . . . . . . . . . . . . . . 22 Role of Anemia . . . . . . . . . . . . . . . . . . . . . . 22

Apnea of Prematurity: Preparation for Discharge . . . . . . . 22

Bronchopulmonary Dysplasia . . . . . . . . . . . . . . . . . . . 22

Etiology and Pathogenesis . . . . . . . . . . . . . . . . . . . 22

Clinical Course . . . . . . . . . . . . . . . . . . . . . . . . . 22

Classic BPD . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Acute Course and Diagnosis . . . . . . . . . . . . . . . 22

Course of Chronic Ventilator Dependency . . . . . . . . 23

Discharge Planning and Transition to Home Care . . . . 23

The “New” BPD . . . . . . . . . . . . . . . . . . . . . . . . 23

Cardiopulmonary Physiology . . . . . . . . . . . . . . . . . 23

Management. . . . . . . . . . . . . . . . . . . . . . . . 23

Supportive Care and Nutrition . . . . . . . . . . . . . . 24

Fluid Restriction. . . . . . . . . . . . . . . . . . . . . . 24

Diuretics . . . . . . . . . . . . . . . . . . . . . . . 24

Thiazides . . . . . . . . . . . . . . . . . . . . . . . . . 24

Furosemide . . . . . . . . . . . . . . . . . . . . . . . . 24

Chloride Supplements. . . . . . . . . . . . . . . . . . . 24

Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Chronic Mechanical Ventilation. . . . . . . . . . . . . . 24

Inhaled Medications . . . . . . . . . . . . . . . . . . . . . . 24

Short Acting Beta-Adrenergic Agents. . . . . . . . . . . 24

Inhaled Corticosteroids . . . . . . . . . . . . . . . . . . 25

Management of Acute Reactive Airway Disease . . . . . 25

Use of Systemic Steroids in Severe Chronic

Lung Disease. . . . . . . . . . . . . . . . . . . . . 25

Exacerbation of Lung Inflammation . . . . . . . . . . . . . . 26

Monitoring the BPD Patient . . . . . . . . . . . . . . . . . . 26

Nutritional Monitoring . . . . . . . . . . . . . . . . . . 26

Oxygen Monitoring . . . . . . . . . . . . . . . . . . . . 26

Echocardiograms . . . . . . . . . . . . . . . . . . . . . 26

Developmental Screening . . . . . . . . . . . . . . . . . 26

Goal Directed Multidisciplinary Care . . . . . . . . . . . . . 26

Discharge Planning . . . . . . . . . . . . . . . . . . . . 26 Prevention of Chronic Lung Disease . . . . . . . . . . . . . . 26

Use of Sodium Bicarbonate in Acute Cardiopulmonary Care. . . 26

Persistant Metabolic Acidosis . . . . . . . . . . . . . . . . . 26

Chapter 3. Endocrinology . . . . . . . . . . . . . . 29An Approach to the Management of Ambiguous Genitalia . . . . . 29

Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Multidisciplinary Team Management of Disorders of Sexual

Evaluation of a Baby with Ambiguous Genitalia. . . . . . . . 29

History. . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Maternal . . . . . . . . . . . . . . . . . . . . . . . 29

Familial . . . . . . . . . . . . . . . . . . . . . . . 29

Figure 3–1. Sexual Differentiation . . . . . . . . . . . . . . . 29

Figure 3–2. Pathways of adrenal hormone synthesis. . . . . . 29 Physical examination . . . . . . . . . . . . . . . . . . . 29

General Examination . . . . . . . . . . . . . . . . 29

External Genitalia . . . . . . . . . . . . . . . . . . 30

Investigations . . . . . . . . . . . . . . . . . . . . . . . 30

Karyotype . . . . . . . . . . . . . . . . . . . . . . 30

Internal Genitalia . . . . . . . . . . . . . . . . . . 30

Figure 3–3. Approach to disorders of sexual differentiation . . 30

Hormonal Tests . . . . . . . . . . . . . . . . . . . 31

The Role of the Parent . . . . . . . . . . . . . . . . . . . . . 31

Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . 31

Hypothyroxinemia of Prematurity . . . . . . . . . . . . . . . . 31

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Table 3–1. Thyroxine values according to gestational age . . . 31

Table 3–2. Thyroxine and thyrotropin levels according togestational age. . . . . . . . . . . . . . . . . . . . . . . 31

Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . 31

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Steroid Therapy for Adrenal Insufficiency . . . . . . . . . . . . 32

Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . 32


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Evaluation of Hypothalamic-Pituitary-Adrenal Axis

and Function. . . . . . . . . . . . . . . . . . . . . . . . 32

Laboratory Testing . . . . . . . . . . . . . . . . . . . . . . . 32

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Persistent Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . 33

Disorders of Insulin Secretion and Production . . . . . . . . . 33

Endocrine Abnormalities . . . . . . . . . . . . . . . . . . . . 33

Disorders of Ketogenesis and Fatty Acid Oxygenation . . . . 33

Defects in Amino Acid Metabolism . . . . . . . . . . . . . . 33

Inborn Errors of Glucose Production. . . . . . . . . . . . . . 33

Laboratory Evaluation for Presistent Hypoglycemia. . . . . . 33

Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . 33

Chapter 4. Environment . . . . . . . . . . . . . . . 35NICU Environment. . . . . . . . . . . . . . . . . . . . . . . . . 35

Effects of Environment . . . . . . . . . . . . . . . . . . . . . 35

Therapeutic Handling and Positioning . . . . . . . . . . . . . 35

Handling. . . . . . . . . . . . . . . . . . . . . . . . . . 35

Positioning . . . . . . . . . . . . . . . . . . . . . . . . 35

Containment . . . . . . . . . . . . . . . . . . . . . 36

Correct Positioning . . . . . . . . . . . . . . . . . 36

Proper Positioning Techniques. . . . . . . . . . . . 36

Environmental Factors . . . . . . . . . . . . . . . . . . . . . 36 Tastes and Odors . . . . . . . . . . . . . . . . . . . . . 36

Sound . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Effects of Sound . . . . . . . . . . . . . . . . . . . 37

Interventions . . . . . . . . . . . . . . . . . . . . . 37

Light, Vision, and Biologic Rhythms . . . . . . . . . . . 37

Effects of Light . . . . . . . . . . . . . . . . . . . 37

Parents: The Natural Environment . . . . . . . . . . . . . . . 37

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Thermal Regulation . . . . . . . . . . . . . . . . . . . . . . . . 38

Table 4–1. Sources of heat loss in infants . . . . . . . . . . . 38

Thermal Stress . . . . . . . . . . . . . . . . . . . . . . . . . 38

Responses: Shivering . . . . . . . . . . . . . . . . . . . 38

Consequences . . . . . . . . . . . . . . . . . . . . . . . 38 Normal Temperature Ranges * . . . . . . . . . . . . . . 38

Management. . . . . . . . . . . . . . . . . . . . . . . . 38

Delivery Room. . . . . . . . . . . . . . . . . . . . 38

Transport . . . . . . . . . . . . . . . . . . . . . . . 38

Bed Selection * . . . . . . . . . . . . . . . . . . . 38

Incubators . . . . . . . . . . . . . . . . . . . . . . 38

Radiant Warmers. . . . . . . . . . . . . . . . . . . 39

Table 4–2. Neutral thermal environmental temperatures:

Suggested starting incubator air temperatures for clinical

approximation of a neutral thermal environment . . . . . 39

Figure 4–1. Effects of environmental temperature on oxygen

consumption and body temperature. . . . . . . . . . . . 39

Weaning from Servo to Manual Control * . . . . . . . . 40

Weaning from Manual Control to Open Crib * . . . . . . 40 Ancillary Measures . . . . . . . . . . . . . . . . . . . . 40

Weaning to Open Crib. . . . . . . . . . . . . . . . . . . 40

Chapter 5. Gastroenterology . . . . . . . . . . . . 41Necrotizing Enterocolitis (NEC). . . . . . . . . . . . . . . . . . 41

Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Gastroschisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Short Bowel Syndrome (SBS) . . . . . . . . . . . . . . . . . . . 41

Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Short-term Goals . . . . . . . . . . . . . . . . . . . . . 42

Long-term Goals . . . . . . . . . . . . . . . . . . . . . 42

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Cholestasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Omega-3 Fatty Acids (Omegaven) . . . . . . . . . . . . . . . . 43

Inclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . 43

Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . 43

Use of Omegaven. . . . . . . . . . . . . . . . . . . . . . . . 43

Duration of Treatment . . . . . . . . . . . . . . . . . . . . . 44

Home Use of Omegaven . . . . . . . . . . . . . . . . . . . . 44

Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Recognizing Underlying End-stage Liver Disease . . . . . . . 44

Gastroesophageal Reflux (GER). . . . . . . . . . . . . . . . . . 44

Erythromycin . . . . . . . . . . . . . . . . . . . . . . . . . . 44

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Chapter 6. Genetics. . . . . . . . . . . . . . . . . . 47Inborn Errors of Metabolism . . . . . . . . . . . . . . . . . . . 47

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Categories of Inborn Errors . . . . . . . . . . . . . . . . 47

Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Figure 6–1. Presentations of metabolic disorders . . . . . . . 48

Hyperammonemia. . . . . . . . . . . . . . . . . . . . . 48

Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . . 48

Disorders of Fatty Acid Oxidation . . . . . . . . . . . . 48

Fetal Hydrops . . . . . . . . . . . . . . . . . . . . . . . 48

Maternal-fetal Interactions . . . . . . . . . . . . . . . . 48

Table 6–1. Metabolic disorders, chromosomal abnormalities,

and syndromes associated with nonimmune fetal hydrops . 49 Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . 49

Neurologic Status . . . . . . . . . . . . . . . . . . . . . 49

Liver Disease . . . . . . . . . . . . . . . . . . . . . . . 49

Cardiac Disease . . . . . . . . . . . . . . . . . . . . . . 50

Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . 50

Online Resources. . . . . . . . . . . . . . . . . . . . . . . . 51

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Cystic Fibrosis * . . . . . . . . . . . . . . . . . . . . . 51

Prediagnosis treatment. . . . . . . . . . . . . . . . . . . 51

Galactosemia . . . . . . . . . . . . . . . . . . . . . . . 51

GSD1 . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

MSUD. . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Organic aciduria. . . . . . . . . . . . . . . . . . . . . . 51 PKU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Urea cycle disorders. . . . . . . . . . . . . . . . . . . . 52

Newborn Screening. . . . . . . . . . . . . . . . . . . . . . . 52

Chromosomal Abnormalities . . . . . . . . . . . . . . . . . . 52

Chromosomal Microarray (CMA) . . . . . . . . . . . . 52

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Table 6–2. Newborn Screening Program in Texas . . . . . . . 52

Chapter 7. Hematology . . . . . . . . . . . . . . . 53Approach to the Bleeding Neonate . . . . . . . . . . . . . . . . 53

Neonatal Hemostatic System. . . . . . . . . . . . . . . . . . 53


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Table 7–1. Differential diagnosis of bleeding in the neonate 53

Abnormal Bleeding. . . . . . . . . . . . . . . . . . . . . . . 53

Coagulation Disorders . . . . . . . . . . . . . . . . . . 53

Thrombocytopenias . . . . . . . . . . . . . . . . . . . . 54

Neonatal Alloimmune Thrombocytopenia (NAIT) . . . . 54

Table 7–2. Causes of neonatal thrombocytopenia . . . . 54

Figure 7–1. Guidelines for platelet transfusion in

the newborn . . . . . . . . . . . . . . . . . . . . . 54

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Blood Transfusion . . . . . . . . . . . . . . . . . . . . . . . . . 55

Trigger Levels . . . . . . . . . . . . . . . . . . . . . . . . . 55

Table 7–3. Risk factors for severe hyperbilirubinemia . . . . . 55

Transfusion and Risk of Necrotizing Enterocolitis. . . . . . . 56

Transfusion Volume . . . . . . . . . . . . . . . . . . . . . . 56

Erythropoietin . . . . . . . . . . . . . . . . . . . . . . . . . 56

Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Figure 7–2. Nomogram for designation of risk based on the

hour-specific serum bilirubin values . . . . . . . . . . . 56

Table 7–4. Hyperbilirubinemia: Age at discharge and

follow-up . . . . . . . . . . . . . . . . . . . . . . . . . 56

Risk Factors for Severe Hyperbilirubinemia . . . . . . . . . . 57

Differential Diagnosis of Jaundice . . . . . . . . . . . . . . . 57

Figure 7–3. Guidelines for phototherapy in hospitalized

infants of ≥35 weeks’ gestation . . . . . . . . . . . . . . 57 Jaundice Appearing on Day 1 of Life . . . . . . . . . . . 57

Jaundice Appearing Later in the First Week . . . . . . . 57

Jaundice Persisting or Appearing Past the First Week . . 57

Cholestatic Jaundice. . . . . . . . . . . . . . . . . . . . 57

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Figure 7–4. Guidelines for exchange transfusion in infants

35 or more weeks’ gestation. . . . . . . . . . . . . . . . 58

Follow-up of Healthy Term and Late-term Infants at

Risk for Hyperbilirubinemia . . . . . . . . . . . . . . . 58

Management . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Phototherapy . . . . . . . . . . . . . . . . . . . . . . . 58

Intravenous Immune globulin . . . . . . . . . . . . . . . 59

Indications for Exchange Transfusion . . . . . . . . . . 59

Management of Hyperbilirubinemia in Low Birth Weight Infants . . . . . . . . . . . . . . . . . . . . 59

Table 7–5. Guidelines for Management of Hyperbilirubinemia

in Low Birth Weight Infants. . . . . . . . . . . . . . . . 59

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Exchange Transfusion . . . . . . . . . . . . . . . . . . . . . . . 59

Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Before the Exchange . . . . . . . . . . . . . . . . . . . . . . 60

Important Points to Remember . . . . . . . . . . . . . . . . . 60

Exchange Procedure . . . . . . . . . . . . . . . . . . . . . . 60

After the Exchange . . . . . . . . . . . . . . . . . . . . . . . 60

Hypervolemia–polycythemia . . . . . . . . . . . . . . . . . . . 60

Etiologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Chapter 8. Infectious diseases . . . . . . . . . . . 61Bacterial Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

General Points . . . . . . . . . . . . . . . . . . . . . . . . . 61

Blood Cultures . . . . . . . . . . . . . . . . . . . . . . . . . 61

Age 0 to 72 Hours (early-onset, maternally acquired sepsis) . . 61

Indications for Evaluation. . . . . . . . . . . . . . . . . 61

Term Infants (infants > 37 weeks’ gestation) . . . . 61

Preterm Infants (infants < 37 weeks’ gestation) . . . 61

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 61

Term Infants . . . . . . . . . . . . . . . . . . . . . 61

Preterm Infants. . . . . . . . . . . . . . . . . . . . 61

Initial Empirical Therapy . . . . . . . . . . . . . . . . . 61

Duration of Therapy. . . . . . . . . . . . . . . . . . . . 61

Late-onset Infection . . . . . . . . . . . . . . . . . . . . . . 61

Indications for Evaluation. . . . . . . . . . . . . . . . . 62

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 62

Initial Empirical Therapy . . . . . . . . . . . . . . . . . 62

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Group B Streptococcus (GBS) . . . . . . . . . . . . . . . . . . . 62

Management of At-risk Infants . . . . . . . . . . . . . . . . . 62

Figure 8–1. Incidence of early-and late-onset group B

streptococcus . . . . . . . . . . . . . . . . . . . . . . . 62

Figure 8–2. Algorithms for the prevention of early-onset

group B streptococcus. . . . . . . . . . . . . . . . . . . 63

Figure 8–3. Time course of acute hepatitis B at term and

chronic neonatal infection. . . . . . . . . . . . . . . . . 64

Figure 8–4. Recommended immunization schedule for

persons age 0–6 years—United States, 2010 * . . . . . . 64

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Figure 8–5. Algorithm for screening for group B streptococcal

(GBS) colonization and use of intrapartum prophylaxis for

women with preterm* labor (PTL) . . . . . . . . . . . . 65 Figure 8–6. Algorithm for screening for group B streptococcal

(GBS) colonization and use of intrapartum prophylaxis for

women with preterm* premature rupture of membrane

(pPROM) . . . . . . . . . . . . . . . . . . . . . . . . . 65

Figure 8–7. Recommended regimens for intrapartum antibiotic

prophylaxis for prevention of early-onset group B

streptococcal (GBS) disease* premature rupture of

membrane (pPROM) . . . . . . . . . . . . . . . . . . . 66

Cytomegalovirus (CMV) . . . . . . . . . . . . . . . . . . . . . 66

General Points . . . . . . . . . . . . . . . . . . . . . . . . . 66

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Fungal Infection (Candida) . . . . . . . . . . . . . . . . . . . . 66

General Points . . . . . . . . . . . . . . . . . . . . . . . . . 66 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Chemoprophylaxis . . . . . . . . . . . . . . . . . . . . . . . 66

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Gonococcal Disease . . . . . . . . . . . . . . . . . . . . . . . . . 67

Managing Asymptomatic Infants. . . . . . . . . . . . . . . . 67

Managing Symptomatic Infants . . . . . . . . . . . . . . . . 67

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Vaccine Use in Neonates . . . . . . . . . . . . . . . . . . . . 67

Figure 8–8. Time course of acute hepatitis B at term and

chronic neonatal infection. . . . . . . . . . . . . . . . . 67

Maternal Screen Status . . . . . . . . . . . . . . . . . . . . . 67

Positive . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Unknown . . . . . . . . . . . . . . . . . . . . . . . . . 68

Routine Vaccination . . . . . . . . . . . . . . . . . . . . . . 68

Recommended Doses of Hepatitis B Virus Vaccines . . . 68

Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Hepatitis C Virus Infection . . . . . . . . . . . . . . . . . . . . 68

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Herpes Simplex Virus (HSV) . . . . . . . . . . . . . . . . . . . 68

Newborns of Mothers with Suspected HSV . . . . . . . . . . 68

A Careful History. . . . . . . . . . . . . . . . . . . . . . . . 69


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At-risk Infants . . . . . . . . . . . . . . . . . . . . . . . . . 69

Maternal . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Neonatal . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Management of At-risk Infants. . . . . . . . . . . . . . . . . 69

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Human Immunodeficiency Virus (HIV) . . . . . . . . . . . . . 69

Treatment of Newborn Infants . . . . . . . . . . . . . . . . . 69

Figure 8–9. Recommended immunization schedule for

persons aged 0-6 years—United States, 2012. . . . . . . 70

Dosage. . . . . . . . . . . . . . . . . . . . . . . . . . . 70

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Immunization Schedule for Hospitalized Infants . . . . . . . 70

Respiratory Syncytial Virus (RSV) . . . . . . . . . . . . . . . . 72

Infection Prophylaxis . . . . . . . . . . . . . . . . . . . . . . 72

Indications for Use of Palivizumab. . . . . . . . . . . . . . . 72

Dosage. . . . . . . . . . . . . . . . . . . . . . . . . . . 72

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Rotavirus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Syphilis, Congenital . . . . . . . . . . . . . . . . . . . . . . . . 72

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Figure 8–10. Algorithm for evaluation of positive

matermal RPR. . . . . . . . . . . . . . . . . . . . . . . 73

Table 8–1. Treponemal and non-treponemal serologic testsin infant and mother . . . . . . . . . . . . . . . . . . . . 73

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Symptomatic Infants or Infants Born to Symptomatic

Mothers . . . . . . . . . . . . . . . . . . . . . . . 73

Asymptomatic Infants. . . . . . . . . . . . . . . . . . . 73

Biologic False-positive RPR . . . . . . . . . . . . . . . 73

Evaluation for At-risk Infants . . . . . . . . . . . . . . . . . 73

Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Dosing. . . . . . . . . . . . . . . . . . . . . . . . . . . 74

ID Consultation. . . . . . . . . . . . . . . . . . . . . . . . . 74

Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Newborns of PPD-positive Mothers . . . . . . . . . . . . . . 74 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Varicella-Zoster Virus (VZV) . . . . . . . . . . . . . . . . . . . 74

Exposure in Newborns . . . . . . . . . . . . . . . . . . . . . 74

Clinical Syndromes Varicella Embryopathy . . . . . . . 74

Perinatal Exposure . . . . . . . . . . . . . . . . . . . . 74

Varicella-Zoster Immune Globulin (VariZIG) and Intravenous

Immune Globulin (IVIG) . . . . . . . . . . . . . . . . . 74

Indications for VariZIG . . . . . . . . . . . . . . . . . . 74

Dosing . . . . . . . . . . . . . . . . . . . . . . . . 75

Where to Obtain VariZIG . . . . . . . . . . . . . . 75

Indications for IVIG. . . . . . . . . . . . . . . . . . . . 75

Isolation 67

Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

References . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Chapter 9. Medications . . . . . . . . . . . . . . . 77Medication Dosing . . . . . . . . . . . . . . . . . . . . . . . . . 77

Table 9–1. Usual dosing ranges . . . . . . . . . . . . . . . . 77

Managing Intravenous Infiltrations . . . . . . . . . . . . . . . . 77

Phentolamine mesylate . . . . . . . . . . . . . . . . . . . . . 77

Hyaluronidase . . . . . . . . . . . . . . . . . . . . . . . . . 78

Common Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . 78

Serum Antibiotic Level . . . . . . . . . . . . . . . . . . . . . 78

Table 9–2. Guidelines for initial antibiotic doses and

intervals based on categories of postconceptual age . . . 79

Table 9–3. Medication Infusion Chart . . . . . . . . . . . . . 80

Chapter 10. Metabolic Management . . . . . . . . . 81Fluid and Electrolyte Therapy. . . . . . . . . . . . . . . . . . . 81

Water Balances . . . . . . . . . . . . . . . . . . . . . . . . . 81

Table 10–1. Fluid (H2O) loss (mg/kg per day) in standard

incubators . . . . . . . . . . . . . . . . . . . . . . . . . 81

Table 10–2. Fluid requirements (mL/kg per day) . . . . . . . 81

Electrolyte Balance. . . . . . . . . . . . . . . . . . . . . . . 81

Table 10–3. Composition of GI fluids . . . . . . . . . . . . . 81

Short-term Intravascular Fluid Therapy (day 1 to 3) . . . . . 81

Fluid Composition . . . . . . . . . . . . . . . . . . . . . . . 81

Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . . . 81

Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Etiology of Hypoglycemia . . . . . . . . . . . . . . . . . . . 82

Evaluation and Intervention . . . . . . . . . . . . . . . . . . 82

Fluid and Venous Line Management . . . . . . . . . . . . . . 82

Glucose Calculations . . . . . . . . . . . . . . . . . . . . . . 82

Hyperglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Management . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Hyperkalemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Evaluation and Treatment . . . . . . . . . . . . . . . . . . . 84

Suspected Hyperkalemia . . . . . . . . . . . . . . . . . . . . 84Hyperkalemia with Cardiac Changes. . . . . . . . . . . . . . 84

Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Infant of Diabetic Mother (IDM) . . . . . . . . . . . . . . . . . 84

Metabolic Complications. . . . . . . . . . . . . . . . . . . . 84

Congenital Malformations . . . . . . . . . . . . . . . . . . . 84

Table 10–4. Common anomalies in infants of diabetic mothers. . 84

Admission Criteria for Newborn Nursery . . . . . . . . . . . 84

Protocol in Newborn Nursery . . . . . . . . . . . . . . . . . 84

Hypocalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Early Hypocalcemia . . . . . . . . . . . . . . . . . . . . . . 84

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Other Factors . . . . . . . . . . . . . . . . . . . . . . . 85

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 85

Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Late Hypocalcemia . . . . . . . . . . . . . . . . . . . . . . . 85

Assesment and Management of Seizures due to Hypocalcemia

in Infants 3 to 10 Days of Age Born at Greater Than 34

Weeks’ Gestation . . . . . . . . . . . . . . . . . . . . . . . 85

Initial Assesment . . . . . . . . . . . . . . . . . . . . . . . . 85

Intravenous Medication Therapy . . . . . . . . . . . . . . . . 85

Oral Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Hypercalcemia or Hyperphosphatemia * . . . . . . . . . . . . . 86

Use of Sodium Bicarbonate in Acute Cariopulmonary Care . . 86

Persistent Metabolic Acidosis . . . . . . . . . . . . . . . . . . . 87

Figure 10–1. Screening for and management of postnatal

glucose homeostasis in late-preterm (LPT 34-36 6/7

weeks) and term small-for-gestational age (SGA) infants

and infants born to mothers with diabetes (IDM)/large- for-gestational age (LGA) infants. . . . . . . . . . . . . 87

Chapter 11. Neurology . . . . . . . . . . . . . . . . 89Encephalopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Table 11–1. Sarnat stages of encephalopathy . . . . . . . . . 89

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Intervention/therapies. . . . . . . . . . . . . . . . . . . . . . 89

Treatment Criteria for Whole Body Cooling . . . . . . . . . . 89

TCH Total Body Cooling Protocol . . . . . . . . . . . . . . . 90

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90


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Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Incidence . . . . . . . . . . . . . . . . . . . . . . . . . 90

Background and Pathogenesis . . . . . . . . . . . . . . . . . 90

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Initial Treatment. . . . . . . . . . . . . . . . . . . . . . 90

Table 11–2. Most Common Etiologies of Neonatal Seizures . . . 91

Outcome and Duration of Treatment . . . . . . . . . . . . . . 91

Cerebral Hemorrhage and Infarction. . . . . . . . . . . . . . . 91

Periventricular, Intraventricular Hemorrhage (PIVH) . . . . . 91

Periventricular Leukomalacia (PVL) . . . . . . . . . . . . . . 92

Perinatal and Neonatal Stroke (term and near term infant) . . 92

Traumatic Birth Injuries (Nervous System) . . . . . . . . . . . 93

Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Cephalohematoma. . . . . . . . . . . . . . . . . . . . . 93

Skull Fractures . . . . . . . . . . . . . . . . . . . . . . 93

Subgaleal hemorrhage. . . . . . . . . . . . . . . . . . . 93

Intracranial hemmorrhages . . . . . . . . . . . . . . . . 93

Brachial palsies and phrenic nerve injury. . . . . . . . . 93

Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . . . . 93

Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Neural Tube Defects. . . . . . . . . . . . . . . . . . . . . . . . . 93

Meningomyelocele . . . . . . . . . . . . . . . . . . . . . . . 93 Prenatal Surgery. . . . . . . . . . . . . . . . . . . . . . 93

Immediate Management. . . . . . . . . . . . . . . . . . 94

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 94

Discharge Planning . . . . . . . . . . . . . . . . . . . . 94

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Drug-exposed Infants. . . . . . . . . . . . . . . . . . . . . . . . 94

Nursery Admission . . . . . . . . . . . . . . . . . . . . . . . 94

Maternal Drug and Alcohol History . . . . . . . . . . . . . . 94

General. 83

Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Treatment of Withdrawal. . . . . . . . . . . . . . . . . . . . 94

Nonpharmacologic Measures . . . . . . . . . . . . . . . 94

Pharmacological Measures . . . . . . . . . . . . . . . . 94 Opioid Withdrawal Guidelines . . . . . . . . . . . . . . . . . 95

Opioid Weaning Options . . . . . . . . . . . . . . . . . 95

Additional Considerations . . . . . . . . . . . . . . . . . . . 95

Methadone. . . . . . . . . . . . . . . . . . . . . . . . . 95

Pain Assessment and Management . . . . . . . . . . . . . . . . 95

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Nonpharmacologic Pain Management . . . . . . . . . . . . . 96

Pharmacologic Pain Management . . . . . . . . . . . . . . . 96

Morphine Sulfate . . . . . . . . . . . . . . . . . . . . . 96

Table 11–3. Suggested management of procedural pain in

neonates at Baylor College of Medicine affiliated

hospital NICUs . . . . . . . . . . . . . . . . . . . . . . 96

Figure 11–1. Neonatal abstinence scoring system . . . . . . . 97

Fentanyl Citrate . . . . . . . . . . . . . . . . . . . . . . 98 Procedural Pain Management . . . . . . . . . . . . . . . . . 98

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Hypoxic-ischemic Encephalopathy . . . . . . . . . . . . . . 98

Seizures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Drug-exposed Infants. . . . . . . . . . . . . . . . . . . . . . 98

Pain Assessment and Management . . . . . . . . . . . . . . . 99

Chapter 12. Normal Newborn . . . . . . . . . . . 101Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Transitional Period . . . . . . . . . . . . . . . . . . . . . . 101

Routine Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Bathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Cord Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Eye Care * . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Eye Prophylaxis and Vitamin K Administation . . . . . . . .101

Feeding, Breastfeeding . . . . . . . . . . . . . . . . . . . . .102

Lactation Consultants . . . . . . . . . . . . . . . . . . .102

Maternal Medications . . . . . . . . . . . . . . . . . . .102

Methods and Practices . . . . . . . . . . . . . . . . . .102

Assessment . . . . . . . . . . . . . . . . . . . . . . . .102

Ankyloglossia . . . . . . . . . . . . . . . . . . . . . . . . .102

Supplementation: Health Term Newborns . . . . . . . . . . .102

Indications for supplementation-infant issues . . . . . .102

Indications for supplementation-maternal issues . . . . .102

Supplementation: Vitamins and Iron . . . . . . . . . . . . . .102

Figure 12–1. Breastfed infant with > 8% weight loss

algorithm . . . . . . . . . . . . . . . . . . . . . . . . .103

Working Mothers . . . . . . . . . . . . . . . . . . . . .104

Contraindications to Breast Feeding . . . . . . . . . . .104

Maternal Medications . . . . . . . . . . . . . . . . . . .104

Feeding, Formula Feeding . . . . . . . . . . . . . . . . . . .104

Formula Preparations . . . . . . . . . . . . . . . . . . .104

Feeding During the First Weeks. . . . . . . . . . . . . .104

Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104

Screening - Hearing . . . . . . . . . . . . . . . . . . . . . .104 Screening - Blood * . . . . . . . . . . . . . . . . . . . . . 105

Glucose Screening of at Risk Infants . . . . . . . . . . .105

State Newborn Screening . . . . . . . . . . . . . . . . .105

Ben Taub General Hospital (BTGH) . . . . . . . . . . .105

Texas Children’s Hospital (TCH) . . . . . . . . . . . . .105

Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105

Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105

Sleep Position. . . . . . . . . . . . . . . . . . . . . . . . . .105

Positional Plagiocephaly Without Synostosis (PWS). . .105

Urination and Bowel Movements . . . . . . . . . . . . . . .105

Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

Cardiac, Murmurs . . . . . . . . . . . . . . . . . . . . . . . . .106

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . .106

Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

Birthmarks . . . . . . . . . . . . . . . . . . . . . . . . . . .106

Dimples. . . . . . . . . . . . . . . . . . . . . . . . . . . . .107

Cutaneous Markers Associated with Occult Spinal

Dysraphism . . . . . . . . . . . . . . . . . . . . .107

References . . . . . . . . . . . . . . . . . . . . . . . . . . .107

Ear Tags and Pits . . . . . . . . . . . . . . . . . . . . . . . .107

References . . . . . . . . . . . . . . . . . . . . . . . . . . .107

Forceps Marks . . . . . . . . . . . . . . . . . . . . . . . . .107

Lacerations . . . . . . . . . . . . . . . . . . . . . . . . . . .107

Nipples, Extra . . . . . . . . . . . . . . . . . . . . . . . . .107

Rashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Scalp Electrode Marks . . . . . . . . . . . . . . . . . . . . . 94 Subcutaneous Fat Necrosis . . . . . . . . . . . . . . . . . . .108

Extracranial Swelling . . . . . . . . . . . . . . . . . . . . . . . 108

Caput Succedaneum . . . . . . . . . . . . . . . . . . . . . .108

Cephalohematoma . . . . . . . . . . . . . . . . . . . . . . .108

Subgaleal Hemorrhage . . . . . . . . . . . . . . . . . . . . .108

Cause and Appearance . . . . . . . . . . . . . . . . . .108

Evaluation and Management . . . . . . . . . . . . . . .108

Table 12–1. Features of extracranial swelling . . . . . . . . 108

Hospital Discharge . . . . . . . . . . . . . . . . . . . . . . . . .108

Early Discharge. . . . . . . . . . . . . . . . . . . . . . . . .108

Criteria for Early Discharge . . . . . . . . . . . . . . . . . .109


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Chapter 14. Surgery . . . . . . . . . . . . . . . . 129Perioperative Management . . . . . . . . . . . . . . . . . . . . 129

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129

Blood Products . . . . . . . . . . . . . . . . . . . . . . . . .129

Complications . . . . . . . . . . . . . . . . . . . . . . . . .129

Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . .129

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . .129

Peripheral and Central Venous Access . . . . . . . . . . . . .129

Peripheral . . . . . . . . . . . . . . . . . . . . . . . . .129

Central. . . . . . . . . . . . . . . . . . . . . . . . . . .129

Stomas, Intestinal. . . . . . . . . . . . . . . . . . . . . . . .130

Specific Surgical Conditions . . . . . . . . . . . . . . . . . . . . 130

Bronchopulmonary Sequestration (BPS). . . . . . . . . . . .130

Chylothorax. . . . . . . . . . . . . . . . . . . . . . . . . . .130

Cloacal Malformations and Cloacal Exstrophy . . . . . . . .131

Congenital Cystic Adenomatoid Malformation (CCAM) . . .131

Congenital Diaphragmatic Hernia (CDH) . . . . . . . . . . .131

Congenital Lobar Emphysema (CLE) . . . . . . . . . . . . .132

Duodenal Atresia . . . . . . . . . . . . . . . . . . . . . . . .132

Esophageal Atresia and Tracheal Fistula . . . . . . . . . . . .132

Extracorporeal Life Support (ECLS). . . . . . . . . . . . . .133

Table 14–1. ECLS Criteria . . . . . . . . . . . . . . . . . . .133

ECLS Circuit . . . . . . . . . . . . . . . . . . . . . . .133

Cannulae . . . . . . . . . . . . . . . . . . . . . . .133 Physiology of ECLS . . . . . . . . . . . . . . . . . . .133

Venoarterial . . . . . . . . . . . . . . . . . . . . .133

Venovenous . . . . . . . . . . . . . . . . . . . . .133

Gastroschisis . . . . . . . . . . . . . . . . . . . . . . . . . .133

Hirschsprung Disease (HD) . . . . . . . . . . . . . . . . . .134

Imperforate Anus (IA) . . . . . . . . . . . . . . . . . . . . .134

Inguinal Hernia . . . . . . . . . . . . . . . . . . . . . . . . .134

Intestinal Atresia . . . . . . . . . . . . . . . . . . . . . . . .134

Malrotation and Midgut Volvulus . . . . . . . . . . . . . . .135

Meconium Ileus (MI). . . . . . . . . . . . . . . . . . . . . .135

Chapter 15. End of Life Care, Grief &Bereavement . . . . . . . . . . . . . . . . . . . . 137

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . .123Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . .137

Understanding and Communicating at the End of Life . . . . .137

Attachment in Pregnancy. . . . . . . . . . . . . . . . . . . .137

Professional and Societal Perceptions of Death and Grieving. . . 137

Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . .137

Determination of Limitation or Withdrawal of Care . . . . . .137

The Texas Advance Directives Act and its Application

to Minors. . . . . . . . . . . . . . . . . . . . . . .137

Special Circumstances Surrounding Delivery Room

Resuscitation. . . . . . . . . . . . . . . . . . . . .138

Developing Consensus between the Medical Team

and the Family . . . . . . . . . . . . . . . . . . . .138

Disagreement between the Medical Team and the Family. . 138

Bioethics Committee Consultation . . . . . . . . . . . .138 Patients in Child Protective Services Custody . . . . . .138

Imparting Difficult Information . . . . . . . . . . . . . .138

Documentation . . . . . . . . . . . . . . . . . . . . . .139

The Transition to Comfort Care . . . . . . . . . . . . . . . . . 140

Supporting the Family . . . . . . . . . . . . . . . . . . . . .140

Care of the Dying Infant . . . . . . . . . . . . . . . . . . . .140

Pharmacologic Management. . . . . . . . . . . . . . . . . . . .140

Narcotics . . . . . . . . . . . . . . . . . . . . . . . . . . . .140

Benzodiazepines * . . . . . . . . . . . . . . . . . . . . . . .141

Habituated Patients . . . . . . . . . . . . . . . . . . . . . . .141


Oral Medications . . . . . . . . . . . . . . . . . . . . . . . .141

Adjunct Medications . . . . . . . . . . . . . . . . . . . . . .141

Death of the Infant . . . . . . . . . . . . . . . . . . . . . . . . .141

Transitioning to Conventional Ventilation, Decreasing

Ventilatory Support, and Removal of Endotracheal Tube . . 141

Pronouncing the Death . . . . . . . . . . . . . . . . . . . . .141

The Option of No Escalation of Care . . . . . . . . . . . . .141

Organ Donation. . . . . . . . . . . . . . . . . . . . . . . . .141

Medical Examine . . . . . . . . . . . . . . . . . . . . . . . .141

Autopsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . .141

Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142

Perinatal Hospice . . . . . . . . . . . . . . . . . . . . . . . .142

Funeral Homes . . . . . . . . . . . . . . . . . . . . . . . . .142

Nursing Bereavement Support Checklist. . . . . . . . . . . .142

Lactation Support. . . . . . . . . . . . . . . . . . . . . . . .142

Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . .142

Support of Hospital Team Members . . . . . . . . . . . . . .142

The Grief Process . . . . . . . . . . . . . . . . . . . . . . . . .142

Timing and Stages of Grief. . . . . . . . . . . . . . . . . . .142

Special Circumstances Relating to Fetal or Infant Death . . . 143

Religious and Cultural Differences Surrounding Death and

Grieving . . . . . . . . . . . . . . . . . . . . . . . . . .143

Self-Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .143

References . . . . . . . . . . . . . . . . . . . . . . . . . . .143 Figure 15–1. Fetal End of Life Algorithm . . . . . . . . . . .143

Figure 15–2. Neonatal End of Life Algorithm . . . . . . . . .144

Appendix. Overview of Nursery RoutinesCharting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145

Lab Flow Sheets . . . . . . . . . . . . . . . . . . . . . . . .145

Problem Lists . . . . . . . . . . . . . . . . . . . . . . . . . .145

Procedure Notes . . . . . . . . . . . . . . . . . . . . . . . .145

Weight Charts and Weekly Patient FOCs and Lengths. . . . .145

Communicating with Parents . . . . . . . . . . . . . . . . . . .145

Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . .145

Child Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Occupational and Physical Therapy . . . . . . . . . . . . . . . 145

Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145Discharge or Transfer Documentation . . . . . . . . . . . . . . 145

Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

Note. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

At Ben Taub . . . . . . . . . . . . . . . . . . . . . . . . . .146

Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . .146

Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . .146

Gloves . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

Gowns . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

Stethoscopes . . . . . . . . . . . . . . . . . . . . . . . . . .146

Isolation Area. . . . . . . . . . . . . . . . . . . . . . . . . .146

Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146

Nutrition Support After Discharge . . . . . . . . . . . . . . . . 146

Parent Support Groups . . . . . . . . . . . . . . . . . . . . . .146ROP Screening . . . . . . . . . . . . . . . . . . . . . . . . . . .146

General Guidelines—Ben Taub General Hospital . . . . . . . .146

Triage of Admissions . . . . . . . . . . . . . . . . . . . . . .146

Daily Activities . . . . . . . . . . . . . . . . . . . . . . . . .146

Rounds . . . . . . . . . . . . . . . . . . . . . . . . . .146

Code Warmer Activities. . . . . . . . . . . . . . . . . .146

Neo Resuscitation Team Response . . . . . . . . .147

Scheduled Lectures . . . . . . . . . . . . . . . . . . . .147

Ordering Routine Studies. . . . . . . . . . . . . . . . . . . .147

Routine Scheduled Labs, X rays, etc . . . . . . . . . . .147

Ordering TPN and Other Fluids. . . . . . . . . . . . . .147

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Cardiology Consultations. . . . . . . . . . . . . . . . . . . .147

Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . .147

Transfer and Off-service Note . . . . . . . . . . . . . . . . .147

Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . 147

Clinic Appointments Protocol at Ben Taub. . . . . . . . . . .147

Level 1 Clinics . . . . . . . . . . . . . . . . . . . . . .147

Level 2 Clinics . . . . . . . . . . . . . . . . . . . . . .148

General Guidelines—Texas Children’s Hospital. . . . . . . . . 148

Texas Children’s NICU Daily Activities . . . . . . . . . . . .148

Transfer and Off-service Notes. . . . . . . . . . . . . . . . .148

Texas Children’s Night Call Activities . . . . . . . . . . . . . 148

Neurodevelopmental Follow-up . . . . . . . . . . . . . . . .148

High-risk Developmental Follow-up Clinic. . . . . . . .148

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I-VI

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General Care (babies < 1500 grams)

Example of Admission Orders

Each infant’s problems will be unique. Appropriate routines will vary bygestation and birth weight. Each order, including all medication doses

and IV rates, must be individualized. In current practice each infant has

a basic admission order set in the EMR. Additional orders are added per

individual indication. The following categories of orders are common in

VLBW infants.

Indicate• Unit of admission (eg, NICU) and diagnosis.

Order• A humidified convertible incubator/radiant warmer is preferred for

infants with BW less than 1250 grams or less than 32 weeks. If

servo-control mode of warmer or incubator is used, indicate servo

skin temperature set point (usually set at 36.5°C). Always useradiant warmer in servo-control mode.

• Use plastic wrap blanket to reduce evaporative water loss if on a

radiant warmer for babies who weigh 1250 grams or less.

Monitoring Orders• Cardio-respiratory monitor.

• Oximeter - oxygen saturation target 90-95% for premature infants

and term babies with acute respiratory distress (alarm limits 88-

96%).

• Vital signs (VS) and blood pressure (BP) by unit routines unless

increased frequency is indicated.

• Umbilical artery catheter (UAC) or peripheral arterial line to BP

monitor if invasive monitoring is done.

Metabolic Management Orders• I&O measurements.

• Type and volume of feeds or NPO.

• IV fluids or parenteral nutrition.

• If arterial line is in place, order heparinized NS at 0.5 mL per hour.

Respiratory Orders• If infant is intubated, order ET tube and size.

• Standard starting ventilator settings for infants with acute lung

disease:

Ventilator Orders should include mode and settings:

CPAP –Bubble CPAP, and level of end expiratory pressure

SIMV – rate, PIP, Ti, PEEP

A/C – PIP, Ti, PEEP, Back Up Rate

VG – Target Vt, Pmax (instead of PIP)

FiO2 – as needed to maintain target saturations

Diagnostic Imaging• Order appropriate radiographic studies.

• Order cranial US between 7 and 14 days of life.

Labs• Admission labs: CBC with differential and platelets, blood type,

Rh, Coombs, glucose

• Obtain results of maternal RPR, HIV, GBS and hepatitis screens.

• Order other routine labs.

• Order labs to manage specific conditions as needed (eg, electrolytes

at 12 to 24 hours of life).• Order newborn screen at 24 to 48 hours of age and DOL 14.

Medication OrdersMedication orders commonly include:

• vitamin K – 0.5 mg IM.

• eye prophylaxis – erythromycin ophthalmic ointment.

• Surfactant replacement (as indicated) – (indicate BW, product

and dose needed) (see Cardiopulmonary chapter).

• antibiotics – if infant is considered to be at risk for sepsis (see

Infectious Diseases chapter).

• Vitamin A (for infants with BW 1000 grams or less) – 5000 IU

intramuscularly every Monday, Wednesday, Friday for 4 weeks

(12 doses).• caffeine citrate (for infants BW 1250 grams or less) – 20 mg/kg

loading dose followed by 5 mg/kg/day given once daily. Initiate

therapy within first 10 days of life.

Screens and Follow-up• Order hearing screen before hospital discharge. Hearing screens

should be performed when the baby is medically stable, > 34 weeks

postmenstrual age and in an open crib.

• Order ophthalmology screening for ROP if:

» less than 1500 grams birth weight or 30 weeks’ gestation or less

or

» 1500 to 2000 grams birth weight or greater than 30 weeks’ gesta-

tion with unstable clinical course where physician believes infantis at risk for ROP.

• Before discharge,

» observe infant in car safety seat for evidence of apnea,

bradycardia, or oxygen desaturation,

» offer CPR training to parents,

» schedule high-risk follow-up clinic as recommended below,

» write orders for palivizumab as appropriate.

• Schedule other laboratory screening tests as recommended below.

Suggested Lab StudiesThese labs are appropriate for many VLBW admissions to NICU and

are provided as a general guideline. Many babies will not require this

volume of tests, others will require more. Review this list with the

Attending Neonatologist. Regularly review routine scheduled labs and

eliminate those no longer necessary. See Table 1–1 and Table 1–2.

Follow-upMany of these infants will require follow-up for CNS, cardiac, renal,

ophthalmologic, or otologic function. Additional follow-up of specific

conditions may be warranted as well.

Cranial ultrasounds (US)—Order US for infants less than 1500 grams

birth weight between 7 and 14 days of age. When the baby reaches term

or at discharge, another US is recommended to detect cystic periven-

tricular leukomalacia (PVL).

Care of Very Low

Birth Weight Babies1

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Chapter 1—Care of Very Low Birth Weight Babies Section of Neonatology, Department of Pediatrics, Baylor College of Medicine

Infants with US that demonstrates significant IVH require follow-up

ultrasounds (weekly, every other week, or monthly) to identify progres-

sion to hydrocephalus.

Screening for retinopathy of prematurity (ROP) – Initial and follow-

up eye exams by a pediatric ophthalmologist should be performed

at intervals recommended by the American Academy of Pediatrics

(Pediatrics 2006; 117:572–576). If hospital discharge or transfer

to another neonatal unit or hospital is contemplated before retinal

maturation into zone III has taken place or if the infant has been treated

by ablation for ROP and is not yet fully healed, the availability of

appropriate follow-up ophthalmologic examination must be ensured and

specific arrangements for that examination must be made before such

discharge or transfer occurs.

Development Clinic – TCH Infants who weigh less than 1501 grams

at birth should be scheduled for the Desmond Developmental Clinic

at four months adjusted age. Infants with HIE, Twin-Twin Transfusion

syndrome or those requiring ECMO should also be referred. Patients

in these categories should have an initial developmental consultation

and evaluation before discharge. Other infants whose clinical course

placing them at high risk will be scheduled on an individual basis. Clinic

appointments are made through the Neonatology office.

Hearing screen – Perform a pre-discharge hearing screen on all

infants admitted to a Level 2 or 3 nursery. Infants with congenital

cytomegalovirus (CMV), bronchopulmonary dysplasia (BPD), ormeningitis and infants treated with ECMO might have a normal screen

at discharge but later develop sensorineural hearing loss.

Monitoring for anemia – Laboratory testing (a hemoglobin/hematocrit

with a reticulocyte count, if indicated) to investigate the degree of

physiologic anemia of prematurity should be considered as needed based

on an infant’s clinical status, need for positive pressure/ oxygen support,

size, recent phlebotomies, and most recent hematocrit. Frequency

of such testing may vary from every 1 to 2 weeks in the sick, tiny

premature infant on positive pressure support to once a month or less in

a healthy, normally growing premature infant. Efforts should be made to

cluster such routine sampling with other laboratory tests.

Specialized Care

(babies ≤ 26 weeks’ gestation)The following care procedures are recommended initial management for

infants who are 26 or fewer weeks’ gestation.

Prompt Resuscitation and StabilizationInitiate prompt resuscitation and stabilization in the delivery room with

initiation of CPAP, or intubation and intermittent positive pressure venti-

lation (IPPV) and surfactant replacement if needed.

Volume ExpansionAvoid use of volume expanders. But if given, infuse volume expanders

over 30 to 60 minutes. Give blood transfusions over 1 to 2 hours.

A pressor agent such as dopamine is preferable to treat nonspecific

hypotension in babies without anemia, evidence of hypovolemia, or

acute blood loss.

Respiratory CareDetermination of the need for respiratory support in these infants after

delivery should include assessment of respiratory effort and degree of

distress. ELBW infants, whose mothers received antenatal steroids,

may be vigorous and have good respiratory effort at birth. Such a

patient can receive a trial of spontaneous breathing on NCPAP startingin the delivery room. If respiratory distress develops or pulmonary

function subsequently deteriorates, the infant should be intubated and

given early rescue surfactant (within first 2 hours). See Chapter 2 -

Cardiopulmonary Care. The goal of care is maintenance of adequate

inflation of the immature lung and early surfactant replacement in

those exhibiting respiratory distress to prevent progressive atelectasis.

Achieving adequate lung inflation and assuring correct ET tube position

before dosing are essential for uniform distribution of surfactant

within the lung (correct ET position may be assessed clinically or by

radiograph).

After initial surfactant treatment, some babies will exhibit a typical

course of respiratory distress and require continued ventilation.

However, many will have rapid improvement in lung compliance.

Rapid improvement in lung compliance necessitates close monitoring

and prompt reduction in ventilator PIP, FiO2, and rate. Initial reduction

in ventilator settings after surfactant should be determined by clinical

assessment (eg, adequacy of chest rise). Monitor clinically and obtain

blood gases within 30 minutes of dosing and frequently thereafter.

When ventilator support has been weaned to minimal levels, attempt

extubation and place infant on nasal CPAP. Minimal support includes:

• FiO2 30% or less

• PIP 20 cm or less

• Vt 3.6-4.5 ml/kg (VG)

• Rate less than 25/min (SIMV)

• PEEP 5-6 cm

Infants meeting these criteria may be extubated and placed on nasalCPAP. This often will require loading with caffeine.

Vitamin AMany extremely preterm infants have low plasma and tissue concen-

trations of vitamin A. A large randomized trial demonstrated that

supplemental vitamin A (5000 IU three times per week for 4 weeks)

in infants with BW 1000 grams or less requiring positive pressure at

birth is safe, and results in a small reduction in their risk of developing

bronchopulmonary dysplasia. All infants 1000 grams or less at birth on

positive pressure (CPAP or mechanical ventilation) should be started on

vitamin A (for dosing, see Medication Orders section in this chapter)

Table 1–2. Labs during early hospitalization, days 1 to 3

Electrolytes, glucose

BUN Every 12 to 24 hours (depends on infant’s size and

metabolic stability)

Calcium (ionized) 24 and 48 hours of age

TSB every 24 hours (depends on size, presence of

bruising, ABO-Rh status, pattern of jaundice)

Hematocrit every 24 to 48 hours (depends on size, previous

hematocrit, and ABO-Rh status)

Table 1–1. Admission labs

CBC, platelets at admission

Blood culture, ABG at admission, if appropriate

Glucose screening at 30 minutes of age

Electrolytes, glucose

BUN 12 or 24 hours of age (depends on infant’s size and

metabolic stability)

Calcium (ionized) at 24 and 48 hours of age

Total Serum Bilirubin at 24 hours of age or if visibly jaundiced (depends on size, presence of bruising, ABO-Rh status)

Newborn screens

First screen at 24 to 48 hours of age

Second screen Repeat newborn screen at

Documents

Guidelines 2012 2013