CARE OF NORMAL NEWBORN

This protocol should be extended to a normal neonate only, and not the high risk neonates. Normal
neonate for the purpose of this protocol has been defined as follows:
Birth weight greater than 2500 g and gestation of 37 weeks or more
Birth weight between 10th to 90th percentiles as per intrauterine growth charts
Absence of maternal illness or intra-partum event that may put a neonate at risk of illness (e.g.
gestational diabetes , antepartum hemorrhage etc
Normal Apgar scores with no need for resuscitation at birth
No postnatal illness such as respiratory distress, sepsis, dyselectrolemia, hypoglycemia or
polycythemia

Care at birth
1, 2
Personnel and Equipment to be present at delivery : One health provider (physician or nurse)
trained in neonatal resuscitation must be physically available at time of birth of all infant irrespective of
its risk status (high or low). It is not good enough to have someone on call.

If the delivery is anticipated to be high risk because of presence of risk factors identified before birth,
more advanced neonatal resuscitation may be required. In these cases, 2 persons should be present
solely to manage the baby. The goal should be to provide a resuscitation team, with specified leader
and an identified role of each member. For multiple births, there should be separate teams.

The resuscitation corner must be physically located in the delivery room itself. The health professional
designated to care for the baby at birth should check for the Resuscitation Preparedness at the
birthing place well in time before the baby is delivered (Table 1). One may refer the Neonatal
Resuscitation Programme for details of resuscitation3
Table 1. Checklist for Resuscitation Preparedness

For Providing Warmth Preheat the warmer by turning on manual mode for at least 20 minutes
Make available at least 3 towels and blanket
Thermoregulation in Plastic Bag or plastic wrap.
small babies
For positioning The shoulder rolls should be prepared and kept ready
For clearing airway 10 to 12F suction catheter attached to wall suction set at 80-100 mmHg
Meconium aspirator
For ventilation Check for the availability and the functioning of the self inflating bags
Check for availability of all sizes of the masks 00, 0, and 1
8F feeding tube and 20 mL syringe
For oxygen delivery Oxygen tubing or T piece resuscitator that can deliver the free flow oxygen
Pulse oximeter
Option for providing varying concentration of oxygen (blender, air, oxygen)
For intubation Laryngoscope with blades of sizes 0 and 1
Endotracheal tubes, sizes- 2.5, 3.0, 3.5, 4.0
For medication Access to 1:10,000 epinephrine and normal saline
Supplies for administrating medications and placing emergency umbilical venous
catheter
Neonatal case record sheet for documentation
For Transportation The transport incubator should be stationed in the birthing place for the transportation
in all high risk deliveries

The Neonatal Resuscitation Programme guidelines are based on the American Academy of Pediatrics (AAP) and
American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care of the neonate.3 The evidence based guidelines originally published in October 2010 are based on the
international Liaison Committee on Resuscitation (ILCOR) consensus on science statement. The evidence-
based worksheets, prepared by ILCOR, can be viewed in the science area of NRP Web site at www.aap.org/nrp.

Time of Birth: The attending physician/nurse should note the time of birth. It is important to call out
the time of birth loudly; this helps in accurate recording of the time and alerts other personnel in case
any help is needed.

Standard Precautions and asepsis at birth: The personnel attending the delivery must exercise all
the universal/standard precautions in all cases.4 All fluid products from the baby/ mother should be
treated as potentially infectious. Gloves, masks and gowns should be worn when resuscitating the
newborn. The protective eyewear or face shields should be worn during procedures that are likely to
generate droplets of blood or other bodily fluids.
It is important to prevent infection at birth by observing five cleans: 5
(1) Clean hands: appropriate hand-hygiene and wearing sterile gloves
(2) Clean surface: use clean and sterile towel to dry and cover the baby
(3) Clean cord: the umbilical cord should be cut with a clean and sterile blade/scissor
 (4) Clean thread : The cord should be clamped with a clean and sterile clamp or tie
(5) Do not apply anything to the cord.

Prevention and management of hypothermia: Immediately after birth the newborn is at maximum
risk of hypothermia. This early hypothermia may have a detrimental effect on the health of the infant.
Special care should be taken to prevent and manage hypothermia. It should be ensured that the delivery
room is 250C and free from draft of air. The pediatrician should receive the baby directly (no middle

A meta-analysis including 15 trials (1912 neonates) 9 showed that delayed cord clamping
was associated with benefits at 2 to 6 months:
Improved hematocrit (WMD: 3.7 g/dL, 95% CI 2.00 5.40)
Iron status measured by ferritin concentration
Clinical anemia (RR; 0.53; 95% CI, 0.40 0.70) .

person should be allowed) in a pre-warmed sterile linen sheet.

The infant should be dried thoroughly including the head and face areas.6 any wet linen should not be
allowed to remain in contact with the infant. The infant may be placed on the mothers abdomen
immediately after the birth to ensure early skin-to-skin (STS) contact with the mother.7 This will not only
maintain the newborns temperature, but also promote early breastfeeding and decreases the pain and
bleeding in the mother. The baby should be observed for the transition period and made wear the caps

A review by Puieg J et al (2007)8 found that skin-to-skin contact between the mother and her baby immediately
after birth reduces crying, improves mother-infant interaction, keeps the baby warm, and helps the mother to
breastfeed successfully. No important negative effects were identified.

and socks.
Delayed clamping of umbilical cord: Umbilical cord clamping must be delayed for nearly 2 minutes in
order to allow transfer of additional amount of blood from placenta to the infant. This delayed cord
clamping in term babies is associated with improved hematologic status, iron status and clinical anemia
at 2 to 6 months. Even though, there was an increase in polycythemia among infants in whom late
clamping was done, this appeared to be benign.
Cleaning of baby: The baby should be dried and cleaned at birth with a clean and sterile cloth. The
cleaning should be gentle and should only wipe out the blood and the meconium and not be vigorous
enough to remove the vernix caseosa (white greasy material on the skin). The vernix, protects skin of
the infant and helps maintain temperature.10 This gets absorbed on its own after sometime. Currently
there is no evidence of advantage of cleaning the baby with paraffin or any other emollient at birth and
the same is not recommended.

Clamping of the cord: The umbilical cord should be clamped at 2-3 cm away from the abdomen using
a commercially available clamp, a clean and autoclaved thread or a sterile rubber band. The stump
should be away from the genitals to avoid contamination. When the commercial clamps are not
available, the rubber band could be a better option than a thread, as once cord starts shriveling; the
rubber band would still maintain its grip while the thread might loosen up.11 Inspect the cord every 15-
30 minutes for initial few hours after birth for early detection of any oozing from the cord12

Routine stomach wash: Performing routine stomach wash in the babies to prevent gastritis (amniotic
fluid or meconium) should not be done. There are no studies that report the advantage of this ritual.

Care of the Eye: At birth both the eyes of the neonates should be cleaned with separate swabs. The
sterile water or the normal saline may be used for this purpose. The swipe to clean the eyes should be
gentle and from the inner canthus area to the outer canthus. Currently, there is insufficient evidence to
recommend the routine antibiotic prophylaxis for prevention of opthalmia neonatorum in Indian
settings13, 14, 15. The cleaning on a daily basis is not recommended as a routine.

Placement of identity band: The birthing places with high birth rates should take utmost care to
ensure the identity of the mother-baby dyad by an appropriate method as per the hospital policy. Each
infant must have an identity band containing name of the mother, hospital registration number, gender
and birth weight of the infant.16 Reliability of the foot prints for identification has not been
investigated.

Recording of Apgar scores: The apgar scores should be recorded at 1 minutes and 5 minutes of birth17.
This score has a limited value in guiding for resuscitation and initial stabilization. The prediction of the
subsequent outcomes by Apgar scores is also poor.18 However; Apgar scores may help deciding the need
for nursery admission.
CARE OF BABY DURING THE INITIAL FEW HOURS AFTER BIRTH

Weight record of the Baby: The baby should be weighed after stabilization and the temperature is
documented to be normal. A sterile preheated sheet (or a single use paper towel) should be placed on 5
to 10 gm sensitivity weighing machine. Zeroing of the machine should be performed. The baby is then
gently placed on the weighing machine and the weight recorded.19 Weighing of the baby is a complex
skill and it requires adequate training of health providers.

Initiation of breastfeeds: The breastfeeding should be initiated at the earliest time possible. The health
provider should actively assist the mother to put the baby on breast irrespective of the mode of
delivery. Breastfeeding counseling alone without any active proactive support is unlikely to result in high
rates of successful breastfeeding.20 Time of initiation of the breastfeeding should be documented.

Vitamin K administration: Vitamin K should be administered to all the babies (0.5 mg for babies less
than 1000 grams and 1 mg for babies more than 1000 gms).21 It is preferable to administer the K1,
however if not available the K3 may be administered.22 This should be administered as an IM injection
using the 26 G (1/2 inch) needle and a 1 ml syringe on the anterolateral aspect of the thigh.

First Examination: The baby should be thoroughly examined by the attending person from head to toe
and the findings should be recorded in neonatal record sheet. It is very important to examine midline
structures for malformations (e.g. cleft lip, neck masses, chest abnormality, omphalocele, meningocele,
claocal abnormality etc). Special attention should be given to identify and document the anal opening.
There is no need for routine passage of catheter in the stomach, nostrils and the rectum for detection of
esophageal atresia, choanal atresia and ano-rectal malformation, respectively. The baby should be
examined for presence of birth injuries in cases with difficult extraction. The axillary temperature of the
baby should be recorded before the baby is shifted out from the birthing place.

Communication with the Family: Before leaving the birthing place, the health professional should
communicate with the mother and the family members. The following facts should be clearly told to the
family: (1) gender of the baby (2) birth weight (3) well being of the baby. One should ensure that the
family members and the mother get to witness the gender and the identity number of the baby.

Rooming in: Under no circumstances a normal newborn should be separated from the mother. In the
initial few hours of life, the baby is very active, and the closeness of the baby to the mother will facilitate
the early breastfeeding and bonding. The studies have shown that any separation during these initial
hours may have a significant adverse impact on various outcomes including successful breastfeeding in
later stage of life.
CARE OF BABY BEYOND FEW HOURS AFTER BIRTH

Care of the cord: The umbilical stump should be kept dry and devoid of any application. The nappy of
the baby should be folded well below the stump to avoid any contamination.23.24

Oil Massage: The benefits of the oil application have been described for the low birth weight babies in
both the developed and the developing countries28, 29, 30. However, a paucity of data still exists for the oil
application and/ or massage in the term babies.31 Oil massage is a low cost traditional practice that is
well ingrained into the Indian culture, with no reported adverse outcome. The same may be allowed in a
gentle way and with clean hands. Care should be taken not to use oils with additives or the irritant oils
(such as mustard oil) for this purpose.

Exclusive breastfeeds: A proactive and a systematic approach should be followed to initiate, support
and maintain breastfeeds. The various advantages of the breast feeds should be discussed with the
mother to motivate her for breastfeeding. Availability of a dedicated lactation nurse or councilor would
significantly increase the chances of successful breastfeeding.

Bath: The routine dip baths should be avoided till the baby is in the hospital premises as this increases
the risk of hypothermia.32 The sponging of the baby should be done once a day with clean water, as per
the requirement. The dip bath may be undertaken once the cord has fallen and the baby is discharged
from the hospital

Powder application: Currently there is no evidence to suggest the regular use of any powder and the
same should be avoided.

Position of sleep: No Indian study has addressed the issue of relation of sleep position to occurrence of
SIDS. There is substantial evidence in the literature from the developed countries of an association of
prone position and the SIDs independent of the other variables.33,34 However, the converse, viz a
reduced incidence of SIDS with supine position has also not been investigated and reported. None of
the studies were conducted in the hospital or the facility setting. Considering the above all the healthy
term newborns should be preferably is made to sleep on their backs.

Traditional practices that should be discouraged: The application of Kajal/ surma in the eyes, putting oil
in the ear or applying the cow-dung on cord must be strongly discouraged35.

Timing of discharge in a Normal Newborn: Whenever possible the baby should undergo an observation
period of 48 to 72 hrs in the health facility (for establishment of breastfeeding and observation for any
morbidity including jaundice). However, an early discharge within 24 to 48 hrs may be considered for
the non-primigravida mothers who have a history of successful breastfeeding.

The following criteria should be met in all the babies prior to discharge planning:

25 26 27
Three large cluster randomized trials from Nepal , Bangladesh and Pakistan have shown a
encouraging reduction in neonatal mortality rate after application of topical chlorhexadine to the
umbilicus in the early days of life. Nepal (RR 0.66; 95% CI 0.46-0.95), Bangladesh (RR 0.80;
95% CI 0.65-0.98) and Pakistan (RR 0.62; 95% CI 0.45-0.85).
 The routine formal examination of the newborn has been performed and documented
The newborn has received the immunization as per schedule
The mother is confident and trained to take care of the neonate
The newborn is not having a significant jaundice or any other illness requiring close observation
by a health provider.
The newborn is breastfeeding adequately. The adequacy of feeds can be determined by
o Passage of urine 6 to 8 times every 24 hrs
o Baby sleeping well for 2- 3 hrs after feeds
o There is no excessive weight loss (normally babies do not lose more than 8 to 10% in
initial 3 to 4 days)
The mother has been counseled regarding routine newborn care and her queries are answered.
Follow-up advice should be communicated to the mother of the baby. Babies, particularly born
to primigravida mothers should be called for follow up visit at 48 hrs of discharge if discharged
before 48 hours. The breastfeeding and the jaundice in these babies should be evaluated38,
ADVICE ON DISCHARGE: NORMAL NEWBORN

1. Exclusive Breastfeeds: All mothers should be advised to exclusively breastfeed the babies till 6
months of age. All the advantages of the breast milk, short term and long term should be
discussed with the mother to facilitate a success.
2. Immunization: The mother should be explained the schedule of the immunization and the date
of the next immunization should be mentioned on the discharge card.
3. The follow- date for the babies discharged early (within 48 hrs) for assessment of jaundice
should be communicated to the parents.
4. The danger signs should be documented and mother should be educated to recognize the same
and report early when they are recognized36,37,38,39:
a. Difficulty in feeding
b. Convulsions
c. Lethargy (movement only when stimulated)
d. Fast breathing (RR > 60/min)
e. Severe chest in drawing
f. Temperature of more than 37.5 deg C or below 35.5 deg C

Table 1 provides research priorities in regard to normal newborn care.

The Young infant study published in Lancet 2008; 371;S135-147; evaluated 3177 children
aged 06 days and 5712 infants aged 759 days for clinical signs and symptoms, and
determined the specificity and sensitivity of each one in predicting a severe illness. The
study reported that (a) history of difficulty feeding; (b), history of convulsions; (c), movement
only when stimulated;(d) respiratory rate of 60 breaths per minute or more; (e) severe chest
in drawing, temperature of 375C or more or below 355C, had the highest Sensitivity
(85%) and specificity (75%) for severe illness.

Cochrane review by Brown S et al40 looked at 7 studies (n=3435) looked at the early postnatal discharge from
hospital for healthy mothers and term infants and the re-admission within 8 weeks. They found that the failure of
breastfeeding was an important cause for the readmission. Hence, a review of cases discharged early at 2-3 days
after discharge, may have a role in preventing readmission.
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breastfeeding status. Journal of Midwifery & Women's Health. 2007; 52:116125.
21. Puckett RM, Offringa M. Prophylactic vitamin K for vitamin K deficiency bleeding in neonates. Cochrane
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Horton R.Why are 4 million newborn babies dying each year? Lancet 2005; 364:399-401.
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on growth, blood flow & sleep pattern in infants. Indian J Med Res. 2000;112:212-7.
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32. Bergstrm A, Byaruhanga R, Okong P. The impact of newborn bathing on the prevalence of neonatal
hypothermia in Uganda: a randomized,controlled trial. Acta Paediatr. 2005; 94:1462-7.
33. Kattwinkel J, Brooks J, Myerberg D; American Academy of Pediatrics, Task Force on Infant Positioning and
SIDS. Positioning and SIDS. Pediatrics 1992; 89:11206.
34. American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome.
Changing concepts of sudden infant death syndrome: implications for infant sleeping environment and
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35. Mehrotra SK, Maheshwari BB. Prevalence of ocular lesions in a rural community. Indian J Ophthalmol
1975;23:17-20.
36. Young Infants Clinical Signs Study Group. Clinical signs that predict severe illness in children under age 2
months: a multicentre study. Lancet. 2008;371:135-42.
37. Bang AT, Bang RA, Reddy MH, Baitule SB, Deshmukh MD, Paul VK, de C Marshal TF.Simple clinical criteria
to identify sepsis or pneumonia in neonates in the community needing treatment or referral. Pediatr
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Meenakshi M, Kapil A, Paul VK, Weber M.Clinicoepidemiological profile and predictors of severe illness in
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Research question Subjects Study Intervention Outcomes to be measured
design
1. Effect of delayed cord Term LBW RCT I : Delayed cord clamping Short term: hematocrit, Hb, rates of
th
clamping in term LBW (weight<10 (2 to 3 minutes) polycythemia, serum bilurubin levels
babies (IUGR) centile) C : immediate cord during neonatal period
clamping Fe status and clinical Anemia at 3
and 6 months
Neurodevelopment at 18 to 24
months
2. Is footprint of baby a Term Descrip Nil Proportion of footprints reliable
reliable method to normal tive enough to determine the identity of
ascertain the identity neonates neonate, when presented to experts.
of a neonate
3. Reliability and cost Term RCT I : Use of biometric system The cost involved and identity
effectiveness of use of Normal O: conventional system establishment by a expert by both
the biometric system neonates e.g. footprint the methods
for the identification
of the mother baby
dyad
4. What is the safest Term normal RCT Subjects can be Rates of cord slippage, oozing of
method for clamping neonates randomized to 3 methods blood
the cord of clamping e.g. Need for re-clamping in the first 24
(1) Commercial clamp hrs Parental satisfaction and
(2) thread acceptability
(3) rubber band Cost
5. Does providing the Term Normal RCT I: Use of Cap and Socks The incidence of episodes of hypothermia
cap and socks Neonates immediately after birth in the first 24 hrs temp monitoring
compared to routine C: Use of the routine
wrapping reduce the wrapping
risk of hypothermia in
a newly born baby?
6. Epidemiology of Term Case Nil Profile of disease
vitamin K deficiency normal series
bleeding (both clinical neonates retrosp
and bio-chemical) in ective)
 neonates in Indian
settings
7. Evaluation of benefits Term RCT I : Prophylaxis using Biochemical Levels of PIVKA, Clinical VKDD
of Vitamin K1 vs normal Vitamin K1 (Early & Late)
routinely used K3 in neonates C : Prophylaxis using
the doses used for Vitamin K3
prophylaxis (0.5 to 1
mg)
8. Feasibility of the use Term RCT I : Prophylaxis using oral Biochemical Levels of PIVKA, Clinical VKDD
of oral Vitamin K normal Vitamin K (Early & Late)
formulation for VKDD neonates C : Prophylaxis using IM
prophylaxis, as most Vitamin K
babies are born in
rural setting where
the IM administration
is not possible
9. What are reasons Term Cohart Nil Proportion of babies readmitted during
(Post discharge normal the first month
Morbidities) for Neonate The disease profile / reasons for the
readmission after admission of these neonates
discharge following
birth hospitalization in
the first month of life?
10. Postnatal age at re- Term Cohort Nil The distribution of the admission
admission after normal characteristics of the neonates admitted
discharge following neonate in the first month of life (maximum
birth hospitalization in admitted at different day of life)
the first month of life?
11. What should be Term RCT Different hospital stays Breastfeeding rates
optimum hospital stay neonates such as: Readmissions rates
of normal neonates? delivered by Hypothermia, jaundice rates
Normal For normally delivered Maternal morbidities (need
and neonates: 24 hr vs 48 hr collaboration with ObGyn)
cesarean vs. 72 hr Maternal satisfaction
(Study both
group For cesarean babies: 48 hr
separately) vs 72 hr vs. 96 hr
 AIIMS PROTOCOLS 2014

Fluid and Electrolyte Management in Neonates

Aim of fluid and electrolyte management is to maintain fluid homeostasis which can be altered by
physiological immaturity of organ systems involved in maintaining homeostasis or systemic illness in
neonates.

Adaptation to extrauterine life consists of three phases of fluid balance. After birth, there is efflux of
fluid from the intracellular to the extracellular compartment.3 This results in salt and water diuresis by
48-72 hours of age. Loss of this excess extracellular fluid (ECF) and evaporative water loss from
immature skin result in physiological weight loss during first week of life. Since the ECF compartment is
larger in more preterm neonates, the weight loss is greater in preterm neonates. Term infants are
expected to lose up to 7% to 10% of their birth weight as compared to 10% to 15% weight loss in
premature neonates. First phase of transition ends with maximum weight loss. Second intermediate
phase is characterized by diminished insensible water loss along with increasing maturation of skin
barrier, a fall in urine volume to less than 12 ml/kg per hour, and a low sodium excretion. Third phase
consists of stable growth and is characterized by continuous weight gain with a positive net balance for
water and sodium.

Renal function
Kidneys in the neonate have limited capacity to excrete either concentrated (due to immaturity of the
distal nephron with an anatomically shortened loop of Henle) or diluted urine (due to physiologically low
glomerular filtration rate). Physiological range for urine osmolality in neonates varies from a lower limit
of 50 mmol/L to upper limits of 600 mmol/L in preterm neonates and 800 mmol/L in term neonates.5,6
An acceptable osmolality range of 300-400 mmol/L corresponds to a daily urine output of 2-3 ml/kg/hr.

Neonatal kidneys have limited capacity to excrete or to conserve sodium. Normally there is a salt and
water diuresis in the first 48-72 hours of life. Therefore, sodium supplementation should be started after
ensuring initial diuresis or at least 5-6% weight loss.6-9 Preterm neonates have a limited tubular capacity
to reabsorb sodium and hence have increased urinary losses. Failure to supplement sodium after the
first week of life can result in low body stores of sodium and poor weight gain.6,9-11 Sodium requirements
range from 3-5 mEq/kg/day in preterm neonates after the first week of life. Very low birth weight
infants on exclusive breast-feeding may need sodium supplementation in addition to breast milk till 32-
34 weeks corrected age.11,12

Fluid losses
In addition to mandatory water loss by the kidneys and gastro-intestinal system (termed as sensible
loss), additional water losses occur due to evaporation from the skin and respiratory tract. This water
loss is termed as insensible water loss (IWL). Insensible water losses tend to be higher in preterm infants
(Table 1).
 AIIMS PROTOCOLS 2014

Table 1: Insensible water loss according to birth weight on day 1

Birth weight Insensible water loss (ml/kg/day)

<1000 g 60-80
1000 1500 g 40-60
>1500 g 20

Evaporation loss through the skin usually contributes to 70% of IWL.3 The remaining 30% is contributed
by losses from the respiratory tract. The emphasis in fluid and electrolyte therapy should be on
prevention of excessive IWL rather than replacement of increased IWL. Hence incubators, plastic
barriers and heat shields should be used liberally in the management of extremely premature neonates.

Guidelines for fluid and electrolyte therapy

First week of postnatal life
The goals for fluid and electrolyte administration during first week after birth are to allow contraction of
ECF (without compromising intravascular fluid volume and cardiovascular function) with negative water
balance of not more than 10%, to allow a negative net balance for sodium of 2-5 mmol/kg per day, to
maintain normal serum electrolyte concentrations, to avoid oliguria (0.51.0 ml/kg per hour) for longer
than twelve hours and to ensure avoid excessive transepidermal water loss. Once period of transition is
over goals are to replace actual water and electrolytes and to progressively increase oral feeds.

Table 2: Parenteral fluid and electrolyte requirements during first week after birth

Parenteral fluid in mL/kg/d

Day after birth
1 2 3 4 5 6
Term neonate 60-120 80-120 100-130 120-150 140-160 140-180

Preterm neonate with 60-80 80-100 100-120 120-150 140-160 140-160

birth weight >1500 g
Preterm neonate with 80-90 100-110 120-130 130-150 140-160 160-180
birth weight <1500 g
Electrolyte requirement (mEq/kg)*
Sodium 0-3 (careful adjustment needed in neonates weighing <1000 g)
Potassium 0-2 (start after onset of diuresis)
Chloride 0-5
*No electrolyte supplementation is required during initial 48 hr of life

Amount of actual fluid intake to be prescribed from recommended range for each day (Table 2) is
selected with careful monitoring to achieve physiological weight loss, normal tissue perfusion and
normal serum electrolytes.

Restricted fluids in preterm neonates: what is evidence?

A review of four randomized clinical studies with different levels of fluid intake during the first week of
life concluded that fluid restriction reduces the risk of patent ductus arteriosus, necrotizing enterocolitis
and death with trend towards reduction in risk of bronchopulmonary dysplasia.4
 AIIMS PROTOCOLS 2014

After first postnatal week

The goals for fluid and electrolyte administration in stable growing neonates are to maintain water and
electrolyte homeostasis and to provide enough extra water and electrolytes to build up new tissue at
intrauterine growth rates.

Table 3: Parenteral fluid and electrolyte requirements after first postnatal week

Fluid Sodium Potassium

(ml/kg/d) (mmol/kg/d) (mmol/kg/d)
Term neonate 140-160 2.0-3.0 1.5-3.0
Preterm neonate 140-160 3.0-5.0 (to 7.0) 2.0-5.0

Sodium and potassium should be started in the IV fluids after 48 hours, each in a dose of 2-3
mEq/kg/day. Calcium may be used in a dose of 4 ml/kg/day (40 mg/kg/day) of calcium gluconate for the
first 3 days in certain high-risk situations (see protocol on hypocalcemia). Dextrose infusion should be
maintained at 4-6 mg/kg/min. Dextrose 10% may be used in babies with birth weight more than 1250
grams and 5% dextrose in babies with birth weight less than 1250 grams.

Examples
Babies 1500 grams or more (most term and preterm babies)
Day 1
A full term infant on intravenous fluids would need to excrete a solute load of about 15 mosm/kg/day
through kidneys. To excrete this solute load at a urine osmolarity of 300 mosm/kg/day, the infant would
need a minimum of 50 ml/kg free water. Allowing for an additional IWL of 20 ml/kg, the initial fluids
should be 60-70 ml/kg/day. The initial fluids should be 10% dextrose with no electrolytes in order to
maintain a glucose infusion rate of 4-6 mg/kg/min.

Day 2 - Day 7
As the infant grows and receives enteral milk feeds, the solute load presented to the kidneys increases
and the infant requires more fluid to excrete the solute load. Water is also required for fecal losses and
for growth purposes. The fluid requirements increase by 15-20 ml/kg/day till a maximum of 150
ml/kg/day. Sodium and potassium should be added after 48 h of age and glucose infusion should be
maintained at 4-6 mg/kg/min

Babies <1500 grams (mostly preterm babies<32 wk)

Day 1
 AIIMS PROTOCOLS 2014

The urine output in a preterm baby would be similar to a term baby. However, the fluid requirement will
be higher due to increased IWL and increased weight loss (extracellular fluid loss). It is recommended
that caps, socks and plastic barriers to be used to reduce the IWL under the radiant warmer. Using this
method, it is possible to manage VLBW infants with fluids of 80 ml/kg/day on day 1 of life.

Day 2-Day 7
As the skin matures in a preterm baby, the IWL progressively decreases and becomes similar to a term
baby by the end of the first week. Hence, the fluid requirement in a preterm baby, initially higher due to
increased IWL, would become similar to a term baby by the end of the first week. Plastic barriers, caps
and socks are used throughout the first week in order to reduce IWL from the immature skin. Fluids
need to be increased at 10-15 ml/kg/day till a maximum of 150 ml/kg/day. Sodium and potassium
should be added after 48 hours and glucose infusion should be maintained at 4-6 mg/kg/min

Strategies to reduce insensible water loss

Double wall incubators reduce insensible water loss in VLBW neonates by about 30% if humidity of 90%
is used at thermo-neutral temperature. The use of radiant warmers for VLBW care may increase water
loss and impair thermoregulation. Thin, transparent plastic barriers (e.g. cling-wrap) may be used to
increase the local humidity and limit air movement.13 These transparent plastic films may be fixed to the
supporting walls of the radiant warmer in order to create a micro-environment around the baby. These
plastic barriers are effective in reducing IWL without interfering with the thermal regulation of the
warmer. They have been found to reduce the IWL by 50-70% for infants under the radiant warmer. The
use of emollient ointments or coconut oil decreases insensible water loss of up to 50% in open care
conditions.14-16 Endotracheal intubation and mechanical ventilation using warmed and humidified air
significantly reduce insensible respiratory water.

Monitoring of fluid and electrolyte status

Body weight: Serial weight measurements can be used as a guide to estimate the fluid deficit in
newborns. Term neonates lose 1-2% of their birth weight daily with a cumulative loss of 7-10% in the
first week of life. Preterm neonates lose 2-3% of their birth weight daily with a cumulative loss of 10-
15% in the first week of life. Failure to lose weight in the first week of life should be an indicator for fluid
restriction. However, excessive weight loss in the first 7 days or later would be non-physiological and
would merit correction with fluid therapy.

Clinical examination: The usual physical signs of dehydration are unreliable in neonates. Infants with
10% (100 ml/kg) dehydration may have sunken eyes and fontanel, cold and clammy skin, poor skin
turgor and oliguria. Infants with 15% (150ml/kg) or more dehydration would have signs of shock
(hypotension, tachycardia and weak pulses) in addition to the above features. Dehydration would merit
correction of fluid and electrolyte status gradually over the next 24 hours.

Serum biochemistry: Serum sodium and plasma osmolarity would be helpful in the assessment of the
hydration status in an infant. Serum sodium values should be maintained between 135-145 mEq/L.
Hyponatremia with weight loss suggests sodium depletion and would merit sodium replacement.
Hyponatremia with weight gain suggests water excess and necessitates fluid restriction. Hypernatremia
 AIIMS PROTOCOLS 2014

with weight loss suggests dehydration and would require fluid correction over 48 hours. Hypernatremia
with weight gain suggests salt and water load and would be an indication of fluid and sodium restriction.

Urine output, specific gravity (SG) and osmolarity: The capacity of the newborn kidney to either
concentrate or dilute urine is limited and estimation of urine SG would be useful to guide fluid therapy.
The acceptable range for urine output would be 1-3 ml/kg/hr, for specific gravity between 1.005 and
1.012 and for osmolarity between 100 and 400 mOsm/L. Specific gravity can be checked by dipstick or
by a hand-held refractometer. Osmolarity is estimated by freezing point osmometer.

Blood gas: Blood gases are not needed routinely for fluid management. However, they are useful in the
acid base management of patients with poor tissue perfusion and shock. Hypo-perfusion is associated
with metabolic acidosis.

Laboratory guidelines for fluid and electrolyte therapy

Intravenous fluids should be increased in the presence of (a) Increased weight loss (>3%/day or a
cumulative loss >20%), (b) Increased serum sodium (Na>145 mEq/L) (c) Increased urine specific gravity
(>1.020) or urine osmolality (>400 mOsm/L), (d) Decreased urine output (<1 ml/kg/hr). Similarly fluids
should be restricted in the presence of (a) Decreased weight loss (<1%/day or a cumulative loss <5%), (b)
Decreased serum sodium in the presence of weight gain (Na<130 mEq/L), (c) Decreased urine specific
gravity (<1.005) or urine osmolality (<100 mOsm/L), (d) Increased urine output (>3 ml/kg/hr).

Specific clinical conditions

Extreme prematurity (gestation <28 weeks, birth weight <1000 grams): These babies have large
insensible water losses due to thin, immature skin barrier. The stratum corneum matures rapidly in 1-2
weeks and therefore fluid requirements become comparable to larger infants by the end of the second
week. Fluid requirement in the first week may be decreased substantially by reducing the IWL with the
use of plastic transparent barriers, coconut oil application or using double walled incubators.4,13,14 The
initial fluids on day 1 should be electrolyte free and should be made using 5% dextrose solutions to
prevent risks of hyperglycemia. Sodium and potassium should be added after 48 h of life.

Respiratory distress syndrome (RDS): The renal function in preterm babies may be further
compromised in the presence of hypoxia and acidosis due to RDS. Positive pressure ventilation may lead
to increased secretion of aldosterone and ADH, leading to water retention. Symptomatic patent ductus
arteriosus (PDA) is more likely to occur in the presence of RDS. Results from various studies have shown
that restricted water intake has a beneficial effect on the incidence of PDA, CLD, NEC and death.4 Hence
fluid therapy in sick preterm infants should be monitored strictly using the above mentioned clinical and
laboratory criteria.

Perinatal asphyxia and brain injury: Perinatal asphyxia may be associated with syndrome of
inappropriate ADH (SIADH) secretion. Fluid restriction in this condition should be done only in the
presence of hyponatremia. The intake should be restricted to two-thirds maintenance fluids till serum
 AIIMS PROTOCOLS 2014

sodium values return to normal. Once urine production increases by the third postnatal day, fluids may
be gradually restored to normal levels. Renal parenchyma injury from perinatal asphyxia may result in
acute tubular necrosis (ATN), which is commonly accompanied by oliguria or anuria In case of oliguric
renal failure, fluid intake should be restricted to replenishment of IWL and metabolic water requirement
(400 mL/m2 or 40 mL/kg) and any other losses (urine output, gastric secretions etc.) During the recovery
phase of ATN, there can be large urinary sodium and potassium losses, which should be calculated and
replaced.

Diarrhea: The correction of fluid deficit is done over 24 hours. Ongoing losses need to be assessed and
corrected 6-8 hourly.
 AIIMS PROTOCOLS 2014

References

1. Wadhawan R, Oh W, Perritt R, et al. Association between early postnatal weight loss and death
or BPD in small and appropriate for gestational age extremely low-birth-weight infants. J Perinatol
2007;27:359-64.
2. Stephens BE, Gargus RA, Walden RV, et al. Fluid regimens in the first week of life may increase
risk of patent ductus arteriosus in extremely low birth weight infants. J Perinatol 2008;28:123-8.
3. Bell EF, Oh W. Fluid and electrolyte management. In: Avery GB, Fletcher MA, MacDonald MG,
eds. Neonatology: Pathophysiology of the Newborn. 5th ed. Philadelphia: Lippincott Williams and
Wilkins; 1999:345-61.
4. Bell EF, Acarregui MJ. Restricted versus liberal water intake for preventing morbidity and
mortality in preterm infants. Cochrane Database Syst Rev 2008:CD000503.
5. Chevalier RL. Developmental renal physiology of the low birth weight pre-term newborn. J Urol
1996;156:714-9.
6. Modi N. Renal function, fluid and electrolyte balance and neonatal renal disease. In: Rennie JM,
Roberton NRC, eds. Textbook of Neonatology. 3rd ed. Edinburgh: Churchill Livingstone; 1999:1009-36
7. Hartnoll G, Betremieux P, Modi N. Randomised controlled trial of postnatal sodium
supplementation in infants of 25-30 weeks gestational age: effects on cardiopulmonary adaptation. Arch
Dis Child Fetal Neonatal Ed 2001;85:F29-32.
8. Hartnoll G, Betremieux P, Modi N. Randomised controlled trial of postnatal sodium
supplementation on oxygen dependency and body weight in 25-30 week gestational age infants. Arch
Dis Child Fetal Neonatal Ed 2000;82:F19-23.
9. Al-Dahhan J, Haycock GB, Nichol B, Chantler C, Stimmler L. Sodium homeostasis in term and
preterm neonates. III. Effect of salt supplementation. Arch Dis Child 1984;59:945-50.
10. Mbiti MJ, Ayisi RK, Orinda DA. Sodium supplementation in very low birth weight infants fed on
their own mothers milk: II. Effects on protein and bone metabolism. East Afr Med J 1992;69:627-30.
11. Ayisi RK, Mbiti MJ, Musoke RN, Orinda DA. Sodium supplementation in very low birth weight
infants fed on their own mothers milk I: Effects on sodium homeostasis. East Afr Med J 1992;69:591-5.
12. Higgins ST, Baumgart S. Fluid and electrolyte disorders. In: Spitzer AR, ed. Intensive care of the
fetus and neonate. St. Louis Mosby-Year book; 1996:1034-49.
13. Kaushal M, Agarwal R, Aggarwal R, et al. Cling wrap, an innovative intervention for temperature
maintenance and reduction of insensible water loss in very low-birthweight babies nursed under radiant
warmers: a randomized, controlled trial. Ann Trop Paediatr 2005;25:111-8.
14. Nangia S, Paul VK, Chawla D, Agarwal R, Deorari AK, Sreenivas V. Topical coconut oil application
reduces trans-epidermal water loss (TEWL) in very low birth weight (VLBW) neonates: A randomized
clinical trial. In: Pediatric Academic Society. Toronto; 2007:7933.21.
15. Nopper AJ, Horii KA, Sookdeo-Drost S, Wang TH, Mancini AJ, Lane AT. Topical ointment therapy
benefits premature infants. J Pediatr 1996;128:660-9.
16. Lane AT, Drost SS. Effects of repeated application of emollient cream to premature neonates'
skin. Pediatrics 1993;92:415-9.
 [June 2014] 1

Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Shock in Newborn

Weak & fast pulse ( HR>160/min) AND

Extremities cold to touch AND
Capillary Refill Time >3 sec
With or without the following signs:
Colour- very pale
Lethargy, not arousable on stimulation

Provide warmth
Secure airway
Support breathing, circulation and temperature
Start oxygen, if saturation (<90%) is low
Measure blood glucose; correct hypoglycemia (Follow STP)

If bleeding is NOT the likely cause If bleeding is the likely cause

Establish IV access Establish IV access

Give IV normal saline or Ringer Lactate 10 ml/kg Give IV normal saline or Ringer Lactate 10 ml/kg
body weight over 10 minutes, repeat bolus if no or body weight over 10 min
partial improvement with maximum of three If no improvement, repeat fluid of 10 ml/kg after
boluses over one hour 20 minutes as above
Give IV 10% Dextrose at maintenance rate Immediately give a blood transfusion using type
Treat for Sepsis (Follow STP) O, Rh negative blood
Continue O2 as required Give Vitamin K 1 mg IV

Monitor hourly (Panel 2):

Heart rate, oxygen saturation
Determine Diagnosis (Panel 1)
Capillary refill time
Urine output
Sensorium

If signs of shock improve If signs of shock persist

Continue maintenance IV fluid as per Continue IV Fluid and O2

weight and day of life (Follow STP) REFER
Reassess above parameters hourly
Give specific treatment based on
diagnosis (Follow specific STP) 1

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Panel 1: Diagnostic clues based on history and clinical examination

Cause History / Examination

Blood loss Antepartum hemorrhage

Blood loss internal/external Follow STP on Emergency
Age day 1 Management Sheet A

Asphyxia Need for Resuscitation for poor respiratory efforts at birth

Hypoxic ischemic encephalopathy (See STP for Management of
asphyxiated neonates)
Sepsis Predisposing factors for infection
Age > day 3 Follow STP

Severe dehydration Loose stool, vomiting, failure to feed + Signs of dehydration

Cardiac Term baby; normal at birth
Age day 3-4
Look for feeble or delayed femoral pulse, cardiac murmur
(coarctation of aorta)
Persistent Pulmonary Meconium stained term baby
REFER
Hypertension of the Age day 1-3
Newborn (PPHN)

Panel 2: Monitoring of baby with shock

Signs At admission 1 hr 2 hr 3 hr 4 hr

Heart Rate/min
Capillary refill time
Urine output
Sensorium
Temperature difference
(core-extremities)
 [June 2014 ] 1
Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

IV Fluid Therapy for Newborns

Indications to start IV fluids:

! Birth
weight < 1200 grams OR
! Birth weight > 1200 grams and sick; or Sick Newborn
of any birth weight
Indications of sickness: Presence of one of the following
Fast breathing ( RR >60/min ) ,with distress
Unconscious or Lethargic (no spontaneous movements)
No feeding or feeding poor after having fed well; or
intolerance to gastric feeds
Abdominal distension and/or vomiting (bilious/bloody)
Uncontrolled seizures

Less than 1500 grams More than 1500 grams AND/OR

Sick Newborn

Fluids based on day of life* Fluids based on day of life*

Day of Fluid amount Nature of fluid Day of Fluid amount Nature of fluid
Life (mL/kg/day) Life (mL/kg/day)
1 80 10% dextrose 1 60 10% dextrose
2 95 10% dextrose 2 80 10% dextrose
3 110 10% dextrose with 3 100 10% dextrose with
4 125 sodium 3mmol/kg, 4 120 sodium 3mmol/kg,
5 140 potassium 5 140 potassium 2mmol/kg
6 150 2mmol/kg** 6 150
7 150
7 150

Reassess after 24-48 hours Reassess after 24-48 hours

YES Stable and able to accept oral feeds NO YES

Stable and able to accept oral feeds NO

! START on enteral feeds ! Continue i.v. fluids

! START on enteral feeds ! Continue i.v. fluids
10-15mL/kg, 3 hourly
10-15mL/kg, 2 hourly
! Measure abdominal girth
! Measure abdominal girth ! Deduct the same before feeding
before feeding amount from daily IV
fluid requirement
! Increase to full feeds over 12-24
! Increase 20- 30mL/kg/day hours
! STOP feeding (bilious/blood- ! STOP feeding (bilious/ blood-
stained gastric aspirate, stained gastric aspirate,
GRV>25%/ >3mL)*** GRV>25%/ >3mL)***

* DO NOT INCREASE fluid on the next day, if weight gain, tachycardia, oedema feet, puffy eyes, urine output < 1mL/kg/hr
** If the premixed solutions are not available, add normal saline 20 ml/kg to the required volume of 10% dextrose, but
infuse only the required daily volume
***Measure gastric residual volume (GRV) only if there is increase in abdominal girth by 2 cm, above baseline.
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket
Book of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 ONTOP-IN 2012: Calculation of Dopamine & Dobutamine

Calculation for dose of Dopamine & Dobutamine

How to give Dopamine

1 ml of commercially available contains 40 mg of dopamine. In a baby weighing 2.5 kg

if we want to start dopamine at a rate of 10 mcg/kg/min:

=10 x 2.5 = 25 mcg/min=25x60=1500 mcg/hour=1500x24=36000 mcg/day

=36 mg of dopamine in 24 hours

It means if we add 0.9 ml of dopamine in 24 ml of fluid and give @ rate of 1 ml/hr with
syringe pump or 1 microdrops per min (which is virtually impossible) with the micro drip
set, we will give dopamine @ 10 mcg/kg/min.

Increment
If we want to increase dopamine to 15 mcg/kg/min then give the same fluid @ 1.5 ml/hr

The above method is to give a separate infusion of Dopamine, however it could

also be added to 24 hours fluid as explained below:

e.g. 2.5 kg neonate in shock with a fluid requirement of 100 ml/kg/day, has received 2
fluid boluses of 10 ml/kg of normal saline, without any improvement. Plan is Total Fluid
needed for this baby in 24 hours=100x2.5=250ml/day.

Fluid to be given every 8 hours = 85 ml. Let us learn how much dopamine to be added
in 8 hours fluid i.e. 85ml to be given at a rate of 10 mcg/kg/min.

Amount of dopamine required in one minute = 10x2.5=25 mcg

Amount of dopamine required in one hour=25x60=1500 mcg

Amount of dopamine required in 8 hours = 1500x8=12000 mcg = 12.0 mg

1 ml of available dopamine preparation = 40 mg of dopamine

To make 12 mg of dopamine we need 0.3 ml, add this volume to 85 ml of fluid and give
over 8 hours at a rate of 10 ml/hour or at a rate of 10 micro drops/min with a burette set,
which will deliver dopamine at a rate of 10 mcg/kg/min

AIIMS - WHO CC 1
 ONTOP-IN 2012: Calculation of Dopamine & Dobutamine

How to give Dobutamine

1 ml of commercially available contains 25 mg of dobutamine. In a baby weighing 3.75

kg if we want to start dobutamine at a rate of 10 mcg/kg/min:

=10 x 3.75 = 37.5 mcg/min=37.5x60=2250 mcg/hour=2250x24=54000 mcg/day

=54 mg of dobutamine in 24 hours

It means if we add 2.2 ml of dobutamine in 24 ml of fluid and give @ rate of 1 ml/hr with
syringe pump or 1 microdrops per min (which is virtually impossible) with the micro drip
set, we will give dobutamine @ 10 mcg/kg/min

Increment
If we want to increase dobutamine to 15 mcg/kg/min then give the same fluid @ 1.5
ml/hr

The above method is to give a separate infusion of Dobutamine, however it could

also be added to 24 hours fluid as explained below:

e.g. 3.75 kg neonate in shock with a fluid requirement of 100 ml/kg/day, has received 2
fluid boluses of 10 ml/kg of normal saline, without any improvement. Plan is Total Fluid
needed for this baby in 24 hours=100x3.75=375ml/day

Fluid to be given every 8 hours = 125 ml. Let us learn how much dobutamine to be
added in 8 hours fluid i.e. 125ml to be given at a rate of 10 mcg/kg/min

Amount of dobutamine required in one minute = 10x3.75=37.5 mcg

Amount of dobutamine required in one hour=37.5x60=2250 mcg

Amount of dobutamine required in 8 hours = 2250x8=18000 mcg = 18 mg

1 ml of available dobutamine preparation = 25 mg of dobutamine

To make 18 mg of dobutamine we need 0.7 ml, add this volume to 125 ml of fluid and
give over 8 hours at a rate of 15 ml/hour or at a rate of 15 micro drops/min with a
burette set, which will deliver dobutamine at a rate of 10 mcg/kg/min

AIIMS - WHO CC 2
 Post-resuscitation management of asphyxiated neonate
Perinatal asphyxia (PA) is a major public health problem. As per the latest estimates, PA
accounts for 9% (i.e. 08 million) of total Under-5 mortality (i.e. 8.8 millions) worldwide, being
one of the three most common causes of neonatal deaths along with prematurity and bacterial
infections.1 Of a total of 2.7 million stillbirths globally, approximately 1.2 million occur during
intrapartum period, largely owing to asphyxia.2 NNPD (2002-2003) reported PA to be the
commonest cause of still-births, accounting for 45.1% of all such cases.

As reported in NNPD (2002-2003) APGAR scores of <7 was found at 1 minute in 8.4% while 2.4 %
had scores of <7 at 5 minutes of life of all intramural births at 18 neonatal units in IndiaError!
Bookmark not defined.
. Oxygen was used as most commonly used resuscitative measure in 9.5%, bag
and mask ventilation in 6.3% and chest compressions in 0.8% while use of other medications in
0.5%. PA was responsible for 28.8% of all neonatal deaths. Manifestations of hypoxic ischaemic
encephalopathy (HIE) were seen in approximately 1.4% of all babies. Apart from neonatal
deaths, asphyxia is responsible for life long neuromotor disability in a large number of children.

Definitions

There is no one definition of PA (Table 1). The definition of PA is context specific and can be
sensitive e.g. those given by WHO and NNPD for the purpose of deciding immediate care of
newborn or a specific definition such as the one given by AAP for the purpose of giving a label or
predicting the long term outcome.

Table 1: Different definitions of perinatal asphyxia

World Health Oragnization3 Failure to initiate and sustain breathing
NNPD Network4 Moderate PA: Slow/gasping breathing or an Apgar score of 4 to 6 at 1
minute
Severe PA: No breathing or an Apgar score of 0-3 at 1 minute of age

American Academy of Presence of all of following criteria:

Pediatrics and American Profound metabolic or mixed acidemia (pH< 7.00) in umbilical cord
College of Obstetrics and blood
Gynecology5 Persistence of low Apgar scores less than 3 for more than 5 minutes
Signs of neonatal neurologic dysfunction (e.g., seizures,
encephalopathy, tone abnormalities)
Evidence of multiple organ involvement (such as that of kidneys,
lungs, liver, heart and intestine).

Consequences of asphyxia

PA is a multi-organ-system disorder affecting virtually every organ-system in the body including

brain, heart, lungs, kidneys and intestine. Care of asphyxiated infant therefore should be
oriented towards determining the severity of dysfunction of critical organ systems and provide
appropriate support to allow recovery to happen. Many of these complications are potentially
fatal. In term infants with asphyxia, renal, CNS, cardiac and lung dysfunction occur in 50%, 28%,

1
25% and 25% cases, respectively6. The extent of organ system dysfunction determines the early
outcome of an asphyxiated neonate (Table 2).

Table 2: Organ system dysfunction in perinatal asphyxia

CNS Hypoxic ischemic encephalopathy, intracranial hemorrhage, seizures, long-term

neurological sequelae
Cardiac Myocardial dysfunction, valvular dysfunction, rhythm abnormalities, congestive
cardiac failure
Renal Hematuria, acute tubular necrosis, renal vein thrombosis
Pulmonary Delayed adaptation, respiratory failure, meconium aspiration, surfactant
depletion, primary pulmonary hypertension
GI tract Necrotizing enterocolitis, hepatic dysfunction
Hematological Thrombocytopenia, coagulation abnormalities
Metabolic Acidosis, hypoglycemia, hypocalcemia, hyponatremia

Hypoxic ischemic encephalopathy (HIE) refers to the CNS dysfunction associated with PA, and is
often the prime concern while managing asphyxiated neonate as it can kill the neonate, and
carries a potential to cause serious long-term neuromotor sequelae among survivors.

A detailed classification of HIE in term neonates was proposed by Sarnat and Sarnat 7.A simpler
and practical classification of HIE by severity of manifestations provided by Levene et al is
recommended for routine use (Table 2)8. Thomson score is based on features of HIE and it can
have a maximum (worst) score of 22. A score of 15 or more has shown a positive predictive
value of 92%, negative predictive value of 82%, sensitivity of 71% and specificity of 96% for
abnormal outcome at 12 months of age21.

Table 2: Classification of HIE (Levene) 8

Feature Mild Moderate Severe

Consciousness Irritable Lethargy Comatose
Tone Hypotonia Marked hypotonia Severe hypotonia
Seizures No Yes Prolonged
Sucking/respiration Poor suck Unable to suck Unable to sustain
spontaneous respiration

2
Table 3: Thomson score21

Sign 0 1 2 3

Tone normal hyper hypo flaccid

LOC normal hyperalert, stare lethargic comatouse
Fits none < 3 per day > 2 per day
Posture normal fisting, cylcing strong distal flexion decerebrate
Moro normal partial absent
Grasp normal poor absent
Suck normal poor absent bites
Respir normal hyperventilation brief apnea IPPV (apnea)
Fontanell normal full, not tense tense

Evolution of HIE changes

HIE evolves gradually beginning from the time of insult to hours and days later. The initial
hypoxic-ischemic event results in infarction of the brain tissue (primary energy failure). The
subsequent injury (secondary injury) is mediated by reperfusion and free radicals in an area
surrounding the necrotic area (penumbra). The penumbra undergoes a programmed neuronal
death (apoptosis) even after the hypoxic insult is over. The time gap between these two phases
could be 6 hr to 24 hr, and provides a window to institute specific therapeutic intervention.

Clinical features of severe HIE in time frame

Birth to 12 hours Depressed level of alertness, periodic breathing or respiratory failure, intact
pupillary and occulomotor responses, hypotonia, seizures
12 to 24 hours Variable change in level of alertness, more seizures, apnoeic spells,
jitteriness, weakness in proximal limbs, upper>lower (full term),
hemiparesis (full term), lower limbs (premature)
24 to 72 hours Stupor or coma, respiratory arrest, brain stem pupillary and occulomotor
disturbances, catastrophic deteoriation with severe intraventricular
haemorrhage and periventricular haemorrhagic infarction (premature)
After 72 hours Persistent yet diminishing stupor, disturbed sucking, swallowing, gag and
tongue movements, hypotonia>hypertonia, weakness in proximal limbs,
upper>lower (full term), hemiparesis (full term), lower limbs or hemiparesis
(premature)

3
Management of a neonate with perinatal asphyxia

As of today, the management of asphyxiated babies is mainly supportive and involves

maintaining optimum oxygenation, ventilation, perfusion, metabolic milieu and control of
seizures (Figure 1).

Delivery room care

Obtain arterial cord blood for analysis: After cutting the cord apply additional clamp on
umbilical cord on placental side keeping a cord segment of 10 to 15 cm between two
clamps.
Take a heparinized syringe and puncture the cord (clamped segment, once placenta is out;
and resuscitation is over) to take blood sample from umbilical artery.

Presence of metabolic acidosis (pH <7.00 and base deficit greater than 16 mmol/L) indicates
relatively long standing asphyxia (many minutes to hours), while presence of respiratory acidosis
in absence of metabolic acidosis indicates presence of acute asphyxia (minutes) as in cord
prolapse, acute abruption of placenta etc.

What is evidence?

A recent meta-analysis has shown a good correlation of Cord ABG abnormalities (pH<7.00
and base deficit 16 mmol/l) with short term (mortality, HIE, IVH or PVL) and long term
prognosis (cerebral palsy).
Low arterial cord pH was significantly associated with neonatal mortality (odds ratio 16.9, 95% CI 9.7
to 29.5), HIE (OR: 13.8, 95% CI-6.6 to 28.9), IVH or PVL (OR: 2.9, 95% CI- 2.1 to 4.1), and cerebral
palsy (OR: 2.3, 95% CI: 1.3 to 4.2). 17

Transfer the infant to NICU if

Apgar score 0-3 at 1 minute
Prolonged bag and mask ventilation (60 seconds or more )
Chest compression

Even babies transferred to mother should be monitored frequently in the first 48-72 hours for
development of any features suggestive of HIE.

NICU care

1. Maintain normal temperature

After drying, place the baby under the radiant warmer
Maintain normal body temperature of the baby
Avoid Hyperthermia 9

2. Maintain normal oxygenation and ventilation

Assess the infant for adequacy of oxygenation and ventilation and provide support
as needed
Keep under oxygen hood in case of adequate spontaneous breathing

4
 Assisted ventilation is required if there is apnea, or spontaneous respiration is
inadequate or there is continuing hypoxia or hypercarbia,
Maintain saturations between 90% and 95% and avoid any hypoxia or hyperoxia
Measure arterial blood gas if any respiratory or perfusion abnormalities are present
(maintain pO2 between 60 torr and 90 torr and pCO2 at 35 to 45 torr). Avoid
hypocarbia, as this would reduce the cerebral perfusion, and hypercarbia, which can
increase intracranial pressure and predispose the baby to intracranial bleed.

3. Maintain normal tissue perfusion

Ensure normal perfusion i.e. normal blood pressure, capillary refill time of less than
3 seconds, normal urine output, and absence of metabolic acidosis
Start intravenous fluid in all infants with Apgar scores <4 at 1 minute or <7 at 5
minutes of age or a baby that is not well- having respiratory problems,
encephalopathy or abnormal tone.
In sick babies, place arterial line for guiding management of blood pressure. BP
should be tightly maintained in upper normal range according to gestation and
postnatal age specific BP charts avoiding wider fluctuation.11
If the tissue perfusion is inadequate, infuse normal saline (or Ringers lactate) 10
mL/kg over 5-10 min
Administer dobutamine (preffered) or dopamine to maintain adequate cardiac
output, as required.
Do not restrict fluid as this practice may predispose the babies to hypoperfusion.
Restrict fluid only if there is hyponatremia (Sodium<120 mg%) secondary to
syndrome of inappropriate secretion of ADH (SIADH) or if there is renal failure. Do
echocardiography In infants needing ionotropic support and also to assess
contractibility and the asphyxial injury to the heart. It helps to guide appropriate
management strategy20.

4. Maintain normal hematocrit and metabolic milieu

Check blood glucose levels and maintain blood glucose levels between 75 mg/dL
and 100 mg/dl.
Check hematocrit. Correct Anemia and maintain hematocrit between 45% and 55%.
If the venous hematocrit in a baby is above 65%, bring it down to 55% by partial
exchange transfusion using normal saline.
Check blood gases to detect metabolic acidosis as needed and maintain pH above
7.30.
In case of severe asphyxia, provide calcium in a maintenance dose of 4 mL/kg/day
(of 10% calcium gluconate) for 1-2 days as a continuous infusion or as 1:1 diluted
boluses, slowly under cardiac monitoring and maintain serum calcium concentration
in the normal range.
5. Treat seizures
Refer to seizure protocol.
6. Nutrition: Start oral feeding once baby is hemodynamically stable, off vasopressors and
normal abdominal examination (no distension, passing stool and normal bowel sounds).
7. Miscellaneous
Administer Vitamin K (1 mg IM) to all infants with perinatal asphyxia

5
Role of special investigations

Electroencephalography (EEG):

EEG is not indicated routinely in all asphyxiated babies but it helps in the diagnosis and
management of seizures and prognosticating the babies for long term outcomes. The prognosis
is likely to be poor if the EEG shows:
1) Long periods of inactivity (more than 10 seconds)
2) Brief period of bursts (less than 6 seconds) with small amplitude bursts
3) Interhemispheric asymmetry and asynchrony
4) Isoelectric and low voltage (less than 5 microvolts) 25

Amplitude-integrated electroencephalography (aEEG) is simplified form and can be performed

on continuous basis in NICU. Following abnormalities would indicate poor prognosis:
Wide fluctuations in the amplitude with the baseline voltages dropping to near zero
Peak amplitudes under 5 mV
Seizure spikes

While a normal aEEG may not necessarily mean that the brain is normal, a severe or moderately
severe aEEG abnormality may indicate brain injury and poor outcome. The time of onset of
sleep wake cycling (SWC) has a prognostic value. If SWC returns before 36 hours then outcome
is good22 .

Cranial ultrasound (US):

Cranial US is not good for detecting changes of HIE in the term babies. However, hypoechoic
areas can be seen in very severe cases (having large areas of infraction).

In preterm babies, US can pick up periventricular leukomalacia and intraventricular-

periventricular hemorrhage by serial cranial US during the first week of life.

Computed tomography (CT):

In acute stage of HIE in term babies generalized low attenuation of brain parenchyma. CT is
more useful after a traumatic delivery and suspected of having an extra-axial haemorrhage

Magnetic resonance imaging (MRI):

Abnormalities of thalami and basal ganglia in term infants and that of white and grey matter at
term equivalent age in preterm infants and an altered signal at the level of the posterior limb of
the internal capsule are strong predictors of subsequent risk of poor neurodevelopmental
outcome.13,14,24
Second most common pattern of injury is injury to the watershed regions. Diffusion weighted
MRI can pick up abnormalities within days after birth, though more pronounced in later during
the first week. MRI is preferred over CT as it has a greater inter observer agreement and no
radiation exposure.

6
Newer modes of therapy

1. Therapeutic hypothermia

Institution of moderate therapeutic hypothermia (TH; (330C to 340C) in infants of at least 36 wk

gestation (not preterm) with moderate to severe encephalopathy (not mild) in intensive care
unit settings initiated within 4- 6 hr and continued for 72 hr of age has shown to reduce
mortality and neuro-morbidity by 18 months of age.10,12 TH can be instituted by selectively
cooling the head or the whole body. It is a safe modality in settings where intensive care
facilities to manage sickest neonates are available.

TH has become standard of care in developed countries. However , in low to middle income
countries where the patient profile is different (concomitant IUGR, infection and nutritional
deficiencies), and there is a paucity of intensive care, and many births occur out of hospital,
small studies have shown that there may be increase in mortality with TH. The true value of TH
in low to middle income countries is yet to be tested18.

Therapeutic hypothermia : What is evidence?

A cochrane review (8 RCTs; 638 term infants with moderate/ severe encephalopathy and evidence
of intrapartum asphyxia) showed that TH reduced combined outcome of mortality or major
neurodevelopmental disability by 24% to 18 months of age.

2. Prophylactic phenobarbitone

Some interest has been generated in the protective role of prophylactic phenobarbitone
in newborns with perinatal asphyxia. A dose of 40 mg/kg administered prophylactically was
associated with a better neuro-developmental outcome at 3 years of age.15 However the
Cochrane review database systematic review by Evans et al (2007) that included the 5 RCTs
derived no difference in the risk of death, neurodisability.16 Another study using 40 mg/kg within
1st hour showed a significant reduction in HIE with no difference in
complications.19Recommendation for use of prophylactic phenobarbitone still awaits further
studies.

What is evidence?

The systematic review by Evans DJ showed no significant difference in the risk of the combined outcome
of death or severe neurodevelopmental disability (typical RR 0.78, 95% CI 0.49, 1.23).

3. Drugs under investigation

A large number of drugs are under investigation for neuro-protection in HIE. These need to be
used in the early period of hypoxic ischemic injury. They act by causing blockade of free radical
generation (allopurinol, oxypurinol), scavenging of oxidants (superoxide dismutase, glutathione,
N-acetyl cysteine and alpha tocopherol), calcium channel blockade (flunarizine, nimodipine),

7
blockage of NMDA receptors (magnesium, MK801, dextromethorphan) and blockage of
inflammatory mediators (phospholipase A2, indomethcin). Corticosteroids have no role on the
treatment of HIE. Likewise, the current evidence does not support the use of mannitol in the
management of HIE.

Follow up

Follow all the neonates with the moderate and severe asphyxia, especially those with stage II
and III HIE staging. They should have a complete neurological assessment and intervention if
needed during the follow up. A formal psychometric assessment at 18 months should be
performed in all these babies.

Long term outcome

Among the infants who survive severe HIE, the sequelae include mental retardation, epilepsy,
and cerebral palsy of varying degrees. The latter can be in the form of hemiplegia, paraplegia, or
quadriplegia. Such infants need careful evaluation and support. They may need to be referred to
specialized clinics capable of providing coordinated comprehensive follow-up care.

The incidence of long-term complications depends on the severity of HIE. Up to 80% of infants
who survive severe HIE develop serious complications, 10-20% develop moderately serious
disabilities, and up to 10% are normal. Among the infants who survive moderately severe HIE,
30-50% may suffer from serious long-term complications, and 10-20% with minor neurological
morbidities. Infants with mild HIE tend to be free from serious CNS complications.

Predictors of mortality and neurological morbidity after perinatal hypoxic ischaemic

insult

Extended very low APGAR scores (at 20 minutes)

Time to establish spontaneous respiration (for 30 or more minutes)

Neonatal neurological examination(severe HIE)

Brain imaging (USG, MRI)

Other investigations (EEG, amplitude integrated EEG, Evoked potentials like BERA)

8
Research Subjects Study Intervention Outcomes to be measured
question design

Does fluid Neonates RCT Comparison of 2/3 Worst HIE stage

restricted in with maintenance and full Incidence of hyponatremia,
asphyxiated perinatal maintenance fluid renal failure, shock
babies improve asphyxia Neurological examination at
short term with any discharge
morbidities and HIE Neurological outcome at 18
long term months
prognosis?

9
References

1. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H,
Walker CF, Cibulskis R, Eisele T, Liu L, Mathers C; Child Health Epidemiology Reference
Group of WHO and UNICEF. Global, regional, and national causes of child mortality in
2008: a systematic analysis. Lancet 2010 Jun 5;375(9730):1969-87. Epub 2010 May 11.

2. Lawn JE, Blencowe H, Pattinson R, Cousens S, Kumar R, Ibiebele I, Gardosi J, Day LT,
Stanton C; Lancet's Stillbirths Series steering committee. Stillbirths: Where? When?
Why? How to make the data count? Lancet 2011 Apr 23;377(9775):1448-63. Epub 2011
Apr 13.

3. World Health Organizaton. Perinatal mortality: a listing of available information.

FRH/MSM.96.7.Geneva:WHO,1996

3. Report of the National Neonatal Perinatal Database (National Neonatology Forum,

India) 2003

4. Committee on fetus and newborn, American Academy of Pediatrics and Committee on

obstetric practice, American College of Obstetrics and Gynecology. Use and abuse of the
APGAR score. Pediatr 1996;98:141-142.

5. Perlman JM, Tack ED, Martin T, Shackelford G, Amon E. Acute systemic organ injury in
term infants fter asphyxia. Am J Dis Child 1989;143:617-20

6. Sarnat HB, Sarnat MS: Neonatal encephalopathy following fetal distress: A clinical and
electroencephalographic study. Arch Neurol 33: 695-706, 1976.

7. Levene MI. The asphyxiated newborn infant. In: Levene MI, Lilford RJ. Fetal and
neonatal neurology and neuro-surgary. Edinburgh: Churchil Livingstone 1995: 405-426.

8. Laptook A, Tyson J, Shankaran S, McDonald S, Ehrenkranz R, Fanaroff A, Donovan E,

Goldberg R, O'Shea TM, Higgins RD, Poole WK; National Institute of Child Health and
Human Development Neonatal Research Network. Elevated temperature after hypoxic-
ischemic encephalopathy: risk factor for adverse outcomes.Pediatrics 2008;122:491-9.

9. Edwards AD, Brocklehurst P, Gunn AJ, Halliday H, Juszczak E, Levene M, Strohm B,

Thoresen M, Whitelaw A, Azzopardi D. Neurological outcomes at 18 months of age after
moderate hypothermia for perinatal hypoxic ischaemic encephalopathy:synthesis and
meta-analysis of trial data. BMJ. 2010 Feb 9;340:c363. doi:10.1136/bmj.c363.

10. Zubrow A B, Hulman S, Kushner H, Falkner B. Determinents of blood pressure in infants

admitted to neonatal intensive care units:a prospective multicentre study. Journal of
Perinatology 1995;15:472-479.

10
11. John S. Wyatt, Peter D. Gluckman, Ping Y. Liu, Denis Azzopardi, Roberta Ballard, A. David
Edwards, Donna M. Ferriero, Richard A. Polin, Charlene M. Robertson, Marianne
Thoresen, Andrew Whitelaw, Alistair J. Gunn for the CoolCap Study Group Determinants
of Outcomes After Head Cooling for Neonatal Encephalopathy. Pediatrics 2007; 119:
912-921.

12. Lianne J, Woodward, Peter J Anderson, Nicole C Austin, Kelly Howard, Terrie E Inder.

Neonatal MRI to predict neurodevelopmental outcomes in preterm infants. NEJM 2006;

355: 685-94

13. Thayyil S, Chandrasekaran M, Taylor A, Bainbridge A, Cady EB, Chong WK, Murad S,
Omar RZ, Robertson NJ. Cerebral magnetic resonance biomarkers in neonatal
encephalopathy: a meta-analysis. Pediatrics 2010 Feb;125:e382-95. Epub 2010, Jan 18.

14. Hall RT, Hall FK, Daily DK. High-dose phenobarbital therapy in term newborn infants
with severe perinatal asphyxia: a randomized, prospective study with three-year follow-
up. J Pediatr. 1998 Feb;132(2):345-8.

15. Evans DJ, Levene MI, Tsakmakis M. Anticonvulsants for preventing mortality and
morbidity in full term newborns with perinatal asphyxia. Cochrane Database Syst Rev
2007 Jul 18;(3):CD001240.

16. 17 Malin G L, Morris R K, Khan K S. Strength of association between umbilical cord pH

and perinatal and long term outcomes: systematic review and meta-analysis.
BMJ. 2010; 340: c1471.

17. Thayyil S. Brain Cooling in Babies: Are We Ready for Clinical Trials in Developing
Countries? Indian Pediatr 2011;48: 441-442

18. Vargas-Origel A, Espinosa- Garcia JO, Muniz-Quezada E, Vargas-Nieto MA, AguilarGarcia

G, Prevention of hypoxic- ischemic encep[halopathy with high dose, early phenobarbitol
therepy. Gac Med Mex, 2004;140:147-153

19. 20 Ranjit M S . Cardiac abnormalities in birth asphyxia Indian J Paediatr 2000

Jul;67(7):529-32.

20. Thompson CM, et al: The value of a scoring system for hypoxic encephalopathy in
predicting neurodevelopmental outcome, Acta Paediatr 86;757, 1997.

21. Osredkar D, et al: Sleep wave cycling on amplitude integrated electroencephalography

in term newborns with hypoxic ischaemic encephalopathy, Paediatrics 115:327, 2005.

11
 22. Ilves P, et al: Changes in Doppler ultrasonography in asphyxiated term infants with
hypoxic ischaemic encephalopathy, Acta Paediatr 87:680, 1998.

23. Rutherford MA, et al: Abnormal magnetic resonance signal in the internal capsule
predicts poor neurodevelopmental outcome in infants with hypoxic ischaemic
encephalopathy, Paediatrics 102: 323, 1998.

Menache CC, et al; Prognostic value of neonatal discontinuous EEG, Paediatr Neurol 27:93,200

12
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Management of an asphyxiated newborn

Flowchart 1
Immediate Management of an asphyxiated newborn

Newborn with birth asphyxia

Baby requiring bag and mask ventilation (BMV) OR
Intubation with or without medications at birth

Categorize based on the severity of asphyxia

Mild asphyxia Moderate or severe asphyxia

Requiring BMV for less than 60 seconds Requiring BMV for 60 seconds or more and/or
No intubation or medications at birth Needed for intubation or medications at birth

Assess at 5 minutes after birth:

Assess sensorium and tone
Look for abnormal movements
See Flowchart 2

Normal tone and sensorium; Abnormal sensorium/tone

No abnormal movements; OR
No other complications Abnormal movements

Shift to mothers side;

Initiate breastfeeding;
If not able to breastfeed, start
alternative methods of feeding

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Flowchart 2
Management of a newborn who has been resuscitated for moderate or severe birth asphyxia

Newborn with moderate or severe asphyxia, who

Required bag and mask ventilation (BMV) for 60 seconds or more at birth, OR
Needed intubation or medications at birth

Check vitals (Annexure1):

If any one of vital
Temperature, heart rate, capillary refill
signs is abnormal
time (CRT), colour, oxygen saturation Follow Sheets A and B
(SpO2), respiratory rate, lower chest (Management of Emergencies)
retractions, abnormal movements

1. Maintain normal temperature If Hypothermia, Follow STP

o
Avoid hyperthermia (temperature >37.5 C)
2. Maintain oxygenation and Secure airway
ventilation Start oxygen by nasal cannula or hood if SpO2 is <90%
(Target SpO2 90-95%)
3. Maintain normal perfusion Administer normal saline bolus if CRT is prolonged
Transfuse if there is evidence of blood loss
If shock, Follow STP
4. Maintain normal blood Start IV 10% Dextrose for the next 12 hours
glucose Check blood glucose every 12 hours in the first 48-72 hours of life
Maintain blood glucose between 60 and 120 mg/dl
If Hypoglycaemia, Follow STP
5. Watch for seizures Administer phenobarbitone if the baby has seizures
(Follow STP for Seizures)

Assess if the infant has encephalopathy, 8-hourly until 72 hours (based on consciousness,
tone, seizures, and suck/respiration; (Panel 1):

No or mild encephalopathy Moderate or severe hypoxic-

ischemic encephalopathy (HIE)

Initiate alternative methods of

feeding, after vitals are stable Monitor vital signs and urine output (Panel 2)
Shift to Breastfeeding as soon as Continue IV fluids; restrict fluids to 60 mL/kg/d on the first day; do not
possible increase volume if baby urinates <6 times/day
Initiate intra gastric tube feeding followed by spoon/paladai feeds
gradually after vitals are stable
Assess for sepsis, if the baby does not improve even after 3 days
If no improvement or deterioration, REFER

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Panel 1: Classification of hypoxic-ischemic encephalopathy (Levene)

Feature Mild Moderate Severe

Consciousness Irritability Lethargy Comatose

Tone Hypotonia Marked hypotonia Severe hypotonia
Seizures No Yes Prolonged
Sucking/respiration Poor suck Unable to suck Unable to sustain
spontaneous respiration

Panel 2: Monitoring of an asphyxiated baby

Signs At 2 hr 4 hr 6 hr 8 hr 10 hr 12 hr
admission
Temperature
Color
Heart rate
Capillary Refill Time
Respiration Rate
Oxygen saturation
(SpO2)
Urine output
(8 hourly)
Neurological
examination (Panel 1)
(8 hourly):
Consciousness
Tone
Seizures
Sucking

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Management of Neonatal Seizures

Neonatal seizures (NS) are the most frequent and distinctive clinical manifestation of
neurological dysfunction in the newborn infant. Infants with NS are at a high risk of neonatal
death or neurological impairment/epilepsy disorders in later life. Though mortality due to NS has
decreased from 40% to about 20% over the years, the prevalence of long-term
neurodevelopment sequelae has largely remained unchanged at around 30%.1 Improper and
inadequate management of seizures could be one of the major reasons behind this
phenomenon.

Epidemiology

The National Neonatal Perinatal Database (NNPD; 2002-03), which collected data from 18
tertiary care units across the country, has reported an incidence of 10.3 per 1000 live-births.2
The incidence was found to increase with decreasing gestation and birth weight - for example,
preterm infants had almost twice the incidence when compared to term neonates (20.8 vs. 8.4
per 1000 live-births) while very low birth weight infants had more than 4-fold higher incidence
(36.1 per 1000 live-births).2

Definition

A seizure is defined clinically as a paroxysmal alteration in neurologic function, i.e. motor,

4
behavior and/or autonomic function. This definition includes :
1. Epileptic seizures: phenomena associated with corresponding EEG seizure activity e.g.
clonic seizures
2. Non-epileptic seizures: clinical seizures without corresponding EEG correlate e.g. subtle
and generalized tonic seizures
3. EEG seizures: abnormal EEG activity with no clinical correlation.

Classification
3
Four major types of NS have been identified (Table 1):
Subtle seizures: They are called subtle because the clinical manifestations are mild and are
often missed. They are the commonest type, constituting about 50% of all seizures. Common
examples of subtle seizures include:
1. Ocular - Tonic horizontal deviation of eyes or sustained eye opening with ocular fixation or
cycled fluttering
2. Oralfaciallingual movements - Chewing, tongue-thrusting, lip-smacking, etc.
3. Limb movements - Cycling, paddling, boxing-jabs, etc.
4. Autonomic phenomena - Tachycardia or bradycardia
5. Apnea may be a rare manifestation of seizures, particularly in term infants. Apnea due to
seizure activity has an accelerated or a normal heart rate when evaluated 20 seconds
after onset. Bradycardia is thus not an early manifestation in convulsive apnea but may
occur later due to prolonged hypoxemia.

Clonic seizures: They are rhythmic movements of muscle groups. They have both fast and
slow components, occur with a frequency of 1-3 jerks per second, and are commonly
associated with EEG changes.

Tonic seizures: This type refers to a sustained flexion or extension of axial or appendicular
muscle groups. These seizures may be focal or generalized and may resemble decerebrate
(tonic extension of all limbs) or decorticate posturing (flexion of upper limbs and extension of
lower limbs). Usually there are no EEG changes in generalized tonic seizures.

Myoclonic seizures: These manifest as single or multiple lightning fast jerks of the upper or
lower limbs and are usually distinguished from clonic movements because of more rapid speed
of myoclonic jerks, absence of slow return and predilection for flexor muscle groups. Common
changes seen on the EEG include burst suppression pattern, focal sharp waves and
hypsarrhythmia.

Myoclonic seizures carry the worst prognosis in terms of neurodevelopmental outcome and
seizure recurrence. Focal clonic seizures have the best prognosis.

3, 5-9
Common causes of neonatal seizures

The most common causes of seizures as per the recently published studies from the country
are hypoxic ischemic encephalopathy, metabolic disturbances (hypoglycemia and
hypocalcemia), and meningitis.8,9 Etiology could, however, vary between different centres
depending upon the patient population (term vs. preterm), level of monitoring (only clinical vs.
electrical and clinical seizures), etc.

Hypoxic-ischemic encephalopathy (HIE): HIE secondary to perinatal asphyxia is the

commonest cause of NS. Most seizures due to HIE (about 50-65%) start within the first 12 hrs
of life while the rest manifest by 24-48 hours of age. Additional problems like hypoglycemia,
hypocalcemia, and intracranial hemorrhage may co-exist in neonates with perinatal asphyxia
and these should always be excluded. Subtle seizures are the most common type of seizures
following HIE.

Metabolic causes: Common metabolic causes of seizures include hypoglycemia,

hypocalcemia, and hypomagnesemia. Rare causes include pyridoxine dependency and inborn
errors of metabolism (IEM).

Infections: Meningitis should be excluded in all neonates with seizures. Meningoencephalitis

secondary to intrauterine infections (TORCH group, syphilis) may also present as seizures in
the neonatal period.

Intracranial hemorrhage: Seizures due to subarachnoid, intraparenchymal or subdural

hemorrhage occur more often in term neonates, while seizures secondary to intraventricular
hemorrhage (IVH) occur in preterm infants. Most seizures due to intracranial hemorrhage occur
between 2 and 7 days of age. Seizures occurring in a term well baby on day 2-3 of life is often
due to subarachnoid hemorrhage.

Developmental defects: Cerebral dysgenesis and neuronal migration disorders are rare
causes of seizures in the neonatal period.

Miscellaneous: They include polycythemia, maternal narcotic withdrawal, drug toxicity (e.g.
theophylline, doxapram), local anesthetic injection into scalp, and phacomatosis (e.g. tuberous
sclerosis, incontinentia pigmentii). Accidental injection of local anesthetic into scalp may be
suspected in the presence of fixed and dilated pupil and absence of dolls eye reflex. Multifocal
clonic seizures on the 5th day of life may be related to low zinc levels in the CSF fluid (benign
idiopathic neonatal convulsions).

Seizures due to SAH and late onset hypocalcemia carry a good prognosis for long term neuro-
developmental outcome while seizures related to hypoglycemia, cerebral malformations, and
meningitis have a high risk for adverse outcome.
 3, 6-7
Approach to an infant with neonatal seizures

1. History
Seizure history: A complete description of the seizure should be obtained from the
parents/attendant. History of associated eye movements, restraint of episode by passive flexion
of the affected limb, change in color of skin (mottling or cyanosis), autonomic phenomena, and
whether the infant was conscious or sleeping at the time of seizure should be elicited. The day
of life on which the seizures occurred may provide an important clue to its diagnosis. While
seizures occurring on day 0-3 might be related to perinatal asphyxia, intracranial hemorrhage,
and metabolic causes, those occurring on day 4-7 may be due to sepsis, meningitis, metabolic
causes, and developmental defects.
Antenatal history: History suggestive of intrauterine infection, maternal diabetes, and narcotic
addiction should be elicited in the antenatal history. A history of sudden increase in fetal
movements may be suggestive of intrauterine convulsions.
Perinatal history: Perinatal asphyxia is the commonest cause of neonatal seizures and a
detailed history including history of fetal distress, decreased fetal movements, instrumental
delivery, need for resuscitation in the labor room, Apgar scores, and abnormal cord pH (<7)
and base deficit (>10 mEq/L) should be obtained. Use of a pudendal block for mid-cavity
forceps may be associated with accidental injection of the local anesthetic into the fetal scalp.
Feeding history: Appearance of clinical features including lethargy, poor activity, drowsiness,
and vomiting after initiation of breast-feeding may be suggestive of inborn errors of metabolism.
Late onset hypocalcemia should be considered in the presence of top feeding with cows milk.

Family history: History of consanguinity in parents, family history of seizures or mental

retardation and early fetal/neonatal deaths would be suggestive of inborn errors of metabolism.
History of seizures in either parent or sib(s) in the neonatal period may suggest benign familial
neonatal convulsions (BFNC).

2. Examination

Vital signs: Heart rate, respiration, blood pressure, capillary refill time and temperature should
be recorded in all infants.

General examination: Gestation, birth weight, and weight for age should be recorded as they
may provide important clues to the etiology for example, seizures in a term well baby may be
due to subarachnoid hemorrhage while seizures in a large for date baby may be secondary to
hypoglycemia. The neonate should also be examined for the presence of any obvious
malformations or dysmorphic features.

CNS examination: Presence of a bulging anterior fontanel may be suggestive of meningitis or

intracranial hemorrhage. A detailed neurological examination should include assessment of
consciousness (alert/drowsy/comatose), tone (hypotonia or hypertonia), and fundus
examination for chorioretinitis.

Systemic examination: Presence of hepatosplenomegaly or an abnormal urine odor may be

suggestive of IEM. The skin should be examined for the presence of any neuro-cutaneous
markers. Presence of hypopigmented macules or ash-leaf spot would be suggestive of tuberous
sclerosis.

3. Investigations

Essential investigations: Investigations that should be considered in all neonates with

seizures include blood sugar, serum sodium and calcium, cerebrospinal fluid (CSF)
examination, cranial ultrasound (US), and electroencephalography (EEG). CSF examination
should be done in all cases as seizure may be the first sign of meningitis. It should not be
omitted even if another etiology such as hypoglycemia is present. CSF study may be withheld
temporarily if severe cardio-respiratory compromise is present or even omitted in infants with
severe birth asphyxia (documented abnormal cord pH/base excess and onset of seizures within
12-24 hrs of life).

One should carry out all these investigations even if one or more investigations are positive, as
multiple etiologies may coexist, e.g. sepsis, meningitis and hypoglycemia.

Additional investigations: These may be considered in neonates who do not respond to a

combination of phenobarbitone and phenytoin or earlier in neonates with specific features.
These include neuroimaging (CT, MRI), screen for congenital infections (TORCH) and for inborn
errors of metabolism (IEM). An arterial blood gas may have to be performed if IEM is strongly
suspected.

Imaging: Neurosonography is an excellent tool for detection of intraventricular and parenchymal

hemorrhage but is unable to detect SAH and subdural hemorrhage. It should be done in all
infants with seizures. CT scan should be done in all infants where an etiology is not available
after the first line of investigations. It can be diagnostic in subarachnoid hemorrhage and
developmental malformations. Magnetic resonance imaging (MRI) is indicated only if
investigations do not reveal any etiology and seizures are resistant to usual anti-epileptic
therapy. It can be diagnostic in cerebral dysgenesis, lissencephaly, and other neuronal
migration disorders.
Electroencephalogram (EEG): EEG has both diagnostic and prognostic role in seizures. It
should be done in all neonates who need anticonvulsant therapy. Ictal EEG may be useful for
the diagnosis of suspected seizures and also for diagnosis of seizures in muscle-relaxed
infants. It should be done as soon as the neonate is stable enough to be transported for EEG,
preferably within first week. EEG should be performed for at least one hour.10 Inter-ictal EEG is
useful for long-term prognosis of neonates with seizures. A background abnormality in both term
and preterm neonates indicates a high risk for neurological sequelae. These changes include
burst-suppression pattern, low voltage invariant pattern and electro-cerebral inactivity.

Amplitude integrated EEG (aEEG): This new method provides continuous monitoring of cerebral
electrical activity at the bedside in critically sick newborns. aEEG is helpful in evaluating the
background as well in identification of seizure activity in NS. As with conventional EEG,
background abnormalities like burst-suppression or continuous low voltage pattern in aEEG also
help in prognosticating the infant with seizures particularly in the setting of HIE. Seizure activity
on aEEG is characterized by a rapid rise in both the lower and upper margins of the trace.
Some seizures that are focal or relatively brief are, however, missed by this technique.3

Screen for congenital infections: TORCH screen and VDRL should be considered in the
presence of hepatosplenomegaly, thrombocytopenia, intrauterine growth restriction, small for
gestational age, and presence of chorioretinitis.

Metabolic screen: This includes blood and urine ketones, urine reducing substances, blood
ammonia, anion gap, urine and plasma aminoacidogram, serum and CSF lactate/ pyruvate
ratio.

Management

1. Initial medical management:

The first step in successful management of seizures is to nurse the baby in thermoneutral
environment and to ensure airway, breathing, and circulation (TABC). Oxygen should be
started, IV access should be secured, and blood should be collected for glucose and other
investigations. A brief relevant history should be obtained and quick clinical examination should
be performed. All this should not require more than 2-5 minutes.

2. Correction of hypoglycemia and hypocalcemia:

If glucostix shows hypoglycemia or if there is no facility to test blood sugar immediately, 2

mL/kg of 10% dextrose should be given as a bolus injection followed by a continuous infusion of
6-8 mg/kg/min.
If hypoglycemia has been treated or excluded as a cause of convulsions, the neonate should
receive 2 mL/kg of 10% calcium gluconate IV over 10 minutes under strict cardiac monitoring. If
serum calcium levels are suggestive of hypocalcemia, the newborn should receive calcium
gluconate at 8 mL/kg/d for 3 days. If seizures continue despite correction of hypocalcemia, 0.25
mL/kg of 50% magnesium sulfate should be given intramuscularly.

3. Anti-epileptic drug therapy (AED)3

Anti-epileptic drugs (AED) should be considered in the presence of even a single clinical
seizure since clinical observations tend to grossly underestimate electrical seizures and
facilities for continuous EEG monitoring are not universally available. If aEEG is being used,
elimi
nati
First-line AED: Evidence and recommendations
ng
The Cochrane review found only one RCT that showed comparable seizure control all
rate with phenobarbital and phenytoin (RR 1.03, 95% CI 0.96 to 1.62), controlling
elec
seizures in only half of cases.11
trica
Based on the available evidence, the WHO guidelines on neonatal seizures l
recommend phenobarbitone as the first-line agent for management of neonatal
seiz
seizures.12
ure
activ
3
ity should be the goal of AED therapy. AED should be given if seizures persist even after
correction of hypoglycemia/ hypocalcemia (Figure 1).

Phenobarbitone (Pb)

It is the drug of choice in neonatal seizures. The dose is 20 mg/kg/IV slowly over 20 minutes
(not faster than 1 mg/kg/min). If seizures persist after completion of this loading dose, additional
doses of phenobarbitone 10 mg/kg may be used every 20-30 minutes until a total dose of 40
mg/kg has been given. The maintenance dose of Pb is 3-5 mg/kg/day in 1-2 divided doses,
started 12 hours after the loading dose.

Phenytoin

Phenytoin is indicated if the maximal dose of phenobarbitone (40 mg/kg) fails to resolve
seizures or earlier, if adverse effects like respiratory depression, hypotension or bradycardia
ensue with phenobarbitone. The dose is 20 mg/kg IV at a rate of not more than 1 mg/kg/min
under cardiac monitoring. Phenytoin should be diluted in normal saline as it is incompatible with
dextrose solution. A repeat dose of 10 mg/kg may be tried in refractory seizures. The
maintenance dose is 3-5 mg/kg/d (maximum of 8 mg/kg/d) in 2-4 divided doses. Oral
suspension has very erratic absorption from gut and should be avoided in neonates.
Fosphenytoin, the prodrug of phenytoin, does not cause the same degree of hypotension or
cardiac abnormalities, has high water solubility (can be given IM), and is less likely to lead to
soft-tissue injury when compared with phenytoin. It is dosed in phenytoin equivalents - 1.5
mg/kg of fosphenytoin is equivalent to 1 mg/kg of phenytoin.

Benzodiazepines
This group of drugs may be required in up to 15-20% of neonatal seizures. The commonly used
benzodiazepines are lorazepam and midazolam. Diazepam is generally avoided in neonates
because of its short duration of antiepileptic effect but very prolonged sedative effect, narrow
therapeutic index, and the presence of sodium benzoate as a preservative. Lorazepam is
preferred over diazepam as it has a longer duration of action and results in less adverse effects
(sedation and cardiovascular effects). Midazolam is faster acting than lorazepam and may be
administered as an infusion. It causes less respiratory depression and sedation than lorazepam.

Second-line AED: Evidence and recommendations

The Cochrane review11 found one study that randomized infants who failed to
respond to phenobarbital to receive either lidocaine or midazolam as second-line
agents. There was a trend for lidocaine to be more effective in reducing seizure
burden (RR 0.40 95% CI 0.14 to 1.17) but both groups had similarly poor long term
outcomes assessed at one year.
Based on the available evidence, the WHO guidelines on neonatal seizures
recommend either midazolam or lidocaine as the second-line AED in neonatal
seizures.12

However, given the lack of robust evidence and constraints involved in providing
respiratory support and/or monitoring in most neonatal units in India, it seems
appropriate to use phenytoin as the second-line agent in neonates with seizures.

However, when used as continuous infusion, the infant has to be monitored for respiratory
depression, apnea, and bradycardia (equipment for resuscitation and assisted ventilation should
be available at the bedside of all neonates given multiple doses of AED).
The doses of these drugs are given below:
Lorazepam: 0.05 mg/kg IV bolus over 2-5 minutes; may be repeated
Midazolam: 0.15 mg/kg IV bolus followed by infusion of 0.1 to 0.4 mg/kg/hour.
According to Volpe, the expected control rate of neonatal clinical seizures to anticonvulsants is
40% to the initial 20-mg/kg loading dose of phenobarbitone, 70% to a total of 40 mg/kg of Pb,
85% to a 20-mg/kg of phenytoin, and 95% to 100% to 0.05 to 0.1 mg/kg lorazepam.1

Antiepileptic drugs for seizures refractory to above treatment

In exceptional circumstances when the seizures are refractory to phenobarbitone, phenyotin,
and midazolam, the following drugs might be tried:
Lidocaine: It is usually administered as a bolus dose of 4 mg/kg IV followed by an infusion rate
of 2 mg/kg/hr. It is tapered over several days. Adverse effects include arrhythmias, hypotension,
and seizures. It should not be administered with phenytoin.
Paraldehyde: A dose of 0.1-0.2 mL/kg/dose may be given IM or 0.3 mL/kg/dose mixed with
coconut oil in 3:1 may be used by per rectal route. Additional doses may be used after 30
minutes and q 4-6 hourly. Adverse effects include pulmonary hemorrhage, pulmonary edema,
hypotension, and liver injury.
Sodium valproate: Per rectal or IV route may be used in acute condition. The dose is 20-25
mg/kg/d followed by 5-10 mg/kg every 12 hours. It should, however, be used with caution in
newborns given the uncertain risk of hepatotoxicity following its use.
Vigabatrin: It has been used in neonates with infantile spasms. The dose is 50 mg/kg/day.
Topiramate: It shows promise in neonatal seizures because of its potential neuroprotective
effect against injury caused by seizures. It has been used for refractory infantile spasms in
infants. The higher volume of distribution compared with other drugs requires higher initial and
maintenance doses of approximately 3 mg/kg.

Other therapies
Pyridoxine: A therapeutic trial of pyridoxine is reserved as a last resort in refractory seizures.
Intravenous route is the preferred method; however, suitable IV preparations are not universally
available. Hence intramuscular (IM) route may have to be used (1 mL of injection neurobion has
50 mg pyridoxine and 1 mL each may be administered both the sides in either the gluteal region
or anterolateral aspect of thigh). It should ideally be done in the NICU as hypotension and
apnea can occur.
 Exchange transfusion: This is indicated in life-threatening metabolic disorders, accidental
injection of local anesthetic, trans-placental transfer of maternal drugs (e.g. chlorpropamide),
and bilirubin encephalopathy.

Maintenance anti-epileptic therapy

Principles of AED used in older children and adults are applicable to neonates also.
Monotherapy is the most appropriate strategy to control seizures. Attempts should be made to
stop all anti-epileptic drugs and wean the baby to only phenobarbitone at 3-5 mg/kg/day. If
seizures are uncontrolled or if clinical toxicity appears, a second AED may be added. The
choice may vary from phenytoin, carbamezepine, and valproic acid.

When to discontinue AED

This is highly individualized and no specific guidelines are available. The goal is to discontinue
phenobarbitone as early as possible. We usually try to discontinue all medications at discharge
if clinical examination is normal, irrespective of etiology and EEG. If neurological examination is
persistently abnormal at discharge, AED is continued and the baby is reassessed at one month.
If the baby is normal on examination and seizure free at 1 month, phenobarbitone is
discontinued over 2 weeks. If neurological assessment is not normal, an EEG is obtained. If
EEG is not overtly paroxysmal, phenobarbitone is tapered and stopped. If EEG is overtly
abnormal, the infant is reassessed in the same manner at 3 months and then 3 monthly till 1
year of age (Figure 2).

Table 2 provides a brief list of the possible studies that could emanate from the identified
research gaps.
References

1. Tekgul H, Gauvreau K, Soul J, Murphy L, Robertson R, Stewart J, et al. The current

etiologic profile and neurodevelopmental outcome of seizures in term newborn

infants. Pediatrics 2006;117:1270-80.

2. National Neonatal Perinatal Database. Report for the year 200203.

http://www.newbornwhocc.org/pdf/nnpd_report_2002-03.PDF (accessed Jan 8,

2012).

3. Volpe JJ, editor. Neurology of the newborn. 5th ed. Philadelphia: Saunders Elsevier,

2008. p.203-44.

4. Mizrahi EM, Kellaway P, editors. Diagnosis and management of neonatal seizures.

Lippincott-Raven, 1998. p. 15-35.

5. Painter MJ, Scher MS, Stein MD, Armatti S, Wang Z, Gardner JC, et al.

Phenobarbitone compared with phenytoin for treatment of neonatal seizures. N Engl

J Med 1999;341:485-9.

6. Rennie JM. Neonatal seizures. Eur J Pediatr 1997;156:83-7.

7. Laroia N. Controversies in diagnosis and management of neonatal seizures. Indian

Pediatr 2000;37:367-72.

8. Iype M, Prasad M, Nair PM, Geetha S, Kailas L. The newborn with seizures -- a

follow-up study. Indian Pediatr 2008;45:749-52.

9. Kumar A, Gupta A, Talukdar B. Clinico-etiological and EEG profile of neonatal

seizures. Indian J Pediatr 2007;74:33-7.

10. Wical BS. Neonatal seizures and electrographic analysis: evaluation and outcomes.

Pediatr Neurol 1994;10:271-5.

11. Booth D, Evans DJ. Anticonvulsants for neonates with seizures. Cochrane Database

Syst Rev. 2004 Oct 18;(4):CD004218.

12. WHO. Guidelines on Neonatal Seizures. Geneva: World Health Organization, 2012
Table 1 Investigations required in a neonate with seizures

Essential investigations (required in all Additional investigations

with few exceptions*)
Blood sugar Hematocrit (if plethoric and/or at risk for
Serum sodium and calcium polycythemia)
Cerebrospinal fluid (CSF) examination Serum bilirubin (if icteric)
Cranial ultrasound (US) and Serum magnesium
Electroencephalography (EEG) and/or Arterial blood gas and anion gap (lethargy,
amplitude integrated EEG vomiting, family history, etc.)
Imaging: CT and/or MRI (if no etiology found
after essential investigations)
TORCH screen for congenital infections
Work-up for inborn errors of metabolism
 Table 2 Objectives and outcomes of possible studies

S. Title Objectives Possible outcome variables Study design

No
1. Epidemiology of To understand the epidemiology 1. Incidence, etiology and type of Cohort study
neonatal seizures of seizures in term and preterm neonatal seizures (for
neonates in resource restricted 2. Age at onset of seizures incidence);
3. EEG changes during ictal and
settings Case-series
inter-ictal periods
4. Outcomes of neonates with for others
seizures
2. First-line agent for To compare the seizure control 1. Seizure control rates Randomized
treatment of rates following therapy with (complete control as defined trial
neonatal seizures phenobarbitone with by EEG)
2. Time taken to achieve control
midazolam/lignocaine, newer
of seizure episode
drugs such leviteracetam, 3. Duration of AED therapy and
topiramate in neonates with hospital stay
convulsions 4. Neurodevelopment outcomes
at 18-24 months age
3. Optimal second- To compare the seizure control Same as above Randomized
line agent for rates following therapy with trial
treatment of midazolam, lignocaine or
neonatal seizures levetiracetam in infants who
failed to respond to
phenobarbital therapy
4. Discontinuing To determine the optimal timing 1. Seizure recurrence Randomized
AEDs in neonates and method of discontinuation of 2. Neurodevelopment outcomes trial/ cohort
with seizures AEDs in newborns whose at 18-24 months age study
seizures are controlled on
current AED treatment (for e.g.
stopping AED after 72 hours vs.
after 2-4 weeks; abrupt stoppage
of phenobarbitone vs. gradual
tapering followed by stopping)
 Figure 1 Acute management of neonatal seizures

Neonate with seizures

Identify and characterize the seizure

Secure airway and optimize breathing, circulation, and temperature
Start oxygen if seizures are continuous
Secure IV access and take blood samples for baseline investigations including sugar,
calcium, magnesium, sodium, potassium, arterial blood gas, hematocrit, sepsis screen
If hypoglycemic (blood sugar <40 mg/dL): administer 2 mL/kg of 10% dextrose as bolus
followed by a continuous infusion of 6-8 mg/kg/min
If blood sugar is in normal range, sample for blood calcium should be withdrawn; if
abnormal, 2 ml/kg of calcium gluconate (10%) should be given IV under cardiac
monitoring

Seizures persist

Administer phenobarbitone 20 mg/kg IV

stat over 20 minutes

Seizures continue

Repeat phenobarbitone in 10 mg/kg/dose

aliquots until 40 mg/kg dose is reached

Seizures continue

Administer phenytoin 20 mg/kg IV slowly

over 20 minutes under cardiac monitoring

Seizures continue

Repeat phenytoin 10 mg/kg/dose

Seizures continue

Consider lorazepam /midazolam bolus and

midazolam infusion if needed;

Seizures continue

Consider other antiepileptic drugs,

pyridoxine, and exchange transfusion

Seizures controlled

Wean AED slowly to maintenance phenobarbitone

 Figure 2 Weaning of anticonvulsant therapy

Newborn on anticonvulsant therapy

Wean all antiepileptic drugs except

phenobarbitone once seizure controlled

Perform neurological examination

prior to discharge

Normal Abnormal

Stop phenobarbitone Continue

prior to discharge phenobarbitone
for 1 month

Repeat neurological
examination at 1 month

Normal
examination Abnormal examination

Evaluate EEG

Taper drugs Normal EEG Abnormal EEG

over 2 weeks Taper drugs Continue drug;
over 2 weeks reassess at 3 months*

*Intractable seizures may need lifelong therapy; consider switching over to other drugs (phenytoin or
carbamazepine)
 For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children)

Management of a newborn with seizures

Flowchart 1: Initial management

Newborn with abnormal movements

Differentiate from jitteriness/other abnormal movements (Panel 1)

Seizures

Secure airway;
Optimize breathing, circulation, and temperature;
Start oxygen in the presence of cyanosis and/or low
SpO2 (<90%)

Measure Blood Glucose Measure Serum Calcium, if possible

If low, give IV Calcium*

Blood glucose < 45 mg/dl Blood glucose > 45 mg/dl

Seizure continues No Seizure
mg/dL

Give 2 ml/kg 10% dextrose IV; Give phenobarbitone 20 mg/kg IV

Start IV Dextrose maintenance infusion slowly over 20 minutes (Panel 2) REFER Start Oral Calcium
(See STP for Hypoglycemia) (Panel 6)

Seizures continue No Seizures * For giving IV

Seizures continue despite calcium, cardiac
normal blood glucose monitoring is
Repeat phenobarbitone 10 mg/kg Ongoing Care preferred.
every 30 min until a total of 40 Therefore, baby
mg/kg is reached should be
referred to
higher center for
treating
Seizures continue hypocalcemia.

* Lorazepam can cause severe Give IV Lorazepam* 0.05 mg/kg bolus over 2-5
respiratory depression; use these, if minutes (Panel 3) OR
ventilation facilities are available, IV phenytoin 20 mg/kg slowly over 20 minutes
otherwise use phenytoin and REFER if no (Panel 4)
improvement

Do Lumbar Puncture if clinical examination No Seizure Seizures continue

shows bulging anterior fontanel, opisthotonus,
lethargy or unconsciousness
After immediate treatment, also assess signs Ongoing Care REFER
for other illnesses

1
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children)

Panel 1: Convulsions vs. Jitteriness

Convulsions Jitteriness
Have both fast and slow components Fast movements (4-6 per second); tremors are
Slow movements (1-3 jerks per second) of equal amplitude
Not provoked by stimulation Provoked by stimulation
Does not stop with restraint Stops with restraint
Neurological examination - often abnormal Neurological examination usually normal
Often associated with eye movements (tonic Not associated with eye movements or
deviation or fixed stare) and/or autonomic changes autonomic changes
(changes in heart rate)

Panel 2: Protocol for administering phenobarbitone

Presentation Injection 200 mg/ml; 1 ml ampoules
Dosage Loading dose: 20 mg/kg IV or IM
Maintenance: 5 mg/kg/day PO (once daily)
Route Intravenous and per oral
Directions for use Take 0.1 mL of solution and dilute with 0.9 mL of water for injection to
make 1 mL
Resultant concentration is 20 mg/mL
Give required amount slowly over 15-20 minutes.
Caution May cause respiratory arrest

Panel 3: Protocol for administering lorazepam

Presentation Injection 2 mg/ml OR 4 mg/ml; 1 ml ampoules
Dosage Loading dose: 0.05 mg/kg IV;
May be repeated, if necessary.
Route Intravenous route
Directions for use Take 1.0 mL of solution and dilute with 9.0 mL of water for injection to
make 10 mL
Dilute again by adding 1.0 mL of the reconstituted solution to 9.0 mL of
water for injection to make 10 mL
Resultant concentration is 0.02 or 0.04 mg/mL (depending upon the
original concentration in the ampoule)
Give the required amount slowly over 2-5 minutes.
Caution May cause respiratory arrest

Panel 4: Protocol for administering phenytoin

Presentation Injection 100 mg/2ml
Dosage Loading dose: 15-20 mg/kg IV
Route Intravenous route
Directions for use Dilute in normal saline
Give slowly at a rate 1 mg/kg/min infusion over 15-20 minutes
Caution After giving, flush the cannula with saline to prevent phlebitis
Do not use cloudy solutions

2
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children)

Panel 5: Protocol for administering IV calcium gluconate

Presentation 9 mg/ml ampoules
Dosage 1-2 ml/kg/dose every 6-8 hourly
Directions for use Dilute in equal amount of distilled water
Inject very slowly while MONITORING HEART RATE
If there is bradycardia, discontinue the injection.
Caution Take care to avoid extravasation, if being given as infusion, as it may
cause sloughing of skin

Panel 6: Protocol for administering oral calcium

Presentation Suspension containing elemental calcium and elemental phosphorus in
ratio of 2 :1
Dosage 120 mg/Kg/day calcium and 60 mg/kg/day phosphorus; divided into 8
hourly doses
Caution Ensure compliance

3
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children)

Flowchart 2: Ongoing care of newborn with seizures

Seizures controlled with initial management

Start maintenance Phenobarbitone 5 mg/kg PO once daily

12 hours after the last seizures

Monitor for recurrence of seizures

Recurrence of seizures No clinical seizures in the next 72 hours

Treat as described under

Initial management of
neonatal seizures to control If controlled by Phenobarbitone If controlled by more than one
the seizure and REFER alone, stop without tapering of drug, stop the drugs one by one.
the doses Phenobarbitone stopped the last

4
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children)

Annexure 1: Differential diagnosis of neonatal seizures and spasms

Findings Probable
History Examination Investigations or Diagnosis
Other Known
Diagnoses
Time of onset day 1 to 3 Convulsions, jitteriness Blood glucose Hypoglycemia
History of maternal diabetes Lethargy, or less than
Poor or no feeding unconsciousness 45 mg/dl
Small baby (less than 2.5 kg (2.6 mmol/l)
at birth or born before 37
weeks gestation)
Large baby (more than 4 kg
at birth)
Mother not immunized with Spasms Infection of Tetanus
tetanus toxoid umbilicus
Poor feeding or no feeding after
having fed well initially
Time of onset day 3 to 14
Unclean birth
Application of unclean or
harmful substances (e.g. animal
dung) to umbilicus
Time of onset day 2 Seizures Sepsis Possible meningitis
or later Lethargy or
unconsciousness
Bulging anterior fontanelle
Complicated or difficult labour or Convulsions or Asphyxia or
birth (fetal distress) unconsciousness other brain
Failure of baby to spontaneously Lethargy or injury
breathe at birth unconsciousness
Resuscitation required at birth Breathing difficulty
Time of onset within 24 hours of Abnormal body
birth temperature
Floppiness or reduced
activity
Irritability
Time of onset day 1 to 7 Convulsions or Intraventricular
Sudden deterioration of condition unconsciousness bleeding
Sudden pallor Small baby (less than 2.5 kg
at birth or born before 37
weeks gestation)
Severe breathing difficulty
Time of onset of encephalopathy Convulsions Positive Bilirubin
day 3 to 7 Opisthotonus Coombs test encephalopathy
Serious jaundice Poor or no feeding High Serum (kernicterus)
Late or no treatment of serious Lethargy or floppiness Bilirubin
jaundice
*The diagnosis cannot be made if a finding listed in bold is absent. The presence of a finding listed in bold, however, does not
guarantee the diagnosis.

5
For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Patent Ductus Arteriosus
in Preterm Neonates
Introduction

Patent ductus arteriosus (PDA) is a major morbidity seen in premature infants, with its incidence being
inversely related to gestational age and birth weight. Studies report incidence of 15-40% in very low
birth weight infants (<1500g) where as in premature extremely low birth weight infants (<28weeks; <
1000g) its as high as 50-65%.1,2

The closure of ductus arteriosus (DA) following birth is an important component of transitional
circulation, thereby directing the entire right ventricular output to the lungs to facilitate its oxygenation.
Contrary to this the ductus arteriosus acts as conduit for diverting the partially oxygenated blood to
support systemic circulation in fetus. The closure of DA is mediated by a shift in balance of
vasoconstricting (endothelin) and dilating (PGE2) mediators, which in turn is mediated by increased
oxygenation and reduced flow through the DA. Premature infants are at increased risk of PDA due to
elevated levels of PGE2, increased PGE2 receptor levels and reduced intrinsic vascular tone as a result of
weak actin myosin complex formation. Generally the ductus arteriosus functionally close in term infants
by 12-24 hrs, whereas the closure may be delayed by 3-5 days in preterm neonates.3

Hemodynamic consequences of PDA

The presence of PDA has significant effects on myocardial functions as well as systemic and pulmonary
blood flow. Preterm newborns adapts, by increasing the left ventricular contractility, and thereby
maintaining the effective systemic blood flow even when the left to right shunts equals 50% of the left
ventricular output4 This is mainly accomplished by increase in stroke volume (SV) rather than heart rate.

Despite the increased left ventricular output, there is significant redistribution of blood flow to major
organ systems, with the presence of ductal steal due to left to right shunt. There is flow across the
ductus all throughout the cardiac cycle, the direction of which depends on the difference between
systemic and pulmonary pressures. Usually there is shunting from systemic to pulmonary circulation
called ductal steal, the maximum of which occurs at the beginning of the cardiac systole when the
pressure gradient is maximum. Contrary to the belief that ductal run off occurs only in diastole, it is
present all throughout the cardiac cycle. However, its effect on systemic circulation is best
demonstrated on echocardiogram during diastole, as a retrograde flow in the descending aorta, or other
systemic vessels on Doppler, instead of the normal low velocity forward flow. This steal phenomenon
may lead to systemic hypo perfusion, despite increased cardiac output. Hence hemodynamically
significant PDA has negative effect on cerebral circulation and oxygenation, which may lead to injury of
the immature brain.
Diagnosis of PDA

Clinical diagnosis of PDA and its pitfalls

The clinical features of a PDA are mainly because of the hyperdynamic circulatory effects caused by the
shunt, resulting in bounding peripheral pulses (diagnosed clinically by easily palpable dorsalis pedis),
wide pulse pressure (>25 mm of Hg), hyperactive precordium (visible precordial pulsations in more than
2 rib spaces), systolic murmur (usually ejection systolic; rarely pansystolic or continous), persistant
tachycardia etc.

In a ventilated infant, fluctuating FiO2, increasing pressure requirements, unexplained CO2 retention or
metabolic acidosis, recurrent apnea etc suggests a symptomatic ductus. However diagnosis of PDA
based on clinical features alone has mainly two pitfalls i.e. low sensitivity and delay in detection. In
studies comparing clinical examination vs echocardiography, there was a delay of 1-4 days in diagnosis
of PDA based on clinical findings alone.5 More over these signs were insensitive (sensitivity of 30-40%)
and had poor predictive value (60%).

Role of echocardiography

Echocardiography is the gold standard, for diagnosis as well as for assessing severity of PDA.6 The
features suggestive of patent ductus arteriosus include

(a) 2-D and color Doppler- short axis view: Direct visualization of the ductus. In 2-D short axis view,
in the presence of a patent ductus, the appearance is classically described as three-legged stool
appearance. In color Doppler, there is continuous flare in the MPA.
(b) Short axis view, Pulsed Doppler: Turbulence in main pulmonary artery (MPA) due to left to right
shunt jet flowing into MPA.
(c) Four chamber view: Bowing of interatrial septum to right with enlarged left atrium and left
ventricle
(d) Long axis view: LA/Ao ratio > 1.5:1
(e) Raised left ventricular stroke volume

However these signs only establish the presence of a patent ductus and do not reflect the
hemodynamic significance of the ductus. The echocardiographic markers indicating the
hemodynamic significance and degree of shunting have been well described in a recent review by
Sehgal, et al (Table 1).7
Table 1: Echocardiographic markers of hemodynamically significant PDA

Echocardiography parameter* No PDA Mild Moderate Large

Features of ductus arteriosus
Trans ductal diameter (mm) 0 <1.5 1.5-3.0 >3.0
Ductal velocity Vmax (cm/sec) 0 >2 1.5-2.0 < 1.5
Antegrade PA diastolic flow (cm/sec) 0 >30 30-50 >50
Pulmonary overcirculation
Left atrial /aortic root width ratio 1.1 0.2 <1.4:1 1.4-1.6 >1.6:1
Left ventricular/ aortic root width ratio 1.9 0.3 - 2.2 0.4 2.27 0.27
E wave/ A wave ratio <1 <1 1-1.5 >1.5
IVRT(ms) <55 46-54 36-45 <35
LVSTI 0.34 0.09 - 0.26 0.03 0.24 0.07
Systemic hypoperfusion
Retrograde diastolic flow (as % of forward 10 < 30 30-50 > 50
flow)
Aortic stroke volume (ml/kg) 2.25 2.34
Left ventricular output (ml/kg/min) 190-310 - - >314
LVO/SVC flow ratio 2.4 0.3 - - 4.5 0.6
* LVO = left ventricular output, SVC = superior vena cava, LVSTI = left ventricular stroke volume index, IVRT = isovolumic relaxation time, PWD = pulse wave Doppler,
CWD = continuous wave Doppler, PA =pulmonary artery. (Empty boxes implies data not available)

Echocardiography also helps in ruling out other structural heart diseases and facility for in-house
echocardiography enables serial monitoring as well as determines treatment responses.

Limitations of echocardiography

Even though echocardiography is the gold standard for diagnosis of PDA, it has its own limitations
especially with regard to decisions on treatment.8

a) There is limited data prove that functional echocardiography alters the neonatal outcomes.
b) Though the criteria for assessment of degree of shunting are established, there is lack of
universal consensus regarding the best criteria for initiating treatment of PDA. No data till date
supports decision to treat PDA based of echocardiography criteria alone.
c) Many neonatal units lack ready access to echocardiography and it is still a consultative tool,
making serial assessments practically difficult.
d) Last but not least, the echocardiography is highly operator dependent and hence it needs to be
always used in conjunction with clinical findings.
Recommendations on use of echocardiography in PDA

a) Though early screening echocardiography could predict possible significant PDA, there is no data
to support routine screening in all preterm infants, as it does not seem to change the long term
outcomes.
b) Echocardiography establishes presence of ducts and its hemodynamic significance, but it cannot
be used in isolation to decide on treatment. Treatment decision should be in conjunction with
clinical symptoms.
c) In all infants in whom treatment of PDA is considered, echocardiography before treatment is
essential to establish the diagnosis as well as to rule out other structural heart disease (e.g. duct
dependent condition in which closure of PDA is contraindicated)
d) Post treatment echocardiography is required to document the response to treatment and assess
the ductus.
e) Early targeted treatment based on echocardiographic criteria alone cannot be recommended at
this point of time even though some large RCT (DETECT Trial , Australia) is currently evaluating
the same

Other diagnostic tests

The other diagnostic tests have very limited role, especially in preterm babies with PDA. Chest
radiograph findings are non-specific and features like cardiomegaly and pulmonary plethora occurs late
when significant PDA leads to congestive heart failure.

An emerging newer diagnostic modality is biomarkers like brain natriuretic peptide (BNP) and N-
terminal-pro- BNP which has shown good sensitivity and specificity. Though these markers are
promising, there widespread clinical use is yet to emerge.9

Management of PDA

The management of PDA could be broadly divided into three aspects- pharmacological closure of
ductus, general supportive measures and surgical ligation of the PDA.

To treat or not to treat a PDA

Despite three decades of intense research enrolling thousands of preterm infants, yet evidence for the
long term benefits of pharmacological closure of PDA is inconclusive and debatable.9 The decision to
treat PDA depends on the 3 factors- the spontaneous closure rate, adverse effect of ductal patency and
risk benefit of treatment.

In a recent systematic review, Benitz et al evaluated the effect of medical and surgical treatment- either
prophylactic or therapeutic on various outcomes.10 Although all modes of interventions effectively
closed the ductus, there was little beneficial effect on the outcomes. Hence the therapeutic decision to
treat ductus arteriosus is complex and there is a hot debate for conservative approach especially in
preterm infants more than 1000g in whom the spontaneous closure rate is high.

Pharmacological closure of PDA

Indications for treatment*

Treatment should be considered in preterm infants with echocardiographically proven hemodynamically

significant ductus arteriosus with one of the following conditions

1. Features of congestive heart failure

2. Requiring prolonged respiratory support ( invasive or non invasive) unlikely to be due to other
reasons
3. Unexplained oxygen requirement(FiO2 30%) or rising O2 requirement on respiratory support
4. Recurrent apnea requiring respiratory support (CPAP/Nasal IMV/invasive ventilation) attributed
to PDA

* These indications are based on pragmatic clinical decision and not based on high quality evidence
* Treatment of all infants otherwise clinically asymptomatic, based on echocardiography findings of hs-
PDA alone is not warranted
*Definition of hs-PDA: Presence of PDA >1.5mm with one of the following LA/Ao ratio >1.5:1, LV/Ao ratio
>2.2:1, retrograde flow diastolic flow in descending aorta, celiac or cerebral arteries > 30% of ante grade
flow; Left ventricular output >320mL/kg/min.

Mechanism and agents of pharmacological closure

The pharmacological basis for medical therapy is the use of non selective cyclo-oxygenase (COX)
inhibitors, which inhibits prostaglandin synthesis and causes ductal constriction.11 The two most widely
studied and used non selective COX inhibitors are

Indomethacin
Ibuprofen

Indomethacin versus Ibuprofen

The Cochrane meta-analysis comparing ibuprofen with indomethacin in preterm <37 weeks gestation or
low birth weight (<2500 gm), involving 20 trials enrolling 1092 infants, there was no difference in the
failure of duct closure (RR=0.94; 95% CI 0.76, 1.17).12 Oral ibuprofen was used in 3 trials, while
intravenous preparation was used in the rest. The ibuprofen group had significantly lower serum
creatinine levels and decreased incidence of oliguria. There was 32% reduction in NEC in ibuprofen
group (RR=0.68; 95% CI 0.47, 0.99). There was no difference in other outcomes like mortality, reopening
rate of PDA, need for surgical ligation of PDA, duration of ventilator support, chronic lung disease (CLD),
IVH or ROP. Studies have shown a closure rate of 70-80% with either indomethacin or ibuprofen in
preterm babies 32 weeks.
 Oral Iboprufen

Considering the fact that intravenous ibuprofen is not available in Indian market and the high cost for
imported indomethacin injections, oral ibuprofen is a promising alternative. In randomized controlled
trial of oral vs. intravenous ibuprofen for VLBW infants with PDA, the rate of ductal closure was higher
(oral=84.3% vs. IV=62.5%; P=0.04) and renal side effects were lesser in the oral ibuprofen group. Hence
oral ibuprofen may be a safe and easily available cheap option for treatment of PDA.13 The though
concerns of pulmonary hypertension, increased risk of unconjugated hyperbilirubinemia, lack of short
term neuroprotective effect were reported with iboprufen, it seems to be of little clinical significance.

There is very limited data on use of oral indomethacin and its not generally recommended especially
with oral iboprufen being easily available.

Recommendation

1. Both Indomethacin and Iboprufen are equally effective in closing PDA with closure arte of 70-
80%.
2. Iboprufen currently appears to be the superior option with its better safety profile, especially
reduced NEC rates.
3. Infants
a. On full enteral feeds (atleast 120ml/kg/day) Oral Iboprufen
b. On parentral fluids, partial feeds IV Indomethacin*

4. The question of which drug confers better long term intact survival is yet unanswered
*IV iboprufen is not available in Indian market

Dosage and Duration of treatment

Indomethacin

Short versus Long course

The two most commonly followed dosing schedules for indomethacin are the short course (3
intravenous doses at 12 hourly intervals with starting dose of 0.2 mg/kg followed by 0.1 mg/kg for
babies less than 2 days of age, 0.2 mg/kg for 2-7 days and 0.25 mg/kg for > 7 days old infants) and the
long course (0.1 mg/kg per day for 6 doses) therapy.

The basis for the long course therapy is that, indomethacin induced prostaglandin inhibition is a
transient phenomenon and the prostaglandin levels normalizes within 6-7 days after the short course
therapy, which increases the chance for reopening of the duct.

A Cochrane meta-analysis, comparing short course (0.3 to 0.6 mg/kg, 3 doses) vs. the long course (0.6 to
mg/kg, 6 to 8 doses) indomethacin therapy for PDA included 431 preterm infants from 5 randomized
controlled trials, failed to reveal significant difference between the two groups as regards to PDA closure
rate, need for surgical ligation or re-opening rates. The prolonged course group had nearly two times
more risk of necrotizing enterocolitis (NEC) compared to the conventional dose group (RR=1.87, 95% CI
1.07, 3.27). Hence prolonged long course treatment cannot be recommended for routine treatment of
PDA.14

Continuous vs intermittent bolus administration of Indomethacin

There have been concerns of effect of continuous versus bolus administration of indomethacin on the
efficacy of therapy as well as side effect profile, especially reduced blood flow to various organ systems
particularly reduced cerebral circulation when bolus administration was given. The recent Cochrane
meta-analysis involving 2 trials comparing the continuous i.e. indomethacin given after 24 hours of life
as slow intravenous infusion over 36 hours vs. bolus dose i.e. indomethacin given after 24 hours of life
as intravenous infusion over 20 min concluded that the evidence was insufficient to draw conclusion
regarding the efficacy for the treatment of PDA. There is an insignificant trend towards increased rates
of PDA closure rate on day 2 and day 5 in the bolus administration group. There was no significant
difference in secondary outcomes like reopening of PDA, neonatal mortality, IVH or NEC. The review
demonstrated that there was a decrease in cerebral blood flow velocity, after bolus injections which
persisted even at 12-24 hours compared to the continuous infusion group. However the clinical impact
of this reduced blood flow to organ systems, especially brain is unclear.15

Recommendation on dosage

Dosage of Indomethacin and Iboprufen for pharmacological treatment of a PDA16

Indomethacin IV Loading dose: 0.2 mg/kg/dose
Infusion Subsequent doses ( adjusted as per postnatal age)
over 30 <2 days: 0.1 mg/kg/dose 12 hourly x 2 doses
min 2-7 days: 0.2 mg/kg/dose 12 hourly x 2 doses
>7 days: 0.25 mg/kg/dose 12 hourly x 2 doses
Iboprufen IV or oral Loading dose: 10 mg/kg/dose
Subsequent dose: 5mg/kg/dose 24 hourly x 2 doses

Following the first course, a second course with same dosage could be used in case of persistent
PDA needing treatment or re-opening of the ductus with symptoms.

Failure of medical treatment: Persistence of hemodynamically significant ductus or reopening

despite two courses of treatment defines failure of medical treatment.

Side effects and monitoring

Adverse effects of treatment with NSAIDS include

Renal compromise due to its effect on COX 1,

Bleeding tendency due to its effect on platelet function and
Increased risk of necrotizing enterocolitis.
Monitoring during therapy
Baseline Urine output, RFT, platelet count
Daily Urine output
RFT,
Alternate day
Platelet counts (daily if baseline counts are <150,000/mm3

Contraindications
Renal: Urine output< 0.6 ml/kg/h, blood urea > 40 mg/dL, creatinine >1.8 mg/dL
Bleeding: Bleeding from IV sites, skin bleeds, gastrointestinal bleeding, enlarging or evolving
intraventricular hemorrhage (IVH), platelet count < 60,000/mm3
Gastrointestinal: necrotizing enterocolitis; blood in stool

General measures

1. Fluid restriction

In Cochrane metaanalysis, restriction of fluid intake to mean of 120 ml/kg/day as compared to 160
ml/kg/day in the initial few weeks of life is found to be beneficial with lower incidence of PDA, CLD and
mortality.17 Similarly Vanhaesebruock et al in a prospective observational study, in 30 preterm infants
30 weeks gestation with RDS requiring surfactant replacement therapy and mechanical ventilation,
showed 100% ductal closure rate with conservative treatment i.e. restricted fluid (130 ml/kg/day) with
low inspiratory time (Ti=0.35) and high positive end expiratory pressure (PEEP=4.5mbar), with no
increase in complication rates.18

2. Role of furosemide and dopamine in medical management of PDA

There has been concern of furosemide adversely affecting the efficacy of indomethacin therapy, by
increasing the clearance of indomethacin, resulting in failure of therapy.19 However, the latest Cochrane
meta-analysis involving 70 patients enrolled in 3 trials, fails to show any increase in treatment failure
(RR=1.25; 95% CI 0.62, 2.52) or reduction in toxicity of indomethacin therapy in PDA.20 Hence routine
use of furosemide in indomethacin treated symptomatic PDA is not recommended and is
contraindicated in presence of dehydration.

Low dose dopamine is considered to be beneficial in reversing indomethacin induced oliguria in preterm
babies with PDA. However, there is no evidence to support this notion. In the Cochrane meta-analysis by
Barrington, et al21 use of dopamine in indomethacin treated symptomatic PDA showed improvement in
urine output but there was no effect on serum creatinine or incidence of oliguria. The use of dopamine
had no effect on the rate of failure for ductal closure. The evidence for effect of dopamine on cerebral
circulation, IVH or death before discharge is insufficient. Hence use of dopamine for prevention of renal
dysfunction induced by COX inhibitors cannot be recommended

3. Mechanical ventilation strategy

In infants on ventilator support with hs-PDA, using slightly higher PEEP and lower Ti might be helpful,
though data is very limited.18
Recommendations

1. In clinically symptomatic or echocardiographically diagnosed PDA, it is recommended to restrict

parenteral fluid intake to 120 mL/kg/day, provided other parameters like urine output, serum
Na, urine specific gravity etc are within normal limits
2. Infants on full enteral feeds with hs-PDA a fluid intake of up to 150 ml/kg/day may be used and
calorie density may be increased in case of inadequate weight gain
3. No role for routine use of dopamine in treating NSAID induced oliguria
4. No role for routine use of frusomide in treatment of PDA except in case of established
congestive heart failure

Surgical ligation

It is reserved for infants with symptomatic hs-PDA with

1. Failure of medical therapy

2. Contraindications to medical therapy
Studies have also shown in preterm <28 weeks gestation that need for surgical ligation of PDA is an
independent risk factor for increased rates of CLD, ROP and adverse neurodevelopmental outcome.22

PDA and Neonatal Outcomes

The presence of PDA has been associated with adverse neonatal outcomes like CLD and NEC. 23,24
However none of the studies have shown cause-effect relationship, and studies have failed to
consistently show association between symptomatic PDA and adverse outcomes like cerebral palsy,
cognitive delay, ROP, NEC or CLD once adjusted for prematurity and perinatal factors.22

References

1) Van Overmeire B, Van de Broek H, Van Laer P, Weyler J, Vanhaesebrouck P. Early versus late
indomethacin treatment for patent ductus arteriosus inpremature infants with respiratory distress
syndrome. J Pediatr 2001; 138:205-11.
2) Fanaroff AA, Stoll BJ, Wright LL, et al. Trends in neonatal morbidity and mortality for very low birth
weight infants. Am J Obstet Gynecol. 2007; 196:147e1e8.
3) Clyman R I. Mechanisms regulating the ductus arteriosus. Biol Neonate 2006; 89: 330335.
4) Shimada S, Kasai T, Konishi M, Fujiwara T. Effects of patent ductus arteriosus on left ventricular
output and organ blood flows in preterm infants with respiratory distress syndrome treated with
surfactant. J Pediatr 1994; 125: 270-277.
5) Skelton R, Evans N, Smythe J. A blinded comparison of clinical and echocardiographic evaluation of
the preterm infant for patent ductus arteriosus. J Paediatr Child Health. 1994;30:406411.
6) Evans N, Malcolm G, Osborn D, Kluckow M Diagnosis of patent ductus arteriosus in preterm infants.
NeoReviews 2004; 5: 86-97.
7) Sehgal A, McNamara PJ. Does echocardiography facilitate determination of hemodynamic significance
attributable to the ductus arteriosus. Eur J Pediatr 2009; 168: 907914.
8) Kluckow M, Seri I, Evans N Functional Echocardiography: An emerging clinical tool for the
Neonatologist J Pediatr. 2007 Feb;150(2):125-30.
9 ) Sasi A, Deorari AK. Patent ductus arteriosus in preterm infants. Indian Peditr 2011; 48: 301-308.
10) Benitz WE. Treatment of persistent patent ductus arteriosus in preterm infants: time to accept the
null hypothesis. Journal of Perinatology 2010; 30: 241252.
11) Narayanan-Sankar M, Clyman RI. Pharmacologic closure of patent ductus arteriosus in the neonate.
NeoReviews 2003; 4: 215-221.
12) Ohlsson A, Walia R, Shah SS. Ibuprofen for the treatment of patent ductus arteriosus in preterm
and/or low birth weight infants. Cochrane Database Syst Revs. 2010; 4: CD003481.
13) Cherif A, Khrouf N, Jabnoun S, Mokrani C, Amara MB, Guellouze N ,et al. Randomized pilot study
comparing oral ibuprofen with intravenous ibuprofen in very low birth weight infants with patent ductus
arteriosus. Pediatrics 2008; 122: e1256-e1261.
14) Herrera C, Holberton J, Davis PG. Prolonged versus short course of indomethacin for the treatment
of patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev. 2007; 2: CD003480.
15) Gork AS, Ehrenkranz RA, Bracken MB. Continuous versus intermittent bolus doses of indomethacin
for patent ductus arteriosus closure in symptomatic preterm infants. Cochrane Database Syst Rev. 2008;
1: CD006071.
16) Clyman RI. Patent ductus arteriosus in preterm neonates. In Averys diseases of the new born. Eds:
Taeush HW, Ballard RA. 7th edn WB Saunders pp 699-710.
17) Bell EF, Acarregui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in
preterm infants. Cochrane Database Syst Rev 2000;(2):CD000503.
18) Vanhaesebrouck S, Zonnenberg I, Vandervoort P, Bruneel E, Van Hoestenberghe M, Theyskens C.
Conservative treatment for patent ductus arteriosus in the preterm Arch. Dis. Child Fetal Neonatal Ed
2007; 92:F244F247.
19) Green TP, Thompson TR, Johnson De, Lock JE. Furosemide promotes patent ductus arteriosus in
premature infants with respiratory distress syndrome. N Engl J Med 1983; 308: 743-8.
20) Brion LP, Campbell DE. Furosemide for prevention of morbidity in indomethacin treated infants with
patent ductus arteriosus. Cochrane Database Syst Rev. 2001; 3: CD001148.
21) Barrington KJ, Brion LP. Dopamine versus no treatment to prevent renal dysfunction in indomethacin
treated preterm newborn infants. Cochrane Database Syst Rev. 2002; 3: CD003213.
22) Chrone N, Leonard C, Piecuch R, Clyman R I. Patent ductus arteriosus and its treatment as risk
factors for neonatal and neurodevelopmental morbidity Pediatrics 2007; 119:1165-1174.
23) Rojas MA, Gonzalez A, Bancalari E, Claure N, Poole C, Silva-Neto G: Changing trends in the
epidemiology and pathogenesis of neonatal chronic lung disease. J Pediatr 1995; 126: 605 610.
24) Dollberg S, Lusky A, Reichman B. Patent ductus arteriosus, indomethacin and necrotizing
enterocolitis in very low birth weight infants: a population-based study. J Pediatr Gastroenterol Nutr
2005; 40:1848.
 Respiratory distress in the newborn
Respiratory distress in newborn is one of the commonest conditions requiring admission in newborn
nursery and it contributes to 30-40% of admissions in NICU.1 Respiratory distress occurs in 2.2% of all
newborns and in almost 60% of the infants below 1000 gm (ELBW infants).2 A neonate can develop
respiratory distress due to a wide variety of conditions, which are not limited to respiratory or
cardiovascular causes.

Management of respiratory distress may vary from providing warmth and oxygen to maximum
respiratory support such as high frequency ventilation or inhaled nitric oxide therapy. Appropriate
management includes proper assessment of the infant for the cause, and precise decision making about
the need for and the level of respiratory support required and other supportive measures.

Definition
Respiratory distress is defined according to the National Neonatal Perinatal Database (NNPD)3 as
presence of any two of the following features:

1. Respiratory rate >60/minute

2. Subcostal/intercostal recessions
3. Expiratory grunt/groaning
In addition to the above features, presence of nasal flaring, suprasternal retractions, decreased air entry
on auscultation of the chest also will indicate the presence of respiratory distress. An infant who has an
advanced degree of respiratory distress may exhibit additional signs, such as cyanosis, gasping, choking,
apnea, and stridor.4

Incidence
Respiratory distress occurs in almost 2.2-3.3% of the live born infants.2,5 According to the NNPD data
AK Deorari 23/7/12 1:06 PM
(2002-03), 5.8% of the live born infants had respiratory morbidities.3 The incidence also varies with the
Formatted: Tabs:Not at 2.05 cm
gestational age of the infants with the incidence being inversely proportional to the gestational age and
birth weight. In a prospective study, it was found that almost 58% of the ELBW infants (birth weight
<1000 g) developed respiratory distress but it was only 0.7% in infants who were of normal weight
(2500-4000g).
AK Deorari 23/7/12 1:06 PM
2
Deleted:

Causes
Respiratory distress in a newborn can be due to a wide variety of conditions, majority of which are
uncommon and should be considered in cases with unusual presentations (Table 1). The frequency of a
particular condition as the cause of respiratory distress in an infant depends on various factors with
gestation being the most important one. In preterm infants, respiratory distress syndrome (RDS) being
the most common cause (almost 90%) while in the late preterm and term infants transient tachypnea of
newborn (TTN) is the predominant cause (68%).2

Table 1 Causes of respiratory distress in the newborn.

Upper Airway Obstruction
Choanal atresia
Nasal stenosis
Pierre Robin sequence
Laryngeal stenosis or atresia
Hemangioma
Vocal cord paralysis
Vascular rings
Tracheobronchial stenosis
Cleft palate
AK Deorari 12/7/12 12:36 PM
Pulmonary Diseases Deleted:

Respiratory distress syndrome (RDS) AK Deorari 12/7/12 12:36 PM

Deleted: Masses
Transient tachypnea of the newborn (TTN) ... [1]

Aspiration (including meconium aspiration syndrome; MAS) AK Deorari 12/7/12 12:36 PM

Deleted: Nasal stuffiness
Pneumonia
Pneumothorax AK Deorari 12/7/12 12:38 PM
Comment [1]: Can we just mention important
Pneumomediastinum cause and reduce list
Primary pulmonary hypertension
Tracheoesophageal fistula (TEF)
Pulmonary hemorrhage
Pulmonary hypoplasia
Pulmonary agenesis
Cystic adenomatoid malformation
Pleural effusion
Chylothorax
Neoplasm
Bronchopulmonary sequestration
Pulmonary arteriovenous malformation
Pulmonary interstitial emphysema
Pulmonary edema
Congenital alveolar proteinosis
Congenital lobar emphysema
Cardiac Diseases
Cyanotic congenital heart disease
Acyanotic congenital heart disease
Arrhythmia
Congestive cardiac failure
Cardiomyopathy
Thoracic Causes AK Deorari 12/7/12 12:38 PM
Chest wall deformity Deleted: Pneumopericardium

Thoracic mass
AK Deorari 12/7/12 12:39 PM
Deleted: M
Metabolic Disorders
Hypoglycemia
Infant of a diabetic mother
Inborn errors of metabolism
Diaphragmatic Causes
Hernia
Paralysis
Neuromuscular Diseases
Central nervous system damage (birth trauma, hemorrhage)
Medication (maternal sedation, narcotic withdrawal)
Muscular disease (myasthenia gravis)
Intraventricular hemorrhage
Meningitis
Hypoxic-ischemic encephalopathy
Seizure disorder
Obstructed hydrocephalus
Infantile botulism
Spinal cord injury
Infectious Causes
Sepsis
Pneumonia (especially group B Streptococcus)
Hematological Causes
Anemia
Polycythemia
Abnormal hemoglobin
Miscellaneous Causes
Asphyxia
Acidosis
Hypo/hyperthermia
Hypo/hypernatremia

Assessment of respiratory distress

Initial assessment
Initial assessment of respiratory distress in the delivery room should be done to find out life threatening
conditions, which require immediate management such as inadequate or obstructed airway (gasping,
choking, stridor) or circulatory collapse (bradycardia, hypotension, poor perfusion). If such features are
present then emergency measures such as bag and mask ventilation or intubation should be carried out
as necessary.4

History
A detailed history is important in assigning a cause to the respiratory distress in a given infant (Table 2).
Table 2: Relevant history in a neonate with respiratory distress6
AK Deorari 12/7/12 12:44 PM
Antenatal
Formatted: Font:Bold
Diabetes mellitus
Fever, UTI
Polyhydramnios/oligohydramnios
Rh isoimmunization
Drug abuse
Antenatal steroids status
Intranatal
PPROM/ PROM
Intrapartum fever/ Chorioamnionitis
Sedative use
Meconium stained liquor
Abnormal fetal monitoring
Instrumental delivery/ Birth trauma
Need for bag& mask ventilation
Postnatal
Gestational age
Shake test
Onset/ Course of respiratory distress
Radiological features

General examination
It should be done to identify any feature which may give a clue to the etiology such as dysmorphic
features, anomalies, features of intrauterine growth restriction, single umbilical artery, scaphoid
abdomen, drooling of saliva etc.

Assessment of respiratory distress

Respiratory rate
Respiratory rate (RR) should be counted for full one minute with a timer and when the baby is quiet and
preferably when baby is not hungry or immediately after feeds.3 A normal neonate has a RR of 40-
60/min. RR above 60/min is considered as tachypnea. But at times, baby can have respiratory rates well
below 60/min but with significant retractions or has apneic episodes interspersed, which may signify
severe respiratory distress with impending respiratory failure.

Grunting
Infants develop an expiratory groaning noise called grunting when they have significant respiratory
distress. Grunting happens when the infant attempts to keep the alveoli open to maintain the functional
residual capacity by partially closing the glottis during expiration.4 Grunting generally disappears first
when the baby starts improving but it can also disappear in a baby who is worsening because of
exhaustion. Hence it has to be assessed in the context of other features such as oxygen saturation, color
and activity of the infant.
Stridor
Stridor is produced due to narrowing of the major airways. It is often inspiratory but can be expiratory
or biphasic. Stridor can occur in newborn due to laryngomalacia, Pierre Robin sequence etc.

Chest retractions
Retractions have to be assessed in the suprasternal, intercostal, subcostal and xiphoid area. Retractions
can be mild to severe depending on the severity of respiratory distress. Suprasternal recession more
often suggests upper airway obstruction and may be a pointer toward upper airway anomaly in
neonates. Intercostal retraction suggests alveolar involvement. Nasal flaring also has to be looked for
when assessing for chest retractions.

Oxygen saturation
Oxygen saturation has to be checked preferentially both preductal and postductal. Preductal SpO2 is
checked by applying the pulse oximeter probe to the right hand and postductal by putting the probe on
the legs. A preductal-postductal difference of more than 5% to 10% indicates probable right-to-left
shunt through patent ductus arteriosus (PDA) in the setting of persistent pulmonary hypertension of the
newborn (PPHN).7

Respiratory system examination

Respiratory system examination includes inspection of the chest for symmetry of chest movements
bilaterally, auscultation for the symmetry of breath sound and for the presence of any adventitious
sounds such as crepitations. When there is suspicion of pneumothorax, transillumination of the chest
should be carried out.

Scoring the severity of respiratory distress

Scoring the respiratory distress is essential as it provides an objective way of assessing the severity, and
also monitoring the score at regular intervals helps in deciding the course of the illness either
improvement or deterioration. Silverman score8 (Table 2) and Downes score9 (Table 3) are used to
assess the severity of the respiratory distress.
Table 2 Silverman score
Feature Score 0 Score 1 Score 2
Upper chest movement None Respiratory lag See-Saw
respiration
Lower chest retractions None Minimal Marked
Xiphoid retractions None Minimal Marked
Nasal flaring None Minimal Marked
Grunting None Audible with Audible without
stethoscope stethoscope

Chest movement:
Upper chest movement

Upper chest movement is assessed by observing the synchrony of the movement with the abdomen.
Upper chest is the part of the chest anterior to the mid axillary line. Synchronized movement of upper
chest with abdomen is scored 0, while lag of upper chest behind the abdomen is scored as 1 and see-
saw movement of the chest and abdomen as 2.
Lower chest retractions
Lower chest retractions are assessed by observing the retractions between the ribs below the mid
AK Deorari 23/7/12 1:07 PM
axillary line and is rated as none, minimal or marked. This indicates loss of FRC of lungs.
Deleted: rectractions
Xiphoid retractions
Similarly, retraction below the xiphoid process are rated as none, minimal or marked.
Nasal flaring
Normally, there should be no nasal flaring. Minimal flaring is scored as 1 and marked flaring is scored
as 2.
Expiratory grunting
Grunting that is audible with a stethoscope is scored 1, and grunting that is audible without using a
stethoscope is scored 2. The higher the score, more severe is the respiratory distress.
A score greater than 7 indicates that the baby is in respiratory failure.

Table 3 Downes score

Feature Score 0 Score 1 Score 2
Cyanosis None In room air In 40% FiO2
Retractions None Mild Severe
Grunting None Audible with Audible without
stethoscope stethoscope
Air entry Normal Decreased Barely audible
Respiratory rate <60 60-80 >80 or apnea

Score: > 4 = Clinical respiratory distress- monitor arterial blood gases

> 7 = Impending respiratory failure
In a recent study it was found that Downes score of 5 had a sensitivity of 88%, specificity of 81%,
positive predictive value of 72% and negative predictive value of 92% for detecting hypoxemia in
neonates with respiratory distress.10

Hemodynamic stability
Pulse rate, blood pressure and capillary refill time have to be monitored to identify hypoperfusion which
can be secondary to prolonged hypoxemia.

Causes
Respiratory distress syndrome
RDS also called as hyaline membrane disease (HMD) is seen almost exclusively in preterm infants. The
risk of RDS decreases with increasing gestational age: 60% of babies born at fewer than 28 weeks
gestation, 30% of babies born between 28 and 34 weeks gestation, and fewer than 5% of babies born
after 34 weeks gestation develop RDS.11 Other factors that increase the risk of RDS include male sex,
maternal gestational diabetes, perinatal asphyxia, hypothermia, and multiple gestations. Antenatal
steroids and prolonged rupture of membranes decrease the risk of RDS. RDS presents at the time of or
soon after birth, and symptoms worsen over time. Shake test done from the gastric aspirate may be
negative.12

Along with the history and physical examination, a chest radiograph is needed for the diagnosis of RDS.
The typical chest radiograph shows diffuse atelectasis and the classic ground glass appearance of the
lung fields. Air bronchograms, which are air-filled bronchi superimposed on the relatively airless
parenchyma of the lung tissue, also are seen commonly on chest radiograph.

Transient tachypnea of newborn (TTN)

This relatively benign, self-limited disease also is known as RDS type 2 or wet lungs. It occurs in
approximately 11 per 1,000 live births and appears more often in boys, in infants delivered by cesarean
section, and in infants who have perinatal asphyxia, or maternal complications such as asthma, diabetes,
or analgesia or anesthesia during labor.13,14 Respiratory morbidity in elective caesarean section is
inversely related to gestational age: 73.8/1000 in the 37th week, 42.3/1000 in the 38th week, and
17.8/1000 in the 39th week of gestation (therefore elective cesarean sections should be delayed until 39
to 40 wk).15

It represents transient pulmonary edema resulting from delayed clearance of fetal lung liquid. It can
occur in both term and preterm neonates. Lung liquid is produced actively in utero by a chloride pump
that causes influx of chloride and water from the interstitium into the alveolar space.

Approximately 2 to 3 days before delivery, lung liquid starts to clear due to transformation of the
secretory channels to absorptive ones under the hormonal changes which occur with the onset of
labor.16 Because this liquid contains very little protein, low oncotic pressure also favors the movement of
water from the alveolar spaces into the interstitium. At this time, prostaglandin secretion by the feto-
placental unit increases to trigger labor. Prostaglandins are responsible for the lymphatic dilatation that
accelerates clearance of liquid from the interstitium.

After birth, when the lungs expand with air, water moves rapidly from air spaces to connective tissue, to
be removed gradually from the lungs by the lymphatic system and pulmonary blood vessels. Infants who
have TTN present clinically with tachypnea and occasionally grunting and nasal flaring immediately after
birth. Typically, arterial blood gases reveal respiratory acidosis and mild-to-moderate hypoxemia.17

Chest radiography reveals hyperinflation, perihilar streaking due to dilated lymphatics, increased
interstitial markings, fluid in the interlobar fissures and occasionally pleural effusion and mild
cardiomegaly.

TTN is generally a benign, self-limited disease that usually responds well to oxygen therapy. Mechanical
ventilation seldom is needed, although many infants require nasal continuous positive airway pressure
(nCPAP) support. The CPAP may assist in maintaining alveolar surface area as well as absorbing the
retained intra-alveolar fluid.

Infants whose disease is uncomplicated usually recover without long term pulmonary sequelae. Full
recovery is expected within 2 to 5 days.

Meconium aspiration syndrome (MAS)

MAS is defined as respiratory distress in an infant born through meconium stained amniotic fluid whose
symptoms cannot otherwise be explained. Approximately 13% of all live births are complicated by
meconium stained amniotic fluid, and of these, 4% to 5% of infants develop MAS.18 Passage of
meconium in utero may represent fetal hypoxemia. Meconium can be aspirated before, during, or after
delivery.

Once aspirated, meconium can cause obstruction of the air passages, chemical pneumonitis with
activation of several inflammatory mediators, and inactivation of lung surfactant. The infant who has
MAS may present with varying degrees of respiratory distress and is likely to have a barrel chest with
audible rales or rhonchi on auscultation.

The chest radiograph usually shows patchy areas of atelectasis alternating with areas of overinflation.
Pneumothorax may be seen in 10% to 20% of infants who have MAS.19
Pneumonia
Pneumonia may be acquired in utero, during delivery (or perinatally), or postnatally in the nursery or at
home. At autopsies of both stillbirths and live born neonatal deaths, pneumonia was found to be
present in 20% to 60% in different centers.20

Pneumonia which presents before 72 hours of life is almost synonymous with early onset sepsis (EOS)
and the risk factors include maternal fever, chorioamnionitis, prolonged rupture of membranes (PROM),
unclean vaginal examination and prematurity. The causative agent varies, depending on whether the
infection is acquired before, during, or after birth in the nursery or at home.

Congenital pneumonia is a severe disease that frequently results in either stillbirth or death within the
first 24 hours after birth. Pneumonias that are acquired later present most often as systemic disease. In
neonatal pneumonia, the chest radiograph may reveal classical patchy infiltrates, but the findings also
may be indistinguishable from RDS. The presence of a pleural effusion supports the diagnosis of
pneumonia; it has been reported in up to 67% of cases, but essentially never in uncomplicated RDS.20
Mild cardiac enlargement in the absence of cardiac anomalies also is seen more often in pneumonia
than in RDS.

Management includes oxygen therapy, ventilatory support, antibiotics, and often vasopressor support
such as dopamine and dobutamine.

Congenital heart disease

Infants who have CHD may present with cyanosis or heart failure. Signs that generally are consistent
with CHD include: visibly hyperactive precordial impulse, gallop rhythm, poor capillary refill, weak
pulses, decreased or delayed pulses in lower extremities, hepatomegaly, and abnormal vascularity or
cardiomegaly on chest radiography.21 A single second heart sound without split also may be indicative
of CHD. Nadas criteria also can be applied to identify infants with congenital heart disease.

A neonate who has cyanosis without marked respiratory distress and an O2 saturation of less than 85%
in both room air and 100% oxygen likely has an intracardiac shunt.

If the O2 saturation increases to more than 85% on 100% oxygen, a full hyperoxia test should be
performed. The test consists of obtaining a baseline right radial (preductal) arterial blood gas
measurement with the child breathing room air and repeating the measurement while the infant is
receiving 100% O2. Arterial PaO2 measurement greater than 250 mm Hg on 100% oxygen rules out
cyanotic CHD, between 100 and 250 mm Hg suggests cyanotic CHD with good mixing or pulmonary
disease, and less than 100 mm Hg suggests cyanotic CHD (or severe pulmonary hypertension).22
Echocardiography needs to be done to confirm the diagnosis.
Table 4: Comparison of common causes of respiratory distress in neonates
Condition Risk factors Clinical course Radiological features

Respiratory Prematurity (usually <34 Onset at or soon after Low volume lungs
distress weeks) birth Fine reticulo-
syndrome Lack of antenatal steroids Progresses till 48 granular pattern-
(RDS) Infant of diabetic mother hours, static for 48 hrs Ground glass
Birth asphyxia and improves later. appearance
Rh isoimmunization FiO2 requirement often Air bronchograms
more than 40% White- out lungs
Surfactant modifies
the typical course
Transient Predominantly late Onset at or soon after Hyperinflated lungs
tachypnea of preterm and term infants birth Perihilar sreaking
newborn (TTN) Born by Caesarean Maximum severity at Fluid in minor
section birth and improves fissure
Maternal diabetes gradually Pleural effusion
FiO2 requirement Mild cardiomegaly
seldom more than 40%
Early onset Risk factors such as Onset at birth or Homogeneous/
sepsis (EOS)/ PROM,chorioamnionitis, delayed Non-homogeneous
pneumonia maternal fever, unclean May fail to improve opacities bilaterally
vaginal examinations with oxygen/ CPAP
Meconium Meconium stained Onset may be at birth Hyperinflated lungs
aspiration amniotic fluid or delayed Coarse nodular
syndrome Meconium staining of opacities
(MAS) cord/ skin Patchy atelactasis
Hyperinflated chest Areas of
Features of PPHN overinflation

Management:
Investigations
Often the diagnosis requires appropriate history along with the reports of antenatal investigations,
clinical examination and a proper chest x ray. Sepsis screen, blood cultures may be required when sepsis
is strongly suspected. CSF examination is warranted in the presence of clinical sepsis or positive blood
culture. Other investigations specific to the suspected clinical condition such as CT thorax in case of lung
anomalies, or echocardiography in PPHN or congenital heart disease may be required.

Treatment
The basic principles of treatment include
1. Supportive care
2. Respiratory support


3. Monitoring for and management of complications

4. Specific therapy
Supportive care
This includes maintenance of thermo-neutral environment by caring the infant under radiant warmer or
in incubator, ensuring normal blood glucose levels with intravenous fluids and monitoring the vital
parameters such as heart rate, respiratory rate and scoring of the respiratory distress.

Respiratory support
Respiratory support provided to the infant depends on many factors such as the size of the infant,
hemodynamic stability, the pathologic condition under treatment, the severity of respiratory distress
and the presence of complication if any. The objective is to ensure adequate oxygenation and
ventilation, and thereby decrease the work of breathing. The aim would be to maintain pH>7.25, pO2 50-
70 mm Hg, pCO2 <50 mmHg and SpO2 88%-93%.

Supplemental oxygen
Most often babies with conditions such as TTN or mild RDS may require only supplemental oxygen
which is delivered through head box. The FiO2 requirement of the baby has to be monitored at regular
intervals so that any increase in requirement to maintain the SpO2 in the optimal range can be identified
early and thereby the worsening of the lung condition, or consequent complications developing if any.

CPAP
Infants who fail to maintain adequate oxygenation and ventilation on supplemental oxygen or those
who have significant respiratory distress with Silverman or Downes score more than 4 will require
CPAP. CPAP is generally used in preterm infants with mild to moderate respiratory distress. It may be
also be used in late preterm and term infants with TTN or pneumonia if tolerated.23

Mechanical ventilation
Infants who fail to maintain oxygenation and ventilation on CPAP will require mechanical ventilation.
Mode of ventilation and the settings will vary based on the weight and gestation of the infant, the
condition being treated and the existing unit policy. Those who fail conventional ventilation may require
high frequency ventilation.

Inhaled nitric oxide therapy

Infants with features suggestive of PPHN will require inhaled iNO if they meet the criteria.

Monitoring and management of complications

Infants with respiratory distress need to be monitored for worsening of the distress, hemodynamic
instability, features of PPHN, acute kidney injury due to hypoxia and complications due to mechanical
ventilation etc. If any such complications develop they should be managed appropriately.

Specific therapy
Specific treatment strategies include surfactant replacement therapy for RDS, antibiotics for
EOS/pneumonia, surgical resection for lung malformations etc.
References
1. Mathai SS, Raju U, Kanitkar M et al. Management of respiratory distress in the newborn. MJAFI
2007; 63 :269-272.
2. Rubaltelli FF, Dani C, Reali MF, et al: Acute neonatal respiratory distress in Italy: a one-year
prospective study, Acta Paediatr 87:1261-1268, 1998.
3. NNPD working definitions.NNPD report 2002-03. NNPD network, ICMR; p 67.
4. Hany Aly. Respiratory Disorders in the Newborn: Identification and Diagnosis. Pediatrics in
Review 2004;25;201.
5. Bonafe` L, Rubaltelli F. The incidence of acute neonatal respiratory disorders in Padova county:
an epidemiological survey. Acta Paediatr 1996; 85: 123640.
6. Jackson JC. Respiratory distress in the preterm infant. In: Averys diseases of the newborn 9th
edition. Eds; Gleason CA, Devaskar S , Elsevier Philadelphia 2012.p633-646.
7. Kinsella JP. Inhale nitric oxide in the term newborn. Early Human Development 84 (20 08) 709
716.
8. Silverman WA, Andersen DH. A controlled clinical trial of effects of water mist on obstructive
respiratory signs, death rate and necropsy findings among premature infants.
Pediatrics:1956:17;1-10.
9. Downes JJ, Vidyasagar D, Boggs TR Jr, Morrow GM 3rd. Respiratory distress syndrome of
newborn infants. I. New clinical scoring system (RDS score) with acid--base and blood-gas
correlations. Clin Pediatr (Phila). 1970 Jun;9(6):325-31.
10. Anita Rusmawati, Ekawati L. Haksari, Roni Naning. Downes score as a clinical assessment for
hypoxemia in neonates with respiratory distress. Paediatr Indones. 2008;48:342-5.
11. Warren JB, Anderson JM. Core Concepts : Respiratory Distress Syndrome. Neoreviews
2009;10;e351-361.
12. Kopelman AE, Matthew OP. Common respiratory disorders of the newborn. Pediatr
Rev.1995;16:209 217.
13. Avery ME, Gatewood OB, Brumly G. Transient tachypnea of the newborn. Am J Dis Child.
1966;111:380.
14. Haliday H, McClure G, Reid M. Transient tachypnoea of the newborn: two distinct clinical
entities? Arch Dis Child. 1981;56:322325.
15. Morrison JJ, Rennie JM, Milton PJ: Neonatal respiratory morbidity and mode of delivery at term:
influence of timing of elective caesarean section. Br J Obstet Gynaecol 102:101-106, 1995.
16. Jain L, Eaton DC. Physiology of fetal lung fluid clearance and the effect of labor. Semin Perinatol
2006; 30:34-43.
17. OBrodovich H, Canessa C, Ueda J, et al: Expression of the epithelial Na+ channel in the
developing rat lung. Am J Physiol 265:C491-C496, 1993.
18. Dargaville PA, Copnell B. The epidemiology of meconium aspiration syndrome: Incidence, Risk
Factors, Therapies, and Outcome. Pediatrics 2006;117:1712-21.
19. Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal and
nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders:
multicentre, randomised controlled trial.Lancet. 2004;364:597 602.
20. Flidel-Rimon O, Shinwell ES. Respiratory Distress in the term and near-term Infant. Neoreviews
2005;6;e289-296.
21. Parker TA, Kinsella JP. Respiratory Failure in the Term Newborn. In: Averys diseases of the
newborn 9th edition. Eds; Gleason CA, Devaskar S , Elsevier, Philadelphia 2012.p647-657.
22. Weschler SB, Wernovsky G. Cardiac disorders. In: Cloherty JP, Eichenwald EC, Stark AR Eds. Manual of
Neonatal Care 6 edition. Lippincott William& Wilkins USA 2011.p 388
th

23. Sankar MJ, Sankar J, Agarwal R, Paul VK, Deorari AK. Protocol for administering continuous
positive airway pressure in neonates. Indian J Pediatr 2008; 75:471-478.
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Breathing difficulty in the Newborn

Breathing difficulty
Chest indrawing
Grunting

Check * $
Respiratory Rate
Cyanosis
#
Oxygen saturation (SpO2)

o RR>90/minute with grunting/ o RR 60-90/minute AND retractions/ o RR 60-90/minute OR

retractions OR grunting OR o Oxygen < 0.5 L/min on nasal
o RR<30/minute OR o RR>90/minute OR prongs or catheter or <
o Cyanotic on > 1 L/min on nasal o Oxygen 0.5 to 1 L/min on nasal prongs 3L/min on oxygen by hood
prongs or catheter or > 5L/min O2 on or catheter or 3-5 L/min on oxygen by & pink or SpO2 >90%
oxygen by hood ** or SpO2 <90% hood & pink or SpO2 >90%

Severe respiratory distress Moderate respiratory distress Mild respiratory distress

Specific Management

o Start CPAP, if not available o Chest x-ray o Consider chest x-ray

REFER o Maintain O2 and IV line o Continue care (feeding,
No Improvement No Improvement
o Maintain IV line, o Treat for sepsis temperature control)
o Treat for sepsis o May require CPAP, if not available o Deteriorates or increasing
o Chest x-ray, if needed REFER oxygen requirement: Give
o if no improvement REFER antibiotics
(for assisted ventilation)

Watch for signs of improvement

a. Decreasing oxygen requirement
b. No grunting or indrawing or cyanosis
c. Decreasing RR

Remove oxygen observe every 15 minutes for next one hour to see for pink tongue & lips, consider alternative methods or direct
breast feeding once off oxygen . No difficulty in breathing, feeding well, pink for at least 2 days without oxygen: discharge.

*Refer to Panel for assessment of respiratory distress

$
Signs of surgical conditions - scaphoid abdomen (diaphragmatic hernia), drooling of saliva (esophageal atresia)
#
If Pulse Oximeter is available
** Congenital heart disease should be ruled out if cyanosis but no distress at > 5 L/ min
*** Aminophylline may be required in preterm infant to manage apnoea 1

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Assessment of severity of respiratory distress

Panel 1: WHO Classification of respiratory distress

Classification Respiratory Rate Grunting or Chest Requirement of oxygen

(bpm) indrawing
By hood Nasal catheter Nasal cannula

Severe More than 90 Present >5L/min >1 L/min 3-5 L/min

Less than 30

Moderate More than 90 Absent 3-5 L/min 0.5-1.0 L/min 0.5-1.0 L/min

Moderate 60 90 Present 3-5 L/min 0.5-1.0 L/min 0.5-1.0 L/min

Mild 60 90 Absent <3 L/min <0.5 L/min <0.5 L/min

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 AIIMS- NICU
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Chronic Lung Disease in Newborns

M. Jeeva Sankar, Ramesh Agarwal, Ashok K Deorari, Vinod K Paul

Division of Neonatology, Department of Pediatrics

All India Institute of Medical Sciences
Ansari Nagar, New Delhi 110029

Address for correspondence:

Prof Ashok Deorari
Professor
Department of Pediatrics
All India Institute of Medical Sciences
Ansari Nagar, New Delhi 11002

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Introduction

Chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD) occurs in preterm infants
who require mechanical ventilation and/or oxygen therapy for a primary lung disorder. Though
the incidence of CLD has largely remained unchanged over the years, the improved survival of
more immature infants has led to increased numbers of infants with this disorder.1 These infants
are more likely to have persistent respiratory symptoms requiring frequent hospital admissions
especially in the first two years after birth.

Definition and Incidence

The lack of uniformity in the diagnostic criteria for CLD partly explains the wide variation in the
reported incidence among different centers.2 The initial diagnostic criteria mandated continuing
oxygen dependency during the first 28 days of life with compatible clinical and radiographic
findings to label an infant as having BPD.3 The fact that many infants would have intervals in the
first few weeks during which they do not require any supplemental oxygen signified the major
drawback of this definition. Later, it was proposed to use the need for supplemental oxygen at
36 weeks postmenstrual age (PMA) as the diagnostic criterion especially in preterm very low
birth weight (VLBW) infants.4 The later definition, used widely in clinical trials even now, has the
limitation of spuriously labeling more mature infants (e.g. those born at 34-35 weeks) as having
CLD.

To address the inconsistencies in the diagnostic criteria, the US National Institute of Health
(NIH) organized a consensus conference in 2000 which suggested a new definition by
incorporating many elements of previous definitions of BPD. The suggestion was to use oxygen
need for > 28 days and at 36 weeks PMA to identify different severity of BPD (Table 1).5

Recently, Ehrenkranz et al validated the consensus definition in a cohort of preterm (<32 weeks)
extremely low birth weight (ELBW) infants and reported an incidence of 77% by the new
criteria.6 Few reports are available from the centers in India; one study from Chandigarh found
the incidence of CLD (defined as need for oxygen at or beyond 28 days of life) to be 50% and
9% in ELBW and VLBW infants respectively.7

Pathogenesis

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CLD has a multifactorial etiology; the major risk factors include prematurity, oxygen therapy,
mechanical ventilation, infection, patent ductus arteriosus (PDA), and genetic predisposition.8
By far the most important factor in the pathogenesis of CLD is prematurity. Exposure of
immature lungs to high O2 concentrations and positive pressure ventilation results in oxidative
stress and ventilator induced lung injury (barotrauma/volutruma). The resulting injury and
inflammation lead to abnormal reparative processes in the lung. This is compounded by
inflammation resulting from infections (intra-uterine/postnatal infection) that occur commonly in
these infants. PDA contributes further to this process by inducing pulmonary edema and
vascular endothelial injury. Recently, genetic polymorphisms are also thought to play a role in
the causation of BPD.9

Pathology: Old vs. New BPD

The severe form of BPD (old BPD) seen in infants who received aggressive ventilation and
were exposed to high inspired oxygen concentration from birth is rare nowadays. This form was
characterized by severe morphological changes including emphysema, atelectasis and fibrosis,
and marked epithelial metaplasia and smooth muscle hypertrophy in the airways and in the
pulmonary vasculature.10

In contrast, the milder forms of BPD (new BPD) seen today occurs in infants who had only mild
respiratory failure requiring shorter duration of ventilation and/or oxygen therapy immediately
after birth. Pathologically, this form is characterized by a striking decrease in alveolar septation
and impaired vascular development, changes more compatible with an arrest in lung
development than with mechanical injury.11

Clinical and Radiological features

Respiratory signs in infants with CLD include fast but shallow breathing, retractions, and
paradoxical breathing. Rales and coarse rhonchi are usually heard on auscultation.

Radiographic features of old and new BPD are quite different, not surprising given the vastly
different pathologic findings. Old BPD, as originally described by Northway, had four distinct
stages: stage 1, consistent with hyaline membrane disease; stage 2, opaque lung fields with air
bronchograms due to areas of atelectasis alternating with emphysema; stage 3, small
radiolucent fields; and stage 4, hyperinflated lungs with generalized cystic areas and dense
fibrotic strands.10 In contrast, infants with new BPD show only haziness reflecting diffuse loss of
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lung volume or increased lung fluid. Occasionally they have dense areas of segmental or lobar
atelectasis or pneumonic infiltrates, but they do not show severe over inflation.

Management

Given the multitude of factors that contribute to the pathogenesis of bronchopulmonary

dysplasia, it is not surprising that there is no magic bullet for its prevention and/or treatment.
Indeed, the best bet for prevention of BPD would be to prevent preterm births itself, an
implausible option as of now.

Prevention

Prevention requires a multidisciplinary approach starting right from the antenatal period.

Antenatal period:

Use of antenatal steroids in mothers at risk for delivering a premature infant reduces the
incidence of neonatal deaths and RDS but does not reduce the incidence of CLD. This could
arguably be due to increased survival of very immature infants who are at high risk of BPD or
because of the to inability to detect a real protective effect.12 Antenatal thyrotropin-releasing
hormone (TRH) has not been effective in prevention of BPD.13

After birth:

A. Ventilatory strategies

Given that no ideal pharmacological agents are available for prevention of BPD, attention has
now shifted to optimal ventilatory strategies that would prevent/reduce lung injury and permit
adequate lung development.
i) Continuous positive airway pressure (CPAP): Early initiation of nasal CPAP has been shown
to reduce the need for intubation and mechanical ventilation. Since one of the major risk
factors for BPD is the need for mechanical ventilation, use of early CPAP should logically
reduce its incidence. Numerous studies, mostly non-randomized, have reported the benefits
of early CPAP in minimizing the need for mechanical ventilation and the incidence of chronic
lung disease.14 Surprisingly few randomized controlled trials are available till date in this
regard. Recently, a multi-centric study on CPAP versus intubation and ventilation in infants
born at 25-28 weeks gestation found significant reduction in the need for oxygen at 28 days

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of life but not at 36 weeks PMA.15 Similarly, extubation to CPAP following early surfactant
administration (INtubateSURfactantExtubate) has been shown to reduce the need for
mechanical ventilation but it is still uncertain if BPD is reduced by this approach. Clearly,
more evidence is needed in this regard before coming to any meaningful conclusion.
ii) Nasal intermittent positive pressure ventilation (NIPPV): NIPPV is a method of augmenting
NCPAP by delivering ventilator breaths via the nasal prongs. It is thought to improve the
tidal and minute volumes and decrease the inspiratory effort required by neonates as
compared to nCPAP. This should reduce the need for reintubation thus avoiding ventilator
induced lung injury (VILI). The Cochrane review that included three RCTs found a trend
towards reduction in rates of chronic lung disease (typical RR 0.73; 95% CI: 0.49, 1.07).16
However, more trials are required to document the safety and effectiveness of this relatively
new modality.
iii) Patient-triggered ventilation (PTV): Patient triggered modes (SIMV, assist-control, and
pressure support ventilation) improve the infant-ventilator asynchrony; this should
theoretically reduce the risk of VILI. The Cochrane review concluded that though PTV is
associated with shorter duration of ventilation, it does not reduce the incidence of BPD.17
iv) High-frequency ventilation (HFV): Animal studies indicate that HFV could lead to less lung
injury when compared to conventional ventilation. However, randomized controlled trials
comparing elective use of HFV with conventional ventilation in preterm infants have yielded
conflicting results. A recent meta-analysis that included 17 RCTs of conventional versus high
frequency ventilation found no significant difference in the incidence of BPD. Therefore,
elective use of HFV cannot be recommended for preterm infants with RDS at present.18
v) Volume targeted ventilation: The observation that volutrauma and not barotrauma is the
primary determinant of VILI has enthused neonatologists to use volume controlled/targeted
modes of ventilation in place of conventional pressure controlled modes. Only a few
randomized trials are available in this regard till date. The Cochrane review that included
four RCTs found significant reduction in the duration of ventilation and pneumothorax rates
but only a borderline reduction in the incidence of BPD (typical RR 0.34; 95% CI: 0.11,
1.05).19 The trials did not report the combined outcome of BPD and death as well as long
term respiratory/neurodevelopmental outcomes. More studies are needed to address the
question of whether volume controlled ventilation would result in better long term respiratory
outcomes.

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vi) Permissive hypercapnia: Retrospective studies have suggested that hypocapnia that occurs
during assisted ventilation is an independent risk factor for BPD. Subsequently, minimal
ventilation using smaller tidal volumes / less peak inflation pressures while accepting mild
hypercapnia (PaCO2 45-55 mm Hg) was studied in preterm infants. One such study in
preterm ELBW infants (target PaCO2 >52 mm Hg in study group) reported less need for
mechanical ventilation but no reduction in the need for supplemental oxygen at 36 weeks
PMA.20 Clearly, more studies are needed to prove the intended benefits of this promising
strategy.
vii) Permissive hypoxemia: Exposure to high oxygen concentration has long been recognized
as an important factor in the pathogenesis of BPD. Preterm infants are more vulnerable to
the harmful effects of free oxygen radicals. Surprisingly, there are few data to suggest either
the optimal oxygen level required or the optimum target range for oxygen saturations (SpO2)
in these infants. Observational studies suggest that in comparison with the more liberal
oxygen therapy, the restrictive approach of accepting lower oxygen saturation values is
associated with decreased incidences of CLD and ROP. Two RCTs have been conducted to
see whether it is better to aim for high oxygen saturation in infants who are more than a few
weeks old: BOOST-trial and STOP-ROP trial.21, 22
Both these studies indicate that
maintaining higher oxygen saturation (>95%) is associated with increased need for oxygen
at 36 weeks PMA and greater use of postnatal steroids and diuretics in premature infants
(when compared to maintaining lower oxygen saturation of 89-94%). Still, the uncertainty
about optimal oxygenation has led to wide variation of policies on oxygen-monitoring and
therapy in neonatal nurseries. In response to the growing demand to resolve this
uncertainty, an international collaborative effort has been mounted to conduct large
multicentre RCTs, the results of which may help determine the optimal oxygen saturation
targets in very premature infants.

B. Fluids and Nutrition

i. Fluid restriction: Anecdotal data indicate that relative fluid restriction reduces incidence
of BPD in preterm infants. However, the systematic review of studies on fluid restriction
has not found any significant reduction.23 Moreover what represents fluid restriction in
VLBW infants is not definitely known. Hence, no definite recommendation can be made
regarding fluid restriction as a strategy for reducing the incidence of BPD.

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ii. Nutrition: Nutrition plays an important role in lung development and maturation.
Aggressive parenteral nutrition and early enteral feeding may help decrease the
incidence of BPD in VLBW infants.24 Ideally, nutritional management should begin from
day one of life to minimize the respiratory morbidities. The initial management should
meet the estimated fluid, protein, and energy needs. Since enteral feeding is often
delayed in these infants due to gastrointestinal immaturity, parenteral nutrition with
proteins and lipids should be initiated as soon as possible after birth. It should be
continued until daily oral intake reaches at least 130 mL/kg. Only expressed breast milk
is to be used for enteral feeding. Fortifying breast milk with human milk fortifier (HMF)
will make up for deficiencies of protein and minerals like calcium and phosphorus. If
fluids need to be restricted, addition of fat such as medium chain triglyceride (MCT) oil or
glucose polymers will help in achieving the adequate growth.
The role of specific nutrients (e.g. inositol, vitamin E, selenium, glutamine etc. except for
vitamin A) however, remains speculative till now.

C. Pharmacological strategies

i) Exogenous surfactant: Prophylactic surfactant therapy in infants born before 30 weeks of

gestation has not been shown to reduce the incidence of BPD. However, surfactant
treatment for established RDS (rescue therapy) in infants born at or after 30 weeks
gestation is associated with significant reduction in the incidence of BPD.25 The apparent
lack of effect in the first group could probably be due to the increased survival of more
immature infants (similar to antenatal steroids).
ii) Vitamin A: Vitamin A is essential for maintaining the integrity of respiratory tract epithelial
cells. Very preterm infants are relatively deficient in vitamin A which has been shown to be
associated with CLD. A large RCT of 807 infants with a birth weight of less than 1000 g has
shown that a large dose of intramuscular vitamin A (5000 units three times a week for 4
weeks from birth) decreases the risk of CLD (OR 0.89; 95%CI 0.8-0.99).26 A meta-analysis
of seven RCTs has also confirmed this finding.27 We use intramuscular vitamin A (in the
above said dose) for ELBW infants with respiratory distress requiring supplemental oxygen
or mechanical ventilation at 24 hours of age.
iii) Methylxanthines: Xanthines such as caffeine and aminophylline have been routinely used
for prevention/treatment of apnea and for facilitation of extubation in premature infants.
Recently, a large RCT that used caffeine for these indications in infants with birth weights of
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500-1250g has shown a significant decrease in the incidence of BPD. The authors attributed
this rather unexpected finding to reduced duration of mechanical ventilation in the caffeine
treated group.28 However, caffeine is not available in India and one should be careful before
extrapolating the beneficial effects to aminophylline. We use aminophylline after extubation
and for treatment of apnea of prematurity in preterm VLBW infants.
iv) Indomethacin / Ibuprofen therapy for PDA: Patent ductus arteriosus is one of the major risk
factors for BPD. Hence, prevention or treatment of PDA should ideally reduce its risk.
However, prophylactic use of indomethacin in very low birth weight infants has failed to
show any reduction in the incidence of BPD despite a significant reduction in the incidence
of PDA.29 Similar results are obtained with ibuprofen, another drug used for closure of
PDA.30 In contrast, treatment of symptomatic PDA could possibly reduce the incidence of
BPD.31
v) Postnatal steroids: Given that inflammation plays a central role in the pathogenesis of BPD,
steroids were thought to be a natural choice for its management. However, this therapy has
turned out to be the most controversial area of care following reports of adverse
neurodevelopmental outcomes. Conventionally, steroid therapy is categorized into 3 broad
groups based on the timing of initiation: early (during the first 96 hrs after birth), moderately
early (between postnatal days 7 and 14), and delayed (after 3 weeks of age). Meta-analyses
of RCTs of the first two regimes have shown a significant reduction in the incidence of BPD
at 36 weeks PMA.32, 33
However, there are important concerns regarding both short-term
(hypertension, gastrointestinal perforation, poor somatic growth) as well as long-term
adverse effects (neurodevelopmental outcomes including cerebral palsy). One systematic
review in this regard found that infants who received steroids were twice as likely to develop
cerebral palsy as the control infants.34 In view of these findings, routine early use of high-
dose steroids is not recommended at present. Considering the fact that no other treatment
options have proved to be consistently beneficial in preventing BPD, some centers still
recommend moderate early use of steroids at lower doses and for shorter durations in
ventilator-dependent infants. We use steroids occasionally in ELBW infants who continue to
be on mechanical ventilation even after 10-14 days of life (3-day course using low dose
dexamethasone). 35
Inhaled steroids thought to reduce the adverse effects associated with systemic
administration have not been shown to be beneficial either for prevention or for treatment.36

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vi) iNO: Animal studies have shown that iNO therapy, in addition to causing pulmonary
vasodilatation also reduces lung inflammation and promotes lung growth. Unfortunately,
most clinical studies in preterm infants with severe respiratory failure have not demonstrated
any reduction in the risk of death or CLD with iNO.37 Recently, two large RCTs conducted in
this regard indicate that iNO therapy might be beneficial in a select group of preterm
infants.38, 39 However, one should remember that the appropriate dose, timing, duration, and
more importantly, the subgroup of infants who are likely to benefit with this mode of therapy
have not yet been clearly defined. Moreover, the prohibitive cost of iNO therapy precludes
its use on a routine basis.
vii) Diuretic therapy: Diuretics help by increasing the reabsorption of fluid from the lungs.
Though studies have shown beneficial effects in lung physiology, no such effects were
observed in mortality or the incidence of BPD. Coupled with the potential risks involved with
long term therapy, chronic use of furosemide or any other diuretics cannot be recommended
now. However, diuretics can be used sparingly if there are clinical/radiographic features of
pulmonary edema in an infant with evolving or established BPD.40 We use furosemide 0.5-1
mg/kg/day in infants with features suggestive of excess lung fluid; we stop after 24-48 hours
if no improvement is noted in the clinical condition.
viii)Mast cell stabilizers: Cromolyn sodium has been shown to decrease neutrophil migration
and activation thus minimizing inflammation in the lungs. Two trials that have studied the
possible role of cromolyn for prevention and treatment of BPD have not shown any benefit.41
ix) Bronchodilators: They have not been found to be useful for prevention of BPD. 42
x) Emerging therapies: Preterm infants are susceptible to oxidant injury because they are
deficient in antioxidant enzymes. Hence, antioxidants such as superoxide dismuatase
(SOD) promise to be an exciting strategy for prevention of BPD. A randomized trial that
enrolled around 300 infants proved the safe nature of the drug CuZnSOD, but did not find
any difference in the primary outcome of BPD at 36 weeks PMA. Interestingly, SOD treated
infants had fewer episodes of respiratory illness at I year of age suggesting that the drug
could prevent long-term lung injury caused by reactive oxygen species.43 Further studies are
needed to define its exact role in the management of BPD. Other antioxidants/free radical
scavengers like vitamins C and E, allopurinol, N-acetyl-Cysteine have not been proved to be
useful till now.
The options available for prevention and their current status are summarized in Table 2.

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Treatment of evolving/established BPD

There are extremely limited data from clinical trials on which to base optimal ventilatory
management in established BPD. The major goal is to maintain adequate gas exchange with as
minimal support as possible. CPAP and NIPPV should be attempted as much as possible. For
infants on ventilator, the settings should be titrated keeping in mind the rapidly changing
pulmonary mechanics (increasing airway resistance as well as improving compliance). Often,
slow rates with long Ti are needed as the disease progresses. Some neonates with marked
variability in compliance and resistance may benefit from volume targeted ventilation. Similarly,
PTV may be useful in infants who fight the ventilator.44 Accepting relatively high PaCO2 (45-55
mm Hg provided pH >7.25) and slightly low saturations (88-93%) would help in minimizing the
ventilator settings and thus help in early extubation (Table 3).

The role of drugs in evolving/established BPD is minimal except in select group of infants (Table
3). Most of the drugs used in this regard have already been discussed under prevention of BPD.
Diuretics and bronchodilators can be used if the clinical condition warrants but should be
stopped if no response occurs within 24-48 hours of initiation of therapy. This is especially
important in case of diuretic therapy. Steroids initiated after 3 weeks of life (late regime) does
not reduce the need for oxygen at 36 weeks PMA but definitely reduces the need for home
oxygen therapy. However, it is associated with increased incidence of growth failure and
hypertension.45 One should weigh the risk-benefit ratio before initiating steroids for an infant with
established BPD. Infants with BPD spells (sudden episodes of deterioration due to marked
expiratory airflow limitation) may require sedation and muscle relaxation to reduce agitation.

Infants developing BPD require 20 to 40% more calories than their age-matched healthy
controls. Their caloric requirement varies from 120 to 150 Kcal/kg/day. This can be achieved by
fortifying breast milk with human milk fortifier (HMF) or infant formula. For infants who require
more calories, fat supplementation (e.g. MCT oil) is preferable to adding carbohydrates because
of the less pronounced effects on CO2 levels (Table 3).24

Figure 1 summarizes the steps of prevention and treatment of BPD (starting from the antenatal
period until the time of discharge) in a preterm VLBW infant.

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Table 1: Definition of BPD 5

Gestational age
< 32 weeks > 32 weeks

Time point of 36 weeks PMA or discharge* > 28 days but < 56 days postnatal age
assessment or discharge*
Treatment with oxygen > 21% for at least 28 days > 21% for at least 28 days

BPD
Mild Breathing room air at 36 weeks PMA Breathing room air at 56 days postnatal
or discharge* age or discharge*
Moderate Need* for <30% oxygen at 36 weeks Need* for <30% oxygen at 56 days
PMA or discharge* postnatal age or discharge*
Severe Need for > 30% oxygen and/or Need for > 30% oxygen and/or positive
positive pressure (IMV/CPAP) at 36 pressure (IMV/CPAP) at 56 days
weeks PMA or discharge* postnatal age or discharge*

*- whichever comes first

(PMA, Postmenstrual age; BPD, bronchopulmonary dysplasia; IMV, Intermittent mandatory ventilation; CPAP, continuous
positive airway pressure)

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Table 2: BPD - Preventive strategies and their current status

Strategies Proven benefit Promising Probably beneficial No benefit

(needs more studies) (effects + )
Ventilatory - NIPPV Early CPAP High frequency
Volume targeted Patient triggered modes ventilation
ventilation
Permissive
hypercapnia
Permissive hypoxemia
Fluids and - Aggressive early Fluid restriction
nutrition enteral and
parenteral nutrition
Pharmacological Vitamin A Antenatal steroids Antenatal TRH
Postnatal steroids (but Exogenous surfactant Prophylactic
harmful as well) Superoxide dismutase Methylxanthines indomethacin /
iNO therapy ibuprofen
Diuretics Inhaled steroids
Bronchodilators
Mast cell stabilizers
(NIPPV, Nasal intermittent positive pressure ventilation; CPAP, continuous positive airway pressure; iNO, Inhaled nitric
oxide; TRH, Thyrotropin releasing hormone)

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Table 3: Management of evolving or established BPD #

Evolving BPD Established BPD
(2-4 weeks age) (>4 weeks age)
Ventilatory Minimizing ventilatory support Minimizing ventilatory support
strategies (e.g. using nCPAP whenever possible)
Tolerating slightly higher PaCO2 (45-
55 mm Hg provided pH >7.25) Tolerating higher PaCO2 (55-60 mm
Target SpO2 : 88-93% Hg provided pH >7.25)
If on IMV: Target SpO2 : 89-94%
o Use PTV if possible If on IMV:
o Slow rates (25-40/min) o Use PTV if possible
o Moderate PEEP (4-5 cm H2O) o Slow rates (20-40/min)
o Moderate Ti (0.35-0.45 sec) o Moderate PEEP (4-8 cm H2O)
o Low tidal volume (3-6 mL/kg) o Longer Ti (0.4-0.7 sec)
o Early extubation to CPAP o Larger tidal volume (5-8 mL/kg)

Pharmacological Methylxanthines to facilitate Steroids:* Individualize based on the

strategies extubation clinical condition
Steroids:* Consider in ELBW infants Specific management:
on ventilator support even after 10- o Bronchodilators for bronchospasm
14 days of age o Sedation and muscle relaxation for
Specific management: BPD spells
o Diuretics for features of pulmonary
edema
o Bronchodilators for bronchospasm
Others Nutrition: Same as for evolving BPD
o Increase daily calorie intake to 120
to 150 Kcal/kg/d
o Give expressed breast milk
fortified with HMF
o Use fat supplementation (e.g. MCT
oil) for providing additional calories
o Give multivitamin supplements to
meet RDA
#
Modified from Reference 44
* Could result in potentially harmful effects including adverse neurodevelopmental outcomes; counsel parents
before initiation of therapy

(nCPAP, nasal continuous positive airway pressure ;IMV, intermittent mandatory ventilation; PTV, patient
triggered ventilation; PEEP, positive end expiratory pressure; Ti, Inspiratory time; HMF, human milk
fortifier; MCT, medium chain triglycerides; RDA, recommended dietary allowance)

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Antenatal period Antenatal steroids (2 doses of betamethasone 24 hrs apart)

At birth Avoid excessive pressure during resuscitation (use appropriate size bag for BMV)

Birth to 24 hrs Fluids: 60-80 mL/kg/d

Nutrition: oral feeds - breast milk (MEN/full feeds) to be initiated in stable
infants
Early CPAP
If on ventilator:
o Early rescue surfactant as indicated
o Settings: fast rates (50-60/min), moderate PEEP (4-5 cm H2O),
short Ti (0.25-0.4 s)
o Target values- SpO2: 87-92%; PaCO2 45-55 mm Hg; pH: 7.25-7.35
o Early extubation to CPAP

24 hrs to 1 week Fluids: daily increment of 15-20 mL/kg/d to reach a maximum of 150 mL/kg/d
by day7
Nutrition:
o Parenteral: TPN for ELBW infants till full enteral feeds are achieved
o Enteral: Gradually increase feed volume by 20-30 mL/kg/d if accepting
well; give only breast milk; fortify with HMF after reaching 100 mL/kg/d
If on ventilator:
o Settings and target values as above
o Extubate to CPAP if possible
o Methylxanthines to facilitate extubation
For ELBW infants on oxygen or ventilator support at 24 hrs: Inj. vitamin A

1 to 4 weeks Fluids: 150 to 160 mL/kg/d

Nutrition: Fortify breast milk with HMF; add more calories if needed
If on ventilator:
o Settings and target values as in Table 3
o Extubate to CPAP as early as possible
Diuretics/steroids/bronchodilators as indicated (see Table 3)

> 4 weeks Fluids: 150 to 160 mL/kg/d

Nutrition: Fortify breast milk with HMF; add more calories if needed
If on ventilator:
o Settings and target values as in Table 3
o Extubate to CPAP as early as possible
Sedatives/steroids/bronchodilators as indicated (see Table 3)

Figure1: Flow-chart for management of BPD

(BMV, bag and mask ventilation; CPAP, continuous positive airway pressure; PEEP, positive end expiratory pressure;
MEN, Minimal enteral nutrition; ELBW, extremely low birth weight infants; TPN, total parenteral nutrition; HMF, human
milk fortifier; PTV, patient triggered ventilation; Ti, Inspiratory time)
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DK. Trends in severe BPD rates between 1994 and 2002. J Pediatr 2005; 146: 46973
2. Bancalari E, Claure N. Definitions and diagnostic criteria for bronchopulmonary
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3. Bancalari E, Abdenour GE, Feller R, Gannon J. Bronchopulmonary dysplasia: clinical
presentation. J Pediatr 1979;95:819-23
4. Shennan AT, Dunn MS, Ohlsson A, Lennox K, Hoskins EM. Abnormal pulmonary
outcomes in premature infants: prediction from oxygen requirement in the neonatal
period. Pediatrics 1988;82:527-32
5. Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med
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6. Ehrenkranz RA, Walsh MC, Vohr BR, Jobe AH, Wright LL, Fanaroff AA, Wrage LA, Poole
K; National Institutes of Child Health and Human Development Neonatal Research
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7. Narang A, Kumar P, Kumar R. Chronic Lung Disease in Neonates: Emerging problem in
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8. Kinsella JP, Greenough A, Abman SH. Bronchopulmonary dysplasia. Lancet
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9. Makri V, Hospes B, Stoll-Becker S, Borkhardt A, Gortner L.Polymorphisms of surfactant
protein B encoding gene: modifi ers of the course of neonatal respiratory distress. Eur J
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10. Northway WH Jr, Rosan RC, Porter DY: Pulmonary disease following respiratory therapy
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11. Jobe AH. The New BPD: an arrest of lung development. Pediatr Res 1999; 46:641-3
12. Crowley PA. Antenatal corticosteroid therapy: a meta-analysis of the randomized trials,
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13. Crowther CA, Alfi revic Z, Haslam RR. Thyrotrophin releasing hormone added to
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14. Avery ME, Tooley WH, Keller JB, Hurd SS, Bryan MH, Cotton RB, et al. Is chronic lung
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15. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB; COIN Trial
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2008;14;358:700-8
16. Davis PG, Lemyre B, De Paoli AG. Nasal intermittent positive pressure ventilation
(NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm
neonates after extubation. Cochrane Database of Systematic Reviews
2001;3:CD003212
17. Greenough A, Dimitriou G, Prendergast M, Milner AD. Synchronized mechanical
ventilation for respiratory support in newborn infants. Cochrane Database of Systematic
Reviews 2008;3: CD000456.
18.Thome UH, Carlo WA, Pohlandt F. Ventilation strategies and outcome in Randomised
Trials of High Frequency Ventilation. Arch Dis Child. 2005;90:F466-73
19. McCallionN, Davis PG, MorleyCJ. Volume-targeted versus pressure-limited ventilation in
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20. Carlo WA, Stark AR, Wright LL, Tyson JE, Papile LA, Shankaran S, et al. Minimal
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J Pediatr 2002;141:370-4
21. Askie LM, Henderson-Smart DJ, Irwig L, Simpson JM. Oxygen-saturation targets and
outcomes in extremely preterm infants. N Engl J Med 2003; 4;349:959-67
22. Supplemental Therapeutic Oxygen for Prethreshold Retinopathy of Prematurity (STOP-
ROP), a randomized, controlled trial. I: primary outcomes. Pediatrics. 2000;105:295-310
23. Barrington KJ, Al-Hazzani FN. Fluid restriction for treatment of preterm babies with
chronic lung disease. (Protocol) Cochrane Database of Systematic Reviews 2005;
(3):CD005389.
24. Biniwale MA, Ehrenkranz RA. The role of nutrition in the prevention and management of
bronchopulmonary dysplasia. Semin Perinatol 2006;30:200-8
25. Engle WA; American Academy of Pediatrics Committee on Fetus and Newborn.
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26. Tyson JE, Wright LL, Oh W, Kennedy KA, Mele L, Ehrenkranz RA, Stoll BJ, Lemons JA,
Stevenson DK, Bauer CR, Korones SB, Fanaroff AA. Vitamin A supplementation for
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27. Darlow BA, Graham PJ. Vitamin A supplementation for preventing morbidity and
mortality in very low birth weight infants. Cochrane Database Syst Rev 2002; 4:
CD000501.
28. Schmidt B, Roberts RS, Davis P, Doyle LW, Barrington KJ, Ohlsson A, et al. Caffeine for
Apnea of Prematurity Trial Group. Caffeine therapy for apnoea of prematurity. N Engl J
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29. Schmidt B, Davis P, Moddemann D, Ohlsson A, Roberts RS, Saigal S, et al; Trial of
Indomethacin Prophylaxis in Preterms (TIPP) Investigators. Long-term effects of
indomethacin prophylaxis in extremely-low-birth-weight infants. N Engl J Med
2001;344:1966-72
30. Shah SS, Ohlsson A. Ibuprofen for the prevention of patent ductus arteriosus in preterm
and/or low birth weight infants. Cochrane Database Syst Rev 2006;(1):CD004213.
31. Clyman RI. Recommendations for the postnatal use of indomethacin: an analysis of four
separate treatment strategies. J Pediatr. 1996;128:601-7
32. Halliday HL, Ehrenkranz RA. Early postnatal (< 96 hours) corticosteroids for preventing
chronic lung disease in preterm infants. Cochrane Database Syst Rev 2003; (1):
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33. Halliday HL, Ehrenkranz RA. Moderately early (714 days) postnatal corticosteroids for
preventing chronic lung disease in preterm infants. Cochrane Database Syst Rev 2003;
(1): CD001144.
34. Barrington KJ. The adverse neuro-developmental effects of postnatal steroids in the
preterm infant: a systematic review of RCTs. BMC Pediatrics 2001; 1: 114.
35. Sankar MJ, Deorari AK. Postnatal corticosteroids for chronic lung disease (CLD). Indian
Pediatr 2007;44:531-9
36. Shah V, Ohlsson A, Halliday HL, Dunn MS. Early administration of inhaled
corticosteroids for preventing chronic lung disease in ventilated very low birth weight
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37. Barrington KJ, Finer NN. Inhaled nitric oxide for respiratory failure in preterm infants.
Cochrane Database Syst Rev; 2006: CD000509.
38. Kinsella JP, Cutter GR, Walsh WF, Gerstmann DR, Bose CL, et al. Early inhaled nitric
oxide therapy in premature newborns with respiratory failure. N Engl J Med
2006;355:354-64
39. Ballard RA, Truog WE, Cnaan A, Martin RJ, Ballard PJ, et al. Inhaled nitric oxide in
preterm infants undergoing mechanical ventilation. N Engl J Med 2006;355:343-53
40. Baveja R, Christou H. Pharmacological strategies in the prevention and management of
bronchopulmonary dysplasia. Semin Perinatol 2006;30:209-18
41. Ng GY, Ohlsson A. Cromolyn sodium for the prevention of chronic lung disease in
preterm infants. Cochrane Database Syst Rev. 2001;(2):CD003059
42. Ng GY, da S, Ohlsson A. Bronchodilators for the prevention and treatment of chronic
lung disease in preterm infants. Cochrane Database Syst Rev. 2001;(3):CD003214.A
43. Davis JM, Parad RB, Michele T, et al. Pulmonary outcome at one year corrected age in
premature infants treated at birth with recombinant CuZn superoxide dismutase.
Pediatrics 2003;111: 46976
44. Ambalavanan N, Carlo WA. Ventilatory strategies in the prevention and management of
bronchopulmonary dysplasia. Semin Perinatol 2006;30:192-9
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 Chest X-rayUse and Interpretation 391

Cardiac:
Cardio thoracic ratio/cardiac size

Chest X-rayUse Pulmonary vascular markings

32 and Interpretation
Specific chamber enlargement
Projection
The following features distinguish AP from a PA film:
In PA films, the scapulae lie postero-laterally and are away
from the lung fields, whereas they tend to overlap the lungs
INDICATIONS in AP films.
The indications for a chest X-ray include: Due to its anterior placement, the heart appears larger in
1. For evaluating the initial cause of respiratory distress AP rather than PA film.
2. For suspected cardiac or pericardial disease The cervico-thoracic vertebral end plates are tangential to
3. To check position of endotracheal tube, umbilical venous or the AP projection beam, making them prominently seen in
arterial lines, peripherally inserted central catheters or chest AP view, while the lamina appears more prominent in PA
tubes view.
4. For evaluating cause of worsening respiratory distress in a The ribs appear to be more horizontally placed in AP than
ventilated neonate after ruling out mechanical problems PA view.
(tube block/secretions/dislodgement) or ventilator
dysfunction. Practical Tip
Tip
Some conditions where X-rays are not indicated include: Most neonatal chest X-rays are AP films, unless the baby is made to lie prone.
1. Routine/daily X-rays in ventilated neonates
2. Routine pre/post extubation X-rays Exposure
3. After re-intubation in a neonate where the optimal tip-to- Lucency of soft tissue shadowdarker the soft tissue, more
lip distance is known based on initial X-ray is the exposure.
4. Evaluation of an isolated episode of desaturation/apnea. Ease of visibility of retrocardiac vertebraeif the retrocardiac
vertebrae are easily seen, the film is over exposed.
INTERPRETATION
Relative lucency of lung fields.
While describing an X-ray, the following vital observations need
to be made:1,2 Rotation
Projection (AP versus PA film) The chest X-ray is said to be rotated if:
Exposure (hard versus soft films) The distance of the posterior ends of ribs from the midline
Rotation of spine are unequal on either side. The film is rotated to
Soft tissue/bone that side on which the distance appears greater.
Lungs: Medial end of clavicles are not equidistant from the midline.
Expansion
Parenchymal appearancelucency, nature of opacities, The first criterion is usually more helpful as the lower chest
fissure tends to be rotated more commonly than the upper chest, as
Cardiac and diaphragmatic margins the latter is usually stabilised at the time of taking X-rays.

390
392 AIIMS Protocols in Neonatology Chest X-rayUse and Interpretation 393

Soft Tissue/Bone 2. Lesser diaphragmatic excursions occur during inspiration

The importance of carefully looking at the bones cannot be over- in neonates as compared to older children.
emphasised especially for picking up changes of osteopenia
and fractures. This is not discussed in detail here. CHARACTERISTIC APPEARANCE OF COMMON DISEASE
CONDITIONS
ThymusNormal and Abnormal
Respiratory Distress Syndrome (RDS)
The thymus may create some challenge in the interpretation of
neonatal chest X-rays. One needs to differentiate its normal The condition is caused by the deficiency of surfactant pro-
from abnormal appearance. duction by type II alveolar cells, which results in alveolar
Normally, thymus appears as a bilateral smoothly outlined collapsibility with over inflation of larger alveoli and resultant
superior mediastinal fullness blending with the cardiac transudation of proteinaceous fluid into alveoli, creating the
silhouette. Some normal variants of thymus: classical hyaline membranes. The radiological features of the
Notch signuniform enlargement of thymus on both sides condition are:
with prominent notch on inferior left border Under-aerated lungs
Sail signcharacteristic sail like border of normal thymus, Reticulo-granularity (presence of air in the terminal bron-
more commonly seen on right side chioles and alveolar ducts against a background of alveolar
Undulating waviness of the lateral border of thymus due to atelectasis)
indentation of ribs Air bronchograms (with progress of disease, more and more
distal airways collapse, leaving the proximal bronchi which
INTERPRETATION OF LUNG FIELDS stand out as air bronchograms. Note that air bronchograms
may be absent in an expiratory film)
Lung Expansion Diffuse granularity
Normal lung expansion: Up to 6 ribs anteriorly and 8 ribs In severe cases or in expiratory films, these findings may be
posteriorly. This follows the normal position of the diaphragm replaced by white-out lungs due to diffuse alveolar
between 5th to 7th anterior ribs. atelectasis
The radiological features of hyper-expansion are: The severity of RDS has been classified based on radiological
findings as follows:
1. Presence of more than 6 ribs anteriorly and 8 ribs
posteriorly Mild: Normal/decreased aeration, reticulo-granularity
2. Flattening of diaphragm Moderate: Decreased aeration, air bronchograms and indistinct
3. Increased lucency of lung fields (blackness) diaphragm and heart borders
4. Air under the heart/herniation of lung to opposite side Severe: Confluent opacification of lungs with loss of mediastinal
5. Ribs more horizontal and diaphragmatic borders.
However, the evaluation of lung expansion by counting the
number of ribs (or intercostal spaces) above the diaphragm can Transient Tachypnea of Newborn (Retained Fluid Syndrome)
be tricky in newborns due to two reasons: This is a condition resulting from the delayed clearance of fetal
1. This technique represents the expansion in two dimensions lung fluid, overloading the interstitium, lymphatics and cardio-
only. But newborns, unlike older infants and children, have vascular system. X-ray picture is characterised by:
highly compliant thoracic cage, which can easily expand in Prominent hilum with perivascular streaky shadows
the antero-posterior dimension as well. Prominent interlobar fissure
394 AIIMS Protocols in Neonatology Chest X-rayUse and Interpretation 395

Small pleural effusion Bilateral nodular opacities (this represents areas of focal
There may be mild cardiomegaly alveolar atelectasis with focal alveolar over distension in
Normal to increased lung volume between).
Sometimes, a large piece of meconium can obstruct the
Pulmonary Interstitial Emphysema (PIE) bronchus leading to emphysema of one lung/lobe and
It is caused by the dissection of air from alveoli into the compression of the other lung.
parenchyma and interstitium of lungs and perivascular sheaths
of vessels, tracking towards the hilum. X-ray appearance is Pneumonia
characterised by The radiological picture is variable and may range from
Radiolucent streakslinear or irregular, branching/cystic reticulo-granularity to lobar or segmental consolidation.
spaces (honey comb like) or pneumatoceles. Asymmetry of reticulo-granular pattern with air broncho-
PIE may present with linear or cystic changes. Linear grams may be seen.
lucencies of PIE may be differentiated from air bronchograms Coarse granular patchy infiltrates with irregular areas of
in that the latter are generally smooth and branching, in hyper inflation.
contrast to interstitial air which is coarser and non-branching. Pleural Effusion
Pneumothorax Detected by the blunting of posterior and later, the lateral
This results from the dissection of extra-alveolar air to the costophrenic angle (only in erect film).
hilum, followed by rupture into pleural space. Increased radio- In supine radiographs, there is decreased translucency of
lucency of the ipsilateral lung and sharpness of mediastinal the lung with preserved pulmonary vascular markings.
border are the earliest signs of pneumothorax. The characteristic If enough fluid is present, it is seen as a peripheral band
X-ray findings are: separating the lung and lateral chest wall.
Clear border of collapsed lung Broncho Pulmonary Displane
Absent lung markings beyond the collapsed lung border
The radiological appearance is variable and depends on the
[This differentiates pneumothorax from vertical skin folds]
postnatal age (Northway, et al).
May or may not be accompanied by mediastinal shift
Herniation of the pneumothorax bounded by parietal pleura Stage I (23 days)Air bronchograms, reticulo-granularity
into the contralateral side (similar to RDS)
The thymus is compressed by pneumothorax whereas it is Stage II (410 days)Opacification; Coarse irregular densities
elevated by pneumomediastinum. Stage III (1020 days)Small generalised radiolucent cysts
Stage IV (1 month)Dense fibrotic strands, generalised cystic
Pneumomediastinum
areas, hyper-inflated lungs
It is the presence of air adjacent to the heart outlining the
thymus and elevating it. Types of Bubbles in Chest X-ray
There are three types of bubbles in chest X-ray which are as
Meconium Aspiration Syndrome (MAS) follows:
The radiological appearance may range from hyper-expansion Type I : Seen in RDS
to collapse: Small and uniform, rounded
Gross hyper-expansion of lungs 12 mm in diameter
396 AIIMS Protocols in Neonatology Chest X-rayUse and Interpretation 397

More prominent in lung bases Cardiac Size

Due to over distension of the terminal airways This may be assessed simply by measuring the cardiothoracic
Become less pronounced on expiration ratio (CT ratio). CT ratio is the largest transverse diameter of
Type II : Seen in pulmonary interstitial emphysema (PIE) the heart divided by the smallest internal diameter of the chest.
Nodular and tortuous in shape A CT ratio of more than 0.6 suggests cardiomegaly in
Peribronchial and perivascular in location newborns.
Do not empty on expiration Pulmonary Vasculature
Type III : Larger than the first two types of bubbles Normally, it is difficult to appreciate pulmonary vascular
Irregular shaped markings in the lateral third of the lung fields as well as in the
Seen in focal hyper-aeration syndrome, e.g. lung apices.
broncho-pulmonary dysplasia Increased pulmonary vascularity is said to be present when
Also become less pronounced on expiration, like the pulmonary vessels are seen in the lateral third of the film
type I bubbles. or in the lung apices or if the right pulmonary artery which is
visible in the right hilus appears wider than the trachea.
CONGENITAL DIAPHRAGMATIC HERNIA Decreased pulmonary blood flow/PBF (oligemia) is
diagnosed by the relative blackness of lung fields with small
Bochdalek defects present with a well defined dome shaped soft lung hilum (Table 32.1).
tissue opacity usually on the left chest. Importantly, intestinal
loops may be gasless in the first few hours of life and the classical Table 32.1: Causes of decreased and increased PBF
appearance of gas filled loops in the chest may appear only few Causes of decreased PBF Causes of increased PBF
hours after birth. Tricuspid valve: Tricuspid atresia Acyanotic:
Ebsteins anomaly Ostium primum/secundum ASD
Morgagni hernias are seen as opacities adjacent to the right Right ventricle: Ventricular septal defect
costophrenic angle. Tetralogy of Fallot Patent ductus arteriosus
Pulmonary stenosis (PS) Cyanotic: Admixture lesions without PS
Tracheo-Esophageal Fistula Arterial: Transposition of great arteries
Peripheral pulmonary artery Total anomalous pulmonary venous
A soft rubber tube is better than an infant feeding tube for the stenosis drainage
radiological diagnosis of TEF. The X-ray shows coiling of the Pulmonary atresia Persistent truncus arteriosus
tube in the upper esophagus. If one desires to delineate the Persistent truncus (type IV) Single ventricle
extent of gap between the upper and lower pouch, a lateral
X-ray is preferable. Absent stomach gas suggests associated Specific Chamber Enlargement
esophageal atresia. In an AP view, the right heart border is formed above
downwards by superior vena cava (SVC), ascending aorta (AA),
INTERPRETATION OF THE CARDIAC SHADOW IN X-RAY 3 right atrial appendage (RAA) and the right atrium (RA). The left
The most important features to be noted are: heart border is formed by the aortic arch (AoA), main
pulmonary artery (PA), left atrial appendage (LAA) and the
1. Cardiac size left ventricle (LV). This forms the basis for diagnosing various
2. Pulmonary vasculature chamber enlargements. Note that the right ventricle (RV) does
3. Shape and size of different chambers/cardiac situs not contribute to either of the borders and usually presents
398 AIIMS Protocols in Neonatology Chest X-rayUse and Interpretation 399

with an up-turned apex, when enlarged. Left atrial enlargement Practical Tips
Tips
results in splaying of the carina and double left heart border While doing an X-ray
appearance. Specific X-ray picture in congenital heart disease Follow aseptic precautions.
is provided (Table 32.2). Adequate hand hygiene is a must for all including radiographer.
Always make note and discuss the exposure settings with the radiographer
Table 32.2 Specific X-ray picture in congenital heart lesions in order to optimise image quality. A rough guide is to use 3050 kV (kilo
Heart lesion X-ray picture Volts) and 410 mA (milliAmps).
Avoid direct contact of the X-ray plate with the baby to prevent hypothermia.
Ventricular septal defect Prominent pulmonary vascular markings, left atrial
Always place the X-ray plate in the separate tray meant for that purpose.
and ventricular enlargement
In small babies, beware of hypothermia as the radiant warmer is tilted away
Patent ductus arteriosus Prominent main pulmonary artery, left atrial and
during the X-ray and provide extra heat source if necessary. X-ray can be
ventricular enlargement
done through an incubator safely.
Coarctation of aorta Reverse 3 sign along the upper left heart border- Instruct health care providers to wear lead apron and use gonad shield for
hypoplastic aortic knob along with left ventricular the baby. Maintain safe distance for health care professionals when an X-ray
prominence; inferior rib border notching is being filmed in order to prevent radiation hazard.
Tetralogy of fallot Coeur en sabot (boot shaped) heartcaused by a Expose only the area of interest and remove chest leads, tubings, etc. from
small pedicle (atretic PA) with an up-turned apex the field.
due to RV hypertrophy; pulmonary oligemia Make sure that the baby is not rotated.
Truncus arteriosus Narrow pedicle, frequently accompanied by absent As far as possible, quieten the baby to avoid swings in respiratory depth.
thymus
While rreading
eading an X-ray
Total anomalous Snowman appearance caused by the dilated
Read schematically, jumping to the diagnosis may entail the risk of missing
pulmonary venous vertical vein, innominate vein and SVC, pulmonary
additional details.
connection (supracardiac) plethora
Correlate findings with clinical details.
Transposition of great Egg on side appearance due to the narrow pedicle
Make note of age in hours/days, serial sequence number and interventions
arteries created by the parallel orientation of aorta and
done before (such as surfactant administration) and after the X-ray (pulling
pulmonary artery
out a deeply placed endotracheal tube).
Use of a view box and magnifying glass for reading X-ray is the ideal.
LINE POSITIONS
Umbilical Arterial Line
High: Between T6 and T9 vertebrae REFERENCES
Low: Between L3 and L4 vertebrae 1. Deorari A, Kumar P, Murki S. Workbook on CPAP: science,
evidence and practice. 2nd edn. Neonatal chest X-ray interpreta-
Umbilical Venous Line tion, New Delhi. 2011;p 5964.
0.5 cm to 1 cm above the diaphragm 2. Swischuk LE. Imaging of the newborn, infant and young child.
5th edn. Philadelphia: Lippincott Williams and Wilkins:
Endotracheal Tube Tip Respiratory system 2004;p 1108.
At least 2 cm above carina OR between the lower border of T2 3. Abdulla R. Heart Diseases in Children: A Pediatricians Guide.
to upper border of T3 thoracic vertebrae Chicago: Springer: Chapter 2, Cardiac Interpretation of Pediatric
Chest X-ray 2011;p 1734.
Percutaneous Central Line (PICC)
When inserted from upper limb, the line must have crossed
the first rib and passed medially with the tip lying between T3
and T6 vertebrae.
Symposium on AIIMS Protocols in Neonatology 1

Apnea in the Newborn

Satish Mishra, Ramesh Agarwal, M. Jeevasankar, Rajiv Aggarwal1, Ashok K. Deorari and Vinod K. Paul

Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New
Delhi, 1Narayana Hridalaya, Bangalore, Karnataka, India

ABSTRACT
Apnea, defined as cessation of breathing resulting in pathological changes in heart rate and oxygen saturation, is a common
occurrence especially in preterm neonates. It is due to immaturity of the central nervous system (apnea of prematurity) or
secondary to other causes such as metabolic disturbances etc. Secondary causes of apnea should be excluded before a
diagnosis of apnea of prematurity is made. Methylxanthines and continuous positive airway pressure form the mainstay of
treatment. Mechanical ventilation is reserved for apnea resistant to the above therapy. An approach to the management of apnea
in neonates is described. [Indian J Pediatr 2008; 75 (1) : 57-61] E-mail: [email protected]

Key words : Apnea; Methylxanthines

About 30-45% of preterm babies exhibit a periodic usually presents after 1-2 days of life (the detection may
breathing pattern characterized by 3 or more respiratory be delayed by the presence of ventilatory support in the
pauses of greater than 3 seconds duration. Periodic initial days of life) and within the first 7 days.
breathing is a normal event, reflective of immaturity of
Secondary causes: Secondary causes of apnea
respiratory control system in these infants and does not
include: (a) Temperature instability: hypothermia and
merit any treatment. In contrast, apnea is a pathological
hyperthermia, (b) Neurological: birth trauma, drugs,
cessation of breathing that results in hemodynamic
intracranial infections, intracranial hemorrhage, seizures,
disturbances and hence merits treatment.
perinatal asphyxia, congenital myopathies or
Definition neuropathies, placental transfer of narcotics, magnesium
sulphate, or general anesthetics, central nervous system
Apnea is defined as cessation of respiration for longer
malformations, (c) Pulmonary: respiratory distress
than 20 sec, or shorter duration in presence of cyanosis or
syndrome (RDS), pneumonia, pulmonary hemorrhage,
bradycardia.1
obstructive airway lesion, pneumothorax, hypoxemia,
Incidence hypercarbia, tracheal occlusion by neck flexion, (d)
Cardiac: congenital cyanotic heart disease, hypo/
Apnea in preterm infants is usually related to immaturity
hypertension, congestive heart failure, patent ductus
of the central nervous system and is called apnea of
arteriosus, increased vagal tone (e) Gastro-intestinal:
prematurity (AOP). It can also occur secondary to other
gastro esophageal reflux, abdominal distension, (f)
causes and is a common manifestation of most neonatal
Hematological: anemia, (g) Infections: sepsis, pneumonia,
diseases. Incidence of AOP is inversely proportional to
meningitis, necrotizing enterocolitis, (h) Metabolic:
gestational age. It varies from 10% in infants born at
acidosis, hypoglycemia, hypocalcemia, hyponatremia,
gestation of 34 weeks or more to more than 60% in infants
hypernatremia and, (i) Inborn errors of metabolism.
born at less than 28 weeks of gestation.1
AOP is a diagnosis of exclusion and should be
ETIOLOGY OF APNEA2,3 considered only after secondary causes of apnea have
been excluded. Common causes of secondary apnea
Apnea of prematurity(AOP). It is probably related to include sepsis, pneumonia, asphyxia, temperature
immaturity of the central nervous system. This condition instability and anemia.

TYPES OF APNEA4
Correspondence and Reprint requests : Dr. Vinod K Paul, Professor,
Department of Pediatrics, All India Institute of Medical Sciences, Central apnea: (40%) Central apnea is characterized by
Ansari Nagar, New Delhi-110029, India
total cessation of inspiratory efforts with no evidence of
[Received November 3, 2007; Accepted December 3, 2007] obstruction.

Indian Journal of Pediatrics, Volume 75January, 2008 57

 S. Mishra et al

Obstructive apnea. (10%) In obstructed apnea, the of heart rate or color.

infant tries to breathe against an obstructed upper airway,
Subtle seizures: Apnea is an uncommon presentation of
resulting in chest wall motion without airflow throughout
a neonatal seizure in preterm infants. Sudden alteration
the entire apneic episode
in muscle tone, twitching movements, vacant stare and
Mixed apnea. (50%) Mixed apnea consists of up rolling of eyes suggests a seizure. Also tachycardia
obstructed respiratory efforts usually following central preceding/ accompanying an apneic attack usually
pauses. Purely obstructive apnea in the absence of a suggests seizure activity.
positional problem is probably uncommon.
EVALUATION OF A CHILD WITH APNEA
MONITORING
Emergency treatment
The neonate should be checked for bradycardia, cyanosis
All babies less than 34 weeks gestation should be
and airway obstruction. The neck should be positioned in
monitored for at least in the first week of life or till
slight extension; oro-pharynx gently suctioned, if
absence of apneic episodes for at least 7 days. Babies 34
required and tactile stimulation should be given. Most
weeks gestation should be monitored if they are sick.3
apneic spells respond to tactile stimulation. Oxygen by
Apnea Monitors5 head box or nasal cannula is provided if the infant is
hypoxic (maintain saturation between 90-93%). If the
Pulse oximeters: These are commonly used for
neonate continues to remain apneic and does not respond
monitoring of apnea. These monitors detect changes in
to tactile stimulation, ventilation with bag and mask
heart rate and/or saturation due to apneic episodes.
(BMV) using 100% oxygen should be initiated. If BMV
Facility for detecting chest wall movement is absent in
fails to initiate spontaneous respiration in the newborn,
these monitors.
then the infant should be managed with positive pressure
Other apnea monitors ventilation.
Movement sensors Clinical examination
(i) Ripple type mattress
After stabilization, the infant should be evaluated for a
(ii) Mattress with sensory pad
possible underlying cause. History should be reviewed
(iii) Pressure sensitive capsule
for possible causes of secondary apnea including
These monitors interpret chest/abdominal movements perinatal asphyxia, maternal drugs, neonatal sepsis and
as respiration. In general, these monitors will fail to feed intolerance. The infant should be examined for
diagnose obstructive apnea and may not distinguish temperature instability, hypotension, jaundice, pallor,
body movements from breathing. cardiac murmur for PDA and poor perfusion. Onset of
apnea within the first 7 days in a premature infant
Thoracic impedence based monitors: These monitors (gestation < 34 weeks) would be suggestive of apnea of
translate changes in thoracic impedence that occur with prematurity (AOP).
breathing as respiratory activity. Like the movement
sensors, these monitors also fail to diagnose obstructive Investigations
apnea.
Neonates with apnea should be investigated to exclude
Respiratory inductive plethysmography: It uses common causes of secondary apnea. Investigations that
abdominal and thoracic movements during respiration. should be considered include blood glucose, hematocrit,
Abdominal thoracic bands or the Graseby capsule are electrolytes, sepsis8 screen, blood culture, arterial blood
used, the inductance of which changes with breathing. gas, chest X-ray, abdominal X-ray, ultrasound head and
other investigations depending on the history and
Magnetometer: Electrical signal produced by chest or physical examination.
abdominal movement then can be detected by the sensor.
Apnea monitors based on chest wall movement are
TREATMENT
likely to miss obstructive apnea. Monitors with facilities
for measuring heart rate and oxygen saturation would be
more useful in the monitoring of significant apnea in General measures
preterm infants.
Maintain airway, breathing and circulation.
Differential Diagnosis Avoid vigorous suctioning of oro-pharynx
Periodic breathing: It consists of breathing for 10-15 Avoid oral feeds repeated episodes of apnea
seconds, followed by apnea for 5-10 sec without change requiring BMV.

58 Indian Journal of Pediatrics, Volume 75January, 2008

 Apnea in the Newborn

Decrease environmental temperature to lower end Continuous positive airway pressure (CPAP)
of thermo-neutral range. Avoid swings in Mechanical ventilation
environmental temperature.
Kinesthetic stimulation
Treatment of the underlying cause: sepsis, anemia,
Pharmacotherapy for AOP
polycythemia, hypoglycemia, hypocalcemia,
respiratory distress syndrome (RDS). Aminophylline, caffeine and doxapram have been used
in the treatment of AOP. The indications for starting
Transfuse packed cells if hematocrit <30%.
drugs are:
Specific measures for AOP Mechanical ventilation
These include For treatment for apnea of prematurity.6
Drugs including aminophylline, caffeine, doxapram Post extubation to reduce the incidence of apnea.7

Algorithm for management of neonatal apnea

Neonate with apnea

Emergency treatment
Maintain temperature, ABC

Investigations
BS,PCV,ABG
Evaluation to exclude secondary Sepsis screen
causes of apnea CXR, AXR
Na, K, Ca
US Head

Apnea of prematurity

Start specific
Treatment
Start aminophylline

Apnea responds No response

Continue till CPAP

34 weeks
Trial of doxapram Responds
No response

Stop drugs if Fails

no apnea for
last 7 days IMV/sNIPPV Continue x 48 hours

(ABC: airway; breathing; circulation; BS: blood sugar; PCV: packed cell volume; ABG: arterial blood gas; Na: sodium;
K: potassium; Ca: calcium; US: ultrasound; CPAP: continuous positive airway pressure; IMV: intermittent mandatory
ventilation); SNIPPV: Synchronised nasal intermittet positive preserve ventilation)

Indian Journal of Pediatrics, Volume 75January, 2008 59

 S. Mishra et al

Methylxanthines caution or preferably avoided.

Methylxanthines have been the mainstay of At present, indications for doxapram include failure
pharmacologic treatment of AOP. Xanthine therapy to respond to both methylxanthine and CPAP therapy.
increases minute ventilation, improves CO2 sensitivity, The loading dose is preferably avoided. Doxapram
decreases hypoxic depression of breathing, enhances infusion is started at 0.5 mg/Kg/hour and increased
diaphragmatic contractility, and decreases periodic gradually to a maximum of 2-2.5 mg/Kg/hr. Doxapram
breathing. The major mechanism of action is likely may be tried for a period of 48 hours before weaning the
through competitive antagonism of adenosine receptors. drug. Methylxanthine therapy should be continued
Adenosine acts as an inhibitory neuro-regulator in the during doxapram infusion. Adverse effects include
central nervous system and is released during hypoxia. seizures, hypertension, hyperactivity, hyperglycemia and
Neonates exhibit hypoxic respiratory depression, and the abdominal distension. It should be avoided in the first
ability of methylxanthines to block this response may week of the life or if the serum bilirubin is high, because
contribute to their effect on apnea. A recent Cochrane an association with intraventricular hemorrhage and
review of the use of methylxanthines concluded that kernicterus has been reported.13 Injection doxapram has
methylxanthines are effective in reducing the number of 0.9% benzyl alcohol as a preservative. The recommended
apneic attacks and the use of mechanical ventilation. dose of 2-2.5 mg/Kg/hr would deliver 21.6-32.4 mg/Kg/
day of benzyl alcohol. Although this dose is below the
The loading dose of intravenous aminophylline is 5 to
toxic dose of alcohol (45 mg/Kg/day), there have been
6 mg/Kg, followed by 1.5 to 3 mg/Kg every 8 to 12 hours.
case reports of gasping syndrome with this lower dose
Oral theosphylline can be administered once the infant
in literature.
becomes stable in the same dose. Caffeine, both oral and
intravenous use, has some advantages over theophylline. Which drug to use?
Because it has a higher therapeutic index, toxicity is less
Present evidence shows that aminophylline, caffeine and
of a concern. Also, once-daily dosing is possible due to its
doxapram are equally effective in the treatment of AOP.
longer half-life. A typical loading dose of 20 mg/Kg
However, their clinical use is dependent upon adverse
caffeine citrate is followed in 24 hours by 5 to 8 mg/Kg
effects. The drug of choice would be caffeine, which is not
per dose, administered once every 24 hours.
available in India. Hence, we prefer to use aminophylline
Recommended therapeutic levels are 5 to 10 g/ml for
as the drug of choice in the management of AOP.
aminophylline and 8 to 20 g/ml for caffeine. 8
Aminophylline should be continued till 34 weeks Continuous positive airway pressure
corrected gestational age and stopped thereafter if no
Continuous positive airway pressure (CPAP), usually
episodes of apnea have occurred in the last 7 days.
administered using nasal prongs (NCPAP), is also an
Aminophylline initiated in order to facilitate extubation
effective treatment of AOP and is typically used when
may be stopped after 7 days.9
clinically significant episodes persist despite optimal
Elimination of methylxanthines is prolonged in infants methylxanthine therapy.15 At CPAP level of 5 cm water,
especially in preterm neonates. Xanthine therapy should infants with AOP will have fewer episodes. This
be discontinued at least 1 to 2 weeks prior to discharge, a reduction is primarily related to significant reduction in
guideline that is especially relevant for caffeine because episodes of obstructive and mixed apneas and has been
of its longer half-life. Do not discharge the patient until attributed to splinting open of the upper airways by the
methylxanthines have been stopped. There is no role for positive airway pressure. If NCPAP in conjunction with
prophylactic use of methylxanthines for prevention of a methylxanthine, is not sufficient to prevent recurring
apnea, bradycardia, or desaturation in premature episodes associated with bradycardia and intermittent
infants.10 Adverse effects include tachycardia, jitteriness, hypoxemia, some investigators have suggested use of
irritability, feed intolerance, vomiting and nasal intermittent positive pressure ventilation (NIPPV).
hyperglycemia. The drug is available as: NIPPV may most likely be needed when episodes are
related predominantly to central apneas and are not
Injection: Aminophylline ampoule 250 mg per 10-ml
effectively eliminated by the NCPAP.3 CPAP may also be
ampoule.
used to reduce post-extubation apnea in preterm
Oral: Theophylline 50 mg/5 ml in Theoped syrup
infants.16
Caffeine: The drug is not available in India at present.
A CPAP of 5 cm H2O is usually used. CPAP may be
Doxapram11, 12
delivered by nasal prongs or nasopharyngeal tube.
Intravenous Doxapram might reduce AOP in the short Endotracheal CPAP is not used in the treatment of apneic
term. The possible effects of treatment are usually not spells. CPAP has no role in prophylaxis against apnea of
sustained after 48 hours of commencement of doxapram prematurity. Adverse effects of CPAP include
treatment. More over, doxapram is associated with barotrauma, abdominal distension, feeding intolerance
serious side effects and hence should be used with and local nasal irritation

60 Indian Journal of Pediatrics, Volume 75January, 2008

 Apnea in the Newborn

Mechanical Ventilation lower developmental indices at two years.3

The infant should be ventilated if both pharmacotherapy

REFERENCES
and CPAP have been tried and significant apneas
continue to occur. If the lungs are normal, the infant
should be ventilated at minimum pressures (peak 1. Hunt CE. Apnea and sudden infant death syndrome. In
Kligman RM, Neider ML, Super DM, eds. Practical strategiesin
inspiratory pressure of 10-12 cm of water and positive
pediatric diagnosis and therapy. Philadelphia; WB Saunders,
end expiratory pressure of 3-5 cm of water), low rate (20- 1996: 135-147.
25 per minute), short Ti (0.35-0.40 seconds) and low FiO2 2. Bhatia J. Current options in the management of apnea of
(0.3-0.5). This method is effective in all forms of apnea. prematurity. Clin Pediatr 2000; 39 : 327-336.
3. Thompson MW, Hunt CE. In MacDonald MG, Mullett MD,
Kinesthetic stimulation Seshia MMK, eds. Averys Neonatology Pathophysiology &
Management of the Newborn 6 th ed. Philadelphia; Lippincott
Water bed, oscillating bed mattress. Present evidence Williams and Wilkins, 1998; 539-45.
does not support any role for this mode of therapy either 4. Martin RJ, Abu-Shaweesh, Baird TM. Pathophysiologic
in the prevention or treatment of apnea.17 Mechanisms Underlying Apnea of Prematurity. Neo Reviews
2002; 3 : e59.
5. Deorari AK. In Deorari AK, Paul VK, eds. Neonatal Equipment
PERSISTENT APNEA Everything that you like to know 3rd ed. New Delhi; Sagar
Publication, 2006; 60-61.
6. Henderson-Smart DJ, Steer P. Methylxanthine treatment for
Apneic episodes may persist beyond 37-40 weeks in some apnea in preterm infants. Cochrane Database Syst Rev 2000.
infants, especially those born before 28 weeks of 7. Henderson-Smart DJ, Steer P. Prophylactic methylxanthine for
extubation in preterm infants. Cochrane Database Syst Rev 2004.
gestation. Methylxanthine therapy should be continued if 8. Martin RJ, Abu-Shaweesh , Baird TM. Clinical Associations,
apneic episodes continue to occur beyond 34 weeks of Treatment, and Outcome of Apnea of Prematurity. Neo
corrected gestational age. The neonate should be re- Reviews 2002; 3: e66.
evaluated for secondary causes of apnea especially 9. Miller MJ, Martin RJ. Apnea of prematurity. Clin Perinatol
neurological problems and gastro-esophageal reflux. 1992; 19 : 789-808.
10. Henderson-Smart DJ, Steer PA. Prophylactic methylxanthine
Home monitoring is not possible in our country and these
for prevention of apnea in preterm infants. Cochrane Database
infants would require NICU care until drugs can be Syst Rev 2006.
weaned and stopped. 11. Henderson-Smart DJ, Steer PA. Doxapram treatment for
apnea in preterm infants. Cochrane Database Syst Rev 2004.
12. Hansen T, Corbet A. Control of breathing. In Taeusch HW,
SUDDEN INFANT DEATH SYNDROME Ballard RA, eds. Averys diseases of the newborn, 7 th ed.
(SIDS) AND APNEA Philadelphia, WB Saunders, 1998; 552-561.
13. Jardine DS, Rogers K. Relationship of benzyl alcohol to
kernicterus, intraventricular hemorrhage, and mortality in
AOP is not found to be an independent risk factor for premature infants. Pediatrics; 83 : 721.
SIDS. Only 2-4% of patients with SIDS have a history of 14. Kumar M, Kabra NS, Paes B. Carnitine supplementation for
preterm infants with recurrent apnea. Cochrane Database Syst
AOP. Rev 2004.
15. Henderson-Smart DJ, Subramanian P, Davis PG. Continuous
positive airway pressure versus theophylline for apnea in
NEURODEVELOPMENT OUTCOME preterm infants. Cochrane Database Syst Rev 2005.
16. Davis PG, Henderson-Smart DJ. Nasal continuous positive
airway pressure immediately after extubation for preventing
Most reports have found little evidence of any morbidity in preterm infants. Cochrane Database Syst Rev 2003.
neurodevelopment risk directly attributed to a history of 17. Osborn DA, Henderson-Smart DJ. Kinesthetic stimulation for
AOP. Precisely measured predischarge apnea related to treating apnea in preterm infants. Cochrane Database Syst Rev
AOP, however, has been reported to be predictive of 2003.

Indian Journal of Pediatrics, Volume 75January, 2008 61

 AIIMS- NICU protocols 2008

Protocol for Administering Continuous Positive Airway Pressure

in Neonates

M. Jeeva Sankar, Jhuma Sankar, Ramesh Agarwal, Vinod Paul, Ashok

Deorari

Division of Neonatology, Department of Pediatrics

All India Institute of Medical Sciences

Address for correspondence:

Prof Ashok Deorari
Professor
Department of Pediatrics
All India Institute of Medical Sciences
Ansari Nagar, New Delhi 110029
Email: [email protected]

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INTRODUCTION

Continuous positive airway pressure (CPAP), often thought to be the missing link
between supplemental oxygen and mechanical ventilation, is gaining immense
popularity in neonatal intensive care units. Being technically simple, inexpensive and
effective, it has become the primary mode of respiratory support in preterm very low
birth weight (VLBW) infants. The evidence, clinical studies, and the controversies
1, 2
regarding its use have been extensively reviewed and are not discussed here. This
protocol deals mainly with the practical aspects of CPAP administration in neonates.

DEFINITION AND BACKGROUND

CPAP refers to the application of positive pressure to the airway of a spontaneously

breathing infant through out the respiratory cycle.

The first clinical use of CPAP was reported by Gregory et al in a landmark report in
1971. They described the use of CPAP via endotracheal tube or a head box in preterm
infants with respiratory distress syndrome (RDS).3 Shortly after this, Kattwinkel
reported successful use of nasal prongs to provide CPAP in these infants.4 After the
initial enthusiasm, it gradually fell out of favor in 1980s because of the advent of
newer modes of ventilation (such as high frequency ventilation) and the perceived
complications of CPAP (such as air leak). However, reports of significantly lower
incidence of chronic lung disease (CLD) from Columbia University unit that used more
CPAP (Hudson prongs) as compared to other North American Centers have led to a
resurgence of interest in CPAP over the past 15 years. 5

CPAP: HOW DOES IT WORK?

CPAP predominantly helps by preventing collapse of the alveoli with marginal stability.
This results in better recruitment of alveoli thus increasing the functional residual
capacity (FRC). The physiologic effects of CPAP are represented in Figure 1.

COMPONENTS OF CPAP SYSTEM

The components of a CPAP system are:

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1. Gas source: To provide continuous supply of warm humidified and blended

gases i.e. air and oxygen
2. Pressure generator: To create the positive pressure in the circuit
3. Patient interface/delivery system: To connect the CPAP circuit to the infants
airway.

CPAP

Prevents collapse of alveoli Stabilizes the Splints open Stretches lung

with marginal stability chest wall Upper airway and pleura
Conservation of
endogenous surfactant
Reduces
Recruitment of Reduces airway obstructive apnea
more alveoli resistance
Stimulates
stretch receptors

Reduces work of breathing

Maintains lung at FRC
Reduces mixed and
central apnea
Increased alveolar surface area Improves V/Q mismatch and
for gas exchange
Reduces intrapulmonary shunt

PaCO2 PaO2
Reduces PVR
Figure 1: Effects of CPAP

Improves pH

Figure1: Effects of CPAP

(FRC, functional residual capacity; V/Q, ventilation-perfusion ratio; PVR, pulmonary vascular
resistance; PaCO2 & PaO2, partial pressure of carbon-di-oxide and oxygen respectively in the
arterial blood)

Devices used for pressure generation

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PaO2
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The pressure sources of CPAP can be broadly grouped into: 6

1. Continuous flow devices
2. Variable flow devices (Figure2)

Bubble CPAP: A typical bubble CPAP setup is shown in Panel 2. One has to remember
that though classified as a continuous flow device, flow may still need to be adjusted
to maintain continuous bubbling in the water chamber and thus the required level of
CPAP.
Variable flow CPAP: A typical example is the Infant flow driver (IFD). It uses the
Bernoulli Effect via dual injector jets directed towards each nasal prong to maintain a
constant pressure. If the infant requires more inspiratory flow, the Venturi action of
the injector jets entrains additional flow. When the infant makes a spontaneous
expiratory effort, there is a fluidic flip that causes the flow to flip around and to leave
the generator chamber via the expiratory limb (Coanda effect). So, unlike in the other
methods of CPAP where the infant has to exhale against the incoming gas flow, the
fluidic flip of the variable flow devices assist his exhalation thus reducing the work of
breathing.

CPAP pressure generators

Continuous flow devices Variable flow devices

Vary the CPAP pressure by a The desired CPAP level is generated
mechanism by varying the flow

1. Infant ventilator/Stand-alone CPAP Common examples:

machines: 1. Infant flow driver (IFD)
Pressure is generated by the exhalation valve and 2. Viasys SiPAP
adjusted by varying the expiratory orifice size
CPAP pressure is generated at the airway proximal to
2. Bubble CPAP: the infants nares.
Pressure is generated by submerging the

Figure2: Types of CPAP devices

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We use continuous flow CPAP by both conventional ventilators and bubble CPAP
device in our unit.
The advantages and disadvantages of each of these methods are given in Table 1.

Table 1: A comparison of CPAP devices used for pressure generation7

Device Examples Approxima Advantages Disadvantages Remarks

te Cost
(INR)
Conventional Bear Cub, Bird- 5 10 lakhs No need of a Expensive Of practical utility in
ventilator VIP, Draeger separate Standard flow of 5-8L/ units having ventilators
derived Baby log, equipment min may be but not so in a small
CPAP Newport, Can be easily insufficient in the hospital/nursing home
Sechrist, switched over to presence of high leak without a neonatal
Siemens, SLE, mechanical Difficult to know if the ventilator.
etc. ventilation, if set flow is sufficient or
CPAP fails not (insufficient flow
can lead to increased
WOB)

Stand-alone Lectromedik, 25,000 to Economical Most of them do not Though inexpensive,

CPAP Meditrin, 80,000 Useful for small have proper blenders they have not been
machines Phoenix, hospitals and/or pressure tested adequately;
(Indigenous Shreeyash, Can have bubble manometer niggling issues
CPAP) Zeal CPAP option observed during daily
use
Bubble CPAP Indian: Simple and Flow has to be altered It seems unlikely that
Mediserve, 50,000 to inexpensive to ensure proper oscillations delivered at
Meditrin 80,000 Oscillations bubbling the nares are
produced by It is difficult to detect transmitted up to the
Imported: continuous high flow which can alveoli;
Fisher & 1,60,000 bubbling might lead to over distension Still, the stand-alone
Paykel contribute to gas of the lungs option makes it an easy
exchange (akin to and cost effective
HFV) proposition in
Can identify large developing countries
leaks at the nares
(bubbling stops)
Variable flow Arabella, IFD, 3 lakhs Maintains more Expensive On theoretical grounds,
devices Viasys SiPAP uniform pressure Requires more this device scores more
Might decrease technical expertise than the other two;
the WOB However the
Recruits lung prohibitive cost and the
volume more lack of evidence
effectively regarding its
superiority preclude its
widespread use
(WOB, work of breathing; HFV, high frequency ventilation; IFD, infant flow driver)

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Devices used for CPAP delivery (Patient interface)

Various devices used for CPAP delivery include:

1. l)
Nasal prongs (single/double or binasa- Commonly used
2. Long (or) nasopharyngeal prongs
3. Nasal cannulae
4. Nasal masks (Figure 3).

Face mask, endotracheal, and head box are no longer used for CPAP delivery in
neonates. Endotracheal CPAP is not recommended because it has been found to
increase the work of breathing (infant has to breathe through a straw).

The advantages and disadvantages of each of these methods have been summarized
in Table 2.

Figure 3: CPAP delivery systems

Table 2: Advantages and disadvantages of common CPAP delivery systems

Delivery system Advantages Disadvantages Remarks

Nasal prongs Simple device Relatively difficult to fix Studies have shown that
(single/binasal) Lower resistance leads Risk of trauma to nasal they are more effective
Example: to greater septum and turbinates than nasopharyngeal
Argyle transmission of Leak through mouth prongs (in post-extubation
Hudson pressure means end expiration setting)8
IFD prongs Mouth leak acts like a pressure is variable
pop-off mechanism
Nasopharyngeal prongs Easy availability More easily blocked by Though more economical
(e.g. using a cut endotracheal Economical secretions and easily available, they
tube) More secure fixation Likely to get kinked are found to be inferior to

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Length is estimated by short binasal prongs8

measuring the distance from
the earlobe to the tip of the
chin or nose;
Tube placement is confirmed
by direct visualization of the
tip behind the uvula

Nasal cannulae Ease of application Unreliable pressure Mainly tried in apnea of

(with an outer diameter of delivery prematurity paucity of
3mm and flows up to 2 L/min) May need high flows to data in other conditions
generate pressure 9

if only oxygen is used Still experimental

(without air blender)
FiO2 delivered may be
high
Large leaks around the
cannulae

Nasal masks Minimal nasal trauma Difficulty in obtaining an New generation masks are
adequate seal yet to be studied in detail
(IFD, infant flow driver)

In our unit, we use short bi-nasal prongs for delivering CPAP (both ventilator and

bubble CPAP).

INDICATIONS FOR CPAP

The common clinical indications of CPAP have been listed in Panel 1.

Panel 1: Indications for CPAP

Common indications
1. Respiratory distress syndrome (RDS)
2. Apnea of prematurity (especially obstructive apnea)
3. Post-extubation in preterm VLBW infants
4. Transient tachypnea of newborn (TTNB)/delayed adaptation
Other indications
1. Pneumonia
2. Meconium aspiration/ other aspiration syndromes
3. Pulmonary edema/pulmonary hemorrhage
4. Laryngomalacia/ tracheomalacia/ bronchomalacia

Practically, CPAP is very useful in preterm (<35 weeks) infants with respiratory
distress/failure of any etiology. Some of these indications have been briefly described
below:

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1. RDS: The most common indication for CPAP is mild to moderate RDS. It helps
in this condition by preventing collapse of alveoli with marginal stability. The
recruitment of more alveoli helps to increase the FRC thus helping in better
oxygenation (Figure 1). Numerous studies have proved its efficacy in reducing
the need for mechanical ventilation and probably the incidence of chronic lung
disease in infants with RDS.10, 11

CPAP and surfactant: The beneficial effect of CPAP in preterm infants (<29 to 30
weeks) could probably be enhanced by administering surfactant. In this approach, if
respiratory distress progresses even after initiating CPAP, the baby is intubated, given
surfactant, and then extubated and put back on CPAP again. Known as INSURE
(Intubation-Surfactant-Extubation), this approach might further reduce the need for
subsequent ventilation and improve the outcome in extreme preterm infants.12
However, clinical trials have not shown any reduction in the incidence of CLD so far.
More studies are needed to confirm or refute its possible beneficial effects. We do not
routinely employ INSURE technique at present.

2. Apnea of prematurity: The mechanism by which CPAP helps in apnea of

prematurity has been explained before (Figure 1). It is typically used when
clinically significant episodes persist despite optimal methylxanthine therapy.

3. Post-extubation in VLBW infants: CPAP reduces the incidence of apnea,

respiratory acidosis, and increased oxygen requirement in VLBW infants
extubated after a brief period of mechanical ventilation.

4. Delayed adaptation/TTNB: In these conditions associated with excess lung

fluid, CPAP helps by maintaining the lung expansion. Though useful in
premature infants, term and near-term neonates with TTNB often do not
tolerate this mode of respiratory support.

5. Pneumonia: CPAP can be tried in stable infants with mild to moderate

respiratory distress due to pneumonia. It helps in this condition by maintaining
the lung expansion preventing any collapse due to fluids and secretions.

6. Meconium aspiration syndrome: Use of CPAP is a contentious issue in this

condition as most of the infants would already have hyperexpanded lung fields
and CPAP might further aggravate it. Moreover, these term infants are unlikely

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to tolerate CPAP well. It is only indicated in a rare infant with predominant

collapse/atelectasis (preferably proven by chest X-ray).

We use CPAP predominantly in preterm infants (<35 weeks and birth weight <1800g)
with respiratory distress, apnea of prematurity, delayed adaptation, and pneumonia;
also we extubate VLBW infants to CPAP routinely. We occasionally use CPAP in near-
term and term infants with transient tachypnea and pneumonia.

CONTRAINDICATIONS OF CPAP

The important contraindications for CPAP include:

1. Progressive respiratory failure with PaCO2 levels >60 mmHg and/or inability
to maintain oxygenation (PaO2 <50 mmHg)
2. Certain congenital malformations of the airway (choanal atresia, cleft palate,
tracheo esophageal fistula, congenital diaphragmatic hernia, etc.)
3. Severe cardiovascular instability (hypotension)
4. Poor respiratory drive (frequent apnea and bradycardia) that is not improved
by CPAP.

GUIDELINES FOR CPAP THERAPY

When to initiate CPAP?

The timing of initiation of CPAP in preterm infants with respiratory distress needs
further elaboration.
Early CPAP: It is important to note that CPAP helps mainly by preventing the alveolar
collapse in infants with surfactant deficiency. Once atelectasis and collapse have
occurred, CPAP might not help much. Therefore, all preterm infants (<35 weeks) with
any sign of respiratory distress (tachypnea/chest in-drawing/grunting) should be
started immediately on CPAP.
Prophylactic CPAP: Extending this logic, some have advocated use of prophylactic
CPAP (before the onset of respiratory distress) in preterm VLBW infants as majority of
them would eventually develop respiratory distress. However, there is no evidence for
any additional benefit with this approach; indeed, there are concerns regarding

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increased adverse effects such as intraventricular hemorrhage. Hence, prophylactic

CPAP is NOT recommended at present.13

How to set up a CPAP apparatus?

The steps in setting-up a bubble CPAP are summarized in Panel 2.

How to fix the CPAP delivery system (nasal cannula)

The most difficult aspect of using nasal CPAP is the positioning and fixation of the
patient interface. The optimal technique of fixation depends on the type of delivery
system used; the exact technique used does not matter as long as the device is
secure and not traumatizing.

Short binasal prongs: It is important to choose the appropriate sized prong that
snugly fits in the nasal cavity to avoid a significant leak. However, to avoid causing
any injury, it should be fixed straight and not pressed hard against the nasal septum.
We use a modified cap (made from adult cotton socks) and tapes to secure the
binasal prongs (Figure 4).

Steps of initiation and nursing care before and during CPAP

The steps of initiation and nursing care during CPAP therapy are given in Panel 2.

PROTOCOL FOR CPAP THERAPY

Protocol for CPAP therapy in the three most common clinical indications is given in
Table 3.

MONITORING WHILE ON CPAP

The following parameters need to be monitored while the infant is on CPAP:

1. Continuous monitoring of respiratory rate, heart rate, SpO2

2. Serial monitoring of
a. Severity of respiratory distress by using Downes or Silverman score
b. Arterial blood gases (ABGs)
c. Perfusion - CFT, BP, peripheral pulses, urine output
d. Abdominal girth

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The target saturation and blood gases during CPAP therapy are: SpO2 - 90-93%;
PaO2 50 to 70 mmHg; PaCO2 45 to 50 mmHg

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Panel 2: Steps of Initiation and Nursing Care during CPAP7

A. How to set-up a bubble CPAP?

1. Connect the air and oxygen tubing (pressurized gases from either central manifold or from
compressor and oxygen cylinder respectively)
2. Attach both to the air-oxygen blender
3. Set the flow using flow meter (usually at 5-8 L/min)
4. Set up the inspiratory limb:
a. From the flow meter to the humidifier and
b. From the humidifier to the patient end (e.g. nasal cannula); fill water in the humidifier and
humidify the gases to 34-370C.
5. Set up the expiratory limb - from the patient end to a chamber filled with sterile water.
Immerse it under the water up to the required depth (which is determined by the intended
pressure - e.g. to deliver 5 cm H20, immerse up to 5 cm mark in the tube).
6. Attach a pressure manometer at the patient end

7. Set required pressure and FiO2, low pressure alarm and apnea alarm
8. Occlude the patient end of the ventilator circuit with your palm and observe if:
a. Bubbling occurs in the water chamber - If there are no bubbles, look for any leak in the
circuit; if no leak is found, increase the flow by 1 L/min and recheck.
b. The set pressure is delivered (see the manometer reading) - If it is less than the set
pressure, look for any leaks in the circuit/around the cannula. If no leak is found,
increase the flow and recheck.

B. Initiation of CPAP
1. Place a roll under infants shoulder to slightly extend the neck
2. Application of prongs:
a. Choose the correct size prong (the prongs should fill the nasal opening without
stretching the skin)
b. Apply a thin strip of Tegaderm on overlying skin of septum
c. Place the prongs with the curve downwards and fix as shown in Figure 4.
3. Attach the patient end of the ventilator circuit to the cannula
4. Attach a pulse-oximeter to the infant

C. Nursing Care
1. Monitor the infant frequently (see text); observe if the baby is comfortable

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2. Pass an orogastric tube. Keep the proximal end of tube open. If the infant is being fed while on
CPAP, close the tube for half an hour after giving feeds and keep it open for the next 90
minutes (if fed 2hourly).
3. Do regular but gentle nasal suction to clear the mucus 4 hourly or as and when required.
4. Clean the nasal cannula and check its patency once per shift.
5. Change the infants position regularly every 2-4 hours and check the skin condition frequently
for redness and sores.

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Choose an adult cotton sock

Mark 3- 4 lines with a pencil (according to the required

size)

Cut along the dotted line

(One end has to be stitched for the other 2 pieces)

Stitch the edges (to make them smooth)

Make two holes at the sides (to attach the tapes)

Attach tapes to these holes

Fix the cannula using the tapes as shown

Figure 4: Steps in fixation of CPAP nasal cannula

HAZARDS/COMPLICATIONS OF CPAP
CPAP though less invasive and generally safer than IMV, is not free of side effects.

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1. Pulmonary air leaks are probably the most important clinically significant
adverse effect of CPAP.14 It occurs following over distension of the lungs caused
by inappropriately high pressures. They tend to occur when the lung
compliance starts improving and the oxygen requirements also show a
reduction. One has to note that the two recent trials on CPAP for RDS have
shown either a trend or a definite increase in the incidence of pneumothorax.15,
16
Therefore, extra vigilance is required during CPAP therapy.
2. Decreased cardiac output due to reduction in the venous return, decreased
right ventricular stroke volume, and altered dispensability of left ventricle.17
This effect can be minimized by using optimal CPAP and achieving adequate
intravascular volume.
3. Impedance of pulmonary blood flow with increased pulmonary vascular
resistance (with inappropriately high CPAP pressure)
4. Gastric distension and CPAP belly syndrome. These complications are rarely
seen nowadays. The risk is further minimized by routine use of orogastric tube.
5. Nasal irritation, damage to the septal mucosa, or skin damage and necrosis
from the fixing devices.

Table 3 Protocol for CPAP therapy in the three common neonatal conditions

Indications
RDS Apnea of prematurity Post extubation

Apnea of prematurity
Post extubation
How to initiate
CPAP?
Pressure Start at 5cm H2 O Start at 4cm H2 O Start at 4-5cm H2 O
FiO2 0.5 (titrate based on SpO2 ) 0.21-0.4 (as decided by 0.05 to 0.1 above the
SpO2 ) pre-extubation FiO2
What to do if
there is no
improvement? Increase in steps of 1-2cm H2 O to Increase up to 5cm H2 O Increased in steps of
Pressure reach a maximum of 7-8 cm H2 O (further increase is not 1-2cm H2 O to reach a
warranted usually in this maximum of 7-8cm H2 O
condition - may lead to
Increase in steps of 0.05 (if hyperinflation) Increase in steps of
FiO2 oxygenation is still compromised) up FiO2 increase does not help 0.05 to a maximum of
to a maximum of 0.8 much 0.8
Failure of CPAP Worsening respiratory distress (as Recurrent episodes of apnea Same as for RDS
indicated by Silverman scoring) and/or requiring PPV
hypoxemia (PaO2 <50mmHg) / hypercarbia
(PaCO2 >60mmHg) despite CPAP pressure
of 7-8 cm H2 O and FiO2 of 0.8
(Likely to occur in infants with (Likely to occur in ELBW

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(Likely to occur in infants with severe RDS, central apneas sepsis ) infants and in sepsis /
associated sepsis, and in ELBW infants pneumonia, PDA,
who have not received ANS) metabolic acidosis, and
collapse)

Weaning from
CPAP
When to When there is no respiratory distress No episodes of Same as for RDS
wean and SpO2 / blood gases are normal apnea/desaturation /
Reduce FiO2 in steps of 0.05 to 0.4, bradycardia for atleast
How to wean then decrease pressure in steps of 12-24 has hrs
1-2cm H2 O until 3-4 cm H2 O (infants Same as for RDS
clinical condition will guide the speed
of weaning)

CONCLUSION

CPAP has been well established as the first line therapy in the management of
respiratory distress in preterm VLBW infants. It helps by preventing alveolar collapse,
maintaining airway stability and stabilizing the chest wall. Various devices, both for
pressure generation and for delivery of CPAP, are available for use in neonates. The
advantages and disadvantages of each device, method of fixation of short binasal
prongs, and a protocol for initiation of CPAP have been discussed in this protocol.

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References

1. Sankar MJ, Deorari AK. CPAP A gentler mode of ventilation. J Neonatol 2007;
21:160-5
2. Upadhyay A, Deorari AK. Continuous positive airway pressure - a gentler
approach to ventilation. Indian Pediatr 2004;41:459-69
3. Gregory GA, Kitterman JA, Phibbs RH, et al: Treatment of idiopathic respiratory
distress syndrome with continuous positive airway pressure. N Engl J Med
1971;284:333-40
4. Kattwinkel J, Nearman HS, Fanaroff AA, Katona PG, Klaus MH. Apnea of
prematurity. Comparative therapeutic effects of cutaneous stimulation and nasal
continuous positive airway pressure. J Pediatr 1975;86:588-92
5. Avery ME, Tooley WH, Keller JP, et al. Is chronic lung disease in low birth weight
infants preventable? A survey of eight centers. Pediatrics 1987;79:26-30
6. Courtney SE, Barrington KJ.Continuous positive airway pressure and noninvasive
ventilation. Clin Perinatol. 2007;34:73-92
7. Anonymous. Continuous Positive Airway Pressure Machines. In: Deorari AK, Paul VK
(eds). Neonatal Equipment. 3rd edn. New Delhi: Sagar Publications 2006: p 129-137
8. De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for
administration of nasal continuous positive airway pressure (NCPAP) in preterm
neonates. Cochrane Database of Syst. Rev. 2002: CD002977.
9. Sreenan C, Lemke RP, Hudson-Mason A, et al. High-flow nasal cannulae in the
management of apnea of prematurity: a comparison with conventional nasal
continuous positive airway pressure. Pediatrics 2001;107:10813
10. Gittermann MK, Fusch C, Gittermann AR, Regazzoni BM, Moessinger AC. Early
nasal continuous positive airway pressure treatment reduces need for intubation
in very low birth infants. Eur J Pediatr 1997;156:384-8
11. Poets CF, Sens B. Changes in intubation rates and outcome of VLBW -a population
based study. Pediatrics 1996;98:24-7
12. Verder H, Robertson B, Greisen G, Ebbesen F, Albertsen P, Lundstron JT. Surfactant
therapy and nasal continuous positive airway pressure for newborns with
respiratory distress syndrome. Danish-Swedish Multicentre Study Group. N Engl J
Med 1994; 331: 1051-5.

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13. Subramaniam P, Henderson-Smart DJ, Davis PG. Prophylactic nasal continuous

positive airways pressure for preventing morbidity and mortality in very preterm
infants. Cochrane Database of Syst.Rev.2005: CD001243.
14. Hall RT, Rhodes PG: Pneumothorax and pneumomediastinum in infants with
idiopathic respiratory distress syndrome receiving CPAP. Pediatrics 55: 493, 1975.
15. Buckmaster AG, Arnolda G, Wright IM, Foster JP, Henderson-Smart DJ. Continuous

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 Jaundice in the Newborns

Jaundice is the most common morbidity in the first week of life, occurring in 60% of term and 80% of
preterm newborn. Jaundice is the most common cause of readmission after discharge from birth
hospitalization.1

Jaundice in neonates is visible in skin and eyes when total serum bilirubin (TSB) concentration exceeds 5
to 7 mg/dL. In contrast, adults have jaundice visible in eyes (but not in skin) when TSB concentration
exceeds 2 mg/dL. Increased TSB concentration in neonate results from varying contributions of three
factors namely increased production from degradation of red cells, decreased clearance by the
immature hepatic mechanisms and reabsoption by enterohepatic circulation (EHC).

High serum bilirubin levels carry a potential to cause neurological impairment with serious
consequences in a small fraction of jaundiced babies. In most cases, jaundice is benign and no
intervention is required. Approximately 5-10% of them have clinically significant jaundice that require
treatment to lower serum bilirubin levels in order to prevent neurotoxicity.

Physiological versus pathological jaundice

Jaundice attributable to physiological immaturity of neonates to handle increased bilirubin production is

termed as physiological jaundice. Visible jaundice usually appears between 24 to 72 hours of age. TSB
level usually rises in term infants to a peak level of 12 to 15 mg/dL by 3 days of age and then falls. In
preterm infants, the peak level occurs on the 3 to 7 days of age and TSB can rise over 15 mg/dL. It may
take weeks before the TSB levels falls under 2 mg/dL in both term and preterm infants.

Pathological jaundice is said to be present when TSB concentrations are not in physiological jaundice
range, which is defined arbitrarily and loosely as more than 5 mg/dL on first day, 10 mg/dL on second
day, and 12-13 mg/dL thereafter in term neonates.2 Any TSB value of 17 mg/dL or more should be
regarded as pathologic and should be evaluated for the cause, and possible intervention, such as
phototherapy.3

It may be noted that the differentiation between pathological and physiological is rather arbitrary,
and is not clearly defined. Presence of one or more of following conditions would qualify a neonate to
have pathological jaundice2:

1. Visible jaundice in first 24 hours of life. However slight jaundice on face at the end of first day
(say 18 to 24 hr) is common and can be considered physiological.
2. Presence of jaundice on arms and legs on day 2
3. Yellow palms and soles anytime
4. Serum bilirubin concentration increasing more than 0.2 mg/dL/hour or more than 5 mg/dL in 24
hours
5. If TSB concentration more than 95th centile as per age-specific bilirubin nomogram
6. Signs of acute bilirubin encephalopathy or kernicterus
7. Direct bilirubin more than 1.5 to 2 mg/dL at any age
8. Clinical jaundice persisting beyond 2 weeks in term and 3 weeks in preterm neonates
Causes of pathological jaundice

Common causes of pathological jaundice include:

1. Hemolysis: blood group incompatibility such as those of ABO, Rh and minor groups, enzyme
deficiencies such as G6PD deficiency, autoimmune hemolytic anemia
2. Decreased conjugation such as prematurity
3. Increased enterohepatic circulation such as lack of adequate enteral feeding that includes
insufficient breastfeeding or the infant not being fed because of illness, GI obstruction
4. Extravasated blood: cephalhematoma, extensive bruising etc

Clinical assessment of jaundice

The parents should be counselled regarding benign nature of jaundice in most neonates, and for
the need to be watchful and seek help if baby appears too yellow. The parents should be
explained about how to see for jaundice in babies (in natural light and without any yellow
background).

Visual inspection of jaundice (Panel 1) is believed to be unreliable, but if it is performed properly

(ie examining a naked baby in bright natural light and in absence of yellow background), it has
reasonable accuracy particularly when TSB is less than 12 to 14 mg/dL or so. Absence of
jaundice on visual inspection reliably excludes the jaundice. At higher TSBs, visual inspection is
unreliable and, therefore, TSB should be measured to ascertain the level of jaundice.4

All the neonates should be examined at every opportunity but not lesser than every 12 hr until
first 3 to 5 days of life for occurrence of jaundice. The babies being discharged from the hospital
at 48 to 72 hours should be seen again after 48 to 72 hours of discharge.

The neonates at higher risk of jaundice should be identified at birth and kept under enhanced
surveillance for occurrence and progression of jaundice. These infants include5:

o Gestation<38 wk
o Previous baby with significant jaundice
o Visible jaundice in first 24 hr
o Age specific TSB level being above 95th centile (if measured)

Inadequacy of breastfeeding is a common cause of exaggerated jaundice during initial few days
(breastfeeding jaundice). Breastfeeding problems such as improper positioning and attachment,
cracked or sore nipple, engorgement, perceived inadequacy of milk production are very
common and require intense and sustained support from health professionals caring mothers
and babies. Breastfeeding support must include, in addition to providing adequate information,
actual helping the mothers to learn proper positioning and attachment, and adequate measures
to address breastfeeding problems.
Panel 1 Visual inspection of jaundice
1. Examine the baby in bright natural light. Alternatively, the baby can be examined in white
fluorescent light. Make sure there is no yellow or off white background.
2. Make sure the baby is naked.
3. Examine blanched skin and gums, and sclerae
4. Note the extent of jaundice (Kramers rule)6
o Face 5-7 mg/dL
o Chest 8-10 mg/dL
o Lower abdomen/thigh 12 -15 mg/dL
o Soles/Palms >15 mg/dL
5. Depth of jaundice (degree of yellowness) should be carefully noted as it is an important indicator
of level of jaundice and it does not figure out in Karmers rule.

A deep yellow staining (even in absence of yellow soles or palms) is often associated with sever
jaundice and therefore TSB should be estimated in such circumstances.

Measurement of serum bilirubin

1. Transcutaneus bilirubinometry (TcB)4

a. TcB is a useful adjunct to TSB measurement, and routine employment of TcB can
reduce need for blood sampling by nearly 30%. However, current devices are costly and
has a significant recurring cost of consumables such as disposable tips etc.

b. TcB can be used in infants of 35 weeks or more of gestation after 24 hr. TcB is unreliable
in infants less than 35 weeks gestation and during initial 24 hr of age. TcB has a good
correlation with TSB at lower levels, but it becomes unreliable once TSB level goes
beyond 14 mg/dL.

c. Hour specific TcB can be used for prediction of subsequent hyperbilirubinemia. TcB
value below 50th centile for age would rule out the risk of subsequent
hyperbilirubinemia with high probability (high negative predictive value)7

d. Trends in TcB values by measuring 12 hr apart would have a better predictive value than
a single value.8

e. We routinely perform TcB measurement in infants of 35 wk or more gestation to screen

for hyperbilirubinemia. A TcB value of greater than 12 to 14 mg/dL is confirmed by TSB
measurement.
 2. Measurement of TSB

a. Indication of TSB measurement:

i. Jaundice in first 24 hour
ii. Beyond 24 hr: if visually assessed jaundice is likely to be more than 12 to 14
mg/dL (as beyond this TSB level, visual assessment becomes unreliable) or
approaching the phototherapy range or beyond.
iii. If you are unsure about visual assessment
iv. During phototherapy, for monitoring progress and after phototherapy to check
for rebound in select cases (such as those with hemolytic jaundice)

b. Frequency of TSB measurement depends upon the underlying cause (hemolytic versus
non-hemolytic) and severity of jaundice as well as host factors such as age and
gestation. In general, in nonhemolytic jaundice in term babies with TSB levels being
below 20 to 22 mg/dL, TSB can be performed every 12 to 24 hr depending upon age of
the baby. As opposed to this, a baby with Rh isoimmunisation would require TSB
measurement every 6 to 8 hours during initial 24 to 48 hours or so.

c. Methods of TSB measurements

i. Biochemical: High performance liquid chromatography (HPLC) remains the gold

standard for estimation of TSB. However, this test is not universally available
and laboratory estimation of TSB is usually performed by Vanden Bergh
reaction. It has marked interlaboratory variability with coefficient of variation
being up to 10 to 12 percent for TSB and over 20 percent for conjugated
fraction.10
ii. Micro method for TSB estimation: It is based on spectrophotometry and
estimates TSB on a micro blood sample. It is useful in neonates, as bilirubin is
predominantly unconjugated.

Approach to a jaundiced neonate:

A step wise approach should be employed for managing jaundice in neonates (Figure 1).

All the neonates should be visually inspected for jaundice every 12 hr during initial 3 to 5 days of life.
TcB can be used as an aid for initial screening of infants. Visual assessment (when performed properly)
and TcB have reasonable sensitivity for initial assessment of jaundice.

As a first step, serious jaundice should be ruled out. Phototherapy should be initiated if the infant meets
the criteria for serious jaundice. TSB should be determined subsequently in these infants to determine
further course of action.

Though recommended by AAP5, screening of all infants with TSB in order to predict the risk of
subsequent hyperbilirubinemia does not seem to be a feasible option in resource restricted settings.
 Figure 1: Approach to an infant with jaundice

Perform visual assessment (VA) of jaundice: every 12 h during initial 3 to 5 days of life.
VA can be supplemented with transcutneous bilirubinometry (TcB), if available

Step 1: Does the baby have serious jaundice*?

Yes No

Start
phototherapy Step 2: Does the infant have significant jaundice to
require TSB measurement#?

Yes No

Measure TSB level and determine if baby requires Continued observation every
phototherapy or exchange transfusion (refer to Table 1) 12 to 24 hr for initial 3 to 5
days

Step 3: Determine the cause of jaundice

(Table 2) and provide supportive and
follow up care

* #
Serious jaundice: Measure serum bilirubin if:
a. Presence of visible jaundice in first 24 h a. Jaundice in first 24 hour
b. Yellow palms and soles anytime b. Beyond 24 hr: if on visual assessment or by transcutenous
c. Signs of acute bilirubin encephalopathy or kernicterus: bilirubinometry, TSB is likely to be more than 12 to 14
hypertonia, abnormal posturing such as arching, mg/dL or approaching phototherapy range or beyond.
retrocollis, opisthotonus or convulsion, fever, high c. If you are unsure about visual assessment
pitched cry)
th
d. TcB value more than 95 centile as per age specific
nomogram
Management of jaundice

1. Infants born at gestation of 35 weeks or more

American Academy of Paediatrics (AAP) criteria should be used for making decision regarding
phototherapy or exchange transfusion in these infants.5 AAP provides two age-specic
nomograms- one each for phototherapy and exchange transfusion. The nomograms have lines
for three different risk categories of neonates (Figure 2 and 3). These lines include one each for
for lower risk babies (38 wk or more and no risk factors), medium risk babies (38 wk or more
with risk factors, or 35 wk to 37 wk and without any risk factors) and higher risk (35 wk to 37 wk
and with risk factors).

TSB value is taken for decision making and direct fraction should not be reduced from it. As a
rough guide, phototherapy is initiated if TSB vales are at or higher than 10, 13, 15 and 18 mg/dL
at 24, 48, 72 and 96 hours and beyond, respectively in babies at medium risk. The babies at
lower and higher risk have their cut-offs at approximately 2 mg/dL higher or 2 mg/dL lower than
that for medium risk babies, respectively.

Risk factors include presence of isoimmune hemolytic anemia, G6PD deficiency, asphyxia,
temperature instability, hypothermia, sepsis, significant lethargy, acidosis and
hypoalbuminemia.

Figure 2. AAP nomogram for phototherapy in hospitalized infants of 35 or more weeks gestation.5
Figure 3 depicts nomogram for exchange transfusion in three risk categories of babies. Any baby
showing signs of bilirubin encephalopathy such as hypertonia, retrocollis, convulsion, fever etc should
receive exchange transfusion without any delay.

Figure 3. AAP nomogram for exchange transfusion in infants 35 or more weeks gestation.5
 2. Preterm babies

There are no consensus guidelines to employ phototherapy or exchange transfusion in preterm

babies. The proposed TSB cut-offs for phototherapy and exchange transfusion are arbitrary and
clinical judgement should be exercised before making a decision (Table 1).

Table 1 Phototherapy and exchange transfusion cut-offs for preterm babies9

Total serum bilirubin (mg/dL)

Birth weight Healthy baby Sick baby

Phototherapy Exchange Phototherapy Exchange

transfusion transfusion
<1000 gm 5-7 11-13 4-6 10-12

1001-1500 gm 7-10 13-15 6-8 11-13

1501-2000 gm 10-12 15-18 8-10 13-15

2001-2500 gm 12-15 18-20 10-12 15-18

Therapeutic options

1. Phototherapy
Phototherapy (PTx) remains the mainstay of treating hyperbilirubinemia in neonates. PTx is
highly effective and carries an excellent safety track record of over 50 years. It acts by
converting insoluble bilirubin (unconjugated) into soluble isomers that can be excreted in urine
and feces. Many review articles have provided detailed discussion on phototherapy related
issues. The bilirubin molecule isomerizes to harmless forms under blue-green light (460 to 490
nm); and the light sources having high irradiance in this particular wavelength range are more
effective than the others.

Types of phototherapy lights

The phototherapy units available in the market have a variety of light sources that include
florescent lamps of different colors (cool white, blue, green, blue-green or turquoise) and
shapes (straight or U-shaped commonly referred as compact florescent lamps ie CFL), halogen
bulbs, high intensity light emitting diodes (LED) and fibro-optic light sources.

With the easy availability and low cost in India, CFL phototherapy is being most commonly used
device. Often, CFL devices have four blue and two white (for examination purpose) CFLs but this
combination can be replaced with 6 blue CFLs in order to increase the irradiance output.

In last couple of years, blue LED is making inroads in neonatal practice and has been found to at
least equally effective. LED has advantage of long life (up to 50,000 hrs) and is capable of
delivering higher irradiance than CFL lamps.

Fiber-optic units can be used to provide undersurface phototherapy in conjugation with

overhead CFL/LED unit to enhance the efficacy of PTx but as a standalone source, fiber-optic
unit is lesser effective than CFL/LED unit.

It is important that a plastic cover or shield be placed before phototherapy lamps to avoid
accidental injury to the baby in case a lamp breaks.

Maximizing the efficacy of phototherapy

The irradiance of PTx lights should be periodically measured, and a minimum level of 30
W/cm2/nm in the wavelength range of 460 to 490 nm must be ensured. As the irradiance
varies at different points on the footprint of a unit, it should be measured at several points. The
lamps should be changed if the lamps are flickering or ends are blackened, if irradiance falls
below the specified level or as per the recommendation of manufacturers.

Expose maximal surface area of the baby. Avoid blocking the lights by any equipment (say
radiant warmer), a large diaper or eye patch, a cap or hat, tape, dressing or electrode etc.
ensure good hydration and nutrition of the baby. Make sure that light falls on the baby
perpendicularly if the baby is in incubator. Minimize interruption of Ptx during feeding sessions
or procedures.
 Administering phototherapy

Make sure that ambient room temperature is optimum (250 to 280) to prevent hypothermia or
hyperthermia in the baby. Remove all clothes of the baby except the diaper. Cover the babys
eyes with patches, ensuring that the patches do not block the babys nostrils. Place the naked
baby under the lights in a cot or bassinet if weight is more than 2 kg or in an incubator or radiant
warmer if the baby is small (<2 kg).

Keep the distance between baby and light 30 to 45 cm (or as per manufacturer
recommendation).

Ensure optimum breastfeeding. Baby can be taken out for breastfeeding sessions and the eye
patch can be removed for better mother-infant interaction. However, minimize interruption to
enhance effectiveness of phototherapy. There is no need to supplement or replace breast milk
with any other types of feed or fluid (e.g. breast-milk substitute, water, sugar water, etc.)

Monitoring & stopping phototherapy

Monitor temperature of the baby every 2 to 4 hr. Measure TSB level every 12 to 24 hours.
Discontinue PTx once two TSB values 12 hr apart fall below current age specific cut offs. The
infant should be monitored clinically for rebound bilirubin rise within 24 hours after stopping
phototherapy for babies with hemolytic disorders.

Role of sunlight
Exposing the baby to sunlight does not help in treatment of jaundice and is associated with risk
of sunburn and therefore should be avoided.

2. Exchange transfusion

Double volume exchange transfusion (DVET) should be performed if the TSB levels reach to age
specific cut-off for exchange transfusion or the infant shows signs of bilirubin encephalopathy
irrespective of TSB levels.

Indications for DVET at birth in infants with Rh isoimmunization include:

1. Cord bilirubin is 5 mg/dL or more

2. Cord Hb is 10 g/dL or less

At birth, if a baby shows signs of hydrops or cardiac decompensation in presence of low PCV
(<35%), partial exchange transfusion with 50 mL/kg of packed cells should be done to quickly
restore oxygen carrying capacity of blood.

The ET should be performed by pull and push technique using umbilical venous route. Umbilical
catheter should be inserted just enough to get free flow of blood.
 Table 2: Type and volume of blood for exchange transfusion
SN Condition Type of blood
1 Rh isoimmunization Rh negative and blood group O or that of baby
Suspended in AB plasma
Cross matched with babys and mothers blood
2 ABO incompatibility Rh compatible and blood group O (Not that of baby)
Suspended in AB plasma
Cross matched with babys and mothers blood
3 Other conditions (G6PD Babys group and Rh type
deficiency, non-hemolytic, Cross matched with babys and mothers blood
other isoimmune
hemolytic jaundice
Volume of blood: Twice the blood volume of baby (total volume: 160 to 180 mL/kg)
To prepare blood for DVET, mix two thirds of packed cells and one-third of plasma

3. Intravenous immunoglobulins (IVIG)

IVIG reduces hemolysis and production of jaundice in isoimmune hemolytic anemia (Rh
isoimmunisation and ABO incompatibility) and thereby reduces the need for phototherapy and
exchange transfusion.

We give IVIG (0.5 to 1 gm/kg) in all cases of Rh isoimmunisation and selected case of ABO
incompatibility with severe hemolysis. IVIG administration can cause intestinal injury and
necrotizing enterocolitis.

4. IV hydration
Infants with severe hyperbilirubinemia and evidence of dehydration (e.g. excessive weight loss)
should be given IV hydration. An extra fluid of 50 mL/kg of N/3 saline over 8 hr decreases the
need for exchange transfusion.11

5. Other agents

There is no proven evidence of benefit of drugs like phenobarbitone, clofibrate, or steroids to

prevent or treat hyerbilirubinemia in neonates and therefore these agents should not be
employed in treatment of jaundiced infants.

Prolonged jaundice

There is no good definition of prolonged jaundice (PJ). Generally, persistence of significant jaundice for
more than 2 wk in term and more than 3 weeks in preterm babies is taken as PJ. Though, it is not
uncommon to see persistence of mild jaundice in many infants for 4 to 6 weeks of age. Most of these
babies do well without any specific intervention or investigation.
The first and foremost step to manage an infant with PJ is to rule out cholestasis (Figure 2). Yellow
colored urine is a reasonable marker for cholestasis; however the urine color could be normal during
initial phase of cholestasis. For the practical purpose, an infant with PJ with normal colored urine can be
considered to have unconjugated hyperbilirubinemia. If the infant has dark colored urine, the infant
should be managed as per cholestasis guidelines.

Infants with true PJ (unconjugated hyperbilirubinemia) should be assessed clinically for severity and
possible cause of prolongation of jaundice (Table 3). If the clinical assessment of jaundice suggests TSB
levels below phototherapy cut offs for age (say <15 to 18 mg/dL in term infant), the infant may not be
subjected to any unnecessary investigations. As many of these infants have PJ as a result of inadequate
feeding, appropriate measures are taken to optimize breastfeeding. Thyroid screen can be considered in
such infants at this stage if routine metabolic screen for hypothyroidism has not been carried out at
birth.

If baby appears significant jaundice at this stage, TSB level should be performed and possible underlying
cause should be looked for. In such infants, G6PD level, thyroid screen, ABO of infant & mother if not
done earlier should performed to delineate possible cause.

Infants having TSB in phototherapy range should be started on phototherapy. The adequacy of
breastfeeding should be assessed by history, observation of breastfeeding session, and degree of weight
loss. Many of the mothers, even at this stage, have persisting breastfeeding problems such as poor
attachment, sore nipple etc.

Breast mild jaundice (BMJ) is relatively a common cause of jaundice, but, inadequacy of breastfeeding
being more common than it should be carefully ruled out. BMJ being an innocuous entity, cessation of
breastfeeding is not required in practically any case. Infants with BMJ should be treated with
phototherapy, if required. For a rare infant with TSB hovering in exchange range, a brief trial of
interruption of breastfeeding can be considered. We havent stopped breastfeeding even for once for
treatment of BMJ in last 15 years!

In an infant failing to respond to these measures, a diagnosis of CNS should be entertained. A trial of
phenobarbitone can be considered to establish the diagnosis.
Table 3: Causes of prolonged jaundice

Common
1. Inadequacy of breastfeeding
2. Breast milk jaundice
3. Cholestasis
4. Continuing hemolysis eg Rh, ABO and G6PD hemolysis

Rare
1. Extravasated blood eg cephalhematoma
2. Hypothyroidism
3. Criggler Najjar Syndrome
4. GI obstruction such as malrotation
5. Gilbert syndrome
 Figure 2: Approach to a neonate with prolonged jaundice

Persistence of jaundice >2 wk in term & >3 wk in preterm babies

Check if the infant is passing high colored urine

(staining nappies)

If yes: manage as per If No:

cholestasis guidelines 1. Visually assess severity of jaundice (measure TSB, if required)
2. Assess for and manage inadequate breastfeeding
3. Perform clinical examination to ascertain the cause:
extravasated blood, hemolysis, hypothyroidism1

Level of jaundice/TSB not in PTx range: TSB in PTx range:

Manage conservatively Initiate PTx
Follow up as needed until resolution of Perform: G6PD, thyroid screen, ABO of infant &
jaundice mother, if not done earlier

TSB persistently high, unresponsive to PTx and hovering

in exchange range: consider cessation of breastfeeding
for 48 h (required in exceptional cases only)
TSB persistent high despite PTx/cessation of
breastfeeding: consider phenobarbitone trial to rule
out CNS

1
thyroid screen can be considered at this stage
TSB: total serum bilirubin; CNS: Crigglar Najjar syndrome; PTx: phototherapy
Research issues relevant to Indian context are outlined in Table 4.

Table 4: Research issues in neonatal jaundice

S Research Subjects Study Intervention Outcomes to be
N question/ design measured
objective
s
1. What is Neonates with Randomiz Gp 1: Safety and
efficacy non-hemolytic ed trial The infant is feasibility
and jaundice (TSB discharged and outcomes: ability of
safety of well below home the family to
home exchange phototherapy is manage,
photothe transfusion provided temperature of
rapy? range) baby, familys
Gp 2: photoherapy perceptions, any
in the hospital mishaps
Efficacy outcomes:
failure of
phototherapy,
duration of
phototherapy
2. Ability of Neonates with Diagnosti Test: visual Sensitivity;
parents jaundice (all c test in a estimation of specificity and
to severity level) cohort jaundice by the likelihood ratios
correctly parents
detect
significan Gold standard:
t jaundice visual estimation of
jaundice by the
paediatrician & TSB

3. To Neonates with Randomiz Gp 1: fibroptic failure of

compare non-hemolytic ed trial phototherapy phototherapy,
efficacy jaundice (TSB duration of
of well below Gp 2: conventional phototherapy and
fibroptic exchange Ptx rate of bilirubin
with transfusion decline
conventio range)
nal (CFL)
Ptx
4. To Neonates with Randomiz Gp 1: double failure of
compare non-hemolytic ed trial surface phototherapy,
efficacy jaundice (TSB phototherapy duration of
of . well below phototherapy and
double exchange Gp 2: single surface rate of bilirubin
surface vs transfusion Ptx decline
single range)
surface
Ptx
5. Do the Neonates with Cohort Gp 1: Neonates Duration of
babies cry non-hemolytic study with non-hemolytic phototherapy
more jaundice and jaundice
often gestation and Gp 2: Gestation and
under postnatal-age postnatal-age
photothe matched matched neonates
rapy? neonates without
without hyperbilirubinemia
 hyperbilirubin
emia
6. Temperat Neonates with Cohort None Measurement of
ure hyperbilirubin study ambient and babys
variation emia temperature every
under undergoing 2 to 4 hr
different phototherapy
Photothe with different
rapy types of
devices phototherapy
devices
(staright
lamps, CFL,
LED, halogen
lamp)
7. Efficacy Neonates with Randomiz Experiment 1 failure of
of non-hemolytic ed trial Gp 1: Intermittent phototherapy,
intermitte jaundice phototherapy (2 hr duration of
nt vs. on and 2 hr off) phototherapy and
continuo Gp 2: Continuous rate of bilirubin
us ptx phototherapy decline
without any off
period
Experiment 2
Gp 1: Continuous
phototherapy
during day time
and no
phototherapy
during night time
(2100 to 0600 hrs)
Gp 2: Continuous
phototherapy
without any off
period

8. Efficacy Neonates with Randomiz Gp 1: turquoise failure of

of blue non-hemolytic ed trial light phototherapy phototherapy,
green jaundice (TSB duration of
(turquois well below Gp 2: blue light phototherapy and
e) vs. blue exchange phototherapy rate of bilirubin
ptx transfusion decline
range)
9. Predictor Neonates with Cohort Monitor the infants
s of ABO settings study for presence and
jaundice (mother being absence of risk
in ABO O and baby factors (
settings either A or B
10. Single vs. Neonates with Randomiz Gp 1: PTx stopped Need for re-
two non-hemolytic ed trial when one TSB initiation of
values jaundice value is below age phototherapy
below specific cut-off Duration of
cut-offs phototherapy
for Gp 2: PTx stopped Rate of
stopping when two bilirubin
PTx consecutive TSB decline
values are below
 age specific cut-off

11. What is Late preterm Cohort Measure birth Follow the infants
populatio and term study weight and weight for development of
n neonates and 72 h precisely hyperbilirubinemia
attributab to calculate %
le risk of weight loss. Collect Calculate adjusted
feeding info on other risk odds ratio,
inadequa factors such as attributable risk
cy for oxytocin use, and population
hyperbilir cephalhematoma, attributable risk for
ubinemia blood group feeding inadequacy,
in incompatibility,
jaundice G6PD deficiency,
mutations,
ethnicity and
others.
References

1. Young Infants Clinical Signs Study Group. Clinical signs that predict severe illness in children under age 2
months: a multicentre study. Lancet 2008;371:135-42.

2. Madan A, Mac Mohan JR, Stevenson DK.Neonatal Hyperbilrubinemia. In: Averys Diseases of the
Newborn. Eds: Taeush HW, Ballard RA, Gleason CA. 8th edn; WB Saunders., Philadelphia, 2005: pp 1226-
56.

3. Maisels MJ, Gifford K: Normal serum bilirubin levels in newborns and effect of breast-feeding. Pediatrics
78:837-43, 1986.

4. Rennie J, Burman-Roy S, Murphy MS; Guideline Development Group. Neonatal jaundice: summary of NICE
guidance. BMJ. 2010 May 19;340:c2409. doi:10.1136/bmj.c2409.

5. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of

hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;114:297-316.

6. Kramer LI. Advancement of dermal icterus in jaundiced newborn. Am J Dis Child 1969;118:454-8.

7. Kaur S, Chawla D, Pathak U, Jain S. Predischarge non-invasive risk assessment for prediction of significant
hyperbilirubinemia in term and late preterm neonates. J Perinatol. 2011 Nov 17. doi:
10.1038/jp.2011.170.

8. Dalal SS, Mishra S, Agarwal R, Deorari AK, Paul V. Does measuring the changes in TcB value offer better
prediction of Hyperbilirubinemia in healthy neonates? Pediatrics 2009;124:e851-7.

9. Halamek LP, Stevenson DK. Neonatal Jaundice. In Fanroff AA, Martin RJ (Eds): Neonatal Perinatal
Medicine. Diseases of the fetus and Infant. 7ed. St louis, Mosby Year Book 2002. pp 1335.

10. van Imhoff DE, Dijk PH, Weykamp CW, Cobbaert CM, Hulzebos CV; BARTrial Study Group.
Measurements of neonatal bilirubin and albumin concentrations: a need for improvement and quality
control. Eur J Pediatr 2011;170:977-82.

11. Mehta S, Kumar P, Narang A. A randomized controlled trial of fluid supplementation in term neonates
with severe hyperbilirubinemia. J Pediatr 2005;147:781-5.
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Hyperbilirubinemia in Newborn

o Any visible jaundice on first day Jaundice lasting more than

o Yellow palms or soles of feet 3 weeks after birth

o Start phototherapy
o Estimate total serum bilirubin
o Check blood group of baby & mother

Check total serum bilirubin cut offs

(Panel 1)

o Bilirubin exchange level Bilirubin phototherapy Bilirubin < phototherapy o Estimate conjugated
OR level level bilirubin
o Signs of kernicterus o Conjugated
(lethargy or floppiness, not bilirubin>2mg/dl (34
feeding, convulsions, umol/l)
opisthotonus)

o
o REFER for See
exchange
Table1
o Continue phototherapy o Stop phototherapy REFER for specific diagnosis
transfusion ooRecheck bilirubin level every o Continue observation
o Continue phototherapy 12-24 hours until it is 3 mg/dl o Recheck bilirubin every 24
pending transport below o the p*See Table 1,
hototherapy hours, if concern persists
level Annexure 1

o
Determine probable diagnosis of Jaundice See Panel 2
*See Table 1, Annexure 1

Panel 1: Total serum bilirubin cut offs for phototherapy or exchange transfusion
Phototherapy Exchange transfusion
Age Healthy babies Babies with risk Healthy babies Babies with risk
factors* factors*

Day 1 Any visible jaundice 260 (15) 220 (10)

Day 2 260 (15) 170 (10) 425 (25) 260 (15)
Day >3 310 (18) 250 (15) 425 (25) 340 (20)

The values are expressed in umol/l (mg/dl) in parenthesis

*Gestation <35 weeks or weight<2000 grams, sepsis, hemolysis, asphyxia, sick baby

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket
Book of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Panel 2
Specific Diagnoses and Treatment
Diagnosis Counseling and Actions Treatment

Cephalhematoma/ Takes 4-6 weeks to disappear o Phototherapy, if bilirubin

extensive bruises level above the cut-off
Hemolytic jaundice o Recheck Hemoglobin on follow up 2-4 o Exchange transfusion if
(ABO or Rh weeks bilirubin above the cut
incompatibility, G6PD o Anti- D prophylaxis for Rh off
deficiency; previous family incompatibility o Promote feeding
history, hepato- o Avoid drugs & chemicals in G6PD optimally
splenomegaly, pallor ) deficiency -Sulfas, antimalarial,
aspirin, fava beans, mothballs
o If the cause of jaundice is Rh factor
incompatibility, advice mother
regarding future pregnancies
Prematurity Frequent feeding
Neonatal hepatitis In case of clay or white colored stool , Need specific management
high colored urine staining the clothes, (Referral to higher center)
baby needs referral

Panel 3
Tips for delivering safe and effective phototherapy
1. Protect the eyes with eye patches/covers
2. Keep the baby naked with a small nappy to cover the genitalia
3. Place the baby as close to the lights as the manufacturers instructions allow.
4. Use white cloth or aluminum foil around the light source to reflect light back onto the baby,
making sure not to impede the airflow that cools the bulbs
5. Do not place anything over the top of the phototherapy unit. This may block air vents or light and
items may fall on the baby
6. Encourage frequent breastfeeding. Unless there is evidence of dehydration, supplementing
breastfeeding or providing IV fluids is unnecessary
7. Change position from supine to prone after each feed in order to expose the maximum surface
area of baby to phototherapy
8. Keep diaper area dry and clean
9. Phototherapy does not have to be continuous and can be interrupted for feeding, clinical
procedures, and to allow maternal bonding
10. Monitor temperature every 4 hours and weight every 24 hours. Giving frequent feeding will
prevent excessive weight loss and temperature from rising
11. Measure serum bilirubin every 12-24 hours. Visual assessment of jaundice during phototherapy
is unreliable
12. Change tube lights every 6 months (or usage time >1200 hrs) whichever is earlier; or if tube ends
blacken or if tubes flicker. Life of Compact Fluorescent lamps is 3000 hours while that of LED bulbs is
30,000 to 50,000 hours

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket
Book of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 AIIMS- NICU protocols 2008

Feeding of Low Birth weight Infants

M. Jeeva Sankar, Ramesh Agarwal, Satish Mishra, Ashok Deorari, Vinod Paul,

Division of Neonatology, Department of Pediatrics

All India Institute of Medical Sciences
Ansari Nagar, New Delhi 110029

Address for correspondence:

Prof Vinod Paul
Professor & Head
Department of Pediatrics
All India Institute of Medical Sciences
Ansari Nagar, New Delhi 110029
Email: [email protected]

Conflict of interest: None

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 AIIMS- NICU protocols 2008

INTRODUCTION

Globally, about 18 million infants are born with a birth weight of <2500g every year.1 Though these low birth weight
(LBW) infants constitute only about 14% of the total live births, they account for 60-80% of total neonatal deaths.2
Most of these deaths can be prevented with extra attention to warmth, prevention of infections and more importantly,
optimal feeding.

FEEDING OF LBW INFANTS: WHY IS IT IMPORTANT?

Nutritional management influences immediate survival as well as subsequent growth and development of LBW
infants. Even simple interventions such as early initiation of breastfeeding and avoidance of pre-lacteal feeding have
been shown to improve their survival in resource restricted settings.3 Early nutrition could also influence the long term
neurodevelopmental outcomes; malnutrition at a vulnerable period of brain development has been shown to have
deleterious effects in experimental animals.4

FEEDING OF LBW INFANTS: HOW IS IT DIFFERENT?

Term infants with normal birth weight require minimal assistance for feeding in the immediate postnatal period - they
are able to feed directly from mothers breast. In contrast, feeding of LBW infants is relatively difficult because of the
following limitations:
1. Though majority of them are born at term, a significant proportion are born premature with inadequate
feeding skills. They might not be able to breastfeed and would require other methods of feeding such as
spoon or gastric tube feeding.
2. These infants are prone to have significant illnesses in the first few weeks of life; the underlying condition
often precludes enteral feeding.
3. Preterm very low birth infants (VLBW) infants have higher fluid requirements in the first few days of life due
to excessive insensible water loss.
4. Since intrauterine accretion of nutrients occurs mainly in the later part of the third trimester, VLBW infants
(usually born before 32 weeks gestation) have low body stores at birth. Hence, they require
supplementation of various nutrients. Even term LBW infants who are likely to be growth restricted need
higher calories for catch-up growth.
5. Because of the gut immaturity, they are more likely to experience feed intolerance necessitating adequate
monitoring and treatment.

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 AIIMS- NICU protocols 2008

PROTOCOL FOR FEEDING LBW INFANTS

In this protocol, we intend to address the following issues in feeding the LBW infants:
1. How to decide the initial method of feeding in a given LBW infant?
2. For infants initiated on modes other than breastfeeding:
a. How to progress to breastfeeding?
b. What milk to be given?
c. How much milk to be given?
3. What supplements are required?
4. How to assess the feeding adequacy and monitor the growth?
5. How to identify and manage feed intolerance?

DECIDING THE INITIAL METHOD OF FEEDING

It is essential to categorize LBW infants into two major groups sick and healthy - before deciding the method of
feeding.

Sick infants

This group constitutes infants with significant respiratory distress requiring assisted ventilation, shock requiring
inotropic support, seizures, symptomatic hypoglycemia/hypocalcemia, electrolyte abnormalities, renal/cardiac failure,
surgical conditions of gastrointestinal tract, necrotizing enterocolitis (NEC), hydrops, etc. These infants are usually
started on intravenous (IV) fluids. Enteral feeds should be initiated as soon as they are hemodynamically stable with
the choice of feeding method based on the infants gestation and clinical condition (see below).

It is important to realize that enteral feeding is important even in sick neonates. Oral feeds should not be delayed in
them without any valid reason. Even infants with respiratory distress and/or on assisted ventilation can be started on
enteral feeds once the initial acute phase is over and the infants color, saturation and perfusion have improved.
Similarly, sepsis (unless associated with shock/sclerema/NEC) is not a contraindication for enteral feeding.

Feeding in healthy LBW infants

Enteral feeding should be initiated immediately after birth in healthy LBW infants with the appropriate feeding method
determined by their gestation and oral feeding skills.

Maturation of oral feeding skills: Breastfeeding requires effective sucking, swallowing and a proper coordination
between suck/swallow and breathing. These complex skills mature with increasing gestation (Table 1).

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 AIIMS- NICU protocols 2008

The fetus is able to swallow amniotic fluid by as early as 11 to 12 weeks gestation. Mouthing can be observed at 15
weeks but the coordinated sucking movements are not usually present until about 28 weeks gestation. Single sucks
can be recorded manometrically at 28 weeks and sucking bursts by 31 weeks gestation. A mature sucking pattern
that can adequately express milk from the breast is not present until 32-34 weeks gestation.5 However, the
coordination between suck/swallow and breathing is not fully achieved until 37 weeks of gestation.

The maturation of oral feeding skills and the choice of initial feeding method at different gestational ages are
summarized in Table 1.

Table 1 Maturation of oral feeding skills and the choice of initial feeding method in LBW infants5

Gestational age Maturation of feeding skills Initial feeding method

< 28 weeks No proper sucking efforts Intravenous fluids
No propulsive motility in the gut
28-31 weeks Sucking bursts develop Oro-gastric (or naso-gastric)
No coordination between suck/swallow and breathing tube feeding with occasional
spoon/paladai feeding
32-34 weeks Slightly mature sucking pattern Feeding by spoon/paladai/cup
Coordination between breathing and swallowing begins
>34 weeks Mature sucking pattern Breastfeeding
More coordination between breathing and swallowing

How to decide the initial feeding method

Traditionally, the initial feeding method in a LBW infant was decided based on her birth weight. This is not an ideal
way because the feeding ability depends largely on gestation rather than the birth weight.

However, it is important to remember that not all infants born at a particular gestation would have same feeding skills.
Hence the ideal way in a given infant would be to evaluate if the feeding skills expected for his/her gestation are
present and then decide accordingly (Figure 1).

All stable LBW infants, irrespective of their initial feeding method should be put on their mothers breast.
The immature sucking observed in preterm infants born before 34 weeks might not meet their daily fluid and
nutritional requirements but helps in rapid maturation of their feeding skills and also improves the milk
secretion in their mothers (Non-nutritive sucking).

Spoon/paladai feeding

In our unit, we use paladai feeding in LBW infants who are not able to feed directly from the breast. The steps of
paladai feeding are described in Panel 1.6

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 AIIMS- NICU protocols 2008

>34 weeks

Initiate
Breastfeeding

Observe if:
weeks
1. Positioning &attachment are good
2. Able to suck effectively and long
enough (about 10-15 min)

Yes
Start feeds by
No
spoon/paladai
Breastfeeding
weeks
Observe if:
1. Accepting well without
spilling/coughing
2. Able to accept adequate amount

Yes Start feeds by

No OG/NG tube

Spoon/paladai
Observe if:
feeding 1. Vomiting/ abdominal distension <28 weeks
occurs
2. The pre-feed aspirate exceeds
>25% of feed volume
No

Yes
Gastric tube Start IV
feeding fluids

Figure 1: Deciding the initial feeding method in LBW infants

Intra-gastric tube feeding

The steps of intra-gastric tube feeding are given in Panel 2. Some of the controversial issues in gastric tube feeding
are discussed below:
Naso-gastric vs. oro-gastric feeding: Physiological studies have shown that naso-gastric (NG) tube increases the
airway impedance and the work of breathing in very preterm infants.7 Hence, oro-gastric tube feeding might be
preferable in these infants. We employ only oro-gastric tube feeding in our unit.
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 AIIMS- NICU protocols 2008

Intermittent bolus vs. continuous intra-gastric feeding: There are no differences in the time to reach full enteral
feeding / somatic growth / incidence of NEC between infants fed by intermittent bolus or continuous intra-gastric
feeding.8 Studies have shown that gastric emptying and duodenal motor responses are enhanced in infants given
continuous intra-gastric feeding.9 But a major disadvantage of this method is that the lipids in the milk tend to
separate and stick to the syringe and tubes during continuous infusion resulting in significant loss of energy and fat
content. We use intermittent bolus feeding in our unit.

Panel 1: Steps of Paladai Feeding6

1. Place the infant in up-right posture on mothers lap

2. Keep a cotton napkin around the neck to mop the spillage.
3. Take the required amount of expressed breast milk by using a clean syringe
4. Fill the paladai with milk little short of the brim;
5. Hold the paladai from the sides; DO NOT put your finger
6. Place it at the lips of the baby in the corner of the mouth
7. Tip the paladai to pour a small amount of milk into the infants mouth
8. Feed the infant slowly; he/she will actively swallow the milk
9. Repeat the process until the required amount has been fed
10. If the infant does not actively accept and swallow, try to arouse him/her with gentle stimulation
11. While estimating the milk intake, deduct the amount of milk left in the cup and the amount of estimated spillage
12. Wash the paladai with soap and water and then put in boiling water for 20 minutes to sterilize before next feed

Panel 2: Steps of Intra-gastric Tube Feeding6

1. Before starting a feed, check the position of the tube

2. Remove the plunger the syringe (ideally a sterile syringe should be used)
3. Connect the barrel of the syringe to the end of the gastric tube
4. Pinch the tube and fill the barrel of the syringe with the required volume of milk
5. Hold the tube with one hand, release the pinch and elevate the syringe barrel
6. Let the milk run from the syringe through the gastric tube by gravity;
DO NOT force milk through the gastric tube by using the plunger of the syringe
7. Control the flow by altering the height of the syringe. Lowering the syringe slows the milk flow, raising the syringe makes
the milk flow faster
8. It should take about 10-15 minutes for the milk to flow into the infants stomach
9. Observe the infant during the entire gastric tube feed. Do not leave the infant unattended. Stop the tube feed if the infant
shows any of the following signs: breathing difficulty, change in colour/ looks blue, becomes floppy, and vomiting
10. Cap the end of the gastric tube between feeds; if the infant is on CPAP, the tube is preferably left open after about half an
hour
11. Avoid flushing the tube with water or saline after giving feeds.

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 AIIMS- NICU protocols 2008

PROGRESSION OF ORAL FEEDS

All LBW infants, irrespective of their gestation and birth weight, should ultimately be able to feed directly from the
mothers breast. For preterm LBW infants started on IV fluids/OG tube/paladai feeding, the steps of progression to
direct and exclusive breastfeeding are summarized in Figure 2.

Term LBW infants started on IV fluids (because of their sickness) can be put on the breast once they are
hemodynamically stable.

Infants on IV
fluids*

If hemodynamically stable

Start trophic feeds by OG tube

& Monitor for feed intolerance

If accepting well

Gradually increase the feed volume

Taper and stop IV fluids
Infants on OG tube

At 30-32 weeks PMA

Try spoon feeds once or twice a day

Also, put on mothers breast and allow NNS

If accepting spoon feeds well

Gradually increase the frequency

and amount of spoon feeds
Reduce OG feeds accordingly
Infants on spoon/paladai
feeds

Put them on mothers breast before each feed

Observe for good attachment & effective sucking

If able to breastfeed effectively

#
Taper and stop spoon feeds once the
mother is confident

Figure 2: Progression of oral feeding in Preterm LBW infants

(IV, intravenous; OG, oro-gastric tube; PMA, postmenstrual age; NNS, non-nutritive sucking)
* Term and near-term sick infants started on IV fluids can be initiated on breastfeeding once they are hemodynamically stable;

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 AIIMS- NICU protocols 2008

#
Some infants may have to be given spoon feeding for some period even after they start accepting breastfeeding
Special situations
Extremely low birth weight infants: They are usually started on parenteral nutrition from day 1. Enteral feeds in the
form of trophic feeding or minimal enteral nutrition (MEN) are initiated once the infant is hemodynamically stable.
Further advancement is based on the infants ability to tolerate the feeds (See AIIMS protocol on Minimal enteral
nutrition).10
Severe IUGR with antenatally detected Doppler flow abnormalities: Fetuses with abnormal Doppler flow such as
absent/reversed end diastolic flow (A/REDF) in the umbilical artery are likely to have had mesenteric ischemia in
utero. After birth, they have a significant risk of developing feed intolerance and NEC.11 The timing of initiation of oral
feeds in these infants is controversial. We usually delay feeding up to 48-72 hours in preterm (<35 weeks) infants
with A/REDF.
Infants on CPAP/ventilation: These infants can be started on OG tube feeds once they are hemodynamically
stable. But it is important to leave the tube open intermittently to reduce gastric distension.

CHOICE OF MILK FOR LBW INFANTS

All LBW infants, irrespective of their initial feeding method should receive ONLY breast milk. This can be ensured
even in those infants who are fed by paladai or gastric tube by giving expressed breast milk (mothers own milk or
human donor milk).

Expressed breast milk (EBM): All preterm infants mothers should be counseled and supported in expressing their
own milk for feeding their infants. Expression should ideally be initiated within hours of delivery so that the infant gets
the benefits of feeding colostrum. Thereafter, it should be done 2-3 hourly - this would ensure that the infant is
exclusively breastfed and also helps in maintaining the lactation in the mother.

The steps of breast milk expression are given in Panel 3. We counsel mothers for expression of breast milk soon
after delivery by demonstration and by using poster & videos (available on our website: www.newbornwhocc.org)

Expressed breast milk can be stored for about 6 hours at room temperature and for 24 hours in refrigerator.

Donor human milk: In centers where optimal milk banking facilities are available, donor human milk can be used for
feeding a LBW infant. At present, only a few centers in India have standardized human milk banking facilities. Hence,
it is not a practical option in most of the settings across India.

Special situations

Sick mothers/ contraindication to breastfeeding: In these rare circumstances, the options available are

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 AIIMS- NICU protocols 2008

1. Formula feeds:
a. Preterm formula in VLBW infants and
b. Term formula in infants weighing >1500g at birth
2. Animal milk: e.g. undiluted cows milk

Once the mothers condition becomes stable (or the contraindication to breastfeeding no longer exists), these infants
should be started on exclusive breastfeeding.

Panel 3: Steps of expression of breast milk6

1. The mother should wash her hands thoroughly.

2. She should hold a clean wide mouthed container near her breast.
3. Ask her to gently massage the breast for 5-10 minutes before expressing the milk (using the pulp of two fingers or with
knuckles of the fist in a circular motion towards the nipple as if kneading dough). Massage should not hurt her.
4. Ask her to put her thumb ABOVE the nipple and areola, and her first finger BELOW the areola opposite the thumb. She
should support the breast with her other fingers.
5. Ask her to press her thumb and first finger slightly inward towards the chest wall.
6. She should press her breast behind the nipple and areola between her fingers and thumb. She must press on the lactiferous
sinuses beneath the areola.
7. Press and release, press and release. This should not hurt-if it hurts, the technique is wrong. It may take some time before
milk starts coming.
8. Ask her to press the areola in the same way from the SIDES, to make sure that milk is expressed from all segments of the
breast.
9. She should express one breast first till the milk flow slows; then express the other side; and then repeat both sides.
10. Avoid rubbing or sliding her fingers along the skin.
11. Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the milk.

HOW MUCH MILK IS TO BE GIVEN?

It is essential to calculate the fluid requirements and feed volumes for infants on paladai/gastric tube feeding.

Fluid requirement: The daily fluid requirement is determined based on the estimated insensible water loss, other
losses, and urine output. Extreme preterm infants need more fluids in the initial weeks of life because of the high
insensible water loss.

We usually start fluids at 80 mL and 60 mL/kg/day for infants birth weights of <1500g and 1500-2500g respectively.
Further requirements are calculated by daily estimation of weight loss/gain, serum sodium, urine output and specific
gravity. The usual daily increment would be about 15-20 mL/kg/day so that by the end of first week 150 mL/kg/day is
reached in both the categories. We usually reach a maximum of 180mL/kg/day by day 14 (Refer to AIIMS protocol on
Fluids and electrolyte management in term and preterm neonates).12

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Feed volume: After estimating the fluid requirements, the individual feed volume to be given by OG tube or paladai
(2-hrly/3-hrly) should be determined.

NUTRITIONAL SUPPLEMENTATION IN LBW INFANTS

LBW infants, especially those who are born preterm require supplementation of various nutrients to meet their high
demands. Since the requirements of VLBW infants differ significantly from those with birth weights of 1500-2499
grams, they have been discussed separately.

Supplementation for infants with birth weights of 1500-2500g

These infants are more likely to be born at term or near term gestation (>34 weeks); hence, they do not require multi-
nutrient supplementation or fortification of breast milk (cf. VLBW infants). However, vitamin D and iron might still have
to be supplemented in them. While iron supplementation is mandatory for all infants, vitamin D supplementation is
contentious because of the paucity of the data regarding its levels and deficiency status in different populations.
Some argue that the daily requirement of vitamin D is met usually by de novo synthesis in the skin (following
exposure to sun light) and hence no supplementation is required. WHO does not recommend routine vitamin D
supplementation in LBW infants.13

However, the American Academy of Pediatrics recommends vitamin D supplementation (200 IU/day) even in term
infants who are exclusively breast fed. Considering that LBW infants are more at risk of osteopenia than healthy term
infants, most neonatal units tend to supplement vitamin D in them.14 One has to assess the mothers nutritional
status, their exposure to sun, and the infants exposure to sun before adopting a policy for their respective unit(s).

We supplement both vitamin D and iron in infants with birth weights of 1500-2499 grams; vitamin D (200 IU) is
started at 2 weeks and iron (2 mg/kg/day) at 2 months of life; both are continued till 1 year of age (Table 2).

Table 2 Nutritional supplements for infants with birth weights of 1500-2499 g

Nutrients Method of Dose When to start Till when?
supplementation
Vitamin D* Multivitamin drops/syrup 200-400 IU/day 2 weeks of life Till 1 year of age
Iron Iron drops/syrup 2 mg/kg/day 6 8 weeks of age Till 1 year of age
(maximum 15mg/day)
* See text

Supplementation in VLBW infants

These infants who are usually born before 32-34 weeks gestation have inadequate body stores of most of the
nutrients. Expressed breast milk has inadequate amounts of protein, energy, calcium, phosphorus, trace elements
(iron, zinc) and vitamins (D, E & K) that are unable to meet their daily recommended intakes (Table 3). Hence, these

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infants need multi-nutrient supplementation till they reach term gestation (40 weeks postmenstrual age). After this
period, their requirements are similar to those infants with birth weights of 1500-2499 grams.

Multi-nutrient supplementation can be ensured by one of the following methods:

1. Supplementing individual nutrients e.g., calcium, phosphorus, vitamins, etc.
2. By fortification of expressed breast milk:
a. Fortification with human milk fortifiers (HMF)
b. Fortification with preterm formula

Table 3 Recommended Dietary Allowance in Preterm VLBW infants and the Estimated Intakes with
Fortified/unfortified Human Milk
RDA* At daily intake of 180 mL/kg
(Units/kg/day)
Only expressed EBM fortified with EBM fortified with Preterm
breast milk# Lactodex-HMF formula (4g/100mL)
(4g/100mL)
Energy (kcal) 105-130 117 144 153
Protein (g) 3.5-4.0 2.46 3.2 3.4
Carbohydrates (g) 10-14 11.6 16.84 15.58
Fat (g) 5.4-7.2 6.8 7.1 9.06
Calcium (mg) 210 43.2 223 103
Phosphorus (mg) 110 22.2 112 52
Vitamin A (IU) 90-270 680 3308 980
Vitamin D (IU/day) 400 3.5 903 40
Vitamin E (IU) >1.3 1.9 6.3 3.6
Vitamin B1 (mcg) > 48 36.2 79.4 231
Vitamin B2 (mcg) > 72 84.2 156.2 564.2
Vitamin B6 (mcg) > 42 25.7 115.7 221
Folic acid (mcg) 39.6 6 150 36
Zinc (mg) >0.6 0.6 0.96 0.96
Remarks Deficient in protein, calcium, Deficient in protein Deficient in calcium, phosphorus,
phosphorus, and vitamins vitamin D, and folic acid; protein
B1, B6 and D; Zinc content is slightly less.
is slightly less than the RDA
15
* AAPCON 2004
#
Based on preterm mature milk
(RDA, recommended dietary allowance; EBM, expressed breast milk)

Supplementing breast milk with minerals and vitamins: The following nutrients have to be added to the
expressed breast milk to meet the VLBW infants high requirements:

1. Calciuma and phosphorusa (140-160 mg/kg/d & 70-80 mg/kg/d respectively for infants on EBM)
2. Vitamin Db (400 IU/day), vitamin B complex and zincb (about 0.5mg/day) usually in the form of
multivitamin drops

a
E.g. Syr. Ostocalcium (GlaxoSmithKline Co.), Syr. Ossopan-D (TTK Healthcare)
b
E.g. Dexvita drops (Tridoss Co.), Visyneral-zinc drops (Lifeon Co.), Dexvita drops (Tridoss Co.)
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 AIIMS- NICU protocols 2008

3. Folate (about 50 mcg/kg/day) c

4. Iron (2 mg/kg/day)d
However, one has to remember that supplementation of minerals and vitamins would not meet the high protein
requirements of these infants (Table 3). Hence, this method is usually not preferred.

To avoid abnormal increase in the osmolality, these supplements should be added at different times in the day.

Fortification with HMF: Fortification of expressed breast milk with HMF increases the nutrient content of the milk
with out compromising its other beneficial effects (such as reduction of NEC, infections, etc.). Experimental studies
have shown that the use of fortified human milk results in net nutrient retention that approaches or is greater than
expected intrauterine rates of accretion in preterm infants.16 Though there are concerns about the increase in
osmolality, clinical studies have not shown any significant adverse effects following fortification of human milk. The
Cochrane review on fortification found short term improvement in weight gain, linear and head growth with out any
increase in adverse effects such as NEC.17

The standard preparations of human milk fortifiers (HMF) used in developed countries are not available in India. The
only preparation available (Lactodex-HMF, Raptakos, Brett & Co. Ltd; Rs. 10/- per sachet) has some limitations:
inappropriately high vitamin A, no iron, etc. Short of other options, it may still have to be used in VLBW infants. One
study from Chandigarh has reported better growth with its use.18

As seen from Table 3, preterm VLBW infants on expressed breast milk fortified with HMF do not require any
supplementation (except for iron).

Fortification with preterm formula: The other option available for fortification is preterm formula (e.g. Dexolac
Special Care [Wockhardt Co.], Pre-Lactogen [Nestle Co.]). The recommended concentration is 0.4g per 10mL of
breast milk. Though more economical than fortification by HMF, this method has two major drawbacks - it is difficult
to measure such small amounts of formula powder and the RDA of some minerals and vitamins (e.g. calcium,
phosphorus, vitamin D, folic acid) are not met even after fortification. While the former problem can be managed to a
certain extent by using a small scoop of 1g size for 25mL of milk, the later is circumvented by additional
supplementation (Table 3).

The recommended dietary allowances (RDA) and the estimated intakes with fortified human milk are given in Table
3.

Fortification/supplementation in VLBW infants Summary:

c
E.g. Folium (Speciality Meditech Co. ) Folvite (Wyeth Lederle Co.)
d
E.g. Ferrochelate (Albert David Co.) Tonoferon (East India Co.)
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The protocol for nutritional supplementation in VLBW infants until 40 weeks PMA and beyond is described in Tables
4 & 5.

We use HMF fortification for all preterm (<32 weeks) VLBW infants. It is started once they reach 150 mL/kg/day of
enteral feeds in the dose recommended by the manufacturer (4g [2 sachets] /100mL of expressed breast milk). We
start iron at 4-6 weeks in the dose of 2mg/kg/day.

If HMF is unavailable or parents could not afford it, we fortify EBM with preterm formula (0.4g/10 mL). Since calcium,
phosphorus, and vitamin D intakes are low even after fortification with formula, we supplement these nutrients
additionally (Table 4). We also add zinc and iron as mentioned before.

We continue fortification till the infant reaches 40 weeks PMA or attains 2kg (whichever is later).

Table 4 Nutritional supplementation in VLBW infants till 40 weeks PMA

Type of feeding
Only expressed EBM fortified with Lactodex-HMF* EBM fortified with Preterm formula
breast milk*

Calcium Start calcium supplements (140-160 Not needed Start calcium supplements to meet the
mg/kg/day) once the infant is on full enteral RDA once the infant is on full enteral feeds
feeds (e.g. Syr. Ostocalcium at 5-6mL/kg/d)
(e.g. Syr. Ostocalcium at 8-10mL/kg/d)
Phosphorus Start supplements (70-80 mg/kg/day) once Not needed Start supplements to meet the RDA once
the infant is on full enteral feeds the infant is on full enteral feeds (e.g. Syr.
(e.g. Syr. Ostocalcium at 8-10mL/kg/d) Ostocalcium at 5-6mL/kg/d)
Zinc and Start multivitamin supplements once the Not needed Not needed
vitamins B1, infant is on full feeds
B6 (e.g. ViSyneral zinc / Dexvita drops at
0.5mL/day)
Vitamin D (Usually obtained from multivitamin drops Not needed (Usually obtained from multivitamin drops
and calcium supplements that contain and calcium supplements that contain
vitamin D.) vitamin D)
Folic acid Start supplements once the infant is on full Not needed Start supplements once the infant is on full
feeds feeds
(e.g., Folvite/folium drops at 0.3 mL/day) (e.g., Folvite/folium at 0.1 mL/day)
Iron Start iron (2 mg/kg/d) at 4-6 weeks of life Start iron (2 mg/kg/d) at 4-6 weeks Start iron (2 mg/kg/d) at 4-6 weeks of life
(e.g. Tonoferon drops at 2 drops/kg/day) (e.g. Tonoferon drops at 2 drops/kg/day) (e.g. Tonoferon drops at 2 drops/kg/day)
(PMA, postmenstrual age; EBM, expressed breast milk; HMF, human milk fortifier)

Note: The examples quoted are only indicative; Readers are encouraged to use similar products of their choice.

Table 5 Nutritional supplementation in VLBW infants after 40 weeks PMA

Nutrients Method of Dose Till when?

supplementation
Vitamin D Multivitamin drops/syrup 200-400 IU/day Till 1 year of age

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 AIIMS- NICU protocols 2008

Iron Iron drops/syrup 2 mg/kg/day Till 1 year of age

(maximum 15mg/day)

Growth monitoring of LBW infants

Regular growth monitoring helps in assessing the nutritional status and adequacy of feeding; it also identifies those
infants with inadequate weight gain.

All LBW infants should be weighed daily till the time of discharge from the hospital. Other anthropometric parameters
such as length and head circumference should be recorded weekly.

Both term and preterm LBW infants tend to lose weight (about 10% and 15% respectively) in the first 7 days of life;
they regain their birth weight by 10-14 days. Thereafter, the weight gain should be at least 15-20g/kg/day till a weight
of 2-2.5 kg is reached. After this, a gain of 20 to 30 g/day is considered appropriate.19

LBW infants should be discharged after:

o They reach 34 weeks gestation and are above 1400g AND
o They show consistent weight gain for at least 3 consecutive days.

Growth charts: Using a growth chart is a simple but effective way to monitor the growth. Serial plotting of weight and
other anthropometric indicators in the growth chart allows the individual infants growth to be compared with a
reference standard. It helps in early identification of growth faltering in these infants.

Two types of growth charts are commonly used for growth monitoring in preterm infants: intrauterine and postnatal
growth charts. Of these, the postnatal growth chart is preferred because it is a more realistic representation of the
true postnatal growth (than an intrauterine growth chart) and also shows the initial weight loss that occurs in the first
two weeks of life. The two postnatal charts that are most commonly used for growth monitoring of preterm VLBW
infants are: Wrights and Ehrenkranz charts.20, 21 We use either of these in our unit.

Once the preterm LBW infants reach 40 weeks PMA, WHO growth charts should be used for growth monitoring.

Management of inadequate weight gain

Inadequate weight gain is a common and pertinent problem in LBW infants. It starts at the time of initial admission
and continues after discharge resulting in failure to thrive and wasting in the first year of life. The common causes are
summarized in Panel 4.

Management of inadequate weight gain consists of the following steps:

1. Proper counseling of mothers and ensuring adequate support for breastfeeding their infants; includes
assessment of positioning/attachment, managing sore/flat nipple etc.

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2. Explaining the frequency and timing of both breastfeeding and spoon/paladai feeds: Infrequent feeding is
one of the commonest causes of inadequate weight gain. Mothers should be properly counseled regarding
the frequency and the importance of night feeds. A time-table where mother can fill the timing and amount of
feeding is very helpful in ensuring frequent feeding.
3. Giving EBM by spoon/paladai feeds after breastfeeding also helps in preterm infants who tire out easily
while sucking from the breast.
4. Proper demonstration of the correct method of expression of milk and paladai feeding: It is important to
observe how the mother gives paladai feeds; the technique and amount of spillage should be noted. This
should be followed by a practical demonstration of the proper procedure.
5. Initiating fortification of breast milk when indicated
6. Management of the underlying condition(s) such as anemia, feed intolerance,etc.
7. If these measures are not successful, increase either the
a. Energy (calorie) content of milk by adding MCT oil, corn starch, etc. Infants on formula feeds can
be given concentrated feeds (by reconstituting 1 scoop in 25 mL of water) OR
b. Feed volume to 200 mL/kg/day.

Panel 4 Causes of inadequate weight gain

1. Inadequate intake
Breastfed infants:
Incorrect feeding method (improper positioning/attachment)*
Less frequent breastfeeding, not feeding in the night hours*
Prematurely removing the baby from the breast (before the infant completes feeds)
Infants on spoon /paladai feeds:
Incorrect method of feeding* (e.g. excess spilling)
Incorrect measurement/calculation
Infrequent feeding
Not fortifying the milk in VLBW infants
Energy expenditure in infants who have difficulty in accepting spoon feeds

2. Increased demands
Illnesses such as hypothermia/cold stress*, bronchopulmonary dysplasia
Medications such as corticosteroids

3. Underlying disease/pathological conditions

Anemia*, hyponatremia, late metabolic acidosis
Late onset sepsis
Feed intolerance and/or GER

* Common conditions
(EBM, expressed breast milk; GER, gastroesophageal reflux)

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 AIIMS- NICU protocols 2008

FEED INTOLERANCE

The inability to tolerate enteral feedings in extremely premature infants is a major concern for the pediatrician /
neonatologist caring for such infants. Often, feed intolerance is the predominant factor affecting the duration of
hospitalization in these infants.

There are no universally agreed-upon criteria to define feed intolerance in preterm infants.17 Various clinical features
that are usually considered to be the indicator(s) of feed intolerance are summarized below (Panel 5):

Panel 5 Indicator(s) of feed intolerance17

Symptoms:
1. Vomiting (altered milk/bile or blood-stained)*
2. Systemic features: lethargy, apnea
Signs:
1. Abdominal distension (with or without visible bowel loops)*
2. Increased gastric residuals: >2mL/kg or any change from previous pattern
3. Abdominal tenderness
4. Reduced or absent bowel sounds
5. Systemic signs: cyanosis, bradycardia, etc.

* Common signs

Of these, vomiting, abdominal distension, and increased gastric residual volume form the triad for defining feed
intolerance.

Vomiting: The characteristic of vomitus is important in assessing the cause: while altered milk is usually innocuous,
bile- or blood-stained aspirate should be thoroughly investigated.

Abdominal distension: It is essential to serially monitor the abdominal girth in all preterm LBW infants admitted in
neonatal nursery. This helps in early identification of feed intolerance and eliminates the need for routine gastric
aspirate.

Gastric residual volume: It indicates the rapidity of gastric emptying. Since several factors (both systemic and local)
influence the gastric emptying, the residual volume is a poor and non-specific indicator of fed intolerance. Measures
to enhance the specificity - by quantifying the volume and by using different cut-offs for defining feed intolerance -
have not been found to be much useful. Moreover, repeated gastric aspiration to look for residuals could injure the
delicate mucosa aggravating the local pathology.

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 AIIMS- NICU protocols 2008

We monitor the abdominal girth every 2 hours in all preterm LBW infants admitted in the nursery. We do not
routinely aspirate the gastric contents before giving next feed. It is done only if there is an increase in
abdominal girth by >2 cm from the baseline.

Management of feed intolerance

The common factors attributed to feed intolerance in preterm infants are: immature intestinal motility, immaturity of
digestive enzymes, underlying medical conditions such as sepsis, inappropriate feed volume, and giving
hyperosmolar medications/feedings, and importantly, necrotizing enterocolitis (NEC).

While issues such as feed volume and osmolality can be controlled to an extent, feed intolerance due to immaturity is
rarely amenable to any intervention; conservative management till the gut attains full maturity is often the only option
left.

The steps in evaluation and management of an infant with feed intolerance are given in Figure 3.

Conclusion
Optimal feeding of LBW infants is important for the immediate survival as well as for subsequent growth. Unlike their
normal birth weight counterparts, these infants have vastly different feeding abilities and nutritional requirements.
They are also prone to develop feed intolerance in the immediate postnatal period. It is important for all health care
providers caring for such infants to be well versant with the necessary skills required for feeding them. It is equally
important to have a protocol based approach to manage various issues that occur while feeding them.

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 AIIMS- NICU protocols 2008

Increase in abdominal girth by >2 cm OR

Vomiting (altered milk)

Aspirate the stomach contents

(Observe the nature and volume of gastric contents)

Clear; NOT bile- or blood-stained Bile- or blood-stained aspirate / vomit

Aspirate volume <2-3mL Aspirate volume Aspirate volume

or < 25% of feed volume 25-50% of feed volume >50% of feed volume

Look for local cause Reduce next feed Withhold one or two feeds
Continue feeds volume (equal to the Monitor Withhold feeds for 24-48 hrs
Monitor aspirate volume)
Evaluate for systemic and
Monitor
local causes
Restart feeds

Feed intolerance recurs Manage accordingly

Assess clinical stability and evaluate for

systemic signs

No systemic signs and Systemic signs +

clinically stable

Check the position of OG tube Withhold feeds for 24-48 hrs and
Try changing the infants position (from Evaluate for systemic causes
supine to prone or right lateral decubitus)
Withhold feeds for 12-24 hrs and reassess

Figure 3 Approach to feed intolerance in LBW infants

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Clinically stable
(no systemic signs)
 AIIMS- NICU protocols 2008

References

1. UNICEF. State of the Worlds Children 2005. New York: UNICEF, 2004.
2. Bang A, Reddy MH, Deshmukh MD. Child mortality in Maharashtra. Economic Political weekly 2002;37:4947-65.
3. Edmond KM, Kirkwood BR, Tawiah CA, Agyei SO. Impact of early infant feeding practices on mortality in low
birth weight infants from rural Ghana. J Perinatol. 2008 Mar 6; [Epub ahead of print]
4. Levitsky DA, Strupp BJ. Malnutrition and the brain: changing concepts, changing concerns. J Nutr.
1995;125:2212S20S
5. Omari TI, Rudolph CD. Gastrointestinal Motility. In: Polin RA and Fox WW (Eds). Fetal and Neonatal Physiology.
2nd edition. Philadelphia, WB Saunders Co, 1998: pp. 1125-38
6. Anonymous. Feeding. In: Deorari AK, Paul VK, Scotland J, McMillan DD, Singhal N (Eds). Practical Procedures
for the Newborn Nursery. 2nd edition. New Delhi, Sagar Publishers, 2003: pp 71-78
7. Stocks J. Effect of nasogastric tubes on nasal resistance during infancy. Arch Dis Child. 1980;55:17-21
8. Premji SS, Chessell L. Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature
infants less than 1500 grams. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD001819.
9. DeVille KT, Shulman RJ, Berseth CL. Slow infusion feeding enhances gastric emptying in preterm infants
compared to bolus feeding. Clin Res 1993;41:787A.
10. Mishra S, Agarwal R, Jeevasankar M, Deorari AK, Paul VK. Minimal enteral nutrition. Indian J Pediatr.
2008;75:267-9.
11. Dorling J, Kempley S, Leaf A. Feeding growth restricted preterm infants with abnormal antenatal Doppler results.
Arch Dis Child Fetal Neonatal Ed. 2005;90:F359-63
12. Chawla D, Agarwal R, Deorari AK, Paul VK. Fluid and electrolyte management in term and preterm neonates.
Indian J Pediatr. 2008;75:255-9
13. Bahl R. Personal Communication.
14. Abrams SA. Abnormalities of serum calcium and magnesium. In: Cloherty JP, Eichenwald EC, Stark AR (Eds).
Manual of Neonatal Care. 6th edn. Philadelphia: Lippincott Williams & Wilkins 2008; p558.
15. American Academy of Pediatrics Committee on Nutrition: Nutritional needs of preterm infants. In: Kleinman RE
(ed): Pediatric Nutrition Handbook American Academy of Pediatrics. Elk Grove Village, IL, American Academy of
Pediatrics, 2004: pp 23-54.
16. Schanler RJ, Garza C. Improved mineral balance in very low birth weight infants fed fortified human milk. J
Pediatr 1987;112:452-6
17. Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane
Database of Systematic Reviews 1998, Issue 4. Art. No.: CD000343.
Downloaded from www.newbornwhocc.org 20
 AIIMS- NICU protocols 2008

18. Mukhopadhyay K, Narnag A, Mahajan R. Effect of human milk fortification in appropriate for gestation and small
for gestation preterm babies: a randomized controlled trial. Indian Pediatr. 2007 Apr;44(4):286-90.
19. Schanler RJ. Enteral Nutrition for the High-Risk Neonate. In: Taeusch HW, Ballard RA, Gleason CA (eds):
Averys Diseases of the Newborn, 8th edn. Philadelphia, Saunders, 2005, pp.1043-60.
20. Wright K, Dawson JP, Fallis D, Vogt E, Lorch V. New postnatal growth grids for very low birth weight infants.

Downloaded from www.newbornwhocc.org 21

 Module 4 - Feeding Normal & LBW

FEEDING OF NORMAL AND

LOW BIRTH WEIGHT BABIES
The module is designed to complement in-service and pre-service education and orientation of
nursing personnel involved in care of newborns.

LEARNING OBJECTIVES
The participants will learn about:

Enteral feeding of normal birth weight and low birth weight babies
Breastfeeding counseling and support
Managing common problems encountered during breastfeeding
Feeding by paladai and intra-gastric tube

Module 4 : Feeding of Normal and Low Brith Weight Babies

MODULE CONTENTS
The module includes following elements:
l Text material: Easy to read format for quick reproduction and essential reference material
for the participants. Key messages are highlighted in the boxes.
l Demonstration: Observing steps involved in successful breast feeding in a hospital
setting.
l Role play: There will be a role play on "initiation of breastfeeding".
l Video film: Learning positioning, attachment, and effective sucking by baby on breast.
l Self-evaluation: At the end of text, self evaluation based on what has been learnt is
included. Feel free to consult your text material if you need assistance in recapitulating.

I. FEEDING OF NORMAL BIRTH WEIGHT BABIES

1. INTRODUCTION
The best milk for a newborn baby is unquestionably the breast milk. All healthy normal weight
babies (> 2500g) must be exclusively breastfed till the age of 6 months. Health professionals
must have adequate knowledge and skills in order to support and help mothers in establishing
breastfeeding successfully.

2. BREASTFEEDING
It is essential to help the mothers of healthy newborn babies to establish breastfeeding as soon
as possible after delivery. Health workers should know about the advantages of breast milk, the
anatomy of breast and physiology of lactation so that they can teach and counsel the mothers
with confidence. All newborns without any complications should be kept in skin to skin contact
with their mothers during the first hour after birth to promote breast feeding & to prevent
hypothermia.
Exclusive breastfeeding should be given for the first six months of life; complementary food
should be started after six months of age.
2.1 Advantages of breastfeeding
Exclusively breast fed babies are at decreased risk of
l Diarrhea
l Pneumonia
l Ear infection and
l Death in first year of life
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The advantages of breast feeding are summarized in Figure 1.

Advantages
of
Breast
Benefits to the baby
l Complete food, feeding Benefits to mother
l Helps in involution
species specific
of uterus
l Easily digested
l Delays pregnancy
and well absorbed
l Lowers risk of breast
l Protects against infection
and ovarian cancer
l Promotes emotional
Benefits to family l Decreases mothers
bonding and society work load
l Better brain growth
l Saves money
Module 4 : Feeding of Normal and Low Brith Weight Babies

l Promotes family planning

l Decreases need
for hospitalization
l Contributes to
child survival

Figure 1: Advantages of breast feeding

2.2 Anatomy and physiology

The breast consists of glandular tissue, supporting tissue and fat. Milk is secreted by the
glands and travels through tubules which drain into lactiferous sinuses. The sinuses, which
store small quantities of milk, lie beneath the areola. They open out on to the nipple
through lactiferous ducts. A thin layer of muscle (myo-epithelium) surrounds each gland.
The contraction of these muscles causes ejection of milk from the glands (see Figure 2).

Muscle cells
{ Oxytocin makes
them contract

Milk secreting cells

{ Prolactin makes them
secrete milk

Ducts

Lactiferous sinuses
{ Milk collects
here

Nipple

Areola (brown area behind nipple)

Montgomarys glands

Alveoli
Supporting tissue
and fat

Figure 2: Anatomy of breast

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2.3 Milk secretion and ejection

Milk is produced as a result of the interaction between hormones and reflexes. During
pregnancy, the glandular tissue is stimulated to produce milk due to various hormonal
influences. Two reflexes, mediated by two different hormones, come into play during
lactation.
a. Prolactin reflex
Prolactin is produced by the anterior pituitary gland which is responsible for milk
secretion by the mammary gland cells. When the baby sucks, the nerve endings in the
nipple carry information to the anterior pituitary gland which in turn releases prolactin.
This hormone passes through the blood to the glands in the breast promoting milk
secretion.
This cycle from stimulation to secretion is called the prolactin reflex or the "milk
secretion reflex". The earlier the baby is put on the breast, the sooner the reflex is
initiated. The more the baby sucks at the breast, the greater is the stimulus for milk

Module 4 : Feeding of Normal and Low Brith Weight Babies

production. The greater is the demand for milk, larger is the volume of milk produced.
It is therefore important for mothers to feed baby early and frequently and ensure
complete emptying of the breasts at each feed. Since prolactin reflex is active at night,
night feeding (or expression of milk) helps to improve milk production.

Prolactin milk secretion reflex

Sensory
Secreted AFTER feed impulse from
to produce NEXT feed nipple

Prolactin
in blood
ENHANCING FACTORS HINDERING FACTORS
- Sucking - Incorrect position
- Expression of milk - Painful breast
- Emptying of breast - Prelacteal feeds
- Night feeds - Top feeding

Baby
sucking

Figure 3: Prolactin reflex

b. Oxytocin reflex
Oxytocin is a hormone produced by the posterior pituitary gland. It is responsible for
contraction of the myo-epithelium around the glands leading to ejection of the milk
from the glands into the lactiferous sinuses and the lacteal ducts.
This hormone is produced in response to stimulation of the nerve endings in the nipple
by sucking as well as by the thought, sight or sound of the baby. Since this reflex is
affected by the mother's emotions, a relaxed, confident attitude helps this "milk
ejection reflex". On the other hand, tension, pain and lack of confidence hinders the
milk flow. This stresses the importance of a kind and supportive person - professional
health worker or a relative - to reassure the mother and help gain confidence so that
she can successfully breastfeed.

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 Module 4 - Feeding Normal & LBW

Oxytocin milk ejection reflex

Oxytocin in blood
contracts Sensory impulse
myoepithelial cells from nipple
Oxytocin
in blood
ENHANCING FACTORS
- Think lovingly of baby HINDERING FACTORS
- Sound of baby - Worry
- Sight of baby - Stress
- Mother is relaxed / Baby - Pain
comfortable/confident sucking - Doubt
Module 4 : Feeding of Normal and Low Brith Weight Babies

Figure 4: Oxytocin reflex

Sucking by the baby is the most important stimulus for

production and secretion of milk in the mother

DEMONSTRATION

There will be demonstration using Wall Charts by the facilitators on 'Anatomy of breast and
physiology of lactation'.

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2.4 Types of breast milk

The composition of breast milk varies at different stages after birth to suit the needs of the
baby. Milk of a mother who had delivered a preterm baby is different from the milk of a
mother who has delivered a full term baby.
1. Colostrum is the milk secreted during the first week after delivery. It is yellow, thick
and contains more antibodies and white blood cells. Though secreted only in small
quantities, it has higher protein content and is most suited for the needs of the baby; it
should NEVER be discarded.
2. Transitional milk is the milk secreted during the following two weeks. The
immunoglobulin and protein content decreases while the fat and sugar content
increases.
3. Mature milk follows transitional milk. It is thinner and watery but contains all the
nutrients essential for optimal growth of the baby.

Module 4 : Feeding of Normal and Low Brith Weight Babies

4. Preterm milk is the breast milk of a mother who delivers prematurely. It contains
higher quantities of proteins, sodium, iron, and immunoglobulins that are needed by
her preterm baby.
5. Fore milk is the milk secreted at the start of a feed. It is watery and is rich in proteins,
sugar, vitamins, minerals, and water and satisfies the baby's thirst.
6. Hind milk comes later towards the end of a feed and is richer in fat content, provides
more energy, and satisfies the baby's hunger. For optimum growth the baby needs
both fore and hind milk. The baby should therefore be allowed to empty one breast
fully before offering the other one. Baby receiving predominant foremilk may cry
excessively.
You are still
breastfeeding
Meena ! that is
why the is so
healthy.
GOOD FOR YOU I am glad
I didnt follow
Urmilas advice
and give
meena
a bottle
Urmilas
baby
is often He has
sick started to
have loose
stools.
Should
I stop breast
feeding?

Breast feeding should be continued during diarrhea as well as other

illnesses. It helps the baby to get optimal nutrition and recover from the
illness faster.

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 Module 4 - Feeding Normal & LBW

3. HELPING A MOTHER TO BREASTFEED

All mothers, particularly the first-time mothers would require some help to initiate
breastfeeding. Hence it is important for the health care providers to help them to breastfeed
their babies. The steps are summarized below.

Step 1: Preparing the infant and the mother

l Ensure that the infant is clinically stable
l Ensure that the infant is alert
l Make sure that the mother is comfortable and relaxed
l Make her sit down in a comfortable and convenient position

Module 4 : Feeding of Normal and Low Brith Weight Babies

Step 2: Demonstrate various positions for breastfeeding a baby

Underarm position Using the opposite arm

Mother in lying down position

A mother can feed the infant in various positions as shown above. Whatever the position, it is
important to remember that the baby has to be fully supported with her forearm and the
hands.

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 Module 4 - Feeding Normal & LBW

Step 3: Demonstrate the four key points in position

The four key points in proper positioning:
l Baby's head in line with the body
l Whole body well supported
l Baby turned towards the mother
l Baby's abdomen touching mother's abdomen

Step 4: Show the mother how to support her breast with the other hand

Explain the mother that she should

l put her fingers below her breast
l use her first finger to support the breast
l put her thumb above the areola helping to shape the breast
Module 4 : Feeding of Normal and Low Brith Weight Babies

l not keep her fingers near the nipple

Step 5: Showing the mother how to help the baby to attach

Ask the mother to
l express a little milk on to her nipple
l touch the baby's lips with her nipple
l wait until the baby's mouth is opening wide, and the tongue is down and forward
l move the baby quickly onto her breast, aiming the nipple towards the baby's
palate and his lower lip well below the nipple

Step 6: Look for signs of good attachment

The four key signs of good attachment are:
l More areola is visible above the baby's mouth than below it
l Baby's mouth is wide open
l Baby's lower lip is turned outwards
l Baby's chin is touching the breast
Examples of good and poor attachment are shown in Figure 5

Good attachment Poor attachment

Figure 5: A well attached and poorly attached infant

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 Module 4 - Feeding Normal & LBW

The causes of poor attachment include:

l Use of feeding bottles
l Inexperienced mother
l Lack of skilled support
l Inverted nipples
Hence it is very important NOT TO INTRODUCE BOTTLE FEEDS at any point of time. Poor
attachment usually leads to problems such as:
l Pain or damage to nipple or sore nipple
l Breast engorgement as milk is not removed effectively
l Hungry and irritable baby because of poor milk supply
l Poor weight gain of the baby

Module 4 : Feeding of Normal and Low Brith Weight Babies

Correct positioning and attachment will ensure effective sucking and
prevent sore nipples and breast engorgement

For an infant who shows signs of good attachment, the next step would be to assess if he/she
suckles and swallows effectively:

Step 7: Assess if the infant is suckling and swallowing effectively

Effective sucking Ineffective sucking
Infant takes several slow deep sucks Infant suckles for a short time
followed by swallowing, and but tires out and is unable to
then pauses continue for long enough.

If an infant is not able to attach and suckle effectively at the breast, or is not able to suckle for
long enough to complete a feed, he or she will need to be fed with a spoon or paladai until
effective feeding ability develops.

4. HELP MOTHER RECOGNIZE WHEN THE BABY IS READY TO BREASTFEED

A normal newborn baby will show one or more of the following signs when he is ready to
breastfeed:
l Opens eyes
l Seeks breast
l Head back slightly
l Tongue down and forward
l Mouth wide open
l Licks and saliva drips

5. HOW FREQUENTLY A MOTHER HAS TO BREASTFEED HER BABY?

A healthy newborn baby can be breastfeed ON DEMAND i.e. whenever the baby cries for feeds.
The usual time interval between each feed is about 2 to 3 hours. Mothers should be advised that
they should feed their babies AT LEAST 8-10 times in 24 hours and importantly they should not
omit any night feeds.

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6. ASSESSING THE ADEQUACY OF BREASTFEEDING

After the mother has been counseled and helped in establishing breastfeeding successfully,
ensure that the infant is getting enough breast milk. Often, mothers would be worried about the
amount of milk secreted and whether it is sufficient for their babies. It is the duty of health
personnel to assess and then reassure about the adequacy of breastfeeding.
Breastfeeding is considered adequate if it results in softening of breast after feeding and the
baby
1. Sleeps well in between feeds
2. Passes urine at least 6-8 times in a day
3. Crosses birth weight by 2 weeks
4. Gains weight at least @ 25-30 g/day after initial 7-10 days

Breastfeeding is considered adequate if the infant passes urine 6-8 times in

Module 4 : Feeding of Normal and Low Brith Weight Babies

24 hours, sleeps for 2-3 hrs after feeds, and gains weight adequately

7. EXTRA NUTRITION FOR MOTHER

The energy requirements of women are increased by pregnancy (+350 Kcal) and lactation
(+600Kcal daily during first 6 months and +520Kcal during next 6 months) over and above their
normal requirements. This is to provide for the extra energy needs associated with the
deposition of tissues or the secretion of milk with good health.

8. PROMOTING EXCLUSIVE BREASTFEEDING

It is the duty of the health personnel to ensure exclusive breastfeeding in the postnatal wards
and nurseries. All mothers should be helped and supported in establishing breastfeeding. If
there are any problems, they must be attended to. Mothers should also be counseled regarding
exclusive breastfeeding at the time of discharge.

9. EARLY BREASTFEEDING
l Helps establish successful and exclusive breastfeeding
l Helps the uterus contract to decrease bleeding after birth
l Encourages maternal-baby bonding
To encourage early breastfeeding, position the baby near the mother's breasts, where the baby
can attach when ready to feed. Though a baby may not feed successfully during the first hour
after birth, it is important to encourage breastfeeding during this time. To encourage early
breastfeeding, keep mother and baby together unless a problem separates them. Babies are
often alert immediately after birth and will move and turn toward the mother's breast .

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Key messages to promote exclusive breast feeding

1. Promote skin to skin contact at birth and put baby to breast as soon as possible
after birth. This is important for the mother, baby, and for milk production
2. On the first day, breast milk is thick and yellowish (known as colostrum). Feeding
this milk provides nutrition and prevents infections. Some babies will not latch
during first feeding session. Give no liquids other than breast milk (or colostrum)
even if the baby does not feed. DO NOT DISCARD COLOSTRUM
3. Keep baby close to mother. It is safe for baby to sleep with mother
4. Mother may lie down, sit on a bed, chair or floor to breast feed her baby
5. Breast feed during day and at night for at least eight to ten times and whenever
baby cries with hunger
6. The more the baby sucks at breast, more milk the breast will produce and

Module 4 : Feeding of Normal and Low Brith Weight Babies

healthier the baby becomes
7. Allow baby to feed at one breast until he leaves the nipple on his own. Then feed
him at the other breast if he continues to be hungry
8. Give baby only breast milk for the first six months
9. Don't give baby ghutti water, gripe water, honey, animal or powdered milk
10. NEVER use bottles or pacifier

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 Module 4 - Feeding Normal & LBW

7. ISSUES IN BREAST FEEDING

7.1 Inverted / flat nipples
Flat or short nipples which protract well (become prominent or pull out easily) do not cause
difficulty in breast feeding. Only inverted or retracted nipples make attachment to the
breast difficult. They should be diagnosed in the antenatal period. These mothers need
additional support to feed their babies.
Treatment is started after birth of the baby. Nipple is manually stretched and rolled out
several times a day. To improve attachment in inverted nipple stimulate nipple before
feeding and shaping breast by supporting underneath with the fingers and pressing above
with the thumb. A plastic syringe is used to draw out the nipple and the baby is then put to
the breast.

STEP ONE Cut along the line with blade

Module 4 : Feeding of Normal and Low Brith Weight Babies

Use 10 or 20 cc syringe

STEP TWO

Insert plunger from cut end

STEP THREE

Before the feeds 5-8 times/day

Mother gently pulls the plunger

STEP FOUR Before removing the syringe, press at the edge and
allow air to enter and then remove it

Figure 6: Management of inverted nipple using syringe

7.2 Sore nipples

A sore nipple is caused by incorrect attachment of the baby to the breast. A baby who
sucks only at the nipple does not get enough milk so he sucks more vigorously resulting in
a sore nipple. This results in pain during feeding and fissures or cracks on nipple. Frequent
washing with soap and water and pulling the baby off the breast while he is still sucking
may also result in sore nipple. Fungal infection may cause sore nipple after the first few
weeks.
Treatment consists of ensuring correct positioning and attachment of the baby to the
breast. Hind milk should be applied to the nipple after a feed and the nipples should be
allowed to heal in between feeds.

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 Module 4 - Feeding Normal & LBW

SORE NIPPLES
Causes
l Incorrect attachment: Nipple sucking
l Frequent use of soap and water
l Fungal infection of nipple (especially after the first week of life )
Treatment
l Continue breast feeding and change position. Attach baby to the areola while feeding
l Apply hind milk to the nipple after breast feed
l Expose the nipple to air between feeds. Do not wash each time before and after feed
l Use local antifungal medication when indicated

7.3 Breast engorgement

Milk production increases during the second and third day after delivery. If feeding is
Module 4 : Feeding of Normal and Low Brith Weight Babies

delayed, infrequent or the baby is not well positioned at the breast, the milk accumulates
in the alveoli. As milk production increases, the amount of milk in the breast exceeds the
capacity of the alveoli to store it comfortably. Such a breast becomes swollen, hard, warm,
and painful often mother feels ill and is termed as an engorged breast.
Inhibitor of Breast milk

- If breast remain full of milk

secretion stops

Treatment: Breast engorgement can be prevented by early and frequent breast feeds
and correct attachment of the baby to the breast. Treatment consists of local warm water
packs for not more than 15 minutes. Paracetamol can be given to the mother to relieve
pain. Gently express the milk to soften the breast and then help the mother to correctly
latch the baby to the breast.
7.4 Breast abscess
If conditions like engorged breast, cracked nipple, blocked duct or mastitis are not treated
early, then breast abscess may develop. The mother may have high grade fever and pain
in breast.
Treatment: Mother must be treated with analgesics and antibiotics. The abscess must be
incised and drained. Breast feeding must be continued from the other breast.
7.5 Not enough milk
Mothers often complain that they do not have enough milk. One has to make sure that her
perception about adequacy of milk is true. Only reassurance is needed if baby is gaining
weight and passing adequate amount of urine.

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 Module 4 - Feeding Normal & LBW

Common causes of not enough milk include - not breastfeeding frequently, too short or
hurried breastfeeds, poor position, breast engorgement or mastitis.
Treatment: If baby is not gaining weight adequately, ask mother to feed the baby more
frequently especially during night. Make sure that attachment is proper. Any painful
condition in mother such as sore nipple and mastitis should be taken care of. Mother
should increase her fluid intake and often massaging breast may help. Back massages are
especially useful for stimulating lactation; metoclopramide or domperidone may also help
in some cases.

Module 4 : Feeding of Normal and Low Brith Weight Babies

Figure 7: A helper rubbing a mother's back to release her stress

Back massages are helpful in relaxation of mother which stimulates hormone

production. You should demonstrate the technique of massage to the relative
who can provide it to the mother. Massage should be provided for 15-30
minutes, three-four times a day

8. CONTRAINDICATIONS TO BREAST FEEDING

Mother can feed their babies in nearly all situations. There are indeed very few contraindications
to breastfeeding as mentioned below:
1. Mother on antimetabolite/anticancer/radioactive drug: In these situations,
breastfeeding should be withheld for the period the mother is on the drug. Meanwhile she
can express and discard the milk so as to maintain lactation. Mother can resume breast
feeding after a certain period of cessation of the medication.
2. Inborn error of metabolism: Inborn errors of metabolism like galactosemia and
phenylketonuria. Infants with some IEM should not be breast fed. It is ideal to consult an
expert in Genetics before deciding to stop breastfeeding.
3. HIV : Exposed infants <6 months of age, exclusive breastfeeding is the preferred feeding
option. If breastfeeding may not be possible, for example in situations of maternal death
and severe maternal illness replacement Exclusive feeding should be done only when AFASS
(Available, Feasible, Affordable, Safe, Sustainable) criteria are fulfilled. More details on
module on 'Care of Normal Newborn

Neonatal Division, AIIMS, New Delhi

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 Module 4 - Feeding Normal & LBW

EXPRESSION
OF BREAST MILK

1Wash your hands well with

soap and water

2
Module 4 : Feeding of Normal and Low Brith Weight Babies

Place a clean container below

your breast to collect milk

3Massage the breast gently

towards the nipple

4
Place your thumb and index finger opposite
each other just outside the areola
(Areola is the dark soft circle around the nipple)
Areola

5 Now press back towards

your chest, then gently squeeze
to express milk
www.newbornwhocc.org

6
Repeat step 5 at different
positions around the areola

Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences

Neonatal Division, AIIMS, New Delhi

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 Module 4 - Feeding Normal & LBW

II. FEEDING OF HEALTHY LOW BIRTH WEIGHT BABIES

1. INTRODUCTION
Feeding of low birth weight (LBW <2500gms) babies differs from that of normal birth weight
babies. These babies (especially those <1800 gm) often have difficulty in taking milk directly
from breast and may require more help and ongoing monitoring. They also require more
calories and protein.
2. METHODS OF FEEDING
LBW babies are often born prematurely (before 37 weeks). Unlike term normal birth weight
babies, these preterm LBW babies have some limitations that would make breastfeeding
difficult. The limitations include:
l Inability to suck effectively
l Inability to co-ordinate sucking and swallowing
l Inability to co-ordinate swallowing and breathing

Module 4 : Feeding of Normal and Low Brith Weight Babies

Because of these limitations, some LBW babies cannot be given any oral feeds, while some
might require gavage feeding.
After birth, all low birth weight babies gradually develop the ability to breastfeed directly. Till
that time, they have to be fed by some alternative methods such as orogastic tube feeding or by
using spoon, cup or paladai.
The best way to determine the correct method of feeding for each baby is by observing the infant
during feeding. Depending upon the ability and behavior of the baby while breastfeeding or
spoon/paladai feeding, one can decide the most appropriate method of feeding.
Though this is the 'ideal' method, we can also use birth weight as a guide to decide the method
of feeding. This is only a rough guide, since not all babies with a particular birth weight would
behave in the same way. Preferred methods of feeding for different birth weight categories are
given below:
Birth weight Preferred method of feeding
<1200 gm Baby may need IV fluids initially. Then initiate oro-gastric
tube (gavage) feeding gradually.
1201-1500 gm Most would need spoon/paladai feeds, while some need
oro-gastric tube (gavage) feeding initially.
1501-2000 gm Most babies would accept breastfeeding while some might
need paladai feeds.
>2000 gm Breastfeed as normal birth weight babies but with monitoring.

For babies who are less than 1200 gm, intravenous (IV) fluids might be needed initially. Once
they are stable, gavage feeding can be introduced slowly.
Most babies who are less than 1500 gm and stable can be fed by spoon/paladai. Some might
require feeding by oro-gastric tube. Give ONLY expressed breast milk by either spoon or by
tube. For babies on intra gastric tube feeds, one can try cup or spoon feeds once or twice a day.
If he accepts well, one can reduce the number of tube feeds. The mother can also let baby suck
on her breast after she expresses milk to stimulate her lactation.
Babies between 1500-2000 gm are usually able to accept breastfeeding while some may
require feeds by paladai. Mother should be involved in the care of baby and should be trained
and supervised for paladai feeding.
Babies more than 1800-2000 gms are usually able to feed on the breast. Let the mother put her
baby to breast as soon as she is well enough. Continue to follow-up and weigh them regularly to
make sure that they are getting enough breast milk .

Neonatal Division, AIIMS, New Delhi

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 Module 4 - Feeding Normal & LBW

3. WHAT TO FEED?
LBW babies who are not able to breastfeed directly have to be given EXPRESSED BREAST
MILK either by orogastric tube or by spoon/paladai.
Expression of breast milk
The method of expression is explained in the module on 'Common procedures'.
4. HOW TO FEED?
4.1 Paladai feeding
A paladai is a small bowl with a long pointed tip traditionally used for feeding LBW infants in
some cultures.
The advantages of this feeding method are that it is usually faster than spoon or cup
feeding and that there is less spillage. The disadvantage is that the caregiver has to be
very careful to avoid pouring large amounts of milk into the infant's mouth.
Module 4 : Feeding of Normal and Low Brith Weight Babies

Figure 8: Paladai/spoon feeding

Steps of paladia/spoon feeding

1. The infant should be awake and held sitting semi-upright on the caregiver's lap,
and wrapped to provide support and to keep the arms out of the way
2. Put a measured amount of milk in the paladai
3. Hold the paladai so that the pointed tip rests lightly on the infant's lower lip
4. Tilt the paladai to pour a small amount of milk into the infant's mouth
5. Feed the infant slowly
6. Make sure that the infant has swallowed the milk already taken before giving
any more
7. When the infant has had enough, he or she will close his or her mouth and will
not take any more. Do not force-feed the infant
8. To estimate the amount of milk taken, subtract the milk left in the cup from the
original amount. Also subtract the estimated spillage, if any
9. Wash the spoon /paladai with soap and water .Then put in boiling water for 20
minutes to sterilze before next use

4.2 Oro-gastric tube feeding

Intra-gastric tube feeding is appropriate for an infant who is clinically stable but cannot
accept oral feeds fully.
Intra-gastric tube feeding can be given by two routes, naso-gastric or oro-gastric:
1. Naso-gastric tubes have the advantage that they are more easily fixed in place.
2. Oro-gastric tubes are useful for very preterm babies, particularly those with
respiratory distress.
Neonatal Division, AIIMS, New Delhi
- 20 -
 Module 4 - Feeding Normal & LBW

Naso-gastric tubes, by blocking one nostril, might increase the airway resistance and the
work of breathing in preterm infants. This may lead to increased incidence of desaturation
and apnea.

Intra-gastric tube feeding can be given by two routes: naso-gastric or oro-

gastric; Oro-gastric tube feeding is preferred in very preterm infants

The procedure of insertion of oro-gastric tube and giving a gastric tube feed are
explained in the module on "Common Procedures'.

Module 4 : Feeding of Normal and Low Brith Weight Babies

DEMONSTRATION
Facilitator will conduct a demonstration on 'Intra-gastric tube feeding' and "Expression of breast
milk" using a breast model.

VIDEO

Video on Expression of breast milk , intragastric & paladai feeding

There will be video demonstration on expression of breast milk intra-gastric feeding, paladai
feeding. The video demonstration will be followed by discussion.

_________________________________________________________________________

_________________________________________________________________________

Neonatal Division, AIIMS, New Delhi

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 Module 4 - Feeding Normal & LBW

Feeding of low birth weight and sick newborns

Flowchart 1 : Deciding the initial feeding method

ASSESSMENT ACTION

No Start intravenous fluids

Is the baby clinically stable?

Module 4 : Feeding of Normal and Low Brith Weight Babies

(Also see Flowchart 2)

Yes

No Start intravenous fluids

Is birth weight more than 1200 grams?
(Also see Flowchart 2)

Yes

Is the baby able to breastfeed

effectively?
When offered breast, the baby roots, Yes
Initiate breastfeeding
attaches well and suckles effectively
Able to suckle long enough to satisfy
needs

No

Is the baby able to accept feeds by

alternative methods?
When offered cup or spoon feeds, Yes Give oral feeds by
the baby opens the mouth, takes cup/spoon/paladai*
milk and swallows without coughing/
spluttering
Able to take an adequate quantity to
satisfy needs

No Start oro-/naso- gastric

tube feeds

Paladai is a small cup with a beak

Neonatal Division, AIIMS, New Delhi

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 Module 4 - Feeding Normal & LBW

Flowchart 2 : Babies on IV fluids: Progression to oral feeds

Infants on IV fluids

If hemodynamically stable
# Possible signs of feed intolerance:
Start MEN* / trophic feeds 10-15 ml/kg/day - Vomiting soon after feed
by oro/naso-gastric tube, & - Abdominal distension
Monitor for feed intolerance# - Gastric residue>25% of previous feed
Revert to IV fluids if feed intolerance
Module 4 : Feeding of Normal and Low Brith Weight Babies

If tolerating well

Gradually increase the feed by 10-15 ml/kg/day Baby on oro-/naso-gastric

rd
Taper and Stop IV fluids once feed reach 2/3 feeding
of total daily requirement
If tolerating feed well#

Try to spoon-feed once or twice a day

Also, put onto mothers' breast

If accepting feed well

Gradually increase the frequency

and amount of spoon/paladai feed
Reduce tube feeds accordingly

Baby on Spoon/paladai feed

Put baby on mother's breast before each feed

Observe for good attachment & effective sucking

If able to breastfeed
effectively

Direct breastfeeding
Taper and stop spoon/paladai feed
once the mother is confident

* Minimal Enteral Nutrition

Neonatal Division, AIIMS, New Delhi

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Symposium on AIIMS Protocols in Neonatology III

Minimal Enteral Nutrition

Satish Mishra, Ramesh Agarwal, M. Jeevasankar, Ashok K. Deorari and Vinod K. Paul

WHO Collaborating Centre for Training & Research in Newborn Care, Division of Neonatology, Department of
Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

ABSTRACT
Although parenteral nutrition has been used widely in the management of sick very low birth weight infants, a smooth transition
to the enteral route is most desirable. Trophic feeding is the practice of feeding small volume of enteral feeds in order to
stimulate the development of the immature gastrointestinal tract of the preterm infant. This practice has also been termed as
minimal enteral nutrition (MEN). MEN improves gastrointestinal enzyme activity, hormone release, blood flow, motility and
microbial flora. Clinical benefits include improved milk tolerance, greater postnatal growth, reduced systemic sepsis and shorter
hospital stay. There is currently no evidence of any adverse effects following MEN. MEN can be commenced in neonates on
ventilation and total parenteral nutrition. A protocol of giving MEN has been presented here. [ Indian J Pediatr 2008;
75(3) : 267-269] E-mail: [email protected]

Key words : Very low birth weight infant; Minimal enternal nutrition; Expressed breast milk

Because of concern that oral feedings might increase the preterm neonates may be partly responsible for the
risk of necrotizing enterocolitis (NEC), some high-risk common problems of feed intolerance encountered in
infants have received prolonged period of total parenteral these newborns.
nutrition (TPN) without any enteral feedings. However,
Minimal enteral nutrition (MEN)
lack of enteral nutrients may diminish gastrointestinal
functional and structural integrity by diminishing This is a practice wherein some minute volumes of feeds
hormonal activity, growth of intestinal mucosa, lactase are given to the baby in order to stimulate the
activity, nutrient absorption, or motor maturation. These development of the immature gastrointestinal tract of the
problems may then compromise later feeding tolerance preterm infant. Studies have shown that neonates who
and growth, and thus prolong the hospital stay. The were fed earlier with minimal feeds had lower episodes of
practice of providing minimal enteral nutrition (MEN) or feeding intolerance and gained weight faster as compared
trophic feedings (small volume feedings that provide to neonates who were fed late.2-4 These feeds are of small
minimal calories) for some period after birth was volume ranging from 10 to 15mL/Kg/day and not
developed as a strategy to enhance the functional intended for providing adequate calories. Although MEN
maturation of the gastrointestinal tract and to facilitate a does not provide sufficient calories for growth, it is
smooth and rapid transition from parenteral to enteral beneficial as it exerts a trophic effect on the gut mucosa.
nutrition .
Benefits of MEN
Problems of delayed feeding
Animal studies have shown a 2-3 fold increase in
In several animal species, absence of enteral nutrients is intestinal mucosa mass with early feeding. The trophic
associated with diminished intestinal growth, atrophy of effect on intestinal mucosa may be mediated via various
intestinal mucosa, delayed maturation of intestinal growth factors in human milk. These include insulin,
enzymes, and increase in permeability and bacterial epidermal growth factor and other peptides known to
translocation. A lack of enteral nutrients also affects exert direct trophic effects. Premature infants receiving
intestinal motility, perfusion, and hormonal responses.1 It MEN had cumulative greater milk intake, which was
is possible that a prolonged delay in starting feeds in associated with lower serum alkaline phosphatase
activity. 5 Intestinal motility pattern matures more rapidly
in premature infants receiving early enteral feeding. 4
Correspondence and Reprint requests : Dr. Ashok K Deorari, Investigators have demonstrated that trophic feeds were
Professor, Department of Pediatrics, All India Institute of Medical associated with greater absorption of calcium and
Sciences, Ansari Nagar, New Delhi 110029, India. phosphorus, greater lactase activity, and reduces
[Received February 7, 2008; Accepted February 7, 2008] intestinal permeability.

Indian Journal of Pediatrics, Volume 75March, 2008 267

 S. Mishra et al

Besides the effect on intestinal mucosa, other beneficial following MEN.9

responses to MEN include: (a) motor effects: which
Indications for MEN
include better peristaltic activity and coordinated motor
activity in response to feeding. (b) vascular effects: which All preterm infants especially 32 weeks of gestation, in
include post-prandial decrease in splanchnic vascular whom enteral feeding has not yet been started due to
resistance. This decrease would be associated with an underlying illness, should be commenced on MEN.
increase in intestinal blood flow and oxygen uptake in
Contraindications
response to feeding. (c) endocrine: effects which include
the significant increases in plasma concentrations of MEN should be avoided in infants with severe
enteroglucagon, gastrin, and gastric-inhibiting hemodynamic instability, suspected or confirmed NEC,
polypeptide in preterm infants after milk feedings of as evidence of intestinal obstruction perforation or
little as 12 mL/kg per day. Similar surges in the trophic paralytic ileus. Mechanical ventilation and or use of
hormones were not seen in intravenously nourished umbilical catheters are not contraindication to using
infants. 6 MEN
Clinical benefits of MEN Protocol for MEN
Cochrane meta-analysis on studies evaluating the clinical MEN should be commenced after ensuring hemodynamic
effects of MEN done by Tyson et al,7 has showed that, stability in preterm neonates. This is usually possible by
among infants given trophic feedings, there was an day 2-3 in sick preterm neonates. However MEN may be
overall reduction in mean days to full feeding (weighted started on the first day itself in hemodynamically stable
mean difference [WMD] = -2.6 days; number of days that neonates if no contraindications to feeding exist.
feeding was withheld (WMD = -3.1 days; and total Expressed human breast milk is the preferred milk for
hospital stay (WMD = -11.4 days) compared to infants MEN. Commercial formulas are best avoided for MEN.10
given no enteral nutrient intake. There was no significant Recommended volume is 10-15 mL/Kg/day. This should
increase in the risk of necrotizing enterocolitis (relative be divided into equal aliquots and administered by
risk = 1.16 [0.75, 1.79]). McClure et al, 8 have shown a gavage feeding in a 3-6 hourly schedule. In preterm very
reduction in episodes of culture confirmed sepsis and low birth weight infants born with antenatal diagnosis of
faster weight gain in babies receiving minimal enteral altered in umbilical arterial blood flow (reversed or
nutrition. However, conclusive evidence in favor of MEN absent end diastolic flow), MEN can possibly be delayed
is not yet available due to the small size and number of for 2 to 3 days. Advancement of feeds should also be slow
studies on this issue. Nonetheless, due to obvious and carefully monitored in these infants.
beneficial effects (Table 1), MEN has become a widely
used practice in neonatal intensive care units. Monitoring

Adverse effects of MEN The infant should be monitored for any evidence of feed
intolerance including abdominal girth, gastric residuals or
There is currently no evidence of any adverse effects clinical signs of NEC. If the abdominal girth has increased
by 2 cm, gastric residual volume (GRV) should be
TABLE 1. Advantages of Gastrointestinal Priming with MEN1
checked. Feeding should be stopped in the presence of
1. Shortens time to regain birth weight significant aspirate (>25% of feed or >3mL whichever is
2. Improves feeding tolerance more) and/or bilious or blood stained aspirates.
3. Enhances enzyme maturation
4. Improves gastrointestinal motility Progression to full feeds As baby gains clinical
5. Improves mineral absorption, mineralization stability, feeds are advanced at the rate of 20-30 mL/Kg/
6. Lowers incidence of cholestasis day. Baby is monitored as mentioned above and volume
TABLE 2. Protocol on Minimal Enteral Nutrition (MEN)* of feeds increased gradually to full enteral feeds.

For whom
All preterm infants especially those less than 32 weeks gestation, who are hemodynamically stable but cannot be given enteral feeds

What to feed
Preferably expressed breast milk (EBM)

How much to feed

EBM 8-12 mL/kg/day divided into 4-8 feeds given by gavage feeding

For <1000g 1-2ml every 4-6 hour; for 1000 g 2-3 ml every 2-4 hour;
*Can be started while baby is on ventilator and /or receiving total parenteral nutrition
*In severe birth asphyxia, MEN should be started after 48-72 hours
*VLBW infants born with antenatal diagnosis of altered umbilical arterial blood flow (reversed or absent end diastolic flow), MEN can
possibly be delayed for 2 to 3 days.

268 Indian Journal of Pediatrics, Volume 75March, 2008

 Minimal Enteral Nutrition

In view of profound clinical benefits routine practice of 4. Berseth CL. Effect of early feeding on maturation of the
minimal enteral nutrition should be encouraged in preterm infants small intestine. J Pediatr 1992; 120 : 947-953.
5. Klagsbrun M. Human milk stimulates DNA synthesis and
developing countries using expressed breast milk for
cellular proliferation in cultured fibroblasts. Proc Natl Acad Sci
VLBW infants. USA 1978; 75 : 5057-5061.
6. Berseth CL. Minimal enteral feedings. Clin Perinatol 1995; 22:
REFERENCES 195-205.
7. Tyson JE, Kennedy KA. Trophic feeds for parenterally fed
infants. Cochrane Database Syst Rev 2005.
1. Schanler RJ. Enteral nutrition for high risk neonates. In
8. McClure RJ, Newell SJ. Randomized controlled study of
Ballard RA, ed. Averys Diseases of the Newborn, Philadelphia;
clinical outcome following trophic feeding. Arch Dis Child Fetal
WB Saunders, 2005: 1044.
Neonatal 2000; 82 : F29-F33.
2. Dunn L, Hulman S, Weiner J, Kliegman R. Beneficial effects of
9. McClure RJ. Trophic feeding of the preterm infant. Acta Pediatr
early hypocaloric enteral feeding on neonatal gastrointestinal
2001; 90 : 19-23.
function. Preliminary report of a randomized trial. J Pediatr
10. Troche B, Harvey-Wilkes K, Engle WD, Nielsen HC, Frantz
1988; 112 : 622-629.
ID, Mitchell ML, Hermos RJ. Early minimal feedings promote
3. Slagle Ta, Gross SJ. Effect of early low volume enteral
growth in critically ill premature infants. Biol Neonate 1995; 67:
substrate on subsequent feeding tolerance in very low birth
172-181.
weight infants. J Pediatr 1988; 113 : 526-531.

Indian Journal of Pediatrics, Volume 75March, 2008 269

Symposium on AIIMS Protocols in Neonatology II

Management of Infants with Intra-uterine Growth

Restriction
Ashok K. Deorari, Ramesh Agarwal and Vinod K. Paul

Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New
Delhi, India

ABSTRACT
Intra-uterine growth restriction (IUGR) contributes to almost two-thirds of LBW infants born in India. Poor nutritional status and
frequent pregnancies are common pre-disposing conditions in addition to obstetric and medical problems during pregnancy.
Growth restriction may be symmetrical or asymmetrical depending on the time of insult during pregnancy. The pathological
insult in an asymmetrical IUGR occurs during the later part of the pregnancy and has a brain-sparing effect. Common
morbidities are more frequent in <3rd percentile group as compared to 3rd10th percentile group. Guidelines for management
of IUGR neonates in these two groups have been provided in the protocol. [Indian J Pediatr 2008; 75 (2) : 171-174] E-mail:
[email protected]

Key words : IUGR; LBW; Postnatal management

Nearly one third of neonates born in India are low birth the terminology. SGA a statistical definition, is used for
weight (LBW), weighing less than 2500 grams at birth. A neonates whose birth weight is lower than (less than 10th
babys low birth weight is either the result of preterm percentile for that particular gestational age) population
birth (before 37 completed weeks of gestation) or due to norms. IUGR is a clinical definition and includes neonates
intrauterine growth restriction (IUGR). Later condition is with clinical evidence of malnutrition. This may be in the
akin to malnutrition and may be present in both term and form of loose skin folds on the face and in the gluteal
preterm infants. Neonates affected by IUGR are usually region, absence of subcutaneous fat and peeling of skin.
undernourished, undersized and therefore, low birth Although most IUGR infants would also be SGA, it is
weight. Two-third LBW neonates born in India fall in possible that a small minority of IUGR infants may have
this category.1 Since, IUGR neonates are more likely to birth weights above the 10 th percentile. These
suffer complications including cold stress and morphological IUGR infants would behave like SGA
hypoglycemia, it is important that these infants are infants and should be managed along the same lines as
identified and managed appropriately at birth.2 Even after SGA infants. For purposes of discussion in this paper, the
recovering from neonatal complications, they remain term IUGR would include both the groups of infants .
more prone to poor physical growth, poor
neurodevelopmental outcome, recurrent infection and
chronic diseases (hypertension, hyperlipidemia, diabetes ETIOLOGY
mellitus, coronary heart disease) later in life3.

Poor nutritional status of the mother and frequent

IUGR AND SGA (SMALL-FOR-GESTATIONAL AGE) pregnancies are the major cause of IUGR. Mothers with a
weight of less than 40 Kg and a height of less than 145 cm
often give birth to SGA infants. Insufficient nutritional
Although both the terms are used inter-changeably and
intake during pregnancy also has an adverse effect on
both denote malnutrition, there is a minor difference in
fetal weight. Maternal hypertension, pre-eclampsia, post-
maturity, frequent pregnancies, multiple pregnancy,
anemia, malaria and tobacco use are other causes of
Correspondence and Reprint requests : Dr Ashok K. Deorari, IUGR. 4-6 Chronic maternal diseases of heart, kidneys,
Professor, Department of Pediatrics, All India Institute of Medical lungs or liver may also lead to IUGR.
Sciences, Ansari Nagar, New Delhi 110029, India.
[Received January 11, 2008; Accepted January 11, 2008]

Indian Journal of Pediatrics, Volume 75February, 2008 171

 Ashok K. Deorari et al

TYPES OF IUGR TABLE 1. Common Morbidities in SGA Neonates

Period: Jan 1999 to Period: Aug 04 to

Infants with IUGR are often classified as having Dec 00 (n=156) Jul 05 (n=144)
symmetrical (head circumference, length and weight
Weight <3rd Weight 3rd-10th Weight <10th
equally affected) or asymmetrical (with relative head
percentile percentile (n=109)
growth sparing) growth restriction. Infants with (n=47) percentile (n=144)
symmetric IUGR often have an earlier onset and are
associated with causes that affect total fetal cell number Birth asphyxia
including chromosomal, genetic, teratogenic, intra-uterine Total 4(8.5%) 10 (9.2%) 25 (17%)
Moderate 2 8
infections and severe hypertensive etiologies. Asymmetric Severe 2 2 -
IUGR is often of a later onset, demonstrates preservation Hypoglycemia
of blood flow to brain and is associated with poor Total 12 (25.5%) 14 (12.8%) 24 (17%)
maternal nutrition or late onset exacerbation of maternal Symptomatic 6 3 3
vascular disease (pre-eclampsia, chronic hypertension).7 Asymptomatic 6 11 21
Polycythemia
Total 14 (29.8%) 17 (15.6%) 14 (10%)
CLINICAL FEATURES Symptomatic 3 8 3
Asymptomatic 11 9 11
Hypothermia 0 4 (3.7%) (13.2%)
IUGR or SGA infants are often term or near-term in *Includes 1 baby with hypothermia and 18 babies with cold stress
gestation. Their birth weight usually falls below the 10th
percentile.8 The neonate has an emaciated look and loose and only 7% at 24 h of life. No cases of polycythemia were
skin because of lack of subcutaneous tissue. These are detected at 48 and 72 h of life.
particularly prominent over the buttocks and the thighs.
They look alert and are often plethoric. Comparison of the
head circumference with chest circumference is helpful in MANAGEMENT
the identification of a SGA infant. In infants with
appropriate growth, the head size is usually bigger than
the chest by about 2-cm. In SGA infants, the head Early delivery is indicated if there is arrest of fetal growth
circumference usually exceeds the chest circumference by and pulmonary maturity is satisfactory. Fetal hypoxia
more than 3 cm. A preterm SGA infant would have a may necessitate emergency cesarean section and one
combination of clinical features suggestive of both, should be prepared to receive an asphyxiated infant. If
prematurity and IUGR.9 liquor is meconium stained and the neonate is depressed,
endotracheal suctioning is essential.10 Infant should be
screened for any congenital malformations. Based on
PROBLEMS OF SGA INFANTS initial assessment, decision is taken to either keep the
infant in nursery or with mother (Fig. 1).
Common neonatal morbidities encountered in SGA Birth weight 3 rd 10 th percentile : In the absence of
infants born in our hospital are given in Table 1. The complications including perinatal asphyxia and
common morbidities encountered in IUGR neonates respiratory distress, these neonates may be managed with
include: (a) perinatal asphyxia, (b) hypothermia, (c) the mother (Table 2). Skin-to-skin care helps in
hypoglycemia and (d) polycythemia. These morbidities maintaining temperature and facilitates breast-feeding.
are commoner in the more severely growth restricted Early initiation of breastfeeding and/ or assisted feeding
babies (<3rd percentile) as compared to babies in the 3rd to helps in averting hypoglycemia. Term SGA infants
10th percentile category. usually do not pose any serious difficulties because they
have no problems in direct breast-feeding. To avoid
From August 2004 to July 2005, 144 SGA babies were
hypoglycemia, they should be put to breast within one
born in our hospital. 24 (17%) developed hypoglycemia
hour of birth. However, these infants are at risk of
and 14 (10%) had polycythemia requiring partial
morbidities and should be monitored regularly for
exchange transfusion. Amongst 24 babies with
hypoglycemia and polycythemia in the first 48-72 hours.
hypoglycemia 50% of the total episodes occurred at 2 h,
22% at 48 h, 11% each at 6 and 12 h and only 4% each at 24 Neonates with asymptomatic hypoglycemia should be
and 72 h of age. 12 (50%) had multiple episodes of supplemented with sugar fortified formula feeds. This
hypoglycemia. 3 babies were symptomatic and required may be given with the help of a cup and spoon/ paladai.
intravenous fluid therapy. Rest were managed with Neonates with normoglycemia on regular feeds should be
supplementary oral feeds. Of 14 babies with gradually weaned to exclusive breast-feeding within the
polycythemia, only 3 were symptomatic. Polycythemia next 3-4 days. Failure to maintain normoglycemia despite
was detected at 2 h in 50%, at 6 h in 29%, at 12 h in 14% regular oral feeds should be treated with IV fluids.

172 Indian Journal of Pediatrics, Volume 75February, 2008

 Management of Infants with Intra-uterine Growth Restriction

TABLE 2. Management of SGA Infants neonatal intensive care unit.11

Criteria for admission to Nursery Birth weight <3 rd percentile, gestation <35 weeks :
All SGA infants < 2 SD (3rd percentile) Neonates with severe growth restriction (<3rd percentile)
- Infants with gestational age < 35 wks
or with presence of complications should be managed in
- Infants with birth asphyxia, respiratory distress etc.
Care of SGA infants with mothers (birth weight between 3rd and the intensive care unit (Table 2). This group would
10th percentile, gestation >35 wks) include infants with perinatal asphyxia, symptomatic
Early initiation of breast feeding (within 1 hour) hypoglycemia, symptomatic polycythemia, prematurity
Skin-to-skin care to maintain temperature, monitoring of (<35 weeks), respiratory distress and hypothermia. They
cold stress by mother and health professionals.
should be monitored for hypoglycemia, polycythemia
Monitor blood sugar, hematocrit
Prevent infections and feed intolerance in the initial few days.
Care of SGA infants in Nursery (birth weight <3rd percentile or
Infants with gestation <30 weeks (birth weight <1200
gestation <35 wks)
Nurse in thermo neutral environment grams) should be started on IV fluids initially and
It stable, early initiation of feeds ( EBM). gradually weaned to oral feeds over the next few days. In
Feed by orogastric tube or katori-spoon /paladai if gestation the absence of other complications, oro-gastric feeds
>32 wks should be started for neonates >30 weeks (>1200 grams)
Initial intravenous fluids followed by orogastric or katori- and gradually shifted to katori-spoon/ paladai feeding. An
spoon /paladai if gestation <32 wks
Monitor blood sugar, hematocrit
infant on full oral feeds with spoon-feeding may be tried
Care of SGA infants with absent or reversed en-diastolic blood on direct breast-feeding. These high-risk infants need to
flow be observed for a minimum of 72 hours for hypoglycemia.
At higher risk of development of NEC Infants on full katori-spoon feeding and/ or breast-
If preterm (gestation <32 weeks): Nil per oral or on minimal feeding may be shifted to the mother after 72 hours if she
enteral nutrition for first 48-72 h of life followed by gradual
is confident of on going-care.
advancement of feed volume
Paladai/spoon feeding : Feeding with a spoon (or a
Neonates with symptomatic hypoglycemia should be
similar device such as paladai) and katori (or any other
shifted to a special care nursery and managed
receptacle such as cup) has been found to be safe in SGA
appropriately with a glucose bolus followed by a
infants.8 This mode of feeding is a bridge between gavage
continuous glucose infusion at 6-8 mg/Kg/min.
feeding and direct breast-feeding. It is based on the
Neonates with asymptomatic polycythemia and a premise that neonates with a gestation of 30-32 weeks or
hematocrit <75 maybe managed conservatively by more are in a position to swallow the feeds satisfactorily
increasing fluid intake. The infant should receive regular even though they may not be good at sucking or
(2-3 hourly) breast feeds with extra supplementation. coordinated sucking and swallowing. A medium sized
Infants with symptomatic polycythemia or hematocrit >75 katori and a small (1-2 ml size) spoon should be used. The
should be managed by partial exchange transfusion in the spoon should be filled just short of the brim with

SGA*

Term (borderline)
<35 wk

<3rd percentile 3rd 10th percentile

Admit nursery Monitor with mother Admit nursery

Breastfeeding or katori-spoon Breastfeeding <30 wk initial on IV

30 34 wk orogastric or katori-spoon
*Blood sugar, hematocrit, temperature monitoring
Fig. 1. Algorithm for management of SGA infants

Indian Journal of Pediatrics, Volume 75February, 2008 173

 Ashok K. Deorari et al

expressed milk, should be placed at the corner of mouth significant morbidities (e.g., hypoglycemia, polycythemia,
and milk should be allowed to flow into the infants birth asphyxia) during hospital stay.
mouth slowly, avoiding any spillage. The infant would
actively swallow the milk. This process should be REFERENCES
repeated till the required amount has been fed. If the
infant does not actively accept and swallow the feed, an 1. United Nations Childrens Fund and World Health
attempt should be made to wake the infant with gentle Organization, Low Birthweight: Country,regional and global
stimulation. If he is still sluggish, do not insist on this estimates. UNICEF, New York, 2004.
method. It is better to switch back to gavage feeds till the 2. Arora NK, Paul VK, Singh M. Morbidity and mortality in
term infants with intrauterine growth retardation. J Trop
infant is ready.
Pediatr 1987; 33 : 186-189.
3. Teberg AJ, Walther FJ, Pena IC. Mortality, morbidity, and
outcome of the small-for-gestational-age preterm infant. Semin
SGA/IUGR BABIES WITH ABSENT OR REVERSED
Perinatol 1988; 12 : 84-94.
END-DIASTOLIC FLOW (AREDF) IN UMBILICAL 4. Mavalankar DV, Gray RH, Trivedi CR, Parikh VC. Risk
ARTERY factors for small for gestational age births in Ahmedabad,
India. J Trop Pediatr 1994; 40 : 285-290.
5. Arora NK, Singh M, Paul VK, Bhargava VL. Etiology of fetal
In the IUGR fetus, hypoxemia produces circulatory growth retardation in hospital born infants. Indian J Med Res
redistribution towards the brain and away from the 1987; 85 : 395-400.
viscera and placenta, culminating in umbilical artery or 6. Bhatia BD, Agarwal KN, Jain NP, Bhargava V. Growth
pattern of intrauterine growth retarded (IUGR) infants in first
aortic AREDF in the most severely affected fetuses. The
nine months of life. Acta Pediatr Scand 1984; 73 : 189-196.
combination of antenatal and persisting postnatal 7. Singh M. Disorders of weight and gestation. In Singh M, ed.
disturbances of gut perfusion, interacting with the Care of the Newborn, 5th ed. New Delhi; Sagar Publications,
metabolic demands of feeding, may adversely affect 1999; 224-245.
intestinal tissue oxygenation, combining with stasis and 8. Singh M, Giri SK, Ramachandran K. Intrauterine growth
curves of live-born infants. Indian Pediatr 1974; 11: 475-479.
immunological factors to contribute to the development
9. Paul VK. Management of LBW babies. In Deorari AK, ed.
of NEC. A review by Dorling et al including 14 studies NNF Teaching Aids on Newborn Care. 2nd ed, New Delhi; Noble
and 1178 neonates found higher risk of NEC in IUGR Vision, 1998; 25-36 .
babies with AREDF (odds ratio: 2.13; 95% CI: 1.49 to 10. Niermayer S, Kattwinkel J, Van Reempts P, Nadkarni V,
3.03).12 Although evidence for feeding strategy to be Phillips B, Zideman D et al. International guidelines for
adopted in these babies is limited, it may be prudent to neonatal resuscitation. An excerpt from the guidelines 2000
for cardiopulmonary resuscitation and emergency
start and persist with minimal enteral nutrition for first cardiovascular care. International consensus on Science.
48-72 h of life. Contributors and reviewers for the neonatal resuscitation
guiidelines. Pediatrics 2000; 106 : E29.
LONG-TERM OUTCOME AND FOLLOW-UP 11. Deorari AK, Paul VK, Shrestha L, Singh M. Symptomatic
neonatal polycythemia: comparison of partial exchange
transfusion with saline versus plasma. Indian Pediatr 1995; 32:
IUGR babies are at risk for poor growth and neuro- 1167-1171.
developmental outcome.3 We routinely follow IUGR 12. Dorling J, Kempley S, Leaf A. Feeding growth restricted
babies with birthweight below <3rd percentile and those preterm infants with abnormal antenatal Doppler results. Arch
with birthweight 3-10 th percentile if they develop Dis Child Fetal Neonatal Ed 2005; 90 : F359-F363.

174 Indian Journal of Pediatrics, Volume 75February, 2008

 Parenteral Nutrition
The goal of nutrition management in neonates, especially very low birth weight (VLBW) infants is the
achievement of postnatal growth at a rate that approximates the intrauterine growth of a normal
fetus at the same postmenstrual age. Although, this is best achieved with optimal enteral nutrition,
early enteral feeding is commonly limited by immaturity of gastrointestinal motor function,
manifested principally as delayed stomach emptying, gastro-esophageal reflux, abdominal
distension, and infrequent stooling. Likewise, establishing an alternative source of nutrition becomes
a life-sustaining intervention in surgical neonates with congenital or acquired disease causing
gastrointestinal failure.

Importance of nutrition: What is evidence?

Suboptimal nutrient intake during neonatal period has been associated with increased
vulnerability to infections, greater need of ventilatory support, poor growth and
neurodevelopment outcome, susceptibility to cardiovascular diseases, reduced cell growth in
specific organ systems (heart, kidney and pancreas).1,2
.

Indications
Parenteral nutrition (PN) should be considered in neonates who are not on significant enteral feeds
for more than 3-5 days or are anticipated to be receiving less than 50% of total energy requirement
by day 7 of life (Table 1).

Table 1: Indications of parenteral nutrition

Birth weight less than 1000 g
Birth weight 1000-1500 g and anticipated to be not on significant feeds for 3 or more days
Birth weight more than 1500 g and anticipated to be not on significant feeds for 5 or more days
Surgical conditions in neonates: Necrotizing enterocolitis, Gastroschisis, Omphalocele, Tracheo-
esophageal fistula, Intestinal atresia, Mal-rotation, Short bowel syndrome, and Meconium ileus

Energy
A daily energy intake of 110-120 kcal/kg is needed to meet the metabolic demands of a healthy
premature neonate and to allow for growth rate comparable to intrauterine growth rate.3,4 Energy
requirement of term neonate is 90-100 kcal/kg/day. Energy intake of sick neonates (e.g. acute
respiratory illness, chronic lung disease, necrotizing enterocolitis) is not exactly known but is likely to
be near upper limits of the energy requirement of preterm infant.

10% dextrose solution provides 0.34 kcal/ml. 10% lipid solution provides 0.9 Kcal/ml and 20% lipid
solution provides 1.1 Kcal/ml. If sufficient amount of non-protein energy is not provided, amino
acids are catabolized for energy production. Adequate balance between nitrogen and non-protein
energy sources (Protein/Energy ratio: 3-4 g/100 kcal) is needed to promote protein accretion.5
Balance between carbohydrates and fat is needed to prevent excessive fat deposition and excessive
production of CO2. The ideal distribution of calories should be 50-55% carbohydrate, 10-15%
proteins and 30-35% fats.

Amino acids
PN should provide 3.0-3.5 g/kg/day of AA. An optimal AA solution should contain essential (valine,
leucine, isoleucine, methionine, phenylalanine, threonine, lysine and histidine) and conditionally
essential (cysteine, tyrosine, glutamine, arginine, proline, glycine and taurine) AAs, should not have
excess of glycine and methionine and should not contain sorbitol. Depending on practical feasibility,
AA infusion should be started on the first day of birth preferably soon after birth. To avoid negative
protein balance, one should start with at least 1.5 g/kg/d and then increase by 1 g/kg/d to maximum
of 3.5 g/kg/d.

AA solutions are available as 10% and 20% preparations (appendix).

Proteins in PN: what is evidence?

The amount started on day 1 of PN has varied from 0.5 to 3.0 g/kg/d in different studies. 6 Although,
intake of about 1.5 g/kg/d is needed to prevent negative nitrogen balance, higher intake of 3-3.5
g/kg/d can be safely administered starting from first day of birth.2 Early provision of protein is critical
to attain positive nitrogen balance and accretion, as premature babies lose about 1% of their protein
stores daily.7

Carbohydrates
Carbohydrates are the main energy substrate for the neonates receiving PN. The amount of
carbohydrate delivered in the form of dextrose is commonly initiated at the endogenous hepatic
glucose production and utilization rate of 4 to 6 mg/kg/min. This provides energy intake of 40-50
kcal/kg/d and preserves carbohydrate stores. Once the GIR supports acceptable serum glucose
values, it is advanced in a gradual, stepwise fashion (2 mg/kg/min/day) to a suggested maximum
glucose oxidative rate for neonates of 12-13 mg/kg/min to support growth and maintained there
unless serum glucose values change significantly. Insulin infusion should not be used to increase the
GIR. However, if infant is developing high glucose levels despite glucose infusion rate of 4-6
mg/kg/minute, insulin infusion can be started.

Glucose is available as 5%, 10%, 25% and 50% solutions.

Carbohydrates in PN: What is evidence?

Excessive carbohydrate delivery above the amount that can be oxidized for energy and glycogen
storage can lead to an increase in basal metabolic rate, fat deposition, cholestasis or hepatic
steatosis.8-10 Use of insulin to achieve higher glucose infusion rate and promote growth has been
associated with lactic acidosis.11

Lipids
Lipids can be started on first day at dose of 1.0 g/kg/d and then increased gradually in stepwise
fashion to 3.0 g/kg/d.4 In preterm neonates with hyperbilirubinemia in range of exchange
transfusion threshold, lipids may be restricted to minimum amounts (1 g/kg/d) that will provide only
the essential fatty acids.12

IVL emulsions are available in two strengths: 10% and 20% (Appendix). Use of 20% lipid emulsion is
preferable to a 10% solution to decrease the risk of hypertriglyceridemia, hypercholesterolemia, and
hyperphospholipidemia.13 When lipids are exposed to light, they form potentially toxic lipid
hydroperoxides. Hence lipid syringes and tubing should be covered by wrapping it in aluminum foil.

Lipids in PN: What is evidence?

Even a short delay of 3 to 7 days in supplying lipids to parenterally fed preterm infants leads to
biochemical EFA deficiency.14

Minerals
Sodium, potassium, chloride, calcium, magnesium and phosphorus need to be provided in PN
solution as per their daily needs (Table 2). Except phosphate, all these minerals are easily available in
India. Sodium, potassium, and chloride are essential to life and requirements are dependent on
obligatory losses, abnormal losses, and amounts necessary for growth. Calcium, phosphorus, and
magnesium are the most abundant minerals in the body. They are closely interrelated to each other
in metabolism, the formation of tissue structure, and function. Estimated and advisable intakes
(Table 2) are based on accretion studies and urinary and fecal losses from balance studies.15

Table 2: Daily requirement of minerals

Mineral Requirement
Sodium 0-3 meq/kg/d (1st week of life)
2-3 meq/kg/d (beyond 1st week in term neonates)
3-5 meq/kg/d (beyond 1st week in preterm
neonates)
Potassium 0-2 meq/kg/d (1st week of life)
1-3 meq/kg/d (beyond 1st week)
Chloride 2-3 meq/kg/d
Calcium 150-200 mg/kg/day
Magnesium 15-25 mg/d
Phosphate 20-40 mg/kg/d

Vitamins
Vitamins are added in PN solution to meet the daily requirement (Table 3). Separate preparations of
fat-soluble and water-soluble vitamins suitable for neonates are not available in India. Multivitamin
injection (MVI), when added in a dose of 1.5 mL/kg to lipid solution meets the need of vitamin A and
most other vitamin. Furthermore, intravenous vitamin delivery may be less due to photo-
degradation of vitamins A, D, E, K, B2, B6, B12, C, and folic acid and adsorption of vitamins A, D, and E
into the vinyl delivery bags and tubing. Vitamin K needs to be given separately as weekly
intramuscular injections. Although vitamin B12 is not present in MVI, its deficiency is not manifested
unless the neonate is on long-term PN.
Table 3: Recommended vitamin intake
Vitamin Term (daily dose) Preterm (dose/kg/day)
Vitamin A (IU) 2300 1640
Vitamin D (IU) 400 160
Vitamin E (IU) 7 2.8
Vitamin K (g) 200 80
Vitamin B6 (g) 1000 180
Vitamin B12 (g) 1 0.3
Vitamin C (mg) 80 25
Biotin (g) 20 6
Folic acid (g) 140 56
Niacin (mg) 17 6.8
Pantothenic acid (mg) 5 2
Riboflavin (g) 1400 150
Thiamin (g) 1200 350

Trace elements
Trace elements like zinc, copper, manganese, selenium, fluorine and iodine should be provided in PN
solutions.4 Zinc is universally recommended from day one of TPN, whereas the other trace minerals
are generally provided after 2 weeks of TPN without any appreciable enteral feeding. Copper,
selenium, molybdenum, and iron can be delivered separately also. Dosage of zinc to be provided is
150-400 microgram/kg/d even with short-term PN, but a suitable preparation is difficult to find in
Indian market.

Fluids
Intravenous fluid is the carrying medium for PN. It is started at 60-80 mL/kg/d and advanced by 15-
20 mL/kg/d to maximum of 150 mL/kg/d by end of first week of life. Fluid therapy is regulated by
monitoring hydration status of the infant (weight gain/loss, serum sodium, urinary specific gravity,
urine output and osmolality of plasma and urine).

Evidence-based recommendations
Evidence-based recommendations for use of PN constituents are summarized in Table 4.

Table 4: Evidence-based recommendations for parenteral nutrition

Component Recommendations
Fluids Day 1: 60-80 mL/kg/d.
Postnatal weight loss up to 3% per day to a maximum of 10 to 15% is
acceptable. This is achieved by progressively increasing the fluid intake to 120-
150 mL/kg/d by one week of age.
Energy An intake of 50 kcal/kg/d is sufficient to match ongoing expenditure, but it does
not meet additional requirements of growth. The goal energy intake is 100-120
kcal/kg/d (higher in infants with chronic lung disease)
Protein Optimal parenteral amino acid intake is 3.5 g/kg/d.
Parenteral amino acids can begin from day 1 at 1-1.5 gm/kg/d
Carbohydrates From day one, 6 mg/kg/min can be infused, increased by 2 mg/kg/min/d to 12-
14 mg/kg/min and adjusted to maintain euglycemia
Insulin is only used in infants who continue to have hyperglycemia associated
with glycosuria and osmotic dieresis even after the glucose intake has been
 reduced to 4 to 6 mg/kg/min. Insulin is given as a continuous infusion
commencing at a rate of 0.05 units/kg/h, increasing as required for persistent
hyperglycemia.
Fat Intravenous fat, 1 g/kg/d can be started from day 1, at the same time as when
intravenous amino acids are started. This is increased to 2 g/kg/d and 3 g/kg/d
over the next two days.
It is delivered as a continuous infusion of 20% intravenous fat via a syringe
pump, separate from the infusate containing the amino acids and glucose. The
syringe and infusion line should be shielded from ambient light.
Minerals and Minerals should include: sodium, chloride, potassium, calcium, phosphorus,
magnesium.
Trace Elements Trace elements should include: zinc, copper, selenium, manganese, iodine,
chromium, and molybdenum.
Vitamins Vitamins must be added to the fat emulsion to minimize loss during
administration due to adherence to tubing and photo-degradation.

Dispensing PN solution
In developed countries PN solution is prepared by central pharmacy and delivered ready to be used.
But this facility is usually not available in most of Indian hospitals and physicians and nurses have to
chart and prepare PN. Steps for calculation and preparing PN are as follows (a PN chart is provided in
appendix):

1. Determine total fluid requirement for the day

2. Subtract amount of fluid to be used for medications (e.g. diluting and infusing antibiotics) and
enteral feeds
3. Plan AA, IVL and glucose to be given over 24 h
4. Take IVL suspension in one syringe and add MVI in to it.
5. In second syringe mix AA, dextrose, electrolytes and trace elements
6. IVL+MVI suspension is infused separately from AA-glucose-minerals solution, although they can
be mixed at the site of infusion using a three-way adapter.
7. For calculating amount of each PN component, use following formula:


=

For example, for a baby weighing 1.5 kg to be given 3 mEq/kg of sodium, amount of 3% NaCl to be
used is:
3 / 1.5

3% = = 9
0.5 /
Computer assisted prescribing of PN should be encouraged, as this can save time, improve the
quality of nutritional care and reduce errors.16 All PN solutions should be administered with accurate
flow control. The infusion system should undergo regular visual inspection. Peripheral infusions
should be checked frequently for signs of extravasation. The pump should have free flow prevention
if opened during use, and have lockable settings.
Route of administration
PN can be delivered through peripheral or central venous lines. Short-term PN can be given through
peripheral venous line. Peripheral access offers the advantage of a lower risk of infection due to the
greater distance of the catheter from the central circulation as well as a smaller risk of mechanical
complications.

However, nutrition delivery is limited with peripheral lines due to constraints created by a solution's
osmolarity. The limiting factor in deciding route of delivery is osmolarity of the AA-glucose solution
which is dependent on dextrose concentration. A dextrose concentration greater than 12.5% has an
acidic pH and can be irritating to the peripheral veins. In addition to dextrose, electrolytes and
minerals added to the solution increase the osmolarity of the solution. Hypertonic solution need to
be administered through central venous line.

Increasing use of peripherally inserted central catheters (PICC) has facilitated administration of PN
while avoiding many potential complications of surgically inserted central lines. Another attractive
option in neonates is central line inserted through umbilical vein. Umbilical venous catheter can be
used for up to 14 days after which risk of complications increases.17,18

Position of central line should be confirmed by X-ray before starting infusion through it. To avoid risk
of pericardial tamponade, tip of the central catheter should lie outside the pericardial sac (on the
chest x-ray is at least 0.5 cm outside the cardiac outline). In comparison to catheters made of stiffer
material (polyvinylchloride, polypropylene, polyethylene), softer catheters (silicone and
polyurethane) are less thrombogenic and less traumatic, and are, therefore, preferable for long-term
use. The venous access used for PN should not be interrupted for giving antibiotics or other
medications. For this a separate intravenous line should be established.

Monitoring and complications

Meticulous monitoring is needed in a neonate receiving PN. Monitoring protocol and its rationale is
summarized in Table 5. Monitoring should be more frequent in the initial stages. Once a steady
metabolic stage has been achieved, monitoring can be reduced to once a week.

Complications of PN can be nutrient-related or venous access-related. Nutrient related

complications include hypoglycemia (plasma sugar < 54 mg%) and hyperglycemia (plasma sugar >
150 mg/dL) (glucose-related), azotemia and metabolic acidosis (protein-related),
hypertriglyceridemia (triglyceride >200 mg/dL) (lipid-related), cholestasis and trace element
deficiency. Most of these complications can be avoided by proper monitoring and provision of
nutrients. PN-related cholestasis is usually complication of long-term PN and can be avoided by
provision of at least minimal-enteral nutrition. Catheter-related complications include occlusion,
dislodgement and infection.

Table 5: Monitoring schedule for a neonate on parenteral nutrition

Parameter Frequency
Blood sugar 2-3 times a day while increasing glucose infusing rate
Once a day while on stable glucose infusion rate
Urine sugar once per nursing shift
Serum electrolytes Twice a week initially, then weekly
Blood urea Twice a week initially, then weekly
 Calcium, magnesium Weekly
and phosphorous
Serum albumin Weekly
Packed cell volume Weekly
Liver function tests Weekly
Serum triglycerides Weekly
Anthropometry
Weight Daily at the same time
Head circumference Weekly
Length Weekly
Nutrient intake Energy in kcal per kg day
calculation Proteins in grams per kg per day

Prevention of infection
Hospital-acquired infection (HAI) is a major complication of PN. All efforts should be made to avoid
HAI.

Aseptic precautions during preparation of PN

Use of laminar flow
No compromise on disposables
Trained staff
No reuse of the PN solutions
No interruption of the venous line carrying PN
Use of bacterial filter

Quality improvement
Following process and outcome indicators should be audited in neonatal units which use parenteral
nutrition:

1. Incidence rate of central catheter-associated blood stream infection (per 1000 catheter
days)
2. Incidence rate of central catheter occlusion necessitating catheter removal
3. Incidence rate of parenteral nutrition-associated cholestasis
4. Proportion of eligible neonates who receive parenteral nutrition.
Appendix
Table: Sources of parenteral solutions
Component Source Concentration
Proteins Aminoven 6% and 10%
Primene
Lipids Intralipid 10%, 10% PLR (phospholipids
reduced), 20%
Glucose Dextrose 5%, 10%, 255, 50%
NaCl NaCl 0.9%, 3%
KCl KCl 15%
Calcium Calcium gluconate 10%
Multivitamin Adult MVI -
Trace elements Celcel -
TMA
Magnesium Magnesium sulfate 50%
sulfate
TPN worksheet
An example worksheet provided below can be used to calculate and chart parenteral nutrition
therapy. Steps of charting parenteral nutrition include:

1. Determine birth weight, present weight and weight change since 24 h previous to start of
parenteral nutrition therapy. Birth weight is used to plan nutrient and fluid intake till baby starts
gaining weight and weight on the day of calculation exceeds birth weight. Thereafter weight on
the day of therapy is used for all calculations.
2. Depending on day of birth and fluid status of the neonate, determine total fluid to be
administered over the 24 h period. Of the total fluid calculated amount to be used for giving
parenteral nutrition is determined by subtracting fluid to be administered as enteral feed and as
diluent for intravenous drugs (e.g. antibiotics).
3. Plan amino acids, lipids, glucose and electrolytes (sodium and potassium) to be given over 24 h.
4. For calculating amount of each PN component, use following formula:


=

For example, for a baby weighing 1.5 kg to be given 3 mEq/kg of sodium, amount of 3% NaCl to be
used is:
3 / 1.5

3% = = 9
0.5 /
5. Take lipid suspension in one syringe and add MVI in to it. To account for some volume loss in
dead space of the syringe and fluid administration set, one can take additional 20% amount in
syringe (overfill). Rate of administration can be calculated by dividing total volume (before
overfill) by duration of administration (24 h).
6. In second syringe amino acids, dextrose, electrolytes and trace elements are mixed together. In
this solution also, to account for some volume loss in dead space of the syringe and fluid
administration set, one can take additional 20% amount of each constituting. More than one
syringe can be used if volume to be administered exceeds syringe capacity.
7. Lipids, amino acids and electrolytes to be used are calculated based on formula given above.
After taking into account fluid allowance consumed for each component, remaining fluid is used
for administration of glucose. Total grams of glucose to be administered can be calculated by
multiplying glucose infusion rate with birth weight and 1.44. Different glucose strength solution
can be used to provide the amount of dextrose in the allocated fluid (left after taking into
consideration all other constituents of parenteral nutrition).
8. Lipid + MVI suspension is infused separately from amino acid-glucose-minerals solution,
although they can be mixed at the site of infusion using a three-way adapter.
Name Date of birth Age
B. wt Weight Gain/los
s
Total fluid rate(ml/kg/day) Net
fluid(ml)
Feed volume(ml) Other
medication
s (ml)
Parenteral fluid (ml)
Strengt gm/kg/day mEq/kg/ Strength
h (%) d
Lipid planned Sodium
Amino acid planned Potassi
um
GIR planned

Multiply with 1.2 for overfill

Lipid volume required (ml)
MVI (ml)
Total lipid solution (ml)
Fluid rate (ml/hr)

Amino acid (ml)

10% Calcium gluconate
(ml)
Sodium chlroride
Potassium chloride
TMA
Magnesium
Others Energy Kcal/kg
Carbohy
drate
Protein
Net (ml) Fat
Total

Fluid left for Glucose

Total grams of glucose to
be given
5% dextrose (ml)
10% dextrose (ml)
25% dextrose (ml)
50% dextrose (ml)
Net (ml)
Glucose fluid rate
Research Subjects Study design Interventio Outcomes to be
question n measured
1. Can Preterm Randomized Peripherally 1. Energy, amino
parenter neonates controlled inserted acids, lipids
al needing trial central delivered
nutrition parentera catheter 2. Weight gain
be l nutrition versus 3. Rate of
delivere peripheral hospital-acquired
d venous blood
through catheter stream
peripher infections
al
venous
catheter
2. Umbilica Preterm Randomized 7 versus 14 1. Rate of
l venous neonates controlled days hospital-acquired
catheter needing trial blood
can be parentera stream
used for l nutrition infections
what
duration
without
increasin
g risk of
infection
?
3. What Preterm Prospective No Rate of
are SGA and cohort study complications:
complica AGA 1. Neonatal
tions of neonates Retrospective cholestasis
parenter case-control 2. Age at full
al study feeds
nutrition 3. Weight gain
in SGA 4. Rate of
neonate hospital-
s? acquired
blood stream
infections
4. What Preterm Randomized Starting full 1. Energy, amino
are neonates controlled dose acids, lipids
benefits needing trial parenteral delivered
and parentera nutrition 2. Weight gain
harms of l nutrition immediatel 3. Rate of
giving y after birth hospital-acquired
aggressiv versus blood
e gradually stream
nutrition building up infections
? the dose 4. Metaboli
administere c profile: serum
d ammonia, blood
5. Should Preterm Randomized Lipid 1. Free bilirubin
dose of neonates controlled restricted to 2. Concentratio
lipids be needing trial 1-1.5 g/kg n of free
restricte parenteral day versus radicals/oxid
d in nutrition full dose 3 ative
neonate and with g/kg/d metabolites
 s under significant 3. Brainstem
phototh hyperbiliru auditory
erapy? binemia evoked
response
6. What is Neonates Prospective None 1. Proportion of
quality needing cohort study neonates
of parenteral who get
delivery nutrition as parenteral
of per unit nutrition as
parenter protocol per evidence-
al based unit
nutrition protocol
2. Rate of
catheter
related
complication
s
3. Rate of
parenteral
nutrition
related
complication
s
4. Energy and
metabolite
actually
administered
References

1. Vlaardingerbroek H, van Goudoever JB, van den Akker CH. Initial nutritional management of
the preterm infant. Early Hum Dev 2009;85:691-5.
2. te Braake FW, van den Akker CH, Riedijk MA, van Goudoever JB. Parenteral amino acid and
energy administration to premature infants in early life. Semin Fetal Neonatal Med 2007;12:11-8.
3. Hulzebos CV, Sauer PJ. Energy requirements. Semin Fetal Neonatal Med 2007;12:2-10.
4. Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R. 1. Guidelines on Paediatric Parenteral
Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition
(ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by
the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41 Suppl 2:S1-
87.
5. Ziegler EE, Thureen PJ, Carlson SJ. Aggressive nutrition of the very low birthweight infant.
Clin Perinatol 2002;29:225-44.
6. van den Akker CH, Vlaardingerbroek H, van Goudoever JB. Nutritional support for extremely
low-birth weight infants: abandoning catabolism in the neonatal intensive care unit. Curr Opin Clin
Nutr Metab Care 2010;13:327-35.
7. Heird WC, Discoll J. Total parenteral nutrition. NeoReviews 2003;4:e137-e9.
8. Kanarek K, Santeiro M, Malone J. Continuous infusion of insulin in hyperglycemic low-birth
weight infants receiving parenteral nutrition with and without lipid emulsion. . J Parenter Enteral
Nutr 1991;15:417-20.
9. Henry B. Pediatric Parenteral Nutrition Support. . In: Nevin-Folino N, ed. Pediatric Manual of
Clinical Dietetics: Faulhabes; 2003:495-514.
10. Shulman RJ. New developments in total parenteral nutrition for children. Curr Gastroenterol
Rep 2000;2:253-8.
11. Poindexter BB, Karn CA, Denne SC. Exogenous insulin reduces proteolysis and protein
synthesis in extremely low birth weight infants. J Pediatr 1998;132:948-53.
12. Aba-Sinden A, Bollinger R. Challenges and controversies in the nutrition support of the
preterm infant. Support Line 2002;2:2-15.
13. Haumont D, Deckelbaum RJ, Richelle M, et al. Plasma lipid and plasma lipoprotein
concentrations in low birth weight infants given parenteral nutrition with twenty or ten percent lipid
emulsion. J Pediatr 1989;115:787-93.
14. Gutcher GR, Farrell PM. Intravenous infusion of lipid for the prevention of essential fatty acid
deficiency in premature infants. Am J Clin Nutr 1991;54:1024-8.
15. Ziegler EE, O'Donnell A, Nelson S. Body composition of the reference fetus. . Growth
1976;40:320-41.
16. Puangco MA, Nguyen HL, Sheridan MJ. Computerized PN ordering optimizes timely nutrition
therapy in a neonatal intensive care unit. J Am Diet Assoc 1997;97:258-61.
17. O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular
catheter-related infections. The Hospital Infection Control Practices Advisory Committee, Center for
Disease Control and Prevention, U.S. Pediatrics 2002;110:e51.
18. Butler-O'Hara M, Buzzard CJ, Reubens L, McDermott MP, DiGrazio W, D'Angio CT. A
randomized trial comparing long-term and short-term use of umbilical venous catheters in
premature infants with birth weights of less than 1251 grams. Pediatrics 2006;118:e25-35.
 Sepsis in the Newborn

Sepsis is the commonest cause of neonatal mortality; it is responsible for about 30-50% of the total
neonatal deaths in developing countries.1,2 It is estimated that up to 20% of neonates develop sepsis
and approximately 1% die of sepsis related causes.2 Sepsis related mortality is largely preventable
with prevention of sepsis itself, timely recognition, rational antimicrobial therapy and aggressive
supportive care.

Epidemiology: Indian data

The incidence of neonatal sepsis according to the data from National Neonatal Perinatal Database
(NNPD, 2002-03) is 30 per 1000 live births. The NNPD network comprising of 18 tertiary care
neonatal units across India found sepsis to be one of the commonest causes of neonatal mortality
contributing to 19% of all neonatal deaths3.

Among intramural births, Klebsiella pneumoniae was the most frequently isolated pathogen
(32.5%), followed by Staphylococcus aureus (13.6%). Among extramural neonates (referred from
community/other hospitals), Klebsiella pneumoniae was again the commonest organism (27%),
followed by Staphylococcus aureus (15%) and Pseudomonas (13%).3

Definition
Neonatal sepsis is a clinical syndrome characterized by signs and symptoms of infection with or
without accompanying bacteremia in the first month of life. It encompasses various systemic
infections of the newborn such as septicemia, meningitis, pneumonia, arthritis, osteomyelitis, and
urinary tract infections.

Superficial infections like conjunctivitis and oral thrush are not usually included under neonatal
sepsis.

Classification of neonatal sepsis

Neonatal sepsis can be classified into two major categories depending up on the onset of
symptoms:4
Early onset sepsis (EOS): It presents within the first 72 hours of life. In severe cases, the neonate
may be symptomatic at birth. Infants with EOS usually present with respiratory distress and
pneumonia. The source of infection is generally the maternal genital tract. Some maternal/ perinatal
conditions have been associated with an increased risk of EOS. Knowledge about these potential risk
factors would help in early diagnosis of sepsis.
Based on the studies from India, the following risk factors seem to be associated with an increased
risk of early onset sepsis:4, 5
1. Low birth weight (<2500 grams) or prematurity
2. Febrile illness in the mother with evidence of bacterial infection within 2 weeks prior to
delivery
3. Foul smelling and/or meconium stained liquor

1
 4. Rupture of membranes >24 hours
5. Single unclean or > 3 sterile vaginal examination(s) during labor
6. Prolonged labor (sum of 1st and 2nd stage of labor > 24 hrs)
7. Perinatal asphyxia (Apgar score <4 at 1 minute)
Presence of foul smelling liquor or three of the above mentioned risk factors warrant initiation of
antibiotic treatment. Infants with two risk factors should be investigated and then treated
accordingly.

Late onset sepsis (LOS): It usually presents after 72 hours of age. The source of infection in LOS is
either nosocomial (hospital-acquired) or community-acquired and neonates usually present with
septicemia, pneumonia or meningitis.6,7 Various factors that predispose to an increased risk of
nosocomial sepsis include low birth weight, prematurity, admission in intensive care unit,
mechanical ventilation, invasive procedures, administration of parenteral fluids, and use of stock
solutions.

Factors that might increase the risk of community-acquired LOS include poor hygiene, poor cord
care, bottle-feeding, and prelacteal feeds. In contrast, breastfeeding helps in prevention of
infections.

Clinical features
Non-specific features: The earliest signs of sepsis are often subtle and nonspecific; indeed, a high
index of suspicion is needed for early diagnosis. Neonates with sepsis may present with one or more
of the following symptoms and signs (a) Hypothermia or fever (former is more common in preterm
low birth weight infants) (b) Lethargy, poor cry, refusal to suck (c) Poor perfusion, prolonged
capillary refill time (d) Hypotonia, absent neonatal reflexes (e) Brady/tachycardia (f) Respiratory
distress, apnea and gasping respiration (g) Hypo/hyperglycemia (h) Metabolic acidosis.

Specific features related to various systems:

Central nervous system (CNS): Bulging anterior fontanelle, vacant stare, high-pitched cry, excess
irritability, stupor/coma, seizures, neck retraction. Presence of these features
should raise a clinical suspicion of meningitis
Cardiac: Hypotension, poor perfusion, shock
Gastrointestinal: Feed intolerance, vomiting, diarrhea, abdominal distension, paralytic ileus,
necrotizing enterocolitis (NEC)
Hepatic: Hepatomegaly, direct hyperbilirubinemia (especially with urinary tract
infections)
Renal: Acute renal failure
Hematological: Bleeding, petechiae, purpura
Skin changes: Multiple pustules, abscess, sclerema, mottling, umbilical redness and
discharge.

2
Investigations
Since treatment should be initiated in a neonate suspected to have sepsis without any delay, only
minimal and rapid investigations should be undertaken8.

Blood culture: It is the gold standard for diagnosis of septicemia and should be performed in all
cases of suspected sepsis prior to starting antibiotics. A positive blood culture with sensitivity of the
isolated organism is the best guide to antimicrobial therapy. Therefore it is very important to follow
the proper procedure for collecting a blood culture.

The resident doctor/staff should wear sterile gloves prior to the procedure and prepare a patch of
skin approximately 5 cm in diameter over the proposed veni-puncture site. This area should be
cleansed thoroughly with 70% isopropyl alcohol, followed by povidone-iodine, and followed again
by alcohol. Povidone-iodine should be applied in concentric circles moving outward from the centre.
The skin should be allowed to dry for at least 1 minute before the sample is collected.

One-mL sample of blood should be adequate for a blood culture bottle containing 5-10 mL of
culture media. Since samples collected from indwelling lines and catheters are likely to be
contaminated, cultures should be collected only from a fresh veni-puncture site. All blood cultures
should be observed for at least 72 hours before they are reported as sterile. It is now possible to
detect bacterial growth within 12-24 hours by using improved bacteriological techniques such as
BACTEC and BACT/ALERT blood culture systems. These advanced techniques can detect bacteria at a
concentration of 1-2 colony-forming unit (cfu) per mL.

Septic screen9,10: All neonates suspected to have sepsis should have a septic screen to corroborate
the diagnosis. However, the decision to start antibiotics need not be conditional to the sepsis screen
result, if there is a strong clinical suspicion of sepsis.

The various components of the septic screen include total leukocyte count (TLC), absolute
neutrophil count (ANC), immature to total (IT) neutrophil ratio, micro-erythrocyte sedimentation
rate and C reactive protein (CRP) (Table 1).

Table 1: A practical sepsis screen

Components Abnormal value
3
Total leukocyte count <5000/mm
Absolute neutrophil count Low counts as per Manroe chart11 for term and
Mouzinhos chart12 for VLBW infants
Immature/total neutrophil >0.2
Micro-ESR >15 mm in 1st hour
C reactive protein (CRP) >1 mg/dl
(ESR, erythrocyte sedimentation rate)

3
The ANC varies considerably in the immediate neonatal period and the normal reference ranges are
available from Manroes charts.11 The lower limit for normal ANC begins at 1800/cmm at birth, rises
to 7200/cmm at 12 hours of age and then declines and persists at 1800/cmm after 72 hours of age.
For very low birth weight infants, the reference ranges are available from Mouzinhos charts.12 The
I/T ratio is 0.16 at birth and declines to a peak value of 0.12 after 72 hours of age.

Presence of two abnormal parameters in a screen is associated with a sensitivity of 93-100%,

specificity of 83%, positive and negative predictive values of 27% and 100% respectively in detecting
sepsis. Hence, if two (or more) parameters are abnormal, it should be considered as a positive
screen and the neonate should be started on antibiotics. If the screen is negative but clinical
suspicion persists, it should be repeated within 12 hours. If the screen is still negative, sepsis can be
excluded with reasonable certainty.

Lumbar puncture (LP): The incidence of meningitis in neonatal sepsis has varied from 0.3-3% in
various studies.3,6 The clinical features of septicemia and meningitis often overlap; it is quite
possible to have meningitis along with septicemia without any specific symptomatology. This
justifies the extra precaution of performing LP in neonates suspected to have sepsis.

In EOS, lumbar puncture is indicated in the presence of a positive blood culture or if the clinical
picture is consistent with septicemia. It is not indicated if antibiotics have been started solely due to
the presence of risk factors. In situations of late onset sepsis, LP should be done in all infants prior to
starting antibiotics.

Lumbar puncture could be postponed in a critically sick neonate. It should be performed once the
clinical condition stabilizes. The cerebrospinal fluid characteristics are unique in the newborn period
and normal values are given in Table 2.13

Table 2: Normal cerebrospinal fluid examination in neonates13

CSF Components Normal range
Cells/mm3 8 (0-30 cells)
PMN (%) 60%
CSF protein (mg/dL) 90 (20-170)
CSF glucose (mg/dL) 52 (34-119)
CSF/ blood glucose (%) 51 (44-248)

(PMN, polymorphonuclear cells; CSF, cerebrospinal fluid)

4
Radiology: Chest x-ray should be considered in the presence of respiratory distress or apnea. An
abdominal x-ray is indicated in the presence of abdominal signs suggestive of necrotizing
enterocolitis (NEC). Neurosonogram and computed tomography (CT scan) should be performed in
all patients diagnosed to have meningitis.

Urine culture: urine cultures have a low yield and are not indicated routinely. However, neonates at
risk for fungal sepsis, with urogenital malformation or vesicoureteral reflex or suspected of UTI
(crying during micturition) should have a urine examination done to exclude urinary tract infection
(UTI). Urine cultures obtained by suprapubic puncture, bladder catheterization or clean catch
sample from midstream of urine.

UTI may be diagnosed in the presence of one of the following: (a) >10 WBC/mm3 in a 10 mL
centrifuged sample (b) >104 organisms/mL in urine obtained by catheterization and (c) any organism
in urine obtained by suprapubic aspiration

Management
Supportive: Adequate and proper supportive care is crucial in a sick neonate with sepsis. He/she
should be nursed in a thermo-neutral environment taking care to avoid hypo/hyperthermia. Oxygen
saturation should be maintained in the normal range; mechanical ventilation may have to be
initiated if necessary. If the infant is hemodynamically unstable, intravenous fluids should be
administered and the infant is to be monitored for hypo/hyperglycemia. Volume expansion with
crystalloids/colloids and judicious use of inotropes are essential to maintain normal tissue perfusion
and blood pressure. Packed red cells and fresh frozen plasma might have to be used in the event of
anemia or bleeding diathesis.

Antimicrobial therapy: There cannot be a single recommendation for the antibiotic regimen of
neonatal sepsis for all settings. The choice of antibiotics depends on the prevailing flora in the given
unit and their antimicrobial sensitivity. This protocol does not aim to provide a universal
recommendation for all settings but lays down broad guidelines for the providers to make a rational
choice of antibiotic combination. Decision to start antibiotics is based upon clinical features and/ or
a positive septic screen. However duration of antibiotic therapy is dependent upon the presence of
a positive blood culture and meningitis (Table 3).

Table 3. Duration of antibiotic therapy in neonatal sepsis

Diagnosis Duration
Meningitis (with or without positive blood/CSF culture) 21 days

Blood culture positive but no meningitis 14 days

Culture negative sepsis (screen positive and clinical 5-7 days

course consistent with sepsis)

5
Indications for starting antibiotics: The indications for starting antibiotics in neonates at risk of EOS
include any one of the following:
(a) presence of >3 risk factors for early onset sepsis (see above)
(b) presence of foul smelling liquor
(c) presence of 2 antenatal risk factor(s) and a positive septic screen and
(d) strong clinical suspicion of sepsis.
The indications for starting antibiotics in LOS include:
(a) positive septic screen and/or
(b) strong clinical suspicion of sepsis.

Prophylactic antibiotics: We do not use prophylactic antibiotics in the following circumstances:

infants on IV fluids/TPN, meconium aspiration syndrome, and after exchange transfusion(s). An
exchange transfusion conducted under strict asepsis (single use catheter, sterile gloves, removal of
catheter after the procedure) does not increase the risk of sepsis and hence does not merit
antibiotics. However a messy exchange transfusion could be treated with prophylactic antibiotics. In
our unit, ventilated neonates are treated with prophylactic amikacin for the period of ventilation.

Choice of antibiotics: Empirical antibiotic therapy should be unit-specific and determined by the
prevalent spectrum of etiological agents and their antibiotic sensitivity pattern. Antibiotics once
started should be modified according to the sensitivity reports. Guidelines for empirical antibiotic
therapy have been provided in Table 4.
Table 4. Empirical choice of antibiotics for treatment of neonatal sepsis

Clinical situation Septicemia & Meningitis

Pneumonia

FIRST LINE Penicillin or Ampicillin Add Cefotaxime

Community-acquired and
(Resistant strains unlikely) Gentamicin

SECOND LINE Ampicillin or Cloxacillin Add Cefotaxime

Hospital-acquired and
Some strains are likely to be Gentamicin or Amikacin
resistant

THIRD LINE Cefotaxime or

Piperacillin-Tazobactam or
Ciprofloxacin Same (Avoid Cipro)
Hospital-acquired sepsis and
(Most strains are Amikacin;
Likely to be resistant)

Consider Vancomycin if MRSA is suspected.

6
The empirical choice of antibiotics is dependent upon the probable source of infection. For
infections that are likely to be community-acquired where resistant strains are unlikely, a
combination of ampicillin or penicillin with gentamicin may be a good choice as a first line therapy.

For infections that are acquired during hospital stay, resistant pathogens are likely and a
combination of ampicillin or cloxacillin with gentamicin or amikacin may be instituted. In nurseries
where this combination is ineffective due to the presence of multiple resistant strains of klebsiella
and other gram-negative bacilli, a combination of a third generation cephalosporin (cefotaxime or
ceftazidime) with amikacin may be appropriate. 3rd generation cephalosporins have very good CSF
penetration and are traditionally thought to have excellent antimicrobial activity against gram
negative organisms. Hence they were considered to be a good choice for the treatment of
nosocomial infections and meningitis. However, recent reports suggest that at least 60-70% of the
Gram-ve organisms are resistant to them.14-16 More over, routine use of these antibiotics might
increase the risk of infections with ESBL (extended spectrum beta-lactamase) positive organisms.
Therefore it is preferable to use antibiotics such as piperacillin-tazobactam or
methicillin/vancomycin in units with high incidence of resistant strains.

A combination of piperacillin-tazobactam with amikacin should be considered if pseudomonas

sepsis is suspected. Penicillin resistant staphylococcus aureus should be treated with cloxacillin,
nafcillin or methicillin. Addition of an aminoglycoside is useful in therapy against staphylococcus.
Methicillin resistant staphylococcus aureus (MRSA) should be treated with a combination of
ciprofloxacin or vancomycin with amikacin. Ciprofloxacin has excellent activity against gram-
negative organisms also; however, it does not have good CSF penetration. It may be used for the
treatment of resistant gram-negative bacteremia after excluding meningitis.

For sepsis due to enterococcus, a combination of ampicillin and gentamicin is a good choice for
initial therapy. Vancomycin should be used for the treatment of enterococcus resistant to the first
line of therapy.
The dosage, route, and frequency of commonly used antibiotics are given in Table 5.

Reserve antibiotics: Newer antibiotics like aztreonam, meropenem and imipenem are also now
available in the market. Aztreonam has excellent activity against gram-negative organisms while
meropenem is effective against most bacterial pathogens except methicillin resistant
staphylococcus aureus (MRSA) and enterococcus. Imipenem is generally avoided in neonates
because of the reported increase in the incidence of seizures following its use. Empirical use of these
antibiotics should be avoided; they should be reserved for situations where sensitivity of the
isolated organism warrants its use.

Adjunctive therapy
Exchange transfusion (ET): Sadana et al17 have evaluated the role of double volume exchange
transfusion in septic neonates with sclerema and demonstrated a 50% reduction in sepsis related
mortality in the treated group. We perform double-volume exchange transfusion with cross-
matched fresh whole blood as adjunctive therapy in septic neonates with sclerema.

7
Intravenous Immunoglobulin (IVIG): Non-specific pooled IVIG has not been found to be useful.18
Granulocyte-Macrophage colony stimulating factor (GM-CSF): This mode of treatment is still
experimental.19

Table 5. Drugs, route of administration and doses of common antibiotics used.

Drug Route Birth Weight 2000g Birth Weight >2000g

0-7 d >7 days 0-7 days >7 days

Amikacin I/V, I/M 7.5 q12h 7.5 q8h 10 q12h 10 q8h

Ampicillin
Meningitis I/V 100 q12h 100 q8h 100 q 8h 100 q6h
Others I/V, I/M 25 q12h 25 q8h 25 q8h 25 q6h

Cefotoxime
Meningitis I/V 50 q6h 50 q6h 50 q6h 50 q6h
Others I/M, I/V 50 q12h 50 q8h 50 q12h 50 q8h

Piperacillin+ I/V 50-100 q12h 50-100 q8h 50-100 q12h 50-100 q12h
Tazobactam

Ceftriaxone I/M, I/V 50 q24h 50 q24h 50 q24h 75 q24h

Ciprofloxacin I/V, PO 10-20 q24h 10-20 q24h 10-20 q12h 10-20 q12h

Cloxacillin
Meningitis I/V 50 q12h 50 q8h 50 q8h 50 q6h
Others I/V 25 q12h 25 q8h 25 q8h 25 q6h

Gentamicin
Conventional I/V, I/M 2.5 q12h 2.5 q8h 2.5 q12h 2.5 q8h
Single dose I/M 4 q24 h 4 q24 hr 5 q24h 5 q24h

Netilmicin I/V, I/M 2.5 q12h 2.5 q8h 2.5 q12h 2.5 q8h

Penicillin G (units/kg/dose)
Meningitis I/V 75,000 q12h 75,000 q8h 75,000 q8h 75,000 q6h
-100,000 -1,00,000 -1,00,000 -1,00,000
Others I/V, I/M 25,000 q12h 25,000 q8h 25,000 q8h 25,000 q6h

Vancomycin I/V 15 q12h 15 q8h 15 q12h 15 q8h

All doses are in mg/kg/dose; (I/V, intravenous; I/M, intramuscular; PO, per-oral; h, hourly)

8
 Table 7 : Research questions pertaining to neonatal sepsis
Research question Subjects Study Interven Outcomes to
design tion be measured

1. Does antimicrobial All Before and Bundle The incidence

stewardship (AMS) babies after study of of health care
reduce the rates of admitted intervent associated
health care to NICU ions to infections,
associated infections constitut neonatal
in NICU? e AMS: mortality
2.What is the rate of All Retrospectiv None Rates of
medication errors babies e study medication
with regard to admitted errors and
antibiotic prescripti- to NICU estimated
on in a level II NICU? in the additional costs
last two due to it
years
3. What are the All Descriptive None The rates of
trends of de- babies study de-escalation
escalating from admitted of therapy and
broad-spectrum to NICU incidence of
combination therapy and infections/mor
to directed therapy receiving bidities after
and the rates of antibioti antibiotic
relapse of infection cs change
in those undergoing
this de-escalation?
4. What is the culture All Descriptive None The rate of
positivity rates in babies study blood, CSF and
babies previously born in (stratified by other fluids
exposed with the birth culture
antibiotics? hospital weight/gest
to ational age)
mothers
with
prior
antibioti
c
exposur
e
5. What is the All Descriptive None The costs of
antimicro-bial babies both out of
expenditu-re(both receiving pocket and
out of pocket and antibioti hospital supply
hospital supply) and cs in antibiotic per
trends over time? NICU baby receiving
antibiotics

10
6. Does the use of All RCT Rifampin Colony count
rifampin in cases of babies of MRSA in
proven MRSA developi colonized
infection reduce the ng patients
rates of colonization proven
and incidence of MRSA
MRSA? infection

11
References

1. Bang AT, Bang RA, Bactule SB, Reddy HM, Deshmukh MD. Effect of home-based neonatal care and
management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354:1955-61
2. Stoll BJ. The global impact of neonatal infection. Clin Perinatol 1997;24:1-21
3. Report of the National Neonatal Perinatal Database (National Neonatology Forum) 2002-03.
4. Singh M, Narang A, Bhakoo ON. Predictive perinatal score in the diagnosis of neonatal sepsis. J Trop Pediatr.
1994 Dec;40(6):365-8
5. Takkar VP, Bhakoo ON, Narang A. Scoring system for the prediction of early neonatal infections. Indian Pediatr.
1974;11:597-600
6. Baltimore RS. Neonatal nosocomial infections. Semin Perinatol 1998;22:25-32
7. Wolach B. Neonatal sepsis: pathogenesis and supportive therapy. Semin Perinatol1997;21:28-38
8. Gerdes JS, Polin R. Early diagnosis and treatment of neonatal sepsis. Indian J Pediatr 1998;65:63-78.
9. Polinski C. The value of white blood cell count and differential in the prediction of neonatal sepsis. Neonatal
Netw 1996;15:13-23
10. Da Silva O, Ohlsson A, Kenyon C. Accuracy of leukocyte indices and C-reactive protein for diagnosis of neonatal
sepsis: a critical review. Pediatr Infect Dis J 1995;14:362-6
11. Manroe BL, Weinberg AG, Rosenfeld CR, Browne R. The neonatal blood count in health and disease. I.Refernce
values for neutrophilic cells. J Pediatr 1979;95:89-98
12. Mouzinho A, Rosenfeld CR, Sanchez PJ, Risser R. Revised reference ranges for circulating neutrophils in very-
low-birth-weight neonates. Pediatrics 1994;94:76-82.
13. Sarff LD, Platt LH, McCracken GH Jr. Cerebrospinal fluid evaluation in neonates: Comparison of high-risk
neonates with and without meningitis. J Pediatr 1976;88:473-7
14. Upadhyay A, Aggarwal R, Kapil A, Singh S, Paul VK, Deorari AK. Profile of neonatal sepsis in a tertiary care
neonatal unit from India: A retrospective study. Journal of Neonatology 2006;20:50-57.

15. Deorari Ashok K. For the Investigators of the National Neonatal Perinatal Database (NNPD). Changing pattern
of bacteriologic profile in Neonatal Sepsis among intramural babies. Journal of Neonatology 2006;20:8-15.

16. Zaidi AK, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, Goldmann DA. Hospital-acquired neonatal infections in
developing countries. Lancet 2005;365:1175-88.
17. Sadana S, Mathur NB, Thakur A. Exchange transfusion in septic neonates with sclerema: effect on
immunoglobulin and complement levels. Indian Pediatr 1997;34:20-5
18. Jenson HB, Pollock HB. The role of intravenous immunoglobulin for the prevention and treatment of neonatal
sepsis. Semin Perinatol 1998;22:50-63
19. Goldman S, Ellis R, Dhar V, Cairo MS. Rationale and potential use of cytokines in the prevention and treatment
of neonatal sepsis. Clin Perinatol 1998;25:699-710

12
 Protocol for sepsis

Suspected Early Onset Suspected Late Onset

Sepsis (EOS) Sepsis (LOS)

2 antenatal risk factors present or Foul smelling liquor or

Clinical features suggestive of Presence of >3 antenatal risk
sepsis factors

Sepsis screen (if negative, repeat Blood culture

after 12 hours) Blood culture Lumbar puncture
Blood culture Lumbar puncture Abdomen x-ray, urine examination (if
Lumbar puncture, chest x-ray (If required)
required)

Septic screen +ve

Start antibiotics

No meningitis No meningitis No meningitis No meningitis Meningitis +

Cultures sterile Cultures sterile Cultures sterile Cultures positive Cultures +
Screen negative Screen negative Screen positive Screen + Screen +
Clinical course Clinical course Clinical course
not compatible compatible with compatible with
with sepsis sepsis sepsis

Stop antibiotics Treat empirically Treat empirically Antibiotics acc. to Antibiotics for 21
after 3 days with antibiotics for with antibiotics for sensitivity for 14 days
7days 7-10 days days

NB. If no response is seen within 48-72 hours of starting treatment, a repeat blood culture should be obtained to determine appropriate
choice and duration of antibiotic therapy. A lumbar puncture should be repeated in gram negative meningitis to assess for response to
therapy.

13
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Neonatal sepsis

A. TREAT FOR SEPSIS IF

Breathing difficulty (RR>60/min) AND Severe chest drawing OR grunting

OR

ANY TWO of the FOLLOWING SIGNS ARE PRESENT:

1) Fast breathing ( RR >60/min )

2) Convulsions
3) Unconscious or Lethargic (no spontaneous movements)
4) Abnormal body temperature (axillary temperature <36.5 or >37.5 C)
5) No feeding or feeding poor after having fed well
6) Abdominal distension and/or vomiting

B. WHEN AGE of the baby is 3 DAYS or less, TREAT IF:

Any of the following two maternal risk factor present: maternal fever, foul-smelling or
purulent amniotic fluid, prolonged labour >18 hours

Reassess after 2 days and treatment is continued only if there are signs of sepsis (or
positive blood culture)

C. Suspect meningitis if the baby has convulsions, opisthotonus,

unconsciousness, lethargy or a bulging anterior fontanel

Treat seizures, if present (see STP on Seizure)

If possible, perform a lumbar puncture and send the cerebrospinal fluid (CSF) to the
laboratory for cell count, Gram stain, culture and sensitivity.

Begin treatment for meningitis while awaiting for laboratory confirmation

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

MANAGEMENT

Sepsis (when meningitis is not suspected)

Take a blood sample, and send it to the laboratory for hemoglobin & hematocrit (to decide the
need for blood transfusion), peripheral blood smear (to confirm sepsis), and culture and
sensitivity, when possible

Treat the baby with intravenous (IV) antibiotics: ampicillin (or penicillin) and gentamicin
according to babys age and weight (See Panel) for at least 10 days

If a baby with sepsis is at greater risk of staphylococcus infection (e.g. extensive skin pustules,
abscess, or omphalitis in addition to signs of sepsis), they should be given cloxacillin and
gentamicin instead of ampicillin and gentamicin.

Assess the babys condition every six hours for signs of improvement:

If babys condition is improving after 72 hours of treatment with antibiotics:

Continue ampicillin and gentamicin to complete 10 days of treatment

If the babys condition is NOT improving after 72 hours of treatment with antibiotics:
If the blood culture is positive, change antibiotics according to the results of the
culture and sensitivity, and give new antibiotics for 10 days

If the blood culture is not possible or the organism cannot be identified:

discontinue ampicillin. Give IV cefotaxime, in addition to gentamicin, for 10
days.

Meningitis

Give IV ampicillin and IV gentamicin according to the babys age and weight (Panel). Remember
than for meningitis, higher dose of ampicillin is given

If possible, confirm the diagnosis of meningitis:

White blood cell count in the CSF is 20/mm3 or more if the baby is less than seven days
old; or 10/mm3 or more if the baby is seven days or older; OR

Culture or Gram stain of the CSF is positive.

If the babys condition is improving after 48 hours of treatment with antibiotics, continue the
antibiotics for 14 days or for seven days after signs of improvement are first noted, whichever is
longer.

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

If the babys condition is not improving after 48 hours of treatment, change antibiotics.
Discontinue ampicillin. Give IV cefotaxime according to the babys age and weight in addition to
gentamicin, for 14 days or for seven days after signs of improvement are first noted, whichever
is longer.

If still no improvement, REFER

Supportive Treatment

Maintain IV fluids as required (See STP)

Maintain temperature (See STP)

Give Oxygen as required

Introduce feeding as soon as possible

Manage seizure (See STP)

Manage abdominal distension:

- Nil orally

- Gastric aspiration 2 hourly until no distension

- If not improved in 12 hours, REFER to higher center

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Panel: Antibiotics dosage for sepsis and meningitis in neonates

Antibiotic Each dose Frequency

Age 1 to 7 days Age 8 days or more
Ampicillin for 50 mg/kg/dose 12 hourly 8 hourly
sepsis
Ampicillin for 100 mg/kg/dose 12 hourly 8 hourly
meningitis
Cloxacillin for 50 mg/kg/ dose 8 hourly 8 hourly
sepsis
Gentamicin (for sepsis or <2 kg 4 mg/kg once <2 kg 7.5 mg/kg once daily
meningitis) daily or 3.5 mg/kg/dose
every 12 hour
2 kg or 5 mg/kg once 2 kg or 7.5 mg/kg once daily
more daily more or 3.5 mg/kg/dose
every 12 hour
Cefotaxime for 50 mg/kg/ dose 12 hourly 8 hourly
sepsis
Cefotaxime for 50 mg/kg/ dose 8 hourly 6 hourly
meningitis

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 AIIMS- NICU protocols 2010

PERINATAL HIV

Sunil Saharan*, Rakesh Lodha, Ramesh Agarwal, Ashok Deorari, Vinod

Paul

*Junior Resident , Miami Children Hospital , Florida

Division of Neonatology, Department of Pediatrics

All India Institute of Medical Sciences

Ansari Nagar, New Delhi 110029

Address for correspondence:

Dr Ramesh Agarwal

Assistant Professor

Department of Pediatrics

All India Institute of Medical Sciences

Ansari Nagar, New Delhi 110029

Downloaded from www.newbornwhocc.org

1. Introduction:

The human immunodeficiency virus (HIV) pandemic is one of the most

serious health crises the world faces today. AIDS has killed more than 25

million people since 1981 and an estimated 33.4 (31.1-31.8) million people are

now living with HIV, about 2.1 (1.2-2.9) million of whom are children (1). In

2008 alone, an estimated 430,000 children were newly infected with HIV with

majority of transmission being perinatal. UNAIDS estimated that 200000

cumulative new HIV infections have been averted in the past 12 years by use

of ART for prophylaxis in pregnant women (1). In India estimated 2.31 million

(1.8-2.9) people are living with HIV infection as on year 2007. Adult prevalence

of HIV infection in our country is 0.34% (0.25-0.43%) with prevalence of HIV in

pregnant women being 0.48%. Out of the estimated number of people living

with HIV/AIDS, 39% are females and 3.5% are children. (2).

2. Mode of transmission

Most children living with HIV acquire the infection through mother-to-

child transmission (MTCT). HIV infection can be transmitted from an infected

mother to her fetus during pregnancy, during delivery, or by breast-feeding.

HIV can be transmitted to the fetus as early as the first and second trimester of

pregnancy. However, maternal transmission to the fetus occurs most

commonly in the perinatal period. Perinatal transmission is an extremely

important mode of transmission of HIV infection in developing countries.

3. Risk factors for Perinatal HIV transmission (3)

Viral factors: High viral load, non-syncytium inducing phenotype, HIV-1

 Maternal factors: Advanced disease (low CD4 count, symptoms of

AIDS), primary infection of mother during pregnancy, first of twins,

rupture of membranes more than four hrs, maternal bleeding, mother

not on antiretroviral therapy, vaginal delivery, other sexually

transmitted diseases, isolated HIV-1 infection

Fetoplacental factors: chorioamnionitis, placenta previa, prematurity

(increased peripartum transmission)

Infant factors: HLA concordance with mother

Postnatal factors: breast feeding, higher breast milk virus load,

mastitis or maternal nipple lesions, maternal seroconversion during

breastfeeding, infant having thrush at less than six month age (in

breastfeeding infant)

4. Prevention of perinatal HIV

In the absence of any intervention the risk of perinatal

transmission is 1530% in non-breastfeeding populations (4).

Breastfeeding by an infected mother increases the risk by 520%

to a total of 2045% (5).

The risk of MTCT can be reduced to under 2% by interventions

that include antiretroviral (ARV) prophylaxis given to women

during pregnancy and labour and to the infant in the first 6 weeks

of life, obstetrical interventions including elective caesarean

delivery (prior to the onset of labour and rupture of membranes),

and complete avoidance of breastfeeding (6-8).

5. ARV regimens for treating pregnant women (9)

Refer to figure-1.

For HIV-infected pregnant women in need of ART for their own health,

ART should be administered irrespective of gestational age and continue

throughout pregnancy, delivery and thereafter (recommended for all HIV-

infected pregnant women with CD4 cell count <350 cells/mm3,

irrespective of WHO clinical staging; and for WHO clinical stage 3 or 4,

irrespective of CD4 cell count)

Recommended regimen for pregnant women with indication for ART is

combination of zidovudine (AZT), lamivudine (3TC) and nevirapine (NVP)

or efavirenz (EFV) in antepartum, intrapartum and postpartum period;

EFV-based regimens should not be newly-initiated during the first

trimester of pregnancy.

Recommended regimen for pregnant women who are not eligible for

ART, but for preventing MTCT is to start ART as early as 14 weeks

gestation or as soon as possible when women present late in pregnancy,

in labour or at delivery. Two options for ART are available:

o Option A: daily AZT in antepartum period, combination of single

dose of NVP at onset of labour and dose of AZT and 3TC during

labour followed by combination of AZT and 3TC for 7 days in

postpartum period.

o Option B: consists of triple ARV drugs starting as early as 14

weeks of gestation until one week after all exposure to breast

 milk has ended (AZT + 3TC + LPV or AZT + 3TC + ABC or AZT +

3TC + EFV); [ABC= abacavir].

Omission of the Single dose-NVP and AZT+3TC intra and postpartum

may be considered for women who receive at least four weeks of AZT

before delivery.

If a woman received a three-drug regimen during pregnancy, a

continued regimen of triple therapy is recommended for mother through

the end of the breastfeeding period.

6. ARV regimens for infants born to HIV infected mothers (9)

For breastfeeding infants: daily NVP from birth until 6 weeks of

age or until one week after all exposure to breast milk has ended. The

dose of nevirapine is 10 mg/ d for infants < 2.5 kg; 15 mg/ d for infants

more than 2.5 kg

For non-breastfeeding infants: daily AZT or daily NVP from birth

until 6 weeks of age. The dose of zidovudine is 4 mg/ kg twice a day.

7. Intrapartum interventions

Avoid rupture of membranes unless medically indicated.

Delivery by elective caesarean section at 38 weeks before onset of

labour and rupture of membranes.

Avoid procedures increasing risk of exposure of child to maternal blood

and secretions like use of scalp electrodes.

8. Breast feeding
 Breast-feeding is an important mode of transmission of HIV infection in

developing countries. The risk of HIV infection via breast-feeding is

highest in the early months of breast-feeding (10). Exclusive breast-

feeding has been reported to carry a lower risk of HIV transmission than

mixed feeding.

Factors that increase the likelihood of transmission include detectable

levels of HIV in breast milk, the presence of mastitis and low maternal

CD4+ T cell count.

Mothers known to be HIV-infected should only give commercial infant

formula milk as a replacement feed when specific conditions are met

(referred to as AFASS affordable, feasible, acceptable, sustainable and

safe in the 2006 WHO recommendations on HIV and Infant Feeding)(11)

o Mother, or other caregiver can reliably provide sufficient infant

formula milk to support normal growth and development of the
infant.

o Mother or caregiver can prepare it cleanly and frequently enough

so that it is safe and carries a low risk of diarrhea and
malnutrition.

o Mother or caregiver can, in the first six months, exclusively give

infant formula milk.

o Family is supportive of this practice.

o Mother or caregiver can access health care that offers

comprehensive child health services.
 Mothers known to be HIV-infected may consider expressing and heat-

treating breast milk as an interim feeding strategy in special

circumstances such as:

o Low birth weight or is otherwise ill in the neonatal period and

unable to breastfeed

o Mother is unwell and temporarily unable to breastfeed

o Temporary breast health problem such as mastitis

o To assist mothers to stop breastfeeding

o If antiretroviral drugs are temporarily not available

Replacement feeding should be given by katori spoon; bottle feeds

should be avoided.

If replacement feeding is not feasible, mothers known to be HIV-infected

(and whose infants are HIV uninfected or of unknown HIV status) should

exclusively breastfeed their infants for the first 6 months of life,

introducing appropriate complementary foods thereafter, and continue

breastfeeding for the first 12 months of life. Breastfeeding should then

stop once a nutritionally adequate and safe diet without breast milk can

be provided.

Breastfeeding should stop gradually in one month.

9. Postnatal Diagnosis of HIV Infection (12)

Refer to figure-2

In children younger than 18 months diagnosis of HIV infection is based

on: a positive virological test at 6 weeks for HIV or its components

(usually by HIV-DNA PCR). The diagnosis should be confirmed by a

 second test on a separate sample shuold be repeated at the earliest

(12).

If an infant or child is breastfeeding, he or she remains at risk of

acquiring HIV infection throughout the breastfeeding period. Virological

assays to detect HIV infection should be conducted at least six weeks or

more after the complete cessation of breastfeeding to rule out HIV

infection.

Positive antibody testing is not recommended for definitive or

confirmatory diagnosis of HIV infection in children until 18 months of

age (13).

10. Co-trimoxazole prophylaxis

Co-trimoxazole prophylaxis is recommended for all HIV-exposed infants

under age 18 months starting at 46 weeks of age or when first seen

and continued until HIV infection can be excluded (14).

Co-trimoxazole prophylaxis is also recommended for a breastfeeding

child of any age, continued until HIV infection can be excluded following

cessation of breastfeeding, with testing performed six weeks or more

after breastfeeding was stopped.

In children < 6 month dose is 2.5 mL once a day (trimethoprim 40 mg &

sulphamethoxazole 200 mg/ 5 mL)

11. Immunization (15)

HIV exposed or infected but asymptomatic children should receive all

standard vaccines as per national schedule.

 HIV infected children with immune suppression or symptoms should

receive all standard vaccines except BCG, OPV, and varicella vaccines.

Consider HiB and pneumococcal vaccines in all HIV exposed children

(irrespective of symptoms or CD4 count).

References
1. UNAIDS/WHO. AIDS Epidemic Update. December, 2009.

2. National AIDS Control Organization. HIV Sentinel Surveillance and HIV

estimation in India 2007. Available at:
http://nacoonline.org/upload/Publication/M&E%20Surveillance,
%20Research/HIV%20Sentinel%20Surveillance%20and%20HIV
%20Estimation%202007_A%20Technical%20Brief.pdf (accessed on
25/1/2010).

3. Havens P, Waters D. Management of the infant born to a mother with

HIV infection. Pediatr Clin North Am 2004; 51: 909-937.

4. The Working Group on Mother-to-Child HIV. Transmission of, Rates of

mother-to child transmission of HIV-1 in Africa, America, and Europe:
results from 13 perinatal studies. J Acquir Immune Defic Syndr 1995;
8:50610.

5. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child

HIV transmission in resource-poor countries: translating research into
policy and practice. JAMA 2000; 283:1175-82.

6. Lallemant M, Jourdain G, Le Coeur S, et al. Single-dose perinatal

nevirapine plus standard zidovudine to prevent mother-to-child
transmission of HIV-1 in Thailand. N Engl J Med 2004; 351:217-28.

7. Thorne C, Patel D, Fiore S, Peckham C, Newell ML. Mother-to-child

transmission of HIV infection in the era of highly active antiretroviral
therapy. Clinical Infectious Diseases 2005; 40:458465.

8. Magoni M, Bassani L, Okong P et al. Mode of infant feeding and HIV

infection in children in a program for prevention of mother-to-child
transmission in Uganda. AIDS 2005; 19:433-7.

9. WHO. Rapid advice: Use of antiretroviral drugs for treating pregnant

women and preventing HIV infection in infants. November 2009.
10. Dunn DT, Tess BH, Rodrigues LC, Ades AE. Mother-to-child transmission
of HIV: implications of variation in maternal infectivity. AIDS 1998;
12:2211-6.

11. WHO. Rapid advice: Revised WHO principles and recommendations on

infant feeding in the context of HIV. November 2009.

12. WHO. Antiretroviral therapy of HIV infection in infants and children:

towards universal access 2010.

13. Chantry CJ, Cooper ER, Pelton SI, Zorilla C, Hillyer GV, Diaz C.
Seroreversion in human immunodeficiency virus-exposed but uninfected
infants. Pediatr Infect Dis J 1995; 14:382-7.

14.WHO. Guidelines on co-trimoxazole prophylaxis for HIV-related

infections among children, adolescents and adults in resource-limited
settings recommendations for a public health approach. 2006.

15. Anonymous. Immunization in special circumstances. In, Shah RC, Shah

NK, Kukreja S (Eds). IAP Guide Book on Immunization, Mumbai; IAP
Committee on Immunization, 2005-2006; 52-54.
 Figure 1 Protocol on approach to a baby born to HIV
infected mother8

HIV infected mother: diagnosed by ELISA test

Clinical assessment and CD4 count of mother

No indication of ART for the

mother

ART indicated for mother ART for preventing MTCT

Three drug ART Triple ARV starting at 14

weeks
AZT + 3TC + NVP Until one week after exposure to
or breast milk has
stopped
AZT + 3TC + EFV* Or
AZT starting at 14 weeks
Intrapartum Sd-NVP + AZT+3TC*
Postpartum AZT+3TC 7 days*

*: EFV-based regimens should not be

newly-initiated during the first trimester Baby born to HIV positive mother
of pregnancy

1. Check antenatal ART (drugs, duration, and

compliance)
2. Caesarean / normal delivery
3. Check for PROM
4. Intrapartum ART given or not
 Infant: NVP for 6 wk or AZT for 6 wk

* Sd-NVP and AZT+3TC intra- and post-partum can be omitted if mother

receives more than 4 weeks of AZT during pregnancy
Note:
For breastfeeding infants: daily NVP from birth until 6 weeks of age or until one week
after all exposure to breast milk has ended

Abbreviations: ART - Antiretroviral therapy

AZT - Zidovudine (4 mg/kg twice a day for the infant)
Sd NVP - Single dose nevirapine
3TC - Lamivudine
NVP - Nevirapine (10 mg/ d for infants < 2.5 kg; 15 mg/ d for infants
more than 2.5 kg)
EFV - Efavirenz
 Figure 2 Diagnostic approach for HIV exposed infants11

Neonate born to HIV infected mother

HIV testing by DNA PCR at or around 6 week age

Positive Negative

Repeat DNA PCR at the earliest on a

different blood sample

Repeat test* If negative, No HIV

If breastfed: 6-8 wk after cessation infection (Perform
If positive, confirms HIV infection of breastfeeding antibody testing should
(Perform antibody testing after 18 month of age) If not breastfed: at 4-6 month age be done after 18 month)

Test may also need to be repeated in infants who develop symptoms or

signs suggestive of HIV infection.
 Hypocalcemia in Newborns

Calcium (Ca) is actively transferred from mother to fetus during last trimester, as demonstrated by a
significantly higher level of total Ca concentration in cord blood compared to maternal serum.1
Parathyroid hormone (PTH) and calcitonin (CT) do not cross the placental barrier. PTH related peptide
(PTHrP) is the main regulator of the positive Ca balance across the placenta. Serum Ca (SCa) in the fetus
is 10 to 11 mg/dL at term (1 to 2 mg/dL higher as compared to mother).

After birth, the SCa levels in newborns depend on the PTH secretion, dietary calcium intake, renal
calcium reabsorbtion, and skeletal calcium and vitamin D status. Hence, after delivery, SCa levels start
decreasing (the rate and extent of decrease is inversely proportional to the gestation) and reaches a
nadir of 7.5 to 8.5 mg/dL in healthy term babies by day 2 of life. This postnatal drop in SCa may be
related to decreased PTH level, end organ unresponsiveness to PTH2, abnormalities of vitamin D
metabolism, hyperphosphatemia, hypomagnesemia, and hypercalcitonemia, which occur by 12-24 hours
of age. 3

PTH levels increase gradually in the first 48 hours of life and normal levels of SCa are achieved by 3rd day
of life.4 The efficacy of the intestinal absorption and the renal handling of Ca mature by 2 to 4 weeks.
This transition phase is responsible for the increased risk of early onset hypocalcemia in high-risk
neonates.

Calcium homeostasis in newborn

Body Ca exists in two major compartments: skeleton (99%) and extracellular fluid (1%). Ca in the
extracellular fluid is present in three forms5:

Bound to albumin (40%)

Bound to anions like phosphorus, citrate, sulfate and lactate (10%) and
Free ionized form (50%)

Ionized serum calcium (iSCa) is crucial for many biochemical processes including blood coagulation,
neuromuscular excitability, cell membrane integrity and function, and cellular enzymatic and secretory
activity.

Measurement of the total serum Ca (tSCa) concentration alone can be misleading because the
relationship between tSCa and iSCa is not always linear. Correlation between two is poor when the
serum albumin concentration is low and, to a lesser degree, with disturbances in acid-base status, both
of which occur frequently in premature or sick infants. With hypoalbuminemia, tSCa is low while iSCa is
normal. Falsely low iSCa may be recorded in alkalosis and with heparin contamination of blood sample.
In general, the tSCa falls by 0.8 mg/dL (0.2 mmol/L) for every 1.0 g/dL fall in the plasma albumin
concentration.

Therefore, estimation of tSCa is a poor substitute for measuring the iSCa.

2

Definition

Hypocalcemia is defined by different tSCa and iSCa cutoffs for preterm and term infants (Table 1).6

Panel 1: Definition of hypocalcemia

Gestation of infants Total serum calcium level Ionic serum calcium level

Preterm <7 mg/dL (1.75 mmol/L) <4 mg/dL (1 mmol/L)

Term <8 mg/dL (2 mmol/L; total) <4.8 mg/dL (1.2 mmol/L)

The SCa is usually reported in different units viz. mg/dL, mEq/L and mmol/L The relationship between
these units is related to the following equations:

mmol/L = [mg/dL x 10] molecular wt

mEq/L = mmol/L x valency

Since the molecular weight of Ca is 40 and the valence is +2, 1 mg/dL is equivalent to 0.25 mmol/L and
to 0.5 mEq/L. Thus, values in mg/dL may be converted to molar units (mmol/L) by dividing it by 4.

Early onset neonatal hypocalcemia (ENH)

Table 1 Causes of early onset hypocalcaemia

Prematurity
Preeclampsia
Infant of diabetic mother
Perinatal stress/ asphyxia
Maternal intake of anticonvulsants (phenobarbitone, phenytoin sodium)
Maternal hyperparathyroidism
Iatrogenic (alkalosis, use of blood products, diuretics, phototherapy, lipid infusions etc)

This condition is fairly common and seen within the first 3 to 4 days of life in following clinical settings
(Table 1):

Prematurity: This may be related to premature termination of trans-placental supply, exaggeration of

the postnatal drop to hypocalcemic levels, increased calcitonin and diminished target organ
responsiveness to parathyroid hormone.

Infant of diabetic mother (gestational and insulin dependent): This may be related to increased
calcium demands of a macrosomic baby.7 Magnesium depletion in mothers with diabetes mellitus
causes hypomagnesemic state in the fetus. This hypomagnesemia induces functional
hypoparathyroidism and hypocalcemia in the infant. A high incidence of birth asphyxia and prematurity
in infants of diabetic mothers are also contributing factors.
3

Perinatal asphyxia: Delayed introduction of feeds, increased calcitonin production, increased

endogenous phosphate load, renal insufficiency, and diminished parathyroid hormone secretion- all may
contribute to hypocalcemia.

Maternal hyperparathyroidism: This causes intrauterine hypercalcemia suppressing the parathyroid

activity in the fetus resulting in impaired parathyroid responsiveness to hypocalcaemia after birth.
Hypocalcaemia may be severe and prolonged.

Intrauterine growth restriction (IUGR): Infants with IUGR may have hypocalcemia if they are born
preterm and/or have had perinatal asphyxia. IUGR or Small for gestational age (SGA) is not an
independent risk factor for ENH.

Maternal anticonvulsants: Intake of anticonvulsants like phenobarbitone and phenytoin alters the
vitamin D metabolism and predisposes them to its deficiency. The infants of epileptic mothers may be at
risk of neonatal hypocalcemia. It can be prevented by vitamin D supplementation to mothers.

Iatrogenic: Any condition causing alkalosis increases the binding of the calcium with albumin and
causes decrease in iSCa.
There is no universal recommendation regarding routine screening of at-risk infants for ENH. However
following categories of infants may be considered for the same:
(a) Preterm infants born before 32 wks
(b) Infants of diabetic mothers
(c) Infants born after severe perinatal asphyxia defined as Apgar score < 4 at 1 minute of age
Time schedule for screening: at 24 and 48 hours of age risk babies.

Clinical presentation:

Asymptomatic: ENH is usually asymptomatic unlike the late onset variety and is incidentally detected.

Symptomatic: The symptoms may be of neuromuscular irritability - myoclonic jerks, jitteriness,

exaggerated startle, and seizures. They may represent the cardiac involvement like- tachycardia, heart
failure, prolonged QT interval, decreased contractibility. More often they are non-specific and not
related to the severity of hypocalcemia. Apnea, cyanosis, tachypnoea, vomiting and laryngospasm are
other symptoms that are noted.

Diagnosis

Laboratory: by measuring total or ionized serum calcium. Ionized calcium is the preferred mode for
diagnosis of hypocalcemia.

ECG: QoTc >0.22 seconds or QTc >0.45 seconds

QTc = QT interval in seconds

R-R interval in seconds

QoTc = QoT interval in seconds

R-R interval in seconds
4

(QT interval is measured from origin of q wave to end of T wave on ECG; QoT is measured from origin of
q wave to origin of T wave).

A diagnosis of hypocalcemia based only on ECG criteria is likely to yield a high false positive rate.
Although these parameters have good correlation with hypocalcaemia in low birth weight infants
(sensitivity of 77% and specificity of 94.7%)8, neonates suspected to have hypocalcemia by ECG criteria
should have the diagnosis confirmed by measurement of serum calcium levels.

Treatment of early onset hypocalcemia (Figure 1)

Patients at increased risk of hypocalcemia: Preterm infants (32 weeks), sick infants of diabetic
mothers and those with severe perinatal asphyxia should receive 40 mg/kg/day of elemental calcium (4
mL/kg/day of 10% calcium gluconate) for prevention of early onset hypocalcemia. However there is not
sufficient evidence for this practice. Infants tolerating oral feeds may receive this calcium orally q 6
hourly. Therapy should be continued for 3 days. Oral calcium preparations have high osmolality and
should be avoided in babies at higher risk of necrotizing enterocolitis.

Patients diagnosed to have asymptomatic hypocalcemia: Infants detected to have hypocalcemia

on screening and who are otherwise asymptomatic should receive 80-mg/kg/day elemental calcium (8
mL/kg/day of 10% calcium gluconate) for 48 hours (Algorithm 1). This may be tapered to 50% dose for
another 24 hours and then discontinued. Neonates tolerating oral feeds may be treated with oral
calcium (IV preparation may be used orally).

Patients diagnosed to have symptomatic hypocalcemia: These patients should receive a bolus
dose of 2 mL/kg/dose diluted 1:1 with 5% dextrose over 10 minutes under cardiac monitoring. When
there is severe hypocalcaemia with poor cardiac function, calcium chloride 20 mg/kg may be given
through a central line over 10-30 minutes (as chloride in comparison to gluconate does not require the
metabolism by the liver for the release of free calcium). This should be followed by a continuous IV
infusion of 80 mg/kg/day elemental calcium for 48 hours. Continuous infusion is preferred to IV bolus
doses (1 mL/kg/dose q 6 hourly). Calcium infusion should be dropped to 50% of the original dose for the
next 24 hours and then discontinued. The infusion may be replaced with oral calcium therapy on the last
day. Normal calcium values should be documented at 48 hours before weaning the infusion.

All categories of hypocalcemia should be treated for at least 72 hours. Continuous infusion is preferred to
IV bolus doses. Symptomatic hypocalcemia should be treated with a continuous infusion for at least 48
hours.
 5

Figure 1: Management of early neonatal hypocalcaemia

Hypocalcemia
(tSCa<7 mg/dL)

Symptomatic Asymptomatic

IV calcium gluconate IV/PO calcium gluconate

2 mL/kg as bolus# 80 mg/kg/day for 48 hr*
80 mg/kg/day for 48 hr* 40 mg/kg for 24 hr*
Document normal SCa level & Then stop
reduce to 40 mg/kg for 24 hr*
Then stop

One mL of calcium gluconate contains 9 mg of elemental calcium

#
diluted 1:1 in 5% dextrose and administered under cardiac monitoring
*
added to IV fluids and given as infusion. Take care of extravasation as that can result into skin sloughing. In
case of asymptomatic ENH, the same can be given PO.
6

Precautions and side effects:

Bradycardia and arrhythmia are known side effects of bolus IV calcium administration. Hence, bolus
doses of calcium should be diluted 1:1 with 5% dextrose and given slowly (over 10 to 30 minutes) under
cardiac monitoring. An umbilical venous catheter (UVC) may be used for administration of calcium only
after ensuring that the tip is positioned in the inferior vena cava. Hepatic necrosis may occur if the tip of
the UVC lies in a branch of the portal vein. Umbilical artery catheter (UAC) should never be used for
giving calcium injections. Accidental injection into the UAC may result in arterial spasms and intestinal
necrosis.

Skin and subcutaneous tissue necrosis may occur due to extravasation. Hence, IV sites where calcium is
being infused should be checked at least q 2 hourly to monitor for extravasation.

Prolonged or resistant hypocalcemia

This condition should be considered in the following situations:

Symptomatic hypocalcemia unresponsive to adequate doses of calcium therapy
Infants needing calcium supplements beyond 72 hours of age
Hypocalcemia presenting at the end of the first week.
These infants should be investigated for causes of LNH (see below).

Late onset neonatal hypocalcemia (LNH)

This condition is rare as compared to ENH. It usually presents at the end of the first week of life. It is
usually symptomatic in the form of neonatal tetany or seizures. This is usually caused by high phosphate
intake (iatrogenic). The causes are listed in Table 2.

Table 2 Causes of late onset hypocalcemia

Increased phosphate load: cow milk, renal insufficiency

Hypomagnesemia
Vitamin D deficiency
Maternal vitamin D deficiency
Malabsorption
Renal insufficiency
Hepatobiliary disease
PTH resistence
Transient neonatal pseudohypoparathyroidism
Hypoparathyroidism
Primary: hypoplasia/aplasia (Di Georges syndrome, CATCH 22 syndrome), activating
mutations of the calcium sensing receptor (CSR)
Secondary: maternal hyperparathyroidism, metabolic syndromes (Kenny-caffey
syndrome, long-chain fatty acyl CoA dehydrogenase deficiency, Kearns-sayre syndrome
Iatrogenic: citrated blood products, lipid infusion, bicrbonate therepy, loop diuretics,
glucocorticosteriods, phosphate therepy, aminoglycosides (mainly gentamicin),
Alkalosis
Phototherapy
7

Examination:
Such babies should have an examination with special emphasis on cataracts, hearing, and any evidence
of basal ganglia involvement (movement disorder).

Investigations

First line Second line Others

Serum phosphate Serum magnesium Serum magnesium
Serum alkaline phosphatase Serum parathormone levels Serum parathormone levels
(SAP) (PTH) (PTH)
Liver function tests Urine calcium creatinine ratio Urine calcium creatinine ratio
Renal function tests Maternal calcium, phosphate, Maternal calcium, phosphate,
X ray chest/ wrist and alkaline phosphatase and alkaline phosphatase
Arterial pH

Disorder causing hypocalcaemia Findings

Hypoparathyroidism High : phosphateLow : SAP, PTH,

1,25(OH)D3
Pseudohypoparathyroidim High : SAP, PTH, Phosphate
Low : 1,25 D3
Chronic renal failure High : phosphate, SAP, PTH, pH
(acidotic), deranged RFT
Low : 1,25 D3
Hypomagnesemia High : PTH
Low : phosphate, Mg,1,25 D3
VDDR1 High : SAP, PTH
Low : Phosphate, 1,25 D3
VDDR II High : SAP, 1, 25 D3, PTH
Low : Phosphate

should be strongly suspected. (See Table 4 for interpretation of diagnostic investigation.)

8

Treatment of LNH

The treatment of LNH is specific to etiology and may in certain diseases be life-long.

1. Hypomagnesemia: Symptomatic hypocalcemia unresponsive to adequate doses of IV calcium

therapy is usually due to hypomagnesemia. It may present either as ENH or later as LNH. The
neonate should receive 2 doses of 0.2 mL/kg of 50% MgSO4 injection, 12 hours apart, deep IM
followed by a maintenance dose of 0.2 mL/kg/day of 50% MgSO4, PO for 3 days.

2. High phosphate load: These infants have hyperphosphatemia with near normal calcium
levels. This happens in situation of non-huamn milk feeding (containing high phosphate
content). Exclusive breast-feeding should be encouraged and top feeding with cows milk should
be discontinued. Phosphate binding gels should be avoided.

3. Hypoparathyroidism9: These infants tend to be hyperphosphatemic and hypocalcemic with

normal renal function. Elevated phosphate levels in the absence of exogenous phosphate load
(cows milk) and presence of normal renal functions, indicates parathormone inefficiency.

It is important to realize that if the phosphate level is very high, then adding calcium may lead to
calcium deposition and tissue damage. Thus attempts should be made to reduce the phosphate
(so as to keep the calcium and the phosphate product less than 55).10 These neonates need
supplementation with calcium (50 mg/kg/day in 3 divided doses) and 1,25(OH)2 vitamin D3 (0.5-1
g/day). Syrups with 125 mg and 250 mg per 5 ml of calcium are available. 1, 25(OH)2 vitamin D3
(calcitriol) is available as 0.25 g capsules. Therapy may be stopped in hypocalcemia secondary
to maternal hyperparathyroidism after 6 weeks.

4. Vitamin D deficiency states: These babies have hypocalcemia associated with

hypophosphatemia due to an intact parathormone response on the kidneys. They benefit from
Vitamin D3 supplementation in a dose of 30-60 ng/kg/day.

Monitoring

The baby is monitored for the SCa, and phosphate, 24 hour urinary calcium, and calcium creatinine ratio.
Try to keep the calcium in the lower range as defective distal tubular absorption leads to hypercalciuria
and nephrocalcinosis.11

Prognosis and outcome

Most cases of ENH resolve within 48-72 hours without any clinically significant sequelae.

LNH secondary to exogenous phosphate load and magnesium deficiency also responds well to
phosphate restriction and magnesium repletion. When caused by hypoparathyroidism, hypocalcemia
requires continued therapy with vitamin D metabolites and calcium salts. The period of therapy depends
on the nature of the hypoparathyroidism which can be transient, last several weeks to months, or be
permanent.
10

Panel 2 : List of researchable issues in neonatal hypocalcemia

S.NO Research question Type of study Intervention Outcome measures

1. What is the incidence of Cohort study by Nil Incidence,
neonatal hypocalcemia, enrolling at risk Age at which it is detected in
age at onset, clinical infants (Table 1 hours,
manifestations and short and 2) Rate of occurrence of
term outcomes? different clinical
(Epidemiology of manifestation,
hypocalcemia) Neurological examination at
discharge,
Risk factors
2 What is long term Infants with Nil Neurodevelopment at 18
outcomes of neonatal hypocalcemia months
hypocalcemia? and
gestation
matched infants
without
hypocalcemia
3 Does routine prophylactic Randomized Group1: Prophylactic Incidence of
calcium supplementation in control trial calcium asymptomatic and
at-risk babies reduces the supplementation at 40 symptomatic
incidence of neonatal mg/kg/dL to at-risk hypocalcemia.
hypocalcemia? babies Complications of therapy
Group 2: such as
No calcium thrombophlebitis,
arrhythmias, gastro
intestinal side effects and
nephrocalcinosis
11

References:

1. Schauberger CW, Pitkin RM, Maternal-perinatal calcium relationships. Obstet Gynecol 1979;53:74-6
2. Linarelli LG, Bobik J, Bobik C. Newborn urinary cyclic AMP and developmental responsiveness to
parathyroid harmone. Pediatrics 1972;50:14-23
3. Hillman, Rajanasathit S, slatopolsky E, haddad JG. Serial measurements of serum calcium, magnesium,
parathyroid hormone, calcitonin, and 25-hydroxy-vitamin D in premature and term infants during the first
week of life. Pediatr Res 1977;11:789-44
4. Salle BL, Delvin EE, Lapillonne A, Bishop NJ, Glorieux FH. Perinatal metabolism of vitamin D. Am J Clin Nutr
2000;71(5 suppl):1317S-24S.
5. Singh J, Moghal N, Pearce SH, Cheetham T. The investigation of hypocalcaemia and rickets. Arch Dis Child.
May 2003;88(5): 403-7.
6. Oden J, Bourgeois M. Neonatal endocrinology. Indian J Pediatr 2000;67:217-23
7. Schwartz R, Teramo KA. Effects of diabetic pregnancy on the fetus and newborn. Semin Perinatol
2000;24:120-35
8. Nekvasil R, Stejskal J, Tuma A. Detection of early onset neonatal hypocalcemia in low birth weight infants
by Q-Tc and Q-oTc interval measurement. Acta Paediatr Acad Sci Hung. 1980;21(4):203-10.
9. Marx SJ. Hyperparathyroid and hypoparathyroid disorders. N Engl J Med 2000;343:1863-75
10. Sharma J, Bajpai A, Kabra M et al. Hypocalcemia Clinical, biochemical, radiological Profile and follow-up
in a Tertiary hospital in India. Indian Pediatrics 2002; 39: 276-282.
11. Rigo J, Curtis MD. Disorders of Calcium, Phosphorus and Magnesium Metabolism in Richard J Martin,
Avory A Fanaroff, Michele C Walsh (eds) . Neonatal Perinatal Medicine- Diseases of the fetus and infant.
th
8 edition; Elsevier, Pihladelphia, 2006: p1508-14
 Hypoglycemia in the Newborn

There is no universal definition for hypoglycemia.1 Various investigators have empirically recommended
different blood lucose levels (BGLs) that should be maintained in neonatal period to prevent injury to
the developing brain.2,3 The normal range of blood glucose is variable and depends upon factors like
birth-weight, gestational age, body stores, feeding status, availability of energy sources as well as the
presence or absence of disease.4,5 Further, there is no concrete evidence to show the causation of
adverse long-term outcomes by a particular level or duration of hypoglycemia.6 Hence, a consensus has
been to evolve an operational threshold.

Definition
The operational threshold for hypoglycemia is defined as that concentration of plasma or whole blood
glucose at which clinicians should consider intervention, based on the evidence currently available in
literature.7 Operational threshold has been defined as BGL of less than 40 mg/dL (plasma glucose level
less than 45 mg/dL).8

WHO defines hypoglycemia as BGL of less than 45 mg/dL.

Screening for hypoglycemia

Screening for hypoglycemia is recommended in high risk infants (Table 1).

Table 1: Indication for routine blood glucose screening 9

1 Low birth weight infants (<2000 grams)
2 Preterm infants (35 weeks)
3 Small for gestational age infants (SGA) : birth weight <10th percentile
4 Infant of diabetic mothers (IDM)
5 Large for gestational age (LGA) infants: birth weight >90th percentile*
6 Infants with Rh-hemolytic disease
7 Infants born to mothers receiving therapy with terbutaline/propranolol/lebatolol/oral hypoglycemic
agents
8 Infants with morphological IUGR. This group includes neonates with birth weight between 10th to 25th and
possibly up to 50th percentile, with features of fetal under-nutrition such as three or more loose skin folds
in gluteal region, overall decreased subcutaneous fat, and head circumference to chest circumference
difference greater than 3 cm
9 Any sick neonate such as those with perinatal asphyxia, polycythemia, sepsis, shock etc, when they are in
active phase of illness. The screening may be discontinued once their condition gets stabilized.
10 Infants on total parenteral nutrition
* LGA infants because of constitutional reasons such as infants of constitutionally large parents may be exempted from routine
screening

1
 2

Time schedule for screening

There is a paucity of the literature that looks into optimal timing and the intervals of glucose monitoring.
Lowest blood sugar values are seen at 2 hours of life. IDMs frequently experience asymptomatic
hypoglycemia very early viz. 1 to 2 hours and rarely beyond 12 hours (range 0.8 to 8.5 h), supporting
need for early screening for this population.10 However, preterm and SGA may be at highest risk up to
36 h (range 0.8 to 34.2 h).11

Some SGA and preterm infants may develop hypoglycemia when feeding is not established. Based on
these assumptions and current knowledge, Table 2 elaborates the schedule and frequency of monitoring
in different situations.

Table 2: Schedule of blood glucose monitoring

Category of infants Time schedule
1 At risk neonates (SN 1-8 in Table 1) 2, 6, 12, 24, 48, and 72 hrs

2 Sick infants Every 6-8 hrs

(Infants with sepsis, asphyxia, shock during active phase (individualize as needed)
of illness. Once the underlying condition is under
control, frequency of screening can be reduced or
omitted)
3 Stable VLBW infants on parenteral nutrition Initial 72 h: every 6 to 8 hrs
After 72 hr: once a day
Infants exhibiting signs compatible with hypoglycemia at any time also need to be investigated.

Education and counseling of caregivers regarding the screening

Parents should be made aware that their infant is at-risk and therefore requires blood tests at regular
intervals. This will ensure appropriate parental participation in monitoring and allay fears if further
interventions are required.

Infants in whom screening is not required

Screening for hypoglycemia is not recommended in term healthy breast-fed appropriate-for-gestational
age (AGA) infants. However, term infants with poor feeding, presence of inadequate lactation or
presence of cold stress may be considered for screening on an individual basis.

Method of blood glucose level estimation

Point of care (POC) reagent strips (Glucose oxidase method): Though widely used, glucose
estimation by this method is unreliable especially at levels where therapeutic intervention is
required such as BGL 40 to 50 mg/dL. They are useful for screening purpose but low values
should be confirmed by proper laboratory analysis. However, treatment of hypoglycemia may
be initiated based on the results of the reagent strips.

It is important to consider the variations between capillary and venous, blood and plasma, and
immediate and stored samples (whole blood sugar value is 10% to 15% lesser than that of
plasma value; the BGL can fall by 14 to 18 mg/dL per hour in samples that await analysis.12
Arterial samples have slightly higher value compared to venous or capillary samples.
 3

The first generation strips focused on change in color by enzymatic reaction on application of
blood drop. The color can be read by naked eye or by reflectance meters. However, the results
get affected by hematocrit values, acidosis, presence of bilirubin, presence of edema etc.

The newer generation glucose reagent strips generate a current on reaction of glucose with
enzymes such glucose oxidase or glucose dehydrogenase. The amount of current is proportional
to amount of sugar present in plasma. Though these second generation glucose readers are
more accurate than the previous version but still are not entirely reliable. Any abnormal BGLs by
this technique must be confirmed by standard laboratory methods.

Laboratory diagnosis: This is the most accurate method. In the laboratory, glucose can be
measured by either the glucose oxidase (calorimetric) method or by the glucose electrode
method (as used in blood gas & electrolyte analyzer machine). Blood samples should be analyzed
quickly to avoid erroneously low glucose levels.

Clinical signs associated with hypoglycemia

Asymptomatic: It is well known that low BGL may not manifest clinically and be totally
asymptomatic. There is considerable controversy in regard to the need for treatment the infants
with low BGLs but without any symptoms. 13,14

Symptomatic: A smaller proportion of infants with hypoglycemia can be symptomatic. Clinical

signs of hypoglycemia are variable and may include stupor, jitteriness, tremors, apathy, episodes
of cyanosis, convulsions, intermittent apneic spells or tachypnea, weak and high pitched cry,
limpness and lethargy, difficulty in feeding, and eye rolling. Episodes of sweating, sudden pallor,
hypothermia and cardiac arrest have also been reported.

Diagnosis
Asymptomatic hypoglycemia is said to be present when BGL is less than 45 mg/dL (to be
confirmed by laboratory estimation) and the infant does not manifest with any clinical features
Symptomatic hypoglycemia should be diagnosed if hypoglycemia (BGL is less than 45 mg/dL)
coexists with clinical symptoms. Neonates generally present with nonspecific signs that result
from a variety of illnesses. Therefore, careful evaluation should be done to look for all possible
causes especially those that can be attributed to hypoglycemia.

If clinical signs attributable to hypoglycemia persist despite intravenous glucose, then other causes of
persistent / resistant hypoglycemia should be explored.
 4

Management of asymptomatic hypoglycemia

Table 3 summarizes management of an infant with asymptomatic hypoglycemia

Table 3: Management plan of infants with asymptomatic hypoglycemia

Blood sugar 20-45 mg/dL Trial of oral feeds (expressed breast milk or formula) and repeat
blood test after 1 hour.
1. If repeat BGL is >45 mg/dL, two hourly feeds is ensured
with 6 hourly monitoring of BGL for 48 hrs. the target
blood glucose value is 50 to 120 mg/dL.
2. If repeat blood sugar is <45 mg/dL, IV Dextrose is started
and further management is as for symptomatic
hypoglycemia
Blood sugar levels <20 mg/dL IV Dextrose is started at 6 mg/kg/min of glucose. Subsequent management is
as for symptomatic hypoglycemia

Oral feeds issues

Direct breast-feeding is the best option for trial of an oral feed. If the infant is unable to suck, expressed
breast milk may be given. Breast milk promotes ketogenesis (ketones are important alternate sources
for the brain along with other sources such as pyruvate, free fatty acids, glycerol, and amino acids). If
breast milk is not available, then formula feeds may be given.

Some of the randomized clinical trials in SGA15 and appropriate-for-gestational age16 infants found that
the sugar or sucrose fortified milk (5 g sugar per 100 mL milk) raises blood glucose and prevents
hypoglycemia. Such supplementation may be tried in the asymptomatic neonates with blood sugar
levels between 20 to 45 mg/dL. However, this practice carries a potential to compromise breast feeding
rates, and therefore one should be prudent in exercising this option.

Management of symptomatic hypoglycemia

All symptomatic infants should be treated with IV fluids

For symptomatic hypoglycemia including seizures, a bolus of 2 mL/kg of 10% dextrose (200 mg/kg)
should be given. This mini-bolus helps to rapidly correct BGL.14 The bolus should be followed by
continuous glucose infusion at an initial rate of 6-8 mg/kg/min. BGL should checked after 30 to 60 min,
and then every 6 hour until blood sugar is >50 mg/dL.

If BGL stays below 45 mg/dL despite bolus and glucose infusion, glucose infusion rate (GIR) should be
increased in steps of 2 mg/kg/min every 15 to 30 min until a maximum of 12 mg/kg/min.

After 24 hours of IV glucose therapy, once two or more consecutive BGLs are >50 mg/dL, the infusion
can be tapered off at the rate of 2 mg/kg/min every 6 hours with BGL monitoring. Tapering has to be
accompanied by concomitant increase in oral feeds. Once a rate of 4 mg/kg/min of glucose infusion is
achieved and oral intake is adequate and the BGLs are consistently >50 mg/dL, the infusion can be
stopped.

It is important to ensure continuous glucose infusion preferably using an infusion pump and without any
interruption. Do not stop glucose infusion abruptly as severe rebound hypoglycemia may occur. Avoid
using more than 12.5% dextrose infusion through a peripheral vein due to the risk of thrombophlebitis.
 5

Practical tip: If there is persistent hypoglycemia, check the intravenous line for functioning. Also recheck
the intravenous fluid preparation and infusion rate.

Recurrent / resistant hypoglycemia

This condition should be considered when infant fails to maintain normal BGL despite a GIR of 12
mg/kg/min or when stabilization is not achieved by 7 days of therapy. High levels of glucose infusion
may be needed in the infants to achieve euglycemia.

Table 4 : Important causes of resistant hypoglycemia

Congenital hypopitutarism
Adrenal insufficiency
Hyperinsulinemic states
Galactosemia
Glycogen storage disorders
Maple syrup urine disease
Mitochondrial disorders
Fatty acid oxidation defect

Table 5 :Investigations to be done in resistant hypoglycemia

Serum insulin levels
Serum cortisol levels
Growth hormone levels
Blood ammonia
Blood lactate levels
Urine ketones and reducing substances
Urine and sugar aminoacidogram
Free fatty acid levels
Galactose 1 phosphate uridyl transferase levels

Besides increasing GIR for resistant hypoglycemia, certain drugs may be tried. Before administration of
drugs, take the samples to investigate the cause (Table no 4). Drugs that are used include the following:
Hydrocortisone 5 mg/kg/day IV or PO in two divided doses for 24 to 48 hrs

Diazoxide can be given orally 10-25 mg/kg/day in three divided doses . Diazoxide acts by
keeping the KATP channels of the -cells of the pancreas open, thereby reducing the secretion of
insulin. It is therefore useful in states of unregulated insulin secretion like in insulinomas.

Glucagon 100 g/kg subcutaneous or intramuscular (max 300 g) maximum of three doses.
Glucagon acts by mobilizing hepatic glycogen stores, enhancing gluconeogenesis and promoting
ketogenesis. These effects are not consistently seen in small-for-gestational age infants. Side
effects of glucagon include vomiting, diarrhea and hypokalemia and at high doses it may
stimulate insulin release.

Octreotide (synthetic somatostatin in dose of 2-10 g/kg/day subcutaneously two to three times
a day.
 6

Do not use diazoxide and glucagon in small for gestational age infants.

Useful formulae
(a) GIR = % of dextrose being infused x rate (mL/hr)
(mg/kg/min) body weight (in kg) x 6

(b) Infusion rate = IV rate (mL/kg/day) x % of dextrose

(mg/kg/min) 144

(c) Infusion rate = Fluid rate (mL/kg/day) x 0.007 x % of dextrose infused

(mg/kg/min)

Follow-up and outcome

The outcome of hypoglycemia is determined by factors like, duration, degree of hypoglycemia, rate of
cerebral blood flow, cerebral utilization of glucose, and also co-morbidities. Special attention should be
paid to neuro-developmental outcome, overall IQ, reading ability, arithmetic proficiency and motor
performance.

The infants can be assessed at one month corrected age for vision / eye evaluation. At 3, 6, 9, 12 and 18
months corrected age they can be followed up for growth, neurodevelopment, vision and hearing loss.
Vision can be assessed with Teller acuity card and hearing should be assessed by Brainstem evoked
auditory responses. Neurodevelopment will be assessed by the clinical psychologist using DASII 2. MRI at
4-6 weeks provides a good estimate of hypoglycemic injury and therefore should be considered in follow
up of such infants subject to affordability.17

Hypoglycemia and Neurodevelopment outcome what is the evidence

Systemic review involving 18 studies concluded that there is no good correlation between the two and
further well designed good quality studies are needed.18
A recent study involving 35 neonates who had symptomatic hypoglycemia showed that 94% of them
had some white abnormalities and on follow up at 18 months of age, 65% of them had demonstrated
some impairment in development. 19
 7

Research needs
Table 7 provides list of some researchable issues in field of neonatal hypoglycemia.

Table 6 Achieving appropriate glucose infusion rate at different daily fluid intakes
Daily fluid Glucose infusion rate (GIR)
volume
(mL/kg/d 6 mg/kg/min 8 mg/kg/min 10 mg/kg/min
) D10 D25 D10 D25 D10 D25
60 42 18 24 36 5 55
75 68 7 49 26 30 45
90 90 - 74 16 55 35
105 85* - 99 6 80 25
120 100* - 120 - 97 18
 8

REFERENCES:
s
1. Cornblath M, Hawdon JM, Williams AF, et al. Controversie regarding definition of neonatal hypoglycemia:
suggested operational thresholds. Pediatrics 2000; 105: 1141-5.
2. Termote B, Verswijvel G, Gelin G, et al Neonatal hypoglycemic brain injury. JBR-BTR 2008; 91: 116-7.
3. Inder T. How low can I go? The impact of hypoglycemia on the immature brain. Pediatrics 2008; 122: 440-1.
4. Mitanchez D. Glucose regulation in preterm newborn infants. Horm Res 2007; 68: 265-71.
5. Cornblath M, Ichord R. Hypoglycemia in the neonate. Semin Perinatol 2000; 24: 136-49
6. Rozance PJ, Hay WW Jr. Hypoglycemia in newborn infants: features associated with adverse outcomes. Biol
Neonate 2006; 90: 74-86.
7. Cornblath M, Schwartz R. Outcome of neonatal hypoglycemia Br Med J. 1999;318 :194.
8. William W, Hay Jr, Tonse NK Raju, et al. Knowledge gaps and research needs for understanding and treating
neonatal hypoglycemia: Workshop report from Eunice Kennedy Shriver National Institute of Child Health
and Human Development. J Pediatr 2009; 155: 612-17.
9. Kalhan S, Parimi P. Gluconeogenesis in the fetus and neonate. Semin Perinatal 2000; 24: 94-106.
10. Srinivasan G, Pilades RS, Cattamanchi G, et al. Plasma glucose values in normal neonates: a new look. J
Pediatr 1986; 109: 114-7.
11. Holtrop PC. The frequency of hypoglycemia in full term and small for gestational age newborns. Am J
Perinatol 1993; 10: 150-4.
12. Cowett RM, Damico LB. Capillary (heel stick) versus venous blood sampling for determination of glucose
concentration in neonate. Biol Neonate 1992; 62: 32-6.
13. Lucas A, Morley R. Outcome of neonatal hypoglycemia. Br Med J 1999; 318: 194.
14. Filan PM, Inder TE, Cameron FJ, et al. Neonatal hypoglycemia and occipital cerebral injury. J Pediatr 2006;
148: 552-5.
15. Singhal PK, Singh M, Paul VK. Prevention of hypoglycemia: A controlled evaluation of sugar fortified milk
feeding in small- for- date infants. Indian Pediatr 1992; 29:1365-9.
16. Singhal PK, Singh M, Paul VK, et al. A controlled study of sugar fortified milk feeding in prevention of
neonatal hypoglycemia. Indian J Med Res 1991; 94: 342-5.
17. Duvanel CB, Fawer CL, Cotting J, et al. Long term effects of neonatal hypoglycemia on brain growth and
psychomotor development in small-for-gestational age preterm infants. J Pediatr 1999; 134: 492-8.
18. Boluyt N, van Kempen A, Offringa M. Neurodevelopment after neonatal hypoglycemia: A systematic review
and design of an optimal future study. Pediatrics 2006; 117: 2231-43.
19. Burns CM, Rutherford MA, Boardman JP et al. Patterns of cerebral injury and neurodevelopmental
outcomes after symptomatic neonatal hypoglycemia. Pediatrics 2008; 122: 65-74.
 9

Figure 1. Algorithm for management of neonatal hypoglycemia

Hypoglycemia
Blood sugar <45 mg/dL

Symptomatic including
Asymptomatic seizures

Bolus of 2 mL/kg 10%

20-45 mg/dL <20 mg/dL glucose

IV glucose infusion @ 6 mg/kg/min

Monitor hourly till euglycemic and
Trial of oral feeds then 6 hrly

Blood sugar >50 mg/dL Blood sugar <50 mg/dL

Monitor the blood sugar after 1
hour
Stable for 24 hours on IV fluids; Increase glucose @ 2
2 values of blood sugar >50
mg/kg/min till
mg/dL
euglycemia
> 45 mg/dL < 45 mg/dL

Weaning at 2 mg/kg/min every

6 hrs; Increase till the glucose
Frequent feeds oral feeds; infusion rate is >12
Monitoring to continue 6 hrly mg/kg/min

Stop IV fluids when

Monitor blood sugar the rate is 4 mg/kg/min Refer to Specialist center for further
and the infant is stable investigation
Stop after 48 hrs
Stop monitoring when 2
values are more than 50 on Hydrocortisone
Before discharge ensure that Diazoxide (not in SGA)
full oral feeds
there is no feeding difficulty Glucagon (not in SGA)
Octreotide
 Table 7: List of researchable issues in neonatal hypoglycemia

S.NO Research question Type of study Intervention Outcome measures

1. What is the incidence of Cohort study by Nil Incidence,
neonatal hypoglycemia, enrolling at risk Age at which it is detected in hours,
age at onset, clinical infants (Table1) Rate of occurrence of different
manifestations and short clinical manifestation,
term outcomes? Neurological examination at
(Epidemiology of discharge and MRI findings,
hypoglycemia)
2 Does asymptomatic Randomized Group 1: Treat Neurodevelopmental outcome at
hypoglycemia need control trial with IV fluids 18-24 months of age
treatment with Group 2 : No IV
intravenous glucose? fluids(unless
symptoms
appear)
3 Evaluation of accuracy of Diagnostic Nil Estimation of correlation and
point of care with evaluation study agreement between two methods.
reagent strips when
compared to lab values
(gold standard) for
detecting hypoglycemia.

10
 ANNEXURE
1. How to calculate the desired concentration of glucose in intravenous fluid
and how to mix various solutions for creating a desired concentration of
glucose in IV infusate?

The formula for preparing 100 mL of fluid with a desired concentration of glucose
using 5% dextrose and 25% dextrose solutions is given by the formula 5X-25 = Y
where X is the required percentage of dextrose and Y is the amount of 25%
dextrose (in mL) to be made up with 5% dextrose to make a total of 100 mL.

For example, to prepare 100ml of 10% dextrose from 5% dextrose and 25%
dextrose, add 5x10-25=25ml of 25% dextrose to the remaining volume, i.e. 100-
25 =75 ml of 5% dextrose.

To prepare 100 ml of 12.5% dextrose, add 5x12.5-25=37.5ml of 25% dextrose to

62.5 ml (100-37.5) of 5% dextrose.

2. How to calculate the glucose infusion rate (GIR)?

Neonatal blood glucose concentrations correlate closely with glucose infusion

rates. Glucose Infusion Rate (GIR) is expressed in terms of milligrams of
glucose per kilogram body weight per minute (mg/kg/min). It can be calculated
using one of the following formulae39 :

(a) GIR = % of dextrose being infused x rate of infusion (in ml/hr)

(mg/kg/min) Body weight (in kg) x 6

(b) GIR = Rate of IV fluids (in ml/kg/day) x % of dextrose infused

(mg/kg/min) 144

(c) GIR = Rate of IV fluids (in ml/kg/day) x % of dextrose infused x 0.007

Method 1 for calculating GIR (same as (b) above)

Decide desired fluid intake of the neonate in mL/kg/day (24 hrs) Convert this to
mL/kg/min by dividing the figure by 1440

(Since 24 hours have 1440 minutes)

If 10% dextrose is being used, multiply the figure obtained in (b) above by 100 to
find out the Glucose Infusion Rate (GIR) in mg/kg/min.

(Since 10% Dextrose has 100 mg/mL of dextrose. Similarly, 5% dextrose has 50
 mg/mL; 7.5% dextrose has 75mg/mL of dextrose and so on)

(d) Based on desired fluid intake and desired GIR, the concentration of dextrose
in the IV infusate can be decided.

(e) Example

(i) Let the neonate's fluid intake be 80 mL/kg/day

(ii) This is 80/1440 = 0.055 mL/kg/min

(iii) If 10% dextrose is given, then the GIR is :

0.055 x 100 = 5.5 mg/kg/min

Method 2 for fluid rate and GIR (Using 10% dextrose only)24

Step1

a) 100 mL of 10% dextrose has 10 gm or 10,000 mg of glucose

b) If this 100 ml is given over 24 hours then GIR is
10,000/1440 = 6.95 mg/min; say 7.0 mg/min
(Since 24 hours have 1440 minutes)
c) Therefore 1 mL/day of 10% dextrose will provide a GIR of 0.07 mg/min
d) Based on the above, GIR for a neonate can be calculated as follows: GIR
(mg/kg/min) = IV fluid rate (mL/kg/day) x 0.07

Step 2 Increasing GIR by 1mg/kg/min

(a) Add 2 mL/kg of 25% dextrose to the volume of fluid to be infused over 8
hrs see explanation below:

[i] 25% Dextrose has 250 mg/mL of dextrose; 2 mL/kg has 500 mg/kg

[ii] The 8 hour period has 8 x 60 = 480 minutes

[iii] 2 mL/kg of 25% dextrose over 8 hrs will increase the GIR by 5 00/480
or roughly 1 mg/kg/min

(b) Example

1. Let the neonate's fluid intake be 80 mL/kg/day

2. With 10% dextrose the GIR is 80x0.07 = 5.6 mg/kg/min

3. If GIR has to be increased by 1 mg/kg/min then add 2 ml/kg of 25%

dextrose to the fluid to be infused over 8 hrs
 (c) Caveat: For this formula to work, the GIR has to be kept at or below a tenth of
the total fluid intake in mL/kg/day e.g. if the total fluid intake is 100
mL/kg/day, you cannot increase GIR beyond 10 mg/kg/min using this formula
to increase GIR beyond this limit, fluid intake has to be increased.

3. How to convert gm/dL to mmol/L & vice versa?

There are two main methods of describing concentrations: by weight, and by molecular
count. Weights are in grams, molecular counts in moles.

To convert mmol/L of glucose to mg/dl, multiply by 18. To convert mg/dL of glucose to

mmol/L, divide by 18 or multiply by 0.055.

4. How to calculate GIR in an infant on oral feeds along with simultaneous

intravenous infusion of glucose? (also see Figures 2 and 3)

Glucose infusion needs to be calculated while giving feeding and can be done by the
same formula Glucose infusion rate while on feeding (mg/kg/min) =

[IV rate (ml/hr) x Dextrose conc (g/dl) x .0167 / wt (kg)] + [Feed rate (ml/hr) x Dextrose
conc* (g/dl) x .0167 / wt (kg)]

Amount of dextrose in milk : Breast milk = 7.1 gm/dL, Term formula = 7. 1gm/dL,
Preterm formula = 8.5 gm/dL
Figure 2: Calculating glucose concentration to be used based on amount of fluid
and GIR
Figure 3 Calculation of GIR of baby on fluids and feeds (assuming breast milk or term
formula)
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Management of hypoglycemia in newborns

Flowchart 1:
Identify a baby with hypoglycemia

SUSPECT: SUSPECT:
1. Small baby (birth weight <2 kg) Baby with one or more emergency signs
2. Large baby (birth weight of 4 kg or more) (Sheet A-Management of Emergencies)
3. Baby of diabetic mother Baby with one or more of the following clinical features
lethargy/stupor, poor suck or difficulty in feeding,
jitteriness, convulsions, apnea

Check blood glucose every 12 hours Check blood glucose every 12 hours until the
until 48-72 hours of life baby is stable or the symptoms have resolved

Blood glucose <45 mg/dl

Hypoglycemia

Follow Flowchart 2 or 3

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and
Pocket Book of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/,
http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Flowchart 2
Management of a baby with blood glucose of 25-45 mg/dl but no symptoms of hypoglycemia

Blood glucose 25-45mg/dl

AND
Baby has no symptoms

Breastfeeding or expressed breast milk by cup/spoon/paladai

Monitor blood glucose after 3 hours or before next feed

> 45 mg/dl 25-45 mg/dl < 25 mg/dl

Increase frequency (if breast-fed) or Follow Flowchart 3

Increase volume of feed (if cup / spoon /
paladai-fed)

Monitor blood glucose before next

feeds;
Discontinue monitoring if blood glucose
is 45 mg/dl or more on two consecutive
measurements

Baby with blood glucose 25-45 mg/dl who has symptoms of hypoglycemia,
follow Flowchart 3

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and
Pocket Book of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/,
http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Flowchart 3
Management of a baby with blood glucose less than 25 mg/dl
OR/AND symptoms of hypoglycemia

Blood glucose <25 mg/dl

OR
Blood glucose 25-45 mg/dl and symptoms of hypoglycemia

Bolus of 2 ml/kg 10% Dextrose IV over 5 minutes

(if no IV line, give the same by intra-gastric tube)

IV 10% Dextrose at daily maintenance rate

Monitor blood glucose after 30 minutes

Blood glucose <45 mg/dl Blood glucose >45 mg/dl

If blood glucose remains <45 mg/dl after 2 boluses, Continue glucose infusion
continue IV 10% Dextrose and arrange for referral

Monitor blood glucose every 3 hours:

If level is 45 mg/dl or more on two
consecutive measurements, start decreasing
glucose infusion;
Increase oral feeding concurrently

Stop IV fluids when oral feeding reaches at

least 2/3 of daily requirement;
Allow the baby to breastfeed;
Stop monitoring when 2 values of blood
glucose are more than 45 mg/dl on full oral
feeding

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and
Pocket Book of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/,
http://www.newbornwhocc.org/
 Inborn Errors of Metabolism Presenting in Neonates

Inborn errors of metabolism (IEM) are disorders in which there is a block at some point in the
normal metabolic pathway caused by a genetic defect of a specific enzyme. The number of
diseases in humans known to be attributable to inherited point defects in metabolism now
exceeds 500.1 While the diseases individually are rare, they collectively account for a significant
proportion of neonatal and childhood morbidity and mortality. Diagnosis is important not only
for treatment and prognostication but also for genetic counselling and antenatal diagnosis in
subsequent pregnancies.

Clinical Presentation
Severe illness in the newborn, regardless of the underlying cause, tends to manifest with non-
specific findings, such as poor feeding, drowsiness, lethargy, hypotonia and failure to thrive. IEM
should be considered in the differential diagnosis of any sick neonate along with common
acquired causes such as sepsis, hypoxic-ischemic encephalopathy, duct-dependant cardiac
lesions, congenital adrenal hyperplasia and congenital infections (Panel 1).

Panel 1. Clinical pointers for suspicion of IEM2

Deterioration after a period of apparent normalcy
Parental consanguinity
Family history of neonatal deaths
Rapidly progressive encephalopathy and seizures of unexplained cause
Severe metabolic acidosis
Persistent vomiting
Peculiar odor
Acute fatty liver or HELLP (hemolysis, elevated liver enzymes & low platelet counts) during
pregnancy: seen in women carrying fetuses with long-chain-3-hydroxyacyl-coenzyme
dehydrogenase deficiency (LCHADD)

A variety of examination findings may provide a clue to the underlying IEM (Panel 2). Patterns of
presentation include2,3:

Encephalopathy with or without metabolic acidosis

Encephalopathy, seizures, and tone abnormalities are predominant presenting features of
organic acidemias, urea cycle defects and congenital lactic acidosis. Intractable seizures are
prominent in pyridoxine dependency, non-ketotic hyperglycinemia, molybdenum co-factor
defect and folinic-acid responsive seizures.

Acute liver disease

This could manifest as:
Jaundice alone- Gilbert syndrome, Criggler-Najjar syndrome
Hepatic failure (jaundice, ascites, hypoglycemia, coagulopathy)- Tyrosinemia, galactosemia,
neonatal hemochromatosis, glycogen storage disease type IV.
Neonatal cholestasis: alpha-1 antitrypsin deficiency, Niemann-Pick disease type C.

1
Hypoglycemia: persistent and severe hypoglycemia may be an indicator of an underlying IEM.
Hypoglycemia is a feature of galactosemia, fatty acid oxidation defects, organic acidemias,
glycogen storage disorders and disorders of gluconeogenesis.

Dysmorphic features
Dysmorphic features are seen in peroxisomal disorders, pyruvate dehydrogenase deficiency,
congenital disorders of glycosylation (CDG), and lysosomal storage diseases. Some IEMs may
present with non-immune hydrops fetalis; these include lysosomal storage disorders and CDG.

Cardiac disease
Cardiomyopathy is a prominent feature in some IEM including fatty acid oxidation defects,
glycogen storage disease type II and mitochondrial electron transport chain defects.

Panel 2: Clinical pointers towards specific IEM

Clinical finding Disorder
Coarse facies Lysosomal disorders
Cataract Galactosemia, Zellweger syndrome
Retinitis pigmentosa Mitochondrial disorders
Cherry red spot Lipidosis
Hepatomegaly Storage disorders, urea cycle defects
Renal enlargement Zellweger syndrome
Eczema/alopecia Biotinidase deficiency
Abnormal kinky hair Menke disease
Decreased pigmentation Phenylketonuria

Investigations

Metabolic investigations should be initiated as soon as the possibility is considered. The

outcome of treatment of many IEM especially those associated with hyperammonemia is
directly related to the rapidity with which problems are detected and appropriate management
instituted.

First line investigations (metabolic screen)

Panel 3 summarizes the tests to be performed in all babies with suspected IEM.

Panel 3. List of tests to be performed in all babies with suspected IEM

1) Complete blood count: (neutropenia and thrombocytopenia seen in propionic and
methylmalonic academia)
2) Arterial blood gases and electrolytes
3) Blood glucose
4) Plasma ammonia (Normal values in newborn: 90-150 g/dl or 64-107 mol/L)
5) Arterial blood lactate (Normal values: 0.5-1.6 mmol/L)
6) Liver function tests
7) Urine ketones
8) Urine reducing substances.
9) Serum uric acid (low in molybdenum cofactor deficiency)

2
Figure 1 gives the algorithmic approach to a newborn with suspected IEM. Disease category can
be diagnosed based on blood ammonia, blood gas analysis and urine ketone testing.
Hyperammonemia without acidosis is caused by urea cycle defects.

Metabolic acidosis with or without hyperammonemia is a feature of organic acidemias and fatty
acid oxidation defects. Figure 2 explains the algorithmic approach to neonate with persistent
hypoglycemia and suspected underlying IEM.

Panel 3 explains the categorization of IEM based on simple metabolic screening tests.

3
Fig 1: Approach to newborn with suspected metabolic disorder

Suspected Metabolic Disorder

Plasma NH3

High Normal

Blood pH & CO2 Blood pH & CO2

Normal Acidosis Normal

(PKU, NKH, Galactosemia,
Peroxisomal disorders,
Aminoacidopathies)

No ketosis No ketosis
Ketosis with or without
Lactic acidosis

Urea cycle defect FAOD Organic acidemias

Mitochondrial disorders

Plasma citrulline

(>1000 mol/L) (25-50 mol/L) (Undetectable)

ASA deficiency Urinary ASA Urinary orotic acid

(citrullinemia)

+ - + -
ASAL deficiency THAN OTC CPS/NAGS
(ASAuria) deficiency deficiency

(FAOD: fatty acid oxidation defects, PKU: Phenylketonuria, NKH: Nonketotic hyperglycinemia, ASA:
Argininosuccinic acid, OTC: Ornithine transcarbamoylase, CPS: carbamoylphosphate synthetase I; NAGS:
N-acetylglutamate synthetase, THAN: transient hyperammonemia of newborn, ASAL: argininosuccinic acid
lyase)

4
Figure 2: Approach to newborn with persistent hypoglycemia and suspected IEM

Hypoglycemia

Urine nonglucose reducing substances

Present Absent

Urine ketones

Positive Negative

Glycogen storage Fatty acid

Diseases Oxidative defects
Gluconeogenic defects Ketogenesis defects
Galactosemia Organic acidemias Hyperinsulinism

5
Panel 3: Categorization of neonatal IEM using metabolic screening tests

Acidosis Ketosis Lactate Ammonia Diagnosis

- + - - Maple syrup urine disease
+ +/- - +/- Organic aciduria
+ +/- + - Lactic acidosis
- - - + Urea cycle
- - - - Non-ketotic hyperglyceminuria,
sulfite oxidase deficiency,
peroxisomal, Phenylketonuria,
galactosemia

Second line investigations (ancillary and confirmatory tests)

These tests need to be performed in a targeted manner, based on presumptive diagnosis

reached after first line investigations:

1) Gas chromatography mass spectrometry (GCMS) of urine- for diagnosis of organic

acidemias.

2) Plasma amino acids and acyl carnitine profile: by tandem mass spectrometry (TMS)- for
diagnosis of organic acidemias, urea cycle defects, aminoacidopathies and fatty acid
oxidation defects.

3) High performance liquid chromatography (HPLC): for quantitative analysis of amino acids in
blood and urine; required for diagnosis of organic acidemias and aminoacidopathies.

4) Lactate/pyruvate ratio- in cases with elevated lactate.

5) Urinary orotic acid- in cases with hyperammonemia for classification of urea cycle defect.

6) Enzyme assay: This is required for definitive diagnosis, but not available for most IEMs.
Available enzyme assays include: biotinidase assay- in cases with suspected biotinidase
deficiency (intractable seizures, seborrheic rash, alopecia); and . GALT (galactose 1-
phosphate uridyl transferase ) assay- in cases with suspected galactosemia (hypoglycemia,
cataracts, reducing sugars in urine).

7) Neuroimaging: MRI may provide helpful pointers towards etiology while results of definitive
investigations are pending. Some IEM may be associated with structural malformations e.g.
Zellweger syndrome has diffuse cortical migration and sulcation abnormalities. Agenesis of
corpus callosum has been reported in Menkes disease, pyruvate decarboxylase deficiency
and nonketotic hyperglycinemia.4 Examples of other neuroimaging findings in IEM include:

Maple syrup urine disease (MSUD): brainstem and cerebellar edema

6
 Propionic & methylmalonic acidemia: basal ganglia signal change
Glutaric aciduria: frontotemporal atrophy, subdural hematomas

8) Magnetic resonance spectroscopy (MRS): may be helpful in selected disorders E.g. lactate
peak elevated in mitochondrial disorders, leucine peak elevated in MSUD.

9) Electroencephalography (EEG): some EEG abnormalities may be suggestive of particular

IEM; e.g. comb-like rhythm in MSUD, burst suppression in NKH and holocarboxylase
synthetase deficiency.5

10) Plasma very long chain fatty acid (VLCFA) levels: elevated in peroxisomal disorders.

11) Mutation analysis when available.

12) CSF aminoacid analysis: CSF Glycine levels elevated in NKH.

Precautions to be observed while collecting samples

1. Should be collected before specific treatment is started or feeds are stopped, as may be
falsely normal if the child is off feeds.

2. Samples for blood ammonia and lactate should be transported in ice and immediately
tested. Lactate sample should be arterial and should be collected after 2 hrs fasting in a
preheparinized syringe. Ammonia sample is to be collected approximately after 2 hours of
fasting in EDTA vacutainer. Avoid air mixing. Sample should be free flowing.

3. Detailed history including drug details should be provided to the lab. (sodium valproate
therapy may increase ammonia levels).

Samples to be obtained in infant with suspected IEM when diagnosis is uncertain and
death seems inevitable (Metabolic autopsy)6
1. Blood: 5-10 ml; frozen at -200C; both heparinized (for chromosomal studies) and EDTA (for
DNA studies) samples to be taken
2. Urine: frozen at 20oC
3. CSF: store at 20oC
4. Skin biopsy: including dermis in culture medium or saline with glucose. Store at 4-80C. Do
not freeze.
5. Liver, muscle, kidney and heart biopsy: as indicated.
6. Clinical photograph (in cases with dysmorphism)
7. Infantogram (in cases with skeletal abnormalities)

Treatment
In most cases, treatment needs to be instituted empirically without a specific diagnosis. The
metabolic screen helps to broadly categorize the patients IEM (e.g. urea cycle defect, organic
academia, congenital lactic acidosis etc), on the basis of which, empirical treatment can be
instituted.

7
Aims of treatment
1) To reduce the formation of toxic metabolites by decreasing substrate availability (by
stopping feeds and preventing endogenous catabolism)
2) To provide adequate calories
3) To enhance the excretion of toxic metabolites.
4) To institute co-factor therapy for specific disease and also empirically if diagnosis not
established.
5) Supportive care- treatment of seizures (avoid sodium valproate may increase ammonia
levels), maintain euglycemia and normothermia, fluid, electrolyte & acid-base balance,
treatment of infection, mechanical ventilation if required.

Management of hyperammonemia7,8
1) Discontinue all feeds. Provide adequate calories by intravenous glucose and lipids. Maintain
glucose infusion rate 8-10 mg/kg/min. Start intravenous lipid 0.5 g/kg/day (up to 3
g/kg/day). After stabilization gradually add protein 0.25 g/kg till 1.5 g/kg/day.

2) Dialysis is the only means for rapid removal of ammonia, and hemodialysis is more effective
and faster than peritoneal dialysis; however peritoneal dialysis may be more widely
available and feasible. Exchange transfusion is not useful.

3) Alternative pathways for nitrogen excretion:

Sodium benzoate (IV or oral)- loading dose 250 mg/kg then 250-400 mg/kg/day in 4
divided doses (intravenous preparation is not available in India).
Sodium phenylbutyrate (not available in India)-loading dose 250 mg/kg followed by 250-
500 mg/kg/day.
L-arginine (oral or IV)- 300 mg/kg/day (intravenous preparation not available in India)
L-carnitine (oral or IV)- 200 mg/kg/day

4) Supportive care: treatment of sepsis, seizures, ventilation. Avoid sodium valproate.

Acute management of newborn with suspected organic acidemia9

1) The patient is kept nil per orally and intravenous glucose is provided.
2) Supportive care: hydration, treatment of sepsis, seizures, ventilation.
3) Carnitine: 100 mg/kg/day IV or oral.
4) Treat acidosis: Sodium bicarbonate 0.35-0.5mEq/kg/hr (max 1-2mEq/kg/hr)
5) Start Biotin 10 mg/day orally.
6) Start Vitamin B12 1-2 mg/day I/M (useful in B12 responsive forms of methylmalonic
acidemias)
7) Start Thiamine 300 mg/day (useful in Thiamine-responsive variants of MSUD).
8) If hyperammonemia is present, treat as explained above.

Management of congenital lactic acidosis

1) Supportive care: hydration, treatment of sepsis, seizures, ventilation. Avoid sodium
valproate.
2) Treat acidosis: sodium bicarbonate 0.35-0.5mEq/kg/hr (max 1-2mEq/kg/hr)

8
 3) Thiamine: up to 300 mg/day in 4 divided doses.
4) Riboflavin: 100 mg/day in 4 divided doses.
5) Add co-enzyme Q: 5-15 mg/kg/day
6) L-carnitine: 50-100 mg/kg orally.

Treatment of newborn with refractory seizures with no obvious etiology (suspected metabolic
etiology)10

1) If patient persists to have seizures despite 2 or 3 antiepileptic drugs in adequate doses,

consider trial of pyridoxine 100 mg intravenously. If intravenous preparation not
available, oral pyridoxine can be given (15 mg/kg/day).
2) If seizures persist despite pyridoxine, give trial of biotin 10 mg/day and folinic acid 15
mg/day (folinic acid responsive seizures).
3) Rule out glucose transporter defect: measure CSF and blood glucose. In glucose
transporter defect, CSF glucose level is equal to or less than 1/3rd of the blood glucose
level. This disorder responds to the ketogenic diet.

Management of asymptomatic newborn with a history of sibling death with suspected IEM:

1) After baseline metabolic screen, start oral dextrose feeds (10% dextrose).
2) After 24 hours, repeat screen. If normal, start breast feeds. Monitor sugar, blood gases
and urine ketones, blood ammonia 6 hourly.
3) Some authorities recommend starting medium chain triglycerides (MCT oil) before
starting breast feeds,3 however, this is not being followed in our center (because of
unpalatibility of MCT oil).
4) After 48 hours, repeat metabolic screen. Obtain samples for TMS and urine organic acid
tests.
5) The infant will need careful observation and follow-up for the first few months, as IEM
may present in different age groups in members of the same family.

Long term treatment of IEM

The following modalities are available:

1) Dietary treatment: This is the mainstay of treatment in phenylketonuria, maple

syrup urine isease, homocystinuria, galactosemia, and glycogen storage disease
Type I & III. Special diets for PKU and MSUD are commercially available in the west.
These are not available in India, but can be imported. These special diets are
however very expensive, and cannot be afforded by most Indian patients. Based on
the amino acid content of some common food products available in India, dietary
exchanges are calculated and a low phenylalanine diet for PKU and diet low in
branched chain amino acids for MSUD are being used in our center. However, there
are no studies to document the efficacy of these indigenous diets. Some disorders
like urea cycle isorders and organic acidurias require dietary modification (protein
restriction) in addition to ther modalities.11

2) Enzyme replacement therapy (ERT): ERT is now commercially available for some
lysosomal storage disorders.12 However, these disorders do not manifest in the

9
 newborn period, an exception being Pompes disease (Glycogen storage disorder
Type II) which may present in the newborn period and for which ERT is now
available.

3) Cofactor replacement therapy: The catalytic properties of many enzymes depend on

the participation of non protein prosthetic groups, such as vitamins and minerals, as
obligatory cofactors. The following co-factors may be beneficial in certain IEM:13

Thiamine: mitochondrial disorders, thiamine responsive variants of MSUD, PDH

deficiency & complex I deficiency)
Riboflavin: Glutaric aciduria Type I, Type II, mild variants of ETF, ETF-DH, complex I
deficiency
Pyridoxine: 50% of cases of homocystinuria due to cystathionine -synthetase
deficiency, pyridoxine dependency with seizures, xanthurenic aciduria, primary
hyperoxaluria type I, Hyperornithemia with gyrate atrophy
Cobalamin: Methylmalonic academia (cblA, cblB), Homocystinuria and methylmalonic
academia (cblC, cblD, cblF)
Folinic acid: Hereditary orotic aciduria, Methionine synthase deficiency, Cerebral folate
transporter deficiency, hereditary folate malabsorption, Kearns-Sayre syndrome
Biotin: Biotinidase deficiency, holocarboxylase synthetase deficiency

Panel 4 provides some commercially preparation of commonly used drugs for managing IEM.

Panel 4: Commercially available formulations used in IEM

Co-factor Trade name, formulation
Pyridoxine Tab Benadon (40mg) (Nicholas Piramal), Inj Vitneurin (1
ampoule contains 50 mg pyridoxine)
Hydroxycobalamin (Vitamin Inj Trineurosol (1000mcg/ml)
B12) (Tridoss Laboratories)
Thiamine Tab Benalgis (75 mg) (Franco India)
Riboflavin Tab Riboflavin (5 mg) (Shreya)
Biotin Tab Essvit (5mg, 10mg) (Ecopharma)
Carnitine Syrup L-Carnitor (5ml=500 mg), Tab L-Carnitor (500 mg), Inj
carnitor (1g/5ml) (Elder)
Folinic acid Tab Leukorin (15 mg) (Samrath)
Sodium Benzoate Satchet 20g (Hesh Co.)
Arginine ARG-9 Satchet (3g) (Noveau Medicament)
Coenzyme Q Tab CoQ 30 mg, 50 mg. (Universal Medicare)

Prevention
1) Genetic counselling and prenatal diagnosis: Most of the IEM are single gene defects,
inherited in an autosomal recessive manner, with a 25% recurrence risk. Therefore when the
diagnosis is known and confirmed in the index case, prenatal diagnosis can be offered,
wherever available for the subsequent pregnancies. The samples required are chorionic
villus tissue or amniotic fluid. Modalities available are:14
Substrate or metabolite detection: useful in phenylketonuria, peroxisomal defects.

10
 Enzyme assay: useful in lysosomal storage disorders like Niemann-Pick disease,
Gaucher disease.
DNA based (molecular) diagnosis: Detection of mutation in proband/ carrier parents
is a prerequisite.

2) Neonatal screening: Tandem mass spectrometry is used in some countries for neonatal
screening for IEM. Disorders which can be detected by TMS include aminoacidopathies
(phenylketonuria, MSUD, homocystinuria, citrullinemia, argininosuccinic aciduria,
hepatorenal tyrosinemia), fatty acid oxidation defects, organic acidemias (glutaric
aciduria, propionic acidemia, methylmalonic acidemia, isovaleric acidemia). The cost of
this procedure is high. Also, the though the test is highly sensitive, the specificity is
relatively low; and there are difficulties in interpretation of abnormal test results in
apparently healthy infants.

11
References
1) Childs B, Valle D, Jimenez-Sanchez. The Inborn error and biochemical variability. In: Scriver CR,
Beaudet AL, Sly WS & Valle D (eds). The metabolic and molecular basis of inherited disease, 8 th ed,
New York: McGraw-Hill, 2001: 155-166.

2) A Clinical guide to inherited metabolic diseases. JTR Clarke. 3rd Ed (2006), Cambridge University
Press, Cambridge.

3) Cataltepe SU, Levy HL. Inborn errors of metabolism. In: Cloherty JP, Eichenwald EC, Stark AR eds.
Manual of neonatal care. 6th Edition. Lippincott Williams & Wilkins 2008; Philadelphia: 558-573.

4) Blaser S, Feigenbaum A. A neuroimaging approach to inborn errors of metabolism. Neuroimag Clin

N Am 2004; 14: 307-329.

5) Nordli DR, De Vivo DC. Classification of infantile seizures: Implications for identification and
treatment of inborn errors of metabolism. J Child Neurol 2002; 17 (Suppl 3): 3S3-3S8.

6) Leonard JV, Morris AAM. Diagnosis and early management of inborn errors of metabolism
presenting around the time of birth. Acta Pediatrica 2006; 95: 6-14.

7) Summar M. Current strategies for the management of neonatal urea cycle disorders. J Pediatr 2001;
38: S30-S39.

8) Leonard JV, Morris AAM. Urea cycle disorders. Semin Neonatol 2002; 7: 27-35.

9) de Baulny HO, Saudubray JM. Branched-chain organic acidurias. Semin Neonatol 2002; 7: 65-74.

10) Wolf NI, Bast T, Surtees S. Epilepsy in inborn errors of metabolism. Epileptic Disord 2005; 7(2): 67-81.

11) Kabra M. Dietary management of Inborn errors of metabolism. Indian J Pediatr 2002; 69: 421-426.

12) Brady RO, Schiffmann R. Enzyme-replacement therapy for metabolic storage disorders. Lancet
Neurol 2004; 3: 752-756.

13) Saudubray JM, Sedel F, Walter JH. Clinical approach to treatable inborn metabolic diseases: an
introduction. J Inherit Metab Dis 2006; 29: 261-274.

14) Elias S, Simpson JL, Shulman LP. Techniques for prenatal diagnosis. In: Rimoin DL, Connor JH,
Pyeritz RE, Korf BR eds. Emery and Rimoins Principles and practice of medical genetics. Churchill-
Livingstone, London 2002: 802-825.

12
 Congenital Hypothyroidism

Congenital Hypothyroidism (CH) is a preventable cause of mental retardation. The worldwide

incidence is 1:3000-4000 live births and the estimated incidence in India is 1:2500-2800 live
1
births. Thyroid dysgenesis is the commonest cause accounting for 75-80% of all cases of CH.

Embryology and physiology of the thyroid in the fetus

Thyroid gland originates as a proliferation of endodermal epithelial cells at 3 to 4 weeks of
gestation. Synthesis and secretion of thyroxine (T4) and triiodothyronine (T3) starts from 12
weeks of gestation. Thyrotropin-releasing hormone (TRH) and thyroid stimulating hormone
(TSH) are detectable by the end of first trimester, but the activity of the hypothalamic-pituitary-
thyroid (HPT) axis is low with insufficient production of thyroid hormones until 18 to 20 weeks
of gestation. Therefore, the fetus depends on transplacental passage of thyroid hormones
during this period. In the second half of gestation, fetal T4 and TSH levels increase progressively.

In the hypothyroid fetus, transplacental passage of maternal thyroid hormones, and increased
conversion of T4 to T3 in fetal brain by type 2 deiodinase confer neuroprotection, and near
normal cognitive outcomes are possible if maternal thyroid function is normal and postnatal
therapy is initiated early. and In contrast, when both maternal and fetal hypothyroidism are
2
present, as in severe iodine deficiency, there is significant neuro-intellectual impairment.
Subtle or overt hypothyroidism in the mother during pregnancy also adversely affects the
3
cognitive outcome of the offspring.

Neonatal physiology
As a response to the cold ex-utero environment, there is an early postnatal surge of TSH, rising
to 60-80 mU/L within 30 - 60 minutes after delivery, with a rapid fall to about 20 mU/L in first
24 hours, and further decrease to below 10 mU/L by the end of first week. T4 levels also
increase to peak levels ofapproximately 17 g/dL at 24 -36 hours, with a gradual decline over 4
to 5 weeks. Preterm infants demonstrate a similar but blunted response.
Etiology of CH

CH can be permanent or transient (Table I).

Table 1 Etiology of CH

1. Permanent hypothyroidism

b. Thyroid dysgenesis (aplasia, hypoplasia or ectopia)

c. Thyroid hormone biosynthetic defects

d. Iodine deficiency (endemic cretinism)

e. Hypothalamic-pituitary hypothyroidism

2. Transient hypothyroidism

a. TSH binding inhibitory immunoglobulins

b. Exposure to goitrogens (iodides or antithyroid drugs)

c. Transient hypothyroxinemia of prematurity

d. Sick euthyroid syndrome

Thyroid dysgenesis is the commonest cause of permanent CH affecting 1 in 4000 live births. It
is usually sporadic with a 2:1 female to male preponderance. Some of the genes proposed as
4
operative in dysgenesis have recently been identified as TITF1, TITF2, PAX8 and TSHR.

Thyroid hormone synthetic defects account for 10-15% of all cases. These are inherited as
autosomal recessive disorders. The defect can lie in iodide trapping or organification,
iodotyrosine coupling or deiodination, and thyroglobulin synthesis or secretion. The commonest
of these is a defect in the thyroid peroxidase (TPO) activity leading to impaired oxidation and
organification of iodide to iodine. These disorders usually result in goitrous hypothyroidism.
Iodine deficiency is responsible for endemic cretinism and hypothyroidism in some regions of
India.

Hypothalamic-pituitary hypothyroidism is rare and has an estimated incidence of 1 in

50,000. It may be isolated or associated with deficiency of other pituitary hormones and present
with hypoglycemia and microphallus.

Transient hypothyroidism due to transplacental transfer of TSH binding inhibitory

immunoglobulins (TBII) from mothers with autoimmune thyroid disease is seen in 1: 50,000
births. Their effect wanes off by 3 to 6 months in the majority, but may last up to 9 months.
Exposure to iodine in sick preterm infants (e.g. application of povidone iodine for skin
disinfection (Wolff-Chaikoff effect) or intake of iodine containing expectorants by pregnant
mothers can also induce transient hypothyroidism.

Transient hypothyroxinema of prematurity refers to low serum concentration of thyroid

hormones in up to 85% of preterm infants in early postnatal life as compared to term infants.
This reflects the underdevelopment of the HPT axis. The normal levels of fT4 and TSH in preterm
5
infants are presented in Table 2. There has been a concern that transient hypothyroxinemia is
associated with adverse neurodevelopmental outcomes and decreased survival in affected
6
infants.

Sick euthyroid syndrome reflects suppression of the pituitarys response to TRH, with
inappropriately low TSH concentrations in the context of low T3 and in the more severe cases,
low T4 concentrations.

Table 2. Reference ranges for serum free T4 (fT4) and TSH in preterm infants

Age in weeks Free T4 (ng/dL) TSH (mu/L)

25-27 06-2.2 0.2-30.3

28-30 0.6-3.4 0.2-20.6

31-33 1.0-3.8 0.7-20.9

34-36 1.2-4.4 1.2-21.6

Diagnosis

Newborn screening- Ideally universal newborn screening at 3 to 4 days of age should be done for
detecting CH (coupled with screening of other inborn errors of metabolism, wherever it is
undertaken). If screening is being done only for CH, cord blood may also be used. Universal
newborn screening is currently being done in many parts of the world. Three approaches are
being used for screening:

1. Primary TSH, back up T4

2. Primary T4, back up TSH

3. Concomitant T4 and TSH

The advantages and disadvantages of these approaches are presented in Box 1

Box 1: Approaches to screen for congenital hypothyroidism: advantages and disadvantages

1. Primary TSH, back up T4: TSH is measured first, and T4 is measured only if TSH is >20mu/L.
This approach is most widely used and cost-effective, but likely to miss central
hypothyroidism, thyroid binding globulin (TBG) deficiency and hypothyroxinemia with
delayed elevation of TSH.

2. Primary T4, back up TSH: T4 is checked first and if low, TSH is also checked. This is likely to
miss milder/subclinical cases of CH in which T4 is initially normal with elevated TSH.

7
3. Concomitant T4 and TSH: Most sensitive approach but incurs a higher cost.
th
Screening programs use either percentile based cut-offs (e.g, T4 below 10 centile or TSH above
th
90 centile)(7) or absolute cut-offs such as T4 <6.5 ug/dL and TSH >20mu/L. Among infants with
proven CH, TSH is >50 mu/L in 90% and T4 is <6.5 ug/dL in greater than 75% of cases.

Abnormal values on screening should always be confirmed by a venous sample (using age
8-10
appropriate cut-offs given in Table 3 ). Most centers initiate treatment after drawing the
infants sample if TSH >30 mu/L or T4 is low, and the decision to continue or withhold treatment
is taken after obtaining the venous blood report. For intermediate screening values of TSH, with
normal T4 (if available), the treatment is initiated only after confirmation of diagnosis based on
the blood report.

Table. 3 Reference ranges for T4, fT4 and TSH in term infants according to postnatal age6, 7

Age T4 (g/dL) fT4 (pg/mL) TSH (U/mL)

mean (range) mean (SD)/ range mean (range)

Cord blood 10.8 (6.6-15) 13.8 (3.5) 10.0 (1-20)

1-3 days 16.5 (11-21.5) * 5.6 (1-10)

4-7 days * 22.3 (3.9) *

1-2 weeks 12.7 (8.2-17.2) * 2.3 (0.5-6.5)

2-6 weeks 6.5-16.3** 0.9-2.2 1.7-9.1**

6 weeks to 12 months 11.1 (5.9-13) * 2.3 (0.5-6.5)

*No data available ** data for median/mean not available

In the absence of universal screening, newborns with the following indications should be
screened:

1. Family history of CH

2. History of thyroid disease or antithyroid medicine intake in mother

3. Presence of other conditions like Down syndrome, trisomy 18, neural tube defects,
congenital heart disease, metabolic disorders, familial autoimmune disorders and
Pierre-Robin syndrome, which are associated with higher prevalence of CH

Thyroid function should be tested in any infant with signs and symptoms of hypothyroidism such
as postmaturity, macrosomia or wide open posterior fontanel at birth or prolonged jaundice,
constipation, poor feeding, hypotonia, hoarse cry, umbilical hernia, macroglossia, or dry
edematous skin in infancy. The tests should be performed even in infants who have had a
normal newborn screening report.

Once the diagnosis is established, further investigations to determine the etiology should be
99m
done. A nuclear scan using sodium pertechnate ( Tc) is especially useful in diagnosing true
athyrosis or ectopy as well as goitrous hypothyroidism due to dyshormonogenesis. However,
since the scan can be done only before initiating treatment, one should not withhold therapy if
11,12
it is not possible to get it performed immediately. A list of diagnostic studies useful in
infants with congenital hypothyroidism is presented in Table 4 and an algorithmic approach to
investigation in Figure 1.
 Figure 1 Approach to a newborn infant with positive screening test for CH

Positive Screening test on filter paper sample

Serum T4/ Free T4, TSH

Normal Abnormal

Thyroid scan

Normal Absent uptake Ectopic

Tg Measurement Ultrasound

Normal Absent Normal gland No Thyroid tissue

TBII measurement * TBII measurement *

Positive Negative Positive Negative

Transient TH Tg TSH receptor Transien Thyroid Ectopi

CH synthetic synthetic or TH t agenesis c
defect or biosynthetic
defect or

TBII = TSH binding inhibitory immunoglobulin (*not routinely available)

Tg = thymoglobulin, TH = thyroid hormone
Adapted from Fisher DA. Management of congenital hypothyroidism. J Clin Endocrinol Metab
1991;72:585-8
Table 4 Diagnostic studies for evaluation of CH

1. Imaging Studies: will determine location and size of thyroid gland

a. Scintigraphy (99mTc or 123 I)

b. Sonography

2. Function Studies

a. 123 I uptake

b. Serum thyroglobulin

3. Suspected inborn error of T4 synthesis

a. 123 I uptake and perchlorate discharge

4. Suspected autoimmune thyroid disease

a. Maternal and neonatal serum TBII measurement (not routinely available)

5. Suspected iodine exposure or deficiency

a. Urinary iodine measurement

6. Ancillary test to determine severity of fetal hypothyroidism

a. Radiograph of knee for skeletal maturation

When should we ask for free T4 levels?

In most situations, T4 (total) levels are sufficient for diagnosis of hypothyroidism and
monitoring treatment, but free T4 can be obtained as a more robust marker of the
bioavailable T4, when readily accessible. When availability or cost is a constraint, free T4
8, 13
should be definitely estimated in following situations:

1. In premature or sick newborns, T4 (total) values may be low because of abnormal

protein binding or low levels of thyroxine binding globulin (TBG) due to immaturity of
liver function, proteinuria or undernutrition. Therefore, free T4 values provide a better
estimate of true thyroid function.

2. A case of low T4 with normal TSH. If free T4 is normal, it can be a case of congenital
partial (prevalence 1:4000 to 12000 newborns) or complete (prevalence 1:15000
newborns) TBG deficiency. TBG levels should be evaluated to confirm this but this test is
not available routinely. If free T4 is also low along with low T4 with normal TSH, central
hypothyroidism should be suspected.

3. During monitoring for adequacy of treatment, we usually monitor T4 (total) level. This
assumes a normal TBG level. This can be confirmed by measuring free T4 or TBG levels
once at the time of the first post-treatment T4 measurement.
Treatment of CH

Term as well as preterm infants with low T4 and elevated TSH should be started on L-thyroxine
as soon as the diagnosis is made. The initial dose of L-thyroxine should be 10-15 g/kg/day with
the aim to normalize the T4 level at the earliest.

Those infants with severe hypothyroidism (very low T4, very high TSH and absence of distal
femoral and proximal tibial epiphyses on radiograph of knee) should be started with the highest
14
dose of 15g/ kg/ day.

Monitoring of therapy:

T4 should be kept in the upper half of normal range (10 to 16 g/dL) or free T4 in the
1.4 to 2.3 ng/dL range with the TSH suppressed in the normal range.
Check T4 and TSH levels according to the following schedule:

0 to 6 months: every 6 weeks

6 months to 3 years: every 3 months
Beyond 3 years: every 6 monthly
6 to 8 weeks after any dosage change.
Monitor growth and development of the infant.
Avoid over treatment as it can lead to premature fusion of cranial sutures, acceleration
of skeletal maturation and problems with temperament and behavior.

Special situations

1. Asymptomatic hyperthyrotropinemia (Elevated TSH, normal T4)

Can be transient or permanent
Perinatal iodine exposure is an important cause of transient elevation of TSH in
neonatal period.
Other causes include defects in biological activity of TSH or TSH receptor, mild
thyroid hormone biosynthesis defect, subtle developmental defects or disturbance
in the negative feedback control of TSH.
There is controversy regarding need for treatment
Persistently elevated TSH> 10 U/ml is generally treated. However, in the presence
of free T4 levels in upper half of normal range, expectant management can be
followed with repetition of tests after 2 weeks.
In case treatment is started, it should be continued till 3 years of age, with
monitoring of thyroid function as detailed above. If TSH and T4 have always been
within normal limits with no need for escalation of dose during the first 3 years,
thyroid function should be re-evaluated after withholding thyroxine for a period of 6
14
weeks.

2. Isolated hypothyroxinemia (Low T4 and normal TSH levels)

This clinical situation is commonly seen in preterm infants due to immaturity of HPT
axis and is labeled as Transient hypothyroxinemia of prematurity. As of now,there
is insufficient evidence that early treatment with thyroid hormone leads to
 improved outcomes.
Central (hypothalamic/ pituitary) hypothyroidism (Incidence 1 in 1,00,000) is also
characterized by low T4. TSH may be low or normal. In term infants, with low total
as well as free T4, this diagnosis should be considered,, especially in presence of
midline facial abnormalities, hypoglycemia, microphallus, or visual abnormalities.
The infant should undergo testing for other pituitary hormones and MR imaging of
hypothalamus and pituitary.
TBG deficiency (rare) can also present with low T4 and normal TSH. Free T4 is
normal and no treatment is required.

3. Transient Hypothyroidism

The causes are listed in Table 1

Infants with transient hypothyroidism due to maternal goitrogenic drugs need not
be treated unless low T4 and elevated TSH values persist beyond 2 weeks. Therapy
can be discontinued after 8-12 weeks. Intake of antithyroid drugs can be continued
by the hyperthyroid mothers during breast feeding because concentration of these
drugs is very low in breast milk.
In infants born to mothers with autoimmune thyroiditis, treatment should be
started if T4 is low. If presence of TBII is documented in the infant, treatment can be
8
discontinued at 3-6 months. However, when TBII estimation is not available,
treatment should be continued till the age of 3 years, when T4 and TSH can be
tested after withholding thyroxine for 6 weeks.

The management has been summarized in Panel 1.

Table 5 provide research priorities in CH.

Outcome

The best outcome occurs with L-thyroxine therapy started by 2 weeks of age at 9.5 g/kg or
more per day, compared with lower doses or later start of therapy. Residual defects can include
impaired visuospatial processing and selective memory and sensorimotor defects. More than
80% of infants given replacement therapy before three months of age have an IQ greater than
85 but may show signs of minimal brain damage, including impairment of arithmetic ability,
7
speech, or fine motor coordination in later life. When treatment is started between 3-6
months, the mean IQ is 71 and when delayed to beyond 6 months, the mean IQ drops to 54.16
References

1. Desai MP, Upadhye P, Colaco MP, Mehre M, Naik SP, Vaz FE, Nair N, Thomas M. Neonatal
screening for congenital hypothyroidism using the filter paper thyroxine technique. Indian J
Med Res 1994; 100: 36-42.
2. Fisher DA, Klein AH. Thyroid development and disorders of thyroid function in the newborn.
N Engl J Med 1981; 304:702712.
3. Haddow JE, Palomaki GE, Allan WC, Williams JR, Knight GJ, Gagnon J, O'Heir CE, Mitchell ML,
Hermos RJ, Waisbren SE, Faix JD, Klein RZ.. Maternal thyroid deficiency during pregnancy
and subsequent neuro-psychological development of the child. N Engl J Med 1999;19;
341:549-55.
4. Macchia P. Recent advances in understanding the molecular basis of primary congenital
hypothyroidism. Mol Med Today 2000;6:3642.
5. Adams LM, Emery JR, Clark SJ, Carlton EI, Nelson JC. Reference ranges for newer thyroid
function tests in premature infants. J Pediatr 1995;126:1227.
6. Fisher DA. Thyroid function and dysfunction in premature infants. Pediatr Endocrinol Rev.
2007 Jun;4(4):317-28.
7. American Academy of Pediatrics, Rose SR; Section on Endocrinology and Committee on
Genetics, American Thyroid Association, Brown RS; Public Health Committee, Lawson
Wilkins Pediatric Endocrine Society, Foley T, Kaplowitz PB, Kaye CI, Sundararajan S, Varma
SK. Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics
2006; 117:2290-303.
8. Fisher DA. Disorders of the thyroid in newborns and infants. In Sperling MA, ed. Pediatric
Endocrinology, 2nd edition. Philadelphia: Saunders, 2002; 161-86.
9. Soldin OP, Jang M, Guo T, Soldin SJ. Pedistric reference intervals for free thyroxine and free
triiodothyronine. Thyroid 2009; 19: 699-702.
10. Fisher DA. Disorders of the thyroid in childhood and adolescence. In Sperling MA, ed.
Pediatric Endocrinology, 2nd edition. Philadelphia: Saunders, 2002; 187-210.
11. LaFranchi S. Congenital hypothyroidism: etiologies, diagnosis and management. Thyroid
1999;9:735-40.
12. Fisher DA. Management of congenital hypothyroidism. J Clin Endocrinol Metab 1991;72:525-
8.
13. Brown RS. The thyroid gland. In Brook CGD, Hindmarsh PC eds. Clinical Pediatric
Endocrinology, 4th edition. London: Blackwell Science, 2001; 288-320.
14. LaFranchi SH, Austin J. How should we be treating children with congenital hypothyroidism?
J Pediatr Endocrinol Metab 2007; 20:559-78.
15. Postnatal thyroid hormones for preterm infants with transient hypothyroxinaemia.
Cochrane Database Syst Rev. 2007: CD005945.
16. Klien AH, Meltzer S, Kenny FM. Improved prognosis in congenital hypothyroidism treated
before age three months. J Pediatr 1972;81:912-5.
.
Table 5: Research priorities
Research question Subjects Study Interve Outcomes to be
design ntion measured
What is the effect of transient Preterm Cohort study None Development
hypothyroxinemia of newborns, quotient
prematurity on neuro-
intellectual outcome and birth weight <
mortality at 1 year of age 1500 g
Presence/ absence of
neurological disability

What is the effect of Women found Cohort study None Birth weight
maternal subtle to have
Gestation
hypothyroidism in elevated TSH
pregnancy on gestation, and normal T4 Congenital
birth weight and neuro- on screening malformations
developmental outcome in within first 20
offspring? weeks of Neuro-development
gestation, and at 2 years of age
their offspring
 Polycythemia in Neonates
Polycythemia or an increased hematocrit is associated with hyperviscosity of blood. As the blood
viscosity increases, there is impairment of tissue oxygenation and perfusion and tendency to
form microthrombi. Significant damage may occur if these events occur in the cerebral cortex,
kidneys and adrenal glands. Hence this condition requires urgent diagnosis and prompt
management.

The viscosity of blood is directly proportional to the hematocrit and plasma viscosity and
inversely proportional to the deformability of red blood cells. Symptoms of hypoperfusion
correlate better with viscosity as compared to hematocrit. Viscosity is, however, difficult to
measure at the bedside. Hyperviscosity is therefore suspected in the presence of an abnormally
high hematocrit with or without suggestive symptoms.

Relationship between viscosity and hematocrit is almost linear up to a hematocrit of 65% and
exponential thereafter.1,2 The polycythemia-hyperviscocity syndrome is thus usually confined to
infants with hematocrits of more than 65%; it is very rare with hematocrits of <60%.

Definition
A diagnosis of polycythemia is made in the presence of a venous hematocrit more than 65% or a
venous hemoglobin concentration in excess of 22 gm/dL. Hyperviscosity is defined as a viscosity
greater than 14.6 centipoise at a shear rate of 11.5 per second.3

Incidence
The incidence of polycythemia is 1.5% to 4% of all live births.4,5 The incidence is higher among
both small for gestational age (SGA) and large for gestational age (LGA) infants. The incidence of
polycythemia is 15% among term SGA infants as compared to 2% in term AGA infants.6

Neonates born at high altitudes also have a higher incidence of polycythemia.1 Maternal
smoking is an important risk factor for polycythemia.7 Term neonates born to mothers engaged
in smoking during pregnancy are 2.5 times more likely to require a partial exchange transfusion
for polycythemia than the counterparts of non-smoker mothers.7 Infants born by cesarean
section have a lower hematocrit values than those delivered vaginally.8 Infants subjected to
delayed cord clamping carry nearly four times greater risk of asymptomatic polycythemia.9

In the last 3 years the incidence of polycythemia ranged from 0.95% to 1.5% in our centre.

Physiological changes in postnatal life

Significant changes take place in the hematocrit from birth through the first 24 to 48 hr of life.
The hematocrit peaks at 2 hr of age and values up to 71% may be normal at this age.10-11 It
gradually declines to 68% by 6 hr and usually stabilizes by 12 to 24 hr. The initial rise in
hematocrit is related to a transudation of fluid out of the intravascular space.

1
Clinical features
Polycythemia can result in a wide range of symptoms involving several organ systems (Table 1).
About 50% of neonates with polycythemia develop one or more symptoms. However, most of
these symptoms are non-specific, and may be related to the underlying conditions rather than
due to polycythemia per se.

Table 1. Clinical features ascribed to polycythemia and hyperviscosity

Central nervous system
Early: Hypotonia and sleepiness, irritability, jitteriness , seizures and infarcts
Late: motor deficits, lower achievement and IQ scores

Metabolism
Hypoglycemia
Jaundice
Hypocalcemia

Heart and lungs

Tachycardia, tachypnea, respiratory distress
Cyanosis, plethora
Chest radiography: cardiomegaly, pulmonary plethora
Echocardiography: increased pulmonary resistance, decreased cardiac output

Gastrointestinal tract
Poor suck, vomiting
Feed intolerance abdominal distension
Necrotizing enterocolitis

Kidneys
Oliguria (depending on blood volume)
Transient hypertension
Renal vein thrombosis

Hematology
Mild thrombocytopenia
Thrombosis (rare)

Miscellaneous
Peripheral gangrene,
Priapism,
Testicular infarction

2
Screening for polycythemia
Screening should be done for polycythemia in certain high-risk groups (Table 2).
Any infant with clinical features suggestive of polycythemia should be investigated for the same.

Table 2. Screening for polycythemia

Eligible candidates
(a) Small for gestational age (SGA) infants
(b) Infants of diabetic mothers (IDM)
(c) Large for gestational age (LGA) infants
(d) Monochorionic twins especially the larger twin
(e) Infants with morphological features of growth retardation such as many loose folds of skin
around the buttock and thighs, loss of subcutaneous fat, difference of HC and CC>3 cm

Schedule
2 hr, 6 hr, 12 hr, 24 hr, 48 hr and 72 hr of age

Method
Centrifuge venous blood in heparinized capillaries for 3 to 5 min @ 10000 to 15000 rpm

Capillary vs. venous hematocrit

Capillary hematocrit measurements are unreliable and highly subject to variations in blood flow.
Capillary hematocrits are significantly higher than venous hematocrits. This difference is even
more apparent in infants receiving large placental transfusion.12

Practice tip

Capillary samples may be used for screening, but all high values should be confirmed by a
venous sample for the diagnosis of polycythemia.

Methods of hematocrit determination

Two methods are available:
1. Automated hematology analyzer: This calculates the hematocrit from a direct measurement
of mean cell volume and the hemoglobin.

2. Micro-centrifuge: Blood is collected in heparinized micro-capillaries (110 mm length and 1-2

mm internal diameter) and centrifuged at 10,000 to 15,000 rotations per minute (rpm) for
3-5 minutes. Plasma separates and the packed cell volume is measured to give the
hematocrit.

An automated analyzer gives lower values as compared to hematocrits measured by the

centrifugation method.13 Most of the reported data on polycythemia is on centrifuged
hematocrits.

3
Management
Before a diagnosis of polycythemia is considered, it is mandatory to exclude dehydration. If the
birth weight is known, re-weighing the baby and looking for excessive weight loss (more than
10% to 15%) would help in the diagnosis of dehydration. If this is present, it should be corrected
by increasing fluid/feed intake. The hematocrit should be measured again after correction of
dehydration. Once a diagnosis of polycythemia is made, associated metabolic problems
including hypoglycemia should be excluded.

Management of polycythemia is dependent upon two factors (Figure):

1. Presence of symptoms suggestive of polycythemia and/or
2. Absolute value of hematocrit

Figure: Management algorithm of polycythemia

Venous hematocrit: 65% or more

Exclude dehydration
(Check weight loss)

Symptomatic Asymptomatic

Hematocrit: Hematocrit: Hematocrit:

75% or more 70% to 74% 65% to 69%

Consider Monitor for

hydration symptoms

Partial exchange transfusion

4
(a) Symptomatic polycythemia
The definitive treatment for polycythemia is to perform a partial exchange transfusion (PET).
PET involves removing some of the blood volume and replacing it with normal saline so as to
decrease the hematocrit to a target hematocrit of 55%. Following PET, symptoms like jitteriness
may persist for 1-2 days despite the hematocrit being lowered to physiological ranges.

The volume of blood to be exchanged is given by the formula shown in Panel 1.

Panel 1: Volume to be exchanged

= Blood volume* x (observed hematocrit desired hematocrit)
Observed hematocrit

*Blood volume is ideally should be found out from Rawlings Chart114. As a rough guide, it is 80-90
mL/kg in term babies and 90-100 mL/kg in preterm babies

For example, for a 35 wk gestation newborn weighing 2 kg (assume blood volume 90 mL/kg) and
observed hematocrit of 75% and desired hematocrit of 55%, the amount of blood to be
exchanged would be:

=2*90* (75-55/75)
=48 mL of blood to be exchanged with normal saline to bring hematocrit from 75% to 55%

As a rough guide, the volume of blood to be exchanged is usually 20 mL/kg.

PET: peripheral vs. umbilical route

PET may be carried out via the peripheral or the central route.

In the former, blood is withdrawn from the peripheral arterial line and replaced simultaneously
with saline via a peripheral venous line.

In the central route, blood can be withdrawn from umbilical venous catheter and saline replaced
by a peripheral vein. Alternatively, in central route, the umbilical venous catheter may be used
for both withdrawal of blood and replacement of saline (pull and push technique, similar to
double volume exchange transfusion for severe jaundice), or the blood is withdrawn from
umbilical arterial line and saline replaced from umbilical venous line.

The route of PET may influence infection rates, mesenteric artery flow abnormalities, and NEC
rates.15,16

5
PET: choice of exchange fluid
Crystalloids such as normal saline (NS) or Ringers lactate (RL) are preferred over colloids

Panel 2: Choice of exchange fluid: What is evidence?

A systematic review determined efficacy of crystalloid versus colloid solutions to identify

the best fluid for PET17:

Clinically unimportant difference in hematocrit favoring colloids than crystalloids:

o at 2-6 h: 2.3% (95% CI 1.3% to 3.3%)
o at 24 hr: 1.7% (95% CI 0.8% to 2.7%)

because they are less expensive and are easily available. Crystalloids produce nearly comparable
reduction in hematocrit as colloids (Panel 2),17,18 and do not have the risk of transfusion
associated infections. Moreover, adult plasma has been shown to increase the blood viscosity
when mixed with fetal erythrocytes.

We use only normal saline for partial exchange transfusion.

(b) Asymptomatic polycythemia:

The line of management in infants with asymptomatic polycythemia depends upon their
hematocrit values.
i. Hematocrit 75% or more: These infants are usually managed with PET.

ii. Hematocrit between 70% and 74%: Conservative management with hydration may be
tried in these infants. An extra fluid/feeds of 20 mL/kg may be added to the daily fluid
requirements. The additional fluid may be ensured by either enteral (supervised
feeding) or parenteral route (IV fluids). The rationale for this therapy is that fluid
brings about hemodilution and the resultant decrease in viscosity.

iii. Hematocrit between 65% and 70%: They only need monitoring for any symptoms of
polycythemia and re-estimation of hematocrit. Further management depends upon
the repeat hematocrit values.

Evidence for management of polycythemia

PET reverses the physiological abnormalities associated with the polycythemiahyperviscocity
syndrome. It improves capillary perfusion, cerebral blood flow and cardiac function. However,
there is very little data to suggest that PET improves long term outcome in patients with
polycythemia. The latest Cochrane review (2010) concluded that there are no proven clinically
significant short or long-term benefits of PET in polycythemic newborn infants who are clinically

6
 Panel 3: Partial exchange transfusion for polycythemia: What is evidence?

A Cochrane review (2010) 19 on this issue showed:

No effect on neonatal mortality (one study; RR 5.23, 95% CI 0.66, 41.26).
No difference in developmental delay (4 low quality studies; RR 1.45, 95% CI 0.83 to
2.54)
Increased risk of NEC in infants receiving PET (2 studies; RR 11.18, 95% CI 1.49, 83.64)
No differences in short-term complications including hypoglycemia (two studies) and
thrombocytopenia (one study)

well or who have minor symptoms related to hyperviscosity. PET may increase the risk of NEC
(Panel 3).19

However, as studies included in the review were of low quality as large number of surviving
infants were not assessed for developmental outcomes, and therefore, the true risks and
benefits of PET are unclear. In a recent study by Iris et al. showed that restrictive management
of polycythemia does not increase short term complications.20

Given the uncertainty regarding the long term outcomes, it is preferable to restrict PET in
symptomatic infants with hematocrit of >65% and in asymptomatic neonates with hematocrit of
>75%.

Table 3 provides research issues in polycythemia.

7
References
1. Mackintosh TF, Walkar CH. Blood viscosity in the newborn. Arch Dis Child 1973; 48: 547-53.

2. Phibbs RH. Neonatal Polycythemia. In: Rudolph AB(ed): Pediatrics, 16th ed. New York: Appleton
Century Crofts, 1997, pp 179.

3. Ramamurthy RS, Brans WY. Neonatal Polycythemia I. Criteria for diagnosis and treatment.
Pediatrics 1981; 68: 168-74.

4. Wirth FH, Goldberg KE, Lubchenco LO: Neonatal hyperviscocity I. Incidence. Pediatrics 1979; 63: 833-
6.

5. Stevens K, Wirth FH. Incidence of neonatal hyperviscosity at sea level. Pediatrics 1980; 97: 118

6. Bada HS, Korones SB, Pourcyrous M, et al. Asymptomatic syndrome of polycythemic hyperviscocity:
effect of partial exchange transfusion. J Pediatr 1992; 120: 579-85.

7. Awonusonu FO, Pauly TH, Hutchison AA. Maternal smoking and partial exchange transfusion for
neonatal polycythemia. Am J Perinatol 2002; 19: 349-54.

8. Lubetzky R, Ben-Shachar S, Mimouni FB, et al. Mode of delivery and neonatal hematocrit. Am J
Perinatol 2000; 17: 163-5.
9. Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic
review and meta-analysis of controlled trials. JAMA 2007; 297: 1241-52.

10. Shohat M, Merlob P, Reisner SH: Neonatal Polycythemia. I. Early diagnosis and incidence relating to
time of sampling. Pediatrics 1984; 73: 7-10.

11. Shohat M, Reisner SH, Mimouni F, et al. Neonatal polycythemia II. Definition related to time of
sampling. Pediatrics 1984; 73:11-3.

12. Oh W. Neonatal polycythemia and hyperviscosity. Pediatr Clin North Am 1986; 33: 523-32.

13. Goldberg K, Wirth FH, Hathaway WE, et al. Neonatal hyperviscocity II. Effect of partial exchange
transfusion. Pediatrics 1982; 69: 419-25.

14. Rawlings JS, Pettett G, Wiswell TE, et al. Estimated blood volumes in polycythemic neonates as a
function of birth weight. J Pediatr 1982; 101: 594-9.

15. Rodriguez-Balderrama I, Rodriguez-Juarez DA, Cisneros-Garcia N, et al. Comparison of 2 methods of

partial exchange transfusion in newborns with polycythemia: peripheral-peripheral and central-
peripheral]. Bol Med Hosp Infant Mex 1993; 50: 633-8

16. Hein HA, Lathrop SS. Partial exchange transfusion in term, polycythemic neonates: absence of
association with severe gastrointestinal injury. Pediatrics 1987; 80: 75-8.

17. de Waal KA, Baerts W, Offringa M. Systematic review of the optimal fluid for dilutional exchange
transfusion in neonatal polycythaemia. Arch Dis Child Fetal Neonatal Ed 2006; 91: F7-10.

18. Deorari AK, Paul VK, Shreshta L, Singh M. Symptomatic neonatal polycythemia: Comparison of
partial exchange transfusion with saline versus plasma. Indian Pediatr 1995; 32: 1167-71.

8
19. Ozek E, Soll R, Schimmel MS. Partial exchange transfusion to prevent neurodevelopmental disability
in infants with polycythemia. Cochrane Database Syst Rev 2010 Jan 20;(1):CD005089.

20. Morag I, Strauss T, Lubin D, Schushan-Eisen I, Kenet G, Kuint J. Restrictive management of neonatal
Polycythemia. Am J Perinatol 2011; 28: 677-682.

9
 Table 3 : List of researchable issues in neonatal polycythemia

S.NO Research question Type of study Intervention Outcome measures

1. What is the incidence of neonatal Cohort study by Nil Incidence,
polycythemia, age at onset, clinical enrolling at risk
Age at which it is detected in hours,
manifestations and short term infants (as outlined in
outcomes? Table 2) Rate of occurrence of different clinical
(Epidemiology of polycythemia) manifestation,
Neurological examination at discharge and MRI
findings,
2 Does partial exchange transfusion Randomized control Group 1: Treat with PET Alleviation of symptoms or reducing the
helps in improving short term and trial incidence of symptoms related to
Group 2 : No PET
long term outcomes in neonatal polycythemia ( as mentioned in Table 1 )
polycythemia ( Both asymptomatic
and symptomatic) Neurodevelopmental outcome at 18-24
months of age.

3 Does partial exchange transfusion Before-and-after measurement of the Estimation and comparison of different
improve the functional parameters of study parameters before and parameters mentioned by ultrasound before
different organ systems such as after PET and after partial exchange transfusion.
myocardial performance, middle
cerebral and mesenteric flow and
pulmonary artery pressure?
4 Variation in hematocrit values in at Cohort study by Nil Variation in hematocrit during initial 48-72 hr
risk neonates during initial 48 to 72 enrolling at risk
Diagnostic utility (sensitivity, specificity, PPV,
hr and infants (as outlined in
NPV and likelihood ratios) of cord/2-hr
Table 2)
does cord/2-hr hematocrit value hematocrit for subsequent development of
predict subsequent polycythemia? polycythemia

10
 Blood components transfusion in neonates
Neonates receiving intensive care often receive transfusion of blood products. Preterm neonates
comprise the most heavily transfused group of patients, and about 85% of extremely low birth weight
newborns receive a transfusion by the end of their hospital stay.1,2

Blood components used in modern day practice include blood components such as red blood cell
components, platelet concentrates, and plasma rather than whole blood. Transfusion of blood products
in the vulnerable neonates need to be strictly regulated to avoid the inherent risks of transfusion such as
transmission of infections.3

Donor identification and selection

Donor selection is done according to predefined criteria. Usually voluntary (nor replacement) donors
who do not require any remuneration are preferred over paid donors. Donors should be provided with
educational materials on the essential nature of blood, the blood donation procedure, blood
components, and the important benefits to patients.

The donors should be given a questionnaire to identify any health risk factors which can be of concern to
themselves and the recipients. Information on the protection of personal data, including confirmation
that there will be no disclosure of the identity of the donor, of information concerning the donor's
4
health and of the results of the tests performed also should be provided.

Collection of blood:

About 450 to 500 mL blood is collected by puncturing vein in the antecubital area after appropriate
antiseptic precautions. Blood is collected into bags prefilled with an anticoagulant which is comprised
usually of citrate, phosphate and dextrose or other preservatives. The shelf life of the stored blood
depends upon the nature of the preservative used.

Apheresis is a technique by which blood components are produced from whole blood donations by
selectively collecting one or more components directly from donors and returning the rest to the
circulation. Apheresis can be used to collect platelets, plasma, red cells or granulocytes from the donor.
The main advantage of apheresis collections are that more than one dose of platelets or red cells can be
collected from one donor per donation, thus reducing patient exposure to multiple donors.5

Testing of donated blood:

All donations are tested for mandatory microbiological markers (hepatitis B and C, HIV, and syphilis). A
proportion of donations also undergo testing for other viruses (e.g. CMV) and additional typing, such as
extended blood grouping and human leukocyte antigen (HLA) typing, for patients with specific
requirements.4-6
Preservation and storage:

As there are very few clinical indications for transfusion of whole blood, vast majority of the blood is
processed into its basic components: red cells, platelets and plasma. This is achieved by centrifugation of
whole blood in the primary collection pack, followed by manual or automated extraction of the
components into satellite packs.

The initial storage temperature of whole blood determines the nature of the components that can be
produced from it. For platelet production, whole blood must be processed on the day of blood collection
or stored overnight at 22C. However, for the production of red cells, whole blood can be stored at 4C
for 48-72 hours prior to separation. Plasma is separated from whole blood on the day of collection or
from blood that has been stored at 22C for up to 24 hours.4, 5

PRESERVATION OF WHOLE BLOOD

Whole blood was stored with acid citrate dextrose (ACD) as the preservative initially. Later less acidic
citrate phosphate dextrose (CPD) was used. Both ACD and CPD conferred a shelf life of 21 days.
Subsequently adenine was added to the preservative thus forming CPD-A which improved the ATP
content of the stored blood and thus increased the shelf life to 35 days.

PRESERVATION OF RED CELLS

Additive solutions

With the advent of component therapy and preferential use of red cells for transfusion, preparation of
red cell concentrates resulted in inadvertent removal of the preservatives thus resulting in decreased
red cell shelf life. To circumvent this problem red cell additive solution were developed which allowed
maximum recovery of plasma and preparation of red cell concentrate with a final hematocrit of 60%.
Three types of additive solutions are available AS-1, AS-3 and AS-5.

This new blood collection system has a primary bag containing a standard anticoagulant (CPD) and a
satellite bag containing an additive solution. Blood is collected in the primary bag containing
anticoagulant solution. After the plasma is removed from the whole blood into another empty satellite
bag, the additive solution is added to the red cells, thus providing nutrients to red cells for improved
viability. The red cells can be stored for six weeks at 2-6C. The additive solution should be added to red
cells within 72 hours since phlebotomy. Additive solution having mannitol are not routinely used for
exchange or neonatal transfusion4.

Frozen red cells

Frozen red cells are primarily used for autologous transfusion and the storage of rare group blood. Red
cells which are less than 6 days old are frozen rapidly after addition of cryopreservative agent containing
glycerol. Glycerol prevents damage to red cells when frozen by maintaining a liquid phase and also by
preventing hypertonicity. Frozen red cells can be stored for 10 years. Frozen red cells have to be thawed
and deglycerolized before use. Frozen red cells once thawed can be stored at 2-6oC for only 24 hours.
Special RBC preparations

Leucocyte depletion

Leukocyte depletion or reduction is done to reduce the concentration of leucocytes to less than 5x106
leukocytes per unit of RBCs by using special filters.

Leukocyte reduction helps in preventing non-hemolytic febrile transfusion reactions (NHFTR), HLA
alloimmunization, transmission of leukotropic viruses (CMV, EBV and HTLV-1), transfusion related
GVHD, and transfusion related acute lung injury (TRALI).4

Mukagatare and associates reported that leukocyte reduction signicantly decreased the rate of all
transfusion reactions from 0.49% to 0.31% (P<0.001), the rates of febrile non-hemolytic transfusion
reactions from 0.35% to 0.24% (P<0.002), and the rate of allergic reactions from 0.05% to 0.01%
(P<0.001).7

Implementation of universal WBC reduction has been found to decrease the incidence of
bronchopulmonary dysplasia (OR, 0.42; 0.25 to 0.70), retinopathy of prematurity (OR, 0.56; 0.33 to 0.93)
and necrotizing enterocolitis (OR, 0.39, 0.17 to 0.93).8

Gamma irradiation

Gamma irradiation of blood components is done to inactivate donor T cells, and the associated risk of
transfusion associated graft versus host disease (TA-GVHD), which may occur in immunosuppressed
patients, very small babies, in large volume transfusions and during intrauterine transfusions9 or when
the donor is related.

Irradiation reduces the shelf life of RBCs to 28 days and also causes leakage of potassium out of RBCs.10
Irradiated RBCs should be used within 4 hours in neonates to avert the risk of hyperkalemia.

Irradiated RBCs are recommended for babies with birth weight below 1.2 kg. It may be preferable for
any transfusions till 4 months of age.

Washed RBCs

Washing RBCs with saline is done to remove plasma and to reduce potassium in the RBCs. Washed RBCs
are recommended for intrauterine transfusions, exchange transfusion and large volume transfusions
(more than 20 mL/kg). For patients with immunoglobulin A deficiency or severe allergic or anaphylactoid
reactions to red cells, it may be necessary to remove >90% of plasma by washing and re-suspending red
cells in saline.3

CMV reduced RBCs

CMV reduced RBCs reduce the risk of transmission of CMV infection, which may be a cause of
considerable concern in newborns especially preterm infants. CMV reduction can be achieved by either
leucoreduction of blood components, or by pre-selecting donors who are CMV negative.

A meta-analysis of the available controlled studies indicates that CMV-seronegative blood components
are more efficacious than WBC-reduced blood components in preventing transfusion-acquired CMV
infection.11

Red cells for intrauterine transfusion:

Red cells are transfused in-utero to treat severe fetal anemia. In order to keep the volume transfused to
a minimum, they are prepared by removing some of the plasma from whole blood to achieve a high
hematocrit of 0.70 to 0.90. Because of concerns over the potential toxicity of adenine and mannitol in
red cell additive solutions, red cells for IUT and exchange transfusion are prepared and stored in plasma.
 PLATELETS:

Random donor platelet (RDP)

Platelets can be isolated from the whole blood donations or by apheresis. From whole blood, platelet
can be produced either by platelet rich plasma (PRP) method or buffy- coat method. In the PRP method,
whole blood is subjected to 'soft spin' initially which separates the whole blood into PRP and red cells.
The PRP is then subjected to a 'hard spin' to remove plasma and concentrate the platelets. In the buffy-
coat method, whole blood is subjected to a 'hard spin' and buffy- coat separated. The buffy coats from
four to six donations are then pooled with a unit of plasma or platelet additive solution and then
subjected to a 'soft spin' and the PRP removed.4,5

Single donor platelet (SDP)

SDP units are obtained by a process called plateletpheresis wherein multiple units of platelets are
collected from single donor and the RBCs and platelet poor plasma are returned to the donor. The
procedure is repeated 4 to 6 times, yielding 4 to 6 units of platelets from one individual. It is especially
useful to prevent alloimmunization in multiply transfused patients. Both SDPs and RDPs are irradiated.
The concentration of platelets is more in SDP than in RDP, with SDP having a platelet concentration of
3x1011/unit and RDP having a concentration of 0.5x1010 per unit. In neonatal transfusion practice, RDP is
generally adequate to treat thrombocytopenia. SDP is required only if prolonged and severe
thrombocytopenia is anticipated, requiring multiple platelet transfusions.Platelets should be stored at
22-24C with continuous gentle agitation in platelet incubator and agitator. Maintenance of pH above
is essential and the function of platelets depends on the permeability of the storage bag to oxygen
and carbon dioxide. Platelets stored in bags made of polyolefin have longer half life up to about 7 days.
However it is recommended to store platelets in new bags for 5 days only from the date of collection of
blood. Platelets are stored with agitation at 222C for up to 5 days. Washed platelets can be used in
patients with anaphylactic reactions to the plasma component. Washed platelets have a shelf life of only
24 hours.

GRANULOCYTES

Granulocytes are normally collected by apheresis and contain mainly neutrophils but also significant
numbers of lymphocytes, red cells and platelets. Granulocytes can also be prepared from buffy coats.
Granulocyte transfusion should provide a dose of at least 1 1010 neutrophils.

Granulocytes should be transfused as soon as possible after collection or preparation but can be stored
at 22C for up to 24 hours without agitation and are irradiated prior to transfusion to prevent
transfusion-associated graft-versus-host disease (TA-GVHD). Post transfusion recovery of granulocytes in
circulation and migration into inflammatory loci is better if transfused within 8 hours of storage than
granulocytes stored for 24 hours.12

FRESH FROZEN PLASMA (FFP):

FFP is produced by rapidly freezing the plasma within 8 hours of collection in order to preserve the
activity of coagulation factors V and VIII which are relatively labile.

Frozen-plasma components can be stored for up to 24 to 36 months depending on the storage

temperature, which is usually below -30C. Once thawed, FFP should be used immediately but can be
stored for up to 24 hours at 4C.13

CRYOPRECIPITATE
It is prepared from FFP by thawing at 2 to 4o C. Undissolved cryoprecipitate is collected by centrifugation
and supernatant plasma is aseptically expressed into a satellite bag.

Cryoprecipitate can be stored for 12 months at -18 C or lower. Thawed Cryoprecipitate can be stored
for 6 hours at 2-6 C and pooled cryoprecipitate kept at 2-6C should be used within 4 hours.13
 Fig 1: Collection, processing and storage of blood

Education
Recruitment
Selection
Donation

Process into blood components

Test for
HIV, HBV, HCV, Syphilis Platelet pheresis

Filter to remove leucocytes

Red cells Pooled Platelets Plasma

4oC 22oC -30oC

35 days 5 days 24 months

Indications for PRBC transfusion in neonatal practice

PRBCs are the most commonly used blood product in neonatal transfusions.2,3 Preterm infants requiring
intensive care are in need of repeated PRBC transfusion because of their immaturity, ongoing illness and
the need for repeated sampling. Transfusion of PRBCs results in resolution of symptomatic anemia and
improvement in tissue oxygenation. PRBC transfusion in preterm neonates should be restricted to
minimum to prevent complications which are unique to them such as increased incidence of retinopathy
of prematurity (ROP), CMV infection and even necrotizing enterocolitis (NEC). To achieve this,
transfusion guidelines in neonates should ensure reduction in the number of transfusions and donor
exposures.

Restrictive versus Liberal Transfusion

In order to limit the number of transfusions and the number of donors as well, restrictive transfusion
policy is recommended. In general for young, mechanically ventilated preterm infants, the capillary
hemoglobin should not be less than 11.5 g/dl; for older, stable infants, the hemoglobin should not be
allowed to fall below 7.5 g/dl.

Restricted versus liberal blood transfusion in VLBW infants: What is the evidence?

Cochrane review by Whyte et al on low versus high hemoglobin threshold for blood transfusion
in very low birth weight infants did not find any significant difference in the combined outcome
of death or serious morbidity at first hospital discharge (RR 1.19; 0.95 to 1.49).14

The guidelines for transfusion of PRBC vary according to age, level of sickness and hematocrit are as
follows (Table 1, 2).

Table 1: Guidelines for packed red blood cells (PRBCs) transfusion thresholds for preterm neonates3,15

SN Levels of respiratory support Oxygen <28 days 28 days

requirement PCV Hb PCV Hb
1 Assisted ventilation FiO2 0.3 <40 <12 <30 <10

FiO2 <0.3 <35 <11

2 CPAP Any FiO2 <30 <10 <25 <8

3 Spontaneously Any Age

breathing
a Symptomatic FiO2 0.35 <35 <11
anemia*
FiO2 >0.21-<0.34 <30 <10

b Oxygen FiO2 >0.21 <25 <8

therapy

c Room air <20 <7

*Symptomatic anemia as defined by more than 9 apneic and bradycardic episodes in 12 hours or 2 or more requiring bag and
mask ventilation in 24 h while on adequate methylxanthine therapy or HR>180/min or RR >80/min sustained for 24h or weight
gain less than 10 g/day for 4 days on 100 kcal/kg/day or requiring surgery

Table 2: Guidelines for packed red blood cells (PRBCs) transfusion thresholds for term neonates16

Condition Hb (g/dL)
Severe pulmonary disease <13
Moderate pulmonary disease <10
Severe cardiac disease <13
Major surgery <10
Symptomatic anemia <8
Practical Issues

1. Amount of transfusion to be given: It has been seen that transfusion with PRBC at a dose of 20
mL/kg is well tolerated and results in an overall decrease in number of transfusions compared to
transfusions done at 10 mL/kg. There is also a higher rise in hemoglobin with a higher dose of
PRBCs.17

2. Properties of RBC products used in neonatal transfusion:

a. Fresh RBCs (less than 7 days old) with high 2, 3-DPG levels ensure higher tissue oxygen
delivery. They also reduce the risk of hyperkalemia.

b. Multiple donor exposures in small and sick neonates can be prevented by reserving a
bag of fresh PRBC for up to 7 days for a newborn and withdrawing small aliquots
required as and when needed

3. Choosing the blood group for neonatal transfusions18

a. It is preferable to take samples from both, mother and the newborn, for initial testing
prior to transfusion. Mothers sample should be tested for blood group and for any
atypical red cell antibodies.

b. ABO compatibility is essential while transfusing PRBCs. Though ABO antigens may be
expressed only weakly on neonatal erythrocytes, neonates serum may contain
transplacentally acquired maternal IgG anti-A and/or anti-B.

c. Blood should be of newborns ABO and Rh group. It should be compatible with any ABO
or atypical red cell antibody present in the maternal serum.

d. In exchange transfusions for Rh hemolytic disease of newborn, blood transfused should

be compatible with mothers serum. Ideally Rh negative blood of the babys ABO group
has to be used after cross matching with maternal serum. If compatible ABO group is
not available then group O and Rh negative blood can be used.

4. Volume and rate of transfusion:

a. Volume of packed RBC = Blood volume (mL/kg) x (desired minus actual hematocrit)/
hematocrit of transfused RBC

b. Rate of infusion should be less than 10 mL/kg/hour in the absence of cardiac failure.

c. Rate should not be more than 2 mL/kg/hour in the presence of cardiac failure.

d. If more volume is to be transfused, it should be done in smaller aliquots.

 5. Expected response:

Each transfusion of 9 mL/kg of body weight should increase hemoglobin level by 3 g/dL.
Meticulous monitoring of input, output and vital signs are mandatory during blood transfusion.

PLATELET TRANSFUSION
Thrombocytopenia is defined as platelet count less than 1.5 lakh/cubic mm.19 Presence of
thrombocytopenia leads to an increase in risk of bleeding. Dysfunctional platelets in the presence of
normal platelet counts may also cause bleeding tendency. Thrombocytopenia has been observed in 1
5% of newborns at birth.20-22 Severe thrombocytopenia defined as platelet count of less than
50,000/cubic mm may occur in 0.1%0.5% of newborns.22,23 In NICU, there is a higher incidence; with
thrombocytopenia being observed in up to 22% to 35% of all babies admitted to NICUs and in up to 50%
of those admitted to NICUs who require intensive care. Significant proportions (20%) of these episodes
of thrombocytopenia are severe.24,25 Thus a large number of neonates are at risk of bleeding due to
thrombocytopenia in NICU.

Table 3: Indications for platelet transfusion in nonimmune thrombocytopenia in newborn19

1. Platelet count less than 30,000/cubic mm: transfuse all neonates, even if asymptomatic
2. Platelet count 30,000 to 50,000/cubic mm: consider transfusion in
a. Sick or bleeding newborns
b. Newborns less than 1000 gm or less than 1 week of age
c. Previous major bleeding tendency (IVH grade 3-4)
d. Newborns with concurrent coagulopathy
e. Requiring surgery or exchange transfusion
3. Platelet count more than 50,000 to 99,000/cubic mm: transfuse only if actively bleeding

Practical Issues:
1. Platelets should never be filtered through a micropore blood filter before transfusion, as it will
considerably decrease the number of platelets.
2. Female Rh-negative infants should receive platelets from Rh-negative donors to prevent Rh
sensitization from the contaminating red blood cells.
3. The usual recommended dose of platelets for neonates is 1 unit of platelets per 10 kg body
weight, which amounts to 5 mL/kg. The predicted rise in platelet count from a 5-mL/kg dose
would be 20 to 60,000/cubic mm.24,25 Doses of up to 10-20 ml/kg may be used in case of severe
thrombocytopenia.

Granulocyte transfusion

Granulocyte concentrates have limited therapeutic effectiveness in general except for bacterial sepsis or
disseminated fungal infection unresponsive to antibiotics in infants. The concentrate should be CMV
seronegative and be irradiated as it contains large number of lymphocytes but leukofilters should not be
used for granulocyte transfusions. The usual dose is 1-2 x 10 neutrophils/Kg body weight, in a volume of
15 ml/Kg. Cochrane review on the effect of granulocyte transfusion on suspected or confirmed sepsis
with neutropenia did not find any reduction in mortality when compared to placebo (RR 0.89, 95% CI
0.43 to 1.86).26

Fresh frozen plasma

FFP has traditionally been used for a variety of reasons, including volume replacement, treatment of
disseminated intravascular coagulopathy (DIC), during the treatment of a bleeding neonate, for
prevention of intraventricular hemorrhage, and in sepsis.3 It has not been shown to have any survival
benefits in most of these conditions and currently the only valid indications for transfusing FFP in a
newborn include

1. Disseminated intravascular coagulopathy

2. Vitamin K deficiency bleeding
3. Inherited deficiencies of coagulation factors

Other rare indications include patients with afibrinogenemia, von Willebrand factor deficiency,
congenital antithrombin III deficiency, protein C deficiency and protein S deficiency when specific factor
replacement is not available. It is also used for reconstitution of blood for exchange transfusion.

Cryoprecipitate

Cryoprecipitate contains about 80 to 100 U of factor VIII in 10-25 mL of plasma, 300 mg of fibrinogen
and varying amounts of factor XIII.13

Indications for use of cryoprecipitate:

1. Congenital factor VIII deficiency
2. Congenital factor XIII deficiency
3. Afibrinogenemia & dysfibrinogenemia
4. von Willebrand disease

Practical Issues:

1. FFP should be group AB, or compatible with recipient's ABO red cell antigens
2. Volume of FFP to be transfused is usually 1020 mL/kg
3. Volume of cryoprecipitate to be transfused is usually 5 mL/kg

TRANSFUSION ASSOCIATED RISKS

Blood transfusion reactions may be broadly classified as

1. Infectious
2. Non-infectious
 a. Acute
i. Immunologic
ii. Non-immunologic
b. Delayed

Infectious complications

In India, it is mandatory to test every unit of blood collected for hepatitis B, hepatitis C, HIV/AIDS,
syphilis and malaria.27 However, transfusion transmitted infections are still a considerable risk, because
of the relative insensitivity of screening tests, and several other organisms besides those tested for,
which may be transmitted through blood.

1. Viral infections: Transmissible diseases can be caused by viruses like human immunodeficiency
virus (HIV), hepatitis B and C viruses (HBV & HCV), and cytomegalovirus (CMV). Other
uncommon viruses like hepatitis G virus and human herpes virus-8 have also been detected.
Viral infections contaminate platelet products more commonly than RBC products due to a
higher temperature used for storage of platelet products.28 Though screening for HIV, HBV and
HCV is mandatory in blood banks, other viruses still present an unaddressed problem.
Insensitivity of pathogen testing is also an issue, and risk of viral infections with blood
transfusions remains real. Risk of post transfusion hepatitis B/C in India is about 10% in adults
despite routine testing because of low viremia and mutant strain undetectable by routine
ELISA.29 HIV prevalence among blood donors is different in various parts of the country.

CMV: Transfusion related CMV infections in newborns were initially identified in the year 1969,
and since then transfusion associated CMV transmission is a well known entity. It has been
reported that there is a seroconversion rate of 10-30% in preterm newborns transfused with
CMV positive blood. Leukodepletion and selection of CMV negative donors decreases the risk of
transfusion transmitted CMV.30

2. Bacterial infections: Bacteria in donor blood are derived from either asymptomatic bacteremia
in the donor, or from inadequate skin sterilization leading to bacterial contamination of the
blood. Platelets are at a higher risk of causing bacterial infection than other blood components,
as they are stored at room temperature, leading to rapid multiplication of infectious organisms.
The highest fatality is seen when the contaminating organism is a gram-negative bacteria. In
case of a febrile non-hemolytic reaction post transfusion, bacterial contamination always
remains a possibility. It generally causes a higher rise in temperature than other febrile
transfusion reactions.
3. Parasites: Plasmodium, trypanosome, and several other parasites may be transmitted through
blood, depending on the endemicity of the area. Transfusion transmitted malaria is not
uncommon in India, and may occur in spite of blood bag testing, as the screening tests for
malaria are insensitive.29
4. Prions : Variant Cruetzfold Jacob Disease ( v CJD) is an established complication of blood
transfusion and has been reported since 2004. It is thought to have an incubation period of
approximately 6.5 years. There is no easy test as yet to detect the presence of prions. It is not
 very clear whether leuko-reduction prevents transmission of CJD28. Restricted transfusions and
avoidance of transfusions unless essential, are the only ways currently to prevent transmission.

Noninfectious complications: These can be further sub classified as immune mediated and nonimmune
mediated reactions, and as acute and delayed complications.

Acute immune mediated reactions

1. Immune mediated hemolysis

Acute hemolytic transfusion reactions are a common cause of transfusion related fatality in
adult patients, but these are rare in neonates. Newborns do not form red blood cell (RBC)
antibodies; all antibodies present are maternal in origin.

(1) Newborns must be screened for maternal RBC antibodies, including ABO antibodies if
non-O RBCs are to be given as the first transfusion.
(2) If the initial results are negative, no further testing is needed for the initial 4 postnatal
months.
Infants are at a higher risk of passive immune hemolysis from infusion of ABO-incompatible
plasma present in PRBC or platelet concentrates. Smaller quantities of ABO-incompatible plasma
(less than 5 mL/kg) are generally well tolerated. Newborns do not manifest the usual symptoms
of hemolysis that are observed in older patients, such as fever, hypotension, and flank pain. An
acute hemolytic event may be present as increased pallor, presence of plasma free hemoglobin,
hemoglobinuria, increased serum potassium levels, and acidosis. Results of the direct
antiglobulin (Coombs) test may confirm the presence of an antibody on the RBC surface.
Treatment is mainly supportive and involves maintenance of blood pressure and kidney
perfusion with intravenous saline bolus of 10 to 20 mL/kg along with forced diuresis with
furosemide. Enforcing strict guidelines for patient identification and issue of blood; and
minimizing human error is essential in preventing immune mediated hemolysis.

2. TRALI (Transfusion related acute lung injury): It refers to noncardiogenic pulmonary edema
complicating transfusion therapy. It is a common and under-reported complication occurring
after therapy with blood components. It has been associated with all plasma-containing blood
products, most commonly whole blood, packed RBCs, fresh-frozen plasma, and platelets. It has
also been reported after the transfusion of cryoprecipitate and IVIG. The most common
symptoms associated with TRALI are dyspnea, cough, and fever, associated with hypo- or
hypertension. It occurs most commonly within the initial 6 hours after transfusion. The presence
of anti-HLA and/or anti-granulocyte antibodies in the plasma of donors is implicated in the
pathogenesis of TRALI. Diagnosis requires a high index of suspicion, and confirmation of donor
serum cross-reacting antibodies against the recipient. Treatment is mainly supportive in this
self-limiting condition. 31-32
3. Febrile nonhemolytic transfusion reactions (FNHTR) are suspected in the absence of hemolysis
with an increase in body temperature of less than 2C. For reactions associated with a
temperature rise of greater than 2C or with hypotension, bacterial contamination also should
be suspected and a Gram stain and microbial culture performed on the remaining blood
product.
 4. Allergic reactions
Allergic reactions are caused by presence of preformed immunoglobulin E antibody against an
allergen in the transfused plasma, and are a rare occurrence in newborns. In some cases, release
of residual cytokines or chemokines (eg, RANTES) from stored platelets also may cause allergic
reactions. These reactions are generally mild, and respond to antihistaminics. Severe
anaphylactic reactions are rare.

Acute non immune reactions

1. Fluid overload: Neonates are at increased risk of fluid overload from transfusion because the
volume of the blood component issued may exceed the volume that may be transfused safely
into neonates. Care should be taken to ensure that, in the absence of blood loss, volumes
infused do not exceed 10 to 20 mL/kg. There is no role for routine use of frusemide while
transfusing newborns.

2. Metabolic complications33: These complications occur with large volume of transfusions like
exchange transfusions.

a) Hyperkalemia: In stored blood, potassium levels tend to be high. It has been seen that after
storage for around 42 days, potassium levels may reach 50 mEq/L in a RBC unit.34 Though
small volume transfusions do not have much risk of metabolic disturbances, large volume
transfusions may lead to hyperkalemia. Washing PRBCs before reconstituting with FFP
before exchange transfusion helps in preventing this complication.

b) Hypoglycemia: Blood stored in CPD blood has a high content of glucose leading to a rebound
rise in insulin release 1-2 hours after transfusion. This may lead to hypoglycemia and
routine monitoring is necessary, particularly after exchange transfusion, after 2 and 6 hours,
to ensure that this complication does not occur.

c) Acid- base derangements: Metabolism of citrate in CPD leads to late metabolic alkalosis.
Metabolic acidosis is an immediate complication occurring in sick babies who cannot
metabolize citrate.

d) Hypocalcemia and hypomagnesemia are caused by binding of these ions by citrate present
in CPD blood.

Delayed complications

1. Alloimmunization: Alloimmunization is an uncommon occurrence before the age of 4 months, and is

caused by transfusion of blood products with are mismatched for highly immunogenic antigens like
Rh. 35
2. Transfusion associated graft versus host disease (TA-GVHD): Newborns are at risk for TA-GVHD if
they have received intrauterine transfusions, exchange transfusions, or are very small, or
immunocompromised. Unchecked donor T cell proliferation is the cause of TA-GVHD, and it can be
effectively prevented by leucoreduction of the transfused blood products in at risk patients.

Research issues: Research issues relevant to Indian context are outlined in Table 4.

Table 4 Research issues

Research question Subjects Study design Interven Outcomes to be
tion measured
1. What is the All neonates Impleme Number of
effect of admitted in Before and ntation transfusions, donor
implementatio NICU after of strict exposure, transfusion
n of strict receiving intervention transfusi associated
transfusion transfusion. trial on complications.
guidelines in criteria
the transfusion
practices in
NICU?
2. What is the All VLBW PRBC Growth parameters
effect of lower neonates Randomized transfusi such as weight, length
cut off for admitted in trial ons at and OFC at birth and
PRBC NICU two discharge; Time taken
transfusion on receiving different to discharge.
the growth transfusion. cut off
parameters of levels
VLBW infants
at discharge?
REFERENCES

1. Bell EF, Strauss RG, Widness JA, Mahoney LT, Mock DM, et al. Randomized Trial of Liberal Versus
Restrictive Guidelines for Red Blood Cell Transfusion in Preterm Infants. Pediatrics 2005;115:1685-1691.
2. Ohls R J. Transfusions in the Preterm Neonates. NeoReviews 2007;8 :377-386.
3. Murray NA, Roberts IAG. Neonatal transfusion practice. Arch Dis Child FN 2004;89:101-107.
4. McClelland Ed. In Handbook of transfusion medicine. United Kingdom blood services 4th edition. TSO
publishers London;2007.p5-22.
5. James V Ed. In Guidelines for blood transfusion services in the United Kingdom 7th edition. TSO publishers
London;2005.p21-32.
6. Dhingra N Ed. In Screening donated blood for transfusion transmissible infections. WHO Recommendations
2010.
7. Mukagatare I, MonfortM, deMarchin J,Gerard C. The effect of leukocyte-reduction on the transfusion
reactions to red blood cells concentrates [French]. Transfus Clin Biol. 2010;17:1419.
8. Fergusson D, Hebert PC, Lee SK, et al. Clinical outcomes following institution of universal leukoreduction of
blood transfusions for premature infants. JAMA. 2003;289:19501956.

9. Schroeder ML. Transfusion-associated graft-versus-host disease. Br J Haematol 2002;117:275287.

10. Pelszynsky MM, Moroff G, Luban NLC, Taylor BJ, Quinones RR. Effect of y Irradiation of Red Blood Cell
Units on T-cell Inactivation as Assessed by Limiting Dilution Analysis: Implications for Preventing
Transfusion-Associated Graft-Versus-Host Disease. Blood 1994;83:1683-1 689.
11. Vamvakas EC. Is white blood cell reduction equivalent to antibody screening in preventing transmission of
cytomegalovirus by transfusion? A review of the literature and meta-analysis. Transfus Med Rev.
2005;19:181199
12. Strauss RG. Transfusion therapy for neonates. Am J Dis Child 1991; 145 : 904-911.
13. Brandon S. Poterjoy, Cassandra D. Josephson. Platelets, Frozen Plasma, and Cryoprecipitate: What is the
Clinical Evidence for Their Use in the Neonatal Intensive Care Unit? Semin Perinatol 2009;33(1):66-74.
14. Whyte R, Kirpalani H. Low versus high haemoglobin concentration threshold for blood transfusion for
preventing morbidity and mortality in very low birth weight infants. Cochrane Database of Systematic
Reviews 2011, Issue 11. Art. No.: CD000512. DOI: 10.1002/14651858.CD000512.pub2.
15. Cloherty JP, Eichenwald EC, Stark AR Eds. In: Manual of Neonatal Care 7th edition. Lippincott William&
Wilkins USA 2011.p 441.
16. Behrman ER Ed. Red blood cell transfusions and erythropoietin therapy. In Nelson Textbook of Pediatrics
th
19 edition, Elsievers 2010.p1647.

17. Paul DA, Leef KH, Locke RG, Stefano JL . Transfusion volume in infants with very low birth weight: a
randomized trial of 10 versus 20 ml/kg. J Pediatr Hematol Oncol 2002;24:436.
18. Chatterjee K, Sen A. Step by Step Blood Transfusion Services. 1st ed. New Delhi. Jaypee Publishers;
2006.p.238-300.
19. Roberts I,Murray NA. Neonatal thrombocytopenia: causes and management. Arch Dis Child FN
2003;88:F359-364.
20. Hohlfeld P, Forestier F, Kaplan C, Tissot JD, Daffos F. Fetal thrombocytopenia: a retrospective survey of
5,194 fetal blood samplings. Blood 1994;84:18516.
21. Burrows RF, Kelton JG. Incidentally detected thrombocytopenia in healthy mothers and their infants. N Engl
J Med 1988;319:1425.
22. Sainio S, Jarvenpaa A-S, Renlund M, Riikonen S, Teramo K, et al. Thrombocytopenia in term infants: a
population-based study. Obstet Gynecol 2000;95:4416.
23. Uhrynowska M, Niznikowska-Marks M, Zupanska B. Neonatal and maternal thrombocytopenia: incidence
and immune background. Eur J Haematol 2000;64:4246.
24. Castle V, Andrew M, Kelton J, Girm D, Johston M, et al. Frequency and mechanism of neonatal
thrombocytopenia. J Pediatr 1986;108:74955.
25. Murray NA, Howarth LJ, McCloy MP, Letsky EA, Roberts IAG. Platelet transfusion in the management of
severe thrombocytopenia in neonatal intensive care unit (NICU) patients. Transfus Med 2002;12:3541.
26. Pammi M, Brocklehurst P. Granulocyte transfusions for neonates with confirmed or suspected sepsis and
neutropenia. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD003956.

27. Choudhury LP, Tetali S. Ethical challenges in voluntary blood donation in Kerala, India. J Med Ethics.
2007;33:140-2.
28. Madjdpour C, Heindl V, Spahn DR. Risks, benefits, alternatives and indications of allogenic blood
transfusion. Minerva Anestesiol 2006;72:283-98
29. Choudhury N, Phadke S. Transfusion transmitted diseases. Indian J Pediatr. 2001;68:951-8.
30. Bowden RA, Slichter SJ, Sayers M, Weisdorf D, Cays M et al. A Comparison of Filtered Leukocyte-
Reduced and Cytomegalovirus (CMV) Seronegative Blood Products for the Prevention of Transfusion-
Associated CMV Infection After Marrow Transplant. Blood 1995;86:3598-3603.
31. Yang X, Ahmed S, Chandrasekaran V. Transfusion-related acute lung injury resulting from designated blood
transfusion between mother and child: a report of two cases. Am J Clin Pathol. 2004;121:590-2.
32. Looney MR, Gropper MA, Manhay MA. Transfusion-Related Acute Lung Injury* A Review. Chest
2004;126;249-258.
33. Martin CR, Cloherty JP. Neonatal hyperbilirubinemia. In: Cloherty JP, Eichenwald ER, Stark AR, editors.
Manual of Neonatal Care. 5th Ed. Philadelphia: Lippincott Willams and Wilkins.2004, p.185-221.
34. Strauss RG. Transfusion approach to neonatal anemia. NeoReviews 2000;1:e74-80.
35. Galel S A, Fontaine MJ. Hazards of Neonatal Blood Transfusion. NeoReviews 2006;7:e 69-75.
 THERMAL MANAGEMENT
A newborn baby is homeothermic, but his ability to maintain his body temperature can be easily
overwhelmed by environmental temperatures. Thermal protection of the newborn is a set of continuing
measures, which starts at birth, to ensure that he maintains a body temperature of 36.5C to 37.5C
(Table 1).1 According to NNPD 2002-2003, incidence of hypothermia among extramural babies was 18.4
%.2

Table 1: Temperature ranges

Normal axillary temperature 36.5-37.5C
Mild hypothermia or cold stress 37-36.4C
Moderate hypothermia 32-35.9
Serve hypothermia <32C
Hyperthermia >37.5C

Thermoneutral environment (TNE)

TNE refers to a narrow range of environmental temperature at which the basal metabolic rate (BMR) of
the baby is at a minimum, oxygen consumption is at least and baby maintains its normal bodt
temperature is called thermoneutral range of temperature.2 Range of neutral temperature varies
accordingly for the gestation and postnatal age (Table 2).

As opposed to TNE, thermoregulatory environment refers to environmental temperature beyond TNE

range, at which baby would be able to maintain its body temperature but by increasing its BMR.

The infants therefore should be kept in TNE so that their energy is utilized for growth and other vital
functions.

Table 2: Thermoneutral zone

Weight of the Recommended ambient temperature
baby
35*C 34*C 33*C 32*C

Less than 1500 g 1 to 10 days old 11 days to 3 wk 3 wk to 5 wk old More than 5 wk old
old
1500 to 1999 g 1 to 10 days old 11 days to 4 wk More than 4 wk old
old
2000 to 2499 g 1 to 2 days old 3 days to 3 wk old More than 3 wk old

D2500 g or more 1 to 2 days old 3 days old or more

Recording temperature
It is not necessary to measure the temperature of healthy newborn babies routinely, particularly when
the warm chain is strictly followed.

Temperature should be monitored every 1-2 hour for a baby with serious illness, twice daily for babies
weighing between 1500 to 2499 gm, four times daily for babies below 1500 gm and once a day for other
babies who are doing well.

Methods of recording temperature

Touch method
Abdomen skin temperature is assessed by touch with dorsum of hand. Abdominal temperature is
representative of the core temperature. Babys temperature can be assessed with reliable accuracy by
human touch, which can be easily taught to parents and can be practiced at home as well. The
interpretation is as follows:
Babys feet and hands are warm: Thermal comfort
Peripheries are cold, the trunk is warm: Cold stress
Peripheries and the trunk both are cold: Hypothermia

Thermometers
WHO recommends the use of low reading thermometer which can record up to 30C. American
Academy of Pediatrics (AAP) recommends against using mercury thermometers because the glass can
break, and mercury is poisonous.3 The best is to use a digital thermometer.

Thermister probe
Skin temperature can be recorded by a thermister. The probe is attached to skin over upper abdomen.
The thermister will sense the skin temperature and display on the panel.

The concept of warm chain

The warm chain is a set of ten interlinked steps carried out at birth and later which will reduce the
chances of hypothermia in all newborns

1. Thermal care in delivery room

After birth, newborns temperature can drop at a rate of 0.1C and 0.3C per minute for core and skin
temperature respectively. Delivery room needs to be prepared much in advance. The room should be
clean, warm (at least 25-28C) and free from draughts from open windows and doors or from fans.

If the temperature of the room is less than optimal, a heater should be available to warm the room. All
the towels, blankets, caps, babys clothes should be prewarmed. The radiant warmer should be switched
on at least 20 to 30 minute in advance and put into manual mode with 100% heater output.
2. Warm resuscitation

3. Immediate drying
After birth, the baby should be immediately dried with a dry towel, starting with the head. After drying
thoroughly, the baby should then be covered with a second, dry towel and a cap put on its head.

4. Skin-to-skin contact
Baby can be kept in mothers chest in skin contact while mother is being attended including placental
delivery, episiotomy, suturing, transferred and kept in postnatal ward for initial few hours. If a baby is in
cold stress, the baby should be immediately put in skin to skin contact with mother.

5. Breast feeding
Breast feeding should begin as soon as possible after birth preferably within an hour. This ensures
adequate supply of calories for heat generation.

6. Bathing / weighing postponing

Bathing should be postponed in a term baby at least till next day. Weighing should be done only after
covering the baby adequately and making zero correction for clothing.

7. Clothing and bedding

Newborns should be covered with one (or) two layers of clothes and cap, shocks and hand gloves.
Swaddling, a custom of wrapping bands should be avoided.

8. Rooming in
Babies and mother should be attached together for 24 in the same bed and breast fed on demand.

9. Warm transportation
In case of transport- whether to home, to another hospital / another section, thermal protection should
be ensured. Stable babies including preterm and LBW babies should be transported well wrapped and in
skin to skin contact with mother.

VLBW, unstable, admitted babies should be transported using an incubator. Temperature should be
checked before and after transport. All peripheral hospitals caring for high risk mothers should go for in-
utero transfer as early as possible.

10. Training and awareness rising:

All the health care personnel involved in the newborn care should be adequately trained and informed
about the principles of warm chain.
Thermal management in preterm babies
Apart from the routine procedures and adhering to warm chain, extra care is required for preterm
babies.

Polythene occlusive wraps

NRP 2010 recommends the use of polythene wraps for all babies <28 weeks this technique involves the
covering the premature infant in a polyethylene bag or a cover that can be applied on neck, drying of
the baby is not done. The baby should be immediately received on to a radiant warm. Wrapping reduces
evaporative heat loss, while allowing radiant heat delivery to the baby.4

Polythene occlusive wraps: What is the evidence?

A Cochrane review has confirmed the efficacy of plastic bags in addition to radiant warming in
improving the NICU admission temperature of premature babies <28 weeks gestation5

All preterm babies <34 weeks should be admitted and nursed either in a radiant warmer / preferable in
an incubator. All preterm babies when transferred to open cot / to mother, kangaroo mother care
should be started and be ensured minimum 10-14 hrs a day.

Incubators
Incubators should be preferred over radiant women for the care of preterm babies.6 Incubators
decrease the insensible water loss (IWL), but radiant warmers rather increase the IWL. Infants
temperature is regulated by controlling the air temperature within the hood to provide an optimal TNE
or by servo-control of the heating device to the infants skin temperature.

a) Mechanisms
Convective heat loss dependent on air flow, the incubators reduce the exposure of babies to air
currents. Evaporative process of heat loss will be limited by providing maximum possible relative
humidity within the incubator. Radiative heat losses are minimized by the hood on the baby or by using
double walled incubators.

The modern incubator incorporates a transparent plastic hood with various access ports. A warming
device is positioned below the bed surface and air is blown over the warming element. Air or air-oxygen
mixture is humidified using a quiet fan; the warm humidified air is then circulated through the hood to
attain a uniform temperature within. A low rate of air circulation, ideally not more than 20-30 lit /min
minimizes convective heat losses and noise level should be kept below 60 db.

Double wall vs. single wall incubator: what is evidence?

Double wall incubators which has an additional inner wall suspended. The double wall
incubators had advantages as far as decreasing heat loss and decreasing heat production.7
b) Practical tips
In air mode, desired temperature of the environment around the baby is set and the heater output
adjusts itself to maintain this. The appropriate set temperature is decided by using the thermo
neutral temperature charts
In servo mode, the desired skin temperature is set to 36.5 C. The feedback system modifies heater
output to keep the baby temperature constant
For sick babies, servo mode is preferred. Because, the servo mode, it helps to assess the
temperature requirement for the baby. Set the temperature at 36.5C. The probe should be
properly positioned, if it gets dislodged, there is a danger of overheating
Switch to air mode when the baby is stable. Air mode is preferred for procedures also. When
switching over to air mode, set the air temperature to equal the average incubator air temperature
during the previous day of skin mode

c) Humidification
Humidity should be started in all infants <31 weeks gestation at 85% humidity.

Infants of 28-30 weeks: If temperature remains stable for 24 hours, start to decrease humidity
by 5% day by day.

Infants of <28 weeks: Maintain humidity of 85% for first 7 days and if stable for 7 days, decrease
humidity by 5% daily.

Humidification chamber
One should fill the chamber for humidification with appropriate volume of sterile distilled water. Since
this water can be potential source of infection, it must be changed daily completely. The chamber
should be washed and dried thoroughly with clean towel clothes.

Weaning from incubator

There is no clear cut recommendation on what is the exact weaning time from open incubator to cot8.
The baby can be weaned, when the baby started consistently gaining weight, maintain euthermia when
ambient temperature <30C. After weaning to open cut, the axillary temperature should be checked and
then every 4 hourly as of routine.

Radiant warmers
Radiant warmer is an open care convenient system for management of preterm and >1800 g babies,
because maintenance is easy and allows easy access for doing procedures, but the disadvantage is that
insensible water is greater increased under radiant warmer.
a) Principle
The radiant warmers produces radiant heat by a heating rod usually made of quartz crystal; this is
uniformly reflected onto the surface by parabolic reflectors. They also reduce conductive heat loss by
warming the microenvironment.

b) Modes
Skin servo mode of control is preferred over manual mode. Servo control is a mode in which the heater
output is determined automatically by the information based on the skin temperature. In servo, set the
skin temperature at 36.5C, cover the infants head, arms and legs, only stable babies should be clothed.
Room temperature should be sufficiently high at least 25C/77F.

Manual mode is a mode in which operator himself determines the heater output, not routinely used
because of risk of overheating or under heating. Manual mode is used for prewarming the linen, rapid
rewarming of hypothermic baby and if the baby has fever.

c) Practical tips
If on manual mode babys temperature should be checked at least every 15 minutes
There should never be more than one baby under a warmer as this may allow cross infection,
unequal heat distribution
In small babies, cling wraps mode of polythene sheets can be used for covering the tops of side walls
which will help in reducing the insensible water loss
One of the disadvantages of radiant warmer is that of increased water loss, hence it is advised to
give extra fluid and proper daily weighing in small babies.

Heated water filled mattress:

It is an economical device for keeping LBW/sick babies. Generally, they are of five liters of water
capacity. An electric heating plate and control unit fit into a compartment in the bottom of the mattress
and it keeps the temperature of water at 35-38C. This is not routinely used, because of practical
difficulties.

Portable infant warmer-PCM devices

1. It consists of a precision heat source used to melt wax within 30 minutes. Models exists that work
both with and without electricity.
2. It consists of a sealed pouch containing PCM. Maintains 37C for 4 hours without electricity pouch
can be reheated repeatedly.

Some in vitro studies have proven the efficacy of phase changing materials which constantly maintain
the temperature of the LBW over a defined time period. Trials are needed to assess the efficacy of PCM
as a modality for effective thermal management in newborns.

Kangaroo mother care:

For LBW babies, who are stable, KMC is perhaps the most effective way of keeping babies warm. KMC is
a no cost, easy, applicable at home, which has multiple added advantages. Regular breast feedings and
skin-skin contact are encouraged for all LBW babies who are prone for hypothermia.
Hypothermia:
Clinical features of hypothermia can be discussed under the four different situations

a) Initial signs of hypothermia are generally those which appear because of peripheral
vasoconstriction like pallor, acrocyanosis, cool extremities, decreased peripheral perfusion,
there can be early signs of CNS manifestations like irritability.
b) Later signs include features of CNS depression like lethargy, bradycardia, apnea, poor feeding,
hypotonia, weak suck or cry, emesis. Because of increase in pulmonary artery pressure, there
can be symptoms o respiratory distress mainly tachypnea. Abdominal signs like increased gastric
residuals, abdominal distention or emesis can occur.
c) Prolonged hypothermia leads to increased metabolism leading to hypoglycemia, hypoxia,
metabolic acidosis, coagulation failure, sometimes, PPHN like situation, ARF in extreme case
high likely hood of mortality.
d) Chronic periods of cold stress lead to weight loss and poor weight gain.

Management:

a) Cold stress
Cover the baby adequately- remove cold/wet clothes, cover the baby adequately with warm
clothes
Warm the environments including room / bed
Ensure skin to skin contact with mother, if not possible, kept next to mother after fully
covering the baby
Immediately breastfeed the baby
Monitor axillary temperature every hr till it reaches 36.5, then hourly for next 4 hours, 2
hourly for 12 hour thereafter

b) Moderate hypothermia:
In this situation, one should provide the baby with additional source of heat.
Maintain skin to skin contact
Warm room / bed
Take measures to reduce heat loss
Provide extra heat by room heater, radiant warmer, incubator ,applying warm towel or
using phase changing mattresses

c) Severe hypothermia
All babies with severe hypothermia (<32C) should be immediately admitted to the hospital
Rapid rewarming should be done immediately which can be done using a radiant warmer or
air heated incubator
Rapid rewarming is done up to 34C, then slow rewarming to 36.5C
Take all measures to reduce heat loss
Start IVF at 60-80 ml/kg of 10% dextrose
Possible oxygen if needed
Check whether the baby received Inj vit K or not. Give Inj vitamin K 1mg in term and 0.5mg
in preterm babies
If not improving immediately, think of causes like sepsis
 Hyperthermia
Hyperthermia is also a common problem with neonates. Very common in dry warm climate areas.
Temperature of more than 37.5C is defined as hyperthermia in newborns.

a) Causes
Too hot environment high room temperature
The baby has many layers of covers / clothes
Dehydration fever the baby may be in a dehydration state
Sepsis

b) Dehydration fever
Dehydration results in excess weight loss for the baby and hence one of the important clue for
dehydration fever is excess weight loss. Fever generally subsides with correction of breastfeeding issues
or when extra feeds given properly.

c) Symptoms
Early: Irritable, tachycardia, tachypnea, flushed face, hot and dry kin
Late: Apathetic, lethargic and then comatose
Severe forms of hyperthermia can lead to shock, convulsions, even death in neglected cases

d) Management
Place the baby in a normal environment (25-28C) away from heat source
Undress the baby partial / fully
Give frequent breast feeds give breast milk or by katori spoon if needed
If temperature >39, sponge can be done with tap water

Measure the temperature hourly till be becomes normal

Practice tip:
Dont use the
Examine coldbaby
/ icefor
water for sponge. Tap water is good enough
any infection
Research issues: Research issues relevant to Indian context are outlined here

SN Research question Subjects Study design Intervention Outcomes to be

measured
1 What is the Documented Cohort study Mortality and
Outcome of neonates severe neurodevelopmental
who have suffered hypothermia Outcome at 2 years
prolonged severe
hypothermia?
2 What is the incidence All neonates Observational Incidence of
and seasonality of eligible studies hyperthermia,
hyperthermia dehydration in
Among newborns in relation to
tropical climates? seasonality and
different climate
zones in a tropical
country like India
3 Evaluation of new All neonates Comparative Individual difference
methods of eligible studies in the accuracy of
thermometry in 1.Mercury vs body temperatures
neonates Infrared and correlation with
thermometry core temperatures
2. Mercury vs
Phase change
thermometers
4 What is the efficacy of LBW Comparative Average axillary and
phase changing neonates studies core temperatures,
materials in thermal incidence of cold
maintenance? stress and
hypothermia
References
1. Thermal protection of newborns, a practical guide, WHO- 1997
2. NNPD report 2002-2003, www.newbornwhocc.org
3. Caring for Your Baby and Young Child: Birth to Age 5: American Academy of Pediatrics
4. International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with
Treatment Recommendations, Circulation 2010;122;S516-S538
5. McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S. Interventions to prevent hypothermia at birth in preterm and/or low
birth weight infants. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004210
6. Flenady V, Woodgate PG. Radiant warmers versus incubators for regulating body temperature in newborn infants.
Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD000435. DOI: 10.1002/14651858.CD000435
7. Laroia N, Phelps D, Roy J. Double wall versus single wall incubator for reducing heat loss in very low birth weight
infants in incubators. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004215. DOI:
10.1002/14651858.CD004215
8. Gray PH, Flenady V. Cot-nursing versus incubator care for preterm infants. Cochrane Database of Systematic Reviews
2001, Issue 2. Art. No.: CD003062. DOI: 10.1002/14651858.CD003062
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Hypothermia

0
Axillary temperature <36.5 C

- Look for possible cause of hypothermia

- Check room temperature

Hypothermia

Mild hypothermia 360C 36.40C

Ensure room is warm (maintain at 250C
280 C)
Position baby skin-to-skin with mother
Continue breast feeding
Recheck temperature in 1 hour;
- If temperature is normal, cover the baby
adequately including head, hands and
feet
- If no improvement, treat as Moderate
Hypothermia

Moderate hypothermia 320C 35.9oC Severe hypothermia <32oC

Provide warmth using a warmer
Provide warmth using a warmer (or electric bulb)
Rapid re-warming till baby is 34oC and then slow
If no warmer is available, start skin to skin with
re-warming*
mother (KMC). Cover mother and baby together
Start oxygen and maintenance IV fluids
optimally using pre-warmed clothes
Ensure room is warm (maintain at 250C 280 C) Give Inj Vitamin K , if not given or status unknown
Continue breast feeding Ensure room is warm (maintain at 250C 280 C)
Measure blood glucose, if <45mg/dl, treat for
Measure blood glucose, If <45mg/dl, treat for
hypoglycemia (See STP for Hypoglycemia)
hypoglycemia (See STP for Hypoglycemia)
Reassess every 15 minutes, if temperature does
Reassess every 15 minute; if temperature does not
not improve increase setting of warmer - Reassess
improve, increase setting of warmer - Reassess
If no improvement, REFER
If no improvement or no warmer ,REFER

Hypothermia can be a sign of infection

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book
of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
Hypothermia in Newborns
What is hypothermia? Prevent heat loss: The warm chain How to keep a sick/LBW baby
Hypothermia is defined when babys body temperature falls Prevent heat loss at birth warm in facility
o
below36.5 C
Keep delivery room temperature at least 25C
You can measure temperature of a baby by keeping 1. Keep baby under radiant warmer or inside an incubator
Dry immediately; wrap in a warm towel
thermometer in roof of axilla for three minutes
Provide skin-to-skin contact, initiate
breastfeeding
Why it is important ? Bathing the infant
1. Hypothermia decreases chances of survival of a low Postpone till next day
birth weight baby
2. Hypothermia aggravates the illness severity in a sick Do not bathe a sick baby
baby Avoid till cord falls in LBW baby
3. Hypothermia decreases growth of a low birth weight
baby Bathe using warm water in a warm room. Dry 2. Provide
immediately. Wrap in dry warm towel, cover Kangaroo Mother Care
head. Place near mother.
Severity of hypothermia Dress newborns with several layers of loose
clothing and monitor temperature
o o
Normal range (36.5 C to 37.5 C) 37.5o
Keep mother and newborn together in a warm 3. If radiant warmer/incubator not available
o o 36.5o room keep the nursery warm
Cold stress (36.1 C to 36.4 C)
36.0o
Moderate hypothermia How to keep a LBW baby warm at home Birth weight (kg) Ideal nursery temperature
o o o
(32.0 C to 36.0 C) 32.0 1.0-1.5 30-33C
o 1.5-2.0 28-30C
Severe hypothermia (<32.0 C)
2.0-2.5 26-28C

Why does it occur? How to rewarm a hypothermic baby

1. When delivery room is too cold Ensure a warm room
2. Baby is not dried immediately after birth Keep the room warm Keep baby wrapped in
3. Baby is kept away from mother warm clothes Remove wet cold clothes, replace with warm
4. Baby has inadequate clothing
clothes
5. Exposure during bathing Rewarm quickly by skin-to-skin contact
and/or a heating device such as radiant heater
Which babies are at highest risk? or incubator
Continue breast-feeding
1. Low birth weight babies
2. Sick babies Monitor temperature at regular intervals
3. Babies immediately after birth Assess for infection if hypothermia persists
Keep baby on exclusive Provide Kangaroo Mother
breast feeding Care

Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi
 Kangaroo mother care
Kangaroo mother care (KMC) is a method of care of preterm or low birth weight (LBW) infants by
placing them in skin to skin (STS) contact with mother or other caregiver in order to ensure optimum
growth and development of the infant.1-4 Initially devised as an alternative to conventional
technology-based care, KMC is now considered as a standard of care for LBW infants for all settings
as an adjunct or alternative to conventional technology based care.

Benefits of KMC: What is evidence? 5

A Cochrane review on benefits of KMC demonstrated that:
Improved exclusive breast feeding rates at discharge (RR 1.21; 95% CI, 1.08-1.36), at 1-3 months of
(RR 1.20; 95% CI: 1.01-1.43) and a trend towards improved rates at 6-12 months (RR 1.29; 95% CI
0.95-1.76)
Reduction in the risk of mortality (Seven trials, 1614 infants; RR 0.60; 95% CI 0.39-0.93;)
Reduction in nosocomial infection/sepsis (RR 0.42, 95% CI 0.24 to 0.73)
Reduction in hypothermia (RR 0.23, 95% CI 0.10 to 0.55)
Reduction in length of hospital stay (mean difference 2.4 days, 95% CI 0.7 to 4.1)

Components of KMC 6-8

1. Kangaroo position
The kangaroo position consists of skin-to-skin contact (SSC) between the mother and the
infant in a vertical position, between the mothers breasts and under her clothes
The provider must keep herself in a semi- reclining position to avoid the gastric reflux in the
infant
The kangaroo position is maintained until the infant no longer tolerates it- as indicated by
sweating in the baby or baby refusing to stay in KMC position
When continuous care is not possible, the kangaroo position can be used intermittently,
providing the proven emotional and breastfeeding promotion benefits
The kangaroo position must be offered for as long as possible (but at least 1-2 hr/sitting),
provided the infant tolerates it well.

2. Kangaroo nutrition
Kangaroo nutrition is the delivery of nutrition to kangarooed infants as soon as oral
feeding is possible.
Goal is to provide exclusive or nearly exclusive breastfeeding with fortification, if needed.

3. Kangaroo discharge and follow up

Early home discharge in the kangaroo position from the neonatal unit is one of the original
components of the KMC intervention.
Mothers at home require adequate support and follow up hence a follow-up program and
access to emergency services must be ensured.

KMC in different settings

KMC may be used in three different scenarios:

1. No specialized care for LBW neonates
LBW infants born at home or at first level health facility with no specialized care and no
possibility of being transferred to a proper healthcare unit can be provided KMC as the sole
modality of care. In such cases, KMC including skin-to-skin contact, breastfeeding and the best
 possible health-care follow-up represent the best available means for survival of non-sick
premature infants.
2. Specialized care but limited resources
Here KMC represents an effective alternative which allows better utilization of available
resources.
3. Specialized care and adequate resources
KMC is used as an adjunct to technology based care to establish healthy bonding between
mother and infant and to increase the breastfeeding rates. The intermittent kangaroo position in
hospital is the most widely used component in such a setting.

Requirements for KMC implementation 6-8

KMC is feasible everywhere, because it is not based on equipment, and it presents advantages for
the organization of health services provided the following requirements are met:

1. Appropriate health facility

a. The health facility (the hospital or the neonatal ward) should allow entry of the parents
in the neonatal unit at all times.
b. A room near to or at the neonatal unit, furnished with comfortable seats for the
mothers, is needed for KMC practice and for education of mothers and families.
c. Reclining chairs in the nursery and postnatal wards, and beds with adjustable back rest
should be arranged.
d. Mother can also provide KMC sitting on an ordinary chair or in a semi-reclining posture
on a bed with the help of pillows.

2. Appropriate supporting staff and professionals

a. The presence of a nurse available full time, trained in assisting mothers in KMC is
indispensable.
b. Staff should receive adequate training on KMC including on nutrition of LBW infants.
Additional training is needed on expression and storage of breast milk, using alternate
methods of feeding, and daily monitoring of growth of LBW infants. The training may
best be done by exposing them to units already practicing KMC.
c. Educational material such as information sheets, posters, and video films on KMC in
local language should be available to the mothers, families and the community.

3. Good quality follow-up

a. Early discharge in kangaroo position should be not attempted if adequate and
appropriate follow up cannot be ensured.
b. KMC should be provided as an in-hospital activity, allowing mothers and infants to room
together for as long as needed.
4. Institutional, social and community support
a. The requirement for a successful KMC program can be summarized in three words:
communication, sensitiveness and education.
b. Apart from supporting the mother, family members should also be encouraged to
provide KMC when mother wishes to take rest.
c. Mother would need her family's cooperation to deal with her conventional
responsibilities of household chores till the baby requires KMC.
d. Community awareness about the benefits should be created. This is particularly
important when there are social, economic or family constraints.
 Birth weight

<1200 gram 1200 to 1800 grams >1800 grams

Most infants suffer from Many infants suffer Generally stable at birth
serious morbidities, from serious
therefore birth should morbidities
take place in specialized
centres the neonatal Transfer to a
specialized centre, if
possible
Best transported in
STS with mother /

May take days to

weeks before KMC can
be initiated May take days before KMC KMC can be initiated
can be initiated immediately after birth

Figure 1: Timing of KMC initiation for different birth weight categories.

Criteria for eligibility of KMC 6-8

1. Baby

All stable LBW babies are eligible for KMC. However, sick and very small babies (<1200 gm)
needing special care should be cared under radiant warmer initially. KMC should be started after
the baby is hemodynamically stable. Short KMC sessions can be initiated during recovery with
ongoing medical treatment (IV fluids, oxygen therapy). KMC can be provided while the baby is
being fed via orogastric tube or on oxygen therapy. Figure-1 shows the timing of KMC initiation
for different birth weight categories.

2. Mother

All mothers can provide KMC, irrespective of age, parity, education, culture and religion.6

The following points must be taken into consideration when counselling on KMC:
1. Willingness: The mother must be willing to provide KMC. Healthcare providers should
counsel and motivate her. Once the mother realizes the benefits of KMC for her baby, she
will learn and undertake KMC.
2. General health and nutrition: The mother should be free from serious illness to be able to
provide KMC. She should receive adequate diet and supplements recommended by her
physician.
3. Hygiene: The mother should maintain good hygiene: daily bath/sponge, change of clothes,
hand washing, short and clean finger nails.

Initiation of KMC
1. Counseling
a. When baby is ready for KMC, arrange a time that is convenient to the mother and
her baby.
b. Demonstrate to her the KMC procedure in a caring and gentle manner and with
patience. Answer her queries and allay her anxieties.
c. Encourage her to bring her mother/mother in law, husband or any other member of
the family.
d. It helps in building positive attitude of the family and ensuring family support to the
mother which is particularly crucial for post-discharge home-based KMC.8
e. It is helpful that the mother starting KMC interacts with someone already practicing
KMC for her baby.

2. Mothers clothing
a. Mother can wear any front-open dresses as per local culture. This may include sari, a
blouse, front open gown, a suit, or a simple shirt (Figure 2).
b. KMC can be done with special apparel (such as KEM bag or AIIMS KMC jacket)
designed to suit the needs of mothers.
c. Any other suitable apparel that can retain the baby for extended period of time can
be adapted locally.
 d.

A B

C D
Figure 2: Mother (A) and father (B) practicing KMC in front open gown and shawl. AIIMS KMC jacket
(C) and mother performing KMC using AIIMS KMC jacket (D).

3. Babys clothing: Baby is dressed with cap, socks, nappy, and front-open sleeveless shirt.

KMC procedure6-8

1. Kangaroo positioning (Figure 3):

a. The baby should be placed between the mother's breasts in an upright position.
b. The head should be turned to one side and in a slightly extended position. This
slightly extended head position keeps the airway open and allows eye to eye contact
between the mother and her baby.
c. The hips should be flexed and abducted in a "frog" position; the arms should also be
flexed. Baby's abdomen should be at the level of the mother's epigastrium. Mother's
breathing stimulates the baby, thus reducing the occurrence of apnea.
 d. Support the babys bottom with a sling/binder.

Figure 3: Positioning in KMC

2. Monitoring
a. Babies receiving KMC should be monitored carefully especially during the initial
stages.
b. Nursing staff should make sure that babys neck position is neither too flexed nor
too extended, airway is clear, breathing is regular, color is pink and baby is
maintaining temperature.
c. Mother should be involved in observing the baby during KMC so that she herself can
continue monitoring at home.
3. Feeding
a. The mother should be explained how to breastfeed while the baby is in KMC
position.
b. Holding the baby near the breast stimulates milk production.5,6
c. She may express milk while the baby is still in KMC position. The baby could be fed
with paladai, spoon or tube, depending on the condition of the baby.
4. Duration
a. Skin-to-skin contact should start gradually in the nursery, with a smooth transition
from conventional care to continuous KMC.
b. Sessions that last less than one hour should be avoided because frequent handling
may be stressful for the baby.
c. The length of skin-to-skin contacts should be gradually increased up to 24 hours a
day, interrupted only for changing diapers.
d. When the baby does not require intensive care, she should be transferred to the
post-natal ward where KMC should be continued.

Can the mother continue KMC during sleep and resting? 7

The mother can sleep with baby in kangaroo position in reclined or semi recumbent position about
30 degrees from horizontal (Figure 8). This can be done with an adjustable bed or with pillows on an
ordinary bed. A comfortable chair with an adjustable back may be used for resting during the day
(Figure 8).
 A B

Figure 4: Mother practicing KMC in reclining posture (A) and KMC chair (B)

Discharge criteria
The standard policy of the unit for discharge from the hospital should be followed. Generally the
following criteria are accepted at most centres: 7
Baby's general health is good
Gaining weight (at least 15-20 gm/kg/day for at least three consecutive days)
Maintaining body temperature satisfactorily for at least three consecutive days in room
temperature.
Feeding well and receiving exclusively or predominantly breast milk.
The mother and family members are confident to take care of the baby

When to discontinue KMC?

When the mother and baby are comfortable, KMC is continued for as long as possible, at the
institution & then at home. Often this is desirable until the baby's gestation reaches term or the
weight is around 2500 g. She starts wriggling to show that she is uncomfortable, pulls her limbs out,
cries and fusses every time the mother tries to put her back skin to skin. This is the time to wean the
baby from KMC. Mothers can provide skin-to-skin contact occasionally after giving the baby a bath
and during cold nights.

Post-discharge follow-up
Close follow up is a fundamental pre-requisite of KMC practice. Baby is followed once or twice a
week till 37-40 weeks of gestation or till the baby reaches 2.5 to 3 kg of weight. Thereafter, a follow
up once in 2-4 weeks may be enough till 3 months of post-conception age. Later the baby should be
seen at an interval of 1-2 months during first year of life. The baby should gain adequate weight (15-
20 gm/kg/day up to 40 weeks of post-conception age and 10 gm/kg/ day subsequently). More
frequent visits should be made if the baby is not growing well or his condition demands.

Research priorities
The research priorities has been provided in Table 1
 Table 1: Research issues relevant to Indian context

Research Subjects Study design Interventions Outcomes to be

question measured
What is effectiveness Small (<1200 gm) RCT Gp A: KMC Safety
and safety of KMC in or infants with Gp B: no Mortality
small or sick infants sickness (with KMC Hospital stay
respiratory distress, (conventiona Confidence of
infection, asphyxia, l care) health
oxygen providers
requirement, and mothers
intravenous fluids)

Safety and efficacy of Low birth weight Cluster RCT Gp A: KMC Safety
KMC in home setting/ neonates after Gp B: no Confidence of
community setting discharge KMC mothers
(conventiona Mortality
l care)
Identification of Qualitative - Feedback
barriers (from health Mothers/ KMC research Questionnaire
facility as well as caregivers (other (feedback (incorporating
family and community family members) questionnaire barriers in
perspectives) to KMC ) KMC
caregiving)
Defining monitoring Sick or small Observationa KMC with Number of episodes
requirements for (<1500 gm) LBW l studies monitoring of apnea, and
successful KMC (level neonates (HR, desaturation
of infant monitoring) Saturation,
in small and sick RR)
babies
Defining requirements Mothers/ KMC Qualitative - Feedback
for successful KMC caregivers (other research Questionnair
(such as that of family members) (feedback e
privacy, special attire, questionnaire
chair/cot) )
 References
1. Ludington-Hoe SM, Hadeed AJ, Anderson GC. Physiological response to skin to skin contact in
hospitalized premature infants. J Perinatol.1991; 11: 19-24
2. Whitelaw A, Heisterkamp G, Sleath K, Acolet D, Richards M. Skin to skin contact for very low
birthweight infants and their mothers. Arch Dis Child 1988; 63(11):1377-81.
3. Sloan NL, Camacho LW, Rojas EP, Stern C. Kangaroo mother method: randomized controlled trial of
an alternative method of care for stabilized low-birthweight infants. Maternidad Isidro Ayora Study
Team. Lancet 1994; 344(8925):782-5.
4. Charpak N, Ruiz-Pelaez JG, Charpak Y. Rey-Martinez Kangaroo Mother Program: an alternative way
of caring for low birth weight infants? One year mortality in a two cohort study. Pediatrics 1994;
94(6 Pt 1):804-10.
5. Conde-Agudelo A, Belizn JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and
mortality in low birthweight infants. Cochrane Database Syst Rev. 2011 Mar 16; (3):CD002771.
6. Udani RH, Nanavati RN. Training manual on Kangaroo mother care. Published by the Department of
neonatology. KEM Hospital and Seth GS medical college Mumbai. September 2004.
7. Website of KMC India Network. Guidelines for parents and health providers are available online at
www.kmcindia.org17.
8. World Health Organization. Kangaroo mother care: a practical guide. Department of Reproductive Health
and Research, WHO, Geneva.2003.
 AIIMS- NICU protocols 2008

Follow-up of High Risk Neonates

Pradeep Kumar, M.Jeeva Sankar, Savita Sapra, Ramesh Agarwal, Ashok

Deorari and Vinod Paul

Division of Neonatology, Department of Pediatrics

All India Institute of Medical Sciences
Ansari Nagar, New Delhi 110029

Address for correspondence:

Dr Ramesh Agarwal
Assistant Professor
Department of Pediatrics
All India Institute of Medical Sciences
Ansari Nagar, New Delhi 110029
Email: [email protected]

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 AIIMS- NICU protocols 2008

Introduction

Improving perinatal and neonatal care has led to increased survival of infants who are
at-risk for long-term morbidities such as developmental delay and visual/hearing
1, 2
problems Moreover, many of these neonates (e.g. extremely low birth weight infants)
tend to have higher incidence of growth failure and ongoing medical illnesses A proper
and appropriate follow-up program would help in early detection
of these problems thus paving way for early intervention.

Importance of follow-up care

Numerous studies have shown that despite substantial improvements in the neonatal
mortality, the incidence of chronic morbidities and adverse outcomes among survivors
has not declined much.3 This highlights the need for a follow-up care service that would
ensure systematic monitoring of the general health and neurodevelopmental outcomes
after discharge from the hospital. The monitoring would help the infants and their
families (early identification of problems and hence early rehabilitation services) as well
as the physicians involved in their care (to improve the quality of care provided and for
research purposes). There is a common perception that high risk follow-up mainly
concerns with detection and management of neurosensory disability. Infact growth
failure and ongoing illnesses are equally , if not more important issues in high risk follow-
up. Adequate emphasis must be placed on these .

However, a rigorous follow-up of all the neonates discharged from a particular health
facility would neither be practical nor feasible. Therefore, it is important to select a cohort
of neonates who are at a higher risk of developing these adverse outcomes at-risk
infants. Surprisingly, there are no standardized guidelines for follow up of high risk
infants even in tertiary care centers4. We have devised a follow up protocol which
identifies the subset of neonates to be followed up and outlines the optimal time for
follow-up visits and the appropriate assessment measures to be adopted .

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 AIIMS- NICU protocols 2008

Setting up of follow up services

High risk infants follow-up requires a multidisciplinary approach involving a team of

pediatricians, child psychologist, pediatric neurologist, ophthalmologist,
otorhinolaryngologist, physiotherapist, occupational therapist, medical social worker, and
a dietician. The respective role of each team member is summarized in Table 1.

Table 1: Personnel required for follow-up program and their individual roles

S. No Team member Role(s)

1. Pediatricians / Serves as the nodal person of the team

neonatologists
To assess growth and screen for developmental
delay
To manage intercurrent illnesses

2. Child psychologist(s) For formal neurodevelopmental assessment

Screening for behavioral problems and their
management

3. Pediatric neurologist Long-term management of neurological illnesses

such as seizures

4. Ophthalmologist Follow-up of ROP screening/treatment

Assessment of visual acuity and screening for
problems such as strabismus, nystagmus, refractory
errors, etc.

5. Otorhinolaryngologist Hearing assessment (BERA, OAE, etc.)

Management of hearing impairment, if any

6. Dietician Dietary advice regarding complementary feeding

Management of infants with failure to thrive and
those with special needs (e.g. galactosemia)

7. Medical social worker To take care of the social issues to help improve
follow up rates

8. Physiotherapist Assessment and grading of muscle tone and power

Plan an appropriate training program for each infant
with tone abnormalities
To teach the parents for continuing the prescribed
exercises at home

9. Speech / occupational Rehabilitation of infants with impairment/disability

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 AIIMS- NICU protocols 2008

therapist

Ideally, all the required personnel should be available under one roof at a place
earmarked for follow-up care. If this is not feasible, at least the services of pediatrician,
clinical psychologist, dietician, medical social worker, and physiotherapist should be
ensured in the follow-up clinic. Medical social worker is an important member of the
team liasoning with the family and helps them to keep follow up visits. Infants who need
hearing/visual assessment or speech therapy can be referred to the concerned specialist
on fixed days.

Who needs follow-up care?

Selection of high-risk infants should be based on the gestational age, birth weight,
occurrence and severity of perinatal/neonatal illnesses, interventions received in the
neonatal intensive care unit (NICU), presence of malformations, etc. It can further be
modified for each unit based on their admission and outcome profiles.

Panel 1 lists the cohort of high risk infants whom we follow-up in our unit.

Panel 1: High risk neonates who need follow-up care (customize as per policy)

1. Babies with <1800g birth weight and/or gestation <35 weeks

2. Small for date (<3rd centile) and large for date (>97th centile)
3. Perinatal asphyxia - Apgar score 3 or less at 5 min and/or hypoxic ischemic
encephalopathy
4. Mechanical ventilation for more than 24 hours
5. Metabolic problems Symptomatic hypoglycemia and hypocalcemia
6. Seizures
7. Infections meningitis and/or culture positive sepsis
8. Shock requiring inotropic/vasopressor support
9. Major morbidities such as chronic lung disease, intraventricular hemorrhage, and
periventricular leucomalacia
10. Infants born to HIV-positive mothers
11. Twin with intrauterine death of co-twin
12. Twin to twin transfusion
13. Hyperbilirubinemia > 20mg/dL or requirement of exchange transfusion
14. Rh hemolytic disease of newborn
15. Major malformations
16. Inborn
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17. Abnormal neurological examination at discharge
 AIIMS- NICU protocols 2008

The developing brain of premature babies is extremely vulnerable to injury; the risk for
neurodevelopmental deficit increases with decreasing gestational age and birth weight
resulting in relatively high risk of cerebral palsy, developmental delay, hearing and vision
impairment and subnormal academic achievement 5. Similarly, small for date infants
(birth weight < 3rd centile) are also at significant risk of poor long term outcomes. Those
who required mechanical ventilation for more than 24hours, babies with metabolic
problems symptomatic hypoglycemia as half of them have abnormal
neurodevelopmental outcome, symptomatic hypocalcemia, birth asphyxia Apgar score 3
or less at 5 min, abnormal neurological examination at discharge, seizures,
hyperbilirubinemia > 20mg/dL or requirement of exchange transfusion, Rh hemolytic
disease of newborn as they have anemia presenting till three to six months age,
infections culture positive sepsis or meningitis, babies born to HIV infected mothers,
twin with intrauterine death of co-twin due to increased incidence of cerebral venous
thromboembolic phenomenon, twin to twin transfusion or major malformation. All infants
cared for in the NICU should have periodic preventive assessment by their primary care
physicians which should include regular assessment of growth, sensory function,
behavior and neurodevelopment. Infants with suspect findings should be referred for
more comprehensive evaluation to a center with experience in follow up of high risk
neonates.

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 AIIMS- NICU protocols 2008

Pre-requisites for follow-up

To ensure proper follow-up of the high risk infants, parents (especially mother) and other
family members should be counseled even before discharge from the hospital.
Discharge should be planned well in advance so that the mother can be counseled
adequately.

Discharge planning: Discharge planning should ideally begin as soon as the baby is
admitted in the nursery. This gives adequate time for the caretakers to ask questions
and practice skills. The following criteria should be fulfilled before discharging a high risk
infant:
Hemodynamically stable; able to maintain body temperature in open crib
On full enteral feeds (either breast feeding or by paladai/spoon)
Parents confident enough to take care of the baby at home
Has crossed birth weight and showing a stable weight gain for at least three
consecutive days; in case of very low birth weight infants, weight should be at
least 1400 grams before considering for discharge.
Not on any medications (except for vitamins and iron supplementation). Ideally
preterm babies on theophylline therapy for apnea of prematurity should be off
therapy for at least five days to make sure that there is no recurrence.
Received vaccination as per schedule (based on postnatal age).

These criteria can be individualized to meet the infant and family needs.

Counseling prior to discharge: Counseling plays an important role in the care of these
babies at home; regular counseling sessions should be done before discharge. Parents
should be given advice regarding:
Temperature regulation proper clothing, cap, socks, Kangaroo mother care
etc.
Feeding type and amount of milk, method of administration, and nutritional
supplementation, if any.
Prevention of infections hand washing, avoidance of visitors, etc.
Follow-up visits where and when (Table I)
Danger signs recognition and where to report if signs are present
Vaccination schedule, next visit, etc.

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 AIIMS- NICU protocols 2008

Special needs e.g. next visits for ROP screening.

If possible the family should be provided with the telephone number of the health
care provider e.g. on-duty doctor in case the family needs to consult for infants
illness.

Procedure for follow-up

Venue: A specified site should be earmarked for follow up services. The parents should
be properly communicated about the venue and it should also be mentioned in the
discharge summary. Registration procedure at the follow-up clinic should be simplified to
avoid any undue delay. Ongoing illness is common problem among these infants. If the
infant develops any illness requiring admission, priority should be given for the same.

Record maintenance: There should be a separate but uniform file for each high risk
infant . We have separate files for male and female babies. Male babies get blue and
female babies get pink files. Addresses and telephone numbers should be entered
clearly in the file. If possible, an alternate address and telephone number should also be
recorded. It may be good idea to enquire an important landmark for locating the house in
case one needs to make a home visit. The family should also be given a booklet
containing follow-up information.

Schedule: The follow up schedule should be explained to the parents (see below).
Timings should be fixed and adhoc visits should be discouraged.

Corrected age: Age of the child since the expected date of delivery. The correction for
gestational immaturity at birth should be done till 24 months age. All developmental
milestones are assessed according to corrected age to compensate for the prematurity.
The addition of complementary feeds is also according to corrected age.

Postnatal age: Age of the child since birth. Immunization is done according to postnatal
age.

When to follow up

For the purpose of follow-up visits, at-risk infants can be grouped under two major
categories: (1) preterm/LBW infants and (2) infants with other conditions. The follow-up

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 AIIMS- NICU protocols 2008

schedule for both these categories has been summarized in Table II. This schedule
represents minimum number of visits of high risk neonates. If the baby has ongoing
issues or illness, more frequent visits are recommended. Please note that first contact of
the infant with the health providers after discharge is important and helps in identification
of adjustment problems at home. Ideally this contact should be achieved by the home
visit.

Table II: Follow-up schedule of at-risk infants

Cohort Schedule for follow-up

1. Infants with <1800g birth After 3-7 days of discharge to check if the baby has been
weight and/or gestation adjusted well in the home environment. Every 2 weeks
<35 weeks until a weight of 3 kg (immunization schedule until 10-14
weeks to be covered in these visits)
At 3, 6, 9, 12 and 18months of corrected age and then
every 6 months until age of 8years

2. All other conditions 2 weeks after discharge

At 6, 10, 14 weeks of postnatal age
At 3, 6, 9, 12 and 18months of corrected age and then
every 6 months until age of 8years
Note: If a preterm infant (< 35 weeks) develop any other morbidity covered in other conditions, he
should be followed up as per the schedule outlined for the first group of cohort

The selection of age of assessment depends on developmental acquisitions available at

a given age, availability and applicability of appropriate test instruments at specific ages
and the cost and feasibility of long-term tracking in the population in question. The long
term follow up of complete cohorts is optimal for determining the outcome of high risk
neonates and the safety of antenatal and perinatal interventions. Very low birth weight
babies or those born at less than 33 weeks gestation should be followed up for eye
check up for retinopathy of prematurity till the postnatal age of 44 weeks.

Some neurological abnormalities that are identified in the first year of life are transient or
improve whereas findings in other children may worsen over time.7 By 12 months
corrected age the cognitive and language assessment can be done. By 18-24 months
corrected age there is improved prediction to early school age performance.8, 9, 10
The
importance of long term follow up lies in the fact that minor neurological disabilities may
not be detected early and become apparent only with increasing age. Standard follow-up
for many multicenter networks is currently at 18-24 months corrected age.

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 AIIMS- NICU protocols 2008

What should be done at follow up?

Table III summarizes the plan for follow up.

Table III: Follow up plan for high risk infants

Assessment Age in months

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 AIIMS- NICU protocols 2008

Assessment of feeding and dietary 1 2 3 6 9 12 15 18 24 ......8years

counseling
Growth monitoring All visits
Immunization As per schedule (based on postnatal age)
Neurological examination
Developmental assessment and DQ
Hearing (BERA)
Ophthalmic evaluation
USG/CT brain As indicated
if previous test abnormal

1. Assessment of feeding and dietary counseling: Parents should be asked

about the infants diet and offered dietary counseling at each visit. Breast feeding
frequency and adequacy should be assessed. The amount, dilution and mode of
feeding should be noted if supplemental feeding is given. It is a good idea to
enquire about source of milk as milk supplied by local vendors is often diluted
(dilution has the same impact on the infant whether done by the family or the
vendor!). It is also important to record the duration of exclusive breast feeding. If
a baby is not gaining adequate weight on exclusive breast feeding take care of
any illness, maternal problems which may interfere with feeding and milk output.
If poor weight gain persists despite all measures to improve breast milk output,
supplementation can be considered.

Complementary feeding should be started at 6 months corrected age. Initially,

semisolids should be advised in accordance with the local cultural practices . Spend
adequate time on explaining what to give and how to give. The common practice of
giving too little or too dilute complementary food such as rice-water, dal-water, too
much of juice, etc should be discouraged. The recommended meal frequencies
assuming a diet with energy density of 0.8 kcal per gram or above and low breast
milk intake are: 23 meals per day for infants aged 68 months; 34 meals per day
for infants aged 911 months and children 1224 months; additional nutritious
snacks may be offered 12 times a day, as desired. Complementary foods should be
varied and include adequate quantities of meat, poultry, fish or eggs, as well as
vitamin A-rich fruits and vegetables every day. Where this is not possible, the use of
fortified complementary foods and vitamin mineral supplements may be necessary to
ensure adequacy of particular nutrient intakes. As infants grow, the consistency of
complementary foods should change from semisolid to solid foods and the variety of
foods offered should increase. By eight months, infants can eat finger foods and by

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 AIIMS- NICU protocols 2008

12 months, most children can eat the same types of food as the rest of the family.
The major problem with the family food is that it is not nutrient-rich11.

2. Growth monitoring: Growth (including weight, head circumference, mid-arm

circumference and length) should be monitored and plotted on an appropriate
growth chart at each visit. We use Wrights charts (till 40 weeks PMA) and WHO
growth charts (for preterm infants after 40 weeks PMA and for term infants) for
growth monitoring . The infants growth pattern (slope of the curve) is compared
with the standard curve; any deviation should be noted and appropriate remedial
action taken. Weight should be taken on an electronic weighing scale. Length
should be measured with an infantometer. The infant should be held supine and
legs fully extended. The feet should be pressed against the movable foot piece
with the ankles fixed to 90. Head circumference should be measured with
nonstretchable fiberglass tape.12

3. Developmental assessment: Assessment of developmental milestones should

be done according to the corrected age. The milestones should be assessed in
four domains- gross motor, fine motor, language, and personal-social (see page
10 with instructions for filling given in page 9 of HRC file). The date of
assessment and the infants corrected age should be mentioned against each
milestone. Based on the date of achievement of milestones in a particular
domain and the expected age of achieving them, the developmental age can be
calculated.

Infants who lag behind in any domain should undergo a formal developmental
evaluation by a clinical psychologist using tests such as Developmental assessment
of Indian Infant II (DASII II)13. This scale consists of 67 items for assessment of motor
development and 163 items for assessment of mental development. Motor scale
assesses control of gross and fine motor muscle groups. Mental scale assesses
cognitive, personal and social skills development. Both mental development index
and psychomotor development index can be calculated by DASII. The age
placement of the item at the total score rank of the scale is noted as the child
developmental age. This converts the child total scores to his motor age (MoA) and

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 AIIMS- NICU protocols 2008

mental age(MeA). The respective ages are used to calculate his motor and mental
development quotients respectively by comparing them with his chronological age
and multiplying it by 100. (DMoQ = MoA/CA x 100 and DMeQ = MeA/CA x 100).
The composite DQ is derived as an average of DMoQ and DMeQ.

The Vineland Social Maturity Scale measures social competence, self-help skills,
and adaptive behavior from infancy to adulthood. The Vineland scale consists of a
117-item interview with a parent or other primary caregiver.

It is emphasized here that developmental stimulation of the child should not be

delayed if the above mentioned tests are not available. Age appropriate
stimulation should be provided to these babies. Mental development index and
Psychomotor development index at 3, 12,18 and 24 months and every 3 months
if abnormal.

4. Immunization: Immunization should be ensured according to chronological age

. Parents should be offered the option of using additional vaccines such as
Hemophilus influenzae B, typhoid and MMR.

5. Ongoing problems: They should be mentioned in the follow up notes . The

management of ongoing illnesses is an integral part of any high risk follow up
program. The hospital admission of the child should be prioritized, if required.

6. Neurological assessment: Evaluation of muscle tone is an integral part of the

neurological examination. A waxing and waning pattern of neuromotor
development from 28 weeks of gestation to the end of first year of life was
reported by Amiel-Tison. From 28 to 40 weeks gestation, the acquisition of
muscle tone and motor function spreads from lower extremities towards the
head. After full term, the process is reversed so that relaxation and the motor
control proceed downwards for the next 12 to 18 months. So the upper limbs
begin to relax and acquire skills before the lower limbs. The axial tone follows a
similar pattern. Head control appears first followed by the ability to sit, stand and
walk. Hypertonia or hypotonia should be looked for by measuring the following
angles: adductor angle, popliteal angle, ankle dorsiflexion, and scarf sign; any

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 AIIMS- NICU protocols 2008

asymmetry between the extremities should also be recorded. Any history of

seizures or involuntary movements should also be recorded.

Hypertonia in lower limbs is defined as when either adductor angle is restricted to

less than the age specific norms as per Amiel-Tison or if there is scissoring or tight
tendo-achilles or restriction of ankle dorsiflexion on extension of knee. Hypertonia in
upper limbs is defined as when scarf sign does not cross midline at one year
corrected age. Hypertonia of the neck extensors can be inferred by an increased gap
between the nape of the neck and examination table with the infant lying in supine
position.

The following angles should be measured to assess tone as shown in Figure1,

Table IV:

Table IV: Muscle Tone Norms

Age Adductor Popliteal Dorsiflexion Scarf sign

(months) angle angle angle

0-3 40 -80 80 -100 60 -70 Elbow does not cross

midline
4-6 70 -110 90 -120 60 -70 Elbow crosses midline
7-9 110 -140 110 -160 60 -70 Elbow goes beyond

axillary line
10-12 140 -160 150 -170 60 -70
Truncal extensor hypertonia: there is a tendency of body to go into
hyperextension or opisthotonus.

Cerebral palsy: Definitely abnormal neurological examination with upper motor

neuron signs with motor developmental delay.

Spastic hypertonia syndromes:

Hemiplegia- only one half of body involved

Diplegia- paresis of lower limbs more than upper limbs

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 AIIMS- NICU protocols 2008

Quadriplegia- Paresis of all four limbs with upper limb involvement equal to or
more than lower limbs.

Abnormal neurological examination should be defined as definite abnormalities In

the form of:

a) Brisk reflexes with hypertonia or

b) Brisk reflexes with hypotonia or

c) Definitely and consistently elicited asymmetrical signs or

d) Persistent abnormal posturing or abnormal movements

The tone abnormalities should be taken care by regular physiotherapy. This

improves mobility of joints and locomotion of the child. The child should be
provided with special shoes if required. Orthopedic evaluation should be done
and corrective surgery for contractures should be done as required. All possible
efforts should be made to improve mobility of these children and make them
functionally less dependent and independent if possible.

Eye evaluation: The check-up for retinopathy of prematurity starts in the NICU and
continues till 44 weeks postconceptional age or till the retinal vessels have matured.
Refer to protocol on Retinopathy of prematurity14 .

At 9 months corrected age the ophthalmologist should evaluate the baby for vision,
squint, cataract and optic atrophy. Subjective visual assessment can be made from
clinical clues as inability to fixate eyes, roving eye movements and nystagmus.
Objective visual assessment should be done with the Teller Acuity Card. It has
seventeen 25.5 51 cm cards. Fifteen of these contain 12.5 12.5 cm patches of
square-wave gratings( vertical black and white strips) ranging in spatial frequency
from 38.0 cycles/cm to 0.32 cycles/cm. The range is in half octave steps. A cycle
consists of one black and one white stripe and an octave is a halving or doubling of
spatial frequency. In Snellens terms it is an halving or doubling of the denominator
e.g. 6/6, 612, 6/24. Half octave steps would be 6/6, 6/9, 6/12, 6/18, 6/24 and so on.

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 AIIMS- NICU protocols 2008

There is a low vision card containing 25.5 23 cm patch of 0.23 cm cycle/cm( 2.2
cm wide black or white stripes). The seventeenth card is a blank grey card with no
grating pattern. The gratings have 82 84% contrast and are matched to the
surrounding grey card to within 1% in space average luminance. This minimizes the
chance of a patient fixating because of brightness difference. Detection of pattern
alone determines the fixating preference. Proper illumination without any shadows
should be ensured (10 candelas /sqm). Testing distance from patients eyes to the
cards should be maintained constant as it determines the visual acuity. Children from
7m to 3y should be tested at 55 cm and later at 84 cm.

Rehabilitation for visual impairment should be early so that the child gets appropriate
stimulation. If delayed the restoration of the vision may not be possible because of
continuous sensory deprivation of the optic nerve. The child should be provided with
glasses or corrective surgery as appropriate. It should be emphasized that a good
high risk follow up program does not only pick up handicaps early but also ensures
early corrective measures and rehabilitation. This emphasizes the multidisciplinary
and well coordinated approach to such babies

7. Hearing evaluation: High risk infants have higher incidence of moderate to

profound hearing loss (2.5-5% vs. 1%). Since clinical screening is often
unreliable, brainstem auditory evoked responses (BAER/BERA) should be
performed between 40 weeks PMA and 3 months postnatal age. A screening
BERA is usually done initially. If this is abnormal, a diagnostic BERA should be
done within 2 weeks of the initial test. Infants with unilateral abnormal results
should have follow-up testing within three months. The test should be carried out
in a sound-proof room and the infant should be sedated with oral triclofos
50mg/kg 30 min before the procedure. To measure the electrical pulses, small
monitoring electrodes are placed on the scalp. Earphones provide a clicking
noise to the ear and the response from the brainstem is measured time-locked to
the clicks. The clicks may become louder or softer, faster or slower, to see how
the auditory responds to these different stimulus parameters. The other method
of assessment for hearing is oto-acoustic emission (OAE). This records acoustic
feedback from the cochlea through the ossicles to the tympanic membrane and
ear canal following a click stimulus. It is quicker to perform than BERA but is
more likely to be affected by debris or fluid in the external and middle ear. It is

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 AIIMS- NICU protocols 2008

unable to detect some form of sensorineural hearing loss including auditory

dyssynchrony.

The severity of hearing loss is profound (70 dB or more of hearing loss), severe (50
dB - 70 dB), moderate (30 dB - 50 dB) and mild (15 dB - 30 dB).

The audiological testing should be done at 3 months of age. Infants with true hearing
loss should be referred for early intervention to enhance the childs acquisition of
developmentally appropriate language skills. The child should be provided with
hearing aids and if severe to profound hearing loss cochlear implants should be
considered by 12 months age. Fitting of hearing aids by the age of 6 months has
been associated with improved speech outcome. Initiation of early intervention
services before three months age has been associated with improved cognitive
development at 3years age15

Early stimulation
The high risk baby requires more attention of the family members. Parents and
family members need to aid the development process in an age appropriate way
spending quality time with children. Such interactions improve parent child
relationship and bring about positive parental attitudinal change. Effective
parents supervise their children in an age appropriate way, use consistent
positive discipline, communicate clearly and supportively, and show warmth,
affection, encouragement, and approval. The actions of the child should be
appreciated. This makes him happy and encourages doing more activities.

0-2 months:
Activities
Maintain eye to eye contact
Talk and sing to the baby while bathing, dressing and feeding
Help the baby to turn his head to sound and light
Auditory

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 AIIMS- NICU protocols 2008

Provide different sounds to the child like rattle, bell, squeezing a toy.
Make the child listen to music, high pitched and low pitched human
sounds
Humming in a soft low voice
Visual
Keep the baby in a well lighted room
Shine mobile, color balls and hang bright clothes
Tactile
Put the baby on different surfaces like soft clothes, mattresses, rubber mat
and mothers lap
Change the childs position frequently like putting on his back, sides and
tummy
Kinesthetic
Support the head and gently rock the child avoiding sudden jerky
movements
2-4 months
General stimulation
Hold the baby at the shoulder
Place things just out of the reach of the baby. Stimulate him to reach out
and grasp the object
Auditory
Give sound producing toys
Talk to the child more frequently
Point out the names of objects shown to the child
Visual
Hang bright objects about 30cm above the crib
Maintain eye contact while talking to the child
Tactile
Give the child paper to crumble and things to bite and suck
Place the child on a rubber mat on the ground allowing him to move freely

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 AIIMS- NICU protocols 2008

4-6 months:
General activities:
Sit the baby in the mothers lap and ask her to gently bounce her knees
singing songs.
Place the child flat on the back on the ground over a soft surface. Show
him a colorful toy. Slowly turn him by flexing the far away leg. Assist him to
turn over the tummy.
Show an attractive toy and encourage the child to reach out to it.
Put your hands under the childs feet and move his legs up and down like
pedaling a cycle.
Auditory
Shake a bell or a squeaky toy over the head of the baby. Encourage him
to turn his head and locate the sound
6-8 months:
Call the child by his name
Make the child sit as long as possible. Give support to his pelvis.
Give him pieces of paper to tear
Encourage him to roll over his tummy by showing him colorful toys on one
side.
8-10 months:
Make the child stand by holding onto the furniture
Encourage the child to clap hands
Give him a small container and ask to drop small thing into it.
Encourage him to produce monosyllables.
Show him picture books and assist to turn the pages.
10-12 months:
Let the child play with other children
Name the body parts while bathing him
Take the child on a walk and show him different animals and birds

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 AIIMS- NICU protocols 2008

Do simple actions like clapping, bye-bye and encourage copying these

actions.
Encourage him to pull to stand by holding the furniture
Make the child sit in front of a mirror so that he can see himself
12-15 months:
Give picture books to the child. Talk about what you see and let him turn
the pages
Ask him to put cubes one over the other
Ask him to put things into the container and then take out things out of the
container.
Hide a small toy under a cloth. Encourage the baby to find the hidden toy.
Ask the child to scribble by drawing a few lines. First demonstrate what he
is supposed to do.

How to ensure a good follow up rate

The importance of follow up should be emphasized frequently to the parents. The

permanent and present addresses along with phone numbers should be kept to ensure
follow up. If the parents do not turn up for follow up they should be telephoned and
letters should be posted to ensure good follow up rates. There should be a dedicated
person who can adjust the timing with the parents. If possible home visits should be
arranged for those who do not turn up. There should be a comprehensive assessment of
the child under one roof to minimize the hassles of roaming from one corner of the
hospital to the other.

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 AIIMS- NICU protocols 2008

References

1. Narayan S, Aggarwal R, Upadhyay A, Deorari AK, Singh M, Paul VK. Survival and morbidity in
Extremely Low Birth Weight (ELBW) infants. Indian Pediatr 2003; 40: 130-135.

2. Costello D, Friedman H, Minich N, Siner B, Taylor G, Schuchlter M, Hack M. Improved

neurodevelopmental outcomes for extremely low birth weight infants in 2000-2002. Pediatrics 2007;
119: 37-45.

3. Escobar G, Littenberg B, Petitti DB Outcome among surviving very low birthweight infants: a meta-
analysis. Arch Dis Child Feb1991; 66: 204 - 211.

4. Wang CJ, McGlynn EA, Brook RH, et al. Quality-of-care indicators for the neuro-developmental follow-
up of very low birth weight children: results of an expert panel process. Pediatrics. 2006; 117(6):2080
2092.

5. Vohr BR, Wright L, Anna M, Perritt R, Poole WK, Tyson JE, et al. Center for the Neonatal Research
Network Center differences and outcomes of exteremely low birth weight infants. Pediatrics
2004:113:781-789.

6. Chaudhari S, Bhalerao M, Chitale A, Pandit A, Nene U. Pune Low Birth Weight Study - A Six Year
Follow Up. Indian Pediatr1999; 36:669-676.

7. Drillien C. Abnormal neurological signs in the first year of life in low birth weight infants: possible
prognostic significance. Dev Med Child Neurol 1997; 14:575-84.

8. Weisglas-Kuperus N, Baerts W, Smrkovsky M, Sauer PJ. Effects of biological and social factors on the
cognitive development of very low birth weight children. Pediatrics.1993; 92:658 665.

9. Dezoete JA, MacArthur BA, Tuck B. Prediction of Bayley and Stanford-Binet scores with a group of very
low birthweight children. Child Care Health Dev.2003; 29:367 372.

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 AIIMS- NICU protocols 2008

10. Lee H, Barratt MS. Cognitive development of preterm low birth weight children at 5 to 8 years old. J Dev
Behav Pediatr.1993; 14:242 249.

11. Report of the global consultation, and summary of guiding principles for complementary feeding of the
breastfed child Authors: World Health Organization

12. Implementation of the WHO Multicenter Growth Reference Study in India N. Bhandari, S. Taneja, T.
Rongsen, J. Chetia, P. Sharma, R. Bahl, D. K. Kashyap, and M. K. Bhan, for the WHO Multicenter
Growth Reference Study Group

13. Phatak B. Mental and motor growth of Indian babies (1-30 months). Final report. Department of Child

Development, MSUB, Baroda, 1970.

14. Chawla D, Agarwal R., Deorari AK, Paul VK. Retinopathy of Prematurity. Indian Journal of Pediatrics
2008;75(1):73-76

15. NIH Joint Committee on Infant Hearing. Year 2000 position statement: Principles and guidelines for
early hearing detection and intervention programmes. Pediatrics 2000; 106:798-817.

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 AIIMS- NICU protocols 2008

Adductor
Scarf sign angle

Dorsiflexion Popliteal
angle angle

Figure1:Amiel-Tison method of assessment of tone in infants

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 Retinopathy of Prematurity (ROP)

Retinopathy of prematurity (ROP) is a vaso-proliferative disorder of the retina among preterm

infants. Normally, neonates born at less than 32 weeks of gestationare at risk of developing ROP.
However preterm infants born at 32 weeks or later can also develop severe ROP if they had
turbulent NICU course or required prolonged oxygen therapy. About one-fourth of neonates
undergoing screening may show evidence of ROP.While it regresses on its own in majority of
affected infants, it progresses to the stage of retinal detachment and blindness in a relatively smaller
percentage of infants. Timely screening and treatment of ROP can prevent blindness and minimize
vision abnormalities.

What is evidence?
Studies from India have reported ROP in 20% to 52% of screened neonates.1-9 More recent
studies reporting lower rates of ROP ranging from 20% to 30%.1,2

Classification of ROP
International Classification of ROP (ICROP) is used for classifying ROP.15 ICROP describes
vascularization of the retina and characterizes ROP by its position (zone), severity (stage), and extent
(clock hours) (Figure 1 in Appendix and Table 1).

Table 1: Classification of ROP (ICROP)15

Location Zone 1 Circle with optic nerve at its centre and a radius of twice the distance from
optic nerve to macula
Zone 2 Concentric circle from edge of zone 1 to ora serrata nasally and equator
temporally
Zone 3 Lateral crescent from zone 2 to ora serrata temporally

Severity Stage 1 Presence of thin white demarcation line separating vascular from
avascular retina
Stage 2 Addition of depth and width to the demarcation line of stage 1, so as the
line becomes ridge
Stage 3 Presence of extra retinal fibrovascular proliferation with abnormal vessels
and fibrous tissue extending from ridge to vitreous
Stage 4 Partial retinal detachment not involving macula (4A) and involving macula
(4B)
Stage 5 Complete retinal detachment

Plus disease Presence of dilatation and tortuosity of retinal vessels at posterior pole of
eye. Also associated with papillary rigidity and vitreous haze.
Extent Extent of ROP described in 300 clock hours ( a total of 12 clock hours of 300
each)

Aggressive posterior ROP (AP-ROP):A rapidly progressing, severe form of ROP, if untreated, itusually
progresses rapidly to stage 5 ROP. The characteristic features of this type of ROP include its
posteriorlocation, prominence of plus disease, and the ill-defined nature of the retinopathy. This
may not have classical ridge or extraretinal fibrovascular proliferation, but rather have innocuous
looking retina and vessels forming arcades. This type of ROP is likely to get missed by inexperienced
examiners. Observed most commonly in Zone I, it may also occur in posterior Zone II.
Protocol for screening
The aim of the screening program is to detect ROP early, follow it up closely during its evolution, and
treat if it assumes potentially serious severity level.

Which infants should be screened?

Selecting neonates for screening depends on risk of ROP at different gestation. Gestation and birth
weight cut-off for screening shifts lower as the quality of care improves. Based on current incidence
and risk factors reported in Indian literature following group of neonates should be screened.

1. Babies with birth weight <1500 g

2. Babies born at <32 weeks of gestation

3. Selected preterm infants with a birth weight between 1500 and 2000 g or gestation of more
than 32 weeks with sickness like need of cardio-respiratory support, prolonged oxygen
therapy, repeated episodes of apnea of prematurity, anemia needing blood transfusion and
neonatal sepsisorbelieved by their attending pediatrician or neonatologist to be at high
risk.This third criterion is important as it brings in many more larger babies into the
screening guidelines ambit without raising the screening parameters.19

other risk factors of developing ROP include anemia, blood transfusion, sepsis, apnea,
hypotension and poor weight gain. In general, other risk factors are surrogate markers of
sickness in the baby. Therefore, sicker the baby higher is the risk.

When and how often to screen

First screening examination should be carried out at 32 weeks of post menstrual age (PMA) or 4
weeks of postnatal age, whichever is later.20

Practice tip:A good rule to remember is to perform first screening at 4 weeks of PMA.

What is evidence?

Progression of ROP follows a distinct timeline as per PMA rather than postnatal age (PNA) of the
infant. Hardly any ROP is detected before 32 weeks of PMA. However, ROP usually does not
develop before 3 weeks of PNA.

The median age at detection of stage 1 ROP is 34 weeks. Threshold ROP appears at 34 to 38
weeks. Vascularization is complete by 44 weeks of gestation. Therefore critical phase during
screening is 34to 38 weeks when the infant is likely to reach the threshold stage of disease and
may require treatment for prevention of blindness.
Follow-up examinations are normally required every one to two weeks depending upon ROP staging,
andshould be recommended by the examining ophthalmologist.

ROP screening can be terminated once there is complete vascularization of retina without any ROP,
or if the ROP has shown regression. This normally happens at around 40 to 44 weeks of PMA.

Where to examine the baby?

Neonates are best examined in the neonatal unit itself under supervision of attending
pediatrician/neonatologist. It is not wise to transport small babies to ophthalmic outpatient or ward
for examination.

How to dilate the pupils?

Pupils are dilated with phenylephrine 2.5% and tropicamide 0.5% to 1%. One drop of tropicamide is
instilled every 10-15 minutes up to 4 times starting 1 hour before the scheduled time for
examination. This is followed by phenylephrine, just one drop before examination. Phenylephrine is
available in 10% concentration; it should be diluted 4 times before use in neonates. Repeated
instillation of phenylephrine is avoided for the fear of hypertension.

Practice tip: If pupils are not dilating despite administration of mydriatic drops, aggressive-
posterior ROP should be suspected.

What does the examination entail?

Screening of ROP involves indirect ophthalmoscopy (IO) using 20D or 28/30 D lens by an experienced
ophthalmologist. After instilling a topical anesthetic drop like proparacaine, a wire speculum is
inserted to keep the eye-lids apart.First the anterior segment of the eye is examined to look for
tunica vasculosa lentis, pupillary dilation, and lens / media clarity followed by the posterior pole to
look for plus disease, followed by sequential examination of all clock hours of the peripheral retina.
A sclera depressor is often used to indent the eye externally to examine areas of interest, rotate and
stabilize the eye.

How to record findings during screening?

Ophthalmological notes should be made after each ROP examination, detailing zone, stage and
extent in terms of clock hours of any ROP and the presence of any pre-plus or plus disease. These
notesshould include a recommendation for the timing of the next examination (if any) and be kept
with the babys medical record (Figure 1 in Appendix).

What precautions are taken during examination?

ROP screening examination can have short-term effects on blood pressure, heart rate and
respiratory function in the premature baby.14The examinationshould be kept as brief as possible and
precaution is taken to ensure that emergency situations can be dealt with promptly and
effectively.Discomfort to the baby should be minimized by administering oral sucrose just before
examination, pretreatment of the eyes with a topical proparacaine and swaddling the baby. Baby
should not be fed just before examination to avoid vomiting and aspiration. Hand hygiene should be
practiced to maintain asepsis.
 What is evidence?

A systematic review and meta-analysis comprising four studies has reported that oral sucrose
reduces pain during eye examination.14 Of two studies reporting the role of topical proparacaine
drops has observed significant pain reduction.

Use of wide-field digital camera (RetCam) for screening

A wide-field digital camera (RetCam) capable of retinal imaging in preterm infants has been
evaluated as an alternative to IO for screening. Retinal images taken by camera can be stored,
transmitted to expert, reviewed, analyzed and sequentially compared over time and are useful for
telemedicine purposes.However, due to high cost and limitations in diagnostic accuracy particularly
with poor image quality, RetCam cannot replace IO in current scenario.Digital fundus images
acquired by RetCamcan serve as a useful adjunct to conventional bedside ROP screening by IO.

What is evidence?
Studies comparing RetCam with indirect ophthalmoscopy (IO)have reported variable sensitivity
but good specificity.13

Treatment
The treatment involves ablation of peripheralnormal avascular retina and thereby abolishing hypoxic
drive of retina (mediated by over-expression of vascular endothelial growth factor; VEGF). This
results in regression of established ROP. Care is taken not to touch the retina with ROP as it would
result in severe bleeding.

Indication for peripheral retinal ablation:

Treatment of ROP is based on differentiation of following two types of ROP:

Type 1 ROP:
Zone I, any stage ROP with plus disease
Zone I, stage 3 ROP without plus disease
Zone II, stage 2 or 3 ROP with plus disease

Type 2 ROP:
Zone I, stage 1 or 2 ROP without plus disease
Zone II, stage 3 ROP without plus disease

Peripheral retinal ablation should be carried out for all cases with type 1 ROP and continued serial
examinations are advised for type 2 ROP.

What is evidence?
Classification of ROP into type 1 and 2 is based on results of Early Treatment for Retinopathy of
Prematurity Randomized Trial (ETROP).12Before ETROP study laser ablation was performed in
neonates with threshold ROP, a classification based on location and stage of ROP.

ETROP study demonstrated improved visual outcome if laser ablation is performed in eyes with
high-risk pre-threshold ROP. Type 1 ROP includes threshold ROP and subset of pre-threshold
ROP likely to benefit from early treatment.
 Treatment modalities
Peripheral retinal ablation is carried out either by cryotherapy or by diode laser. Diode laser ablation
has largely replaced cryotherapy as it is associated with a lower rate of postoperative ocular and
systemic complications and lesser damageto the adjacent tissues. Additionally, laser spots on
retina are visible during the procedure minimizing the skip areas requiring re-treatment. The
procedure can be carried out under general anesthesia or under sedation depending on the
feasibility and expertise.

What is evidence?
In a Cochrane systematic review peripheral retinal ablation as compared to no treatment was
associated with improved structural and functional outcome in treated eyes. 11 Due to ablation
of peripheral avascular retina, visual fields were reduced in treated eyes.

Pre-anesthetic preparation
Oral feeds should be discontinued 3 hours prior to the procedure (Table 2). Baby should be
started on intravenous fluids, and put on cardio-respiratory monitor. Dilatation of pupil is ensured
(as described earlier).

Anesthesia/ sedation
Topical anaesthesia alone provides insufficient analgesia for ROPtreatment and should not be solely
relied upon. Ideally, babies should be treated under general anesthesia or under opiod sedationin an
operation theatre. If shifting to operation theatre is not possible or is causing delay in treatment,
babies may be treated more rapidly in the neonatal unit under adequate sedation and analgesia.

Procedure
Both the eyes can be treated at the same sitting unless contraindicated by instability of the baby. If
baby is not tolerating the procedure, consider abandoning the procedure for the time being. Vital
signs and oxygen saturation should be monitored very closely.

Monitoring after laser therapy

After laser therapy first examination should take place 5-7 days aftertreatment and should be
continued at least weekly for signs of decreasingactivity and regression. Re-treatment should be
performed usually 10 to 4 days after initialtreatment when there has been a failure of the ROP to
regress.

Post-operative care
The baby should be closely monitored. If condition permits, oral feeds can be started shortly
after the procedure.

Premature babies, especially those with chronic lung disease may have increase or re-
appearance of apneic episodes or an increase in oxygen requirement. Therefore they should be
carefully monitored for 48-72 hours after the procedure.

Antibiotic drops (such as chloramphenicol) should be instilled 6-8 hourly for 2-3 days.

Bevacizumab
Intravitreal injection of bevacizumab, a neutralizing anti-VEGF moleculehas been demonstrated to
diminish the neovascularresponse significantly in animal models and human studies.As VEGF is an
important mediator of lung growth and brain development, and there is significant systemic absorption
of anti VEGF mediation after intravitreal injection, there are concerns regarding toxicity of such therapy.
Due to lack of data on potentially serious systemic adverse effects administration of intravitreal
bevacizumab (anti-VEGF monoclonal antibody) is not routinely recommended in neonates with ROP.
It may be used only when laser photocoagulation fails and after taking informed consent from the
parents.

What is evidence?
A multicentre RCT showed that intravitreal injection of bevacizumab is superior to conventional laser
therapyin infants with treatable ROP (stage 3+) in zone I but not in zone II.16Additional advantage of
bevacizumab was that retinal vessels continued to grow as opposed to permanent destruction of the
same with laser therapy.17,18The trial was not large enough to rule out potential serious side effects of
this treatment modality.
Table 2 : Preparation for laser ablative therapy
Take consent
Ensure good pupillary dilatation
Nil by mouth 3 h prior to procedure
Start on intravenous fluids
Put on vital sign monitor/pulse oximeter
Warmer for maintaining temperature
Arrange equipment and check functioning thereof
o Endotracheal tubes No. 2.5, 3, 3.5
o Resuscitation bag & face masks
o Oxygen delivery system
o Syringes, infusion pumps, ventilator

Prevention
Prenatal steroids
Use of prenatal steroids is a well-known approach to prevent respiratory distress and
intraventricular hemorrhage, two important risk factors of ROP. Though prenatal steroids have not
reduced occurrence of ROP, perhaps because it saves smaller babies who are at higher risk of
developing ROP, but, as it reduces sickness level in preterm infants, prenatal steroids are likely to
reduce severe ROP.

Judicious oxygen therapy

Oxygen is a drug and it should be used judiciously. Each neonatal unit should have a written policy
regarding when and how to use oxygen and target saturations.

If a preterm neonate <32 weeks gestation needs resuscitation at birth, inhaled oxygen concentration
(FiO2) should be titrated to prevent hyperoxia and achieve gradual increase in oxygen saturation
(70% at 3 minute and 80% at 5 minute after birth).21 During acute care of a sick preterm neonate,
ROP is more likely to develop if partial pressure of oxygen in arterial blood is more than 80 mm Hg.

Oxygen level in blood should be continuously monitored using pulse oximetry keeping a saturation
target of 90% to 93%, with limits set at 88% and 95%. It has been observed that if oxygen saturation
in a baby on oxygen therapy is kept between 85% and 93%, in about 90% samples partial pressure of
oxygen is in desirable range (40 to 80 mm Hg).It is important that a work culture is inculcated
wherein physicians and nurses respond to monitor alarms.

What is evidence?
A large scale RCT (SUPPORT trial) indicated that maintaining low saturations (85% to 89%)
compared to high saturations (91% to 95%) in preterm infants<28 week did not reduce
composite outcome of death or severe ROP but it resulted in lower severe ROP and higher
death rates.10

Therefore it is recommended that saturations in preterm neonates be maintained between 90%

and 95%. Saturations should be monitored in preterm infants receiving oxygen therapy to
prevent hyperoxia or hypoxia.

Judicious use of blood transfusions

Transfusion of packed RBCs is another risk factor of ROP. Adult RBCs are rich in 2,3 DPG and adult
Hb binds less firmly to oxygen, thus releasing more oxygen to the retinal tissue. Packed cell
transfusions should be given when hematocrit falls below following ranges:
Ventilated infants: 40%
Infants with cardio-pulmonary disease but not on ventilators: 35%
Sick infantsbut no cardiopulmonary instability: 30%,
Symptomatic anemia (tachycardia >180/minute or respiratory rate > 60 for 24hour,
doubling of the oxygen requirement in last 48 hours, lactate > 2.5 mEq/L or acute metabolic
acidosis with pH <7.20 or weight gain less than 10 grams/kg/day over 4 days while receiving
120 kcal/kg/day): 25%
Asymptomatic anemia: 20%.

Other interventions
Supplementation of high doses of Vitamin E or reduced ambient light exposure is not associated
with reduced incidence of ROP. In neonates with early stages of ROP administrationof
supplementation oxygen to achieve oxygen saturation in supra-physiological range and toreduce
retinal hypoxia is not associated with halt in progressionof ROP.

Quality improvement

Protocolized approach

All units caring for babies at risk of ROP should have a written protocol in relation to the
screening for, and treatment of, ROP. This should include responsibilities for follow-up of
babies transferred or discharged from the unit before screening is complete.

If babies are transferred either before ROP screening is initiated or when it has been started
but not completed, it is the responsibility of the consultant neonatologist to ensure that the
neonatal team in the receiving unit is aware of the need to start or continue ROP screening.

Whenever possible ROP screening should be completed prior to discharge. There should be
a record of all babies who require review and the arrangements for their follow-up.

For babies discharged home before screening is complete, the first followup out-patient
appointment must be made before hospital discharge and the importance of attendance
explained to the parents.

Auditing
Following outcomes should be regularly audited in units with ROP screening and
treatment programme.

Completeness of screening program: Percentage of eligible babies who receive at

least one ROP eye examination

Timing of first screen:Percentage of eligible babies receiving first ROP

screeningexam by 4 weeks of postnatal age.

Timing of treatment: Percentage of babies needing ROP treatment for their ROP who
are treated within 48 hours of the decision totreat being made
Research issues: Research issues relevant to Indian context are outlined in Table 3.
Research Subjects Study design Interventio Outcomes to be
question n measured
1. What Neonates Cohort study Nil Visual acuity,
isvisual eligible for visual field,
outcome screening refractive errors
of of ROP and and anatomical
neonate a) Sponta abnormalities in
s with neous retina (foveal
ROP? regress thickness, retinal
ion of folds etc.), color
ROP vision
b) ROP
needin
g laser
ablatio
n
c) No
ROP
2. What Neonates Cohort study Nil Risk ratios for
are eligible for with possible factors
factors screening enrolment at like intrauterine
determi of ROP and initiation of growth status,,
ning a) Sponta screening antenatal steroid
spontan neous exposure,
eous regress OR postnatal
regressi ion of nutrition
on of ROP Case control (macro/micro
ROP? b) ROP study with nutrient intake,
needin regressed or weight gain),
g laser treated ROP sepsis, respiratory
ablatio support
n
3. What is Neonates Cohort study Nil Association
role of eligible for with between ROP
genetic screening enrolment at outcome and
factors of ROP and initiation of putative genetic
in a) Sponta screening factors like VEGF
epidemi neous polymorphism
ology of regress OR
ROP? ion of
ROP Case control
b) ROP study with
needin regressed or
g laser treated ROP
ablatio or No ROP
n
c) No
ROP
4. Which All Before and Quality Incidence of ROP
measure neonates after improveme and its subtypes
s can eligible for intervention nt measures
reduce screening study delivered
incidenc of ROP individually
e of ROP or
in a combined
 particula e.g.
r unit? education
of health
care
providers,
oxygen
saturation
monitoring,
ROP
screening
protocols
5. How to All Randomized Possible Pain measured by
reduce neonates controlled interventio validated pain
pain eligible for trial ns include scores e.g.
experien screening topical Premature infant
ced by of ROP anesthetic pain profile
neonate drops in
s during combinatio
screenin n with oral
g for sucrose,
ROP? swaddling
or other
pharmacolo
gical/non-
pharmacolo
gical
measures
6. What Neonates Randomized Laser Visual acuity,
are long- with ROP controlled ablation visual field,
term and trial versus refractive errors
outcome a) Laser intravitreal and anatomical
s in ablatio OR bevacizuma abnormalities in
neonate n b retina (foveal
s who OR National/regio thickness, retinal
receive b) Bevaci nal registry folds etc.), color
bevacizu zumab Nil vision
mab for
treatme
nt of
ROP
Appendix

Figure 1: Classification of retinopathy of prematurity

References
1. Kumar P, Sankar MJ, Deorari A, et al. Risk factors for severe retinopathy of prematurity in
preterm low birth weight neonates. Indian J Pediatr 2011;78:812-6.
2. Aggarwal R, Deorari AK, Azad RV, et al. Changing profile of retinopathy of prematurity. J Trop
Pediatr 2002;48:239-42.
3. Maheshwari R, Kumar H, Paul VK, Singh M, Deorari AK, Tiwari HK. Incidence and risk factors
of retinopathy of prematurity in a tertiary care newborn unit in New Delhi. Natl Med J India
1996;9:211-4.
4. Narayan S, Aggarwal R, Upadhyay A, Deorari AK, Singh M, Paul VK. Survival and morbidity in
extremely low birth weight (ELBW) infants. Indian Pediatr 2003;40:130-5.
5. Charan R, Dogra MR, Gupta A, Narang A. The incidence of retinopathy of prematurity in a
neonatal care unit. Indian J Ophthalmol 1995;43:123-6.
6. Dutta S, Narang S, Narang A, Dogra M, Gupta A. Risk factors of threshold retinopathy of
prematurity. Indian Pediatr 2004;41:665-71.
7. Vinekar A, Dogra MR, Sangtam T, Narang A, Gupta A. Retinopathy of prematurity in Asian
Indian babies weighing greater than 1250 grams at birth: ten year data from a tertiary care center in
a developing country. Indian J Ophthalmol 2007;55:331-6.
8. Rekha S, Battu RR. Retinopathy of prematurity: incidence and risk factors. Indian Pediatr
1996;33:999-1003.
9. Gopal L, Sharma T, Ramachandran S, Shanmugasundaram R, Asha V. Retinopathy of
prematurity: a study. Indian J Ophthalmol 1995;43:59-61.
10. Carlo WA, Finer NN, Walsh MC, et al. Target ranges of oxygen saturation in extremely
preterm infants. N Engl J Med 2010;362:1959-69.
11. Andersen CC, Phelps DL. Peripheral retinal ablation for threshold retinopathy of prematurity
in preterm infants. Cochrane Database Syst Rev 2000:CD001693.
12. Good WV. Final results of the Early Treatment for Retinopathy of Prematurity (ETROP)
randomized trial. Trans Am Ophthalmol Soc 2004;102:233-48; discussion 48-50.
13. Kemper AR, Wallace DK, Quinn GE. Systematic review of digital imaging screening strategies
for retinopathy of prematurity. Pediatrics 2008;122:825-30.
14. Sun X, Lemyre B, Barrowman N, O'Connor M. Pain management during eye examinations for
retinopathy of prematurity in preterm infants: a systematic review. Acta Paediatr 2010;99:329-34.
15. The International Classification of Retinopathy of Prematurity revisited. Arch Ophthalmol
2005;123:991-9.
16. Mintz-Hittner HA, Kennedy KA, Chuang AZ. Efficacy of intravitreal bevacizumab for stage 3+
retinopathy of prematurity. N Engl J Med 2011;364:603-15.
17. Good WV, Palmer EA. Bevacizumab for retinopathy of prematurity. N Engl J Med
2011;364:2359; author reply 61-2.
18. Gilbert CE, Zin A, Darlow B. Bevacizumab for retinopathy of prematurity. N Engl J Med
2011;364:2359-60; author reply 61-2.
19. Adhikari S, Badhu BP, Bhatta NK, Rajbhandari RS, Kalakheti BK. Retinopathy of prematurity in
a tertiary care hospital in eastern Nepal. JNMA J Nepal Med Assoc 2008;47:24-7.
20. Screening examination of premature infants for retinopathy of prematurity. Pediatrics
2006;117:572-6.
21. York JR, Landers S, Kirby RS, Arbogast PG, Penn JS. Arterial oxygen fluctuation and
retinopathy of prematurity in very-low-birth-weight infants. J Perinatol 2004;24:82-7.
 ACUTE RENAL FAILURE IN NEONATES
Acute renal failure (ARF) is a frequent clinical condition in sick neonates. There is a wide
variation in the incidence of ARF across studies. It affects approximately 1% to 24% of newborns
in the NICU.1,2 In a recent report from a tertiary centre of Thailand, the prevalence of ARF
among newborns was found to be 6.3%, with more than 65% developing within 7 days of birth.3
ARF is an acute reduction in glomerular filtration rate (GFR) with both failure to remove solutes
and water leading to concurrent net solute and water retention oligo-anuric renal failure. 2

Classification
Based on the urine output, it can be of two types:
1. Oligoanuric 2. Non-oliguric
Practical tip
Normal urine output can be found in up to one third neonates with ARF. Conversely, anuria
can also occur in syndrome of inappropriate ADH secretion in the absence of ARF.

Based on the site of origin of insult it can be of types: 4

1. Prerenal (75- 80%)
2. Intrinsic renal (10-15%)
3. Postrenal (5%)

Persistence of insult can convert pre renal or post renal failure to intrinsic renal failure. However,
there is an increasing awareness that even moderate decrease in renal function is important in
the critically ill and contributes significantly to morbidity as well as mortality.

Diagnosis
Plasma Creatinine
Neonatal ARF is defined as
1. Plasma creatinine more than 1.5 mg/dL for at least 24 to 48 hrs if mothers renal
function is normal2
2. Serum creatinine raised more than 0.3 mg/dL over 48 hours
3. Serum creatinine fails to fall below maternal plasma creatinine within 5-7 days

Some studies say, if the neonates creatinine increases two times between any two
measurements, this is defined as ARF. The above definitions have reasonable accuracy in term
neonates. In preterm neonates, there is a transient increase in serum creatinine, peaking on day
4, followed by a progressive decline to normal neonatal levels by a postnatal age of 3 to 4
weeks. This occurs due to re-absorption of creatinine across the permeable tubules.
Urine output
Oliguria: It has been defined as urine output less than 1 mL/kg/hr after first day of life for both
term and preterm neonates. However, some term neonates may void for the first time at
around 24 hrs of life. It has been seen that 17% of newborns void in the delivery room,
approximately 90% by 24 hours, and 99% void by 48 hours.1

Practical tip
ARF can also present with normal renal output in one third of the cases, especially in
asphyxiated neonates. Further, in VLBW infants without ARF, there could be oliguric phase that
resolve spontaneously in the first few days of life.1

Concept of acute kidney injury (AKI)

An attempt has been made to define renal failure bringing uniformity across age, gender and
body mass index and reduce the need for a baseline value of serum creatinine. The product of
such an attempt is the concept of acute kidney injury (AKI).5

Definition of AKI
An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute
increase in serum creatinine of more than or equal to 0.3 mg/dL ( 26.4 mol/L), a percentage
increase in serum creatinine of more than or equal to 50% (1.5-fold from baseline), or a
reduction in urine output (documented oliguria of less than 0.5 mL/kg per hour > 6 hours). Thus,
the concept of AKI creates a new paradigm which encompasses not only established renal
failure but also functional impairment relative to the physiological demand.5

Pre-renal versus intrinsic renal failure

The usefulness of differentiating prerenal from intrinsic renal failure was believed to lie in
the fact that in the former the damage to the kidneys is yet to begin, whereas in the latter it
already has. However, with the increasing recognition of AKI as a continuum of volume
responsiveness through unresponsiveness, this distinction has blurred out. There is a
definite role of appropriate fluid therapy in reversing the renal damage in the former.5

When a baby has not passed urine in the past 12 hrs, the first thing is to look for distended
bladder by palpation of the abdomen or ultrasound (if available at bed side). It is better to
avoid catheterization of the bladder to prevent infection, but it may be necessary in sick
babies. If required, it has to be done with a 5 Fr lubricated feeding tube under strict asepsis.
Compression of the bladder (supra pubic pressure) should be avoided especially in preterm
infants for the fear of VUR and rarely bladder rupture. 1

After confirming the absence of urine in the bladder, a fluid challenge can be given. The
common causes of pre renal azotemia are hypovolemia, systemic hypotension and hypoxia
(in more than 80% of cases). 2 In the absence of obvious sign of fluid, a normal saline bolus of
10 mL/kg can be given over 20 min (or 20 mL/kg over 2 hrs). In spite of the fluid challenge, if
urine output fails to ensue, frusemide can be given in a single dose of 1 mg/kg (in a non
dehydrated patient).
Approach to a neonate with renal failure:
History:
a) Prenatal history:
History of maternal drug intake like enalapril or indomethacin which decrease
glomerular filtration should be sought
Maternal uncontrolled diabetes is associated with genitourinary malformations.
Oligohydramnios may result from fetal oliguria due to bilateral congenital renal
disease, bilateral/lower urinary tract obstruction or maternal drugs. Likewise,
polyhydramnios may result from a defect in urinary concentration whereas
hydrops may be the first sign of congenital nephrotic syndrome
b) Family history: May be present in cases of polycystic kidney disease, renal tubular
disorders and congenital nephrotic syndrome.
c) Natal history:
Perinatal asphyxia, respiratory distress, sepsis and shock may predispose the
kidneys to anoxic injury culminating in acute tubular necrosis.
Oliguria in asphyxia may result from prerenal failure mediated by endothelin,
intrinsic renal failure (ATN) or SIADH.
Seizures may occur secondary to hypoxia, intracranial hemorrhage,
hypoglycemia, hypocalcemia, hypertension and uremia.
d) Micturition history: As much as 7% newborns do not void in the first 24 hours. The most
common cause of delayed micturition is inadequate perfusion of the kidneys. However,
intrinsic renal disorders and urinary tract obstruction need to be ruled out.

Physical examination:
Examination must include assessment of hydration (edema/dehydration), vital signs including
blood pressure and a search for dysmorphic features (abnormal ears, pre-auricular pits,
ambiguous genitalia, hypospadias, abdominal wall defects, aniridia, Potter facies), which are
associated with renal malformations. Spontaneous pneumothorax may be associated with renal
abnormalities. Abdominal masses are present in 0.8% newborns, most of which are
genitourinary in origin. A suprapubic mass could indicate a palpable bladder. In males, the urine
stream should be carefully observed as thin stream, dribbling or post voidal residual bladder
suggest posterior urethral valve.

Routine renal ultrasound for babies with single umbilical artery: what is evidence?

Studies indicate that 10% of babies with single umbilical artery (SUA) have an associated major
congenital renal malformation. However a recent meta-analysis ascertains that 14 cases of SUA
will have to be screened to pick up one major renal malformation, which could also be picked
up with a good pediatric follow up. So the value of routinely screening all babies with SUA for
renal malformations is not established.6
Laboratory investigations:
Babies with ARF must be investigated not only to look for the cause and but also to look at the
complications. Apart from serum creatinine and blood urea, serum electrolytes, arterial blood
gas analysis, urine sodium, urine creatinine must be done.

Role of indices
Differentiation of prerenal and intrinsic renal failure can be done basing on urinary indices
(Table 1: Parameters to differentiate pre renal from intrinsic renal failure1. The important
prerequisite is that the urine sample for measuring indices must be obtained prior to fluid and
diuretic challenge. Among the indices available, fractional excretion of Na (FENa) is the most
preferred. FENa more than 2.5% to 3.0% is associated with intrinsic ARF.

Preterm babies lose more sodium in the urine due to the tubular immaturity, hence a FENa of
more than 6% can be used to define intrinsic ARF in babies born between 29-32 weeks of
gestation.7 Likewise renal failure index (RFI) more than 4 in term and more than 8 in preterm
babies <32 weeks is suggestive of intrinsic ARF.

Table 1: Parameters to differentiate pre renal from intrinsic renal failure1

Parameters Prerenal Intrinsic renal
Urinary Na 20 mEq/L >50 mEq/L
Renal failure index* Low <1 High >4
$
Fractional excretion of Na 1 >3

* Renal failure index (RFI): Urinary Na X plasma creatinine X 100

Urine creatinine

$ Fractional excretion of sodium (FENa): Urinary Na X plasma creatinine X 100

Plasma sodium X urine creatinine

Urine microscopic analysis: The presence of granular and hyaline casts, RBC, protein and
tubular cells suggests an intrinsic cause. In asphyxia, there is an increase in epithelial cells and
transient microscopic hematuria with leucocytes. The excretion of low molecular weight
proteins like beta2-glycoprotein is a sensitive indicator of tubular damage as in asphyxia.

Radiological Evaluation:
Ultrasonography and Doppler: Useful in ruling out congenital anomalies like polycystic kidneys,
dysplasia of kidneys and obstructive causes like posterior urethral valves. Renal Doppler studies
are useful in diagnosing vascular thrombosis.

Voiding cysto-urethrography can identify lesions of the lower urinary tract that cause
obstruction, such as posterior urethral valves.
Etiology of renal failure
Having differentiated prerenal from intrinsic renal failure, look for the exact etiology of renal
failure. There are several causes of ARF (Table 2).

Table 2: Etiology of neonatal renal failure:

I. Congenital malformations
Renal agenesis
Renal hypoplasia/dysplasia
Cystic diseases of kidney e.g. autosomal recessive polycystic kidney
II. Acquired renal disorders
Acute tubular necrosis
Perinatal asphyxia
Perinatal hypoxia due to respiratory distress syndrome, traumatic delivery
Sepsis
Hypovolemia due to dehydration, severe patent ductus arteriousus,
intraventricular hemorrhage, post operatively, increased insensible water loss
Vascular
Arterial thrombosis or embolism or stenosis
Venous thrombosis (Infants of diabetic mothers, dehydration, polycythemia)
Drugs: Maternal use of ACE* inhibitors, indomethacin
Neonate: indomethacin, aminoglycosides, radiographic contrast media
III. Urinary tract obstruction
Posterior urethral valves
Pelviureteric obstruction, ureterovesical obstruction
* ACE: angiotensin converting enzyme.

In one series of newborns with ARF, sepsis was the most common cause of AKI (30.9%) followed
by hypovolemia (18.7%), kidney, ureter and bladder (KUB) anomalies (12.2%), congestive heart
failure (12.2%) and birth asphyxia (11.5%).3

Some special considerations:

A neonate with oliguric ARF, hematuria, hypertension with/without loss of femoral pulses
suffers from bilateral renal artery thrombosis. Thrombolysis / thrombectomy is indicated in
refractory hypertension in such a neonate
Management
Renal venousof Acute renal
thromboses should befailure
suspected in any newborn who presents with bilateral
flank mass, proteinuria, hematuria with/without oliguria and thrombocytopenia in the
presence of a setting like polycythemia, severe dehydration and maternal diabetes

Fluid management
Fluids must be restricted to insensible water loss (IWL) along with urinary loss. The
urinary loss must be replaced volume for volume. The insensible water loss in a term
neonate is 25 mL/kg/day. In preterm neonates, this can vary between 40-100 mL/kg/day
depending on gestation, postnatal age, use of radiant warmers, phototherapy etc.8
 Fluid requirement should be revised based on urine output, weight and assessment of
extracellular volume status, preferably every 8 hourly.

The insensible water losses should be replaced with 5-10% dextrose. The urine output
should be replaced volume by volume with N/5 saline.5

During the polyuric phase, hourly monitoring of urine output and serial monitoring of
serum electrolytes with appropriate replacement of sodium, potassium and water are
indicated to prevent dehydration, hyponatremia and hypokalemia.1

Electrolyte disturbances
Hyponatremia
Babies can have hyponatremia in oliguric renal failure.
Hyponatremia is due to dilution secondary to water retention hence has to be corrected with
fluid restriction. In most of the cases, there is no sodium deficit.
If serum sodium is between 120-135 mEq/L, restriction of fluids will suffice. Serum
sodium must be monitored at least 12 hrly.

If hyponatremia is associated with symptoms like seizures, or if serum sodium is less

than 120 mEq/L, it requires prompt correction with 3% hypertonic saline over 2 hours,
using the formula

Na required (mEq) = [Na desired Na actual] x body weight (kg) x 0.8

Hyponatremia unresponsive to above therapy is an indication for dialysis.

Babies with non-oliguric ARF may have urinary sodium losses of up to 10 mEq/kg/day
and these must be replaced.

Care should be taken not to increase the serum sodium by more than 0.5 mEq/L/h.

Hyperkalemia
Hyperkalemia (K+ > 6.5 mEq/L1): It is one of the most dangerous complications of ARF. It results
from reduction in glomerular filtration rate, urinary potassium secretion, acidosis, immature
tubular response to aldosterone and cellular breakdown.

Practical tip
If hyperkalemia is associated with hypoglycemia, hyponatremia and hypotension, consider a
diagnosis of adrenal insufficiency.
 The first step in the management of hyperkalemia is to stop all potassium in the fluids as
well as drugs which can accentuate hyperkalemia (indomethacin, ACE inhibitors, potassium
sparing diuretics)

ECG will help in diagnosing cardiac effects of hyperkalemia. If ECG changes are evident, IV
calcium gluconate ??? ml/kg 10% slowly with cardiac monitoring is given. This will decrease
the myocardial excitability but will not lower the potassium levels.

This should immediately be followed by methods to decrease the potassium levels (Table 3).
Hyperkalemia which is unresponsive to medications is one of the most common indications
for instituting dialysis.

Table 3: Management of Hyperkalemia1:

ECG strip of hyperkalemia

Level of K+ at Medication Dose Mechanism/ Degree Onset of

which it is of effect action
instituted
ECG changes Calcium gluconate (10%) 0.5 to 1 mL/kg over 5-10 Modifies myocardial 5-10 min
suggestive of min excitability, no decrease in
hyperkalemia K levels
6.5-7.5 mEq/L Glucose and insulin 0.5 g/kg/h of glucose and Intracellular uptake of 30 min.
0.1 U/kg/hr infusion of potassium
insulin
6.5-7.5 mEq/L Salbutamol IV infusion 4 g/kg over 20 min Intracellular uptake of
potassium 30-40 min
More than 6.0 Cation exchange resin 1g/kg intrarectally q 6 h Exchange of K for Na or
mEq/L (Na/Ca polystyrene Ca. 1-2 hrs, may take
sulfonate) 1g/kg reduces K levels by upto 6 hours
1 mEq/kg
More than 7.5 Exchange blood 2/3 Washed RBC Uptake of K by RBC. Minutes
mEq/L transfusion reconstituted with 5%
albumin
K+ more than 7.5 Peritoneal dialysis Use a dialysate with low Dialysis Minutes.
mEq/L K+ concentration

Practical tips1:
Saturate the plastic tubing with insulin solution before infusing to the baby
Oral administration of resins is associated with the risk of concretions, hypernatremia and
fluid overload avoid in VLBW infants and those with poor peristalsis
Salbutamol aerosol may not be very effective in neonates
Hypocalcemia
Hypocalcemia can develop in babies with ARF due to hyperphosphatemia and skeletal resistance
to parathyroid hormone. Symptomatic hypocalcemia should be corrected by infusing 10%
calcium gluconate at a dose of 0.5-1 mL/kg over 5-10 min under cardiac monitoring. Also, during
the oliguric phase, no intake of phosphorous/ magnesium is to be provided.
Role of dopamine
At doses less than 5 mEq/L, dopamine acts via DA1 and DA2 receptors to increase renal blood
flow. But preterm infants are hypersensitive to alpha receptors and hence even low doses of
dopamine can cause vasoconstriction and raise renal vascular resistance.9 This may explain the
difficulty in dosing of dopamine for improving renal function. Dopamine when combined with
frusemide causes natiruresis and diuresis in preterm infants with RDS and oliguria.10

Dopamine in ARF: what is evidence?

The Cochrane meta-analysis of three studies concluded that dopamine has no role in the
management of acute renal failure due to indomethacin.11

In their meta-analysis, Friedrich et al., analyzed 61 randomized or quazi-randomized controlled

trials of low dose dopamine and found no improvement of survival, no decrease in dialysis
requirement, no improvement in renal function and improvement in urine output only on the
first day of therapy in adults with ARF of any cause.12
Nutrition
The goal is to provide 100 kcal/kg/day as babies with ARF are catabolic. Proteins or
amino acids can be provided in a dose of 1-2 g/kg/day13.
If enteral feeding is possible, breast milk can be used, failing which, low phosphate
formula can be given. Caloric density can be increased by adding medium chain
triglycerides.
In the baby is on parenteral nutrition, a central venous catheter may be needed to
infuse hypertonic glucose in order to prevent hypoglycemia.

Acidosis
Mild metabolic acidosis is common in babies with ARF. If pH is <7.2 and bicarbonate <18 mEq/L,
sodium bicarbonate is given in a dose of 1-2 mEq/kg over 3-4 hrs. But monitoring for fluid
overload, hypernatremia, intracranial hemorrhage and hypocalcaemia is needed. Babies with
persistent acidosis require dialysis.

Hypertension
Fluid overload in neonatal ARF can result in hypertension, which can be controlled with fluid
restriction and antihypertensive agents. The development of severe hypertension in the setting
of neonatal ARF should raise the suspicion for renal artery or venous thrombosis.

Commonly used antihypertensives in newborns are oral amlodipine (0.1-0.3 mg/kg/dose q 12-24
hourly), enalapril (0.1-0.4 mg/kg/day q 6-12 hourly, with careful monitoring of potassium and
renal functions) and intravenous diazoxide (2-5 mg/kg/dose over 5 min q 4-24 hourly)1.

Renal replacement therapy

The indications of renal replacement therapy are:
Hyperkalemia refractory to medication
Hyponatremia with volume overload (pulmonary edema, severe hypertension)
Metabolic acidosis (TCO2 < 16-18 mEq/L)
Hypocalcemia
 Hyperphosphatemia refractory to therapy
Inability to provide adequate nutrition due to fluid restriction.
The two purposes of renal replacement are ultrafiltration (removal of water) and dialysis
(removal of solutes). Dialysis is a process of removal of plasma solutes by diffusion down their
concentration gradient across a semi permeable membrane. Filtration involves removal of
protein free plasma across a membrane by convection.

Peritoneal dialysis (PD) catheters: Peritoneal access in most institutes is achieved by a stiff
catheter and trocar, but when used beyond 48-72 hours, infection rates are high.14 Risk of
infection and visceral injury is less with soft PD catheters made of silicone polymer of methyl-
silicate, either in curled or straight configurations15,16 (Fig. 1).

Most of the catheters have side holes that allow for easy ingress and egress of fluid. Permanent
catheters have cuffs. Straight Tenckhoff and coiled Tenckhoff catheters are available. Coiled
Tenckhoff catheters are useful for chronic dialysis. Detailed description of drug dose
modification in ARF is available in literature5.

Figure 1: Peritoneal dialysis circuit

Dialysis
solution bag

Twist clamp

Clamp

Peritoneal cavity
Waste
products bag

Procedure:
The first step involves creating a fluid filled reservoir by infusing 20-30 ml/kg dialysate
into the peritoneum using a cannula.
After this, the catheter is inserted into the peritoneal cavity and connected to a three
way cannula. The common sites of insertion are in the midline below the umbilicus,
right or left lower quadrant of the abdomen. Urinary bladder must be emptied before
insertion of the catheter.
The dialysate fluid is connected to a pediatric burette set and its terminal end is
connected to one of the ports of three way cannula. The remaining port of the three
way is connected to a intravenous (IV) set, the end of which is let into a sterile container
(empty IV fluid bottle).
 The abdomen is filled with 20-30 mL/kg of dialysis fluid infused over 10 min. A dwell
time of 20 to 30 min is used before draining the fluid over 10 min. The dwell time can be
reduced in case of respiratory compromise.
A total of 20-40 cycles can be used or it can be continued till the desired effect is
obtained.
Blood sugar, serum electrolytes and blood gas should be monitored every 6 hourly and
serum creatinine every 24 hourly. At the end of the procedure the catheter can be
removed and the tip and the fluid are sent for culture.

Dialysate Fluids:
The common dialysate fluid contains 1.7% dextrose with lactate. If higher gradient is required as
in case of fluid overload 3% solution can be used. This can be prepared by adding 25 mL of 50%
dextrose to one liter of 1.7% PD fluid.
In case of liver failure as in asphyxia, lactate free bicarbonate containing fluid has to be
used as these babies may be unable to metabolize lactate quickly. If baby becomes
hypokalemic during the procedure, add one mL of KCl to one liter of dialysate fluid.

Composition of dialysis solutions5:

Osmotic agent: Dextrose 1.4- 3.9 g/dL or icodextrin 7.5 g/dL or amino acids 1.1 g/dL
Base: Lactate 35-40 mEq/L or bicarbonate 34 mEq/L
Sodium 132-134 mEq/L, Calcium 1.25-1.75 mM/L,
Magnesium 0.25-0.75 mM/L, Chloride 95-103.5 mEq/L

Complications of PD:
PD is invasive procedure and the following complications/contraindications need to be
remembered.
The chief complication of PD is peritonitis, the common organisms being coagulase
negative Staphylococcus, S. aureus and gram negative bacteriae.5

Catheter related bleeding, catheter malfunction, perforation of abdominal viscera,

adhesion of catheter tip to momentum.

Hyperglycemia can occur when higher concentrations of dextrose are used.

PD cannot be done in babies with necrotizing enterocolitis, babies who underwent

abdominal surgery and in those with severe respiratory compromise as it may worsen
with abdominal distension. This may be circumvented with smaller volume cycles.

Hypothermia must be prevented by using pre-warmed dialysis fluid.

PD will be less effective in poor cardiac output or gut hypo perfusion.

Hemofiltration and hemodiafiltration are effective in neonates with ARF in whom PD is

contraindicated. The complication rates are less. Hemofiltration is particularly useful in the
presence of fluid overload, but it needs a vascular access with large sized catheters and
adequate mean arterial blood pressure. Hemodiafiltration is more useful in the presence of fluid
overload and azotemia with electrolyte disturbances.2

Outcome
Non oliguric renal failure has a better prognosis when compared to oliguric renal failure.
Mortality ranges from 25 to 78% in oligo anuric renal failure.17 Long term abnormalities in GFR
and tubular function are common in babies who survive ARF and is secondary to hyperfilteration
in the surviving nephrons.

Follow up
All babies who develop ARF need follow up. Adequacy of growth and nutrition, blood pressure,
and renal function status has to be monitored. Newborns who have had ARF are predisposed to
the development of chronic renal failure in the future. Long-term follow-up of extremely low
birth weight infants who had neonatal ARF has shown that the risk factors for progression of
renal disease at 1 year of age included a random urinary protein/creatinine ratio of greater than
0.6, serum creatinine greater than 0.6 mg/dL and a tendency to obesity with a body mass index
greater than the 85th percentile.18

Research priorities:

Role of novel therapies like ATP Magnesium chloride/ thyroxine / peptide growth
factors/ cytokines/ calcium channel blockers in intrinsic AKI

Research Question Subjects Study design Proposed Outcomes

The role of biomarkers Newborns with Cohort study Use as a diagnostic test,
(urinary neutrophil acute kidney compared to existing
gelatinase-associated injury as defined gold standards (urine
lipocalin, cystatin C, in the protocol output and serum
urinary interleakin 18 creatinine)
and L-type fatty acid Prognosis to predict
binding protein) in the risk of progression,
diagnosis and chronic renal failure or
prognosis of neonates mortality
with ARF/AKI (like
cystatin C)
Role of early treatment Newborns with Randomised To assess the benefit
strategies Intravenous acute kidney controlled (response measured as
fluid bolus and diuretic injury , trial improvement in urine
challenge preferably early output or creatinine)
AKI and risks
Usefulness of novel Newborns with Randomised To assess the benefit
therapies such as acute kidney controlled (response measured as
recombinant human injury trial improvement in urine
growth factors, output or creatinine)
erythropoietin, atrial
natriuretic peptide or
N-acetyl cysteine in
 Flow chart

Oliguria : urine output < 1mL/kg/hr for the past 12 hrs in a baby more than 24 hrs of age

Assess urinary bladder size by clinical or bedside USG if available

Assess and correct dehydration
Check for any underlying condition predisposing to ARF like
hypotension, hypoxia, and hypovolemia
Send blood and urine for creatinine and sodium
No evidence of CCF

Normal saline bolus 10 ml/kg over 20 min

Urine output present <1mL/kg/hr Urine output present > 1mL/kg/hr

Inj frusemide 1mg/kg stat

UOP < 1 UOP > 1

ml/kg/hr ml/kg/hr

PRE RENAL FAILURE

INTRINSIC RENAL FAILURE

UOP: urine output

CCF: congestive cardiac failure`
 Reference
1. Suhas M, Nafday, et al, In Renal Disease Averys Neonatology pathophysiology and
management of newborn, 6th e, editors M G MacDonald; Lippincott Williams and Wilkins. 981-
1065.
2. Gouyon J B, Guignard J P. Management of acute renal failure in newborns. Pediatr Nephrol
2000;14:1037-1044.
3. Vachvanichsanong P, McNeil E, Dissaneevate S, Dissaneewate P, Chanvitan P, Janjindamai W.
Neonatal acute kidney injury in a tertiary centre in a developing country. Nephrol Dial Transplant
2012 Mar;27(3):973-7.
4. Hentschel R, Lodige B, Bulla M. Renal insufficiency in the neonatal period. Clin Nephrol 1996:
46:548.
5. Bagga A, Sinha A, Gulati A. Protocols in Pediatric Nephrology, 1st e, CPS publishers and
Distributors Pvt Ltd.
6. Thummala MR, Raju TN, Langenberg P. Isolated single umbilical artery anomaly and the risk for
congenital malformations: A meta-analysis. J Pediatr Surg 1998 Apr;33(4):580-5.
7. Ishizaki Y, etal, Evaluation of diagnostic criteria of acute renal failure in premature infants Acta
Paediatr Jpn 1983,35:311-315.
8. Chawla D, Agarwal R, Deorari AK, Paul VK. Fluid and electrolyte management in term and
preterm neonates. AIIMS-NICU protocols 2008, www.newbornwhocc.org.
9. Seri I. Effects of low dose dopamine infusion on cardiovascular and renal functions cerebral blood
flow and plasma cathecolamines levels in sick preterm neonates. Pediatric Res 1993, 34:742-749.
10. Tulassy T, Seri I, Acute oliguria in preterm infants with hyaline membrane disease; interaction of
dopamine and frusemide. Acta Pediatr Scand 1986,75:420-424.
11. Barrington K, Brion LP. Dopamine versus no treatment to prevent renal dysfunction in
indomethacin-treated preterm newborn infants. Cochrane Database of Systematic Reviews 2002,
Issue 3. Art. No.:CD003213.
12. Friedrich JO, Adhikari N, Herridge MS. Meta-analysis: Low dose dopamine increases urine output
but does not prevent renal dysfunction or death. Ann Intern Med 2005;142:510-24.
13. Philippe SF Jacquelyyn RE, Tivadar T, Seri I. In Acute and chronic renal failure, Averys diseases of
newborn, editors William Taeusch, Roberta Ballard, and Christine A. Gleason, 2005, 8 edition,
Saunders. 1298-1306.
14. Gulati A, Bagga A. Management of acute renal failure in the pediatric intensive care unit. Indian J
Pediatr 2011 Jun;78(6):718-25.
15. Coulthard M G, Brayan V, Managing acute renal failure in very low birthweight infants. Arch dis
child 1995; 73: F187-F192.
16. Marsha ML, Annabelle NC, Peter DY. Neonatal peritoneal dialysis. NeoReviews 2005;.6:No.8 e384
- e391.
17. Chevalier R. Prognostic factors in neonatal acute real failure. Pediatrics 1984; 74: 165-272.
18. Annabelle NC, Minnie MS. Acute renal failure management in the neonate. NeoReviews 2005, 6:
e369 - e376.
 Management of Pain and Developmental Supportive
Care in Neonatal Intensive Care Unit
Developmental care refers to set of actions like reduction in noise and light, minimal handling, effective
pain prevention and treatment aimed at reducing the stresses in the NICU and optimizing
neurobehavioral outcome.1 Developmental care interventions are potentially beneficial to sick neonates
especially those born prematurely to cope with the adverse external environment in NICU. Structured
developmental supportive programs like Newborn Individualized Development Care and Assessment
Program (NIDCAP) combines various measures to provide individualized care based on the each babies
need.

Developmentally supportive care: what is evidence?

A Cochrane meta-analysis (2006) included 36 RCTs and examined the effects of developmental care
interventions like positioning, clustering of nursery care activities, modification of external stimuli
and individualized developmental care interventions (e.g. NIDCAP). There were:
Modest beneficial effects in the form of decreased moderate-severe chronic lung disease,
decreased incidence of necrotizing enterocolitis and improved family outcomes
Limited long-term positive effect on behavior and motor outcome at 5 years corrected age

For operationalizing of evidence based developmental care program, the following core measures are
proposed:

1. Protected Sleep
2. Pain and stress assessment and management
3. Developmentally supportive activities of daily living
4. Family centered- care
5. Creating a healing environment

These patients centered five point core measures needs to be integrated into the routine clinical
practice and its performance needs systematic audit, so as to reap best results (Table 1).

TABLE 1 Evidence based core developmental care strategies in NICU

Core Measure Practice parameters

Protect sleep All non-emergent care giving is provided while infant is awake (No disturbance while
baby is sleeping)
Promote sleep by facilitative tuck, swaddling and skin-to-skin care
Light and sound levels are minimized. Day-night pattern is simulated by reducing
lights in night to facilitate nocturnal sleep
Family education on care giving activities that promote safe sleep
Prevent and treat Assess if baby suffers from pain once during each nursing shift and during all
pain procedures using a validated score (refer to pain section)
Provide non-pharmacologic and/or pharmacologic measures to reduce pain for all
stressful and/or painful procedures
 Care giving activities are adapted to minimize pain and stress
Parents are educated regarding infant pain and involved in its management

Provide Use boundaries around the infants to maintain them in flexed posture (similar to in-
developmentall utero posture) (Figure 1)
y supportive Provide non-nutritive sucking while the infant is being fed by gavage or paladai by
care allowing the baby on suck on mothers finger or breast
Provide lactation counseling and support to initiate and maintain lactation in the
mother
Protect the integrity of skin during application, and removal of adhesive products
(minimize use eg do not strap to achieve hemostasis after sampling instead just put a
cotton swab and hold it for some time. Adhesive should be removed only after 72 hr
of application once it has loosened from skin surface. Wet the plaster before removal)
Provide family Disease has serious impact on social fabric of the family. Consider individuals beyond
centered care infant, and issues beyond disease such as those related to financial condition and
relationship within family. Consider cost-benefit ratio of treatment/investigation
(Do not consider modality that you plan to employ.
infant as a solo Allow the parents to visit the infant in NICU and to have conversation with the
entity) treating team. Involve parents in decision making regarding treatment of the infant.
Family observations and input regarding their infant are sought by the clinical care
providers
Family is supported in parenting activities such as skin-to-skin care, holding the baby,
feeding, dressing, diapering, singing and all infant care interactions
Babies in NICU should be divided to available nurses on the shift so that all care giving
activities of a baby should be carried out by the allotted nurse of that baby. The
practice of task-specific allotment of nurses (such as one nurse responsible for
feeding, another for injections to all babies) must be avoided.
Practice primary nursing. That means one nurse becomes primary nurse of a baby
and that baby always get allotted to the primary nurse in whatever shift duty she
comes. Her name should be recorded on bedside identification tag and is
communicated to the family. Primary nurse of the baby is responsible for keeping a
close liaison with family and physicians for holistic care of the baby.

Healing Minimize sound and lights. Do not place anything on incubators. Close the incubator
environmen doors gently. Cover incubators with a cloth sheet to minimize light. Do not use
t procedure light unnecessarily
Make sure health professionals follow caring behaviors such as adherence to hand
hygiene protocols, cultural sensitivity, open listening skills and a empathic relationship
with families
Do not perform investigation for a routine. Consider utility of an investigation before
you do it. If it is unlikely to change your management, it is unnecessary and potentially
harmful by causing pain and increasing the infection risk.
Promote free and healthy communication between physicians, nurses and other
professionals working in NICU. A cohesive team is more likely to avoid errors and
provide healing touch.
#
modified as per feasibility in developing country settings
Figure 1 Boundaries to promote in- utero posture of the infant

Note that boundary is tall enough to contain the baby and the cloth sheet should be tied
at ends so as to maintain the round shape of it. Warmer bassinet has been covered using
a thin plastic sheet to minimize insensible water losses
Pain Assessment and Management
Preterm infants have well developed pain perception mechanisms, but do not have those required for
pain modulation as in term infants or an adult. Repeated stimuli in later result in progressive attenuation
of pain while it result in increasing severity of pain in the former. Therefore preterm infants not only
perceive pain but do it at much more intensity as well as for much longer time.

Pain has lasting bad effects on infants brain development which manifests later as abnormal pain
perception, behavioral abnormalities, cognitive defects and learning disabilities.Error! Bookmark not
defined. Hence routine assessment and management of pain, forms an important part of the
developmental supportive care.2

Pain Assessment
Assessment of pain, an integral part of any pain prevention program is challenging in neonates. Use
Premature Infant Pain Profile (PIPP; Table 2) for assessment of acute pain.3

TABLE 2 Premature Infant Pain Profile (PIPP) Error! Bookmark not defined.
SN Parameters Score
0 1 2 3
1. What is gestation of infant? 36wks 32-356/7 28-316/7 28 wks
2. Score behavioral state before Active awake Quite awake Active sleep Quite/sleep
the procedure (15 sec) Eyes-open Eyes- open Eyes-closed Eyes closed
Facial Nofacial Facial movements Nofacial
movements + movements + movements
3. Record baseline HR and find 0-4/min increase 5-14/min 15-24/min 25/min
out maximum HR during the
procedure
4. Record baseline SO2% and 0-24% fall 25-49% fall 5-74% fall 75% fall
find out minimum SO2%
during the procedure
5. Observe the infant for 30 sec None Min Moderate Maximum
immediately after the (0-9% of time) (10-39% of time) (40-69% of time) (70% of
procedure (for brow bulge, time)
eye squeeze and nasolabial
furrow)
Health professionals should record PIPP score of all babies oncen/nursing shift and before the procedures. The issue
os pain should be discussed on the rounds. The minimum score is 0 and maximum score is 21. Higher is the score
greater the pain. Score < 5: no pain; 6-10: moderate pain; and >10: severe pain

Preventing or reducing pain

General measures
Pain is managed most effectively by preventing, limiting or avoiding noxious stimuli The following
measures in combination are followed to minimize pain:
Avoid bright light, loud noise
Limit the number of painful procedures and handling
 Bundling of investigations and nursing interventions
Swaddling, facilitated tucking, distraction measures like talking, music etc
Tactile stimulation like stroking, caressing, massaging

Non-pharmacological measures
The environmental and behavioral interventions that do not use pharmacological agents are collectively
called non-pharmacological measures. These include:
1. Sucrose/glucose solution induced analgesia
2. Breast feeding/breast milk supplementation
3. Skin to skin care
4. Non-nutritive sucking using pacifiers

The non-pharmacological measures are thought to alleviate pain by activating gate control mechanism,
secretion of endogenous endorphins, diversion of attention and by pre-empting hypersensitivity.4

Sucrose analgesia
Sucrose administration is particularly useful for short procedures like venipuncture, heel prick etc. Oral
administration of concentrated sucrose solution (24% to 50%) acts by release of endogenous opiods like
beta-endorphin. Analgesic effect lasts for 5-8 min and should be combined with other non
pharmacological measures for maximum benefit. Alternative to sucrose is dextrose, which is less widely
used.

TABLE 3 Dose of sucrose/dextrose for analgesiaError! Bookmark not defined.,Error! Bookmark not
defined.
Concentration For babies who are NPO Preterm (<32 Late PT/ Term
weeks)
24% Sucrose / 25% Dextrose 01-02 mL 01-05 mL 02-1 mL
The sucrose solution is given orally by a syringe 2-3 min before procedure and may be repeated 1-2 min
after the procedure Intragastric administration has no analgesic effect

Breast feeding and breast milk supplementation

Almost as effective as sucrose analgesia in reducing pain in newborns undergoing single painful
procedure
TABLE 4 Evidence supporting non-pharmacological analgesic measures in neonates

Agent Evidence
Sucrose (24%) Cochrane meta-analysis 5 Reduction in pain scores( PIPP)
44 studies, 3496 infants Decreases physiological indicators of pain (heart rate
increase)
Less behavioral indicators of pain (duration of cry, facial
action
6
Breast milk and Cochrane meta-analysis Less duration of cry, lesser increase in heart rate
breastfeeding 11 studies Lesser PIPP score
Lesser increase in neonatal facial coding score
Breast feeding was better than breast milk
supplementation
4
Non-nutritive Systematic review Favorable effect on heart rate, respiration and oxygen
sucking Skin to skin 13 RCT saturation, on the reduction of motor activity, and on the
care 2 Meta-analysis excitation states after invasive measures
Swaddling Non-nutritive sucking, swaddling and facilitated
Facilitated tucking tucking are particularly useful
Music Combination of measures always provide better analgesia

Pharmacological measures
The pharmacological measures can be broadly divided into
Local anesthetic agents
Systemic agents: opioids, acetaminophen

Non steroidal anti-inflammatory agents (NSAID) are generally not used in newborns as analgesics.

Local anesthetics
Local anesthesia is particularly useful for management of acute procedure related pain with the
exception of heel lances. 7 It can be either topically applied on intact skin or injected subcutaneously.

The common topical preparations marketed are:

1. Eutectic mixture of local anesthetics (EMLA): is a mixture of two local anesthetics namely
lidocaine and prilocane that comes as 5% cream.
2. Tetracaine (4%)
3. Liposomal lidocaine 4% cream.

The dose of EMLA is 1-2 g with contact period of 30 min to 1 hour. Apply the cream over 2-3 cm2 area
with 1-2 mm thickness and cover with transparent (tegaderm) dressing. For maximal analgesic effect,
the topical anesthetics should be combined with other non-pharmacological measures like sucrose
analgesia or breast milk supplementation.
The major drawback is the delayed onset of action and a contact period of at least 1 hour prior to the
procedure, which makes it unsuitable for emergent procedures. The risk of methemoglobinemia
associated with repeated use of EMLA cream, is not seen with newer preparations like tetracine gel
For emergent procedures, subcutaneous local anesthetic injection (lidocaine hydrochloride 2%) is the
preferred over the topical creams.

Opioids
The opioid drugs are the mainstay in the management of severe pain related to mechanical ventilation,
endotracheal intubation and post surgical pain in neonates.

The two most commonly used agents are morphine and fentanyl.

Morphine
Morphine has slower onset of action with mean onset at 5 min with peak effect at 15 min. It is
metabolized in the liver to morphine-3- glucoronide, an opioid antagonist and morphine-6-glucoronide a
potent analgesic. Newborn babies especially preterm infants mainly produce morphine-3-glucoronide
leading to emergence of tolerance after 2-3 days of therapy.

The observed side effects include hypotension, need for prolonged ventilations, delay in reaching full
feeds, and rarely bronchospasm secondary to histamine release12.

Fentanyl
Fentanyl is a synthetic opioid analgesic. It is 50 to 100 times more potent and more rapid in onset of
action compared to morphine. Fentanyl is preferred over morphine in infants with hypotension as
cardiovascular side effects are lesser. 8 The unique side effect of fentanyl is chest wall rigidity especially
if given as rapid intravenous bolus.

The other opioids used are methadone, sulfentanil, remifentanil etc, which are used for short
procedures like endotracheal intubation and short neonatal surgeries

Analgesia for specific procedures

Elective and semi-elective intubation

Intubation of neonates in awake state is associated with increase in heart rate, greater fall in oxygen
saturations / heart rate, increased intracranial pressure, increased risk of IVH, airway trauma and failure
of procedure especially, in in-experienced hand.9

The AAP committee on fetus and newborn recommends avoiding awake intubation of newborn babies
except in emergent situations like delivery room intubation and in cases where intravenous access is
unavailable.10

The AAP recommends:

Analgesic agents or anesthetic dose of a hypnotic drug should be given
Vagolytic agents and rapid-onset muscle relaxants should be considered
Use of sedatives alone such as benzodiazepines without analgesic agents should be avoided
A muscle relaxant without an analgesic agent should not be used.
TABLE 5: Sedation for elective intubation

The preferred regimen includes:

1. Inj. Fentanyl 1-4 mcg/kg, given slow IV over 3-5 min

2. Inj. Atropine 0.02 mg/kg (minimum dose should of 0.1 mg)
3. Inj. Vecuronium 0.1 mg/kg administered IV, 2-3 minutes prior to the procedure

Avoid using paralytic agents in case experienced person is unavailable for intubations.

Mechanical ventilation
Mechanical ventilation is a painful and uncomfortable experience which might, adversely affect the
course of acute illness as well as long term neurodevelopment11. However there is insufficient evidence
for routine use of pharmacological measures in all ventilated infants.

Indications for continuous infusion of opioids in ventilated neonates are:

Post operative patients especially in the first 48-72 hours
Illnesses like meconium aspiration syndrome or congenital diaphragmatic hernia with PPHN
Asynchrony or fighting with ventilator. Rule out causes like ventilator malfunction, tube block or
inappropriate settings before infant is sedation for this indication.

Avoid use of midazolam especially in preterm babies. Do not use paralytic agents routinely in ventilated
babies.

Analgesia/sedation in ventilated neonates: what is evidence?

A Cochrane meta-analysis (2005) including 13 studies and 1505 infants concluded that there is
insufficient evidence to recommend routine use of opioids However, when used, morphine is safer
than midazolam showing reduction in pain severity as noted by lower PIPP scores and there was no
long term/ short term reduction in morbidity/mortality
Table 6 and 7 provides details on how to provide analgesia in different procedures

TABLE 6 Analgesia measures for routine bedside procedures

Procedure Analgesia measure recommended
General measures Sucrose analgesia* Breast milk* Facilitated tucking /
caressing
Venipuncture Sampling# + + +
Heel prick# + + + +
Subcutaneous/ IM + + + +
injection
Adhesive tape removal + + + +
IV Cannulation + + +
*Either sucrose analgesia or breast feeding can be adopted depending on the availability and feasibility; for slightly longer
procedure sucrose analgesia is preferred over breast milk/ breast feeding
#
Venipuncture should be the preferred mode of blood sampling as heel lance is more painful

TABLE 7 Analgesic measures for specific proceduresError! Bookmark not defined.,12

Procedure Intubated Non-intubated
Arterial Inj Morphine 01-02 mg/kg IV EMLA cream locally
puncture/cannulation EMLA cream locally Sucrose analgesia
Lumbar puncture Sucrose analgesia General measures
PICC line placement
Chest tube placement Inj Morphine 01-02 mg/kg IV Inj Morphine 01 mg/kg IV*
Local infiltration with Lignociane 2% Local infiltration with Lignociane 2%
Sucrose analgesia Sucrose analgesia

Chest drain removal Inj Morphine 01- 02 mg/kg EMLA cream locally
Sucrose analgesia Sucrose analgesia
General measures General measures
ROP screening Inj Morphine 01- 02 mg/kg IV Local anesthetic eye drops
Local anesthetic eye drops Sucrose analgesia
Sucrose analgesia Post screen- paracetamol
Post screen-paracetamol
ROP Laser surgery Inj Morphine 01- 02 mg/kg IV Inj Morphine 01- 02 mg/kg IV*
Local anesthetic eye drops Local anesthetic eye drops
Sucrose analgesia Sucrose analgesia
Post OP- paracetamol 15 mg/kg q 6 General measures
hourly for 1-2 day Post OP- paracetamol 15 mg/kg q 6
hourly for 1-2 day
CT/ MRI- for sedation Inj Morphine 01- 02 mg/kg IV Oral Chloral hydrate 50-100 mg/kg
Inj Midazolam 01- 03 mg/kg IV Oral Trichlophos- 20 mg/kg
IV Midazolam 01- 02 mg/kg IV single
dose
*In non ventilated babies while using opioids- Watch for apnea/ respiratory depression; IV Naloxone should be kept ready and
used in case of respiratory depression or apnea (01 mg/kg or 025 ml/kg IV); Inj Fentanyl may be substituted for Inj Morphine;
Dose 1-4 mcg/kg slow iv over 3-5 min
** Even ventilated patients on opioid infusion during procedures needs additional analgesic measures
Table 8 provides details of different analgesic agents. Table 10 provides research priorities.

TABLE 8 Drugs and dosages of analgesic/sedative medications commonly used in NICU

Drug Dose Preparation/ Pharmacology Adv effect

administration
Morphine Bolus:100-200 1 mL=15 mg. Narcotic analgesic Respiratory
mcg/kg slow IV over Dilute in - NS/ 10D/5D to make a Onset: 5min depression
5 min maximum concentration of 5 Peak :15 min Bradycardia
1/2
Infusion:10-20 mg/mL T : 9 hrs Hypotension
mcg/kg/hr IV Incompatible with phenytoin, Ileus,
phenobarbitone Urinary retention
Tolerance
Fentanyl Bolus 1-5 mcg/kg IV 1 mL=50 mcg 50-100 times more Respiratory
slow IV over 5-10 Dilute in NS/5D/10D potent than morphine depression
min Incompatible with phenytoin, Rapid onset; less Chest wall rigidity
Infusion 1-5 phenobarbitone hypotension than with rapid push
mcg/kg/hour IV morphine Urinary retention
T1/2: 1-15 hrs Tolerance
Midazolam Bolus: 01- 02 1 mL=1 mg Short acting Respiratory
mg/kg slow IV Dilute in NS/5D/10D benzodiazepine depression
IV Infusion: 0.01- Incompatible with NaHCO3, fat Sedation only, no Myoclonic Jerk
0.06 mg/kg/hour emulsion analgesic effect Hypotension (esp
Intranasal/sublingua T1/2: 4-6 hrs in term with rapid push)
l route (dose 0.2-0.3 infants; preterm
mg/kg) may also be variable up to 22 hrs
used Not recommended in
neonates esp. preterm
Vecuronium 0.1 mg/kg Available as powder Non depolarizing Respiratory
(1 vial=10 mg/20mg) muscle relaxant depression
Dilute in 5D/NS to make 1 Onset 1-2 min; Hypotension
mg/mL) duration of action 1-2 Avoid routine use
hours in ventilated
Consider using during neonates.
non emergent
intubation as
premedication
Paracetamol 10-15 mg/kg/dose Syp 5 mL= 125 mg Rectal route erratic
PO 6-8 hrly Drops 1 ml=100 mg absorption
30 mg/kg/ dose per Suppositories 80 mg
rectal
Chloral 25-75 mg/kg 1ml=100mg No analgesia, only Bradycardia
hydrate PO/rectally sedation Gastric irritation
Administer with feeds Contraindicated
( high osmolality, may in hepatic/renal
cause GI intolerance) dysfunction
EMLA cream 1- 2 g for 1 hr Lidocaine-prilocaine 5% (Eg.Oint Delayed onset Methemoglobine
Prilox available in India) - 1 hr mia
5g/30g with tegaderm dressing Not effective for heel
lance
TABLE 9 Research priorities

Research Question Study Design Intervention Outcome measures

What are the effects of Prospective Structured Pschymotor and Mental
developmental supportive care like Cohort Development developmental index as
NIDCAP and pain management RCT supportive program measured by Bayley scale
protocols on long term neuro and pain of infant development or
developmental outcomes in preterm management other suitable objective
and term neonates? program e.g. scales like DASI II at 18-
NIDCAP 24 months.
Objective Neurological
assessment at 18-24
months.
Efficacy and safety of Dextrose 25% RCT Dextrose 25% Pain assessment by
versus Sucrose 24% in procedural Vs Sucrose 24% standardized pain scales
analgesia in NICU For procedures like like PIPP
venipuncture, ROP Comparison changes of
examination, IV physiological parameters
cannulation, arterial like heart rate,
puncture, Lumbar saturations, respiratory
puncture rate etc during procedure
Knowledge attitude and practice of Survey None Structured questionnaire
pain management in resource poor based survey and
settings and feasibility of pain develop a scoring for
protocol assessment of
participants
Compare the common pain Cohort study Compare pain scales Validity of different scale
assessment tools in NICU and adopt with PIPP scale as compared to PIPP
one as standard based on its validity standard Time required for
as well as ease of use assessment and accuracy
by staff nurses and
resident doctors
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12. Hall R W, Shbarou RM Drug of choice for sedation and analgesia in newborn ICU Clin Perinatol
2009; 36:15-26.
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

SHEET A
RAPID ASSESSMENT AND IMMEDIATE MANAGEMENT OF
EMERGENCIES

Look for EMERGENCY

signs

Not breathing at APNEA OR

GASPING Start PPV
all (even when RESPIRATION Continue oxygen
stimulated) OR
gasping
respiration OR If bleeding is the likely cause of

Make sure newborn is warm; manage airways; start oxygen if saturation

respiratory rate shock:
less than Infuse normal saline 10

<90%; insert IV; measure blood glucose; correct low blood glucose
20/minute ml/kg body weight over 10

REFER TO SHEET B AFTER EMERGENCY MANAGEMENT,

minutes
Stop external bleeding
Give Vit K IV

OR IF EMERGENCY SIGNS ARE ABSENT

Weak and fast pulse
(HR>180wmt) AND SHOCK If bleeding is not the likely cause
Extremities cold to of shock:
touch AND Capillary Give 10 ml/kg normal saline
over 30 min
Refill Time> 3 sec,
(Follow STP)
with or without pallor,
or lethargy or
unconscious

Manage airways, Check and manage

Bleeding BLEEDING low blood glucose, check Calcium,
Give anticonvulsants
(Follow STP)

Seizures SEIZURES
Treat Hypoglycemia
(Follow STP)

Blood glucose less

HYPOGLYCEMIA
than 45 mg/dL Keep under warmer Rapid re-warm if
temp <32 up to 34 C and then
gradual rewarming
MODERATE TO
SEVERE (Follow STP)
Temperature
HYPOTHERMIA
<36.0C

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book of
Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

SHEET B
ASSESSMENT FOR SPECIFIC CONDITIONS
(AFTER EMERGENCY MANAGEMENT OR IF EMERGENCY SIGNS ARE ABSENT)
NEONATAL HISTORY
Age of the neonate and the birth weight if available.
Was the baby born term? If not, then at what gestation?
Delayed Cry/ not breathing at birth/ requirement of BMV at birth
Is the baby having any other problem in feeding/ choking/ vomiting?
When did the problem start?
Has the baby worsened?
ASK

MATERNAL HISTORY
Medical, obstetric, social history,
Pregnancy: Duration, chronic diseases, HIV, any complications, history of maternal fever
Labour: Any complications, duration of rupture of membranes, any complication-fetal distress,
prolonged labor, caesarean section, color and smell of amniotic fluid, instrumental delivery,
vaginal delivery, malposition, malpresentation, any other complications

EXAMINATION
Recheck Temperature*
Recheck Heart rate*
Recheck Respiratory rate*
LOOK

Severe chest indrawing, grunting, central cyanosis. *IF taken more

than 30 minutes
Abdominal distention and/or vomiting
before
Seizure
Lethargy
Jaundice
Newborn with Any other obvious abnormality
hypothermia Any other obvious abnormality
Newborn with Seizure
Follow STP
Follow STP
Preterm
Neonate with breathing difficulty

Follow STP for Feeding of

Follow STP
Low Birth weight and Sick Neonates

Neonate with birth asphyxia

Newborn with sepsis Requiring bag and mask ventilation / intubation /
drugs at birth Follow STP
Suspect if any of following signs are present
Breathing difficulty, abnormal movements,
unconscious or lethargic, not feeding or poor feeding,
abdominal distension, or vomiting
OR Neonate with jaundice Follow STP
Maternal risk factors for sepsis present

See STP for Baby may have more than one condition to treat; so look for all conditions
SEPSIS

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket Book of
Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 SEARO-WHO STPS 2011-12

SHEET C
Assessment for specific conditions
NEONATAL HISTORY
Age of the neonate and the birth weight if available.
Was the baby born term? If not, then at what gestation?
Delayed Cry/ not breathing at birth/ requirement of BMV at birth
Is the baby having any other problem in feeding/ choking/ vomiting?
When did the problem start?
ASK

Has the baby worsened?

MATERNAL HISTORY
Medical, obstetric, social history,
Pregnancy: Duration, chronic diseases, HIV, any complications, history of maternal fever
Labour: Any complications, duration of rupture of membranes, any complication-fetal
distress, prolonged labor, caesarean section, color and smell of amniotic fluid, instrumental
delivery, vaginal delivery, malposition, malpresentation, any other complications

EXAMINATION
Temperature*
Heart rate*
LOOK

Respiratory rate* *IF taken more

Severe chest indrawing, grunting, cyanosis, than 30 minutes
before
abdominal distension.
Posture, Movement
Lethargy
Jaundice, Any other obvious abnormality

Neonate with convulsions after emergency management

Evaluate the level of consciousness; look for abnormal eye
movements

Neonate with breathing difficulty Refer to treatment protocol

Fast breathing (60 breaths/min or more) CONVULSIONS
PRETERM OR severe chest in-drawing OR grunting

Refer to treatment protocol

Refer to treatment protocol
PRETERM
Neonate with birth asphyxia BREATHING DIFFICULTY
Requiring bag and mask ventilation / chest
Neonate with sepsis compressions / intubation / drugs at birth
Suspect if one/more of following Non-vigorous baby born through meconium stained
Decreased feeding/activity, lethargy/hypotonia, Refer treatment protocol
liquor
Vomiting, diarrhea, abdominal distension, POST RESUSCITATION MANAGEMENT
temperature instability, convulsion or deranged
sensorium Neonate with jaundice
OR Any visible jaundice on day1 Refer to treatment protocol
Maternal risk factors for sepsis Yellow palms and soles JAUNDICE
Jaundice lasting for more than 3 weeks
AIIMS
Refer New Delhi
to treatment protocol after birth
SEPSIS
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Transport of a sick baby

Determine the indication* to transport the baby to higher health facility:

Birth weight <1000 grams / gestation <28 weeks
Severe respiratory distress
Shock not responding to fluid boluses and vasopressors
Severe jaundice needing exchange transfusion
Major congenital malformations e.g. meningomyelocele, complex heart disease
Refractory seizures
Abdominal distension with bilious vomiting

Preparation for baby

Stabilize the baby (temperature, airway, breathing, circulation
and blood sugar)
Secure IV line and give necessary treatment before transfer
Oxygen if indicated

Prepare for transport

Counsel the parents and family before transport
Communicate with & write a brief note to the referral hospital
Arrange a capable healthcare provider, mother and a relative to accompany (if available)
Assemble supplies and equipment to carry and arrange for transport (see box)
Give one dose of antibiotics before transport

Care during transport

Monitor frequently (temperature, airway and breathing, circulation, IV cannula and infusions
Ensure that the baby receives feeds or fluid
Oxygen if indicated
Stop the vehicle, if necessary, to manage problems

Feedback after transport

Communicate with team at referral hospital to know:
Condition of the baby at arrival
Outcome of the baby
Post-discharge advice & follow up

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket
Book of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/
 Standard Treatment Protocol for management of common newborn conditions in small hospitals
(Adapted from WHO Guidelines)

Annex: Supplies and equipment to carry

Equipment and supplies Drugs & fluids

Cover adequately-socks, cap Fluids & feeds: Any drug (e.g.

Source of warmth, blanket o Expressed breast milk antibiotics) the
Resuscitation equipment: o Oro gastric tube to feed baby is receiving if
o bag o IV infusion set a dose is
o appropriate sized mask o Butterfly set or IV set anticipated during
o suction apparatus Syringes and needles (various the trip
o oxygen cylinder with sizes and types) IV fluid ( NaCl ,
flow meter Adhesive tape Ringer lactate , 10%
o nasal catheter, or head Sterile gloves dextrose )
box Antiseptic solution and cotton-
Stethoscope, thermometer wool balls
Extra napkins (diapers)
A source of illumination: Torch
If the baby is able to feed and the mother is not accompanying the baby, carry expressed breast milk and send
mothers blood sample.

For additional / next level management please refer to WHO Guidelines (Managing Newborn Problems and Pocket
Book of Hospital Care of Children), http://www.ontop-in.org/sick-newborn/, http://www.newbornwhocc.org/