diff --git "a/notes/Ghai-Essential-Pediatrics_4.txt" "b/notes/Ghai-Essential-Pediatrics_4.txt" new file mode 100644--- /dev/null +++ "b/notes/Ghai-Essential-Pediatrics_4.txt" @@ -0,0 +1,2141 @@ +Micronutrients in Health and Disease - + + + +Table 7.3: Spectrum of iodine deficiency disorders IDD +Fetus Abortions, stillbirths Congenital anomalies Endemic cretinism +Increased perinatal mortality Neonate Neonatal goiter +Endemic mental retardation Neonatal hypothyroidism +Child, adolescent Goiter +Impaired mental function Subclinical hypothyroidism Retarded physical development + + +Recommended daily intake of Iodine The recom­ mended daily allowance of iodine is as follows: 90 mg for preschool children (0 to 59 months); 120 mg for school children (6 to 12 yr); 150 mg for adults (above 12 yr); and 200-250 mg for pregnant and lactating women. + +Iodine Deficiency in the Fetus +The consequence of iodine deficiency during pregnancy is impaired synthesis of thyroid hormones by the mother and the fetus. Since the physiologic role of thyroid hor­ mones is to ensure the coordination of different develop­ mental events through specific effects on the rate of cell differentiation and gene expression, an insufficient supply of thyroid hormones to the developing brain results in mental retardation. + +Iodine Deficiency in the Neonate +The brain of the human infant at birth has only reached about one-third of its ll size and continues to grow rapidly until the end of the second year. The thyroid hormone, dependent on an adequate supply of iodine, is essential for normal brain development. The continuing presence of iodine deficiency is a threat to early brain development. +Neonatal chemical hypothyroidism is defined by serum levels of T4 lesser than 3 mg/ dl and TSH grea­ ter than 100 mU/ml. In severely iodine deficient environ­ ments in Northern India, where more than 50% of the population has urinary iodine levels below 25 mg/ g creatinine, the incidence of neonatal hypothyroidism is 75-115 per thousand births. In Delhi, where only mild iodine deficiency is present with low prevalence of goiter, the incidence drops to 6 per thousand. +Neonatal hypothyroidism persists into infancy and childhood if the deficiency is not corrected and results in retardation of physical and mental development. These observations indicate a much greater risk of mental defect in severely iodine-deficient populations than is indicated by the presence of cretinism. + +Iodine Deficiency in Children +Moderate iodine deficiency is associated with abnormalities in psychoneuromotor and intellectual development of + +children who are clinically euthyroid, but who do not exhibit other features of endemic cretinism. Some patients may show goiter (Fig. 7.7) (see Chapter 17). Studies in moderately iodine-deficient areas indicate that fine motor skills and visual problem solving improved in school children after iodine repletion. + + + + + + + + + + + + + + + + + + +Fig. 7.7: A 14-yr-old girl with goiter + +Therapy +Iodization of salt is the most practical option. Other options for correction of IDD are administration of iodized oil capsules every 6-10 months, direct administration of iodine solutions, such as Lugol iodine at regular intervals and iodization of water supplies by direct addition of iodine solution. The National Goiter Control Program (1962) for control of iodine deficiency disorders was started by establishment of salt iodination plants to ensure an adequate supply of iodized salt in the country. Based on an assumption of a mean intake of salt of 5 g/ day, the recommended level of iodination is one part of iodine in 25,000 to 50,000 parts of salt. + +Iron +Iron deficiency remains a major nutritional problem among infants and young children. The National Family Health Survey (NFHS) II, conducted in 1998-99, docu­ mented that 74% children between the ages of 6-35 months were anemic. The NFHS III (2005-06) shows similar data. Iron deficiency anemia is associated with impaired performance in mental and physical functions, including physical coordination and capacity, cognitive abilities, and social and emotional development. The precise effects vary with the age groups studied. The health consequences of iron deficiency in young children are serious and often irreversible. A description of clinical features, diagnosis, treatment and prevention of iron deficiency anemia is given in Chapter 12. + +Nwborn Infants + + + + + + + +Ramesh Agarwal, Vinod K Paul, Ashok K Deorari + + + + + + + +Newborn infants are unique in their physiology and the health problems that they experience. Neonatal period is characterized by transition to extrauterine life and rapid growth and development. This is the phase in life with the greatest risk of mortality. It is also the most critical period for longterm physical and neurocognitive development. +Newborn health is the key to child health and survival. More than under half of under 5 child deaths occur in the neonatal period (see Chapter 1). Preterm birth complica­ tions account for 35% of all neonatal deaths and constitute the most important cause of neonatal mortality (Fig. 8.1). Bacterial infections (sepsis, pneumonia and diarrhoea) contribute to 33% of neonatal deaths. Other causes of neonatal mortality are birth asphyxia (20%) and congenital malformations (9%). Almost three-fourths of all neonatal deaths occur among the low birth weight newborns. Of all the neonatal deaths, about 40% occur within first 24 hr, half within 72 hr and three fourths within one week of birth. Predominant causes of death in the first week of life include birth asphyxia and preterm birth complications. Health of the mother and care during pregnancy and at childbirth has profound influence on neonatal outcome. As noted in Chapter 1, decline in neonatal mortality is critical to achieve national health goals. The stagnant early neonatal mortality is a cause for concern. + +Definitions +Neonatal period. From birth to under four weeks (<28 days) of age. An infant is called a neonate during this phase. First week of life (<7 days or <168 hr) is known as early neonatal period. Late neonatal period extends from 7th to <28th day. + +Postneonatal period. Period of infancy from 28 days to <365 days of life. + +Weeks of gestation refer to completed weeks of gestation, e.g. 36 weeks gestation, refer to range of gestation from 36 weeks O day to 36 weeks and 6 days. + + + + + + + + + + + + + + + + + +Fig. 8.1: Causes of neonatal deaths (2010) + +Perinatal period. Perinatal period extends from 22nd week of gestation (L154 days or weighing L500 g at birth) to less than 7 days of life. +Live birth. A product of conception, irrespective of weight or gestational age, that, after separation from the mother, shows any evidence of life such as breathing, heart-beat, pulsation of umbilical cord or definite movement of voluntary muscles. +Fetal death. A fetal death is a product of conception that, after separation from the mother, does not show any evidence of life. +Still-birth. Fetal death at a gestational age of 22 weeks or more or weighing more than 500 g at birth. +Term neonate. A neonate born between 37 and <42 weeks (259-293 days) of gestation. +Preterm neonate. A neonate born before 37 weeks (<259 days) of gestation irrespective of the birth weight. + +124 +Newborn Infants - + + + +Post-term neonate. A neonate born at a gestation age of 42 weeks or more (294 days or more). +Low birthweight (LBW) neonate. A neonate weighing less than 2500 g at birth irrespective of the gestational age. +Very low birthweight (VLBW) neonate. A neonate weighing less than 1500 g at birth irrespective of the gestational age. +Extremely low birthweight (ELBW) neonate. A neonate weighing less than 1000 g at birth irrespective of the gestational age. +Neonatal mortality rate (NMR). Deaths of infants under the first 28 days of life per 1000 live births per year. +Perinatal mortality ratio (PNMR). Number of perinatal deaths (stillbirths plus neonatal deaths before 7 days of life) per 1000 live births. It is designated as a ratio since the numerator is not part of the denominator. (For rate, like in NMR, numerator is part of denominator.) + +Online Learning Resource Material +The Newborn Division of Department of Pediatrics, vlS, has produced excellent resource material for leing of health professionals. The material is in form of modules, posters, videos and webinars on common newborn issues and is available at: www.newbornwhocc.org. +The online material complements the information provided in this Chapter. The readers are encouraged to visit the website and use the resource to enhance their leaing. + +RESUSCITATION OF A NEWBORN +Of the 25 million infants born every year in India, 3-5% experience asphyxia at birth. Asphyxia is characterized +by progressive hypoxia, hypercapnia, hypoperfusion and +acidosis. It may lead to multiorgan dysfunction that may cause death. Hypoxic ischemic encephalopathy (HIE) resulting from asphyxia may lead to longterm neuromo­ tor sequelae. +There is broad consensus on the evidence based resuscitation of newborn babies at birth. The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have recently updated the resuscitation guidelines that are being propagated worldwide through the Neonatal Resuscitation Program (NRP). A summary of the recommendations of AHA-AAP (2010) is provided here. + +Pathophysiology of Asphyxia +When an infant is deprived of oxygen, an initial brief period of rapid breathing occurs. If the asphyxia continues, the respiratory movements cease and the infant enters into a period of apnea known as primary apnea. During primary apnea, the heart rate begins to fall, neuromuscular tone gradually diminishes but the blood pressure remains normal. In most instances, tactile stimulation during this period will reinitiate respiration. + + +If the asphyxia continues, the infant develops deep gasping respiration, the heart rate continues to decrease, the blood pressure begins to fall and the infant becomes flacid. The breathing becomes weaker until the infant gasps and enters into a period of secondary apnea. The infant is now unresponsive to stimulation and does not spontaneously resume respiratory efforts unless resuscita­ tion in the form of positive pressure ventilation is initiated. It is important to note that as a result of fetal hypoxia, the infant may go through the phases of primary and secondary apnea even in utero. Hence, apnea at birth may be either primary or secondary apnea. These two are clinically indistinguishable; in both instances, the infant is not breathing and the heart rate may be below 100 beats per minute. Hence, when faced with an apneic infant at birth, one should assume that one is dealing with secondary apnea and be ready to undertake full resusci­ tation efficiently without wasting too much of time in +providing tectile stimulation. + +Lung Inflation +During intrauterine life, the lungs do not take part in gas exchange, which is taken care ofby the placenta. The lung alveoli in the fetus are filled with fluid secreted by type II alveolar cells. The process of fluid removal starts with onset of labor. The fluid gets reabsorbed from the alveoli into the perivascular space and then into blood and lymphatic channels. The process of labor may facilitate removal of lung fluid, whereas removal is slowed when labor is absent (as in elective cesarean section). +Removal of lung fluid from the alveoli is facilitated by respiration soon after birth. The first few breaths after birth are effective in expanding the alveoli and replacing the lung fluid with air. Problems in clearing lung fluid may occur in infants whose lungs have not inflated well with the first few breaths, such as those who are apneic at birth or have a weak initial respiratory effort as with prema­ turity or sedation. + +Pulmonary Circulation +Oxygenation depends not only on air reaching the alveoli, but also on pulmonary circulation. During intrauterine life, there is little blood flow in the lungs due to pulmonary vasoconstriction. After birth, pulmonary vasodilatation takes place resulting in fall in pulmonary vascular resistance and increased blood flow in the pulmonary circuit. +An asphyxiated infant has hypoxemia (low-oxygen content of the blood) and acidosis (low pH). In the presence of hypoxemia and acidosis, the pulmonary arterioles remain constricted and ductus arteriosus remains open (persistence of fetal circulation). As long as there is poor pulmonary blood flow, proper oxy­ genation of the tissues of the body is impossible because there is inadequate uptake of oxygen, even when the infant is being properly ventilated. +_____s_s _e_n_ti_a__Pe__d_ia_t_ri -------------------------------- +c +s +E +1 + + +In mildly asphyxiated babies whose oxygen and pH are only slightly lowered, it may be possible to increase pulmonary blood flow by quickly restoring ventilation. However, pulmonary perfusion in severely asphyxiated infants may not improve with ventilation alone. The combination of oxygenation and correction of metabolic acidosis would be necessary to open the pulmonary arterioles that would improve pulmonary blood flow. + +Cardiac Function and Systemic Circulation +In asphyxia, there is redistribution of blood flow to preserve blood supply to vital organs. There is vasoconstriction in the bowel, kidney, muscles and skin, thus preserving blood flow to the heart and brain (diving-in reflex). +As asphyxia is prolonged, myocardial function and cardiac output too deteriorate and blood flow to all organs is further reduced. This sets in the stage for progressive organ damage. At this point, it may be necessary to provide cardiac stimulants (epinephrine) and volume expanders (normal saline) to support the heart and circulation. + +Preparing for Resuscitation +With careful consideration of antepartum and intrapartum risk factors, asphyxia can be anticipated in up to only half of the newborns who will eventually require some form of resuscitation. In others, the need for resuscitation can come as a complete surprise. Therefore, each delivery should be viewed as an emergency and basic readiness must be ensured to manage asphyxia. Preparation for delivery should include: +i. A radiant heat source ready for use +ii. All resuscitation equipments immediately available and in working order (Table 8.1) +iii. At least one person skilled in neonatal resuscitation + +Evaluation +Evaluation is based primarily on the following three signs: respiration, heart rate (HR) and color. Though all three signs are evaluated simultaneously, low heart rate is the most important sign for proceeding to the next step. + +Role of Apgar Scores in Resuscitation +The Apgar score is an objective method of evaluating the newborn's condition (Table 8.2). It is generally performed at 1 minute and again at 5 minutes after birth. However, resuscitation must be initiated before the 1-minute score + + +Table 8.1: Neonatal resuscitation supplies and equipment Suction equipment +Mechanical suction +Suction catheters 10, 12 or 14 F Meconium aspirator +Bag and mask equipment +Neonatal resuscitation bags (self-inflating) Face-masks (for both term and preterm babies) Oxygen with flow meter and tubing +Intubation equipment +Laryngoscope with straight blades no. 0 (preterm) and no. 1 (term) +Extra bulbs and batteries (for laryngoscope) +Endotracheal tubes (internal diameter of 2.5, 3.0, 3.5 and 4.0 mm) +Medications +Epinephrine +Normal saline or Ringer lactate Naloxone hydrochloride +Miscellaneous +Linen, shoulder roll, gauze Radiant warmer Stethoscope +Syringes 1, 2, 5, 10, 20, 50 ml Feeding tube 6 F +Umbilical catheters 3.5, 5 F Three way stopcocks Gloves + +is assigned. Therefore, the Apgar score is not used to guide the resuscitation. +While the Apgar score is not useful for decision making at the beginning of resuscitation, the change of score at sequential time points following birth can reflect how well the baby is responding to resuscitative efforts. Hence, Apgar scores should be obtained every 5 minutes for up to 20 minutes, if the 5-minute Apgar score is less than 7. + +TABC of Resuscitation +The components of the neonatal resuscitation procedure related to the TABC of resuscitation are shown here: +T-Temperature: Provide warmth, dry the baby and remove the wet linen. +A-Airway: Position the infant, clear the airway (wipe baby's mouth and nose or suction mouth, nose and in + + + + +Sign +Heart rate Respiration Muscle tone Reflex irritability Color + + +0 +Absent Absent Limp +No response Blue or pale + +Table 8.2: Apgar score 1 +Slow (<100 beats/min) Weak cry +Some flexion Grimace +Body pink, extremities blue + + +2 +Normal (>100 beats/min) Good strong cry +Active movements Cough or sneeze Completely pink +Newborn Infants - + + + +some instances, the trachea in non-vigorous baby born through meconium stained liqor). If necessary, insert an endotracheal (ET) tube to ensure an open airway. +B-Breathing: Tactile stimulation to initiate respirations, positive-pressure breaths using either bag and mask or bag and ET tube when necessary. +C-Circulation: Stimulate and maintain the circulation of blood with chest compressions and medications as indicated. +Resuscitation Algorithm +Figure 8.2 presents the algorithm of neonatal resuscitation. At the time of birth, one should ask three questions about the newborn: +i. Term gestation? +ii. Breathing or crying? +iii. Good muscle tone? (flexed posture and active +movement of baby denotes good tone) + +If answers to all the three questions are 'Yes', the baby does not require any active resuscitation and "Routine care" should be provided. Routine care consists of four steps: +i. Warmth: Provided by putting the baby directly on the mother's chest in skin-to-skin contact. +ii. Clearing ofairway if required: Done by wiping the baby's mouth and nose using a clean cloth. No need to suction routinely. +iii. Dry the baby +iv. Ongoing evaluation for vital parameters. Helping mother in breastfeeding will facilitate easy transition to extrauterine environment. +If answer to any of the three questions is "No", the baby requires resuscitation. After cutting the cord, the baby +should be subjected to a set of interventions known as Initial steps. + + + + + +Birth I +I I I I I I I I I +I +30 sec I I I I I I I +60 sec + + +Term gestation? Yes +Breathing or crying? Good tone? + +No +Provide warmth, clear airway if necessary, dry, stimulate + + +Heart rate below 100, No gasping or apnea? + +Yes 1 + +Positive pressure ventilation [ SpO, monitoring ] +! + + +1 Heart rate below 100? 1 No Yes + +Routine care Provide warmth +Clear airway, if necessary Dry +r +Keep with mother Ongoing evaluation + +No + + +,"Labored breathing +�� pe2!.stent cyanosis? + +Yes +Clear airway, SpO, monitoring +Co�erCPAP ] + + +Assessment + + + + + + +Evaluation + + + + + + + + +Evaluation + + + +[ Take ven� �ective step7") + + +Heart rate below 60? +_! +:i + +Yes!___ - +r-- +Consider intubation Chest compressions +Coordinate with positive pressure ventilation +! + + +!.eart rate below 60? Yesu +J +IV epinephrine + + +care + + + + + +Targeted SpO, after birth 1 minute: 60-65% +2 minutes: 65-70% +3 minutes: 70-75% Evaluation 4 minutes: 75-80% +5 minutes: 80-85% 10 minutes: 85-95% + + +Fig. 8.2: The algorithm of neonatal resuscitation. CPAP continuous positive airway pressure; PPV positive ventilation; Sp02 saturation of oxygen. +(Adapted with permission from American Academy of Pediatrics 2010) +__ ss_e___t_ P_e_d___t_-r _________________________________ +i +c +s_ +i +a +i +a_ +l +n +E +_ + + +Initial Steps Warmth +The baby should be placed under the heat source, preferably a radiant warmer. The baby should not be covered with blankets or towels to ensure full visualization and to permit the radiant heat to reach the baby. + +Positioning +The baby should be placed on her back or side with the neck slightly extended. This brings the posterior pharynx, larynx and trachea in line and facilitates breathing. Care should be taken to prevent hyperextension or flexion of the neck, since either may interfere with respiration. +To help maintain the correct position, place a rolled blanket or towel under the shoulders, elevating them % or 1 inch off the mattress. This shoulder roll is particularly helpful if the infant has a large occiput resulting from molding, edema, or prematurity (Fig. 8.3). + + +-- + +Dry, Stimulate and Reposition +After suctioning, the baby should be dried adequately using pre-warmed linen to prevent heat loss. The wet linen should be removed away from the baby. The act of suctioning and drying itself provides enough stimulation to initiate breathing. If the newborn continues to have poor respiratory efforts, additional tactile stimulation in form of flicking the soles or rubbing the back gently may be provided briefly to stimulate the breathing. However, one should not waste too much of time in providing tactile stimulation. + +Management o f Infant Born Through Meconium-Sta ined Liquor (MSL) +When baby passes meconium in utero, meconium may be aspirated into infant's mouth and potentially into the trachea and lungs. Steps must be taken after delivery to reduce serious consequences of aspiration of meconium (Fig. 8.4). (Note: Intrapartum suctioning of the mouth and nose after delivery of the head and before delivering the shoulders is no longer recommended). + +No need for lntrapartum suction + + +Birth: assess heart rate, breathing and tone + + +Vigorous: +Heart rate 100/min or more, strong respiratory efforts and good muscle tone +� + + +Non-vigorous: +Heart rate<100/min or weak/no respiratory efforts or poor muscle tone + + + +Fig. 8.3: Rolled towel under the shoulders Only initial steps + +Tracheal suction; repeat if necessary + + + + +Clear Airway if Necessary +The appropriate method for clearing the airway will depend on the presence or absence of meconium. +If no meconium is present, secretion may be removed from the airway by wiping the nose and mouth with a clean cloth or by suctioning with a bulb syringe or suction catheter. The mouth is suctioned before nose ('M' before 'N') to ensure the infant does not aspirate, if she should gasp when the nose is suctioned. If the infant has copious secretion from the mouth, the head should be turned to the side. This will allow secretions to collect in the side of mouth, where they can be easily removed. +For suctioning, the size of suction catheter should be 12 or 14 Fr. The suction pressure should be kept around 80 mm Hg (100 cm water) and should not exceed 100 mm Hg (130 cm water). One should not insert the catheter too deep in mouth or nose for suction as stimulation of posterior pharynx can produce vagal response resulting in brady­ cardia or apnea. The maximum time limit for suctioning is 15 seconds. +Clearing of the airways in babies born through meconium stained liquor is discussed later. + +Fig 8.4: Management of a baby born through meconium stained liquor + +After delivery, the first step is to identify whether the infant is vigorous or non-vigorous. A newborn infant is classified as vigorous if he has all the three signs namely strong respiratory efforts, good muscle tone and a heart rate greater than 100/min. Absence of any sign would imply a non-vigorous baby. +The vigorous baby does not require any tracheal suctioning and the routine care or initial steps are provided. +For non-vigorous babies, the initial steps are modified as below: +• Place the baby under radiant warmer. Postpone drying and suctioning to prevent stimulation. +• Remove the residual meconium in the mouth and posterior pharynx by suctioning under direct vision using a laryngoscope. +• Intubate and suction out meconium from the lower airway. +Tracheal suctioning is best done by applying suction directly to the endotracheal tube (ET). Continuous suction is applied to the ET tube as it is withdrawn. Tracheal suctioning can be repeated if the previous suctioning has +Newborn Infants - + + + +revealed meconium and baby has not developed significant bradycardia. + +Evaluation +After providing initial steps, the baby should be evaluated by assessing respiration, HR and color (or oxygen saturation by pulse oximetry). + + +Oxygen Pressure gauge + + +Pressure release (pop-off) valve + +Valve assembly + + + +Respiration is evaluated by observing the infant's chest movements. HR can be assessed by auscultating the heart or by palpating the umbilical cord pulsation for 6 seconds. The number of beats or pulsation is multiplied by 10 to obtain the HR per minute (e.g. a count of 12 in 6 seconds is a HR of 120 per minute). Color is evaluated by looking at tongue, mucous membranes and trunk. A blue hue to the lips, tongue and central trunk indicates central cyanosis. Presence of cyanosis in extremities (acrocyanosis) does not have any significance. +• If the baby has good breathing, HR 100/min or more and no cyanosis, then she does not require any addi­ tional intervention and the baby should be monitored frequently. +• If the baby has labored breathing or persistent central cyanosis, administration of CP AP in preterm babies and supplemental oxygen in term babies is recommended. Baby should have its oxygen saturation monitored and supplemental oxygen is titrated to achieve the targeted saturations (Fig. 8.2). +• If the baby is apneic, has gasping breathing or heart rate is below 100 min, positive pressure ventilation (PPV) is needed. + +Supplemental Oxygen +Central cyanosis requires supplemental oxygen, which can be provided by an oxygen mask or oxygen tube held in cupped hand over baby's face or by flow inflating bag and mask. The flow of oxygen should be at least 5 1/ minute. Supplemental oxygen cannot be provided by self inflating bags. + +Positive Pressure Ventilation (PPV) +PPV is usually given by using a self-inflating bag and face mask (bag and mask ventilation or BMV). The self­ inflating bag is easy to use as it reinflates completely without any external compressed source of gas. The disadvantage of such bag is that it cannot be used to administer free-flow of oxygen. +The resuscitation bag (Fig. 8.5) should have a capacity of 240 to 750 ml. If the bag is attached to an oxygen source (at 5-6 liter/min) and a reservoir, it delivers 90-100% oxygen. In absence of reservoir, it delivers 40% to 50% oxygen. +Oxygen should be treated as a drug. Both too little or too much of oxygen is bad for the baby. Even a brief exposure to high concentration of oxygen can have detrimental effect on the baby. Studies have shown that + + + + + +Patient outlet Fig. 8.5: Self-inflating bag +(Adapted with premission from AAP 2005) + +term babies resuscitated with room air compared to 100% oxygen have better survival and longterm outcomes. The evidence in favor or against the use of oxygen in preterm babies is yet lacking. +It is therefore recommended that term babies should be initiated on room air resuscitation. Ideally, oxygen satu­ ration should be monitored by pulse oxirnetry and oxygen delivery should be titrated to maintain the oxygen satura­ tion in the targeted range (Fig 8.2). In absence of pulse oxirnetry, room air should be substituted by 100% oxygen if the baby fails to improve (improvement in HR and breathing) by 90 seconds. +PPV in preterm babies is recommended using inter­ mediate concentration of oxygen (30% to 60%). The oxygen concentration should be titrated by continuously moni­ toring of oxygen saturation by pulse oximetry. BMV is indicated if: +i. The infant is apneic or gasping +ii. HR is less than 100 beats per minute +iii. Persistent central cyanosis despite administration of 100% free flow oxygen +In suspected or confirmed diaphragmatic hernia, bag and mask ventilation is contraindicated. Similarly, in non­ vigorous babies born through MSL, bag and mask venti­ lation is carried out only after tracheal suctioning. + +Procedure +The infant's neck should be slightly extended to ensure an open airway. The care provider should be positioned at head end or at the side of baby so as to have an unobstructed view of infant's chest and abdomen. Select an appropriate sized face mask that covers the mouth and nose, but not eyes of the infant (Fig. 8.6). The face mask should be held firmly on face to obtain a good seal. The bag should be compressed using fingers and not by hands. +PPV is the single most effective step in babies who fail to breathe at birth. Ensuring adequacy of ventilation is the most important priority in such babies. +If the baby is not responding to PPV by prompt increase in HR, ventilation corrective steps are taken: observe for +. __E_s_s_e_n_ t_ia_l_P_e_d_i_a _tr_ic_s ________________________________ +_ + +Improvement in the infant's condition is judged by increasing HR, spontaneous respiration and improving color. If the infant fails to improve, check adequacy of ventilation in form of visible chest rise. If chest rise is inadequate, one should take necessary action as described earlier. +PPV may cause abdominal distension as the gas escapes into the stomach via esophagus. Distended stomach presses on the diaphragm and compromises the ventilation. Therefore, if ventilation is continued for more than two minutes, an orogastric tube (feeding tube size 6-8 Fr) should be inserted and left open to decompress the abdomen. + + + + +Fig. 8.6: Properly fitting mask (Adapted with permission from AAP 2005) + +an appropriate rise of the chest and auscultate for breath sounds. If chest does not rise and there are no audible breath sounds, the steps outlines in Table 8.3 should be undertaken. + +Table 8.3: Ventilation corrective steps (MRSOPA) Action Condition +Inadequate seal Re apply mask +Blocked airway Reposition the infant's head Blocked airway Clear secretions by suction +Blocked airway Ventilate with mouth slightly open Inadequate pressure Increase pressure slightly +Consider alternate Blocked airway(endotracheal tube) airway + +When normal rise of the chest is observed, one should begin ventilating. Ventilation should be carried out at a rate of 40 to 60 breaths per minute, following a 'squeeze, two, three' sequence (Fig. 8.7). +Usual pressure required for the first breath is 30-40 cm of water. For subsequent breaths, pressure of 15-20 cm of water is adequate. After the infant has received 30 seconds of PPV, evaluate the HR and take a followup +action as in Fig. 8.2. + +Chest Compressions +The heart circulates blood throughout the body delivering oxygen to vital organs. When an infant becomes hypoxic, the HR slows and myocardial contractility decreases. As a result there is diminished flow of blood and oxygen to the vital organs. +Chest compressions (CC) consist of rhythmic com­ pression of the sternum that compress the heart against the spine, increase intrathoracic pressure and circulate blood to the vital organs of the body. CC help in mechanically pumping the blood to vital organs of the body. CC must always be accompanied by BMV so that only oxygenated blood is being circulated during CC. + +Chest compressions are indicated if HR is below 60/ min even after 30 seconds of PPV. Once the HR is 60/min or more, chest compressions should be discontinued. + + +Procedure +There are two techniques for chest compressions: (i) thumb technique (Fig. 8.8), and (ii) two-finger technique (Fig. 8.9). With the thumb technique, the two thumbs are used to depress the sternum, with the hands encircling the torso and the fingers supporting the back. In two-finger technique, the tips of the middle finger and either index or ring finger of one hand is used to depress the sternum. The other hand is used to support the infant's back, unless the infant is on a firm surface. + + + +One (Squeeze) + +Two Three (Release ......) + +One (Squeeze) + + +Two Three (Release ...... ) + + + + + + + + + +Fig. 8.7: Correct rhythm of providing positive pressure ventilation. (Adapted with permission from American Academy of Pediatrics 2005) +Newborn Infants - + + +30 breaths are administered (a total of 120 events). To obtain the proper ratio of 90 compressions and 30 ventilations in 1 minute (3:1), chest should be compressed three times in 1 h seconds, leaving out approximately h second for ventilation. +Thumbs or the tips of fingers (depending on the method used) should remain in contact with the chest during compression and release. Do not lift your thumbs or fingers off the chest between compressions. +To determine efficiency of chest compressions, the carotid or femoral pulsation should be checked periodically. Possible complications of chest compressions include +broken ribs, laceration of liver and pneumothorax. + + + + +Fig. 8.8: Chest compression with two finger technique (Adapted with permission from AAP 2005) + + + + + + + + + + + + + + +Fig. 8.9: Chest compression with thumb technique (Adapted with permission from AAP 2005) + +When chest compression is performed on a neonate, pressure is applied to the lower third of sternum. Care must be taken to avoid applying pressure to xiphoid. To locate the area, one should slide the fingers on the lower +edge of thoracic cage and locate xiphisternum. The lower +third of the sternum is just above it. + +Rate +It is important to ventilate between chest compressions. A positive breath should follow every third chest compression. In one minute, 90 chest compressions and + +Evaluation +After a period of 30 seconds of chest compressions, the heart rate is checked: +HR below 60. Chest compressions should continue along with bag and mask ventilation. In addition, medications (epinephrine) have to be administered. +HR 60 or above. Chest compressions should be dis­ continued. BMV should be continued until the heart rate is above 100 beats per minute and the infant is breathing spontaneously. + +Endotracheal Intubation +Endotracheal (ET) intubation is required only in a small proportion of asphyxiated neonates. Intubation is a relatively difficult skill to learn and it requires frequent practice to maintain the skill. + +Indications +The indications of ET intubation are: (i) when tracheal suction is required (in non-vigorous babies born through MSL), (ii) when prolonged BMV is required, (iii) when BMV is ineffective, and (iv) when diaphragmatic hernia is suspected. The other conditions where ET intubation may be considered are: before starting chest compressions and for administering epinephrine. + +Endotracheal Tube (ET) +ET should be of uniform diameter throughout the length of the tube (and not tapered near the tip) and have vocal cord guide at the tip and centimeter markings. ET tube size depends on the weight or gestation of the baby (Table 8.5). + + + + + +Heart rate Above 100 + +60 to 100 Below 60 + +Table 8.4: Followup action for heart rate response Action +If spontaneous respiration is present, discontinue ventilation gradually: provide tactile stimulation by gently rubbing the body, and monitor heart rate, respiration and color +Continue ventilation; take ventilation corrective steps Continue to ventilate; start chest compressions +__ _ss_ e_ n_ _t i_ al_ P_ _ed_ _ ia_ tr_ i_ c_ _________________________________ +s +E + +Table 8.5: Appropriate endotracheal tube size + +Inner diameter of tube (mm) +2.5 +3.0 +3.5 + +4.0 + +Weight (g) +<1000 1000-2000 2000-3000 >3000 + +Gestational age (weeks) +<28 +28-34 +34-38 >38 + + + +Most ET currently manufactured for neonates have a black line near the tip of the tube which is called a vocal cord guide. Such tubes are meant to be inserted so that the vocal cord guide is placed at the level of the vocal cords. This helps position the tip of ET above the bifurcation of trachea. +For intubation, a neonatal laryngoscope, with straight blades of sizes 'O' (for preterm babies) and 'l' (term babies) is required. Before intubating, the appropriate blade is attached to the handle of laryngoscope and the light is turned on. + +Procedure +The infant's head should be in nidline and the neck kept slightly extended. The l goscope is held in the left hand between the thumb and the first three fingers, with the blade pointing away from oneself. Standing at the head end of the infant, the blade is introduced in the mouth and advanced to just beyond the base of the tongue so that its tip rests in the vallecula. The blade is lifted as shown in Fig. 8.10 and landmarks looked for; the epiglottis and glottis should come into view. The glottic opening is surrounded by vocal cords on the sides. Once the glottis and vocal cords are visualized, the ET is introduced from the right side of the mouth and its tip inserted into the glottis until the vocal cord guide is at the level of the glottis, thus positioning it half way between the vocal cords and carina. +yn + +Medications +The majority of infants requiring resuscitation will have a response to prompt and effective ventilation with 100% oxygen. Only a few require medications. + + + + + +Correct Incorrect +Fig. 8.10: Direction of pull on the laryngoscope (Adapted with permission from N> 2005) +Medications used in resuscitation include epinephrine and volume expanders (Table 8.6). Sodium bicarbonate and naloxone are indicated only for special circumstances (Table 8.6). There is no role of atropine, dexamethasone, calcium, mannitol and dextrose for newborn resuscitation in the delivery room. +Route ofadministration: Since veins in scalp or extremities are difficult to access during resuscitation, umbilical vein is the preferred route. No intracardiac injection is recommended. For umbilical vein catheterization, 3.5 Fr or 5 Fr umbilical catheter, is inserted into the umbilical vein such that its tip is just inside the skin surface and there is free flow of blood. +Direct injection into the umbilical cord is undesirable. Epinephrine may be injected directly into the tracheo­ +bronchial tree through ET. Since absorption is erratic, this method is to be used only if venous access cannot be obtained. The drug is injected by a syringe or a feeding tube (5 Fr) into the endotracheal tube, flushed with 0.5 ml of normal saline and dispersed into the lungs by PPV. + +Indications +Use of adrenaline is indicated if HR remains below 60 despite adequate ventilation and chest compressions for 30 seconds. + + +Table 8.6: Medications: indication, dosage and effects + +Medication Indication Effects (concentration) + + +Concentration Dose of the Route administered prepared solution + + + +Epinephrine (1:1000) + +Normal saline, Ringer lactate + +Naloxone +(0.4 mg/ml) + +HR <60/ min after 30 sec of effective PPV and chest compressions +Acute bleeding with hypovolemia + +Respiratory depression +with maternal history +of narcotic use witin 4 hr of birth + +Inotropic; chronotropic; peripheral vasoconstrictor +Increased intravascular volume improves perfusion +Narcotic antagonist + + +1:10000 + + + + +0.4 mg/ml + +0.1-0.3 ml/kg + + +10 ml/kg + + +0.25 ml/kg (0.1 mg/kg) + + +IV; through umbilical vein (endotracheal route if no N access) +Umbilical vein + + +N preferred; delayed +onset of action with +intramuscular use; adinister only after restoring ventilation + +Sodium bicarbonate is administered only if prolonged asphyxia is associated with metabolic acidosis despite use of epinephrine and volume expanders. IV intravenous; PPV positive pressure ventilation +Newborn Infants - + + + +Suggested Reading +Kattwinkel J. Textbook of Neonatal Resuscitation. In: Kattwinkel J (ed). 6th ed. American Academy of Pediatrics and American Heart As­ sociation, 2010 + +ROUTINE CARE +Care at Birth +Personnel and equipment to be available 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 high risk delivery is anticipated because of presence of risk factors identified before birth, more advanced resuscitation may be required. In such 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 comer 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. Details on neonatal resuscitation have been provided in the previous section. + +Standard precautions and asepsis at birth. The personnel attending the delivery must exercise all the universal/ standard precautions in all cases. All fluid from the baby/ mother should be treated as potentially infectious. Gloves, masks and gowns should be worn when resuscitating the newborn. The protective eye wear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids. +Observe 'five cleans' to prevent sepsis at birth: +i. Clean hands: Hand-hygiene and wear sterile gloves ii. Clean surface: Use clean and sterile towel to dry and +cover the baby +iii. Clean blade: The umbilical cord to be cut with a clean and sterile blade/scissor +iv. Clean tie: The cord should be clamped with a clean and sterile clamp or tie +v. Nothing to be applied on the cord. Keep it dry. +Prevention and management of hypothermia. Immediately after birth the newborn is at high 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. The temperature of delivery room should be 25°C and it should be free from draft of air. The baby should be received in a pre-warmed sterile linen sheet at birth. The infant should be dried thoroughly including the head and face, and any wet linen should not be allowed to remain in contact with the infant. The infant may be placed on the mother's abdomen immediately after the birth for early skin-to-skin (STS) + +contact. This will not only maintain the newborn's temperature, but also promote early breastfeeding and decreases the pain and bleeding in the mother. The baby should be observed during the transition period and made to wear the caps and socks. + +Delayed clamping of umbilical cord. Umbilical cord clamping must be delayed for 1 to 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. In preterm infants, delayed cord clamping is associated with reduced IVH and other morbidities. + +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 vemix, protects skin of the infant and helps maintain temperature. This gets absorbed on its own after sometime. +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 (Fig 8.11). The stump should be away from the genitals to avoid contamination. The cord should be inspected every 15-30 minutes during initial few hours after birth for early detection of any oozing. +Placement of identity band: Each infant must have an identity band containing name of the mother, hospital registration number, gender and birth weight. + +Care of Baby In the Initial Few Hours After Birth +Recording of weight. The baby should be weighed after stabilization and when the temperature is documented to be normal. A sterile pre-heated sheet ( or a single use paper towel) should be placed on weighing machine with 10 g + + + + + + + + + + + + + + + + +Fig. 8.11: Correct application of the umbilical clamp +___ _ss_ e_ _ _t i_ al_ P_ _ed_ _ ia_ tr_cs_ ________________________________ +i +n +_ +E +_ + + +sensitivity. Electronic weighing scales are ideal. Zeroing of the machine should be performed. The baby is then gently placed on the weighing machine and the weight is recorded. +First examination. The baby should be thoroughly examined at birth from head to toe and the findings should be recorded in neonatal record sheet. Examine midline structures for malformations (e.g. cleft lip, neck masses, chest abnormality, omphalocele, meningocele, cloaca! abnormality). Special attention should be given to identify and document the patent 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 anorectal malformation, respectively. The baby should be examined for presence of birth injuries. The axillary temperature of the baby should be recorded before the baby is shifted out from the birthing place. +Initiation of breastfeeding. The breastfeeding should be initiated at the earliest, but certainly within one hour of birth. The health provider should assist the mother to put the baby on breast irrespective of the mode of delivery. Breastfeeding counseling alone without proactive support is unlikely to result in high rates of successful breast­ feeding. Extra support is provided to primipara mothers and small babies. +Vitamin K. It should be administered to all the babies (0.5 mg for babies less than 1000 g and 1 mg for babies more than 1000 g). It is preferable to administer the Kl pre­ paration, however, if not available, vitamin K3 may be administered. Vitamin K3 can cause hemolysis in G6PD deficient babies. +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: (i) gender of the baby, (ii) birth weight and (iii) 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 early breastfeeding and bonding. Studies have shown that any separation during initial hours may have a deterimental effect on successful breastfeeding. + +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. +Oil massage. The benefits of oil application have been described for low birth weight babies in both developed + +and developing countries. 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. Coconut oil makes a good choice. +Exclusive breastfeeding. A proactive and a systematic approach should be followed to initiate, support and maintain breastfeeding. The various advantages of the breastfeeding should be discussed with the mother to motivate her. Availability of dedicated lactation nurse or counseler significantly improves the chances of successful breastfeeding. +Position of sleep. Evidence has linked prone position to the occurrence of sudden infant death syndrome (SIDS). All healthy term newborns should be put to sleep on their back (supine position). +Traditional practices that should be discouraged. The application of kajal or surma in the eyes, putting oil in the ear or applying cow-dung on cord must be strongly discouraged. + +Timing of discharge in a normal newborn. A normal baby should stay in the health facility for at least 24 hr. Smaller babies or those with feeding problems or sickness should remain in hospital as required. +The following criteria should be met in all the babies prior to discharge: +• The routine formal examination of the newborn has been performed and documented +• The newborn is breastfeeding properly. The adequacy of feeds can be determined by: +- Passage of urine 6 to 8 times every 24 hr - Baby sleeping well for 2-3 hr after feeds +• 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 significant jaundice or any other illness requiring closer observation by a health provider +• The mother has been counseled regarding routine newborn care and her queries are answered +• Followup advice should be communicated to the mother. Babies, particularly born to primigravida mothers should be called for followup visit at 48 hr of discharge if discharged before 48 hr +• Parents have been explained the following 'danger signs' when they need to bring the baby to the hospital: +i. Difficulty in feeding ii. Convulsion +iii. Lethargy (movement only when stimulated) iv. Fast breathing (RR >60/min) +Newborn Infants - + + + +v. Severe chest indrawing +vi. Temperature of more than 37.5°C or below 35.5°C • A date for followup has been assigned. A normal +newborn with adequacy of breastfeeding and no significant jaundice by 72 hr of age can be seen at 6 weeks of age. In presence of any high risk factor (e.g. low birth weight, prematurity significant jaundice, or feeding not established), the baby should be seen within 2-3 days of discharge. + +Common Parental Concerns +• Weight loss in first week: Normally babies lose 8-10% of birth weight in the first week of life which is regained by 7-10 days age. Subsequently there should be a gain of 20 to 40 g per day. +• Crying during micturition: The sensation of a full bladder is uncomfortable to many babies who cry before passing urine and they quieten as soon as micturition starts. Crying during passage of urine as opposed to before the act of rnicturition should alert clinician to the possibility of urinary tract infection. +• Bathing: During the first week, till cord falls off, only sponging is recommended which can be given after the first 24 hr of life. Later, bathing every 2-3 days is quite sufficient. A draught-free warm room, warm water and quick completion of bath ensure that the baby does not get cold during bathing. The head constitutes a large surface area of the baby; therefore, it should be washed last and dried first. Bathing time can be used to inspect baby's cord, eyes and skin for any discharge, rash or redness. +• Cosmetics: Babies have a sensitive skin and use of cosmetics should be mized. A low alkalinity, mild, non-perfumed/non-medicated soap should be used. Any oil except mustard oil can be used. Sprinkling talcum powder on babies can result in its inhalation and should be avoided. A void products containing boric acid (present in most prickly heat preparations). +• Regurgitation: Babies commonly regurgitate small amount of curdled milk soon after feeding. This behavior is normal as long as the baby gains weight and passes urine 6-8 times a day. +• Frequent stools: During the first few days of life, the stool color in breastfed neonates changes from black-green to yellow by the end of first week. In between, the stools appear loose ('transitional stools'). The stool frequency may increase at this time. It is attributed to the enhanced gastrocolic reflex which results in the passage of small stools just after feeding. If the baby remains well hydrated, has no signs of sepsis, feeds well, passes urine 6-8 times per day and gains weight, there is no cause for concern. +• Breast engorgement: Under the effect of transplacentally transmitted hormones, the breasts in boys and girls may get hypertrophied and secrete milk like fluid. It + +resolves spontaneously in a few days. Engorged breasts should not be sqeezed or massaged as it could lead to +soreness and infection. +• Rashes and skin peeling: Papular lesions on erythe­ matous base can be seen in many babies; dispersed over the trunk and face, on day two or three of life. These lesions, called erythema toxicum, are eosinophil-laden sterile lesions. They resolve spontaneously and require no treatment (Fig. 8.12). Pyoderma, on the other hand, are pus-filled lesions occurring in response to local infection of the skin, commonly occurring in creases where dirt accumulates such as thigh fold, back of neck, etc. If boils are <10 in number and there are no signs of sepsis, local cleaning with antiseptic solution and application of 1.0% gentian violet is sufficient. Further investigation and treatment for sepsis is indicated if there are > 10 lesions, signs of sepsis or non-resolution after topical treatment. +Skin peeling is another normal skin finding noted especially in post-term and IUGR babies. Oil massaging can decrease the flaking and no other intervention is required. + + + + + + + + + + + + + + + + +Fig. 8.12: Erythema toxicum + +• Diaper rash: There is redness, inflammation and excoriation of skin in diaper area due to maceration by stools and urine. The problem is more frequent with plastic nappies. The treatment consists of keeping the area dry, avoiding rubbing of the skin for cleaning and application of a soothing cream. Use of cotton diaper is less often associated with this rash. + +EVALUATION OF NEWBORN +Most neonates are born healthy, normal and free from disease. Some (approximately 10%) need observation in nursery. +Newborn examination yields different information at different times. Hence, newborns should be examined in detail at following time points: (i) soon after birth, (ii) at +_ E_ssen_t iatP_ed_ iatric_ _________________________________ +s +_ +_ +_ +_ +_ +_ +_ _ +_ +_ _ + +24 hr of birth, (iii) before discharge from hospital, and again (iv) at followup visit. +Immediately after birth, the Apgar scores are assigned +at 1 and 5 minutes (Table 8.2). If the score is less than 7, it is assigned every 5 minutes until 20 minutes or till two successive score are 7 or greater. These scores rapidly assess the cardiopulmonary status. Apgar scores may be falsely low in infants born very preterm and those with + +maternal drug intake, sepsis, congenital heart disease and central nervous system malformations. Low Apgar scores are poor predictor of long term neurodevelopmental outcome. +If systemic examination reveals an abnormal finding, laboratory evaluation may be warranted. Table 8.7 +provides a schema for the comprehensive history and examination of the newborn. + + + + + +History + +General +Past obstetric history Antenatal + +Obstetric or medical complications + +Labor + + +Delivery + +Immediate care at birth Feeding history Postnatal problems Family history +Past medical problems Personal/social history +General examination Immediately after birth +Appearance Vital signs + +Anthropometry Gestation Classification by +intrauterine growth Congenital anomalies Birth trauma Common signs Special signs + + +Feeding Reflexes +Systemic examination +Chest +Cardiovascular system Abdomen + +Musculoskeletal system Central nervous system + +Table 8. 7: Newborn history and examination: Format for case presentation + + +Mother's name and age, parity, last menstrual period, expected date of delivery +Past pregnancies: when, gestation, fetal or neonatal problems, current status of children +Number of antenatal visits, tests (hemoglobin; urine albumin, sugar; ultrasound; blood group, VDRL, HIV), tetanus toxoid immunization, supplements (iron, folic acid, calcium, iodine) +Obstetric complications (toxemia, urinary tract infections, twins/triplets, placenta previa, accidental hemorrhage); fetal problems (IUGR, hydrops, Rh isoimmunization); medical problems (diabetes, hypertension); investigations, medications, course +Presentation, lie, onset of labor (spontaneous/induced), rupture of membranes (spontaneous/ artificial), liquor (clear/meconium stained); duration of first and second stage of labor; fetal heart rate (tachycardia, bradycardia, irregular) +Place of delivery, vaginal (spontaneous/ forceps/vacuum), cesarean (indication, elective/ emergency); local/general anesthesia; other drugs; duration of third stage; postpartum hemorrhage +Resuscitation; time of first breath and cry; Apgar score; cord care; passage of urine/stool Breastfeeding (when initiated, frequency, adequacy); other feeds +Feeding problems, jaundice, eye discharge, fever; current problems History of perinatal illness in other siblings +History of past medical problems, if any Socioeconomic status, family support + + +Weight, gestation, congenital anomalies, sex assigning, Apgar scores, examination of umbilical vessel, and placenta +Overall appearance: well or sick looking; alert/unconscious +Temperature, cold stress; respiratory rate, retractions, grunt/stridor; heart rate, palpable femoral arteries; blood pressure, capillary refill time; cry; apneic spells +Weight, length, head circumference, chest circumference +Assessment by physical criteria; more detailed assessment by expanded New Ballard examination Appropriate/small/large for gestational age; symmetric or asymmetric small for gestational +age; signs of IUGR +Head to toe examination for malformations or abnormalities Signs of trauma; cephalohematoma +Cyanosis, jaundice, pallor, bleed, pustules, edema, depressed fontanel +Caput; eye discharge; umbilical stump: discharge or redness; jitteriness; eye discharge; oral thrush; development peculiarities (toxic erythema, Epstein pearls, breast engorgement, vaginal bleeding, capillary hemangioma, mongolian spot) +Observe feeding on breast (check positioning and attachment) Moro, grasp, rooting + + +Shape; respiratory rate; retractions; air entry; adventitious sounds Apical impulse, heart sounds, murmur +Distension, wall edema, tenderness, palpable liver/spleen/kidneys, any other lump, ascites, hernial sites, gonads, genitalia +Deformities; tests for developmental dysplasia of hip; club foot +State of consciousness; vision, pupils, eye movements; facial sensation; hearing; sucking and swallowing; muscle tone and posture; power; tendon reflexes + + +IUGR intrauterine growth retardation + +� + + + + + +General Observation +The least disturbing examination should be done first; this gives an opportunity to assess the state of alertness, posture, spontaneous activity, color, any obvious respiratory distress or malformation. The newborns should be examined when they are in light sleep or awake but quiet (happens after 1-1.5 hr of feeding). +A newborn with hypotonia has an extended posture as in a baby with hypoxic encephalopathy. A clear note of the color of the baby, including cyanosis, pallor, jaundice and plethora should be made. One should also look at the spontaneous movements shown by the baby. + +Vital Signs +In a sick baby, assessment of vital parameters takes priority over all other examination. Temperature is measured in the apex of the baby's axilla by holding the thermometer for at least 3 minutes. The finding of hypothermia (tempe­ rature of less than 36.5°C) in neonate has very important connotations. Neonates have a normal respiratory rate of 40-60 breaths/minute. The heart rate is faster in preterm babies compared to term babies. The normal range is 110-160 beats per minute. Bradycardia (rate <100/min) may be associated with heart disease while tachycardia (rate >160/min) may be due to sepsis, anemia, fever or congestive cardiac failure. Capillary refill time is assessed by applying firm pressure on the sternum area for 5 seconds than releasing and observing the time taken to refill. The refill time is prolonged (more than 3 sec) because of poor peripheral circulation as in the shock or hypothermia. + +Assessment of Size and Growth +Depending on the weight, the neonates are termed as low birth weight (LBW, less than 2500 g), very low birth weight (VLBW, less than 1500 g) or extremely low birth weight (ELBW, less than 1000 g). The aberrant growth pattern is assessed by plotting the weight against the gestational age on a standard intrauterine growth curve (which is different from postnatal growth curves for assessing growth after birth), as shown in Fig. 8.13. A neonate whose weight falls between the 10th and <90th percentile is considered as appropriate for gestational age (AGA); if the weight falls below 10th percentile, the neonate is classified as small for gestational age (SGA); the neonate is classified as large for gestational age (LGA), if the weight falls at 90th percentile or above for gestational age. + +Anthropometry +The weight is measured in grams (g). Length is measured using an infantometer. The newborn baby at birth is about 50 cm long. Head circumference is measured by placing a soft non-stretchable tape around the head just above the eyebrows and finding the largest circumference over the occiput. This is 33-37 cm at birth in term babies. A large + +Newborn Infants -4000 +3800 97 centile +t +.. +-- +f +f +.. +-+ +- +·l +3600 � 90 centile +I +3400 I -r I -3200 1- +50 centile +3000 +2800 +2600 10 centile �2400 +-t- +T +:E 2200 -2 SD + +-� 2000 +t +.. +.. +1 + +� 1800 +co + +1600 +t +t +- +1400 + +1200 � ..... + +._ +l +.. +1000 + 800 � +Preterm Term Post-term 600 + +31 32 33 34 35 36 37 38 39 40 41 42 43 44 Gestation, weeks +Fig. 8.13: Intrauterine growth curves. SD standard deviation + +head may be due to macrocephaly (Fig. 8.14), the causes include hydrocephalus and cerebral parenchymal diseases. Chest circumference is about 3 cm lesser than head circum­ ference and if the difference is more than 3 cm it is an indication of intrauterine growth retardation (IUGR). The Pondera! index (Pl) is calculated by multiplying the weight in grams by hundred and then dividing by cube of length in cm. This parameter is usually less than 2 in asymmetric IUGR baby and 2 or more in a baby who has either normal growth or has symmetrical IUGR. + + + + + + + + + + + + + + + + +Fig. 8.14: A newborn infant with large head (macrocephaly). Note bossings of both frontal eminences +__ ss_en_t_ia_i_P_e_d_i_a_tr_ics------------------------------- +_ +E +__ + + +Assessment of Gestational Age +Based on gestation, neonates can be classified as preterm (<37 week), post-term (�42 week) or term (37-41 completed weeks). +The detailed evaluation requires examination of physical features and neurological maturity (Fig. 8.15). The scoring system commonly used is the Expanded New Ballard Scores (ENBS), which has an accuracy of 1 week. + +Regional General Examination +Skin and hair. The skin is examined with regard to thickness, transparency and edema, rashes and lesions like hemangioma. Jaundice is detected by pressing on the skin so that the yellow color of subcutaneous tissue due to billirubin deposition is highlighted. The skin may exhibit minor clinical problems that are innocuous and self­ +limiting. Ecchymoses or petechiae may relate to birth trauma, especially if present on head and neck region. The hair should be observed carefully. Lanugo are the fine hair +of fetal period that shed in two periods; one at 28 weeks and later at term. The common finding on examination of nails is the presence of hypoplastic nails that may be +transient in the toe, but, if present in fingers, may indicate in utero exposure to valproate. +Head and fontanel. The size and shape of the head along +with sutures and fontanels should be examined carefully. Upon palpation, molding gives the impression of a cliff +with rise on one side and a sharp fall on the other side, whereas a synostosis (fusion of bones) feels like a mountain +range with rise on both sides of elevation. Some neonates have delayed ossification and resorption of bones making +the skull feel soft like a ping pong ball. This condition, termed craniotabes, is benign in neonates and it resolves spontaneously. The most common findings after birth are caput succedaneum and cephalohematoma (Fig. 8.16). These should be differentiated as shown in Table 8.8. A full and +tense fontanel is abnormal in a quiet neonate. Large fontanels and split sutures are most often normal variants but they can be associated with increased intracranial pressure, certain chromosomal abnormalities, hypo­ thyroidism and impaired bone growth like osteogenesis imperfecta. +Neck, face, eyes and ears. Newborns have short necks. The neck is examined for masses such as enlarged thyroid gland, sternomastoid tumor and cystic hygroma. Facial nerve paresis may occur due to birth injury; this is identified by the presence of asymmetric fades while the baby is crying with open eyes and the inability to move the lips. This should be differentiated from the absence of depressor anguli oris in which asymmetric crying fades is observed; however, in this condition, the eyes remain tightly shut while crying (Fig. 8.17A and B). Nose is looked for its size, shape, secretions, patency and flaring. The flaring of the nostrils indicates an increase in respiratory +efforts regardless of the cause. + + +The alveolar ridge may have natal teeth or retention +cysts (also called Epstein pearls) that disappear in few weeks. It is very important to examine the palate for cleft. +Subconjunctival hemorrhages are common after vaginal delivery and resolve spontaneously. The cornea should be clear. Pupils should be equal in size, reactive to light and symmetrical. +Gross hearing is often assessed by looking for blink on response to noise. More formal hearing screening for all newborns is now recommended. Accessory auricles and preauricular tags are common finding that may be associated with renal anomalies. +Umbilicus, anus and spine: Inspect the number of vessels in the umbilical cord. A single umbilical artery may be found in 0.7% of live births; this may be associated with renal and gastrointestinal tract anomalies. +One should palpate the base of the umbilical cord for a hernia and estimate the diameter of the fascial opening (Fig. 8.18). The spine should be palpated with a finger to exclude spina bifida, masses and any scoliosis. The anal opening should be examined for its patency and position. +Genitalia (male and female): The genital area is examined by the hips abducted in the supine position. The urethra and clitoris are examined for patency and cliteromegally respectively. +Extremities: One should make sure that the arms and limbs are fully movable with no evidence of dislocation or asymmetry of movements. The fingers are counted and any abnormality noted like nail hypoplasia, syndactyly, polydactyly, oligodactyly or unequal limbs. A calcaneo­ valgus deformity is usually self-correcting within the next few months but equinovarus is much more sinister and should be brought to the notice of an orthopedic specialist (Fig. 8.19). + +Systemic Examination +Chest The anteroposterior diameter of the neonate's chest is roughly same as the transverse diameter. Respiratory distress is indicated by nasal flaring, grunting, tachypnea and intercostal and subcostal retractions. Such distress may indicate pneumonia, respiratory distress syndrome (RDS), delayed reabsorption of lung fluid or any other cardiorespiratory cause. Stridor may be inspiratory, indicating large airway obstruction, or there may be expiratory prolongation, indicating a small airway obstruction. +Cardiovascular system An infant with heart disease manifests with tachypnea, cyanosis or both. The position of apical impulse may give idea regarding presence of conditions like congenital diaphragmatic henia (CDH) and pneumothorax. +Abdomen Inspection of abdomen may reveal unusual flatness or scaphoid shape of abdomen that may be +Newborn Infants - + + +Term Babies Preterm Babies + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +Figs 8, 1 SA to F: Salient difference in physical characteristics of preterm and term neonates: (A) Well-curved pinna, cartilage reaching up to periphery; (B) flat and soft pinna, cartilage not reaching up to periphery; (C) well pigmented and pendulous scrotal sacs, with fully descended testes; (D) light pigmentation and not yet descended testes; (E) deep transverse creases on the soles; (F) faint marks on the sole, no deep creases +__ ssent iaiPed iatric ________________________________ _ +E +_ +_ +_ +_ +_ +_ +_ +_ +_ +_ +_ +_ +_ +_ +_ +s + +Term Babies Preterm Babies + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +Figs 8.1 SG to L: Salient difference in physical characteristics of preterm and term neonates: CG) Well formed breast bud C>S mm); CH) Poorly developed breast bud; Cl) silky hair, where individual strands can be made out; (J) fuzzy hair; CK) labia majora covering clitoris and labia minora; CL) prominent labia minora and clitoris +Newborn Infants - + + +Table 8.8: Differences between caput succedaneum and cephalohematoma + +Characteristic +Incidence Location +Time of presentation Time course + +Characteristic findings Association + +Caput succedaneum +Common Subcutaneous plane +Maximum size and firmness at birth +Softens progressively from birth and resolves within 2-3 days +Diffuse; crosses suture line None + + +Cephalohematoma +Less common +Over parietal bones, between skull and periosteum Increasing size for 12-24 hr and then stable +Takes -6 weeks to resolve + +Does not cross suture line; has distinct margins Linear skull fracture (5-25%); hyperbilirubinenia + + +back with the knees fully flexed and the hips flexed to a right angle. Both the hips should be tested separately. Pelvis is stabilized with one hand with thumb being on the medial side of thigh and fingers on greater + + + + + + + + + + + +Fig. 8.16: Cephalohematoma. Note the overlying bruising + + +associated with CDH. Visible gastric or bowel patterns may indicate ileus or other obstruction. Normally 1-2 cm of liver, tip of the spleen and the lower pole of the left kidney may be palpated. Tenderness of abdomen is an important sign in necrotizing enterocolitis (NEC). + +Musculoskeletal system The common alterations are deformations caused by adverse mechanical factors in utero. Most positional deformities are mild and resolve in time. The hips are to be exained to detect hip problems before permanent damage occurs by one year of age. +Developmental dysplasia of hips (DOH) occurs in 1 of 800 live births, more commonly in girls, those with a family history and delivered by breech. There are two major tests to detect developmental dysplasia of hip (DOH). +i. Barlow maneuver: Barlow test is done to dislocate the unstable hip joint. Both the hips should be tested separately. Pelvis is stabilized with one hand with thumb being on the medial side of thigh and fingers on greater trochanter. With the other hand, opposite hip is flexed and adducted, and posterior pressure is applied with thumb so as to dislocate hip. If the hip is dislocatable, a distinct outward movement of the hip is felt. Once pressure is released, hip moves again in the acetabulurn. +ii. Orto Zani's sign. This maneuver helps to judge if the hip has already been dislocated. The baby is placed on its + + + + + + + + + + + + + + + + + + + + + + + + +Figs 8.17A and B: (A) Absent depressor anguli oris muscle. Note asymmetry of face on crying, presence of nasolabial folds and closed eyes. (B) newborn with right sided lower motor nerve facial palsy secondary to forceps application. Note absence of nasolabial fold +__ s_s_e_n_ti_a _i _P_e_d_ia_t_ri_cs-------------------------------- +E +_ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +Figs 8.18: (A) Umbilical hernia; and (B) Inguinal hernia + + + + + + + + + + + + + + + +Fig. 8.19: Congenital talipes equinovarus deformity + + +trochanter. With the other hand, opposite thigh is abducted and the fingers of the examining hands push the femoral head anteriorly. In dislocated hip, the femoral head suddenly slips into the acetabulum with a distinctly palpable "clunk". If pressure is now applied with the thumbs outwards and backwards of the inner side of the thigh, the femoral head again slips + +over the posterior lip of the acetabulum. If the femoral head slips into the acetabulum again when the pressure is released, it is merely unstable, rather than dislocated. This test is important because the treatment in early neonatal life is simple and efficient and consists simply in maintaining the hips in full abduction and at least 90° flexion with malleable metal splints. +Neurological examination This consists of the assess­ ment of the level of alertness and examination of cranial nerves, motor and sensory system and neonatal reflexes. +Cranial nerves. Neonates respond to cotton soaked in peppermint by 32 weeks of gestation. By 26 weeks the infant consistently blinks in response to light and by term gestation, fixation and following (tested using fluffy red yarn ball) is well established. +By 28 weeks the infant startles or blinks to loud noise. Sucking and swallowing are important aspects that should be examined as they give insight into the proper functioning of the V, VII, IX, X and XII cranial nerves. +The act of sucking requires the coordinated action of breathing, sucking and swallowing. Suck-swallow coordination so as to accept paladai feeding is present by 32 weeks. Suck-swallow and breathing coordination occurs by 34 weeks when baby can breastfeed. However, perfect coordination of suck-swallow and breathing develops only by 38 weeks of gestation. +Motor examination. By 28 weeks there is minimal resistance to passive manipulation of all the limbs and a distinct flexor tone is appreciated in lower extremities by 32 weeks. By 36 weeks, flexor tone is palpable in both the lower and upper extremities. +Primary neonatal reflexes. Moro reflex is best elicited by the sudden dropping of the baby's head in relation to trunk; the response consists of opening of the hands and extension and abduction of the upper extremities, followed by anterior flexion (embracing) of upper extremities with an audible cry (Figs 8.20A and B). The hand opening is present by 28 weeks, extension and abduction by 32 weeks and anterior flexion by 37 weeks. Moro reflex disappears by 3-6 months in normal infants. The most common cause of depressed or absent Moro reflex is a generalized disturbance of the central nervous system. An asymmetrical Moro reflex is indicative of root plexus injury. +The palmar grasp is clearly present at 28 weeks of gestation and is strong by 32 weeks. This allows the lifting of the baby at 37 weeks of gestation. This becomes less consistent on development of voluntary grasping by 2 months. The tonic neck response is another important response elicited by rotation of the head, that causes extension of the upper extremity on the side to which the face is rotated and flexion of the upper extremity on the side of the occiput (Fig. 8.21). This disappears by 6 to 7months. +-----------------------------------Ne__b_o_r_n_inf_a_n_t_s..- +w + + + + + + + + + + + + + + + + + + + + + + + + + + + + +Figs 8.20A and B: Moro reflex (A) Abduction and extension of arms is followed by (B) Adduction and flexion component + + +THERMAL PROTECTION +Newborn babies are prone to hypothermia as they have poor heat regulating mechanisms. During intrauterine life, the fetal temperature is 0.5°C higher than the maternal temperature due to metabolic reactions that generate heat. After birth, the infant is exposed to outside environment which has lower temperature. + +Sources of Heat Loss +Heat loss in a newborn occurs through 4 ways: +i. Radiation to surrounding environment not in direct contact with baby +ii. Convection to air flowing in surrounding +iii. Conduction to substances in direct contact with baby iv. Evaporation of amniotic fluid and moisture from baby's +skin to atmosphere + +Why are Newborns Susceptible to Hypothermia? +• Large surface area of babies compared to their weight: The head constitutes a significant portion of the newborn's surface area and can be a source of great heat loss +• Limited heat generating mechanisms + +Fig. 8.21: Asymmetrical tonic neck reflex + +• Vulnerability to getting exposed, being dependant on others for early detection and rectification +Additional factors that contribute to heat loss in LBW babies include: +• Poor insulation due to lower subcutaneous fat • Decreased brown fat +• More permeable skin +• Larger surface area than term babies +• Poorer physiological response to hypothermia and early exhaustion of metabolic stores like glucose. + +Sources of Heat Productio +n +On exposure to cold and wet environment, the neonate tries to generate heat by increasing physical activity (crying, increased body movements) and by mounting a sympathetic surge that causes vasoconstriction and non­ shivering thermogenesis in the brown fat. Brown fat is richly vascularized, sympathetically innervated fat collections located in the axillae, groin and nape of the neck, interscapular area and perirenal area. Release of norepinephrine uncouples beta-oxidation in fat that results in heat production. Blood passing through brown fat gets heated up to keep baby warm. Preterm and small for gestational age infants have scanty brown fat stores. +Response to hypothermia. Hypothermia induced peripheral vasoconstriction leads to increased metabolism with excess oxygen consummation and glucose utilization. Switch to anaerobic metabolism in hypothermia causes metabolic acidosis (Fig. 8.22). The acidosis induces pulmonary vasoconstriction and pulmonary hypertension further worsening the hypoxemia. When body temperature drops below 32°C, hemoglobin cannot release oxygen resulting in the blood having a bright red color because of good oxygen content but it cannot be released to tissues (tissue hypoxia). With severe hypothermia, hypoxemia, bradycardia, hypoglycemia and metabolic acidosis contributes towards increased mortality in hypothermic babies. +__ ss_e___ti_ai_P_e_d___t_r c ________________________________ +n +i +a _ +i +_ +s +E +_ + +Hypothermia + + +Catecholamine release Reduced surfactant production + + +Uncoupling of-I} Increased metabolic ratej +oxidation in brown fat +I_� + + +Pulmonary and peripheral +vasoconstriction + + +Hypoglycemia I Increased oxygen requirementj + + +Displace bilirubin bound to albumin +Hyperbilirubinemia + + +Anerobic metabolism, glycolysis Hypoxemia +Metabolic acidosis + +Fig. 8.22: Response to cold stress in sick neonate + + + +Hyperthemiia. An immature thermoregulating mechanism and decreased ability to sweat predispose newborns to hyperthermia. Factors like overclothing, high environ­ mental temperature in summers, poor feeding and dehydration are the common factors that can lead to hyperthermia. + +Defin tions +i +Thermoneutral environment. Thermoneutral zone refers to narrow range of environmental temperature in which a baby has the lowest basal metabolic rate and oxygen utilization and the baby has normal body temperature. The thermoneutral zone is different for babies of different gestation and postnatal age. Thermoneutral zone is higher for lower gestation and smaller birth weight; lower for clothed babies compared to naked ones and is higher in the earlier hours and days of life than later age. This is because preterm, small, naked and younger neonates need extra warmth to maintain body temperature. +Normal body temperature: 36.5°C to 37.5°C +° +Hypothermia: Axillary temperature less than 36.5 C + +Cold stress: 36.0-36.4°C +Moderate hypothermia: 32-35.9°C +Severe hypothermia: <32°C +Hyperthermia: Axillary temperature more than 37.5°C + +Measurement of Temperature +The thermometer for measuring temperature in neonates should have low reading values till 30°C, so that degree of severe h othermia can be accurately assessed. Methods of measurement are listed in Table 8.9. A reasonable idea can be obtained by touching the baby's hands and feet and abdomen by back of examiner's hand. If everything appears warm, baby has normal temperature. Warm abdomen but cold feet and hands indicate hypothermia. Cold feet and hands as well as the abdomen would indicate that the baby has severe hypothermia. +yp + +Frequency of Measurement +The frequency of temperature measurement can be once daily for healthy babies who are otherwise well, two to three times daily for healthy small babies (2 to 2.5 kg), + + +Table 8. 9: Methods of temperature measurement + +Name Axillary + + +Skin probe + + +Touch + + +Method +Bulb of thermometer is placed in the roof of dry ailia for 3 inutes +while holding the baby's arm close +to the trunk +Probe of thermal sensor is placed on the skin over upper abdomen; panel displays the measured temperature +The back of hand is used to appreciate +the skin temperature. Temperature is considered normal if the baby's abdomen, feet and hands are warm; +cold if the abdomen is warm but feet +and hands are cold; and hypothermia if abdomen, feet and hands are cold + +Timing +Intermittent measurement + + +Continuous monitoring + + +Intermittent measurement + + +Comment +Standard method of temperature recording; closely approximates the core temperature + + +Useful in regulating the heater output in radiant warmer and incubators + +Crude method; helps mothers and health workers estimate the baby's temperature quickly +------------------------------------N_e_w_b_o_r_n_i_n_fa__nt_s__ + +four times daily for very small babies ( <2 kg) and every two hour for sick babies. Mother should be encouraged to assess body temperature of the neonate by touching the baby. + + +Disorders of Body Temperature +Hypothermia may happen as a result of exposure to a cold environment such as low ambient temperature, cold surface, or cold air, or the baby is wet or not clothed adequately. Hyperthermia may result if the infant is exposed to warm environment such as in summers, direct sun exposure, or overheating in the incubator or radiant warmer. Hypothermia as well as hyperthermia can also indicate underlying serious illness. + +Hypothermia Prevention +Warm chain: The strategy for prevention of hypothermia is known as warm chain. The 'warm chain' is a set of ten steps (Table 8.10) aimed at decreasing heat loss, promoting heat gain and ensuring that baby is not exposed to the circumstances that can result in hypothermia. + +Table 8.10: Ten steps of warm chain +i. Warm delivery room ii. Warm resuscitation +iii. Immediate drying iv. Skin to skin contact +v. Breastfeeding +vi. Bathing postponed vii. Appropriate clothing +viii. Mother and baby together ix. Professional alertness +x. Warm transportation + +• The birthing room should have ambient temperature of at least 25°C and should be free from drafts of air (keep windows and doors closed). +• After delivery, the baby should be dried immediately, put in skin to skin contact on mother's abdomen and covered by warm and dry linen. The wet towel should be discarded. The baby should be capped and dressed adequately (Fig. 8.23). +• Kangaroo mother care (KMC) is an effective way to keep LBW baby warm. +• Frequent breastfeeding is critical to provide energy to keep the baby warm. +• Bathing and weighing are postponed. Term babies can be sponged after 24 hr of life in summer months. Bathing should be postponed during winters and in sick or LBW babies until the umbilical cord falls off ( end of first week). Dressing the baby in multiple layers of warm and light clothes provides better thermal protection than a single layer of heavy woolen clothing. + + + + + + + + + + + + +Fig. 8.23: A well clothed baby + +• Mother and baby should be kept on the same bed (co-bedding/rooming in). +• Warm transportation: This is the weakest link in the warm chain with greatest possibility of severe and undetected hypothermia. +• Training/awareness of healthcare providers: Unless persons involved in the care of newborns realize the implications of hypothermia it cannot be detected or managed effectively. +Incubators and radiant warmers. These equipment are used to assist sick and small neonates maintain their normal body temperature (Figs 8.24A and B). Incubator is a transparent acrylic cabin which has warm air circulating around the baby to keep him warm. There is an inbuilt feedback system (servo-control) that controls ambient temperature inside incubator by altering heater output based on baby's temperature and thereby maintains the temperature of baby in the normal range. +A radiant warmer is an open system (as compared to incubator which is a closed cabinet) and the neonate lies on a crib. There is overhead radiant warmer that modulates its heater output based on baby's temperature sensed by a skin probe. +Radiant warmers and incubators should be used in the servo control mode with the abdominal skin temperature maintained at 36.5°C to 37°C depending on the birth weight of the neonate. + +Signs and Symptoms +Peripheral vasoconstriction results in acrocyanosis, cool extremities and delayed peripheral capillary refill time (CRT). The baby becomes restless and then lethargic. Chronic or recurrent episodes of hypothermia result in poor weight gain. Cardiovascular manifestations may occur in the form of bradycardia, hypotension, raised pulmonary artery pressure with resultant hypoxemia, tachypnea and distress. Presence oflethargy, poor reflexes, +__ s_s_e _ _t1a_1_P_ e_d_1a_ _tr1_cs----------------------------- +n +E +_ + +• Initiate skin to skin contact, is possible. If not possible, dress the baby in warm clothing and keep him in a warm room. Alternately a radiant warmer or incubator may be used. +• Monitor temperature frequently. If the temperature of baby is not rising, check if adequate amount of heat being provided. Sepsis should be suspected unrespon­ sive hypothermia. +• Ensure frequent feeding to prevent hypoglycemia. Monitor vitals. +Severe hypothermia +• Remove all wet clothing and place baby in an incubator (air temperature 35-36°C), preheated radiant warmer or thermostatically controlled heated mattress set at 37-38°C. Alternately, one may use a room heater. +• Once baby's temperature reaches 34°C, the rewarming process should be slowed down. +• Temperature is measured every hour for 3 hr. If rise of temperature has been by 05°C per hr then heating is considered adequate, and temperature measurement is continued 2 hourly until normal body temperature is attained, and thereafter 3 hourly for 12 hr. If rise of temperature is not adequate, one should check the heating technique. +• Provide oxygen, empirical antibiotics, saline bolus if shock, IV dextrose and vitamin K. Monitor vitals. + +Suggested Reading +Guidelines for perinatal care. Second Edition, American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 1998 Thermal protection of the newborn: A practical guide. WHO/FHW / +MSM/97.2 + + + +Figs 8.24A and B: A very low birth weight (VLBW) baby being cared for in (A) an incubator and (B) radiant warmer. Note that baby is well clothed and the incubator is covered with cloth to prevent excessive light or noise for adequate comfort of the baby + +decreased oral acceptance and apnea denotes neurological depression. Abdomen distension, vomiting and feeding intolerance make enteral intake difficult. Acidosis, hypoglycemia, oliguria, azotemia and generalized bleeding can occur in severe cases. Babies who are chronic cold stress do not gain adequate weight. + +Management +Methods for temperature maintenance include skin to skin contact, warm room, radiant warmers, incubators and increasing ambient temperature by use of hot air blowers, or a 200 watt bulb. +Cold stress or moderate hypothermia +• Remove the baby from the source that may be causing hypothermia such as cold environment, cold clothes, cold air or wet clothing. + +FLUID AND ELECTROLYTE MANAGEMENT +Transition from fetal to extrauterine life is accompanied by remarkable changes in body fluid composition. Neo­ nates are born with an excess of total body water (TBW) primarily in the extracellular fluid (ECF) compartment. This excess of TBW is normally lost by diuresis during first week of life. Term neonates lose about 7%-10% of body weight during first 3 to 5 days of life. Preterm neonates have proportionately higher TBW and, therefore, may lose up to 10%-15% of birth weight during first week of life. +The heart, kidneys, the skin and the neuroendocrine system regulate fluid and electrolyte balance in neonates. In neonates, kidneys have a limited capacity to concentrate or dilute urine due to lower glomerular filtration rate and reduced proximal and distal tubular sodium reabsorption. In addition to water loss by the kidneys and gastrointestinal system, additional water losses occur due to evaporation from the skin and respiratory tract (insensible water loss; IWL). IWL is higher in preterm infants owing to thin skin. Fever, increased respiratory rate, radiant warmers and phototherapy increase IWL. +Newborn Infants - + + + +Guldellnes for Fluld Therapy +Healthy babies of 1200 g or more should be started on enteral feeding with breast milk. A baby of 1800 g or more would be able to breastfeed directly while a smaller baby may require expressed breast milk fed by suitable alternate route. + +Intravenous (IV) fluid therapy. IV fluids are indicated when baby is either small or sick. Babies less than 1200 g or gestation <30 week should be started on IV fluids routinely. Sick babies (irrespective of weight or gestation) such as those with respiratory distress, significant asphyxia, feed intolerance, hemodynamic instability, gastrointestinal malformations (like tracheoesophgeal fistula, intestinal atresia, etc.) or any other severe illness precluding oral feeding should be given IV fluids. Peripheral intravenous line is the most common route used to provide fluids. Fluid requirement is calculated based on birth weight, day of life and the current fluid balance. + +Babies with birth weight 2,1500 g. Infants on IV fluids require to excrete a solute load of about 15 mOsm/kg/day in the urine. To excrete this solute load at a urine osmolarity of 300 mOsm/kg/ day, the infant would have to pass a minimum of 40 ml/kg/ day of urine. Allowing for an additional IWL of 20 ml/kg, the initial fluids should be 60-80 ml/kg/day. The initial fluids should be 10% dextrose with no electrolytes in order to maintain a glucose infusion rate of4-6 mg/kg/min. (Table 8.11). As the infant grows and receives enteral 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. Therefore, the fluid requirements increase by 15-20 ml/kg/day till a maxi­ mum of 150 ml/kg/day by the 7th day. Sodium and potassium should be added to IV fluids after 48 hr. + +Babies with birthweight <1500 g. The urine output in these babies is similar to a baby of 1500 g or more. However, the fluid requirement is higher due to increased IWL. These babies need 80 ml/kg/day of 10% dextrose on day 1 of life (Table 8.11). The babies should be well dressed including provision of caps and socks to reduce the IWL under the radiant warmer. As the skin matures, the IWL progressively decreases and fluid requirement becomes similar to bigger babies. Fluids need to be increased at + + +10-15 ml/kg/day up to a maximum of 150 ml/kg/day by 5th to 7th day. Sodium and potassium should be added to IV fluids after 48 hr. +Problems with IV fluid therapy include local and systemic infection, phlebitis, fluid overload and extra­ vasation. Because IV fluid therapy is a major risk factor for nosocomial infection, all asepsis precautions must be followed during insertion of IV cannula or administering fluids. Oral feeds should be started at the earliest possible opportunity when clinical condition of neonate improves and IV fluid should be stopped when oral feeds constitute about two-thirds of daily fluid requirement. IV sites should be inspected frequently to timely detect extravasation. + +Calculation of fluids for a 1250 g baby: +Day 1: 100 ml (80 ml/kg) to be infused at 4.2 ml/hr Day 2: 120 ml (95 ml/kg) to be infused at 5.0 ml/hr + +Monitoring of Fluid and Electrolyte Status +Fluid therapy should be monitored every 12 to 24 hr in a baby on IV fluids using following parameters: +Body weight. Serial weight measurements can be used as a guide to estimate the fluid deficit in newborns. Term neonates lose 1-3% of their birth weight daily with a cumulative loss of 5-10% 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 may be an indicator of excessive fluid administration. However, excessive weight loss (>3% in 24 hr) in the first 5-7 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% (150 ml/kg) or more dehydration would have signs of shock (hypotension, tachycardia and weak pulses). +Urine output. A well hydrated baby would pass urine at 1 to 3 ml/kg/hr. + +Suggested Reading +Chawla D, Agarwal R, Deorari AK, Paul VK. Fluid and electrolyte management in term and preterm neonates. Indian J Pediatr. 2008;75:255-9 + + + + +Table 8.11: Dally fluid requirements during first week of life (ml/kg/day) + +Birth weight Day 1 + +<1500 g 80 +�1500 g 60 + + +Day 2 Day 3 + +110 +95 +75 90 + +Day 4 Day 5 Dny 6 + +120 130 140 +105 120 135 + + +Day 7 and onwards + +150 +150 +___ sse___ al_P_e_d__t_r_s _______________________________ +i +_ +c +_ +i +a +n +t_ +i +E +_ +_ + + +KANGAROO MOTHER C_A_R_E ________ +Kangaroo mother care (KMC) refers to care of preterm or low birth weight infants by placing the infant in skin-to­ skin contact with the mother or any other caregiver. Initially conceived as an alternative to conventional warmer care for LBW infants, KMC has now become standard of care either as an alternative to or an adjunct to technology-based care. +KMC was first suggested in 1978 by Dr Edgar Rey in Bogota, Colombia. The term kangaroo care is derived from practical similarities to marsupial caregiving, i.e. the infant is kept warm in the maternal pouch and close to the breasts for unlimited feeding. + +C omponents +i. Kangaroo position. The kangaroo position consists of skin-to-skin contact between the mother and the nfant in a vertical position, between the mother's 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. +ii. Kangaroo nutrition: Kangaroo nutrition is exclusive breastfeeding. +iii. Kangaroo discharge and Jollowup: 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 followup hence a followup program and access to emergency services must be ensured. + +Benefits +Physiological Benefits +KMC results in keeping neonates warm and cozy. Babies get protected against cold stress and hypothermia. Physiological parameters such as heart and respiratory rates, oxygenation, sleep patterns get stabilized. + +Clinical Benefits +KMC significantly increases milk production in mothers and exclusive breastfeeding rates. KMC improves weight + +gain in the infants and improves thermal protection. It reduces incidence of respiratory tract and nosocomial infections, improves emotional bonding between the infant and mothers and results in earlier discharge from the hospital. + +Criteriafor Eligibility Baby +KMC is indicated in all stable LBW babies (Fig. 8.25). However, sick babies should be cared under radiant warmer initially and KMC should be started once 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. + +Mother +All mothers can provide KMC, irrespective of age, parity, education, culture and religion. The mother must be willing to provide KMC. 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. She should maintain good hygiene. Mother would need family's cooperation to deal with her conventional responsibilities of household chores till the baby requires KMC. + +Initiation of KMC +Counseling. When baby is ready for KMC, arrange a time that is convenient to the mother and her baby. The first few sessions are important and require extended interaction. Demonstrate to her the KMC procedure in a caring, gentle manner and with patience. Answer her queries and allay her anxieties. Encourage her to bring her mother/ mother-in-law, husband or any other member of the family. 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. It is helpful that the mother starting KMC interacts with someone already practicing KMC for her baby. +Mother's clothing. KMC can be provided using any front­ open, light dress as per the local culture. KMC works well + + + +Birth weight + + + + + + +May take days to weeks before KMC can be initiated + + +May take a few days before KMC can be initiated + +Fig 8.25: Kangaroo mother care (KMC) protocol + +KMC can be initiated immediately after birth +------------------------------------N_e_w_b_o_r_n_i_n_ta__n t__s .. + + + + + + + + + + + + + + + + + + + + +I +J + + + + + + + + +D + +Figs 8.26A to D: (A) Mother and (B) father practicing KMC in front open gown and shawl; (C) AIIMS KMC jacket; and (D) mother performing KMC using AIIMS KMC jacket + +with blouse and sari, gown or shawl (Fig. 8.26). Suitable apparel that can retain the baby for extended period of time can be adapted locally. +Baby's clothing. Baby is dressed with cap, socks, nappy and front open sleeveless shirt. + +Procedure +Kangaroo positioning. The baby should be placed between the mother's breasts in an upright position (Fig. 8.27). 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. 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. Support +the baby's bottom with a sling or binder. Fig. 8.27: Kangaroo positioning +-..E_s_s_e _n_t1_a1_Pe_d_ 1_a_tr_1c_ ____________________________ _ +s + + +Monitoring. Babies receiving KMC should be monitored carefully, especially during the initial stages. Nursing staff should make sure that baby's neck position is neither too flexed nor too extended, airway is clear, breathing is regular, color is pink and baby is maintaining temperature. Mother should be involved in observing the baby during KMC so that she herself can continue monitoring at home. +Feeding. The mother should be explained how to breastfeed while the baby is in KMC position. Holding the baby near the breast stimulates milk production. 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. + +Privacy. The staff must respect mother's sensitivities in this regard and ensure culturally acceptable privacy standards in the nursery and the wards where KMC is practised. +Duration. Skin-to-skin contact should start gradually in the nursery, with a smooth transition from conventional care to continuous KMC (Figs 8.28A and B). Sessions that last + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +Figs 8.28A and B: Kangaroo mother care being provided in postnatal ward + +less than one hour should be avoided because frequent handling may be stressful for the baby. The length of skin­ to-skin contact should be gradually increased up to 24 hr a day, interrupted only for changing diapers. When the baby does not require intensive care, she should be transferred to the postnatal ward where KMC should be continued. +The mother can sleep with baby in KMC position in reclined or semi-recumbent position about 30 degrees from horizontal. 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. + +When to Stop KMC +KMC is continued till the baby finds it comfortable and cosy. KMC is unnecessary once the baby attains a weight of 2500 g and a gestation of 37 weeks. A baby who, upon being put in the kangaroo position, tends to wriggle out, pulls limbs out, or cries or fusses is no longer in need of KMC. + +BREASTFEEDING +Breast milk is an ideal food for neonates. It is the best gift that a mother can give to her baby. It contains all the nutrients for normal growth and development of a baby from the time of birth to the first six months of life. Ensuring exclusive breastfeeding for six months has a potential to reduce under-5 mortality rate by 13%, by far the most effective intervention that is known to reduce newborn and child deaths. +To accrue the maximum benefits, the breastfeeding must be exclusive (only breast milk; nothing other than breast milk except vitamin drops, if indicated), initiated within half an hour of birth and continued through first six months after birth. Coverage Evaluation Survey (2009) reported that only 33.5% of infants were breastfeeding started within an hour of birth. Only 36.8% of infants aged 6 to 9 months received exclusive breastfeeding until 6 months of age. + +Benefits of Breast Milk +Nutritional superiority. Breast milk contains all the nutrients a baby needs for normal growth and development, in an optimum proportion and in a form that is easily digested and absorbed. +Carbohydrates. Lactose is in a high concentration (6-7 g/ dl) in breast milk. The galactose is necessary for formation of galactocerebrosides. Lactose helps in absorption of calcium and enhances the growth of lactobacilli, the good bacteria, in the intestine. +Proteins. The protein content of breast milk is low (0.9-1.1 g/dl) compared to animal milk. Most of the protein is in form of lactalbumin and lactoglobulin (60%), which is easily digested. Human milk contains amino acids like +Newborn Infants - + + + +taurine and cysteine which are necessary for neuro­ transmission and neuromodulation. These are lacking in cow milk and formula. +Fats. Breast milk is rich in polyunsaturated fatty acids, necessary for the myelination of the nervous system. It also contains omega 2 and omega 6 (very long chain) fatty acids, which are important for the formation of prosta­ glandins and cholesterol, required as a base for steroid hormones. +Vitamins and minerals. The quantity and bioavailability of vitamins and minerals is sufficient to the needs of the baby in the first 6 months of life. +Water and electrolytes. Breast milk has a water content of 88% and hence a breastfed baby does not require any additional water in the first few months of life even during summer months. The osmolality of breast milk is low, presenting a low solute load to the kidneys. +Immunological superiority. Breast milk contains a number of protective factors which include immunoglobulin­ mainly secretary IgA, macrophages, lymphocytes, lactoferrin, lysozyme, bifidus factor and interferon among others. Breastfed babies are less likely to develop infection. A breastfed baby is 14 times less likely to die of diarrhea and almost four times less likely to die of respiratory infection. +Other benefits. Breast milk contains a number of growth factor, enzymes and hormones. The epidermal growth factor in breast milk enhances maturation of the intestinal cells and reduces the risk of allergy in later life. Enzymes like lipases increase the digestion of fats in the milk. +Protection against other illness. Breastfed babies have a lower risk of allergy, ear infections and orthodontic problems. They have a lower risk of diabetes, heart disease and lymphoma in later life. +Mental growth. Babies who are breastfed are better bonded to their mothers. Studies have shown that babies who were breastfed had a higher IQ than those babies who were given other forms of milk. +Benefits to mother. Breastfeeding soon after birth helps uterine involution, reducing chances of postpartum hemorrhage. It provides protection against pregnancy due to lactational amenorrhea. If the mother has been exclusively breastfeeding her baby and has not resumed menses then there is no need for any other contraception during initial 6 months after delivery. +Breastfeeding is most convenient and time saving. It reduces the risk of cancer of breast and ovary. Breast­ feeding is the most effective way of shedding extra weight that mother has gained during pregnancy. + +Breast Anatomy +The breast is made up of glandular tissue, supporting tissue and fat (Fig. 8.29). The glandular tissue consists of + + +Oxytocin makes them contract +{ +Muscle cells + +Milk secreting Prolactin makes +{ +cells them secrete milk + + +Lactiferous Milk collects sinuses here +{ + + + + + + + +S uppo rt.1ng t·issue Alveoli and fat +Fig. 8.29: Anatomy of breast + +small clusters of sac-like spaces which produce milk. Each sac is lined by network of myoepithelial cells that propel the milk into lactiferous ducts towards nipple. Before reaching the nipple, the ducts widen to form lactiferous sinuses which store milk. The lactiferous sinuses lie beneath the junction of areola and rest of breast. +The areola and nipples are extremely sensitive as they are supplied by a rich network of nerve endings. On the areola there are small swellings of glands which produce an oily fluid to keep the nipple skin soft. Since the lactiferous sinuses lie beneath the areola, a baby must suck at the nipple and areola. The gum line of the baby should rest at the junction of areola and rest of breast tissue in order to express milk stored in lactiferous sinuses. + +Physiology +Lactogenesis is a complex phenomenon involving many hormones and reflexes. Two hormones are most important, prolactin and oxytocin. +Prolactin reflex (milk secretion reflex). Prolactin produced by the anterior pituitary gland is responsible for milk secretion by the alveolar epithelial cells (Fig. 8.30A). When the baby sucks, the nerve ending in the nipple carry impulse to the anterior pituitary which in turn release prolactin and that acts on the alveolar glands in the breast to stimulate milk secretion. +This cycle from stimulation to secretion is called the prolactin reflex or the milk secretion reflex. The more the baby sucks at the breast, the greater is the milk production. The earlier the baby is put to the breast, the sooner this reflex is initiated. The greater the demand more is the pro­ duction. It is, therefore, important for mothers to feed early, frequently and empty out the breasts completely at each feeding session. Since prolactin is produced during night time, breastfeeding during night is very important for maintenance of this reflex. +_ E_s_s_e_n_ ti_i_P_e_d_i_atric_________________________________ +_ +s +a +_ +_ +_ +_ + +Oxytocin reflex (milk ejection reflex). Oxytocin is a hormone +produced by the posterior pituitary. It is responsible for ejection of the milk from the glands into the lactiferous +sinuses. This hormone is produced in response to stimulation to the nerve endings in the nipple by suckling as well as by the thought, sight, or sound of the baby (Figs 8.308 and C). Since this reflex is affected by the mother's emotions, a relaxed, confident attitude helps the milk ejection reflex. On the other hand, tension and lack of confidence hinder the milk flow. +Factors which reduce milk production are: +• Dummies, pacifiers and bottles not only interfere with breastfeeding but also predispose the baby to diarrhea. +• Giving supplements such as sugar water, gripe water, +honey, breast milk substitutes or formula, either as prelacteal (before initiation of breastfeeding) or +supplemental (concurrent to breastfeeding) feeds. Studies have reported that even 1 or 2 supplemental feeds reduce the chances of successful breastfeeding. +• Painful breast conditions like sore or cracked nipples and engorged breast. +• Lack of night feeding, as the prolactin reflex is not adequately stimulated. +• Inadequate emptying of breast such as when baby is sick or small and the mother does not manually express breast milk or when baby is fed less frequently. + +Reflexes in the Baby +A baby is born with certain reflexes which help the baby to feed. These include rooting, sucking and swallowing reflexes. +The rooting reflex. When cheek or the side of the mouth is touched, the baby opens her mouth and searches for the nipple. This is called rooting reflex. This reflex helps the baby to find the nipple and in proper attachment to the breast. +The suckling reflex. When baby's palate is touched with nipple, the baby starts sucking movements. This reflex is very strong immediately after birth. The sucking reflex consists of: +• Drawing in the nipple and areola to form an elongated teat inside the mouth. +• Pressing the stretched nipple and areola with the jaw and tongue against the palate. +• Drawing milk from the lactiferous sinuses by wave­ like peristaltic movement of the tongue underneath the areola and the nipple and compressing them against the palate above. +To suckle effectively, the baby has to attach (latch) well. Obtaining good attachment at breast is a skill, which both +the mother and the baby have to learn. + + + + +Prolactin +Secreted after feed to produce next feed + + +Prolaclin in blood + + + + + + + + +A + + + + +Oxytocin reflex Works before or during feed to make milk flow + + +Oxytocin in blood + + + + + + + + +B + + + + + + + + + + + +These help reflex + + + + +C + + + + + +Sensory impulses from niP.P.le + + + + + + + + + +Prolactin: secreted more at night; suppresses ovulation + + + + + + + + + + + + + + + + +Oxytocin makes uterus contract + + + +The method of suckling at the breast and bottle is entirely +different. Suckling on a bottle filled with milk is a passive + +Figs 8.30A to C: (A) Prolactin and (B) oxytocin reflex; (C) factors which help and hinder oxytocin reflex +Newborn Infants - + + + +process and the baby has to control the flow of milk into the mouth with her tongue. While breastfeeding requires active efforts by the baby. A bottlefed baby develops nipple confusion and refuses to feed on the breast. Single session of bottlefeeding lessens the chances of successful breast­ feeding. Bottle feeding of babies is fraught with risk of serious infections and consequent ill health. +The swallowing reflex. When the mouth is filled with milk, the baby reflexly swallows the milk. It requires a couple of suckles before baby can get enough milk to trigger swallowing reflex. It requires coordination with breathing. The suckle-swallow-breathe cycle lasts for about one second. + +Composition of Breast Milk +The composition of breast milk varies at different time points of lactation to suit the needs of the baby. Milk of a mother who has delivered a preterm baby is different from milk of a mother delivered a term baby. +i. Colostrum is the milk secreted during the initial 3--4 days after delivery. It is small in quantity, yellow and thick and contains large amount of antibodies and immune-competant cells and vitamins A, D, E and K. +ii. Transitional milk is the milk secreted after 3-4 days until two weeks. The immunoglobulin and protein content decreases while the fat and sugar content increases. +iii. Mature milk follows transitional milk. It is thinner and watery but contains all the nutrients essential for optimal growth of the baby. +iv. Preterm milk is the milk of a mother who delivers before 37 week. It contains more proteins, sodium, iron, immunoglobulins and calories as per the requirement of preterm baby. +v. Foremilk is the milk secreted at the start of a feed. It is watery and is rich in proteins, sugar, vitamins, minerals and water that quenches the baby's thirst. +vi. Hindmilk comes later towards the end of feed and is richer in fat that provides more energy and gives a sense of satiety. Thus, the composition of milk also varies during the phase of feeding. For optimum growth, the baby needs both fore as well as hind­ milk. Therefore, the baby should be allowed to empty out one breast completely before switching over to the other. + +Technique of Breastfeeding +Mothers require substantial assistance to learn the technique of breastfeeding. With correct technique, breastfeeding is natural and a pleasurable experience for the mother. However a variety of breastfeeding problems do occur in large proportion of mothers that require counseling and support from the health providers for their prevention and appropriate treatment. Provision of lactation support services by lactational counsellor or + + +trained health providers greatly increase the success of breastfeeding. + +Positioning +Position of the mother. The mother can assume any position that is comfortable to her and the baby. She can sit or lie down. Her back should be well supported and she should not be leaning on her baby (Figs 8.31A to C). + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +C +Figs 8.31A to C: Different postures of feeding +__ _s_s_e_n_ti_a _ _P_e_d_ia_t_ri_c_ _______________________________ +l +s +E + + +Position of baby. Make sure that baby is wrapped properly in a cloth +i. Baby's whole body is supported not just neck or shoulders +ii. Baby's head and body are in one line without any twist in the neck +iii. Baby's body turned towards the mother (abdomens of the baby and the mother touching each other) +iv. Baby's nose is at the level of the nipple. + +Attachment (Latching) +After proper positioning, the baby's cheek is touched and that initiates rooting reflex. Allow the baby to open his mouth widely and at that point, the baby should be latched on to the breast ensuring that the nipple and most of the areola are within baby's mouth (Fig. 8.32). It is important that the baby is brought on the mother's breast and mother should not lean on to baby. + + + + + + + + + + + + + +Fig. 8.32: Good attachment +Signs of good attachment +i. The baby's mouth is wide open +ii. Most of the nipple and areola in the mouth, only upper areola visible, not the lower one +iii. The baby's chin touches the breast iv. The baby's lower lip is everted + +Effective Suckling +• Baby suckles slowly and pauses in between to swallow (suck, suck, suck.. and swallow). One may see throat cartilage and muscles moving and hear the gulping sounds of milk being swallowed. +• Baby's cheeks are full and not hollow or retracting during sucking. + +Problems in Breastfeeding +Inverted nipples. Flat or short nipples which become prominent easily on pulling out do not pose difficulty in breastfeeding. However, truly inverted or retracted nipples make latching difficult. As the baby is not able to take nipple and areola in the mouth properly, sucking on the nipples makes them sore and excoriated. Treatment is + +started after birth of the baby. The nipple is manually everted, stretched and rolled out several times a day. A plastic syringe is used to draw out to correct the problem (Fig. 8.33). + + + +� +� ! fl +I +n +s +e +r +t +- +Step two -- +� � - .J from cut end Step three .. +p +i +s +t +o +n +Mother gently pulls the piston + + +Fig. 8.33: Syringe treatment for inverted/flat nipple + +Sore nipple. Nipples become sore when baby suckles on the nipple rather than areola because of incorrect attachment. As the baby is unable to express milk, he sucks vigorously in frustration and bites the nipple causing soreness. Frequent washing with soap and water and pulling the baby off the breast while he is still sucking may also result in sore nipple. Treatment consists of correct positioning and latching of the baby to the breast. A mother would be able to feed the baby despite sore nipple if the baby is attached properly. Hind milk should be applied to the nipple after a feed and the nipple should be aired and allowed to heal in between feeds. She should be advised not to wash nipple each time before/ after feeding. She can clean breast and nipple once daily at time of bathing. There is no need to apply any cream or ointment to the sore nipples. +Breast engorgement. The milk production increases by the second and third day after delivery. If feeding is delayed or 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 and is termed as an 'engorged breast' (Fig. 8.34). +Breast engorgement can be prevented by early and frequent feeds and correct attachment of the baby to the breast. + + + + + + + + + + + +Fig. 8.34: Engorged breast. Note tense and shiny skin; nipple shows excoriation +Newborn Infants - + + +Treatment consists of local warm water packs, breast massage and analgesics to relieve the pain. Milk should be gently expressed to soften the breast. + +Breast abscess. If a congested engorged breast, cracked nipple, blocked duct or mastitis are not treated in the early stages, breast abscess formation can occur. The mother has high grade fever and a raised blood count. She must be treated with analgesics and antibiotics. The abscess may require incision and drainage. Breastfeeding must be +continued. Step 2 + +Not enough milk. First make sure that the perception of "not enough milk" is correct. If baby is satisfied and sleeping for 2-3 hr after breastfeeding, passing urine at least 6-8 times in 24 hr and gaining weight, the mother is producing enough milk. There could be a number of reasons for insufficient milk such as incorrect method of breastfeeding, supplementary or bottle feeding, no night breastfeeding, engorgement of breast, any illness, painful condition, maternal stress or insufficient sleep. Try to +identify the possible reason and take appropriate actions. Step 3 Advise mother to take sufficient rest and drink adequate +fluids. Feed the baby on demand. Let the baby feed as long as possible on each breast. Advise the mother to keep the baby with her. + + +Expressed Breast Milk (EBM) +If a mother is not in a position to feed her baby (e.g. ill mother, preterm baby, working mother, etc.), she should express her milk in a clean wide-mouthed container and this milk should be fed to her baby. EBM can be stored at room temperature for 6-8 hr, in a refrigerator for 24 hr and a freezer at -20°C for 3 months. + +Method of Milk Expression +Ask the mother to wash her hands thoroughly with soap and water before she expresses. She should make herself comfortable. Gently massage the breast (Fig. 8.35). Hold the container under her nipple and areola. Place her thumb on top of the breast at least 4 cm from the tip of the nipple and the first finger on the undersurface of the breast opposite the thumb. Compress and release the breast tissue between her fingers and thumb a few times. +If the milk does not appear, she should reposition her thumb and finger closer to the nipple and compress and release the breast as before. Compress and release all the way around the breast. Express milk from both breasts. +To maintain adequate lactation, mother should express milk at least 8 to 10 times in 24 hr. + +CARE OF LOW BIRTH WEIGHT BABIES +Low birth weight (LBW; birth weight less than 2500 g) babies have higher morbidity and mortality. LBW results from either preterm birth (before 37 completed weeks of gestation) or due to intrauterine growth restriction (IUGR) or both. + + + + + +Step4 + +Fig. 8.35: Four steps of breast milk expression. Step 1: Massage the breasts gently toward the nipples; Step 2: Place the thumb and index finger opposite each other just outside the dark circle around the nipple; Step 3: Press back toward the chest, then gently squeeze to release milk; Step 4: Repeat step 3 in different positions around the areola + +IUGR is similar to malnutrition and may be present in both term and preterm infants. Neonates affected by IUGR are usually undernourished and have loose skin folds on the face and in the gluteal region (Fig. 8.36), absence of subcutaneous fat and peeling of skin. Problems faced by a preterm and IUGR neonate are different, although the management principles are common to both (Table 8.12). + +IUGR (Intrauterine growth restriction). IUGR results when the fetus does not grow as per the normal fetal growth trajectory. IUGR fetal growth restriction results from one or many adverse factors that affect the normal growth pattern of the fetuses. There are two types of IUGR babies: • Symmetric IUGR: When insult on the fetal growth occurs early. The size of the head, body weight and length are equally reduced. Causes include genetic and +chromosomal disorders or TORCH infections. +__ _s_s_e_n_t _ia_i_P_e_d_ i_at_r_ic_ _________________________________ +s +E + + + + + + + + + + + + + + + + +Fig. 8.36: Baby with intrauterine growth retardation showing many loose folds of skin + + +Table 8.12: Major problems in preterm babies and those with intrauterine growth retardation (IUGR) +Preterm babies +Hypothermia Perinatal asphyxia +Respiratory (hyaline membrane disease, pulmonary hemorr-hage, pneumothorax, bronchopulmonary dysplasia, pneumonia) +Bacterial sepsis Apnea of prematurity +Metabolic (hypoglycemia, hypocalcemia) Hematologic (anemia, hyperbilirubinemia) Feeding problems and poor weight gain +Babies with IUGR +Perinatal asphyxia Meconium aspiration Hypothermia Hypoglycemia +Feed intolerance Polycythemia Poor weight gain + +• Asymmetric IUGR: The insult on the fetal growth occurs during late gestation producing a brain sparing effect. Head circumference is relatively preserved compared to length and weight. Causes include placental insufficiency, pregnancy-induced hypertension or maternal medical diseases. +Small for gestational age (SCA): It is a statistical definition and denotes weight of infant being less than 2 standard deviation or less than the tenth percentile of the population norms (plotted on intrauterine growth chart). SGA and IUGR are considered synonymous. + +Issues in LBW Care +Besides the pathologies that can affect all neonates irrespective of weight and gestation, LBW may have additional complications requiring special care. + +Resuscitation +Problems +• Compromised intrauterine environment with higher chances of perinatal asphyxia +• Preterm babies have immature lungs that may be more difficult to ventilate and are also more vulnerable to lung injury by positive pressure ventilation. +• Immature blood vessels in the brain are prone to hemorrhage +• Thin skin and a large surface area, which contribute to rapid heat loss +• Increased risk of hypovolemic shock caused by small blood volume +Management +• Prepare for high risk of need for resuscitation +• Gentle resuscitation (small tidal volume) using small bags for positive pressure ventilation, use of CP AP +• Take extra care to avoid hypothermia + +Temperature Control +Problems +• Higher surface area to body weight ratio • Low glycogen stores +• Low subcutaneous fat +Management +• Frequent monitoring and educating parents for need to check temperature +• Special attention to maintenance of the warm chain • Kangaroo mother care + +Fluids and Feeding +These have been discussed under the section on feeding. +Infection +Problems +• Immature defenses +• Greater probability of invasive interventions like mechanical ventilation, umbilical vessel catheterization. +Management +• Strict adherence to asepsis, hand hygiene • Minimal handling of babies +• Low threshold for suspicion of sepsis, adequate and appropriate use of antibiotics +• Decreasing exposure to adults/ other children with communicable diseases particularly respiratory. + +Metabolic Derangements +Problems +• Low hepatic glycogen stores with rapid depletion in stress places these infants at increased risk of hypo­ glycemia. +• Immature glucose homeostatic mechanisms in premature babies can also lead to decreased inability to utilize glucose and resultant hyperglycemia, especially during stressful periods like infection. +Newborn Infants -- + \ No newline at end of file