NICU MUST-KNOWS APGAR SCORE

ESSENTIAL NEWBORN CARE

1. Immediate and thorough drying (prevent
hypothermia)
2. Early skin to skin contact (thermoregulation,
bonding, skin flora)
3. Properly timed cord clamping (reduce anemia)
TERM: 1-3 mins
PRETERM: 30 sec-1 min
4. Non-separation of newborn to mother for early
initiation of breastfeeding

ROUTINE NEWBORN CARE

1. Identification: done twice in delivery room and in
NICU
BALLARD SCORE
2. Vitamin K prophylaxis
A. K1 Phytomenadione: Natural
B. K2 Menaquinone: rebound hemorrhage
C. K3 Menadione: rebound hemorrhage
3. Eye prophylaxis
A. 0.5% Erythromycin
B. 1% tetracycline
C. 1% Silver nitrate – chemical conjunctivitis
D. 2.5% povidone iodine (WHO)
4. Cord care
5. Bathing: 6th hour of life
6. Vaccine
A. BCG
B. Hepa B

NEWBORN SCREENING
1. Congenital Adrenal Hyperplasia
2. Congenital Hypothyroidism
3. Phenylketonuria
4. Galactosemia
5. Maple Syrup Disease
6. G6PD

METHODS OF HEAT LOSS *DUBOWITZ: BALLARDS

1. EVAPORATION: lost by water evaporation from
the skin of the infant NORMAL VALUES
Ex: Thorough drying of infant after delivery
2. RADIATION: heat loss from the infant (warm) to a
colder nearby (not in contact) object
Ex: Use of droplight
3. CONDUCTION: direct heat loss from the infant to
the surface w/ which he/she is in direct contact
Ex: Using pre-warmed linen and cloth
4. CONVECTION: heat loss from the infant to the
surrounding air
Ex: Turn the aircon off
HC > CC – birth to 6 months
HC = CC – 6-12 months
 REFLEXES PURPOSE OF INITIAL PE:
1. To ensure that there is no evidence of significant
cardiopulmonary instability that requires
intervention
2. To identify congenital anomalies

BREASTFEEDING
BENEFITS OF BREASTFEEDING
B – est for infants
R – educes allergies
E – economical
A – antibodies (IgA – most abundant)
S - terile
T – emperature is always right
F – resh
E – asily digested
E – motional bonding
D – iarrhea is reduced
I – mmediately available
N – utritionally optimal
G – astroenteritis

Breastfeeding is NOT contraindicated in Mastitis

Mothers taking Magnesium Sulfate CAN still breastfeed
their babies
PHYSIOLOGIC CHANGES IN THE NEWBORN
PERIODS OF REACTIVITY
1. Tears often are not present with crying until after
1-3 months 1. First period
2. Physiologic jaundice: appears after 24 hours - 30 minutes after birth. Usually alert and
Peaks: Day 2-3 attentive/responsive.
Disappears 5th day of life - Regularly reflect a state of sympathetic discharge
3. Caput succedaneum: fluids, edema; crosses - Irregular respiratory effects and relative
midline resolves in days/weeks tachycardia
4. Lumbar lordosis: up to 6 years of age - Exhibits spontaneous startle reactions, tremors,
bursts of crying, side to side movements of the
5. Physiologic balding: up to 4 months of age
head, smacking of lips, and tremors on extremities.
6. Witch’s milk: galactorrhea in neonates because of
2. Sleep phase
persistence of mother’s estrogen in neonate’s
- After the burst of activity, the newborn enters a
blood
period of depressed activity and sleep
- Newborn are difficult to awaken
PHYSICAL EXAM OF THE NEWBORN 3. Second period
TIMING OF PHYSICAL EXAMINATION - Emerges between 2-6 hrs of age with same motor
and autonomic manifestations same as the 1st
1. Immediately after birth
period
2. Nursery room within 24 hours after birth
- Gagging and vomiting are evident
3. Focused examination within 24 hours before
- Variable duration lasting for 10mins to several
discharge
hours.
 JAUNDICE PHOTOTHERAPY
Normal Bilirubin production in NEWBORNS: 6-8mg/kg/day INDICATION: High intermediate risk zone in Bhutani Chart
LIGHT: blue range (420-470nm)
Estimated total bilirubin level based on dermal affectation: MECHANISM: reversible photo-isomerization and photo-
CEPHALOCAUDAL oxidation
DISTANCE: 15-20cm
KRAMER’S INDEX PRECAUTIONS:
FACE = 5mg/dL 1. Eyes must be closed and adequately covered to
CHEST = 10mg/dL prevent light exposure and corneal damage
ABDOMEN = 15mg/dL 2. Infant should be shielded from bulb breakage
PALMS AND SOLES = 20mg/dL 3. Body temperature should be monitored
4. Irradiance should be measured directly
BHUTANI: Bilirubin 5. Genitalia protected

LUNG MATURITY COMPLICATIONS

1. Loose stools
DEXAMETHASONE: 6mg q12 x 4 doses (IM) 2. Erythematous macular rash/purpuric rash
3. Overheating
BETAMETHASONE: 12mg q24 x 2doses 4. Dehydration: increase insensible loss, diarrhea
5. Hypothermia
PHYSIOLOGIC VS PATHOLOGIC JAUNDICE 6. Bronze baby syndrome
7. Corneal damage
PHYSIOLOGIC PATHOLOGIC
8. Anemia
Appears on 2nd to 3rd DOL May appear on 1st 24 HOL
9. Thrombocytopenia
Disappears by the 5th DOL Variable 10. Constipation
Peaks on Days 2 to 3 Variable 11. Burns
Total Bilirubin – usually Usually >5 mg/dL 12. Sterility
<5mg/dL Conjugated bilirubin
>2mg/dL at anytime
MECONIUM STAINING
th th
Presents after 48 HOL Present in the first 24-36
HOL
TB increases NOT TB increases
>5mg/dL/day >0.5mg/dL/day
TB peaks at 14-15 mg/dL TB increase to >15 mg/dL
Serum bilirubin: >12
CAPUT SUCCADANEUM CEPHALHEMATOMA
mg/dL in full term, 10-14
mg/dL in preterm CAPUT SUCCEDANEUM VS CEPHALHEMATOMA
neonates
Direct bilirubin is <10% of Direct bilirubin is >10% of
TB TB (>2mgdL)
Resolves in 1 week in full Persists beyond: 1 week in
term; 2 weeks in preterm term; 2 weeks in preterm

BREASTFEEDING VS BREASTMILK JAUNDICE

1. CAPUT SUCCEDANEUM
DESCRIPTION: diffuse, ecchymotic, edematous swelling of
the soft tissues.
EXTENSION: extend across the midline and suture lines
PATHOPHYSIOLOGY: associated with molding of the head
and overriding of parietal bones
RISK FACTORS: long difficult delivery; vacuum/forceps
delivery
RESOLUTION: 1st few days
COMPLICATIONS: hyperbilirubinemia
JAUNDICE
 2. CEPHALHEMATOMA 3. IDM
DESCRIPTION: firm tense mass with a palpable rim localized 4. LGA
over 1 area of the skull 5. Rare medical causing hypoglycemia
EXTENSION: limited to the surface of 1 cranial bone
PATHOPHYSIOLOGY: subperiosteal hemorrhage CBG IDM
RISK FACTORS: forceps delivery; large head; 1st pregnancy – At Birth 8 hrs
difficult prolonged labor 30 mins 12 hrs
RESOLUTION: 2 weeks to 3 months, calcify by the end of the 1 hr 24 hrs
2nd week 1 hr and 30 mins 36 hrs
COMPLICATIONS: hyperbilirubinemia, infection 2 hrs 48 hrs
4 hrs
3. SUBGALEAL HEMORRHAGE
DESCRIPTION: collection of blood
NEVI
EXTENSION: beneath the aponeurosis that covers the scalp
and serves as the insertion of the occipitofrontalis muscle
PATHOPHYSIOLOGY: secondary to rupture of emissary veins
connecting the dural sinuses within the skull with the
superficial veins of the scalp.
RISK FACTORS: associated with vacuum-assisted delivery
RESOLUTION: over 2-3 weeks
COMPLICATIONS: hypotension, anemia, hyperbilirubinemia

RASHES

FORMULAS

CBG
INDICATIONS:
1. Preterm
2. SGA
CORRECTED AGE OF PRETERM INFANTS II. TRANSIENT TACHYPNEA OF NEWBORN: RDS TYPE 2
EARLY BALLARD + (AGE IN DAYS ÷ 7) • Transient: usually improves within 24 hours;
disappears within 72 hours
HMD VS TTN • Wet-lung syndrome
• term to late preterm
• Early onset respiratory distress
• Mild. self-limited disorder, recovery within 3 days

INCREASED INCIDENCE
• Term or late preterm
• Premature, precipitous & operative births ->
prolonged delivery
• Male, born to asthmatic mother
• Delayed cord clamping
• Macrosomia
• Multiple gestation

PATHOPHYSIOLOGY:
• Absence of hormonal changes that accompany
ETIOLOGY/PATHOPHYSIOLOGY
onset of spontaneous labor
• Surfactant deficiency: produced by Type 2
• Abdominal delivery (non-spontaneous
pneumocytes; LS ratio 2:1
labor)
• Maturation of surfactant system -> Phosphatidy
− No thoracic squeeze
glycerol
• Transient pulmonary edema d/t delayed clearance
• FRC fails to develop -> collapsed lung/atelectasis
of fetal lung liquid
• High O2 concentration (damage epithelial lining
• Fluid accumulation in peribronchiolar lymphatics
cells)
and bronchovesicular spaces
• Genetics, hypoxia
• Diminished lung compliance and distensibility
• Hyper/Hypoxemia
• Lungs are liverlike, atelectasis CLINICAL MANIFESTATION:
• Typically presents at 6 hours of life
DIAGNOSIS
• Mild to moderate respiratory distress
• Premature infants with distress
• Improves in 24 hours; can last up to 72 hours in
• CXR: Fine reticulo-granularity (ground glass), air severe cases
bronchogram, typical pattern seen at 6-12 hours
• Rapid recovery, absence of radiographic findings
• ABG: progressive hypoxemia, hypercarbia, of RDS
metabolic acidosis, high base excess
• CXR: prominent pulmonary vascular finding fluid in
interlobar fissures
CLINICAL MANIFESTATIONS
o overaeration
• Peaks in 3 days then gradually improves o flat diaphragms
• Babies are born pinkish with very loud cry but signs o rarely: small pleural effusion
appear few minutes after birth o mild to moderate cardiomegaly
• Tachypnea
• Grunting MALIGNANT TTN: refractory hypoxemia due to PPHN in
• IC and SC retractions infants born via CS
• Alar flaring • give ECMO
• Duskiness
MANAGEMENT:
MANAGEMENT • Supportive: humidified O2, IVF, NPO, Antibiotics
• Intratracheal surfactant replacement • Caffeine or theophylline: increase central
• Oxygen (O2 sat at 88-94%) respiratory drive by lowering the threshold of
• Permissive hyoercapnea (55-65) response to hypercapnia as well as enhancing
• IVF, NPO, CPAP, Mech. vent, infection control: use contractility of the diaphragm and preventing
of orogastric tube diaphragmatic fatigue
• Coxopram: patent respiratory stimulant, acts
PREVENTION predominantly on peripheral chemoreceptors and
• Prevent prematurity
 is effective in neonates with apnea of prematurity microorganism frequently seen. Usually ampicillin
that is unresponsive to methylxanthines + aminoglycoside (gentamicin) or cefotaxime
• Transfusion of packed RBC o Susceptibility profile
• Nasal continuous positive airway pressure (CPAP, o Site
3-5 cm H2O) and high flow humidification using o Penetration of antibiotic
nasal canula 1-2.5L/min) o Safety
• CPAP is preferred for mixed or obstructive apnea
RESUSCITATION
APNEA INVERTED TRIANGLE OF NEONATAL RESUSCITATION
• cessation of breathing more than 10-20 sec or for
any duration accompanied by bradycardia or
oxygen desaturation
1. SERIOUS APNEA: preterm infants
o defined as cessation of breathing for
longer that is 20 sec or for any duration if
accompanied by cyanosis and bradycardia

2. OBSTRUCTIVE APNEA: pharyngeal instability, neck

flexion)
o Characterized by absence of airflow but
persistent chest wall motion

3. CENTRAL APNEA: caused by decreased CNS stimuli GOLDEN RULE: 30 seconds

to respiratory muscles, both airflow and chest wall
motion are absent MEDICATIONS: (LANE)
Lidocaine – bolus (1mg/kg/IV/IO); Max dose: 100mg; 2-3mg
4. MIXED APNEA: most common pattern (50-75% of ET
cases) Atropine – 0.02mg/kg IV/IO; 0.03mg/kg ET; Max dose
o with obstructive apnea preceding (usually) (Child: 0.5mg; adolescent 1mg)
or following central apnea Naloxone – <5y/o or ≤20kg: 0.1mg/kg/IV/IO ET
Epinephrine – 0.01mg/kg IV/IO; 0.1mg/kg ET; Max dose:
1mg IV/IO
SEPSIS NEONATORUM

• Systemic bacterial infection with (+) blood culture Other Drugs for Resuscitation and Arrythmias
in 1st month of life Adenosine – 0.1mg/kg (max 6mg); repeat: 0.2mg/kg
Amiodarone – 5mg/kg IV/IO
• Signs and symptoms often nonspecific
Calcium chloride – 20mg/kg/IV/IO (0.2mL/kg)
• High index of suspension is required to identify
Glucose – 0.5-1g/kg/IV/IO
and evaluate at risk infants
Magnesium sulfate – 25-50mg/kg/IV/IO over 10-20min;
• Commonly caused by: Group B Streptococcus, E.
Max dose: 2g
coli, L. monocytogenes and H. influenza
Procainamide – 1mEq/kg/dose IV/IO slowly
Early-onset = <7 days of age often associated with maternal
obstetric complications AMINOGLYCOSIDES
Late-onset = 7 days of age up to 1 month MOA: irreversible inhibitors of protein synthesis “induce
misreading of mRNA -> incorrect AA -> causes break up of
LABORATORY polysomes into non-functional monosomes
• Definitive diagnosis: (+) blood culture
• Antigen detection assay: detect bacterial cell wall DRUGS
or capsule OLDER NEWER
• WBC count – insensitive and non-specific Streptomycin Gentamicin Amikacin
• Acute Phase Reactant Kanamycin Tobramycin Netilmicin
Neomycin Sisomicin
TREATMENT Hygromycin B Paramomicin
• Empiric antibiotic therapy: choice of empiric *Clindamycin is a 50s inhibitor
therapy based on timing and setting of disease
COVERAGE: Gram-negative enteric bacteria; tuberculosis • Post antibiotic effect
(2nd line); not active vs anaerobes
CLINICAL USE: Administered sing-daily dosing: as effective and often less
• Serious life-threatening g(-) infection toxic, determination of serum concentration is probably
• Complicated skin, bone or soft tissue infection unnecessary, achieves greater post-antibiotic effect.
• Complicated UTI
• Septicemia DILATED FUNDOSCOPIC EXAM
• Peritonitis and other severe intra-abdominal
Performed in the ff:
infections
• All infants born ≤30 weeks AOG
• Severe pelvic inflammatory disease
• Infants born ≥30 weeks AOG but with unstable
o Gold standard: clindamycin + gentamicin
clinical course, including those that require
• Endocarditis
cardiorespiratory support
• Mycobacterium infection
• Any infant weighing <1,500g
• Neonatal sepsis
• Ocular infections and otitis externa
CRITERIA FOR DISCHARGE
ADVERSE EFFECTS: For preterm/LBW
Among elderly, dehydrated patient or those with renal or • Taking all nutrition by nipple (bottled or breastfed)
hearing impairment and treatment >5 days • Growths with steady increments (30g/day)
• Nephrotoxicity • Weight: 1,800-2100g
• Ototoxicity – auditory and vestibular • No recent episodes of apnea/bradycardia
• Neuromuscular blockade -> respiratory paralysis • Parenteral drug discontinued or converted to oral
(neomycin) – antidote = Calcium gluconate or • All should have hearing test
neostigmine • Mother’s knowledge, skill, confidence
• CNS – headache, tremors, lethargy, numbness, documented in:
seizures o Administration of medications
• Blurred vision o Use of oxygen, apnea, monitors, oximeter
• Rash, urticaria, fever, pain at injection site o Nutritional support (timing, volume,
• Diarrhea, nausea/vomiting (paramomycin) mixing concentrated formulas)
o Recognition of illness and deterioration
CONTRAINDICATIONS: tinnitus, vertigo, high frequency o Basic cardiopulmonary resuscitation
hearing loss, reduced renal function, dehydration, • Stable temperature regulation
pregnancy and lactation, infants, elderly • Ophthalmologic examination if:
o <27 weeks AOG
CHARACTERISTICS: requires oxygen uptake, bactericidal o <1,250g at birth
Structure: hexose ring either streptidine (streptomycin) or
2-deoxystreptamine (others), amino sugar, glycosidic LUBCHENCO: SGA, AGA, LGA
linkage
Resistance: enzyme inactivation, impaired entry of drug
due to cell mutation in deletion

PHARMACOKINETICS
• Poorly absorbed from intact GIT except when
there’s ulceration
• Entire oral dose excreted in feces after oral
administration
• Highly polar compounds that do not enter cells
readily but penetrate inflamed meninges (20%)
• Water-soluble, stable in solution, more active at
alkaline
• Synergistic with beta-lactams or vancomycin
• Tissue concentrations not high except in renal
cortex, bile (50%), pleural or synovial fluid (50-
90%)
• Half-life: 2-3hrs, increasing to 24-48hrs with
significant impairment of renal function
• Concentration-dependent killing activity