Neonatology😊

Important terminologies

Baby born at

• < 37 completed weeks of gestation: Preterm neonates

• 37-42 weeks of gestation: Term neonates

• > 42 weeks of gestation: Post term/mature neonates

Birthweight

If birth weight is gestational age

• 10th - 90th percentile of expected
• Appropriate for GA

• < 10th percentile of expected:
• Small for date (SFD) or Small for gestational age (SGA)

• > 90th percentile of expected:
• Large for date (LFD) or Large for gestational age (LGA)
• LFD is seen in:
• Infant of diabetic mother,
• congenital hypothyroidism,
• Beckwith-wiedmann syndrome
• Soto’s syndrome

Normal term neonate

• Heart rate: 120-140 bpm

• Respiratory rate: 40-60/min

• Peripheral/ Acrocyanosis:
• Commonly present at birth

• Short systolic murmur:
• Normally present,
• pulmonary vascular resistance is ↓↓
• sudden increase in the pulmonary blood flow

TORCH

TOXOPLASMOSIS

• Primary toxoplasma infection during pregnancy.
• Severity → more if affected earlier (11 weeks)

• Mnemonic: Toxic killing → Kanni kude (chorioretinitis) thalayilott (cerebral calcification) inject cheyth (↑ size → hydrocephalus)

• Definitive host: Cat.

• Intermediate host: Human.

Mode of transmission

• Ingestion
• Sporulated oocyst via contaminated soil/food/water.
• Bradyzoites via undercooked meat.

• Blood transfusion & Vertical
• Tachyzoites.

• Blood and sex - tachy

• Relax (Brady) and eat meat
• Beef - brady

• spores from soil

• Cat → Oocyst
• Infective Stage.
• Diagnostic Stage.

• Diagnosis
• Serological diagnosis.
• Direct identification of parasite from:
• Peripheral blood.
• Amniotic fluid.
• Tissue sections.

Variants of toxoplasmosis

• Adult toxoplasmosis
• Asymptomatic.
• LN enlarged.

• HIV+ toxoplasmosis
• Encephalitis.
• Most commonly brainstem is affected.

• Congenital Toxoplasmosis
• More severe in trimester I.
• More common in trimester III.
• Chorioretinitis.
• Intracerebral calcification.
• Convulsions.
• Microcephaly
• Mental retardation.



• Mnemonic: CHC
• Small for gestational age.
• Prematurity.
• Hydrops fetalis, i.e., generalized anasarca.
• Persistence jaundice.
• Thrombocytopenia.
• Focal Chorioretinitis
• Most common manifestation
• HYDROCEPHALUS.
• Macrocephaly due to hydrocephalus.
• Cerebral calcification
• On NCCT

Important Information

• Toxoplasma → intracerebral calcification.

• CMV → periventricular calcification.

Diagnosis

• Frenkel test

• Sabin Feldman test: Gold standard.
• Test uses Methylene blue and tachyzoite stage
• If colorless - antibodies present.
• If color is present - antibodies absent.

Prevention and Treatment

• Pyrimethamine + Sulfadiazine.

• Early diagnosis of infection

• Treatment of mothers is by sulphadiazine.

Congenital CMV Infection

• Largest of Herpesviridae

• SRK (salivary, resp, kidney) → Largest → lives in mannat (Monocytes) → big muscle fibre (human fibroblast culture)

• Reservoir: Humans only

• Transmission:
• Common: oral, respiratory, body secretions
• Less common: transplacental, sexual

• Multiplication sites (mnemonic SRK in Mannat):
• Salivary gland
• Respiratory tract
• Kidney

• Latent in: Monocytes

• M/c infection during 1st 4 months of organ transplant

Infections

Infections	Features
Congenital	M/c intrauterine infection Defects: • mental retardation • microcephaly • periventricular calcification • chorioretinitis
Perinatal	usually asymptomatic
Immunocompromised	CMV chorioretinitis
Immunocompetent	IMN-like syndrome Features: fever, sore throat ↳ No lymphadenopathy, splenomegaly, or specific antibodies

Features`

• 1st CMV infection — 30%.

• 2nd CMV infection — 1-2% (Developing countries like India).

• Congenital CMV
• 90% of → asymptomatic
• No use of routine screening.
• Most important long-term sequelae in SYMPTOMATIC CMV
• Sensorineural hearing loss.
• Most common non syndromic causes of hearing loss.

Clinical features in Congenital CMV

• Microcephaly
• < 3 SD of HC

• Chorioretinitis.

• Hepatosplenomegaly.

• Jaundice.

• Petechiae.

• Periventricular calcifications.

Congenital Varicella

Teratogenic period:

• Infected in 1st trimester
• 0.4% of babies

• 2nd trimester → 12-20 weeks (after 3 months till 5 months end)
• 2% of babies
• Congenital / Fetal Varicella Syndrome
• Indication for MTP

Clinical features

• Cicatricial scarring in zoster like or
• Dermatomal distribution around umbilicus.

• Limb hypoplasia.

• Low birth weight.

• CNS involvement:
• Microcephaly,
• developmental delay,
• intellectual disability,
• seizures.

• Eye involvement:
• Chorioretinitis,
• cataract,
• microphthalmia (small eye).

• Renal involvement:
• Hydronephrosis.

• Autonomic dysfunction:
• Swallowing dysfunction,
• neurogenic bladder.

Diagnosis of congenital varicella infection

• history of varicella during pregnancy.

• clinical features in a baby.

• Anti-varicella IgM in a baby.

Neonatal Varicella Syndrome

• Pregnant female acquires infection 5 days before to 2 days after delivery

• Features
• Hepatitis
• Pneumonia
• Skin rash
• Meningoencephalitis

• Treatment :
• Give VZIG
• IV Acyclovir to child

• For mother :
• Oral Acyclovir

Congenital rubella syndrome.

• Risk of transmission ↑↑↑ → if earliest before 11 weeks of gestation

• Least r/o perinatal transmission

• Virus excretion → saliva, urine

• Mnemonic : Rubee → Blue bee( Blueberry rash)
• Sitting in salt and pepper (Salt & Pepper Fundus)
• Shiny Pearly eyes → Nuclear pearly cataract
• Can't see (Small eyes) can't hear (SNHL) also had some heart disease.
• adich Padam (PDA) aakki

• Triad of Gregg
• PDA
• Cataract
• SNHL

Complications

1. Congenital heart diseases:
• Most common: Patent Ductus Arteriosus > PS
• Least common: Atrial Septal Defect.

2. Sensorineural hearing loss.

3. Blueberry muffin lesion:
• Bluish red nodular lesions
• characteristic of congenital rubella.

4. Microcephaly, IUGR.

5. Glaucoma.

6. Hepatosplenomegaly.

7. Jaundice.

8. Thrombocytopenia.

Key Ocular Manifestations:

• Congenital nuclear cataract
• Nuclear Pearly Cataract
• Most common cataract in CRS

• Micro-ophthalmos
• abnormally small eyes

• Salt & Pepper Retinopathy

NOTE:

• Salt & Pepper Fundus



• Mnemonic: Salt and pepper movie
• Ruby (Rubella) → a Star (Stargardts)
• Rough (Refsum) Labor (Lebers) who has Syphillis (CS) Raped (RP → Retinitis Pigmentosa) her → got Rid (Thioridazine) of body
• Thio Ridazine :
• Thio Ridazine → rid of
• Brown (Brown vision) Cuteee (QT prolongation) with colorful eyes (RP),
• like Salt and Pepper () movie
• but ejaculated retrograde ()

• Diagnosed by:
• Presence of IgM rubella antibodies in the infant shortly after birth
  (since IgM does not cross the placenta)
• Persistence of IgG antibodies for >6 months
  (maternally derived antibody would have disappeared)

Assessment of gestational age of a neonate

Expanded new Ballard score (ENBS)

• Between 20-44 weeks
• Intrauterine

• Parameters of physical maturity and neurological maturity

Weeks	Score
20	-10
22	-5
24	0
26	5
28	10
30	15
32	20
34	25
36	30
38	35
40	40
42	45
44	50

Neurological maturity

Upper limb

• Square window

• Scarf sign

Lower limb

• Popliteal angle

• Heel to ear

Signs of physical maturity in a preterm neonate

General

• Small/emaciated

• Skin
• thin, pink and fragile
• more chances of infections and neonatal sepsis

• Lesser subcutaneous fat
• more chances of developing hypothermia

• Generalized hypotonia
• extended posture

• Abundant lanugo
• but little vernix caseosa

Head to toe

• Head appears relatively large

• Anterior fontanelle
• diamond shaped area on the skull
• large and wide open
• other causes:
• rickets,
• cleidocranial dysostosis,
• osteogenesis imperfecta,
• congenital infections,
• hydrocephalus

• Ear cartilage is poorly formed
• ear recoil is poor

• Breast buds <5mm

• Male:
• Undescended testis,
• poorly formed smooth scrotum

• Female:
• Labia majora is widely separated,
• labia minora is clearly visible

• Absent deep creases on the sole

Meconium

• First stool of a newborn

• Color: Greenish-black

• Composition:
• Amniotic fluid
• Mucus
• Intestinal epithelial cells
• Bile

• Color:
• Due to combined components of meconium
• Not primarily from bilirubin or biliverdin

PASSING URINE AND MEOCONIUM

• Meconium by 24 hours (9% pass by 48 hours)

• Urine by 48 hours

Hearing Test in Children

• All newborns must be tested
• 2 step screening process:
• 1st: OAE testing
• 2nd: ABR testing

• Recommended techniques:
• 1. Otoacoustic Emissions (OAE)
• Detects conductive or cochlear hearing loss
• Assesses pathway:
• External ear → Outer hair cells of cochlea
• 2. Auditory Brainstem Evoked Response (ABR/BERA)
• More reliable test
• Detects:
• Conductive hearing loss
• Cochlear/Sensorineural hearing loss
• Assesses pathway:
• External ear → Brainstem

Neonatal Hearing Screening Recommendations
(1–3–6 Rule)

• By 1 month: Primary screening

• By 3 months: Secondary testing

• By 6 months: Interventions

Conditions in neonates not requiring any specific treatment

Skin/mucosa

• Erythema toxicum
• Usually present in 1st week of life
• Sterile eosinophil filled lesions
• Reddish maculopapular lesions present mainly on the trunk

• Milia:



• Colorless papules due to the plugging of sweat ducts

• Mongolian spots:
• Bluish black areas of discolouration
• mainly on lower back, buttocks, back of thigh

• Stork bites or Angel Kiss:





• Capillary hemangiomas
• seen in between the brows, nape of the neck

• Subconjunctival hemorrhage

Other conditions

• Mastitis neonatorum:
• B/l breast engorgement in both males and females
• due to the effect of maternal hormones

• Milk output can also be sometimes seen

• Vaginal bleeding in female neonates:
• Due to withdrawal of maternal hormones

• Hymenal tags in females

• Physiological phimosis in males

• Physiological weight loss

Physiological weight loss

• Term neonates:
• loss upto 10% of their birth weight in 3-5 days
• Regain by Day 10 of life

• Preterm neonates:
• Upto 15% of their birth weight in 7-10 days
• Regain by Day 15 of life

Cephalhematoma Vs Caput Succedaneum

Feature	Caput Succedaneum	Cephalhematoma
Collection	Fluid	Blood
Cause	Prolonged stagnation of fetal head during labor	Traumatic instrumental delivery
ㅤ	Due to edema in the layers of scalp	Subperiosteal hemorrhage involving cranial bones
Location	Above periosteum (can cross sutures/ midline)	Below periosteum (cannot cross suture line)
Pits on pressure	Yes	No
Associated with fracture	No	Yes
Appearance	Present at birth in its maximum size	24-48 hours to appear completely
Disappearance	Disappears in 48-72 hours	Take upto 5-7 weeks to disappear Drainage is contraindicated
ㅤ	No neonatal jaundice	Predisposes to neonatal jaundice

Primitive neonatal reflexes

Moro's reflex

• Begins to appear: 28 weeks of gestation

• Completely appears: 37 weeks of gestation

• Disappears: 5-6 months post natally
• if does not disappear beyond 6 months- Cerebral damage

• Absent Moro's reflex:
• Stage 3 HIE (Hypoxic ischaemic encephalopathy),
• Down's syndrome

• Asymmetric Moro's reflex
• Erb's palsy
• Congenital hemiplegia
• Fracture of clavicle
• Unilateral shoulder joint dislocation

Rooting reflex

• Begins to appear: 32 weeks of gestation

• Disappears: 1 month post natally

Suckling reflex

• Begins to appear: 32 weeks of gestation

• Disappears: 3 months post natally

Palmar grasp reflex

• Begins to appear: 28 weeks of gestation

• Disappears: 3 months post natally

Plantar grasp reflex

• Begins to appear: 35 weeks of gestation

• Disappears: 3-5 months post natally

Asymmetric tonic neck reflex

• When head of the neonate is turned to one side,
• the upper and lower limbs of
• same side are extended
• opposite side are flexed

• Begins to appear: 35 weeks of gestation

• Disappears: 3-5 months post natally

Appearing after birth

• Baby Landed symmetrically in Parachute

STNR (Symmetric Tonic Neck Reflex)

• Begins to appear: 4-6 months post natally

• Disappears: 8-12 months

Landau reflex

• Begins to appear: 4-6 months post natally

• Disappears: 12-24 months

Parachute reflex

• Begins to appear: 7-8 months post natally

• Persists throughout life

Neonatal resuscitation

• Ideal temperature of delivery room:
• 25°C - 28°C

Suction during neonatal resuscitation

• Suction of all babies after delivery is not required
• only when there is a lot of secretions

• Mouth 1st > then nose (to prevent aspiration)

• NOT intratracheal / intrapartum suctioning

Routine care provided if

• Term gestation

• Good muscle tone

• Normal breathing/ crying

Components

• Provide warmth: Radiant warmer/ skin contact

• Clear airway if required

• Dry the baby

• Ongoing evaluation- for respiratory distress

Indications of PPV during neonatal resuscitation

• Apnea

• Gasping

• HR < 100bpm

Process

• Given using a self inflating bag and mask



• rate of 30-40 breaths/ min

• +/- Oxygen

• Reservoir:
• Increases the FIO2

• In term babies
• start with room air (FIO2-21%)

• In preterm babies
• start with 30% oxygen using a blender

Absolute contraindications to bag and mask ventilation

• TEF

• CDH

Congenital Diaphragmatic Hernia

• Absence of the pleuroperitoneal membrane.

• Leads to persistence of the pleuroperitoneal canal (Bochdalek foramen)

• M/c → Left > right

• Clinical Features:
• Scaphoid abdomen with respiratory distress.

Type	Morgagni Hernia	Bochodalek Hernia
Location	Right anteromedial/Retrosternal	Most common Left posterolateral
Defect Development	Central tendon of diaphragm D/t enlarged Space of Larry (Contain Superior Epigastric Artery) (space between sternum § costal origins of diaphragm.	Pleuroperitoneal canal/membrane
Herniating Structures	Transverse colon	Stomach, spleen, transverse colon
Mnemonic	ㅤ	Boche → CPM → Left

Diagnosis:

• Prenatal detection can be done.
• scaphoid abdomen

• Bowel gas shadows are present in the thorax

• Diaphragmatic outline is not clearly visible

• Heart shadow is not visualized due to mediastinal shift

Complications

• 1st most common cause of death:
• Pulmonary hypoplasia
  (due to reduced space for lung development)
• scaphoid abdomen
• respiratory distress and
• features of mediastinal shift

• 2nd most common cause of death:
• Pulmonary hypertension (PPHN).
• Managed with inhaled nitrates.

Management (Mx)

• Best ventilation: IPPV (Intermittent Positive Pressure Ventilation).

• ExUtero Intrapartum Treatment Procedure (EXIT)
• Airway is ensured before the infant is separated from Placenta
• Also done in Laryngeal atresia, Stenosis, Teratoma, Hygroma, Oral tumors

• Resuscitation: 
• with Bag and mask ventilation C/I

• If there is severe respiratory distress
• Intubation and bag and tube ventilation needs to be done

• Surgical Management (Sx):
• Circular incision around the diaphragm.
• Bowel reduced back into abdominal cavity.
• Mesh placed to reinforce the repair.

Eventration of diaphragm

• Similar to CDH but not a true hernia.

• Thinning of pleuroperitoneal membrane



 

Chest compressions in neonatal resuscitation

• Indication: HR < 60/min, despite effective PPV

• Ratio
• CC : PPV = 3 : 1

• Site:
• Lower 1/3rd of body of sternum
• just below the midline line joining the 2 nipples

• Use of O2:
• 100% O2

Inj. Adrenaline

• Indication:
• HR < 60/min
• despite 60 seconds of chest compressions and PPV

• Dose:
• 0.02 mg/kg/dose or
• 0.2 ml/kg/dose of 1:10,000
• (0.1 mg/mL)
• can be repeated 3 times

• Preferred route:
• IV through the Umbilical venous catheterisation (UVC)
• Intratracheal (only if vascular access cannot be secured)
• Mnemonic: LUV → Left umbilical vein (not right)

Resuscitation of a baby born through meconium stained liquor (MSL)

Latest recommendations

• Continue resuscitation as per neonatal resuscitation protocol

• Routine endotracheal intubation and tracheal suction
• of all non-vigorous neonates is not required

• At least 1 person skilled in endotracheal intubation should be available during resuscitation

Delayed cord clamping

• For at least 30 sec in all stable term and preterm neonates

Advantages

• Higher Hb level

• Lesser need for blood transfusion

• Lesser risk of hypotension

• There is a slight higher risk of neonatal jaundice
• but the advantages outweigh the risk

Essential Newborn care

• Keep baby warm and dry

• Resuscitation, if required

• Care of eyes
• two separate sterile gauze swiped from medial to lateral

• Care of cord
• use of sterile cord clamp and cord tie;
• nothing to be applied to the umbilical cord

• Initiation of breastfeeding

Feeding of preterm neonates

Gestational age- recommended initial mode of feeding

• <28 weeks:
• IV fluids +/- TPN

• 28-31 weeks:
• Orogastric or Gavage feeding

• 32-34 weeks:
• Katori spoon or Paladai feeding

• 34 weeks:
• Direct breastfeeding

Feed for Term baby in first 24 hours after delivery

• 60 ml/kg

Diseases of the newborn

Neonatal sepsis

M.c. organism responsible for neonatal sepsis

Candida parapsilosis

• Significance:
• Most common non-albicans cause of invasive candidiasis in neonates.

• Transmission:
• C. parapsilosis:
• Primarily nosocomial, total parenteral nutrition (TPN);
• associated with colonization of healthcare workers’ hands.
• C. albicans:
• Usually acquired from maternal genital tract.

Risk factor for early onset sepsis (< 72 hrs)

• Maternal fever

• Foul smelling liquor

• Multiple PV examinations during pregnancy

• Low birth weight

• Prematurity

Risk factor for late onset sepsis (< 72 hrs)

• Lack of breastfeeding

• Skin infection of the neonate

• Infection of the umbilical cord stump

• Multiple interventions

Most common method to prevent neonatal sepsis

• Proper hand washing of the caregivers (for 3 minutes)

Investigations

• Most effective method for prevention: Proper Handwashing

• Earliest C/F: Baby not feeding well

• Initial Ix: Sepsis screen

• IOC: Culture

• R/F:
• Preterm
• ROM >18hrs
• PPV

Sepsis screen

• Positive when any 2 / 5 parameters are abnormal
1. TLC (< 5000)
2. ANC (< 1800)
3. IT ratio (> 0.2)
4. CRP (positive)
5. Micro ESR (> 15 mm in 1st hr)

• Confirmatory test to diagnose neonatal sepsis:
• Blood culture

• In Early: Additionally take
• CSF analysis
• Chest Xray
• Usually the infection is Meningitis or pneumonia
• Urine C/S not much role in early neonatal sepsis

Treatment of choice

• IV broad spectrum empirical antibiotics

Duration of antibiotic therapy

• Blood c/s negative:
• 5-7 days

• Blood c/s positive:
• 10 days

• CSF s/o meningitis:
• 21 days

Neonatal hypothermia

• Definition: Axillary temperature <35.5°
• Min 3 mins

In AHA 2020 Guidelines :

• Hypothermia in NB is defined as temp. <36°c

• Cold stress:
• 36 - 36.4 °C

• Moderate hypothermia:
• 32 - 35.9 °C

• Severe hypothermia:
• < 32°C

Most important mechanism for protection against hypothermia in neonates:

• Non shivering thermogenesis

• Due to the presence of brown fat
• Around scapula, axilla
• lipid deposits rich in mitochondria
• Release of norepinephrine and uncoupling of beta oxidation of fat → heat production

• Mnemonic: AD ThyLI (adi thyli)

• Newborns: Interscapular, perirenal, mediastinal, perivascular, supraclavicular.

• Adults: Less, but persists in supraclavicular and paravertebral regions.

Maximum heat loss:

• via head of the baby

• Recommended to keep the head of the baby covered

• Measurement: Rectal temperature (best for core temperature)

• Rewarming: Cardiopulmonary bypass machine (best for severe hypothermia)

Classification in adults:

1. Cold Stress: > 35°C.

2. Mild: 32 - 35°C.

3. Moderate: 28 - 32°C.
• <30°C hypothalamus stops functioning.
• Shivering stops
• Reflexes are low.
• Osborn J waves in ECG → Indicate severity
• Paradoxical undressing 
• Severe cold exposure → failure of thermoregulation → ↑ blood flow → failure of Vasoconstriction → ↑ sense of warmth → undressing → death
• Kills the patient & can mimic sexual offense
• Hide & die syndrome/terminal burrowing.

4. Severe: <28°C.
• No motion, Absent reflexes & shivering, Coma
• Osborn J waves in ECG → Indicate severity

Autopsy findings:

• White deaths.

• Pink hypostasis.

• Wischnewski’s bleeding spot in stomach.

• Note : Pink hypostasis also seen in refrigerated body.

Frost Bite

• Cause: Prolonged exposure to dry cold

• Pathophysiology:
• Ice crystals form in tissue
• Membrane damage + microvascular damage

• D/t exposure to freezing temperature.

• Site: Periphery (Finger, feet, tip of nose/ear lobes).

• Rx: Gradual rewarming at 40°C.
• Rewarming → Re-perfusion injury

• Grading after rewarming

Trench Foot

• Cause: 
• Prolonged exposure to cold + moisture (tissue remains wet)

• Pathophysiology:
• Microvascular damage
• Stasis & occlusion

Management of Frost Bite and Trench Foot

• Rapid re-warming of affected leg (water: 40°C)
• Beware of re-perfusion injury

• Do not rub the tissues (causes severe pain)

• Hyperkalemia, acidosis can occur

• If gangrene + → Wait for demarcation line → Amputation

Clinically cold stress is

• abdomen is warm

• soles are cold

Areas rich in brown fat

• Axilla

• Groin

• Nape of neck

• Inter scapular area

Under-Five Clinics:

• Elements:
• Promotive care
• Core
• Family planning
• Curative care
• Preventive care
• Health Education

Kangaroo mother care

• Elements (SAANS):
• Skin-to-skin (Hypothermia prevention)
• Airway disease prevention
• Ambulatory support
• Nutritional support (Exclusive breastfeeding)
• Support (Emotional)

Indication

• All stable low birth weight neonates

Components

1. Kangaroo position:
• Skin-to-skin contact

2. Kangaroo nutrition:
• Exclusive breastfeeding,
• no supplementation

3. Early discharge from hospital

Advantages

• Lesser chances of:
• Sepsis,
• Hypothermia
• Neonatal mortality

• Higher weight gain (better gain of anthropometric parameters)

• Earlier discharge from hospital

• Higher breastfeeding rates

STOP KMC

• baby attains 2.5 Kg or 37 weeks.

GOBI FFF

• Given by WHO/UNICEF.

• Aim: Promote child survival

• Components:
• Growth monitoring
• Oral rehydration solution
• Breastfeeding
• Immunization
• Female fertility
• Female literacy
• Food (Female nutrition)

BFHI, MAA, CLMC:

• Baby Friendly Hospital Initiative (BFHI):
• UNICEF initiative to promote child survival

• Mother’s Absolute Affection (MAA):
• Gov of India, MoHFW initiative to promote breastfeeding
• Normal delivery: Within 1 hour
• C-section: Within 4 hours

• Comprehensive Lactational Management Centers (CLMC):
• Promote breast milk donation
• CHCs & District hospitals:
• Breast pumps & breastmilk storage facilities (+)

Important Dates & Weeks

Date/Period	Event
April 14th	Ayushman Bharat Health & Wellness Centre Day
Last week of April	World Immunization Week
May 28th - June 8th	Intensified Diarrhoea Control Fortnight
August 1st - 7th	World Breastfeeding Week
September 1st - 7th	National Nutrition Week
November 15th - 21st	Newborn Week

Devices used to keep neonates warm

1. Radiant warmer

• Open care system

• Method by which neonate is kept warm:
• Radiation

2. Incubator

• Baby is kept inside a closed box

• Method by which neonate is kept warm:
• Convection

• Preferred for preterm neonates
• helps to maintain humidity to prevent further losses due to evaporation

Neonatal hypoglycemia

Definition

• Blood glucose <40 mg/dl or

• plasma glucose <45 mg

• M.c: Jitteriness/ tremors
• (when limbs are held, jitteriness stops and is not associated with up rolling of eyes; whereas in seizures, movements do not stop when limb is held)

• Others:
• Apnea, seizures, increased sweating, lethargy

Treatment

• If asymptomatic:
• Offer a feed and
• Frequent feeding
• Regular monitoring of blood glucose

• If symptomatic or <20 mg/dl:
• IV 10% dextrose 2 ml/kg
• Continuous glucose infusion
• GIR → glucose infusion rate (6 mg/kg/min)

Important causes of persistent hypoglycemia during infancy

Endocrine causes

• Congenital hyperinsulinemia
• most common cause
• earlier known as Nesidioblastosis
• currently it is known as PHHI- persistent hyperinsulinemic hypoglycemia of infancy
• Mnemonic: HI → HyperInsulinemia

• Congenital hypopituitarism

• Congenital adrenal insufficiency

Metabolic disorders

• Glycogen storage disease

• Galactosemia

• Hereditary fructose intolerance

• Mitochondrial disorders

• Fatty acid oxidation defects

Problems in infants of diabetic mother

Large for date/ macrosomia:

• ↑↑ chances of obstructed/prolonged labor
• Use of instruments
• Increased chances of birth trauma
• Increased chances of birth/perinatal asphyxia

Metabolic

• Hypoglycemia

• Hypocalcemia

• Polycythemia

• Hyperbilirubinemia

Respiratory system

• Increased risk of
• Respiratory distress syndrome/
• Hyaline membrane disease
• due to delayed maturation of surfactant
• Even in term babies

• Note:
• Usually RDS is disease of preterm neonates,

Cardiovascular system

• M.c. CHD: VSD

• Most specific: Transposition of great arteries

Neurologic system

• M.c: Neural tube defects

• Most specific: Sacral agenesis/ Caudal regression syndrome

APGAR score

Question Trick

• If given MINIMAL RESPONSE
• ⇒ Reflex irritability (Grimace) + Some muscle tone
  ⇒ 1 + 1 = 2

• Total score: 10

• Minimum score: 0

• APGAR score > 7 - normal

• APGAR score 0-3 - severely depressed neonate

• Note
• Nasogastric tube is used to irritate nasal mucosa to elicit grimace.
• Normal newborn heart rate : 130-160/min.

Perinatal asphyxia

• Definition: Inability to initiate or sustain breathing — damage to brain (HIE)

CEREBRAL PALSY

• NON PROGRESSIVE, NON REVERSIBLE

• DPT vaccine can be given

Parts of brain most commonly affected due to asphyxia

• In term neonate with HIE
• Parasagittal area
• Spastic quadriplegia
• Multicentric encephalomalacia
• Status marmoratus:
• Basal galglia affected
• m/c Choreo-athetoid type

• In preterm neonates:
• Periventricular area
• normal intelligence → scissoring + W-sitting + commando crawl
• Spastic diplegia
• Periventricular encephalomalacia
• Best prognosis (because intellect is spared)

• Spastic hemiplegia
• Porencephalic cyst

Diagnosis

• APGAR score:
• 0-3 for > 5 mins

• Cord blood pH:
• pH < 7

• CNS dysfunction:
• Seizures,
• tone abnormalities,
• abnormal Moro's
• Scissoring gait
• Commando crawl

• Neonatal multiorgan dysfunction:
• Acute kidney injury,
• liver dysfunction

• Cortical thumb

Neonatal seizures

Staging of HIE (Hypoxic Ischemic encephalopathy)

Sarnat staging

• if Sar nuts → HIE

• Treatment: Mainly supportive care

• Therapeutic hypothermia may be tried in moderate HIE

NOTE

• EEG shows burst suppression
• SSPE
• HIE stage 3

Respiratory distress syndrome

• M.c cause of respiratory distress is a preterm neonate

• Basic defect: deficiency of mature surfactant

 

• Type 1 pneumocytes:
• Thin squamous cells
• Predominant cells (cover 95% of alveolar surface).
• Flat cells.
• Primary site for gas exchange.

• Type 2 pneumocytes:
• Cuboidal cells (cover 5% of alveolar area).
• Have microvilli on their surface.
• Secrete surfactant.
• Appear larger with big, rounded nuclei in sections.
• Described as mimicking Clara cells.

Surfactant

• Produced by- type II alveolar cells or type 2 pneumocytes

• Synthesis begins in fetal lungs at- 20 weeks

• Begins to appear in amniotic fluid- 28 weeks

• Mature and in adequate amount- > 35 weeks

• Most important component of surfactant:
• DPPC (Dipalmitoyl Phosphatidyl Choline) > Lecithin

• Most important surfactant protein:
• Surfactant Protein B

Function of surfactant- to decrease the surface tension of alveoli

• Prevents alveoli from collapsing

• Increases lung compliance

When mature surfactant is deficient

• Alveolar collapse

• Interstitial edema

• Alveolar damage

• Decreased lung compliance

• Deposition of fibrin
• hyaline membrane disease

• Small volume lungs with ground glass haziness of lungs is seen

• Sometimes air bronchogram is seen
• radiolucent areas

Silverman score

• Only Preterm

• Grunt is a noise due to expiration against a partially closed glottis

Downe's score

• For term and preterm neonate

Parameter	0	1	2
Cyanosis	None	Peripheral cyanosis	Central cyanosis
Retractions	None	Mild	Moderate → Severe
Grunting	None	Audible only with stethoscope	Audible without stethoscope
Air entry	Normal	Decreased	Absent
Respiratory rate	<60	60-80	>80 or Apnea

• Maximum score: 10

• Minimum score: 0

• Score < 3 - Normal

• Score > 7 - Severe respiratory distress

Treatment of respiratory distress syndrome

Mild

• CPAP (continuous positive airway pressure)
• prevents alveoli from collapsing during expiration
• +/- O2

Moderate to severe

Intratracheal surfactant

• INSURE:
• Intubate — give Surfactant — Extubate
• Indication
• RDS + > 30% need for oxygen

• LISA:
• Less Invasive Surfactant Administration

• LAST RESORT → Respiratory support:
• Mechanical ventilation

Prevention of RDS

Antenatal corticosteroids

Meconium aspiration syndrome

• C/F:
• SGA/IUGR baby
• meconium stained liquor
• respiratory distress soon after birth
• Green staining of vocal cord

• On examination: Increased antero-posterior diameter of the chest due to hyperinflation

CXR

• Obstructive emphysema
• Hyperinflated lungs (appear more black, flattening of diaphragm)

• Chemical pneumonitis

• Segmental collapse

Treatment:

• Supportive

Transient tachypnea of newborn (TTNB)

• Also called delayed adaptation

• Due to delayed clearance of lung fluid

• M.c in babies born through
• C section

CXR

• Fluid in interlobar fissure

• Perihilar streaking/ prominent broncho vascular markings

• Pleural effusion

Management:

• Self-limiting

Neonatal apnea

• Definition: Cessation of breathing for
• at least 20 seconds or
• for any duration + either bradycardia/cyanosis

Causes

• Neonatal sepsis,

• Neonatal jaundice,

• Polycythemia,

• Hypoglycemia,

• Hypocalcemia,

• Anemia,

• Apnea of prematurity

Treatment

• Drug of choice for apnea of prematurity:
• Inj caffeine citrate

• Treat the cause

• Respiratory support

Bronchopulmonary dysplasia

• Baby on persistent O2 support

• Baby received > 21 % O2 for > 28 days

• Then developed RDS

Necrotising enterocolitis

Important risk factors

• Prematurity,

• Lack of breastfeeding/ use of formula feeding,

• 10% cases can occur in term neonates

Stages of NEC → BPG

Stage	Systemic Signs	Treatment
Ia	• Occult blood in stool BAT • Bradycardia • Apnea • Temperature instability	• NPO, antibiotics 3 days
Ib	• Fresh blood in stool	• Same as IA
IIa	• Pneumatosis intestinalis in X ray	• NPO, antibiotics 7 to 10 days
IIb	• Portal vein gas (Pneumatosis portalis)	• NPO, antibiotics 14 days
IIIa	• Peritonitis • DIC	• NPO, antibiotic 14 days, • fluid resuscitation, • inotropic support
IIIb	• Gas under diaphragm/pneumoperitoneum • FOOTBALL SIGN	• Surgery

Pneumoperitoneum

Signs on X ray:

• Air in peritoneal cavity due to ruptured hollow viscus organ (perforation, post laparoscopy).

• On CT, jet black appearance shows air.

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1. On erect chest X ray:

• Free air under the diaphragm.

2. Decubitus abdomen sign:

• Left lateral decubitus position with horizontal X-ray beam.

• Provides good contrast against liver.

• Air around lesser sac can escape through epiploic foramen.

• Black air seen above liver.

3. Football sign:

• Patient supine.

• In neonate

• Air beneath anterior abdominal wall.

• Suggestive of Massive pneumoperitoneum.

4. Rigler's sign

• Double bowel sign.

• Air inside and outside the bowel makes bowel loops clearly visible.

• Important Information:
• Rigler's triad: Seen in gall stone ileus.

5. Cupola sign:

• Air beneath the central diaphragm.

Ligament sign:

• Falciform ligament seen



• Falciform ligament connects anterior abdominal wall and liver.
• Ligament visualized due to air on either side.
• All ligament signs are seen in pneumoperitoneum.

7. Inverted V sign:

• Paired umbilical ligament sign (seen due to air around the ligament).

Pseudo Pneumoperitoneum

• Air in the bowel beneath the diaphragm.

• Bowel markings are seen.

Chilaiditi syndrome:

• Presence of colonic loop between diaphragm and liver.

• Colonic interposition.