Guidelines for Acute Care of the Neonate Edition 26, 2018–2019 Updated: July 2018 Arnold J. Rudolph, MMBCh (1918 - 1995) Section of Neonatology Department of Pediatrics Baylor College of Medicine Houston, Texas Guidelines for Acute Care of the Neonate Edition 26, 2018-2019 Updated: July 2018 Editors Caraciolo J. Fernandes, M.D. Mohan Pammi, M.D., Ph.D. Lakshmi Katakam, M.D., M.P.H. Section Editors Diane M. Anderson, Ph.D., R.D., LD Mufeed Ashraf, MD Jonathan Davies, M.D. Catherine Gannon, M.D. Joseph A. Garcia-Prats, M.D. Ganga Gokulakrishnan, M.D., M.S. Amy B. Hair, M.D. Karen E. Johnson, M.D. Timothy C. Lee, M.D. Krithika Lingappan, M.B.B.S. George Mandy, M.D. Tiffany M. McKee-Garrett, M.D. Frank X. Placencia, M.D. Muralidhar Premkumar, M.B.B.S. Christopher J. Rhee, M.D. Danielle R. Rios, M.D., M.S. Binoy Shivanna, M.D., M.B.B.S. Michael E. Speer, M.D. Section of Neonatology Department of Pediatrics Baylor College of Medicine Houston, Texas Copyright © 1981–2018 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine. Edition 26, First printing July 2018 Published by Guidelines for Acute Care of the Neonate Section of Neonatology, Department of Pediatrics Baylor College of Medicine 6621 Fannin Suite W6104 Houston, TX 77030 All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Printed in the United States of America. 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Braun Medical, Inc., Irvine CA VariZIG is a registered trademark of Cangene Corporation, Winnipeg, Manitoba, Canada Vaseline is a registered trademark of Cheeseborough-Pond’s Inc., Greenwich CT Vitrase is a registered trademark of ISTA Pharmaceuticals, Inc., Irvine CA Ursodiol is a registered trademark of Glenmark Pharmaceuticals, Ltd., Goa India Zantac is a registered trademark of Pfizer Inc. Ltd., New York NY Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Foreword It is my privilege to introduce this year’s edition of Baylor Neonatology Guidelines, now in the 26th year of its publication. The editors of these guidelines – Drs. Fernandes, Pammi and Katakam – are continuing the legacy of Dr. James Adams and his tradition of generating practical, up-to-date and evidence-based guidelines that provide bedside clinicians with a ready reference for patient care. The editors, section editors, and various authors have worked hard to preserve relevant material from the guidelines and add new relevant information. They have continued to incorporate more and more the GRADE system of categorizing the evidence supporting these guidelines, and expanded the pool of authors in this edition. Community neonatology colleagues, nurse practitioners, dietitians, and fellows are all members of author teams now. The Baylor Neonatology Guideline book is used extensively in our Newborn Center (including the Mother Baby Unit), the Ben Taub NICU, and our Community Neonatology neonatal units. It ensures consistency of care among the large number of clinicians in our Newborn Center and at multiple locations in the Houston area. It has been, and will remain one of the most valuable resources and a distinguishing asset of the Neonatology Section. In addition, it is a resource for practicing neonatologists all over the world. Most importantly, these guidelines ensure that we provide excellent high-quality care to NICU infants and their families and improve their outcomes. As the Service Chief and Section Head of Neonatology, it has been my honor to support the team of editors and authors who have worked hard to bring us this distillation of evidence, experience, and clinical wisdom. Gautham Suresh, MD, DM, MS, FAAP Professor of Pediatrics, Baylor College of Medicine Section Head and Service Chief of Neonatology Texas Children's Hospital Guidelines for Acute Care of the Neonate, Edition 26, 2018–19 i Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Preface We are pleased to release the 26th revision of “Guidelines for the Acute Care of the Neonate”, a compendium of multidisciplinary collaboration between members of the Newborn Center at Texas Children’s Hospital and Baylor College of Medicine. This edition is dedicated to the two legends of the BCM Neo Section who left lasting legacies - Dr. Arnold J. Rudolph, who taught us the art of neonatology and Dr. James Adams, who, in addition to being an educator extraordinaire, was singularly influential in developing the ‘BCM Neo Guidelines’ over the first 24 years. The ‘Baylor Neo Guidelines’, as this handbook is fondly referred to, is meant to serve as a resource for neonatology fellows, pediatric housestaff, nurse practitioners, nurses and other clinicians who care for sick neonates in Baylor-affiliated hospitals. This body of work is reflective of general principles, concepts, and treatment recommendations that are agreed upon by the authors, editors, and section members. When appropriate, national guidelines are cited to help with the decision-making process. Also, regional traits unique to the southeast Texas or Houston are considered when appropriate. The guidelines are reviewed and revised annually (or more frequently as needed) as new evidence and recommendations for clinical care become available. Users should refer to the most recent edition of these guidelines, which may be downloaded for free from ‘Physician publications’ tab of the Baylor Neonatology website (www.neonate.net). Starting with the 25th edition, we began qualifying our clinical recommendations using the ‘GRADE’ framework for rating quality of evidence and strength of recommendations. Our guidelines cite the quality of evidence and the strength of our recommendations whenever possible. Our chapter authors and section editors have worked hard to create the content you see within and will monitor their areas of clinical interest for emerging evidence that may be of value to the bedside clinician caring for a sick neonate. We look forward to serving you in the coming years. Sincerely, Caraciolo J. Fernandes, MD Mohan Pammi, MD, PhD Lakshmi Katakam, MD, MPH Disclaimer These are guidelines only and may not be applicable to populations outside the BCM Affiliated Hospitals. These guidelines do not represent official policy of Texas Children’s Hospital, Ben Taub General Hospital, BCM, or the BCM Department of Pediatrics, nor are they intended as universal practice guidelines or standards of care. Specific circumstances often dictate deviations from these guidelines. Each new admission and all significant new developments must be discussed with the fellow on call and with the attending neonatologist on rounds. All users of this material should be aware of the possibility of changes to this handbook and should use the most recently published guidelines. ii Guidelines for Acute Care of the Neonate, Edition 26, 2018–19 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Contributing Authors All authors are members of the faculty at Baylor College of Medicine in the Department of Pediatrics, Section of Neonatology and attending physicians at Texas Children’s Hospital, unless otherwise noted. Allied health contributors are all members of the Texas Children’s Hospital staff. Senait Adebo, MD Leah Elizondo, MD Timothy C. Lee, MD Maria Kristine Reyes, MD Assistant Professor Neonatal-Perinatal Fellow Associate Professor Assistant Professor Division of Pediatric Surgery Diane Anderson, PhD, RD, LD Nidia B. Espinosa, MS, RD, LD Christopher J. Rhee, MD Associate Professor Neonatal Dietitian Krithika Lingappan, MBBS Assistant Professor Associate Professor Athis Arunachalam, MD Regine Fortunov, MD Danielle R. Rios, MD, MS Assistant Professor Assistant Professor Jenelle Little, MD Assistant Professor Assistant Professor Mufeed Ashraf, MD Mayra Freeman-Ladd, MD Emily Rodman, PharmD, BCPPS Assistant Professor Assistant Professor Pablo Lohmann, MD Clinical Pharmacy Specialist-NICU Assistant Professor Sangeetha Athis Rajh, MD Bheru Gandhi, MD Charles Roitsch, DO Instructor Assistant Professor Laura Lucas, MS, RD, CSP, LD Neonatal-Perinatal Fellow Neonatal Dietitian Melinda Colleen Brand, PhD, RN, NNP-BC Catherine Gannon, MD Elizabeth Sager, MD Neonatal Nurse Practitioner Assistant Professor Ashley Lucke, MD Neonatal-Perinatal Fellow Neonatal-Perinatal Fellow Elizabeth Bacon, MS, RD, LD, CNSC,CSP Joseph Garcia-Prats, MD Rita Shah, MD Neonatal Dietitian Professor Agnes Mandy, RD, LD Assistant Professor Neonatal Dietitian Ashley S. Bruns, DO Ann Gerges, MD Michael E. Speer, MD Perinatal-Neonatal Fellow Assistant Professor George T. Mandy, MD Professor Associate Professor Rebecca J. Burke, MD Jamie Gilley, APRN, MSN, NNP-BC Nathan C. Sundgren, MD, PhD Perinatal-Neonatal Fellow Neonatal Nurse Practitioner L. Adriana Massieu, RD, CNSC, LD Assistant Professor Neonatal Dietitian Melissa M. Carbajal, MD Ganga Gokulakrishnan, MD, MS Alana Thomas, MD Assistant Professor Assistant Professor Tiffany McKee-Garrett, MD Assistant Professor Associate Professor Amy Carter MS, RD, LD Laura Gollins, MBA, RD, LD Cecilia Torres-Day, MD Neonatal Dietitian Neonatal Dietitian Jamie J. McKissick, MSN, APRN, NNP-BC Assistant Professor Neonatal Nurse Practioner Laura Caudill, RD, CLEC, LD Sharada H. Gowda, MD Lois M. Tracy, MSN, APRN, NNP-BC Neonatal Dietitian Assistant Professor Tiffany L. Molina, MD Neonatal Nurse Practitioner Neonatal-Perinatal Fellow Mary F. Colby-Hale, MSN, APRN, NNP-BC Charleta Guillory, MD, MPH Santiago O. Valdes, MD Neonatal Nurse Practitioner Associate Professor Alice Obuobi, MD Assistant Professor Assistant Professor Section of Pediatric Cardiology William J. Craigen, MD Amy B. Hair, MD Professor Assistant Professor Scott W. Osborne, MD Gregory Valentine, MD, DTM Department of Molecular & Human Genetics Assistant Professor Neonatal-Perinatal Fellow Patrice Hochevar, RD, CNSC, LD Bridget Cross MSN, APRN, NNP-BC Neonatal Dietitian Lisa Owens, DO Nidhy Paulose Varghese, MD Neonatal Nurse Practitioner Senior Faculty Assistant Professor Karen E. Johnson, MD Division of Pulmonary Medicine Milenka Cuevas Guaman, MD Associate Professor Mohan Pammi, MD Assistant Professor Associate Professor Bernadette White, MD Lakshmi Katakam, MD, MPH Neonatal-Perinatal Fellow Viral Dave, MD Associate Professor Shweta Parmekar, MD Assistant Professor Assistant Professor Lindsay Whittington, RN, VA-BC Simon Yousef Kayyal, MD Staff Nurse Jonathan Davies, MD Assistant Professor of Neurology Frank X, Placencia, MD Assistant Professor Assistant Professor Mona Khattab, MD, MS Stephanie Blair Deal, MD Assistant Professor Jennifer L. Placencia, PharmD Assistant Professor Clinical Pharmacy Specialist-NICU Seema Lalani, MD Chris K. Dischler, MSN, APRN, NNP-BC Associate Professor Muralidhar Premkumar, MBBS Neonatal Nurse Practitioner Department of Molecular & Human Genetics Assistant Professor Contributors Endocrinology section was written with the advice of the Pediatric Endocrine and Metabolism Section, in particular, Lefki P. Karaviti, MD and George Jeha, MD. Environment section, in particular NICU Environment, written with the advice of Carol Turnage-Carrier, MSN RN CNS and Lisa Davenport MSN, RN, CNS. Infectious Disease section was written with the advice of the Pediatric Infectious Disease Section, in particular, Drs. Carol J. Baker, Judith R. Campbell, Morven S. Edwards, and Flor Munoz-Rivas. Human Immunodeficiency Virus (HIV) section written with the advice of the Allergy & Immunology Section. Nutrition section was written with the advice of Nancy Hurst, PhD, RN, IBCLC, and Kristina Tucker, RN, IBCLC. Guidelines for Acute Care of the Neonate, Edition 26, 2018–19 iii Section of Neonatology, Department of Pediatrics, Baylor College of Medicine iv Guidelines for Acute Care of the Neonate, Edition 26, 2018–19 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Contents Section 1. Care of Very Low Birth Weight Babies Section 4. Environment Ch. 1.1 General Care (Babies < 1500 grams) ..................... 2 Ch. 4.1 NICU Environment .............................................. 60 Ch. 1.2 Specialized Care for ELGAN Babies ..................... 3 Ch. 4.2 Thermal Regulation ............................................. 63 Ch. 1.3 Umbilical Catheters................................................ 4 Section 5. Endocrinology Ch. 5.1 Approach to Disorders of Sexual Development .. 68 Section 2. Respiratory Care Ch. 5.2 Hypothyroxinemia of Prematurity ....................... 70 Ch. 2.1 Delivery Room Stabilization ................................ 10 Ch. 5.3 Steroid Therapy for Adrenal Insufficiency .......... 71 Ch. 2.2 Control of Breathing and Apnea of Prematurity .. 11 Ch. 5.4 Hypoglycemia ...................................................... 72 Ch. 2.3 Management of Neonatal Respiratory Distress .... 13 Ch. 5.5 Transitional Neonatal Hypoglycemia ................. 72 Ch. 2.4 Non-Invasive Respiratory Support ....................... 14 Ch. 5.6 Persistent Hypoglycemia ..................................... 74 Ch. 2.5 Weaning from CPAP and Nasal Cannula ............ 17 Ch. 2.6 Conventional Ventilation of Preterm and Term Section 6. Genetics Neonates ............................................................... 18 Ch. 6.1 Inborn Errors of Metabolism ............................... 78 Ch. 2.7 High-frequency Oscillatory Ventilation ............... 22 Ch. 6.2 Genetic Testing .................................................... 85 Ch. 2.8 Bronchopulmonary Dysplasia .............................. 24 Section 7. Hematology Ch. 2.9 Prevention of Bronchopulmonary Dysplasia ....... 30 Ch. 7.1 Approach to the Bleeding Neonate ...................... 88 Ch. 2.10 Interdisciplinary Care and Discharge Planning of the Ventilator Dependent Patient ......................... 31 Ch. 7.2 Platelet Disorders ................................................. 89 Ch. 2.11 Pulmonary Hypertension in Lung Diseases ......... 32 Ch. 7.3 Transfusion of Blood Products ............................ 90 Ch. 2.12 Congenital Diaphragmatic Hernia ........................ 33 Ch. 7.4 Pathophysiology and Differential Diagnosis of Jaundice .............................................................. 92 Ch. 2.13 Neonatal ECMO ................................................... 35 Ch. 7.5 Management of Neonatal Jaundice ...................... 94 Section 3. Cardiac Care Ch. 7.6 Polycythemia ....................................................... 97 Ch. 3.1 Cardiovascular Physiology................................... 40 Ch. 7.7 Neonatal Thrombosis ........................................... 99 Ch. 3.2 Circulatory Insufficiency ..................................... 43 Ch. 3.3 Congenital Heart Disease ..................................... 50 Ch. 3.4 Arrhythmias ......................................................... 56 Guidelines for Acute Care of the Neonate, Edition 26, 2018–19 v Contents Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Section 8. Infectious Diseases Section 10. Newborn Care Ch. 8.1 Bacterial Sepsis .................................................. 104 Ch. 10.1 Routine Care ...................................................... 138 Ch. 8.2 Group B Streptococcus (GBS) ........................... 105 Ch. 10.2 Cardiac Murmurs ............................................... 140 Ch. 8.3 Cytomegalovirus (CMV) ................................... 107 Ch. 10.3 Dental................................................................. 140 Ch. 8.4 Fungal Infection (Candida) ................................ 107 Ch. 10.4 Dermatology ...................................................... 141 Ch. 8.5 Gonococcal Disease ........................................... 110 Ch. 10.5 Extracranial Swelling ......................................... 142 Ch. 8.6 Hepatitis B ......................................................... 110 Ch. 10.6 Feeding .............................................................. 143 Ch. 8.7 Hepatitis C ......................................................... 111 Ch. 10.7 Hospital Discharge ............................................. 146 Ch. 8.8 Herpes Simplex Virus (HSV)............................. 112 Ch. 10.8 Neuromusculoskeletal ........................................ 147 Ch. 8.9 Human Immunodeficiency Virus (HIV) ............ 113 Ch. 10.9 Newborn Screening ........................................... 150 Ch. 8.10 Respiratory Syncytial Virus (RSV) .................... 114 Ch. 10.10 Urology .............................................................. 151 Ch. 8.11 Rotavirus ............................................................ 115 Section 11. Gastroenterology Ch. 8.12 Syphilis, Congenital ........................................... 115 Ch. 11.1 Spontaneous Intestinal Perforation .................... 156 Ch. 8.13 Tuberculosis ....................................................... 116 Ch. 11.2 Intestinal Failure and Intestinal Rehabilitation .. 157 Ch. 8.14 Varicella-Zoster Virus (VZV) ............................ 117 Ch. 11.3 Cholestasis ......................................................... 158 Ch. 8.15 Zika Virus .......................................................... 118 Ch. 11.4 Intravenous Lipid Emulsions ............................. 160 Section 9. Neurology Ch. 11.5 Gastroesophageal Reflux (GER)........................ 161 Ch. 9.1 Encephalopathy .................................................. 122 Section 12. Nutrition Ch. 9.2 Seizures .............................................................. 124 Ch. 12.1 Initiation and Intravenous Fluids ....................... 164 Ch. 9.3 Cerebral Hemorrhage and Infarction .................. 126 Ch. 12.2 Parenteral Nutrition ........................................... 165 Ch. 9.4 Neural Tube Defects .......................................... 128 Ch. 12.3 Enteral Nutrition ................................................ 167 Ch. 9.5 Drug-exposed Infants ......................................... 129 Ch. 12.4 Nutrition Assessment ......................................... 178 Ch. 9.6 Pain Assessment and Management .................... 132 Ch. 12.5 Guidelines for Oral Feeding .............................. 179 Ch. 9.7 Vein of Galen ..................................................... 134 Ch. 12.6 Discharge Nutrition Preparation ........................ 181 vi Guidelines for Acute Care of the Neonate, Edition 26, 2018–19
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