Guidelines for Acute Care of the Neonate, 21st Edition, 2013–14

176 Pages·2014·5.06 MB·English

Guidelines for Acute Care of the Neonate
21st Edition, 2013–2014
Updated: April 2014
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
21st Edition, 2013–2014
Updated: April 2014
Editors
James M. Adams, M.D
Caraciolo J. Fernandes, M.D
Associate Editors
Steven A. Abrams, M.D.
Diane M. Anderson, Ph.D., R.D.
Catherine M. Gannon M.D.
Joseph A. Garcia-Prats, M.D.
Alfred Gest M.D.
Leslie L. Harris, M.D.
Timothy C. Lee M.D.
Tiffany M. McKee-Garrett, M.D.
Muralidhar Premkumar, M.D.
Christopher J. Rhee, M.D.
Michael E. Speer, M.D.
Section of Neonatology
Department of Pediatrics
Baylor College of Medicine
Houston, Texas
Copyright © 1981–2013 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine.
21st Edition, First printing July 2013
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.
840 Ventilator System is a trademark of Puritan Bennett Corporation, Overland Park KS
A+D (Original Ointment) is a registered trademark of Schering-Plough Healthcare Products, Inc., Memphis TN
Alimentum is a registered trademark of Abbott Laboratories, Ross Products Division, Columbus OH
Argyle is a registered trademark of Sherwood Services AG, Schaffhausen, Switzerland
Babylog is a registered trademark of Dräger, Inc. Critical Care Systems, Telford PA
ComVax is a registered trademark of Merck & Company, Inc., Whitehouse Station NJ
Dacron is a registered trademark of Koch Industries, Inc., Wichita KS
Desitin is a registered trademark of Pfizer Inc., New York NY
Elecare is a registeted trademark of Abbott Laboratories, Inc., Abbott Park IL
Enfacare is a registered trademark of Mead Johnson & Company, Evansville IN
Enfamil is a registered trademark of Mead Johnson & Company, Evansville IN
ENGERIX-B is a registered trademark of SmithKline Beecham Biologicals S.A., Rixensart, Belgium
Fer-In-Sol is a registered trademark of Mead Johnson & Company, Evansville IN
Gastrografin is a registered trademark of Bracco Diagnostics, Inc., Princeton NJ
Giraffe Omnibed is a registered trademark of General Electric Company, Schenectady NY
Gomco is a registered trademark of Allied Healthcare Products, Inc., St. Louis MO
Infant Star is a registered trademark of Nellcor Puritan Bennett, Inc., Pleasanton CA
Intralipid is a registered trademark of Fresenius Kabi AB Corporation, Uppsala, Sweden
Kerlix is a registered trademark of Tyco Healthcare Group LP, Mansfield MA
Liqui-E is a registered trademark of Twin Laboratories, Inc., Ronkonkoma NY
M.V.I. Pediatric is a trademark of aaiPharma Inc., Wilmington NC
Neo-Calglucon is a registered trademark of Sandoz Pharmaceuticals Corporation, East Hanover NJ
Neocate is a registered trademark of SHS International, Liverpool, England
NeoSure is a registered trademark of Abbott Laboratories, Ross Products Division, Columbus OH
NeoFax is a registered trademark of Thomson Healthcare, Inc., Montvale NJ
Nutramigen is a registered trademark of Mead Johnson & Company, Evansville IN
Omegavan is a registered trademark of Fresinius Kabi, Germany
PedVaxHIB is a registered trademark of Merck & Company, Inc, Whitehouse Station NJ
Poly-Vi-Sol is a registered trademark of Mead Johnson & Company, Evansville IN
Pregestimil is a registered trademark of Mead Johnson & Company, Evansville IN
Prilosec is a registered trademark of AstraZeneca, Sodertalje, Sweden
Protonix is a registered trademark of Wyeth Corporation, Madison NJ
Puritan Bennett is a registered trademark of Puritan Bennett Corporation, Overland Park KS
Reglan is a registered trademark of Wyeth Pharmaceuticals, Philadelphia PA
SensorMedics is a registered trademark of SensorMedics Corporation, Anaheim CA
Servo300 is a registered trademark of Siemens Medical Solutions USA, Inc.,
Danvers MA5 Silastic is a registered trademark of Dow Corning Corporation, Midland MI
Similac is a registered trademark of Abbott Laboratories, Ross Products Division, Columbus OH
Stomahesive is a registered trademark of E.R. Squibb & Sons, L.L.C., Princeton, NJ
Survanta is a registered trademark of Abbott Laboratories, Ross Products Division, Columbus OH
Trophamine is a registered trademark of Kendall McGaw, 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
Zantac is a registered trademark of Pfizer Inc. Ltd., New York NY
Acknowledgments
Guidelines for Acute Care of the Neonate, 21st Edition, 2013–14
Clinical Review Committees
Care of Very Low Birth Weight Babies, Cardiopulmonary Care
James M. Adams, MD (Chair), Maria Afanador MD, Xanthi Couroucli, MD, Vedanta Dariya MD, Jonathan Davies MD, Daniella Dinu MD,
Kimberly N. Dinh Pharm D, Caraciolo J. Fernandes, MD, Al Gest MD, Ganga Gokulakrishnan, MD, Charleta Guillory, MD, Leslie L. Harris,
MD, Pamela S. Hilvers MD, Karen E. Johnson, MD, Yvette R. Johnson, MD MPH, Jeffrey Kaiser, MD, Krithika Lingappan, MD, George
Mandy, MD, Alice Obuobi, MD, Jennifer Placencia PharmD, Jochen Profit, MD, Christopher Rhee MD, Danielle Rios, MD, Alina Saldarriaga
MD, Cecilia Torres-Day MD, Stephen E. Welty MD.
Endocrinology
Catherine M. Gannon MD (Chair), Joseph A. Garcia-Prats, MD, Leslie L. Harris, MD, Binoy Shivanna, MD, Mohan Pammi, MD
Environment
James M. Adams, MD (Chair), Margo Cox, MD, Caraciolo J. Fernandes, MD, Al Gest MD
Gastroenterology
Steven Abrams, MD (Chair), Amy Hair, MD, Madhulika Kulkarni, MD, Muraliadhar Premkumar, MD
Genetics
Muralidhar Premkumar, MD (Co-Chair), Michael Speer, MD (Co-Chair), Gerardo Cabrera-Meza, MD, Caraciolo J. Fernandes, MD
Hematology
Caraciolo J. Fernandes, MD (Chair), S. Gwyn Geddie, MD, Adel A. ElHennawy, MD, Leslie L. Harris, MD, Yvette R. Johnson, MD,
Muraliadhar Prekumar, MD, Mohan Pammi, MD, Katherine Weiss, MD
Infectious Diseases, Medications
Michael E. Speer, MD (Chair), Jennifer Placencia, PharmD, Charleta Guillory, MD, Amy Hair, MD, Leslie L. Harris, MD, Kimberly Dinh,
PharmD, Valerie Moore, MD, Frank X. Placencia, MD, Mohan Pammi, MD, Leonard E. Weisman, MD
Neurology
Christopher Rhee, MD (Chair), Daniela Dinu, MD, Jeffrey Kaiser, MD, Yvette R. Johnson, MD MPH, Binoy Shivanna, MD,
Normal Newborn Care
Tiffany McKee-Garrett, MD (Chair), Sheena Bhasar PA-C, Gerardo Cabrera-Meza, MD, Stephanie Deal MD, Tam Duong MD, Catherine M.
Gannon, MD, Joseph A. Garcia-Prats, MD, Jenelle Little, MD, Ursula Maldonado MD, Melisa Moncure PA-C, Laura Rubinos MD
Nutrition, Metabolic Management
Diane M. Anderson, PhD, RD (chair), Saify Abbasi, MD, Steven A. Abrams, MD, Amy Carter, RD, LD, Margo Cox, MD, Gerardo Cabrera-
Meza, MD, Nidia Delgados, MS, RD, LD, Kimberly Dinh, PharmD, BCPS, Ganga Gokulakrishnan, MD, Amy Hair, MD, Keli Hawthorne MS,
RD, LD, Nancy Hurst, RD, Madhulika Kulkami, MD, Tommy Leonard, MD, Krithika Lingappan, MD, Adriana Massieu, RD, CNSD, LD,
Alice Obuobi, MD, Jennifer Placencia, PharmD, Laura Romig RD, LD, Alina Saldarriaga, MD, Cecilia Torres-Day, MD, Lindsay Tufte, RD,
CSP, LD
Surgery
Michael E. Speer, MD (Co-Chair), Tim Lee, MD (C0-Chair), Daniella Dinu, MD, Leslie L. Harris, MD
End of Life Care, Grief & Bereavement
Leslie L. Harris, MD (Chair), Jennifer Arnold, MD, Marcia Berretta, LCSW, Torey Mack, MD, Frank X. Placencia, MD, Alina Saldarriaga,
MD, Pamela Taylor, D.Min, BCC, Tamara Thrasher-Cateni (Family Centered Care Specialist)
Contributors
Endocrinology chapter written with the advice of the Pediatric Endocrine and Metabolism Section, in particular, Drs. Lefki P. Karaviti, Luisa
M. Rodriguez, and Rona Yoffe. Environment chapter, in particular NICU Environment, written with the advice of Carol Turnage-Carrier,
MSN RN CNS. Infectious Disease chapter written with the advice of the Pediatric Infectious Disease Section, in particular, Doctors Judith R.
Campbell, Morven S. Edwards, Mary Healy, and Flor Munoz-Rivas. Human Immunodeficiency Virus (HIV) section written with the advice of
the Allergy & Immunology Section. Genetics chapter written with the advice of Dr. Bill Craigen of the Department of Molecular and Human
Genetics. Neurology chapter written with the advice of the Neurology Section.
Guidelines for Acute Care of the Neonate, 21st Edition, 2013–14 i
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Preface
Purpose
The purpose of these guidelines is to help neonatology fellows, pediatric house officers, and others with the usual routines followed in caring
for common problems encountered in the care of neonates. These guidelines were designed by the Section of Neonatology at Baylor College
of Medicine (BCM). Where appropriate, national guidelines or reference to peer-reviewed scientific investigations are cited to help in the
decision-making process. Also, regional traits unique to the southeast Texas patient population are used when appropriate. The guidelines are
reviewed and revised annually (or more frequently as necessary) as new recommendations for clinical care become available. Users should refer to
the most recent edition of these guidelines.
Dedication
These guidelines are dedicated to Dr. Arnold J. Rudolph (1918–1993), who taught the art of neonatology and whose life continues to touch us in
innumerable ways.
Disclaimer
These are guidelines only and may not be applicable to populations outside the BCM Affiliated Hospitals. These guidelines do not represent offi¬cial
policy of Texas Children’s Hospital, Ben Taub General Hospital, BCM, or the BCM Department of Pediatrics, nor are they intended as 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.
Summary of major changes, 21st edition
Minor changes were made in addition to the major content changes detailed below.
Cardiopulmonary
• Changes to Respiratory Distress – Goals of Management and
Modes of support
• Ventilator Management – Approach to Acute and Chronic Mechani-
cal Ventilation Updates to criteria for patient selection for home
ventilation
• Changes to Control of Breathing - Planning for Discharge
• Updates to Exogenous Surfactant
• Updates to Respiratory Management of Congenital Diaphragmatic
Hernia
• Updates to Bronchopulmonary Dysplasia
Environment
• Updates to Thermal Regulation
Metabolic
• Updates – Hypoglycemia, Management of Glucose Intolerance
Nutrition
• Updates to use of TPN Guidelines
* Asterisk indicates information new to this edition.
ii Guidelines for Acute Care of the Neonate, 21st Edition, 2013–14
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Contents
Chapter 1. Care of Very Low Birth Weight Babies . .1 Table 2–2b Calculation of effective Fio2, Step 2
Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . . 9
General Care (babies < 1500 grams) . . . . . . . . . . . . . . . . . 1 Nasal CPAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Example of Admission Orders. . . . . . . . . . . . . . . . . . 1 Continuous Flow CPAP. . . . . . . . . . . . . . . . . . . . . .9
Table 1–1. Admission labs . . . . . . . . . . . . . . . . . 2 Bubble CPAP
Table 1–2. Labs during early hospitalization . . . . . . . . 2
Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Indications for Nasal CPAP . . . . . . . . . . . . . . . . . . . . . . 9
Apnea of Prematurity . . . . . . . . . . . . . . . . . . . . 9
Specialized Care (babies ≤ 26 weeks’ gestation) . . . . . . . . . . . 2 Maintenance of Lung Recruitment . . . . . . . . . . . . . 9
Acute Lung Disease. . . . . . . . . . . . . . . . . . . . 10
Umbilical Venous Catheters . . . . . . . . . . . . . . . . . . . . . . 3 Heated Humidified High Flow Nasal Cannula. . . . . . . . . 10
Placing UVCs. . . . . . . . . . . . . . . . . . . . . . . . . . .4 CPAP Effect . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 1–1. Double-lumen system . . . . . . . . . . . . . . . . 3
Figure 1–2. Suggested catheter tip placement; anatomy of Enhanced Dead Space Ventilation (Pharyngeal Washout). . . . . . 11
the great arteries and veins . . . . . . . . . . . . . . . . . 3
Recommended Use in Neonates. . . . . . . . . . . . . . . . . . . 11
Chapter 2. Cardiopulmonary Care. . . . . . . . . . .5 Mechanical Ventilation . . . . . . . . . . . . . . . . . . . . . . . 11
Endotracheal Tube Positioning. . . . . . . . . . . . . . . . . 11
Resuscitation and Stabilization . . . . . . . . . . . . . . . . . . . . 5 Importance of Adequate Lung Recruitment . . . . . . . . . . 11
Figure 2–1. Resuscitation—stabilization process: birth to Overview of mechanical Ventilation
post-resuscitation care. . . . . . . . . . . . . . . . . . . .5 Infants with BPD-chronic ventilation
HFOV
Circulatory Disorders . . . . . . . . . . . . . . . . . . . . . . . . . 5 Volume Guarantee
Fetal Circulation . . . . . . . . . . . . . . . . . . . . . . . . . 5 Initial Settings. . . . . . . . . . . . . . . . . . . . . . . 12
Figure 2–2 - Fetal circulation. . . . . . . . . . . . . . . .6 Maintenance of VG
Postnatal (Adult) Circulation . . . . . . . . . . . . . . . . . . 5 Weaning VG
Figure 2–3. Postnatal (adult) circulation . . . . . . . . . . 6 Table 2–3. Ventilator manipulations to effect changes
Transitional Circulation . . . . . . . . . . . . . . . . . . . . . 5 in PaO and PaCO . . . . . . . . . . . . . . . . . . 12
2 2
Figure 2–4. Transitional circulation. . . . . . . . . . . . .6 Synchronized Ventilation. . . . . . . . . . . . . . . . . . . . 12
Disturbances of the Transitional Circulation. . . . . . . . . . .5 SIMV . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Parenchymal Pulmonary Disease . . . . . . . . . . . . . . 5 Assist–control (AC) . . . . . . . . . . . . . . . . . . . 13
Persistent Pulmonary Hypertension of the Newborn . . . . 5 Pressure Support Ventilation . . . . . . . . . . . . . . . 13
Congenital Heart Disease . . . . . . . . . . . . . . . . . . 6 Chronic Mechanical Ventilation . . . . . . . . . . . . . . . . 13
Patent Ductus Arteriosus (PDA) . . . . . . . . . . . . . . 6
Circulatory Insufficiency. . . . . . . . . . . . . . . . . . . . .6 15 Table 2–4. Useful Respiratory Equations. . . . . . . . . . 14
Figure 2–5. Mean aortic blood pressure during the first
12 hours of life. . . . . . . . . . . . . . . . . . . . .7 High-frequency Oscillatory Ventilation (HFOV) . . . . . . . 14
Nonspecific Hypotension. . . . . . . . . . . . . . . . . . . . .6 Indications for Use . . . . . . . . . . . . . . . . . . . . 14
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Physiology. . . . . . . . . . . . . . . . . . . . . . . . . 14
Hypovolemic Shock . . . . . . . . . . . . . . . . . . . . . . . 7 HFOV Management. . . . . . . . . . . . . . . . . . . . 15
Etiologies . . . . . . . . . . . . . . . . . . . . . . . . . .7 Monitoring . . . . . . . . . . . . . . . . . . . . . . . . 15
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Special Considerations . . . . . . . . . . . . . . . . . . 15
Cardiogenic Shock . . . . . . . . . . . . . . . . . . . . . . . . 7 Weaning. . . . . . . . . . . . . . . . . . . . . . . . . . 15
Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . 7 Non-Invasive Ventilation (NIPPV). . . . . . . . . . . . . . . 15
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Selection and Preparation for Home Ventilation . . . . . . . . 16
Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Criteria for DC to Home Ventilation . . . . . . . . . . . 16
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Migration to Home Ventilator. . . . . . . . . . . . . . . 16
Monitoring and Equipment . . . . . . . . . . . . . . . . 16
Management of Respiratory Distress Special Issues . . . . . . . . . . . . . . . . . . . . . . . 16
Basic Strategies
Infants 30 0/7 weeks’ gestation or less . . . . . . . . . . . . . . 8 Surfactant Replacement Therapy . . . . . . . . . . . . . . . . . . 16
Infants More Than 30 0/7 Weeks’ Gestation . . . . . . . . . . . 9 Prophylactic treatment . . . . . . . . . . . . . . . . . . . . . 16
Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Rescue treatment . . . . . . . . . . . . . . . . . . . . . . . . 16
Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . 9 Surfactant Product Selection and Administration . . . . . . . 17
Table 2–2a Calculation of effective Fio2, Step 1 . . . . . 10 Curosurf® . . . . . . . . . . . . . . . . . . . . . . . . . 17
Survanta® . . . . . . . . . . . . . . . . . . . . . . . . . 17
** AAsstteerriisskk iinnddiiccaatteess iinnffoorrmmaattiioonn nneeww ttoo tthhiiss eeddiittiioonn..
Guidelines for Acute Care of the Neonate, 21st Edition, 2013–14 iii
Contents Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Surfactant Replacement for Term Babies with Management . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Hypoxic Respiratory Failure . . . . . . . . . . . . . . . 17 Supportive Care and Nutrition . . . . . . . . . . . . . . 26
Fluid Restriction. . . . . . . . . . . . . . . . . . . . . . 26
Inhaled Nitric Oxide (iNO) . . . . . . . . . . . . . . . . . . . . . 17 Diuretics. . . . . . . . . . . . . . . . . . . . . . . . . . 26
Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . 17 Thiazides . . . . . . . . . . . . . . . . . . . . . . . . . 26
Indications for use . . . . . . . . . . . . . . . . . . . . . . . 17 Furosemide . . . . . . . . . . . . . . . . . . . . . . . . 26
Administration . . . . . . . . . . . . . . . . . . . . . . . . . 18 Chloride Supplements. . . . . . . . . . . . . . . . . . . 26
Weaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Oxygen . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Inhaled Medications. . . . . . . . . . . . . . . . . . . . 27
Use of Systemic Steroids in Severe Chronic
Patent Ductus Arteriosus. . . . . . . . . . . . . . . . . . . . . . . 18 Lung Disease . . . . . . . . . . . . . . . . . . . 27
Treatment of PDA . . . . . . . . . . . . . . . . . . . . . . . 18 Exacerbation of Acute Lung Inflammation. . . . . . . . . . . 28
Ibuprofen Treatment . . . . . . . . . . . . . . . . . . . . . . 18
Administration and Monitoring . . . . . . . . . . . . . . . . 18 Management of Acute Reactive Airway Disease . . . . . . . . . . 28
Monitoring the BPD Patient . . . . . . . . . . . . . . . . . . 28
Indomethacin Treatment. . . . . . . . . . . . . . . . . . . . . . . 18 Nutritional Monitoring . . . . . . . . . . . . . . . . . . 28
Oxygen Monitoring . . . . . . . . . . . . . . . . . . . . 28
The Meconium Stained Infant. . . . . . . . . . . . . . . . . . . . 19 Echocardiograms . . . . . . . . . . . . . . . . . . . . . 28
After Delivery . . . . . . . . . . . . . . . . . . . . . . . . . 19 Developmental Care. . . . . . . . . . . . . . . . . . . . 28
Immediate Post-procedure Care . . . . . . . . . . . . . . . . 19 Goal Directed Multidisciplinary Care . . . . . . . . . . . . . 28
Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Discharge Planning. . . . . . . . . . . . . . . . . . . . . . . 29
Prevention of Chronic Lung Disease. . . . . . . . . . . . . . 29
Figure 2-6. Algorithm for decision to intubate Meconium
Stained Newborns . . . . . . . . . . . . . . . . . . . . . . . 19 Use of Sodium Bicarbonate in Acute Cardiopulmonary Care. . . . 29
Persistent Metabolic Acidosis . . . . . . . . . . . . . . . . . . . . 29
Respiratory Management of Congenital Diaphragmatic Hernia . . 19
Strategy of Respiratory Management . . . . . . . . . . . . . 19
Goals of Initial Ventilator Support . . . . . . . . . . . . . . . 20 Chapter 3. Endocrinology . . . . . . . . . . . . . . 31
Goals of Continuing Ventilator Support . . . . . . . . . . . . 20
An Approach to the Management of Ambiguous Genitalia . . . . . 31
Neonatal ECMO . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Hypoxic Respiratory Failure . . . . . . . . . . . . . . . . . . 20 Multidisciplinary Team Management of Disorders of
General Inclusion/Exclusion Criteria. . . . . . . . . . . . . . 20 Sexual Differentiation. . . . . . . . . . . . . . . . . . . 31
Baylor/TCH Primary Indications. . . . . . . . . . . . . . . . 20 Evaluation of a baby with ambiguous genitalia . . . . . . . . 31
ECMO Failure . . . . . . . . . . . . . . . . . . . . . . . . . 20 History. . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Preparation for Bypass . . . . . . . . . . . . . . . . . . . . . 21 Maternal . . . . . . . . . . . . . . . . . . . . . . . 31
Initiation of Bypass. . . . . . . . . . . . . . . . . . . . . . . 21 Familial . . . . . . . . . . . . . . . . . . . . . . . 31
Anticoagulation. . . . . . . . . . . . . . . . . . . . . . . . . 21 Physical examination . . . . . . . . . . . . . . . . . . . 31
Patient Care During ECMO . . . . . . . . . . . . . . . . . . 21 General Examination . . . . . . . . . . . . . . . . 31
Weaning from ECMO . . . . . . . . . . . . . . . . . . . . . 21 External Genitalia . . . . . . . . . . . . . . . . . . 32
Special Considerations . . . . . . . . . . . . . . . . . . . . . 21 Investigations . . . . . . . . . . . . . . . . . . . . . . . 32
Surgery on ECMO . . . . . . . . . . . . . . . . . . . . . . . 22 Karyotype . . . . . . . . . . . . . . . . . . . . . . 32
Internal Genitalia . . . . . . . . . . . . . . . . . . 32
Control of Breathing. . . . . . . . . . . . . . . . . . . . . . . . . 22 Hormonal Tests . . . . . . . . . . . . . . . . . . . 33
Central Respiratory Drive . . . . . . . . . . . . . . . . . . . 22 Figure 3–1. Sexual Differentiation . . . . . . . . . . . . 31
Airway Patency and Receptors. . . . . . . . . . . . . . . . . 23 Figure 3–2. Pathways of adrenal hormone synthesis . . . 31
Respiratory Pump. . . . . . . . . . . . . . . . . . . . . . . . 23 Figure 3–3. Approach to disorders of sexual
Management of Apnea . . . . . . . . . . . . . . . . . . . . . 23 differentiation . . . . . . . . . . . . . . . . . . . . 32
General Measures . . . . . . . . . . . . . . . . . . . . . 24 The Role of the Parent . . . . . . . . . . . . . . . . . . . . . 33
Xanthines . . . . . . . . . . . . . . . . . . . . . . . . . 24 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . 33
Nasal CPAP . . . . . . . . . . . . . . . . . . . . . . . . 24
Role of Anemia . . . . . . . . . . . . . . . . . . . . . . 24 Hypothyroxinemia of Prematurity. . . . . . . . . . . . . . . . . . 33
Apnea of Prematurity: Preparation for Discharge . . . . . . . 24 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Table 3–1. Thyroxine values according to gestational age. . . 33
Bronchopulmonary Dysplasia . . . . . . . . . . . . . . . . . . . . 24 Table 3–2. Thyroxine and thyrotropin levels according to
Etiology and Pathogenesis . . . . . . . . . . . . . . . . . . . 24 gestational age. . . . . . . . . . . . . . . . . . . . . . . 33
Clinical Course . . . . . . . . . . . . . . . . . . . . . . . . . 25 Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . 33
Classic BPD. . . . . . . . . . . . . . . . . . . . . . . . 25 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
The “New” BPD . . . . . . . . . . . . . . . . . . . . . 25 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Cardiopulmonary Physiology . . . . . . . . . . . . . . . . . 25 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Tracheobronchomalacia . . . . . . . . . . . . . . . . . . . . 26 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
* Asterisk indicates information new to this edition.
iv Guidelines for Acute Care of the Neonate, 21st Edition, 2013–14
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Contents
Steroid Therapy for Adrenal Insufficiency. . . . . . . . . . . . . . 34 Chapter 5. Gastroenterology . . . . . . . . . . . . 43
Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . 34 Necrotizing Enterocolitis (NEC). . . . . . . . . . . . . . . . . . . 43
Evaluation of Hypothalamic-Pituitary-Adrenal Axis Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . 43
and Function. . . . . . . . . . . . . . . . . . . . . . . . 34 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Laboratory Testing . . . . . . . . . . . . . . . . . . . . . . . 34 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Gastroschisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Persistent Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . 35
Disorders of Insulin Secretion and Production. . . . . . . . . 35 Intestinal Failure and Rehabilitation. . . . . . . . . . . . . . . . . 43
Endocrine Abnormalities. . . . . . . . . . . . . . . . . . . . 35 Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Disorders of Ketogenesis and Fatty Acid Oxygenation . . . . 35 Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Defects in Amino Acid Metabolism . . . . . . . . . . . . . . 35 Short-term Goals . . . . . . . . . . . . . . . . . . . . . 44
Inborn Errors of Glucose Productions . . . . . . . . . . . . . 35 Long-term Goals . . . . . . . . . . . . . . . . . . . . . 44
Laboratory Evaluation for Persistent Hypoglycemia. . . . . . 35 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . 35
Cholestasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Chapter 4. Environment . . . . . . . . . . . . . . . 37 Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
NICU Environment . . . . . . . . . . . . . . . . . . . . . . . . . 37 Investigations. . . . . . . . . . . . . . . . . . . . . . . . . . 44
Effects of Environment. . . . . . . . . . . . . . . . . . . . . 37 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Therapeutic Handling and Positioning . . . . . . . . . . . . . 37
Handling. . . . . . . . . . . . . . . . . . . . . . . . . . 37 Omega-3 Fatty Acides (Omegaven) . . . . . . . . . . . . . . . . . 45
Positioning . . . . . . . . . . . . . . . . . . . . . . . . 37 Inclusion Criteria. . . . . . . . . . . . . . . . . . . . . . . . 45
Containment . . . . . . . . . . . . . . . . . . . . . 38 Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . 45
Correct Positioning . . . . . . . . . . . . . . . . . 38
Proper Positioning Techniques. . . . . . . . . . . . 38 Use of Omegaven . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Environmental Factors . . . . . . . . . . . . . . . . . . . . . 38 Duration of Treatment . . . . . . . . . . . . . . . . . . . . . 46
Tastes and Odors . . . . . . . . . . . . . . . . . . . . . 38 Home Use of Omegaven . . . . . . . . . . . . . . . . . . . . 46
Sound . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Effects of Sound . . . . . . . . . . . . . . . . . . . 39 Recognizing Underlying End-stage Liver Disease . . . . . . . . . 46
Interventions. . . . . . . . . . . . . . . . . . . . . 39 Gastroesophageal Reflux (GER). . . . . . . . . . . . . . . . . . . 46
Light, Vision, and Biologic Rhythms . . . . . . . . . . . 39
Effects of Light . . . . . . . . . . . . . . . . . . . 39 Erythromycin. . . . . . . . . . . . . . . . . . . . . . . . . . 47
Parents: The Natural Environment . . . . . . . . . . . . . . . 39 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Chapter 6. Genetics . . . . . . . . . . . . . . . . . 49
Thermal Regulation . . . . . . . . . . . . . . . . . . . . . . . . . 40 Inborn Errors of Metabolism . . . . . . . . . . . . . . . . . . . . 49
Table 4–1. Sources of heat loss in infants . . . . . . . . . . . 40 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Thermal Stress . . . . . . . . . . . . . . . . . . . . . . . . . 40 Categories of Inborn Errors. . . . . . . . . . . . . . . . 49
Responses to Cold Environment . . . . . . . . . . . . . 40 Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Consequences . . . . . . . . . . . . . . . . . . . . . . . 40 Figure 6–1. Presentations of metabolic disorders . . . . . . . 50
Normal Temperature Ranges * . . . . . . . . . . . . . . 40 Hyperammonemia. . . . . . . . . . . . . . . . . . . . . 50
Management. . . . . . . . . . . . . . . . . . . . . . . . 40 Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . . 50
Delivery Room. . . . . . . . . . . . . . . . . . . . 40 Disorders of Fatty Acid Oxidation . . . . . . . . . . . . 50
Transport. . . . . . . . . . . . . . . . . . . . . . . 40 Fetal Hydrops . . . . . . . . . . . . . . . . . . . . . . . 50
Bed Selection * . . . . . . . . . . . . . . . . . . . 40 Table 6–1. Metabolic disorders, chromosomal abnormalities,
Incubators . . . . . . . . . . . . . . . . . . . . . . 40 and syndromes associated with nonimmune fetal hydrops . 51
Radiant Warmers. . . . . . . . . . . . . . . . . . . 41 Maternal-fetal Interactions . . . . . . . . . . . . . . . . 50
Weaning from Servo to Manual Control *. . . . . . 42 Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . 51
Weaning from Manual Control to Open Crib * . . . 42 Neurologic Status . . . . . . . . . . . . . . . . . . . . . 51
Ancillary Measures . . . . . . . . . . . . . . . . . 42 Liver Disease . . . . . . . . . . . . . . . . . . . . . . . 51
Figure 4–1. Effects of environmental temperature on oxygen Cardiac Disease . . . . . . . . . . . . . . . . . . . . . . 52
consumption and body temperature. . . . . . . . . . . . 41 Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . 52
Table 4–2. Neutral thermal environmental temperatures: Online Resources . . . . . . . . . . . . . . . . . . . . . 53
Suggested starting incubator air temperatures for clinical References. . . . . . . . . . . . . . . . . . . . . . . . . 53
approximation of a neutral thermal environment . . . . . 41 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Cystic Fibrosis * . . . . . . . . . . . . . . . . . . . . . 53
Prediagnosis Treatment . . . . . . . . . . . . . . . . . . 53
* Asterisk indicates information new to this edition.
Guidelines for Acute Care of the Neonate, 21st Edition, 2013–14 v
Contents Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Galactosemia. . . . . . . . . . . . . . . . . . . . . . . . 53 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
GSD1 . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Before the Exchange . . . . . . . . . . . . . . . . . . . . . . 62
MSUD. . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Important Points to Remember. . . . . . . . . . . . . . . . . 62
Organic Aciduria . . . . . . . . . . . . . . . . . . . . . 53 Exchange Procedure . . . . . . . . . . . . . . . . . . . . . . 62
PKU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 After the Exchange. . . . . . . . . . . . . . . . . . . . . . . 62
Urea Cycle Disorders . . . . . . . . . . . . . . . . . . . 54
Newborn Screening. . . . . . . . . . . . . . . . . . . . . . . 54 Hypervolemia–polycythemia . . . . . . . . . . . . . . . . . . . . 62
Table 6–2. Newborn Screening Program in Texas . . . . . . . 54 Etiologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Chromosomal Abnormalities. . . . . . . . . . . . . . . . . . 54 Treatmen . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Chromosomal Microarray (CMA) . . . . . . . . . . . . 54
References. . . . . . . . . . . . . . . . . . . . . . . . . 54
Chapter 8. Infectious diseases . . . . . . . . . . . 63
Chapter 7. Hematology . . . . . . . . . . . . . . . 55
Bacterial Sepsi. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Approach to the Bleeding Neonate . . . . . . . . . . . . . . . . . 55 General Points . . . . . . . . . . . . . . . . . . . . . . . . . 63
Neonatal Hemostatic System. . . . . . . . . . . . . . . . . . 55 Blood Cultures . . . . . . . . . . . . . . . . . . . . . . . . . 63
Abnormal Bleeding. . . . . . . . . . . . . . . . . . . . . . . 55 Age 0 to 72 Hours (early-onset, maternally acquired sepsis) . 63
Table 7–1. Differential diagnosis of bleeding in the neonate 55 Indications for Evaluation. . . . . . . . . . . . . . . . . 63
Coagulation Disorders . . . . . . . . . . . . . . . . . . 55 Term Infants (infants > 37 weeks’ gestation) . . . . 63
Thrombocytopenias . . . . . . . . . . . . . . . . . . . . 56 Preterm Infants (infants < 37 weeks’ gestation). . . 63
Table 7–2. Causes of neonatal thrombocytopenia . . . . 56 Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . 63
Figure 7–1. Guidelines for platelet transfusion in the Term Infants . . . . . . . . . . . . . . . . . . . . . 63
newborn . . . . . . . . . . . . . . . . . . . . . . . 56 Preterm Infants. . . . . . . . . . . . . . . . . . . . 63
Neonatal Alloimmune Thrombocytopenia (NAIT) . . . . 56 Initial Empirical Therapy . . . . . . . . . . . . . . . . . 63
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Duration of Therapy. . . . . . . . . . . . . . . . . . . . 63
Late-onset Sepsis. . . . . . . . . . . . . . . . . . . . . . . . 63
Blood Transfusion . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Indications for Evaluation. . . . . . . . . . . . . . . . . 64
Trigger Levels . . . . . . . . . . . . . . . . . . . . . . . . . 57 Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . 64
Transfusion Volume . . . . . . . . . . . . . . . . . . . . . . 58 Initial Empirical Therapy . . . . . . . . . . . . . . . . . 64
Erythropoietin . . . . . . . . . . . . . . . . . . . . . . . . . 58 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Group B Streptococcus (GBS). . . . . . . . . . . . . . . . . . . . 64
Risk Factors for Severe Hyperbilirubinemia. . . . . . . . . . 59 Management of At-risk Infants. . . . . . . . . . . . . . . . . 64
Table 7–3. Risk factors for severe hyperbilirubinemia. . . . . 57 References . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Differential Diagnosis of Jaundice . . . . . . . . . . . . . . . 59 Figure 8-4. Algorithm for prevention of early-onset GBS
Jaundice Appearing on Day 1 of Life. . . . . . . . . . . 59 disease among newborns . . . . . . . . . . . . . . . . . 60
Jaundice Appearing Later in the First Week . . . . . . . 59 Figure 8–1. Incidence of early-and late-onset group B
Jaundice Persisting or Appearing Past the First Week . . 59 streptococcus . . . . . . . . . . . . . . . . . . . . . . . 64
Cholestatic Jaundice. . . . . . . . . . . . . . . . . . . . 59 Figure 8–2. Algorithms for the prevention of early-onset
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 group B streptococcus. . . . . . . . . . . . . . . . . . . 65
Figure 7–2. Nomogram for designation of risk based on Figure 8-3. Indications and nonindications for intrapartum
the hour-specific serum bilirubin values . . . . . . . . . 58 antibiotic prophylaxis to prevent early-onset group B
Follow-up of Healthy Term and Late-term Infants at Risk for streptococcus . . . . . . . . . . . . . . . . . . . . . . . 66
Hyperbilirubinemia . . . . . . . . . . . . . . . . . . . . 60 Figure 8-4. Algorithm for secondary prevention of early-onset
Table 7–4. Hyperbilirubinemia: Age at discharge and follow-up. 58 group B streptococcal (GBS) disease among newborns . 66
Management . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Figure 8-5. Algorithm for screening for group B streptococcal
Phototherapy . . . . . . . . . . . . . . . . . . . . . . . 60 (GBS) colonization and use of intrapartum prophylaxis
Figure 7–3. Guidelines for phototherapy in hospitalized for women with preterm* labor (PTL) . . . . . . . . . . 67
infants of ≥35 weeks’ gestation . . . . . . . . . . . . . . 59 Figure 8-6. Algorithm for screening for group B streptococcal
Intravenous Immune globulin. . . . . . . . . . . . . . . 61 (GBS) colonization and use of intrapartum prophylaxis
Indications for Exchange Transfusion . . . . . . . . . . 61 for women with preterm* premature rupture of membrane
Figure 7–4. Guidelines for exchange transfusion in infants (pPROM) . . . . . . . . . . . . . . . . . . . . . . . . . 67
35 or more weeks’ gestation. . . . . . . . . . . . . . . . 61 Figure 8-7. Recommended regimens for intrapartum antibiotic
Management of Hyperbilirubinemia in Low Birth prohphylaxis for prevention of early-onset group B
Weight Infants . . . . . . . . . . . . . . . . . . . . 61 streptococcal (GBS) disease* premature rupture of
Table 7–5. Guidelines for Management of Hyperbilirubinemia membrane (pPROM) . . . . . . . . . . . . . . . . . . . 68
in Low Birth Weight Infants . . . . . . . . . . . . . . . 61
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Cytomegalovirus (CMV) . . . . . . . . . . . . . . . . . . . . . . 68
General Points . . . . . . . . . . . . . . . . . . . . . . . . . 68
Exchange transfusion . . . . . . . . . . . . . . . . . . . . . . . . 61 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Fungal Infection (Candida) . . . . . . . . . . . . . . . . . . . . . 68
* Asterisk indicates information new to this edition.
vi Guidelines for Acute Care of the Neonate, 21st Edition, 2013–14