Protocols in Neonatology Srinivas Murki, Rhishikesh Thakre
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table
A
Abdomen 188
Abdominal distension 4, 94, 158, 159fc, 159t, 160t
Abdominal mass 160t
causes of 158, 160f
Abruptio placentae 346
Absolute neutrophil count 34, 35, 383, 386
Acceptable, feasible, affordable, sustainable, and safe criteria 307t
Acid suppressants 326
Acidosis 43, 346
correction of 72
metabolic 9, 32, 49, 208
Acrocyanosis 8
Activated partial thromboplastin time 97, 99, 101
Acute kidney injury, rule out 204
Acyclovir 317
role of 316
Acyl carnitine profile 129
Addisonian crisis 145
Adenosine 64, 156
Adhesive tape 156
Adrenal deficiency, congenital 142t
Adrenal insufficiency 81
Adrenocorticotropic hormone 141, 142, 145
Aerophagia 158
Afibrinogenemia 361
Aggressive nutrition, concept of 371
Air
leak syndromes 152
tanks 155
transport 153
Airway 5, 150
assessment of 5fc
congenital malformations of 352
malformation, congenital pulmonary 399
oral 156
Albumin, serum 85
Allogenic transplant 331
Alpha 1 antitrypsin deficiency 200
Amenorrhea, primary 139
American Academy of Pediatrics 49, 113, 223
Amiel tison 275
Amikacin 340, 343, 343t
Amino acid 45, 367
metabolism, disorders of 127
profile, quantitative 129
Aminoglycosides 340
Aminophylline 166t
Ammonia
levels 127
serum 130
Amniotic fluid, meconium stained 15
Amphotericin 340, 341, 345
Ampicillin 156, 340, 341, 343, 344t
Anaerobic organisms 340
Analgesia 169
Analgesics 324
Androgen
insensitivity syndrome 143, 145
clinical classification of 147f
synthesis, abnormal 147
Androstenedione 143
Anemia 107, 108fc, 109, 109t, 113
etiology of 113
evaluation of 110
forms of 110
hemolytic 107, 109
hemorrhagic 109
hypoplastic 110, 113
investigations 111t
late neonatal 359
physiologic 108
severe 358
Anesthesia, before induction of 445
Angiotensin-converting enzyme 73, 178, 204
Anogenital ratio 140
Anorectal malformations 210
Antenatal hydronephrosis 401
causes of 217t
management plan of 402fc
Antenatal steroids 94, 291, 292, 435
role of 349
Antenatal ultrasound scan, abnormal 408
Anthropometry 442
Antibiotic 19, 63, 237, 325, 341
choice of 38t
duration of 39, 39fc
prescription protocol 343
prophylaxis 219
resistant organisms 339
stewardship program 342
therapy 384
Anticoagulants 325
Anticonvulsants 325
medication 47
Antidepressants 325
Antiemetics 326
Antiepileptic drug 45, 47
alternative 48t
Antifetal platelet membranes antibody 104
Antifungal 325
agents 173t
prophylaxis 173
Antihistaminics 326
Antimicrobial solution, choice of 418
Antimüllerian hormone 138, 142, 146
Antiphospholipid syndrome 320
Antiplatelet antibodies 99
Antiretroviral prophylaxis 305
Antiretroviral therapy 304306
Antiseptic solution 156
Anti-tuberculous therapy 100
Anus 188
Aorta, coarctation of 58
Aortic arch 58
Aortic stenosis 58, 59
Apgar score 33, 43, 334t
Apnea 8, 32, 42, 89, 94, 163, 165, 165t, 263
causes of 163
common causes of 163t
management 164fc
mimic 163
nonepileptic 42
prematurity 165, 165t, 352
Apneic episode, acute 163
Apneic infant, stabilization of 164
Apt test 99
Arachidonic acid 258
Arrhythmias 64
cardiac 149
Arterial blood gas 17, 26, 45, 90, 104, 349, 352, 376
sampling 124
Arterial oxygen
content, reduced 373
saturation 377
Arteriovenous malformations, pulmonary 65
Artery, pulmonary 62
Arthritis, septic 32
Asepsis 237
Aspergillosis 174
Asphyxia 49, 179b
perinatal 72
Atonic neck reflex 121
Atresia, pulmonary 58
Atrial flutter 64
Atrial septal defect 59, 60
Atropine 156
Attention deficit hyperactivity disorder 273
Auditory brainstem response 262
Auditory steady state response 271
Auscultation 60
Autism, red flag signs for 277t
Autoantibody, maternal 104
Autoimmune diseases 320
Autosomal dominant 129, 169
Autosomal recessive 129, 169
polycystic kidney disease 401
B
Baby infant growth chart calculator 451
Bacillus Calmette-Guérin 262
vaccination 312
Bacillus stearothermophilus 414
Bacteria, gram-positive 38
Bacterial colonization 339
Balloon
atrial septostomy 65
valvuloplasty 65
Benzodiazepines 326
Betamethasone 291
Bifid scrotum 137f
Biliary atresia, extrahepatic 212
Bilirubin
encephalopathy 49, 117
transcutaneous 56
Bilitool 454
Biochemical 194
monitoring 371
Birth injury 431
Birth weight 6, 55, 149, 182, 295
extremely low 33, 74, 109, 234, 281, 340, 357, 408, 438
very low 29, 32, 227, 383, 394
Bleeding
disorders 97, 100t, 296
evaluation of 97
neonatal 97
in early pregnancy 178
newborn 97, 100t
clinical examination 98t
history 98t
prevention of 100
umbilical 225
Blindness, permanent 263
Blood
ammonia 45
and blood products 360t, 361
component therapy 357
culture 17, 385, 389
sensitivity 34
technique of 389
exchange transfusion 53
flow, pulmonary 62
glucose screening 78t
group, choice of 54, 357t
loss 25
presence of 282f
pressure 15, 28, 65, 71, 366
role of 23
product transfusion, complications of 362t
sample
collection of 127
site of 88
volume of 389
smear, peripheral 383
sugar 17, 45
estimation 117
monitoring of 119
random 46
transfusion 112t, 263, 357t, 359
therapy 357
viscosity 89
volume of 358
Body fluid
compartment, composition of 69t
compositions 67f
Body mass index 452
Body weight 70, 310
Bowel
loops, visible 94
motility, immature 161
obstruction, medical management of 161
Bradycardia 8, 32, 75, 94
Brain injury 72
Brainstem evoked response audiometry 270, 271
Breast
discharge 223
engorgement 224f, 232
milk 94, 229, 255
expressed 256, 257
fortification 252, 256
storage and handling 293
transporting 293
Breastfeeding 312, 328t
and medications 324, 327
and vaccination 295
cues 230
early 436
exclusive 182
football positioning for 230f
initiation and maintenance 229
Breathing 150
assessment of 5, 5fc
spontaneous 333
work of 65
Bronchomalacia 352
Brucellosis 320
Bulb syringe 155
C
Caffeine 166t
citrate 165
Calcium 45, 65, 69, 256, 435
concentration 84
gluconate 156
Callus formation 434
Calories, balance of 367
Candida
albicans 171, 224
dermatitis 220f
glabrata 171
krusei 171
lusitaniae 171
parapsilosis 171
stellatoidea 171
Capillary refill time 5, 15, 22, 366
Caput succedaneum 431
Carbohydrate 367, 367t
metabolism, disorders of 127
Carbon dioxide, end tidal 156
Cardiac catheterization 65
Cardiac failure 63
congestive 60, 65
Cardiac function 125
Cardiac index 29
Cardiomyopathy 58
Cardiorespiratory support 263
Cardiovascular disease 349
Cardiovascular drugs 326
Cardiovascular examination 58
Cardiovascular system 16, 187
Cardioversion 64
Cataract 267
Catecholamine, use of 27
Catheter
handling of 447
maintenance of 447
Cefotaxime 344t, 345
Centers for Disease Control and Prevention growth charts 254
Central line associated bloodstream infection bundle 342
approach 436
checklist 446
Central nervous system 17, 42, 117, 124t, 390, 395, 431
depression 9
infection 43
malformations 117
Central venous oxygen saturation 29
Central venous pressure 29
Cephalhematoma 431
Cephalosporins 340
Cerebral
artery infarction 43
palsy 117, 123, 124
diagnosis of 276
perfusion 435
Cerebrospinal fluid 34, 46, 117, 124, 312, 319, 387, 431
analysis 35
Cerebrovascular accidents 89
Cesarean section 305
Chest 355
indrawing 58, 187
physiotherapy 378
X-ray 17, 36, 60
Chickenpox 315, 316, 316t
infection, timing of 315
maternal 315
severe 315
Chloramphenicol 172
Cholestasis 52
medical management of 215t
neonatal 213t, 214fc, 215t
Chorioamnionitis, maternal 33
Choroid plexus hemorrhage 43
Ciprofloxacin 340
Circulation 150
assessment of 5, 5fc
Circulatory blood volume 25
Citrate phosphate dextrose 360
adenine 360
Clavicles 188
Clavicular fractures 434
Clitoral size 140
Clitoral width 140
Clotrimazole 224
Cloxacillin 340, 341
Coagulation screening tests 104
Colic 221, 238
etiology of 238
infantile 238, 240
management of 239
Colistin 340
Colorimetric method 78
Colostrum feeding, early 436
Commercial endotracheal tube holders 156
Complete androgen insensitivity syndrome 138
Complete blood count 34, 37, 95, 97, 101, 102, 124, 383
Computed tomography 45, 126, 160
Computer-aided syndrome diagnosis, websites for 453
Congenital heart defect, suspected 57
Conjunctivitis 32
Consanguinity, history of 139
Consciousness, assessment of 6fc
Constant positive airway pressure 112
system 355
Continuous flow devices 352
Continuous positive airway pressure 19, 22, 36, 95, 152, 158, 164, 166, 234, 341, 250, 347, 350, 352, 353, 355, 356, 435
adequate 354
components of 352
failure 354
setting of 353f
Convulsions, benign neonatal 44
Coombs’ test, direct 50, 51, 223
Cord
blood 112
banking, types of 331
screening 392t
care 181
clamping 181, 235
delayed 112, 332
Corticosteroids, antenatal 291
Corynebacterium 390
Co-trimoxazole prophylaxis 308t
therapy 306, 308
Coxsackievirus 43
Cradle cap 225
Cranial ultrasound 106, 280
C-reactive protein 26, 34, 35, 37, 39, 95, 124, 384, 386388
Creatinine phosphokinase 124
Crying infant 239fc
Cryoprecipitate 357, 361
use of 361
Cryptorchidism 137f, 301
Cyanosis 57, 58, 61t, 89, 187
Cystic adenomatoid malformation, congenital 18, 22, 398
Cystic fibrosis, rule out 161
Cystoscopy 142
Cytology 36
Cytomegalovirus 32, 43, 111, 164, 212215, 361, 363
infection 14, 359
D
Danger signs 182, 187, 228b, 238
Day-wise recommended fluid volume 365t
D-dimer test 99
Death
after 334, 430
before 429
declaration 335
Decongestants 326
Decontamination 411
Deep tendon reflex 124, 126
Dehydration 209
Dehydroepiandrosterone 142
Delivery, mode of 168
Deoxycorticosterone 142, 144
Deoxyribonucleic acid 194
Depressor anguli oris muscle, congenital hypoplasia of 433
Development observation chart 275t
Developmental supportive care 287
Dexamethasone 291, 291t
Dextrose 70, 150, 367, 367t
solution 156
Diabetes 346
insipidus 43
Diaper
dermatitis 220, 220f
rash 220
Diaphragmatic hernia, congenital 14, 398
Diarrhea 94, 225
Diethylenetriaminepentaacetic acid 206, 219
DiGeorge syndrome 432
Digoxin 63
Dihydrotestosterone 142145
Dimercaptosuccinic acid 206, 401
Discordant genitalia 139
Disinfection 411
Disseminated intravascular coagulation 50, 99, 100, 103, 108
Docosahexaenoic acid 258
Dohle bodies 384
Donor
blood group 54t
human milk 256
Double volume exchange transfusion 39, 100
Double-bucket technique 412
Double-catheter pull push technique 54
Downe's score 13, 20t, 353
Doxapram 165
Dubin-Johnson syndrome 212
Ductus arteriosus 58
constriction of 377
Ductus dependent lesions 58
Duodenal atresia 159, 210
Dysautonomia, familial 121
Dyselectrolytemia 105
Dysfibrinogenemia 361
Dysplasia, bronchopulmonary 14, 72, 165
E
Echovirus 43
Ectopic testis 301
Edema 366
pulmonary 58, 352
Electrocardiogram 61, 236, 333
Electrocardiography 62, 124, 125
Electroencephalogram 124, 437
Electroencephalography 41, 42, 4547
Electrolyte 455
imbalance 32, 68
maintenance of 169
serum 71
supplementation 69
Electromyography 124126
Emesis 94
Empiric antibiotic therapy, selection of 339
Encephalitis 117
Encephalopathy 116, 133
severity of 117
Endocarditis 320
infective 390
Endotracheal intubation 155
Endotracheal tube 155, 347, 349, 356
care 450
Enzyme
deficiency 142
replacement therapy 136
Eosinophilic granules 384
Epidermolysis bullosa 168, 169, 169t
management of 169
Epilepsy 47
Epinephrine 156
Epstein-Barr virus 320
Erb's palsy 432
Erythrocyte sedimentation rate 384, 386
Erythropoietin 108, 112, 361
Escherichia coli 33, 43
Esophageal atresia 152
Ethylenediaminetetraacetate 104, 105
Evoked otoacoustic emission test 270
Exchange transfusion 53, 55, 103, 263, 339
checklist 447
External genitalia, virilization of 141f
External masculization score 139t
Extracellular fluid 67, 71
Extracellular water 71
Extracorporeal membrane oxygenation 22, 28, 29, 103, 357
Eye
care 181
complications 267
discharge 227
manifestations 128t
preparation 264
F
Facemask oxygen 374t
Facial
dysmorphism 212
nerve palsy 432
False positive culture report 390
Fat
calories 367
soluble 202
subcutaneous 221f
Fatty acid
oxidation
defect 80
disorders of 124, 127
very long chain 126
Feed intolerance 94, 253
clinical symptoms of 94
Feeding 125, 169, 198, 251
method 248
oral 251
skills, maturation of 248
Feet 189
Female external genitalia 141
Fentanyl 156
Fenton fetal-infant chart 192
Ferritin, serum 214
Fetal infant growth charts 191
Fever
with rash 178
without rash 178
Fibrillation, ventricular 64, 75
Fibrosis, cystic 200
Floppy infant 120, 121t
etiology of 123t
phenotype 123t
Fluconazole 173, 340, 341, 345, 345t
Flucytosine 172
Fluid 67, 69, 207, 455
administration, rate of 69
and electrolyte 237, 365
management 67
status, monitoring of 70
therapy 67
deficit therapy, replacement of 71
intravenous 19, 55
maintenance of 169
replacement 92
restriction 72
solution 76
supplement 55
therapy 366t
goals of 366t
Fluorescence in situ hybridization 124, 126f
Fluorescent treponemal antibody absorption 319, 320
Follicle-stimulating hormone 140, 302, 303
Foramen of Monro 283f
Fracture long bones 434
Free fatty acid 80
Fresh frozen plasma 100, 360
transfusion 99, 360
Functional intestinal obstruction 161
Fungal infection 171, 171b, 174
systemic 171
Fungal sepsis 33, 36
Fungus 340
G
Galactosemia 81
Galeazzi's sign 189f
Gamma-glutamyl transferase 213
Gamma-glutamyl transpeptidase 213
Gas chromatography mass spectrophotometry 45
Gasping respiration 32
Gastric
aspirate 385
decompression 65
residual 94, 95
volume 253
Gastroesophageal reflux 14, 95, 163
disease 14
management of 125
Gastrointestinal tract 158
anomalies 364
Gastroschisis 364
Gene therapy 136
Gene Xpert 312
Genitalia 141t, 188
Gentamicin 156, 172, 340
Gestation 165t
Gestational age 43, 53, 149, 182, 209, 209t, 248, 295, 333, 350
large for 15, 16, 77, 85, 182
small for 15, 16, 77, 80, 182, 319
Glaucoma 267
Gliding testis 301
Glomerular filtration rate 204
Glucose 36, 435
6-phosphate dehydrogenase 51, 108, 111
deficiency 50, 53
concentration 78
infusion 82
rate 22, 68, 70t, 79, 80, 82, 237, 367, 456
tapering of 81
oxidase 78
sampling 78t
screening 78
status 68
Glycerine 45
Glycogen storage
disease 81, 124
disorder 80
Goldenhar's syndrome 432
Gonads 139
dysgenetic 147
palpable 138f
Graft versus host disease 330
Gram-negative organisms 340
Gram-positive organisms 340
Granulocyte
colony-stimulating factor 39
transfusion 363
Granuloma, umbilical 226, 226f
Graves’ disease 394
Great artery 57
transposition of 59, 62, 63, 65
Gross Motor Function Classification System 274, 275
Growth
and nutrition follow-up 276
characteristics of medium 389
charts 451, 452
longitudinal postnatal 192
neonatal 452
web-based 451
monitoring 191, 371
red flag signs for 277t
H
Hand
drying 418
hygiene 450
five moments of 416
types of 417
Handwashing 416
agents 418t
choice of 417
pre-requisites of 417
purpose of 416
steps of 416, 416
tips on 417t
Head box oxygen 374t
Head circumference 193
Health and disease, developmental origins of 254
Hearing
assessment 270t
follow-up 277fc
impairment 269b
severity of 270b
loss 270
signs of 269
symptoms of 269
red flag signs for 275t
screening 269
importance of 269
neonatal 271fc
tests 270
Heart
block, congenital 64
defect
congenital 57f
critical congenital 58, 59
cyanotic 58, 62t
disease 59t
congenital 14, 16, 17, 17b, 22, 57, 59, 60, 65fc, 88, 149, 178
failure, congestive 210
rate 15, 28, 64, 65, 86, 112, 366
characteristics, monitoring of 33
Heat loss, source of 11
Heel prick, site of 196f
Hemangioma 222
capillary 222f
cavernous 222f
strawberry 222
Hematocrit 22, 45, 91
Hematopoietic progenitor cells 330
Hemodialysis 208
Hemofiltration 208
Hemoglobin 17
Hemolysis, signs of 50
Hemolytic diseases 53
Hemorrhage
epidural 431
fetal 263
germinal matrix 280
intracerebral 104
intracranial 43, 117
intraventricular 121, 124, 163, 262, 263, 280, 282f, 359, 388, 436
periventricular 43
pulmonary 352
subarachnoid 43, 432
subdural 43, 432
subgaleal 431
Hepatic oxygen sensors 108
Hepatitis 320
B 361
immunoglobulin 310
immunoprophylaxis scheme 296t
surface antigen 309, 310
vaccination 295
virus 309, 363
C 361
virus 363
fulminant 315
Hepatobiliary iminodiacetic acid 213, 214
Hermaphrodite 137
Herpes simplex 46
virus 32, 111, 212215
High efficiency particulate air 174
Hips 189
developmental dysplasia of 272
Hirschsprung's disease 161, 210
Hormone, luteinizing 140, 142, 143, 302, 303
Hospital-acquired infection 391
Housekeeping surfaces, cleaning methods of 412
Human breast milk, role of 255
Human chorionic gonadotropin 143146
stimulation test 142
Human immunodeficiency virus 304, 306, 307t, 361, 363
care of 308
transmission 304t, 305
Human milk 293
fortifier 95, 253, 256
use of 436
optimizing use of 250t, 255t
Human platelet antigens 106
Human T-lymphotropic virus 363
Humidification 10, 450
role of 375
Hydration 71t
Hydronephrosis 216t, 219
classification of 216
congenital 216
fetal 216
Hydrops fetalis 346
Hydroxyprogesterone 144
Hydroxysteroid dehydrogenase 142146
Hyperammonemia 129, 130fc
management of 135
Hyperandrogenism, gestational 146
Hyperbilirubinemia
conjugated 212
direct 32, 212
management of 454
severe 149
treatment of 119
Hypercapnia, permissive 436
Hyperechogenic lesions 283f
Hyperekplexia 41
Hyperglycemia 32
Hyperglycinemia, nonketotic 45
Hyperinsulinemia 81
Hyperinsulinism 81
Hyperkalemia 72, 75, 207
Hypernatremia 43, 71, 74
correction of 75
Hyperoxia 436
test 61, 61t
Hyperphosphatemia 85
Hyperplasia, congenital adrenal 88, 139, 146
Hypertension
persistent pulmonary 16, 20, 22, 28, 29, 103
pregnancy induced 346
Hyperthermia 187
Hypertrophy, left ventricular 62
Hypocalcemia 43, 62, 84, 86t
asymptomatic 86
clinical suspicion of 84
early onset 43
etiology of 85t
late-onset 43
neonatal 84b
specific treatment of 86
symptomatic 86
Hypocapnia 436
Hypoglycemia 9, 32, 43, 62, 77, 77t, 79fc, 82, 89, 90, 116, 117, 129, 130
asymptomatic 80
clinical detection of 78
control 82
etiology of 80t
hyperinsulinemic 82t
management of 79, 80t
neonatal 77
persistent 80fc, 81, 81t, 131fc
prolonged 81
recurrent 80fc
symptomatic 80
Hypoglycemic episode 81
Hypokalemia 75
management of 75t
Hypomagnesemia 43
Hyponatremia 43, 71, 73fc, 74, 74fc, 193, 208
Hypoperfusion, systemic 435
Hypopituitarism 81
Hypoplasia, pulmonary 349
Hypoplastic left heart syndrome 58, 63
Hypospadiasis 137f, 139
Hypotension 24, 25t, 105
Hypothermia 7, 32, 187
clinical manifestations of 8
consequences of 9
management of 9
prevention of 11t
severity of 7t
therapeutic 118
treatment strategies for 9t
Hypothyroidism 209
congenital 392, 393, 393t, 394
maternal 394
Hypotonia 8, 32, 120, 126fc
Hypoxemia 373
Hypoxia 9, 58, 346
fetal 388
intrauterine 88
perinatal 121
treatment strategies for 375
Hypoxic ischemic encephalopathy 116, 121, 122, 124, 126
prevention of 119
treatment of 118
Hypsarrhythmia 45
I
Iatrogenic blood loss, reduction of 112
Ibuprofen 100
Icterus 49
Idiopathic thrombocytopenic purpura 105
Immune
disorders 331
thrombocytopenic purpura 98, 100
Immunization 388
Immunoglobulins 39
Immunosuppressant 327
Imperforated anus 159
Implantable cardioverter-defibrillator 22
Incomplete screening test 198
Incubators 9
Indian Academy of Pediatrics growth charts 452
Indomethacin 100
Infant feeding, principles of 306
Infant Health and Development Program 276
Infantile neuroaxonal degeneration 121
Infection 346
control 19
practices 436
focal 390
intrauterine 44
perinatal 44
suspected 32
suspicion of 6
Infertility 139
Infusion
device 156
intravenous 156
Inguinal hernia 161
Inguinal region 137f
Inspired oxygen, fraction of 350
Intensity 53
Intensive care unit 33, 408
Intersex 137
Intestinal obstruction 158
acquired 161
Intestine, atresia of 364
Intracellular fluid 67
Intrauterine growth 119
restriction 7, 46, 49, 80, 88, 103, 178, 185, 213
Intravenous immunoglobulin 28, 55, 100, 438
role of 55
Intraventricular antibiotics, use of 438
Intussusceptions 161
Invasive candidiasis 345
Iron 256, 368
supplementation 113
Ischemia, hypoxic 42
Isoniazid prophylaxis 312
Isovaleric academia 134
J
Jaundice 49, 52fc, 56f, 223, 223f, 232
assessing severity of 49
direct 212
etiology of 49, 50fc
evaluation of 51, 51t
management of 54, 55t, 56b
onset of 50
physiological 4
prolonged 52
rapid progression of 50
severe 4, 339
Jejunoileal atresia 210
Jitteriness 4, 41, 89
Jugular venous pressure 71
K
Kangaroo care 243
Kangaroo discharge 243
Kangaroo feeding policy 243
Kangaroo mother care 243, 244, 246, 247, 250, 435
advantages of 243
benefits of 244t
chart 245
components of 243
discontinuation of 246
don'ts of 246
duration of 245, 245t
implementation 247
initiation of 247fc
monitoring in 246, 246t
position 244, 245f
ward 247
Kangaroo position 243
Kasai's portoenterostomy 214
Kidney
congenital anomalies of 216
injury, acute 206
solitary 402
Kimaya 455
Klebsiella 33, 390
Klumpke's palsy 432
Knees, asymmetry of 189f
Koebner phenomenon 168
L
Labia majora 139, 140
Labial fusion, posterior 137
Lactate 129, 130
Lactic acidosis 129
congenital 135
Large intestine, disorders of 210
Laryngeal mask airway 155
Laryngeal nerve palsy 433
Laryngomalacia 352
Laryngoscope spare
batteries 155
bulbs 155
Laser nephelometry 387
Latest Newborn Resuscitation Program 112
Latex agglutination assay 387
Left ventricular outflow tract 60
Legal issues 154
Length 193
Lethargy 89
Leukemia 331
Leukocyte filtration 111
Levene staging 118t
Levofloxacin 341
Lidocaine 48
Light, types of 53
Light-emitting diode 312
fluorescence microscopy 312
Limb, upper 16, 17, 57, 65, 188
Linear fractional transformation 124
Lipid storage disease 121
Liquid-based mycobacteria growth indicator tube 312
Liver 173, 315
disease, chronic 320
Lobar emphysema, congenital 18, 22, 398
London dysmorphology database 453
Low birth weight 4, 6, 7, 33, 243, 244, 250, 250t, 251, 252fc, 295, 364, 394
baby 248, 250, 295
feeding 248
nutritional management of 248
Low molecular weight heparin 100
Lower chest retraction 20
Lower limb 16, 17, 57
pulses 65
Lower motor neuron
disease, suspected 124
lesion 122, 126
Lumbar puncture 40, 413
Lung
appearance 397
disease, chronic 22, 263, 377, 437
injury 349
normal 400b
pathology 17t
Lymphogranuloma venereum 320
Lymphoma 331
Lysosomal disorder 121, 127
M
Magnesium 45
Magnetic resonance imaging 43, 51, 82, 126, 262, 432
brain 45
chest, role of 18
role of 135
Major congenital anomalies 4, 149
Malaria 320, 361
Malassezia furfur 173, 225
Malrotation 210
Maple syrup urine disease 45, 198
Mastitis 233
Mean airway pressure 29, 112, 349
Mean arterial pressure 28
Mean blood pressure 22
Mean corpuscular volume 107, 108, 111
Measles 320
Mechanical obstruction, congenital 158
Mechanical ventilation 22, 33, 350, 353
Meconium 209
aspiration 388
syndrome 14, 1618, 339, 352, 398, 399
first passage of 209
ileus 161, 210
plug syndrome 161, 210
Medium-chain
triacylglycerols 256, 258
triglycerides 370
Membrane
premature rupture of 37, 40, 44, 346
prolonged rupture of 33
Menaquinone 202
Meningitis 32, 38, 40, 117
signs of 35
symptoms of 35
Meningomyelocele 152
Meperidine 324
Mercaptoacetyltriglycine 206
Meropenem 340, 341, 344
dosing interval for 344t
Mesenteric thrombosis 161
Metabolic crisis 121
Metabolic disorders 43, 81
Metabolic inherited disorders 198, 199t
Metabolic screening, types of 196, 196t
Metabolism
inborn errors of 14, 43, 80, 116, 117, 124, 127, 128t, 149, 163
suspected inborn errors of 127
Methicillin-resistant Staphylococcus aureus 390
Methylmalonic academia 134
Methylxanthines 165
Metronidazole 340
Microcentrifuge 90
Microerythrocyte sedimentation rate 384
Microhemagglutination tests 320
Micturating cystourethrogram 160, 206, 218, 401
Midazolam 156
Minerals 368
Minimal enteral nutrition 250t, 371, 436
Minimum inhibitory concentration 340, 391
Mitochondrial disorder 121, 129
Mitochondrial metabolism, disorders of 127
Mitral atresia 57
Mixed gonadal dysgenesis 147
M-neonate 452
Mobile applications 452, 453, 456t
resources for e-learning 455
Mobiou's syndrome 432
Molecular genetic study 125
Monitoring oxygen therapy 376
Monovalent hepatitis B vaccine 310
Moro reflex 432
Morphine sulfate 156
Mortality rate, infant 195
Mother-to-child transmission 304, 309
prevention of 304, 309, 309t
Motor system 122t
Motor unit disease 121
Mucopolysaccharidosis 123
Mucous membranes 366
Müllerian duct syndrome, persistent 146
Müllerian inhibiting substance 145, 302
Multicystic dysplastic kidney 401
Multiorgan dysfunction 116, 149
Multiple births 346
Multiple carboxylase deficiency 134
Multiple pregnancy 178
Multivitamins 256, 368
Mumps 320
Murmur 58
pathological 61t
Muscle biopsy 125
Muscular torticollis, congenital 433
Myopia 263
N
Nail involvement, importance of 170
Nares dilatation 20
Nasal
cannula 155, 374t
catheter 374t
continuous positive airway pressure 350
intermittent positive pressure ventilation 164, 166, 350
septal dislocation 433
Nasopharyngeal catheter 375t
Natal tooth 223, 224f
National Institute for Health and Care Excellence 223
Guidelines 52
National Institute of Child Health and Human Development 192
Near-infrared spectroscopy 376
Necrotizing enterocolitis 8, 72, 94, 95, 100, 103, 158, 163, 291, 359, 364, 377, 388
Neonatal anemia 107
approach of 109
causes of 109
early 358
management of 110
Neonatal convulsions
causes of 47t
incidence of 47t
outcome of 47t
Neonatal encephalopathy 116, 118
causes of 116
early detection of 118
treatment of 118
Neonatal intensive care unit 6, 94, 107, 182, 193, 234, 250, 260, 269, 272, 274, 342, 359, 364, 408, 435, 437, 451, 456
antibiotic policy in 339
charts, use of 451
environment 289
tools 454
Neonatal jaundice management 437
Neonatal online training and education 455
Neonatal reflexes, absent 32
Neonatal resuscitation 155, 156
equipment checklist 179t
Neonatal seizures 41, 42, 47, 48t
drug therapy of 48
management of 46fc, 48
Neonatal sepsis 32, 34t, 38t, 263
antibiotic choice in 340t
classification of 33
early onset 179b
screen 383, 386t
Neonatal transport 149
equipment 154
Neonatal virtual learning environment 456
Nerve
biopsy 125
conduction
study 125
velocity 125
Neurofibromatosis 44
Neurologic dysfunction score, bilirubin-induced 49, 49t
Neutropenia, non-infectious causes of 384b
Neutrophilia, non-infectious causes of 383b
Neutrophils
count 383
immature 35
Nevirapine 305
prophylaxis 305t
Newborn intensive care unit 264, 287
Newborn screening 58, 136, 194
Nikolsky's sign 168
Nipple
flat 230
inverted 230
sore 232
Nitric oxide, inhaled 22
Noise 153
Nonductal-dependent cyanotic lesions 58
Noninvasive positive pressure ventilation 22
Nonsteroidal anti-inflammatory drugs 324
Nontreponemal antibody tests 318, 319
Nuclear scan 394
Nutrition 19, 208, 237, 441, 455
maintenance of 169
parenteral 364
Nutritional supplementation 255, 257
O
Occupational therapy 125
Odor 128t
Oligoanuria 204, 206
diagnosis of 204
Oligohydramnios 346
Oliguria 72
presence of 72
Ophthalmology 170
Optimum nutritional policy 436
Oral antidiabetic agents 326
Oral polio vaccine 262
Oral thrush 32, 224, 224f
Organic academia 135
Organic acidemia 132fc
Organic acids 45
metabolism, disorders of 127
urine for 129
Ornithine transcarbamylase deficiency 134
Orphanet 453
Oscillometric method 24
Osteomyelitis 32, 390
Otoacoustic emission 262, 271
Oxygen 19, 373, 374
administration 235
analyzer 155
blender 155
concentrators 373t
cylinders 373t
delivery 375
device 374, 376t
different modes of 375t
dose for 375
reduced 373
hood 155
masks, neonatal 155
source of 373
tanks 155
therapy 373
prolonged 263
toxicity 376
tubing and adapters 155
Oxygenation 376t
index 13
status 377
P
P450-oxidoreductase 138
Packed cell volume 22, 50, 51, 262
Packed red blood cell 112, 357, 358, 360
Pallidum particle agglutination 320
Pallor 50
severe 4
Pancytopenia 102
Paralytic ileus 161
Parenteral glucose therapy 79
Parkins score 182
Partial androgen insensitivity syndrome 138
Partial exchange transfusion 91
technique of 92
Partial thromboplastin 97, 99101
time 105, 201
Patent ductus arteriosus 22, 28, 29, 60, 72, 100, 163, 291
management of 95
Peak inspiratory pressure 235, 349
Pedialink 456
Peditools 454
Pelvic ureteric junction 218, 219
Penicillin 340
Penile
length 139
width 139
Perinatal intensive care 272
Peripheral smear 104
examination 99
Peritoneal dialysis 208
Peritrigonal blush 285
Periventricular hemorrhagic infarction, presence of 283f
Periventricular leukomalacia 262, 284, 285f
classification of 284
Peroxisomal disorders 127
Phallic length nomogram 140f
Phenobarbital 156
Phenomizer 453
Phenylketonuria 198
Phimosis 224
Phosphorus 256
Phototherapy 49, 55
administration of 52
Phrenic nerve injury 433
Physiotherapy 125
Phytonadione 202
Piperacillin 340, 341, 344
Placental transfusion 88
Plasma 357
derivatives 359
loss 25
Plastic wraps 435
Platelet 357, 359
count 359
transfusion 99, 105, 105t, 106, 359, 359t
Pneumatosis intestinalis 94
Pneumonia 32, 38, 315, 342, 352
Pneumoperitoneum 158
Pneumothorax 388
Poland's syndrome 432
Polyarteritis nodosa 320
Polycythemia 8890, 91fc
assessing severity of 88
neonatal 88
signs of 90t
symptoms of 89, 90t
Polymerase chain reaction 117, 214, 312, 320
Poor postnatal weight gain 263
Positive blood culture, causes of persistence of 390
Positive end-expiratory pressure 235, 349, 352
Positive ferric chloride reaction 129
Positive pressure ventilation 116, 235, 180, 435
intermittent 437
Postasphyxia management 437
Postural drainage 378, 379f
Potassium 69, 75
Prader grading 141, 141f
Prebiotics 95
Pregnancy loss 409
Prenatal steroids 292
Pressure gages 155
Pressure manometer 156
Preterm
birth 255, 364
brain injury
diagnosis of 436
prevent 435
screening of 436
golden hour care for 234
growth chart 191, 452
Probiotics 95
Procalcitonin 35
Progressive familial intrahepatic cholestasis 213
Prophylactic therapy 347b
Propionibacterium acne 390
Propionic academia 134
Prostaglandin 63, 65, 165
Protein 36, 367
calorie 367
Prothrombin time 105, 201
Prune Belly syndrome 403
Pseudohermaphrodite 137
Pseudomonas 390
Public umbilical cord blood banking 331fc
Pulmonary function test 125
Pulse oximeter 16, 16t, 45, 234, 236
Pyelography, intravenous 160
Pyloric stenosis 158
Pyridoxine dependency 43
Pyruvate 45, 129, 130, 131fc
R
Radiant warmer 435
Radiation protection measures 396
Radioimmunoassay 387
Raised intracranial pressure 431
Random donor 360t
platelets 359
Rapid plasma reagin 318, 319
Rashes 4
Rashtriya Bal Surakhsa Karyakram 264
Real time polymerase chain reaction 312
Recombinant granulocyte-macrophage colony-stimulating factor 361
Red blood cell 99, 107, 111, 112, 363, 383
Red flag sign 121
Reflexes 189
absent 9
Refractory thrombocytopenia, causes of 103
Regurgitation 228
Renal disorders, congenital 401
Renal failure 72
Renal function 173
Renal replacement 208
Renal scars 218
Renal ultrasound 205
Renal vascular thrombosis, bilateral 206
Renal vein thrombosis 103
Renography, diuretic 218
Respiratory arrest 13
Respiratory disorders 398t
Respiratory distress 13, 14, 16, 17, 18b, 21fc, 32, 57, 89, 149, 152, 350, 400b
cardiac cause of 16t
history 14t
management of 18
quantify 20
risk factors 14t
severe 58, 121
syndrome 14, 1618, 20, 22, 50, 72, 103, 263, 291, 348fc, 350, 352, 353fc, 376, 388, 398, 399
management of 346, 436
Respiratory equipment care 450
Respiratory failure 13
hypoxic 149
Respiratory phase 397
Respiratory rate 15, 20, 65, 71, 112
Respiratory support 125, 237
Respiratory system 16, 187
Restlessness 4
Resuscitation 178, 179b, 333, 334
cardiopulmonary 154
procedure 409
Reticulocyte count 50
Retinal detachment 263
Retinopathy of prematurity 113, 262264, 265f, 267, 359, 376, 377
care 267fc
classification of 265t
examination 264, 267t
screening 263, 266fc
technique of 264f
Retractile testis 301
Rotor-wing aircraft 152
Rubella 32, 43, 111
Rule of three 221, 238
Rule of thumb 384
S
Sabouraud dextrose agar 172
SAGIL symptom checker 452
Sclerema 32
Sclerosis, tuberous 44
Screening test 195t
systemic candidiasis 172b
Scrotal fusion, complete 141
Scrotum 139, 302
Seborrheic dermatitis 225, 225f
Seizure 32, 46, 89, 121, 149, 187
clinical types of 42t
clonic 41
disorder, chronic 47
drug-associated 43
epileptic 41
evaluation of 42
mimics 41
monitoring 125
nonepileptic 41
persistent 132
refractory 135
treatment 125
Sensorium 71
Sepsis 36, 49, 117, 210
calculator, early onset 455
culture
negative 38
positive 38, 342
early onset 33, 3739, 340, 387
late-onset 3234, 39, 340, 387
management of 95
prevention of 119
rule out 383
screen positive 342
signs of 40
symptoms of 40
screen 17, 40, 149
Septicemia 32, 38
Serum creatinine phosphokinase 124
Serum glutamic
oxaloacetic transaminase 213
pyruvic transaminase 213
Severe hypoxic ischemic injury 149
Sexual development
46 XX disorder of 146, 146fc
46 XY disorder of 145fc, 146
disorders of 137, 138t, 139, 143t, 144, 146
sex chromosome disorder of 147
Sexual differentiation, disorders of 144fc
Sexually transmitted diseases 322
Shock 23, 24, 25t, 30, 57, 346
cardiogenic 25
clinical manifestations of 25t
compensated 23
diagnostic of 71
distributive 25
hypovolemic 25
irreversible 23
neonatal 23, 24t, 30, 30t
obstructive 25
phases of 23, 23t
thermal 9
types of 24, 24t
uncompensated 23
Silverman Anderson score 13, 20t, 21, 350, 353
Simethicone 240
Simple replacement transfusion 110
Single catheter pull push technique 53
Single donor platelet 359
transfusion 360t
Skin 189
care 169, 227, 236
disorders, blistering 168
incision 445
infection, suspecting 169
mottling 8
to-skin contact 243
early 182
turgor 366
Skull fractures 431
Sleep myoclonus
benign 41
neonatal 228
Small intestine, disorders of 210
Small left colon syndrome 210
Society for Fetal Urology 401, 402
Sodium 69, 72, 73
bicarbonate 156
serum 45
valproate therapy 127
Special care neonatal unit 6
Spectrum beta-lactamase, extended 38, 340
Spinal cord injury 433
Spinal muscular atrophy 121124
Spine 188
Staphylococcus aureus 33, 38, 417
Stem cell 330
banking 330
hematopoietic 330
Stenosis, pulmonary 59
Sterile
equipment 181
linen 181
water 156
Sterilization 411, 414
Steroids 30
role of 292
Stillbirth 409
declaration form 334
Stools not passed in first 48 hours 209
Stork bites 222f
Strabismus 263, 267
Stress behaviour, signs of 288
Stroke 117
Sturge-Weber anomaly 44
Superior vena cava 26, 29
Supportive care 9, 18, 36, 105
Surfactant replacement therapy 346, 350t
benefits of 346b
Surgery 388
Surgical therapy 82
Symptomatic neonatal hypocalcemia, management of 87fc
Syndrome of inappropriate antidiuretic hormone 73, 74
Syphilis 156, 320, 322, 323
congenital 318, 322
early 322
congenital 318
late congenital 319
maternal 322
therapy for 323t
serologic tests for 319
Syringe infusion pumps 151
Systemic lupus erythematosus 178, 320
T
T pallidum particle agglutination 320
Tachycardia 32, 64, 75
paroxysmal supraventricular 64
supraventricular 75
ventricular 64, 75
Tachypnea 13, 58
transient 14, 18, 352, 398, 399
Tandem mass
spectrometry 136, 214
spectrophotometry 45
Tazobactam 341, 344
Teicoplanin 340
Temperature
airway breathing circulation dextrose 65
assessment of 4, 4fc
instability 32, 94
monitoring 7
normal 8
Tensilon test 125
Term growth charts 192
Testicular activity, abnormal 146
Testosterone 142, 143
Tetralogy of Fallot 58, 59, 62, 400
Thawing breast milk 293
Theophylline 165
Thermal
care 18, 234, 441
strategies 10
issues 153
management 10fc
Thermometer, types of 8
Thermoneutral environment 7
Thiomersal issue 296
Thrombocytopenia 102, 102t, 103t
alloimmune 104
autoimmune 104, 104t
neonatal 102, 103fc
alloimmune 106, 359
nonimmune 359
Thyroid
function test 392
evaluation of 395fc
replacement 394
status, maternal 394
stimulating hormone 210, 213, 262, 392, 393, 393t, 395
testing 393t, 394
Thyroiditis, maternal autoimmune 394
Tigecycline 340
Tissue oxygen delivery 27fc
Total anomalous pulmonary venous connection 14, 58, 59, 62, 63, 400
Total body
water 70
composition 68t
weight 67
Total leukocyte count 34, 45, 386
Total parenteral nutrition 171, 197, 237, 364, 365, 367, 368, 368t, 371, 371t, 373
administration of 365
calculation for 369
compounding 370f
preparation of 364
solutions 370t
therapy, broad outline of 364
Total serum bilirubin 52, 56
levels 55t
Toxicology screen 125
Toxoplasmosis other rubella cytomegalovirus and herpes infections 32, 122, 123
Tracheoesophageal fistula 14, 16, 22
Tracheomalacia 352
Transfusion 197
general principles of 361
guidelines 110, 358t
Transmission, risk of 304, 315
Transport
incubators 151, 435
indications of 149
modes of 152t
preparation 150
team
responsibilities 153
types of 151
Trauma, avoidance of 169
Tremors 89
Treponema pallidum 319
particle agglutination 319
Treponemal tests 320
Tricuspid atresia 57
Trisomy 13 432
Trisomy 18 432
Truncus arteriosus 58
Tube feeds 251
Tuberculosis 311, 320
Tubular necrosis, acute 205
Twin-to-twin transfusion 88
U
Ultrasonography 124, 160, 217, 284
Umbilical artery catheter 206
Umbilical cord blood 330
advantages of 330
banking 330
Umbilical discharge 225, 226f
Umbilical hernia 226, 226f
Umbilical vein 54f
catheter 65
Undescended testis 302fc
Upper chest retraction 20
Upper motor neuron lesion 122, 126
Urea cycle defects 131
Ureteroceles 403
Ureteropelvic junction obstruction 401, 402
Ureterovesical obstruction 403
Urethral opening 140, 302
Urethral valves, posterior 403
Urethrogram, retrograde 142
Urinary sodium excretion 205, 205t
Urinary tract
congenital anomalies of 216
infection 32, 38, 178, 218, 219
obstruction 216
Urine
analysis 205
culture 34, 36, 218
not passed in first 48 hours 204
output 71, 72, 236
specific gravity 71
Urogenital sinus, opening of 141
V
Vaccination 296
Vaccine administration 295
Vaginal bleeding 4, 227, 227f
Vaginal discharge 227f
Vaginoscopy 142
Vancomycin 340, 341, 344, 344t
Vanillylmandelic acid 160
Varicella zoster immune globulin 317
Vasoconstriction, pulmonary 9
Venereal Disease Research Laboratory 318, 319
Test 45
Ventilation
high frequency 22
intermittent mandatory 166
noninvasive 436
system 174
Ventilator-associated pneumonia 436, 450
compliance of 342
Ventilatory minute volume 374
Ventricular septal defect 58, 59
Vesicoureteral reflux 216, 219, 401
Vibration 153, 378
Viral infections 212
Virilization 140
Vision, red flag signs for 275t
Vitamin 370
A 215, 256, 258
B12 109, 113
D 85, 256
E 109
supplementation 438
K 200, 201
absence 201
administration of 9, 181
deficiency bleeding 201, 360
forms 202, 203t
levels 202
oral 202
prophylactic 200
risk of 202
storage of 203
supplementation 202, 202t
therapeutic 200
K1 202
K2 202, 203
K3 202
Voiding cystourethrogram 217
Volpe's classification 281
Volvulus 210, 364
von Willebrand disease 361
W
Warm chain 10, 11b
Weaning oxygen 377
Weight 193
gain 72
poor 9
Wet mopping 412
White blood cells 384
count 383
Wolff-Parkinson-White syndrome 64
X
Xiphoid retraction 20
Z
Zidovudine 305, 306t
Zoster immune globulin 315, 316
×
Chapter Notes

Save Clear


1Clinical Approach to Sick Newborn
SECTION OUTLINE
  1. Identification of “At Risk” Newborn and Admission to SCNU/NICU
  2. Hypothermia
  3. Respiratory Distress
  4. Neonatal Shock
  5. Suspected Infection
  6. Neonatal Seizures
  7. Jaundice
  8. Suspected Congenital Heart Defect
  9. Fluid and Electrolyte Therapy
  10. Hypoglycemia
  11. Hypocalcemia
  12. Polycythemia
  13. Feed Intolerance: Gastric Residues
  14. Bleeding Newborn
  15. Thrombocytopenia
  16. Anemia
  17. Neonatal Encephalopathy
  18. Floppy Infant
  19. Suspected Inborn Errors of Metabolism
  20. Disorder of Sex Development
  21. Neonatal Transport
  22. Abdominal Distension
  23. Apnea
  24. Blistering Skin Disorders
  25. Systemic Fungal Infections
2

Identification of “At Risk” Newborn and Admission to SCNU/NICUCHAPTER 1

Rajiv Sharan
 
WHAT IS TRIAGE?
Triage is a process of rapidly examining all sick newborn when they arrive in hospital in order to place them in one of the following categories with the help of TABC concept. The basic purpose of triage is to ensure that sickest newborn gets earliest treatment.
 
Concept of TABC
When sick newborn arrives in emergency department of a hospital the assessment is done based on TABC concept where:
  • T stands for temperature
  • A stands for airways
  • B stands for breathing
  • C stands for circulation, consciousness/coma and/or presence of convulsion.
 
EMERGENCY SIGNS
If any of the following are present (alone or in combination):
  • T: Moderate or severe hypothermia (Temperature <35.9°C).
  • A: No chest movement or no air entry in lungs/obstructed airways and/or central cyanosis.
  • B: Not breathing/severe respiratory distress with increased work of breathing as evidenced by respiratory rate >60/minute with nasal flaring and/or chest retractions and/or grunting/gasping/head bobbing.
  • C: Capillary refill time >3 seconds and/or poor pulse and/or decreased urine output.
    • Color of baby mottled or pale with or without cyanosis.
    • Presence of unconsciousness as evidenced by no response or minimal response.
    • Presence of convulsion.
 
PRIORITY SIGNS
If any of the following are present (alone or in combination):
  • T: Mild-hypothermia (temperature ~ 36.0–37.4°C) or fever (temperature >37.5°C)
  • A: Decreased air entry in either lungs ± chest signs by auscultation, e.g. crackles or wheezing.
  • B: Fast breathing respiratory rate >60/minute ± retractions.
  • C: Capillary refill time <3 seconds but decreased urine output.
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Apart from above signs presence of the following features also classifies the newborn as having priority signs:
  • Low-birth weight (weight <1,800 g)
  • Irritability/restlessness/jitteriness
  • Refusal to feed
  • Abdominal distension
  • Severe jaundice
  • Severe pallor
  • Bleeding from any site (apart from physiological vaginal bleed in female)
  • Major congenital anomaly
  • Large baby (weight >4 kg)
  • Redness around umbilical area with or without pus discharge.
 
NON URGENT SIGNS
Newborns with nonurgent signs are mostly well and can wait for their turn to be addressed. TABC assessment in newborn with nonurgent sign is normal and usually newborns present with following features:
  • Physiological jaundice
  • Transitional stools
  • Developmental peculiarity
  • Minor malformations
  • Rashes.
 
When and Where to Triage?
The process should begin as soon as the newborn arrives in the emergency department of the treatment facility or hospital or outpatient department of the hospital.
 
Time for Triaging
The process to triage newborns in having three above listed signs should take minimum time. The staff nurse on duty should complete the triage stratification at the earliest. It is important that they should know how to look for several signs at the same time for rapid assessment.
 
Who should Triage?
Triaging should be done by experienced clinical staff nurse with involvement of the junior nurses.
 
How to Triage?
Triaging of newborns shall be a rapid assessment with focus on TABC concept. After completing TABC assessment the various other features as mentioned above should be taken into account. The basic purpose of triage is to ensure that sickest newborn gets earliest treatment.
Keep in mind the concept of TABC. First assess temperature, then airway, breathing, circulation and lastly consciousness level/coma/convulsion.
Temperature assessment (Flowchart 1): To assess the temperature one should feel the newborn's soles and abdomen.
  • If abdomen and soles both are warm, the newborn has normal temperature.
  • If soles are cold and abdomen is warm, the newborn is suffering from mild hypothermia/cold stress.
  • If the soles and abdomen are cold, the newborn has moderate/severe hypothermia.
Axillary thermometer should be used to record the newborn's temperature. Any other positive finding should be noted.
zoom view
Flowchart 1: Assessment of temperature.Note: Normal newborn baby is usually warm.
5
Newborn having hypothermia needs warming. The method of warming depends on the actual temperature.
Airway and breathing assessment (Flowchart 2): Airways and breathing pattern is assessed simultaneously for the sake of saving time. The following points should be looked for:
  • Is the newborn breathing/gasping/grunting/having head bobbing or nasal flaring?
  • Is the airway obstructed?
  • Is the newborn blue?
  • Does newborn have severe respiratory distress with or without retractions?
Any positive finding should be addressed on urgent basis and airways should be made patent. Oxygen is usually started before a definite diagnosis is made.
Circulation assessment (Flowchart 3): To assess if the newborn has circulatory problems one should:
  • Look for cold and clammy skin.
  • Look for capillary refill time (CRT) and note if it is more than or less than 3 seconds.
  • Look for weak and fast pulse rate.
Prolonged CRT (>3 sec) is a surrogate marker of poor peripheral perfusion. Fast and weak pulse with decreased urine output in this setting may herald a shock like state. Such newborns need warmth and oxygen. An intravenous (IV) line should be inserted and bolus 20 mL/kg of normal saline/Ringer's lactate (NS/RL) initiated over 15–20 minutes. Color of skin of the newborn may be an early catch to an experienced eye. Pallor, mottling, and cyanosis are key visual indicators of reduced circulation to skin.
zoom view
Flowchart 2: Assessment of circulation.Note: Normal breathing appears regular without excessive respiratory muscle effort or audible respiratory sound. While in abnormal breathing there is increased or excessive nasal flaring or abnormal muscle use or decreased or absent respiratory effort or noisy breathing.
Pallor signifies white skin coloration from lack of peripheral blood flow. Mottling/patchy skin discoloration, with patches of cyanosis is due to vascular instability or cold. Cyanosis can be a sign of shock or respiratory failure.
Assessment of consciousness level in newborns (Flowchart 4): AVPU scale (“alert, pain, unres ponsive”) can be used to rapidly assess the newborn. AVPU in comparison with GCS scale is read as: A = 15, V = 12, P = 8, U = 3.
  • A: Is the newborn alert?
  • V: Is the newborn responding to voice?
  • P: Is the newborn responding to pain?
  • U: Is the newborn not responding? (Unresponsive).
Any unresponsive newborn or newborn with convulsion needs immediate attention.
After placing the newborn under radiant warmer airways/breathing should be assessed and addressed. Peripheral IV line should be established at the earliest, RBS infused checked and injection phenobarbitone 20 mg/kg slowly over 20 minutes in a convulsing baby.
zoom view
Flowchart 3: Assessment of airway and breathing.(CRT: capillary refill time)Note: Normal warm child is usually suggestive of normal circulation whereas cyanosis, mottling, paleness/pallor or obvious bleeding suggests abnormal circulation.
6
zoom view
Flowchart 4: Assessment of consciousness.(AVPU: Alert, voice, pain, unresponsive)Note: A normal conscious child has normal cry and responds to parents or to environmental stimuli such as light, etc. and has good muscle tone and moves extremity well whereas abnormal or decreased cry and poor response to parents/environment suggests abnormal conscious level.
 
CRITERIA FOR ADMISSION TO SCNU/LEVEL II NICU
All newborns with emergency/priority signs and some babies with nonurgent signs will require admission in hospital for further management or for observational purpose. Other indications that may require admission into special care neonatal unit/neonatal intensive care unit (SCNU/NICU) may be enumerated as:
  • Birth weight ≤1,800 g.
  • Low-birth weight: Babies between 2,500 g and 1,800 g; if the clinical examination shows the baby needs supervised treatment should be shifted to SCNU and not postnatal ward.
  • Prematurity <34 weeks of gestation and any baby >34 weeks if is not sucking well.
  • Suspicion of infection
  • Clinical concern of respiratory problems like: (1) Apnea or cyanotic episodes, (2) Any respiratory distress causing concern.
  • Clinical concern of gastrointestinal problems, e.g. feeding problems severe enough to cause clinical concern and bile stained vomiting or signs suggestive of bowel obstruction.
  • Clinical concern of metabolic disorder, e.g. low serum glucose level and acidotic breathing.
  • Clinical concern of neurological disorder. (1) Convulsion (2) Perinatal asphyxia.
  • Congenital anomalies including surgically correctable lesions.
  • Any clinical condition which may require initial period of observation.
SUGGESTED READING
  1. Children and Infant—Recognition of a sick baby or child in the emergency department—NSW Policy Guidelines; 2011.
  1. Emergency Triage Assessment and Treatment — World Health Organization Publication.