Neonatal ICU Protocols
Neonatal ICU Protocols
Editors
Neelam Kler
MBBS MD (Ped) Chairperson
Department of Neonatology Institute of Child Health Sir Ganga Ram Hospital New Delhi, India Padma Bhushan 2014
Pankaj Garg
MBBS MD (Ped) DNB (Ped) Senior Consultant Department of Neonatology Institute of Child Health Sir Ganga Ram Hospital New Delhi, India
Anup Thakur
MBBS MD (Ped) DNB (Neonatology)
Consultant Department of Neonatology Institute of Child Health Sir Ganga Ram Hospital New Delhi, India
Forewords
Ann R Stark
DeWayne M Pursley Ashok Deorari VK Bhutani ON Bhakoo
Jaypee Brothers Medical Publishers (P) Ltd
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Neonatal ICU Protocols
First Edition: 2020
9789389587234
Printed at:
Sidharth Kler, Aditya Kler, Tanmay Garg, Paavni, Atharv Sachdeva Thakur, Anika Sachdeva Thakur
- Aakriti Soni MBBS
- Intern
- Sir Ganga Ram Hospital
- New Delhi, India
- Abdul Razak MD
- Associate Professor
- Department of Pediatrics
- Division of Neonatology
- McMaster University
- Hamilton, ON, Canada
- Amrit Jeevan DCH MD (Ped) MRCPCH (UK) DNB (Neonatology)
- Consultant
- Department of Neonatology
- Surya Mother and Child Superspecialty Hospital
- Mumbai, Maharashtra, India
- Anita Singh MD (Ped) DNB (Neonatology)
- Associate Professor
- Department of Neonatology
- Sanjay Gandhi Postgraduate Institute of Medical Sciences
- Lucknow, Uttar Pradesh, India
- Anumodan Gupta MD (Ped) DNB (Neonatology)
- Consultant Pediatrics
- Department of Pediatrics
- Government Medical College
- Kathua, Jammu, India
- Anup Thakur MD (Ped) DNB (Neonatology)
- Consultant
- Department of Neonatology
- Sir Ganga Ram Hospital
- New Delhi, India
- Anurag Fursule DNB (Ped) DNB (Neonatology) Fellow
- Department of Neonatology
- Sir Ganga Ram Hospital
- New Delhi, India
- Arpita Gupta Assistant Professor
- Developmental and Behavioral Pediatrics
- Department of Pediatrics
- Maulana Azad Medical College
- New Delhi, India
- Arti Maria MD DM (Neonatology)
- Consultant and Head
- Department of Neonatology
- Dr Ram Manohar Lohia Hospital
- New Delhi, India
- Arun Soni DNB (Ped)
- Senior Consultant
- Department of Neonatology
- Sir Ganga Ram Hospital
- New Delhi, India
- Arvind Shenoi MD DM (Neonatology)
- Chief Neonatologist and Medical Director
- Department of Neonatology
- CloudNine Hospital, Bengaluru, Karnataka, India
- Ashish Jain MD DM
- Associate Professor
- Department of Neonatology
- Maulana Azad Medical College
- New Delhi, India
- Ashish Mehta MD
- Director and Consultant
- Department of Neonatology
- Fellow in Neonatal Medicine College of Pediatrics, Australia
- ARPAN Newborn Care Centre Pvt Ltd
- Ahmedabad, Gujarat, India
- B Adhisivam DCH DNB PhD
- Additional Professor and HOD
- Department of Neonatology
- Jawaharlal Institute of Postgraduate Medical
- Education and Research (JIPMER)
- Puducherry, India
- B Vishnu Bhat MD
- Director-Medical Research
- Professor of Pediatrics and Neonatology
- Aarupadai Veedu Medical College (AVMC) Puducherry, India Former Director
- Senior Professor and Head
- Department of Neonatology
- Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER)
- Puducherry, India
- Brajesh Jha MD
- Senior Resident (DM Neonatology)
- Department of Neonatology
- Maulana Azad Medical College
- New Delhi, India
- Deblina Dasgupta MD (Ped) FNB Pediatric Nephrology
- Fellow
- Division of Pediatric Nephrology and Renal Transplantation
- Institute of Child Health
- Sir Ganga Ram Hospital
- New Delhi, India
- Geeta Gathwala DCH MD (Ped) DM (Neonatology)
- Senior Professor and Head
- Department of Pediatrics and Neonatology
- Pandit Bhagwat Dayal Sharma Postgraduate
- Institute of Medical Sciences
- Rohtak, Haryana, India
- Harish Chellani MD DCH
- Additional DGHS and Professor
- Department of Pediatrics
- Vardhman Mahavir Medical College and
- Safdarjung Hospital
- New Delhi, India
- Harish Nayak DOMS MS FRCS FRC (Ophth)
- Consultant Pediatric Ophthalmologist
- CloudNine Hospital
- Bengaluru, Karnataka, India
- Alderhey Children's Hospital
- Liverpool, UK
- Jaswinder Kaur MD (Ped)
- Clinical Associate
- Division of Pediatric Gastroenterology
- Hepatology and Liver Transplantation
- Institute of Child Health
- Sir Ganga Ram Hospital
- New Delhi, India
- Jogender Kumar DM (Neonatology)
- Assistant Professor
- Division of Neonatology Department of Pediatrics
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Kanav Anand MD (Ped) FPN
- Consultant Pediatric Nephrologist
- Division of Pediatric Nephrology and Renal Transplantation
- Institute of Child Health
- Sir Ganga Ram Hospital
- New Delhi, India
- Karthik Nagesh N MD FRCPCH (UK) FNNF Neonatal Intensive Care Fellowship (UK)
- Chairman
- Neonatology and NICUs
- Manipal Group of Hospitals
- Head Department of Neonatology
- Chairman, Manipal Advanced Children's Center
- Manipal Hospitals, Professor of Neonatology and Pediatrics, Manipal University
- Bengaluru, Karnataka, India
- Kavitha Rao DNB (Ophth)
- Fellowship in VR Surgery
- Consultant Vitreo-Retinal Surgeon
- Retina Institute of Karnataka
- Bengaluru, Karnataka, India
- Koshy Marucoickal George MBBS
- Neonatologist
- Rapides Regional Medical Center
- Alexandria, Louisiana, USA
- Kumari Gunjan MD (Ped) DNB Neonatology Fellow
- Department of Neonatology
- Sir Ganga Ram Hospital
- New Delhi, India
- M Jeeva Sankar MD DM
- Associate Professor
- WHO Collaborating Centre for Training and Research in Newborn Care
- Department of Pediatrics
- All India Institute of Medical Sciences
- New Delhi, India
- Maneesha PH DNB
- Fellowship in Neonatology
- Department of Neonatology
- Consultant Neonatologist People Tree @ Meenakshi Hospitals
- Bengaluru, Karnataka, India
- Nandkishor S Kabra DM (Neonatology) MD (Ped) DNB (Ped) MSc (Clinical Epidemiology)
- Director and Head
- Department of Neonatology
- Surya Children's Medicare Pvt Ltd
- Mumbai, Maharashtra, India
- Naveen Jain DM (Neonatology)
- Head
- Department of Neonatology
- Kerala Institute of Medical Sciences
- Thiruvananthapuram, Kerala, India
- Naveen Parkash Gupta MD (Ped) DNB (Neonatology) Fellowship in Neonatal Perinatal Medicine (Canada)
- Senior Consultant
- Department of Neonatology
- Rainbow Children's Hospital
- New Delhi, India
- Nirupama Laroia MD (Ped)
- Professor Department of Pediatrics
- Division of Neonatology
- University of Rochester, NY, USA
- Nishad Plakkal MD (Ped) Fellowship in Neonatal Perinatal Medicine (Canada)
- Associate Professor
- Department of Neonatology
- Jawaharlal Institute of Postgraduate Medical
- Education and Research (JIPMER)
- Puducherry, India
- Nishant Wadhwa MBBS DCH (Ped) DNB
- Consultant and Chief
- Division of Pediatric Gastroenterology
- Hepatology and Liver Transplantation
- Institute of Child Health
- Sir Ganga Ram Hospital
- New Delhi, India
- Pankaj Garg DNB MBBS MD
- Senior Consultant
- Department of Neonatology
- Sir Ganga Ram Hospital
- New Delhi, India
- Pradeep Kumar Sharma MD (Ped) DM (Neonatology)
- Senior Consultant Neonatologist
- Department of Neonatology
- Satguru Partap Singh (SPS) Hospitals
- Ludhiana, Punjab, India
- Praveen Kumar MD (Ped) DM (Neonatology)
- Professor
- Department of Pediatrics, Division of Neonatology
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Raktima Chakrabarti MD (Ped) Fellowship (Neonatology)
- Consultant Pediatrician and Neonatologist
- Department of Neonatology
- Cloudnine Hospitals
- Gurugram, Haryana, India
- Ranjan Kumar Pejaver FRCPCH (UK) FRCPI FIAP FNNF
- Professor
- Department of Pediatrics
- Kempegowda Institute of Medical Sciences
- Bengaluru, Karnataka, India
- Chief Neonatologist
- People Tree @ Meenakshi Hospitals
- Bengaluru, Karnataka, India
- Sachin Kumar Dubey (Maj)
- MD (Ped) DNB (Neonatology)
- Consultant Neonatology
- Department of Pediatrics
- Yashoda Superspecialty Hospital
- Ghaziabad, Uttar Pradesh, India
- Sanjay Wazir DM (Neonatology)
- Director
- Department of Neonatology and Pediatrics
- Cloudnine Hospitals
- Gurugram, Haryana, India
- Sanjiv B Amin MD MS
- Professor
- Department of Pediatrics
- University of Rochester School of Medicine
- Rochester, NY, USA
- Shiv Sajan Saini DM (Neonatology)
- Assistant Professor
- Department of Pediatrics
- Division of Neonatology
- Postgraduate Institute of Medical Education and
- Research (PGIMER), Chandigarh, India
- Shridevi S Bisanalli MD DM
- Faculty
- Department of Neonatology
- St John's Medical College
- Bengaluru, Karnataka, India
- Sindhu Sivanandan MD DM
- Assistant Professor
- Department of Neonatology
- Jawaharlal Institute of Postgraduate Medical
- Education and Research (JIPMER)
- Puducherry, India
- Sonalika Mehta MBBS MD
- Consultant Neonatologist
- Department of Neonatology
- Rainbow Hospitals
- New Delhi, India
- Suman Rao PN MD (Ped) DM
- Professor and Head of Department
- Department of Neonatology
- St John's Medical College
- Bengaluru, Karnataka, India
- Supreet Khurana MD (Ped) DM (Neonatology)
- Assistant Professor
- Department of Neonatology
- Government Medical College Hospital
- Chandigarh, India
- Susanta Kumar Badatya MD (Ped) DNB (Neonatology)
- Consultant Neonatologist
- Department of Neonatology Apollo Cradle
- New Delhi, India
- Swarna Rekha Bhat MD
- Former Professor
- Department of Pediatrics
- Division of Neonatology
- St John's Medical College
- Bengaluru, Karnataka, India
- Tapas Bandyopadhyay MD (Ped) DM (Neonatology)
- Assistant Professor
- Department of Neonatology
- Dr Ram Manohar Lohia Hospital
- New Delhi, India
- Umesh Vaidya MBBS DNB
- Consultant and Head Division of Neonatology
- King Edward Memorial (KEM) Hospital
- Pune, Maharashtra, India
- Venkataseshan Sundaram DM (Neonatology)
- Additional Professor
- Division of Neonatology
- Department of Pediatrics
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Vivek Choudhury MD (Ped) DNB (Neonatology)
- Consultant Neonatologist
- Department of Neonatology
- Apollo Cradle, New Delhi, India
- Wg Cdr (Dr) Ajoy Kumar Garg MD (Ped) DNB (Neonatology)
- Assistant Professor
- Department of Pediatrics
- Army Hospital Research and Referral (R&R)
- New Delhi, India
We were very pleased to learn that our distinguished colleague Professor Neelam Kler and her associates, Drs Pankaj Garg and Anup Thakur, have collaborated to develop a new and much needed Neonatal ICU Protocols. Drawing on national experts in neonatology and supplemented by their own decades of experience providing neonatal care at the renowned Sir Ganga Ram Hospital in New Delhi, India, the editors have developed an important resource for neonatal care providers in India.
A key characteristic of the handbook is that it is easy-to-use and can be applied directly at the bedside. Thirty-three individual chapters focus on the important issues in providing contemporary neonatal care. Rather than providing a long narrative, each chapter is organized with clear headings that include relevant information noted with bullet points. Ample tables, flowcharts, diagrams, illustrations, and photos provide additional well-organized information and supplement the text. At the end of each chapter, bulleted Key Points emphasize the “take home” messages. The self-assessment questions that follow will be helpful to students at every level, from residents and fellows to practicing neonatologists. Finally, a list of carefully selected articles provides a handy resource for more extensive reading.
The importance of high quality neonatal care cannot be overstated. The newborn period—the first 28 days of life—is the most vulnerable time for a child's survival. In India, deaths during this period represent more than half of the deaths occurring among children under 5 years of age. The interventions that are effective in the care of preterm and medically fragile newborns are unique to that period and require substantial training and mastery. Textbooks such as Neonatal ICU Protocols can be effective tools in improving outcomes for this most vulnerable of populations. Combined with public health measures, improved clinical outcomes facilitated by making current knowledge readily accessible can contribute to improved survival and help minimize sequelae of neonatal illness.
Another potential benefit of this handbook would be that neonatal care is standardized within a facility or perhaps across several in a region, since reducing variation tends to improve clinical outcomes. Standardization also provides a platform for quality improvement, allowing incremental tests of change. Finally, recognizing where evidence is limited may stimulate readers to pursue research and expand our knowledge.
We are confident that the Neonatal ICU Protocols will be increasingly found in NICUs throughout India, contribute to optimizing care of our fragile patients, and provide a study guide to a new generation of learners in our field. We look forward to further editions as knowledge continues to expand.
Ann R Stark MD
DeWayne M Pursley MD MPH
Department of Neonatology Beth Israel Deaconess Medical Center
Harvard Medical School, USA
FOREWORD
Ensuring healthy survival of all neonates is among the highest priorities of our times. The global community has committed itself to attain an under-five child mortality rate of less than 20 per 1,000 live births in all countries by 2035. This would only be achieved if the neonatal mortality rate declines to less than 10 per 1,000 live births. For India, this would be nearly halving the current neonatal mortality rate of 23 per 1,000 live births.
India's success in reduction of neonatal mortality since the launch of the National Rural Health Mission has been modest. Nonetheless, the country mounted a spectacular effort in establishing newborn care corners and special newborn care units, thus creating an impressive neonatal care infrastructure in the public sector. There has also been a concomitant expansion of neonatal care services in the private sector. This massive expansion of neonatal care services has also brought to the fore an extraordinary need for skilled nurses and doctors. Sir Ganga Ram Hospital, New Delhi, India, which runs one of the best tertiary care, newborn units for more than three decades in the city of Delhi, has been in the forefront of training healthcare providers in neonatal care. The unit has tried to capture the best learnings in neonatology in the current handbook. This compilation is a timely step towards filling the gap for knowledge translation for ensuring quality of care for sick newborns. The handbook has 33 chapters on common issues faced while caring a sick newborn. It provides comprehensive, systematic approach in identification and management of sick neonates. The evidence-based practices are tailored to day-to-day needs of neonatology fellows, resident doctors, and practicing pediatricians. I am confident that the effort of updating chapters of the handbook in the future will continue with the energetic next generation leadership of the unit.
I would like to congratulate the contributors, reviewers, and the editorial team for an outstanding product. The credit goes to a very large team of neonatologists trained in India who have contributed in this endeavor. I am glad to see many young neonatologists, most of whom I know personally, contributing to this book. They are exceptional up-to-date educators with hands-on experience in managing sick neonates. My special congratulations to Dr Neelam Kler for taking, leadership role in this endeavor.
I am sure this handbook will help in providing safe, affordable care with focus on quality in neonatal units in the country and beyond.
Ashok Deorari
MD FAMS FNNF
Professor and Head
PDepartment of Pediatrics
In-charge
PWHO Collaborating Center for Education and Research in Newborn Care
PChairman, Skills Center Lead for QI in SEARO
PAll India Institute of Medical Sciences
PNew Delhi, India
PPresident (2020)
PNational Neonatology Forum (NNF), India
FOREWORD
Padma Bhushan Dr Neelam Kler leads her team Dr Pankaj Garg and Dr Anup Thakur to take the key steps that will help develop a national “standard of care” for neonatal medicine for Indian families. Collaboration with national experts provides a unique insight that bridges the gap between academic knowledge and practical realties that burden practicing front-line clinicians. The algorithms and tables categorizing neonatal conditions should be used as guidelines for judgment-driven disease management.
This handbook deals with the current state of neonatology and provides a comprehensive, systematic approach in the identification and management of sick neonates to make evidence-based decisions in clinical practice for both public and private sectors. Sections on follow-up care deserve special mention. Future publications could include individual attention to antibiotic stewardship, breastfeeding, small-for-dates neonates, phototherapy, hyperammonemia syndromes and NICU-based neurodevelopmental protection and maturation. Other novel areas on the horizon in future editions include prenatal and perinatal cardiac disorders and other fetal disorders that require specific neonatal care.
The handbook is directed for use by the bedside clinician who is still a student of neonatal diagnosis and disorders before the results of laboratory tests are available. It is well structured and easy-to-read. Editors are specifically congratulated for attempting to provide a forum for families who are likely to be readers.
Content in this handbook should be updated periodically (more than annually). Hopefully this will be achieved through a web-based portal for rapid alerts, novel approaches and newer sections. These are exciting prospects and speak to the mission of the handbook as a knowledge resource that governs national intensive neonatal care patterns for safer care of vulnerable infants.
Contributions of Drs Neelam Kler, Pankaj Garg and Anup Thakur are significant and over the years will help clinicians and families to develop sound as well as safe judgment.
Well done and well-read.
VK Bhutani
Professor of Pediatrics (Neonatology)
Lucile Salter Packard Hospital
Standford University, USA
FOREWORD
Neonatal intensive care has become more rewarding because of the improving intact survival rates of high-risk neonates. This has been possible because of better understanding of neonatal physiology, new technology, and improved skills of collating the two.
The current book uses this amalgam to describe the practical approach to evaluation and management of a sick neonate. The text is kept to minimum and there is liberal use of tables and illustrations. Flowcharts and algorithms make the decision making easy.
To keep the book small and easily portable recent literature has been condensed, but provides adequate evidence for appropriate decision making. Additional highlight of this book is that each chapter closes with key points which highlight the take home message. The self-assessment questions following the key points should be helpful to the student for self evaluation. This book can be carried to the bedside in a pocket and should be a boon for the residents, fellows, consultants, and the senior nursing staff involved in neonatal intensive care.
I congratulate Dr Neelam Kler and her editorial staff along with expert contributors to various chapters for bringing out a very useful and timely publication. In fact, going through this book one felt like a student once again.
ON Bhakoo
MD FIAP FAMS FNNF
Former Professor and Head Department of Pediatrics and Neonatology
Postgraduate Institute of Medical Education and Research
Chandigarh, India
PREFACE
I do not know what I may appear to the world, but to myself I seem to have been only like a boy playing on the seashore, and diverting myself in now and then finding a smoother pebble or a prettier shell than ordinary, whilst the great ocean of truth lay all undiscovered before me.
—Isaac Newton
The confines of knowledge are limitless. How much sand can we hold from the vast shores of knowledge? As we begin this Neonatal ICU Protocols, we attempt to unravel the art and science of neonatology in a comprehensive manner, understanding that it is a tall order. Well! It is not just a compendium of 33 chapters covering most practical aspects of neonatal intensive care, but a treasury of recent evidence-based literature accrued and turned into an elixir by a team of experts from India and abroad in an easy-to-read format with ample numbers of figures, tables, and diagrams. The cardinal points at the end of each chapter and self-assessment questions further add up to the potion. The realms of neonatology are vast and the book being limited by its volume does not encompass some of its aspects such as drugs, procedures, quality improvement and perinatal medicine, which we intent to include in the future editions. While the pursuit for excellence may be eluding, we the editors and the authors have put into our hard work with unfeigned passion to make this book a small treatise for medical students, residents, pediatricians, nurses and neonatologists to assist them in management of critical and sick neonates ultimately helping them to save these little angels, who are our tomorrow.
Walt Disney aptly said, “There is more treasure in books than in all the pirate's loot on Treasure Island.” We hope the readers not only enjoy reading the book but also practice its principles of management in neonatal intensive care.
Neelam Kler
Pankaj Garg
Anup Thakur
ACKNOWLEDGMENTs
We are indebted to our teachers for the knowledge and skills imparted to us to take care of sick and vulnerable neonates.
We are extremely thankful to our colleagues Drs Satish Saluja, Arun Soni, Manoj Modi, team of residents and nurses for providing an environment of clinical and academic excellence in the department. We are grateful to our institution Sir Ganga Ram Hospital New Delhi, India for nurturing a culture of humanitarian care and stand by its ethos to provide world class healthcare in a safe, comfortable and caring environment at an affordable cost to all sections of the society.
We are thankful to Dr Naveen Parkash Gupta for reviewing some important sections of the book and providing us with important feedbacks to improve its content and readability. We sincerely acknowledge the secretariat help provided by Ms Renu Bisht. We thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Ms Chetna Malhotra Vohra (Associate Director–Content Strategy) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who invited us to edit the textbook and guided its framework throughout the period of writing.
Our heartfelt gratitude goes to the neonates in the neonatal intensive care unit (NICU) and their families who have always inspired us to practice the art of compassionate neonatal care. Last but not least, we thank our families for bearing with us.