NICU NOTES

Essential Newborn Care (ESSENTIAL INTRAPARTUM AND NEWBORN CARE)

1. Immediate and thorough drying
- First to dry: Head
- Head and neck comprises majority of surface area of newborn
2. Early skin to skin contact
3. Properly timed cord clamping
TERM: 1-3 mins
PRETERM: 30 sec-1 min
4. Non-separation of newborn to mother for early initiation of breastfeeding

Routine Newborn Care

1. Identification: 2x
A. Delivery room
B. NICU

2. Vitamin K prophylaxis
A. K1 Phytomenadione: Natural
B. K2 Menaquinone: rebound hemorrhage
C. K3 Menadione: rebound haemorrhage

3. Eye prophylaxis
A. 0.5% Erythromycin
B. 1% tetracycline
C. 1% Silver nitrate – chemical conjunctivitis
D. 2.5% povidone iodine (WHO)

4. Cord care

5. Bathing: 6th hour of life

6. Vaccine
A. BCG
Course of BCG (0.5 INTRADERMAL RIGHT DELTOID)
W- Wheals 20-30 mins
I-Induration 3-5 weeks
P- Pustules 4-6 weeks
U-lceration- 6-8 weeks
S- Scar 10-12 weeks

B. Hepa B (ANTEROLATERAL THIGH; IM)

JI CONARCO/ JI FONACIER/ JI MANUEL/

PGI FUGGAN/ PGI LIMBO
JULY 2018 ROTATION PEDIA
Newborn Screening (BASIC)
1. Congenital Adrenal Hyperplasia
2. Congenital Hypothyroidism
3. Phenylketonuria
4. Galactosemia
5. Maple Syrup Disease
6. G6PD
Expanded:
• Hemoglobinopathies
• Disorders of amino acid and organic acid metabolism
• Disorders of fatty acid oxidation
• Disorders of carbohydrate metabolism
• Disorders of biotin metabolism and cystic fibrosis

Methods of Heat Loss

1. EVAPORATION: lost by water evaporation from the skin of the infant
Ex: Thorough drying of infant after delivery
2. RADIATION: heat loss from the infant (warm) to a colder nearby (not in contact)
object
Ex: Use of droplight
3. CONDUCTION: direct heat loss from the infant to the surface with which he or she is
in direct contact
Ex: Using pre-warmed linen and cloth
4. CONVECTION: heat loss from the infant to the surrounding air
Ex: Turn the aircon off

APGAR Score
SCORE 0 1 2
Heart Rate Absent <100 bpm >100 bpm
Respiratory Rate Absent, irregular Slow, crying Good
Some flexion of
Muscle Tone Limp Active motion
extremities
Reflex Irritability No response Grimace Cough or sneeze
Color Blue, pale Acrocyanosis Completely pink
7-10: NORMAL
4-6: BORDERLINE
<3: RESUSCITATE
1ST MINUTE: ASSESS NEED FOR RESUSCITATION
5TH MINUTE: EFFECTIVENESS OF RESUSCITATION
Normal Values

CR 120-160 HGB 14-20/22

RR 30-60 HCT 45-65
Temp 36.5-37.4 HGT 40-160
Fair Suck 15-30 cc RBS 50-160
Good Suck 30-60 cc PC 150-450
PT >70% WBC 9-30
INR <1.2% - Segmenters 54-62
PTT <50% - Lymphocytes 25-33
TC <20 difference - Monocytes 3-7
T:C <1.5 ration - Eosinophils 1-3
- Band 3-5
Calories in 20 mL of breastmilk: 20 calories
Frequency of stool: 4 times a day (As long as intake is adequate and there is no excessive
weight gain)
Urine output: 1.0 cc/kg/hr (May be up to 7 cc/kg/hr since GFR of newborns is increased)
Normal kcal for newborns: 110-160 kcal/day

Reflexes
Reflex Onset Fully Developed Duration/Disappears
Plantar 11 weeks 7-9 months
Palmar Grasp 28 weeks 32 weeks 2-3 months
Less prominent after
Rooting 32 weeks 36 weeks
1 month
Moro 28-32 weeks 37 weeks 5-6 months
Tonic Neck 35 weeks 1 month 6-7 months
4-5 months
Placing/Stepping 37 weeks Patient can creep
and crawl
Remains throughout
Parachute 7-8 months 10-11 months
life
Covered up by
Landau 9-10 months
voluntary action
Covered up by
Righting 4-8 months
voluntary action

Steps of Response of MORO Reflex

Abduction  Extension  Flexion  Adduction
 Signs and Symptoms Blood Culture and Sensitivity
CLINICAL SEPSIS + -
BACTEREMIA - +
SEPSIS NEONATORUM + +
Physiologic Changes in the Newborn
1. Tears often are not present with crying until after 1-3 months
2. Physiologic jaundice: appears after 24 hours
Peaks: Day 2-3
Disappears 5th day of life
3. Caput succedaneum: fluids, edema; crosses midline, resolves in days/weeks
4. Lumbar lordosis: up to 6 years of age
5. Physiologic balding: up to 4 months of age
6. Witch’s milk: galactorrhea in neonates because of persistence of mother’s estrogen in
neonates blood

Physical Exam of the Newborn

TIMING OF PHYSICAL EXAMINATION
1. Immediately after birth
2. Nursery room within 24 hours after birth
3. Focused examination within 24 hours before discharge
PURPOSE OF INITIAL PE:
1. To ensure that there is no evidence of significant cardiopulmonary instability that
requires intervention
2. To identify congenital anomalies

Breastfeeding
Absolute Contraindications Relative Contraindications
1. Antineoplastics 1. Neuroleptics
2. Radio pharmaceuticals 2. Sedatives
3. Ergot alkaloids 3. Tranquilizers
4. Iodide/mercurial 4. Metronidazole
5. Atropine 5. Tetracycline
6. Lithium 6. Sulfonamides
7. Chloramphenicol 7. Steroids
8. Cyclosporine
9. Nicotine
10. Alcohol
Breastfeeding is NOT contraindicated in Mastitis
Mothers taking Magnesium Sulfate CAN still breastfeed their babies
Physiologic VS Pathologic Jaundice
PHYSIOLOGIC PATHOLOGIC
Appears on 2nd to 3rd DOL May appear on first 24 HOL
Disappears by the 5th DOL Variable
Peaks on Days 2 to 3 Variable
Total Bilirubin – usually <5mg/dL Usually >5 mg/dL
Conjugated bilirubin >2
mg/dL at anytime

Presents after 48th HOL Present in the first 24-36th HOL

TB increases NOT >5 mg/dL/day
TB peaks at 14-15 mg/dL
Direct bilirubin is <10% of TB
Resolves in 1 week in full term; 2 weeks in
preterm
TB increases >0.5 mg/dL/day
TB increase to >15 mg/dL
Serum bilirubin: >12 mg/dL in full term
10-14 mg/dL in preterm neonates
Direct bilirubin is >10% of TB (>2mgdL)
Persists beyond: 1 week in term; 2 weeks in
preterm

Breastfeeding Jaundice Breastmilk Jaundice

Onset Within first 7 days More than 7 days
Pathophysiology Decrease milk Unknown
intake  Increase May be due to β-
enterohepatic glucoronidase in
circulation breastmilk
Management Fluid and caloric intake Stop breastfeeding

PHOTOTHERAPY
1. INDICATION: High intermediate risk zone in Bhutani Chart
2. LIGHT: blue range (420-470 mm)
3. MECHANISM: reversible photo-isomerization and photo-oxidation
4. DISTANCE: 15-20 cm
5. PRECAUTION:
a. Eyes must be closed and adequately covered to prevent light
b. Infant should be shielded from bulb breakage
c. Body temperature should be monitored
d. Irradiance should be measured directly
e. Genitalia protected
Complications of Phototherapy
1. Loose stools
2. Erythematous macular rash/purpuric rash
3. Overheating
4. Dehydration: increase insensible loss, diarrhea
5. Hypothermia
6. Bronze baby syndrome
7. Corneal damage
8. Anemia
9. Thrombocytopenia
10. Constipation
11. Burns
12. Sterility

BHUTANI CHART
Meconium Staining
Cord 30 minutes – 1 hour
Nailbeds 2 – 4 hours
Skin 4 – 6 hours
Vernix 10 hours
Vocal Cords >12 hours
Contents of Meconium:
1. Intestinal epithelial cells
2. Lanugo
3. Amniotic fluid
4. Mucus
5. Bile
6. Water

Caput Succedaneum VS Cephalhematoma

Caput Succedaneum Cephalhematoma
Physiologic Pathologic
Fluid, edema Blood
Crosses midline Does not cross the midline
Resolves in days/weeks Resolves in weeks/months
Prone to Jaundice
Forceps delivery

RASHES
Milia
Retention of keratin within the
superficial dermis
− Multiple, pinpoint white papules
representing benign superficial keratin
cysts
Miliaria
- Group of transient eccrine disorders
- d/t occlusion of the eccrine ducts at
various levels, resulting in rupture of
ducts and leakage of sweat in the
epidermis and papillary dermis
A. MILIARIA CRYSTALLINA: most
common type
• 1-2 mm superficial clear
noninflammatory vesicles and reflects
superficial obstruction of the eccrine
duct at the level of stratum corneum
• MC on forehead and upper trunk

B. MILIARIA RUBRA (PRICKY HEAT)

• due to intra-epidermal obstruction
due to sweat gland
• occurs later than miliaria crystalline

C. MILIARIA PROFUNDA
• rare in newborns
• Nonpruritic, flesh-colored, deep-
seated whitish papules
• Asymptomatic, usually lasting only 1
hr after overheating has ended
• Concentrated on the trunk and
extremities
• Occlusion is in upper dermis
• Only seen in tropics usually following
a severe bout of miliaria rubra
Erythema toxicum
- Numerous small areas of red skin
with a yellow-white papule in the
center
- Most noticeable 48hr after birth but
may appear as late as 7-10 days

Nevi

MACULAR HEMANGIOMA
- “Stork bites,” “Salmon patch”
- True vascular nevus normally
seen on the occipital area,
eyelids, and glabella
- Disappear spontaneously
within the 1st year of life

PORT-WINE STAIN
- “Nevus flammeus”
- Does not blanch with pressure
and does not appear with time
MONGOLIAN SPOT
- Dark blue or purple bruise-like
macular spots usually located
over the sacrum

CAVERNOUS HEMANGIOMA
- Large, red, cyst-like, firm, ill-
defined mass and may be
found anywhere on the body

STRAWBERRY HEMANGIOMA
- (Flat, bright red sharply
demarcated lesions that are
most commonly found on the
face
- Spontaneous regression usually
occurs (70% disappearance by
7 yrs of age)
Formulas

# of cc/day
TFI Oral = Wt. in kg

OF cc/day × 20 cal
TCI Oral = 30
Wt. in kg

Total UO (cc)/24 hr
UO = Wt in kg
Gastric capacity = Wt (kg)×25
150
Full feeds = Wt (kg)×
8

Hypoglycemic:
D10WmL = 2×Wt (g)

cc/hr × 24 hr
TFI IV = Wt. in kg

D
cc/hr × 24 ×( )×4
100
TCI IV = Wt. in kg
*D = Dextrosity

D
cc/hr × 24 ×( ) × 1000
100
GIR = 1440/Wt. in kg

Normal GIR: 4-8 mL/kg/min

Hyaline Membrane Disease (HMD) VS Transient Tachypnea of the Newborn

I. Hyaline Membrane Disease: RDS Type 1

INCREASED INCIDENCE REDUCED INCIDENCE

1. Preterm infants (28-32 1. Chronic or pregnancy
weeks) associated
2. Male, white hypertension
3. IDM 2. Maternal opiate use
4. Delivery <37 weeks 3. PROM
AOG 4. Neonatal
5. Multifetal pregnancy corticosteroid use
6. Cesarean/Precipitous
delivery
7. Asphyxia, cold stress,
history of similarly
ETIOLOGY/PATHOPHYSIOLOGY
➢ Surfactant deficiency: produced by Type 2 pneumocytes; LS ratio 2:1
➢ Maturation of surfactant system  Phosphatidylglycerol
➢ FRC fails to develop  Collapsed lung/atelectasis
➢ High O2 concentration (Damage epithelial lining cells)
➢ Genetics, hypoxia
➢ Hyper/Hypoxemia
➢ Lungs are liver-like, atelectasis

DIAGNOSIS
➢ Premature infants with distress
➢ CXR: Fine reticulo-granularity (ground glass), air bronchogram, typical pattern seen at 6-
12 hours
➢ ABG: progressive hypoxemia, hypercarbia, metabolic acidosis, high base excess

CLINICAL MANIFESTATIONS
➢ Peaks in 3 days then gradually improves
➢ Babies are born pinkish with very loud cry but signs appear few minutes after birth
➢ Tachypnea
➢ Grunting
➢ IC and SC retractions
➢ Alar flaring
➢ Duskiness

MANAGEMENT
➢ Intratracheal surfactant replacement
➢ Oxygen (O2 sat at 88-94%)
➢ Permissive hyoercapnea (55-65)
➢ IVF, NPO, CPAP, Mech. vent, infection control: use of orogastric tube

PREVENTION
➢ Prevent prematurity

II. Transient Tachypnea of the Newborn: RDS Type 2

➢ Transient: usually improves within 24 hours; disappears

➢ within 72 hours
➢ Wet-lung syndrome
➢ Term to late preterm
➢ Early onset respiratory distress
➢ Mild. self-limited disorder, recovery within 3 days
INCREASED INCIDENCE
➢ Term or late preterm
➢ Premature, precipitous & operative births  prolonged delivery
➢ Male, born to asthmatic mother
➢ Delayed cord clamping
➢ Macrosomia
➢ Multiple gestation

PATHOPHYSIOLOGY:
• Absence of hormonal changes that accompany onset of spontaneous labor
o Abdominal delivery (non-spontaneous labor)
− No thoracic squeeze
• Transient pulmonary edema d/t delayed clearance of fetal lung liquid
• Fluid accumulation in peribronchiolar lymphatics and bronchovesicular spaces
• Diminished lung compliance and distensibility

CLINICAL MANIFESTATION:
➢ Typically presents at 6 hours of life
➢ Mild to moderate respiratory distress
➢ Improves in 24 hours; can last up to 72 hours in severe cases
➢ Rapid recovery, absence of radiographic findings of RDS
➢ CXR: prominent pulmonary vascular finding
o Fluid in intralobar fissures
o Overaeration
o Flat diaphragms
o Rarely: small pleural effusion
o Mild to moderate cardiomegaly

MALIGNANT TTN: Refractory hypoxemia due to PPHN in infants born via CS

➢ Give ECMO
MANAGEMENT:
➢ Supportive: humidified O2, IVF, NPO, Antibiotics
➢ Caffeine or theophylline: increase central respiratory drive by lowering the threshold of
response to hypercapnia as well as enhancing contractility of the diaphragm and
preventing diaphragmatic fatigue
➢ Coxopram: patent respiratory stimulant, acts predominantly on peripheral
chemoreceptors and is effective in neonates with apnea of prematurity that is
unresponsive to methylxanthines
➢ Transfusion of packed RBC
➢ Nasal continuous positive airway pressure (CPAP, 3-5 cm H2O) and high flow
humidification using nasal canula 1-2.5L/min)
➢ CPAP is preferred for mixed or obstructive apnea
Apnea
➢ Cessation of breathing more than 10-20 sec or for any duration accompanied by
bradycardia or oxygen desaturation

1. SERIOUS APNEA: preterm infants

➢ Defined as cessation of breathing for longer that 20 sec or for any duration
➢ if accompanied by cyanosis and bradycardia

2. OBSTRUCTIVE APNEA: pharyngeal instability, neck flexion

➢ Characterized by absence of airflow but persistent chest wall motion

3. CENTRAL APNEA: caused by decreased CNS stimuli to respiratory muscles, both airflow and
chest wall motion are absent

4. MIXED APNEA: most common pattern (50-75% of cases)

➢ with obstructive apnea preceding (usually) or following central apnea

Sepsis Neonatorum
➢ Systemic bacterial infection with (+) blood culture in 1st month of life
➢ Signs and symptoms often nonspecific
➢ High index of suspension is required to identify and evaluate at risk infants

LABORATORY
➢ Definitive diagnosis: (+) blood culture
➢ Antigen detection assay: detect bacterial cell wall or capsule
➢ WBC count – insensitive and nonspecific
➢ Acute Phase Reactant

TREATMENT
➢ Empiric antibiotic therapy: choice of empiric therapy based on
• Timing and setting of disease microorganism frequently seen
• Susceptibility profile
• Site
• Penetration of antibiotic
• Safety
Essential Newborn Care
- According to DOH, many initiatives, globally and locally, help save lives of pregnant
women and children. Essential newborn care (ENC) is one
- Essential newborn care is a simple, cost-effective newborn care intervention that can
improve neonatal as well as maternal care
- It emphasizes a core sequence of actions, performed methodically
- It is organized so that essential time-bound interventions are not interrupted
- It fills a gap for a package of bundled interventions in a guideline format
a) Immediate and thorough drying (Prevent hypothermia, stimulate baby to
cry/breathe)
o Within the first 30 seconds, call out the time of birth, dry the newborn at least 30
seconds, do a quick check of breathing while drying
o Within 0-30 minutes, do not wipe off vernix (provides thermoregulation for
newborn), do not bathe the newborn, do not hang upside down, no squeezing of
chest
b) Early skin-to-skin contact (Prevent infection, allow colonization of maternal flora on
newborn skin)
o Optimal method of maintaining temperature in the stable newborn
o Infants may initially be placed on the mother’s abdomen/chest
o After thorough drying, position the newborn prone, cover the back with sterile
blanket and cover the head with a newborn bonnet
c) Properly timed cord clamping
o Term: 1-3 minutes ; Preterm: 30 seconds-1minute
o Delayed clamping of the umbilical of the umbilical cord has value in reducing the
incidence of anemia in infancy
o Wait for 1-3 minutes or until the pulsation stops before clamping
o Put the clamp 5 cm above the umbilicus and another clamp 2-3 cm above the
umbilicus (Best access of intravenous cannulation)
d) Non separation of newborn to mother for early initiation of breastfeeding
o Leave the newborn to the mother’s chest for early initiation of breastfeeding
o Benefits from successful first breastfeeding include: there will be successful
breastfeeding onwards and release of oxytocin that promotes uterine
contraction to prevent uterine bleeding
Routine Newborn Care
a) Identification of newborn: delivery room and NICU (2 times)
b) Vitamin K prophylaxis: 1 mg IM shortly after birth to prevent hemorrhagic disease of the
newborn. Since the gut flora is still sterile, Vit K is not yet produced after birth so
newborns are at risk for hemorrhage
c) Eye prophylaxis: prevents ophthalmia neonatorum (gonococcal infection)
Erythromycin (good for chlamydia) 0.5% tetracycline sterile ophthalmic
ointments in each lower conjunctival sac
Silver nitrate 1% (can cause chemical conjunctivitis); 2.5% povidone iodine

d) Cord care
e) Bathing: On the 6th hour of life
f) Vaccine: BCG and Hepatitis B

Periods of Reactivity
a) First period of reactivity
o First 15-30 minutes after birth
o Usually alert and attentive/responsive
o Regularly reflect a state of sympathetic discharge
o Irregular respiratory effects and relative tachycardia
o Exhibits spontaneous startle reactions, tremors, bursts of crying, side to side
movements of the head, smacking lips and tremors on the extremities
o Bowel sounds, passage of meconium, saliva production become evident as a
reflection of parasympathetic discharge
o ↑ period on normal premature, term who are ill/stressed delivery
b) Sleep phase
o After the burst of activity, the newborn passes 1-2° period of depressed activity
and sleep
o Newborns are difficult to awaken during this phase
c) Second period of reactivity
o Emerges between 2-6 hours of age with the same motor and autonomic
manifestations same as the first period
o Gagging and vomiting are evident
o Variable duration lasting for 10 mins to several hours
Methods of Heat Loss
a) Evaporation from skin and lungs e.g. thorough drying after delivery
b) Radiation from the infant (warm) to a colder nearby (no contact) object e.g. use of
droplight
c) Conduction from direct heat loss from the infant to the surface with which he/she is in
direct contact e.g. prewarmed cloth/linen use
d) Convection from the infant to the surrounding air e.g. turn off aircon (Ideal aircon
temp: 25-28°C)
Generation of body heat depends in large part of the body weight, but heat loss depends on the
surface area
Compensation to heat loss leads to: Metabolic acidosis, hypoxemia, hypoglycemia, etc.
Therefore, it is important to maintain the body heat of newborns.

AMINOGLYCOSIDES “mycins”
MOA: IRREVERSIBLE inhibitors of protein synthesis
*induce misreading of mRNA  incorrect AA  causes break up of polysomes into non-
functional monosomes

DRUGS
Older aminoglycosides:
Streptomycin
Kanamycin
Newer aminoglycosides:
Gentamycin
Tobramycin
Neomycin
Amikacin
Netilmicin
Sisomicin
Paramomicin
Hygromycin B

*NOTE: Clindamycin is not an aminoglycoside but a separate drug, 50s inhibitor.

COVERAGE
Gram-negative enteric bacteria
Tuberculosis (2nd line tx)
Not active vs anaerobes

CLINICAL USE
✓ Serious, life-threatening G(-) infection
✓ Complicated skin, bone or soft tissue infection
✓ Complicated urinary tract infection
✓ Septicemia
✓ Peritonitis and other severe intra-abdominal infections
✓ Severe pelvic inflammatory disease
✓ Gold std tx: Clindamycin & gentamycin
✓ Endocarditis
✓ Mycobacterium infection
✓ Neonatal sepsis
✓ Ocular infections and otitis externa (topical)
ADVERSE EFFECT/CONTRAINDICATION
ADV: Among elderly, dehydrated patient, those with renal or hearing impairment, and
treatment > 5 days
1. Nephrotoxicity – NGT (Neomycin, gentamycin & tobramycin)
2. Ototoxicity – auditory and vestibular
*auditory – NAK, can’t hear knock knock (neomycin, amikacin, kanamycin)
*vestibular – nakakahilo papuntang SG (streptomycin & gentamycin)
3. Neuromuscular blockade >> respiratory paralysis (neomycin) *antidote: Ca gluconate or
neostigmine
4. CNS – headache, tremors, lethargy, numbness, seizures
5. Blurred vision
6. Rash, urticaria, fever, pain at injection site
7. Diarrhea, nausea/vomiting (paromomycin)
Contraindications: Tinnitus, vertigo, high frequency, hearing loss; Reduced renal function;
Dehydration; Pregnancy and lactation; Infants, elderly

Characteristics: requires oxygen uptake, bactericidal

Structure: Hexose ring either streptidine (streptomycin) or 2-deoxystreptamine (other
aminoglycosides); Amino sugar; Glycosidic linkage
Pharmacokinetics:
- Poorly absorbed from intact GIT except when there’s ulceration
- Entire oral dose excreted in the feces after oral administration
- Highly polar compounds that do not enter cells readily but penetrate inflamed meninges
(20%)
- Water soluble, stable in solution, more active at alkaline than at acid pH
- Synergistic with Beta lactams or vancomycin
- Concentration not high in most tissues even after parenteral administration except the
renal cortex, bile (50%), pleural or synovial fluid (50-90%)
- Excretion: glomerular filtration. Directly proportional to creatinine clearance; feces
(neomycin, paromycin)
- Half life in serum is 2-3 hours, increasing to 24-48 hours in patients with significant
impairment of renal function
- Concentration-dependent killing activity
- Post antibiotic effect
Administered single-daily dosing: As effective and often less toxic, determination of serum
concentration is probably unnecessary, achieves greater post-antibiotic effect
 Caput Succedaneum Cephalhematoma Subgaleal
Hemorrhage
Description Diffuse, ecchymotic, Subperiosteal Collection of blood
edematous swelling hemorrhage
of the soft tissues
Extension Extend across the Limited to the Beneath the
midline and suture surface of 1 cranial aponeurosis that
lines bone covers the scalp and
serves as the
insertion for the
occipitofrontalis
muscle
Pathophysiology Assoc. w/ molding of Becomes a firm tense Secondary to rupture
head and overriding mass with a palpable of emissary veins
of the parietal bones rim localized over 1 connecting the dural
area of the skull sinuses within the
skull with the
superficial veins of
the scalp
Risk Factors Long difficult Forceps delivery; Assoc. w/ vacuum
st
delivery; Large head; 1 assisted delivery
vacuum/forceps pregnancy; difficult
delivery prolonged labor
Resolution 1st few days 2 wk-3mo: calcify by Over 2-3 wk
the end of the 2nd wk
Complications/WOF Hyperbilirubinemia Hyperbilirubinemia; Hypotension,
infection anemia,
hyperbilirubinemia
A. Caput Succedaneum, B. Cephalhematoma
Caput Succedaneum:

Cephalhematoma:
Subgaleal hemorrhage:

INVERTED TRIANGLE OF RESUSCITATION

LANE
Lidocaine
Atropine
Naloxone
Epinephrine
Golden Rule: 30
seconds
CBG indications (5)
1. Preterm
2. SGA
3. IDM
4. LGA
5. Rare medical condition causing hypoglycemia
CBG IDM

At birth 8 hours

30 mins 12 hours

1 hour 24 hours

1 hour 36 hours
and 30
mins

2 hours 48 hours
4

Compute the “corrected age” of preterm infants to compare to normal aged babies:
Early Ballard Score + (age in days/7)

For lung maturity

DEXAMETHASONE
6 mg q 12 x 4 doses (IM)
BETAMETHASONE
12 mg q 24 x 2 doses

Allowable blood loss (weight in kg) (total blood volume) x. 1

Average blood volumes
• Premature Neonates 95 mL/kg
• Full Term Neonates 85 mL/kg
• Infants 80 mL/kg
Normal BILIRUBIN production in NEWBORN: 6-8 mg/kg/day
Estimated Total Bilirubin Level Based on Dermal Affectation:
FACE= 5 mg/dl
CHEST= 10 mg/dl
ABDOMEN= 15 mg/dl
PALMS and SOLES= 20mg/dl

BENEFITS OF BREASTFEEDING:
B-est for Infants
R-educes allergies
E-conomical
A-ntibodies
S-terile
T-emperature is always right
F-resh
E-asily digested
E-motional bonding
D-iarrhea is reduced
I-mmediately available
N-utritionally optimal
G-astroenteritis is reduced

Types of Umbilical Cord

DUBOWITZ: BALLARDS
LUBCHENGCO: SGA, AGA, LGA
BHUTANI: BILIRUBIN
FENTON: PRETERM GROWTH CHART

Normal values:
HR: 120-160 bpm
RR: 30-60 cpm
Temp: 36.5-37.4
HC: 33-38 cm
CC: 30-36 cm
BL: 50 cm (45-55 cm)
BWT Filipino: 3,000 g
*HC > CC – at birth to 6 months
HC = CC – 6 to 12 months
Mother’s Kit
- Suction bulb (orange)
- Gloves
- Container
- Kendall Sterile Water
- Suction tip

MONITORING
Q15: 1st 2 hours
Q30: 2nd 2 hours
Q1: 3rd 2 hours
Q4: After 6 hours

Refer if: (except within 6 hours)

CR: <110 or >160 bpm
RR: <30 or >60 cpm
Temp: <36.5 or >37.4°C
O2S: Preterm < 88%
Term < 95%
*Repeat if deranged; Refer smartly
* Do not write “breastfeeding” on monitoring sheet. Come back after a few minutes.

Criteria for Discharge (Preterm/LBW)

• Taking all nutrition by nipple (bottled/breast)
• Growth with steady increment (30 g/day)
• Wt: 1800 – 2100 g
• No recent episodes of apnea/bradycardia
• Parenteral drug d/c or converted to oral
• All should have hearing test
• Mother’s knowledge, skill, confidence documented
o Administration of medications
o Use of oxygen, apnea monitors, oximeter
o Nutritional support (timing, volume, mixing concentrated formulas)
o Recognition of illness and deterioration
o Basic cardiopulmonary resuscitation
• Stable temperature regulation
• Ophthalmic examination if:
o < 27 weeks AOG
o < 1250 g at birth
ROR (Dilated Fundoscopic Exam) should be performed in the following:
• All infants born ≤ 30 weeks AOG
• Infants born ≥ 30 weeks AOG but with unstable clinical course, including those that
require cardiorespiratory support
• Any infant born weighing <1500 g
Prices:
Hepatitis B vaccine: 800 pesos
BCG vaccine: 500 pesos
Newborn screening (R): 800 pesos (Covered by Philhealth) / (S) 2200 pesos (Expanded newborn
screening)
Otoacoustic emission test (OAE): 700 pesos

JI’s Responsibilities When Catching a Newborn

1. Check the parturient patients from time to time for the status of labor, but not so
frequent.
2. Prepare 2 plastic tackle boxes and 1 steel tray from the red cart. Place it on the newborn
examination table.
3. Make sure sterile cloth is placed on the newborn examination table. Ask the OB nurses.
4. Get droplight from the OB labor room; turn it on and adjust the light facing the sterile
cloth for it to get warm
5. Make sure the wall clock is working.
6. Get pediatric stethoscope beside the red cart. Blue-labeled steth is for baby boy and
pink-labeled steth is for baby girl.
7. From the mother’s box, get the following:
➢ Neonatal suction tube
➢ Long tube
➢ Specimen cup, fill it with sterile water from OB pitcher
➢ O2 humidifier sterile water
➢ Blue plastic knob/connector
➢ 2-3 gloves, sterile depending on the procedure
➢ NSD – 3 gloves (Residents, PGI, JI)
➢ CS – 2 gloves (PGI, JI), resident’s gloves are served by the nurses at the OR
➢ Rubber bulb
8. Prepare the set-up for suction and oxygenation. Turn on the pressure knob of the knob.
Turn on the oxygen to 10-15 lpm.
9. Make sure one JI is left with the mother at the delivery room while other JIs are
preparing.
10. While catching the baby, 1 should be checking the HR every 6 seconds then multiply it
by 10 and announce the HR every time.
11. Assist the resident in EINC (Essential intrapartum and newborn care)
12. After EINC, return/bring all the tools to NICU.
13. Do ROR bilateral
14. Do Ballards scoring every 6th HOL and 12th HOL.
Addendum: For service patients, you can administer Hep B vaccine.
 JUNIOR INTERN RESPONSIBILITIES

PRE-DUTY DUTY FROM

7-4 pm 12 nn Until 12 nn
Sunday & Holidays 8-12nn except Tue & Fri  7am Sundays & Holidays until 12
Sundays & Holidays: 8am nn
➢ Monitoring until 4 pm ➢ Monitoring ➢ Paper works:
➢ Ballards Scoring ➢ Ballards Scoring o SOAP
➢ History and PE (2PM) ➢ History and PE o Update Clinical
➢ Catch: 7am to 3pm ➢ Catch: 3pm to 6am Abstract
CRIB ROUNDS: 7:00 – 7:30AM (Monday)

Monitoring (6am-10am-2pm-10pm-2am-6am)

➢ NICU
o Q15 for the first 2 hours
o Q30 for the next 2 hours
o Q1 for the next 2 hours
o Q4 until may go home
➢ ROOMING IN (Babies staying at their mother’s room)
o Q4
o Monitoring sheet at the chart
* Clean your hands with alcohol before touching the babies

*Saturday- Monitor RIGHT after review (VS at 12 nn)

*If mother refused, go back after 1 hour
*Don’t ever ever forget to monitor the rooming-in babies

BALLARD’S SCORING
➢ PRETERM – at birth, 6 hours after birth, 12 hours after birth
➢ TERM – 6 hours after birth, 12 hours after birth
*Make sure you are guided by your PGIs
*Make sure it is equivalent to the gestational age of the baby, if not, at least close to the
gestational age of the baby
PARTURIENT & CATCH (BABY OUT!!)
➢ Always check for any parturients:
o Update your residents about the internal examination (cervical dilatation,
effacement, bag of water & station)
➢ WHAT TO BRING:
o Large Tackle box (INSIDE: ambubag, meds)
o Small Tackle bos (INSIDE: bonnet, cord clamp, blade)
o Steel Tray (INSIDE: Laryngoscope)
o NICU Stethoscope
➢ WHAT TO DO:
o Prepare the things from the Mother’s kit
• Aquapack (humidifier)
• 3 sterile gloves
• Suction tube
• Small container for sterile water (pitcher from the Delivery Room)
• Tube with white at the end (cut in half, hook ½ at the O2 for the oxygen,
hook the end of the other ½ at the O2, other end at the suction tube
• Set O2 at 5LPM (oxygen), and 20mmHg (suction)
• Suction bulb
o Once at the warmer outside the DR, count the heart rate every 6 secondsx 10,
don’t stop unless the resident tells you to stop
o Check for the red orange reflex
o SERVICE PATIENT: Give Hepa B
PAPER WORKS
➢ NEW PATIENT (PARTURIENT)
SERVICE PAY
- Written History & PE at the - Typewritten history & PE done by
Interdisciplinary/Progress Notes the JI
- Typewritten History & PE
- Newborn Package Consent
- Doctor’s Order (with CR, RR, Temp, HC,
CC, AC, BL, Wt. on the side)
- Newborn Record
- Clinical Abstract
- Lubchengco
- Tagubilin (Home Instructions) – must be
done with the residents – 2 copies

*CONTENTS OF HISTORY & PE

• Birth History – Live, born, term, single, female, delivered via __, APGAR score of __ & __,
Birthweight of __, __ for gestational age
• Neonatal History – Patient was born to a __ year old G_P_ (TPAL)…
• Maternal History – First, Second and Third Trimester
• Outcome
• PE
• Plan (4D’s: Diet, Diagnostics, Drugs, Disposition
*JIIC – typeqritten complete history & PE for the service patient
*Co-JIIC – complete the interdisciplinary/progress notes of the JIIC
* if there is a parturient, start the Neonatal and Maternal History
*Once baby is delivered, write the Birth History, Outcome, PE and Plan
➢ SOAPing
o Make sure it is already finished by 6:30 am
o All Babies must have SOAPING (either service or pay)
o Must have the following: Urine output, Bowel Movement, TCI oral, TFI Oral, TFR,
TFI IV, TCI IV)

➢ CLINICAL ABSTRACT
o Must always be updated!!
 ➢ TAGUBILIN
o By the JIIC or Co-JIIC
o Also write at the Chart
- May go home
- HOME INSTRUCTIONS:
1. Continue milk feeding on demand
2. Burp baby after every feeding
3. Watch out for vomiting, decreased suck, diarrhea, yellow
discoloration of skin, seizure & fever
4. Clean cord daily wit 70% isopropyl alcohol
5. Bathe baby daily
6. Expose baby to sunlight for 15 minutes daily between 6am & 8 am
- Follow up on ___ 1pm at FEU-NRMF OPD Rm 6
Service Team
o Follow up 5-7 days (Tue and Thurs, 1pm at FEU-NRMF OPD Rm 6)

REPORTING
➢ PE of the Newborn
➢ Neonatal Pneumonia
➢ Sepsis
➢ Jaundice
➢ Other Reports assigned by the Residents

WHAT TO STUDY
➢ Essential & Routine Newborn Care
➢ Difference between Breastmilk and Breastfeeding Jaundice
➢ Meconium Staining
➢ Difference between Cephalhematoma & Caput Succedaneum
➢ Types of Umbilical Cord
➢ Cases of the Patients (MUST!! You can only see interesting cases once in a blue moon, so
might as well study them! It’s for your own good)
➢ Review the compiled notes

*Don’t be afraid to ask questions from Pedia Residents! ☺

DRUGS FOR RESUSCITATION AND ARRHYTHMIAS

ADENOSINE 0.1 mg/kg (max 6mg)

repeat: 0.2 mg/kg
AMIODARONE 5mg/kg IV/IO
ATROPINE 0.02 mg/kg/IO
0.03 mg/kg IV/IO
Max Dose: (Child: 0.5 mg; adolescent 1 mg)
CALCIUM CHLORIDE 20 mg/kg/IV/IO (0.2 ml/kg)
EPINEPHRINE 0.01 mg/kg IV/IO
0.1 mg/kg ET
Max dose: 1 mg IV/IO
GLUCOSE 0.5- 1q/kg/IV/IO
LIDOCAINE Bolus (1mg/kg/IV/IO)
Max Dose: 100mg
2-3 mg ET
MAGNESIUM SULFATE 25-50 mg/kg/IV/IO over 10-20 min
Max Dose: 2g
NALOXONE </= 5 y/o: or </= 20 kg: 0.1 mg/kg/IV/IO ET
PROCAINAMIDE 1 mEq/kg/dose IV/ IO slowly

JI CONARCO/ JI FONACIER/ JI MANUEL/

PGI FUGGAN/ PGI LIMBO
JULY 2018 ROTATION PEDIA