Identification of a sick child and its further management is the key to success in sick neonates.......Ppt for Pediatricians & neonatologist

1. Identification, Management & Referral of a
Sick Neonate
Dr.Mahesh Hiranand
M.D
Mamta child health care ce

2. My Perspective
Your perspective

3. Who is a Pediatric Practioner ?Who is a Pediatric Practioner ?
* One doing OPD & attends to occasional* One doing OPD & attends to occasional
sick newborn babies.sick newborn babies.
* Attached to a maternity home, attends* Attached to a maternity home, attends
RES calls & refers if sick .RES calls & refers if sick .
* Actively attends RES calls ,manages in* Actively attends RES calls ,manages in
a specialized unit rarely refers.a specialized unit rarely refers.

4. Load of sick neonates in the region
Crude birth rate 22.8/1000 (2007)
Population 16 Lacs
Total live birth 36000
* TBA/ANM/Dai delivered.
* GH-16.
* PGIMER.
* GMCH.
* GH Mohali & Pkl .
* ESI hosp, Polyclinics.
* Approx 50 private maternity centers.

5. * A max of 50 NICU beds to cater to a* A max of 50 NICU beds to cater to a
population of 3 million.population of 3 million.
* At best 4 high level-II(>150/yr) & 6 basic* At best 4 high level-II(>150/yr) & 6 basic
level-II(<100/yr) NICU’s.level-II(<100/yr) NICU’s.
* Ventilation facilities(15 vents) complete with* Ventilation facilities(15 vents) complete with
laboratory, radiology & central oxygenlaboratory, radiology & central oxygen
atat
4 units.4 units.
* 15 Pediatricians trained in neonatology for* 15 Pediatricians trained in neonatology for
3-24 months provide this care.3-24 months provide this care.
Current status of newborn care inCurrent status of newborn care in
Tri-cityTri-city

6. A max of 50 NICU beds ( 2008)
Up from 6-8 beds (1995)

7. 4 high level-II & 6 basic level-II NICU’s

8. Ventilation facilities(15) complete with
Central O2,lab & radiology at 4 centers.

9. 15 Pediatricians trained in
Neonatology (3-24 mths)

10. Which one of them is really sick ??Which one of them is really sick ??

11. Sickness markers in a newbornSickness markers in a newborn
Refusal to feed Difficulty waking upRefusal to feed Difficulty waking up
Labored breathing Abnormal jerksLabored breathing Abnormal jerks
Urine voiding <6 Fewer than 2 stoolsUrine voiding <6 Fewer than 2 stools
Yellow color Blue or pale skinYellow color Blue or pale skin
Distended abdomen Projectile vomitingDistended abdomen Projectile vomiting

12. Physical signs that denote troublePhysical signs that denote trouble
Tachypnoea Grunting ApnoeaTachypnoea Grunting Apnoea
Bradycardia Cyanosis MurmurBradycardia Cyanosis Murmur
Plethora Pallor JaundicePlethora Pallor Jaundice
Hypotension Petechiae HypotoniaHypotension Petechiae Hypotonia

13. Signs of sicknessSigns of sickness
What is a desirable clinical signWhat is a desirable clinical sign
– Singly or in combination, must have modest PPVSingly or in combination, must have modest PPV
Should score overShould score over “looks unwell”, “gut feeling”“looks unwell”, “gut feeling”
– Must not be infrequentMust not be infrequent
– There should be 2 sets of signsThere should be 2 sets of signs
Predictors of sickness/sepsis , ie need for referralPredictors of sickness/sepsis , ie need for referral
Predictors of moratlityPredictors of moratlity

14. Signs in PGI NICUSigns in PGI NICU
0 10 20 30 40 50 60
Grunt
Abd dist
Aspirates
Tachycardia
Fever
Retractions
Lethargy
Apnea
Unwell look
Tachypnea
Not feeding
Temp<35.5
PPV Frequency
Singh, Dutta, Narang et al, J Trop Ped, 2003
These 7
signs had
PPV >30%

15. How does that help my practice?How does that help my practice?
Good predictors ofGood predictors of
sickness & sepsis:sickness & sepsis:
– Lethargy,Lethargy,
↓↓ feeding,feeding,
– fever,fever,
– retract’sretract’s
↓↓ movem’ts,movem’ts,
– abd distension,abd distension,
– tachypneatachypnea
• Good predictors of
mortality
• Hypotension
• Hypothermia
• Hypoxemia
• Acidemia
• Multiple seizures
• Oliguria
• ELBW
• SGA
• Asphyxia

16. Commonest neonatal problemsCommonest neonatal problems
* Prematurity & low birth weight.* Prematurity & low birth weight.
* Suspected & manifest sepsis.* Suspected & manifest sepsis.
* Birth asphyxia.* Birth asphyxia.
* Respiratory problems.* Respiratory problems.
* Neonatal hyperbilirubinemia.* Neonatal hyperbilirubinemia.
* Metabolic problems: Hypoglycemia.* Metabolic problems: Hypoglycemia.
* Surgical problems.* Surgical problems.
* Congenital malformations.* Congenital malformations.

17. Care of newborn in a Maternity homeCare of newborn in a Maternity home
Myth-1: Providing primary careMyth-1: Providing primary care
to a newborn is expensive.to a newborn is expensive.
Myth-2: Highly qualified andMyth-2: Highly qualified and
trained nurses are essential.trained nurses are essential.
Myth-3: Pediatrician can beMyth-3: Pediatrician can be
called if the baby is born sick.called if the baby is born sick.
Fact: It is cheaper thanFact: It is cheaper than
creating a setup for D & C.creating a setup for D & C.
Fact: Unqualified staff & mothersFact: Unqualified staff & mothers
can be trained to look after acan be trained to look after a
sick baby under supervisionsick baby under supervision
Fact: Its all over… Asphyxia is aFact: Its all over… Asphyxia is a
lethal game of 5 mins.lethal game of 5 mins.

18. Is the welfare of newborn responsibility of a Pediatrician alone
Lets lobby for the respectful survival of fetus
Integration of maternity & neonatal health care
Services is the most desired need of the hour..

19. Good antenatal care

20. Good Resuscitation facility

21. Early & exclusive breast feeding

22. Compassionate nursing

23. Neonatal ResuscitationNeonatal Resuscitation
** “ Pediatrician On call ” concept must go .“ Pediatrician On call ” concept must go .
NRP GuidelineNRP Guideline
““ Well trained personnel must be present atWell trained personnel must be present at
the site of Infant delivery. ”the site of Infant delivery. ”
Preparation & anticipation is the key.Preparation & anticipation is the key.
Identify & train the right personnel.Identify & train the right personnel.
What is the cost of creating aWhat is the cost of creating a

24. Rs.30000/
Rs.3000/
Rs.15000/
Total cost
Rs.50000/
Cost of a complete resuscitation trolley
??????

25. Things to avoid in Resuscitation
* Do not overdo the suction… its noxious.
* Donot panic if ET cant be put in… Bag & Mask
* Avoid high O2 conc to resuscitate a
premmy.
•Be gentle on the Ambu… TV of 250 v/s 35 ml.

26. Things to avoid in Resuscitation
Sod bicarbonate is reserved for specific use.
Donot give volume expanders casually.
Do not focus heavily on cardiac resuscitation.
No role of steroids, Calcium, Coramine etc.

27. Birth AsphyxiaBirth Asphyxia
A baby born asphyxiatedA baby born asphyxiated
???? Guilt & FEAR???? Guilt & FEAR
* 1-2 % incidence at best Delivery rooms.* 1-2 % incidence at best Delivery rooms.
* Term IDM’s , IUGR , Breech & Post date.* Term IDM’s , IUGR , Breech & Post date.
* Incorrect reporting of APGAR scores.* Incorrect reporting of APGAR scores.

28. Birth AsphyxiaBirth Asphyxia
Non Funct ioningNon Funct ioning
equipmentequipment
&&
AnAn
I ncompet ent / MissingI ncompet ent / Missing
Resuscit at orResuscit at or

29. Organ dysfunction in AsphyxiaOrgan dysfunction in Asphyxia
BrainBrain : HIE manifests as gamut of signs.: HIE manifests as gamut of signs.(100%)(100%)
Seizures are seen in upto 50% cases.Seizures are seen in upto 50% cases.
Raised ICP indicates poor prognosis.Raised ICP indicates poor prognosis.
PulmonaryPulmonary : PPHN, MAS, Edema & RDS: PPHN, MAS, Edema & RDS(85%)(85%)
KidneyKidney : ATN seen in upto 70%: ATN seen in upto 70% OLIGURIAOLIGURIA
HeartHeart : TR, Poor LV function & PAH: TR, Poor LV function & PAH (60%)(60%)
GI SysGI Sys : Bowel ischemia & NNEC: Bowel ischemia & NNEC (15%).(15%).
Hematologic & Hepatic effectsHematologic & Hepatic effects

30. Management of AsphyxiaManagement of Asphyxia
Identify & keep a close watch on all HRPs.Identify & keep a close watch on all HRPs.
Involve the Pediatrician during ANPInvolve the Pediatrician during ANP
Meticulous intrapartum monitoring.Meticulous intrapartum monitoring.
Perinatal team on standby 24X7.Perinatal team on standby 24X7.

31. Management of AsphyxiaManagement of Asphyxia
At BirthAt Birth : Prevent hypothermia by all means.: Prevent hypothermia by all means.
Minimize hypoxia & assess acidosis.Minimize hypoxia & assess acidosis.
NICUNICU : Judicious FLUID …. Do not overload.: Judicious FLUID …. Do not overload.
Smooth Ventilation & Oxygenation.Smooth Ventilation & Oxygenation.
Seizure control using all modalities.Seizure control using all modalities.
Phenobarbitone--Pheytoin--MidazolamPhenobarbitone--Pheytoin--Midazolam
W/F : Raised ICP, Oliguria Cardiac dys & PPHNW/F : Raised ICP, Oliguria Cardiac dys & PPHN

32. Neonatal SepsisNeonatal Sepsis
* Neonatal sepsis is a major killer. ( 52% mort)* Neonatal sepsis is a major killer. ( 52% mort)
SUSPECT DIAGNOSE MANAGESUSPECT DIAGNOSE MANAGE
Early onsetEarly onset Birth canalBirth canal Late onsetLate onset EnvironmentEnvironment
Risk factors:Risk factors: Prematurity,POL/PROM>24 hrsPrematurity,POL/PROM>24 hrs
Freq P/V, cervical sutures etcFreq P/V, cervical sutures etc
Maternal infections UTI,Diarrhoea.Maternal infections UTI,Diarrhoea.
Asphyxia & Meconium aspirationAsphyxia & Meconium aspiration
Late onsetLate onset Preterm,Prolonged IV/ AntibioticsPreterm,Prolonged IV/ Antibiotics
CommunityCommunity acquiredacquired Poor hygiene, bottle feeding, overcrowdingPoor hygiene, bottle feeding, overcrowding

33. Neonatal SepsisNeonatal Sepsis
Microbiology:Microbiology: How often do you identify the bug.How often do you identify the bug.
Manifestations:Manifestations:
Early signs are subtle noted by mother/nurse.Early signs are subtle noted by mother/nurse.
““Looking unwell”.......Looking unwell”....... Cold mottled limbsCold mottled limbs
Resp dist,Poor feeding,Vomiting & Full abdResp dist,Poor feeding,Vomiting & Full abd
Lethargy, Irritability & Temp instability.Lethargy, Irritability & Temp instability.
Fulminant sepsisFulminant sepsis
Cyanosis, Apnoea, Seizures, Bleeding &ScleremaCyanosis, Apnoea, Seizures, Bleeding &Sclerema
Vague symptomsVague symptoms  Low thresh hold for sepsisLow thresh hold for sepsis

34. Sepsis EvaluationSepsis Evaluation
““No sure shot test to document sepsis”No sure shot test to document sepsis”
CBC :CBC : TLC <5000/TLC <5000/mm3mm3 ANC > 1750/ANC > 1750/mm3mm3
I/T ratio ( >0.2) Band cells > 2000/I/T ratio ( >0.2) Band cells > 2000/mm3mm3
Platelet count low in 25 % .Platelet count low in 25 % .
Blood culture :Blood culture : Gold standard for sepsisGold standard for sepsis
Ideal volumeIdeal volume 1 ML1 ML (63-(63-
98%)98%)
Ideal timeIdeal time 48 hrs48 hrs (97%)(97%)

35. Acute phase reactants :Acute phase reactants :
CRP is the most studied & reliableCRP is the most studied & reliable
Levels of more than 10mg/dl suggest sepsis.Levels of more than 10mg/dl suggest sepsis.
Daily serial values are 80-90% sensitiveDaily serial values are 80-90% sensitive Bentz 1998Bentz 1998
uESR in service for past 50 years.uESR in service for past 50 years.
Upper limit = Age in days + 3 mm/hr.Upper limit = Age in days + 3 mm/hr.
Poor & variable sensitivity of 30-70%.Poor & variable sensitivity of 30-70%.
Sepsis screen is a combination of tests for rapid diagnosis of sepsisSepsis screen is a combination of tests for rapid diagnosis of sepsis
TLC/ANC, I/T ratio, CRP & uESRTLC/ANC, I/T ratio, CRP & uESR
11 rpt at 24 hrs 2rpt at 24 hrs 295% sen 395% sen 3 Presume sepsis+Presume sepsis+

36. Treatment of Neonatal SepsisTreatment of Neonatal Sepsis
Decision to Treat:Decision to Treat: Risk factors, Clinical signsRisk factors, Clinical signs
Results of sepsis screen.Results of sepsis screen.
Choice of Antibiotics :Choice of Antibiotics : ? Vanco? Vanco ? Merop? Merop Piper?Piper?
Is it fashionable to use newer antibiotics only?Is it fashionable to use newer antibiotics only?
Organism Sensitivity ExperienceOrganism Sensitivity Experience
Empirical therapyEmpirical therapy Ampicillin+ Aminogly / IIICephaloAmpicillin+ Aminogly / IIICephalo
IV & IV not IMIV & IV not IM Co-amoxy + III CephaloCo-amoxy + III Cephalo
Duration of ABs:Duration of ABs: Level of suspicion of sepsisLevel of suspicion of sepsis
Diagnostics & Cl course.Diagnostics & Cl course.

37. Treatment of Neonatal Sepsis
Decision to treat : Risk factors, Clinical
picture
Results of sepsis screen.
Choice of Antibiotics: ? Vanco ?Merop ? Piper
Organism Sensitivity Experience
Empirical therapy Ampicillin + AminoG/Cephalo III
Coamoxyclav + Cephalo III
Duration of antibioticsLevel of suspicion of sepsis

38. JAUNDICE IN NEW BORNJAUNDICE IN NEW BORN
BABIESBABIES
Yellow discolouration of skin ,eyes & mucosaYellow discolouration of skin ,eyes & mucosa
Adults appear icteric at 2Mg & neonate at 7 mg%Adults appear icteric at 2Mg & neonate at 7 mg%
PHYSIOLOGICAL PATHOLOGICALPHYSIOLOGICAL PATHOLOGICAL
* Almost 100% develop* Almost 100% develop.. * 10% develop.* 10% develop.
* Appears 48hrs,peaks 72hrs* Appears 48hrs,peaks 72hrs.. * Early onset, delayed peak* Early onset, delayed peak
* Light staining* Light staining * Deeper staining* Deeper staining
* No Rx needed* No Rx needed.. * Phototherapy/Exchange* Phototherapy/Exchange
Which babyWhich baby is headingis heading towards pathological Jaundice ?towards pathological Jaundice ?

39. ASSESSMENT OF SEVERITYASSESSMENT OF SEVERITY
OF JAUNDICEOF JAUNDICE
Examine all babies every 36-48hrly till Day7.Examine all babies every 36-48hrly till Day7.
Assess Jaundice in good day light.Assess Jaundice in good day light.
Jaundice progresses in Cephalo-caudal direction.Jaundice progresses in Cephalo-caudal direction.
Staining below knee/Wrist corresponds to high TSBStaining below knee/Wrist corresponds to high TSB
Skin assessment could be fallacious after PT.Skin assessment could be fallacious after PT.

40. IS
Physical
Exam
For
Jaundice
Reliable ?

41. When in Doubt …… Always ask for a TSBWhen in Doubt …… Always ask for a TSB
Bare minimum Lab analysisBare minimum Lab analysis
TSB, Blood group, Rh typing & Coombs*TSB, Blood group, Rh typing & Coombs*
Blood film, Reticulocyte, G6PD & PCV.Blood film, Reticulocyte, G6PD & PCV.
Prolonged Jaundice( >2weeks)Prolonged Jaundice( >2weeks)
Direct Bilirubin, thyroid functions, urine c/sDirect Bilirubin, thyroid functions, urine c/s
TORCH analysis, Metabolic screenTORCH analysis, Metabolic screen
Liver function test & Ultrasound abdomenLiver function test & Ultrasound abdomen

42. Neonatal HyperbilirubinemiaNeonatal HyperbilirubinemiaTreatment of Neonatal Hyperbilirubinemia
Depends upon weight, gestation,TSB & level of sickness.
Phototherapy
Effective modality to treat levels upto 20 mg%.
Types: Double surface, CFL, LED, Biliblanket.
Ideal distance 15-30cms Irradiance > 10uw/cm2.
Tough to maintain temperature in winters.
Skin assessment fallacious, repeat TSB 12 hrly.
When to stop PT  Term at 13 & preterm at 10mg.
Maintain Hydration & nutrition for better results.
Discourage Home PT ,Sun therapy & Luminal.

43. Exchange Transfusion For Jaundice
Exchange Transfusion in a term at TSB> 25mg%.
Fresh blood (<7ds), 160ml/kg in CPD used.
IV line secured for glucose, Calcium & other drugs.
Exchange aliquots <1.5kg--5ml 1-5 to 2-5kg--10ml
TSB & PCV done at 4Hrs, Intensive PT to continue.
W/F Hypocalcemia, hypoglycemia & hyperkalemia

44. Whats new For babies with Jaundice…
Oral Agar
Effective in term breast/formula fed
babies with TSB>15mg. Economical
and shortens the duration of PT.
High dose IVIg
O.5-1gm/kg used in Iso immune
hemolysis. Acts by coating the Fc rec.
Metalloporphyrins
Tin/Zinc porphy inhibit heme
oxygenase
used in ABO & Criggler najar synd.

45. Respiratory Distress SyndromeRespiratory Distress Syndrome
Commonest & most feared problem in NICUCommonest & most feared problem in NICU
““ Preterm boy born by LSCS to Diabetic motherPreterm boy born by LSCS to Diabetic mother
developing Asphyxia”developing Asphyxia”
Prenatal DiagnosisPrenatal Diagnosis
* L/S ratio * Lamellar body count* L/S ratio * Lamellar body count
Antenatal steroidsAntenatal steroids
Betamethasone(2) or Dexamethasone(4) to allBetamethasone(2) or Dexamethasone(4) to all
mothers between 24-34 wks with intact membsmothers between 24-34 wks with intact membs
Incidence falls by 50%, Mortality by 40%.Incidence falls by 50%, Mortality by 40%.

46. Respiratory SupportRespiratory Support
Most premmies with RDS need resp support.Most premmies with RDS need resp support.
Oxygen therapyOxygen therapy
* RR>60,retractions, Flare,grunting & low* RR>60,retractions, Flare,grunting & low
spo2spo2
* Warm & humidified O2 to maintain* Warm & humidified O2 to maintain Spo2 90-95%Spo2 90-95%
* Head box, nasal prongs/catheter…* Head box, nasal prongs/catheter… WAFTINGWAFTING
* Warmidifiers & O2 concentrators* Warmidifiers & O2 concentratorsReliableReliable
Flow rates : Head box (3lit) Prongs( 1-2lit)Flow rates : Head box (3lit) Prongs( 1-2lit)
NP catheter (1lit)NP catheter (1lit)

47. Surfactant Replacement TherapySurfactant Replacement Therapy
Best studied therapy – Is almost a miracle Rx.Best studied therapy – Is almost a miracle Rx.
Billions of bubbles created by SURF inflates the lungs.Billions of bubbles created by SURF inflates the lungs.
* Type :* Type : Natural preferred over syntheticNatural preferred over synthetic
* Timing :* Timing : Prophylactic- Given soon after birth.Prophylactic- Given soon after birth.
Early rescue- Given as distress setsEarly rescue- Given as distress sets
* Dose :* Dose : 100mg/kg through an ET tube.100mg/kg through an ET tube.
* Effects :* Effects : Inflates lung & improves oxygenationInflates lung & improves oxygenation
Reduces risk of air leaks & early recoveryReduces risk of air leaks & early recovery

48. Respiratory SupportRespiratory Support
How do you assess worsening RDS….How do you assess worsening RDS….
Clinical scoring, Spo2, Blood gases, XrayClinical scoring, Spo2, Blood gases, Xray
FiO2 levelsFiO2 levels
Also look at Perfusion, BP & urine output.Also look at Perfusion, BP & urine output.
What can you do before this baby crashes…What can you do before this baby crashes…
CPAPCPAP
Halts progression, Less barotraumaHalts progression, Less barotrauma
Noninvasive, easy to use & avoids IMVNoninvasive, easy to use & avoids IMV
MethodMethod Nasal, Nasopharyngeal & ETNasal, Nasopharyngeal & ET

49. Respiratory SupportRespiratory Support
CPAPCPAP DisadvantagesDisadvantages
* Doesnot improve ventilation infact worsens it.* Doesnot improve ventilation infact worsens it.
* Hypercarbia & impaired cardiac output .* Hypercarbia & impaired cardiac output .
* Maintaining it in a large child difficult.* Maintaining it in a large child difficult.
Mechanical VentilationMechanical Ventilation
* Amazing range of neonate specific ventilators.* Amazing range of neonate specific ventilators.
* Goal is to limit TV & Ti, avoid collapse & wean.* Goal is to limit TV & Ti, avoid collapse & wean.
* SIMV is the preferred mode of ventilation.* SIMV is the preferred mode of ventilation.

50. Meconium Aspiration SyndromeMeconium Aspiration Syndrome
* MSAF is seen in upto 10-15% live births* MSAF is seen in upto 10-15% live births
* Postmature, SGA, Presentation & CORD* Postmature, SGA, Presentation & CORD
Can MAS be prevented ??Can MAS be prevented ??
Intrapartum monitoring AmnioinfusionIntrapartum monitoring Amnioinfusion
Should all infants be subjected to NP/TRAC SuctionShould all infants be subjected to NP/TRAC Suction
PPHN the most feared complication.PPHN the most feared complication.
Rx : Mag sulph, ??Oral viagra , HFV & iNORx : Mag sulph, ??Oral viagra , HFV & iNO
Prolonged O2 dependence is common.Prolonged O2 dependence is common.

51. Extremely Low birth weight baby ( < 1000grams)
Unique group , Fragile & sensitive to changes .
Standard management protocols ensures good results.
Collobrative efforts between HRP & Level 3 NICU teams.
What is a viable Micropremmy ??????
> 23 weeks > 500 Grams
Never Ever Give Up On Them
How Invasive One should be while caring for a ELBW

52. Extremely Low Birth Weight Infant
Minimum procedures & handling is the key.
Challenge to manage ROP in an ELBW baby.
Course of stay always stormy & eventful.
Maintaining prolonged IV access a problem.
Morbidity Mortality Parental concern COST

53. 26 weeks 475 gms Survived Intact Thriving
Minimum handling
Bare essential tests
Early trophic feeds
Meticulous monitoring
Non invasive Neonatology
Nano Baljeet

54. ELBW – Standard Care Protocol
Prenatal Consultation
Parental education & participation .
Resuscitation
Define limits Minimize heat losses Early SRT & Resp suppt.
Ventilation strategy
Low TV short Ti Avoid Hyperoxia & Hypocapnia
Fluid therapy
Limit losses Restrict boluses Maintain Electrolytes I/O
Nutrition
Early trophic feeds & TPN
Patent ductus arterious
Avoid fluid overload Early medical Treatment
Infection Control
Meticulous hand washing Limit invasive handling

55. Cost of careCost of care
““ The average cost of treatment per baby per dayThe average cost of treatment per baby per day
In a high level-II NICU is around Rs. 3000-5000/.In a high level-II NICU is around Rs. 3000-5000/.
Additional cost for ventilation is around Rs. 3000/.”Additional cost for ventilation is around Rs. 3000/.”
** Infrastructure * Equipment * Nursing careInfrastructure * Equipment * Nursing care
* Drugs & Disposables * Oxygen * Laboratory* Drugs & Disposables * Oxygen * Laboratory
* Biomedical waste * Power backup * Security* Biomedical waste * Power backup * Security
* Insurance * Staff * Repairs * Taxes* Insurance * Staff * Repairs * Taxes

56. Which baby may be referred?Which baby may be referred?
Who needs continuous electronic monitoringWho needs continuous electronic monitoring
– HR, SpOHR, SpO2,2, BP, CVPBP, CVP
Who requires investigations that areWho requires investigations that are
– Either too specialized (eg. metabolic, endocrine, etc)Either too specialized (eg. metabolic, endocrine, etc)
– Or need physical presence of baby (neuro-imaging, EEG,Or need physical presence of baby (neuro-imaging, EEG,
advanced radiology, pathology etc)advanced radiology, pathology etc)
Who requires specialized evaluationWho requires specialized evaluation
– Uncertain diagnosisUncertain diagnosis
– Specialized opinion (Genetics, Hemat, Neuro, Cardiac etc)Specialized opinion (Genetics, Hemat, Neuro, Cardiac etc)
Who needs specialized interventionWho needs specialized intervention
– TPNTPN
– VentilationVentilation
– InotropesInotropes
– Invasive procedures (chest drain etc)Invasive procedures (chest drain etc)

57. Who should not be referred?Who should not be referred?
Babies >1500 g, but fairly problem-freeBabies >1500 g, but fairly problem-free
Birth asphyxia with no Stage II-III HIE orBirth asphyxia with no Stage II-III HIE or
end-organ damageend-organ damage
All unconjugated jaundiceAll unconjugated jaundice
– Exceptions: Rh isoimmunized or hydropic orExceptions: Rh isoimmunized or hydropic or
kernicterickernicteric
Sepsis with no resp/hemodynamic/renalSepsis with no resp/hemodynamic/renal
compromise & no organ dysfunctioncompromise & no organ dysfunction

58. Things to do before referringThings to do before referring
Stabilize for transportStabilize for transport
Write a detailed referral summaryWrite a detailed referral summary
Talk to receiving consultantTalk to receiving consultant
Talk to familyTalk to family

59. StabilizationStabilization
S= SugarS= Sugar
– Ensure BS is well above lower cut-offEnsure BS is well above lower cut-off
T= TemperatureT= Temperature
– Euthermic. No cold stress.Euthermic. No cold stress.
A= Airway patentA= Airway patent
– Clear secretions, ensure correct position, intubate if necessaryClear secretions, ensure correct position, intubate if necessary
B= Blood testsB= Blood tests
– Ensure all reports, incl. Xrays attachedEnsure all reports, incl. Xrays attached
– Pending reports (eg. blood culture) mentionedPending reports (eg. blood culture) mentioned
L= Lines & tubes fastenedL= Lines & tubes fastened
– IV canulas, OG tubes, ET tubes well fastenedIV canulas, OG tubes, ET tubes well fastened
– Write whether tubes repositioned after last XrayWrite whether tubes repositioned after last Xray
E= Emotional supportE= Emotional support

60. It is unfair to send a
moribund patient to
an institution just to
get rid of the patient
before death

61. Talking to familyTalking to family
Do not give false hopesDo not give false hopes
– जातेजाते हीही बेडबेड िमिलिमिल जाएगाजाएगा
– जैसेजैसे हीही मिशीनमिशीन मिेमिे डालेगेडालेगे सबसब ठीकठीक होहो जाएगाजाएगा
Do not create impression that everythingDo not create impression that everything
is free & everyone can be made “pooris free & everyone can be made “poor
free” in government hospitalsfree” in government hospitals
Give realistic idea of prognosisGive realistic idea of prognosis
Keep channels open for back referralKeep channels open for back referral

62. ConclusionsConclusions
Think before you referThink before you refer
– A lot of problems can be tackled locallyA lot of problems can be tackled locally
Certain clinical signs are better predictorsCertain clinical signs are better predictors
of sickness & death than othersof sickness & death than others
Stabilize patients before referralStabilize patients before referral
Communicate with receiving consultant &Communicate with receiving consultant &
with familywith family
Make comprehensive referral summaryMake comprehensive referral summary

63. My Special Thanks to
Dr. Sourabh Dutta Add Professor,
Neonatology , PGIMER, Chandigarh
Nestle Nutrition services .
My Staff at Mamta child health care centre
Cosmo Hospital Mohali
All the lil babies that we have cared for…………

64. Thanks for your attention

67. All Sickly newborns deserve
an ambulance like this one.

68. Good resuscitation facility

69. VLBW babies with susp. sepsisVLBW babies with susp. sepsis
Fanaroff, PIDJ, 1998
0 20 40 60
Apneas*
GI problems
Increased O2*
Increased vent*
Feed intol.
Lethargy*
Temp instab
Hypotension*
Frequency
PPV
*= p<0.05

72. Transport of a sick Neonate
“ The best transport incubator is the uterus”
Within the city (upto 20 kms)
Round the clock equipped & staffed
ambulance avialable at Rs.2000/.
Outside the city (up to 50 kms)
Facility available at Rs.5000/
“ Any takers for developing this facility a lil
further”

74. Need for referralNeed for referral
* Referrals are seldom made by the practioners.* Referrals are seldom made by the practioners.
* Lack of trust in the treating team ….* Lack of trust in the treating team ….
* More often financial compulsions.* More often financial compulsions.
* Surgical problem with medical presentation.* Surgical problem with medical presentation.
* Suspected cardiac lesion.* Suspected cardiac lesion.

75. Referral by the primary CaretakerReferral by the primary Caretaker
* Communicate the need for transfer.* Communicate the need for transfer.
* Notify the referral hospital.* Notify the referral hospital.
* Arrange for safe transport.* Arrange for safe transport.
* Detailed referral note attached.* Detailed referral note attached.
* Follow up the progress of baby.* Follow up the progress of baby.
Referral against adviseReferral against advise
* Liability of Rx details & transport.* Liability of Rx details & transport.
* Should clearance of bill be made an issue?* Should clearance of bill be made an issue?

77. PrematurityPrematurity
* VLBW may survive HMD to get NEC at 5 weeks.* VLBW may survive HMD to get NEC at 5 weeks.
* To manage severe ROP in VLBW is a challenge.* To manage severe ROP in VLBW is a challenge.
* Minimum procedures, sampling & handling is the key.* Minimum procedures, sampling & handling is the key.
* Maintaining prolonged IV access is a problem.* Maintaining prolonged IV access is a problem.

78. Neonatal jaundiceNeonatal jaundice
Exchange transfusion at TSB> 24mg%.Exchange transfusion at TSB> 24mg%.
CFL phototherapy is the most effective.CFL phototherapy is the most effective.
TSB at 24 hrs age a reliable indicator.TSB at 24 hrs age a reliable indicator.
Are you checking the photo irradiance ??.Are you checking the photo irradiance ??.

79. * A max of 50 NICU beds to cater to a* A max of 50 NICU beds to cater to a
population of 3 million.population of 3 million.
* At best 4 high level-II(>150/yr) & 6 basic* At best 4 high level-II(>150/yr) & 6 basic
level-II(<100/yr) NICU’s.level-II(<100/yr) NICU’s.
* Ventilation facilities(15 vents) complete with* Ventilation facilities(15 vents) complete with
laboratory, radiology & central oxygenlaboratory, radiology & central oxygen
atat
4 units.4 units.
* 15 Pediatricians trained in neonatology for* 15 Pediatricians trained in neonatology for
3-24 months provide this care.3-24 months provide this care.
Current status of newborn care inCurrent status of newborn care in
Tri-cityTri-city

80. Transport of the sick neonateTransport of the sick neonate
““ The best transport incubator is the uterus ”The best transport incubator is the uterus ”
Within the city( up to 20kms)Within the city( up to 20kms)
* Round the clock ambulances equipped* Round the clock ambulances equipped
and staffed available at Rs.2000/ (3).and staffed available at Rs.2000/ (3).
Outside the city( up to 50 kms)Outside the city( up to 50 kms)
* Facility available at Rs.5000/.* Facility available at Rs.5000/.
Any takers for developing this facility aAny takers for developing this facility a
lil furtherlil further

81. Role of ObstetriciansRole of Obstetricians
““Is welfare of a Newborn responsibility of PediatricianIs welfare of a Newborn responsibility of Pediatrician
alone”alone”
Lets lobby for the right of fetus for a respectful survivalLets lobby for the right of fetus for a respectful survival
All that it takes is :All that it takes is :
* Good antenatal care * Provision of asepsis* Good antenatal care * Provision of asepsis
* Adequate feeding* Adequate feeding
Integration & coordination of Maternity homes &Integration & coordination of Maternity homes &
Level-II neonatal care is the most desired needLevel-II neonatal care is the most desired need

82. PHOTO LUX METER
It measures luminance of light.
Reliable & inexpensive.
1uw/cm2/nm = 600 lux

83. Please appreciate the baby’s struggle inside a head box

84. Non contact Oxygen deliveryNon contact Oxygen delivery
* Wafting : Aiming stream of O2 at the patient.* Wafting : Aiming stream of O2 at the patient.
to produce initial relief & enablingto produce initial relief & enabling
child to sleep hence allowing furtherchild to sleep hence allowing further
management.management.
* Efficacy of wafting O2 therapy not quantified.* Efficacy of wafting O2 therapy not quantified.
* Methods : Resuscitator bag, Baby face mask* Methods : Resuscitator bag, Baby face mask
standard green oxygen tubing.standard green oxygen tubing.

85. A novel & cost effective O2 delivery methodA novel & cost effective O2 delivery method
““ A twin holed feeding tube directing a streamA twin holed feeding tube directing a stream
of O2 at the nostrils is a very effective ,easyof O2 at the nostrils is a very effective ,easy
and affordable step down O2 delivery method”and affordable step down O2 delivery method”
Indications:Indications:
1. Prolonged O2 dependence as in MAS1. Prolonged O2 dependence as in MAS
Cong Pneumonias & HMD.Cong Pneumonias & HMD.
2. In children who do not tolerate mask, prongs2. In children who do not tolerate mask, prongs
or even head box.or even head box.
““IT saves on the cost of Oxygen”IT saves on the cost of Oxygen”

86. Venous access in difficult situation
Focus a halogen lamp
On cannulation site for
3-5 mins to produce
Warming & venodilatation.

88. Infusates & Antibiotics:Infusates & Antibiotics:
Never use the top port for injections.Never use the top port for injections.
Antibiotics/Injections are diluted appropriately.Antibiotics/Injections are diluted appropriately.
““Reverse injections”Reverse injections”
Daily dose of antibiotics & other drugsDaily dose of antibiotics & other drugs
are injected through a 3- way connectorare injected through a 3- way connector
in reverse direction towards the Pediatricin reverse direction towards the Pediatric
Infusion set and later drip is restarted. ThisInfusion set and later drip is restarted. This
ensures a uniform slow rate of antibioticensures a uniform slow rate of antibiotic
delivery thus preventing thrombophlebitis.delivery thus preventing thrombophlebitis.

91. This is why I do it… Thank youThis is why I do it… Thank you

92. Current status of Neonatal care inCurrent status of Neonatal care in
regionregion
* Paradoxical situation of inadequate NSCU’s* Paradoxical situation of inadequate NSCU’s
in spite of growing enthusiasm aboutin spite of growing enthusiasm about
neonatal care amongst the Pediatricians.neonatal care amongst the Pediatricians.
**

93. Twin holed nasal catheter delivering direct stream
of oxygen at nostrils is an ideal step down O2
delivery system.
It is well tolerated & allows feeding, bathing &
handling of the baby .
It saves on the cost of O2.

94. TREATMENT OF NEONATALTREATMENT OF NEONATAL
JAUNDICEJAUNDICE
Depends upon weight, gestation, birth history & sicknessDepends upon weight, gestation, birth history & sickness
TREATMENT MODALITIESTREATMENT MODALITIES
PhototherapyPhototherapy
Effective modality to treat mod levels (upto 20 mg%).Effective modality to treat mod levels (upto 20 mg%).
Types : Conventional, double surface ,Halogen, CFL & LEDTypes : Conventional, double surface ,Halogen, CFL & LED
Eyes & male genitalia should be covered.Eyes & male genitalia should be covered.
Hydration & nutrition should be adequately maintained.Hydration & nutrition should be adequately maintained.
Bilirubin should be monitored at 12-24 hrly interval.Bilirubin should be monitored at 12-24 hrly interval.
Is Your PT machine good enough ???Is Your PT machine good enough ???

95. Conclusions
• Think before you refer
– A lot of problems can be tackled locally
• Certain clinical signs are better predictors
of sickness & death than others
• Stabilize patients before referral
• Communicate with receiving consultant &
with family
• Make comprehensive referral summary
Conclusions
• Think before you refer
– A lot of problems can be tackled locally
• Certain clinical signs are better predictors
of sickness & death than others
• Stabilize patients before referral
• Communicate with receiving consultant &
with family
• Make comprehensive referral summary
Conclusions
• Think before you refer
– A lot of problems can be tackled locally
• Certain clinical signs are better predictors
of sickness & death than others
• Stabilize patients before referral
• Communicate with receiving consultant &
with family
• Make comprehensive referral summary

96. Which baby may be referred?Which baby may be referred?
Who needs continuous electronic monitoringWho needs continuous electronic monitoring
– HR, SpOHR, SpO2,2, BP, CVPBP, CVP
Who requires investigations that areWho requires investigations that are
– Either too specialized (eg. metabolic, endocrine, etc)Either too specialized (eg. metabolic, endocrine, etc)
– Or need physical presence of baby (neuro-imaging, EEG,Or need physical presence of baby (neuro-imaging, EEG,
advanced radiology, pathology etc)advanced radiology, pathology etc)
Who requires specialized evaluationWho requires specialized evaluation
– Uncertain diagnosisUncertain diagnosis
– Specialized opinion (Genetics, Hemat, Neuro, Cardiac etc)Specialized opinion (Genetics, Hemat, Neuro, Cardiac etc)
Who needs specialized interventionWho needs specialized intervention
– TPNTPN
– VentilationVentilation
– InotropesInotropes
– Invasive procedures (chest drain etc)Invasive procedures (chest drain etc)

97. Who should not be referred?Who should not be referred?
Babies >1500 g, but fairly problem-freeBabies >1500 g, but fairly problem-free
Birth asphyxia with no Stage II-III HIE orBirth asphyxia with no Stage II-III HIE or
end-organ damageend-organ damage
All unconjugated jaundiceAll unconjugated jaundice
– Exceptions: Rh isoimmunized or hydropic orExceptions: Rh isoimmunized or hydropic or
kernicterickernicteric
Sepsis with no resp/hemodynamic/renalSepsis with no resp/hemodynamic/renal
compromise & no organ dysfunctioncompromise & no organ dysfunction

98. Things to do before referringThings to do before referring
Stabilize for transportStabilize for transport
Write a detailed referral summaryWrite a detailed referral summary
Talk to receiving consultantTalk to receiving consultant
Talk to familyTalk to family

99. StabilizationStabilization
S= SugarS= Sugar
– Ensure BS is well above lower cut-offEnsure BS is well above lower cut-off
T= TemperatureT= Temperature
– Euthermic. No cold stress.Euthermic. No cold stress.
A= Airway patentA= Airway patent
– Clear secretions, ensure correct position, intubate if necessaryClear secretions, ensure correct position, intubate if necessary
B= Blood testsB= Blood tests
– Ensure all reports, incl. Xrays attachedEnsure all reports, incl. Xrays attached
– Pending reports (eg. blood culture) mentionedPending reports (eg. blood culture) mentioned
L= Lines & tubes fastenedL= Lines & tubes fastened
– IV canulas, OG tubes, ET tubes well fastenedIV canulas, OG tubes, ET tubes well fastened
– Write whether tubes repositioned after last XrayWrite whether tubes repositioned after last Xray
E= Emotional supportE= Emotional support

100. It is unfair to send a
moribund patient to
an institution just to
get rid of the patient
before death

101. Talking to familyTalking to family
Do not give false hopesDo not give false hopes
– जातेजाते हीही बेडबेड िमिलिमिल जाएगाजाएगा
– जैसेजैसे हीही मिशीनमिशीन मिेमिे डालेगेडालेगे सबसब ठीकठीक होहो जाएगाजाएगा
Do not create impression that everythingDo not create impression that everything
is free & everyone can be made “pooris free & everyone can be made “poor
free” in government hospitalsfree” in government hospitals
Give realistic idea of prognosisGive realistic idea of prognosis
Keep channels open for back referralKeep channels open for back referral

102. ConclusionsConclusions
Think before you referThink before you refer
– A lot of problems can be tackled locallyA lot of problems can be tackled locally
Certain clinical signs are better predictorsCertain clinical signs are better predictors
of sickness & death than othersof sickness & death than others
Stabilize patients before referralStabilize patients before referral
Communicate with receiving consultant &Communicate with receiving consultant &
with familywith family
Make comprehensive referral summaryMake comprehensive referral summary