KVV E-Modules

1. Neonatal Hyperbillirubinemia- Dr. Parvathy Balakrishnan

2. Neonatal Hyperbillirubinemia- Dr. Parvathy Balakrishnan

3. Birth Injuries-Dr. Parvathy Balakrishnan

BIRTH INJURIES Background & Risk Factors Definition: A birth injury is an impairment of the infant’s body function or structure that arises from adverse influences at birth—this includes events before, during, or after delivery, even during resuscitation. Incidence: Rates have steadily declined over time—from approximately 2.6 per 1,000 live births in 2004 to around 1.9 per 1,000 in 2012. Risk Factors: Fetal-related: Macrosomia (large baby), macrocephaly, prematurity or very low birth weight, malpresentation (especially breech), congenital anomalies, low amniotic fluid. Maternal-related: Obesity, diabetes, cephalopelvic disproportion, small stature, primiparity (first childbirth), dystocia (difficult labor), prolonged or rapid labor. Iatrogenic/instrumentation-related: Use of forceps, vacuum extraction, versions, and extractions. Examination Guidelines Newborns deemed at risk—for example those who needed resuscitation—should receive a comprehensive physical and neurologic evaluation. Key areas include symmetry, cranial nerve function, joint range of motion, and skin integrity (including scalp). Types of Birth Trauma: A. Head & Neck Injuries 1. Scalp Monitoring Electrode Trauma Can cause minor abrasions or lacerations; typically superficial and heal without intervention. 2. Extra cranial Haemorrhages Caput Succedaneum: A subcutaneous edema on the scalp with poorly defined margins that may extend over suture lines; typically benign and resolves in days. Monitor for hypovolemia and treat hyperbilirubinemia as needed. Subgaleal Hematoma: More serious; can bleed under the scalp layers and become infected. May require antibiotics or drainage if there's deterioration. 3. Intracranial Hemorrhage 4. Skull Fractures Linear fractures (often parietal): Typically asymptomatic unless accompanied by bleeding. Use skull radiograph for diagnosis. Depressed fractures (often frontal or parietal): Often from forceps. Require neurosurgical evaluation and possibly closed elevation. Occipital osteodiastasis: A serious separation of the occiput that can lead to cerebellar injury—often lethal in breech deliveries. Dural tears can result in herniation and leptomeningeal cysts; follow-up imaging recommended. 5. Facial or Mandibular Fractures Can arise from difficult delivery or forceps. Look for facial asymmetry, swelling, crepitus, or feeding difficulty. Healing begins within 7–14 days; requires prompt imaging, specialist consultation, and sometimes antibiotics. 6. Nasal Injuries Often due to mechanical pressure during delivery. Cartilage dislocation is more common than fracture (<1% incidence). Early treatment prevents septal deformities; otolaryngology consult may be needed. 7. Ocular Injuries Retinal haemorrhages: Common and benign; resolve within days. Sub conjunctival haemorrhages: Also frequent; benign. Instrument-related injuries (e.g., forceps) leading to hyphema, vitreous bleeding, corneal damage, or orbital trauma are rare but may require ophthalmologic intervention. 8. Pharyngeal/Oesophageal Injuries Minor trauma may result from bulb suctioning; more serious perforations can occur from nasogastric or endotracheal tube placement. Present with difficulty feeding and excessive secretions. Requires imaging and sometimes surgical or chest tube interventions. B. Cranial Nerve, Spinal Cord & Peripheral Nerve Injuries Cranial Nerve Injuries Facial Nerve (VII): Most common peripheral nerve injury (~1% of births). Caused by compression or forceps. Presents as asymmetrical crying facies. Peripheral injuries involve the entire side of the face; central injuries affect only the lower half. Typically resolve by ~6 weeks; bilateral involvement may need tracheostomy. Spinal Cord Injuries Rare, but can occur due to excessive neck extension, breech delivery, or shoulder dystocia. May result in asymmetric breathing due to phrenic nerve dysfunction. Diagnosed via imaging; most recover in 1–3 months. Persistent cases may require diaphragm plication or nerve pacing. Brachial Plexus Injuries Incidence ~1 per 1,000 births. 1. Erb–Duchenne palsy (C5–C6): Arm held in "waiter’s tip" position; common type (~90%); good recovery with therapy. 2. Total plexus palsy: Entire arm flaccid; may involve Horner syndrome. 3. Klumpke palsy (C7–T1): Very rare; hand weakness plus possible Horner syndrome. Imaging helps differentiate from fractures. Treatment is conservative; surgery considered if no biceps function by 3 months. Recovery is generally favorable (>90%) if nerve roots are intact. C. Bone & Skeletal Injuries 1. Clavicular Fractures Most common birth fracture (up to 2% in some studies, higher in others). Often manifests a few days after birth. Diagnosed via X-ray, managed with immobilization; full recovery expected. 2. Femoral Epiphyseal Separation Can mimic hip dysplasia. Typically diagnosed via ultrasound. Treatment involves immobilization (10–14 days) and pain management. D. Intra‑Abdominal Injuries Hepatic Injury Most common intra-abdominal birth injury. Risk in macrosomic or breech neonates. Presents with signs of blood loss in the first 1–3 days. Management includes volume resuscitation and possible surgery. Splenic Injury Presents similar to liver injury; may be managed conservatively if stable or surgically if needed. Adrenal Hemorrhage Often unilateral (90%) and right-sided (75%). Signs include flank mass, shock, or adrenal insufficiency. Diagnosis via ultrasound; treat with volume replacement and steroids if needed. Surgery is rare. E. Soft Tissue Injuries Petechiae & Ecchymoses: Common and usually benign. If uncertain, evaluate for bleeding disorders. Resolve within ~1 week. Lacerations & Abrasions: May result from scalp electrodes or C-section incisions. Clean and monitor—some may need suturing or antibiotics. Subcutaneous Fat Necrosis: Presents in the first two weeks with firm nodules; resolves over weeks to months. Monitor for hypercalcemia.

4. Normal New Born- Dr. Leya Sara Samuel

Care of the Normal Newborn Three-fourths of all infant deaths and 60% of all under-five deaths occur during the neonatal period in India (UNICEF, 2017). Essential care of newborn (ENC) practices protect the newborn from morbidity and mortality in the immediate postnatal period. This protocol is for well infants in the post-natal ward. 1.1. Learning Objectives To understand the practices that are required for normal babies To have a checklist for daily monitoring and discharge of well neonates. 1.2. Admission Policy All neonates who are more than 34 weeks and more than 1800g and are well at birth are to be admitted by the mother’s side. All neonates are supposed to have a separate in-patient case record that is to be maintained till both the mother and infant are discharged from the hospital. In case the mother is re-admitted for medical issues and the baby is with the mother, the infant needs to be admitted with a separate case-sheet. 1.3. Safe Cord Care The umbilical cord is a common entry point for pathogens after birth. Clean cord care practices prevent sepsis in the newborn especially in areas where hygiene is poor and infection rates are high. Cord clamping should be delayed for at least 60 seconds after birth for vigorous term and preterm newborns. Follow aseptic precautions while clamping and cutting the cord. Use a sterile clamp 2-3 cm from baby’s abdomen. If there is oozing of blood after clamping, place a second clamp between the skin and the first clamp. We follow clean, dry cord care as recommended by WHO for newborns in health facilities. Daily application of chlorhexidine (4%) to the umbilical cord stump during the first week of life is recommended for newborns delivered in community settings with high neonatal mortality rate (>30 per 1000) and where un-hygienic cord care practices exist (application of cow dung or ash to the cord stump). DO NOT apply any substance to stump. DO NOT bind or bandage stump. Leave stump uncovered. 1.4. Maintenance of Normothermia: Optimal Thermal Care A series of simple measures can prevent hypothermia in most neonates, starting before the baby’s birth and continuing in the newborn unit, maternity ward and home. The steps of warm chain practiced at the time of birth is discussed in Chapter two. After birth: Dry baby with a clean, dry, warm cloth. Encourage skin-to-skin contact for all stable babies. Encourage breastfeeding as soon as possible after birth, ideally within the first hour. Postpone bathing for at least 24 hours or until after discharge. The baby should be clothed adequately in the postnatal ward and at home. The infant’s head should be covered with a cap before wrapping. Use socks and mittens for extremities. A rule of thumb is that neonates need one extra layer of clothing when compared to adults. Change wet nappies promptly to prevent heat loss. Room in mother and baby 24 hours a day to encourage bonding and breastfeeding. Kangaroo mother care is advised for all low birth weight babies. 1.5. Early Initiation of Breastfeeding The advantages of early breast-feeding cannot be over-emphasized. Refer to Chapter breast feeding for optimal position and attachment during breastfeeding. Encourage and implement skin-to-skin contact at birth for all stable term and late preterm neonates Breastfeed on demand and during day and at night at least eight times. Exclusive breastfeeding for the first 6 months. Discourage the use of pre-lacteal feeds, gripe water, honey, or any other milk. 1.6. Protection from Infection Newborns – especially those born prematurely and of low birth weight are at risk of infection before, during and after birth. Key infection prevention practices are summarized below. Optimal clean delivery behavior (six cleans as described by the WHO, including clean hands, clean perineum, clean delivery surface, clean cord cutting instrument, clean cord tying, and clean cord care). Early and exclusive breastfeeding. Strict hand-hygiene practices Clean practices at home- hygiene, no pre-lacteals. Wash the face, neck, underarms of the neonate daily. Wash the buttocks when soiled and dry thoroughly. If not using diapers, use cloth on baby’s bottom to collect stool. Dispose as for woman’s pads. DO NOT bathe a baby before 24 hours of age or until after discharge. We do not recommend bathing of newborn infants while in hospital. DO NOT put anything in the baby’s eyes or ears. At birth, both the eyes of the neonates should be cleaned with separate swabs soaked in sterile water or normal saline. The swipe to clean the eyes should be gentle and should be done from the inner to the outer canthus. 1.7. Physical Examination In asymptomatic neonates, a complete physical examination is done before discharge. This includes a detailed head-to-toe examination followed by systemic examination. Carefully examine every baby naked, in bright natural light and in absence of yellow background, for jaundice. We discharge babies born to O blood group or Rh-negative mothers only after 48 hours of observation, unless incompatibility is ruled out before that. Rule out congenital malformations. Check red reflex after 24 hours or at discharge. Check femoral pulses after 24 hours or at discharge. Check for dislocation of hips. Pulse-oximeter screening – ideally to be done at 24-36 hours of age. (See Chapter on CCHD for details on pulse oximetry screen) 1.8. Checklist for Daily Monitoring in the Post-natal Ward All neonates are examined once daily till discharge by the pediatric postgraduate. Neonates at risk of problems need to be monitored more closely (twice/thrice daily). The following assessments are made: Address any concerns that the mother may have. On the first postnatal exam, review maternal records especially ultrasound scans & blood tests (blood group, ICT, HIV, HbSAg) and ask the mother about any problems during pregnancy (polyhydramnios, hydronephrosis, any other congenital abnormalities. (It is preferable to screen all scan records as some records may have been missed during the delivery). Enquire about the health of siblings and any problems during neonatal period. Enquire any maternal medications & check on LACTMED about its safety (Most medications are usually safe except chemotherapy and combinations of psychotropic drugs) Urine and stool passage. Vitals (temperature, HR, RR, Color, CFT), activity of the infant. General physical exam – rash, umbilical discharge Weight pattern at least every 48 hours (ideally Q24H) for infants with breastfeeding problems. Progression of jaundice (by Kramer’s rule) Breastfeeding position, attachment. For infants at risk of hypoglycemia: breastmilk expression and paladai feeding. Kangaroo care for eligible infants 1.9. Newborn Screening Universal hearing screen is advised for all neonates. At JIPMER, OAE is done before discharge and if the results are REFER, a repeat test is done within 1 month of age. If the repeat assessment is also REFER, the infant is referred to the ENT department for a diagnostic brain stem evoked response audiometry screen (BERA) and subsequent follow-up. If OAE cannot be done for logistics reason, behavioral observation audiometry (BOA) is done for all well newborns by audiologist. If failed, they undergo OAE. Pulse oximeter screening done after 24 hours of age is a sensitive screening tool for detecting critical congenital heart defects in newborns. Again, due to the huge number of inborn births, it is not currently done in JIPMER but is under consideration. We do not routinely screen for inborn errors of metabolism (IEM) for all neonates born in JIPMER due to logistic reasons. Whenever feasible, we recommend screening for at least the common and treatable disorders (congenital hypothyroidism, congenital adrenal hyperplasia, G6PD deficiency, biotinidase deficiency and galactosemia). We do screening for congenital hypothyroidism among all high-risk neonates or if there is a history of maternal hypothyroidism or any features suggestive of hypothyroidism (like a wide anterior fontanelle). Similarly, all high risk or symptomatic neonates should have a metabolic screen, as symptoms of IEM mimic those of infections etc. For discharge planning of high-risk neonates, please refer to appropriate Chapter. 1.10. Immunization All neonates are given OPV, BCG and Hepatitis B vaccines at birth or within 24 hours. High-risk neonates are given the vaccines once they are ready for discharge and stable. Subsequent immunization is carried out in the Under-5 clinic, Wednesdays at 2-4 pm. 1.11. Discharge Checklist This checklist is an aid to ensure all necessary examinations/ procedures are completed prior to discharge. The mother is confident of feeding by direct feeding or paladai, and the infant has taken at least 2 successful consecutive feedings. Normal vital signs 12 hours prior to discharge. Normal urine and stooling patterns. Weight loss is less than 10% (cumulative) and less than 5% in 1 day. Jaundice is well below risk for postnatal age & gestation. All antenatal scan issues have been addressed (e.g. hydronephrosis: USG kidney is complete) The infant has completed any treatment that has been rendered (e.g. antibiotic course is completed, or stable glucose in case of asymptomatic hypoglycemia). TSH screening as per protocol. Hearing screening. Screening for hip dysplasia. Red reflex (to rule out media opacities in the eye, like cataract). Vaccination is complete. Vitamin K is given in the delivery room 1.12. Advice on Discharge Exclusive breastfeeding till 6 months of age. DO NOT give bottle feeds, gripe water, vasambu to the baby. Wash hands well with soap and water before touching the baby. DO NOT instill oil in baby’s nose/ mouth. Regular immunization. Bath may be to be every alternate day with a neutral pH soap & warm water for babies > 2500 g. Avoid bath in low birth weight infants till 2500 g. The bathing procedure needs to be as quick as possible. The infant needs to normothermic and is to be fed before a bath. Emollients like coconut oil or olive oil for massage by parent maybe used (avoid mustard oil, mineral oil (present in most baby oils) Danger signs: poor feeding, poor activity, seizures, hypothermia, jaundice, umbilical discharge or bleeding. Vitamin D3 (400 IU/ day) to be continued till 1-year of age. Iron (2-3 mg/kg/day) to be started at 4 months of age and continued till 2-years of age. Seek health care if any danger signs are noted. 1.13. Early Detection of Danger Signs If any of the danger signs are noted, the baby should be taken to a healthcare facility immediately Fast breathing (respiratory rate ≥ 60 breaths/minute) Severe chest in-drawing Fever (temperature ≥ 38 °C) Hypothermia (temperature < 35.5 °C) No movement at all or movement only on stimulation Feeding poorly or not feeding at all Convulsions Jaundice involving the extremities Abdominal distension Persisting vomiting or vomits containing blood or bile At JIPMER, parents of normal neonates discharged from postnatal ward are requested to visit under- 5 clinic (Wednesday afternoon, 2 pm), Pediatrics OPD or Emergency for subsequent care. 1.14. Key Messages Essential newborn care includes clean cord care, thermal care, early initiation of breastfeeding within the first hour of birth and protection from infection. Careful assessment of the infant daily and prior to discharge helps identify and manage problems early. Explain danger signs to the mother prior to discharge, and how to seek help. 1.15. Suggested Reading Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics. 2005;115:519-617. KapooCare of the Normal Newborn Three-fourths of all infant deaths and 60% of all under-five deaths occur during the neonatal period in India (UNICEF, 2017). Essential care of newborn (ENC) practices protect the newborn from morbidity and mortality in the immediate postnatal period. This protocol is for well infants in the post-natal ward. 1.1. Learning Objectives To understand the practices that are required for normal babies To have a checklist for daily monitoring and discharge of well neonates. 1.2. Admission Policy All neonates who are more than 34 weeks and more than 1800g and are well at birth are to be admitted by the mother’s side. All neonates are supposed to have a separate in-patient case record that is to be maintained till both the mother and infant are discharged from the hospital. In case the mother is re-admitted for medical issues and the baby is with the mother, the infant needs to be admitted with a separate case-sheet. 1.3. Safe Cord Care The umbilical cord is a common entry point for pathogens after birth. Clean cord care practices prevent sepsis in the newborn especially in areas where hygiene is poor and infection rates are high. Cord clamping should be delayed for at least 60 seconds after birth for vigorous term and preterm newborns. Follow aseptic precautions while clamping and cutting the cord. Use a sterile clamp 2-3 cm from baby’s abdomen. If there is oozing of blood after clamping, place a second clamp between the skin and the first clamp. We follow clean, dry cord care as recommended by WHO for newborns in health facilities. Daily application of chlorhexidine (4%) to the umbilical cord stump during the first week of life is recommended for newborns delivered in community settings with high neonatal mortality rate (>30 per 1000) and where un-hygienic cord care practices exist (application of cow dung or ash to the cord stump). DO NOT apply any substance to stump. DO NOT bind or bandage stump. Leave stump uncovered. 1.4. Maintenance of Normothermia: Optimal Thermal Care A series of simple measures can prevent hypothermia in most neonates, starting before the baby’s birth and continuing in the newborn unit, maternity ward and home. The steps of warm chain practiced at the time of birth is discussed in Chapter two. After birth: Dry baby with a clean, dry, warm cloth. Encourage skin-to-skin contact for all stable babies. Encourage breastfeeding as soon as possible after birth, ideally within the first hour. Postpone bathing for at least 24 hours or until after discharge. The baby should be clothed adequately in the postnatal ward and at home. The infant’s head should be covered with a cap before wrapping. Use socks and mittens for extremities. A rule of thumb is that neonates need one extra layer of clothing when compared to adults. Change wet nappies promptly to prevent heat loss. Room in mother and baby 24 hours a day to encourage bonding and breastfeeding. Kangaroo mother care is advised for all low birth weight babies. 1.5. Early Initiation of Breastfeeding The advantages of early breast-feeding cannot be over-emphasized. Refer to Chapter breast feeding for optimal position and attachment during breastfeeding. Encourage and implement skin-to-skin contact at birth for all stable term and late preterm neonates Breastfeed on demand and during day and at night at least eight times. Exclusive breastfeeding for the first 6 months. Discourage the use of pre-lacteal feeds, gripe water, honey, or any other milk. 1.6. Protection from Infection Newborns – especially those born prematurely and of low birth weight are at risk of infection before, during and after birth. Key infection prevention practices are summarized below. Optimal clean delivery behavior (six cleans as described by the WHO, including clean hands, clean perineum, clean delivery surface, clean cord cutting instrument, clean cord tying, and clean cord care). Early and exclusive breastfeeding. Strict hand-hygiene practices Clean practices at home- hygiene, no pre-lacteals. Wash the face, neck, underarms of the neonate daily. Wash the buttocks when soiled and dry thoroughly. If not using diapers, use cloth on baby’s bottom to collect stool. Dispose as for woman’s pads. DO NOT bathe a baby before 24 hours of age or until after discharge. We do not recommend bathing of newborn infants while in hospital. DO NOT put anything in the baby’s eyes or ears. At birth, both the eyes of the neonates should be cleaned with separate swabs soaked in sterile water or normal saline. The swipe to clean the eyes should be gentle and should be done from the inner to the outer canthus. 1.7. Physical Examination In asymptomatic neonates, a complete physical examination is done before discharge. This includes a detailed head-to-toe examination followed by systemic examination. Carefully examine every baby naked, in bright natural light and in absence of yellow background, for jaundice. We discharge babies born to O blood group or Rh-negative mothers only after 48 hours of observation, unless incompatibility is ruled out before that. Rule out congenital malformations. Check red reflex after 24 hours or at discharge. Check femoral pulses after 24 hours or at discharge. Check for dislocation of hips. Pulse-oximeter screening – ideally to be done at 24-36 hours of age. (See Chapter on CCHD for details on pulse oximetry screen) 1.8. Checklist for Daily Monitoring in the Post-natal Ward All neonates are examined once daily till discharge by the pediatric postgraduate. Neonates at risk of problems need to be monitored more closely (twice/thrice daily). The following assessments are made: Address any concerns that the mother may have. On the first postnatal exam, review maternal records especially ultrasound scans & blood tests (blood group, ICT, HIV, HbSAg) and ask the mother about any problems during pregnancy (polyhydramnios, hydronephrosis, any other congenital abnormalities. (It is preferable to screen all scan records as some records may have been missed during the delivery). Enquire about the health of siblings and any problems during neonatal period. Enquire any maternal medications & check on LACTMED about its safety (Most medications are usually safe except chemotherapy and combinations of psychotropic drugs) Urine and stool passage. Vitals (temperature, HR, RR, Color, CFT), activity of the infant. General physical exam – rash, umbilical discharge Weight pattern at least every 48 hours (ideally Q24H) for infants with breastfeeding problems. Progression of jaundice (by Kramer’s rule) Breastfeeding position, attachment. For infants at risk of hypoglycemia: breastmilk expression and paladai feeding. Kangaroo care for eligible infants 1.9. Newborn Screening Universal hearing screen is advised for all neonates. At JIPMER, OAE is done before discharge and if the results are REFER, a repeat test is done within 1 month of age. If the repeat assessment is also REFER, the infant is referred to the ENT department for a diagnostic brain stem evoked response audiometry screen (BERA) and subsequent follow-up. If OAE cannot be done for logistics reason, behavioral observation audiometry (BOA) is done for all well newborns by audiologist. If failed, they undergo OAE. Pulse oximeter screening done after 24 hours of age is a sensitive screening tool for detecting critical congenital heart defects in newborns. Again, due to the huge number of inborn births, it is not currently done in JIPMER but is under consideration. We do not routinely screen for inborn errors of metabolism (IEM) for all neonates born in JIPMER due to logistic reasons. Whenever feasible, we recommend screening for at least the common and treatable disorders (congenital hypothyroidism, congenital adrenal hyperplasia, G6PD deficiency, biotinidase deficiency and galactosemia). We do screening for congenital hypothyroidism among all high-risk neonates or if there is a history of maternal hypothyroidism or any features suggestive of hypothyroidism (like a wide anterior fontanelle). Similarly, all high risk or symptomatic neonates should have a metabolic screen, as symptoms of IEM mimic those of infections etc. For discharge planning of high-risk neonates, please refer to appropriate Chapter. 1.10. Immunization All neonates are given OPV, BCG and Hepatitis B vaccines at birth or within 24 hours. High-risk neonates are given the vaccines once they are ready for discharge and stable. Subsequent immunization is carried out in the Under-5 clinic, Wednesdays at 2-4 pm. 1.11. Discharge Checklist This checklist is an aid to ensure all necessary examinations/ procedures are completed prior to discharge. The mother is confident of feeding by direct feeding or paladai, and the infant has taken at least 2 successful consecutive feedings. Normal vital signs 12 hours prior to discharge. Normal urine and stooling patterns. Weight loss is less than 10% (cumulative) and less than 5% in 1 day. Jaundice is well below risk for postnatal age & gestation. All antenatal scan issues have been addressed (e.g. hydronephrosis: USG kidney is complete) The infant has completed any treatment that has been rendered (e.g. antibiotic course is completed, or stable glucose in case of asymptomatic hypoglycemia). TSH screening as per protocol. Hearing screening. Screening for hip dysplasia. Red reflex (to rule out media opacities in the eye, like cataract). Vaccination is complete. Vitamin K is given in the delivery room 1.12. Advice on Discharge Exclusive breastfeeding till 6 months of age. DO NOT give bottle feeds, gripe water, vasambu to the baby. Wash hands well with soap and water before touching the baby. DO NOT instill oil in baby’s nose/ mouth. Regular immunization. Bath may be to be every alternate day with a neutral pH soap & warm water for babies > 2500 g. Avoid bath in low birth weight infants till 2500 g. The bathing procedure needs to be as quick as possible. The infant needs to normothermic and is to be fed before a bath. Emollients like coconut oil or olive oil for massage by parent maybe used (avoid mustard oil, mineral oil (present in most baby oils) Danger signs: poor feeding, poor activity, seizures, hypothermia, jaundice, umbilical discharge or bleeding. Vitamin D3 (400 IU/ day) to be continued till 1-year of age. Iron (2-3 mg/kg/day) to be started at 4 months of age and continued till 2-years of age. Seek health care if any danger signs are noted. 1.13. Early Detection of Danger Signs If any of the danger signs are noted, the baby should be taken to a healthcare facility immediately Fast breathing (respiratory rate ≥ 60 breaths/minute) Severe chest in-drawing Fever (temperature ≥ 38 °C) Hypothermia (temperature < 35.5 °C) No movement at all or movement only on stimulation Feeding poorly or not feeding at all Convulsions Jaundice involving the extremities Abdominal distension Persisting vomiting or vomits containing blood or bile At JIPMER, parents of normal neonates discharged from postnatal ward are requested to visit under- 5 clinic (Wednesday afternoon, 2 pm), Pediatrics OPD or Emergency for subsequent care. 1.14. Key Messages Essential newborn care includes clean cord care, thermal care, early initiation of breastfeeding within the first hour of birth and protection from infection. Careful assessment of the infant daily and prior to discharge helps identify and manage problems early. Explain danger signs to the mother prior to discharge, and how to seek help. 1.15. Suggested Reading Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics. 2005;115:519-617. Kapoor S, Thelma BK. Status of newborn screening and inborn errors of metabolism in India. Indian J Pediatr. 2018;85:1110-7. Mahle WT, Newburger JW, Matherne GP, et al. Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the American Heart Association and American Academy of Pediatrics. Circulation. 2009;120:447-58. Rite Gracia S, Pérez Muñuzuri A, Sanz López E, et al. Criteria for hospital discharge of the healthy term newborn after delivery. An Pediatría Engl Ed. 2017;86:289. World Health Organization. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. Geneva: WHO Press World Health Organization; 2006.r S, Thelma BK. Status of newborn screening and inborn errors of metabolism in India. Indian J Pediatr. 2018;85:1110-7. Mahle WT, Newburger JW, Matherne GP, et al. Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the American Heart Association and American Academy of Pediatrics. Circulation. 2009;120:447-58. Rite Gracia S, Pérez Muñuzuri A, Sanz López E, et al. Criteria for hospital discharge of the healthy term newborn after delivery. An Pediatría Engl Ed. 2017;86:289. World Health Organization. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. Geneva: WHO Press World Health Organization; 2006.

5. Neonatal Hypoglycaemia- Dr. Leya Sara Samuel

NEONATAL HYPOGLYCAEMIA Hypoglycemia is the most common metabolic disturbance occurring in the neonatal period. Screening at-risk infants and the management of low blood glucose levels in the first hours to days of life is a frequent issue in the care of the newborn infant. Yet, a clear definition of neonatal hypoglycemia is lacking. Current screening guidelines and management algorithms are based on limited evidence, relying more on expert opinion to guide recommendations. Despite a better understanding of early glucose homeostasis and transitional hypoglycemia in the first 48 hours of life, gaps in our knowledge persist. Observations have shown that healthy infants experience transient hypoglycemia as a part of the normal adaption to extrauterine life, with a decline in blood glucose concentrations to values as low as 20 to 25 mg/dL in the first two hours of life.  However, because we do not routinely measure blood glucose concentrations in healthy infants without risk factors for hypoglycemia, it is difficult to define 'normal' levels of blood glucose in the first 48 hours of life. As Harding et al. question: "even if healthy infants experience low glucose concentrations, can we extend these values to infants at risk of impaired metabolic adaption?" And how low is too low?  A 1988 multicenter nutritional study by Lucas et al. suggested a blood glucose concentration <47 mg/dL as the critical threshold associated with adverse neurodevelopmental outcomes. The study looked at blood glucose levels in 661 preterm infants with a birth weight of <1850 grams enrolled in a nutritional study investigating early feeding strategies and cognitive outcomes. Investigators found that the number of days of blood glucose concentrations <47 mg/dL associated with lower motor and mental developmental scores on the Bayley Scales of Infant Development at 18 months corrected age. Infants that experienced hypoglycemia (glucose <47 mg/dL) on 5 or greater days had 3 to 5 times increased risk of neurodevelopmental impairment. The authors concluded that "even moderate hypoglycemia is associated with a considerable increase in adverse neurodevelopmental sequelae" and called for a reevaluation of the then current practice trends. As a result, this value of '47 mg/dL' became widely accepted as the standard numerical value to define neonatal hypoglycemia for all infants, even healthy, term, appropriate for gestational age infants. It is clear that extremely low blood glucose concentrations in neonates can cause apnea, irritability, lethargy, seizures, and brain damage; and that prolonged or symptomatic hypoglycemia may correlate with long-term neurodevelopmental deficits. However, the long- term significance of early, asymptomatic and transiently low glucose levels remain not well established. And the evidence to support a clear numerical value of blood glucose that is associated with brain injury or reliably predicts adverse neurodevelopmental outcomes is lacking. Even Lucas et al. acknowledged that 'the association between [blood glucose concentrations <47 mg/dL] and poor neurodevelopmental outcomes might not be causal and might reflect a failure to adjust for confounding factors.' Etiology Healthy infants experience an expected drop in blood glucose concentrations immediately following birth as a part of the normal physiologic transition to extrauterine life. Abruptly clamping the umbilical cord at birth disrupts the infant's connection to the placenta, upon which it relied to supply glucose and other metabolites necessary to meet its energy needs in utero. The continuous supply of exogenous intravenous glucose from the placenta suddenly ceases, and the infant's blood glucose concentration declines in the first hours of life. For most healthy infants, this transitional neonatal hypoglycemia is brief, transient and most often asymptomatic. Infants are at risk for more severe or prolonged hypoglycemia due to one or a combination of the following underlying mechanisms: insufficient glucose supply, with low glycogen or fat stores or poor mechanisms of glucose production; increased glucose utilization caused by excessive insulin production or increased metabolic demand; or the failure of counter- regulatory mechanisms (i.e., pituitary or adrenal failure). Neonatal hypoglycemia most commonly affects the following groups of infants:   Intrauterine growth restriction or small compared to gestational age infants   Infants of diabetic mothers or large for gestational age infants   Late-preterm infants (34 to 36.6 weeks gestational age)   Preterm, intrauterine growth restricted and small for gestational age infants are at risk for hypoglycemia because they are born with decreased glycogen stores, decreased adipose tissue and experience increased metabolic demands because of their relatively large brain size. In very low birth weight (<1000 g) preterm infants, the enzymes involved in gluconeogenesis are expressed at low levels; thus their ability to produce endogenous glucose is poor, contributing to their risk of severe or prolonged low glucose concentrations. Infants of diabetic mothers (IDM) and large for gestational age infants experience fetal hyperinsulinism and increased peripheral glucose utilization, putting them at risk for hypoglycemia in the immediate postnatal period. The placenta supplies the fetus with a direct source of glucose via facilitated diffusion, such that fetal glucose concentrations are proportional to maternal levels. Prolonged elevations in maternal glucose concentrations result in fetal hyperglycemia and pancreatic overstimulation to increase endogenous fetal insulin production. These elevated levels of fetal insulin persist after birth and, in the absence of a continuous exogenous glucose source, result in increased glucose utilization and lower blood glucose concentrations. IDM have a decreased ability to mobilize glycogen stores after birth and experience a relative adrenal insufficiency with decreased levels of catecholamines, further contributing to the risk of low blood glucose levels. Infants experiencing perinatal stress (e.g., fetal distress, perinatal ischemia, maternal preeclampsia/eclampsia, sepsis, hypothermia) or those with congenital heart disease have increased metabolic energy requirements, which puts them at risk for hypoglycemia. Perinatal stress causes a state of 'hypoglycemic hyperinsulinism' that can persist for days to weeks, resulting in persistently low glucose concentrations requiring ongoing interventions to maintain euglycemia. Other iatrogenic causes of transient neonatal hypoglycemia include intrapartum administration of maternal medication (e.g., beta-adrenergic tocolytic agents, valproic acid, propranolol, and conduction anesthetics), delayed feeding, and exogenous insulin administration. Low glucose concentrations beyond the first 48 hours of life raise concern for an underlying disorder as the etiology of hypoglycemia. The underlying physiologic mechanisms that cause pathologic or persistent hypoglycemia are similar to those described above: hyperinsulinism (e.g., congenital hyperinsulinism, Beckwith-Wiedmann syndrome, Soto syndrome), insufficient energy supply (i.e., inborn errors of metabolism that result in deficiencies in glycogen, amino acids, or free fatty acids), or a deficiency in cortisol or growth hormone (e.g., Costello syndrome, hypopituitarism, congenital adrenal hyperplasia). Causes of persistent neonatal hypoglycemia include :  Congenital hyperinsulinism   Congenital syndromes: Beckwith-Wiedemann syndrome, Soto syndrome, Costello syndrome   Endocrine disorders: congenital hypopituitarism, congenital adrenal hyperplasia, hypothyroidism   Inborn errors of metabolism: maple syrup urine disease, glycogen storage disorders, hereditary fructose intolerance, galactosemia, fatty acid oxidation disorders Epidemiology The reported incidence of neonatal hypoglycemia is variable, depending on several factors: the population of infants included, the frequency and timing of glucose testing, the method of testing, and the definition of hypoglycemia used. A 2006 study by Harris et al. that sought to determine the incidence of hypoglycemia (blood glucose <47 mg/dL) in the first 48 hours of life in infants greater than 35 weeks gestation at risk of hypoglycemia by AAP guidelines found that 25% of all deliveries were at risk for hypoglycemia; of those at-risk infants, 51% experienced at least one episode of hypoglycemia. Pathophysiology The fetus depends on maternal metabolism and placental circulation to provide the glucose, ketones, free fatty acids, and amino acids necessary to meet its energy requirements. The placenta supplies fetal circulation with a direct source of glucose. Clamping the umbilical cord at birth abruptly disrupts this continuous source of glucose, resulting in a rapid decline in blood glucose levels in the first 2 to 3 hours of life. Low blood glucose concentrations cause a surge of insulin and other hormones (including catecholamines, glucagon, and corticosteroids) that stimulate glucose production via gluconeogenesis and glycogenolysis and enhance fatty acid oxidation. This provides the infant with an endogenous source of glucose and other energy substrates necessary to sustain its metabolism ; the result is the gradual rise of blood glucose levels over the next several hours to days. Low glucose levels are also thought to stimulate the neonate’s appetite and help the neonate adapt to intermittent feeds. Any mechanism that disrupts this sequence of physiologic changes puts the infant at risk of more severe or prolonged periods of low glucose. The risk for hypoglycemia is greatest in the first hours after birth. Persistent hypoglycemia results from excessive insulin secretion, a deficiency of cortisol or growth hormone, or inborn errors of metabolism. History and Physical The clinical presentation of neonatal hypoglycemia is variable. An otherwise healthy infant may remain asymptomatic despite extremely low blood glucose levels during the period of transitional hypoglycemia. Clinical symptoms do not correlate with blood glucose levels. Symptoms of neonatal hypoglycemia include :  Sweating   Feeding difficulties, poor suck    Weak or high-pitched cry   Tremors  Hypothermia   Irritability   Lethargy/stupor   Hypotonia  Seizures  Coma  Apnea, grunting or tachypnea   Cyanosis  Evaluation The two major academic societies, the American Academy of Pediatrics (AAP) and the Pediatric Endocrine Society (PES), present conflicting guidelines for screening at-risk infants and the management of neonatal hypoglycemia. The most recent AAP guidelines recommend screening for late preterm and term infants that experience symptoms of hypoglycemia, and asymptomatic infants at highest risk for hypoglycemia in the first 12 to 24 hours of life. "At risk" infants include late preterm (34-36.6 weeks gestation), term infants who are small for gestational age, infants of diabetic mothers, and large for gestational age infants. The guidelines state that 'routine screening and monitoring of blood glucose is not needed in healthy term infants after a normal pregnancy and delivery.' The Pediatric Endocrine Society (PES) recommends screening all infants with risk factors for prolonged or pathologic hypoglycemia, including :  Symptomatic hypoglycemia  Large for gestational age  Perinatal stress o Perinatal hypoxia/ischemia, fetal distress o Maternal pre-eclampsia/eclampsia o Meconium aspiration syndrome, erythroblastosis fetalis, polycythemia, hypothermia  Premature or post-term delivery  Infant of diabetic mother  Family history of genetic hypoglycemia  Congenital syndrome (e.g., Beckwith-Wiedermann), abnormal physical features (e.g., midline facial malformations) Per the PES guidelines, infants unable to maintain pre-prandial blood glucose values >50 mg/dL in the first 48 hours of life or >60 mg/dL thereafter are at risk for persistent hypoglycemia and require further workup prior to discharge home. The PES recommends that the evaluation of infants at risk for persistent hypoglycemia for an underlying etiology occur after the first 48 hours of life, to exclude those infants experiencing transient low glucose levels (i.e., transitional neonatal hypoglycemia). The PES recommends evaluation of the following infants to exclude persistent causes of hypoglycemia :   Symptomatic hypoglycemia or severe hypoglycemia requiring treatment with intravenous dextrose   Infants unable to maintain blood glucose concentrations >50 mg/dL in the first 48 hours of life and >60 after 48 hours of age   Family history of a genetic form of hypoglycemia   Congenital syndrome (e.g., Beckwith-Wiedermann), abnormal physical features (e.g., midline facial malformations) Point-of-care testing (POCT) offers a quick and cost-effective method for screening for hypoglycemia. However, these methods have limitations. Most standard instruments use non- enzymatic methods to measure blood glucose concentration, which are less accurate at lower glucose values than laboratory analysis using glucose oxidase methods (the gold standard). Whole blood samples (used in POCT) have 10% to 18% lower glucose concentrations than plasma, depending on the hematocrit. Therefore, abnormally low glucose values on POCT require confirmation by measuring plasma glucose concentration using clinical laboratory methods. More recently, the use of continuous glucose monitoring (CGM) in the detection and management of neonatal hypoglycemia is under investigation. A study published in 2010 by Harris et al. looked at the usefulness of continuous glucose monitoring in 102 infants >32 weeks gestation at risk of hypoglycemia during the first 7 days of life. Infants were screened for hypoglycemia with intermittent blood glucose measurements and started on early oral feeds or intravenous dextrose solution per clinical guidelines. Investigators found that detected hypoglycemia (blood glucose <47 mg/dL) was present in 44% of infants using continuous glucose monitoring, versus 32% of infants with intermittent blood glucose sampling. And that there is good agreement between interstitial (used in continuous monitoring) and blood glucose measurements. The study suggests that continuous glucose monitoring is a safe, easy to use, and detects more episodes of hypoglycemia. In infants with persistent hypoglycemia suspected of having an underlying disorder, measuring bicarbonate, lactic acid, beta-hydroxybutyrate, free fatty acids, insulin and carnitine levels during hypoglycemia (blood glucose <50 mg/dL) is useful in differentiating between the metabolic causes of persistent hypoglycemia and aids in the diagnosis of hyperinsulinism and disorders of fatty acid oxidation. Treatment / Management In the absence of a consistent definition of neonatal hypoglycemia, recommendations differ as to the lower level of glucose that is acceptable and when intervention is necessary. Though strategies focus on target glucose concentrations, the ultimate goal of management is to reduce the risk of brain injury and long-term neurodevelopmental deficits that may correlate with hypoglycemia. Early initiation of breastfeeding is crucial for all infants. For asymptomatic infants at risk of neonatal hypoglycemia, the AAP recommends initiating feeds within the first hour of life and performing initial glucose screening 30 minutes after the first feed. The AAP recommends goal blood glucose levels equal to or greater than 45 mg/dL prior to routine feedings, and intervention for blood glucose <40 mg/dL in the first 4 hours of life and <45 mg/dL at 4 to 24 hours of life. The best intervention for asymptomatic hypoglycemia is to increase feeding frequency. Increasing breastfeeding is challenging for some infants. Difficulties with infant latching, poor feeding, and low volumes of breast-milk may interfere with the successful establishment of early breastfeeding in the first hours of life. Most commonly, infant formula is the choice for asymptomatic neonatal hypoglycemia in late preterm and term infants. Formula is inexpensive, readily available, easy to give, and has a high carbohydrate content, resulting in a rapid rise of blood glucose concentrations within minutes. However, the use of infant formula risks interrupting establishment of breastfeeding and alters the neonatal microbiome, potentially increasing the risk of infections and allergies. Blood glucose levels should be re-checked one hour after feeding. It is uncertain whether early episodes of low glucose in the first 48 hours of life need correction in asymptomatic, healthy infants without risk factors for hypoglycemia. Dextrose gel 200 mg/kg massaged into the buccal mucosa is an effective treatment alternative in asymptomatic late preterm and term infants. Dextrose gel is relatively inexpensive, well tolerated, and its use has been shown to decrease admissions to neonatal intensive care unit for intravenous dextrose. Additionally, the use of dextrose gel may be a more advantageous treatment option over infant formula because it promotes breastfeeding and maternal-infant bonding.  The AAP recommends admission to the neonatal intensive care unit and intervention with intravenous dextrose for the following: All symptomatic infants with a glucose level less than 40 mg/dL Infants with persistent hypoglycemia despite increased feeding frequency ***Asymptomatic at-risk infants with extremely low blood glucose concentrations <25 mg/dL in the first 4 hours of life or <35 mg/dL at 4 to 24 hours of life. Intravenous glucose is given as a bolus of 200 mg/kg (dextrose 10% at 2 mL/kg), followed by continuous infusion of dextrose 10% at 5 to 8 mg/kg per minute (80 to 100 mL/kg per day) to maintain blood glucose levels of 40 to 50 mg/dL. Infants on intravenous dextrose infusions require close monitoring with frequent measurements of blood glucose levels, as often as every hour for the first 12 hours, then less frequently one target glucose values are achieved. In infants of diabetic mothers, lower glucose infusions rates of 3 to 5 mg/kg/minute may be used to minimize pancreatic stimulation and endogenous insulin secretion. Infants requiring higher rates of intravenous dextrose (>12 to 16 mg/kg/minute) or for more than 5 days are more likely to have a persistent cause of hypoglycemia. Second-line therapies for the treatment of persistent hypoglycemia include the use of corticosteroids or glucagon. Corticosteroids increased blood glucose concentrations by decrease peripheral utilization of glucose and are given as hydroxycortisone 5 to 15 mg/kg per day or prednisone 2 mg/kg per day. Glucagon is a hormone that stimulates endogenous glucose production via glycogenolysis and gluconeogenesis; thus its effectiveness depends on the infant having adequate glycogen stores. It is most useful in term infants and infants of diabetic mothers. Glucagon dosing is as a 30 mcg/kg bolus or 300 mcg/kg per minute continuous infusion. The PES recommends target glucose concentrations >50 mg/dL for infants at risk of hypoglycemia without a suspected congenital disorder during the first 48 hours of life, and >60 mg/dL thereafter. Infants unable to maintain these glucose targets despite regular feedings schedule should be evaluated to exclude a persistent cause of hypoglycemia prior to discharge home to ensure early recognition and facilitate treatment. For infants with persistent hypoglycemia, the goal of management in infants with suspected hyperinsulinism is to prevent recurrent episodes of low blood glucose levels that put the infant at risk for future episodes of hypoglycemia. For neonates with inborn errors of metabolism and impaired endogenous glucose production, the goal of management is to prevent metabolic acidosis and subsequent growth failure. The Pediatric Endocrine Society recommends giving endogenous glucose to keep blood glucose levels >70 mg/dL in these infants. Diazoxide infusions of 10 to 15 mg/kg per day may be used in infants with congenital hyperinsulinism to inhibit insulin secretions; effects are seen within 2 to 4 days. Recommendations call for early consultation with endocrinology or genetics. Differential Diagnosis The symptoms of neonatal hypoglycemia are nonspecific and overlap with symptoms of other conditions, including prematurity, sepsis, hypoxic-ischemic encephalopathy and hyponatremia. As discussed above, though rare, persistent causes of hypoglycemia must be excluded.  Prognosis The implications of asymptomatic hypoglycemia in the first 48 hours of life on long-term neurodevelopmental outcomes remains bot well established. As a result of an influential study published in 1988 by Lucas et al. suggesting that recurrent, moderate neonatal hypoglycemia correlated with serious motor and mental impairments at 18 months corrected age, it was accepted that even early, asymptomatic hypoglycemia could harm long-term development. Several other observational studies presented similar conclusions. However, it is difficult to prove causation in observed outcomes. Contributing to the challenge in understanding the effects of low glucose levels, most studies have failed to include euglycemia controls and use variable definitions of 'hypoglycemia.'[2] A 2006 systematic review assessing the evidence of neonatal hypoglycemia on neurodevelopmental outcomes by Boluyt et al. found that a majority of studies were of overall poor quality and that the results of the two high-quality studies were invalid because of heterogeneity in methods. The authors' conclusion was that none of the studies provided valid evidence of the effects of neonatal hypoglycemia on neurodevelopment on which to make clinical recommendations and called for a well-designed, prospective study on this topic. Despite requests for further research of infants at risk of hypoglycemia with long-term neurodevelopmental follow up, there have only been two studies that meet the methodological criteria recommended by Boluyt et al.: A 15-year follow-up study of recurrent hypoglycemia in preterm infants by Tin et al. and The Children with Hypoglycemia and Their Later Development (CHYLD) study. Published in 2012, the Tin et al. study sought to confirm the findings of the 1988 Lucas et al. study. This prospective study included preterm infants <32 weeks gestation born between 1990 and 1991 who had blood glucose measurements taken in the first 10 days of life. Investigators matched infants that had experienced recurrent neonatal hypoglycemia (defined as blood glucose <47 mg/dL on 3 or more days in the first 10 days of life) with euglycemia controls and found no differences in development or physical disability at age 2 years. On reassessment at age 15 years, investigators again found no difference in development or IQ scores between the two groups. The authors concluded that the "study found no evidence to support the belief that recurrent low blood glucose levels in the first 10 days of life usually pose a hazard to preterm infants". The CHYLD study is a prospective cohort investigation of infants born >32 weeks gestation with risk factors for neonatal hypoglycemia. The initial findings showed that treatment of neonatal hypoglycemia to maintain blood glucose >47 mg/dL did not correlate with an increased risk of neurosensory impairment at 4.5 years of age. Infants that experienced more severe or prolonged episodes of low blood glucose did not have worse outcomes. Investigators could not establish a numerical glucose level at which risk increased, but found that glucose instability (the proportion of measurements and duration of time blood glucose values were outside the range of 54 to 72 mg/dL) in the 48 hours of life was most predictive of worse developmental outcomes. Infants with the greatest glucose instability had a 2 to 3-fold increased risk of neurosensory impairment. Interestingly, moderate "hyperglycemia," blood glucose values >72 mg/dL, did correlate with an increased risk of poor visual motor and executive functioning. This finding raises the question: are infants experiencing low and "high" early blood glucose values at risk of worse neurodevelopmental outcomes? Complications Severe, prolonged hypoglycemia in the neonatal period can have devastating outcomes, including long-term neurodevelopmental disabilities, cerebral palsy, and death. Infants with congenital causes of persistent hypoglycemia have significantly higher rates of morbidity and mortality: 25 to 50% have developmental disabilities. Nervous tissue can survive long periods of low blood glucose levels by utilizing alternative energy substrates (ketones, amino acids, lactate) to fuel its metabolic demands. The hypothesis is that the utilization of these alternative metabolites may have a neuroprotective effect on the immature neonatal brain. Ultimately, however, a glucose supply must be established. In 1967, Anderson et al. published a case series of the pathologic findings of 6 infants with severe, prolonged hypoglycemia in the first week of life. The authors reported that severe, prolonged hypoglycemia caused extensive degeneration of the central nervous system and, if left untreated, ultimately resulted in death. The brain damage was less severe in infants treated with exogenous glucose. Thus, early recognition of conditions that cause persistent hypoglycemia is critical.

6. Breastfeeding- Dr. Sabu Richard Abraham

1. Preparing the Mother for Breastfeeding The antenatal mother has to be motivated and prepared for breastfeeding. In the last trimester of pregnancy, breast and nipples should be examined for retracted or cracked nipples. Oiling, massaging and applying suction using ‘inverted syringe technique’ are useful. Primigravidas and those who have experienced difficulty with lactation previously need more care and motivation. Antenatal mother should take more food, extra 300 kcal and 15 g protein and lactating mother should take extra 400-500 kcal and 25 g protein. This can be achieved by one to two extra helpings of family food. She should also take plenty of green leafy vegetables, seasonal fruits and fluids. 2. Initiation of Breastfeeding Baby must be put to breast within half an hour after normal delivery and within four hours after caesarean sections. Prelacteal feeds like gold rubbed in water, honey, distilled water, glucose etc., should not be given. These items will satisfy the thirst and will reduce the vigour to suck and may lead to diarrhoea and helminthic infestation. Soon after birth, the baby is awake, alert and ‘biologically ready’ to breastfeed and initiation of breastfeeding is very easy. Later on, the baby goes to prolonged sleep and thereafter initiation may be difficult. Breastfeeding can be initiated even when mother is sedated or on IV fluids. In the first 2-\ days, small quantity of colostrum (10-40 ml) that is secreted is all what the baby needs. Colostrum is rich in protein and immunoglobulins. The mother and baby should be relaxed and comfortably postured during breastfeeding. Initially they may need some help. The baby’s head may be resting on the elbow of the mother and she should support the baby with the same hand. She should also support the breast between the index finger and middle finger of the opposite hand during feeding. ‘Rooming-in’ is keeping the mother and the baby in the same room, ‘bedding-in’ is keeping the mother and baby in the same bed and ‘mothering-in’ is keeping the baby on the abdomen of the mother. These measures ensure mother-infant bonding and skin-to-skin contact. Skin-to-skin contact, eye-to eye contact and mother—infant bonding lead to successful breastfeeding and emotional adjustment. Sucking should be continued as long as the baby desires to suck. This will satisfy the sucking instinct of the baby and will express the ‘hind-milk’ which is more nutritious. When sucking takes place only for a few minutes, the baby will get only the ‘foremilk’. This will satisfy only the thirst of the baby and ‘hindmilk’ has to be fed to satisfy the nutritional demands and to ensure more milk production. It is better to suckle from both the breasts and generally babies finish feeding by twenty minutes. In case of twin babies, exclusive breastfeeding should be the choice. 3. Reflexes that Help in Breastfeeding Three reflexes, namely rooting, sucking and swallowing, help the baby in breastfeeding. When the breast nipple is allowed to touch the cheek of the baby, the baby will open the mouth and initiate sucking. This is called rooting reflex. Sucking and swallowing become coordinated by 34 weeks of gestation. Sucking by the baby, prolactin (milk production) reflex and oxytocin (milk ejection) reflex initiate and maintain lactation in the mother. Sucking acts as the afferent stimulus for prolactin and oxytocin reflexes. Oxytocin reflex is also called ‘let down reflex’. Let down reflex will be efficient only when the mother is relaxed and comfortable. Trickling of a few drops of milk from the opposite breast while initiating feeding (let down reflex) gives a positive clue about milk production and ejection. Colostrum is replaced by ‘transition milk’ in a few days and later on by ‘mature milk’. It gradually increases till 6 months after delivery and later plateaus off. Average quantity of milk is 500-800 ml/day. 4.Common Problems during Breastfeeding a) Flat or inverted nipples: The size of the resting nipple is not important. It is just a guide to show where the baby has to take the breast. The areola and the breast tissue beneath should be capable of being pulled out to form the teat. Occasionally, on attempting to pull out the nipple, it goes deeper into the breast; this is true inverted nipple. b) Fullness and engorgement of the breast: Fullness of the breast is a frequent problem. However, milk flow continues and the baby can feed normally. If enough milk is not removed, engorgement of breast may result. Breast engorgement is an accumulation in the breast of increased amounts of blood and other body fluids, as well as milk. The engorged breast becomes very full, tender and lumpy. The common causes of engorged breasts are: giving prelacteal feeds, delayed initiation of breastfeeds, early removal of the baby from the breast, bottle-feeding and any restriction on breastfeeding. Engorgement may cause the nipple to flatten, making it difficult for the baby to suckle effectively. The mother too avoids feeding because of a tight and painful breast. This leads to inadequate emptying, decreased production of milk and sometimes infection. Engorgement of the breast can be prevented by avoiding prelacteal feeds, keeping the baby on mother’s milk both in hospital and home, unrestricted and exclusive breastfeeding on demand, and feeding in the correct position. Once engorgement occurs, the baby should be breastfed frequently followed by expression of breast milk. The following measures will help relieve the problem usually within 24 to 48 hours: ■ Applying moist heat to the breast 3 to 5 minutes before a feed, followed by gentle massage and stroking the breast towards the nipple ■ Expressing enough milk to soften the areola, enabling proper attachment ■ Feeding frequently, every 2-2.5 hours or sooner at least for 15-20 minutes each side after milk let down has occurred ■ Feeding the baby in a quiet, relaxing place ■ Paracetamol may be needed to relieve the pain in the breast c) Sore nipple and cracked nipples: If a baby is not well attached to the breast he or she sucks only the nipple (poor attachment). It is the most common cause of sore nipples in the first few days. If feeding continues in a poor position, it may lead to a cracked nipple because of physical trauma to this area and later to mastitis and breast abscess. Oral thrush in the baby is another important cause of sore/cracked nipples, but it usually develops after a few weeks of birth. To prevent soreness and cracking of the nipples, attention should be paid to teaching correct feeding positions and techniques to the mother. If there is pain in the nipple area during breastfeeding, mother should wait until the baby releases the breast, or insert her finger gently into the baby’s mouth to break the suction first, so as to avoid injury to the nipple. Then the mother should be helped with attachment and repositioning the baby, so that it will not cause pain. This is the test of correct attachment. Breastfeeding should be continued on the affected breast as it usually heals after correcting the sucking position. Medicated creams are best avoided as they may worsen the soreness and draw away the attention from the crucial issue. d) Blocked duct: If the baby does not suckle well on a particular segment of the breast, the thick milk blocks the lactiferous duct leading to a painful hard swelling. This ‘blocked duct’ is not associated with fever. Treatment requires improved removal of milk, and avoiding any obstruction to milk flow. Ensure that the infant is sucking in good position. Some authors recommend holding the infant with the chin towards the affected part of the breast, to facilitate milk removal from that section, while others consider that generally improved attachment is adequate. Explain the need to avoid anything that could obstruct the flow of milk, such as tight clothes and pinching or scissoring the breast too near the nipple. Encourage the mother to breastfeed as often and as long as her infant is willing, with no restrictions, including night feeds. Suggest that she apply wet heat (e.g., warm compresses or a warm shower) over the breast. e) Mastitis and abscess: If the blockage of the duct or engorgement persists, infection may supervene. The breast becomes red, hot, tender and swollen. Mastitis must be treated promptly and adequately. If treatment is delayed or incomplete, recovery is less satisfactory. There is an increased risk of developing breast abscess and relapse. A breast abscess may occur sometimes without mastitis. The main principles of treatment are: ■ Supportive counselling ■ Effective milk removal ■ Antibiotic therapy ■ Symptomatic treatment Antibiotic treatment is indicated if either: ■ Cell and bacterial colony counts and cultures are available and indicate infection, or ■ Symptoms are severe from the beginning, or ■ A nipple fissure is visible, or ■ Symptoms do not improve after 12-24 hours of improved milk removal. 5. How often to breastfeed? Exclusive demand feeding is the ideal schedule to follow. There is no ‘tailor made schedule’, as milk production, sucking habits, stomach capacity etc., vary from baby to baby. Practise frequent breastfeeding initially and allow ‘self-regulation’ by the baby. The mother can soon find out the average time interval the baby will rest after a feed. She can adjust her rest period in between. Almost all mothers can be relied upon to practise demand feeding. She will know why her baby is crying; e.g., is it to sleep? Is it due to illness? etc. There is no need to give boiled and cooled water or fruit juice in between while the baby is on exclusive demand feeding. A full-term appropriate for gestational age (AGA) baby who is thriving well does not need multivitamin drops as well. 6. Burping after feeding Babies tend to take in a lot of air during feeding. This will lead to abdominal distension, colics, regurgitation etc. To get rid of this, the mother has to do ‘winding’ or burping. The baby can be put on the left shoulder, the head has to be supported with mother’s left hand and then with the right arm support the buttocks and gently pat on the baby’s back with the right hand. Slowly air will escape and the baby will become comfortable. Burping can also be done in other positions, e.g., place the baby prone in the mother’s lap and gently pat on the back. 7. How to know whether breast milk is sufficient or not? Most of the mothers and grandmothers are worried whether breast milk is sufficient or not? They may put pressure on the doctor to prescribe an infant milk substitute (IMS). When mothers come complaining that breast milk is not sufficient, a patient listening is required. The following points will help in decision making. Is the baby frequently passing plenty of pale-coloured urine? Is the baby passing 1-6 liquid stools per day ? Is the baby gaining weight? If yes, the baby is getting enough milk. Next ask whether the mother is offering other feeds or feeding bottle in between. This preload will decrease the vigour of sucking and will lead to incomplete emptying of breast and suppression of lactation. Feeding bottles cause ‘nipple confusion’. Sucking from the bottle is a totally different and at the same time a more easier art compared to breastfeeding. When both are offered, babies who generally tend to be lazy, resort to the more easier technique of bottle feeding. If baby requires mother's milk and bottle feeding, the complete emptying of the breast is very essential before the bottle feed is started. 8. How long to breastfeed? Breastfeeding should be continued well into the second year of life. It is better to breastfeed till two years of life; the period of maximum brain growth and myelination. After 4-6 months of age, weaning foods should be offered in addition to breastfeeding. 9. Whether to breastfeed when the baby or the mother is ill? Breastfeeding should be continued when the baby is ill. It should be discontinued only if there are gastrointestinal contraindications to oral feeding. It can be given during infections like rhinitis, viral fever, diarrhoeal diseases, respiratory infections, asthma etc. It is the most easily digestible food for the ill baby. It will be the best pacifier to the sick baby and it often acts as a life saviour to many babies. It will satisfy the nutritional and fluid demands and will offer anti-infective and immunological factors. Babies may suck with less vigour and so they may be offered more frequent feeds. Expressed breast milk (EBM) should be given if the baby cannot suck. This will prevent suppression of lactation. Babies with congestive heart failure do very well on EBM as it has a very low sodium content. A few drops or small quantities of EBM given to sick babies on IV fluids has been shown to paint the gut with immunological factors, to promote gut function and to reduce the incidence of necrotising enterocolitis (NEC). Breastfeeding can be continued during most of the maternal illnesses including viral fever, mastitis, breast abscess, UTI, TB, hepatitis B etc. If the mother is an open case of TB, she should be initiated on chemotherapy and the baby should be put on chemoprophylaxis. In India, where TB is rampant and the chance for drug resistance is high, it is better to give INH and rifampicin instead of INH alone. After 3 months, ensure that mother is sputum negative and do Mantoux (Mx) test on the baby. If Mx test is negative, stop drugs and give BCG. If Mx test is positive, continue treatment for a total of 6-9 months. In hepatitis B, the baby can be given hepatitis B specific immunoglobulin, followed by hepatitis B vaccination. In AIDS, as long as there is no caretaker or agency to take up the feeding and care of the baby, breastfeeding may be continued. This is the only possible option in many cases even though there is a chance of HIV transmission through breast milk. The chance for perinatal transmission of AIDS is almost 30%. In mastitis and breast abscess, temporary stoppage and expression of breast milk from the affected side may be required. In postpartum psychosis, breastfeeding can be allowed under supervision. In sore nipples, ensure proper attachment of the baby to the areola, apply milk or oil on the nipple, expose the nipple to air and treat oral thrush in the baby by clotrimazole mouth paints. It can also be applied on the nipple. 10. Contraindications to Breastfeeding Even though there are a few temporary contraindications to breastfeeding, permanent contraindications are very rare. Congenital lactose intolerance and galactosaemia are contraindications. These are extremely rare conditions and such babies cannot be given animal milk also. In acquired lactose intolerance which is temporary, breastfeeding can be continued. Similarly, breastfeeding can be continued in the so-called ‘breast milk jaundice' thought to be due to 3-alpha 20-beta pregnanediol which may inhibit bilirubin conjugation. 11. The Advantages of Breastfeeding The numerous advantages of breast milk are beyond description and understanding. a) The physical benefits are optimum fluidity and warmth. b) It is very economical. The approximate cost to artificially feed a baby less than 6 months of age is estimated to be more than one-third of the average family income, i.e., almost more than the per capita income. We are unable to afford this at national level, community level or at family level. c) It is very convenient. There is no need to carry or sterilize utensils. It can be made available anywhere at any time. d) It is very physiological. It is the sweetest milk with high lactose content. The protein is easily digestible. The lipids are rich in essentia] fatty acids, long chain polyunsaturated fats (LCP), phospholipids and prostaglandin precursors. It supplies enzymes like amylase, lipoprotein lipase, bile salt stimulated lipases (BSSL), oxidases, lactoperoxidases, leucocyte myeloperoxidase etc. These enzymes increase digestibility and also act as defence against microbes. It also contains growth regulating factors, growth promoting factors and growth modulators. LCPs promote brain growth and reduce dyslexia and hyperactivity. e) Biochemically it is superior. The protein is mostly whey protein (80%) rich in a-lactalbumin and lactoferrin and the rest is casein (20%) Lactablumin is rich in tryptophan which is the precursor of serotonin which plays an important role as neurotransmitter. Lactoferrin ensures absorption of iron and zinc and it is bacteriostatic as well. It binds iron and makes it unavailable to the bacteria. Alpha-casein and lactoglobulin, which are allergens, are absent in human milk. Even though protein is lower in breast milk, non-protein nitrogens are high The non-protein nitrogen in breast milk plays a significant role in the growth and development of the infant. It is also rich in binding proteins that bind thyroxin, Bp , vitamin D etc. The calcium-phosphorous ratio is more than 2 and it ensures calcium absorption. f) Immunologically, it is extremely safe and is non-allergenic. It supplies passive immunity. Macrophages, lysozymes and complements offer immunity to the baby. It also supplies acute phase reactants. Nutritional composition of breast mik supports the gut microflora which plays essential role in enhancing the immunity of the infants. It contains immunoglobulins, secretory components and secretory IgA (SIgA). SIgA offers surface protection to the respiratory and GI tracts. Immunoglobulins other than SIgA are generally split up in the gut. SIgA are produced in the mammary gland by plasma cells that originate from immunocompetent lymphoid tissue, namely, gut associated lymphoid tissue (GALT) and bronchus associated lymphoid tissue (BALT) by virtue of enteromammary and bronchomammary axes. IgG and IgM levels become undetectable in the second month of lactation. Secretory IgA may resist proteolytic degradation in the neonatal gut and may offer some protection. Breast milk supplies T and B lymphocytes. T lymphocytes are responsible for transfer of immunological memory. The ‘bioactive factors’ in milk are proteins like lactoferrin, non-protein nitrogen like nucleotides, enzymes, hormones, growth factors, factors for host defence, oligosaccharides, mucins, probiotic substances and polyamines. The bifidus factor promotes the growth of lactobacilli. Polya-mines like spermine, spermidine and putrescine promote cell growth and differentiation. Putrescine is a precursor of gamma amino butyric acid (GAB A). GAB A is an inhibitory neurotransmitter. g) Psychologically, it ensures emotional stability and personality development due to close contact with the mother and mother-infant bonding.

7. Breastfeeding- Dr. Sabu Richard Abraham

Reference: KE Elizabeth,Nutrition and Child Development 6th edition.

8. Neonatal- Dr. Sabu Richard Abraham

The Neonatal Resuscitation Program : The Neonatal Resuscitation Program (NRP®) will help you learn the cognitive, technical, and teamwork skills that you need to resuscitate and stabilize newborns. Most newborns make the transition to extrauterine life without intervention. Within 30 seconds after birth, approximately 85% of term newborns will begin breathing. An additional 10% will begin breathing in response to drying and stimulation. To successfully transition, approximately • Five percent of term newborns will receive positive-pressure ventilation (PPV). • Two percent of term newborns will be intubated. • One to 3 babies per 1,000 births will receive chest compressions or emergency medications. The likelihood of requiring these lifesaving interventions is higher for babies with certain identified risk factors and those born before full term. Even though the majority of newborns do not require intervention, the large number of births each year means that timely intervention can save many newborn lives. Because the need for assistance cannot always be predicted, health care providers need to be prepared to respond quickly and efficiently at every birth. During your NRP course, you will learn how to evaluate a newborn, make decisions about what actions to take, and practice the steps involved in resuscitation. As you practice together in simulated cases, 2 your team will gradually build proficiency and speed. The most gratifying aspect of providing skillful assistance to a compromised newborn is that your efforts are likely to be successful. The time that you devote to learning how to resuscitate 11ewborns is time very well spent. Why do newborns require a different approach to resuscitation than adults? Most often, adult cardiac arrest is a complication of coronary artery disease. It is caused by a sudden arrhythmia that preve11ts the heart from effectively circulating blood. As circulation to the brain decreases, the adult victim loses consciousness and stops breathing. At the time of arrest, the adult victim's blood oxygen and carbon dioxide ( C02) content is usually normal and the lungs remain filled with air. During adult resuscitation, chest compressions maintain circulation until electrical defibrillation or medications restore the heart's function. In contrast, most newborns requiring resuscitation have a healthy heart. When a newborn requires resuscitation, it is usually because respiratory failure interferes with oxygen and C0 2 exchange. • Before birth, fetal respiratory function is performed by the placenta instead of the fetal lungs. When the placenta is functioning normally, it transfers oxygen from the mother to the fetus and carries C0 2 away from the fetus to the mother. A healthy fetus makes breathing movements, which are important for normal lung growth. • When placenta! respiration fails, the fetus receives an insufficient supply of oxygen and C02 cannot be removed. Acid increases in the fetal blood as cells attempt to function without oxygen and C0 2 accumulates. • Fetal monitoring may show a decrease in activity, loss of heart rate variability, and heart rate decelerations. If placenta! respiratory failure persists, the fetus will make a series of reflexive gasps followed by apnea and bradycardia. • If the fetus is born in the early phase of respiratory failure, tactile stimulation may be sufficient to initiate spontaneous breathing and recovery. If the fetus is born in a later phase of respiratory failure, stimulation alone will not be sufficient and the newborn will require assisted ventilation to recover. The most severely affected newborns may require chest compressions and epinephrine. At the time of birth, you may not know if the baby is in an early or a late phase of respiratory failure • After birth, the baby's lungs must take over respiratory function. They must be filled with air to exchange oxygen and C02 • Respiratory failure can occur if the baby does not initiate or cannot 1naintain effective breathi11g effort. • If respiratory failure occurs either before or after birth, the primary problem is a lack of gas exchange. Therefore, the focus of neonatal resuscitation is effective ventilation of the baby's lungs. Many concepts and skills are taught in this program. Establishing effective ventilation of the baby's lungs during neonatal resuscitation is the single most important concept emphasized throughout the program. Ventilation of the newborn's lungs is the single most important and effective step in neonatal resuscitation.

9. Neonatal- Dr. Sabu Richard Abraham

1. Neonatal Hyperbillirubinemia

? LAQ on neonatal hyperbilirubinemia A 2-day-old term male neonate is brought to the neonatal unit with complaints of yellowish discoloration of the skin and eyes noticed by the mother since morning. The baby was delivered vaginally at home and cried immediately after birth. The mother is O negative and the baby is B positive. On examination, the baby is icteric up to the abdomen (Kramer zone 3), feeding poorly, and is slightly lethargic. Total serum bilirubin is found to be 18 mg/dL. Direct Coombs test is positive 1. What is the most likely diagnosis? Mention the type and cause of hyperbilirubinemia in this case. 2. What is the role and interpretation of the Direct Coombs test in this neonate? 3. Outline the steps in the management of this newborn ? SAQ on neonatal hyperbilirubinemia 1. Define neonatal hyperbilirubinemia. Write the differences between physiological and pathological jaundice. 2. Enumerate the causes of unconjugated hyperbilirubinemia in neonates. 3. Write short notes on phototherapy: indications, mechanism, and side effects. 4. Compare breastfeeding jaundice and breast milk jaundice. 5. Write a short note on exchange transfusion in neonatal jaundice: indications and procedure outline.

2. Birth Injuries

SAQ - Short Answer Questions on Birth Injuries 1. Enumerate causes and types of birth injuries. 2. Write a short note on Erb’s palsy. 3. Differentiate between caput succedaneum and cephalohematoma. BAQ – Brief Answer Questions on Birth Injuries 1. Define birth injury. 2. Mention four types of birth injuries. 3. Name two risk factors for birth injury. 4. What is caput succedaneum? 5. Differentiate between Erb’s palsy and Klumpke’s palsy.

3. Normal New Born- Dr. Leya Sara Samuel

1. Make a checklist for “resuscitation preparedness”. 2. List the standard precautions for asepsis at birth. 3. Criteria for discharge of a normal newborn. 4. What all should you look for in the first examination of a newborn 5. When to initiate breastfeeding in newborn and what is exclusive breast feeding?

4. Neonatal Hypoglycaemia- Dr. Leya Sara Samuel

1. Etiology of neonatal hypoglycaemia. 2. Clinical features of hypoglycaemia 3. Screening for hypoglycaemia in newborns. 4. 2day old 36weeker baby born to primi mother with gestational diabetes wa noticed to have reduced activity and reduced feeding. GRBS was 23mg/dl.

5. Breastfeeding- Dr. Sabu Richard Abraham

1.Write down the physiology of lactation . 2.List the advantages of breastfeeding in mother and baby separately. 3.List down the proper latching techniques during breastfeeding. 4.Difference between fore milk,hind milk and colostrum. 5. How to counsel a primi mother regarding effective breastfeeding and its importance.

6. Neonatal- Dr. Sabu Richard Abraham

1.Explain the importance of team briefing and equipment check before every delivery. 2.How does delayed cord clamping impact preterm versus term infants? 3.Describe the MRSOPA sequence. 4.Outline the indications,technique,and compression to ventilation ratio for neonatal chest compressions according to NRP 8th edition. 5.List the indications,dosage,and route for epinephrine administration during neonatal resuscitation.

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