Quadrant -I (Video)
Neonatal Hyperbillirubinemia- Dr. Parvathy Balakrishnan
Birth Injuries-Dr. Parvathy Balakrishnan
Normal New Born- Dr. Leya Sara Samuel
Neonatal Hypoglycaemia- Dr. Leya Sara Samuel
Quadrant - II (Study Material)
1. Neonatal Hyperbillirubinemia- Dr. Parvathy Balakrishnan
View File2. Neonatal Hyperbillirubinemia- Dr. Parvathy Balakrishnan
View File3. 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.
Quadrant - III (Assignments)
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.