Partha’s Management Algorithms in Pediatric and Adolescent Practice Dhanya Dharmapalan, A Parthasarathy, Anupama S Borker, Alok Gupta, Remesh Kumar
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart and t refer to table
A
Abdomen
acute 303
ultrasound of 135
X-ray 250
Acanthosis nigricans 120f
Accidental/suicidal one-time ingestion 253fc
Acetylcholine, accumulation of 254
Acid-base
analysis, simplified 92
disorders 92, 93t
status 92
Acid-fast bacilli 66
Acidosis 328
lactic 94
metabolic 94fc, 328
Aciduria, organic 94
Acne
moderate 277f
vulgaris 276, 276fc
management guidelines 276
Adrenal hyperplasia, congenital 14, 15, 230, 235, 236
Adrenarche 15
premature 15, 16
Adriamycin 173
Adverse event following immunization 45, 46, 47f, 48f, 49, 50fc
classification of 50t
management of 45
Airway 99, 261, 269
control 264
Alagille syndrome 110
Alanine aminotransferase 20
Alcohol 260
intoxication 263
treatment 263
Allergic
gape 186, 187f
mannerism 186, 187f
rhinitis 186, 186fc
classification of 188fc
clinical signs of 186
diagnosis of 186
grading of 188f
management of 188f, 188fc
pharmacological management of 188
salute 186, 187f
shiners 186, 186f
Allergy 55, 56fc, 185
rhinitis, prevalence of 186
Allogeneic hematopoietic stem cell transplantation 156, 157
All-trans retinoic acid 171
Alopecia areata 278
classical 278f
management of 278fc
Alpha fetoprotein 14
Alpha-2-adrenergic agonists 29
Alprazolam 262
Amblyopia, detection of 289
American College of Chest Physicians 96
Amlodipine 132
Amodiaquine 329t
Amphetamine 263
intoxication 263
Anal
anomalies 310
stenosis 310
Analgesia
nonopioid 9
opioid 9
Analgesics 161
Anaphylaxis 47, 192, 202
diagnosis of 192, 192fc
food induced 194
management guidelines 192
Anaplastic large cell lymphoma 175
Anemia 10, 25, 37, 150fc, 170
management of 38fc
megaloblastic 37f
nutritional 37
severe 328
sideroblastic 37
Angioedema 200, 203, 204, 206fc
acquired 206
hereditary 206
Angiotensin converting enzyme 133, 206
inhibitors 89, 126, 132
Angiotensin receptor blocker 89, 132
Anion gap 92, 94
Anorectal manometry 313
Anorexia 38
Anteposed anus 310
Anteroventral periventricular nucleus 228
Anthracycline 154
Antibiotics 60
Antibodies containing products 56
Antidepressant medicines 31
Antiepileptic drug 72, 75
Antifibrinolytic drugs 161
Anti-glomerular basement membrane disease 128
Antileukemia therapy 170
Antimicrobial therapy 59
Antinuclear antibody 205
Anti-obesity drugs 22
Anti-phospholipid antibody 215
Antiretroviral therapy 326
Antiviral therapy 88
Anxiety 25
Aorta, coarctation of 81, 130
Aortic stenosis 81
Apley's definition 302
Apnea 58, 99
Appendicitis 308
acute 303
clinical presentations 308
epidemiology 308
investigations 308
management 308
Argon plasma coagulation 119f
Arrhythmia, cardiac 332
Artemether 329t
Arterial blood gas 92, 249, 269
analysis 92
Arteriovenous malformation 70, 117
Artery, pulmonary 78, 80
Artesunate 329t
Arthritis 212, 213, 213fc
enthesitis-related 212, 213, 214fc, 215f
juvenile
idiopathic 211
psoriatic 213
Ascorbic acid 153
Asparaginase 154
Aspartate aminotransferase 20
Asphyxia 9
Aspiration 99
recurrent 97
syndromes 103
Asplenia 54
Asthma 19, 99, 103, 104, 132, 189
acute severe 191t
classification of 190fc
clinical diagnosis of 189fc
diagnosis of 189
drugs used in 191t
management of 190
treatment of 190f
Astrocytomas, general management of 183fc
Atenolol 132
Atomoxetine 28
Atopic dermatitis 279
management of 279, 279fc
over face, classical 280f
Atopic eczema 280
Atopy patch tests 196
Atrial
Enlargement
left 82
right 82
hypertrophy, left 83
septal defect 80, 81
Attention-deficit hyperactivity disorder 23, 25, 26
Autism spectrum disorder 18
Autoimmune 205
urticaria 204, 207f
Autoinflammatory disease 206
Autorefractive screening 287
Auxiliary nurse midwife 46
Azathioprine 121, 215
Azithromycin 58, 59, 61
B
Bacillus calmette-Guérin 42, 47
Bacterial
bronchitis 98
endocarditis, subacute 128
infection, local 316
Baldness, smooth patch of 278f
Balloon-occluded retrograde transvenous obliteration 116
Barium enema 313
B-cell acute lymphoblastic leukemia risk classification 154t
Behavior therapy 27
Benzodiazepines abuse 262
treatment 263
Beta-human chorionic gonadotropin 14
Bicarbonate 92, 94
Biliary atresia 112, 113f, 113fc
Bleeding 170
nonvariceal 118
time 159
types of 164
Bleomycin 173
Blood
flow, pulmonary 78, 78t, 79t
group 169
pressure 118, 126, 127, 129, 136, 211
diastolic 20
high 22
low 94
measurements 129f
normal 130
systolic 20
specimen 326
urea nitrogen 127
Body mass index 20, 131, 219, 221
Bone
age 233, 235, 242
marrow 169
Bowel bladder dysfunction 134, 136
Brain
damage 74
injury, preterm 11
tumors 180
classification of 182fc
diagnosis of 181t
general management of 182, 182fc, 184fc
Breast milk expression 7
Breastfeeding 35
Breathing 261
British Thoracic Society 96
Bronchiectasis 97, 98
Bronchomalacia 99
Burkitt lymphoma 175
Buspar 263
Buspirone 263
C
Calcineurin inhibitors 130
Calcium 7, 37
channel blockers 126, 132
metabolism 36
phosphate 8
supplements 39
Cannabis 260
Capillary blood gas 249
Captopril 132
Carbamazepine 73, 263
Carbon monoxide 106
Cardiac failure, congestive 79, 82, 119, 121
Cardiovascular disease 215
Carvedilol 132
Cataracts 284, 287
Centers for Disease Control and Prevention 58, 63
Central nervous system 14, 17, 67, 70, 154, 155, 168, 169, 182, 200, 269, 332
prophylaxis 155
Cerebral
malaria 328
palsy 17
Cerebrospinal fluid 49, 62, 84
Chemical pneumonitis 252f
Chemotherapy 54, 55fc, 174fc
maintenance 155
Chest
pain, localized 300
X-ray 68, 78, 79, 8183, 252f
Child's speech development 16
Children's oncology group 175
Chloramphenicol 60, 61
Chloroma 168
Cholesterol 21
Choroid plexus
carcinoma 184
tumors 182
Chromosome, intrachromosomal amplification of 154
Ciliary dyskinesia 104
Clarithromycin 58, 59
Clobazam 73
Clonazepam 262, 263
Clonidine 2729, 133
Clotting time 159
Club drugs 264
laboratory tests 264
signs 264
symptoms 264
treatment 264
Cobblestone posterior pharyngeal wall 186, 187f
Cocaine 130, 263, 310
intoxication 263
Cognitive behavioral therapy 28
Cold chain 42
failure 42, 43fc, 44
management of 43
monitors 42
Coloboma 287
Coma 328
Comedonal acne 277
Common safety method 288
Complete androgen insensitivity syndrome 244
Complete blood count 110, 118, 125, 127, 135, 169, 215, 222, 249
Conduct disorder 28
Consciousness, impaired 328
Constipation 114, 114fc, 115fc, 152
absolute 304
chronic 310, 310t
habitual 313f
idiopathic 313, 313t
progress of 310
severe 311t
Continuous positive airway pressure 9, 262, 267, 297
Convulsions, multiple 328
Coronary artery
bypass graft surgery 20
disease 20, 332
occlusion 86
Corticosteroids 55fc, 130
Cotrimoxazole 326
Cough 316
dominant asthma 99
evaluation of 96
management of 96, 100fc
nature of 97
nonspecific 99
otogenic 100
postviral 100
Coxsackie virus
A 86
B 86
Cramps, abdominal 152
Cranial nerves 181
Craniopharyngioma, general management of 184fc
C-reactive protein 84, 85, 135, 205
Crohn's disease 153
Cryoglobulinemia 128
Cushing's syndrome 19, 273
Cutaneous mastocytosis 203
Cyanosis 58, 78, 99
Cyclophosphamide 173, 175, 215
Cystic fibrosis 96, 97, 104
Cystinosis 125
Cystourethrography, micturating 135
Cytomegalovirus
congenital 111
infection, congenital 111
Cytopenia 168
D
Dacarbazine 173
Darier's transverse line 186, 187f
Daunorubicin 154
Dehydration 58
Dehydroepiandrosterone sulphate 15, 234236
Dehydrogenase, lactic 169
Delayed puberty 241, 242fc, 244fc
management of 241, 244b
Dengue
case classification 333
fever 331, 332
clinical manifestations of 331
grading of 333
management of 335
severe 331
fluid management 331
new classification 331
hemorrhagic fever 331333, 334fc336fc
infection, natural course of 333
shock 336fc
syndrome 331333
syndrome 332
viral infection 332fc
Dennie-Morgan fold 186, 186f
Denver developmental screening chart 17
Deoxyribonucleic acid 326
Depression 25
mild 30
moderate-to-severe 30
treatment of 30
Dermatosis 34f
Developmental language disorders 17, 18
Developmental screening chart 17
Dexamethasone 154
Diabetes mellitus 61, 132, 219
Diabetic ketoacidosis 94, 125
Diaphoresis 78
Diarrhea 38, 93, 94, 152, 304, 316
Diazepam 262
Dietary management 21
Dihydroartemisinin 329
Dimercaptosuccinic acid 131, 135
Dinitrochlorobenzene 278
Diphenylcyclopropenone 278
Diphtheria, tetanus, pertussis 42, 44, 47, 162f
Direct radionuclide cystogram 135
Disseminated intravascular coagulation 62, 150, 159
Distension, abdominal 303, 311, 312, 312f
Donor human milk 6
Double-outlet right ventricle 79
Down syndrome 156
Doxorubicin 154, 175
Doxycycline 60, 61
Drug-sensitive tuberculosis 66, 67t
Dry blood spot 326
Duhamel's procedure 313
Duodenal ulcer 119f
Dysarthria 17
Dysfluency disorders 17
Dyshormonogenesis 240
Dysnatremia 269
Dysplasia, bronchopulmonary 130
Dyspnea 78
Dysuria 134, 309
E
Ear infection 316
Echocardiography 104
Ectopic anus 310
Edema, pulmonary 328, 332
Ejection systolic murmur 82, 83
Electrocardiogram 79, 131
Electroencephalogram 72, 75
Embryonal cell tumors 181, 184
general management of 183fc
Emesis 181
Empyema thoracis 300
causes 300
clinical features 300
investigations 300
pathology 300
treatment options 300
Enalapril 132
Encephalitis 71fc
Encephalopathy 58, 71, 71fc
Encopresis 115, 311
Endoscopic variceal ligation 116, 117f, 118
Endotherapy 116
Enterocolitis, severe 304
Enzyme-linked immunosorbent assay 334
Ependymal tumors 181
Ependymoma 184
general management of 183fc
Epidermal growth factor 218
Epididymitis 146
diagnosis of 147
Epididymo-orchitis 146, 147
diagnosis of 147
Epileptic aphasia, acquired 18
Epistaxis 153
Epstein-barr virus 86
Erythema 280f
Erythrocyte
cells 27
sedimentation rate 84, 85, 205, 212
Erythromycin 58, 59
Erythropoietin 38, 130
Escitalopram 31
Esomeprazole 118
Esophageal varices, large 117f
Estimated glomerular filtration rate 127, 133
Ethambutol 66
Etoposide 173
Euro-lupus nephritis trial 216
Exotropia
management of 291fc
types of 291fc
Expiratory pressure, maximal 107
Extracellular fluid 333
Extrahepatic portal venous obstruction 117
Extraocular movement assessment 289
Eye 332
Eyelashes, long 187f
F
Facial pain 98
Factor replacement therapy 164f
Falciparum malaria
severe 328
uncomplicated 328
Familial exudative vitreoretinopathy 293
Fanconi syndrome, causes of 125b
Fast eye movement 287
Fasting glucose 20
Fatty liver disease, nonalcoholic 119, 120, 120f, 121
Fecal impaction, management of 114fc
Fecal soiling 115
Felbamate 73
Fever 98, 316
low-grade 134
Fibrin sealants 161
Fibrinogen/fibrin degradation products 159
Fine needle aspiration cytology 171
Flaccid paralysis, acute 47
Flexible fiberoptic bronchoscopy 103
Fluid and electrolyte management 268
Fluorescent in situ hybridization 169
Fluoxetine 31
Flurazepam 262
Focal nodular hyperplasia 121
Folic acid 34, 152
Follicle stimulating hormone 14, 15, 228, 236
Food allergy 193, 193t
causes 193
diagnosis of 195
management of 195
natural history 195
primary prevention of 196
protocol for 197fc
signs of 194t
symptoms of 194t
Forced choice preferential looking techniques 287
Forced expiratory volume 106
Forced vital capacity 105, 106
Fresh frozen plasma 249
infusions 164
Functional constipation, management of 114
Fundal varices glue therapy 117f
Furosemide 133
G
Gabapentin 73
Galactose-1-phosphate uridyl transferase 111
Galactosemia 110, 125
Gallbladder 110
Gamma-aminobutyric acid 74, 228
Gamma-glutamyl transpeptidase 112
Gamma-hydroxybutyrate 264
Ganglia, parasympathetic 312
Gastric ulcer 119f
Gastroesophageal reflux disease 97, 99, 104, 117
Gastrointestinal
bleeding 153
involvement 210
system 194
tract 200, 249
Gene therapy 165
Generalized tonic-clonic seizure 72
Germ cell tumor 176, 177
intracranial 184
Gestational age 226
Glaucoma 284
Glioma 81
high-grade 184
low-grade 182
Glomerulonephritis 126
acute 128b, 130
infection-related 126, 127fc, 130
membranoproliferative 128
postinfectious 126
Glossitis 38
Glucocorticoid 154
Glucose
6-phosphate dehydrogenase deficiency 61, 150
infusion rate 268
Glycogen storage disease 125
Goiter 240, 240fc
Gonadotropin-releasing hormone 14, 15, 228, 235
Goodpasture's syndrome 128
Goserelin 237
Great arteries, transposition of 78, 80fc
Growth
and development 13
assessment of 10
chart 233f
factor, insulin-like 222, 224, 242
hormone 219, 222, 224, 225
deficiency 224, 224fc, 225, 225fc, 226
dose of 226t
monitoring 227fc
Guanfacine 28, 29
Gums 168
H
H1N1 infection 63
categories of 63t
management of 64fc
Haemophilus influenzae 54, 98, 102
Hair loss
extensive 279
limited 278
Halitosis 98
Harada score 84
Harrison's sulcus 78, 99
Hashimoto's thyroiditis 240
Headache 70, 70fc, 98, 181
Hearing
assessment 17
development 9
impairment 18
problems 25
screen 10
Heart
Disease
acyanotic 81, 81fc
congenital 78, 81, 81fc, 83, 83fc
cyanotic 78, 78fc
failure 132
congestive 79, 82, 83, 97
sounds 79
Helicobacter pylori infection 118
Hematochezia 116
Hematocrit 150
Hematology 149
Hematopoietic stem cell transplantation 54, 112
Hematuria 134
Hemobilia 116
Hemoglobin 37, 38, 150
Hemolytic-uremic syndrome 130
Hemophagolymphohistiocytosis 110, 112
Hemophilia 160, 163, 163fc, 165
A 160, 161
B 160, 161
C 160, 161
types of 160
Hemorrhage
intraventricular 11
pulmonary 332
subarachnoid 70
Hemorrhagic disease 158, 159f, 159fc
Henoch-Schönlein purpura 128, 146, 210, 211, 211f
management of 210fc
Hepatic vein 121
Hepatitis
A 55
autoimmune 121
B 55
chronic 121
immune globulin 54
immunization 54fc
surface antigen 169
C
chronic 121
virus 86, 121, 169
Hepatoblastoma 176, 177fc
tumors 176, 177
Hernias 143
congenital 142
features of 142t
inguinal 142fc, 305f
repair, complications of 143
surgery for 143
High anion gap metabolic acidosis 92, 93, 95fc
High bowel atresia 303
High flow nasal cannula 262
Hirschsprung's disease 310, 311, 312f, 313, 313f, 313t
clinical features 312
diagnosis 312
pathological anatomy 312
physiology 312
Histrelin 237
Hodgkin's lymphoma 171, 173t, 174fc
staging 173t
treatment of 174fc
Hormone
adrenocorticotropic 15, 73, 235, 236
antidiuretic 269
luteinizing 14, 15, 228, 230, 236
Human
breast milk feeding 7
chorionic gonadotropin 15, 241, 242
immunodeficiency virus 7, 54, 169, 326
infection 54, 55fc
leukocyte antigen 213
milk
fortifier 8, 10, 40
optimizing use of 6t
Hydralazine 133
Hydrocarbon 250
Hydrocele 142, 143, 144, 144fc
features of 142t
Hydrochlorothiazide 133
Hydropneumothorax, right 301f
Hydroxychloroquine 215
Hymenoptera sting 202
Hypercalcemia 310
Hyperleukocytosis 170
Hypernatremia 272, 273
causes of 273
management of 272
neonatal 273
steps of 272fc
Hyperoxia test 78, 78t
Hyperparasitemia 328
Hyper-reactive airway disease 97
Hypersensitivity vasculitis 128
Hypersomnia 29
Hypertension 94, 129, 130, 131fc, 133, 264
asymptomatic 130
causes of 129, 130t
endocrine causes of 130
management of 129
portal 116, 117
pregnancy-induced 262, 266
primary 130
pulmonary 78, 82
stages of 129, 130t, 132fc
symptomatic 130
therapy 129
transient 130
Hyperthermia 3
sign of 2
Hypertrophy
left ventricular 83
right ventricular 83
Hypoglycemia 34, 328
Hypogonadism
idiopathic hypogonadotropic 242
management of 241, 242b
Hypokalemia 310
Hyponatremia 269271
euvolemic 271, 271t
hypervolemic 271, 271t
hypovolemic 270, 271, 271t
management of 269, 271
steps of 269fc
Hyposmia 98
Hyposplenia 54
Hypothermia 34
management of 3t
mild 3
moderate 3
severe 3
sign of 2
Hypothyroidism 237, 310
congenital 10, 237, 238fc, 239, 239fc, 240t
juvenile 240, 240fc, 240t
Hypotonia, severe 94
Hypotonic fluid losses 273
Hypovolemia 94
Hypoxemia, persistent 58
I
Idiopathic rapidly progressive glomerulonephritis 128
Imipramine 263
Immune thrombocytopenic purpura 150
Immunization 10, 41, 54
framework 51fc
Immuno solid-phase allergen chip 201
Immunoglobulin
A nephropathy 128
E 193, 194, 196, 201, 205
intravenous 74, 85
Immunosuppressive therapy 54, 55fc
Impetigo 280
alternative therapy 280
management of 280, 281fc
over face 281f
types of 280, 281fc
Inactivated influenza vaccine 55, 56
Indian Academy of Pediatrics 65
Indian Society of Pediatric Nephrology 134
Infection 170
control strategies 64
hospital-associated 10
prevention of 10
Infectious disease 57, 62
Inferior vena cava 121
Influenza vaccine 55
Insect
bite 199
sting 198
allergy 198
venom allergy 201t
management of 200fc
Insomnia 29
Inspiratory pressure, maximal 106
International League Against Epilepsy 73
Interstitial lung disease 97, 99, 104, 106
Intestinal obstruction 309, 310
Intra-articular corticosteroid injection 213
Intra-articular glucocorticoid 214
treatment 213
Intradermal test 196, 201
Intrauterine growth restriction 39, 219
Intravenous immunoglobulin 212, 215
Intussusception 308
clinical features 308
investigations 308
IQ tests 24
Iron 7, 8
deficiency anemia 150, 152t
management of 150, 151b, 151fc
prevention of 153
poisoning 248
diagnosis of 248, 248c
therapy 152t
medicinal 151
parenteral 153
Isocitrate dehydrogenase 182
Isoniazid 66
preventive treatment 67
J
Jaundice 316, 328
Jugular venous pressure 78, 79
Juvenile hypothyroidism
evaluation of 240
management of 240, 240fc
Juvenile rheumatoid arthritis 169
K
Kangaroo mother care 9, 268
Kawasaki disease 84, 84b, 84fc, 85, 85fc
atypical 84
classic 84
management of 86
medical management of 85t
Kayser-Fleischer ring 120f
Kerosene poisoning 250, 250fc, 251, 251fc
Ketamine 264
Kidney
biopsy 128
disease
chronic 94, 226
improving global outcomes guidelines, 129
function tests 169
injury, acute 94
Klinefelter syndrome, management of 241, 243fc
Koilonychia 150f
Kussmaul respirations 94
Kwashiorkor 34
L
Labetalol 132
Lacosamide 73
Lamotrigine 73
Landau-Kleffner syndrome 18
Language delay 24
Lansoprazole 118
Large B-cell lymphoma 175
Laryngeal web 296, 296fc
Laryngomalacia 296, 296fc
Larynx, congenital lesions of 296
Leukemia 168, 169t
acute 168, 170t
lymphoblastic 154, 155fc, 156, 157, 169, 169t, 170, 170t
myeloblastic 168, 169, 170t, 171t
myeloid 170
promyelocytic 171
diagnosis of 169fc
extramedullary 168
mixed lineage 156
sign of 168t
symptoms of 168t
treatment of 170
Leukocoria 293fc
management of 293fc
types of 293fc
Leukocytoclastic vasculitis 210
Leukocytosis 168
Leukomalacia, periventricular 11
Leukotriene receptor antagonists 188, 190
Leuprolide 237
Levetiracetam 73
Liquid ecstasy 264
Live vaccine 56
immunization 54, 54fc
Liver
failure, acute 111
function test 110, 118, 169
transplantation 253
Lorazepam 262
Losartan 132
Low-birth-weight 2, 39, 39f, 40, 40fc, 54, 265
Lowe's syndrome 125
Low-molecular-weight heparin 85
Lumefantrine 329t
Lung
biopsy 104
disease 104
cavitary 97
diffusing capacity of 106
Lupus nephritis 128
Lymphadenitis 47
Lymphadenopathy 168, 172, 172fc
Lymphoid cells, innate 278
Lymphoma 171, 172t
diagnosis of 172fc
lymphoblastic 175
staging of 171, 173t
treatment of 175
Lysergic acid diethylamide 264
M
Macrophage activation syndrome 212
Magnetic resonance imaging 14, 15, 89, 103, 135
Malacia 99
Malar rash 216f
Malaria management 328, 330fc
clinical features 328
diagnosis 328
Malaria, uncomplicated 328
Malarial anemia, severe 328
Mallory-Weiss tear 117
Malnutrition, severe acute 34, 34f, 35
Marasmus 34
Masses
abdominal 176, 176t
mediastinal 172
Matrix metalloproteinases 89
Mayer-Rokitansky-Küster-Hauser syndrome 244
Mean corpuscular
hemoglobin 151
volume 151
Measles 55, 98
mumps, and rubella 42, 55
vaccine 55
Meconium peritonitis 305f
Mefloquine 329t
Meningomyelocoele 311
Mental disorders 25
Metaiodobenzylguanidine 176
Metformin 22
Methicillin-resistant Staphylococcus aureus 280
community acquired 103
Methotrexate 173, 213
Methylphenidate 28
Methylprednisolone 212, 213, 215
Midazolam 74
Mid-diastolic murmur 78
Mid-intestinal obstruction 305f
Minimal residual disease 155, 157, 169
Missed opportunities for vaccination strategy
10-step process of 52
benefits of 53
resource guides 53
World Health Organization's 52
Mitochondrial
disorders 94
hepatopathy 110, 112
Mitral regurgitation 81
Moraxella catarrhalis 98, 102
Mucociliary dysfunction 103
Multiple pituitary hormone deficiency 242, 244
Multisystem disease 215
Murmur, pansystolic 81, 82
Murphy's sign 309
Mycophenolate mofetil 215
Mycoplasma pneumoniae 103
Myelodysplastic syndrome 150
Myocardial damage, viral-induced 87fc
Myocarditis 87, 87t, 88, 88b, 88t
acute 86, 88, 89fc
over time 86f
Myopia 284
N
N-acetylcysteine 253
dosage regimens 254B
National Cancer Institute 154
National Institute for Health and Clinical Excellence Guidelines 134
National Nutritional Anemia Control Program 152, 153
Nausea 152, 309
Necrotizing enterocolitis 6, 10
Neonatal
cholestasis syndrome 110, 110fc, 111, 112, 113f
supportive treatment of 113fc
hemochromatosis 110, 111
intensive care unit 9, 284
thyroid screening protocol 237, 237fc
Nephritis, acute postinfectious 128
Nephrology 123
Neuritis, brachial 47
Neuroblastoma 176, 177fc
tumors 176, 177
Neurology 69
Neuromuscular disease 58
Neuronal and mixed neuronal-glial tumors 182
Nifedipine 132
Nitrazepam 73
Nitroblue tetrazolium test 104
N-methyl-D-aspartate receptors 74
Non-allergic reactions 200
Nonanion gap metabolic acidosis 93
Noncirrhotic portal fibrosis 117
Non-Hodgkin's lymphoma 171, 175177
current French, American, British classification for 175b
staging of 175
treatment of 175fc
Non-steroidal anti-inflammatory drug 161, 194, 204, 205, 214
Noonan syndrome 226
Normal anion gap metabolic acidosis 92, 96fc
Nucleic acid amplification test, cartridge-based 66, 68, 98
Nutrition 10, 33
O
Obstructive sleep apnea 297, 297fc
Oligoarthritis 213
Omentum, necrosis of 306f
Omeprazole 118
Oncovin 173
Ophthalmology 283
Opioid 260, 264
treatment 264
Oppositional defiant disorder 26, 28
Optic nerve glioma, general management of 183fc
Opto-kinetic nystagmus 287
Oral
fluconazole 118
food challenge test 196
iron therapy 152
side effects of 152
polio vaccine 47
rehydration solution 35
typhoid vaccines 56
Organophosphate compound poisoning 254, 255fc, 256, 256t
Orogastric tube 40
feeding 39f
Oromotor stimulation 9
Oseltamivir administration 63
Osteitis 47
Osteomyelitis 47
Otoacoustic emission 10
Otorhinolaryngology 295
Outflow tract, right ventricular 79
Ovarian germ cell tumor 180fc
Oxcarbazepine 73
Oxygen saturation 267
P
Packed red
blood cell 169, 170
cell transfusion 151
Pain
abdominal 94, 302, 307t, 309
history of 309
hypogastric 309
parietal 303
splanchnic 303
unilateral abdominal 300
visceral 303
Pallor 150f
Pandora's box 302
Papules 277f, 280f
Paracetamol
overdose 254
poisoning 252, 253
clinical features of 252
supportive therapy of 254b
Parahemophilia 160, 161
treatment of 164
Paraspinal nerve tumors 181
Partial androgen insensitivity syndrome 242, 244
Partial thromboplastin time 159
Patent ductus arteriosus 81
Pediatric
intensive care unit 94, 269
obesity, pediatric 22
surgery 299
tuberculosis, diagnosis of 66
Pelvic
masses 310
rhabdomyosarcoma 179fc
Peritonitis 306f
Pertussis 58
management of 58fc
Pharmacotherapy 30, 130
Phenobarbital 73
Phimosis 140
pathological 140f, 141fc
physiological 140, 141fc
Phosphorus 7, 37
supplements 39
Physiotherapy 163
Pineal region tumors 181
Plasmodium
falciparum malaria 328
knowlesi 330
hyperparasitemia 328
malaria 329, 330
malariae 329, 330
ovale 329, 330
uncomplicated 330
vivax 329
Plastic wraps, use of 2
Pneumonia 58
community acquired 103
nonresolving 101, 102fc
normal versus delayed resolution of 101
Poisoning 247
Polio vaccines 55
Polyarteritis nodosa 128
Polyarthritis 213
Polycystic kidney disease, autosomal recessive 130
Polyethylene glycol 114
Polymerase chain reaction 58, 60, 89
Polyuria 94
Poor school performance 23
Positron emission tomography 174, 174fc, 176
scans 103
Postnasal drip 98
Potassium supplements 126
Prader-Willi syndrome 19, 226
Prazosin 133
Precocious puberty 14, 15, 228, 230, 234fc, 236fc
classification of 230, 230fc
diagnosing 233f
etiology of 230, 230fc
evaluation of 14, 14fc, 15fc, 15t
management of 230, 236fc
suppression of 16
Precordium 78
Prednisolone 121, 154
Prednisone 173, 175
Preeclampsia 266
Pregnancy, first trimester of 329
Prehypertension 130
Pressure, intracranial 130
Preterm labor, management of 266
Prick-to-prick test 196
Procalcitonin 135
Procarbazine 173
Processus vaginalis 143
Progressive familial intrahepatic cholestasis 112
Prophylaxis 64
Propofol 74
Propranolol 132
Protein 37
Prothrombin
complex concentrates 160
time 110, 159
Proton pump inhibitors 118
Protracted bacterial bronchitis 97
Pseudohyponatremia 270
Pseudostrabismus 289
Pseudotumor cerebri 19
Psychotherapy 30
evidence-based 30
Ptosis 287
Pubertal development 228
early 230, 231fc, 234fc
Tanner staging of 229t
Puberty
normal sequence of 229fc
physiology of 228fc
Pulmonary function tests 105
Pustules over face 277f
Pyrazinamide 66
Pyrimethamine 329t
Pyuria 134
Q
Quinine 331
R
Rachitic rosary 36f
Radiotherapy 54, 55
Rapid diagnostic test 328
Rapidly progressive renal failure 211
Rashes, urticarial 207f
Ready-to-use therapeutic food 35
Receptive expressive emergent language scale 17
Recurrent urinary tract infection, management of 136fc
Red blood cell 38, 249
volume 37
Red cell distribution width 38
Red currant jelly stools 308
Reflux nephropathy 130
Renal
artery, thrombosis of 130
diseases 128
failure, acute 328
function test 135, 169
impairment 328
parenchymal disease 130
pelvis dilatation 9
tubular acidosis 94, 96, 124, 124fc
vein, thrombosis of 130
Renovascular disease 130
Rescue therapy 115
Respiratory
alkalosis 92
disorders 94
distress syndrome 262, 267
acute 62, 249, 252f, 332
pressures, maximal 106
system 19, 194
tract infection, recurrent 78
Reticulocyte count 169
Retinoids, topical 277
Retinopathy 284, 285fc, 293
development of 284
Reverse transcription-polymerase chain reaction 169
Revised National Tuberculosis Control Program 66
Rhabdomyosarcoma tumors 176, 177
Rheumatoid factor 213
Rheumatology 209
pediatric 210
Rhinitis 98
Rhinosinusitis 98
pediatric 298, 298fc
Riboflavin 37
Ribonucleic acid 326
Rickets 36
management of 37fc
nutritional 36
sign of 36f
vitamin D dependent 36, 37
Rickettsia infection 60
Rickettsial disease 60, 61
management of 61t, 62fc
Rifampicin 66
Rotavirus vaccines 56
Roux-en-y gastric bypass 22
Rule of four 188f
Rumack-Matthew nomogram 253f
S
Schober test 213
Schwartz formula 125
Sclerotherapy, endoscopic 117f, 118
Scrotal edema, idiopathic 146, 146f, 147
Scrotum, acute 145f, 146fc
Secondary language disorders 18
Seizure 94, 181, 271
disorder 72, 72fc
termination 74, 75fc
types of 73t
Selective serotonin reuptake inhibitors 25
Sepsis 47
Sertraline 31
Sexual maturity rating 221, 231, 240
Shake test 45f
Shock 271, 328
Short stature 218, 219, 222, 222fc
causes of 219, 219fc
diagnosing 219, 220fc
disproportionate 226fc
homeobox 219, 226
idiopathic 226
interpretation of 223, 223fc
proportionate 225, 225fc
Sibutramine 22
Simple partial seizure 72
Single ventricle physiology, stages of 80t
Sinusitis 98
viral 98
Skin 194
mode 2
prick test 196, 201, 207f
tests 201t
Skinfold thickness measurements 20
Skin-to-skin contact 2
Slow eye movement 287
Small for gestational age 221, 234
Soave's procedure 313
Sodium
disturbances 269
excess 273
nitroprusside 133
Solid organs transplant 55
Somatic growth 218fc
infancy-childhood-puberty model of 218f
Speech 16, 24
and language
delay 23
disorders, classification of 17fc
delay, warning signs of 17
disorder of 17
rhythm, disorder of 18
Spinal surgery, history of 311
Spirometry 105, 107
interpretation 106fc
normal evaluation 106fc
Spontaneous urticarial, chronic 208t
Squaric acid dibutyl ester 278
Stanford-Binet and Wechsler series 24
Staphylococcal scalded skin syndrome 281f
Status epilepticus 73, 75
complications of 75t
super-refractory 74
Stenosis, pulmonary 78, 79, 81
Sting reaction, types of 202t
Strabismus 284, 289
management of 290fc, 292
surgery 292
types of 290fc
Streptococcus pneumoniae 98, 102
Sublingual immunotherapy 202
Substance abuse 260, 261fc
management of 261fc
Sulfadoxine 329t
Sulfamethoxazole 58, 59
Sulfonamide therapy 61
Suppurative lung disease, chronic 97, 98
Suprapubic aspiration 135
Swelling
inguinal 142
inguinoscrotal 142
scrotal 142
Swenson's procedure 313
Syndrome of inappropriate antidiuretic hormone secretion 271
Systemic juvenile idiopathic
arthritis 211
syndrome 212
Systemic lupus erythematosus 70, 169, 215, 216f
T
Tachycardia 94, 132, 133
Tachypnea 78
Tanner stages 231
Telangiectasia 153
Temazepam 262
Testes, torsion of 145, 145f, 146f
Testicular germ cell tumor 179fc
Tetanus-diphtheria-acellular pertussis 42
Tetracyclines 60
Tetralogy of Fallot 78, 79, 79t
Thelarche, premature 15
Theophylline 190
Thermal control, mode of 2
Thiamine 37
Thiopentone 74
Thoracic Society of Australia and New Zealand 96
Thrombocytopenia 47, 159
Thyroid
function tests 240
stimulating hormone 131, 237, 238
Tibia, ecchymosis over shin of 162f
Tics 28
Tissue hypoxia 284
Tongue and teeth, staining of 152, 152f
Topical calcineurin inhibitor 279
Topiramate 73
Total anomalous pulmonary venous connection 78, 80, 80fc
Total iron-binding capacity 38
Total lung capacity 105
Tourette's syndrome 28
Tourniquet test 333
Toxic alcohol poisoning, antidotes for 263
Toxic shock syndrome 47
Toxin ingestion 94
Tracheoesophageal fistula 99, 103
Tracheomalacia 99
Transferrin receptor saturation 38
Transjugular intrahepatic portosystemic shunt 116
Triclosan 278
Tricuspid atresia 80
three stages of 80t
Trimethoprim 59
Triptorelin 237
Tuberculin skin test 66, 68
Tuberculosis 6668, 97, 98, 150
diagnosis of 68fc
extrapulmonary 68
management of 68fc
multidrug-resistant 66, 68, 68b
mycobacterium 68, 102
pediatric 67t
treatment 66
Tubular necrosis, acute 130
Tumor lysis syndrome 168, 170
Tumors
abdominal 176, 176fc, 176t, 177
astrocytic 181
necrosis factor 87
neuroendocrine 130
Turner syndrome 226, 241
management of 241, 245fc
Tyrosinemia 111, 125
U
Ultrasonogram 169
Universal Immunization Program 52
Upper airway cough syndrome 97, 98
Upper gastrointestinal bleeding 116, 118fc
causes of 117fc
management of 116
Upper respiratory tract infections, viral 98
Urethral
catheterization 135
valves, posterior 136, 141
Uric acid 169
Urinary tract infection 131, 134, 135t, 136, 141
diagnosis of 134
recurrent 135, 135t, 138
Urine
collection, method of 135
dipstick 134
examination 134
microscopy 134
Urticaria 200, 203, 205
activity score 208t
acute 203, 204
classification of 203
inducible 204
pigmentosa 203
prevalence of 203
spontaneous 204, 208
vasculitis 203
V
Vaccine
reaction 45, 45fc
vial monitor 44, 45f
Valproate 73
Variceal bleeding 116
Varicella 55
Vascular endothelial growth factor 284
Venom immunotherapy 202
Ventricular assist device 89
Ventricular septal defect 78, 79, 81
Very-low-birth-weight 2, 7
Vesicoureteral reflux 131, 135, 136, 141
high-grade 134
Video-assisted thoracoscopic surgery 301f
Vigabatrin 73
Vinblastine 173
Vincristine 154, 173, 175
Viral myocarditis, pediatric 86
Viral rhinosinusitis 98
Vision 287
assessment of 287, 288fc
disorders, binocular 292
Visual acuity testing 287
Visual disorders 25
Vitamin
A 37
B12 38
C 37
D 6, 241
deficiency 36
D3 36
E 37
K 264
deficiency 158, 159f
Voiding cystourethrogram 131
Volvulus neonatorum 307
clinical features 307
investigations 307
management 307
Vomiting 94, 152, 303, 309
nonbilious 303
persistent 58
von Willebrand's disease 161
Vulval anus 310
W
Wasp 199f
Wegener's granulomatosis 128
Weight loss 38, 94
White blood cell 84, 154, 169, 170
White coat hypertension 130
Wilms tumor 176, 177, 178fc
treatment 176
Wilson's disease 119, 125
World Health Organization 34, 40, 46, 58
classifies pediatric brain tumors 181t
Y
Yellow fever 56
Z
Zinc 7
Zonisamide 73
×
Chapter Notes

Save Clear


NewbornCHAPTER 1

Contributors: Rhishikesh Thakre,
Naveen Jain
Reviewer: Alok Gupta
  • ⇒  Thermal Care
  • ⇒  Best Practices in Breast Milk Feeding
  • ⇒  Developmental Supportive Care
  • ⇒  Screening Protocols for High-risk Newborns at Discharge
1.1 Thermal Care2
Rhishikesh Thakre
 
INTRODUCTION
The purpose of thermal care is a series of measures to be taken to ensure that the newborn:
  • Maintains a normal body temperature (36.5–37.5°C)
  • Does not become too cold (<36.5°C = hypothermia)
  • Does not become too hot (>37.5°C = hyperthermia)
These measures must be initiated from the time of birth, during hospital stay and at home (Boxes 1.1.1 and 1.1.2). Neonatal temperature may start falling by 0.5–1°C every minute if not supported after birth.
All newborns must be assessed for thermal wellbeing at every opportunity. No single sign is pathognomonic of thermal instability (Table 1.1.1). The recommended method of screening for thermal wellbeing is measuring axillary temperature by thermometer.
Table 1.1.1   Assessment of thermal wellbeing.
Signs of hypothermia
Signs of hyperthermia
  • Cool skin temperature
  • Pallor
  • Mottling of extremities
  • Decreased pulses
  • Prolonged capillary refill time
  • Apnea
  • Heart rate changes
  • Decreased activity
  • Increased heart rate
  • Increased respiratory rate
  • Flushed appearance
  • Extended posture
  • Skin warm to touch
  • Brisk capillary refill
  • Apnea
 
CHOICE OF HEATING EQUIPMENT: WARMER OR INCUBATOR
The decision of using incubator or radiant warmer in hospital care is based upon:
  1. Familiarity and ease of use.
  2. Experience of the staff.
  3. Quality of infection control measures.
Each equipment has its advantages and disadvantages. Following babies may be candidates for incubator care:
  • Care of extremely low-birth-weight (LBW) babies for humidification.
  • For isolating an infected baby to achieve barrier nursing.
  • For use at low ambient temperature or when there is a lot of convective current where a radiant warmer fails to work.
  • For transporting babies.
 
MODE OF THERMAL CONTROL—SKIN OR AIR MODE
 
Skin Mode
The heater output is controlled by the baby's skin temperature which is set at a desired level. The heater cycles to keep the skin temperature at that constant.
 
Advantages
  1. Useful in rewarming of hypothermic babies in a graded manner.
  2. A set skin temperature of 36°C would suffice for all LBW babies.
  3. Reduced need for close monitoring of infant temperature.
 
Disadvantages
  1. Marked fluctuations in air temperature.
  2. If the skin probe gets partially dislodged or displaced, overheating occurs.
  3. Inappropriately low ambient temperature if the infant is febrile.
  4. Fever is likely to be missed unless infant temperature is checked frequently.
  5. Masking of hypo- or hyperthermia in baby.
    3
 
Air Mode
The air temperature is set to a desired level and a thermostat in the air flow maintains this temperature.
 
Advantages
  1. Proportionate heat control.
  2. Fluctuations in air temperature minimal.
 
Disadvantages
  1. If the air probe is placed away from the body, it will cause variable heating.
  2. If the air probe is covered, it will cause variable temperature changes.
 
SITE OF TEMPERATURE PROBE
  • The thermal sensor in skin mode needs to be fixed over abdomen firmly if the baby is in supine position.
  • In prone position, the flank may be used.
  • Areas with high metabolic rate as the right hypochondrium (due to underlying liver) need to be avoided.
  • Probe should not be applied over bruised or broken skin.
 
SETTING TEMPERATURE
During the first week after birth, LBW babies should be provided with a carefully regulated thermal environment that is near the thermoneutral point. This can be achieved by adjusting temperature to maintain an anterior abdominal skin temperature of at least 36.5°C, using either servo-control or frequent manual adjustment of air temperature.
 
MANAGING A COLD BABY HYPOTHERMIA (TABLE 1.1.2)
  • Active intervention must be done if the axillary temperature is less than 36.5°C.
  • The method, or combination of methods selected will depend on the severity of the hypothermia and the availability of staff and equipment.
  • Measure the baby's temperature every hour for 3 hours. Once the baby's temperature is normal, measure the baby's temperature every 3 hours for 12 hours.
  • If the baby's temperature is increasing at least 0.5°C per hour over the last 3 hours, rewarming is successful.
  • Ensure feeding and euglycemia if baby is active or start IV fluids and check sugar.
  • Every hypothermic newborn should be assessed for infection.
 
MANAGING HYPERTHERMIA (>37.5°C)
Hyperthermia, because of overheating or underlying infection, can be ruled out by following bedside clues (Table 1.1.3).
  • Put off the heat source.
  • Do not give antipyretic drugs to reduce the baby's temperature.
  • If hyperthermia is due to overheating, reduce the temperature setting on the warming device:
    • Undress the baby partially or fully for 10 minutes and then clothe the baby.
    • Observe for signs of sepsis (e.g. poor feeding, vomiting, and breathing difficulty) and repeat when the baby's temperature is within the normal range.
    • Measure the baby's temperature every hour until it is within the normal range.
    • Review nursing care practices to ensure that the problem does not happen again.
  • If the hyperthermia is due to exposure to a high ambient temperature or sun exposure:
    • Place the baby in a normal temperature environment (25°–28°C).
    • Undress the baby partially or fully for 10 minutes, then dress and cover the baby.
    • If the baby's temperature is more than 39°C: Sponge the baby or give the baby a bath for 10–15 minutes in water that is about 4°C lower than the baby's current temperature; Do not use cold water or water that is more than 4 °C lower than the baby's temperature.
    • Measure the baby's temperature every hour.
    • If the baby's temperature is still abnormal after 2 hours, treat for sepsis.
Table 1.1.2   Management of hypothermia.
Mild hypothermia
(36–36.5°C)
Moderate hypothermia
(32–36°C)
Severe hypothermia
(<32°C)
Warm clothing
Yes
Yes
No
Skin-to-skin contact
Yes
Yes
No
Breastfeeding
Yes
Yes
No
Radiant warmer
No
Yes
Yes
B-glucose estimation
No
Yes
Yes
IV fluids
No
Consider
Yes
Antibiotics
No
Yes
Yes
4
  • Allow the baby to begin breastfeeding at the earliest. If the baby cannot be breastfed, give expressed breast milk using an alternative feeding method.
  • If there are signs of dehydration (sunken eyes or fontanel, loss of skin elasticity, or dry tongue or mucous membranes):
    • Establish an IV line and give IV fluid at maintenance volume according to the baby's age. Increase the volume of fluid by 10% of the baby's body weight on the first day that the dehydration is noted.
    • Measure blood glucose. If the blood glucose is less than 45 mg/dL (2.6 mmol/L), treat for low blood glucose.
    • Once the baby's temperature is within the normal range, measure the baby's temperature every 3 hours for 12 hours. If the baby's temperature remains within the normal range, discontinue measurements.
    • If the baby is feeding well and there are no other problems requiring hospitalization, discharge the baby.
  • Advice the mother how to keep the baby warm at home and protect from overheating.
 
PRACTICE POINTERS (BOX 1.1.3)
  1. No heating device can function efficiently in a cold room.
  2. The head has the greatest potential for heat loss due to its surface area, therefore, cover the head to minimize heat losses in smaller babies.
  3. All staff using the equipment must have received the appropriate on-the-job training in its use.
  4. An instruction manual must always be available for reference purposes.
  5. A specific procedure for cleaning and maintenance of equipment must be specified and adhered to.
 
PARENT INFORMATION
  1. Keep the baby and mother together.
  2. Cover the baby's head always with a cap.
  3. If the environment is cold, place socks and gloves with warm clothing. If the environment is warm, use loose cotton clothing and ensure air circulation by keeping the windows open, fan turned on with no direct draft of air over the baby.
  4. Breastfeed the baby exclusively and on demand.
  5. Report if: (a) Baby's trunk and soles appear warm or cold to touch, and (b) Baby does not feed over 6 hours.
Table 1.1.3   Differentiating an overheated infant from febrile infant.
Signs
Overheated infant
Febrile infant
Posture
Appearance
Skin color
Hand/feet
Abdominal—skin temperature
Extended posture
Healthy appearance
Pink skin color
Warm hands and feet
Abdominal—skin temperature
difference <2°C
Flexed posture
Looks unwell
Pale skin
Cool hands and feet
Abdominal—skin temperature
difference >3°C
 
KEY POINTS
  1. The newborn cannot regulate its temperature as well as an adult and, therefore, needs to be protected from cold and heat.
  2. Thermal instability in a newborn is more due to lack of knowledge than to lack of equipment.
  3. In trying to keep babies warm, it is important to make sure they do not become overheated. Hyperthermia is as dangerous as hypothermia.
  4. There is no single environmental temperature that is appropriate for all sizes, gestational ages and conditions of newborn babies.
  5. Every hypo- or hyperthermic newborn should be assessed for infection.5
 
BIBLIOGRAPHY
  1. EM McCall EM, Alderdice FA, Halliday HL, et al. Interventions to prevent hypothermia at birth in preterm and/or low-birth-weight babies. Cochrane Database Syst Rev. 2008;(1):CD004210.
  1. Sinclair JC. Servo-control for maintaining abdominal skin temperature at 36°C in low-birth-weight infants. Cochrane Database Syst Rev. 2002;(1):CD001074.
  1. Thermal protection of the newborn: a practical guide. Geneva: Department of Reproductive Health and Research (RHR), World Health Organization;  1997.
1.2 Best Practices in Breast Milk Feeding
Rhishikesh Thakre
 
INTRODUCTION
Human milk is the preferred source of nutrition for all newborns. It is considered as safe and appropriate, because of its better digestion and absorption, improvement in host defense, and improved neurodevelopmental outcomes.
 
GOOD CLINICAL PRACTICES FOR SUCCESSFUL BREASTFEEDING
Good practices for initiating, maintaining lactation prior to birth, in delivery room, postnatal ward, NICU, home and in office practices are highlighted (Boxes 1.2.1 to 1.2.6).
 
OPTIMIZING USE OF HUMAN MILK IN TERM/PRETERM
Key issues that need to be addressed to optimize use of human milk in term and preterm newborns are described in Table 1.2.1.
6
Table 1.2.1   Optimizing use of human milk in term/preterm.
Whom to give
Preferred choice of feed for all well or sick, but stable neonates, irrespective of gestation
How to give
Breastfeeding (>34 weeks), by expressed milk in (32–34 weeks, wati-spoon), by tube feeding (<32 weeks, sick neonates)
When to give
As early as feasible in unstable (as trophic feeds) and in delivery room (putting to mother's breast for > 34 weeks)
How frequently
On demand in well babies. Every 2–3 hourly in sick babies (as indicated)
Monitor
Position, attachment, weight, frequency and color of urine/stool, maternal concerns and wellbeing
How long
Exclusive till 6 months
Disadvantage
A subset of < 32 weeks (<1,500 g) may have slower growth on unsupplemented breast milk. The implications for slower growth are unclear
Contraindication
Infants with galactosemia, maple syrup urine disease, phenylketonuria, mother on cytotoxic drugs, radioactive compounds or maternal severe illness like psychosis, sepsis
Note
Discourage prelacteals (water, honey, ghutti, etc.)
 
ROLE OF BREAST MILK SUBSTITUTES
  1. Donor human milk is available as an alternative feeding option if breast milk is unavailable or mother cannot breastfeed. The donor breast milk is similar to mother's milk, has better tolerance and may reduce the risk of necrotizing enterocolitis (NEC). Pooled donor and mature human milks are meant for short-term use and are inadequate to support growth and bone mineralization in the low-birth-weight infant. A Cochrane review has found that feeding with formula compared to donor breast milk increases the risk of serious gut problems in preterm or low-birth-weight infants. The human milk banks are, however, few and not accessible to majority.
  2. Formula is used when neonates are not receiving breast milk or donor milk. Formula feeding has shown to cause better short-term growth and earlier hospital discharge. However, formula feeds are difficult to tolerate compared to human milk, may cause vomiting, abdominal distention, increased risk of infection and NEC. Studies show use of preterm formula (<2,000 g) was significantly contributing to higher weight gain at hospital discharge but no significant differences in weight, height or head circumference at 18 months and at 7.5–8 years in infants who had been fed preterm or standard infant formula.
  3. Studies examining the impact of nutrient-enriched formula on growth outcomes had mixed results. Considering the weak evidence of benefits and substantially higher costs of nutrient-enriched formula, its routine use cannot be justified in developing country settings.
  4. Animal milk has been used in developing world based on personal beliefs and cultural practices. Adverse effects and hazards following animal milk use have been documented in several studies. No policy statements on the use of animal milk were located from international or national organizations.
  5. Others: The use of water for enteral feeding also has been shown not to affect intestinal motility as compared with milk. Using glucose solution as first feed is strongly discouraged as it is hyperosmolar.
 
ROLE OF NUTRITIONAL SUPPLEMENTATION IN EXCLUSIVE BREASTFED NEONATES
Vitamin D: Breast milk alone is not sufficient to maintain newborn vitamin D levels within a normal range. On a community level, the WHO recommendations suggest intake of vitamin D of 400 IU per day.7
Iron: Iron supplementation at 6–8 weeks of age and as early as 2 weeks in very-low-birth-weight (VLBW) infants leads to significant improvements in hemoglobin at 4 weeks and 8 weeks and associated with improved neurocognitive development.
Calcium-phosphorus: Preterm human milk provides insufficient calcium and phosphorus to meet their estimated needs. There are no data on the effect of phosphorus and calcium supplementation on key clinical outcomes in infants with a birth weight greater than 1,500 g. It is suggested to supplement till 40 weeks postmenstrual age (PMA).
Zinc: There are no data on the effect of zinc on key clinical outcomes in preterm infants. Data from two trials in developing countries suggest that term low-birth-weight infants in developing countries may have lower mortality and morbidity if they receive zinc supplementation. There seems to be no evidence that zinc supplementation in these infants improves neurodevelopment or affects growth.
Human milk fortification: A Cochrane review on “multicomponent fortified human milk for promoting growth in preterm infants” concluded that supplementation of human milk with multicomponent fortifiers is associated with short-term increases in weight gain, linear and head growth. There are insufficient data to evaluate long-term neurodevelopmental and growth outcomes, although there appears to be no effect on growth beyond 1 year of life. The issues of concern in developing countries are higher prevalence of infections, a greater risk of contamination and high fortifier costs.
LCPUFA/DHA supplementation: In a Cochrane review, most studies found no significant differences in any visual assessment between supplemented and control infants. There was also no evidence that supplementation of formula with n-3 and n-6 long-chain polyunsaturated fatty acid (LCPUFA) impaired the growth of preterm infants.
 
SPECIAL ISSUES IN HUMAN BREAST MILK FEEDING
 
Breast Milk Expression
Low-cost interventions including initiation of milk expression sooner after birth when not feeding at the breast, relaxation, massage, warming the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps.
 
Human Immunodeficiency Virus +ve Mother
  • Individualized decision making and counseling.
  • Screening for acceptable, feasible, affordable, sustainable and safe (AFASS) criteria.
  • Promote and actively counsel on exclusive breastfeeding.
  • Expressed breast milk feeding for 6 months if all AFASS criteria not met.
  • Avoid mixed feeding, early weaning, and abrupt weaning.
  • Prepare for stopping breastfeeding at 6 months if AFASS criteria are met.
  • Continue maternal antiretroviral therapy.
 
SUMMARY
  • Breast milk is the most optimal for feeding and is the preferred choice for all neonates— well or sick.
  • When not available, pasteurized donor human milk followed by formula milk is acceptable alternatives.
  • All efforts must be made to ensure lactation in NICU mothers.
  • Exclusive breastfeeding is recommended for at least first 6 months of life.
  • Routine use of the multicomponent fortification of the breast milk should be avoided and targeted to less than 32 weeks gestation or less than 1,500 g birth weight baby who fails to gain weight despite adequate breast milk feeding.
 
BIBLIOGRAPHY
  1. Davanzo R, Travan L, Brovedani P. Practical strategies for promoting breastfeeding in neonatal intensive care. Minerva Pediatr. 2010;62(3 Suppl 1):205–6.
  1. Edmond K, Bhal R. Optimal feeding of the low-birth-weight infants. Technical Review. Geneva: World Health Organization  2006. pp. 1–130.
  1. Henderson G, Fahey T, McGuire W. Multicomponent fortification of human breast milk for preterm infants following hospital discharge. Cochrane Database Syst Rev. 2007;(4):CD004866.
  1. Lechner BE, Vohr BR. Neurodevelopmental Outcomes of Preterm Infants-fed Human Milk: A Systematic Review. Clin Perinatol. 2017;44(1):69–83.
  1. McFadden A, Gavine A, Renfrew MJ, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev. 2017;2:CD001141.
  1. Meier PP, Johnson TJ, Patel AL, et al. Evidence-based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review. Clin Perinatol. 2017;44(1):1–22.
  1. Quigley M, Henderson G, Anthony MY, et al. Formula milk versus donor breast milk for feeding preterm or low-birth-weight infants. Cochrane Database Syst Rev. 2014;(4):CD002971.
  1. Smith HA, Becker GE. Early additional food and fluids for healthy breastfed full-term infants. Cochrane Database Syst Rev. 2016;(8):CD006462.
8
1.3 Developmental Supportive Care
Naveen Jain
 
INTRODUCTION
Preterm babies spend many days/weeks in the NICU. Environment of the ICU, sensory inputs and experiences of the preterm baby are very different from what the fetus experiences in utero. These may have impact on “normal development”. Development supportive care refers to the practices that are expected to simulate the natural environment/experiences of the fetus and minimize deviation from normal development.
Some of the practices are provided in Table 1.3.1.
 
EARLY PARENT PARTICIPATION
Preterm babies spend many days to weeks in the NICU. Conventionally, Indian NICUs limit the access of parents to NICU. This leads to long separation of the baby from his/her parents. Parents must be allowed to visit their baby unrestricted or at least allowed long visiting hours. They must be encouraged to touch their baby, talk to the baby and get involved in care processes like feeding (even by orogastric tube), diaper changes, touch and massage. They may even be trained to give nutritional supplements like calcium phosphate, iron, human milk fortifier (HMF), etc. This decreases the parent separation anxiety, decreases risk of infections (as parents are not carriers of multidrug resistant bugs like NICU staff!).
Table 1.3.1   Description of developmental supportive care practices.
S. No.
Distortion in experiences of preterm
Developmental supportive care
1.
Parent separation
Early parent participation
2.
Baby position
Nesting, swaddling
3.
Sensory experiences
Massage, tactile stimulation
4.
Light
Minimize bright light/dimming/day-night
5.
Sound
Minimize loud noises/music therapy/mothers voice (KMC)
6.
Frequent disturbance
Clustering of care
7.
Pain
Policy on pain
8.
Swallowing problems
Oromotor stimulation
9.
Thermoregulation
Kangaroo mother care
 
Baby Position
In utero, the fetus is floating in amniotic fluid, and does not face gravity. But in the NICU, long durations of unsupported positioning of limbs may result in lengthening of some muscle groups and tone abnormalities. Babies placed supine in a nest demonstrate better postures and movements (general movements assessment tool). Symmetrical, flexed, and midline position using special wrap (Dandle ROOTM) also showed improvement in subsequent development.
 
Massage
A meta-analysis of 17 studies showed an advantage as improved weight gain and early discharge from hospital. No direct benefit on neurobehavior was demonstrated. A study is underway to assess the effect of massage on MRI, EEG of very preterm infants (PREMM—preterm massage by mother). Preterm babies receiving tactile kinesthetic stimulation (massage protocol) demonstrated better behavior (self-regulated and adjusted behavior responses).
 
Lighting
An elaborate paper was published recently describing details of NICU lighting, role of natural light, protection of baby's eyes from constant bright light, use of color in NICU, day-night cycling, dimming of light, etc. Recommendations include focused light of 2,000 Lux for procedures. Day light 100–200 Lux that includes natural light at night less than 50 lux.
 
Sound and Noise Levels
It is rational to reduce the noise of alarms, banging of incubator doors and decreasing loud conversations near babyside. There are systematic studies to prove the same. Music played in the unit has been tried, but no demonstrable benefit is noted. Ear plugs were used in a small trial, no difference was noted in babies with ear plugs.
 
Clustering of Care
Clubbing of procedures is expected to reduce the handling time and give more rest time to babies. But, scientific studies comparing clustering with care with routine care showed no differences.9
 
Minimizing Pain in Neonatal Intensive Care Unit
Decreasing painful procedures, nonpharmacological pain alleviation (breast milk, sucrose, etc.), topical analgesia, opioid and nonopioid analgesia.
 
Oromotor Stimulation
A systematic review that included 11 trials and 855 participants, showed shorter time to oral feeding, improved efficiency of feeding, greater feed intake and better weight gain. Some studies used non-nutritive sucking in addition, by placing a pacifier in the baby's mouth. In an Indian study, oromotor stimulation significantly reduced the duration of gavage feeding. The baby's cheeks, lips, tongue, and jaw were stroked and gums rubbed before every feed.
 
Kangaroo Mother Care
Recently published systematic review that included 13 studies demonstrated clear benefits in growth of very low-birth-weight babies and breast milk feeding rates.
Kangaroo mother care (KMC) involves skin-to-skin contact between the baby (wearing just a diaper) and between the breasts of the mother or bare chest father. The baby is covered with a blanket. This improves thermoregulation. Continuous kangaroo care (as long as possible) is recommended. KMC may be started very early, even when baby is on continuous positive airway pressure (CPAP), high flow nasal cannula (HFNC) or IV fluids. It is best continued as long as the baby likes the KMC.
 
FACILITATE AND PROMOTE LANGUAGE, VISION AND HEARING DEVELOPMENT
  • Placing black/white/red, or high-contrast pictures and objects in line of vision, 8–15 inches from face as long as infant remains relaxed and focused.
  • Providing auditory stimulation such as tapes of mother's and father's voices, music boxes, and classical music when infant is quiet, alert, relaxed, and appears interested.
  • Talking or singing to infant when providing care or holding and touching him/her, using different pitches or volume in voice.
  • Allowing for face-to-face interaction with infant with or without talking, depending on infant's developmental level.
 
BIBLIOGRAPHY
  1. Casavant SG, Bernier K, Andrews S, et al. Noise in the Neonatal Intensive Care Unit: What Does the Evidence Tell Us? Adv Neonatal Care. 2017;7(4):265–73.
  1. Lai MM, D'Acunto G, Guzzetta A, et al. PREMM: preterm early massage by the mother: protocol of a randomised controlled trial of massage therapy in very preterm infants. BMC Pediatr. 2016;16(1):146. doi: 10.1186/s12887-016-0678-7.
  1. Rodríguez RG, Pattini AE. Neonatal intensive care unit lighting: update and recommendations. Arch Argent Pediatr. 2016;114(4):361–7.
  1. Thakur N, Batra P, Gupta P. Noise as a Health Hazard for Children, Time to make a noise about it. Indian Pediatr. 2016;53(2):111–4.
  1. Tian X, Yi LJ, Zhang L, et al. Oral motor intervention improved the oral feeding in preterm infants: Evidence Based on a Meta-analysis With Trial Sequential Analysis. Medicine (Baltimore). 2015;94(31):e1310.
  1. Westrup B. Family-centered developmentally supportive care. NeoReviews. 2014;15(8):e325–35.
  1. Zahed M, Berbis J, Brevaut-Malaty V, et al. Posture and movement in very preterm infants at term age in and outside the nest. Childs Nerv Syst. 2015;31(12):2333–40.
1.4 Screening Protocols for High-risk Newborns at Discharge
Naveen Jain
 
INTRODUCTION
Babies who are sick at birth and require intensive care support (e.g. very preterm, asphyxia), who have risk factors in pregnancy (e.g. mother on anti-epileptic drugs), potential of adverse outcomes (e.g. renal pelvis dilatation) require special care before discharge from hospital and follow-up thereafter.
This chapter will explain preterm babies as one group and all other at-risk babies as another.10
 
PRETERM BABIES
  1. Warmth: Educate parents to continue kangaroo mother care, wrap the baby in double layer of cotton clothes and caps, socks, and mittens. Advice them to touch the baby's abdomen and hands/feet with dorsum of the hand to assess thermal stability.
  2. Nutrition: Encourage the mother to provide her own breast milk supplemented with protein (human milk fortifier), calcium/phosphorus, iron, and multivitamins. An electric breast pump should be used 3–4 hourly till the baby is able to suck effectively directly (after 34 weeks gestation).
  3. Prevention of infection: Avoid crowded areas and visitors for a few weeks. Wash hands with soap and water before handling the baby. If formula milk is used, pay attention to sterilization and hygiene of water used, in handling of container, spoons, bottles, and avoid milk that is prepared more than 3–4 hours earlier.
  4. Assessment of growth: Weight, length, and occipital frontal circumference (OFC) must be plotted on growth charts for preterm babies. Babies must be tracking all parameters along their birth centile or parallel to the growth curves for a week prior to discharge (e.g. Fenton's growth chart).
  5. Immunization: BCG, OPV and hepatitis B can be given to almost all babies prior to discharge. If baby is 6 weeks old, then DTP, HIB, PCV, IPV, HB and rotavirus vaccines also can be given. The immunization schedule is the same as for term born babies. No change/delay is necessary because of prematurity.
  6. Screening tests before discharge:
    • Retinopathy of prematurity screening:
      • Retinopathy of prematurity (ROP) screening is recommended for all babies less than 34 weeks and/or less than 1,750 g at birth.
      • Screening must start at 3–4 weeks after birth.
      • An ophthalmologist trained in ROP screening must identify severe RoP requiring laser photocoagulation.
      • Also, advise parents to continue screening for risk of late retinal detachment and other visual problems such as refraction problems, squint, etc. necessitating eye examination at 3–6 months and 9–12 months. Thereafter, an annual check-up is recommended till 6 years of age.
    • Hearing screen: Otoacoustic emission (OAE) and automated brainstem-evoked response (ABER) audiometry must be performed ideally before discharge. As sensorineural impairment is possible, ABER is mandatory. Hearing impairment must be confirmed and treatment initiated before the baby is 6 months old.
    • Anemia of prematurity: Preterm babies do not respond to anemia by increase in RBC production. They may require RBC transfusions if hemoglobin levels are low (most units transfuse at < 7 g/dL, some at strict thresholds of 6 g/dL). Hemoglobin levels are checked at 1–2 weeks intervals, starting from 4 weeks of life, till they are stable.
    • Osteopenia of prematurity: Serum phosphorus and alkaline phosphatase levels are measured at 4 weeks of life and 1–2 weekly thereafter, till alkaline phosphatase levels are normal (some units practice till 40–44 weeks’ gestation age). If phosphorus levels are low (<5) and alkaline phosphatase high (>900), intake of calcium phosphate (150–200 mg/kg of calcium and 75–100 mg/kg of phosphorus) and vitamin D (400–1,000 IU/day).
    • Congenital hypothyroidism: Two screening tests are recommended—first at 3–7 days of life and second test at 2–4 weeks of age.
    • Physical examination: Examine for cardiac murmur, inguinal hernia, oral thrush, hemangioma, and hepatosplenomegaly.
    • Neurological examination: Serial head circumference, neurobehavior, and structured neurologic examination (e.g. Hammersmith neonatal neurologic examination).
    • Neuroimaging: First ultrasound head for all preterm babies less than 32 weeks gestation at birth. Follow-up ultrasound at 36–40 weeks age (good predictive ability).
    • Parent readiness: Parents must be prepared through early participation and care of the baby, while in NICU and by serial health education sessions. Preterm baby must be roomed in with the parents for a few days before discharge, so that they are better prepared to take care of the baby.
    • Referral to primary care physician.
  7. Ensure active medical problems are resolved or care process planned:
    • Hospital-associated infection (HAI): Any fever/significant change in health, within a month after discharge can be HAI. Babies may have to be reinvestigated and treated (Table 1.4.1).
    • Chronic lung disease of prematurity (bronchopulmonary dysplasia) is more common in extreme preterm babies. They may require home oxygen therapy. The parents must be educated regarding higher risks of respiratory insufficiency with minor illness requiring admission to hospital as an emergency.
    • Risk of strictures in babies who had necrotizing enterocolitis (NEC) of any stage. Babies may present11 with abdominal distension/vomiting, although they may be passing stools.
    • Preterm brain injury [(intraventricular hemorrhage/periventricular leukomalacia (IVH/PVL)]—increased risk of seizures, swallowing problems and may require enrolment to early intervention programs.
Table 1.4.1   Post-discharge care of preterm babies.
Post-discharge care
Age
Responsibility
Warmth
Serial health education
Special educator
Nutrition
Serial health education
Special educator
Prevention of infection
Serial health education
Special educator
Growth charts
From birth
Doctor/nurse
Immunization
Standard schedule
Doctor
Retinopathy of prematurity (ROP) screening
3–4 weeks onward
Doctor
Hearing screen
Before discharge (6 months)
Doctor
Hemoglobin
4 weeks/1−2 weekly
Doctor
Phosphorus/alkaline phosphatase
4 weeks/1−2 weekly
Doctor
TSH/free—T4
3−7 days/2−4 weeks
Doctor
Neuroimaging
1−2 weeks/36−40 weeks
Doctor
Neurological examination
40 weeks
Doctor
Physical examination
Before discharge
Doctor
 
At-risk Neonates
Disease-specific predischarge screening and follow-up must be documented and educated to parents.
Examples:
  1. HIE/seizures/meningitis—neurological examination at discharge, 4–8–12 months age and periodically thereafter.
  2. Antenatal renal pelvis dilatation—first postnatal ultrasound after third day. One more ultrasound at 1 month of age (even if first one was normal).
BIBLIOGRAPHY
  1. Ehrenkranz RA, Younes N, Lemons JA, et al. Longitudinal growth of hospitalized very-low-birth weight infants. Pediatrics. 1999;104(2 pt 1):280–9.
  1. Joint Committee on Infant Hearing of the American Academy of Pediatrics, Muse C, Harrison J, et al. Supplement to the JCIH 2007 position statement: principles and guidelines for early intervention after confirmation that a child is deaf or hard of hearing. Pediatrics. 2013;131/(4):e1324–49.
  1. Nair MKC, George B, Jain N, et al. Perinatal Risk Stratification of Preterm Neonates and Developmental Outcomes - PRE (Preterm Risk Evaluation) Network. J Neonatol. 2014;28(3):3.
  1. Phatak P. Manual on Developmental Assessment Scales for Indian Infants (DASII) (revised Baroda norms, 1997). Pune: Anand Agencies;  1997.
  1. Sujatha R, Jain N. Prediction of neurodevelopmental outcome of preterm babies using risk stratification score. Indian J Pediatr. 2016;83(7):640–4.
  1. Wang CJ, McGlynn EA, Brook RH, et al. Quality-of-care indicators for the neurodevelopmental follow-up of very low-birth-weight children: results of an expert panel process. Pediatrics. 2006;117(6):2080–92.12