Pediatric Neonatology High Yield One Liners

Important one liners 

WHO Recommendations for care of the preterm or LBW infants-2022 

• Updated in the year 2022, containing 25 recommendations (11 new, 14 updated) and 1 good practice statement (new).
• 11 are strong recommendations and 14 are conditional.
• Pertain to the care of preterm and low birth weight neonates.
• Cover three domains: Preventive and promotive care, care for complications and family involvement & support.

Plain Language Summary 

• KMC as soon as possible in all preterm and LBW, duration is 8-24 hr.
• Mother's milk is best >Donor human milk >preterm formula milk (in <32 weeks and VLBW neonates)
• Multicomponent fortification of human milk may be considered in < 32 weeks and VLBW neonates.
• Scheduled feeding is better than responsive feeding in <34 weeks infants.
• Advancement of feeds at the rate of 30 ml/kg/day.
• EBF for 6 months of age.
• Enteral iron supplementation is strongly recommended, but enteral zinc and vit D may be considered.
• Enteral vit A is considered in <32 weeks and VLBW neonates on human milk.
• Probiotics may be considered for <32 weeks infants.
• Emollients may be considered in preterms and LBW neonates.
• CPAP is recommended for RDS and may be considered in < 32 weeks with or without distress. Bubble CPAP is preferred.
• Caffeine is recommended in extubation, treatment of apnea and may be considered in apnea prevention.

Points to remember regarding Subgaleal Hemorrhage

• If caput succedaneum increases in size more than 24 hours or does not disappear by 72 hours and is associated with neurologic deficit or hemodynamic instability, one differential to consider is encephalocele according to NNF protocols.
• Cephalohematoma is usually unilateral but can be bilateral in some cases.
• Palpable modules due to calcified cephalohematomas can persist until 3–4 months of age.
• The source of bleeding in the subgaleal space is emissary veins.
• The bleeding comes from the emissary veins; these veins join the superficial scalp veins as well as the internal deep-seated dural veins of the CNS.
• For every 1 cm increase in OFC due to subgaleal bleeding, there is a corresponding blood loss of 40 ml
• The maximum capacity of subgaleal spaces is 260 ml.
• Subgaleal space can accommodate up to 40% of total blood volume (According to NNF clinical protocols in perinatology).

Points To Remember regarding  neonatal apnea

• An alternative to The CPAP in neonatal apnea is HHH fnc (Heated Humidified High-Flow Nasal Cannula) which provides oxygen or airflow at 1-4 L/min. But nasal CPAP has better efficacy; thus, nasal CPAP is one alternative to this modality.
• Caffeine citrate also reduces the chances of BPD later.
• GER's relationship with the apnea is not proven
• Using PPI or H2 blockers in preterm infants can paradoxically increase the apnea risk. So, they should be discouraged. All the pro kinetics such as domperidone, lansoprazole, and lansoprazole with domperidone should be avoided in preterm newborns.
• Nelson says that in 92 percent of infants, apnea of prematurity resolves by 37 weeks of Postmenstrual age. And in 98%, it resolves by 40 weeks of postmenstrual age.
• Persistent Apnea in AOP: may continue to happen even beyond 37 to 40 weeks, especially in those born <28 weeks. So, Mx therapy needs to be continued and additional evaluation needed for secondary causes like CNS issues and GER
• In the absence of significant events, home monitoring can be safely discontinued at 44wk PMA
• AoP is not a risk factor for sudden infant death syndrome (SIDS).
• There is no role for prophylactic methylxanthine therapy in extremely premature neonates to prevent AOP.
• AoP may produce adverse neurological outcomes at 1-2 years as per retrospective studies, but no prospective evidence yet.

Things To Know - Cloherty 

• Neonatal Cold Injury
• A rare extreme form of hypothermia is seen in LBW infants and term infants with CNS disorders.
• Core body temperature falls below 32.2℃ (90 ° F).
• Skin color can be bright red due to the failure of oxyhemoglobin to dissociate at low temperatures, often with skin edema and sclerema.
• Central cyanosis or pallor may also be seen.
• Systemic complications like azotemia, bleeding manifestation, metabolic acidosis, and DIC can occur.
• Managed on the line of severe hypothermia. May need IVF bolus, O2 and metabolic acidosis correction. Avoid feeding if unstable.

Important questions 

Q. Which is the most benign to life-threatening swelling?

Ans. Caput succedaneum is the most benign, followed by cephalohematoma and subgaleal hematoma, which can be life- threatening in many patients. (This same order follows for frequency as well).

Q. What is the strongest risk factor for skull fractures (especially depressed skull fractures)?

Ans. Forceps delivery followed by fetal compression.

Q. What are the indications for doing CT or MRI in skull fractures?

Ans. The indications include:

• If there are symptoms of intracranial hemorrhage or compression, then a CT or MRI should be done.
• Serious skull fracture, For example, if there is a suspected depressed skull fracture of more than 1 centimeter, confirmation will only happen on a CT scan.
• Thirdly, if the patient has an underlying suspected coagulation disorder, there is a possibility that the skull fracture is small. Still, the underlying hemorrhage is significant.

Q. A child of 3-4 weeks of age with a history of squatting and ejection systolic murmur in the left intercostal space or pulmonary area with a single-second heart sound. The chest X-ray shows a boot-shaped heart. What is the diagnosis?

Ans. Tetralogy of Fallot

Q. A child has cyanosis in the first two weeks of life, which is associated with congestive cardiac failure. The chest X-ray shows an eggshaped heart. What is the diagnosis?

Ans. Transposition of the great arteries (TGA)

Q. A neonate has a wide fixed splitting of the second heart sound with cyanosis. The chest X-ray shows the snowman appearance/ figure of 8/cottage loaf appearance. What is the diagnosis?

Ans. Supracardiac total anomalous pulmonary venous connection (TAPVC)

Q. A pregnant female had taken lithium during pregnancy, associated with Wolff-Parkinson-White (WPW) syndrome, along with severe cyanosis. The cyanosis improves with prostaglandins in the newborn period. What is the diagnosis?

Ans. Ebstein's anomaly. It is characterized by atrialization of the right ventricle

Q. A neonate presents with severe cyanosis, which improves with prostaglandins (ductus-dependent lesion) and left ventricular dominance along with decreased PBF. What is the diagnosis?

Ans. Tricuspid atresia

Q. What is the type of apnea in apnea of prematurity?

Ans. Mixed apnea is the form found in apnea of prematurity because the brain is immature. The central apnea will be happening, but a preceding, obstructive apnea will precipitate it.

Q. What can be done if the heart rate is ≥ 100/min, but the child is cyanotic?

Ans. If the child has acrocyanosis, then nothing should be done. If the child has central cyanosis, the child needs to be watched, and if persistent, check for SPO by attaching the monitor to the right upper limb. If SPO is below age-dependent cut- 2 2 off, then free flow oxygen should be started. Visual assessment of cyanosis is inaccurate and insufficient to start oxygen. In a child, neonatal resuscitation ventilation is the most important step. Improvement in heart rate is the most accurate parameter to tell the adequacies of ventilation and overall neonatal resuscitation.

Q. What is the maximum dextrose concentration that can be administered in a neonate?

Ans. 

• Using peripheral IV cannula: 12.5%
• Using central venous catheter: 25%

Also read: Frequently asked questions in Pediatric Cardiology

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