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⭐⭐⭐⭐⭐ NEONATAL JAUNDICE

A) Define Physiological Jaundice in a Newborn

• Appears after 24 hours of birth (never before)
• Peaks at 3rd-4th day in term; 5th-7th day in preterm
• Disappears by 10th day in term; 14th day in preterm
• Total serum bilirubin does not exceed 12 mg/dL in term (15 mg/dL in preterm)
• Direct (conjugated) bilirubin < 2 mg/dL
• Baby is otherwise healthy - feeds well, no signs of illness

1. Increased bilirubin load - fetal Hb breakdown (HbF has shorter RBC lifespan ~70-90 days vs. 120 days in adults)
2. Immature hepatic uptake (↓ ligandin/Y protein)
3. Decreased UDP-glucuronosyltransferase activity (conjugation enzyme)
4. Increased enterohepatic circulation (↑ intestinal beta-glucuronidase)
5. Lack of gut flora

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B) Causes of Pathological Jaundice

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C) Pathological vs Physiological Jaundice

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D) Approach to a Child with Jaundice

• Time of onset, duration, progression
• Family history (hemolytic disease, metabolic disorders)
• Maternal blood group, Rh status
• Dark urine, pale stools (cholestasis?)
• Feeding history, infections (sepsis)

• Assess extent: face → trunk → limbs → palms/soles (Kramer's zones - higher zone = higher bilirubin)
• Pallor (hemolysis), hepatosplenomegaly (hemolysis/infection/metabolic)
• Signs of sepsis, dysmorphic features
• Neurological: lethargy, high-pitched cry, opisthotonus (bilirubin encephalopathy)

• Serum bilirubin (total, direct, indirect)
• Blood group - mother and baby (ABO/Rh incompatibility)
• DCT (Direct Coombs Test) - for hemolytic disease
• CBC - anemia, polycythemia
• Peripheral smear - spherocytes, fragmented cells
• Reticulocyte count - elevated in hemolysis
• G6PD assay
• LFTs, TORCH screen, TFTs as indicated
• Urine - reducing substances (galactosemia)

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E) Treatment of Unconjugated Hyperbilirubinemia

1. Phototherapy (First line)

• Mechanism: Light converts unconjugated bilirubin to water-soluble lumirubin (photoisomers) - excreted in bile/urine without conjugation
• Wavelength: 430-490 nm (blue-green spectrum)
• Indications (AAP guidelines): Based on hour-specific nomogram (bilirubin level + age in hours + risk factors)
• Technique: Naked baby (covered eyes + genitals), turn 2-hourly, monitor temperature, continue feeds
• Intensive phototherapy: Multiple lights, bili-blanket; used when bilirubin rises rapidly

2. Exchange Transfusion (When phototherapy fails or bilirubin critically high)

• Indications:
  • Bilirubin approaching exchange level on nomogram
  • Signs of acute bilirubin encephalopathy
  • Hemolytic disease with rapid rise (> 0.5 mg/dL/hr)
• Procedure: Double-volume exchange (2 × 80 mL/kg = 160 mL/kg) via umbilical vein catheter
• Purpose: Removes antibody-coated RBCs + bilirubin + maternal antibodies
• Complications: Hypocalcemia, hypoglycemia, thrombocytopenia, NEC, air embolism, infection

3. Pharmacological (Adjuncts)

• IV Immunoglobulin (IVIG): 0.5-1 g/kg for isoimmune hemolytic jaundice - reduces hemolysis
• Phenobarbitone: Induces UGT enzyme - used in Crigler-Najjar type II
• Tin-mesoporphyrin: Inhibits heme oxygenase (experimental)
• Adequate hydration + feeding: Reduces enterohepatic circulation

4. Treat Underlying Cause

• Antibiotics for sepsis, thyroid hormone for hypothyroidism, etc.

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⭐⭐⭐⭐⭐ RESUSCITATION OF NEWBORN AT BIRTH

Steps of Resuscitation (NRP - Neonatal Resuscitation Program)

PRE-BIRTH PREPARATION

• Antenatal counseling, team briefing, equipment check
• Warm radiant warmer, suction, oxygen, bag-mask, ET tubes, medications ready

STEP 1: Initial Assessment (First 30-60 seconds - "Golden Minute")

1. Term gestation?
2. Good muscle tone?
3. Breathing or crying?

STEP 2: Initial Steps (0-60 seconds)

• Warm - place under radiant warmer (prevent hypothermia)
• Position - neck slightly extended ("sniffing position")
• Clear airway - suction mouth first, then nose (if secretions or meconium)
• Dry and stimulate - flick soles, rub back
• Reposition - reassess airway

Meconium-stained liquor: Only suction trachea with ETT if baby has poor tone, poor respiratory effort, or HR < 100 after 1 min PPV

STEP 3: Assess - Breathing and Heart Rate

• Breathing: Normal, labored, or apneic?
• Heart Rate (HR): Best assessed by auscultation or 3-lead ECG
  • HR ≥ 100 + breathing well → Post-resuscitation care
  • Labored breathing / cyanosis → CPAP + SpO₂ monitor
  • Apnea or HR < 100 → PPV

STEP 4: Positive Pressure Ventilation (PPV)

• Indications: Apnea, gasping, HR < 100/min
• Rate: 40-60 breaths/min ("breathe-two-three, breathe-two-three")
• Pressure: 20-25 cm H₂O (first breaths may need 30-40 cm H₂O)
• O₂: Start with room air (21%) in term babies; adjust via SpO₂
• Reassess HR after 30 seconds of PPV

STEP 5: If HR Still < 100 after PPV

• Check chest movement - ventilation corrective steps (MR SOPA: Mask adjustment, Reposition, Suction, Open mouth, Pressure increase, Airway - intubate)
• Consider ETT or laryngeal mask insertion

STEP 6: If HR < 60 despite adequate ventilation

• Intubate (if not already done)
• Chest compressions: 3:1 ratio (3 compressions : 1 breath) = 90 compressions + 30 breaths/min
• Technique: Two-thumb encircling method (preferred) OR two-finger method
• Depth: 1/3 of AP chest diameter
• Switch to 100% O₂
• Insert UVC (umbilical vein catheter)
• ECG monitoring

STEP 7: Medications (if HR < 60 despite compressions + ventilation)

• Epinephrine (Adrenaline):
  • IV (UVC): 0.01-0.03 mg/kg (1:10,000 solution)
  • ET route: 0.05-0.1 mg/kg (higher dose via ET)
• Normal saline 10 mL/kg - if hypovolemia suspected
• Consider pneumothorax (needle decompression)

APGAR Score (assessed at 1, 5, 10 minutes)

• Score 7-10: Normal
• Score 4-6: Moderate depression - stimulate, supplemental O₂
• Score 0-3: Severe depression - immediate resuscitation

Neonatal Resuscitation Algorithm:

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⭐⭐⭐ PRETERM BABY

Define Preterm Baby

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Factors Affecting Prematurity (Risk Factors)

Maternal Factors

• Previous preterm birth (strongest predictor)
• Pre-eclampsia / hypertension
• Antepartum hemorrhage (placenta previa, abruption)
• Infections: UTI, bacterial vaginosis, chorioamnionitis
• Uterine anomalies (bicornuate, septate uterus)
• Cervical incompetence
• Multiple gestation (twins, triplets)
• Assisted reproductive technology (ART/IVF)
• Extremes of age (< 18 years, > 35 years)
• Malnutrition, smoking, drug/alcohol use
• Diabetes mellitus, thyroid disease
• Short inter-pregnancy interval (< 18 months)

Fetal Factors

• Multiple gestation
• Fetal anomalies
• Polyhydramnios
• IUGR

Placental / Uterine Factors

• Preterm/prelabor rupture of membranes (PPROM)
• Placental insufficiency

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Complications of Preterm Baby

Respiratory

• Respiratory Distress Syndrome (RDS) / Hyaline Membrane Disease - due to surfactant deficiency (most important)
• Bronchopulmonary Dysplasia (BPD) - chronic lung disease
• Apnea of prematurity - due to immature respiratory center
• Pulmonary hypoplasia

Cardiovascular

• Patent Ductus Arteriosus (PDA) - failure of ductus to close
• Hypotension
• Bradycardia

CNS (Most feared long-term complications)

• Intraventricular Hemorrhage (IVH) - germinal matrix bleed
• Periventricular Leukomalacia (PVL) - white matter injury
• Cerebral palsy
• Attention deficit disorders
• Sensorineural hearing loss

Gastrointestinal / Metabolic

• Necrotizing Enterocolitis (NEC) - ischemic bowel necrosis (serious)
• Feeding difficulties / dysmotility / reflux
• Hypoglycemia - poor glycogen stores
• Hypocalcemia, hyponatremia

Eyes

• Retinopathy of Prematurity (ROP) - abnormal retinal vascularization from O₂ exposure

Skin / Temperature

• Hypothermia - thin skin, lack of brown fat, large surface area to body weight ratio
• Excessive insensible water loss

Immune / Hematological

• Increased sepsis/meningitis - immature immune system, no maternal IgG (transferred after 34 wks)
• Anemia of prematurity - short RBC lifespan + insufficient erythropoietin

Metabolic Bone Disease

• Osteopenia of prematurity - inadequate calcium/phosphorus stores

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⭐⭐⭐⭐⭐ LOW BIRTH WEIGHT AND SMALL FOR DATE

A) Definitions

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B) Known Causes of IUGR

Maternal Causes (Most common)

• Hypertension / Pre-eclampsia - uteroplacental insufficiency
• Malnutrition - maternal undernutrition
• Chronic diseases: Renal disease, SLE, severe diabetes, cardiac disease, thyroid disease
• Smoking (small placentas - high risk)
• Alcohol, drug abuse
• Anemia (severe)
• Multiple gestation

Placental Causes

• Placental insufficiency, infarction, abruption
• Circumvallate placenta
• Single umbilical artery

Fetal Causes

• Chromosomal abnormalities (aneuploidy - 25% of severe early IUGR)
• TORCH infections (Toxoplasma, Rubella, CMV, Herpes, Syphilis)
• Congenital malformations
• Multiple gestation

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C) Complications Anticipated in Full-term LBW (IUGR) Neonate

Immediate / Short-term

Long-term Complications

• Neurodevelopmental delay - cerebral palsy, learning disabilities
• Growth failure - many remain short
• Barker Hypothesis / DOHaD (Developmental Origins of Health and Disease):
  • IUGR babies have increased risk of hypertension, type 2 diabetes, coronary artery disease, obesity, metabolic syndrome in adult life (fetal programming)

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D) Steps to Prevent Complications in Full-term LBW Neonate

At Delivery

• Skilled birth attendant; warm delivery room
• Anticipate and prepare for resuscitation
• Delayed cord clamping (1-3 minutes) - reduces anemia

Temperature Management (Prevent Hypothermia)

• Dry immediately, place under radiant warmer
• Kangaroo Mother Care (KMC) - skin-to-skin contact
• Warm clothing, cap, socks
• Target temperature: 36.5-37.5°C (axillary)

Feeding (Prevent Hypoglycemia)

• Early initiation of breastfeeding within 30 minutes of birth
• Exclusive breastfeeding - monitor blood glucose
• Blood glucose monitoring at 30 min, 1hr, 2hr, 6hr, 12hr of life
• Treat hypoglycemia (BG < 45 mg/dL): IV dextrose 10% 2 mL/kg bolus

Infection Prevention

• Hand hygiene, aseptic technique
• Avoid unnecessary invasive procedures
• KMC improves immune function
• Vaccinations as per schedule

Monitoring

• Daily weight, head circumference, length
• Serial blood glucose, hematocrit
• Monitor for polycythemia (hematocrit > 65%): dilutional exchange transfusion if symptomatic

Polycythemia Management

• Adequate hydration
• Symptomatic polycythemia → partial exchange transfusion with normal saline

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Sources: Creasy & Resnik's Maternal-Fetal Medicine; Medical Physiology (Boron); ROSEN's Emergency Medicine; Guyton & Hall Textbook of Medical Physiology