Guidelines For Acute Care Of The Neonate
Guidelines for Acute Care of the NeonateEdition 26, 2018–2019Updated: July 2018Arnold J. Rudolph, MMBCh (1918 - 1995)Section of NeonatologyDepartment of PediatricsBaylor College of MedicineHouston, Texas
Guidelines for Acute Care of the NeonateEdition 26, 2018-2019Updated: July 2018EditorsCaraciolo J. Fernandes, M.D.Mohan Pammi, M.D., Ph.D.Lakshmi Katakam, M.D., M.P.H.Section EditorsDiane M. Anderson, Ph.D., R.D., LDMufeed Ashraf, MDJonathan Davies, M.D.Catherine Gannon, M.D.Joseph A. Garcia-Prats, M.D.Ganga Gokulakrishnan, M.D., M.S.Amy B. Hair, M.D.Karen E. Johnson, M.D.Timothy C. Lee, M.D.Krithika Lingappan, M.B.B.S.George Mandy, M.D.Tiffany M. McKee-Garrett, M.D.Frank X. Placencia, M.D.Muralidhar Premkumar, M.B.B.S.Christopher J. Rhee, M.D.Danielle R. Rios, M.D., M.S.Binoy Shivanna, M.D., M.B.B.S.Michael E. Speer, M.D.Section of NeonatologyDepartment of PediatricsBaylor College of MedicineHouston, Texas
Copyright 1981–2018 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine.Edition 26, First printing July 2018Published byGuidelines for Acute Care of the NeonateSection of Neonatology, Department of Pediatrics Baylor College of Medicine6621 Fannin Suite W6104Houston, TX 77030All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed inany form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Printed in the United Statesof America.A D (Original Ointment) is a registered trademark of Schering-Plough Healthcare Products, Inc., Memphis TNAlfamino is a registered trademark of Nestlé HealthCare Nutrition, Florham Park, NJAlimentum is a registered trademark of Abbott Laboratories, Ross Products Division, Columbus OHAquophor is a registered trademark of Beiersdorf, Hamburg GermanyArgyle is a registered trademark of Sherwood Services AG, Schaffhausen, SwitzerlandBabylog is a registered trademark of Dräger, Inc. Critical Care Systems, Telford PAComVax is a registered trademark of Merck & Company, Inc., Whitehouse Station NJDacron is a registered trademark of Koch Industries, Inc., Wichita KSDanvers MA5 Silastic is a registered trademark of Dow Corning Corporation, Midland MIDesitin is a registered trademark of Pfizer Inc., New York NYD-Vi-Sol is a registered trademark of Mead Johnson & Company, Evansville INElecare is a registered trademark of Abbott Laboratories, Inc., Abbott Park ILEnfacare is a registered trademark of Mead Johnson & Company, Evansville INEnfaport is a registered trademark of Mead Johnson & Company, Evansville INEnfamil is a registered trademark of Mead Johnson & Company, Evansville INENGERIX-B is a registered trademark of SmithKline Beecham Biologicals S.A., Rixensart, BelgiumFer-In-Sol is a registered trademark of Mead Johnson & Company, Evansville INGastrografin is a registered trademark of Bracco Diagnostics, Inc., Princeton NJGerber is a registered trademark of the Gerber Products Company/Nestlé Infant Nutrition, Florham Park, NJGiraffe Omnibed is a registered trademark of General Electric Company, Schenectady NYGomco is a registered trademark of Allied Healthcare Products, Inc., St. Louis MOGood Start is a registered trademark of the Gerber Products Company/Nestlé Infant Nutrition, Florham Park, NJInfant is a registered trademark of Fresenius Kabi AB Corporation, Uppsala, SwedenKerlix is a registered trademark of Tyco Healthcare Group LP, Mansfield MALiqui-E is a registered trademark of Twin Laboratories, Inc., Ronkonkoma NYMedela is a registered trademark of Olle Larsson Holding AG, Zug, SwitzerlandM.V.I. Pediatric is a trademark of Pharma Inc., Wilmington NCNeo-Calglucon is a registered trademark of Sandoz Pharmaceuticals Corporation, East Hanover NJNeocate is a registered trademark of SHS International, Liverpool, EnglandNeoSure is a registered trademark of Abbott Laboratories, Ross Products Division, Columbus OHNeoFax is a registered trademark of Thomson Healthcare, Inc., Montvale NJNutramigen is a registered trademark of Mead Johnson & Company, Evansville INOmegavan is a registered trademark of Fresinius Kabi, GermanyPedVaxHIB is a registered trademark of Merck & Company, Inc, Whitehouse Station NJPoly-Vi-Sol is a registered trademark of Mead Johnson & Company, Evansville INPregestimil is a registered trademark of Mead Johnson & Company, Evansville INPremasol is a registered trademark of Baxter Health Care Corporation, Deerfield IL.Prevacid is a registered trademark of NovartisPrilosec is a registered trademark of AstraZeneca, Sodertalje, SwedenProlacta is a registered trademark of Prolacta Bioscience, Inc. City of Industry, CAProtonix is a registered trademark of Wyeth Corporation, Madison NJPurAmino is a registered trademark of Mead Johnson & Company, Evansville INPuritan Bennett is a registered trademark of Puritan Bennett Corporation, Overland Park KSReglan is a registered trademark of Wyeth Pharmaceuticals, Philadelphia PASensorMedics is a registered trademark of SensorMedics Corporation, Anaheim CASilastic is a registered trademark of Dow Corning Corporation, Midland, MISimilac is a registered trademark of Abbott Laboratories, Ross Products Division, Columbus OHStomahesive is a registered trademark of E.R. Squibb & Sons, L.L.C., Princeton, NJSurvanta is a registered trademark of Abbott Laboratories, Ross Products Division, Columbus OHTrophAmine is a registered trademark of B. Braun Medical, Inc., Irvine CAVariZIG is a registered trademark of Cangene Corporation, Winnipeg, Manitoba, CanadaVaseline is a registered trademark of Cheeseborough-Pond’s Inc., Greenwich CTVitrase is a registered trademark of ISTA Pharmaceuticals, Inc., Irvine CAUrsodiol is a registered trademark of Glenmark Pharmaceuticals, Ltd., Goa IndiaZantac is a registered trademark of Pfizer Inc. Ltd., New York NY
Section of Neonatology, Department of Pediatrics, Baylor College of MedicineForewordIt is my privilege to introduce this year’s edition of Baylor Neonatology Guidelines, now in the 26th year of its publication. Theeditors of these guidelines – Drs. Fernandes, Pammi and Katakam – are continuing the legacy of Dr. James Adams and histradition of generating practical, up-to-date and evidence-based guidelines that provide bedside clinicians with a ready referencefor patient care. The editors, section editors, and various authors have worked hard to preserve relevant material from theguidelines and add new relevant information. They have continued to incorporate more and more the GRADE system of categorizingthe evidence supporting these guidelines, and expanded the pool of authors in this edition. Community neonatology colleagues, nursepractitioners, dietitians, and fellows are all members of author teams now.The Baylor Neonatology Guideline book is used extensively in our Newborn Center (including the Mother Baby Unit), the Ben TaubNICU, and our Community Neonatology neonatal units. It ensures consistency of care among the large number of clinicians in ourNewborn Center and at multiple locations in the Houston area. It has been, and will remain one of the most valuable resources and adistinguishing asset of the Neonatology Section. In addition, it is a resource for practicing neonatologists all over the world. Mostimportantly, these guidelines ensure that we provide excellent high-quality care to NICU infants and their families and improve theiroutcomes. As the Service Chief and Section Head of Neonatology, it has been my honor to support the team of editors and authorswho have worked hard to bring us this distillation of evidence, experience, and clinical wisdom.Gautham Suresh, MD, DM, MS, FAAPProfessor of Pediatrics, Baylor College of MedicineSection Head and Service Chief of NeonatologyTexas Children's HospitalGuidelines for Acute Care of the Neonate, Edition 26, 2018–19i
Section of Neonatology, Department of Pediatrics, Baylor College of MedicinePrefaceWe are pleased to release the 26th revision of “Guidelines for the Acute Care of the Neonate”, acompendium of multidisciplinary collaboration between members of the Newborn Center at TexasChildren’s Hospital and Baylor College of Medicine. This edition is dedicated to the two legendsof the BCM Neo Section who left lasting legacies - Dr. Arnold J. Rudolph, who taught us the art ofneonatology and Dr. James Adams, who, in addition to being an educator extraordinaire, was singularlyinfluential in developing the ‘BCM Neo Guidelines’ over the first 24 years.The ‘Baylor Neo Guidelines’, as this handbook is fondly referred to, is meant to serve as a resource forneonatology fellows, pediatric housestaff, nurse practitioners, nurses and other clinicians who care for sickneonates in Baylor-affiliated hospitals. This body of work is reflective of general principles, concepts, andtreatment recommendations that are agreed upon by the authors, editors, and section members. Whenappropriate, national guidelines are cited to help with the decision-making process. Also, regional traitsunique to the southeast Texas or Houston are considered when appropriate. The guidelines are reviewedand revised annually (or more frequently as needed) as new evidence and recommendations for clinical care become available. Usersshould refer to the most recent edition of these guidelines, which may be downloaded for free from ‘Physician publications’ tab of theBaylor Neonatology website (www.neonate.net).Starting with the 25th edition, we began qualifying our clinical recommendations using the ‘GRADE’ framework for rating quality ofevidence and strength of recommendations. Our guidelines cite the quality of evidence and the strength of our recommendationswhenever possible. Our chapter authors and section editors have worked hard to create the content you see within and will monitortheir areas of clinical interest for emerging evidence that may be of value to the bedside clinician caring for a sick neonate. We lookforward to serving you in the coming years.Sincerely,Caraciolo J. Fernandes, MDMohan Pammi, MD, PhDLakshmi Katakam, MD, MPHDisclaimerThese are guidelines only and may not be applicable to populations outside the BCM Affiliated Hospitals. These guidelines do notrepresent official policy of Texas Children’s Hospital, Ben Taub General Hospital, BCM, or the BCM Department of Pediatrics, nor arethey intended as universal practice guidelines or standards of care. Specific circumstances often dictate deviations from these guidelines.Each new admission and all significant new developments must be discussed with the fellow on call and with the attending neonatologiston rounds. All users of this material should be aware of the possibility of changes to this handbook and should use the most recentlypublished guidelines.iiGuidelines for Acute Care of the Neonate, Edition 26, 2018–19
Section of Neonatology, Department of Pediatrics, Baylor College of MedicineContributing AuthorsAll authors are members of the faculty at Baylor College of Medicine in the Department of Pediatrics, Section of Neonatology andattending physicians at Texas Children’s Hospital, unless otherwise noted. Allied health contributors are all members of the TexasChildren’s Hospital staff.Senait Adebo, MDAssistant ProfessorLeah Elizondo, MDNeonatal-Perinatal FellowDiane Anderson, PhD, RD, LDAssociate ProfessorNidia B. Espinosa, MS, RD, LDNeonatal DietitianAthis Arunachalam, MDAssistant ProfessorRegine Fortunov, MDAssistant ProfessorMufeed Ashraf, MDAssistant ProfessorMayra Freeman-Ladd, MDAssistant ProfessorSangeetha Athis Rajh, MDInstructorBheru Gandhi, MDAssistant ProfessorMelinda Colleen Brand, PhD, RN, NNP-BC Catherine Gannon, MDNeonatal Nurse PractitionerAssistant ProfessorElizabeth Bacon, MS, RD, LD, CNSC,CSPNeonatal DietitianJoseph Garcia-Prats, MDProfessorAshley S. Bruns, DOPerinatal-Neonatal FellowAnn Gerges, MDAssistant ProfessorRebecca J. Burke, MDPerinatal-Neonatal FellowJamie Gilley, APRN, MSN, NNP-BCNeonatal Nurse PractitionerMelissa M. Carbajal, MDAssistant ProfessorGanga Gokulakrishnan, MD, MSAssistant ProfessorAmy Carter MS, RD, LDNeonatal DietitianLaura Gollins, MBA, RD, LDNeonatal DietitianLaura Caudill, RD, CLEC, LDNeonatal DietitianSharada H. Gowda, MDAssistant ProfessorMary F. Colby-Hale, MSN, APRN, NNP-BC Charleta Guillory, MD, MPHNeonatal Nurse PractitionerAssociate ProfessorWilliam J. Craigen, MDProfessorDepartment of Molecular & Human GeneticsBridget Cross MSN, APRN, NNP-BCNeonatal Nurse PractitionerMilenka Cuevas Guaman, MDAssistant ProfessorViral Dave, MDAssistant ProfessorJonathan Davies, MDAssistant ProfessorStephanie Blair Deal, MDAssistant ProfessorChris K. Dischler, MSN, APRN, NNP-BCNeonatal Nurse PractitionerAmy B. Hair, MDAssistant ProfessorPatrice Hochevar, RD, CNSC, LDNeonatal DietitianKaren E. Johnson, MDAssociate ProfessorLakshmi Katakam, MD, MPHAssociate ProfessorSimon Yousef Kayyal, MDAssistant Professor of NeurologyMona Khattab, MD, MSAssistant ProfessorSeema Lalani, MDAssociate ProfessorDepartment of Molecular & Human GeneticsTimothy C. Lee, MDAssociate ProfessorDivision of Pediatric SurgeryKrithika Lingappan, MBBSAssociate ProfessorJenelle Little, MDAssistant ProfessorPablo Lohmann, MDAssistant ProfessorLaura Lucas, MS, RD, CSP, LDNeonatal DietitianAshley Lucke, MDNeonatal-Perinatal FellowAgnes Mandy, RD, LDNeonatal DietitianGeorge T. Mandy, MDAssociate ProfessorL. Adriana Massieu, RD, CNSC, LDNeonatal DietitianTiffany McKee-Garrett, MDAssociate ProfessorMaria Kristine Reyes, MDAssistant ProfessorChristopher J. Rhee, MDAssistant ProfessorDanielle R. Rios, MD, MSAssistant ProfessorEmily Rodman, PharmD, BCPPSClinical Pharmacy Specialist-NICUCharles Roitsch, DONeonatal-Perinatal FellowElizabeth Sager, MDNeonatal-Perinatal FellowRita Shah, MDAssistant ProfessorMichael E. Speer, MDProfessorNathan C. Sundgren, MD, PhDAssistant ProfessorAlana Thomas, MDAssistant ProfessorCecilia Torres-Day, MDJamie J. McKissick, MSN, APRN, NNP-BC Assistant ProfessorNeonatal Nurse PractionerLois M. Tracy, MSN, APRN, NNP-BCNeonatal Nurse PractitionerTiffany L. Molina, MDNeonatal-Perinatal FellowSantiago O. Valdes, MDAssistant ProfessorAlice Obuobi, MDSection of Pediatric CardiologyAssistant ProfessorScott W. Osborne, MDAssistant ProfessorGregory Valentine, MD, DTMNeonatal-Perinatal FellowLisa Owens, DOSenior FacultyNidhy Paulose Varghese, MDAssistant ProfessorDivision of Pulmonary MedicineMohan Pammi, MDAssociate ProfessorShweta Parmekar, MDAssistant ProfessorFrank X, Placencia, MDAssistant ProfessorBernadette White, MDNeonatal-Perinatal FellowLindsay Whittington, RN, VA-BCStaff NurseJennifer L. Placencia, PharmDClinical Pharmacy Specialist-NICUMuralidhar Premkumar, MBBSAssistant ProfessorContributorsEndocrinology section was written with the advice of the Pediatric Endocrine and Metabolism Section, in particular, Lefki P. Karaviti, MD andGeorge Jeha, MD. Environment section, in particular NICU Environment, written with the advice of Carol Turnage-Carrier, MSN RN CNS andLisa Davenport MSN, RN, CNS. Infectious Disease section was written with the advice of the Pediatric Infectious Disease Section, in particular,Drs. Carol J. Baker, Judith R. Campbell, Morven S. Edwards, and Flor Munoz-Rivas. Human Immunodeficiency Virus (HIV) section writtenwith the advice of the Allergy & Immunology Section. Nutrition section was written with the advice of Nancy Hurst, PhD, RN, IBCLC, andKristina Tucker, RN, IBCLC.Guidelines for Acute Care of the Neonate, Edition 26, 2018–19iii
Section of Neonatology, Department of Pediatrics, Baylor College of MedicineivGuidelines for Acute Care of the Neonate, Edition 26, 2018–19
ContentsSection of Neonatology, Department of Pediatrics, Baylor College of MedicineSection 1. Care of Very Low Birth Weight BabiesSection 4. EnvironmentCh. 1.1General Care (Babies 1500 grams) . 2Ch. 4.1NICU Environment . 60Ch. 1.2Specialized Care for ELGAN Babies . 3Ch. 4.2Thermal Regulation . 63Ch. 1.3Umbilical Catheters. 4Section 5. EndocrinologySection 2. Respiratory CareCh. 5.1Approach to Disorders of Sexual Development . 68Ch. 2.1Delivery Room Stabilization . 10Ch. 5.2Hypothyroxinemia of Prematurity . 70Ch. 2.2Control of Breathing and Apnea of Prematurity . 11Ch. 5.3Steroid Therapy for Adrenal Insufficiency . 71Ch. 2.3Management of Neonatal Respiratory Distress . 13Ch. 5.4Hypoglycemia . 72Ch. 2.4Non-Invasive Respiratory Support . 14Ch. 5.5Transitional Neonatal Hypoglycemia . 72Ch. 2.5Weaning from CPAP and Nasal Cannula . 17Ch. 5.6Persistent Hypoglycemia . 74Ch. 2.6Conventional Ventilation of Preterm and TermNeonates . 18Section 6. GeneticsCh. 2.7High-frequency Oscillatory Ventilation . 22Ch. 2.8Bronchopulmonary Dysplasia . 24Ch. 2.9Prevention of Bronchopulmonary Dysplasia . 30Ch. 6.1Inborn Errors of Metabolism . 78Ch. 6.2Genetic Testing . 85Section 7. HematologyCh. 7.1Approach to the Bleeding Neonate . 88Ch. 7.2Platelet Disorders . 89Ch. 2.11 Pulmonary Hypertension in Lung Diseases . 32Ch. 7.3Transfusion of Blood Products . 90Ch. 2.12 Congenital Diaphragmatic Hernia . 33Ch. 7.4Pathophysiology and Differential Diagnosis ofJaundice . 92Ch. 7.5Management of Neonatal Jaundice . 94Ch. 7.6Polycythemia . 97Ch. 7.7Neonatal Thrombosis . 99Ch. 2.10 Interdisciplinary Care and Discharge Planning ofthe Ventilator Dependent Patient . 31Ch. 2.13 Neonatal ECMO . 35Section 3. Cardiac CareCh. 3.1Cardiovascular Physiology. 40Ch. 3.2Circulatory Insufficiency . 43Ch. 3.3Congenital Heart Disease . 50Ch. 3.4Arrhythmias . 56Guidelines for Acute Care of the Neonate, Edition 26, 2018–19v
ContentsSection of Neonatology, Department of Pediatrics, Baylor College of MedicineSection 8. Infectious DiseasesSection 10. Newborn CareCh. 8.1Bacterial Sepsis . 104Ch. 10.1 Routine Care . 138Ch. 8.2Group B Streptococcus (GBS) . 105Ch. 10.2 Cardiac Murmurs . 140Ch. 8.3Cytomegalovirus (CMV) . 107Ch. 10.3 Dental. 140Ch. 8.4Fungal Infection (Candida) . 107Ch. 10.4 Dermatology . 141Ch. 8.5Gonococcal Disease . 110Ch. 10.5 Extracranial Swelling . 142Ch. 8.6Hepatitis B . 110Ch. 10.6 Feeding . 143Ch. 8.7Hepatitis C . 111Ch. 10.7 Hospital Discharge. 146Ch. 8.8Herpes Simplex Virus (HSV).
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine. Contributing Authors. Guidelines for Acute Care of the Neonate, Edition 26, 2018 – 19 iii . All authors are members of the faculty at Baylor College of Medicine in the Department o
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