Neonatal ICU Protocols

Neonatal ICU Protocols Editors

Neelam Kler MBBS MD (Ped)

Chairperson Department of Neonatology Institute of Child Health Sir Ganga Ram Hospital New Delhi, India Padma Bhushan 2014

Pankaj Garg

Anup Thakur

MBBS MD (Ped) DNB (Ped)

MBBS MD (Ped) DNB (Neonatology)

Senior Consultant Department of Neonatology Institute of Child Health Sir Ganga Ram Hospital New Delhi, India

Consultant Department of Neonatology Institute of Child Health Sir Ganga Ram Hospital New Delhi, India

Forewords

Ann R Stark DeWayne M Pursley Ashok Deorari VK Bhutani ON Bhakoo

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Neonatal ICU Protocols First Edition: 2020 Reprint: 2022 ISBN: 978-93-89587-23-4 Printed at Repro India Limited

Dedicated to

Sidharth Kler, Aditya Kler, Tanmay Garg, Paavni, Atharv Sachdeva Thakur, Anika Sachdeva Thakur

CONTRIBUTORS Aakriti Soni MBBS Intern Sir Ganga Ram Hospital New Delhi, India

Abdul Razak MD Associate Professor Department of Pediatrics Division of Neonatology McMaster University Hamilton, ON, Canada

Amrit Jeevan                            DCH MD (Ped) MRCPCH (UK) DNB (Neonatology)

Consultant Department of Neonatology Surya Mother and Child Superspecialty Hospital Mumbai, Maharashtra, India

Anita Singh  MD (Ped) DNB (Neonatology) Associate Professor Department of Neonatology Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Anumodan Gupta  MD (Ped) DNB (Neonatology) Consultant Pediatrics Department of Pediatrics Government Medical College Kathua, Jammu, India

Anup Thakur  MD (Ped) DNB (Neonatology) Consultant Department of Neonatology Sir Ganga Ram Hospital New Delhi, India

Anurag Fursule  DNB (Ped) DNB (Neonatology) Fellow Department of Neonatology Sir Ganga Ram Hospital New Delhi, India

Arpita Gupta  Assistant Professor Developmental and Behavioral Pediatrics Department of Pediatrics Maulana Azad Medical College New Delhi, India

Arti Maria  MD DM (Neonatology) Consultant and Head Department of Neonatology Dr Ram Manohar Lohia Hospital New Delhi, India

Arun Soni  DNB (Ped) Senior Consultant Department of Neonatology Sir Ganga Ram Hospital New Delhi, India

Arvind Shenoi  MD DM (Neonatology) Chief Neonatologist and Medical Director Department of Neonatology CloudNine Hospital, Bengaluru, Karnataka, India

Ashish Jain  MD DM Associate Professor Department of Neonatology Maulana Azad Medical College New Delhi, India

Ashish Mehta MD Director and Consultant Department of Neonatology Fellow in Neonatal Medicine College of Pediatrics, Australia ARPAN Newborn Care Centre Pvt Ltd Ahmedabad, Gujarat, India

B Adhisivam  DCH DNB PhD Additional Professor and HOD Department of Neonatology Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry, India

viii Contributors B Vishnu Bhat MD

Jaswinder Kaur  MD (Ped)

Director-Medical Research Professor of Pediatrics and Neonatology Aarupadai Veedu Medical College (AVMC) Puducherry, India Former Director Senior Professor and Head Department of Neonatology Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry, India

Clinical Associate Division of Pediatric Gastroenterology Hepatology and Liver Transplantation Institute of Child Health Sir Ganga Ram Hospital New Delhi, India

Brajesh Jha MD Senior Resident (DM Neonatology) Department of Neonatology Maulana Azad Medical College New Delhi, India

Deblina Dasgupta  MD (Ped) FNB Pediatric Nephrology Fellow Division of Pediatric Nephrology and Renal Transplantation Institute of Child Health Sir Ganga Ram Hospital New Delhi, India

Geeta Gathwala  DCH

MD (Ped) DM (Neonatology)

Senior Professor and Head Department of Pediatrics and Neonatology Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences Rohtak, Haryana, India

Harish Chellani  MD DCH Additional DGHS and Professor Department of Pediatrics Vardhman Mahavir Medical College and Safdarjung Hospital New Delhi, India

Harish Nayak  DOMS MS FRCS FRC (Ophth) Consultant Pediatric Ophthalmologist CloudNine Hospital Bengaluru, Karnataka, India Alderhey Children’s Hospital Liverpool, UK

Jogender Kumar  DM (Neonatology) Assistant Professor Division of Neonatology Department of Pediatrics Postgraduate Institute of Medical Education and Research, Chandigarh, India

Kanav Anand  MD (Ped)

FPN

Consultant Pediatric Nephrologist Division of Pediatric Nephrology and Renal Transplantation Institute of Child Health Sir Ganga Ram Hospital New Delhi, India

Karthik Nagesh N  MD FRCPCH (UK) FNNF Neonatal Intensive Care Fellowship (UK)

Chairman Neonatology and NICUs Manipal Group of Hospitals Head Department of Neonatology Chairman, Manipal Advanced Children’s Center Manipal Hospitals, Professor of Neonatology and Pediatrics, Manipal University Bengaluru, Karnataka, India

Kavitha Rao  DNB (Ophth) Fellowship in VR Surgery Consultant Vitreo-Retinal Surgeon Retina Institute of Karnataka Bengaluru, Karnataka, India

Koshy Marucoickal George MBBS Neonatologist Rapides Regional Medical Center Alexandria, Louisiana, USA

Kumari Gunjan  MD (Ped) DNB Neonatology Fellow Department of Neonatology Sir Ganga Ram Hospital New Delhi, India

Contributors M Jeeva Sankar  MD DM

Nishant Wadhwa  MBBS DCH (Ped) DNB

Associate Professor WHO Collaborating Centre for Training and Research in Newborn Care Department of Pediatrics All India Institute of Medical Sciences New Delhi, India

Consultant and Chief Division of Pediatric Gastroenterology Hepatology and Liver Transplantation Institute of Child Health Sir Ganga Ram Hospital New Delhi, India

Maneesha PH DNB Fellowship in Neonatology Department of Neonatology Consultant Neonatologist People Tree @ Meenakshi Hospitals Bengaluru, Karnataka, India

Nandkishor S Kabra                            DM (Neonatology) MD (Ped) DNB (Ped) MSc (Clinical Epidemiology)

Director and Head Department of Neonatology Surya Children’s Medicare Pvt Ltd Mumbai, Maharashtra, India

Naveen Jain  DM (Neonatology) Head Department of Neonatology Kerala Institute of Medical Sciences Thiruvananthapuram, Kerala, India

Naveen Parkash Gupta  MD (Ped) DNB (Neonatology) Fellowship in Neonatal Perinatal Medicine (Canada)

Senior Consultant Department of Neonatology Rainbow Children’s Hospital New Delhi, India

Nirupama Laroia  MD (Ped) Professor Department of Pediatrics Division of Neonatology University of Rochester, NY, USA

Nishad Plakkal  MD (Ped) Fellowship in Neonatal Perinatal Medicine (Canada)

Associate Professor Department of Neonatology Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry, India

Pankaj Garg  DNB MBBS MD Senior Consultant Department of Neonatology Sir Ganga Ram Hospital New Delhi, India

Pradeep Kumar Sharma  MD (Ped)

DM (Neonatology)

Senior Consultant Neonatologist Department of Neonatology Satguru Partap Singh (SPS) Hospitals Ludhiana, Punjab, India

Praveen Kumar  MD (Ped)

DM (Neonatology)

Professor Department of Pediatrics, Division of Neonatology Postgraduate Institute of Medical Education and Research, Chandigarh, India

Raktima Chakrabarti                    MD (Ped) Fellowship (Neonatology)

Consultant Pediatrician and Neonatologist Department of Neonatology Cloudnine Hospitals Gurugram, Haryana, India

Ranjan Kumar Pejaver  FRCPCH (UK) FRCPI FIAP FNNF Professor Department of Pediatrics Kempegowda Institute of Medical Sciences Bengaluru, Karnataka, India Chief Neonatologist People Tree @ Meenakshi Hospitals Bengaluru, Karnataka, India

Sachin Kumar Dubey (Maj)                  MD (Ped) DNB (Neonatology)

Consultant Neonatology Department of Pediatrics Yashoda Superspecialty Hospital Ghaziabad, Uttar Pradesh, India

ix

x

Contributors Sanjay Wazir  DM (Neonatology) Director Department of Neonatology and Pediatrics Cloudnine Hospitals Gurugram, Haryana, India

Sanjiv B Amin  MD MS Professor Department of Pediatrics University of Rochester School of Medicine Rochester, NY, USA

Shiv Sajan Saini  DM (Neonatology) Assistant Professor Department of Pediatrics Division of Neonatology Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Shridevi S Bisanalli  MD DM Faculty Department of Neonatology St John’s Medical College Bengaluru, Karnataka, India

Sindhu Sivanandan  MD DM Assistant Professor Department of Neonatology Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry, India

Sonalika Mehta  MBBS MD Consultant Neonatologist Department of Neonatology Rainbow Hospitals New Delhi, India

Suman Rao PN  MD (Ped) DM Professor and Head of Department Department of Neonatology St John’s Medical College Bengaluru, Karnataka, India

Supreet Khurana  MD (Ped) DM (Neonatology) Assistant Professor Department of Neonatology Government Medical College Hospital Chandigarh, India

Susanta Kumar Badatya                        MD (Ped) DNB (Neonatology)

Consultant Neonatologist Department of Neonatology Apollo Cradle New Delhi, India

Swarna Rekha Bhat MD Former Professor Department of Pediatrics Division of Neonatology St John’s Medical College Bengaluru, Karnataka, India

Tapas Bandyopadhyay                          MD (Ped) DM (Neonatology)

Assistant Professor Department of Neonatology Dr Ram Manohar Lohia Hospital New Delhi, India

Umesh Vaidya  MBBS DNB Consultant and Head Division of Neonatology King Edward Memorial (KEM) Hospital Pune, Maharashtra, India

Venkataseshan Sundaram  DM (Neonatology) Additional Professor Division of Neonatology Department of Pediatrics Postgraduate Institute of Medical Education and Research, Chandigarh, India

Vivek Choudhury  MD (Ped) DNB (Neonatology) Consultant Neonatologist Department of Neonatology Apollo Cradle, New Delhi, India

Wg Cdr (Dr) Ajoy Kumar Garg               MD (Ped) DNB (Neonatology)

Assistant Professor Department of Pediatrics Army Hospital Research and Referral (R&R) New Delhi, India

FOREWORD We were very pleased to learn that our distinguished colleague Professor Neelam Kler and her associates, Drs Pankaj Garg and Anup Thakur, have collaborated to develop a new and much needed Neonatal ICU Protocols. Drawing on national experts in neonatology and supplemented by their own decades of experience providing neonatal care at the renowned Sir Ganga Ram Hospital in New Delhi, India, the editors have developed an important resource for neonatal care providers in India. A key characteristic of the handbook is that it is easy-to-use and can be applied directly at the bedside. Thirty-three individual chapters focus on the important issues in providing contemporary neonatal care. Rather than providing a long narrative, each chapter is organized with clear headings that include relevant information noted with bullet points. Ample tables, flowcharts, diagrams, illustrations, and photos provide additional well-organized information and supplement the text. At the end of each chapter, bulleted Key Points emphasize the “take home” messages. The self-assessment questions that follow will be helpful to students at every level, from residents and fellows to practicing neonatologists. Finally, a list of carefully selected articles provides a handy resource for more extensive reading. The importance of high quality neonatal care cannot be overstated. The newborn period— the first 28 days of life—is the most vulnerable time for a child’s survival. In India, deaths during this period represent more than half of the deaths occurring among children under 5 years of age. The interventions that are effective in the care of preterm and medically fragile newborns are unique to that period and require substantial training and mastery. Textbooks such as Neonatal ICU Protocols can be effective tools in improving outcomes for this most vulnerable of populations. Combined with public health measures, improved clinical outcomes facilitated by making current knowledge readily accessible can contribute to improved survival and help minimize sequelae of neonatal illness. Another potential benefit of this handbook would be that neonatal care is standardized within a facility or perhaps across several in a region, since reducing variation tends to improve clinical outcomes. Standardization also provides a platform for quality improvement, allowing incremental tests of change. Finally, recognizing where evidence is limited may stimulate readers to pursue research and expand our knowledge. We are confident that the Neonatal ICU Protocols will be increasingly found in NICUs throughout India, contribute to optimizing care of our fragile patients, and provide a study guide to a new generation of learners in our field. We look forward to further editions as knowledge continues to expand.

Ann R Stark  MD DeWayne M Pursley  MD MPH Department of Neonatology Beth Israel Deaconess Medical Center Harvard Medical School, USA

FOREWORD Ensuring healthy survival of all neonates is among the highest priorities of our times. The global community has committed itself to attain an under-five child mortality rate of less than 20 per 1,000 live births in all countries by 2035. This would only be achieved if the neonatal mortality rate declines to less than 10 per 1,000 live births. For India, this would be nearly halving the current neonatal mortality rate of 23 per 1,000 live births. India’s success in reduction of neonatal mortality since the launch of the National Rural Health Mission has been modest. Nonetheless, the country mounted a spectacular effort in establishing newborn care corners and special newborn care units, thus creating an impressive neonatal care infrastructure in the public sector. There has also been a concomitant expansion of neonatal care services in the private sector. This massive expansion of neonatal care services has also brought to the fore an extraordinary need for skilled nurses and doctors. Sir Ganga Ram Hospital, New Delhi, India, which runs one of the best tertiary care, newborn units for more than three decades in the city of Delhi, has been in the forefront of training healthcare providers in neonatal care. The unit has tried to capture the best learnings in neonatology in the current handbook. This compilation is a timely step towards filling the gap for knowledge translation for ensuring quality of care for sick newborns. The handbook has 33 chapters on common issues faced while caring a sick newborn. It provides comprehensive, systematic approach in identification and management of sick neonates. The evidence-based practices are tailored to day-to-day needs of neonatology fellows, resident doctors, and practicing pediatricians. I am confident that the effort of updating chapters of the handbook in the future will continue with the energetic next generation leadership of the unit. I would like to congratulate the contributors, reviewers, and the editorial team for an outstanding product. The credit goes to a very large team of neonatologists trained in India who have contributed in this endeavor. I am glad to see many young neonatologists, most of whom I know personally, contributing to this book. They are exceptional up-to-date educators with hands-on experience in managing sick neonates. My special congratulations to Dr Neelam Kler for taking, leadership role in this endeavor. I am sure this handbook will help in providing safe, affordable care with focus on quality in neonatal units in the country and beyond.

Ashok Deorari

MD FAMS FNNF

Professor and Head Department of Pediatrics In-charge WHO Collaborating Center for Education and Research in Newborn Care Chairman, Skills Center Lead for QI in SEARO All India Institute of Medical Sciences New Delhi, India President (2020) National Neonatology Forum (NNF), India

FOREWORD Padma Bhushan Dr Neelam Kler leads her team Dr Pankaj Garg and Dr Anup Thakur to take the key steps that will help develop a national “standard of care” for neonatal medicine for Indian families. Collaboration with national experts provides a unique insight that bridges the gap between academic knowledge and practical realties that burden practicing front-line clinicians. The algorithms and tables categorizing neonatal conditions should be used as guidelines for judgment-driven disease management. This handbook deals with the current state of neonatology and provides a comprehensive, systematic approach in the identification and management of sick neonates to make evidencebased decisions in clinical practice for both public and private sectors. Sections on follow-up care deserve special mention. Future publications could include individual attention to antibiotic stewardship, breastfeeding, small-for-dates neonates, phototherapy, hyperammonemia syndromes and NICU-based neurodevelopmental protection and maturation. Other novel areas on the horizon in future editions include prenatal and perinatal cardiac disorders and other fetal disorders that require specific neonatal care. The handbook is directed for use by the bedside clinician who is still a student of neonatal diagnosis and disorders before the results of laboratory tests are available. It is well structured and easy-to-read. Editors are specifically congratulated for attempting to provide a forum for families who are likely to be readers. Content in this handbook should be updated periodically (more than annually). Hopefully this will be achieved through a web-based portal for rapid alerts, novel approaches and newer sections. These are exciting prospects and speak to the mission of the handbook as a knowledge resource that governs national intensive neonatal care patterns for safer care of vulnerable infants. Contributions of Drs Neelam Kler, Pankaj Garg and Anup Thakur are significant and over the years will help clinicians and families to develop sound as well as safe judgment. Well done and well-read.

VK Bhutani Professor of Pediatrics (Neonatology) Lucile Salter Packard Hospital Standford University, USA

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