Ebook Manual of neonatal care (7/E): Part 2

(BQ) Part 2 book Manual of neonatal care has contents: Common neonatal procedures, skin care, disorders of sex development, inborn errors of metabolism, orthopaedic problems, neural tube defects, neonatal seizures, intracranial hemorrhage, lyme disease, congenital toxoplasmosis,... and other contents.

45 Anemia Helen A Christou I HEMATOLOGIC PHYSIOLOGY OF THE NEWBORN (1–5) Significant changes occur in the red blood cell (RBC) mass of an infant during the neonatal period and ensuing months The evaluation of anemia must take into account this developmental process, as well as the infant’s physiologic needs A Normal development: The physiologic anemia of infancy (1) In utero, the fetal aortic oxygen saturation is 45%, the erythropoietin levels are high, and the RBC production is rapid The fetal liver is the major site of erythropoietin production After birth, the oxygen saturation is 95%, and the erythropoietin is undetectable RBC production by day is Ͻ1/10th the level in utero Reticulocyte counts are low, and the hemoglobin level falls (see Table 45.1) Despite dropping hemoglobin levels, the ratio of hemoglobin A to hemoglobin F increases and the levels of 2,3-diphosphoglycerate (2,3-DPG) (which interacts with hemoglobin A to decrease its affinity for oxygen, thereby enhancing oxygen release to the tissues) are high As a result, oxygen delivery to the tissues actually increases This physiologic “anemia” is not a functional anemia in that oxygen delivery to the tissues is adequate Iron from degraded RBCs is stored At to 12 weeks, hemoglobin levels reach their nadir (see Table 45.2), oxygen delivery to the tissues is impaired, renal erythropoietin production is stimulated, and RBC production increases Infants who have received transfusions in the neonatal period have lower nadirs than normal because of their higher percentage of hemoglobin A (1) During this period of active erythropoiesis, iron stores are rapidly utilized The reticuloendothelial system has adequate iron for 15 to 20 weeks in term infants After this time, the hemoglobin level decreases if iron is not supplied B Anemia of prematurity is an exaggeration of the normal physiologic anemia (Tables 45.1 and 45.2) RBC mass and iron stores are decreased because of low birth weight; however, hemoglobin concentrations are similar in preterm and term infants The hemoglobin nadir is reached earlier than in the term infant because of the following: a RBC survival is decreased in comparison with the term infant b There is a relatively more rapid rate of growth in premature babies than in term infants For example, a premature infant gaining 150 g/week requires approximately a 12 mL/week increase in total blood volume 563 563-571_Cloherty_Ch45.indd 563 7/2/11 1:04 AM 564 ANEMIA Table 45.1 Hemoglobin Changes in Babies in the First Year of Life Hemoglobin level Week Term babies Premature babies (1,200–2,500 g) Small premature babies (Ͻ1,200 g) 17.0 16.4 16.0 18.8 16.0 14.8 15.9 13.5 13.4 12.7 10.7 9.7 10 11.4 9.8 8.5 20 12.0 10.4 9.0 50 12.0 11.5 11.0 Source: Glader B, Naiman JL Erythrocyte disorders in infancy In: Taeusch HW, Ballard RA, Avery ME, eds Diseases of the Newborn Philadelphia: WB Saunders; 1991 c Many preterm infants have reduced red cell mass and iron stores because of iatrogenic phlebotomy for laboratory tests This has been somewhat ameliorated with the use of microtechniques d Vitamin E deficiency is common in small premature infants, unless the vitamin is supplied exogenously The hemoglobin nadir in premature babies is lower than in term infants, because erythropoietin is produced by the term infant at a hemoglobin level of 10 to 11 g/dL and is produced by the premature infant at a hemoglobin level of to g/dL Iron administration before the age of 10 to 14 weeks does not increase the nadir of the hemoglobin level or diminish its rate of reduction However, this iron is stored for later use Once the nadir is reached, RBC production is stimulated, and iron stores are rapidly depleted because less iron is stored in the premature infant than in the term infant Table 45.2 Hemoglobin Nadir in Babies in the First Year of Life Maturity of baby at birth Hemoglobin level at nadir Time of nadir (wk) Term babies 9.5–11.0 6–12 Premature babies (1,200–2,500 g) 8.0–10.0 5–10 Small premature babies (Ͻ1,200 g) 6.5–9.0 4–8 Source: Glader B, Naiman JL Erythrocyte disorders in infancy In: Taeusch HW, Ballard RA, Avery ME, eds Diseases of the Newborn Philadelphia: WB Saunders; 1991 563-571_Cloherty_Ch45.indd 564 7/2/11 1:04 AM Hematologic Disorders II 565 ETIOLOGY OF ANEMIA IN THE NEONATE (6) A Blood loss is manifested by a decreased or normal hematocrit (Hct), increased or normal reticulocyte count, and a normal bilirubin level (unless the hemorrhage is retained) (4,5) If blood loss is recent (e.g., at delivery), the Hct and reticulocyte count may be normal, and the infant may be in shock The Hct will fall later because of hemodilution If the bleeding is chronic, the Hct will be low, the reticulocyte count will go up, and the baby will be normovolemic Obstetric causes of blood loss, including the following malformations of placenta and cord: a Abruptio placentae b Placenta previa c Incision of placenta at cesarean section d Rupture of anomalous vessels (e.g., vasa previa, velamentous insertion of cord, or rupture of communicating vessels in a multilobed placenta) e Hematoma of cord caused by varices or aneurysm f Rupture of cord (more common in short cords and in dysmature cords) Occult blood loss a Fetomaternal bleeding may be chronic or acute It occurs in 8% of all pregnancies; and in 1% of pregnancies, the volume may be as large as 40 mL The diagnosis of this problem is by Kleihauer-Betke stain of maternal smear for fetal cells (2) Chronic fetal-to-maternal transfusion is suggested by a reticulocyte count Ͼ10% Many conditions may predispose to this type of bleeding: i Placental malformations—chorioangioma or choriocarcinoma ii Obstetric procedures—traumatic amniocentesis, external cephalic version, internal cephalic version, breech delivery iii Spontaneous fetomaternal bleeding b Fetoplacental bleeding i Chorioangioma or choriocarcinoma with placental hematoma ii Cesarean section, with infant held above the placenta iii Tight nuchal cord or occult cord prolapse c Twin-to-twin transfusion Bleeding in the neonatal period may be due to the following causes: a Intracranial bleeding associated with: i Prematurity ii Second twin iii Breech delivery iv Rapid delivery v Hypoxia b Massive cephalhematoma, subgaleal hemorrhage, or hemorrhagic caput succedaneum c Retroperitoneal bleeding d Ruptured liver or spleen e Adrenal or renal hemorrhage f Gastrointestinal bleeding (maternal blood swallowed from delivery or breast should be ruled out by the Apt test) (see Chap 43): i Peptic ulcer ii Necrotizing enterocolitis iii Nasogastric catheter g Bleeding from umbilicus 563-571_Cloherty_Ch45.indd 565 7/2/11 1:04 AM 566 ANEMIA Iatrogenic causes Excessive blood loss may result from blood sampling with inadequate replacement B Hemolysis is manifested by a decreased Hct, increased reticulocyte count, and an increased bilirubin level (1,2) Immune hemolysis (see Chap 26) a Rh incompatibility b ABO incompatibility c Minor blood group incompatibility (e.g., c, E, Kell, Duffy) d Maternal disease (e.g., lupus), autoimmune hemolytic disease, rheumatoid arthritis (positive direct Coombs test in mother and newborn, no antibody to common red cell antigen Rh, AB, etc.), or drugs Hereditary RBC disorders a RBC membrane defects such as spherocytosis, elliptocytosis, or stomatocytosis b Metabolic defects Glucose-6-phosphate dehydrogenase (G6PD) deficiency (significant neonatal hemolysis due to G6PD deficiency is seen only in Mediterranean or Asian G6PD-deficient men; blacks in the United States have a 10% incidence of G6PD deficiency but rarely have significant neonatal problems, unless an infection or drug is operative), pyruvate kinase deficiency, 5Ј-nucleotidase deficiency, and glucose-phosphate isomerase deficiency c Hemoglobinopathies i ␣- and ␥-Thalassemia syndromes ii ␣- and ␥-Chain structural abnormalities Acquired hemolysis a Infection: bacterial or viral b Disseminated intravascular coagulation c Vitamin E deficiency and other nutritional anemias1 d Microangiopathic hemolytic anemia, cavernous hemangioma, renal artery stenosis, and severe coarctation of the aorta C Diminished RBC production is manifested by a decreased Hct, decreased reticulocyte count, and normal bilirubin level Diamond-Blackfan syndrome Congenital leukemia or other tumor Infections, especially rubella and parvovirus (see Chap 48) Osteopetrosis, leading to inadequate erythropoiesis Drug-induced suppression of RBC production Physiologic anemia or anemia of prematurity (see I.A and I.B.) III DIAGNOSTIC APPROACH TO ANEMIA IN THE NEWBORN (SEE TABLE 45.3) A The family history should include questions about anemia, jaundice, gallstones, and splenectomy B The obstetric history should be evaluated 563-571_Cloherty_Ch45.indd 566 7/2/11 1:04 AM Hematologic Disorders Table 45.3 567 Classification of Anemia in the Newborn Reticulocytes Bilirubin Coombs test RBC morphology Diagnostic possibilities Normal or ↓ Normal Negative Normal Physiologic anemia of infancy or prematurity; congenital hypoplastic anemia; other causes of decreased production Normal or ↑ Normal Negative Normal Acute hemorrhage (fetomaternal, placental, umbilical cord, or internal hemorrhage) ↑ Normal Negative Hypochromic microcytes Chronic fetomaternal hemorrhage ↑ ↑ Positive Spherocytes Nucleated RBC Immune hemolysis (blood group incompatibility or maternal autoantibody) Normal or ↑ ↑ Negative Spherocytes Hereditary spherocytosis Normal or ↑ ↑ Negative Elliptocytes Hereditary elliptocytosis Normal or ↑ ↑ Negative Hypochromic microcytes ␣- or ␥-Thalassemia syndrome ↑ ↑ Negative Spiculated RBCs Pyruvate kinase deficiency Normal or ↑ Normal or ↑ Negative Schistocytes and RBC fragments Disseminated intravascular coagulation; other microangiopathic processes ↑ ↑ Negative Bite cells (Heinz bodies with supravital stain) Glucose-6-phosphate dehydrogenase deficiency Normal, ↑ or ↓ ↑ Negative Normal Infections; enclosed hemorrhage (cephalhematoma) ↓ ϭ decreased; ↑ ϭ increased; RBC ϭ red blood cell Source: Adapted from the work of Dr Glader B Director of Division of hematologyoncology California: Children’s Hospital at Stanford, 1991.3 563-571_Cloherty_Ch45.indd 567 7/2/11 1:04 AM 568 ANEMIA C The physical examination may reveal an associated abnormality and provide clues to the origin of the anemia Acute blood loss leads to shock, with cyanosis, poor perfusion, and acidosis Chronic blood loss produces pallor, but the infant may exhibit only mild symptoms of respiratory distress or irritability Chronic hemolysis is associated with pallor, jaundice, and hepatosplenomegaly D Complete blood cell count Capillary blood Hct is 2.7% to 3.9% higher than venous Hct Warming the foot reduced the difference from 3.9% to 1.9% (1,2) E Reticulocyte count (elevated with chronic blood loss and hemolysis, depressed with infection and production defect) F Blood smear (Table 45.3) G Coombs test and bilirubin level (see Chap 26) H Apt test (see Chap 43) on gastrointestinal blood of uncertain origin I Kleihauer-Betke preparation of the mother’s blood A 50-mL loss of fetal blood into the maternal circulation will show up as 1% fetal cells in the maternal circulation.2 J Ultrasound of abdomen and head K Parental testing Complete blood cell count, smear, and RBC indices are useful screening studies Osmotic fragility testing and RBC enzyme levels (e.g., G6PD, pyruvate kinase) may be helpful in selected cases L Studies for infection Toxoplasmosis, rubella, cytomegalovirus (CMV), and herpes simplex (see Chap 48) M Bone marrow (rarely used, except in cases of bone marrow failure from hypoplasia or tumor) IV THERAPY A Transfusion (see Chap 42) Indications for transfusion The decision to transfuse must be made in consideration of the infant’s condition and physiologic needs (8) a Infants with significant respiratory disease or congenital heart disease (e.g., large left-to-right shunt) may need their Hct maintained above 40% Transfusion with adult RBCs provides the added benefit of lowered hemoglobin oxygen affinity, which augments oxygen delivery to tissues Blood should be fresh (3–7 days old) to ensure adequate 2,3-DPG levels b Healthy, asymptomatic newborns will self-correct a mild anemia, provided that iron intake is adequate c Infants with ABO incompatibility who not have an exchange transfusion may have protracted hemolysis and may require a transfusion several weeks after birth This may be ameliorated with the use of intravenous immune globulin (IVIG) If they not have enough hemolysis to require treatment with phototherapy, they will usually not become anemic enough to need a transfusion (see Chap 26) d Premature babies may be quite comfortable with hemoglobin levels of 6.5 to mg/dL The level itself is not an indication for transfusion Although one study suggested a possible increased risk for NEC in anemic infants, several 563-571_Cloherty_Ch45.indd 568 7/2/11 1:04 AM Hematologic Disorders 569 studies also suggested an unanticipated relationship between late onset necrotizing enterocolitis and elective transfusion in stable growing premature infants (7) Sick infants (e.g., with sepsis, pneumonia, or bronchopulmonary dysplasia) may require increased oxygen-carrying capacities and therefore need transfusion Growing premature infants may also manifest a need for transfusion by exhibiting poor weight gain, apnea, tachypnea, or poor feeding (8) Transfusion guidelines are shown in Table 45.4 Despite efforts to adopt uniform transfusion criteria, significant variation in transfusion practices among neonatal intensive care units (NICUs) has been reported (9) Blood products and methods of transfusion2 (see Chap 42) a Packed RBCs The volume of transfusion may be calculated as follows: Weight in kilogram ϫ blood volume per kilogram ϫ (Hct desired Ϫ Hct observed) ϭ volume of transfusion Hct of blood to be given The average newborn blood volume is 80 mL/kg; the Hct of packed RBCs is 60% to 80% and should be checked before transfusion We generally transfuse 15 to 20 mL/kg; larger volumes may need to be divided b Whole blood is indicated when there is acute blood loss c Isovolemic transfusion with high Hct-packed RBCs may be required for severely anemic infants, when routine transfusion of the volume of packed RBCs necessary to correct the anemia would result in circulatory overload (see Chap 26) d Irradiated RBCs are recommended in premature infants weighing Ͻ1,200 g Premature infants may be unable to reject foreign lymphocytes in transfused blood We use irradiated blood for all neonatal transfusions Leukocyte depletion with third-generation transfusion filters has substantially reduced the risk of exposure to foreign lymphocytes and CMV (4,10) However, blood from CMV-negative donors for neonatal transfusion is preferable (see Chap 42) Table 45.4 Transfusion Guidelines for Premature Infants Asymptomatic infants with Hct Ͻ21% and reticulocytes Ͻ100,000/UL (2%) Infants with Hct Ͻ31% and hood O2 Ͻ36% or mean airway pressure Ͻ6 cm H2O by CPAP or IMV or Ͼ9 apneic and bradycardic episodes per 12 h or 2/24 h requiring bag-and-mask ventilation while on adequate methylxanthine therapy or HR Ͼ180/min or RR Ͼ80/min sustained for 24 h or weight gain of Ͻ10 g/d for d on 100 Kcal/kg/d or having surgery Infants with Hct Ͻ36% and requiring Ͼ35% O2 or mean airway pressure of 6–8 cm H2O by CPAP or IMV CPAP ϭ continuous positive airway pressure by nasal or endotracheal route; HR ϭ heart rate; Hct ϭ hematocrit; IMV ϭ intermittent mandatory ventilation; RR ϭ respiratory rate From the multicenter trial of recombinant human erythropoietin for preterm infants Source: Data from Strauss RG Erythropoietin and neonatal anemia N Engl J Med 1994;330(17):1227–1228 563-571_Cloherty_Ch45.indd 569 7/2/11 1:04 AM 570 ANEMIA e Directed-donor transfusion is requested by many families Irradiation of directed-donor cells is especially important, given the human leukocyte antigen (HLA) compatibility among first-degree relatives and the enhanced potential for foreign lymphocyte engraftment f Because of concern for multiple exposure risk associated with repeated transfusions in extremely low birth weight (ELBW) infants, we recommend transfusing stored RBCs from a single unit reserved for an infant (1) B Prophylaxis Term infants should be sent home from the hospital on iron-fortified formula (2 mg/kg/day) if they are not breastfeeding (12) Premature infants (preventing or ameliorating the anemia of prematurity) The following is a description of our usual nutritional management of premature infants from the point of view of providing RBC substrates and preventing additional destruction: a Iron supplementation in the preterm infant prevents late iron deficiency (13) We routinely supplement iron in premature infants at a dose of to mg of elemental iron/kg/day once full enteral feeding is achieved (see Chap 21) b Mother’s milk or formulas similar to mother’s milk, in that they are low in linoleic acid, are used to maintain a low content of polyunsaturated fatty acids in the RBCs (3) c Vitamin E (15 to 25 IU of water-soluble form) is given daily until the baby is 38 to 40 weeks’ postconceptional age (this is usually stopped at discharge from the hospital) (see Chap 21) d These infants should be followed up carefully, and additional iron supplementation may be required e Methods and hazards of transfusion are described in Chap 42 f Recombinant human erythropoietin (rh-EPO) has been evaluated as a promising measure in ameliorating anemia of prematurity (14–19) Studies in which we participated showed that rh-EPO stimulates RBC production and decreases the frequency and volume of RBC transfusions administered to premature infants However, many studies have shown that erythropoietin treatment is of limited benefit in reducing the number of transfusions once strict transfusion criteria are instituted In addition, a Cochrane Review metaanalysis showed that early EPO use increased the risk of retinopathy of prematurity, therefore we not recommend it as a routine procedure (16,17,20) Complementary strategies to reduce phlebotomy losses and the use of conservative standardized transfusion criteria have contributed to significant reductions in transfusions REFERENCES Bifano EM, Ehrenkranz Z, eds Perinatal hematology Clin Perinatol 1995:23(3) Blanchette V, Doyle J, Schmidt B, et al Hematology In: Avery GB, Fletcher MA, MacDonald MG, eds Neonatology 4th ed Philadelphia: Lippincott–Raven Publishers; 1994:952–999 Glader B, Naiman JL Erythrocyte disorders in infancy In: Taeusch HW, Ballard RA, Avery ME, eds Diseases of the Newborn Philadelphia: WB Saunders; 1991 Nathan DG, Oski FA Hematology of Infancy and Childhood 4th ed Philadelphia: WB Saunders; 1993 563-571_Cloherty_Ch45.indd 570 7/2/11 1:04 AM Hematologic Disorders 571 Oski FA, Naiman JL Hematologic Problems in the Newborn 3rd ed Philadelphia: WB Saunders; 1982 Molteni RA Perinatal blood loss Pediatr Rev 1990;12(2):47–54 Singh R, Visitainer PF, Frantz ID, et al Association of Necrotizing Enterocolitis with anemia and packed red blood transfusions in preterm infants J Perinatol 2011;31:176– 182 Ross MP, Christensen RD, Rothstein G, et al A randomized trial to develop criteria for administering erythrocyte transfusions to anemic preterm infants to months of age J Perinatol 1989;9:246 Ringer SA, Richardson DK, Sacher RA, et al Variations in transfusion practice in neonatal intensive care Pediatrics 1998;101(2):194–200 10 Andreu G Role of leukocyte depletion in the prevention of transfusion-induced cytomegalovirus infection Semin Hematol 1991;28(3 suppl 5):26–31 11 Strauss RG Blood banking issues pertaining to neonatal red blood cell transfusions Transfus Sci 1999;21(1):7–19 12 American Academy of Pediatrics Committee on Nutrition: Iron-fortified infant formulas Pediatrics 1989;84(6):1114–1115 13 Hall RT, Wheeler RE, Benson J, et al Feeding iron-fortified premature formula during initial hospitalization to infants less than 1800 grams birth weight Pediatrics 1993;92(3):409–414 14 Shannon KM, Keith JF III, Mentzer WC, et al Recombinant human erythropoietin stimulates erythropoiesis and reduces erythrocyte transfusions in very low birth weight preterm infants Pediatrics 1995;95(1):1–8 15 Maier RF, Obladen M, Scigalla P, et al The effect of epoetin beta (recombinant human erythropoietin) on the need for transfusion in very low birth weight infants European Multicentre Erythropoietin Study Group N Engl J Med 1994;330(17):1173–1178 16 Strauss RG Erythropoietin and neonatal anemia N Engl J Med 1994;330(17):1227–1228 17 Wilimas JA, Crist WM Erythropoietin—not yet a standard treatment for anemia of prematurity Pediatrics 1995;95(1):9–10 18 Soubasi V, Kremenopoulos G, Diamandi E, et al In which neonates does early recombinant human erythropoietin treatment prevent anemia of prematurity? Results of a randomized, controlled study Pediatr Res 1993;34(5):675–679 19 http://www2.cochrane.org/reviews/en/ab004863.html Accessed 2011 20 Ohlsson A, Aher SM Early erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants Cochrane Database of Syst Rev 2006;19(3):CD004863 DOI:10.1002/14651858.CD004863.PUB2 563-571_Cloherty_Ch45.indd 571 7/2/11 1:04 AM 46 Polycythemia Deirdre O’Reilly As the central venous hematocrit rises, there is increased viscosity and decreased blood flow When the hematocrit increases to Ͼ60%, there is decreased oxygen delivery (1) (see Figure 46.1) Newborns have larger, irregularly shaped red blood cells (RBC) with different membrane characteristics than the RBCs of adults (1–3) As viscosity increases, there is impairment of tissue oxygenation and decreased glucose in plasma, leading to increased risk of microthrombus formation If these events occur in the cerebral cortex, kidneys, or adrenal glands, significant damage may result Hypoxia and acidosis increase viscosity and deformity further Poor perfusion increases the possibility of thrombosis I DEFINITIONS A Polycythemia is defined as venous hematocrit of at least 65% (2,3) Hematocrit measurements vary greatly with site of sample, and capillary hematocrit may be up to 20% higher than venous (2) Hematocrit initially rises after birth from placental transfer of RBCs, then decreases to baseline by approximately 24 hours (4) The mean venous hematocrit of term infants is 53% in cord blood, 60% at hours of age, 57% at hours of age, and 52% at 12 to 18 hours of age (2) B Hyperviscosity is defined as viscosity Ͼ2 standard deviations greater than the mean (3) Blood viscosity, as described by Poiseuille, is the ratio of shear stress to shear rate and is dependent on such factors as the pressure gradient along the vessel, radius, length, and flow (4) The relationship between hematocrit and viscosity is nearly linear below a hematocrit of 60%, but viscosity increases exponentially at a hematocrit of 70% or greater (Figure 46.1) (4,5) Other factors affect blood viscosity, including plasma proteins such as fibrinogen, local blood flow, and pH (3,4) The hyperviscosity syndrome is usually seen only in infants with venous hematocrits above 60% II INCIDENCE The incidence of polycythemia is 1% to 5% in term newborns (1,3,6,7) Polycythemia is increased in babies that have intrauterine growth restriction (IUGR), are small for gestational age (SGA), and are born postterm III CAUSES OF POLYCYTHEMIA A Placental red cell transfusion Delayed cord clamping may occur either intentionally or in unattended deliveries a When the cord is clamped within minute after birth, the blood volume of the infant is approximately 80 mL/kg 572 572-577_Cloherty_Ch46.indd 572 6/30/11 1:34 PM Index granulocyte-colony stimulating factor (G-CSF), 644 granulocytes, 534–535 Graves’ disease fetal/neonatal goiter, 27 hyperthyroidism, 25–26 group B Streptococcus (GBS) See also earlyonset sepsis (EOS) current status of, 634 epidemiology, risk factors, 624, 633, 633t evaluation, treatment, 634–635 microbiology, pathogenesis, 632 prevention, 633–634 growth, intrauterine curves, 232–235f growth failure, BPD, 426 growth restriction, multiple births, 131–132 H H2 blockers, 342 hCG See human chorionic gonadotropin hearing, hearing loss, 846 BPD, 426 conductive, 846 defined, incidence, 846 ELBW infants, 187 etiology, 846–848 follow-up testing, 848–849, 849t habilitation/treatment, 849–850 medical evaluation, 849 NICU graduates, 846–850, 849t prognosis, 850 screening tests, 848 heart See cardiac disorders heart block, 525 HELLP syndrome, 41 hemangiomas, 31 strawberry, 837 hematemesis, 811–812 hematochezia, 811–812 hematuria, 358, 372-373, 373t hemolysis, exchange transfusion, 331 hemolysis, microangiopathic, 41 hemolytic disease See also hyperbilirubinemia ABO, 338–339 antigens involved in, 323t, 324–325t bilirubin toxicity, 317–318 infants with, 319 isoimmune, 337–338 hemolytic transfusion reaction, 532 hemophilia, 539 hemorrhage See also intracranial hemorrhage; pulmonary hemorrhage adrenal, 72 extracranial, 64 subgaleal, 99 985-1008_Cloherty_Index.indd 993 993 hemorrhagic disease of the newborn (HDN), 544–545 heparin, 45, 555–557, 556t, 557t, 558t low-molecular-weight (LMW), 556–557, 557t, 558t hepatic injury, 71–72 hepatitis B virus, 610–613 blood transfusions, 529, 530t C virus, 613–614 E virus, 614–615 G virus, 615 introduction to, 610 vaccine doses, 612t hepatocellular dysfunction, 41 hepatosplenomegaly, 315 hernia BPD, 426 diaphragmatic, 814–816 inguinal, 824–825 herpes simplex virus (HSV) clinical manifestations, 595–596 diagnosis, 596–597 epidemiology, 594–595 prevention, management, 597–599, 598t transmission, 595 treatment, 597 herpes zoster virus See varicella-zoster virus heterotaxy syndrome, 507 high-frequency oscillatory ventilation (HFOV), 161 high-frequency ventilation (HFV), 380–381 high-risk newborns, 63 Ballard examination, 76, 77f cord blood banking, 89 defined, 74–76 GA, birth weight classification, 76, 77f LGA, 88–89 postterm infants, 82–86 preterm birth, 78–82 SGA, IUGR infants, 86–88 Hirschsprung disease, 821 HLA See human leukocyte antigen home care, 214 See also discharge, discharge planning hospice care, 218 HPT axis See hypothalamic-pituitarythyroid axis HSV See herpes simplex virus HTLV I/II See human T-lymphotropic virus I/II human chorionic gonadotropin (hCG), 24, 803–805 human immunodeficiency virus (HIV) blood transfusions, 529, 530t breastfeeding contraindications, 268 7/1/11 4:56 AM 994 INDEX human immunodeficiency virus (Continued) clinical disease, 605–607 defined, 603 diagnosis, 607–608 epidemiology, 603–604 prevention, 609–610 transmission, 604–605 treatment, 608–609 human leukocyte antigen (HLA), 530, 532 human T-lymphotropic virus I/II (HTLV I/II), 529, 530t humeral fractures, 71 humidity, skin care, 833 hydralazine, 520 hydrocele, 96 hydrocortisone CAH, 801 hypoglycemia, 292 replacement, shock, 467 hydrometrocolpos, 820 hydronephrosis, 361–362 hydrops, 334–337 hydrops fetalis, 769, 770t hyperammonemia, 773, 774f, 779-782, 780f hyperbilirubinemia See also bilirubin ABO hemolytic disease, 338–339 background, 304–306 bilirubin nomogram, 313f bilirubin toxicity, 317–318 breastfeeding, 313–314 causes of, 309–310t conjugated, direct, 332–334 etiology diagnosis, 308f exchange transfusion, 322f, 329–332 family history, 307–314 follow-up, 311t, 312f hemolytic disease, antigens involved in, 323t, 324–325t hydrops, 334–337 isoimmune hemolytic disease, 337–338 neurotoxicity, risk factors, 322t nonphysiologic, 307–317 phototherapy, 314f, 325–329 physiologic, 306–307 serum bilirubin levels, 320–321f severe, risk factors, 311t hypercalcemia definition, etiology, 300–301 diagnosis, 301–302 treatment, 302–303 hyperglycemia defined, 293 diabetes, pregnancy, 11 etiology, 293–295 treatment, 295–296 985-1008_Cloherty_Index.indd 994 hyperkalemia exchange transfusion, 331 fluid, electrolyte management, 279–281, 282f packed RBC, 533 VLBW infants, 283 hyperlipidemia, 246 hypermagnesemia, 45, 303 hypernatremic disorders, 275, 281–282 hyperosmolar formula, 295 hyperoxia testing, 485–486 hypertension, hypertensive disorders BPD, 425 categories, 39 preeclampsia, 40, 44 renal conditions, 366–367, 369–370t, 371t risk factors, 40t, 44 hyperthermia, 62, 179, 184 hyperthyroidism hypercalcemia, 301 maternal, 25–26 neonatal, 26, 37–38 hypertriglyceridemia, 246 hyperviscosity, 572 See also polycythemia hypocalcemia definition, pathophysiology, etiology, 297–298 diagnosis, 298–299 exchange transfusion, 331 IDMs, 20 packed RBC, 532 seizures, 736 treatment, 299–300 hypoglycemia defined, 284–285 diabetes, pregnancy, 11 diagnosis, 288–290 etiology, 286–288 exchange transfusion, 331 follow-up, evaluation, 293 glucose rates, 289f hyperinsulinemic, 286–287 IDMs, 17–19 IEM, 771, 773f, 778-779, 779t, 786 incidence, 284 knowledge gaps, 286 management, 290–293 neonatal, 17 operational threshold, 285 hypokalemia, 279 hypomagnesemia defined, treatment, 303 exchange transfusion, 331 IDMs, 21 seizures, 736 7/1/11 4:56 AM Index hyponatremic disorders, 273–275, 274t, 283 hypoosmolar hyponatremia See hyponatremic disorders hypoplastic left heart syndrome, 495–498, 496f hypoplastic right heart syndrome, 499–500, 500f hypotension, 468, 488 hypothalamic-pituitary hypothyroidism, 30 hypothalamic-pituitary-thyroid (HPT) axis, 24 hypothermia, therapeutic, 724–725 hypothyroidism central, 30 hyperbilirubinemia, 315 maternal, 26–27 neonatal, 26 hypotonia, 767-768, 783 hypovolemic shock, 463–464 See also shock hypoxia hypoxic insult, NEC, 341 respiratory failure, 201 hypoxic-ischemic encephalopathy (HIE) See also perinatal asphyxia defined, 711–712 PVL, 704 Sarnat stages, 716t–717t seizures, 732–734, 734t I ICH See intracranial hemorrhage ICROP See International Classification of Retinopathy of Prematurity IDMs See infants of diabetic mothers immunizations, prematurity, 186 immunoglobulin, hyperimmune, 536 immunoglobulin, intravenous (IVIG) EOS, 627 LOS prevention, 643–645 newborn use, 535–536 parvovirus treatment, 601–602 inborn errors of metabolism (IEM), 767 clinical presentation, 767-769 hyperammonemia, 779-782, 780f hypoglycemia, 778-779, 779t hypotonia, 783 infant management, 785–786 introduction to, 767 liver dysfunction, 783-785 metabolic acidosis, 770-771, 772f, 774-778, 775f neonate evaluation, 770-774, 771t postmortem diagnosis, 787 routine newborn screening, 787, 788–789t seizures, 736–737, 767, 782-783 985-1008_Cloherty_Index.indd 995 995 infantile epileptic encephalopathy, 737 infants of diabetic mothers (IDMs) See also diabetes, pregnancy evaluation of, 16–17 frequent problems, 20–22 hypoglycemia, 17–19 malformations, 20 respiratory distress, 19–20 infections See also perinatal infections blood transfusion, 529, 530f BPD, 418, 425–426 ELBW infants, 163–164 exchange transfusion, 331 skin, 651–652, 839 infections, bacterial See bacterial infections infections, congenital CMV, 588–594 CNS, 735 defined, 588 enteroviruses, 618–619 hepatitis, 610–615 HIV, 603–610 parvovirus, 599–603 rubella, 619–622 V-ZV, 615–618 infections, fungal See fungal infections infections, viral See viral infections infectious enterocolitis, 344 injuries, soft tissue, 72–73 inotropes, 466, 487 insensible water loss (IWL), 269–270, 270f inspissated bile syndrome, 333 insulin AKI management, 365 hyperkalemia, 280–281 infusions, hyperglycemia, 295–296 lispro, hyperglycemia, 296 PN, 247 requirements, pregnancy, 13 intersex See disorders of sex development intestinal obstructions, surgery, 810, 817–821 intestinal perforation (IP), 344 intra-abdominal injuries, 71–72 intracranial hemorrhage (ICH), 686 EH, 689 GMH/IVH, 692–702, 693, 696, 699 intraparenchymal hemorrhage, 690–692 introduction to, 686–687, 687 IPH, 690–692 PVL, 703–706 SAH, 689–690 SDH, 686–689 seizure, 734–735, 734t intrauterine fetal demise (IUFD), 127–128 7/1/11 4:56 AM 996 INDEX intrauterine growth curves, 232–235f intrauterine growth restriction (IUGR) causes, diagnosis, 5–6 multiple pregnancy, 127 preeclampsia, 41, 45 risks, management, 86–88 intravenous extravasations, 835 intravenous therapy, 853 intubation medication, 880, 880–881 neonatal resuscitation, 55 PPHN, 439 procedure, 856–858, 857 inulin clearance GFR, 360t iodine clearance increase, 24 excess, 31 hyperthyroidism treatment, 25–26 maternal medication, breastfeeding, 38 preparation, 37 radioactive, 25–26 worldwide deficiency, 31 iron, nutrition, 258 irradiation, blood transfusions, 529–530 isoimmune hemolysis, isoimmune hemolytic disease, 337–338 isonatremic disorders, 273 isovaleric acidemia, 776 J jaundice, 21, 98, 313–314 See also hyperbilirubinemia joints, examination, 98 K kangaroo care, 175 Kayexalate, 281, 365 kernicterus, 317 ketoacidosis, 13 kidneys See also renal conditions acute kidney injury (AKI), 362–366, 363–364t congenital anomalies, 366 cystic disease, 376 perinatal asphyxia, 718 Klumpke palsy, 70 L labor, delivery conditions, 75–76 lacerations, 63, 72 lactoferrin, 644 lamellar bodies, 407 large for gestational age (LGA), 88–89 laryngeal web, 816 laryngotracheal clefts, 816 985-1008_Cloherty_Index.indd 996 latent syphilis, 664 See also syphilis late-preterm infants See prematurity, premature infants LCPUFAs See long-chain polyunsaturated fatty acids lecithin-sphingomyelin (L/S) ratio, 15t, 406–407 left-to-right shunt lesions, 509–513 leukoreduction, blood transfusions, 529–530 Lewis antigen, 338 LFTs See liver function tests LGA See large for gestational age life-sustaining treatment, withdrawing/ withholding, 222–224, 226–228 lipids, nutrition, 243 lipomeningocele, 744 See also neural tube defects Listeria monocytogenes, 636–637 liver dysfunction, IEM, 768, 783–785 dysfunction, newborn bleeding, 539 perinatal asphyxia, 718 liver function tests (LFTs), 773 lobar emphysema, 817 long-chain polyunsaturated fatty acids (LCPUFAs), 258–259 lorazepam, 148–149 LOS See late-onset sepsis L/S ratio See lecithin-sphingomyelin ratio lumbar puncture, 853 lung maturity, lungs See pulmonary disorders Lyme disease, 683 lymph nodes, examination, 98 lymphatic vessels disorders, 837 M macrosomia in high-risk newborns, 75 IDMs, 21 prenatal diagnosis, macular hemangioma, 837 magnesium disorders, 303 magnesium sulfate, 43 magnetic resonance angiography (MRA), 122 magnetic resonance spectroscopy (MRS), 122 malaria, blood transfusions, 529 Malassezia furfur, 650 malformations, 111–112 See also birth defects major, 111 minor, 111 malpractice insurance coverage, 194 7/1/11 4:56 AM Index mandibular fractures, 65 MAP See mean airway pressure maple syrup urine disease, 774, 775 marijuana, maternal use, 150 MAS See meconium aspiration syndrome maturation phase, 834 MDROs See multiply drug-resistant organisms mean airway pressure (MAP), 383–384 mechanical ventilation adjuncts to, 391 air leak, 390, 392 apnea, 391 blood gas effects, 382–385 BPD, 389–391, 419–420 complications, sequelae, 391–392 CPAP, 377–378 disease states, 385–391, 386t HFV, 380–381 introduction to, 377 MAP, 383–384 MAS, 389, 433 medication, 881 negative pressure, 381 oxygenation, 382, 382t, 383f PPHN, 439 pressure-limited, time-cycled, continuous flow, 378 pulmonary mechanics, 385, 386t RDS, 385–389, 412–414 respiration support indications, 381 synchronized, patient triggered, 378–379 volume-cycled ventilators, 379–380 meconium aspiration syndrome (MAS), 433 cause, incidence, 429 management, 431–434 mechanical ventilation, 389 medications, 433 neonatal resuscitation, 60 pathophysiology, 429–430, 430f prevention, 430–431 meconium passing, 811, 819–821 meconium peritonitis, 808 meconium-stained amniotic fluid (MSAF) See meconium aspiration syndrome medications, 104–105, 887 meningitis, 624, 626t See also early-onset sepsis; late-onset sepsis meningocele, 744 See also neural tube defects metabolic bone disease See osteopenia metabolism See also inborn errors of metabolism acute disorders, seizure management, 735–736, 735t testing, birth defects, 122 testing, PN, 246, 246t 985-1008_Cloherty_Index.indd 997 997 metatarsus adductus (MTA), 760 methadone, 140–141, 148 methamphetamine, maternal use, 150 Methicillin-resistant Staphylococcus aureus (MRSA), 640 methylmalonic acidemia, 777 miconazole, 647 microcephaly, 315 microphallus, 804 microvascular disease, 15 middle cerebral artery, assessment, milia, 97, 836 milk See also breastfeeding care, handling of, 267 discharge planning, 261 fortified, 248–249 jaundice, 314 nutrition compositions, 251–254t term infants, 250 milrinone, cardiac disorders, 519 minerals, nutrition, 243–245 Mongolian spots See dermal melanosis monochorionic diamniotic, 124–125 monochorionic monoamniotic, 124–125 monozygotic (MZ) twins, 124–125 See also multiple births morbidity, multiple births, 131–132 morphine, 147–148 motor system, examination, 101 mouth, examination, 100 MRA See magnetic resonance angiography MRI brain, 122 MRS See magnetic resonance spectroscopy MRSA See Methicillin-resistant Staphylococcus aureus MSAF (meconium-stained amniotic fluid) See meconium aspiration MSAFP See maternal serum alphafetoprotein MTA See metatarsus adductus Mucocutaneous candidiasis, 647–648 mucous plug syndrome, 820–821 mucus/salivation, postnatal surgical disorders, 810 multiple births, 125, 129 classification, 124 diagnosis, 125–126 epidemiology, 124–125 etiology, 125 fetal, neonatal complications, 127–131 long-term morbidity, 131–132 maternal complications, 126–127 outcomes, 131–133 multiply drug-resistant organisms (MDROs), 643 7/1/11 4:56 AM 998 INDEX multizygous pregnancy See dizygotic (DZ) twins muscle relaxation, mechanical ventilation, 391 Mycobacterium tuberculosis See tuberculosis myelocystocele, 744 See also neural tube defects myelomeningocele, 743 See also neural tube defects myocardial dysfunction IDMs, 21–22 PPHN, 437 transient, 517 myocarditis, 513 myoclonic epilepsy, 737 myoclonic seizures, 730 See also seizures MZ See monozygotic twins N NAIT See neonatal alloimmune thrombocytopenia narcotics addicted infant management, 142–143f infant withdrawal, 141–149 neonatal abstinence syndrome, 145–145f pregnancy exposure, 140–141 nasogastric feedings, 257–258 neck, 63–67, 100 necrotizing enterocolitis (NEC) diagnosis, 342–344 epidemiology, 340–341 management, 345–348, 345t nutrition, 260 pathogenesis, 341–342 prevention, 349 prognosis, 348–349 negative pressure, 381 Neisseria gonorrhoeae, 652–653 neonatal abstinence syndrome, 145–145f neonatal alloimmune thrombocytopenia (NAIT), 581–583 neonatal morphine solution (NMS), 146 neonatal opium solution (NOS), 146–147 neonatal resuscitation See resuscitation, neonatal Neonatal Skin Condition Score (NSCS), 832, 832t nephrocalcinosis, 375, 426 neural tube defects definition, pathology, 743–745 diagnosis, 745 evaluation, 745–749, 747–748t management, 749–752 prevention, 745 prognosis, 752–755 types of, 743–744 in utero repair, 749–750 985-1008_Cloherty_Index.indd 998 neuroblastoma, 824 neurodevelopmental outcomes developmentally supportive care, 167–171t pain, stress management, 871 prematurity, follow-up care, 188–189 neurologic deterioration, IEM, 767 neurologic examination, 100–101 neuromotor problems, 188 neurosyphilis, 664 See also syphilis neutral thermal environment, 179, 180–182t nevi, junctional, 838 nevus flammeus, 837 simplex, 97, 837 newborn care assessments, 106–107 circumcision, 107–108 discharge, 108–110 family, social issues, 107 feedings, 107 follow-up, 110 nursery admission, 103 routine care, 104 routine medications, 104–105 screening, 105–106 skin care, 831–839 transitional care, 103–104 newborn examination abdomen, 96 birth defects, 115–116 cardiorespiratory system, 94–95 extremities, joints, spine, 98–99 family history, 91, 92–93t general examination, 91 genitalia, rectum, 96–97 head, 99–100 neurologic, 100–101 screening, IEM, 787, 788–789t skin, 97–98 thorax, 95–96 vital signs, measurements, 91–94 NICU See neonatal intensive care unit nitric oxide, 161 inhaled, 422–423, 439–440 nitroglycerine, 519–520 NMS See neonatal morphine solution nonstress test (NST), 6–7 NOS See neonatal opium solution nose, 65–66, 100 NSCS See Neonatal Skin Condition Score NST See nonstress test nuchal lucency, 2, 126 nursery admission, 103 nutrition, 230–262 BPD, 260–261, 424 7/1/11 4:56 AM Index discharge planning, 261–262 ELBW infants, 164–165 enteral, 248–259 GER, 259 growth, 230–231, 232–235f NEC, 260 oral dietary supplements, 257t parenteral, 240–247 RDS, 414–415 recommendations, 231–240, 236–239t nystatin, 647 O octreotide, hypoglycemia, 292 ocular See eyes Ohtahara syndrome, 738 OI See oxygenation index oligohydramnios, 41, 808 oliguria, 41, 275–277, 276t omphalitis, 652 omphalocele, 821–822 operational threshold, hypoglycemia, 285 ophthalmia neonatorum See conjunctivitis ophthalmologic care, ELBW infants, 187 opioids, 881–884 organic aciduria, 776 orogastric feedings, 257–258 orthopaedic problems, 757 congenital, infantile scoliosis, 758–759 DDH, 759–760 feet deformities, 760–761 fractured clavicle, 758 genu recurvatum, 760 polydactyly, 758 torticollis, 757–758 osteomyelitis, 655 osteopenia defined, etiology, 762–763 diagnosis, 763–764 PN, 246 treatment, 764–766 ovotesticular DSD, 805 oxygen BPD, 420, 421f noninvasive monitoring, 394–395 oxygenation, 382, 382t, 383f PPHN, 439 RDS, 408 therapy, MAS, 432 use, monitoring, 393–395 oxygenation index (OI), 454 P PACs See premature atrial contractions pain, stress, 871 assessment, 874–875, 874t 985-1008_Cloherty_Index.indd 999 999 background, 870–869 control, 851 decision matrix, procedure intensity, 875, 876–877t developmentally supportive care, 175–176 evaluation, 873–875 management, 875–879 medical, developmental outcomes, 871 pharmacologic management, 879–884 physiologic responses to, 870 postoperative, 881–882, 883f principles of, 871–873 procedural pain algorithm, 875, 878f pancreas, annular, 820 pancreatic lesions, 294 paregoric, 147 parenteral nutrition (PN), 240–247 parents See family parvovirus clinical manifestations, 600–601 defined, 599 diagnosis, 601 epidemiology, 600 prevention, 602–603 transmission, 600 treatment, 601–602 patent ductus arteriosus (PDA) BPD, 418 ELBW infants, 163 left-to-right shunt lesions, 509–510 pulmonary hemorrhage, 444 RDS, 415–416, 420 shock, 468 Pavlik harness, 759–760 PCP See phencyclidine PDA See patent ductus arteriosus pediatric nursing homes, rehabilitation hospitals, 215 PEEP See positive end-expiratory pressure Pendred syndrome, 30 penis, 96 See also disorders of sex development (DSD) percutaneous umbilical blood sampling (PUBS), 4–5 perinatal asphyxia brain imaging, 719 defined, 711–712 diagnosis, 714–715 EEG, 719–720 etiology, 712–713 incidence, 712 laboratory evaluation, 718–719 multiorgan dysfunction, 717–718 neurologic signs, 715–717 neuroprotective strategies, 723–725 outcome, 725–726 7/1/11 4:56 AM 1000 INDEX perinatal asphyxia (Continued) pathologic findings, 720 pathophysiology, 713–714 Sarnat stages, 716–717t seizures, 715–717, 722, 726, 732–734 treatment, 720–723 perinatal depression, 467, 711 perinatal infections See also infections CMV, 588–594 defined, 588 hepatitis, 610–615 HIV, 603–610 HSV, 594–599 V-ZV, 615–618 periventricular hemorrhagic infarction (PVHI), 694 See also germinal matrix hemorrhage/intraventricular hemorrhage periventricular leukomalacia (PVL) clinical presentation, diagnosis, 704–705 etiology, pathogenesis, 703–704 management, 705–706 prognosis, 706 peroxisomal disorders, IEM, 783 persistent pulmonary hypertension of the newborn (PPHN) defined, 435 diagnosis, 437–438 epidemiologic associations, 435–436 management, 438–442 MAS, 434 multiple births, 131 pathology, pathophysiology, 436–437 postneonatal outcomes, 442 petechiae, 72, 315 PG See phosphatidylglycerol PGE1, cardiac disorders, 517, 518t pharyngeal injury, 67 phencyclidine (PCP), 150–151 phenobarbital hyperbilirubinemia, 332 infant narcotic withdrawal, 147–148 perinatal asphyxia, 722 seizure treatment, 739 phenytoin, 722, 739 PHH (posthemorrhagic hydrocephalus) See posthemorrhagic ventricular dilation phosphatidylglycerol (PG), 407 phosphodiesterase inhibitors, 519 phosphorus, 352–353, 782 photoisomerization, 326 photo-oxidation, 326 phototherapy guidelines, hyperbilirubinemia, 314f hyperbilirubinemia, 325–326 indications for, 326 photochemical reactions, 326 985-1008_Cloherty_Index.indd 1000 side effects of, 328–329 technique of, 326–328 phrenic nerve injury, 69 physical examination of newborn, 91 PIE See pulmonary interstitial edema piebaldism, 838 PIH See pregnancy-induced hypertension placenta abruption, 126 aromatase deficiency, 802 multiple births, 124–125 pathological examination, 126 polycythemia, 572–574 thyroid disorders, 24–25 plasma fresh frozen, 533–534, 543 frozen, 533–534 levels, IEM, 773–774 thawed, 533–534 plastic leaching, 851 platelet activating factor (PAF), 342 platelets, 534, 539, 584–585, 585t PN See parenteral nutrition pneumomediastinum, 451 pneumonia diagnosis, 653–654 EOS, 625 nosocomial, 654 ventilator-associated, 654 pneumopericardium, 451–452 pneumoperitoneum, 452, 810 pneumothorax air leak, 447–450 needle aspiration, 447–448 polycystic kidney autosomal recessive polycystic kidney disease (ARPKD), 376 polycythemia, 572 causes, 572–574 clinical findings, 574 defined, 572 diagnosis, 575 hypoglycemia, 287 IDMs, 21 incidence, 572 management, 575–576 outcome, 576 PPHN, 442 screening, 574–575 polydactyly, 758 polyhydramnios, 13, 808 portal vein thrombosis (PVT), 552 port-wine stain See nevus positive end-expiratory pressure (PEEP), 445 posthemorrhagic hydrocephalus (PHH) See posthemorrhagic ventricular dilation 7/1/11 4:56 AM Index posthemorrhagic ventricular dilation (PVD), 694–695, 699f See also germinal matrix hemorrhage/ intraventricular hemorrhage postmaturity syndrome, 85 postterm infants, 82–86 potassium, 279–281, 352 PPHN See persistent pulmonary hypertension of the newborn precautions, procedures, 851 prednisone, 37, 659 preeclampsia, 41–46 chronic hypertension risk, 44 delivery, 41 diagnosis, 40–41 etiologies, 39–40 hypertensive disorder categories, 39 incidence, epidemiology, 39 innovations, treatments, 45 management, 41–44 multiple gestations, 127 newborn implications, 45 recurrence risk, 44 pregnancy-induced hypertension (PIH), 127 preimplantation genetic diagnosis (PGD), premature atrial contractions (PACs), 525, 526f premature ventricular contractions (PVCs), 525–526, 527f prematurity, follow-up care cognitive delay, 188–189 dental problems, 188 emotional, behavioral health, 189 growth, 186–187 immunizations, 186 introduction to, 185 neuromotor problems, 188 parent function, support, 190 programs, 189–190 respiratory issues, 185–186 sensory issues, 187 prematurity, premature infants See also extremely low birth weight (ELBW) infants anemia, 563–564, 564t, 570 bilirubin, 318, 321f BPD, 426 breastfeeding, 266 discharge, late-preterm infants, 109–110 discharge readiness, 205–206 enteral nutrition, 248–250 ethical decision making, 222 etiology, 78 fluid, electrolyte management, 272, 272f hyperbilirubinemia, 315, 325 hypocalcemia, 297 985-1008_Cloherty_Index.indd 1001 1001 incidence of, 78 management of, 79–80 multiple births, 126–127, 131–132 NEC, 340 neonatal resuscitation, 61 problems, 78–79 problems, long-term, 81–82, 83f, 84f serum creatinine values, 360f shock, 467–468 survival of, 80, 81f, 82f temperature maintenance, 178, 183 urine/renal values, 359t prenatal diagnosis antepartum tests, 6–8 fetal disease, 1–5 fetal size, growth-rate, 5–6 fetal well-being, 6–10 GA assessment, genetic disease, 3–5 intrapartum assessment, 8–10 IUGR, 5–6 lung maturity, macrosomia, maternal serum analysis screening, 1–3 prerenal azotemia, 362 pressure-limited, time-cycled, continuous flow, 378 preterm labor, spontaneous, 14 prethreshold ROP, 843 See also retinopathy of prematurity primary syphilis, 664 See also syphilis probiotics, 349, 644 procedures, 851–869 propionic acidemia, 776–777 propranolol, 37, 523 proteinuria, 40–41, 372 pseudohermaphroditism See disorders of sex development pseudohypoparathyroidism, 298 Pseudomonas aeruginosa, 641–642 psychotropic medications, maternal use, 151–152 PUBS See percutaneous umbilical blood sampling pulmonary air leak See air leak pulmonary atresia, 499–500, 500f pulmonary disorders lung biopsy, ECMO, 460 lung injury, BPD, 417–418 perinatal asphyxia, 718 prenatal diagnosis, pulmonary hemorrhage, 443–445 pulmonary hypertension, 201, 425 pulmonary hypoplasia, 437 pulmonary interstitial edema (PIE), 450–451 7/1/11 4:56 AM 1002 INDEX pulmonary stenosis, 498–499, 499f pulmonary vascular resistance, 471 pulmonary vasospasm, 437 pulmonary veins, 507, 508f pulse oximetry, 94, 394 purpura fulminans, 548 pustulosis, 651–652 PVCs See premature ventricular contractions PVD See posthemorrhagic ventricular dilation PVHI See periventricular hemorrhagic infarction PVL See periventricular leukomalacia pyridoxine dependency, 737 pyrimethamine, 659 pyruvate metabolism defects, 777–778 R radioactive iodine, 25–26 radionuclide scintigraphy, 361 RDS See respiratory distress syndrome rectum examination, 96–97 recurrent laryngeal nerve injury, 68 red blood cells (RBCs) diminished production, anemia, 566 hemoglobin, bilirubin, 304 packed, 530–533 refractive errors, ELBW infants, 187 renal blood flow (RBF), 350–351 renal conditions, 350–376 abdominal masses, 354t AKI, 362–366, 363–364t ARPKD, 376 assessment, 353–361 blood pressure, 367–368, 367t, 368t, 369–370t, 371t common problems, 361–376 congenital syndromes, 355–358t embryogenesis, functional development, 350–353 hematuria, 372–373, 373t inulin clearance GFR, 361t normal serum creatinine values, 360f normal values, 359t perfusion, EMCO, 457 proteinuria, 372 surgical emergencies, 822–823 tubular disorders, 374–375 ultrasonography, 361–362 UTI, 374 vascular thrombosis, 368–372 renal tubular acidosis (RTA), 374–375 renal vein thrombosis (RVT), 22, 547, 552 reperfusion, asphyxia, 714 respiration apnea pathogenesis, 398 985-1008_Cloherty_Index.indd 1002 failure, EMCO, 454 newborn examination, 94 prematurity, follow-up care, 185–186 support, ELBW infants, 159–161 support, indications, 381 system distress, IDMs, 19–20 respiratory chain defects, 783 respiratory distress syndrome (RDS) acute complications, 415–416 CPAP, 408–409 diabetes, pregnancy, 15t, 16t identification, 406–407 introduction to, 406 lesions, surgical emergencies, 812–817 long-term complications, 416 mechanical ventilation, 385–389, 412–414 oxygen, 408 postnatal surgical disorders, 810 supportive therapy, 414–415 surfactant replacement, 409–412, 411t transport, 201 respiratory syncytial virus (RSV), 185–186, 622–623 resuscitation, neonatal, 47 air leak, 60–61 apgar scores, 52t, 61 delivery, 50–59 ELBW infants, 157–160 evolving practices, 62 general principles, 47–48 meconium aspiration, 60 medication, 55–59, 57–58t prematurity, 61 preparation, 48–50 shock, 60 TTTS, 131 withdrawing/withholding, 62 retinopathy of prematurity (ROP), 840 aggressive posterior, 843 BPD, 426 classification, definitions, 840–843 diagnosis, 840 ICROP, 841, 842f pathogenesis, 840 prevention, 844 prognosis, 844 treatment, 843–845 Rhesus D hemolytic disease, 337–338 rickets, VLBW infants, 186–187 Robin anomaly, 816 ROP See retinopathy of prematurity RSV See respiratory syncytial virus RTA See renal tubular acidosis rubella, 619–622 RVT See renal vein thrombosis 7/1/11 4:56 AM Index S sacral agenesis/dysgenesis, 744 See also neural tube defects “safety pause,” 851 SAH See subarachnoid hemorrhage sarcoma botryoides, 824 Sarnat stages of HIE, 716–717t saturated phosphatidylcholine level, 15t scaphoid abdomen, 810 SCM injury See sternocleidomastoid injury scoliosis, 758–759 infantile, 758–759 screening, newborn care, 105–106 scrotal swelling, 825–826 scrotum examination, 96 SDH See subdural hemorrhage sebaceous hyperplasia, 97, 836 security of newborns, 103 seizures asphyxia, 715–717, 722, 726, 732–734 diagnosis, 729–732, 731f drug doses, 740t eclamptic, 44 etiology, 732–738, 734t IEM, 767, 782–783 investigations, 738 prognosis, 741–742 treatment, 738–740 seizures clonic, focal, 729 seizures tonic, focal, 730 selective serotonin reuptake inhibitors (SSRIs), 151–152 sensorineural loss, 846 See also hearing, hearing loss sepsis hyperglycemia, 294 NEC, 343 PN, 247 skin infection, 651 sepsis, late-onset defined, 637–638 epidemiology, risk factors, 638, 639t microbiology, 638–642 prevention, 643–645 symptoms, evaluation, 642 treatment, 643 septic arthritis, 655 septic shock, 468 See also shock sex assignment, 791, 806–807 See also disorders of sex development sexual development, 792–795, 793f, 794f, 794t See also disorders of sex development SGA See small for gestational age shingles See varicella-zoster virus 985-1008_Cloherty_Index.indd 1003 1003 shock clinical scenarios, management, 467–468 defined, 463 diagnosis, 464–465 distributive, 463 etiology, 463–464 investigations, 465 neonatal resuscitation, 60 obstructive, 464 treatment, 465–467 SIDS See sudden infant death syndrome single ventricles, complex, 507–508 sinus bradycardia, tachycardia, 524 skin care anatomy, 831 common lesions, 836 developmental abnormalities, 838 dryness, newborn examination, 97 infections, 651–652, 839 intravenous extravasations, infiltration, 835 introduction to, 831 newborn examination, 97–98 pigmentation abnormalities, 837–838 practices, 831–834 scaling disorders, 838–839 vascular abnormalities, 836–837 vesicobullous eruptions, 839 wounds, 834–835 skull fracture, 65 sleep problems, follow-up care, 189 small for gestational age (SGA), 86–88, 315 small left colon syndrome, 22 smoking, SIDS, 402 social development, follow-up care, 189 sodium bicarbonate, AKI management, 365 FENa, 271 handling, 351–352 spine, 68–69, 98–99 spiramycin, 658 splenic injury, 72 SSRIs See selective serotonin reuptake inhibitors Staphylococcus aureus, 640 state system examination, 101 sternocleidomastoid injury, 66–67 steroids, CAH, 801, 801f strabismus, ELBW infants, 187 subarachnoid hemorrhage (SAH), 689–690 subdural hemorrhage (SDH), 685–689 subgaleal hematoma, 64–65 subgaleal hemorrhage, 99 sucking blisters, 98 sudden infant death syndrome (SIDS), 401–402 sulfadiazine, 659 7/1/11 4:56 AM 1004 INDEX sulfonylureas, hyperglycemia, 296 supraventricular tachycardia (SVT), 521–524 surface area formula, 801 surfactant(s) MAS, 433 replacement, BPD, 420 replacement, RDS, 409–412, 411t therapy, ELBW infants, 161 therapy, pulmonary hemorrhage, 444–445 surgical emergencies, 809 abdominal masses, 824 appendicitis, 821 fetus, surgical conditions, 808–809 gastroschisis, 822 inguinal hernia, 824–825 intraoperative management, 828–829 lesions, intestinal obstruction, 817–821 lesions, respiratory distress, 812–817 omphalocele, 821–822 postnatal disorders, 810–812 preoperative management, 827–828 renal disorders, 822–823 scrotal swelling, 825–826 tests, 826–827 tumors, 823–824 SVT See supraventricular tachycardia sympathomimetic amine infusions, 517–518, 518t syphilis, 664 blood transfusions, 529, 530t congenital, 664–665 diagnosis, 665–667 epidemiology, 665 evaluation, treatment, 668–670 follow-up, 670 infection control, 671 maternal screening, treatment, 667–668 pathophysiology, 664–665 tertiary, 664 systemic hypertension, 425 T tachycardia emergency treatment, 527 narrow QRS complex, 521–524, 522f sinus, 524 transient fetal, 44 ventricular, 524 wide-complex, 524 TB See tuberculosis TBG See thyroxine-binding globulin TcB See transcutaneous bilirubin TDD See total digitalizing dose TEF See tracheoesophageal fistula temperature conduction, temperature control, 179 985-1008_Cloherty_Index.indd 1004 control method hazards, 184 heat loss, 179 heat production, 178 maintenance, 178–179 neutral thermal environments, 179, 180–182t newborn examination, 91 preventing heat loss, 179–183 teratogens, 113–114t teratomas, 823–824 term infants apnea, 397 bilirubin, 318, 320f breastfeeding, 263 enteral nutrition, 250 fluid, electrolyte management, 272 hyperbilirubinemia, 319–325 serum creatinine values, 360f, 360t urine/renal values, 359t testes, 96, 802 See also disorders of sex development tetanus, neonatal, 647 tetralogy of Fallot, 502–503, 502f threshold ROP, 843 See also retinopathy of prematurity thrombin, 546 thrombocytopenia, 578 early onset, 578–580, 579f immune, 581–584 introduction to, 578 late onset, 580–581, 581f platelet transfusions, 584–585, 585t thromboembolic disorders, venous, 548–550 thrombolysis, 557–560, 560t thrombophilias, acquired See acquired thrombophilias thrombophilias, inherited, 547–548 thromboses, 546 aortic, major arterial, 550–552 central catheter, 560–561, 561t cerebral sinovenous, 552–553 IDMs, 22 PVT, 552 venous thromboembolic disorders, 548–550 thrombosis, neonatal, 546 arterial, 550–552 catheter, 560–561, 561t diagnosis, 553 epidemiology, risk factors, 547–548 management, 553–561 physiology, 546 specific clinical conditions, 548–553 thyroid, thyroid disorders, 24 antithyroid drugs, 25, 31 congenital hypothyroidism, 28–37 7/1/11 4:56 AM Index diagnosis, 34–36 dysgenesis, 28 embryogenesis, 27–28 fetal/neonatal goiter, 27 hormone reference ranges, 29–30t hypothyroxinemia, 31–34 maternal hyperthyroidism, 25–26 maternal hypothyroidism, 26–27 maternal medications, breastfeeding, 38 neonatal hyperthyroidism, 37–38 newborn screening follow-up, 35f permanent, causes of, 28–30 physiology, fetus/newborn, 27–28 physiology, pregnancy, 24–25 prognosis, 36–37 test, imaging interpretation, 32–33t thyroidectomy, 25 transient, causes of, 31 treatment, monitoring, 36 thyroiditis autoimmune, 26 thyroid-stimulating hormone (TSH), 24–38 thyroxine, 36, 38 thyroxine-binding globulin (TBG), 24 tidal volume, measuring, 396 “time out,” 851 tobacco, maternal use, 150 torticollis, 757 total digitalizing dose (TDD), 520 toxoplasmosis, 655 epidemiology, 656 maternal/fetal infection, 657–659 neonatal infection, 659 outcomes, 663 pathophysiology, 656 trace elements, nutrition, 245 tracheal agenesis, 816–817 tracheoesophageal compression, 27 tracheoesophageal fistula (TEF), 812–814 transcutaneous bilirubin (TcB), 315 transcutaneous oxygen, 395 transesophageal pacing, 527 transfusion reactions, 532–533 febrile, 533 transfusion-associated acute lung injury (TRALI), 532 transfusion-associated graft-versus-host disease (TA-GVHD), 533 transfusions, blood See blood transfusions transient tachypnea of the newborn (TTN), 403–407 transillumination, 447 transitional care, 103–104 transport, neonatal air transport, 186, 201, 202t cardiac disorders, 488 985-1008_Cloherty_Index.indd 1005 1005 fixed-wing, 193 ground, 193 indications for, 192–193 introduction to, 192 legality, 193 medications used, 198–199t NICU arrival, 200–201 organization of services, 193–195 prior management, 200 referring hospital responsibilities, 195–197 simulation, 202 specific conditions, 201 supplies for, 196–197t transport teams, 193 equipment, 195t responsibilities, 197–199 supplies, 196–197t transpyloric feedings, 258 trauma, birth bone injuries, 70–71 head, neck injuries, 63–67 intra-abdominal injuries, 71–72 introduction to, 63 nerve, spinal cord injuries, 67–70 newborn bleeding, 539 soft tissue injuries, 72–73 Treponema pallidum, 664 See also syphilis tricuspid atresia, 501–502, 501f trisomy 21 screening, 2–3 trophic feedings See minimal enteral feeding true hermaphroditism See ovotesticular DSD truncus arteriosus, 506–507, 506f TTTS See twin-to-twin transfusion syndrome tube feeding, 250, 250t tuberculosis (TB), 672 BCG vaccination, 680–681 congenital, 677–678 breastfeeding contraindications, 267–268 common medications, 679t of fetus, newborn, 677–680, 679t incidence, 672 maternal, 673–677, 676f transmission, pathogenesis, 672–673 tubular disorders, 374–375 tubular function, 351–353 tumors, surgery, 823–824 twins See multiple births recipient, 129 twin-to-twin transfusion syndrome (TTTS), 129–131 type 1, diabetes See diabetes, pregnancy tyrosinemia, 784 7/1/11 4:56 AM 1006 INDEX U UCB See umbilical cord blood UCDs See urea cycle disorders ultrasonographic examinations birth defects, 122 multiple births, 126 renal conditions, 361–362 umbilical cord artery blood flow, artery catheterization procedure, 860–865, 860f, 862f care, 104 delayed clamping, polycythemia, 572–573 multiple-lumen catheters, 865–867 PUBS, 4–5 vascular catheterization procedure, 858–868 vein catheterization, 865, 866f venous system, 859f umbilical cord blood (UCB), 536 undervirilized 46,XY males, 802–805 urea cycle disorders (UCDs), 779–782, 780f Ureaplasma urealyticum, 654 urinary tract infection (UTI), 374, 654–655 urine abnormal odor, IEM, 769, 769t analysis, IEM, 773 electrolytes, 271 normal values, 359t uterine activity assessment, 8–9 V VA EMCO See venoarterial ECMO vacuum caput, 64 valium See diazepam vancomycin, 640–641, 644 vanishing twin, 126 varicella-zoster virus (V-ZV) diagnosis, 616 epidemiology, 615–616 introduction to, 615 prevention, 617–618 treatment, 616–617 vasa previa, 131 vascular abnormalities, 836–837 vascular catheterization, 858–868 See also catheterization vascular disruption syndromes, 128 vascular rings, 817 vasodilators, 519–520 vasopressor therapy, 466–467 vCJD See Creutzfeldt-Jakob disease VCUG See voiding cystourethrography velamentous cord insertion, 131 venoarterial (VA) ECMO, 456 985-1008_Cloherty_Index.indd 1006 venous blood drawing, 852 venous thromboembolic disorders, 548–550 venovenous (VV) ECMO, 456 ventilation See also mechanical ventilation blood gas effects, 384–385, 384t ELBW infants, 160–161 MAS, 433 pulmonary, 395–396 ventilator-associated pneumonia, 654 ventilators, volume-cycled, 379–380 ventricular fibrillation, 524 ventricular septal defect, 512–513, 512f ventricular tachycardia, 524 verapamil, SVT, 523 very low birth weight (VLBW) infants See extremely low birth weight (ELBW) infants; prematurity, follow-up care; prematurity, premature infants vesicobullous eruptions, 839 viral infections, 588 CMV, 588–594 enteroviruses, 618–619 hepatitis, 610–615 HIV, 603–610 HSV, 594–599 introduction to, 588, 589t parvovirus, 599–603 RSV, 622–623 rubella, 619–622 V-ZV, 615–618 virilized 46,XX females, 797–802 vitamin(s) A, 161, 247, 422 D, 45, 300, 782–783 E, 258 infant nutrition, 243, 244t K, 538, 543 supplementation, discharge planning, 261–262 VLBW (very low birth weight) infants See extremely low birth weight (ELBW) infants; prematurity, follow-up care; prematurity, premature infants voiding cystourethrography (VCUG), 361 volume-cycled ventilators, 379–380 vomiting, 810–811, 827–828 VV EMCO See venovenous ECMO V-ZV See varicella-zoster virus W warfarin, newborn bleeding, 538 warmer, radiant, 49 well newborn care See newborn care; term infants West Nile virus (WNV), 529, 530t 7/1/11 4:56 AM Index whole blood See also blood bleeding treatment, 543 component transfusions, 529–530 newborn use, 535 Wilms tumor, 824 WNV See West Nile virus 985-1008_Cloherty_Index.indd 1007 1007 Wolff-Parkinson-White (WPW) syndrome, 522–524, 523f wound care, 834–835 Z zygosity, 124 See also multiple births 7/1/11 4:56 AM ... Perinatol 20 03 ;23 (4):3 12 316 30 Andrew M, Vegh P, Caco C, et al A randomized, controlled trial of platelet transfusions in thrombocytopenic premature infants J Pediatr 1993; 123 (2) :28 5 29 1 31 Murray... Table 45 .2 Hemoglobin Nadir in Babies in the First Year of Life Maturity of baby at birth Hemoglobin level at nadir Time of nadir (wk) Term babies 9.5–11.0 6– 12 Premature babies (1 ,20 0 2, 500 g)... trial of recombinant human erythropoietin for preterm infants Source: Data from Strauss RG Erythropoietin and neonatal anemia N Engl J Med 1994;330(17): 122 7– 122 8 563-571_Cloherty_Ch45.indd 569 7 /2/ 11