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Polycythaemia Neonatal Management Clinical Guideline

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Polycythaemia Neonatal Management Clinical Guideline Polycythaemia Neonatal Management Clinical Guideline V1.0 June 2021 Summary Infant identified as at risk of Capillary Hct Infants at risk polycythaemia with identified >65% and Capillary Infant of one sign or one sign or Haematocrit diabetic mother symptom symptom identified (Hct) >70% Prolonged delayed cord clamping >2 mins Twin to Twin transfusion Venous Full Blood Count Intrauterine sample growth restriction (IUGR) Cord pH <7.0 Large for gestational age Asymptomatic Symptomatic >98th centile Chromosomal anomalies such as Trisomy 21, 18 and 13 Venous Hct Venous Hct Venous Hct Venous Hct Severe 65-70% >70% 65-70% >70% Preeclampsia Observations 4 Admit to NNU hourly for 12 hours Neonatal Unit 4 hours NEWS Observations 4 hourly 2 x pre feed blood IV dextrose observations. for 12 hours. sugars ECG Monitoring Ensure 2 x pre feed blood Ensure adequate High risk feeding adequate sugars. hydration, increase regime hydration, urine Ensure adequate fluid intake to one Fluid balance output. Observe hydration, urine day ahead if Monitor for signs of output. tolerated. electrolytes and Signs or jaundice. Observe for signs of Observing bilirubin Symptoms jaundice. adequate urine 12 hourly FBC Hypoglycaemia Repeat FBC after 12 output until requiring hours. Observe for signs asymptomatic treatment with of jaundice and Hct <70% IV Dextrose Jaundice requiring Symptomatic or phototherapy worsening FBC CNS symptoms with unknown Venous cause - Hct 75% Irritability, If worsening lethargy, symptoms seizure Poor feed absorption - not Consider Partial Exchange transfusion via UVC/UAC tolerating and peripheral venous line hourly feeds, Nil by Mouth until Hct < 65% then as per high risk bilious feeding regime aspirates Monitor urine output and fluid balance and investigate Urine output < further causes 1ml/kg/hr Regular electrolytes and bilirubin and plot on appropriate chart 6-12 hourly FBC depending on severity of symptoms Polycythaemia Neonatal Management Clinical Guideline V1.0 Page 2 of 14 1. Aim/Purpose of this Guideline 1.1. To assist staff with identifying possible causes for, and infants at risk of Neonatal Polycythaemia. This guidance is for the management of these infants in order to prevent further complications. Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We cannot rely on opt out, it must be opt in. DPA18 is applicable to all staff; this includes those working as contractors and providers of services. For more information about your obligations under the DPA18 please see the Information Use Framework Policy or contact the Information Governance Team [email protected] 2. The Guidance Polycythaemia is defined as a venous packed cell volume/haematocrit (Hct) of over 65%. This condition affects approximately 1-5% of newborns in the postnatal period. Many affected infants are asymptomatic and the characteristic clinical features and related complications are thought to occur as a result of hyperviscosity. It is however important to note that not all polycythaemic infants suffer from hyperviscosity. Hyperviscosity can result in serious clinical consequences due to reduced blood flow to organs leading to poor tissue perfusion and possible microthrombus formation. Sampling variability can occur when measuring haematocrit and therefore a venous, free flowing sample is gold standard and must always be obtained to confirm diagnosis. The treatment of polycythaemia is also variable because it is uncertain whether intervention affects long-term outcome and may be associated with some gastrointestinal morbidity. Dehydration is also a common case of polycythaemia when identified into the 2nd -3rd day of life. This should be corrected and treated accordingly then haematocrit reviewed subsequently. 2.1. Infants at risk of Polycythaemia Infant of diabetic mother Delayed Cord clamping with other risk factors Twin to Twin transfusion Polycythaemia Neonatal Management Clinical Guideline V1.0 Page 3 of 14 Intrauterine growth restriction (IUGR) Intrapartum Hypoxia Large for gestational age Chromosomal anomalies such as Trisomy 21, 18 and 13 Maternal Preeclampsia Endocrine abnormalities such as hypothyroidism, congenital adrenal hyperplasia 2.2. Signs and Symptoms Many polycythaemic infants will be asymptomatic and only appear plethoric on examination. Polycythaemic infants who are developing hyperviscocity may present with these signs and symptoms over the first 24 hours; Respiratory distress +/- Apnoea Cyanosis Cardiopulmonary complications such as tachycardia, Persistent Pulmonary Hypertension of the Newborn (PPHN), cardiomegaly Gastrointestinal problems such as poor feeding, vomiting, Necrotising enterocolitis (NEC) Neurological complications such as lethargy, irritability, jitteriness, seizures Persistent hypoglycaemia requiring high GIR Hypocalcaemia Jaundice requiring more than standard phototherapy Renal complications such as decreased urine output, renal vein thrombosis Coagulation difficulties such as thrombocytopenia 2.3. Investigations Haematocrit in term infants, who appear clinically well, should not be measured routinely, including those with risk factors. However, if signs or symptoms occur then the following investigations should be undertaken: Full maternal and infant history to identify predisposing factors Systematic clinical examination including: respiratory status, capillary refill time, femorals and bowel sounds Polycythaemia Neonatal Management Clinical Guideline V1.0 Page 4 of 14 Identify any risk of dehydration such as significant weight loss in first 5 days In any infant identified to be at risk of polycythaemia and presenting with one of the stated signs or symptoms they must have a venous full blood count (FBC) sent to the laboratory with a full electrolyte sample (green bottle) and blood gas for blood glucose The diagnosis of polycythaemia can only be made from a venous Hct. It is important to acknowledge that many infants may present with symptoms similar to those attributed to polycythaemia with hyperviscosity and that other aetiologies should also be considered. Symptoms of hyperviscosity are likely to be severe and persistent. 2.4. Management 2.4.1. Asymptomatic and Symptomatic Management 2.4.1.1. Asymptomatic Infants with Hct 65-70% Clinical polycythaemia management not required Ensure adequate hydration by monitoring oral intake and seeking prompt support from infant feeding team if required Observing adequate urine output Observe for signs of jaundice 2.4.1.2. Asymptomatic Infants with Hct 70-75% Observations 4 hourly for 12 hours, following flowchart if any symptoms occur Two pre-feed blood sugars and manage as per Hypoglycaemia guideline if required Ensure adequate hydration by monitoring oral intake and seeking prompt support from infant feeding team if required Observe adequate urine output Observe for signs of jaundice Repeat venous FBC after 12 hours 2.4.1.3. Symptomatic Infants with Hct 65-70%- see decision making flowchart Observations 4 hourly for 12 hours, following flowchart if any further symptoms occur Polycythaemia Neonatal Management Clinical Guideline V1.0 Page 5 of 14 Two pre-feed blood sugars and manage as per Hypoglycaemia guideline if required Ensure adequate hydration by monitoring oral intake and seeking prompt support from infant feeding team if required. Increase fluid intake to one day ahead, pass nasogastric tube if unable to maintain volumes orally Observing adequate urine output Observe for signs of jaundice 2.4.1.4. Symptomatic infants with Hct >70%- see decision making flowchart Consider admitting to Neonatal Unit and commence IV dextrose for 24 hours minimum (can be fed a day ahead if mild symptoms only- e.g. jaundice only requiring phototherapy, one off hypoglycaemia) ECG Monitoring High risk feeding regime Monitor fluid balance and urine output Monitor electrolytes and bilirubin and plot on appropriate chart 12 hourly FBC and electrolytes until asymptomatic and HCT <70% If worsening symptoms such as persistent hypoglycaemia or respiratory distress despite intravenous fluids, to discuss with Neonatal Consultant about performing a partial exchange transfusion 2.4.1.5. Symptomatic or Asymptomatic infants with Hct >75%- see decision making flowchart Consider Partial Exchange transfusion via Umbilical Venous Catheter/Umbilical Arterial Catheter and peripheral venous line Consideration should be given to investigation of other causes of polycythaemia especially if persistent/worsening symptoms Nil by mouth until Hct < 65% then as per high risk feeding regime Polycythaemia Neonatal Management Clinical Guideline V1.0 Page 6 of 14 Monitor urine output and fluid balance Regular electrolytes and bilirubin, and plot on appropriate chart 6-12 hourly FBC depending on severity of symptoms 2.4.2. Partial Exchange Transfusion 2.4.2.1. The accepted treatment of polycythaemia is partial exchange transfusion (PET), however it should be noted that PET has not been shown to have beneficial effects on long term outcomes and due to associated complications should therefore be discussed with the Neonatal Consultant before being undertaken(1). Partial Exchange Transfusion in preterm infants is higher risk and must
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