NEONATOLOGY: MANAGEMENT, PROCEDURES, ON-CALL PROBLEMS, DISEASES, AND DRUGS 5th Edition. (2004) Tricia Lacy Gomella, MD Part-Time Assistant Professor of Pediatrics The Johns Hopkins University School of Medicine Baltimore, Maryland Associate Editors M. Douglas Cunningham, MD Clinical Professor, Division of Neonatology Department of Pediatrics College of Medicine University of California, Irvine Vice President for Special Projects Pediatrix Medical Group Orange, California Fabien G. Eyal, MD Professor of Pediatrics Chief and Louise Lenoir Locke Professor of Neonatology Medical Director, Intensive Care Nurseries University of South Alabama Children's and Women's Hospital Mobile, Alabama Karin E. Zenk, PharmD, FASHP Practice Consultant and Associate Clinical Professor of Pediatrics College of Medicine University of California, Irvine, Irvine, California Lange Medical Books/McGraw-Hill Medical Publishing Division Copyright 2004 by The McGraw-Hill Companies NEONATOLOGY: MANAGEMENT, PROCEDURES, ON-CALL PROBLEMS, DISEASES, AND DRUGS - 5th Ed. (2004) FRONT MATTER TITLE PAGE a LANGE clinical manual Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs - fifth edition Editor Tricia Lacy Gomella, MD Part-Time Assistant Professor of Pediatrics The Johns Hopkins University School of Medicine Baltimore, Maryland Associate Editors M. Douglas Cunningham, MD Clinical Professor, Division of Neonatology Department of Pediatrics College of Medicine University of California, Irvine Vice President for Special Projects Pediatrix Medical Group Orange, California Fabien G. Eyal, MD Professor of Pediatrics Chief and Louise Lenoir Locke Professor of Neonatology Medical Director, Intensive Care Nurseries University of South Alabama Children's and Women's Hospital Mobile, Alabama Karin E. Zenk, PharmD, FASHP Practice Consultant and Associate Clinical Professor of Pediatrics College of Medicine University of California, Irvine, Irvine, California Lange Medical Books/McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto COPYRIGHT Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, fifth edition Copyright 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher. Previous editions copyright 1999, 1994, 1992, 1988 by Appleton & Lange 34567890 DOC/DOC 0987654 ISBN: 0-07-138918-0 ISSN: 0697-6295 Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. This book was set by PineTree Composition The editors were Janet Foltin, Harriet Lebowitz, and Barbara Holton The production supervisor was Richard Ruzycka The cover designer was Mary Scudlarek The index was prepared by Benjamin Tedoff R. R. Donnelley, Inc. was the printer and binder. This book is printed on acid-free paper. INTERNATIONAL EDITION ISBN 0-07-121906-4 Copyright 2004. Exclusive rights by The McGraw-Hill Companies, Inc., for manufacture and export. This book cannot be re-exported from the country to which it is consigned by McGraw-Hill. The International Edition is not available in North America. DEDICATION To my twin sons, Leonard and Patrick, and singletons, Andrew and Michael NOTICE The authors and editors have made every effort to ensure timely and accurate guidelines in this manual. However, it is impossible to list every clinical situation or institution-specific guidelines for diagnosis and treatment. The authors and editors cannot be held responsible for any typographic or other errors found in this manual. Trade names listed herein are the sole property of the manufacturer and do not imply endorsement. CONTENTS Emergency Medications and Therapy for Neonates ¼(Inside front and back covers) Contributors ¼xi Preface ¼xix Section I. Basic Management 1. Prenatal Testing …1 Prenatal Diagnosis 1 / Antepartum Tests of Fetal Well-Being 3 / Intrapartum Tests of Fetal Well-Being 4 / Tests of Fetal Lung Maturity 6 2. Delivery Room Management …8 Obstetric Anesthesia and the Neonate 8 / Resuscitation of the Newborn 12 3. Assessment of Gestational Age …21 Classification 21 / Methods of Determining Postnatal Gestational Age 21 4. Newborn Physical Examination …29 5. Temperature Regulation …39 Hypothermia and Excessive Heat Loss 39 / Hyperthermia 43 6. Respiratory Management …44 General Physiologic Support 44 / Monitoring 44 / Ventilatory Support 51 / Pharmacologic Respiratory Support and Surfactant 56 / Strategies for Respiratory Management of Certain Newborn Diseases 60 / Overview of High- Frequency Ventilation 61 / High-Frequency Ventilators, Techniques, and Equipment 62 / Liquid Ventilation 66 / Glossary of Terms Used in Respiratory Support 67 7. Fluids and Electrolytes …69 Fluid and Electrolyte Balance 69 / Fluid Therapy 70 / Fluid Calculations 73 / Modifiers of Fluid and Electrolyte Requirements 75 8. Nutritional Management …77 Growth Assessment of the Neonate 77 / Nutritional Requirements in the Neonate 77 / Principles of Infant Feeding 78 / Breast-feeding 90 / Total Parenteral Nutrition 94 / Caloric Calculations 99 9. Neonatal Radiology …102 Common Radiologic Techniques 102 / Radiographic Examples 107 / Radiographic Pearls 110 10. Management of the Extremely Low Birth Weight Infant During the First Week of Life …120 11. Extracorporeal Membrane Oxygenation (ECMO) …132 12. Infant Transport …136 13. Follow-up of High-Risk Infants …139 14. Studies for Neurologic Evaluation …144 Neuroimaging 144 / Electrographic Studies 146 15. Neonatal Bioethics …151 Section II. Procedures 16. Arterial Access …157 Arterial Puncture (Radial Artery Puncture) 157 / Percutaneous Arterial Catheterization 158 / Umbilical Artery Catheterization 160 17. Bladder Aspiration (Suprapubic Urine Collection) …165 18. Bladder Catheterization …167 19. Chest Tube Placement …169 20. Endotracheal Intubation …172 21. Exchange Transfusion …175 22. Gastric Intubation …180 23. Heelstick (Capillary Blood Sampling) …182 24. Lumbar Puncture (Spinal Tap) …184 25. Paracentesis (Abdominal) …186 26. Pericardiocentesis …188 27. Venous Access …190 Percutaneous Venous Catheterization 190 / Percutaneous Central Venous Catheterization 192 / Venipuncture (Phlebotomy) 197 / Umbilical Vein Catheterization 197 / Intraosseous Infusion 201 Section III. On-Call Problems 28. Abnormal Blood Gas …203 29. Apnea and Bradycardia ("A's and B's") …208 30. Arrhythmia …212 31. Bloody Stool …219 32. Counseling Parents Before High-Risk Delivery …222 33. Cyanosis …226 34. Death of an Infant …230 35. Eye Discharge (Conjunctivitis) …233 36. Gastric Aspirate (Residuals) …237 37. Gastrointestinal Bleeding from the Upper Tract …241 38. Hyperbilirubinemia, Direct (Conjugated Hyperbilirubinemia) …244 39. Hyperbilirubinemia, Indirect (Unconjugated Hyperbilirubinemia) …247 40. Hyperglycemia …251 41. Hyperkalemia …254 42. Hypertension …257 43. Hypoglycemia …262 44. Hypokalemia …267 45. Hyponatremia …270 46. Hypotension and Shock …273 47. Is the Infant Ready for Discharge? …278 48. No Stool in 48 Hours …283 49. No Urine Output in 48 Hours …287 50. Pneumoperitoneum …289 51. Pneumothorax …292 52. Polycythemia …295 53. Poor Perfusion …298 54. Postdelivery Antibiotics …300 55. Pulmonary Hemorrhage …304 56. Sedation and Analgesia in a Neonate …306 57. Seizure Activity …310 58. Traumatic Delivery …314 59. Vasospasms …321 Section IV. Diseases and Disorders 60. Ambiguous Genitalia …324 61. Blood Abnormalities …332 ABO Incompatibility 332 / Anemia 334 / Polycythemia and Hyperviscosity 341 / Rh Incompatibility 344 / Thrombocytopenia and Platelet Dysfunction 349 62. Cardiac Abnormalities …354 Congenital Heart Disease 354 / Patent Ductus Arteriosus 361 / Persistent Pulmonary Hypertension of the Newborn 364 63. Common Multiple Congenital Anomaly Syndromes …373 64. Hyperbilirubinemia …381 Unconjugated (Indirect) Hyperbilirubinemia 381 / Conjugated (Direct) Hyperbilirubinemia 388 65. Inborn Errors of Metabolism With Acute Neonatal Onset …396 66. Infant of a Diabetic Mother …418 67.