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Management of Low Birth Weight Infants

Nov 17 | 1:30 PM

The birth weight of child is a key indicator of its susceptibility to childhood illness and chances of survival. Though the current frequency of low birth weight in India has decreased to 16% over the last decade, the country still has a long way to go. Appropriate management of low birth weight newborns and prevention of conditions linked to low birth weight can prevent a high number of infant deaths. Join us as Dr. Kavish Mehta explains the modalities and the challenges faced during management of the low birth weight infants.

[Music] good evening everyone i am dr i welcome you all on behalf of team veterans uh today we have with us dr kaveesh mehta uh sir has been practicing neonatologist and neonatology in nashik for the past four years uh sir has contributed chapters an integrated handbook of family medicine uh so it is also a contributor to iap clinical ethics of neonatology sir primarily treats low birth weight babies as well as high risk babies with congenital issues welcome sir thank you thank you also we have with us dr avantika chaitanya is a mbbs graduate and a pediatric residency applicant welcome dr avantika hi over to you so and dr avantika thank you um i'll be introducing dr kaveesh as well as giving a short introduction about the topic a very warm welcome and good evening to all the doctors medical students and other healthcare professionals who have joined in for this talk today which is being posted on netflix my name is dr van dijk and i'm a pediatric residency applicant i will be your host and moderator for this enriching talk about the challenges faced on the management of low birth weight babies low birth with babies or low birth weight is a term that is used to describe babies who are born being less than five pounds eight ounces that is two thousand five hundred grams a low birth age infant may be healthy but they're also prone to many serious problems and for a pediatrician management of low birth babies can be quite challenging the low birth weight baby's tiny bodies are not as strong as the babies of normal birth weight they may have a harder time fighting infection taking feeds and even gaining weight low birth weight babies often have a hard time staying warm too because of the relative lack of subcutaneous fat on their bodies the birth weight of an infant is an important indication of its susceptibility to childhood disease and survival prospects as well though the current frequency of low birth weight in india has decreased to 16 over the last decade the country still has a long way to go appropriate management of low birth weight newborns and prevention of conditions linked to low birth weight can help us prevent a high number of infant deaths here to enlighten us about the management of low birth weight infants is dr kaveesh madha dr kavish mehta is a practicing neonatologist in narshik since four years he completed his residency from dr aaron cooper hospital mumbai and his fellowship in neonatology from the indian academy of pediatrics he is currently working as a consultant neonatologist at shishukov hospital nashik it mainly deals in low birth weight babies and high-risk infants with continental issues this will be an interactive token session with videos and interactive polls in between as well followed by live q a session where you can come up on stage and ask your doubts and questions without further ado please join me in welcoming dr kaveesh mehta onto the stage welcome sir thank you so much it was a very nice description being an mbbs student then knowing so much about the pediatrics and that to low birth weight babies you have done a very good study on it and definitely you will be a very good pediatrician uh all the best to you today is a very good day to present this it is a coincidence basically we never decided that you know this is the day when we will present and uh today happens to be the world prematurity day and we are talking on premature babies so glad to talk on this today i'll start with my presentation so management of freedom and low birth weight babies we need to talk on this freedom may be low birth weight babies their issues and how to go about it uh talking about preterm first what is a free term what uh what are the weeks that we call it as you know a preterm baby and what are extremely term knowing that knowing about the low birth weight how less is uh the weight you know of the babies which we have survived away which have been surviving in india and with this type of talks with this type of seminars and visit with because of the awareness created due to these platforms lot of babies are coming up there is a lot of anxiety which has come down because of this type of awareness talks and in this last 10 years you can see after 2010 there are many neonatal fellows which have come up why why we are discussing this today because what is the main concern because uh this prematurity it has become uh it is rising in india and it is presently around 21 3.6 million premature births in india and 23.6 percent of around the 15 million global pre-term births are happening and of this almost 13 are live freedom births so still a lot to do many things are still to be done the premature deaths contribute to around 16.8 percent of neonatal mortality rate in india and it's a huge it's a huge number to talk about today's scope of my talk i have divided into simple who is a preterm classification of a freedom and low birth weight babies and challenges faced by them nutritional care of freedom babies are actually truly speaking to talk about preterm babies in this one maybe in 40 minutes or 45 minutes it's it's very less time but i try to cover it up it will be just a trailer of a management or maybe a low birth weight babies i won't be able to if any senior is there over here i apologize uh initially only because to give 40 minutes to only a preterm and talking about management is very less but i try to cover as much it is possible we'll be talking on discharge criteria and some follow-up care so to start with according to the gas station age as we know that nine months and seven days so any baby who is born from 37 weeks to 42 weeks is a term baby a normal baby term baby more than 42 weeks is post term in less than 37 weeks is a preterm baby so in preterm we have classified uh into three types and this classification is basically to classify the even the problems the diseases faced in them in that particular weeks and that comes from the maturity of the baby like how mature the baby is and what all problems we can expect in that age group so they are classified into late preterm preterm and extreme freedom a late freedom is anywhere between 34 weeks and first day till 36.6 days a free term is from around 29.1 day from 29.1 weeks to around 33.6 and then extreme freedom is less than 28 weeks and even from the weight point of view we do classify them as low birth weight very low birth weight and extremely low birth rate so uh low birth weight baby is less than 2.5 kgs a very low birth weight baby is less than 1500 grams and an extremely low birth weight is less than one thousand grams so uh talking on uh the gas station age and the birth weight babies are classified into sga or iugr i'll be talking about it more um and the approved aga is appropriate for gas station age and lga is large for gas station age so it appropriate for gas station which is anywhere from 2.5 kg to 4 kgs and large for gas station which is more than 90 percentile on the growth chart or maybe are more than 4 kgs large for gas station age usually they are due to uh maybe a mother who has diabetes in her pregnancy so gestational diabetes or maybe some other reasons and sga and iug are what we are concerned today we need to talk on this small for gas station age or interact like growth restriction so small for gestation age is a birth weight that is below the 10th percentile and iugr is a condition in which baby doesn't grow to normal weight during pregnancy iugr is more of a practical this thing sga is a statistical value igr is when the growth of fetus is or restricted in utero and sga is when the fetus is smaller than normal for its gestation age in iugr we do classify it further into symmetrical igr and asymmetrical energy symmetrical iugr is all the head circumference the length of the baby everything is small and in a symmetrical there is head sparing which happens a symmetrical it usually happens uh later gestation is like maybe more than 25 weeks you know in that babies we so we see a symmetrical igr but in symmetrical igr means there is some compromise which is going on since maybe the first trimester itself or maybe the second trimester so we do need to classify that that gives a lot of information and the proper investigation and management can be planned according to it so coming on to small for gas station h and iugr as you can see these are the two pictures which shows a 2.1 kg baby with iugr and a 3.2 kg which is appropriate for gas station range so in iugr baby as you can see there is a lot of the muscle mass is less fats are less baby looks quite leaner than malnourished we cannot call it as malnourished but a leaner baby and you can see the tone of the lower limbs also it's a little bit hypotonic there are increased holes in the thighs and even the bones are apparently seen properly so the subcutaneous fat is quite less nipples are widely placed in a full uh bond baby and in iugr as you can see the space is quite narrow so iugr baby the look wise also they are little bit old uh old man look we call and in full term baby they are quite fluffy they are uh there are many other parameters there is a new ballad score also which we do in the babies which tells us if if we don't know the gas station age from new balance school we can make it out whether the baby is small for gestational age and how much freedom what is the gestational age of the baby so and it has to be done in residency days we use definitely it has to be done in every baby which comes to nico so coming on to the ideology ideology wise uh why there are pre-term babies and so many preterms and all of a sudden in this few years we are hearing about it and you know there are a lot of premature births which are happening so common factors to it as maternal factors socioeconomic factors pregnancy related factors like pih pregnancy induced hypertension gestational diabetes then there are multiple pregnancies which are happening the ivf pregnancies or maybe you know assisted uh pregnancies which are happening they are twins triplets which we got which we face every day and because of the multiple gestation definitely the babies have maybe the more there are more chances of freedom deliveries in them and [Music] usually late pre terms we see with around 1.5 to 2 kg these are common uh weights which we see nowadays and uh due to some vivid factors and infections infections uh there are some infections called as a torch group of infections they come up in may be in around first and second trimester then they are quite fatal for the baby if they are coming up in third trimester definitely they need to they show a typical signs and they need to be a strong suspicion from clinical features like you know uh hepatosplenomegaly and babies are quite compromised in their growth there are growth restrictions which are seen in them a strong suspicion need to be made on congenital infections and talking about the management part and straight away come on the management part of the preterm babies so this slide is a very important slide i think uh delivery room management as soon as we get a call that a baby is going to be delivered in half an hour or maybe today we are planning after the steroid injections and italy uh the first thing which comes to our mind antenatally uh after the antenatal history is the preparation of the delivery room preparation of a safe transport and proper nicu arrangements for the newborn baby it as as much as possible to my obstetric friends i usually tell that please give us some time at least half an hour if at all possible if at all it is not normally delivered so that we can prepare for the uh case and in delivery room like uh we we have all uh seen as doctors that you know what is the resuscitation protocol that is abc that is airway breathing and circulation so in this in freedom management we take it as tabc that is temperature airway breathing and circulation temperature is given the at most importance so as soon as a preterm baby i extreme freedom baby i would call less than 28 weeks we wrap the baby in a plastic sheet nowadays there are commercial uh sheets also plastic sheets which are available which are sterilized and that can be used as soon as the baby is born in the delivery room we keep the baby not even wiping the baby with cloth or anything like that we would directly place the baby into the plastic sheet and then after closing uh the baby from head to toe only the face is kept open from which we will be taking care of airway and breathing and the umbilical cord which is outside so that we can put the lines umbilical line as soon as the tab is taken care of yeah in respiratory support the nrp recommends availability of pulse oximeter in blended o2 and the low saturation protocol so i'll be i'll be speaking about it in next slides about the saturation protocol uh breathing spontaneously with distress sinuses and heart rate of more than hundred cpap of four to six centimeter watt of water to prevent ethylectasis is strongly indicated so what does this mean i usually i i carry a machine called as neopup which is a delivery room cpap machine and as soon as a baby is born uh less than 28 weeks we start with the first is the temperature and then we start with delivery room cpap which prevents the collapse of the lvo lines and algorithm very distended because of it and uh most more more appropriate that if at all the baby is not at all breathing well and there are no efforts as such then directly give uh intubating the baby with the appropriate size 82 and taking the baby with the cpap or maybe the neopop ventilation is indicated and i have seen tremendous good results because of it even the respiratory management becomes very easy babies are able to breathe nicely we have less of hypoxic systemic episodes and even the initial golden minute becomes very strong so talking about the golden minute yeah the first minute is very very important for any any baby but talking about three terms yeah the golden minute is very important we need to uh assure about the tavcs uh coming to this slide this slide is a part of each and every uh doctor who trains himself in pediatrics this is a nrp neonatal resuscitation program i'll be not going in details about this because this in itself is a new new topic in a new lecture in itself uh but nrp neonatal resuscitation program has to be paid back and whenever uh anyone gets a chance even if they have done earlier but anyone gets a chance to do the enhance please do it because they will take you through each and every aspect of this chart and you don't miss out on this this is the first initial 60 seconds are the most important and then comes the further k so uh before the slide uh before this slide i'll and then just ask anyone means if at all uh there is a poll which we can take yes yeah so when the baby is born and you you take the initial measurement you take the initial steps of resuscitation or effect on the resuscitation is not required baby is crying well so do you use pulse oximeter in your settings so i would like to know that you know how many people check the spo2 of babies yes yes yes that's a very good very good and i would tell uh that that is even the rest 25 percent please start using it because it rules out the continental heart disease in itself then it's a very simple tool to rule out the concentrated heart disease and to lessen the anxiety during the delivery room next i would another hole i would like to take that if the baby cries when color is okay everything is fine at five minutes how much should be the saturation of the baby in the delivery room so the options are a is more than 95 percent 90 to 95 percent 85 to 90 and 80 to 85 percent 90 to 95 percent has got about 15 votes that's 41 percent of people have voted for 90 to 95 yeah so i think so we need to be more uh this this awareness needs to be brought for that this is a wrong answer for most of the people right answer is d i would say because at five minutes we expect a saturation of around 80 to 85 percent as you can see the targeted saturations are around 80 to 85 percent at five minutes this is the who protocol and no need to get panicked just give some time maybe pick some saturation to move more than 90 percent in 10 minutes time so give some time because uh giving odu at first place you know it is not the solution there are many uh doctors which i still see and i feel i feel it is not right i had attended a talk from uh dr subramaniam from us and he highlighted on this that you know if at all there is some perinatal asphyxia which has happened and as soon as the baby cries then we see the saturation and if at all it is 45 50 percent in panic mode we start with the o2 but that can lead to an hyperoxia injury a very beautiful lecture on that i would strongly suggest to visit legends uh of nicu in youtube you can find a lecture but he is he tells there are many uh studies to support that that you know initial oxygen we should target a saturation of around 80 to 85 percent with 5 minutes and 85 to 95 percent 10 minutes coming on to the next slide so initial management uh like t a b c t a b we talked about uh coming on to fluid uh the circulation part uh for uh kids who are less than 28 weeks i would say directly inserting an umbilical line within one hour or so that is our protocol in our unit and it works very well because you know we avoid and we avoid many bricks and many iv extravasations also so initial umbilical line and starting with the fluids is what i would suggest and uh initial sugar so once the baby comes out there are two things which we need to take care of that is one is the oxygen part and second is the glucose part so glucose part will be taken care by the fluid and electrolytes so iv fluids uh baseline fluid needs inversely needs are inversely proportional to the gas station range and the birth rate a very low perforate may be more fluid losses during first week up to 150 kg per day is observed in first day of life according to the guidelines they say that uh initial fluid requirement is almost around 100 95 to 100 ml per day i'll be putting up a chart in the next second and subsequent days of life we gradually increase with the iv fluids it is around 15 to 20 ml per kg per day and maximum in an extreme free term we may reach up to 180 and in some babies we have reached up to 200 also [Applause] uh babies in those babies we have reached up to 180 160 ml per kg per day and it depends on many clinical factors also so total hemodynamic monitoring the nibbp the saturation the heart rate and depending on the urine output these all things are titrated accordingly so additional fluid is required in the babies who are given phototherapy and restrictions of fluid intake uh have to be taken into account in babies whom we are treating we are facing a pda or renal insufficiency and ppd so this is a chart where i uh in 1 to 1.5 kg less than 24 hours we start with initial fluid of 80 to 100 and unless more than 1.5 kg we start with 60 to 80 ml per kg per day and then we gradually increase as i discussed before so in an extreme preterm less than 1 kg we start with 100 maybe 110 sometimes and in a close there are two uh ways of handling this extreme preterm babies one is a closed incubator and one is an open incubator extreme preemies are definitely i'll be sharing the slides of the closed incubator also which we are uh handling over here so in that there is some humidification which we give which is a very good factor for a freedom for the skin care and overall sepsis control also uh challenges faced in free term so in central nervous system uh i'll be talking system wise like cns cvs rs and perhapterm and wise so in central nervous system uh the most complication which we face is ivh intraventricular hemorrhage and this is the only thing which i am worried about in initial one week of life ibh it is graded in two but there are two three breeding systems in it and there is a protocol which we follow over here to screen up newborn baby the extreme freedom or a billionaire baby the first day we do a neuro sonography the third day the seventh day and the 21st day it varies with the different nicu's but over here we are following day one day seven and day twenty one so uh it it helps us you know to uh give us a prognosis to the patient to the relatives and to explain them that you know what precautions we are taking what challenges we are facing with the baby and what will be the outcome at least we can can give them a rough idea and uh ivh is definitely grade one grade two can be dealt with we have seen babies who are doing really good in grade one and grade two grade three and grade four it carries a uh variate from masses grade four definitely not a very good progresses and uh obc childs who develop later on cp and different motor issues also and neonatal caesars also um in babies who had a hypoxic histaminic episode in uh we do see neonatal scissors there is a grading system in that also in which we see sarnat grading system in stage one stage two and stage three stage one babies apparently do well stage two is babies who have a new little caesars and in less than 24 hours and those babies definitely need an extra care in terms of caesar control and glucose management at the same time what is the cause of the caesar so if at all it is high then therapy that is uh what nowadays it's a quite a hot topic like you can say from 2009 onwards many people have started using in india also uh it's like head cooling or the whole body it's a different chapter altogether to discuss on that but there is a uh which which we can definitely think of and it is now expense which says it is in more than 34 weeks that people have started using it i personally have used babies more than 36 weeks the head cooling and the whole body uh talking about pvl yeah pva also is a very dirty complication which we can face in the pre-term babies and uh to prevent all this there are many uh things which i'll be talking about like developmental supportive care and the cluster care which we give to the babies and the clothes in cubic closed incubator care these all things help us to reduce all these things you know because uh less noise less light and minimal touch prevention of sepsis and family centered care are the solutions which i can tell you to prevent all these complications central nervous system wise other things let's let's i think so uh talk about other systems first uh the more management part i'll be speaking in the latest slide uh from cardiovascular system wise yeah there is this term called as cerebral autoregulation which happens in initial days initial one to two days uh these are the most important days and uh in this we need to measure the if at all if the baby is less than 26 weeks we do have a umbilical artery line through which we monitor the uh blood pressure timing and adding dinotropes or giving some support it it has to be regulated time to time and initial 48 hours are the most crucial for any freedom maybe so what is cerebral natural regulation means to talk it in simple words i'll say that the baby baby's body it prevents all the important organs of the body first that is the brain the kitties these are first uh given a proper uh circulation the and uh the most compromised part is the gut so usually we do not start feeds on the first day if at all there is some fluctuation hemodynamic instability which is seen if at all the babies hemodynamic receptor we do start feeds from the first day itself those are called as a tropic fields these are the small quantities which we give uh so i know troops are required after usually 24 hours of life and depending on the condition depending on the condition of the uh heart like we do a point of care ultra sound or media 2d echo which is there besides the bed so in that we definitely see that if at all how is the ventricular function which is going on and accordingly we need to add any dopamine or any other hydrophilus my first choice in babies who are less than 26 weeks is domitami and in babies who are more than 28 weeks is but there are many reasons to it difficult to talk about this right now but definitely it is a very interesting chapter to be precise and to be to go into details uh talking about pda yeah pda is a patent that is arteriosus everyone knows about it pda it is it is a beneficial thing when the baby is inside the home but as soon as the baby is born pda is definitely the functional closure happens within 24 hours and the anatomical closure happens by maybe around a week or so but in few babies because of some hemodynamic instability or maybe some fluid miscalculation or maybe more fluid which is going because of that the pda might be a very big problem so how would you diagnose it though it is basically a 2d echo which is done bedside that is a gold standard or else if that facility is not available in many centers uh there are some clinical parameters through which we can know that like bounding pulses and the baby is desaturating there is unexplained tachycardia then there are some if the baby is on some feeds and there is some feed intolerance then we don't suspect pda uh some babies with congenital heart disease yeah so congenital heart disease is there having cyanotic in a cyanotic heart diseases cyanotic heart diseases definitely will need your care in initial few days and uh talking about pph which is not very common in preterm babies but we do see them in late free terms it's more than 34 weeks and in babies who have mercurial aspiration syndrome so pbhm typically it presents with the versatile uh a live eye saturation uh a baby becomes quite unstable all of a sudden when the baby cries or in any stimuluses given the baby desaturates this is the bedside judgment of it gold standard definitely a 2d echo to confirm the diagnosis uh yeah talking about respiratory system yeah this is the most important part in a breeder baby because in babies the lungs are not very well expanded they are not very very developed uh but when we when i try to explain to the relatives it is like keeping the lungs are quite hard they are like solid rock and what we need to do is make them little bit softer in medical terms yeah definitely we need to decrease the surface tension which is there between the air and fluid interface in the lungs and we need to expand the alveoli the alveoli in a preterm baby are collapsing we need to ex give a certain amount of pwp to make the lungs functional and surfactant is the solution to it there are many commercial uh surfactants which are available out of a name a few like uh surveillance or some other wine based and curacao which is available which i use in extreme prematures uh talking about hyaline membrane disease there are usually three stages which which we see and in nowadays uh with good antenatal steroids and a good maternal care and prevention of infection we see that the lungs are quite mature and even if the if at all there are two set of two doses of anti little steroids which have gone in the babies those babies have really good uh matured lungs but in babies less than 28 weeks we usually give a prophylactic uh early rescue maybe you can say surfactant within as soon as the baby is born if possible in the delivery room itself or maybe as soon as the baby is transferred in the nicu within 15 minutes we give the surfactant uh which helps in a very good and easy ventilatory management in babies uh who are around more than 32 weeks to 36 weeks uh we try to do a technique called as insure that is incubate surfactant and extubate so it's a wonderful technique i i would say and there are many studies which support that and uh personally even i have a very good experience in many babies that uh we avoid ventilation mechanical ventilation in that we just give the surfactant we take the tube out and put the cpap on cpap or hfnc whichever is required cpap is continuous positive airway pressure and hfnc that is high flow hh fnc which is called as heated humidified hydro nasal cannula uh talking about apneas it is a big concern in the preterm babies and it can last up to one month or maybe in babies till the time uh they are discharged from the nicu and the common drugs which are available to prevent it is caffeine capnia sorry caffeine uh the brand names are captia and acne so nowadays we are more uh in favor of caffeine the loading dose is around 20 mg per kg followed by after 24 hours it is 5mg per kg iv odors and knowing about apnea there are two three types you can say there is one is a central cause one is a obstructive cause and the third one which is the most common that is a mixed variety of this and in babies uh who are on hfnc or cpap they have this uh you know they have lot of secretions which can lead to obstructive apnea so even that needs to be uh taken care of so treatment not frequent but shallow suctioning is required or maybe sometimes nasal nasal saline nasal drops are required for the babies to keep the nasal passage very free as they are as the babies neonates are nasal breeders uh talking about ventilation uh nowadays we are talking about uh volume targeted ventilation in neonates uh though i have not used much but i am we we are using over here which is uh simply more of ventilation and pressure control mode of ventilation gentle ventilation is the uh first thing which we need to keep in mind from day one and uh every day means i make it a point when we go to the babies for the rounds and what what all things we can try to decrease you know the fio2 the pressures and depending on the clinical condition of course but uh always make it a point that you know as soon as if we can come out of the ventilation and go on to a non-invasive because nowadays we are more into a favor of non-invasive ventilation so uh basically to prevent bpd and further complications uh bpd is bronchopulmonary dysplasia which is a nightmare i would say we have lost babies uh because of ppt uh ppd is basically uh defined as any baby who requires oxygen for more than you know corrected age of 36 weeks or maybe more than uh 21 days of life the baby is requiring o2 vpt is basically the structural changes which happens in the lungs of a premature baby because of the additional ventilation and what all things which we do in the baby so uh bbt it is definitely an acquired thing which we can prevent with many uh many strategies and uh talking about uh post natal steroids yeah bpd definitely post natal steroids play a very good role but it is a double-edged sword early better to be given early late steroids are not to be are not indicated or maybe there are some neurological side effects so uh a very cautious uh approach has to be uh there in ppt management in postnatal steroids specifically uh pneumothorax yeah suppose after uh the surfactant administration we need to keep that in mind and the pressures and uh the ventilation uh strategies has to be quite optimized to prevent demo thorax we're talking about abdomen or the complication in abdomen is necrotizing enterocolitis which we see in babies uh nec we have seen the babies who you know who have been rampantly increased on feeds and if at all the sepsis also sets in very fast early onset sepsis in babies with early onset or maybe a late onset sepsis but nec can is a preventable thing going gradually on the feeds uh keeping a keen observation on the aspirants or maybe any signs any hemodynamic instability uh definitely needs to be taken care of feed intolerance is any feeds means if at all for example we have reached a feed of around 5 ml we are getting aspirates of around 2 ml 3ml and those are altered aspirates there are some maybe yellowish in color or lacking color definitely we need to hold on to the feeds find out the cause treat the sepsis appropriately it can be sorted out another thing which we observe in preterms is once we achieve uh full feeds uh we find difficult because there is a lot of time which has gone with the rt fees you know we have babies develop such swallow coordination at around 32 to 34 weeks so for that we need to give rd feeds in that time and at 30 to 34 weeks when we start with the oral feeds at a particular weight then at that time we do face a problem of second swallow coordination and in our center we are we are practicing oral motor stimulation and early intervention in that case physiotherapists are involved in that care and even sisters are trained and in some stage at around 35 36 weeks when the baby is quite stable we even train the mothers to do that to give the automotive stimulation and encourage the oral feeds at that time uh early uh there is one term which we use is non-nutritive sucking which has to be started in babies once they are stable when they are you know off apneas or food to support and uh they are quite hemodynamically stable then we do start with non-nutritive suffering that is expressing all the breast milk and then just giving the baby to the latching the baby to the breast to just have a good suck and to initiate the breastfeeding earlier so non-nutritive suffering has to be started little bit early as soon as the baby is stable and uh and giving kangaroo that is i'll be speaking in the next slides that is very very important and it solves many of our issues i'll be speaking about it later uh these are some topics i will be talking about in preterm management sepsis control plays a very important part uh maximum number of deaths which we have seen in an icu in india is because of sepsis so strict infrastructure it starts from infrastructure development another thing is hand washing training of the staff training of sisters training of the guys which are there in bad boys or maybe the classic workers which are there working in the meq uh strict uh family uh you can set up explaining about the need of handwashing and uh strict us relatives of the baby the parents of the baby who will be visiting the nicu and taking care of the nutritional care i have been talking more in detail about nutritional care in next slides skin care is a very important thing in extreme preemies as you know that skin is the largest organ in the body and it any breach in the skin can lead to you know sepsis and in the baby and sepsis is the most difficult part to deal with neonates so skin care needs to be taken care of there are some emollients which we use in the uh for the skin care and in extreme premise the closed care system with the humidifier it plays a very big part uh kangaroo mother can i talk uh pain management is one thing which we use we we have some pain charts also in our nicu and taking uh at most care of the pain like while removing the stickings or maybe when putting the iv or maybe any procedure which we do definitely pain needs to be in your mind and pain management has to be done appropriately and that comes with lot of awareness and training to the staff developmentally supportive care this is a very very important uh aspect in premature uh babies it it has many components like family centered care then family centered care means you know educating the parents about the baby and you know the because first type parent definitely they find it very difficult to see their babies with lot of wires and a lot of the lines which are going inside there's a tube which is going inside the mouth and the nose and umbilicus and maybe in some babies we put the urine catheters so we need to be aware about it how we are taking care of it the uh staff has to be more friendly they need to be more interactive sessions between doctors staff and their parents which calms their anxiety even the mother needs to be taught about [Applause] small small things you know once the if at all it is a c-section we start involving the mother up maybe after day five or so and in small cares like you know just placing your baby maybe uh positioning your baby in our nicu we follow the nest care also the nesting which is done for the baby so it gives a very cocoon-like is very good and other aspects in developmental supportive care is like you know less lighting less of noise a cluster care basically what we do in prematures [Music] so coming into kangaroo care benefits to the baby are decreased length of stay in the nicu baby's breathing is easier baby has more quiet and restful sleep bb has improved brain development and to the parents like mother definitely they feel there are less acne episodes which we observe in babies even kmc and uh they think babies are more satisfied uh that is what we feel and even mother starts getting milk appropriately there is more amount of milk which is produced because of that feeling the extractor which works and even mothers feel more confident in their ability to take care for their babies uh about the nutrition i'll move a little bit fast slide are more and time is little bit less freedom nutrition needs to be taken care of very important uh aspect in beta management so you've talked about this early nutrition have biological effect on the individual with important implications on later health a short-term outcome early introduction may influence propensity to life-threatening disease like adc and systemic sepsis long-term outcome major effect on cognitive function and decreased risk in later life such as cardiovascular disease there are some parker's hype there is a hypothesis which is there and a very beautiful hypothesis which needs to be read by every pediatrician who is taking care of uh for a breather uh which gives a sensitivity it increases our sensitivity to take care of the new newborns uh biological clock yeah the key enzyme in gluconeogenic pathways may not develop until near uh term delivery so low glycogen stores are there and babies are at a high risk of hypoglycemia so proper sugar monitoring daily is required even this uh two uh diagnosis sepsis in uh late onset sepsis and neonates in nicu uh the first parameter to go down the sugar many times we catch by it that the sugar is going high or maybe sugar so that is uh the first sign uh fat stores as we know they are very less in the babies talking about total parental nutrition in babies uh we start with amino and amino acids in premature babies in less than uh 28 weeks i would talk specifically we start with two to three grams per kg per day on day one itself and uh we can increase gradually up to four grams to four point five grams per kg per day in uh talking about internal lipids we start with around one to one point five gram per kg per day and gradually increase to three to three point five there was a notion that you know it can cause sepsis or not but i would say that we have been using in our units with proper precautions and proper septic measures we have now not faced as yet any infection any sepsis because of intra liquids we can definitely use it definitely there are some parameters uh even that is in itself a 40 minute talk you can say on tpn but there are some tests which we do on regular basis to keep a watch that there is no over usage of this medicines uh talking about minerals vitamins yeah so uh lipid soluble are in educates and they are low in preterms and undernourished mothers uh calcium and phosphorus we start with calcium iv calcium from day one itself and we do uh check the calciums ionic calcium also has been a key factor to be seen in hiv babies uh you know because of any uh late onset neolithic relate uh nutritional seizures so in that also hypercalcium is a major cause so calcium uh measurement and uh calcium supplements are needed time to time so [Music] proteins yeah a net proof uh protein uh calcul actually in an ico definitely every day by taking grounds we have to calculate on calories and the protein value which are going on the recommendation by is figan is minimum of 3.2 gram per kg per day and maximum we can go up to 4.2 as i uh mentioned earlier carbohydrates yeah it provides 40 of all the existed energy mainly in the form of lactose so ten percent ferments two short chain fatty acids and ninety percent reaches a portal vein and it is stored as glycogen in uh by especially it recommends around 10.5 to 12 gram per 100 kilo calories the low perforating fund requires large amount of lactose for calcium absorption and it allows colonization of the gut by beneficial fermented flora uh glycoside is enzyme well developed in freedom in funds thus maltose and glucose are well tolerated the carbohydrate proportion portion of various special formulas for the lower weight infant contains around 40 to 50 of lactose and 50 to 60 of glucose polymer uh about this yeah we do start with uh extra calories we do give two babies once they reach at least 50 percent of their uh feeds or required fields we start with uh hmm that is human bill fortifier and we do start with mct oil that is medium chain triglyceride or oils which are commercially available in the market and to add on to the extra calories for proper growth um talking about macronutrients yeah sodium uh we do observe we do uh check with the sodium levels and potassium and chloride levels on day three onwards uh britain have massive renal loss in early neonatal period so sodium has to be observed and uh iv fluid has to be titrated accordingly uh for uh taking care of the sodium we do add crl in the iv fluid and kcl also is needed with calcium and uh dextrose 10 percent or d5 percent depending on the glucose levels and we do add with multivitamins from data onwards in there so we talked about calcium iron mineral for it is a it is the major mineral for brain development uh new headlines which suggests that to do start early in life like we do in our unit we practice starting in supplements from day uh 21 onwards latest recommendations are to start with around three to five uh mg per kg in uh maybe around uh three to four weeks at around 21 days of life use of recombinant uh erythropoietin is also indicated there are two three studies which have come up just lately in 2019 and 20 which are supporting to give erythropoietin uh early every a weekly dose which is given subcutaneous uh zinc helps in the cell replication and growth accumulates mainly in the late trimester so human milk it contains 200 ml per kg per day it currently is once 165 zero mites at four months 160 miles and recommendation for a preterm is 1 mg per kg per day uh vitamins also i'll skip a little bit i'll talk only about vitamin d vitamin d in term babies we required around 400 iu per kg and in three terms it is around 160 io per kg as soon as the baby reaches full feeds we start with vitamin d supplements um then uh for for guidelines for the use of fortified breast milk uh you hmf status is used hmf is definitely a human milk fortifier uh not a formula or not the babies who are on formula feed need to be given uh this hmm statues infant bonds in less than 32 weeks need to be fortified with the milk or any baby with less than 1500 grams uh benefits it improves weight gain increases the linear growth improved protein status increases bone mineralization and normalization of serum calcium phosphorus and alkaline phosphatase uh talking about vitamin k we uh do give it at birth and the protocol which we follow in our unit is every sunday we give a shot of vitamin k the baby is still the time they are discharged it is usually point one and ml per kg uh and in x you pre terms we give around 0.5 mg per kg and it will not give you 0.1 mg in terms and in 3 terms it is 0.5 mg content of hmf i'll skip this slide mct oil i'll talk about medium chain triglyceride fat supplements it is always all almost we add around four to six drops first we start with alternate feeds and then gradually giving in each speed and it has been very wet already till now we have not faced any problems with mct oil uh it helps in continued steady uh weight gain and can develop a greasy diarrhea but we have not much observed in our unit each amalet almost contains around 8 kilocals uh skipping this slide so talking about when is the infant ready for the discharge it is uh the points are very clear it is not the weight that i'll discharge might be at 1.8 or maybe 1.9 kg because that becomes a long stay in an ico and uh i'll i'll be talking more of practical rather than the theoretical stuff especially in countries like india developing country yeah definitely we cannot in private and private hospitals nico is quite expensive so her spate criteria is not the only one the sustained pattern of weight gain is there every day the baby is getting around 15 20 25 grams educate maintenance of normal temperature is you know even if the former is off the baby is able to maintain the temperature maybe it's not getting hypothermic or maybe hyperthermic uh computed feeding by breast means mother is trained in giving breast feeding at least once twice and mother is very well trained in giving palada feeds and during the feed baby is not getting desaturated that is a time you know there is some hemodynamic stability that is a good time we can think of discharge and physiologically mature and stable cardiorespiratory function appropriate immunization uh immunization yeah we do give immunize we do immunize babies and once they cross 1.8 kgs that is what the protocol is there in our unit uh appropriate metabolic screening has been done in all the babies and apnea free period of five to seven days this is very important uh we usually stop the caffeine therapy and observe for five days enlightenment and once the baby is off of any acne episodes and of caffeine since five days it's a good time to think about it uh newborn screening is done in babies i'll be talking about ophthalmic evaluation and audiologist evaluation in later slides so nutritional risk assets and therapeutic dietary modifications are given and hematological status essence and appropriate therapy has been given so this is a good time to go follow-up care rsv is the most important cause of respiratory infection in premature babies and good hand hygiene and passive avoidance of passive cigarette smoking exposure is the key to prevent it infuser vaccine is recommended in babies at six months of age and it has to be given to all the premature babies about air travel not recommended for bpd infants i would say because they might require a supplemental oxygen for a long period of time uh immunization i told about it uh we can stream schedule as term infants with exception of hepatitis b medically stable thriving babies hepatitis b as early as 30 days of age regardless of gestation age or birth weight rotavirus it is usually not given until the nico discharge is planned growth wise in funds with bpd uh you know a lot more calorie needs to be the caloric requirement is little bit high uh in ppt we can also give vitamin a supplements not much of role but there are some studies which say that vitamin a supplement helps in growth failure but if growth failure persists that is euger extractor and growth restriction is there then in those babies extra calorie intake needs to be taken care of in some babies uh till now we have we had one baby who required guests to meet you because of the feed intolerance um but that baby is also even doing very well at around six months of life the baby has achieved full oral feed and at one one year of life the baby is absolutely okay with knowing the growth is at around five to six percent time but we have seen this we have a positive k positive this thing uh input in this talking about anemia we do start with iron at 21 days of life multivitamin drops are started once the baby is on full feeds and before discharge uh vitamin d supplements are given recommended is 400 iu but we can go as high up to 800 io in a premature baby metabolic screening at around three to four weeks of each or maybe whenever the baby is on full feeds then we can do a metabolic screening in ophthalmic evolution we do it at around 21 uh days of life or or it may be around 28 days of life and rop screening has to be done in each and every baby who is a printer who is less than 37 weeks of age and has 26 weeks uh recommendation is at six weeks with 27 to 28 weeks five weeks is done 29 30 weeks we do it at four weeks and more than 30 weeks we do it at three weeks of age [Music] hearing uh follow-up that is usually we do it after the initial discharge but if at all possible whenever the baby is in an icu if we have a uh audiologist who comes to the indigo uh better to be done before the discharge oe is done before discharge acoustic emission test and it gives it is a screening test it basically gives us an idea of the inner ear and it is it is recommended nowadays uh we are doing away in all the fulton babies also over here um so basic uh funda is that uh any auditory uh sensory neural impairment or anything early intervention can help uh so these are some pictures of mind which uh like first picture is when we are ready for receiving an extreme freedom with a as you can see there is a blender oxygen which is there with the neo puff which is there to give the deli divinium cpap and sterile linens with properly uh pre-bombed uh with the pre-worm sitting in the incubator itself and the second picture there is a transport incubator which we have and with the pulse oximeter portable pulse oximeter which is very much required to see the spo2 and the heart rate of the baby till the baby reaches an icu uh this picture is telling about first star of the baby first star goes like this with all the instruments aside besides the baby and uh we are inserting a uvc line uh umbilical catheter and umbilical artery catheter and a pain catheter and starting with the tpn in the first star itself is the key uh this is a closed incubator which i talked about this is an ideal thing to for a extreme premature baby you can see some uh smog which is the form which is coming which is uh which is the sign that the humidifier has been started we start with 95 percent humidity for extreme freedom baby less than 28 weeks extreme freedom babies we start with 95 humidity and then gradually we come down by five percent after two days after 48 hours and we reach up to around maybe around 50 percent and then we stop it so this gives a very good uh sepsis control also uh it gives a very good skin care it is uh totally in developmental supportive care and a cluster care basically is given through this thing this photo i have specifically kept because to understand the uh simulation process simulation is uh we do it very often in our nicu that we have a baby uh with some scenarios which we give to our residents over here and uh to our sisters and staff also that what nrp techniques we can do as soon as if at all the baby desaturates what all things we can do so the simulation techniques needs to be done in all the with the staff workers on a regular basis this improves uh the quality of care of nicu so with this i'll come to the take homes management of freedom starts from delivery room itself uh in resuscitation there is tabc which needs to be taken home very nicely because tabc is the base of a nice of neonatal care management in golden minute and golden r and in icu care is always about a teamwork it is not only the doctor it is the sisters care of i think more than the doctor and cleaning staff radiologist ophthalmologist audiologist and super specialist team which is all together makes a baby which comes out successfully uh developmental supportive care i talked a lot about it is the key for good outcomes thank you so much many things and details of many things it is not possible uh it was truly an a to z talk on the management of all the potential problems that the low earthquake newborns face and how we go about them i'm sure we all learned a lot of new things today especially regarding the oxidation oxygen saturation and d-site in the early minutes post-war which i'm pretty sure a lot of us were not aware aware about uh and for all the future pediatricians and the pediatricians in this session it was definitely a much needed talk for us so thank you once again dr mecca i think we can move on to the live q a round uh if anyone has any questions they can come up on stage and there were a couple of questions on the comments as well um [Music] i think uh so the first question that was asked was what is the link between soto syndrome and large for gestational age this was asked by aadhaar soto syndrome is a disorder characterized by distinctive facial appearances over growth in childhood and learning disabilities or delayed development infants and children tend to grow quickly they are significantly taller than their siblings and peers and have an unusual uh large edge uh i was talking about blast for gestation age uh it would be very early to uh tell you know that the baby has so close and large for decision definitely it is imagined i i talked about it more than four kgs uh in front of diabetic mothers and uh in them definitely more important care which has to be taken is measuring the sugars please we have another question from dr sharon uh as a pediatric applicant i would like to know what motivates you to pursue neonatology post-residency um see when i finished my pediatrics i was working in kokilav hospital and over there we had a very beautiful nicu uh to be honest it was that nicu which attracted me with a beautiful care and i saw babies as glasses of 555 grams coming out very nicely neurologically very well developed and while working there i got this idea of pursuing a new little fellowship and you know it is a wonderfully designed program and once i started working four years over there and uh that time i realized that you know a neonatologist is a very sensitive branch and it's required to push it gives us an adrenaline rush also it means it is a work which is totally defined in one space in one area which needs a lot of potential and it is quite challenging so i basically decided to go into it because of the niko work which i i saw in adafs and now i'm enjoying the purpose of it because i have almost 425 which are coming out in this four years mortality of around maybe around 0.8 the next question is what about vitamin k when would you give it for a low birth weight baby and what i discussed about it term baby it is 1 mg and in freedom less than 1 kg it is 0.5 mg intramuscularities or maybe a high reduce all right and again dr neera kumar has asked to discuss about he just wants to know actually i'm not able to get your voice uh yeah so doctor nirav kumar has asked a question about re-feeding syndrome and in preterm babies re-feeding syndrome basically uh it is a potential shift you know because of uh in the fluids and electrolytes which happens this may occur in a malnourished patient basically in an icu's we do face a lot of electrolyte disturbances and it literally it can be a result of the harmony and metabolic changes which takes place and it can cause serious clinical complications as we talked about nutrition that all slides are very important to take care of the refeeding syndrome it was a very interesting lecture i i definitely definitely enjoyed it i felt like i learned a lot and it was very comprehensive in one hour time you covered so much and it was it was a very very comprehensive lecture as well and right from the start till discharge everything was covered good thank you so much sir thank you for a wonderful session and looking forward for your next session next session and also thank you doctor you

BEING ATTENDED BY

Dr. Darius Justus & 430 others

SPEAKERS

dr. Kavish  Mehta

Dr. Kavish Mehta

Consultant Neonatologist at Shishukalp Clinic, Nashik

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dr. Avanthika Chaithanya

Dr. Avanthika Chaithanya

Dr Avanthika Chaithanya is a pediatric residency applicant, applying for the NRMP Match 2022-2023. She loves working with children! She has 3 months of US Clinical Experience(Clerkships) in Pediatrics...

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dr. Kavish  Mehta

Dr. Kavish Mehta

Consultant Neonatologist at Shishukalp Clinic...

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dr. Avanthika Chaithanya

Dr. Avanthika Chaithanya

Dr Avanthika Chaithanya is a pediatric reside...

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