Guidelines for Acute Care of the Neonate

251 Pages·2017·7.66 MB·English

Guidelines for Acute Care of the Neonate
Edition 26, 2018–2019
Updated: July 2018

Arnold J. Rudolph, MMBCh (1918 - 1995)

Section of Neonatology
Department of Pediatrics
Baylor College of Medicine
Houston, Texas

Guidelines for Acute Care of the Neonate
Edition 26, 2018-2019

Updated: July 2018

Editors
Caraciolo J. Fernandes, M.D.
Mohan Pammi, M.D., Ph.D.
Lakshmi Katakam, M.D., M.P.H.

Section Editors
Diane M. Anderson, Ph.D., R.D., LD
Mufeed Ashraf, MD
Jonathan Davies, M.D.
Catherine Gannon, M.D.
Joseph A. Garcia-Prats, M.D.
Ganga Gokulakrishnan, M.D., M.S.
Amy B. Hair, M.D.
Karen E. Johnson, M.D.
Timothy C. Lee, M.D.
Krithika Lingappan, M.B.B.S.
George Mandy, M.D.
Tiffany M. McKee-Garrett, M.D.
Frank X. Placencia, M.D.
Muralidhar Premkumar, M.B.B.S.
Christopher J. Rhee, M.D.
Danielle R. Rios, M.D., M.S.
Binoy Shivanna, M.D., M.B.B.S.
Michael E. Speer, M.D.

Section of Neonatology
Department of Pediatrics
Baylor College of Medicine
Houston, Texas
Copyright © 1981–2018 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine.
Edition 26, First printing July 2018
Published by
Guidelines for Acute Care of the Neonate
Section of Neonatology, Department of Pediatrics Baylor College of Medicine
6621 Fannin Suite W6104
Houston, TX 77030

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Section of Neonatology, Department of Pediatrics, Baylor College of Medicine

Foreword

It is my privilege to introduce this year’s edition of Baylor Neonatology Guidelines, now in the 26th year of its publication. The
editors of these guidelines – Drs. Fernandes, Pammi and Katakam – are continuing the legacy of Dr. James Adams and his
tradition of generating practical, up-to-date and evidence-based guidelines that provide bedside clinicians with a ready reference
for patient care. The editors, section editors, and various authors have worked hard to preserve relevant material from the
guidelines and add new relevant information. They have continued to incorporate more and more the GRADE system of categorizing
the evidence supporting these guidelines, and expanded the pool of authors in this edition. Community neonatology colleagues, nurse
practitioners, dietitians, and fellows are all members of author teams now.
The Baylor Neonatology Guideline book is used extensively in our Newborn Center (including the Mother Baby Unit), the Ben Taub
NICU, and our Community Neonatology neonatal units. It ensures consistency of care among the large number of clinicians in our
Newborn Center and at multiple locations in the Houston area. It has been, and will remain one of the most valuable resources and a
distinguishing asset of the Neonatology Section. In addition, it is a resource for practicing neonatologists all over the world. Most
importantly, these guidelines ensure that we provide excellent high-quality care to NICU infants and their families and improve their
outcomes. As the Service Chief and Section Head of Neonatology, it has been my honor to support the team of editors and authors
who have worked hard to bring us this distillation of evidence, experience, and clinical wisdom.

Gautham Suresh, MD, DM, MS, FAAP
Professor of Pediatrics, Baylor College of Medicine
Section Head and Service Chief of Neonatology
Texas Children's Hospital

Guidelines for Acute Care of the Neonate, Edition 26, 2018–19 i
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine

Preface

We are pleased to release the 26th revision of “Guidelines for the Acute Care of the Neonate”, a
compendium of multidisciplinary collaboration between members of the Newborn Center at Texas
Children’s Hospital and Baylor College of Medicine. This edition is dedicated to the two legends
of the BCM Neo Section who left lasting legacies - Dr. Arnold J. Rudolph, who taught us the art of
neonatology and Dr. James Adams, who, in addition to being an educator extraordinaire, was singularly
influential in developing the ‘BCM Neo Guidelines’ over the first 24 years.
The ‘Baylor Neo Guidelines’, as this handbook is fondly referred to, is meant to serve as a resource for
neonatology fellows, pediatric housestaff, nurse practitioners, nurses and other clinicians who care for sick
neonates in Baylor-affiliated hospitals. This body of work is reflective of general principles, concepts, and
treatment recommendations that are agreed upon by the authors, editors, and section members. When
appropriate, national guidelines are cited to help with the decision-making process. Also, regional traits
unique to the southeast Texas or Houston are considered when appropriate. The guidelines are reviewed
and revised annually (or more frequently as needed) as new evidence and recommendations for clinical care become available. Users
should refer to the most recent edition of these guidelines, which may be downloaded for free from ‘Physician publications’ tab of the
Baylor Neonatology website (www.neonate.net).
Starting with the 25th edition, we began qualifying our clinical recommendations using the ‘GRADE’ framework for rating quality of
evidence and strength of recommendations. Our guidelines cite the quality of evidence and the strength of our recommendations
whenever possible. Our chapter authors and section editors have worked hard to create the content you see within and will monitor
their areas of clinical interest for emerging evidence that may be of value to the bedside clinician caring for a sick neonate. We look
forward to serving you in the coming years.
Sincerely,

Caraciolo J. Fernandes, MD
Mohan Pammi, MD, PhD
Lakshmi Katakam, MD, MPH

Disclaimer
These are guidelines only and may not be applicable to populations outside the BCM Affiliated Hospitals. These guidelines do not
represent official policy of Texas Children’s Hospital, Ben Taub General Hospital, BCM, or the BCM Department of Pediatrics, nor are
they intended as universal practice guidelines or standards of care. Specific circumstances often dictate deviations from these guidelines.
Each new admission and all significant new developments must be discussed with the fellow on call and with the attending neonatologist
on rounds. All users of this material should be aware of the possibility of changes to this handbook and should use the most recently
published guidelines.
ii Guidelines for Acute Care of the Neonate, Edition 26, 2018–19
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Contributing Authors

All authors are members of the faculty at Baylor College of Medicine in the Department of Pediatrics, Section of Neonatology and
attending physicians at Texas Children’s Hospital, unless otherwise noted. Allied health contributors are all members of the Texas
Children’s Hospital staff.

Senait Adebo, MD Leah Elizondo, MD Timothy C. Lee, MD Maria Kristine Reyes, MD
Assistant Professor Neonatal-Perinatal Fellow Associate Professor Assistant Professor
Division of Pediatric Surgery
Diane Anderson, PhD, RD, LD Nidia B. Espinosa, MS, RD, LD Christopher J. Rhee, MD
Associate Professor Neonatal Dietitian Krithika Lingappan, MBBS Assistant Professor
Associate Professor
Athis Arunachalam, MD Regine Fortunov, MD Danielle R. Rios, MD, MS
Assistant Professor Assistant Professor Jenelle Little, MD Assistant Professor
Assistant Professor
Mufeed Ashraf, MD Mayra Freeman-Ladd, MD Emily Rodman, PharmD, BCPPS
Assistant Professor Assistant Professor Pablo Lohmann, MD Clinical Pharmacy Specialist-NICU
Assistant Professor
Sangeetha Athis Rajh, MD Bheru Gandhi, MD Charles Roitsch, DO
Instructor Assistant Professor Laura Lucas, MS, RD, CSP, LD Neonatal-Perinatal Fellow
Neonatal Dietitian
Melinda Colleen Brand, PhD, RN, NNP-BC Catherine Gannon, MD Elizabeth Sager, MD
Neonatal Nurse Practitioner Assistant Professor Ashley Lucke, MD Neonatal-Perinatal Fellow
Neonatal-Perinatal Fellow
Elizabeth Bacon, MS, RD, LD, CNSC,CSP Joseph Garcia-Prats, MD Rita Shah, MD
Neonatal Dietitian Professor Agnes Mandy, RD, LD Assistant Professor
Neonatal Dietitian
Ashley S. Bruns, DO Ann Gerges, MD Michael E. Speer, MD
Perinatal-Neonatal Fellow Assistant Professor George T. Mandy, MD Professor
Associate Professor
Rebecca J. Burke, MD Jamie Gilley, APRN, MSN, NNP-BC Nathan C. Sundgren, MD, PhD
Perinatal-Neonatal Fellow Neonatal Nurse Practitioner L. Adriana Massieu, RD, CNSC, LD Assistant Professor
Neonatal Dietitian
Melissa M. Carbajal, MD Ganga Gokulakrishnan, MD, MS Alana Thomas, MD
Assistant Professor Assistant Professor Tiffany McKee-Garrett, MD Assistant Professor
Associate Professor
Amy Carter MS, RD, LD Laura Gollins, MBA, RD, LD Cecilia Torres-Day, MD
Neonatal Dietitian Neonatal Dietitian Jamie J. McKissick, MSN, APRN, NNP-BC Assistant Professor
Neonatal Nurse Practioner
Laura Caudill, RD, CLEC, LD Sharada H. Gowda, MD Lois M. Tracy, MSN, APRN, NNP-BC
Neonatal Dietitian Assistant Professor Tiffany L. Molina, MD Neonatal Nurse Practitioner
Neonatal-Perinatal Fellow
Mary F. Colby-Hale, MSN, APRN, NNP-BC Charleta Guillory, MD, MPH Santiago O. Valdes, MD
Neonatal Nurse Practitioner Associate Professor Alice Obuobi, MD Assistant Professor
Assistant Professor Section of Pediatric Cardiology
William J. Craigen, MD Amy B. Hair, MD
Professor Assistant Professor Scott W. Osborne, MD Gregory Valentine, MD, DTM
Department of Molecular & Human Genetics Assistant Professor Neonatal-Perinatal Fellow
Patrice Hochevar, RD, CNSC, LD
Bridget Cross MSN, APRN, NNP-BC Neonatal Dietitian Lisa Owens, DO Nidhy Paulose Varghese, MD
Neonatal Nurse Practitioner Senior Faculty Assistant Professor
Karen E. Johnson, MD Division of Pulmonary Medicine
Milenka Cuevas Guaman, MD Associate Professor Mohan Pammi, MD
Assistant Professor Associate Professor Bernadette White, MD
Lakshmi Katakam, MD, MPH Neonatal-Perinatal Fellow
Viral Dave, MD Associate Professor Shweta Parmekar, MD
Assistant Professor Assistant Professor Lindsay Whittington, RN, VA-BC
Simon Yousef Kayyal, MD Staff Nurse
Jonathan Davies, MD Assistant Professor of Neurology Frank X, Placencia, MD
Assistant Professor Assistant Professor
Mona Khattab, MD, MS
Stephanie Blair Deal, MD Assistant Professor Jennifer L. Placencia, PharmD
Assistant Professor Clinical Pharmacy Specialist-NICU
Seema Lalani, MD
Chris K. Dischler, MSN, APRN, NNP-BC Associate Professor Muralidhar Premkumar, MBBS
Neonatal Nurse Practitioner Department of Molecular & Human Genetics Assistant Professor
Contributors

Endocrinology section was written with the advice of the Pediatric Endocrine and Metabolism Section, in particular, Lefki P. Karaviti, MD and
George Jeha, MD. Environment section, in particular NICU Environment, written with the advice of Carol Turnage-Carrier, MSN RN CNS and
Lisa Davenport MSN, RN, CNS. Infectious Disease section was written with the advice of the Pediatric Infectious Disease Section, in particular,
Drs. Carol J. Baker, Judith R. Campbell, Morven S. Edwards, and Flor Munoz-Rivas. Human Immunodeficiency Virus (HIV) section written
with the advice of the Allergy & Immunology Section. Nutrition section was written with the advice of Nancy Hurst, PhD, RN, IBCLC, and
Kristina Tucker, RN, IBCLC.
Guidelines for Acute Care of the Neonate, Edition 26, 2018–19 iii
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine

iv Guidelines for Acute Care of the Neonate, Edition 26, 2018–19
Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Contents

Section 1. Care of Very Low Birth Weight Babies Section 4. Environment

Ch. 1.1 General Care (Babies < 1500 grams) ..................... 2 Ch. 4.1 NICU Environment .............................................. 60

Ch. 1.2 Specialized Care for ELGAN Babies ..................... 3 Ch. 4.2 Thermal Regulation ............................................. 63

Ch. 1.3 Umbilical Catheters................................................ 4 Section 5. Endocrinology

Ch. 5.1 Approach to Disorders of Sexual Development .. 68
Section 2. Respiratory Care

Ch. 5.2 Hypothyroxinemia of Prematurity ....................... 70
Ch. 2.1 Delivery Room Stabilization ................................ 10

Ch. 5.3 Steroid Therapy for Adrenal Insufficiency .......... 71
Ch. 2.2 Control of Breathing and Apnea of Prematurity .. 11

Ch. 5.4 Hypoglycemia ...................................................... 72
Ch. 2.3 Management of Neonatal Respiratory Distress .... 13

Ch. 5.5 Transitional Neonatal Hypoglycemia ................. 72
Ch. 2.4 Non-Invasive Respiratory Support ....................... 14

Ch. 5.6 Persistent Hypoglycemia ..................................... 74
Ch. 2.5 Weaning from CPAP and Nasal Cannula ............ 17

Ch. 2.6 Conventional Ventilation of Preterm and Term Section 6. Genetics
Neonates ............................................................... 18
Ch. 6.1 Inborn Errors of Metabolism ............................... 78
Ch. 2.7 High-frequency Oscillatory Ventilation ............... 22
Ch. 6.2 Genetic Testing .................................................... 85
Ch. 2.8 Bronchopulmonary Dysplasia .............................. 24
Section 7. Hematology
Ch. 2.9 Prevention of Bronchopulmonary Dysplasia ....... 30
Ch. 7.1 Approach to the Bleeding Neonate ...................... 88
Ch. 2.10 Interdisciplinary Care and Discharge Planning of
the Ventilator Dependent Patient ......................... 31 Ch. 7.2 Platelet Disorders ................................................. 89

Ch. 2.11 Pulmonary Hypertension in Lung Diseases ......... 32 Ch. 7.3 Transfusion of Blood Products ............................ 90

Ch. 2.12 Congenital Diaphragmatic Hernia ........................ 33 Ch. 7.4 Pathophysiology and Differential Diagnosis of
Jaundice .............................................................. 92
Ch. 2.13 Neonatal ECMO ................................................... 35
Ch. 7.5 Management of Neonatal Jaundice ...................... 94
Section 3. Cardiac Care
Ch. 7.6 Polycythemia ....................................................... 97
Ch. 3.1 Cardiovascular Physiology................................... 40
Ch. 7.7 Neonatal Thrombosis ........................................... 99
Ch. 3.2 Circulatory Insufficiency ..................................... 43

Ch. 3.3 Congenital Heart Disease ..................................... 50

Ch. 3.4 Arrhythmias ......................................................... 56

Guidelines for Acute Care of the Neonate, Edition 26, 2018–19 v
Contents Section of Neonatology, Department of Pediatrics, Baylor College of Medicine
Section 8. Infectious Diseases Section 10. Newborn Care

Ch. 8.1 Bacterial Sepsis .................................................. 104 Ch. 10.1 Routine Care ...................................................... 138

Ch. 8.2 Group B Streptococcus (GBS) ........................... 105 Ch. 10.2 Cardiac Murmurs ............................................... 140

Ch. 8.3 Cytomegalovirus (CMV) ................................... 107 Ch. 10.3 Dental................................................................. 140

Ch. 8.4 Fungal Infection (Candida) ................................ 107 Ch. 10.4 Dermatology ...................................................... 141

Ch. 8.5 Gonococcal Disease ........................................... 110 Ch. 10.5 Extracranial Swelling ......................................... 142

Ch. 8.6 Hepatitis B ......................................................... 110 Ch. 10.6 Feeding .............................................................. 143

Ch. 8.7 Hepatitis C ......................................................... 111 Ch. 10.7 Hospital Discharge ............................................. 146

Ch. 8.8 Herpes Simplex Virus (HSV)............................. 112 Ch. 10.8 Neuromusculoskeletal ........................................ 147

Ch. 8.9 Human Immunodeficiency Virus (HIV) ............ 113 Ch. 10.9 Newborn Screening ........................................... 150

Ch. 8.10 Respiratory Syncytial Virus (RSV) .................... 114 Ch. 10.10 Urology .............................................................. 151

Ch. 8.11 Rotavirus ............................................................ 115
Section 11. Gastroenterology

Ch. 8.12 Syphilis, Congenital ........................................... 115
Ch. 11.1 Spontaneous Intestinal Perforation .................... 156

Ch. 8.13 Tuberculosis ....................................................... 116
Ch. 11.2 Intestinal Failure and Intestinal Rehabilitation .. 157

Ch. 8.14 Varicella-Zoster Virus (VZV) ............................ 117
Ch. 11.3 Cholestasis ......................................................... 158

Ch. 8.15 Zika Virus .......................................................... 118
Ch. 11.4 Intravenous Lipid Emulsions ............................. 160

Section 9. Neurology Ch. 11.5 Gastroesophageal Reflux (GER)........................ 161

Ch. 9.1 Encephalopathy .................................................. 122
Section 12. Nutrition

Ch. 9.2 Seizures .............................................................. 124
Ch. 12.1 Initiation and Intravenous Fluids ....................... 164

Ch. 9.3 Cerebral Hemorrhage and Infarction .................. 126
Ch. 12.2 Parenteral Nutrition ........................................... 165

Ch. 9.4 Neural Tube Defects .......................................... 128
Ch. 12.3 Enteral Nutrition ................................................ 167

Ch. 9.5 Drug-exposed Infants ......................................... 129
Ch. 12.4 Nutrition Assessment ......................................... 178

Ch. 9.6 Pain Assessment and Management .................... 132
Ch. 12.5 Guidelines for Oral Feeding .............................. 179

Ch. 9.7 Vein of Galen ..................................................... 134
Ch. 12.6 Discharge Nutrition Preparation ........................ 181

vi Guidelines for Acute Care of the Neonate, Edition 26, 2018–19