1. Neonatal Intensive Care an update
Dr.S.Boopathi MD, DNB Paediatrics(AIIMS),
MRCPCH(UK)
Fellow Neonatal Medicine, University Hospital Wales, UK

2. Evolution of Neonatal care and NICU
1900s- IMR 250-300/1000 live birth
1950s :More insight into newborn physiology and the normals
1970 s :Antenatal steroids; 1980 :Use of surfactants
Applying technology to save lives- Advanced Ventilators, Drug delivery devices, Monitors, point of care
investigations, microsampling and assay techniques etc etc
1990s The Decade of Microprimies
•Protocol based NEONATAL care. Structured and mandatory training in Newborn resuscitation, and other key
areas, Specialized nurses trained in Newborn care
2000s to present
•In utero transfer and centralized care for sick infants, Dedicated Newborn and Paediatric retrieval and
transport services, Concept of golden hour in primies care
•Recent developments- probiotics in NEC, Therapeutic cooling for HIE, Parentral nutrition, Improved
aseptics

3. Preterm birth the growing problem

4. Preterm newborn(≥ 23 weeks- <37 weeks)
 Not normal
 Immature lungs
 Immature kidneys
 Immature brain
 Poor reserves- Fat, protein and glycogen
 Immature thermoregulatory mechanisms
 Immature or poorly developed Immune systems
 Lack of bonding with parents

5. Preterm Birth- Common problems

6. EPICURE 2 Study Arch Dis Child Fetal Neonatal 2014

7. Managing a Preterm Birth
GOLDEN HOUR IN PRETERM BIRTH < 32 weeks
 Day 1 most dangerous Period of life for a preterm infant
 BE GENTLE
 Complete the following within first 1 hour after birth
 Admit to NICU
 Normal temperature
 Stabilise the infant on CPAP/Mechanical ventilation
 Secure the vascular access including UVC and UAC
 x-ray- Confirm all line and tube positions on Perform first blood gas
 Record vital signs
 Commence IV fluids and starter TPN.
 Administer medications including vitamin K, first dose of antibiotics, and
caffeine where applicable.
Improves survival rates and incidence of other complications

9. Hypothermia and Thermal control of newborn
Kangaroo mother care
Closed Incubator
Open care warmer
Embrace warmer with PCMFood grade plastic wrap <30 weeks

10. Sepsis
 Common cause of neonatal mortality
 30-50% of Neonatal deaths
 Wide prevalance of Gram negative multidrug resistant organisms in India
 Risks- Maternal sepsis, PROM, Multiple PV examinations, Perinatal asphyxia, Poor hygiene and
asepsis routines, Overcrowded and poorly staffed NICU
Management
 Prevention-Hand washing is the most effective way to prevent infection, Strict infection
control policies
 Prophylactic antibiotics in c/o risk factors
 Judicial use of antibiotics based on cultures
 Meticulous care with lines
 Training of nurses and DrS, SOP in the unit

11. Respiratory distress syndrome of preterm
or SDLD or Hyaline membrane disease

12. Chronic lung disease of prematurity/Bronchopulmonary dysplasia
 Continued Need of O2/Respiratory support at Day 28
or at 36 Weeks GA
 Risk Factors GA <30 weeks, B Wt<1500 gms, HMD,
Patent Ductus arteriosus, Maternal infection,
Mechanical Ventilation, Excess O2 use, Fluid overload
 Old BPD - Presurfactant era- mean B wt – 2000 gm, GA
33 weeks
 Vs New BPD-Mean GA 28 weeks, B wt <1000 gm
Treatment
 Lung protective strategies from hour 0
 Nutritional support
 Steroids, Bronchodilators, Diuretics,Treatment of
PDA, immunization(Routine +Flu+RSV)

13. Intracranial(Intraventricular) Haemorrhage and
Periventricular leucomalacia/White matter Injury

14. Intracranial(Intraventricular) Haemorrhage and
Periventricular leucomalacia/White matter Injury
 Common in <32 weeks GA.
 Primary reason for neurodevelopmental problem in infants <32 weeks
 Fragile subependymal germinal matrix and watershed areas of blood supply
Risks
 Maternal infection, Lack of antenatal steroids, Aggressive handling at delivery, Haemodynamic
disturbances, Hypocarbia, Hypoxia, Increase in Intrathoracic pressure, coagulation disorders etc
Presentation
Usually asymptomatic at onset.
Grade 3, 4 IVH and Severe PVL – Poor prognosis
Diagnosis and Treatment
By Bedside Ultrasound imaging
Prevention must be the aim
Managing hydrocephalous, CP etc.

15. Necrotizing Enterocolitis
Most Common GI emergency In a neonate
Incidence 0.3- 2.4/1000 live birth
Risk factors
Prematurity
Hypoxic or Hemodynamic insult for the baby
Lack of breast milk
H2 Blockers(?), Blood transfusion(?)
Prevention
Exclusive Breast milk
Cautious enteral feeding
Probiotics
Minimise hypoxic insult to the gut
Bell staging criteria
suspected(I), Definite(II), Advanced(III)
Treatment
Nil by Mouth, IV antibiotics, surgical intervention if needed

16. Nutrition

17. Nutrition

18. Retinopathy of prematurity
 Vasoproliferative disorder of retina in
preterm infants due to excess O2.
 Results in Blindness and Vision problems
 Seen in 20-30% of at risk infants
 At risk group
 <32 weeks
 <1500 gms B Wt
 ≥32 weeks – If Critcally sick and on
Prolonged O2 RX
 Keep O2 saturation at 90-93%(Alarm limits
88 & 95%)
 Screening at 4weeks/ 32 weeks
 Treatment
 Laser photocoagulation
 Anti VEGF A-Bevacizumab(Avastin).

20. Patent Ductus Arteriosus(PDA)
 Incidence 15- 40 % <1500 gm, <1000 gms- 50-65%
 Functional closure in term infants by 12 -24 hrs
Hemodynamic problems, Difficult ventilation
 Myocardial strain
 L to R shunt
 Ductal steel, Risk of NEC
Diagnosis- ECHO
Treatment
Medical- Fluid restriction, Diuretics,
Ibuprofen, Indomethacin, Paracetamol
Surgical – Duct ligation

21. Birth Asphyxia or Hypoxic Ischemic encephalopathy
 Responsible for 28% of all neonatal deaths
Treatment

Maintain TABC, Normal Blood sugars, Na, K, Ca, Mg
 Treat Seizures
 Therapeutic Hypothermia(33-34°C for 72 hours) a promising treatment in newborns
with mild to moderate
• pH < 7.0 or base deficit of -12 mmol/l or more
• Ongoing resuscitation requirement including positive pressure ventilation after 10 mins
• Apgar score < 6 at 10 mins
• Clinical signs of encephalopathy
• Abnormal EEG
• Commenced ASAP or within 6 hours of birth

23. Meconium aspiration Syndrome
 Passage of meconium inutero due to Acute/chronic Hypoxia, Infection
 Meconium stained Amniotic fluid(MSAF)
 Incidence 8-25%, MAS develops in 5% of MSAF
 Care at birth- No need for perineal suction
○ If baby vigorous- Routine Care,
○ Baby not vigorous- Suction of oropharynx under direct vision and continue with
resuscitation
 Causes varying degrees of respiratory distress
 30-50% of cases develop Persistent Pulmonary hypertension(PPHN)
Treatment
 Antibiotics, CPAP, Mechanical ventilation
 PPHN- iNo, IV sildenafil, ionotropes, ECMO.

24. Managing a surgical Infant
 Bowel problems- Atresia, Malrotation, Hernia,
Gastrochisis, Omphalocele, Necrotising
Enterocolitis, Bowel perforation
 Congenital diaphragmatic hernia
 Imperforate anus
 Lung malformations- CCAM, Lung Cysts etc
 Tracheooesophageal fistula with OA
 Neural tube defects- Meningocele,
Meningomyelocele etc
 Fetal Cardiac defects
• Antenatal Ultrasound and MRI helps in planning pregnancy and prognostication
• Surgery followed by postoperative care in ICU-
– Pain control, fluid and electrolyte management, Nutrition and monitor for complications.

25. 1.Unchanging/increasing premature delivery rate with significant associated mortality and
morbidity
2.New technology gains, and their safe clinical application
1.Question of "how small is too small" and how this care will be paid for
2.Advancement in Fetal diagnostics and Therapeutics
3.Inutero transfer of high risk pregnancies and centralization of care
4.MAKE IN INDIA and MADE IN INDIA
Future challenges