Contents Chapter Topic Page Neonatology Respiratory Cardiology

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distance of the light source from the baby, the optimum distance being 35 - 50 cm in conventional lights. Types of photolights Conventional phototherapy Fibre optic phototherapy (Biliblanket) Intensified phototherapy In cases of mild to moderate jaundice conventional and fibre optic phototherapy usually suffice but where jaundice is significantly high (e.g. >300 umol/L in a 5 day old or 250 umol/L in a 24 hour old infant ) intensified phototherapy should be used. The methods of providing intensified phototherapy are as follows: i. high intensity blue lights ( F20 T12 / BB ) with 7 overhead lamps, and 4 lamps placed below the infant. ii. combined fibreoptic blanket with standard phototherapy system above, thus increasing the surface area of the infant exposed to light. iii. several phototherapy lamps placed around the infant, if a fibreoptic unit is not available. iv. placing a white reflecting surface (e.g. sheet) around the bassinet, so that light is reflected onto the baby's skin when using a single phototherapy unit so as to increase the area of exposure. Phototherapy : Practical considerations. Position light source 35-50 cm from top surface of the infant (when conventional fluorescent photolights are used.) Expose infant appropriately Cover infant's eyes Turn infant every 2 hours Monitor serum bilirubin levels as indicated Monitor infant's temperature 4 hourly to avoid chilling or overheating Allow parental-infant interaction Discontinue phototherapy when bilirubin is less than threshold levels and has been falling for 24 hours. In infants without haemolytic disease, the average bilirubin rebound after phototherapy is less than 1 mg/dl (17 µmol/dl). Discharge from hospital need not be delayed in order to observe the infant for rebound, and in most cases, no further measurement of bilirubin is necessary. However, if phototherapy is initiated early and discontinued before the infant is 3 to 4 days old, additional ambulatory follow-up may be necessary Measure intensity of phototherapy light periodically using irradiance meters Turn off light during feeding and blood taking Hydration- there is no evidence to support any influence of excess fluid administration on serum bilirubin concentration. Some infants admitted with high bilirubin levels may also be mildly dehydrated, and may need fluid supplementation. More frequent breastfeeding is recommended because it inhibits the enterohepatic circulation of bilirubin and thus lowers the serum bilirubin level. Other routine supplementation e.g. with dextrose water is not indicated
Once the baby is on phototherapy, visual observation as a means of monitoring is unreliable. Serum bilirubin levels must guide the management. EXCHANGE TRANSFUSION (ET) Bilirubin levels beyond which kernicterus may occur if an ET is not carried out have not been established. The modality of treatment should be based on the clinical history, risk factors and physical examination of the infants. The table below illustrates the recommended levels for various modalities of treatment adapted from the American Academy Pediatrics for infants of 35 or more weeks of gestation based on different levels of risk. (Pediatrics 2004, 114: 297-316). Table 2. Guidelines for Phototherapy and ET in Hospitalised Infants of 35 or More Weeks’ Gestation Hours of life Infants at lower risk (≥ 38 wk and well) Intensive Phototherapy Total Serum Bilirubin levels mg/dL (umol/L) Infants at medium risk (≥ 38 wk + risk factors OR 35- 37 6/7 wk and well) ET Intensive Phototherapy Infants at higher risk (35- 37 6/7 wk + risk factors) ET Intensive Phototherapy < 24* 24 12 (200) 19 (325) 10 (170) 17 (290) 8 (135) 15 (255) 48 15 (255) 22 (375) 13 (220) 19 (325) 11 (185) 17 (290) 72 18 (305) 24 (410) 15 (255) 21 (360) 13 (220) 18.5 (315) 96 20 (340) 25 (425) 17 (290) 22.5 (380) 14 (240) 19 (325) > 96 21 (360) 25 (425) 18 (305) 22.5 (380) 15 (255) 19 (325) Note: 1. Immediate exchange transfusion is recommended if infants show signs of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonus, fever, high pitch cry) or if TSB is ≥ 5 mg/dL (85 umol/L) above the exchange levels stated above. 2. Start conventional phototheraphy at TSB 3 mg/dL (50 umol/L) below the levels for intensive phototherapy. 3. Risk factors – isoimmune hemolytic disease; G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis or albumin < 3.0 g/dL 4. Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin. 5. During birth hospitalisation, ET is recommended if the TSB rises to these levels despite intensive phototherapy 6. For readmitted infants, if the TSB level is above the ET level repeat the TSB measurement every 2 to 3 hours and consider ET if the TSB levels remain above the ET level for 6 hours under intensive phototherapy 7. *Infants jaundiced at < 24 hours of life are not considered healthy and require further evaluation. Infants who are of lower gestation will require phototherapy and ET at lower levels, (please check with your specialist) ET
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Contents Chapter Topic Page 1 Norma
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Dermatology 67 Atopic Dermatitis…
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Dato’ Dr. Lim Nyok Ling Consultan
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ISSN 1823-3856 Printed by: Perniaga
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Foreword One of the maxims of scien
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B. Anthropometric Measurements a) H
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Immunisation 1. Immunisation schedu
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2 General Notes 2.1 Many vaccines (
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3.5.6 Rubella - Contraindicated in
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4.8 Rubella May have rash, fever,
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5.5 Close contacts of immuno-defici
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Developmental Assessment Developmen
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Hearing Assessment Warning signs fo
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Global Developmental Delay History
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Developmental Milestones Table AGE
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AGE Gross Motor Vision & Fine Motor
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Principles of Transport of the Sick
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3.1 Airway Management Establish a p
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3.7 Environment Neutral Thermal Env
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7. Special Surgical Conditions 7.1
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• Ventilation - Most of the babie
Page 43 and 44: Neonatal Resuscitation High Risk De
Page 45 and 46: • Drugs are available (and prepar
Page 47 and 48: Meconium stained liquor: Meconium i
Page 49 and 50: Summary: Use of medications during
Page 51 and 52: Definition Premature infant: < 37 w
Page 53 and 54: 8. Supplements: a. At birth : Vitam
Page 55 and 56: Enteral Feeding in Neonates 1. Intr
Page 57 and 58: 32 weeks Well babies Start milk imm
Page 59 and 60: Total Parenteral Nutrition for Neon
Page 61 and 62: Clearance is usually monitored by m
Page 63 and 64: Daily weight Meticulous care of th
Page 65 and 66: Monitor BUSE and correct any imbala
Page 67 and 68: C. UAC and UVC care UAC position Le
Page 69 and 70: HIGH FREQUENCY OSCILLATORY VENTILAT
Page 71 and 72: 6. Infants must be monitored closel
Page 73 and 74: pH , PaCO2, PaO2, HCO3 - , Bases Ex
Page 75 and 76: Q. Name a likely diagnosis A. RDS 3
Page 77 and 78: A. Definition Birth Asphyxia There
Page 79 and 80: E. Management I. Good intrapartum c
Page 81 and 82: c. All doctors managing such infant
Page 83 and 84: Etiology Determination of etiology
Page 85 and 86: FLOW CHART: MANAGEMENT OF NEONATAL
Page 87 and 88: 2. Klauss & Fanaroff: Care of The H
Page 89 and 90: D. Asymptomatic Hypoglycaemia Feed
Page 91 and 92: NEONATAL JAUNDICE What is jaundice?
Page 93: Physical examination • General co
Page 97 and 98: Reference: extracted from MOH publi
Page 99 and 100: - 1ml of 4.2% NaHCO3 given for ever
Page 101 and 102: a. If unconjugated hyperbilirubinae
Page 103 and 104: APNOEA IN THE NEWBORN Definition :
Page 105 and 106: History NEONATAL SEPSIS Septic Neon
Page 107: Antibiotic choice will depend on pr
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Contents Chapter Topic Page Neonatology Respiratory Cardiology

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