The first part of this post are notes I took from the lectures of the most recent STABLE Course I recently took. The speakers are an outstanding neonatologist and an outstanding respiratory therapist.*
The course is based on the Stable Program and on the 2013 6th edition Stable Program Learner Manual. (1) The Manual should be read in its entirety before the course to gain maximum benefit.
Text in the post in quotes is from the STABLE Manual or other sources not from lecture notes. Text in brackets [ ] are my comments or from the STABLE Manual. And I added the YouTube videos referenced in the post as examples. The speakers did not mention any of the YouTube videos.
The mnemonic STABLE stands for:
Sugar and Safe Care
Temperature
Airway
Blood Pressure
Lab Work
Emotional Support
The foundation of the STABLE course and Program is competence in Neonatal Resuscitation which is taught in the Neonatal Resuscitation Course. (2)
The most important thing about newborn care or infant care or anything in pediatrics are the ABCs. And the ABCs (airway, breathing, and circulation) are the neonatal resuscitation program and everything in stable builds on the neonatal resuscitation program.
S sugar and safe care module
The first thing is: if the infant is sick, we need to avoid enteral feeding. The newborn should be NPO and IV fluid, D10W, should be begun. [And the appropriate laboratory evaluation, monitoring, respiratory support, and antibiotics should be given.
For symptomatic hypoglycemia you would give a bolus of 2 mL per kilogram of the 10 W and begin an IV infusion of the D10W at 80 mL per kilogram per day.
“Symptoms of hypoglycemia include irritability, tremors, jitteriness, exaggerated Moro reflex, high-pitched cry, seizures, lethargy, floppiness, cyanosis, apnea, and poor feeding.”
[The AAP has recently given guidance on screening and treatment of hypoglycemia in newborns. (3) and I have posted the chart from that article in Screening and Management of Postnatal Glucose Homeostasis in Late Preterm and Term SGA, IDM/LGA Infants–Guidance from the AAP].
In this module is also covered bowel obstruction. And the first thing to remember is that green vomitus, bilious vomitus, should prompt rapid evaluation by neonatal expert. And the upper G.I. radiograph needs to be done in a tertiary care center. The reason that green vomitus is so important is that it could be a sign of midgut rotation which is a surgical emergency.
Other causes of bowel obstruction include duodenal atresia, which is more common in trisomy 21, and for which the double bubble sign is the classic abdominal x-ray finding.
Meconium ileus is different from meconium plug. Meconium ileus is a blockage of the terminal ileum caused by meconium there.
Meconium plugs are in the colon and are diagnosed by water-soluble contrast enema. If meconium plugs are diagnosed later we might want to work the patient up for Hirschbrung’s disease. Hirschbrung’s disease is usually not the diagnosis made in the newborn period. It is usually diagnosed in the first year of life in the infant having problems with chronic constipation.
The neonatologist spoke of a case of meconium plug causing colonic obstruction with bowel obstruction on x-ray of the abdomen. The key, she said, is to pass and NG tube to the stomach to rule out tracheosophagealfistula/esophageal atresia and to pass a soft red rubber catheter up the anus to rule out a high anal obstruction. These two actions are critical because both entities require immediate surgery and hence the diagnosis of each entity must be made promptly.
IV access
Use a 24 gauge IV catheter. The neonatolgist states that we never use butterfly needles anymore. And it’s critical to check the IV hourly for infiltration.
Emergency Umbilical Venous Catheter Placement
[The 3 x 3 Method for Placing Emergency Umbilical Venous Catheters (UVCs) is by Drs. Bryne and Strand from the Indiana University School of Medicine Department of Pediatrics and is available on YouTube titled Emergency UVC Placement. There is a complete transcript of the text of the video on my blog post, Emergency Umbilical Vein Catheterization for Newborns—An Outstanding Video Resource along with the video itself.
The causes of hypoglycemia in the newborn
1. Inadequate glycogen stores as occurs in preterm infants and small for gestational age infants.
2. Hyperinsulinemia as occurs in the infant of a diabetic mother or an infant that is large for gestational age
3. Increased glucose utilization as occurs in sick infants. Sickness or stress or anaerobic metabolism leads to rapid depletion of the newborns limited glycogen stores.
For more on newborn hypoglycemia please see reference (3)
It is critical to begin treatment when indicated by the bedside glucose test. Bedside tests, the speaker states, are very accurate now.
It is also critical in newborns with low blood sugar to document the baby’s symptoms at the time of the hypoglycemia. Also we want to obtain repeat blood sugars every 15 to 30 min. until it is greater than 50 mg/dL. And we want to document the symptoms at the time the blood sugar is normal.
The most common symptoms of hypoglycemia are tachypnea and jitteriness.
You don’t want to give too much IV fluid as you will cause hyperglycemia, fluid overload, and hyponatremia.
An example of when you might want to use an emergency umbilical venous catheter placement is when you have been working to get a peripheral IV in for about 30 minutes in a hypoglycemic sick [meaning symptomatic] baby. Now it’s time to place a UVC.
In the newborn, the neonatologist states that she has not had the use intra-osseous access because in the first week of life you can usually get a UVC. But and IO is an option if you need to use it.
The neonatologist states that we don’t routinely use heparin anymore for central lines because of the danger of dosing errors and of heparin-induced thrombocytopenia.
Temperature Module
The normal temperature for newborn is 36.5° on a grade to 37.5° sod agreed with the goal of 37° on a great. Heat loss in the newborn can occur very rapidly as much as 0.2 to 1° grade per minute.
You must have a dedicated blanket warmer unit.
For the infant less than 1.5 kg you need to cover the infant with a plastic bag keeping the head and face clear without drawing the baby immediately after delivery.
Do not bathe the infant if the infant is hypothermic.
The neonatologist states that at St. Vincent’s, we do not do rectal temperatures on any newborn because of the risk of intestinal perforation.
My question to the neonatologist was: does a baby in apparent good health, asymptomatic, and without risk factors who is found to be mildly hypothermic need an immediate complete workup. She said that in a case like this just rewarming the baby and see how the baby does. You would work up persistent hypothermia. And she says that much of neonatal hypothermia is because the mom turns down the temperature in her room due to her feeling very hot and also perhaps because the baby is left undressed to check fingers and toes and show off how cute it is. So the most common cause of newborn hypothermia is most probably inadvertent environmental exposure. But it still needs to be addressed carefully.
Persistent pulmonary hypertension (right to left shunting secondary to increased pressure in the pulmonary arterial circulation)
The treatment of persistent pulmonary hypertension is: 1. Volume load 2. Avoid pulmonary vasospasm or avoid making it worse by increasing oxygen saturation, by avoiding acidosis (respiratory or metabolic), avoid hypothermia, and give antibiotics for sepsis.
Respiratory distress
Mild respiratory distress can be indicated by nothing more than a mild tachypnea.
Moderate respiratory distress is indicated by retractions and note that nasal flaring indicates at least moderate respiratory distress. One of the speakers noted that many people who do not regularly work with newborns will miss the sign of nasal flaring.
[For video of nasal flaring please see Dr. Larry Mellnick’s YouTube video Nasal Flaring (the patient in the video is not the newborn but the example will show you what nasal flaring looks like and the fact that it can be subtle). And for an outstanding video showing the general signs of respiratory distress in infant please see Dr. Larry Mellnickk’s YouTube video Infant Respiratory Distress Signs.]
Grunting
“Grunting is the infant’s attempt to increase functional residual capacity (lung volume) when there is collapse of alveoli. The infant will partially closes vocal cords to try and trap air in the lungs when exhaling. The grunting sound is made when the infant exhales through the partially closed vocal cords. Grunting ‘splints open’the small airways and helps to maintain functional residual capacity in the alveoli. Until the infant tires too much, grunting serves as a mechanism to improve oxygenation and ventilation.” p 102
“Older infants and children who grunt are usually severely ill, however, this rule may not apply to all newborns with grunting respirations. Most late preterm and term infants who have grunting respirations will begin grunting within 30 min. after birth and will stop running by two hours after birth. When grunting is observed, evaluate the infant for other signs of respiratory distress (tachypnea, nasal flaring, cyanosis, [decreased oxygen saturation], and retractions). If grunting does not stop after a few hours following birth, or if grunting appears for the first time several hours after birth, this is a warning sign that merits further evaluation. As a rule, the louder and more severe the grunting the more severe is the respiratory distress.” p 102
Airway
Remember that if bag-mask ventilation is working–good heart rate, oxygen sat, etc–then you can pass an orogastric tube and keep bagging. The respiratory therapist states that in one of her cases she was able to maintain a newborn with bag-mask ventilation for twenty minutes (the reason why the baby was not intubated was not given).
The ET tube centimeter numbers start with 0 at the tip (the end inserted into the airway) and go to 15 cm at the other end.
The lip-to-tip rule is the weight in kilograms plus 6 equals the lip to tip distance (the mark at the lip).
Blood Pressure Module
“Assessment of the infant’s perfusion and overall well-being must accompany blood pressure measurement. This is because an infant may have a blood pressure in the ‘normal range,’ but on exam, may have evidence of altered mental state and poor cardiac output: prolonged CRT, cool extremities, or mottled skin. Findings such as these would be consistent with a state of compensated shock. Inaddition, laboratory tests, in particular a blood gas and lactate level (see Table 4.2) may also provide useful information regarding the degree of shock an infant may be experiencing. However, if there is a clinical indication, treatment should not be delayed while awaiting laboratory results.” p 195
The neonatologist says that we rarely do skull x-rays anymore. If you are worried enough to get a skull x-ray you should just get a CT scan of the head to look for brain injury. To look for skull fracture you just request bone windows. A head CT takes only a minute now so we don’t need to sedate the baby.
Fetal-maternal transfusion can cause severe neonatal anemia without any clinical evidence. The neonatologist says that what usually happens in a case like this is that the newborn ends up getting an emergency c-section for fetal distress. And when the baby comes out it is as pale as a styrofoam cup.
Laboratory Module
“Signs of sepsis may range from subtle and non-specific to unmistakably apparent. It is best practice to administer antibiotics to any neonate who has any signs that could indicate infection.” p. 230. “Broad spectrum antibiotic coverage is discussed on page 250.” Treatment options for asymptomatic infants with risk factors for sepsis are discussed on pp 254 – 256.
Clinical Signs of Sepsis (from Table 5.2 p 234): “Infected infants most commonly present with some degree of respiratory distress.” Other signs include temperature intolerance (hypothermia more commonly than hyperthermia), feeding intolerance, cardiovascular signs (tachycardia or bradycardia, hypotension, skin mottling, prolonged capillary refill time, pale or gray skin), abnormal neurologic status (irritability, increased sleepiness, lethargy, hypotonia, seizures), abnormal skin findings (omphalitis, blisters on the skin [or oral mucus membranes], soft tissue swelling and redness, cellulitis, necrotic skin lesions).
[The lab tests necessary for the evaluation of a newborn prior to transport are the 4 Bs: Blood Count (CBC), Blood Culture, and Blood Gas (which can be a capillary or venous gas) (p 235).]
“A neonate with sepsis may have a completely normal CBC and a normal CRP in the early phase of illness.” “Never withhold antibiotic treatment in an ill neonate on the sole basis that the CBC (or CRP) is normal.” p 239
[The following lab tests are usually obtained after transport: C-Reactive Protein (CRP), Cerebrospinal fluid (CSF), Electrolytes, Ionized Calcium,Renal Function Tests (BUN and creatinine), Liver Enzymes (AST, ALT, GGT, Bilirubin [unconjugated and conjugated]), Coagulation Studies (PT, PTT, Fibrinogen, D-dimer), and Magnesium (if magnesium given during labor). pp 237 + 238]
*The course speakers are uncredited because any errors in the post are mine.
Resources:
(1) The S.T.A.B.L.E. Program, Learner/ Provider Manual: Post-Resuscitation/ Pre-Transport Stabilization Care of Sick Infants- Guidelines for Neonatal Healthcare Providers (Pre-transport/ Post-Resuscitation Stabilization). 6th ed, 2013. Kristine Karlsen.
(2) Neonatal Resuscitation Textbook, 6th ed, 2011. American Academy of Pediatrics/American Heart Association.
(3) Clinical Report—Postnatal Glucose Homeostasis in Late-Preterm and Term Infants [Abstract] [Full Text PDF]. Pediatrics; originally published online February 28, 2011; DOI: 10.1542/peds.2010-3851. David H. Adamkin, MD, Committee on Fetus and Newborn
(4) The NICU Peripheral Brain blog: This site was created by Dr. Phillip Gordon, section head of neonatology at the Tulane School of Medicine. The NICU Toolbox page has a number of useful tools for caring for newborns including the excellent Tulane Emergency Department Quick Guidelines for the Newborn. The Sarnat Score Cheat Sheet is a simplified version of the neonatal neurologic exam used as an aid to determine need for therapeutic hypothermia in newborns with hypoxic-ischemic encephelopathy (a clearer and easier to use “Neuorological exam to evaluate candidacy for therapeutic/neuroprotective hypothermia” is found on p 87 of the 2013 STABLE Program Learner Manual, 6th ed).
(5) Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. 7th ed, 2013. [This book along with The Neonatal Resuscitation Textbook and the STABLE Program Manual should, I think, be in every pediatrician’s library.]
(6) Manual of Neonatal Care. 7th ed, 2011. [This book along with The Neonatal Resuscitation Textbook and the STABLE Program Manual should, I think, be in every pediatrician’s library.]
(7) Emergency Umbilical Vein Catheterization for Newborns—An Outstanding Video Resource. Posted on July 19, 2012 by Tom Wade MD.
