Non-pharamcologic measures to reduce pain Clinical Audit Sustainable development goals relating newborn health Antibiotic Stewardship Human milk fortification Kangaroo mother care Stages of mammogenesis & Lactogenesis & milk let down reflex Total Parenteral Nutrition Mechanisms of heat loss from a baby & what is a neutral thermal environment Questions from neonatal resuscitation Methods of hearing screen Measures to prevent cross infection in a neonatal unit How would you reduce medication errors? Ceftriaxone and calcium drug interaction? Fetal circulation
SEQs in Neonatology Written exam are well-structured problem/scenario based questions, followed by a set of questions asking for a diagnosis, or a differential diagnosis, investigation and/or management, and crucial associations or outcomes of the condition if any.
The SEQ hides a diagnosis, as well as it tells about multiple issues the baby is having at the moment. The diagnosis could be a set of multiple conditions.
For example, the stem may guide you towards the diagnosis of Meconium aspiration syndrome. Many candidates will write the same answering the question that what is your diagnosis? Meconium aspiration syndrome. However, an observant candidate will also dig out perinatal asphyxia, and more so Persistent Pulmonary Hypertension if there are clues. So his/her diagnosis will be Perinatal Asphyxia with Meconium Aspiration Syndrome with persistent pulmonary hypertension of the newborn.
PEARL : WRITE/FORMULATE a complete diagnosis.
Moving further, the stem hides multiple issues. You have to try to make a diagnosis out of those issues, as well as address them all in your investigation plan and in the management. For example, for the scenario may have a mention of abdominal distension with blood stained aspirates, or thrombocytopenia, or seizures, or hypoglycemia, so you have to address all of these issues alongside. I remember a scenario in which a preterm baby was born at 30 weeks of gestation, and was now 30 days old and having poor weight gain, etc etc. So i addressed all the issues but i didnt forget that its the time for his Retinopathy of prematurity screening also.
PEARL: Treat patient as a whole, like we do in our real practice. Address issues apart from diagnosis in your investigations list, and in your management plan. You may write issues separately while reading the stem, it will help you while writing management. If differential diagnosis (D/D) is asked, and in the next question you are asked about investigations and management plan, then write investigations and management for all D/Ds.
And to add more, you have to manage a baby in such a way that the baby got better, got multidisciplinary consultation and management (as required) and was discharge home (on the drugs and multivitamins and/or minerals _____ , _________-, ________), and that this is your follow up plan in neonatology, for growth and development, and for any other discipline.
PEARL: Bachay ko gher pohancha ker followup kerwana hai, and growth and development and post discharge screenings and multidisciplinary followups nhi bhulna (like we do in real practice). You have to discharge the baby home, have followup for growth & development, and mention post-discharge screening if any, and the followup in other specialties.
& in every management plan see that if the following content may be added, the mandatory care we give to every newborn:
General Management that you have to write almost in every answer:
Admit the baby in Neonatal Intensive Care Unit (NICU) and place under radiant warmer or incubator (as per scenario)
Thermoregulation: Maintain body temperature
Maintain neutral thermal environment with environmental temperature between 25 to 28°C and humidity around 60-70%
Maintain Normoglycemia: Keep glucose infusion rate (GIR) at 4 to 6 mg/kg/min; increase if required, BSR monitoring (as per scnario)
Oxygen therapy with nCPAP/ high flow or low flow as required per stem, and pass orogastric tube for stomach decompression to prevent nCPAP belly, or if there is abdominal distension with aspirates etc, Replace OG loses with N/2 with 5% DW.
Add maintenance fluids:
Add Calcium on Day 0
Add Sodium and Potassium on Day 3
Differential Diagnosis, Nutrition & Supportive Care
If D/D asked, then write Ix for all D/D
Management for all D/D
Nutrition:
Orogastric tube feeding with expressed breast milk
If nothing per oral (NPO), give total parenteral nutrition (TPN) or peripheral parenteral nutrition (without lipids, <12.5% DW, <3% Protein); provide micronutrient and mineral supplements once approaching 100ml/Kg/day (except iron, that will not be added if there is sepsis)
Early initiation of OG feeds
Buccal colostrum 0.5 mL on both inner sides of cheeks every 6 hours to prevent necrotizing enterocolitis (NEC) and invasive bacterial infection
Neurodevelopmental Care:
Nesting of baby
Dimmed lights in the night
Pain management related to procedures
Minimal handling and clustering of care
Partial Kangaroo Mother Care (KMC) in NICU
Calculate Oxygenation Index (OI) in a ventilated baby
Counselling of parents relating to the condition, ongoing management, complications of the condition and management, and prognosis
POCUS (Point-of-Care Ultrasound)- such as screening cranial scan, or position check of lines, ETT, or for pneumothorax.
Multidisciplinary care as required
Follow-up after discharge, and growth & development monitoring, and Followup Cranial US Scnas, or renal US Scans, or ROP screening, as indicated.
So this management plan or an improved version according to the case you are managing must be mentioned along the specific management plan you are about to write. (The same as we do in our real practice)
Everyone reads multiple theory books, goes through guidelines, yet there are books that can be recommended to read and learn.
To build competency in the field of Neonatology, you have to build evidence based knowledge in Neonatology. For your routine practice (or for examination in neonatology, DO NOT ATTEMPT PAST PAPERS WITHOUT FIRST BUILDING A KNOWLEDGE ABOUT ROUTINE CASES YOU ENCOUNTER), the must-read books recommended by me are:
Gomella's Neonatology:
Go through the complete book, starting with the commonest case you encounter in your practice. This may be your main reference book for theory. You have to understand every chapter including the talk on settings of environmental temperature and incubator temperature settings, though may seem dry chapter, but the most crucial one where in your viva there may be a discussion on it. A short essay question on 4 mechanisms of heat loss is also there in 2026 written exam, with elaborate reasoning demanded about why 'this premie' in the stem is losing heat more as compared to a term baby. Now, reading all of the Gomella doesnt guarantee that you are going to make a diagnosis in SEQ, that is another drill, which comes by attempting SEQs, MCQs, and pondering on the differential diagnoses.
Protocols in Neonatology by Prof. Dr. Irfan Sb.
I highly recommend this book, it serves both as a knowledge base and a set of guidelines. Every page in this book will have a worth in some part of your real practice as well as in examination. Common approaches are to add from Gomella's Neonatology to this book, anything you wish to add to the content in this book. The topics like TPN, etc can be elaborated a little more, so i will share my notes on such topics. You have to keep this book in your pocket.
Neonatology Review: by Dara Brodsky Link to read it online: https://openlibrary.org/books/OL47689219M/Neonatology_Review It is available online for reading in OpenLibrary, make your free account and borrow it and read it. Make your notes, screenshots, etc. You have to go through this complete book. Highly recommended.
Challenging Cases in Neonatology: by Dara Brodsky It is based on "Index of Suspicion in the Neonatology" that are published in the journal named NeoReviews by American Academy of Pediatrics. There are 300 pages or so in this book. It will give you lateral thinking, and SEQs come from here too. So you have to go through it all. A very interesting collection of cases.
NHS 2025 Neonatal Guidelines Go through all the day-to-day issues you encounter. It will be very fruitful. Keep it as a reference material also.
Avery's Diseases of the Newborn (Elseviers) -- As a reference if you are stuck SOLVING some case.
Nelson's Textbook of Pediatrics- As a reference if you are stuck
Yes you read it right, Nelson's Textbook of Pediatrics will be your good reference for multiple topics like IEMs, endocrinology, Myopathies, to mention a few. You already read that, so revising a topic and building notes from here will be easier.
Reference for Procedures in Neonatology:
MacDonalds Atlas of Procedures in Neonatology
FOR MCQs:
Neonatology Review: Q&A by Dara Brodsky An excellent book that gives you additional knowledge apart from the insight into solving an MCQ. Highly recommended. Go through this book timely. Who knows that the MCQ you are solving right now, will be similar to the SEQ you will have in exam, or it will be a question in your viva.
My own MCQ notes:I'll share these too in here.
ONCE YOU HAVE KNOWLEDGE BASE OF ROUTINE CASES, YOU ARE READY TO ATTEMPT THE PAST PAPERS.
The following content may serve as your guide to ace Neonatology Fellowship Examination. You may use this content as supplement to your ongoing preparation, or to help you see gaps in your preparation. You may add comments on any topic here. Your comments may help others learn something that is missing here. Once reviewed, I may also make your comment the part of the topic.
Anything from TOACS list below may be asked in SEQs, or anything from SEQs may come in TOACS. And obviously all of the knowledge may be asked in Clinicals/Viva.
Good Luck, best wishes, and prayers.
:::: WRITTEN EXAMINATION GUIDE For Neonatology Fellowship Examination
>>Link: Initial Topic List for SEQ preparation :: (with a reminder again that anything from TOACS list below may come in SEQs, or anything from SEQs may come in TOACS. And obviously all of the knowledge may be asked in Clinicals Viva)
Review the patient's full medical chart, including all diagnostic investigations, treatment indications, and potential contraindications before proceeding.
2.Counsel Parents & Obtain Written Consent:Informed Consent Phase.
Discuss the procedure's benefits, potential risks, and alternatives with the parents or legal guardians. Obtain signed informed written consent.
Do not miss an opportunity to counsel parents or care takers if they come to you to know the status of the baby.
If there has been a sick event or improvement in the condition of baby, do counsel parents.
Try to make points of the points once you have counselled them.
Urdu terminologies:
For a baby who is nothing per oral, tell parents that, bacha doodh nhi pi rha lekin bachay ko glucose ki drip say sahara dy rhay hain takeh sugar kam na ho, iske ilawa protein ki drip (aminovil) bhi ja rhi hai
if giving aminovil)
Baby on inoptropes (bachay ka blood pressure low ho jata hai jiske liyay blood pressure barhanay wali dawai ja rhi hai, bacha icu mei dakhil hai aur her tarah ki ngahdasht ki ja rhi hai takeh yeh behtar ho skay)
Early onset sepsis/ Late onset sepsis ( bachay kay jism mei jaraseem honay ka shubah hai jis kaye liyay test bhaij diay gaye hain, ya bhaijay jayengay ya reports agai hai aur un mei infection aya hai, iske liyay dawai yani antibiotic shuru kera di gayei hai)
Birth asphyxia: Bacha paidaesh per late roya hai aur bachay kay demagh ko oxygen kam gayei hai jiske liyay bachay ko oxygen say aur machine say sahara dey rhay hain. bachay per nazar rkhi ja rhi hai keh gurday, anntriyan aur dil sahi kaam kertay rhain.
Preterm baby (bacha waqt say pehlay paida huwa aur iskay phaiphray kamzor hain jin ko taiz oxygen say sahara diya ja rha hai, bachay ka jigar, antriyan , gurday, dil sb kuch waqt say pehlay ka hai aur chota hai, aur in sb cheezo per nazar rkhi ja rhi hai, hum dekhain gay keh kab bachay ko nali kay zariyay doodh dena hai)
Here is a clear and structured framework summarizing the complete step-by-step clinical counseling protocol:
Phase 1: Pre-Counseling Preparation
Chart Review: Thoroughly study the patient’s medical case file, diagnostic results, and history prior to entering the counseling area.
Phase 2: Environment & Communication Setup
Environment & Appointment: Select a quiet, private space with minimal interruptions and schedule sufficient uninterrupted time.
Greeting: Warmly welcome and greet the patient and their accompanying party.
Attendance Limit: Limit accompanying attendants to a maximum of two (or as designated by the patient) to prevent room overcrowding, maintain privacy, and avoid unnecessary interruptions.
Seating Positioning: Arrange seats so the healthcare provider, patient, and attendant form a 60 degrees cone arrangement at approximately 1.5 arm lengths distance.
Phase 3: Uninterrupted Active Listening & Assessment
Open-Ended Initiation: Begin by giving the floor to the patient/attendant. Ask open-ended questions such as:"What is your understanding of your condition so far?" "What have you been told about the procedure we are planning?"
Active Listening ("Listen, Listen, Listen"): Do not interrupt while they speak.
Observational Assessment: While listening, evaluate:
The patient/attendant’s health literacy and level of understanding.
Their current perception and emotional weight regarding the illness/diagnosis.
Empathy & Reflection: Validate their feelings using reflective statements and explicit empathy before transitioning to your portion.
Phase 4: Structured Information Delivery
Boundary Setting (Transition): Softly set the expectation for uninterrupted delivery using a clear, gentle statement:"Thank you for sharing that. Now, I will explain the situation and details step-by-step. Please hold any questions until I finish, and I will make sure we address every single one."
Communication Style: Use non-jargon language, everyday analogies, visual diagrams, and evidence-based clinical information.
Framing Strategy (Prognosis & Outcomes):
Present favorable outcomes, benefits, and positive prognostic factors first.
Present risks, complications, side effects, and guarded prognostic factors last.
Content Coverage:
For Disease Management: Outline available medicinal, surgical, or conservative treatment pathways alongside their respective advantages and drawbacks.
For Procedures: Detail why the procedure is recommended, how it aids diagnosis or treatment, evidence-based success rates, and potential procedural risks/complications.
Phase 5: Guided Decision-Making & Autonomy
Shared Decision-Making: Present options clearly without making the final choice for the patient.
Unbiased Guidance: Assist their decision based strictly on medical logic, patient benefit, and the principle of non-maleficence (primum non nocere), keeping personal bias out of the discussion.
Phase 6: Documentation & Next Steps
Chart Documentation: Record the discussion, treatment options presented, patient/family understanding, and the final decision in the patient’s medical record.
Procedural Follow-Through: Execute standard clinical protocols following the decision (e.g., obtaining formal written informed consent, recording baseline pre-procedural vital signs, and scheduling next steps).
Statistics: Neonatal mortality rate (NMR) of Pakistan is 36/1000 live births (as of April, 2026) Total yearly births 6.9 million Total yearly neonatal deaths 259,000 Births attended by skilled birth attendant 68 % Deaths from birth asphyxia 20.9 % (50,000 per year)(1/5th of total deaths) Preterm 40% what? deaths?
Every birth should be attended by a skilled birth attendant. If 2 babies are expected, 2 teams should be available to resuscitate. Every high-risk birth should be attended by 2 skilled birth attendants with their team.
85% babies cry spontaneously after birth 10% more cry after drying/stimulating
~5% breather with PPV <1% need ETT <0.1 % need chest compressions or adrenaline
Preparation: Identify team leader Assign roles to the team members and brief the team Review case history and antenatal risk factors Counsel family Prepare environment, mother's hands, chest and abdomen perform hand hygiene, wear gloves, and check equipment
At birth: Note time of birth, Start timer. Place sheet on abdomen of mother and place wet baby on that sheet Dry - stimulate - Keep warm Change the sheet, now place the baby on abdominal skin of mama, and put sheet on baby If the baby breathes > give routine care Breathing No? > Open airway - Clear airway if obvious secretions ......if still not breathing, cut the cord and move to resuscitation area and give 5 PPVs.
When a baby cries, you give cap When a baby doesnt breathe, you open airway, clear airway if required, cut the cord, and move to resuscitation area and give 5 PPVs If chest doest rise, you do MR SOPA If chest rises, you check heart rate, every 30 seconds If heart rate <60 you turn FiO22 100%, Pass ETT, and start chest compressions, attach cardiac monitor if not already attached. If heart rate < 60 despite 60 seconds of chest compressions, you perform CARDIA, and give inj adrenaline UVC>IO>ETT>peripheral iv line. *If there is a time for passing UVC and ETT has already been passed, then give adrenaline per ETT.
Once the baby starts regular breathing during resuscitation, you give cap to the baby, and move the baby to neonatal unit for post resuscitation care that includes: Family counselling , documentation of events, STABLE, and system wise monitoring. STABLE Sugar >45 mg/dL Temperature Airway Breathing Labs (ABGs) Emotional support Monitoring for brain, heart, respiratory system, gut, renal Team briefing, and audit for continuous quality improvement (CQI)
Routine Care: (a crying baby) Dry the baby, Give cap to the baby Keep warm, skin to skin on mother's chest Cut the cord at 1 minute Encourage breast feeding within 1 hour of birth Observe the baby for warmth, breathing.
Resuscitation of baby outside delivery room (in hospital ward, or outside hospital, or in a vehicle)
Safety (scene + safety from mother's secretions etc) Call for help Birth Keep warm Secretions can be cleared by wiping off with cloth If inside hospital ward, baby may be given Oxygen via flow meter if required, Transfer the baby to NICU as soon as possible
Key updates from 8th to 9th edition Dr. M. Tauseef Omer
Umbilical Cord Management: The algorithm now explicitly includes a cord management plan in the first minute. Delayed cord clamping (DCC) is advised for at least 60 seconds (up from 30–60s) for infants not requiring immediate resuscitation. Focus on delayed cord clamping and natural transition before oxygen titration.
Cord Milking: NOW recommended for non-vigorous infants 35-42 weeks when DCC isn't possible, but not recommended for those <34 weeks due to IVH risk.
Oxygen Targets & Management: The 1-minute SpO2 target (previously 60%-65%) has been removed to prioritize initial assessments/ventilation, with the target table now starting at 2 minutes. Stronger emphasis on spO2 monitoring. Early SpO₂ values (before 2 minutes) are highly variable and not reliable for titration.
Initial FiO2 Adjustments:
>35 weeks 21% (already in 8th Ed)
32 - 34 weeks 21 - 30 % FiO2 (9th Ed)
<32 FiO2 ≥30 (Increased)
For preterm infants, the 9th edition suggests higher initial oxygen: 21–30% for 32–34 weeks, and 30% for less than 32 weeks.
Ventilation Rates & Pressures: The recommended ventilation rate has shifted to 30–60 breaths per minute (previously 40–60). Initial Positive Inflation Pressure (PIP) is set to 25 cmH20 for babies >32 weeks. For babies <32 weeks it is 20-25 cmH20. If PEEP is required it is 5cmH20.
Evaluation Timing: The timeframe to begin ventilation corrective steps if the heart rate does not increase or the chest does not rise has been extended to 15 to 30 seconds (formerly 15 seconds) to allow for a more accurate clinical assessment.
Laryngeal Mask (LMA): The LMA is now considered a primary option alongside the face mask for initial ventilation, rather than just a rescue device for failed intubation.
Corrective Steps (MR. SOPA): Providers are no longer required to follow the MR. SOPA steps in a fixed order. Instead, they should choose the most clinically appropriate step first.
Suctioning and Airway: Routine suctioning is no longer included in the standard resuscitation steps, emphasizing "suction if needed" rather than automatic suctioning.
Endotracheal Tube insertion depth: ETT Insertion Depth (Tip-to-Gum)The 8th Edition's "Initial Depth" table (based on weight and gestation) has been updated to the "Tip-to-Gum" measurement for more accuracy:
The Change: You now measure from the upper gum line to the centimeter mark on the ETT, rather than the lip. This reduces the risk of the tube shifting when the baby moves their mouth.
(ETT placement still recommended to be confirmed using colorimetric change paper blue/purple to yellow) ( Also pass OG tube 8 Fr)
The table for ETT size has been revised. Nasal-Tragus length + 1 cm is discussed as getting estimate of depth of insertion.
New Curriculum Components: The 9th edition introduces new, optional lessons for neonatal intensive care unit (NICU) resuscitation, congenital heart disease, and a specialized NRP Cardiac course.
Oral fenofibrate (10 mg/kg) acts as an effective adjunct to phototherapy in term neonates with hyperbilirubinemia, significantly reducing total serum bilirubin (TSB) levels. It works by inducing glucuronyl transferase activity, boosting bilirubin conjugation and excretion. Studies show it is safe, reduces hospital stay duration, and significantly lowers bilirubin levels within 24 to 48 hours.
No major side effects were reported with a single dose.
Apart from all that you are doing for the management of the baby, do not forget the following.
Thermoregulation: ..Maintain body temperature 98 to 99.5 degF ..Maintain a neutral thermal environment with environmental temperature between 25 to 28 degC and humidity around 60%
Maintain normoglycemia Glucose infusion rate (GIR) 4 to 6 mg/Kg/min if feeds are not yet started. May need to increase GIR as required.
Monitoring of vital signs .. Pulse rate, respiratory rate, capillary refill time, oxygen saturation, temperature, blood pressure
nCPAP Care Bundle Mechanical Ventilation Care bundle
Apnea of prematurity Care Bundle
Maintenance fluids and electrolytes: Calcium supplements on Day 0 Na and K on Day 3
Infection prevention Maintain hand hygiene Advise hygiene of hands and chest to mother
Disinfection of equipment and devices used in case of baby as per protocols of the unit.
Minimal Handling and Clustering of care provided to the baby.
Partial or complete kangaroo mother care.
Prevent oxygen toxicity Oxygen Saturation Targets: 91 to 95 % with alarms set at 89% to 96% to avoid both hypoxia and hyperoxia. Calculate oxygenation index in mechanically ventilated babies.
Neurodevelopmental care: Make nest around baby, dim lights in the night for 8 to 12 hours for circadian rhythm to develop, and to promote physiologic stability.
Pain management before procedures.
Nutrition: ..Apply buccal colostrum in oropharynx of babies who are on OG feeding or nill per oral (unless contraindicated). ..Orogastric tube feeding with expressed breast milk ..Peripheral parenteral nutrition ..Total Parenteral nutrition ..Oral breast feeding .. Human milk fortification ..Micronutrient and multivitamin supplementation
-Screening for DDH -Screening for ICH
Point of care ultrasound scan (POCUS)
Multidisciplinary care.
Written counselling of parents relating the ongoing management, prognosis, complications associated with the disease and treatment, and risks such as neurocognitive delays, etc, if any.
Discharge and follow-up -Disease specific instructions at discharge -General instructions (breast feeding advice, vaccinations advice, vitamin D3 drops (400 IU/drop) one drop daily) -Retinopathy of prematurity screening at follow-up or during admission -Screening cranial ultrasound scan at follow-up or during admission -Hearing assessment, visual assessment and complete developmental assessement --Advocacy of breast feeding, and counselling against formula feeding. --Advise mother to take her own care, balance her diet, have adequate sleep, and maintain hand hygiene. So parents may need family planning advice also.
Critical baby Care bundle It should be formulated as per case basis.
Preterm baby care bundle , review and include surfactant
Complications associated with mechanical ventilation in neonates by Dr. M. Tauseef Omer
Category
Complications
Pulmonary
Oxygen toxicity Barotrauma due to excessive pressures Volutrauma due to excessive volumes Repeated alveolar collapse and expansion (atelectotrauma) Increased inflammation (bio trauma) endotracheal tube trauma (endotrauma) high or inadequate flow (rheotrauma) All of these traumas add up in the pathophysiology of Chronic Lung Disease. Pneumothorax, pulmonary hemorrhage, atelectasis, BPD, VAP
Cardiovascular
Hypotension (high intra thoracic pressures reduce cardiac output, impaired venous return) Exacerbation of PPHN by poor oxygenation and ventilator settings
Neurological
IVH due to fluctuations in cerebral blood flow Neurodevelopmental impairment (mechanical ventilation >21 days is associated with higher risk of cerebral palsy and delayed milestones.
Gastrointestinal
Feeding intolerance, and oral aversion, NEC (due to altered perfusion and systemic stress)
Infectious
Sepsis (endotracheal tube provides a portal for infections) ventilator-associated pneumonia
Long-Term Outcomes
Growth restriction (due to prolonged illness delayed catch-up growth)
neurocognitive delay (survivors of prolonged ventilation show higher rates of learning difficulties, high mortality (studies show 40-50% mortality in mechanically ventilated babies in resource limited settings)
by Dr. M. Tauseef Omer
Point-of-Care Ultrasound (POCUS) holds immense value in the neonatal unit. It is a non-invasive, bedside utility that helps make immediate decisions.
It enables clinicians to rapidly identify both normal and abnormal findings, supporting the diagnosis of a wide range of conditions.
Applications:
Cardiac: 4 chamber view and Situs Univentricular heart Pulmonary hypertension Normal and abnormal anatomy of great vessels of heart Wall motion Ventricular septal defect Patent ductus arteriosus Pneumopericardium Pericardial effusion
Lungs: Normal signs relating lungs Pneumothorax Pleural effusion Consolidation Endotracheal tube position Chest tube position Respiratory distress syndrome vs TTN (LUSco score) Diaphragmatic assessment for weaning from ventilator or phrenic nerve injury
Gastrointestinal and KUB:
Bowel perfusion and vascularity Size of liver, spleen, kidneys, pelvis, ureters Necrotizing enterocolitis (Air in bowel wall, air in porta hepatis, aperistaltic segments of intestine) Nephrocalcinosis Guidance for paracentesis Position of umbilical lines Position of OG tube Tracheo-esophageal fistula Hypertrophic pyloric stenosis Midgut volvulus & Axis of superior mesenteric vessels Intussusception Meconium peritonitis Bladder volume Bladder wall thickness Cystic kidney diseases Renal Vein thrombosis Portal Vein thrombosis Ascites
Neurosonography: Intraventricular haemorrhage Ventricular dimensions Bedside brain perfusion HIE Raised ICP by optic sheath diameter assessement Landmarks for lumbar puncture Landmarks for ventricular tap
Peripheral vascular assess and assessment of soft tissue injury
Hemodynamic monitoring IVC collapsibility for assessment of volume status Guidance for inotropic support
Human milk fortifier (HMF) also known as breast milk fortifier (BMF) helps meet the nutritional demands of preterm and low-birth-weight infants whose needs exceed what is provided by unfortified human milk alone.
Indications:
HMF is required for all babies born <34 weeks’ gestation or those weighing <1.8 kg who are fed exclusively on mother’s expressed breast milk or donor expressed breast milk
The short term goal is adequacy of growth (weight 15 - 22 g/Kg/day), length (0.9 cm/week), OFC (0.9 cm/week). Reduced risk of retinopathy of prematurity, intraventricular haemorrhage, bronchopulmonary dysplasia ( Poor nutrition in the first weeks of life impairs lung repair and alveolar development). There is also reduced mortality.
Long term goal: Better brain growth, and hence neurodevelopmental outcomes (language, motor, cognitive). MRI studies show improved gray matter and cerebellar volumes in infants with good early growth, which correlates with stronger learning and motor skills later in childhood.
Avoid excessive catch-up growth as it is linked with obesity later in life, hypertension, and metabolic syndrome (insulin resistance, glucose intolerance, hypertension, dyslipidemia), and diabetes or ischemic heart disease later in life. Increased risk of chronic kidney disease (rapid growth stresses immature kidneys). Neurodevelopment is impaired due to altered white matter microstructure with excessive fat accumulation in the body. There is also early onset of puberty specially in girls as more adipose tissue secretes higher levels of Leptin, which stimulates hypothalamus to secrete GnRH surges earlier. Higher insulin levels also enhance ovarian and testicular steroidogenesis. So there is accelerated bone age and earlier pubertal milestones.
When to begin human milk fortification: Fortification should begin once the infant’s milk intake reaches 100 mL/kg/day.
Advancement of feeding volumes: Once HMF is introduced, the total milk volume should be advanced to a maintenance level of 165 mL/kg/day as tolerated
When to discontinue human milk fortification: 1. Discontinue when the infant reaches term age and 3.6 Kg weight, such that the baby maintains 15 to 22 g/Kg/day of weight gain. 2. If the baby is receiving >50% nutrition via preterm formula.
Continue fortification after discharge in babies <1.8 Kg, < 37 weeks, or those showing slow growth velocity.
Types of HMF:
Powder form
Liquid form
Human milk based
Bovine milk based
Bovine Milk-Based Fortifiers: These are the most commonly used in the and provide protein from either intact or hydrolyzed cow's milk. They have evolved from powdered forms to sterile liquid concentrates, which are preferred because they eliminate the risk of bacterial contamination (e.g., Cronobacter sakazakii) associated with non-sterile powders.
Human Milk-Based Fortifiers: Produced from pasteurized donor human milk, these contain only human-sourced proteins, fats, and carbohydrates. They are often used for the most immature infants (e.g., birth weight <1000 g) due to concerns about bovine protein tolerance, though they are significantly more expensive.
Nutrient Modulars: Single nutrients, such as medium-chain triglyceride (MCT) oil
Methods to determine the amount of fortification:
1. Standard Fortification: This involves adding a fixed amount of fortifier to human milk to reach a target caloric density, typically 24 kcal/oz. While easy to implement, it fails to account for the natural variability in the protein and fat content of the base human milk.
2. Adjustable Fortification: This strategy uses the infant’s metabolic response, specifically blood urea nitrogen (BUN) levels, as a guide. If the BUN is low (<9 mg/dL), it may indicate a need for more protein; if high (>16 mg/dL), protein intake is reduced. This method has been shown to improve short-term growth and later neurodevelopmental scores.
3. Targeted (Individualized) Fortification: This is the most precise method, utilizing bedside human milk analyzers to measure the exact macronutrient content of a mother's milk. Specific modular components (protein, fat, or carbohydrate) are then added to meet the infant's exact requirements. Although labor-intensive, it can lead to significantly better weight and linear growth.
Nutritional Composition and Targets
To achieve optimal growth and body composition, fortified feeds aim for specific ranges:
Protein: Preterm infants require 3.5 to 4.4 g/kg/day of protein
Energy: The target is typically 110 to 130 kcal/kg/day. In cases of chronic illness like bronchopulmonary dysplasia (BPD), requirements may rise to 150 kcal/kg/day.
Minerals: Fortification is essential for skeleton mineralization
Targets include 150–220 mg/kg/day of calcium and 75–140 mg/kg/day of phosphorus
Serum phosphorus levels should be maintained above 4 mg/dL to avoid bone resorption
Vitamins: Most HMF products are enriched with vitamins A, D, E, and K, as well as water-soluble vitamins, to prevent deficiencies and support retinal and neural maturation
Procedure for fortification:
Counsel parents about need of milk fortification, and narrate the advantages and possible adverse effects with fortification. Get written consent from parents.
Mother should wash her hands and chest. Express milk manually or with a breast pump (manual or electric) into a clean container. Container may be stored in fridge and HMF should ideally be added to milk just before feed. HMF mixed milk may be stored in refrigerator and used within 12 hours of preparation. Once added, gently swirl the container to mix the components.
Adverse effects relating the use of fortifiers: Increase in infections and NEC in infants fed fortified vs unfortified human milk.
Delayed gastric Emptying: The addition of fortifiers can delay gastric emptying and increase gastric residuals, which may be mistaken for signs of feeding intolerance or necrotizing enterocolitis (NEC).
Osmolality: Fortification increases the osmolality of human milk, which may contribute to GI distress.
Nutrient Loss: Fat and nutrients from fortified milk can adhere to feeding bags and tubing, especially during continuous feeds. Placing the infusion syringe at a 45-degree angle can help ensure even distribution
Risk of hypernatremia, metabolic acidosis, hypocalcemia, hypophosphatemia, raised or low BUN in neonates <28 weeks of gestation or <1000g weight. Therefore, weekly monitoring of these parameters is recommended.
Excessive weight gain related complications
Monitoring: Daily weight measurement. Continuous monitoring for abdominal distension, stool pattern, and feed intolerance. Weekly monitoring of serum electrolytes, renal function tests, arterial blood gases, serum calcium and serum phosphate.
Human milk fortifier available in Punjab, Pakistan.
Pre-Nan Human milk Fortifier It is in powdered form, 1 gram powder in 1 sachet. Mix 1 pack in 25 cc of expressed human milk 100% hydrolyzed whey protein: aids digestion and absorption Increases the protein content of breast milk to 0.36 grams
Available from:
Pharmacia, near FMH Lahore
And from the internal Pharmacy of Hameed Latif Hospital, Lahore.
The following breakdown provides the nutritional contents for a single 1g sachet of Nestlé PreNAN Human Milk Fortifier.
Macronutrients
Component
Amount per 1g sachet
Energy
4.3 kcal (18.2 kJ)
Protein
0.36 g (100% partially hydrolyzed whey)
Carbohydrates
0.32 g (Sugars: 0.03 g)
Total Fat
0.18 g
MCT (Medium Chain Triglycerides)
0.1 g
DHA
1.37 mg
Linoleic Acid
8.38 mg
Alpha-linolenic Acid
3.91 mg
Minerals & Trace Elements
Calcium: 18.9 mg
Phosphorus: 11 mg
Sodium: 9.18 mg
Potassium: 12.1 mg
Chloride: 8.03 mg
Magnesium: 1 mg
Iron: 0.45 mg
Zinc: 0.24 mg
Copper: 13 mcg
Manganese: 2 mcg
Selenium: 0.7 mcg
Iodine: 3.17 mcg
Vitamins
Vitamin A: 83.2 mcg RE
Vitamin D: 0.88 mcg
Vitamin E: 0.94 mg TE
Vitamin K: 1.88 mcg
Vitamin C: 4.69 mg
B-Complex: Includes B1, B2, B6, B12, Niacin, Folic Acid, Pantothenic Acid, and Biotin.
Additional Nutrients
Choline
Inositol
Taurine
L-Carnitine
Recommended intake
Premature and low birth weight infants: the standard dosage is 1 g of powder, or one single sachet, per 25 ml of breast milk. It is recommended to gradually increase the dose, starting with 1 g of PreNAN® Breast Milk Strengthener per 50 ml of breast milk. After assessing breast milk tolerance within 24 hours of administration, the amount can be increased to a full dose of 1 g of PreNAN® Breast Milk Strengthener per 25 ml of breast milk or follow hospital feeding guidelines.
How to use
When proceeding to prepare milk, wash your hands thoroughly. Immediately before use, sterilize all the items you will need (bottle, pacifier and cap, syringe). If you use frozen breast milk, thaw it gradually in the refrigerator (below 4°C). Do not thaw milk by leaving it at room temperature or thaw it in the microwave. Shake or stir the milk before pouring it into a bottle or syringe. Next, pour the measured, appropriate amount of breast milk you want to fortify into the container. Before you add Nestlé PreNAN®, warm your breast milk to body temperature. Do not heat in the microwave. A standard serving is prepared by adding powder from one sachet (1 g) for every 25 ml of lukewarm breast milk at 35-40°C. Your doctor may order you to prepare a serving with different proportions of milk and powder. Cover the container and shake it gently until the powder dissolves completely in the milk. Feed your baby immediately after preparing the milk. Prepare only one serving of milk each time. Do not store leftover milk that your baby has not accepted.
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