Pakistan Neonatal Resuscitation Course (PNRC): Pearls

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

ECG Axis- simplified assessment

 

Updates in the NRP 9th edition

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. 

(Review) Oral Fenofibrate for hyperbilirubinemia

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.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10130838/

Facets of Neonatal Care

Facets of Neonatal Care
by Dr. M. Tauseef Omer

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

Family centered care

Baby friendly hospital initiative

Mechanical Ventilation in Neonates

Complication associated with mechanical ventilation in neonates

Complications associated with mechanical ventilation in neonates

  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)

Point of Care Ultrasound Scan (POCUS)

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 Fortification

Human milk fortification
by Dr. M. Tauseef Omer


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 BMF 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 1.8 Kg weight.
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:

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 122 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.

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.

Nutritional values

100 g of powder contains: energy value 1826 kJ/ 435 kcal, fat 18.1 g (including saturated fatty acids 12.2 g, including medium-chain triglycerides (MCT) 10.9 g), carbohydrates 32 g (including sugars 2.5 g), protein 36 g, salt 2.3 g; vitamin A 8320 µg, vitamin D 88 µg, vitamin E 94 mg, vitamin K 188 µg, vitamin C 469 mg, thiamine (B1) 3.5 mg, riboflavin (B2) 4.7 mg, niacin 35 mg, vitamin B6 3.1 mg, folic acid 938 µg, vitamin B12 4.7 µg, biotin 82 µg, pantothenic acid 16 mg; sodium 918 mg, potassium 1210 mg, chlorine 803 mg, calcium 1890 mg, phosphorus 1095 mg, magnesium 100 mg, iron 45 mg, zinc 24 mg, copper 1.3 mg, manganese 0.15 mg, fluorine <0.06 mg, selenium 70 µg, chromium <23 µg, molybdenum <20 µg, iodine 317 µg; linoleic acid 838 mg, ?-linolenic acid 391 mg, DHA (docosahexaenoic acid) 137 mg, choline 202 mg, inositol 108 mg, taurine 47 mg, L-carnitine 62 mg. Osmolarity 339 mOsm/l.
A 100 kcal serving contains: energy value 422 kJ/ 100 kcal, fat 4.2 g (including saturated fatty acids 2.8 g, including medium-chain triglycerides (MCT) 2.5 g), carbohydrates 7.5 g (including sugars 0.6 g), protein 8.2 g, salt 0.53 g; vitamin A 1915 µg, vitamin D 20 µg, vitamin E 22 mg, vitamin K 43 µg, vitamin C 108 mg, thiamine (B1) 0.8 mg, riboflavin (B2) 1.1 mg, niacin 8.1 mg, vitamin B6 0.7 mg, folic acid 216 µg, vitamin B12 1.1 µg, biotin 19 µg, pantothenic acid 3.8 mg; sodium 211 mg, potassium 278 mg, chlorine 185 mg, calcium 435 mg, phosphorus 252 mg, magnesium 23 mg, iron 10 mg, zinc 5.4 mg, copper 0.3 mg, manganese 0.035 mg, fluorine <0.014 mg, selenium 16 µg, chromium <5.3 µg, molybdenum <4.6 µg, iodine 73 µg; linoleic acid 193 mg, ?-linolenic acid 90 mg, DHA (docosahexaenoic acid) 32 mg, choline 46 mg, inositol 25 mg, taurine 11 mg, L-carnitine 14 mg. Osmolarity 339 mOsm/l.
1 sachet (1 g of powder) contains: energy value 18.2 kJ/ 4.3 kcal, fat 0.18 g (including saturated fatty acids 0.12 g, including medium-chain triglycerides (MCT) 0.1 g), carbohydrates 0.32 g (including sugars 0.03 g), protein 0.36 g, salt 0.02 g; vitamin A 83.2 µg, vitamin D 0.88 µg, vitamin E 0.94 mg, vitamin K 1.88 µg, vitamin C 4.69 mg, thiamine (B1) 0.04 mg, riboflavin (B2) 0.05 mg, niacin 0.35 mg, vitamin B6 0.03 mg, folic acid 9.38 µg, vitamin B12 0.05 µg, biotin 0.82 µg, pantothenic acid 0.16 mg; sodium 9.18 mg, potassium 12.1 mg, chlorine 8.03 mg, calcium 18.9 mg, phosphorus 11 mg, magnesium 1 mg, iron 0.45 mg, zinc 0.24 mg, copper 0.01 mg, manganese 0.002 mg, fluorine <0.0006 mg, selenium 0.7 µg, chromium <0.23 µg, molybdenum <0.2 µg, iodine 3.17 µg; linoleic acid 8.38 mg, ?-linolenic acid 3.91 mg, DHA (docosahexaenoic acid) 1.37 mg, choline 2.02 mg, inositol 1.08 mg, taurine 0.47 mg, L-carnitine 0.62 mg. Oosmolarity 339 mOsm/l.

Updates on therapeutic hypothermia in neonates (Clinical report 2026 AAP )Summary by Dr Tauseef Omer

 Updates on therapeutic hypothermia in neonates (Clinical report 2026 AAP )Summary by Dr Tauseef Omer

AAP 2026 Clinical Report: Updates on the management of therapeutic hypothermia in neonates

AAP 2026 Clinical Report: Updates on the management of therapeutic hypothermia in neonates

Summary by Dr. M. Tauseef Omer

Full link

Over 2014 guidelines on the management of therapeutic hypothermia in neonates, the American Academy of Pediatrics has published a clinical report in 2026.

Re-emphasis:

1. Analyses of aggregate data from randomized-controlled trials, as well as data from registries, indicate that moderate therapeutic hypothermia with a target temperature of 33.5 °C initiated within 6 hours of birth and continued for 72 hours is a safe and effective neural rescue strategy for infants with moderate-to-severe HIE who are born at or greater than 36 weeks’ gestation.

2. Infants offered therapeutic hypothermia should meet inclusion criteria from published clinical trials such as (CoolCap Selective head cooling, NICHD Whole body cooling, TOBY Whole body cooling, neo-neuro whole body cooling, ICE trial, Selective head cooling with mild systemic cooling in China) , however, sentinel event is not necessary to initiate therapeutic hypothermia. 

Eligibility criteria include the following:

• Evidence of a peri-partum hypoxic-ischemic event based on biochemical criteria.

  1. Providers should advocate for the delivery team to draw cord blood gases for all depressed neonates and to facilitate the identification of neonates with HIE who may benefit from cooling.

  2. If a cord gas cannot be obtained, a blood gas during the first hour or as soon as possible after birth should be obtained.

• Evidence of moderate-to-severe encephalopathy by neurological exam (as below) or seizures is required. If moderate or severe encephalopathy is present and biochemical and clinical criteria are borderline without another identifiable cause, clinicians may consider therapeutic hypothermia.
  
  

  
  
  `
  
  There is limited evidence regarding the safety and effectiveness of therapeutic hypothermia for infants born at 35 0/7 to 35 6/7 weeks’ gestation. And this should be discussed with parents.
  
  May consider cooling up to 24 hours of life, but there is limited benefit in such cases, and this should be discussed with parents.
  
  There is insufficient evidence to support the use of therapeutic hypothermia for infants with mild HIE
  
  In all cases of possible HIE, even when therapeutic hypothermia is not administered, hyperthermia should be avoided.
  
  Erythropoietin (EPO) does no offer any additional benefit to date. Previous studies explored its neuroprotective and anti-apoptotic effects. So, therapeutic hypothermia and EPO is not advised outside research settings
  
  Medical centers offering therapeutic hypothermia should be capable of providing comprehensive clinical care, including mechanical ventilation; physiologic (vital signs, temperature) and biochemical (blood gas) monitoring; neuroimaging, including MRI prior to hospital discharge; continuous neuromonitoring and seizure detection with continuous EEG (preferred) or with aEEG; neurologic consultation accessible at all times, at minimum via telephone or telemedicine; family support; and a system in place for monitoring longitudinal neurodevelopmental outcomes.

Previously, we followed this criteria:

NICHD (National Institute of Child Health and Human Development) whole-Body Cooling

GA ≥36 weeks and ≤6 h of age

Moderate or severe encephalopathy 

Non syndromic baby

Acidosis
pH ≤7.00 or base deficit ≥16 mmol/L on umbilical cord or any blood sample obtained within 60 min of birth
OR
If blood gas is not available or pH 7.01 to 7.15 or base deficit 10 to 15.9 mmol/L on blood sample obtained within 60 min of birth.

PLUS
2 additional criteria:

History of an acute sentinel/perinatal event (eg, cord prolapse, fetal heart rate decelerations)
AND
Need for assisted ventilation at birth and continued for 10 min
OR
Apgar score ≤5 at 10 min after birth 

Pneumocephalus in a neonate, an interesting case report by Maria Stefano et al.

Video

Pneumocephalus in a neonate, an interesting case report by Maria Stefano et al.

Preventing central line associated blood stream infections (CLABSI) in neonatal units

 Several factors increase a neonate's risk of developing a CLABSI:

• Patient-Related: Prematurity and low birthweight are significant risk factors. Infants requiring a PICC are at increased risk due to poor skin integrity, an immature immune system, and multiple invasive procedures1.

• Device-Related: Use of Central Venous Catheters (CVCs), including peripherally inserted central venous catheters (PICCs) and umbilical catheters, with risk increasing with the duration of central venous access.

• Medication-Related: Prolonged parenteral nutrition and the use of IV lipid emulsions are known risk factors, as lipid emulsions can potentiate microbial growth and impair host defenses. Postnatal administration of corticosteroids also increases risk.

Common Pathogens in CLABSI

• Coagulase-Negative Staphylococci (CoNS): These are the most predominant pathogens, accounting for over 50% of infections. Staphylococcus epidermidis is a common example8. CoNS are lower-virulence pathogens but can form biofilms on devices.

• Gram-Negative Organisms: Account for approximately 20% of infections.

• Staphylococcus aureus: Accounts for 4%–9% of CLABSIs1. Methicillin-resistant S. aureus (MRSA) is an increasing concern.

• Enterococcus species: Account for 3%–5% of infections.

• Candida species (Fungi): Account for approximately 10% of infections1. Malassezia furfur is an unusual lipophilic yeast that can cause catheter-related infections in infants receiving intralipid therapy.

Management and Prevention Strategies

Prevention is paramount in controlling CLABSIs. Key strategies include:

• Hand Hygiene: The single most important strategy for avoiding transmission of contagions in the NICU.

• Infection Control Bundles: Most institutions adopt "care bundles" of practices for central line insertion and maintenance that have proven effective in reducing CLABSI rates12. These bundles were disseminated through collaboratives like the California Perinatal Quality Care Collaborative (CPQCC).

    ◦ During Catheter Insertion:

        ▪ Hand hygiene.

        ▪ Aseptic technique.

        ▪ Skin antisepsis: Chlorhexidine is the preferred antiseptic for catheter site care over povidone-iodine13. The solution must be allowed to air-dry completely.

        ▪ Sterile dressing technique.

    ◦ During Catheter Maintenance:

        ▪ Daily review of line necessity: CVCs should be removed as soon as they are no longer necessary. Line stewardship focuses on this daily review.

        ▪ Daily inspection of the insertion site and dressing: Opaque dressings should be removed and the site inspected visually if there are signs of possible CLABSI.

        ▪ Standardization of practices around IV tubing changes.

        ▪ "Scrubbing the hub" of the central line to minimize contamination.

        ▪ Replacing transparent dressings on short-term central line sites at least every 7 days, with consideration for pediatric patients where the risk of dislodging may outweigh the benefit.

        ▪ Some NICUs have incorporated bathing strategies for patients with central lines.

• Antibiotic Stewardship: Minimizing indiscriminate use of antibiotics is mandatory as it has been associated with increased nosocomial sepsis. Prophylactic antibiotics for central lines are generally not recommended due to limited data and concerns about resistance and side effects.

• Breastfeeding: Promotion of fresh maternal milk is considered a key step in preventing NICU infections due to its anti-infective properties.

• Probiotics: May help restore gut immune function and potentially reduce the risk of late-onset sepsis (LOS).

• Antifungal Prophylaxis: Specific antifungal prophylaxis with fluconazole has been associated with a significant reduction in invasive fungal infections and is recommended in NICUs with high rates of invasive candidiasis.

Treatment of CLABSI

• Empiric Antibiotic Therapy: Treatment is often initiated before a definitive causative agent is identified. For nosocomial sepsis, which includes CLABSIs, the flora of the NICU must be considered. Vancomycin plus an aminoglycoside (e.g., gentamicin or amikacin) is usually begun for staphylococcal coverage. Some NICUs use cefazolin or nafcillin instead of vancomycin for staphylococcal coverage.

• Catheter Removal:

    ◦ For CLABSIs due to gram-negative or fungal pathogens, catheters should be removed as early as possible.

    ◦ For CLABSIs caused by CoNS, catheter removal should occur if culture results are persistently positive or if the patient’s condition is unstable17. Delaying CVC removal for 3 to 5 days after starting anticoagulant therapy may be considered due to emboli risk, though this is controversial.

• Duration of Therapy: The length of antibiotic therapy is not data-driven, but 7 to 10 days is a common duration of treatment. Inflammatory markers like C-reactive protein (CRP) may be used to guide the length of therapy.