Chapter 12: The Newborn – Resuscitation, SGA/LGA, Preterm Care

Resuscitation (NRP) · SGA (IUGR) · LGA (macrosomia, IDM) · Preterm infant: developmental care, fluid balance, sodium/potassium, thermoregulation, enteral nutrition
📌 Core principles: NRP algorithm: Airway, Breathing, Circulation. SGA infants at risk for hypoglycemia, polycythemia, hypothermia. LGA often maternal diabetes → hypoglycemia, birth trauma. Preterm care: humidified incubator, fluid restriction (insensible losses high), early minimal enteral feeds, fortification.

📖 Core summary: resuscitation, SGA/LGA, preterm care

🫁 Neonatal resuscitation (NRP)
Warm, dry, stimulate. Assess tone, breathing, heart rate. PPV if apnea or HR <100. Chest compressions if HR <60 despite adequate ventilation. Epinephrine if HR <60 after compressions. Oxygen titration.
📏 Small for gestational age (SGA)
Weight <10th centile. Causes: placental insufficiency, maternal hypertension, infection, smoking. Risks: hypoglycemia, polycythemia, hypothermia, thrombocytopenia, NEC. Early feeding, glucose monitoring.
📈 Large for gestational age (LGA)
Weight >90th centile. Causes: maternal diabetes (IDM), genetic. Risks: birth trauma (shoulder dystocia, clavicle, brachial plexus), hypoglycemia, polycythemia, hyperbilirubinemia. Monitor glucose, examine for trauma.
🧸 Preterm infant – developmental care
Minimize light/noise, positioning (nesting), facilitated tucking, skin‑to‑skin (kangaroo care), cluster care, reduce painful procedures. Improves growth, stability, neurodevelopment.
💧 Preterm – fluid & electrolytes
High insensible losses (incubator humidity 70‑90%). Start 80‑100 mL/kg/d, adjust based lytes, weight. Na+ supplementation after diuresis (day 3‑5). Monitor K+ (risk hyperkalemia day 1‑2).
🍼 Preterm – enteral nutrition
Start trophic feeds (10‑20 mL/kg/d) day 1‑2. Use breast milk (fortify if <1500g) or preterm formula. Advance 20‑30 mL/kg/d. Monitor for NEC. Probiotics may reduce NEC risk.
🌡️ Preterm – thermoregulation
Incubator or radiant warmer. Target axillary temperature 36.5‑37.5°C. Humidity initially high (70‑90%), wean as skin matures. Avoid cold stress (hypoglycemia, acidosis, apnea).
📊 Key preterm monitoring: Daily weight, strict I/O, serum electrolytes (Na, K, Ca, glucose), calorie counts. Fortify milk when full feeds achieved.

🔍 Approach to resuscitation, SGA/LGA, preterm care

1
Resuscitation (delivery room) – Warm, dry, stimulate. Evaluate HR, respiratory effort. PPV at 40‑60 breaths/min. If HR <60 despite PPV → chest compressions (3:1 ratio) + 100% oxygen (taper if SpO₂ targets met).
2
SGA infant initial care – Measure glucose within 1h (target >45 mg/dL). Monitor Hct (polycythemia). Keep warm (hypothermia common). Start early feeds.
3
LGA/IDM infant – Glucose screen at 1h, then before feeds for 12‑24h. Exam for clavicle fracture, brachial plexus injury. Large size may cause birth asphyxia.
4
Preterm (<34 wk) initial stabilization – Polyethylene bag/wrap to reduce heat loss. Respiratory support (CPAP, surfactant). Place in incubator (70‑90% humidity).
5
Fluid & electrolyte management (preterm) – Start D10W with maintenance Na+ after diuresis (day 3‑5). Weigh daily. Target urine output 2‑4 mL/kg/h. Monitor Na, K, Ca, glucose.
6
Enteral feeding advancement – Start trophic feeds (10‑20 mL/kg/d) day 1. Advance 20‑30 mL/kg/d as tolerated. Fortify human milk for VLBW.

📋 Stepwise management protocols

1
NRP algorithm (initial steps) – Warm, dry, stimulate, position, clear airway if needed. Reassess. Proceed to PPV if apnea/gasping or HR <100.
2
Preterm thermoregulation bundle – Increase delivery room temperature to 25‑26°C. Use plastic wrap/bag for <28 wk. Incubator with servo‑control, humidity 70‑90% for first days.
3
Fluid prescription (preterm, day 1) – 80‑100 mL/kg/d D10W (no electrolytes). Monitor glucose. Add sodium (2‑4 mEq/kg/d) after diuresis (when weight loss 5‑10%). Potassium added once urine output established.
4
Enteral feeding protocol (VLBW) – Day 1: trophic feeds (breast milk or preterm formula) 0.5‑1 mL q3‑6h. Advance by 20‑30 mL/kg/d. Fortify human milk when enteral intake >100 mL/kg/d.
5
Developmental care interventions – Nesting (rolled blankets), minimal handling, clustered cares, quiet times, cycled lighting, kangaroo care (skin‑to‑skin) when stable.
6
SGA hypoglycemia protocol – Glucose <45 mg/dL: feed immediately if asymptomatic. IV D10W 2 mL/kg bolus if symptomatic or unable to feed. Monitor glucose q1h until stable.
⚡ Key reminder: Preterm infants have high insensible water loss (especially <28 wk). Humidity reduces losses. Hyponatremia after day 3‑5 suggests sodium supplementation needed.

🧠 Reflex prompts – resuscitation, SGA/LGA, preterm care

🫀 Newborn with HR 50, apnea despite 30 sec PPV. Next step:
Chest compressions (3:1 ratio, 90 compressions + 30 breaths/min). Ensure effective ventilation.
📏 SGA infant with Hct 70%. Risk & management?
Polycythemia → hyperviscosity (hypoglycemia, jaundice, thrombosis). Partial exchange transfusion if symptomatic.
📈 LGA infant of diabetic mother – early glucose screening:
Check glucose at 1h, then before feeds for 12‑24h. Treat if <45 mg/dL.
💧 Preterm infant (24 wk) day 2: weight loss 12% from birth, sodium 148 mEq/L. Cause?
High insensible water loss (low humidity). Increase humidity to 80‑90%, adjust fluids upward.
🍼 Minimal enteral (trophic) feeding benefit:
Stimulates gut maturation, reduces NEC, improves feeding tolerance. Start day 1 even in VLBW.
🌡️ Incubator humidity for <28 wk preterm:
Start at 80‑90% first 3‑5 days, then wean as skin matures. Reduces transepidermal water loss.