"Neonatology" — Practice

Question 1

What is the primary indicator of effective ventilation during newborn resuscitation?

Accepted Answer

B

Question 2

Jaundice appearing within the first 24 hours of life is

Accepted Answer

B

Question 3

A term baby born by elective caesarean has tachypnoea from birth with mild grunting, and the radiograph shows perihilar streaking and fluid in the horizontal fissure. Diagnosis?

Accepted Answer

C

Question 4

Which organism most commonly causes early-onset neonatal sepsis in India?

Accepted Answer

B

Question 5

According to current WHO guidance, when should kangaroo mother care be started in a stable-appearing 1.4 kg preterm infant?

Accepted Answer

B

Question 6

A baby is cyanosed at 6 hours with saturations of 70 percent that do not rise on 100 percent oxygen. Breath sounds and chest radiograph are unremarkable. Explain what this indicates and what must be done.

Accepted Answer

Failure of saturation to rise on 100 percent oxygen indicates a right-to-left shunt rather than lung disease.

The reasoning is mechanical. In lung disease, blood still passes through the pulmonary capillaries, so raising the inspired oxygen concentration raises the alveolar partial pressure and improves oxygenation to some degree. In a right-to-left shunt, a fraction of the cardiac output bypasses ventilated lung entirely, and no amount of inspired oxygen can act on blood that never meets an alveolus.

Two causes must be separated. Persistent pulmonary hypertension of the newborn is failure of the normal fall in pulmonary vascular resistance, so blood continues to shunt across the foramen ovale and ductus. Cyanotic congenital heart disease produces the same physiology structurally.

Comparing pre-ductal and post-ductal saturations, meaning right hand against foot, distinguishes ductal shunting and is done immediately.

If a duct-dependent lesion is suspected, prostaglandin E1 is started to keep the ductus open. This is counterintuitive but essential, because in these lesions the duct is the only route maintaining pulmonary or systemic flow, and its closure is fatal.

Question 7

A term baby in an Indian tertiary unit has moderate hypoxic ischaemic encephalopathy at 4 hours of age. Should therapeutic hypothermia be started? Justify.

Accepted Answer

No. Therapeutic hypothermia is standard care for moderate or severe encephalopathy in high-income settings but is not recommended in India.

The HELIX trial randomised infants with moderate or severe neonatal encephalopathy in seven tertiary units in India, Sri Lanka and Bangladesh. It found no reduction in the combined outcome of death or disability at 18 months, and a significant increase in death alone.

What makes the result decisive is the quality of the participating centres. They had invasive ventilation, cardiovascular support, 3 Tesla magnetic resonance imaging and state-of-the-art servo-controlled cooling devices. This was not a trial of improvised cooling in a resource-poor ward. If the intervention was harmful under those conditions, it cannot be assumed safe in less well-equipped settings.

The likely explanation lies in the differing nature and timing of the insult. Much of the injury in these populations appears to be antenatal or of longer duration, so the therapeutic window on which cooling depends may already have closed by the time of randomisation.

Management is therefore supportive: strict normothermia, seizure control, maintenance of glucose and electrolytes, and attention to the kidney, myocardium, liver and gut, all of which are injured by the same insult.

Question 8

A breastfed term baby is still jaundiced at 3 weeks, thriving and gaining weight well. What must be done and why is it not enough to observe?

Accepted Answer

The bilirubin must be fractionated into conjugated and unconjugated components before anything else is concluded.

The likely diagnosis is breast milk jaundice, which is unconjugated, appears after the first week, persists for several weeks in a thriving breastfed baby, and requires no treatment other than continued breastfeeding. It is common and benign.

Observation is nonetheless unsafe, because the appearance of a well, thriving, jaundiced baby is shared by biliary atresia. Conjugated hyperbilirubinaemia is always pathological, and biliary atresia is the diagnosis that cannot be missed.

The reason urgency attaches to it is surgical. The Kasai portoenterostomy has a far better outcome when performed early, and the window is measured in weeks. A baby whose jaundice is attributed to breast milk and reviewed in a month may have passed the point at which surgery can succeed.

Stool and urine colour must be checked at the same time. Pale, clay-coloured stools with dark urine indicate obstructed bile flow, and this examination costs nothing.

This is why the rule is stated as a time limit rather than a clinical impression: jaundice persisting beyond 14 days in a term infant is fractionated, regardless of how well the baby looks.

Question 9

Why is neonatal sepsis described as the exception to the transitions framework, and what practical rule follows?

Accepted Answer

Because sepsis does not correspond to any single transition and instead imitates the failure of all of them.

Each transition failure has a recognisable signature. Surfactant deficiency produces respiratory distress. Failure of the pulmonary pressure reversal produces oxygen-unresponsive cyanosis. Inadequate glycogen produces hypoglycaemia. Immature conjugation produces jaundice. Absent brown fat produces hypothermia. Each points somewhere specific.

Sepsis produces any of these. A septic newborn may present with respiratory distress indistinguishable from surfactant deficiency, with hypothermia, with hypoglycaemia, with jaundice, or with nothing more than reduced feeding and reduced activity.

The practical rule that follows is that sepsis is considered alongside whatever else is being treated, not after that diagnosis has failed. Empirical antibiotics are started while the alternative is being pursued, because the cost of unnecessary antibiotics for 48 hours is far lower than the cost of a 12-hour delay in a septic neonate.

The corollary is that the mother's observation carries genuine diagnostic weight. A report that the baby is feeding less well or is less active than yesterday is often the earliest and sometimes the only sign, and it precedes anything a clinician can measure.

Practice — "Neonatology"

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