NICU PROTOCOLS

PARAMITHA CHILDREN HOSPITAL,

KOMPALLY, HYDERABD

Prepared & approved by

Dr. Abhishek PV

Dr. Sri Harsha

Dr. Venkat Reddy Kallem

Dr. Shravani Maram

Admission criteria:
1) Gestational Age < 34 weeks or Birth weight < 1800 grams or > 4000 grams
2) Any sick neonate requiring intensive care monitoring
3) Neonate with congenital malformations
4) Jaundice within 24 hours requiring intensive phototherapy, exchange transfusion
5) Jaundice ≥ 16 mg/dl requiring intensive phototherapy
6) Neonates with hypoglycemia, hypothermia, feeding difficulty, seizures, sepsis

Discharge criteria:
1) PMA of >33 weeks and weight >1500 grams
2) Primary disease is passive
3) Apnea free for 7 days
4) Consistent weight gain of 15 g/kg/day for at least 3 days
5) On room air, hemodynamically stable
6) Able to maintain temperature in crib care
7) Accepting Direct Breast Feeding or spoon feeds
8) Mother is confident in baby care
 Respiratory care of the neonate
Respiratory distress: presence of at least 2 of the following 3 features
1) Tachypnea (RR >60/min)
2) Retractions (intercostals and subcostal)
3) Expiratory grunt
Etiology
1. RDS – prematurity <34 weeks, no or partial steroid cover, APH, IDM
2. Pneumonia – PPROM / PROM
3. TTNB – late preterm or term, LSCS
4. MAS – MSL, evidence of fetal distress
5. PPHN – asphyxia, MSL
6. Pneumothorax – need for resuscitation, MSL, CPAP support, intubation and PPV
7. Congenital malformations (TEF, CDH, CPAM) - polyhydramnios, pooling of secretions,
coiling of OG tube in esophagus (TEF), scaphoid abdomen and heart sounds on right side
(CDH)
8. Aspiration pneumonia
9. Laryngomalacia, vascular malformations, subglottic stenosis – stridor, suprasternal
retractions, tachypnea
10. Pain, polycythemia, anemia
Management plan
Initial management of a baby with respiratory distress
1) Check temperature, heart rate, peripheral pulses, CFT, Spo2, NIBP, GRBS
2) Assess the severity of respiratory distress by Silverman Anderson score (preterm neonate) or
Downe score (term neonate)
3) Check bilateral air entry, heart sounds, murmur, transillumination
4) Check for patency of upper airway (look for stridor, supraclavicular and suprasternal
retractions, pass an OG tube to rule out TEF)
5) Look for pallor, plethora, meconium staining, mottling, alertness, tone, and activity
6) Initial mode of respiratory support
 Preterm (<34 weeks) with RD – Early CPAP with PEEP 5-7, Fio2 30%; Surfactant if
PEEP ≥ 5, Fio2 ≥ 30%
  Late preterm / Term with RD – HFNC / CPAP with PEEP 5-7, Fio2 30%
7) Secure an IV access, start iv fluids
8) To send blood culture and start antibiotic if risk factors for EOS / pneumonia
9) Supportive care: to maintain Euglycemia, Normothermia, correct electrolyte imbalance
10) Indications of intubation and mechanical ventilation
a) Worsening respiratory distress requiring (PEEP > 7, FIO2 > 60% (CPAP failure)
b) Metabolic acidosis (pH <7.2 with BE >-10),
c) Respiratory acidosis (Paco2 >55 mmHg with pH <7.2)
d) Poor respiratory efforts
e) PPHN
f) shock
g) pulmonary hemorrhage
h) recurrent apnea requiring B&M ventilation
Continuous Positive Airway Pressure (CPAP)
Indications
1. Respiratory distress
2. Apnea not responding to medication
Initial settings
1. Initial pressure of 5 cm of water (titrated as per retractions, maximum 7 cm of H20)
2. Flow of 5litres per minute
3. FiO2 ranging from 0.3 to 0.5 (titrated based on SpO2 maximum 0.5)
4. Humidification to be maintained at 37 0C.
5. CPAP pressure and FiO2 should be adjusted depending on clinical assessment of the neonate
and maintenance of oxygen saturation between 90-95%.
Monitoring
1. Flow rate, Fio2, pressure (settings), bubbles in the water chamber, humidifier temperature,
water level in humidifier and bubble chamber, tubing below the infant level (machine end);
2. Interface size, fixation, distance between interface and infant nostrils, nasal injury (patient
end)
Weaning
1. PEEP ≤ 5 cm of H2O, Fio2 ≤30%
2. Hemodynamically stable
3. Good respiratory efforts
4. Apnea free for 24 hours

Mechanical ventilation
Indications
1. Worsening respiratory distress requiring (PEEP > 7, FIO2 > 60% (CPAP failure)
2. Metabolic acidosis (pH <7.2 with BE >-10),
3. Respiratory acidosis (Paco2 >55 mmHg with pH <7.2)
4. Poor respiratory efforts
5. PPHN
6. Shock
7. Pulmonary hemorrhage
8. Recurrent apnea requiring B&M ventilation
Initial settings
1. ET tube size:
a. <1000grams – 2.5mm
b. 1000-2000 grams- 3.0 mm
c. 2000-3000grams- 3.0 -3.5 mm
d. 3000-4000grams- 3.5 mm
2. ET tube position: In CXR 0.5 cm above carina or at T2-T3 level
3. Ventilator settings: SIMV mode / Assist control mode
4. PIP: To achieve adequate chest rise and oxygenation (Pao2 60-80mmHg)
5. PEEP: According to disease pathology (apnea – 4 cm H20, RDS – 5 cm H20, MAS/
Pneumonia – 4-5 cm H20). Titrated as per retractions and lung expansion on CXR (6-8
spaces is adequate)
6. FiO2: titrated to maintain spo2 91-95%
7. Rate – 40/min
8. Ti – 3 times the time constant
9. VG- 4-5 ml/kg
10. Humidification to be maintained at 37 0C.
Monitoring
1. Chest rise – should be just visible chest rise
2. Retractions – should be minimal or no retractions
3. Inflation of lungs on chest x ray
4. Perfusion – peripheries should be warm and pink, CFT ≤ 3 seconds, pulses – well felt, urine
output 1-3 ml/kg/hour, heart rate
5. Bilateral air entry
6. Monitor: heart rate (140-160/min), spo2 ( 91-95%) , NIBP /IBP as per Zubrow BP centiles
7. ABG – pH ≥7.25, Paco2- 40-60 mmHg, PaO2- 50-70 mmHg.
Weaning
1. Decrease PIP by 1 cm of H20 every 2-4 hours
2. PEEP ≤ 5 cm of H2O, Fio2 ≤30%
3. Hemodynamically stable
4. Good respiratory efforts

Ventilator Associated Pneumonia (VAP) care bundle

Care practices to be followed for neonates on ventilatory support
1. Hand hygiene with soap and water
2. Wear mask, cap, and gloves
3. ANTT during intubation
4. 300 elevation of the head end
5. Frequent change in position
6. Heated humidified inspired gas at 370c and 100% relative humidity
7. Use of distilled water in the humidifier
8. No condensation in the inspiratory limb
9. Drain condensate to water trap
10. Ventilator circuit should be parallel to baby and in dependent position
11. 2 persons while suctioning, follow ANTT
12. Oral suction before ET suction
13. Use 2 separate tubing for ET and oral suctioning
14. Oral coating with colostrum
15. Avoid antacids
16. Encourage enteral feeds if possible
17. Prevent unplanned extubation
18. Wean off ventilation as soon as possible

VAP care bundle

CLABSI care bundle
 Management of Persistent Pulmonary Hypertension (PPHN)
Features suggestive of PPHN:
1) History of Meconium-stained liquor, asphyxia, severe RDS, CDH, pneumonia
2) High Fio2 requirement
3) Preductal and post ductal Spo2 difference ≥ 4%, lability in saturation
4) 2D echo s/o dilated RA, RV; deviation of interventricular septum to left; poor contractility;
TR jet, PDA right to left shunt
Management:
1. Correct hypothermia, hypoglycemia, hypocalcemia
2. Monitor pre and post ductal spo2
3. Titrate Fio2 depending on Spo2
4. Check ABG for respiratory and metabolic acidosis, oxygenation index
5. Antibiotics if risk factors present
6. Lung recruitment – intubation and mechanical ventilation
Indications
1. Fio2 ≥ 50% on CPAP/ NIMV
2. Acidosis in ABG (Paco2 ≥50 mmHg, BE ≥10)
3. Signs of shock
Ventilation strategy
1. Lung protective ventilation
2. Maintain pH- ≥7.25, Paco2- 40-60 mmHg, PaO2- 50-70 mmHg
3. HFO if conventional mechanical ventilation fails
7. Cardiac support
If cardiac dysfunction present – Dobutamine 2.5 - 10mic/kg/min, Milrinone 0.33- 0.99
mic/kg/min
Dopamine or noradrenaline if hypotension present due to dobutamine and milrinone
Sildenafil 0.4 mg/kg loading followed by 1.6mg/kg/day infusion (as a second line agent for
pulmonary vasodilatation)
8. Inhaled Nitric Oxide (iNO)
Indication
1. Refractory PPHN with OI > 25 for 6 hours
 Prerequisite
1. Adequate lung recruitment
2. Cardiac dysfunction corrected
Initial settings
1. iNO to be started with 20ppm
Monitoring
1. ABG repeated after 1 hour of initiation
2. Response to iNO – decrease in OI by 20%, increase in Pao2 by 20%.
3. Monitor methemoglobinemia ( ≤ 2% is normal)
Weaning
1. If Fio2 is ≤ 60% and Pao2 > 60%
2. Wean from 20ppm to 5 ppm in 5 ppm steps every 2- 4 hours depending on stability
3. If patient is stable on 5 ppm wean by 1-2 ppm steps every 6-12 hourly
4. If patient stable at 1 ppm stop iNO – expect an increase in Fio2 by 15%
9. ECMO – to be considered if OI > 40
 Surfactant Replacement Therapy (SRT)
Indication
1. Preterm <34 weeks, on CPAP with PEEP ≥ 5 and /or FiO2 ≥ 30%
2. Late preterm with RDS (CXR s/o RDS, on CPAP PEEP ≥ 5 and/or FiO2 ≥ 30
3. MAS on mechanical ventilation with Fio2 ≥ 50%, MAP ≥ 8cm of H20 ( based on clinician
decision)
Types of Surfactant
1. Survanta (Beractant – Minced lung extract) – 4ml/kg
2. Curosurf (Poractant alpha – Minced lung extract) – 2.5ml/kg
3. Neosurf (Bovine Lipid Extract Surfactant – Lung lavage extract) – 5ml/kg
Technique of administration
1. IN-SUR-E: intubation surfactant administration and extubation
Monitoring & complications
1. Improvement in saturation (titrate FiO2)
2. Pneumothorax due to sudden increase in compliance of lung (decrease PEEP)
3. Pulmonary hemorrhage (Rare)
 Management of Apnea
Apnea in a newborn is defined as cessation of breathing for more than 20 seconds or lesser
duration if associated with bradycardia and or desaturation. More common in preterm ≤ 32
weeks of gestation. Based on the mechanism of occurrence apneas are classified into three types,
central, obstructive, and mixed type. Out of the three mixed variety is most common.
Stepwise management of apnea
1. Look for breathing efforts, neck position, oral and nasal secretions, SPO2, HR
2. Check GRBS, Temperature
3. Tactile stimulation, suctioning if required, optimal neck position
4. Consider starting caffeine if gestation ≤ 34 weeks
5. Monitor HR, SPO2, breathing efforts, color
6. If the HR, SPO2, Color improved and breathing efforts present – close monitoring for further
apneas and further evaluation
7. Correct hypoglycemia, hypothermia, electrolyte imbalance (if any)
8. If No improvement in HR, SPO2, breathing efforts
a. PPV for 30 seconds
b. If improved – close monitoring for further apneas and further evaluation
c. If no improvement the continue PPV for 30 more seconds
i. If improved – close monitoring for further apneas and further evaluation
ii. If no improvement, then consider noninvasive ventilation and if failed
then intubation and mechanical ventilation with appropriate settings
9. Evaluation: septic screen, electrolytes, calcium, GRBS, 2D echo for PDA, NSG for IVH,
CXR
 Caffeine
Indication
1. ≤ 32 weeks and ≤ 1250 grams
2. ≤ 34 weeks with apnea
Dose
20 mg/kg loading followed by maintenance 5 mg/kg/day once daily
Weaning
1. Off respiratory support and apnea free for 7 days
2. 36 weeks of PMA
3. In ≤ 28 weeks, prolonged oxygen support and BPD continued till 40-44 weeks PMA
 Hospital breastfeeding policy
1. Breast feeding is encouraged in all babies with birth weight more than 1800 gram or more
than 34 weeks of gestation as per the maturation skills
2. Our team of doctors and nurses will help the mothers in positioning and attachment skills,
identifying feeding cues and other skills necessary for breast feeding
3. All mothers will be counselled regarding the advantages of the breast feeding and mothers
who are not willing to breast feed will be educated regarding the risks of other available
feeding options
4. Using pacifiers, dummies, feeding bottles and teats is strongly prohibited
5. Infants who are not able to breast feed from their mothers will be given expressed breast milk
as the first option and if breast milk is not available then formula milk will be given. Reason
for all replacement feeds will be documented and audited time to time
6. Mothers who are not able to breast feed their babies in view of medical reasons in the baby
will be trained in techniques of milk expression
7. Maneuvers which help in milk expression in the form of Kangaroo mother care, skin to skin
contact and nonnutritive sucking will be encouraged
8. Mother will be provided all the information about how to get help with respect to breast
feeding issues after discharge
9. Breast feeding policy is routinely communicated to all staff
10. All staff in the hospital will be trained in implementing our breast-feeding policy
Advantages of breast feeding
Benefits to baby Benefits to mother Benefits to society
Complete food Helps in involution of uterus Saves money
Easily digested Delays pregnancy Decreased need for
Well absorbed Decrease mother’s workload hospitalization
Protects against infection Decrease risk of ovarian cancer Improves child survival
Promote bonding
Better brain growth
Helping a mother breastfeed her baby
Step 1:
Preparing the infant and  Ensure infant is clinically stable and alert
mother  Ensure mother is comfortable and relaxed
 Make her sit in a comfortable and convenient position
Step 2:
Positioning  Baby’s head is in line with the body
 Whole body is well supported
 Baby turned towards mother
 Baby’s abdomen touching mother’s abdomen
Step 3:
Helping mother support  Put her fingers below the breast
her breast  Use first finger to support the breast
 Put her thumb above areola to shape the breast
 Not to keep fingers near the nipple
Step 4:
Helping baby to attach  Express little milk onto mother nipple
 Touch baby lips with her nipples
 Wait until baby mouth is wide open
 Move the baby onto the breast
Step 5:
Looking for signs of  More areola is visible above baby mouth than below it
good attachment  Baby mouth is wide open
 Baby lower lip is turned outwards
 Baby chin is touching the breast
Step 6:
Assess for good suck  Baby sucking both nipple and areola
and swallow  No regurgitation or vomiting while swallowing

Frequency of breast feeding

 A newborn baby can be breastfed on demand
 Mother should be advised that they should feed their babies every 2 to 3 hourly, at least 8 to
10 times per day
Adequacy of breast feeding
Breast feeding is considered adequate if the following are present
1. Mother getting drops of milk from the other breast while feeding on one side
2. Sleeps comfortably for 2 hours after feed
3. Passes urine 6 to 8 times /day
4. Crosses birthweight by 2 weeks
5. Gains weight at least 25 to 30 g/day after initial 7 to 10 days and
6. If breast softens after feeding
Process of breast milk expression

Breast milk storage and thawing

Mode of feeding in preterm / low birth weight babies
Birth weight / Gestational age Preferred method of feeding
<1200 grams / < 28 weeks Orogastric feeds and IV fluids
1201 – 1500 grams / 28 – 31 weeks OG feeds / Spoon or paladai after stabilization
1501 – 2000 grams / 32 – 34 weeks Spoon / Paladai feeds and breast feeds with monitoring
>2000 grams / > 34 weeks Breastfeeds with monitoring

Choice of milk to be given

Order of preference with respect to choose of milk is
1. Mothers breast milk is the first choice for feeding
2. Pasteurized donor human milk
3. Preterm formula
Minimal enteral nutrition protocol & Feed advancement protocol
 <1000 grams 1000-1500grams >1500 grams

Initiation MEN (10-20ml/kg/day) 20 ml/kg/day on day 1 40-60ml/kg/day

with in 24-48 hours
Advancement 20ml/kg/day 30-40 ml/kg/day 30-40 ml/kg/day

Target to reach full 10 -14 days 7 days 3-4 days

feeds

Intravenous fluid – choice of fluid & advancement

First 48 hours – 10% Dextrose and later Isolyte – P
Fluid volume for initiation and advancement (in ml/kg/day)
Birth Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
weight
>2500 60 -80 80-100 100-120 120-150 140-160 160-180 160-180
grams
1500 - 60-80 80-100 100-120 129-140 140-160 160-180 160-180
2500
grams
<1500 80- 90 90-110 110-130 130-150 140-160 160-180 160-180
grams

Mode of feeding
1. < 32 weeks – OG / NG feeds 2nd hourly
2. 32-34 weeks – spoon / paladay feeds 2nd hourly
3. >34 weeks – direct breast feeds + spoon feeds 2nd hourly
Feed intolerance
Feed intolerance criteria: presence of any 2 of the following
1. Abdominal girth increases by ≥ 2 cm
2. Gastric aspirate more than 50% of the previous feed
3. Altered aspirate
4. Firm or tense abdomen
Milk Fortification – when to start, which product, dilution, when to stop
1. For < 32 weeks and < 1500 grams
2. Fortification of MOM /DOM
3. No fortification for formula feeds
4. BOVINE / human milk fortifier – Lactodex HMF in our unit
5. When baby reaches 150 ml/kg/day of enteral feeds
6. 1 sachet in 25 ml of EBM
7. Fortification continued till baby reaches 1800 – 2000 grams
8. Monitor for feed intolerance *
9. Monitor for adequate calorie, protein, micro and macronutrient supplementation, weight gain
Multinutrient supplementation
1. Iron @ 2mg/kg/day from 2 weeks of postnatal age till one year of age
2. Vitamin D @ 400IU per day from the point of full feeds till one year of age
3. Calcium (@ 150mg/kg/day) and phosphate (@ 75mg/kg/day) from the point of full feeds till
baby reaches 4kg weight
4. Multivitamin drops (@ 1ml per day) from the point of full feeds till baby reaches 4kg weight
Probiotics :
1) Used in preterm < 32 weeks and /or weight < 1500 grams
2) Start once baby tolerates 2ml 2nd hourly feeds
3) Multistrain probiotic (Darolac)
4) Half sachet twice daily
5) Continued till 6 weeks PMA, Discharge or 36 weeks whichever is earlier
6) Contraindicated in sepsis, NEC stage II or more
Growth charts to be used
For stat assessment – Fenton growth charts
For serial daily assessments – Ehrenkranz growth charts

Total parenteral nutrition protocol

Indications
1. Preterm infants on MEN
2. Term infants with surgical conditions
Constituents & initiation
1. Parenteral nutrition on day 1 in preterm with <1500 grams
2. IV fluid with GIR 6
3. Aminoven 2-3 gram /kg/day increased by 0.5-1gm/kg/day to maximum of 4gram/kg/day
by day 3 to day 4
4. Lipid 1-2 gram/kg/day increased by 0.5-1 gram/kg/day to maximum of 3 gram/kg/day by
day 3 to day 4
5. Calcium gluconate – 4 to 6 ml/kg/day
6. Sodium - 3 meq/kg/day (ELBW may require up to 5-6 meq/kg/day)
7. Potassium – 1 to 2 meq/kg/day
8. Sodium and potassium to be added after 48 hours of life, after urine output is established
9. TPN to be prepared 48 hourly, for 2.5 days to account for losses in tubing.
10. Heparin 0.5 units/ml to be added to TPN to reduce the thrombosis and phlebitis of the
central line and to maintain longevity of the line.
11. GIR > 12 mg/kg/min must be infused through central line
12. Minimum GIR of 4mg/kg/min to be maintained
Monitoring
1. Weight – daily
2. Length – weekly
3. Head circumference – weekly
4. GRBS – 6th hourly, SOS when GIR changed
5. Electrolytes – Every 48 hours
6. Creatinine – twice weekly
7. Blood urea – twice weekly
8. Triglycerides – weekly
9. Urine output – daily

TPN chart
NAME DAY OF LIFE WEIGHT GESTATION DATE

Total Fluid requirement =

Fluid deducted =
Remaining fluid for TPN =
Per day for 2.5 days

LIPID (5ml = 1 gram)

AMINOVEN (10 ml=1gram)

SODIUM (3 meq/kg)

POSTASSIUM (2 meq/kg)

MAGNESIUM (0.2 ml/kg)

MVI (1ml/kg)

CALCIUM (4ml/kg)

DEXTROSE

KANGAROO MOTHER CARE

KMC is a method of care of preterm and low birth weight infants by placing them in skin-to-skin
contact (STS) with mother or other caregiver to ensure optimum growth and development of the
infant.
Benefits of KMC:
1. Improved breastfeeding rates
2. Reduced infection
3. Reduced risk of mortality
4. Reduced length of hospital stay
5. Reduced risk of hypothermia
Components of KMC:
1. Kangaroo position: SSC between the mother and the infant in a vertical position, between
mother’s breast and under her clothes.
2. Kangaroo nutrition – mother should be shown how to breastfeed, spoon/ paladai feed the
baby. OG feeds to be continued. Exclusive breastfeeding is encouraged.
3. Kangaroo discharge – discharge in kangaroo position and follow-up
Criteria for eligibility of KMC:
1. All LBW infants who are hemodynamically stable
2. Mothers who are willing, comfortable, good hygiene, health and general condition
Duration:
1. More than 2 hours to 24 hours in a day
When to discontinue:
When the baby is term, weight >2500 grams, when the baby is uncomfortable, cries and pulls her
limbs out whenever mother keeps in skin-to-skin contact.

Grievance handling policy

Definition:
Grievance: Grievance would only mean a grievance relating to any patient / client arising out of
the implementation of the policies/rules or decisions of the Hospital.
Scope:
This policy and procedure set out the essential elements for the management of complaints from
inception to final outcome.
Policy:
The Grievance redressal procedure shall address the grievance with help and advice of medical
officer on duty, doctor on duty, head of department and chairperson
Appropriate actions shall be taken to redress the grievance by the grievance redressal committee
of Paramitha children hospital, Kompally. Counselling sessions shall be scheduled with the
complaint/s and all attempts shall be made to ensure that there is a redressal of grievance to
patient/ client satisfaction.
Purpose:
a) The purpose of this policy is to provide a framework to lodge a complaint to the Internal
Complaints Committee,
b) To provide guidelines on how to lodge a complaint or grievance and how that Complaint or
grievance will be dealt with.
Internal Complaints Committee
Following is the list of members of the committee:
1. Dr. Y. SRI HARSHA – Chairperson
2. Dr VENKAT REDDY KALLEM – Member
3. Dr. ABHISHEK P.V – Member
4. Dr. V. SWATHI – Member
5. Dr. M. SHRAVANI – Member
Responsibility:
Medical Officer-in-charge, Internal Complaints Committee, Legal Section, Paramitha hospital,
Kompally
Process Details:
1. Provision of complaint box in the patient care areas.
2. Display of grievance redressal mechanism in prominent areas.
3. Display of important mobile number like chairperson and members of grievance committee.
Complaints Handling:
The complaint will be taken up by the Internal Complaints Committee (ICC).
Grievance Procedure:
After registering the complaints, a preliminary enquiry will be called for. The findings will be
shared with the concerned Head of Department, and the person who lodged the complaint for
resolution. If the authority is not satisfied, a secondary investigation may be asked for more
findings for non-partial resolution. The findings will be discussed with accused / department and
complainant for rectification and preventive action.

Principles of bereavement counselling

1. Assure parents that it is normal to feel uncomfortable at this time
2. Allow parents to spend as much time as they need with their baby
3. Make repeated offers for holding the baby
4. Name the baby
5. Provide privacy, but do not abandon the parents
6. Encourage relatives and friends to see the baby, according to the parents’ wishes
7. Warn about gasping and muscle contractions
8. Reassure parents that their baby was not alone, not afraid, and not in pain at the time of death
9. Reassure parents that nothing more could be done
10. Provide mementos to create memories
11. Ensure that spiritual support is available
12. Take pictures
13. Explain the need and procedure for an autopsy Explain options and procedures for memorial
services

Hearing Screening
Screening for hearing impairment in neonatal period is important for timely detection and
appropriate treatment. Early diagnosis provides the opportunity for early intervention in hearing
impaired children, thus enhancing their overall quality of life. All newborns irrespective of risk
factors should be screened for hearing impairment.
Hearing loss can be categorized as:
1. No hearing loss: 10 to 15 dB
2. Slight: 16 to 25 dB
3. Mild: 26 to 40 dB
4. Moderate: 41 to 55 dB
5. Moderately severe: 56 to 70 dB
6. Severe: 71 to 90 dB
7. Profound: above 91 dB
Recommendations on Screening:
1. Automated auditory brain stem response (AABR) and / or otoacoustic emissions (OAE) are
recommended for newborn hearing screening.
2. A two-stage screening protocol with OAE as the first screen, followed by ABR for those who
fail the OAE screen.
3. If abnormal OAE is detected, it is repeated at 6 weeks on the 1st immunization visit. If again
abnormal, ABR is done for confirmation followed by full audiological evaluation and
remediation with hearing aids (cochlear implant may be required in cases of profound
hearing loss or poor response to hearing aids).
4. All NICU babies undergo ABR testing to rule out auditory desynchrony/ auditory
neuropathy.
5. In babies with abnormal ABR, detailed enquiry is made to identify and record any risk
factors.
6. Any baby missing screening before hospital discharge is called for OAE test on the first
immunization visit.
7. All babies with abnormal ABR should undergo detailed ENT evaluation hearing aid fitting
and auditory rehabilitation before 6 months of age
8. For premature infants (born at & before 34 weeks of gestation), hearing screening should
ideally be done after they reach 34 wks. postmenstrual age to reduce false positive results.
9. The goal is to screen newborn babies before 1 month of age, diagnose hearing loss before 3
months of age and start intervention before 6 months of age.

Neonate

First screen First screen

OAE AABR

PASS FAIL FAIL PASS

Sceond Sceond
Clinical follow Clinical follow
screen screen
up up
OAE/AABR OAE/AABR

PASS FAIL FAIL PASS

Clinical follow Conventional Conventional Clinical follow

up ABR ABR up

Retinopathy Of Prematurity
Retinopathy of prematurity (ROP) is a developmental vascular proliferative disorder of the retina
seen in preterm infants with incomplete retinal vascularization.
Pathophysiology of ROP progress through two phases, phase I being vaso-obliterative
phase and phase II characterized by vaso-proliferation. Immediately after birth oxygen tension
increases in the infant with room air and more so with supplemental oxygen. This hyperoxia
causes suppression of VEGF and erythropoietin (EPO) levels and loss of placenta leads to
decreased levels of growth factors like omega 3 fatty acid and insulin like growth factor 1 (IGF
1). This change leads to vaso-obliteration of retinal vessels resulting in peripheral avascular
retina (phase I). With maturation of the infant and increased metabolic activity of the peripheral
retina VEGF levels increase resulting in abnormal growth of new vessels called as
neovascularization (phase II). These new vessels growth if uncontrolled may result in tractional
retinal detachment and loss of vision.
International classification of ROP (ICROP) standardized the nomenclature for
classification of ROP with respect to zone (location of disease), extent (circumferential
involvement) and staging (appearance of disease at vascular and avascular junction) of ROP.
Screening for ROP is done by trained ophthalmologist with binocular indirect
ophthalmoscopy. All preterm infants with gestation < 34 weeks and birth weight < 2000 grams
or any preterm infant with risk factors for ROP should be screened. First screening to be done at
30 days of life (4 weeks of PMA) or earlier at 2 – 3 weeks of age in case of preterm infants < 28
weeks of gestation or birth weight < 1200 grams.
Treatment options available for ROP are cryotherapy, laser therapy and anti VEGF
therapy. Cryotherapy and laser therapy causes ablation of peripheral avascular retina thereby
decreasing VEGF levels. Anti VEGF drugs like bevacizumab, ranibizumab and pegaptanib
directly binds to VEGF and decreases its effects. Surgical options available for advanced ROP
with retinal detachment include scleral buckling, vitrectomy, lensectomy and lens sparing
vitrectomy but have poor visual outcomes.

Figure: Overview of ROP

Figure: ROP screening
Figure: ICROP III Classification
Hypothermia
Relevance:
Hypothermia is common in infants born at hospitals (prevalence range from 32% to 85%) and
homes (prevalence range from 11% to 92%), even in tropical environments.
Classification of hypothermia:
1. Normal axillary temperature: 36.5 – 37.5 0C
2. Mild hypothermia / cold stress: 36 – 36.4 0C
3. Moderate hypothermia: 32-35.9 0C
4. Severe hypothermia: below 32 0C
Symptomology:
Hypothermia can present as Apnea, Acidosis, Bleeding, Cardiac arrest, DIC, Hypotension,
Hypoglycemia, Pulmonary hemorrhage ,Shock, and even Death
Why neonates are prone to hypothermia?
Neonates are prone to hypothermia due to
1. Larger surface area per unit body weight
2. Limited heat generating mechanisms (non-shivering thermogenesis)
3. Vulnerability to getting exposed.
Causes Of Hypothermia:
1. Situations causing excessive heat loss: Cold environment, Wet or naked body, Cold linen,
and transport
2. Procedures: bathing, blood sampling
3. Poor ability to conserve: LBW, IUGR
4. Poor metabolic heat production: deficiency of brown fat
5. Hypoxia, hypoglycemia, sepsis
Mechanism of heat loss:
1. Conduction: loss of heat when an infant lies on a cold surface
2. Radiation: loss of heat from infant skin to distant cold objects.
3. Evaporation: loss of heat from infants’ wet skin to surrounding air.
4. Convection: loss of heat from infants’ skin to surrounding air.
Temperature monitoring:
1. Axillary temperature recording for 3 min – recommended for routine monitoring
2. Rectal temperature – rectal thermometer
3. Skin temperature - recorded by thermistor
4. Human touch – back of fingers
Management of hypothermia:
1) Cold stress:
a. Remove cold clothes and cover baby with warm clothes
b. Warm the room
c. Ensure skin to skin contact with mother and breast feed the baby
d. Monitor axillary temperature every ½ hour till temp reaches 36.5 c then hourly for
next four hours, 2ndhrly for 12 hours thereafter
2) Moderate hypothermia:
a. Maintain skin to skin contact
b. Take measures to reduce heat loss
c. Provide extra heat by room heater, radiant warmer, incubators.
d. Continue breast feeding, treat hypoglycemia.
e. Reassess every 15 min
3) Severe hypothermia:
a. Rapid rewarming up to 34 0C then slow rewarming to 36.5 0C
b. Take measures to reduce heat loss
c. Start iv fluids 60-80ml/kg of 10% dextrose
d. Start supplemental oxygen if needed
e. Give vit k
f. Consider sepsis as d/d

Hyperthermia
Defined as temperature of more than 37.5 0C
Causes:
1) Too hot environment
2) Overwrapping
3) Dehydration fever – excessive weight loss, feeding issues
4) Sepsis – tachycardia,
5) Respiratory distress,
6) Apnea,
7) Hypoglycemia,
8) Lethargy,
9) Vomiting,
10) Seizures,
11) Shock
Management:
1) Place the baby in normal environment (25 – 28 0C) away from heat source
2) Undress partially
3) Sponging with tap water if temp & more than 39 0C
4) Correct dehydration with IV fluids and feeds
5) Treat sepsis, supportive care
6) Monitor temperature hourly till it becomes normal

Follow up of high-risk neonates

Improving perinatal and neonatal care has led to increased survival of infants who are at risk for
long-term morbidities such as developmental delay, visual /hearing impairment, growth failure,
chronic medical illness. Hence an appropriate and structured follow-up program is required for
early detection of and early intervention. The importance of follow-up should be emphasized to
parents. They should be called to turn up for follow-up and if possible, home visits should be
arranged.
High risk neonates who need follow-up care:
1. Infants with birth weight < 1800 grams and gestation < 35 weeks
2. Small for gestational age (< 3rd centile) and large for gestational age infants(> 97th centile)
3. Perinatal asphyxia
4. Mechanical ventilation for > 24 hours
5. Symptomatic hypoglycemia and hypocalcemia
6. Seizures
7. Infections- meningitis, culture positive sepsis
8. Shock
9. IVH, PVL, BPD
10. TTTS
11. Twin with intrauterine co twin death
12. Hyperbilirubinemia TSB &gt;20mg/dl, need for exchange transfusion
13. Major malformations
14. IEM
15. Infants born to HIV positive mothers
16. Abnormal neurological examination at discharge
When to follow-up:
1) Preterm (< 35 weeks) and VLBW infants: 48 to 72 hours after discharge, followed by once in
every week till 1800 grams, followed by every 2 weeks till 3kg, followed by vaccination
visits. At 3, 6,9,12 and 18 months corrected gestational age and then every 6 months till 5
years of age
2) Infants with other conditions: 48 to 72 hours after discharge, followed by 2 weeks after
discharge, followed by vaccination visits. At 3, 6,9,12 and 18 months corrected gestational
age and then every 6 months till 5 years of age
What should be done in follow-up:
1. Assessment of feeding and dietary counselling
2. Growth monitoring – Weight, length, HC, MAC
3. Development assessment – gross motor, fine motor, language, and social skills
4. Neurological assessment – tone, reflexes, posture, extrapyramidal signs, etc
5. Immunization
6. Assessment of Ongoing medical illness
7. Ophthalmic evaluation – ROP screening, refractive errors, squint, strabismus, visual acuity
8. Hearing evaluation – BERA, audiological testing
9. Early stimulation, physiotherapy, occupational therapy

Disinfection policy
Disinfectants & germicides
Housekeeping routines

Antibiotics policy
1) No antibiotics will be given to neonates without drawing blood cultures
2) Antibiotics will be deescalated as per the culture and sensitivity pattern of the organism
grown
3) First line or empirical therapy is Amikacin only
4) Any clinical suspicion or positive sepsis screen along with Amikacin one more antibiotic
with broad spectrum coverage (Piperacillin tazobactam) will be added
5) Upgradation or escalation of antibiotics beyond these will be done only after discussion with
consultant and microbiologist advise will also be taken along with clinical monitoring of the
neonate
6) Surveillance cultures and auditing of the culture reports and antibiotics usage in the unit will
be done once a month and appropriate changes will be done as per the prevailing organism
and sensitivity pattern of the antibiotics
7) Duration of antibiotics is 5 – 7 days, 10 – 14 days and 21 days for probable sepsis, culture
positive sepsis and meningitis respectively
8) Empirical antibiotics will be given only in preterm neonates with gestation < 35 weeks and
PPROM or clinical signs of chorioamnionitis
9) Perioperative antibiotic therapy will be given only for 24 hours
10) Antifungal prophylaxis is not followed in our unit

Visitors’ policy
Counselling timings
1. Morning – 10:30 AM – 11:30 AM
2. Evening – 5:00 PM – 6:00 PM
NICU Visiting Hours
1) 10:30 AM – 12:30 PM and 5:00 PM – 6:30 PM
Getting to the NICU
1) NICU is in 3rd floor.
2) Identify yourself and your relationship with the baby with the security.
3) The security will open the door for you.
4) Once you enter the unit, remove any jewelry, pull up your sleeves to the elbow, and scrub
hands and arms at the sink before going to the baby’s bedside.
Visiting Guidelines
1. Only one visitor at a time is allowed.
2. Mother is allowed to see the baby any time during day and night (24/7)
3. Visit only your baby and refrain from asking about other patients. All information is private.
4. The staff will not share your baby’s information with someone else, nor will we share
information about another baby with you.
5. No visitors under age 14 are permitted

Please follow these strictly for the safety of your and all babies in NICU
 Always Wash Your Hands before Touching Your Baby
 Anyone who will be touching your baby that they should remove all jewelry (watches, rings,
bracelets, etc.), roll up their sleeves above the elbows, and wash their hands first (for about 1
minutes) and wear the gown provided.
 Use the alcohol hand sanitizer at your baby’s bedside before you touch your baby each time.
 Anyone visiting the NICU should not have cold/flu, fever, nausea, vomiting, diarrhea, pink
eye, cold sores, chicken pox, or any other active infection.
 Wearing a face mask and a gown is mandatory before entering into NICU

Therapeutic Hypothermia protocol

 Any neonate with history of delayed cry / absent cry at birth / requirement of

Resuscitation at birth

Is the gestational age > 35 weeks? Yes / No

(If gestational age details not available, is the birth weight > 2500gram?
Is the post-natal age < 6 hours? Yes / No
(If age 6 to 12 hours – collective decision of the team after discussing with
consultant on case-to-case basis)
Is there any “Evidence of asphyxia,” as defined by the presence of at least Yes / No
1 of the following:
1. Apgar score less than 6 at 10 minutes or continued need for resuscitation
with positive pressure ventilation or chest compressions at 10 minutes
2. Any acute perinatal sentinel event that may result in HIE (e.g., abruptio
placentae, cord prolapse, severe FHR abnormality)
3. Cord pH < 7.0 or base excess of −16 mmol/L or less
4. If cord pH is not available, arterial pH < 7.0 or base excess less than
−16 mmol/L within 60 minutes of birth
Is the baby having Moderate or Severe Encephalopathy on clinical Yes / No
examination (SIBEN Score)?

SIBEN Score

MILD MODERATE SEVERE

Level of consciousness Hyperalert Lethargy Stupor/Coma

Spontaneous activity Normal Decreased Not present

Posture Mild distal flexion Marked distal flexion Decerebrate

Tone Normal Hypotonia Flaccidity

Suck Weak Weak or absent Not present

Moro Strong Weak Not present

Pupils Mydriasis Miosis Diverted/nonreactive

Heart rate (HR) Tachycardia Bradycardia Lack of HR variability

Breathing Spontaneous Periodic Apnea

Seizures Absent Present—Frequent Present—infrequent

If answer to all the questions is “YES”

Detailed counselling (Audio / Video) to be done to the family members regarding the Benefits
and risks associated with the treatment [THERAPEUTIC HYPOTHERMIA / COOLING]

If the parents are willing for the treatment after counselling, take informed consent from them
with all the points which are discussed

Initial stabilization and prerequisites before starting Therapeutic Hypothermia

General Secure central venous access (UVC / PICC Line) and central arterial line
(UAC)
One peripheral venous access
Connect Pulse oximetry probes
Connect ECG leads
Insert Urine catheter
Insert OG tube
Airway & Secure the airway and intubate if airway is compromised and baby is not able
breathing to maintain the airway
Start mechanical ventilation if severe encephalopathy or baby is not having
good respiratory efforts or apnea
Circulation Assess the circulatory status (HR, CRT, NIBP, Pulse volume), Pre – Post
SPO2)
Get the baseline echo for assessing Contractility and PAH
Start Inotropes and Vasopressors as per the clinical & echo assessment
CNS Start anti-epileptic as per requirement
Investigation CBP, CRP, Blood culture, Ionic Calcium, LFT, RFT, PT, APTT, EEG
s (irrespective of seizures)


Start Therapeutic Hypothermia

Metabolic screening protocol

IEM should be considered in the differential diagnosis of any sick neonate along with
common acquired causes such as sepsis, hypoxic-ischemic encephalopathy, duct-
dependant cardiac lesions, congenital adrenal hyperplasia and congenital
infections.
Clinical pointers towards an underlying IEM include:
 Deterioration after a period of apparent normalcy
 Parental consanguinity
 Family history of neonatal deaths
 Rapidly progressive encephalopathy and seizures of unexplained cause
 Severe metabolic acidosis
 Persistent vomiting
 Peculiar odour
 Acute fatty liver or HELLP (hemolysis, elevated liver enzymes & low
platelet counts) during pregnancy: seen in women carrying fetuses with
long-chain-3- hydroxyacyl-coenzyme dehydrogenase deficiency
(LCHADD).
Approach to metabolic acidosis

Approach to hypoglycaemia
Approach to hyperammonaemia
 Transport protocol

Baby name: MR No.: Date & time of call

Age: Sex: M / F / Other Gestation (weeks): Birth weight (grams):
Transport doctor: Transport nurse:

Transport kit Yes / No

 Endotracheal Tubes – #2.0, #2.5, #3.0 & # 3.5 Laryngoscope
 Blade Size – #0 & #1
 Face Mask – Pre-term and Term
 laryngoscope with Extra Batteries – 2 in number
 Nasal Prongs
 Oxygen Tubes
 Prediluted Drugs (Adrenaline 1:10,000, NaHCo3 , Dopamine, Dobutamine,
Calcium gluconate)
 IV fluids (2 in number) : Pediadrip Set, Normal Saline, 10% Dextrose, 5%
Dextrose, Sterile Water for Injection
 Feeding Tubes
 Mucus Sucker
 Suction Catheters Portable Suction Glucometer with Strips Stethoscope
 Pulse Oximeter (Battery charged) with Extra Set of Probes
 Syringe Pump (Battery Charged)
 Syringes (5 in number) 1 cc, 2 cc, 5 cc, 10 cc
 3 way Extension
 Blood Pressure Cuff
 Sterile Towel, Head Cap
 IV Cannula 24 No. (5 in number) IV Cannula and ET Plasters
 Sterile Cotton, Diapers
 Oxygen Source (in the ambulance)
 Incubator / Thermostat
 Transport Ventilator, T-piece Resuscitator
 New Set of Ventilator Tubing
Procedure checklist Yes / No
 Temperature
 Heart Rate
 Respiratory Rate
 GRBS
 Blood pressure
 SPO2
 CFT
 Respiratory Support – CPAP / Oxygen / Ventilation
 Intubation done if respiratory support required
 Vitamin K given
 Medications Received, Dose, Timings, Route
 Any Investigations Sent
 X-ray Chest Done
 Any Relevant History
 IV Cannula (No. of days)
 Counselling of Parents done Regarding Need for Transport
 Written Informed Consent Taken for Transport from Attendants
 Copy of Maternal Records
 Blood sample of mother collected
 Copy of Neonatal Treatment Record
 Receiving Team Informed about the Baby
 Interventions done during Transport
Stabilization Post transport
 Temperature
 GRBS
Handover given to
 Doctor:
 Nurse:
Time of handover:
 Checklist for intubation

Baby name: MR No.: Date & time of call

Age: Sex: M / F / Other Gestation (weeks): Birth weight (grams):
Intubation: Elective / Emergency ET tube No.:
Procedure done by doctor: ET fixed at:

Yes / No
EQUIPMENT LIST
 Functioning laryngoscope with Straight Blade 00, 0, 1
 Ambu Bag with Reservoir
 Masks of Different Sizes
 Oxygen Connection Tubes
 Sterile Gloves
 Endotracheal Tubes of Different Sizes (Based on Infant Weight)
 Cap / Mask / Gloves
 Midazolam
 Syringes – 5 ml
 Tegaderm / Duropore
 Scissors
 Suction Catheter
 Orogastric Tube
 Pulse Oximeter
 Stethoscope
PROCEDURE CHECKLIST
 Laryngoscope Function Checked
 Cap / Mask / Hand wash / Gloves
 Oxygen Tube Connected to Central Oxygen
 Suction Catheter Connected and Pressure Set at 80 – 100 mmHg
 Sedation
 Positioning of Infant
 Procedure Done
 Saturation Maintained
 Air entry checked
 ET Tube Fixed at Lip with Duropore
 Extra Length of ET Tube Cut
 X-ray Chest Ordered / ET Tube Position Rechecked and Repositioned
 ET Tube Card Filled / Date and Time Noted
 Connected to Ventilator
 Procedure Notes Done

Checklist for surgery

Yes / No
PRE-OPERATIVE
 Informed Consent Taken
 High Risk Consent Taken
 Case Sheet Prepared (Shifting Notes)
 Procedure Risk Explained
o By Paediatrician / Neonatologist
o By Pediatric Surgeon / Anaesthetist
 Basic Investigations : Blood Group, CBP (lavender top), Sr. Electrolytes, Bl. Urea,
Sr. Creatinine (Red top) PT, APTT (Blue top), BT, CT
 Inform Anaesthetist for Pre Anaesthetic Check-up
 Inform Operation Theatre
 Prophylactic Antibiotic before Surgery
 Reserve Blood Products (PRBC/FFP) along with Cross Matching Sample
 Blood Products Needed for Surgery at least 3 hrs before Surgery
 Proper IV Access to Baby
 ET Tube Positioned
 Shift with Warmer
OPERATIVE
 Case Sheet sent to OT
 Thermoregulation during Surgery Planned
 Blood Products sent to OT
POST-OPERATIVE
 Bed Ready before Baby Arrives in NICU
 Ventilator (if necessary) kept Ready
 ET Tube Position Confirmed
 Operation Notes
 Post-operative Counselling
 Advice by Surgeon
 Analgesics
 Time of Feeding
 Time of Suture Removal

Checklist for surfactant administration

Baby name: MR No.: Date & time:

Age: Sex: M / F / Other Gestation (weeks): Birth weight (grams):
Doctor: Nurse:
Consent taken from parents: Yes / No Chest X ray done: Yes / No
Surfactant administered at (hours of life): ET tube size:
Pre-surfactant Fio2 (%): PEEP (cm H2O):
Surfactant brand: No of aliquots:

Yes / No
EQUIPMENT LIST
 Surfactant of Desired Brand
 Desired Volume / Number of Vials Ordered
 Syringes – 5 ml, 10 ml, 2 ml
 Surgical Blade
 Infant Feeding Tube 5 Fr, 6 Fr
 Endotracheal Tube of Sizes – 2, 2.5, 3, 3.5
 Functioning laryngoscope with Straight Blade of Size 00, 0, 1
 T-piece Resuscitator
 Masks of different Sizes
 Oxygen Connection Tubes
 Sterile Gloves / Cap / Mask / Gown
 Midazolam
 Tegaderm / Duropore
 Scissors
 Stethoscope
 Suction Catheter
 Pulse Oximeter
PROCEDURE CHECKLIST
 Laryngoscope Function Checked
 Cap / Mask
 Hand washing Done
 Gloves put on
 Oxygen Tube Connected
 Suction Catheter Connected
 Pressure of Vacuum Set 100 mmHg
 Infant Feeding Tube Cut at Desired Length
 Surfactant Loaded in Syringe
 Sedation Given
 Positioning of Infant
 Intubated with Correct Size ET Tube
 Air Entry Checked
 Saturations Checked
 ET Tube Fixed at Lip with Duropore
 Surfactant given Aseptically
 Connected to CPAP / Ventilator
 Pressure / FiO2 Reset
 Procedure Notes Written on Case Sheet
 Checklist for peritoneal dialysis

Baby name: MR No.: Date & time:

Age: Sex: M / F / Other Gestation (weeks): Birth weight (grams):
Doctor: Nurse:
Consent taken from parents: Yes / No Last creatinine:
Indication: Urine output last 24 hours:

Yes / No
EQUIPMENT LIST
 PD Catheter 12 Fr with Trocar and Connector
 Scalpel
 IV Cannula 20 G
 Peritoneal Dialysate Fluid (1.7%)
 IV Set – 2
 Empty Bottle for Draining
 3-way Connector
 Xylocaine (2%)
 2 ml, 10 ml Syringes
 Dressing set with Sterilium, Betadine
 Silk Thread and Needle for Suture
 Peritoneal Dialysis Chart
 Cap / Mask / Gown
 Latex Glove 2 Pairs
 Fixing Tape
 Nasogastric Tube No. 5 Fr / 6 Fr
 Drapes – 2
PROCEDURE CHECKLIST
 Cap / Mask worn
 Hand washing Done
 Gown and then Gloves put on
 Pre procedure Decompression of Abdomen
 Catheterization of Bladder
 Skin preparation with 2% Chlorhexidine
 Dressing and Draping
 Site of Insertion Properly Selected – Right / left
 Catheter Inserted and Fixed
 PD Fluid Connected
 Heparin Added into PD Fluids
 Hemostasis Maintained
 Check for Obstruction, Bleeding, Dislodgement, leakage, Extravasation,
Infection
 PD Chart Properly Prepared and Nurses Explained on Documentation
 Volume of PD Fluid per Exchange
 Frequency and Duration of Exchanges Recorded
 Fill Time, Dwell Time, and Drain Time Clearly Written
 Weight Charting Daily
 Signs of Peritonitis Explained to Duty Nurse
 Mention When to Stop PD
 Electrolyte Monitoring / Renal Profile Monitoring Chart
 Peritoneal Dialysis Procedure Notes Written

Checklist for Exchange transfusion

Baby name: MR No.: Date & time:

Age: Sex: M / F / Other Gestation (weeks): Birth weight (grams):
Doctor: Nurse:
Consent taken from parents: Yes / No Maximum TSB:
Indication: TSB before exchange:
Exchange Volume (2*Blood vol*weight): ml Aliquot volume (ml):
Baby’s blood group: Mother’s blood group:
ABO / Rh incompatibility: Yes / No No of aliquots:
Start time: End time:

Donor blood bag no. Date of collection Blood group Checked by

Pre-exchange condition
Pallor: Yes / No Bilirubin encephalopathy: Yes / No BIND stage:
Respiratory support: Yes / No Sickness status:
Any medications ongoing:

Yes / No
EQUIPMENT LIST
 Blood Ordered
 Mother Sample Obtained for Cross Match
 Umbilical Catheter 3.5 Fr, 5 Fr, 6 Fr, 7 Fr
 Gloves Latex (2 Pairs)
 Dressing Set
 Cap / Mask / Gown (2 Pairs)
 Spirit / Betadine / Chlorhexidine 2%
 Drapes (2)
 Syringe 5 ml (2), 10 ml (2), 2 ml (2)
 IV Cannula 24 No. (1)
 Three Way Stop Cock (2)
 Blood Transfusion Set
 IV Set (2)
 Plastic or Glass Bottle for Disposal of Blood
 Saline / Sterile Water
 Transparent Dressing
 Paper Tape / Tegaderm / Duropore
 Surgical Blade
 Sucrose Analgesia
 Exchange Cycle Chart Prepared
 Cycle Volume and Cycle Number Determined
PROCEDURE CHECKLIST
 Umbilical Cannulation Done
 Umbilical Catheter in-situ
 Proper Aseptic Precautions taken during Cannulation
 Back Flow Checked
 Need of Peripheral Artery
 Phototherapy Continued During Procedure
 Blood Bag No. and Blood Group Cross-checked
 Three Way Connected to Umbilical Catheter
 Blood Bag Sufficiently Warm
 Transfusion Set and IV Set Properly Connected
 Cycle Started with Pull Out
 Same Volume Pushed In
 Bag Mixing done Intermittently
 Hemodynamics Monitored
 Desired Number of Cycles Done
 Blood Volume was Sufficient for Cycles
 Last Aliquot sent for PCV, TSB and Calcium
 Procedure Notes Written
 Any complication noted during procedure
 Vitals monitoring Post exchange transfusion

Checklist for umbilical lines

Baby name: MR No.: Date & time:

Age: Sex: M / F / Other Gestation (weeks): Birth weight (grams):
Doctor: Nurse:
UAC / UVC size: Fixed at:

Yes / No
EQUIPMENT LIST
 Umbilical Catheter 3.5 Fr, 5 Fr, 6 Fr, 7 Fr
 Gloves Latex (2 pairs)
 Dressing Set
 Cap / Mask / Gown (2 pairs)
 Spirit / Betadine / Chlorhexidine 2%
 Measuring Tape
 Drapes (2)
 Syringe 5 ml (4), Saline / Sterile Water
 Transparent Dressing
 Paper Tape / Tegaderm / Duropore
 Surgical Blade
 IV Fluids Prepared (Dextrose 10%, TPN etc) / IV Set
 Sucrose
PROCEDURE CHECKLIST
 Length of Insertion from Shoulder to Umbilicus Length and Chart
 Cap Mask Worn / Handwash / Gown / Gloves
 Site Preparation with Spirit and Betadine
 Site Covered with Drapes
 Proper Size Umbilical Catheter Inserted Depending on Size of Vein and Artery
 Back Flow Checked
 Fixed at Measured Length with Transparent Tape and Tegaderm
 Flushed with Saline
 X-ray Ordered or Position Checked with Ultrasound and Fixed
 Position of UVC / UAC Noted Down on Card
 Vital and Temperature of Infant Checked
 Hemostasis Secured
 IV Fluids Connected
 Heparin Connected to Umbilical Artery Line
 Periodical Checks for local Signs of Inflammation / Swelling
 Watch for Lower Limb Color and Perfusion
 Hub of Line Covered with Sterile Gauze
 Procedure Notes Done

Checklist for peripherally inserted central line

Baby name: MR No.: Date & time:

Age: Sex: M / F / Other Gestation (weeks): Birth weight (grams):
Doctor: Nurse:
Site: Fixed at:
 Yes / No
EQUIPMENT LIST
 PICC line Size (Depending upon Site of Insertion)
 Gloves Latex (2 pairs)
 22 Gauze Cannula
 Dressing Set
 Cap / Mask / Gown (2 pairs)
 Measuring Tape
 Drapes (2)
 Spirit / Betadine / Chlorhexidine 2%
 Syringe 5 ml (2)
 Saline / Sterile Water
 Transparent Dressing
 Paper Tape / Tegaderm / Duropore
 IV Fluids Prepared (Dextrose 10%, TPN etc) / IV set
 Sucrose
PROCEDURE CHECKLIST
 Site Selection for Insertion
 Length of Line to be Inserted Measured
 Cap Mask Worn
 Hand Scrub Performed
 Gown and then Gloves Worn
 Site Preparation with Spirit and Betadine/ Chlorhexidine
 Site Covered with Drapes
 Cannula Inserted at Selected Site
 Guide Wire Passed (Seldinger Technique)
 PICC line Inserted Taking Care of All Aseptic Precautions
 Guide Wire Removed
 Back Flow Checked
 Fixed at Measured Length
 Fixed with Transparent Tape and Tegaderm
 Flushed with Saline
 X-ray Ordered or Line Tip checked with Ultrasound
 Position Rechecked and Fixed (line Tip in SVC or IVC)
 Vitals and Temperature of Infant Checked
 Hemostasis Secured
 Limb Checked for Signs of Ischemia
 IV Fluids / TPN Connected
 Hub of Line Covered with Sterile Gauze
 Procedure Notes Done
 Periodical Checks for local Signs of Inflammation / Swelling

Checklist for lumbar puncture

Baby name: MR No.: Date & time:

Age: Sex: M / F / Other Gestation (weeks): Birth weight (grams):
Doctor: Nurse:

Yes / No
EQUIPMENT LIST
 Neonatal lumbar Puncture Tray (drape, needle holder, cotton, guaze)
 22 G and 24 G Needles
 Surgical Masks
 Sterile Gloves
 2 x 2 Gauze
 Cotton Balls
 Sample labels with Sterile Bottles
 Sharps Container
PROCEDURE CHECKLIST
 Informed Consent from Parent
 Blood Sugar Measured
 No Active Bleeding
 Platelet > 50000 / mm3
 Infection at lumbar Puncture Site
 No Evidence of Raised ICP (posturing, bulging AF)
 Hand wash, Cap, Mask, Gown and Gloves
 Baby Positioned lateral Decubitus with no Flexion of Neck
 Site Cleaned with Betadine and Spirit
 Puncture Site Identified (L4 and L5, ischial spine)
 Bevel up and Needle Advanced into the Subarachnoid Space
 Needle Advanced towards Navel
 CSF Collected into Four Sterile Bottles (Biochemistry, Cell Counts, Gram
Stain, Culture)
 Puncture Site Cleaned with Spirit to Remove Betadine
 Pressure Applied to Site
 Procedure notes Documented

Checklist for discharge of healthy neonate

Day of Life
Weight at Discharge and Percentage of Weight Loss _______grams _____%
Establishment of Breast Feeds Yes / No
Passage of Meconium Yes / No
Passage of Urine Yes / No
Eye Examination – Red reflex (Cataract) Normal / abnormal
Cleft Palate Yes / No
Murmurs & Femoral Pulses Yes / No
Hip Examination (DDH) Normal / abnormal
Genitals Normal / abnormal
Examination of the Back Normal / abnormal
Newborn Screening Yes / No
Bilirubin levels (TSB / TCB) _____ mg/dl Yes / No
Risk stratification
Pulse oximetry screening Pass / Fail
BCG / OPV / Hepatitis B (1) Yes / No
Complaints from Mother Yes / No
Review on (Date)
Name of the Doctor

Checklist for discharge of high-risk neonate from NICU

Day of Life
Mother confident of handling and feeding the baby Yes / No
Mother trained in spoon feeds Yes / No
Mother trained in KMC Yes / No
Maintaining temperature in open crib Yes / No
Achieved the cut off weight for discharge as per unit Yes / No
Or
Crossed the birth weight
Or
Weight gain documented on 3 consecutive days
Anthropometry (weight, length, OFC) documented Yes / No
Accepting spoon feeds without any spillage / breast feeds Yes / No
IV lines removed Yes / No
No apneas in last 5 – 7 days & off caffeine since last 3 days Yes / No
Mother explained about medications Yes / No
Danger signs explained Yes / No
Follow up dates for BERA, ROP, NSG, Developmental assessment
explained to family
Information about vaccines
Review on (Date)
Name of the Doctor