6.2 Neonatal Resuscitation, Jaundice, & Common Congenital Anomalies

6.2 Neonatal Resuscitation, Jaundice, & Common Congenital Anomalies

The transition from intrauterine to extrauterine life requires rapid physiological adaptation. Proficiency in Neonatal Resuscitation Program (NRP 8th Edition) protocols, structured evaluation of neonatal jaundice according to Canadian Paediatric Society (CPS) guidelines, and early recognition of surgical congenital anomalies are essential competencies for the MCCQE Part I.

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Neonatal Resuscitation Program (NRP 8th Edition)

Approximately 10% of newborns require assistance to establish breathing at birth, and 1% require intensive resuscitation. NRP emphasizes that hypoxia in neonates is almost exclusively respiratory in origin; establishing effective lung inflation is the absolute priority.

The "Golden Minute"

The initial steps and evaluation must be completed within 60 seconds of birth.

1. Initial Assessment (3 Questions):

   • Term gestation?
   • Good muscle tone?
   • Breathing or crying?
   • If YES to all: Keep with mother (skin-to-skin), dry, cover, clear airway if necessary, routine care.
   • If NO to any: Move to radiant warmer for initial steps.

2. Initial Steps (20–30 Seconds):

   • Warm and maintain normal temperature (36.5°C–37.5°C).
   • Position head in "sniffing" position to open airway.
   • Clear secretions from mouth then nose with bulb syringe if obstructed or meconium present.
   • Dry thoroughly and discard wet linen.
   • Stimulate by gently rubbing the back or flicking the soles of the feet.

3. Evaluation of Heart Rate & Respiration:

   • Assess HR via stethoscope or 3-lead ECG monitor.
   • Apnea, gasping, OR Heart Rate < 100 bpm: Initiate Positive Pressure Ventilation (PPV) immediately.
   • Target Oxygen Saturation: Start PPV with 21% O2 (room air) for term infants (≥35 weeks) and 21%–30% O2 for preterm infants (<35 weeks). Connect pulse oximeter to right hand/wrist (pre-ductal).

Ventilation Corrective Steps: MR. SOPA

If the heart rate is not increasing despite PPV, check chest movement. If chest is not moving adequately, perform MR. SOPA steps:

• Mask readjustment
• Reposition head (sniffing position)
• Suction mouth and nose
• Open mouth slightly
• Pressure increase (increase by 5–10 cm H2O increments up to max 40 cm H2O)
• Alternative airway (endotracheal tube or laryngeal mask airway)

Chest Compressions & Epinephrine

• Indication: Heart rate < 60 bpm despite at least 30 seconds of effective PPV that moves the chest (preferably via endotracheal tube).
• Technique: Two-thumb encircling-hands technique over lower third of sternum. Depth: 1/3 of AP diameter of chest.
• Compression to Ventilation Ratio: 3:1 (90 compressions and 30 breaths per minute = 120 events/min). Increase oxygen to 100% O2 during compressions.
• Medications: If HR remains < 60 bpm despite 60 seconds of chest compressions with 100% O2, administer IV/IO Epinephrine (0.02 mg/kg of 0.1 mg/mL [1:10,000]). ETT route is secondary (0.1 mg/kg) while securing IV/IO access.

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Neonatal Hyperbilirubinemia & Jaundice

Jaundice affects up to 60% of term and 80% of preterm infants in the first week of life. The clinical imperative is differentiating benign physiological elevation from pathological hyperbilirubinemia that risks kernicterus (acute bilirubin encephalopathy).

Pathological vs. Physiological Jaundice

• Pathological Jaundice (ALWAYS Abnormal):

  • Onset within the first 24 hours of life.
  • Rapid rate of rise (> 8.5 µmol/L/hour or > 85 µmol/L/day).
  • Total Serum Bilirubin (TSB) exceeding phototherapy thresholds on CPS nomograms.
  • Conjugated (direct) bilirubin > 17 µmol/L (or > 20% of TSB).
  • Jaundice persisting beyond 14 days in term or 21 days in preterm infants.
  • Etiologies: Immune hemolysis (ABO incompatibility, Rh isoimmunization), non-immune hemolysis (G6PD deficiency, spherocytosis), sepsis, cephalohematoma breakdown.

• Physiological Jaundice:

  • Onset after 24 hours (typically peaks at days 3–5 in term, up to day 7 in preterm).
  • Caused by increased red cell mass, shorter RBC lifespan (90 days), and immature hepatic glucuronosyltransferase (UGT1A1) conjugation.

• Breastfeeding Jaundice (Lack of Breast Milk):

  • Onset days 2–5. Caused by insufficient milk intake → dehydration, decreased stooling → increased enterohepatic circulation of bilirubin. Management: Increase feeding frequency, lactation support.

• Breast Milk Jaundice:

  • Onset days 4–7, peaking at 2–3 weeks. Caused by factors in breast milk (e.g., beta-glucuronidase) that promote intestinal deconjugation. Benign; breastfeeding should continue.

Conjugated Hyperbilirubinemia & Biliary Atresia

Exam Trap: Any infant with jaundice lasting past 2 weeks of age MUST have total and direct (conjugated) bilirubin measured. Conjugated hyperbilirubinemia is NEVER physiological.

Biliary Atresia is a progressive idiopathic obliterative cholangiopathy of extrahepatic bile ducts.

• Presentation: Jaundice extending beyond 2 weeks, acholic (pale/clay-colored) stools, dark tea-colored urine, hepatomegaly.
• Diagnosis: Abdominal ultrasound (triangular cord sign, absent/contracted gallbladder), intraoperative cholangiography (gold standard).
• Management: Urgent Kasai portoenterostomy performed before 60 days of life to restore bile drainage and prevent irreversible biliary cirrhosis.

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Common Surgical Congenital Anomalies