2025 – PAGE 171 – NEONATOLOGY

TOTAL PARENTERAL NUTRITION (TPN)

Total Parenteral Nutrition (TPN) monitoring should focus on frequent electrolyte checks and adjustments because there is a high potential for morbidity from electrolyte abnormalities. Lipid and protein requirements can change quickly as a child gains weight. Since requirements are weight-based, measure levels frequently and adjust as needed based on changes in weight.

RETINOPATHY OF PREMATURITY (ROP)

According to the AAP, all kids < 1500 g OR < 30 weeks should be screened for Retinopathy of Prematurity (ROP). The greatest risk is for kids born at < 29 weeks gestation or who have a birth weight of < 1200 g. The first retinal exam is scheduled based on the gestational age at birth. For a gestational age of 27–30 weeks at birth, the first exam is at 4 weeks of chronologic age. I suspect this is a low-yield fact.

PEARL: AGE and WEIGHT should guide your suspicion for ROP, NOT exposure to oxygen.

NEONATAL JAUNDICE, HYPERBILIRUBINEMIA, AND HEMOLYTIC DISEASE OF THE NEWBORN

NEONATAL JAUNDICE

Causes of neonatal jaundice include breastfeeding jaundice, human milk jaundice, and physiologic jaundice. Descriptions are below:

• BREASTFEEDING JAUNDICE: Jaundice that occurs within the first few days of life and is due to insufficient intake and the resulting dehydration. DO NOT withhold breast milk. Treat by working on technique.
• HUMAN MILK JAUNDICE (AKA BREAST MILK JAUNDICE): Usually occurs after about 1 week of feeding with breast milk, but can occur as early as DOL 3. It has a complicated etiology: innate steroids in the mom’s milk decrease induction of conjugating enzymes in the liver, resulting in indirect hyperbilirubinemia. Ensure there is an adequate number of feeds (8–12 per day). If the baby appears healthy and the total bilirubin is less than 20, it’s okay to watch or even consider supplementing with formula. This can last for weeks to months. If it’s greater than 20, it’s okay to HOLD BREAST MILK for one day and give formula instead. You may then resume breast milk. The indirect bilirubinemia will improve, and the bilirubin level will likely stay down.
  • MNEMONIC: If the term has “FED” or “FEEDING” in it, think of it as a problem in the technique. That will require more feeds/hydration. If the term has “MILK” in it, the problem is an intrinsic issue with the milk itself.
• PHYSIOLOGIC JAUNDICE: This is a diagnosis of exclusion. Look for a healthy infant with jaundice on DOL 2 through 5 with no pathologic explanation. The duration is brief as compared to breast milk jaundice, which can last for weeks to months.

HYPERBILIRUBINEMIA

Jaundice on DOL 1 is always BAD and can quickly result in dangerous hyperbilirubinemia (consider TORCH infections and G6PD deficiency in your differential). Obtain a total and direct (conjugated) bilirubin level. Previously, phototherapy was contraindicated when direct bilirubin exceeded 20% of the total bilirubin, but recent AAP guidelines support phototherapy for elevated total serum bilirubin even when direct bilirubin is also elevated. In the rare case of conjugated bilirubin >50% of total bilirubin, consulting with an expert is advised.

PEARL: Use of alcohol, heroin, phenobarbital, phenytoin, and tobacco are all associated with a DECREASED risk of hyperbilirubinemia.