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Iowa Neonatology Fellows (including Jon E. Mazursky, MD, Chetan A. Patel, MD, Mark W. Thompson, MD) and John Dagle, MD, PhD
Peer Review Status: Internally Peer Reviewed
Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed
To differentiate fetal blood from swallowed maternal blood in the evaluation of bloody stools.
Mix specimen with 3-5 ml of tap water and centrifuge. Supernatant must have a pink color to proceed. To 5 parts of supernatant, add 1 part of 0.25 N (1%) NaOH.
A pink color persisting over 2 minutes indicates fetal hemoglobin. Adult hemoglobin gives a pink color that becomes yellowish brown in 2 minutes or less indicating denaturation of the adult hemoglobin.
Iowa Neonatology Fellows and John Dagle, MD, PhD
Peer Review Status: Internally Peer Reviewed
The controversial indications for circumcision are thoroughly discussed in the literature and are dealt with in the AAP policy statement, Pediatrics Vol. 130 No. 3 September 1, 2012, pp. 585 -586.
Male circumcision is a common procedure, generally performed during the newborn period in the United States. In 2007, the American Academy of Pediatrics (AAP) formed a multidisciplinary task force of AAP members and other stakeholders to evaluate the recent evidence on male circumcision and update the Academy’s 1999 recommendations in this area. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. The American College of Obstetricians and Gynecologists has endorsed this statement.
Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.
The procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in life.
Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.
Parents ultimately should decide whether circumcision is in the best interests of their male child. They will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices. The medical benefits alone may not outweigh these other considerations for individual families.
Findings from the systematic evaluation are available in an accompanying 32-page technical report- Male Circumcision Task Force Statement . The American College of Obstetricians and Gynecologists has endorsed the above Task Force statement.
The glans of the penis is easier to keep clean if the male is circumcised. Because of this ease of cleanliness, certain infections which can occur in uncircumcised boys or men with poor hygiene cannot occur in those who are circumcised. Circumcision will prevent several conditions that cause an accumulation of fluid and swelling around the foreskin and glans, as well as a problem known as phimosis, which is the inability to retract the foreskin. Newborn circumcision protects against the later development of cancer of the penis, although this is an extremely rare disease. Also the incidence of urinary tract infection in male infants is decreased when circumcision is performed during the newborn period.
The immediate risks of circumcision are bleeding, inadvertent injury to the remainder of the penis, and infection. Although circumcision is considered to be a generally safe procedure, in rare cases these or other complications can lead to severe problems and even death. Inflammation of the external urethral opening (meatitis) is more common in circumcised boys. Newborn circumcision is usually performed without anesthesia. Although the procedure is relatively brief, the newborn experiences some pain and discomfort.
In recent years, there has been more interest in providing local anesthesia for this procedure, but by no means is this universally accepted. Local anesthesia is provided by injecting a medication into the nerves at the base of the penis. If performed properly, this procedure will reduce the infant's pain and behavioral changes. Complications due to local anesthesia are rare and consist mainly of bleeding and damage to the skin where the injection occurs. Local anesthesia adds an additional element of risk to the procedure.
The pediatric chief residents are given instruction in Gomco clamp circumcision and dorsal penile block. The Gomco clamp method is described in detail in the chapter entitled "Circumcision" 378-388 in Atlas of Procedures in Neonatology, 2nd edition. Fletcher and MacDonald (eds), 1993, JB Lippincott Co., Philadelphia.
Iowa Neonatology Fellows
Revised John Dagle MD, PhD
Peer Review Status: Internally Peer Reviewed
Any infant, especially those born preterm, receiving greater than ambient oxygen concentration must have his arterial oxygen tension or saturation monitored.
An ill infant without an indwelling arterial catheter should have arterial O2 tension monitored by arterial puncture or transcutaneous PO2 monitor. An acceptable alternative would be continuous pulse oximetry with the upper saturation alarm limit set at 95%, but caution should always be used to prevent exposure to high amounts of oxygen. If questions arise regarding the appropriate level of oxygen saturation, peripheral arterial puncture should be performed.
Frequency of sampling depends on the clinical situation and the reliability of the other monitoring devices. Generally, a significant change in ventilator or CPAP setting should be followed by a capillary or arterial sample within 15 minutes to an hour. If performing a peripheral arterial puncture for blood gas purposes, note should be made of the location, as many infants have shunting through the ductus arteriosus that may affect the interpretation.
The amount of blood needed for laboratory tests with peripheral arterial puncture should be determined prior to puncture. The syringes used for blood gas sampling can be obtained from the blood gas laboratory.
Arterial puncture, although not as commonly used in NICU's as other methods of monitoring, can be performed with relative ease, using the radial, temporal, posterior tibial, or dorsalis pedis artery. The brachial and femoral artery should be used only in emergency situations, because of the risk of complications at those sites. Indwelling catheters may be placed in the radial, posterior tibial or dorsalis pedis artery but should not be placed in the temporal or brachial artery.
Prep the site with 3 alcohol swabs and wear appropriately fitting gloves. Goggles or eyeglasses are also recommended. The artery should be easily palpable or visible with transillumination. If using the radial artery, an Allen test should be performed prior to puncture. An arm board may be useful to prevent extreme dorsiflexion of the wrist which makes the procedure more difficult. A 25 gauge butterfly needle, with TB or 3 ml syringe should be used. The bevel up position should be used, except in the most superficial arteries. The angle of insertion should be 25o for a superficial and 45o for a deep artery, against the flow of the artery. Blood should flow spontaneously or with gentle suction.
After the needle is removed, continuous pressure should be applied for 5 minutes, with care not to squeeze with the fingertips. If hematoma formation is prevented, the artery may be used multiple times. Observe the extremity for 15-20 minutes after the procedure for arterial spasm.
Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed
If an exchange transfusion is necessary, compatible blood must be ordered. If a severely affected ( i.e. hydropic) infant with Rh hemolytic disease is anticipated at birth, it may be necessary to have blood available in the nursery prior to the delivery. The request should be for O negative packed red blood cells of the specific volume needed and of the appropriate CMV status. This blood may be utilized in any one of the following ways:
When the need for an emergency, complete exchange transfusion is virtually certain, arrangements can be made in advance for O negative whole blood or O negative PRBC's resuspended in fresh frozen plasma.
For double-volume exchange transfusions for hemolytic disease of the newborn or for hyperbilirubinemia without hemolysis, the blood used will be packed cells (type O, Rh specific for the infant) resuspended to the desired hematocrit in compatible fresh frozen plasma.
A partial exchange transfusion is often done for polycythemia (see section on polycythemia).
Although the standard anticoagulant (CPD) is acidic, the blood need not be buffered. If the infant is severely acidemic, consult the staff neonatologist.
If possible, the infant should be NPO and the stomach contents aspirated prior to the procedure.
The exchange transfusion should be done under a radiant warmer using sterile technique.
The donor blood should be warmed using the blood warmer to a temperature not exceeding 37oC.
The infants blood pressure, respiratory rate, heart rate and general condition should be monitored during the exchange transfusion according to standard nursing protocol.
If the serum bilirubin concentration is at a dangerous level and the blood for exchange transfusion is not yet ready, consider priming the infant with 1 gram/kg (4 ml/kg) of a 25% solution of salt-poor albumin to bind additional bilirubin and keep it in the circulation until the exchange can be accomplished..
The umbilical vein catheter should be inserted until there is free flow of blood immediately prior to starting the exchange transfusion. See section on placement of umbilical catheters for technique. The exchange transfusion should not be done through an umbilical artery line unless the UAC is used only for blood withdrawal with simultaneous replacement through the umbilical vein or peripheral IV. At the beginning of the exchange transfusion, the first blood sample withdrawn should be sent for for 1)total and direct bilirubin; 2) hemoglobin and hematocrit; 3) glucose; and 4) calcium.
Use the "exchange transfusion kit", which contains catheters, stopcocks, waste bag, and calcium gluconate.
Ideally, blood (or colloid in the event of a partial volume exchange) should be infused through a peripheral vein at a rate equal to blood withdrawal from the UVC. If the "push-pull" (single catheter) technique is utilized, no more than 5 ml/kg body weight should be withdrawn at any one time.
The exchange volume is generally twice the infant's blood volume, (generally estimated to be 80 ml/kg). The total volume exchange should not exceed one adult unit of blood (450-500 ml). A standard two-volume exchange will remove approximately 85% of the red cells in circulation before the exchange and reduce the serum indirect bilirubin level by one-half. The exchange of blood should require a minimum of 45 minutes.
The need for giving supplemental calcium is controversial. If used give 0.5 to 1.0 ml of 10% calcium gluconate IV, after each 100 ml of exchange blood. Monitor heart rate for bradycardia.
At the end of an exchange transfusion blood should be sent for sodium, glucose, calcium, total and direct bilirubin, and hemoglobin and hematocrit.
At the end of an exchange transfusion, the umbilical vein catheter is usually removed. In the event of a subsequent exchange, a new catheter can be inserted.
Hypoglycemia often occurs in the first or second hour following an exchange transfusion. It is therefore necessary to monitor blood glucose levels for the first several hours after exchange.
The serum bilirubin concentration rebounds to a value approximately halfway between the pre- and post- exchange levels by two hours after completing the exchange transfusion. Therefore, the serum bilirubin concentration should be monitored at two to four hours after exchange and subsequently every three to four hours.
Feedings may be attempted two to four hours after the exchange transfusion.
Iowa Neonatology Fellows
Revised John Dagle MD, PhD
Peer Review Status: Internally Peer Reviewed
Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed
In critically ill infants, placement of intravenous catheters is often difficult and time consuming. The intraosseous route offers immediate vascular access required for emergency administration of drugs during resuscitation. Intraosseous infusion uses the rich vascular network of long bones to transport fluids and drugs from the medull
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