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PE19.1-17 | Neonatology — PBL Case

CLINICAL SETTING

You are a final-year MBBS student on your paediatrics night duty at a 50-bed district hospital in Tamil Nadu. The hospital has a 6-cot special newborn care unit (SNCU) with a radiant warmer, CPAP, phototherapy unit, and basic laboratory. There is no neonatologist; a general paediatrician is on call from home and a trained paediatric nurse is on the ward. It is 11 PM on a monsoon night when the ward gets busy.

Trigger 1: A Distress Call from Labour Room

A call comes from the labour room: a 26-year-old G2P1 with poor antenatal care has delivered a baby at approximately 34 weeks gestation by emergency LSCS for fetal distress. The birth weight is 1750 g. At 1 minute, the baby is blue, limp, apnoeic, with a heart rate of 55 bpm. The nurse looks at you expectantly — the paediatrician is still driving in from home.

DISCUSSION POINTS

  • Classify this neonate using the NRP algorithm: what does a heart rate of 55 bpm and apnoea tell you, and what is the immediate intervention?
  • The nurse hands you a resuscitation bag. What are the steps of the 'golden minute' in order? At what heart rate do you begin chest compressions, and what is the compression:ventilation ratio for neonates?
  • How would you classify this neonate's birth weight and gestational age? What are the terms 'LBW', 'VLBW', and 'SGA'? What makes this neonate 'high-risk'?
Click to reveal Trigger 2: After Stabilisation — Assessment at 30 Minutes (discuss previous trigger first!)

Trigger 2: After Stabilisation — Assessment at 30 Minutes

With bag-mask PPV and then CPAP (FiO₂ 35%, PEEP 5 cmH₂O), the baby's heart rate improves to 138 bpm and colour improves. APGAR is 6 at 5 minutes. At 30 minutes, the nurse documents: axillary temperature 35.4°C, blood glucose (heel-prick glucometer) 28 mg/dL, respiratory rate 72/min with subcostal retractions and an expiratory grunt, SpO₂ 89% on CPAP. A blood sample is sent for sepsis screen (CBC, blood culture, CRP). Chest X-ray is requested.

DISCUSSION POINTS

  • Three problems are identified: hypothermia (35.4°C), hypoglycaemia (28 mg/dL), and respiratory distress. What is your management priority order, and why?
  • For the hypoglycaemia: what is the definition of neonatal hypoglycaemia? What do you give and at what dose? Why is 25% dextrose inappropriate in a neonate?
  • The chest X-ray shows bilateral ground-glass opacity with air bronchograms. What is the diagnosis? What specific treatment is available, and what antenatal intervention could have reduced the severity?
  • How do you assess and score the respiratory distress using the Silverman-Anderson score? The nurse asks how this is different from the APGAR score — how do you explain?
Click to reveal Trigger 3: Day 3 — New Problems (discuss previous trigger first!)

Trigger 3: Day 3 — New Problems

On day 3, the baby (now on low-flow nasal cannula O₂ 0.5 L/min) develops jitteriness and brief tonic movements of the right arm at 6 AM. Blood glucose is 72 mg/dL. The nurse also notes the baby is increasingly yellow — serum bilirubin is reported as total 13.2 mg/dL, direct 0.4 mg/dL. The mother is blood group O+; the baby is A+. A direct Coombs test is positive. The paediatrician asks you to summarise the two new problems and propose management.

DISCUSSION POINTS

  • The focal tonic movements with normal blood glucose: what are the differential diagnoses for neonatal seizures at day 3? What is the first-line antiseizure drug and its loading dose?
  • Classify the hyperbilirubinaemia: is it physiological or pathological? What does the positive direct Coombs test indicate? What is the likely underlying diagnosis?
  • The total bilirubin is 13.2 mg/dL at 72 hours in a 34-week neonate. Using the AAP/NNF risk-based approach, what is the approximate phototherapy threshold for this neonate? Does this baby need treatment?
  • The mother asks: 'Is my baby jaundiced because I am not breastfeeding enough?' How do you explain the difference between breastfeeding jaundice and the haemolytic jaundice this baby has?
Click to reveal Trigger 4: Day 10 — Fever, Abdominal Distension, and a Family Conference (discuss previous trigger first!)

Trigger 4: Day 10 — Fever, Abdominal Distension, and a Family Conference

On day 10, the baby (now on oral feeds of expressed breast milk via nasogastric tube, weight 1680 g on a recovery curve) develops temperature instability (37.9°C axillary), abdominal distension, and blood-streaked stools. The baby also becomes lethargic with a bulging anterior fontanelle. CBC shows WBC 22,000/mm³ with left shift, CRP 48 mg/L. Abdominal X-ray shows intestinal loops with suspected pneumatosis intestinalis. Blood culture is sent. The family are waiting outside and are anxious — the grandmother says 'he was doing so well, why is this happening now?'

DISCUSSION POINTS

  • What are the two diagnoses to consider? Distinguish late-onset neonatal sepsis from necrotising enterocolitis in this presentation. What organisms typically cause LOS in a preterm NICU patient on day 10?
  • The blood culture grows Klebsiella pneumoniae sensitive to cefotaxime and amikacin. What empirical antibiotics would you have started, and would you now change the regime?
  • The bulging anterior fontanelle with fever suggests meningitis as a complication. What is the management of LOS with meningitis in a preterm neonate? Why is lumbar puncture sometimes deferred?
  • How do you counsel the family? Address the grandmother's question, the severity of the current illness, the prognosis for neurodevelopmental outcome, and what the family can do to support the baby (expressed breast milk, KMC when stable). Use empathetic, plain language.

Group Task Assignments

Group 1: Collaborative Task

Group 2: Collaborative Task

Group 3: Collaborative Task

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PE19.2] What is the complete NRP algorithm for a neonate with HR <60 bpm despite 30 seconds of effective PPV? Describe the compression:ventilation ratio, compression depth/rate, and when epinephrine is given.
  2. [PE19.1] How is the Ballard score different from APGAR and Silverman-Anderson? For what clinical purpose is each used, and at what time after birth?
  3. [PE19.4] What is the Sarnat classification of HIE, and what are the criteria for therapeutic hypothermia (gestation, time window, temperature target, duration)?
  4. [PE19.5] How does the pathophysiology of RDS differ from TTN, and how does the chest X-ray appearance differ between the two?
  5. [PE19.10] What is the definition of neonatal hypoglycaemia, which neonates are at highest risk, and what is the correct IV treatment regimen (drug, concentration, dose in mL/kg, and why 25% dextrose is avoided)?
  6. [PE19.15] Explain the AAP/NNF hour-specific bilirubin nomogram: what factors shift the phototherapy threshold, and how do you distinguish physiological, breast milk, and haemolytic jaundice?
  7. [PE19.13] Differentiate early-onset (EOS) from late-onset neonatal sepsis (LOS) with respect to timing, causative organisms, and empirical antibiotic choice in a district hospital NICU in India.
  8. [PE19.8] What are the WHO criteria for Kangaroo Mother Care (KMC), the evidence for its benefit in LBW neonates, and the conditions under which KMC can be provided even for neonates on low-flow oxygen?