Neonatal Assessment & Physiology

Foetal-to-Neonatal Circulatory Transition

At birth, the respiratory and circulatory systems undergo rapid adaptation. Lung fluid is absorbed, pulmonary vascular resistance falls, systemic resistance rises, and two critical foetal shunts close:

Foramen Ovale

Functional closure occurs within hours of birth as left atrial pressure exceeds right atrial pressure (reversal of foetal gradient). Anatomical closure may take weeks to months. Persistence = patent foramen ovale (PFO), relevant in cyanotic disease.

Ductus Arteriosus

Functionally closes within 24–72 hours in term neonates due to rising PaO2 and falling prostaglandin E2 (PGE2). In preterm infants, the duct often remains patent (PDA). Indomethacin or ibuprofen promote closure; surgical ligation reserved for refractory cases.

Transitional circulation may persist longer in preterm, hypoxic, or acidotic neonates — persisting right-to-left shunting causes cyanosis and contributes to PPHN.
Normal Neonatal Values by Gestation
ParameterTerm (≥37 wks)Late Preterm (34–36 wks)Preterm (<32 wks)
Heart Rate (bpm)120–160120–160120–170
Respiratory Rate (/min)40–6040–6040–65
SpO2 target (post-ductal)94–98%93–97%91–95%
Systolic BP (mmHg)60–8050–7045–65
Temperature (°C axillary)36.5–37.536.5–37.536.5–37.5
Blood glucose (mmol/L)2.6–7.02.6–7.02.6–7.0
SpO2 of 91–95% is the strict target in preterm <32 weeks to prevent retinopathy of prematurity (ROP). Avoid hyperoxia — SpO2 >95% must trigger FiO2 reduction.
Apgar Score

Assessed at 1 minute (response to resuscitation) and 5 minutes (short-term outcome indicator). Total maximum = 10. Score <7 at 5 minutes warrants continued reassessment.

Criterion012
Appearance (colour)Blue/pale all overPink body, blue extremitiesPink all over
Pulse (heart rate)Absent<100 bpm≥100 bpm
Grimace (reflex irritability)No responseGrimace/weak cryCough/sneeze/vigorous cry
Activity (muscle tone)Limp/flaccidSome flexion of limbsActive motion
RespirationAbsentWeak/irregularRegular, strong cry
Score 7–10: Normal. Routine care.
Score 4–6: Moderate concern. Stimulate, consider respiratory support.
Score 0–3: Severe concern. Initiate full NLS resuscitation immediately.
Gestational Age Assessment – Ballard Score

Neuromuscular Maturity (6 items)

  • Posture: degree of flexion (0 = frog-leg; 4 = fully flexed)
  • Square window: wrist flexion angle
  • Arm recoil: speed of return to flexion
  • Popliteal angle: extension at knee
  • Scarf sign: elbow crossing midline
  • Heel to ear: leg extension toward ear

Physical Maturity (6 items)

  • Skin: sticky/gelatinous → parchment/leathery
  • Lanugo: none → abundant → thinning → bald areas
  • Plantar surface: heel-toe distance, creases
  • Breast: impalpable → full areola 5–10mm bud
  • Eye/ear: fused → open; pinna soft → firm
  • Genitalia: male – descended testes; female – labia majora

Total Ballard score mapped to gestational age chart. New Ballard Score (NBS) valid from 20–44 weeks. Best performed within 12–96 hours of birth.

Neonatal Examination

Fontanelles

  • Anterior fontanelle: closes 9–18 months; diamond-shaped
  • Posterior fontanelle: closes 6–8 weeks; triangle-shaped
  • Bulging fontanelle: raised ICP – meningitis, hydrocephalus, IVH
  • Sunken fontanelle: dehydration

Primitive Reflexes

  • Moro reflex: disappears ~4–6 months
  • Rooting reflex: disappears ~4 months
  • Sucking reflex: present from 28–34 weeks; disappears ~4 months
  • Palmar grasp: disappears ~5–6 months
  • Babinski (plantar): upgoing toes normal until 12–18 months

Hip Examination – DDH Screening

  • Ortolani test: relocates dislocated hip – feel/hear "clunk" as femoral head returns to acetabulum
  • Barlow test: dislocates unstable hip – posterior pressure on adducted hip
  • Risk factors: female sex, breech presentation, family history, oligohydramnios
  • Positive screen → urgent USS hip within 2 weeks

Other Examination Points

  • Red reflex (bilateral) – absence suggests congenital cataract/retinoblastoma
  • Palate – cleft assessment with light and gloved finger
  • Femoral pulses – absent/weak = coarctation of aorta
  • Genitalia – ambiguous genitalia needs urgent multidisciplinary review
Neonatal Jaundice

Physiological Jaundice

  • Appears day 2–3, resolves by day 7 (term) or day 14 (preterm)
  • Unconjugated (indirect) bilirubin
  • Caused by: shortened RBC lifespan, immature hepatic conjugation, increased enterohepatic circulation
  • Well neonate, no haemolysis, bilirubin below phototherapy threshold

Pathological Jaundice (red flags)

  • Day 1 jaundice (any) = pathological until proven otherwise
  • Rapidly rising bilirubin (>8.5 μmol/L/hour)
  • Persisting beyond day 14 (term) or day 21 (preterm) = conjugated jaundice screen
  • Dark urine + pale stools = conjugated hyperbilirubinaemia → biliary atresia excluded urgently

Bilirubin Assessment Tools

G6PD (glucose-6-phosphate dehydrogenase) deficiency prevalence is high throughout the GCC region — up to 25% in some Gulf populations. G6PD deficiency causes haemolytic jaundice, presents early (day 1–2), may be severe and progress rapidly to exchange transfusion levels. Screen all neonates for G6PD in high-prevalence populations. Avoid G6PD-precipitating agents: certain medications (e.g. nitrofurantoin, some antimalarials), henna, naphthalene (mothballs). Jaundice may recur with oxidant stress throughout life.

Neonatal Resuscitation (NLS Algorithm)

Newborn Life Support (NLS) – Step-by-Step Algorithm
All staff in attendance at high-risk deliveries must be NLS-trained. Two-person resuscitation is ideal. Document all actions with accurate timestamps.
1
Dry & Stimulate (30 seconds): Dry vigorously with warm towels, replace wet towel, stimulate by rubbing back/soles of feet. Exception: do NOT vigorously stimulate if <28 weeks — place in polyethylene bag immediately without drying.
2
Assess Tone / Breathing / Heart Rate (the 3 S's): Skin tone (flexed vs floppy), Spontaneous breathing (present/absent), Sounds/HR (auscultate with stethoscope — most reliable; pulse oximetry may take 2–3 min to register).
3
Position & Airway: Neutral position (slight neck extension). Suction only if meconium-stained liquor AND baby is not vigorous (no routine suctioning of vigorous meconium babies — evidence does not support it).
4
If HR <100 or absent breathing → Give 5 Inflation Breaths: Duration 2–3 seconds each, pressure 30 cmH2O (20 cmH2O in preterm), via T-piece resuscitator (preferred over bag-mask for pressure control). FiO2: 21% (air) in term; 21–30% in preterm <35 weeks. Reassess HR after 5 breaths.
5
If HR improves → Continue Ventilation at 30–40 breaths/min until regular breathing established. Titrate FiO2 with pulse oximetry to target SpO2.
6
If HR <60 after 30 seconds of effective ventilation → Start Chest Compressions: 2-thumb encircling technique (preferred). Depth: 1/3 chest diameter. Ratio: 3 compressions : 1 ventilation breath (3:1). Rate: ~90 compressions + 30 breaths per minute. Increase FiO2 to 100%.
7
Vascular Access & Drugs: Umbilical venous catheter (UVC) — fastest vascular access in neonatal resuscitation; insert 3–5 cm until free flow of blood. Adrenaline (epinephrine): 10–30 mcg/kg IV/IO/UVC (0.1–0.3 mL/kg of 1:10,000 solution). Repeat every 3–5 minutes if persistent bradycardia.
Meconium-Stained Liquor (MSL)
  • Present in ~10–15% of deliveries
  • Vigorous baby: crying, good tone, HR >100 → NO routine suction; dry and stimulate as normal
  • Non-vigorous baby: consider direct laryngoscopy; suction under direct vision if thick meconium obstructing airway
  • Risk of meconium aspiration syndrome (MAS) — causes ball-valve obstruction, pneumonitis, PPHN
  • Avoid bag-mask ventilation if large meconium plug suspected (may drive meconium further)
Temperature Control
  • Target: 36.5–37.5°C for all neonates
  • <28 weeks: immediately into polyethylene bag/wrap (head out) without pre-drying; warm delivery room ≥26°C; radiant warmer; warmed humidified gases
  • Hypothermia (<36°C) increases mortality, metabolic acidosis, hypoglycaemia, coagulopathy
  • Hyperthermia (>38°C) worsens HIE outcomes — avoid in perinatal asphyxia
  • Hat for all small preterm infants immediately after delivery
Pre-term Delivery Preparation

Antenatal Corticosteroids (ACS)

  • Betamethasone: 2 doses 24 hours apart IM (12 mg each), ideally 24h–7 days before delivery
  • Indicated at 23–34+6 weeks (consider up to 36+6 in some guidelines)
  • Benefits: reduced RDS, IVH, NEC, neonatal mortality
  • Mechanism: accelerates pulmonary surfactant maturation

Surfactant Therapy – Indications

  • RDS (respiratory distress syndrome) in preterm
  • Early surfactant (prophylactic in <27 weeks; rescue in others)
  • LISA technique (Less Invasive Surfactant Administration): thin catheter into trachea whilst on CPAP — avoids intubation and ventilator-associated lung injury
  • INSURE: Intubate → Surfactant → Extubate to CPAP

Magnesium Sulphate – Neuroprotection

  • Indicated when delivery anticipated <32 weeks gestation
  • Loading dose: 4g IV over 20–30 minutes; maintenance 1–2g/h until delivery or for 24 hours
  • Reduces cerebral palsy risk by ~30%
  • Monitor for magnesium toxicity: loss of patellar reflexes, respiratory depression, cardiac arrest
  • Antidote: calcium gluconate 1g IV

Preparation Checklist

  • Resuscitaire functional, pre-warmed
  • T-piece resuscitator checked
  • Intubation equipment: correct ET tube sizes (2.5/3.0/3.5 mm)
  • Surfactant drawn up and at 37°C
  • UVC trolley prepared
  • Neonatal team briefed; roles assigned
Post-Resuscitation Stabilisation
ParameterTargetAction if Outside Range
SpO2 (term, first 10 min)60% at 1 min → 91–95% by 10 minTitrate FiO2
Blood glucose2.6–7.0 mmol/LDextrose infusion; check feeds
Temperature36.5–37.5°CWarm/cool as needed; cooling if HIE criteria met
Blood pressureMAP ≥ gestational age (in mmHg)Dopamine/dobutamine; volume if shocked
pH7.25–7.45Ventilation adjustment; sodium bicarbonate rarely

Respiratory Support in NICU

CPAP (Continuous Positive Airway Pressure)
  • Non-invasive; delivers continuous distending pressure to maintain alveolar patency throughout respiratory cycle
  • Reduces work of breathing; conserves surfactant; prevents atelectasis
  • Settings: Pressure 4–8 cmH2O; FiO2 titrated to maintain SpO2 91–95% (preterm) / 94–98% (term)
  • Interfaces: binasal prongs (preferred), nasal mask, nasopharyngeal tube
  • Complications: nasal septum trauma, abdominal distension (pass NG tube), pneumothorax
  • INSURE technique: Intubate → give Surfactant → Extubate back to CPAP; minimises mechanical ventilation
  • Failure criteria: FiO2 >40–50%, apnoea, worsening blood gases → escalate
High Flow Nasal Cannula (HFNC)
  • Heated, humidified gas at flow 2–8 L/min (up to 2 L/kg/min)
  • Generates variable low-level CPAP effect; washes out nasopharyngeal dead space
  • Less nasal trauma than prong CPAP; easier to nurse
  • Indications: mild–moderate RDS, post-extubation support, apnoea of prematurity (AOP)
  • Note: Generated pressure is unpredictable — not equivalent to CPAP for severe RDS
  • Monitor for gastric distension; pass NG tube
  • Non-inferior to CPAP as post-extubation support in many RCTs
Conventional Mechanical Ventilation

Ventilation Modes

  • SIMV (Synchronised Intermittent Mandatory Ventilation): set mandatory breaths synchronised with baby's effort; allows spontaneous breathing between
  • AC/SIPPV (Assist Control / Synchronised IPPV): every breath triggered; risk of hyperventilation if baby breathes too fast
  • PRVC/VG (Pressure-Regulated Volume Control / Volume Guarantee): volume-targeted; pressure auto-adjusted; reduces lung injury
  • Volume Guarantee (VG): preferred mode in many NICUs — target tidal volume 4–6 mL/kg; reduces BPD and IVH

Target Blood Gas Parameters

  • pH: 7.25–7.40
  • PaO2: 7–10 kPa (50–75 mmHg)
  • PaCO2: 5.5–7 kPa (45–55 mmHg) — permissive hypercapnia acceptable in preterm to reduce volutrauma

Ventilator Settings

  • PIP (Peak Inspiratory Pressure): set to achieve adequate chest rise and tidal volume 4–6 mL/kg
  • PEEP (Positive End-Expiratory Pressure): 4–6 cmH2O standard
  • Rate: 40–60 breaths/min (SIMV); 30–60 (AC)
  • I:E ratio: typically 1:2 to 1:1.5
  • FiO2: lowest to maintain target SpO2; wean actively

Extubation Criteria

  • FiO2 <30%
  • MAP <8 cmH2O
  • Adequate spontaneous respiratory effort
  • Acceptable blood gases
  • Caffeine loading prior to extubation in preterm (reduces apnoea)
  • Plan for post-extubation CPAP or HFNC
HFOV – High Frequency Oscillatory Ventilation
  • Delivers very small tidal volumes at high frequency (10–15 Hz), superimposed on a constant mean airway pressure (MAP)
  • Reduces volutrauma; good for: refractory hypoxia, pulmonary interstitial emphysema (PIE), diffuse atelectasis
  • MAP: set 1–2 cmH2O above conventional MAP; aim for optimal lung inflation
  • Frequency: 10–15 Hz (higher = less CO2 elimination per stroke — counterintuitive)
  • Amplitude (ΔP): adjusted to achieve visible chest "wiggle/jiggle" — indicator of adequate CO2 removal
  • FiO2: titrated as per oxygen targets
  • Monitor for air trapping, over-inflation on CXR
iNO – Inhaled Nitric Oxide
  • Selective pulmonary vasodilator — inhaled NO diffuses to vascular smooth muscle, causes localised vasodilation without systemic hypotension
  • Primary indication: PPHN (Persistent Pulmonary Hypertension of the Newborn) in ≥34 weeks gestation with hypoxic respiratory failure (OI ≥25)
  • Standard dose: 20 ppm; titrate down over days
  • Response: improvement in oxygenation within 30–60 minutes
  • Monitor: methaemoglobinaemia (MetHb <5%); NO2 levels
  • Do NOT abruptly discontinue — risk of rebound pulmonary hypertension; wean gradually
  • Non-responders: consider ECMO referral
Surfactant Therapy

Available Preparations

DrugSourceDose
Poractant alfa (Curosurf)Porcine100–200 mg/kg intratracheally
Beractant (Survanta)Bovine100 mg/kg intratracheally
Calfactant (Infasurf)Bovine105 mg/kg intratracheally
Note: Poractant alfa and beractant are derived from animal sources. This is generally permissible under necessity (darura) in Islamic jurisprudence; however, institutional policies in GCC may vary. Consult hospital ethics/chaplaincy as needed.

LISA Technique (Less Invasive Surfactant Administration)

  • Baby remains on CPAP (spontaneously breathing)
  • Thin catheter (e.g. 5Fr feeding tube) passed through vocal cords under direct laryngoscopy
  • Surfactant instilled over 1–2 minutes
  • Catheter removed; CPAP maintained throughout
  • Advantages: avoids intubation/ventilation; less lung injury; faster CPAP stabilisation
  • Requires: adequate spontaneous breathing, pre-medication (sucrose/fentanyl per protocol)
Retinopathy of Prematurity (ROP) – Oxygen Management

Hyperoxia causes abnormal retinal neovascularisation in preterm infants. Strict oxygen targeting is a key nursing responsibility in NICU.

SpO2 target in <32 weeks gestation: 91–95%. SpO2 alarm limits: Low 90%, High 95%. Any alarm >95% triggers immediate FiO2 reduction. Document FiO2 changes every nursing entry.
GestationSpO2 TargetRationale
<32 weeks (NICU phase)91–95%Reduces ROP risk; avoids free radical damage
32–36 weeks93–97%Lower ROP risk; broader target acceptable
Term/corrected ≥37 weeks94–98%Normal physiological target
During procedures (suction/repositioning)Allow transient dips; respond if <85% >30 secondsMinimise unnecessary FiO2 increases

ROP screening: ophthalmology review at 31–32 weeks corrected age (or 4 weeks chronological age, whichever is later) for all infants <32 weeks or <1500g.

Common NICU Conditions

Necrotising Enterocolitis (NEC)

Devastating bowel inflammation/necrosis primarily in preterm infants; one of the leading causes of mortality and morbidity in the NICU.

Bell's Modified Staging

StageClassificationSystemic SignsAbdominal SignsRadiological Signs
Stage ISuspected NECTemperature instability, apnoea, bradycardiaMild distension, feeding intolerance, pre-feed aspiratesNormal or mild ileus
Stage IIConfirmed NECAs above + metabolic acidosis, thrombocytopeniaGross distension, absent bowel sounds, bloody stoolsPneumatosis intestinalis (gas in bowel wall), portal venous gas
Stage IIIAdvanced NECShock, DIC, hypotension, severe apnoeaPeritonitis, erythema of abdominal wall, severe tendernessPneumoperitoneum (free air = perforation)

Management

  • Nil by mouth (NBM) — bowel rest
  • Nasogastric (NG) tube — free drainage
  • IV antibiotics: piperacillin-tazobactam + gentamicin + metronidazole (local protocol variation)
  • Total Parenteral Nutrition (TPN) — maintain nutrition while NBM
  • Strict fluid balance; frequent clinical review every 4–6 hours
  • Surgical consultation for Stage IIB/III: peritoneal drain vs laparotomy
  • Serial AXR (abdominal X-ray) every 6–12 hours to monitor progression
  • Blood cultures prior to antibiotics
  • Correct coagulopathy: FFP, platelets as needed
  • Duration of antibiotics: 7–10 days (confirmed); 14 days (post-operative)
Human breast milk (own mother's milk or pasteurised donor breast milk) significantly reduces the incidence of NEC compared to formula. Regarding donor breast milk in the GCC context: the predominant view among Islamic scholars is that donor breast milk from an Islamic milk bank is permissible when medically necessary, provided milk kinship (rada'a) is documented to allow future marriage decisions. Saudi Arabia, UAE, and several GCC states have issued fatwas permitting donor milk under controlled conditions. Each family should receive counselling and informed consent documentation. Where donor milk is unavailable, formula is preferable to withholding nutrition.

NEC Prevention Bundle

Own mother's breast milk as first choice · Trophic feeds early (within 24–48h if stable) · Standardised feeding advancement protocol · Probiotic supplementation per local protocol · Avoid unnecessary antibiotic exposure · Hand hygiene bundles
Intraventricular Haemorrhage (IVH)

Bleeding originating in the germinal matrix (highly vascularised, fragile tissue present until ~34 weeks), extending into the ventricles. Primarily affects preterm infants <32 weeks.

Papile Grading System

GradeDescriptionPrognosis
Grade IGerminal matrix haemorrhage only; no ventricular extensionExcellent; usually no long-term deficit
Grade IIBlood in ventricles; <50% ventricular volume; no dilationGood; minor risk of neurodevelopmental problems
Grade IIIBlood fills >50% of ventricle; ventricular dilationSignificant risk of neurodevelopmental impairment
Grade IVPeriventricular haemorrhagic infarction (PVHI); parenchymal extensionHigh mortality/severe disability risk

Screening Protocol

  • Cranial ultrasound (USS): Day 3 and Day 7 in all <32 weeks
  • Repeat USS at 36 weeks corrected if Grade III/IV found
  • MRI brain at term-equivalent age (36–40 weeks) in Grade III/IV

Prevention Strategies

  • Antenatal corticosteroids (ACS)
  • Magnesium sulphate for neuroprotection <32 weeks
  • Delayed cord clamping (30–60 seconds)
  • Avoid fluctuations in cerebral blood flow: gentle handling, head midline, avoid rapid IV boluses
  • Correct haemodynamic instability early
  • Prophylactic indomethacin (some centres)
Hypoxic-Ischaemic Encephalopathy (HIE)

Criteria for Therapeutic Hypothermia

All criteria must be met:

  • Gestation ≥36 weeks
  • Clinical evidence of perinatal asphyxia (at least one of): Apgar ≤5 at 10 min / cord pH <7.0 or base deficit ≥16 / need for resuscitation at 10 minutes
  • Clinical evidence of encephalopathy on examination or aEEG
  • Within 6 hours of birth (cooling must start within 6 hours)

Cooling Protocol

  • Target temperature: 33.5°C (range 33–34°C) core rectal/oesophageal
  • Duration: 72 hours using cooling blanket or vest system
  • Rewarm passively at 0.5°C/hour after 72 hours
  • Avoid hyperthermia during rewarming

Monitoring During Cooling

  • aEEG (amplitude-integrated EEG): continuous brain monitoring — detect seizures, assess background pattern recovery
  • Continuous core temperature monitoring
  • 4-hourly observations: HR, BP, glucose, electrolytes, coagulation
  • Avoid medications that cause hypotension during cooling

Seizure Recognition in Neonates

  • Subtle seizures: eye deviation, cycling limb movements, apnoea, lip smacking — most common in term; may be missed
  • Tonic: sustained posturing (flexion/extension)
  • Clonic: rhythmic jerking; focal or multifocal
  • Myoclonic: sudden jerks; may be normal sleep myoclonus — EEG differentiates
  • Treatment: phenobarbitone first-line (20 mg/kg IV); levetiracetam second-line
Patent Ductus Arteriosus (PDA)

Persistence of the foetal communication between pulmonary artery and descending aorta. Clinically significant PDA causes left-to-right shunting, pulmonary overcirculation, and systemic steal.

Clinical Features

  • Continuous or systolic murmur ("machinery murmur") at upper left sternal edge
  • Bounding pulses; wide pulse pressure
  • Increasing respiratory support requirements
  • Hypotension, poor perfusion (systemic steal)
  • Confirm with echocardiography

Management Options

  • Conservative: fluid restriction, diuretics, optimal PEEP; many PDAs close spontaneously
  • Medical (COX inhibitors): ibuprofen or indomethacin IV — promote ductal closure (avoid if renal impairment, bleeding, NEC)
  • Paracetamol: emerging evidence as COX inhibitor for PDA closure
  • Surgical ligation: for symptomatic PDA failing medical management
  • Catheter-based closure: in eligible patients (>~1.5 kg)

Neonatal Nutrition & Developmental Care

Breast Milk – Benefits & NICU Support

Why Breast Milk is Gold Standard

  • Anti-infective properties: secretory IgA, lactoferrin, lysozyme, macrophages, lymphocytes
  • Growth factors: EGF, IGF, TGF-β — promotes gut maturation
  • Species-specific: exactly matched to human neonatal needs; formula is an approximation
  • NEC prevention: exclusive breast milk feeds reduce NEC by ~58% compared to formula
  • Neurodevelopmental: DHA/ARA in breast milk promotes brain and retinal development
  • Reduces rates of: sepsis, ROP, BPD, rehospitalisation, SIDS

Supporting Lactation in NICU

  • Expressing schedule: 8–12 times per 24 hours, including at least once overnight; begin within 1–6 hours of birth
  • Hospital-grade electric double pump most effective
  • Colostrum: rich in immune factors; even small volumes (0.5–1 mL per feed) are valuable
  • Label all expressed breast milk (EBM): mother's name, date, time, volume
  • Stored at 4°C for up to 5 days (refrigerated) or 3–6 months (frozen at −18°C)
  • Kangaroo mother care (KMC) promotes prolactin release and lactation success
  • Lactation consultant referral for all NICU families
Enteral Feeding Advancement in Preterm
PhaseVolumeRationale
Trophic / Minimal Enteral Feeds (MEF)10–20 mL/kg/dayPrimes gut; stimulates gut hormones; does not provide full nutrition — TPN concurrent
Incremental advancementIncrease by 15–20 mL/kg/dayAllows gut adaptation; monitor tolerance at each increment
Full enteral feeds150–180 mL/kg/day (preterm)Full nutritional requirements met; aim within 7–14 days in stable preterm
FortificationHuman milk fortifier (HMF) addedAdds protein/calcium/phosphorus to breast milk for growing preterm (<34 weeks, <1800g)

Feed Tolerance Assessment

Bilious aspirates are a red flag for bowel obstruction or NEC — do NOT recommence feeds until surgical/medical review completed.
Total Parenteral Nutrition (TPN) in Preterm

Macronutrients

ComponentDay 1Target
Amino acids (protein)1.5 g/kg/day3.5–4 g/kg/day
Lipid emulsion0.5–1 g/kg/day3 g/kg/day
Glucose6–8 mg/kg/min GIRMaintain BG 2.6–10 mmol/L
Total fluid60–80 mL/kg/day150–180 mL/kg/day (EBM included)

Monitoring TPN

  • Blood glucose every 3–6 hours initially
  • Electrolytes (Na/K/Ca/Phos/Mg) daily initially
  • Triglycerides twice weekly (lipids)
  • LFTs weekly (TPN cholestasis risk)
  • Direct bilirubin (conjugated) weekly if prolonged TPN
  • Strict catheter care (PICC/UVC/UAC): infection bundle, daily site inspection
Developmental Care – NIDCAP Framework

Neonatal Individualised Developmental Care and Assessment Program (NIDCAP) — minimises sensory overload and supports neurodevelopment in the NICU environment.

Core Principles

  • Cluster care: group all nursing interventions together to allow longer uninterrupted rest periods
  • Noise reduction: keep NICU noise <45 dB (incubator); avoid tapping on incubators; speak quietly
  • Light management: dim lighting for sleep cycles; cover incubators with blankets; avoid direct bright light
  • Nested positioning: boundaries/nests create a contained environment mimicking the uterus; promotes flexion, reduces stress behaviours
  • Non-nutritive sucking (NNS): pacifier/dummy during tube feeds — promotes oral development, calms infant, reduces pain response

Kangaroo Mother Care (KMC)

  • Skin-to-skin contact: baby (nappy only) placed prone on parent's chest
  • Benefits: thermal regulation, improved oxygenation, weight gain, breastfeeding success, bonding, microbiome colonisation with maternal organisms, reduced cortisol (stress), reduced length of hospital stay
  • Commence as early as the clinical condition allows (even on respiratory support in stable infants)
  • WHO recommends KMC as standard of care for stable preterm/LBW infants
Cultural integration of KMC in GCC: some families may require private screens/curtained areas to maintain modesty (Islamic values regarding awra). Nursing staff should proactively offer private spaces and facilitate fathers and mothers equally in KMC. Involving grandmothers (who carry significant cultural authority) in KMC education can improve uptake. Avoid cultural assumptions — assess individual family preferences.

Donor Breast Milk — GCC Islamic Jurisprudence Context

The issue of donor breast milk in GCC NICUs intersects with Islamic law on rada'a (milk kinship/fosterage). Islamic jurisprudence holds that if a woman breastfeeds an infant 5 or more times (per most madhabs), a milk-kinship relationship is established, creating marriage prohibitions similar to blood relations. This has historically led to reluctance among Muslim families to use donor breast milk from unknown donors.

However, the contemporary scholarly consensus — including rulings from the International Islamic Fiqh Academy (IIFA), Saudi Arabia's Council of Senior Scholars, and UAE fatwa bodies — is that:

Nursing practice recommendation: provide families with written information in Arabic about the milk bank process, the fatwa position, and the medical evidence. Offer an interpreter and, where requested, facilitate a meeting with a hospital Islamic scholar. Respect parental decision-making and document the discussion in the medical record.

GCC Context & Exam Preparation

GCC-Specific NICU Epidemiology

High IVF Rate → Preterm

GCC countries have among the highest rates of assisted reproductive technology (ART) globally. IVF multiple pregnancies (twins, triplets) significantly increase preterm birth rates, NICU admissions, and complex neonatal presentations.

Consanguinity & Genetics

High consanguinity rates in GCC (20–60% in some populations) increase autosomal recessive conditions: metabolic disorders (PKU, organic acidaemias), haemoglobinopathies, congenital anomalies — these may present in the NICU.

G6PD Deficiency

Prevalence up to 25% in some Gulf populations (X-linked recessive; affects males more severely). Presents as severe early-onset jaundice, haemolytic anaemia. Standard neonatal screening in most GCC countries. Avoid triggers throughout life.

Neonatal Screening Programmes in GCC
CountryNumber of ConditionsNotable Inclusions
Saudi Arabia (MOH)~12 conditionsG6PD, CH, PKU, CAH, galactosaemia, biotinidase, haemoglobinopathies, amino acid disorders
UAE (DHA/DOH)~9 conditionsG6PD, CH, PKU, CAH, galactosaemia; expanding programme
Qatar (NCDC)~20+ conditionsExpanded NBS panel including fatty acid oxidation disorders
Kuwait, Bahrain, OmanVariable; 5–15+Core conditions; programmes expanding
Heel-prick (Guthrie card) collected at 48–72 hours of age (post-feeding). Early discharge or transfers must ensure the test is completed. Abnormal screen requires urgent repeat and specialist metabolic referral — not a diagnosis, requires confirmation.
Regulatory Bodies & Exam Preparation (DHA / DOH / SCFHS)

Key Regulatory Bodies

  • SCFHS (Saudi Commission for Health Specialties) — Saudi Arabia nursing licensing and classification exams
  • DHA (Dubai Health Authority) — healthcare professional licensing in Dubai; DHA exam for nurses
  • DOH (Department of Health Abu Dhabi) — Haad/DOH exam for Abu Dhabi licensing
  • MOPH Qatar — prometric-based exam for Qatar registration
  • MOH Kuwait/Oman/Bahrain — country-specific licensing requirements

High-Yield Neonatal Exam Topics

  • NLS algorithm: correct sequence and drug doses
  • Apgar score: components and scoring
  • NEC: Bell's staging and management steps
  • IVH: Papile grading and USS timing
  • Jaundice: physiological vs pathological, phototherapy thresholds
  • G6PD: prevalence, triggers, neonatal presentation
  • SpO2 targets: preterm <32 weeks = 91–95% (not 94–98%)
  • HIE cooling criteria: ≥36 weeks, within 6 hours
  • Surfactant: LISA vs INSURE
  • Breast milk: benefits and NICU support strategies
10 MCQ Practice Questions
1. A premature infant at 29 weeks gestation is on CPAP. What is the correct SpO2 target range for this infant?
  • A. 88–92%
  • B. 91–95%
  • C. 94–98%
  • D. 96–100%
Answer: B – 91–95%. This is the strict target for infants <32 weeks to prevent retinopathy of prematurity (ROP). Higher SpO2 increases risk of ROP. Lower than 91% increases risk of hypoxic injury. Alarm limits should be set at 90% (low) and 95% (high).
2. A term neonate is found to have jaundice at 16 hours of age. The next most appropriate step is:
  • A. Reassure parents; recheck at 48 hours
  • B. Start phototherapy empirically
  • C. Measure total serum bilirubin and plot on Bhutani nomogram
  • D. Increase feeding frequency and discharge if feeding well
Answer: C. Any jaundice appearing within 24 hours is pathological until proven otherwise. TSB must be measured immediately and plotted against age in hours on the Bhutani nomogram (or NICE NG98 threshold chart) to determine the treatment threshold. G6PD screen should also be sent.
3. During neonatal resuscitation, the newborn has no respiratory effort and HR is 50 bpm after 30 seconds of effective ventilation. What is the next step?
  • A. Increase ventilation rate to 60 breaths/min
  • B. Administer adrenaline 100 mcg/kg IV
  • C. Start chest compressions at 3:1 ratio with ventilation, increase FiO2 to 100%
  • D. Intubate and give surfactant
Answer: C. NLS algorithm: if HR <60 after 30 seconds of effective positive pressure ventilation, begin chest compressions using 2-thumb encircling technique at 3:1 compression-to-ventilation ratio, and increase FiO2 to 100%. Adrenaline (10–30 mcg/kg) is given if HR remains <60 after compressions are established.
4. A preterm infant at 26 weeks has an abdominal X-ray showing pneumatosis intestinalis. According to Bell's staging, this is classified as:
  • A. Stage I – Suspected NEC
  • B. Stage II – Confirmed NEC
  • C. Stage III – Advanced NEC with perforation
  • D. Normal finding in premature infants
Answer: B. Pneumatosis intestinalis (gas in the bowel wall) is the radiological hallmark of Stage II (confirmed) NEC. Pneumoperitoneum (free air under the diaphragm) indicates Stage III (perforation). Portal venous gas is also a Stage II finding and carries a poor prognosis.
5. Which of the following is a contraindication to therapeutic hypothermia for HIE?
  • A. Cord pH of 6.95
  • B. Apgar score of 3 at 10 minutes
  • C. Gestational age of 34+2 weeks
  • D. Onset of seizures at 4 hours of age
Answer: C. Therapeutic hypothermia is indicated at ≥36 weeks gestation. Evidence from the landmark trials (TOBY, CoolCap, NICHD) was established in term/near-term infants ≥36 weeks. There is insufficient evidence and potential harm for hypothermia in infants <36 weeks; it is therefore currently contraindicated in this group.
6. A neonate presents with jaundice on day 1 and the G6PD screen returns low. The mother reports she applied henna to her abdomen during late pregnancy. What is the most likely mechanism of jaundice?
  • A. Physiological jaundice due to RBC breakdown
  • B. ABO incompatibility causing immune haemolysis
  • C. G6PD deficiency-induced haemolytic jaundice triggered by oxidant exposure (henna)
  • D. Biliary atresia causing conjugated hyperbilirubinaemia
Answer: C. Henna (lawsone) is an oxidant that can cross the placenta and trigger haemolysis in G6PD-deficient neonates. G6PD deficiency is highly prevalent in GCC populations. Day 1 jaundice from G6PD haemolysis can be severe and progress rapidly to exchange transfusion levels. Henna application to skin is a traditional cultural practice that carries risk for G6PD-deficient neonates.
7. In the LISA (Less Invasive Surfactant Administration) technique, what distinguishes it from conventional surfactant administration (INSURE)?
  • A. LISA uses a higher dose of surfactant
  • B. LISA requires general anaesthesia
  • C. LISA instils surfactant via thin catheter while the infant remains on CPAP without intubation
  • D. LISA is only suitable for infants >32 weeks gestation
Answer: C. LISA involves inserting a thin catheter (e.g. 5Fr feeding tube) through the vocal cords under laryngoscopy, instilling surfactant, then removing the catheter while the infant continues spontaneous breathing on CPAP. INSURE involves intubation, surfactant, then extubation to CPAP. LISA avoids the risks of intubation and mechanical ventilation and is associated with less BPD and less need for mechanical ventilation.
8. An infant born at 30 weeks gestation has a cranial ultrasound on day 3 showing blood filling 60% of the right lateral ventricle with ventricular dilation but no parenchymal extension. This is classified as:
  • A. IVH Grade I (Papile)
  • B. IVH Grade II (Papile)
  • C. IVH Grade III (Papile)
  • D. IVH Grade IV (Papile)
Answer: C. Papile Grade III = blood filling >50% of the ventricular volume with ventricular dilation. Grade IV (now termed Periventricular Haemorrhagic Infarction, PVHI) involves parenchymal extension/haemorrhagic infarction. Grade I = germinal matrix only; Grade II = blood in ventricle, <50% volume, no dilation.
9. What is the correct ratio of chest compressions to ventilation breaths in neonatal resuscitation?
  • A. 15:2
  • B. 30:2
  • C. 3:1
  • D. 5:1
Answer: C – 3:1. Neonatal resuscitation uniquely uses a 3:1 ratio (3 compressions to 1 ventilation breath), giving approximately 90 compressions and 30 breaths per minute. This differs from adult CPR (30:2) because neonatal cardiac arrest is almost always secondary to respiratory compromise — adequate ventilation is therefore paramount in neonates.
10. A 28-week infant on TPN. On day 3, amino acid infusion should ideally be targeting which range?
  • A. 0.5–1 g/kg/day
  • B. 1.0–1.5 g/kg/day
  • C. 2.5–3.5 g/kg/day (advancing toward target of 3.5–4 g/kg/day)
  • D. 5–6 g/kg/day
Answer: C. In preterm TPN, amino acids should start on day 1 at 1.5 g/kg/day and advance to 3.5–4 g/kg/day. By day 3, the target should be in the 2.5–3.5 g/kg/day range. Adequate protein is critical for preventing catabolism and supporting brain growth in the NICU. Lipids similarly advance from 0.5–1 g/kg/day on day 1 to a target of 3 g/kg/day.

Neonatal Jaundice Action Tool

Based on NICE NG98 thresholds. For clinical decision-support only — always apply clinical judgement and consult senior clinician.