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It occurs intermittently after feeds Noncommunicating hydrocele buy female viagra toronto, more often on the right in normal infants and is of no signifcance discount 100 mg female viagra. If the attacks are prolonged female viagra 50 mg amex, discomfort purchase 100 mg female viagra with mastercard, fatigue and malnutrition may side, presenting with a well transilluminated scrotal swell- develop. It usually disappears nostril, orbital pressure, carotid sinus pressure, induction spontaneously by 6 months of age. In case of its persis- of vomiting and therapy with drugs such as chlorpromazine tence beyond one year of age, herniotomy is needed. Nonretractable Prepuce Nasolacrimal Duct Blockade (Physiological Phimosis) A proportion (2%) of the newborn may have persistent Many male newborns may have a prepuce that is adherent watery discharge and even conjunctivitis (usually unilat- to the underlying glans. Te condition should be consid- the nasolacrimal duct and clears spontaneously by 1–3 ered pathological only if the difculty in retracting the pre- months. All that is needed is frequent wash of the eye with puce over the glans is persistent beyond 3 years of age and a moist sterile swab and gentle massage of the skin over causes bulging of the foreskin on passing urine. In the presence of an infection, antimi- Mothers need to be advised not to attempt to forcibly crobial eye drops may be indicated. Hymenal Tags About 60% of normal baby girls show mucosal tags at the Umbilical Hernia (Fig. Such a baby measures 46 cm or less z Buccal pad of fat is prominent in length (crown-heel) and has head circumference of 32 cm z Excessive lanugo hair present all over the body or less. Bright light is supposed to z Retinopathy of prematurity (earlier termed retrolental fbropla- act by producing chemically excited state and generating sias) (Fig. Ponderal and thin, skin losing its normal elasticity and hanging in index* is below 2 against the normal of over 2. An artist’s depiction labia minora and clitoris are edematous so that labia majora are widely of the condition developing in a premature infant’s eye as a result of placed and not covering labia minora. Maternal malnutrition, heart disease, tuberculosis, renal disease and bronchial pregnancy-induced hypertension and other diseases asthma, etc. Since cell population is reduced, adverse infuence early during gestation, reducing growth potential is considerably afected, resulting in both cell number and cell size. Incidence of accompanying congenital malformations Twin pregnancy: After 35 weeks of gestation, the is high. Te early in embryonic life causing hypoplastic type of magnitude of infants in developing world is enormous. Out of a total of 22 million such infants in the world, 21 Placental dysfunction:Maternal problems such as toxe- million belong to the developing countries. India’s share mias of pregnancy and hypertension may be responsi- is quite substantial—7–10 million. Birth (perinatal) asphyxia as a result of cerebral anoxia Hypothermia Prevention Hypoglycemia Female literacy and formal education:A well-informed, Polycythemia from chronic hypoxia educated mother is likely to have better health before and Food intolerance during pregnancy, avoid harmful agents and infuences Permanent retardation in linear growth and psycho- during pregnancy and show better reproductive perfor- motor development. Management is dictated by Maternal infections: Malaria, urinary tract infection this decision. Early feeding not only prevents hypoglycemia, but also To prevent hypothermia in the neonates. Prognosis Prompt and systematic resuscitation whenever indi- Intrauterine growth retardation infants are easy to feed cated. Clean hands: Hand hygiene, using sterile gloves z Detailed examination done and recorded. Clean cord tie: Clean and sterile ties/clamp passing urine 6–8 times/24 hours and sleeping well for 2–3 hours 4. Care in First Few Hours z Health education to mothers—proper mother care techniques like feeding, bathing, infection and prevention measures, etc. Warm chain z Proper discharge slip has been prepared and handed over to Exclusive breastfeeding, initiated within half-one hour parents. Before discharge, certain criteria Management of common problems of neonates must be met (Box 17. Early detection of high-risk cases and management Follow-up Safe and suitable referral to special care/intensive care centers. First follow-up visit—normal at 6 weeks when check-up as well as immunization can be given. Tis has a bearing on management, including tion is supine position rather than prone position. Since the dates z Rooming-in (bedding-in): Mother should be of last menstruation are frequently not forthcoming from encouraged to indulge in rooming-in, i. Yet another method umbilical stump is shed and the local area becomes of determining the gestational age is fetal ultrasonographic clean. Te expanded new Ballard scoring system (that in- sponging may be given after 24 hour of birth. Female: Widely separated labia majora with exposed labia minora and clitoris Discharge and Follow-up z Breast nodule: Less than 5 mm diameter All normal newborns need to stay in the hospital for a z Ear cartilage: Defcient with poor elastic recoil z Scalp hair: Wooly (fne) or fuzzy (fufy). Creases over 40–50 mm: –1 crease transverse 2/3 entire sole <40 mm: –2 crease only Breast Imperceptible Barely Flat areola–no Stripped areola, Raised areola, Full areola, perceptible bud 1-2 mm bud 3-4 mm bud 5-10 mm bud Eye/ear Lids fused Lids open, Slightly curved Well-curved Formed and Thick cartilage, loosely (–1), pinna fat, stays pinna; soft; slow pinna, soft but frm, instant ear stif tightly (–2) folded recoil ready recoil recoil Genitals, male Scrotum fat, Scrotum empty, Testes in upper Testes descend- Testes down, Testes pendu- smooth faint rugae canal, rare rugae ing, few rugae good rugae lous, deep rugae Genitals, Clitoris Prominent Prominent Majora and Majora large, Majora cover female prominent, clitoris, small clitoris, enlarging minora equally minora small clitoris and labia fat labia minora minora prominent minora Table 17. Presence of one or more of these As a rule, his ideal body temperature (axillary) should signs is an indication for prompt evaluation. Warm labor/delivery room with a minimal temperature of 25°C z Of color and lethargy 2. Delayed bathing—best postponed to end of frst week by which time the cord has fallen Pulmonary 7. Appropriate clothing; wrapping in several layers of warm, but z Tachypnea ( respiratory rate >60/min) light clothes rather than a single layer of thick cloth z Chest retractions/indrawing 8. Professional alertness—well-trained and sensitized healthcare Gastrointestinal providers z True diarrhea 10. Failure to pass urine by 48 hours Skin Clinical Features z Umbilical sepsis Low body temperature (35–30°C or even less), cold z Pyoderma skin with or without acrocyanosis (from peripheral z Sclerema. Te standard method of measuring Tachypnea and respiratory distress (from high pulmo- newborn’s body temperature is axillary thermometer. It is further categorized as: cally-controlled heated mattress) Cold stress: 36–36. Etiopathology Sclerema should arouse suspicion of: Cold injury Gram-negative septicemia Fig. Histologic changes include broadening around mother’s waist may assist in keeping the baby in position. Better growth Protection against infection Clinical Features Reduction in frequency of apneic spells Te overlying skin becomes hard and stretched and cannot Better mother-infant bonding. With the involvement of the thorax, respiratory Neonate-related difculty (shallow and rapid breathing) and cyanosis may z The neonates should have no medical problem. Treatment Mother-centric z The mother should be healthy, willing and coop- Terapy is directed at the underlying cause together with erative. Recovery occurs, despite aggres- sive treatment, only in a small proportion of cases. Kangaroo Mother Care is a very efective method of Appropriate clothing is employed to hold the baby in providing nursing and warmth through skin to skin contact position. Tis assists in keeping the baby warm Sanabria and Prof Martinez of the University of Colombia, all times. Bagota, Latin America in 1979 in response to shortage of He is made to feed at the breast on demand (minimal incubators and severe hospital infections. Maintenance of infant’s temperature Else, the baby may be wrapped in woolen clothing. A modern incubator, available in most specialized A severe form of hyperthermia develops in neonates nurseries, is an excellent device to maintain temperature and infants who are warmly dressed for the low outdoor and humidity according to baby’s requirements. Te incubator temperature should be such as the neonate contributes to development of fever with a will maintain the axillary temperature of the baby temperature as high as 41–44°C. Manifestations include fushing, apathy, dry and warm A low reading rectal thermometer, graduated for skin. Later, stupor, grayish pallor, coma, seizures and 20–40° range, is a must for accurate recording of the hemorrhagic shock may follow. Fluid and electrolyte imbalance, if present, should also be Tis enables accurate observations of his general corrected. Once oxygenation and temperature is maintained, breast- feeding should be started within half to one hour. It is not only species specifc, but Tis is an economic alternative for the expensive incubator also baby specifc. It contains all the nutrients for normal for providing microenvironment for high-risk neonates.

Debate has also arisen as to whether or not large proteins such as growth factors can penetrate the stratum corneum order female viagra 50mg free shipping. Growth factors are cytokines and proteins that regulate niques include liposomal transdermal delivery purchase female viagra american express, micropora- intercellular signaling buy generic female viagra 100mg online, cell growth discount 100mg female viagra otc, cell development, and tion, phonophoresis, and iontophoresis. Growth factors developed for skin care products include epidermal growth factor, transforming growth factor, and 20 Hormones platelet-derived growth factor. Endogenous hormones play a key role in the integrity of human skin, hair, and nails. The exogenous application of estrogen and testosterone is and proteins that regulate intercellular signaling, cell growth, under investigation; however, their use in topical prepara- cell development, and tissue repair. Topical estrogen and estro- teins for epithelial repair, promotes angiogenesis, and accel- gen–progesterone preparations are also currently used in erates wound healing. The improves memory and sexual function; limited studies how- wound healing benefits of growth factors have also been ever have been done on the effects of topically applied tes- evaluated with use after ablative and non-ablative laser resur- tosterone. Side effects of topically applied androgenic facing with treated skin exhibiting less erythema and steroids, including acne and hirsutism, have limited their use improved wound healing. However, when topically applied, these agents do not effectively penetrate the skin to reach the deeper muscles 21. Peptides are sequences of amino acids that mimic the been performed to prove any sustainable benefits. Three classes of peptides used in topical antiaging regi- cept with limited studies. The large size of these molecules mens include signal peptides, carrier peptides, and limits is penetration through the stratum corneum. The ability of these large-molecular-weight compounds are popularly used in over-the-counter antiaging regimens. Peptides are sequences of amino acids that mimic the amino acids in collagen and 1. Proteins are agents developed to improve skin and hair elastin and are believed to increase collagen and elastin syn- hydration thesis. One caveat of peptide use in skin products is the inability of these large- molecular-weight compounds to Protein when applied topically has the unique ability to penetrate the stratum corneum. Similar to a humectant, the There are three types of peptides used in cosmeceuticals: ability to hold water improves the appearance of aged skin signal peptides, carrier peptides, and neurotransmitter- by providing hydration and assisting in barrier repair. Proteins have also been added to many hair conditioners to Signal peptides are short-chain amino acids that augment restore hair shaft fractures induced by aging and repeated communication between cells. An alternative peptide, tyro- 23 Antiacne Agents sine-tyrosine-arginine-alanine-aspartic-alanine, inhibits pro- collagen C-proteinase, an enzyme that cleaves C-propeptide Many of the products previously mentioned in this chapter from procollagen-I and thereby decreases collagen break- including retinoids, salicylic acid, and azelaic acid are useful down. Alternatively, lysine-threonine-threonine-lysine-serine in the management of acne [194]. Azelaic acid is a Carrier peptides are peptides with an ability to deliver met- naturally occurring botanical with mild antimicrobial and als to the skin. Copper is a cofactor for lysyl ceuticals include niacinamide, which increases desquama- oxidase, the enzyme needed for collagen synthesis. Topical preparations containing 1–10% sulfur are mild peptide known as Argireline® (acetyl-glutamyl-glutamyl- keratolytics and bacteriostatic agents against P. Sodium methoxyl-glutaminyl-arginyl-arginylamide) function similar sulfacetamide is also a bacteriostatic agent with activity to botulism toxin. Argireline mimics the N-terminal domain against both gram-positive and gram-negative bacteria. Johns wort water based lotions Ginkgo biloba Abrasive scrubs Evening Primrose oil Toners Tea tree oil Astringents Allantoin Acetone Aloe vera Propylene glycol Panthenol Glycerin Bisabolol Glycolic acid Salicylic acid Lactic acid Fragrances Dyes 24 Anti-redness Agents 25 Irritancy Facial redness is multifactorial. Irritant and allergic dermatitis is common with over-the- lation and inflammation can be reduced by skin care products counter skin care products. Fragrances, preservatives, and vehicles are common cul- Product ingredients used for erythema include soothing agents prits of irritancy or hypersensitivity. Patient education regarding product ingredients and their and anti-inflammatory agents such as green tea [195]. Moisturizers proper use can enhance compliance and decrease skin and cosmetics have also been developed with green tinted color- irritation. Patients with facial redness should avoid products containing harsh acids such as salicylic Contact dermatitis, either irritant or allergic, is seen com- acid. Products with fragrance enhance irritancy and can poten- monly with cosmeceuticals [196]. Although many natural or synthetic products are potent skin developed to quantify skin firmness, blood flow, and skin sensitizers or irritants, the vehicles in which these products are hydration. These instruments are now in widespread use to made also contain preservatives, fragrances, and colorings that quantify and measure objective parameters, and will be use- can cause irritant or allergic contact dermatitis [197]. Conclusion Additionally, chemicals such as benzyl alcohol and benzyl In 2006, the cosmeceutical market rose to nearly eight bil- aldehyde, often used as a fragrance, can be added to products lion dollars in profits in the United States alone. These prod- development, use, and marketing of these products will ucts are routinely used in “fragrance free” cosmetics. Similarly, designed, randomized placebo-controlled trials and basic products labeled as “unscented” do not imply that no fra- science research is lacking. Vehicles containing these preser- vatives are so widespread that it is often challenging for the patient who has developed an irritant or allergic reaction to these agents to effectively depict the culprit ingredient. Bibliography Patch testing is recommended for any patient with contact dermatitis. Food and Drug about product ingredients is imperative, particularly when an Administration Center for Food Safety and Applied Nutrition unknown or treatment recalcitrant contact hypersensitivity Office of Cosmetics and Colors Fact Sheet. Cosmet Toilet 108:37–38 The increasing demand for cosmeceuticals and rapid growth 5. Exp Dermatol 15(7): need for improved methods to evaluate the safety and effi- 483–492 cacy of these products in well-controlled trials. A report from the Standardization Group of the European Society of Contact thered our knowledge and understanding of topical products Dermatitis. Skin color changes can also be objectively differentiation and barrier homeostasis. Skin Pharmacol Appl measured using tools such as tristimulus colorimeters that Skin Physiol 14 Suppl 1:28–34 11. Exp Dermatol envelope: an important marker of stratum corneum maturation in 16:490–499 healthy and dry skin. Loden M (2003) Role of topical emollients and moisturizers in the relates of the epidermal permeability barrier. Piacquadio D, Kligman A (1998) The critical role of the vehicle to barrier repair lipids alleviate childhood atopic dermatitis: changes therapeutic efficacy and patient compliance. J Am Acad Dermatol in barrier function provide a sensitive indicator of disease activity. Semin Cutan model for assessing the damaging effects of soaps and surfac- Med Surg 20:209–214 tants on human stratum corneum. Int J Dermatol izers to reduce dry skin and irritation and to prevent their return. Exp Dermatol 8(4): Divergent mechanisms for correction of permeability barrier dys- 261–266 function. Bikowski J (2001) The use of therapeutic moisturizers in various Influence of aging and malignant transformation on keratinocyte dermatologic disorders. Ludwig A, Dietel M, Schäfer G, Müller K, Hilz H (1990) Am Acad Dermatol 39:S2–S7 Nicotinamide and nicotinamide analogues as antitumor promoters 60. Dermatol Surg anisms of intrinsic skin aging and retinoid-induced repair and 31(7 Pt 2):860–865; discussion 865 reversal. J Am Acad Dermatol 54:507–512 of photodamaged skin after therapy with tretinoin emollient 84. J Am Acad Dermatol 25(2 Pt 1):231–237 photocarcinogenesis by topical nicotinamide. Coderch L, De Pera M, Fonollosa J, De La Maza A, Parra J (2002) 199(Suppl 1):57–60 Efficacy of stratum corneum lipid supplementation on human 66. Creidi P, Humbert P (1999) Clinical use of topical retinaldehyde 31(7 Pt 2):814–817; discussion 818 on photoaged skin. Joyeux M, Lobstein A, Anton R, Mortier F (1995) Comparative tene cream for the treatment of photodamage: a 12-month multi- antilipoperoxidant, antinecrotic and scavenging properties of ter- center, randomized trial. Scharffetter-Kochanek K, Wlaschek M, Brenneisen P (1997) tion topical antioxidants vitamin C and vitamin E.

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As aircraft increasingly incorporate Wi-Fi capa- bilities 100 mg female viagra, they may have the means to transfer data via a secure Internet method buy female viagra master card. Several companies currently manufacture devices for telemedicine services aboard aircraft 100mg female viagra fast delivery, including transmission of patient medical data purchase cheapest female viagra, audio, and video from the aircraft. The theoretical benefts of telemedicine devices must be weighed by the airline against their cost and frequency of utilization. In addition to considerations of improved passenger care, the greatest cost-beneft to the airline would be prevention of diversion. However, no data currently exists dem- onstrating the outcome beneft or cost-effectiveness of these devices. As technology evolves and data is obtained regarding their use, telemedicine devices may increas- ingly be used aboard commercial aircraft. Other existing technological solutions are also being explored, including the transmission of photographs or digital transmission of the airline’s medical event form using the existing Internet network of the aircraft. There should especially be tracking of aircraft diversions, both because these cases represent the most serious cases for passengers and also the most impactful instances for the airline. This is particularly important in determining what criteria are used to recommend a diversion and provid- ing consistency in those challenging decisions. The Medical Director also needs to review any cases where a passenger was cleared to fy and then had an in-fight event or diversion. While assessment of patient outcomes after in-fight medical emergencies is not required or commonly available, airlines may obtain outcome information for qual- ity assurance purposes. Conclusions Management of in-fight medical emergencies requires the successful interaction of multiple personnel in a unique environment. Ground-based medical support serves a critical role through contracts with most commercial airlines to provide medical recommendations for the pilot in command, fight crew, and airline dis- patch. Fatalities above 30,000 feet: characterizing pediatric deaths on commercial airline fights worldwide. A retrospective study of medical emergency calls from a major international airline. The legal implications of prefight medical screening of civil airline pas- sengers. Potential error in the use of an automated external defbrillator during an in-fight medical emergency. Use of Commercial Aircraft 16 for Emergency Patient Transport Laurent Verner, Matthew Beardmore, Tobias Gauss, and François-Xavier Duchateau 16. Compared to specialized fxed-wing air ambulances, commercial aircrafts offer improved fight stability and allow long-haul fights without refueling stops at a minimum of half the cost [1]. Importantly, the repa- triation should not impact the fight’s schedule nor expose other passengers to haz- ards, especially any infectious risks [3]. This chapter describes the various arrangements available on commercial airliners in terms of patient installation and additional oxygen administration and provides notice on medical clearance. The use of commercial airliners for the simultaneous transport of multiple patients is also described. Seated patients should be stable enough to travel as a standard passenger, including being able to follow safety instructions, such as putting their seats in upright position during takeoff and landing. Such patients follow the same procedures and route through the airport as normal passengers for aircraft embarka- tion and disembarkation. They should require a minimum of interventions en route as the environment around a standard commercial aircraft seat is extremely restric- tive to medical care. For disabled patients and/or to avoid long walks within the airport, a wheelchair service can be requested. There are three types of wheelchair services corresponding to the level of disability: R, S, and C. The “R” type (for “ramp”) offers a service to the bottom of the ramp meaning that the patient should be able to climb the ramp if the aircraft has no direct access via an air bridge to the gate. The “S” type (for “step”) offers a service to the top of the ramp requiring the patient to walk to their cabin seat from the aircraft door. Some airlines offer a specifc cabin confguration, allowing the lower leg to be in extension: the frontal extra-seat. This confguration is generally used where the entire cabin is economy class or when the business-class seats do not allow suff- cient room to extend the leg. The seat back in front of the patient’s seat is lowered, making it possible to extend the leg (Fig. Supine patients are transported on a stretcher, which is a metallic structure with a mattress, fxed on the armrests of three-seat rows in economy class. The patient is conventionally positioned facing the rear of the aircraft on the mattress and securely fastened using an aviation-type multiple-point restraint system. A curtain is usually included to allow some privacy and delineate a dedicated space which is more appropriate for medical care (Fig. The embarkation and disembarkation of the patient use a specifc pathway through exit doors at the rear of the cabin to the ambulance on the tarmac. This particular unit will not be fur- ther detailed in this text since it is much more a specialized air-ambulance module plugged into a commercial aircraft than representative of what is more generally possible on commercial fights. Continuous-fow reg- ulators usually offer predefned free fows of 2 and 4 L/min on 2 separate aviation- specifc connectors. There are several sizes of tanks, from lightweight handheld portable cylinders up to a maximum of 3,200 L; the latter requires an attachment to the fxing rails on the cabin foor. There is also a specifc three-pin quick-release connector to allow the connection of a ventilator. The oxygen-conserving systems provide oxygen for approximately fve times longer than the continuous-fow ver- sion for the same supply volume. They deliver a pulsed fow of oxygen to the patient triggered by back pressure in the oxygen tubing during exhalation. The effciency of these devices is of particular interest in the context of long-haul fights and, while they are sensitive enough to function appropriately for most patients, there are situ- ations where the patient will require a continuous-fow regulator. These approval forms are to be completed by the treating medical offcer or by the medical team responsible for the transfer by delegation. Details regarding the disease, time frames, prognosis for the fight, and special arrangements planned are required. The medical department of the airline approves or declines the transfer request based on this document. Such situations are distressing for both victims and their families, especially when incidents occur in geographical areas with limited medical facilities or capabilities. The response may involve using large civilian jet aircrafts as aeromedical platforms [4, 5]. Although there is a long history of the military transferring large numbers of casu- alties by fxed-wing aircraft, confguring large civilian jets for aeromedical capability is a relatively new concept. There are a few such governmental initiatives [6], but because of the rarity of this situation, many governments or medical providers use makeshift aircraft confgurations that can be very effective provided that appropriate coordina- tion and logistical support are applied [7]. One important consideration is the instal- lation of stretchers after the cabin seats have leaned forward, at least in the section of the cabin dedicated to lying patients. This experience showed that the principle of allocating patients to different clinical areas within the cabin is both effective and effcient as it facilitates medical care onboard and streamlines the embarkation and disembarkation procedures [5, 7]. We propose up to three distinct areas: self-caring or minimally-dependent injured patients seated at the front, injured but noncritical patients on stretchers in the middle of the cabin, and the rear of the cabin dedicated to critically ill patients for possible/ongoing intensive medical care. Multidrug-resistant bacteria among patients treated in foreign hospitals: management considerations during medical repatriation. Response to large civilian air medical jets: implications for Australian disaster health. Large jet conversions: mass evacuation in the face of changing global medical needs. Responding as a Nonphysician 17 Healthcare Provider Edward Meyers, Christin Child, Lisa Bowman, and John Gilday 17. As you are considering the various options to fll your time over the next several hours, you notice activity 2 rows ahead of you. Based upon what you are seeing and overhear, you recognize that a medical emergency is occurring.

It may present as: observation during the frst couple of days discount female viagra amex, needs only Slight purulent discharge from localized infection of saline irrigation or sulfacetamide drops (10%) discount female viagra 100 mg on line. Gonococcal ophthalmia is treated with (it is respon- Even septicemia and neonatal tetanus may well be sible for profuse purulent discharge) systemic penicillin regarded as forms of umbilical sepsis cheap female viagra 50 mg otc. If left untreated therapy (100 cheap female viagra 100mg without prescription,000–150,000 units/kg/day in 2 or 3 divided or inadequately treated, localized infection may be doses) and penicillin, gentamicin or chloramphenicol eye accompanied by formation of a pinkish, rounded, drops. Conjunctivitis caused by Chlamydia trichomatis (inclu- Prevention: It lies in aseptic care of the umbilicus, sion blenorrhea) needs treatment with 10% sulfacetamide including its cutting. Treatment: It consists of administering a broad- Pyoderma spectrum antibiotic and local application of triple-dye, Superfcial skin eruptions, usually caused by Staphylococ- gention violet paint or a powder/cream containing cus aureus and albus result from contaminated hands of bactracin and neomycin. No treat- needs cauterization by touching it with silver nitrate or ment other than local application of triple-dye is indicated. Systemic Infections Tese are identical despite varying causative agents 305 and may vary from inapparent or silent to fulminant, Neonatal Sepsis (Nns) depending on severity of infection, maturity and birth Sepsis is a serious neonatal problem. Loose motions, abdominal distention, fever or hypo- thermia (latter is more common and more dangerous), Etiopathogenesis failure to gain weight, pallor, jaundice, respiratory dis- Infection may be contracted antenatally, or during or after tress and skin eruptions are other prominent features. Te neonatal occurrence of convulsions, high-pitched cry, blank units must, therefore, have an ongoing review of the listless appearance, bulging anterior fontanel and neck causative organisms and their antibiotic sensitivity pattern retraction should arouse suspicion of its existence. Predisposing factors and etiologic Depending on involvement of various systems, there pathogens are listed in Box 17. One should take advantage of the clinical clues for probable etiologic diagnosis (Table 17. Diferential Predisposing factors and etiologic pathogens diagnosis is from conditions such as hypoglycemia, Box 17. Presence of two or more parameters means Instrumentation a positive sepsis screen. A repeat screen is indicated in Equipment (use of catheters, respirator, resuscitator, feeding case of a negative result after 12 hours; every 48 hours bottles, solutions for cold sterilization, incubator, face masks and white aprons, etc) in ventilated neonates. Grayish-black gangrenous lesions over skin Pseudomonas Handling by medical personnel, including doctors and Peripartum fu-like maternal illness, gastro- Listeria nurses, may. Lumbar puncture is of value if meningitis is sus- Maintenance of optimal body temperature, i. Nasal saline drops to clear nasal block, if any Other useful investigations include chest X-ray, blood Blood transfusion (packed cells) for anemia and shock; sugar, urine for routine and culture and serum bilirubin. In of accompanying meningitis, a third generation case of scleroma, endotoxic shock and meningitis, admini- cephalosporin (cefotaxime) + ampicillin/amikacin stration of hydrocortisone may be considered. Prolonged chemotherapy ampicillin + gentamicin/amikacin and the second line should be supplemented with vitamin K and other vitamin cefatoxime + amikacin. For resistant Staphylococcus, coamoxyclav or Close monitoring, timely institution of appropriate antimi- vancomycin is the best. In nosocomial septicemia (Staph- crobial therapy and intensive supportive care are the key ylococcus, Klebsiella, Pseudomonas), ceftazidime/cefap- factors in survival of the neonates with sepsis. Mortality is higher in: sensitivity report warrants a change in the antimicrobial Early-onset (within 72 hours of birth) septicemia therapy, it should be made. Presence of meningeal involvement Gram-negative septicemia Minimum duration of antimicrobial therapy Box 17. It is believed to be the outcome Sequelae of interaction between intestinal mucosal injury, luminal Tese include: bacteria, enteral feedings and immature host response. Congenital: It is due to transplacental transmission of the malarial parasite and is rare since placenta, as a rule, is supposed to act as a barrier to such a transfer. In a span of over two decades, we could diagnose it in only 50 instances, though we have all along been actively looking for it. Naturally-acquired malaria: It results following an actual bite of a previously infected female anopheles mosquito. Clinical Features Clinical manifestations include unexplained pyrexia with hepatosplenomegaly, anemia, slight jaundice, poor feed- Fig. Supportive treatment directed at controlling fever, raising hemoglobin level and maintaining water and electrolyte balance and nutrition is also warranted. On forcing the feed, refex Blood for transfusion must be tested for malarial para- spasm of masseters, pharyngeal muscles leads to trismus site. Spasms of Standard measures for control and eradication of limbs and generalized rigidity with opithotonos in exten- malaria. Refex laryngeal spasm may cause apnea and that of respiratory muscles the cyanosis. India umbilical stump following cutting of the cord with an stands declared as neonatal tetanus-free in 2015. Physiologic Unlike adults in whom it is clinically detectable with a serum Pathologic bilirubin of less than 2 mg/dL, in neonates it is apparent only z Increased production of bilirubin when serum bilirubin is less than 5 mg/dL. Serum bilirubin level at which jaundice z Drugs becomes clinically detectable is 5 mg/dL. In z Extrahepatic atresia of bile duct term infants, it appears on second or third day (between z Hereditary spherocytosis 30 and 72 hours) and reaches peak on 4th or 5th day. It z Neonatal hepatitis is generally mild, the serum bilirubin seldom exceeding z Drug-induced hemolytic anemia 12–15 mg%. Persistent jaundice during frst month In case of the preterm baby, physiological jaundice z Inspissated bile syndrome may appear little earlier (but always after 24 hours), may z Cretinism be relatively deeper (upto 15 mg/dL) and reaches peak on z Congenital hypertrophic pyloric stenosis. Nevertheless, the infant needs Te following points should be particularly noted: to be closely followed up for undue rise or persistence of Maternal and family history with special reference to maternal infections during pregnancy, drugs given hyperbilirubinemia. In the latter situation, he should be during pregnancy or labor, previous sibling(s) afected investigated for pathologic jaundice. Tis is termed as exaggerated General condition of the infant—whether healthy, physiologic jaundice or hyperbilirubinemia. Pathological Jaundice (Unconjugated Hyperbilirubinemia) Clinical Examination Te neonatal jaundice not conforming to time table or Gestational age, activity and general condition of the infant. Te cause may be insufcient lactation leading to inad- Clinical detection and grading of severity of jaundice equate feeding, dehydration and hemoconcentration. Laboratory Investigations Breast Milk Jaundice Serum bilirubin, both direct and indirect. Conjugated A small proportion of exclusively breastfed infants also tend (direct) bilirubin less than 0. Coombs test of mother as well as baby Occasionally, undue anxiety in the parents may warrant Blood culture temporary withdrawal of breastfeeding just for 2–3 days. Comparison of clinical features of physiological and pathological jaundice in Principles of Management neonates Phototherapy and exchange transfusion are the two major Parameter Physiological jaundice Pathological jaundice efective therapeutic modalities available today. Additional options include pharmacotherapy in the form of phenobar- Onset More than 24 hours of birth Less than 24 hours of birth bital, agar-agar, albumin infusion, n-mesoporphyrin and Serum Slow Rapid: 0. With light sources of this range, 311 Clinical methods of detection of neonatal Box 17. A small portion gets oxidized to Blanching Blanching the skin of tip of nose, sternum, abdomen, palms and soles biliverdin. A common observation during photo-therapy be made as follows: is the bleaching of the exposed areas. Te areas of skin that z Face: 5 mg/dL remain covered continue to have yellow touch. Whether liver z Chest and upper abdomen: 10 mg/dL z Lower abdomen, thighs and upper arm: 12 mg/dL also plays signifcant role during photoexposure is being cur- z Thighs and upper arm: 12 mg/dL rently investigated. Icterometer It is now generally opined that blue light is superior to This is a noninvasive method which is more accurate and less sub- white light. The tool used is a transparent plastic with fve graded yellow sources are far better. Most neonatal units employ stand- stripes of diferent shades corresponding to the serum bilirubin levels. Alternatively, It is pressed against the tip of the nose (in case of very dark skin, gums make a better option). Tese lamps can be Transcutaneous bilirubinometer mounted with refectors in frames. The smaller size, focused area, lower scatter and higher irra- photoprobe is pressed against the skin of forehead or sternum (in case of very dark skin, a drop of blood on a flter paper make a better diance. Following analysis by the computerized spectrophotometer, acceptability to nursing staf. Such a phototherapy unit delivers about 200 foot can- dles of light to the infant. Te only problem with blue light is that it interferes with reasonable observations of the baby.