Neonatology

Intrapartum
Sepsis Risk
Antibiotic
Maternal Factors
Treatment Management
GBS Status (1 major or
(>4 hrs prior to
2 minor)
delivery)
+ - + Routine Care
+ - - CBC, blood culture, Treat if CBC
abnormal
+ + + CBC, blood culture
Treat if: CBC abnormal or <35 wks
+ + - CBC, blood culture
Treat with antibiotics
+ (-) Intact - Routine Care
Membranes,
no active
labor, C/S
- - +/- Routine Care
- + + CBC, blood culture, Treat if CBC
abnormal
- + - CBC, blood culture, Treat if CBC
abnormal
? - +/- Routine Care
? Only ROM + Routine Care
>24 hr
? Only ROM - CBC, blood culture, Treat if CBC
>24 hr abnormal
? + + CBC, blood culture
Treat if: CBC abnormal or <35 wks
? + - CBC, blood culture
Treat with antibiotics

Major Risk Factors: Minor Risk Factors:

Delivery <35 weeks Delivery 35-37 weeks
Maternal Fever >100.4F Maternal Fever >99.5F
Chorioamnionitis Multiple births
Sustained FHR >160 Fetal Tachycardia >160
Prev child w/ GBS disease Maternal Tachycardia >120
Malodorous fluid/ uterine tenderness
Symptomatic infant –low BP, temperature instability, lethargy, irritability, hypotonia, poor
perfusion, cyanosis, mottling, feeding intolerance, tachypnea, respiratory distress, apnea,
tachycardia, low glucose, metabolic acidosis.

Abnormal CBC: WBC <5,000, or I:T (bands ÷ (polys + bands)) ratio >0.2

FOR FULL TERM INFANTS

Ampicillin 50 mg/kg/dose IV/IM (100 if meningitis)
0-7 days q8h
>7 days q6-8h
Gentamicin 2.5 mg/kg/dose IM/IV
0-7 days q12h [peak = 5-12, trough=0.5-1]
>7 days q8h
Vancomycin
0-7 days 10-15 mg/kg/dose IV q8-12h [trough=5-10]
>7 days 15-20 mg/kg/dose IV q8h
Cefotaxime 50 mg/kg/dose IM/IV
0-7 days q8-12h
>7 days q8h
 DELIVERY ROOM RESUSCITATION
Warm, Dry, Suction, Stimulate
APGAR SCORES

Sign 0 Points 1 Point 2 Points

A Activity (Muscle Tone) Flaccid Some flexion Flexed, MAEs
P Pulse Absent <100 bpm >100 bpm
G Grimace (Reflex Irritability) No Response Grimace/Weak Crying
A Appearance (Skin Color) Blue-gray/pale Acrocyanosis Pink all over
R Respiration Absent Weak, irregular Good, crying

DR to NICU:
1. <1800 gm
2. <34 weeks
3. Cyanosis on RA
4. Apnea
5. Seizures
6. Congenital malformations requiring surgery
7. IDM Class D and above

Nursery to NICU:
1. Apnea
2. RR >90/min x 2 episodes, greater than 4 hours of life
3. Feeding intolerance after 24 hours
4. Drug withdrawal
5. Hypoglycemia
6. Seizures

Cedars OBS Nursery:

1. ROM>24 hours with abnormal clinical symptoms
2. Maternal history of drug abuse and newborn symptomatic withdrawal
3. IDM Class > A1 (24 hrs), and A2, B, C
4. IM/IV Medications
5. Respiratory rate >60
6. Respiratory Distress (grunting, flaring, retractions
7. <36 weeks GA or < 5 lbs (2268 gm)
• Blade: 0 = preterm, 1 = term (although 0 may be easier to use on term babies too)
• ETT: distance = kg + 6; 2.5 if <1kg (<28wks), 3.0 if 1-2kg (28-34wks), 3.5 if 2-3.7kg, 4.0 if
>3.7kg
• CPR: Bag = 30/min (1 breath q2 sec.); Compressions = 90/min; Ratio = 3:1
• Decels: variable = cord compression; late = placenta problem

Lines

Lines Depth Level Size IVF

UAC 3(wt)+9 T6-9 5 Fr (>1.5kg) ½ unit/cc heparin
L3-4 3.5F (<1.5kg)
UVC UAC/2 +1 0.5-1cm 5 Fr ½ unit/cc heparin
Above the
diaphragm
 Fluids, Electrolytes, and TPN
Formula kcal/cc
Breastmilk/Enf20 0.67
Breastmilk 1:50 HMF 0.7
Breastmilk 1:25 /Enf24 0.8
MCT Oil 7
cc/kg/day DOL 0 DOL 1 DOL 2 DOL 3+
Term, enteral or mixed 80 100 120 150
Term, parenteral 80 100 120 120
VLBW: 1 – 1.5 kg 60-80
VLBW: 0.75 – 1.0 kg 100
VLBW: <0.75 kg 120
Initial Initial Advance Advance Preterm Term Max
preterm term preterm Term Needs Needs
GDR 5-7 7-9 1.5-2.5 1.5-2.5 - - 16-19
mg/kg/min
Protein 1-2 2-2.5 0.5 1 2.5-3 2-2.5 3-3.5
gm/kg/d
Lipid 0.5 0.5-1 0.5 0.5-1 0.25-3 0.5-3 3-3.5
gm/kg/d
Calorie Goals: 110-140 kcal/kg/day if <1500g / 80-120 kcal/kg/day if term
NaCl: 3-4 mEq/kg/day
KCl: 2-3 mEq/kg/day Ca Gluconate: 200-400 mg/kg/day
DEXTROSE
• Dextrose % = (GDR x kg x 144) / total vol
• GDR= (Dextrose % x total volume) / (kg x 144)
• Dextrose kcals: (%D x total vol x 3.4) / 100
AMINO ACID
• Protein % = (gm/kg x kg x 100) / total vol
• Protein gm/kg = (%protein x total vol) / (kg x 100)
• Protein kcals: (%protein x total vol x 4) / 100
FAT
• Lipid ml = gm/kg x kg x 5
• Lipid gm/kg = (total vol x 0.2) / kg
• Lipid kcals: total vol x 2
Compatibility:
Dextrose %: Max protein %:
17.5 4.5
20 4.25
22.5 4
25 3.75
30 3.5
32.5 3.25
35 3
Polycythemia
HCT > 65 needs to be repeated with central draw; If 65-69 observe. If 65-69 partial exchange
transfusion. If HCT ≥70 partial exchange regardless of sx.

Ductal Dependent Lesions

Pulmonary atresia, +/- VSD, preductal coarct, tricuspid atresia, HLHS, interrupted aortic arch.
Treat: PGE 0.05 mcg/kg/min, decrease to 0.01 mg/kg/min slowly. May cause fever, apnea,
bradycardia, hypotension, diarrhea.
PDA
+/- harsh holosystolic murmur, palmar pulses, bounding pulses, widened pulse press, ↑HR,
↑RR, hyperactive precordium, metabolic acidosis
TX: fluid restriction, diuretics, ventilatory support. Indomethacin – If < 48hr, give 0.2 mg/kg for
1st dose, then 0.1 mg/kg for 2nd and 3rd doses. If 2-7 days, 0.2 mg/kg for 3 doses. Don’t give
if Cr >1.8 or Plt <80. If uop <0.5, then give lasix 1mg/kg. If fails, surgical ligation.

PPHN
cyanosis, progressive hypoxia, increased A-a gradient, low CVP and BP
TX: ventilation – use low MAP, high FiO2 (ideal ABG 7.5/25-30/>50), rapid rate ventilation,
alkalosis, volume, pressors. Consider nitrous oxide. Consider ECMO if OI > 40. OI = (MAP *
FiO2)/ PaO2

Mean BP =[wt (kg) * 10] +20

Seizures
Phenobarbital: load 15-20 mg/kg over 10-15 minutes, maintenance 3-5 mg/kg/day QD.
Therapeutic levels 15-40. Monitor apnea & ↓BP

IVH – Screening Head Ultrasound

All infants < 1500g or <34 wks at birth
Also for 5 min apgar <6, seizures, micro/macrocephaly, TORCH, dysmorphism
Optimal age 7-10 days of life
-infants >1250g with history of asphyxia or signs and symptoms of IVH
Follow-up at 1 month of life, sooner if larger hemorrhage

IVH – Stages
I – subependymal (germinal matrix)
II – intraventricular, no dilatation
III – intraventricular, with dilatation
IV – intraparenchymal

Apnea of Prematurity
Caffeine: loading dose 10-20 mg/kg PO/IV, then maintenance dose 5-10 mg/kg/dose QD.
Check level 24h post loading, therapeutic level 20-25.

Retinopathy of Prematurity (ROP) Screening

BW < 1300 g or <30 wks, even if not on oxygen
BW < 1800 g or <35 wks, if oxygen given
First exam: 5-7 weeks after birth and before discharge home
 EXTRA NEONATOLOGY WEB CONTENT

Gestational age (wks) Approximate weight (gm)

23 500
27 1000
31 1500
33 2000
35 2500
37 3000
40 3500

Cord Gases Arterial (To Mom) Venous (From Mom)

pH 7.11-7.38 (mean 7.24) 7.18-7.41 (mean 7.32)
pCO2 49 (36-60) 38 (26-52)
pO2 16 (7-23) 27 (15-40)
BE -4 -4

ABG guidelines:
Preterm Term PPHN
pH ≥ 7.25 ≥ 7.30 7.35-7.5
pCO2 35-55 35-55 30-40
pO2 45-65 60-80 80-120 (goal 100)

Initial Vent Settings

Disease IMV PIP PEEP IT FiO2
RDS 30-60 18-30 3-4 0.4 low
PPHN 40-60 20-30 3 high
MAS >60 20-30 3-5 0.3 high

Goal: RDS – pO2 50-70, pCO2 40-55

PPHN – pO2 80-120, pCO2 25-35

Surfactant
For low birth weight <1350 g at risk for RDS. Give 4cc/kg/dose Survanta via ETT. Repeat up
to 4doses q6h if FiO2 > 40%. If MAS: 6 cc/kg q6h X 2-3 doses. Watch out for pulmonary
hemorrhage.

Glucose for hypoglycemia

2 cc/kg push of D10W; start IV at GDR = 8mg/kg/min. Keep accuchecks > 45

UCLA NICU NOTES:

• Vitals parameters: 37.5-38>T<36, 180>HR<100, 60-70>RR<35, MBP (wt x10)+20,
• O2 sats 88-92% for preemies (to prevent ROP) / >97% for term
• Preductal sat = right arm
• When giving opiates (morphine, fentanyl) to non-intubated patient, have bag valve mask
and narcan at bedside
• Thoracentesis: at level of nipple, anterior axillary line, just above the rib
• Heparin flushes: broviac = 50units/kg (max 150 units) in 3cc of NS qd; PICC/CVC
(minisilastic) = 10 units qd
• Mondays: growth labs: TPN: all lytes, LFTs, Hct, retic if not transfused in past 2 wks,
BUN/Cr, triglyceride ; Enteral: Hct, retic if not transfused in past 2 wks, alk phos, iCa, phos,
lytes if on diuretics
• Mondays: growth plotting: weight, head circumference
• Weekly med levels: phenobarb, vanco, gent, caffeine….
• Weekly ROP exams: Tues or Wed: all preterm <32wks, initial exam at 4-6wks then as
prescribed; cyclomydril 1 gtt OU q5min x 3 to start 1 hr prior to exam
• Head ultrasounds: all preterm <32wks by 2-3 wks if healthy or earlier if unstable; within 1st
3 days if <26wks
• Synagis: first Monday of each month Nov-April: all preterm <32wks, 32-36 wks if h/o O2
requirement, term if h/o respiratory distress or congenital heart disease
• Alk phos: If >500, consider increasing the Ca and Phos in the TPN to provide a good mix of
both to mineralize bone. Also, start IV or po vitamin D.

Survival data (USC = 1994-1998, not including congenital anomalies): *Intact = without
blindness, deafness, MR or CP
Best Gest. Survival Intact Weight Survival Intact
Age (USC) Survival (gms) Survival
(national) * (national) *
18-21 0/30 = 0% 0% ≤ 500 4/55 = 7% 0%
22 3/23 = 13% 0% 501-600 19/38 = 50% 30
23 16/40 = 40% 30% 601-700 34/42 = 81% 60%
24 16/23 = 70% 60% 701-800 35/41 = 85% 70%
25 19/22 = 86% 70% 801-900 28-30 = 93% 80%
26-27 76/84 = 90% 80% 901-1000 43/44 = 98% 90%
≥28 297/308 = 90-95% 1001-1500 266/271 = 95%
96% 98%