Drug Formulary Neonatal 2006

Neonatal DrugFormulary

Neonatal DrugFormulary

Santosh T Soans MBBS MD DCH

Professor and Head, Department of PaediatricsAJ Institute of Medical Sciences

Mangalore

Murali Keshava Sarpangala MBBS DNB (Paediatrics)

RegistrarAJ Institute of Medical Sciences

Mangalore

JAYPEE BROTHERSMEDICAL PUBLISHERS (P) LTD

New Delhi

Published by

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Neonatal Drug Formulary

© 2006, Santosh T Soans, Murali Keshava Sarpangala

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher.

This book has been published in good faith that the material provided by authors is original. Every effort is made to ensure accuracy ofmaterial, but the publisher, printer and authors will not be held responsible for any inadvertent error(s). In case of any dispute, all legalmatters are to be settled under Delhi jurisdiction only.

First Edition: 2006ISBN 81-8061-845-5Typeset at JPBMP typesetting unitPrinted at Gopsons Papers Ltd, Sector 60, Noida

PREFACE

Neonatology has progressed in leaps and bounds in the last three decades. Major advances have beenmade in the treatment of various neonatal disorders. A number of highly beneficial new drugs havebeen developed and it is important that authentic information regarding the proper administration ofthese drugs is readily at hand for the use of the pediatrician/neonatologist.

Hence, we thought to bring out this book which the postgraduates and residents working in thedepartment of neonatology can have as a ready reference to prescribe in the NICU.

In this volume, we have covered commonly used antimicrobial agents used in the NICU with dos-ages and side effects. We have also covered standard IV infusion, safe medications in lactation alongwith separate chapters on Special Nutrition, Neonatal Ventilation and Reference Laboratory Values.

We hope this book will be useful for pediatricians and neonatologists alike in day-to-day practice.

Santosh T SoansMurali Keshava Sarpangala

ACKNOWLEDGEMENTS

Bringing out a well researched book like this is never an easy task and many people have helped in theirown ways and made it possible for this book to see the light of day. I hereby wish to acknowledge a fewof my colleagues and friends who have provided me help, inspiration and motivation: Sanjeev Rai,Pavan Hegde, Diwaker Rao, Bharath Raj, Habib Khan, Prakash Saldanah, Manjunath Hegde, MaheshNayak.

CONTENTS

1. Antimicrobial Agents .................................................................................................................. 1

2. Drug Formulary .......................................................................................................................... 18

3. Drugs in Resuscitation .............................................................................................................. 33

4. Standard IV Infusion ................................................................................................................ 36

5. Safe Medicine ............................................................................................................................. 39

6. Pharmacokinetics ....................................................................................................................... 46

7. Special Nutrition ........................................................................................................................ 52

8. Specific Therapeutics ................................................................................................................ 58

9. Neonatal Ventilation ................................................................................................................. 64

10. Reference Lab Values ............................................................................................................... 67

Index .............................................................................................................................................. 97

Dosages (mg/kg/day) and Intervals of Administration

Body Weight <2000g Body Weight >2000gAntibiotics Routes of Age 0-7 days >7 days Age 0-7 days >7 days Comments

Administration

Acyclovir IV 10 mg/kg q8h for 10-14 days(zovirax, Dilution to 5 mg/ml, infuse 8h Prophylactic dose: Adverse reactions noted:ocuvir) over 1 hour Transient renal dysfunction250 mg, 5 mg/kg q8h and thrombophlebitis. Incre-500 mg ase dosing interval q24 hvial when renal functions < 25%

of normal. Oral absorptionnot tested in neonates.

Amikacin IM, IV <28 wk 7.5 mg/kg q24h <28 wk 7.5 mg/kg q18h Ototoxicity, nephrotoxicity,(mikacin) 28-34 wk 7.5 mg/kg q18h 28-34 wk 7.5 mg/kg q12h neuromuscular blockade,(50 mg/ml >34 wk 7.5 mg/kg q12h >34 wk 7.5 mg/kg q8h BM suppression, eosino-2 ml vial) IV infusion over 30 minutes philia and tremor. Syner-

gestic action with diuretics.Therapeutic range: 20-30mg/L (peak) and <8 mg/L(trough) CSF penetration ispoor, even in meningitis. Pre-ferred in serious infections ofgram-negative bacilli. Sus-ceptible pathogens includePseudomonas, E.coli, Proteus,Klebsiella, Serratia, Staphylo-coccus. It exerts bactericidalaction by inhibiting proteinsynthesis.

Amoxicillin PO 50 mg/kg 50 mg/kg 50 mg/kg 50 mg/kg SE: rash, diarrhoea. It exerts(mox) IV, IM q12 h q8h q12h q8h bactericidal by virtue of its(250 mg, Increase dose to 100 mg/kg in ability to inhibit synthesis of500 ml suspected meningitis the bacterial cell wall. Sus-vials) ceptible pathogens include α

and β-hemolytic strepto-cocci, strep pneumoniae,strep faecalis, Bacillus anthra-sis, Clostridium spp except C.difficile, some non-Beta-lactamase staphylococci, B.Pertusis, Haemophillus, E.coli,Proteus, Salmonella, Shigella,Treponema, Pseudomonas.

Amoxyclav PO, IV ——— 40 mg/kg/day q8h ——— 40 mg/kg/day q8h Inhibits production of β-(augmentin) (Amoxycillin (Amoxycillin lactamases. Many β-

6.7 mg/kg q8h 13.3 mg/kg q8h lactamase producing strains

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CHAPTER

1 Antimicrobial Agents

2 Neonatal Drug Formulary

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Administration

Clavulinic acid Clavulinic acid of staph aureus and coagu-1.7 mg/kg q8h) 3.3 mg/kg q8h) lase negative Staphylococcus

species are made sensitive.

Amphotericin IV 0.5-1.0 mg/kg/O.D with maximum of 1.0 mg/kg/day for 4-6 weeks Adverse reactions: hypoten-B (fungizone) (total dose of 25-40mg) sion, thrombophlebitis, renalPolyene anti- NOTE: dysfunction (hypokalemia,fungal (a) Dilute in D5W or D10W only. azotemia, RTA, hematologic(50 mg/vial) (b) Minimum dilution is 0.1mg/ml. (anemia, thrombocytopenia,

(c) Infuse over 2-6 hours. granulocytopenia) Monitor(d) Start with 0.25 mg/kg/day increase dose by 0.25 mg/kg/day. closely hematologic and renal(e) Reconstituted preparations should be protected from light. status (CBC, platelet count,(f) The first 0.1 mg of the first dose will be considered as test dose. serum BUN, creatinine, elec-(g) Total dose should not exceed 20-30mg/kg trolytes). Reduce dosage or

interrupt therapy or alternateday therapy when renal func-tion falls to <20% of normal.Adverse effects appear to beless common in neonates.Fever, chills, nausea and vomi-ting are common side effects,may premedicate with aceta-minophen and diphenhy-dramine 30min before and 4hrs after infusion.

Ampicillin IV, IM At high doses SE are same as(roscillin) Meningitis 50 mg/kg q12h 50 mg/kg q8h 50 mg/kg q8h 50 mg/kg q6h penicillin. May cause intersti-

Other 25 mg/kg q12h 25 mg/kg q8h 25 mg/kg q8h 25 mg/kg q6h tial nephritis, hemolytic anae-disease mia and pseudo-membra-PO 62.5 mg/kg/dose q6h nous colitis. More active than

penicillin against Listeria Mono-cytogenes, E.coli, Proteus,Salmonella. CSF penetration isslightly better than penicillinG.

Azlocillin IV 50 mg/kg q12h 50 mg/kg q12h 100 mg/kg q12h 100 mg/kg q8h Must not be mixed in samesyringe or infusion withaminoglycosides.

Aztreonam IV, IM 30 mg/kg q12h 30 mg/kg q8h 30 mg/kg q8h 30 mg/kg q6h β-lactum antibiotic, active(Azenam) against gram-negative enteric

bacilli including pseudo-monas aeruginosa. SE: Throm-bophlebitis, eosinophilia; leu-kopenia, neutropenia, throm-bocytopenia, increase liverenzymes, hypotension, sei-zures. If creatinine clearanceis between 10-30 ml/min, thedose should be halved aftergiving an initial loading dose.In severe reveal failure or ondialysis should recieve thestandard loading dose, fol-lowed by ¼ of the loading doseat standard dose interval. Itinteracts with penicillin-binding

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Antimicrobial Agents 3

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Administration

proteins of susceptible micro-organisms and induces the for-mation of long filaments bacte-rial structures lending to lysis ofthe bacterial cell.

Carbenicillin IV, IM 75 mg/kg 75 mg/kg 75 mg/kg 75 mg/kg It has additive inhibition ofq12h q8h q8h q6h platelet function and hence may

increase the risk of haemorrhage.May produce hypokalemia. Donot mix with genta.

Cefaclor PO — — — 20 mg/kg q12h Active against haemophillus(keflor) influenzae including strains(125 mg/ producing β- lactamases.5ml)

Cefazolin IV, IM 20 mg/kg 20 mg/kg 20 mg/kg 20 mg/kg Caution with penicillin allergy or(Reflin) q12h q12h q12h q8h renal impairment. Leukopenia,(125 mg, thrombocytopenia, increase liver250 mg enzymes, false +ve urinary redu-vials) cing substances. Active against

gram-positive including staphy-lococcus aureus (even penicilli-nase producing organisms),Group A beta-hemolytic strepto-cocci, Streptococcus pneumoniae,gram-negative including E.coliProteus, Klebsiella, H. influenzae,Enterobacter.

Cefotaxime IV, IM 50 mg/kg 50 mg/kg 50 mg/kg 50 mg/kg Good CNS penetration. Rash.(traxim) q12h q8h q12h q8h Thrombocytopenia, leucopenia.(500 mg Active against staphylococci,vial) H. influenzae, Salmonella, Shigella,

Serratia, Spirochetes, Citrobacter,Neisseria, Proteus and Pseudomo-nas. In renal impairment withcreatinine clearance of 5ml/minor less, dose is reduced to ½.

Cefoxitin IV 15 mg/kg 30 mg/kg 15 mg/kg 30 mg/kg Thrombophlebitis. Activityq8h q6h q8h q6h against bacteroides fragilis and

indole positive proteus.

Ceftazidime IV, IM Rash, false positive Coomb’s(fortum, Meningitis 50 mg/kg q12h 50 mg/kg q8h 50 mg/kg q8h 50 mg/kg q8h test. Active against pseudomo-Tazid) Other 30 mg/kg q12h 30 mg/kg q8h 30 mg/kg q12h 30 mg/kg q8h nas. It has extended spectrum of(250 mg disease activity against gram-negativevial) bacteria especially pseudomonas.

Give IV infusion over 30 minutes Highly stable to betalactamases.In renal insufficiency dose ismodified according to creatinineclearance. Urticaria, neutropenia,thrombocytopenia, pseudomem-branous colitis, increased liver en-zymes.

Ceftriaxone IV, IM Reversible cholelithiasis sludging(monocef) Meningitis 100 OD 100 OD 100 OD 100 OD in GB and jaundice.

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Administration

(250 mg Loading Caution in neonates with hyper-vial) Maintenance 50 mg/kg q12h 50 mg/kg q12h 50 mg/kg q12h 50 mg/kg q12h bilirubinemia. Skin rash,

Other 50 OD 50 OD 50 OD 50 mg/kg OD pseudomembranous colitis.disease Potentiates nephrotoxicity along

with aminoglycosides and fruse-mide. Chloramphenicol de-creases its efficacy. Pseudomo-nas shows variable susceptibil-ity. Stable against beta-lacta-mases.

Cefuroxime IV, IM Not recommended for menin-(altacef, forcef) 30 mg/kg q12h 30 mg/kg q8h 30 mg/kg q12h 30 mg/kg q8h gitis. Pseudo-membranous coli-(250 mg vial) tis, transient increase in urea

For IV infusion, dilute reconstituted dose and creatinine, rash. Activewith NS or DS and infuse over 30 minutes. against staphylococci, strepto-

cocci, Neisseriae, H. influenzae andgram-negative organisms in-cluding E.coli, Klebsiella, Proteus.Not active against Pseudomo-nas or streptococcus faecalis.Specially active against beta-lactamase producing strains ofH. influenzae and N. Gonorrhoeae.

Cephalothin IV, IM 20 mg/kg q12h 20 mg/kg q8h 20 mg/kg q12h 20 mg/kg q8h Limited experience in neonates.

Chloram- IV, PO 25 mg/kg 25 mg/kg 25 mg/kg 50 mg/kg q12 Dose related or ideosyncraticphenicol once daily once daily once daily BM suppression, “Gray baby”(enteromycetin) syndrome, phenobarbitone,(250 mg, Give IV bolus with NS or DS rifampicin decreases chloram-500 mg vial) phenicol levels. Phenytoin inc-(as sodium reases chloramphenicol levels.succinate) Therapeutic levels = 15-25mg/

L for meningitis; 10-20mg/L forother infection. Active againstmost gram-positive and gram-negative bacteria. Active againstNeisseriae, Streptococcus pneu-moniae, H. influenzae, staphylo-cocci, streptococci, Salmonella,Shigella, Anaerobes, Ricketssiaeand Brucella. Not effectiveagainst Pseudomonas.

Cipro- PO 7.5 mg/kg 7.5 mg/kg 7.5 mg/kg 7.5 mg/kg Damage to cartilage is observedfloxacin IV q12h q12h q12h q12h in experimental animals. Has(cifran, 5 mg/kg q12h 5 mg/kg q12h 5 mg/kg q12h 5 mg/kg q12h stood the test of time and nociplox) such thing documented in(2 mg/ml, Infusion given over 30-60 minutes humans? Active against Pseu-50 ml/ domonas. When given orally100 ml requires acidic media for absor-for IV infusion) ption. Concurrent administra-

tion of sucralfate, magnesium-aluminium antacids and raniti-dine decreases its absorption.Theophylline concentrations aremarkedly elevated when co-ad-ministered with ciprofloxacin.Potentials oral anticoagulants.

Contd...


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Administration

Clindamycin IV, IM Not indicated in meningitis,(clincin) 5 mg/kg q12h 5 mg/kg q8h 5 mg/kg q8h 5 mg/kg q6h Diarrhoea, rash, Stevens-(150 mg/ml Johnson syndrome. Pseudo-2 ml vial) Dilute to 6 mg in 1 ml with NS membranous colitis, Thrombo-

and D5 infuse slowly over 10-30 cytopenia, Granulocytopenia.minutes. Active against Staphylococci ,

Streptococci, Bacteroides fragilisand some anaerobes.

Clotrimazole Topical Apply to skin BID x 4-8 wks Erythema, blistering, urticaria(candid) Thrush: Dissolve slowly one troche in the mouth 5times/day x 14 days. where applied.

Cloxacillin IV Double dose for meningitis.(klox) 25 mg/kg q12h 25 mg/kg q8h 25 mg/kg q8h 25 mg/kg q6h Active against Staphylococcus(250 mg aureus, coagulase negativevial) Dose may be increased to 100 mg/kg in staphylococci. Poor activity

severe infections. Do not mix with amino- against Treponema pallidumlycosides. and anaerobes. Its potency is

lost in solution with erythromy-cin, gentamycin, kanamycin,colistin sulfate, chlorpromazine,vitamin C and polymyxin B sul-fate. Chloramphenicol antago-nizes its bactericidal activity.

Colistin PO, IM 40 mg/kg 40 mg/kg 40 mg/kg 40 mg/kg Active against gram-negativesulphate q6h q6h q6h q6h anaerobes including most ente-Polymixin robacteria except proteus, pro-antimicrobial Give deep IM vidential and serratia. Activity

is also seen against Pseudomo-nas, Legionella, H. influenzae,Acinetobacter, V. cholera, Salmo-nella, Shigella and pasteurella.

Co-trimoxa- Minor infections : For use with caution in infantszole (bactrim, Prophylaxis (UTI): 4 mg TMP + 24 mg SMX/kg q12h <1 month; (TMP) to (SMX)septran) Serious Infections and 4 mg TMP + 20 mg SMX/kg once daily ratio is 1 to 5. Can displace bili-(480 mg in IV Pneumocystitis carinii 10 mg TMP+ 50 mg SMX/kg q12h rubin bound to albumin. Both5 ml anpaele pneumonia inhibit folic acid synthesis by the240 mg/ PO Pneumocystitis carinii 480 mg/m2 q12h EOD (3 days/wk) pathogen but at different stages5 ml prophylaxis which results in some potentia-suspension tion of action. Active against

staphylococci, enterococci,E.coli, Proteus. Diffuses well intoCSF and brain. Steven-Johnsonsyndrome, agranulocytosis,thrombocytopenia.

Erythro- PO, 10 mg/kg q12h 10 mg/kg q8h 10 mg/kg q12h 15 mg/kg q8h May increase serum theophyllinmycin IV level. Cyclosporine, digoxin,(althrocin) IV infusion is given after CBZ MPS increases serum

diluting in 5% dextrose (not available in indian market) levels. Caution: liver disease,(100 mg/ml with terfenadine cisapride.drops) Estolate may cause cholestasis.

Active against gram-positiveorganisms, including penicilli-nase producing staphylococci,diphtheria, mycoplasma, ureaplasmas, chlamydia, bordetellapertusis and most gram-nega-

Contd...


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Administration

tive organisms. It is used as analternative to penicillin, in thoseallergic to penicillin. Topicalpreparations are also available.Antibacterial activity potenti-ated by acetazolamide and so-dium bicarbonate.

Flucloxa- IV, - 50 mg/kg q12h - 50 mg/kg q8h Double dose for meningitis.cillin PO - 25 mg/kg q12h - 25 mg/kg q8h Active against Staphylococcus50 mg/ml 25-50 mg/kg q6h aureus, coagulase negative sta-suspension phylococci. Poor activity

against Treponema pallidum andanaerobes.

Fluconazole IV < 14 days 6-12 mg/kg every 72 hr Systemic candidiasis and cry-(zocon) PO 14-28 days 6-12 mg/kg every 48 hr ptococcal infection. 3 mg/kl for(2 mg/ml) >28 days 6-12 mg/kg every 24 hr mucosal candidiasis. Reduce25 ml bottle dose in renal impairement. In

over 10-30 min.

Flucytosine IV PO 25 mg/kg q6h 25-50 mg/kg q6h Adverse reactions noted: entero-(5 FC) Theurapeutic level = 25-100mg/L colitis, nausea/vomiting diar-(10 mg/ml rhoea, hepatotoxicity, bone250 ml IV infusion over 20-40 min through filter marrow suppression. Monitorbottle) closely hematologic, renal and

liver function status. Increasedosing interval q12h when renalfunction 50% of normal and toq24h when renal function <10%of normal.

Fucidic acid IV, PO 5 mg/kg q6h 5 mg/kg q6h 5mg/kg q6h 5 mg/kg q6h For IV use dissolve powder inbuffer provided and infuse doseover 6 hours.

Ganciclovir IV Induction 5 mg/kg q12h or 2-5 mg/kg q8h for 14-21 days. Limited experience in neonates.500 mg vial Maintenance therapy: 5 mg/kg OD for 5 days/wk. Reduce dose in renal failure.

Neutropenia, thrombocytope-Reconstitute with 10 ml water (50 mg/ml) nia, retinal detachment. IM andInfuse over 1 hour. Irritant, handle carefully. SC administration are contrain-

dicated because of high pH (II).

Gentamycin IV, IM(garamycin) <28 wk 2.5 mg/kg q24h <28 wk 2.5 mg/kg q18h Proximal tubule dysfunc-(10 mg/ml, 28-34 wk 2.5 mg/kg q18h 28-34 wk 2.5 mg/kg q12h tion, ototoxicity.40 mg/ml, > 34 wk 2.5 mg/kg q12h >34 wk 2.5 mg/kg q8h Therapeutic level=6-10mg/L2 ml vial) (peak) <2mg/L (trough). Elimi-

nated more quickly in patientswith cystic fibrosis, multiple scle-rosis, burns, neutropenic pa-tients. Active against gram-negative organisms, weak activ-ity against staphylococci andstreptococci. Babies on dialysisan 8 hr dialysis reduces serumlevels of gentamycin by 50%. Atthe end of each session give2mg/kg. Cephalosporin, hydro-cortisone and indomethacin po-tentiate nephrotoxicity. Poten-

Contd...


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Administration

tiates neuromuscular blockingagents. Frusemide potentiatesits toxicity.

Imipenem IM IV 20 mg/kg 20 mg/kg 20 mg/kg 20 mg/kg Pruritis, urticaria, seizures,beta-lactam q6-8h q6-8h q6-8h q6-8h hypotension, increased leverantibiotic over 30-60 enzymes, blood dyscrasias.(500 mg with mins. IM formation cannot be given500 mg cilas- IV. Each gram contains 3.2 mEqtatin) sodium.

Isoniazid PO 5 mg/kg 5 mg/kg 5 mg/kg 5 mg/kg q12-24h Pyridoxine supplement should(Isonex) q12-24h q12-24h q12-24h be given (5 mg).50 mg tab

Kanamycin IV,IM 5 mg/kg 5 mg/kg 10 mg/kg 10 mg/kg q8h Retinal toxicity and ototoxicity(kancin) q12h q8h q12h poorly absorbed orally. Give

over 30min IV. Reduce dosagefrequency with renal impair-ment. Active against Staphylo-coccus aureus (including penicil-linase producing organisms),Staphylococcus epidermidis, H.influenzae, E.coli, Klebsiella, Ser-ratia and Proteus.

Meropenem IV Sepsis : 20 mg/kg q12h 20 mg/kg 20 mg/kg Limited experience in neonates.(meronem) Meningitis : 40 mg/kg q8h q12hr q8hr Dose should be reduced incarbapenem patients with creatinine clear-beta-lactam Slow IV injection ance less than 51ml/min. 26-50(500 mg ml/min give recommendedvial) dose q12h. 10-25ml/min give

½ the recommended dose q12h.<10 ml/min give ½ the recom-mended dose q24h monitorLFT, blood counts.

Metronidazole IV Loading 15mg/kg stat, maintenance 24 hr later as the following: Neutropenia. Candidiasis may(metrogyl) 7.5 mg/kg 7.5 mg/kg 7.5 mg/kg 7.5 mg/kg worsen. Potentiates anti-coagu-(5 mg/ml, q12h q12h q12h q12h lants. Use with caution in20 ml ampoule, patients with liver or renal dis-100 ml container) Infuse over 30 min. ease (GFR <10ml/min). Active

against anaerobes (useful innecrotising enterocolitis) andentamoeba histolytica. T½ is 23-25hrs (term) 59-109 hrs (pre-term). CSF penetration is excel-lent.

Methicillin IV, 25-50 mg/kg 25-50 mg/kg 25-50 mg/kg 25-50 mg/kg Double the dose for meningitis.IM q12h q8h q8h q6h Hematuria, nephritis, reversible

BM suppression, eosinophilia,rash.

Mezlocillin IV 75mg/kg 75mg/kg 75mg/kg 75mg/kg Allergic reaction, seizures,q12h q8h q12h q6h vomiting and hematological

abnormalities (eosinophilia, leu-kopenia, neutropenia, anaemia)elevated BUN, creatinine andliver enzymes.

Contd...


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Administration

Moxalactum IV, IM 50 mg/kg 50 mg/kg 50 mg/kg 150mg/kg/q12h q8h q12h q8h

Nafcillin IV 25 mg/kg 25 mg/kg 25 mg/kg 25 mg/kg Similar to penicillin. Use withq12h q8h q8h q6h caution in infants with com-

promised hepatic function.Good CSF penetration.

Neomycin PO 12.5 mg/kg 12.5 mg/kg 12.5 mg/kg 12.5 mg/kg Ototoxicity and nephrotoxicitysulfate q6h q6h q6h q6h

Netilmycin IV 3.5 mg/kg 3.5 mg/kg 3.5 mg/kg 3.5 mg/kg Theurapeutic range 10-12(netromycin) q12h q8h q12h q8h mg/L (peak) and <2mg/L(10mg, 25mg (trough). Active against most50mg in 1 ml) Do not mix with other antimicrobials gram-negative and some gram-

positive organisms, includingsome which are resistant to otheraminoglycosides. Activity isalso seen against Pseudomonas,methicillin resistant strains ofStaph aureus and Proteus. Notactive against streptococci oranaerobes.

Nystatin PO 400,000-800,000 units/day d/v q6h (100,000 U/ml suspension) after feeds. It is poorly absorbed fromTopical Applied as ointment or cream 3-4 times daily (100,000U/g) GI tract.

Oxacillin IV, IM 25 mg/kg 25 mg/kg 25 mg/kg 25 mg/kg May cause thrombophlebitisq12h q8h q8h q6h and Clostridium difficile colitis.

Limited experience in neonates.

Palivizumab IM 15 mg/kg once a month during RSV season (Nov-Apr) Preferred over anterolateral(synagis) aspect of thigh.

Penicillin G IV 50,000 50,000 50,000 50,000 Active against few gram-posi-(benzyl) Meningitis u/kg 12h u/kg q8h u/kg q8h u/kg q6h tive and gram-negative bac-

teriae. Useful against strepto-cocci and pneumococci, con-genital syphilis, tetanus, listeria

Other 25,000 25,000 25,000 25,000 and few anaerobes (gas gang-diseases u/kg q12h u/kg q8h u/kg q8h u/kg q6h rene). Diffuses well into tissues

and body fluids, but penetra-tion into the CSF is poor exceptwhen the meninges are inflamed.

Penicillin G IM 50,000 U/ 50,000 U/ 50,000 U/ 50,000 U/kg OD(procaine) kg OD kg OD kg OD(Bisterpen)

Penicillin IM 50,000 U 50,000 U 50,000 U 50,000 UBenzathine (one dose (one dose (one dose (one dose only)(Penidure) only) only) only)

Penicillin V PO 62.5 mg/kg 62.5 mg/kg 62.5 mg/kg 62.5 mg/kg(keypen) q6h q6h q6h q6hr

Piperacillin IV, IM 200 mg/kg/d 200 mg/kg/d 300 mg/kg/d 300 mg/kg/d May increase the risk of haemor-(piprapen) q8h q6h q8h q6h rhage with high doses. Activeureidopeni- against all major gram-positive

Contd...


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Administration

cillin. (with and gram-negative organismstazobaltam) except those producing beta-(2.25 gm vial) lactamases. It has a good anti-

pseudomonas cover.

Polymyxin PO, IM, IV 2.5 mg/kg 2.5 mg/kg 2.5 mg/kg 2.5 mg/kg q8h Does not cross blood-brainB sulfate q12h q12h q12h barrier. Synergy with trimetho-(poly-B) prim and useful combination

with rifampicin,especially intreatment of multiresistantstrains.

Pyrimethamine PO Toxoplasmosis: Supplement with folinic acid.25 mg tab. Loading: 2 mg/kg OD for 2 days Glossitis, seizures and rash.

Maintenance: 1 mg/kgOD for 2 – 6 month, then 3 days per week to complete 12 m treatment

Rifampicin PO 10 mg/kg 10 mg/kg q12h 10 mg/kg 10 mg/kg q12h(R-cin) once daily once daily

Ribavirin Aerosol Administer using a (SPAG –2) small particle aerosol generator provided Rash and conjunctivitis have(Ribavin) by the company. The drug is delivered via an oxygen hood or through been observed. Special pre-

the inhalation tubing of a ventilator. Concentration of drug in reservoir cautionary measures need to be(20 mg/ml) is not varied with patient weight. Treatment is carried out for taken when drug is being given12-18 hours per day for 3-7 days. through a ventilator to avoid

drug deposition and consequentmalfunctioning of expiratoryvalve.

Spiramycin PO Immunocompromised : 0.75million IU/day d/v q8h for 5 days Active against streptococci,(Rovamycin) Toxoplasmosis : 0.15-0.30 million IU/kg/day d/v q12h for 6 wk staphylococci, diphtheria, per-Macrolide Meningococcal meningitis prophylaxis : 150000 IU/kg/day for 5 days tusis, Listeria, Clostridia,(0.75 million Legionella, chlamydia, myco-IU tab) plasma, N. meningitides, Toxo-

plasma gondii and Crypto-sporidia. Not active againstgram-negative aerobes. Syner-gism with metronidazoleagainst anaerobes seen.

Ticarcillin IV, IM 75 mg/kg 75 mg/kg 75 mg/kg 100 mg/kg Active against Pseudomonasq12h q8h q8h q8h

Ticarcillin + IV 75 mg/kg 75 mg/kg 75 mg/kg 75 mg/kg Hypersensitivity reaction,clavulanic q12h q8h q8h q6h phlebitis, pseudomembranousacid colitis, hypernatremia and inhi-(Timentin) bition of platelet aggregation.

Monitor renal function.

Tobramycin IV, IM 2 mg/kg 2 mg/kg 2 mg/kg 2 mg/kg More active against Pseudo-(tobacin q24h q12h q12h q8h monas. Active against Staphy-tobraneg) lococcus aureus, E.coli, Klebsiella,Aminoglyco- Proteus, Serratia and Citrobacterside (10 mg/ ototoxicity and impaired renalml 1 ml, function. Less active against2 ml vial) streptococcus. Adjust dose in

renal failure.

Vancomycin IV Recommended dosage designed to achieve one hour post infusion levels of Infuse over 60min to avoid(vancorin) 25-30 mg/L, trough levels of 5 -10 mg/L and average vancomycin serum Redman’s syndrome; increase(500 mg Concetrations at steady state of 13.5 mg/L, immediate post infusion. dose in CNS infections tovial) Vancomycin serum concentrations are predicted to be < 40 mg/L. 60 mg/kg/day d/v q6h. Ac-

tive only against gram- positive

Contd...


Contd...


Administration

Dose (mg/kg/dose) Dosing Interval bacteria. Mainly used against<27 wk 27 q36h penicillin-resistant staphylo-27-30 wk 24 q24h cocci (Staphylococcus aureus,31-36 wk 27 q18h coagulase-negative staphylo->37 wk 22.5 q12h cocci, streptococci and gram-Dilute with NS or DS to give 5 mg in 1 ml. positive anaerobes includinginfuse over 1 hour Clostridium difficile)

Vidarabine IV <1 month: 15-30 mg/kg/day infused over 12-24 hour period for Adverse reactions noted in10 consecutive days. (Minimum dilution is 0.45 mg/ml of IV fluid. adults; nausea, vomiting diar-In line filter > 0.45 micron recommended) rhoea, rash, ataxia, tremors,

myoclonus and bone marrowdepression. These have not beenobserved in neonates. Monitorhematologic, renal and hepaticstatus. Reduces dose by 25% insevere renal failure.

Zidovudine PO 2 mg/kg 6h for 6 wk Severe anaemia,(retrovir) IV 1.5 mg/kg 6h for 6 wk neutropenia, GI upset.10 mg/ml,susp. andInj.

*All dose in mg/kg/dose, unless mentioned specifically. q8h indicates interval between doses.Comments code for anti-bacterial agents:1. Increase dosing interval in renal impairment.2. Reduce dose in liver impairment.3. Monitoring of serum drug concentration recommended.4. Check special protocol for administration.5. Close clinical monitoring for dose related and ldiosyncratic toxicity recommended.6. Inadequate pharmacokinetic studies in neonates; only indicated in very unusual situations.

Clearance of amikacin, gentamicin and vancomycin is influenced both by the gestational age (GA) and the postnatal age. Therefore in infants> 7 days old, it might be useful to consider the postconceptional age (PCA) in the dosing schedule. Please note the dosage is in mg/kg/dose.


✓=generally susceptible

Staphylococci ✓1 ✓1 ✓ ✓1 ✓1 ✓1 ✓ ✓ ✓1 ✓1 ✓1

Staphylococcus aureus ✓1 ✓1 ✓ ✓ ✓ ✓1 ✓1 ✓1

Streptococci ✓ ✓ ✓ ✓

Streptococcus pneumoniae ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Beta-hemolytic streptococci ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Streptococcus faecalis ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Streptococcus viridans ✓ ✓ ✓ ✓ ✓ ✓ ✓

Corynebacterium diphtheriae ✓ ✓

Bacillus anthracis ✓ ✓ ✓ ✓

Listeria monocytogenes ✓ ✓ ✓ ✓

Escherichia coli ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Haemophilus influenzae ✓ ✓ ✓ ✓ ✓ ✓ ✓2 ✓

Klebsiella sp ✓ ✓ ✓

Neisseria gonorrhoeae ✓1 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Neisseria meningitis ✓ ✓ ✓ ✓ ✓ ✓

Proteus mirabilis ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Salmonella sp ✓ ✓ ✓ ✓ ✓ ✓

Shigella sp ✓ ✓ ✓ ✓

Morganella morganii ✓ ✓ ✓ ✓

Proteus vulgaris ✓ ✓ ✓ ✓

Providencia sp

Providencia rettgeri ✓ ✓ ✓ ✓

Providencia stuarti ✓

Enterobacter sp ✓ ✓ ✓ ✓ ✓ ✓

Citrobacter sp ✓ ✓ ✓

Pseudomonas aeruginosa ✓ ✓ ✓

Serratia sp ✓ ✓ ✓

Acinetobacter sp ✓ ✓

Streptobacillus moniliformis ✓ ✓

Moraxella (Branhamella)catarrhalis ✓ ✓ ✓

Contd...

Pen

icill

in G

Pen

icill

in V

Clo

xaci

llin

Am

oxic

illi

n

Am

pic

illi

n

Bac

amp

icil

lin

Am

oxic

illi

n/p

ot.

Cla

vula

nat

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Am

pic

illi

n/su

lbac

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Car

beni

cilli

n

Pip

erac

illin

Tic

arci

llin

Organisms generally susceptible to penicillins

Organisms Natural Penicil- Aminopenicillins Extended spectrumpenicillins linase

resistant

Gra

m-p

osit

ive

Gra

m-n

egat

ive


Contd...

Clostridium sp ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Peptococcus sp ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Peptocostreptococcus sp ✓ ✓ ✓ ✓ ✓ ✓ ✓

Bacteroides sp ✓3 ✓ ✓ ✓ ✓

Fusobacterium sp ✓ ✓ ✓ ✓ ✓

Eubacterium sp ✓ ✓ ✓

Treponema pallidum ✓ ✓

Actinimyces bovis ✓ ✓ ✓

Veillonella sp ✓

1. Non-penicillinase-producing. 2. Non-beta-lactamase-producing. 3. B fragilis is resistant.

An

aero

bic


Organisms generally susceptible to cephalosporins

Organisms First generation Second generation Third generation

✓=generally susceptible+ = demonstrated in vitro activity

Staphylococci1 ✓2 ✓ ✓ ✓2 ✓ ✓2 ✓ ✓3 ✓ ✓ ✓

Staphylococci, beta-hemolytic ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Streptococcus pneumoniae ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Streptococcus pyogenes

Acinetobacter sp ✓2 ✓ ✓ + +

Citrobacter sp ✓2 + + ✓ ✓ + + ✓

Enterobacter sp ✓2 ✓2 + ✓ ✓ ✓ ✓ ✓

Escherichia coli ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Haemophilus influenzae ✓ ✓ ✓3 ✓3 ✓3 ✓3 ✓3 ✓3 ✓3 ✓3 ✓3

Haemophilus parainfluenzae + +3 ✓ ✓ +

Hafnia alvei

Klebsiella sp ✓ ✓ ✓ ✓ ✓ ✓ + ✓ ✓ ✓ ✓ ✓

Moraxella (Branhamella) catarrhalis + ✓ + ✓3 + ✓

Morganella (Proteus) morganii ✓2 ✓ ✓ ✓ ✓ ✓ +

Neisseria gonorrhoeae + ✓ + + ✓3 ✓ ✓ ✓ +

Proteus mirabilis ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Proteus vulgaris ✓ + ✓ ✓ ✓ ✓ ✓

Providencia sp ✓ + + + + +

Providencia rettgeri ✓ ✓ + ✓ ✓ ✓ + +

Pseudomonas aeruginosa ✓ ✓2 ✓2 ✓2 ✓

Salmonella sp ✓ + + + + + +

Salmonella typhi + + +

Serratia sp + ✓ ✓ ✓ ✓ ✓

Shigella sp ✓ + + + + + +

Bacteroides sp ✓ ✓ ✓ ✓ + ✓

Bacteroides fragilis ✓ ✓ ✓ +

Clostridium sp ✓ + ✓ ✓ + + +

Clostridium difficile +

Eubacterium sp + +

Fusobacterium sp ✓ + + ✓ + +

Peptococcus sp + ✓ + ✓ ✓ ✓ + +

Peptostreptococcus sp + ✓ + ✓ ✓ ✓ + +

1. Coagulase-positive, coagulase-negative and penicillinase-producing.2. Some strains are resistant.3. Including some β-lactamase-producing strains.

Cep

hale

xin

Cef

adro

xil

Cef

azol

in

Cef

aclo

r

Cef

uro

xim

e

Cef

onic

id

Cef

ixim

e

Cef

oper

azon

e

Cef

otaz

ime

Cef

tizo

xim

e

Cef

tria

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Cef

tazi

dim

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An

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Gra

m-n

egat

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Gra

m-p

osi

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Significance of blood culture isolates

Significance Organisms

Almost always significant Group B StreptococcusStreptococcus pneumoniaeListeria monocytogenesHaemophilus influenzaeEnterococci (Streptococcus faecalis, S. faecium,S. Bovis, etc).Group A StreptococcusGroup C/G streptococciNeisseria meningitidisNeisseria gonorrhoeaGram-negative bacilliCandida and other fungi

Sometimes significant (about 50%) Staphylococcus aureusCoagulase – negative staphylococci (S. epidermidis etc.)Streptococcus viridans group (including S. mitis, S. mitior,S. milleri, S. Sanguis, etc)a

Clostridium speciesMultiple isolates (polymicrobial)

Almost always contaminats DiphtheroidsPropionibacteriumBacillus species

Antibiotic guidelines in neonatal infection

Clinical Risk Possible Suggested CommentsSituations Factors Organisms Regimes

‘Early’ onset PROM > 24 hr GBS Benzylpenicillin + If all cultures subsequently provesepsis/? RDS Maternal E. coli gentamicin negative, antibiotics can be stopped

infection – fever, Other enterobacteria after 48 hours if the baby is wellleucocytosis etc. proven septicaemia is usually treatedMaternal colonisation for 10 daysOffensive or Listeria Benzylpenicillin Convert penicillin to Ampicillingreen liquor monocytogenes + gentamcin following confirmation of diagnosis

Sepsis Presence of Staph aureus staph Flucloxacillin + In proven S. Epidermidisafter >5 days septic spots, Spp gentamicin Septicaemia secondary

Umbillical Other gram-positive To long – lineflare, central and - negative Sepsis, change to vancomycin ifvenous line organisms symptoms not resolved by 48 hrsin situ

Pneumonia after Ventilated Not available, no Flucloxacillin +prolonged stay Earlier course growth or Staphylococcus gentamicinin the neonatal of antibioticsunit Last ET

AspirateConjuctivitis/ Coliforms CefotaximePneumonitis Pseudomonas Ceftazidime +

Aeruginosa gentamicinChlamydia Erythromycin

Necrotising Preterm `Gut organisms’ Benzylpenicillin +enterocolitis Birth asphyxia including anaerobes gentamicin+

Umbilical Metronidazolecatheterisation Or cefotaxime and

metronidazoleUrinary tract Commoner in E. coli other enterobacteria Ampicillin + gentamicininfection males CSF GBS Benzylpenicillin

Contd...


Contd...

Meningitis Gram film: + gentamicinGram-positive cocci inchains: Gram-negativebacilli, gram-positivebacilli Coliforms Cefotaxime and gentamicin Change according to cultureNo bacteria seen Listeria monocytogenes Ampicillin and gentamicin and sensitivity results

Cefotaxime and gentamicin

Septic risk scoring

0 1 2

Phase I

Duration of ROM (hour) <12 12-24 >24Maternal temperature (F) 98-99 99-100 >100Apgar score at 5 minutes 08-10 05-07 <5Amniotic fluid appearance Clear Meconium or blood-stained Purulent or foul smellingWeight of infant (g) >2500 1500-2500 <1500

Phase II

Appearance of placenta Clear opalescent PurulentGastric aspirate PMN count 0-5 6-15 >15 or bacteria engulfed in PMNMaternal temperature (F)1-2 hours postpartum 98-99 99-100 >100Material WBC onday of delivery (mm3) 10,000-15,000 15,000-20,000 >20,000Maternal urinalysis (microscopic) Clear Bacteria or white cells Both bacteria and white cellsState of infant Normal Questionable Respiratory distress or lethargy

Specific antibiotic therapy in early-onset neonatal septicemia

First line Ampicillin + gentamicin / amikacin (to cover most Gram-positive and Gram-negative pathogens)In ampicillin resistance A third generation cephalosporin + gentamicin / amikacinIn accompanying meningitis Ampicillin / amikacin + a third generation cephalosporin

Specific antibiotic therapy in late-onset neonatal septicemia

First line Ampicillin + gentamicin/amikacinSecond line Cefotaxime + amikacin. Add cloxacillin if staph is suspected. For resistant staph, vancomycin or

coamoxyclav should be preferred.For nosocomial infections Ceftazidime or cefoperazone + netilmicin

Suggested antibiotic regimens for sepsis and meningitis

Organism Antibiotic Bacteremia Meningitis

GBS Ampicillin or penicillin G 10-14 days 21 days

E. coli Cefotaxime or ampicillin and gentamicin 14 days 21 days14 days 21 days

Enterobacter, Cefotaxime or cefipime or meropenem and gentamicin 14 days 21 daysKlebsiella

Enterococcus Ampicillin or vancomyin and gentamicin 10 days 21 days

Listeria Ampicillin and gentamicin 10-14 days 21 days

Pseudomonas Ceftazidime or piperacillin / tazobactam and gentamicin or tobramycin 14 days 21 days

S. aureus Nafcillin 10-14 days 21 days


FIRST LINE ANTIBIOTICS

These are suggetions for initial treatment until sensitivity test results are available:Acinetobacter: Ticarcillin +/- tobramycin.Actinomyces isralli: Benzylypenicillin.Aeromonas: Cotrimoxazole.Afipla felis (cat scratch): Ciprofloxacin or cotrimoxazole.Bacillus anthracis: Benzylpenicillin.Bacteroides : oral: Benzylpenicillin metronidazole.Bordetella pertusis: Erythromycin.Borrelia burgdorferi (Lyme disease): Tetracycline or ceftriaxone.Borellia recurrents (relapsing fever): Tetracycline or benzylpenicillin.Branhamella catarrahalis: See moxarella catarrhalis.Brucella: Tetracycline + gentamicin, or cotrimoxazole.Calymmatobacterium granulomatis (granuloma inguinale): Tetracycline.Campylobacter jejuni: Ciprofloxacin or erythromycin.Chlamydia pneumoniae (TWAR strain): Tetracycline or erythromycin.Chlamydia psittaci (psittacosis, ornithosis): Tetracycline or erythromycin.Chlamydia trachomatis: Erythromycin. Trachoma: Topical and oral tetracycline or sulphonamide.Clostridia: Benzylpenicillin. Clostridium difficile: Vancomycin or metronidazole.Botulism: Oral vancomycin.Corynebacteria: Erythromycin. JK group: Vancomycin.Eikenella corrodens: Amoxycillin +/- clavulanic acid.Enterobacter: Cefotaxime + amikacin.Escherichia Coli: Cefotaxime +/- gentamycinFrancisella tularensis (tularaemia): Gentamicin.Fusobacterium: Benzylpenicillin.Gardnerella (haemophilus) vaginalis: Metronidazole.Haemophilus ducreyi (chancroid): Erythromycin.Haemophilus influenzae: Cotrimoxazole. Severe inftn: Cefotaxime or ceftriaxone.Klebsiella pneumoniae: Cefotaxime +/- gentamicin.Legionella: Erythromycin + rifampicin.Leptospira: Benzylpenicillin.Leptotrichia buccalis: Benzylpenicillin.Listeria : Monocytogenes: Amoxycillin +/- gentamicin.Morganella morganil: Cefotaxime +/- gentamicin.Moxarella catarrhalis: Cotrimoxazole or cefotaxime.Mycoplasma pneumoniae: Erythomycin or tetracycline.Neisseria gonorrhoeae: Ceftriaxone.Neisseria meningitides: Benzylpenicillin.Nocardia: Cotrimoxazole.Pasturella multocida: Benzylpenicillin.Proteus: Cefotaxime +/- gentamicin. Indole negative: Amoxycillin.Providencia: Cefataxime +/- gentamicin.Pseudomonas cepacia: Cotrimoxazole.Pseudomonas mallei (glanders): Streptomycin + either tetracycline or chloramphenicol.Pseudomonas maltophilla: See xanthomonas maltophilia.Pseudomonas pseudomallei (melioidosis): Ceftazidime.Rickettsia: Tetracycline or chloramphenicol.Rochalimaea henselae (bacillary angioniatosis): Erythromycin.Salmonella : Cefotaxime. S.typhi: Ceftriaxone.Serratia: Cefotaxime +/- gentamicin.Shigella: Ciprofloxacin or cotrimoxazole or amoxycillin or ceftriaxone.Spirillum minus (rat bite fever): Benzylpenicillin.


Staphylococcus: Flucloxacillin +/- gentamicin. Resistant: Vancomycin +/- gentamicin and/or rifampicin.Streptobacillus moniliformis (rat bite fever): Benzylpenicillin.Streptococcus: Benzylpenicillin. Enterococcus : Amoxycillin + gentamicin or amikacin. S. Viridans: Benzylpenicillin +/- gentamicin.Treponema pallidum (syphilis): Benzylpenicillin.Treponema partenue (yaws): Benzylpenicillin.Ureaplasma urealyticum: Erythromycin.Vibrio cholerre (cholere): Tetracycline or cotrimoxazoleVibrio vulnificus: Tetracycline or cefotaxime.Xanthomonas maltophilia: Cotrimoxazole.Yersinia enterocolitica: Cotrimoxazole.Yersinia pestis (plague): Streptomycin.

Viral Infection Therapy

Viral infection Prevention/therapy

Hepatitis B virus Hepatitis B immunoglobulinHepatitis B vaccine

Herpes simplex virus AcyclovirVidarabine

Varicella-zoster virus AcyclovirVidarabine

Respiratory syncytial virus Ribavrin (aerosol)Cytomegalovirus Ganciclovir (potential)Human immunodeficiency virus Azidothymidine (AZT) (Potential)

Drug Route Dosage Comments

Acetaminophen PO, PR Newborn: 25 mg/kg/day d/v q4-5h Contraindicated in infants with G-6PD deficiency.(crocin, calpol) Infant: 50-60 mg/kg/day d/v q4-6h Overdose results in delayed hepatotoxicity. Anti-

dote: N-acetyl cysteine.

Acetazolamide PO 2-10 mg/kg/dose d/v q8h Side effect: Hypokalemia, acidosis and GI distur-(Diamox) Max 100mg/kg/day. bances

Acetylcysteine PO, PR Preterm: 2 ml q4-6h (of 5% solution) For severe atelectasis combined with intensive chest(Mucomix) Via nebulizer Term: 3ml q4-6h (of 5% solution) physiotherapy. May induce bronchospasm, stoma-

(10% solution) Meconium ileus: 5-30ml/day (10%) titis, drowsiness, rhinorrhoea, nausea, vomiting andQ3-6hr in equal dilution with DW/NS hemoptysis. Aerosolized bronchodilator given 10-

15 min prior to acetyl cysteine improves efficacy.

Adenosine IV 0.05 μg/kg rapid bolus. Increase in Very short t½ of 15 seconds. It is antagonized by(adenecor) increments of 0.05 μg/kg at 2 min interval theophylline. Sinus bradycardia, AV block and(6mg/2ml) until sinus rhythm is restored. Maximum flushing. Flush IV line with NS soon after drug

dose is 0.3 μg/kg. dosing.

Alfacalcidol PO 0.05 μg/kg OD(1-α Vit D)

Albuterol ET 0.05-0.15 mg/kg/dose q4-6h Tachycardia, hypertension, arrhythmias, tremor,(Roventil) hypokalemia, irritability.

Amiloride IV 200-500 μg/kg/dose q12h Side effects: Hyponatremia,vomiting,start with low(1mg/ml) dose for BPD.

Aminophylline IV, PO Apnea of prematurity: Ethylenedlamine salt of theophylline. Contains 80%(minophyl) Loading: 6 mg/kg over 20 mins theophylline. See theophylline for comments.(250mg/10ml) Maintenance: 5 mg/ kg/day d/v q12h Therapeutic level for asthma 10-20mg/L,

or 0.2 mg/kg/hr. Give first maintenance apnoea 6-13mg/Ldose 12h after loading dose.

Ammonium PO, IV 1-2 mEq/kg/dose(slow infusion) For correction of hypochloremic metabolicchloride alkalosis.

Amrinone IV 0.75 mg/kg bolus over 2 min followed by Thrombocytopenia.5-10 μg/kg/min as infusion.

Arginine HCl IV 750 mg/kg/day. Metabolic acidosis, hyperglycemia, hyperkalemia.Becomes essential amino acid if urea cycle is notintact.

Atracurium IV Loading: 0.5 mg/kg Indicated in infants requiring mechanical ventila-(tracrium) Maintenance: 5-10 mg/kg / day every tion who continue to have inadequate oxygenation

20-30 min (24 hr after loading dose) despite optimal supportive care.Therapeutic levels = 5-25 mg/L It has little effect on CVS.

Atropine (tropine) IV 0.01 mg/kg/dose, to be repeated Indicated for bradycardia, presumed to be vagal(600μg/ml) ET q10-15 minutes with the total maximum in origin.

dose of 0.04 mg/kg. Side effects: Dry mouth, blurred vision, hyperther-mia, tachycardia, constipation, urinary retention,restlessness.

Contd...

CHAPTER

2 Drug Formulary

Drug Formulary 19

Contd...

Contraindication: Glaucoma, obstructive uropathy,tachycardia.Antidote: Physostigmine

Budesonide Nebulised 500μg-1mg/dose diluted to 4 ml withRespule1mg/ NS q12h.200mg-1mg /dose q12h2ml. (MDI200μgpuff)

Bumetanide IV, IM, PO 0.015-0.1mg/kg/dose over 1-2 mins Forty-times more potent than furosemide.Toxicitysimilar to furosemide.

Caffeine Citrate PO Loading: 20 mg/kg Methylxanthine derivative, compared with amino-Maintenance: 5-10 mg/kg/day q6h. phylline it is more potent CNS stimulator, has theDose of caffeine base is ½ the above dose. same but milder side effects, longer half life, and

wider therapeutic ranges. Should monitor serumlevels. Therapeutic level 8-25μg/ml. Side effects:Rarely appear at level<50μg/ml.Contraindication:Caffeine benzoate preparation has been associatedwith causation of kernicterus.

Calcium IV Cardiac resuscitation: 1-2 ml/kg/dose Contains elemental ca++ 0.23 m mol/ml or 100 mg/Gluconate (10%) (over 10 minutes) ml. Monitor closely for bradycardia, dysrhythmiasInjection Symptomatic hypocalcemia: 1-2 ml/kg by and extravasation. (may cause tissue necrosis)

slow infusion over 30 Infusion rate not to exceed 20mg Ca++ /kg/min.Side effects: Hypotension and bradycardia, associ-ated with arrhythmias in digitalized patient, mayprecipitate when used with bicarbonate.

Maintenance: 2-4 ml/kg/day (200-400 mg/kg/day) mixed in compatible IV fluids 6h

PO 400-800 mg/kg/day (36-72 mg/kg/day IV preparation can be given orally to supplementelemental Ca++) divided equally among nutritional intake in preterm infants to a totalfeedings q 6h. Start with 400 mg/kg/day intake of 150 mg/kg/day of elemental calcium,(36 mg/kg/day of elemental Ca++ ) and including content of feedings. Less irritating toincrease gradually as tolerated. Gl tract than calcium chloride.Elemental Ca PO4 Brand Ca PO4 RatioCalcinol syrup 105 – Human milk 30-35 12-15 2:1Macalvit 92 – Preterm milk 25 14 1.8:1Ossopan 33 + Cow milk 122 90 1.2:1Ostocalcium 82 + Lactogen 1 74 57 1.2:1Ossidos 67 + Lactodex (LBW) 128 64 2:1Omnical 45 + Lactodex 88 47 1.8:1

Dexolac sp care 105 57 1.8:1Milk care 112 48 2.3:1

Calcium PR, PO Acute hyperkalemia: 1mg/kg/dose 1 g/kg decreases serum K+ by 0.5-2.0 m mol/L.Polystyrene q6h as needed (Exchanges 1.6 mmol K+/g of resin). PreparationSulfonate of 0.25 g/ml in 25% sorbitol should be used to(Resonium prevent G.I obstruction.Calcium)

Calcium lactate (13% Ca) → 400-500mg/kg/day q4-8h POCalcium glubionate (6.4% Ca) → 1200 mg/kg/day q4-6h POCalcium chloride (27% Ca) → 0.2ml/kg/dose IVCalcium Carbonate (40% Ca) → 50 – 150mg/kg/day q4-6h PO

Captopril (aceten) PO Initial dose: 0.05 mg/kg q8h Increase or Tablets must be crushed and diluted in steriledecrease dose by 50-100% to titrate BP to water to a concentration of 1 mg/ml. Suspensiondesired range. (Dosage range 0.05-0.5 must be shaken well for 5 minutes Use withinmg/kg/dose) 30 minutes of mixing. Adverse effects: Rash, hypo-0.1-0.4 mg/kg/day q6-8h tension, oliguria, cough, hyperkalemia, proteinuria,onset of action within 15-30 min of agranulocytosis Contraindicated in neonates withadministration bilateral renal artery stenosis or unilateral renalPeak effect within 1-2H renal artery stenosis with single kidney. DosageAdminister 1hr prior to meals. reduction required in patients with renal

impairment.Carbimazole IV 250 μg/kg q8h(neo-mercazole)

Contd...


Contd...

Carnitine (carnitor) PO 50-100 μg/kg/day q8h Nausea, vomiting and abdominal cramps plasmaIV free carnitine level 35-60 μ mol/L.

Chloral hydrate PO 10-30 mg/kg/dose q6-8h prn Can cause gastric irritation; laryngospasm if aspi-PR Recommended maximum dose rated. Caution in preterm infants; reported cases

100 mg/kg/day of coma 24-48 hours following doses;postulated tobe due to delayed gastric emptying and/or imma-ture liver function. Avoid large doses in severecardiac disease. Contraindicated in severe hepatic/renal impairment.

Chlorpromazine PO,IM 750 μg/kg/dose q6h Used in treatment of opiate withdrawal to reduce(emetil) Maximum dose is 1.5 mg/kg q6h threshold for seizures. Not for IV use.Cholestyramine PO 80mg active resin q8h with feeds. Side effects: Diarrhoea,constipation,malabsorption

of fat soluble vitamins and metabolic acidosis.Clonazepam IV 100-200 μg/kg bolus over 30min or Increased secretions.(lonazep, rivotril) PO 10-30 μg/kg/hr infusion.

Maintenance: 25-50 μg/kg/day

Chlorpheniramine IV 250mg/kg for anaphylaxis.(avil)Chlorothiazide PO/IV 20-40 mg/kg/day d/v q12h Dehydration and electrolyte (Na, Cl, K) imbalance.(ditide) Never IM Use with caution inliver and severe renal disease.

Hypercalcemia, hyperbilirubinemia, alkalosis,hyperglycemia, hyperuricemia, hypo magne-semia, blood dyscrasias, pancreatitis.

Cimetidine PO Preterm: 4-8 mg/kg/day divided q12h Use in neonates still experimental. Eliminated(lock-2) IV Term neonates: 10 mg/kg/day divided mostly unchanged by kidney. Reduction of dosage

q8h. Infants: 10-20 mg/kg/day required in renal dysfunction. Can cause CNS sidedivided q6h effects, diarrhoea, rash, neutropenia,and

gynaecomastia. Increases serum levels of some drugsincluding theophylline and phenytoin.

Cisapride PO 0.2-0.3mg/kg/dose q6-8 h 30 min Stop 24 h prior to pH study. Diarrhoea. Avoid usebefore feed. with miconazole, ketoconazole, itraconazole due to

possible occurance of cardiac arrhythmias.

Corticotropin IM 3-5 units/kg/day d/v q6h(ACTH)

Cortisone acetate PO Physiological replacement: 0.5-0.75 mg/ Glucose intolerance, Cushing’s syndrome, pituitary(cortone acetate) IM kg/day q8h or 0.25-0.35 mg/kg/day q6h adrenal suppression, edema, hypertension, cataract,

Stress: 31-50mg/m2/day q6h on days –2, hypokalemia and skin atrophy.-1, 0, 1, 2, 3 and 4 of perioperative period.

Cromolyn ET 20 mg/dose Bronchospasm, cough, nasal congestion andpharyngeal irritation.

Curare IV 0.3 mg/kg/dose q3-4h prn Hypotension, shock, bradycardia.

Defibrillation 1-4 Joules/kg; increase 50% each time. Indicated for VT/VF.

Dexamethasone IM, IV, PO Pre-extubation to decrease upper airway Side effects: Include hypertension, hyperglycemia,(dexona) edema: 1.5 mg/kg/day d/v q8h X 24h. salt retention, leucocytosis , adrenal suppression

Then 0.9 mg/kg/day d/v q8h X 24H and with long-term use may rarely cause hyper-then stop. Cerebral edema: Initial dose trophic cardiomyopathy. May increase risk of infec-= 0.5-1.5mg/kg; Maintenance: 0.2- tion. Consider steroid coverage for periods of stress0.5mg/kg/day q6h × 5days. Anti after therapy for BPD and in inter current illness.inflammatory 0.025-0.05 mg/kg/doseq6-12h

Suggested course of dexamethasone treatment for severe BPD

Length of Course Day Dose

Short 1 0.1 mg/kg q12h2 0.075 mg/kg q12h3 0.05 mg/kg q12hMay repeat weakly, if necessary

Long 1 and 2 0.1 mg/kg q12h

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Drug Formulary 21

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If no response after 48-72 h of this dosing, stop.If response:

3 and 4 0.075 mg/kg q12h5, 6 and 7 0.05 mg/kg q12h8 OFF9 0.05 mg/kg q12h10 END

Diazepam IV 0.1-0.3 mg/kg /dose slow IV push over Indication: Not used as a first line anticonvulsant.(Valium) 2 minutes; repeat q5-10min. As needed Short-term adjunctive therapy in status epilepticus.

up to a total dose of 1.0 mg/kg Risk of CNS and respiratory depression, hypoten-For status epilepticus: sion and phlebitis. Contraindicated in hyperbiliru-Bolus 0.2 mg/kg IV, followed by 0.1-0.3 binemic neonates. Caution in glaucoma, shock andmg/kg/h as continuous infusion. depression(dilute in D5W to 0.1 mg/ml)

PR 0.5-1.0 mg/kg; parenteral preparationto be used in conjuction with a syringe andcatheter inserted into the rectum.

Diazoxide PO 1.7-5 mg/kg q8h in hyperinsulinemic Hyponatremia, salt and water retention GI(Hyperstat) IV hypoglycemia. disturbances, ketoacidosis, rash, hyperuricemia,

Hypertension: 1-3mg/kg. Slow IV. Can hypertrichosis, arrhythmia, hypotension,repeat hourly. hyperglycemia.

Digoxin (digoxin, IV, PO Loading Maintenance a. Loading dose is given in three divided doseslanoxin) (μg/kg)IV (μg/kg/day) IV (1/2, ¼, ¼) q8h. Start maintenance 24 hours after

Preterm 20μg 4-6 μg d/v q12h last digitalizing dose in preterm and 12 hours afterTerm 30μg 6-8 μg d/v q12h in full term neonates.>2 mo 40μg 10 μg d/v q12hNote: Above dosages are for CHF, b. Maintenance dose is generally 25% of the totalproducing levels of 0.5-2 mg/ml. loading dose.Higher doses may be needed for c. The PO dose is 25% more than the IV dose.treatment of arrhythmias. d. At one month of age, increase maintenance dose to

that of full term neonates.Caution in renal failure; Contraindication – ventricu-lar dysrhythmias; Adverse effects: In neonates ondigoxin, cardioversion and Ca infusion may lead toventricular fibrillation (pretreatment with lidocainemay prevent this).

Disopyramide PO 3.5-7.5 mg/kg q6h CI in conduction block, myasthenia gravis.Therapeutic level 2-5 μg/ml.

Dobutamine IV 2.5-15 μg/kg/min Acts directly on β1 receptors to increase myocardiac

(dobutrex) (recommended maximum 30 μg/kg/min.) contractility. Also stimulates α1

and β2 receptors.

Calculation: Same as dopamine. No dopaminergic effect. Adverse effect:6xwt(kg) =mg tobe added to 100 ml Dysrhythmias, systemic hypertension or increase inD5W. yeilds 1ml/hr =1μg/kg/min. pulmonary capillary wedge pressure. May be

preferred over dopamine as an inotrope in theneonate with shock, but without severehypotension.Incompatible with alkaline solutions.

Domperidone PO Gastroesophageal reflux in older infants: Dopamine antagonist. Gastrointestinal prokinetic(domstal) 0.3 mg/kg/dose 10-20 min. agent. Does not readily enter CNS, however, in

young infants extrapyramidal reactions may occurto immature blood-brain barrier.

Dopamine IV Constant IV infusion: Initial 2-5 μg/kg/ Dose- dependent pharmacological actions:(dopaplus) min increasing gradually up to 30 μg/kg/ Renal: 2-4 μg/kg/min IV. Inotropic (b1) : 5-10 μg/

min for Desired cardiac/vascular effects. kg/minIV. Vasocostrictive (a): 10 μg/kg/min IV.Minimum dilution = 1.6 mg/ml Care must be exercised to prevent local infiltrationIn D5W or D10W. since vasoconstriction activity will lead to vaso-Suggested method for calculation spasms and tissue necrosis. Manufacturer recom-of dopamine and isoproterenol mends reinfiltrating the area with an alpha- blocker,(Dilute with D5W or D10W) e.g. phentolamine 5-10 mg (1 mg/ml in normalSelect: Desired drug dose desired saline in adults after extravation, but no clinicalIV fluid rate. experience in neonates as to dosage or efficacy.

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Calculation: mg/100ml Empirically, only a few drops of the 1mg/ml solu- wt(kg) × 6 × desired dose μg/kg/min) tion are needed to reverse the vasoconstriction.=

desired IV fluid rate (ml/hr) Should weigh benefits against potential risks (localeffect of reinfiltration in a tiny infant and systemiceffect of hypotension)

Dornase alpha ET 2-5mg q12-24h for tenacious pulmonary Pharyngitis, laryngitis, conjunctivitis.(pulmozyme) secretions.

Doxapram IV Initial: 0.5 mg/kg/hr Investigational drug. May be useful in neonatal(caropram) Infusion Increase dose by 0.5mg/kg/hr q6h apnea resistant to theophylline. Do not use if IVH

Maximum maintenance dose: 1.5mg/kg/hr grade III or IV, seizure disorder, increased bloodWhen the apneic episodes controlled, taper pressure or in first three days of life.the dose by 0.1 mg/kg/hr q8h to the Theophylline therapy is usually continued.lowest effective dose.

Edrophonium IV Test for myasthenia gravis: 0.1mg Keep resuscitation kit ready as it may precipitatehydrochloride single dose. cholinergic crisis, arrhythmias, bronchospasm.(Tensilon) Contraindicated in GI or GU obstruction or

arrhythmias. Antidote: 0.01-0.04 mg/kg/dose ofatropin.

Enalapril (vasotec) PO 0.005-0.01 mg/kg/dose q8-24h; Cardiopulmonary compromise, hyperkalemia,depending on BP agranulocytosis. CI in renal artery stenosis. Decrease

IV 5-10 μg/kg/dose q8h-24h; administer dose in renal failure.over 5 min

Epinephrine Via 0.25 ml/kg diluted to 3 ml with normal Indicated drug. May be useful in neonatal apnea(Racemic) for Nebulizer saline q1-2h Max total dose 0.5 ml resistant to theophylline. Do not use if IVH gradeinhalation 2.25% III or IV, seizure disorder, increased blood pressure

or in first three days of life.Theophylline therapy is usually continued.

Epinephrine IV 0.1-0.5 μg/kg/min (infusion) To support in babies with true or relative(1:1,000) mix with D5W or D10W hypotension. Acts directly on both α and β(1mg/ml) Calculation: Same as Dopamine adrenergic receptors, with β2 effects predominating

0.5-1ml of 1:10000 as ionotropic agent. at lower doses. Alpha adrenergic stimulationproduces an increase in heart rate and systolic bloodpressure. Not effective if acidosis is present.

Ergocalciferol PO Preterm: 400-800 IU/day. Hypercalcemia, weakness, diarrhoea, polyuria,(calciferol) metastatic calcification, nephrocalcinosis.

Erythromycin PO 3-5 mg/kg/dose q6h GI distress.IV 3-5 mg/kg/dose q6h; infuse over 60 min

Erythropoietin IV, SC 50-100 units/kg; 3 times per week. Hypertension, seizures, thrombotic events and(Epogen, Procrit) allergic reactions. Has delayed onset of actions

(wks) hence not suitable for acute anemia.

Ethamsylate IM, IV 12.5mg/kg q6h (total of 16 doses) To reduce risk of cerebral haemorrhage in preterminfant.

Exosurf IT 5 ml/ kg/ dose q12h for details see, Synthetic surfactant for the prophylaxisspecific protocol. and treatment and; hyaline membrane disease.

Fentanyl citrate IV, SC Pain / sedation: Slow IV push over 5 min: Adverse effects; respiratory depression and apnea,(Sublimaze) 1-2 μg/kg/ dose, followed by 1-5 μg/kg bradycardia, chest wall rigidity (with large doses),

/dose. functional ileus, neonatal abstinene syndrome.Anesthesia: Slow IV push over 5 min: Tolerance develops rapidly to sedative and20-75μg/kg/dose analgesic effects, necessitating increases in dosage.Onset of action: 1-2 min.Peak action: 10 min.

Fludorocortisone PO Congenital adrenal hyperplasia: 0.05 to 0.2 Excessive therapy can cause hypertension.(Floricot) mg once a day 0.1mg 9-fluorocotisol =1mg Contraindication: CHF, Systemic fungal infection.

DOCA.Flumazenil IV 8-15 μg/kg (maximum single dose Seizures, agitation and CNS stimulation, flushing,(Romazicon) 200 μg) repeated every minute to a vomiting. Avoid benzodiazepines for seizures

maximum total accumulative dose of 0.5 control.mg/kg or 100 μg whichever is lower. Fluoride drops (1=1 mg fluoride lon per 8 drops).

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Drug Formulary 23

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Fluoride drops > 2 wk – 2 years; 0.25 mg/day. Supplementation recommended for all infants if(1-1 mg fluoride 1 on concentration of fluoride in drinking water has <0.3per 8 drops) ppm fluoride.

Folic Acid (folvite) PO Hemolytic anaemia: 0.25μg/kg/day Normal serum level >4 ng/ml.for 6 months. Dietary supplementationin preterm (<33wk) 50μg/day.

Folinic acid PO 5mg/dose twice a wk in toxoplasmosis. Used along with pyrimethamine.

Furosemide (Lasix) IV, IM, Initial; 1 mg/kg/ dose q24h in preterm, Dehydration and electrolyte (Na, Cl, K) imbalances,(20mg/2ml) q12h in full term; up to q6h > 1 month. ototoxicity, metabolic alkalosis, nephrocalcinosis,

Maximum single IV dose is 2 mg/kg hyperuricemia and increased calcium excretion.(IV push over 2-3 minutes).

PO Maximum rate of infusion: 0.5mg/kg/min.1-4mg/kg/dose.

Gentian violet (1%) Topical Dilute to 0.5% solution 3-4 drops q8h-12h Stains the part. Do not apply over face.

Glucagon IM, IV 30 μg/kg IM; may repeat prn to max. Limited use in neonates because helpful in(glucagon novo) 1 mg 0.5-2 mg/ day as continuous hypoglycemia only if liver glycogen is available.

infusion (dilute in D5W or D10W) Indicated in persistent hypoglycemia despiteaggressive glucose infusion (> 14 mg/kg min) orproblem of fluid over load.

Heparin (hep) IV To keep indwelling lines open: 1 unit/ml in During heparinization monitor baseline andflushing and parenteral solutions. For subsequent coagulation studies; clotting time,heparinization: Initial dose; 50 units/kg PT, APTT, platelet count and fibrinogen DiluteMaintenance: 20-25 units/kg/hr as with D 5W or 10 D10W.infusion.Reversal of Heparin Therapy Bleeding, allergy, alopecia, thrombocytopenia.Time since last Protamine dose CT = 20-30 min, APTT=1.5-2.5 times control valueheparin dose (mg/100 unit before dose.(min) heparin received) Antidote: Protamine sulfate (1mg per 100U< 30 1.0 heparine in previous 4hours).30-60 0.5-0.7560-120 0.375-0.5>120 0.25-0.375Maximum dose of 50mg.Infusion rate of a 10mg/ml solutionshould not exceed 5mg/min.Hypersensitivity reaction to protaminesulfate may occur in patients with knownhypersensitivity to fish or those previouslyexposed to protamine therapy or protaminecontaining insulin.

Hepatitis B IM 200 IU as soon after birth as possible For prophylaxis in newborns whose mothersImmunoglobulin (within 12 hour) are hepatitis B antigen (HbsAg) positive.(HBIG) (hepaglob)

Hepatitis B IM 0.5 ml (10μg) administered within Hepatitis B vaccine may be given at the same time(Recombinant 7 days of birth and again at as HBIG, but should be given at a separate site.vaccine) 1 and 6 months of age.

Hyaluronidase SC 15 unit diluted in 1 ml of saline and Use to treat IV extravasation of certain drugs, but(hynidase) infiltrate the affected area. do not use for treatment of extravasation of alpha

adrenergic blockers, e.g. dopamine

Hydralazine IV Initial dose: 0.2 mg/kg q4-6h prn as Causes direct relaxation of smooth muscle in(apresoline) required for BP control. Dose may be peripheral vascular bed. May cause tachycardia,

gradually increased by 0.1 mg/kg/dose to SVT, diarrhoea, emesis, lupus like syndrome,maximum of 2 mg /kg/dose. Give by slow agranulocytosis, decrease dosage in renal failure.IV push at rate not exceeding 0.2 mg/min

PO PO dose generally twice the effective Oral bioavailability generally 50% that of IV route.IV dose

Hydrochloro- PO 2-4 mg/kg/day d/v q12h Start with Same as chlorothiazide.thiazide(hydride) 1 mg /kg/ day and increase the dose by

1 mg/kg /day every 2 days

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Hydrocortisone IV For adrenal crisis: 25 mg IV bolus, followed Wide variation in glucocorticoid requirements. Dose(efcorlin) by continuous infusion of 50-100mg/m2/ must be individualized according to growth and

24 hr until improvement occurs. hormone data. Can cause adrenal suppression,Anti-inflammatory:1-2.5mg/kg/dose. growth retardation, fluid and electrolyte

disturbances, hypertension, hyperglycemia,increases susceptibility to infections.

PO Maintenance dose for congenital adrenalhyperplasia: 20-25 mg/m2/day dividedTID.

IV For neonatal hypoglycemia: 1-2 mg/kg/ Indicated in persistent hypoglycemia despitedose q8h aggressive glucose infusion (> 14 mg/kg min) or

problem of fluid overload.Immunoglo- IMbulins:Hepatitis Bimmunoglobulin Neonates born to HbsAg positive mothers:(HBIG) (hepaglob) 100-200 IU soon after birth(200 IU/ml) (atleast <5 days) Booster dose:

32-48IU/kg between 2 and 3 monthsafter initial dose.

Human normal IM Immunotherapy: 10% 0.6 ml/kg; CI: Selective IgA deficiencies,hypersensitivity.immunoglobin 16.5% 0.4ml/kg. SP for signs of anaphylactoid reactions.(Bharglob) IM Prophylaxis of infections:

10% 0.4ml/kg: 16.5% 0.25ml/kg.

Rabies IM 20 IU/kg.1/2 the dose should be First dose of vaccination given at the same time butimmunoglobulin infiltrated in and around the wound at a differnt site.

and1/2 administered IM

RSV IV 750 mg (15ml) monthly during RSV season.immunoglobulin 1.5 ml/kg/h 15 min. ×

3 ml/kg/h 15 min. ×6 ml/kg/h until finished

Tetanus IM, IT Tetanus neonatorum: 500 –10000 IU IM Local pain, fever, flushing and chills may occur.immunoglobulin or 250 IU IT prophylaxis : 250–500 IU IM(TIG) (Tetglob)

Varicella –Zoster IM 250 mg Indicated in any mother suffering from chickenpoximmunoglobulin upto 5 days earlier to 15 days after delivery.(VZIG) Antibody titre (IgG) >32 is seen in all if mother has

suffered chicken pox before 6 days of delivery.

Immunoglobulin IV Replacement therapy for congenital Can cause anaphylactoid and hypersensitivity(sandoglobulin) or acquired antibody deficiency: reaction start infusion at very slow rate and increase

100–200 mg/kgq 2-4 weeks slowly. Adjunctive therapy in severe infectionsTreatment: 0.2g/day over 3 hour (septicemia) with theoretical benefits.for 4 days; Term: 0.4 g/day over3 hours for 4 days.For neonates with passive autoimmunethrombocytopenia: 0.5g/kg/day for5 days (Reconstitute in 0.9% salinesolution as a 5% solution and infuse over12 hours on each of 2 consecutive days).

Indomethacin IV 0-7 days: 0.2 mg/kg/dose at hour 0 Adverse effects; Renal dysfunction(microcid) 0.1 mg/kg/dose at hours 12 (oliguria, hyponatremia, hyperkalemia,

0.1 mg/kg/dose at hours 36 elevated BUN), platelet dysfunction,>7 days: 0.2 mg/kg/dose at hour 0 hypoglycemia. May reduce renal clearance0.2 mg/kg/dose at hours 12 of aminoglycosides, digoxin, theophylline,0.2 mg/kg/dose at hours 36 vancomycin. Close monitoring of serumInfuse over 20-30 mins. concentrations of these drugs and dosage

adjustments may be required.

Insulin IV Start with 0.05 unit/kg/hr as a 1-Flush tubing with 50ml of solution prior to(Actrapid) continuous infusion. (Add 10 U/kg of infusion.

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Drug Formulary 25

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insulin to 100 ml of 10% dextrose 1 ml/ 2 – Connect with the shortest possible tubingkg/hr=0.1 U/kg/hr). Titrate infusion tomaintain blood glucose concentration 1 and 2 will reduce adsorption loss and improvebetween 5.0 and 9.0 m mol/L and/or delivery.dextrostick between 80-160.

Glucose/Insulin This combination produces 1 unit insulininfusion /2gm glucose.

0.1 unit/kg insulin with 4 ml/kg of 25%dextrose for hyperkalemia.

Ipratropium Via nebulizer Inhalation solution: 0.125 mg (0.5ml) No enough experience with neonates. Could be usedbromide diluted to 2-3 ml with normal saline q6h. as bronchodilator in infants with BPD.(Ipravent) Can be mixed with salbutamol. Contraindication in narrow angle glaucoma and

bladder neck obstruction.Iron PO Treatment of Iron deficiency: 6 mg/kg/ Fer-in-sol delivers 2.5 mg elemental iron/0.1 ml.

day elemental iron. • Wt (kg) × 4.5 × (desired Hb – patients Hb) = mgPrevention of iron deficiency: 3 mg/kg/ of Ironday elemental iron. • Blood loss(ml) × Hct = mg of iron

100

Isoprenaline IV 0.1-0.5 μg/kg/min as infusion. For bradycardia and hypotension.Isoproterenol IV Infusion 0.05-0.5 μg/kg/min β1 and β2 adrenergic agonist: Dose dependent

Initial: 0.05 mg/kg/min; may increase inotropic and vasodilator effect. May decreaseq15 minutes by 0.05 μg/kg/minute to coronary and renal blood flow. Adjust rate ofmax dose of 1.5 μg/kg/min. infusions to keep HR <200/min.Suggested method for calculation of SP in CHF may precipitate arrhythmias whendrug solution (see Dopamine above) used with epinephrine.

Kayexalate PO, PR 0.5-1.0 g/kg q2-6h prn Has delayed onset, electrolyte disturbances,alkalosis.

Labetalol PO, IV Bolus 0.25 mg/kg over 2 min dose can be Cl in CHF, heart block, sinus tachycardia. May causedoubled and repeated every 10 min until bradycardia, edema and bronchospasm.desired clinical response or total dose of4mg/kg is reached.Maintenance:0.25-1 mg/kg/dose q4h (IV)1.5-2 mg/kg/dose q12h (PO)0.25-1.5 mg/kg/h continuous infusion.Max concentration of 1mg/ml

Levothyroxine PO, IM, IV 8-10 μg/kg/day SP in those on anticoagulants. Titrate dosage with(Eltroxin) clinical status and serum T4 and TSH. May cause

hyperthyroidism, rash, growth disturbances.

Lidocaine IV Ventricular arrhythmias: Initial dose: For short term control of ventricular arrhythmias;(Xylocaine) 0.5 mg/kg over 5 min. May repeat may cause hypotension. Should be used in critical

once after 5 min subsequent infusion: care areas only. Seizures, asystole, respiratory10-50 μg/kg/min. arrest is also known. Decrease dose in presence of

hepatic or renal failure.

Lidocaine/ Topical 2-5g/site for painful procedures. To be applied 60 min prior to the procedure.prilocaine cream(EMLA cream)

Lignocaine IV 1mg/kg as bolus, followed by 20 μg/kg/ For cardiac arrhythmias.min as maintenance infusion.

Lorazepam (calmese) IV Initial: 0.05 mg/kg/ dose, repeat every May be useful in seizures refractory to15 min prn. Phenobarbital and phenytoin. May causeMaintenance: Dose not determined, but respiratory depression. Injectable product maysuggest 0.05 mg/kg dose q 6-8h prn be given rectally.

Magnesium IV For hypomagnesemia; 25 –50 mg For IV use, the solution should be diluted to 1%Sulfate 50% inj Mg SO4/kg /dose (0.1-0.2 mmol Mg/kg): (add 1 ml 50% sulfate injection to 49 ml NS or(4mEq/ml) may repeat q6h for 3-4 doses sterile water) and the required dose infused overor (2 m mol/ml) Maintenance: 1 hour.

31.2mg – 62.5mg MgSO4/kg day To be added to total IV fluid. Monitor for(0.125 – 0.25 mmol Mg/kg day). hypotension, respiratory depression, hypermagne-

semia SP in renal insufficiency and neonates

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on digoxin. Antidote: Calcium gluconate.In PPHN: 200mg/kg over 30 mins followed by 20-60mg/kg/hr by infusion adjusted to maintain S.mg3.5-5.5mmol/L.

Mannitol (20%) IV 0.5-2.0g/kg/dose over 20 mins. For management of cerebral edema.Medium Chain PO 1-8 ml/24h, divided equally Contains 7.6 kcal/ml. Does not contain essentialTriglycerides between foods fatty acids. May cause diarrhea if introduced(MCT oil) too rapidly. Contraindicated in patients with liver

disease.

Meperidine IV, IM 0.5 mg/kg, repeated as required q4th; Can cause respiratory depression (less thanmaximum dose; 20 mg/kg infuse morphine), hypotension. Specific antidote forover 5 minutes narcotic overdose; Naloxone 0.1 mg/kg IV.

Contraindication in cardiac arrhythmias, asthma,increased ICP. Caution in renal failure:accumulated metabolite has CNS effects (Coombs,positive hemolytic A).

Metalazone IV, PO 0.2-0.4 mg/kg/day Electrolyte imbalance, GI upset, hyperglycemia.(zaroxolyn) OD CI in jaundiced baby(? Displaces bilirubin) marrow

suppression, hyperuricemia, rash.

Metaproterenol PO 1.5-3.0 mg/kg/day q8h For bronchospasm in BPD.

Methadone PO 0.2-0.4 mg/kg/day d/v q12h Dependency, CNS and respiratory depression,IV (neonatal abstinence syndrome) bradycardia, hypotension. It is long acting and

0.2 mg/kg/day d/v q12h is difficult to titrate.(narcotic dependence)

Methyldopa IV Initial: 10 mg/kg/day D/v q6 –8h. Monitor for hemolysis, leukopenia and(Aldomet) PO Increase dose gradually over several hepatotoxicity. Contraindication in pheochlo-

days until desired effect achieved mocytoma and active liver disease. May(maximum 60 mg/kg/day). interfere with lab tests for creative, urinary

catecholamines.Methylene blue (1%) IV 1-2mg/kg/dose slow IV push It is a reducing agent; it may decrease hemoglobin

over 5 minutes. May repeat in 1h. O2 capacity.

Metoclopramide IV Feeding intolerance in preterm neonates: Dopamine antagonist, gastrointestinal prokinetic(perinorm) 0.1 mg/kg day d/v q8h Max dose agent. May cause dystonic reactions (torticollis,

0.5 mg/kg day. oculogyric crisis), akathisia, sedation although nonehave been observed in limited studies involvingneonates. Premedicate with diphrihydramine whenusing as an anti-uretic. Use with caution inpatients with history of seizure disorder.

PO Gastroesophageal reflux in older infants:0.4 mg/kg/day d/v qid PO 10-20 minutesbefore feeds.

Midazolam IV Loading dose 50 μg/kg when on ventilator.Maintenance of 50-150 μg/kg/hr.

Morphine IV, IM Pain: Slow IV push over 5 minutes 0.05 Can cause respiratory depression and apnea,(Morphine mg/kg dose q6 – 8h prn continuous hypotension, bronchospasm, seizures, functionalsulphate, infusion: 0.1 mg/kg loading dose, ileus, neonatal abstinence syndrome. Tolerance tomorcontin) followed by 0.02 mg/kg/hr. sedative and analgesic effects develops rapidly,

necessitating dosage increases. Specific antidotefor narcotic overdose: Naloxone 0.1 mg/kg IV.

NaCl2 (3%) IV 4 ml/kg for hypo natremic seizures Hypernatremia.

Naloxone (Narcan) IM, IV, SC 10mg/kg for narcotic overload. Once20 mg/ml may be repeated prn at 2-3 min interval.Neomycin (0.5%) Topical Apply q6h

Neostigmine IM 0.04mg/kg as test dose for myasthenia gravisPO 1 mg/kg q6h as maintenance.

Nifedipine (Depin) SL 1-2mg/kg/day in four divided doses. Should be given sublingualy and not to be swollen.Severe hypotension, edema, flushing, tachycardia.SP in patients with aortic stenosis, CHF.

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Drug Formulary 27

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Nitroglycerin IV Start with 0.1 μg/kg/min. And titrate The role of nitroglycerin therapy in the neonate is atinfusion rate to desired response. present unclear and its use is consideredMax dose 5 μg/kg/min experimental. It may preferred over nitroprusside1-2 μg/kg/min – decreases preload in the treatment of severe cardiac failure to reduce3-5 μg/kg/min – decreases after load. after load. Sp in severe renal impairment, increased

ICP, hepatic failure

Nitroprusside IV Initial 0.25 μg/kg/min. Titrate infusion Indicated in refractory hypertension. Toxicity(Pruside) rate by doubling rate of infusion until manifested by hypotension, reflex tachycardia,

desired of adverse effects are observed. methaemoglobinemia, cyanide toxicity withRecommended maximum rate of infusion metabolic acidosis. Acute withdrawal mayis 6 μg/kg/min. For infusion dilute to a precipitate hypertensive crisis. Monitor thiocyanateconcentration of 100 μg/ml. Protect levels if used >48 hrs.solution and line from light.

Norepinephrine IV 0.01-2.0 μg/kg/min. Tachycardia, hypertension. Avoid arterial infusion.(Levophed)

Octreotide SC 1-10 μg/kg/dose q4hr Causes growth harmone suppression. Start with(Octride) IV lower end of dosage range.Omeprazole (Omez) PO 0.7 mg/kg/day and may be increased

to 3 mg/kg/day.

Oxybutylin PO 0.4-0.8 mg/kg/day d/v q6-12h Cl in glaucoma, GI obstruction, megacolon, myas-thenia gravis, hypovolemia.

Pancuronium IV 0-1 Week: 0.03 mg/kg/dose Indicated in infants requiring mechanical ventila-(Pavulon) 1-2 weeks: 0.06 mg/kg/dose tion who continue to have inadequate oxygenation

2-4 weeks: 0.09 mg/kg/dose despite optimal supportive care. Can cause tachy-3-4 weeks : 0.10 mg/kg/dose cardia. Effects potentiated in hypokalemia, hyper-(Infuse slowly over 3-5 minutes: magnesemia, and with concomitant use of amino-repeated as required q1-2h). glycosides, halothane and succinyl choline.

Antidote: Neostigmine with atropine/glycopyr-rolate.

Paraldehyde IV Loading: 3 ml/kg/hr (150 mg/kg/hr) For IV administration, add 5 ml (5g) to 100 ml NSof a 5% solution x 3 hours. Maintenance: or D5W to make a 5% solution. Administer via0.4 ml/kg/hr (20 mg/kg/hr) of 5% autosyringe pump with a glass syringe. IV tubingsolution. and syringe must be protected from light by

wrapping. IV tubing (and syringe if plastic) shouldbe replaced every four hours.

PR 0.3 ml/kg/dose (300 ml/kg) q4-6h prn Adverse effects: Pulmonary edema and hemor-dissolve dose in equal volume of olive oil rhage, hypotension, local irritation, displacementprior to administration. Irregularly of bilirubin from albumin. Routine use discouragedabsorbed by rectal route. except for treatment of status epilepticus resistant

to initial therapy with Phenobarbital, phenytoin,diazepam; or lorazepam. Contraindicated inpulmonary or hepatic disease.

Paregoric PO Initial dose 0.2-0.3 ml total dose q3h-q4h. Monitor CNS depression. Adverse effects: SimilarSubsequnt doses: to morphine. Give with feeds to minimize GIIncrease by 0.05 ml upto maximum irritation.of 0.7ml total dose

Paediatric opium PO Initial dose: 0.05 ml/kg q3–4h; increase For neonatal narcotic withdrawal. Can causeSolution (0.04%= by 0.05 ml increment until effective dosage constipation and CNS depression.0.4 mg/ml achieved to maximum of 1 ml.morphineequivalent)

Pethidine IM 1 mg/kg q12h Special precaution for respiratory depression.

Phenobarbitone IV Loading: 20 mg/kg IV slowly (maximum Indication: Neonatal seizures. If seizures continue(Gardenal) IV, IM, PO rate of infusion 2 mg/kg/min). after the initial IV loading dose, additional doses

Maintenance: 3-5 mg/kg/day (first dose of 10 mg/kg (spaced at 20-30 minute intervals) cangiven 24 hour after loading). be given, up to a total loading dose of 40 mg/kg to

achieve a plasma level of 170 μmol/L (must en-sure adequate respiratory control if using high dose).Liver enzyme inducing dose: 2mg/kg/day.

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Sedation, lethargy and hypersensitivity reactions.Note: long half life in neonates. Drug levels increasedwith alkalosis. Drug interactions: reduces serumlevels of chloramphenicol; plasma Phenobarbitonelevels increases by phenytoin and valproate.Therapeutic level: 20-25 μg/ml

Phentolamine SC 0.1mg/kg (2-5 mg maximum total dose). Hypotension. Inject solution into affected area.(Regitine) Prepare solution by diluting 2.5-5mg in

10ml NS.

Penicillamine PO 250 mg/dose qid (Wilson’s disease) Medication given 1 hour before or 2 hr after meals.100 mg/kg/day qid x 5 days (Arsenic Augments absorption of lead in GI tract. May causepoisoning) cataract, flu like syndrome, rashes, lupus like30 mg/kg/day qid (cystinuria). syndrome, leukopenia, leukocytosis, eosinophilia,

thrombocytopenia, nephrotic syndrome.

Phenylephrine (2.5%) Drops 1 drop in each eye for cycloplegia

Phenytoin (Dilantin) IV Neonatal seizures: Loading: 20 mg/kg IV Infuse in normal saline only. Rapid IV adminis-slowly (maximum rate of infusion tration may cause hypotension and bradycardia.0.5 mg/kg/min). Indication; neonatal seizures refractory to Pheno-

barbital alone. Adverse effects: Drowsiness andbehavioural changes hypersensitivity reactions.Drug interactions: Increases serum levels ofchloramphenicol; diazepam or phenobarbitol mayincrease or decrease phenytoin levels.

IV, PO Maintenance: 4-6 mg/ kg /day d/v q12h. Therapeutic level: 15-20 μg/ml.if > 1 week old may require increases infrequency of administration (Frequentdrug monitoring essential in the first2 weeks of age due to rapid changes inelimination rate).

IV Dysrhythmias: More effective in the treatment of ventricular than1mg/kg IV (maximum rate of infusion supraventricular arrhythmias. Hypotension if0.5 mg/kg/min). may repeat every infused too closely together.5-10 min up to total dose of 15 mg/kg(infuse in normal saline).

PO Maintenance : 2-8 mg/kg /day d/v q12h.

Phosphate Either NeutraPhos A or IV injection. Monitor serun Ca, PO4 and alkaline phosphatase.Supplements preparations can be given orally to

supplement nutritional intake in preterminfants to a total intake of 75 mg/kg/dayof phosphorus, including content of feeds.Begin with 20-25 mg/kg/day andgradually increase dose to full supplementto prevent diarrhoea.

1. Neutra Phos A PO 1 ml of reconstituted solution = 3.3 mgphosphorus, 0.1mmol Na++, 0.1 m mol k+.prn over 10 min PO: 0.51 –mg/kg dayd/v q6h.

2. Potassium IV 1ml= 93 mg (3 m mol) phosphorus phosphate PO = 4.4 mmol K+3. Sodium IV 1ml = 46.5mg (3m mol) phosphorus phosphate PO = 4mmol Na+

Potassium chloride IV, PO 2-3 m Eq/kg/day. Arrhythmias, thrombophlebitis, GI irritation.

Prednisolone PO 0.5 mg/kg q6h.(Wysolone)

Primidone PO Loading: 15-20 mg Use justified for refractory seizures; close(Mysoline) Maintenance: 12-20 mg /kg/day monitoring of phenobarbitone level is necessary, since

levels rise after primidone loading and fall preci-pitously with phenobarbitone discontinuance.

Procainamide PO 2.5-8 mg/kg q4h CI in conduction block, myasthenia gravis.

Contd...Contd...

Drug Formulary 29

IV 7 mg/kg over 1 hr Therapeutic level 4-10 μg/ml. Hypotension,20-60 μg/kg/min as infusion. lupus like reaction.

Propranolol (Inderal) IV 0.01 mg/kg/dose q6h; increase prn to Bradycardia, hypotension, bronchospasm,PO maximum of 0.15 mg/kg/dose q6h. hypoglycemia.

0.25 mg/kg/dose q6h; increase prn tomaximum of 5mg/kg/day.

Prostacyclin IV 5-10 ng/kg/min. Beware of hypotension. Change infusion q12h.

Prostaglandin E1 IV Initial: 0.05 – 0.1 μg/kg/min (IV) For maintaining blood flow through patent ductus(Prostin VR) maintenance: once stable improvement, in certain congenital heart disease. Maximal effect:(500μg/ml) decrease to half or less. cyanotic lesions <30 min, acyanotic average < 3

Lowest effective dose 0.01 μg/kg min. hour. Major adverse effects: hypotension andSuggested protocol: apnea.Add 1 Concen- ml/hr ´

Ampule tration Weight (kg),(500 μg) to: (μg/ml) Needed to

infuse 0.1μg/kg/min

200 ml 2.5 2.4100 ml 5 1.250 ml 10 0.6

Protamine IV See table.

Pyridoxine IV PO Initial: 50-100 mg IV over 1-2 minutes Indication: For diagnosis and treatment of(vitamin B6) maintenance: 50-100 mg PO daily. pyridoxine dependent seizures. Initial dosing should

be accompanied by EEG monitoring. No toxicityreported with therapeutic doses.

Quinidine PO 5 –15 mg/kg day d/v q6h For abolishing and preventing premature contrac-(Natcardine) tions of atrial, A – V junctional or ventricular origin.

Useful adjunct to digoxin in atrial flutter and fibrillation (Should not be given until ventricular ratecontrolled). Therapeutic serum level 6.2–18.5μmol/L. decrease dosage if QRS interval increasesby 50% contraindicated in complete A – V block.

Ranitidine IV 1.5 mg/kg q12h(Rantac) PO 1-2 mg/kg q8h

Salbutamol Via nebulizer For weight <1 kg =1.00 mg/dose Monitor cardiovascular status.(Ventorlin) (5 mg/ml For weight > 1 kg =2.00 mg/dose

solution) Diluted to 2-3 ml with normal salineq2–6 prn

Sodium benzoate PO 250 mg/kg loading doseIV 250 mg/kg/day maintenance dose d/v q8h

Sodium bicarbonate IV 2 m mol/kg over 4 mins in hyperkalemia. Hypernatremia, hyperosmolality, hypercarbia.(4.2%) In Acidosis: for ½ correction in m mol = Assure adequate ventilation, do not give if PaCo2(0.5 m Eq/ml) wt(kg) × base deficit (m mol/L) × ½ >50 torr. Do not give faster than 1 ml/min.

3Cardiac arrest = 1mmol/kg

Sodium polystyrene PR 1g/kg dose q6h (Pharmacy supplies For treatment of hyperkalemia associated withsulfonate resin 0.25 g/ml in 25% sorbitol to prevent oliguria or anuria. Exchanges –1 m mol of K/g resin.(kayexalate) GI obstruction. Monitor for hypocalcemia, hypomagnesemia,

hypokalemia and hypernatremia.

Sodium NitroprussideIV Start with infusion rate of 500ng/kg/minand slowly increase to a maximum of8mg/kg/min in hypertension

Spironolactone PO 1-3 μg/kg/day Hyperkalemia(Aldactone)

Sulphadiazine PO Congenital toxoplasmosis: 50mg/kg/day(sulphadiazine)

Contd...


Contd...

Succinylcholine IV 1-2 mg/kg/dose Premedicate the patient with atropine(Scoline) (0.03 mg/kg) it will increase the serum level of

potassium. Prolonged action in liver disease oraminoglycoside therapy.

Sucralfate PO 30mg/kg q6H(Sparacid liquid)Survanta ET 4 ml/kg/dose (100mg/kg) q6-8h Natural surfactant for the prophylaxis and

treatment of hyaline membrane disease.Natural surfactant extracts (NSEs) Synthetic surfactants1. Survanta 1. ALEC

Dose: 100 mg of phospholipid, i.e. 4 ml/kg. (7:3 mixture of DPPC: PG dispersed in 1ml saline)2. Surfactant-TA Dose: 100 mg for premature 23-34 wk

Dose: 60-120 mg/kg (Higher dose of 120 mg/kg - At birth first dose as pharyngeal insulin.better results). - Next after 10mts, 1hr and 24hr.

3. Curosurf (Porcine lung extract) 2. Exosurf neonatalDose: 200 mg/kg initially, followed by 100 mg/kg at (108 mg phospholipid DPPC in 10ml phials with 10ml of solvent)12 and 24 hr later. - 5 ml/kg birth wt.

4. CLSE (calf lung surfactant extracts) - 2 doses of 5 ml/kg at 12hr interval are recommended for rescue therapy.Dose: 100 mg/kg initially and subsequently. - In reference to DPPC, the dose is 67.5 mg DPPC/kg birth wt.

5. BeractantDose: 100 mg/kg initially and subsequently.

6. SF-RIDose: 50 mg/kg B wt initially and subsequently.

7. Human amniotic fluid extract (homologous)Dose: 60mg/kg initially and subsequently.

The composision of natural pulmonary surfactant:Chemical substance %Dipalmitoylphatidylcholine (DPPC) 36.3Unsaturate phosphatidylcholine 32.3Phosphatidylglycerol (PG) 9.9Phosphatidylinositol (PI) 1.6Sphingomyelin 2.3Phosphatidic acid 1.3Cholesterol 2.4Diacylglycerol 0.3Protein (SP-A, SP-B and SP-C) 10.6Other phospholipids -Neutral lipids -

Susphrine IM, SC 0.005 ml/kg/dose q8h for hypoglycemia Tachycardia, hypertension, local reaction. Goodresults seen in term AGA or LGA infant.

Terbutaline PO 100 μg/kg/day For bronchospasm in BPD monitor heart rate.SC 0.005-0.01 mg/kg/dose

THAM (3.6%)Trishydroxy IV Loading dose: 3-5 mg/kg of undiluted Indicated in severe metabolic acidosis whenmethyl solution. Maintenance: 3-16 ml/kg/h of bicabonate therapy is contraindicated because ofaminomethane undiluted solution hypernatremia or hypercapnea may cause

Dose for half correction = hemorrhagic liver necrosis or hypoglycemiaWt(kg) x base deficit(m mol/L) 61ml THAM gives 0.5m mol of bicarbonate.

Theophyline IV, PO Apnea of prematurity Loading: With advancing postnatal age, the clearance of the(TR phyllin) 5 mg/kg Maintenance: drug increases. The dosing interval may need to be

GA (wk) mg/kg/day reduced to 8h to maintain therapeutic levels.27-30 5.81 (0.02 PNA in wk) Monitor serum levels to avoid toxicity. For31-34 4.82 + (0.28 PNA in wk) bronchodilator effect higher levels may be needed.Term 0.3 (age in wk)+8 q8-12h May cause tachycardia, arrhythmia,Target level = 8-12mg/L hyperglycaemia, jitteriness, GI upset, diuresis, and

seizures. Increase dose by 20% to convert to amino-phylline.

Thiamine IV 0.3-0.5 mg/day Allergic reactions and anaphylaxis. Therapeutic(Vit B1) range : 1.6 – 4.0 mg/dl(Biamine)

Contd...

Drug Formulary 31

Contd...

L-Thyroxine PO Initial dose is 8-10 μg/kg/day (preterm) SP in those on anticoagulants. Titrate dosage with(Eltroxin) and 5-8 μg/kg/day (term). Increase dose clinical status and serum T4 and TSH/ May cause

by 12 μg/day q2 wk until TSH hyperthyroidism, rash, growth disturbances.<20 mU/L and T4 130-90 n mol/L. usually25-50 μg is given daily

Tincture of opium PO 0.8-2.0 ml/kg/day d/v q4h for neonatal Sedation, respiratory depression.decrease 10%(1:25 dilution) absteinence syndrome per day as tolerated.

Tissue plasminogen IV See table. Vomiting, hypotension, fever, bleeding from IVactivator (tPA) access sites.

Tolazoline IV Load: 0.5-1 mg/kg over 5mins. Pulmonary vasodilator, major side effects(Priscoline) Maintenance: 0.1 mg/kg/hr hypotension, oliguria and GI bleeding. Investiga-

tional drug.

Tromethamine IV 3 ml/kg/dosemax rate = 1 ml/h1 ml = 0.3 mEq.

Valproic acid PO Preterm: 15 mg/kg/day once daily full Dosage recommendations in neonates based onterm: 40 mg/kg/day once daily. preliminary data. Its use should be restricted toCan be increased upto 30mg/kg/dose infants with seizures refractory to more traditionalq12hr. therapy. Adverse effects: Hepatoxicity (monitor

serum transminases), hyperglycinemia orhyperammonemia. GI disturbances, sedation,altered coagulation, pancreatitis, increased serumamylase. Therapuetuc serum levels; 350-700 μmol/L

Vasopressin IM, SC 2.5-10 U toal dose q12h-q16h Broncho constriction, diarrhoea and electrolyte im-(aqueous) balance.

Vecuronium IV 0.03 – 0.15 mg/kg/dose q1h-2h PRN Neuromuscular effects may be prolonged after0.05-0.1 mg/hr as continuous infusion. continuous infusion and when aminoglycosides areMax concentration of 1mg/ml administered concurrently.

Vitamin D (Arachitol) PO Term infants: 400 IU/day Preterminfants: 800 IU/day (total intake).CI in hypercalcemia and vitamin D toxicity.

Vitamin E PO 25 mg/kg OD For anaemia of prematurity.

Vitamin K IM Preventive dose: 1.0 mg IM at birth, for Recommended daily allowance 15 mg.PO >1500g and 0.5 mg if baby <1500 g

1mg at birth, followed by 0.5 mg at 1wkand 1month (breast fed babies), whereassingle dose for formula fed babies.

Vitamin Solution PO 1.0 ml per day. Contains (in 1.0 ml):Vitamin A 1500 I.UVitamin D 400 I.UVitamin E 5.1 I.UAscorbic acid 35 mgThiamine 0.5 mgRiboflavin 0.6 m gNiacinamide 8 mg

Multi-vitamin PO 1.6 ml per day. Contains (in 1.6 ml): Vitamin solution 1.0mlpreparation in Aquasol E (25. I.U) 0.5 mlNICU Folic acid (0.05 mg) 0.1 ml

Solution very hyperosmolar and should be dilutedin at least four times the volume of formula foradministration.


COMMERCIAL VITAMIN PREPARATIONS

Composition of multi-vitamins drop per 0.6 ml or 10 drops

Abdec Hovite Visyneral Multivia-plex Becadex Dropovit Vimagna Vidaylin

Vitamin A1500 IU 5000 IU 6000 IU 5000 IU 2500 IU 5000 IU 4800 IU 3000 IU 5000 IUVitamin B400 IU 1000 IU 1200 IU 1000 IU 200 IU 4000 IU 1200 IU 600 IU 1000 IUVitamin B10.5 mg 1.0 mg 1.1 mg 1.0 mg 1.0 mg 2.0 mg 1.2 mg 0.5 mg 1.5 mgVitamin B20.6 mg 0.4 mg 1.0 mg - 1.67 mg 1.0 mg 1.8 mg 1.15 mg 1.2 mgVitamin B60.3-0.5 mg 1.0 mg 1.0 mg 1.0 mg 1.0 mg 1.5 mg 1.2 mg 0.1 mg 0.5 mgVitamin B120.5-1 μgm - - 2 mcg - - - - -Niacin8.0 mg 5 mg 5.0 mg - 15 mg 10 mg 15 mg 5.0 mg 10 mgPentothenic 2 mg 2 mg 3 mg 4.0 mg - 3.0 mg 2.0 mg -AcidFolic acid - - - - - - - -Vitamin C25-50 mg 50 mg 50 mg - 40 mg 50 mg 30 mg 20 mg 50 mgVitamin E15-25 IU - 0.3 mg 1.0 mg - - 1.2 mg - -

DRUGS USED IN RESUSCITATION

Drug Indication Dose Route Response Complication

Sodium Metabolic 2-3 mEq/kg/dose IV over 2-5 minutes Increased pH if Hypernatremia, HyperosmolarBicarbonate (4.2%) acidosis Total dose adequately ventilated solution, risk for ?IVH0.5mEq/ml. 1 kg 2 mEq(4 ml)

2 kg 4 mEq(8 ml)3 kg 6 mEq(12 ml)4 kg 8 mEq(16 ml)

Epinephrine Asystole or 0.1-0.2 ml/kg IV, ETT intracardiac Increased heart rate, Hypertension, ventricular(1: 10,000) severe Total dose blood pressure and fibrillation

bradycardia 1 kg 0.1-0.3 ml cardiac output2 kg 0.2-0.6 ml3 kg 0.3-0.9 ml4 kg 0.4-1.2 ml

Glucose (10%) Hypoglycemia 0.5g/kg (5 ml/kg) Increases blood glucosefollowed byinfusion 5 ml/kg/hr(Approx 8 mg/kg/min) IV

Glucose (25%) Hypoglycemia 0.5 g/kg (2 ml/kg) / IV Increased blood glucose Rebound hypoglycemia,

dose over 10 min hyperosmolar solutionCalcium Gluconate Low cardiac 1-2 ml/kg dose IV over 2-5 minutes Improved cardiac Bradycardia, dysrhythmias(10%) output output

Dopamine Low cardiac 5-20 μg/kg/min IV Increased cardiac output, Dysrhythmias? Decreaseoutput, shock, to maintain BP increased peripheral renal perfusion at rate

6 (kg) μg/kg/min vascular resistance > 12-15 μg/kg/mindesired fluid (ml/hr)=per 100ml of solutionsTotal dose1 kg 5-20 μg/min2 kg 10-40 μg/min3 kg 15-60 μg/min4 kg 20-80 μg/min

Volume Hypovolemic 10-20 ml/kg (0.5-1g/kg) IV over 2-4 hr Increased perfusion Circulatory overload inexpanders:- shock cardiogenic shock. ContainsAlbumin 5%, 0.13-0.16mEq Na/mlFresh frozenplasma(1g/20 ml)

Crystalloid Hypovolemia, 10-20 ml/kg IV Increased perfusion Hypervolemia pulmonary edema,(0.9 NS, RL) hypotension CHF

Dextran– 40 Hypovolemic 0.25-0.5g/kg/hr IV Increased perfusion Circulatory overload. Therapy10% solution shock should not be continued longer

than 5 days

Group O Rh Acute blood 10-20 ml/kg IV Increased perfusion Crossmatch against mother’snegative blood loss and oxygen carrying serum(whole blood) capacity

Contd...

CHAPTER

3 Drugs in Resuscitation


Contd...

Naloxone Narcotic 0.2 mg/kg/ dose IV, ET IM, SC Improved respiratory Respiratory depression at birth,(Narcan 0.4 depression (0.5 ml/kg) effort when given when mother was given narcoticsmg/ml) (rare) 0.01 mg/kg/dose for rapidly repeat prn prior to delivery

reversal of opiateanalgesia

Atropine Bradycardia 0.01 mg/kg/dose IV Normal HR Hyperthermia, tachycardiaeven after (0.025 ml/kg/dose) urinary retention.epinephrine

INTUBATION SEDATION GUIDELINES

Drug name Standard dosage Patient specific dose Route Special considerationsper weight

Anticholinergic Medications

Atropine 0.02 mg/kg Do not use if <2kgInfuse over 1 min. Minimum dose is0.1 mg/dose

Sedative Medications

Midazolam (Versed) 0.05-0.1 mg/kg IV Do not use if <35 weeks gestational Intravenous ageMidazolam (Versed) 0.2-0.3 mg/kg Intranasally Do not use if <35 weeks gestational Intranasal age

Analgesic Medications

Fentanyl 1-4 mcg/kg IV Infuse slow IV pushChest wall rigidity may occurHave Pancuronium 0.1 mg/kg IV ´ 1at bedside

Music Relaxants – Only Use if Able to Provide Adequate Facial/Mask PPV

Succinylcholine 1-2 mg/kg Use 2 mg/kg/dose if <1 yoAlways administer atropine firstDo not repeat dose

Rocuronium (Zemuron) 0.6-1.2 mg/kgVecuronium (Norcuron) 0.1 mg/kg Dilute dry powder

Vecuronium 10 mg vial with 10 ml ofnormal saline or sterile water forinjectionPreferred paralytic for neonates ifnecessary

Pancuronium (Pavulon) 0.1 mg/kg

Drugs in Resuscitation 35

INOTROPIC AND VASOACTIVE AGENTS COMMONLY USED IN SHOCK

Drug Dose Hemodynamic effect Comment(μg/kg/min)

Dopamine 1-5 Splanchnic, real and cerebral vasodilatation Stimulates beta receptors by direct and indirect mecha-nisms; may cause tachydysrhythmias; may increasepulmonary vascular resistance; doses > 20 μg/kg/min occasionally required for normotension, but mayresult in severe tissue ischemia

5-15 Increased contractility and heart rate15-20 Peripheral and renal vasoconstriction

Dobutamine 1-20 Increased contractility Minimal effect on heart rate; no selective renal effect

Isoproterenol 0.05-0.5 Increased contractility and heart rate; May cause tachydysrhythmias; increases myocardialperipheral vasodilatation oxygen consumption

Epinephrine 0.05-1.0 Increased contractility and heart rate; May cause tachydysrhythmias; increases myocardialmarked peripheral, renal and mesenteric oxygen consumption; increases glucose levels;vasoconstriction increased risk of severe tissue ischemia.

Norepinephrine 0.05-1.0 Marked peripheral vasoconstriction May cause severe tissue and organ ischemia; use incombination with vasodilator

Nitroprusside 0.05-8.0 Peripheral arterial and venous vasodilatation Risk of cyanide toxicityPhentolamine 1-20 Alpha antagonist: arterial and venous May produce reflex tachycardia; expensive

dilationHydralazine 0.1-0.5 Peripheral arterial vasodilatation May produce reflex tachycardia

(mg/kg)q3-6h

STANDARD IV INFUSION ROUTINELY PREPARED

CHAPTER

4 Standard IV Infusion

1. AdenosineInjection – 6 mg/2 mlDiluent – NS1 ml of Adenosine (3 mg) + 5 ml NS6 ml = 3000 microgram pH 6.3-7.31 ml = 500 mgm0.1 ml = 50 mgmInfuse as 0.1 ml (50 mgm)/kg/dose over 2 secs

2. AdrenalineInjection–1 mg/ml (1:1000)Diluent–NS, G 5%, G 10%To prepare standard infusion of 50 ugm/mlAdrenaline 1ml = 1mgAdd 1 ml adrenaline +19ml NS, G5%, G10%1mg in 20 ml1000 microgm in 20 ml100 mgm in 2 ml50 mgm/mlCompatible–Heparin, Dobutamine, DoxapramIncompatible–Aminophyllin, Lignocaine, Sod. BicarbpH–2.5-3.6Protect infusion from sunlight

3. AminophyllineInjection–250 mg/10 mlDiluent–NS, G5%, G10%250 mg-10ml1 ml Aminophyllin (25mg) + 4ml of NS, G5%, G10%5 ml = 25 mg1 ml = 5 mgCompatible – Heparin, DopamineIncompatible – Adrenalin, Amiodarone, Cefotaxime,Dobutamine, Doxapram, Insulin, MorphinepH 8.5 – 10.0

4. Alprostadil (Prostaglandin E1)Injection-500 microgm/ml or 0.5 mg/mlDiluent – NS, G 5%To prepare a standard infusion of 5 μgm/ml(i.e. 5000 nano grams in 1ml)Babies under 1kgDraw 0.5 ml Alprostadil (500 microgm / ml) and add to 49.5ml of NS or G 5%50 ml=250 micrograms1 ml = 5 micrograms = 5000 nanograms

To prepare a standard infusion of 10microgram/ml(i.e. 10,000 nanograms in 1ml)Babies over 1kg.Draw 1ml Alprostadil (500 microgm) and add to 49ml NSor G 5% and mix well50ml = 500 micrograms1ml = 10 micrograms = 10000 nanograms

5. DiazepamInjection–10 mg/2mlDiluent – G 5% or G 10%To prepare standard solution of 0.1mg/ml or 100 micro-gram/mlTake 2 ml Diazepam (10 mg) + 98 ml G 5% or G 10%100 ml = 10 mg1 ml = 0.1 mg = 100 microgramsInfuse as 50–100 ugm/kg/hourIncompatible – Do not infuse with any other drug includingNSpH–8

6. DoxapramInjection–100 mg/5 mlDiluent–NS, G 5%, G 10%To prepare standard infusion of 1000 microgram in 1mlTake 2.5 ml Doxapram injection (50mg)+47.5ml of NS, G 5% or G 10%50 ml = 50 mg1 ml = 1 mg = 1000 microgramsCompatible–Adrenaline, Dopamine, KCI, SalbutamolIncompatible–Alkaline solns, i.e. Aminophyllin, digoxinFurosemide Thiopentone.

7. DigoxinElixir 50 microgram = 0.05 mg/mlInjection–100 microgm = 0.1 mg in 1mlDiluent – NS or G 5%Take 1ml of digoxin injection (100 micrograms)+ 4 ml of NS or G 5%5 ml = 100 microgram1 ml = 20 microgramCompatible – Furosemide, Heparin, Lignocaine, Morphine,KCI, VerapamilIncompatible–Dobutamine, Doxapram, FluconazolepH 6.8 = 7.2

Standard IV Infusion 37

8. DobutamineInjection–250 mg/20mlDiluent – NS, G 5%, G 10%To prepare a standard infusion of 1000 microgms or 1mg in1mlDobutamine 250 mg / 20 ml, i.e. 12.5 mg/mlTake Dobutamine 4 ml (250 mg in 20 ml) + 46 mlNS, G 5%, G 10% and mix well50 mg in 50 ml1 mg in 1 ml1000 micrograms in 1 mlCompatible – Adrenaline, Amiodarone, Atropine, Dopam-ine, Isoprenaline, Hydralazine, Lignocaine, Morphine, No-radrenaline, Pethidine, Phentolamine, Propranolol Strep-tokinaseIncompatible–Acyclovir, Alkalis-Aminophyllin, Digoxin,Furosemide, MgSO4 SodabicarbpH 2.5 - 5.5

9. DopamineInjection–200 mg/5mlDiluent – NS, G 5%, G 10%To prepare a standard infusion of 1,000 micrograms in 1 mlDopamine contains 200mg in 5 mli.e. 40 mg in 1 ml.Take 1 ml Dopamine + 39 ml NS, G 5% or G 10% and mixwell40 mg in 40 ml1 mg = 1 ml1000 microgram in 1 mlCompatible – Aminophyllin, Amiodarone, Chlorampheni-col,Dobutamine, Doxapram, KCL, Streptokinase, TolazolineIncompatible–Acyclovir, Amphotericin, Benzyl penicillinFurosemide, Soda bicarb and other alkaline soln.pH 2.25 – 4.5

10. Epoprostenol (Prostacycline)Injection – 500 microgramDiluent – Diluent provided, NSReconstitute with diluent provided to make epoprostenol500 micrograms in 50 ml10 micogram = 1 ml10 micogram/ ml – concentrated solutionA.To prepare a standard infusion of 500 nanogram in 1 ml

babies under 1 kgTake 2.5 ml of conc. Soln. (25 microgram) + 47.5 ml NSand mix well25 micrograms in 50 ml500 nanograms in 1 ml

B. To prepare a standard infusion of 1000 nanograms in 1ml babies over 1 kg

Take 5 ml of Conc. Soln. (50 micrograms) + 45 ml of NS mixwell50 ml = 50 micrograms1 ml = 1 microgram1 ml = 1000 nanogramsIncompatible – Do not infuse with any other drug includingGlucosepH 10.5

of G 5%50 ml = 100 microgram1 ml = 2 microgram0.1 ml = 0.2 microgmStart with 0.2 mg/kg/min and increase to 2 mg/kg/minmaximumCompatible – Dobutamine, HeparinpH 2.5-2.8

11. HeparinInjection – 1000 units / mlDiluent – NS, G 5% or G 10%To prepare a standard infusion of 50 units in 1 ml – smallpreterm babiesTake 2.5 ml of heparin (2500 units) + 47.5 ml of NS, G 5 % orG 10% mix well2500 units in 50 ml50 units in 1 ml.To prepare a standard infusion of 100 units in 1 ml – Largerbabies and term babiesTake 5 ml of heparin (5000 units) + 45 ml NS, G 5% or G 10%and mix well5000 units in 50 ml100 units in 1 mlCompatible – Aminophyllin, amphotericin, Ascorbic acid,Calcium gluconate, Digoxin, Isoprenaline, Noradrenaline,KCL, Streptokinase, Suxamethonium.Incompatible–Most other drugs including antibioticsSome antihistamines, narcotic analgesics, phenothiazinespH 5-8

12. InsulinInsulin – 100 units/mlDiluent – NS or waterTo prepare a standard infusion of 0.1 unit in 1 mlTake 1 ml of human neutral insulin (100 units)+ 9 ml of NS or water. mix well100 units in 10 ml10 units in 1 ml – Diluted insulin solutionTake 0.5 ml of diluted insulin solution (5 units) and add to49.5 NS, G 5%, G 10% and mix well5 units in 50 ml1 unit in 10 ml0.1 unit in 1 mlCompatible–Heparin, MetodopramideIncompatible–Aminophyllin, Phenytoin, Soda bicarbSulphonamides, ThiopentonepH 7-7.8

13. IsoproterenolInjection – 100 microgram = 0.1 mg/mlDiluent G 5%Take 1 ml (100 microgram of Isoproterenol + 49ml.100 microgms in 5 ml20 microgms in 1 mlCompatible – Cefuroxime, Digoxin, Dobutamine,Suxamethonium, Vancomycin, VerapamilIncompatible–Aminophyllin, Pethidine, Sod. Bicarbonate,ThiopentonepH 3.5


14. Lidocaine HClInjection–20 mg/mlDiluent–G 5%, NSTake 1 ml (20mg) of lidocaine + 99 ml of 5% Dextrose Mixwell.20 mg = 100ml1 mg =5 ml1000 microgram = 5 ml200 microgram = 1 ml20 microgram = 0.1 mlInfuse as 20-50 μmg/kg/min i.e. 6-15 ml/kg/hourCompatible–Dobutamine, Heparin, StreptokinaseIncompatible – Adrenaline

15. MorphineInjection–10mg/ml, 1mg/mlDiluent – NS, G 5%, G 10%To prepare a standard infusion of 20 micrograms in 1 mlTake 1 ml (1 mg/ml) of Morphine + 49ml of NS, G 5%, G10% and mix well1 mg in 50 ml1000 microgms in 50 ml • 20 μg-1 ml.

16. NitroprussideInjection–50 mgReconstitute with 2 ml G 5% provided.Take 1 ml of reconstituted Na Nitroprusside (25mg) + 124ml of G 5% or NS mix well125 ml = 25 mg5 ml = 1 mg = 1000 microgram1 ml = 200 microgramCompatible–Dopamine, Dobutamine (only if diluent is NS)pH 3.5 – 6.0

17. Tolazoline HclInjection–25 mg/mlDiluent-NS, G 5% or G 10%To prepare a standard infusion of 5 mg in 1 mlTake 5 ml of tolazoline (125 mg) add to 20 ml of NSG 5% or G 10% and mix well125 mg in 25 ml5 mg in 1 mlCompatible–DopamineIncompatible–IndomethacinpH 3-4

CHAPTER

5 Safe Medicine

PEAK AND TROUGH LEVELS OF FEW ANTIBACTERIAL AGENTS

Drug Optimal sample time Optimal serum Time to steady Toxic levelconcentration state afterrange dose change

Amikacin Peak 30 min after 30 min infusion 25-30 μg/ml 24 – 48 hours -Trough# 4-8 μg/ml

Chloramphenicol Peak 1.5 hour after 30 min infusion 15-25 μg/ml 72 hours 50 μg/mlTrough# 5-10 μg/ml

Gentamicin Peak 30 minutes after 6-8 μg/mlTrough# 30 min infusion 0.52 μg/ml 24 – 48 hours 12 μg/ml

Tobramycin Peak same as gentamicin 6-8 μg/ml 24 – 48 hours >10 μg/mlTrough# 0.5-2 μg/ml

Vancomycin Peak 1 hour after 1 hour infusion 25-30 μg/ml 24 – 72 hours >50 μg/mlTrough# 5 –10 μg/ml

# Trough serum concentration: Sample taken within 30 minutes prior to the next dose.• Serum measurements are routinely obtained at steady state which is usually around the third dose after start or change of dosage and

then once weekly. Earlier measurements may be necessary in very sick infants with fluctuating renal conditions.• Not necessary to draw serum levels of drugs unless infant will be maintained on therapy for more than 3 days.

THERAPEUTIC RANGE OF VARIOUS DRUGS

Drug Optimal Optimal serum Time to steady state after dose changesample time concentration

range

Carbamazepine Trough# 4-12 μg/ml 3-4 days

Digoxin Trough# 0.5 –2 ng/ml 4 –7 days with total digitalization and 12 weeks without digi-talization

Phenobarbital Trough# 15-40 μg/ml 14 days

Quinidine Trough# 2-6 μg/ml 24 hr

Phenytoin Trough# 10-20 μg/ml 4 days after IV doses (rapid increase in elimination rate overthe first weeks of life necessitates frequent monitoring of druglevels).

Theophylline Trough# (Steady Apnea: 5 1-0 μg/ml Approximately 96 hours varies with agestate IV or oral) BPD: 10-15 μg/ml 3–5 days

Valproic acid Trough# 50-100 μg/ml

# Trough serum drug concentration: Sample taken within 30 minutes prior to the next dose.


CONCENTRATION AND DURATION OF FEW INFUSIONS

Medication Recommended minimum Minimum infusion timedilution

Amikacin 6 mg/ml 5–10 minutesAmpicillin 50 mg/ml 5-10 minutesCefazolin 100 mg/ml 5-10 minutesCefotaxime 100 mg/ml 5-10 minutesClindamycin 6 mg/ml 5-10 minutesCloxacilin 50 mg/ml 5-10 minutesGentamicin 5 mg/ml 5-10 minutesMetronidazole 5 mg/ml 5-10 minutesPenicillin G 100,000 u/ml 5-10 minutesTicarcillin 50 mg/ml 5-10 minutesTobramycin 5 mg/ml 5-10 minutesVancomycin 5 mg/ml 60 minutesAminophylline 5 mg/ml 5 –10 minutesCimetidine 15 mg/ml 5 –10 minutesDiazepam 5 mg/ml 2 minutesDigoxin 0.05 mg/ml 3 –5 minutesFurosemide 10mg/ml 2-3 minutesMorphine 1 mg/ml 3-5 minutesPhenobarbital 30mg/ml Not > 2 mg/kg/minPhenytoin 50 mg/ml Not >0.5 mg/kg/min

DRUG LOSS DURING EXCHANGE TRANSFUSION

Drug Percent LossOne volume Two volume

Amikacin 7.1 13.8Ampicillin 7.7 14.7Carbamazepine 3.7 7.2Carbenicillin 5.6 10.9Colistin 18.7 33.9Diazepam 2.3 4.5Digoxin* 1.2 2.4Furosemide 4.9 9.5Gentamicin 5.2 10.1Kanamycin 5.6 10.9Methicillin 10.1 19.1Oxacillin 19.6 35.4Penicillin G (crystalline) 6.0 11.6Penicillin G (procaine) 2.4 4.8Phenobarbital 6.4 12.3Phenytoin 3.1 6.2Theophylline* 17.8 32.4Tobramycin 10.3 19.6Vancomycin 5.7 11.0

* Whole blood volume used in calculation.

Safe Medicine 41

AGENTS TO BE AVOIDED IN GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENT PATIENTS

Antimalarials Analgesics

Primaquine Analgesics(Person with the African A variant may take it at Acetylsalicylic acid (aspirin); moderate doses can be usedreduced dosage 15 mg/d or 45 mg twice weeklyunder surveillance) Safe alternative: Paracetamol

Pamaquine AnthelminticsChloroquine (May be used under surveillance when required β-Naphthalfor prophylaxis or treatment of malaria) Stibophen

NiridazoleSulfonamides and Sulfones Miscellaneous Agents Sulfanilamide Vitamin K analogues (1mg of menaphthone can be given to babies Sulfapyridine Sulfadimdine Sulfacetamide (albucid) Napthalene (Mothballs) Sulfafurazole Salicylazosulfapyridine Probenecid (Salazopyrin, Azulfidine) Dimercaprol (British antilewisite BAL) Dapsone Methylene blue Sulfoxone Arsine Glucosulfone sodium (Promin) Phenylhydrazine SeptrinOther Antibacterial Compounds Acetylphenylhydrazine

Nitrofurans-nitrofurantoin,furazolidone, nitrogfurazone Toludine blue[Nalidivic acid] MepacrineChloramphenicolP-aminosalicylic acid

Agents that can safely be administered in therapeutic doses to glucose-6-phosphate dehydrogenase deficient patients

Acetaminophen (paracetamol, tylenol, crocin, calpol) PhenylbutazoneAcetylsalicylic acid (aspirin) Phenytoin

Aminopyrine (pyramindon, amidopyrine, aminophenazone) Probenecid (Benemid)

Actazoline (Anistine) Procainamide hydrochloride (Pronestyl)

Antipyrine Pyrimethamine (Daraprim)

Ascorbic acid (vitamin C) Quinidine

Benzhexol (Artane) Quinine

Chloramphenicol Streptomycin

Chlorguanidine (proguanil, Paludrine) Sulfacytine

Chloroquine Sulfadiazine

Colchicine Sulfaguanidine

Disphenhydramine (Benadryl) Sulfamerazine

Isoniazid Sulfamethoxypridazine (Kynex)

L-Dopa Sulfisoxazole (Gantrisin)

Menadione sodium bisulfite (Hykinone) Tiaprofenic acid

Menaphthone Trimethoprim

p-Aminobenzoic acid Tripelennamine (pyribenzamine)Vitamin-K


DRUGS IN BREASTFEEDING

Drugs Whose Amount in Milk is too Small to be Harmful to the Neonate, in Ordinary Doses

Acetazolamide ImipramineAlbendazole InsulinsAntacids Ipratropium Br. (inhalation)Amitriptyline Iron dextran (i. m)Amoxapine Iron salts (oral)Antifungal drugs (topical) KetoprofenAspirin (low dose) LignocaineBaclofen MebendazoleBeclomethasone (Inhaler) MethyldopaBenzyl benzoate (topical) MexiletineBupivacaine NaproxenBuprenorphine NafopamCephalosporins NiclosamideCisapride ParacetamolCloxacillin Permethrin (topical)Codeine PiperacillinCromoglycate sodium PiperazineDextropropoxyphene PiroxicamDiclofenac PraziquantelDigoxin PyrantelDomperidone PyrazinamideErgometrine SalbutamolErythromycin SucralfateEthambutol TerbutalineFolic acid Valproate sodGentamicin Vitamins (maintenance dose)HaloperidolHeparinHydralazine WarfarinIbuprofen

DRUGS TO BE USED WITH SPECIAL PRECAUTION (SP) IN BREASTFEEDING WOMEN OR DRUGS CONTRAINDICATED (CI)

Drug Comment/Possible adverse effect on breastfed infant

ACE inhibitors(Enalapril, Lisinopril) : SP; amount in milk small, management of risk not known, watch for hypotensionAcenocumarol : SP; give prophylactic vit K to neonateAcyclovir : SP; significant amount in milkAlcohol : Intoxication, reduced sucklingAllopurinol : SP; secreted in milk, no data on risk to neonateAmiloride : CI; no information on risk to neonate; may reduce lactationAminoglycosides : SP; risk not known, most manufacturers advise cautionAmiodarone : CI; risk of hypothyroidism from released iodineAmlodipine : SP; no data on risk to neonateAmphetamines : CI; significant amount in milk, irritability, poor sleeping pattern.Ampicillin/Amoxicillin : SP; diarrhoea, candidiasisAndrogens : CI; masculinization of female neonate, precocious development of male neonate,

reduced lactationAnthraquinones (senna etc) : CI; diarrhoeaAnticancer drugs : CI; anaemia, diarrhoea, immunosuppressionAnticonvulsants : SP; monitor neonate for side effectsAntidepressants (tricyclic) : SP; use doses<150 mg amitriptyline or monitor neonate for side effects, sedation,

respiratory depressionAntihistamines (H1) : SP; significant amount in milk, watch for drowsinessAntihistamines (2nd generation) : No data on risk to neonate.Antipsychotics : SP; drowsiness, muscle dystonia; avoid chlorpromazine, haloperidol, clozapine;

amount in milk small, but long term effect on developing nervous system not knownAspirin (high dose) : SP; avoid high doses, bleeding, Reye’s syndrome, metabolic acidosis

Safe Medicine 43

Atorvastatin : Avoid; no data on risk to neonateAtropine : SP; monitor for anti-muscarinic effectsAzathioprine : CI; immunosuppressionAzithromycin : Avoid; no information on risk to neonateBarbiturates : SP; drowsiness, lethargy, withdrawal symptomsBenzodiazepines : SP; compatible in single dose; avoid repeated doses; lethargy, hypotonia, reduced

suckling, weight lossBeta blockers : SP; amount in milk generally small; bradycardia, hypotension, cyanosisBromocriptine : Suppresses lactationBuspirone : Avoid; no information on risk to neonateCaffeine : Avoid regular consumption of large amounts, irritability, CNS effectsCarbamazepine : SP; amount in milk small but monitor neonateCarbimazole : SP; hypothyroidism, use lowest effective dose, or suspend breastfeedingCarisoprodol : SP; concentrated in milk; avoid.Celecoxib : Avoid; no information on risk to neonateChloral hydrate : CI; sedationChloramphenicol : CI; diarrhoea, ideosyncratic bone marrow supression, gray baby syndrome (unlikely)Chloroquine : SP; amount in milk small; haemolysis in < 1 month old infant and in G-6PD deficientCimetidine : SP; significant amount in milk, but no harmful effect reportedCiprofloxacin : CI; high concentration in milk, theoretical risk of arthropathyClemastine : SP; drowsy, irritability, refusal to feed, high pitched cry, neck stiffness.Clindamycin : SP; amount in milk small, but risk of diarrhoea, watch for blood in stoolsClofazimine : SP; skin discolourationClonidine : SP; sedation, hypotensionCocaine : SP; cocaine intoxicationCorticosteroids : SP; compatible in single doses; pituitary- adrenal suppression possible with > 10 mg

prednisolone daily to mother, impaired growthCotrimoxazole : SP; folate deficiency, risk of kernicterus, haemolysis in G6PD deficient; safe for

healthy older neonatesCyclophosphamide : SP; possible immune suppression; unknown effect on growth or association with

carcinogenesisCI; neutropenia

Cyclosporine : CI; significant amount in milkSP; immune suppression

Dapsone : SP;haemolytic anaemia, jaundiceDepot medroxyprogesteron acetate (i.m) : Compatible with breastfeeding from 6 weeks postpartumDiltiazem : SP; significant amount in milkDisopyramide : SP; small amount in milk, antimuscarinic effectsDoxepin : SP; sedation, respiratory depressionDoxorubicin : SP; possible immune suppression unknown effect on growth or association with

carcinogenesis.Ephedrine : SP; irritability, sleep disturbanceErgotamine : SP; vomiting, diarrhoea, convulsions (doses used in migrane medication)

CI; ergotism, may suppress lactationEstrogens : CI; gynaecomastia in male neonate, may suppress lactationEthosuccimide : CI; hyperexcitability, poor sucklingFamotidine : SP; present in milk, but harm to neonate not knownFlucanazole : CI; secreated in milk, but harm to neonate not knownFluoxetine : SP; small amount in milk, but can accumulate in neonate; avoid if possibleFurosemide : SP; small amount in milk, electrolyte disturbancesGemfibrozil : Avoid; no information on risk to neonateGold salts : CI; rashes and other reactionsHeroin : SP; tremors, restlessness, vomiting, poor feedingIndomethacin : CI; CNS effects, convulsionsIodine/Iodides : CI; concentrated in milk, hypothyroidism and goiterIodine radioactive : CI; suspend breastfeeding for 24 hr after diagnostic dose and for long-term after

therapeutic doseIsoniazid : SP; neuropathy, convulsions, jaundice, give prophylactic pyridoxineItraconazole : Avoid; unless essential; amount in milk smallKetoconazole : CI; secreted in milk but harm to neonate not knownKetorolac : Avoid as no data on safetyLansoprazole : Avoid unless essential; no data in safetyLevodopa/carbidopa : SP; no data on safetyLithium carbonate : CI; intoxication, cardiac arrythmias (achieves 1/3 to1/2 therapeutic blood concen-

tration)


Losartan : SP; magnitude of risk not known; avoid if possibleMafloquine : SP; secreted in milk, but harm to neonate unlikelyMesalazine : SP; amount in milk small; watch for diarrhoeaMetformin : CI; secreted in milk; hypoglycaemia, lactic acidosisMethotrexate : SP; possible immune suppression; unknown effect on growth or association with

carcinogenesisCI; neutropenia

Metoclopramide : SP; watch for diarrhoea, dystonia in neonateMetronidazole : Significant amount in milk : In vitro mutagen; avoid high doses; suspend breast-

feeding for 12 –24 hr after single doseMontelukast : Avoid; no data on risk to neonateMorphine (and other opioids) : SP; usual doses unlikely to affect neonate; lethargy, poor growth, with drawal symp-

toms in infants of dependent mothersNalidixic acid : SP; small risk of haemolytic anaemia; avoid if possibleNeostigmine : SP; small amount in milk but monitor neonateNicotine : SP; vomiting, diarrhoea, decreased milk production

CI; tachycardia, restlessness, shockNifedipine : SP; small amount in milk but monitor neonateNitrofurantoin : SP; small amount in milk, haemolysis in G6PD deficient neonate.Norfloxacin : Avoid; no information on risk to neonateOmeprazole : Avoid unless essential; no data on safetyOral contraceptives : Avoid until six month after birth, see estrogensPenicillins : Toxicity unlikely but risk of allergyPhencyclidine (PCP) : SP; potent hallucinogenPhenindoine : SP; increased prothrombin and partial thromboplastin timePhenobarbitone : SP; Sedation, infantile spasms after weaning from milk containing phenobarbitone,

methemoglobinemia (rare)Phenolphthalein : CI; diarrhoea, rashesPhenytoin : SP; small amount in milk, but monitor neonatePrimidone : SP; sedation, feeding problemProgestins : Low doses safe, may suppress lactation at high dosesPropylthiouracil : SP; hypothyroidism with high doses onlyPyrimethamine- sulfadoxine : SP; significant amount in milk; appears safe if infant is olderQuinidine : SP; significant amount in milk but harm to neonate not knownRadioactive compounds : CI; Secreted in milk(Copper 64, Gallium 67, Indium 111,Iodine 123, Iodine 125, Iodine131,Radioactive sdatium, Technetium 99m,99m RC macroaggregates) : CI;diarrhoea, rashesRanitidine : SP; significant amount in milk but harm to neonate not knownRifampin : SP; significant amount in milk small, but monitor infant for jaundiceRofecoxib : Avoid; no information on risk to infantSertraline : SP; present in milk but no harm reported in short termSpironolactone : SP; drowsiness, hirutism, gynaecomastiaStreptomycin : Compatible with breast feeding; monitor infant for diarrhoea and thrushSulfasalazine : SP; bloody diarrhoeaSulfonamides : SP; rashes, small risk of kernicterus in neonate, haemolysis in G6PD deficient; safer

for older infantsSulfonylureas : SP; no adverse effect reported, but watch for hypoglycaemiaTetracyclines : CI; growth retardation, candidiasis, tooth discolourationTheophylline : SP; irritability, CNS effectsThiazide diuretics : SP; amount in milk small; may reduce lactationThyroxine : SP; monitor for hyperthyroidismTinidazole : SP; present in milk; suspend breastfeeding till three days after stoppingVancomycin : SP; present in milk, but absorption from neonate’s gut unlikelyVerapamil : SP; small amount in milk, but monitor neonateVigabatrin : CI; present in milk, no data on risk to neonateVitamin A and D : Avoid high doses, risk of hypervitaminosisZolpidem : Avoid unless essential; amount in milk small, but watch for sedation in neonate

TERATOGENICITY

Drugs can affect the foetus at 3 stages-i. Fertilization and implantation – conception to 17 days- failure of pregnancy which often goes unnoticed.

ii. Organogenesis – 18 to 55 days of gestation- most vulnerable period, deformities are produced.

Safe Medicine 45

iii. Growth and development- 56 days onwards – developmental and functional abnormalities can occur, e.g. ACE inhibitorscan cause hypoplasia of organs, specially lungs and kidneys; NSAIDs may induce premature closure of ductus arteriosus.The type of malformation depends on the drug as well as stage of exposure to the teratogen. The proven humanteratogens are listed below:

Other drugs may be low grade teratogens and it is almost impossible to declare a drug to be absolutely safe during pregnancy.It is, therefore, wise to avoid all drugs during pregnancy unless compelling reasons exist for their use regardless of the asignedpregnancy category, or presumed safety.

Drug Abnormality

Alcohol IUGR,mental retardation, ventricular septal defect, fetal alcohol syndrome (IUGR, short palpebral fissure,epicanthic folds, maxillary hypoplasia, micrognathia and thin upper lip), joint contractures.

Aminopterin Abortion, malformationsAmphetamine Congenital heart diseaseCocaine Microcephaly, IUGRAntithyroid drugs GoiterMethylmercury Microcephaly, mental retardationPhenytoin Fetal hydantoin syndrome (low and broad nasal bridge, mild ptosis, coarse hair and distal digital hypoplasia

consisting of nail hypoplasiaMethyltestosterone VirilizationStilbesterol Vaginal adenocarcinoma in adolescentsThalidomide PhocomeliaWarfarin Nose, eye and hand defects, growth retardationSodium Valproate Spina bifida, limb defects (radial ray reduction defects consisting of absence or hypoplasia of radius, first

metacarpal and thumb) and other neural tube defectsTrimethadione Malformation like V-shaped eyebrows, epicanthus, low set ears with anteriorly folded helix and palatal

anomalies.Tetracyclines Discoloured and deformed teeth, retarded bone growthProgestins Virillization of female foetusPhenobarbitone Various malformationsLithium Foetal goiter and hypothyroidismIsotretinoin Craniofacial, heart and CNS defectsIndomethacin/aspirin Premature closure of ductus arteriosusCorticosteroids Cleft palate and lip, cardiac defectsCarbamazepine Craniofacial dysmorphism and nail hypoplasia, developmental delay, cardiac defects, short nose with long

philtrum, neural tube defects, other abnormalitiesAnticancer drugs Multiple defects, foetal death(methotrexate)Androgens Virillization; limb, esophageal, cardiac defects

PASSAGE OF ANTIBIOTICS ACROSS THE PLACENTA

Percent antibiotic in indicated category AntibioticEqual to serum concentration Amoxicillin

AmpicillinCarbenicillinChloramphenicolMethicillinNitrofurantoinPenicillin GSulfonamidesTetracyclinesTrimethoprim

50% of serum concentration Aminoglycosides(except ones below)10%-15% of serum concentration Amikacin

CephalosporinsClindamycinNafcillinTobramycin

Negligible(<10% of serum concentration) DicloxacillinErythromycin

CHAPTER

6 Pharmacokinetics

PHARMACOKINETICS

LoadingDose (mg/kg) = Vd x Cp / F = MD x t ½ / Dl x 0.693MaintenanceDose (mg/kg) = LD x Dl / t ½ x 1.44 = Css x Vd x Dl / t ½ x F x 1.44Steady stateConc. (ug/ml) = F x MD / Cl x Dl = t ½ x F x MD/ 0.693 x Vd x DlVol. Distri-bution (L/kg) = D / Co = D x t ½ / 0.693 x AUCClearance(L/kg/hr) = Vd / 1.44 x t ½ = D/AUC = D x 0.693 / t ½ x CoEliminationcontant (Kel) = 0.693 / t ½ConcentrationAt tine T hr = Co/ e T x Kel

AUC = Area under curve (hr. ug/ml)

Cl = Clearance (L/kg/hr) (x 16.67 = ml/kg/min)

Co = Concentration at time zero (ug/ml, mg/L)

Cp = Plasma/serum,concentration (ug/ml, mg/L)

Css = Steady state concentration (ug/ml, mg/L)

D = Dose (mg/kg)

Dl = Dose interval (hours)

e = 2.71828

F = Fraction of drug absorbed

Kel = Elimination constant

LD = Loading dose (mg/kg)

MD = Maintenance dose (mg/kg)

T ½ = Half life (hours)

Vd = Volume of distribution (L/kg)

0.693 = Natural logarithm of 2

PATHOLOGICAL STATES

Gastrointestinal diseases

The changes are complex and drug absorption can be increased or decreased :1. Coeliac disease: Absorption of amoxycillin is decreased but that of cephalexin and cotrimoxazole is increased.2. Achlorhydria: Decreases aspirin absorption by favouring its ionization.

Pharmacokinetics 47

Liver disease

Oral medication; Propranolol, alprenolol, verapamil, salbutamol, nitroglycerine, pethidine, methyltestosterone, propoxyphene, amitrip-tyline, parenteral medication: isoprenaline, lidocaine, hydrocortisone, morphine, testosterone.

1. Bioavailability of drugs like is increased due to loss of hepatocellular function and portocaval shunting.2. Metabolism and elimination of some drugs (morphine, pentobarbitone, lidocaine, propranolol) is decreased and their dose

should be reduced.3. Prodrugs needing hepatic metabolism for activation, e.g. prednisone, bacampicillin, sulindac are less effective and should be

avoided.4. Oral anticoagulants can remarkedly increase prothrombin time because clotting factors are already low.5. Hepatotoxic drugs should be avoided in liver disease.

Kidney disease

• Clearance of drugs that are primarily excreted unchanged (aminoglycosides, digoxin, phenobarbitone) is reduced parallelto decrease in creatinine clearance (CLcr). Loading dose of such a drug is not altered (unless edema is present) but mainte-nance doses should be reduced or dose interval prolonged proportionately. A rough guideline is given in the box:

CLcr (patient) Dose rate to be reduced by

50-70 ml/min 1.5 times

30-50 ml/min 2 times

10-30 ml/min 3 times

5-10 ml/min 6 times

• Dose rate of drugs only partly excreted unchanged in urine also needs reduction, but to lesser extents. If the t½ of the drugis prolonged, attainment of steady-state plasma concentration with maintenance doses is delayed proportionately.

• The permeability of blood-brain barrier is increased in renal failure; opiates, barbiturates, phenothiazines, benzodiazepinesetc. produce more CNS depression.

• Pethidine should be avoided because its metabolite nor-pethidine can accumulate on repeated dosing and cause seizures.• Antihypertensive drugs produce more postural hypotension in patients with renal insufficiency.• In renal failure tetracyclines have an anti-anabolic effect and accentuate uraemia; nonsteroidal anti-inflammatory drugs and

carbenoxolone cause more fluid retention; potentially nephotoxic drugs, e.g. cephaloridine, cephalothin, aminoglycoside,tetracyclines (except doxycycline), sulfonamides (crystalluria), cyclosporine, penicillamine, gold, vancomycin should beavoided.

• Thiazide diuretics tend to reduce g.f.r.: are ineffective in renal failure and can worsen uraemia.• Potassium sparing diuretics are contraindicated; can cause hyperkalemia and cardiac depression.• Urinary antiseptics like nalidixic acid, nitrofurantoin and methenamine mandelate do not achieve high concentration in

urine and are likely to produce systemic toxicity.

ANTIMICROBIALS REQUIRING ADJUSTMENT IN RENAL FAILURE

Pharmacokinetics Adjustments in renal failure

Drug Route of Normal Normal Method Creatinine Clearance (ml/min) Supplementalexcretion T

1/2 (hr) dose interval > 50 10-50 <10 dose for

dialysis

Acyclovir Renal 2.1-3.8 q8h I q8h q24h q48h Yes (He)Amikacin Renal 2-3.0 q8-12h I q12h q12-18h q24h

D 60-90% 30-70% 20-30% Yes (He,P)Amoxicillin Renal 0.9-2.3 q8h I q8h 8-12h q12-16h Yes (He)

(hepatic) No (P)Amphotericin B Nonrenal 24 q24h I q24h q24h q24-36h No (He,P)Ampicillin Renal 0.8-1.5 q4-6h I q6h q6-12h q12-16h Yes (He)

(hepatic) No (P)Carbenicillin* Renal 1.2-1.5 q4-6h I q8-12h q12-24h q24-48h Yes (He)

(hepatic) No (P)

Contd...


Contd...

Cefactor Renal 0.75 q8h D 100% 50-100% 33% Yes (He,P)(hepatic)

Cefamandole Renal 1.0 q4-8h I q6h q6-8h q8h Yes (He)Cefazolin Renal 1.4-2.2 q8h I q8h q12h q24-48h Yes (He)

No (P)Cefotaxime Renal 1 q6-8h I q6-8h q8-12h q12-24h Yes (He)

(hepatic) No (P)Cefoxitin Renal 1.0 q6-8h I q8h q8-12h q24-48h Yes (H)

No (P)Ceftazidime Renal 1.8 q8-12h I q12h q12-24h q24-48h Yes (He)

(hepatic) No (P)Cefuroxime Renal 1.6-2.2 q6-8h I q8-12h q24-48h q48-72h Yes (He)

No (P)Cephalexin Renal 0.9 q6h I q6h q6-8h q8-12h Yes (He)

No (P)Cephalothin# Renal 0.5-1.0 q6h I q6h q6-8h q9-12h Yes (He)

(hepatic) No (P)Ethambutol Renal 4 q24h I q24h q24-36h q48h Yes (He, P)Fluconazole# Renal 20-50 q24h D 100% 25-50% 25% Yes (He, P)Flucytosine Renal 3-6 q6h I, D q6h, 50% q12-24h, q24-48h, Yes (He, P)

30-50% 20-30%Ganciclovir Renal 2.5-3.6 q8-12h DI 50-100% 25-50% 25% and Yes (He)

and and q24h q24hq8-12h

Gentamicin# Renal 2.5-3.0 q8-12h I q8-12h q12h q24h, Yes (He, P)D 60-90% 30-70% 20-30%

Isoniazid Hepatic 2-4 $ q24h D 100% 100% 66-75% Yes (He, P)(renal) 0.5-1.5 (fast)

Kanamycin Renal 2-3 q8h I q8-12h, q12h q24h, Yes (He,P)D 69-90% 30-70% 20-30%

Methicillin Renal 0.5-1.0 q4-6h I q4-6h q6-8h q8-12h No (He, P)(hepatic)

Metronidazole Hepatic 6-14 q8h I q8h q8-12h q12-24h Yes (He)(renal)

Nitrofurantoin Nonrenal 1-1.7 q8h D 100% Avoid Avoid Yes (He)Penicillin G Renal 0.5 q4-6h I q6-8h q8-12h q12-16h Yes (He)

(hepatic) No (P)Piperacillin Renal 0.8-1.5 q6h I q4-6h q6-8h q8h Yes (He)

(hepatic)Sulfamethoxazole Hepatic 9-11 q12h I q12h q18h q24h Yes (He)

(renal) No (P)Ticarcillin* Renal 1-1.5 q4-6h I q8-12h q12-24h q24-48h Yes (He)

(hepatic) No (P)Tobramycin† Renal 2.5-3 q8h I q8-12h q12h, q24h, Yes (He, P)

D 60-90% 30-70% 20-30%Trimethoprim Renal 8-15 q12h I q12h q18h q24h Yes (H)

(hepatic) No (P)Vancomycin Renal 6-10 q6-8h I q24-72h q72-240h q240h Y/N (He) & No (P)

* May inactivate aminoglycosides in patients with renal impairment.† Rate of acetylation of isoniazid.# May add to peritoneal dialysate to obtain adequate serum levels.& If using high-flux polysulfone hemodialysis, give supplemental dose following dialysis.Method: D = Dose reduction I = Increase interval between doses

He = Hemodialysis P = Peritoneal dialysis

Pharmacokinetics 49

NON-ANTIMICROBIALS REQUIRING ADJUSTMENT IN RENAL FAILURE

Pharmacokinetics Adjustments in renal failure

Drug Route of Normal Normal Method Creatinine Clearance (ml/min) Supplementalexcretion T

1/2 (hr) dose interval > 50 10-50 <10 dose for

dialysis

Acetaminophen Hepatic 2 q4h I q4h q6h q8h Yes (He)No (P)

Acetylsalicylic Hepatic 2-19 q4h I q4h q4-6h Avoid Yes (He, P)Acid * (renal)Adriamycin Renal (hepatic) 16-30 Single treatment D 100% 100% 75% ?Allopurinol Renal 0.7-1.6 q24h I q8h, 100% q8-12h q12-24h, Yes (He)

D 75% 50%Azathioprine # Hepatic IV: 12.5 min; q24h D 100% 100% 75% Yes (He)

PO: 0.5-4h I q24h q24h q36hCaptopril Renal 1.9 q12h D 100% 100% 50% Yes (He)

(hepatic)Carbamazepine Hepatic 20-36 q8-12h D 100% 100% 75% No (He, P)

(renal)Chloral Hydrate Hepatic 7-14 q8h PRN D 100% Avoid Avoid Yes (He)Cimetidine Renal 1.5-2 q12h I q6h, q8h, q12h, No (He)

(hepatic) D 100% 75% 50%Digoxin† Renal (GI) 36-44 q24h D 100% 25-75%, 10-25%, No (He, P)

I q24h q36h q48hDiphenhydramine Hepatic 4-7 q6h I q6h q6-9h q9-12h ?Enalapril Renal 7 q12-24h D 100% 50% 25% Yes (He)

(hepatic)Famotidine Renal 2.5-4 q12-24h I q20-40h, q30-60h, q68-136h, No (He, P)

(hepatic) D 100% 50% 25%Hydralazine# Hepatic (GI) 2-4.5 q8h (fast), & I q8-12h q8-12h q8-16h (fast), No (He, P)

q12h (slow) q12-24h (slow)Insulin (regular) Hepatic 9 min Variable D 100% 75% 50% ?

(renal)Metaclopramide Renal 4 q6-8h D 100% 75% 50% No (He)

(hepatic)Methotrexate Renal Tripha-sic, Single D 100% 50% Avoid Yes (He)

0.1, 2.3, 27 treatment No (P)Phenobarbital Hepatic 65-150 q8-12h I q8-12h q8-12h q12-16h Yes (He, P)

(renal, 30%)Primidone Hepatic 6-12 q8-12h I q8-12h q8-12h q12-24h Yes (He)

(renal, 20%)Ranitidine Renal 1.5-3 q8-12h D 100% 75% 50% Yes (He)

(hepatic)Spironolactone Renal 10-35 q6h I q6-12h q12-24h|| Avoid ?

(hepatic)Thiazides Renal 1-2 q12h D 100% 100% Avoid ?

* With large doses T1/2 prolonged up to 30 hr.† Decrease loading dose 50% in end-stage renal disease because of decreased volume of distribution.# Dose interval varies for rapid and slow acetylators with normal and impaired renal function.& Rate of acetylation of hydralazine.|| Hyperkalemia common in GFR <30 ml/min.# Azathioprine rapidly converted to mercaptopurine.


DRUGS REQUIRING NO ADJUSTMENT

Drug Extra dose for dialysis

Antibiotics

CeftriaxoneChloramphenicol HeClindamycinCloxacillinErythromycinKetoconazoleMiconazoleNafcillinPyrimethamineRifampin

Non-antibiotics

AmitriptylineBusulfanChlorpheniramineChlorpromazine HeClonidineCodeineCorticosteroids (any)Cytosine arabinosideDiazepamDiazoxideDiltiazem He, PFentanyl5-FluorouracilFlurazepam HeFurosemideHaloperidolHeparinIbuprofenImipramineIndomethacinLidocaineMeperidineMetolazoneMidazolamMinoxidilMorphineNaloxoneNifedipineNitroprusside HePentazocine HePentobarbitalPhenytoinPrazosinPropoxyphenePropranololQuinidine He, PSecobarbitalSuccinylcholineTheophylline He, PValproic acidVerapamilVincristineWarfarin

He = HemodialysisP = Peritoneal dialysis

Pharmacokinetics 51

Congestive heart failure

• Decreasing drug absorption from g.i.t. due to mucosal edema and splanchnic vasoconstriction. Procainamide and hydro-chlorothiazide.

• Loading doses caine and procainamide should be lowered.• Dosing rate of lignocaine, procainamide, theophylline should be reduced. The decompensated heart is more sensitive to

digitalis.

Thyroid disease

• The hypothyroid patients are more sensitive to digoxin, morphine and other CNS depressants.• Hyperthyroid patients are relatively resistant to inotropic action but more prone to arrhythmic action of digoxin.

Other examples of modification of drug response by pathological states are:

• Antipyretics lower body temperature only when it is raised (fever).• Thiazides induce more marked diuresis in edematous patients.• Myocardial infarction patients are more prone to adrenaline and digitalis induced cardiac arrhythmias.• Myasthenics are very sensitive to curare.• Schizophrenics tolerate large doses of phenothiazines.• Head injury patients are prone to go into respiratory failure with normal doses of morphine.• Atropine, imipramine, furosemide can cause urinary retention in individuals with prostatic hypertrophy.• Hypnotics given to a patient in severe pain may cause mental confusion and delirium.• Cotrimoxazole produces a much higher incidence of adverse reactions in AIDS patients.

Drugs that cause significant displacement of bilirubin from albumin in vitro

SulfonamidesMoxalacinmFusidic acidRadiographic contrast media for cholangiography (sodium iodipamide, sodium ipodate, iopanoic acid, meglumine ioglycamateAspirinApazoneTolbutamideRapid infusions of albumin preservatives (sodium caprylate and N-acetyltryptophan)Rapid infusions of ampicillinLong-chain free fatty acids (FFA) at high molar ratios of FFA: albumin

CHAPTER

7 Special Nutrition

COMPOSITION OF VARIOUS MILKS (ALL PER 100 ML OF MILK)

Milk Energy (Kcal) Protein (g) Casein whey CHO Fat Na K Ca P(g) (g) (mmol) (mmol) (mmol) (mmol)

Mature term breast milk 70 1.3 1:2 7 4.2 0.65 1.5 0.9 0.5Preterm breast milk 67 1.8-2.4 N/A 6 4 2.2 1.8 0.6 0.5PretermEBM + Fortifier 80 2.5-3.1 N/a 9 4 3.1 - 1.8 1.4Donor bank milk 46 1.1 N/A 7.1 1.7 0.7 - 0.9 0.5Cow’s milk 67 3.4 3:1 4.6 3.9 2.2 3.9 3 3Whey based term formula 65-68 1.5 1:1.5 7.0-7.3 3.6-3.8 0.8 1.4-2.2 0.9-1.5 0.9-1.1Casein based term formula 65-69 1.5-1.9 4:1 7.2-8.6 3.1-3.6 0.8-1.1 1.6-2.2 1.2-2.1 1.2-1.8Follow on (>6 months) 70 1.8 3.5:1 7.2 4.6 1.0 2.2 2.2 1.6LBW formula 80 2.0-2.4 1:1.5 7.0-8.5 3.5-4.9 1.3-2.0 1.8 1.8-2.7 1.1-1.7LBW follow- on 74 1.8 1.5:1 7.5 4.1 1.0 1.9 2.0 1.3

AVERAGE DAILY NUTRITIONAL REQUIREMENTS

Age Water (ml/kg) Kcal./kg Protein Na K Ca2 PO4

3-

(g/kg) mmol/kg (mmol/kg)

Infant >2.5 kg at birth1day 60-90 115 2.2 2-3 2-3 1.5 1.52days 90-120 115 2.2 2-3 2-3 1.5 1.510 days 120-150 105 2.0 2-3 2-3 1.5 1.53 months 140-160 105 2.0 2.0 2-3 1.5 1.5Infant <2.5 kg at birth<1 month 130 - 200 110-165 2.9-4.0 1-8 2-5 2-6 2-5

NUTRITIONAL NEEDS OF LOW BIRTH WEIGHT INFANTS

Energy intake 110 - 165 kcal/kg/dayFluid 130-200 ml/kg/dayProtein intake Whey: Casein ratio 2.9-4.0 g/kg/day

amino acids Whey predominant should not fall belowhuman milk content

Fat intake Linoleic acid 4.0-9.0 g/kg/daymedium chain triglycerides (MCT) >3% of total energy or 0.5 g/100 kcal

<40% of total fatCarbohydrates Starch hydrolysates: sucrose; glucose <15 g/kg/day of lactose;intake Glucose polymers and lactose (50:50);

Contd...

Special Nutrition 53

Contd...

Minerals Sodium 1.3-3.5 mmol/kg/dayChloride 2.0-3.5 mmol/kg/dayPotassium 2-5 mmol/kg/dayCalcium 90-250 mg/kg/dayPhosphorus 65-125 mg/kg/dayCa:P ratio 1.4-2.0Magnesium 15 mg/kg/dayZinc 0.6-1.4 mg/kg/dayCopper 110-150 mg/kg/day

Vitamins Vitamin A 120-420 μg/dayVitamin K 0.5-1.0 mg at birthVitamin E 0.5-0.6 mg/100kcalVitamin D 500-2000 IU/day

RECOMMENDED DAILY ALLOWANCES OF VITAMINS AND MINERALS

Vitamin A 420 IU Calcium 360 mgVitamin D 400 IU Phosphorus 240 mgVitamin E 3 mg Magnesium 50 mgVitamin C 35 mg Iron 10 mgThiamine 0.3 mg Zinc 3 mgRiboflavin 0.4 mg Iodine 40 μgNiacin 6.0 mgVitamin B6 0.3 mgFolic acid 30 μgVitamin B12 0.5 μg

GUIDELINES FOR THE MODES OF PROVIDING FLUIDS AND FEEDING

Age Categories of neonates

Birth weight <1200g 1200-1800g >1800gGestation <30 weeks 30-34 weeks >34 weeksInitial Intravenous fluids. Gavage feeds Breastfeeding. If unsatisfactory

Try gavage feeds, if not sick. give katori or spoon feedsAfter 1-3 days Gavage feeds Katori-spoon feeds BreastfeedingLater (1-2 wk) Katori-spoon feeds Breastfeeding BreastfeedingAfter some more time (4-6 wk) Breastfeeding Breastfeeding Breastfeeding

TUBE FEEDING GUIDELINES

Birth weight (g) Initial rate (ml/kg/day) Volume increase (ml/kg/day)

<800 10 10-20800-1000 10-20 10-20

1001-1250 20 20-301251-1500 30 301501-1800 30-40 30-401801-2500 40 40-50

>2500 50 50


ORAL DIETARY SUPPLEMENTS AVAILABLE FOR USE IN INFANTS

Nutrient Product Source Energy content

Fat MCT oil Medium-chain 8.3 kcal/g (Mead Johnson) triglycerides 7.7 kcal/mlMicrolipid Long-chain 4.4 kcal/ml (Mead Johnson) triglyceridesCorn oil Long-chain 9 kcal/gm

triglycerides 8.4 kcal/mlCarbohydrate Polycose Glucose polymers 3.8 kcal/gm

(Ross) 8 kcal/tsp (powder)2 kcal/ml (liquid)

Protein Promod (Ross) Whey 4.2 kcal/gConcentrate 5.5 kcal/tsp

MCT = medium-chain triglyceride

IRON SUPPLEMENTATION GUIDELINES IN THE PREMATURE INFANT

Birth weight< 1000 g 1000-1500 g 1500-1800 g >1800 g Comments

Total dose 4 mg/kg/day 3-4 mg/kg/day 2-3 mg/kg/day 2 mg/kg/day -Formula Supplement with Supplement with Supplement with Supplement with Low iron elemental iron elemental iron elemental iron elemental iron

4 mg/kg/day 3-4 mg/kg/day 2-3 mg/kg/day 2 mg/kg/day - Iron fortified Supplement with Additional Additional No additional

elemental iron elemental iron 1mg/kg/day supplementation2 mg/kg/day 1-2 mg/kg/day as needed -

Human milk (HM) Elemental iron Elemental iron Elemental iron Elemental iron only 4 mg/kg/day 3-4 mg/kg/day 2 mg/kg/day 2 mg/kg/day Infants under 1800g

should be on 24 cal/oz HM(with human milk fortifier)

before iron supplementationis begun

Combination Supplement with Supplement with Supplement with Supplement with (formula plus HM) elemental iron elemental iron elemental iron elemental iron Low iron 4 mg/kg/day 3-4 mg/kg/day 2-3 mg/kg/day 2 mg/kg/day - Iron fortified Calculate for total Calculate for total Additional No additional

iron dose of iron dose of 1 mg/kg/day supplementation 4 mg/kg/day 3-4 mg/kg/day as needed -

COFACTOR / LIMITING AMINO ACID THERAPY

Disorder Vitamin / cofactor Dose (mg/d) Amino acid supplement

Phenylketonuria - - TyrosineNeonatal tyrosinemia Vitamin C 50-100 -Classical homocytinuria Pyridoxine and folic acid 100-500 Cystine

10-20Hartnup disease Niacin 100-250 -Mitochondrial disorder Riboflavin 100-150 -Maple syrup urine disease Thiamine 10-20 -Methylmalonic acidaemia B

121.0-3.0 Bicarbonate

Multiple carboxylase deficiency Biotin 5-10 -Isovaleric academia - - Glycine and L-carnitineHawkinsinuria Vitamin C 1000 -


SOME IMPORTANT METABOLIC CONDITIONS

Condition Deficiency Acidosis and Treatment Antenatalketosis detection

Propionic Propionyl CoA carboxylase +++ IV glucose exchange transfusion dialysis YesacidaemiaMaple syrup urine disease Branched chain +++ IV glucose exchange/dialysis, severe Yes(branched chain Ketoaciduria) Keto-acid dehydrogenase neonatal illnessMethylmalonic acidaemia Methylmalonyl CoA mutase +++ IV glucose/HCO3 exchange/dialysis Yes

B12 – 1mg o.d. low protein dietIsovaleric Acidaemia Isovaleric acid +++ IV glucose / HCO3 low leucine diet Yes(sweaty feet) dehydrogenaseMultiple carboxylase Various carboxylases +++ IV glucose/HCO3 neonate is often Yesdeficiency involved in biotin metabolism biotin responsive

COMMERCIAL FORMULAS AND FOODS

Formulas for metabolic disorders

Indicated use Product

Phenylketonuria (PKU) Lofenalac, Phenyl – FreePKU, infant PKU 1, Analog XPPKU, child PKU 2, Maxamaid XPMaple Syrup Urine Disease MSUDMSUD, infant MSUD 1, Analog MSUDMSUD, child MSUD 2, Maxamaid MSUDTyrosinemia LowPhenylTyr (3200AB), Analog XPHEN,Tyrosinemia, infant TYR, METTyrosinemia, child TYR 1Homocystinuria TYR 2, Maxamaid XPHEN, TYRHomocystinuria, infant Low methionine (3200K), Maxamaid XMETHomocystinuria, child Hominex – 1Histinemia, infant Hominex – 2Histinemia, child Hist 1aHyperlysinemia, infant Hist 2aHyperlysinemia, child LYS 1aI proprionic acidemia methylmalonic aciduria LYS 2AC. proprionic acidemia methylmalonic aciduria OS 1aMethylmalonic acidemia OS 2 aHyperammonemia, infant Analog XMET, TYR, MET, or MaxamaidHyperammonemia, child XMET, THRE, VAL, ISLEUDisaccharidase deficiency UCD 1

UCD 2Monosaccharide and Disaccharide – Free DietPowder (3232A)

COMPOSITION OF HUMAN MILK, STANDARD INFANT FORMULAS, AND SOME SPECIALIZED FORMULAS

Formula type Calorie distribution Carbohydrate type Protein type Fat type Osmolality (mOsm)

Human milk Cabohydrate 38%, Lactose Whey 50%, Casein 20% Human milk fat 300Protein 7%, fat 55%

Enfamil Carbohydrate 43% Lactose Nonfat Cow’s milkprotein, 9%, fat, 48% Demineralized whey Coconut, soy or 300

60%, Casein 40% oleo, or both safflowerSimilac Carbohydrate 43%, Lactose Nonfat cow’s milk

protein 9%, fat 48%, Casein 82%, Whey 18% Coconut, soy 300

Contd...


Contd...

Formula type Calorie distribution Carbohydrate type Protein type Fat type Osmolality (mOsm)

Gerber Carbohydrate 43%, Lactose Nonfat Cow’s milk Palm olein Soy 320protein 10%, fat, 46% Casein 82%, Whey 18%, Coconut Sunflower

Good Start Carbohydrate 44%, Lactose, 70% Whey protein 42% Palm olein 265Protein 10%, Fat, 50% Maltodextrin, 30% hydrolyzed Soy coconut

sunflowerSimilac Carbohydrate 41%, Lactose Nonfat cow’s milk, Soy, coconut 280PM 60/40 protein 10%, fat, 50% Demineralized whey,

Whey 60%, Casein 40%

Formulas free of lactose and or cow’s milk protein and special milk based (casien – hydrolysate) formulas

Lactofree Carbohydrate 42%, Corn syrup solids Milk protein isolate Palm olein Soy 200protein 9%, fat 49% Coconut Sunflower

Soy Carbohydrate 40%, Corn syrup solids or Soy isolate Soy or coconut, or 250-296Isomil Protein 11-13% sucrose, or both both, corn, oleo,Nursoy safflowerAlsoydGerber SoycSoy (sucrose free)Isomil SF Corn syrup solids Soy isolate Soy, coconut, palm 180-200

Carbohydrate 40% olein, sunflowerProsobeea Protein 12%,

fat, 48%Neocate infant Carbohydrate 47%, Corn syrup solids Amino acids Safflower 342w/iron protein 12%, fat, 41% Refined Vegetable oil

(coconut, soy)Nutramigen Carbohydrate 44%, Corn syrup solids, Casein hydrolysate Palm olein, soy, 320

Protein 12%, fat 45% modified corn starch coconutAlimentum Carbohydrate 41%, Sucrose, modified Casein hydrolysate MCT 50%,

protein 11%, fat 48% tapico starch safflower, soy 370Pregestimil Carbohydrate 41% Corn syrup solids, Casein hydrolysate MCT 55%, corn 300

protein 11%, fat 48% modified corn starch, with L-cysteine, 20%, safflowerdextrose L- tryptophan, 12.5%, soy 12.5%

L – tyrosineRCF (Ross Carbohydrate 40%, Type desired 52g Soy isolate Soy, coconut Varies with sourcecarbohydrate protein 12%, fat 48% and 12 oz H2O with of carbohydratefree) 13 oz RCF – full

strength

Formulas with altered fat, protein, and carbohydrates

Fat alterations Carbohydrate 46%, Corn syrup solids, Sodium caseinate MCT 85%, corn 220Portagen protein 14%, Fat 40% sucrose 12.5%, lecithinProgestimila See above 2.5%Alimentum See aboveElementalNeocate One Carbohydrate 58.5%, Maltodexterin 68%, Amino acids Safflower 65%, 835, liquid,

Protein 10%, Sucrose 32% MCT 35%, 1cal/ml; 610,Fat 31.5%, powder, 1 Cal/ml

Peptamen Jr Carbohydrate 55%, Maltodexterin, starch Hydrolyzed whey MCT 60%, SOY, 260, unflavoured,protein 12%, fat 33%, CANOLA 1 cal/ml, 365,

vanilla, 1 cal/ mlVivonex Carbohydrate 62%, Maltodexterin, Amino acids MCT 68%, soy 360, 0.8cal/mlPaediatric protein 12%, fat 26%, modified starch 32%Enfamil Carbohydrate 44%, Lactose 40%, corn Nonfat cow’s milk MCTs 40%, corn 300premature protein 12%, fat 44% syrup soilds, 60% Demineralized whey 40%, coconut, 20%

Whey 60%, casein 40%

Contd...


Contd...

Similac special Carbohydrate 42%, Lactose 50%, Nonfat cow’s milk MCTs 50%, corn 300care protein 11%, fat 47% hydrolyzed corn Demineralized whey 30%, coconut, 20%

starch, 50% Whey 60%, Casein 40%Similac Neocare Carbohydrate, 41% Lactose, 50% corn Nonfat cow’s milk MCT 25% Coconut, 290

protein 10%, fat 49% syrup solids 50% Demineralized whey 30%, or 20%Whey 50%, casein 50% powder only,

SOY 45% OR 28%powder only,safflower 27%,powder only

SUGGESTED INTAKES OF PARENTERAL VITAMINS IN INFANTS

Vitamin Estimated needs 40% of a Single-dose 1.5mL MVI PediatricTerm Infants Preterm Infants Vial MVI Paediatric per 100 mL PN

(dose/day) (dose/kg/day) per Kilogram of Administered atBody Weight a Rate of 150

ml/kg/day

Lipid Soluble A (μg) 700 500 280 315 D (IU) 400 160 160 180 E (IU) 7 2.8 2.8 3.2 K (μg) 200 80 80 90Water Soluble Thiamine (mg) 1.2 0.35 0.48 0.54 Riboflavin (mg) 1.4 0.15 0.56 0.63 Niacin (mg) 17 6.8 6.8 7.65 Pantothenate (mg) 5 2.0 2.0 2.25 Pyridoxine (mg) 1.0 0.18 0.4 0.45 Biotin (μg) 20 6.0 8.0 9.- Vitamin B12 (μg) 1.0 0.3 0.4 0.45 Vitamin C (mg) 80 25 32 36 Folate (μg) 140 56 56 63

Standard TPN Regimen

Day 1 Day 2 Day 3 Day 4

Protein (g/kg per 24 h) 1.0 1.5 2.0 2.5Nitrogen (g/kg per 24 h) 0.16 0.23 0.33 0.4Carbohydrate (g/kg per 24 h) 10 12 14 15Fat (g/kg per 24 h) 1 2 3 4Energy (kcals/kg per 24 h) 50 68 86 100Sodium (mmol/kg per 24 h) 3 3 3 3Potassium (mmol/kg per 24 h) 2.5 2.5 2.5 2.5Calcium (mmol/kg per 24 h) 1.9 1.9 1.9 1.9Phosphorus (mmol/kg per 24 h) 1.5 1.5 1.5 1.5Volume (ml/kg per 24 h) 150 150 150 150

CHAPTER

8 Specific Therapeutics

TIME TABLE FOR ELECTIVE SURGICAL REPAIR

• Meningocele Earliest possible• Cleft lip 3-9 months• Hirschsprung’s disease Early at diagnosis• Inguinal hernia Early, if fit• Anal and rectal aresia Colostomy at birth• Cleft palate 18-36 months• Cryptorchidism after 1 year• Exstrophy of bladder 1-3 months• Umbilical hernia 1-5 years• Phimosis 1-5 years• Hypospadias 3-5 years

NORMAL LONGITUDINAL BLOOD PRESSURE IN FULL-TERM INFANTS (mm Hg)

Boys GirlsAge Systolic Diastolic Systolic Diastolic

1st day 67 ± 7 37 ± 7 68 ± 8 38 ± 74th day 76 ± 8 44 ± 9 75 ± 8 45 ± 81 month 84 ± 10 46 ± 9 82 ± 9 46 ± 103 months 92 ± 11 55 ± 10 89 ± 11 54 ± 106 months 96 ± 9 58 ± 10 92 ± 10 56 ± 10

ANTIHYPERTENSIVE AGENTS FOR THE NEWBORN

Dose Comment

Diuretics: 0.5 – 1.0 mg/kg/dose May cause hyponatremia,Furosemide IV, IM, PO Hypokalemia, hypercalciuria.Chlorothiazide 20-50 mg/kg/day; May cause hyponatremia,

divided qid or bid Hypokalemia, hypochloremiaVasodilators: 1-8 mg/kg/day;Hydralazine. divided q6-8 hr May cause tachycardiaCalcium channel blockersNifedipine 0.2mg/kg/dose sublingual, PO Limited use in neonates. May cause tachycardiaBeta receptor antagonist Propranolol 0.5-5.0 mg/kg/ day PO; divided q6-8 hr May cause bronchospasmAlpha/beta receptor antagonist Labetalol 0.5 –1.0 mg/kg/dose IV, q4-6 hr Limited use in neonatesACE inhibitorsCaptopril 0.15- 2.0 mg/kg/day PO, divided q8-12 hr May cause oliguria, hyperkalemia, renal failureEnalapril 5-10 microg/kg/dose IV q8 –24 hr May cause oliguria, hyperkalemia, renal failure

Specific Therapeutics 59

THROMBOLYTIC THERAPY

1) Low dose for blocked catheters

Regimen Monitoring

Instillation UK 5000/ml 1.5-3.0ml / Lumen 2-4 hr NoneInfusion UK 150 units/kg/H per lumen 12048 hr Fibrinogen, TT,PT,APTT

2) Systemic thrombolytic therapy

Load Maintenance Monitoring

UK 4000 units/kg 4000 units/kg/hr for 6 hr Fibrinogen, TT,PT,APTTSK 4000 units/kg 2000 unit/kg/hr

max 2,50,000 units Fibrinogen, TT,PT,APTTTPA0.05-5 mg/kg/hr 0.5 mg/kg/h for 6 hr Fibrinogen, TT,PT,APTT

PROTAMINE DOSAGE TO REVERSE HEPARIN THERAPY

Based on total amount heparin received in prior 4 hours

Time since last heparin dose (min) Protamine dose(mg/100 U heparin received)

<30 1.030-60 0.5-0.75

60-120 0.375-0.5>120 0.25-0.375

INITIAL DOSING OF ENOXAPRIN, AGE-DEPENDENT (IN MG/KG/DOSE SQ)

Age Initial treatment dose Initial prophylactic dose

Term infant 1.5 q12h 0.75 q12hPreterm infants 1.0 q12h 0.75 q12h

SYSTEMIC THROMBOLYTIC THERAPY

Agent Load Infusion Comments

tPA None 0.1-0.5 mg/kg/hr for 6 h Duration usually 6 h; can continue for 12 h or re-peat after 24 h, although lysis of clot will continuefor hours after infusion stops.

Streptokinase 2000-4000 U/kg 1000-2000 U/kg/hr for 6 h. Only one course should be given.over 10 min Consider premed with tylenol and benadryl.

Urokinase 4000 U/kg 4000 U/kg/hr for 6 h Longer duration may be necessary based on clinicalover 10 min response.

*tPA = Tissue Plasminogen Activator

LOCAL SITE-DIRECTED THROMBOLYTIC THERAPY

Agent Infusion Notes

tPA 0.03-0.05 mg/kg/h Adjust infusion rate if no clinical effect to 0.1-0.5 mg/kg/hUrokinase 150 U/kg/h Increase infusion by 200 U/kg/h if no clinical effect


MONITORING AND DOSAGE ADJUSTMENT OF ENOXAPARIN BASED ON ANTI-FACTOR Xa LEVEL MEASURED 4 HOURSAFTER DOSE OF ENOXAPARIN

Anti-factor Xa Level (u/ml) Hold dose Dose change Repeat anti-Xa-level

<0.35 - +25% 4 h after next dose0.35-0.49 - +10% 4 h after next dose

0.5-1.0 - - 24 h1.1-1.5 - -20% Before next dose1.6-2.0 3 h -30% Before next dose, then 4h after next dose

>2.0 Until level is 0.5 u/ml -40% Before next dose; if level not <0.5 u/ml, repeat q12h

COMPARISON OF THROMBOLYTIC AGENTS

Streptokinase Urokinase TPA

Half-life (plasma) 18-30 min 12 min 4-5 minHalf-life (lytic effects) 82-184 min 61 min 46 minFibrin specificity Minimal Minimal ModerateAntigenicity Yes No NoLoad 2000 U/kg 4400 U/kgMaintenance 2000 U/kg/h 4400 U/kg/h 0.2-0.5 mg/kg/h*

* Adjust dose for preterm infants.

NORMAL ELECTROCARDIOGRAPHIC VALUES

Criteria Day 1 Day 30

Heart rate 119 ( 85 – 145 ) 163 (115 – 190 )P-R interval 0.10 (0.07 – 0.13 ) 0.09 (0.07 – 0.13 )P duration 0.051 (0.040 – 0.075) 0.048 (0.040 – 0.065)QRS duration 0.065 (0.05 – 0.09) 0.057 (0.04 – 0.08)P amplitude in II 1.5 (0.5 – 2.6 ) 1.6 (0.5 – 2.7)QRS axis 135 (160 – 180) 110 (0 – 180)T axis 70 (-20-80 ) 35 (-20-120 )T amplitude in V4 4.3(8.5)* 5.3 (8.5)*T amplitude in V6 2.4 (4.5)* 3.5 (7.5 )*R amplitude in V4R 8.6 (3.5 – 15.0 ) 6.3 (3.0 – 12.0 )R IN V1 11.9 (5.0 – 30.0 ) 11.1 (4.0 – 20.0)R in V5 9.4 (2.0 – 20.0 ) 15.0 (3.8 – 30.0)R in V6 5.4 (1.5 – 15.0) 10.8 (1.0 – 22.0)S in V4R 3.8 (0 – 12.0 ) 1.8(0 – 9.0 )S in V1 9.7(0 – 26.0) 6.1(0 – 15)S in V5 9.5 (5.0 – 22.0) 8.3 (0 – 30 )S in V6 5.6 (0.2 – 20.0) 4.8(0 – 18.0)

*Maximum value

FETAL ANTIARRYTHMIC AGENTS

Drug Arrythmia Dose in mothers Route Comments

Procainamide SVT,VT 100 mg bolus over 2 min; IV Therapeutic level 4 – 10 ng/ml. Fetal levels mayupto 25 mg/min to 1 g over PO exceed maternal.Rarely effective.GI side effectsfirst hour; Maintenance: often limit compliance.hypotension with IV.2 – 6 mg/min1g; then upto 500 mgq3h

Contd...


Contd...

Disopyramide SVT ,VT Loading dose 300 mg; then PO Therapeutic level 3 – 6 mg/ml; toxic >7mg/ml.100 – 200 mg q6h Hypotension, negative ionotropic agent. Limited

experience in fetus; side effects limit compliance;may worsen CHF; may stimulate uterine contrac-tions.

Flecainide SVT, VT 100 – 400 mg bid PO Therapeutic trough level <1 μg/ml. Nausea, nega-tive ionotropic effect, proarrythmia.Probably safewith structurally normal heart. Contraindicated withcardiac pump failure.

Propafenone SVT, VT 150 – 300 mg tid PO Therapeutic level 0.2 – 3.0 μg/ml.Increases digoxinlevel; prolongs QRS duration; negative ionotropiceffect;GI side effects common.

Propranolol SVT, VT 1 – 6 mg, slowly IV May prefer long acting and cardioselective40 – 160 mg q6h PO β blockers.Useful to suppress ectopy in fetuses with

recurrent SVT; may depress respirations or causehypoglycemia or bradycardia in neonate; possibleassociation with low birth weight.

Amiodarone SVT, VT 5 mg/kg over 20min; IV Therapeutic level 1.0 – 2.5 μg/ml. Drug of last500-1000 mg over 24hr. PO resort for fetal treatment. Side effects fetal or1200 – 1600 mg/d in 2 d/v maternal hypo/hyperthyroidism. Approximatelydoses for 7 – 14 days, then 20% of patients may excrete in milk for several400 – 800 mg qid for 1–3 wk; weeks. Can cause corneal deposits, photo-Maintenance: 200-400 mg/d. sensitivity, life-threatening pulmonary alveolitis,

hepatitis, myopathy, neuropathy.Sotalol SVT, VT 80 – 320 mg bid PO Limited fetal experience; should probably be con-

sidered for early inclusion in treatment protocol ifβ-blockade is not contraindicated.Sinus bradycar-dia, negative ionotropic, Av block, proarrythmiamore common in renal failure and also in females.

Verapamil SVT 5 – 10 mg over 30 – 60 sec IV Use of IV verapamil in neonates is contraindicated,80 – 160 mg tid PO use with caution in fetuses. Depresses sinoatrial

and atrioventricular node function; contraindicatedin sinus node dysfunction and with magnesiumsulfate.Interacts with β-blockers;may cause cardio-vascular collapse if given to immature heart withCHF and also with ventricular tachycardia.

Adenosine Reentrant SVT 100 – 200 mg/kg estimated IV May be useful as diagnostic test to identifyfetal weight as rapid bolus reentrant SVT; may break incessant SVT;does notinto umbilical vein prevent recurrent SVT.AV block, transient arryth-

mia after conversion .Digoxin SVT 1 mg d/v over 24hr to IV Therapeutic level 1 – 2 ng/ml. Contraindicated in

VT and WPW syndrome; may be poorly absorbedload only PO by hydropic fetuses;should have frequent ECG0.25 – 1.0 mg daily in monitoring for evidence of toxicity.Dose should be2 divided doses. adjusted downward in renal failure.

PHYSIOLOGIC BASIC OF TYPES OF APNEA

Type Airflow Respiratory effort Gas exchange Clinical

Mixed Intermittent Intermittent Impaired or absent Most commonCentral Absent Absent Absent CNS immaturityObstructive Absent Present, increased Absent Head neck postureAwake Absent Present Impaired Related to GE Reflux


CAUSES OF APNEA

Central Obstructive Mixed

• Prematurity Airway obstruction Combination of central and obstructive• Hypoxia, acidosis, e.g. asphyxia • Nasal• ICH • Neck flexion• Sepsis, meningitis • Tongue falling back• Drugs: narcotics anesthetic agents• Metabolic-hypoglycemia hypocalcemia,

electrolyte imbalance

BED SIDE EVALUATION OF APNEA

Event Threshold Physiologic basic Respond to

Apnea >10 seconds Central apnea StimulationBradycardia < 80 beats/ min Hypoxemia/ hypercapnia PositionCyanosis Mucosal/systemic Hypoxemia/ shunt OxygenDesaturation <85% saturation Hypoxemia Oxygen

CLINICAL INTERVENTIONS IN NEONATAL APNEA

Interventions Mode Basis

Tactile stimulation Gentle, non-cyclic and non painful Increase sensory feedbackProprioceptive stimulation Gentle rocking, water mattress, etc. Increase sensory feedbackHead – neck posture Support back of neck, prevent flexion Maintain patency of upper airwayRelationship to feed Slow gastric filling Prevent GE refluxPharmacotherapy Based on severity or frequency of event For >2 episodes in 8 hr or if resuscitation is needed.Low airflow with cannulae 0.5 to 1.0 liters/min via nasal cannulae Maintain FRC and chest wall stabilityNasal CPAP At 4 to 7 cm H2O Increase FRC, decrease upper airway resistance

PHARMACOTHERAPY FOR NEONATAL APNEA

Drug Loading dose Maintenance dose (mg/kg) Half-life (hr) Serum range Route(mg/kg) (mcg/ml)

Caffeine 10 2.5 ( 1 or 2 doses) - 60 10-20 Po/i.vTheophylline 5.5 to 7.0 2.5 to 8 (divided) -28 5.-15 PoAminophylline 6 to 8.0 2.0 to 6.0 (divided) -28 5-15 i.v

ANTENATAL DRUGS FOR SURFACTANT PRODUCTION

Betamethasone 12 mg q24h IM Total 2 dosesDexamethasone 6 mg q12h IM Total 4 dosesAmbroxal 1 g q24h IV Total 5 dosesTRH 400 mg q8h IV Total 4 dosesAminophylline 250 mg q12h IM Total 6 doses


OXYGEN DELIVERY DEVICES

Device Flow rate (L/min) FiO2(%)

• Nasal cannula 0.5 – 5 24 – 40• Nasopharyngeal cannula 3 – 6 32 – 44• Simple face mask 4 – 10 24 – 55• Face tent 10 – 15 35 – 40• Venturi mask 4 – 10 25 – 60• Partial rebreathing mask 10 – 12 60 – 80• Oxyhood 10 – 15 80 – 90• Non-rebreathing mask 10 – 12 90 – 100

SARNAT AND SARNAT STAGES OF HYPOXIC-ISCHEMIC ENCEPHALOPATHY

Stage Stage 1 (Mild) Stage 2 (Moderate) Stage 3 (Severe)

Level of consciousness Hyperalert; irritable Lethargic or obtunded Stuporous, comatoseNeuromuscular control: Uninhibited, overeactive Diminished spontaneous movement Diminished or absent spontaneous

movement Muscle tone Normal Mild hypotonia Flaccid Posture Mild distal flexion Strong distal flexion Intermittent decerebration Stretch reflexes Overactive Overactive, disinhibited Decreased or absent Segmental myoclonus Present or absent Present AbsentComplex reflexes: Normal Suppressed Absent Suck Weak Weak or absent Absent Moro Strong, low threshold Weak, incomplete high threshold Absent Oculovestibular Normal Overactive Weak or absent Tonic neck Slight Strong AbsentAutonomic function: Generalized sympathetic Generalized parasympathetic Both systems depressed Pupils Mydriasis Miosis Midposition, often unequal; poor light

reflex Respirations Spontaneous Spontaneous; occasional apnea Periodic; apnea Heart-rate Tachycardia Bradycardia Variable Bronchial and salivary Sparse Profuse Variable secretions Gastrointestinal Normal or decreased Increased diarrhoea Variable

motilitySeizures None Common focal or multifocal Uncommon (excluding decerebration)

(6 to 24 hours of age)Electroencephalographic Normal (awake) Early: Generalized low-voltage, Early: Periodic pattern withfindings slowing (continuous delta and theta) isopotential phases

Later: Periodic pattern (awake); Later: Totally isopotentialseizures focal or multifocal;1.0 to 1.5 Hz spike and wave

Duration of symptoms < 24 hours 2 to 14 days Hours to weeksOutcome About 100% normal 80% normal; abnormal if symptoms About 50% die; remainder with

more than 5 to 7 days severe sequelae

DOSE OF INTRAVENOUS INDOMETHACIN IN PREMATURE INFANTS WITH PATENT DUCTUS ARTERIOSUS

Age Dose (12-18 hour intervals)

Initial Second and third

< 48 hours 0.2 mg/kg 0.1 mg/kg2-7 days 0.2 mg/kg 0.2 mg/kg> 7 days 0.2 mg/kg 0.5 mg/kg

Dose of Ibuprofen in premature infants with patent ductus arteriosus:Loading dose of 10 mg/kg statMaintenance is with 5 mg/kg q12h for 2 doses

CHAPTER

9 Neonatal Ventilation

INITIAL VENTILATOR SETTINGS

Non-compliant stiff lungs Compliant normal lungs

Rate 60/min 40/minTi 0.4 sec 0.3 – 0.4 secPIP Increase from 18 cm H2O until adequate chest wall movement 14 cm H2OPEEP 4cm H2O 3 cm H2OFiO2 As required to maintain oxygenation As required to maintain oxygenation

EFFECT OF CHANGE IN VENTILATORY PARAMETERS ON THE BLOOD GAS

Desired status Rate PIP PEEP Ti FiO2

Increase PaCO2 ↓ ↓ − − −Decrease PaCO2 ↑ ↑ − − −Increase PaO2 - ↑ ↑ ↑ ↑Decrease paO2 - ↓ ↓ ↓ ↓

VENTILATOR MANIPULATIONS TO INCREASE OXYGENATION

Parameter Advantage Disadvantage

↑ FiO2 Minimizes barotraumas Fails to affect V/Q matchingEasily administered Direct toxicity, especially > 0.60

↑ Pi Critical opening pressure Barotrauma: air leak, BPImproves V/Q

↑ PEEP Maintains FRC/prevents collapse Shifts to stiffer compliance curveSplints obstructed airways Obstructs venous returnRegularizes respiration Increases expiratory work and CO2

Increases dead space

↑ Ti Increases MAP without increase Pi Necessitates slower rates, higher Pi“Critical opening time” Lower minute ventilation for given Pi-PEEP combination

↑ Flow Square wave-maximizes MAP Greater shear force, more barotraumasGreater resistance at greater flows

↑ Rate Increases MAP while using lower Pi Inadvertent PEEP with high rates or long-term constants

* All manipulations (except FiO2) result in higher mean airways pressure (MAP).

Neonatal Ventilation 65

VENTILATOR MANIPULATIONS TO INCREASE VENTILATION AND DECREASE PaCO2

Parameter Advantage Disadvantage

↑ Rate Easy to titrate Maintains same dead space/tidal volumeMinimizes barotrauma May lead to inadvertent PEEP

↑ Pi Better bulk flow (improved dead space/tidal volume) More barotraumasShifts to stiffer compliance curve

↓ PEEP Widens compression pressure Decreases MAPDecreases dead space Decreases oxygenation/alveolar collapseDecreases expiratory load Stops splinting obstructed/closed airwaysShifts to steeper compliance curve

↑ Flow Permits shorter Ti, longer Te More barotrauma↑ Te Allows longer time for passive expiration in face of Shortens Ti

prolonged time constant Decreases MAPDecreases oxygenation

MAP = mean airways pressure; ↑ = increase; ↓ = decrease; Ti = inspiratory time; Te = expiratory time; Pi = peak inspiratory pressure;PEEP = positive end-expiratory pressure; FiO2 = fractional concentration of inspired oxygen.

NEONATAL PULMONARY PHYSIOLOGY BY DISEASE STATE

Disease Compliance Resistance Time constant (s) FRC (ml/kg) V/Q matching Workml/cm H

2O cm H

2O/ml/s

Normal term 4–6 20–40 0.25 30 ml/kg ¾ ¾RDS ↓↓ ¾ ↓↓ ↓ ↓/↓↓ ↑Meconium aspiration ¾/↓ ↑/↑↑ ↑ ↑/↑↑ ↓↓ ↑BPD ↑/↓ ↑↑ ↑ ↑↑ ↓↓/↓ ↑↑Air leak ↓↓ ¾/↑ ¾/↑ ↑↑ ↓/↓↓ ↑↑VLBW apnea ↓ ¾ ↓↓ ¾/↓ ↓/¾ ¾/↑

↑ = increase; ↓=decrease; ¾ = little or no change; / = either / or

GUIDELINES FOR THE INITIAL VENTILATORY SETTINGS DISEASE WISE

PIP PEEP Rate I:E Ratio Ti FiO2

• Pulmonary interstitial emphysema 15-25 0-2 50-60 / min 1:2 to 1:3 - -• BPD 20-25 3-4 30-40 1:1.5 - -• MAS 25-35 cm H

2O 0-3 40-60 1:3 0.2 to 0.3 sec -

• Pneumonia 15-25 0-3 30-40 1:2 0.3 to 0.4 sec -• Rec Apnea 10-15 2-3 30-40 1:1 0.5 sec -• Interstitial pulm edema 40 4-6 30-40 1:1 0.5 -• Hypoplastic lungs Upto 20 - 60-80 - - 1• Post-op ventilatory support 15-20 4-6 20-30 1:1.5 - -

VENTILATORY CALCULATIONS

❖ AaDO2 =(760 × FiO2 – 47) – (PCO2/0.8)❖ Time constant = resistance × compliance❖ Resistance = 1/radius4

❖ Compliance = TV/(PIP - PEEP)> 80 Normal< 20 bad prognosis


❖Hypoxemia scoring = PaO2 FIO2

<200 ARDS<300 Acute Lung Injury (ALI)> 300 Normal(Approximately 1LO2 = FiO2 of 4)

❖ Oxygenation index = MAP × (FiO2/PaO2) × 100>40 is indication for ECMO

❖ Peak expiratory flow rate = (Height –100 ) × 5 +100❖ Ventilation index = (RR × PIP × PaCO2)/1000

> 90 for 4 hours is ominous.

NEONATAL INFANT PAIN SCALE (NIPS)

0 1 2 Score

Facial expression Relaxed muscles Tight facial muscles -Cry No cry Moaning Continuous cry -Breathing patterns Relaxed Change in breathing pattern -Arms Relaxed/restrained Flexed/extended (tense, rigid or rapid extension) -Legs Relaxed/restrained Flexed/extended (tense, rigid, or rapid extension) -State of arousal Sleeping/awake Fussy -

Toal score: -

BEHAVIOURAL PAIN SCORE FOR FULL-TERM INFANTS UNDERGOING INTERVENTIONS OR POSTOPERATIVE CARE

Behaviour 0 (Satisfactory) 1 (Mediocre) 2 (Poor) Score

Sleep (during preceding hour) Longer naps (>10 minutes) Short naps (5-10 minutes) None -Facial expression of pain Calm, relaxed Less marked, intermittent Marked, constant -Quality of cry No cry Modulated (distracted by Screaming, painful,

normal sound) high pitched -Spontaneous motor activity Normal Moderate agitation Thrashing, incessant -

agitationSpontaneous excitability and Quiet Excessive reactivity Tremulous, clonicresponsiveness to ambient (to any stimulation) movements,stimulation spontaneous -

Moro reflexesFlexion of fingers and toes Absent Less marked, intermittent Very pronounced, -

marked and constantSucking Normal for age Intermittent (three or four) Absent or disorganized

stops with crying sucking -Global evaluation of tone Normal for age Moderate tonicity Strong hypertonicity -Consolability Calm before 1 minute Quiet after 1 minute of effort None after 2 minutes -Sociability (eye contact), Easy and prolonged Difficult to obtain Absentresponse to voice, smile;real interest in face Total: -

CHAPTER

10 Reference Lab Values

REFERENCE LABORATORY VALUES

Conventional units SI units

• Acid Phosphatase 7.4 – 19.4 U/L 7.4 – 19.4 U/L• Alanine Amino Transferase (ALT)/(SGPT) 13 – 45 U/L 13 – 45 U/L• Alkaline Phosphatase 77 – 375 U/L 77 – 375 U/L• Alpha – 1 Antitrypsin 143 – 490 mg/ dl• Amino acid Neonates (Mean ± SD)Taurine 141± 40Hydroxyproline 32Aspartic acid 8 ± 4Threonine 217 ± 21Serine 163 ± 34Proline 183 ± 32Glutamic acid 52 ± 25Glycine 343 ± 69Alanine 329 ± 55Valine 136 ± 39Half cystine 62 ± 13Methionine 29 ± 8Isoleucine 39 ± 8Leucine 72 ± 17Tyrosine 69 ± 16Ornithine 91 ± 25Lysine 200 ± 46Histidine 77 ± 16Arginine 54 ± 17Tryptophan 32 ± 17β-alanine 14.5• Ammonia (Heparinized venous specimen on ice analyzed within 30 min)

Day 1 19 – 150 μg / dl 64 – 107 μmol/L> Day 1 79 – 129 μg/dl 59 – 92 μmol/L

• Amylase 5 – 65 U/L 5 – 65 U/L• Antinuclear Antibody (ANA) Not significant Likely significant

< 1:80 > 1:320Patterns with Clinical Correlation Centromere CREST syndrome

Nuclear SclerodermaHomogenous SLE

ARTERIAL BLOOD GAS

p H PaO2 (mmHg) PaCO2 (mmHg) HCO3 mEq/L BE

Day 1 - Preterm 7.26 - 7.29 52-67 39-56 22-23 -5 - -2.2- Term 7.31-7.37 62-86 32-39 18-21 -6 - -2

Day 5 7.34-7.42 62-92 32-41 19-23 -5.8 - -1.2Scalp pH in labour of 7.25 or above is normal


METABOLIC ACIDOSIS

Increased anion gap (>15mEq/L) Normal anion gap (<15 mEq/L)

Acute renal failure Renal bicarbonate lossInborn errors of metabolism Renal tubular acidosisLactic acidosis AcetazolamideLate metabolic acidosis Renal dysplasiaToxins (e.g. benzyl alcohol) Gastrointestinal bicarbonate loss

DiarrhoeaCholestyramineSmall-bowel drainageDilutional acidosisHyperalimentation acidosis

Asparate Amino Transferase (AST)/ Transaminase (SGOT) 25- 75 U/L 25 – 75 U/LAlanine Amino Transferase (ALT)/ Transaminase (SGPT) 25- 75 U/L 25 – 75 U/LBase Excess -4 - + 3 mEq/L -4 - +3 mmol/LBicarbonate 18 – 25 mEq/L 18 – 25 mmol/L

BILIRUBIN (TOTAL)

Cord Blood 0-1 day 1- 2 day 3 – 5 day Older infant

Preterm <2 mg/dl < 8 mg/dl <12mg/dl < 16 mg/dl < 2 mg/dl(< 34 mcmol/L) (<137 mcmol/L) (<205 mcmol/L ) (< 274 mcmol/L) (<34 mcmol/L)

Bilirubin (Conjugated) > 0.6 mg/dl < 34 mcmol/L

CALCIUM TOTAL

Preterm 6.2-11mg/dl 1.6 – 2.8 mmol/Lterm < 10 days 7.6 010.4 mg/dl 1.9 – 2.6 mmol/L> 10 days 9.0-11.0 mg/dl 2.3 – 2.8 mmol/LCalcium (Ionized)< 36 hours 4.20-5.48 mg/dl 1.0 – 1.3 mmol/L>36 hours 4.40-5.68 mg/dl 1.1 – 1.4 mmol/L

Ceruloplasmin 22 – 43 mg/dlChloride (serum) 98 – 113 mEq/L 98 – 113 mmol/lt

Chloride (Sweat) <50 mEq/L <50 mmol/LCholesterol 45 – 100 mg/dl –Cholinesterase 600 – 1500 U/LCortisol - 150 – 600 nmol/LComplement C3 77 – 99 mg/dl –Copper 9 – 46 μg/dl –Creatinekinase 10-200 U/L 10-200 U/L

CREATININE – mg /dL μμμμμmol / L (MICROMOL)

Age (day) <28 week 29-32 33-36 week > 37 week

7 0.95(1.31) 0.94(1.40) 0.77(1.25) 0.56(0.96)14 0.81(1.17) 0.78(1.14) 0.62(1.02) 0.43(0.65)28 0.66(0.94) 0.59(0.97) 0.40 (0.68) 0.34(0.54)

Reference Lab Values 69

Creatinine Phosphokinase

Day 1 upto 500 U/L Up to 500 U/L> Day 1 upto 440 U/L Up to 440 U/L

FerritinNewborn 25-200 ng/ml 20-200ng/ml1 month 200-600ng/ml 200 – 600 ng /mlFibronogen .9 - 5.0 g/LSplit products 10mg/LFree fatty acids .1 – 0.6 mmol/LFolic acid (serum)Serum 65 ng/ml 11-47 nmol/LRBC 50-200 ng/ml 340 – 453 nmol/LGalactose 20mg/dl

Gamma-glutamyltransferase (GGT)

Cord blood 19-270 U/L 19-270 U/LPreterm 56-233 U/L 56-233 U/LTerm< 3 weeks 0-130 U/L 0-130 U/L> 3 weeks 4 –120 U/L 4 –120 U/L

GlucosePreterm 20-60mg/dl 1.1-3.3 mmol/LTerm< 1 day 40-60 mg/dl 2.2 –3.3 mmol/L> 1 day 0-80 mg/dl 0.8-4.5 mmol/L

Growth hormoneCord blood 10 – 15 ng/ml Day1 0 – 40 ng/mlHaptoglobin - 48 mg/dl

ImmunoglobulinsIgA → none detectedIgG → 2.5 – 10.3 g/LIgM → 0.12 – 1.17g/L

Insulin (Fasting) 3-26 mU/LHyperinsulinism → Insulin > 10 mU/L when blood glucose <2mmol/L or glucose : insulin ratio <0.3

Iron 100 – 250 μg/dl 17.9 – 44.8 μ mol/LLactate < 27 mg/dL 0.0- 3.0 mmol/L

Lactate Dehydrogenase (LDH) (At 37° C)0-4 days 290–775 U/L 290 – 775 U/L4 –10 days 545–2000 U/L 545 – 2000 U/L>10 days 180–430 U/L 180 –430 U/LLipase 10–85 U/LMagnesium 1.7–2.5 mg/dl 0.7 -1.0 mmol/LOsmolality 275–300 mosm/kg 275 – 300 mmol/kg

Serum osmolality = S. Na × 2+ BUN (mg/dl) + Glucose2.8 18

(BUN molecular weight is 28, glucose molecular weight is 180)PhenylalaninePreterm 2.0-7.5 mg/dl 121-454 μ mol/LTerm 1.2 –3.4 mg/dl 73-206 mmol/LPhospholipids(total) 75 – 170 mg/dl

Phosphorus<10 days 4.5 –9.0 mg/dl 1.45-2.91 mmol/L>10 days 4.5 –6.7 mg /dl 1.45-2.16 mmol/L

Potassium 3.7 –5.9 mEq/L 3.7-5.9 mmol/L

Prealbumin 7-39 mg /dl


PROTEIN ELECTROPHORESIS (g / dL)

Age Total protein Albumin/ α1 globulin α2 globulin β globulin γ globulin

Cord blood 4.8 – 8.0 2.2 – 4.0 0.3-0.7 0.4-0.9 0.4-1.6 0.8-1.6Day 1 4.4 – 7.6 3.2 – 4.8 0.1-0.3 0.2-0.3 0.3-0.6 0.6-1.2> day 1 4.4.-7.6 2.5-5.5 0.1-0.3 0.3-1.0 0.2-1.1 0.4-1.3

Protoporphyrin 17 – 56 μg/dl 0.3 –1.0 μmol/LPyruvate 0.3 –0.9 mg/dl 0.03–0.1 mmol/LRenin activity 1–4 ng/ml/hr

SodiumPreterm 130–140 mEq/l 130–140 mmol/LTerm 133–146 mEq/l 133–146 mmol/LThyroid stimulating hormone (TSH)Birth 3 – 22 nmol/LDay 1 14 – 20 nmol/LDay 2 11 – 15nmol/LDay 14 <1 – 10nmol/LTriodothyronine (T3) 100 – 300 ng/dl 1.5 – 4.6 nmol/LThyroxine (T4) 6.5 –16.3 mg/dl 84 – 210 nmol/LFree T4Preterm 25 –27 wk 0.6 – 2.2 ng/dl

28 – 30 wk 0.6 – 3.4 ng/dl31 – 33 wk 1.0 – 3.8 ng/dl34 – 36 wk 1.2 – 4.4 ng/dl

Term 37 – 42 wk 2.0 – 5.3 ng/dlThyrotropinPreterm 25 – 27 wk 0.2 – 30.3 mU/L

28 – 30 wk 0.2 – 20.6 mU/L31 – 33 wk 0.7 – 27.9 mU/L34 – 36 1.2 – 21.6 mU/L

Term 37 – 42 wk 1.0 – 39 mU/L

Thyroxine Binding Globulin (TBG)1.0 – 4.5 mg/dl 160 – 750 nmol/L

Thyroglobulin 10 – 250 ng/ml 15 – 375 pmol/LTransferrin 130 – 275 mg/dl 1.30 – 2.75g /LTriglycerides (fasting)Cord blood 10 – 98mg/dl 0.10 – 0.98g/LUrea nitrogenPreterm 3 – 25 mg dl 1.1 – 8.9 mmol/LTerm 4 – 12 mg/dl 1.4 – 4.3 mmol/LUric acid 2.4 – 6.4 mg dl 0.14 – 0.38 mmol/LVitamin A (Retinol)Preterm 13 – 46 μg/dl 0.46 – 1.61 μmol/LTerm 18 – 50 μg/dl 0.63 – 1.75 μmol/LVit B1 (Thiamine) 5.3 – 7.9 μg/dl 0.16 – 0.23 μmol/LVit B2 (Riboflavin) 4 – 24 μg/dl 106 – 638 nmol/LVit B12 (Cobalamin) 160 – 1300 pg/μg 118 – 959 pmol/LVit C (Ascorbic acid) 0.4 – 1.5 mg/dl 23 – 85 μmol/LVitamin D – 28 – 165 nmol/LVitamin E 3 – 15mg/L 7.0 – 35 μmol/LZinc 70 – 120 μg/dl

NORMAL VALUES OF BLOOD FRACTIONS

Activated Partial Thromboplastin Time (APTT)

Preterm 35-100 secTerm 35-70 sec1 month 35-45 sec


BONE MARROW DIFFERENTIAL COUNTS; MEAN PERCENT CHANGES WITH AGE (RANGE)

1 week 1 month

Myeloblasts 0.3 (0 – 1) 1.2 (0.4 – 1.9)Promyelocytes 1 (0.5 – 1.5) 1.8 (1 – 2.5)Myelocytes 1.6 (0.6 – 2.4) 4.3 (2.5 – 7.2)Metamyelocytes 2 (0.7 – 3) 5.5 (3.1 – 9.1)Bands 19 (13 – 23) 22.9 (17 – 32)Segmented neutrophils 23.3 (9.6 – 39) 22 (8.7 – 30.2)Eosinophils 1.3 (1– 3) 2.9 (1.9 – 5.3)Basophils <0.1 (0-0.2) <0.1 (0 – 0.2)Pronormoblasts 1.6 (0.4 – 2.5) 0.8 (0.4 – 1.1)Normoblasts 37.8 (21 – 54) 19.1 (12 – 25)Lymphocytes 6.1 (3.7 – 8) 14.5 (9.5 – 19)Monocytes 5.3 (2 – 7.3) 5.2 (3–10)Plasma cells - 0.2 (0 – 0.2)M : E rato 1.24 2.91

Clotting time (CT) 37°C, glass tubes 5-8 minSilicon tubes about 30 min prolonged

COAGULATION FACTOR ASSAYS

Reference values for coagulation tests in healthy premature infants (30 to 36 weeks of gestation) during the first monthof life

Day 1 Day 5 Day 30Tests Mean Boundaries Mean Boundaries Mean Boundaries

PT (S) 13.0 (10.6 – 16.2) 12.5 (10.0 – 15.3) 11.8 (10.0 – 13.6)APTT (s) 53.6 (27.5 – 79.4) 50.5 (26.9 – 74.1) 44.7 (26.9 – 62.5)TCT (s) 24.8 (19.2 – 30.4) 24.1 (18.8 – 29.4) 24.4 (18.8 – 29.9)Fibrinogen (g/L) 2.43 (1.50 – 3.73) 2.80 (1.60 – 4.18) 2.54 (1.50 – 4.14)H (μ/ml) 0.45 (0.20 – 0.77) 0.57 (0.29 – 0.85) 0.57 (0.36 – 0.95)V (U/ml) 0.88 (0.41 – 1.44) 1.00 (0.46 – 1.54) 1.02 (0.48 – 1.56)VII (U/ml) 0.67 (0.21 – 1.13) 0.84 (0.30 – 1.38) 0.83 (0.21 – 1.45)VIII (U/ml) 1.11 (0.50 – 2.13) 1.15 (0.53 – 2.05) 1.11 (0.50 – 1.99)VWF (U/ml) 1.36 (0.78 – 2.10) 1.33 (0.72 – 2.19) 1.36 (0.66 – 2.16)IX (U/ml) 0.35 (0.19 – 0.65) 0.42 (0.14 – 0.74) 0.44 (0.13 – 0.80)X (U/ml) 0.41 (0.11 – 0.71) 0.51 (0.19 – 0.83) 0.56 (0.20 – 0.92)XI (U/ml) 0.30 (0.08 – 0.52) 0.41 (0.13 – 0.69) 0.43 (0.15 – 0.71)XII (U/ml) 0.38 (0.10 – 0.66) 0.39 (0.09 – 0.69) 0.43 (0.11 – 0.75)PK (U/ml) 0.33 (0.09 – 0.57) 0.45 (0.26 – 0.75) 0.59 (0.31 – 0.87)HMWK (U/ml) 0.49 (0.09 – 0.89) 0.62 (0.24 – 1.00) 0.64 (0.16 – 1.12)XIIIa(U/ml) 0.70 (0.32 – 1.08) 1.01 (0.57 – 1.45) 0.99 (0.51 – 1.47)XIIIb (U/ml) 0.81 (0.35 – 1.27) 1.10 (0.68 – 1.58) 1.07 (0.57 – 1.57)Plasminogen (U/ml) 1.70 (1.12 – 2.48) 1.91 (1.21 – 2.61) 1.81 (1.09 – 2.53)

PT = Prothrombin Time; APTT = Activated Partial Thromboplastine Time; TCT = Thrombin Clotting Time; vWF = von Willebrand Factor;HMWK = High Molecular Weight Kininogen; H = Biotin (S) = In seconds.


Reference values for coagulation inhibitors in healthy premature infants during the first month of life

Tests Day 1 Day 5 Day 30Mean Boundaries Mean Boundaries Mean Boundaries

AT – III (U/ml) 0.38 (0.14 – 0.62) 0.56 (0.30– 0.82) 0.59 (0.37 – 0.81)

α2M (U/ml) 1.10 (0.56 – 1.82) 1.25 (0.71 –1.77) 1.38 (0.72 – 2.04)

α2AP (U/ml) 0.78 (0.40 – 1.16) 0.81 (0.49– 1.13) 0.89 (0.55 – 1.23)

C1 INH (U/ml) 0.65 (0.31 – 0.99) 0.83 (0.45– 1.21) 0.74 (0.40 – 1.24)

α2AT (U/ml) 0.90 (0.36 – 1.44) 0.94 (0.42– 1.46) 0.76 (0.38 – 1.12)

HC II (U/ml) 0.32 (0.00 – 0.60) 0.34 (0.00– 0.69) 0.43 (0.15 – 0.71)

Protein C (U/ml) 0.28 (0.12 – 0.44) 0.31 (0.11– 0.51) 0.37 (0.15 – 0.59)

Protein S (U/ml) 0.26 (0.14 – 0.38) 0.37 (0.13– 0.61) 0.56 (0.22 – 0.90)

AT – III = Anti-thrombin III, α2AT = α2 Anti-trypsin, α2AP = α2 Anti-plasmin, α2M = α2 Macroglobulin, C1 INH = C1 Esterase Inhibitor,HC II = Heparin Cofactor II

Reference values for coagulation tests in the healthy full-term infant during the first month of life

Tests Day 1 Day 5 Day 30

PT (s) 13.0 ± 1.43 12.4 ± 1.46 11.8 ± 1.25

APTT (s) 42.9 ± 5.80 42.6 ± 8.62 40.4 ± 7.42

TCT (s) 23.5 ± 2.38 23.1 ± 3.07 24.3 ± 2.44

Fibrinogen (g/L) 2.83 ± 0.58 3.12 ± 0.75 2.70 ± 0.54

II (U/ml) 0.48 ± 0.11 0.63 ± 0.15 0.68 ± 0.17

V (U/ml) 0.72 ± 0.18 0.95 ± 0.25 0.98 ± 0.18

VII (U/ml) 0.66 ± 0.19 0.89 ± 0.27 0.90 ± 0.24

VIII (U/ml) 1.00 ± 0.39 0.88 ± 0.33 0.91 ± 0.33

vWF (U/ml) 1.53 ± 0.67 1.40 ± 0.57 1.28 ± 0.59

IX (U/ml) 0..53 ± 0.19 0.53 ± 0.19 0.51 ±0.15

X (U/ml) 0.40 ± 0.14 0.49 ± 0.15 0.59 ± 0.14

XI (U/ml) 0.38 ± 0.14 0.55 ± 0.16 0.53 ± 0.13

XII (U/ml) 0.53 ± 0.20 0.47 ± 0.18 0.49 ± 0.16

PK (U/ml) 0.37 ± 0.16 0.48 ± 0.14 0.57± 0.17

HMWK (U/ml) 0.54 ± 0.24 0.74 ± 0.28 0.77 ± 0.22

XIIIa (U/ml) 0.79 ± 0.26 0.94 ± 0.25 0.93 ± 0.27

XIIIb (U/ml) 0.76 ± 0.23 1.06 ± 0.37 1.11 ± 0.36

Plasminogen (CTA, U/ml) 1.95 ± 0.35 2.17 ± 0.38 1.98 ± 0.36

Reference values for the inhibition of coagulation in the healthy full-term infant during the first month of life

Tests Day 1 Day 5 Day 30

AT-III 0.63 ± 0.12 0.67 ± 0.13 0.78 ± 0.15

α2M 1.39 ± 0.22 1.48 ± 0.25 1.50 ± 0.22

α2AP 0.895 ± 0.15 1.00 ± 0.15 1.00 ± 0.12

C1INH 0.72 ± 0.18 0.90 ± 0.15 0.89 ± 0.21

α2AT 0.83 ± 0.22 0.89 ± 0.20 0.62 ± 0.13

HCII 0.43 ± 0.25 0.48 ± 0.24 0.47 ± 0.20

Protein C 0.35 ± 0.09 0.42 ± 0.11 0.43 ± 0.11

Protein S 0.36 ± 0.12 0.50 ± 0.14 0.63 ±0.15


APPROACH TO A BLEEDING NEONATE

PT APTT BT CT Platelet

Factor VIII IX, XI XII N ↑ ↑ N −/↑ NvWD N ↑↑/N ↑↑ - NVit K deficiency ↑↑ ↑↑ - - NFactor VII deficiency ↑↑ N - - -Factor XIII deficiency N N N - NITP, hypo/aplasia, leukaemia N N - - ↓↓HSP, CMV - - - - N (Petechiae)HUS ↑ ↑ - ↑ ↓

Mean hematologic values in preterm and term newborns

Determination Preterm Term28 wks 34 wks Cord Blood Day 1 Day 3 Day 7 Day 14

Hemoglobin (gm/dl) 14.5 15.0 16.8 18.4 17.8 17.0 16.8Hematocrit (%) 45.0 47.0 53.0 58.0 55.0 54.0 52.0Red blood cells (Cumm 106) 4.0 4.4 5.2 5.8 5.6 5.2 5.1MCV (u3) 120.0 118.0 107.0 108.0 99.0 98.0 96.0MCH (pg/cell) 40.0 38.0 34.0 35.0 33.0 32.5 31.5MCHC (%) 31.0 32.0 31.7 32.5 33.0 33.0 33.0Reticulocytes (%) 5-10 3-10 3-7 3-7 1-3 0-1 0-1Nuc. RBC’s - - 500.0 200.0 0.5 0 0

Hemoglobin F Mean (SD) % total Hb

Days1 day 77.07 (7.3)5 days 76.8 (5.8)3 wk 70.0 (7.3)6-9 wk 52.9 (11)Carboxyhemoglobin < 5% of totalMethemoglobin <2% of total

Hemoglobin Nadir in Babies in the first year of life

Maturity of Baby at Birth Hemoglobin Level at Nadir Time of Nadir

Term babies 9.5 – 11.0 6-12 wkPreterm (1200 – 2500 gm) 8.0 – 10.0 5 – 10 wkPreterm (<1200 gm) 6.5 – 9.0 4 – 8 wk

Erythrocyte sedimentation rate (ESR) 0-4 mm/hr

Kleihauer-Betke Test

Kleihauer-Betke test on the mother’s blood smear showing fetal pink cells are diagnostic of feto-maternal hemorrhage androutine examination of the placenta and umbilical cord should be mandatory before disposal, for all deliveries particularly of highrisk babies/deliveries. The amount of blood loss into the maternal circulation may be calculated by using following formula:

24000 × Fetal RBCCc of fetal blood =

MaterialRBC


THE LEUKOCYTE COUNT AND DIFFERENTIAL COUNT DURING THE FIRST TWO WEEKS OF LIFE (NUMBER /mm3)

Age Leukocytes Neutrophils Eosinophils Basophils Lymphocytes MonocytesTotal Segmented Band

Cord bloodMean 18,100 11,000 9400 1600 400 100 5500 1050Range 9,000-30,000 6,000-26,000 20-850 0-640 2,000-11,000 400-3,100

1 wkMean 12,200 5500 4700 830 500 50 5000 1100Range 5,000- 21000 1,500-10,000 70-1100 0-250 2,000-17,000 300-2700

2 wkMean 11,400 4500 3900 630 350 50 5500 1000Range 5,000-20,000 1,000-9500 70-1000 0-230 2,000-17,000 200-24001

NEUTROPHILIA VALUES PREDICTIVE OF NEONATAL BACTERIAL INFECTION

Parameter Diagnostic value per mm3 Postnatal age

Absolute neutrophil count <1800 and >5400 At birth< 7800 and >14400 12 hr< 7200 and >12600 24 hr< 5000 and > 9000 48 hr< 1800 and > 5400 > 72 hr

Immature(Band form): Total neutrophils ratio > 0.16 At birth> 0.13 60 hr> 0.12 5 days

Shift to left: Number of lobes of neutrophils are decreased (<3)1. Hemolytic anemias2. Acute infections – specially bacterial

Shift to right: Number of lobes are increased (>5)1. Megaloblastic anemia2. Polycythemia

VENOUS PLATELET COUNTS IN NORMAL LOW BIRTH WEIGHT INFANTS, RANGE (X 10,000)

Day Low birth weight Term

Cord blood 80-356 100-281-3 day 61- 335 80-320

1 wk 124 – 678 100-3002 wk 147 – 670 100-310

211

Post transfusion platelet count - Pretransfusion platelet countPlatelet transfusion efficacy = × BSA(m )

Platelets infused × 10

This is calculated at 1 hr and 24 hr after transfusion.

1 hr 24 hr

10,000 7,500 NormalNormal ↓ Consumption coagulopathy

↓ ↓ Immune destruction


Prothrombin time (PT)


Reptilase timePreterm 18-30 secTerm 18-24 sec1 month 18-22 sec

Serum iron and iron-binding capacity

Values of serum iron, total iron binding capacity, and transferrin saturation in infants during the first year of life

2 weeks 1 month

Serum ironμM/L 22 (11-36) 22 (10-31)μg/dl 120 (63 – 201) 125 (58 – 172)TIBCμM/L 34±8 36 ± 8μg/dl 191 ± 43 199 ± 43

Transferrin saturation % 68 (30-99) 63 (35 – 94)

Total iron binding capacity (TIBC)250-400μg/dl 45-72 μmol/L

Thrombin Time


NORMAL BLOOD CHEMISTRY VALUES, TERM NEONATES

Determination <1 wk >1wk

Sodium (mmol/L) 133 -146 134 - 144Potassium (mmol/L) 3.2 - 5.5 3.4 - 6.0Chloride (mmol/L) 96 - 111 96 - 110Calcium (mg/dl) 7.9 - 10.7 8.5 - 10.6Calcium (ionized) 3.9 - 6.0 -Phosphorus (mg/dl) 4.0 - 4.1 3.6 - 6.6Blood urea (mg/dl) 2 - 13 2 - 16Total protein (g/dl) 4.1 - 6.3 -Glucose (mg/dl) 55 - 115 -Lactate (mmol/L) 1.1 - 2.3 -

Normal blood chemistry values, low birth weight neonates, first day

Determination <1000g 1001-1500g 1501-2000g 2001 – 2500g

Sodium (mmol/L) 138 133 135 134Potassium (mmol/L) 6.4 6.0 5.4 5.6Chloride (mmol/L) 100 101 105 104Urea (mg/dl) 22 21 16 16Total protein (g/dl) 4.8 4.8 5.2 5.3


ANALYSES OF CEREBROSPINAL FLUID

Premature 0-25 mononuclear0-10 polymorphonuclear0-1000 RBC

Glucose >50% of blood glucoseProtein 50-400 mg/dl 0.5 - 4 g/ LTermDay 1 0-20 mononuclear

0-10 polymorphonuclear0-50 RBCGlucose > 44% of blood glucose

Proteins 40-100 mg/dl 0.4 – 1g/LDay 30 0-5 mononuclear

0-10 polymorphonuclear0-50 RBC

Glucose >44% of blood glucoseProtein < 40 mg /dl 0.05–0.4 g/L

URINARY BIOCHEMICAL VALUES

Determination 17-Ketosteroids 17-hydroxycorticoids Pregnanetriol

Adrenal steroids (mg/d)< 1 wk 2 – 2.5 0.05 – 0.3 0.01>1 wk 0.5 0.05 – 0.5 0.01

Determination Values

Electrolytes (depends on intake)Sodium (mmol/L) 18-60Potassium (mmol/L) 10-40Chloride (mmol/kg/d) 1.7 – 8.5Bicarbonate (mmol/L) 1.5 – 2Creatinine (mg/kg/d) Preterm 8.3 – 19.9 Term 10–15.5Calcium/Creatine Ratio <0.7Copper <19 mg/dayCoproporphyrin <195 mg/LGlucose (mg/L) 50Oxalate 54 mg/dayVMA (μg/mg creatinine) 5-19 (<1 mg/24hr)HVA (μg/mg creatinine) 3-16Protein TracePhosphate Index -0.2 - +0.04porphobilinogen 2 mg/LUroporphyrin 41.5 mg/LTitratable acidity Minus bicarbonate (mmol/minute/m2)Premature 0 – 12Term 0 – 11

Ammonia 1st day 0.02-0.50 mEq/kg/24 hr7th day 0.26-0.86 mEq/kg/24 hr

Calcium 1st day 0.1-0.3 mg/24hr7th day 1.8-3.4 mg/24 hr

Creatinine clearance 40-65 ml/min/1.73 m2

Galactose <60 mg/dlNitrogen 1st day 2-76 mg/kg/24hr

7th day 66-150 mg/kg/24hr


Osmolality at birth 79-118 mOsm/kg1st 24 hr 115-232 mOsm/kg>24 hr 150-250 mOsm/kg

(Max. 600 mOsm/kgpH 5.1-6.8Urea 0-2 days 39 mg/kg/24 hr

2-4 days 52 mg/kg/24 hr5-7 days 73 mg/kg/24 hr

HVA, homovanillic acid; VMA, Vanillylmandelic acid.

Indices to differentiate between pre-renal and intrinsic renal failure and SIADH

Pre-renal Renal SIADH

Ratio of urine/plasma concentrations:

• Urea >20 <10 >15

• Osmolality >1.3 <1.3 >2

• FeNa <1% (term) <3% Close to 1<5% (preterum)

• RFI <3 >3 >1

• Creatinine >20 <15 >30

Urine values:

• Sodium <40 >40 >40

• Specific gravity >1.015 <1.015 >1.020

• Osmolality >400 <400 >500

UNa × Pcr × 100* FeNa = ________________

PNa × Ucr

UNa × 100* RFI = _______________

Ucr × Pcr* FeNa = Fractional excretion of sodium RFI = Renal failure index

ANALYSES OF FECES

Constituents Meconium Neonatal stool

Amount 70 – 90 g 15 – 25g/day (breast milk fed)30 – 40 g/d (formula fed)

Bilirubin 25 – 102 mg/100g -

Bile acids, total 120 – 225 mg/day -

Iron 1.2 – 2.7 mg/100g -

Fat: • Total fat 0.16 – 0.38g/day <1g/ day (breast milk) • Neutral fat 0.3 – 1.3g/day • Fatty acids 0.4 0.14 – 0.97 g/day

Coefficient of fat absorption - > 93% (Breast milk)>83% (Formula)

Alpha 1 antitrypsin - <4.4mg/g (Breast milk)<2.9 mg/g(Formula)


AMNIOTIC FLUID ANALYSIS

Ab450 nm 28 wk 0-0.48 A 0-0.48 A40 wk 0-0.02 A 0-0.02 A

Bilirubin 28 wk<0.075 mg/dl <1.3 μmol/L40wk <0.025 mg/dl < 0.43 μmol/L

Creatinine After 37wk Gestation After 37 wk Gestation> 2.0 mg/dl > 180 μmol/L

Estriol (E3), free Wk ng/ml nmol/L

16-20 1.0-3.2 3.5 –11.120-24 2.1-7.8 7.3-27.124-28 2.1-7.8 7.3-27.128-32 4.0-13.6 13.9-47.232-36 3.6-15.5 12.5-53.836-38 4.6-18.0 16.0-62.538-40 5.4-19.8 18.7-68.7

Alpha fetoprotein(AFP) Wk mg/ml

15 13.5 ± 3.4216 11.7 ±3.3817 10.3 ± 3.0318 9.5 ± 3.2219 7.1 ± 2.8620 5.7 ± 2.45

Lecithin/sphingomyelin (L/S) ratio 2.0 – 5.0 indicates probable fetal lung maturity (> 3. 0 in infants of diabetic mothers).

L/S Ratio Lung maturity Risk of RDS (%)

<1.5 Immature lung 581.5-1.9 Transitional lung 172-2.5 Mature lung 11>2.5 Mature lung 0.5

Lecithin phosphorus >0.10 mg/dl indicates > 0.032 mmol/Lprobable adequate fetal indicateslung maturity probable

adequate fetallung maturity

Risk of RDS %

Saturated < 500 mg/dl Immature lung HighPhosphatedyl 500-1000 mg/dl Mature lung 7-10Cholin (SPC) > 1000 mg/dl Mature lung <5

Shake Test (done on gastric fluid/pharyngeal or tracheal aspirate/amniotic fluid). It is done before 1 hour of age. Add 0.5 ml of fluid to 0.5ml absolute alcohol and shake vigorously for 15 seconds in a 4 ml glass test tube and allowed to stand for 15 minutes.

Grade Interpretation Risk of RDS (%)

Immature No bubbles 601+ Very small bubbles in meniscus extending <1/3 of distance around test tube 202+ Single rim of bubble >1/3 of distance around test tube 1-19%3+ Single rim of bubbles present all round the test tube with a double row in some areas <1%4+ Double row or more of bubbles all around the test tube. Fully mature lung -

Phosphatidyl inositol (PI) Phosphatidyl glycerol (PG) Interpretation

++ - About to mature+ - Immature lung++ ++ Mature lung


L/S Ratio Phosphatidyl glycerol (PG) Risk of RDS %

Mature - 10Low - 93Presence of meconium and blood in amniotic fluid does not affect PG levels.

EXAMINATION OF SWEAT

Chloride Normal <40 mmol/LIndeterminate 45 - 60Cystic fibrosis >60

Sodium Normal <40 mmol/LIndeterminate 40 - 60Cystic fibrosis >60

EVALUATION OF TRANSUDATE VS EXUDATES (PLEURAL, PERICARDIAL, OR PERITONEAL FLUID)

Measurement Transudate Exudates

Specific gravity <1.016 >1.016Protein (g/dl) <3.0 >3.0

Fluid serum ratio <0.5 >0.5LDH (IU) <200 >200

Fluid serum ratio <0.6 >0.6WBC’s <1000/mm3 >1000/mm3

RBCs <10,000 VariableGlucose Same as serum Less than serum

pH 7.4 – 7.5 <7.4

LDH, Lactate dhydrogenase; RBCs, red blood cells; WBCs, white blood cells

NOTE

Amylase >5000 U/ml or pleural fluid: serum ratio > 1 suggests pancreatitis.

NOTE

• Always obtain serum for glucose, LDH, protein amylase, etc.• Not required to meet all of the following criteria to be considered as exudates.• In peritoneal fluid, WBC> 600/mm3 suggests peritonitis. Collect anaerobically in a heparinized syringe.

Infant and child mortality rates, (NFHS Survey)

Parameters Urban Rural Total

Neonatal Mortality 34.1 52.9 48.6Post – neonatal mortality 22 32. 29.9Infant mortality 56.1 85 78.5Child mortality 19.6 37.6 33.4Under – 5 mortality 74.6 119.4 109.3

Health indicators of India, (UNICEF 2000)

Parameters Year Declared Values

Under 5 Mortality rate (1998) 105Infant mortality rate (1998) 69Total population (Thousands) (1998) 982223Annual births (Thousands) (1998) 24671Crude birth rate (1998) 25

Contd...


Contd...

% Pregnant women received T.T (1990-98) 80% births attended by Health personnel (1990-99) 34% low birth weight (1990-97) 33Exclusively breastfed (0-3 months) (1990-99) 51%Breastfed withComplementary food ( 6-9 months) (1990-99) 31%Still breastfeeding (20–23 months) (1990-99) 67%

DETERMINING ENDOTRACHEAL TUBE SIZE

Infant weight (g) Gestational Tube diameter Size of suction Depth of placementage (wks) Inside Outside Catheter (tip to lip)

<1000 < 28 2.5mm 12 Fr 5 Fr 7 cm1000-2000 28 – 34 3mm 14 Fr 6.5 Fr 8 cm2000-3000 34 – 38 3.5mm 16 Fr 6.5 Fr 9 cm>3000 > 38 4mm 18 Fr 7 Fr 10 cm

Tube size = Gestational age in wks / 10

Definition of perinatal asphyxia (AAP - ACOG 1992)

1. Profound metabolic/ mixed academia; umbilical cord arterial blood pH < 7.02. Presistence of an Apgar score of 0 - 3 for > 5 min3. Neurological sequelae in the immediate neonatal period: Seizures, hypotonia, coma or hypoxic-ischemic encephalopathy

(HIE).4. Multiple Organ Dysfunction Syndrome (MODS) in the immediate neonatal period.

Normal blood gas values in term newborns

Maternal artery 10 min Umbilical vein 30-60 min Umbilical artery 5 hr

PO2 95 27.5 16 50 54 74PCO2 32 39 49 46 38 35PH 7.4 7.32 7.24 7.21 7.29 7.34

INTRAPARTUM MONITORING FETUS

1. Fetal HR Monitoring - Tachycardia > 160 bpm;- Bradycardia < 120 bpm

2. Fetal Scalp PH (Scalp pH in labour of 7.25 or above is considered normal)3. Non-stress test and acoustic stimulation test

Criteria for interpreting Non-Stress Test (NST) and Acoustic Stimulation Test (AST)

Reactivity terms Criteria

Reactive NST Two fetal heart rate (FHR) accelerations of atleast 15 bpm, lasting a total of 15 sec in 10 min period.Non-reactive NST No 10 min window containing two acceptable (as defined by reactive NST) acceleration for

maximum of 40 minReactive AST Two FHR accelerations of atleast 15 bpm, lasting a total of 15 sec, within 5 min after application of

acoustic stimulus or one acceleration of at least 15 bpm above baseline lasting 120 sec.Non-reactive AST After three applications of acoustic stimulation at 5min intervals, no acceptable accelerations (as defined

by reactive AST) for 5min after third stimulus

4. Biophysical profile scoring


Fetal variable Normal (Score = 2) Abnormal (Score = 0)

Fetal HR • > 2 accelerations • <2 episodes of accelerations• >15 beats/min • Accelerations <15 beats /minutes• Lasting for > 15 seconds • In 20 minutes• Associated with fetal movements• In 20 minutes

Fetal breathing movements • 1 episode of 30 seconds in 30 minutes • Absent or no episodeFetal Tone Demonstration of Either

• Active extension /flexion • Slow extension /partial flexion• Brisk repositioning/trunk rotation • Moverment of limb or full extension• Opening and closing of Hand, mouth • Absent fetal movements• Kicking

Gross body movements • 3 discrete body movements in 30 minutes • < 2 episodes of body movements in30 minutes

Amniotic fluid volume evaluation • 1 packet of fluid measures 1 cm in • Either no packet or <1 cm in two2 perpendicular planes perpendicular planes

Interpretation

Total score Impression Action

10 Normal fetus • Repeat once/wk• Twice /wk in high risk pregnancy

8 Normal fetus with low risk of chronic asphyxia • Same as above• If with oligohydramnios immediate

delivery if fetus is mature6 Fetus with chronic asphyxia • Repeat every 4 – 6 hours

• If with oligohydramnios immediatedelivery

4 Definate asphyxia • Delivery immediately if lecithin/sphingomyelin ratio is >2

• Repeat after 24 hours and if score isbelow 4 deliver immediately

2 Profound asphyxia • Watch for 120 minutes and if noimprovement deliver immediately

• Score improving < 4 deliver irrespectiveof lung maturity

5. Cardiotocography (Fetal HR)• Early deceleration → Head compression• Variable deceleration → Cord compression, acute haemorrhage• Late Deceleration → contraction induced hypoxia

6. Umbilical flow velocity (Doppler) → Shows decreased /absent /reversal of blood flow

APGAR SCORE

Sign Score0 1 2

A Appearance (colour) Blue, pale Body pink, extremities blue Completely pinkP Pulse (HR) Absent <100 >100G Grimace (reflex, irritability to suctioning) No response Grimace Cough/sneezeA Activity (muscle tone) Limp Some flexion Well flexedR Respiration (breathing efforts) Absent Weak, irregular Strong cryScore = 8-10 No Asphyxia

5-7 Mild Asphyxia3-4 Moderate Asphyxia0-2 Severe Asphyxia


GLASGOW COMA SCALE

❖ Eye opening (Total points 4)

Spontaneous 4To voice 3To pain 2None 1

❖❖❖❖❖ Best verbal response (Total points 5)Older Children Infants and young childrenFully oriented 5 Appropriate words/smile/fix and followConfused 4 Consolable cryingInappropriate 3 persistingly irritableIn comprehensible 2 Restless/agitatedNone 1 None

❖ Best motor response (Total points 6)

Obeys 6Localizes pain 5Withdraws 4Flexion (decorticate) 3Extension (decerebrate) 2None 1

❖ 15 best

13-15 mild injury9 –12 moderate injury< 8 severe injury

❖ Silverman-Anderson retraction score

Score Upper chest Lower chest Xiphoid retraction Nasal flare Grunt

0 Synchronous None None None None1 Lag on inspiration Just visible Just visible Minimal Audible with stethoscope2 See saw respiration Marked Marked Marked Audible to nacked ear

❖ Downe’s score

Score RR Cyanosis Air entry Retractions Grunt

0 < 60 None Good None None1 60-80 In room air Mildly decreased Mild Audible with Stethoscope2 > 80 apnoea In 40% O2 Markedly decreased Moderate- severe Audible without stethoscope

❖ ABG score

0 1 2 3

PaO2 > 60 50-60 <50 <50PH >7.3 7.2-7.29 7.19 <7.1PaCO2 <50 50-60 61-70 >70


CRIB (CLINICAL RISK INDEX FOR BABIES) SCORE

Factor Score

Birth weight (g)1351-1500 0851-1350 1701-850 4<700 7

Gestation (wk)>24 0<24 1

Congenital malformations*None 0

Not acutely life-threatening 1Acutely life-threatening 3Maximum base excess in first 12hr (mmol/l)

< -7.0 0-7.0 to – 9.9 1-10.0 to – 14.9 2< -15.0 3

Minimum appropriate FiO2 in first 12 hr< 0.40 00.41-0.60 20.61-0.90 30.91-1.00 4

Maximum appropriate FiO2 in first 12 hr< 0.40 00.41-0.80 10.81-0.90 30.91-1.00 5

* Excluding babies with lethal congenital malformation.CRIB score of 0-5 5% mortality

6-10 35% mortality11-15 70% mortality>16 >80% mortality

SCORE FOR NEONATAL ACUTE PHYSIOLOGY (SNAP)

Parameter 1-Point Range 3-Point Range 5-Point Range

• Blood pressureHigh 66-68 81-100 >100Low 30-35 20-29 <20

• Heart RateHigh 180-200 201-250 >250Low 80-90 40-79 <40

• Respiratory Rate 60-100 >100 —-• Temperature, °F 95-96 92-94.9 <92• PO2 mm Hg 50-65 30-50 <30• PO2/Fio2 ratio 2.5-3.5 0.3-2.49 <0.3• PCO2 mm Hg 50-65 66-90 >90• Oxygenation index 0.07-0.20 0.21-0.40 >0.40• Hematocrit, %

High 66-70 >70 —Low 30-35 20-29 <20

• White blood cell count (x 1000) 2.0-5.0 <2.0 —-• Immature total ratio >0.21 —- —-• Absolute neutrophil count 500-999 <500 —-• Platelet count (x1000) 30-100 0-29 —-

Contd...


Contd...

• Blood urea nitrogen, mg/dl 40-80 >80 —-• Creatinine, mg/dl 1.2-2.4 2.5-4.0 >4.0• Urine output, ml/kg/h 0.5-0.9 0.1-0.49 <0.1• Indirect bilirubin (by birth weight)

> 2 kg: /dl 15-20 >20 —-< 2 kg: mg/dl/kg 5-10 >10 —-

• Direct bilirubin, mg/dl <2.0 —- —-• Sodium, mEq/L

High 150-160 161-180 —Low 120-130 <120 —-

• Potassium, mEq/LHigh 6.6-7.5 7.6-9.0 —-Low 2.0-2.9 <2.0 —-

• Calcium (ionized), mg/dlHigh ≥1.4 —- —-Low 0.8-1.0 <0.8 —-

• Calcium (total), mg/dlHigh ≥12 —- —-Low 5.0-6.9 <5.0 —-

• Glucose (or reagent strip), mg/dlHigh 150-250 >250 —-Low 30-40 <30 —-

• Serum bicarbonate, mEq/LHigh ≥33 —- —-Low 11-15 < 10 —-

• Serum pH 7.20-7.34 7.10-7.19 <7.10• Seizures Single Multiple —-• Apnea Responsive to stimulation Unresponsive to stimulation Complete apnea• Stool guaiac Positive —- —-

Urine metabolic screening

❖ Benedicts test – Galactosemia, hereditary fructose intolerance.❖ Cyanide Nitroprusside test – Cysteine, homocysteine❖ Cetrimide – MPS❖ DNPH (α keto acid) test – MSUD, GSD, Hyperglycinemia❖ Ferric chloride test – PKU (green) Histidine (olive) MSUD (brown) Tyrosinemia (quick fade green)❖ Nitrosonaphthal test– Tyrosinosis.❖ Silver nitroprusside test – Homocysteine

PRIMITIVE REFLEXES

1. Spinal cord level reflexes: (appears by birth and disappears by 2 wk)Flexor withdrawal reflexExtensor thrust reflexCrossed extensor reflex

2. Brainstem level reflexes: (appears by 2 wk and disappears by 6 months)Asymmetric tonic neck reflexSymmetric tonic neck reflexTonic labyrinthine reflexPositive supporting reflexNegative supporting reflex

3. Mid brain level reflexes: (appears by 4 months and disappears by 2 years)Neck righting reflexLabrynthine righting reflexOptical righting reflex

4. Cortical level reflexes: (appears by 2 yr and remains lifelong) These are all balancing reflexes.5. Automatic movement reaction:

Moro reflex (appears by birth and disappears by 3 months)


Parachute reflex (appears by 9 months and remains lifelong)Landau reflex (appears by 3 months and disappears by 2 yr)

6. Other reflexes: Stepping reflex (birth – 6 wk) Placing reflex ( birth – 6 wk) Palmar grasp (birth – 6 m) Plantar grasp (birth – 10 m) Sucking and rooting (birth – 4 m (awake)

– 7 m (aspleep)Glabellar tapSnouting reflexPalmomental reflex

BLOOD VOLUME

Estimated blood volumes

Age Plasma volume (ml/kg) Erythrocyte mass (ml/kg) Total blood volume (ml/kg)From plasma volume From erythrocyte mass

Cord blood 41.3 43.1 82.1 86.11-7d 46(51-54) 37.9 78(82-86) 77.8

Blood volume = (Patients wt in kg) × (90 cc/kg)

Elective Blood Transfusion

1. Packed cell volume (ml) = weight (kg) × 4 × desired rise in Hb (g/dl)OR

desired PCV – observed PCVVolume = wt (kg) × blood volume × ________________________________

PCV of blood to be transfused

Maximum tranfusion 10 ml/kg over a period of 3 - 4 hours2. Whole blood volume (ml) = weight (kg) × 6 × desired rise in Hb (g/dl)3. Volume of partial exchange

blood volume × desired rise in Hb=

22 - (Hb initial + Hb desired)

2

IV fluid requirement of LBW neonates ml/kg/day

Day <1000 gm (5% dextrose ) 1000-1499 gm (10% dextrose ) ≥ 1500 gm (10% dextrose)

1 100 90 802 110 100 903* 120 110 1004 125-150 120 1105 125-150 125-150 125-150

* Add electrolytes form day 3

Factors affecting water loss (IWL) in preterm infants

Increase IWL (%) Decreases IWL (%)

Severe prematurity (100-300) Humidification in incubator (50-100)Open warmer bed (50-100) Plastic heatshield (30-50)Phototherapy (30-50) Ventilation with humidified air (20-30)Tachypnoea (20-30)


Fluid requirement changes in different conditions

Conditions Fluid requirement changes

Phototherapy + 20-40 ml/kg/dRadiant warmer + 20-30 ml/kg/dHigh ambient temperature + 10-20 ml/kg/dHyperthermia + 10-20 ml/kg/dIncrease activity + 10-15 ml/kg/dIntubation ventilation - 10-15 ml/kg/dDouble walled incubators - 10-15 ml/kg/dHumidity (40%) - 15-20 ml/kg/dHeat shield polythene sheets - 15-20 ml/kg/dPlastic blanket - 15-20 ml/kg/dSkin coverings - 15-20 ml/kg/d

Electrolyte requirements in newborn (mEq/kg/day)

Term PretermDays Na K Cl (mEq/kg/day) Na K Cl (mEq/kg/day)

1 - - - - - -2 3 3 3 2 3 23 3 3 3 2 3 24 to 7 3 3 3 4-8 5 37 to 15 3 3 3 4-8 5 3

COMMONLY USED INTRAVENOUS SOLUTIONS COMPOSITION PER LITRE

Solution Dextrose (g) Na+ K+ Ca++ Mg++ Cl– HCO3– HPO4

– Lactate Acetate Calories MOsmmEq

5% Dextrose 50 - - - - - - - - - 200 26610% Dextrose 100 - - - - - - - - - 400 532Normal saline (0.9% NaCl) - 154 0 0 0 154 - - - - - 2925% Dextrose in Normal Saline 50 154 - - - 154 - - - - 200 5585% Dextrose in 0.2% NaCl 50 33 0 0 0 33 0 0 0 0 200 350Ringer’s Lactate - 130 4 3 - 109 - - 28 - - 261Ringer’s Lactate with 5% Dextrose 50 130 4 3 - 109 - - 28 - 200 530Lactate K Saline (Darrow) - 121 35 - - 103 - - 53 - 17 310Isolyte P (Pediatric Maintenance 50 25 20 - 3 22 - 3 - 23 200 350with Dextrose)3% NaCl - 513 - - - 513 - - - - - 10265% NaCl - 855 - - - 855 - - - - - 1710

OSMOLALITY OF FLUID

Fluid Osm/kg H-20

• 5% Dextrose 300• 10% Dextrose 615• N/5 in 5% Dextrose 350• NaHCO3 (7.5%) 1700• Breast milk 300• 10% Dextrose + NaHCO3 (1:1) 1000• 15% Dextrose 850• 20% Dextrose 1400


CLINICAL CORRELATION OF JAUNDICE IN SKIN AND LEVELS OF SERUM BILIRUBIN

Jaundice S. Bilirubin mg/dl

Only face 5Upto umbilicus 10Upto knee 12Upto ankle 15Foot > 15

APPROACH TO INDIRECT HYPERBILIRUBINEMIA IN HEALTHY TERM INFANTS WITHOUT HEMOLYSIS

Age (hr) Consider Phototherapy Exchange Phototherapyphototherapy transfusion if and exchange transfusion

phototherapy fails

24-48 12 15 20 > 25 49-72 15 18 25 > 30> 72 17 20 25 > 30

> 2 wk - ** ** **

** Jaundice suddenly appearing in the 2nd week of life or continuing beyond the 2nd week of life with significant hyperbilirubinemia levelsto warrant therapy should be investigated in details, as it most probably is due to a serious underlying etiology such as biliary atresia,galactosemia, hypothyroidism or neonatal hepatitis.

SUGGESTED MAXIMUM INDIRECT SERUM BILIRUBIN CONCENTRATIONS (mg/dL) IN PRETERM INFANTS

Birth weight (g) Phototherapy Exchange transfusion

< 1000 12-13 10-121000 – 1499 7-9 12-151500 – 1999 10-12 15-182000-2500 >13 18-20

Exchange transfusion

Choice of blood for exchange tranfusion1. In ABO incompatibility : Use O Positive blood. Ideal is to have O Positive cells suspended in AB plasma.2. In Rh isoimmunization: Emergency O Negative blood. Ideal is O Negative cells suspended in AB plasma.3. Other conditions: Baby’s blood group.

Total volume for exchange transfusion

Calculated using the formula 2 × blood volume + 50 ml

Wt Blood volume<1 kg 100 ml/kg1-2 kg 90 ml/kg>2 kg 80 ml/kg

Aliquots used in exchange tranfusion

Wt Aliquot (ml)

<850 g 1-3850g – 1 kg 5

1-2 kg 102-3 kg 15>3 kg 20


PHOTOTHERAPY TABLE

Birth weight is plotted against infant’s age in days. If the serum indirect bilirubin (mg/dl) is greater than the plotted number, considerphototherapy.

DaysBirth wt. (gm)

1 2 3 4 5 6 7

<1000 3 3 3 5 5 7 71000-1249 5 5 5 7-8 8 10 121250-1499 8 8 8 10 12 13 131500-1749 10 10 10 12 12 13 131750-1999 10 10 12 13 13 13 132000-2499 10 12 12 15 15 15 15>2500 10 12 13 15 17 17 17

EXCHANGE TRANSFUSION TABLE

DaysBirth wt. (gm)

1 2 3 4 5 6 7

<1000 8 8 8 10 10 10 101000-1249 10 10 10 10 10 15 151250-1499 12 12 12 15 15 15 151500-1749 15 15 15 15 15 15 161750-1999 15 15 15 16 16 17 172000-2499 18 18 18 18 18 18 18>2500 20 20 20 20 20 20 20

Early indications for exchange blood transfusion in infants with Rh-hemolytic disease of the newborn

1. Cord hemoglobin of 10 g/dl or less2. Cord bilirubin of 5 mg/dl or more3. Unconjugated serum bilirubin of 10 mg/dl within 24 hours or 15 mg/dl within 48 hours or rate of rise of >0.5 mg/dl per

hour

THERMONEUTRAL ENVIRONMENT

Weight (g) 0-6hr 6-12hr 12-24hr 24-36hr 36-48hr 48-72hr

<1200 350 C 35 34 34 34 341200-1500 34.1 34 33.8 33.6 33.5 33.51501-2500 33.4 33.1 32.8 32.6 32.5 32.3

>2500 32.9 32.8 32.4 32.1 31.9 31.7

TRANSPORT

Transport Team Equipment

Transport incubator equipped with monitors for heart rate, vascular pressures, oxygen saturation, temperatureSuction deviceInfusion pumpsGel-filled mattress


Adaptors to plug into both hospital and vehicle powerAirway equipmentAnesthesia bag with manometerLaryngoscopes with no. 0 and no. 1 bladesMagill forcepsInstrument tray for chest tubes and vascular cathetersStethoscopeTanks of oxygen and compressed air oxygen, compressed air, heat, light and a source of electrical power.The carrier must be ready to depart within 30 min.

Supplies used by Transport Teams

Airways Kelly clampAlcohol swabs Lubricating ointmentArmboards Monitor leads and transducersBatteries Needles: 18,20, 26 gaugeBenzoin Oxygen tubingBetadine swabs Replogle nasogastric tubeBlood culture bottles Scalpel blades, no. 11Blood pressure cuff Sterile gownButterfly needles: 23 and 25 gauge StopcocksChest tubes: 10 and 12F, and connectors StylusChemstrip Suction catheters: 6,8 and 10 F and trapsClipboard with transport data forms, permission forms, Suture material (silk 3-0, 4-0, on curved needle)progress notes, and booklet for parentsCulture tubes Syringes: 1, 3, 10, 50 mlEndotracheal tubes: 2.5, 3.0, 3.5, 4.0 mm TapeFace mask, term and premature T-connectorsFeeding tubes: 5 and BF ThermometerGauze pads Tubes for blood specimensGloves, sterile and exam Umbilical catheters: 3.5 and 5 F (double lumen)Heimlich valves Urine collection bagsIntravenous tubing Xeroform gauzeIntravenous catheters: 22 and 24 gauge

Medications used on Transport

Albumin 5% GentamicinAmpicillin HeparinAtropine IsoproterenolCalcium LidocaineCalcium gluconate MidazolanDexamethasone MorphineDextrose 50% in water NaloxoneDextrose 10% in water Normal salineDiphenylhydantoin PancuroniumDigoxin PhenobarbitalDobutamine Potassium chlorideDopamine Prostaglandin E1 (on ice)Epinephrine Sodium bicarbonateErythromycin eye ointment Sterile waterFentanyl Vitamin K1




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Index

A

Agents that can safely be administeredin therapeutic doses toglucose-6-phosphate dehydro-genase deficient patients 41

Agents to be avoided in glucose-6-phosphate dehydrogenasedeficient patients 41

Amniotic fluid analysis 78Analyses of cerebrospinal fluid 76Analyses of feces 77Antenatal drugs for surfactant

production 62Antibiotic guidelines in neonatal

infection 14Antihypertensive agents for the

newborn 58Antimicrobial agents 1

dosages and intervals of administra-tion 1

organisms generally susceptible tocephalosporins 13

organisms generally susceptible topenicillins 11

Antimicrobials requiring adjustment inrenal failure 47

Apgar score 81Approach to a bleeding neonate 73

hemoglobin F mean (SD)% total Hb73

hemoglobin Nadir in babies in thefirst year of life 73

Kleihauer-Betke test 73mean hematologic values in preterm

and term newborns 73Approach to indirect hyperbilirubi-

naemia in healthy term infantswithout hemolysis 87

Arterial blood gas 67Average daily nutritional requirements

52

B

Bed side evaluation of apnea 62Behavioural pain score for full-term

infants undergoing interven-tions or postoperative care 66

Bilirubin (total) 68Blood pressure for weight percentiles

93Blood volume 85

elective blood transfusion 85electrolyte requirements in newborn

86estimated blood volumes 85factors affecting water loss (IWL) in

preterm infants 85fluid requirement changes in

different conditions 86IV fluid requirement of LBW

neonates 85Bone marrow differential counts; mean

percent changes with age(range) 71

C

Calcium total 68Causes of apnea 62Clinical correlation of jaundice in skin

and levels of serum bilirubin87

Clinical interventions in neonatal apnea62

Coagulation factor assays 71reference values for coagulation

inhibitors in healthy prema-ture infants during the firstmonth of life 72

reference values for coagulation testsin healthy premature infants(30 to 36 weeks of gestation)during the first month of life71

reference values for coagulation testsin the healthy full-term infantduring the first month of life72

reference values for the inhibition ofcoagulation in the healthy full-term infant during the firstmonth of life 72

Cofactor/limiting amino acid therapy54

Commercial formulas and foods 55composition of human milk,

standard infant formulas, andsome specialized formulas 55

formulas for metabolic disorders 55formulas free of lactose and or cow’s

milk protein and special milkbased (casien-hydrolysate)formulas 56

formulas with altered fat, protein,and carbohydrates 56

Commercial vitamin preparations 32Commonly used intravenous solutions

composition per litre 86Comparison of thrombolytic agents 60Composition of various milks 52Concentration and duration of few

infusions 40Congestive heart failure 51Creatinine 68Creatinine phosphokinase 69Crib (clinical risk index for babies)

score 83

D

Determining endotracheal tube size 80Dose of intravenous indomethacin in

premature infants with patentductus arteriosus 63

Drug formulary 18Drug loss during exchange transfusion

40


Drugs in breastfeeding 42Drugs requiring no adjustment 50Drugs that cause significant displace-

ment of bilirubin fromalbumin in vitro 51

Drugs to be used with special precau-tion in breastfeeding womenor drugs contraindicated 42

Drugs used in resuscitation 33

E

Effect of change in ventilatory para-meters on the blood gas 64

Evaluation of transudate vs exudates79

Examination of sweat 79Exchange transfusion table 88

early indications for exchange bloodtransfusion in infants with Rh-hemolytic disease of thenewborn 88

F

Fetal antiarrhythmic agents 60First line antibiotics 16

G

Gamma-glutamyltransferase 69Glasgow coma scale 82

ABG score 82best motor response (total points 6)

82best verbal response (total points 5)

82Downe’s score 82eye opening (total points 4) 82Silverman-Anderson retraction score

82Guidelines for the initial ventilatory

settings disease-wise 65Guidelines for the modes of providing

fluids and feeding 53

H

Health indicators of India (UNICEF2000) 79

I

Indices to differentiate between pre-renal and intrinsic renal failureand SIADH 77

Infant and child mortality rates (NFHSsurvey) 79

Initial dosing of enoxaprin, age-dependent 59

Initial ventilator settings 64Inotropic and vasoactive agents

commonly used in shock 35Intrapartum monitoring fetus 80

interpretation 81Intubation sedation guidelines 34Iron supplementation guidelines in the

premature infant 54

L

Leukocyte count and differential countduring the first two weeks oflife 74

Local site-directed thrombolytictherapy 59

M

Metabolic acidosis 68Monitoring and dosage adjustment of

enoxaparin based on anti-factor Xa level measured 4hours after dose of enoxaparin60

N

Neonatal infant pain scale 66Neonatal pulmonary physiology by

disease state 65Neonatal ventilation 64Neutrophilia values predictive of

neonatal bacterial infection 74Non-antimicrobials requiring adjust-

ment in renal failure 49Normal blood chemistry values, term

neonates 75normal blood chemistry values, low

birth weight neonates, firstday 75

Normal blood gas values in termnewborns 80

Normal electrocardiographic values 60Normal longitudinal blood pressure in

full-term infants 58Normal values of blood fractions 70Nutritional needs of low birth weight

infants 52

O

Oral dietary supplements available foruse in infants 54

Osmolality of fluid 86Oxygen delivery devices 63Oxygen dissociation curve 94

P

Passage of antibiotics across theplacenta 45

Pathological states 46gastrointestinal diseases 46kidney disease 47liver disease 47

Peak and trough levels of antibacterialagents 39

Pharmacokinetics 46Pharmacotherapy for neonatal

apnea 62Phototherapy guidelines for neonatal

hyperbilirubinemia 92Phototherapy table 88Physiologic basic types of apnea 61Primitive reflexes 84Protamine dosage to reverse heparin

therapy 59Protein electrophoresis 70Prothrombin time 75

R

Recommended daily allowances ofvitamins and minerals 53

Reference laboratory values 67Risk estimation of icterus 91

S

Safe medicine 39

Index 99

Sarnat and sarnat stages of hypoxic-ischemic encephalopathy 63

Score for neonatal acute physiology(snap) 83

Septic risk scoring 15Serum iron and iron-binding capacity

75Significance of blood culture isolates 14Some important metabolic conditions

55Special nutrition 52Specific antibiotic therapy in early-

onset neonatal septicemia 15Specific antibiotic therapy in late-onset

neonatal septicemia 15Specific therapeutics 58Standard IV infusion routinely

prepared 36Standard TPN regimen 57Suggested antibiotic regiments for

sepsis and meningitis 15Suggested intakes of parenteral

vitamins in infants 57

Suggested maximum indirect serumbilirubin concentrationsin preterm infants 87

aliquots used in exchangetransfusion 87

calculated using the formula 2 ×blood volume + 50 ml 87

exchange transfusion 87Systemic thrombolytic therapy 59

T

Teratogenicity 44Therapeutic range of various drugs 39Thermoneutral environment 88Thrombin time 75Thrombolytic therapy 59Thyroid disease 51Time table for elective surgical

repair 58Transport 88

medications used on transport 89

supplies used by transport teams 89transport team equipment 88

Treatment guideline in icterus 95Tube feeding guidelines 53

U

Urinary biochemical values 76Urine metabolic screening 84

V

Venous platelet counts in normal lowbirth weight infants, range(X 10,000) 74

Ventilator manipulations to increaseoxygenation 64

Ventilator manipulations to increaseventilation and decreasePaCO2 65

Ventilatory calculations 65Viral infection therapy 17

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Drug Formulary Neonatal 2006

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