NICU

Evernote :
Merck Manual Newborn
Exutero1.wordpress.com
muscKids survival guide
Stanford
Nutrition Feeds ; Newborn Nursery
U of Chicago
Peds Nutrition Feeds
UCSF
Nutrition
Neonatal Survival Guide

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#. Assessment of Newborn
#. Sepsis r/o
#. Bilirubin
#. Hypoglycemia
#. DM Newborn
#. Drug Moms

#. Newborn Education

#. Growth
#. Nutrition / Feeds
#. Supplements
#. TPN
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Newborn Exam

• Fractures:
> proximal humerus: tape/wrap immobilize to body and will heal in 12d. Can f/u outpt w/ ortho but not really necessary.
> clavicular:
> femur:
> distal bones are all BAD and should not happen.
• Spine dimpling : spine US if concerned.
> red flags: multiple, reach bone / can’t see the bottom.
> safe if: single, can see the bottom, does not “stick” (as in stuck to bone when try to move it), and if distal to end of coccyx
• Red reflex:
• Murmurs


Sepsis r/o

• Indicated for: maternal chorio, extended ROM, neonatal depression / delayed transition
• Protocol:
> Bcx, CBC, amp + gent x48 hr
> amp / gent dosing:
• Immature (bands + metamyelocytes + myelocytes)/Total (segs + immature) ratio: ANC:bands -
> if <0.16 = wnl;
> if >0.2: red flag!
• Fever: >38.0C / 100.4F
• CBC: wnl WBC 10-35,000.
• Abx 2nd line: vanc + cefotaxime

Normal Values:  WBC:  10,000 to 35,000  Immature to Total neutrophil ratio (I:T): < 0.16  [Immature cells (bands + metamyelocytes + myelocytes) divided by the total neutrophil  count (segmented neutrophils + immature cells) ] Absolute Neutrophil count: >1,500  (Total neutrophil count percent x WBCs) Platelets: 150,000 to 500,000  Hematocrit: Critical Values WBC < 5,000  I:T ratio > or = 0.2  Absolute neutrophil count (ANC) < 1,500  Platelets <150,000  Hct >65, <40  Blood Culture:  Any positive blood culture is a critical value that must be notified to a physician  immediately

Hypoglycemia:
• Glucose should be >45 by 12hrs.
• If glucose <40 and symptomatic ==> start IV glucose.

• If asymptomatic:
• Birth-4hrs – feed in 1st hr and check 30min after, if <25 then feed and check in 1 hr then if < 25 give IV glucose and if 25-40 then refeed and repeat
•4-24hrs – feed q2-3hrs, screen before each feed and if < 35 then feed and check in 1 hr then if < 35 give IV glucose and if 35-45refeed and repeat
• At 24hrs if >45 stop screening
• Glucose is 200mg/kg push (2cc of D10w)/kg. --> check in 10m
• Maintenance 8mg/kg/min

• Glucose Infusion Rate = GIR = mg/kg/min = [
IV Rate (mL/hr) * Dextrose Conc (g/dL) * 1000 (mg/g)]/[Weight (kg) * 60 (min/hr) * 100 (mL/dL)]
> where the dextrose concentration is expressed as a whole number, e.g. 5 or 10.
> A GIR of 5-8 mg/kg/min is typical. Infants who are not feeding should not be allowed a rate less than 5 mg/kg/min for any significant period of time. The GIR needed to optimize nutrition in neonates is 14 mg/kg/min.

Glucose monitoring guideline

DM Newborn:

• Anomalies:


Drugs / Substance
CHOP Pathway for Neonatal Abstinence Syndrome
• Concern about concurrent: Meth / Opiates / Cocaine / Benzos / Etoh

• NAS scores begin at 2hrs life. 30-60 min after each feed (?or before feeds) - every 3-4 hrs.
• NAS 24 Rule : 3 consecutive scores averaging >8 or 2 consecutive average >12.
• <24: if short half-life substance (obs 72hr); if long (obs 5-7d; earlier if good f/u and home).
• >24: Rx: if opiate - morphine, clonidine. If non-opiate or unknown - phenobarb (??).
• Morphine dose: 0.02mg/kg/24 hrs = ~0.05mg/kg q3hr dose.

• Weaning rx (if NAS <9): decrease morphine dose by 10% of stabilizing dose each subsequent day. Allow 24-48 hr between morphine weans. DC morphine totally when tolerated dose of 0.12-0.16 mg/kg/d (0.02 mg/kg/dose) for 24-48 hrs.

  • After discontinuing morphine, continue to perform NAS scoring q3-4 hours with feeds. If NAS score is greater than 8, recheck in 2 hrs. If NAS score is still greater than 8, give a "rescue dose" of morphine. The dose given should be equal to the most recently discontinued dose. If infant needs several "rescue doses", consider resuming prior morphine schedule.
  • Q: can mom on methadone breast feed? YES.
  • Q: what are sx of newborn NAS? sneezy dwarf (rhinorrhea, yawns, diarrhea, n/v, tremors/jittery, crying).
  • Q: Narcan to newborn NAS? NO. cause seizures.
  • Q: when does withdrawal happen? Depends on agent - heroine 1-2 days; methadone 4 days.
  • Q: what % of newborns w/ opiate moms need rx? 1/2 - 2/3.


Bilirubin:

• If <35 weeks
> bilitool no longer applies.
> Rule of thumb for PTx / transfusion therapy is 1% x BW kg = transfusion threshold; 1/2 that value = PTx threshold.
• Term: bilitools.
• High risk:
> Intravascular lysis: ABO incompatibility / Coombs
> Excess blood being hemolyzed: hematoma, brusing
• Kernicterus:
• DDx:
• pathologic vs physiologic? physiologic (after 4d, <20mg/dl, rare kernicterus, resolves early) vs pathologic (day 1-2, >20mg/dl, common kernicterus, late resolution)
• Breastfeeding jaundice: insufficient feeding => insufficient BM to carry away bilirubin
• Breastmilk jaundice: something in breast milk inhibit biliuribin breakdown, peak day 6-14
• Hemolytic: intrinsic (elliptocytes, spherocytes, G6PD deficiency, Pyruvate kinase deficient, alpha-thal, SCD) vs extrinsic (ABO incompatible / Coombs+, Rh, anti-Kell, anti-Rhc)
• Non-hemolytic: cephalohematoma, polycythemia, UTI/sepsis, hypothyroid, Gilbers, Crigler-Najjar)
• When to evaluate for pathologic?


Bhutani Nomogram
F3.large


PTx
phototxnomogram

Transfusion

Growth
• Gain should be 20-30 g/day; length ~1 cm / week and head circumference 0.5cm / wk
• Caloric intake should be >80-100 kcal/kg/d and protein 3 g/kg/d to get growth (and prevent catabolism!).

Nursery Feeds
• Milk should be in day 3 or 4
• Neonate should feed at least 8x/24hrs
• Should NOT sleep through the night (“good baby” bad?)
• Breastfed babies should have at least 6 wet diapers / day and 4 yellow seedy stools/day.
• After 4 wks of life, stooling may become 1x/day or less.
• Wt loss expected until day of life 5; regain BW at day 14 of life.
• Wt loss >8% worrisome, >10-12% need dehydration / serum Na evaluation!
• Caloric requirement for infant: (120kcal/kg) x (median wt for current ht/current wt)
• Protein for catch is up 3g/kg/day - up to 5g/kg/day.

• Newborn: 1.5-3oz q2-3hrs
• 2mo: 4-5 oz q3-4hrs.
• 4mo: 4-6 oz each feed
• 6mo: 6-8oz every 4-5 hrs.



GBS in Newborn
> <37 and GBS+
> GBS inadequate tx + if >37 wks (48hr obs, ---

CDC:
Screen Shot 2016-10-30 at 9.29.04 AM


Nursery Feeds

NICU Nutrition/Feeds


• Newborn nutrition components (requirements): fluids + calories + glucose + lipids + protein.
• Have to account for each of those components separately.

#. Fluids
• Fluid goal should be 150 cc/kg/day.
• Caloric goal should be 120 kcal/kg/day if pre-term; 110 kcal/kg/day if term.
• Breastfeeding takes 3 days to come-down; baby comes with excess fluids at birth (bag of NS!) to tide over until milk let-down. Average output for first 1-2 days is 15cc/kg/d only (and thats ok).

• When ready to start PO feeding, in terms of fluids:
> If healthy & happy, ok to feed adlib (w/ some minimums).
> If <2kg, begin 5cc each feed and increase by 20cc/kg/day.
> If >2kg, begin 10cc each feed and increase by 30cc/kg/day

#. Calories
• Calories come from protein, glucose, and lipids.
> cals = (lipids 1gm = 9 kcal) + (protein 1g = 4 kcal) + (dextrose 1g = 4kcal)
> note that functional caloric calculations should not include protein since it should be set aside for anabolism.
> To calculate IVF D10 to calories: x% dextrose)(x volume/kg/day)(0.034) .
- ex.
For a 3 kg patient who received 300 cc of D12: 100 cc * 12 % * 0.034 = 40.8 kg/kg/day from glucose. 
>  % dextrose = x g of dextrose in 100cc.

#. Protein:
• Management of protein primarily in TPN setting.

#. Lipids
• Management of lipids primarily in TPN setting.
• Goal is to titrate up to 3g/kg of lipid
• Rate of lipid = (X gm/kg) • pt wt kg = target X gm in 1 day
> X gm • 5 ml/gm = X ml needed per day
> X ml needed / 24hrs = X ml / hr for the next 24hrs.

#. Glucose
• Glucose management primarily in hypoglycemic, maternal DM, requiring IVF D10W.
• Goal: typically is 5-8 mg/kg/min - titrate to blood glucose if DM.
• Glucose Infusion Rate = GIR = mg/kg/min = [
IV Rate (mL/hr) * Dextrose Conc (g/dL) * 1000 (mg/g)]/[Weight (kg) * 60 (min/hr) * 100 (mL/dL)]
> where the dextrose concentration is expressed as a whole number, e.g. 5 or 10.
> Infants who are not feeding should not be allowed a rate less than 5 mg/kg/min for any significant period of time. The GIR needed to optimize nutrition in neonates is 14 mg/kg/min.


#. Supplements
• Breast-fed: Possible deficient Vit B12 in breastmilk of vegetarian mothers.
• Formula-fed: First 6 mo don’t need anything. After 4 mo, get Fe supplement from fortified foods
• D-Vi-Sol: for full term; 1cc qday
• Pre-term: Poly-Vi-Sol w/ Fe: 1cc PO qday. 50cc bottle. Indications: all pre-term babies (have greater need).
• Vit K: 1x IM 0.5-1mg. minimize post-natal decline of K-dependent coag factors (2,7,9,10). PPx vs hemorrhagic dz of newborn.
• Vit D:
• Vit E:
• Iron:
> pre-term: 2mg/kg/d for 12 mo of life.
> Term: 0-6 mo 0.27 mg/d. Exclusively / partially breastfed need PO Fe supplement at 4 mo until PO food Fe ok. > Formula fed - first 12 mo formula has enough Fe. At 6-12 mo, PO Fe should be 11mg/day.

TPN / NG
• Call St. Joes Phoenix NICU - get their TPN order template for details.
• TPN begins with starter TPN “vanilla” (D10 base) and on day 2 goes to nl TPN.
• Starter TPN = D10W + (D10W+protein).
> D10W + protein rate = 2.3 cc/kg/hr. The rest of the hourly TF make it up in D10W.
• TPN or NPO fluid feeds at 80cc/kg/day (TF) on DOL#1 and increase 20cc/kg/day until hit 150cc/kg/day.
• If on TPN: get labs NICU panel: (CMP, Mg,

, TG), H/H, retic count (if >34 wks)
• TPN to transition to enteral feeds ASAP.
• Begin NG (nasal garage) feeds at 5-10cc q3-4hrs and increase daily by 20-30cc/kg/day.
• Pre-term babies at risk of NEC - bloody stool, abdomen distension, fever, emesis. Due to stomach not being ready yet (matures in later 3rd trimester).


Calculating Calories Provided by Nutrition
Formula feeds
1.   Calculate total intake (e.g. ml’s per hour x 24). This gives you total mLs.
2.   Divide total intake by 30 mL’s per ounce. This gives you total ounces in.
3.   Multiply total ounces in by number of calories per ounce. Infant formulas are usually 20 kcal/oz, but these are often fortified to 22, 24, or 30 kcal/oz. This gives you total calories per day.
4.   Divide by weight in kg. This gives you kcal/kg/day.
Example:
4.5 kg infant receiving 28 ml/hr of 24 kcal/oz Similac by ND tube.
28 ml/hr x 24 hrs / 30 ml/oz x 24 kcal/oz / 4.5 kg = 120 kcal/kg/day
Nutrition Requirement: kilocalories per day depending on weight.













AgeRequirement
kcal/lb/daykcal/kg/day
< 6 mo50–55110–120
1 yr4595–100
15 yr2044
 
Ex. 6 mo old at 15 kg (or 30 lbs) needs how many kcal per day?
15kg x 110 = 1650 kcal per day
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Needed:
(____kcal per day) / (____kcal per oz formula) =  number of oz needed for 1 day. 



Feeds: 0-2 mo: From PediatricPartnersKC.com
Your baby needs only breast milk or iron-fortified infant formula for the first 4 to 6 months of life. Most formula-fed babies will eat every 2 to 4 hours and breastfed babies every 2 to 3 hours. For a discussion of how to decide what type of milk to feed your baby, read How to Choose What to Feed.
Breast Milk or Infant Formula
0-1 month 18-24 oz in 24 hours
1-2 month 22-28 oz in 24 hours
2-3 month 25-32 oz in 24 hours
3-4 month 28-36 oz in 24 hours
Intake may also vary depending on the weight of the infant. Bigger babies will eat more.

Feeding Tips:

  • Your baby is likely getting enough to eat if he is having 6 to 8 wet diapers per day.
  • Breastfed babies may need to eat more often than formula-fed babies. This is normal. Breast milk is digested faster and babies will become hungry earlier than if they were formula fed.
  • Babies need only breast milk or formula for the first 4 months of life. Avoid giving your infant juice or food (including cereal) until 4 months of age (unless your doctor recommends it).
  • Do not add cereal to the bottle, unless recommended by your doctor. It does not make babies sleep longer.
  • Avoid putting your baby to bed with a bottle of formula. This may lead to tooth decay and ear infections.
  • Hold your baby upright when feeding. Lying a baby flat to drink a bottle may cause choking or ear infections.
  • Do not force your baby to finish a bottle. When your baby gets full, he will turn his head and push the nipple out of his mouth or fall asleep.
  • In addition to being hungry, your baby may cry because he is bored or lonely, or needs a diaper change.
  • Hold your baby close to you and cuddle him as you feed him.
  • Look at your baby and let him look at you while he eats.
  • Gently try to burp your baby mid-feeding and at the end of each feeding.
  • There is no need to sterilize bottles before use. Wash with warm, soapy water, and rinse well.
  • Use cold tap water or baby bottled water to make formula, then heat later in warm water, not the microwave. Warm tap water has more minerals in it, so is not ideal to drink.
  • The American Academy of Pediatrics recommends all primarily breast fed infants begin iron and vitamin D supplement. Vitamins for infants are available in your pharmacy in the vitamin section.
  • Vitamin D is not in breast milk. Every 8.3 ounces of formula has 100 IU. It is recommended for infants under 1 year to have 400 IU per day. If your infant has less than 33 ounces of formula per day a supplement is recommended. Skin can make it if exposed to sunlight, but no one knows how much is ideal and the risk of too much sun is great. Read more on our Vitamin D page.
  • Iron is in breast milk and term babies are born with iron stores in the liver to last 4-6 months, but many babies are deficient when tested. Because iron deficiency can cause growth and developmental problems, prevention is worth the effort.

Feeds >2 mo: ?


Shock
• Fluids: 10cc/kg bolus; NS or 1/2NS, may add albumin
• Pressors: dopamine
• Note that if intubated, high PEEP may cause form of cardiac tamponade.

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NICU Cheat-sheet: Reese

Calorie (TotalFluids*cal/30)/wt. goal 120 for premees

Bm - 20cal

Formulas – Neosure 22, SSC 24, Enfamil, Pregestimil, Alimentum, Neocate, Elecare, Human Fortified Breastmilk

Hep B vaccine at 2kg or more

Phototherapy

GA <28 weeks – TB >5 (86 GA 28 to 29 weeks – TB 6 to 8 (103 to 137 GA 30 to 31 weeks – TB 8 to 10 (137 to 171 GA 32 to 33 weeks – TB 10 to 12 (171 to 205 GA >34 weeks – TB 12 to 14 (205 to 239

Exchange Transfusion

GA <28 weeks – TB 11 to 14 (188 to 239 GA 28 to 29 weeks – TB 12 to 14 (205 to 239 GA 30 to 31 weeks – TB 13 to 16 (222 to 274 GA 32 to 33 weeks – TB 15 to 18 (257 to 308 GA >34 weeks – TB 17 to 19 (291 to 325

Infxn: give abx to all preterm w/ signs/sx for 48hrs until cx neg

First Line: Ampicillin 50 mg/kg per dose or 100 mg/kg per dose for meningitis (frequency either q8 or q12 based on PMA and DOL)

Gentamicin 4 mg/kg, 4.5 mg/kg , 5 mg/kg per dose based on PMA and DOL (frequency either q24 or q36 or q48 based on PMA and DOL)

NEC Tx: npo, ngt, tpn, abx, serial kub, --> sx only for serious cases


NICU panel:
• blood gas (A,V,C), electrolytes, hemoglobin, bilirubin, iCa+2, gluose. It may also include a lactate for the cardiac babies, septic

Surfactant if indicated and prophylactically for all < 29wks

Surfactant – Survanta 4ml/kg in aliquots, Infasurf 3 ml/kg in 2 aliquots, Curosurf 2.5 ml/kg in 2 aliquots. Survanta < 700g, Curosurf > 700g, Infasurf if unresponsive to 2 doses of other 2 meds


Retinopathy - screening dilation <1500g or <31w -- tx photocoag

IVH - screening US in <1500g or <32w -- all supportive tx

Norm breast feeding day one. 15ml/kg is norm baby has edema for few days that is the wt loss. Full breast milk comes in 3days.

Resp myths.

1. tachypnea sating well do NOT give O2
2. pneumo do not over O2 saturate it does not reabsorb
3. rescusitation: use room air for term, blended for premie
4. pulm htn need only to be pink, not 100% o2


If infant needs resp help. Start at NC --> cpap --> if req >60% --> intubate + surfactant.

Vol on vent = 4-5ml/kg