Drug Formulary Neonatal 2006

Neonatal Drug
Formulary
Neonatal Drug
Formulary
Santosh T Soans
MBBS MD DCH
Professor and Head, Department of Paediatrics

AJ Institute of Medical Sciences
Mangalore
Murali Keshava Sarpangala
MBBS DNB (Paediatrics)
Registrar
AJ Institute of Medical Sciences
Mangalore
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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 of
material, but the publisher, printer and authors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition: 2006
ISBN 81-8061-845-5
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, Sector 60, Noida
PREFACE
Neonatology has progressed in leaps and bounds in the last three decades. Major advances have been
made in the treatment of various neonatal disorders. A number of highly beneficial new drugs have
been developed and it is important that authentic information regarding the proper administration of
these 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 the
department 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 dosages and side effects. We have also covered standard IV infusion, safe medications in lactation along
with 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 Soans
Murali Keshava Sarpangala
ACKNOWLEDGEMENTS
Bringing out a well researched book like this is never an easy task and many people have helped in their
own ways and made it possible for this book to see the light of day. I hereby wish to acknowledge a few
of 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, Mahesh
Nayak.
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
CHAPTER
Antimicrobial Agents
Dosages (mg/kg/day) and Intervals of Administration
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Body Weight >2000g

Age 0-7 days >7 days
Comments
Acyclovir
(zovirax,
ocuvir)
250 mg,
500 mg
vial
IV
10 mg/kg q8h for 10-14 days

Dilution to 5 mg/ml, infuse 8h
over 1 hour
5 mg/kg q8h
Amikacin
(mikacin)
(50 mg/ml
2 ml vial)
IM, IV
<28 wk
28-34 wk
>34 wk
7.5 mg/kg q24h

<28 wk
7.5 mg/kg q18h
28-34 wk
7.5 mg/kg q12h
>34 wk
IV infusion over 30 minutes
Amoxicillin P O
(mox)
IV, IM
(250 mg,
500 ml
vials)
50 mg/kg
q12 h
50 mg/kg
50 mg/kg 50 mg/kg
q8h
q12h
q8h
Increase dose to 100 mg/kg in
suspected meningitis
SE: rash, diarrhoea. It exerts

bactericidal by virtue of its
ability to inhibit synthesis of
the bacterial cell wall. Susceptible pathogens include
and -hemolytic streptococci, strep pneumoniae,
strep faecalis, Bacillus anthrasis, Clostridium spp except C.
difficile, some non-Betalactamase staphylococci, B.
Pertusis, Haemophillus, E.coli,
Proteus, Salmonella, Shigella,
Treponema, Pseudomonas.
Amoxyclav PO, IV
(augmentin)
40 mg/kg/day q8h
(Amoxycillin
6.7 mg/kg q8h
Inhibits production of lactamases. Many lactamase producing strains
Prophylactic dose:
7.5 mg/kg q18h

7.5 mg/kg q12h
7.5 mg/kg q8h
40 mg/kg/day q8h
(Amoxycillin
13.3 mg/kg q8h
Adverse reactions noted:

Transient renal dysfunction
and thrombophlebitis. Increase dosing interval q24 h
when renal functions < 25%
of normal. Oral absorption
not tested in neonates.
Ototoxicity, nephrotoxicity,
neuromuscular blockade,
BM suppression, eosinophilia and tremor. Synergestic action with diuretics.
Therapeutic range: 20-30
mg/L (peak) and <8 mg/L
(trough) CSF penetration is
poor, even in meningitis. Preferred in serious infections of
gram-negative bacilli. Susceptible pathogens include
Pseudomonas, E.coli, Proteus,
Klebsiella, Serratia, Staphylococcus. It exerts bactericidal
action by inhibiting protein
synthesis.
Contd...
Contd...
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Body Weight >2000g

Clavulinic acid
1.7 mg/kg q8h)
Amphotericin IV
B (fungizone)
Polyene antifungal
(50 mg/vial)
Ampicillin
(roscillin)
Azlocillin
IV, IM
Meningitis
Other
disease
PO
IV
Aztreonam IV, IM
(Azenam)
Clavulinic acid
3.3 mg/kg q8h)
0.5-1.0 mg/kg/O.D with maximum of 1.0 mg/kg/day for 4-6 weeks

(total dose of 25-40mg)
NOTE:
(a) Dilute in D5W or D10W only.
(b) Minimum dilution is 0.1mg/ml.
(c) Infuse over 2-6 hours.
(d) Start with 0.25 mg/kg/day increase dose by 0.25 mg/kg/day.
(e) Reconstituted preparations should be protected from light.
(f) The first 0.1 mg of the first dose will be considered as test dose.
(g) Total dose should not exceed 20-30mg/kg
50 mg/kg q12h 50 mg/kg q8h

50 mg/kg q8h
25 mg/kg q8h
50 mg/kg q6h
25 mg/kg q6h
62.5 mg/kg/dose q6h
Comments
of staph aureus and coagulase negative Staphylococcus
species are made sensitive.
Adverse reactions: hypotension, thrombophlebitis, renal
dysfunction (hypokalemia,
azotemia, RTA, hematologic
(anemia, thrombocytopenia,
granulocytopenia) Monitor
closely hematologic and renal
status (CBC, platelet count,
serum BUN, creatinine, electrolytes). Reduce dosage or
interrupt therapy or alternate
day therapy when renal function falls to <20% of normal.
Adverse effects appear to be
less common in neonates.
Fever, chills, nausea and vomiting are common side effects,
may premedicate with acetaminophen and diphenhydramine 30min before and 4
hrs after infusion.
At high doses SE are same as
penicillin. May cause interstitial nephritis, hemolytic anaemia and pseudo-membranous colitis. More active than
penicillin against Listeria Monocytogenes, E.coli, Proteus,
Salmonella. CSF penetration is
slightly better than penicillin
G.
Must not be mixed in same

syringe or infusion with
aminoglycosides.
30 mg/kg q8h
-lactum antibiotic, active

against gram-negative enteric
bacilli including pseudomonas aeruginosa. SE: Thrombophlebitis, eosinophilia; leukopenia, neutropenia, thrombocytopenia, increase liver
enzymes, hypotension, seizures. If creatinine clearance
is between 10-30 ml/min, the
dose should be halved after
giving an initial loading dose.
In severe reveal failure or on
dialysis should recieve the
standard loading dose, followed by of the loading dose
at standard dose interval. It
interacts with penicillinbinding
30 mg/kg q6h
Contd...
Contd...
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Body Weight >2000g

Comments
proteins of susceptible microorganisms and induces the formation of long filaments bacterial structures lending to lysis of
the bacterial cell.
Carbenicillin IV, IM
75 mg/kg
q12h
75 mg/kg
q8h
75 mg/kg
q8h
75 mg/kg
q6h
It has additive inhibition of

platelet function and hence may
increase the risk of haemorrhage.
May produce hypokalemia. Do
not mix with genta.
Cefaclor
(keflor)
(125 mg/
5ml)
PO
20 mg/kg q12h
Active against haemophillus

influenzae including strains
producing - lactamases.
Cefazolin
(Reflin)
(125 mg,
250 mg
vials)
IV, IM
20 mg/kg
q12h
20 mg/kg
q12h
20 mg/kg
q12h
20 mg/kg
q8h
Caution with penicillin allergy or

renal impairment. Leukopenia,
thrombocytopenia, increase liver
enzymes, false +ve urinary reducing substances. Active against
gram-positive including staphylococcus aureus (even penicillinase producing organisms),
Group A beta-hemolytic streptococci, Streptococcus pneumoniae,
gram-negative including E.coli
Proteus, Klebsiella, H. influenzae,
Enterobacter.
Cefotaxime IV, IM
(traxim)
(500 mg
vial)
50 mg/kg
q12h
50 mg/kg
q8h
50 mg/kg
q12h
50 mg/kg
q8h
Good CNS penetration. Rash.

Thrombocytopenia, leucopenia.
Active against staphylococci,
H. influenzae, Salmonella, Shigella,
Serratia, Spirochetes, Citrobacter,
Neisseria, Proteus and Pseudomonas. In renal impairment with
creatinine clearance of 5ml/min
or less, dose is reduced to .
Cefoxitin
IV
15 mg/kg
q8h
30 mg/kg
q6h
15 mg/kg
q8h
30 mg/kg
q6h
Thrombophlebitis. Activity
against bacteroides fragilis and
indole positive proteus.
Ceftazidime
(fortum,
Tazid)
(250 mg
vial)
IV, IM
Meningitis
Other
disease
Ceftriaxone IV, IM
(monocef) Meningitis


Give IV infusion over 30 minutes
100 OD
100 OD
100 OD
100 OD
Rash, false positive Coombs

test. Active against pseudomonas. It has extended spectrum of
activity against gram-negative
bacteria especially pseudomonas.
Highly stable to betalactamases.
In renal insufficiency dose is
modified according to creatinine
clearance. Urticaria, neutropenia,
thrombocytopenia, pseudomembranous colitis, increased liver enzymes.
Reversible cholelithiasis sludging
in GB and jaundice.
Contd...
Contd...
Antibiotics
(250 mg
vial)
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Loading
Maintenance 50 mg/kg q12h 50 mg/kg q12h
Other
50 OD
50 OD
disease
Body Weight >2000g


50 OD
50 mg/kg OD
Comments
Caution in neonates with hyperbilirubinemia. Skin rash,
pseudomembranous colitis.
Potentiates nephrotoxicity along
with aminoglycosides and frusemide. Chloramphenicol decreases its efficacy. Pseudomonas shows variable susceptibility. Stable against beta-lactamases.
Cefuroxime IV, IM
(altacef, forcef)
(250 mg vial)
Cephalothin IV, IM
Limited experience in neonates.
ChloramIV, PO
phenicol
(enteromycetin)
(250 mg,
500 mg vial)
(as sodium
succinate)
25 mg/kg
once daily
25 mg/kg
once daily
50 mg/kg q12
Dose related or ideosyncratic

BM suppression, Gray baby
syndrome, phenobarbitone,
rifampicin decreases chloramphenicol levels. Phenytoin increases chloramphenicol levels.
Therapeutic levels = 15-25mg/
L for meningitis; 10-20mg/L for
other infection. Active against
most gram-positive and gramnegative bacteria. Active against
Neisseriae, Streptococcus pneumoniae, H. influenzae, staphylococci, streptococci, Salmonella,
Shigella, Anaerobes, Ricketssiae
and Brucella. Not effective
against Pseudomonas.
CiproPO
floxacin
IV
(cifran,
ciplox)
(2 mg/ml,
50 ml/
100 ml
for IV infusion)
7.5 mg/kg
7.5 mg/kg
q12h
q12h
7.5 mg/kg
q12h
5 mg/kg q12h
Damage to cartilage is observed

in experimental animals. Has
stood the test of time and no
such thing documented in
humans? Active against Pseudomonas. When given orally
requires acidic media for absorption. Concurrent administration of sucralfate, magnesiumaluminium antacids and ranitidine decreases its absorption.
Theophylline concentrations are
markedly elevated when co-administered with ciprofloxacin.
Potentials oral anticoagulants.
For IV infusion, dilute reconstituted dose

with NS or DS and infuse over 30 minutes.
25 mg/kg
once daily
Give IV bolus with NS or DS
7.5 mg/kg
q12h
5 mg/kg q12h
Infusion given over 30-60 minutes
Not recommended for meningitis. Pseudo-membranous colitis, transient increase in urea

and creatinine, rash. Active
against staphylococci, streptococci, Neisseriae, H. influenzae and
gram-negative organisms including E.coli, Klebsiella, Proteus.
Not active against Pseudomonas or streptococcus faecalis.
Specially active against betalactamase producing strains of
H. influenzae and N. Gonorrhoeae.
Contd...
Contd...
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Clindamycin IV, IM
(clincin)
(150 mg/ml
2 ml vial)
Clotrimazole Topical
(candid)
Cloxacillin
(klox)
(250 mg
vial)
IV
5 mg/kg q8h
5 mg/kg q6h
Dilute to 6 mg in 1 ml with NS
and D5 infuse slowly over 10-30
minutes.
Apply to skin BID x 4-8 wks

Thrush: Dissolve slowly one troche in the mouth 5times/day x 14 days.
25 mg/kg q8h
25 mg/kg q6h
Dose may be increased to 100 mg/kg in

severe infections. Do not mix with aminolycosides.
Colistin
PO, IM
sulphate
Polymixin
antimicrobial
40 mg/kg
q6h
Co-trimoxazole (bactrim,
septran)
(480 mg in IV
5 ml anpaele
240 mg/
PO
5 ml
suspension
Minor infections :
Prophylaxis (UTI):
Serious Infections and
Pneumocystitis carinii
pneumonia
Pneumocystitis carinii
prophylaxis
Erythromycin
(althrocin)
(100 mg/ml
drops)
Body Weight >2000g

PO,
IV
40 mg/kg
q6h
40 mg/kg
q6h
40 mg/kg
q6h
Give deep IM
4 mg TMP + 24 mg SMX/kg q12h

4 mg TMP + 20 mg SMX/kg once daily
10 mg TMP+ 50 mg SMX/kg q12h
480 mg/m2 q12h EOD (3 days/wk)
IV infusion is given after

diluting in 5% dextrose (not available in indian market)
Comments
Not indicated in meningitis,
Diarrhoea, rash, StevensJohnson syndrome. Pseudomembranous colitis, Thrombocytopenia, Granulocytopenia.
Active against Staphylococci,
Streptococci, Bacteroides fragilis
and some anaerobes.
Erythema, blistering, urticaria
where applied.
Double dose for meningitis.
Active against Staphylococcus
aureus, coagulase negative
staphylococci. Poor activity
against Treponema pallidum
and anaerobes. Its potency is
lost in solution with erythromycin, gentamycin, kanamycin,
colistin sulfate, chlorpromazine,
vitamin C and polymyxin B sulfate. Chloramphenicol antagonizes its bactericidal activity.
Active against gram-negative
anaerobes including most enterobacteria except proteus, providential and serratia. Activity
is also seen against Pseudomonas, Legionella, H. influenzae,
Acinetobacter, V. cholera, Salmonella, Shigella and pasteurella.
For use with caution in infants
<1 month; (TMP) to (SMX)
ratio is 1 to 5. Can displace bilirubin bound to albumin. Both
inhibit folic acid synthesis by the
pathogen but at different stages
which results in some potentiation of action. Active against
staphylococci, enterococci,
E.coli, Proteus. Diffuses well into
CSF and brain. Steven-Johnson
syndrome, agranulocytosis,
thrombocytopenia.
May increase serum theophyllin
level. Cyclosporine, digoxin,
CBZ MPS increases serum
levels. Caution: liver disease,
with terfenadine cisapride.
Estolate may cause cholestasis.
Active against gram-positive
organisms, including penicillinase producing staphylococci,
diphtheria, mycoplasma, urea
plasmas, chlamydia, bordetella
pertusis and most gram-negaContd...
Contd...
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Body Weight >2000g

Comments
tive organisms. It is used as an
alternative to penicillin, in those
allergic to penicillin. Topical
preparations are also available.
Antibacterial activity potentiated by acetazolamide and sodium bicarbonate.
Flucloxacillin
50 mg/ml
suspension
IV,
PO
50 mg/kg q12h
25 mg/kg q12h
50 mg/kg q8h
25 mg/kg q8h
25-50 mg/kg q6h
Fluconazole IV
(zocon)
PO
(2 mg/ml)
25 ml bottle
< 14 days
14-28 days
>28 days
6-12 mg/kg every 72 hr

Flucytosine IV PO
(5 FC)
(10 mg/ml
250 ml
bottle)
25 mg/kg q6h
Theurapeutic level = 25-100mg/L
Fucidic acid IV, PO
5 mg/kg q6h
Systemic candidiasis and cryptococcal infection. 3 mg/kl for

mucosal candidiasis. Reduce
dose in renal impairement. In
over 10-30 min.
Ganciclovir IV
500 mg vial
Induction 5 mg/kg q12h or 2-5 mg/kg q8h for 14-21 days.

Maintenance therapy: 5 mg/kg OD for 5 days/wk.
25-50 mg/kg q6h
IV infusion over 20-40 min through filter
5 mg/kg q6h
5mg/kg q6h
5 mg/kg q6h
Reconstitute with 10 ml water (50 mg/ml)

Infuse over 1 hour. Irritant, handle carefully.
Gentamycin IV, IM
(garamycin)
(10 mg/ml,
40 mg/ml,
2 ml vial)
<28 wk
28-34 wk
> 34 wk
2.5 mg/kg q24h

2.5 mg/kg q18h
2.5 mg/kg q12h
<28 wk
28-34 wk
>34 wk
Double dose for meningitis.

Active against Staphylococcus
aureus, coagulase negative staphylococci. Poor activity
against Treponema pallidum and
anaerobes.
2.5 mg/kg q18h

2.5 mg/kg q12h
2.5 mg/kg q8h
Adverse reactions noted: enterocolitis, nausea/vomiting diarrhoea, hepatotoxicity, bone

marrow suppression. Monitor
closely hematologic, renal and
liver function status. Increase
dosing interval q12h when renal
function 50% of normal and to
q24h when renal function <10%
of normal.
For IV use dissolve powder in
buffer provided and infuse dose
over 6 hours.
Reduce dose in renal failure.
Neutropenia, thrombocytopenia, retinal detachment. IM and
SC administration are contraindicated because of high pH (II).
Proximal tubule dysfunction, ototoxicity.
Therapeutic level=6-10mg/L
(peak) <2mg/L (trough). Eliminated more quickly in patients
with cystic fibrosis, multiple sclerosis, burns, neutropenic patients. Active against gramnegative organisms, weak activity against staphylococci and
streptococci. Babies on dialysis
an 8 hr dialysis reduces serum
levels of gentamycin by 50%. At
the end of each session give
2mg/kg. Cephalosporin, hydrocortisone and indomethacin potentiate nephrotoxicity. PotenContd...
Contd...
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Body Weight >2000g

Comments
tiates neuromuscular blocking
agents. Frusemide potentiates
its toxicity.
Imipenem
IM IV
beta-lactam
antibiotic
(500 mg with
500 mg cilastatin)
20 mg/kg
q6-8h
over 30-60
mins.
20 mg/kg
q6-8h
20 mg/kg
q6-8h
20 mg/kg
q6-8h
Pruritis, urticaria, seizures,

hypotension, increased lever
enzymes, blood dyscrasias.
IM formation cannot be given
IV. Each gram contains 3.2 mEq
sodium.
Isoniazid
(Isonex)
50 mg tab
5 mg/kg
q12-24h
5 mg/kg
q12-24h
5 mg/kg
q12-24h
5 mg/kg q12-24h
Pyridoxine supplement should

be given (5 mg).
Kanamycin IV,IM
(kancin)
5 mg/kg
q12h
5 mg/kg
q8h
10 mg/kg
q12h
10 mg/kg q8h
Retinal toxicity and ototoxicity

poorly absorbed orally. Give
over 30min IV. Reduce dosage
frequency with renal impairment. Active against Staphylococcus aureus (including penicillinase producing organisms),
Staphylococcus epidermidis, H.
influenzae, E.coli, Klebsiella, Serratia and Proteus.
Meropenem IV
(meronem)
carbapenem
beta-lactam
(500 mg
vial)
Sepsis : 20 mg/kg q12h

Meningitis : 40 mg/kg q8h
20 mg/kg
q12hr
20 mg/kg
q8hr

Dose should be reduced in
patients with creatinine clearance less than 51ml/min. 26-50
ml/min give recommended
dose q12h. 10-25ml/min give
the recommended dose q12h.
<10 ml/min give the recommended dose q24h monitor
LFT, blood counts.
Metronidazole IV
(metrogyl)
(5 mg/ml,
20 ml ampoule,
100 ml container)
Loading 15mg/kg stat, maintenance 24 hr later as the following:

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

Hematuria, nephritis, reversible
BM suppression, eosinophilia,
rash.
Mezlocillin
IV
75mg/kg
q12h
75mg/kg
q8h
75mg/kg
q12h
75mg/kg
q6h
Allergic reaction, seizures,

vomiting and hematological
abnormalities (eosinophilia, leukopenia, neutropenia, anaemia)
elevated BUN, creatinine and
liver enzymes.
PO
Slow IV injection
Infuse over 30 min.
Neutropenia. Candidiasis may

worsen. Potentiates anti-coagulants. Use with caution in
patients with liver or renal disease (GFR <10ml/min). Active
against anaerobes (useful in
necrotising enterocolitis) and
entamoeba histolytica. T is 2325hrs (term) 59-109 hrs (preterm). CSF penetration is excellent.
Contd...
Contd...
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
50 mg/kg
q8h
Body Weight >2000g

Moxalactum IV, IM
50 mg/kg
q12h
Nafcillin
IV
25 mg/kg
q12h
q8h
q8h
q6h
caution in infants with compromised hepatic function.

Good CSF penetration.
Neomycin
sulfate
PO
12.5 mg/kg
q6h
12.5 mg/kg
q6h
12.5 mg/kg
q6h
12.5 mg/kg
q6h
Ototoxicity and nephrotoxicity
Netilmycin IV
(netromycin)
(10mg, 25mg
50mg in 1 ml)
3.5 mg/kg
q12h
3.5 mg/kg
q8h
3.5 mg/kg
q12h
3.5 mg/kg
q8h
Theurapeutic range 10-12

mg/L (peak) and <2mg/L
(trough). Active against most
gram-negative and some grampositive organisms, including
some which are resistant to other
aminoglycosides. Activity is
also seen against Pseudomonas,
methicillin resistant strains of
Staph aureus and Proteus. Not
active against streptococci or
anaerobes.
Nystatin
PO
Topical
400,000-800,000 units/day d/v q6h (100,000 U/ml suspension) after feeds. It is poorly absorbed from
Applied as ointment or cream 3-4 times daily (100,000U/g)
GI tract.
Oxacillin
IV, IM
25 mg/kg
q12h
25 mg/kg
50 mg/kg
q12h
Comments
25 mg/kg
150mg/kg/
q8h
25 mg/kg
Do not mix with other antimicrobials
25 mg/kg
q8h
25 mg/kg
q8h
25 mg/kg
q6h
Similar to penicillin. Use with
May cause thrombophlebitis

and Clostridium difficile colitis.
Palivizumab IM
(synagis)
15 mg/kg once a month during RSV season (Nov-Apr)
Preferred over anterolateral

aspect of thigh.
Penicillin G
(benzyl)
IV
Meningitis
50,000
u/kg 12h
50,000
u/kg q8h
50,000
u/kg q8h
50,000
u/kg q6h
Other
diseases
25,000
u/kg q12h
25,000
u/kg q8h
25,000
u/kg q8h
25,000
u/kg q6h
Active against few gram-positive and gram-negative bacteriae. Useful against streptococci and pneumococci, congenital syphilis, tetanus, listeria
and few anaerobes (gas gangrene). Diffuses well into tissues
and body fluids, but penetration into the CSF is poor except
when the meninges are inflamed.
Penicillin G
(procaine)
(Bisterpen)
IM
50,000 U/
kg OD
50,000 U/
kg OD
50,000 U/
kg OD
50,000 U/kg OD
Penicillin
Benzathine
(Penidure)
IM
50,000 U
(one dose
only)
50,000 U
(one dose
only)
50,000 U
(one dose
only)
50,000 U
(one dose only)
Penicillin V
(keypen)
PO
62.5 mg/kg
q6h
62.5 mg/kg
q6h
62.5 mg/kg
q6h
62.5 mg/kg
q6h
300 mg/kg/d
q8h
300 mg/kg/d
q6h
Piperacillin IV, IM
(piprapen)
ureidopeni-
200 mg/kg/d 200 mg/kg/d

q8h
q6h
May increase the risk of haemorrhage with high doses. Active

against all major gram-positive
Contd...
Contd...
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Body Weight >2000g

cillin. (with
tazobaltam)
(2.25 gm vial)
Polymyxin
B sulfate
(poly-B)
PO, IM, IV
Comments
and gram-negative organisms
except those producing betalactamases. It has a good antipseudomonas cover.
2.5 mg/kg
q12h
2.5 mg/kg
q12h
2.5 mg/kg
q12h
2.5 mg/kg q8h
Does not cross blood-brain

barrier. Synergy with trimethoprim and useful combination
with rifampicin,especially in
treatment of multiresistant
strains.
Pyrimethamine PO
25 mg tab.
Toxoplasmosis:
Loading: 2 mg/kg OD for 2 days
Maintenance: 1 mg/kg
OD for 2 6 month, then 3 days per week to complete 12 m treatment
Rifampicin
(R-cin)
PO
10 mg/kg
once daily
Ribavirin
(Ribavin)
Aerosol
Administer using a (SPAG 2) small particle aerosol generator provided

by the company. The drug is delivered via an oxygen hood or through
the inhalation tubing of a ventilator. Concentration of drug in reservoir
(20 mg/ml) is not varied with patient weight. Treatment is carried out for
12-18 hours per day for 3-7 days.
Rash and conjunctivitis have

been observed. Special precautionary measures need to be
taken when drug is being given
through a ventilator to avoid
drug deposition and consequent
malfunctioning of expiratory
valve.
Spiramycin P O
(Rovamycin)
Macrolide
(0.75 million
IU tab)
Immunocompromised : 0.75million IU/day d/v q8h for 5 days

Toxoplasmosis : 0.15-0.30 million IU/kg/day d/v q12h for 6 wk
Meningococcal meningitis prophylaxis : 150000 IU/kg/day for 5 days
Active against streptococci,

staphylococci, diphtheria, pertusis, Listeria, Clostridia,
Legionella, chlamydia, mycoplasma, N. meningitides, Toxoplasma gondii and Cryptosporidia. Not active against
gram-negative aerobes. Synergism with metronidazole
against anaerobes seen.
Ticarcillin
75 mg/kg
q12h
75 mg/kg
q8h
75 mg/kg
q8h
100 mg/kg
q8h
Active against Pseudomonas
Ticarcillin + IV
clavulanic
acid
(Timentin)
75 mg/kg
q12h
75 mg/kg
q8h
75 mg/kg
q8h
75 mg/kg
q6h
Hypersensitivity reaction,
phlebitis, pseudomembranous
colitis, hypernatremia and inhibition of platelet aggregation.
Monitor renal function.
Tobramycin IV, IM
(tobacin
tobraneg)
Aminoglycoside (10 mg/
ml 1 ml,
2 ml vial)
2 mg/kg
q24h
2 mg/kg
q12h
2 mg/kg
q12h
2 mg/kg
q8h
More active against Pseudomonas. Active against Staphylococcus aureus, E.coli, Klebsiella,
Proteus, Serratia and Citrobacter
ototoxicity and impaired renal
function. Less active against
streptococcus. Adjust dose in
renal failure.
Vancomycin IV
(vancorin)
(500 mg
vial)
Recommended dosage designed to achieve one hour post infusion levels of

25-30 mg/L, trough levels of 5 -10 mg/L and average vancomycin serum
Concetrations at steady state of 13.5 mg/L, immediate post infusion.
Vancomycin serum concentrations are predicted to be < 40 mg/L.
IV, IM
10 mg/kg q12h
10 mg/kg
once daily
Supplement with folinic acid.

Glossitis, seizures and rash.
10 mg/kg q12h
Infuse over 60min to avoid

Redmans syndrome; increase
dose in CNS infections to
60 mg/kg/day d/v q6h. Active only against gram- positive
Contd...
10
Contd...
Antibiotics
Body Weight <2000g

Routes of
Age 0-7 days
>7 days
Administration
Body Weight >2000g

Dose (mg/kg/dose)
<27 wk
27
27-30 wk
24
31-36 wk
27
>37 wk
22.5
Dilute with NS or DS to give 5 mg in 1 ml.
infuse over 1 hour
Vidarabine
IV
Zidovudine P O
(retrovir)
IV
10 mg/ml,
susp. and
Inj.
Dosing Interval
q36h
q24h
q18h
q12h
Comments
bacteria. Mainly used against
penicillin-resistant staphylococci (Staphylococcus aureus,
coagulase-negative staphylococci, streptococci and grampositive anaerobes including
Clostridium difficile)
<1 month: 15-30 mg/kg/day infused over 12-24 hour period for
10 consecutive days. (Minimum dilution is 0.45 mg/ml of IV fluid.
In line filter > 0.45 micron recommended)
Adverse reactions noted in

adults; nausea, vomiting diarrhoea, rash, ataxia, tremors,
myoclonus and bone marrow
depression. These have not been
observed in neonates. Monitor
hematologic, renal and hepatic
status. Reduces dose by 25% in
severe renal failure.
2 mg/kg 6h for 6 wk
1.5 mg/kg 6h for 6 wk
Severe anaemia,
neutropenia, GI upset.
*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 infant
s> 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.
11
Organisms generally susceptible to penicillins
Ticarcillin
Piperacillin
Carbenicillin
Ampicillin/
sulbactam
Extended spectrum
Clavulanate
Amoxicillin/pot.
Bacampicillin
Ampicillin
Aminopenicillins
Amoxicillin
Penicillin V
Penicillinase
resistant
Cloxacillin
Natural
penicillins
Penicillin G
Organisms
Gram-positive
=generally susceptible
Staphylococci
Staphylococcus aureus
Streptococci
Streptococcus pneumoniae
Beta-hemolytic streptococci
Streptococcus faecalis
Streptococcus viridans
Corynebacterium diphtheriae
Bacillus anthracis
Listeria monocytogenes
Escherichia coli
Haemophilus influenzae
Neisseria gonorrhoeae
Neisseria meningitis
Proteus mirabilis
Salmonella sp
Shigella sp
Klebsiella sp
Gram-negative
Morganella morganii
Proteus vulgaris
Providencia rettgeri
Providencia stuarti
Providencia sp
Citrobacter sp
Pseudomonas aeruginosa
Serratia sp
Enterobacter sp
Acinetobacter sp
Streptobacillus moniliformis
Moraxella (Branhamella)
catarrhalis
Contd...
12

Contd...
Anaerobic
Clostridium sp
Peptococcus sp
Peptocostreptococcus sp
Bacteroides sp
Fusobacterium sp
Eubacterium sp
Treponema pallidum
Actinimyces bovis
Veillonella sp
1. Non-penicillinase-producing.
2. Non-beta-lactamase-producing.
3. B fragilis is resistant.
Staphylococci, beta-hemolytic
Ceftazidime
Ceftriaxone
Ceftizoxime
Cefotazime
Cefoperazone
Cefixime
Staphylococci1
Cefaclor
Cefonicid
Third generation
Cefuroxime
=generally susceptible
+ = demonstrated in vitro activity
Second generation
Cefazolin
First generation
Cefadroxil
Organisms
Cephalexin
Gram-positive
Organisms generally susceptible to cephalosporins
Streptococcus pyogenes
Acinetobacter sp
Citrobacter sp
Enterobacter sp
Escherichia coli
Haemophilus parainfluenzae
+3
Gram-negative
Hafnia alvei
Klebsiella sp
Moraxella (Branhamella) catarrhalis
Proteus mirabilis
Proteus vulgaris
Providencia sp
Providencia rettgeri
Salmonella typhi
Serratia sp
Shigella sp
Bacteroides sp
Bacteroides fragilis
Anaerobic
Clostridium sp
Clostridium difficile
Eubacterium sp
Fusobacterium sp
Pseudomonas aeruginosa
Salmonella sp
Morganella (Proteus) morganii
+
3
Neisseria gonorrhoeae
Peptococcus sp
Peptostreptococcus sp
1. Coagulase-positive, coagulase-negative and penicillinase-producing.

2. Some strains are resistant.
3. Including some -lactamase-producing strains.
13
14
Significance of blood culture isolates

Significance
Organisms
Almost always significant
Group B Streptococcus
Enterococci (Streptococcus faecalis, S. faecium,
S. Bovis, etc).
Group A Streptococcus
Group C/G streptococci
Neisseria meningitidis
Neisseria gonorrhoea
Gram-negative bacilli
Candida and other fungi
Staphylococcus aureus
Coagulase negative staphylococci (S. epidermidis etc.)
Streptococcus viridans group (including S. mitis, S. mitior,
S. milleri, S. Sanguis, etc)a
Clostridium species
Multiple isolates (polymicrobial)
Diphtheroids
Propionibacterium
Bacillus species
Sometimes significant (about 50%)
Almost always contaminats
Antibiotic guidelines in neonatal infection

Clinical
Situations
Risk
Factors
Possible
Organisms
Suggested
Regimes
Comments
Early onset
sepsis/? RDS
PROM > 24 hr
Maternal
infection fever,
leucocytosis etc.
Maternal colonisation
Offensive or
green liquor
GBS
E. coli
Other enterobacteria
Benzylpenicillin +
gentamicin
Listeria
monocytogenes
Benzylpenicillin
+ gentamcin
If all cultures subsequently prove

negative, antibiotics can be stopped
after 48 hours if the baby is well
proven septicaemia is usually treated
for 10 days
Convert penicillin to Ampicillin
following confirmation of diagnosis
Sepsis
after >5 days
Presence of
septic spots,
Umbillical
flare, central
venous line
in situ
Staph aureus staph

Spp
Other gram-positive
and - negative
organisms
Flucloxacillin +
gentamicin
Pneumonia after
prolonged stay
in the neonatal
unit
Ventilated
Earlier course
of antibiotics
Last ET
Aspirate
Conjuctivitis/
Pneumonitis
Not available, no
growth or Staphylococcus
Flucloxacillin +
gentamicin
Coliforms
Pseudomonas
Aeruginosa
Chlamydia
Cefotaxime
Ceftazidime +
gentamicin
Erythromycin
Necrotising
enterocolitis
Preterm
Birth asphyxia
Umbilical
catheterisation
`Gut organisms
including anaerobes
Urinary tract
infection
Commoner in
males CSF
E. coli other enterobacteria

GBS
Benzylpenicillin +
gentamicin+
Metronidazole
Or cefotaxime and
metronidazole
Ampicillin + gentamicin
Benzylpenicillin
In proven S. Epidermidis
Septicaemia secondary
To long line
Sepsis, change to vancomycin if
symptoms not resolved by 48 hrs
Contd...
15
Contd...
Meningitis
Gram film:
Gram-positive cocci in
chains: Gram-negative
bacilli, gram-positive
bacilli
No bacteria seen
+ gentamicin
Coliforms
Cefotaxime and gentamicin

Ampicillin and gentamicin
Cefotaxime and gentamicin
Change according to culture

and sensitivity results
Septic risk scoring

0
<12
98-99
08-10
Clear
>2500
12-24
99-100
05-07
Meconium or blood-stained
1500-2500
>24
>100
<5
Purulent or foul smelling
<1500
Clear
0-5
opalescent
6-15
Purulent
>15 or bacteria engulfed in PMN
98-99
99-100
>100
10,000-15,000
Clear
Normal
15,000-20,000
Bacteria or white cells
Questionable
>20,000
Both bacteria and white cells
Respiratory distress or lethargy
Phase I
Duration of ROM (hour)
Maternal temperature (F)
Apgar score at 5 minutes
Amniotic fluid appearance
Weight of infant (g)
Phase II
Appearance of placenta
Gastric aspirate PMN count
Maternal temperature (F)
1-2 hours postpartum
Material WBC on
day of delivery (mm3)
Maternal urinalysis (microscopic)
State of infant
Specific antibiotic therapy in early-onset neonatal septicemia

First line
In ampicillin resistance
In accompanying meningitis
Ampicillin + gentamicin / amikacin (to cover most Gram-positive and Gram-negative pathogens)
A third generation cephalosporin + gentamicin / amikacin
Ampicillin / amikacin + a third generation cephalosporin
Specific antibiotic therapy in late-onset neonatal septicemia

First line
Second line
For nosocomial infections
Ampicillin + gentamicin/amikacin
Cefotaxime + amikacin. Add cloxacillin if staph is suspected. For resistant staph, vancomycin or
coamoxyclav should be preferred.
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
14 days
21 days
21 days
Enterobacter,
Klebsiella
Cefotaxime or cefipime or meropenem and gentamicin
14 days
21 days
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
16
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 +/- gentamycin
Francisella 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 cotrimoxazole
Vibrio 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 immunoglobulin
Hepatitis B vaccine
Acyclovir
Vidarabine
Acyclovir
Vidarabine
Ribavrin (aerosol)
Ganciclovir (potential)
Azidothymidine (AZT) (Potential)
Herpes simplex virus

Varicella-zoster virus
Respiratory syncytial virus
Cytomegalovirus
Human immunodeficiency virus
17
CHAPTER
Drug Formulary
2
Drug
Route
Dosage
Comments
Acetaminophen
(crocin, calpol)
PO, PR
Newborn: 25 mg/kg/day d/v q4-5h

Infant: 50-60 mg/kg/day d/v q4-6h
Contraindicated in infants with G-6PD deficiency.

Overdose results in delayed hepatotoxicity. Antidote: N-acetyl cysteine.
Acetazolamide
(Diamox)
PO
2-10 mg/kg/dose d/v q8h

Max 100mg/kg/day.
Side effect: Hypokalemia, acidosis and GI disturbances
Acetylcysteine
(Mucomix)
PO, PR
Via nebulizer
(10% solution)
Preterm: 2 ml q4-6h (of 5% solution)

Term: 3ml q4-6h (of 5% solution)
Meconium ileus: 5-30ml/day (10%)
Q3-6hr in equal dilution with DW/NS
For severe atelectasis combined with intensive chest

physiotherapy. May induce bronchospasm, stomatitis, drowsiness, rhinorrhoea, nausea, vomiting and
hemoptysis. Aerosolized bronchodilator given 1015 min prior to acetyl cysteine improves efficacy.
Adenosine
(adenecor)
(6mg/2ml)
IV
0.05 g/kg rapid bolus. Increase in

increments of 0.05 g/kg at 2 min interval
until sinus rhythm is restored. Maximum
dose is 0.3 g/kg.
Very short t of 15 seconds. It is antagonized by

theophylline. Sinus bradycardia, AV block and
flushing. Flush IV line with NS soon after drug
dosing.
Alfacalcidol
(1- Vit D)
PO
0.05 g/kg OD
Albuterol
(Roventil)
ET
0.05-0.15 mg/kg/dose q4-6h
Tachycardia, hypertension, arrhythmias, tremor,

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

dose for BPD.
Aminophylline
(minophyl)
(250mg/10ml)
IV, PO
Apnea of prematurity:
Loading: 6 mg/kg over 20 mins
Maintenance: 5 mg/ kg/day d/v q12h
or 0.2 mg/kg/hr. Give first maintenance
dose 12h after loading dose.
Ethylenedlamine salt of theophylline. Contains 80%

theophylline. See theophylline for comments.
Therapeutic level for asthma 10-20mg/L,
apnoea 6-13mg/L
Ammonium
chloride
PO, IV
1-2 mEq/kg/dose(slow infusion)
For correction of hypochloremic metabolic

alkalosis.
Amrinone
IV
0.75 mg/kg bolus over 2 min followed by

5-10 g/kg/min as infusion.
Thrombocytopenia.
Arginine HCl
IV
750 mg/kg/day.
Metabolic acidosis, hyperglycemia, hyperkalemia.

Becomes essential amino acid if urea cycle is not
intact.
Atracurium
(tracrium)
IV
Loading: 0.5 mg/kg

Maintenance: 5-10 mg/kg / day every
20-30 min (24 hr after loading dose)
Therapeutic levels = 5-25 mg/L
Indicated in infants requiring mechanical ventilation who continue to have inadequate oxygenation
despite optimal supportive care.
It has little effect on CVS.
Atropine (tropine)
(600g/ml)
IV
ET
0.01 mg/kg/dose, to be repeated

q10-15 minutes with the total maximum
dose of 0.04 mg/kg.
Indicated for bradycardia, presumed to be vagal

in origin.
Side effects: Dry mouth, blurred vision, hyperthermia, tachycardia, constipation, urinary retention,
restlessness.
Contd...
Drug Formulary
19
Contd...
Contraindication: Glaucoma, obstructive uropathy,
tachycardia.
Antidote: Physostigmine
Budesonide
Respule1mg/
2ml. (MDI200g
puff)
Nebulised
500g-1mg/dose diluted to 4 ml with

NS q12h.200mg-1mg /dose q12h
Bumetanide
IV, IM, PO
0.015-0.1mg/kg/dose over 1-2 mins
Forty-times more potent than furosemide.Toxicity

similar to furosemide.
Caffeine Citrate
PO
Loading: 20 mg/kg
Maintenance: 5-10 mg/kg/day q6h.
Dose of caffeine base is the above dose.
Methylxanthine derivative, compared with aminophylline it is more potent CNS stimulator, has the
same but milder side effects, longer half life, and
wider therapeutic ranges. Should monitor serum
levels. Therapeutic level 8-25g/ml. Side effects:
Rarely appear at level<50g/ml.Contraindication:
Caffeine benzoate preparation has been associated
with causation of kernicterus.
Calcium
Gluconate (10%)
Injection
IV
Cardiac resuscitation: 1-2 ml/kg/dose

Contains elemental ca++ 0.23 m mol/ml or 100 mg/
(over 10 minutes)
ml. Monitor closely for bradycardia, dysrhythmias
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, associated with arrhythmias in digitalized patient, may
precipitate when used with bicarbonate.
Maintenance: 2-4 ml/kg/day (200-400 mg/
kg/day) mixed in compatible IV fluids 6h
400-800 mg/kg/day (36-72 mg/kg/day
IV preparation can be given orally to supplement
elemental Ca++) divided equally among
nutritional intake in preterm infants to a total
feedings 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 to
increase gradually as tolerated.
Gl tract than calcium chloride.
Elemental
Ca
PO4
Brand
Ca
PO 4
Ratio
Calcinol syrup
105
Human milk
30-35
12-15 2:1
Macalvit
92
Preterm milk
25
14
1.8:1
Ossopan
33
+
Cow milk
122
90
1.2:1
Ostocalcium
82
+
Lactogen 1
74
57
1.2:1
Ossidos
67
+
Lactodex (LBW) 128
64
2:1
Omnical
45
+
Lactodex
88
47
1.8:1
Dexolac sp care 105
57
1.8:1
Milk care
112
48
2.3:1
PO
Calcium
Polystyrene
Sulfonate
(Resonium
Calcium)
PR, PO
Acute hyperkalemia: 1mg/kg/dose

q6h as needed
Calcium
Calcium
Calcium
Calcium
lactate (13% Ca) 400-500mg/kg/day q4-8h PO

glubionate (6.4% Ca) 1200 mg/kg/day q4-6h PO
chloride (27% Ca) 0.2ml/kg/dose IV
Carbonate (40% Ca) 50 150mg/kg/day q4-6h PO
Captopril (aceten)
PO
Initial dose: 0.05 mg/kg q8h Increase or

decrease dose by 50-100% to titrate BP to
desired range. (Dosage range 0.05-0.5
mg/kg/dose)
0.1-0.4 mg/kg/day q6-8h
onset of action within 15-30 min of
administration
Peak effect within 1-2H
Administer 1hr prior to meals.
Carbimazole
(neo-mercazole)
IV
250 g/kg q8h
1 g/kg decreases serum K + by 0.5-2.0 m mol/L.

(Exchanges 1.6 mmol K+/g of resin). Preparation
of 0.25 g/ml in 25% sorbitol should be used to
prevent G.I obstruction.
Tablets must be crushed and diluted in sterile

water to a concentration of 1 mg/ml. Suspension
must be shaken well for 5 minutes Use within
30 minutes of mixing. Adverse effects: Rash, hypotension, oliguria, cough, hyperkalemia, proteinuria,
agranulocytosis Contraindicated in neonates with
bilateral renal artery stenosis or unilateral renal
renal artery stenosis with single kidney. Dosage
reduction required in patients with renal
impairment.
Contd...
20
Contd...
Carnitine (carnitor)
PO
IV
50-100 g/kg/day q8h
Nausea, vomiting and abdominal cramps plasma

free carnitine level 35-60 mol/L.
Chloral hydrate
PO
PR
10-30 mg/kg/dose q6-8h prn

Recommended maximum dose
100 mg/kg/day
Can cause gastric irritation; laryngospasm if aspirated. Caution in preterm infants; reported cases
of coma 24-48 hours following doses;postulated to
be due to delayed gastric emptying and/or immature liver function. Avoid large doses in severe
cardiac disease. Contraindicated in severe hepatic/
renal impairment.
Chlorpromazine
(emetil)
Cholestyramine
PO,IM
750 g/kg/dose q6h

Maximum dose is 1.5 mg/kg q6h
80mg active resin q8h with feeds.
Clonazepam
(lonazep, rivotril)
IV
PO
100-200 g/kg bolus over 30min or

10-30 g/kg/hr infusion.
Maintenance: 25-50 g/kg/day
Used in treatment of opiate withdrawal to reduce

threshold for seizures. Not for IV use.
Side effects: Diarrhoea,constipation,malabsorption
of fat soluble vitamins and metabolic acidosis.
Increased secretions.
Chlorpheniramine
(avil)
Chlorothiazide
(ditide)
IV
250mg/kg for anaphylaxis.
PO/IV
Never IM
20-40 mg/kg/day d/v q12h
Dehydration and electrolyte (Na, Cl, K) imbalance.

Use with caution inliver and severe renal disease.
Hypercalcemia, hyperbilirubinemia, alkalosis,
hyperglycemia, hyperuricemia, hypo magnesemia, blood dyscrasias, pancreatitis.
Cimetidine
(lock-2)
PO
IV
Preterm: 4-8 mg/kg/day divided q12h

Term neonates: 10 mg/kg/day divided
q8h. Infants: 10-20 mg/kg/day
divided q6h
Use in neonates still experimental. Eliminated

mostly unchanged by kidney. Reduction of dosage
required in renal dysfunction. Can cause CNS side
effects, diarrhoea, rash, neutropenia,and
gynaecomastia. Increases serum levels of some drugs
including theophylline and phenytoin.
Cisapride
PO
0.2-0.3mg/kg/dose q6-8 h 30 min

before feed.
Stop 24 h prior to pH study. Diarrhoea. Avoid use

with miconazole, ketoconazole, itraconazole due to
possible occurance of cardiac arrhythmias.
Corticotropin
(ACTH)
IM
3-5 units/kg/day d/v q6h
Cortisone acetate
(cortone acetate)
PO
IM
Physiological replacement: 0.5-0.75 mg/

kg/day q8h or 0.25-0.35 mg/kg/day q6h
Stress: 31-50mg/m2/day q6h on days 2,
-1, 0, 1, 2, 3 and 4 of perioperative period.
Glucose intolerance, Cushings syndrome, pituitary

adrenal suppression, edema, hypertension, cataract,
hypokalemia and skin atrophy.
Cromolyn
ET
20 mg/dose
Bronchospasm, cough, nasal congestion and

pharyngeal irritation.
Curare
IV
0.3 mg/kg/dose q3-4h prn
Hypotension, shock, bradycardia.
PO
Defibrillation
Dexamethasone
(dexona)
IM, IV, PO
1-4 Joules/kg; increase 50% each time.
Indicated for VT/VF.
Pre-extubation to decrease upper airway

edema: 1.5 mg/kg/day d/v q8h X 24h.
Then 0.9 mg/kg/day d/v q8h X 24H
then stop. Cerebral edema: Initial dose
= 0.5-1.5mg/kg; Maintenance: 0.20.5mg/kg/day q6h 5days. Anti
inflammatory 0.025-0.05 mg/kg/dose
q6-12h
Side effects: Include hypertension, hyperglycemia,

salt retention, leucocytosis , adrenal suppression
and with long-term use may rarely cause hypertrophic cardiomyopathy. May increase risk of infection. Consider steroid coverage for periods of stress
after therapy for BPD and in inter current illness.
Suggested course of dexamethasone treatment for severe BPD

Length of Course
Day
Dose
Short
1
2
3
May repeat weakly, if necessary
1 and 2
0.1 mg/kg q12h

0.075 mg/kg q12h
0.05 mg/kg q12h
Long
0.1 mg/kg q12h

Contd...
Drug Formulary
21
Contd...
If no response after 48-72 h of this dosing, stop.
If response:
3 and 4
5, 6 and 7
8
9
10
Diazepam
IV
0.1-0.3 mg/kg /dose slow IV push over
(Valium)
2 minutes; repeat q5-10min. As needed
up to a total dose of 1.0 mg/kg
For status epilepticus:
Bolus 0.2 mg/kg IV, followed by 0.1-0.3
mg/kg/h as continuous infusion.
(dilute in D5W to 0.1 mg/ml)
0.075 mg/kg q12h

0.05 mg/kg q12h
OFF
0.05 mg/kg q12h
END
Indication: Not used as a first line anticonvulsant.
Short-term adjunctive therapy in status epilepticus.
Risk of CNS and respiratory depression, hypotension and phlebitis. Contraindicated in hyperbilirubinemic neonates. Caution in glaucoma, shock and
depression
PR
0.5-1.0 mg/kg; parenteral preparation

to be used in conjuction with a syringe and
catheter inserted into the rectum.
Diazoxide
(Hyperstat)
PO
IV
1.7-5 mg/kg q8h in hyperinsulinemic

hypoglycemia.
Hypertension: 1-3mg/kg. Slow IV. Can
repeat hourly.
Hyponatremia, salt and water retention GI

disturbances, ketoacidosis, rash, hyperuricemia,
hypertrichosis, arrhythmia, hypotension,
hyperglycemia.
Digoxin (digoxin,
lanoxin)
IV, PO
Loading
Maintenance
(g/kg)IV
(g/kg/day) IV
Preterm
20g
4-6 g d/v q12h
Term
30g
6-8 g d/v q12h
>2 mo
40g
10 g d/v q12h
Note: Above dosages are for CHF,
producing levels of 0.5-2 mg/ml.
Higher doses may be needed for
treatment of arrhythmias.
a. Loading dose is given in three divided doses

(1/2, , ) q8h. Start maintenance 24 hours after
last digitalizing dose in preterm and 12 hours after
in full term neonates.
Disopyramide
PO
b. Maintenance dose is generally 25% of the total

loading dose.
c. The PO dose is 25% more than the IV dose.
d. At one month of age, increase maintenance dose to
that of full term neonates.
Caution in renal failure; Contraindication ventricular dysrhythmias; Adverse effects: In neonates on
digoxin, cardioversion and Ca infusion may lead to
ventricular fibrillation (pretreatment with lidocaine
may prevent this).
3.5-7.5 mg/kg q6h
CI in conduction block, myasthenia gravis.

Therapeutic level 2-5 g/ml.
Dobutamine
(dobutrex)
IV
2.5-15 g/kg/min
(recommended maximum 30 g/kg/min.)
Calculation: Same as dopamine.
6xwt(kg) =mg tobe added to 100 ml
D5W. yeilds 1ml/hr =1g/kg/min.
Acts directly on 1 receptors to increase myocardiac

contractility. Also stimulates 1 and 2 receptors.
No dopaminergic effect. Adverse effect:
Dysrhythmias, systemic hypertension or increase in
pulmonary capillary wedge pressure. May be
preferred over dopamine as an inotrope in the
neonate with shock, but without severe
hypotension.Incompatible with alkaline solutions.
Domperidone
(domstal)
PO
Gastroesophageal reflux in older infants:

0.3 mg/kg/dose 10-20 min.
Dopamine antagonist. Gastrointestinal prokinetic

agent. Does not readily enter CNS, however, in
young infants extrapyramidal reactions may occur
to immature blood-brain barrier.
Dopamine
(dopaplus)
IV
Constant IV infusion: Initial 2-5 g/kg/

min increasing gradually up to 30 g/kg/
min for Desired cardiac/vascular effects.
Minimum dilution = 1.6 mg/ml
In D5W or D10W.
Suggested method for calculation
of dopamine and isoproterenol
(Dilute with D5W or D10W)
Select: Desired drug dose desired
IV fluid rate.
Dose- dependent pharmacological actions:

Renal: 2-4 g/kg/min IV. Inotropic (b1) : 5-10 g/
kg/minIV. Vasocostrictive (a): 10 g/kg/min IV.
Care must be exercised to prevent local infiltration
since vasoconstriction activity will lead to vasospasms and tissue necrosis. Manufacturer recommends reinfiltrating the area with an alpha- blocker,
e.g. phentolamine 5-10 mg (1 mg/ml in normal
saline in adults after extravation, but no clinical
experience in neonates as to dosage or efficacy.
Contd...
22
Contd...
Calculation: mg/100ml
wt(kg) 6 desired dose g/kg/min)
=
desired IV fluid rate (ml/hr)
Empirically, only a few drops of the 1mg/ml solution are needed to reverse the vasoconstriction.
Should weigh benefits against potential risks (local
effect of reinfiltration in a tiny infant and systemic
effect of hypotension)
Dornase alpha
(pulmozyme)
ET
2-5mg q12-24h for tenacious pulmonary

secretions.
Pharyngitis, laryngitis, conjunctivitis.
Doxapram
(caropram)
IV
Infusion
Investigational drug. May be useful in neonatal

apnea resistant to theophylline. Do not use if IVH
grade III or IV, seizure disorder, increased blood
pressure or in first three days of life.
Theophylline therapy is usually continued.
Edrophonium
hydrochloride
(Tensilon)
IV
Initial: 0.5 mg/kg/hr

Increase dose by 0.5mg/kg/hr q6h
Maximum maintenance dose: 1.5mg/kg/hr
When the apneic episodes controlled, taper
the dose by 0.1 mg/kg/hr q8h to the
lowest effective dose.
Test for myasthenia gravis: 0.1mg
single dose.
Enalapril (vasotec)
PO
0.005-0.01 mg/kg/dose q8-24h;

depending on BP
5-10 g/kg/dose q8h-24h; administer
over 5 min
Cardiopulmonary compromise, hyperkalemia,

agranulocytosis. CI in renal artery stenosis. Decrease
dose in renal failure.
IV
Keep resuscitation kit ready as it may precipitate

cholinergic crisis, arrhythmias, bronchospasm.
Contraindicated in GI or GU obstruction or
arrhythmias. Antidote: 0.01-0.04 mg/kg/dose of
atropin.
Epinephrine
(Racemic) for
inhalation 2.25%
Via
Nebulizer
0.25 ml/kg diluted to 3 ml with normal

saline q1-2h Max total dose 0.5 ml
Indicated drug. May be useful in neonatal apnea

resistant to theophylline. Do not use if IVH grade
III or IV, seizure disorder, increased blood pressure
or in first three days of life.
Theophylline therapy is usually continued.
Epinephrine
(1:1,000)
(1mg/ml)
IV
0.1-0.5 g/kg/min (infusion)

mix with D5W or D10W
Calculation: Same as Dopamine
0.5-1ml of 1:10000 as ionotropic agent.
To support in babies with true or relative

hypotension. Acts directly on both and
adrenergic receptors, with 2 effects predominating
at lower doses. Alpha adrenergic stimulation
produces an increase in heart rate and systolic blood
pressure. Not effective if acidosis is present.
Ergocalciferol
(calciferol)
PO
Preterm: 400-800 IU/day.
Hypercalcemia, weakness, diarrhoea, polyuria,

metastatic calcification, nephrocalcinosis.
Erythromycin
PO
IV
3-5 mg/kg/dose q6h

3-5 mg/kg/dose q6h; infuse over 60 min
GI distress.
Erythropoietin
(Epogen, Procrit)
IV, SC
50-100 units/kg; 3 times per week.
Hypertension, seizures, thrombotic events and

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 preterm

infant.
Exosurf
IT
5 ml/ kg/ dose q12h for details see,

specific protocol.
Synthetic surfactant for the prophylaxis

and treatment and; hyaline membrane disease.
Fentanyl citrate
(Sublimaze)
IV, SC
Pain / sedation: Slow IV push over 5 min: Adverse effects; respiratory depression and apnea,
1-2 g/kg/ dose, followed by 1-5 g/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 and
20-75g/kg/dose
analgesic effects, necessitating increases in dosage.
Onset of action: 1-2 min.
Peak action: 10 min.
Fludorocortisone
(Floricot)
PO
Flumazenil
(Romazicon)
IV
Congenital adrenal hyperplasia: 0.05 to 0.2

mg once a day 0.1mg 9-fluorocotisol =1mg
DOCA.
8-15 g/kg (maximum single dose
200 g) repeated every minute to a
maximum total accumulative dose of 0.5
mg/kg or 100 g whichever is lower.
Excessive therapy can cause hypertension.

Contraindication: CHF, Systemic fungal infection.
Seizures, agitation and CNS stimulation, flushing,
vomiting. Avoid benzodiazepines for seizures
control.
Fluoride drops (1=1 mg fluoride lon per 8 drops).
Contd...
Drug Formulary
23
Contd...
Fluoride drops
(1-1 mg fluoride 1 on
per 8 drops)
Folic Acid (folvite)
PO
> 2 wk 2 years; 0.25 mg/day.
Supplementation recommended for all infants if

concentration of fluoride in drinking water has <0.3
ppm fluoride.
Hemolytic anaemia: 0.25g/kg/day

for 6 months. Dietary supplementation
in preterm (<33wk) 50g/day.
Normal serum level >4 ng/ml.
Used along with pyrimethamine.
Folinic acid
PO
5mg/dose twice a wk in toxoplasmosis.
Furosemide (Lasix)
(20mg/2ml)
IV, IM,
Initial; 1 mg/kg/ dose q24h in preterm,

Dehydration and electrolyte (Na, Cl, K) imbalances,
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).
Maximum rate of infusion: 0.5mg/kg/min.
1-4mg/kg/dose.
PO
Gentian violet (1%)
Topical
Dilute to 0.5% solution 3-4 drops q8h-12h
Stains the part. Do not apply over face.
Glucagon
(glucagon novo)
IM, IV
30 g/kg IM; may repeat prn to max.

1 mg 0.5-2 mg/ day as continuous
infusion (dilute in D5W or D10W)
Limited use in neonates because helpful in

hypoglycemia only if liver glycogen is available.
Indicated in persistent hypoglycemia despite
aggressive glucose infusion (> 14 mg/kg min) or
problem of fluid over load.
Heparin (hep)
IV
To keep indwelling lines open: 1 unit/ml in

flushing and parenteral solutions. For
heparinization: Initial dose; 50 units/kg
Maintenance: 20-25 units/kg/hr as
infusion.
Reversal of Heparin Therapy
Time since last Protamine dose
heparin dose
(mg/100 unit
(min)
heparin received)
< 30
1.0
30-60
0.5-0.75
60-120
0.375-0.5
>120
0.25-0.375
Maximum dose of 50mg.
Infusion rate of a 10mg/ml solution
should not exceed 5mg/min.
Hypersensitivity reaction to protamine
sulfate may occur in patients with known
hypersensitivity to fish or those previously
exposed to protamine therapy or protamine
containing insulin.
During heparinization monitor baseline and

subsequent coagulation studies; clotting time,
PT, APTT, platelet count and fibrinogen Dilute
with D 5W or 10 D10W.
Bleeding, allergy, alopecia, thrombocytopenia.
CT = 20-30 min, APTT=1.5-2.5 times control value
before dose.
Antidote: Protamine sulfate (1mg per 100U
heparine in previous 4hours).
Hepatitis B
Immunoglobulin
(HBIG) (hepaglob)
IM
200 IU as soon after birth as possible

(within 12 hour)
For prophylaxis in newborns whose mothers

are hepatitis B antigen (HbsAg) positive.
Hepatitis B
(Recombinant
vaccine)
IM
0.5 ml (10g) administered within

7 days of birth and again at
1 and 6 months of age.
Hepatitis B vaccine may be given at the same time

as HBIG, but should be given at a separate site.
Hyaluronidase
(hynidase)
SC
15 unit diluted in 1 ml of saline and

infiltrate the affected area.
Use to treat IV extravasation of certain drugs, but

do not use for treatment of extravasation of alpha
adrenergic blockers, e.g. dopamine
Hydralazine
(apresoline)
IV
Initial dose: 0.2 mg/kg q4-6h prn as

required for BP control. Dose may be
gradually increased by 0.1 mg/kg/dose to
maximum of 2 mg /kg/dose. Give by slow
IV push at rate not exceeding 0.2 mg/min
PO dose generally twice the effective
IV dose
Causes direct relaxation of smooth muscle in

peripheral vascular bed. May cause tachycardia,
SVT, diarrhoea, emesis, lupus like syndrome,
agranulocytosis, decrease dosage in renal failure.
2-4 mg/kg/day d/v q12h Start with

1 mg /kg/ day and increase the dose by
1 mg/kg /day every 2 days
Same as chlorothiazide.
PO
Hydrochlorothiazide(hydride)
PO
Oral bioavailability generally 50% that of IV route.
Contd...
24
Contd...
Hydrocortisone
(efcorlin)
IV
For adrenal crisis: 25 mg IV bolus, followed

by continuous infusion of 50-100mg/m2/
24 hr until improvement occurs.
Anti-inflammatory:1-2.5mg/kg/dose.
PO
Maintenance dose for congenital adrenal

hyperplasia: 20-25 mg/m2/day divided
TID.
For neonatal hypoglycemia: 1-2 mg/kg/
dose q8h
IV
Wide variation in glucocorticoid requirements. Dose

must be individualized according to growth and
hormone data. Can cause adrenal suppression,
growth retardation, fluid and electrolyte
disturbances, hypertension, hyperglycemia,
increases susceptibility to infections.
Indicated in persistent hypoglycemia despite

aggressive glucose infusion (> 14 mg/kg min) or
problem of fluid overload.
Immunoglobulins:
Hepatitis B
immunoglobulin
(HBIG) (hepaglob)
(200 IU/ml)
IM
Human normal
immunoglobin
(Bharglob) IM
IM
Immunotherapy: 10% 0.6 ml/kg;

16.5% 0.4ml/kg.
Prophylaxis of infections:
10% 0.4ml/kg: 16.5% 0.25ml/kg.
CI: Selective IgA deficiencies,hypersensitivity.

SP for signs of anaphylactoid reactions.
Rabies
immunoglobulin
IM
20 IU/kg.1/2 the dose should be

infiltrated in and around the wound
and1/2 administered IM
First dose of vaccination given at the same time but

at a differnt site.
RSV
immunoglobulin
IV
750 mg (15ml) monthly during RSV season.

1.5 ml/kg/h 15 min.
3 ml/kg/h 15 min.
6 ml/kg/h until finished
Tetanus
immunoglobulin
(TIG) (Tetglob)
IM, IT
Tetanus neonatorum: 500 10000 IU IM

Local pain, fever, flushing and chills may occur.
or 250 IU IT prophylaxis : 250500 IU IM
IM
250 mg
Indicated in any mother suffering from chickenpox

upto 5 days earlier to 15 days after delivery.
Antibody titre (IgG) >32 is seen in all if mother has
suffered chicken pox before 6 days of delivery.
Immunoglobulin
(sandoglobulin)
IV
Replacement therapy for congenital

or acquired antibody deficiency:
100200 mg/kgq 2-4 weeks
Treatment: 0.2g/day over 3 hour
for 4 days; Term: 0.4 g/day over
3 hours for 4 days.
For neonates with passive autoimmune
thrombocytopenia: 0.5g/kg/day for
5 days (Reconstitute in 0.9% saline
solution as a 5% solution and infuse over
12 hours on each of 2 consecutive days).
Can cause anaphylactoid and hypersensitivity

reaction start infusion at very slow rate and increase
slowly. Adjunctive therapy in severe infections
(septicemia) with theoretical benefits.
Indomethacin
(microcid)
IV
0-7 days: 0.2 mg/kg/dose at hour 0

0.1 mg/kg/dose at hours 12
>7 days: 0.2 mg/kg/dose at hour 0
Infuse over 20-30 mins.
Adverse effects; Renal dysfunction

(oliguria, hyponatremia, hyperkalemia,
elevated BUN), platelet dysfunction,
hypoglycemia. May reduce renal clearance
of aminoglycosides, digoxin, theophylline,
vancomycin. Close monitoring of serum
concentrations of these drugs and dosage
adjustments may be required.
Insulin
(Actrapid)
IV
Start with 0.05 unit/kg/hr as a

continuous infusion. (Add 10 U/kg of
1-Flush tubing with 50ml of solution prior to

infusion.
Varicella
Zoster
immunoglobulin
(VZIG)
Neonates born to HbsAg positive mothers:

100-200 IU soon after birth
(atleast <5 days) Booster dose:
32-48IU/kg between 2 and 3 months
after initial dose.
Contd...
Drug Formulary
25
Contd...
insulin to 100 ml of 10% dextrose 1 ml/
kg/hr=0.1 U/kg/hr). Titrate infusion to
maintain blood glucose concentration
between 5.0 and 9.0 m mol/L and/or
dextrostick between 80-160.
Glucose/Insulin
infusion
2 Connect with the shortest possible tubing

1 and 2 will reduce adsorption loss and improve
delivery.
This combination produces 1 unit insulin

/2gm glucose.
0.1 unit/kg insulin with 4 ml/kg of 25%
dextrose for hyperkalemia.
Ipratropium
bromide
(Ipravent)
Via nebulizer
Inhalation solution: 0.125 mg (0.5ml)

diluted to 2-3 ml with normal saline q6h.
Can be mixed with salbutamol.
Iron
PO
Treatment of Iron deficiency: 6 mg/kg/

day elemental iron.
Prevention of iron deficiency: 3 mg/kg/
day elemental iron.
Isoprenaline
Isoproterenol
IV
IV Infusion
0.1-0.5 g/kg/min as infusion.

0.05-0.5 g/kg/min
Initial: 0.05 mg/kg/min; may increase
q15 minutes by 0.05 g/kg/minute to
max dose of 1.5 g/kg/min.
Suggested method for calculation of
drug solution (see Dopamine above)
For bradycardia and hypotension.

1 and 2 adrenergic agonist: Dose dependent
inotropic and vasodilator effect. May decrease
coronary and renal blood flow. Adjust rate of
infusions to keep HR <200/min.
SP in CHF may precipitate arrhythmias when
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

doubled and repeated every 10 min until
desired clinical response or total dose of
4mg/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
Cl in CHF, heart block, sinus tachycardia. May cause

bradycardia, edema and bronchospasm.
Levothyroxine
(Eltroxin)
PO, IM, IV
8-10 g/kg/day
SP in those on anticoagulants. Titrate dosage with

clinical status and serum T4 and TSH. May cause
hyperthyroidism, rash, growth disturbances.
Lidocaine
(Xylocaine)
IV
Ventricular arrhythmias: Initial dose:

0.5 mg/kg over 5 min. May repeat
once after 5 min subsequent infusion:
10-50 g/kg/min.
For short term control of ventricular arrhythmias;

may cause hypotension. Should be used in critical
care areas only. Seizures, asystole, respiratory
arrest is also known. Decrease dose in presence of
hepatic or renal failure.
Lidocaine/
prilocaine cream
(EMLA cream)
Topical
2-5g/site for painful procedures.
To be applied 60 min prior to the procedure.
Lignocaine
IV
1mg/kg as bolus, followed by 20 g/kg/

min as maintenance infusion.
Initial: 0.05 mg/kg/ dose, repeat every
15 min prn.
Maintenance: Dose not determined, but
suggest 0.05 mg/kg dose q 6-8h prn
For cardiac arrhythmias.
Lorazepam (calmese) IV
Magnesium
Sulfate 50% inj
(4mEq/ml)
or (2 m mol/ml)
IV
For hypomagnesemia; 25 50 mg
Mg SO4/kg /dose (0.1-0.2 mmol Mg/kg):
may repeat q6h for 3-4 doses
Maintenance:
31.2mg 62.5mg MgSO4 /kg day
(0.125 0.25 mmol Mg/kg day).
No enough experience with neonates. Could be used

as bronchodilator in infants with BPD.
Contraindication in narrow angle glaucoma and
bladder neck obstruction.
Fer-in-sol delivers 2.5 mg elemental iron/0.1 ml.
Wt (kg) 4.5 (desired Hb patients Hb) = mg
of Iron
Blood loss(ml) Hct = mg of iron
100
May be useful in seizures refractory to

Phenobarbital and phenytoin. May cause
respiratory depression. Injectable product may
be given rectally.
For IV use, the solution should be diluted to 1%
(add 1 ml 50% sulfate injection to 49 ml NS or
sterile water) and the required dose infused over
1 hour.
To be added to total IV fluid. Monitor for
hypotension, respiratory depression, hypermagnesemia SP in renal insufficiency and neonates
Contd...
26
Contd...
on digoxin. Antidote: Calcium gluconate.
In PPHN: 200mg/kg over 30 mins followed by 2060mg/kg/hr by infusion adjusted to maintain S.mg
3.5-5.5mmol/L.
Mannitol (20%)
Medium Chain
Triglycerides
(MCT oil)
IV
PO
0.5-2.0g/kg/dose over 20 mins.

1-8 ml/24h, divided equally
between foods
For management of cerebral edema.

Contains 7.6 kcal/ml. Does not contain essential
fatty acids. May cause diarrhea if introduced
too rapidly. Contraindicated in patients with liver
disease.
Meperidine
IV, IM
0.5 mg/kg, repeated as required q4th;

maximum dose; 20 mg/kg infuse
over 5 minutes
Metalazone
(zaroxolyn)
IV, PO
0.2-0.4 mg/kg/day
OD
Can cause respiratory depression (less than

morphine), hypotension. Specific antidote for
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).
Electrolyte imbalance, GI upset, hyperglycemia.
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
IV
0.2-0.4 mg/kg/day d/v q12h

(neonatal abstinence syndrome)
0.2 mg/kg/day d/v q12h
(narcotic dependence)
Dependency, CNS and respiratory depression,

bradycardia, hypotension. It is long acting and
is difficult to titrate.
Methyldopa
(Aldomet)
IV
PO
Initial: 10 mg/kg/day D/v q6 8h.

Increase dose gradually over several
days until desired effect achieved
(maximum 60 mg/kg/day).
Methylene blue (1%)
IV
1-2mg/kg/dose slow IV push

over 5 minutes. May repeat in 1h.
Monitor for hemolysis, leukopenia and

hepatotoxicity. Contraindication in pheochlomocytoma and active liver disease. May
interfere with lab tests for creative, urinary
catecholamines.
It is a reducing agent; it may decrease hemoglobin
O2 capacity.
Metoclopramide
(perinorm)
IV
Feeding intolerance in preterm neonates:

0.1 mg/kg day d/v q8h Max dose
0.5 mg/kg day.
PO
Gastroesophageal reflux in older infants:

0.4 mg/kg/day d/v qid PO 10-20 minutes
before feeds.
Loading dose 50 g/kg when on ventilator.
Maintenance of 50-150 g/kg/hr.
Midazolam
IV
Morphine
(Morphine
sulphate,
morcontin)
IV, IM
Pain: Slow IV push over 5 minutes 0.05

mg/kg dose q6 8h prn continuous
infusion: 0.1 mg/kg loading dose,
followed by 0.02 mg/kg/hr.
NaCl 2 (3%)
IV
4 ml/kg for hypo natremic seizures
Naloxone (Narcan)
20 mg/ml
Neomycin (0.5%)
IM, IV, SC
Dopamine antagonist, gastrointestinal prokinetic

agent. May cause dystonic reactions (torticollis,
oculogyric crisis), akathisia, sedation although none
have been observed in limited studies involving
neonates. Premedicate with diphrihydramine when
using as an anti-uretic. Use with caution in
patients with history of seizure disorder.
Can cause respiratory depression and apnea,

hypotension, bronchospasm, seizures, functional
ileus, neonatal abstinence syndrome. Tolerance to
sedative and analgesic effects develops rapidly,
necessitating dosage increases. Specific antidote
for narcotic overdose: Naloxone 0.1 mg/kg IV.
Hypernatremia.
Topical
10mg/kg for narcotic overload. Once

may be repeated prn at 2-3 min interval.
Apply q6h
Neostigmine
IM
PO
0.04mg/kg as test dose for myasthenia gravis

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.
Contd...
Drug Formulary
27
Contd...
Nitroglycerin
IV
Start with 0.1 g/kg/min. And titrate

infusion rate to desired response.
Max dose 5 g/kg/min
1-2 g/kg/min decreases preload
3-5 g/kg/min decreases after load.
The role of nitroglycerin therapy in the neonate is at

present unclear and its use is considered
experimental. It may preferred over nitroprusside
in the treatment of severe cardiac failure to reduce
after load. Sp in severe renal impairment, increased
ICP, hepatic failure
Nitroprusside
(Pruside)
IV
Initial 0.25 g/kg/min. Titrate infusion

rate by doubling rate of infusion until
desired of adverse effects are observed.
Recommended maximum rate of infusion
is 6 g/kg/min. For infusion dilute to a
concentration of 100 g/ml. Protect
solution and line from light.
Indicated in refractory hypertension. Toxicity

manifested by hypotension, reflex tachycardia,
methaemoglobinemia, cyanide toxicity with
metabolic acidosis. Acute withdrawal may
precipitate hypertensive crisis. Monitor thiocyanate
levels if used >48 hrs.
Norepinephrine
(Levophed)
IV
0.01-2.0 g/kg/min.
Tachycardia, hypertension. Avoid arterial infusion.
Octreotide
SC
(Octride)
IV
Omeprazole (Omez) P O
1-10 g/kg/dose q4hr
Causes growth harmone suppression. Start with

lower end of dosage range.
Oxybutylin
PO
0.4-0.8 mg/kg/day d/v q6-12h
Cl in glaucoma, GI obstruction, megacolon, myasthenia gravis, hypovolemia.
Pancuronium
(Pavulon)
IV
0-1 Week: 0.03 mg/kg/dose

1-2 weeks: 0.06 mg/kg/dose
2-4 weeks: 0.09 mg/kg/dose
3-4 weeks :
0.10 mg/kg/dose
(Infuse slowly over 3-5 minutes:
repeated as required q1-2h).
Indicated in infants requiring mechanical ventilation who continue to have inadequate oxygenation
despite optimal supportive care. Can cause tachycardia. Effects potentiated in hypokalemia, hypermagnesemia, and with concomitant use of aminoglycosides, halothane and succinyl choline.
Antidote: Neostigmine with atropine/glycopyrrolate.
Paraldehyde
IV
Loading: 3 ml/kg/hr (150 mg/kg/hr)

of a 5% solution x 3 hours. Maintenance:
0.4 ml/kg/hr (20 mg/kg/hr) of 5%
solution.
PR
0.3 ml/kg/dose (300 ml/kg) q4-6h prn

dissolve dose in equal volume of olive oil
prior to administration. Irregularly
absorbed by rectal route.
For IV administration, add 5 ml (5g) to 100 ml NS

or D5W to make a 5% solution. Administer via
autosyringe pump with a glass syringe. IV tubing
and syringe must be protected from light by
wrapping. IV tubing (and syringe if plastic) should
be replaced every four hours.
Adverse effects: Pulmonary edema and hemorrhage, hypotension, local irritation, displacement
of bilirubin from albumin. Routine use discouraged
except for treatment of status epilepticus resistant
to initial therapy with Phenobarbital, phenytoin,
diazepam; or lorazepam. Contraindicated in
pulmonary or hepatic disease.
Paregoric
PO
Paediatric opium
Solution (0.04%=
0.4 mg/ml
morphine
equivalent)
PO
Initial dose 0.2-0.3 ml total dose q3h-q4h.

Subsequnt doses:
Increase by 0.05 ml upto maximum
of 0.7ml total dose
Initial dose: 0.05 ml/kg q34h; increase
by 0.05 ml increment until effective dosage
achieved to maximum of 1 ml.
Pethidine
IM
1 mg/kg q12h
Special precaution for respiratory depression.
Phenobarbitone
(Gardenal)
IV
IV, IM, PO
Loading: 20 mg/kg IV slowly (maximum

rate of infusion 2 mg/kg/min).
Maintenance: 3-5 mg/kg/day (first dose
given 24 hour after loading).
Indication: Neonatal seizures. If seizures continue

after the initial IV loading dose, additional doses
of 10 mg/kg (spaced at 20-30 minute intervals) can
be given, up to a total loading dose of 40 mg/kg to
achieve a plasma level of 170 mol/L (must ensure adequate respiratory control if using high dose).
Liver enzyme inducing dose: 2mg/kg/day.
0.7 mg/kg/day and may be increased

to 3 mg/kg/day.
Monitor CNS depression. Adverse effects: Similar

to morphine. Give with feeds to minimize GI
irritation.
For neonatal narcotic withdrawal. Can cause
constipation and CNS depression.
Contd...
28
Contd...
Sedation, lethargy and hypersensitivity reactions.
Note: long half life in neonates. Drug levels increased
with alkalosis. Drug interactions: reduces serum
levels of chloramphenicol; plasma Phenobarbitone
levels increases by phenytoin and valproate.
Therapeutic level: 20-25 g/ml
Hypotension. Inject solution into affected area.
Phentolamine
(Regitine)
SC
0.1mg/kg (2-5 mg maximum total dose).

Prepare solution by diluting 2.5-5mg in
10ml NS.
Penicillamine
PO
250 mg/dose qid (Wilsons disease)

100 mg/kg/day qid x 5 days (Arsenic
poisoning)
30 mg/kg/day qid (cystinuria).
Medication given 1 hour before or 2 hr after meals.

Augments absorption of lead in GI tract. May cause
cataract, flu like syndrome, rashes, lupus like
syndrome, leukopenia, leukocytosis, eosinophilia,
thrombocytopenia, nephrotic syndrome.
IV
Neonatal seizures: Loading: 20 mg/kg IV

slowly (maximum rate of infusion
0.5 mg/kg/min).
IV, PO
Maintenance: 4-6 mg/ kg /day d/v q12h.

if > 1 week old may require increases in
frequency of administration (Frequent
drug monitoring essential in the first
2 weeks of age due to rapid changes in
elimination rate).
Dysrhythmias:
1mg/kg IV (maximum rate of infusion
0.5 mg/kg/min). may repeat every
5-10 min up to total dose of 15 mg/kg
(infuse in normal saline).
Maintenance : 2-8 mg/kg /day d/v q12h.
Infuse in normal saline only. Rapid IV administration may cause hypotension and bradycardia.
Indication; neonatal seizures refractory to Phenobarbital alone. Adverse effects: Drowsiness and
behavioural changes hypersensitivity reactions.
Drug interactions: Increases serum levels of
chloramphenicol; diazepam or phenobarbitol may
increase or decrease phenytoin levels.
Therapeutic level: 15-20 g/ml.
Phenylephrine (2.5%) Drops

Phenytoin (Dilantin)
IV
PO
Phosphate
Supplements
1 drop in each eye for cycloplegia
More effective in the treatment of ventricular than

supraventricular arrhythmias. Hypotension if
infused too closely together.
1. Neutra Phos A
PO
2. Potassium
phosphate
3. Sodium
phosphate
IV
PO
IV
PO
Either NeutraPhos A or IV injection.

Monitor serun Ca, PO4 and alkaline phosphatase.
preparations can be given orally to
supplement nutritional intake in preterm
infants to a total intake of 75 mg/kg/day
of phosphorus, including content of feeds.
Begin with 20-25 mg/kg/day and
gradually increase dose to full supplement
to prevent diarrhoea.
1 ml of reconstituted solution = 3.3 mg
phosphorus, 0.1mmol Na++, 0.1 m mol k+.
prn over 10 min PO: 0.51 mg/kg day
d/v q6h.
1ml= 93 mg (3 m mol) phosphorus
= 4.4 mmol K+
1ml = 46.5mg (3m mol) phosphorus
= 4mmol Na+
Potassium chloride
IV, PO
2-3 m Eq/kg/day.
Prednisolone
(Wysolone)
PO
0.5 mg/kg q6h.
Primidone
(Mysoline)
PO
Loading: 15-20 mg
Maintenance: 12-20 mg /kg/day
Procainamide
PO
2.5-8 mg/kg q4h
Arrhythmias, thrombophlebitis, GI irritation.
Use justified for refractory seizures; close

monitoring of phenobarbitone level is necessary, since
levels rise after primidone loading and fall precipitously with phenobarbitone discontinuance.
CI in conduction block, myasthenia gravis.
Contd...
Contd...
Drug Formulary
7 mg/kg over 1 hr
20-60 g/kg/min as infusion.
Therapeutic level 4-10 g/ml. Hypotension,

lupus like reaction.
Propranolol (Inderal) IV
PO
0.01 mg/kg/dose q6h; increase prn to

maximum of 0.15 mg/kg/dose q6h.
0.25 mg/kg/dose q6h; increase prn to
maximum of 5mg/kg/day.
Bradycardia, hypotension, bronchospasm,

hypoglycemia.
Prostacyclin
IV
5-10 ng/kg/min.
Beware of hypotension. Change infusion q12h.
Prostaglandin E1
(Prostin VR)
(500g/ml)
IV
IV
Initial: 0.05 0.1 g/kg/min (IV)

maintenance: once stable improvement,
decrease to half or less.
Lowest effective dose 0.01 g/kg min.
Suggested protocol:
Add 1
Concenml/hr
Ampule
tration Weight (kg),
(500 g) to:
(g/ml)
Needed to
infuse 0.1
g/kg/min
200 ml
2.5
2.4
100 ml
5
1.2
50 ml
10
0.6
29
For maintaining blood flow through patent ductus

in certain congenital heart disease. Maximal effect:
cyanotic lesions <30 min, acyanotic average < 3
hour. Major adverse effects: hypotension and
apnea.
Protamine
IV
See table.
Pyridoxine
(vitamin B6)
IV PO
Initial: 50-100 mg IV over 1-2 minutes

maintenance: 50-100 mg PO daily.
Indication: For diagnosis and treatment of

pyridoxine dependent seizures. Initial dosing should
be accompanied by EEG monitoring. No toxicity
reported with therapeutic doses.
Quinidine
(Natcardine)
PO
5 15 mg/kg day d/v q6h
Ranitidine
(Rantac)
IV
PO
1.5 mg/kg q12h

1-2 mg/kg q8h
For abolishing and preventing premature contractions of atrial, A V junctional or ventricular origin.
Useful adjunct to digoxin in atrial flutter and fibril
lation (Should not be given until ventricular rate
controlled). Therapeutic serum level 6.218.5
mol/L. decrease dosage if QRS interval increases
by 50% contraindicated in complete A V block.
Salbutamol
(Ventorlin)
Via nebulizer
(5 mg/ml
solution)
For weight <1 kg =1.00 mg/dose

For weight > 1 kg =2.00 mg/dose
Diluted to 2-3 ml with normal saline
q26 prn
Sodium benzoate
PO
IV
250 mg/kg loading dose

250 mg/kg/day maintenance dose d/v q8h
Sodium bicarbonate
(4.2%)
(0.5 m Eq/ml)
IV
2 m mol/kg over 4 mins in hyperkalemia.

In Acidosis: for correction in m mol =
wt(kg) base deficit (m mol/L)
3
Cardiac arrest = 1mmol/kg
Hypernatremia, hyperosmolality, hypercarbia.

Assure adequate ventilation, do not give if PaCo 2
>50 torr. Do not give faster than 1 ml/min.
Sodium polystyrene
sulfonate resin
(kayexalate)
PR
1g/kg dose q6h (Pharmacy supplies

0.25 g/ml in 25% sorbitol to prevent
GI obstruction.
For treatment of hyperkalemia associated with

oliguria or anuria. Exchanges 1 m mol of K/g resin.
Monitor for hypocalcemia, hypomagnesemia,
hypokalemia and hypernatremia.
Sodium NitroprussideIV
Start with infusion rate of 500ng/kg/min

and slowly increase to a maximum of
8mg/kg/min in hypertension
Spironolactone
(Aldactone)
PO
1-3 g/kg/day
Sulphadiazine
(sulphadiazine)
PO
Congenital toxoplasmosis: 50mg/kg/day
Monitor cardiovascular status.
Hyperkalemia
Contd...
30
Contd...
Succinylcholine
(Scoline)
IV
1-2 mg/kg/dose
Sucralfate
(Sparacid liquid)
Survanta
PO
30mg/kg q6H
ET
4 ml/kg/dose (100mg/kg) q6-8h
Natural surfactant extracts (NSEs)

1. Survanta
Dose: 100 mg of phospholipid, i.e. 4 ml/kg.
2. Surfactant-TA
Dose: 60-120 mg/kg (Higher dose of 120 mg/kg
better results).
3. Curosurf (Porcine lung extract)
Dose: 200 mg/kg initially, followed by 100 mg/kg at
12 and 24 hr later.
4. CLSE (calf lung surfactant extracts)
Dose: 100 mg/kg initially and subsequently.
5. Beractant
Dose: 100 mg/kg initially and subsequently.
6. SF-RI
Dose: 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)
Unsaturate phosphatidylcholine
Phosphatidylglycerol (PG)
Phosphatidylinositol (PI)
Sphingomyelin
Phosphatidic acid
Cholesterol
Diacylglycerol
Protein (SP-A, SP-B and SP-C)
Other phospholipids
Neutral lipids
Premedicate the patient with atropine

(0.03 mg/kg) it will increase the serum level of
potassium. Prolonged action in liver disease or
aminoglycoside therapy.
Natural surfactant for the prophylaxis and
treatment of hyaline membrane disease.
Synthetic surfactants
1. ALEC
(7:3 mixture of DPPC: PG dispersed in 1ml saline)
Dose: 100 mg for premature 23-34 wk
- At birth first dose as pharyngeal insulin.
- Next after 10mts, 1hr and 24hr.
2. Exosurf neonatal
(108 mg phospholipid DPPC in 10ml phials with 10ml of solvent)
- 5 ml/kg birth wt.
- 2 doses of 5 ml/kg at 12hr interval are recommended for rescue therapy.
- In reference to DPPC, the dose is 67.5 mg DPPC/kg birth wt.
%
36.3
32.3
9.9
1.6
2.3
1.3
2.4
0.3
10.6
-
Susphrine
IM, SC
0.005 ml/kg/dose q8h for hypoglycemia
Terbutaline
PO
SC
100 g/kg/day
0.005-0.01 mg/kg/dose
IV
Loading dose: 3-5 mg/kg of undiluted

solution. Maintenance: 3-16 ml/kg/h of
undiluted solution
Dose for half correction =
Wt(kg) x base deficit(m mol/L)
6
1ml THAM gives 0.5m mol of bicarbonate.
Indicated in severe metabolic acidosis when

bicabonate therapy is contraindicated because of
hypernatremia or hypercapnea may cause
hemorrhagic liver necrosis or hypoglycemia
Theophyline
(TR phyllin)
IV, PO
Apnea of prematurity Loading:

5 mg/kg Maintenance:
GA (wk)
mg/kg/day
27-30
5.81 (0.02 PNA in wk)
31-34
4.82 + (0.28 PNA in wk)
Term
0.3 (age in wk)+8 q8-12h
Target level = 8-12mg/L
With advancing postnatal age, the clearance of the

drug increases. The dosing interval may need to be
reduced to 8h to maintain therapeutic levels.
Monitor serum levels to avoid toxicity. For
bronchodilator effect higher levels may be needed.
May cause tachycardia, arrhythmia,
hyperglycaemia, jitteriness, GI upset, diuresis, and
seizures. Increase dose by 20% to convert to aminophylline.
Thiamine
(Vit B1)
(Biamine)
IV
0.3-0.5 mg/day
Allergic reactions and anaphylaxis. Therapeutic

range : 1.6 4.0 mg/dl
THAM (3.6%)
Trishydroxy
methyl
aminomethane
Tachycardia, hypertension, local reaction. Good

results seen in term AGA or LGA infant.
For bronchospasm in BPD monitor heart rate.
Contd...
Drug Formulary
31
Contd...
L-Thyroxine
(Eltroxin)
PO
Initial dose is 8-10 g/kg/day (preterm)

SP in those on anticoagulants. Titrate dosage with
and 5-8 g/kg/day (term). Increase dose
clinical status and serum T4 and TSH/ May cause
by 12 g/day q2 wk until TSH
hyperthyroidism, rash, growth disturbances.
<20 mU/L and T4 130-90 n mol/L. usually
25-50 g is given daily
Tincture of opium
(1:25 dilution)
PO
0.8-2.0 ml/kg/day d/v q4h for neonatal

absteinence syndrome
Sedation, respiratory depression.decrease 10%

per day as tolerated.
Tissue plasminogen
activator (tPA)
IV
See table.
Vomiting, hypotension, fever, bleeding from IV

access sites.
Tolazoline
(Priscoline)
IV
Load: 0.5-1 mg/kg over 5mins.

Maintenance: 0.1 mg/kg/hr
Pulmonary vasodilator, major side effects

hypotension, oliguria and GI bleeding. Investigational drug.
Tromethamine
IV
3 ml/kg/dose
max rate = 1 ml/h
1 ml = 0.3 mEq.
Valproic acid
PO
Preterm: 15 mg/kg/day once daily full

term: 40 mg/kg/day once daily.
Can be increased upto 30mg/kg/dose
q12hr.
Dosage recommendations in neonates based on

preliminary data. Its use should be restricted to
infants with seizures refractory to more traditional
therapy. Adverse effects: Hepatoxicity (monitor
serum transminases), hyperglycinemia or
hyperammonemia. GI disturbances, sedation,
altered coagulation, pancreatitis, increased serum
amylase. Therapuetuc serum levels; 350-700 mol/L
Vasopressin
(aqueous)
IM, SC
2.5-10 U toal dose q12h-q16h
Broncho constriction, diarrhoea and electrolyte imbalance.
Vecuronium
IV
0.03 0.15 mg/kg/dose q1h-2h PRN

0.05-0.1 mg/hr as continuous infusion.
Max concentration of 1mg/ml
Neuromuscular effects may be prolonged after

continuous infusion and when aminoglycosides are
administered concurrently.
Vitamin D (Arachitol) P O
Term infants: 400 IU/day Preterm

infants: 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
PO
Preventive dose: 1.0 mg IM at birth, for

>1500g and 0.5 mg if baby <1500 g
1mg at birth, followed by 0.5 mg at 1wk
and 1month (breast fed babies), whereas
single dose for formula fed babies.
Recommended daily allowance 15 mg.
Vitamin Solution
PO
1.0 ml per day.
Contains (in 1.0 ml):

Vitamin A 1500 I.U
Vitamin D 400 I.U
Vitamin E 5.1 I.U
Ascorbic acid 35 mg
Thiamine 0.5 mg
Riboflavin 0.6 m g
Niacinamide 8 mg
Multi-vitamin
preparation in
NICU
PO
1.6 ml per day.
Contains (in 1.6 ml): Vitamin solution 1.0ml

Aquasol E (25. I.U) 0.5 ml
Folic acid (0.05 mg) 0.1 ml
Solution very hyperosmolar and should be diluted
in at least four times the volume of formula for
administration.
32
COMMERCIAL VITAMIN PREPARATIONS

Composition of multi-vitamins drop per 0.6 ml or 10 drops
Vitamin A
1500 IU
Vitamin B
400 IU
Vitamin B 1
0.5 mg
Vitamin B 2
0.6 mg
Vitamin B 6
0.3-0.5 mg
Vitamin B12
0.5-1 gm
Niacin
8.0 mg
Pentothenic
Acid
Folic acid
Vitamin C
25-50 mg
Vitamin E
15-25 IU
Abdec
Hovite
Visyneral
Multivia-plex
Becadex
Dropovit
Vimagna
Vidaylin
5000 IU
6000 IU
5000 IU
2500 IU
5000 IU
4800 IU
3000 IU
5000 IU
1000 IU
1200 IU
1000 IU
200 IU
4000 IU
1200 IU
600 IU
1000 IU
1.0 mg
1.1 mg
1.0 mg
1.0 mg
2.0 mg
1.2 mg
0.5 mg
1.5 mg
0.4 mg
1.0 mg
1.67 mg
1.0 mg
1.8 mg
1.15 mg
1.2 mg
1.0 mg
1.0 mg
1.0 mg
1.0 mg
1.5 mg
1.2 mg
0.1 mg
0.5 mg
2 mcg
5 mg
2 mg
5.0 mg
2 mg
3 mg
15 mg
4.0 mg
10 mg
-
15 mg
3.0 mg
5.0 mg
2.0 mg
10 mg
-
50 mg
50 mg
40 mg
50 mg
30 mg
20 mg
50 mg
0.3 mg
1.0 mg
1.2 mg
CHAPTER
Drugs in Resuscitation
3
DRUGS USED IN RESUSCITATION
Drug
Indication
Dose
Route
Response
Complication
Sodium
Bicarbonate (4.2%)
0.5mEq/ml.
Metabolic
acidosis
2-3 mEq/kg/dose
Total dose
1 kg
2 mEq(4 ml)
2 kg
4 mEq(8 ml)
3 kg
6 mEq(12 ml)
4 kg
8 mEq(16 ml)
IV over 2-5 minutes
Increased pH if
adequately ventilated
Hypernatremia, Hyperosmolar
solution, risk for ?IVH
Epinephrine
(1: 10,000)
Asystole or
severe
bradycardia
0.1-0.2 ml/kg
Total dose
1 kg
0.1-0.3
2 kg
0.2-0.6
3 kg
0.3-0.9
4 kg
0.4-1.2
IV, ETT intracardiac
Increased heart rate,

blood pressure and
cardiac output
Hypertension, ventricular
fibrillation
Glucose (10%)
Hypoglycemia
0.5g/kg (5 ml/kg)
followed by
infusion 5 ml/kg/hr
(Approx 8 mg/kg/min) IV
Increases blood glucose
Glucose (25%)
Hypoglycemia
0.5 g/kg (2 ml/kg) /
IV
Increased blood glucose Rebound hypoglycemia,
dose over 10 min

1-2 ml/kg dose
IV over 2-5 minutes
Improved cardiac
output
IV
Increased cardiac output, Dysrhythmias? Decrease

increased peripheral
renal perfusion at rate
vascular resistance
> 12-15 g/kg/min
ml
ml
ml
ml
hyperosmolar solution
Bradycardia, dysrhythmias
Calcium Gluconate
(10%)
Low cardiac
output
Dopamine
Low cardiac
output, shock,
5-20 g/kg/min
to maintain BP
6 (kg) g/kg/min
desired fluid (ml/hr)
=per 100ml of solutions
Total dose
1 kg
5-20 g/min
2 kg
10-40 g/min
3 kg
15-60 g/min
4 kg
20-80 g/min
Volume
expanders:Albumin 5%,
Fresh frozen
plasma
(1g/20 ml)
Hypovolemic
shock
10-20 ml/kg (0.5-1g/kg) IV over 2-4 hr
Increased perfusion
Circulatory overload in
cardiogenic shock. Contains
0.13-0.16mEq Na/ml
Crystalloid
(0.9 NS, RL)
Hypovolemia,
hypotension
10-20 ml/kg
IV
Increased perfusion
Hypervolemia pulmonary edema,

CHF
Dextran 40
10% solution
Hypovolemic
shock
0.25-0.5g/kg/hr
IV
Increased perfusion
Circulatory overload. Therapy

should not be continued longer
than 5 days
Group O Rh
negative blood
(whole blood)
Acute blood
loss
10-20 ml/kg
IV
Increased perfusion
and oxygen carrying
capacity
Crossmatch against mothers

serum
Contd...
34
Contd...
Naloxone
(Narcan 0.4
mg/ml)
Narcotic
depression
(rare)
Atropine
Bradycardia
even after
epinephrine
0.2 mg/kg/ dose

(0.5 ml/kg)
0.01 mg/kg/dose for
reversal of opiate
analgesia
0.01 mg/kg/dose
(0.025 ml/kg/dose)
IV, ET IM, SC
Improved respiratory
effort when given
rapidly repeat prn
Respiratory depression at birth,

when mother was given narcotics
prior to delivery
IV
Normal HR
Hyperthermia, tachycardia
urinary retention.
INTUBATION SEDATION GUIDELINES

Drug name
Standard dosage
per weight
Patient specific dose
Route
Special considerations
Anticholinergic Medications
Atropine
0.02 mg/kg
Do not use if <2kg

Infuse over 1 min. Minimum dose is
0.1 mg/dose
Sedative Medications
Midazolam (Versed)
Intravenous
Midazolam (Versed)
Intranasal
0.05-0.1 mg/kg
IV
0.2-0.3 mg/kg
Intranasally
Do not use if <35 weeks gestational

age
Do not use if <35 weeks gestational
age
Analgesic Medications
Fentanyl
1-4 mcg/kg
IV
Infuse slow IV push

Chest wall rigidity may occur
Have Pancuronium 0.1 mg/kg IV 1
at bedside
Music Relaxants Only Use if Able to Provide Adequate Facial/Mask PPV

Succinylcholine
1-2 mg/kg
Rocuronium (Zemuron) 0.6-1.2 mg/kg

Vecuronium (Norcuron) 0.1 mg/kg
Pancuronium (Pavulon) 0.1 mg/kg
Use 2 mg/kg/dose if <1 yo

Always administer atropine first
Do not repeat dose
Dilute dry powder
Vecuronium 10 mg vial with 10 ml of
normal saline or sterile water for
injection
Preferred paralytic for neonates if
necessary
Drugs in Resuscitation 35
INOTROPIC AND VASOACTIVE AGENTS COMMONLY USED IN SHOCK
Drug
Dose
(g/kg/min)
Hemodynamic effect
Comment
Dopamine
1-5
Splanchnic, real and cerebral vasodilatation
Dobutamine
5-15
15-20
1-20
Increased contractility and heart rate

Peripheral and renal vasoconstriction
Increased contractility
Stimulates beta receptors by direct and indirect mechanisms; may cause tachydysrhythmias; may increase
pulmonary vascular resistance; doses > 20 g/kg/
min occasionally required for normotension, but may
result in severe tissue ischemia
Isoproterenol
0.05-0.5
Epinephrine
0.05-1.0
Norepinephrine
0.05-1.0
Increased contractility and heart rate;

peripheral vasodilatation
Increased contractility and heart rate;
marked peripheral, renal and mesenteric
vasoconstriction
Marked peripheral vasoconstriction
Nitroprusside
Phentolamine
0.05-8.0
1-20
Hydralazine
0.1-0.5
(mg/kg)
q3-6h
Minimal effect on heart rate; no selective renal effect
May cause tachydysrhythmias; increases myocardial

oxygen consumption
May cause tachydysrhythmias; increases myocardial
oxygen consumption; increases glucose levels;
increased risk of severe tissue ischemia.
May cause severe tissue and organ ischemia; use in
combination with vasodilator
Peripheral arterial and venous vasodilatation Risk of cyanide toxicity
Alpha antagonist: arterial and venous
May produce reflex tachycardia; expensive
dilation
Peripheral arterial vasodilatation
May produce reflex tachycardia
CHAPTER
Standard IV Infusion
STANDARD IV INFUSION ROUTINELY PREPARED

1. Adenosine
Injection 6 mg/2 ml
Diluent NS
1 ml of Adenosine (3 mg) + 5 ml NS
6 ml = 3000 microgram pH 6.3-7.3
1 ml = 500 mgm
0.1 ml = 50 mgm
Infuse as 0.1 ml (50 mgm)/kg/dose over 2 secs
2. Adrenaline
Injection1 mg/ml (1:1000)
DiluentNS, G 5%, G 10%
To prepare standard infusion of 50 ugm/ml
Adrenaline 1ml = 1mg
Add 1 ml adrenaline +19ml NS, G5%, G10%
1mg in 20 ml
1000 microgm in 20 ml
100 mgm in 2 ml
50 mgm/ml
CompatibleHeparin, Dobutamine, Doxapram
IncompatibleAminophyllin, Lignocaine, Sod. Bicarb
pH2.5-3.6
Protect infusion from sunlight
3. Aminophylline
Injection250 mg/10 ml
DiluentNS, G5%, G10%
250 mg-10ml
1 ml Aminophyllin (25mg) + 4ml of NS, G5%, G10%
5 ml = 25 mg
1 ml = 5 mg
Compatible Heparin, Dopamine
Incompatible Adrenalin, Amiodarone, Cefotaxime,
Dobutamine, Doxapram, Insulin, Morphine
pH 8.5 10.0
4. Alprostadil (Prostaglandin E1)
Injection-500 microgm/ml or 0.5 mg/ml
Diluent NS, G 5%
To prepare a standard infusion of 5 gm/ml
(i.e. 5000 nano grams in 1ml)
Babies under 1kg
Draw 0.5 ml Alprostadil (500 microgm / ml) and add to 49.5
ml of NS or G 5%
50 ml=250 micrograms
1 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 NS
or G 5% and mix well
50ml = 500 micrograms
1ml = 10 micrograms = 10000 nanograms
5. Diazepam
Injection10 mg/2ml
Diluent G 5% or G 10%
To prepare standard solution of 0.1mg/ml or 100 microgram/ml
Take 2 ml Diazepam (10 mg) + 98 ml G 5% or G 10%
100 ml = 10 mg
1 ml = 0.1 mg = 100 micrograms
Infuse as 50100 ugm/kg/hour
Incompatible Do not infuse with any other drug including
NS
pH8
6. Doxapram
Injection100 mg/5 ml
DiluentNS, G 5%, G 10%
To prepare standard infusion of 1000 microgram in 1ml
Take 2.5 ml Doxapram injection (50mg)
+47.5ml of NS, G 5% or G 10%
50 ml = 50 mg
1 ml = 1 mg = 1000 micrograms
CompatibleAdrenaline, Dopamine, KCI, Salbutamol
IncompatibleAlkaline solns, i.e. Aminophyllin, digoxin
Furosemide Thiopentone.
7. Digoxin
Elixir 50 microgram = 0.05 mg/ml
Injection100 microgm = 0.1 mg in 1ml
Diluent NS or G 5%
Take 1ml of digoxin injection (100 micrograms)
+ 4 ml of NS or G 5%
5 ml = 100 microgram
1 ml = 20 microgram
Compatible Furosemide, Heparin, Lignocaine, Morphine,
KCI, Verapamil
IncompatibleDobutamine, Doxapram, Fluconazole
pH 6.8 = 7.2
Standard IV Infusion
8. Dobutamine
Injection250 mg/20ml
Diluent NS, G 5%, G 10%
To prepare a standard infusion of 1000 microgms or 1mg in
1ml
Dobutamine 250 mg / 20 ml, i.e. 12.5 mg/ml
Take Dobutamine 4 ml (250 mg in 20 ml) + 46 ml
NS, G 5%, G 10% and mix well
50 mg in 50 ml
1 mg in 1 ml
1000 micrograms in 1 ml
Compatible Adrenaline, Amiodarone, Atropine, Dopamine, Isoprenaline, Hydralazine, Lignocaine, Morphine, Noradrenaline, Pethidine, Phentolamine, Propranolol Streptokinase
IncompatibleAcyclovir, Alkalis-Aminophyllin, Digoxin,
Furosemide, MgSO4 Sodabicarb
pH 2.5 - 5.5
9. Dopamine
Injection200 mg/5ml
To prepare a standard infusion of 1,000 micrograms in 1 ml
Dopamine contains 200mg in 5 ml
i.e. 40 mg in 1 ml.
Take 1 ml Dopamine + 39 ml NS, G 5% or G 10% and mix
well
40 mg in 40 ml
1 mg = 1 ml
1000 microgram in 1 ml
Compatible Aminophyllin, Amiodarone, Chloramphenicol,
Dobutamine, Doxapram, KCL, Streptokinase, Tolazoline
IncompatibleAcyclovir, Amphotericin, Benzyl penicillin
Furosemide, Soda bicarb and other alkaline soln.
pH 2.25 4.5
10. Epoprostenol (Prostacycline)
Injection 500 microgram
Diluent Diluent provided, NS
Reconstitute with diluent provided to make epoprostenol
10 micogram = 1 ml
10 micogram/ ml concentrated solution
A. To prepare a standard infusion of 500 nanogram in 1 ml
babies under 1 kg
Take 2.5 ml of conc. Soln. (25 microgram) + 47.5 ml NS
and mix well
500 nanograms in 1 ml
B. To prepare a standard infusion of 1000 nanograms in 1
ml babies over 1 kg
Take 5 ml of Conc. Soln. (50 micrograms) + 45 ml of NS mix
well
50 ml = 50 micrograms
1 ml = 1 microgram
1 ml = 1000 nanograms
Incompatible Do not infuse with any other drug including
Glucose
pH 10.5
37
of G 5%
1 ml = 2 microgram
0.1 ml = 0.2 microgm
Start with 0.2 mg/kg/min and increase to 2 mg/kg/min
maximum
Compatible Dobutamine, Heparin
pH 2.5-2.8
11. Heparin
Injection 1000 units / ml
Diluent NS, G 5% or G 10%
To prepare a standard infusion of 50 units in 1 ml small
preterm babies
Take 2.5 ml of heparin (2500 units) + 47.5 ml of NS, G 5 % or
G 10% mix well
2500 units in 50 ml
50 units in 1 ml.
To prepare a standard infusion of 100 units in 1 ml Larger
babies and term babies
Take 5 ml of heparin (5000 units) + 45 ml NS, G 5% or G 10%
and mix well
5000 units in 50 ml
100 units in 1 ml
Compatible Aminophyllin, amphotericin, Ascorbic acid,
Calcium gluconate, Digoxin, Isoprenaline, Noradrenaline,
KCL, Streptokinase, Suxamethonium.
IncompatibleMost other drugs including antibiotics
Some antihistamines, narcotic analgesics, phenothiazines
pH 5-8
12. Insulin
Insulin 100 units/ml
Diluent NS or water
To prepare a standard infusion of 0.1 unit in 1 ml
Take 1 ml of human neutral insulin (100 units)
+ 9 ml of NS or water. mix well
100 units in 10 ml
10 units in 1 ml Diluted insulin solution
Take 0.5 ml of diluted insulin solution (5 units) and add to
49.5 NS, G 5%, G 10% and mix well
5 units in 50 ml
1 unit in 10 ml
0.1 unit in 1 ml
CompatibleHeparin, Metodopramide
IncompatibleAminophyllin, Phenytoin, Soda bicarb
Sulphonamides, Thiopentone
pH 7-7.8
13. Isoproterenol
Injection 100 microgram = 0.1 mg/ml
Diluent G 5%
Take 1 ml (100 microgram of Isoproterenol + 49ml.
100 microgms in 5 ml
20 microgms in 1 ml
Compatible Cefuroxime, Digoxin, Dobutamine,
Suxamethonium, Vancomycin, Verapamil
IncompatibleAminophyllin, Pethidine, Sod. Bicarbonate,
Thiopentone
pH 3.5
38
14. Lidocaine HCl

Injection20 mg/ml
DiluentG 5%, NS
Take 1 ml (20mg) of lidocaine + 99 ml of 5% Dextrose Mix
well.
20 mg = 100ml
1 mg =5 ml
1000 microgram = 5 ml
200 microgram = 1 ml
20 microgram = 0.1 ml
Infuse as 20-50 mg/kg/min i.e. 6-15 ml/kg/hour
CompatibleDobutamine, Heparin, Streptokinase
Incompatible Adrenaline
15. Morphine
Injection10mg/ml, 1mg/ml
To prepare a standard infusion of 20 micrograms in 1 ml
Take 1 ml (1 mg/ml) of Morphine + 49ml of NS, G 5%, G
10% and mix well
1 mg in 50 ml
1000 microgms in 50 ml 20 g-1 ml.
16. Nitroprusside
Injection50 mg
Reconstitute with 2 ml G 5% provided.
Take 1 ml of reconstituted Na Nitroprusside (25mg) + 124
ml of G 5% or NS mix well
125 ml = 25 mg
5 ml = 1 mg = 1000 microgram
CompatibleDopamine, Dobutamine (only if diluent is NS)
pH 3.5 6.0
17. Tolazoline Hcl
Injection25 mg/ml
Diluent-NS, G 5% or G 10%
To prepare a standard infusion of 5 mg in 1 ml
Take 5 ml of tolazoline (125 mg) add to 20 ml of NS
G 5% or G 10% and mix well
125 mg in 25 ml
5 mg in 1 ml
CompatibleDopamine
IncompatibleIndomethacin
pH 3-4
CHAPTER
Safe Medicine
PEAK AND TROUGH LEVELS OF FEW ANTIBACTERIAL AGENTS

Drug
Optimal sample time
Optimal serum
concentration
range
Time to steady
state after
dose change
Toxic level
Amikacin
Trough#
Peak 30 min after 30 min infusion
25-30 g/ml
4-8 g/ml
24 48 hours
Chloramphenicol
Trough#
Peak 1.5 hour after 30 min infusion 15-25 g/ml

5-10 g/ml
72 hours
50 g/ml
Gentamicin
Trough#
Peak 30 minutes after

30 min infusion
6-8 g/ml
0.52 g/ml
24 48 hours
12 g/ml
Tobramycin
Trough#
Peak same as gentamicin
6-8 g/ml
0.5-2 g/ml
24 48 hours
>10 g/ml
Vancomycin
Trough#
Peak 1 hour after 1 hour infusion
25-30 g/ml
5 10 g/ml
24 72 hours
>50 g/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
sample time
Optimal serum
concentration
range
Time to steady state after dose change
Carbamazepine
Trough#
4-12 g/ml
3-4 days
Digoxin
Trough#
0.5 2 ng/ml
4 7 days with total digitalization and 12 weeks without digitalization
Phenobarbital
Trough#
15-40 g/ml
14 days
Quinidine
Trough#
2-6 g/ml
24 hr
Phenytoin
Trough#
10-20 g/ml
4 days after IV doses (rapid increase in elimination rate over

the first weeks of life necessitates frequent monitoring of drug
levels).
Theophylline
Trough# (Steady
state IV or oral)
Apnea: 5 1-0 g/ml

BPD: 10-15 g/ml
Approximately 96 hours varies with age

35 days
Valproic acid
Trough#
50-100 g/ml
# Trough serum drug concentration: Sample taken within 30 minutes prior to the next dose.
40
CONCENTRATION AND DURATION OF FEW INFUSIONS

Medication
Recommended minimum
dilution
Amikacin
Ampicillin
Cefazolin
Cefotaxime
Clindamycin
Cloxacilin
Gentamicin
Metronidazole
Penicillin G
Ticarcillin
Tobramycin
Vancomycin
Aminophylline
Cimetidine
Diazepam
Digoxin
Furosemide
Morphine
Phenobarbital
Phenytoin
6 mg/ml
50 mg/ml
100 mg/ml
100 mg/ml
6 mg/ml
50 mg/ml
5 mg/ml
5 mg/ml
100,000 u/ml
50 mg/ml
5 mg/ml
5 mg/ml
5 mg/ml
15 mg/ml
5 mg/ml
0.05 mg/ml
10mg/ml
1 mg/ml
30mg/ml
50 mg/ml
Minimum infusion time

510 minutes
5-10 minutes
5-10 minutes
5-10 minutes
5-10 minutes
5-10 minutes
5-10 minutes
5-10 minutes
5-10 minutes
5-10 minutes
5-10 minutes
60 minutes
5 10 minutes
5 10 minutes
2 minutes
3 5 minutes
2-3 minutes
3-5 minutes
Not > 2 mg/kg/min
Not >0.5 mg/kg/min
DRUG LOSS DURING EXCHANGE TRANSFUSION

Drug
Amikacin
Ampicillin
Carbamazepine
Carbenicillin
Colistin
Diazepam
Digoxin*
Furosemide
Gentamicin
Kanamycin
Methicillin
Oxacillin
Penicillin G (crystalline)
Penicillin G (procaine)
Phenobarbital
Phenytoin
Theophylline*
Tobramycin
Vancomycin
* Whole blood volume used in calculation.
Percent Loss
One volume
Two volume
7.1
7.7
3.7
5.6
18.7
2.3
1.2
4.9
5.2
5.6
10.1
19.6
6.0
2.4
6.4
3.1
17.8
10.3
5.7
13.8
14.7
7.2
10.9
33.9
4.5
2.4
9.5
10.1
10.9
19.1
35.4
11.6
4.8
12.3
6.2
32.4
19.6
11.0
Safe Medicine 41
AGENTS TO BE AVOIDED IN GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENT PATIENTS
Antimalarials
Analgesics
Primaquine
(Person with the African A variant may take it at
reduced dosage 15 mg/d or 45 mg twice weekly
under surveillance)
Pamaquine
Chloroquine (May be used under surveillance when required
for prophylaxis or treatment of malaria)
Analgesics
Acetylsalicylic acid (aspirin); moderate doses can be used
Sulfonamides and Sulfones

Sulfanilamide
Sulfapyridine
Sulfadimdine
Sulfacetamide (albucid)
Sulfafurazole
Salicylazosulfapyridine
(Salazopyrin, Azulfidine)
Dapsone
Sulfoxone
Glucosulfone sodium (Promin)
Septrin
Other Antibacterial Compounds
Nitrofurans-nitrofurantoin,
furazolidone, nitrogfurazone
[Nalidivic acid]
Chloramphenicol
P-aminosalicylic acid
Safe alternative: Paracetamol

Anthelmintics
-Naphthal
Stibophen
Niridazole
Miscellaneous Agents
Vitamin K analogues (1mg of menaphthone can be given to babies
Napthalene (Mothballs)
Probenecid
Dimercaprol (British antilewisite BAL)
Methylene blue
Arsine
Phenylhydrazine
Acetylphenylhydrazine
Toludine blue
Mepacrine
Agents that can safely be administered in therapeutic doses to glucose-6-phosphate dehydrogenase deficient patients
Acetaminophen (paracetamol, tylenol, crocin, calpol)
Phenylbutazone
Acetylsalicylic 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
42
DRUGS IN BREASTFEEDING
Drugs Whose Amount in Milk is too Small to be Harmful to the Neonate, in Ordinary Doses
Acetazolamide
Albendazole
Antacids
Amitriptyline
Amoxapine
Antifungal drugs (topical)
Aspirin (low dose)
Baclofen
Beclomethasone (Inhaler)
Benzyl benzoate (topical)
Bupivacaine
Buprenorphine
Cephalosporins
Cisapride
Cloxacillin
Codeine
Cromoglycate sodium
Dextropropoxyphene
Diclofenac
Digoxin
Domperidone
Ergometrine
Erythromycin
Ethambutol
Folic acid
Gentamicin
Haloperidol
Heparin
Hydralazine
Ibuprofen
Imipramine
Insulins
Ipratropium Br. (inhalation)
Iron dextran (i. m)
Iron salts (oral)
Ketoprofen
Lignocaine
Mebendazole
Methyldopa
Mexiletine
Naproxen
Nafopam
Niclosamide
Paracetamol
Permethrin (topical)
Piperacillin
Piperazine
Piroxicam
Praziquantel
Pyrantel
Pyrazinamide
Salbutamol
Sucralfate
Terbutaline
Valproate sod
Vitamins (maintenance dose)
Warfarin
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)
Acenocumarol
Acyclovir
Alcohol
Allopurinol
Amiloride
Aminoglycosides
Amiodarone
Amlodipine
Amphetamines
Ampicillin/Amoxicillin
Androgens
:
:
:
:
:
:
:
:
:
:
:
:
Anthraquinones (senna etc)

Anticancer drugs
Anticonvulsants
Antidepressants (tricyclic)
:
:
:
:
Antihistamines (H1)
Antihistamines (2nd generation)
Antipsychotics
:
:
:
Aspirin (high dose)
SP; amount in milk small, management of risk not known, watch for hypotension
SP; give prophylactic vit K to neonate
SP; significant amount in milk
Intoxication, reduced suckling
SP; secreted in milk, no data on risk to neonate
CI; no information on risk to neonate; may reduce lactation
SP; risk not known, most manufacturers advise caution
CI; risk of hypothyroidism from released iodine
SP; no data on risk to neonate
CI; significant amount in milk, irritability, poor sleeping pattern.
SP; diarrhoea, candidiasis
CI; masculinization of female neonate, precocious development of male neonate,
reduced lactation
CI; diarrhoea
CI; anaemia, diarrhoea, immunosuppression
SP; monitor neonate for side effects
SP; use doses<150 mg amitriptyline or monitor neonate for side effects, sedation,
respiratory depression
SP; significant amount in milk, watch for drowsiness
No data on risk to neonate.
SP; drowsiness, muscle dystonia; avoid chlorpromazine, haloperidol, clozapine;
amount in milk small, but long term effect on developing nervous system not known
SP; avoid high doses, bleeding, Reyes syndrome, metabolic acidosis
Safe Medicine 43
Atorvastatin
Atropine
Azathioprine
Azithromycin
Barbiturates
Benzodiazepines
:
:
:
:
:
:
Beta blockers
Bromocriptine
Buspirone
Caffeine
Carbamazepine
Carbimazole
Carisoprodol
Celecoxib
Chloral hydrate
Chloramphenicol
Chloroquine
Cimetidine
Ciprofloxacin
Clemastine
Clindamycin
Clofazimine
Clonidine
Cocaine
Corticosteroids
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
Cotrimoxazole
Cyclophosphamide
Cyclosporine
Dapsone
Depot medroxyprogesteron acetate (i.m)
Diltiazem
Disopyramide
Doxepin
Doxorubicin
:
:
:
:
:
:
Ephedrine
Ergotamine
:
:
Estrogens
Ethosuccimide
Famotidine
Flucanazole
Fluoxetine
Furosemide
Gemfibrozil
Gold salts
Heroin
Indomethacin
Iodine/Iodides
Iodine radioactive
:
:
:
:
:
:
:
:
:
:
:
:
Isoniazid
Itraconazole
Ketoconazole
Ketorolac
Lansoprazole
Levodopa/carbidopa
Lithium carbonate
:
:
:
:
:
:
:
Avoid; no data on risk to neonate

SP; monitor for anti-muscarinic effects
CI; immunosuppression
Avoid; no information on risk to neonate
SP; drowsiness, lethargy, withdrawal symptoms
SP; compatible in single dose; avoid repeated doses; lethargy, hypotonia, reduced
suckling, weight loss
SP; amount in milk generally small; bradycardia, hypotension, cyanosis
Suppresses lactation
Avoid regular consumption of large amounts, irritability, CNS effects
SP; amount in milk small but monitor neonate
SP; hypothyroidism, use lowest effective dose, or suspend breastfeeding
SP; concentrated in milk; avoid.
CI; sedation
CI; diarrhoea, ideosyncratic bone marrow supression, gray baby syndrome (unlikely)
SP; amount in milk small; haemolysis in < 1 month old infant and in G-6PD deficient
SP; significant amount in milk, but no harmful effect reported
CI; high concentration in milk, theoretical risk of arthropathy
SP; drowsy, irritability, refusal to feed, high pitched cry, neck stiffness.
SP; amount in milk small, but risk of diarrhoea, watch for blood in stools
SP; skin discolouration
SP; sedation, hypotension
SP; cocaine intoxication
SP; compatible in single doses; pituitary- adrenal suppression possible with > 10 mg
prednisolone daily to mother, impaired growth
SP; folate deficiency, risk of kernicterus, haemolysis in G6PD deficient; safe for
healthy older neonates
SP; possible immune suppression; unknown effect on growth or association with
carcinogenesis
CI; neutropenia
CI; significant amount in milk
SP; immune suppression
SP;haemolytic anaemia, jaundice
Compatible with breastfeeding from 6 weeks postpartum
SP; significant amount in milk
SP; small amount in milk, antimuscarinic effects
SP; sedation, respiratory depression
SP; possible immune suppression unknown effect on growth or association with
carcinogenesis.
SP; irritability, sleep disturbance
SP; vomiting, diarrhoea, convulsions (doses used in migrane medication)
CI; ergotism, may suppress lactation
CI; gynaecomastia in male neonate, may suppress lactation
CI; hyperexcitability, poor suckling
SP; present in milk, but harm to neonate not known
CI; secreated in milk, but harm to neonate not known
SP; small amount in milk, but can accumulate in neonate; avoid if possible
SP; small amount in milk, electrolyte disturbances
CI; rashes and other reactions
SP; tremors, restlessness, vomiting, poor feeding
CI; CNS effects, convulsions
CI; concentrated in milk, hypothyroidism and goiter
CI; suspend breastfeeding for 24 hr after diagnostic dose and for long-term after
therapeutic dose
SP; neuropathy, convulsions, jaundice, give prophylactic pyridoxine
Avoid; unless essential; amount in milk small
CI; secreted in milk but harm to neonate not known
Avoid as no data on safety
Avoid unless essential; no data in safety
SP; no data on safety
CI; intoxication, cardiac arrythmias (achieves 1/3 to1/2 therapeutic blood concentration)
44
Losartan
Mafloquine
Mesalazine
Metformin
Methotrexate
:
:
:
:
:
Metoclopramide
Metronidazole
:
:
Montelukast
Morphine (and other opioids)
:
:
Nalidixic acid
Neostigmine
Nicotine
:
:
:
Nifedipine
Nitrofurantoin
Norfloxacin
Omeprazole
Oral contraceptives
Penicillins
Phencyclidine (PCP)
Phenindoine
Phenobarbitone
:
:
:
:
:
:
:
:
:
Phenolphthalein
Phenytoin
Primidone
Progestins
Propylthiouracil
Pyrimethamine- sulfadoxine
Quinidine
Radioactive compounds
(Copper 64, Gallium 67, Indium 111,
Iodine 123, Iodine 125, Iodine131,
Radioactive sdatium, Technetium 99m,
99m RC macroaggregates)
Ranitidine
Rifampin
Rofecoxib
Sertraline
Spironolactone
Streptomycin
Sulfasalazine
Sulfonamides
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
Sulfonylureas
Tetracyclines
Theophylline
Thiazide diuretics
Thyroxine
Tinidazole
Vancomycin
Verapamil
Vigabatrin
Vitamin A and D
Zolpidem
:
:
:
:
:
:
:
:
:
:
:
SP; magnitude of risk not known; avoid if possible

SP; secreted in milk, but harm to neonate unlikely
SP; amount in milk small; watch for diarrhoea
CI; secreted in milk; hypoglycaemia, lactic acidosis
SP; possible immune suppression; unknown effect on growth or association with
carcinogenesis
CI; neutropenia
SP; watch for diarrhoea, dystonia in neonate
Significant amount in milk : In vitro mutagen; avoid high doses; suspend breastfeeding for 12 24 hr after single dose
Avoid; no data on risk to neonate
SP; usual doses unlikely to affect neonate; lethargy, poor growth, with drawal symptoms in infants of dependent mothers
SP; small risk of haemolytic anaemia; avoid if possible
SP; small amount in milk but monitor neonate
SP; vomiting, diarrhoea, decreased milk production
CI; tachycardia, restlessness, shock
SP; small amount in milk but monitor neonate
SP; small amount in milk, haemolysis in G6PD deficient neonate.
Avoid unless essential; no data on safety
Avoid until six month after birth, see estrogens
Toxicity unlikely but risk of allergy
SP; potent hallucinogen
SP; increased prothrombin and partial thromboplastin time
SP; Sedation, infantile spasms after weaning from milk containing phenobarbitone,
methemoglobinemia (rare)
CI; diarrhoea, rashes
SP; small amount in milk, but monitor neonate
SP; sedation, feeding problem
Low doses safe, may suppress lactation at high doses
SP; hypothyroidism with high doses only
SP; significant amount in milk; appears safe if infant is older
SP; significant amount in milk but harm to neonate not known
CI; Secreted in milk
CI;diarrhoea, rashes
SP; significant amount in milk but harm to neonate not known
SP; significant amount in milk small, but monitor infant for jaundice
Avoid; no information on risk to infant
SP; present in milk but no harm reported in short term
SP; drowsiness, hirutism, gynaecomastia
Compatible with breast feeding; monitor infant for diarrhoea and thrush
SP; bloody diarrhoea
SP; rashes, small risk of kernicterus in neonate, haemolysis in G6PD deficient; safer
for older infants
SP; no adverse effect reported, but watch for hypoglycaemia
CI; growth retardation, candidiasis, tooth discolouration
SP; irritability, CNS effects
SP; amount in milk small; may reduce lactation
SP; monitor for hyperthyroidism
SP; present in milk; suspend breastfeeding till three days after stopping
SP; present in milk, but absorption from neonates gut unlikely
SP; small amount in milk, but monitor neonate
CI; present in milk, no data on risk to neonate
Avoid high doses, risk of hypervitaminosis
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 inhibitors
can 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 human
teratogens 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 asigned
pregnancy 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.
Abortion, malformations
Congenital heart disease
Microcephaly, IUGR
Goiter
Microcephaly, mental retardation
Fetal hydantoin syndrome (low and broad nasal bridge, mild ptosis, coarse hair and distal digital hypoplasia
consisting of nail hypoplasia
Virilization
Vaginal adenocarcinoma in adolescents
Phocomelia
Nose, eye and hand defects, growth retardation
Spina bifida, limb defects (radial ray reduction defects consisting of absence or hypoplasia of radius, first
metacarpal and thumb) and other neural tube defects
Malformation like V-shaped eyebrows, epicanthus, low set ears with anteriorly folded helix and palatal
anomalies.
Discoloured and deformed teeth, retarded bone growth
Virillization of female foetus
Various malformations
Foetal goiter and hypothyroidism
Craniofacial, heart and CNS defects
Premature closure of ductus arteriosus
Cleft palate and lip, cardiac defects
Craniofacial dysmorphism and nail hypoplasia, developmental delay, cardiac defects, short nose with long
philtrum, neural tube defects, other abnormalities
Multiple defects, foetal death
Aminopterin
Amphetamine
Cocaine
Antithyroid drugs
Methylmercury
Phenytoin
Methyltestosterone
Stilbesterol
Thalidomide
Warfarin
Sodium Valproate
Trimethadione
Tetracyclines
Progestins
Phenobarbitone
Lithium
Isotretinoin
Indomethacin/aspirin
Corticosteroids
Carbamazepine
Anticancer drugs
(methotrexate)
Androgens
Virillization; limb, esophageal, cardiac defects
PASSAGE OF ANTIBIOTICS ACROSS THE PLACENTA

Percent antibiotic in indicated category
Equal to serum concentration
50% of serum concentration

10%-15% of serum concentration
Negligible(<10% of serum concentration)
Antibiotic
Amoxicillin
Ampicillin
Carbenicillin
Chloramphenicol
Methicillin
Nitrofurantoin
Penicillin G
Sulfonamides
Tetracyclines
Trimethoprim
Aminoglycosides(except ones below)
Amikacin
Cephalosporins
Clindamycin
Nafcillin
Tobramycin
Dicloxacillin
Erythromycin
CHAPTER
Pharmacokinetics
6
PHARMACOKINETICS
Loading
Dose (mg/kg)
Maintenance
Dose (mg/kg)
Steady state
Conc. (ug/ml)
Vol. Distribution (L/kg)
Clearance
(L/kg/hr)
Elimination
contant (Kel)
Concentration
At tine T hr
Vd x Cp / F
MD x t / Dl x 0.693
LD x Dl / t x 1.44
Css x Vd x Dl / t x F x 1.44
F x MD / Cl x Dl
t x F x MD/ 0.693 x Vd x Dl
D / Co
D x t / 0.693 x AUC
Vd / 1.44 x t
D/AUC = D x 0.693 / t x Co
0.693 / t
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)
Dose (mg/kg)
Dl
Dose interval (hours)
2.71828
Fraction of drug absorbed
Kel
Elimination constant
LD
Loading dose (mg/kg)
MD
Maintenance dose (mg/kg)
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, amitriptyline, 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 parallel
to decrease in creatinine clearance (CLcr). Loading dose of such a drug is not altered (unless edema is present) but maintenance 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 t of the drug
is 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, benzodiazepines
etc. 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 be
avoided.
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
Drug
Acyclovir
Amikacin
Amoxicillin
Amphotericin B
Ampicillin
Carbenicillin*
Adjustments in renal failure
Route of
excretion
Normal
T1/2 (hr)
Normal
dose interval
Method
Creatinine
> 50
Clearance
10-50
(ml/min)
<10
Supplemental
dose for
dialysis
Renal
Renal
2.1-3.8
2-3.0
q8h
q8-12h
0.9-2.3
q8h
q8h
q12h
60-90%
q8h
q24h
q12-18h
30-70%
8-12h
q48h
q24h
20-30%
q12-16h
Yes (He)
Renal
(hepatic)
Nonrenal
Renal
(hepatic)
Renal
(hepatic)
I
I
D
I
24
0.8-1.5
q24h
q4-6h
I
I
q24h
q6h
q24h
q6-12h
q24-36h
q12-16h
1.2-1.5
q4-6h
q8-12h
q12-24h
q24-48h
Yes (He,P)
Yes (He)
No (P)
No (He,P)
Yes (He)
No (P)
Yes (He)
No (P)
Contd...
48
Contd...
Cefactor
Cefamandole
Cefazolin
Cefotaxime
Cefoxitin
Ceftazidime
Renal
(hepatic)
Renal
Renal
Renal
(hepatic)
Renal
0.75
q8h
100%
50-100%
33%
Yes (He,P)
1.0
1.4-2.2
q4-8h
q8h
I
I
q6h
q8h
q6-8h
q12h
q8h
q24-48h
q6-8h
q6-8h
q8-12h
q12-24h
1.0
q6-8h
q8h
q8-12h
q24-48h
Yes (He)
Yes (He)
No (P)
Yes (He)
No (P)
Yes (H)
No (P)
Yes (He)
No (P)
Yes (He)
No (P)
Yes (He)
No (P)
Yes (He)
No (P)
Yes (He, P)
Yes (He, P)
Yes (He, P)
1.8
q8-12h
q12h
q12-24h
q24-48h
Cefuroxime
Renal
(hepatic)
Renal
1.6-2.2
q6-8h
q8-12h
q24-48h
q48-72h
Cephalexin
Renal
0.9
q6h
q6h
q6-8h
q8-12h
Renal
(hepatic)
Renal
Renal
Renal
0.5-1.0
q6h
q6h
q6-8h
q9-12h
4
20-50
3-6
q24h
q24h
q6h
I
D
I, D
q24h
100%
q6h, 50%
Ganciclovir
Renal
2.5-3.6
q8-12h
DI
q48h
25%
q24-48h,
20-30%
25% and
q24h
Gentamicin#
Renal
2.5-3.0
q8-12h
2-4 $
0.5-1.5 (fast)
2-3
q24h
q12h
30-70%
100%
q24h,
20-30%
66-75%
Yes (He, P)
Hepatic
(renal)
Renal
I
D
D
50-100%
and
q8-12h
q8-12h
60-90%
100%
q24-36h
25-50%
q12-24h,
30-50%
25-50%
and q24h
0.5-1.0
q4-6h
q8-12h,
69-90%
q4-6h
q12h
30-70%
q6-8h
q24h,
20-30%
q8-12h
Yes (He,P)
Renal
(hepatic)
Hepatic
(renal)
Nonrenal
Renal
(hepatic)
Renal
(hepatic)
Hepatic
(renal)
Renal
(hepatic)
Renal
I
D
I
No (He, P)
6-14
q8h
q8h
q8-12h
q12-24h
Yes (He)
1-1.7
0.5
q8h
q4-6h
D
I
100%
q6-8h
Avoid
q8-12h
Avoid
q12-16h
0.8-1.5
q6h
q4-6h
q6-8h
q8h
Yes (He)
Yes (He)
No (P)
Yes (He)
9-11
q12h
q12h
q18h
q24h
1-1.5
q4-6h
q8-12h
q12-24h
q24-48h
2.5-3
q8h
8-15
q12h
I
D
I
q8-12h
60-90%
q12h
q12h,
30-70%
q18h
q24h,
20-30%
q24h
6-10
q6-8h
q24-72h
q72-240h
q240h
Cephalothin#
Ethambutol
Fluconazole#
Flucytosine
Isoniazid
Kanamycin
Methicillin
Metronidazole
Nitrofurantoin
Penicillin G
Piperacillin
Sulfamethoxazole
Ticarcillin*
Tobramycin
Trimethoprim
Vancomycin
Renal
(hepatic)
Renal
q8h
* 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
Yes (He)
Yes (He, P)
Yes (He)
No (P)
Yes (He)
No (P)
Yes (He, P)
Yes (H)
No (P)
Y/N (He) & No (P)
Pharmacokinetics
NON-ANTIMICROBIALS REQUIRING ADJUSTMENT IN RENAL FAILURE
Pharmacokinetics
Adjustments in renal failure
Drug
Route of
excretion
Normal
T1/2 (hr)
Normal
dose interval
Method
Creatinine
> 50
Clearance
10-50
(ml/min)
<10
Supplemental
dose for
dialysis
Acetaminophen
Hepatic
q4h
q4h
q6h
q8h
Acetylsalicylic
Acid *
Adriamycin
Allopurinol
Hepatic
(renal)
Renal (hepatic)
Renal
2-19
q4h
q4h
q4-6h
Avoid
Yes (He)
No (P)
Yes (He, P)
16-30
0.7-1.6
Single treatment
q24h
100%
q8h, 100%
Hepatic
IV: 12.5 min;

PO: 0.5-4h
1.9
q24h
q12h
100%
q24h
100%
100%
q8-12h
75%
100%
q24h
100%
75%
q12-24h,
50%
75%
q36h
50%
?
Yes (He)
Azathioprine #
D
I
D
D
I
D
20-36
q8-12h
100%
100%
75%
No (He, P)
7-14
1.5-2
q8h PRN
q12h
q24h
4-7
7
q6h
q12-24h
100%
q6h,
100%
100%
q24h
q6h
100%
Avoid
q8h,
75%
25-75%,
q36h
q6-9h
50%
Avoid
q12h,
50%
10-25%,
q48h
q9-12h
25%
Yes (He)
No (He)
36-44
D
I
D
D
I
I
D
2.5-4
q12-24h
2-4.5
q20-40h,
100%
q8-12h
9 min
q8h (fast), &

q12h (slow)
Variable
I
D
I
D
100%
q6-8h
100%
75%
50%
No (He)
Tripha-sic,
0.1, 2.3, 27
65-150
Single
treatment
q8-12h
100%
50%
Avoid
q8-12h
q8-12h
q12-16h
Yes (He)
No (P)
Yes (He, P)
6-12
q8-12h
q8-12h
q8-12h
q12-24h
Yes (He)
1.5-3
q8-12h
100%
75%
50%
Yes (He)
10-35
q6h
q6-12h
q12-24h||
Avoid
1-2
q12h
100%
100%
Avoid
Captopril
Carbamazepine
Chloral Hydrate
Cimetidine
Digoxin
Diphenhydramine
Enalapril
Famotidine
Hydralazine#
Insulin (regular)
Metaclopramide
Methotrexate
Phenobarbital
Primidone
Ranitidine
Spironolactone
Thiazides
Renal
(hepatic)
Hepatic
(renal)
Hepatic
Renal
(hepatic)
Renal (GI)
Hepatic
Renal
(hepatic)
Renal
(hepatic)
Hepatic (GI)
Hepatic
(renal)
Renal
(hepatic)
Renal
Hepatic
(renal, 30%)
Hepatic
(renal, 20%)
Renal
(hepatic)
Renal
(hepatic)
Renal
q30-60h,
q68-136h,
50%
25%
q8-12h q8-16h (fast),
q12-24h (slow)
75%
50%
* 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.
Yes (He)
Yes (He)
No (He, P)
?
Yes (He)
No (He, P)
No (He, P)
?
49
50
DRUGS REQUIRING NO ADJUSTMENT

Drug
Extra dose for dialysis
Antibiotics
Ceftriaxone
Chloramphenicol
Clindamycin
Cloxacillin
Erythromycin
Ketoconazole
Miconazole
Nafcillin
Pyrimethamine
Rifampin
He
Non-antibiotics
Amitriptyline
Busulfan
Chlorpheniramine
Chlorpromazine
Clonidine
Codeine
Corticosteroids (any)
Cytosine arabinoside
Diazepam
Diazoxide
Diltiazem
Fentanyl
5-Fluorouracil
Flurazepam
Furosemide
Haloperidol
Heparin
Ibuprofen
Imipramine
Indomethacin
Lidocaine
Meperidine
Metolazone
Midazolam
Minoxidil
Morphine
Naloxone
Nifedipine
Nitroprusside
Pentazocine
Pentobarbital
Phenytoin
Prazosin
Propoxyphene
Propranolol
Quinidine
Secobarbital
Succinylcholine
Theophylline
Valproic acid
Verapamil
Vincristine
Warfarin
He = Hemodialysis
P = Peritoneal dialysis
He
He, P
He
He
He
He, P
He, P
Pharmacokinetics
51
Congestive heart failure

Decreasing drug absorption from g.i.t. due to mucosal edema and splanchnic vasoconstriction. Procainamide and hydrochlorothiazide.
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

Sulfonamides
Moxalacinm
Fusidic acid
Radiographic contrast media for cholangiography (sodium iodipamide, sodium ipodate, iopanoic acid, meglumine ioglycamate
Aspirin
Apazone
Tolbutamide
Rapid infusions of albumin preservatives (sodium caprylate and N-acetyltryptophan)
Rapid infusions of ampicillin
Long-chain free fatty acids (FFA) at high molar ratios of FFA: albumin
CHAPTER
Special Nutrition
COMPOSITION OF VARIOUS MILKS (ALL PER 100 ML OF MILK)

Milk
Energy (Kcal)
Mature term breast milk

Preterm breast milk
Preterm
EBM + Fortifier
Donor bank milk
Cows milk
Whey based term formula
Casein based term formula
Follow on (>6 months)
LBW formula
LBW follow- on
Protein (g)
Casein whey
CHO
(g)
Fat
(g)
Na
(mmol)
K
(mmol)
Ca
(mmol)
P
(mmol)
70
67
1.3
1.8-2.4
1:2
N/A
7
6
4.2
4
0.65
2.2
1.5
1.8
0.9
0.6
0.5
0.5
80
46
67
65-68
65-69
70
80
74
2.5-3.1
1.1
3.4
1.5
1.5-1.9
1.8
2.0-2.4
1.8
N/a
N/A
3:1
1:1.5
4:1
3.5:1
1:1.5
1.5:1
9
7.1
4.6
7.0-7.3
7.2-8.6
7.2
7.0-8.5
7.5
4
1.7
3.9
3.6-3.8
3.1-3.6
4.6
3.5-4.9
4.1
3.1
0.7
2.2
0.8
0.8-1.1
1.0
1.3-2.0
1.0
3.9
1.4-2.2
1.6-2.2
2.2
1.8
1.9
1.8
0.9
3
0.9-1.5
1.2-2.1
2.2
1.8-2.7
2.0
1.4
0.5
3
0.9-1.1
1.2-1.8
1.6
1.1-1.7
1.3
AVERAGE DAILY NUTRITIONAL REQUIREMENTS

Age
Infant >2.5 kg at birth
1day
2days
10 days
3 months
Infant <2.5 kg at birth
<1 month
Water (ml/kg)
Kcal./kg
Protein
(g/kg)
Na
K
mmol/kg
Ca2
PO 43(mmol/kg)
60-90
90-120
120-150
140-160
115
115
105
105
2.2
2.2
2.0
2.0
2-3
2-3
2-3
2.0
2-3
2-3
2-3
2-3
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
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
Fluid
Protein intake
Whey: Casein ratio

amino acids
Fat intake
Linoleic acid
medium chain triglycerides (MCT)
Carbohydrates
intake
Starch hydrolysates: sucrose; glucose
110 - 165 kcal/kg/day

130-200 ml/kg/day
2.9-4.0 g/kg/day
Whey predominant should not fall below
human milk content
4.0-9.0 g/kg/day
>3% of total energy or 0.5 g/100 kcal
<40% of total fat
<15 g/kg/day of lactose;
Glucose polymers and lactose (50:50);
Contd...
Special Nutrition
Contd...
Minerals
Sodium
Chloride
Potassium
Calcium
Phosphorus
Ca:P ratio
Magnesium
Zinc
Copper
Vitamin A
Vitamin K
Vitamin E
Vitamin D
Vitamins
1.3-3.5 mmol/kg/day
2.0-3.5 mmol/kg/day
2-5 mmol/kg/day
90-250 mg/kg/day
65-125 mg/kg/day
1.4-2.0
15 mg/kg/day
0.6-1.4 mg/kg/day
110-150 mg/kg/day
120-420 g/day
0.5-1.0 mg at birth
0.5-0.6 mg/100kcal
500-2000 IU/day
RECOMMENDED DAILY ALLOWANCES OF VITAMINS AND MINERALS

Vitamin A
Vitamin D
Vitamin E
Vitamin C
Thiamine
Riboflavin
Niacin
Vitamin B 6
Folic acid
Vitamin B12
420 IU
400 IU
3 mg
35 mg
0.3 mg
0.4 mg
6.0 mg
0.3 mg
30 g
0.5 g
Calcium
Phosphorus
Magnesium
Iron
Zinc
Iodine
360 mg
240 mg
50 mg
10 mg
3 mg
40 g
GUIDELINES FOR THE MODES OF PROVIDING FLUIDS AND FEEDING

Age
Categories of neonates
Birth weight
Gestation
Initial
After 1-3 days
Later (1-2 wk)
After some more time (4-6 wk)
<1200g
<30 weeks
Intravenous fluids.
Try gavage feeds, if not sick.
Gavage feeds
Katori-spoon feeds
Breastfeeding
1200-1800g
30-34 weeks
Gavage feeds
Katori-spoon feeds
Breastfeeding
Breastfeeding
>1800g
>34 weeks
Breastfeeding. If unsatisfactory
give katori or spoon feeds
Breastfeeding
Breastfeeding
Breastfeeding
TUBE FEEDING GUIDELINES
Birth weight (g)
Initial rate (ml/kg/day)
Volume increase (ml/kg/day)
<800
800-1000
1001-1250
1251-1500
1501-1800
1801-2500
>2500
10
10-20
20
30
30-40
40
50
10-20
10-20
20-30
30
30-40
40-50
50
53
54
ORAL DIETARY SUPPLEMENTS AVAILABLE FOR USE IN INFANTS

Nutrient
Product
Source
Energy content
Fat
MCT oil
(Mead Johnson)
Microlipid
(Mead Johnson)
Corn oil
Medium-chain
triglycerides
Long-chain
triglycerides
Long-chain
triglycerides
Glucose polymers
8.3 kcal/g
7.7 kcal/ml
4.4 kcal/ml
Carbohydrate
Polycose
(Ross)
Protein
Promod (Ross)
9 kcal/gm
8.4 kcal/ml
3.8 kcal/gm
8 kcal/tsp (powder)
2 kcal/ml (liquid)
4.2 kcal/g
5.5 kcal/tsp
Whey
Concentrate
MCT = medium-chain triglyceride
IRON SUPPLEMENTATION GUIDELINES IN THE PREMATURE INFANT
< 1000 g
Total dose
Formula
Low iron
Birth weight
1000-1500 g
1500-1800 g
>1800 g
Comments
-
4 mg/kg/day
Supplement with
elemental iron
4 mg/kg/day
Supplement with
elemental iron
2 mg/kg/day
Elemental iron
4 mg/kg/day
3-4 mg/kg/day
Supplement with
elemental iron
3-4 mg/kg/day
Additional
elemental iron
1-2 mg/kg/day
Elemental iron
3-4 mg/kg/day
2-3 mg/kg/day
Supplement with
elemental iron
2-3 mg/kg/day
Additional
1mg/kg/day
as needed
Elemental iron
2 mg/kg/day
2 mg/kg/day
Supplement with
elemental iron
2 mg/kg/day
No additional
supplementation
Combination
Supplement with
(formula plus HM)
elemental iron
Low iron
4 mg/kg/day
Iron fortified
Calculate for total
iron dose of
4 mg/kg/day
Supplement with
elemental iron
3-4 mg/kg/day
Calculate for total
iron dose of
3-4 mg/kg/day
Supplement with
elemental iron
2-3 mg/kg/day
Additional
1 mg/kg/day
as needed
Supplement with
elemental iron
2 mg/kg/day
No additional
supplementation
Iron fortified
Human milk (HM)
only
Elemental iron
2 mg/kg/day
Infants under 1800g

should be on 24 cal/oz HM
(with human milk fortifier)
before iron supplementation
is begun
-
COFACTOR / LIMITING AMINO ACID THERAPY

Disorder
Phenylketonuria
Neonatal tyrosinemia
Classical homocytinuria
Hartnup disease
Mitochondrial disorder
Maple syrup urine disease
Methylmalonic acidaemia
Multiple carboxylase deficiency
Isovaleric academia
Hawkinsinuria
Vitamin / cofactor
Dose (mg/d)
Amino acid supplement
Vitamin C
Pyridoxine and folic acid
50-100
100-500
10-20
100-250
100-150
10-20
1.0-3.0
5-10
1000
Tyrosine
Cystine
Niacin
Riboflavin
Thiamine
B12
Biotin
Vitamin C
Bicarbonate
Glycine and L-carnitine
-
Special Nutrition
55
SOME IMPORTANT METABOLIC CONDITIONS

Condition
Deficiency
Acidosis and
ketosis
Treatment
Antenatal
detection
Propionic
acidaemia
Maple syrup urine disease
(branched chain Ketoaciduria)
Methylmalonic acidaemia
Propionyl CoA carboxylase
+++
IV glucose exchange transfusion dialysis
Yes
Branched chain
+++
Keto-acid dehydrogenase
Methylmalonyl CoA mutase +++
Yes
Isovaleric Acidaemia
(sweaty feet)
Multiple carboxylase
deficiency
Isovaleric acid
+++
dehydrogenase
Various carboxylases
+++
involved in biotin metabolism
IV glucose exchange/dialysis, severe

neonatal illness
IV glucose/HCO3 exchange/dialysis
B12 1mg o.d. low protein diet
IV glucose / HCO3 low leucine diet
IV glucose/HCO 3 neonate is often
biotin responsive
Yes
Yes
Yes
COMMERCIAL FORMULAS AND FOODS

Formulas for metabolic disorders
Indicated use
Product
Phenylketonuria (PKU)
PKU, infant
PKU, child
Maple Syrup Urine Disease
MSUD, infant
MSUD, child
Tyrosinemia
Tyrosinemia, infant
Tyrosinemia, child
Homocystinuria
Homocystinuria, infant
Homocystinuria, child
Histinemia, infant
Histinemia, child
Hyperlysinemia, infant
Hyperlysinemia, child
I proprionic acidemia methylmalonic aciduria
C. proprionic acidemia methylmalonic aciduria
Methylmalonic acidemia
Hyperammonemia, infant
Hyperammonemia, child
Disaccharidase deficiency
Lofenalac, Phenyl Free

PKU 1, Analog XP
PKU 2, Maxamaid XP
MSUD
MSUD 1, Analog MSUD
MSUD 2, Maxamaid MSUD
LowPhenylTyr (3200AB), Analog XPHEN,
TYR, MET
TYR 1
TYR 2, Maxamaid XPHEN, TYR
Low methionine (3200K), Maxamaid XMET
Hominex 1
Hominex 2
Hist 1a
Hist 2a
LYS 1a
LYS 2A
OS 1a
OS 2 a
Analog XMET, TYR, MET, or Maxamaid
XMET, THRE, VAL, ISLEU
UCD 1
UCD 2
Monosaccharide and Disaccharide Free Diet
Powder (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%,
Protein 7%, fat 55%
Carbohydrate 43%
Lactose
Whey 50%, Casein 20%
Human milk fat
300
Lactose
protein, 9%, fat, 48%
Lactose
Coconut, soy or
oleo, or both safflower
300
Carbohydrate 43%,
protein 9%, fat 48%,
Nonfat Cows milk

Demineralized whey
60%, Casein 40%
Nonfat cows milk
Casein 82%, Whey 18%
Coconut, soy
300
Enfamil
Similac
Contd...
56
Contd...
Formula type
Calorie distribution
Gerber
Good Start
Similac
PM 60/40
Carbohydrate type
Carbohydrate 43%,
protein 10%, fat, 46%
Carbohydrate 44%,
Protein 10%, Fat, 50%
Lactose
Carbohydrate 41%,
protein 10%, fat, 50%
Lactose
Protein type
Lactose, 70%
Maltodextrin, 30%
Fat type
Nonfat Cows milk

Casein 82%, Whey 18%,
Whey protein 42%
hydrolyzed Soy coconut
sunflower
Nonfat cows milk,
Demineralized whey,
Osmolality (mOsm)
Palm olein Soy

Coconut Sunflower
Palm olein
320
265
Soy, coconut
280
Formulas free of lactose and or cows milk protein and special milk based (casien hydrolysate) formulas
Lactofree
Soy
Isomil
Nursoy
Alsoyd
Gerber Soyc
Soy (sucrose free)
Isomil SF
Prosobeea
Neocate infant
w/iron
Nutramigen
Alimentum
Pregestimil
RCF (Ross
carbohydrate
free)
Carbohydrate 42%,
protein 9%, fat 49%
Carbohydrate 40%,
Protein 11-13%
Corn syrup solids
Milk protein isolate
Corn syrup solids or

sucrose, or both
Soy isolate
Corn syrup solids

Carbohydrate 40%
Protein 12%,
fat, 48%
Carbohydrate 47%,
Corn syrup solids
protein 12%, fat, 41% Refined Vegetable oil
(coconut, soy)
Carbohydrate 44%,
Corn syrup solids,
Protein 12%, fat 45% modified corn starch
Carbohydrate 41%,
Sucrose, modified
protein 11%, fat 48% tapico starch
Carbohydrate 41%
Corn syrup solids,
protein 11%, fat 48% modified corn starch,
dextrose
Carbohydrate 40%,
protein 12%, fat 48%
Type desired 52g

and 12 oz H2O with
13 oz RCF full
strength
Palm olein Soy

200
Coconut Sunflower
Soy or coconut, or 250-296
both, corn, oleo,
safflower
Soy isolate
Soy, coconut, palm 180-200

olein, sunflower
Amino acids
Safflower
342
Casein hydrolysate
Palm olein, soy,

coconut
MCT 50%,
safflower, soy
MCT 55%, corn
20%, safflower
12.5%, soy 12.5%
320
Soy, coconut
Varies with source

of carbohydrate
Casein hydrolysate
Casein hydrolysate
with L-cysteine,
L- tryptophan,
L tyrosine
Soy isolate
370
300
Formulas with altered fat, protein, and carbohydrates

Fat alterations
Portagen
Progestimila
Alimentum
Elemental
Neocate One
Peptamen Jr
Vivonex
Paediatric
Enfamil
premature
Carbohydrate 46%,
protein 14%, Fat 40%
See above
See above
Corn syrup solids,

sucrose
Sodium caseinate
MCT 85%, corn

12.5%, lecithin
2.5%
220
Carbohydrate 58.5%,
Protein 10%,
Fat 31.5%,
Carbohydrate 55%,
Maltodexterin 68%,
Sucrose 32%
Amino acids
Safflower 65%,
MCT 35%,
Maltodexterin, starch
Hydrolyzed whey
MCT 60%, SOY,

CANOLA
Maltodexterin,
modified starch
Lactose 40%, corn
syrup soilds, 60%
Amino acids
MCT 68%, soy

32%
MCTs 40%, corn
40%, coconut, 20%
835, liquid,
1cal/ml; 610,
powder, 1 Cal/ml
260, unflavoured,
1 cal/ml, 365,
vanilla, 1 cal/ ml
360, 0.8cal/ml
Carbohydrate 62%,
Carbohydrate 44%,
Nonfat cows milk

Demineralized whey
Whey 60%, casein 40%
300
Contd...
Special Nutrition
Contd...
Similac special
care
Carbohydrate 42%,
Similac Neocare
Carbohydrate, 41%
Lactose 50%,
hydrolyzed corn
starch, 50%
Lactose, 50% corn
syrup solids 50%
Nonfat cows milk

Demineralized whey
Nonfat cows milk
Demineralized whey
Whey 50%, casein 50%
MCTs 50%, corn

30%, coconut, 20%
300
MCT 25% Coconut,

30%, or 20%
powder only,
SOY 45% OR 28%
powder only,
safflower 27%,
powder only
290
SUGGESTED INTAKES OF PARENTERAL VITAMINS IN INFANTS

Vitamin
Estimated needs
Term Infants
Preterm Infants
(dose/day)
(dose/kg/day)
Lipid Soluble
A (g)
D (IU)
E (IU)
K (g)
Water Soluble
Thiamine (mg)
Riboflavin (mg)
Niacin (mg)
Pantothenate (mg)
Pyridoxine (mg)
Biotin (g)
Vitamin B12 (g)
Vitamin C (mg)
Folate (g)
40% of a Single-dose
Vial MVI Paediatric
per Kilogram of
Body Weight
1.5mL MVI Pediatric

per 100 mL PN
Administered at
a Rate of 150
ml/kg/day
700
400
7
200
500
160
2.8
80
280
160
2.8
80
315
180
3.2
90
1.2
1.4
17
5
1.0
20
1.0
80
140
0.35
0.15
6.8
2.0
0.18
6.0
0.3
25
56
0.48
0.56
6.8
2.0
0.4
8.0
0.4
32
56
0.54
0.63
7.65
2.25
0.45
9.0.45
36
63
Standard TPN Regimen
Protein (g/kg per 24 h)

Nitrogen (g/kg per 24 h)
Carbohydrate (g/kg per 24 h)
Fat (g/kg per 24 h)
Energy (kcals/kg per 24 h)
Sodium (mmol/kg per 24 h)
Potassium (mmol/kg per 24 h)
Calcium (mmol/kg per 24 h)
Phosphorus (mmol/kg per 24 h)
Volume (ml/kg per 24 h)
Day 1
Day 2
Day 3
Day 4
1.0
0.16
10
1
50
3
2.5
1.9
1.5
150
1.5
0.23
12
2
68
3
2.5
1.9
1.5
150
2.0
0.33
14
3
86
3
2.5
1.9
1.5
150
2.5
0.4
15
4
100
3
2.5
1.9
1.5
150
57
CHAPTER
Specific Therapeutics
TIME TABLE FOR ELECTIVE SURGICAL REPAIR
Meningocele
Cleft lip
Hirschsprungs disease
Inguinal hernia
Anal and rectal aresia
Cleft palate
Cryptorchidism
Exstrophy of bladder
Umbilical hernia
Phimosis
Hypospadias
Earliest possible
3-9 months
Early at diagnosis
Early, if fit
Colostomy at birth
18-36 months
after 1 year
1-3 months
1-5 years
1-5 years
3-5 years
NORMAL LONGITUDINAL BLOOD PRESSURE IN FULL-TERM INFANTS (mm Hg)

Boys
Girls
Age
Systolic
Diastolic
Systolic
Diastolic
1st day
4th day
1 month
3 months
6 months
67
76
84
92
96
37
44
46
55
58
68
75
82
89
92
38
45
46
54
56
7
8
10
11
9
7
9
9
10
10
8
8
9
11
10
7
8
10
10
10
ANTIHYPERTENSIVE AGENTS FOR THE NEWBORN
Diuretics:
Furosemide
Chlorothiazide
Vasodilators:
Hydralazine.
Calcium channel blockers
Nifedipine
Beta receptor antagonist Propranolol
Alpha/beta receptor antagonist Labetalol
ACE inhibitors
Captopril
Enalapril
Dose
Comment
0.5 1.0 mg/kg/dose

IV, IM, PO
20-50 mg/kg/day;
divided qid or bid
1-8 mg/kg/day;
divided q6-8 hr
May cause hyponatremia,

Hypokalemia, hypercalciuria.
May cause hyponatremia,
Hypokalemia, hypochloremia
0.2mg/kg/dose sublingual, PO
0.5-5.0 mg/kg/ day PO; divided q6-8 hr
0.5 1.0 mg/kg/dose IV, q4-6 hr
Limited use in neonates. May cause tachycardia

May cause bronchospasm
Limited use in neonates
May cause tachycardia
0.15- 2.0 mg/kg/day PO, divided q8-12 hr May cause oliguria, hyperkalemia, renal failure
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
UK 5000/ml 1.5-3.0ml / Lumen 2-4 hr

UK 150 units/kg/H per lumen 12048 hr
None
Fibrinogen, TT,PT,APTT
Load
Maintenance
Monitoring
UK 4000 units/kg
SK 4000 units/kg
4000 units/kg/hr for 6 hr

2000 unit/kg/hr
max 2,50,000 units
0.5 mg/kg/h for 6 hr
Instillation
Infusion
2) Systemic thrombolytic therapy
TPA0.05-5 mg/kg/hr
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
30-60
60-120
>120
1.0
0.5-0.75
0.375-0.5
0.25-0.375
INITIAL DOSING OF ENOXAPRIN, AGE-DEPENDENT (IN MG/KG/DOSE SQ)

Age
Initial treatment dose
Initial prophylactic dose
1.5 q12h
1.0 q12h
0.75 q12h
0.75 q12h
Term infant
Preterm infants
SYSTEMIC THROMBOLYTIC THERAPY

Agent
Load
Infusion
Comments
tPA
None
0.1-0.5 mg/kg/hr for 6 h
Streptokinase
2000-4000 U/kg 1000-2000 U/kg/hr for 6 h.

over 10 min
4000 U/kg
4000 U/kg/hr for 6 h
over 10 min
Duration usually 6 h; can continue for 12 h or repeat after 24 h, although lysis of clot will continue
for hours after infusion stops.
Only one course should be given.
Consider premed with tylenol and benadryl.
Longer duration may be necessary based on clinical
response.
Urokinase
*tPA = Tissue Plasminogen Activator
LOCAL SITE-DIRECTED THROMBOLYTIC THERAPY

Agent
Infusion
Notes
tPA
Urokinase
0.03-0.05 mg/kg/h
150 U/kg/h
Adjust infusion rate if no clinical effect to 0.1-0.5 mg/kg/h

Increase infusion by 200 U/kg/h if no clinical effect
60
MONITORING AND DOSAGE ADJUSTMENT OF ENOXAPARIN BASED ON ANTI-FACTOR Xa LEVEL MEASURED 4 HOURS
AFTER DOSE OF ENOXAPARIN
Anti-factor Xa Level (u/ml)
Hold dose
Dose change
Repeat anti-Xa-level
<0.35
0.35-0.49
0.5-1.0
1.1-1.5
1.6-2.0
>2.0
3h
Until level is 0.5 u/ml
+25%
+10%
-20%
-30%
-40%
4 h after next dose

4 h after next dose
24 h
Before next dose
Before next dose, then 4h after next dose
Before next dose; if level not <0.5 u/ml, repeat q12h
COMPARISON OF THROMBOLYTIC AGENTS
Half-life (plasma)
Half-life (lytic effects)
Fibrin specificity
Antigenicity
Load
Maintenance
Streptokinase
Urokinase
TPA
18-30 min
82-184 min
Minimal
Yes
2000 U/kg
2000 U/kg/h
12 min
61 min
Minimal
No
4400 U/kg
4400 U/kg/h
4-5 min
46 min
Moderate
No
0.2-0.5 mg/kg/h*
* Adjust dose for preterm infants.
NORMAL ELECTROCARDIOGRAPHIC VALUES

Criteria
Day 1
Day 30
Heart rate
P-R interval
P duration
QRS duration
P amplitude in
QRS axis
T axis
T amplitude in
T amplitude in
R amplitude in
R IN V1
R in V5
R in V6
S in V4R
S in V1
S in V5
S in V6
119 ( 85 145 )
0.10 (0.07 0.13 )
0.051 (0.040 0.075)
0.065 (0.05 0.09)
1.5 (0.5 2.6 )
135 (160 180)
70 (-20-80 )
4.3(8.5)*
2.4 (4.5)*
8.6 (3.5 15.0 )
11.9 (5.0 30.0 )
9.4 (2.0 20.0 )
5.4 (1.5 15.0)
3.8 (0 12.0 )
9.7(0 26.0)
9.5 (5.0 22.0)
5.6 (0.2 20.0)
163 (115 190 )

0.09 (0.07 0.13 )
0.048 (0.040 0.065)
0.057 (0.04 0.08)
1.6 (0.5 2.7)
110 (0 180)
35 (-20-120 )
5.3 (8.5)*
3.5 (7.5 )*
6.3 (3.0 12.0 )
11.1 (4.0 20.0)
15.0 (3.8 30.0)
10.8 (1.0 22.0)
1.8(0 9.0 )
6.1(0 15)
8.3 (0 30 )
4.8(0 18.0)
II
V4
V6
V4R
*Maximum value
FETAL ANTIARRYTHMIC AGENTS

Drug
Arrythmia
Dose in mothers
Route
Comments
Procainamide
SVT,VT
100 mg bolus over 2 min;

upto 25 mg/min to 1 g over
first hour; Maintenance:
2 6 mg/min
1g; then upto 500 mgq3h
IV
PO
Therapeutic level 4 10 ng/ml. Fetal levels may

exceed maternal.Rarely effective.GI side effects
often limit compliance.hypotension with IV.
Contd...
Contd...
Disopyramide
SVT ,VT
Loading dose 300 mg; then

100 200 mg q6h
PO
Flecainide
SVT, VT
100 400 mg bid
PO
Propafenone
SVT, VT
150 300 mg tid
PO
Propranolol
SVT, VT
1 6 mg, slowly
40 160 mg q6h
IV
PO
Amiodarone
SVT, VT
5 mg/kg over 20min;

IV
500-1000 mg over 24hr.
PO
1200 1600 mg/d in 2 d/v
doses for 7 14 days, then
400 800 mg qid for 13 wk;
Maintenance: 200-400 mg/d.
Sotalol
SVT, VT
80 320 mg bid
PO
Verapamil
SVT
5 10 mg over 30 60 sec
80 160 mg tid
IV
PO
Adenosine
Reentrant SVT
100 200 mg/kg estimated

fetal weight as rapid bolus
into umbilical vein
IV
Digoxin
SVT
1 mg d/v over 24hr to
IV
load only
0.25 1.0 mg daily in
2 divided doses.
PO
Therapeutic level 3 6 mg/ml; toxic >7mg/ml.

Hypotension, negative ionotropic agent. Limited
experience in fetus; side effects limit compliance;
may worsen CHF; may stimulate uterine contractions.
Therapeutic trough level <1 g/ml. Nausea, negative ionotropic effect, proarrythmia.Probably safe
with structurally normal heart. Contraindicated with
cardiac pump failure.
Therapeutic level 0.2 3.0 g/ml.Increases digoxin
level; prolongs QRS duration; negative ionotropic
effect;GI side effects common.
May prefer long acting and cardioselective
blockers.Useful to suppress ectopy in fetuses with
recurrent SVT; may depress respirations or cause
hypoglycemia or bradycardia in neonate; possible
association with low birth weight.
Therapeutic level 1.0 2.5 g/ml. Drug of last
resort for fetal treatment. Side effects fetal or
maternal hypo/hyperthyroidism. Approximately
20% of patients may excrete in milk for several
weeks. Can cause corneal deposits, photosensitivity, life-threatening pulmonary alveolitis,
hepatitis, myopathy, neuropathy.
Limited fetal experience; should probably be considered for early inclusion in treatment protocol if
-blockade is not contraindicated.Sinus bradycardia, negative ionotropic, Av block, proarrythmia
more common in renal failure and also in females.
Use of IV verapamil in neonates is contraindicated,
use with caution in fetuses. Depresses sinoatrial
and atrioventricular node function; contraindicated
in sinus node dysfunction and with magnesium
sulfate.Interacts with -blockers;may cause cardiovascular collapse if given to immature heart with
CHF and also with ventricular tachycardia.
May be useful as diagnostic test to identify
reentrant SVT; may break incessant SVT;does not
prevent recurrent SVT.AV block, transient arrythmia after conversion .
Therapeutic level 1 2 ng/ml. Contraindicated in
VT and WPW syndrome; may be poorly absorbed
by hydropic fetuses;should have frequent ECG
monitoring for evidence of toxicity.Dose should be
adjusted downward in renal failure.
PHYSIOLOGIC BASIC OF TYPES OF APNEA

Type
Airflow
Respiratory effort
Gas exchange
Clinical
Mixed
Central
Obstructive
Awake
Intermittent
Absent
Absent
Absent
Intermittent
Absent
Present, increased
Present
Impaired or absent
Absent
Absent
Impaired
Most common
CNS immaturity
Head neck posture
Related to GE Reflux
62
CAUSES OF APNEA
Central
Obstructive
Mixed
Airway obstruction
Nasal
Neck flexion
Tongue falling back
Combination of central and obstructive
Prematurity
Hypoxia, acidosis, e.g. asphyxia
ICH
Sepsis, meningitis
Drugs: narcotics anesthetic agents
Metabolic-hypoglycemia hypocalcemia,
electrolyte imbalance
BED SIDE EVALUATION OF APNEA

Event
Threshold
Physiologic basic
Respond to
Apnea
Bradycardia
Cyanosis
Desaturation
>10 seconds
< 80 beats/ min
Mucosal/systemic
<85% saturation
Central apnea
Hypoxemia/ hypercapnia
Hypoxemia/ shunt
Hypoxemia
Stimulation
Position
Oxygen
Oxygen
CLINICAL INTERVENTIONS IN NEONATAL APNEA

Interventions
Mode
Basis
Tactile stimulation
Proprioceptive stimulation
Head neck posture
Relationship to feed
Pharmacotherapy
Low airflow with cannulae
Nasal CPAP
Gentle, non-cyclic and non painful

Gentle rocking, water mattress, etc.
Support back of neck, prevent flexion
Slow gastric filling
Based on severity or frequency of event
0.5 to 1.0 liters/min via nasal cannulae
At 4 to 7 cm H2O
Increase sensory feedback

Increase sensory feedback
Maintain patency of upper airway
Prevent GE reflux
For >2 episodes in 8 hr or if resuscitation is needed.
Maintain FRC and chest wall stability
Increase FRC, decrease upper airway resistance
PHARMACOTHERAPY FOR NEONATAL APNEA

Drug
Loading dose
(mg/kg)
Maintenance dose (mg/kg)
Half-life (hr)
Serum range
(mcg/ml)
Route
Caffeine
Theophylline
Aminophylline
10
5.5 to 7.0
6 to 8.0
2.5 ( 1 or 2 doses)
2.5 to 8 (divided)
2.0 to 6.0 (divided)
- 60
-28
-28
10-20
5.-15
5-15
Po/i.v
Po
i.v
ANTENATAL DRUGS FOR SURFACTANT PRODUCTION

Betamethasone
Dexamethasone
Ambroxal
TRH
Aminophylline
12 mg q24h
6 mg q12h
1 g q24h
400 mg q8h
250 mg q12h
IM
IM
IV
IV
IM
Total
Total
Total
Total
Total
2
4
5
4
6
doses
doses
doses
doses
doses
OXYGEN DELIVERY DEVICES
Device
Flow rate (L/min)
FiO2 (%)
0.5 5
36
4 10
10 15
4 10
10 12
10 15
10 12
24
32
24
35
25
60
80
90
Nasal cannula
Nasopharyngeal cannula
Simple face mask
Face tent
Venturi mask
Partial rebreathing mask
Oxyhood
Non-rebreathing mask
40
44
55
40
60
80
90
100
SARNAT AND SARNAT STAGES OF HYPOXIC-ISCHEMIC ENCEPHALOPATHY

Stage
Stage 1 (Mild)
Stage 2 (Moderate)
Stage 3 (Severe)
Level of consciousness
Neuromuscular control:
Hyperalert; irritable
Uninhibited, overeactive
Lethargic or obtunded
Diminished spontaneous movement
Muscle tone
Posture
Stretch reflexes
Segmental myoclonus
Complex reflexes:
Suck
Moro
Oculovestibular
Tonic neck
Autonomic function:
Pupils
Normal
Mild distal flexion
Overactive
Present or absent
Normal
Weak
Strong, low threshold
Normal
Slight
Generalized sympathetic
Mydriasis
Mild hypotonia
Strong distal flexion
Overactive, disinhibited
Present
Suppressed
Weak or absent
Weak, incomplete high threshold
Overactive
Strong
Generalized parasympathetic
Miosis
Respirations
Heart-rate
Bronchial and salivary
secretions
Gastrointestinal
motility
Seizures
Spontaneous
Tachycardia
Sparse
Spontaneous; occasional apnea

Bradycardia
Profuse
Stuporous, comatose
Diminished or absent spontaneous
movement
Flaccid
Intermittent decerebration
Decreased or absent
Absent
Absent
Absent
Absent
Weak or absent
Absent
Both systems depressed
Midposition, often unequal; poor light
reflex
Periodic; apnea
Variable
Variable
Normal or decreased
Increased diarrhoea
Variable
None
Uncommon (excluding decerebration)
Electroencephalographic
findings
Normal (awake)
Duration of symptoms
Outcome
< 24 hours
About 100% normal
Common focal or multifocal

(6 to 24 hours of age)
Early: Generalized low-voltage,
slowing (continuous delta and theta)
Later: Periodic pattern (awake);
seizures focal or multifocal;
1.0 to 1.5 Hz spike and wave
2 to 14 days
80% normal; abnormal if symptoms
more than 5 to 7 days
Early: Periodic pattern with

isopotential phases
Later: Totally isopotential
Hours to weeks
About 50% die; remainder with
severe sequelae
DOSE OF INTRAVENOUS INDOMETHACIN IN PREMATURE INFANTS WITH PATENT DUCTUS ARTERIOSUS

Age
< 48 hours
2-7 days
> 7 days
Dose (12-18 hour intervals)

Initial
Second and third
0.2 mg/kg
0.2 mg/kg
0.2 mg/kg
0.1 mg/kg
0.2 mg/kg
0.5 mg/kg
Dose of Ibuprofen in premature infants with patent ductus arteriosus:

Loading dose of 10 mg/kg stat
Maintenance is with 5 mg/kg q12h for 2 doses
CHAPTER
Neonatal Ventilation
9
INITIAL VENTILATOR SETTINGS
Rate
Ti
PIP
PEEP
FiO 2
Non-compliant stiff lungs
Compliant normal lungs
60/min
0.4 sec
Increase from 18 cm H2O until adequate chest wall movement
4cm H2O
As required to maintain oxygenation
40/min
0.3 0.4 sec
14 cm H2O
3 cm H2O
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
Easily administered
Fails to affect V/Q matching

Direct toxicity, especially > 0.60
Pi
Critical opening pressure

Improves V/Q
Barotrauma: air leak, BP
PEEP
Maintains FRC/prevents collapse

Splints obstructed airways
Regularizes respiration
Shifts to stiffer compliance curve

Obstructs venous return
Increases expiratory work and CO 2
Increases dead space
Ti
Increases MAP without increase Pi

Critical opening time
Necessitates slower rates, higher Pi

Lower minute ventilation for given Pi-PEEP combination
Flow
Square wave-maximizes MAP
Greater shear force, more barotraumas

Greater 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
Minimizes barotrauma
Better bulk flow (improved dead space/tidal volume)
Maintains same dead space/tidal volume

May lead to inadvertent PEEP
More barotraumas
Shifts to stiffer compliance curve
Decreases MAP
Decreases oxygenation/alveolar collapse
Stops splinting obstructed/closed airways
Pi
PEEP
Flow
Te
Widens compression pressure

Decreases dead space
Decreases expiratory load
Shifts to steeper compliance curve
Permits shorter Ti, longer Te
Allows longer time for passive expiration in face of
prolonged time constant
More barotrauma
Shortens Ti
Decreases MAP
Decreases 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
Normal term
RDS
Meconium aspiration
BPD
Air leak
VLBW apnea
Compliance
ml/cm H2O
Resistance
cm H2O/ml/s
Time constant (s)
FRC (ml/kg)
V/Q matching
Work
46
/
/
2040
0.25
30 ml/kg
/
/
/
= increase; =decrease; = little or no change; / = either / or
GUIDELINES FOR THE INITIAL VENTILATORY SETTINGS DISEASE WISE
Pulmonary interstitial emphysema

BPD
MAS
Pneumonia
Rec Apnea
Interstitial pulm edema
Hypoplastic lungs
Post-op ventilatory support
PIP
PEEP
Rate
I:E Ratio
Ti
FiO 2
15-25
20-25
25-35 cm H2 O
15-25
10-15
40
Upto 20
15-20
0-2
3-4
0-3
0-3
2-3
4-6
4-6
50-60 / min
30-40
40-60
30-40
30-40
30-40
60-80
20-30
1:2 to 1:3
1:1.5
1:3
1:2
1:1
1:1
1:1.5
0.2 to 0.3 sec

0.3 to 0.4 sec
0.5 sec
0.5
-
1
-
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
66

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)
Facial expression
Cry
Breathing patterns
Arms
Legs
State of arousal
Relaxed muscles
No cry
Relaxed
Relaxed/restrained
Relaxed/restrained
Sleeping/awake
Tight facial muscles

Moaning
Change in breathing pattern
Flexed/extended (tense, rigid or rapid extension)
Flexed/extended (tense, rigid, or rapid extension)
Fussy
Continuous cry
Toal score:
Score
-
BEHAVIOURAL PAIN SCORE FOR FULL-TERM INFANTS UNDERGOING INTERVENTIONS OR POSTOPERATIVE CARE
Behaviour
0 (Satisfactory)
Sleep (during preceding hour) Longer naps (>10 minutes)

Facial expression of pain
Calm, relaxed
Quality of cry
No cry
1 (Mediocre)
2 (Poor)
Score
Short naps (5-10 minutes)

Less marked, intermittent
Modulated (distracted by
normal sound)
Moderate agitation
None
Marked, constant
Screaming, painful,
high pitched
Thrashing, incessant
agitation
Tremulous, clonic
movements,
spontaneous
Moro reflexes
Very pronounced,
marked and constant
Absent or disorganized
sucking
Strong hypertonicity
None after 2 minutes
Absent
Spontaneous motor activity
Normal
Spontaneous excitability and

responsiveness to ambient
stimulation
Quiet
Flexion of fingers and toes
Absent
Less marked, intermittent
Sucking
Normal for age
Global evaluation of tone

Consolability
Sociability (eye contact),
response to voice, smile;
real interest in face
Normal for age

Calm before 1 minute
Easy and prolonged
Intermittent (three or four)

stops with crying
Moderate tonicity
Quiet after 1 minute of effort
Difficult to obtain
Excessive reactivity
(to any stimulation)
Total:
CHAPTER
Reference Lab Values
10
REFERENCE LABORATORY VALUES
Conventional units
SI units
Acid Phosphatase
7.4 19.4 U/L
Alanine Amino Transferase (ALT)/(SGPT)
13 45 U/L
Alkaline Phosphatase
77 375 U/L
Alpha 1 Antitrypsin
143 490 mg/ dl
Amino acid
Neonates (Mean SD)
Taurine
141 40
Hydroxyproline
32
Aspartic acid
84
Threonine
217 21
Serine
163 34
Proline
183 32
Glutamic acid
52 25
Glycine
343 69
Alanine
329 55
Valine
136 39
Half cystine
62 13
Methionine
29 8
Isoleucine
39 8
Leucine
72 17
Tyrosine
69 16
Ornithine
91 25
Lysine
200 46
Histidine
77 16
Arginine
54 17
Tryptophan
32 17
-alanine
14.5
Ammonia (Heparinized venous specimen on ice analyzed within 30 min)
Day 1
19 150 g / dl
> Day 1
79 129 g/dl
Amylase
5 65 U/L
Antinuclear Antibody (ANA)
Not significant
< 1:80
Patterns with Clinical Correlation
Centromere
Nuclear
Homogenous
7.4 19.4 U/L

13 45 U/L
77 375 U/L
64 107 mol/L
59 92 mol/L
5 65 U/L
Likely significant
> 1:320
CREST syndrome
Scleroderma
SLE
ARTERIAL BLOOD GAS

pH
Day 1
- Preterm
- Term
7.26 - 7.29
7.31-7.37
Day 5
7.34-7.42
Scalp pH in labour of 7.25 or above is normal
PaO 2 (mmHg)
PaCO 2 (mmHg)
HCO 3 mEq/L
BE
52-67
62-86
62-92
39-56
32-39
32-41
22-23
18-21
19-23
-5 - -2.2
-6 - -2
-5.8 - -1.2
68
METABOLIC ACIDOSIS
Increased anion gap (>15mEq/L)
Normal anion gap (<15 mEq/L)
Acute renal failure

Inborn errors of metabolism
Lactic acidosis
Late metabolic acidosis
Toxins (e.g. benzyl alcohol)
Renal bicarbonate loss

Renal tubular acidosis
Acetazolamide
Renal dysplasia
Gastrointestinal bicarbonate loss
Diarrhoea
Cholestyramine
Small-bowel drainage
Dilutional acidosis
Hyperalimentation acidosis
Asparate Amino Transferase (AST)/ Transaminase (SGOT)

Alanine Amino Transferase (ALT)/ Transaminase (SGPT)
Base Excess
Bicarbonate
25- 75 U/L
25- 75 U/L
-4 - + 3 mEq/L
18 25 mEq/L
25 75 U/L
25 75 U/L
-4 - +3 mmol/L
18 25 mmol/L
BILIRUBIN (TOTAL)
Cord Blood
Preterm
<2 mg/dl
(< 34 mcmol/L)
Bilirubin (Conjugated)
0-1 day
1- 2 day
3 5 day
Older infant
< 8 mg/dl
(<137 mcmol/L)
> 0.6 mg/dl
<12mg/dl
(<205 mcmol/L )
< 16 mg/dl
(< 274 mcmol/L)
< 34 mcmol/L
< 2 mg/dl
(<34 mcmol/L)
CALCIUM TOTAL
Preterm
term < 10 days
> 10 days
Calcium (Ionized)
< 36 hours
>36 hours
6.2-11mg/dl
7.6 010.4 mg/dl
9.0-11.0 mg/dl
1.6 2.8 mmol/L

1.9 2.6 mmol/L
2.3 2.8 mmol/L
4.20-5.48 mg/dl
4.40-5.68 mg/dl
1.0 1.3 mmol/L

1.1 1.4 mmol/L
Ceruloplasmin
Chloride (serum)
22 43 mg/dl
98 113 mEq/L
98 113 mmol/lt
Chloride (Sweat)
Cholesterol
Cholinesterase
Cortisol
Complement C3
<50 mEq/L
45 100 mg/dl
600 1500 U/L
77 99 mg/dl
<50 mmol/L
Creatinekinase
10-200 U/L
10-200 U/L
150 600 nmol/L
9 46 g/dl
Copper
CREATININE mg /dL mol / L (MICROMOL)

Age (day)
<28 week
29-32
33-36 week
> 37 week
7
14
28
0.95(1.31)
0.81(1.17)
0.66(0.94)
0.94(1.40)
0.78(1.14)
0.59(0.97)
0.77(1.25)
0.62(1.02)
0.40 (0.68)
0.56(0.96)
0.43(0.65)
0.34(0.54)
Reference Lab Values 69

Creatinine Phosphokinase
Day 1
> Day 1
Ferritin
Newborn
1 month
Fibronogen
Split products
Free fatty acids
Folic acid (serum)
Serum
RBC
Galactose
upto 500 U/L

upto 440 U/L
Up to 500 U/L
Up to 440 U/L
25-200 ng/ml
200-600ng/ml
.9 - 5.0 g/L
10mg/L
.1 0.6 mmol/L
20-200ng/ml
200 600 ng /ml
65 ng/ml
50-200 ng/ml
20mg/dl
11-47 nmol/L
340 453 nmol/L
Gamma-glutamyltransferase (GGT)
Cord blood
Preterm
Term
< 3 weeks
> 3 weeks
19-270 U/L
56-233 U/L
19-270 U/L
56-233 U/L
0-130 U/L
4 120 U/L
0-130 U/L
4 120 U/L
Glucose
Preterm
Term
< 1 day
> 1 day
20-60mg/dl
1.1-3.3 mmol/L
40-60 mg/dl
0-80 mg/dl
2.2 3.3 mmol/L

0.8-4.5 mmol/L
Growth hormone
Cord blood
Day1
Haptoglobin
10 15 ng/ml
0 40 ng/ml
- 48 mg/dl
Immunoglobulins
IgA none detected
IgG 2.5 10.3 g/L
IgM 0.12 1.17g/L
Insulin (Fasting) 3-26 mU/L
Hyperinsulinism Insulin > 10 mU/L when blood glucose <2mmol/L or glucose : insulin ratio <0.3
Iron
Lactate
100 250 g/dl

< 27 mg/dL
Lactate Dehydrogenase (LDH) (At 37 C)

0-4 days
290775 U/L
4 10 days
5452000 U/L
>10 days
180430 U/L
Lipase
1085 U/L
Magnesium
1.72.5 mg/dl
Osmolality
275300 mosm/kg
Serum osmolality = S. Na 2+ BUN (mg/dl) + Glucose
2.8
(BUN molecular weight is 28, glucose molecular weight is 180)
Phenylalanine
Preterm
2.0-7.5 mg/dl
Term
1.2 3.4 mg/dl
Phospholipids(total)
75 170 mg/dl
17.9 44.8 mol/L

0.0- 3.0 mmol/L
290 775 U/L
545 2000 U/L
180 430 U/L
0.7 -1.0 mmol/L

275 300 mmol/kg
18
121-454 mol/L
73-206 mmol/L
Phosphorus
<10 days
>10 days
4.5 9.0 mg/dl

4.5 6.7 mg /dl
1.45-2.91 mmol/L
1.45-2.16 mmol/L
Potassium
3.7 5.9 mEq/L
3.7-5.9 mmol/L
Prealbumin
7-39 mg /dl
70
PROTEIN ELECTROPHORESIS (g / dL)

Age
Cord blood
Day 1
> day 1
Total protein
Albumin/
1 globulin
2 globulin
globulin
globulin
4.8 8.0
4.4 7.6
4.4.-7.6
2.2 4.0
3.2 4.8
2.5-5.5
0.3-0.7
0.1-0.3
0.1-0.3
0.4-0.9
0.2-0.3
0.3-1.0
0.4-1.6
0.3-0.6
0.2-1.1
0.8-1.6
0.6-1.2
0.4-1.3
Protoporphyrin
Pyruvate
Renin activity
Sodium
Preterm
Term
Thyroid stimulating hormone (TSH)
Birth
Day 1
Day 2
Day 14
Triodothyronine (T3)
Thyroxine (T4)
Free T4
Preterm
Term
Thyrotropin
Preterm
Term
Thyroxine Binding Globulin (TBG)
Thyroglobulin
Transferrin
Triglycerides (fasting)
Cord blood
Urea nitrogen
Preterm
Term
Uric acid
Vitamin A (Retinol)
Preterm
Term
Vit B1 (Thiamine)
Vit B2 (Riboflavin)
Vit B12 (Cobalamin)
Vit C (Ascorbic acid)
Vitamin D
Vitamin E
Zinc
17 56 g/dl
0.3 0.9 mg/dl
14 ng/ml/hr
0.3 1.0 mol/L

0.030.1 mmol/L
130140 mEq/l
133146 mEq/l
130140 mmol/L
133146 mmol/L
100 300 ng/dl

6.5 16.3 mg/dl
3 22 nmol/L
14 20 nmol/L
11 15nmol/L
<1 10nmol/L
1.5 4.6 nmol/L
84 210 nmol/L
25
28
31
34
37
27 wk
30 wk
33 wk
36 wk
42 wk
0.6
0.6
1.0
1.2
2.0
2.2
3.4
3.8
4.4
5.3
25
28
31
34
37
0.2
0.2
0.7
1.2
1.0
30.3 mU/L
20.6 mU/L
27.9 mU/L
21.6 mU/L
39 mU/L
27
30
33
36
42
wk
1.0 4.5 mg/dl

10 250 ng/ml
130 275 mg/dl
160 750 nmol/L

15 375 pmol/L
1.30 2.75g /L
10 98mg/dl
0.10 0.98g/L
3 25 mg dl
4 12 mg/dl
2.4 6.4 mg dl
1.1 8.9 mmol/L

1.4 4.3 mmol/L
0.14 0.38 mmol/L
13 46 g/dl
18 50 g/dl
5.3 7.9 g/dl
4 24 g/dl
160 1300 pg/g
0.4 1.5 mg/dl
3 15mg/L
70 120 g/dl
0.46 1.61 mol/L

0.63 1.75 mol/L
0.16 0.23 mol/L
106 638 nmol/L
118 959 pmol/L
23 85 mol/L
28 165 nmol/L
7.0 35 mol/L
NORMAL VALUES OF BLOOD FRACTIONS

Activated Partial Thromboplastin Time (APTT)
Preterm
Term
1 month
wk
wk
wk
ng/dl
ng/dl
ng/dl
ng/dl
ng/dl
35-100 sec
35-70 sec
35-45 sec

BONE MARROW DIFFERENTIAL COUNTS; MEAN PERCENT CHANGES WITH AGE (RANGE)
Myeloblasts
Promyelocytes
Myelocytes
Metamyelocytes
Bands
Segmented neutrophils
Eosinophils
Basophils
Pronormoblasts
Normoblasts
Lymphocytes
Monocytes
Plasma cells
M : E rato
1 week
1 month
0.3 (0 1)
1 (0.5 1.5)
1.6 (0.6 2.4)
2 (0.7 3)
19 (13 23)
23.3 (9.6 39)
1.3 (1 3)
<0.1 (0-0.2)
1.6 (0.4 2.5)
37.8 (21 54)
6.1 (3.7 8)
5.3 (2 7.3)
1.24
1.2 (0.4 1.9)

1.8 (1 2.5)
4.3 (2.5 7.2)
5.5 (3.1 9.1)
22.9 (17 32)
22 (8.7 30.2)
2.9 (1.9 5.3)
<0.1 (0 0.2)
0.8 (0.4 1.1)
19.1 (12 25)
14.5 (9.5 19)
5.2 (310)
0.2 (0 0.2)
2.91
Clotting time (CT) 37C, glass tubes 5-8 min

Silicon 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 month
of life
Day 1
Tests
Mean
PT (S)
APTT (s)
TCT (s)
Fibrinogen (g/L)
H (/ml)
V (U/ml)
VII (U/ml)
VIII (U/ml)
VWF (U/ml)
IX (U/ml)
X (U/ml)
XI (U/ml)
XII (U/ml)
PK (U/ml)
HMWK (U/ml)
XIIIa(U/ml)
XIIIb (U/ml)
Plasminogen (U/ml)
13.0
53.6
24.8
2.43
0.45
0.88
0.67
1.11
1.36
0.35
0.41
0.30
0.38
0.33
0.49
0.70
0.81
1.70
Boundaries
(10.6
(27.5
(19.2
(1.50
(0.20
(0.41
(0.21
(0.50
(0.78
(0.19
(0.11
(0.08
(0.10
(0.09
(0.09
(0.32
(0.35
(1.12
16.2)
79.4)
30.4)
3.73)
0.77)
1.44)
1.13)
2.13)
2.10)
0.65)
0.71)
0.52)
0.66)
0.57)
0.89)
1.08)
1.27)
2.48)
Mean
12.5
50.5
24.1
2.80
0.57
1.00
0.84
1.15
1.33
0.42
0.51
0.41
0.39
0.45
0.62
1.01
1.10
1.91
Day 5
Boundaries
(10.0
(26.9
(18.8
(1.60
(0.29
(0.46
(0.30
(0.53
(0.72
(0.14
(0.19
(0.13
(0.09
(0.26
(0.24
(0.57
(0.68
(1.21
15.3)
74.1)
29.4)
4.18)
0.85)
1.54)
1.38)
2.05)
2.19)
0.74)
0.83)
0.69)
0.69)
0.75)
1.00)
1.45)
1.58)
2.61)
Mean
11.8
44.7
24.4
2.54
0.57
1.02
0.83
1.11
1.36
0.44
0.56
0.43
0.43
0.59
0.64
0.99
1.07
1.81
Day 30
Boundaries
(10.0
(26.9
(18.8
(1.50
(0.36
(0.48
(0.21
(0.50
(0.66
(0.13
(0.20
(0.15
(0.11
(0.31
(0.16
(0.51
(0.57
(1.09
13.6)
62.5)
29.9)
4.14)
0.95)
1.56)
1.45)
1.99)
2.16)
0.80)
0.92)
0.71)
0.75)
0.87)
1.12)
1.47)
1.57)
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.
72
Reference values for coagulation inhibitors in healthy premature infants during the first month of life
Tests
Day 1
Mean
Boundaries
Mean
Day 5
Boundaries
Mean
Day 30
Boundaries
AT III (U/ml)
0.38
(0.14 0.62)
0.56
(0.30 0.82)
0.59
2M (U/ml)
1.10
(0.56 1.82)
1.25
(0.71 1.77)
1.38
(0.37 0.81)
(0.72 2.04)
2 AP (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)
2AT (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, 2AT = 2 Anti-trypsin, 2AP = 2 Anti-plasmin, 2M = 2 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
0.49 0.16
XII (U/ml)
0.53 0.20
0.47 0.18
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
2M
1.39 0.22
1.48 0.25
1.50 0.22
2 AP
0.895 0.15
1.00 0.15
1.00 0.12
0.89 0.21
C 1INH
0.72 0.18
0.90 0.15
2 AT
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
Factor VIII IX, XI XII

vWD
Vit K deficiency
Factor VII deficiency
Factor XIII deficiency
ITP, hypo/aplasia, leukaemia
HSP, CMV
HUS
PT
APTT
BT
CT
Platelet
N
N
N
N
/N
N
N
N
N
-
N
N
N
N
N (Petechiae)
Mean hematologic values in preterm and term newborns

Determination
Hemoglobin (gm/dl)
Hematocrit (%)
Red blood cells (Cumm 106)
MCV (u3)
MCH (pg/cell)
MCHC (%)
Reticulocytes (%)
Nuc. RBCs
28 wks
Preterm
34 wks
Cord Blood
Day 1
Term
Day 3
Day 7
Day 14
14.5
45.0
4.0
120.0
40.0
31.0
5-10
-
15.0
47.0
4.4
118.0
38.0
32.0
3-10
-
16.8
53.0
5.2
107.0
34.0
31.7
3-7
500.0
18.4
58.0
5.8
108.0
35.0
32.5
3-7
200.0
17.8
55.0
5.6
99.0
33.0
33.0
1-3
0.5
17.0
54.0
5.2
98.0
32.5
33.0
0-1
0
16.8
52.0
5.1
96.0
31.5
33.0
0-1
0
Hemoglobin F Mean (SD) % total Hb

Days
1 day
5 days
3 wk
6-9 wk
Carboxyhemoglobin
Methemoglobin
77.07 (7.3)
76.8 (5.8)
70.0 (7.3)
52.9 (11)
< 5% of total
<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
9.5 11.0
8.0 10.0
6.5 9.0
6-12 wk
5 10 wk
4 8 wk
Term babies
Preterm (1200 2500 gm)
Preterm (<1200 gm)
Erythrocyte sedimentation rate (ESR)
0-4 mm/hr
Kleihauer-Betke Test
Kleihauer-Betke test on the mothers blood smear showing fetal pink cells are diagnostic of feto-maternal hemorrhage and
routine examination of the placenta and umbilical cord should be mandatory before disposal, for all deliveries particularly of high
risk babies/deliveries. The amount of blood loss into the maternal circulation may be calculated by using following formula:
Cc of fetal blood =
24000 Fetal RBC

MaterialRBC
74
THE LEUKOCYTE COUNT AND DIFFERENTIAL COUNT DURING THE FIRST TWO WEEKS OF LIFE (NUMBER /mm3)
Age
Leukocytes
Total
Neutrophils
Segmented
Band
Eosinophils
Basophils
Lymphocytes
Monocytes
Cord blood
Mean
Range
18,100
11,000
9,000-30,000 6,000-26,000
9400
1600
400
20-850
100
0-640
5500
2,000-11,000
1050
400-3,100
1 wk
Mean
Range
12,200
5500
5,000- 21000 1,500-10,000
4700
830
500
70-1100
50
0-250
5000
2,000-17,000
1100
300-2700
2 wk
Mean
Range
11,400
5,000-20,000
3900
630
350
70-1000
50
0-230
5500
2,000-17,000
1000
200-2400
4500
1,000-9500
NEUTROPHILIA VALUES PREDICTIVE OF NEONATAL BACTERIAL INFECTION

Parameter
Absolute neutrophil count
Immature(Band form): Total neutrophils ratio
Shift
1.
2.
Shift
1.
2.
Diagnostic value per mm3
Postnatal age
<1800 and >5400

< 7800 and >14400
< 7200 and >12600
< 5000 and > 9000
< 1800 and > 5400
> 0.16
> 0.13
> 0.12
At birth
12 hr
24 hr
48 hr
> 72 hr
At birth
60 hr
5 days
to left: Number of lobes of neutrophils are decreased (<3)

Hemolytic anemias
Acute infections specially bacterial
to right: Number of lobes are increased (>5)
Megaloblastic anemia
Polycythemia
VENOUS PLATELET COUNTS IN NORMAL LOW BIRTH WEIGHT INFANTS, RANGE (X 10,000)
Day
Low birth weight
Term
Cord blood
1-3 day
1 wk
2 wk
80-356
61- 335
124 678
147 670
100-28
80-320
100-300
100-310
Platelet transfusion efficacy =
Post transfusion platelet count - Pretransfusion platelet count

Platelets infused 10 11
This is calculated at 1 hr and 24 hr after transfusion.

1 hr
24 hr
10,000
Normal
7,500
Normal
Consumption coagulopathy
Immune destruction
BSA(m 2 )

Prothrombin time (PT)
Reptilase time
Preterm
Term
1 month
13-23 sec
13-16 sec
12-16 sec
Preterm
Term
1 month
18-30 sec
18-24 sec
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
Serum iron
M/L
g/dl
TIBC
M/L
g/dl
Transferrin saturation %
Total iron binding capacity (TIBC)
250-400g/dl
2 weeks
1 month
22 (11-36)
120 (63 201)
22 (10-31)
125 (58 172)
348
191 43
36 8
199 43
68 (30-99)
63 (35 94)
45-72 mol/L
Thrombin Time
Preterm
Term
1 month
12-28 sec
10-18 sec
10-12 sec
NORMAL BLOOD CHEMISTRY VALUES, TERM NEONATES

Determination
Sodium (mmol/L)
Potassium (mmol/L)
Chloride (mmol/L)
Calcium (mg/dl)
Calcium (ionized)
Phosphorus (mg/dl)
Blood urea (mg/dl)
Total protein (g/dl)
Glucose (mg/dl)
Lactate (mmol/L)
<1 wk
>1wk
133 -146
3.2 - 5.5
96 - 111
7.9 - 10.7
3.9 - 6.0
4.0 - 4.1
2 - 13
4.1 - 6.3
55 - 115
1.1 - 2.3
134 - 144
3.4 - 6.0
96 - 110
8.5 - 10.6
3.6 - 6.6
2 - 16
-
Normal blood chemistry values, low birth weight neonates, first day
Determination
Sodium (mmol/L)
Potassium (mmol/L)
Chloride (mmol/L)
Urea (mg/dl)
Total protein (g/dl)
<1000g
1001-1500g
1501-2000g
2001 2500g
138
6.4
100
22
4.8
133
6.0
101
21
4.8
135
5.4
105
16
5.2
134
5.6
104
16
5.3
76
ANALYSES OF CEREBROSPINAL FLUID

Premature
Glucose
Protein
Term
Day 1
Proteins
Day 30
Glucose >44% of blood glucose
Protein
0-25 mononuclear
0-10 polymorphonuclear
0-1000 RBC
>50% of blood glucose
50-400 mg/dl 0.5 - 4 g/ L
0-20 mononuclear
0-50 RBC
Glucose > 44% of blood glucose
40-100 mg/dl 0.4 1g/L
0-5 mononuclear
0-50 RBC
< 40 mg /dl
0.050.4 g/L
URINARY BIOCHEMICAL VALUES

Determination
Adrenal steroids (mg/d)
< 1 wk
>1 wk
17-Ketosteroids
17-hydroxycorticoids
Pregnanetriol
2 2.5
0.5
0.05 0.3
0.05 0.5
0.01
0.01
Determination
Values
Electrolytes (depends on intake)

Sodium (mmol/L)
Potassium (mmol/L)
Chloride (mmol/kg/d)
Bicarbonate (mmol/L)
Creatinine (mg/kg/d)
Preterm
Term
Calcium/Creatine Ratio
Copper
Coproporphyrin
Glucose (mg/L)
Oxalate
VMA (g/mg creatinine)
HVA (g/mg creatinine)
Protein
Phosphate Index
porphobilinogen
Uroporphyrin
Titratable acidity Minus bicarbonate
Premature
Term
Ammonia
Calcium
Creatinine clearance
Galactose
Nitrogen
18-60
10-40
1.7 8.5
1.5 2
8.3 19.9
1015.5
<0.7
<19 mg/day
<195 mg/L
50
54 mg/day
5-19 (<1 mg/24hr)
3-16
Trace
-0.2 - +0.04
2 mg/L
41.5 mg/L
(mmol/minute/m2 )
0 12
0 11
1st
7th
1st
7th
day
day
day
day
1st day
7th day
0.02-0.50 mEq/kg/24 hr
0.26-0.86 mEq/kg/24 hr
0.1-0.3 mg/24hr
1.8-3.4 mg/24 hr
40-65 ml/min/1.73 m2
<60 mg/dl
2-76 mg/kg/24hr
66-150 mg/kg/24hr

Osmolality
at birth
1st 24 hr
>24 hr
pH
Urea
0-2 days
2-4 days
5-7 days
79-118 mOsm/kg
115-232 mOsm/kg
150-250 mOsm/kg
(Max. 600 mOsm/kg
5.1-6.8
39 mg/kg/24 hr
52 mg/kg/24 hr
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
>15
Ratio of urine/plasma concentrations:

Urea
>20
<10
Osmolality
>1.3
<1.3
>2
<1% (term)
<5% (preterum)
<3%
Close to 1
FeNa
RFI
<3
>3
>1
Creatinine
>20
<15
>30
<40
>40
>40
>1.015
<1.015
>1.020
>400
<400
>500
Urine values:
Sodium
Specific gravity
Osmolality
UNa Pcr 100

* FeNa = ________________
Ucr
PNa
UNa 100
* RFI = _______________
U cr 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
0.16 0.38g/day
0.3 1.3g/day
0.4 0.14 0.97 g/day
<1g/ day (breast milk)
Coefficient of fat absorption
> 93% (Breast milk)

>83% (Formula)
Alpha 1 antitrypsin
<4.4mg/g (Breast milk)

<2.9 mg/g(Formula)
Fat:
Total fat
Neutral fat
Fatty acids
78
AMNIOTIC FLUID ANALYSIS

Ab450 nm
28 wk 0-0.48 A
40 wk 0-0.02 A
28 wk<0.075 mg/dl
40wk <0.025 mg/dl
After 37wk Gestation
> 2.0 mg/dl
Bilirubin
Creatinine
Estriol (E3), free
Alpha fetoprotein(AFP)
0-0.48 A
0-0.02 A
<1.3 mol/L
< 0.43 mol/L
After 37 wk Gestation
> 180 mol/L
Wk
ng/ml
nmol/L
16-20
20-24
24-28
28-32
32-36
36-38
38-40
1.0-3.2
2.1-7.8
2.1-7.8
4.0-13.6
3.6-15.5
4.6-18.0
5.4-19.8
3.5 11.1
7.3-27.1
7.3-27.1
13.9-47.2
12.5-53.8
16.0-62.5
18.7-68.7
Wk
mg/ml
15
16
17
18
19
20
13.5 3.42
11.7 3.38
10.3 3.03
9.5 3.22
7.1 2.86
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
1.5-1.9
2-2.5
>2.5
Immature lung
Transitional lung
Mature lung
Mature lung
58
17
11
0.5
Lecithin phosphorus
>0.10 mg/dl indicates

probable adequate fetal
lung maturity
> 0.032 mmol/L

indicates
probable
adequate fetal
lung maturity
Risk of RDS %
Saturated
Phosphatedyl
Cholin (SPC)
< 500 mg/dl

500-1000 mg/dl
> 1000 mg/dl
Immature lung
Mature lung
Mature lung
High
7-10
<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 0.5
ml 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
1+
2+
3+
4+
No bubbles
Very small bubbles in meniscus extending <1/3 of distance around test tube
Single rim of bubble >1/3 of distance around test tube
Single rim of bubbles present all round the test tube with a double row in some areas
Double row or more of bubbles all around the test tube. Fully mature lung
60
20
1-19%
<1%
-
Phosphatidyl inositol (PI)
Phosphatidyl glycerol (PG)
Interpretation
++
+
++
++
About to mature
Immature lung
Mature lung

L/S Ratio
Phosphatidyl glycerol (PG)
Risk of RDS %
Mature
10
Low
93
Presence of meconium and blood in amniotic fluid does not affect PG levels.
EXAMINATION OF SWEAT
Chloride
Normal
Indeterminate
Cystic fibrosis
Normal
Indeterminate
Cystic fibrosis
Sodium
<40
45 >60
<40
40 >60
mmol/L
60
mmol/L
60
EVALUATION OF TRANSUDATE VS EXUDATES (PLEURAL, PERICARDIAL, OR PERITONEAL FLUID)

Measurement
Transudate
Exudates
Specific gravity
Protein (g/dl)
Fluid serum ratio
LDH (IU)
Fluid serum ratio
WBCs
RBCs
Glucose
pH
<1.016
<3.0
<0.5
<200
<0.6
<1000/mm 3
<10,000
Same as serum
7.4 7.5
>1.016
>3.0
>0.5
>200
>0.6
>1000/mm 3
Variable
Less than serum
<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
Neonatal Mortality
Post neonatal mortality
Infant mortality
Child mortality
Under 5 mortality
Urban
Rural
Total
34.1
22
56.1
19.6
74.6
52.9
32.
85
37.6
119.4
48.6
29.9
78.5
33.4
109.3
Health indicators of India, (UNICEF 2000)

Parameters
Under 5 Mortality rate
Infant mortality rate
Total population (Thousands)
Annual births (Thousands)
Crude birth rate
Year Declared
Values
(1998)
(1998)
(1998)
(1998)
(1998)
105
69
982223
24671
25
Contd...
80
Contd...
% Pregnant women received T.T
% births attended by Health personnel
% low birth weight
Exclusively breastfed (0-3 months)
Breastfed with
Complementary food ( 6-9 months)
Still breastfeeding (2023 months)
(1990-98)
(1990-99)
(1990-97)
(1990-99)
80
34
33
51%
(1990-99)
(1990-99)
31%
67%
DETERMINING ENDOTRACHEAL TUBE SIZE

Infant weight (g)
Gestational
age (wks)
<1000
1000-2000
2000-3000
>3000
Tube diameter
Inside
Outside
< 28
28 34
34 38
> 38
2.5mm
3mm
3.5mm
4mm
12
14
16
18
Size of suction
Catheter
Depth of placement
(tip to lip)
5 Fr
6.5 Fr
6.5 Fr
7 Fr
7 cm
8 cm
9 cm
10 cm
Fr
Fr
Fr
Fr
Tube size = Gestational age in wks / 10
Definition of perinatal asphyxia (AAP - ACOG 1992)

1. Profound metabolic/ mixed academia; umbilical cord arterial blood pH < 7.0
2. Presistence of an Apgar score of 0 - 3 for > 5 min
3. 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
PO 2
PCO 2
PH
Maternal artery 10 min
Umbilical vein 30-60 min
95
32
7.4
16
49
7.24
27.5
39
7.32
50
46
7.21
Umbilical artery 5 hr
54
38
7.29
74
35
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
Non-reactive NST
Two fetal heart rate (FHR) accelerations of atleast 15 bpm, lasting a total of 15 sec in 10 min period.
No 10 min window containing two acceptable (as defined by reactive NST) acceleration for
maximum of 40 min
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.
Reactive AST
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
>15 beats/min
Lasting for > 15 seconds
Associated with fetal movements
In 20 minutes
1 episode of 30 seconds in 30 minutes
Demonstration of
Active extension /flexion
Brisk repositioning/trunk rotation
Opening and closing of Hand, mouth
Kicking
3 discrete body movements in 30 minutes
<2 episodes of accelerations

Accelerations <15 beats /minutes
In 20 minutes
Fetal breathing movements

Fetal Tone
Gross body movements

Amniotic fluid volume evaluation
Absent or no episode
Either
Slow extension /partial flexion
Moverment of limb or full extension
Absent fetal movements
< 2 episodes of body movements in
30 minutes
Either no packet or <1 cm in two
perpendicular planes
1 packet of fluid measures 1 cm in

2 perpendicular planes
Interpretation
Total score
Impression
Action
10
Normal fetus
Normal fetus with low risk of chronic asphyxia
Fetus with chronic asphyxia
Definate asphyxia
Profound asphyxia
Repeat once/wk
Twice /wk in high risk pregnancy
Same as above
If with oligohydramnios immediate
delivery if fetus is mature
Repeat every 4 6 hours
If with oligohydramnios immediate
delivery
Delivery immediately if lecithin/
sphingomyelin ratio is >2
Repeat after 24 hours and if score is
below 4 deliver immediately
Watch for 120 minutes and if no
improvement deliver immediately
Score improving < 4 deliver irrespective
of 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
A
P
G
A
R
Score =
Appearance (colour)
Pulse (HR)
Grimace (reflex, irritability to suctioning)
Activity (muscle tone)
Respiration (breathing efforts)
8-10 No Asphyxia
5-7 Mild Asphyxia
3-4 Moderate Asphyxia
0-2 Severe Asphyxia
Score
1
Blue, pale
Absent
No response
Limp
Absent
Body pink, extremities blue

<100
Grimace
Some flexion
Weak, irregular
Completely pink
>100
Cough/sneeze
Well flexed
Strong cry
82
GLASGOW COMA SCALE

Eye opening (Total points 4)
Spontaneous
To voice
To pain
None
4
3
2
1
Best verbal response (Total points 5)

Older Children
Fully oriented
Confused
Inappropriate
In comprehensible
None
Infants and young children

Appropriate words/smile/fix and follow
Consolable crying
persistingly irritable
Restless/agitated
None
5
4
3
2
1
Best motor response (Total points 6)

Obeys
Localizes pain
Withdraws
Flexion (decorticate)
Extension (decerebrate)
None
6
5
4
3
2
1
15 best
13-15 mild injury
9 12 moderate injury
< 8 severe injury
Silverman-Anderson retraction score

Score
Upper chest
Lower chest
Xiphoid retraction
Nasal flare
Grunt
0
1
2
Synchronous
Lag on inspiration
See saw respiration
None
Just visible
Marked
None
Just visible
Marked
None
Minimal
Marked
None
Audible with stethoscope
Audible to nacked ear
Downes score
Score
RR
Cyanosis
Air entry
Retractions
Grunt
0
1
2
< 60
60-80
> 80 apnoea
None
In room air
In 40% O2
Good
Mildly decreased
Markedly decreased
None
Mild
Moderate- severe
None
Audible with Stethoscope
Audible without stethoscope
ABG score
PaO 2
PH
PaCO 2
> 60
>7.3
<50
50-60
7.2-7.29
50-60
<50
7.19
61-70
<50
<7.1
>70

CRIB (CLINICAL RISK INDEX FOR BABIES) SCORE
Factor
Score
Birth weight (g)

1351-1500
851-1350
701-850
<700
Gestation (wk)
>24
<24
Congenital malformations*
None
Not acutely life-threatening
Acutely life-threatening
Maximum base excess in first 12hr (mmol/l)
< -7.0
-7.0 to 9.9
-10.0 to 14.9
< -15.0
Minimum appropriate FiO2 in first 12 hr
< 0.40
0.41-0.60
0.61-0.90
0.91-1.00
Maximum appropriate FiO 2 in first 12 hr
< 0.40
0.41-0.80
0.81-0.90
0.91-1.00
0
1
4
7
0
1
0
1
3
0
1
2
3
0
2
3
4
0
1
3
5
* Excluding babies with lethal congenital malformation.

CRIB score of 0-5
5% mortality
6-10 35% mortality
11-15 70% mortality
>16
>80% mortality
SCORE FOR NEONATAL ACUTE PHYSIOLOGY (SNAP)
Parameter
Blood pressure
High
Low
Heart Rate
High
Low
Respiratory Rate
Temperature, F
PO2 mm Hg
PO2/Fio2 ratio
PCO2 mm Hg
Oxygenation index
Hematocrit, %
High
Low
White blood cell count (x 1000)
Immature total ratio
Absolute neutrophil count
Platelet count (x1000)
1-Point Range
3-Point Range
5-Point Range
66-68
30-35
81-100
20-29
>100
<20
180-200
80-90
60-100
95-96
50-65
2.5-3.5
50-65
0.07-0.20
201-250
40-79
>100
92-94.9
30-50
0.3-2.49
66-90
0.21-0.40
>250
<40
<92
<30
<0.3
>90
>0.40
66-70
30-35
2.0-5.0
>0.21
500-999
30-100
>70
20-29
<2.0
<500
0-29
<20
Contd...
84
Contd...
Blood urea nitrogen, mg/dl

Creatinine, mg/dl
Urine output, ml/kg/h
Indirect bilirubin (by birth weight)
> 2 kg: /dl
< 2 kg: mg/dl/kg
Direct bilirubin, mg/dl
Sodium, mEq/L
High
Low
Potassium, mEq/L
High
Low
Calcium (ionized), mg/dl
High
Low
Calcium (total), mg/dl
High
Low
Glucose (or reagent strip), mg/dl
High
Low
Serum bicarbonate, mEq/L
High
Low
Serum pH
Seizures
Apnea
Stool guaiac
40-80
1.2-2.4
0.5-0.9
>80
2.5-4.0
0.1-0.49
>4.0
<0.1
15-20
5-10
<2.0
>20
>10
-
150-160
120-130
161-180
<120
6.6-7.5
2.0-2.9
7.6-9.0
<2.0
1.4
0.8-1.0
<0.8
12
5.0-6.9
<5.0
150-250
30-40
>250
<30
33
11-15
7.20-7.34
Single
Responsive to stimulation
Positive
< 10
7.10-7.19
Multiple
Unresponsive to stimulation
-
<7.10
Complete apnea
-
Urine metabolic screening
Benedicts test Galactosemia, hereditary fructose intolerance.

Cyanide Nitroprusside test Cysteine, homocysteine
Cetrimide MPS
DNPH ( 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 reflex
Extensor thrust reflex
Crossed extensor reflex
2. Brainstem level reflexes: (appears by 2 wk and disappears by 6 months)
Asymmetric tonic neck reflex
Symmetric tonic neck reflex
Tonic labyrinthine reflex
Positive supporting reflex
Negative supporting reflex
3. Mid brain level reflexes: (appears by 4 months and disappears by 2 years)
Neck righting reflex
Labrynthine righting reflex
Optical 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 tap
Snouting reflex
Palmomental 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
1-7d
41.3
46(51-54)
43.1
37.9
82.1
78(82-86)
86.1
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 PCV
Volume = wt (kg) blood volume ________________________________
PCV of blood to be transfused
Maximum tranfusion 10 ml/kg over a period of 3 - 4 hours
2. 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
2
3*
4
5
100
110
120
125-150
125-150
90
100
110
120
125-150
80
90
100
110
125-150
* Add electrolytes form day 3
Factors affecting water loss (IWL) in preterm infants

Increase IWL (%)
Decreases IWL (%)
Severe prematurity (100-300)

Open warmer bed (50-100)
Phototherapy (30-50)
Tachypnoea (20-30)
Humidification in incubator (50-100)

Plastic heatshield (30-50)
Ventilation with humidified air (20-30)
86
Fluid requirement changes in different conditions

Conditions
Fluid requirement changes
Phototherapy
Radiant warmer
High ambient temperature
Hyperthermia
Increase activity
Intubation ventilation
Double walled incubators
Humidity (40%)
Heat shield polythene sheets
Plastic blanket
Skin coverings
+ 20-40 ml/kg/d
+ 20-30 ml/kg/d
+ 10-20 ml/kg/d
+ 10-20 ml/kg/d
+ 10-15 ml/kg/d
- 10-15 ml/kg/d
- 10-15 ml/kg/d
- 15-20 ml/kg/d
- 15-20 ml/kg/d
- 15-20 ml/kg/d
- 15-20 ml/kg/d
Electrolyte requirements in newborn (mEq/kg/day)
Days
Na
Term
K
Cl (mEq/kg/day)
Na
Preterm
K
Cl (mEq/kg/day)
1
2
3
4 to 7
7 to 15
3
3
3
3
3
3
3
3
3
3
3
3
2
2
4-8
4-8
3
3
5
5
2
2
3
3
COMMONLY USED INTRAVENOUS SOLUTIONS COMPOSITION PER LITRE

Solution
Dextrose (g)
Na + K+
Ca++ Mg ++ Cl
HCO 3
mEq
HPO 4 Lactate
Acetate
Calories
MOsm
5% Dextrose
10% Dextrose
Normal saline (0.9% NaCl)
5% Dextrose in Normal Saline
5% Dextrose in 0.2% NaCl
Ringers Lactate
Ringers Lactate with 5% Dextrose
Lactate K Saline (Darrow)
Isolyte P (Pediatric Maintenance
with Dextrose)
3% NaCl
5% NaCl
50
100
50
50
50
50
154
154
33
130
130
121
25
0
0
3
3
-
0
0
3
154
154
33
109
109
103
22
0
-
0
3
0
28
28
53
-
0
23
200
400
200
200
200
17
200
266
532
292
558
350
261
530
310
350
513 855 -
513
855
1026
1710
0
0
4
4
35
20
OSMOLALITY OF FLUID
Fluid
5% Dextrose
10% Dextrose
N/5 in 5% Dextrose
NaHCO 3 (7.5%)
Breast milk
10% Dextrose + NaHCO3 (1:1)
15% Dextrose
20% Dextrose
Osm/kg H-20
300
615
350
1700
300
1000
850
1400

CLINICAL CORRELATION OF JAUNDICE IN SKIN AND LEVELS OF SERUM BILIRUBIN
Jaundice
Only
Upto
Upto
Upto
Foot
S. Bilirubin mg/dl
face
umbilicus
knee
ankle
5
10
12
15
> 15
APPROACH TO INDIRECT HYPERBILIRUBINEMIA IN HEALTHY TERM INFANTS WITHOUT HEMOLYSIS
Age (hr)
Consider
phototherapy
Phototherapy
Exchange
transfusion if
phototherapy fails
Phototherapy
and exchange transfusion
24-48
49-72
> 72
> 2 wk
12
15
17
-
15
18
20
**
20
25
25
**
> 25
> 30
> 30
**
** Jaundice suddenly appearing in the 2nd week of life or continuing beyond the 2nd week of life with significant hyperbilirubinemia levels
to 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
1000 1499
1500 1999
2000-2500
12-13
7-9
10-12
>13
10-12
12-15
15-18
18-20
Exchange transfusion
Choice of blood for exchange tranfusion
1. 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: Babys blood group.
Total volume for exchange transfusion
Calculated using the formula 2 blood volume + 50 ml

Wt
<1 kg
1-2 kg
>2 kg
Blood volume
100 ml/kg
90 ml/kg
80 ml/kg
Aliquots used in exchange tranfusion

Wt
<850 g
850g 1 kg
1-2 kg
2-3 kg
>3 kg
Aliquot (ml)
1-3
5
10
15
20
88
PHOTOTHERAPY TABLE
Birth weight is plotted against infants age in days. If the serum indirect bilirubin (mg/dl) is greater than the plotted number, consider
phototherapy.
Days
Birth wt. (gm)

<1000
1000-1249
1250-1499
1500-1749
1750-1999
2000-2499
>2500
3
5
8
10
10
10
10
3
5
8
10
10
12
12
3
5
8
10
12
12
13
5
7-8
10
12
13
15
15
5
8
12
12
13
15
17
7
10
13
13
13
15
17
7
12
13
13
13
15
17
EXCHANGE TRANSFUSION TABLE

Days
Birth wt. (gm)

<1000
1000-1249
1250-1499
1500-1749
1750-1999
2000-2499
>2500
8
10
12
15
15
18
20
8
10
12
15
15
18
20
8
10
12
15
15
18
20
10
10
15
15
16
18
20
10
10
15
15
16
18
20
10
15
15
15
17
18
20
10
15
15
16
17
18
20
Early indications for exchange blood transfusion in infants with Rh-hemolytic disease of the newborn
1. Cord hemoglobin of 10 g/dl or less
2. Cord bilirubin of 5 mg/dl or more
3. 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
1200-1500
1501-2500
>2500
35
34
33.1
32.8
34
33.8
32.8
32.4
34
33.6
32.6
32.1
34
33.5
32.5
31.9
34
33.5
32.3
31.7
35 C
34.1
33.4
32.9
TRANSPORT
Transport Team Equipment
Transport incubator equipped with monitors for heart rate, vascular pressures, oxygen saturation, temperature
Suction device
Infusion pumps
Gel-filled mattress

Adaptors to plug into both hospital and vehicle power
Airway equipment
Anesthesia bag with manometer
Laryngoscopes with no. 0 and no. 1 blades
Magill forceps
Instrument tray for chest tubes and vascular catheters
Stethoscope
Tanks 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
Alcohol swabs
Armboards
Batteries
Benzoin
Betadine swabs
Blood culture bottles
Blood pressure cuff
Butterfly needles: 23 and 25 gauge
Chest tubes: 10 and 12F, and connectors
Chemstrip
Clipboard with transport data forms, permission forms,
progress notes, and booklet for parents
Culture tubes
Endotracheal tubes: 2.5, 3.0, 3.5, 4.0 mm
Face mask, term and premature
Feeding tubes: 5 and BF
Gauze pads
Gloves, sterile and exam
Heimlich valves
Intravenous tubing
Intravenous catheters: 22 and 24 gauge
Kelly clamp
Lubricating ointment
Monitor leads and transducers
Needles: 18,20, 26 gauge
Oxygen tubing
Replogle nasogastric tube
Scalpel blades, no. 11
Sterile gown
Stopcocks
Stylus
Suction catheters: 6,8 and 10 F and traps
Suture material (silk 3-0, 4-0, on curved needle)
Syringes: 1, 3, 10, 50 ml
Tape
T-connectors
Thermometer
Tubes for blood specimens
Umbilical catheters: 3.5 and 5 F (double lumen)
Urine collection bags
Xeroform gauze
Medications used on Transport

Albumin 5%
Ampicillin
Atropine
Calcium
Calcium gluconate
Dexamethasone
Dextrose 50% in water
Dextrose 10% in water
Diphenylhydantoin
Digoxin
Dobutamine
Dopamine
Epinephrine
Erythromycin eye ointment
Fentanyl
Gentamicin
Heparin
Isoproterenol
Lidocaine
Midazolan
Morphine
Naloxone
Normal saline
Pancuronium
Phenobarbital
Potassium chloride
Prostaglandin E 1 (on ice)
Sodium bicarbonate
Sterile water
Vitamin K1
90
Phototherapy guidelines for neonatal hyperbilirubinemia
92
94
Index
A
Agents that can safely be administered

in therapeutic doses to
glucose-6-phosphate dehydrogenase deficient patients 41
Agents to be avoided in glucose-6phosphate dehydrogenase
deficient patients 41
Amniotic fluid analysis 78
Analyses of cerebrospinal fluid 76
Analyses of feces 77
Antenatal drugs for surfactant
production 62
Antibiotic guidelines in neonatal
infection 14
Antihypertensive agents for the
newborn 58
Antimicrobial agents 1
dosages and intervals of administration 1
organisms generally susceptible to
cephalosporins 13
organisms generally susceptible to
penicillins 11
Antimicrobials requiring adjustment in
renal failure 47
Apgar score 81
Approach to a bleeding neonate 73
hemoglobin F mean (SD)% total Hb
73
hemoglobin Nadir in babies in the
first year of life 73
Kleihauer-Betke test 73
mean hematologic values in preterm
and term newborns 73
Approach to indirect hyperbilirubinaemia in healthy term infants
without hemolysis 87
Arterial blood gas 67
Average daily nutritional requirements
52
Bed side evaluation of apnea 62

Behavioural pain score for full-term
infants undergoing interventions or postoperative care 66
Bilirubin (total) 68
Blood pressure for weight percentiles
93
Blood volume 85
elective blood transfusion 85
electrolyte requirements in newborn
86
estimated blood volumes 85
factors affecting water loss (IWL) in
preterm infants 85
fluid requirement changes in
different conditions 86
IV fluid requirement of LBW
neonates 85
Bone marrow differential counts; mean
percent changes with age
(range) 71
C
Calcium total 68
Causes of apnea 62
Clinical correlation of jaundice in skin
and levels of serum bilirubin
87
Clinical interventions in neonatal apnea
62
Coagulation factor assays 71
reference values for coagulation
inhibitors in healthy premature infants during the first
month of life 72
reference values for coagulation tests
in healthy premature infants
(30 to 36 weeks of gestation)
during the first month of life
71
reference values for coagulation tests

in the healthy full-term infant
during the first month of life
72
reference values for the inhibition of
coagulation in the healthy fullterm infant during the first
month of life 72
Cofactor/limiting amino acid therapy
54
Commercial formulas and foods 55
composition of human milk,
standard infant formulas, and
some specialized formulas 55
formulas for metabolic disorders 55
formulas free of lactose and or cows
milk protein and special milk
based (casien-hydrolysate)
formulas 56
formulas with altered fat, protein,
and carbohydrates 56
Commercial vitamin preparations 32
Commonly used intravenous solutions
composition per litre 86
Comparison of thrombolytic agents 60
Composition of various milks 52
Concentration and duration of few
infusions 40
Congestive heart failure 51
Creatinine 68
Creatinine phosphokinase 69
Crib (clinical risk index for babies)
score 83
D
Determining endotracheal tube size 80
Dose of intravenous indomethacin in
premature infants with patent
ductus arteriosus 63
Drug formulary 18
Drug loss during exchange transfusion
40
98
Drugs in breastfeeding 42
Drugs requiring no adjustment 50
Drugs that cause significant displacement of bilirubin from
albumin in vitro 51
Drugs to be used with special precaution in breastfeeding women
or drugs contraindicated 42
Drugs used in resuscitation 33
E
Effect of change in ventilatory parameters on the blood gas 64
Evaluation of transudate vs exudates
79
Examination of sweat 79
Exchange transfusion table 88
early indications for exchange blood
transfusion in infants with Rhhemolytic disease of the
newborn 88
F
Fetal antiarrhythmic agents 60
First line antibiotics 16
G
Gamma-glutamyltransferase 69
Glasgow coma scale 82
ABG score 82
best motor response (total points 6)
82
best verbal response (total points 5)
82
Downes score 82
eye opening (total points 4) 82
Silverman-Anderson retraction score
82
Guidelines for the initial ventilatory
settings disease-wise 65
Guidelines for the modes of providing
fluids and feeding 53
H
Health indicators of India (UNICEF
2000) 79
I
Indices to differentiate between prerenal and intrinsic renal failure
and SIADH 77
Infant and child mortality rates (NFHS
survey) 79
Initial dosing of enoxaprin, agedependent 59
Initial ventilator settings 64
Inotropic and vasoactive agents
commonly used in shock 35
Intrapartum monitoring fetus 80
interpretation 81
Intubation sedation guidelines 34
Iron supplementation guidelines in the
premature infant 54
Normal blood gas values in term

newborns 80
Normal electrocardiographic values 60
Normal longitudinal blood pressure in
full-term infants 58
Normal values of blood fractions 70
Nutritional needs of low birth weight
infants 52
O
Oral dietary supplements available for
use in infants 54
Osmolality of fluid 86
Oxygen delivery devices 63
Oxygen dissociation curve 94
P
L
Leukocyte count and differential count
during the first two weeks of
life 74
Local site-directed thrombolytic
therapy 59
M
Metabolic acidosis 68
Monitoring and dosage adjustment of
enoxaparin based on antifactor Xa level measured 4
hours after dose of enoxaparin
60
N
Neonatal infant pain scale 66
Neonatal pulmonary physiology by
disease state 65
Neonatal ventilation 64
Neutrophilia values predictive of
neonatal bacterial infection 74
Non-antimicrobials requiring adjustment in renal failure 49
Normal blood chemistry values, term
neonates 75
normal blood chemistry values, low
birth weight neonates, first
day 75
Passage of antibiotics across the

placenta 45
Pathological states 46
gastrointestinal diseases 46
kidney disease 47
liver disease 47
Peak and trough levels of antibacterial
agents 39
Pharmacokinetics 46
Pharmacotherapy for neonatal
apnea 62
Phototherapy guidelines for neonatal
hyperbilirubinemia 92
Phototherapy table 88
Physiologic basic types of apnea 61
Primitive reflexes 84
Protamine dosage to reverse heparin
therapy 59
Protein electrophoresis 70
Prothrombin time 75
R
Recommended daily allowances of
vitamins and minerals 53
Reference laboratory values 67
Risk estimation of icterus 91
S
Safe medicine 39
Index 99
Sarnat and sarnat stages of hypoxicischemic encephalopathy 63
Score for neonatal acute physiology
(snap) 83
Septic risk scoring 15
Serum iron and iron-binding capacity
75
Significance of blood culture isolates 14
Some important metabolic conditions
55
Special nutrition 52
Specific antibiotic therapy in earlyonset neonatal septicemia 15
Specific antibiotic therapy in late-onset
neonatal septicemia 15
Specific therapeutics 58
Standard IV infusion routinely
prepared 36
Standard TPN regimen 57
Suggested antibiotic regiments for
sepsis and meningitis 15
Suggested intakes of parenteral
vitamins in infants 57
Suggested maximum indirect serum

bilirubin concentrations
in preterm infants 87
aliquots used in exchange
transfusion 87
calculated using the formula 2
blood volume + 50 ml 87
exchange transfusion 87
Systemic thrombolytic therapy 59
supplies used by transport teams 89

transport team equipment 88
Treatment guideline in icterus 95
Tube feeding guidelines 53
Teratogenicity 44
Therapeutic range of various drugs 39
Thermoneutral environment 88
Thrombin time 75
Thrombolytic therapy 59
Thyroid disease 51
Time table for elective surgical
repair 58
Transport 88
medications used on transport 89
Venous platelet counts in normal low

birth weight infants, range
(X 10,000) 74
Ventilator manipulations to increase
oxygenation 64
Ventilator manipulations to increase
ventilation and decrease
PaCO2 65
Ventilatory calculations 65
Viral infection therapy 17
U
Urinary biochemical values 76
Urine metabolic screening 84
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Neonatal Drug

Professor and Head, Department of Paediatrics

Murali Keshava Sarpangala

MBBS DNB (Paediatrics)

202 Batavia Chambers, 8 Kumara Krupa Road,

282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza,

4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road,

1-A Indian Mirror Street, Wellington Square,

106 Amit Industrial Estate, 61 Dr SS Rao Road,

KAMALPUSHPA 38, Reshimbag,

Neonatal Drug Formulary

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

Body Weight <2000g

Body Weight >2000g

10 mg/kg q8h for 10-14 days

7.5 mg/kg q24h

SE: rash, diarrhoea. It exerts

Inhibits production of lactamases. Many lactamase producing strains

7.5 mg/kg q18h

Adverse reactions noted:

Neonatal Drug Formulary

Body Weight <2000g

Body Weight >2000g

0.5-1.0 mg/kg/O.D with maximum of 1.0 mg/kg/day for 4-6 weeks

50 mg/kg q12h 50 mg/kg q8h

50 mg/kg q12h 50 mg/kg q12h

100 mg/kg q12h 100 mg/kg q8h

Must not be mixed in same

30 mg/kg q12h 30 mg/kg q8h

-lactum antibiotic, active

Body Weight <2000g

Body Weight >2000g

It has additive inhibition of

Active against haemophillus

Caution with penicillin allergy or

Good CNS penetration. Rash.

50 mg/kg q12h 50 mg/kg q8h

50 mg/kg q8h 50 mg/kg q8h

Give IV infusion over 30 minutes

Rash, false positive Coombs

Neonatal Drug Formulary

Body Weight <2000g

Body Weight >2000g

50 mg/kg q12h 50 mg/kg q12h

30 mg/kg q12h 30 mg/kg q8h

20 mg/kg q12h 20 mg/kg q8h

20 mg/kg q12h 20 mg/kg q8h

Limited experience in neonates.

Dose related or ideosyncratic

Damage to cartilage is observed

30 mg/kg q12h 30 mg/kg q8h

For IV infusion, dilute reconstituted dose

Give IV bolus with NS or DS

Infusion given over 30-60 minutes

Not recommended for meningitis. Pseudo-membranous colitis, transient increase in urea

Body Weight <2000g

5 mg/kg q12h 5 mg/kg q8h

Apply to skin BID x 4-8 wks

Dose may be increased to 100 mg/kg in

10 mg/kg q12h 10 mg/kg q8h

Body Weight >2000g

4 mg TMP + 24 mg SMX/kg q12h

10 mg/kg q12h 15 mg/kg q8h

IV infusion is given after