NEONATES • Maternal drugs which may adversely affect the

• The survival of very premature babies has been greatly newborn baby
increased through the use of antenatal betamethasone o opiates for pain relief during labor
and neonatal surfactant treatment to prevent and treat o B-blockers for pregnancy-induced hypertension
surfactant deficiency o benzodiazepines for eclamptic seizures
• the feto-placental unit creates a unique route for drug • Corticosteroids
delivery o used to promote fetal lung maturation when
• Drug disposition and metabolism in the neonate are very preterm delivery is planned or expected
different from those at any other time of life o Drug of Choice: Betamethasone for promote
• preterm babies grow very fast, so doses have to be re- fetal lung function
calculated at regular intervals o Prednisolone – is metabolized in the placenta
• drug elimination in the neonate can be much slower than and does not reach the fetus
in children, especially in the first week, so dose intervals • Enteral Drug absorption
have to be longer. o erratic in any newborn baby
• 23 weeks gestation – earliest in pregnancy at which o unavailable in the ill baby because the stomach
newborn can survive (10%) does not always empty effectively
• <32 weeks – high risk of death/disability • Most drugs are given intravenously to ensure
• gestation at birth vs. birth weight-practical and prognostic maximum bioavailability
value • Rectally Administered:
• high-risk pregnancy pts – transferred for delivery to a o paraldehyde and diazepam for neonatal seizures
hospital capable of providing neonatal intensive care o paracetamol for simple analgesia
o 1-2% of all babies will receive intensive care, and • Trachea
the most common reason is the need for o the preferred route of administration when
respiratory support surfactant administration is required or where
• <32 weeks gestation with NICU – go home when feeding adrenaline (epinephrine) is given for
adequately. 35-40 postmenstrual age resuscitation
• Neonatal inpatients for 3-4 months – 3x weight, dramatic • Buccal Route
change in physiology and metabolism o used to administer glucose gel in the treatment
of hypoglycemia
Definitions of Terms • Skin
Normal length of human 37 up to 42 completed o extremely thin and a poor barrier to water loss
pregnancy (term) weeks of gestation during very preterm baby of 28 weeks’ gestation
Preterm <37 weeks of gestation at o harmful with prolonged contact with
birth chlorhexidine in 70% methylated spirit which
Post-term 42 completed weeks causes severe chemical burn and results in

onwards systemic methyl alcohol poisoning

Neonatal Period Up to the 28 th

postnatal day • Intramuscular route

Low birth weight (LBW) <2500g o normally avoided in premature babies because

Very low birth weight <1500g of their small muscle bulk

(VLBW) o exceptions: Vitamin K and Naloxone

Extremely low birth weight <1000g

(ELBW) Distribution
• drugs are distributed within a baby’s body as a function
of their lipid and aqueous solubility, as at any other
Drug Disposition
time of life
Absorption
• The size of the body water pool under renal control is
• Placenta – important and unique source of drug
related not to the baby’s surface area but to body
absorption available until birth
weight.
• Maternal drugs pass to fetus and back again during
• absolute glomerular filtration rate increases
pregnancy
logarithmically with post-conceptional age
• From delivery – drugs in neonatal circulation must be
irrespective of the length of a baby’s gestation
dealt with by baby’s own system
 o has implications for predicting the behavior of - rare in babies born at or near term
water-soluble drugs such as gentamicin - increasingly likely in preterm
• The amount of adipose tissue can vary substantially - it is prevented both by the use of antenatal
between different babies betamethasone in the mother and the postnatal
o baby born more than 10 weeks early, and babies administration of surfactant to babies at risk which
of any gestation who have suffered intrauterine has greatly reduced mortality
growth restriction – little body fat - Manifested by obvious difficulty with breathing, with
o infant of a diabetic mother – large fat layer and nasal flaring, rib recession, tachypnea and a
this affects the retention of predominantly lipid- requirement for oxygen
soluble drugs - becomes worse over the first 2 days, reached a
• protein binding in the plasma is influenced by the plateau and then gradually improved
amount of albumin available - A big baby born around 32-34 weeks of gestation
with mild RDS
Metabolism o no more treatment needed than extra oxygen
• is not qualitatively different to that in the older child - smaller, more premature or more severely affected
(hydroxylation, oxidation and conjugation to sulphate babies need some degree of mechanical assistance
or glucuronide) o either continuous positive airway pressure by
• it is the efficiency with which these processes are nasal prongs or full artificial ventilation through
carried out that distinguishes the baby from the older an endotracheal tube.
person o A few babies require high inspired
• is also affected by the physiological hyperbilirubinemia concentrations of oxygen (up to 100%) for
of the newborn several days.
• bilirubin can compete both for enzyme-binding sites - pulmonary oxygen is not as much a problem to the
and for glucoronate, and may thus affect drug neonate as it is to the adult, though it may have a
metabolism for as long as unconjugated causal role in the development of bronchopulmonary
hyperbilirubinemia persists dysplasia.
- The major concern is the damage that prolonged
Elimination arterial hyperoxia can do to the retina, resulting in
• relative immaturity of hepatic and renal function retinopathy of prematurity.
results in correspondingly slow elimination of most - The goal is to give enough inspired oxygen to keep
drugs from the neonate, which is not a problem the arterial partial pressure within a range of about 6–
• Phenobarbital 20mg/kg – loading dose, will remain in 12 kPa.
circulation for days in useful therapeutic quantities - Mechanical ventilation is not a comfortable
• Gentamicin and vancomycin – relatively narrow experience, for adults or children, but it has taken a
therapeutic index, must be given far less frequently long time to appreciate that this may also be true for
than in children or adults and serum drug levels must premature babies.
be assayed to avoid toxicity o Paralyzing agents such as pancuronium are
• Pethidine and diamorphine – opiates most likely to sometimes given to ventilated neonates but
cause significant respiratory depression in the these only prevent the baby from moving
neonate and are not sedative.
o Treatment: Naloxone 20𝜇cg/mL o Pancuronium
§ adult naloxone 400𝜇cg/mL may be § is widely used
given IM to prevent late-onset § wears off slowly so that the baby is
narcosis not suddenly destabilized.
o Atracurium
Major Clinical Disorders § Shorter acting agents
Respiratory Distress Syndrome (RDS) § often used for temporary paralysis
- sometimes called hyaline membrane disease from its for intubation.
appearance on lung histology, or surfactant
deficiency lung disease in recognition of the etiology
- is lack of sufficient pulmonary surfactant at the time
of birth
 - Morphine o Potential serious side effects of both drugs
o given either as intermittent doses or as an include renal impairment, gastric
infusion, to provide narcosis and analgesia hemorrhage and gut perforation.
to reduce the distress of neonatal intensive o Surgery
care whether or not the baby is paralyzed § considered when one or more
- Antenatal steroids courses of medical treatment fail to
o given to the mother reduce the incidence, close the PDA or if drugs are
severity and mortality of RDS caused by contraindicated for any reason.
surfactant deficiency. - There are no good randomised controlled trials to
o Unfortunately, it is not possible to identify guide clinicians on the best approach to managing
and treat all mothers whose babies could PDA.
benefit.
o Babies of less than 32 weeks' gestation gain Bronchopulmonary dysplasia (BPD)
most benefit because they are at greatest - Generically known as chronic lung disease of
risk of death and disability from RDS. prematurity,
o Optimum treatment is four oral doses of - most frequently occurs in very immature babies who
6mg betamethasone, each given 12-hourly, have undergone prolonged respiratory support.
or two doses of 12 mg intramuscularly 24 h - The factors predisposing to BPD
apart. o the degree of prematurity
- Introduction of exogenous surfactant (derived from o the severity of RDS
the pig or calf) are currently more effective than o infection
artificial synthetic ones o occurrence of PDA
o First dose should be given as soon as o oxygen toxicity
possible after birth since the earlier it is o probably intrinsic genetic factors
given, the greater the benefit - defined as oxygen dependency at 36 weeks of post-
menstrual age, in a baby born before 32 weeks.
Patent ductus arteriosus (PDA) - Established BPD not severe enough to need
- Can be a problem in the recovery phase of RDS continuing mechanical ventilation is either treated
- Usually shows itself as a secondary increase in with nasal continuous positive airway pressure with
respiratory distress and/or ventilator requirement, or without oxygen supplementation, or if less severe
and increasing oxygen requirement, wide pulse again is treated with oxygen through nasal cannulae.
pressure and a characteristic heart murmur - Enough oxygen must be used to maintain an oxygen
- As pressure in the pulmonary artery falls, an open saturation high enough to control pulmonary artery
duct allows blood from the aorta to flow into the pressure, while avoiding chronic low-grade hyperoxia
pulmonary artery, which engorges the lungs and which could contribute to retinopathy of prematurity.
reduces their compliance, while putting strain on the o Optimum oxygen saturations in these babies
heart. have not been rigorously defined but the
- Echocardiography outcome of several large trials is awaited.
o used to confirm the clinical suspicion. - A chronic inflammatory process is part of the
- About one-third of all babies with birth weights less pathology of BPD, and for this reason much attention
than 1000 g will develop signs of PDA, but treatment has been given to the role of corticosteroids in
is only needed when the baby is hemodynamically treating it.
compromised. o Steroid use generally results in a rapid fall in
- When treatment is needed the options are either oxygen requirements, but does not improve
medical treatment (with indometacin or ibuprofen) or mortality
surgical ligation. § Dexamethasone is used within the
o IV Indometacin - when given enterally its first 1 or 2 weeks there may even be
absorption is unpredictable and it may need an increased rate of cerebral palsy,
to be given before the baby has started § steroid use is when a baby remains
enteral feeds. ventilator dependent at the age of 4
o IV Ibuprofen - alternative. weeks or more.
 § both the initial dose (usually - home oxygen programs for ex-premature babies with
between 50 and 250cg/kg) and the BPD are now widespread.
rate of reduction of dose are - Most babies manage to wean off supplementary
generally individualized to the baby. oxygen in a few months but a very few may need it for
§ Common and reversible side up to 2 years.
effects: hypertension and glucose
intolerance Infection
• the effects on growth can - Important pathogens in the first 2 or 3 days after birth
be more serious if steroids are group B -hemolytic streptococci and a variety of
are given for a long time. Gram- negative organisms, especially Escherichia
- leads to increases in both pulmonary artery pressures coli.
and lung water content. - Coagulase- negative staphylococci and
- The consequent strain on the heart can lead to heart Staphylococcus aureus are more important
failure, with excessive weight gain, increasing oxygen subsequently.
requirements and clinical signs such as edema and a - it is wise to use narrow- spectrum agents and short
cardiac ‘gallop’ rhythm. courses of antibiotics whenever possible, and to
- Diuretics – first-line treatment for heart failure in any discontinue blind treatment quickly, for example,
group and also improve lung compliance and reduce after 48 h if confirmatory evidence of bacterial
the work of breathing. infection, such as blood culture, is negative.
o Thiazide - Superficial candida infection
§ improve pulmonary mechanics as o is common in all babies
well as treating heart failure - Systemic candida infection
o Furosemide o risk in very preterm babies receiving
§ is used but its side effects are prolonged courses of broad-spectrum anti-
significant urinary loss of potassium biotics, with central venous access, and
and calcium, and renal calcification. receiving intravenous feeding.
o Alternative: combine a thiazide with o prophylaxis with either enteral nystatin or
spironolactone systemic fluconazole in the highest risk
§ causes less calcium and potassium preterm babies.
loss. - It is usual to start antibiotics prophylactically
o However, BPD is not routinely treated with whenever pre-term labor is unexplained, where there
diuretics, since many babies do well without has been prolonged rupture of the fetal membranes
them. prior to delivery, and when a baby is ventilated from
- Systemic hypertension sometimes occurs among birth.
babies with BPD and may need treatment with o A standard combination for such early
antihypertensive drugs such as nifedipine. treatment is penicillin G and an
- Sildenafil aminoglycoside, to cover group B
o Off-label use to prevent pulmonary streptococci and Gram-negative pathogens.
hypertensive crises in babies after cardiac o Treatment can be stopped after 48h if
surgery cultures prove negative.
o very variable pharmacokinetics in babies, so - Blind treatment starting when a baby is more than
the dose is difficult to define, and the 48h old has to take account of the expected local
commonly recommended upper limit of 2 pathogens, but will always include cover for S. aureus.
mg/kg four times a day may not be sufficient - Cephalosporin such as cefotaxime and ceftazidime
for some babies o promoted for use in the blind treatment of
o for babies with severe BPD with neonatal infection on the grounds of their
echocardiography that demonstrates lower toxicity when compared to amino-
pulmonary arterial pressures close to, or glycosides, their wide therapeutic index and
greater than, systemic pressure the absence of any need to monitor serum
- Significantly preterm babies still in oxygen at 36 concentrations.
weeks' postmenstrual age are almost certain to need o main disadvantage – breadth of their
oxygen at home after discharge, spectrum
 § may result in fungal overgrowth or - it has been difficult to disentangle causal associations
the spread of resistance, although from spurious links to conditions that occur anyway in
they compare favourably with ill infants, such as the need for blood transfusion
ampicillin in this regard. - The pathophysiology is related to damage of the gut
- the antibiotics can be stopped when cultures are mucosa
negative o May occur because of hypotension or
- no need to measure levels in babies receiving amino- hypoxia, coupled with the presence of
glycosides, thereby negating much of the apparent certain organisms in the GIT that invade the
advantage of cephalosporins. gut wall to give rise to NEC
- there is now good evidence for giving gentamicin 24 - Almost NEVER arises in a baby who has never been
hourly rather than more frequently, as it has similar fed
efficacy and less potential for toxicity. - Early ‘minimal’ feeding and intiating feeding with
- Methicillin-resistant S. aureus (MRSA) has emerged breast milk – appears to be protective
as a real problem in hospitals in recent years, but - The most important protection that can be given
there is little evidence that neonatal units are a exogenously is enteral probiotics
particularly hazardous environment. - A baby who becomes ill with NEC is often septicemic
- Cytomegalovirus (CMV) and may present acutely with a major collapse,
o Most important active viral infection in respiratory failure and shock, or more slowly with
neonates abdominal distension, intolerance of feeds with
o a major factor in non-hereditary sensori- discoloured gastric aspirates and blood in the stool.
neural hearing losd - The medical treatment is respiratory and circulatory
o treatment: intravenous ganciclovir and oral support if necessary, antibiotics, and switching to
valganciclovir intravenous feeding for a period of time, usually 7–10
- Vertically transmitted HIV days.
o most important one from which to protect o The antibiotic strategy for NEC is to cover
babies gram (+), gram (-), and anaerobic bacteria
o For CMV, which is now thought to be § Metronidazole – used to cover
o goal of management: prevent ‘vertical’ anaerobes
transmission from mother to baby. • Behaves very differently in
o The main strategy: use aggressive maternal neonates compared with
treatment throughout pregnancy to older children and adults
suppress the maternal viral load. • Elimination half life in term
o Zidovudine babies = 20h
§ Given as a single agent for 4 weeks • Elimination half life in
to the baby when the maternal viral preterm babies 109 h (due
load is low, or triple therapy if the to poor heapitc
load is high hydroxylation in infants
Serious neonatal infections and pathogens born before 35 weeks’
Septicemia Staphylococcus epidermis, gestation
group B streptococci, E. coli • Monitor serum levels of
System candidiasis Candida spp this drug

Necrotizing enterocolitis No single causal pathogen § Clindamycin is preferred in some

Osteomyelitis S. aureus other countries

Meningitis Group B streptococci, E. coli - One of the most difficult surgical judgements is
deciding if and when to operate to remove necrotic

Necrotizing enterocolitis (NEC) areas of gut or deal with a perforation.

- Important complication of neonatal intensive care

- Can arise in any baby
- Most commonly occurs in premature babies and
those already ill
- Associated with being small for gestational age, birth
asphyxia and the presence of a PDA
Hemorrhagic disease of the newborn or Vitamin K-dependent b. Doxapram – given as an adjunct to both
bleeding caffeine and nCAP, to avoid resorting
- Very rare mechanical ventilation
- It may cause death or disability if it presents with an - Most clinicians stop giving respiratory stimulants
intracranial bleed when the baby is around 34 weeks of postmenstrual
- It affects only breastfed babies (except in the case of age, by which time most babies will have achieved an
malabsorption) because they get very little Vit. K in adequate degree of cardiorespiratory stability and no
maternal milk and their gut bacteria do not synthesize longer need even the most basic forms of monitoring
it device.
- Formula fed infants get sufficient vit. K in their diet
- IM Phytomenadione 1mg (0.5mL) Seizures
o given either to every newborn baby or - May arise as part of an encephalopathy
selectively to babies who have certain risk (accompanied by altered consciousness or isolated
factors such as instrumental delivery, events when the baby is neurologically normal
preterm birth, etc. between seizures)
o Intramuscular injections are an invasive and - Investigation – finding an underlying cause
unpleasant intervention for the baby since o about half of all term babies having fits
muscle bulk is small in the newborn, and without an encephalopathy, no underlying
particularly the preterm, and other cause can be found.
structures such as the sciatic nerve can be - Treatment may be needed to control acute seizure (
damaged even if the intention is to give the does not terminate quickly), or given long term (to
injection into the lateral thigh. prevent the occurrence of fits)
o reserved for those babies with doubtful oral o Phenobarbital
absorption, for example, all those admitted § First-choice for the acute treatment
for special care, or at high risk because of § Effective, seldom causes
enzyme-inducing maternal drugs such as respiratory depression
anticonvulsants. § Long elimination half-life = active
o can be given orally, so long as an adequate for many hours or days
number of doses is given, and this has been o Diazepam
shown to be effective in preventing disease § Sometimes used IV or rectally
§ Side effects: upsets temperature
Apnea control, causes unpredictable
- is the absence of breathing respiratory depression, and is very
- preterm babies are prone to prolonged pauses in sedating compared to
respiration of over 20s which can be associated with phenobarbital.
significant falls in arterial oxygenation o Paraldehyde
- has both central and obstructive components § occasionally used because it is
- often accompanied by bradycardia easy to give rectally, is relatively
- requires treatment to prevent life-threatening non-sedating and short acting.
episodes of arterial desaturation § excreted by exhalation
- Main goal of medical treatment – reduce the number § smell can make the working
of severity of the episodes without having to resort to environment quite unpleasant for
artificial ventilation staff.
- episodes of apnea and bradycardia can be treated in o Phenytoin
three ways: § used when fits remain uncontrolled
1. intubing and mechanically ventilating the baby after two loading doses of
2. Nasal continuous positive airway pressure phenobarbital (total 40 mg/kg) but
(nCPAP) is not usually given long term
3. Respiratory stimulants because of its narrow therapeutic
a. Caffeine – both reduces apnea in the index.
short term and improves long-term o Clonazepam, Midazolam (infusion),
outcome Lidocaine (infusion)
 § For seizures that are intractable Principles and Goals of Therapy
o Longer term treatment is commonly with • Ultimate aim of neonatal care at all levels is to maximize
phenobarbital but after the first few disability-free survival and identify treatable conditions
postnatal months, carbamazepine or sodium which otherwise compromise growth or development
valproate is more suitable. • Potential problems should be anticipated
- Hypoxic–ischaemic encephalopathy (HIE) • Complexities of intensive care should be avoided
o results either from intrapartum asphyxia or • Drugs used in neonatal care are not licensed for such use,
from an antepartum insult such as placental or are used off-label
abruption, is an important cause of seizures. • There is a high potential for errors because of the small
- Convulsions doses used, which sometimes call for unusual levels of
o are a marker of a more severe insult dilution when drawing up drugs
o they usually occur within 24 h of birth and • Constant vigilance, electronic prescribing and the use of
may last for several days, after which they specialized neonatal formularies are all important in
spontaneously resolve. preventing harm
o The less severely affected babies quickly
return to neurological normality. Rapid Growth
o No drug has been shown to improve - Once the need for intensive care has passed, the
outcome when given after the insult has growth of a premature baby can be very rapid indeed
occurred if the child is being fed with a high-calorie formula
o Cooling a baby to between 33 and 34 °C for modified for use with preterm infants.
72 h has been shown to improve the degree - Most babies born at 27 weeks, and weighing around
of neurodisability among survivors and has 1kg, can be expected to double their birth weight by
rapidly become standard therapy the time they are 8 weeks old
- The therapeutic dilemma lies in the degree of - Dose of all medications is calculated on the basis of
aggression with which convulsions should be treated, body weight
since no conventional anticonvulsant is very effective - Constant review of dose is necessary to maintain
in reducing electrocerebral seizure activity, even efficacy, particularly for drugs that may be given for
when the clinical manifestations of seizures are several weeks such as respiratory stimulants,
abolished, and as stated before, convulsions tend diuretics and anticonvulsants
naturally to cease after a few days. - Weaning a baby from a medication
- Seizures which compromise respiratory function o To hold the dose constant so that the baby
need to be treated to prevent serious falls in arterial gradually ‘grows out’ of the drug
oxygen tension and possible secondary neurological o Is frequently used with diuretic medication in
damage. BPD, the need for which becomes less as
- Babies with frequent or continuous seizure activity the baby’s somatic growth reduces the
are difficult to nurse and cause great distress to their proportion of damaged lung in favor of
parents. healthy tissue
o it is usual to try to suppress the clinical
manifestation of seizure activity, and Therapeutic drug monitoring
phenobarbital remains the most commonly - It is routine to assay levels of antibiotics such as
used first-line treatment. aminoglycosides and vancomycin, of which the
- Therapeutic drug monitoring can provide helpful trough measurement is of most value since it is
information and may need to be repeated from time accumulation of the drug which must be avoided.
to time during follow-up. - it may be necessary to assay minimal inhibitory or
bactericidal concentrations of antibiotics in blood or
cerebrospinal fluid if serious infections are being
treated
- where phenobarbital or other anticonvulsants are
given long term, intermittent measurement of serum
levels can be a useful guide to increasing the dose
- all these drugs have a long half-life, so it is most
important that drug concentrations are not measured
 too early, or too frequently, to prevent inappropriate - most premature babies show individual
changes in dose being made before a steady state is characteristics, which emphasizes that individualized
reached care is as important in this age group as in any other
- neonatal pain and distress have effects on
Avoiding harm nociception and behavior well into the childhood
- intramuscular injection are considered potentially years
harmful because of the small muscle bulk of babies - involvement of parents in every aspect of care is a
- it is not always easy to establish venous access and necessary goal in neonatal clinical practice
occasionally it may be necessary to use the - care is increasingly regarded as a partnership
intramuscular route instead between professionals and parents rather than the
- for vaccines the intramuscular route is unavoidable province of professionals alone
- for sick preterm infants ventilated for respiratory - routine administration of oral medication is thus an
failure, handling of any kind is a destabilizing act in which parents may be expected to participate
influence, so the minimal necessary intervention and for those whose baby has to be discharged home
should be the rule still requiring continuous oxygen
- a good practice to minimize the frequency of drug
administration and to try to coordinate the doses of Case 1 Ms A went into labour as a result of an antepartum
different medications haemorrhage at 28 weeks of gestation. There was no time to
give her steroids when she arrived at the maternity unit and
Time-scale of clinical changes her son, J, was born by vaginal delivery in good condition.
- it may be necessary to assay minimal inhibitory or However, he required intubation and ventilation at the age of
bactericidal concentrations of antibiotics in blood or 10min to sustain his breathing; surfactant was immediately
cerebrospinal fluid if serious infections are being given down the endotracheal tube. He was not weighed at the
treated time but was given intramuscular vitamin K and then taken to
- surfactant is required it should be given as soon as the special care unit. On arrival in the unit, baby J was weighed
possible after birth to premature babies who are (1270g) and placed in an incubator for warmth. He was
intubated and ventilate connected to a ventilator. Blood was taken for culture and
- infection can be rapidly progressive, so starting basic haematology, and he was prescribed antibiotics. A
antibiotics is a priority when the index of suspicion is radiograph confirmed the diagnosis of respiratory distress
high or where congenital bacterial infection is likely syndrome.
o antiretroviral drugs when a baby is born to a
mother positive for HIV, especially if the 1. What antibiotic(s) would be appropriate initially for baby
maternal viral load is high J? over the next 2 days, baby J required modest
- early urgent immunization with hepatitis B vaccine ventilation and remained on antibiotics. A second dose of
and the administration of antihepatitis B surfactant was given 12h after the first. Parenteral feeding
immunoglobulin are very important in preventing was commenced on day 2 as per unit policy, and on day 3
vertical transmission of hepatitis B when the mother very slow continuous milk feeding into his stomach was
is e-antigen positive started. Blood cultures were negative at 48h and the
- premature babies who are still on the neonatal unit 8 antibiotics were stopped. On day 4 he was extubated into
weeks after birth get their routine immunizations, 30% oxygen. On day 5, baby J looked unwell with a rising
since these should be given according to oxygen requirement, increased work of breathing and
chronological age irrespective of prematurity poor peripheral perfusion. Examination revealed little else
except that his liver was enlarged and a little firm, his
Patient and Parent Care pulses rather full and easy to feel and there was a
- premature infants cannot communicate their needs moderate systolic heart murmur. One possibility was
- even when receiving intensive care, any infant who is infection
not either paralyzed or very heavily sedated does in - Blind antibiotic cover is usually started until negative
fact respond with a wealth of cues and non-verbal blood cultures are received. Penicillin and gentamicin
communication in relation to their needs would provide good cover for streptococci and gram-
- monitors do not replace clinical skills, but provide negative organisms, which are the most likely
supplementary information and advance warning of potential pathogens at this stage. A suitable dose
problems would be 30mg/kg of penicillin every 12h and
 2.5mg/kg of gentamicin every 12h. alternatively, a Case 2 Baby B was born at 25 weeks' gestation and was
third-generation cephalosporin such as cefotaxime ventilated for 5 days before being extubated onto continuous
could be used for initial blind treatment. If cultures positive airways pressure. On extubation she was initially in air,
were negative at 48h, antibiotics could be stopped but now at the age of 4 weeks she is mostly in about 30%
provided that there were no clinical indications to oxygen, fully fed on milk, and growing well. Her chest X-ray
continue shows the pattern typical of chronic lung disease. One
2. Which antibiotics would be appropriate for baby J on day morning she is noticed to be in 45% oxygen, she has had a
5? large weight gain and she looks quite edematous all over.
- Antibiotic treatment should take account of the likely
pathogens such as S. aureus and others causing 1. What do these symptoms suggest? After careful
nosocomial infections. A suitable choice for the evaluation, baby B is given oral dose of furosemide
former would be flucloxacillin, if there was no concern 1mg/kg, following which the edema goes down, her
about MRSA, or vancomycin if there was. The weight falls and her oxygen requirement returns to 30%
vancomycin starting dose wuld be 15mg/kg every - The symptoms suggest heart failure. Medical
12h. the addition of another agent with good Gram- examination would probably have revealed an
negative activity such as gentamicin or a third- enlarged liver, and the heart might have had a ‘gallop’
generation cephalosporin would provide good cover. rhythm as well. In babies, the symptoms and signs
3. How could his heart failure and patent ductus arteriosus commonly suggest both left and right ventricular
be treated? After appropriate treatment he looked failure
progressively better an when the blood culture was 2. What are the disadvantages of giving regular furosemide
negative after 2 days, the antibiotics were stopped. By the in this situation? A thiazide diuretic and spironolactone
age of 2 weeks, baby J was on full milk feeds and the duct are prescribed. Four days later, routine biochemistry tests
had closed. He was in air. However, he began to have show a sodium of 125mmol/L.
increasingly frequent episodes of spontaneous - Regular treatment with furosemide causes
bradycardia, sometimes following apneic spells in excess hypercalcuria, as well as excessive loss of sodium and
of 20s duration. Examination between episodes showed a potassium. Chronic hypercalcuria can lead to
health, stable baby. Investigations such as hematocrit, nephrocalcinosis. For this reason, a combination of
serum sodium and an infection screen were normal thiazides and spironolactone is commonly used
- IV indomethacin or ibuprofen would be suitable for 3. What is the choice the attending team has to make?
the treatment of patent ductus arteriosus. - The sodium is low (but the normal range in preterm
Furosemide (1mg/kg as a single dose) is the drug of babies is 130-140 mmol/L, lower than in children and
choice for acute heart failure adults). That it is low is probably an effect of the
4. At 2 weeks, which drug of choice could be used to treat diuretics. The choice lies between carrying on with
his apnea and bradycardia? What would be the expected the diuretics and supplementing the sodium intake,
duration of treatment with this drug? or stopping the diuretics and observing the baby for
- Caffeine is now the drug of choice. A suitable dose for any recurrence of heart failure.
caffeine for baby J would be a loading dose of
20mg/kg with maintenance dose of 5mg/kg/day,
increasing to 10mg/kg/day if necessary. The
frequency of episodes of apnea and bradycardia
should decline immediately. The treatment is likely to
continue until he is about 34 weeks of postmenstrual
age, when his control of breathing should be mature
enough to maintain good respiratory function