Train mother/caretaker to administer drug in suspension form at home

Neonates may be advised drugs in suspension form.

It may be a premade suspension such as an oral antibiotic, or a drug in tablet form that will be mixed in water to make a suspension, or a capsule opened and its contents dissolved in water to make a suspension.

Every suspension has a strength of drug.

Such as, Susp Clarithromycin may be available as 125mg/5mL or 250mg/5mL

It means that there is 125 mg of clarithromycin in every 5 mL of suspension.

So,

If weight of the neonate is 3 Kg.

Dose of clarithromycin: 7.5mg per kg per dose given 12 hourly 

Dose to be given: 3 x 7.5 = 22.5 mg per dose

 Now, 

125 mg are in 5 mL

1 mg is in 5/125

And 22.5 mg is in 5/125 multiplied by 22.5

Equals: 0.9 cc per dose

Or

0.9cc to be given 12 hourly

.....

3cc and 5cc syringes have lock mechanism.

1cc syringe, and 

10 cc syringes do not have lock mechanism.

So, 

One may use a 1cc syringe with detachable needle to administer 0.9cc of suspension to baby twice a day.

Or if the required drug is, say 2.5 cc, one may use a 10cc syringe.

----- Train mother how much drug is to be given. Tell her if she forgets the method/dose she may visit hospital and ask us again. (Try to train 2 persons who will care for the baby).

------ write dose clearly in mL on discharge slip or patient chart, frequency, and the duration in days 

------ After training re-evaluate if care taker is able to give the right dose.

------ mention in the chart that you have trained and evaluated (Name:    ) regarding administration of drug (  ) at home.

......

You may crush tablets and mix these in water to make a suspension.

Say, tab furosemide 20mg may be crushed, and mixed in 10cc water in syringe.

It will give 20mg furosemide in 10mL

Or, 1 mg in 10/20

Or 1mg in 0.5 mL

Or 2mg in 1 mL

And then mother may be advised to Shake the syringe first, and pour ___ cc in spoon and then give to the baby.

Do not place 10cc syringe direct to baby mouth.

Mother may inadvertently press the plunger more than required.

Document in chart whom you trained and evaluated 

Septran - Trimethoprim Sulfamethoxazole neonatal dose

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ATTENTION:

If baby has jaundice or hepatic compromise, then do not advise below 4 weeks.

Link: Septran Dosage

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Also see this link: 

How to train mother/caretaker to administer a drug in suspension form to neonate at home

Hypoglycemia (updates ongoing)

Glucose infusion rate (GIR) (mg/Kg/minute)  formula

Percentage of Glucose x dose (ml/kg/day) divided by 144

Grades of Intraventricular haemorrhage

Hyponatremia

Sodium Deficit (mEq) = (Desired Na⁺ – Actual Na⁺) × 0.6 × Weight (kg)

Desired sodium is 135 mEq/L

Endotracheal suctioning in Neonate

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Visit: Endotracheal suctioning in neonate

Hypokalemia

Hypocalcemia

Neonatal Hyperglycemia

Prime the IV Tubing

Discard the first 20–30 mL of the insulin solution through the tubing. This step saturates the tubing with insulin, minimizing adsorption to the plastic and ensuring the patient receives the intended dose.

A 2012 in vitro study published in Diabetes Technology & Therapeutics evaluated insulin adsorption at various dwell times (0, 15, 30, and 60 minutes) and found no significant difference in insulin concentration delivered from the tubing across these intervals. 

The key takeaway: a 20 mL flush of the insulin solution through the tubing is sufficient to saturate the plastic and minimize adsorption.

Other protocols encourage a dwell time of 30 minutes after flushing with 5 mL of insulin infusion, till the level of 3 way connector (if used).

New Ballard score and training videos

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Download pdf here

New Ballard Score

Training videos:

Training videos

OPD Days with room numbers Children Hospital Lahore

 

DDH Screening

DDH screening algorithm Starship Guidelines

Barlow's and Ortolani manuvers

Video

🧠 Understand the Purpose

Barlow maneuver: Provocative—tests if the hip can be dislocated.

Ortolani maneuver: Reductive—tests if a dislocated hip can be reduced.

👐 Hand Positioning & Technique

Barlow: With the infant supine and hips flexed to 90°, gently adduct the hip while applying posterior pressure on the knee. A palpable “clunk” suggests dislocation.

Ortolani: Abduct the hip while lifting the femoral head anteriorly with your fingers on the greater trochanter. A “clunk” indicates reduction.

Palpate with fingertips, not the palm, to detect subtle shifts.

Compare both hips one at a time and repeatedly in early neonatal visits

 – Interpretation

Positive Barlow: A palpable “clunk” or sensation of the femoral head slipping out of the acetabulum indicates the hip is dislocatable—i.e., it’s unstable but still located at rest.

Negative Barlow: No movement or clunk felt—suggests the hip is stable and not prone to dislocation under stress.

Positive Ortolani: A distinct “clunk” as the femoral head reduces into the acetabulum—indicates a dislocated but reducible hip.

Negative Ortolani: No clunk—either the hip is normal, or it’s dislocated and irreducible (especially in older infants or those with soft tissue contractures).

So a positive barlow and a positive ortolani means that the femur head is dislocable and reduces back, such that there is a risk fir ddh

Hypernatremia - ongoing

Hyperkalemia

Value more than 6 mEq/L is hyperkalemia.

Commence ECG monitoring

Daily requirement is 1 to 2 mEq/Kg/day

Levels of Serum potassiun and ECG changes:

6 mEq/L   tall, peaked T waves

7 mEq/L   flat or absent p wave, wide qrs complex, bradycardia

>7.5 mEq/L  ventricular arrhythmias, sine wave pattern

Starship guidelines are good on this but cannot be followed fully as concerns insulin infusiom with 25% DW, because it has to be given via central line only. 

Starship Guidelines for hyperkalemia

Follow instead the algorithm of  Children Hospital Lahore, where 10 % DW is used. We may give upto 12.5%DW only via peripherla iv line so as to prevent the risk of phlebitis.

Discharge on Request (DOR) and Leave Against Medical Advice (LAMA)

 1.  If parents request to be discharged from Neonatal Unit, then decide based on babys condition if the baby is stable enough to stay at home.  If the baby is not stable and needs intensive support, the baby cannot be discharged on request. Counsel the parents about babys condition so that they continue to receive care in the hospital. Address their concerns and make sure that the baby continues to receive care. However, if the parents have no grievance from hospital staff, and due to certain issues at home or with family they wish to leave then this will be LAMA (Leave against medical advice) not DOR.

2. In case of LAMA take a blank sheet of paper, write bio data of baby, working diagnosis, critical condition, and the statement (in urdu) that they are leaving on their own will against the medical advice and have no grievance from hospital staff. Get thumb impression of father with his name (or mother or guardian)  on LAMA slip. Advise same medicine and fluids on it that you were giving to the baby. Now, write the same statement in patient chart (in urdu), that the parents have been counselled about critical condition but they wish to leave due to (this reason) against medical advice, and that they have no grievance from hospital staff. Get thumb impression with name of Guardian here too.

3. Every effort should be done that baby does not get LAMA.

4. In a considerably stable baby, you may issue a Discharge on Request (DOR). In this case a hospital discharge slip is issued. A statement of DOR (in urdu) will be written on discharge slip and thumb impression of parents will be taken, and the same urdu statement will be written on chart with the thumb impression and name of father/guardian.

It will be a proper discharge slip, if antibiotic days are to be completed (usually 7 or 10 days) then IV antibiotics will be advised. (Write correct dose and route and frequency, must mention infusion volume and time if drug is given as infusion). Mention if any labs are to be followed yet (mostly blood culture, CBC or CRP), or if any labs should be repeated on followup (mostly CBC AND CRP) or if screening Ultrasound scans are due or Echocardiography time has to be taken.

Mention follow-up after 1 day in SIMS Neonatology or any government hospital nearby if they are leaving for a distant city.

Mention Vitamin D drops 400 IU per day for 6 months

Vaccinations

Mother feeding

Do not forget to add antiepileptics if the baby is receiving IV form, switch to oral form and instruct+educate+evaluate attendents if they can administer antiepileptics at home.

And Hearing+visual+developmental screening from Children Hospital Lahore, Development OPD, in cases of perinatal asphyxia, kernicterus, intracranial haemorrhage, meningitis.

In preterm babies (selected population) retinopathy of prematurity (ROP) screening is also advised, (search ROP Screening in this website).

Narrate Red Flag Signs to parents and mention the same on DOR. 

Ask staff on duty to complete all discharge formalities and attach copy of DOR slip in patients chart.

 

Fosfomycin Neonatal Dose and Administration Tips

This is the dosage reference for fosfomycin.

Oral and IV formulations are available commercially in Pakistan.

https://drive.google.com/file/d/1rPcFgkFwxIzcm6uEhVww2F0C9u0UZfDz/view?usp=drivesdk

As per above document, we will prepare it in 5% DW, not normal saline as it can cause sodium load.

Also, there is 2 step dilution, but the final strength that is 40mg/mL, may further be diluted in 10 cc of 5%DW to be given over 30 minutes at least.

Also, read leaflet for stability of drug after preparation of vial, in fridge.

The Neonatal Examination (ongoing updates)

 Items Required:

Hand sanitizer
Measuring Tape
Torch
Tongue depressor
Stethoscope
Thermometer
Fundoscope
Pulse Oximeter
Neonatal size reflex hammer
weighing scale
blood pressure apparatus with neonatal size cuff

Charts: Growth Charts, Down syndrome growth charts, Sarnat scoring Chart, NEC staging chart, New Ballard scoring chart

Pulse Rate: 120 to 160 per minute Awake (& 85 to 90 per minute asleep) (pulse rate may be higher than these limits in preterm babies)

Respiratory rate: 40 to 59 per minute

Blood pressure:

Premies at birth: Systolic 48 to 60 mmHg, diastolic 22 to 34

Premies at 7 days: systolic 60 to 74 mmHg, diastolic 34 to 46

Term at birth: 70/44, 78 +/-10  by  50 +/- 9 at 14 days , and 85+/- 10 by 46 +/-9 at 4 weeks

Temperature:
Axillary/(mouth) 94 to 99 degF
Ear (/rectal) 97 to 100.4 degF
Skin 97 to 99 deg
(Mouth and rectal routes are not preffered)

CRT <3 seconds

spO2 90 to 95 %

Pre-Post ductal saturation difference <3%

Head circumference: 32 to 35 cm for a term baby
OFC increases by 0.5cm/week for the next few months, OFC at 1 month is 36 cm, OFC at 2 months is 39 cm, OFC at 3 months is 41cm , ofc at 6 months is 44cm, ofc at 1 year is 47cm, at 2 years it is 49 cm, and at 5 years it is 51 cm

Weight:
2.5 to 3.5 Kg
LBW <2.5 Kg
VLBW <1.5 Kg
ELBW <1 Kg
Incredibly LBW <750g

25 wks to 29 wks (0.6 to 1 Kg)

30 wks to 34 wks (1.1 Kg to 1.8 Kg)

35 wks to 41 wks (1.9 Kg to 3.5 Kg)

Length:
50 cm at term

Gestational Age: Ballard Scoring

Growth Charts: 

Maintenance Fluids Requirements

Sodium requirement is 2 to 4 mEq per Kg per day

Potassium requirement is 1 to 2 mEq/Kg per day 

Dehydration in Neonates:

Maintenance fluid volumes

Reference: NHS 2025 neonatal guidelines

Type of fluid:
Day 1   (10% DW)
Day 2   (10% DW)
Day 3   (10 % DW with N/5 with 2cc KCl/100 mL)

To Prepare these fluids, refer to this content:

https://www.babyhealth.pk/2025/06/iv-fluids-chart-children-hospital-lahore.html