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

Drugs causing significant hyponatremia:

Feature              Furosemide                     Linezolid                         Omeprazole

Typical Drop	5 mmol/L	8 mmol/L	Can be severe 34 mmol/L
Time to Onset	Days (initiation/escalation)	Median 10 days (7-15 days)	4–11 days (Rapid onset)
Primary Mechanism	Direct renal sodium loss	SIADH	SIADH or excessive urinary loss
Reversal	Fast (Hours/Days)	Days after stopping	Rapid after stopping

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Fictitious hyponatremia:

Type	Common Causes	Mechanism	Key Lab Finding
Pseudohyponatremia	Severe high triglycerides, High protein/IVIG	Large molecules displace water; lab machine miscalculates sodium.	Normal serum osmolality
Translocational	High blood sugar (Hyperglycemia), Mannitol infusion	Osmotic "pull" moves water from cells into blood, diluting sodium.	High serum osmolality
Artifactual	Drawing blood from a site near an IV drip (e.g., D5W)	The blood sample is physically diluted by IV fluid before testing.	Depends on IV fluid type

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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

Desired sodium is 135 mEq/L

Correction rate: 8 to 10 mEq/L/day

Important note: When 3% sodium chloride is not available, remember that, 8.4% NaHCO3 available in out unit equals 6% Na solution.

Endotracheal suctioning in Neonate

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Visit: Endotracheal suctioning in neonate

Hypokalemia

For every 0.1 unit increase in arterial pH, serum potassium levels can drop by approximately 0.5 mEq/L due to this shift alone. (Na/K ATPase causes K to go into the cells and H+ to move out of the cells to maintain normal blood pH)

$$

If a patient receives 10mg of furosemide daily, it leads to around 0.5 mmol/L fall in serum potassium.

At standard therapeutic does of adrenaline infusion, initially serum K rises (due to release from live) an then serum potassium falls by 0.7 mmol/L daily due to intracellular shift of K (activation of Na/K ATPase). 3 Sodium move out of cell and 2 K move into the cells, and so Na rises by 2mmol/L daily with standard therapeutic treatment.

Amikacin causes a 0.4 mEq drop in potassium levels over a 7 day treatment course.

Vancomycin causes a 1 mEq drop over 3 days treatment 

Aminophylline causes a transcellular shift of 0.5 mEq at standard treatment doses  over 1 hour. And it reverses over next 2 to 3 hours.

Caffeine citrate, a methylxanthine like aminophylline, can cause hypokalemia through a combination of a transcellular shift (moving potassium into cells) and renal loss (excreting potassium in urine). 0.5 mmol/L fall over 2 hours, that reverses over next 3 to 6 hours.

Salbutamol nebulization at standard doses or albuterol infusion at standard doses causes 0.5 mmol/L over 2 hours, and it reverts over 3 to 4 hours.

An infusion of 10 units of R insulin causes fall of 1 mmol/L over 1 hour by transcellular shifts, and it reverts over next 3 to 4 hours.

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

...

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

Guidelines for management of Hypernatremia in neonates

Amikacin causes hyponatremia (more often) and rarely hypernatremia (by impairing kidneys ability to concentrate urine and hence losing too much water, same mechanism for amphotericin)

8.4% Sodium bicarbonate (1mEq/mL)

Cefotaxime sodium (2 mEq Na per gram of drug)

Ceftriaxone sodium (3.5 mEq sodium per gram of drug), though ceftriaxone is not recommended routinely in neonatology.

Co-amoxiclav (Oral) contains amoxicillin as trihydrate salt, and clavulanic acid as potassium salt.

Co-amoxiclav (IV) contains amoxicillin as sodium salt 2.5mmol/gram and clavulanic acid as potassium salt 1mmol/gram.
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Pseudohypernatremia:
--low serum albumin (if indirect ion selective electrodes are used)

--hypotriglyeridemia

--sample of blood drawn from site proximal to infusion of sodium bicarbonate or any other sodium containing infusion.

Relating hypoalbuminemia: In real physiologic terms, for every 1g/dL fall of serum albumin, serum sodium falls by 2 mEq/L. This is because albumin is a negatively charged ion, and it hold positively charged sodium with it.

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 peripheral iv line so as to prevent the risk of phlebitis.

Factitious hyperkalemia:

• In-vitro Hemolysis: The most common cause, where red blood cells rupture during collection or processing, releasing their high internal potassium into the serum.

• Delayed Processing: If blood sits too long before being separated in a centrifuge, potassium naturally leaks out of the cells.
• Thrombocytosis
• Leukocytosis
• Specimens not stored between 15 to 25 degC
• Sample collection proximal to potassium containing infusions

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)

Potassium may be added on Day 2 (Ref: NHS)
Sodium N/5 to be added on 3rd Day of life (Ref : NHS)

Fluid restriction by 20 to 30 mL/Kg/Day to be considered in following cases:
Birth asphyxia

CDH (Consider keeping at 60ml/Kg/day) Ref. NHS Guidelines
SIADH
PDA
Chronic lung disease

To Prepare these fluids, refer to this content:

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

Growth charts for all gestational ages

 https://drive.google.com/drive/folders/1k6HJs91Yv0nRS-L9I0r2G3pHnazZF62f?usp=sharing

Mechanism of PDA closure

**The mechanism of closure of Patent Ductus Arteriosus (PDA) after birth involves 5 steps:**

**Step 1: Increase in Oxygen Levels**

- After birth, lungs expand and oxygen levels in the blood increase.

- Higher oxygen levels signal the ductus arteriosus to close.

**Step 2: Release of Constricting Hormones**

- Increased oxygen triggers release of constricting hormones like:

 - **Bradykinin degradation increases** (bradykinin normally keeps PDA open, so its decrease helps closure)

 - Endothelin-1 increases (constricts ductus arteriosus)

 - Prostaglandin F2α increases (constricts ductus arteriosus)

**Step 3: Decrease in Dilating Prostaglandins**

- Decrease in prostaglandin E2 (PGE2) and prostaglandin I2 (PGI2) levels:

 - These prostaglandins normally keep the ductus arteriosus open during fetal life.

**Step 4: Muscular Contraction**

- The ductus arteriosus muscle layer contracts due to the hormonal changes.

- This contraction reduces blood flow through the ductus arteriosus.

**Step 5: Endothelial Cell Overgrowth and Fibrosis**

- Within 1-4 weeks after birth, endothelial cells overgrow the ductus arteriosus opening.

- Fibrosis (scar tissue formation) permanently closes the ductus arteriosus.

**Mechanisms of PDA closure fail in preterm babies due to several reasons:**

1. **Immature Lung Function**: 

 - Lower oxygen levels in blood due to inadequate lung expansion and gas exchange.

 - Delays the trigger for PDA closure.

2. **Increased Sensitivity to Dilating Prostaglandins**:

 - Preterm babies have higher levels of prostaglandin E2 (PGE2) and prostaglandin I2 (PGI2).

 - These prostaglandins keep the PDA open.

3. **Decreased Sensitivity to Constricting Hormones**:

 - Lower response to endothelin-1 and other constricting hormones.

 - Reduces PDA constriction and closure.

4. **Immature Ductus Arteriosus Muscle**:

 - Weaker muscular contraction of the ductus arteriosus.

 - Fails to reduce blood flow through the PDA effectively.

5. **Genetic and Environmental Factors**:

 - Genetic predisposition.

 - Antenatal exposure to magnesium sulfate or other medications that relax smooth muscles.

6. **Lower Bradykinin Degradation**:

 - Bradykinin levels remain higher, promoting PDA patency.

7. **Increased Inflammatory Mediators**:

 - Elevated levels of inflammatory markers promote PDA dilation.

These factors combined increase the likelihood of persistent patent ductus arteriosus (PDA) in preterm infants.

**Comparison of PDA Closure Duration in Preterm vs Term Babies:**

**Functional Closure:**

- Refers to cessation of significant blood flow through the PDA.

 

| | Preterm Babies | Term Babies |

| --- | --- | --- |

| **Functional Closure Duration** | 7-14 days | 1-3 days |

**Anatomical Closure:**

- Refers to complete physical closure of the PDA duct.

| | Preterm Babies | Term Babies |

| --- | --- | --- |

| **Anatomical Closure Duration** | 4-12 weeks | 1-4 weeks |

In summary:

- Preterm babies take longer to achieve both functional (7-14 days vs 1-3 days) and anatomical closure (4-12 weeks vs 1-4 weeks) of PDA compared to term babies.

- This prolonged duration increases the risk of complications in preterm infants.

Endotracheal Intubation Guidelines

https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/intubation

Safer Care Victoria

Size of ETT (internal diameter)

Gest Age (weight)

25 wks to 29 wks (0.6 to 1 Kg) : 2.5mm and suction catheter 6F

30 wks to 34 wks (1.1 Kg to 1.8 Kg) : 3.0mm and suction catheter 6 - 8 F

35 wks to 41 wks (1.9 Kg to 3.5 Kg) : 3.5mm and suction catheter 8F

Depth of insertion (from lips)

Weight + 6cm

We use straight laryngoscope blades in neonatology (Miller Blades).  (not the Mc blades)
Miller Blade size:

00 for extremely preterm (<28 wks gestation)
0 for preterm

1 for term babies

LMA size: For all babies <5 Kg, LMA size 1 is used.

Orogastric Tube Placement Guidelines

NHS Wales

https://wisdom.nhs.wales/health-board-guidelines/swansea-bay-neonatal-postnatal-ward/neonatal-file/chapter-2-insertion-of-orogastric-and-nasogastric-feeding-tubes-abmu-neonatal-guideline-v2019-1-pdf/&ved=2ahUKEwipysD2vdONAxVFRuUKHbvlFfAQFnoFCJUBEAE&usg=AOvVaw1Al4nJWaaosji-xXU9XEeo

Add to it:

Lubricate with normal saline, or lubricant 

Flush with normal saline or water after feeds to ensure patency and bacterial colonization 

A common practice for decades is actually being removed from guidelines due to evidence showing:

**Stethoscope confirmation of ORogastric (OG) tube placement by hearing air bubbles is NOT reliable:**

Studies cite:

1. **False positive rates up to 50%**: Air sounds can be heard over intestines or other areas.

2. **False negative rates up to 20%**: Correctly placed tubes might not produce audible air sounds.

3. **Variability in listener experience and technique**: Affects accuracy of assessment.

Current guidelines from:

- American Academy of Pediatrics (AAP)

- Neonatal Resuscitation Program (NRP)

- European Resuscitation Council (ERC)

recommend confirmation of OG tube placement using:

1. **Aspiration of stomach contents**

2. **Measurement of pH of aspirate** (should be acidic)

3. **Chest X-ray (if clinically indicated or for larger tubes)**

4. **Visualization of tube in stomach via ultrasound (if available)**

IV fluids preparation chart children hospital lahore