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NEONATAL FORMULARY · Aldactazide 2 - 4 mg/kg/day ÷ q12h PO/OG Contains hydrochlorothiazide and...
Transcript of NEONATAL FORMULARY · Aldactazide 2 - 4 mg/kg/day ÷ q12h PO/OG Contains hydrochlorothiazide and...
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NEONATAL FORMULARY
As drug elimination in this population is most closely related to the combination of gestational age (GA) and
postnatal age (PNA), postmenstrual age (PMA) - which combines GA and PNA - is frequently used to guide
drug dosing.
Example: 28 week GA neonate who is 3 weeks PNA is now (28 + 3) = 31 weeks PMA.
(NOTE: Post-conceptual age (PCA) and post-menstrual age (PMA) are used interchangeably.) DRUG DOSE COMMENTS
Acetaminophen < 33 wks PMA: 10-12 mg/kg q 6-8
hr PRN. MAX 40 mg/kg/day
>33wks PMA and term < 10 days
old: 10-15 mg/kg q 6 hr PRN.
MAX 60 mg/kg/day
TERM > 10 days: 10-15 mg/kg q
4-6 hr PRN. MAX 90 mg/kg/day
PO/OG/PR
Consider all sources of acetaminophen in total daily
max. Use of scheduled doses with immunizations
may diminish immune response: consider PRN
instead. Suppository available in 20, 40, and 80mg
precut doses.
Acetazolamide 5 mg/kg Q 12 hours
PO/OG/IV
Limit duration to 48 hours and re-evaluate need.
Used to assist with alkalosis management when
diuretic reduction and/or electrolyte
supplementation were ineffective
Acyclovir
Premature:
< 33 wks PMA: 20 mg/kg q12h IV
33-36 wks PMA: 20 mg/kg q8h IV
Term: 20 mg/kg q8h IV
Infuse over 1 hr; monitor serum Cr; adjust dosage if
renal dysfunction. Serial ANC twice/week
recommended when giving 15-20 mg/kg q8h.
Dosing for preterm infants is controversial; consultation with ID and
pharmacist is recommended. Dosage
modification is needed in renal impairment.
RESTRICTED antibiotic.
Adenosine 0.05 mg/kg rapid bolus, IV
If ineffective, increase dose to
0.1 mg/kg
Treatment for SVT; consult pediatric cardiologist
prior to use.
Albuterol
0.25 - 0.5 mg/kg by nebulization
q 4-8 hr
or
1-2 puffs by MDI q 4-8 hr
1.25 – 2.5 mg/hour continuous
nebulization
Continuous nebulization may be considered in
treatment of hyperkalemia. Tachycardia is common
with doses approaching 1mg/kg.
Drug delivery through ventilator circuits is
variable.
Available in 0.63 mg/3 mL and 1.25 mg/3 mL unit
dose as well as 5 mg/mL stock solution. MDI is
90 mCg/puff.
FOR HYPERKALEMIA
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NOTE: Levalbuterol (Xopenex) is now non-
formulary. Consider use only when tachycardia
persists despite albuterol dosage reduction.
Levalbuterol dose should start at 50% of albuterol
dose listed.
Aldactazide 2 - 4 mg/kg/day ÷ q12h
PO/OG
Contains hydrochlorothiazide and spironolactone in
a 1:1 ratio. Concentration is 5 mg/mL. Order in mg
of either component.
Aldactone
See Spironolactone
Amikacin
Amikacin
INTERVAL (based on PMA):
Premature: 12-15 mg/kg/dose
IV, IM
< 28 wks PMA q36h
29-32 wks PMA q24h
33-36 wks PMA q18h
Term: 10 mg/kg/dose IV, IM
0-7 days: q18h
> 7 days: q12h
Levels not needed unless 1) treatment to continue
past 3 days; 2) there is renal impairment; 3) patient
received an unusually high dose. Monitor serum
concentrations and adjust dosage to achieve post
concentrations of 25-35 mCg/mL and trough
concentrations
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Amphotericin B Initial dose: 0.5 mg/kg/day IV over
6 hours; subsequent daily doses
increased by 0.25 - 0.5 mg/kg/day
increments until reach
0.75-1 mg/kg/day. Infuse over 2-6
hours.
Closely assess vital signs during initial dose
infusion. Serum potassium, magnesium and
creatinine levels should be monitored.
Modify dose in renal failure. Patients with Candida
sepsis generally treated to a total dose of 15-30
mg/kg.
Amphotericin B
liposome
(AmBisome)
5 mg/kg IV Q 24 hours RESTRICTED antifungal Serum potassium, magnesium and creatinine levels
should be monitored.
Ampicillin < 1.2 kg: 50-100 mg/kg q12h
1.2 - 2 kg:
0-7 days: 50-100 mg/kg q12h
> 7 days: 50-100 mg/kg q8h
> 2 kg:
0-7 days: 50-100 mg/kg q8h
> 7 days: 50-75 mg/kg q6h IV, IM
For Group B Strep meningitis:
0-7 days: 100 mg/kg/dose q8h
> 7 days: 300 mg/kg/day in
4 to 6 divided doses
IV, IM
UTI prophylaxis: 50 mg/kg Q 24h
The higher doses are used in meningitis; for other
indications, use the lower doses.
Aspirin ~5 - 10 mg/kg/dose PO/OG Daily Prophylaxis after cardiac surgery. Pick the dose
closest to 20.25 or 40.5mg (1/4 or ½ tab of “baby”
aspirin). Refer to Cardiology/CV clinical notes.
Ativan
See Lorazepam
Atropine
0.01-0.03 mg/kg IV, SC, ET
0.02mg/kg IV/IM
Severe bradycardia; rarely indicated.
Premedication for Intubation
Atrovent
See Ipratropium
AZT
See Zidovudine
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Beclomethasone
(QVAR) metered
dose inhaler
40mcg/accuation
Weight
Range
Dose
Less than
551grams
3 puffs BID X 7 days,
2 puffs BID X 7 days,
3 puffs daily X 7 days,
2 puffs daily X 7 days,
Then STOP
551-750
grams
4 puffs BID X 7 days,
3 puffs BID X 7 days,
2 puffs BID X 7 days,
1 puffs BID X 7 days,
Then STOP
751-850
grams
5 puffs BID X 7 days,
4 puffs BID X 7 days,
2 puffs TID X 7 days,
1 puff TID X 7 days,
Then STOP
Greater than
850 grams
4 puffs TID X 7 days,
3 puffs TID X 7 days,
2 puffs TID X 7 days,
1 puff TID X 7 days,
Then STOP
May order as “QVAR Wean Per Protocol” upon
initiation of dosing.
Neonates requiring mechanical ventilation.
Consider use as early as 3-14 days of age.
May reduce subsequent systemic steroid needs or
aid in weaning from mechanical ventilation.
Preferred over fluticasone because more neonatal
efficacy data and no documented HPA axis
suppression. 500mCg/day MAX.
Bicitra 2-3 mL/kg/day ÷ 3-4 doses
PO/OG
For metabolic acidosis unresponsive to usual
measures. 1 mL contains ~ 1 mEq of citrate and
1 mEq sodium. Citrate is metabolized to
bicarbonate.
Butorphanol
(Stadol)
5-10 mCg/kg/dose every 4-6 hours
slow IV push
Narcotic analgesic.
Caffeine Citrate Loading dose: 20 mg/kg
Maintenance dose: 5 mg/kg/dose
every 24 hours
IV, PO/OG
Minimum IV dose able to be
infused on pumps is 2 mg.
Serum caffeine concentrations of 5 to 20 mCg/mL
are desired. Consider checking trough level ~7 days
after starting caffeine in patients with PMA < 31
weeks. Consider checking level prior to extubation
or in patients failing to respond or with tachycardia.
Refer to Caffeine Monitoring in Apnea section of
text.
Calcium Chloride
(100 mg/mL)
Emergency use: 0.3 mEq/kg over
2-5 minutes; IV
For Rickets of Prematurity:
70 - 150 mg/kg/day ÷ bid PO/OG
* alternate bid dosing with K phos
so one or the other is given every 6
hours.
► Cardiac arrest/severe bradycardia; rarely
indicated. Very hyperosmolar. Avoid administration
through scalp veins or small peripheral veins. MAX
concentration for peripheral IV administration
20 mg/mL. Order in mEq.
(1.4 mEq elemental Ca+2 per mL)
► Give just prior to a feeding in a nipple or via
OG/NG tube; do not give mixed in formula or
breastmilk. Only given when full volume enteral
feeds are established.
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Calcium Gluconate
10%
(100 mg/mL)
Emergency use: 0.3 mEq/kg over
2-5 minutes; IV
(1 mL Calcium/kg)
Hypocalcemia: 0.25-0.5 mEq/kg
infused over a minimum of 1 hour;
IV
May also be given PO/OG
Cardiac arrest/severe bradycardia; rarely indicated.
Hyperosmolar. Avoid administration through scalp
veins or small peripheral veins. 50 mg/mL is MAX
concentration for peripheral IV administration.
Addition to maintenance IV fluids and slow
administration over 24 hours is preferred to faster
intermittent infusions. Order in mEq.
(0.45 mEq elemental Ca+2 per mL). Do NOT infuse
into same line with TPN.
Captopril Initial dose:
0.05 to 0.1 mg/kg/dose every
8-12 hours. Slowly titrate as
needed up to 0.5 mg/kg/dose.
PO/OG
Monitor serum potassium in presence of K+-sparing
diuretics or K+ supplements. Neutropenia and
proteinuria may be seen. Begin at lowest dose and
titrate. Administer on empty stomach.
Contraindicated in renovascular disease. MAX
neonatal dose 2 mg/kg/d. MAX infant dose
6 mg/kg/d.
Cefazolin
(Ancef)
< 2 kg: 20 mg/kg/dose q12h; IV
> 2 kg: 20 mg/kg/dose q8h; IV
Neurosurgery may use for prophylaxis. Not for
routine Gram negative coverage.
Cefepime
(Maxipime) < 30wk PMA:
Scr 0.7-1.3:
20 mg/kg Q12h
Scr < 0.7 OR Meningitis:
30 mg/kg q12h
> 30 wk PMA:
Scr 0.7-1.3
30 mg/kg q12h
Scr < 0.7
50 mg/kg q12h
Meningitis
50 mg/kg q8h
May be preferred over cefotaxime due to less
promotion of bacterial resistance; less impact on GI
flora; and better Pseudomonas activity.
Dosage adjustment required in renal impairment.
Cefotaxime
(Claforan)
All doses are 50 mg/kg/dose
IV, IM
INTERVAL:
< 1.2 kg or 0-7 days PNA q12h
> 1.2 kg and > 7 days PNA q8h
Not generally used for initial rule-out sepsis. Some
suggest up to 300 mg/kg/day divided q6h for
meningitis in term neonates. Dosage adjustment
required in renal impairment.
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Ceftazidime
(Fortaz)
All doses are 50 mg/kg/dose
IV, IM
INTERVAL:
< 1.2 kg or 0-7 days PNA q12h
> 1.2 kg and > 7 days PNA q8h
RESTRICTED ANTIBIOTIC
Reserve for pseudomonas aeroginosa or pathogens
resistant to other agents. Dosage adjustment
required in renal impairment.
Cefuroxime IV, IM Preterm 2 kg AND
< 7 days: 25 mg/kg q12h
≥ 7 days: 33.3 mg/kg q8h
Term: 33.3 mg/kg q8h
Chloral Hydrate
Sedative dose:
25 mg/kg/dose q8-12h PO/OG/PR
Hypnotic dose:
50 mg/kg PO/OG/PR
Watch for accumulation with repeated doses,
especially in preterms. Tolerance to sedation
develops.
► Single use before procedures.
Chlorothiazide
(Diuril)
2-8 mg/kg/day ÷ q12h IV
20-40 mg/kg/day ÷ q12h PO/OG
Monitor electrolytes. May cause hypokalemia,
hypochloremia, hyponatremia, or alkalosis. Do not
confuse with hydrochlorothiazide. For use in renal
failure, consult Nephrology.
Chlorpromazine
(Thorazine)
0.25 to 1 mg q6-8h IV, PO/OG
NOTE: Dose is not in mg/kg.
Dose is usually tapered rather than
abruptly discontinued.
Used in CV/cardiology patients to reduce
pulmonary vascular resistance. Watch for
hypotension, hypothermia, eosinophilia, and
excessive sedation. Efficacy data supporting
prolonged/intermittent dosing in neonates is lacking.
Cholecystokinin
(CCK)
(Sincalide)
0.02 mCg/kg/dose 2-3 times/day
IV
Promotes gallbladder contraction in cholestasis
Frequent shortage issues
Clindamycin
All doses are 5 mg/kg/dose IV, IM
INTERVAL:
< 1.2 kg q12h
1.2 - 2 kg:
0-7 days PNA q12h
> 7 days PNA q8h
> 2 kg:
0-7 days PNA q8h
> 7 days PNA q6h
May cause severe colitis. Stop drug if significant
diarrhea occurs.
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Clonidine Neonatal Abstinence Syndrome
(Adjunct Therapy)
0.5-1 mCg/kg PO q4-6h
(depending on feeding schedule)
Note: dosing units are
MICROgrams.
Curent concentration is 50
mCg/mL. Minimum measurable
dose is 2.5 mCg.
PO/OG
- To be used along with morphine WHEN morphine
dose >0.2mg/kg q3hr AND Finnegan scores remain
>8
- Start at lower end of dosing range.
- If Finnegan scores >8 consistently while receiving
clonidine, may increase frequency or dose
- Consider written hold parameters for low heart rate
or blood pressure (ex. Hold for HR
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Digoxin Premature:
Total digitalizing loading dose: 15-20 mCg/kg given over 24
hours in 3 divided doses IV
Maintenance: 4-6 mCg/kg/day ÷ q12h IV
Term:
Total digitalizing loading dose: 30-40 mCg/kg given over 24
hours in 3 divided doses IV
Maintenance: 5-10 mCg/kg/day ÷ q12h IV
All orders should be written in mCg.
► Oral doses 25% more than IV doses. Reduce
dose in renal impairment.
► Oral doses 25% more than IV doses. Reduce
dose in renal impairment.
IV preparation from pharmacy is 20 mCg/mL. PO
preparation is 50 mCg/mL.
Dobutamine
5-20 mCg/kg/min IV Less effective at raising BP than dopamine in
premature neonates. Consider for myocardial
dysfunction. Vasodilation at high dose.
Drips available as 0.5, 1, or 2 mg/mL. All
concentrations compatible with TPN.
Dopamine 2-5 mCg/kg/min IV
5-20 mCg/kg/min IV
► “Renal” dose
► “Inotropic and vasoconstrictive” dose.
Drips available as 0.4, 0.8, or 1.6 mg/mL.
Compatible with TPN up through 1.6mg/mL.
Enoxaparin
(LMW heparin)
Subcutaneous
< 2 months or Preterm:
Prophylaxis: 0.75 mg/kg Q 12hr
Treatment: 1.5 mg/kg/dose Q 12hr
Term and > 2 months:
Prophylaxis: 0.5 mg/kg Q 12hr
Treatment: 1 mg/kg/dose Q 12hr
Anti-Xa (heparin) level may be monitored 4 hours
after the 3rd dose in patients receiving
TREATMENT or cardiac patients receiving
prophylactic doses.
Epinephrine
1:10,000 only
0.1 - 0.3 mL/kg/dose IV, ET; (the
higher dose preferred for ET); may
repeat every 3 - 5 min. Dilute to
0.5 - 1 mL with normal saline for
ET administration. Continuous
infusion: 0.05 - 1.0 mCg/kg/min IV
For cardiac arrest, severe bradycardia not responsive
to routine resuscitation. Causes vasoconstriction.
Continuously monitor heart rate, blood pressure,
and perfusion. Drips available as 10 or 16 mCg/mL.
ETT dosing 0.5ml/kg – 1ml/kg per 7th Ed NRP
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Fentanyl 1 - 4 mCg/kg IV; may repeat every
2 - 4 hours as indicated.
2mCg/kg IV/intranasal for
intubation premedication
Continuous infusion: Start at
0.5 mCg/kg/hr and titrate to pain
relief. Mean required dose is 0.64-
0.75 mCg/kg/hour (range 0.5 – 2
mCg/kg/hr).
Higher doses may be required in
ECMO patients.
Tolerance may develop rapidly. Respiratory
depression, withdrawal, hypotension, bradycardia,
flushing, desaturations, and chest wall rigidity may
occur.
► Continuous infusion is indicated for severe pain
uncontrolled by intermittent administration of
opiates in patients intolerant of morphine infusion.
* Use of fentanyl in patients where analgesia is not
required is NOT indicated. Titrating to sedation
(side effect) often results in excessive doses.
Benzodiazepines (lorazepam or midazolam) may
be a better choice when sedation is the primary
desired effect. Drips available as 2 or 10 mCg/mL.
Ferrous sulfate
Order in mg
of salt
5 to 20 mg/kg/day in 1 or 2 divided
doses (1 - 4 mg/kg elemental)
20-30 mg/kg/day in 2 or 3 divided
doses (4 – 6 mg/kg elemental)
PO/OG
Prophylaxis
Treatment of iron deficiency anemia
Consider dietary sources of iron as well toward total
dose. Available as 75mg/mL (15mg/mL elemental
iron) drops. Standard doses are 11.25, 18.75, 26.25,
30, 37.5, and 45 mg.
Fluconazole For Systemic Candidiasis:
< 30wk PMA and < 7 days old
CONSULT CLINICAL
PHARMACIST
DOSE: 12 MG/KG
INTERVAL:
< 30wk PMA and 7-14 days old
Q24HRx2 DOSES then Q72hr
< 30wk PMA and >14 days old
Q24HR
> 30wk PMA and < 14 days old:
Q24HRx2 DOSES then Q48hr
> 30wk PMA and > 14 days old:
Q24HR
IV, PO/OG
For patients with serum creatinine > 1.3mg/dL,
dosing interval should be modified after first 2
doses. Check serum creatinine daily in renal
impairment and Consult Clinical Pharmacist
Modify dosage in renal impairment.
Monitor serum creatinine twice weekly and LFT’s
weekly. May significantly alter phenytoin levels.
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Fluticasone
(Flovent)
MDI’s as 44, 110,
and 220
mCg/accuation
500 mCg/kg/day ÷ q12h for up to 4
weeks. (750 mCg/day MAX)
May taper:
500 mCg/kg/day x 1 week;
375 mCg/kg/day x 1 week;
188 mCg/kg/day x 1 week;
94 mCg/kg/day x 1 week;
Stop
Neonates requiring mechanical ventilation.
Adrenal suppression. *Current MDI product
cannot be used in ventilator circuit.
Beclomethasone preferred over fluticasone because
more neonatal efficacy data and no documented
HPA axis suppression. The 44 mCg inhaler makes
tapering doses easier.
Fosphenytoin
(Cerebyx)
Loading dose: 15-20 mg PE/kg IV
at no greater than 1.5 mg/kg/minute
Maintenance dose: 4 - 8 mg
PE/kg/day divided BID
IV, IM
Ordered in PE (phenytoin
equivalents)
Causes less venous irritation than phenytoin.
Consider use in patients with only small peripheral
venous access available. Use with caution in hyper-
bilirubinemia. Much more expensive than
phenytoin. Serum concentrations should be
monitored and doses adjusted to maintain
concentrations between 8 and 15 mCg/mL. Trough
levels are most useful. Hypotension and bradycardia
possible. Consider checking free phenytoin level if
toxicity is suspected, total level is >15 or patient is
hypoalbuminemic.
Furosemide
(Lasix)
1 mg/kg/dose
Preterm: q24h
Term: q12h
IM, IV, PO/OG
Monitor electrolytes. May cause hypokalemia,
hypochloremia, hyponatremia, alkalosis,
dehydration, and ototoxicity. Oral doses
approximately twice IV doses. For renal failure,
consult Neonatology and Nephrology
Gentamicin INTERVAL: (based on PMA &
PNA):
Less than/equal to 3 weeks PNA:
- ≤28 weeks PMA: 3mg/kg q36h
- 29-32 weeks PMA: 3mg/kg q24h
- 33weeks PMA: 3.5mg/kg q24h
Greater than 3 weeks PNA:
- ≤28 weeks PMA: 3mg/kg q24h
- 29weeks PMA: 3.5mg/kg q24h
ECMO patients:
3.5 mg/kg q24h
Levels not needed unless treatment to continue past
3 days, or there is renal impairment, or patient
received an unusually high dose. Monitor serum
concentrations and adjust doses to achieve post
concentrations of 5 - 10 mCg/mL and troughs
< 2 mCg/mL. Give less frequently in neonates with
birth depression, congenital heart disease, renal
impairment, or on inotropic support. Consultation
with pharmacist for dosing recommendation in renal
impairment is suggested. Monitor respiratory status
closely in offspring of myasthenics and those
exposed to magnesium.
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Glucagon 100 micrograms/kg IM Max 300 micrograms
Hepatitis B
immune globulin
(HBIG)
0.5 mL x 1 IM within 12 hours of
birth.
Indicated for newborns whose mothers have acute
Hep B infections or who are HBsAg-positive, or in
preterm newborns < 2 kg with unknown maternal
HBsAg status.
Hepatitis B vaccine Maternal HBsAg status positive or
unknown: 0.5 mL IM within 12
hours of age.
Maternal HBsAg negative:
0.5 mL IM at birth or before
discharge.
Refer to Hepatitis B section under Infectious
Diseases in the text.
0.5 mL Recombivax HB = 5 mCg
0.5 mL Engerix B = 10 mCg
In preterm infants < 2 kg at birth born of HBsAg
negative moms, delay administration of 1st dose
until 1 month chronologic age. Use of scheduled
acetaminophen doses with immunizations may
diminish immune response: consider PRN instead.
Hyaluronidase
(Wydase)
1 mL of 15 unit/mL solution as
5 separate 0.2 mL subcutaneous/
intradermal injections
Use within 1 hour of extravasation of hyperal/other
solution - NOT for pressors. Inject around periphery
of extravasation. Consult Plastic Surgery service if
affected area is > 1 cm.
Hydralazine IV: 0.1-0.2 mg/kg/dose q6-8h; may
slowly increase as needed to MAX
1 mg/kg/dose.
PO/OG: 1 mg/kg/day ÷ q6-8h;
may slowly increase as needed to
MAX 7 mg/kg/day.
► Acute hypertension or hypertensive crisis
► Chronic hypertension.
Hydrochlorothiazid
e
2 - 4 mg/kg/day ÷ q12h
PO/OG
May cause hypokalemia, hypochloremia,
hyponatremia, or alkalosis. Monitor electrolytes.
Only available PO
Hydrocortisone Hypotension unresponsive to
pressors: 1 mg/kg/dose q8h IV
Physiologic replacement:
10-15 mg/m2/day ÷ q8h IV
Stress dose:
20-50 mg/m2/day ÷ q8h
IV/PO/OG
When using for hypotension unresponsive to
pressors, limit use to 5 days.
Complications: hypertension, hyperglycemia, failure
to gain weight, GI ulceration/perforation (especially
when given concurrently with indomethacin).
BSA (m2) = [(0.05) x (wt in kg)] + 0.05
Hyperstat
See Diazoxide
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Indomethacin
(Indocin) PROPHYLAXIS OF IVH
0.1 mg/kg/dose q24 hrs x 3 doses
IV
CLOSURE OF PDA Age Dose (mg/kg)
1st 2nd 3rd
< 48 hr 0.2 0.1 0.1
2-7 days 0.2 0.2 0.2
> 7 days 0.2 0.25 0.25
IV
Interval: q12 – 24h x 3 doses
► For premature infants < 1250gm birthweight
requiring ventilatory support for RDS. Give 1st dose
ASAP and within 12 hours of birth.
► To be used under direction of
neonatologist/pediatric cardiologist. Monitor platelet
count and serum creatinine. Q24 hour dosing may be
preferred in extreme premature infants.
Insulin 0.01-0.1 unit/kg/hour
0.1 unit/kg/hr X 1 hour
For Hyperglycemia unresponsive to glucose
reduction. Drip concentration 0.25units/mL with
3mL tubing prime & discard.
For Hyperkalemia: Using drip of 1 unit regular
insulin in 50mL D10W. Dose of 5mL/kg over 1
hour gives 0.1 units/kg insulin and 0.5gm/kg
glucose.
CONSULT NEONATOLOGIST
Ipratropium
(Atrovent)
25 mCg/kg q6-8h – round to
nearest unit dose. Nebulized into
the ventilator circuit.
Tachycardia.
Iron See Ferrous Sulfate
Isoproterenol 0.05 – 2 mCg/kg/min IV infusion
Treatment of bradycardia. Continuous ECG and
blood pressure monitoring; essential to watch for
hypertension and tachycardia.
IVIG 400 mg/kg/dose IV
400-1000 mg/kg/day for 2-5 days
IV
► Neonatal sepsis
► For alloimmune thrombocytopenia.
Administer 5% solution at 0.5 mL/kg/hr and
gradually increase to maximum of 4 mL/kg/hr if
tolerated. Availability of drug is limited. See
PowerPlan
Kayexalate 0.5 - 1 gm/kg/dose q6h PRN
PO/OG or PR
Rectal may be given more
frequently if needed.
Approximately 1 mEq potassium is
removed per 1 gm of resin.
Use sorbitol as diluent (oral 3-4 mL/kg of 10%
sorbitol solution; rectal 2-3 mL/kg of 25% sorbitol
solution).Avoid commercially available suspension.
May also decant daily feeding volume: add
kayexalate to total daily feed volume, let sit for 1
hour. Pour off top layer to use for feeds and discard
residue at the bottom (use in consultation with renal
service)
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Lansoprazole
(Prevacid)
1 mg/kg qday x 3 weeks
PO/OG
For ENT patients following supraglottoplasty/ENT
laser procedures.
Levocarnitine 50mg/kg/day in 3-4 divided doses
IV/PO
For use in consultation with metabolism service
Up to 50mg/kg/day may be added to TPN
Linezolid 0 – 7 days and < 34 weeks PMA:
10 mg/kg IV/PO q 12 hr
> 7 days or > 34 weeks PMA:
10 mg/kg IV/PO q8 hr
For treatment of vancomycin resistant
entrococcal infection.
RESTRICTED antibiotic.
Lorazepam
(Ativan)
0.05-0.1 mg/kg/dose every 6-8
hours PRN for sedation.
IV, PO/OG
Use the longer intervals in prematures. Tolerance
may develop. Respiratory and cardiac depression,
withdrawal, hypotension, bradycardia, myoclonic
movements, and desaturations may occur.
Potential for drug accumulation with frequent
dosing.
Magnesium
Sulfate
Hypomagnesemia:
0.1 - 0.25 mEq/kg/dose IV, IM.
Dilute to 0.5 mEq/mL and infuse
over 2 - 4 hours.
Calcium gluconate should be available as an
antidote; monitor serum concentrations.
Addition to maintenance IV fluids and slow
administration over 24 hours is preferred to faster
intermittent infusions.
Meropenem
INTERVAL: (based on PMA &
PNA):
< 32 wks PMA: 20 mg/kg
< 2 wks PNA: q12h
> 2 wks PNA: q8h
Reserve for bacteria not susceptible to other
antibiotics. RESTRICTED antibiotic.
Meropenem
INTERVAL: (based on PMA &
PNA):
> 32 wks PMA
< 2 wks PNA: 20 mg/kg q8h
> 2 wks PNA: 30 mg/kg q8h
> 90 DAYS PNA: 20 mg/kg q8h
40 mg/kg q8h
Reserve for bacteria not susceptible to other
antibiotics. RESTRICTED antibiotic.
Sepsis or Pneumonia
Meningitis
Metoclopramide
(Reglan)
0.1 – 0.2 mg/kg/dose q6h
PO/OG/IV
Irritability; dystonic reactions possible and may be
irreversible. Give before feedings. Use in GER is
controversial
-
Metronidazole
(Flagyl)
< than 34 weeks PMA: 15mg/kg x
1 then 7.5mg/kg IV q12hr
34-40 weeks PMA: 15mg/kg x 1
then 7.5mg/kg IV q8hr
Greater than 40 weeks PMA:
15mg/kg x 1 then 7.5mg/kg IV
q6hr
****Initial dosage of 15mg/kg given IV for all
gestational ages then begin dosing 12 hours later
based on DOL and weight ****
Midazolam
(Versed)
0.05-0.1 mg/kg/dose; may repeat
every 2 - 6 hrs as needed.
Continuous infusion: Start at
20 mCg/kg/hr and titrate to desired
sedation. Mean required dose is
30-60 mCg/kg/hr.
PO/OG/IV
Use the longer intervals in prematures. Tolerance
may develop. Respiratory and cardiac depression,
withdrawal, hypotension, bradycardia, myoclonic
movements, and desaturations may occur.
Potential for drug accumulation with frequent
dosing. Drips available as 0.1 or 1mg/mL.
* Lorazepam is preferred for intermittent
administration because it has no active metabolites,
doesn’t require continuous infusion, and is less
expensive.
Milrinone 0.2 – 0.75 mCg/kg/minute
continuous infusion
For short term use (1-3 days)
Not for premature neonates due to possibilities of
hypotension, tachycardia, and slowed ductal closure.
CONSULT CARDIOLOGY.
For use only in patients with cardiac failure who
have not adequately responded to other
inotropes. Start with lowest dose and titrate. May
have a role in PPHN patients who fail to respond
adequately to iNO. Limited information in
neonates. MODIFY DOSE IN RENAL
IMPAIRMENT. Incompatible with furosemide
Morphine
0.05 - 0.1 mg/kg/dose q 4-8h as
needed IV, IM
PO dose is 1.5 to 2 times the IV
dose
Continuous infusion:
23-26wk PMA: 10 mCg/kg/hr
27-29wk PMA: 20 mCg/kg/hr
> 30wk PMA: 30 mCg/kg/hr
When used for drug withdrawal,
refer to Neonatal Abstinence
Syndrome section under
“Miscellaneous” in text.
Use the longer intervals in premature infants.
Tolerance may develop. Respiratory depression,
withdrawal, hypotension, flushing, bradycardia, and
desaturations may occur.
► Continuous infusion indicated for severe pain not
controlled by intermittent dosing of opiates. Use in a
setting where analgesia is NOT indicated.
* Titrating to sedation (side effect) often results in
excessive doses. Benzodiazepines (lorazepam or
midazolam) may be a better choice when sedation is
the primary desired effect. Drips available as 0.2 or
1 mg/mL.
Nafcillin Dose: 25 mg/kg IV
Venous irritation
-
INTERVAL:
0-7 days PNA:
< 2 kg q12h
> 2 kg q8h > 7 days PNA:
< 1.2 kg q12h
1.2 – 2 kg q8h > 2 kg q6h
Narcan
(Naloxone)
0.1 mg/kg/dose IV, ET preferred;
IM, SC acceptable. May be
repeated every 3-5 minutes.
* Contraindication: maternal narcotic addiction
Nitroglycerin Initial: 0.1-0.5 mCg/kg/min IV
Usual dose: 1-3 mCg/kg/min
Titrate to effect. Vasodilator – reduces preload.
Continuously monitor blood pressure, heart rate,
oxygen saturation.
Nystatin 100,000 units 4 times/day PO
Opium, tincture of Use for neonatal drug withdrawal.
Refer to Neonatal Abstinence
Syndrome section under
Miscellaneous in text.
Oxacillin Dose: 25 mg/kg IV
INTERVAL:
0-7 days PNA:
< 2 kg q12h
> 2 kg q8h > 7 days PNA:
< 1.2 kg q12h
1.2 – 2 kg q8h
> 2 kg q6h
Causes venous irritation
Pancuronium
(Pavulon)
0.04 - 0.1 mg/kg/dose q30-120
minutes PRN IV
Monitor blood pressure and heart rate. Reduce dose
in renal dysfunction.
Pediarix (DTaP +
Hepatitis B + IPV)
0.5 mL IM 2 months chronologic age despite degree of
prematurity. Use of scheduled doses with
immunizations may diminish immune response:
consider PRN instead.
Penicillin G Dose: 25,000 – 50,000 units/kg
IV, IM
INTERVAL:
< 1.2 kg q12h
The higher doses are used in meningitis; for other
indications, use the lower doses.
-
> 1.2 – 2 kg:
0-7 days PNA: q12h
> 7 days PNA: q8h
> 2 kg:
0-7 days PNA: q8h
> 7 days PNA: q6h
For Group B Strep meningitis:
0-7 days: 150,000
units/kg/dose q8h
> 7 days: 112,000 units/kg/dose
q6h
* For treatment of congenital syphilis, refer to
Congenital Syphilis section under Infectious
Diseases in the text.
Phenobarbital Initial loading dose: 15-20 mg/kg
IV over no less than 20 minutes.
Subsequent loading doses: 5-10
mg/kg.
Maintenance dose: 3-5 mg/kg/day
qday or divided bid
Cholestasis/augment biliary
conjugation: 2-3 mg/kg/day
IV, IM, PO/OG
Trough level should be monitored to maintain
concentrations between 15 and 35 mCg/mL.
Check level at point of seizure resolution and
weekly thereafter x 2 weeks. Consult clinical
pharmacist for additional monitoring plan. Some
patients may require more frequent level
monitoring. Dosing may be divided q12h if single
daily dose not tolerated. Use the lower maintenance
dose in patients with history of birth depression or
prematurity.
Phentolamine
(Regitine)
For vasopressor infiltrate: Infiltrate
affected area with multiple small
subcutaneous injections of a 0.5
mg/mL solution. Change needles
between injections.
Use ASAP after pressor extravasation. Dilute with
normal saline. Not for hyperal extravasation.
Hypotension with large doses or doses given IV.
Do not administer more than 2.5 mg total.
Phenylephrine
0.125%
(Neo-Synephrine)
1-2 drops intranasally q8-12h; use
for no more than 24 hours.
For nasal congestion. Monitor blood pressure.
Phenytoin
(Dilantin)
Loading dose: 15-20 mg/kg IV at
no greater than 0.5 mg/kg/min;
may be diluted in 0.9% NaCl only
to a concentration of < 6 mg/mL.
Maintenance dose: 5-8 mg/kg/day
divided bid IV, PO. Higher oral
doses may be necessary to maintain
therapeutic levels.
Loading dose should be administered with
continuous ECG monitoring. Serum concentrations
should be monitored and doses adjusted to maintain
concentrations between 8 and 15 mCg/mL. Trough
levels are the most useful.
Hypotension and bradycardia possible. Check free
phenytoin level if toxicity is suspected, total level is
>15 or patient is hypoalbuminemic. Consider
fosphenytoin if only small peripheral venous access
is available. Can only be infused with normal saline.
Not compatible with heparin.
-
Piperacillin Dose: 75 mg/kg IV
INTERVAL (based on PMA &
PNA):
< 36 wks PMA:
< 7 days PNA: q12h
> 7 days PNA: q8h > 36 wks PMA:
< 7 days PNA: q8h > 7 days PNA: q6h
Adjust dosage in renal impairment.
Piperacillin/
Tazobactam
(Zosyn)
Dose: 84.4 mg/kg IV
INTERVAL (based on PMA &
PNA):
< 36 wks PMA:
< 7 days PNA: q12h
> 7 days PNA: q8h > 36 wks PMA:
< 7 days PNA: q8h
> 7 days PNA: q6h
Polytrim
Ophthalmic
See Trimethoprim and
Polymyxin B Ophthalmic
Potassium chloride For Hypokalemia:
0.5-1mEq/kg/dose IV
Infuse over a minimum of 2 hours.
Potassium
Phosphate
(IV preparation)
For Rickets of Prematurity:
0.5 - 2 mM/kg/day ÷ bid PO/OG
* alternate bid dosing with calcium
chloride so one or the other is
given every 6 hours.
May be added to formula or breastmilk feedings to
mask its unpleasant taste. Only given when full
volume enteral feeds are established.
Propranolol IV: 0.01 mg/kg/dose by slow IV
push q6-8h PRN. May increase
slowly to MAX of 0.15
mg/kg/dose.
PO/OG: 0.25 mg/kg/dose q6-8h.
May increase slowly to MAX of
5 mg/kg/day.
For Tetralogy Spells:
0.15-0.25 mg/kg/dose IV
For arrhythmias, hypertension. Avoid in patients
with respiratory compromise.
-
Prostaglandin E1
(PGE1)
Initial continuous infusion dose of
0.1 mCg/kg/min IV; wean to
0.025 - 0.05 mCg/kg/min as
tolerated.
To be used under direction of neonatologist or
pediatric cardiologist.
Protamine 0.5 - 1 mg IV for every 100 units
of heparin in the previous hour (50
mg/dose MAX).
Bleeding with excessive doses
Ranitidine
(Zantac)
Preterm:
IV: 1 mg/kg/day ÷ q12h
PO/OG: 2 mg/kg/day ÷ q12hrs
Term:
IV: 4 mg/kg/day ÷ q8h
PO/OG: 4-6 mg/kg/day ÷ q8h
* Can also be added to a 24 hour bag of
hyperalimentation at the same total daily dose.
Regitine See Phentolamine
Reglan See Metoclopramide
Rifampin 10 mg/kg/day ÷ q12h IV For synergy in persistently positive Staphylococcal
bacteremia.
Sildenafil 0.25 – 0.5 mg/kg q6-8h PO/OG
Consult Pediatric Cardiology
Sincalide 0.02 mCg/kg IV BID-TID For cholestasis. Use is controversial.
Sodium
Bicarbonate
For Cardiac arrest:
1-2 mEq/kg IV over 5 minutes; use
only for prolonged arrest.
For Metabolic acidosis:
1-2 mEq/kg IV over 1 - 2 hours
Use concentration of 0.5 mEq/mL (4.2%) only.
Use only after adequate ventilation is established.
Not to be used as first line for treating thick
respiratory secretions as no clinical trials exist to
support use. Use Normal Saline as first line.
Spironolactone
(Aldactone)
1-3 mg/kg/day ÷ q12h PO/OG Monitor serum potassium especially when used with
captopril or potassium supplements. May take
several days to see maximal effect. Survanta (Beractant)
RDS: 4 mL/kg/dose per ET
divided into 4 aliquots. Repeat
doses are given at least 6 hours
apart if indicated. MAX of 4 doses
in the first 48 hours of life.
Meconium aspiration syndrome:
6 mL/kg/dose q6h per ET for
MAX of 4 doses.
Use only under direction of neonatologist. Refer to
Surfactant Dosing Guidelines section under
Respiratory Problems in text.
Consult neonatologist for other possible uses such
as in congenital diaphragmatic hernia, persistent
pulmonary hypertension, or HMD in older
gestational age neonates.
-
Synagis
(Palivizumab)
15 mg/kg monthly IM during RSV
season.
See RSV Prophylaxis section under Infectious
Diseases in text for patient inclusion criteria. Must
be ordered on power plan with approval from NICU
pharmacist or PAS. Batch days are Monday and
Thursday with doses to be administered at 1400
Thorazine
See Chlorpromazine
Tobramycin
Same as under Gentamicin
TPA
(Alteplase)
Using a 5 mL syringe, gently and
slowly instill a volume of
1 mg/mL equal to or less than the
internal volume of the catheter.
Do not force the TPA into the
catheter. If device does not allow
infusion or aspiration, a gentle
repeated push-pull action can be
used to instill the TPA.
For clearing an occluded line.
Allow solution to dwell in line for 30-60 minutes;
then attempt to aspirate TPA from the catheter with
a 5 mL syringe. If unsuccessful, wait an additional
30 minutes before trying again to aspirate solution.
Once patency is restored, aspirate and discard 1-2
mL of blood. Replace this volume with normal
saline. For clot dissolution unrelated to occluded
lines, consult neonatologist.
Trifluridine 1% 1 drop in each eye every 2 hours For treatment of primary keratoconjunctivitis caused
by herpes simplex virus types 1 and 2.
Trimethoprim and
Polymyxin B
Ophthalmic
Solution
(Polytrim)
1-2 drops in each eye q4-6h For bacterial conjunctivitis.
Ursodiol
(Actigall)
25 - 30 mg/kg/day ÷ TID PO/OG
For cholestasis
Vancomycin Dose: 15 mg/kg IV
INTERVAL (based on PMA and
PNA):
< 2 weeks old:
- < 28 wks PMA: q24h
- 29 – 32 wks PMA: q18h - ≥33wks PMA: q12h
>2 weeks old:
o < 28 wks PMA: q18h
29 – 32 wks PMA: q12h
≥33wks PMA: q8h
Intravenous therapy reserved for species of
Staphylococcus and enterococcus resistant to other
agents. Levels not needed unless treatment to
continue past 3 days, there is renal impairment, or
patient received an unusually high dose.
Post/peak level should be 25-40 mCg/mL and
trough level 8-15 mCg/mL. Give less frequently in
infants with birth depression, congenital heart
disease, renal impairment, or on inotropic support.
Oxacillin is preferred drug if CONS is susceptible to
both vancomycin and oxacillin.
Vaponephrine 0.25-0.5 mL nebulized x 1
2.25% racemic epinephrine
-
Vecuronium
(Norcuron)
0.1 mg/kg/dose IV every 1-2 hours
as needed.
Monitor blood pressure and heart rate. Less likely to
cause hypertension and tachycardia than
pancuronium. Consider vecuronium when these side
effects become problematic. Drips available as 0.1
or 1 mg/mL.
Versed
See Midazolam
Vidarabine 3%
Ophthalmic
Ointment (Vira-A)
Apply ointment to lower
conjunctival sac every 2 hours
For treatment of primary keratoconjunctivitis caused
by herpes simplex virus.
Vira-A Ophthalmic
See Vidarabine Ophthalmic
Viroptic
Ophthalmic
See Trifluridine
Zantac
See Ranitidine
Zidovudine (AZT) Preterm:
< 30 weeks PMA:
IV: 1.5 mg/kg/dose q12h or
PO/OG: 2 mg/kg/dose q12h
for 4 weeks, then q8h
> 30 weeks PMA:
IV: 1.5 mg/kg/dose q12h or
PO/OG: 2 mg/kg/dose q12h
for 2 weeks, then q8h
Term:
PO/OG: 4 mg/kg/dose q12h or
IV: 1.5 mg/kg/dose q6h
Refer to HIV Exposed Infants section under
Infectious Diseases in text. Dosing to begin within
6-12 hours of birth and continue through 6 weeks.
Do not give IM. Monitor CBC with diff and
hemoglobin. IV infusion to be over 1 hour at < 4
mg/mL concentration in D5W.
Zosyn See Piperacillin/Tazobactam