NICU Calculations and Formulas
• For a number of excellent online NICU calculators go to www.nicutools.org
Ventilatory Support and ECMO
(See PICU chapter)
Vascular Access
(Formulas may not be appropriate for SGA or LGA infants)
• Always check placement with babygram
• Umbilical artery catheter (UAC): For arterial BP monitoring or freq ABGs
• Low line (cm) ≅ BW (kg) + 7 (want L3 – L5, just above aortic bifurcation)
• Assoc w/ more vasospasms of the lower extremities
• High line (cm) ≅ (3 × BW [kg]) + 9 (want T6 – T10, above diaphragm)
• Assoc w/ risk HTN and ↑ risk IVH, ↓ incidence of cyanosis of lower extremities
• Umbilical vein catheter (UVC):
• Normal: (0.5 × UA [cm]) + 1 (want above ductus venosus, at or below RA)
• Low line: Insert to point of initial blood return (for emergent use)
NICU Testing Guidelines (Pediatrics 2006;117:572; Am Fam Physician 2007;75:1349; Arch Dis Child Fetal Neonatal Ed 2005;90:452)
Fluids, Electrolytes, and Nutrition
• Growth parameters and expected weight gain
• Weight <2 kg: Expect gain of 15–30 g/d or 10–20 g/kg/d
• Weight >2 kg: Expect gain of >20 g/d
• W/ preterm, may have initial weight loss of ≤15% (up to 20% in ELBW)
• In term infants, may have initial weight loss of ≤10%
• Fluid requirements: Premature infants have greater ECF volumes
• Initial fluid requirements: 60–120 mL/kg/d
• Term infants ∼60 mL/kg/d
• ELBW ∼120 mL/kg/d (assuming that they are in Giraffe incubators)
• Goal after fluid stabilization: 100–150 mL/kg/d
• Fluid restriction may be needed w/ PDA, BPD, CHF, renal failure, cerebral edema
• Insensible loss inc w/: Inc skin permeability, inc BSA: weight ratio, phototherapy, radiant warmer beds, respiratory distress syndrome, cold stress, inc activity
• Insensible water loss decreases with double-walled incubators
• Monitor fluid status by daily weights, UOP, and serum Na, Hct, and BUN levels
• Fluid loss also results from vomiting, diarrhea, ostomy output, chest tube drainage
• Inadequate hydration can lead to hyperosmolarity and may be a risk for IVH
• Parenteral nutrition in preterm infant (NeoReviews 2011;12:e130)
*Ca/phos ratio should be 1.7/1.
Modified from Manual of Pediatric Nutrition. 4th ed.
• Common total parenteral nutrition orders at MGH
• Fluid orders on DOL #1: NPO and for
• Term infants: D10W at a rate of 60–80 cc/kg/d
• Preterm: D10W at a rate of 80–100 cc/kg/d
• Add electrolytes after adequate UOP & after checking serum lytes at 12–24 hr
• TPN labs
• Daily: Na, K, Cl, CO2, glucose
• Weekly: Above tests plus Ca, Mg, P, alkaline phosphatase, BUN, creatinine, triglyceride, total protein, albumin, bilirubin, AST, ALT, hematocrit
• “Feeder – Grower” labs
• Hct and retic: 24–28 wk GA: Weekly; >28 wk GA: Every other wk
• Chem 10, alk phos
• Breast-fed <32 wk: Weekly Na, K, phos, Ca, alk phos
• Formula-fed <32 wk: Weekly Ca, phos, alk phos
• All breast-fed with supplement: Weekly lytes, Ca, phos
• All infants on ProMod: Weekly BUN
Enteral Feeds (Manual of Pediatric Nutrition. 4th ed)
• Preterm neonates do not establish coordination of suck, swallow, and breathing until 32–34 wk GA; until then, enteral feeding via NGT (bolus vs. continuous) needed
• Enteral nutrition should generally begin as soon as the infant is clinically stable
• Initiation and advancement based on BW w/ attention to feeding tolerance
• Most premature infants start w/ trophic feeds (low vol; 10 mL/kg/d) to stim GI hormones, motility, and maturation and to prevent gut atrophy
• Option of pasteurized donor human breast milk: <31 wk, <1,500 g, after NEC or bowel surgery when mother’s milk not available
• Once stable, volumes increased slowly as tolerated w/ increments ∼10–20 mL/kg/d, allows for gut adaptation and minimizes risk of complications
• Signs of feeding intolerance include inc gastric residuals > 2 × previous hr’s rate (continuous feed) or >½ previous bolus, inc in abd distention, vomiting, or bilious residuals, heme+ or frank blood in stools, ↑ in apnea or bradycardia with feeds
• Trophic feedings should be initiated as soon as possible. Transitional feeding occurs generally between 2–14 d where the enteral feeding advances as TPN decreases to maintain fluid homeostasis. Enteral Feeding Guidelines should be followed. Monitor glucose during transition. TPN can usually be discontinued when enteral feedings reach 100 cc/kg
Respiratory Syncytial Virus (RSV) Prophylaxis (Pediatrics 2009;124:1694)
• Synagis 15 mg/kg IM monthly during RSV season. 1st dose 1 mo before RSV season
• Recommended at discharge (not while in NICU) for
• Infants with chronic lung disease (CLD) (5 doses)
• Infants born before 32 0/7 wk gestation (5 doses)
• Infants born between 32 0/7 and 34 6/7 wk gestation w/ anticipated child care attendance or sibling less than 5 yr old (3 doses or until they reach 90 d old)
• Infants with hemodynamically significant congenital heart disease (5 doses)
• Risk factors: School-aged siblings, day care, exposure to air pollutants, severe neuromuscular dz, congenital abnormalities of the airways, LBW (<2,500 g), crowded living conditions, multiple birth, family history of asthma
Morbidity and Mortality with BW and GA (N Engl J Med 2008;358:1700)
*Complications include bronchopulmonary dysplasia, severe intraventricular hemorrhage, necrotizing enterocolitis, or bronchopulmonary dysplasia and severe intraventricular hemorrhage combined.