NICU Notes — Quick Reference

Compiled from the Toronto Residents' Handbook of Neonatology (2022), CPS Guidelines, AAP NRP 8th Ed., and RCPCH guidance. For on-call use by Paediatrics staff. Always verify with local protocols and senior staff.

23–42Weeks GA Coverage

CPSBased Guidelines

NRP 8Resuscitation

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Antenatal Steroids

Maternal Conditions

MgSO₄

Additional Notes (free text — appended to summary)

Order Checklist

GA-Based Admission Orders & Screening At-a-Glance

Select the infant's gestational age to generate a tailored admission order checklist. Tick items as completed. ⚠ marks higher-priority items at that gestation.

Antenatal

Antenatal Interventions & Counselling

⚠️

Transfer to Tertiary Centre if <30 weeks

Any anticipated delivery <26 weeks — urgent transfer. Arrange transport to a Level 3 centre (e.g., HSC, Sunnybrook, Mt. Sinai, Trillium) for infants <30 weeks gestation.

Antenatal Corticosteroids

Offered to mothers at ≤34+6 weeks at risk of delivery in next 7 days
Consider at ≥22 weeks when early intensive care is planned
Betamethasone 12 mg IM × 2 doses, 24h apart (or 12h if delivery imminent)
Reduces RDS, IVH, NEC, mortality
Maximal efficacy: >48h before delivery
Effective for 2–4 weeks from administration
Max 2 doses; repeat doses NOT recommended routinely

↗ SOGC Guideline

Magnesium Sulphate (MgSO₄)

Neuroprotection for baby + maternal seizure prophylaxis (pre-eclampsia)
Give to mothers at risk of imminent delivery ≤33+6 wk within 24h
Loading dose: 4g IV over 15–20 min
Maintenance: 1g/h IV until delivery or 24h
Decreases risk of CP and neurodevelopmental impairment
Monitor: DTRs, respiratory rate, UO (must stay >25 mL/h)
Antidote: Calcium gluconate 1g IV
Neonatal effect: hypotonia, lethargy, respiratory depression (transient)

↗ CPS Neuroprotection

GBS Prophylaxis (IAP)

Adequate = ≥1 dose ≥4h before delivery
Penicillin G 5 MU IV, then 2.5 MU IV q4h
Alt (low-anaphylaxis risk): Cefazolin 2g IV then 1g q8h
Alt (PCN allergy, high risk): Clindamycin or Vancomycin
Not needed for elective C-section with intact membranes
Pre-term labour: treat as GBS unknown if no swab result

↗ CPS Sepsis Statement

Antenatal Counselling Thresholds

<22 weeks: Comfort care; discuss with family
22–23 wk: Individualized; palliative vs resuscitate
23–24 wk: Offer resuscitation (institutional variation)
≥25 wk: Resuscitate (assumed in Canada)
Survival to discharge: 41% at 23 wk, 67% at 24 wk, 79% at 25 wk
NDD at 4–8 years: ~40% (mod-severe) at 23 wk, ~28% at 24 wk

↗ CPS Preterm Counselling

Tocolysis & Preterm Labour

Goal: delay delivery to allow steroids / transfer
Nifedipine (1st line): 20mg PO, then 10–20mg q4–6h
Indomethacin: 50–100mg PR, then 25mg q6h (use <32 wk, max 48h)
MgSO₄ has mild tocolytic properties (adjunct)
Avoid β-agonists (ritodrine) — significant maternal side effects
Tocolysis contraindicated in chorioamnionitis, severe pre-eclampsia

Antenatal Surveillance — Biophysical Profile (BPP)

BPP Components (2 pts each = 8/8 reassuring)

Tone: limb extension then flexion (≥1 episode)
Movement: ≥3 discrete body movements
Breathing: ≥1 episode ≥30s duration
Amniotic fluid: pocket ≥2cm in 2 planes

NST Reactive Criteria (≥32 weeks)

≥2 accelerations in 20 min
Each peak ≥15 bpm above baseline
Each lasting ≥15 seconds

Absent/reversed end-diastolic flow on UA Doppler = ominous; consider delivery

Medications

Neonatal & Maternal Drug Reference Chart

GA = gestational age at delivery or corrected GA. All weights use birth weight for first 72–120h. Verify all dosing with pharmacy and local protocols.

▸ Maternal Medications (Affecting Fetus/Newborn)

Drug	Indication	When (GA)	Dose	Neonatal Effect	Ref
Betamethasone	Fetal lung maturation, ↓IVH/NEC	22–34+6 wk	12mg IM × 2 doses, 24h apart	↓RDS, ↓IVH. Transient neonatal hyperglycemia.	SOGC
MgSO₄	Neuroprotection (baby), seizure prophylaxis (mom)	≤33+6 wk	Load 4g IV/15min → 1g/h	Neonatal hypotonia, lethargy, resp. depression (transient, usually self-limited)	CPS
Penicillin G / Ampicillin	GBS prophylaxis (IAP)	Any GA, in labour	PCN: 5 MU IV × 1, then 2.5 MU q4h Amp: 2g IV × 1, then 1g q4h	Reduces EOS risk by ~80%	CPS
Labetalol	Maternal hypertension	Any	IV 20mg, may repeat 40–80mg	Neonatal bradycardia, hypotension, hypoglycemia (beta-blockade)
Nifedipine	Tocolysis / maternal HTN	<34 wk for tocolysis	20mg PO, then 10–20mg q4–6h	Generally safe; monitor newborn BP if high maternal doses
Indomethacin	Tocolysis	<32 wk (≤48h use)	50–100mg PR, then 25mg PO/PR q6h	↑Risk of premature PDA closure, NEC if >48h or >32 wk; oligohydramnios
SSRI/SNRI	Maternal depression/anxiety	Any	Various	Poor neonatal adaptation syndrome: tremors, jitteriness, feeding difficulty, resp. distress. Rarely PPHN.
Opioids (maternal)	Labour analgesia	Within 4h of delivery	Various	Transient respiratory depression. DO NOT give naloxone to infant of opioid-dependent mother.

▸ Neonatal Medications — Indications & Dosing

Drug	Indication	When (GA / Age)	Dose	Notes / Cautions	Ref
Caffeine Citrate	Apnea of Prematurity (AOP)	<31+6 wk (until 34–35 wk CGA)	Load: 20 mg/kg PO/IV Maint: 5–10 mg/kg/day	First choice for AOP. Also ↓BPD. Tachycardia, irritability at high levels. Check levels if concern (therapeutic: 15–35 µg/mL). Base 10 mg/kg load = caffeine base equiv.	CPS
Surfactant (Poractant α / Calfactant)	RDS prophylaxis or treatment	<30 wk (consider <32 wk if RDS)	Poractant: 200 mg/kg intratracheal × 1 Repeat 100 mg/kg if needed ×2	Via ETT or LISA/MIST. INSURE method preferred. Consider if FiO₂ >0.30 on CPAP. Early rescue preferred over late.	CPS
Vitamin K	Hemorrhagic disease of newborn (VKDB) prophylaxis	All newborns at birth	>1500g: 1.0 mg IM ≤1500g: 0.5 mg IM	IM preferred over oral. Oral inferior; use only if parents refuse IM. Give within first hour of life.	CPS
Epinephrine (Resuscitation)	Cardiac arrest / persistent bradycardia	Any — during NRP	IV/IO: 0.01–0.03 mg/kg (1:10,000) = 0.1–0.3 mL/kg ETT: 0.05–0.1 mg/kg = 0.5–1 mL/kg	IV preferred. Flush with 3 mL NS after IV dose. Repeat q3–5 min. For 3kg baby: 0.6 mL IV or 3 mL via ETT.	CPS/NRP
Ampicillin	EOS empiric therapy (± Gentamicin)	Any, suspected sepsis	50 mg/kg IV q12h (<1wk, preterm) 50 mg/kg IV q8h (≥1wk or term)	Covers GBS, Listeria, some gram-neg. Pair with Gentamicin for synergy. Adjust for meningitis (200 mg/kg/day).	CPS
Gentamicin	EOS empiric therapy	Any, suspected sepsis	≤29 wk: 5 mg/kg q48h 30–34 wk: 4–5 mg/kg q36h ≥35 wk: 4 mg/kg q24h	Extended-interval dosing preferred. Monitor levels: trough <1 µg/mL, peak 6–12 µg/mL. Nephrotoxic, ototoxic.
Indomethacin (IV)	PDA closure; prophylactic IVH prevention	ELBW (<1000g); PDA management	Prophylactic IVH: 0.1 mg/kg IV q24h × 3 doses PDA: 0.2 mg/kg IV × 1, then 0.1–0.25 mg/kg q12–24h × 2	Monitor UO (hold if <0.6 mL/kg/h), creatinine, platelets. Contraindicated: NEC, bleeding, renal impairment, thrombocytopenia <50.	CPS PDA
Ibuprofen (IV)	PDA closure (alternative to indomethacin)	Preterm with hemodynamically significant PDA	10 mg/kg IV day 1, then 5 mg/kg/day × 2	Less renal impairment than indomethacin. Avoid in NEC, pulmonary hypertension.
Dextrose Gel (40%)	Neonatal hypoglycemia	First 48h, BG <2.6 mmol/L	200 mg/kg (= 0.5 mL/kg of 40% gel) × 1, may repeat × 1 Massage into buccal mucosa, then feed	First-line for asymptomatic hypoglycemia. Follow with feed within 30 min. If no response → IV dextrose.	CPS Hypoglycemia
Phenobarbital	Neonatal seizures (1st line)	Any — active seizures	Load: 20 mg/kg IV over 10–15 min Additional: 10 mg/kg × 2 if needed (max 40 mg/kg) Maint: 5 mg/kg/day	Monitor resp. depression (have PPV ready). Therapeutic level 20–40 µg/mL. Start maintenance 12h after last loading dose.	SickKids Protocol
Lorazepam	Acute seizures (2nd line if Phenobarbital fails)	Any — refractory seizures	0.1 mg/kg IV/PR over 2 min Repeat × 1 after 2 min if needed	Respiratory depression risk; have PPV ready. Short duration of action.
Fosphenytoin	Refractory neonatal seizures	After Phenobarbital failure	20 mg PE/kg IV over 10 min	Monitor cardiac rhythm. Levetiracetam 60 mg/kg IV × 1 is an alternative (increasing evidence for neonates).
Morphine / Fentanyl	Analgesia/sedation in ventilated neonates	Any intubated neonate	Morphine: 0.05–0.1 mg/kg IV q4–6h Fentanyl: 1–4 µg/kg IV slow push (intubation pre-med: 2 µg/kg)	Monitor resp. depression, hypotension. Fentanyl preferred for acute procedures (shorter acting).
Sucrose 24%	Non-pharmacologic pain relief	All neonates — procedural pain	0.5–1 mL to anterior tongue 2 min before procedure Max 4 doses/24h	For heel pricks, IV insertions, NG insertion. Combine with non-nutritive sucking. Not for major surgical pain.
Prostaglandin E₁ (Alprostadil)	Duct-dependent congenital heart disease	Any newborn with suspected CCHD	Start: 0.01–0.05 µg/kg/min IV infusion Titrate up to 0.1 µg/kg/min if needed	⚠ Intubate before starting if high doses anticipated. Side effects: apnea, hypotension, fever, seizures. Call Cardiology first.	CPS CCHD
Phototherapy	Neonatal hyperbilirubinemia	GA-dependent thresholds (see Jaundice section)	Standard: 8–10 µW/cm²/nm Intensive: >30 µW/cm²/nm	Expose maximum skin area. Eye protection mandatory. Check TSB within 4–6h. Discontinue when 20–35 µmol/L below threshold.	CPS Bilirubin
IVIG	Isoimmune hemolytic disease (DAT+)	When TSB rising despite phototherapy	500–1000 mg/kg IV over 2–4h May repeat in 12h if needed	Use when DAT+ and bilirubin nearing exchange transfusion threshold.
Probiotics	NEC prevention	<32+6 wk or <1500g — start with feeds	1 dose PO q24h with first enteral feed	↓Mortality and ↓time to full feeds. Site-specific product (Lactobacillus/Bifidobacterium). Avoid in immunocompromised.
Iron (Elemental)	Iron supplementation for preterm/LBW	BW <2.5kg + predominantly breastfed; start day 10–14	2–2.5kg: 1–2 mg/kg/day × 6 months <2kg: 2–3 mg/kg/day × 1 year	Not needed if formula-fed at adequate volumes. Reassess at well-baby visits.	CPS Iron
Vitamin D	Vitamin D deficiency prevention	All infants from birth	400 IU/day (standard) 800 IU/day (Northern/Indigenous communities, winter)	Give until 1L+ formula/day. Use D-Vi-Sol or Tri-Vi-Sol drops. Check 25-OH-D if concerns.	CPS Vit D
Dopamine / Dobutamine	Neonatal hypotension / low cardiac output	Any — hemodynamic instability	Dopamine: start 5–10 µg/kg/min, up to 20 Dobutamine: 5–15 µg/kg/min	Central line required. Use targeted neonatal echo to guide. Avoid for permissive hypotension without clinical signs of poor perfusion.
Acyclovir	Neonatal HSV infection	Any — suspected/confirmed neonatal HSV	60 mg/kg/day IV ÷ q8h × 14–21 days (skin/eye/mouth 14d; CNS/disseminated 21d)	High index of suspicion with vesicular rash, seizures, encephalopathy, liver failure. Send HSV PCR (blood, CSF, skin).
Morphine (NAS/NOWS)	Neonatal opioid withdrawal	Modified Finnegan ≥8 × 3 or avg ≥12 × 2	0.04–0.1 mg/kg PO q3–6h Wean 10% q24–48h when controlled	Non-pharmacologic first (swaddle, low stimulation, skin-to-skin, breastfeeding). ⚠ Never give naloxone to infant of opioid-dependent mother.

GA Guide

GA-Based Interventions At-a-Glance

Antenatal steroids

✓ offer

✓

consider

MgSO₄ neuro

✓

Caffeine (AOP)

✓ start

✓

consider

stop ~35w

Surfactant

✓ early

✓

if RDS

Probiotics

✓

consider

Prophy Indomethacin

✓ ELBW

Head USS (IVH screen)

✓ d4–7

if ill

ROP Screening

✓ at CGA 31w

✓ GA+4wk

≤30+6 wk

UVC recommended

✓

if unstable

Thermoreg. bag

✓

✓ (<32w)

Therapeutic cooling

≥35w HIE

✓ ≥36w HIE

NRP

Neonatal Resuscitation (NRP 8th Ed.)

🚨

Sequence: Warm → Stimulate → Clear airway → Assess HR

If HR <100 bpm → start PPV. If HR <60 bpm after 30s of PPV → start compressions + 100% O₂ → IV epinephrine.

NRP Algorithm (AAP 8th Ed.) — Simplified

Based on AAP NRP 8th Edition. Always follow your institution's NRP protocol. ↗ AAP NRP Official

Initial Steps

Preterm <32 wk: plastic bag/wrap, servo-warmer, room 25–26°C, hat
FiO₂: 21% (term), 21–30% (preterm) — titrate to SpO₂ targets
PIP: 20–25 cmH₂O, PEEP: 5 cmH₂O
Delay cord clamping ≥60 sec if no immediate resuscitation needed
Dry and stimulate → position airway → clear secretions if needed
APGAR at 1, 5 min (and q5 min to 20 min or score ≥7)

SpO₂ Targets Post-Birth

1 min: 60–65%
2 min: 65–70%
3 min: 70–75%
4 min: 75–80%
5 min: 80–85%
10 min: 85–95%

Ongoing NICU targets: 88–95% for preterm

GA (wk)	Laryngoscope	ETT Size	ETT Depth at Lip (cm)	Approx Weight	UVC Depth (cm) + stump
23–24	Miller 00	2.5	5.5	500–600g	~7–8
25–26	Miller 00	2.5	6.0	700–800g	~8
27–29	Miller 0	2.5–3.0	6.5	900–1000g	~9
30–32	Miller 0	3.0	7.0	1100–1400g	~10
33–34	Miller 0	3.0–3.5	7.5	1500–1800g	~11
35–37	Miller 0–1	3.5	8.0	1900–2400g	~12
38–40	Miller 1	3.5	8.5	2500–3100g	~13
41–43	Miller 1	3.5–4.0	9.0	3200–4200g	~14

Compressions

After 30s effective PPV with no HR improvement
Rate: 90/min compressions + 30 breaths = 120 events/min
Depth: 1/3 AP chest diameter
Use 2-thumb technique (encircling hands)
FiO₂ → 100% when compressions begin
Obtain IV access while doing CPR

Epinephrine Dosing

IV/IO: 0.1–0.3 mL/kg of 1:10,000
Flush 3 mL NS after IV dose (all weights)
ETT: 0.5–1 mL/kg of 1:10,000
Repeat q3–5 min if no response

For 3 kg baby: 0.6 mL IV, or 3 mL ETT

MR. SOPA Corrections

M — Mask readjust
R — Reposition airway
S — Suction mouth first, then nose
O — Open mouth slightly
P — Pressure increase (+5–10, max 40)
A — Alternate airway (ETT or LMA)

Preterm

Preterm Care (<37 Weeks)

Temperature Management

<32 wk: Plastic bag/wrap immediately at delivery
Thermal mattress + preheated radiant warmer
Hat on in delivery room; room temp 25–26°C
Humidified incubator: 75–80% first week
Target axillary temp: 36.5–37.5°C
<27 wk: Open diaper 4–7d (prevent diaper dermatitis)
<27 wk: Sterile water to cleanse skin for first 5 days (no chlorhexidine)

Preterm Vitals & Monitoring

Continuous cardiac/SpO₂ monitoring
Q1h vitals × 72h in VLBW/ELBW
Target SpO₂ 88–95% (avoid hyperoxia)
Target PaCO₂ 45–55 mmHg (avoid <35 → PVL)
Target pH 7.25–7.40
BP: consider cuff vs UAC correlation q8h
POCT glucose q3–6h from 2h of life
Weight: q24h (2-person procedure)

Neuroprotection Bundle

Antenatal MgSO₄ ≤33+6 wk
Antenatal steroids ≤34+6 wk
Delayed cord clamping (or cord milking)
Head midline, HOB 30° × 72h
Minimal handling especially first 72h
Volume-targeted ventilation (preferred mode)
Prophylactic indomethacin in ELBW
Avoid rapid fluid boluses (↑IVH risk)
Maintain PaCO₂ 45–55 mmHg

Access Strategy

<26 wk: UVC + UAC
26–29 wk: UVC ± UAC if unstable
>30 wk: PIV; UVC if unstable or poor access
PICC: avoid first 72h; insert if >5d IVF needed
UVC duration: 5–7d; PICC if longer needed
UAC max 5 days; remove if vascular compromise
All lines: heparin per unit policy

IVH Grading (Papile)

Grade I: Subependymal / germinal matrix only
Grade II: Intraventricular, <50% ventricular volume
Grade III: IVH with ventricular dilation
Grade IV: IVH with parenchymal extension

Head USS: day 4–7, 4–6 weeks, at term CGA. Grades III–IV → weekly USS for PHVD monitoring.

↗ CPS Neuroimaging

Preterm Initial Orders (Birth to 72h) — <32 Weeks

Fluids

Day 1: 80 mL/kg/day D10W (preterm)
Advance by 20 mL/kg/day
Add lytes after first void
TPN: start ASAP in <1500g
Electrolyte-free PN initially

Medications

Vitamin K 0.5mg IM
Caffeine (load 20mg/kg, maint 5–10mg/kg/d)
Sucrose 24% before procedures
Ampicillin + Gentamicin if sepsis risk
Prophy indomethacin if ELBW
Probiotics when feeds start

Investigations

CBC, glucose, G&S, blood gas, CRP ± culture
CXR (after intubation or for line placement)
AXR for UVC/UAC position
Electrolytes at 12–24h
NBS at 24h (repeat at 21d if <32w)

Respiratory

Respiratory Support & Management

Escalation Ladder

High-flow NC (HFNC): 2–8 L/min, FiO₂ as needed
CPAP: 5–8 cmH₂O, FiO₂ titrate to SpO₂
NIPPV: non-invasive positive pressure
SIMV / AC ventilation
HFJV / HFOV for refractory respiratory failure
iNO for PPHN (start 20 ppm)

Intubation Pre-Meds (Preterm)

Atropine 0.02 mg/kg IV (push)
Fentanyl 2 µg/kg IV (slow, over 2 min)
Succinylcholine 2 mg/kg IV (push)
Or: Morphine 0.1 mg/kg IV
Always confirm position with CO₂ detector + CXR

Check unit protocol — premedication policy varies

Pneumothorax — Needle Decompression

2nd ICS, mid-clavicular line
Butterfly: 25G (<32w/<1500g), 23G (others)
Insert over top of 3rd rib (avoid neurovascular bundle)
Aspirate with 10–20 mL syringe + 3-way stopcock
Follow with chest tube if recurrent
Contraindicated: known CDH

RDS / Surfactant — CPS Indications (2021)

1. Prophylactic surfactant is NOT recommended when CPAP is routine in DR and antenatal steroid rate is high (>50%) — Grade A
2. Start non-invasive support (CPAP) from birth for RDS. Give early rescue surfactant for worsening RDS (escalating O₂, clinical/CXR signs) — Grade B
3. Give surfactant if FiO₂ exceeds 0.50 in intubated infant with RDS — Grade A
4. Give surfactant to intubated preterm infants before inter-facility transport — Grade B
5. Repeat dosing only when evidence of ongoing moderate-to-severe RDS — Grade A
6. For spontaneously breathing infants on CPAP, LISA or MIST preferred over INSURE — Grade B
7. Surfactant for MAS or pulmonary hemorrhage: at clinician's discretion — Grade B

Product: Poractant alfa (porcine) preferred — 200 mg/kg first dose, 100 mg/kg repeat ×2. Higher initial dose more effective.

↗ CPS Surfactant Statement (2021)

DOPE — Sudden Deterioration on Ventilator

D — Displacement of ETT (check depth, bilateral air entry)
O — Obstruction of ETT (suction)
P — Pneumothorax (transillumination, needle decomp)
E — Equipment failure (disconnect from vent; bag manually)

Neurology

Neurology — HIE, Seizures, NAS

❄️

Therapeutic Hypothermia — Initiate within 6 hours of birth

Must meet ALL three criteria below (A + B + C). Target 33.5°C whole body × 72h. GA ≥36 weeks, age ≤6h.

Therapeutic Hypothermia Criteria

A — Cord or early blood gas (within 1h)

pH ≤7.0 OR base deficit ≥−16

B — If gas unavailable OR pH 7.01–7.15 / BD −10 to −15.9

Must have BOTH of the following:

History of acute perinatal event (cord prolapse, placental abruption, uterine rupture, maternal trauma/arrest, late or variable decelerations, inadequate resuscitation, etc.)

Apgar score ≤5 at 10 minutes OR continued assisted ventilation/PPV at 10 minutes

C — Evidence of moderate-to-severe encephalopathy

Clinical seizures OR at least 1 sign in 3 or more of the 6 Sarnat categories (see table below)

* SickKids/local protocol may use ≥35 weeks GA and weight >1.8 kg. Exclusions: refractory coagulopathy, major congenital anomalies incompatible with intervention, severe IUGR, intracranial hemorrhage.

Modified Sarnat Score — Encephalopathy Classification

Criterion C requires ≥1 sign in ≥3 of the 6 categories below. Score ALL 6 categories.

Category	Mild	Moderate	Severe
1. Level of consciousness	Hyperalert	Lethargy	Stupor / Coma
2. Spontaneous activity	Normal	Decreased activity	No activity
3. Posture	Mild distal flexion	Distal flexion, full extension	Decerebrate (arms extended & internally rotated, legs extended, feet plantar flexed)
4. Tone	Normal	Hypotonia (focal or general)	Flaccid
5. Primitive reflexes
Suck	Weak	Weak	Absent
Moro	Strong	Incomplete	Absent
6. Autonomic system
Pupils	Dilated	Constricted	Skew deviation / dilated / non-reactive to light
Heart rate	Tachycardia	Bradycardia	Variable HR
Respirations	Normal	Periodic breathing	Apnea

MILD Signs in <3 categories — NOT a cooling candidate

MODERATE Signs in ≥3 categories — Cooling candidate ✓

SEVERE Signs in ≥3 categories — Cooling candidate ✓

Seizure Protocol (≥34 wk)

1st: Lorazepam 0.1 mg/kg IV × 2
2nd: Phenobarbital 20 mg/kg IV, then 10+10 mg/kg
3rd: Fosphenytoin 20 mg PE/kg IV OR Levetiracetam 60 mg/kg IV
4th: Midazolam infusion 0.15 mg/kg load → 2 µg/kg/min (↑ by 2 µg/kg/min q10 min, max 24)
Address underlying cause: glucose, lytes, cultures, consider empiric pyridoxine/pyridoxal-5-phosphate

↗ CPS HIE Guideline

Neonatal Opioid Withdrawal Syndrome (NOWS) / NAS

Modified Finnegan Score

Score at birth, then q3–4h × 72–120h
Treat if score ≥8 × 3 consecutive or avg ≥12 × 2
1st line: Morphine 0.04–0.1 mg/kg PO q3–6h
Wean 10%/day when stable × 24–48h
Discharge if no treatment needed × 72–120h

Non-Pharmacologic (First-Line)

Skin-to-skin / rooming-in
Swaddling, low stimulation environment
Breastfeeding (unless contraindicated)
Small, frequent feeds
⚠️ NEVER give Naloxone to infant of opioid-dependent mother

Nutrition

Nutrition, Fluids & Electrolytes

Total Fluid Intake (TFI) Targets

Adjust for diuresis, Na trend, weight change, clinical status

GIR Formula

GIR (mg/kg/min) = [mL/hr × (10 × %dextrose)] ÷ (60 × weight kg)

Quick: (%dextrose × rate mL/kg/hr) ÷ 6

GIR targets:

Normal: 4–6 mg/kg/min (term), 6–8 (preterm)
>8–10: consider central access
>10–12: consider medications (glucagon, hydrocortisone)

Parenteral Nutrition

BW <1500g: start PN + lipids ASAP
Electrolyte-free PN initially (add lytes after first void)
Protein: 3–4 g/kg/day; Lipids: 3–4 g/kg/day
Glucose: D10W base (adjust per BG)
Calcium: add when diuresing
CVC required for PN >12.5% dextrose

Iron Supplementation

For BW <2.5 kg + predominantly breastfed — start day 10–14:

BW 2.0–2.5 kg: 1–2 mg/kg/day × 6 months
BW <2.0 kg: 2–3 mg/kg/day × 1 year
Ferrous sulphate drops (Fer-In-Sol)

Growth Targets

Preterm: 15–20 g/kg/day weight gain
Length: 1 cm/week
HC: 22–30 wk → 1 cm/wk; >30 wk → 0.5 cm/wk
Term: 20–30 g/day weight gain
Max acceptable initial weight loss: <15% (preterm), <10% (term)
Regain birth weight by ~14 days (preterm)
Use Fenton chart (preterm) / WHO chart (term)

↗ Fenton Calculator

Electrolyte Quick Reference

Hypernatremia

Na >145 in preterm → likely dehydration
↑TFI, check insensible losses, check weight
Correct slowly: max 10–12 mEq/L/day

Hyponatremia

Na <135: check fluid balance
Dilutional: restrict fluids
Renal salt wasting: supplement Na (oral or PN)
Urine Na target >30–50 mEq/L

Hypoglycemia (Neonatal)

<72h: treat if BG <2.6 mmol/L
>72h: treat if BG <3.3 mmol/L
1st: feed + dextrose gel 200 mg/kg buccal
2nd: D10W bolus 2 mL/kg IV, then infusion
Persistent: endocrine workup, glucagon, hydrocortisone

Metabolic Bone Disease (Preterm)

Screen if <34 wk: ionized Ca, phosphate, ALP
Target phosphate >2 mmol/L
ALP >500 U/L → close monitoring + supplement

Bilirubin

Neonatal Hyperbilirubinemia

⚠️

Red Flags — Always Abnormal

Jaundice in first 24h • Conjugated bilirubin >17 µmol/L absolute (or >20% of TSB) • TSB ≥425 µmol/L (severe) • Jaundice >14 days → measure direct bilirubin, check TSH, urinalysis

🔢

The Four Rules of 30 (CPS 2025)

1st: △TSB ≤30 µmol/L → delay discharge, close monitoring. | 2nd: Neurotoxicity RF present → start PT when TSB ≤30 µmol/L of threshold. | 3rd: Stop PT when △TSB >30 µmol/L (≥38w) or >60 µmol/L (35–37w). | 4th: Neurotoxicity RF + TSB ≤30 µmol/L of exchange threshold → consider BET immediately.

△TSB Approach — CPS 2025 (New)

△TSB = Age-specific PT threshold − Measured TSB

Screening (all infants ≥12h):

Measure TSB or TcB at ≥12h (can combine with NBS to reduce pain)
Confirm with TSB if TcB within 50 µmol/L of PT threshold
Calculate △TSB → use to guide discharge and follow-up timing
△TSB ≤30 µmol/L → do NOT discharge; consider PT

Neurotoxicity Risk Factors (use lower threshold graph):

GA <38 weeks
Hypoalbuminemia (serum albumin <30 g/L)
Suspected/confirmed hemolytic disease
Suspected/culture-proven sepsis
Significant hemodynamic or respiratory instability in preceding 24h

↗ hyperbili.com — Online Bilirubin Tool ↗ CPS Hyperbilirubinemia Statement (2025)

Phototherapy Thresholds (≥35 wk)

Use GA-specific graphs from CPS 2025 / hyperbili.com. Separate graphs for with vs. without neurotoxicity risk factors.

Intensive Phototherapy

Narrow-spectrum 460–490 nm, irradiance ≥30 µW/cm²/nm
Maximize skin exposure; eye protection mandatory
Add fibre-optic blanket/pad to increase area exposed
Repeat TSB within 12–24h of starting PT
If TSB rising despite PT → check rate of rise; if ≥5 µmol/L/h (<24h) or ≥3.5 µmol/L/h (>24h) → suspect hemolysis; TSB q4–6h

Stopping Phototherapy

≥38 wk: stop when △TSB >30 µmol/L
35–37 wk: stop when △TSB >60 µmol/L
Rebound TSB check: no sooner than 12–24h after stopping
TcB usable if ≥18h since PT stopped

Work-Up

TSB (confirm TcB if within 50 µmol/L of threshold)
If maternal antibody screen +ve or unknown at delivery: TSB + Hgb + retic + blood smear + DAT + blood group (preferably cord blood)
G6PD assay if hyperbili unexplained or unresponsive to PT (repeat at 3 months if initially negative but still suspected)
Direct bilirubin if jaundice >14 days (rule out conjugated)
Serum albumin if near exchange threshold or critically ill

IVIG

IVIG is not recommended routinely for Rh/ABO hemolytic disease (CPS 2025)
Consider IVIG (0.5–1.0 g/kg IV over 2h) if isoimmune hemolytic disease and BET cannot be readily performed
Repeat in 12h if needed
Role in reducing BET need remains unclear

Pre-Exchange & BET Protocol

Pre-exchange threshold: TSB ≤30 µmol/L below BET threshold → emergency
Start intensive PT immediately + IV fluids
Urgent labs: TSB (total + direct), CBC, albumin, chemistries, blood type + crossmatch, hemolysis workup
TSB q2–3h; withhold feeds; consult Neonatology
Transfer to NICU capable of BET
BET: double-volume (170 mL/kg); restart intensive PT after
Signs of ABE → urgent BET regardless of threshold: hypertonia, retrocollis, opisthotonus, high-pitched cry, fever, seizures

↗ Printable PT/BET Threshold Graphs (CPS)

Sepsis/ID

Early Onset Sepsis (EOS) & Infection

EOS Risk Factors

GBS colonization (this pregnancy)
Previous infant with invasive GBS disease
ROM ≥18 hours
Maternal fever ≥38°C
Chorioamnionitis
Inadequate IAP (<1 dose ≥4h before delivery)
Prematurity (<37 weeks)

↗ EOS Kaiser Sepsis Calculator

Term Infant Sepsis Management

UNWELL (any status): CBC + blood culture + LP + CXR IV Ampicillin + Aminoglycoside GBS+, well, ≥1 risk factor: Close observation 24–48h GBS–/unknown, well, 0 RF: Routine care ≥2 risk factors or chorio: Individualized care (CBC at 4h)

Antibiotic Choice

EOS empiric: Ampicillin + Gentamicin
Meningitis: Ampicillin + Cefotaxime (avoid Gent alone)
MRSA/CONS: Vancomycin
HSV: Acyclovir 60 mg/kg/day ÷ q8h
LP: do before antibiotics if possible; CSF pleocytosis: >25 cells/mm³
Duration: 48–72h if cultures negative and baby well

Neonatal HSV

High suspicion: vesicular rash, seizures, encephalopathy, hepatitis
Maternal primary HSV near delivery → high risk
Skin/Eye/Mouth (SEM): Acyclovir × 14d, then suppressive × 6 mo
CNS/disseminated: Acyclovir × 21d
Send: HSV PCR (blood, CSF, skin swab)

TORCH Infections

CMV: SNHL, microcephaly, periventricular calcifications. Urine CMV PCR. Ganciclovir if CNS disease.
Toxoplasma: Chorioretinitis, hydrocephalus. Pyrimethamine + Sulfadiazine.
Rubella: Cataracts, CHD, SNHL. Supportive.
Syphilis: CBC, LFTs, CXR, LP, long bone X-ray. Benzathine PCN G.
HIV: ART prophylaxis. Avoid breastfeeding.

Hypoglycemia

Neonatal Hypoglycemia

Thresholds

0–72h: BG <2.6 mmol/L → treat
>72h: BG <3.3 mmol/L → treat; <2.8 mmol/L → investigate

Screening Groups

IUGR / SGA <10th percentile
LGA >90th percentile
IDM (maternal diabetes)
Beta-blocker exposure (labetalol)
Prematurity (<37 wk)
Perinatal asphyxia
Beckwith-Wiedemann syndrome

Management Ladder

Asymptomatic mild: Feed (breast or formula) + recheck in 30–60 min
Persistent mild: Dextrose gel 200 mg/kg (0.5 mL/kg 40%) buccal × 1–2 doses + feed
IV therapy: D10W 2 mL/kg bolus, then GIR 4–6 mg/kg/min
Symptomatic: IV glucose immediately; do NOT delay for oral
Refractory: Glucagon 0.03 mg/kg IM (max 1 mg) or IV hydrocortisone 5 mg/kg/day
GIR >10–12: Send critical sample, consult Endocrinology

↗ CPS Hypoglycemia Statement

Screening

Newborn Screening & Surveillance

Ontario NBS (Bloodspot)

Timing: 24–38h after birth (if <24h → repeat within 7 days)
Screens >25 conditions: metabolic, endocrine, SCID, SMA, CF, sickle cell
Preterm <33 wk: repeat at 21 days of life
Results sent to delivering hospital/midwife
Positive → refer to follow-up centre

↗ Ontario NBS

CCHD Screen (Pulse Ox)

All term and late preterm infants at 24–36h
Test: right hand + one foot
Normal: ≥95% both limbs, ≤3% difference
Borderline: any limb 90–94% or >3% difference → repeat ×2 (1h apart)
Fail: any <90% or 3 borderline attempts
Failed → echo + cardiology

↗ CPS CCHD Screen

Hearing Screen

OAE (no risk factors) → AABR if OAE failed
Complete or schedule before discharge
Failed → audiology follow-up by 3 months
Risk factors: family history, NICU admission, ototoxic drugs, craniofacial anomalies, severe jaundice

ROP Screening

Screen: ≤30+6 wk GA, OR BW ≤1250g
First exam: GA + 4 weeks (never before CGA 31 wk or 4 wk of age)
e.g. 22 wk → first exam at CGA 31 wk
e.g. 30 wk → first exam at 34 wk CGA
Type 1 ROP → laser or anti-VEGF treatment

↗ CPS ROP Statement

DDH Screening

Barlow & Ortolani at birth, 2 wk, all well-baby visits until walking
Risk factors: female, family history, breech, first-born, oligohydramnios
Hip ultrasound if abnormal exam or high-risk
Orthopaedics if abnormal USS; Pavlik harness ≤6 months

Metabolic Bone Disease

Screen: <34 wk; baseline then q2–3 weeks
Monitor: ionized Ca, phosphate (target >2 mmol/L), ALP
ALP >500 U/L → supplement Ca + PO₄
Wrist/knee X-ray if severe (rachitic changes)

Procedures

Key Procedures & Formulae

UVC Insertion Depth

Depth (cm) = [(BW in kg × 3 + 9) ÷ 2] + 1 + cord stump length

Target: T8–T9 (junction IVC and right atrium)
Emergency (low-lying): 2–4 cm until blood return
<1.5 kg: 3.5F catheter; >1.5 kg: 5F
Confirm with AP + lateral CXR (lateral is most important)
Max duration: 5–7 days (switch to PICC if longer needed)

UAC Insertion Depth

High position: (BW kg × 3) + 9 + cord stump

High target: T6–T9 (preferred)
Low target: L3–L4 (acceptable)
<1.5 kg: 3.5F; >1.5 kg: 5F
Confirm AP + lateral AXR (AP most important)
Max duration: 5 days; remove if vascular compromise to limbs/buttocks
Must run heparin solution per unit policy

Lumbar Puncture

Landmark: L3–L4 (iliac crests) or L4–L5
22G 1.5-inch needle
Apply EMLA 30 min before (or lidocaine 2%)
Collect ~5–10 drops per tube × 4 tubes
Tube 1: C&S; Tube 2: Protein + glucose; Tube 3: Cell count (use last tube if bloody); Tube 4: Viral PCR
CSF pleocytosis (term): >20–25 cells/mm³ abnormal
Platelets >50 before LP

Needle Thoracocentesis

Site: 2nd ICS, mid-clavicular line
Insert over top of 3rd rib
25G (<32 wk or <1500g), 23G (others)
Butterfly + 3-way stopcock + 10–20 mL syringe
Aspirate → close stopcock → empty syringe → repeat
CXR after stabilization; chest tube if recurrent

Weight-Based Epinephrine

Weight	IV 0.02 mg/kg	ETT 0.1 mg/kg
1 kg	0.2 mL	1.0 mL
2 kg	0.4 mL	2.0 mL
3 kg	0.6 mL	3.0 mL
4 kg	0.8 mL	3.0 mL (max)

Flush IV with 3 mL NS after each dose (all weights)

NEC

Necrotizing Enterocolitis — Bell Staging & Management

🚨

NEC Red Flags — Act Immediately

Bloody stool + abdominal distension + bilious aspirates in a preterm infant = NEC until proven otherwise. NPO, NG decompression, bloods + AXR, surgical consult, broad-spectrum antibiotics, IV access.

Stage	Classification	Clinical Signs	Radiological Signs	Management
IA — Suspected	Suspected NEC	Temperature instability, apnea, bradycardia, lethargy; mild abdominal distension; gastric residuals	Normal or mild ileus	NPO 3 days; NG decompression; IV fluids; septic workup; AXR q6–8h; consider antibiotics
IB — Suspected	Suspected NEC	As above + grossly bloody stools	Normal or mild ileus	As Stage IA
IIA — Definite (mild)	Definite NEC, mildly ill	Above + absent bowel sounds ± abdominal tenderness	Intestinal dilation, ileus, pneumatosis intestinalis	NPO 7–10 days; NG decompression; IV fluids + TPN; blood culture; Ampicillin + Gentamicin + Metronidazole × 10–14d; surgical consult; AXR q6h
IIB — Definite (moderate)	Definite NEC, moderately ill	Above + mild metabolic acidosis, mild thrombocytopenia; definite abdominal tenderness ± cellulitis or right lower quadrant mass	Pneumatosis, ascites, portal venous gas	As IIA + pRBC/platelets/FFP as needed; consider peritoneal drain
IIIA — Advanced (no perforation)	Advanced NEC, critically ill	Above + hypotension, bradycardia, severe apnea, metabolic/respiratory acidosis, DIC, neutropenia	Prominent ascites; no free air	Above + inotropes; ventilatory support; aggressive fluid resuscitation; surgical consult urgent; peritoneal drain may temporize
IIIB — Advanced (perforation)	Advanced NEC, perforated	As IIIA + sudden deterioration	Pneumoperitoneum (free air)	Immediate surgical intervention; laparotomy or peritoneal drain; NICU level care; transfer if required

Antibiotic Regimen

1st line: Ampicillin + Gentamicin + Metronidazole
Metronidazole: 15 mg/kg IV load, then 7.5 mg/kg q12h (preterm) or q8h (term)
Duration: Stage I = 3d (if clinically improving); Stage II = 10–14d; Stage III = 14d minimum
If MRSA or nosocomial concern: substitute Vancomycin for Ampicillin
Antifungals if prolonged NPO + central line + broad antibiotics

Surgical Indications

Absolute: Pneumoperitoneum (free air on AXR)
Strong: Portal venous gas + clinical deterioration
Consider: Fixed dilated loop on serial AXR (>24–36h), abdominal wall erythema, positive paracentesis (brown/feculent fluid), failure to improve on medical management
Peritoneal drain: temporizing in ELBW or unstable infants; not definitive

AXR Interpretation

Pneumatosis intestinalis: Bubbly or linear lucencies in bowel wall — pathognomonic of NEC
Portal venous gas: Branching lucencies over liver — serious, consider surgery
Pneumoperitoneum: Free air under diaphragm or on cross-table lateral (left lateral decubitus) — perforation, needs OR
Fixed loop: Same loop unchanged on serial films >24h — ominous
Order AP + cross-table lateral decubitus; repeat q6–8h in active NEC

Transfusion

Transfusion Thresholds — pRBC, Platelets, FFP

pRBC Transfusion Thresholds

Dose: 15–20 mL/kg over 3–4h. Use irradiated, leukoreduced, CMV-negative blood for preterm infants.

Clinical Context	Hgb Threshold (g/L)	Hct (%)
On respiratory support (any)	115	<35
Stable, off O₂ / minimal support	100	<30
Symptomatic (tachycardia, poor weight gain, apnea)	100–115	<30–35
Acute blood loss / haemodynamic instability	Transfuse regardless of Hgb	—
Pre-surgery (major)	120	<36

ETTNO/TOP trial evidence: liberal vs restrictive thresholds — use clinical judgement alongside Hgb. Discuss each case with attending.

↗ CPS RBC Transfusion Statement

Platelet Transfusion Thresholds

Dose: 10–15 mL/kg over 30–60 min. Target platelet count post-transfusion: >50k (stable) or >100k (actively bleeding / pre-op).

Clinical Context	Threshold (×10⁹/L)
Stable, no bleeding	<25
Sick / septic / coagulopathic	<50
Active bleeding	<50–100
Pre-LP or invasive procedure	<50
Pre-surgery (major)	<100
ELBW <28 wk, first 72h	<50 (some centres <30)
NAIT (alloimmune thrombocytopenia)	<30 (use HPA-matched or washed maternal platelets)

PlaNeT-2 trial: restrictive threshold (25k) non-inferior to liberal (50k) in stable preterm — avoid over-transfusing. Discuss NAIT with haematology.

FFP / Cryoprecipitate

FFP dose: 10–15 mL/kg IV over 30–60 min
Indications: Active bleeding + coagulopathy; PT/INR >1.5× normal + bleeding; pre-operative with coagulopathy; DIC with active bleeding; exchange transfusion (reconstitute pRBC 1:1)
Cryoprecipitate: 5–10 mL/kg; use when fibrinogen <1.0 g/L with bleeding
Do NOT use FFP to correct an elevated INR without active bleeding

DIC Management

Treat the underlying cause (sepsis, NEC, asphyxia)
Platelets: transfuse if <50k + bleeding
FFP: 10–15 mL/kg if PT/PTT prolonged + bleeding
Cryoprecipitate: if fibrinogen <1.0 g/L
Vitamin K 1 mg IV if not yet given
Monitor: CBC, PT/PTT, fibrinogen, D-dimer q4–6h in active DIC
Avoid heparin in neonatal DIC

Blood Product Specs — Preterm

Irradiated: All products for preterm <37 wk (prevents transfusion-associated GVHD)
Leukoreduced: All products (standard in Canada)
CMV-negative: For CMV-negative or unknown status infants <1200g
Age of blood: Prefer <7 days old for ELBW (↓ K⁺ load)
Aliquots: Use pre-aliquoted pRBC to minimize donor exposures
Always confirm blood group before transfusion; type-specific preferred over O-neg

Cardiology

PDA · PPHN · CCHD · Polycythemia

PDA

Patent Ductus Arteriosus

Clinical Signs of Haemodynamically Significant PDA

Murmur: Continuous or systolic, best at upper left sternal border / under left clavicle
Bounding pulses: Increased pulse pressure (>25 mmHg), bounding peripheral pulses
Hyperdynamic precordium: Visible or palpable cardiac impulse
Respiratory deterioration: Increasing FiO₂ / ventilator requirements
Metabolic acidosis without other explanation
Echo criteria (targeted neonatal echo preferred): LA:Ao ratio >1.4, ductal diameter >1.5 mm, LVO >300 mL/kg/min, reversed diastolic flow in descending aorta

↗ CPS PDA Statement

PDA Treatment Decision & Options

Conservative first: Fluid restriction (130–150 mL/kg/d), optimize PEEP, correct anaemia (Hgb >120 g/L), watchful waiting — most PDAs close spontaneously
Medical closure — Indomethacin: 0.2 mg/kg IV day 1, then 0.1 mg/kg q12–24h × 2 doses. Hold if UO <0.6 mL/kg/h, Cr rising, platelets <50, NEC, bleeding
Medical closure — Ibuprofen: 10 mg/kg IV day 1, then 5 mg/kg/day × 2. Less renal impairment. Avoid if PPHN.
Medical closure — Acetaminophen: 15 mg/kg PO/IV q6h × 3–7 days. Emerging evidence; consider if contraindication to NSAIDs
Surgical ligation / catheter closure: If medical treatment fails or contraindicated and PDA remains haemodynamically significant

PPHN

Persistent Pulmonary Hypertension of the Newborn

Recognition

Severe hypoxemia out of proportion to lung disease
Pre/post ductal SpO₂ difference >10%: Right hand (pre-ductal) vs feet (post-ductal) — if pre > post → right-to-left ductal shunt = PPHN
Hyperoxia test: PaO₂ <100 mmHg in 100% O₂ → cardiac vs pulmonary cause; PaO₂ >150 → pulmonary cause likely
Echo: Flattened/deviated septum, TR jet velocity >2.8 m/s (RVSP >35 mmHg), right-to-left shunting at PFO/PDA
Causes: MAS, asphyxia, sepsis, CDH, idiopathic, parenchymal lung disease, polycythemia

Management Ladder

1. Optimize ventilation: Target PaO₂ 55–80 mmHg, PaCO₂ 40–50, pH 7.35–7.45. Avoid hyperventilation (↑IVH risk)
2. Sedation/analgesia: Fentanyl/morphine infusion (reduces agitation → ↓ pulmonary vasoreactivity)
3. Correct reversibles: Treat sepsis, polycythemia, hypoglycemia, hypothermia, hypocalcemia
4. Haemodynamic support: Maintain systemic BP (avoid systemic hypotension — worsens R→L shunt). Dopamine 5–10 µg/kg/min; consider norepinephrine
5. iNO: Start at 20 ppm. Response = ↑PaO₂ ≥20 mmHg or ↓FiO₂ ≥0.2 within 30–60 min. Do not exceed 40 ppm. Wean slowly (do not abruptly stop — rebound). Monitor methaemoglobin (<5%).
6. Sildenafil: 0.5–1 mg/kg PO/NG q6–8h if iNO unavailable or weaning
7. Milrinone: Load 50–75 µg/kg IV over 60 min → infusion 0.25–0.75 µg/kg/min. Improves RV function + ↓PVR. Watch for hypotension.
8. ECMO: If OI >40 on maximal therapy. Transfer to ECMO centre.

OI = (FiO₂ × MAP × 100) / PaO₂. OI >25 = severe; OI >40 = ECMO threshold

CCHD

Critical Congenital Heart Disease — Duct-Dependent Lesions

Duct-Dependent Systemic (Left-Sided Obstruction)

PDA provides systemic flow. Closing duct = shock.

HLHS (hypoplastic left heart)
Critical aortic stenosis
Critical coarctation of aorta
Interrupted aortic arch

Signs:

Shock after duct closes (day 2–7)
↓ or absent femoral pulses
4-limb BP difference (>20 mmHg systolic arm vs leg = CoA)
Hepatomegaly, poor perfusion
SpO₂ may be normal until decompensation

Duct-Dependent Pulmonary (Right-Sided Obstruction)

PDA provides pulmonary flow. Cyanosis improves with PGE₁.

Pulmonary atresia ± VSD
Critical pulmonary stenosis
Tricuspid atresia
Ebstein's anomaly (severe)
Tetralogy of Fallot (severe)

Signs:

Central cyanosis from birth, unresponsive to O₂
SpO₂ 60–80% in room air
Hyperoxia test: PaO₂ remains <100 mmHg in 100% O₂

TGA / Mixing Lesions

Requires mixing or PGE₁ to maintain oxygenation.

Transposition of great arteries (TGA)
Total anomalous pulmonary venous drainage (TAPVD)
Truncus arteriosus
Single ventricle

PGE₁ Protocol:

Start: 0.01–0.05 µg/kg/min IV infusion
Titrate up to 0.1 µg/kg/min if needed
⚠️ Intubate if starting >0.05 µg/kg/min (apnea risk)
Side effects: apnea, hypotension, fever, flushing, seizures, cortical hyperostosis (long-term)
Call Cardiology FIRST; arrange echo + transfer

Polycythemia

Polycythemia & Partial Exchange Transfusion

Definition & Causes

Definition: Venous Hct >65% (or Hgb >220 g/L)
Capillary Hct unreliable — confirm with venous sample
Causes: IDM, IUGR/SGA, twin-twin transfusion (recipient), delayed cord clamping, maternal-fetal transfusion, chromosomal trisomies, endocrine (hypothyroidism, CAH)
Symptoms: Plethora, jitteriness, lethargy, hypoglycemia, respiratory distress, cyanosis, poor feeding, seizures, necrotizing enterocolitis risk, renal vein thrombosis

Partial Exchange Transfusion (PET)

Threshold: Hct >65% WITH symptoms; or Hct >70–75% regardless of symptoms
Goal Hct after PET: 50–55%
Exchange fluid: Normal saline (preferred over albumin)

Volume to exchange (mL) = Weight (kg) × Blood volume (mL/kg) × (Observed Hct − Target Hct) ÷ Observed Hct

Blood volume: 80–85 mL/kg (term); 90–100 mL/kg (preterm)

Example — 3 kg term infant, Hct 72%, target 55%:

3 × 85 × (0.72 − 0.55) ÷ 0.72 = 60 mL to exchange

Use UVC or PIV; exchange in aliquots of 5–10 mL/kg over 30–60 min
Recheck Hct 4h after PET
Monitor glucose throughout

Practical

Transport · RSV Prophylaxis · Consent Frameworks

Transport

When to Call Transport & What to Say

Indications to Arrange Transport

GA <30 weeks at delivery
Birth weight <1000g (ELBW)
Requiring or anticipated to require intubation / HFO / iNO
Suspected CCHD or need for cardiac intervention
Surgical condition (NEC perforation, bowel obstruction, CDH, omphalocele, gastroschisis, TEF)
HIE meeting cooling criteria (ensure cooling initiated before or during transport)
Refractory seizures
Persistent hypoglycemia requiring >10 mg/kg/min GIR
Any infant exceeding your unit's level of care capability

The Transport Call — SBAR Format

S — Situation "I have a [GA] week, [weight]g infant, [age], who was born by [delivery] at [your hospital]. I am calling to arrange transport for [indication]." B — Background Maternal hx, delivery details, APGAR scores, resuscitation required, current status, medications given, access in place. A — Assessment "Currently on [O₂/ventilation], vitals are [HR/RR/BP/temp/SpO₂], blood glucose [x], latest gas [x]. Suspected diagnosis is [x]." R — Recommendation "I need [transport team / NICU bed / surgical consultation]. I have [started/not started] [cooling / PGE₁ / surfactant / antibiotics]."

In Ontario: Call TTNO (Transport Team of Newborn Ontario) or your regional transport coordinator. Have the mother's chart, consent for transport, and a summary ready.

RSV

RSV Prophylaxis — Palivizumab (Synagis)

Eligibility Criteria (CPS 2015, Ontario)

Dose: 15 mg/kg IM monthly × 5 doses during RSV season (November–March in Ontario). Given at discharge or start of season, whichever is later.

Born ≤28+6 wk: All infants, for first 2 RSV seasons if still meeting criteria
Born 29–31+6 wk: First RSV season only
Born 32–35 wk: Only if ≥2 of: childcare attendance, sibling <5 years, smoking exposure in household, congenital airway abnormality, or CLD requiring treatment in past 6 months
Chronic lung disease (CLD/BPD): Receiving O₂ or medication within 6 months of RSV season — first 2 seasons
Haemodynamically significant CHD: All, first 2 seasons (confirm with Cardiology)
Immunocompromised: Discuss with Immunology/ID
Down syndrome: Consider if additional risk factors

↗ CPS RSV Prophylaxis Statement

Practical RSV Notes

Document eligibility in discharge summary and flag for community paediatrician / PCP
First dose given in hospital before discharge if during RSV season
Subsequent doses given by PCP or public health
Palivizumab does not protect against all RSV strains and is not a vaccine
Nirsevimab (Beyfortus): newer long-acting monoclonal antibody — single dose, broader coverage. Check current provincial funding status as eligibility/coverage is evolving.
If infant develops RSV despite prophylaxis — admit, supportive care, isolation

↗ Ontario RSV Guidance

Consent

Consent Frameworks

Transfusion Consent

Explain: why needed, what product (pRBC / platelets / FFP), expected benefit, risks
Risks to discuss: Allergic/febrile reaction, transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), infection (very rare — HIV, HCV, HBV), GVHD (prevented by irradiation), haemolytic reaction
Discuss alternatives (iron supplementation, erythropoietin — rarely used acutely)
Document consent in chart; written consent per institutional policy
Jehovah's Witness families: if life-threatening, transfusion may be authorized by court. Notify medical director / legal early. Do not delay resuscitation.

Procedural Consent (LP, UVC, UAC, etc.)

Elements of valid consent: Disclosure, comprehension, voluntariness, capacity (parent / legal guardian)
For LP: Indication, risks (infection, bleeding, failure, headache — rare in neonates), need for repeat if unsuccessful
For UVC/UAC: Indication, risks (infection, thrombosis, malposition, vascular injury, NEC risk with UAC), alternatives
Emergency procedures: consent can be implied in life-threatening situations — document clinical urgency clearly
Verbal consent is acceptable for many bedside procedures; document discussion in chart

Goals of Care / Withdrawal of Life-Sustaining Treatment

Always involve attending neonatologist, nursing, social work, chaplaincy if needed
Frame around infant's best interests — not what parents want for themselves
Discuss: prognosis with and without continued intervention, quality of life, expected trajectory
Document: goals of care conversation, who was present, what was discussed and decided
Comfort care plan: analgesia (morphine / fentanyl infusion), temperature, feeding, family presence, palliative care referral
Do Not Resuscitate orders require attending signature and clear documentation
CPSO guidance: physicians are not obligated to provide treatment that is medically futile
If disagreement between team and family: ethics consultation early

↗ CPS End-of-Life Care Statement

Formulas

Common Formulas Quick-Card & GIR Calculator

⚡ Interactive GIR Calculator

Weight (kg)

IV Dextrose %

IV Rate (mL/hr)

Feed Rate (mL/hr) optional

Feed Concentration

Total GIR >8 → consider central access. Total GIR >12 → consider endocrine workup.

GIR Formula

GIR = [Rate (mL/hr) × Dext% × 10] ÷ [60 × Wt (kg)]

Quick: [Dext% × Rate (mL/kg/hr)] ÷ 6

Targets:

Preterm: 6–8 mg/kg/min
Term: 4–6 mg/kg/min
>8–10 → central access
>10–12 → endocrine workup

Oxygenation Index (OI)

OI = (FiO₂ × MAP × 100) ÷ PaO₂

OI <10 — mild
OI 10–25 — moderate
OI >25 — severe; consider iNO
OI >40 — ECMO threshold

Use pre-ductal (right radial) PaO₂

Line Depth Quick Reference

UVC = [(BW kg × 3 + 9) ÷ 2] + 1 + stump

UAC high = (BW kg × 3) + 9 + stump

Weight	UVC depth
0.5 kg	~7 cm
1.0 kg	~8 cm
1.5 kg	~9 cm
2.0 kg	~10 cm
3.0 kg	~12 cm

Mean Airway Pressure (MAP)

MAP = [(PIP−PEEP) × Ti ÷ (Ti+Te)] + PEEP

Term target: 8–12 cmH₂O
Preterm target: 6–10 cmH₂O
HFOV: set 1–2 cmH₂O above conventional MAP

Corrected Gestational Age

CGA = GA at birth + Postnatal age (weeks)

Key milestones:

32–34 wk: Feeding cues develop
34–35 wk: Caffeine wean target
34–36 wk: Oral feed transfer
37–42 wk: Discharge window
31 wk: First ROP exam (if born ≤26 wk)

Other Useful Formulas

ETT depth (lip) = GA (wk) ÷ 10 + 6

PET vol = Wt × BV × (Hct−0.55) ÷ Hct

BV = 85 mL/kg term, 95 mL/kg preterm

Maint fluids = 100 mL/kg/day (term, day 3+)

Endocrine

Hypocalcemia · IDM · Congenital Hypothyroidism

Ca²⁺

Neonatal Hypocalcemia

Definition, Causes & Symptoms

Definition:

Total Ca <1.8 mmol/L (preterm) or <2.0 mmol/L (term)
Ionized Ca <1.0 mmol/L (all) — most accurate

Causes:

Early (<72h): Prematurity, IDM, asphyxia, sepsis, MgSO₄ exposure
Late (>72h): High phosphate feeds, hypoparathyroidism, DiGeorge (22q11.2), hypomagnesemia

Symptoms:

Jitteriness, irritability, high-pitched cry
Seizures, tetany, laryngospasm
Prolonged QTc on ECG (>0.45s)
Apnea, poor feeding

Treatment — Ca Gluconate 10%

⚠️

Never IV push. Extravasation → severe tissue necrosis. Confirm IV patency. Monitor HR — bradycardia → slow rate.

Symptomatic / seizure: 1–2 mL/kg IV over 10–30 min (max 10 mL). Dilute 1:1 with D5W.
Maintenance: 200–800 mg/kg/day (2–8 mL/kg/day) added to IV fluids
Oral: Ca gluconate syrup 200–400 mg/kg/day ÷ q6h with feeds
Recheck ionized Ca q4–6h; also check Mg
If hypomagnesemia co-exists: MgSO₄ 0.1–0.2 mEq/kg IV first

DiGeorge/22q11.2: permanent hypoparathyroidism → refer Endocrine; long-term Ca + Vit D

IDM

Infant of Diabetic Mother (IDM)

Complications to Anticipate

Hypoglycemia — monitor BG q30 min × 3, then q1–3h × 24h
Macrosomia — birth trauma risk
Respiratory distress — delayed lung maturation, TTN
Hypocalcemia — check Ca at 12–24h
Hypomagnesemia — check if Ca not responding
Polycythemia — Hct at 2–4h
Hyperbilirubinemia — monitor TSB
Congenital anomalies (T1DM > GDM): CHD, sacral agenesis, NTD
HCM — asymmetric septal hypertrophy; usually resolves
Renal vein thrombosis — haematuria + flank mass

Monitoring Protocol

Birth → 1h: BG at 30 min, 1h Assess for anomalies 1h → 24h: BG q1–3h (target ≥2.6) Feed q2–3h 12–24h: Ca, Mg, CBC (Hct), TSB As indicated: CXR, Echo (murmur/HCM) Renal USS (haematuria)

HCM Management

Suspect: murmur, poor cardiac output in IDM
Echo: asymmetric septal hypertrophy, LVOTO
⚠️ Avoid: Digoxin, inotropes (worsen LVOTO), aggressive diuresis
Obstructive: Propranolol 0.25–1 mg/kg/day PO ÷ q6–8h
Maintain euvolemia; adequate preload
Cardiology follow-up; resolves by 6–12 months

Thyroid

Congenital Hypothyroidism — NBS Follow-Up & Treatment

Positive NBS Screen — Next Steps

Confirm: serum TSH + Free T4
TSH >40 mU/L → treat immediately; do not wait
TSH 10–40 mU/L → repeat in 1–2 weeks; treat if persistent
Thyroid USS (gland present? ectopic? absent?)
Check maternal TPO-Ab, TRAb (if positive → may be transient)
Incidence: 1 in 3000–4000; most common cause: thyroid dysgenesis

↗ CPS Congenital Hypothyroidism

Levothyroxine Initiation

Start within 2 weeks of birth (ideally day 7–14); every week delayed = IQ risk
Dose: 10–15 µg/kg/day PO once daily
Give on empty stomach; separate from iron/calcium/soy by ≥4h
Crush tablet; dissolve in small amount of EBM/water
Monitor: TSH + FT4 at 2w, 4w, then q1–3 months × 1 year
Target: TSH 0.5–2.0 mU/L; FT4 upper half of normal
Over-treatment: irritability, tachycardia, poor weight gain
Refer Paediatric Endocrinology early

NOWS

Modified Finnegan Neonatal Abstinence Scoring Tool

📋

Scoring Instructions

Score 1–2h after birth, then q3–4h × minimum 72–120h (longer with methadone/buprenorphine). Treat if score ≥8 on 3 consecutive assessments, or average ≥12 on any 2. Score between feeds, not during.

CNS Disturbances

Sign	Score
High-pitched cry <5 min	2
Continuous high-pitched cry >5 min	3
Sleeps <1h after feeding	3
Sleeps <2h after feeding	2
Sleeps <3h after feeding	1
Hyperactive Moro reflex	2
Markedly hyperactive Moro reflex	3
Mild tremors when disturbed	1
Moderate-severe tremors when disturbed	2
Mild tremors undisturbed	3
Moderate-severe tremors undisturbed	4
Increased muscle tone	2
Excoriation (specify area)	1
Myoclonic jerks	3
Generalized convulsions	5

Metabolic / Vasomotor / Respiratory

Sign	Score
Sweating	1
Fever 38.0–38.3°C	1
Fever >38.3°C	2
Frequent yawning (>3–4 per interval)	1
Mottling	1
Nasal stuffiness	1
Sneezing (>3–4 per interval)	1
Nasal flaring	2
Respiratory rate >60/min	1
RR >60/min with retractions	2

Gastrointestinal Disturbances

Sign	Score
Excessive sucking	1
Poor feeding	2
Regurgitation (≥2× during/after feed)	2
Projectile vomiting	3
Loose stools (curds/seedy)	2
Watery stools	3

⚡ Finnegan Score Calculator

Validated for opioid exposure only. Non-pharmacologic interventions first in all cases.

NOWS Pharmacotherapy Quick Reference

Initiation

1st line: Morphine 0.04 mg/kg PO q3–4h
Increase by 0.04 mg/kg/dose if score ≥8
Max ~0.2 mg/kg/dose before adding adjunct
Adjunct: Clonidine 0.5–1 µg/kg PO q6h
Phenobarbital if non-opioid withdrawal dominates

Weaning

Begin wean when score <8 × 24–48h
Wean 10% of peak dose q24–48h
Discharge: treatment-free × 72h (120h if methadone/buprenorphine)
May discharge on wean if follow-up secured
⚠️ NEVER give Naloxone to opioid-dependent mother's infant

Follow-Up

Neonatal Follow-Up Clinic Referral Criteria

Neurodevelopmental Follow-Up — Who Gets Referred

Refer before discharge for any of the following:

Born <29 weeks GA — highest priority; follow to age 5–8 years
29–34 weeks with complicated course — IVH ≥Grade 2, PVL, BPD, NEC, sepsis, prolonged ventilation
HIE / therapeutic hypothermia — all infants
Brain injury — IVH Grade 3–4, PVL, neonatal stroke, meningitis
ELBW — BW <1000g regardless of GA
Congenital anomalies — trisomies, CNS malformations
NAS/NOWS — opioid-exposed infants
Severe/recurrent hypoglycemia — BG <2.0 mmol/L
Severe hyperbilirubinemia — TSB reaching pre-exchange threshold
IUGR/SGA — BW <3rd percentile

↗ CPS Preterm Discharge Planning

Specialty Follow-Up — What Goes Where

Clinic	Referral Criteria
Ophthalmology	Any ROP (any stage); severe jaundice; congenital eye anomalies
Audiology	Failed hearing screen; NICU admission; ototoxic drugs; TSB >400; congenital CMV; meningitis
Cardiology	Known/suspected CHD; PPHN requiring iNO; PDA treated; HCM (IDM); unresolved murmur
Surgery	Post-NEC (stricture at 6–8 wk); inguinal hernia (↑ in VLBW); hydronephrosis; undescended testes
Endocrinology	Congenital hypothyroidism; persistent hypoglycemia; DiGeorge; IDM with HCM
Nephrology	AKI; moderate-severe antenatal hydronephrosis; single kidney; renal anomalies
Neurology	Neonatal seizures on anticonvulsants; IVH Grade 3–4; stroke; HIE; abnormal MRI/EEG
Haematology	NAIT; ongoing thrombocytopenia; polycythemia complications; G6PD deficiency
Genetics	Dysmorphic features; positive NBS; chromosomal abnormality; unexplained IUGR
PT / OT / SLP	Prematurity <34 wk; feeding difficulties; brachial plexus injury; hypotonia; torticollis

Discharge Checklist — Before Any NICU Infant Goes Home

Clinical Readiness

Temperature stable in open cot
Apnea-free ≥5–7 days
SpO₂ ≥90–95% in room air
Sustained weight gain on oral feeds
All medications prescribed and dispensed

Screens & Tests

NBS complete (repeat at 21d if <32 wk)
Hearing screen done or scheduled
CCHD screen done
ROP done or scheduled
Final bilirubin check as indicated
Head USS at term CGA (<26 wk)

Follow-Up Arranged

PCP identified; appointment within 72h
Neonatal follow-up clinic referral sent
All specialty referrals completed
RSV prophylaxis assessed ± first dose
Immunizations current by chronological age
Safe sleep, feeding plan, car seat discussed
CPR instruction offered to parents

LOS & Vitals

Late-Onset Sepsis · Normal Vitals by GA · EOS Calculator

EOS Calculator

Kaiser Permanente Neonatal Early-Onset Sepsis Calculator

The Kaiser EOS calculator estimates the probability of early-onset sepsis in infants ≥34 weeks based on objective risk factors and clinical exam. Recommended by CPS for risk-stratifying well-appearing term and late-preterm infants.

↗ Open Kaiser EOS Sepsis Calculator

↗ CPS EOS Management Statement

Applies to infants ≥34 weeks only. For infants <34 weeks, manage per preterm sepsis protocol regardless of calculator output.

LOS

Late-Onset Sepsis (LOS) — >72h of Life

⚠️

LOS vs EOS — Key Differences

LOS occurs after 72h of life. Organisms differ significantly from EOS — CoNS (Staph. epidermidis) is the most common pathogen in NICU, followed by S. aureus, Gram-negatives, and Candida. GBS is less common. Empiric coverage must include Vancomycin for NICU-acquired LOS.

LOS Organisms by Setting

Organism	Frequency	Notes
CoNS (S. epidermidis)	Most common (NICU)	Line-associated; often contaminant — interpret with clinical context. Two positive cultures usually needed.
S. aureus (MSSA/MRSA)	Common	More virulent; metastatic infection, endocarditis risk. Vancomycin empirically; de-escalate to Cloxacillin if MSSA.
E. coli / Klebsiella	Common (gut-associated)	NEC-associated, ESBL-producing strains increasing. Add Gram-neg coverage (Gent or Pip-Tazo).
Candida spp.	Important in ELBW	Risk: broad antibiotics, TPN, central line, steroids, gut pathology. Fluconazole empiric or prophylactic in ELBW.
GBS	Uncommon (>72h)	Late GBS disease (meningitis) still occurs; cover if clinical picture fits.
Enterococcus	Occasional	GI source; Vancomycin ± Ampicillin.
HSV	Think if <4 weeks old	Vesicular rash, hepatitis, seizures, encephalopathy. Add Acyclovir early if suspected.

LOS — Clinical Presentation & Workup

Presenting signs (often subtle in preterm):

Temperature instability (fever or hypothermia)
Apnea / bradycardia (new or worsening A/B/D events)
Lethargy, poor tone, reduced activity
Poor feeding / increased gastric residuals / abdominal distension
Respiratory deterioration — increased O₂ / ventilator requirements
Glucose instability (hypo or hyperglycemia)
Pallor, mottling, prolonged capillary refill
"Just doesn't look right" — trust the nurse

Workup:

Blood culture × 1 (minimum 1 mL; ideally before antibiotics)
CBC + differential, CRP (note: CRP may lag 12–24h)
Blood gas + lactate
Glucose, lytes, LFTs if clinically unwell
CXR if respiratory signs
Urine culture (suprapubic or catheter) — catheter sample acceptable in NICU
LP — see timing guidance below
Consider surface swabs (groin, axilla, ETT) in ELBW for surveillance

Empiric Antibiotics — LOS

NICU-acquired (central line in situ):

Vancomycin + Gentamicin (or Piperacillin-Tazobactam if GI/NEC concern)
Vancomycin dosing: 15 mg/kg q12–24h (adjust by GA + postnatal age); target AUC 400–600 mg·h/L (or trough 10–15 µg/mL)
Add Fluconazole or Amphotericin B if: ELBW + prolonged antibiotics + central line + thrush or gut pathology

Community-acquired LOS (>72h, not NICU):

Ampicillin + Gentamicin (same as EOS)
Add Cefotaxime if meningitis suspected

De-escalation:

MSSA confirmed → Cloxacillin 50 mg/kg IV q6h
CoNS + no clinical sepsis + single culture → consider stopping antibiotics at 48–72h
Negative culture × 48–72h + improving clinically → discontinue

LP Timing in LOS

Perform LP if: Blood culture positive, clinical signs of meningitis (bulging fontanelle, seizures, neck stiffness), or strong clinical suspicion with neurological signs
Defer LP if: Cardiorespiratory instability, coagulopathy (platelets <50k, abnormal INR), clinical deterioration that would delay treatment
Do NOT wait for LP results to start antibiotics if infant is unwell — treat first, LP when stable
If LP deferred but culture positive: treat for meningitis duration (14–21d) unless LP can be done later
Meningitis doses: Ampicillin 200 mg/kg/day ÷ q6–8h; Gentamicin 5–7 mg/kg q24–48h; Cefotaxime 200 mg/kg/day ÷ q6–8h

Fungal Sepsis (Candida)

Risk factors: ELBW, TPN >5 days, broad-spectrum antibiotics, corticosteroids, gut pathology (NEC), central line, H2-blocker use
Clinical: Insidious onset; thrombocytopenia often prominent clue in ELBW; ophthalmic involvement (candidal endophthalmitis)
Workup: Blood culture (fungal); LP; ophthalmology exam; renal USS; echo (if persistent candidemia)
Treatment: Amphotericin B deoxycholate 1 mg/kg/day IV (preferred in ELBW); or Fluconazole 12 mg/kg loading dose then 6–12 mg/kg/day
Duration: ≥14 days from first negative culture
Prophylaxis: Fluconazole 3–6 mg/kg twice weekly in ELBW in units with high Candida rates
Remove central line if possible when candidemia confirmed

Vitals

Normal Vital Signs by Gestational Age & Postnatal Age

Parameter	23–27 wk	28–32 wk	33–36 wk	37–42 wk	Notes / Action Threshold
Heart Rate (bpm)	120–180	120–170	120–160	100–160	Bradycardia <100 bpm (term) or <80 bpm (preterm) = act. Persistent tachycardia >180 = investigate.
Respiratory Rate (/min)	40–70	40–70	40–70	30–60	Tachypnoea >60 = investigate (RDS, TTN, sepsis, CHD). Apnea = pause >20s or shorter with bradycardia/desaturation.
SpO₂ Target (%)	88–95	88–95	88–95	≥95	Avoid SpO₂ >95% in preterm (↑ROP risk). Avoid <88% (hypoxia, ↑PVR). Term infants target ≥95%.
Systolic BP (mmHg)	35–50	40–55	45–65	60–90	Minimum MAP ≈ GA in weeks (e.g. MAP ≥25 at 25 wk). This is a rough guide — treat clinical signs of hypoperfusion, not numbers alone.
Mean BP / MAP (mmHg)	23–30	28–40	35–45	45–60	MAP rule of thumb: minimum MAP = GA (weeks). Treat hypotension only with clinical signs of poor perfusion (elevated lactate, prolonged CRT, ↓UO).
Temperature (°C)	36.5 – 37.5				Axillary (preferred in NICU). Hypothermia <36.5°C → warm, investigate cause. Fever ≥38°C axillary → sepsis workup.
Urine Output (mL/kg/h)	1 – 4				Oliguric <0.5–1 mL/kg/h after day 1. Polyuric >5 mL/kg/h (normal diuresis day 2–4, or diabetes insipidus). Anuric first 24h may be normal.
Blood Glucose (mmol/L)	2.6 – 8.0 (0–72h) \| 3.3 – 8.0 (>72h)				Treat <2.6 (0–72h) or <3.3 (>72h). Hyperglycaemia >10 mmol/L in ELBW → consider insulin infusion 0.01–0.05 units/kg/h.
Capillary Refill Time	< 2 seconds (central)				Test on sternum or forehead. Peripheral CRT less reliable (cold environment). CRT >3s = poor perfusion until proven otherwise.

Minimum Acceptable MAP by GA (Rule of Thumb)

GA (weeks)	Min MAP (mmHg)	Min Systolic (mmHg)
23–24	23–24	35–40
25–26	25–26	38–45
27–28	27–28	42–50
29–32	29–35	45–55
33–36	35–40	50–65
37–42	45–55	60–90

MAP = GA rule is a guide only. Treat based on clinical signs of poor perfusion, not BP alone. Discuss with attending before starting inotropes.

Apnea of Prematurity — Quick Reference

Definition: Cessation of breathing >20s OR shorter pause with bradycardia (<100 bpm) or desaturation (<85%)
Caffeine: Load 20 mg/kg, maintenance 5–10 mg/kg/day. Start at <32 wk. Wean target: 34–35 wk CGA, apnea-free ≥5–7 days
CPAP: 5–6 cmH₂O for persistent AOP despite caffeine
Stimulation: Tactile first; PPV if HR <80 or persistent apnea
Rule out secondary causes: Sepsis, hypoglycaemia, hypocalcaemia, anaemia, temperature instability, drug effect, seizure, GERD, NEC
Bradycardia threshold: <100 bpm (brief, self-resolving) = document. <80 bpm or requires stimulation = report and investigate.

Urology

Antenatal Urinary Tract Dilation (UTD) / Hydronephrosis

💧

CPS Practice Point — January 2026

UTD affects up to 5% of pregnancies. Most are transient, but UTD is associated with VUR (10–40%), UPJO (10–30%), UVJO (5–10%), primary megaureter (5–15%), and PUV (1–5%). Postnatal management is guided by APD measurement + presence of complex features.

APD Thresholds — Antenatal Severity

Severity	2nd Trimester APD	3rd Trimester APD
Mild	4 to <7 mm	7 to <9 mm
Moderate	7 to ≤10 mm	9 to ≤15 mm
Severe	>10 mm	>15 mm

APD = anterior-posterior renal pelvic diameter. APD can fluctuate with fluid status, probe position, and operator technique — always assess alongside complex features.

Complex Features — Always Increases Risk Category

Any of these on antenatal or postnatal USS elevates to high-risk management:

Upper Urinary Tract

Bilateral UTD (male fetus → suspect PUV)
Solitary kidney with UTD → refer Nephrology + Urology
Dysplastic / echogenic / hypoplastic kidney → ↑CKD risk
Peripheral calyceal dilation (cupping around pyramids)
Parenchymal thinning (cortical compression)

Lower Urinary Tract

Hydroureter (ureteral dilation ≥4 mm)
Bladder wall thickening or trabeculation
Distal ureterocele

Amniotic Fluid

Oligohydramnios or anhydramnios

Postnatal Management Pathway (CPS 2026)

3rd Trimester APD 7–9 mm, No Complex Features

Low risk — follow-up postnatal USS optional based on local practice
Counsel family on UTI symptoms
No prophylactic antibiotics
No urology/nephrology referral required

APD 10–14 mm, No Complex Features

Postnatal USS at ≥48h (ideally within first 2 weeks)
If access limited: can defer to within 1 month
If postnatal APD 10–14 mm, no complex features: repeat USS within 6 months; can follow with GP
No prophylactic antibiotics routinely
No mandatory urology referral — counsel re: UTI

APD ≥15 mm OR Complex Features (Any Grade)

Postnatal USS at ≥48h (ideally within first 2 weeks; within 1 month if APD <15 mm + no complex features)
If postnatal APD ≥15 mm: repeat USS within 1 month
Consider VCUG or Lasix renal scan alongside urology/nephrology consult
Refer Paediatric Urology and/or Nephrology
Discuss prophylactic antibiotics using shared decision-making

⚠ Suspected PUV — Urgent

Features: bilateral severe hydroureteronephrosis ± bladder anomalies, renal parenchymal changes, oligohydramnios, "keyhole sign"
Postnatal imaging urgently — do not wait 48h
Consult Paediatric Urology immediately
Witnessed postnatal void does NOT exclude severe obstruction
Order electrolytes + renal function (creatinine)

Prophylactic Antibiotics (CAP)

Evidence does NOT support routine CAP for mild UTD
Consider in shared decision-making for: APD ≥15 mm, complex features, high-grade UTD, uncircumcised males, hydroureteronephrosis
Agent: Trimethoprim (without sulfa) 2 mg/kg/day — avoid TMP-SMX <2 months (↑jaundice risk)
Alternatives: Cephalexin, Nitrofurantoin (avoid nitrofurantoin <1 month — hemolytic anemia risk)
CAP associated with ↑antibiotic resistance (52% vs 17%)

Timing of Postnatal USS

Perform at ≥48h post-birth (earlier USS underestimates UTD due to relative dehydration)
Ideally within first 2 weeks
Can defer to within 1 month if 3rd trimester APD <15 mm and no complex features
If complex feature not mentioned in US report → request specific radiology comment
Bilateral severe disease or PUV suspicion → urgent (same day)

When to Order Blood Work

NOT routinely needed for uncomplicated UTD
Order electrolytes + creatinine for:
Bilateral UTD with parenchymal compression
Suspected PUV
Bilateral cysts, echogenicity, or dysplasia
Solitary kidney with UTD

↗ CPS UTD Practice Point (2026)

Cranial Bleeds

Neonatal Cranial Bleeds — Anatomy, Features & Management

Cross-Section — Layers of the Neonatal Scalp & Skull

Feature	Caput Succedaneum	⚠ Subgaleal Haemorrhage	Cephalhematoma
Layer	Subcutaneous tissue (above galea)	Loose areolar tissue between galea and periosteum (subgaleal space)	Between periosteum and outer skull table (subperiosteal)
Crosses sutures?	✓ Yes — diffuse, poorly demarcated	✓ Yes — can expand over entire calvarium	✗ No — limited by suture lines; sharp borders
Onset	Present at birth	May develop hours after birth; enlarges over time	Develops hours to days after birth
Feel on exam	Soft, pitting oedema; may have overlying skin changes (ecchymosis)	Large, boggy, fluctuant; fluid wave palpable; enlarging HC	Firm collection, well-demarcated, does not cross midline
Potential blood loss	Minimal — not a haemorrhagic space	⚠ Massive — can sequester 40%+ of total blood volume → haemorrhagic shock	Moderate — contained by periosteum; self-limiting
HC change	Minimal	↑HC — 40 mL blood loss per 1 cm ↑HC	May feel large but HC stable or minimally increased
Risk factors	Prolonged labour, vaginal delivery	Vacuum delivery (most common), forceps, prolonged labour, coagulopathy	Forceps/vacuum delivery, prolonged labour, macrosomia
Resolution	Days — resolves spontaneously	Requires urgent management — does NOT resolve spontaneously	Weeks to months; may calcify; do NOT aspirate
Jaundice risk	Minimal	High — large haematoma reabsorption	Moderate — monitor bilirubin

Caput Succedaneum

Benign — reassure parents
No investigation required
Resolves within 4–6 days
Monitor for jaundice if large bruising
No treatment needed

⚠ Subgaleal Haemorrhage — Emergency

Serial HC measurements (q1–2h if enlarging)
Serial vital signs — tachycardia is early sign of haemorrhagic shock
Serial Hct/Hgb — expect fall as blood redistributes
Consider coagulation studies (DIC risk)
Resuscitation: IV access, NS boluses 10–20 mL/kg
Transfusion: pRBC, FFP, platelets, cryoprecipitate as indicated
Transfer to tertiary centre urgently if worsening
40 mL blood loss per 1 cm increase in HC

Cephalhematoma

Benign — usually resolves spontaneously
Do NOT aspirate (↑infection risk)
Monitor for jaundice (haematoma reabsorption)
Consider skull X-ray if concern for underlying fracture
May calcify — reassure parents this is normal
Rarely: bilateral cephalhematomas → rule out coagulopathy
Resolution: 2–6 weeks (may take months if large)

Urology

Undescended Testes (Cryptorchidism)

⚠️

Bilateral nonpalpable testes in a phenotypic male newborn = DSD until proven otherwise

Immediate specialist consultation required. Cannot defer. Bilateral nonpalpable testes ± hypospadias raises concern for a Disorder of Sex Development (DSD) — urgent karyotype and endocrine workup required before assuming simple cryptorchidism.

Epidemiology

Most common congenital genitourinary condition in males
Term infants: 1–4% at birth
Preterm infants: up to 30–45% at birth
80% descend spontaneously by 3 months of age
After 6 months: spontaneous descent is unlikely
True incidence at 1 year: ~1%
Bilateral cryptorchidism: ~10% of all cases
Right side more commonly affected than left

Classification

Palpable UDT: Felt on exam — inguinal canal, prescrotal, superficial inguinal pouch, ectopic
Non-palpable UDT: Intra-abdominal, vanishing testis ("nubbin"), or truly absent
Retractile: Moves in/out of scrotum due to cremasteric reflex — can be guided to scrotum, stays there without tension. No orchidopexy needed but annual review required (risk of ascending)
Congenital: Not in scrotum at birth
Acquired (ascending): Was scrotal at birth, now undescended — refer to surgeon

Long-Term Risks (Untreated)

Infertility: Unilateral UDT → 10–30% infertility risk; Bilateral → 35–90%+; Untreated bilateral → >90%
Testicular malignancy: 3–5× increased lifetime risk vs general population (<1% absolute risk)
Testicular torsion: ↑ risk — abnormal gubernaculum attachment
Inguinal hernia: Commonly associated processus vaginalis
Orchidopexy by 6–18 months reduces (but does not eliminate) these risks

Bilateral Nonpalpable Testes — Neonatal Workup

Step 1 — DSD Exclusion (Urgent)

Karyotype — must be done before sex assignment if any doubt
Bilateral nonpalpable + any degree of hypospadias → karyotype + endocrine workup immediately
Consult Paediatric Endocrinology + Urology
Do NOT assign sex or reassure parents that "it's just undescended testes" before workup complete

Step 2 — Hormonal Assessment

Testosterone (basal)
LH + FSH — elevated gonadotropins suggest anorchism
AMH (Anti-Müllerian hormone) — if detectable, testes present somewhere; undetectable → likely bilateral anorchism
hCG stimulation test — 100 IU/kg IM × 1; check testosterone at 72–96h. No rise → bilateral anorchism
Inhibin B — marker of Sertoli cell function; undetectable = no functional testicular tissue
17-OHP — if karyotype 46XX or virilised female, rule out congenital adrenal hyperplasia

Step 3 — Imaging

USS is unreliable for localising intra-abdominal testes — do NOT use to exclude testes
MRI pelvis — better than USS for non-palpable testes but still poor sensitivity (<50%)
AUA/CUA: imaging does not replace surgical exploration and should NOT delay referral
Definitive localisation: laparoscopy under anaesthesia

Step 4 — Additional Workup

Electrolytes — rule out CAH (salt-wasting crisis in first weeks)
Renal USS — associated genitourinary anomalies common
Genetics review if DSD confirmed
Multidisciplinary team: Paed Endo + Paed Urology + Genetics + Psychology + Nursing

Scenario	DSD Concern?	Urgent Workup?	Referral	Timing
Unilateral palpable UDT, no hypospadias	Low	No — routine	Paed Surgery / Urology	By 6 months corrected age; orchidopexy 6–18 months
Bilateral palpable UDT, no hypospadias	Low–moderate	Consider LH/FSH/testosterone	Paed Urology ± Endocrine	Refer by 6 months; orchidopexy 6–18 months
Bilateral nonpalpable UDT	HIGH — DSD until proven otherwise	YES — karyotype + hormones urgently	Paed Endo + Urology + Genetics	Immediate — do not discharge without specialist consultation
UDT + hypospadias (any degree)	HIGH — DSD until proven otherwise	YES — karyotype urgently	Paed Endo + Urology + Genetics	Immediate
Unilateral nonpalpable UDT	Low (vanishing testis likely)	Consider AMH/hCG stim	Paed Urology	By 6 months; laparoscopy to localise
Preterm male, bilateral UDT	Low (physiological if <36 wk)	No if appropriate for GA	Reassess at 3–6 months corrected age	Most descend by term CGA; reassess at 3 months CGA

Orchidopexy — Timing & Approach

Refer to surgeon if not descended by 6 months corrected age
Optimal timing for orchidopexy: 6–18 months of age (minimises germ cell loss)
Do NOT wait past 18 months — fertility outcomes worsen significantly
Palpable UDT: Inguinal or scrotal orchidopexy depending on location
Non-palpable UDT: Examination under anaesthesia first → laparoscopy if nonpalpable → abdominal orchidopexy (Fowler-Stephens if vessels short)
Circumcision deferred if hypospadias also present — foreskin needed for repair
Hormonal therapy (hCG/GnRH) — not recommended (insufficient evidence, no advantage over surgery)

↗ AUA Cryptorchidism Guideline (2025) ↗ CUA Cryptorchidism Guideline

Counselling Points for Families

Most cases resolve spontaneously by 3 months — reassure if <3 months old
Watchful waiting reasonable until 6 months corrected age
If bilateral nonpalpable at birth: be honest that further workup is needed before full reassurance
Orchidopexy is day surgery, low risk, done under general anaesthesia
Reduces but does not eliminate cancer and fertility risks
Self-examination of testes from puberty — annual review in adolescence
Acute groin/abdominal pain in a boy with UDT → torsion until proven otherwise → urgent surgical review
Document testicular position clearly at every well-baby visit

HIV

Infant Born to a Mother with HIV — Workup, ARV Prophylaxis & Follow-Up

⏱️

Start ARV prophylaxis within 6 hours of birth — ideally in the delivery room

All infants born to mothers with HIV require postnatal ARV prophylaxis regardless of maternal viral load. Regimen depends on maternal viral suppression status and other risk factors. Consult Paediatric Infectious Diseases immediately.

Step 1 — Risk Stratification (Determines ARV Regimen)

LOW RISK — Standard Prophylaxis

Mother on ART throughout pregnancy
Consistently adherent to treatment
Maternal HIV RNA <50 copies/mL at delivery (or within 4 weeks prior)
No concerns about resistance
No acute/recent HIV infection

→ ZDV monotherapy × 4–6 weeks

HIGH RISK — Presumptive 3-Drug Therapy

No antenatal ART received
HIV RNA detectable or unsuppressed at delivery (≥50 copies/mL)
Acute/recent HIV infection during pregnancy
Poor adherence or late initiation of ART
ART started <4 weeks before delivery
Intrapartum HIV diagnosis (no prior treatment)
Known or suspected maternal drug resistance

→ ZDV + 3TC + NVP (or RAL) × 6 weeks

UNKNOWN MATERNAL STATUS

Maternal HIV status unknown at delivery
Rapid HIV test mother STAT in labour
If reactive → treat infant as HIGH RISK immediately while confirmatory tests pending
Do not wait for confirmation to start ARV if rapid test positive

→ Start 3-drug therapy; de-escalate if confirmed negative

Step 2 — ARV Prophylaxis Dosing (Term Infants ≥37 wk)

Drug	Dose (Term ≥37 wk)	Dose (Preterm 34–36 wk)	Frequency	Duration	Key Toxicity
Zidovudine (ZDV/AZT)	4 mg/kg/dose PO	3 mg/kg/dose PO (<30 wk: 2 mg/kg)	q12h	6 weeks (all regimens)	Anaemia, neutropenia — CBC at birth + 4 weeks
Lamivudine (3TC)	2 mg/kg/dose PO	2 mg/kg/dose PO	q12h	2–6 weeks (with 3-drug regimen)	Generally well tolerated; monitor CBC
Nevirapine (NVP) — treatment dose	6 mg/kg/dose PO	4 mg/kg/dose × 1 wk then 6 mg/kg q12h	q12h	2–6 weeks (with 3-drug regimen)	Neutropenia, hepatotoxicity; hypersensitivity rash (rare)
Raltegravir (RAL)	1.5 mg/kg/dose PO (granules preferred; tablet = 2 mg/kg)	Avoid <34 wk	q12h (first 4 wk), then q24h	2–6 weeks (with 3-drug regimen)	Elevated bilirubin (use with caution if jaundice); granule formulation preferred in neonates

Low-Risk Regimen

ZDV 4 mg/kg PO q12h × 4–6 weeks

High-Risk Regimen (3-drug)

ZDV + 3TC + NVP or ZDV + 3TC + RAL × 6 weeks

NVP preferred if HIV-1; RAL if HIV-2 or HIV-1/2 coinfection (HIV-2 not susceptible to NVP). RAL also used if dolutegravir-based maternal ART (transplacental drug levels may substitute for NVP).

⚠ For preterm infants <34 weeks or infants with drug resistance concerns: always consult Paediatric ID. Dosing based on weight and GA — complex in preterm infants.

↗ NIH/DHHS Perinatal HIV Guidelines (Dec 2024)

Step 3 — Neonatal Bloodwork

At Birth (Before Starting ARV)

HIV DNA PCR / HIV-1 RNA NAT — identifies in utero infection
CBC + differential — baseline before ZDV (anaemia risk)
LFTs (ALT, AST, bilirubin) — especially if NVP or RAL planned
Renal function if clinically indicated
Blood group + DAT (routine newborn)
CMV PCR urine/blood within 21 days — cCMV prevalence higher in HIV-exposed infants

At 2–4 Weeks of Age

HIV DNA PCR / NAT — 2nd test (high sensitivity at 2–4 weeks)
CBC + differential — ZDV toxicity monitoring (anaemia/neutropenia typically peaks at 2–4 weeks)
LFTs if on NVP or RAL

At 4–6 Weeks (End of ARV)

HIV DNA PCR / NAT — 3rd test at 4–6 weeks (or 2 weeks after ARV stopped)
CBC — final toxicity check
If starting TMP-SMX prophylaxis (high-risk infants): check CBC before initiation

🔬

HIV NAT Interpretation

Two negative HIV NAT results (one at ≥1 month and one at ≥4 months of age, when not breastfeeding) effectively excludes HIV infection. A single positive result requires immediate repeat testing — do not wait. Positive NAT = start full ART and consult Paediatric ID urgently. HIV antibody tests are unreliable until 18 months (maternal antibodies persist).

PCP Prophylaxis (TMP-SMX)

Start at 4–6 weeks of age for all high-risk infants or those with positive/indeterminate NAT
Dose: TMP-SMX 5 mg/kg/day (TMP component) PO 3× per week (Mon/Wed/Fri)
Continue until HIV infection excluded by two negative NAT results
If HIV confirmed → continue until immune status established (CD4 count)
Low-risk infants with negative NAT results by 6 weeks: TMP-SMX usually NOT required
⚠ Avoid TMP-SMX in newborns <4 weeks (hyperbilirubinemia risk) and in G6PD deficiency

Other Initial Care Points

Vitamin K: 1 mg IM as per all newborns — no change
Hepatitis B vaccine: give per routine schedule (0, 1, 6 months)
Circumcision: no change in timing required for HIV exposure alone
Routine bathing: no change — universal precautions standard
Congenital CMV screen: urine CMV PCR within first 21 days (elevated prevalence in HIV-exposed)
Social work: maternal HIV disclosure, stigma support, adherence support for mother
Notify Paediatric Infectious Diseases before discharge for follow-up planning

Infant Feeding Counselling — Updated 2024 AAP Guidance

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Key 2024 Shift in Guidance (AAP Clinical Report, Pediatrics 2024)

The AAP now supports breastfeeding for virally suppressed mothers with HIV on ART who choose to breastfeed, after shared decision-making. Formula feeding remains safe and eliminates transmission risk entirely. This is a significant change from previous universal formula-only recommendations in high-resource settings. Canadian guidance (CPS/PHAC) has generally aligned with a harm-reduction, family-centred approach — discuss with Paediatric ID for local institutional guidance.

Formula Feeding (Safest — Eliminates Transmission Risk)

Eliminates breastfeeding transmission risk entirely
Recommended when: viral load detectable, ART not taken consistently, mother not willing/able to commit to ARV adherence during breastfeeding, or institutional policy
Should be fully supported — not stigmatised
Provide formula free of charge / funded where possible
Do NOT report to child protective services for formula feeding

Breastfeeding (Supported if Virally Suppressed)

AAP 2024: supported if mother on ART and consistently virally suppressed (HIV RNA <50 copies/mL)
Residual transmission risk: ~0.3–1% per year of breastfeeding even with suppression
Requires: consistent maternal ART adherence, regular maternal VL monitoring during breastfeeding (q3 months), infant ARV prophylaxis while breastfeeding if viral load not confirmed suppressed
Discuss benefits of breastfeeding (bonding, nutrition, immunity, maternal mental health) alongside residual risk
⚠ Do NOT breastfeed if: viral load detectable, ART adherence uncertain, acute illness, cracked/bleeding nipples
If breastfeeding selected: infant continues on ARV prophylaxis (ZDV or NVP) throughout breastfeeding period

Combination / Banked Donor Milk

Pasteurised donor breast milk (from milk bank): safe — pasteurisation inactivates HIV
Unpasteurised informal donor milk sharing: NOT recommended (HIV transmission risk)
Combination feeding (breast + formula): not straightforward — discuss with ID. Mixed feeding may increase transmission risk vs exclusive breastfeeding or formula alone in some data
Abrupt weaning: avoid during maternal illness or viral load blip — increases risk

Clinicians should support the family's informed feeding choice without coercion. It is not appropriate to involve child protective services in response to an informed feeding choice. Shared decision-making with Paediatric ID, maternal HIV team, and lactation support is strongly recommended.

↗ AAP Infant Feeding for Persons with HIV (Pediatrics 2024)

Postnatal Follow-Up Schedule — First 18 Months

Time Point	HIV Testing	Labs	Clinical / ARV	Key Actions
Birth (within 6h)	HIV-1 DNA PCR / NAT #1	CBC, LFTs, bili, renal function	Start ARV within 6h (ZDV ± 3TC ± NVP or RAL)	Risk stratification, consult Paed ID, feeding counselling, social work
2–4 weeks	HIV-1 DNA PCR / NAT #2	CBC (ZDV toxicity), LFTs if on NVP/RAL	ARV continuing; review tolerability	If NAT #2 positive → start full ART urgently, consult ID. If NAT #2 negative → continue prophylaxis.
4–6 weeks	HIV-1 DNA PCR / NAT #3	CBC (final ARV toxicity check)	Stop ARV at 6 weeks if low-risk + NAT negative	Start TMP-SMX if high-risk or NAT indeterminate. Immunisations by chronological age. CMV confirmed if not done.
2–3 months	—	—	TMP-SMX review (stop if 2 negative NATs achieved)	Routine immunisations. Weight and feeding review. Maternal ART adherence check.
4 months	HIV-1 DNA PCR / NAT #4 (if not previously excluded)	—	—	Two negative NATs (one at ≥1 mo + one at ≥4 mo) = HIV effectively excluded if not breastfeeding. Discuss with family.
If breastfeeding	HIV NAT q4–6 months throughout breastfeeding, then 4–6 weeks after weaning	Maternal VL q3 months	Infant ARV prophylaxis throughout breastfeeding	Confirm maternal viral suppression regularly. Stop ARV 4–6 weeks after weaning. Final NAT 6–8 weeks post-weaning.
6 months	—	—	—	Routine immunisations (6-month shots). Growth and development review. Confirm HIV exclusion counselling if not breastfeeding.
12 months	Optional HIV antibody (if clinical concern)	—	—	Routine immunisations (12-month MMR, VZV, Men-C). Reassess if any clinical concerns.
18 months	HIV antibody (confirmatory)	—	—	At 18 months maternal antibodies have cleared. Negative HIV antibody at 18 months = definitive exclusion of HIV infection (if not currently breastfeeding). Counsel family. Discharge from HIV follow-up.

If HIV confirmed at any point: start full 3-drug ART, consult Paediatric ID, notify family with sensitive disclosure support, arrange long-term ID follow-up, assess CD4 count and viral load.

Key Counselling Points for Families

With optimal maternal ART and prophylaxis, mother-to-child transmission risk is <1%
ARV prophylaxis is safe and necessary — primary toxicity is mild anaemia (usually recovers)
Infant will need HIV testing multiple times — explain the schedule clearly
HIV antibody tests before 18 months reflect maternal antibodies, not infection
Most HIV-exposed infants are uninfected — reinforce this positive message
Stigma: maintain strict confidentiality; only disclose to those who need to know clinically
Circumcision: not contraindicated; timing not changed by HIV exposure alone
Vaccinations: all routine vaccines on schedule; live vaccines (MMR, VZV) safe in HIV-exposed uninfected infants

When to Escalate / Red Flags

Any positive HIV NAT → call Paed ID immediately, start full ART
Hgb <70 g/L on ARV → may need to discontinue ZDV; consult ID
Neutrophils <0.75 × 10⁹/L → withhold ARV; consult ID
NVP rash — discontinue if severe (Stevens-Johnson risk, though rare in neonates)
Maternal viral load rebound during breastfeeding → stop breastfeeding, reassess
Failure to thrive, recurrent infections, oral thrush beyond neonatal period → consider HIV diagnosis

↗ NIH Perinatal HIV Guidelines (Dec 2024) ↗ CPS HIV Statements

References

Guidelines & Key References

Canadian (CPS / SOGC)

US / UK / International

Source Document

This reference is primarily based on:

Toronto Residents' Handbook of Neonatology (Nov 2022) — Boone, Dahan, Halpern, Lorenzo, Campbell et al. (University of Toronto / Toronto Centre for Neonatal Health)
Canadian Paediatric Society (CPS) Position Statements (various, 2015–2023)
AAP Textbook of Neonatal Resuscitation 8th Edition (2021)
SOGC Clinical Practice Guidelines
NICE Guidelines NG25, NG98, NG111

⚠️ This resource is a clinical decision support tool. Always verify with current institutional protocols, pharmacy, and senior clinical staff. Drug dosing should be confirmed with a neonatal formulary or pharmacist. Last compiled: 2025.