Neonatal resuscitation

Use this note for the non-delivery related resuscitation of the newborn; see newborn resuscitation for immediate after-delivery resuscitation. See newborn critical care quick reference for vital signs and drug doses, and equipment sizes.

Background

• Neonate <1mo age

Clinical Features

• Neonate in shock

Differential Diagnosis

Sick Neonate

THE MISFITS

• Trauma
• Heart
  • Congenital heart disease
  • Hypovolemia
• Endocrine
  • hypoglycemia
  • Hypothyroidism
  • Congenital adrenal hyperplasia
• Metabolic
  • Sodium
  • Calcium
  • Glucose
• Inborn errors of metabolism
• Seizure
• Formula / feeding problems
  • Hyponatremia
  • Hypocalcemia
  • FPIES / Food protein-induced enterocolitis syndrome
• Intestinal Disasters
  • Duodenal atresia
  • Midgut volvulus
  • Necrotizing enterocolitis
  • Intussusception
• Toxin
• Sepsis

Evaluation

Workup

• Blood glucose (stat)
• Sepsis workup
• Blood gas
• ECG
  • Treatable conditions include SVT
• Ammonia, pyruvate and lactate to rule in inborn errors of metabolism
  • Need to look up values for neonate. Ammonia is high as liver is immature (i.e. that's why neonates are jaundice). Ammonia > 200 requires dialysis

Evaluation

If hypoxic or evidence of CHF assume CHD

• CHF in neonate = hepatomegaly, wheezing, gallop
• if unclear, do Hyperoxia test
  • place infant on 100% O2 for 10 minutes
  • check ABG, if O2<100 torr, highly predictive of CHD
  • some use Pulse Ox <95%, less sensitive
• Abdominal xrays may help rule in intestinal disaster early

Pediatric Hypoglycemia Dextrose Chart

Category	Age	Glucose	Treatment	Initial IV Bolus	Maintenance Dose
Neonatal	<2mo	<40	D10W	2.5-5 mL/kg	6 mL/kg/h
Pediatric	2mo-8yrs	<60	D25W	2 mL/kg	D10W: 6 mL/kg/h for first 10 kg + 3 mL/kg/h for 11–20 kg + 1.5 mL/kg/h for each additional kg >20 kg
Adult	>8yrs	<70	D50W	50mL (1 amp) OR 1 mL/kg

• Consider diluting the D25W or D50W bolus, with NS 1-to-1, as those concentrations may be sclerosing to veins
• Recheck 5 minutes after dose and repeat dose if low.
• Consider glucagon IM/SQ if IV access is not readily available

Management

• IV fluids
• IV antibiotics
  • Ampicillin 50mg/kg Q8h, AND
  • (Ceftazidime or cefotaxime), AND
  • Acyclovir 20 mg/kg/DOSE IV Q8
• Consider pressors
• Intubate and give PGE
  • Sides effects of PGE include apnea (10%)
• If inborn error of metabolism suspected
  • IV dextrose at 1.5 maintenance
  • Dialysis if ammonia >200

Other Empiric Treatments for Unstable Neonates

Medication/Intervention	Indication	Dose/Size (for neonate)
Glucose	Hypoglycemia	5–10 mL/kg of 10% dextrose in water IV
3% normal saline	Symptomatic hyponatremia	3–5 mL/kg bolus IV
Calcium	Hypocalcemia	50–100 milligrams/kg calcium gluconate or 20 milligrams/kg calcium chloride IV
Packed red blood cells	Anemia	10 mL/kg IV
Normal saline	Hypotension, dehydration	5-10 mL/kg IV aliquots (up to 60-80 mL/kg)
10% dextrose in one fourth normal saline	Metabolic disease	1.5 maintenance (6 mL/kg/h for the first 10 kg)
Endotracheal intubation	Hypoventilation or frequent apnea	<3mm for preemie; 3mm for term neonate, 3.5mm for older infant; cuffed tube prefered if not premature

Disposition

• Admit

See Also

Pediatric Critical Care

• Critical care quick reference
• Neonatal resuscitation
• Newborn resuscitation
• PALS (Main)
• Intubation (peds)
• Initial mechanical ventilation settings (peds)
• Vital signs (peds)

Calculators

APGAR Score

APGAR Score

Criteria	0	1	2
Appearance (Color)	1 Blue/pale all over	Blue extremities, pink body	Pink all over
Pulse (Heart Rate)	1 Absent	<100 bpm	≥100 bpm
Grimace (Reflex Irritability)	1 No response	Grimace/weak cry	Cry or pull away
Activity (Muscle Tone)	1 Limp	Some flexion	Active motion
Respiration	1 Absent	Slow/irregular	Good cry
APGAR Score	/ 10

Interpretation
0–3	Critically low — Immediate resuscitation needed.
4–6	Moderately low — May require some resuscitative measures.
7–10	Reassuring — Routine neonatal care.

References
Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg. 1953;32(4):260-267. American Academy of Pediatrics Committee on Fetus and Newborn. The Apgar Score. Pediatrics. 2015;136(4):819-822. PMID 26416932.

External Links

• Pediatric Emergency Playbook Podcast: The Undifferentiated Sick Infant
  • The Undifferentiated Sick Infant (mp3 only)
• EM Cases - Neonatal Resuscitation May 2020
• Justin Morgenstern, "Resuscitation of the crashing infant (pediatric resuscitation)", First10EM blog, October 24, 2016. Available at: https://first10em.com/crashing-infant/.