Managing Neonatal Intensive Care

Required Documents

• Admission H&P with maternal and delivery history
• Current ventilator/respiratory support flow sheet
• Feeding and nutrition log (volumes, type of feed, fortification)
• Active medication list with weight-based doses
• Most recent labs (CBC, CRP, blood gas, bilirubin, metabolic panel)
• Head ultrasound results (for infants < 32 weeks)
• Retinopathy of prematurity (ROP) screening schedule and results

Step 1 — Respiratory Management Documentation

Ventilation Hierarchy (Escalation/De-escalation)

1. Room air → Low-flow nasal cannula (≤ 1 LPM)
2. High-flow nasal cannula (HFNC, 1-8 LPM)
3. CPAP (nasal or mask, 5-8 cm H2O)
4. NIPPV (nasal intermittent positive pressure)
5. Conventional mechanical ventilation (SIMV, AC, PC)
6. High-frequency oscillatory ventilation (HFOV)
7. High-frequency jet ventilation (HFJV)
8. Inhaled nitric oxide (iNO) — for PPHN

Required Documentation Per Shift

• Mode, rate (if applicable), PIP/PEEP or MAP, FiO2, tidal volume (4-6 mL/kg target)
• SpO2 target range (preterm: 90-95% per COT trial data; term varies by condition)
• Blood gas interpretation: pH, pCO2, pO2, HCO3, base deficit
• Permissive hypercapnia targets if applicable (pCO2 45-55 mmHg acceptable for ELBW)
• Surfactant doses administered (Survanta 4 mL/kg, Curosurf 2.5 mL/kg, Infasurf 3 mL/kg) with times
• Extubation readiness criteria: MAP ≤ 7, FiO2 ≤ 0.30, rate ≤ 20, stable blood gases, caffeine on board

Step 2 — Fluid, Nutrition, and Growth Tracking

Daily Fluid Calculation

• DOL 1: 60-80 mL/kg/day (ELBW may start at 80-100 under radiant warmer)
• Advance by 10-20 mL/kg/day based on weight trend, sodium, urine output
• Target full enteral feeds: 140-160 mL/kg/day (higher for ELBW with growth failure)

Feeding Advancement Protocol

• Trophic feeds: 10-20 mL/kg/day × 2-5 days (gut priming; do not advance)
• Advancement: increase by 20-30 mL/kg/day for infants > 1000g; 10-20 mL/kg/day for ELBW
• Human milk priority: maternal breast milk > donor human milk > preterm formula (per AAP)
• Fortification: begin human milk fortifier (HMF) at 100 mL/kg/day feeds; target 24 kcal/oz
• NEC surveillance: abdominal exam each feed; hold feeds for distension, bloody stools, or pneumatosis

Growth Monitoring

• Daily weights (goal: 15-20 g/kg/day after regaining birth weight)
• Weekly length and head circumference
• Plot on Fenton preterm growth chart; transition to WHO at term-equivalent age
• Parenteral nutrition (PN) composition: document dextrose concentration, amino acids (start 3-4 g/kg/day), lipids (start 1-3 g/kg/day), and electrolytes

Step 3 — Infection Surveillance and Antibiotic Stewardship

Early-Onset Sepsis (EOS, < 72 hours)

• Risk stratification per Kaiser EOS calculator (maternal GBS, chorioamnionitis, ROM duration, intrapartum antibiotics, infant clinical status)
• Empiric regimen: ampicillin + gentamicin
• Duration: if cultures negative at 36-48 hours and infant is well, discontinue antibiotics
• Document: culture collection time, antibiotic start time, planned stop date

Late-Onset Sepsis (LOS, > 72 hours)

• Risk factors: central line days, prolonged NPO, prolonged antibiotics
• Empiric regimen per unit protocol (commonly vancomycin + gentamicin or cefepime)
• Track central-line-associated bloodstream infection (CLABSI) bundle compliance
• Document: line type, insertion date, dwell days, daily line-necessity assessment

Antibiotic Stewardship Checklist

• Culture obtained before first antibiotic dose
• Empiric regimen appropriate for age and suspected source
• 36-48 hour culture review with stop date if negative
• Narrowing to targeted therapy once sensitivities available
• Duration documented per source (meningitis 14-21 days, bacteremia 7-10 days, UTI 7-10 days)

Step 4 — Neuromonitoring and Brain Protection

Head Ultrasound Schedule (Infants < 32 weeks)

• Day 3-7 of life (screen for IVH)
• Day 10-14 (evolution of IVH, early PVL)
• 36 weeks CGA or before discharge (late PVL, ventriculomegaly)
• Additional imaging for clinical deterioration (full fontanelle, drop in hematocrit, seizures)

IVH Grading (Papile Classification)

• Grade I: germinal matrix hemorrhage only
• Grade II: IVH without ventricular dilation
• Grade III: IVH with ventricular dilation
• Grade IV: parenchymal hemorrhagic infarction

Neuroprotective Practices

• Minimize handling during first 72 hours for VLBW infants
• Midline head positioning to optimize venous drainage
• Avoid rapid volume boluses and hyperosmolar solutions
• Document head circumference trend (rapid increase suggests post-hemorrhagic hydrocephalus)
• Therapeutic hypothermia for HIE: initiated within 6 hours of birth, 33.5°C × 72 hours (term infants only)

Step 5 — ROP Screening and Monitoring

Screening Criteria

• Birth weight ≤ 1500g OR gestational age ≤ 30 weeks
• Selected infants 1500-2000g with unstable clinical course (per attending discretion)

Screening Timeline

• First exam at 31 weeks postmenstrual age (PMA) OR 4 weeks chronological age, whichever is later
• Follow-up per ophthalmology based on zone, stage, and plus disease findings
• Document: zone, stage (1-5), extent (clock hours), plus disease present/absent

Treatment Thresholds

• Type 1 ROP (treat within 72 hours): zone I any stage with plus; zone I stage 3; zone II stage 2 or 3 with plus
• Type 2 ROP (observe with frequent exams): zone I stage 1 or 2 without plus; zone II stage 3 without plus

Step 6 — Discharge Readiness Assessment

Physiologic Criteria (ALL must be met)

• Maintaining temperature in open crib for 24-48 hours
• Tolerating full enteral feeds with adequate weight gain (≥ 20-30 g/day)
• No apnea/bradycardia/desaturation events for 5-7 days (or stable on home monitor)
• Passed car seat tolerance test (if < 37 weeks CGA at discharge)
• Completed newborn metabolic screen (repeat if initial drawn < 24 hours of age)
• Completed hearing screen
• Hepatitis B vaccine administered
• ROP screening complete or follow-up arranged

Family Readiness

• CPR training completed by caregivers
• Safe sleep education documented (supine, firm surface, no co-sleeping)
• Home medication administration training (if applicable)
• Follow-up appointments scheduled: PCP within 48-72 hours, subspecialty as needed
• Equipment arranged if needed (home oxygen, apnea monitor, feeding supplies)

Checkpoint B — NICU Documentation Review

• Current CGA and weight documented with daily delta
• Respiratory support mode and settings with SpO2 targets
• Blood gas results with interpretation
• Fluid intake and enteral feeding volumes with fortification noted
• Growth plotted on Fenton chart with velocity documented
• Active antibiotics with start date, planned duration, and culture results
• Head ultrasound results documented per screening schedule
• ROP screening status current with next exam date
• Caffeine status documented (if applicable)
• NEC surveillance documented (abdominal exam, stool quality)
• Family meetings and discharge planning updates documented
• All [VERIFY] flags resolved or escalated

Quality Audit

Guidelines

• Follow AAP/AHA NRP 8th Edition for delivery room management
• Apply Vermont Oxford Network (VON) evidence-based care bundles for quality benchmarking
• Use Fenton 2013 preterm growth charts for growth monitoring (transition to WHO at term)
• Follow AAP 2014 ROP screening guidelines and ETROP study treatment criteria
• Apply AAP guidelines on management of hyperbilirubinemia in premature infants
• Follow Papile classification for IVH grading
• Use Kaiser EOS calculator for early-onset sepsis risk stratification
• Follow SUPPORT/COT trial data for SpO2 targeting in preterm infants (90-95%)
• Caffeine citrate dosing: 20 mg/kg loading, 5-10 mg/kg/day maintenance per CAP trial
• NEC staging per modified Bell criteria
• Escalate to attending for any acute decompensation, grade III-IV IVH, NEC staging ≥ IIA, or type 1 ROP
• This skill produces clinical documentation; it does not replace clinical judgment