Neonatal ICU
Bedside NICU reference — gestational age, fluids, respiratory support, sepsis, jaundice, common medications. Every value cited; verify against your local protocol.
Neonatal ICU
Bedside reference for the NICU. Every value below links to a primary or authoritative source. This is a quick-lookup aid, not a substitute for verifying against your unit’s protocol and the original guideline. See also Neonatal Resuscitation, Pediatric Equipment, and Hypoglycemia — Rule of 50s.
Gestational Age & Birth Weight Categories
| Term | Definition |
|---|---|
| Extremely preterm | < 28 weeks |
| Very preterm | 28 0/7 – 31 6/7 weeks |
| Moderate preterm1 | 32 0/7 – 33 6/7 weeks |
| Late preterm1 | 34 0/7 – 36 6/7 weeks |
| Early term | 37 0/7 – 38 6/7 weeks |
| Full term | 39 0/7 – 40 6/7 weeks |
| Late term | 41 0/7 – 41 6/7 weeks |
| Post-term | ≥ 42 0/7 weeks |
Sources: WHO preterm birth fact sheet (extremely/very/moderate-to-late preterm); ACOG Committee Opinion 579 — Definition of Term Pregnancy (early/full/late/post term).
| Birth weight | Cutoff |
|---|---|
| LBW | < 2500 g |
| VLBW | < 1500 g |
| ELBW | < 1000 g |
| Micropreemie2 | < 750 g |
Source: WHO Low Birth Weight indicator (LBW); Brighton Collaboration LBW/VLBW/ELBW case definitions (PMC).
SGA = < 10th percentile · AGA = 10th–90th · LGA = > 90th — use Fenton 2013 preterm growth chart or Olsen 2010 chart.
Apgar Score
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Color | Blue/pale | Body pink, extremities blue (acrocyanotic) | Completely pink |
| Heart rate | Absent | < 100 | > 100 |
| Reflex irritability | No response | Grimace | Cry or active withdrawal |
| Tone | Limp | Some flexion | Active motion |
| Respirations | Absent | Weak, irregular | Strong cry |
Score at 1 and 5 minutes; if 5-min score < 7, continue at 5-min intervals up to 20 min.
Source: AAP/ACOG Apgar Score Committee Opinion, Pediatrics 2015 (Watterberg et al, reaffirmed) — original ACOG text mirrored at ACOG Committee Opinion 644.
Initial Vitals & Targets
| Parameter | Term | Preterm |
|---|---|---|
| Heart rate | 100–160 | 120–170 |
| Resp rate | 30–60 | 40–70 |
| MAP (mmHg) | ≥ 40 | ≥ gestational age (weeks) on day of birth3 |
| SpO₂ pre-ductal | 90–95 | 90–95 (88–94 if < 32 wk) |
| Temperature (axillary) | 36.5–37.5°C — keep on warmer/isolette |
Source: Iowa Neonatology Handbook — Pulmonary chapter (SpO₂, RR targets); Iowa Cardiology — MAP ≈ GA rule; Iowa Temperature chapter (36.5–37.4°C axillary); WHO Thermal Protection of the Newborn (36.5–37.5°C). 88–94% SpO₂ for < 32 wk reflects post-SUPPORT trial (NEJM 2010) / BOOST II (NEJM 2013) consensus.
Pre-ductal SpO₂ targets in first 10 min
| Minute | Target SpO₂ |
|---|---|
| 1 min | 60–65% |
| 2 min | 65–70% |
| 3 min | 70–75% |
| 4 min | 75–80% |
| 5 min | 80–85% |
| 10 min | 85–95% |
Source: 2020 NLS guidelines (Aziz et al, Circulation); table carried unchanged into 2025 NLS (Part 7). Underlying data: Dawson 2010 reference ranges, Pediatrics.
Fluids & Nutrition
Initial IV fluids (first 24 h)
| Weight | Starter rate | Solution |
|---|---|---|
| > 1500 g | 60–80 mL/kg/day | D10W |
| 1000–1500 g | 80–100 mL/kg/day | D10W |
| < 1000 g (or ≤ 26 wk) | 80–150 mL/kg/day | D10W (D5W if hyperglycemic) |
Advance ~20 mL/kg/day; goal ~140–160 mL/kg/day by DOL 5–7. Adjust for insensible losses (radiant warmer, phototherapy +10–20 mL/kg/day; humidified isolette reduces losses).
Source: Iowa Neonatology Handbook — Fluid Management.
Glucose Infusion Rate (GIR)
GIR (mg/kg/min) = (% dextrose × rate mL/kg/day) / 144
- Start GIR 4–6 mg/kg/min; advance by 1–2 mg/kg/min/day
- Maximum peripheral dextrose concentration: D12.5W (higher requires central line)
- Target serum glucose 50–110 mg/dL
Treat hypoglycemia (< 40 mg/dL symptomatic / per protocol): D10W 2 mL/kg IV bolus (= 200 mg/kg dextrose), then ↑ GIR by 2 mg/kg/min. Recheck q15–30 min. See Hypoglycemia Rule of 50s.
Source: Hawaii Pediatric Text — Neonatal Hypoglycemia chapter (GIR formula, bolus, peripheral max); PES Neonatal Hypoglycemia Guideline (J Pediatr 2015, Thornton et al) for glucose targets.
Electrolytes (after 24 h once UOP established)
- Na⁺ 3–5 mEq/kg/day (preterms may need 4–6 after DOL 3 due to immature tubules)
- K⁺ 2–3 mEq/kg/day
- Ca gluconate 200–400 mg/kg/day
Source: Iowa Neonatology Handbook — Fluid Management (Na, K); calcium range from Cloherty NICU Manual / Iowa TPN protocols.
TPN — start within 24 h for VLBW
- Amino acids: start 1.5–2.5 g/kg/day from DOL 0; target 2.5–3.5 g/kg/day (preterm)
- Lipids: start 1 g/kg/day, advance 0.5–1/day to target 3 g/kg/day; SMOFlipid preferred (lower IFALD risk)
- Goal calories: 100–120 kcal/kg/day enteral; 90–100 if parenteral
Source: ESPGHAN/ESPEN/ESPR/CSPEN Pediatric Parenteral Nutrition Guidelines 2018 — Amino Acids (open PDF); ESPGHAN 2018 Lipids chapter via pediatric PN guidelines index.
Feeding advancement
- Trophic feeds 10–20 mL/kg/day ASAP; preferentially mother’s own milk or donor
- Advance 20–30 mL/kg/day in stable infants > 1000 g; slower (10–20) in ELBW
- Hold for: bilious aspirates, gross blood, abdominal distention/discoloration, hemodynamic instability
- NEC monitoring: abdominal exam q3–4h, residuals (color > volume), Bell staging if concerned
Source: East of England Neonatal Network Enteral Feeding Guideline (open PDF); evidence base: SIFT trial (NEJM 2019, Dorling et al) supports advancement rates ~30 mL/kg/day.
Respiratory Support
Initial settings
| Modality | Starting parameters |
|---|---|
| Nasal cannula | 0.1–2 L/min @ FiO₂ titrated |
| HFNC | 2–8 L/min (weight-based ~1–2 L/kg/min, max 8 L/min) |
| CPAP | +5 to +8 cmH₂O, FiO₂ titrated to SpO₂ |
| NIPPV | PIP 15–20, PEEP +5–6, rate 20–40 |
| Conventional vent (TV-AC) | PEEP +5, PIP to TV 4–6 mL/kg (preterm) / 5–7 (term), rate 30–40, iTime 0.30–0.35 |
| HFOV | MAP 2 above conv, ΔP for chest wiggle; Hz 10 (term) / 12–15 (preterm / ELBW) |
Source: 2023/2025 European Consensus Guidelines on the Management of RDS (Sweet et al, Neonatology — Karger); HFNC flow targets from Manley 2013 NEJM HFNC trial and ERS review 2024. Conventional vent TV / HFOV Hz convention per 2025 European RDS guideline.
Surfactant
- Indication: RDS with FiO₂ ≥ 0.30 on CPAP ≥ +6, or intubated < 30–32 wk
- LISA / MIST preferred in spontaneously-breathing preterm infants when feasible
- Re-dose interval is drug-specific (see below)
| Surfactant | Initial dose | Repeat dose & interval |
|---|---|---|
| Beractant (Survanta) | 100 mg/kg (= 4 mL/kg) | up to 3 additional doses q6h, max 4 in 48 h |
| Calfactant (Infasurf) | 105 mg/kg (= 3 mL/kg) | up to 2 additional doses q12h, max 3 total |
| Poractant alfa (Curosurf) | 200 mg/kg (= 2.5 mL/kg) | 100 mg/kg (= 1.25 mL/kg) q12h, max 3 doses |
Source: FDA Survanta label (beractant); FDA Infasurf label (calfactant); FDA Curosurf label (poractant alfa); indication and LISA preference per 2025 European RDS Consensus.
Common blood gas targets
| Parameter | Term | Preterm (permissive) |
|---|---|---|
| pH | 7.30–7.40 | > 7.25 |
| PaCO₂ | 40–55 | 45–55 (up to 65 if pH > 7.20) |
| PaO₂ | 60–80 | 50–70 |
Source: Iowa Neonatology Handbook — Pulmonary chapter; permissive hypercapnia evidence: PHELBI trial (Thome 2015, Lancet Respir Med) and Cochrane permissive hypercapnia review (Ryu 2013).
Neonatal Sepsis
Early-onset (≤ 72 h)
- Pathogens: GBS, E. coli, Listeria (uncommon, classically included)
- Risk factors: chorioamnionitis, GBS+ with inadequate IAP, prolonged ROM (≥ 18 h), preterm, intrapartum fever
- Risk stratification ≥ 34 wk: use Kaiser Permanente Early-Onset Sepsis Calculator
- Empiric: Ampicillin + Gentamicin (cefotaxime if meningitis suspected; avoid routine 3rd-gen for non-meningitic EOS — selects resistant flora)
Source: AAP Puopolo CPG — Management of Neonates ≥ 35 0/7 wk at Risk for EOS (Pediatrics 2018); AAP Puopolo CPG — Management of Neonates < 34 6/7 wk at Risk for EOS (Pediatrics 2018); Kuzniewicz et al, Kaiser EOSC validation (JAMA Pediatr 2017); UCSF Benioff Consensus EOS Guidelines.
Late-onset (> 72 h, often nosocomial)
- Pathogens: Coagulase-negative Staph (~70%), S. aureus (incl. MRSA), gram-negative rods, Candida
- Empiric: Vancomycin + Gentamicin (± cefepime for resistant GNR concern); add antifungal (fluconazole or amphotericin) if line/risk
- Workup: CBC w/ diff, CRP/procalcitonin, blood culture; urine culture (catheter) if > 72 h old; LP if hemodynamically stable
Source: Greenberg et al, Late-Onset Sepsis review (PMC 2024); AAP Hudak — Nafcillin alternative for empiric LOS (Pediatrics 2022).
Empiric antibiotic doses (term, postnatal age > 7 days, normal renal function)
| Drug | Dose |
|---|---|
| Ampicillin4 | 50 mg/kg q8h (meningitis: 100 mg/kg q8h) |
| Gentamicin | 4–5 mg/kg q24h (term); q36h if 30–34 wk PMA; q48h if < 30 wk |
| Vancomycin | 15 mg/kg q12h (adjust by PMA + trough/AUC level) |
| Cefotaxime | 50 mg/kg q8h (q12h if ≤ 1 wk) |
| Acyclovir (HSV) | 20 mg/kg q8h — 14 d SEM, 21 d CNS/disseminated |
| Fluconazole — prophylaxis | 3–6 mg/kg IV twice weekly × 6 wk (ELBW in units with > 10% candidiasis incidence) |
| Fluconazole — treatment | 25 mg/kg load → 12 mg/kg q24h (term) / q48h (< 30 wk PMA) |
Sources: ampicillin per ANMF monograph (PDF); gentamicin extended-interval per Lanao 2004 Monte Carlo neonatal PK (PMC); vancomycin per FDA label / neonatal PK review (PMC); cefotaxime per DailyMed FDA label; acyclovir per Kimberlin neonatal HSV (Neoreviews 2018); fluconazole prophylaxis per IDSA Pappas 2016 Candidiasis Guideline and Kaufman et al, NEJM 2001; fluconazole treatment per Piper et al pediatric PK (PMC).
Hyperbilirubinemia
- Use BiliTool — implements AAP 2022 Kemper hour-specific nomograms — for phototherapy and exchange thresholds
- Measure TcB or TSB at least once before discharge (commonly 24–48 h of age); plot on hour-specific nomogram with adjustment for risk factors
- Neurotoxicity risk modifiers: GA < 38 wk, isoimmune hemolysis (DAT+), G6PD deficiency, sepsis, albumin < 3.0 g/dL, temperature instability, significant lethargy
- Intensive phototherapy: narrow-spectrum LED, irradiance ≥ 30 µW/cm²/nm at ~475 nm, maximize body surface area
- Approaching exchange threshold: IV hydration, intensive phototherapy, IVIG (isoimmune), albumin; prepare for exchange transfusion
Source: AAP CPG — Hyperbilirubinemia in Newborns ≥ 35 wk (Kemper et al, Pediatrics 2022); AAP FAQ on 2022 Hyperbilirubinemia Guideline.
Common NICU Medications
| Indication | Drug | Dose |
|---|---|---|
| Apnea of prematurity | Caffeine citrate5 | Load 20 mg/kg IV/PO, maintain 5 mg/kg/day q24h |
| PDA closure | Indomethacin6 | 0.2 mg/kg × 1, then 2 more doses (0.1–0.25 mg/kg, age-stratified) q12–24h |
| PDA closure | Ibuprofen lysine | 10 mg/kg IV × 1 → 5 mg/kg q24h × 2 |
| PDA closure | Acetaminophen IV (off-label) | 15 mg/kg q6h × 3 days |
| Maintain PDA | Alprostadil (PGE1) | Start 0.05–0.1 µg/kg/min, titrate down to 0.01–0.05 |
| Pulmonary HTN7 | iNO | Start 20 ppm (max), wean as PaO₂ improves |
| BPD prevention | Dexamethasone (DART) | 0.075 mg/kg/dose q12h × 3 d, then taper (cum 0.89 mg/kg over 10 d) |
| Procedural sedation | Fentanyl | 1–2 µg/kg/dose IV q2–4h |
| Sedation infusion | Morphine | Start 0.01–0.03 mg/kg/h; escalate to 0.05–0.1 with tolerance/need |
| NAS | Morphine (Finnegan-driven) | 0.04 mg/kg q3–4h, titrate; methadone alternative |
| Seizures (1st line) | Phenobarbital | Load 20 mg/kg IV, maintain 3–5 mg/kg/day |
| Seizures (2nd line)8 | Levetiracetam | Load 40 mg/kg, maintain ~15–20 mg/kg/day (5 mg/kg q8h) |
| Hypotension | Dopamine | 2–20 µg/kg/min |
| Refractory shock | Hydrocortisone | Preterm: 1 mg/kg load → 0.5–1 mg/kg q8–12h × 5 d |
Sources for drug doses: FDA Cafcit (caffeine) label; FDA NeoProfen (ibuprofen lysine) label; Cochrane acetaminophen for PDA review (2022); Prostin VR (alprostadil) Pfizer label; DART trial (Doyle, Pediatrics 2006); LHSC NICU fentanyl monograph; Neonatal opioid review (PMC); AAP Hudak NAS Clinical Report 2012; ANMF dopamine monograph; Hydrocortisone in neonatal shock review (Frontiers Pediatrics 2025).
Common Bedside Calculations
- Maintenance fluids (Holliday-Segar): 100 mL/kg/day first 10 kg + 50 next 10 + 20 thereafter (or 4-2-1 mL/kg/h) — Holliday-Segar 1957 review (PMC). Less commonly used in first week of NICU life (use weight-based mL/kg/day above).
- ETT depth (cm at lip) = weight (kg) + 69 — Tochen 1979 / Pediatric & Neonatal Resp review
- NG depth: NEX (nose-ear-xiphoid) measurement + ~10% margin — Iowa Neonatology Handbook
- Umbilical lines (Shukla & Ferrara 1986; verify with imaging):
- UAC high = (3 × BW kg) + 9 cm + cord stump length
- UAC low = BW kg + 7 cm (Dunn) — positions tip between L3–L4; high position preferred by most US NICUs
- UVC = (UAC high / 2) + 1 cm — StatPearls Umbilical Artery Catheterization; Verheij 2013 revision (PubMed) suggests dropping the “+1” (Shukla formula over-inserts in ~73%)
- Blood volume: term ~85 mL/kg · preterm ~100 mL/kg — Canadian Blood Services Neonatal Transfusion Guide
- Replacement transfusion: 10–15 mL/kg pRBC over 2–4 h; smaller aliquots (5 mL/kg over 2 h) if anemic with CHF risk — Ontario Pediatric Transfusion Appendix (PDF)
Useful Calculators & References
- Kaiser Permanente Early-Onset Sepsis Calculator — ≥ 34 wk
- BiliTool — hour-specific bilirubin nomograms (AAP 2022)
- PediTools — Fenton growth, gestational age, drug dosing, ETT depth
- Iowa Neonatology Handbook — open, well-cited protocol reference
- NeoFax / Micromedex — neonatal drug reference (subscription)
- STABLE Program — post-resuscitation stabilization mnemonic (Sugar, Temperature, Airway, Blood pressure, Lab work, Emotional support)
- NICHD Extremely Preterm Birth Outcomes Tool — counseling at 22–25 wk
Verification: every value on this page was independently cross-checked against the linked authoritative source(s) on 2026-05-25. Notify the maintainer if you find a discrepancy with a current guideline.
Footnotes
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WHO groups 32–37 weeks as “moderate to late preterm” together. The 32 0/7 – 33 6/7 vs 34 0/7 – 36 6/7 split is the AAP/Engle Late Preterm CPG operational convention. ↩ ↩2
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“Micropreemie” is colloquial; literature variably uses < 750 g, < 800 g, or < 26 weeks. ↩
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Day-of-birth rule of thumb only; always pair with perfusion assessment. ↩
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Ampicillin first-week dosing is q12h, not q8h, per ANMF neonatal monograph. ↩
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FDA label dose is 5 mg/kg/day; escalation to 8–10 mg/kg/day is common practice but off-label. See FDA Cafcit label and CAP trial (Schmidt, NEJM 2006). ↩
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FDA Indocin IV label is age-stratified by postnatal age at first dose. < 48 h: 0.2 → 0.1 → 0.1 mg/kg. 2–7 d: 0.2 → 0.2 → 0.2 mg/kg. > 7 d: 0.2 → 0.25 → 0.25 mg/kg. Intervals 12–24 h. See Indocin IV label (RxList). ↩
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INOmax FDA label indication is ≥ 34 wk hypoxic respiratory failure with pulmonary HTN. Use < 34 wk is off-label. ↩
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NEOLEV2 trial (Sharpe, Pediatrics 2020) found levetiracetam inferior to phenobarbital (28% vs 80% seizure-free at 24 h). ILAE 2023 neonatal seizure guideline still recommends phenobarbital first-line. ↩
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The kg+6 (“7-8-9”) rule overestimates in infants < 28 wk and < 1 kg. Use the NRP weight-based ETT table for ELBW. ↩