Download Neonatal Clinical Management Guidelines

Neonatal Clinical
Management Guidelines
Eighth Edition
Alere’s Guideline Advisory Committee
The Guideline Advisory Committee is a group of respected practicing
neonatologists who collaborate with Alere on the regular revision and
validation of evidence-based clinical management guidelines.
David Adamkin, MD
University of Louisville
Louisville, KY
Gary Dreyer, MD
Mercy Hospital
St. Louis, MO
Jeffrey B. Gould, MD, MPH
Stanford University Medical Center
Palo Alto, CA
Linda L. Gratny, MD
Children’s Mercy Hospitals
and Clinics
Kansas City, MO
Kenneth L. Harkavy, MD
Reston Hospital Center
Reston, VA
Victor C. Herson, MD
Connecticut Children’s
Medical Center
Hartford, CT
Andrew Hopper, MD
Loma Linda University
School of Medicine
Loma Linda, CA
Anthony J. Orsini, DO
Winnie Palmer Hospital
for Women and Babies
Orlando, FL
Steven A. Ringer, MD, PhD
Brigham and Women’s Hospital
Boston, MA
Robert Stavis, MD, PhD
Bryn Mawr Hospital
Bryn Mawr, PA
Thomas E. Wiswell, MD
Florida Children’s Hospital
Orlando, FL
Alere Contributors
Michael Kornhauser, MD
Roy Schneiderman, MD
Introduction
Alere is pleased to present the eighth edition of Neonatal Clinical
Management Guidelines. These guidelines address specific areas of clinical
practice and can be beneficial to the outcome of an infant in the Neonatal
Intensive Care Unit (NICU).
They address issues including:
▪ Feeding
▪ Apnea, Bradycardia
and Desaturation
▪ Thermoregulation
▪ Neonatal Drug
Exposure/Withdrawal
▪ Phototherapy
▪D
ischarge
▪ Sepsis
These guidelines are aimed at providing a reasonable and literature/
peer-based approach to care for each of the areas discussed. The goal
is continuity, efficiency and quality of care.
Alere developed its first edition of Neonatal Clinical Management Guidelines
in 1998 with the help of a distinguished group of neonatologists representing
both academic and clinical practice. Revisions to these guidelines have
occurred on an ongoing basis with input from neonatologists around the
country. This edition was initially reviewed by neonatologists and staff
within Alere, and was subsequently reviewed, edited, and ratified by Alere’s
Guideline Advisory Committee of practicing neonatologists. Panel members
are listed on the previous page.
The appropriate use of these guidelines requires sound medical judgment.
Care should be based on patient assessments and evidence-based
medicine. These guidelines are designed to address common clinical
situations that arise within each area of care. That said, individual patient
circumstances must always be considered, and may lead to modification
in the interpretation and use.
As you become familiar with these guidelines, you may have comments
about them that you wish to share. Please feel free to contact Alere at
www.alere.com.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Table of Contents
Feeding Guideline.................................................................................... 1
Apnea, Bradycardia and Desaturation Guideline.............................21
Thermoregulation Guideline................................................................34
Sepsis Guideline.....................................................................................39
Phototherapy Guideline.........................................................................48
Neonatal Drug Exposure/Withdrawal Guideline..............................54
Discharge Guideline..............................................................................65
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Feeding
Guideline
Applies to all infants in the Neonatal Intensive Care Unit (NICU)
or Special Care Nursery
Key Points
▪ Human milk provides unique short- and long-term benefits.
▪ Cue based is the physiologically sound approach to oral feedings.
▪ Feedings consisting of solely human milk with multidisciplinary team
support provide the greatest chance of success of exclusive breastfeeding.
General Considerations
▪ Human milk is the preferred primary source of infant nutrition. The World
Health Organization recommends exclusive breastfeeding until 6 months
of age to enhance overall health.
▪ Breastfeeding has significant positive effects on maternal health.
▪ Adequate nutrition is important to prevent growth failure and to promote
normal neurodevelopmental outcome. Cumulative energy/protein
deficit is predictive of poor head growth. In conjunction with advancing
enteral feeding, early initiation of parenteral nutrition (within the first 24
hours of birth, particularly in the very low birth weight [VLBW] infant) is
recommended to preserve protein stores and to deliver adequate caloric
intake. For larger infants (e.g. > 2 kg), who are anticipated to be advancing
enteral nutrition within a few days, parenteral nutrition may be deferred.
▪ Early initiation of nutrition support in extremely low birth weight (ELBW)
infants minimizes initial weight loss, improves weight gain, and enhances
earlier achievement of full enteral feedings. Absence of enteral feedings
prior to diagnosis is associated with severity of necrotizing enterocolitis
(NEC). Morbidity risks may be modified by early nutrition.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
1
Feeding Guideline
▪ Growth velocity approaching in utero accretion rates during an ELBW
infant’s hospitalization helps minimize extrauterine growth restriction and
may exert a significant positive effect on neurodevelopment and growth
outcomes at 18 to 22 months corrected age. Goals include the following
catch up: weight 18 gm/kg/day, head circumference 0.9 cm/week after
return to birth weight to discharge. Obesity should be avoided.
▪ Early parenteral nutrition with appropriate intake of amino acids and
lipids is typically well tolerated immediately after birth by VLBW infants.
It significantly increases positive nitrogen balance and caloric intake
without increasing the risk of metabolic acidosis, hyperuricemia or
hypertriglyceridemia.
▪ Standardized feeding regimens provide the single most important tool
to decrease variability in feeding practices. This can result in decreasing
the severity of extrauterine growth restriction, improve nutrient intake and
growth, minimize the duration of total parenteral nutrition and central line
placement, and decrease the incidence of NEC in preterm neonates.
▪ Delays in initiating enteral feedings beyond day two in growth-restricted
infants does not necessarily decrease the incidence of NEC and may lead
to increased risks of cholestatic jaundice.
▪ A multidisciplinary team (including a neonatal nutritionist and a lactation
consultant) and ongoing assessment of feeding progression are helpful
in optimizing the approach to enteral nutrition, particularly for infants
< 1500 grams birth weight.
▪ Fortified human milk or preterm formula is recommended for infants
≤ 34 weeks gestation. Liquid human milk fortifiers should be encouraged
to enhance protein content and minimize risk of bacterial infection,
particularly Enterobacter sakazakii. High protein preterm formula is
recommended for the preterm infant not receiving human milk. Some
current formulations of liquid human milk fortifier may contribute to
significant renal tubular acidosis and affect weight gain and bone
mineralization.
2
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Feeding Guideline
▪ Preterm babies, particularly those ≤ 1800 grams birth weight, have
increased needs for minerals and proteins for optimal growth and bone
mineralization. Therefore, nutrient- and mineral-enriched human milk or
formula is recommended post-discharge to maintain adequate growth
velocity and to prevent metabolic bone disease of prematurity.
▪ American Academy of Pediatrics (AAP) recommendations regarding bone
mineral status evaluation and calcium, phosphorous and vitamin D intake
in preterm infants should be followed.
▪ Iron fortification may reduce the need for blood transfusions and prevent
iron deficiency anemia in VLBW infants.
▪ Enteral feedings are sometimes held because of concern over the
presence of NEC. Isolated positive stool test for occult blood in babies
with indwelling nasogastric (NG) tubes is typically not a sign of NEC unless
accompanied with clinical signs of feeding intolerance and/or abdominal
distension and radiological signs of bowel pathology. In addition, gastric
residuals (green or otherwise) in asymptomatic infants are not necessarily
predictive of NEC.
▪ Caution should be taken regarding using liquid-thickening products
in preterm infants as they are associated with NEC.
▪ Weight should be measured daily unless medically contraindicated.
Head circumference and length should be measured weekly and all
measurements compared to growth curves through 52 weeks (e.g.
Fenton).
▪ Discharged infants, particularly those that are preterm, should have careful
follow-up of growth velocity and nutritional status in the outpatient setting.
▪ Breastfeeding mothers should receive continued support from health care
providers after discharge to help maximize breastfeeding goals.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
3
Feeding Guideline
Human Milk
▪ Human milk from the infant’s mother cannot be replicated by commercial
formula or donor human milk.
▪ Actions to increase breastfeeding rates can minimize preventable illnesses
and deaths
▪ Breastfeeding is associated with a decrease in sudden infant death
syndrome (SIDS).
▪ Breastfeeding may decrease the risk of obesity.
▪ Human milk feedings greatest benefits are linked to higher doses. There is
a positive dose-dependent response on neurocognitive and developmental
tests with a reduced risk of rehospitalization.
▪ Colostrum promotes intestinal growth with anti-inflammatory and antiinfective components. Replacing colostrum with artificial feedings as the
initial postnatal nutrition may have a detrimental effect on the physical and
biochemical integrity of the gastrointestinal tract.
▪ There is a dose-response relationship in the first month of life for reduction
of feeding intolerance, nosocomial infection, NEC, chronic lung disease
and retinopathy of prematurity. An exclusive human milk diet, including
human milk-based fortifier, can decrease the incidence of medical and
surgical NEC and its associated mortality. It is therefore advisable to
promote human milk.
▪D
espite potential for slower growth compared to formula, infants fed
higher doses of exclusive human milk allow discharge at lower weight/
post menstrual age (PMA) via attenuating the incidence and severity of
morbidities. In addition, infants fed human milk match their formula-fed
counterparts in overall growth later in infancy.
▪ Health care providers should fully inform families prenatally and postnatal
of the benefits of human milk. This should be discussed in a culturally
sensitive manner and may include handouts and other educational
resources. Healthy People 2020 objectives continue to strive for increased
breastfeeding rates. Population-wide promotion of exclusive breastfeeding
will be necessary to achieve these targets.
4
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Feeding Guideline
▪ Nursing education can support the mother with initiating and maintaining
successful breastfeeding in her preterm infant.
▪ Quality improvement initiatives can lead to improved rates of human
milk use.
▪ Women who don’t want to breastfeed may be willing to use a breast pump
to supply expressed human milk. Concerns that promotion of human milk
feeding may make women feel guilty or pressured into changing their
decision from using formula is not supported by literature.
▪ The addition of manual breast compression and hands-on pumping to
electric pumping improves human milk production and fat content.
▪ Formula supplementation following birth has the detrimental effect of
diminishing the number of mothers who ultimately exclusively breastfeed
their infant.
▪ Directly putting an infant to breast during the hospital stay is associated
with a greater percentage of human milk feedings at discharge.
▪ Stimulation with human milk odor enhances infant sucking and transition
to full oral feeding.
▪T
he most common reason for cessation of breastfeeding is maternal
perception of inadequate milk production. This may be prevented by
providing education and adequate resources. Lactation consultants may
be helpful in improving the success of long term breastfeeding.
▪ Maternal stress reduction and therapeutic interventions are options
to improve milk volume in pump-dependent women.
▪ Breastfeeding peer counselors (BPC) are new additions to NICUs and
can be incorporated into the lactation team. A BPC should be familiar
with the unique nutritional needs of premature infants and the cultural
and ethnic background of the family. In addition, participation in parent
groups in which peers are breastfeeding can have a positive impact on
the continuation of breastfeeding.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
5
Feeding Guideline
▪ For successful breastfeeding, mothers may need access to a hospitalgrade electric breast pump. Provisions should be made for maternal visits
to facilitate breastfeeding. Breast pumps should be supplied to the mother
as early as possible following delivery of the infant. Single family rooms
may also help promote breastfeeding.
▪ Emphasis should be placed on collecting milk in excess of current needs
to minimize risk of suboptimal production in later weeks. Maternal milk
volume records will facilitate this process.
▪ Creamatocrit measurement is a proven technique for approximating
human milk lipid and caloric content though, at times, may overestimate fat
content and therefore calories. Near-infrared spectrophotometry is a newer
technique to evaluate carbohydrate, fat and protein content in human milk
with subsequent tailored nutrient modifications but is currently considered
a research tool.
▪ Slow weight gain in the infant fed human milk can be attenuated by
separating pumped foremilk from hindmilk and preferentially feeding the
latter. In addition, large volumes of pumped milk obtained in the morning
following a pump-free night will typically have lower caloric content and
should be saved for future use.
▪ Pre- and post-feeding weighing may provide a reliable measurement of
milk intake (1 mL = 1 gram).
▪ Pasteurized donor human milk is a feeding alternative for infants
whose mothers are reluctant or unable to provide their own milk or as
a supplement for women whose pumping volumes are insufficient to
meet their infants’ feeding volume. The United States Food and Drug
Administration (FDA) recommends only using milk from a source that
has taken the appropriate precautions to ensure safety. Allocation
schema should be developed to ensure that this milk is used for the
most appropriate recipients, if the demand outweighs supply.
6
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Feeding Guideline
Non-Nutritive Suck (NNS)
(Applies to all birth weights and gestational ages)
▪ Non-nutritive sucking can be performed at either the breast or via a
pacifier. NNS during gavage feeding improves digestion of enteral
feedings. It facilitates the development of sucking behavior and hence
the transition from gavage to breast/bottle-feeding in preterm infants.
▪ NNS is encouraged in all newborns once an infant’s medical status is
stabilized. NNS may be used for infants during or after feeding by naso/
orogastric tube, before or after PO feeding or outside of feeding times.
▪ In clinically stable VLBW infants who have achieved full volume gavage
feeds, sensory-motor-oral stimulation, together with early NNS facilitate
earlier initiation of oral feedings. Oral feeding experience may result in
more rapid transition to full oral feedings regardless of severity of illness.
These practices are associated with a shorter length of stay.
▪ Use of pacifiers for NNS does not appear to interfere with successful
breastfeeding.
Initiating Enteral Feeding for Infants < 34 Weeks
Gestational Age
Initiate enteral feeding within 2 days of birth if no exclusion criteria are
present (see Relative Exclusion Criteria to Enteral Feeding on page 8),
or within 3 days after exclusion criteria have subsided (timing dependent
on severity of exclusion criteria).
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
7
Feeding Guideline
Minimal Enteral Nutrition
(Trophic Feeding)
Trophic feeding has significant benefits for the preterm infant. The immature
intestinal tract responds to the first enteral feed with rapid increases in gut
mass and surface area, blood flow, motility, digestive capacity and nutrient
absorption. Trophic feeding facilitates feeding tolerance, faster attainment
of full feedings and better growth. This should be considered for infants not
ready for advancing nutritional feeding, and not meeting exclusion criteria
(see Relative Exclusion Criteria to Enteral Feeding below), using the following
regimen.
▪ Start within hours to 3 days of birth.
▪ Human milk (preferably) or formula should be used.
▪ Administer 10-20 mL/kg/day.
Relative Exclusion Criteria to Enteral Feeding
▪ Signs of “gut” dysfunction/not tolerating feeding (i.e., distended or nonsoft abdomen, discolored abdomen, significant gastric drainage or bilious
aspirates, vomiting, absence of bowel sounds or GI bleeding).
▪ Recent events that may produce gut ischemia.
▪ Hemodynamic instability requiring vasopressors.
▪ Anomalies preventing enteral nutrition.
▪ Neither placement of an umbilical artery catheter nor intrauterine growth
restriction are contraindications to initiating or advancing feeds.
Advancing Enteral Feeding for Infants < 34 Weeks
Gestational Age
Rate of Advance (if no exclusion criteria are present)
8
▸
or infants < 1000 grams birth weight in the absence of exclusion factors,
F
feed with an average daily advance of up to 20 mL/kg/day.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Feeding Guideline
▸
or infants ≥ 1000 grams birth weight in the absence of exclusion factors,
F
feed with an average daily advance of up to 30 mL/kg/day.
▪ Standardizing enteral feeding advancement in VLBW infants has the
potential to achieve full volume quicker with accompanying lower rates
of parenteral nutrition use, infection and extrauterine growth restriction.
▪ To meet protein requirements, preterm infants < 34 weeks gestation
should have high protein formula or fortified human milk ideally providing
4 gm/kg/day of protein at 120 kcal/kg/day. This will typically result in
weight gain that approaches in utero accretion rates.
▪ If an infant is not gaining weight at an average of 15-20 gm/kg/day over
48-72 hours, evaluate human milk lipid/caloric content or formula caloric
makeup and consider increasing protein and caloric intake and/or
evaluating /treating possible underlying conditions.
▪ For gavage-fed infants, continuous and intermittent bolus feedings each
have unique advantages. Intermittent bolus feedings may be given by
gravity or, for infants not tolerating gravity feeding, by pump over a longer
period to improve intestinal tolerance. Feeding VLBW infants every
two hours as opposed to every three hours may result in less feeding
intolerance and shorter duration to achieve full volume. Continuous feeds
may be better tolerated in some infants, particularly those with poor
gut motility or malabsorption. Bolus feedings are associated with faster
transition to oral feeds.
▪ Continuous transpyloric feedings are not recommended for routine use
in preterm infants as they are associated with a greater incidence of
complications.
▪ A switch from continuous to bolus feeding should occur prior to
anticipated time of oral feeding so as not to delay oral feeding attempts.
▪ Transition from gavage feeding to breastfeeding may be facilitated
by kangaroo care, NNS and consistent staff support.
▪ The presence of any exclusion criteria may lead to holding of a feeding(s),
which should be reviewed prior to the next feeding(s).
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
9
Feeding Guideline
Starting PO Feeding for Infants < 34 Weeks Gestational Age
▪ Behavioral cues should be part of an ongoing assessment of the infant
by 32 weeks PMA. Oral stimulation procedures prior to beginning PO
feedings may facilitate better PO attempts. Employing this strategy,
studies have shown that preterm infants have the ability to PO feed prior
to 34 weeks PMA. A developmentally supportive cue-based approach
encouraging parental involvement will help guide transition from gavage
to oral feeding. Consequently, PO feeding attempts should be based on
physiology and feeding cues, not arbitrarily chosen based on PMA.
▪ The NNS score should be determined daily to identify readiness for
oral feeding as this system has been shown to reliably indicate feeding
readiness of preterm infants.
▪ With optimal support, VLBW infants have the capacity for early development of oral motor competence that is sufficient for establishment of full
breastfeeding as early as 32 weeks PMA.
Criteria for Starting PO Feeding
(Behavioral cues are paramount, not PMA)
▸
Infant shows hunger cues such as sucking on fingers/pacifier, hand
to mouth behavior, etc.
▸
Infant has periods of wakefulness, particularly before feeding times.
▸
ooting occurs (i.e., turning of the head/opening of the mouth in
R
response to touching of the cheek or the smell of milk).
Criteria for Withholding PO Feeding
10
▸
Respiratory or cardiopulmonary instability is present.
▸
Infant displays poor suck/swallow coordination.
▸
Infant does not display behavioral cues.
▸
An anomaly preventing oral intake is present.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Feeding Guideline
Advancing PO Feeding < 34 Weeks Gestational Age
Increase PO feeding commensurate with the infant’s behavioral cues.
PO feeding is a learned behavior in addition to a maturational process.
Criteria for Increasing PO Feeding
▸
“ Semi-demand” is the most physiologically sound method for advancing
PO feedings. Allow the infant to PO each feeding with gavage
supplement if necessary, with full gavage feeding given only if the infant
is not arousable at feeding times. This will facilitate more PO feeding
attempts, improve nipple feeding performance and hasten earlier
attainment of full PO feeding. Inability to complete an oral feeding
is not a contraindication to offering more frequent opportunities.
▸
If maternal availability is limited, bottle feeding or other oral intake
methods (cup feeding, etc.) should be substituted so that PO feeding
can be initiated/advanced.
▸
trial of ad-lib PO feedings may be reasonable in select infants who have
A
demonstrated the ability to orally complete the majority of their feedings.
Criteria for Not Increasing PO Feeding
▸
Infant does not wake for PO feedings.
▸
Infant has an adverse response to suck/swallow (demonstrates
significant cyanosis, bradycardia, oxygen desaturations, coughing/
choking with feedings, etc.) that is not corrected by a position change
or a brief interruption of feeding.
▸
Evidence of delayed gastric emptying.
▸
Infant shows fatigue or decreased tone during PO feeding attempts.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
11
Feeding Guideline
Feeding for Infants ≥ 34 Weeks Gestational Age
▪ If no exclusion criteria exist (see Relative Exclusion Criteria to Enteral
Feeding on page 8), PO feeding ad-lib should be initiated. If exclusion
criteria exist, initiate enteral feeding within 3 days after exclusion criteria
have subsided (timing dependent on severity of exclusion criteria).
▪ Infants are considered at “full” PO feeding when they are nippling all
feedings in a progressive fashion with volumes appropriate for their age.
Special Clinical Situations
Hypoglycemia
The American Academy of Pediatrics Committee on Fetus and Newborn
provides recommendations for the screening and management of
postnatal hypoglycemia in infants born at 34 weeks gestation and
above. This includes early feedings and glucose screening.
Use of Prokinetic Agents/H2 Blockers
There is insufficient evidence to recommend the use of prokinetic agents,
such as erythromycin or metoclopramide, for infants with or at risk for
feeding intolerance. H2 blocker therapy should be used with caution.
It has the potential to alter gut pH with subsequent changes in colonization
and increased risks of infection and NEC.
Surgical Patient
Infants who undergo surgery are at particular risk of delayed initiation
and advancement of enteral nutrition and suboptimal growth. Infants who
undergo bowel resection are at risk of short gut syndrome and secondary
growth failure. These patients necessitate careful monitoring of their caloric
intake and growth. Nipple feeding difficulties are common in surgical
patients and contribute to prolonged hospitalization.
12
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Feeding Guideline
These babies may benefit from a multi-disciplinary team approach
including gastroenterology/pediatric surgery, nutrition and speech/
occupational therapy involvement to optimize transition from parenteral to
enteral nutrition and decrease the length of postoperative hospitalization.
G-Tube/PEG Timing
There are no definitive standards regarding surgical intervention for
infants not showing reasonable oral feeding progress as PMA advances.
Infants deserve a formal and extensive evaluation to assess oromotor
feeding skills with transfer to another facility if the current resources
are inadequate. If home gavage feedings are not an option, early family
discussions regarding potential need for surgical intervention should
ensue. For long-term oral feeding success, surgical intervention allowing
removal of an indwelling gavage tube may help mitigate oral aversion.
Late Preterm Infant
The late preterm infant born between 34 and 36 6/7 weeks gestation
deserves special consideration in light of reports documenting a
potential for increased morbidity. This group of infants is at increased
risk of poor feeding with secondary poor weight gain and subsequent
hyperbilirubinemia that might require treatment. This particularly
applies to the exclusively breast-fed late preterm infant. As such, late
preterm infants should have appropriate follow-up for feeding problems,
hyperbilirubinemia, significant weight loss and dehydration.
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Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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Feeding Guideline
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14
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Feeding Guideline
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Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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15
Feeding Guideline
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16
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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Feeding Guideline
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patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Feeding Guideline
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18
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Feeding Guideline
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Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Feeding Guideline
Woods CW, Oliver T, Lewis K, Yang Q. Development of necrotizing enterocolitis in premature infants
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Notes
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Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Apnea, Bradycardia and
Desaturation Guideline
Applies to all infants in the Neonatal Intensive Care Unit (NICU)
or Special Care Nursery
Key Points
▪ Due to a paucity of available evidence, there is a variable approach to
the management of infants with suspected apnea, bradycardia and
desaturation events.
▪ Apnea, bradycardia and desaturation may persist following hospital
discharge in clinically asymptomatic, maturing preterm infants.
▪ American Academy of Pediatrics (AAP) supports home monitoring for
early detection of events.
General Considerations
Healthcare providers have a heterogeneous approach to apnea, bradycardia
and oxygen desaturation events. This may be due to site differences in
monitoring, recording and definition of events. Apnea can occur in both
term and preterm infants. Most premature infants have occasional apnea
of prematurity (AOP) as defined by pauses in breathing with or without
cardiovascular changes. AOP is a diagnosis of exclusion. Other etiologies
should be considered prior to making a diagnosis, including infection
(with evaluation for respiratory syncytial virus during the prevalent season),
congenital heart disease, central nervous system disorders, metabolic/
inherited genetic disorders and medication/iatrogenic processes. Apnea
of infancy, which occurs less frequently, refers to infants with a gestational
age of 37 weeks or more at the onset of apnea and is more likely to be
associated with an underlying etiology.
The precise point at which apnea becomes pathologic remains unclear
as healthy preterm and term infants can have normal periods of short
respiratory pauses, heart rate decelerations and oxygen desaturations.
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Apnea, Bradycardia and Desaturation Guideline
Pathologic apnea is commonly defined as occurring when breathing is
interrupted for 20 seconds duration or longer or for less than 20 seconds
when accompanied by a significant decrease in heart rate or oxygen
saturation. Apnea, bradycardia and oxygen desaturation may persist
following hospital discharge in clinically asymptomatic, maturing preterm
infants.
Accurate characterization of AOP is essential, but difficult. In many cases,
nursing observations correlate poorly with data from cardiorespiratory and
oxygen saturation monitors. Review of heart rate, respiratory rate and oxygen
saturation data from bedside monitors may be more reliable in documenting
apnea. Both the complications and possible adverse effects of nonpharmacologic and pharmacologic treatments must be considered when
deciding on an AOP clinical management strategy.
Definition of a Clinically Significant Cardiopulmonary Event
(CSCPE)
Any one of the following is considered a CSCPE:
▪ Apnea ≥ 20 seconds.
▪ Apnea < 20 seconds with heart rate fall to < 80 bpm (more mature infants
or those with a lower resting heart rates may consider using a heart rate
fall > 33.3% below baseline in definition).
▪ Apnea < 20 seconds with oxygen saturation < 85% (excludes transient
oxygen desaturation < 85% unless requiring supplemental oxygen to
resolve).
Isolated bradycardia or oxygen desaturation without associated apnea is not
related to AOP and may be related to obstructive apnea, vagal phenomenon
or other underlying processes.
Transient self-limited events may be benign and physiologic in nature not
indicating pathology. Since criteria for stimulation varies by institution and
from nurse to nurse, characterizing an event as self-limiting does not in itself
suggest the event is not significant. The above definition of CSCPE should
be used when charting and making clinical decisions.
22
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Apnea, Bradycardia and Desaturation Guideline
Criteria for care interventions should be based on the clinical appearance of
the infant within context of accurate interpretation of the bedside monitor.
Monitor tracings may be helpful in accurately assessing CSCPEs. Ensuring
appropriate monitor alarm settings as well as eliminating the need for
continued pulse oximetry in convalescing infants no longer requiring oxygen
will help differentiate pathologic from physiologic events.
Apnea/Bradycardia/Oxygen Desaturation
Induced by Care Interventions
Events that are preceded by a medical or nursing intervention known to
induce events (i.e. placement of gavage tube, nipple feeding, suctioning, eye
exam) are not counted as CSCPEs, as they are triggered by care provider
interventions. However, the severity of these events should be evaluated
when making a decision to send an infant home or to use a home apnea
monitor, as parents may trigger events at home similar to those precipitated
by nurses at the bedside.
Methylxanthine Therapy
The use of methylxanthines in the United States varies across geographic
regions. Short-term side effects including a decrease in lower esophageal
sphincter tone and lower weight gain may be offset by decreasing the risk
of developing chronic lung disease. Short-term improvement in survival and
neurodevelopmental disability are attenuated at five year follow up without
an increase in adverse events. It remains prudent to use methylxanthines
judiciously and discontinue their use when no longer clinically indicated.
Clinical studies have confirmed the advantages of caffeine citrate over
aminophylline/theophylline in the treatment of AOP. Compared to
theophylline, caffeine has a longer half-life, has a wider therapeutic index
(5-25 mcg/mL), fewer GI side effects and can be given in a once-daily
regimen. The development of a commercially available intravenous
preparation has made it readily available and easy to administer. Routine
monitoring of caffeine drug levels is not indicated. If treatment with
methylxanthines is being considered, caffeine is the drug of choice.
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Apnea, Bradycardia and Desaturation Guideline
Discontinuation of Methylxanthines
To minimize potential complications and avoid unnecessary delays
in discharge, a trial off of methylxanthines should be initiated at the
following times:
▪ As soon as feasible when (1) CSCPEs are no longer of concern (generally
3-7 days after the most recent event) and (2) when the infant reaches a post
menstrual age (PMA) of ≥ 32 weeks.
▪ In infants who remain methylxanthine dependent to prevent CSCPEs, an
alternative practice is to continue treatment on an outpatient basis until
43 weeks PMA in conjunction with a home monitor. By this time, AOP
is resolved in the majority of infants and methylxanthines can be safely
discontinued while on documented monitoring.
Feeding Related Events
Events that occur during feeding are generally not reflective of an underlying
airway or breathing abnormality. These events most commonly reflect
immature suck/swallow coordination and are not pathophysiologically related
to AOP. The significance of more severe feeding related events should be
assessed by the degree of apnea and bradycardia, associated color change
and the extent of intervention needed. As such, these aforementioned events
typically do not justify a traditional apnea countdown, but may warrant actions
such as pacing and adjusting nipple flow for bottle fed infants. Thickened
feedings for preterm infants should be instituted with caution and with a nonxanthum gum-based product. Parental/caregiver involvement for teaching at
this stage is imperative.
Gastroesophageal Reflux (GER)
GER is a physiologic process typically associated with minimal clinical
consequences and should be distinguished from pathologic gastroesophageal
reflux disease (GERD). Numerous studies have demonstrated an absence
of a causal relationship between gastroesophageal reflux and AOP and
bradycardia.
24
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Apnea, Bradycardia and Desaturation Guideline
This is reinforced by data utilizing both multiple intraluminal impedance and
pH studies. The incidence of CSCPEs is unchanged pre- and post-feeding.
Furthermore, there is a lack of documented efficacy and potential treatment
complications inherent in the use of GERD medications. Thus, the use
of anti-reflux medications (e.g. antacids, prokinetic agents, proton-pump
inhibitors) to treat AOP and bradycardia cannot be recommended. Any
medication use should take into account risks and benefits with cessation
of therapy if clinical outcomes are not achieved. If continued, a trial off
medication following a set period should be planned given the naturally
expected improvement over time. This includes caffeine used to treat AOP
due to its effect of decreasing lower esophageal sphincter pressure.
Continuous-type feedings may alleviate reflux symptoms, but the benefits
need to be balanced against the risk that a nasogastric catheter located in
the lower esophageal sphincter potentially precipitating GER. Advancing oral
feeds in a timely manner may attenuate these issues.
Infant Positioning
Infants positioned prone sleep longer, have more central apnea and
experience fewer arousals than infants positioned in the supine position.
Arousal from sleep is an important survival response to an acute life
threatening event (ALTE) and any impairment may contribute to sudden
infant death syndrome (SIDS).
Recent data from the Collaborative Home Infant Monitoring Evaluation
(CHIME) demonstrates that preterm infants are no more likely to experience
an extreme cardiorespiratory event when placed in the prone or the side
position when compared to infants placed in the supine position. NICU
nurses often identify prone position as advantageous for patients requiring
intensive care during the initial stages of their illness. Yet infant supine
positioning has clearly been shown to decrease the incidence of SIDS, which
peaks at an age when most NICU graduates are already discharged home.
Specific hospital policies should be developed regarding transitioning to a
supine position taking into consideration the parents’ modeling of nursing
care, which may have greater impact than written or spoken instructions.
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Apnea, Bradycardia and Desaturation Guideline
The transition to supine positioning should take place in a time frame that
allows adequate hospital observation prior to discharge. It is reasonable
to establish a policy that, unless contraindicated, all infants managed in a
crib be supine. Parents should be informed of the potential risks of prone
sleeping prior to discharge consistent with the “Back to Sleep” campaign. In
addition, close observation during the initial period of mother-infant bonding
may help attenuate ALTEs.
Temperature
An increase in environmental temperature can attenuate the maturational
gain in respiratory responses to hypoxia as evidenced by clusters of apnea
observed following a rapid rise in incubator air temperature. Infants should
not be overwrapped to avoid overheating which may precipitate apnea.
Parents should be informed about the association between overheating and
SIDS prior to discharge consistent with the “Back to Sleep” campaign.
Term Infants
Diagnostic evaluation is warranted for any term infant with apnea. By
definition, these patients do not have apnea of prematurity. Apnea of Infancy
is a diagnosis of exclusion that should only be made after a thorough
investigation of all other causes of apnea. Appropriate hospital stay should
be based on the underlying diagnosis and associated co-morbidities with
an appropriate time frame for resolution or monitoring following therapeutic
interventions.
Pneumocardiogram (PCG)
PCG should not be used as a screening tool in asymptomatic infants.
PCGs have a high false positive rate, cannot predict with accuracy the
occurrence of severe apnea or death and are not beneficial in identifying
which patients should be discharged with a home monitor. Thus PCGs
are not recommended in the management of AOP.
26
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▪ Given the lack of validity of PCGs, hospital discharge criteria should be
based on a reasonable time period after discontinuing caffeine or the last
CSCPE, and not timing of PCG. (Refer to Discharge of a Premature Infant
with a History of CSCPEs on page 28.)
▪ The practice of performing repeat PCGs following care interventions is
not indicated given lack of value of the study itself.
▪ Prolonged hospitalization following an abnormal PCG is not indicated
given lack of efficacy of the study itself. Length of stay should be
predicated on the infant’s clinical status.
▪ Periodic breathing is typically a normal physiologic event (can represent
2-6% of breathing time in full term and 19-25% in preterm infants) and
should not be considered pathologic in interpretation of PCG unless
associated with hypoxemia, bradycardia or apnea.
Home Monitoring
The use of home monitors varies by physician practice and regional
preferences. In the high-risk population, cardiorespiratory events are
common but are not likely to be immediate precursors specifically related
to SIDS. These events can be present up to 43 weeks PMA. The use of
home apnea monitors is still a common practice for infants discharged
from a NICU with a recent history of apnea although there is no evidence
that the use of home monitors prevents the occurrence of SIDS. Home
monitoring may be appropriate for infants who have occasional apnea and
are otherwise ready for discharge. Documented monitoring shortens the
duration of home monitoring and is recommended when a home monitor
is prescribed.
According to AAP policy, home monitoring may be considered for the
following patients:
▪ Infants who continue to have documented apnea, bradycardia, and
cyanosis when all other criteria for discharge have been met. Home cardiorespiratory monitoring may be justified to recognize such events. Home
monitoring in this population should be limited to approximately 43 weeks
PMA or after the cessation of episodes, whichever comes later.
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Apnea, Bradycardia and Desaturation Guideline
▪ Infants who have unstable airways, rare medical conditions affecting
regulation of breathing, symptomatic chronic lung disease or are
technology dependent (tracheostomy, continuous positive airway
pressure).
Discharge of a Premature Infant with a History of CSCPEs
(Applies to preterm infants with a history of CSCPEs at or near discharge)
▪ Educate parents on the safe sleeping environment, including proper
bedding and sleep position, avoidance of soft crib toys and a smoke-free
environment.
▪ A five-to-seven day “CSCPE-free” period is typical for preterm infants
discharged home without a monitor, with up to an eight-day “CSCPEfree” period for those preterm infants born at < 32 weeks gestation. This
“countdown” period should begin following the event and not the ensuing
calendar day. Hospital stay should not be extended for non-medical
indications in units that choose shorter observation periods.
▪ It is important to discontinue methylxanthines when the infant is
≥ 32 weeks PMA and 3-7 days after the last CSCPE in order to avoid
confounding the analysis of an apnea-free period prior to discharge.
If caffeine levels are not readily available, the clinician must consider
the half-life of caffeine when determining an appropriate apnea free
period. A 3-7 day observation period is typical. If serum caffeine levels
are available, regularly scheduled drug testing with rapid laboratory
analysis to document sub-therapeutic level (caffeine level < 5 mcg/mL)
may be obtained. A home apnea monitor should be considered
if additional observation is desired in lieu of a sub-therapeutic caffeine
level or a delay in discontinuing caffeine.
▪ If an infant is still receiving methylxanthines (or has recently had
methylxanthines discontinued) consider discharge on a home monitor.
28
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▪ For infants being discharged home on a monitor (with or without
methylxanthines), a 72 hour CSCPE-free period is a reasonable observation
time frame in the hospital prior to discharge. Apnea, bradycardia and
oxygen desaturation events can persist past discharge in preterm infants.
AAP policy statement supports using home cardiorespiratory monitoring
to recognize such events. ALTEs defined as apnea, cyanosis, and marked
hypotonia requiring significant intervention may justify a longer in-hospital
observation period followed by discharge home on a monitor.
▪ For infants having breakthrough CSCPEs during an apnea “countdown,”
consideration should be given to discharging the infant home on a
monitor. While AOP has no association with SIDS and monitoring has no
impact on SIDS incidence, a home monitor may help reassure both the
family and medical team via early detection of potential life-threatening
events. Given the lack of association between AOP and SIDS plus the
known persistence of apnea, bradycardia and oxygen desaturation in
maturing preterm infants following hospital discharge, the practice of
“repeat countdowns” in general should be reserved for infants with events
requiring significant intervention (e.g. vigorous stimulation, supplemental
oxygen, positive pressure ventilation).
▪ Documented monitoring (event recording) is the preferred method for
home monitoring.
▪ When a decision to send an infant home on a monitor is made, family
members should be instructed about home monitor use as soon as
possible. Parents should be specifically instructed that home monitors are
not known to prevent the occurrence of SIDS. An appropriately trained
individual should provide infant CPR education to the caregivers of an
infant prior to discharge on a home monitor.
▪ Consideration whether to discharge home on a monitor must also be given
to families with limited care support or resources at home, such as lack of
home care availability and/or limited access for home monitor follow up.
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Apnea, Bradycardia and Desaturation Guideline
▪ Outpatient follow-up for an infant discharged on a home monitor should be
arranged with an apnea program or with a physician capable of caring for
such a patient. The parents, durable medical equipment (DME) provider and
primary care physician should be given the name and telephone number
prior to discharge of the apnea program responsible for management of
the apnea monitor.
▪ Continued CSCPEs which are not resolving may require further evaluation
and/or treatment. This, at minimum, should include review of event(s)
recording(s) and clinical correlation.
Discharge of a Term Infant with a History of CSCPEs
(Applies to term infants with a history of CSCPEs at or near discharge)
▪ Discharge should be based on the underlying diagnosis and subsequent
care interventions. Two to three days following cessation of events is an
appropriate observation period. Parental teaching including decision to
utilize a home monitor should be completed during this observation period.
▪ Continuous hospital cardiorespiratory monitoring cannot identify infants
who are at risk of SIDS.
Discharge of an Infant with a History of non-CSCPEs
(Applies to all infants with a history of non-CSCPEs at or near discharge)
By definition, these events are not classified as CSCPEs or ALTEs, but
remain difficult to differentiate as physiologic vs. pathologic. Evaluation,
as indicated, should be performed to determine any underlying etiology.
▪ Self-limited events are typically benign and do not warrant additional
evaluation or observation.
▪ Observation for feeding-related events should be based on the severity
of the event and response to interventions. An observation period of
two to three days is appropriate for infants who require more than just
pacing. Observation of feeding related events should include documented
observation of the parents/caregivers ability to feed their baby successfully
prior to discharge home.
30
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▪ Isolated non-CSCPE events which are not self-limited, feeding related or
care-induced merit an observation period of two to three days. Discharge
with a home monitor may be beneficial for early recognition of event
recurrence or if there are concerns of event repetition and family ability
to respond timely.
References: Apnea, Bradycardia and Desaturation
American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk
neonate. Pediatrics. 2008; 122(5):1119-1126.
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleeprelated infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics.
2011; 128(5):1030-1039.
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleeprelated infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics.
2011; 128(5): e1341-e1367.
Aris C, Stevens T, Lemura C. NICU nurses’ knowledge and discharge teaching related to infant sleep
position and risk of SIDS. Advances in Neonatal Care. 2006; 6(5):281-294.
Barrington K, Finer N, Dejuan L. Predischarge respiratory recording in very low birth weight infants.
Journal of Pediatrics. 1996; 129(5):934–940.
Barrington K, Tan K, Rich W. Apnea at discharge and gastro-esophageal reflux in the preterm infant.
Journal of Perinatology. 2002; 22(1):8-11.
Bhat R, Hannam S, Pressler R, et al. Effect of prone and supine position on sleep, apneas, and arousal in
preterm infants. Pediatrics. 2006; 118(1):101-107.
Brandon GD, Adeniyi-Jones S, Kirkby S, et al. Are outcomes and care processes for preterm neonates
influenced by health insurance status? Pediatrics. 2009; 124(1):122-127.
Carbone T, Ostfeld B, Gutter D, et al. Parental compliance with home cardiorespiratory monitoring.
Archives of Disease in Childhood Fetal and Neonatal Edition. 2001; 84(3):270-272.
Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden infant death
syndrome, and home monitoring. Pediatrics. 2003; 111(4 Pt 1):914-917.
Côté A, Hum C, Brouillette RT, et al. Frequency and timing of recurrent events in infants using home
cardiorespiratory monitors. Journal of Pediatrics. 1998; 132(5):783-789.
Darnall R, Ariagno R, Kinney H. The late preterm infant and the control of breathing, sleep, and brainstem
development: A review. Clinics in Perinatology. 2006; 33(4):883-914.
Darnall R, Kattwinkel J, Nattie C, et al. Margin of safety for discharge after apnea in preterm infants.
Pediatrics. 1997; 100(5):795-801.
Di Fiore J. Neonatal cardiorespiratory monitoring techniques. Seminars in Neonatology. 2004; 9(3):195-203.
Di Fiore J, Arko M, Herynk B, et al. Characterization of cardiorespiratory events following
gastroesophageal reflux in preterm infants. Journal of Perinatology. 2010; 30(10):683-687.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Apnea, Bradycardia and Desaturation Guideline
Di Fiore J, Arko M, Miller M, et al. Cardiorespiratory events in preterm infants referred for apnea
monitoring studies. Pediatrics. 2001; 108(6):1304-1308.
Di Fiore J, Arko M, Whitehouse M, et al. Apnea is not prolonged by acid gastroesophageal reflux in
preterm infants. Pediatrics. 2005; 116(5):1059-1063.
Di Fiore T. Use of sleep studies in the neonatal intensive care unit. Neonatal Network. 2005; 24(1):23-30.
Eichenwald EC, Blackwell M, Lloyd JS, et al. Inter-Neonatal Intensive Care Unit variation in discharge
timing: influence of apnea and feeding management. Pediatrics. 2001; 108(4):928-933.
Eichenwald EC, Zupancic JA, Mao WY, et al. Variation in diagnosis of apnea in moderately preterm
infants predicts length of stay. Pediatrics. 2011; 127(1):e53-e58.
Finer N, Higgins R, Kattwinkel J, Martin R. Summary proceedings from the apnea-of-prematurity group.
Pediatrics. 2006; 117(3):47-51.
Finer N, Leone T. Oxygen saturation monitoring for the preterm infant: the evidence basis for current
practice. Pediatric Research. 2009; 65(4):375-380.
Goldsmith JP, Karotkin EH, eds. Assisted Ventilation of the Neonate. 5th edition. Elsevier Saunders; 2011.
Henderson-Smart DJ, De Paoli AG. Methylxanthine treatment for apnoea in preterm infants. Cochrane
Database of Systematic Reviews. 2010, Issue 12. Art. No.: CD000140. DOI: 10.1002/14651858.
CD000140.pub2.
Henderson-Smart DJ, Steer PA. Caffeine versus theophylline for apnea in preterm infants. Cochrane
Database of Systematic Reviews. 2010, Issue 1. Art. No.: CD000273. DOI: 10.1002/14651858.
CD000273.pub2.
Hibbs A, Lorch S. Metoclopramide for the treatment of gastroesophageal reflux disease in infants: a
systematic review. Pediatrics. 2006; 118(2):746-752.
Lister G, Rybin DV, Colton T, Heeren TC, et al. Collaborative Home Infant Monitoring Evaluation Study
Group. Relationship between sleep position and risk of extreme cardiorespiratory events. The Journal of
Pediatrics. 2012; 161(1):22-25.
Martin R, Abu-Shaweesh J, Baird T. Apnoea of prematurity. Paediatric Respiratory Review. 2004;
5(Supplement A):S377-S382.
Millar D, Schmidt B. Controversies surrounding xanthine therapy. Seminars in Neonatology. 2004;
9(3):239-244.
Miller M, Kiatchoosakun P. Relationship between respiratory control and feeding in the developing infant.
Seminars in Neonatology. 2004; 9(3):221-227.
Natarajan G, Lulic-Botica M, Aranda JV. Clinical pharmacology of caffeine in the newborn. NeoReviews.
2007; 8(5):e214-e220.
Natarajan G, Botica ML, Thomas R, Aranda JV. Therapeutic drug monitoring for caffeine in preterm
neonates: an unnecessary exercise? Pediatrics. 2007; 119(5):936-940.
National Institutes of Health Consensus Development Conference on Infantile Apnea and Home
Monitoring, Sept 29 to Oct 1, 1986. Pediatrics. 1987; 79(2):292-299.
Poets C. Gastroesophageal reflux: a critical review of its role in preterm infants. Pediatrics. 2004;
113(2):e128-e132.
Poets A, Steinfeldt R, Poets CF. Sudden deaths and severe apparent life-threatening events in term infants
within 24 hours of birth. Pediatrics. 2011; 127(4):e869-873.
32
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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Apnea, Bradycardia and Desaturation Guideline
Ramanathan R, Corwin MJ, Hunt CE, et al. Cardiorespiratory events recorded on home monitors:
comparison of healthy infants with those at increased risk for SIDS. Journal of American Medical
Association. 2001; 285(17):2199-2207.
Schmidt B, Anderson PJ, Doyle LW, et al. Caffeine for Apnea of Prematurity (CAP) Trial Investigators.
Survival without disability to age 5 years after neonatal caffeine therapy for apnea of prematurity. The
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Schmidt B, Roberts R, Davis P, et al. Caffeine therapy for apnea of prematurity. New England Journal of
Medicine. 2006; 354(20):2112-2121.
Silvestri J. Indications for home apnea monitoring (or not). Clinics in Perinatology. 2009; 36(1):87-99.
Silvestri J, Lister G, Corwin M, et al. Collaborative home infant monitoring evaluation study group.
Factors that influence use of a home cardiorespiratory monitor for infants: the collaborative home infant
monitoring evaluation. Archives of Pediatric and Adolescent Medicine. 2005; 159(1):18-24.
Slocum C, Arko M, Di Fiore J, et al. Apnea, bradycardia and desaturation in preterm infants before and
after feeding. Journal of Perinatology. 2009; 29(3):209-212.
Tipnis NA, Tipnis SM. Controversies in the treatment of gastroesophageal reflux disease in preterm
infants. Clinics in Perinatology. 2009; 36(1):153-164.
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Wheatley E, Kennedy KA. Cross-over trial of treatment for bradycardia attributed to gastroesophageal
reflux in preterm infants. Journal of Pediatrics. 2009; 155(4):516-21.
Woods CW, Oliver T, Lewis K, Yang Q. Development of necrotizing enterocolitis in premature infants
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Zupancic J, Richardson D, O’Brien B, et al. Cost-effectiveness analysis of predischarge monitoring for
apnea of prematurity. Pediatrics. 2003; 111(1):146-152.
Notes
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patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Thermoregulation
Guideline
Applies to infants requiring an incubator for thermal stability
Key Points
▪ Physiologic status, as opposed to arbitrary weight or post menstrual age,
should be used to determine crib readiness.
▪ Incubator weaning to an open crib can proceed safely without adverse
effects on oral feeding or weight gain.
General Considerations
Preterm infants receive care in a neutral thermal environment to prevent cold
stress and thus minimize oxygen requirements and energy consumption.
Before discharge they must be weaned to an open crib and demonstrate the
ability to maintain their temperature. Normal axillary temperature in an open
crib with appropriate clothing is defined as 36.5-37.4°C (97.7-99.3°F).
Arbitrary criteria such as weight, post menstrual age or feeding status are
too often used as a threshold for weaning from incubator to an open crib
based on the belief that these criteria will allow for more rapid weight gain.
This belief and practice pattern is not supported by prospective trials utilizing
current neonatal care techniques. These trials demonstrate that infants have
the ability to begin successful incubator weaning as early as 1500 grams,
when they are clinically stable, without sacrificing weight gain.
More recent data continues to support successful placement of moderately
preterm infants in open cribs at weights as low as 1600 grams without
adverse outcomes. Delays in weaning from incubator to an open crib may
have the detrimental effect of delaying the attainment of full oral feedings,
decreasing growth velocity and prolonging length of stay. Furthermore,
excessive incubator temperature can precipitate iatrogenic apnea.
34
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Thermoregulation Guideline
There is a growing body of evidence to suggest that increased maternal
infant interactions result in better neurodevelopmental outcomes. Maternal
perception may be more positive when the infant is cared for in an open crib
and contribute to increased breastfeeding rates. Nurses caring for infants
in an open crib may also perceive that progressive care is possible due to
improved access. Delaying incubator weaning in preterm infants can have
the undesirable effect of decreasing parental interaction, bonding and delay
discharge planning.
Weaning based on this guideline will allow the premature infant to make a
timely transition to an open crib without experiencing thermal stress and its
attendant problems. These steps will also assist the infant in achieving a safe
and timely discharge.
Criteria for Beginning to Wean Infant from Incubator
▪ Infant is ≥ 32 weeks post menstrual age or weighs approximately 1500
grams. Growth restricted infants of advanced gestational age and similar
weight may be more likely to successfully wean than appropriate for
gestation age (AGA) infants at the same weight. Sufficient chronological
age is an additional factor to indicate ability to begin weaning.
▪ Infant is medically stable and in a condition that permits swaddling.
▪ Infant is gaining weight adequately, at least 10-15 gm/kg/day on average,
if this is expected based on infant’s chronological age and gestation.
▪ Infant is tolerating feeding but does not need to achieve full PO feeds
before incubator weaning is accomplished since progress to these goals
can proceed in parallel.
▪ For air mode weaning, ambient temp is ≤ 32°C (89.6°F) for 24 hours, and
the infant maintains normal temperature with a t-shirt/blanket/hat during
this time.
▪ Environmental temperature should be 22-26°C (72-78°F) to facilitate
weaning.
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Thermoregulation Guideline
Process for Air Mode Manual Weaning
▪ Swaddle the infant in one or two blankets and cover the head prior to
decreasing incubator temperature.
▪ Decrease ambient temperature of incubator by 0.5-1°C every 4-8 hours to
maintain axillary temperature in the normal range. Larger or more mature
(post menstrual age) infants are expected to wean faster.
▪ If the axillary temperature is above normal at any time, wean ambient
temperature by an additional 0.5°C. Measure axillary temperature every
3 -4 hours until the infant is euthermic or in a crib.
▪ The infant should be moved to an open crib when the ambient incubator
temperature of 28°C (82.4°F) has been maintained and tolerated for 8-24
hours.
▪ If the infant’s temperature falls below normal while in the crib (axillary
temperature < 36.5°C [97.7°F]), add extra blankets as needed to assist
the infant in maintaining his/her temperature.
▪ Stop weaning or place infant back in incubator if infant’s temperature
falls below normal in spite of hat/t-shirt/extra blanket or if infant displays
signs of cold stress including mottling, irritability, lethargy, poor feeding
or tachycardia.
Process for Servo Control Weaning
(Servo controlled “self-weaning”)
The servo control system adjusts the environmental temperature to keep
the skin temperature constant. Changes in incubator temperature must be
observed since the infant’s skin temperature will not change. Manufacturer’s
instructions should be followed.
▪ The infant should be undressed or clothed in a t-shirt only. Set the
temperature control to maintain the infant’s temperature within the normal
range. Usually a set point of 36.5°C (97.7°F) skin temperature will maintain
a normal temperature.
36
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▪ Care should be taken to prevent the probe from coming off the skin. If this
should occur, the unit will sense a lower temperature and increase the
environmental temperature, possibly overheating the infant.
▪ Both the ambient temperature and the infant’s axillary temperature should
be recorded every 3-4 hours and compared to avoid masking the infant’s
true condition.
▪ The infant should be moved to an open crib when an ambient temperature
of 28°C (82.4°F) has been maintained and tolerated for 8-24 hours. Dress
and swaddle the infant in one or two blankets and cover the head prior to
removing from the incubator.
▪ If the infant’s temperature falls below normal while in the crib (axillary
temperature < 36.5°C [97.7°F]), add extra blankets as needed to assist
the infant in maintaining his/her normal temperature.
▪ Place infant back in incubator if infant’s temperature falls below normal
in spite of hat/t-shirt/extra blanket or if infant displays signs of cold stress
including mottling, irritability, lethargy, poor feeding or tachycardia.
Incubator Weaning Failure
Crib failure for hypothermia should be based on axillary temperature
measurements less than 36.5°C (97.7°F) in an open crib with appropriate
clothing and bundling. Isolated weight loss is not an indication to place an
infant back in an incubator.
If an infant is placed back into the incubator, a repeat trial of weaning to an
open crib should be considered within 24-48 hours if criteria for weaning
continue to be met. An evaluation of the Neonatal Intensive Care Unit or
Specialty Care Nursery environment (temperature, location near window
or vent, etc.) and/or other medical reasons why the infant may have failed
to wean properly should be considered.
References: Thermoregulation
American Academy of Pediatrics. Committee on Fetus and Newborn. Hospital discharge of the high-risk
neonate. Pediatrics. 2008; 122(5):1119-1126.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Thermoregulation Guideline
Forcada-Guex M, Pierrehumbert B, Borghini A, et al. Early dyadic patterns of mother–infant interactions
and outcomes of prematurity at 18 months. Pediatrics. 2006; 118(1):e107-e114.
Gelhar D, Miserendino C, O’Sullivan P. Research from the research utilization project: environmental
temperatures. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 1994; 23(4):341-344.
Glass L, Silverman WA, Sinclair JC. Effect of the thermal environment on cold resistance and growth of
small infants after the first week of life. Pediatrics. 1968; 41(6):1033-1046.
Medoff-Cooper B. Transition of the preterm infant to an open crib. Journal of Obstetric, Gynecologic, and
Neonatal Nursing. 1994; 23(4):329-335.
Meier PP. Transition of the preterm infant to an open crib: process of the project group. Journal of
Obstetric, Gynecologic, and Neonatal Nursing. 1994; 23(4), 321-326.
Meyer EC, Garcia Coll CT, Lester BM, et al. Family-based intervention improves maternal psychological
well-being and feeding interaction of preterm infants. Pediatrics. 1994; 93(2):241-246.
New K, Flenady V, Davies MW. Transfer of preterm infants from incubator to open cot at lower versus
higher body weight. Cochrane Database of Systematic Reviews. 2011, Issue 9. Art. No.: CD004214. DOI:
10.1002/14651858.CD004214.pub4.
Polin RA, Fox WW, Abman SH, eds. Fetal and Neonatal Physiology. 4th edition. Elsevier Saunders; 2011.
Riley LE, Stark AR, eds. Guidelines for Perinatal Care. 7th Edition. American Academy of Pediatrics and
The American College of Obstetricians and Gynecologists; 2012.
Schneiderman R, Kirkby S, Turenne W, Greenspan J. Incubator weaning in preterm infants and
associated practice variation. Journal of Perinatology. 2009; 29(8):570-574.
West CR, Williams M, Weston PJ. Feasibility and safety of early transfer of premature infants from
incubators to cots: a pilot study. Journal of Paediatrics and Child Health. 2005; 41(12):659-662.
Zecca E, Corsello M, Priolo F, et al. Early weaning from incubator and early discharge of preterm infants:
randomized clinical trial. Pediatrics. 2010; 126(3):e651-e656.
Notes
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38
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Sepsis
Guideline
Applies to infants ≥ 35 weeks gestation being treated for possible
sepsis/pneumonia
Key Points
▪ Guideline includes updated recommendations from the American
Academy of Pediatrics (AAP) and Centers for Disease Control and
Prevention (CDC).
▪ Clinical indicators are most helpful in determining antibiotic treatment
greater than 48 hours in asymptomatic infants.
▪ Acute phase reactants have a low positive predictive value for sepsis.
General Considerations
The evaluation of a newborn infant at risk for sepsis is a frequent occurrence, but treatment duration, particularly for asymptomatic infants, can be
inconsistent. In recent years, medical literature and statements from the
CDC and AAP have helped standardize the initial evaluation and treatment
for these infants. Intrapartum antibiotic prophylaxis (IAP) has decreased the
incidence of sepsis in the newborn. Indications for IAP prophylaxis include:
▪ Mother is group B streptococcal (GBS) positive, late in gestation, and is
not undergoing cesarean delivery before labor onset with intact amniotic
membranes.
▪ GBS status is unknown and there are 1 or more intrapartum risk factors,
including < 37 weeks’ gestation, rupture of membranes for ≥18 hours, or
temperature of ≥100.4°F (38.0°C).
▪ GBS bacteriuria during current pregnancy.
▪ History of a previous infant with GBS disease.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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39
Sepsis Guideline
Judicious use of antibiotic treatment in newborn infants is recommended
to minimize the continuing emergence of resistant organisms. The intent
of this guideline is to foster a safe and appropriate evaluation and
treatment of infants with suspected sepsis/pneumonia that minimizes
exposure to antibiotics.
Evaluation
▪ Symptomatic patients warrant antibiotic therapy.
▪ Maternal chorioamnionitis warrants initiation of antibiotics.
▪ For asymptomatic infants delivered in the absence of suspected
chorioamnionitis:
▸
Infants born to mothers who received adequate IAP do not require
laboratory evaluation for sepsis.
▸
Infants born to mothers who received inadequate IAP with an indication
for IAP:
• Infants with rupture of membranes < 18 hours can be observed in the
hospital for 48 hour and considered for screening with a complete
blood count (CBC) with differential and platelets at 6-12 hours of age.
• Infants ≥ 37 weeks gestation with rupture of membranes ≥ 18 hours
can receive hospital observation for 48 hours. Diagnostic testing should
occur if frequent observations are not possible with CBC with differential
and platelets (at birth and/or at 6-12 hours of life) and a blood culture if
antibiotics are initiated following abnormal laboratory data.
• Infants < 37 weeks gestation should receive a limited evaluation with
CBC with differential and platelets (at birth and/or at 6-12 hours of
life) and a blood culture if antibiotics are initiated following abnormal
laboratory data.
▪C
-reactive protein (CRP) may be included as part of diagnostic evaluation.
40
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Sepsis Guideline
Diagnosis
▪ Differentiating sepsis from systemic inflammation caused by a noninfectious origin using laboratory markers lacks sensitivity. Blood cultures,
though, have a sensitivity of 90% if at least 0.75 mL of blood is collected.
▪ Abnormal laboratory markers for inflammation in an asymptomatic patient
have a low positive predictive value for sepsis.
▸
WBC < 5000
▸
ANC < 1750
▸
I:T ratio > 0.2
▸
RP > 1.0 mg/dL (10 mg/liter) on serial samples (preferably tested at
C
12 hours and 24 hours of life)
• CRP levels increase in the first 4 to 6 hours of infection, usually
becoming abnormal within 24 hours of the onset of infection. Levels
generally peak at two to three days after the onset of infection and
remain elevated until the infection is controlled and the inflammation
begins to resolve. As the inflammation subsides, CRP declines rapidly.
• An isolated CRP level should not be used to diagnose infection.
• The positive predictive value for one abnormal CRP > 1 mg/dL is
only 7% for “proven sepsis” and 35% for “proven or probable (culture
negative) sepsis” while the negative predictive accuracy of two normal
CRP determinations (excluding a value obtained at birth) is > 99%.
• CRP is an unreliable marker in cases of neutropenia.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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41
Sepsis Guideline
Treatment Duration
The following table represents persistent findings that could be consistent
with infection and is intended to assist in determining which infants may
require treatment beyond 48 hours, despite negative cultures.
Symptoms
•
•
•
runting > 6 hours
G
of age
etracting > 6 hours
R
of age
achypnea (RR > 60)
T
beyond 36 hours of life
•
Unexplained apnea
•
Temperature instability
•
Poor feeding
•
Lethargy, irritability
•
↓ Perfusion
Therapy
•
Oxygen > 6 hours
•
CPAP > 6 hours
•
Ventilator support
•
Fluid bolus
•
opamine/
D
dobutamine use
Chest X-Ray
•
Persistent infiltrate
▪ For asymptomatic infants born to a mother with suspected chorioamnionitis, antibiotics should be discontinued by 48 hours when all clinical
and diagnostic evidence conclude that the infant does not have sepsis.
Abnormal laboratory data may indicate a longer treatment course. An
abnormal CBC obtained shortly after birth should be validated at 6-12
hours of age to justify antibiotic treatment beyond 48 hours of life in an
asymptomatic infant.
▪A
symptomatic infants with risk factors for sepsis and negative blood
culture (no chorioamnionitis), should have antibiotics discontinued by
48 hours despite any abnormal laboratory data.
42
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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Sepsis Guideline
▪ Infants diagnosed with sepsis will be treated for a full course of antibiotic
therapy (generally 7-21 days, depending on the organism and its location).
▪ Treatment for pneumonia beyond 7 days is generally reserved for
patients with persistent chest x-ray infiltrate associated with prolonged
symptomatology.
▪ There is no data supporting a prolonged treatment course of antibiotics in
asymptomatic infants born to women with chorioamnionitis and a positive
placental culture.
▪ Recent data demonstrates lack of efficacy of intravenous immune globulin
on the outcomes of neonatal sepsis, hence its use is not recommended.
▪ For infants who require antibiotic therapy beyond 7 days and are otherwise
ready for discharge, home/outpatient antibiotic therapy may be considered
if the infant is asymptomatic and supported by community resources.
Post Treatment Care
▪ Once an infant has completed a full course of antibiotic therapy and meets
all discharge criteria, there is no evidence that suggests the need for
additional monitoring off antibiotic therapy.
▪ Hearing screen may be performed after the last dose of aminoglycoside
antibiotics and can be coordinated as an outpatient if necessary.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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43
Sepsis Guideline
Intrapartum Antibiotic Prophylaxis and Suspected
Chorioamnionitis
Algorithm for secondary prevention of early-onset group B streptococcal
(GBS) disease among newborns
Signs of neonatal sepsis?
Yes
Full diagnostic evaluation*
Antibiotic therapy†
Yes
Limited evaluation¶
Antibiotic therapy†
No
Maternal chorioamnionitis?§
No
GBS prophylaxis indicated
for mother?**
No
Routine clinical care††
Yes
Mother received intraveneous
penicillin, ampicillin,
or cefazolin for ≥ 4 hours
before delivery?
Yes
Observation for ≥ 48 hours†† ¶¶
No
≥ 37 weeks and duration of
membrane rupture < 18 hours?
Yes
Observation for ≥ 48 hours†† ¶¶
No
Either < 37 weeks or duration
of membrane rupture
≥ 18 hours?
Yes
Limited evaluation¶
Observation for ≥ 48 hours††
Figure reproduced with permission from Centers for Disease Control and Prevention
(CDC).
44
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Sepsis Guideline
* Full diagnostic evaluation includes a blood culture, a complete blood count
(CBC) including white blood cell differential and platelet counts, chest
radiograph (if respiratory abnormalities are present), and lumbar puncture
(if patient is stable enough to tolerate procedure and sepsis is suspected).
†
ntibiotic therapy should be directed toward the most common causes of
A
neonatal sepsis, including intravenous ampicillin for GBS and coverage
for other organisms (including Escherichia coli and other gram-negative
pathogens) and should take into account local antibiotic resistance
patterns.
§
onsultation with obstetric providers is important to determine the level
C
of clinical suspicion for chorioamnionitis. Chorioamnionitis is diagnosed
clinically and some of the signs are nonspecific.
¶
imited evaluation includes blood culture (at birth) and CBC with differential
L
and platelets (at birth and/or at 6-12 hours of life).
** See table 3 in CDC publication for indications for intrapartum GBS
prophylaxis.
††
If signs of sepsis develop, a full diagnostic evaluation should be conducted
and antibiotic therapy initiated.
§§
If ≥ 37 weeks’ gestation, observation may occur at home after 24 hours if
other discharge criteria have been met, access to medical care is readily
available, and a person who is able to comply fully with instructions for
home observation will be present. If any of these conditions is not met,
the infant should be observed in the hospital for at least 48 hours and until
discharge criteria are achieved.
¶¶
ome experts recommend a CBC with differential and platelets at age
S
6-12 hours.
Note: 48 hours of antibiotic therapy may be adequate therapy in asymptomatic
patients despite the presence of maternal chorioamnionitis. Empiric antibiotic
treatment should be discontinued once the clinical and laboratory assessments
have ruled out sepsis.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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45
Sepsis Guideline
References: Sepsis
American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and
Newborn. Recommendations for the Prevention of Perinatal Group B Streptococcal (GBS) Disease.
Pediatrics. 2011; 128(3):611-616.
Benitz W, Han M, Madan A, et al. Serial serum C-reactive protein levels in the diagnosis of neonatal
infection. Pediatrics. 1998; 102(4):e41.
Brady MT, Polin RA. Prevention and management of infants with suspected or proven neonatal sepsis.
Pediatrics. 2013;132(1):166-168.
Franz A, Bauer K, Schalk A, et al. Measurement of interleukin 8 in combination with C-reactive protein
reduced unnecessary antibiotic therapy in newborn infants: a multicenter, randomized, controlled trial.
Pediatrics. 2004; 114(1):1-8.
Gerdes J. Diagnosis and management of bacterial infections in the neonate. Pediatric Clinics of North
America. 2004; 21(4):939-959.
Higgins RD, Baker CJ, Raju TN. Executive summary of the workshop on infection in the high-risk infant.
Journal of Perinatology. 2010; 30(6):379-383.
INIS Collaborative Group, Brocklehurst P, Farrell B, King A, et al. Treatment of neonatal sepsis with
intravenous immune globulin. New England Journal of Medicine. 2011; 29: 365(13):1201-1211.
Institute of Medicine of the National Academies, Antibiotic resistance: implications for global health and
novel intervention strategies - workshop summary (2010). [Accessed 2013 October]. Available from:
http://iom.edu/Reports/2010/Antibiotic-Resistance-Implications-for-Global-Health-and-Novel-InterventionStrategies.aspx.
Jackson G, Engle W, Sendelbach D, et al. Are complete blood cell counts useful in the evaluation of
asymptomatic neonates exposed to suspected chorioamnionitis? Pediatrics. 2004; 113(5):1173-1180.
Kumar Y, Qunibi M, Neal N, et al. Time to positivity of neonatal blood cultures. Archives of Disease in
Childhood Fetal and Neonatal Edition. 2001; 85(3):F182-F186.
Mukhopadhyay S, Eichenwald EC, Puopolo KM. Neonatal early-onset sepsis evaluations among wellappearing infants: projected impact of changes in CDC GBS guidelines. Journal of Perinatology. 2013;
33(3):198-205.
Newman TB, Puopolo KM, Wi S, et al. Interpreting complete blood counts soon after birth in newborns at
risk for sepsis. Pediatrics. 2010; 126(5):903-909.
Polin RA; Committee on Fetus and Newborn. Management of neonates with suspected or proven earlyonset bacterial sepsis. Pediatrics. 2012;129(5):1006-1015.
Remington JS, Klein JO, Wilson CB, et al, eds. Infectious Diseases of the Fetus and Newborn. 7th edition.
Elsevier Saunders; 2011.
Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immunization and
Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group
B streptococcal disease--revised guidelines from CDC, 2010. Morbidity and Mortality Weekly ReportRecommendations and Reports. 2010; 59(RR-10):1-36.
Weitkamp J, Aschner J. Diagnostic use of C-reactive protein (CRP) in assessment of neonatal sepsis.
NeoReviews. 2005; 6(11):e508-e515.
46
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Notes
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Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
47
Phototherapy
Guideline
Applies to infants ≥ 35 weeks gestation
Key Points
▪ American Academy of Pediatrics (AAP) presents recommendations for
initiation of phototherapy based on gestation, age and risk factors.
▪ Outpatient monitoring of bilirubin level(s) is supported once phototherapy
is discontinued.
General Considerations
This guideline incorporates the latest recommendations from the AAP,
emphasizing an approach that will reduce the frequency of severe neonatal
hyperbilirubinemia and bilirubin encephalopathy.
▪ Inadequate breastfeeding may lead to dehydration and contribute to the
development of hyperbilirubinemia. Increasing the frequency of nursing
minimizes the risk of developing significant hyperbilirubinemia. Encourage
the mother to provide 8 to 12 breastfeedings per day. According to the
AAP, routine water/dextrose supplementation for non-dehydrated breastfed infants does not prevent hyperbilirubinemia nor decrease total serum
bilirubin (TSB) levels.
▪ Frequent oral feedings may decrease enterohepatic circulation, enhance
bilirubin elimination and attenuate a rise in bilirubin levels.
▪ Routine bilirubin screening prior to discharge has the potential to reduce
the incidence of severe hyperbilirubinemia levels that may lead to bilirubin
encephalopathy.
▪ Prior to discharge, all infants should be assessed for their risk of
hyperbilirubinemia. Two clinical options can either be used individually
or in combination for the systematic assessment of risk: measurement
of the bilirubin level using TSB or transcutaneous bilirubin (TcB) and/or
assessment of clinical risk factors.
48
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Phototherapy Guideline
▪ Bilirubin measurement should be obtained (TcB and/or TSB bilirubin
measurement) if there is known antenatal sensitization, jaundice in the
first 24 hours of life, or jaundice excessive for the infant’s age. Elevated
TcB levels should be verified by TSB. Bilirubin levels should be interpreted
based on the infant’s age in hours.
▪ Visual estimation of the degree of jaundice can be erroneous, particularly
in darkly pigmented infants. TcB or TSB should be measured if question
exists regarding the degree of jaundice.
▪ Phototherapy or exchange transfusion should be initiated per current AAP
criteria.
▪ Prior to discharge, perform a thorough history, physical examination and,
if indicated, laboratory evaluation.
▪ Educate families about the significance and management of jaundice.
▪ Follow up bilirubin levels and exams should be based on the age of the
infant, bilirubin level at time of discharge, presence of breastfeeding and
other risk factors for the development of hyperbilirubinemia.
▪ Infants with lower gestational age, blood incompatibilities, glucose-6phosphate dehydrogenase deficiency, increased weight loss and who
are exclusively breastfed have an increased risk of developing elevated
TcB in a time dependent manner.
▪ Infants discharged with a screening bilirubin level categorized as low risk
still must be vigilantly observed for subsequent hyperbilirubinemia.
▪ Any infant discharged ≤ 72 hours of life should be evaluated by a
healthcare professional within two days of discharge.
▪ Home phototherapy may be considered for infants without risk factors
for hyperbilirubinemia and otherwise meeting discharge parameters.
▪ Infants with breast milk jaundice who are asymptomatic require no
treatment if the total serum bilirubin level remains below the threshold
to initiate phototherapy.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
49
Phototherapy Guideline
General Criteria for Hospital Phototherapy
25
428
20
342
15
257
10
171
5
85
0
Birth
24h
48h
72h
96h
5 Days
6 Days
7 Days
umol/L
Total Serum Bilirubin (mg/dL)
Based on recommendations from the AAP.
0
Age
Infants at lower risk (≥ 38 wk and well)
Infants at medium risk (≥ 38 wk + risk factors or 35-37 6/7 wk and well)
Infants at higher risk (35-37 6/7 wk + risk factors)
▪ Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin.
▪ Risk factors = isoimmune hemolytic disease, G6PD deficiency, asphyxia,
significant lethargy, temperature instability, sepsis, acidosis, or albumin
< 3.0g/dL (if measured).
▪ For well infants 35-37 6/7 week gestation, one can adjust TSB levels for
intervention around the medium risk line. It is an option to intervene at
lower TSB levels for infants closer to 35 weeks and higher or TSB levels
for those closer to 37 6/7 wk.
▪ It is an option to provide conventional phototherapy in hospital or at home
at TSB levels 2-3 mg/dL (35 -50 mmol/L) below those shown but home
phototherapy should not be used in any infant with risk factors.
Figure reproduced with permission from Pediatrics, Vol. 114 (1), Pages 297-316.
Copyright © 2004 by the AAP.
50
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Phototherapy Guideline
The figure on the previous page indicates the appropriate bilirubin level
to initiate “intensive” phototherapy based on gestation, age in hours when
bilirubin was obtained and risk factors.
▪ The three curves differ based on gestation and risk factors.
▪ Intensive phototherapy implies high irradiance covering a large surface
area (i.e. multiple phototherapy sources (as close as 10 cm to the infant).
The threshold for initiating intensive phototherapy is based on the TSB and
age in hours for the appropriate curve. Intensive phototherapy implies the
use of high levels of irradiance in the 430-490 nm wavelength of at least
30 μW/cm2 per nm (measured at the infant’s skin directly below the center
of the phototherapy unit) and delivered to as much of the infant’s surface
area as possible.
▪ Conventional phototherapy refers to the use of fiberoptic or single
overhead phototherapy. The threshold for initiating conventional
phototherapy is TSB 2-3 mg/dL below the appropriate curve, based
on age in hours.
An internet-based application indicating the appropriate bilirubin
level to initiate phototherapy is available taking into account the latest
recommendations from the American Academy of Pediatrics.*
*Alere does not control the content and makes no representations with respect
to that content.
Discontinuing Phototherapy
The AAP has not issued a standard for discontinuing either conventional or
intensive phototherapy in non-readmitted babies. Given that it is an option to
initiate conventional phototherapy 2-3 mg/dL below the curve based on age
in hours, a reasonable stop point for most infants would be 5 mg/dL below
the appropriate curve, based on age in hours (see General Criteria
for Hospital Phototherapy).
▪ There is no medical evidence supporting the practice of stepwise weaning
from intensive to non-intensive phototherapy (triple to double to single
phototherapy). Stepwise weaning, though, may be warranted based on
degree of hyperbilirubinemia and age in hours.
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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51
Phototherapy Guideline
▪ Observation for rebound bilirubin should not delay hospital discharge.
For those infants with hemolytic disease treated with phototherapy or in
cases when phototherapy is initiated and discontinued prior to day of
life 3 or 4, a follow-up bilirubin level within 24 hours after discharge is
recommended. Although significant rebound is rare in infants readmitted
with hyperbilirubinemia and then discharged, a repeat TSB measurement
or clinical follow-up 24 hours after discharge is a feasible option.
Criteria for Readmitted Infants
Infants should be readmitted to the hospital for TSB levels requiring
intensive phototherapy. Phototherapy may be discontinued when the serum
bilirubin level falls 5 mg/dL below the appropriate curve based on age in
hours (see General Criteria for Hospital Phototherapy). Significant rebound
once phototherapy is discontinued is a rare phenomenon. Follow up TSB
levels 24 hours after discharge is optional, though all babies readmitted for
phototherapy should be followed closely by their primary care physician
after discharge.
References: Phototherapy
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia
in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004; 114(1):297-316.
Bhutani VK, Maisels MJ, Stark AR, Buonocore G. Management of jaundice and prevention of severe
neonatal hyperbilirubinemia in infants >or=35 weeks gestation. Expert Committee for Severe Neonatal
Hyperbilirubinemia; European Society for Pediatric Research; American Academy of Pediatrics.
Neonatology. 2008; 94(1):63-67.
BiliToolTM. [Accessed 2013 October]. Available from: http://bilitool.org.
Bromiker R, Bin-Nun A, Schimmel MS, Hammerman C, Kaplan M. Neonatal hyperbilirubinemia in the lowintermediate-risk category on the bilirubin nomogram. Pediatrics. 2012; 130(3):e470-e475.
Committee on Fetus and Newborn. Phototherapy to prevent severe neonatal hyperbilirubinemia in the
newborn infant 35 or more weeks of gestation. Pediatrics. 2011;128(4):e1046-e1052.
Eggert LD, Wiedmeier SE, Wilson J, Christensen RD. The effect of instituting a prehospital-discharge
newborn bilirubin screening program in an 18-hospital health system. Pediatrics. 2006; 117(5):e855-e862.
Kaplan M, Kaplan E, Hammerman C, et al. Post-phototherapy neonatal bilirubin rebound: a potential
cause of significant hyperbilirubinaemia. Archives of Disease in Childhood. 2006; 91(1):31–34.
Keren R, Bhutani VK, Luan X, et al. Identifying newborns at risk of significant hyperbilirubinaemia: a
comparison of two recommended approaches. Archives of Disease in Childhood. 2005; 90(4):415-421.
52
Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Phototherapy Guideline
Kuzniewicz MW, Escobar GJ, Newman TB. Impact of universal bilirubin screening on severe
hyperbilirubinemia and phototherapy use. Pediatrics. 2009; 124(4):1031-1039.
Lazarus C, Avchen RN. Neonatal hyperbilirubinemia management: a model for change. Journal of
Perinatology. 2009; 29(Supplement 1s):S58-S60.
Mah MP, Clark SL, Akhigbe E, et al. Reduction of severe hyperbilirubinemia after institution of
predischarge bilirubin screening. Pediatrics. 2010; 125(5):e1143-e1148.
Maisels MJ, Bhutani VK, Bogen D, et al. Hyperbilirubinemia in the newborn infant ≥ 35 weeks’ gestation:
an update with clarifications. Pediatrics. 2009; 124(4):1193-1198.
Maisels MJ, DeRidder JM, Kring EA, Balasubramaniam M. Routine transcutaneous bilirubin
measurements combined with clinical risk factors improve the prediction of subsequent
hyperbilirubinemia. Journal of Perinatology. 2009(9); 29:612-617.
Maisels MJ, Kring E. Rebound in serum bilirubin level following intensive phototherapy. Archives of
Pediatric and Adolescent Medicine. 2002; 156(7):669-672.
Mantagou L, Fouzas S, Skylogianni E, et al. Trends of transcutaneous bilirubin in neonates who develop
significant hyperbilirubinemia. Pediatrics. 2012; 130(4):e898-e904.
Nanjundaswamy S, Petrova A, Mehta R, et al. The accuracy of transcutaneous bilirubin measurements in
neonates: a correlation study. Biology of the Neonate. 2004; 85(1):21-25.
Preer GL, Philipp BL. Understanding and managing breast milk jaundice. Archives of Disease in
Childhood - Fetal and Neonatal Edition. 2011; 96(6):F461-F466.
Profit J, Cambric-Hargrove AJ, Tittle KO, et al. Delayed pediatric office follow-up of newborns after birth
hospitalization. Pediatrics. 2009; 124(2):548-554.
Stokowski LA. Fundamentals of phototherapy for neonatal jaundice. Advances in Neonatal Care. 2006;
6(6):303-312.
Notes
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Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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53
Neonatal Drug
Exposure/Withdrawal Guideline
Applies to infants who have been prenatally exposed to substances
that cause withdrawal or toxicity
Key Points
▪ Neonatal abstinence syndrome (NAS) scoring, including measurement
following feeding, is indicated.
▪ Treatment should match the drug exposure class.
▪ Newer treatment regimens show promise regarding efficacy and length
of hospital stay.
General Considerations
Fetal exposure to specific drugs can result in neonatal withdrawal or signs
of toxicity. NAS is a condition resulting from the abrupt cessation of in utero
exposure to addictive substances. Maternal histories of drug use (legal or
illegal) during pregnancy are frequently inaccurate as demonstrated by
positive drug screening results in absence of admission of use. Thus, this
history should not be taken as an exclusive indicator of an infant’s in utero
exposure, especially if the infant displays withdrawal symptoms. Conversely,
a negative infant or maternal drug screen should not negate a maternal
admission of drug use.
In the past decade, the number of mothers dependent on opioids has
increased nearly five-fold with a corresponding three-fold increase in
NAS in their offspring. Part of this increase is due to more frequent use of
prescription pain medication during pregnancy. No consistent relationship
has been documented between maternal methadone or buprenorphine
dose and severity of NAS. While up to 90% of infants exposed to narcotics
during fetal life have some symptoms, only 50-75% will require treatment.
Fetal exposure to either buprenorphine or methadone results in similar
incidence of NAS, though the former has been noted to results in shorter
overall duration of NAS.
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Affected infants may exhibit the onset of drug withdrawal symptoms as early
as 24-48 hours or as late as 7-10 days of age depending on the timing of
the mother’s last dose and the drug’s half-life. Subacute signs from opioid
withdrawal may last up to 6 months.
Selective Serotonin Re-uptake Inhibitors (SSRIs) use among pregnant
women has become more prevalent. Symptoms typically occur over the
first week of life and may be due to hyperserotonergic condition and/
or withdrawal state. In infants exposed to SSRIs, 30% are reported to
demonstrate symptoms which can be severe in up to 13% of cases.
Fetal amphetamine exposure does not result in a withdrawal syndrome
typical of opiates. The most common presentation in infants is lethargy,
somnolence and poor feeding, though some present with agitation and
tachypnea. This typically requires short term minimal supportive treatment,
possibly including gavage feeding.
Withdrawal symptoms in infants exposed in utero to cocaine is infrequent
and typically does not require treatment.
Though marijuana is the most common used illicit drug by pregnant women,
it does not cause clinically significant neonatal withdrawal.
Phencyclidine exposure can result in hypertonicity, agitation and gastrointestinal symptoms which can persist up to 2-3 weeks.
NAS is a generalized disorder presenting as a clinical picture of irritability,
gastrointestinal dysfunction, respiratory distress, and vague autonomic
symptoms. In severe or untreated cases, seizures may occur. The prevalence
of maternal multiple drug use complicates attempts to analyze any single
agent’s contribution to the symptom complex.
NAS symptoms may overlap manifestations of neonatal illnesses such
as hypoglycemia, hypocalcemia, hematologic disturbances, sepsis, and
neurological illnesses.
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Neonatal Drug Exposure/Withdrawal Guideline
Infants with drug exposure/dependency may exhibit signs and symptoms
including:
▪ Irritability
▪D
iarrhea
▪ Increased tone
▪V
omiting
▪ Jitteriness
▪F
ever
▪ Nasal stuffiness
▪T
achypnea
▪ Excessive sucking
activity
▪S
neezing/yawning
▪ Disorganized suck
▪ Demand for frequent
feedings (every 2
hours)
▪S
hrill cry
▪ Inconsolable behavior
▪ Altered sleep-wake
cycle
▪ Diaphoresis
▪ Temperature variation
▪ Rub marks or scratch
marks, particularly on
the face
▪ Poor weight gain
▪ Impaired maternalinfant bonding
In utero drug exposure and/or drug withdrawal may put exposed infants at
risk for long-term developmental sequelae. The pharmacologic treatment of
drug withdrawal may not alter their long-term outcome. The goal of therapy
is to control withdrawal symptoms and to optimize feeding and growth.
Other conditions with similar symptoms should be ruled out with appropriate
tests that may include a CBC with differential, glucose, electrolytes,
magnesium and calcium. In rare cases, neurological consults and neuroimaging may be necessary. Urine, meconium and umbilical cord tissue
drug screening may be helpful for identifying the drugs from which the
infant is withdrawing. Meconium drug screening is particularly important in
identifying drugs that may have been taken prior to the 2-3 days preceding
delivery since urinary excretion is short and characteristically addresses drug
exposure in the time period immediate to sample collection. Testing should
be done in compliance with local laws.
Social service referral is necessary and should occur when drug exposure
is diagnosed. Local legal requirements must be met.
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Finnegan Abstinence Scoring System
▪ The Finnegan Abstinence Scoring System is recommended to estimate
the severity of NAS and to measure the infant’s optimum response to
pharmacotherapy and intervention. Another widely used evaluation tool is
the Lipsitz scale, which uses a simpler numeric scoring system to evaluate
the need for therapy. The Lipsitz scale, however, has not been fully
evaluated as a method for identifying infants who require drug therapy.
Therefore, this guideline refers to Finnegan scores for treatment protocols.
Though the Finnegan Abstinence Scoring System was originally validated
for full term infants, it is reasonable to apply it to late preterm infants.
Nursing educational programs can improve accuracy in objective scoring.
▪ Prior to the initiation of treatment, all infants with signs and symptoms of
drug exposure or maternal history that is suggestive of drug use should
be scored every 2-4 hours, one hour following feeding.
▪ Finnegan scores that are ≥ 8 for 3 consecutive scores, ≥ 12 for 2
consecutive scores or ≥ 15 once suggest the need for treatment.
▪ The goal of care is to maintain a Finnegan score of < 8. A Finnegan
score < 8 typically allows appropriate drug weaning.
Treatment Considerations
▪ The initial treatment of a neonate with withdrawal symptoms should be
supportive and should include breastfeeding unless there are concurrent
contraindications (such as maternal HIV or continuing illicit drug use).
Breast milk feedings in mothers using methadone and/or buprenorphine
delay the onset of NAS, reduce its severity and minimize the need for
pharmacologic treatment regardless of the infant’s gestation and type
of drug exposure. Drug therapy may not be necessary for infants with
mild symptoms as well as babies exposed to SSRIs. In addition to
breastfeeding, supportive therapy should include swaddling, holding,
decreasing environmental stimuli (including light and noise) and infant
massage. These actions can lessen symptoms and improve the ability
to deliver appropriate care for these infants.
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Neonatal Drug Exposure/Withdrawal Guideline
▪ Infants may require frequent feeding, and as much as 150 Kcal/kg/day or
greater to achieve ideal weight gain. Hypercaloric formulas may be needed
to meet increased metabolic demand.
▪ A pacifier for excessive sucking should be provided.
▪ Infants should be monitored for sleeping habits, temperature instability,
weight gain or loss and skin excoriation (especially in the diaper area).
▪ Daily weight and I&O should be recorded.
Pharmacotherapy Considerations
The decision to use pharmacologic agents must be individualized and
should be based on the severity of withdrawal symptoms and the risks
versus the benefits of drug therapy. Pharmacological therapy is primarily
based on selecting a drug from the same class as the drug causing the
withdrawal symptoms. Length of treatment will vary depending on the
type(s) of drug exposure and severity of symptoms.
Oral Morphine Sulfate
Used for opiate withdrawal. Recommended drug of choice for narcoticrelated withdrawals.
▪ Initial therapy of 0.2 -0.4 mg/kg/day in 4 -8 divided doses. The dose
may be increased until symptoms are controlled or to a maximum of
0.8-1 mg/kg/day.
▪ The maximum effect is usually seen in 48-72 hours.
▪ When symptoms are controlled, continue the dose for 48-72 hours.
▪ Pharmacological weaning should be based on NAS scores, daily weights
and daily physical exams.
▪ When NAS scores are stable, decrease the dose by 10% of the peak
dose every 24-48 hours, or as tolerated.
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▪ Continued weaning should be determined by the ability to maintain
a Finnegan score consistently < 8.
▪ Drug should be discontinued within 24-48 hours after the dose is weaned
to 0.2 mg/kg/day.
▪ There may be select infants that based on their specific pharmacological
weaning history and NAS scores warrant discontinuation of medication
at a lower dose.
Oral Phenobarbital
Phenobarbital may be considered as adjuvant therapy when NAS scores
are high despite maximum opiate pharmacotherapy. It may be one drug
of choice for non-narcotic related drug exposure and/or withdrawal. It will
assist in the control of hyperactivity, but will not control the gastrointestinal
complications. The blood level necessary to control narcotic withdrawal
signs is unknown.
▪ A loading dose of 10-20 mg/kg/dose is typically effective in attenuating
clinical symptoms.
▪ If NAS symptoms persist, dose should be repeated at 10 mg/kg/dose
every 12 hours until control is attained, while monitoring for signs of
toxicity.
▪ Once control is achieved, the infant should be maintained on 3-5 mg/kg/
day in 1-2 doses.
▪ Monitor phenobarbital levels if clinically indicated.
▪ When clinically stable for 48-72 hours, taper the dose by 10-20% per day
or as tolerated.
▪ Once narcotic weaning is completed, reasonable options include stopping
phenobarbital when the infant is stable at a low dose (2- 3 mg/kg/d) or low
serum level (≤ 15 mcg/mL).
▪ Due to phenobarbital’s long half-life, outpatient management for clinical
follow-up after medication discontinuation or outpatient management for
continued weaning are both acceptable options.
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Neonatal Drug Exposure/Withdrawal Guideline
Clonidine
Clonidine is an alpha 2-adrenergic receptor agonist that has been used to
blunt opiate withdrawal symptoms in adults and older children. There have
been reports showing that adding clonidine to the treatment regimen assists
the weaning process and allows for an earlier discharge.
Methadone
Methadone may be used alone or in combination with other agents for
weaning from in utero drug exposure. In mothers on methadone maintenance,
feeding human milk may minimize or eliminate NAS symptoms in a dose
related fashion. Consider screening with electrocardiogram prior to treatment
and during treatment due to prolonged QRS.
Pharmacotherapy Agents Not Recommended
Tincture of opium is not recommended due to 25x concentration risking
medication errors and 19% alcohol content.
Paregoric is not recommended because of its high alcohol content, anise
oil, benzoic acid and camphor.
Diazepam is not recommended due to possible cerebral and hepatic
dysfunction.
Chlorpromazine has limited use in neonates due to adverse effects such
as cerebellar dysfunction, decreased seizure threshold and hematologic
abnormalities.
Naloxone is contraindicated for infants exposed to in utero opiates.
Discharge Planning for Infants at Risk for Drug Withdrawal
Given the natural history of withdrawal, it is important to closely monitor the
asymptomatic drug-exposed infant during the hospital stay. Infants who are
exposed in utero to opioids or benzodiazepines, if symptom free, may be
ready for discharge as early as the 5th day of life.
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For infants exposed to methadone, close follow up may be necessary for
7-10 days (either on an inpatient basis or as an outpatient if medically and
socially stable) due to late presentation of symptoms resulting from the
drug’s long half-life.
Discharge Criteria for Infants Treated with Medication(s)
▪ The infant is physiologically stable.
▪ The infant is taking oral feeds and gaining weight appropriately.
▪ The infant shows neurobehavioral recovery (can reach full alert state,
responds to social stimuli and can be consoled with routine measures);
has NAS scores < 8 off medication for 24-48 hours; or if being considered
for discharge on home medication, has NAS scores < 8 for 24 - 48 hours.
▪ All necessary assessments have been completed (e.g. hearing screen).
▪ A social service consult should be requested on admission. Referral to
the state’s child protection agency should be made, if deemed appropriate
by the social worker and/or other health care provider(s). The infant’s
caregivers should be involved in the infant’s care as early as possible.
Foster parents should be considered as a possible means of safe
discharge.
Discharge Instructions for Infants with NAS
▪ An explanation of the signs and symptoms of withdrawal should be given
to caregivers.
▪ Instructions should be given to caregivers on infant comfort measures.
▪ A follow-up appointment with the infant’s pediatrician should be arranged
24-48 hours after discharge.
▪ Schedule home care visit(s) by a nurse and/or social worker if this is
required following the initial pediatrician’s office visit.
▪ Appropriate neurodevelopmental follow-up for the infant secondary to highrisk perinatal drug exposure should be considered.
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Neonatal Drug Exposure/Withdrawal Guideline
▪ If necessary, a drug treatment program referral for the infant’s parent(s)
should be initiated during the hospital stay.
▪ In some instances, infants can be discharged and finish weaning from
pharmacotherapy at home. A combined inpatient/outpatient methadone
treatment plan has the potential to significantly shorten hospital stay while
enhancing breastfeeding. This can be done safely and effectively when
both the infant’s caregivers and physicians are in agreement with this plan.
Close follow-up with physician visits and home care is needed to adjust
medication doses and assess the infant’s status. This may involve premeasured dosages with frequent physician visits to refill the prescriptions,
and to account for all doses and document administration of medication
to the infant.
References: Neonatal Abstinence Syndrome
Abdel-Latif M, Pinner J, Clews S, et al. Effects of breast milk on the severity and outcome of neonatal
abstinence syndrome among infants of drug-dependent mothers. Pediatrics. 2006; 117(6):e1163-e1169.
Agthe AG, Kim GR, Mathias KB, et al. Clonidine as an adjunct therapy to opioids for neonatal abstinence
syndrome: a randomized, controlled trial. Pediatrics. 2009; 123(5):e849-e856.
Alto WA, O’Connor AB. Management of women treated with buprenorphine during pregnancy. American
Journal of Obstetrics and Gynecology. 2011; 205(4):302-308.
American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into
human milk. Pediatrics. 2001; 108(3):776-789.
Backes CH, Backes CR, Gardner D, et al. Neonatal abstinence syndrome: transitioning methadonetreated infants from an inpatient to an outpatient setting. Journal of Perinatology. 2012; 32(6):425-430.
Bio LL, Siu A, Poon CY. Update on the pharmacologic management of neonatal abstinence syndrome.
Journal of Perinatology. 2011; 31(11):692-701.
Burgos AE, Burke BL. Neonatal Abstinence Syndrome. NeoReviews. 2009; 10(5);e222-e229.
Coyle M, Ferguson A, Lagasse L, et al. Neurobehavioral effects of treatment for opiate withdrawal.
Archives of Disease in Childhood Fetal and Neonatal Edition. 2005; 90(1):F73-F74.
Ferreira E, Carceller AM, Agogué C, et al. Effects of selective serotonin reuptake inhibitors and venlafaxine
during pregnancy in term and preterm neonates. Pediatrics. 2007; 119(1):52-59.
Finnegan L, Connaughton J, Kron R, et al. Neonatal abstinence syndrome: assessment and management.
Addictive Diseases International Journal. 1975; 2(1-2):141-158.
Finnegan L, Kaltenbach K. Primary Pediatric Care. 2nd edition. Mosby. 1992; 1367-1378.
Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn; American Academy of
Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012; 129(2):e540-e560.
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patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Neonatal Drug Exposure/Withdrawal Guideline
Hussain T, Ewer AK. Maternal methadone may cause arrhythmias in neonates. Acta Paediatrica. 2007;
96(5):768-769.
Isemann B, Meinzen-Derr J, Akinbi H. Maternal and neonatal factors impacting response to methadone
therapy in infants treated for neonatal abstinence syndrome. Journal of Perinatology. 2011; 31(1):25-29.
Jackson L, Ting A, McKay S, et al. A randomized controlled trial of morphine versus phenobarbitone
for neonatal abstinence syndrome. Archives of Disease in Childhood Fetal and Neonatal Edition. 2004;
89(4):F300-F304.
Jansson L, Choo R, Melez M, et al. Methadone maintenance and breast feeding in the neonatal period.
Pediatrics. 2008; 121(1):106-114.
Johnson K, Gerada C, Greenough A. Treatment of neonatal abstinence syndrome. Archives of Disease in
Childhood Fetal and Neonatal Edition. 2003; 88(1):F2-F5.
Johnson K, Greenough A, Gerada C. Maternal drug use and length of neonatal unit stay. Addiction. 2003;
98(6):785-789.
Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or
buprenorphine exposure. New England Journal of Medicine. 2010; 363(24):2320-2331.
Kuschel C. Managing drug withdrawal in the newborn infant. Seminars in Fetal and Neonatal Medicine.
2007; 12(2):e127-e133.
Lainwala S. A retrospective study of length of hospital stay in infants treated for neonatal abstinence
syndrome with methadone versus oral morphine preparations. Advances in Neonatal Care. 2005;
5(5):265-272.
Levinson-Castiel R, Merlob P, Linder N, et al. Neonatal abstinence syndrome after in utero exposure to
selective serotonin reuptake inhibitors in term infants. Archives of Pediatrics & Adolescent Medicine.
2006; 160(2):173-176.
Lipsitz P. A proposed narcotic withdrawal score for use with newborn infants: A pragmatic evaluation of
its efficacy. Clinical Pediatrics. 1975; 14(6):592-594.
Lucas K, Knobel RB. Implementing practice guidelines and education to improve care of infants with
neonatal abstinence syndrome. Advances in Neonatal Care. 2012; 12(1):40-45.
Maichuk G, Zahorodny W, Marshall R. Use of positioning to reduce the severity of neonatal narcotic
withdrawal syndrome. Journal of Perinatology. 1999; 19(7):510-513.
McQueen KA, Murphy-Oikonen J, Gerlach K, Montelpare W. The impact of infant feeding method on
neonatal abstinence scores of methadone-exposed infants. Advances in Neonatal Care. 2011; 11(4):282290.
Montgomery D, Plate C, Alder SC, et al. Testing for fetal exposure to illicit drugs using umbilical cord
tissue vs meconium. Journal of Perinatology. 2006; 26(1):11-14.
Moses-Kolko EL, Bogen D, Perel J, et al. Neonatal signs after late in utero exposure to serotonin reuptake
inhibitors: literature review and implications for clinical applications. Journal of the American Medical
Association. 2005; 293(19):2372-2383.
O’Donnell M, Nassar N, Leonard H et al. Increasing prevalence of neonatal withdrawal syndrome:
population study of maternal factors and child protection involvement. Pediatrics. 2009; 123: e614-e621.
Oei JL, Kingsbury A, Dhawan A, et al. Amphetamines, the pregnant woman and her children: a review.
Journal of Perinatology. 2012; 32(10):737-747.
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Neonatal Drug Exposure/Withdrawal Guideline
Patrick SW, Schumacher RE, Benneyworth BD, et al. Neonatal abstinence syndrome and associated
health care expenditures: United States, 2000-2009. The Journal of the American Medical Association.
2012; 307(18):1934-1940.
Payot A, Berner M. Hospital stay and short-term follow up of children of drug-abusing mothers born in an
urban community hospital – a retrospective review. European Journal of Pediatrics. 2000; 159(9):679683.
Thajam D, Atkinson DE, Sibley CP, Lavender T. Is neonatal abstinence syndrome related to the amount of
opiate used? Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2010; 39(5):503-509.
Notes
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Discharge
Guideline
Applies to all infants in the Neonatal Intensive Care Unit (NICU)
or Special Care Nursery
Key Points
▪ American Academy of Pediatrics (AAP) physiologic-based discharge
criteria are utilized.
▪ Family disposition and discharge needs should be addressed early
in the care continuum.
General Considerations
Historically, preterm infants were discharged only if they reached a
certain weight or post menstrual age (PMA). However, it has been shown
that preterm infants can be safely discharged earlier once physiologic
competency and stability are established. The eligibility and timing of
discharge of any infant in the NICU or Special Care Nursery is a decision
that is determined by the attending physician responsible for the care of
that infant, in conjunction with the infant’s caregiver(s).* Discharge should
be based on the achievement of physiologic competency of the patient, but
may also be affected by the caregiver(s) ability to manage certain aspects
of care at home. Preterm infants with low birth weight experience a higher
rate of readmission and death during the first year after birth. However,
careful discharge planning and appropriate post-discharge follow-up may
reduce these risks. A multidisciplinary unit-based neonatal team (consisting
of a social worker, case manager, primary care nurse and home care
coordinator) should assist the physician/practitioner team with the infant’s
discharge planning process. Developing unit discharge criteria and creating
individualized flow charts for the discharge process can facilitate the timely
completion of discharge tasks.
*Caregiver(s) in context of this guideline includes parents and guardians
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Discharge Guideline
Considerations for Discharge
▪ Discharge planning should begin following admission, despite the inability
to predict the timing of discharge.
▪ Discharge teaching and planning should occur throughout the hospitalization so as not to overwhelm parents and staff at the end of the
hospital stay.
▪ Parental contact and involvement in the care of the infant should be
encouraged from time of admission. An educational-behavioral intervention
program for parents that commences early in the NICU has been shown
to improve mental health outcomes, enhance parent-infant interaction and
reduce length of stay.
▪ An educational program transitioning the preterm infant home in
coordination with the medical home has the potential to decrease hospital
readmission, particularly in the public insurance population.
▪ Caregivers can have lower levels of confidence when infant care includes
medical equipment or procedures. This emphasizes the importance of
early, timely caregiver involvement when discharge encompasses specific
procedural tasks or medical devices.
▪ Discussions should be held on an educational level consistent with the
caregiver(s) background. Interpreter services should be coordinated as
indicated to maintain appropriate family interaction.
▪ An Ethics Committee should be convened early if there are staff concerns
regarding plans of care that are not beneficial to the infant’s long-term
health.
▪ Key transition points (such as weaning to room air, transition to crib, full
oral intake, etc.) that are reflective of an infant’s physiologic status should
be identified throughout the hospitalization. The roles and responsibilities
of the multidisciplinary unit-based neonatal team and care providers should
be emphasized under each of the major transition points.
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Discharge Guideline
▪ Discharge planning should be incorporated into daily medical rounds,
nursing reports and written documentation to include:
▸
Discharge date based on physiologic competency.
▸
ollow up studies scheduled and completed prior to the anticipated
F
discharge. Studies requiring sedation, e.g., brain MRI, should be done
timely so that transient poor feeding does not delay discharge.
▸
iagnostic and elective follow up studies scheduled as an outpatient
D
if the infant is clinically stable and timing of the study is not critical.
▸
Home equipment and medication.
▸
Home health needs.
▸
Home feeding plan.
▸
creening needs (e.g., car seat challenge, hearing, developmental
S
or feeding assessment).
▸
rimary healthcare provider and any required subspecialist(s) for
P
continuing outpatient care.
▪ Primary guardian, if not the parents, for the infant must be identified.
Caregiver(s) should be provided with the appropriate training and
resources to care for the infant after discharge.
▪ A written summary of the infant’s hospital course and specific needs
including medications, treatments, pertinent laboratory and diagnostic test
results, immunizations received and appointments following discharge
should be completed. A copy should be sent to the primary care provider
assuming care of the infant, and a copy given to the caregiver(s).
▪ A written plan for home health care should include (as applicable): the
name of the primary care provider and additional medical consultants,
an individual to be contacted in the event of an emergency, a discharge
feeding plan, a list of necessary supplies and medications, specific
follow-up directions and responsibilities of the home care agency
and caregiver(s).
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Discharge Guideline
Family Considerations for Discharge
During discharge planning, the unit-based neonatal team should:
▪ Encourage on-going caregiver communication and participation in all
aspects of care that are anticipated after hospital discharge. This includes
providing an individualized teaching plan.
▪ Assess caregiver(s) mental and physical capabilities to care for their infant.
Counseling prior to discharge may help identify biopsychosocial risks of
caring for an infant with ongoing care needs. Make referral to community
resources as applicable.
▪ Meet with caregiver(s) to assess the suitability of the infant’s home
environment.
▪ Ask the primary caregiver of the infant to demonstrate that he/she has
learned the required skills necessary for caring for the infant at discharge.
▪ Provide ongoing support and develop a specific care plan to assist
caregiver(s) in their home preparation and engage in evaluating future
needs, including:
68
▸
Transportation to/from the hospital.
▸
Child care needs for siblings during future hospital visits.
▸
Necessary infant care items in the home.
▸
Telephone/utility service availability.
▸
Psychosocial problems that may be encountered.
▸
Community support services.
▸
inancial resources (specifically to ensure that adequate resources
F
are identified commensurate with the infant’s ongoing care needs
and assistance in pursuing alternate resources as applicable).
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Discharge Guideline
▪ The availability of social support is crucial for the success of every
caregiver(s) transition to the care of their infant after discharge. Families
with limited support at home or limited resources such as home care
availability and/or community support must be considered in discharge
planning to assist the infant in a smooth transition home.
Potential High-Risk Situations
These considerations should alert the unit-based neonatal team to the
existence of a potentially high-risk environment which requires attention
prior to discharge. This list is not intended to be all-inclusive.
▪ Insufficient or lack of prenatal care.
▪ Caregiver(s) age < 18 years without a capable and willing adult caregiver
living in the same residence.
▪ Caregiver(s) has/have a history of involvement with the state designated
child protective agency.
▪ Evidence of previous or current caregiver substance abuse.
▪ Potential exposure to second-hand smoke.
▪ Evidence of caregiver(s) physical/mental disability.
▪ Absence of telephone service or other essential utilities in the residence
prior to discharge.
▪ Current legal and/or social services involvement for homelessness,
incarceration, litigation, domestic abuse, etc.
▪ Transportation difficulties or place of residence is located far away from
a hospital or outpatient service center.
▪ Inability to deliver follow-up or home care due to the location of the place
of residence or safety issues.
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Discharge Guideline
Medical Criteria for Discharge
Infants will be eligible for discharge if they meet the following medical
criteria:
▪ Establishment of physiologic competencies (including but not limited
to oral feeding, thermoregulation and respiratory control) and stability
regardless of weight or PMA.
▪ Infant displays normal vital signs, including body temperature and
sufficiently mature cardiorespiratory control, while fully clothed in an
open crib. These conditions should be maintained at an environmental
temperature that is comfortable for a lightly dressed adult consistent with
the “Back to Sleep” campaign.
▪ Infant demonstrates an appropriate overall weight gain, if weight gain
is expected based on PMA (normal weight trend in the 1st week of life
should be followed). Weight gain does not have to occur on one or more
consecutive days before discharge as it can vary due to timing of the
weight checks in relation to feeding, urination or stooling. Weight trend
can be followed as an outpatient in infants taking adequate volume with
a decrease in milk caloric density.
▪ Infant nipples all feedings. Up to 48 hours of full PO feeding may be
adequate observation for infants born < 34 weeks gestation. American
Academy of Pediatrics Committee on Fetus and Newborn support 24
hours of full PO feedings as adequate for babies born ≥ 34 weeks. Infants
discharged within one week of age with weight loss of more than 2% to 3%
of birth weight per day or a maximum of 7% should receive close follow
up shortly after discharge. There may be select infants who, based on their
specific feeding history, warrant an additional hospital observation period
prior to discharge. Appropriate arrangements should be in place for early
post-discharge follow-up.
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▪ Home gavage feedings may be considered in select infant-family dyads
for the infant with proven cardiorespiratory stability when feeding is the
last issue requiring continued hospitalization. Caregiver(s) should be
comfortable and demonstrate competency with all aspects of home
gavage feedings with appropriate community based supports in place.
This practice should have a limited role and be reserved for infants who
are not likely to achieve full oral feedings within a reasonable time frame.
▪ Studies have not demonstrated efficacy in the use of gastroesophageal
reflux disease (GERD) medications. Discontinuation of GERD medications
should be coordinated so discharge is not delayed if the clinical team
desires an observation period following cessation of medication(s). An
alternative option is to continue treatment with follow up as an outpatient.
▪ Up to 48 hours of stable body temperature in an open crib is typically
adequate for infants born < 34 weeks gestation. American Academy of
Pediatrics Committee on Fetus and Newborn support 12 hours of stable
body temperature as adequate for babies born ≥ 34 weeks. There may
be select infants who, based on their specific growth parameters and/or
thermoregulation history, warrant an additional hospital observation period
prior to discharge. Appropriate arrangements should be in place for early
post-discharge follow-up.
▪ For infants placed into an incubator solely for the purpose of phototherapy,
additional hospital observation is typically not required once treatment is
completed.
▪ Infant is breathing room air. Patients demonstrating an inability to actively
wean off oxygen, requiring a fixed low amount of oxygen who are
otherwise stable for medical discharge, should be considered for home
oxygen therapy and appropriate monitoring. As a safety measure, oxygen
saturation nadir in room air should be measured prior to discharge for
these infants.
▪ Up to 48 hours hospital observation after discontinuing oxygen therapy
is typically adequate to ensure medical stability prior to discharge home.
Home pulse oximeter and/or monitor should be considered if the desired
observation period is longer.
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Discharge Guideline
▪ Up to 48 hours hospital observation after discontinuing diuretics is typically
adequate to ensure medical stability prior to discharge home. Home pulse
oximeter should be considered if the desired observation period is longer.
▪ For late preterm infants (born at 34 0/7 through 36 6/7 weeks gestation)
who have demonstrated the necessary physiologic competency and
medical stability and to minimize the risk of readmission, careful discharge
planning including caregiver education and close post-discharge follow up
is indicated instead of continued in-patient monitoring.
▪ Infants born less than 37 weeks gestation have received a car seat
challenge test prior to discharge. Car seats and car beds are available for
lower weight infants not eligible or failing angle tolerance test in a standard
car seat. A similar time frame of cardiorespiratory monitoring in a car
bed should be completed prior to discharge for those infants failing the
car seat angle tolerance test. An outpatient study should be coordinated
prior to transitioning from a car bed to a car seat. Infants with significant
gastroesophageal reflux, neurologic diseases and certain malformations
(e.g., omphalocele, Pierre Robin sequence, osteogenesis imperfecta,
meningomyelocele) may require use of a car bed.
▪ The infant should demonstrate a period of physiologic stability following
eye exam (established by normal vital signs and feeding tolerance for at
least 1-2 feedings). Infants with a previous history of post-exam instability
(typically apnea and/or oxygen desaturation, poor feeding or temperature
instability) should be considered for up to 24 hours observation prior to
discharge.
▪ A follow up retinopathy of prematurity (ROP) examination should not delay
discharge except in those specific clinical situations whereby a narrow
oxygen saturation range is prescribed by the ophthalmologist, or when an
infant is near threshold for treatment and readmission would delay timely
therapy. Any prolonged hospitalization due to concerns in the caregiver(s)
reliability to adhere to outpatient appointments would be a delay secondary
to social disposition and should be addressed as indicated.
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Discharge Guideline
Discharge Planning Activities
The following activities should occur concurrently with the infant’s hospital
course:
▪ Identify contact phone numbers.
▪ Confirm insurance eligibility.
▪ Make sure that the infant has been added to the insurance policy.
▪ Evaluate caregiver(s) ability to perform care required for discharge.
▪ Identify alternate home caregiver(s).
▪ Ensure that the home environment is appropriate and ready; visit if needed.
▪ Evaluate for WIC or other need-based referrals.
▪ Evaluate transportation availability.
▪ An infant should have an appointment scheduled to be seen by a primary
care physician or other health care professional who is experienced in the
care of high-risk neonates within one week of discharge. Specific concerns
such as hyperbilirubinemia, feeding intake, weight gain issues or review
of outstanding tests may require earlier follow-up either in the office or at
home by a nurse.
▪ Appropriate and timely verbal and written information should be provided
to all health care providers scheduled to care for the infant after discharge.
▪ If clinically indicated an infant should receive a home nursing visit or an
evaluation in a physician’s office shortly after discharge.
▪ Home nursing visit(s) should be based on the complexity of the infant’s
clinical status and caregiver(s) capability. Private duty/shift care nursing
should be based on the infant’s needs and coordinated prior to meeting
medical discharge criteria. A detailed home care plan should be
transmitted to the home health agency.
▪ Subspecialty physician visits should be scheduled as clinically indicated.
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Discharge Guideline
▪ Evaluate need for home cardiorespiratory monitor and/or other home
health care needs. An apnea program or a physician familiar with the
management of apnea monitors should manage all infants discharged on
an apnea monitor. The name and phone number of the responsible parties
should be given to the caregiver(s) prior to discharge.
▪ Preterm infants should be kept in the supine position for at least one week
prior to discharge and predominantly in the supine position preferably from
32 weeks PMA onward so that they become acclimated to supine sleeping
before discharge and to model appropriate sleep positioning for the
parent/caregiver. Educational programs promoting safe sleeping practices
can improve family compliance after discharge.
▪ To lower risks of sudden infant death syndrome, the sleep environment
should follow safety recommendations from the American Academy of
Pediatrics. This includes education ensuring infants are placed in their
separate sleep environment prior to the caregiver falling asleep.
▪ To minimize the risk of readmission for dehydration and hyperbilirubinemia,
it is important to educate caregiver(s) how to evaluate feeding success and
detect signs of dehydration and hyperbilirubinemia. Coordinate delivery of
an effective breast pump to the mother as applicable.
▪ Determine appropriate nipple size prior to discharge.
▪ Determine appropriate enteral caloric density prior to discharge and
caregiver(s) ability to follow the prescribed “recipe” for non-ready-to-feed
preparations. Weight trend with potential need to increase milk caloric
density can be coordinated as an outpatient.
▪ A trial of ad-lib PO feedings may be reasonable in select infants who have
demonstrated the ability to orally complete the majority of their feedings.
▪ Preterm infants are at risk for underimmunization; ensure that all
immunizations are up to date. Timing of immunizations should be
coordinated so discharge is not delayed if the medical team desires
a post-immunization observation period.
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PROPRIETARY INFORMATION
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Discharge Guideline
▪ Car seat challenge infants born < 37 weeks gestation. Manufacturer
recommendations should be followed. Testing with appropriate equipment
should occur when the infant is stable in an open crib and preferably
prior to the day of discharge. Lateral support with rolled blankets and
towels may provide needed support for children with poor trunk and neck
control assuming these additions do not affect the fit of the car safety seat.
Retesting with repositioning using manufacturer insert, if available, should
occur immediately for any infant failing the initial test. Marginal failures
should be repeated within 24 hours; significant failures within 24 - 48 hours.
If the patient still fails, consideration for discharge in a car bed, use of
supplemental oxygen or further evaluation should occur.
▪ Regardless of the results of the car seat testing, very low birth weight
infants transported in either a car seat or car bed are at risk for clinically
significant cardiopulmonary events. Caregiver(s) should provide close
observation while limiting duration of travel as much as possible.
▪ Prior to the discharge of an infant with active ROP, caregiver(s) should
understand the importance of the exam. Careful coordination between
the medical team and the ophthalmologist should ensure that the exam
is completed in a timely fashion. Follow-up examinations should be
conducted in the outpatient setting with appropriate monitoring and
evaluation occurring during and after the procedure. If a clinical situation
exists whereby an infant is at risk for significant complications or instability
during or after the exam, the infant should be readmitted for the ROP
examination.
▪ Teach caregiver(s) CPR if indicated.
▪ Complete screening for critical congenital heart disease via pulse oximetry.
▪ Complete screening eye exam(s) for ROP and schedule appropriate followup per current AAP guidelines.
▪ Complete infant hearing screen. If hearing screen cannot be completed
prior to discharge, arrangements must be made for the infant to have
testing performed as an outpatient.
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patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Discharge Guideline
▪ Complete neurodevelopmental and neurobehavioral assessment with
appropriate follow-up, if applicable.
▪ Complete early intervention referral, if applicable.
▪ Confirm metabolic screening status.
▪ Hematological status has been assessed and treatment instituted,
if applicable.
▪ Complete Respiratory Syncytial Virus (RSV) prophylaxis per current AAP
guidelines. The initial dose of palivizumab can be planned either 48 to 72
hours before discharge or promptly after discharge.
▪ Complete circumcision, if applicable.
▪ Check that all medication prescriptions are filled and caregiver(s)
demonstrate safe administration.
▪ Any elective rooming-in process during the day or overnight should be
completed while the infant requires hospitalization for medical reasons.
▪ Elective transfer to an equivalent or lower level of care facility as well as
back-transports to the referring facility should be based on infant’s overall
medical stability, ability of the receiving facility to provide ongoing care and
projected length of stay. Travel distances placing an undue burden on the
family as well as regionalization of neonatal services should be taken into
consideration as well.
References: Discharge
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American Academy of Pediatrics. Joint Committee on Infant Hearing. Year 2007 position statement:
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Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
Alere Neonatal Clinical Management Guidelines | eighth edition
Discharge Guideline
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Alere Neonatal Clinical Management Guidelines were developed to address common clinical situations that arise in the NICU. Individual
patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
PROPRIETARY INFORMATION
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Discharge Guideline
Kemper AR, Mahle WT, Martin GR, et al. Strategies for implementing screening for critical congenital
heart disease. Pediatrics. 2011;128(5):e1259-e1267.
Kemper AR, Wallace DK, and Quinn GE. Systematic review of digital imaging screening strategies for
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Mills MM, Sims DC, Jacob J. Implementation and case-study results of potentially better practices to
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2):S124-S133.
Navar-Boggan AM, Halsey NA, Escobar GJ, et al. Underimmunization at discharge from the neonatal
intensive care unit. Journal of Perinatology. 2012; 32(5):363-367.
O’Neil J, Yonkman J, Talty J, Bull MJ. Transporting children with special health care needs: comparing
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Ortenstrand A, Waldenstrom U, Winbladh B. Early discharge of preterm infants needing limited special
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Phillips RM, Goldstein M, Hougland K, et al. Multidisciplinary guidelines for the care of late preterm
infants. Journal of Perinatology. 2013; 33 Supplement 2:S5-S22.
Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on
Infectious Diseases. 29th Edition. American Academy of Pediatrics; 2012.
Placencia FX, McCullough LB. Biopsychosocial risks of parental care for high-risk neonates: implications
or evidence-based parental counseling. Journal of Perinatology. 2012; 32(5):381-386.
Raines DA, Brustad J. Parent’s confidence as a caregiver. Advances in Neonatal Care. 2012; 12(3):183-188.
Reyna B, Pickler R, Thompson A. A descriptive study of mothers’ experiences feeding their preterm
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patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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Discharge Guideline
Silber JH, Lorch SA, Roenbaum PR, et al. Time to send the preemie home? Additional maturity at
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Smith VC, Hwang SS, Dukhovny D, et al. Neonatal intensive care unit discharge preparation, family
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Vecchi C, Vasquez L, Radin T, et al. Neonatal individualized predictive pathway (NIPP): a discharge
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Vohr BR, Yatchmink YE, Burke RT, et al. Factors associated with rehospitalizations of very low birthweight
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Weiss S, Goldlust E, Vaucher YE. Improving parent satisfaction: an intervention to increase neonatal
parent-provider communication. Journal of Perinatology. 2010; 30(6):425-30.
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patient circumstances should be considered which may lead to modification in the interpretation of these guidelines.
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About Alere Women & Children’s Health
NICU Care Management Program
Alere’s Neonatal Intensive Care Unit (NICU) Care Management Program
is focused on promoting positive clinical outcomes for infants admitted
to the NICU or Special Care Nursery. Alere provides comprehensive care
management services for premature and medically complex newborns,
working in collaboration with bedside physicians, nurses and other health
personnel. We have provided such services for more than 200,000 NICU
infants nationwide.
The Alere NICU program is patient centered, evidence-based and outcomes
driven and is overseen by our board-certified neonatologists and NICU
nurse care managers who have extensive experience in the challenges
that are commonly involved in caring for NICU patients.
Primary goals of Alere’s NICU program include:
▪ Supporting high quality and efficient NICU care in conjunction and
through collaboration with attending physicians, nurses and other
hospital personnel.
▪ Encouraging family involvement, education and interactions with their
physicians and nurses during an infant’s NICU stay.
▪ Supporting the discharge planning process and transition of an infant
at home.
▪ Providing follow-up family contact post hospital discharge to ensure
infant health in the home environment.
▪ Analyzing aggregate collected clinical data to identify clinical practice
benchmarks and define opportunities to enhance care.
The Alere NICU Care Management program is recognized and accredited by
the National Committee for Quality Assurance (NCQA) and by the Utilization
Review Accreditation Commission (URAC). For more information, please visit
www.alere.com.
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www.alere.com
Alere’s NICU Care Management Program
is accredited by the National Committee
for Quality Assurance for Case Management.
Alere’s NICU Care Management Program
is accredited by URAC for Utilization
Review and Case Management.
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