148: Medications Used in the Neonatal Intensive Care Unit

INTRODUCTION

This section provides a description of medications used in the contemporary care of sick newborn infants.^a It is not intended to be an exhaustive list of all drugs available for infants, nor is it intended to be an in-depth source of information about neonatal pharmacology. Readers are encouraged to consult with their institutional pharmacists regarding issues of pharmacokinetics, drug interactions, drug elimination and metabolism, and monitoring drug serum levels. Information on medications and breast-feeding and pregnancy can be found in Chapter 149.

When the designations of neonate/newborn or infant are used for medication doses, it refers to the following:

• Neonate/Newborn: Birth to 28 days postnatal age.

• Infant: >28 days (1 month) to 1 year of age.

ACETAMINOPHEN (APAP) (LIQUIPRIN, TEMPRA, TYLENOL)

INDICATIONS AND USE: Analgesic, antipyretic.

ACTIONS: Analgesic effect—inhibition of prostaglandin synthesis in the central nervous system (CNS) and peripherally, blocking pain impulse generation. Antipyretic effect—inhibition of hypothalamic heat-regulating center.

DOSAGE: PO, PR.

• Preterm infants 28–32 weeks: 10–12 mg/kg/dose PO every 6–8 hours or 20 mg/kg/dose PR every 12 hours. Maximum daily dose: 40 mg/kg.

• Preterm infants 33–37 weeks; term neonates <10 days: 10–15 mg/kg/dose PO every 6 hours or 30 mg/kg PR loading dose; then 15 mg/kg/dose every 8 hours. Maximum daily dose: 60 mg/kg.

• Term infants ≥10 days: 10–15 mg/kg/dose PO every 4–6 hours or 30 mg/kg PR loading dose; then 20 mg/kg/dose every 6–8 hours. Maximum daily dose: 90 mg/kg.

ADVERSE EFFECTS: Rash, blood dyscrasias (neutropenia, leukopenia, and thrombocytopenia), and hepatic necrosis with overdose; renal injury may occur with chronic use.

PHARMACOLOGY: Extensively metabolized by the liver primarily by sulfonation, and by glucuronidation to a much lesser extent. Excretion by the kidney with elimination half-life: term infants—~3 hours, preterm infants >32 weeks—5 hours, and in premature infants <32 weeks—up to 11 hours. Prolonged elimination with liver dysfunction.

COMMENTS: Rectal administration may result in inaccurate dosing. Prophylactic use during vaccination may result in potential reduction in antibody response. Beginning 2011 into 2012—transition to one pediatric concentration 160 mg/5 mL and elimination of 80 mg/0.8 mL infant drops per U.S. Food and Drug Administration (FDA) recommendations. N-acetylcysteine is the antidote of choice for acetaminophen poisoning.

ACETAZOLAMIDE (DIAMOX)

INDICATIONS AND USE: Reduce intraocular pressure in glaucoma; an anticonvulsant in refractory neonatal seizures; decrease cerebrospinal fluid (CSF) production in posthemorrhagic hydrocephalus; treatment of renal tubular acidosis.

ACTIONS: Competitive, reversible, carbonic anhydrase inhibitor; increases renal excretion of sodium, potassium, bicarbonate, and water, resulting in the production of acidosis. Decreases ...