This app is designed to assist with your orientation to the Neonatal Intensive and Special Care Nurseries and Outreach wards.
Use this information alongside the relevant Practice Guidelines.
Monash Medical Centre (MMC) is the major hospital of Monash Health and the principal teaching hospital of Monash University.
Monash Children's Hospital (MCH) combines the paediatric services of MMC Clayton, Dandenong and Casey. The new 230-bed MCH building was completed on the Clayton campus in 2017.
It is one of the largest children’s hospitals in Australia and is one of only two tertiary paediatric hospitals in Victoria.
Births at MMC average approx. 4,100, of which 2,800 per annum are public hospital births and represent a selected high-risk population.
MMC is the quaternary centre for mothers with major medical or surgical problems for whom intesive care may be required, and is recognised as the referral centre for fetal surgical intervention.
Lower risk services are provided at Dandenong and Casey hospitals.
Level 6B nursery
64 beds
34 Level 6 capacity beds; remainder L3-5 capacity
Approximately 1500 admissions per year
Level 4 nursery
20 beds
Level 3 nursery
6 beds
Training and credentialing in neonatal resuscitation commences in the orientation program with the NeoResus Advanced Resuscitation course and follows with graded ‘hands-on’ experience acquired under the supervision of an experienced NICU NNP, Registrar, Fellow or Consultant. Record this experience in the Credentialing Book and keep it up to date
Monash Newborn requires that you become credentialed in newborn procedures before you areallowed to perform them without supervision.
The process for credentialing is detailed in the front of your Credentialing Booklet.
Until you are credentialed for each procedure, you should not perform it unsupervised.
Fellows are given provisional credentialing for 2 months after commencement for procedures Numbered 1 to 16 (excluding number 9) in the Fellow booklet and all relevant procedures in the Registrar booklet.
Instruction in the techniques of insertion of percutaneous CVC lines (PICCs) is confined to NNPs and medical staff pursuing a career in neonatal paediatrics.
Fellows and Nurse Practitioners must be specifically credentialed before inserting PICCs without supervision.
Handover in Room 5.1 at 08:00
Kingfisher NICU Fellow is responsible for compiling weekly radiology meeting list on Monday mornings
Followed by NICU Ward Round
Take responsibility for: admission, assessment and stabilisation, ongoing management, and preparation for discharge/transfer of all infants in the care of their team
Support the HMO/Registrar/NNP in presenting patients on morning ward rounds
More experienced Fellows will be expected to lead the morning round on at least one day per week
Support the HMO/Registrar/NNP in preparing infants for discharge/transfer
Take responsibility for ensuring that the parents of infants are provided with regular updates on their infant’s condition, including attendance at and leadership of family meetings.
Assist Registrar in presenting a brief case synopsis at the Tuesday Radiology meeting
Attend high-risk deliveries where required, in consultation with the Outreach Team.
20:00 Handover to Night Fellow/HMO/Registrar/NNP.
Handover in Room 5.1 at 08:00, followed by a more detailed SCN handover in Room 5.2
Lead morning round for either Kingfisher or Sunbird SCN team
Support HMO/Registrar/NNP in preparing infants for discharge/transfer
Take responsibility for ensuring that the parents of infants are provided with regular updates on their infant’s condition, including attendance at and leadership of family meetings
Assist HMO/Registrar/NNP in presenting brief case synopsis at the Tuesday Radiology meeting
Take an active clinical role in the follow-up of infants transferred to the Hospital in the Home (HITH) program, including: taking a daily formal report by phone or in person from the HITH nurse and Weekly review of patients on the HITH program in Specialist Suites on MCH Level 2
Babies on HITH are considered inpatients, therefore have direct admission rights. Some Babies can be a nurse initiated discharge. If a Baby has a Medical review this must be documented in EMR.
Assist Consultant staff in reviewing ambulatory patients in the Complex Neonatal Review Clinics and Growth and Development Clinics, and any other clinics as required (only where there is no designated Clinic/Audit Fellow)
Handover in NICU at 20:00
Provides a telephone update to the Consultant on Duty at approximately 22:30.
Makes an assessment of all new admissions occurring during their shift
Has a clear understanding of the clinical abilities and procedural skills of the Night HMO/Registrar/NNP and to provide a level of support that ensures their workload is manageable and within their competency
Triage attendance of Night HMO/Registrar/NNP at births, where indicated and requested by the Outreach Night Fellow
Leads morning handover at 08:00
Carry delivery pager #156 after 1630 (M to F and after 1200 on S, S, PH)
Receive handover from the outreach night fellow at 0800
At 0815, attend obstetric handover in birth suite
At 0830, attend maternity ward to prioritise reviews with maternity ward AMUMs and the outreach registrar
Liaise with neonatal unit team teams and outreach consultant re: expected high risk births and admissions
Review and manage infants on birth suite & maternity ward
Attend births where neonatal attendance (advanced skills) is indicated
Respond to Code Greens, Neonatal Code Blues and Neonatal MET calls
Antenatal counselling (inpatient) with outreach consultant supervision/oversigh
Provide telephone consultation to EPC and MC@H
Meet with maternity ward AMUMs at 1600 to ensure urgent matters for the day have been addressed
Liaise with ANUM and midwife responsible for baby to convey plan
Update the outreach handover list and TFT follow up spreadsheet on the G drive daily
Attend multidisciplinary FDU meeting 1st and 3rd Thurs of month 0900 (Webex)
Attend Perinatal M&M meeting 4th Thurs of month 0800 (Webex)
Supervise and support the outreach registrars/NNPs
Carry delivery pager #156 AND #5016 for other pages, and a SMARTpage
Receive 1945 handover from outreach day fellow in the Monash Newborn outreach team office
Attend 2100 obstetric handover in birth suite
Attend 0730 Antenatal Grand Round on Tuesdays (Webex)
Liaise with neonatal unit teams and duty consultant re: expected high risk births and admissions
Review and manage infants on birth suite & maternity ward
Attend births where neonatal attendance (advanced skills) is indicated. Support SCN night registrar in attending births.
Respond to Code Greens, Neonatal Code Blues and Neonatal MET calls
Antenatal counselling (inpatient) if required overnight
Support neonatal unit team if acuity and workload requires
Handover in Room 5.1 at 08:00 and if rostered for SCN a more detailed handover in Room 5.2
Present patients on morning ward rounds
Perform a clinical review of each patient following the ward round. All babies in SCN must be examined twice per week.
Perform clinical procedures on infants under the care of their team.
Present patients at handover rounds (afternoon and evening). Afternoon ward round for NICU is at 16:00 and SCN short shift to handover to the long shift is also at this time
Present brief case synopses at the Tuesday Radiology meeting
Attend high-risk deliveries where required, in consultation with the Outreach Team
Ensure discharge summaries are continually updated
Our aim is to have discharge summaries, referrals, pharmacy scripts and discharge examinations done at least one day prior to planned day of discharge / transfer
For interhospital transfers the receiving hospital medical team must be provided a handover prior to confirming transfer date / time with PIPER
For complex Babies being discharged home, a handover should be provided to the family GP
N1 Registrar: responsible for Kingfisher and Sunbird NICU team patients, and will receive an evening handover from the Long Day NICU Registrar and Fellow at 20:00 each night, this is a walk around handover
N2 Registrar: responsible for Kingfisher and Sunbird SCN team patients, and will receive an evening handover from the Long day SCN Registrar at 20:00 each night in Sunbird Workroom
Ensure that all relevant clinical events are comprehensively documented in EMR and handed over to the appropriate day team at morning handover at 08:00.
Attend high-risk deliveries where required, in consultation with the Outreach Team
Assist in preparing potential discharges for the following day (discharge summaries and newborn examinations)
Carry delivery pager #156
Attend outreach team handover at 0800 in the Monash Newborn outreach office, followed by maternity ward handover
Review and manage infants on birth suite and maternity ward under supervision of the outreach fellow and outreach consultant
Meet with maternity ward AMUMs at 1600 to ensure urgent matters for the day have been addressed
Attend births where neonatal attendance is indicated
Respond to Code Greens, Neonatal Code Blues and Neonatal MET calls
Update the outreach handover list and TFT follow-up spreadsheet on the G drive daily
Attend 0800 outreach handover in the Monash Newborn outreach team office
Attend elective C/S list in theatre
Where available, assist outreach registrar with birth suite and postnatal ward infant review
Call the Duty Consultant when you're unable to come to work. This enables the Consultant to arrange alternative staffing.
Please do not notify sick leave via WhatsApp or the Fellow.
Short-term Neonatal Follow Up Clinic
Monday 13:30 MN Neonatologist and MN Fellow / NNP
Clinic fellow to collect patient list from Rowena on Monday morning
Review of complex neonatal discharges requiring multidisciplinary input
Tuesday AM: A/Prof Flora Wong
Medical and neurodevelopmental assessment of high risk preterm infants at 2 years' corrected age
Tuesdays and alternate Thursdays as scheduled
Contact Atul in advance if you would like to attend these clinics
Multidisciplinary 3 month CA early development screening clinic for infants;
Less than 29 weeks or less than 1000 grams at birth
With moderate - severe brain injury at any gestation
Major surgery (e.g. CDH, TOF, NEC)
Monday PM in Therapies Clinic
<31+6 weeks
>32 weeks with risk factors (e.g. HIE, sepsis, severe IUGR)
Cranial ultrasound should be performed more frequently if hydrocephalus or persistent PVE present. MRI should be considered at term
All babies born at <26 weeks or less than 750 grams require an MR Head at term
Gestation |
Risk |
Timing |
<31+6 weeks |
Low |
Day 3, 8 and 42 |
<31+6 weeks |
High (<24weeks; compromised) |
Day 1, 3, 8, 28 and 42 |
<31+6 weeks |
IVH or PVE |
Day 3, 8, 14 and 42 |
>32 weeks |
High (HIE, sepsis, severe IUGR) |
Day 3 and 28 |
Born < 29 weeks gestation or < 1000 grams
Moderate-Severe brain injury at any gestation. This includes; Grade III-IV IVH, cystic PVL, HIE, neonatal seizures, hydrocephalus etc.
If newborns fall outside of the above eligibility-criteria please speak with Family resource nurse, OT/Physio or Atul regarding follow-up.
When using the calculator select baseline EOS Incidence of 1.0 per 1000 live births as this reflects our local incidence of culture confirmed EOS.
Take a minimum of 1 mL for babies ≥ 35. Any lower volumes risk a false negative blood culture
Blood cultures in EOS will report positive by 36 hours after sample taken
If the culture is negative at 36 hours and the clinical scenario is not otherwise concerning for sepsis it will usually be optimal to stop antibiotics prior to the 36 hour dose.
Enteral feeding in infants with congenital heart disease Guideline
Enteral nutrition for preterm babies Guideline
Parenteral Nutrition Monash Guideline
Commence enteral feeding within 24 hours of birth with colostrum only
Grading up Feeds
BW / Feed Frequency |
Starting feeds |
Grade up regime |
Grade up volumes |
<1000g. Hourly feeds. |
1 mL EBM 4 - 6 hrly and then increase to 1 mL 2 hrly and then 1 mL hrly as EBM becomes available |
0.5 - 1 mL per 24 hrs |
500 - 700g: Increase by 0.5 mL each day. 800 - 1000g increase by 1 mL each day |
1000 - 1500g. 2 hourly feeds. If >1000g and stable, can feed 3 hourly |
Start < 20 mL/kg/day (i.e. 1-2 mL/kg every 2 hours) |
1 mL 6 - 8 hrly |
1000 - 1200g increase by 1 mL every 12 hrs. 1300 - 1500g increase by 1 mL every 8 hrs. 1600 - 1750g increase by 1 mL every 6 hrs or 2 mL every 12 hrs |
>2000g 3 - 4 hourly demand |
60 mL/kg/day |
Increase by 20-30 mL/kg/day as daily increment |
Fortifer: If birth at <32 weeks or BW <1800g. Commence once feed enteral feed volume 100 mL/kg/day. Administer at half concentration for 24 hrs, then at full concentration if tolerated once enteral feed volume 120 mL/kg/day
For <1000g, PN must be started within the first 24 hrs
For <1500g, consider PN early
For infant expected to require IV fluids >3 - 5 days, consider PN
Otherwise Glucose 10% is used on Day 1
Solution 150 (Contains Na 14 mmol and K 6 mmol) in Glucose 10% thereafter
Fluids above Glucose 12.5% concentration are best administered via central venous lines
Week One
Day |
<28/40 or <1000g |
>28/40 or >1000g |
Term |
1 |
80 |
60 |
60 |
2 |
80-100 |
80 |
80 |
3 |
100-120 |
100 |
100 |
4 |
120-140 |
120 |
120 |
5 |
150 |
140 |
140-150 |
6 |
(165) |
(160) |
Fluid volumes in brackets may be increased to this amount at the discretion of the clinical team
Monitoring Requirements
Initially |
Usually |
Longterm |
|
Sodium/Potassium/Calcium with capillary blood gas |
Daily< |
Twice weekly |
Weekly |
Consider triglyceride (≤2.8 mmol/L) |
When receiving 2g/kg/day |
No further testing if (≤2.8 mmol/L) |
No further testing if (≤2.8 mmol/L) |
Urea/Creatinine/Phosphate |
Weekly |
Weekly |
Alternate weeks |
Glucose with capillary blood gas |
Daily |
Twice weekly |
Weekly |
Bilirubin/LFTs |
With Clinical signs |
Alternate weeks |
Infants on long term PN should have monthly monitoring of vitamin A, D and E, iron studies, zinc, B12, selenium and folate. They should be referred to Gastroenterology team and dietician for further advice regarding nutritional blood monitoring
Discharge process for infants with chronic neonatal lung disease on home oxygen therapy Guideline
Obtain and document consent from parents
Medical Officer / NP to order immunisations via EMR
Preterm infants have an increased risk of cardio-respiratory instability after immunisation
Cardio-respiratory monitoring should be performed for the first 48 hours post immunisation
Engerix B Paediatric |
IM |
0.5 mL |
Within 7 days of birth (ideally within 24 hours) |
||
No catch-up required |
||
Infanrix Hexa |
IM |
0.5 mL |
hepB-DTPa-HiB-IPV |
||
Prevenar 13 |
IM |
0.5 mL |
Pneumococcal conjugate (13vPCV) |
||
Rotarix |
oral |
1.5 mL |
Rotavirus |
||
Surfactant replacement therapy Guideline
Preterm infants of birth gestation <37 weeks
Age <72 hours
Diagnosis of respiratory distress syndrome (RDS) likely on clinical assessment, and confirmed on chest x-ray
Required FiO2 persistently ≥0.30 to maintain target SpO2, on nasal CPAP of ≥7 cm H2O. Infants in a lower FiO2, but with other evidence of significant RDS may receive MIST at consultant discretion. Infants of birth gestation <26 weeks are likely to benefit from early surfactant treatment regardless of FiO2 requirement
Adequate spontaneous respiratory drive
Immediate need for intubation
Required FiO2 persistently ≥0.60
Alternative cause for respiratory distress (e.g. untreated pneumothorax, congenital anomaly)
Circulatory compromise/collapse
Maxillo-facial, airway or lung malformation
Recurrent severe apnoea despite caffeine treatment
Already enrolled in the OPTIMIST trial
Preterm infants (or term infants at consultant discretion) for whom MIST is not suitable
Age <72 hours
Diagnosis of respiratory distress syndrome (RDS) likely on clinical assessment, and/or confirmed on chest x-ray
Consider Endotracheal tube in situ (intubation for surfactant treatment in preterm infants on CPAP with required FiO2 persistently ≥0.35-0.40 to maintain target SpO2, if unsuitable for MIST)
Surfactant administration for infants with a diagnosis other than RDS, and for term infants, will be at consultant discretion
Requirement for supplementary oxygen to maintain target SpO2 (surfactant may be administered to ventilated infants without oxygen requirement at consultant discretion, e.g. if <28 weeks’ gestation or clear diagnosis of RDS on chest x-ray)
Ventilated infants with a diagnosis of RDS will receive a second dose of surfactant if receiving FiO2 >0.21 after 8-12 hours
Repeat administration of MIST is appropriate if FiO2 is ≥0.30 to maintain target SpO2, after 8-12 hours
Infants <26 weeks treated with MIST, who subsequently require a second dose of surfactant, will be intubated and receive the second dose via endotracheal tube
-Rationalising medicine administration times to daily to 12 hourly (so its easier for parents on discharge)
-Making sure the colecalciferol product for discharge on a script is the 0.5microg/0.04 mL oral liquid (not the 2000 units/mL)
-Making sure vaccine status is up to date
All doses must be prescribed as caffeine citrate
1 mg caffeine = 2 mg caffeine citrate
Standard |
20 mg/kg |
10 mg/kg/dose every 24 hours, commencing 24 hours after the loading dose |
|
Maintenance doses of up to 20 mg/kg have been used |
Discontinue at 34 weeks (unless significant apnoea continues) |
|
Monitor infant for 5 - 7 days after ceasing caffeine |
Gestation at birth < 32 weeks or |
|
birth weight < 1800 grams |
Continue until 34 - 36 weeks of corrected age or considered no longer at risk of NEC
Sodium Chloride 23.4% (Oral) Guideline
Maintenance dose: 1 - 8 mmol/kg/day orally |
|
Interval: Give in 2 - 4 divided doses |
Weight (kg) x 0.6 x (140 - actual serum sodium in mmol/L)
Note: Prophylactic iron supplementation is not routinely required for babies receiving PreNAN Human Milk Fortifier or PreNAN at 160+ mL/kg/day
Commence Ferrous Sulphate at Day 28 of age if the baby is not receiving PreNAN Fortifier or PreNAN Formula Milk
2 mg/kg/day elemental iron as single or divided dose
2 mg/kg/day elemental iron as single or divided dose if the baby is receiving PreNAN Fortifier or PreNAN Formula Milk
4 mg/kg/day elemental iron as single or divided dose for all other milk types
Prophylactic iron indicated if birth weight < 2000 grams OR GA at birth < 35 weeks |
|
Commence at 4 weeks once tolerating full enteral feeds |
|
Not routinely needed if on fortified EBM or PreNan |
|
Continue until 1 year old if breast feeding or until receiving 750 mL/day of iron containing formula |
Universal vitamin D supplementation for all babies, regardless of gestation, birth weight or feeding method |
Continue until 1 year old
Prophylaxis: 1 mL oral 8 hourly
Treatment: 1 mL oral 6 hourly
Birth weight < 1500 grams |
|
Infants >1500 grams who receive more than 48 hours of IV antibiotics |
|
Consider in infants >1500 grams who require prolonged intubation, and/or postnatal steroids, and/or prolonged parenteral nutrition (TPN) |
Continue until 1500 grams
If receiving for IV antibiotics, cease 3 days after stopping antibiotics
Surfactant replacement therapy Guideline
200 mg/kg (or 2.5 mL/kg)
100 mg/kg (or 1.25 mL/kg) every 8-12 hours
Maximum of three doses in total (inclusive of initial dose)
Birth Weight (g) |
1st dose (mg) |
1st dose (mL) |
2nd/3rd dose (mg) |
2nd/3rd dose (mL) |
|||||
500 |
100 |
1.3 |
50 |
0.6 |
|||||
750 |
150 |
1.9 |
75 |
0.9 |
|||||
1000 |
200 |
2.5 |
100 |
1.3 |
|||||
1250 |
250 |
3.1 |
125 |
1.6 |
|||||
1500 |
300 |
3.8 |
150 |
1.9 |
|||||
1750 |
350 |
4.4 |
175 |
2.2 |
|||||
2000 |
400 |
5 |
200 |
2.5 |
|||||
2500 |
500 |
6.3 |
250 |
3.1 |
|||||
3000 |
600 |
7.5 |
300 |
3.8 |
|||||
0.075 mg/kg/dose 12 hourly for 3 days then,
0.05 mg/kg/dose 12 hourly for 3 days then,
0.025 mg/kg/dose 12 hourly for 2 days then,
0.01 mg/kg/dose 12 hourly for 2 days then cease
TOTAL CUMULATIVE DOSE: 0.89 mg/kg
0.25 mg/kg 8 hourly for up to 3 doses
Commence 4 hours before extubation.
TOTAL CUMULATIVE DOSE: 0.75 mg/kg
To facilitate weaning from assisted ventilation and improve lung function in infants at risk of chronic lung disease
To facilitate extubation
Prevention of serious lower respiratory tract disease caused by RSV in infants at high risk of RSV disease:
Premature infants (<28 weeks' gestation) with established bronchopulmonary dysplasia defined as oxygen / ventilation requirement at 36 weeks' post-menstrual age.
Infants with haemodynamically significant heart disease, defined as: cynotic heart disease, pulmonary hypertension, and heart failure requiring treatment with medications.
Standard |
15 mg/kg as Intramuscular Injection |
The proposed dose is 15mg/kg monthly for 5 doses |
|
Season for approval is May - September |
|
Outpatient Palivizumab Ig clinic dates 2022: - Wednesday 11th May - Wednesday 8th June - Wednesday 6th July - Wednesday 3rd August - Wednesday 31st August |
< 1500 g administer 0.5 mg (0.05 mL) as a single dose at birth
≥ 1500 g administer 1 mg (0.1 mL) as a single dose at birth
Administer 2 mg orally for 3 doses:
First dose: At birth
Second dose: 3 – 5 days of age (at time of newborn screening) or at one week of age
Third dose: 4 weeks of age
For babies being discharged, a discharge script must be provided and filled. Administration of the remaining dose/s is to be done with the infants general practitioner
Metabolic bone diseaese of prematurity Guideline
As a minimum at Day 28:
FBC + Retics, ALP, PO4 and capillary gas every 4 weeks
If ALP >500 (even if PO4 normal) or PO4 <1.8: start Phosphate 1 mmol/kg/day (Step 1)
Recheck ALP and PO4 in 2 weeks. If ALP rising / PO4 falling, increase Phosphate to 2 mmol/kg/day OR start Calcium 1 mmol/kg/day (Step 2)
If on recheck ALP rising / PO4 falling increase Phosphate to 3 mmol/kg/day (Step 3)
If ALP <500, recheck 'Bone Bloods' in 4 weeks, earlier if any concerns. If ALP rising / PO4 falling consider Step 1 (above)
Blood transfusion, red cell administration Guideline
Transfusion: Blood components and human plasma products Guideline
Guidelines for non-acute transfusion in prems and ex-prems:
Done as part of 'Bone Bloods' or if clinically indicated
The table gives the applicable Hb threshold below which transfusion is generally recommended
Postnatal week |
Respiratory Support |
No Respiratory Support |
1 |
110-130 |
100-120 |
2 |
100-125 |
85-110 |
3 |
85-110 |
70-100 |
Retinopathy of Prematurity Criteria for Screening Guideline
GA at birth < 32 weeks OR
Birth weight < 1501g OR
Otherwise requested by neonatologist
For infants born <27 weeks gestation: The first screen must be carried out at 31 weeks postmenstrual age. (e.g. infant born at 26 weeks gestation is to be seen at 31 weeks corrected age)
For infants born >27 weeks gestation: The first screen must be carried out >28 days or >32 weeks gestation corrected age whichever is later (e.g. infant born at 31 weeks gestation is to be seen at >28 days of age or approximately 35 weeks corrected age)
Follow up as determined by ophthalmologist
Eye exams are performed by Opthalmology Consultant or Registrar
Examinations on Tuesdays
Dilating drops - tropicamide 0.5% and phenylephrine 2.5%
One drop to each eye (of each dilating drop), repeat after 15 mins. Total of 2 drops to each eye of each dilating drop.
Eye drops to be given 30 mins prior to eye examination
A quick run through of the standard elements of newborn discharge exam
View on desktop computer: the website uses flash and won't run on most mobile phone browsers
Watch from 13 - 24 minutes for key how-to. The entire video is worth watching.
Discuss any concerns with newborn eye exam with the Neonatal Paediatrician. Conditions such as congenital cataract are emergencies.
A useful summary of a systematic approach to thyroid function tests for newborns
Transplacental passage of thyroid stimulating antibodies (TSHR-Ab aka TRAB) can cause neonatal hyperthyroidism
Between 2% and 12% of infants of mother with Graves develop hyperthyroidism
The newborn usually presents within the first 10 days
A negative maternal screen for TSHR-Ab makes this complication very unlikely
The precise level of TSHR-Ab as measured in 3rd trimester may be very helpful in quantifying the risk in a given newborn.
TSHR-Abs can persist after maternal treatment
If maternal TSHR-Ab negative the risk to infant is low
Newborn screening test 48 - 72 hours and TFTs (TSH and Free T4)
If results normal, repeat TFTs on Day 10
Antenatal evidence fetal hyrotoxicosis
Elevated TSHR-Ab in 3rd trimester
Clinical thyrotoxicosis in 3rd trimester
Carbimazole / propylthiouracil treatment in 3rd trimester
Minimum 48 hours observation (on post-natal) before discharge for at-risk
Cord blood for TSH and T4
If normal follow "Low risk infant" pathway
If hyperthyroid urgent referral to Endocrinology and perform TSH receptor antibody
Findings may include:
Tachycardia and heart failure
Low birth weight and poor weight gain
Feeding difficulty
Irritability
Can cause both hyper and hypothyroidism in the newborn
However risk of either is quite low
Routine Guthrie screening at 48 - 72 hours
TFTs on Day 10
Routine Guthrie screening at 48 - 72 hours
Developmental Dysplasia of Hips Guideline
Request hip ultrasound at 6 weeks CGA
Breech position or transverse lie
Family history of DDH
Associated significant foot deformities
Asymmetric leg length
Asymmetric thigh creases
Instability indicated by "clicky" hips
Place request forms in Green Folder in Monash Newborn Administration Office.
Clicks are not significant. If unsure either:
Re-examine in a day or two, or
Ask Fellow to examine
Urgent referral to Paediatric Orthopaedic Clinic. Discuss with Paediatric Physio prior to discharge
Do not initiate treatment and no need to wait for ultrasound results
Patients will be seen in the Physiotherapist Led Paediatric Orthopaedic Clinic within 1 week
Fax referrals to Paediatric Orthopaedic Case Manager
Fax: 959 44226
Phone: 959 44073
Graf |
alpha |
beta |
Implications |
1 |
> 60 |
< 55 |
Normal |
2a |
50 - 59 |
< 55 |
Immature: repeat at 3 months |
2b |
50 - 59 |
< 55 |
Persisting at 3 months: Referral for Pavlik harness |
2c or worse |
<50 |
≥ 55 |
Urgent referral for Pavlik harness |
A single green vomit in a newborn may be the only early warning sign of malrotation and volvulus
Perhaps 30% of infants with green vomit have a surgical pathology
Any delay in diagnosis of malrotation with volvulus can result in bowel loss
Discuss urgently with Fellow/Neonatologist
History / examination / AXR / gas / blood culture usually indicated
Urgent abdominal ultrasound or upper GI study often required
Consider sepsis
Consider other causes of bowel obstruction
Often no pathology is identified
30 to 50% of murmurs heard are due to CHD
Note that half of newborns with significant CHD don't have a murmur
Perform thorough cardiac exam
4-limb blood pressures
Pre- and post-ductal sats
Post-ductal sats should be ≥ 94% in air
Ask Fellow to examine
Re-examine prior to discharge
Referral to Cardiology. Must be discussed with Neonatologist prior to referral and ECG done prior
Follow up with GP in 4 - 6 weeks
Occasionally (usually when you're seeing children in the Monash Newborn Clinics), only after discussion with Cardiology, you may be asked to refer to the Paediatric Murmur Clinic, you can fill out this form electronically.
Postnatal care in the first week (Hep B Pg 29) Guideline
Administer Hepatitis B vaccination (H-B-Vax II Paedatric or Engerix-B Paediatric) and Hepatitis B Immunoglobulin for neonates born to mothers who are HBsAg positive within 12 hours of birth
To order Hepatitis B Immunoglobulin: In EMR orders type Haem Blood Product Transfusions. Then select Hepatitis B Ig
Refer to Paediatric ID for follow-up at 8 months. Include maternal details / UR, recent viral load
Refer to Paediatric ID for follow-up at 3 - 4 months
Include maternal details / UR, recent viral load
Infant of mother who has diabetes
Prematurity (gestational age <37 weeks
Low birth weight (<2500g) irrespective of gestation
Small for gestational age (<10th percentile)
Clinical wasting, regardless of birthweight
Maternal treatment with medication that interfere with glucose homeostasis, most importantly beta-blockers and sodium valproate.
Large for gestational age (>90th percentile) if no GTT antenatally or GTT abnormal
Family history of metabilc disorders (e.g. MCADD)
Admission to Nurseries with conditions including: prematurity, sepsis, respiratory distress, encephalopathy/CNS depression, rhesus isoimmunisation, polycythemia
If hypoglycemia is unusually severe, or prolonged, or lacks an obvious cause...
Perform critical hypoglycaemia bloods during an episode
Syphilis in Pregnancy and the newborn Guideline
Preventing perinatal transmission of HIV Guideline
Access Prompt for relevant Monash Guidelines or Antenatal care plans as a first resource
If local guidelines are not available the following may be used in consultation with the Duty Neonatologist / Fellow
The guideline from the Australian Society for Infectious Diseases is a helpful resource to get you started
A fetal ultrasound soft marker for aneuploidy
Found in 5 to 25 % of fetal scans (ethnicity dependent)
Represents mineralisation in papillary muscle
In the absence of aneuploidy there are no long term implications
Routine echocardiogram is not required
No increased risk of rhythm disturbance: no need for ECG
Complete a standard neonatal examination
No additional investigations or follow up required
Appropriate reassurance
Well late preterm and/or 2 -2.5 kg baby Postnatal ward Guideline
A dimple or pit below the intergluteal crease
Sacral pits are rarely significant
Asymmetric intergluteal crease
Midline lipoma or vascular birthmark
Very hairy overlying skin
Base of pit not visible
Sacral ultrasound prior to discharge
Hypospadias
Microphallus
Excessive scrotal pigmentation
Hypoglycemia or hyponatremia
Testes may not reach scrotum till 3 to 4 months of age
Ultrasound to locate testes is not usually indicated
Document in the Green Book
Recommend GP review at 6 months
Should be referred to Paedatric Surgeons if not in scrotum by 8 months
Umbilical hernias are common (and are more common in premature infants and infants with Trisomy 21 or congenital hypothyroidism)
Most spontaneously disappear by 2 years old
Uncomplicated umbilical hernias do not require any investigations or treatment
Follow-up with Family GP and refer to Paediatric Surgeon if still present at 2 years old
Term infant of appropriate birth weight: up to 10% weight loss is normal
Preterm infant or SGA infant: up to 7% weight loss is normal
Cesarean delivery increases the likelihood of > 10% weight loss
Flaherman et al Peds 2015 has detailed normative data on weight loss
Excessive weight loss is usually due to problems with lactation and breast feeding
Provide practical support for breast feeding
Consider possible illness in infant
Discuss with Fellow if weight loss 12% or more in term infant
Discuss with Fellow if weight loss 10% or more in preterm or SGA infant
Tongue-ties are not generally of any concern
If there is parental, midwife concern or poor weight gain in the neonatal period frenulotomy may be considered
Prior to consideration of frenulotomy feeding should be assessed by a Lactation Consultant and there should be a discussion with the Neonatal Consultant
If tongue tie thought to be a possible cause of poor feeding / attachment, refer to Paediatric Surgeons
Vitamin D in pregnancy and the newborn Guideline
Promote universal vitamin D supplementation with 400 units vitamin D daily for all babies, regardless of gestation, birth weight or feeding method in the first 12 months.
In the maternity wards: parents will be routinely recommended to obtain Vitamin D drops for their babies from a community pharmacy
In neonatal units: please prescribe daily Vitamin D supplementation to all babies, and provide a script on discharge
In special circumstances only, if there is concern regarding parents/carers' ability to access Vitamin Drops for their babies, a single dose of colecalciferol may be given to the baby before discharge - please see guideline for more details
QR Code Core Teaching Check-In
Mondays and Wednesdays from 1-2pm are protected teaching times and ASCOMs should be forwarded to consultants with the exception of the Outreach Team.
Scheduled teaching can also be viewed remotely via Zoom
Have you ever asked, "what should I read to better understand the rationale behind clinical decision making in the nursery?" The consultants have put together a list of 50(ish) articles as suggested reading for JMOs rotating through Monash Newborn. The idea is that you can complete the list average a mere 2 articles per week in a 6 month period. Included are the sentinel studies that provide the scientific basis or evidence for everyday management. You'll find an impressive number of studies that are locally led, Melbourne is a global leader for NICU research.
Teaching for the day is announced by the overnight NICU fellow and overnight SCN registrar at handover.
-Protected teaching! NICU and SCN JMOs will forward your ASCOMs to the duty consultants for that hour so you can learn uninterrupted. Outreach is not protected, sorry.
-Please be punctual, lots of sessions are taught by our colleagues in other services.
-No core teaching on the first Wednesday of the month because of "Fellows Teaching."
-Presented by the registrars.
-Assigned once per 6 months based on your schedule.
-Goal: educate the JMOs and consultant about the chosen topic.
-Choose your topic with your clinical advisor.
-Doug's advice for grand rounds: choose classic NICU topic or something that interested you, let Brooke know your topic a few days in advance, present an overview and something new about it from the literature, creativity is appreciated.
-Those in attendance provide feedback via "survey monkey" and you can discuss the feedback with your clinical supervisor.
-Presented by fellows/NNPs.
-Assigned once per 6 months based on your schedule.
-Goal to educate the JMOs and consultant about the chosen topic in addition to the manuscript.
-Choose your manuscript with your clinical advisor.
-Doug' advice for journal club: RCTs work best, send the article to Brooke to send to the group a few days in advanced, evaluate if the article would change our practice, and teach us something we didn't learn by reading the article. If you email the corresponding author a question, I guarantee you will hear back within 24 hours or I'll buy you coffee.
-See the powerpoint above from Prof Lex Doyle on how to evaluate an article.
-Those in attendance provide feedback via "survey monkey" and you can discuss the feedback with your clinical supervisor.
-Two presentations per session about current research at Monash Newborn.
-Joint session with the RNs.
-It is a good place to let people know about your projects!
-M&M, joint session with the RNs.
-Risha coordinates and asks the fellows to present the cases for discussion.
-SCN Fellow (on that day) and a Surgical Registrar pair up to present a hot topic in surgical care.
-Can be a recent patient that stimulates a lively conversation with the consultants and JMOs.
-Evidence based discussions work the best.
-Ram Nataraja (consultant) and Janani Krishnan (registrar) coordinate the surgical side.
-City-wide grand rounds coordinated between RCH, RWH, Mercy, Sunshine, and Monash.
-Takes the place of core teaching that day.
-Access via Zoom.
-Clinical X-Ray Meeting: Tuesdays at handover, 8:30-9am
-New Ideas Board: Tuesdays 12:50-1pm
-Pediatric research presentations: 1st Tuesdays 1-2pm
-Perinatal mortality meeting: 2nd Tuesdays 8-9am
-Clinical FDU Multidisciplinary meeting: 2nd Tuesdays 930-10am
-Monash Newborn Unit Meetings: 3rd Tuesdays 1-2pm
-Pediatric ground rounds: Thursdays 1-2pm
Role |
ASCOM Number |
Pager |
KF / Night NICU Fellow |
24469 |
384 |
KF NICU Registrar |
24470 |
4396 |
SB NICU Fellow |
24471 |
4075 |
SB NICU Registrar |
24472 |
4544 |
SCN Fellow |
24473 |
4545 |
KF SCN Registrar |
24474 |
157 |
SB SCN Registrar |
24475 |
4076 |
Outreach Fellow |
0481902531 / Speed Dial: 3269 |
5016 |
Outreach Registrar |
0466028282 |
4574 |
Delivery Pager |
156 |
|
Elective C/S |
4946 |
|
Clinic / Audit Fellow |
4945 |
|
Duty Consultant 1 |
24476 |
|
KF Consultant |
24477 |
|
SB Consultant |
24478 |
|
Outreach Consultant / Duty Consultant 2 |
24479 |
|
SCN Consultant |
24480 |
|
MN Director (Alice) |
24481 |
Casey SCN Reg 08:00 - 16:30 |
83187 |
|
Paed Surgery Reg |
0409610878 |
|
Paed Anaesthetics |
24361 |
|
Endocrinology |
939 |
|
Renal |
4287 |
|
Respiratory |
4104 |
|
Neurology |
4487 |
|
Cardiology |
827 |
|
Cardiology - ECG Fax |
43979 |
|
Cardiology - Monash Heart Fax |
95946239 / 42246 |
|
Cardiology - ECG Technician |
42249 |
|
Genetics Office |
42026 |
Fax: 46022 |
SB ANUM |
24183 |
|
KF ANUM |
24182 |
|
FRN KF |
24218 |
|
FRN SB |
24219 |
|
Lactation |
4834 or 349 |
|
Birth Suites |
45280/79 |
|
Theatre |
43385 |
|
Jessie McPherson SCN |
45369 |
|
Postnatal - North |
45260/61 |
|
Postnatal - South |
45268 |
|
Elective C/S Midwife |
0448134104 |
Social Work SB |
24462; 0466022049 |
|
Social Work KF |
24315; 0466730937 |
|
Physiotherapist |
0481915011 |
|
Occupational Therapist |
0466016198 |
4501 |
Dietician |
0435960630 |
|
Speech |
Adele / Olivia: 0481918067 |
Janella: 0434667142 |
Music Therapy |
0481908002 |
|
Pharmacist SB |
0427711348 |
|
Pharmacist KF |
0466730940 |
515 |
MCH Pharmacy |
23200 |
Imaging (Main number) |
42200 |
|
X-ray 07:45 - 17:00 |
23021 |
|
X-ray out of hours |
42205/06 |
331 |
CT |
42198 |
|
MRI |
23223 |
|
Ultrasound |
23028 |
|
Imaging Fax |
23818 |
|
Imaging Nurses Station |
23022 |
|
Biochemistry |
42662 / 43323 |
|
Blood Bank |
43491 |
|
Cytogentics |
44135 |
|
Cytology |
43036 |
|
Haematology (General) |
43489 |
|
Haematology (Coags) |
43458 |
|
Histopathology |
43493 |
|
Microbiology |
44565 |
|
Serology/Virology |
44527 |
|
VIDRL |
93422600 |
Original idea, design and coding by Dr. M Hewson.
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