Clinical Guides

• Resuscitation
• Respiratory
• Cardiovascular
• Nutrition
• Gastrointestinal
• Neurology
• Infectious disease
• Renal
• Endocrinology
• Haematology
• Miscellaneous

Resuscitation

Normal acid-base at birth	Mild metabolic acidosis	Moderate metabolic acidosis	Severe metabolic acidosis
pH >7.15 and BE> -6 mmol/L and lactate ≤6 mmol/L	pH 7.00 to 7.15 or BE -11 to -6 mmol/L or lactate >6.0 mmol/L	pH 6.90 to <7.00 or BE -15 to -12 mmol/L	pH <6.90 or BE ≤-16
NEWS only indicated if other risks	If normal examination, repeat gas in 3 hours and monitor with NEWS for 24 hours. If the examination is non-reassuring, repeat gas within 1 to 2 hours and perform serial neurological examination for the first 6 hours, as well as NEWS for 24 hours. If in doubt, admit for observation.	Admit for close neurological monitoring for at least 6 hours to assess if therapeutic hypothermia is indicated	Admit, consider therapeutic hypothermia after stabilisation, do not use radiant heater

Sarnat score	Low <4, medium 4-12, high >12
Level of consciousness	0 Normal, 1 Hyperalert, 2 Lethargic (less responsive), 3 Stupor (unresponsive)
Spontaneous activity	0 Normal, 1 Mild decrease, 2 Decreased, 3 None
Tone	0 Normal, 1 Mild increase, 2 Hypotonia, 3 Flaccid
Posture	0 Normal (flexion of all limbs), 1 Distal flexion only, 2, Proximal extension + distal flexion, 3 Decerebrate
Suck (primitive reflexes)	0 Normal, 1 Weak suck, 2 Weak and incoordinated suck or bite only, 3 Absent suck or bite
Autonomic system activity	0 Normal, 1 dilated pupils or HR >160 or RR>60; 2 constricted pupils or HR<100 or periodic breathing, 3 Apnoea and ventilated Mean (SD) pupillary d in term neonates 3.8 (0.8) mm

Grade	Encephalopathy features
Mild	Low Sarnat, hyperalert, increased tone, mild acidosis
Moderate	Persisting medium Sarnat score, moderate acidosis, EEG discontinuous ± seizures
Severe	Apgar <5 or PPV at 10 min, high Sarnat score, severe acidosis, EEG burst suppression, seizures

Respiratory

• Ventilation target: PC0₂ 5.5-7.5 kPa while maintaining pH ≥7.25
• Oxygen:
  • Commence oxygen: <36 weeks Sp0₂<90%, ≥36 weeks Sp02<93%
  • Target on oxygen: 91-95% (6.5-8.0 kPa) all gestations; for PPHN at ≥38 weeks 91-96% (8.0-12.0 kPa)
  • Histogram: <36 weeks aim for time Sp0₂<90% not more than 20% (<80% not more than 10%)
  • Oximetry born <36 weeks and ≥36 weeks: <5% of time Sp0₂<90%, mean Sp0₂≥93%, DSI10 <10/h
• Extubation:
  • PCO₂ in range; pH ≥7.3; HFOV MAP ≤12 and amplitude <1.5 x MAP or SIPPV-VG Vt ≤5 mL/kg
  • SBT: PEEP 6-7 cm H₂0, PS 5 cm H20; a positive (successful) test is defined as absence of apnoea requiring stimulation or bradycardia (HR<100 for ≥10 s) and Fi02 increase ≤10% to maintain target Sp0₂
• Surfactant:
  • Intubate all 23-week infants and 24-week infants with incomplete ACS and give surfactant once stabilised on ventilator
  • Otherwise, first dose if: 24-27 weeks Fi0₂ >0.25 for 1 h or moderate WOB; 28-29 weeks Fi0₂ >0.3 for 1 h or moderate WOB; 30-31 weeks usually only with Fi0₂ >0.3-0.4 and moderate WOB
  • Give second dose if <30 weeks and still intubated after 12 h (give at 6 h if Fi0₂ is increasing despite optimisation of ventilation) or on non-invasive support and Fi0₂ is increasing beyond the above thresholds (give from 6-24 h)
  • Only 1 MIST if 24 weeks and use 2nd MIST cautiously at 25-26 weeks
• RDS/PIP:
  • Start nCPAP 6 cmH₂0, flow 6-8 L/min, increase up to 9 cmH₂0 by CHIPS criteria (≥6 desaturation Sp0₂ <80% or bradycardia <100/min within 6 hours; any ABD requiring PPV; RR>70/min for >30 min)
  • If born at 28 weeks continue for ≥2 weeks at ≥5 cmH₂0
  • Weaning off criteria: stable for ≥48 h on nCPAP 6 cmH₂0 in air and RR <60/min and no desaturation <80 and no ABD requiring intervention and ≥7 d since last attempted trial off; nCPAP 5 cmH₂0 x48 h then remove
  • PIP at term: assign primary neonatologist if on CPAP or Fi0₂ >0.3 at 38 weeks’ PMA
• Diuretics: PIP on maximal nCPAP with oedema or inability to wean; review use every 2 weeks; weekly electrolytes initially
• Glucocorticoids: DART protocol if the infant is not ready for extubation at 10-14 d due to high Fi0₂ (>0.4-0.5), hypercapnia or frequent intermittent hypoxia; corticosteroids are unlikely to help with apnoea or hypoventilation; stop after 3-4 d if limited response and reassess
• Jensen grading of BPD at 36 weeks’ PMA: 0 no support; 1 oxygen therapy <1 L/min; 2 HF or CPAP; 3 mechanical ventilation
• Babies on home oxygen, criteria for weaning:
  • Mean Sp0₂ >95%
  • <3% of time with Sp0₂ <90%
  • Desaturation index 10 <10/h (drop in Sp0₂ of 10% or more below previous baseline and <3 min)

Condition	MAP	I:E	Hz	VThf
Acute RDS	10-16 (wean to 9-12)	1:1	10-15	1.5-2.2 ml/kg*
Established RDS (>48-72 h)	10-16	1:2	9-12	1.8-2.5 ml/kg
PIE	9-13	1:2 or 1:3	7-9	1.8-2.5 ml/kg
PPHN	10-14	1:2	7-9	1.8-2.5 ml/kg

Cardiovascular

• Echo imaging
  • Framerate determines temporal resolution: use 110-130 FPS; minimise sector depth and width to maintain FPS
  • Spatial resolution primarily determined by probe frequency
  • Compression controls dynamic range (higher compression, greater DR, increased grey scale and less contrast)
  • GE: UD clarity reduces speckles, DDP (dynamic depth precession) normally set at 5.6, HD reduces speckles but uses harmonics
  • Doppler:
    • Nyquist limit is the maximum Doppler shift displayed = half pulse repetition frequency (PRF); the velocity scale controls PRF to determine the maximum velocity; increase PRF by decreasing 2D sector depth
    • Colour Doppler: velocity scale determines the range of velocities that are assigned a colour; use the lowest scale for vessel of interest, e.g. coronary arteries <30 cm/s; increase PRF by decreasing depth of colour box; reduce Doppler frequency to increase sensitivity for deeper structures; wall filter reduces motion artefacts (if colour is outside the vessel increase filter)
  • Cardiac output:
    • Doppler gate just distal to valve
    • LVO: AV trace for VTI, AoV annu diam(2D) for z-score, Ao ann diam for CO
    • RVO: PA Trace for VTI, PV ann diam(2D) for CO and z-score
  • LA:Ao
    • M-mode at the level where both aortic cusps are visualized
    • Aortic root: anterior margin of the anterior aortic wall to the anterior echo of the posterior wall at the onset of the QRS complex,
    • LA dimension: anterior echo of the posterior aortic wall to the leading echo of the left atrial posterior wall, at the time of mitral valve opening and peak anterior motion of the aortic root
  • PAAT/RVET: measure mid-MPA
  • Tei index: (ICT + IRT)/ET
• VSD
  • Size: small <40% of AVA; moderate 40-60% of AVA; large >60% AVA.
  • Subtypes: muscular, perimembranous, inlet, outlet/subpulmonic
  • Antenatal small muscular or perimembranous VSD: if no murmur at 12 hours, refer to GP for murmur check at 6 weeks
  • Postnatal VSD: if small GP monitoring, refer if murmur persists >3 years
• Secundum ASD:
  • Size: small 4-5 mm; moderate 6-7 mm; large 8-10 mm; very large >10 mm
  • <6 mm no follow-up; 6+ mm repeat echo at 3 months
• PDA
  • Size mm/kg: <1.5 restrictive, 1.5-3 small, 3-5 moderate, >5 large
  • Screening echo if born <26 weeks at 5-7 d, repeat in 1 week if patent
  • Indomethacin IV (0.2 mg/kg) or ibuprofen PO (20/10 mg/kg) if AEDF in ACA; REDF in aorta, NEC1; pulmonary oedema; CHF (MR, gross dilatation, poor contractility)
  • Consider chlorothiazide (10-20 mg/kg/dose BD) and spironolactone (1-3 mg/kg OD) for pulmonary oedema or CHF
• Branch pulmonary stenosis:
  • repeat echo at 6 weeks if Vmax >2.5 m/s or z-score <-2

	D1 Systolic BP			D10 Systolic BP
Gestation at birth	10th	50th	90th	10th	50th	90th
24	32	41	52	40	51	64
28	35	44	56	47	61	75
32	37	50	62	54	69	85
36	42	55	69	60	76	94
40	47	63	76	65	83	101

	Stroke volume	Systemic VR	Pulmonary VR
Adrenaline	↑↑↑	↑↑↑	↑↑
Noradrenaline	↑/~	↑↑↑	↓/~
Vasopression	~	↑↑↑	↓/~
Dobutamine	↑↑	↓/~	~
Milrinone	↑↑	↓↓	↓↓
Dopamine	↑	↑↑	↑↑↑

PPHN severity	Features
Moderate	TR RVsP 0.5 to 1.0 systolic Reduced IVS relaxation to flat PAAT/RVET 0.2 to 0.3 Ductal R-L shunt 0.2 to 0.4 Atrial R-L shunt <0.4
Severe	TR RVsP >1.0 systolic Flat IVS to paradoxical systolic motion PAAT/RVET <0.2 and/or notching Ductal R-L shunt >0.4 Atrial R-L shunt >0.4

Nutrition

	<28 weeks	≥28-31 weeks	≥32-36 weeks
D1 P100*	2.0 (GDR 3.3)	2.0	2.0 (if <1.5 kg)
D2 P100	3.0 (GDR 5.0)	3.0	3.0 (if <1.5 kg)
D3 P100	3.8 (GDR 6.6)	3.8	3.8 (if <1.5 kg)
SMOF 20%	3.0-3.5	3.0	3.0
Refeeding bloods (CMP)	D3, 7 (±D5, 10)	If <1 kg	–
Feeds	180 ml/kg/d Increase 1 ml q8-24 h Change to q3h when 33 weeks and ≥1.5 kg	180 ml/kg/d Increase 1 ml q4-12 h Change to q3h when 33 weeks and ≥1.5 kg	160 ml/kg/d Start 1-2 ml if <1.5 kg or 2-3 ml q3h if ≥1.5 kg Increase 2-3 ml q3h (or 40-60 ml/kg/d if planned for formula feeding)
Fortification	From 5 ml	From 5 ml	If <2 kg, from 5 ml (or PTF)
Vitamin D (10 ug/400 IU per drop)	0.1 mL (800 IU) from 5 ml or 100 ml/kg/d Measure every 4 weeks	0.1 mL (800 IU) from 5 ml Reduce to 1 drop at 32 weeks Measure if high risk	1 drop (400 IU)

• For moderate and late preterm infants provide IVN if birthweight <1.5 kg and there is likely to be a delay in mothers milk of > 4 days

Gastrointestinal

• NEC:
  • Stage 1 Suspected: distension, feed intolerance, PR bleeding, ABD, intestinal dilatation
  • Stage 2 Radiologically confirmed: pneumatosis, portal venous gas. 2a mildly ill; 2b moderately ill (metabolic acidosis, abdominal tenderness)
  • Stage 3 Radiologically confirmed + shock/critically ill (3a) OR perforation (3b)
• Conjugated hyperbilirubinaemia
  • Red flags for gastroenterologist review: <3 weeks of age, acholic stool, liver failure INR>2.0, no precipitating factor
  • Check maternal toxoplasma, rubella, syphilis, hep B status
  • Firstline investigation: urine CMV, gas, LFT, albumin, coag screen with fibrinogen, FBC, TFT, cortisol
  • Abdominal US with 6-hour fast for persisting or worsening cholestasis
  • Consider Pepti-Junior (medium chain triglycerides)
  • Optimus vit A 0.2 ml (7400 IU), cholecalciferol Puria 0.5 ml (3750 IU), Micel-E 0.5 ml (78 IU), Konakion 0.2 ml (2 mg)

Neurology

• IVH screening: <1 kg or <29 weeks, D5-7, repeat after 4-6 weeks
• EEG:
  • Notch filter 50 hz, High pass filter 0.5 Hz, Low pass filter 70 hz
  • Gain 10 uV/mm and adjust accordingly
  • Use Trends tab to scan, not Review tab
• Myotomes:
  • C5: should abduction
  • C6: Elbow flexion, wrist extension
  • C7: Elbow extension, wrist flexion
  • C8: Thumb extension
  • T1: Finger flexion
• Maternal epilepsy: postnatal review and neurodevelopmental follow-up:
  • Peripartum seizure
  • Monotherapy with agents other than levetiracetam or lamotrigine
  • Polytherapy
• Central hypotonia
  • Molecular karyotype, Prader Willi screen, mytonic dystrophy DM1 gene CTG repeats, Guthrie card for SMA
  • TFT, CK, gas, plasma ammonia, AA, urine organic acids and metabolic screen, very long chain fatty acids
  • Brain MRI, echo

Parameter	PMA	23	24	25	26	27	28	29	30
Ventricular index	median	8.5	8.6	8.8	8.9	9.0	9.2	9.4	9.7
	P97	10.4	10.6	10.8	11.0	11.1	11.4	11.7	12.0
Anterior horn width	median	1.7	1.6	1.5	1.4	1.3	1.3	1.3	1.3
	P97	4.0	3.8	3.6	3.6	3.5	3.7	3.9	4.3
TOD	median	11.6	12.2	12.8	13.3	13.8	14.2	14.6	14.9
	P97	15/7	16.7	17.6	18.5	19.3	20.0	20.7	21.7

• Neonatal montage has 4 channels per side, 3 aEEG (Fp1-O1, Fp2-O2, C3-C4)

Infectious disease

• CMV screening by day 7: <28 weeks or < 1 kg
• Nystatin prophylaxis: 1 ml q8h (0.5 ml NGT, 0.5 ml mucosa); antibiotics >7d, steroids, IVN; <28 or <1 kg until >28 weeks or >1 kg
• Lactoferrin (Bovine) 0.5 ml (10 drops) daily if <32 weeks of <1.5 kg, stop ~35 weeks
• Lactobacillus (Dicoflor 60) 1 capsule daily if <32 weeks of <1.5 kg stop ~35 weeks
• Hepatitis B:
  • Hep B vaccine (Egerix) 0.5 mL (10 microg) IMI and HBIG (HyperHep) 0.5 mL (100-110 IU) IMI
  • HBsAg and anti-HBs at 9 months
  • Infants of HBsAg-positive mothers should be notified: HepB consent
• Syphilis:
  • Paired maternal/neonatal RPR, placental PCR, FBC, LFT, long bone x-ray ±CSF VDRL
  • Neonatal treatment: penicillin G 30 mg/kg q12h x 10/7
  • Follow-up neonatal serology: RPR at 6 weeks, 3, 6 and 12 months (need x2 -ve), repeat CSF in 6 months if neurosyphilis
• Maternal iGAS <28 days:
  • Baby well and ≥8 days of age, give amoxycillin 25 mg/kg BD for 10 days
  • Baby <8 days of age or symptomatic, take blood culture and commence IV penicillin G 30 mg/kg q12 h, and convert to amoxycillin when stable for a total of 10 days of antimicrobial treatment
• Chorioamnionitis: maternal pyrexia >38’C plus one of maternal tachycardia>100, fetal tachycardia >160, purulent discharge, smelly liquor, uterine tenderness, maternal leukocytosis >12-15
• Vaccination:
  • 6 weeks (D42): Rotarix (RV1) 1.5 mL PO; Infanrix-hexa (DTaP-IPV, Hep B/Hib) 0.5 mL IMI; Prevenar 13 (PCV13) 0.5 mL IMI
  • 3 months (D90): Rotarix (RV1); Infanrix-hexa (DTaP-IPV, Hep B/Hib; Prevenar 13 (PCV13) if high risk*, Bexsero (Meningococcal B)
  • 5 months (D150): Infanrix-hexa (DTaP-IPV, Hep B/Hib); Prevenar 13 (PCV13), Bexsero (Meningococcal B)
  • 6 months: QIV influenza, repeat after 1 month, then annually if chronic respiratory or cardiac disease, Down syndrome
  • 12 months: Priorix (MMR), Prevenar 13 (PCV13), Bexsero (Meningococcal B)
  • 15 months: ACT-HIB (Hib), Priorix (MMR), Varilrix (Varicella)
  • 24 months: Pneumovax 23 (23PPV) for high risk*
  • *Pneumococcus high risk: <28 weeks, corticosteroids, chronic pulmonary disease, cardiac disease, Down syndrome
• Palivizumab
• Gram-positive antimicrobial sensitivity
• Gram-negative antimicrobial sensitvity

Timing of onset of maternal chickenpox	Risk of vertical neonatal varicella disease	Neonatal prophylaxis	Isolation and monitoring after birth	Breastfeeding
More than 21 d before birth	Low Acquired passive maternal immunity (risk of congenital varicella syndrome <20 weeks	None	No isolation of mother or baby Refer for neonatal review if exposure < 20 weeks	Yes
From 21-6 d before birth	Low to moderate (mild disease) Some acquired passive maternal immunity (reduced if preterm)	None	Isolate baby with mother in maternity area and observe for 48 to 72 h with NEWS Refer for neonatal review Main risk period for neonatal varicella disease is up to 4 d from birth	Yes
From 5 d before to 2 d after birth	High (disseminated disease) No acquired passive maternal immunity	VZIG 200 IU IMI (1 vial) If ≥35 weeks, consider PO acyclovir for 7 d* If <35 weeks, give IV acyclovir for 7 d	If possible, isolate mother in non-maternity area Baby to stay with mother if ≥35 weeks Discharge to home as soon as possible Main risk period for neonatal varicella disease is 5 to 10 dafter birth Consider KFHCN review	Yes If vesicles on breast, give expressed milk until rash is dry
From 3-28 d after birth	Risk of horizontal transmission	Acyclovir PO for 7 d, starting 7 d after onset of maternal rash If <28 weeks or <1 kg VZIG 125 IU IMI	Discharge mother and baby to home as soon as possible Main risk period for neonatal varicella disease is 7 to 14 d after onset of maternal rash	Yes If vesicles on breast, give expressed milk until rash is dry

Renal

• Hydronephrosis:
  • Low risk: >28 weeks RPD 7 to <10 mm ± central dilatation; RUSS 1-3 months
  • Intermediate risk: >28 weeks RPD ≥10 mm ± central dilatation; RUSS D7 and 1-3 months
  • High risk: >28 weeks RPD ≥7 mm and peripheral or ureteric dilatation, other abnormality, unexplained oligohydramnios; individual management
• AKI KDIGO criteria:
  • Stage 1 Cr rise 1.5-1.9 x lowest baseline or increase ≥26 umol/L in 48 h, UO <0.5 ml/kg/h x 6-12
  • Stage 2 Cr rise 2.0-2.9 x lowest baseline, UO <0.5 ml/kg/h for >12 h
  • Stage 3 Cr rise ≥3.0 x lowest baseline, UO <0.3 ml/kg/h for ≥24 h or anuria ≥12 h
• ANZ Neonatal Kidney Collaborative AKI definition
  • 22-27 weeks >130 umol/L
  • 28-31 weeks >100 umol/L
  • HIE >100 umol/L

Endocrine

• Hypoglycaemia
  • Maternity
  • Primary medical therapy
  • Rescue medical therapy
• Synacthen (tetracosacrtin, synthetic ACTH) 1 ml = 250 ug
  • Dose 250 ug x BSA m²/1.73, IV push
  • Collect cortisol at 30 and 60 min (plasma 0.5 ml)
  • If no IV, give IMI and do capillary collect at 60 min
  • Normal 400 nmol/L at 30 min, 460 nmol/L at 60 min
• Posterior hypospadius/micropenis
  • Testosterone 14 d
  • SRY FISH, cytogenic karyotype
  • US gonads, pelvis ± kidneys
• Maternal diabetes
  • GDM 75 g OGTT: fasting ≥5.3 mmol/L, 1 h ≥10.6 mmol/L, or 2 h ≥9.0 mmol/L
  • Suspected type 2 at booking: HbA1c ≥48 mmol/mol
  • Suspected prediabetes at booking: HbA1c 42 to 47 mmol/mol
• Hypothyroidism
  • Starship checklist

Haematology

• RBC transfusion 20 ml/kg over 4 h
  • Hb 70-80: Fi0₂ 0.25-0.40, surgery, shunt
  • Hb 81-100: Fi0₂ >0.40 or ventilated
  • Hb 101-120: consider if critically unwell, Fi0₂ >0.4 and ventilated
• Erythropoietin if <28 weeks, <1 kg, Hb <95 and reticulocytes <150, commence from ~2 weeks (relative contraindication ROP stage 3, Plus); 400 IU/kg SC twice weekly (can increase to three times weekly), give total iron 6-12 mg/kg (check ferritin, FBC fortnightly)
• Platelets 15 ml/kg over 60 min if <20 (maintain >50 for surgery or LP)
• Albumin 20% 5 ml/kg = 1 g/kg (give 1-2 g/kg), administer over 1 h, frusemide 1 mg/kg IV 1 h post
• Isoimmunisation:
  • High risk: Rhesus (Rh) (D, c, C, e, E, Ce, cE), Kell (K, k), Duffy (Fya) (Cord FBC, Br, DAT, blood group)
  • Low risk: Rh (Cw), Duffy (Fyb), Kidd (Jka, Jkb, Jk3), MNS (S, s), Gernich (Ge3) (if jaundice develops test every q6-12h)
  • Not significant: MNS (N), Lewis (lea, leb, Lea+b), Lutheran (Lua, lub), Sda, H, P1

Cord Br <50 and Hb >110	Cord Br 50-70 and Hb >110	Cord Br >70 and Hb <110
Admit to PNW Repeat bilirubin in 6 h, start phototherapy if >100 μmol/L at 6 h or rate of rise >8 μmol/L/h, otherwise repeat bilirubin in ~12 h	Start prophylactic phototherapy on PNW (fibreoptic blanket and one overhead LED unit) Repeat bilirubin in 6 h, then after q6-12h Admit for intensive phototherapy if the rate of rise is >4 μmol/L/h	Consider admission to KFNC for intensive phototherapy Prepare for exchange if the rate of rise is >4 μmol/L/h

Age	<27 weeks	Exch	27-30 weeks	Exch	31-32 weeks	Exch	33-34 weeks	Exch	35-37 weeks	38 + weeks	Exch
12-24	90	180	110	200	120	225	130	210	200	240	350
25-36	110	205	140	230	155	255	165	240	220	260	430
37-48	125	220	160	250	175	275	190	260	240	285	470
49-72	140	235	175	270	195	295	210	295	260	310	510
>72	150	250	190	290	220	320	240	340	310	350	510

Miscellaneous

• Humidification: <26 weeks 5-7 d 90% (70% from ~ 5 d); 26-28 weeks 5 d 70%; 29-30 weeks 3-5 d 70%, open cot once humidity stopped
• Newborn screening: 24-72 h; <1.5 kg or < 32 weeks D14 and D28; <29 weeks at 36 weeks
• Sucrose 25% 0.5 ml, up to 4 doses in 24 hours, caution <1000 g and/or <31 weeks (under tongue)
• ROP screening:
  • <30 weeks or <1.25 kg; commence 31-32 weeks
  • Drops: phenylephrine 2.5% and topicamide 0.5%, 1 drop each eye, repeated after 5 minutes
  • Zone 1 = twice the radius from disc to fovea; Zone 2 extend to nasal ora serrata; Zone 3 is beyond Zone 2; posterior retina is Zone 1 and part of Zone 2
  • ROP is abnormal vascularisation of hypoxic retina; Stage 1 = demarcation line at the vascular-avascular juncture; Stage 2 = ridge from the demarcation line with small neovascular tufts; Stage 3 = neovascular proliferation from the ridge into the vitreous or flat neovascularization; Plus disease = venous dilation or arterial tortuosity
  • Pathophysiology: phase 1, delayed vessel growth due to higher than physiologic oxygen content of retina via poorly auto-regulated choroidal vasculature; phase 2, avascular retina becomes more metabolically active and relative hypoxia upregulates VEGF causing pathologic neovascularisation.
• Clinic follow-up:
  • KFHCN <32 weeks
  • Clinic <32 or <1 kg, or other clinical concern
• Additives to 500 ml fluids:
  • 3.75 ml of NaCl 4 mmol/ml = 1/5 NS (0.18% NaCl)
  • 10 ml of KCL 1 mmol/ml (0.15% KCL
• Neonatal diagnosis of FGR:
  • Customised birthweight centile <3
  • Customised birthweight centile from 3 to <10 AND two or more additional features: obstetric diagnosis of FGR, major maternal risk factors for FGR, BMI z-score <-1.3, Length z-score <-1.3, Skin or body fat z-score <-1.3
  • Customised birthweight centile ≥10 AND obstetric diagnosis of FGR AND evidence of placental insufficiency
  • Major risk factors: age 40+, smoking, drug use, hypertension, preeclampsia, diabetes with vascular disease, renal impairment, antiphospolipid syn, APH, abruption, previous FGR or SGA, previous preeclampsia, previous stillbirth

Obstetric diagnosis of FGR: Early onset <32 weeks	Late onset 32+ weeks
Any of: *Customised EFW or AC <3 *UA Doppler with absent or reversed end-diastolic flow *Customised EFW or AC <10 AND either abnormal UA Doppler (PI >95th centile) or abnormal uterine artery Doppler (PI >95th centile or bilateral notching)	Either *Customised EFW or AC <3 *Two or more of: • Customised EFW or AC <10 • Slowing of fetal growth: decline in customised EFW or AC by 30 centiles from 28 weeks’ gestation onwards • Abnormal uterine artery Doppler (PI >95th centile) or UA Doppler (PI >95th centile or bilateral notching) or cephalic placental pulsatilty index ratio (<5th centile)

Skinfold mm	10th centile	50th centile	90th centile
Triceps	4.0	5.4	8.0
Subscapular	3.8	5.2	7.0
Suprailiac	3.2	4.4	5.4

• Fetal drug exposures
  • Acetazolamide: risk of transient RTA, monitor NEWS 48 h for tachypnoea, routine hypoglycaemia screening
  • Rituximab: risk of transient B cell deficiency; check lymphocyte subsets and immunoglobulins at birth; if abnormal, notify immunology and repeat at 6 months; avoid rotavirus, other immunisations OK (BCG from 1 year, if requried)
  • Elthrombopag: Vit K IMI OK, FBC 24 hours, day 7, day 21-28 (risk of delayed thrombocytopenia), OK to breastfeed, check LFT day 21-28 if breastfeeding and mother continues on treatment (secretion into milk low)
• Genetic testing
  • Consent form
  • LabPLUS request form
  • Send away test request form