NICU Medications

This drug has recently come into favor for short-term paralysis due to its short duration and rapid reversal. Many anesthesiologists are choosing rocuronium during surgical procedures, and many neonatologists are administering it during elective placements of endotracheal tubes to minimize trauma and improve the success of the procedure. It is administered intravenously and wears off the quickest of all the available paralytics.

This is one of the only antibiotics available to treat a viral infection --- herpes simplex (HSV). Neonatal HSV is potentially lifethreatening. Acyclovir is extremely safe, with minimal side effects. It can be administered either orally or intravenously.

This is an inhaled medication that dilates the pulmonary bronchioles. It is used in older children and adults to treat acute asthma attacks. In infants, it may or may not help with the residual effects of chronic lung disease/bronchopulmonary dysplasia (BPD). It is also used to treat high potassium levels that may occur during renal failure.

This is a very common oral antibiotic that is widely used in all age groups, including neonates, infants, children, and adults. It is used to treat common bacterial infections, such as ear and bladder infections. It is not very good for treating more serious infections, such as pneumonia, strep throat, or infections in the bloodstream (known as “sepsis” or “bacteremia”). In the NICU, it is most commonly used in babies who have abnormalities in their kidneys/bladder that put them at risk for urinary tract infection (UTI – see diagnoses/conditions). This use continues, despite recent evidence-based recommendations from the American Academy of Pediatrics to the contrary. (http://pediatrics.aappublications.org/content/128/3/572.full.html. The New American Academy of Pediatrics Urinary Tract Infection Guideline. Thomas B. Newman, Pediatrics 2011;128;572; originally published online August 28, 2011). Amoxicillin is very safe and well tolerated.

Antibiotic universally used to treat for possible infection right after birth, because it is the only antibiotic that will treat infection with Listeria meningitidis, a rare but potentially devastating disease that can infect babies during the birth process. It also is very effective against the more common, but equally dangerous, Group B streptococcus infection. Given intravenously, ampicillin has virtually no known side effects or toxicities in neonates.

This drug is very similar to midazolam, except it lasts a little longer. Also a benzodiazepine, it is used to decrease agitation or activity that may be making your baby worse, or in conjunction with a painful procedure. It can be given either orally or intravenously, and occasionally may be given rectally or intra-nasally. Its main side effect is respiratory depression. Because babies in the NICU are on continuous monitoring for both breathing and heart rate, this is not a major concern, and any effects on breathing can be immediately detected and reversed.

This is an oral medication used when there is too much acid in your baby’s blood, usually because his/her kidneys are losing too much bicarbonate. This is very common in premature babies, whose kidneys have not yet fully developed and, thus, allow more substances to escape in the urine than they should. The medication is very safe, as the same process that causes the kidneys to excrete the wrong stuff in the first place also results in the BiCitra being eliminated in the urine.

Given either orally or intravenously. Among other effects, it stimulates breathing and is used to treat apnea of prematurity. It also may help decrease the risk of developing chronic lung disease in extremely premature infants, and can stimulate the kidneys to make urine. There is some suggestion that caffeine may also help long-term brain development. Side effects in babies are not like the side effects in adults. Caffeine does not seem to affect blood pressure and rarely causes high heart rates. A wide range of levels in the blood stream is considered safe (called the therapeutic index). Unlike its short half-life in adults, caffeine takes a very long time to completely leave a baby’s body so when it is stopped, it is unlikely that the baby experiences a “caffeine headache” or other unpleasant “caffeine withdrawal” symptoms some adults have experienced.

This is an antibiotic that is sometimes used to treat suspected infection in neonates. It is a 2nd generation cephalosporin, meaning it has broad activity against most gram positive organisms and some gram negative bacteria. Many physicians prescribe this antibiotic when infection is a possibility; however, a recent research study demonstrated that infants given cefotaxime empirically rather than an aminoglycoside had poorer outcomes.

A powerful steroid that can improve lung function in the short term, concerns regarding its long-term effect on brain development have resulted less frequent use than in the past. Dexamethasone can be given either intravenously or orally, and can markedly decrease the level of respiratory support and/or supplemental oxygen an infant may be requiring. However, long term studies on children who received high or repeated doses of dexamethasone have raised questions regarding its negative impact on brain development. Because it remains a very powerful – and potentially life-saving -- tool for the critically ill baby, the risks and benefits of its use should be carefully considered on a case-by-case basis.

Very similar to dopamine, although its effects are slightly different. Dobutamine works more on making the heart beat stronger than does dopamine, works a bit less on increasing the blood pressure, and has virtually no effect on the kidneys. Like dopamine, it can burn the tissues and should be given through a central line whenever possible.

Used in very sick babies to increase blood pressure, help the heart beat stronger, and help the kidneys make urine. It acts very quickly when started, and its effects disappear shortly after it is stopped. It is administered continuously and can damage the surrounding tissues if the medicine leaks out of the vein in which it is infusing. If possible, it should be given through a catheter placed in a major blood vessel that ends deep inside the body.

Used in life-threatening emergencies to make the heart start beating normally, as well as for other less serious conditions. It can be infused continuously like dopamine and dobutamine, and is reserved for patients with hearts that are not working normally or adequately. It also may be given as a aerosol mist if your baby is having trouble breathing after his/her breathing tube has been removed. This substance occurs naturally in the body and has no known side effects.

This is a narcotic pain reliever very similar to morphine in its mechanism of action, its uses and its side effects. Fentanyl is much stronger than morphine, but is shorter acting, and can only be given intravenously. Like morphine, the main side effect of fentanyl is respiratory. Because babies in the NICU are on continuous monitoring for both breathing and heart rate, this is not a major concern, and any effects on breathing can be immediately detected and reversed. Babies who receive fentanyl for very long times may become habituated and the dose will need to be slowly decreased to avoid symptoms of narcotic withdrawal (see “Narcotic Abstinence Syndrome” under Diagnoses/conditions).

This medication is an anti-fungal antibiotic, and is the same medication that your doctor may have prescribed for a vaginal yeast infection. Premature babies are particularly susceptible to systemic yeast infections. If you live in a humid climate, this is even more likely than if you live where the air is dry. Risk factors for acquiring a systemic yeast infection include very low birth weight (<1500 gm), significant prematurity (< 28 wks), prolonged antibacterial treatment, and the presence of a central venous line, like a PICC line, among others. Some units may restrict the type of stuffed animals and other gifts you can put inside your baby’s incubator, due in part to the risk of spreading a fungal infection. Some studies have shown that treating high risk babies with fluconazole on a prophylactic – rather than treatment – basis, may decrease the likelihood of a systemic fungal infection. Fungal infections can be hard to treat and, if the infection should spread into the bloodstream and/or the spinal fluid/brain, can be life-threatening. Fluconazole is quite effective, and has minimal side effects. It can be given orally or intravenously. In the adult population, it has some significant interactions with other common drugs so be sure to ask your neonatologist about this if s/he prescribes fluconazole for your infant.