Neonatal Drug Therapy Manual


Disclaimer: Official controlled document is the CHEO and Ottawa Hospital online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
Original Date: 
June 1996
Revised Date: 
May 2019
  • Adrenocorticol insufficiency
  • Adjunctive therapy for persistent hypoglycemia
  • Hypotension unresponsive to volume and pressor administration
  • Chronic lung disease following Dexamethasone therapy wean
  • Bronchopulmonary dysplasia (BPD) prophylaxis in extremely preterm infants (born with GA < 28 weeks) chorioamnionitis-exposed
  • IV direct: direct over 3 - 5 minutes (for small doses)
  • IV intermittent infusion: over 20 minutes
  • PO

*** A cortisol level should be drawn prior to first dose except when used for chronic lung disease with Dexamethasone therapy wean or when used for BPD prophylaxis in extremely preterm infants

  • Adrenal Insufficiency:
    • Adrenal Crisis
    • IM/IV: Bolus 100 mg/m2 stat (neonates usually 25 mg), then 100 mg/m2/day divided Q6h
    • Maintenance PO: 10 - 15 mg/m2/day divided Q8h
  • Congenital Adrenal Hyperplasia (if in crisis, treat as above):
    • Initial PO: 20 - 30 mg/m2/day in 3 evenly divided doses or 1/4 am, 1/4 noon, 1/2 hs
    • Maintenance PO: 15 - 20 mg/m2/day in 3 evenly divided doses or 1/4 am, 1/4 noon, 1/2 hs
  • Stress Dose for Surgical Procedures:
    • 50 - 100 mg/m2 IV x 1 dose pre-op then 100 mg/m2/day divided Q6h x 24 - 72 hours then taper
  • Refractory Hypotension Despite Inotropic Support:
    • 3 mg/kg/day IV divided Q8h for 5 days
  • Chronic Lung Disease Following Dexamethasone Therapy Wean
    • 7 - 10 mg/m2/day IV/PO once daily
  • BPD prophylaxis in extremely preterm infants ˂ 28 weeks GA, give prophylactic replacement doses of hydrocortisone. Do not give prophylactic indomethacin.
    • Starting within first 24 hours of life; 1 mg/kg/day IV divided Q12h for 7 days followed by 0.5 mg/kg/day IV once daily for 3 days

**Note: For all patients who have been exposed to steroid therapy, monitor for adrenal suppression and if signs and symptoms are present draw serum cortisol level and start hydrocortisone coverage 

 Formula for Body Surface Area (BSA):

Click here for BSA Formula:

Side Effects: 
  • CNS: potential for short and long term adverse neurological effects
  • CVS: edema, hypertension, arrhythmia
  • Endocrine and metabolic: adrenal suppression, hyperglycemia, sodium/water retention, hypokalemia, growth suppression
  • GI: gastrointestinal hemorrhage, gastrointestinal perforation
  • Miscellaneous: immunosuppression
  • Renal: glucosuria
Parameters to Monitor: 
  • BP, HR
  • Serum and urine glucose
  • Serum electrolytes
  • Adrenal function (with lengthy courses)
    • ** Patients who receive more than 14 days of steroids need to follow the Steroid Weaning Protocol and have their baseline cortisol tested. 
  • Long term neurodevelopmental assessment
Reconstitution and Stability: 
  • Hydrocortisone 100 mg/vial (Solu-Cortef) Act-O-Vial
    • Reconstitute Act-O-Vial by pressing down on plastic activator to force diluent into the lower compartment.  Gently agitate.  Remove plastic tab covering center of stopper prior to inserting needle to withdraw dose.  Reconstituted solution is 50 mg/mL
      • For doses < 1 mg: take 0.4 mL (20 mg) and add to 19.6 mL D5W
        • final concentration: 1 mg/mL
      • For doses > 1 mg: take 1 mL (50 mg) and add to 49 mL of D5W
        • final concentration: 1 mg/mL


  • Hydrocortisone 100 mg (sodium succintate) vials (Novopharm)
    • For doses < 1 mg: Add 1.8 mL SWFI. Take 0.4 mL (20 mg) and add to 19.6 mL D5W
      • final concentration: 1 mg/mL
    • For doses > 1mg: Add 1.8 mL SWFI. Take 1 mL (50 mg) and add to 49 mL D5W
      • final concentration: 1 mg/mL
  • Solutions Compatible: D5W, D10W, 0.9% NaCl
  • Y-site Compatible: fentanyl, heparin, KCl, morphine, TPN (amino acids - dextrose)

Incompatible: SMOF


- Baud O, Maury L, Lebail F, Ramful D, El Moussawi F, Nicaise C, et al.  Effect of early low-dose hydrocortisone on survival without bronchopulmonary dysplasia in extremely preterm infants (PREMILOC): a double-blind, placebo-controlled, multicentre, randomised trial. Lancet. 2016 Apr; 387 (10030): 1827-36

- Shaffer M, Baud O, Lacaze-Masmonteil T, Peltoniemi O, Bonsante F, Watterberg K.  Effect of prophylaxis for early adrenal insufficiency using low-dose hydrocortisone in very preterm infants: an individual patient data meta-analysis. J Pediatr. 2019 Apr: 136-142.e5. doi:10.1016/j/peds.2018.1004.Epub 2018 Nov 8

- Ng PC, Lee CH, Bnur FL, Chan IH, Lee AW, Wong E, et al.  A double-blind, randomized, controlled study of a "stress dose" of hydrocortisone for rescue treatment  of refractory hypotension in preterm infants.  Pediatrics 2006; 117 (2): 367-75

-  American Society of Health-System Pharmacists (ASHP). Handbook on Injectable Drugs 19th Edition. Bethesda: ASHP 2017

- The Children's Hospital of Eastern Ontario (2011 Revision). Steroid Weaning Guidelines for Neonates

- Ibrahim H, Sinha IP, Subhedar NV.  Corticosteroids for treating hypotension in preterm infants.  Cochrane Database of Systemic Reviews 2011, Issue 12



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