Oussama Itani

The primary resources for checking medication compatibility with breastfeeding are LactMed, Hale's Medications and Mothers' Milk, and MotherToBaby, all of which are recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. LactMed is the most comprehensive and authoritative free resource, published by the National Library of Medicine and continuously updated. It is available online at https://www.ncbi.nlm.nih.gov/books/NBK501922/ and through mobile applications Technical Report: Breastfeeding and the Use of Human Milk. Pediatrics. 2022. Meek JY, Noble L. Guideline Optimizing Support for Breastfeeding as Part of Obstetric Practice. American College of Obstetricians and Gynecologists (2018). 2018. Susan D. Crowe, Lauren E. Hanley Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant: Clinical Report. Pediatrics. 2026. Parker MG, Stellwagen L, Miller ER, et al

we follow the AAP guideline. Santina A. Zanelli, Courtney J. Wusthoff, Ashley M. Lucke, David A. Kaufman, Committee on Fetus and Newborn, Section on Neurology; Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy: Clinical Report. Pediatrics February 2026; 157 (2): e2025073627. 10.1542/peds.2025-073627

Thankfully it is not very common. I have seen it rarely in neonates with hypoxic ischemic encephalopathy. Treatment of hypercalcemia consists primarily of hydration and diuresis and prednisone. In recalcitrant hypercalcemia addition of bisphosphonates might be needed. Below are pertinent references: Subcutaneous Fat Necrosis Associated With Hypercalcemia in Neonates With Neonatal Encephalopathy Treated With Therapeutic Hypothermia. Seminars in Fetal & Neonatal Medicine. 2021. Rodd C, Schwieger-Briel A, Hagmann C. Subcutaneous Fat Necrosis of the Newborn: A Retrospective Study of 32 Infants and Care Algorithm. Pediatric Dermatology. 2022. Siegel LH, Fraile Alonso C, Tuazon CFR, et al. Hypercalcemia: A Review.The Journal of the American Medical Association. 2022. Walker MD, Shane E. Severe Hypercalcaemia Due to Subcutaneous Fat Necrosis: Presentation, Management and Complications. Archives of Disease in Childhood. Fetal and Neonatal Edition. 2014. Shumer DE, Thaker V, Taylor GA, Wassner AJ. Effectiveness of Pamidronate in Severe Neonatal Hypercalcemia Caused by Subcutaneous Fat Necrosis: A Case Report. European Journal of Pediatrics. 2009. Lombardi G, Cabano R, Bollani L, Del Forno C, Stronati M. Oral Clodronate Therapy for Hypercalcemia Related to Extensive Subcutaneous Fat Necrosis in a Newborn. Journal of the Formosan Medical Association = Taiwan Yi Zhi. 2003. Hung SH, Tsai WY, Tsao PN, Chou HC, Hsieh WS. Use of Zoledronic Acid in a Neonate With Subcutaneous Fat Necrosis Complicated With Severe, Refractory Hypercalcemia. American Journal of Perinatology. 2019. Militello MA, Re MP, Vitaliti G, et al. Etidronate Therapy for Hypercalcemia in Subcutaneous Fat Necrosis of the Newborn. The Journal of Pediatrics. 1999. Rice AM, Rivkees SA. Treatment With Bisphosphonates in Severe Hypercalcemia Due to Subcutaneous Fat Necrosis in an Infant With Hypoxic-Ischemic Encephalopathy. Journal of Perinatology : Official Journal of the California Perinatal Association. 2014. Pérez Martínez E, Camprubí Camprubí M, Ramos Cebrián M, et al.

In the USA the AAP still recommends doing car seat tests for high-risk populations. severeal publications questioned the utilty of car seat testing as there is no strong evidence that it reduces hospital readmissions (Wade N. Harrison, Victor S. Ritter, Kori B. Flower, Carl J. Seashore, Skyler McLaurin-Jiang; The Association Between Routine Car Seat Screening and Subsequent Health Care Utilization. Hosp Pediatr November 2022; 12 (11): 913–922. https://doi.org/10.1542/hpeds.2021-006509 ; Benjamin Hoffman, Mark Vining; Continued Challenges of the Car Seat Tolerance Screen. Hosp Pediatr November 2022; 12 (11): e393–e395. https://doi.org/10.1542/hpeds.2022-006929). Data from Kaiser Permanente showed that outcomes are no different regardless of car seat testing (Braun D, Kaempf JW, Ho NJ, Nguyen MH, Passi R, Burgos AE, Volodarskiy M, Villosis MFB, Gupta M, Habeshian TS, Tam HK, Litam KB, Hong QL, Dong CC, Getahun D. Discontinuation of Car Seat Tolerance Screening and Postdischarge Adverse Outcomes in Infants Born Preterm. J Pediatr. 2023 Oct;261:113577. doi: 10.1016/j.jpeds.2023.113577. Epub 2023 Jun 22. PMID: 37353144.). Also, Canadian Pediatric Society has stopped doing routine car seat testing for lack of strong evidence supporting routine use (Narvey MR; Canadian Paediatric Society, Fetus and Newborn Committee. Assessment of cardiorespiratory stability using the infant car seat challenge before discharge in preterm infants (<37 weeks' gestational age). Paediatr Child Health. 2016 Apr;21(3):155-62. doi: 10.1093/pch/21.3.155. PMID: 27398056; PMCID: PMC4933079). As mentioned by other US colleagues, liability is significant in the USA. Unless the AAP updates its statement, it is hard for clinical neonatologists to stop doing this test. The UCSF Northern California Neonatal Consortium does not recommend routine ICSC testing before discharge for preterm infants or other infants thought to be "at risk" for abnormal oxygenation when in a car seat (Consensus Statement for Infant Car Seat Challenge (ICSC) Testing: UCSF Northern California Neonatal Consortium (NCNC) - UCSF Pediatrics). My personal bias is that passing this test depends significantly on appropriate positioning of the baby to prevent airway obstruction in neonates without congenital airway anomalies or neuromuscular disorders. The debate about car seat testing continues (Shah MD. Discontinuing Predischarge Car Seat Tolerance Tests: Is It Too Premature? J Pediatr. 2023 Nov;262:113663. doi: 10.1016/j.jpeds.2023.113663. Epub 2023 Aug 3. PMID: 37541426.).

This could be an isolated localized hair overgrowth. However, it can be associated with neuroectodermal anomalies. CPAP has no relation to the hair tuft. Hair collar sign has been described. Below are some references. References 1. Commens C, Rogers M, Kan A. Heterotropic brain tissue presenting as bald cysts with a collar of hypertrophic hair: the ‘hair collar’ sign. Arch Dermatol. 1989;125(9):1253–1256 2. Drolet BA, Clowry L Jr, McTigue MK, Esterly NB. The hair collar sign: marker for cranial dysraphism. Pediatrics. 1995;96(2 pt 1):309–313 3. Stevens CA, Galen W. The hair collar sign. Am J Med Genet A. 2008;146A(4):484–487 4. Held I, Rose C, Hamm H, Fölster-Holst R. The hair collar sign: a possible indication of cranial dysraphism. J Dtsch Dermatol Ges. 2011;9(2):136–138 5. Bessis D, Bigorre M,Malissen N, et al;Groupe de Recherche Clinique en Dermatologie Pédiatrique. The scalp hair collar and tuft signs: a retrospective multicenter study of 78 patients with a systematic review of the literature. J Am Acad Dermatol. 2017;76(3):478–487 6. Harrington BC. The hair collar sign as a marker for neural tube defects. Pediatr Dermatol. 2007;24(2):138–140 An additional reference Alexander K.C. Leung and Benjamin Barankin. Visual Diagnosis: A Ring of Long, Dark, Coarse Hair on the Scalp of a 5-month-old Girl. Pediatrics in Review July 2018, 39 (7) e31-e32; DOI: https://doi.org/10.1542/pir.2017-0094