Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Patent ductus arteriosus

While the fetus remains in utero, the ductus arteriosus is an essential component of the circulation, permitting blood to flow right to left from the pulmonary artery to the descending aorta, bypassing the fluid-filled lungs and returning to the placenta for gas exchange. At birth, the low resistance placental circulation is removed, and pulmonary vascular resistance rapidly decreases, coincident with aeration of the lungs, resulting in…

Neonatal sepsis

Introduction Sepsis is the illness resulting from systemic bacterial or (less commonly) fungal infection. It is an ever-present threat in the NICU, accounting for approximately 10% of infant deaths under 1 month of age worldwide ( ) and contributing significantly to long-term neurodevelopmental impairments among NICU survivors. The clinical manifestations of neonatal sepsis are variable. The onset can be abrupt or insidious, and many of the…

Neonatal apnea

Case 1 You are taking care of a 4-day-old male infant, born at 32 weeks’ gestation and weighing 1750 g. He was recently transitioned from mechanical ventilation to nasal cannula. He was doing well until this morning, when you noticed a few drops in his heart rate that were accompanied by desaturations. When you spoke to the nurse, she said he had three episodes like these…

Bronchopulmonary dysplasia

Introduction Bronchopulmonary dysplasia (BPD) is the most prevalent and prognostically one of the most important complications associated with prematurity. In the United States, it affects 10,000 to 15,000 newborns each year, including upwards of half of all babies born weighing less than 1000 g ( ). BPD predisposes infants to a prolonged initial hospitalization and increased risk for mortality and childhood morbidity ( ; ). Chronic…

Principles of mechanical ventilation

Safe and effective respiratory support of newborn infants requires a good understanding of pulmonary physiology, familiarity with the available evidence regarding management of respiratory failure and knowledge of the capabilities of the ventilators at one’s disposal. The clinician must also recognize that individualized patient care is the best approach, and that requires frequent assessment of the patient’s response to treatment and regular assessment of all available…

Respiratory distress syndrome

Introduction Respiratory distress syndrome (RDS) is a developmental lung disease of preterm infants primarily caused by inadequate production of surfactant. Infants with RDS have difficulty maintaining adequate functional residual capacity (FRC), leading to alveolar atelectasis, hypoventilation, and ventilation-perfusion mismatch. Affected infants present shortly after birth with worsening tachypnea, nasal flaring, grunting, retractions, hypercapnia, and hypoxemia. Extensive research in the management of RDS has led to major…

Anemia

Introduction Anemia is a term typically used to describe either a low hemoglobin (Hb) or hematocrit (Hct). Although the word anemia is loosely used in clinical medicine, the exact meaning is difficult to define as it is not binary. Instead, the meaning of an individual Hb or Hct value is relative, requiring interpretation in contemporaneous clinical context. Although oxygen dissolves in the fluid-based plasma compartment of…

Enteral nutrition

Evidence is increasingly accumulating that nutritional inadequacies in the early neonatal period have both short- and long-term consequences. Nonetheless, provision of adequate nutritional support to the high-risk premature infant remains a significant clinical challenge. Among extremely premature infants, duplicating rates of in utero growth remains an elusive goal and postnatal growth failure remains a common complication of neonatal intensive care. This chapter contains exercises designed to…

Practical parenteral nutrition

Indications Parenteral nutrition (PN) is used to provide nutrients to newborn infants who cannot tolerate full enteral nutrition or who have contraindications to enteral nutrition ( Table 6.1 ). TABLE 6.1 Indications for Parenteral Nutrition Prematurity <32 weeks and <1800 g, and some infants <35 weeks and <2200 g with delayed initiation or advancement of enteral feeds Impaired Bowel Integrity Necrotizing enterocolitis (NEC) Bowel perforation Congenital…

Neonatal hyperbilirubinemia

Introduction Neonatal jaundice is the most common physiologic variant encountered in the newborn. More than 60% of healthy term neonates, and even a greater percentage of breastfed infants, display some degree of visible jaundice during the first week of life. Usually the body’s regulatory mechanisms succeed in keeping the serum total bilirubin (STB) level within physiologic levels, and therefore at a concentration that is nontoxic. Indeed,…

Glucose metabolism

Introduction Cornblath and Reisner established nearly 60 years ago that neonatal hypoglycemia was a significant cause of neonatal morbidity and mortality, yet the definition and management of neonatal hypoglycemia have remained unclear. The management of low blood glucose levels is one of the most frequently encountered issues in the newborn nursery. The blood levels of glucose upon which we base our decision making remain a matter…

Fluid and electrolyte management in the newborn intensive care unit

Fluid and electrolyte management is an important and challenging part of the initial care of any very premature or critically ill newborn. The transition from fetal to neonatal life is associated with major changes in fluid and electrolyte homeostasis and total body balance. Before birth, the fetus has a constant and ready supply of water and electrolytes; homeostasis is largely a function of maternal and placental…

Perinatal hypoxia-ischemia

Perinatal asphyxia is a challenging condition because it represents a modifiable etiology for neonatal encephalopathy with the use of hypothermia. This contrasts with other etiologies of neonatal encephalopathy that are not amenable to treatment, such as cerebral malformations, strokes, congenital acquired infections, teratogenic exposures, and cerebral hemorrhages. To be effective, hypothermia needs to be initiated early in life, typically within 6 hours following birth based on…

A physiologic approach to neonatal resuscitation

Introduction Neonatal resuscitation is commonly defined as the assistance given to infants immediately after birth as they transition to newborn life. From a physiologic perspective, this transition involves some of the most complex and profound changes that any human will likely encounter during their life. The airways that are filled with liquid during fetal life must be cleared to allow the entry of air and onset…

Neonatal Neurology in the Low-Resource Setting for the Term and Preterm Newborn

Introduction Prominent identified causes of brain injury in the low-resource setting (LRS) include hypoxic-ischemic encephalopathy (HIE)/neonatal encephalopathy (NE), germinal matrix–intraventricular hemorrhage (GMH-IVH) in the premature infant, prolonged neonatal seizures, neonatal hypoglycemia, and hyperbilirubinemia (kernicterus). The magnitude of the contributions of these individual conditions to brain injury is underestimated in the LRS because of the lack of consistent standardized and repeated neurological assessments; neuroimaging (cranial ultrasound [CUS]…

Passive Addiction and Teratogenic Effects

Drugs can exert major effects on the developing central nervous system (CNS). In the broadest sense, drugs may disturb specific developmental events in the brain and, in turn, produce teratogenic effects. In addition, maternal ingestion of certain drugs can result in passive addiction of the fetus, and postnatally lead to a neonatal withdrawal or abstinence syndrome. The capacity for teratogenicity was first recognized in the late…

Brain Tumors and Vein of Galen Malformations

In this chapter, space-occupying lesions including brain tumors, vein of Galen malformations, and arachnoid cysts are discussed. These disorders are considered in the same chapter because they represent important intracranial mass lesions and share certain clinical features. We do not review in detail management, which is considered in depth in standard neurosurgical writings. Improvements in management in recent years have made the prognosis of these serious…

Injuries of Extracranial, Cranial, Intracranial, Spinal Cord, and Peripheral Nervous System Structures

INTRODUCTION This chapter is focused on injuries of extracranial, cranial, intracranial, spinal cord, and peripheral nervous system structures. In particular, the emphasis is on those disorders that appear to be related primarily to mechanical trauma. Adverse mechanical events occur principally during labor and delivery. Unfortunately, such events often lead to criticism of obstetrical management. Such criticism generally is unwarranted, because the mechanical factors are most often…

Bacterial and Fungal Intracranial Infections

Bacterial infections of the central nervous system (CNS) in the newborn are common and are of major clinical importance. By far the most frequent of these infections is neonatal bacterial meningitis, and this chapter deals with this disorder in detail. Other bacterial processes include primary intracranial infections (e.g., epidural and subdural empyema and brain abscess) and disorders in which involvement of the CNS is secondary to…

Viral, Protozoan, and Related Intracranial Infections

The central nervous system (CNS) and its covering membranes may become involved in a variety of infectious processes, with devastating effects on structure and function. Infections may occur during intrauterine development, in association with the birth process, or in the first postnatal days or weeks. Microbial organisms implicated include several viruses, a protozoan (Toxoplasma gondii) , a spirochete (Treponema pallidum) , and numerous bacteria and fungi.…