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Surgical emergencies in the newborn

This chapter discusses common presentations of surgical emergencies in the newborn. Frequently encountered scenarios are presented as a descriptive case followed by a discussion and explanation of the disease process and treatment options. Necrotizing enterocolitis (NEC) is the most commonly encountered abdominal emergency in the premature newborn and is discussed in further detail in a separate section of this book. Emergencies of the trachea, esophagus, and…

Intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is a major complication of prematurity. Despite the term referring to hemorrhage within the ventricle, it encompasses hemorrhage confined to the germinal matrix (grade I), extension to lateral ventricles without (grade II) or with (grade III) ventricular dilatation, and periventricular parenchymal hemorrhage (grade IV). Although periventricular hemorrhage (grade IV) may be considered as a separate entity ( ), for the purpose of this…

Neonatal seizures

Video 19.1 Benign Neonatal Seizure Introduction Seizure incidence is at its highest in the neonatal period, estimated at 1 to 3 per 1000 term neonates and 10 times higher for preterm/low birth weight newborns ( ). Most cases are considered acute symptomatic seizures, result from acute brain injury, and occur in its immediate aftermath ( Fig. 19.1 ). The underlying etiologies for acute symptomatic seizures in…

Renal failure in neonates

The etiology of neonatal renal failure encompasses both chronic conditions such as congenital defects of the kidney and urinary tract and acute insults such as hypoxia, ischemia, or drug toxicity leading to acute kidney injury (AKI) ( ). AKI in the neonate has been difficult to define, especially in the setting of prematurity, as standard definitions for both adult and pediatric patients rely on changes in…

Persistent pulmonary hypertension of the newborn and hypoxemic respiratory failure

The fetus is in a state of physiologic pulmonary hypertension. The PaO 2 in the descending aorta of the fetus is approximately 20 to 25 mm Hg with an oxygen saturation (Sa o 2 ) of 55% to 58% ( Fig. 17.1 ). In spite of being “hypoxemic” (low PaO 2 levels relative to postnatal standards), the fetus can deliver adequate oxygen to its tissues and…

Congenital heart disease in the newborn period

Introduction Children with congenital heart disease (CHD) have structural defects of the heart and/or great vessels that are present before birth. Defects range from relatively simple lesions, which neither induce symptoms nor need therapy, to complex life-threatening lesions, which require surgery in the neonatal period. CHD is the most common birth defect. Recent prevalence estimates for CHD range from 6 to 10 per 1000 live births.…

Neonatal hypotension

Introduction Hypotension of the premature newborn is a condition commonly encountered in the neonatal intensive care setting. Although no definite cut-off values exist in considering a given newborn to be hypotensive, certain blood pressure ranges will cause significant anxiety among caregivers. The goal of this chapter is to illustrate the complexity involved in the diagnosis and management of neonatal hypotension and guide the clinician in decision…

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…