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Pathophysiology and management of hyperkalemia in the neonate

Potassium (K), the major intracellular (IC) cation (98% of [K] is located inside the cells), is responsible for protein synthesis, cell growth, and regulation of cell volume. Sodium-potassium ATPase (Na-K-ATPase) in cell membranes is responsible for maintaining this gradient, which is critical for excitable cells. Compared with children and adults, neonates have a higher serum potassium concentration ([K]), with very preterm and very low birth weight…

Pulmonary hypoplasia in the fetus with oligohydramnios: Causes, treatment, and prevention

Introduction Normal amniotic fluid production and volume are essential for normal fetal development. Oligohydramnios, or low amniotic fluid volume, when severe can impact normal lung development. As the fetal kidneys are the major source of amniotic fluid in the second half of pregnancy, anomalies associated with poor fetal kidney function lead to oligohydramnios, particularly in the second and third trimesters of pregnancy in humans. Congenital anomalies…

Diagnosis and management of neonatal acute kidney injury

Introduction Acute kidney injury (AKI) is defined as a decrease in overall kidney function, resulting in reduction of glomerular filtration rate (GFR) and subsequent retention of waste products such as urea. As a result, there is a loss of established electrolyte, acid-base, and fluid balance regulation. AKI is a serious, underrecognized yet common complication that occurs in neonates who receive intensive medical care, and there is…

Assessment of neonatal kidney function

Background Two thirds of drugs are eliminated by the kidneys, and their function levels must be taken into account for diagnostic and treatment plans. Kidney function level identifies acute kidney injury (AKI), or chronic kidney disease (CKD) but it cannot be measured directly, so clinicians have to calculate the clearance of a marker (for instance, inulin) over a given time period. A comprehensive review on measuring…

Assessment of renal function in fetuses with lower urinary tract obstruction

Introduction Fetal lower urinary tract obstruction (LUTO) or congenital bladder outlet obstruction has an incidence of 2.2/10,000 pregnancies and is usually diagnosed in late first or early second trimester of pregnancy with the characteristic findings of dilated fetal bladder, dilated proximal ureter, and renal hydronephrosis. LUTO represents a spectrum of congenital anomalies with the principal etiology differing according to fetal sex and additional structural anomalies. If…

Skin Disorders inNewborn Infants

KEY POINTS 1. Neonatal skin matures with gestational age with increasing thickness, less permeability, and higher density of sweat and sebaceous glands. Keratinization begins at 24 weeks and matures near term. 2. Cold stress is an important risk to preterm infants. Lower skin thickness, less subcutaneous fat, and immaturity of the nervous system predisposes to heat loss. 3. Several minor congenital anomalies may predominantly involve the…

Leadership and OrganizationalCulture in Healthcare

KEY POINTS 1. All organizations, be it in healthcare or in any other sector(s) of society, strive for effective, potentially transformational leadership. 2. In any health-care system, infants receiving care in neonatal intensive care units are often the most vulnerable patients, with very high severity levels of illness. 3. The first step in analyzing the impact of leadership in any organization is to observe the interactions…

Organization of Neonatal Intensive Care

KEY POINTS 1. Neonatal intensive care units (NICUs) are organized for the clinical care of premature and critically ill newborn infants. 2. Healthcare centers require a well-considered structure to enable collaborative decision-making to provide family-centered, high-value care to the mother-infant dyad. 3. In most parts of the world, NICUs are designated per the infrastructural levels and the severity of illness of infants receiving care in the units.…

Designing Clinical Trials in Neonatology—International Trials

KEY POINTS 1. Assessing therapeutic safety and efficacy of a drug/device or technology requires carefully designed trials that are sufficiently powered to detect differences in outcomes. 2. International trials can help reduce the time required for the study and improve generalizability of the findings. 3. Variations in regulations for clinical trials between jurisdictions can significantly prolong the time required to conduct the trial. 4. Anticipating challenges…

Neonatal Randomized Controlled Trials

KEY POINTS 1. Neonates and infants often are treated with medicines that have not been approved by regulatory authorities for use in this age group. 2. The inclusion of infants in drug development studies and clinical trials is limited by difficulties in enrollment, concerns for adverse effects due to developmental limitations, and the lack of universally accepted response variables in many conditions. 3. Neonatal randomized controlled…

Quality Improvement in Neonatal Care

KEY POINTS 1. The quality of clinical care and improvement is typically measured in six areas: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equality. 2. Healthcare administered during pregnancy, labor, and childbirth continues to show considerable center-to-center variability and needs careful study both for improving outcomes and also to reduce the possibility of harm. 3. The care of premature and critically ill infants in neonatal intensive care…

Neurodevelopmental Impairment in Specific Neonatal Disorders

KEY POINTS 1. Neonatal intensive care unit graduates are at risk of neurodevelopmental impairment (NDI). 2. NDI can occur in cognitive, motor, vision, hearing, or language domains and can seriously impair the child's social, academic, and behavioral functioning. 3. Periventricular white matter injury is the leading cause of long-term NDI, especially motor impairment in preterm infants. 4. Infants with hypoxic-ischemic encephalopathy, bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular…

Use of Neuroimaging to Predict Adverse Developmental Outcomes in High-Risk Infants

KEY POINTS 1. Nearly half of all very low birth weight infants may have had brain injury due to hypoxia-ischemia, arterial ischemic stroke(s), inflammation, infection, and intraventricular hemorrhages (IVHs). 2. Neuroimaging is increasingly seen in a “biomarker-like role,” where it can add to the information to develop and tailor the clinical developmental screening programs. Cranial ultrasound has been the modality of first choice to screen for…

Early Detection of Cerebral Palsy

Key Points 1. Cerebral Palsy (CP) originates from an injury or abnormality in the developing brain, resulting in abnormal muscle tone, and consequently, in altered movement, posture, and motor function. 2. Tools used to accurately detect CP in the first year of life include a combination of Prechtl General Movement Assessment (GMA), clinical history, standardized neurological exam, brain imaging, and an assessment of motor function. 3.…

Early Diagnosis and Intervention—On Neonatal Follow-Up

KEY POINTS 1. The care of a sick infant must continue into childhood, and families must be guided just as diligently after discharge as they were during intensive care. 2. A continuum of care after discharge, involving dedicated multidisciplinary teams, is important for early intervention and meticulous follow-up. 3. During developmental surveillance, uniform application of one well-validated tool is important for consistency in early intervention and/or…

Early Diagnosis and Intervention in Neonatal Intensive Care Units

KEY POINTS 1. Most infants who develop neurodevelopmental disability (NDD) are normal on examination at birth. 2. Surveillance for NDD must start with neurologic examination in the neonatal intensive care unit and continue through childhood, because early diagnosis and intervention may be beneficial. 3. A tailored care plan should guide healthcare professionals and parents to best practices that support intact outcomes from birth to childhood. 4.…

Palliative Care Family Support in Neonatology

KEY POINTS 1. Neonatal intensive care unit (NICU) admission rates have increased over time, with a consequent increase in the number of extremely premature and critically ill infants who are at risk of chronic illness and mortality. 2. The death of an infant is one of the most devastating and difficult experiences in life. Parents of seriously ill infants bear many roles such as caregiver, advocate,…

Pain and Symptom Management in Newborns Receiving Palliative and End-of-Life Care

KEY POINTS 1. Perinatal palliative care is specialized medical care for fetuses/infants with life-threatening or terminal conditions, with the goal of providing equitable and effective support for curative, life-prolonging, and palliative care for patients and their families. 2. Perinatal hospice may include care of infants diagnosed with a serious medical condition in a physical inpatient setting or at home. 3. Perinatal palliative care is a difficult…

Serious Communication in the Neonatal Intensive Care Unit: Evidence for Strategies and Training

KEY POINTS 1. With a high incidence of morbidity and mortality, the care of critically ill newborns brings unique complexities in communication between the care providers and families. 2. Because newborns cannot make their wishes known, surrogates, generally parents, collaborate with physicians to determine appropriate goals of care. These decisions entail discussions of sophisticated information about the disease process, available therapies, known risks and outcomes, and…

Current State of Perinatal Palliative Care: Clinical Practice, Training, and Research

KEY POINTS 1. Perinatal palliative care (PPC) programs are increasing across the U.S. These services exist in a wide variety of settings from health care institutions to community- or faith-based organizations, have varying levels of ability and comfort in providing PPC for different clinical scenarios and levels of diagnostic certainty, and varying access to multi-disciplinary specialists and variable missions and visions of the program. 2. PPC…