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Stridor and Laryngotracheal Airway Obstruction in Newborns

KEY POINTS 1. Stridor is a sound caused by obstruction of the upper airway, usually from abnormalities within one or more of the subsites of the larynx (supraglottis, glottis, and subglottis) or in the trachea. 2. Stridor is a physical sign and not a diagnosis. It can be characterized by its presence during inspiration or expiration (or both), by its pitch and loudness, and by its…

Neonatal Tracheostomy

KEY POINTS 1. Chronic cardiopulmonary and neurologic disorders are the most common indications for neonatal tracheostomy, overtaking upper airway obstruction. 2. Noninvasive ventilation of neonates is likely reducing indications and the need for tracheostomy. 3. Neonatal tracheostomy is associated with high overall mortality and morbidity and lower quality of life. 4. Postoperative and long-term care is necessary to help mitigate and manage the increased risks associated…

Cataract and Glaucoma

KEY POINTS 1. Cataracts are inherited or sporadic; congenital or acquired; isolated or in a syndrome. 2. Size, density, and location of lens opacity influence its visual significance. 3. Timing of cataract surgery is important; earlier detection and surgery have better outcomes. 4. Primary congenital glaucoma is the most common form of glaucoma in infants. It usually requires surgical treatment. 5. Some forms of infantile glaucoma…

Developmental Anomalies of the Cornea and Iris in Neonates

KEY POINTS 1. Causes of primary neonatal corneal opacification include congenital hereditary endothelial dystrophy (CHED), posterior polymorphous corneal dystrophy, congenital hereditary stromal dystrophy (CHED), and corneal dermoid. Secondary causes include trauma (e.g., forceps), infection, metabolic disorders, and congenital glaucoma. Corneal opacification requires further workup to diagnose the underlying cause and to help plan any surgical intervention. 2. Primary megalocornea is defined as a horizontal corneal diameter…

Developmental Anomalies of the Globe and Ocular Adnexa in Neonates

KEY POINTS 1. Major structural abnormalities of the eye in neonates include anophthalmos (no ocular tissues), microphthalmos (small, disorganized eye), nanophthalmos (small but relatively normally structured eye), and buphthalmos (whole eye is enlarged). 2. Major eyelid defects in neonates include complete fusion of the upper and lower eyelids and a “hidden” eye (cryptophthalmos), focal fusion of the upper and lower eyelids (ankyloblepharon), focal defects in either…

Retinopathy of Prematurity

KEY POINTS 1. Retinopathy of prematurity (ROP) is a disease characterized by altered vascularization of the immature retina of premature infants and is common cause of reduced vision in the developed world. 2. The first, obliterative phase of ROP occurs from birth to a postmenstrual age of about 30 to 32 weeks and is characterized by suppressed growth/obliteration of retinal vessels due to relative hyperoxia. 3.…

Altered Development of the Kidneys and the Urinary Tract

KEY POINTS 1. Congenital renal anomalies account for one-fourth of all congenital anomalies. 2. Early pre- or postnatal detection can facilitate appropriate, timely management. 3. Many infants will require coordinated, multispecialty treatment. 4. Renal abnormalities are being increasingly recognized in four broad groups: (1) congenital anomalies of the kidney and the urinary tract (CAKUTs), such as renal agenesis, kidney hypodysplasia, and abnormalities of the draining systems;…

Neonatal Hypertension

KEY POINTS 1. Blood pressure should be measured with the proper cuff size on the right upper arm with attention to technique when using oscillometric devices in neonates. 2. Blood pressure is rapidly changing during the first weeks of life, especially in premature neonates, and measured values need to be compared with appropriate normal values. 3. In premature infants, the most common causes of hypertension are…

Renal Replacement Therapy

KEY POINTS 1. Renal replacement therapy (RRT) is an effective therapy for treating neonates with acute kidney injury (AKI) and inborn errors of metabolism with hyperammonemia. 2. Peritoneal dialysis is used most frequently to treat AKI in neonates, although intermittent hemodialysis and continuous renal replacement therapy (CRRT) are important alternatives. 3. Timely initiation of RRT may improve outcomes in neonates with AKI and volume overload. 4.…

Neonatal Acute Kidney Injury

KEY POINTS 1. Acute kidney injury (AKI), previously referred to as “acute renal failure”, is defined by an abrupt change in the glomerular filtration rate with rising serum creatinine levels or decrease in urine output. AKI is associated with adverse outcomes. 2. The newborn kidney undergoes a number of physiologic and functional changes after birth that impact its function and increase the susceptibility to AKI. 3.…

Immunodeficiency Syndromes Seen During the Neonatal Period

KEY POINTS 1. At birth, the fetal-neonatal immune system gets activated. It is critical for survival to recognize and eliminate all the potentially dangerous pathogens in the infant’s external and its own enteric environment. 2. The innate arm is particularly necessary because the adaptive immunity is still developing. 3. In immunodeficiency states, the aberrant development of the immune system puts the infant at risk of infections,…

Neonatal Immunity

KEY POINTS 1. The fetal-neonatal immune system becomes activated at birth to play a role in host defense and eliminate environmental pathogens but also to tolerate self-antigens, nutrients, and commensals. 2. The innate immune system is comprised of neutrophils, the monocyte-macrophage lineage, natural killer cells, and the noncytotoxic innate lymphoid cells. 3. Neutrophils are the most numerus subgroup of leukocytes, but unlike in the adult, these…

Treating Neonatal Abstinence Syndrome in the Newborn

KEY POINTS 1. In the United States an infant is born every 15 minutes who will develop symptoms of neonatal abstinence syndrome (NAS); each year, about 32,000 infants are estimated to develop NAS. 2. The exposure of the developing fetus to stimulants, alcohol, cannabinoids, and antidepressant medication can all have a negative impact. To refer specifically to the impact of opioids, the term neonatal opioid withdrawal syndrome…

Management of Myelomeningocele and Related Disorders of the Newborn

KEY POINTS 1. Spina bifida is the most common nonlethal birth defect of the central nervous system and occurs when the vertebral column fails to close, resulting in neurologic impacts from both the abnormal formation and ongoing damage to the exposed nervous tissue. 2. The underlying cause of spina bifida is multifactorial, involving genetic, metabolic, and environmental influences. 3. The Chiari II malformation is classically associated…

Management of Neurotrauma

KEY POINTS 1. Childbirth is a traumatic event; the head of the neonate is subject to multiple forces that, in turn, may result in clinically relevant neurologic injuries. 2. Extracranial scalp traumatic injuries are the most common type of neonatal head trauma. 3. Scalp lesions may hinder the diagnosis of more serious intracranial lesions, such as depressed skull fractures. 4. Intracranial hematomas can be found in…

Intraventricular Hemorrhage and Posthemorrhage Hydrocephalus

KEY POINTS 1. Very-low-birthweight infants are at risk of spontaneous germinal matrix–intraventricular hemorrhages (GM-IVHs). 2. GM-IVHs usually originate within the subependymal germinal matrix lining the ventricles and progress outwards into the ventricles. IVH occurs most frequently during the first 72 hours after birth. 3. A subset of infants with IVH develop periventricular hemorrhagic infarction, posthemorrhagic ventricular dilatation, and posthemorrhagic hydrocephalus (PHH). 4. Posthemorrhagic ventricular dilatation is…

Stroke in Neonates

KEY POINTS 1. Perinatal arterial ischemic stroke most often results from the convergence of multiple stroke risk factors specific to the perinatal period and has a low risk of recurrence. 2. Neonatal arterial ischemic stroke refers to the most common presentation of perinatal stroke when focal seizures or diffuse neurologic signs lead to diagnosis soon after birth. A subset of patients remain undiagnosed in the neonatal…

Neonatal Seizures

KEY POINTS 1. Seizures are very common in the neonatal period and constitute a neurologic emergency. 2. Specific aspects of the physiology of the developing brain make it highly susceptible to hyperexcitability and seizure occurrence. 3. Brain injury often causes or contributes to seizures. Among premature infants, seizures are most often triggered by intraventricular hemorrhage; in term babies, hypoxic-ischemic encephalopathy and stroke are the leading causes…

Management of Encephalopathy of Prematurity

KEY POINTS 1. Encephalopathy of prematurity reflects white and gray matter injury combined with neuronal-axonal abnormalities impacting preterm infants. 2. Key risk factors include hypotension and the need for inotropes, hypoxia, and inflammation. 3. Evaluation of high-risk infants in the neonatal intensive care unit (NICU) includes use of neuroimaging and neurobehavioral assessments such as the General Movements Assessment. 4. Management starts prior to birth and continues…