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Management of Hypoxic-Ischemic Encephalopathy Using Measures Other Than Therapeutic Hypothermia

KEY POINTS 1. Neonatal encephalopathy is an alteration in consciousness or neurologic exam in newborn infants. Hypoxic-ischemic encephalopathy accounts for nearly 50% of all cases. 2. Clinical presentation depends on the duration, timing, and severity of the insult and may evolve over the subsequent hours to days. Clinical staging of encephalopathy is usually based on the Sarnat criteria. 3. Disruption of blood flow causes ischemic injury;…

Management of Hypoxic-Ischemic Encephalopathy Using Therapeutic Hypothermia

KEY POINTS 1. A healthy fetus has considerable aerobic and anaerobic reserves to successfully adapt to transient or mild hypoxia. Prolonged or repeated severe asphyxia results in failure of adaptation and progressive hypotension and hypoperfusion. The severity of brain injury is consistently related to the severity and duration of hypotension. 2. There is no intrinsic, physiologic relationship between the amount of systemic anaerobic metabolism (as reflected…

Neonatal Thrombocytopenia

KEY POINTS 1. Platelets are anuclear cellular fragments that are released from megakaryocytes and are involved in primary hemostasis. 2. The normal platelet counts in newborn infants have been traditionally defined as 150 to 450 × 10 9 These counts decline during the early neonatal period but then begin to rise toward the end of the first week. 3. Platelet production involves the production of thrombopoietic factors…

Evidence-Based Neonatal Transfusion Guidelines

KEY POINTS 1. Anemia occurs when the red blood cell (RBC) mass is not adequate to meet tissue oxygen needs. 2. Target hemoglobin and hematocrit have been used as clinical indicators for RBC transfusion in preterm infants with acute and chronic anemia. 3. The minimal target hematocrit or hemoglobin that optimally balances the risks and benefits of transfusion remains unknown because a marker for transfusion need…

Neonatal Anemia

KEY POINTS 1. Anemia is an abnormal, and an unhealthy, reduction in the blood hemoglobin concentration or the hematocrit. There are limitations in our current definitions of anemia, which are based on “reference intervals” constructed from clinically obtained laboratory tests, not from tests performed on healthy volunteers. 2. Erythropoietin is the main physiologic regulator of red blood cell (RBC) production. 3. Neonatal RBCs frequently show morphologic…

A Practical Guide to Evaluating and Treating Severe Neonatal Indirect Hyperbilirubinemia

KEY POINTS 1. We still need a universally accepted definition of severe hyperbilirubinemia; no particular thresholds of unconjugated or total bilirubin levels have been definitively associated with acute or chronic bilirubin encephalopathy. 2. Several measurements can be useful for the assessment of hemolysis, such as those of end-tidal carbon monoxide, blood levels of analytes such as carboxyhemoglobin and haptoglobin, reticulocyte percent and number, cell-free hemoglobin, and…

Hemodynamic Assessment and Management of a Critically Ill Infant

KEY POINTS 1. Shock is a clinical condition marked by poor tissue perfusion resulting in inadequate oxygen delivery and tissue hypoxia. 2. Neonates with shock have hypotension or poor tissue perfusion, and there are important surrogate markers such as prolonged capillary refill time, low urine output, and lactic acidosis. 3. Early neonatal hypotension seems to increase the risk of brain injury and intraventricular hemorrhage. 4. Current…

Pulmonary Hypertension in Chronic Lung Disease

KEY POINTS 1. Pulmonary hypertension (PH) in young infants is defined as a resting mean pulmonary artery pressure (mPAP) ≥20 mm Hg. 2. The mPAP at birth resembles the systemic blood pressure and then drops to infrasystemic levels over the first few days. However, many infants develop pathologic structural/functional changes in the pulmonary circulation due to lung injury and develop PH. 3. Prematurity-related bronchopulmonary dysplasia (BPD)…

Neonatal Arrhythmia and Conduction Abnormalities

KEY POINTS 1. The normal cardiac electrical signal travels from the atria to the ventricles through a conduction system comprised of the sinus node, atrioventricular (AV) node, His bundle, and Purkinje system. 2. The AV node normally regulates the electrical action potentials from the atria to the ventricles. In some instances, the electrical signal bypasses the decremental AV node via an accessory pathway. AV block is…

Medical and Surgical Management of Critical Congenital Heart Disease

KEY POINTS 1. The natural history of congenital heart diseases (CHDs) varies tremendously. Some critical CHDs become symptomatic and require therapeutic intervention in the neonatal period. 2. Patients with CHDs that result in inadequate pulmonary blood flow typically demonstrate cyanosis within minutes of life that does not improve with the administration of oxygen. Many of these patients need treatment with a prostaglandin infusion (PGE1) while awaiting…

Cardiac Defects—Anatomy and Physiology

KEY POINTS 1. Congenital heart diseases (CHDs) are an important cause of morbidity and mortality in young infants. These malformations account for approximately 300,000 deaths yearly. 2. Cardiac septal defects are the most common type of anomalies. Ventricular septal defects (VSDs) are seen most frequently, in 5 to 50 per 1000 live births. Atrial septal defects (ASDs) also common and account for 8% to 10% of…

Congenital Heart Defects

KEY POINTS 1. Congenital heart disease (CHDs) are seen in 6 to 10 per 1000 live births. These include structural defects of the heart, of the great vessels, or both. 2. During the newborn period, the most important presenting features of CHD are central cyanosis, decreased perfusion to the body, and tachypnea. Cardiac murmurs are frequently heard but have a low sensitivity (44%) and low positive…

Invasive Fungal Infections in theNICU: Candida , Aspergillosis, and Mucormycosis

KEY POINTS 1. Fungal infections including invasive Candida infections and molds (aspergillosis and mucormycosis) are devastating infections most commonly complicating extreme preterm infants due to their underdeveloped immune system combined with the need for intensive care and any neonate with complex gastrointestinal disease. 2. Dermatologic findings of candidiasis and molds are critical to their prompt diagnosis and correct empiric antifungal selection. Congenital cutaneous candidiasis is an…

Congenital Syphilis

KEY POINTS 1. Congenital syphilis is a global public health problem, particularly in the Americas where its incidence appears to be rising. 2. At birth 90% of infants are asymptomatic, the remaining 10% present a wide variety of symptoms from mild to lethal. 3. To confirm the presence of spirochete may be challenging, diagnosis will usually be based on maternal syphilis history, treponemal and non treponemal…

Postnatal Cytomegalovirus Infection Among Preterm Infants

KEY POINTS 1. Cytomegalovirus (CMV) infection is acquired in the postnatal period primarily from mother’s milk feeding. 2. Postnatal CMV (pCMV) infection is usually asymptomatic in healthy term infants. Among very low birth weight (VLBW, birth weight <1500 g) infants, infection occurs in ∼6.5% and is associated with a sepsis-like syndrome in ∼1% but is rarely fatal. 3. Symptomatic pCMV infection is associated with lower gestation,…

Neonatal Herpes Simplex Virus Infections

KEY POINTS 1. Neonatal herpes simplex virus (HSV) infections can cause potentially devastating infections in newborn infants. 2. HSV has a double-stranded linear DNA genome and is seen in two variants, HSV-type 1 and HSV-type 2. 3. Neonatal HSV infections occur in three patterns: prenatal, perinatal, and postnatal. Perinatal infections are most common and are associated with serious morbidity and mortality. 4. HSV infections can be…

Late-Onset Sepsis

KEY POINTS 1. Late-onset sepsis in the neonatal intensive care unit is defined by culture-confirmed infection ≥72 hours after birth. 2. Incidence is highest among preterm infants. 3. The pathophysiology involves colonization with perinatally and/or hospital-acquired organisms, with transition to invasive infection promoted by hospital devices and immature mucosa. 4. Risk factors include prematurity, presence of a central venous catheter, prolonged parenteral nutrition, and lack of…

Early-Onset Sepsis

KEY POINTS 1. Early-onset sepsis (EOS) is defined by blood and/or cerebrospinal fluid culture-confirmed infection occurring 0 to 6 days after birth. 2. Incidence is highest among preterm infants, particularly those born with low gestational ages and with birth weight <1500 g. 3. Pathogenesis commonly involves ascending colonization of the uterine compartment with maternal flora, with subsequent colonization of the fetus and transition to invasive infection…

Disorders of Sex Development for Neonatologists

KEY POINTS 1. Disorders of sex development (DSD) is an umbrella term referring to the large collection of conditions in which establishment of chromosomal, gonadal, or anatomic sex development is atypical. 2. Estimates of the prevalence of DSD vary widely, but it is likely 1 in 5000 to 6000 in the general population. 3. The genetic regulation of sex determination and differentiation involves a complex cascade…

Disorders of Neonatal Mineral Metabolism and Metabolic Bone Disease

KEY POINTS 1. Disorders of mineral homeostasis in the neonatal period are often exaggerated responses to the normal physiologic transition. Parathyroid hormone (PTH) is the principal regulator of postnatal calcium metabolism, with vitamin D and its metabolites involved in the regulation of serum calcium levels. 2. Neonatal hypercalcemia is uncommon and often asymptomatic; calcium concentrations need to be interpreted based on age-related norms, which are higher…