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Hypothalamic-Pituitary-Adrenal Axis in Neonates

KEY POINTS 1. Normal hypothalamic-pituitary-adrenal (HPA) axis production of cortisol and a normal renin-angiotensin-aldosterone axis are needed for the normal regulation of volume status, blood pressure, and serum sodium, potassium and glucose levels in the neonate. Disorders of these axes can be life-threatening. 2. Cortisol deficiency can be due to a disorder of the adrenal gland itself or to impaired ACTH secretion from the pituitary gland.…

Neonatal Thyroid Disease

KEY POINTS 1. Thyroid hormone signaling is required for both normal fetal and pediatric development. 2. The identification of genes critical for thyroid gland development and migration and thyroid hormone metabolism, transport, and receptor function has revealed that derangement of local thyroid hormone signaling can impact development, even in the absence of primary thyroid disease. 3. The goal of thyroid hormone replacement in neonates is to…

Evidence-Based Neonatology: Neonatal Pituitary Hormone Deficiencies

KEY POINTS 1. Congenital pituitary hormone deficiencies can be caused by maldevelopment of central brain structures, acute injury, and pituitary gene mutation. 2. The anterior pituitary is composed of four distinct cell types that produce five different hormones. 3. Understanding the role of each of these hormones allows more timely diagnosis of pituitary hormone deficiencies. 4. Treatment is typically replacement of missing hormones and can be…

Infants of Diabetic Mothers

KEY POINTS 1. Diabetes in pregnant women can be visualized in two distinct subsets: 1% to 2% of women have pregestational disease, whereas 6% to 9% develop diabetes during pregnancy. 2. In mothers with pregestational or early-onset diabetes, placental vasculopathy may cause growth restriction, altered organogenesis, and congenital anomalies. 3. In mothers with gestational diabetes, the fetuses tend to become large for date, show a wide…

Neonatal Hypoglycemia

KEY POINTS 1. Hypoglycemia is frequently seen in premature and critically ill term infants. 2. Neonates are at risk of hypoglycemia in the early neonatal period because of the abrupt interruption of maternal glucose transfer to the baby at birth, imposing a need for independent regulation of plasma glucose concentrations by adjusting insulin secretion and mobilizing counterregulatory responses. 3. Many neonates experience a transitional period of…

Neonatal Nutrition Assessment

KEY POINTS 1. All infants should be classified at birth with the use of appropriate anthropometric measurement techniques to determine risk status for complications such as hypoglycemia or catabolism. Growth charts and tools to determine z -scores are readily available and should be used. 2. Hospitalized infants are at higher risk for growth impairment, so patterns on a growth chart and growth velocity throughout hospitalization should…

Nutrition in Short Bowel Syndrome

KEY POINTS 1. Intestinal failure (IF) is defined as the loss of functional gut mass to levels below those needed for digestion and absorption of fluid and nutrients required to support adequate nutrition and growth. 2. Short bowel syndrome (SBS) is a subtype of IF that occurs due to the anatomic loss of a part of the intestines. 3. Gastroschisis and necrotizing enterocolitis (NEC) are the…

Parenteral Nutrition in Neonates

KEY POINTS 1. Parenteral nutrition is a necessary component of the nutritional and medical management of the premature infant. 2. The fluid, macronutrient, and micronutrient requirements are unique to the premature infant due to their transition from the intrauterine to extrauterine environment, critically ill status, and lack of nutrient stores. 3. Understanding how to properly calculate a premature infant’s parenteral nutrition requirements is critical to ensure…

Enteral Nutrition

KEY POINTS 1. The benefits of enteral nutrition for the preterm infant extend beyond growth and encompass gastrointestinal development and gut inflammatory balance. 2. Preterm infant intake of mother’s milk, including oral immune therapy, is associated with improved outcomes. 3. Pasteurized donor human milk is the preferred feeding supplement when mother’s milk is contraindicated or unavailable and is associated with less necrotizing enterocolitis compared with formula.…

Possible Benefits and Risks of Using Probiotics in Neonates

KEY POINTS 1. Probiotics are live microorganisms that, when consumed in adequate amounts by an adult host, are believed to and in many instances have been shown to confer health benefits. 2. The best-known probiotics belong to the genera Bifidobacteria , Lactobacillus , and Saccharomyces . 3. Extensive clinical evidence indicates that probiotics can reduce the risk of necrotizing enterocolitis (NEC) and late-onset sepsis in term…

Storage and Use of Human Milk in Neonatal Intensive Care Units

KEY POINTS 1. Human milk is an important source of nutrients, immunologic factors, and pre- and probiotic factors for preterm and critically ill infants for up to 6 months after birth. 2. Human milk has positive effects on enhanced maturation of vital organs such as the brain and gastrointestinal system and on immunity, and it is also known to protect at-risk infants against neonatal morbidities such…

Human Milk

KEY POINTS 1. The female breast develops with chronologic maturation, during pregnancy, and with major physiologic/endocrine changes in preparation for lactation after delivery. 2. Care providers need to begin preparing pregnant women for lactation during antenatal visits by providing information about the importance of breastfeeding and about early initiation of breastfeeding. 3. After birth, skin-to-skin contact, initiation of feeding within the first hour, positioning, identification of…

Treatment of Apnea of Prematurity

KEY POINTS 1. There are three types of apnea: central, mixed, and obstructive. Mixed apnea is most common in longer episodes of apnea. 2. Apnea of prematurity is primarily due to the immaturity of respiratory and central nervous systems. 3. Direct interventions are first-line therapies that are evidence-based and include methylxanthine therapies, noninvasive respiratory supports, and/or invasive respiratory supports. 4. Indirect interventions are used in conjunction…

Bronchopulmonary Dysplasia

KEY POINTS 1. Minimally invasive surfactant therapy administered via a thin catheter is the most commonly studied less invasive surfactant administration strategy and has been shown to improve survival free of bronchopulmonary dysplasia (BPD). 2. Compared with continuous positive airway pressure, nasal intermittent positive pressure ventilation (NIPPV) is a useful method to avoid respiratory failure or intubation or extubation failure. However, NIPPV does not improve death…

Pulmonary Hypertension of the Newborn

KEY POINTS 1. Persistent pulmonary hypertension of the newborn (PPHN) represents continued high pulmonary vascular resistance (PVR) after birth resulting in extrapulmonary shunting of the blood from pulmonary to systemic circulation, leading to hypoxemia. 2. The disorder can be idiopathic or primary or could complicate respiratory, neurologic, and cardiovascular morbidities. Perinatal asphyxia with meconium aspiration syndrome or pneumonia can result in impaired lung recruitment, suboptimal oxygenation,…

Invasive and Noninvasive Ventilation Strategies

KEY POINTS 1. Endotracheal tube ventilation, also known as invasive ventilation, although life-saving, is associated with lung injury, especially in premature infants. 2. Volume-targeted ventilation is the preferred mode of invasive conventional mechanical ventilation. 3. High-frequency ventilation is recommended as a rescue mode in conditions not responsive to conventional mechanical ventilation. 4. Early nasal continuous positive airway pressure (NCPAP) and selective early surfactant use is beneficial…

Respiratory Distress Syndrome

KEY POINTS 1. Respiratory distress syndrome (RDS) remains an important cause of morbidity and mortality in preterm infants. 2. The etiopathology of RDS involves structural immaturity and surfactant deficiency in the developing lung. 3. The diagnosis rests on the presence of characteristic clinical and radiographic features in premature infants. 4. Judicious use of antenatal steroids has reduced the frequency and severity of RDS. 5. The use…

Oxygen During Postnatal Stabilization

KEY POINTS 1. There is a precisely controlled sequence of circulatory and respiratory changes at birth that leads to the establishment of adult-type circulation and airborne respiration. 2. Despite the well-established sequence of events, 1 in 10 infants, particularly those born before term, will require interventions to achieve an adequate postnatal adaptation. 3. Oxygen has been widely accepted as the most relevant drug for preterm resuscitation.…

Golden Hour and Thermoregulation

KEY POINTS 1. The first 60 minutes after birth constitutes a Golden Hour for a newborn infant, when appropriate clinical management can improve long-term outcomes. 2. The physiologic transition from intrauterine to extrauterine life is complex, and alterations in this transition can have lasting effects, particularly in premature infants. 3. After an antenatal consult, a delivery team should be assembled and briefed on maternal history, gestational…

Neonatal Resuscitation

KEY POINTS 1. Knowledge of the normal physiologic transition from fetal to neonatal life and potential disruptions of this process is vital to a comprehensive understanding of neonatal resuscitation. 2. Preparation of personnel and equipment prior to resuscitation is essential. 3. The first steps in resuscitation include stimulating the infant, maintaining a normal body temperature through management of heat gain and loss, and assessment of breathing…