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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…

Placental Transfusion in the Newborn

KEY POINTS 1. Delayed cord clamping (DCC) is a very powerful yet simple, no-cost intervention practice that can transform the lives of children and mothers around the world. 2. DCC is a practice of waiting to cut the umbilical cord until sufficient time (3–5 minutes) has elapsed to permit blood flow from the placenta to the newborn while the baby is transitioning to extrauterine life. 3.…

Radiation Safety in Premature and Critically-Ill Neonates

KEY POINTS 1. Digital radiography is a frequently used imaging technique in neonatal intensive care units (NICUs), with many infants having multiple radiographs during their stays. 2. High-energy photons in ionizing radiation can damage DNA, particularly with repeated natural background exposures and diagnostic medical imaging. 3. Radiation dose is a measure of the amount of exposure of the tissues of the body to radiation; it is…

Neonatal Transport

KEY POINTS 1. Transport is not a benign event for the neonate, the family, and the transport team. 2. Transport is a significant transition in care and has risk and safety concerns beyond the physical movement of the neonate. 3. Decompensation is not uncommon due to the movement, vibration, noise, and change in environment during transport and must be anticipated and addressed as needed. 4. Neonatal…

Pharmacologic Management of Neonatal Pain and Agitation

KEY POINTS 1. Preterm neonates are exposed to frequent painful and agitating stimuli during intensive care. Pain and agitation have a negative impact on long-term outcome. 2. Laboratory tests and invasive procedures should be used judiciously in neonates. 3. A systematic scoring system should be used prior to, during, and after acute painful procedures. 4. Neonatal intensive care units should develop an algorithm for the treatment…

Safe Use of Health Information Technology

KEY POINTS 1. Information technology (IT) can improve healthcare in its (1) efficiency in terms of economical achievement of goals, (2) effectiveness by improving the capacity to do so, and (3) efficacy with the capacity to achieve success under ideal, controlled circumstances. 2. IT can improve the safety of healthcare delivery with continuous quality improvement, sociotechnical approaches in hardware and software, and improved use of personnel.…

NICU Environment for Parents and Staff

KEY POINTS 1. The admission of a premature or critically ill infant to a neonatal intensive care unit (NICU) is a stressful event for parents. 2. Parents in the NICU experience stress-induced emotional problems related to infant hospitalization, loss of control, and loss of contact with their infant. 3. The NICU staff can help develop strategies and interventions to help parents feel more comfortable and involved.…

Design of Neonatal Intensive Care Units

KEY POINTS 1. Historically, neonatal intensive care units (NICUs) have been designed as open-bay units with multiple patient beds in a room. However, the trend has shifted toward designing units with single-patient or single-family rooms. 2. Single-family rooms have facilitated a reduction in auditory and noxious stimuli and improvement in positive stimuli to support appropriate development. 3. Parents and families have reported increased engagement in the…

Fetal Treatment of Genetic Disorders

In Utero Stem Cell Transplantation In utero hematopoietic stem cell transplantation (IUHCT) is a promising approach to treat congenital genetic disorders. IUHCT offers multiple therapeutic advantages over postnatal bone marrow transplantation due in part to the fetal immune system’s ability to support transplanted donor cells and develop donor-specific tolerance. The immunologic immaturity of the developing fetus allows antigens that are introduced early in development to not…

Preimplantation Genetic Testing

Abbreviations aCGH Array comparative genomic hybridization AF Amniotic fluid CRISPR Clustered regularly interspaced short palindromic repeat CVS Chorionic villus sampling FISH Fluorescence in situ hybridization HDR Homology directed repair ICM Inner cell mass ICSI Intracytoplasmic sperm injection mtDNA Mitochondrial DNA nDNA Nuclear DNA NGS Next-generation sequencing NHEJ Nonhomologous end joining cfDNA cell-free DNA PCR Polymerase chain reaction PGD Preimplantation genetic diagnosis PGS Preimplantation genetic screening PGT…

Prenatal Diagnostic Testing

Introduction Testing is available for an ever-increasing number of genetic disorders. Although prenatal testing originally focused primarily on Down syndrome, it is now possible to detect a broad range of genetic conditions. Prenatal diagnostic testing is most commonly performed on fetal tissue obtained with amniocentesis or chorionic villus sampling (CVS), although umbilical cord blood obtained through percutaneous sampling is occasionally used. In the early embryo, preimplantation…

Exome and Genome Sequencing

Introduction Current standards for prenatal genetic screening and testing are highly focused on detection of aneuploidies that are compatible with live birth, including trisomy 21, which affects 1:600 newborns overall and is associated with long-term survival, and the less common and more severe trisomies 18 and 13, which respectively affect 1:5000 and 1:15,000 liveborn infants. When an amniocentesis or other prenatal diagnostic procedure is performed for…