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Pharmacological therapy of neonatal abstinence syndrome

Key points Neonatal abstinence syndrome (NAS) secondary to maternal use of opioids during pregnancy continues to remain a major problem in neonates. Nonpharmacological measures are the first-line treatment in the management of NAS. Morphine remains the most popular medication in the treatment of NAS, although methadone and buprenorphine are also effective. Adjunct medications (e.g., phenobarbital, clonidine) are not without adverse effects and may be necessary when…

Neuroprotective therapies in newborns

Key points Preterm and term infants are at risk of acquiring brain injury with lasting neurodevelopmental sequelae. Mechanisms of brain injury in the developing brain are related to unique vulnerabilities due to the maturational stage of the various types of cells in the brain. The pathogenesis of brain injury in both preterm and term infants provides multiple opportunities for therapeutic intervention, such as addressing excitotoxicity, inflammation,…

Antiseizure medications and treatments in neonates

Key points Initial/emergent management of neonatal seizures includes stabilization of the neonate, assessment and correction of reversible causes of seizures, and evaluation for sepsis/meningitis at the same time as antiseizure medications (ASMs) are initiated. Despite limited efficacy data and concern for adverse effects, phenobarbital remains the first-line treatment for most neonatal seizures. Limited evidence supports phenytoin, benzodiazepines, lidocaine, and levetiracetam as second- or third-line agents. Other…

Antibiotic considerations for necrotizing enterocolitis

Key points Necrotizing enterocolitis (NEC) results in an intra-abdominal infection, and treatment includes antimicrobial therapy, bowel rest, parenteral nutrition, and surgery, if clinically or radiologically indicated. In the absence of evidence-based guidelines, many antibiotic combinations are used for NEC treatment in the current practice. Ampicillin and gentamicin are probably adequate for the treatment of stage I or IIA NEC. For proven stage IIB or III NEC,…

Organ dysfunction in sepsis and necrotizing enterocolitis

Key points Sepsis and necrotizing enterocolitis are common sources of morbidity and mortality in the premature infant population. There is a lack of consensus on the definition of neonatal sepsis, confounded by the overlap between pathologic and non-pathologic variability in vital signs, physiology, and exam findings. Improved outcomes in neonatal sepsis and sepsis-like illness will require prompt intervention guided by sensitive, multimodal detection of end-organ dysfunction.…

Gonococcal eye prophylaxis—are mandates still justified?

Key points Neonatal ocular prophylaxis for prevention of gonococcal ophthalmia was first introduced by Credé in 1881. Gonococcal ophthalmia became and still is very uncommon due to the introduction in the 1950s of prenatal screening for Neisseria gonorrhoeae and treatment of pregnant women. Erythromycin ophthalmic ointment is the only preparation available for neonatal ocular prophylaxis in the United States. Neonatal ocular prophylaxis with erythromycin ophthalmic ointment…

Congenital syphilis

Key points The incidence of syphilis in the United States has been increasing since 2012. The two leading causes of missed congenital syphilis prevention opportunities are the lack of adequate maternal syphilis treatment despite a timely diagnosis and absence of prenatal care and subsequent maternal syphilis testing. Although reverse screening algorithms have been adopted in many healthcare settings, traditional screening methods utilizing a quantitative rapid plasma…

Perinatal and neonatal considerations in COVID-19

Key points The incidence of COVID-19 in newborns is low; however, COVID-19 can still cause severe illness and complications. Evidence related to the COVID-19 pandemic and perinatal and neonatal care continues to evolve, but many unanswered questions remain. Pregnant and non-pregnant individuals have similar manifestations of COVID-19 symptoms, but pregnant individuals are at increased risk for severe COVID-19–associated illness; risk is reduced with vaccination. Perinatal transmission…

When to perform lumbar puncture in infants at risk for meningitis in the neonatal intensive care unit

Key points Meningitis occurs most commonly in the neonatal period and is associated with significant morbidity and mortality. Of infants with meningitis, 15% to 38% have negative blood cultures. Selective evaluation of infants with culture-proven bacteremia can result in missed diagnoses of meningitis. Routine lumbar puncture in well-appearing infants evaluated because of maternal risk factors is not recommended. Lumbar puncture can be deferred or omitted from…

Neonatal fungal infections

Key points Major risk factors for invasive Candida infections include extreme prematurity, a compromised gastrointestinal function or barrier, presence of a central venous catheter, and exposure to broad-spectrum antibiotics, acid suppression medications, and high-dose postnatal steroids. Infants at the highest risk weigh <1000 g at birth or 28 weeks’ gestation, due to high mortality and the risk of neurodevelopmental impairments from infections. Preventative measures including targeted…

Antibiotic stewardship

Key points Antibiotics are lifesaving and improve outcomes in neonatal clinical care. Increasing evidence in animal and human models links antibiotic exposure with alterations in the microbiome, the developing immune system, and subsequent effects on health. Empiric antibiotic use is linked to the emergence of infections caused by multidrug-resistant organisms and to increased risk of necrotizing enterocolitis and mortality. The primary goal of antibiotic stewardship programs…

Neonatal herpes simplex virus infection

Key points Herpes simplex virus (HSV) is a virus that can cause severe infection in a neonate but also has treatment options that can improve disease outcomes. There are three periods of acquisition of HSV: in utero, perinatal, and postnatal. HSV can be diagnosed via polymerase chain reaction (PCR) of blood and cerebrospinal fluid (CSF), as well as surface cultures and PCR. It is important to…

When and how to treat neonatal CMV infection

Key points Congenital cytomegalovirus (CMV) is the leading infectious cause of hearing loss and neurologic deficits, affecting up to 1% of live births worldwide. Symptomatic congenital CMV infection should be treated with ganciclovir or valganciclovir for 6 months to reduce or ameliorate long-term neurologic deficits, including hearing loss and developmental delay. Studies suggest that some infants with asymptomatic or mild congenital CMV infection at birth may…

Empiric therapy for neonatal sepsis

Key points Most early-onset infections in high-resource settings are caused by group B Streptococcus and Escherichia coli. Ampicillin + gentamicin is an appropriate empirical antibiotic regimen for early-onset sepsis in most settings. Most late-onset infections are caused by Gram-positive organisms. Nafcillin + gentamicin balances the need for a narrow spectrum with the risks of potentially providing inadequate empirical treatment in most cases. Empirical antimicrobials targeting methicillin-resistant…

Management of the asymptomatic newborn at risk for sepsis

Key points The current incidence of neonatal early-onset sepsis (EOS) among infants born ≥37 weeks is relatively low (≈1/2000) and as much as 20-fold lower among well-appearing term infants. There are three major approaches to EOS risk assessment among term infants: categorical consideration of risk factors, multivariate consideration of risk factors in combination with clinical condition, and consideration of the clinical condition alone as it evolves…

Pathophysiologic importance of platelets in neonatal necrotizing enterocolitis

Introduction The onset of necrotizing enterocolitis (NEC) is associated with decreased platelet counts in most patients within 24 hours, and the severity of this thrombocytopenia (defined as platelet counts <150 × 10 9 /L) typically correlates with the severity and extent of intestinal injury. The platelet counts usually continue to drop until 3 days after disease onset. Patients with the most severe, surgical NEC may develop…

Evidence-based guidelines for administering fresh frozen plasma in the NICU

Introduction Fresh frozen plasma (FFP) is the most commonly used hemostatic agent in neonatal intensive care units (NICUs), especially among critically ill neonates and for those who need extracorporeal life support (ECLS). Current guidelines on FFP administration in neonates are mainly based on poor-quality evidence, and therefore a lack of consensus exists on its optimal use. Making the right diagnosis of coagulopathy in neonates and determining…

Novel approaches to identify NICU patients who would benefit from platelet transfusions

Introduction The underlying reasons for bleeding are multifactorial and likely include a combination of hematologic (i.e., platelet, von Willebrand factor [vWF], coagulation factors) and environmental factors such as vessel wall integrity, inflammation, and hemodynamic status. However, it is unknown to what extent these components contribute to bleeding. Since platelets have a major role in primary hemostasis, a low platelet count is considered a risk factor for…

Recent advances in NICU platelet transfusions

Introduction Thrombocytopenia (defined as a platelet count <150 × 10 9 /L) is the second most common hematologic problem among neonates admitted to the neonatal intensive care unit (NICU), affecting 20% to 25% of this patient population. The incidence of thrombocytopenia increases with decreasing gestational age and birth weight, reaching ~70% among extremely low birth weight (ELBW) neonates (born with a weight <1000 g). The incidence…

Neonatal blood banking and transfusion: Current questions and controversies

Introduction Blood component transfusion is critical to modern neonatal medicine to support oxygen delivery, cardiac output, and maintain hemostasis, especially in the context of preventing bleeding or treating the bleeding neonate. Of all admissions to the neonatal intensive care unit (NICU) in the United States, approximately 1.6% receive any blood transfusion, with red blood cell (RBC) transfusion occurring most commonly. Despite the relatively high frequency of…