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Nutrition and Selected Disorders of the Gastrointestinal Tract

Part 1: Nutrition for the High-Risk Infant David H. Adamkin, Paula G. Radmacher Key Points 1. Begin intravenous amino acids in the first hours of life. 2. Consider using lipid emulsions early with long-chain polyunsaturated fatty acids (LCPUFA) (especially docosahexaenoic acid [DHA], arachidonic acid [ARA], and eicosapentaenoic acid [EPA]) to prevent omega 3 deficiencies. 3. Prioritize the use of human milk. If mother’s own milk is…

Physical Growth: Physical Examination of the Newborn Infant and the Physical Environment

There are tiny, puny infants with great vitality. Their movements are untiring and their crying lusty, for their organs are quite capable of performing their allotted functions. These infants will live, for although their weight is inferior … their sojourn in the womb was longer. Pierre Budin, The Nursling An infant’s problems and prognosis are in large part determined by birth weight and gestational age. The…

Resuscitation and Initial Stabilization

The transition from fetal to neonatal life is a dramatic and complex process involving extensive physiologic changes that are most obvious at the time of birth. Individuals who care for newly born infants during these first few minutes of neonatal life must monitor the progress of the transition and be prepared to intervene when necessary. In the majority of births, this transition occurs without a requirement…

Antenatal and Intrapartum Care of the High-Risk Infant

Everything ought to be done to ensure that an infant be born at term, well developed, and in a healthy condition. But in spite of every care, infants are born prematurely. Pierre Budin, The Nursling Identification of the Pregnancy at Risk The goal of prenatal care is to ensure optimal outcomes for both baby and mother. Prenatal care involves a series of assessments over time, as…

Patient Safety, Quality, and Evidence-Based Medicine

Health care is viewed as a system, a network of interdependent components working together to accomplish a specific aim, which is to meet the needs of patients, families, and communities while constantly improving its performance. The quality of health care is defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional…

Clinical and molecular markers to assist decision-making in neonatal sepsis

Key points Early detection followed by rapid initiation of antimicrobial treatment and measures to prevent and treat organ dysfunction are key to optimizing the outcome of sepsis. Due to the non-specific presentation, the dynamic and heterogeneous nature of sepsis, and the difficulties in objectively defining clinical signs, there is no combination of clinical markers that offers high diagnostic accuracy. Molecular markers mainly assess the systemic inflammatory…

Recent advances and controversies in inborn errors of immunity presenting in the newborn period

Key points Inborn errors of immunity (IEI) presenting in the newborn period include immune deficiencies affecting cellular and humoral immunity, diseases of immune dysregulation, congenital defects in phagocyte function, defects in intrinsic and innate immunity, and autoinflammatory disorders. There are many syndromes associated with IEI that can be recognized in the newborn period through extra-immune manifestations. However, many newborns with IEI appear healthy until they acquire…

Drug-associated acute kidney injury in neonates

Key points Drug-associated acute kidney injury is common in neonates and has important implications for therapeutic decisions and patient clinical outcomes. This chapter reviews the mechanisms of nephrotoxin-induced acute kidney injury and the various medications that are widely used in neonatal intensive care units. Our ability to understand the fundamental principles of management of drug-induced nephrotoxicity requires a multidisciplinary approach aimed at earlier recognition and close…

Vasodilator drugs for pulmonary hypertension in bronchopulmonary dysplasia

Key points Pulmonary hypertension (PH) is an important comorbidity associated with bronchopulmonary dysplasia that increases risk of right ventricular failure and death in premature infants. First-line treatment is aimed at correction of the respiratory status by optimizing lung volumes, oxygenation, and ventilation and eliminating sources of pulmonary inflammation, such as infection or aspiration. Depending on disease severity, PH-targeted therapies may be used in conjunction with or…

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…