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Cardiovascular Problems of the Neonate

Cardiac Malposition and Abnormalities of Abdominal Situs Bodily Arrangement and Situs The development of morphologically right-sided structures on one side of the body, and morphologically left-sided structures on the other side, is termed lateralization or situs . The normal arrangement, in which right-sided structures are on the right side of the body and vice versa, is known as situs solitus . The term visceroatrial situs is…

Congenital Defects of the Cardiovascular System

Summary Congenital heart defects are the most common type of birth defect in infants worldwide. The following chapter provides an overview of the anatomy, physiology, clinical presentation, diagnostic evaluation, and management strategies for a wide range of congenital heart disease encountered in neonates and infants. While the information herein is detailed, it is important to keep in mind that many different anatomic and physiologic variants are…

Patent Ductus Arteriosus

In utero, the ductus arteriosus provides a connection between the pulmonary artery and descending aorta through which deoxygenated blood returning to the right heart is diverted to the placenta for reoxygenation. Although essential to normal fetal physiology, it normally constricts, closes, and becomes a fibrous remnant after birth. Failure of those processes, resulting in persistent ductal patency into childhood or adulthood, has been recognized as a…

Prenatal Diagnosis of Congenital Heart Disease

Introduction Congenital heart disease (CHD) affects 6-8 per 1000 live births. However, only 20% of babies with congenital heart disease would be identified if the examination of the fetal heart were confined to traditional high-risk groups such as increased nuchal translucency, family history of CHD, and teratogen exposure. The current American Society of Echocardiography guidelines suggest the optimal timing for performance of a comprehensive transabdominal fetal…

Pulmonary Vascular Development

Normal development of pulmonary vascular structure and function through prenatal and early postnatal life prepares the lung to perform its basic physiologic function of gas exchange across a thin blood–gas interface. Survival of the newborn is dependent upon rapid adaptation of the fetal cardiopulmonary system to the demands of extrauterine life. As development continues, normal lung function and growth depends on sustained low pulmonary vascular resistance.…

Cardiac Embryology

Introduction Congenital heart defects (CHDs) affect about 1% of all live births around the world, with variations in reporting depending on birth rates and access to medical care. The care of children with CHDs has increasingly become a neonatal specialty, aided by prenatal detection. The fetal diagnosis of critical CHDs decreases postsurgical morbidity and mortality, and reparative or palliative cardiovascular surgery is commonplace in the first…

Therapy for Cardiorespiratory Failure in the Neonate

Assisted ventilation and oxygen therapy remain the standard of care for neonatal respiratory failure. A few term and late preterm infants with a wide range of diagnoses develop intractable cardiorespiratory failure despite maximal ventilatory support. In these patients, severe pulmonary hypertension often contributes to persistent hypoxemia. Two unique therapies for such patients are presented in this section: extracorporeal membrane oxygenation (ECMO), which is now well established…

Bronchopulmonary Dysplasia in the Neonate

The introduction of mechanical ventilation for the management of premature infants with severe respiratory distress syndrome (RDS) in the 1960s changed the natural course of the disease, resulting in increased survival of smaller and sicker infants, many of whom had severe chronic lung damage. Northway and associates were the first to describe this condition in 1967 and introduced the term bronchopulmonary dysplasia (BPD). All these infants…

Upper Airway Lesions in the Neonate

A spectrum of pathologic conditions can affect the neonatal upper airway, resulting in respiratory distress at birth or within the first few weeks of life. The clinical presentations of these disorders, however, are often quite similar. The most common symptom is stridor; other signs and symptoms include cyanosis, apnea, dyspnea, retractions, hypercapnia, difficulty feeding, abnormal cry, and cough. The physician's ability to arrive at a diagnosis…

Neonatal Apnea and the Foundation of Respiratory Control

Breathing results in the exchange of oxygen and carbon dioxide between the lungs and the environment while maintaining homeostasis and control of blood pH. Energy-consuming breathing movements do occur in utero. Maturation of breathing is a continuous process that bridges fetal and neonatal life. Especially for premature infants, immature fetal breathing responses result in irregular respiratory effort, apnea, bradycardia, and hypoxemia. Fetal Breathing Fetal breathing activity…

Neonatal Respiratory Disorders

Multiple pathophysiologic mechanisms can present with pulmonary manifestations in term and preterm infants. The clinical picture is most commonly dominated by respiratory distress, which presents as tachypnea, grunting, flaring, retractions, cyanosis, and hypoxemia. However, apnea and hypoventilation are also common. In preterm infants, these manifestations are commonly associated with respiratory distress syndrome (RDS) as discussed in Chapter 64 . Nonpulmonary etiologies of respiratory distress include thermal…

Assisted Ventilation of the Neonate and Its Complications

Mechanical ventilation has been used to treat neonatal respiratory failure for more than a half century. The earliest applications began as modifications of adult ventilators, treating babies of modest size and prematurity by today's standards. Most devices were time-cycled, pressure-limited ventilators. Landmark advances in respiratory care occurred in the 1970s. Antenatal corticosteroids were shown to enhance fetal lung maturity, and transcutaneous oxygen monitoring taught us much…

Respiratory Distress Syndrome in the Neonate

Enormous strides have been made in understanding the pathophysiology of respiratory distress syndrome (RDS) and the role of surfactant in its cause and treatment (see Chapter 62 ). Nevertheless, RDS, formerly referred to as hyaline membrane disease, remains a dominant clinical problem despite the introduction of pharmacologic acceleration of pulmonary maturity using antenatal corticosteroids and the development of surfactant replacement therapy. Because more of the sickest,…

Assessment of Neonatal Pulmonary Function

Most neonates requiring intensive care present with respiratory symptoms. Although standard techniques for assessing pulmonary function can be applied in a healthy infant, special limitations and problems are encountered in very small or sick neonates. Methods have been developed to evaluate pulmonary function in neonates with suspected abnormalities of the cardiopulmonary system. This section presents a practical and clinical approach to disordered cardiopulmonary function and attempts…

Lung Development and Maturation

A Brief History An understanding of lung development and maturation is central to the care of preterm infants, because lung function is so critical to survival of the preterm. Pattle and Clements first noted surface-active substances in pulmonary edema foam and lung extracts. In 1959, Avery and Mead correlated respiratory failure with decreased surfactant levels in saline extracts from the lungs of infants with respiratory distress…

The Role of Neonatal Neuroimaging in Predicting Neurodevelopmental Outcomes of Preterm Neonates

Cranial Ultrasound Cranial ultrasound (CUS) is the most widely used neuroimaging method for preterm infants. Cranial ultrasound uses high-frequency sound waves, transmitted through open fontanelles, to detect differences in echogenicity between tissues and allow identification of anatomic structures, hemorrhage, and fluid collections. Early reports of CUS to image brain injury in preterm infants utilized anterior fontanelle views. Since that time, the importance of mastoid (posterolateral) and…

Early Childhood Neurodevelopmental Outcomes of High-Risk Neonates

Advances in obstetric and neonatal care, which have been responsible for the improved survival of high-risk neonates, have not resulted in decreased morbidity. Since perinatal interventions can alter later growth and development, long-term follow-up is essential to ensure therapies such as oxygen administration and postnatal steroids, which demonstrate dramatic and immediate positive effects, are not associated with adverse long-term outcomes. The earliest follow-up studies of preterm…

Hearing Loss in the Newborn Infant

Background Tremendous progress has been made during the past 25 years in the identification of hearing loss (HL) in newborns. The National Institutes of Health issued a “Consensus Statement on Early Identification of Hearing Impairment in Infants and Young Children” in 1993 that concluded that all infants admitted to the neonatal intensive care unit (NICU) should be screened for HL before hospital discharge and that universal…

Spinal Dysraphisms

Summary This chapter reviews open and closed neural tube defects. We discuss imaging evaluation as well as physical exam findings. Finally, we discuss current trends in treatment and perinatal care. Introduction Neural tube defects (NTD) are the second-most common birth defect after congenital heart defects, affecting 1-2 in 1000 pregnancies worldwide. Spinal dysraphisms are a subset of neural tube defects and are classified as open or…

Intracranial and Calvarial Disorders

Summary This chapter explores those conditions that cause abnormal head shape or head size in the newborn infant. The underlying causes, clinical presentation, diagnosis, and available interventions will be presented. Examination of the Head Abnormalities are first identified by observation of the general shape and texture of the head and scalp. Palpation of neurocutaneous lesions are noted. The anterior fontanelle, demarking the junction of the frontal…