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Hypotonia and Neuromuscular Disease in the Neonate

Clinicians who care for newborns are often required to consider the possibility that a neuromuscular disorder might be present in a hypotonic infant. The ability to determine the normal expected tone of that infant is vital to assess what additional evaluation might be warranted. Hypotonia can be the result of an insult or disorder in any part of the nervous system, including the brain, spinal cord,…

Seizures in Neonates

Seizures are a common and important clinical manifestation of neurologic dysfunction in the newborn. Building on a traditional foundation of knowledge regarding seizures in the newborn, the last decade has brought new insights into the clinical-electroencephalographic correlates, pathophysiology, and treatment that will be reflected in this chapter. The incidence of seizures varies with gestational age and birth weight and is most common in the very low…

Hypoxic–Ischemic Encephalopathy

Hypoxic–ischemic encephalopathy (HIE) following severe perinatal asphyxia (also referred to in the literature as perinatal hypoxia–ischemia or asphyxia neonatorum ) has an incidence of 1-2 per 1,000 live births in the Western world and is far more common in developing countries (see Chapter 8 ). Although metabolic disorders may mimic perinatal asphyxia, and genetic and placental factors may contribute to the clinical picture, brain imaging techniques…

Intracranial Hemorrhage and Vascular Lesions in the Neonate

Germinal Matrix Hemorrhage–Intraventricular Hemorrhage Incidence Germinal matrix hemorrhage–intraventricular hemorrhage (GMH-IVH) mainly occurs in premature infants, and the risk is higher with decreasing maturity. A 2003 study, however, also showed that IVH, sometimes associated with a thalamic hemorrhage, can be seen in full-term infants, and this can be associated with a sinovenous thrombosis. The first studies using computed tomography (CT) and ultrasonography were performed between 1978 and…

White Matter Damage and Encephalopathy of Prematurity

Brain injury in the premature infant is composed of multiple lesions, traditionally described as germinal matrix intraventricular hemorrhage (IVH) with or without parenchymal involvement, posthemorrhagic hydrocephalus (PHH), and periventricular leukomalacia (PVL). These mostly focal lesions mainly affecting white matter have, in recent years, been recognized to be associated with various other brain alterations, such as cortical and subcortical neuronal loss and distant alteration of white matter…

Normal and Abnormal Brain Development

Normal development of the human central nervous system (CNS) encompasses several steps, including neuroectoderm induction, neurulation, cell proliferation and migration, programmed cell death, neurogenesis and elimination of excess neurons, synaptogenesis, stabilization and elimination of synapses, gliogenesis, and myelination ( Table 51.1 ). TABLE 51.1 Schematic Chronology of the Major Events During Human Neocortical Development Neuroectoderm induction 3rd GW Neurulation 3rd to end of 4th GW Prosencephalic…

Viral Infections in the Neonate

Certain viruses seem to have a predilection for the fetus and may cause abortion, stillbirth, intrauterine infection, congenital malformations, acute disease during the neonatal period, or chronic infection with subtle manifestations that may be recognized only after a prolonged period. It is important to recognize the manifestations of viral infections in the neonatal period not only to diagnose the acute infection but also to anticipate the…

Fungal and Protozoal Infections of the Neonate

Fungal infections in the neonatal intensive care unit (NICU) remain an important health problem associated with substantial morbidity and mortality. Invasive fungal infections encompass infections largely caused by Candida species and with a small portion caused by Aspergillus , Zygomycetes , Malassezia , and Trichosporin . Invasive Candida infections occur in two main patient groups in the NICU: (1) the extremely premature infant and (2) NICU…

Postnatal Bacterial Infections

Neonatal Sepsis Newborns are extremely susceptible to infection, and sepsis is a significant cause of morbidity and mortality in this population. Neonatal sepsis is a systemic inflammatory response syndrome (SIRS) that is secondary to infection. Systemic inflammatory response syndrome is defined by the presence of two or more of the following variables: fever or hypothermia, tachycardia, tachypnea or hyperventilation, and an abnormally high or low white…

Developmental Immunology

Birth represents a functional watershed in the developing immune system. In utero, the fetus is exposed to a constant barrage of “foreign” antigens that are derived mainly from the mother and must downregulate its immune responses to survive. However, after birth, the neonatal immune system is exposed to a new, more varied set of antigens and must evolve dichotomous responses to simultaneously “contain” microbial populations on…

Infants of Substance-Using Mothers

Misuse or abuse of certain illicit and prescription drugs in the United States adversely affects public health in diverse ways and substantially increases overall health care expenditures. Some antenatal drug exposures can produce significant short-term consequences or serious permanent long-term injuries in the child ( Table 46.1 ). The US Department of Health and Human Services, through its annual National Survey on Drug Use and Health…

Pharmacokinetics in Neonatal Medicine

The safe and effective use of medications in the newborn intensive care unit (NICU) requires an understanding of the principles of pharmacokinetics (PK) and pharmacodynamics (PD) that guide individual dosing and aim to provide drug exposures designed for the best clinical outcomes and lowest risk of toxicity. The PK of drugs in neonates is unique and cannot be extrapolated from older children or adults (for excellent…

Principles of Drug Use During Lactation

It is not disputed that breastfeeding has many benefits for both mother and baby and is the optimal nutrition for infants. With an increase in education and support of breastfeeding mothers throughout the United States, the rate of breastfeeding is on the rise. The Centers for Disease Control and Prevention report an increase of breastfeeding initiation from 79% in 2011 to 81.1% in 2013, with a…

Principles of Drug Use in the Fetus and Neonate

Fetal Drug Disposition The use of medications during pregnancy, prescription and over-the-counter, is a common and increasing occurrence. Multiple studies have demonstrated that approximately 90% of pregnant women take at least one medication during the pregnancy. The average number of medications used during pregnancy has increased by 68%, from 2.5-4.2, over the past 30 years, and the use of four or more medications has increased from…

Support for the Family

Normal Mother–Infant Attachment The birth of an infant initiates a series of interactions with parents (particularly the mother) designed to initiate attachment and ensure survival. Attachment is a bidirectional emotional and enduring bond that is reciprocated between infant and the caregiver, a process of synchronous coregulation that influences each other's internal state. Human development is sufficiently resilient to withstand some disturbance of the normal postpartum sequence…

Nutrient Requirements/Nutritional Support in Premature Neonate

Current recommendations for the provision of parenteral and enteral nutrition to the infant born prematurely are based on the goal of approximating the rate and composition of weight gain of a normal fetus at the same postmenstrual age. For a number of reasons this goal is seldom achieved, and postnatal growth failure still remains a significant complication of extreme prematurity. Infants who experience one or more…

The Late Preterm Infant

Births between 34 and 36 6/7 weeks’ gestation (referred to herein as late preterm births ) account for a significant proportion of preterm births in North America and elsewhere. These infants are larger than usual premature infants, and they are generally passed off as mature infants, but they often manifest signs of physiologic immaturity or delayed transition in the neonatal period. Several studies have documented the…

Anesthesia in the Neonate

Developmental Challenges of Neonatal Anesthesia The administration of anesthesia to the neonatal patient requires knowledge and understanding of neonatal anatomy and pathophysiology in addition to the ability to understand how the pharmacology of standard anesthetic drugs is altered in preterm and term neonates. Anesthetic care of these oftentimes critical patients is best performed by specialty trained pediatric anesthesiologists. The creation of a surgical environment that is…

Diagnostic Imaging of the Neonate

Introduction Diagnostic imaging is integral to the evaluation of neonates with medical and surgical conditions. Understanding the advantages and shortcomings of available imaging modalities as well as the most recent practice patterns facilitates selection of appropriate imaging. This chapter begins with a brief introduction to the benefits and potential hazards of relevant imaging modalities; the remainder of the chapter reviews the imaging approach to common neonatal…

Biomedical Engineering Aspects of Neonatal Cardiorespiratory Monitoring

Preterm infants are exceptionally unstable in terms of respiratory control due to both immaturity of the central nervous system and susceptibility to disease and infection. As a result, they exhibit a high incidence of apnea, bradycardia, and desaturation events during the first few months of life. Respiratory support including supplemental oxygen, continuous positive airway pressure (CPAP), and mechanical ventilation are ubiquitous in the neonatal intensive care…