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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…

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…