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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…

Optimization of the NICU Environment

Neurobehavioral Maturation The expected physiologic environment for a preterm infant would be in utero, floating and moving in warm amniotic fluid, mostly in a flexed position, tasting the amniotic fluid, sensing their mother’s movements and circadian rhythm, hearing her voice and sounds from her body but being protected from loud noises, receiving rich amounts of nutrients for optimal growth, and performing gas exchange through the placenta.…

Thermal Environment of the Intensive Care Nursery

Thermal management of the newborn infant is a cornerstone of neonatal care: The field accommodates important advances in care provision spanning from pioneering studies on chronic cold stress and neonatal incubation to kangaroo mother care, prevention of low admission temperatures, and therapeutic hypothermia. Globally, cold stress remains a contributor to neonatal mortality and morbidity, and the potential impact of optimal thermal care provision on infant health…

Chest Compression, Medications, and Special Problems in Neonatal Resuscitation

Advanced resuscitation in the delivery room is rarely needed as long as effective ventilation is quickly established. When compressions are needed, it is critical to minimize pauses, use the most effective two-thumb method from the head of the bed position, and coordinate with breaths that inflate the lung. In rare cases of profound asphyxia, intravenous epinephrine may be needed to reestablish adequate coronary perfusion pressure. Medical…

Oxygen Therapy in Neonatal Resuscitation

Use of Oxygen in Perinatal Asphyxia and Resuscitation Oxidative Stress: Pathophysiologic Background Perinatal asphyxia is a devastating disorder that affects roughly 2% of newborn babies in industrialized countries, but constitutes one of the leading causes of early neonatal death in nonindustrialized countries. Both ischemia and hypoxia reduce oxygen and glucose supply to neurons leading to ATP depletion and inactivation of ATP-depending ion pumps, causing intracellular accumulation…

Role of Positive Pressure Ventilation in Neonatal Resuscitation

Newborn babies who do not spontaneously breathe at birth require support to safely make the transition to extra-uterine life. Over the past 20 years, guidelines for those providing care to these infants have been developed. However, the evidence available to guide initial respiratory support remains limited, reflecting the challenges associated with conducting research in the delivery room. The crucial steps in the adaption to extra-uterine life…

Overview and Initial Management of Delivery Room Resuscitation

The transition from fetus to neonate represents a series of rapid and dramatic physiologic changes during which the placenta is replaced by the lungs as the primary organ of gas exchange. Although this transition goes smoothly most of the time, in approximately 10% of births the active intervention of a skilled individual or team is necessary to ensure that the newborn receives the appropriate assistance to…

Congenital Anomalies

Major anomalies are seen in about 2% of newborns, often prompting parental worry and urgent medical intervention soon after birth. In addition, they are a common cause of long-term illness and death. This chapter reviews some of the significant etiologic and epidemiologic aspects of congenital anomalies. It provides an approach to and a framework for the evaluation of the infant with congenital anomalies, with emphasis on…

Birth Injuries

Birth injuries are those sustained during the birth process, which includes labor and delivery. They may be avoidable, or they may be unavoidable and occur despite skilled and competent obstetric care, as in an especially hard or prolonged labor or with an abnormal presentation. Fetal injuries related to amniocentesis and intrauterine transfusions and neonatal injuries after resuscitation procedures are not considered birth injuries. However, injuries related…

Physical Examination of the Newborn

Immediately after a baby is born, all parents want to know, “Is my baby all right?” A quick initial physical examination of all newborns should be performed in the delivery room to ensure that there are no major anomalies or birth injuries, that the newborn's lips and body appear pink, and that breathing is normal. This primary survey must include a brief look at the entire…

Anesthesia for Labor and Delivery

The goal of modern-day obstetric anesthesia practice is to provide the patient with analgesia as she requests it. That assumes her choice is appropriate to the labor process and to the current conditions as evaluated by her obstetric provider, and has as little impact on the fetus as possible. Depending on the patient's predilections, labor might be approached with prepared responses to modify pain perception, a…

Placental Pathology

The placenta has two opposing functions. It is the sole source of sustenance for the fetus and its sole protection against noxious external influences. It can be argued that no evaluation of a sick neonate is complete without knowing the status of the organ that has accompanied it through the preceding gestation. The specific “value added” by placental examination can be summarized under five overlapping headings:…