Neonates

Neonates are particularly vulnerable, with a reported rate of major complications

of 4.7% for interventional catheterization, which may be explained by reduced
physiologic reserve, presence of uncorrected or partially palliated congenital heart
defects, and an increased risk of obstruction to great vessels and cardiac chambers
by wires and devices.23

From: A Practice of Anesthesia for Infants and Children (Sixth Edition), 2019

Related terms:

Combination Therapy, Drug, Infection, Dose, Diagnosis, Obstetric Delivery, Prema-

turity, Seizure

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Clinical Syndromes and Cardinal Fea-

tures of Infectious Diseases: Approach
to Diagnosis and Initial Management
P. Brian Smith, Daniel K. Benjamin Jr, in Principles and Practice of Pediatric Infec-
tious Diseases (Fourth Edition), 2012

Neonates are uniquely susceptible to infection. The immaturity of the neonatal

immune system and the environment of the neonatal intensive care unit contribute
to the variety of organisms affecting this population. This chapter outlines the clinical
approach to the neonate with signs or symptoms consistent with infection. The
approach should focus first on supportive measures: respiratory support, correc-
tion of metabolic and hematologic derangements, fluid management, and use of
inotropic drugs when indicated. The clinician then should obtain diagnostic studies
and institute antimicrobial therapy considering the timing of infection and the
neonate's previous exposure to maternal and environmental factors.
> Read full chapter

Pain Management in the Neonate

K.J.S. Anand MBBS, DPhil, ... R. Whit Hall MD, in Fetal and Neonatal Secrets (Third
Edition), 2014

Neonates may receive lower morphine infusion rates than older children after
surgery, starting as low as 0.005 mg/kg/h for preterm neonates and 0.01 mg/kg/h for
term neonates. Neonates with cyanotic congenital heart defects also require lower
morphine infusion rates than neonates undergoing noncardiac surgery. Depending
on the dose and other patient characteristics, fentanyl and sufentanil provide vari-
able degrees of suppression of autonomic and hormonal/metabolic responses to
major surgery in neonates, although fentanyl may increase the risk of postoperative
hypothermia. Critically ill neonates, whose vascular tone depends on sympathetic
outflow, may become hypotensive after bolus doses of fentanyl or morphine. In
preterm neonates undergoing ductal closure, higher fentanyl doses (>10.3 mg/kg)
were associated with a decrease in an unstable postoperative respiratory course.
Randomized controlled trials show no differences in the postoperative analgesia
produced by bolus doses versus continuous infusions of morphine; however, ap-
nea or other complications were greater in the bolus-dosing groups. Intravenous
boluses of opioids should be given slowly (over 15 to 30 minutes) to postoperative
neonates.197198199

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Pain in Children
Patricia A. McGrath PhD, Stephen C. Brown MD, in Pain Management Secrets (Third
Edition), 2009

31 Are there special dosing considerations for neonates and

infants?
Neonates and infants require the same three categories of analgesic drugs as
older children. However, the difference in pharmacokinetics and pharmacodynamics
among neonates, preterm infants, and full-term infants warrants special dosing
considerations for infants and close monitoring when they receive opioids. Aceta-
minophen can be safely administered to neonates and infants without concern for
hepatotoxicity when given for short courses at the recommended dose (10 to 15
mg/kg) (Table 30-3). The starting doses for opioid analgesics in infants under 6
months of age are one-quarter to one-half the suggested doses. As for children,
the dosage and mode of administration of opioids need to be titrated between the
degree of analgesia required and a reasonable level of sedation.

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Granulocyte Products
Suzanne A. Arinsburg DO, in Transfusion Medicine and Hemostasis (Second Edi-
tion), 2013

Neonatal Sepsis
Neonates are at particular risk for bacterial and fungal infection because of their
diminished storage pool of neutrophils, which can be rapidly depleted; neonates
also have a qualitative defect of neutrophil function. In 1992, Cairo et al. performed
a clinical trial involving 35 neonates with neutropenia and sepsis randomized to
receive either intravenous immunoglobulin (n = 14) or granulocyte transfusion
(n = 21); survival was significantly higher in the granulocyte transfusion group
(100% survival) versus in the immunoglobulin group (64% survival). Studies com-
paring granulocyte transfusion to placebo or no granulocyte transfusion have not
demonstrated a significant difference in all-cause mortality during hospital stay;
though, these studies were small and performed prior to the development and use
of newer antimicrobial medications. Vamvakas et al. performed a meta-analysis of
seven clinical studies in adults and five clinical studies trials in neonates with sepsis
and reported on the efficacy of granulocyte transfusions in the treatment of
bacterial sepsis. These investigators found that the most significant factor in all
of the studies showing favorable outcomes was the dose of granulocytes transfused.

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HealthCare–Associated Infections in
the Nursery
Susan E. Coffin, Theoklis E. Zaoutis, in Infectious Diseases of the Fetus and Newborn
(Seventh Edition), 2011

Neonates, especially premature neonates who require intensive medical care, are
among the patients at highest risk for nosocomial or health care–associated infec-
tions (HAIs). Although the rate of HAIs varies with the specific patient population and
institution, some series have reported that more than 20% of critically ill neonates
who survive more than 48 hours acquire a nosocomial infection [1–3]. Neonatal HAIs
are associated with significant morbidity, mortality, and excessive direct health care
costs [3]. Prevention of these infections should be a major priority in all neonatal
intensive care units (NICUs) and nurseries. The most important risk factors for HAIs
in neonates, gestational age and birth weight, cannot be modified. Close attention to
clinical practice and the patient care environment is mandatory to minimize the risk
of infections. This chapter reviews the epidemiology, microbiology, pathogenesis,
and prevention of neonatal HAIs.

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TRANSFUSION MEDICINE
Cassandra D. Josephson, Ronald G. Strauss, in Blood Banking and Transfusion
Medicine (Second Edition), 2007

Pathophysiology of Neonatal Neutropenia and Neutrophil Dys-

function
Neonates are unusually susceptible to severe bacterial infections, and several defects
of neonatal body defenses have been reported as possible contributing factors.
PMNs isolated from the blood of neonates exhibit both quantitative and qualitative
abnormalities that may be related to the increased incidence, morbidity, and mor-
tality of bacterial infections. Abnormalities of neonatal PMNs include absolute and
relative neutropenia, diminished chemotaxis, abnormal adhesion and aggregation,
defective cellular orientation and receptor capping, decreased deformability, inability
to alter membrane potential during stimulation, imbalances of oxidative metabo-
lism, and a diminished ability to withstand oxidant stress.74 A complete discussion of
neonatal PMN physiology is beyond the scope of this chapter, and only aspects that
are particularly relevant to PMN transfusions and alternative therapies are reviewed
here.

Neutropenia can occur during neonatal bacterial infections, particularly with ful-
minant sepsis. Because a physiologic neutrophilia occurs in normal neonates, it is
considered quite abnormal for the absolute blood PMN count to fall below 3.0 ×
109/L during the first week of life. Although an abnormally low PMN count can occur
in neonates with disorders as diverse as sepsis, asphyxia, and maternal hyperten-
sion, suspicion of severe bacterial infection must always be high whenever relative
neutropenia (PMN count, <3.0 × 109/L) occurs. The mechanisms responsible are
only partially defined, but abnormalities of neonatal granulopoiesis frequently are
involved. As one factor, the postmitotic marrow PMN storage pool (metamyelocytes
and mature, segmented PMNs) is small. The PMN storage pool accounts for 26%
to 60% of all nucleated cells in the bone marrow of normal neonates. Neonates with
sepsis may exhibit a storage pool numbering less than 10% of nucleated marrow
cells and are considered to have severely diminished marrow PMN reserves.75
Second, storage pool PMNs are released at an excessively rapid and, apparently,
poorly regulated rate from the marrow during stress. Third, PMN production in
response to infection is decreased. The number of committed (clonogenic) PMN
precursors in neonatal marrow is lower in neonates than in older patients, and a
high percentage of these cells are proliferating even when studied at an apparently
basal state.75,76 Therefore, neonatal marrow is functioning at capacity and is unable
to rapidly expand production to meet the increased demands of infection.77 For this
reason, it is logical to consider PMN transfusions until the marrow recovers.

> Read full chapter

Fetal Implications of Maternal Infec-

tions in Pregnancy
Ari Bitnun, ... Greg Ryan, in Infectious Diseases (Fourth Edition), 2017

Varicella-Zoster Virus (VZV).

Neonates whose mothers develop peripartum chickenpox from 5 days before to 48
hours after delivery are at high risk of severe disease, due to the lack of protective
passive maternal antibody. Their risk of severe disease is between 20 and 50% and
their risk of death is approximately 20% in the absence of intervention.7 All such
infants should receive a dose of 125 U (1.25 mL or 1 vial) of zoster immune globulin
intramuscularly as soon as possible after birth.59 Aciclovir at a dose of 1500 mg/m2
per day should be given to symptomatic neonates, with dose adjustments for liver
and renal failure or prematurity. Isolation of the exposed hospitalized infant is
required.

> Read full chapter

Disorders of Carbohydrate Metabolism

David Werny, ... Cate Pihoker, in Avery's Diseases of the Newborn (Tenth Edition),
2018
After Fundoplication
Neonates undergoing fundoplication for gastric reflux or another reason are at risk
of postprandial hypoglycemia related to dumping syndrome. Approximately 25% of
neonates develop dumping syndrome after fundoplasty, most of which is identified
in the first postoperative week (Calabria et al., 2011; Samuk et al., 1996). Hypo-
glycemia occurs 1–3 hours after a meal because of an exaggerated insulin response
to early postmeal hyperglycemia, which is often detectable as well. Treatment is
with slower gastric feeds, and sometimes continuous feeds are required. Treatment
with uncooked cornstarch, pectin, octreotide, and acarbose has been attempted with
various degrees of success as well (Calabria et al., 2011).

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The Neonatal Brain and Opioids

Preeta George, Robert Moore, in Neuropathology of Drug Addictions and Substance
Misuse, 2016

Assessment of Neonatal Pain

Neonates belong to a high-risk category wherein they are extremely susceptible to
insults like pain. Evaluation of neonatal pain is fraught with difficulty (Anand,
1998, 2000). Vital sign changes cannot be used exclusively as a surrogate for pain
as they are influenced by a multitude of factors like volume status, discomfort,
temperature, and other comorbidities. Assessment of pain is a challenge as it relies
extensively on objective measures and behavior (Maxwell, Malavolta, & Fraga, 2013).
Several neonatal pain scales have been developed to evaluate the severity of painful
stimuli and guide treatment (Table 1). These scales include: the Premature Infant
Pain Profile (PIPP); Crying Requires oxygen saturation, Increased vital signs, Expres-
sion and Sleeplessness (CRIES); Neonatal Infant Pain Scale (NIPS); Neonatal Pain
Agitation and Sedation Scale (N-PASS); Pain Assessment Tool (PAT); Scale for Use in
Newborn (SUN); Neonatal Fading Coding System (NFCS); and Bemese Pain Scale
for Neonates (BPSN). These scales incorporate physiological changes and behavioral
patterns to grade severity as well as nature of pain (Grunau, Whitfield, Petrie, & Fryer,
1994).

Even with validated scales, pain assessment can be limited by a number of factors.
Preterm and term neonates vary in their response and behavior to painful stimuli,
which may often be impaired in the former. There is a paucity of tools for the
assessment of the repetitive painful stimuli in neonates, which vary significantly
 from the initial responses to pain. Neonates often become withdrawn exhibiting
a completely different affect when subjected to repeated painful stimuli (Boronat,
Garcia-Fuster, & Garcia-Sevilla, 2001; Grunau, Holsti, & Peters, 2006). Additionally,
these assessment tools fail to assess the subset of population of neonates that are
mechanically ventilated with muscle relaxants and those with neurological problems.
Further refinement of pain assessment tools is a clearly a furtive area for future
research.

> Read full chapter

Regional Blood Flow Monitoring in the

Perioperative Period
George M. Hoffman MD, James S. Tweddell MD, in Hemodynamics and Cardiology:
Neonatology Questions and Controversies (Second Edition), 2012

Neonates with significant congenital cardiac disease experience multiple threats to

adequate cellular oxygen delivery, before, during, and after corrective or palliative
surgery, with or without deliberate intraoperative alteration of blood flow required
to complete the surgical procedure. Factors that can reduce whole-body systemic
oxygen delivery include pulmonary systemic flow tradeoff that can occur in all
neonates with ductal patency and which may be exaggerated with pharmacological
maintenance of ductal patency beyond the first few days of life; inefficiency of
unpalliated or partially corrected cardiac anatomy; functional myocardial limita-
tion following hypoxia-ischemia; anemia; and altered hemoglobin-oxygen transport
function from stored blood. Increased metabolic demand for oxygen can result
from inefficient cardiac anatomy, inotropic support, pain, cold stress, respira-
tory disease, wound healing, infection, and the inflammatory state that often is
exaggerated following surgery and cardiopulmonary bypass in neonates. Even when
whole-body supply-demand relationships appear adequate, regional, organ-specific
supply-demand relationships can be impaired. The increasing use of organ-specific
regional blood flow monitoring can open a window on these vulnerabilities and
guide interventions to maintain adequate organ blood flow and oxygenation, with
evidence for improved function. This chapter reviews the use of regional blood flow
monitoring, primarily via near-infrared spectroscopy (NIRS), related to management
of neonates in the perioperative period.

> Read full chapter

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