A neonatologist must acquire the basic knowledge of a perinatologist through training in a perinatal centre with close obstetric collaboration. As a clinician, he/she must acquire competence in the medical care of critically-ill neonates through 3 years of neonatal experience following general paediatric training. As an administrator, skills are required in nursery management, regional planning, audit and follow-up of high-risk survivors. Skills are required as an educator for medical/nursing staff and the community. Training as a researcher enables appreciation of perinatal research and appropriate application of scientific advances to clinical practice. He/she must become a person who cares, able to understand psychosocial and ethical issues in neonatology.

Administrative Personnel↗

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Prognosis in infants with birth asphyxia.

The risk of neurodevelopmental disability from birth asphyxia secondary to intrapartum complications and obstetric mismanagement is generally overestimated. Between 8-17% of all cerebral palsy is associated with adverse perinatal events suggestive of asphyxia. Less than 10% is probably due directly to birth asphyxia itself. Studies have shown that different methods of intrapartum assessment of fetal well-being (fetal heart rate monitoring, fetal scalp pH, presence of meconium) do not correlate well with each other or with neonatal parameters (acid-base status at birth, Apgar scores, seizures, neurological behaviour) and outcome measures (death, cerebral palsy, mental retardation). The prevalence rate of cerebral palsy in most communities of 2.0-2.5 per 1000 children is not falling in spite of increasing use of obstetric and neonatal interventions aimed at preventing or treating birth asphyxia. Prediction of neurodevelopmental outcome of birth asphyxia is difficult because of a limited ability to measure birth asphyxia quantitatively in the antenatal and neonatal period. The terminology used to describe the condition is often confusing. It has been recommended that substantial cerebral hypoxia can only be presumed when four criteria are met: the infant has an Apgar score < or = 3 at 10 minutes, metabolic acidosis at birth, hypotonia for several hours and seizures. For the paediatrician, a number of clinical observations and laboratory investigations have been suggested as helpful in the prediction of death or disability among term infants with birth asphyxia.

Asphyxia Neonatorum↗

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Chronic lung disease in preterm infants.

The increasing significance of chronic lung disease (CLD) in the neonatal intensive care unit (NICU) is a result of the increased survival of extremely small and preterm infants and a more aggressive management policy for respiratory failure. Many survive with persistent pulmonary dysfunction, the aetiology of which remains poorly understood. CLD consists of several descriptive categories which have a number of clinical features in common.

Chronic Disease↗

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Spectrum of clinical and cardiac dysfunction in bronchopulmonary dysplasia: early prediction of long-term morbidity.

OBJECTIVES: The objective of this study was to correlate the severity of bronchopulmonary dysplasia (BPD) in infants < or = 28 weeks' gestation with clinical and radiologic scoring and cardiac function as measured by echocardiography. STUDY DESIGN: Twenty-five infants with a mean birth weight of 909 gm and gestational age 26 weeks were studied. All infants were categorized with a clinical and radiologic scoring system at 1 and 3 months. All infants were studied with two-dimensional, M-mode, and Doppler echocardiography. RESULTS: A significant correlation was found between clinical and radiologic scores at 1 month (r = 0.42) and between radiologic scorings at 1 and 3 months (r = 0.67). Severe BPD is directly related with mean airway pressure on day 7 of life (p < 0.05), use of intralipids (p < 0.05), and average oxygen exposure (p < 0.05). Left ventricular posterior wall thickness is directly correlated to severity of BPD (p < 0.05), and transmitral flow velocities and early diastolic/atrial contraction flow velocity ratio are inversely related to severity of BPD (p < 0.05). CONCLUSIONS: Severe BPD can be predicted at an early age, and certain subtle cardiac dysfunctions can be used as early markers of BPD.

Analysis of Variance↗

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Principles and practice of parenteral nutrition in the neonatal period.

In extremely preterm or critically ill infants, the parenteral route for maintaining nutritional integrity has to be relied upon before successful transition to the enteral route of feeding is achieved. Parenteral nutrition is now a fundamental part of neonatal intensive care. Fluid intake volumes vary from 60-150 ml/kg/d, depending on maturity of the infant and environmental conditions influencing insensible water loss from the skin. Parenteral nitrogen requirements are 30-35 mmol/kg/d, equivalent to 3.0-3.5 mg/kg/d of amino acids. Hyperglycaemia during parenteral nutrition can be minimised by starting glucose infusion at a rate of 6-8 g/kg/d with progressive increase to 18-20 g/kg/d by 2-3 weeks after birth. Parenteral fat is introduced at 1 g/kg/d, gradually increasing to 3 g/kg/d, given as a continuous infusion. An energy intake of 50 kcal/kg/d is adequate to match ongoing expenditure but an additional energy intake of 70 kcal/kg/d is required to achieve optimal growth. Minerals and trace elements delivered with parenteral nutrition are calculated to meet in-utero accretion rates. Multivitamins available for parenteral use should also be included. Improved techniques for the preparation, administration and monitoring of parenteral nutrition have helped minimise catheter-related and metabolic complications. In neonatal intensive care units where appropriate medical, nursing, pharmacy and laboratory expertise are available, the potential benefits of parenteral nutrition outweigh its hazards. Nevertheless, early initiation of enteral feeding in small subnutritional quantities to supplement parenteral nutrition is of major importance to enhance the growth and development of the gastrointestinal tract.

Humans↗

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Ethical decision-making in newborn infants.

One ethical dilemma which neonatologists are faced with on a regular basis is selective non-treatment, that is, clinical decisions made after the birth of a liveborn infant to withhold or to withdraw treatment in certain circumstances. Although the outcome of extremely preterm of critically ill infants has significantly improved over the last decade, many are often left to die at birth by withholding resuscitation or neonatal intensive care. Criteria for initiating life-sustaining treatment must be developed with proper ethical considerations. There are other infants whose clinical course after initiation of intensive care will suggest that further curative efforts are futile or lack compensating benefit. Criteria for withdrawing life-sustaining treatment must also be developed, and palliative care measures defined. Clinical situations in which selective non-treatment is taking place in neonatal medicine are: (1) when death is considered to be inevitable whatever treatment is provided, (2) even when death is not inevitable, there is a significantly high risk of severe physical and mental disability should the infant survive, and (3) when survival with moderate disability is possible, but the infant is likely to experience ongoing pain and suffering, repeated hospitalisation and invasive treatment, and early death in childhood. The decision-making process of selective non-treatment should involve less medical paternalism and more informed parental involvement. The process is built on trust between the neonatal staff and parents, and requires time, information, honesty and empathy. Ethical issues must be approached with extreme responsibility, extraordinary sensitivity and heroic compassion.

Decision Making↗