Seminars in Fetal & Neonatal Medicine最新文献

Red blood cell transfusions from adult donors can be lifesaving for neonates with severe anemia or acute massive hemorrhage but can be associated with specific and significant risks. Infectious transmission, acute lung injury, and circulatory overload are well known risks and are part of blood transfusion informed consent. Less well-described, but more common, are the risks that occur when transfusing the smallest and most immature neonates, those less than 1000 g. Repeated adult red cell transfusions may worsen inflammatory conditions, such as pulmonary inflammation, and they can increase the incidence and severity of retinopathy of prematurity and neurodevelopmental delay. In this review, we will provide an overview of neonatal transfusion stewardship including instituting both non-pharmacological transfusion-avoidance techniques and pharmacologic strategies to reduce transfusion rates. Erythropoiesis-stimulating agents like erythropoietin and darbepoetin further reduce and can eliminate the need for a transfusion. Instituting non-pharmacologic and pharmacologic strategies will increase the number of NICU infants who remain transfusion free, even those born weighing less than 1000 g.

Application of palliative comfort care versus neonatal intensive care for extremely premature births is a judgment fraught with uncertainty and risk, principally for the pregnant woman and family. Survival and good health are possible, but suffering, chronic health issues, and socio-economic inequities are burdensome to families. Survival rates of infants born at 22, 23, and 24 weeks' gestation are increasing, but morbidity rates and long-term neurodevelopmental impairments are substantial and not improving. Outcomes acceptable to some pregnant women and families are not acceptable to others. Autonomy of pregnant women contrasted with the rights of the fetus and infant are affected by culture, religion, technology, and powerfully persuaded by physicians who possess conflicts-of-interest related to career goals, income, and research priorities. Interventions related to extreme prematurity care such as cesarean deliveries create serious health risks for pregnant women. Intensive care of extremely premature infants is expensive, and lost opportunity costs for families and society are under-appreciated. Physicians should resist dogmatic positions tethered to non-rigorous evidence and technology. Physicians best serve pregnant women by listening to their concerns and preferences, objectively reviewing clinical outcomes, and by avoiding care options presented as restrictive protocols, or wide-open menus. The legitimate zone of parental discretion embraces value pluralistic shared decision-making and informed consent. This principle is unequivocally endorsed by the American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Because there is no unifying cultural, religious, or bioethical ethos, we should embrace shared decision-making recognizing the inherent contingencies and disagreements of extreme prematurity.

The medical management of infants born before 25 weeks' gestation is among the most controversial and challenging areas of perinatology. Despite remarkable advances in neonatal intensive care over the past half century, substantial variability in clinical care and outcomes persists. Infants born at 22-24 weeks' gestation account for approximately 1 in 5 infant deaths in the United States, 1 in 50 neonatal intensive care admissions, and 1 in 3 newborn ventilator-days in United States tertiary centers-yet they are poorly represented in clinical trials and little evidence exists to guide safe and effective care. Drawing from international experience and emerging data, we propose three strategies to improve the care of these patients and their families: (1) identifying the unique physiological characteristics of infants <25 weeks' gestation that require specialized approaches; (2) generating evidence to inform care through collaborative networks; and (3) systematically partnering with families and former patients to guide care and research.

Promoting optimal growth in preterm infants is of paramount importance. Multiple reports have associated better growth during their Neonatal Intensive Care Unit (NICU) stay with improved neurodevelopmental outcome and a lesser risk of certain morbidities. Nowadays, most preterm infants receive human milk (HM) feedings, either mother's own or donor milk. Widespread use of HM to feed preterm infants has contributed to a decrease in complications like necrotizing enterocolitis. This notwithstanding, HM often does not provide sufficient protein and other nutrients to promote adequate growth in these infants and, therefore, must be fortified with specially designed human milk fortifiers of human or bovine origin. These provide added amounts of protein, minerals like sodium, calcium, and phosphorus as well as vitamins and other micronutrients. Which fortification strategy, i.e. type of fortifier, timing of fortification, must be used to promote optimal growth and neurodevelopment is still a matter of debate. The following articles by the well-recognized experts in neonatal nutrition, Drs. Amy Hair and Brenda Poindexter, will describe alternate strategies to fortify HM and their potential benefits, and are a reflection of the scholarly discussions held during the 2025 Neonatal Insights: Best Evidence and Practice in Clinical Neonatology Conference.