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For the journal, see Neonatology (journal).
Not to be confused with Neontology.

Neonatal medicine, or neonatology, is a subspecialty of pediatrics concerned with the care, development, and diseases of newborn infants, particularly those born prematurely or in need of critical care.[1][2] Neonatologists are medical doctors who specialize in the care of newborns, often working in neonatal intensive care units (NICUs).[2] Neonatal care often involves a multidisciplinary team to provide intensive monitoring, respiratory and nutritional support, neonatal resuscitation and transport, and support for families facing complex medical decisions.[3] Conditions commonly managed include complications of prematurity, respiratory disorders, neonatal infections, and congenital anomalies.[4]

The neonatal period is generally defined as the first 28 days of life, during which newborns are especially vulnerable.[4] Advances in neonatal medicine, including incubator technology, mechanical ventilation, phototherapy, and pulmonary surfactant therapy, have contributed to substantially improved survival and outcomes for premature and critically ill infants.[5] Modern neonatal care is delivered in a range of settings, including delivery rooms, newborn nurseries, and NICUs. Neonatology is also an academic discipline that includes clinical and basic science research.[4] Ethical and medical-legal issues often involve decisions about life-sustaining treatment, in which parents and clinicians may need to consider expected survival, suffering, and disability.[6]

Historical developments

Though high infant mortality rates were recognized by the medical community at least as early as the 1860s, advances in modern neonatal intensive care have led to a significant decline in infant mortality in the modern era,[7] falling from 5.0 million deaths globally in 1990 to 2.3 million in 2022.[8] This has been achieved through a combination of technological advances, enhanced understanding of newborn physiology, improved sanitation practices, and development of specialized units for neonatal intensive care.[7][5] Around the mid-19th century, the care of newborns was in its infancy and was led mainly by obstetricians;[9] however, the early 1900s, pediatricians began to assume a more direct role in caring for neonates.[7] The term “neonatology” was coined by Dr. Alexander Schaffer in 1960.[4] The American Board of Pediatrics established an official sub-board certification for neonatology in 1975.

In 1835, the Russian physician Georg von Ruehl developed a rudimentary incubator made from two nestled metal tubs enclosing a layer of warm water.[10] By the mid-1850s, these “warming tubs” were in regular use at the Moscow Foundling Hospital for the support of premature infants.[10] 1857, Jean-Louis-Paul Denuce was the first to publish a description of his own similar incubator design, and was the first physician to describe its utility in the support of premature infants in medical literature.[10] By 1931, Dr. A Robert Bauer added more sophisticated upgrades to the incubator which allowed for humidity control and oxygen delivery in addition to heating capabilities, further contributing to improved survival in newborns.[11]

Nurse using an oxygen meter to monitor oxygen levels in a neonatal incubator, 1950s.

The 1950s brought a rapid escalation in neonatal services with the advent of mechanical ventilation of the newborn, allowing for survival at an increasingly smaller birth weight.[5]

In 1952, the anesthesiologist Dr. Virginia Apgar developed the Apgar score, used for standardized assessment of infants immediately upon delivery, to guide further steps in resuscitation if necessary.[12]

The first dedicated neonatal intensive care unit (NICU) was established at Yale New Haven Hospital in Connecticut in 1965, an effort led by Dr. Louis Gluck.[13] Prior to the development of the NICU, premature and critically ill infants were attended to in nurseries without specialized resuscitation equipment.[13]

In 1968, Dr. Jerold Lucey demonstrated that hyperbilirubinemia of prematurity (a form of neonatal jaundice) could be successfully treated through exposure to artificial blue light.[14] This led to widespread use of phototherapy, which has now become a mainstay of treatment of neonatal jaundice.[15]

In the 1980s, the development of pulmonary surfactant replacement therapy further improved survival of extremely premature infants and decreased chronic lung disease, one of the complications of mechanical ventilation, among less severely premature infants.[5]

Academic training

After completing medical school and postgraduate specialty training in pediatrics, doctors undertake additional subspecialty training focused on neonatal care. Neonatal training programs generally involve several years of supervised clinical practice and culminate in subspecialty certification or accreditation through national medical specialty boards or medical colleges. Among pediatric subspecialties, neonatology is the most widely available globally.[16] Formal training opportunities in neonatology are less common in low-income countries than in middle- and high-income countries.[16]

Resident doctor examining a newborn in a NICU in San Diego, California, United States.

In the United States, residency and fellowship programs are accredited by the Accreditation Council for Graduate Medical Education, which sets national standards for specialty and subspecialty medical training.[17] Physicians with MD or DO degrees complete a three-year residency in pediatrics followed by a three-year fellowship in neonatal–perinatal medicine.[17] Subspecialty certification is administered by the American Board of Pediatrics.[18] Osteopathic physicians may also obtain certification through the American Osteopathic Board of Pediatrics.[19]

In Mexico, medical doctors complete a three-year pediatrics residency before entering a two-year neonatology specialty program. Certification in neonatology is administered by the Consejo Mexicano de Certificación en Pediatría, Sección Neonatología.[20]

In the United Kingdom, after graduation from medical school and completing the two-year foundation programme, a physician wishing to become a neonatologist would enroll in an eight-year paediatric specialty training programme.[21] The last two to three years of this would be devoted to training in neonatology as a subspecialty.

In Canada, subspecialty training in neonatal–perinatal medicine is accredited by the Royal College of Physicians and Surgeons of Canada, which sets national standards for postgraduate medical training and certification. Neonatology programs are typically two-year fellowships following a four-year pediatric residency.[22]

In Australia and New Zealand, neonatal–perinatal medicine training is overseen by the Royal Australasian College of Physicians, which administers physician and pediatric subspecialty training programs across both countries. Trainees complete three years of pediatric training followed by a structured three-year advanced training program in neonatal and perinatal medicine.[23]

Neonatal intensive care unit with newborns in incubators in Telangana, India.

In India, neonatology training is undertaken after postgraduate training in pediatrics and is provided through several pathways. Fellowship programs typically last 12 to 18 months and are overseen by the National Neonatology Forum of India and the Indian Academy of Pediatrics. An additional pathway is offered through the National Board of Examinations in Medical Sciences, which administers the three-year Diplomate of National Board (DrNB) in Neonatology.[24]

In South Korea, board certification in neonatology is available to pediatricians who have completed a four-year pediatrics residency and passed the pediatrics specialist examination. Candidates then complete two years of neonatology training at hospitals designated by the Korean Society of Neonatology, including at least one year as a fellow, before taking written and oral examinations administered by the Korean Pediatric Society.[25]

In Tanzania, neonatology subspecialty training is offered through the Muhimbili University of Health and Allied Sciences, accredited by the Tanzania Commission for Universities, as a Master of Science in Clinical Neonatology. It is a two-year degree program, designed for medical doctors who have completed training in pediatrics, with graduates awarded a neonatology subspecialty certificate.[26]

Scope

Full-term infant immediately after birth, with umbilical cord intact.
Preterm infant receiving nasal CPAP in a neonatal intensive care unit.

Neonatal medicine addresses conditions affecting infants during the neonatal period, generally defined as the first 28 days of life.[4][8] Worldwide, the leading causes of neonatal death are premature birth, neonatal infections, birth complications (e.g., asphyxia, trauma), and congenital anomalies.[8] Routine newborn care includes thermal protection (e.g., skin-to-skin contact between parent and infant), hygienic umbilical cord and skin care, breastfeeding, clinical assessment for signs of illness, and preventive measures (e.g., vaccination, vitamin K injection).[8] While newborns are cared for in many settings, neonatologists typically work in hospitals or neonatal intensive care units (NICUs), where they care for premature or critically ill infants and may also oversee the evaluation and management of healthy newborns. In academic medical centers, neonatologists often participate in clinical and basic science research and may follow infants after discharge to assess long-term developmental outcomes.

Neonatology involves conditions related to fetal growth and development, complications arising from maternal disorders during pregnancy, and problems associated with labor, delivery, and the physiologic transition from fetal to extrauterine life. Neonatologists diagnose and manage genetic and chromosomal disorders, inborn errors of metabolism, infections acquired before, during, or shortly after birth, and disorders involving all major organ systems.[4] Care is often delivered by multidisciplinary teams that may include neonatologists, neonatal nurses, respiratory therapists, dietitians, lactation consultants, physical therapists, pharmacists, social workers, and pastoral care.[27] Neonatal transport involves stabilizing and transferring critically ill or high-risk newborns between facilities, often from birth hospitals to centers with higher-level neonatal intensive care.[28]

Investigations

Investigations relevant to neonatology may begin before birth when fetal or maternal findings suggest risk to the newborn, typically through prenatal evaluation by obstetricians or maternal-fetal medicine specialists. Based on this evaluation, neonatologists may become involved before delivery to counsel families and plan care for newborns expected to require delivery-room stabilization or neonatal intensive care. Prenatal ultrasound is the primary imaging technique used to estimate gestational age, assess fetal growth, and identify structural anomalies. Fetal echocardiography, genetic screening, amniocentesis, and chorionic villus sampling may be used to further evaluate suspected congenital, chromosomal, infectious, cardiac, or growth-related disorders.[29]

Blood collected from an infant’s heel for routine newborn screening.

After birth, evaluation includes Apgar scoring, physical examination, routine newborn screening, and assessment of cardiorespiratory, nutritional, and developmental status. Growth is assessed by repeated measurements of weight, length, and head circumference, with interpretation adjusted for gestational or postmenstrual age. Newborn screening may include blood spot testing for selected metabolic, endocrine, hematologic, and genetic disorders, as well as hearing screening and pulse oximetry screening for critical congenital heart disease. Continuous monitoring of heart rate, respiration, blood pressure, temperature, and oxygen saturation is commonly used in NICUs to detect apnea, hypoxemia, hypotension, fever, and other forms of instability.[29]

Laboratory investigations may include blood gas analysis, glucose and electrolyte testing, bilirubin measurement, blood counts, cultures, inflammatory markers, and urine studies. Cranial ultrasound may be used to identify intraventricular hemorrhage. Echocardiography is used to evaluate congenital heart disease, pulmonary hypertension, and patent ductus arteriosus. Chest radiography (X-ray) is used in respiratory disease and to assess the position of endotracheal tubes, enteric tubes, and vascular lines. Electrocardiography (ECG) and electroencephalography (EEG) may be used to evaluate cardiac rhythm abnormalities and suspected seizures, respectively. Abdominal or renal ultrasound may assess congenital or acquired abdominal and urinary tract disorders. Lumbar puncture (spinal tap) may be performed when central nervous system infection is suspected. Retinal screening is performed in premature infants at risk for retinopathy of prematurity.[29]

Treatments

Treatment in neonatology includes stabilization after birth and ongoing supportive or disease-specific care for preterm or ill newborns.

Neonatal resuscitation may be required when a newborn does not establish effective breathing or circulation after birth. Initial measures include warming, drying, stimulation, airway positioning, and clearing secretions when indicated. Positive-pressure ventilation may be used for apnea, gasping, or persistent bradycardia after initial stabilization. Compared to cardiopulmonary resuscitation (CPR) in adults, chest compressions and medications are used less often.[30][31]

Thermoregulation involves measures to prevent hypothermia, such as drying, skin-to-skin contact, radiant warmers, and incubators.[32][4] Kangaroo care, skin-to-skin contact with a parent or caregiver, is broadly recommended for preterm or low-birth-weight infants to support temperature stability and improve breastfeeding.[32][33] Neonatal incubators are used for preterm or clinically unstable newborns to maintain a controlled thermal environment. Some incubators also allow for regulation of oxygen concentration and relative humidity to reduce evaporative water loss.[4]

Mother holding her preterm infant beside an incubator in a NICU in Porto Alegre, Brazil.

Nutrition and fluid management are central components of neonatal care. Treatment may include breastfeeding support, expressed breast milk, donor human milk, fortified feeds, enteral tube feeding, parenteral nutrition when enteral feeding is not possible, and management of fluid balance, electrolytes, and blood glucose.[34][35] In preterm infants, nutritional management aims to support growth and reduce the risks of undernutrition, feeding intolerance, necrotizing enterocolitis, and complications of parenteral nutrition.[34][35] Developmental and feeding support is often provided for preterm or medically complex infants. Occupational therapists, physical therapists, and speech-language pathologists may assist with positioning, motor development, oral feeding, swallowing, and caregiver education.[4]

Respiratory care may include supplemental oxygen, non-invasive respiratory support, mechanical ventilation, and pulmonary surfactant therapy. In spontaneously breathing preterm infants with respiratory distress, non-invasive support such as nasal CPAP may be used to avoid invasive ventilation. Lung-protective management may include careful oxygen targeting, limiting mechanical ventilation, and management of acid-base status. Other respiratory treatments include caffeine for apnea of prematurity and inhaled nitric oxide for selected infants with pulmonary hypertension.[36][4]

Suspected neonatal sepsis and other serious infections are typically treated with empiric antibiotics and supportive care while diagnostic testing is pending; therapy is modified according to the infant’s age, clinical condition, culture results, and local antimicrobial susceptibility patterns. Some viruses (e.g., herpes simplex virus) may be treated with antiviral medications.[37][4]

Infant receiving phototherapy for neonatal jaundice in a NICU in Ogbomoso, Nigeria.

Phototherapy is commonly used to treat neonatal hyperbilirubinemia, with treatment thresholds based on postnatal age, gestational age, bilirubin level, and risk factors for neurotoxicity. Exchange transfusion is reserved for severe hyperbilirubinemia that does not respond adequately to intensive phototherapy or when acute bilirubin encephalopathy is suspected.[38][4]

Common procedures in neonatal intensive care include endotracheal intubation, umbilical catheter or peripherally inserted central catheter (PICC) placement, and chest tube insertion.[4] Infants with congenital anomalies or complex cardiac, gastrointestinal, or neurologic conditions may require additional care from pediatric medical subspecialists or pediatric surgeons.[4] Therapeutic hypothermia is used for eligible infants with hypoxic-ischemic encephalopathy, a form of brain injury caused by impaired oxygenation or blood flow around birth.[39] For infants with life-limiting conditions, extreme prematurity, or serious congenital anomalies, neonatal care may include palliative care focused on symptom management, family support, and emotional care.[40][4]

Because newborns, and all young children, lack decision-making capacity, medical decisions are generally made by parents with guidance from clinicians.[6] For this reason, pediatric decision-making generally relies on parental authority rather than patient autonomy.[6] From both legal and ethical perspectives, parents are generally presumed to be the appropriate surrogate decision-makers for their children unless there is a specific reason for that authority to be limited or removed.[6] In Prince v. Massachusetts (1944), the US Supreme Court held that parental authority is not absolute and may be restricted to protect a child’s welfare.[41] Parental authority is limited by laws that aim to protect children from harm and by ethical permissibility and medical feasibility.[42][6] Ethical questions often arise when parents’ ability or authority to make decisions for their child is unclear.[43]

In the care of critically ill newborns, decisions often involve whether life-sustaining treatment should be provided, withheld, or withdrawn.[42] In the United States, the Baby Doe Law, a 1984 amendment to the Child Abuse Prevention and Treatment Act, required state child protective services to establish procedures for reporting the medical neglect of disabled newborns, which the law defines as the withholding of treatment unless a baby is irreversibly comatose or the treatment is futile and inhumane.[44] This federal regulation applies only to infants and is intended to prevent discrimination on the basis of disability.[44] In the Netherlands and Belgium, active euthanasia for severely suffering disabled newborns has been permitted under regulated protocols (e.g., the Groningen Protocol), with measures intended to promote transparency and reduce abuse; this practice remains ethically controversial.[44]

Many accounts of neonatal decision-making emphasize the best interests standard.[6] As stated in the UN Convention on the Rights of the Child, as ratified by all United Nations member states (except the United States), “in all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration”.[45] The best interests standard asks decision-makers to weigh expected benefits against expected burdens.[6] That which is most beneficial and least burdensome for the patient is viewed as the decision made in the patient’s best interest.[6] This approach may include judgments about survival, suffering, disability, and quality of life.[43][6] In contrast, the harm principle shifts the focus from identifying the decision in the patient’s best interest to ensuring the decision does not cause significant harm to the patient or family.[6] As stated by the American Academy of Pediatrics, all children deserve medical treatment “likely to prevent substantial harm or suffering or death”.[46] On this view, parental choices are respected within a zone of parental discretion and overriding parental authority is justified only when the parental decision creates a substantial and immediate risk of serious harm, and when an alternative course of action is necessary to prevent that harm and is likely to be effective.[6] Some authors also describe a patient’s right to mercy, understood as a right to not be subjected to painful or otherwise harmful interventions that offer no benefit.[43]

See also

References

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