Challenges and Opportunities in Neonatology

Challenges and Opportunities in Neonatology

Basil O. Ibe
Division of Neonatology, Department of Pediatrics, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA 90502

Mona Hanouni
Attending Neonatologist, Children’s Hospital of Los Angeles, Los Angeles, CA 90027

J Usha Raj
University of Illinois, Chicago, IL 60607

James Popoli
Division of Neonatology, Department of Pediatrics, The Lundquist Institute at Harbor-UCLA Medical Center

Steven Popoli
Division of Neonatology, Department of Pediatrics, The Lundquist Institute at Harbor-UCLA Medical Center


The fetus is exposed to chronic low oxygen environment, which is a desirable physiological condition for fetal pulmonary development and hemodynamics. On the other hand, if the newborn is exposed to low oxygen levels, the blood vessels of the lung thicken and narrow due to overgrowth of the smooth muscle cells in the vessel walls, the baby remains blue, resulting in the condition known as persistent pulmonary hypertension of the newborn (PPHN).  In the United States, PPHN occurs in 0.43-6.8 newborns per 1000 live births and is most common in term and near-term newborns. Despite the significant advances in management of newborn respiratory diseases, PPHN is still associated with a high morbidity and mortality, accounting for about 10-20% of neonatal mortality. The current mainstay of therapy for PPHN is mechanical ventilation, fluid therapy and use of anti-inflammatory agents for cardiovascular support. Correction of hemodynamic acid/base balance and oxygen supplementation are also commendable therapeutic interventions.  New ideas in PPHN therapy should include incorporation of in vivo, ex vivo and in vitro studies on intracellular signaling pathways of pulmonary vascular development in the state of PPHN. These new ideas will entail studies of the cross talk between vasodilators and vasoconstrictors in perinatal pulmonary hemodynamics.

Aseel Alzaghoul, MD, PhD
Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec H3A 1A2, Canada.

Rama Eloulabi
Department of Psychology, Western University, London, Ontario N6A 3K7, Canada.

Paniz Fotoohi
School of Kinesiology and Health Science, York University, Toronto, Ontario M3J 1P3, Canada.

Khalid Yunis, MD
Professor of Pediatrics Head Division of Neonatology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical center, Beirut, Lebanon

Hala Tamim, PhD
School of Kinesiology and Health Science, York University, Toronto, Ontario M3J 1P3, Canada.


Introduction: The aim was to assess the prevalence and factors associated with fear of COVID-19 among Syrian refugee parents in Ontario, Canada.

Methods: A sample of 540 Syrian refugee parents who resettled in Ontario were interviewed between March 2021, and March 2022. The level of fear was measured using the Fear of COVID-19 scale. Multiple linear regression analysis was performed to assess the relationships between socio-demographic, migration, and health-related factors and fear of COVID-19.

Results: The mean (SD) score for the Fear of COVID-19 scale was 15.6 (6.02), and 15.4% of the participants were categorized as having high levels of Fear of COVID-19. Results of the multiple linear regression analysis showed that low self-rated English/French language ability was significantly associated with increased fear of COVID-19  (Adjβ=0.65, p=0.047). When compared to participants who do not need an interpreter, those who needed an interpreter, and were always provided with one, were at reduced fear of COVID-19 (Adjβ=-1.56, p=0.061). In addition, findings indicated that low self-perceived socioeconomic status, more years spent in Canada, living in a refugee camp, and poor self-rated mental health contributed significantly to elevated levels of fear of COVID-19.

Discussion: Targeted intervention and prevention strategies for reducing the fear of COVID-19 should be considered for the Syrian refugee population in Canada. Language ability is one of the factors related to increased fear of COVID-19, thus, providing information and interventions in different languages is essential for this population.

Corrado Moretti
Department of Pediatrics, Policlinico Umberto I, Sapienza University of Rome, Italy

Camilla Gizzi
Department of Neonatology and NICU, Sant’Eugenio Hospital – ASL RM 2, Rome, Italy

Caterina Silvia Barbara
Pediatric Intensive Care Unit, Department of Maternal Science, Policlinico Umberto I, Sapienza University of Rome, Italy

Nicola Pozzi
Neonatal Intensive Care Unit, Department of Maternal and Child Health, San Pio Hospital, Benevento, Italy

Fabio Midulla
Department of Maternal Science, Policlinico Umberto I, Sapienza University of Rome, Italy

Paola Cogo
Department of Medicine, University Hospital S.Maria della Misericordia, University of Udine, Italy


Bronchiolitis is one of the most frequent acute diseases of the lower respiratory tract in infants worldwide, and Respiratory Syncytial Virus remains the most common and aggressive viral disease. The course of the disease is usually benign, but its severity may change by evolving into parenchymal disease. In the more severe cases, its clinical and radiological characteristics may be consistent with acute respiratory distress syndrome. Management of these cases includes admission to paediatric intensive care and invasive mechanical ventilation. This paper reviews the definition of paediatric and neonatal acute respiratory distress syndrome, which was primarily designed and validated for adults. The article investigates the pathophysiology of paediatric acute respiratory distress syndrome further, describing how damage to the alveolar-capillary units, surfactant inactivation and inflammation occurs. Mechanisms that contribute to acute lung injury, such as volutrauma, barotrauma, stress and strain, are illustrated in detail, and an overview of the strategies that may help minimize neonatal lung injury and optimize ventilatory support is provided. These strategies include lung-protective mechanical ventilation, surfactant treatment, inhaled nitric oxide, high frequency oscillatory ventilation, recruiting manoeuvres, prone position and neuromuscular blocking agents. The objective is to help clinicians understand the peculiar pathophysiology of severe bronchiolitis and so guide them in preventing or attenuating lung injury during treatment. As such, this paper aims to contribute to defining optimal treatment of severe cases of bronchiolitis.

Luca Brunelli
Division of Neonatology, Department of Pediatrics, Spencer Fox Eccles School of Medicine, University of Utah

Kee Chan
American College of Medical Genetics and Genomics

James Tabery
University of Utah, Department of Philosophy;

Warren Binford
University of Colorado, School of Medicine, CU Law School;

Amy Brower
American College of Medical Genetics and Genomics; Munroe-Meyer Institute, University of Nebraska Medical Center, Creighton University School of Medicine;


The year 2023 marked the 60th anniversary of screening newborns in the United States for diseases that benefit from early identification and intervention. All around the world, the goal of NBS is to facilitate timely diagnosis and management to improve individual health outcomes in all newborns regardless of their place of birth, economic circumstances, ability to pay for treatment, and access to healthcare. Advances in technology to screen and treat disease have led to a rapid increase in the number of screened conditions, and innovations in genomics are expected to exponentially expand this number further. A system where all newborns are screened, coupled with rapid technological innovation, provides a unique opportunity to improve pediatric health outcomes and advance children’s rights, including the unique rights of sick and disabled children. This is especially timely as we approach the 100th anniversary of the 1924 Geneva Declaration of the Rights of the Child, which includes children’s right to healthcare, and the 1989 United Nations Convention on the Rights of the Child that expanded upon this aspect and affirmed each child’s right to the highest attainable standard of health. In this manuscript, we provide background on the evolving recognition of the rights of children and the foundational rights to healthcare and non-discrimination, provide two examples that highlight issues to access and equity in newborn screening that may limit a child’s right to healthcare and best possible outcomes, detail ways the current approach to newborn screening advances the rights of the child, and finally, propose that the incorporation of genomics into newborn screening presents a useful case study to recognize and uphold the rights of every child.

Ronaldo Afonso Torres
Faculty of Medicine, Governador Ozanan Coelho University Center (UNIFAGOC), Ubá, Minas Gerais, Brazil.

Tiago Ribeiro Torres
Faculty of Medicine, Federal University of Juiz de Fora, Minas Gerais, Brazil.


Introduction: The diagnosis of congenital heart diseases is a challenge for pediatricians due to the diversity of clinical presentations and symptoms, just like several other diseases prevalent in the neonatal period. Often the diagnosis is established during the gestation period, sometimes the hypothesis is formulated by neonatal screening. However, several cases will require clinical suspicion from the pediatrician. Given the possibility of this diagnosis, the evaluation of the infant cardiologist is essential. Unfortunately, this professional is not always readily available. In the intensive care units, health professionals use heart rate, blood pressure, capillary refill, urinary output and acid-base balance for hemodynamic analysis. These data are significant, but nonspecific. Thus, functional echocardiography can improve hemodynamic evaluation with positive impact on diagnosis. Our objective was to conduct a retrospective analysis of hospitalizations in a Brazilian neonatal unit, with the goal of identifying the diagnoses of congenital heart diseases made by a researcher using functional echocardiography, from July 2015 to September 2017, having as inclusion criteria; clinical manifestations of distress or respiratory failure, characterized by tachypnea, signs of dyspnea, need for oxygen therapy or ventilatory support and/or hemodynamic instability, characterized by tachycardia, cyanosis, cold extremities, prolonged capillary filling time, fine pulses and/or hypotension, low urinary output. Results: During the 26 months of the study, 362 neonates were hospitalized. Of these, 223 were included in the research for presenting cardiorespiratory manifestations. We observed three cases of obstructive shock related to cardiac tamponade, 18 cases of congenital heart disease, five cases of hypertrophic myocardiopathy, seven cases of myocardial dysfunction not related to structural heart disease, 46 cases of neonatal persistent pulmonary hypertension and 27 cases of patent ductus arteriosus (six with hemodynamics repercussion).

Conclusions: The results showed functional and/or anatomical changes in 105 patients analyzed (46.7%), identified a diversity of structural cardiopathies, improved hemodynamic evaluation with impact on the therapeutic approach. While using functional echocardiography in neonates, clinicians should be aware that undiagnosed critical congenital heart defects can present during this period. They should acknowledge the limitations of skills, and it should not be used as a screening tool for diagnosing or excluding congenital heart defects. A patient with a suspected critical congenital heart defect should be quickly referred to a pediatric cardiologist, even if this implies out-of-hospital patient’s transportation. We assume that the systematic implementation of this technology by the medical team can improve diagnostic accuracy, which can positively impact the therapy used.

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