Over the past few decades, multiple landmark studies investigating interventions for perinatal benefit have determined best practices for obstetricians worldwide. In this review, we will highlight trials that have demons...Over the past few decades, multiple landmark studies investigating interventions for perinatal benefit have determined best practices for obstetricians worldwide. In this review, we will highlight trials that have demonstrated the effects of maternal intervention for perinatal benefit, including latency antibiotics, antenatal steroids, fetal neuroprotective measures, intrapartum group B streptococcus (GBS) prophylaxis, and delivery timing.
Fetal therapy has continued to expand in treatable conditions and surgical approaches. To maintain the evidence-based approach to optimizing patient care and outcomes, clinical trials investigating these interventions is...Fetal therapy has continued to expand in treatable conditions and surgical approaches. To maintain the evidence-based approach to optimizing patient care and outcomes, clinical trials investigating these interventions is essential. All trials must take in consideration both the potential benefit to the fetus or fetuses with the maternal and perinatal risks. In this review we discuss clinical trials in fetal therapy which have changed the field and provided the highest level of evidence possible. Large-scale trials have been performed in the management of Twin-to-Twin Transfusion Syndrome (TTTS), Spina bifida, Lower Urinary Tract Obstruction (LUTO) and Congenital Diaphragmatic Hernia (CDH). As molecular biology and advanced prenatal diagnostics continues to develop, future trials in gene and enzyme therapy remain on the horizon.
Perinatal health outcomes directly relate to insurance coverage. The Medicaid program is the single largest health insurer of children, providing coverage to almost half of births nationally. Organized as a federal-state...Perinatal health outcomes directly relate to insurance coverage. The Medicaid program is the single largest health insurer of children, providing coverage to almost half of births nationally. Organized as a federal-state partnership, Medicaid allows states to modify minimum standards of eligibility and coverage created by the federal government. The dual funding structure of Medicaid, however, exposes the program to national and local politics, often placing funding in jeopardy. This paper reviews the history, basic design and scope of Medicaid coverage for infants and birthing people. It introduces policy tools such as waivers and amendments used by states to alter their programs and reviews funding threats that may reduce benefits. Recent history related to the impact of the Affordable Care Act and its effect on the number of insured individuals will be discussed as well as 2025 changes to Medicaid funding. Ultimately, physician advocacy is required to ensure Medicaid continues to protect families.
Spontaneous preterm birth remains a leading global cause of neonatal morbidity and mortality, with lasting health socioeconomic consequences. Despite substantial research efforts over the past decades, preterm birth rate...Spontaneous preterm birth remains a leading global cause of neonatal morbidity and mortality, with lasting health socioeconomic consequences. Despite substantial research efforts over the past decades, preterm birth rates are not declining. Large cohort studies have shown that measurement of cervical length by transvaginal ultrasound is the best predictor for identifying women at risk of preterm birth, although sensitivity stays limited. While this has guided randomised clinical trials, preventive strategies remain suboptimal. Progestogens trials have long dominated the research landscape, and evidence synthesis though individual participant data indicates a potential reduction in preterm birth of approximately 30 % for women with a singleton pregnancy and a short cervix. Relative to progestogens, other potentially effective interventions, such as cervical cerclage and pessary have received limited attention, and were evaluated later or not at all. The optimal management of twin pregnancies, an important cause of preterm birth, remains uncertain. Our knowledge base on the prevention of preterm birth can be improved by research with greater uniformity in outcome measures, better prioritization, better evidence synthesis, more balanced resource allocation, and enhanced global collaboration.
Preterm birth is the leading cause of neonatal morbidity and mortality worldwide and contributes to substantial long-term health and economic burdens. Despite decades of research, overall rates remain largely unchanged,...Preterm birth is the leading cause of neonatal morbidity and mortality worldwide and contributes to substantial long-term health and economic burdens. Despite decades of research, overall rates remain largely unchanged, highlighting the urgent need for more effective predictive and preventative strategies. Traditional approaches, including risk-factor scoring, cervical length measurement, and fetal fibronectin testing, provide limited predictive value. Given the limitations of traditional approaches, emerging technologies provide new opportunities to elucidate mechanisms and improve prediction. Proteomic analyses have identified pathways, such as inflammation and angiogenesis, while metabolomics has revealed small-molecule alterations reflecting biochemical and microbial processes. Genetic investigations highlight complex contributions from both maternal and fetal genomes. Artificial intelligence and machine learning are being applied to integrate multi-omics data with clinical variables with early studies suggesting improved predictive accuracy compared with conventional models. Despite these advancements, significant challenges remain. Many prediction studies are constrained by heterogeneous definitions of preterm birth, small sample sizes, and lack of validation across diverse populations. Beyond research limitations, system-level factors such as social determinants of health, environmental exposure, and inequities in access to prenatal care contribute to disparities in both risk and outcomes. These realities underscore the need for predictive tools that are not only scientifically robust but also applicable across diverse populations and care settings. Although clinical translation of novel approaches remains limited, continued innovation, longitudinal research, and commitment to equity will be essential to achieving meaningful improvements in the prediction of preterm birth. Understanding the pathophysiology and applying proven interventions is essential to improving perinatal health outcomes.
Medical-legal partnerships (MLPs) are healthcare delivery models that involve a multi-disciplinary team including clinicians, lawyers, social workers, and case managers, working together to address legal issues of vulner...Medical-legal partnerships (MLPs) are healthcare delivery models that involve a multi-disciplinary team including clinicians, lawyers, social workers, and case managers, working together to address legal issues of vulnerable patient populations. This practice model aims to improve patient outcomes and population health by integrating legal services into clinical settings to address health-harming legal needs. This article will review the history of MLPs in the United States and the status of the MLPs in the NICU setting. In addition, this article will describe the benefits and challenges of implementing a MLP and offer insights into how this partnership assists NICU patients and their families.
Point-of-care ultrasound (POCUS) is an increasingly utilized bedside imaging modality in the neonatal intensive care unit, offering procedural, diagnostic and therapeutic guidance for clinicians. This narrative review ex...Point-of-care ultrasound (POCUS) is an increasingly utilized bedside imaging modality in the neonatal intensive care unit, offering procedural, diagnostic and therapeutic guidance for clinicians. This narrative review explores the key technical aspects of POCUS use in neonates and the expanding body of research supporting its use for both procedural guidance and diagnostic applications. Despite its growing potential to enhance neonatal care, widespread implementation remains challenged by lack of consensus and guidance related to training, credentialing, quality assurance and assessment of competency. A framework for curriculum development is proposed to support the integration of POCUS into neonatology practice. As its role continues to expand, addressing these challenges will be critical to optimizing the benefits of POCUS and improving neonatal outcomes.
Multichannel electroencephalography (EEG) is a well-established tool for detecting neonatal seizures and for the assessment of global brain function. Numerous classification and grading schemes for neonatal EEG in full t...Multichannel electroencephalography (EEG) is a well-established tool for detecting neonatal seizures and for the assessment of global brain function. Numerous classification and grading schemes for neonatal EEG in full term neonates have been proposed but no universally accepted framework exists, hindering international multicentre research and complicating clinical interpretation. This review summarises widely used classification schemes, compares their key features and argues for a consensus-based classification system.
Pediatric residency and pediatric subspecialty fellowship programs have seen reduced growth in the number of applicants relative to the increased number of positions over the last 6 years. There are concerns this will le...Pediatric residency and pediatric subspecialty fellowship programs have seen reduced growth in the number of applicants relative to the increased number of positions over the last 6 years. There are concerns this will lead to a future pediatrician workforce unable to meet the needs of an expanding population of children with highly complex medical conditions. This review will describe the current landscape of the pediatric subspecialty workforce, the factors contributing to pediatric subspecialty applicant shortages, and the potential impacts of these shortfalls on the future of pediatric complex care. Strategies are described to address the insufficient numbers of pediatric subspecialty applicants. Future research is needed to better delineate etiologies and address gaps in the pediatric workforce thus ensuring favorable health outcomes for children.
Climate change threatens human health, particularly vulnerable populations like pregnant individuals, children, and infants. This article examines the multifaceted impacts of climate change on pregnancy and neonatal heal...Climate change threatens human health, particularly vulnerable populations like pregnant individuals, children, and infants. This article examines the multifaceted impacts of climate change on pregnancy and neonatal health. Therefore, we discuss climate vulnerability as a social determinant of health and advocate for integrating climate change screening and counseling into routine perinatal care. As a result, climate health education is critical for both healthcare providers and families, and there is a need for climate-resilient healthcare systems. Furthermore, climate change education is necessary in the NICU, and we advocate for a comprehensive curriculum to equip healthcare professionals with the knowledge and skills to address the unique challenges posed by climate change to this vulnerable population.
Significant portions of the U.S. population face barriers to maternity care, contributing to rising rates of maternal and infant morbidity and mortality, particularly among rural and historically marginalized communities...Significant portions of the U.S. population face barriers to maternity care, contributing to rising rates of maternal and infant morbidity and mortality, particularly among rural and historically marginalized communities. Over 35 % of U.S. counties are designated as "maternity care deserts", lacking obstetric clinicians and birthing facilities. These counties are home to more than 2.3 million reproductive-aged women and account for over 150,000 births annually. Limited access to maternity care is associated with delayed prenatal care, increased preterm birth rates, and higher maternal mortality. Contributing factors include hospital closures, clinician shortages, restrictive policies, and gaps in insurance coverage, disproportionately affecting Medicaid recipients and communities of color. Addressing this crisis requires multifaceted policy solutions. Expanding Medicaid coverage and increasing payment rates can incentivize provider participation and reduce financial barriers to care. Integrating midwifery care offers safe, patient-centered options for low-risk births, yet restrictive state policies and limited training opportunities hinder growth in this workforce. Telehealth presents a promising approach to extending access, particularly in rural areas, by enabling remote consultations, monitoring, and perinatal education. Additionally, fostering regionalized perinatal care networks and investing in workforce development are critical to strengthening the maternity care system. Action is needed to close persistent gaps in maternity care access and ensure equitable, high-quality care for all birthing people. Policymakers, clinicians, and advocates must implement evidence-based solutions to mitigate disparities and improve maternal and infant health outcomes across the U.S.
Medication, equipment, and formula shortages have become commonplace in the neonatal intensive care unit (NICU). These shortages challenge clinicians to provide optimal care despite suboptimal resources. The effects of t...Medication, equipment, and formula shortages have become commonplace in the neonatal intensive care unit (NICU). These shortages challenge clinicians to provide optimal care despite suboptimal resources. The effects of these shortages can impact morbidity and mortality and may extend beyond the NICU admission with consequences for the patient's growth and development. We will review the causes of medication, equipment, and formula shortages and discuss ethical approaches to allocating scarce resources.
South Asian and Sub-Saharan African countries, disproportionately overrepresented in the World Bank's low- and middle-income categories, bear a high burden of small and/or sick newborns. It is important to acknowledge th...South Asian and Sub-Saharan African countries, disproportionately overrepresented in the World Bank's low- and middle-income categories, bear a high burden of small and/or sick newborns. It is important to acknowledge that, in addition to reducing mortality, creating opportunities to enhance their health and well-being, thereby improving quality of life, is an essential metric for evaluating neonatal care success. With increased survival rates for small and/or sick newborns in most high-burden, resource-constrained settings, developing and strengthening specialized, structured neonatal follow-up programs to provide high-quality post-hospital care is imperative for optimizing outcomes and quality of life. This paper proposes a Systems Framework for Neonatal Follow-Up of small and/or sick newborns. While this framework applies to all settings, it is particularly pertinent in low-resource, high-burden countries, considering their unique contextual settings. This framework will provide a significant opportunity to foster meaningful engagement and partnership with a wide range of relevant local stakeholders, including families with small and/or sick newborns, as well as to identify areas for increased strategic investment. Furthermore, a multidimensional checklist aligned with the proposed framework provides a comprehensive tool for assessing neonatal follow-up readiness in health systems. The goal is to accelerate progress by transforming the delivery and accessibility of neonatal follow-up for small and/or sick newborns, thus improving the prospects for favorable long-term outcomes in this highly vulnerable population.
Cesarean delivery (CD), performed in nearly one in three U.S. births, is the most common surgical procedure. As utilization has increased, advances in surgical technique and perioperative management, guided by landmark t...Cesarean delivery (CD), performed in nearly one in three U.S. births, is the most common surgical procedure. As utilization has increased, advances in surgical technique and perioperative management, guided by landmark trials, have refined the procedure and improved outcomes. Some of the most significant trials have focused on antibiotic prophylaxis, prevention of postpartum hemorrhage, and standardization of surgical techniques. For example, pre-incision prophylactic cefazolin has reduced the risk of postoperative infectious morbidity up to 60% compared to administration at the time of cord clamping. Additionally, the introduction of TXA to the treatment of obstetric hemorrhage has been shown to reduce maternal mortality related to hemorrhage. Future research should prioritize continuing reduction of maternal morbidity as CD still incurs increased risk of infectious and bleeding morbidity. Another important focus in the era of increased CD rates is research into the optimal closure of the hysterotomy. Identification of patients at risk of uterine rupture in future pregnancies can improve the safety of trial of labor after cesarean delivery (TOLAC); further investigation into how hysterotomy closure may contribute to the development of placenta accreta spectrum can significantly decrease maternal morbidity from an increasingly common and life-threatening placental disorder.
INTRODUCTION: The diagnosis, management and differentiating of gastroesophageal reflux (GER) and pathologic gastroesophageal reflux disease (GERD) in infants remains a clinical challenge. There is significant clinical an...INTRODUCTION: The diagnosis, management and differentiating of gastroesophageal reflux (GER) and pathologic gastroesophageal reflux disease (GERD) in infants remains a clinical challenge. There is significant clinical and economic burden attributed to GERD in the NICU leading to longer length of stays, higher financial costs, and overuse of medications. CURRENT CLINICAL PRACTICE: Current guidelines promote reduced reliance on acid suppression medication with shorter empiric trials (4 to 8 weeks) for the treatment of GERD, not attributing respiratory or laryngeal symptoms to GER due to a lack of diagnostic evidence, and a recommendation for trial of hydrolyzed formula before initiation of acid suppression. Few studies are demonstrating overall decrease use in all classes of medication for GERD, however, use of medications in infants remains high. DIAGNOSTIC CHALLENGES AND DRIVERS OF OVERUSE: Diagnostic challenges remain in pediatrics including interchangeable use of GER and GERD amongst clinicians, non-specific symptoms attributed to GERD, and lack of gold-standard diagnostic testing. Multichannel intraluminal impedance-pH monitoring (pH/MII) probes allow for an objective assessment of reflux episodes, reflux content, acidity, distance of reflux column or bolus direction, and symptom correlation. CONCLUSION: For any infant with a suspicion of GERD, priority should be made to take a thoughtful and complete history and physical exam, review of growth charts, and not only reviewing charted intake and output but observing feeding and episodes of reflux. A stepwise approach emphasizing non-pharmacological care, shared decision-making, and institutional-level stewardship remains essential to providing high-value care.
As survival rates of extremely preterm (EPT) infants continue to improve, focus has shifted to reduce morbidity and complications in these vulnerable patients. Management of EPT infants presents significant clinical, log...As survival rates of extremely preterm (EPT) infants continue to improve, focus has shifted to reduce morbidity and complications in these vulnerable patients. Management of EPT infants presents significant clinical, logistical, and sometimes ethical challenges. Outcomes across centers are highly variable and strongly influenced by the care provided in the early neonatal period. Standardized guidelines, based on published literature and center-specific experiences, play an important role in improving outcomes for EPT infants. Multidisciplinary guidelines provide a framework for clinical management and support a consistent care approach. Guidelines can improve care throughout the entire neonatal intensive care unit (NICU) course, beginning prior to delivery during antenatal counseling, delivery room management, golden hour, and throughout the NICU stay as infants' needs evolve based on physiologic changes.