Pediatrician-neonatologist: newborn health

A pediatric neonatologist is a physician who combines general pediatric training with advanced specialization in the care of newborns, including premature and critically ill infants. This specialist is responsible for assessing the child's condition from birth, initial resuscitation, and subsequent care in the neonatal intensive care unit (NICU). The role includes diagnosing malformations, managing birth complications, and treating respiratory failure, infections, and metabolic disorders. [1]

Newborns are a unique population: their respiratory, thermoregulatory, metabolic, and immune systems differ significantly from those of older children. A pediatric neonatologist takes these differences into account when selecting medications, infusion volumes, and ventilation techniques. A key part of their work involves working with the obstetrician, anesthesiologist, pediatric surgeon, and parents to ensure prompt decision-making in critical situations. [2]

In modern maternity hospitals and neonatal centers, pediatric neonatologists also perform organizational and strategic functions: they participate in the development of protocols (resuscitation at birth, antibiotic therapy for suspected sepsis, jaundice treatment algorithms), staff training, and quality control systems. Recently published recommendations from professional societies even consider optimal practices for staffing and assignment of responsibilities in neonatology. [3]

Finally, the neonatologist is responsible for planning follow-up care: early postnatal adjustment and discharge require a clear plan for postnatal support and dynamic monitoring of growth, feeding, and neurological status. This is especially important for premature infants, infants with low birth weight, and those who have experienced complications during labor. [4]

When is a consultation with a pediatrician-neonatologist necessary?

Urgent indications (immediate assessment at birth or in the first hours of life) include: weak respiratory activity or apnea in the baby, severe cyanosis, need for mechanical ventilation, severe birth asphyxia, signs of shock, severe hemodynamic instability, high or latent fever, severe maternal blood loss with risk of fetal infection. These situations require immediate neonatal assessment and, possibly, transfer to the intensive care unit. (Table 1 below provides a detailed list and initial management.) [5]

Routine indications: prematurity <37 weeks, birth weight <2500 g (especially <1500 g), suspected congenital anomalies, need for specialized monitoring in mothers with severe infections or chronic maternal diseases (diabetes mellitus, autoimmune diseases). A routine consultation is also indicated in cases of persistent feeding problems, pathological jaundice, suspected hereditary metabolic disorders, and the need for complex diagnostic tests. [6]

Important: Suspected neonatal sepsis or serious bacterial infection of any type requires immediate consultation and, usually, hospitalization. In 2024-2025, WHO and other organizations updated recommendations for the identification and first care of infants aged 0-59 days with serious bacterial infection; the emphasis is on rapid risk assessment and early antibacterial therapy when indicated. [7]

In addition, parents and obstetric staff should involve a neonatologist when planning complex births (twins, large fetus, placental pathology), since preparing and agreeing on an action plan reduces the risk of emergency situations and speeds up decision-making. [8]

Table 1. Indications for urgent and scheduled consultation with a pediatrician-neonatologist

Urgent (immediately)	Planned (within the first days/weeks)
Absence of spontaneous breathing or weak respiratory activity	Prematurity <37 weeks.
Apnea or marked pallor/cyanosis	Weight <2500 g (especially <1500 g)
Need for intubation/ventilation at birth	Suspected congenital anomaly
Suspected sepsis (fever, lethargy, poor feeding)	Mother with severe infection or chronic illness
Severe asphyxia/complex postpartum management	Problems with breastfeeding, pathology of jaundice

Stabilization and resuscitation of a newborn

The first stage is assessing and supporting the transition from intrauterine to extrauterine breathing. Newborn Life Support guidelines are based on international consensus and are updated periodically; current documents emphasize rapid recognition of the need for assistance, the "golden minute" principle, and a standardized sequence of actions: warming, ensuring airway patency, stimulation, and, if necessary, face-mask ventilation and intubation. These algorithms are mandatory in maternity wards. [9]

If ventilation is required, the priority is reliable ventilation until a cardiac response is achieved; the use of positive airway pressure with volume/pressure control is performed under the supervision of an experienced neonatologist. Early assessment of effectiveness is performed using heart rate: heart rate is the primary interactive indicator of resuscitation success. The child's temperature and blood glucose are also assessed concurrently. [10]

In situations of severe asphyxia and the risk of hypoxic-ischemic injury, it is important to organize early multidisciplinary care, including discussion of indications for further supportive measures, monitoring, and, if indicated, hypothermia therapy (see the section on hypoxic-ischemic encephalopathy). It is also necessary to assess the causative factor (e.g., massive maternal hemorrhage, placental insufficiency) and adjust postnatal management. [11]

Equally important is delivery room preparation: the availability of algorithms, staff training, and equipment (resuscitation kits, a heating mat, and neonatal ventilators). Regular simulations and training have been shown to improve clinical outcomes and reduce the time it takes to make the right decisions. [12]

Table 2. Rapid algorithm for stabilization at birth

Step	Action	Transition criterion
1	Warmth, clear airways, stimulation	The baby begins to breathe/cry normally
2	Assess heart rate; if <100, initiate face mask ventilation	HR >100 - observation; <60 - extend support
3	Mask ventilation → intubation if ineffective	Heart rate ↑, improved saturation
4	If the heart rate is <60 after 60 seconds of effective ventilation, follow the algorithm (compressions, adrenaline)	Further team interaction

(Source: International and European guidelines on neonatal resuscitation). [13]

Infectious threats: diagnosis and treatment of neonatal sepsis

Neonatal sepsis is a key and potentially fatal condition in neonatology. Current WHO guidelines (2024) and reviews (2023–2024) emphasize the need for rapid risk assessment, the use of screening algorithms for risk factors at delivery (maternal infection, prolonged rupture of membranes, maternal temperature), and early initiation of empirical antibiotic therapy when clinical signs or a high probability are present. Decisions to initiate antibiotics are made by balancing the risk of missing an infection with the risk of overtreatment with antibiotics. [14]

Diagnosis includes blood cultures, a lumbar puncture if necessary, general and biochemical profiles, lactate, and inflammatory markers; however, no single lab test provides a 100% answer, so the clinical picture remains the primary guide. Risk scores and clinical protocols adapted to local conditions and laboratory availability are used for early recognition. [15]

Empirical therapy is selected based on the local pathogen profile and susceptibility, as well as the age category (early and late sepsis). After receiving culture results, therapy is adjusted. Duration and route of administration (IV) are determined by the severity and presence of proven infection. WHO 2024 provides practical regimens for the management of infants 0-59 days old with serious bacterial infections and recommendations for hospitalization/transfer when referral is not possible. [16]

Particular attention is paid to prevention: strict aseptic technique during procedures, adequate cord handling, maternal monitoring during labor, optimization of antibiotic prophylaxis in obstetrics, and limiting unnecessary secondary invasive procedures on the child. Antimicrobial stewardship programs and local protocols reduce the selection of resistant microorganisms. [17]

Table 3. Suspected neonatal sepsis: basic set of examinations and first aid

Action	Why	Notes
Blood culture before starting antibiotics	Identification of the pathogen	The collection is qualitatively important, but the therapy is not delayed
Complete blood count, lactate, C-reactive protein/procalcitonin	Inflammation/perfusion assessment	A trend is more important than a single point
Spinal tap when indicated	Suspicion of meningitis	They do it if it is clinically justified and the condition is stable.
Initiation of empirical antibiotic therapy	Reducing the risk of progression	Selection by local recommendations

Neonatal jaundice: screening, phototherapy, and indications for exchange transfusion

Neonatal hyperbilirubinemia is a common condition. In 2022, the American Academy of Pediatrics updated its clinical guidelines for the management of jaundice in term and near-term infants ≥35 weeks of gestation; the recommendations include universal screening of bilirubin levels at 18–72 hours of age, the use of predictive nomograms, and standardization of indications for phototherapy and exchange transfusion. Adherence to these algorithms reduces the risk of severe hyperbilirubinemia and kernicterus while decreasing unnecessary hospitalizations. [18]

Phototherapy remains the primary, proven treatment method; thresholds for its initiation depend on the child's age in hours, weight, and the presence of associated factors (hemolytic disease, thermoregulation, dehydration). In cases of very high bilirubin levels or rapid increases in concentration, exchange transfusion is considered as a last resort, with clear indications. [19]

Prevention is essential: proper breastfeeding, weight monitoring, timely screening, and repeat measurements for infants at risk. Canadian and American guidelines also recommend considering local realities, such as laboratory availability and post-discharge monitoring capabilities. Implementing protocols and training staff reduce complications and optimize costs. [20]

If hemolytic disease of the newborn is suspected (blood group conflict, positive direct antiglobulin test), the algorithm is accelerated: more frequent monitoring, a low threshold for initiating phototherapy, and discussion of transfusion measures. Administration of maternal/infant immunoglobulin and other steps are discussed based on clinical indications. [21]

Table 4. Approximate thresholds for phototherapy

Child's age (hours)	Low risk (mg/dL)	Medium risk	High risk
24-48	10-12	13-15	>15
48-72	12-15	16-18	>18
>72	individually, according to the nomogram	-	-

Note: Exact thresholds are based on the AAP nomogram and local protocols; the table is illustrative. Follow local algorithms. [22]

Hypoxic-ischemic encephalopathy (HIE) and therapeutic hypothermia

HIE following perinatal asphyxia is one of the conditions where early and targeted therapy can change the neurological prognosis. A combination of clinical criteria and data (Apgar score, gas exchange, neurological status) determines the need for additional investigations and the initiation of therapy. Based on randomized trials and systematic reviews, therapeutic hypothermia (cooling to a target temperature of 33-34°C for 72 hours followed by revaporization) has become the standard for neonates with moderate-severe HIE in the full-term period. [23]

Critical points: early identification (within the first 6 hours after birth), strict patient selection, and in-hospital monitoring—the rate of cooling and maintaining stable hemodynamics and homeostasis are critical. For pre-test and special cases (late preterm infants, concomitant infections), decisions are made individually; studies in some subgroups are ongoing. [24]

Side effects and risks include hemodynamic instability, coagulation disorders, infections, and electrolyte disturbances; therefore, an experienced team and 24-hour monitoring are required. In resource-limited settings, the choice is patient-centered and requires a benefit-risk assessment. [25]

Follow-up neurological monitoring and early intervention for identified abnormalities (rehabilitation, physical therapy, developmental monitoring) are important. Long-term outcomes depend on the severity of the underlying lesion and the quality of post-regulatory support. [26]

Hardware and laboratory diagnostics in the neonatal intensive care unit

The standard NICU assessment includes oxygen saturation monitoring, continuous heart rate monitoring, gas exchange monitoring during mechanical ventilation, daily/hourly glucose measurements, electrolytes, a biochemical profile, infection markers, and serial neurological assessments. Connecting infusion pumps and ventilators to beds and maintaining temperature control are part of the basic infrastructure. [27]

Neonatal ultrasound imaging (including pulmonary ultrasound and pinpoint neonatal ultrasound) is rapidly evolving and is increasingly being used as a complement to radiography and cardiac echocardiography. Current POCUS guidelines recommend training and protocols for safe and effective use in neonates. [28]

Laboratory blood monitoring in critically ill infants is frequent and necessary, including monitoring bilirubin levels, blood gases, lactate, and coagulation parameters. For premature and low-birth-weight infants, special attention is paid to monitoring calcium, magnesium, and electrolyte levels. The timing and scope of testing are tailored to the condition and therapeutic interventions. [29]

In addition, many centers are implementing algorithms to optimize transfusion therapy, monitor oxygen requirements, and implement lung-protective ventilation protocols (lung-protective strategies). This reduces the incidence of bronchopulmonary complications in preterm infants. [30]

Table 5. Basic monitoring and examinations in the NICU

Indicator	Frequency/Notes
Saturation and heart rate	Continuously
Gas exchange (A-gas)	According to the clinic, with mechanical ventilation - regularly
Bilirubin	According to indications / according to nomogram
Blood glucose	In case of signs of hypo/hyperglycemia, regularly in premature infants
Infection markers, cultures	If infection is suspected before starting antibiotics

Discharge and post-discharge follow-up: what to expect and what to look out for

Discharge criteria are based on stable vital signs, adequate thermoregulation in an open environment, independent or safe feeding, adequate growth/weight monitoring, and the absence of oxygen/supplementation requirements. For premature infants and those with significant complications, individualized follow-up plans are developed: early development clinics, cardiologists, neurologists, and ophthalmologists, as indicated. [31]

Early follow-up includes a visit to a pediatrician/neonatologist within the first 48-72 hours after discharge (or more frequently if needed), monitoring weight gain, assessing feeding, and monitoring jaundice. For children at risk for neurological deficits, regular developmental screenings and early intervention programs are recommended. [32]

Particular attention is paid to the vaccination record and vaccination planning, adapted to the history of prematurity and infectious conditions; parents receive recommendations on care, warning signs (poor feeding, fever, lethargy), and emergency services contacts. Clear communication of information and contact support reduce the number of repeat visits and hospitalizations. [33]

The psychosocial aspect is important: parental support, training in feeding and care techniques, and discussion of possible outcomes and rehabilitation routes are all part of comprehensive care. Teams that involve parents from the early stages achieve better compliance and developmental outcomes for the child. [34]

A brief practical checklist for maternity hospital staff and parents

1. Delivery room readiness: resuscitation kits, thermal insulation, NLS algorithms and staff training. [35]
2. Jaundice screening at 18–72 h in full-term infants; interpretation using a nomogram; early phototherapy when indicated. [36]
3. If sepsis is suspected, cultures should be taken and empirical therapy should be initiated according to local protocols, without delaying treatment for analysis. [37]
4. For moderate-severe HIE, consider therapeutic hypothermia if criteria are met and in experienced centers. [38]