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FIGURE 96.37 Bronchopulmonary dysplasia with hyperinflation This 2-month-old child was treated with mechanical ventilation during the first days of life for hyaline membrane disease The chest film shows generalized overaeration and coarse nodularity with multiple cystlike areas throughout both lung fields Prophylactic administration of Palivizumab decreases the number of admissions and acuity of RSV bronchiolitis in infants with BPD Palivizumab is administered monthly during RSV season Clinicians should ask parents about their child’s status Referral to the primary care provider for Palivizumab is warranted for any infant with BPD who was born less than 32 weeks and is within their first year of life Persistent Pulmonary Hypertension of the Newborn This entity is becoming increasingly recognized in the cyanotic neonate with respiratory distress It is more common in full-term infants in the hours to days after birth Hypoxia, meconium aspiration, congenital diaphragmatic hernia, and pulmonary hypoplasia are common causes immediately after birth; however, any condition that precipitates hypoxic respiratory failure may cause pulmonary hypertension later (e.g., acute viral infections) The constriction of the pulmonary arterial vasculature causes right-to-left shunting of deoxygenated blood through the patent DA or foramen ovale, resulting in hypoxia and severe cyanosis, which may improve with hyperventilation Infants may continue to have low oxygen saturations despite 100% inspired oxygen and aggressive mechanical ventilation When pulse oximetry readings are taken separately in each of the four extremities, oxygenation can be 10% higher in the right arm, the preductal extremity Arterial blood gases will show hypoxemia with or without hypercarbia CXR will show variable findings according to the underlying etiology Aggressive treatment of PPHN should include fluid resuscitation, minimal stimulation including darkening the room and adequate sedation, and maintaining adequate systemic pressures with pressors if needed Use of high-frequency oscillatory ventilation, inhaled nitric oxide, and extracorporeal membrane oxygenation may be lifesaving Any neonate with desaturation, cyanosis, and escalating acute respiratory failure should be admitted to the intensive care unit ABDOMINAL, GASTROINTESTINAL, AND GENITOURINARY EMERGENCIES Goals of Treatment Patient with gastrointestinal emergencies may have massive fluid requirements because of third spacing Hypoglycemia and shock are common Abdominal distention can interfere with ventilation Delays in definitive surgical intervention are associated with worse outcome Therefore, the goals of emergency care are to aggressively fluid resuscitate, to provide adequate glucose, and to decompress the abdomen with nasogastric drainage Some patients will require intubation Urgent consultation with a pediatric surgeon and radiologist will aid in definitive diagnosis and surgical treatment KEY POINTS Bilious emesis in a newborn is a surgical emergency and presumed malrotation until proven otherwise Decompression of obstructed bowel with a nasogastric tube will reduce hydrostatic pressure and lower the risk of ischemia of the gut RELATED CHAPTERS Signs and Symptoms Crying: Chapter 20 Medical, Surgical, and Trauma Emergencies Endocrine Emergencies: Chapter 89 Gastrointestinal Emergencies: Chapter 91 Malrotation and Volvulus CLINICAL PEARLS AND PITFALLS Midgut volvulus is a surgical emergency where operation takes precedence over resuscitation, which can be continued in the operating room, in order to preserve bowel Plain radiographs and US are nonspecific, and the upper GI series is the reference standard for diagnosis Malrotation is nearly universal in patients after congenital diaphragmatic hernia repair, however, the incidence of midgut volvulus in this population is quite low Malrotation is a common comorbidity of heterotaxy syndrome, although the natural history and rate of volvulus in this population are unknown Current Evidence During embryonic development, the bowel undergoes two rotations prior to fixation in the abdomen If rotation and fixation are abnormal or incomplete, the bowel can twist upon itself, resulting in obstruction and/or volvulus with bowel ischemia and subsequent necrosis Approximately in 6,000 live births will have clinically evident malrotation, and over half present within the first month of life All infants with congenital diaphragmatic hernia have abnormal rotation and fixation, however, few go on to develop volvulus (incidence is