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Merenstein &
Gardner’s Handbook
of Neonatal Intensive
Care
EIGHTH EDITION

Sandra L. Gardner, RN, MS

Retired Clinical Nurse Specialist; Retired Pediatric Nurse Practitioner; Director, Professional
Outreach Consultation; Editor, Nurse Currents and NICU Currents, Aurora, Colorado

Brian S. Carter, MD, FAAP

Professor of Pediatrics, University of Missouri-Kansas City School of Medicine, Division of
Neonatology & Bioethics Center, Children’s Mercy Hospital-Kansas City, Kansas City, Missouri

Mary Enzman Hines, PhD, APRN, CNS, CPNP,

APHN-BC
Professor Emeritus, Beth El College of Nursing and Health Sciences, University of Colorado at
Colorado Springs
Certified Pediatric Nurse Practitioner, Rocky Mountain Pediatrics, Lakewood, Colorado

Jacinto A. Hernández, MD, PhD, MHA, FAAP

2
Professor Emeritus of Pediatrics, Section of Neonatology, Department of Pediatrics, University of
Colorado School of Medicine
Chairman Emeritus Department of Neonatology, Children’s Hospital Colorado, Aurora, Colorado

3
Table of Contents
Cover image

Title page

Newborn Metric Conversion Tables

Copyright

Dedication

Contributors

Reviewers

Preface

Introduction
Unit One. Evidence-Based Practice

1. Evidence-Based Clinical Practice

Finding High-Quality Evidence

Pressures to Intervene

Evaluation of Therapies

Qualitative Research Evaluating Experiences in the Neonatal Intensive Care Unit

Systematic Review in Perinatal Care and Evidence-Based Practice

Translating Evidence into Practice

Clinical Practice Guidelines

4
Unit Two. Support of the Neonate

2. Prenatal Environment: Effect on Neonatal Outcome

Physiology

Compromised Fetal Environment

Environmental Effects of Labor on the Fetus

Assessment of Fetal Well-Being

3. Perinatal Transport and Levels of Care

Regional Perinatal Referral and Transport System

Neonatal Transport

Family-Centered Care for Transport

Future of Neonatal Transport

4. Delivery Room Care

A Golden Opportunity

Physiology

Asphyxia and Apnea

Clamping of the Umbilical Cord

Resuscitation of the Newborn

Delivery Room Emergencies

Care During the Transition from the Delivery Room to the Nursery

Care of the Family and Perinatal Decision Making

5. Initial Nursery Care

Assessment and Care at Delivery

Evaluation and Care During the Transitional Period

Physical Assessment of the Newborn

Late-Preterm Infant

Care of the Well Newborn Infant

Parent Teaching

5
6. Heat Balance
Historical Milestones

Physiologic Considerations

Etiology of Heat Imbalances

Prevention of Heat/Cold Stress

Data Collection

Hypothermia

Hyperthermia

Parent Teaching

7. Physiologic Monitoring
Physiology

Noninvasive Monitoring

Data Collection

Interventions

Complications

Controversies

Parent Teaching

8. Acid-Base Homeostasis and Oxygenation

Physiology

Data Collection

Treatment

Complications

9. Diagnostic Imaging in the Neonate

Radiography

Fluoroscopy

Ultrasonography

Computed Tomography

Magnetic Resonance Imaging

Nuclear Scintigraphy

6
 Positron Emission Tomography

Interventional Radiology

Picture Archiving and Communication Systems

Family Education and Involvement

10. Pharmacology in Neonatal Care

Physiology

Data Collection

Drug Categories

Prevention of Therapeutic Mishaps

Methods of Administration

Parent Teaching

11. Drug Withdrawal in the Neonate

Physiology

Etiology of Neonatal Abstinence Syndrome

Prevention

Diagnosis

Treatment and Intervention

Parent Teaching

12. Pain and Pain Relief

Physiology and Pathophysiology

Neuroanatomy

Physiologic Responses

Etiology

Prevention

Data Collection

Treatment

End-of-Life Care

Complications

Parent Teaching

7
13. The Neonate and the Environment: Impact on Development
Developmental Tasks of the Neonate and Infant

Endowment

Environment

Interventions

Unit Three. Metabolic and Nutritional Care of the Neonate

14. Fluid and Electrolyte Management

Physiology

Etiology

Prevention

Data Collection

Treatment

Complications

Parent Teaching

15. Glucose Homeostasis

Fetal Physiology

Neonatal Physiology

Hypoglycemia

Hyperglycemia

Etiology of Hypoglycemia and Hyperglycemia

Prevention of Hypoglycemia and Hyperglycemia

Data Collection

Treatment

Complications

Parent Teaching

16. Total Parenteral Nutrition

Physiology

Indications

Data Collection

8
 Treatment

Complications

Parent Teaching

17. Enteral Nutrition

Physiology

Nutritional Requirements

Composition of Enteral Feedings

Feeding Techniques

Feeding Intolerance and Complications

The Preterm Infant

The Intrauterine Growth–Restricted Infant

Changes in Nutritional Requirements with Illness

Developmental Support

Family Support

Feeding the Preterm Infant After Hospital Discharge

18. Breastfeeding the Neonate with Special Needs

Physiology of Breastfeeding

Psychologic Values of Breastfeeding

Facilitating Successful Breastfeeding

Prevention of Breastfeeding Problems

Data Collection and Intervention

Complications of Breastfeeding

Parent Teaching

19. Skin and Skin Care

Physiology

Etiology

Prevention

Data Collection

Treatment

9
 Complications

Parent Teaching

Unit Four. Infection and Hematologic Diseases of the Neonate

20. Newborn Hematology

Red Blood Cells

Polycythemia and Hyperviscosity

Coagulation

Thrombosis

White Blood Cells

21. Neonatal Hyperbilirubinemia

Pathophysiology

Etiology of Hyperbilirubinemia

Mechanisms of Bilirubin Neurotoxicity

Prevention of Hyperbilirubinemia

Evaluation of the Infant with Hyperbilirubinemia

Treatment

Parent Teaching

Health Systems Approach to Bilirubin

22. Infection in the Neonate

Pathophysiology and Pathogenesis

Etiology

Specific Infectious Diseases

Parent Teaching

Unit Five. Common Systemic Diseases of the Neonate

23. Respiratory Diseases

General Physiology

General Etiologic Factors

General Prevention

10
 General Data Collection

General Treatment Strategies

General Complications

Parent Teaching

24. Cardiovascular Diseases and Surgical Interventions

Congenital Heart Disease: Overview

Specific Conditions

Parent Teaching

Future Research

25. Neonatal Nephrology

Normal Development

Clinical Assessment of Renal Disease in the Neonate

Acute Kidney Injury

Intrinsic Renal Parenchymal Abnormalities

Renal Vein Thrombosis

Hydronephrosis

Hypertension

Abdominal Masses

Renal Tubular Disorders

Urinary Tract Infection

Neurogenic Bladder

Nephrocalcinosis and Nephrolithiasis

Chronic Renal Failure

Nursing Care of the Neonate with Renal Failure

26. Neurologic Disorders

Congenital Malformations

Birth Injuries

Specific Birth Injuries

Hypotonia

11
 Neonatal Seizures

Hypoxic-Ischemic Encephalopathy

Intraventricular Hemorrhage

Pediatric Stroke

27. Genetic Disorders, Malformations, and Inborn Errors of Metabolism

Genetic Principles

Etiology

Data Collection

Treatment and Intervention

The Human Genome Project

Parent Teaching

28. Neonatal Surgery

Diaphragmatic Hernia

Esophageal Atresia and Tracheoesophageal Fistula

Congenital Chest Masses

Intestinal Malrotation and Volvulus

Intestinal Atresia

Necrotizing Enterocolitis

Meconium Ileus

Hirschsprung’s Disease

Anorectal Malformations

Omphalocele and Gastroschisis

Neonatal Tumors

Minimally Invasive Surgery

Parent Teaching

Unit Six. Psychosocial Aspects of Neonatal Care

29. Families in Crisis: Theoretical and Practical Considerations

Normal Attachment

Psychologic Adjustments to a Sick Newborn

12
 Communicating Medical Information: Evidence-Based Practice

Postpartum Mood Disorders

Adaptation to the Intensive Care Environment

30. Grief and Perinatal Loss

The Grief Process

Perinatal Situations in Which Grief is Expected

Stages of Grief

Symptoms of Grief

Male–Female Differences

Timing of Grief Resolution

Interventions

Children and Grief

Pathologic Grief

31. Discharge Planning and Follow-Up of the Neonatal Intensive Care Unit Infant
Planning for Discharge

Neurodevelopmental Follow-Up of High-Risk Infants

Complex Disorders of Brain Development

Perinatal Risk Factors for Neurodevelopmental Impairments

Specific Neurodevelopmental Outcomes

Tracking Health Outcomes: the Primary Care Provider

Long-Term Neurodevelopmental Follow-Up

32. Ethics, Values, and Palliative Care in Neonatal Intensive Care

Historical Overview

Definition of Bioethics

Theories of Ethics

Clinical Dilemmas in the Neonatal Intensive Care Unit

Decision Making in the Neonatal Intensive Care Unit

Ethics Committee or Palliative Care Consultation?

Communicating with Families

13
 Palliative Care in the Intensive Care Setting

Social Ethics

Glossary

Index

Newborn Metric Conversion Tables (Cont’d)

14
Newborn Metric Conversion
Tables
Temperature

Fahrenheit (F) to Centrigrade (C)

NOTE: °C = (°F – 32) × 5/9. Centrigrade temperature equivalents rounded to one decimal place by adding
0.1 when second decimal place is 5 or greater.
The metric system replaces the term “centrigrade” with “Celsius” (the inventor of the scale).
See inside back cover for additional tables.

15
Copyright

3251 Riverport Lane

St. Louis, Missouri 63043

MERENSTEIN & GARDNER’S HANDBOOK OF NEONATAL INTENSIVE CARE,

EIGHTH EDITION ISBN: 978-0-323-32083-2

Copyright © 2016 by Elsevier, Inc.

Copyright © 2011, 2006, 2002, 1998, 1993, 1989, 1985 by Mosby, Inc., an affiliate of
Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any
form or by any means, electronic or mechanical, including photocopying, recording, or
any information storage and retrieval system, without permission in writing from the
publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright
Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright
by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge
in evaluating and using any information, methods, compounds, or experiments
described herein. In using such information or methods they should be mindful of
their own safety and the safety of others, including parties for whom they have a
professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to
check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and contraindications. It is the

16
 responsibility of practitioners, relying on their own experience and knowledge of their
patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Merenstein & Gardner’s handbook of neonatal intensive care / [edited by] Sandra L.
Gardner, Brian S. Carter, Mary Enzman Hines, Jacinto A. Hernandez. -- Eighth edition.
p. ; cm.
Merenstein and Gardner’s handbook of neonatal intensive care
Preceded by Merenstein & Gardner’s handbook of neonatal intensive care / [edited by]
Sandra L. Gardner... [et al.]. 7th ed. c2011.
Includes bibliographical references and index.
ISBN 978-0-323-32083-2 (pbk. : alk. paper)
I. Gardner, Sandra L., editor. II. Carter, Brian S., 1957- , editor. III. Hines, Mary Enzman,
editor. IV. Hernandez, Jacinto A., editor. V. Title Merenstein and Gardner’s handbook of
neonatal intensive care.
[DNLM: 1. Intensive Care, Neonatal. 2. Infant, Newborn, Diseases--therapy. WS 421]
RJ253.5
618.92’01--dc23
2015006347

Executive Content Strategist: Lee Henderson

Content Development Manager: Jean Sims Fornango
Senior Content Development Specialist: Tina Kaemmerer
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Carol O’Connell
Design Direction: Renee Duenow

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

17
Dedication

We dedicate this edition to the memory of Gerald B. Merenstein, MD—our

friend, colleague, and mentor who was also a wonderful husband, father, and
grandfather. As the inspiration for this text, Gerry contributed to the fields of
neonatal and pediatric care through his dedication to nurses, nurse practitioners,
child health associates, interns, residents, fellows, neonates, and their families. We
miss him every day and know that his empathy, knowledge, teaching, and
compassion influences all of us, as well as the newborns, children, and families
that he and we serve.

SLG BSC MEH JAH

In memory of Stephanie Marie Gardner, whose three days of life did have a
purpose.

SLG

To my family: Angel, Sean, Yvonne, Rebecca, and Jacquelyn; my mentors and

colleagues; and all of the children and families who have allowed me to share
with them both joyous and difficult times in their lives.

BSC

To my family James, Jennifer, Sean, Finnoula, Steve, and Sarah for their enduring
source of love, confidence, and encouragement and to all the families who have
informed by practice and knowledge about caring for fragile infants.

MEH

To all the newborn infants, their families, and dedicated caregivers; my beloved
wife Pam and sons Gabriel and Jacinto for their love and constant support.

JAH

In Memoriam

18
Jimmie Lynne Scholl Avery

L. Joseph Butterfield, MD

Lula O. Lubchenco, MD

William A. Silverman, MD

19
Contributors
Rita Agarwal, MD, FAAP, Professor of Anesthesiology, Director of Education, Pediatric
Anesthesia, Pediatric Anesthesia Program Director, Director of the Colorado Review of
Anesthesiology for Surgicenters and Hospital, Children’s Hospital Colorado, University
of Colorado Denver, School of Medicine, Aurora, Colorado

Marianne Sollosy Anderson, MD, Neonatologist, Sequoia Pediatrics, Kaweah Delta

Medical Center, Visalia, California

Jaime Arruda, MD, FACOG, Assistant Professor, Obstetrics and Gynecology,

University of Colorado Denver, Aurora, Colorado

James S. Barry, MD, Associate Professor of Pediatrics, Section of Neonatology,

Department of Pediatrics, University of Colorado Denver School of Medicine, Medical
Director, Neonatal Intensive Care Unit, University of Colorado Hospital Department of
Neonatology Children’s Hospital Colorado, Aurora, Colorado

Wanda Todd Bradshaw, MSN, RN, NNP-BC

Assistant Professor and Lead Faculty, NNP Specialty, Duke University School of Nursing,
Durham, North Carolina
Neonatal Nurse Practitioner, Moses Cone Health System, Greensboro, North Carolina

M. Colleen Brand, PhD, APRN, NNP-BC, Neonatal Nurse Practitioner, Texas

Children’s Hospital, Houston, Texas

Laura D. Brown, MD, Associate Professor of Pediatrics, Section of Neonatology,

Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora,
Colorado

Jessica Brunkhorst, MD, Neonatology Fellow, Children’s Mercy Hospital, Kansas City,
Missouri

Brian T. Bucher, MD, Clinical Fellow, Pediatric Surgery, Department of Pediatric

Surgery, Vanderbilt, Nashville, Tennessee

Deanne Buschbach, RN, MSN, NNP, PNP, Clinical Operations Director for Advanced
Clinical Practice, Pediatric and Neonatal Critical Care APP Service, Pediatric Heart APP
Service, Duke University Medical Center, Durham, North Carolina

Melissa A. Cadnapaphornchai, MD, Associate Professor of Pediatrics and Medicine,

Pediatric Nephrology/The Kidney Center, University of Colorado Denver School of

20
Medicine and Children’s Hospital Colorado, Aurora, Colorado

Angel Carter, DNP, APRN, NNP-BC, Assistant Professor of Nursing, Assistant Chair
—BSN Degree Completion Program, Park University, Kansas City, Missouri

Brian S. Carter, MD, FAAP, Professor of Pediatrics, University of Missouri-Kansas City

School of Medicine, Division of Neonatology & Bioethics Center, Children’s Mercy
Hospital-Kansas City, Kansas City, Missouri

Susan B. Clarke, MS, RNC-NIC, RN-BC, CNS, Professional Development Specialist,

Continuing Education and Outreach, NRP Regional Trainer, Children’s Hospital
Colorado, Aurora, Colorado

C. Michael Cotten, MD, MHS, Associate Professor of Pediatrics, Medical Director,

Neonatology Clinical Research, Duke University, Durham, North Carolina

Heather Furlong Craven, MD, Associate Professor of Pediatrics, Division of

Neonatology, Medical Director of Neonatal Transport Services, Wake Forest School of
Medicine Brenner Children’s Hospital, Winston-Salem, North Carolina

Jane Davis, RNC, BSN, Level III Permanent Charge Nurse, Neonatal Intensive Care
Unit, University of Colorado Hospital, Aurora, Colorado

Jane Deacon, NNP-BC, MS, Neonatal Nurse Practitioner, Children’s Hospital

Colorado, Aurora, Colorado

David J. Durand, MD, Division of Neonatology, UCSF Benioff Children’s Hospital-

Oakland, Oakland, California

Jarrod Dusin, MS, RD, Clinical Dietitian Specialist, Children’s Mercy Hospital, Kansas
City, Missouri

Nancy English, PhD, RN, Fetal Concerns, Director and Coordinator, Colorado High
Risk Maternity and Newborn Program, University of Colorado Health Sciences, The
Children’s Hospital, Aurora, Colorado

Mary Enzman Hines, PhD, APRN, CNS, CPNP, APHN-BC

Professor Emeritus, Beth El College of Nursing and Health Sciences, University of
Colorado at Colorado Springs
Certified Pediatric Nurse Practitioner, Rocky Mountain Pediatrics, Lakewood, Colorado

Lori Erickson, RN, CPNP, APRN, Fetal Cardiac and Cardiac High Acuity Monitoring
APRN, Ward Family Heart Center, Children’s Mercy Hospital, Kansas City, Missouri

Ruth Evans, MS, APRN, NNP-BC, Neonatal Nurse Practitioner, Children’s Hospital
Colorado and University of Colorado Hospital, Aurora, Colorado

Loretta P. Finnegan, MD
President, Finnegan Consulting, LLC, Perinatal Addiction and Women’s Health, Avalon,
New Jersey
Founder and Former Director of Family Center, Jefferson Medical College of Thomas
Jefferson University, Philadelphia, Pennsylvania

21
Sandra L. Gardner, RN, MS, Retired Clinical Nurse Specialist; Retired Pediatric Nurse
Practitioner; Director, Professional Outreach Consultation; Editor, Nurse Currents and
NICU Currents, Aurora, Colorado

Edward Goldson, MD, Professor, Department of Pediatrics, University of Colorado

Denver School of Medicine, The Children’s Hospital, Aurora, Colorado

Linda L. Gratny, MD
Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Neonatologist and Director, Infant Tracheostomy and Home Ventilator Program,
Children’s Mercy Hospital, Kansas City, Missouri

Marie Hastings-Tolsma, PhD, CNM, FACNM

Professor, Nurse Midwifery, Louis Herrington School of Nursing, Baylor University,
Dallas, Texas
Visiting Professor, University of Johannesburg, Johannesburg, South Africa

William W. Hay Jr. MD, Professor of Pediatrics, Section of Neonatology, Scientific

Director, Perinatal Research Center, Co-Director for Child and Maternal Health and the
Perinatal Research Center, Colorado Clinical and Translational Sciences Institute,
University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora,
Colorado

Kendra Hendrickson, MS, RD, CNSC, CSP, Clinical Dietitian Specialist, Neonatal
Intensive Care Unit, University of Colorado Hospital, Aurora, Colorado

Carmen Hernández, MSN, NNP-BC, Neonatal Nurse Practitioner, Rocky Mountain

Hospital for Children, Denver, Colorado

Jacinto A. Hernández, MD, PhD, MHA, FAAP

Professor Emeritus of Pediatrics, Section of Neonatology, Department of Pediatrics,
University of Colorado School of Medicine
Chairman Emeritus Department of Neonatology, Children’s Hospital Colorado, Aurora,
Colorado

Patti Hills, LMSW, LCSW, Fetal Health Center, NICU Social Worker, Children’s Mercy
Hospital, Kansas City, Missouri

Mona Jacobson, MSN, RN, CPNP-PC, Instructor in Pediatrics, Section of Child

Neurology, University of Colorado School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

M. Douglas Jones Jr. MD, Senior Associate Dean for Clinical Affairs, Professor, Section
of Neonatology, Department of Pediatrics, University of Colorado Denver School of
Medicine, Aurora, Colorado

Beena Kamath-Rayne, MD, MPH, Assistant Professor of Pediatrics, Perinatal Institute,

Division of Neonatology, Global Health Center, Cincinnati Children’s Hospital Medical
Center, Cincinnati, Ohio

Rhonda Knapp-Clevenger, PhD, CPNP

Director, Research and Pediatric Nurse Scientist, Center for Pediatric Nurse Research

22
and Clinical Inquiry
Clinical Research Director, Pediatric and Perinatal Clinical Translational Research
Centers, University of Colorado Denver, College of Nursing , Children’s Hospital
Colorado, Aurora, Colorado

Ruth A. Lawrence, MD, DD(Hon), FAAP, FABM, Distinguished Alumna Professor of

Pediatrics and Obstetrics/Gynecology, Northumberland Trust Chair in Pediatrics,
Director of the Breastfeeding and Human Lactation Study Center, University of
Rochester School of Medicine and Dentistry, Rochester, New York

Mary Kay Leick-Rude, RNC, MSN, PCNS, Clinical Nurse Specialist, Children’s Mercy
Hospital, Kansas City, Missouri

Harold Lovvorn III MD, FACS, FAAP, Assistant Professor of Pediatric Surgery,
Vanderbilt University Children’s Hospital, Nashville, Tennessee

Carolyn Lund, RN, MS, FAAN

Neonatal Clinical Nurse Specialist, ECMO Coordinator, Neonatal Intensive Care Unit,
UCSF Benioff Children’s Hospital-Oakland, Oakland, California
Associate Clinical Professor, Department of Family Health Care Nursing, University of
California, San Francisco, California

Marilyn Manco-Johnson, MD, Professor of Pediatrics, Section of Hematology,

University of Colorado Denver and The Children’s Hospital Colorado, Hemophilia and
Thrombosis Center, Aurora, Colorado

Anne Matthews, RN, PhD, FACMG, Professor, Genetics and Genome Sciences,
Director, Genetic Counseling Training Program, Case Western Reserve University,
Cleveland, Ohio

Jane E. McGowan, MD, Professor of Pediatrics, Associate Chair for Research, Drexel
University College of Medicine, Medical Director, NICU, St. Christopher’s Hospital for
Children, Philadelphia, Pennsylvania

Christopher McKinney, MD, Fellow, Pediatric Hematology, Center for Cancer and
Blood Disorders, Children’s Hospital Colorado, University of Colorado-Denver, Aurora,
Colorado

Mary Miller-Bell, PharmD, Clinical Research Pharmacist, Duke University Hospital,

Durham, North Carolina

Susan Niermeyer, MD, MPH, FAAP, Professor of Pediatrics and Epidemiology,

University of Colorado School of Medicine and Colorado School of Public Health,
Aurora, Colorado

Priscilla M. Nodine, PhD, CNM, Assistant Professor, Midwifery, College of Nursing,

University of Colorado Anschutz Campus, Aurora, Colorado

Michael Nyp, DO, MBA, Assistant Professor of Pediatrics, University of Missouri-

Kansas City, Division of Perinatal-Neonatal Medicine, Children’s Mercy Hospital, Kansas
City, Missouri

23
Steven L. Olsen, MD, Associate Professor of Pediatrics, University of Missouri-Kansas
City, Division of Neonatology, Children’s Mercy Hospital, Kansas City, Missouri

Annette S. Pacetti, RN, MSN, NNP-BC, Neonatal Nurse Practitioner, Monroe Carell, Jr.
Children’s Hospital at Vanderbilt, Nashville, Tennessee

Eugenia K. Pallotto, MD, MSCE, Associate Professor, University of Missouri-Kansas

City School of Medicine, Medical Director, NICU, Children’s Mercy Hospital, Kansas City,
Missouri

Mohan Pammi, MD, PhD, MRCPCH, Associate Professor, Baylor College of Medicine,
Houston, Texas

Alfonso Pantoja, MD, Neonatologist, Saint Joseph’s Hospital, Denver Colorado

Julie A. Parsons, MD, Associate Professor of Pediatrics and Neurology, Haberfield

Family Endowed Chair in Pediatric Neuromuscular Disorders, Child Neurology Program
Director, University of Colorado School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

Webra Price-Douglas, PhD, CRNP, IBCLC, Maryland Regional Transport Program,

Baltimore, Maryland

Daphne A. Reavey, PhD, RN, NNP-BC, Neonatal Nurse Practitioner, Children’s Mercy
Hospital, Kansas City, Missouri

Nathaniel H. Robin, MD, FACMG, Professor of Genetics and Pediatrics, University of

Alabama at Birmingham, Birmingham, Alabama

Mario A. Rojas, MD, MPH, Professor of Pediatrics, Division of Neonatal-Perinatal

Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina

Jamie Rosterman, DO, Neonatology Fellow, Children’s Mercy Hospital, Kansas City,
Missouri

Paul Rozance, MD, Associate Professor of Pediatrics, Section of Neonatology,

University of Colorado Denver School of Medicine, Children’s Hospital Colorado,
Aurora, Colorado

Tamara Rush, MSN, RN, C-NPT, EMT, Nurse Manager, Brenner Children’s Hospital-
Wake Forest Baptist Health, Winston-Salem, North Carolina

Mary Schoenbein, BSN, RN, CNN, Perinatal Dialysis Nurse/The Kidney Center,
Children’s Hospital Colorado, Aurora, Colorado

Alan R. Seay, MD, Professor of Pediatrics and Neurology, University of Colorado

School of Medicine, Children’s Hospital Colorado, Aurora, Colorado

Danielle E. Soranno, MD, Assistant Professor of Pediatrics and Bioengineering,

Pediatric Nephrology/The Kidney Center, University of Colorado Denver School of
Medicine and Children’s Hospital Colorado, Aurora, Colorado

John Strain, MD, FACR, CAQ Pediatric Radiology, Neuroradiology

24
Professor of Radiology, Department of Radiology, University of Colorado School of
Medicine
Chairman, Department of Radiology, Children’s Hospital Colorado, Anschutz Medical
Campus, Aurora, Colorado

Julie R. Swaney, MDiv, Manager, Spiritual Care Services, Associate Clinical Professor,
Department of Medicine, University of Colorado Denver Anschutz Medical Campus,
Aurora, Colorado

Tara M. Swanson, MD
Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Director of Fetal Cardiology, Children’s Mercy Hospital, Kansas City, Missouri

David Tanaka, MD, Professor of Pediatrics, Neonatologist, Duke University Medical

Center, Durham, North Carolina

Elizabeth H. Thilo, MD
Associate Professor of Pediatrics, Section of Neonatology, University of Colorado Denver
School of Medicine
Neonatologist, University of Colorado Hospital and Children’s Hospital Colorado,
Aurora, Colorado

Kristin C. Voos, MD, Neonatologist, Children’s Mercy Hospital;, Associate Professor of

Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri

Susan M. Weiner, PhD, MSN, RNC-OB, CNS, Perinatal Clinical Nurse Specialist,
Assistant Clinical Professor/Retired, Freelance Author/Editor, Philadelphia, Pennsylvania

Jason P. Weinman, MD, Assistant Professor of Radiology, University of Colorado

School of Medicine, Medical Director Computed Tomography, Children’s Hospital
Colorado, Aurora, Colorado

Leonard E. Weisman, MD, Professor of Pediatrics, Section of Neonatology, Baylor

College of Medicine, Texas Children’s Hospital, Houston, Texas

Rosanne J. Woloschuk, RD, Clinical Dietitian, The Kidney Center, Children’s Hospital
Colorado, Aurora, Colorado

25
Reviewers
Nancy Blake, PhD, RN, NEA-BC, CCRN, Patient Care Services Director, Critical Care
Services, Children’s Hospital Los Angeles, Los Angeles, California

Fran Blayney, RN-C, BSN, MS, CCRN, Education Manager, Pediatric Intensive Care
Unit, Children’s Hospital Los Angeles, Los Angeles, California

Karen C. D’Apolito, PhD, NNP-BC, FAAN, Professor & Program Director, Neonatal
Nurse Practitioner Program , Vanderbilt University School of Nursing, Nashville,
Tennessee

Mary Dix, BSN, RNC-NIC, Staff Nurse, Neonatal Intensive Care Unit, PIH Health
Hospital-Whittier, Whittier, California

Sharon Fichera, RN, MSN, CNS, NNP-BC, Neonatal Clinical Nurse Specialist,
Children’s Hospital Los Angeles, Los Angeles, California

Joyce Foresman-Capuzzi, MSN, RN, Clinical Nurse Educator, Lankenau Medical

Center, Wynnewood, PA

Delores Greenwood, MSN, RNC-NIC, Education Manager, Newborn and Infant

Critical Care Unit, Children’s Hospital Los Angeles, Los Angeles, California

Nadine A. Kassity-Krich, MBA, BSN, RN, Clinical Professor, Hahn School of Nursing ,
University of San Diego, San Diego, California

Lisa M. Kohr, RN, MSN, CPNP- AC/PC, MPH, PhD(c), FCCM, Pediatric Nurse
Practitioner, Cardiac Intensive Care Unit, Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania

Carie Linder, RNC-NIC, MSN, APRN-BS, Neonatal Nurse Practitioner, Integris Baptist
Medical Center, Oklahoma City, Oklahoma

Twila Luckett, BSN, RN-BC, Pediatric Pain Service, Monroe Carell Jr. Children’s
Hospital at Vanderbilt, Nashville, Tennessee

Erin L. Marriott, MS, RN, CPNP, Pediatric Cardiology Nurse Practitioner , American
Family Children’s Hospital, Watertown Regional Medical Center, Madison, Wisconsin

Andrea C. Morris, DNP, RNC-NIC, CCRN, Neonatal Clinical Nurse Specialist, Citrus
Valley Medical Center-NICU, West Covina, California

26
Mindy Morris, DNP, NNP-BC, CNS, Neonatal Nurse Practitioner, Extremely Low Birth
Weight Program Coordinator, Children’s Hospital of Orange County, Orange, California

Tracy Ann Pasek, RN, MSN, DNP, CCNS, CCRN, CIMI, Clinical Nurse Specialist,
Pain/Pediatric Intensive Care Unit, Children’s Hospital of Pittsburgh, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Patricia Scheans, DNP, NNP-BC, Clinical Support for Neonatal Care , Legacy Health,
Portland, Oregon

Peggy Slota, DNP, RN, FAAN, Associate Professor, Director, DNP and Nursing
Leadership Programs, Carlow University, Pittsburgh, Pennsylvania

Nicole Van Hoey, PharmD, Medical Writer/Editor, Consultant, Arlington, Virginia

Winnie Yung, MN, RN, Registered Nurse, Lucile Packard Children’s Hospital at
Stanford, Palo Alto, California

27
Preface
The concept of the team approach is important in neonatal intensive care. Each health
care professional must not only perform the duties of his or her own role but must also
understand the roles of other involved professionals. Nurses, physicians, other health
care providers, and parents must work together in a coordinated and efficient manner to
achieve optimal results for patients in the neonatal intensive care unit (NICU).
Because this team approach is so important in the field of neonatal intensive care, we
believe it is necessary that this book contain input from major fields of health care—
nursing and medicine. Both nurses and physicians have edited and co-authored every
chapter.
The book is divided into six units, all of which have been reviewed, revised, and
updated for the eighth edition. Unit One presents evidence-based practice and the need
to scientifically evaluate neonatal therapies, emphasizing randomized controlled trials as
the ideal approach. Units Two through Five are the clinical sections, which have been
fully updated for this edition. The chapters within these sections include highlighted
clinical directions for quick reference, Parent Teaching boxes to aid in discharge
instructions, and Critical Findings boxes to prioritize assessment data.
The combination of physiology and pathophysiology and separate emphasis on
clinical application in this text is designed for neonatal intensive care nurses, nursing
students, medical students, and pediatric, surgical, and family practice housestaff. This
text is comprehensive enough for nurses and physicians, yet basic enough to be useful to
families and all ancillary personnel.
Unit Six presents the psychosocial aspects of neonatal care. The medical,
psychological, and social aspects of providing care for the ill neonate and family are
discussed in this section. This section in particular will benefit social workers and clergy,
who often deal with family members of neonates in the NICU.
In this handbook we present physiologic principles and practical applications and
point out areas as yet unresolved. Material that is clinically applicable is set in purple
type so that it can be easily identified.

28
Introduction
In 1974 as the Perinatal Outreach Educator at The Children’s Hospital in Denver,
Colorado, I took a folder to Gerry Merenstein, MD, at Fitzsimmons Army Medical Center
to discuss his lectures for the first outreach education program in La Junta, Colorado.
When we finished, he removed from his desk drawer a 1-inch thick compilation of the
neonatal data, graphs, nomograms, and diagrams he had created for the medical
housestaff during his fellowship. Giving the document to me, he asked that I review it
and let him know what I thought. Several weeks later, I told him it was good except there
was no nursing care or input, which is essential in every NICU. So Gerry asked, “Want to
write a book?”—and the idea for the Handbook was born!
With this eighth edition in 2015, we celebrate 30 years of publication of the Handbook of
Neonatal Intensive Care. Gerry and I co-edited this book for 21 years until his death in
December 2007. To fulfill my promise that Gerry’s name would always be on the book,
the seventh and all subsequent editions will be known as Merenstein & Gardner’s
Handbook of Neonatal Intensive Care. Instead of editing this edition alone or with another
physician, I decided to convene an editorial team consisting of myself, a nurse colleague,
and two neonatologists. Together we bring 170 years of clinical practice, research,
teaching, writing, and consulting in neonatal, pediatric, and family care to this eighth
edition.
We have the distinction in this new edition of translation into Spanish for our
colleagues in Central and South America and Spain. This was an ongoing wish of Gerry
Merenstein, and after much negotiation it is finally a reality. Welcome to all our Spanish-
reading colleagues! In addition, the eighth edition is available on multiple e-platforms to
facilitate use at the bedside.
For our new audience, and for our continuing loyal readers, this is my opportunity to
introduce myself and all the members of the editing team.
I am currently Editor of Nurse Currents and NICU Currents (www.anhi.org) and the
Director of Professional Outreach Consultation
(www.professionaloutreachconsultation.com), a national and international consulting
firm established in 1980. I plan, develop, teach, and coordinate educational workshops
on perinatal/neonatal/pediatric topics. I graduated from a hospital school of nursing in
1967 with a diploma, obtained my BSN at Spalding College in 1973 (magna cum laude),
completed my MS at The University of Colorado School of Nursing in 1975 and my PNP
in 1978. I have worked in perinatal/neonatal/pediatric care since 1967 as a clinician (37
years in direct bedside care), practitioner, teacher, author, and consultant. In 1974, I was
the first Perinatal Outreach Educator in the United States funded by the March of Dimes.
In this role I taught nurses and physicians in Colorado and the seven surrounding states
how to recognize and stabilize at-risk pregnancies and sick neonates. I also consulted

29
Another random document with
no related content on Scribd:
mention of “legislatures” implies no “grant.” On the contrary it is a
command to these “legislatures,” representing the members of the
union of states. The command comes from the superiors of the
states, the “conventions” of the whole American people.
It is not the only command which the “conventions” of that one
people made to the states and their “legislatures.” How absurd to
imply from that command that it is a “grant” of power to those
commanded governments, giving them omnipotence over every
human freedom of the American people who made the command!
We know what Madison told the Americans in the “conventions,”
when he asked them to make his Fifth Article. He told them that it
was a “mode of procedure” in which either the general government
or the state governments could originate, by proposal, the
introduction of changes into the Constitution which is both national
and federal. He pointedly did not tell those Americans that the Fifth
Article is a “grant” of any ability to the state governments to make
national Articles and he pointedly did not tell them that it is a “grant”
of ability to anyone to make any Articles.
Why then was it necessary for the leading brief, in support of the
Eighteenth Amendment, to add to Madison’s explanation of his own
Fifth Article (the explanation that it was a “mode of procedure”) the
absurd statement that it was a “grant” from the “conventions” to the
“conventions” and the state legislatures of power to make
Amendments? Why then was it necessary that this brief, speaking of
the Fifth Article, should say: “The people thus ordained the mode of
Amendment,” exactly what Madison said, “and in their own interest
they established this power of Amendment”—exactly what Madison
pointedly omitted to state to the Americans he asked to make the
Fifth Article?
The answer is simple. Without adding to the Madison statement
what he pointedly omitted to state, without stating the addition as
axiomatic, Hughes could not even begin any argument for the
Eighteenth Amendment.
The statement which Hughes adds to that of Madison is a
statement which flatly contradicts everything we have heard in the
“conventions.” It flatly contradicts everything the Americans did from
1775 on. It flatly contradicts the Tenth Amendment declaration that
the Fifth Article gives no power whatever to the states or their
governments. The added statement is sheer “nonsense,” assumed
and asserted as axiomatic fact.
And, during the last five years, how has every argument against
the Eighteenth Amendment met the “nonsense” of the assumption
that the Fifth Article is a “grant?” In no way at all, except by
assuming and asserting the same “nonsense,” and by then
undertaking to prove another absurdity, namely, that the Fifth Article
does not relate to the making of fundamental changes because the
imaginary “grant” is limited in extent and does not include power to
take away from the importance of the respective political entities
which are the states.
Let no American citizen make any mistake as to this one fact. In
no argument either for or against the Eighteenth Amendment has
there been any challenge to the sheer assumption that the Fifth
Article is a “grant” of ability to make changes in the Constitution
which is both federal and national. On the contrary, in every
argument, the foundation of everything asserted and urged is that
very assumption.
In every argument against the Eighteenth Amendment, possible
changes in the Constitution (which is both federal and national) have
been divided into two classes, but not into the federal class and the
national class. It has been invariably contended that the first class
include those which can be made under the imaginary “grant” of
power in the Fifth Article and in the mode of procedure therein
prescribed. On the other hand, it has been invariably contended that
the other class includes those which cannot be made under that
imaginary “grant” or in any constitutional procedure because they
take away from the citizens of a state their right to govern
themselves.
All arguments alike, whether for or against the Eighteenth
Amendment, have wholly ignored the fact that the citizens of
America, for the protection of the individual liberty of the one
American people, in that character, established the Constitution
and made it the supreme law over the citizens of the respective
states and the states themselves and the state governments and the
league of the states, which the citizens of America continued as
subordinate to their nation of men.
For this reason probably, no argument, on either side, has ever
recognized the identity of the “conventions” of the Seventh Article
with the “conventions” of the Fifth Article. For this reason probably,
no argument has ever recognized the identity of both “conventions”
with the most important factor and reservee in the Tenth
Amendment, “the people” of America, as distinguished from the
lesser reservees, the peoples or citizens of each state, “the states
respectively.”
It is this very failure to recognize this identity which has forced the
opponents of the new Amendment into the “nonsense” of assuming
and asserting, with their adversaries, that the Fifth Article is a “grant”
to the “conventions” and the state “legislatures.” If there had not
been this failure, everyone would have recognized that the
“conventions,” which made the Constitution, neither could nor did
“grant” to themselves, the “conventions” named in the Fifth Article,
any or all of the very power which they were then exercising. The
“nonsense” of the concept of such a “grant” is patent once there is
recognized the identity between the “conventions” with the most
important reservee of the Tenth Amendment, the one American
people of Marshall.
We all know that, for five years, that identity has never been
known or mentioned. The failure to know or to mention it has been
emphasized by the occasional references to “conventions” which
have been made. In one or two arguments, there has been passing
attempt to support the “nonsense,” that the Fifth Article is a “grant,”
but a “grant” limited in extent, by a suggestion that the Eighteenth
Amendment could be “grafted” on the Constitution entirely outside of
any mode of procedure mentioned in the Constitution. The
suggestion has been that it could be “grafted” on the Constitution by
“conventions” of the citizens of each state, provided that the citizens
of every state gave their consent. In these suggestions, we
ourselves, the citizens of America, the whole American people of
Marshall, have figured not at all.
We, who are the citizens of America, must now realize the vital
importance to our personal liberty of our own knowledge that we are
citizens of America as well as citizens of some particular state.
Wilson pointed out to the Americans in the Pennsylvania convention
the dual capacity of the American, if the new Constitution were
adopted. We remember his statement that “it was necessary to
observe the two-fold relation in which the people would stand—first
as citizens of the general government and, secondly, as citizens of
their particular state. The general government was meant for them in
the first capacity; the state governments in the second. Both
governments were derived from the people; both meant for the
people; both therefore ought to be regulated on the same principles.”
And we remember the one most important American principle, that
every government in America must get, directly from its own citizens,
every power to interfere with their individual freedom.
We cannot help contrasting the accurate statement of Wilson, “in
this Constitution the citizens of America appear dispensing a portion
of their power,” with what must be the modern statement, if the
Eighteenth Amendment is in the Constitution, namely, “in this
Constitution the state governments appear dispensing to themselves
and to the national government another portion of the power of the
citizens of America.”
And, if that modern statement is “nonsense,” what else but
“nonsense” are the arguments which rely upon its truth or which do
not point out its absurdity?
What action of our public leaders, even in this year 1923, does not
disclose that they still have the Tory concept that states and their
governments, both of which are political entities, can exercise or
grant power which the Tenth Amendment expressly declares that the
American citizens reserved exclusively to themselves, and which the
Supreme Court, even as late as 1907, clearly held “could be
exercised only by them or upon further grant from them?” No
discerning American has failed to note that the Senate still clings to
the delusion of 1917, that states and their citizens and their
governments have anything whatever to do with the national part of
the Constitution of the citizens of America. In the newspapers, on
January 30, 1923, under the heading, “Favor New Defense for
Constitution,” appeared a dispatch from Washington. It told how the
senators on the Judiciary Sub-Committee had agreed to report
favorably a proposal again to amend the Constitution by changing
the language of the Fifth Article. And the main element of the
proposed change is to provide that any state may require that
ratification by its legislature be subject to confirmation by popular
vote of the citizens of that state.
The citizens of each state make their own Constitution. In it, they
give to their own government what ability they please to interfere
with their own individual freedom. What have the citizens of any
State, what have the citizens of every state, in their capacity as state
citizens, to do with grants of power to the American government to
interfere with the individual liberty of the American citizens? Have not
the American citizens, in every state, protection against grants of
such power to the one government of the American people except by
the citizens of America themselves, in that character? Is there
anything in the Fifth Article, as it was written by Madison and made
by the one American people, which permits any state governments—
which have no power even over their own respective citizens except
by grant from them—to exercise or create new government power to
interfere with the liberty of the citizens of the distinct and supreme
nation, America?
Why persistently and insistently ignore the basic American legal
principle that every state government must get its own power over its
own citizens from them and that the only government of the
American citizens must get its every national (as distinguished from
federal) power directly from the citizens of America, assembled in the
“conventions” named in the Fifth Article?
Is there any doubt that Madison, who wrote the Fifth Article, knew
whom its word “conventions” described? When he asked the one
American people to make the entire Constitution, this is what he told
them about the Seventh Article, in which the same word
“conventions” was used: “This Article speaks for itself. The express
authority of the people alone could give due validity to the
Constitution.” If the Seventh Article “speaks for itself” and points out
that “the people alone” are to make the Constitution, with its grants
of national power in the First Article, what word in that Seventh
Article identifies the makers of the Constitution, which Madison and
all Americans know was made by the one people of America? Is
there any word in it except the one word “conventions” to describe
the people or citizens of America? And if that one word “conventions”
makes the Article speak for itself and tell us that the American
citizens themselves made the whole Constitution, does not the word
“conventions” in the Fifth Article speak just as plainly for itself and tell
us that it also describes and identifies the one people of America, the
citizens of America?
Why then tinker with the Fifth Article and repeat the monumental
error on which the existence of the Eighteenth Amendment is
assumed? Why propose an Amendment to the Fifth Article, which
Amendment will itself assume that the Fifth Article already is a
“grant” to the state legislatures of ability to give away from the
citizens of America their exclusive power to say to what extent and in
what matters their one American government may interfere with their
individual freedom in their character as American citizens?
Why not be sane and admit that the Fifth Article is not a “grant” to
the legislatures of state citizens? It is settled fact that each such
legislature, like every legislature in America, must get its every
power to govern its own citizens from its own citizens. That is why
the Fourth Article guarantee of “a Republican Form of Government”
to every state has taught us (pp. 250-1) the absurdity of the thought
that the Fifth Article enables state governments outside Rhode Island
to give its government power to interfere with the individual freedom
of citizens of Rhode Island. And there is a further and more
monumental absurdity, in this same respect, when we contrast this
Fourth Article guarantee with the assumption that the Fifth Article is
a “grant” to the state legislatures. One of the great purposes for
which the whole American people made themselves one nation of
men was that the strength of such a great nation might be used to
secure to the Americans in every state the ability to govern
themselves without any interference from outside the state, in all
matters except those in which the citizens of America took from them
the ability to govern themselves. That is why the citizens of America
wrote that guarantee into the Fourth Article as a command to their
inferiors, the states and the state governments. Having thus secured
“a Republican Form of Government” to the Americans in every state
by the command of the Fourth Article, is it conceivable that the same
whole American people, immediately thereafter and in the Fifth
Article, created for the citizens of America a government which has
not even the semblance of “a Republican Form of Government”?
That is the concept on which the existence of the Eighteenth
Amendment depends. It is not in the Constitution unless,
immediately after the guarantee of the Fourth Article and in the Fifth
Article, the whole people of America said: “We have just insisted that
the Americans in each state must be governed by a government
which gets its power directly from them. For ourselves, however, as
the whole American people, we are content to let two thirds of
Congress and the legislatures of three fourths of the states interfere
with our individual freedom, in all matters whatsoever. For that
reason, we make this grant to those legislatures. For ourselves, as
one people, we have no desire for a Republican Form of
Government.”
Does not the claim that the Americans did say this in their Fifth
Article entitle us more justly than Henry to exclaim: “I suppose that I
am mad, or that my countrymen are so!” (3 Ell. Deb. 446.)
We know, with certainty, that the Eighteenth Amendment is not in
our Constitution, and we know that the real and invincible challenge
to its existence has never been made. What will be the epitaph of the
audacious attempt of government to dictate to Americans as
“subjects,” when the challenge is presented to the Supreme Court?
No patriotic American can have the slightest doubt. No man, familiar
with its history and traditions, can fail to know the answer of that
Court to the question, “Citizen or Subject?”
It is not unknown that there is growing up in America, even among
many public leaders and lawyers, an unfounded concept that the
Supreme Court was created by the American citizens to make law.
Such concept is quite in accord with the concept—indeed it is part of
the concept—that government can create and constitute new
government of men. But the entire history and tradition of the
Supreme Court flatly denies the existence of any such concept in the
mind of the Court itself. Even in the National Prohibition Cases, the
Court quickly displayed the American concept of the relation of men
to all governments in America. When the lawyers had finished their
incessant talk about the imaginary Fifth Article “grant” which would
make all American citizens “subjects” of some governments of state
citizens, had the Tory concept of such a grant made the slightest
impression upon the mind of the Court? We all know that in the
decisions, which merely negatived four unsound challenges to the
Amendment, the first statement of the Court was a reference to the
power “reserved” in the Fifth Article.
And we know how, in the same litigations, the Court wholly ignored
the absurd claim, even when advanced by a former justice of the
Court, that, when governments had attempted to put anything into
our Constitution, so long as the attempt did not involve changing the
number of senators from a state, the Court was without power to
review the action of governments or to protect the American citizen
against usurpation by government.
The Constitution is not only the same in words, but the
same in meaning, and delegates the same powers to the
government, and reserves and secures the same rights and
privileges to the citizen, and as long as it continues to exist in
its present form, it speaks not only in the same words, but
with the same meaning and intent with which it spoke when it
came from the hands of its framers and was voted on and
adopted by the people of the United States. Any other rule of
construction would abrogate the judicial character of the
Court, and make it the mere reflex of the popular opinion or
passion of the day. This Court was not created by the
Constitution for such purposes. Higher and graver trusts have
been confided to it, and it must not falter in the path of duty.
(Scott v. Sandford, 19 How. 393, at p. 426.)
 The high power has been conferred upon this Court of
passing judgment upon the acts of the state sovereignties and
of the legislative and executive branches of the federal
government, of determining whether they are beyond the
limits of power marked out for them respectively by the
Constitution of the United States. (Luther v. Borden, 1849, 7
How. 1 at p. 47.)
The Court will never be called upon to exercise a higher or graver
trust than to answer the question “Citizen or Subject?”, when the real
challenge is made to the new attempted constitution of government
of men entirely by government. The Court is not unaware that the
whole American people established their Constitution for the one
purpose of protecting individual liberty.
The simple, classical, precise, yet comprehensive language
in which it is couched, leaves, at most, but very little latitude
for construction; and when its intent and meaning is
discovered, nothing remains but to execute the will of those
who made it, in the best manner to effect the purposes
intended. The great and paramount purpose was to unite this
mass of wealth and power, for the protection of the humblest
individual; his rights, civil and political, his interests and
prosperity, are the sole end; the rest are nothing but the
means. (Justice Johnson, Gibbons v. Ogden, 9 Wheat. 1, at
p. 223.)
Nor will anyone familiar with the unbroken tradition of the Supreme
Court listen, with aught but mingled incredulity and indignation, to the
suggestion that the Court itself has not always understood that it is
itself but a part of the limited government of the one American
people, created by that people as one means to that sole end.
“It is emphatically the province and duty of the Judiciary
Department to say what the law is.”
This is the clear statement of Marshall in Marbury v. Madison, 1
Cranch. 137, declaring unconstitutional a section of an act of
Congress, which had been passed at the first session in 1789. The
entire Bench and Bar of America, including the Supreme Court, for
fourteen years, had practiced on the assumption that the section was
constitutional. Yet in 1803, the Supreme Court declared it to be
unconstitutional. Nothing could more clearly establish the knowledge
of the Supreme Court that no continued thought (even by the Court
itself), that any command of legislatures is valid, will ever blind the
Court to its bounden duty to announce the fact that the command
was made without authority from the people, when that fact is once
made clear to the Court.
Exactly the same attitude was taken by the Court in relation to an
income tax and a federal limitation on a national power given to
impose direct taxation.
When that federal limitation was imposed it was aimed only at
taxation on land and at what were then known as “poll” or
“capitation” taxes. In the days of the “conventions” where we have
sat, all other kinds of taxation were deemed to be indirect taxation.
In the very early days of the Supreme Court, this knowledge of the
“convention” days was echoed in decisions which, on that ground,
held that certain taxes, which today might be regarded as direct
taxation, were not within the federal limitation as to apportionment of
direct taxes among the states. Among those taxes, those imposed
without apportionment, were a tax on carriages and receipts of
insurance companies and on the inheritance of real estate. Even as
late as the days of the Civil War, when a tax was imposed upon
incomes and without apportionment among states, the Supreme
Court held that such tax was not a direct tax within the meaning of
“direct tax” to those who imposed the federal limitation.
Nevertheless, when the income tax law of 1894 had been enacted,
its opponents again carried to the Supreme Court the claim that it
violated the federal limitation on the power of direct taxation,
because it did not apportion the tax among the states. And the
Supreme Court, by a divided vote and on the ground that a tax on
the income from land was a tax on the land itself and consequently a
direct tax, held the Income Tax Law of 1894 to be void. It was by
reason of this decision that the Sixteenth Amendment was proposed
and adopted, making the federal change in the Constitution that lifted
the federal limitation from the national power of direct taxation
insofar as a tax on incomes was concerned.
In these decisions, as in the many others which have followed the
same clear American concept of duty and power, the Supreme Court
has always known and followed the reason stated by Hamilton for its
existence as part of the limited government of the one American
people.
In Federalist, Nos. 78 and 81, appealing to the Americans to make
the Constitution, Hamilton points out that the Constitution does not
authorize the Supreme Court to exercise its will to make the law
what the Court thinks it ought to be, but does impose upon the Court
the duty of exercising its judgment to ascertain what the law has
been made by those competent to make it. And then he points out
that the Supreme Court, in this Constitution of a self-governing
people, is made the great bulwark of the people against legislative
encroachment upon the rights or powers of the people reserved to
themselves.
This knowledge of Hamilton has been the knowledge of the
Supreme Court from its institution. It has been reiterated and
explained and expounded in that Court from the days of Marshall to
our own day. It has become part and parcel of the great traditions of
that Court, which are the foundation of the great respect which the
average American citizen pays to its decisions and its authority as
his own great protection against usurpation of power by other
departments of his various governments.
And so the average American citizen will look forward with
certainty to the decision of that Court when the real challenge is
made to the existence of the Eighteenth Amendment by an American
who does know and assert the plain facts which mean that either
there is no Eighteenth Amendment or there never has been an
American citizen. It is simple fact that the existence of the Eighteenth
Amendment, that government-made constitution of government of
men, is absolutely incompatible with the existence of a citizen of
America. It is simple fact that the Fifth Article did not grant to state
governments or to any governments the ability to make Articles like
the First Article or the Eighteenth Amendment, or else the Fifth
Article made all Americans “subjects” of a part of the state
governments, with omnipotent ability in those governments to
legislate for Americans “in all matters whatsoever.”
And it is simple fact that the Supreme Court must and will—when
the real challenge is at last made—decide that the Eighteenth
Amendment is not in the national part of the American Constitution
because it was made by governments and not by the “conventions”
of the Fifth Article. Otherwise, in the face of history, in the face of the
record of the “conventions” of the American citizens, and in the face
of all that the Supreme Court has hitherto decided, the Court must
decide that the American citizen has never existed. The possibility
that there should be such a decision is absolutely beyond
conception.
What the decision will be was long ago foreshadowed and forecast
by Daniel Webster. It would almost seem as if Webster had heard
the Sheppard claim that the states made the Constitution and that
the states had then agreed between themselves that the
governments of thirty-six of the states, in combination, could
command the American citizen in any matter of his individual
freedom. It would almost seem as if Webster had heard Hughes
deny, while his associate lawyers for the Eighteenth Amendment still
asserted with Sheppard, that the Constitution was a compact
between states and then had heard them all insist that the Fifth
Article was a “grant” which made thirty-six governments of state
citizens an omnipotent Parliament over all citizens of America.
“When the gentleman says, the Constitution is a compact between
the states, he uses language exactly applicable to the old
Confederation. He speaks as if he were in Congress before 1789.
He describes fully that old state of things then existing. The
Confederation was, in strictness, a compact; the states, as states,
were parties to it. We had no other general government. But that was
found insufficient, and inadequate to the public exigencies. The
people were not satisfied with it, and undertook to establish a better.
They undertook to form a general government which would stand on
a new basis—not a confederacy, not a league, not a compact
between states, but a constitution; a popular government, founded in
popular election, directly responsible to the people themselves, and
divided into branches, with prescribed limits of power, and
prescribed duties. They ordained such a government; they gave it
the name of a constitution; and therein they established a distribution
of powers between this, their general government, and their several
state governments. When they shall have become dissatisfied with
this distribution, they can alter it. Their own power over their own
instrument remains. But until they shall alter it, it must stand as their
will, and is equally binding on the general government and on the
states.” (Webster’s concluding remarks in the reply to Hayne, 4 Ell.
Deb. 518.)
Is not the same doctrine certain from the Court which knew the
whole Constitution so well that it decided, in the important case of
Barron v. Mayor of Baltimore, supra, p. 376, that the entire
Constitution gave no power of any kind to the state governments? Is
not the same doctrine certain from the Court which held:
The powers the people have given to the General
Government are named in the Constitution, and all not there
named, either expressly or by implication, are reserved to the
people, and can be exercised only by them, or upon further
grant from them. (Turner v. Williams, 194 U. S. 279 at 296.)
When the real challenge to the Eighteenth Amendment is
presented before that Court, it will be necessary for the defenders of
the Amendment to abandon the disguise in which they attempt to
conceal the real nature of their Tory concept. No one of them has
been bold enough to state in words the real claim about the Fifth
Article. That real claim is that the Article is a “grant” and that the
“grant” gives to thirty-six governments of state citizens unrestricted
ability to interfere with the freedom of the American citizen on every
subject enumerated in the First Article and on every subject not
enumerated in the First Article. That is not the way any defender of
the Amendment states his claim. It is always stated that those thirty-
six governments can change the Constitution by putting into it
anything which the American citizens, assembled in their
“conventions,” can put into it. Our education with the Americans in
the “conventions” has taught us that both statements are exactly the
same statement. If the thirty-six state governments can make the
command to the American citizens which is embodied in the First
Section of the Eighteenth Amendment, by putting that command into
the national part of our Constitution, any thirty-six state legislatures
can make any command to the American citizens on any subject
enumerated or not enumerated in the First Article. The claim, that the
Fifth Article “grants” to the thirty-six state governments the right to
put the command in the Constitution, is identical with the claim that
the Fifth Article “grants” to the state governments the right to make
the command to the citizens of America. A legislative command to
human beings, interfering with their individual freedom, is a
legislative command by whatever name it may be called. Mere
omission to call a legislative command by the usual names, an “Act”
or “Statute,” cannot alter its essential nature.
From June 21st, 1788, the birthday of the American nation of men,
there has been but one possible answer to the question which is the
title of this book. That one answer was known to everyone in the
“conventions” which made the Fifth Article. The Americans in those
conventions all knew that they were becoming “citizens” of America,
not “subjects” of any governments. They knew that they were
dispensing part of the power of the American citizens to Congress in
the First Article; and that the rest of that power they were reserving
to themselves. They knew that they were giving no power whatever
to the state governments with whom they never deal except to
command those governments.
That is why Pendleton, in the Virginia convention, made his
statement of fact in the oratorical form of a question, because the
one answer to the question was known and “felt and acknowledged
by all.” His statement of fact, made in the oratorical form of a
question, is, in substance, exactly the title of this book:
“Who but the people can delegate powers?... What have the state
governments to do with it?” (3 Ell. Deb. 37.)
 APPENDICES

APPENDIX I
THE ORIGINAL CONSTITUTION OF THE UNITED STATES

We the People of the United States, in Order to form a more

perfect Union, establish Justice, insure domestic Tranquility, provide
for the common defence, promote the general Welfare, and secure
the Blessings of Liberty to ourselves and our Posterity, do ordain and
establish this Constitution for the United States of America.

Article. I.

Section, 1. All legislative Powers herein granted shall be vested in

a Congress of the United States, which shall consist of a Senate and
House of Representatives.
Section. 2. The House of Representatives shall be composed of
Members chosen every second Year by the People of the several
States, and the Electors in each State shall have the Qualifications
requisite for Electors of the most numerous Branch of the State
Legislature.
No Person shall be a Representative who shall not have attained
to the Age of twenty five Years, and been seven Years a Citizen of
the United States, and who shall not, when elected, be an Inhabitant
of that State in which he shall be chosen.
Representatives and direct Taxes shall be apportioned among the
several States which may be included within this Union, according to
their respective Numbers, which shall be determined by adding to
the whole Number of free Persons, including those bound to Service
for a Term of Years, and excluding Indians not taxed, three fifths of
all other Persons. The actual Enumeration shall be made within
three Years after the first Meeting of the Congress of the United
States, and within every subsequent Term of ten Years, in such
Manner as they shall by Law direct. The Number of Representatives
shall not exceed one for every thirty Thousand, but each State shall
have at Least one Representative; and until such enumeration shall
be made, the State of New Hampshire shall be entitled to chuse
three, Massachusetts eight, Rhode-Island and Providence
Plantations one, Connecticut five, New-York six, New Jersey four,
Pennsylvania eight, Delaware one, Maryland six, Virginia ten, North
Carolina five, South Carolina five, and Georgia three.
When vacancies happen in the Representation from any State, the
Executive Authority thereof shall issue Writs of Election to fill such
Vacancies.
The House of Representatives shall chuse their Speaker and other
Officers; and shall have the sole Power of Impeachment.
Section. 3. The Senate of the United States shall be composed of
two Senators from each State, chosen by the Legislature thereof, for
six Years; and each Senator shall have one Vote.
Immediately after they shall be assembled in Consequence of the
first Election, they shall be divided as equally as may be into three
Classes. The Seats of the Senators of the first Class shall be
vacated at the Expiration of the second Year, of the second Class at
the Expiration of the fourth Year, and of the third Class at the
Expiration of the sixth Year, so that one third may be chosen every
second Year; and if Vacancies happen by Resignation, or otherwise,
during the Recess of the Legislature of any State, the Executive
thereof may make temporary Appointments until the next Meeting of
the Legislature, which shall then fill such Vacancies.
No Person shall be a Senator who shall not have attained to the
Age of thirty Years, and been nine Years a Citizen of the United
States, and who shall not, when elected, be an Inhabitant of that
State for which he shall be chosen.
 The Vice President of the United States shall be President of the
Senate, but shall have no Vote, unless they be equally divided.
The Senate shall chuse their other Officers, and also a President
pro tempore, in the Absence of the Vice President, or when he shall
exercise the Office of President of the United States.
The Senate shall have the sole Power to try all Impeachments.
When sitting for that Purpose, they shall be on Oath or Affirmation.
When the President of the United States is tried the Chief Justice shall
preside: And no Person shall be convicted without the Concurrence
of two thirds of the Members present.
Judgment in Cases of Impeachment shall not extend further than
to removal from Office, and disqualification to hold and enjoy any
Office of honor, Trust or Profit under the United States: but the Party
convicted shall nevertheless be liable and subject to Indictment,
Trial, Judgment and Punishment, according to Law.
Section. 4. The Times, Places and Manner of holding Elections for
Senators and Representatives, shall be prescribed in each State by
the Legislature thereof; but the Congress may at any time by Law
make or alter such Regulations, except as to the Places of chusing
Senators.
The Congress shall assemble at least once in every Year, and
such Meeting shall be on the first Monday in December, unless they
shall by Law appoint a different Day.
Section. 5. Each House shall be the Judge of the Elections,
Returns and Qualifications of its own Members, and a Majority of
each shall constitute a Quorum to do Business; but a smaller
Number may adjourn from day to day, and may be authorized to
compel the Attendance of absent Members, in such Manner, and
under such Penalties as each House may provide.
Each House may determine the Rules of its Proceedings, punish
its Members for disorderly Behaviour, and, with the Concurrence of
two thirds, expel a Member.
 Each House shall keep a Journal of its Proceedings, and from time
to time publish the same, excepting such Parts as may in their
Judgment require Secrecy; and the Yeas and Nays of the Members
of either House on any question shall, at the Desire of one fifth of
those Present, be entered on the Journal.
Neither House, during the Session of Congress, shall, without the
Consent of the other, adjourn for more than three days, nor to any
other Place than that in which the two Houses shall be sitting.
Section. 6. The Senators and Representatives shall receive a
Compensation for their Services, to be ascertained by Law, and paid
out of the Treasury of the United States. They shall in all Cases,
except Treason, Felony and Breach of the Peace, be privileged from
Arrest during their Attendance at the Session of their respective
Houses, and in going to and returning from the same; and for any
Speech or Debate in either House, they shall not be questioned in
any other Place.
No Senator or Representative shall, during the Time for which he
was elected, be appointed to any civil Office under the Authority of
the United States, which shall have been created, or the
Emoluments whereof shall have been encreased during such time;
and no Person holding any Office under the United States, shall be a
Member of either House during his Continuance in Office.
Section. 7. All Bills for raising Revenue shall originate in the House
of Representatives; but the Senate may propose or concur with
Amendments as on other Bills.
Every Bill which shall have passed the House of Representatives
and the Senate, shall, before it become a Law, be presented to the
President of the United States; If he approve he shall sign it, but if
not he shall return it, with his Objections to that House in which it
shall have originated, who shall enter the Objections at large on their
Journal, and proceed to reconsider it. If after such Reconsideration
two thirds of that House shall agree to pass the Bill, it shall be sent,
together with the Objections, to the other House, by which it shall
likewise be reconsidered, and if approved by two thirds of that
House, it shall become a Law. But in all such Cases the Votes of
both Houses shall be determined by yeas and Nays, and the Names
of the Persons voting for and against the Bill shall be entered on the
Journal of each House respectively. If any Bill shall not be returned
by the President within ten Days (Sundays excepted) after it shall
have been presented to him, the Same shall be a Law, in like
Manner as if he had signed it, unless the Congress by their
Adjournment prevent its Return, in which Case it shall not be a Law.
Every Order, Resolution, or Vote to which the Concurrence of the
Senate and House of Representatives may be necessary (except on
a question of Adjournment) shall be presented to the President of the
United States; and before the Same shall take Effect, shall be
approved by him, or being disapproved by him, shall be repassed by
two thirds of the Senate and House of Representatives, according to
the Rules and Limitations prescribed in the Case of a Bill.
Section. 8. The Congress shall have Power To lay and collect
Taxes, Duties, Imposts and Excises, to pay the Debts and provide for
the common Defence and general Welfare of the United States; but
all Duties, Imposts and Excises shall be uniform throughout the
United States;
To borrow Money on the credit of the United States;
To regulate Commerce with foreign Nations, and among the
several States, and with the Indian Tribes;
To establish an uniform Rule of Naturalization, and uniform Laws
on the subject of Bankruptcies throughout the United States;
To coin Money, regulate the Value thereof, and of foreign Coin,
and fix the Standard of Weights and Measures;
To provide for the Punishment of counterfeiting the Securities and
current Coin of the United States;
To establish Post Offices and post Roads;
To promote the Progress of Science and useful Arts, by securing
for limited Times to Authors and Inventors the exclusive Right to their
respective Writings and Discoveries;
To constitute Tribunals inferior to the supreme Court;
 To define and punish Piracies and Felonies committed on the high
Seas, and Offences against the Law of Nations;
To declare War, grant Letters of Marque and Reprisal, and make
Rules concerning Captures on Land and Water;
To raise and support Armies, but no Appropriation of Money to that
Use shall be for a longer Term than two Years;
To provide and maintain a Navy;
To make Rules for the Government and Regulation of the land and
naval Forces;
To provide for calling forth the Militia to execute the Laws of the
Union, suppress Insurrections and repel Invasions;
To provide for organizing, arming, and disciplining, the Militia, and
for governing such Part of them as may be employed in the Service
of the United States, reserving to the States respectively, the
Appointment of the Officers, and the Authority of training the Militia
according to the discipline prescribed by Congress;
To exercise exclusive Legislation in all Cases whatsoever, over
such District (not exceeding ten Miles square) as may, by Cession of
particular States, and the Acceptance of Congress, become the Seat
of the Government of the United States, and to exercise like
Authority over all Places purchased by the Consent of the
Legislature of the State in which the Same shall be, for the Erection
of Forts, Magazines, Arsenals, dock-Yards, and other needful
Buildings;—And
To make all Laws which shall be necessary and proper for carrying
into Execution the foregoing Powers, and all other Powers vested by
this Constitution in the Government of the United States, or in any
Department or Officer thereof.
Section. 9. The Migration or Importation of such Persons as any of
the States now existing shall think proper to admit, shall not be
prohibited by the Congress prior to the Year one thousand eight
hundred and eight, but a Tax or duty may be imposed on such
Importation, not exceeding ten dollars for each Person.