1: Newborn male infant evaluation and care

Question 1

Tobacco

Answer 1

• Maternal tobacco use during pregnancy increases the risk for low birth weight in the fetus.
• There are no characteristic facial abnormalities associated with maternal tobacco use during pregnancy.

Question 2

Alcohol

Answer 2

• There is no “safe” amount of alcohol that can be consumed during pregnancy to ensure that fetal alcohol syndrome does not occur.
• FAS is a distinct pattern of facial abnormalities, growth deficiency, and evidence of CNS dysfunction.
• Victims of FAS may exhibit cognitive disability and learning problems (i.e., difficulties with memory, attention, and judgment) as well as neurobehavioral deficits such as poor motor skills and impaired hand-eye coordination.

Question 3

Marijuana

Answer 3

distinctive effects havent been identified

Question 4

Heroin and other opiate medications

Answer 4

• Maternal heroin use is assoc w/ inc r/o fetal growth restriction, placental abruption, fetal death, preterm labor and intrauterine passage of meconium.
• All infants born to women who use opioids during pregnancy should be monitored for symptoms of neonatal abstinence syndrome (i.e. uncoordinated sucking reflexes leading to poor feeding, irritability, and high- pitched cry) and treated if indicated.

Question 5

Cocaine and Other Stimulants

Answer 5

• cause vasoconstriction leading to placental insufficiency and low birth weight
• National Institute on Drug Abuse notes that “exposure to cocaine during fetal development may lead to subtle, yet significant, later deficits in some children, including deficits in some aspects of cognitive performance, information processing, and attention to tasks abilities that are important for success in school.”

Question 6

SGA

Answer 6

Newborns who are noted to be smaller than expected for their gestational age are considered small for gestational age (SGA).

Question 7

Although they are not synonymous, SGA is often used interchangeably with

Answer 7

-Fetal growth restriction-Intrauterine growth retardation (noted d/r pregnancy) and/or -Intrauterine growth restriction (IUGR);

Question 8

Etiologies of SGA at Birth (1/4)-Maternal Factors

Answer 8

• Both young and advanced maternal age
• Maternal prepregnancy short stature and thinness
• Poor maternal weight gain during the latter third of pregnancy
• Nulliparity
• Failure to obtain normal medical care during pregnancy
• Cigarette smoking, cocaine use, other substance abuse
• Lower socioeconomic status-African-American ethnicity (in the U.S.)-Uterine and placental abnormalities (see below)
• Polyhydramnios

Question 9

Etiologies of SGA at Birth (2/4)-Fetal factors

Answer 9

-Chromosomal abnormalities (e.g., trisomies) and syndromes -Metabolic disorders-Congenital infections (e.g., “TORCH” infections: Toxoplasmosis, “Others”, Rubella, Cytomegalovirus, and Herpes simplex type 2. Examples of “Others” include HIV, Hepatitis B, Human parvovirus, Syphilis and Zika. )-Structural abnormalities

Question 10

Etiologies of SGA at Birth (3/4)-medications and other exposures

Answer 10

-Amphetamines-Antimetabolites (e.g., aminopterin, busulfan, methotrexate) -Bromides-Cocaine-Ethanol-Heroin and other narcotics (e.g., morphine, methadone)-Hydantoin-Isotretinoin-Metal (e.g., mercury, lead)-Phencyclidine-Polychlorinated biphenyls (PCBs)-Propranolol-Steroids-Tobacco (carbon monoxide, nicotine, thiocyanate) -Toluene-Trimethadione-Warfarin

Question 11

Etiologies of SGA at Birth (4/4)-Uterine and placental abnormalities

Answer 11

-Avascular villi-Decidual or spiral artery arteritis-Infectious villitis (as with congenital or TORCH* infections)-Multiple gestation (limited endometrial surface area, vascular anastomoses) -Multiple infarctions-Partial molar pregnancy-Placenta previa and abruption-Single umbilical artery-Umbilical thrombosis-Abnormal umbilical vascular insertions-Syncytial knots-Tumors, including chorioangioma and hemangiomas

Question 12

Maternal GBS Facts (1/2)

Answer 12

-GBS infection is a major cause of neonatal bacterial sepsis.-The incidence of early onset GBS disease is 0.6/1000 live births.-30% of pregnant women have vaginal or rectal colonization of GBS.

Question 13

Maternal GBS Facts (2/2)

Answer 13

-Sans antibacterial ppx 1-2% of infants born to colonized women develop invasive disease (sepsis, pna and meningitis).-RF for early onset GBS dz include prolonged rupture of membranes, prematurity, intrapartum fever and previous delivery of infant who developed GBS dz.

Question 14

The management of babies born to mothers who are colonized with Group B streptococcus depends on a number of factors (5)

Answer 14

-Clinical appearance-Evidence of maternal chorioamnionitis-Receipt of GBS prophylactic antibiotics by mother during labor -Duration of membrane rupture greater than 18 hours-Gestational age less than 37 weeks

Question 15

NBN management of GBS: Any infant who is ill appearing

Answer 15

undergo a full diagnostic evaluation (CBC, blood culture, chest x-ray and lumbar puncture) and receive IV antibiotics.

Question 16

NBN management of GBS: Well appearing infants

Answer 16

undergo a limited laboratory evaluation (CBC and blood culture) or simply be closely monitored over the first few days of life

Question 17

Components of Apgar score include

Answer 17

-Appearance (skin color)-Pulse (heart rate)-Grimace (reflex irritability)-Activity (muscle tone)-Respiration

Question 18

The change in Apgar score between 1 and 5 min

Answer 18

may be a useful indicator of response to resuscitation.

Question 19

a score below 7 at 5 min should prompt

Answer 19

continued resuscitation, with re-assessment every 5 min, up to 20 min, until a score of 7 is achieved.

Question 20

Ballard assessment tool

Answer 20

uses signs of physical and neuromuscular maturity to estimate gestational age.

Question 21

Small for gestational age (SGA)

Answer 21

Weight below the 10th percentile for gestational age

Question 22

Term

Answer 22

Born at > 37 weeks’ gestation

Question 23

Symmetric IUGR

Answer 23

growth pattern in which head, length, and weight are decreased proportionately. Congenital infections may adversely affect brain growth and often result in symmetrical IUGR.

Question 24

Asymmetric IUGR

Answer 24

-greater dec in the size of the length and/or weight without affecting head circumference (“head-sparing phenomenon”).-Poor delivery of nutrition to the fetus (example maternal smoking) often results in asymmetric IUGR

Question 25

Risks for SGA NBN (1/3): hypoglycemia

Answer 25

Etiology:-Decreased glycogen stores-Heat loss -Possible hypoxia-Decreased gluconeogenesiss/s: Commonly asymptomatic, though may exhibit poor feeding and listlessness

Question 26

Risks for SGA NBN (2/3): hypothermia

Answer 26

Etiology:-Cold stress-Hypoxia-Hypoglycemia-Increased surface area-Decreased subcutaneous insulations/s: Commonly asymptomatic, though may exhibit poor feeding and listlessness

Question 27

Risks for SGA NBN (3/3): Polycythemia

Answer 27

Etiology: -Chronic hypoxia-Maternal-fetal transfusions/s: -“Ruddy” or red color to skin-Respiratory distress -Poor feeding -Hypoglycemia

Question 28

Discharge teaching should include the following

Answer 28

-Reasons to seek immediate medical care, including fever, signs of poor feeding, worsening jaundice-Expectations for nml feeding, stooling, UOP-Safety issues (including placing the newborn on his back to sleep, proper infant auto restraint, avoiding cigarette smoke exposure.)-Plan for physician outpatient followup in 48-72 hrs -Social Services f/u plan-24 hr emergency contact info

Question 29

In addition to remembering the ABCs (or airway-breathing-circulation), keep in mind some of the special features of newborn resuscitation

Answer 29

-Use universal precautions-WARM & DRY the infant and remove any wet linens immediately. Infants have a large surface area relative to their body weight and can thus experience significant hypothermia from evaporation.-STIMULATE the infant to elicit a vigorous cry. This helps clear the lungs and mobilize secretions.-SUCTION amniotic fluid from the infant’s nose and mouth. This helps clear the upper airway.-INITIATE FURTHER resuscitation if required. This may include using blow-by oxygen, positive pressure (bag- valve mask) ventilation with oxygen, chest compressions, and medications.

Question 30

Demonstration of Primitive Reflexes (1/6): Rooting

Answer 30

Newborn turns his head toward your finger when you touch his cheek.

Question 31

Demonstration of Primitive Reflexes (2/6): Sucking

Answer 31

Newborn sucks on your finger when you touch the roof of his mouth.

Question 32

Demonstration of Primitive Reflexes (3/6): Startle (Moro)

Answer 32

Support NBN’s head w/ 1 hand and butt w/ the other. W/ the head in a midline position, the hand supporting it is quickly dropped to a position approx 10 cm below its original supporting position, and the head is caught in its new position. In response, the newborn will flex his thighs and knees, fan and then clench his fingers, with arms first thrown outward and then brought together as though embracing something.

Question 33

Demonstration of Primitive Reflexes (4/6): Palmar and Plantar Grasps

Answer 33

-Newborn grasps your finger when you stroke it against the palm of his hand or plantar surface of his foot.

Question 34

Demonstration of Primitive Reflexes (5/6): Asymmetrical Tonic Neck Response

Answer 34

Turning the newborn’s head to one side causes gradual extension of arm toward direction of infant’s gaze with contralateral arm flexion–like a fencer.

Question 35

Demonstration of Primitive Reflexes (6/6): Stepping Response

Answer 35

Newborn’s legs make a stepping motion when you hold him vertically above the table and stroke the dorsum of his foot against the table edge.

Question 36

Red Reflex Examination in Neonates: How?

Answer 36

turn off the room lights and stand at least a foot away from the child’s face with the illuminated ophthalmoscope

Question 37

Infants with more darkly pigmented skin

Answer 37

light golden colored or silver-tinged “red reflex.”

Question 38

An absent red reflex (no reflection noted) may be caused by

Answer 38

-A cataract-An opacified cornea (such as in mucopolysaccharidosis)-Inflammation of the anterior chamber-Developmental anomalies of the eye-Retinoblastoma, a potentially lethal malignancy (careful examination of the eye of an infant with retinoblastoma often identifies a white, irregular mass within the globe).

Question 39

Treating Neonates to Prevent Hemorrhagic Disease of the Newborn

Answer 39

intramuscular administration of Vitamin K at birth

Question 40

Type of VKDB-early (0-24h after birth)

Answer 40

-Severe-Mainly found in infants whose mothers used medications (e.g antiepileptic drugs or isoniazid) that interfere with how the body uses vitamin K

Question 41

Type of VKDB-classical (1-7d after birth)

Answer 41

-Bruising-Bleeding from the umbilical cord

Question 42

Type of VKDB-late (2-12 weeks after birth is typical, but can occur up to 6 months of age in previously healthy infants)

Answer 42

-30-60% of infants have bleeding within the brain-Tends to occur in breastfed only babies who have not received the vitamin K shot-Warning bleeds are rare

Question 43

Infants weighing more than 2000 grams born to mothers positive for hepatitis B surface antigen (HBsAg):

Answer 43

-Should receive hep B vaccine + hep B immune globulin (HBIG) within 12h of delivery.-Additionally, these infants should receive routine series of the vaccine beginning at age 1 mo. -Vertical transmission can be prevented in 85-95% of cases using these interventions.-At 9-18 mo, child should be tested for anti-HBs (Ab to Hep B surface antigen) and HBsAg, and, if found to have inadequate antibody protection, should be re-immunized.

Question 44

Infants born to mothers not tested for HBsAg:

Answer 44

-Should receive hep B vaccine within 12h of delivery.Administration of HBIG can be delayed until the maternal HBsAg is known, and is effective if given within 7 days following delivery if the patient is greater than 2 kg at birth.

Question 45

identifying and teating N gonorrhea why is it important

Answer 45

because ophthalmia neonatorum can result in perforation of the globe of the eye and blindness.

Question 46

Chlamydia trachomatis conjunctivitis in newborns

Answer 46

more common than gonococcal, but chlamydia typically occurs at 7-14 days after birth, and neonatal prophylaxis does little to prevent chlamydia conjunctivitis

Question 47

Routine NBN Meds (1/3): Vit K

Answer 47

NBN routinely receive an intramuscular injection of vit K to prevent hemorrhagic disease of the newborn (also referred to as vitamin K deficiency bleeding/VKDB). The efficacy of oral Vitamin K is unknown.

Question 48

Routine NBN Meds (2/3): Hep B vaccine

Answer 48

consider:-maternal Hepatitis B status (HBsAg positive, status unknown or HBsAg negative) -weight of NBN (>/< 2000g) ….when deciding the timing of the first dose of Hep B vaccine and whether or not Hep B Ig is needed to dec risk for vertical transmission

Question 49

Routine NBN Meds (3/3): Erythromycin (also tetracycline or silver nitrate)

Answer 49

One of these antibiotics is administered topically to prevent gonococcal conjunctivitis.

Question 50

Look for the following prenatal screening lab tests in the maternal record:

Answer 50

-Maternal blood type, Rh and antibody screen -Rubella IgG-Hepatitis B Surface Antigen (HBSAg)-HIV antibody-RPR or VDRL-Urinalysis-Urine nucleic acid amplification testing (NAAT) for chlamydia and gonococcus -Urine or vaginal culture for group B streptococcus-Hepatitis C antibody (in women with a history of IV drug use)-TB skin test (e.g. Mantoux) or TB blood test (e.g. Quantiferon) (in women w/ HIV or who live w/ someone w/ active TB)

Question 51

A 33-year-old G1P0 female with a history of medically controlled seizures gives birth vaginally to a boy with IUGR at 38 weeks’ gestation. The newborn is noted to have dysmorphic cranial features and his head circumference is 28.5 cm (< 5th percentile). What is another associated abnormality you might expect to see in this newborn?

Answer 51

The mother was on an anticonvulsant for her seizures. Taking anticonvulsants during pregnancy may lead to cardiac defects, dysmorphic craniofacial features, hypoplastic nails and distal phalanges, IUGR, and microcephaly. Mental retardation may be seen. A rare neonatal side effect is methemoglobinuria.

Question 52

A 19-year-old female in her 38th week of pregnancy goes into active labor. Shortly after birth her baby is noted to have a high-pitched cry, tremulousness, hypertonicity, and feeding difficulties. The baby is otherwise developmentally normal and the remainder of the physical exam also is normal. What is the drug the baby’s mother likely used during her pregnancy?

Answer 52

Heroin is the correct choice. Opiate use during pregnancy may result in several different symptoms, including CNS findings (irritability, hyperactivity, hypertonicity, incessant high-pitched cry, tremors, seizures), GI symptoms (vomiting, diarrhea, weight loss, poor feeding, incessant hunger, excessive salivation), and respiratory findings (including nasal stuffiness, sneezing, and yawning).

Question 53

A mother brings her 20-day-old male infant to your clinic for the child’s first visit. You learn that the infant was born at home to a 28-year-old G1P1, and the infant has not yet received newborn screening. During your history, you learn that the infant has been vomiting 2 to 3 times per day, and the mother reports that her son seems fussier than her friends’ infants. On exam, you note an eczematous rash and a musty odor to the infant’s skin and urine. Which enzyme deficiency would you expect the infant to display?

Answer 53

This infant likely has phenylketonuria (PKU), an autosomal recessive disorder of amino acid metabolism caused by a deficiency in the enzyme phenylalanine hydroxylase. Affected infants are normally detected by newborn screening, but can present with vomiting, hypotonia, musty odor, developmental delay, and decreased pigmentation of the hair and eyes. The best developmental outcomes occur if a phenylalanine-restricted diet is initiated in infancy.