B8.067 Decision Making in the Newborn Flashcards
neonatal dilemmas by frequency
- rashes
- jaundice
- early discharge
- hypoglycemia
- tachypnea
- DDH
- sepsis (GBS)
- failure to stool/ urinate
what is a late preterm infant
birth between 34 and 36w6d gestation
often the size and weight of term infants
the “problem” with late, preterm infants
treatment by caregivers and parents as if they are developmentally mature
evidence indicates higher risk of mortality and morbidity and hospital readmissions
what types of issues are late preterm infants more at risk for?
airway instability apnea and bradycardia excessive sleepiness excessive weight loss feeding intolerance hyperbilirubinemia hypoglycemia hypothermia immature self regulation respiratory distress sepsis weak suck
what should be the first step if a neonate appears jaundiced?
order a serum bilirubin
function of phototherapy
converts bilirubin into a soluble form for excretion
at what serum bili level is jaundice appreciated visually
around 5 mg/dl
at what stage of life is jaundice ALWAYS pathologic
<24 hours old
how is risk of kernicterus assessed
age in hours compared to serum bili level
options:
-phototherapy
-exchange transfusion
root causes of kernicterus
early discharge (<48 hr) with no early follow up, esp in late pre term infants
failure to check bili in infants noted to be jaundiced in first day of life
failure to recognize risk factors for jaundice
underestimating severity of jaundice by visual assessment
lack of concern
delay in measurement of bili or initiation of phototherapy
failure to respond to parental concern
obstetrical risk factors for nonhemolytic hyperbilirubinemia
previously jaundiced sibling east asian race infant of a diabetic mother bruising, cephalohematoma, vacuum extraction (due to breakdown of Hgb) <37 weeks gestation maternal age > 24
neonatal risk factors for nonhemolytic hyperbilirubinemia
breast feeding male caloric deprivation- weight loss > 25% jaundice before discharge increased hemolysis crigler-najjar hospital stay <72 hrs bilirubin >75% for age
what is the bhutani nomogram
plots age vs serum bilirubin to stratify risk of significant hyperbilirubinemia requiring intervention
what can WE do to prevent kernicterus
dont ignore visible jaundice on first day
check curves for risk
check levels
follow babies discharged in <72 hrs in 24-48 hrs
dont ignore phone calls
don’t delay treatments
maternal risk factors of GBS
positive maternal GBS culture of vagina or rectum
previous infant who had invasive GBS disease
GBS bacteriuria during this pregnancy
delivery at <37 wks
intrapartum fever (>38)
rupture of membranes >18 hrs
full GBS evaluation
CBC w diff blood culture chest Xray lumbar puncture treat
limited GBS evaluation
CBC w diff
blood culture
observe >48 hr
when do you do a full GBS eval
signs of neonatal sepsis!!!
when do you do a limited GBS eval
maternal chorioamionitis
OR
if mother should have received GBS prophylaxis and didnt + neonate is <37 wks and membrane rupture was > 18 hrs
when do you observe for >48 hrs due to GBS risk
if GBS prophylaxis is indicated for the mother AND it was received properly
OR it wasn’t received but the baby is >37 weeks and membrane rupture was < 18 hrs
what is GBS prophylaxis for a mother
IV penicillin, ampicillin, or cefazolin for >4 hrs before delivery
goals of treatment of hypoglycemia in newborn
normalize blood glucose rapidly
maintain blood glucose until normal homeostasis is established
normal treatment of newborn hypoglycemia
enteral feedings
-if baby is term, asymptomatic, and has a good suck
use formula or breast milk (D20)
if next glucose level is <40, enteral feeding should be considered unsuccessful > go to IV
IV treatment of newborn hypoglycemia
bolus 2cc/kg D10W (highest level IV can go) continuous infusion baseline: 4-8 mg/kg/min 100 cc/kg/day of D5W check glucose at 30, 60, and 120 min
follow up on treatment of hypoglycemia
if preprandial glucose > 50 for 12-24 hrs, start to wean
decrease infusion rate by 10-20%
if weaning not possible, look for persistent problem
groups of risk factors for hypoglycemia
- limited glycogen
- hyperinsulinism
- unknown
- large for gestational age
- sepsis
- polycythemia
reasons for limited glycogen in newborn
small for gestational age
prematurity
birth stress
glycogen storage diseases
reasons for hyperinsulinism in newborn
infant of a diabetic mother beckwith-wiedemann nesidoblastosis pancreatic adenoma Rh disease exchange transfusion drugs urinary catheters
what is neonatal abstinence syndrome
a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb
classic triad of NAS
high pitched cry
tremor
tachypnea
screening for NAS
maternal history
maternal urine drug screen
infant drug screen - can have false negative as it requires recent exposure to be accurate
meconium testing - often not available and not practical as it delays diagnosis
neuro symptoms of NAS
excessive irritiability hyper reflexive decreased sleep increased muscle tone tremors myoclonic jerks seizures
GI symptoms of NAS
diarrhea
regurgitation
poor suckling
autonomic symptoms of NAS
diaphoresis
temp instability
sneezing
mottling
nonpharmacologic treatments for NAS
soothing techniques: swaddling, pacifier, rocking
environment modification (quiet, dark rooms)
maternal education and reassurance
-babies cry for numerous reasons
-maternal guilt
-psych and rehab services for mother
60-80% of infants won’t respond to non-pharma and will need pharma therapy
goal of pharmacotherapy in NAS
relief of signs, such as seizures, weight loss, sufficient to allow parental care of infant
no national standardized guidelines
treatment options vary depending on maternal drug exposure
pharmacotherapy options on NAS
typically, opiates used for opioid exposed infants
may use 2nd line agents as needed
may consider other treatment options if polysubstance use
what is developmental dysplasia of the hip
spectrum of disorders affecting the acetabulum and the proximal femur
dynamic condition, can occur
-prenatally
-postnatally
continuum of pathology/outcomes of developmental dysplasia of the hip
stabilize and become normal
stabilize and remain dysplastic
progress to dislocation
DDH statistics
subluxable hips (14/1000) dislocatable hips (2.5/1000) dislocated hips (1.3/1000)
incidence of DDH
varies by race M:F = 1:6 left =60%, right =20%, bilateral =20% multifactorial breech has up to 23% incidence
impact on fam history on DDH
6% with affected sib
12% with affected parent
36% with affected parent and sib
most reliable screening for DDH
physical exam
physical exam for DDH
child should be warm and relaxed
barlow test and ortolani sign good in first 2 months
-barlow attempts to dislocate an unstable hip (applies adduction and posterior pressure)
-ortolani sign attempts to relocate (applies abduction and anterior pressure on knee)
click = innocent soft tissue sign
clunk = bad
presentation of DDT after 2 months of age
barlow and ortolani are of limited value at this stage limitation of abduction asymmetric skin folds uneven knee heights bilateral dislocations can be misleading
when should you use an US for DDT eval?
after 2 months
better than xray until 6 months
