CLIPP Flashcards
at what age is infant expected to regain brithweight
define failure to thrive
sings of generally adequate nourishment in first few weeks of life
regain brithweight by 2 weeks
-failure to regain birthweight by 3 weeks
-continuous weight loss after 10 days
= failure to thrive
-6 feedings per day
-at least 6 wet diapers per day
= signs of generally adequate nourishment
preferred feeding source for all infants
a rare exceptoin
human milk for all
HIV-infected mother is a rare exception, among others
average newborn weight loss in first few days of life, 2 SDs
6% birth weight lost in first few days on average
11-12% is two standard deviations (10% is typically used as red flag)
encourage this frequency of breastfeeds for newborn
e.g. offering the breast whenever the newborn…
encourage 8-12 feeds per 24 hrs
e. g. offering the breast whenever the newborn shows early signs of hunger
- increased alertness
- increased physical activity
- mouthing
- rooting
how to get an idea of adequacy of breast feeds for newborn
gaining weight
urine and stool output
6-12 wet diapers (half voids, half stools) in first week of life
feeding q2-3 hours for 10-15 minutes is average (concern if 4+ hours between feeds, shorter duration)
formal evaluation of breast feeding performance by trained observers 24-48hrs and 3-5 days after discharge
Vit D supplementation for newborns
breast fed
vs
formula fed
start 400IU vit D po within first few days for breast fed infants
(exclusively formula fed ingesting 1L or one quart of formula will get enough vit D)
Normal anterior fontanelle size
2cm avg diameter
.5-3.5 = 2 sd’s
Newborn hypotonia, large fontanels, an umbilical hernia, and jaundice
Think..
Congenital hypothyroidism
TF
Umbilical hernias and jaundice are more common in newborns with congenital hypothyroidism
T
common anyway, but more common w hypothyroid
Inborn error of metabolism
Pres
Prog
appear well for at least the first 1-2 days of life but then become symptomatic due to the protein load in breast milk or formula.
Initial signs include somnolence and poor feeding, usually followed by vomiting and lethargy.
Without treatment, patients develop a progressive encephalopathy.
Presentstion of hypoglycemia in a newborn
Asymptomatic Vs Hypothermic Irritable Jittery Tremors
S and s of intracranial bleed in shaken baby syndrome
AMS
hypotonia
Poor feeding
Large fontanelles
Bruising and retinal bleeding are possible comirbid signs of abuse (not specifically intracranial bleeding)
The most common form of congenital adrenal hyperplasia, 21-OH deficiency, causes decreased production of ____ and ____
Expect this in the first labs you order
Aldosterone
Cortisol
Hyponatremia
Hyperkalemia
(Salt-wasting)
Causes of congenital hypothyroidism
Iodine deficiency (world wide)
Aplasia hypoplasia ectopia
Mom’s autoimmune abs transplacenta transiently
Mom w graves antithyroid meds transplacenta transiently
Pres of congenital hypothyroidism
Usually a few months after birth because protected by mom’s thyroid home
Feeding problems Decreased activity Constipation Prolonged jaundice Skin mottling Umbilical hernia
With time, if untreated, large tongue, hoarse cry and puffy myxedematous facies.
intellectual disability. The longer treatment is delayed, the greater the risk.
Treat congenital hypothyroidism in newborn
Levothyroxine
- maintain TSH 1 μIU/mL (1mIU/L) and T4 in the upper half of the normal range for age
- aim for normalized TSH by 1-2 mos old for good neurologic outcome
- frequent follow-up
peds endocrinology consult
PKU
presentation
advice for pregnant women with PKU
normal at birth
then fail to attain early developmental milestones
develop microcephaly
progressive cognitive impairment
seizures
albinism
musty odor of sweat and urine (due to phenylacetate).
pregnant women with PKU, maintain low phenylanine levels to protect the developing fetus. Though the developing fetus may only be a carrier of the PKU gene, high intrauterine levels of phenylalanine can result in growth retardation, microcephaly, intellectual disability and congenital heart disease for the child.
So get newborn screening
why is early detection of sickle cell disease important
early institution of penicillin prophylaxis can prevent sepsis secondary to infection with Streptococcus pneumoniae.
A two-month-old female presents to clinic for a well-baby checkup. Mom has been happy because the “baby rarely cries and sleeps all the time.” On exam, the baby has yellowing of the skin, decreased activity, appears to have decreased tone, and a large anterior fontanel. What is the most likely diagnosis?
Congenital hypothyroidism
body temperature change, changes in respiration, increased or decreased heart rate, reduced movement, reduced feeding, low blood sugar, seizures, and jaundice
think..
sepsis (blood infection)
abnormal genitalia (females), poor feeding, vomiting, dehydration, and electrolyte changes think...
congenital adrenal hyperplasia
A 6-week-old infant girl whose family recently immigrated from Mexico is brought to clinic for “excessive sleepiness.” The mother states the infant is not easily aroused for feedings and is not as active as she was previously. She is also concerned about her daughter’s large “outtie” belly button. On exam, the patient is afebrile and jaundiced, with a puffy myxedematous face. The fontanels are large but flat. There is a large umbilical hernia. When asked about the results of a newborn screening exam, mom states that the screening was never performed. What would be an expected abnormal lab value(s) associated with her condition?
High TSH, low T4
A 45-day-old infant is brought in by his mother due to lethargy, constipation, and yellow skin color noted since birth. The mother and the baby moved to the U.S. from a foreign country that does not screen its newborns. The baby has been fed only formula since birth. Physical exam of the neonate reveals additional findings of large fontanelles, umbilical hernia, a large tongue, and abdominal distension. What is the next best step in diagnosis?
TSH
first year of life with hypotonia, lethargy, constipation, weak cry, eventually lead to respiratory failure. absent DTRs.
think…
botulism
ornithine transcarbamylase deficiency
presentation
diagnosis
3-day-old has become lethargic and doesn’t want to feed. She has vomited twice and is showing no interest in feeding. On physical exam you note a lethargic infant with an enlarged liver
Hyperammonemia and elevated urine orotic acid
wheezing in infant think…
give bronchodilators and steroids?
viral respiratory infection
eg RSV - can cause airway inflammation and wheezing in infants
maybe asthma if strong family history and clear response to bronchodilators
but IN GENERAL bonchodilators and steroids are NOT helpful in wheezing infants with VIRAL respiratory illness
3 hallmarks of asthma
Airway inflammation
Mucus hypersecretion, and
Reversible airflow obstruction due to bronchoconstriction.
? Remodeling - some evidence suggests that smooth muscle hyperplasia and hypertrophy develop in the setting of longstanding asthma.
1 sentence summary of clinical manifestation of asthma in majority of children
recurrent coughing and/or wheezing that is responsive to bronchodilators (such as beta-agonists) and to anti-inflammatory medications (such as steroids).
triggers for peds asthma (bronchoconstriction)
URTI most often
also allergies cold air exercise smoke exposure
diagnose asthma in peds
child with symptoms of asthma who responds to therapy for asthma and has no other identifiable cause for wheezing has asthma by definition, regardless of age.
asthma vs RAD reactive airway disease
Many children with wheezing early in life do not continue to wheeze beyond 2 to 3 years. Many physicians are therefore reluctant to make a diagnosis of asthma in very young children, fearing that a child would be persistently labeled as having asthma when in fact their symptoms of this condition have resolved.
Some physicians prefer to use the term “reactive airways disease” (RAD) when children appear to have signs and symptoms of underlying airway hyperresponsiveness that is characteristic of asthma, but in whom a diagnosis of asthma is not yet definite.
The use of this term has been somewhat controversial
what is O2 sat
percent hemoglobin saturation
normal O2 sat in healthy person, by age
^94% regardless of age
how can O2 sat be misleading in asthma
and what to get
compensated asthma, hyperventilation will lead to a decrease in PCO2 of the blood. As a child begins to tire and can no longer maintain adequate ventilation, the PCO2 may normalize and even become elevated despite continued normal oxygenation.
Thus, blood gas analysis can be helpful in distinguishing compensated from uncompensated asthma, and in predicting impending respiratory failure.
the WORST sign of respiratory distress in peds
and others
Paradoxical breathing
-diaphragm contracts hard but chest wall muscles not expanding so chest sucks in and belly flares out
tachypnea
retractions
nasal flaring
head bobbing (neck strap accessory breathing muscles)
grunting (forced expiration against closed glottis… to keep airways open with positive pressure
tachypnea vs
hyperpnea vs
hypopnea
rapid rate deep breathing (inc tidal volume) shallow breathing (dec tidal volume)
when should oxygen be withheld for severe hypoxemia
NEVER
Although some patients with chronic hypercarbia (sometimes referred to as “CO2 retainers”) depend on their hypoxemia for their respiratory drive, oxygen should never be withheld in cases of severe hypoxemia. Rather, these patients should be MONITORED CLOSELY and given ONLY AS MUCH OXYGEN AS THEY NEED to MAINTAIN A REASONABLE SATIRATION. Endotracheal intubation should be reserved for patients in whom respiratory failure is imminent or loss of the airway is anticipated.
4 common
3 less common
causes of wheezing in infants and toddlers
viral bronchiolitis
asthma
foreign body aspiration
GER
- tracheomalacia
- extrinsic compression (vascular ring or sling, or other anatomic airway lesion)
- cystic fibrosis
5 questions to ask wheezing infant or toddler
timing of wheeze
assoc with food
change with position or activity
other exacerbating factors
has it happened in past, if so, did it respond to bronchodilators or steroids
5 common causes of cough in toddlers and infants
Viral upper respiratory tract illnesses
Pneumonia
Post-nasal drip due to allergies and/or sinusitis
Foreign body aspiration
GE reflux
dry cough vs wet/junky cough in infant / toddler
dry cough is typical of CHRONIC ASTHMA
whereas a wet cough suggests the presence of SECRETIONS in the airway, whether due to a viral infection, post-nasal drip, gastroesophageal reflux or bronchiectatic disease such as cystic fibrosis.
TF
wheeze is always expiratory
and
stridor is always inspiratory
f
generally yes, but not always… both can be heard anytime in respiratory cycle
triphasic course of pertussis
initial catarrhal stage lasts 1-2 weeks and is characterized by upper respiratory tract infection symptoms.
paroxysmal stage that follows lasts 4-6 weeks and is characterized by repetitive, forceful coughing episodes followed by massive inspiratory effort, which results in the characteristic “whoop.” Infants generally do not develop a “whoop” due to relative weakness of their inspiratory effort.
The paroxysms of cough gradually decrease in frequency and severity as the convalescent stage is entered. Episodic cough may persist for months.
acellular pertussis vaccine efficacy and longevity
even with full immunization, vaccine efficacy is only 70-90%. Additionally, protection from the vaccine wanes with time such that many adolescents are unprotected from pertussis unless reimmunized
rare causes of epiglottitis now that Hib vaccine is a thing
staphylococcal or streptococcal organisms
TF
absence of fever lowers the likelihood of community-acquired pneumonia but does not eliminate it entirely.
T
stridor is due to…
and occurs in which phase of respiratory cycle…
Due to airway narrowing above the thoracic inlet.
Usually heard with inspiration, but can be biphasic if obstruction is severe
wheezing is due to…
and occurs in which phase of respiratory cycle…
diffuse or focal…
polyphonic vs monophonic…
Typically due to airway narrowing below the thoracic inlet.
With mild airway obstruction, wheezing is usually heard only in expiration.
With increasing obstruction, wheezing may become biphasic and may even disappear altogether when obstruction is severe
Although typically diffuse, focal wheeze may be heard in some settings such as mucus plugging.
Polyphonic wheeze is characterized by multiple pitches and is typical of asthma; monophonic wheeze is characterized by only a single pitch and is typical of focal airway obstruction.
ronchi
what do they sound like
what phase of respiratory cycle
what are they due to
Coarse, low-pitched rattling sounds
heard best in expiration.
Thought to be due to secretions and narrowing of airways.
crackles
cause
coarse vs fine
Finer breath sounds heard on inspiration.
Associated with either fluid in the alveoli or with opening and closing of stiff alveoli (as in interstitial disease).
Sometimes described as either coarse or fine. (COARSE crackles are usually thought to be associated with PURULENTsecretions in the alveoli as with pneumonia; FINE crackles are often associated with pulmonary EDEMA or ILD interstitial lung disease.
bronchial breath sounds
describe
cause
Lower in pitch and more hollow-sounding than normal breath sounds.
Caused by air moving through areas of consolidated lung.
most suggestive physical exam finding for airway foreign body
Significant asymmetry of breath sounds
TF
cough, tachypnea, retractions, and absence of fever all support a diagnosis of an asthma exacerbation
T
TF
Cough, tachypnea, and mild retractions are typical features of bronchiolitis
T
TF
asymmetric breath sounds essentially rules out viral URI (I) as the sole process.
T
imaging to get if suspect airway foreign body in kid
pa lat chest
biilateral decubitus
(each lung deflates when on down-side unless hyperinflated by obstruction)
or
inspiratory/expiratory chest films
(asymmetric deflation with expiration.. but more subtle than bilateral decubitus)
chest fluoroscopy - no need to hold breath, can get dynamic evalutaiton
bronchoscopy down the line here
rigid
vs
flexible
bronchoscopy
rigid bronchoscope is a straight metal tube that can only be inserted through the mouth. It allows one to examine the upper and large airways. Because they can accommodate forceps, rigid bronchoscopes are often used for performing transbronchial biopsies and for removing foreign bodies.
Flexible bronchoscopes can be inserted through either the nose or the mouth, and can be used to visualize more distal airways than can be seen with rigid scopes. Because they are smaller than rigid bronchoscopes, flexible scopes used in young children often cannot accommodate forceps.
All but the very smallest scopes include a suction port and can be used to collect lavage specimens.
Asthma pathophys basics
infiltration of inflammatory cells into the airway mucosa
mucus hypersecretion
mucosal edema - accompanied by bronchoconstriction.
Acute asthma predentation
And if severe…
Cough Dyspnea Tachypnea Wheezing Decreased breath sounds
Quiet/stopped wheezing because poor airflow
Cyanosis
Pulsus paradoxus
Chronic asthma is characterized by …. gimme 2
recurrent dyspnea and cough
Is wheezing in asthma focal or diffuse
Typically diffuse
May get focal wheeze with mucus plugging
3 findings on cxr for asthma
Air trapping
Increased interstitial markings
Patchy atelectasis
coughing with liquids suggests…
vs dysphagia with solids
coughing with liquids suggests aspiration
dysphagia with solids suggests narrowing of posterior oropharynx or esophagus
recurrence of fever several days into a respiratory illness makes you think…
bacterial superinfection
most common cause of wheezing in infants
bronchiolitis
pathophys of bronchiolitis
viral (RSV > influenza and parainfluenza) disease of the lower respiratory tract of infants
characterized by bronchiolar obstruction due to edema, mucus, and cellular debris
signs and symptoms of bronchiolitis
Wide spectrum of disease. Most children initially have mild Upper respiratory tract symptoms and often a fever of 38.5-39 C. Respiratory symptoms can progress to cough, wheezing, dyspnea and irritability…
most common causes of PNA in peds
viral
Adenovirus
RSV
Parainfluenza
Influenza
bacterial less common but more severe
- GBS EColi Klebsiella transmitted from birth canal to neonate
- chlamydia w staccato cough between 4-12wks old
- strep pneumo most common infant - 6yo
- mycoplasma, then strep pneumo in school-age and older children
viral vs bacterial pna presentation in peds
viral
prodrome of URTI including cough and rhinorrhea. The cough frequently progresses, and accompanied by fever, tachypnea, crackles
bacterial
present abruptly or preceded by a viral prodrome. Presentation varies, depending on the age and etiology, but typically fever, cough, and signs of respiratory distress (dyspnea, tachypnea, retractions, etc.), crackles or decreased breath sounds
radiographic findings
viral vs bacterial pna
viral
variable but most characteristic diffuse or patchy interstitial infiltrates, hyperinflation, small pleural effusions
bacterial
most typicallly lobar or segmental consolidation and air bronchograms
labs viral vs bacterial pna
viral
- serum WBC tends to be normal or only slightly elevated
- viral antigen testing of respiratory secretions maybe helpful but usually not necessary
bacterial
-serum WBC elevated, neutrophil predominance
treatment of viral vs bacterial pna
viral
supportive
bacterial
abx
imaging for foreign body aspiration
PA Lat cxr
-coin sign - line on PA if in trachea, flat on PA if in esophagus… opposite on lat
inspiratory and expiratory cxr
-unilateral air trapping hyperinflation (seen best on Expiration) on side of obstruction in mainstem bronchus
PA and R and L lateral decubitus films
- PA hyperinflation on affected side as above
- lateral decubitus mediastinal structures will not fall to decubitus side when lying on hyperinflated obstructed side
All vs atelectasis and volume loss on cxr if complete obstruction, not partial
physical exam
foreign body aspiration
inspiratory stridor - extrathoracic
expiratory stridor - intrathoracic
assymetric wheezing… more like expiratory stridor… but large airway sounds may be transmitted… and assymmetric wheezing may result from mucus plugging from asthma or bronchiolitis…
what to worry about with foreign body aspiration specifically of plastic or metal
erosion through bronchial wall
TF
pertussis can present in a 12 year old
T
how long do catarrhal and paroxysmal stages of pertussis last
1-2 wks catarrhal (indistinguishable from URI)
4-6 wks paroxysmal (forceful coughing fits with post-tussive emesis and inspiratory whoop afterward
treat pertussis
azithromycin
clarythromycin
erythromycin
- given in catarrhal phase may shorten clinical course
- given in paroxysmal phase will reduce communicability but not alter course
appearance of peds patient with epiglottitis
appear toxic (fever, stridor, drooling, respiratory distress) in “Sniffing Position” - sitting, leaning forward, neck hyperextended, chin protruding
Croup or laryngotracheobronchitis
is due to
most often occurs in this season
in patients of this age range
parainfluenza
winter
age 2-5yo
unilateral wheezing with decreased breath sounds think…
foreign body aspiration
6 risk factors for neonatal respiratory distress
maternal diabetes - surfactant deficiency and delayed lung maturation
prematurity (lung immaturity and lack surfactant)
maternal GBS infection - neonatal sepsis - respiratory distress
C-section delivery - transient tachypnea of the newborn
prolonged premature rupture of membranes (^18 hrs) - neonatal sepsis
meconium in amnionic fluid - meconium aspiration syndrome
TF
most infants born at 36 wks gestational age have RDS
F
not mostly, but Can occur as late as 37 wks gestation
how many weeks gestation Can RDS occur?
as late as 37 weeks, but not typically that late
transient tachypnea of the newborn
pathogenesis
risks
disorder of prematurity?
from delayed clearance of fluid from the lungs following birth
much more common with diabetic mom or c-section delivery
generally a disorder of TERM infants… Can occur in premature infants… just not at higher rates… so not a disorder of prematurity
neonate risks for pneumothorax
mechanical ventilation
meconium aspiration
severe infant respiratory distress syndrome (e.g. w prematurity)
typical pathogenesis and presentation of hypoglycemia in neonate
infant of diabetic mother (chronic fetal hyperinsulinemia during gestation… persists after birth and drives glucose down)… can be more pronounced in premie
tachypneia (non-specific response)
tf
CHF can be a cause of newborn tachypnea
T
usually from congenital heart defect
neonatal sepsis often due to either or both of these risk factors
GBS infeciton of mom
transmitted from mom during labor
prolongued rupture of membranes (^18hrs)
neonates at greatest risk of hypothermia
premies
small body size
when might you see a pulmonary venous embolism in a neonate
central venous cath placement
Components of Apgar score
heart rate 0 v100 ^100
resp effort 0 weak crying
muscle tone flaccid, some flexion, active movements
reflex irritability not responsive, grimace/weak cry, good cry active withdrawal
color blue/pale throughout, centrally pink, pink throughout
at 1 and 5 minutes
tf apgar scores are diagnostic for asphyxia predictive of neurological outcome need for intubation
F
F
F
standardized assessment with know hard actionable relevance, but subjective relevance…
define Large for gestational age (LGA)
etiology
clinical significance
^90th weight percentile
constitutional vs maternal DM
-may require c-section, foreceps, vacuum
(more freq birth injuries - clavicle fx, bpbp, facial nerve palsy)
-hypoglycemia a high risk if LGA and mom DM
define appropriate for gestational age (AGA)
10th-90th weight percentile
define small for gestational age (SGA)
etiology
clinical significance
v10th weight percentile
premie
constitutional
hypothermia
hypoglycemia (inadequate glycogen stores)
polycythemia and hyperviscocity
blood is transported from the placenta to the fetus via the
umbilical vein
fetal circulation
umbilical vein
some to portal vein to liver
most bypasses liver to IVC
1/3 caval blood to PFO to LA to coronary, cerebral, upper body
2/3 combo w venous blood from upper body in RA to RV out PA… 10% of this to lungs, 90% thru PDA to descending aorta to iliac arteries to hypogastric arteries to umbilical arteries to placenta
successful transition to extrauterine life at birth involves
cut umbilical cord - remove low-resistance placental circulation
initiate air breathing - reduce pulmonary arterial resistance
close PFO and PDA
How is pulmonary fluid eliminated from lungs at birth
What happens if it is not removed
Aka
Uterine contractions force out
Pulmonary lymphatics absorb
Transient tachypnea of the newborn
Aka
Persistent postnatal pulmonary edema
Aka 160-180 hr and 60-80 rr of first hour Fail to normalize to 120-160 and 40-60 in second hour (Rated measured at rest not crying)
Persistent pulmonary hypertension of the newborn
What causes it
What is it
Persistence of the fetal circulation
PPHN can result from several conditions, including meconium aspiration syndrome, diaphragmatic hernia, hypoplastic lungs, and in utero asphyxia. The following findings may indicate that an infant has PPHN:
Tachypnea
Tachycardia
Respiratory distress, with findings such as expiratory grunting and nasal flaring
Generalized cyanosis
Low oxygen levels, even while receiving 100% oxygen
Common
Uncommon
Respirstory causes of cyanosis in a newborn
Common
TTN transient tachypnea of the newb
RDS
Uncommon Pneumothorax Diaphragmatic hernia Choanal atresia Pulmonary hypoplasia Persistent pulmonary hypertension of the newborn (PPHN)
Common
Uncommon
Cardiac causes of cyanosis in a newborn
Common
Tetralogy of Fallot
Transposition of the great arteries (TGA): Defect in which the aorta and pulmonary arteries are transposed, resulting in respiratory distress and severe cyanosis as the ductus arteriosus closes shortly after birth . One risk factor for TGA is being born to a diabetic mother. TGA is often associated with other congenital heart defects, such as a ventricular septal defect, so a murmur may be heard on physical examination.
Uncommon Truncus arteriosus Tricuspid atresia Total anomalous pulmonary venous return Pulmonary atresia
CNS causes of cyanosis in a newborn
Hypoxic-ischemic encephalopathy
Intraventricular hemorrhage
Sepsis/meningitis
Id
Causes of cyanosis in newb
Septic shock
Meningitis
Oxygen challenge test in cyanotic infant
Differentiates between respiratory and cardiac cause of cyanosis
Hyperoxic gas delivery improves PaO2 if resp cause
No effect if cardiac cause
IInfants born to adolescent mothers are at greater risk for:
- lower birth weight
- vertically acquired STIs (due to the higher incidence of STIs in the adolescent population)
- poorer developmental outcomes
- increased risk of fetal death
- increased risk of premature death
how many babies born to women aged 15 to 19 years in the U.S. in 2013
about 250,000 teen births per year
how many births in women v18yo are unintended
2/3 unintended
US taxpayer spending on teen pregnancy per year
$9 billion per year for teen pregnancy
health care, foster care, incarceration rates up in children of teen parents, lost tax revenue from lower educational attainment and income among teen mothers
high school graduation rates of teen mothers versus non-pregnant non-child rearing peers
50% teen moms
vs 90% non-moms
graduate high school
purpose of HEEADSSS interview
screen for risks for 3 leading causes of death in US adolescents
- accidents
- homicide
- suicide
HEEADSSS
standard social history interview mnemonic for adolescents (screen for risks for accidents, homicide, suicide)
Home Education/Employment Eating disorder Activities/Affiliations/Aspirations Drugs Sexuality Suicidal behavior Safety
tf
mom drinking one six-pack of beer per week puts infant at risk for fetal alcohol syndrome
T
there is no “safe” amount of alcohol to drink during pregnancy
how does maternal tobacco use affect baby
low birth weight risk
Fetal alcohol syndrome is a distinct pattern of…
facial abnormalities, growth deficiency, and evidence of central nervous system dysfunction (cognitive disability, poor motor skills and hand-eye coordination, learning problems – i.e., difficulties with memory, attention, and judgment)
tf
maternal marijuana use causes distinct brith abnormalities
f
none identified to date
maternal cocaine / stimulant use effect on baby
vasoconstriction causing placental insufficiency and low birth weight
later cognitive deficits too…
TORCH infections
toxoplasma
rubella
cytomegaolovirus
HSV 2
(O can be for “Other”… HIV HepB Syphilis Parvovirus)
tf
gestetional diabetes limits fetal growth
f
causes macrosomia
LGA large for gestational age
how to know if mom may have suffered from pregnancy-induced hypertension or preeclampsia
if she had hypertension
proteinuria or swelling
standard prenatal lab screening
HIV rubella hep B serology
ABO and Rh blood type
urine drug screen
membrane rupture of how long prior to delivery without antiretroviral therapy increases risk of vertical transmission of HIV
4 hours
which increases risk of vertical transmission of HIV more, vaginal or c-section delivery
vaginal
tf
breastfeeding can vertically transmit HIV from mom to baby
T
tf
gestational age can affect risk of vertical transmission of HIV
T
v37 wks GA ^risk of vertical HIV transmission
how to prevent vertical transmisison of HIV from mom to child
antiretroviral therapy
how many people in US living with AIDS
1.2 million
2012
who gets intrapartum antimocrobial ppx against GBS
those high risk according to guidlines listing a bunch of factors…
maternal rapid HIV antibody test is positive, what steps should be considered to decrease the risk of HIV transmission to the fetus?
treat mom w combo antiretroviral therapy (if viral load > 1000 copies/mL)
cesarean delivery prior to the onset of labor (at 38 weeks’ gestation) and the rupture of membranes
don’t breast feed, vs breast feed on combo antiretrovirals if no clean water or formula available
resuscitate a newborn
how many require some assistance vs extensive rescuscitation to initiate breathing
ABC’s
Warm and dry
Stimulate a cry
Suction nose and mouth
Further blow-by O2, PPV, chest compresisons, medicaitons etc as needed
10% some assistance
1% extensive rescusitation
how to stablize newborn’s temperature
when to get apgars
skin-skin with mom
radiant warmer
incubator
1 and 5 minute apgars
tf
capillary refill is part of apgar
F APGAR appearance (skin color) pulse (heart rate) grimace (reflex irritability) activity (muscle tone) Respiration
calculate an apgar
APGAR appearance (skin color) pulse (heart rate) grimace (reflex irritability) activity (muscle tone) Respiration
0-2 points for each, final score 0-10
define born at term
^37 wks gestational age
Asymmetric IUGR refers to
a greater decrease in the size of the length and/or weight without affecting head circumference (“head-sparing phenomenon”)
vs Symmetric IUGR refers to a growth pattern in which head, length, and weight are decreased proportionately
3 things too look out for in SGA newborn
hypoglycemia (vglycogen stores, ^heat loss, possible hypoxia) - commonly asymptomatic, maybe poor feeding and listlessness
hypothermia (^SA/V ratio, v subq insulation, hypoxia, hypoglycemia) - commonly asymptomatic, maybe poor feeding and listlessness
polycythemia (chronic hypoxia, maternal-fetal transfusion) ruddy red skin color, respiratory distress (sluggish flow, poor perfusion), poor feeding, hypoglycemia
6 primitive newborn reflexes
Rooting - turns head toward your finger when touch cheek.
Sucking - on your finger when you touch roof of mouth.
Startle (Moro) - Support head with one hand and buttocks with other. Drop head to 10 cm below. Newborn will flex thighs and knees, fan and then clench fingers, arms first thrown outward then brought together as though embracing
Palmar and Plantar Grasps - grasps your finger when you stroke it against the palm or plantar surface
Asymmetrical Tonic Neck Response - Turning the head to one side causes gradual extension of arm toward direction of infant’s gaze with contralateral arm flexion–like a fencer.
Stepping Response - legs make stepping motion when hold him vertically above the table and stroke the dorsum of feet against table edge
elicit red reflex in neonate
normal variant
5 causes of absent red reflex
lights off
stand a foot or more away with ophthalmoscope
look for both red reflexes simultaneously
darker skin may have light golden or silver-tinged “red reflex”
cataract, opacified cornea, anterior chamber inflammation, developmental eye anomaly, retinoblastoma - may result in absent red reflex
tf
palpable spleen is abnormal on newborn exam
f
palpable spleen 1-2cm below costal margin is common in healthy infants (30% newborns, 10% one-year-olds, 1% 12-year-olds
how to test newborn for TORCH infection risk
infant toxoplasma titer
maternal and fetal rubella titers
infant urine cx for CMV
maternal HBV HBsAg…
congenital CMV on brain imaging
- Intracranial calcifications (bright areas on CT)
- Diminished number of gyri and abnormally thick cortex (aka lissencephaly or agyria-pachygyria)
- Enlarged ventricles
dx congenital cmv
positive urine cx v3wks of life
cmv sloughs off in saliva and urine in newborn…
sequelae of congenital cmv
progressive hearing loss
microcephaly and intracranial calcifications
hepatosplenomegaly (resolves spontaneously in weeks)
rash (resolves spontaneously in weeks)
treat symptomatic congenital cmv
why
6 mos antiviral asap
improves audiologic and neurodevelopmental outcomes
absolute contraindications to breast feeding
Maternal HIV infection (in the industrialized world)
Active herpes simplex lesions on the breast
Active untreated tuberculosis
Active maternal use of some (not all) non-prescription drugs of abuse
Infants with galactosemia
routine newborn screening for metabolic disorders
PKU and hypothyroidism
Some states also screen for galactosemia, biotinidase deficiency, hemoglobinopathy, maple syrup urine disease (MSUD), homocystinuria, congenital adrenal hyperplasia, cystic fibrosis, G6PD deficiency, and toxoplasmosis
Many states now screen for more than 30 diseases using tandem mass spectrometry.
leading cause of congenital infection in US
how often asymptomatic at birth
how often deadly when symptomatic
CMV most common
90% no symptoms at birth
10-15% mortality if symptomatic
symptoms of congenital CMV
various of
microcephaly, purpuric rash, and hepatosplenomegaly
jaundice, hearling loss, chorioretinitis, intracranial calcificaitons
Taking anticonvulsants during pregnancy may lead to
cardiac defects dysmorphic craniofacial features hypoplastic nails distal phalanges IUGR microcephaly mental retardation methemoglobinuria (rare)
Opiate use during pregnancy may result in
CNS findings (irritability, hyperactivity, hypertonicity, incessant high-pitched cry, tremors, seizures)
GI symptoms (vomiting, diarrhea, weight loss, poor feeding, incessant hunger, excessive salivation)
Respiratory findings (nasal stuffiness, sneezing, and yawning).
PKU path pres dx key to tx
AR phenylalanine hydrozylase deficiency
newborn screening vs vomiting, hypotonia, musty odor, developmental delay, decreased hair and eye pigmentation
start phenylalanine restricted diet
when are infants able to start eating small chunks of food… how to advise parents…
when they have teeth
~9mos ish can start small chunks
introduce new foods 1 at a time to assess for allergies
discuss choking hazards at 9 month visit - no popcorn, grapes, hard candies, or hot dogs!
supplement with breast milk or formula for 100kcal/kg/day
what age to look for neat pincer grasp
12 month
when should baby wave bye bye
9 month
how to assess pallor in dark-skinned pt
conjunctiva, nail beds, mucous membranes.
most frequently diagnosed neoplasm in infants
pres
neuroblastoma 50% present v2yo painless mass in neck, chest, or abdomen asymptomatic vs chronically ill with fever, pallor, weight loss, bone pain from mets... likely dx if above and NO JAUNDICE
tf
infant can present with teratoma
t
but rare
aka and presentation of wilm’s tumor
nephroblastoma
asymptomatic UQ abdominal mass
mean age 3yo
… no lymphadenopathy or juandice, normal development
smooth and not crossing midline generally
50% w assoc syx like abdominal pain, vomiting, hypertension
VMA and HVA are metabolites of…
assessed via… in eval of this possible dx for UQ mass
catecholamines
via urine for eval of neuroblastoma (highly specific, 95%)
small cell rosettes on bone marrow pathology is highly suggestive of…
neuroblastoma
prognosis of stage 4S neuroblastoma in an infant
actually good… likely to spontaneously regress due to nature of tumor derived from embryonal cell line
