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General Pediatrics > CPS neonatal > Flashcards

CPS neonatal Flashcards

1
Q

signs of neonatatal hypoglycemia (9)

A 
jitteriness, termors
episodes of cyanosis
seizures
apneic spells, tachypnea
weak or high pitched cry
limp 
lethargy
difficulty feeding
episodes of sweating,
sudden pallor
hypothermia
cardiac arrest
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2
Q

who do you screen neonatal hypoglycemia

A

LGA, SGA, IDM, preterm

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3
Q

when hypoglycemic?

A

@ 2hrs
< 1.8 - IV rx
< 2 - feed and recheck

@> 2hrs
< 2 - IV rx
< 2.6 - refeed and recheck

GOOD
> 2 at 2hrs of age
> 2.6 at subsequent checks

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4
Q

Rx neonatal symptomatic hypoglycemia

A

Target > 2.6mmol/L

IV bolus 2ml/kg D10W
IV infusion D10 @ 80ml/kg/hr = GIR 5.5mg/kg/min
GIR = Infusion(ml/hr) x Dext/(6xkg)
- investigations +/- specialist referral
IV glucagon 0.1-0.3mg/kg or
IV glucagon infusion 10-20mcg/kg/hr
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5
Q

risk factors neonatal sepsis

A 
GA < 36
chorioamnionitis (Fever, WBC, foul, uterine tenderness)
PROM > 18hrs
previous GBS sepsis
GBS bacturia this pregnancy
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6
Q

name common bacteria in neonatal sepsis & gram stain

A

gram+ cocci: GBS
gram+ rods: listeria
gram-cocci: uncommon
gram-rods:e.coli, kleb, pseudomonas

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7
Q

ROP screening recommendations

A

all infants < 31 weeks or BW < 1250g

if < 28 weeks –> screen at cGA31weeks
if 28 weeks –> screen at PNA 4 weeks

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8
Q

ROP when to treat?

A

zone 1 - stage 3 or any stage with plus disease
zone 2 - stage 2/3 with plus disease

laser photocoagulation
cyrotherapy
intravitreal injection of VEGF

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9
Q

what is acute bilirubin encephalopathy

A

clinical syndrome in setting of severe hyperbili, lethargy, hypotonia, poor suck that can progress to hypertonia (opsthotonos), high pitched cry and fever, to seizures and coma

rare unless TSB > 425umol/L (critical)
severe is > 340umol/L

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10
Q

what is considered elevated direct hyperbilirubinemia?

A

> 18umol/L Or > 20% of TSB

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11
Q

natural history of jaundice

A

term - peak 3-5days
preterm peak 5 - 7 days
pathological - within 24hrs of life

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12
Q

risk factors progression of severe hyperbili 8

A 
GA < 38 weeks
isoimmune hemolytic disease
G6PD
asphyxia
respiratory distress
lethargy
temp instability
sepsis
acidosis
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13
Q

indication for exchange transfusion.

How to do

A

clinical signs of acute bilirubin encephalophaty
if despite photorx, TSB 375-425umol/L

double volume exchange (body=80ml/kg)
central cath placement
remove and replace aliquots of 10% blood volume
expect 1/2 fall. replace 85% blood circulating RBC
irradiated blood - reduce GvHD

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14
Q

s/e exchange transfusion

A 
blood-borne infection
thrombocytopenia, coagulopathy
GvHD
Nec
Portal vein thrombosis
electrolyte - hypoCa, hyperK
cardiac arrhythmias
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15
Q

partial exchange transfusion

A

for polycythemia using N/S

exchange volume = (obs Hct - desired hct) x blood volume / observed hct

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16
Q

post natal corticosteroids - indications

A

after discuss with parents:
high risk of CLD or prolonged ventilator dependence or severe severe CLD
- low dose (initial 0.15-2mg/kg/day) tapering doses over 7 - 10 day course
ICS alternative but unknown duration/dose/effectiveness

caution with AI esp if sepsis/nec etc.

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17
Q

s/e post natal steroid

A

early < 7 days of life
- increased rate of CP, death
hyperglycemia, HTN, GI hemorrhage, GI perforation

late > 7 days of life
- high incidence of HOCM, severe ROP

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18
Q

why ancephalic baby not recommended for organ donation?

A

not usually satisfy brain death criteria as brain stem function
by time death declared, often with ischemic changes and inappropriate
use of life support not improve chances of successful organ donation

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19
Q

Vitamin K prophylaxis - doses

A

IM >/= 1.5kg = 1mg x 1
(all within 6hr after birth)

PO @ first feed, 1mo, 2mo = 3x 2mg doses
both does not provide complete protection, but IM > PO for late HDNB

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20
Q

Hemorrhagic disease of the newborn

- types

A 
early HDNB - within 24hrs of life
- expectant moms if impaired VitK metabolism
classic (first 3 weeks of life) 
- rare if given vit K infant
late HDNB (3-8weeks of life)
- almost exclusively in infants BF
- IM > PO
- IM failure rate 0.25/100,000 infants
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21
Q

circumcision adverse effects

A

pain, minor bleed, local infection
unsatisfactory cosmetic result

late: meatal stenosis (2-10%)

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22
Q

contraindications to circumscision

A

hypospadias

bleeding disorder

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23
Q

benefits of circumscision (3)

A 
phimosis treatment 
UTI reduction 
STI reduction - decrease new HIV by 50-60^
HPV
cancer reduction
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24
Q

universial hearing screen targets

A

target screening by 1 month
confirm diagnosis by 3mo
intervention by 6 moths

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25
Q

risk factors SNHL (6)

A 
FmHx permanent hearing loss
cranofacial - ie external ear
Congenital infection (bact meningitis, CMV, Toxo, Rubella, CMV, herpes, syphilis)
Syndrome associated with SNHL
NICU > 2 days 
ECMO
assisted ventilation
ototoxic drug
hyperbili needing exchange
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26
Q

Types of hearing screen

A

OAE - otoacustic emission first test without risk factors

AABR - automated auditory brainstem response - those who not pass OAE or RF

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27
Q

Limitations of OAE and AABR

A

both for >24hr, min 34cGA
both affected by infant movement, environemntal nose, dysfunction in middle/external ear
BOTH detects from mod hearing loss only (30-40dB)

OAE
- conductive and cochlear hearing loss

AABR
- conductive, cochlear, neural (CN8)

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28
Q

benefits earlier hearing screen

A

early detection = improved receptive and expressive language scrore
cochlear implants between 8-12months and auditory roral therapy possible
Cost-effectivesness

false positive 2 - 4%

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29
Q

CPS FASD types

A

alcohol related birth defects
alcohol related neurodevelopmental defects

vs FASD guidelines 2015 CMAJ

  • FASD with sentinel facial features
  • FASD without sentinel facial features
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30
Q

FASD diagnosis triad

A

maternal exposure
pre natal and post natal growth insufficiency
characteristic facial features

31
Q

FASD characteristics

A 
microcephaly
thin upper lip
absent/hypoplastic filtrum
short palpebral fissures
clindodactyly
ADHD, ID, LD
growth retardation, altered motor tone
hearing
interpersonal skills
lack of inhibitions
life adjustment concerns - depression, suicide, alcohol, crime, pregnancy
32
Q

alcohol screening tool

A 
T-ACE (2 or more = at risk)
Tolerance - before feel effects
Annoyed
Cut down
Eye opener (AM drinking)
33
Q

counsel extreme preterm

A

extreme prem < 26 weeks
< 22 weeks - no intervention
23 - 25 individualized

offer multiple opportunities, documentation, talk likelihood of survival, risk of disability

survival 78% at 25GA, 36% at 23 GA
disability (includes IVH>3, ROP, CLD)
- survival free 
@23 weeks 35-50%
@25 weeks 40-70%
34
Q

anticipation extreme preterm

A 
ensure accurate assessmeng of GI
(ideal US at 8-14weeks)
level 3 NICU
Tocolysis for transfer/ANS
ANS doses
MgSO4 for fetal neuroprotection
Mode of delivery - C/S no significant benefits.
35
Q

brachial plexus palsy

name 2 common presentation

A

Erb’s palsy -C 5, 6, 7
50% cases
arm ADDucted, internal rotated, forearm extended, pronated (waiter’s tip)

Klumpke palsy C8, T1= isolated hand parlaysis and Horner syndrome

36
Q

associations with brachial palsy

A

shoulder dystocia
LGA
IDM
instrumental delivery

37
Q

perinatal brachial plexus recommendations

A 
Educate
=-75% completely recover 1st month
25% permanent impairment
if incomplete recovery by 3 - 4 weeks, unlikely
refer to PT, surgeon, rehab
38
Q

surfactant indications

A
  1. intubated with RDS
  2. intubated with MAS fiO2 > 50%
  3. sick pneumonia OI > 15
  4. intubated with pul Hemorrhage with deterioration
    (consider if < 29GA peripheral center)

retreat - within 72hr of life, persistent/Vent requirements. usually 3 doses max. Q4-6H

39
Q

Surfactant side effects

A 
bradycardia
hypoxemia
blocked ETT
inc risk pul hemorrhage
hyperventilation after
40
Q

benefits surfactant

A

reduce mortality

decrease hypoxemia, duration vent support, air leaks

41
Q

neontal blood transfusion thresholds

A

No resp support
week 1 = 100
week 2 = 85
week 3+ = 65

Resp support
week 1 = 115
week 2 = 100
week 3 = 85

42
Q

blood product considerations in neonates

A

leukoreduction - CMV reduced
irradiation - reduce risk of GvHD
transfusion volume 10-20ml/kg
emergency - 20ml 1min push, then 10m/kg/hr with O neg Blod

43
Q

Other supports other than transfusion

A

iron supplement 2mg/kg/day @ 4 6 weeks of life helps

erythropoietin - little support except those who withhold consent

44
Q

strategies to minimize blood loss in very premature (4)

A 
delayed cord clamping
high volume (20ml/kg) to limit exposure
use appropriate transfusion thresholds
non-nvasive bili monitoring
limit blood testing
45
Q

late preterm discharge considerations (5)

A

> 34 - 37 weeks

  1. hyperbili
    - peaks at day 7 (vs 5 term). inc risk. assess 48hrs after birth
  2. feeding- 24hr of safe feeding prior to d/c. weight loss >10%
  3. apnea/SIDS - apnea of prematurity. No discharge on caffeine. SIDS education
  4. sepsis - higher risk
  5. hypoglycemia - euglycemia prior to d/c
  6. temp control
  7. Follow up f/u within 48hr
46
Q

safe discharge prem < 34 weeks readiness (4)

A

readiness

  1. temp control
  2. apnea - minimum free 5 - 7 days
  3. sats >90 - 95%
  4. weight feed- sustained without CVS instability
47
Q

prem< 34 discharge planning

A 
complete prior to d/c
newborn screen
hearing screen
immunization +/- RSV
\+/- ROP (<31) +/- IVH (<32) screen
car seat challenge
f/u 72hrs
48
Q

Indications HIE cooling

A 
infants >/= 36GA
= 6hrs of age with A+B
Criteria A
 a) Apgar < 5 @ 10min
b) continued vent/resus at 
c) 10mins of age
met acidosis pH < 7 or BE >17 in cord/ABG within 1hr of life

Criteria B
Sanart Mod or Severe
- seizures or at least 3 of 6 categories

Sanart
L - LOC - decreased/lethargic
E - EEG - depressed
A - autonomic (sympathetic/para/absent)
R - primitive reflex
N - neuromotor (hypotonia, absent)
S - seizures (common mod)
S - spont activity
49
Q

how to do HIE cooling

A 
within 6hrs of life
34 +/- 0.5 degrees
selective head or total body
duration unknown (suggested 2-3d)
rewarm up 0.5C Q1-4H 
monitor worsening encephalopathy and seizure
50
Q 
adverse events HIE cooling (4)
name contraindications (2)
A

C/I
severe head trauma
intracranial bleed

S/E
mild bradycardia
hypotension
arrhythmias
mild thrombocytopenia
edema
51
Q

s/e SSRI neonate

A 
SSRI neonatal behavioral syndrome (SNBS)
- commom, mil,d transient
10 - 30% exposed to SSRI
usually within hrs, until 2 weeks
tachypnea, cyanosis, jittery, inc muscle tone
feedign disturbace
higher risk LATE pregnancy vs.  early
52
Q

SSRI neonatal behaviorual syndrome

Rx

A

paroxetine higher associated - consider switch

if late trimester exposure, baby observe in hospital for neurobehavioural/resp for minimum 48hrs.
anticipatory guidance
keep BF

53
Q

inhale nitric oxide indications

A

pulmonary vasodilation with better VQ matching

> 35GA with hypoxemic resp failure with conventional rx
OI > 20-25 or
PaO2 < 100 despite FiO2 100
start 20ppm (up to 40ppm)

decrease after 4 -6hr stability, wean gradually to 5ppm then wean by 1ppm q4H until off if FiO2 < 60%

54
Q

iNO s/ed

A

methemoglobin - NO absorbed into blood and bind to ion of Heme protein, which then is oxidized to methemoglobin
measure & keep < 2.5%
decreased plt aggrevation, inc risk bleeding
abrupt d/c can cuase severe hypoxemia

55
Q

when to delay kangaroo care

A

GA < 27 with high humidification
abdo wall defect/NTD need sterile prior to surgery
newly post op not stable
CVS instability

56
Q

benefits Kangaroo care

A 
dec mortality
Longer BF - dec incidence infection NEC, nosocomial infection
growth and development
more mature sleep organization
pain 
promotes family help, BF
57
Q

post partum depression risks to infants/pregnancy

A 
poor prenatal care
pre-eclampsia,
higher preterm low BW
spont abortion
substance use
risk taking behaviour
58
Q

post partum depression - rx

A

13% of women, often unrecognized
TCA and SSRI cross placemnta but benefits > risks
st John’s wort - not take during pregnancy or lactation

59
Q

ophthalamia neonatorum

recommendaitons

A

routine eye erythromycin ointment not indicated
test 1st preantal - gonorrhea & chlam. Repeat 3rd T or at delivery

if concern untreated Gonorrhea - swab and treat without waiting (IM/IV ceftriaxone) x1
if chalmydia - 50% chance
- can use erythromycin ointment
- swab if sympatomatic, and treat with PO erythromycinx14d (if < 2wks, risk pyloric stenosis)

60
Q

clinical n.gonorrhea ophthalmia neonatorum

A

30-50% transmission
quickly progress to corneal ulceration, perforation of glob and permanent visual impairment
risks - those with risk to STI

61
Q

pacifiers

A

restrict if AOM/chronic OM
if prolonged > 5yo- dental caries, malocclusion, gingival regression
infection - often colonized

can continue in NICU for nonnutritive suck/pain
can signify difficulties with BF

62
Q

neonatal pain management(5)

A
  1. bedside - oral glucose, non pharm. topical anesthetic
  2. post-surgery - established protocols. opiods
  3. Chest tube insertion - local anesthetic + systemic
  4. chest tube removal - short acting analgesia + general
  5. Retinal exam - topical anesthetic eye drops
  6. circumcision - local, dorsal nerve block, SC ring block
63
Q

neonatal intubation

A 
ALL should receive except for emergency or difficult airway
preoxygenate
1. atropine 20mcg/kg 
2. Fentanyl 3-5mcg/kg (slow 1min)
3. succinylcholine 2mg/kg
limite duration of attemps 30s
monitor during intubation
confirm tube placement
64
Q

S/E succinylcholine

A

increase BP, hyperkalemia

Malignant Hyperthermia - AD skeletal
contraindication for suc!

65
Q

perinatal loss - physician role

A 
office visit few weeks later
optimize immediate interactions
simple language, support person available
ame baby
provide privacy
warn about gasping, muscle contractures
explain if need autopsy
options for memorial services
66
Q

car seat challenge

< 37 GA

A

NOT recommended prior to d/c

  • poor reproducibility
  • not as accurate as PSG so not confident even if “pass”

instead, encourage safe car seat use. demonstrate in actual car seat prior to d/c
ONLY for use in moving vehicles, and promptly remove once destination reached

67
Q

antenatal hydronephrosis

A

1% pregnancies
common etiologies
(transient 40-90%)
(UPJO) ureteropelvic junction obstruction
(VUR) vesico-ureteral reflux
Posterior urethral valve
(UVJO) ureteral-vesicular junction obstruction

all grades SFU have 10-15% risk of VUR. Grade not correlated with severity

68
Q

antenatal hydronephrosis f/u

A

all children with ANH need renal u/s

  1. prior to d/c (@ then repeat1wk)
    - severe bilateral ANH
    - any ANH in solitary kidney
  2. between 7-30 days - all others
  3. VCUG prior to d/c
    -postnatal U/S SFU grade 3/4
    - ANH with concern of bladder obstruction
    severe bilteral hydronephrosis (>15mm), dilated ureter, abnormal bladder, etc.
69
Q

DDH examination

A

Up to 8- 12 weeks old
Ortolani - reduce hip
- hip flex at 90D. leg neutral. hip abducted and lift leg anteriorly
Barlow - induce dislocation (provocative)
- adduct hip, apply pressure knee posteriorly

Galeazzi - shortness of femur
assymstrical thigh folds
limited abduction - most reliable

70
Q

DDH treatment

A

< 6mo Pavlik harness
prevents hip extension, limits adduction
23hr/day x 6 week then during sleep x 6 weeks, then off
complication - osteonecrosis (AVN, femoral nerve palsy, skin breakdown)

> 6mo - surgery
18mo - riskvs benefits. possible proxmial femoral growth distrubance, need for additional surgery. etc.

71
Q

management if concern DDH

A

if + O/B refer to ortho (no need US)
if equivocal (soft click, asymmetrical)
- f/u 2 weeks pediatrician.
- if still equivocal, US or refer

(US if < 5mo OR Xray if > 4mo)

72
Q

DDH risk factors

A

Female
Family history
Frank Breech
L hip (more common)

73
Q

DDH association

A

oligiohydramios
torticollis
metatarsus adducts

General Pediatrics (19 decks)

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