CPS neonatal Flashcards
signs of neonatatal hypoglycemia (9)
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
who do you screen neonatal hypoglycemia
LGA, SGA, IDM, preterm
when hypoglycemic?
@ 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
Rx neonatal symptomatic hypoglycemia
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
risk factors neonatal sepsis
GA < 36 chorioamnionitis (Fever, WBC, foul, uterine tenderness) PROM > 18hrs previous GBS sepsis GBS bacturia this pregnancy
name common bacteria in neonatal sepsis & gram stain
gram+ cocci: GBS
gram+ rods: listeria
gram-cocci: uncommon
gram-rods:e.coli, kleb, pseudomonas
ROP screening recommendations
all infants < 31 weeks or BW < 1250g
if < 28 weeks –> screen at cGA31weeks
if 28 weeks –> screen at PNA 4 weeks
ROP when to treat?
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
what is acute bilirubin encephalopathy
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
what is considered elevated direct hyperbilirubinemia?
> 18umol/L Or > 20% of TSB
natural history of jaundice
term - peak 3-5days
preterm peak 5 - 7 days
pathological - within 24hrs of life
risk factors progression of severe hyperbili 8
GA < 38 weeks isoimmune hemolytic disease G6PD asphyxia respiratory distress lethargy temp instability sepsis acidosis
indication for exchange transfusion.
How to do
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
s/e exchange transfusion
blood-borne infection thrombocytopenia, coagulopathy GvHD Nec Portal vein thrombosis electrolyte - hypoCa, hyperK cardiac arrhythmias
partial exchange transfusion
for polycythemia using N/S
exchange volume = (obs Hct - desired hct) x blood volume / observed hct
post natal corticosteroids - indications
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.
s/e post natal steroid
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
why ancephalic baby not recommended for organ donation?
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
Vitamin K prophylaxis - doses
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
Hemorrhagic disease of the newborn
- types
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
circumcision adverse effects
pain, minor bleed, local infection
unsatisfactory cosmetic result
late: meatal stenosis (2-10%)
contraindications to circumscision
hypospadias
bleeding disorder
benefits of circumscision (3)
phimosis treatment UTI reduction STI reduction - decrease new HIV by 50-60^ HPV cancer reduction
universial hearing screen targets
target screening by 1 month
confirm diagnosis by 3mo
intervention by 6 moths
risk factors SNHL (6)
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
Types of hearing screen
OAE - otoacustic emission first test without risk factors
AABR - automated auditory brainstem response - those who not pass OAE or RF
Limitations of OAE and AABR
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)
benefits earlier hearing screen
early detection = improved receptive and expressive language scrore
cochlear implants between 8-12months and auditory roral therapy possible
Cost-effectivesness
false positive 2 - 4%
CPS FASD types
alcohol related birth defects
alcohol related neurodevelopmental defects
vs FASD guidelines 2015 CMAJ
- FASD with sentinel facial features
- FASD without sentinel facial features
FASD diagnosis triad
maternal exposure
pre natal and post natal growth insufficiency
characteristic facial features
FASD characteristics
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
alcohol screening tool
T-ACE (2 or more = at risk) Tolerance - before feel effects Annoyed Cut down Eye opener (AM drinking)
counsel extreme preterm
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%
anticipation extreme preterm
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.
brachial plexus palsy
name 2 common presentation
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
associations with brachial palsy
shoulder dystocia
LGA
IDM
instrumental delivery
perinatal brachial plexus recommendations
Educate =-75% completely recover 1st month 25% permanent impairment if incomplete recovery by 3 - 4 weeks, unlikely refer to PT, surgeon, rehab
surfactant indications
- intubated with RDS
- intubated with MAS fiO2 > 50%
- sick pneumonia OI > 15
- 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
Surfactant side effects
bradycardia hypoxemia blocked ETT inc risk pul hemorrhage hyperventilation after
benefits surfactant
reduce mortality
decrease hypoxemia, duration vent support, air leaks
neontal blood transfusion thresholds
No resp support
week 1 = 100
week 2 = 85
week 3+ = 65
Resp support
week 1 = 115
week 2 = 100
week 3 = 85
blood product considerations in neonates
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
Other supports other than transfusion
iron supplement 2mg/kg/day @ 4 6 weeks of life helps
erythropoietin - little support except those who withhold consent
strategies to minimize blood loss in very premature (4)
delayed cord clamping high volume (20ml/kg) to limit exposure use appropriate transfusion thresholds non-nvasive bili monitoring limit blood testing
late preterm discharge considerations (5)
> 34 - 37 weeks
- hyperbili
- peaks at day 7 (vs 5 term). inc risk. assess 48hrs after birth - feeding- 24hr of safe feeding prior to d/c. weight loss >10%
- apnea/SIDS - apnea of prematurity. No discharge on caffeine. SIDS education
- sepsis - higher risk
- hypoglycemia - euglycemia prior to d/c
- temp control
- Follow up f/u within 48hr
safe discharge prem < 34 weeks readiness (4)
readiness
- temp control
- apnea - minimum free 5 - 7 days
- sats >90 - 95%
- weight feed- sustained without CVS instability
prem< 34 discharge planning
complete prior to d/c newborn screen hearing screen immunization +/- RSV \+/- ROP (<31) +/- IVH (<32) screen car seat challenge f/u 72hrs
Indications HIE cooling
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
how to do HIE cooling
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
adverse events HIE cooling (4) name contraindications (2)
C/I
severe head trauma
intracranial bleed
S/E mild bradycardia hypotension arrhythmias mild thrombocytopenia edema
s/e SSRI neonate
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
SSRI neonatal behaviorual syndrome
Rx
paroxetine higher associated - consider switch
if late trimester exposure, baby observe in hospital for neurobehavioural/resp for minimum 48hrs.
anticipatory guidance
keep BF
inhale nitric oxide indications
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%
iNO s/ed
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
when to delay kangaroo care
GA < 27 with high humidification
abdo wall defect/NTD need sterile prior to surgery
newly post op not stable
CVS instability
benefits Kangaroo care
dec mortality Longer BF - dec incidence infection NEC, nosocomial infection growth and development more mature sleep organization pain promotes family help, BF
post partum depression risks to infants/pregnancy
poor prenatal care pre-eclampsia, higher preterm low BW spont abortion substance use risk taking behaviour
post partum depression - rx
13% of women, often unrecognized
TCA and SSRI cross placemnta but benefits > risks
st John’s wort - not take during pregnancy or lactation
ophthalamia neonatorum
recommendaitons
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)
clinical n.gonorrhea ophthalmia neonatorum
30-50% transmission
quickly progress to corneal ulceration, perforation of glob and permanent visual impairment
risks - those with risk to STI
pacifiers
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
neonatal pain management(5)
- bedside - oral glucose, non pharm. topical anesthetic
- post-surgery - established protocols. opiods
- Chest tube insertion - local anesthetic + systemic
- chest tube removal - short acting analgesia + general
- Retinal exam - topical anesthetic eye drops
- circumcision - local, dorsal nerve block, SC ring block
neonatal intubation
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
S/E succinylcholine
increase BP, hyperkalemia
Malignant Hyperthermia - AD skeletal
contraindication for suc!
perinatal loss - physician role
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
car seat challenge
< 37 GA
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
antenatal hydronephrosis
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
antenatal hydronephrosis f/u
all children with ANH need renal u/s
- prior to d/c (@ then repeat1wk)
- severe bilateral ANH
- any ANH in solitary kidney - between 7-30 days - all others
- 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.
DDH examination
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
DDH treatment
< 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.
management if concern DDH
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)
DDH risk factors
Female
Family history
Frank Breech
L hip (more common)
DDH association
oligiohydramios
torticollis
metatarsus adducts
