CPS Neonatology Flashcards
Natural history of perinatal brachial plexus palsy injury
- ~25% have residual defects
- 75% recover completely within 1st month
- If physical exam shows incomplete recovery by 3-4 weeks then full recovery is unlikely
CPS does not recommend infant car seat challenge for these 4 reasons:
- Inconsistency among ICSC tests
- Lack of evidence that failing is associated with adverse outcomes
- Poor reproducibility
- Not as accurate as PSG
When and to whom to do CCHD screening
- All term and late prems
- Asymptomatic in nonacute settings
- Between 24 and 36 hrs of age
What to do with a failed CCHD screen
- Asses by MRP
- May do: 4 limb BPs, ECG, CXR
- Consult pediatrician
- If stll unclear echo
< 23 weeks survival to discharge
20
(30% severe NDD)
- Palliative care is recommended
23-23+6
- survival (%)
- recommendations on resuscitation
40
(20% severe NDD)
- Intensive care or palliative care
24-24+6
- survival (%)
- recommendations on resusucitation
67%
(20% severe NDD)
- Intensive care or palliative care
> 25 weeks
- survival rates (%)
- recommendation on resuscitation
80
(14% severe NDD)
- Intensive care is recommended
Prognostic factors for extreme prems
besides GA
- Birth weight
- Singleton vs. multiple
- Antenatal corticosteroids
- Gender (males to do worse)
- Birth outside a tertiary perinatal centre
- Chorioamnionitis
- Major congenital anomalies
Potential risk of circumcision
- Minor bleeding
- Local infection
- Severe infection
- Death
- Unsatisfactory cosmetic results
- Meatal stenosis
Potential benefits of circumcision
- Prevention of phimosis
- Decrease in early UTI
- Decrease in UTI in males with risk factors
- Decreased acquisition of HIV
- Decreased acquisition of HPV
- Decreased penile cancer risk
- Decreased cervical cancer risk in female partners
Contraindications to neonatal circumcision
- Hypospadias
- Bleeding diathesis
Post-discharge problems of late preterm
- Hyperbilirubinemia
- Feeding difficulties and growth
- Apnea and SIDS
- Sepsis
- Hypoglycemia and temperature control
4 important infant competencies of premature infant
- Thermoregulation
- Control of breathing
- Respiratory stability
- Feeding skills and weight gain
If NBS is done before 24hrs must have a repeat done within…
7 days
TSB or TCB should be measuring in all infants during…
First 72hr of life
- If not required earlier due to clinical jaundice, should do as same time as NBS
Acute bilirubin encephalopathy
Clinical syndrome in presence of severe hyperbili:
Lethargy, hypotonia and poor suck may progress to hypertonia (oisthotonos and retrocollis) with high-pitched cry and fever and eventually to seizures and coma
Features of chronic bilirubin encephalopathy
Athetoid CP
+/- seizures, dev delay, hearing deficit, oculomotor disturbances, dental dysplasia, mental deficiency
Severe hyperbilirubinemia
> 340 umol/L (at any time during first 28 days)
Critical hyperbilirubinemia
TSB >425umol/L during first 29 days of life
Cons of transcutaneous bili
- Unreliable after initiation of phototherapy
- Unreliable with changes in skin colour and thickness
(more accurate at lower levels so better as a screening devise)
Side effects of phototherapy
- Temperature instability
- Water loss
- Intestinal hypermotility
- Diarrhea
- Interference with maternal-infant interaction
- Rarely: bronze discoloration of the skin
- Potential risk (animal studies) or retinal damage
- Parental anxiety and health care use
Side effects of phototherapy
- Temperature instability
- Water loss
- Intestinal hypermotility
- Diarrhea
- Interference with maternal-infant interaction
- Rarely: bronze discoloration of the skin
- Potential risk (animal studies) or retinal damage
- Parental anxiety and health care use
Before exchange transfusion collect blood for investigation of rare causes:
- Red cell fragility
- Enzyme deficiency – G6PD and PK
- Metabolic disorder
- Hemoglobin electrophoresis
- Chromosome analysis
Benefits of therapeutic hypothermia
- Decrease mortality
- Decrease mod-to-severe neurodevelopmental delay
- Increase survival without neurodev delay
Treatment criteria for therapeutic cooling
Inclusion criteria
- > = 36 weeks GA
- < = 6hrs of age
- Either criteria A+C OR criteria B+C
Criteria A, B and C in therapeutic hypothermia
A = cord pH < 7.0, base deficits >= -16 B = pH 7.01-7.15 or base deficit -10 to -15.9 on cord gas or gas < 1hr AND hx of acute perinatal event AND Apgar < 5 at 10 minutes or at least 10 minutes of PPV C = evidence of mod-to-severe encephalopathy aka seizures or signs in 3+ of 6 categories of Sarnat staging
6 categories of Sarnat staging
- Level of consciousness
- Spontaneous activity
- Posture
- Tone
- Primitive reflexes
- Autonomic system
Contraindications for therapeutic hypothermia
- Moribund infants
- Major congenital or genetic abnormalities
- Severe IUGR
- Clinically significant coagulopathy
- Severe head trauma or intracranial bleeding
Side effects of hypothermia
6
- Sinus brady
- Hypotension
- Thrombocytopenia
- Prolonged bleeding time
- Subcutaneous fat necrosis
- Persistent pulmonary hypertension with impaired oxygenation
Target temperature to be reached with hypothermia
Optimal rectal/esophageal: 33.5+/- 0.5C for whole body cooling
Sarnat stages pupils
Stage 1: mydriasis
Stage 2: miosis
Stage 3: unequal, poor light reflex
Infants at risk for hypoglycemia
- Weight < 10th percentile
- IUGR
- Weight > 90th percentile
- Infants of diabetic mothers
- Prem < 37 weeks GA
- Maternal labetalol use
- Late prem exposure to antenatal steroids
- Perinatal asphyxia
- Metabolic: e.g. CPT-1 deficiency
- Certain syndromes e.g. Beckwith-Wiedemann
Duration of hypoglycemia screening
IDM and LGA – 12hrs
SGA and prems – 24 hrs
When to send critical sample
> 72 hrs: at BG <= 2.8
Critical sample
10 investigations
- Plasma glucose
- Beta-hydroxybutyrate
- Bicarbonate
- Lactate
- Free fatty acids
- Insulin
- Growth hormone
- Cortisol
- Carnitine
- Acylcarnitine profiling
Hypoglycemia at 2 hrs of life
- If < 2.6
- 40% dextrose gel 0.5mL/kg and breast feed OR
- 5mL/kg and breastfeed
Check glucose 30 min post feed
Hypoglycemia after first 2 hrs
- If <= 1.8
- D10W infusion
- If symptomatic: D10W bolus 2mL/kg over 15 minutes
Check glucose after 30 min
Hypoglycemia after first 2 hrs
- 1.8-2.6
- 40% dextrose gel 0.5mL/kg AND feed 5mL/kg and breastfeed OR
- Feed 8mL/kg and breastfeed
Check glucose 30 min post feed
Who should be treated with iNO?
- Infants >= 35 weeks at birth with hypoxemic resp failure who fail to respond to other measures
- Infants with OI > 20-25 when PaO2 remains < 100 despite optimal ventilation with 100% FiO2
- Ideally after an echo
When and how to wean iNO
- After 4-6hrs of stability where FiO2 is <60-80 or OI <=10
- Wean by 50% q4-6hr intervals if OI remains <= 10
- At 5ppm then wean by 1ppm q 4 hrs and then discontinued at 1ppm
Benefit of iNO
Improves oxygenation
Decreases combined outcome of death or ECMO (mostly by decreasing need for ECMO)
Physiologic responses to intubation
- Systemic and pulmonary hypertension (can be reduced with analgesia)
- Bradycardia (can be prevented with atropine)
- Intracranial hypertension (can be avoided with muscle relaxants)
- Hypoxia (reduced with paralysis)
Suggested protocol for admin of premedication for intubation for neonates
- Atropine 20ug/kg IV
- Fentanyl 3-5ug/kg IV (slow infusion)
- Succinylcholine 2mg/kg IV
* fentanyl at risk for frozen chest!
Benefits of kangaroo care
- for the prem infant (6)
- for the mom (3)
For baby:
- cardioresp and temp stability
- decreased arousal and decreased REM (more mature sleep)
- increased sleep time
- increased neurodevelopmental outcomes after discharge
- decreased nosocomial infection
- reduced responses to pain
For mom/parent:
- longer duration of breastfeeding
- higher volumes of milk
- increased maternal confidence
Hemoglobin thresholds in prem infants with resp supports
Week 1: 115
Week 2: 100
Week 3: 85
Hemoglobin thresholds in prem infants without resp supports
Week 1: 100
Week 2: 85
Week 3: 75
“Respiratory support” in premature infant transfusion guidelines
- FIO2 of 25%+
- mechanical increase in airway pressure
Opioid use during pregnancy can be associated with
- Prematurity
- Low birth weight
- Increased risk of spontaneous abortion
- SIDS
- Infant neurobehavioural abnormalities
- Neonatal abstinence
Neonatal abstinence syndrome how long to screen for
- Minimum of 72 hr
- Up to 120 hrs when infant has a longer-acting opioid e.g. methadone or buprenorphine
Naloxone during infant resuscitation is associated with
Seizures
2 patterns of brain injury in HIE and significance
- Watershed (prolonged partial hypoxia-ischemia) – more cognitive impairment than motor
- Basal ganglia/thalamic (acute, profound hypoxia-ischemia) – severe motor and cognitive
Timing for MRI in term neonate with neonatal encephalopathy
- Between 3 and 5 days of life then
2. Repeat MRI at 10-14 days = helpful adjunct
Pros and cons for ultrasound in term neonate brain imaging
- Can help identify hemorrhage, major structural anomalies or calcifications
- NOT recommended as sole imaging modality in term neonates
CT may be useful first imaging modality when
- Urgent situations
- MRI is not available
- Infant is too unstable to undergo MRI
- Trauma or skull fracture is suspected
Grading for IVH
- Limited to germinal matrix
- IVH involves blood in ventricles
- IVH has blood filling and distending ventricular system
- Parenchymal involvement
Grading for PVL on head ultrasound
- Transient periventricular areas with increased echogenicity for 7 days or more
- Small, localized, fronto-parietal cysts
- Extensive periventricular cystic lesions
- Increased echogenicity in deep white matter which are evolving into extensive cystic lesions
Neuroimaging timing for premature infants
<= 31+6 weeks:
Scheduled: HUS @ 7-14 days post-birth and HUS at 4-6 weeks post-birth
- Term corrected imaging if markedly abN findings or RFs (not routine)
- f/u HUSs 7-10 days after initial if grade 2 or higher IVH or WMI or complication
32+ weeks: do initial HUS if RFs, follow up imaging only if abnormal
Risk factors for IVH
Prematurity (#1) Low birth weight < 1000g Chorioamnionitis Events leading to cerebral blood flow instability Lack of antenatal corticosteroids Birth outside of a tertiary care centre
Risk factors for abnormal brain imaging in prems > 32 weeks
- Lower GA
- HC <3rd percentile
- Resuscitation at birth or critical care out of keeping of usual neonatal course
- Complicated monochorionic twin pregnancy
- Postnatal complications
Mothers with PPROM and infant <=32+6:
- Should be treated with penicillin and a macrolide
neuroprotection
Gestation age for antenatal steroids
neuroprotection
<34+6 (select cases 35-36+6)
Optimal interval >48hrs between last dose and birth
Indications for Magnesium sulfate for mothers (neuroprotection)
- Imminent preterm delivery (<=33+6)
Neuroprotection measures for a prem infant (12)
- before delivery (4)
- at delivery (2)
- after delivery for baby
Before delivery: 1. Treat moms with PPROM 2. Transfer moms to tertiary care centre 3. antenatal corticosteroids 4. magnesium sulfate At delivery: 1. C/s if malpresenting 2. delayed cord clamping For baby 1. avoid hypothermia 2. permissive hypercapnia 45-55 3. Treat babies with abx if mom’s have chorio or PPROM 4. Avoid inotropes unless markers of hypoperfusion 5. head position neutral and midline 6. Prophylactic indomethacin for high risk, extreme prems
Leukoreduction of RBCs decrease
CMV
Irradiation of RBCs reduce
Risk of GVHD
Pretransfusion testing for neonates
- ABO grouping and RH typing
- Screen for maternal antibodies (direct and indirect antiglobulin test)
If initial screen is negative do NOT repeat the screen again until 4 months of age
Indications for treatment for ROP
Zone I – any stage with plus disease
Zone I – stage 3 without plus disease
Zone II – stage 2 or 3 ROP with plus disease
Who to screen for ROP
- Born <= 30+ 6 OR
- BWt < = 1250 OR
- More mature infants believed to be at high risk
When to screen for ROP
At 4 weeks of age OR 31 weeks CGA which ever comes later
Surfactant replacement therapy benefits:
Reduces:
- mortality
- deficits in oxygenation
- pulmonary air leaks
- duration of ventilatory support
- length hospital stay
- cost of intensive care
Increases:
- likelihood of surviving without BPD
Risks of endogenous surfactant use
- During instillation: bradycardia, hypoxemia, blockage of endotracheal tube
- Pulmonary hemorrhage
- Overdistention
- Hyperventilation with low PCO2
Surfactant is indicated for:
6
- Intubated infants with RDS
- Infants at significant risk of RDS
- Re-treatment for RDS if O2 requirement of 30% or more
- Intubated infants with MAS requiring more than 50% oxygen
- Sick newborns with pneumonia and OI > 15
- Newborns with pulmonary hemorrhage which leads to clinical deterioration
Complications of depression on pregnancy and infancy
Pregnancy: suicide, miscarriage, preterm birth, low birth weight, resp distress, increased length of hospital stay
Infancy: maternal child bonding, cognitive, emotional and behavioural consequences
SSRI exposure and congenital malformations
- SSRIs unlikely to be associated
- Paroxetine may be associated with cardiac malformations (inconclusive)
SSRI impacts on newborn
- SSRI neonatal behavioural syndrome in 10-30% (mild and self limited, observe for 48hrs)
- Possible PPHN (absolute risk = negligible)
- Possible: lower BWt, lower GA, resp distress, admission to NICU
Responsibilities of referral team in critical transport
- Copies of medical records
- Maternal blood sample and colostrum
- Placenta for pathology
- Consent for transport
- Consent specific for blood product administration
Recommendations for steroids in extreme prems
May be recommended:
- High risk infants (<28 weeks) and those exposed to chorio MAY benefit from physiologic hydrocortisone at replacement doses (e.g. within first 24-48 hrs)
- For subgroup of infants (e.g. ventilated with increasing O2 and worsening lung disease) a short course of dex should be considered AFTER 1 week
Is NOT/cannot be recommended:
- use of dex in first week post birth
- Routine use of dex for infants after first weeks is NOT recommended (nor HC)
- routine use ICS
3 types of vitamin K deficiency bleeding
- Early onset = first 24hrs post birth (e.g. maternal antiepileptics)
- Classic = days 2-7
- Late onset (2-12 weeks up to 6 months) – associated with chronic malabsorption and low vit K intake
Oral vitamin K option
2mg at first feeding then repeated at 2-4 weeks and then 6-8 weeks
