CPS NICU Flashcards
1
Q
Which infants are at highest risk of acquiring HSV?
A
Infants born to mothers who have a first-episode primary infection at the time of delivery since the mother had no pre-existing neutralizing antibodies to transmit to the baby through placenta-remember that most newly acquired cases are asymptomatic
2
Q
What steps may reduce risk of neonatal HSV transmission during pregnancy or at time of delivery?
A
- Acyclovir from 36 wks GA until delivery (no clear evidence on whether this reduces risk)
- Delivery by elective C-section in woman with active HSV lesions at delivery
- Avoid procedures that may break baby’s skin: forceps, vaccuum, fetal scalp monitoring
3
Q
What are the 3 categories of HSV infections?
A
- Disseminated
- Localized CNS
- Skin, eye and mucous membrane
4
Q
When should HSV be considered as a diagnosis in neonates?
A
- General: Fever with irritability,
- CNS: seizures, or abnormal CSF fluid
- Labs: liver dysfunction,
**Remember that in most cases, there is
- no known history of maternal HSV and infant has
- no skin vesicles!
5
Q
What is the dose of acyclovir for treatment of neonatal HSV? What is the duration of treatment?
A
Dose: 60 mg/kg/day or 20 mg/kg/dose IV q8hDuration:
- SEM: 14 days IV
- CNS/disseminated: 21 days minimum IV
(Oral ACV has limited bioavailability thus IV is required)
6
Q
What is the definitive diagnostic test for non-CNS HSV?
A
Isolation of HSV by viral culture (from oropharynx, nasopharyn, skin lesions, mucous membranes)
7
Q
What is the definitive diagnostic test for CNS HSV?
A
HSV PCR (more sensitive than culture)
8
Q
Why is infant serology not useful for diagnosing neonatal HSV infection?
A
- Transplacental IgG antibodies cannot be differentiated from IgG produced by baby
- Production of antibodies is impaired in severely affected infants
- Commercially available assays for HSV IgM abs are of limited reliability
9
Q
What are two side effects of acyclovir?
A
- Nephrotoxicity
- Neutropenia
10
Q
What is the management of ocular HSV in neonates?
A
- IV acyclovir x 14 days
- Topical 1% trifluridine
- Ophtho consult
11
Q
What follow-up should infants with neonatal HSV infections have?
A
Because of potential for neurological sequelae, f/u should include:
- Neurodevelopment
- Ophtho
- Audiology
12
Q
When a diagnosis of neonatal HSV is suspected, what diagnostic investigations should be ordered? (3)
A
- Swabs of vesicular lesions and mucous membranes for culture or PCR
- Blood for HSV PCR may be tested if disseminated NHSV is suspected.
- CSF HSV PCR
- Liver enzymes to assess for disseminated HSV
13
Q
When evaluating for neonatal HSV infection in exposed asymptomatic infants, what diagnostic investigation should be ordered? (1)
A
- Mucous membrane swabs from mouth, nasopharynx and conjunctivae at least 24 hrs after delivery (so that maternal HSV virus on baby’s skin from delivery has time to clear)
14
Q
How long does it take for antibodies to HSV to develop following an infection?
A
Approximately 3 weeks
15
Q
What is the management for an infant delivered by C-section before ROM to a mother with presumed first-episode primary or first-episode nonprimary HSV infection at delivery?
A
Risk of NHSV is very low.
If baby is well:
- Swab the baby’s mucous membranes at > 24 hrs of age (PCR and cultures). Also consider doing blood HSV PCR and CSF HSV PCR
- If swabs are negative OR while HSV tests are pending, the baby can be discharged home
- If swabs are positive, then the infant is managed as a case of neonatal HSV. Readmit for blood PCR and CSF PCR. (Some experts recommending doing CSF analysis as well). Decide of needs 14 or 21 dys of Rx
16
Q
What is the management for an infant delivered by SVD or C-section after ROM to a mother with presumed first-episode primary or first-episode nonprimary HSV infection at time of delivery?
A
- Test mom for HSV-1 and HSV-2 antibodies to figure out if she has primary (no prior HSV antibodies), nonprimary (HSV antibodies present but to the other type of HSV), or recurrent (antibodies present)
- Swab baby’s mucous membranes (PCR and cultures) and start acyclovir (controversial whether to do this at birth with risk of surface contamination or at 24 hr of life)
- If swabs are positive, need to obtain CSF PCR to r/o CNS HSV
- If swabs are negative and mom’s serologies show she has recurrent HSV, then d/c acyclovir
- If swabs are negative and mom has primary HSV or serology testing is not available, baby needs acyclovir x 10 days
17
Q
What is the management for an infant born by C-section to a mother with recurrent HSV at delivery?
A
- Swab mucous membranes (PCR and cultures) at 24 hrs of life and consider blood PCR
- If positive, treat as neonatal HSV
- If negative, d/c home
18
Q
What is the management for an infant born by SVD to a mom with recurrent HSV at delivery?
A
- Swab mucous membranes at 24 hrs (PCR and cultures). Consisder blood PCR
- If positive, treat as neonatal HSV
- If negative, d/c home
**This is because baby is presumed to have HSV antibodies from transplacental transfer
19
Q
What is the management of asymptomatic infants whose mothers have no active lesions at delivery?
(including women on ACV prophylaxis ? from 36 weeks)
A
- Does NOT need swabs or acyclovir therapy
- Infant whose mother has a hx of HSV but no active lesions at delivery should be observed for signs of HSV but does NOT require ACV therapy
- Mucous membrane swabs are not routinely recommended for this infants
- If there were clinical evidence of HSV documented during 3rd trimester or near delivery, could consider mucous membrane swabs.
- Educate re. signs and symptoms of HSV infection
20
Q
Name 4 clinical scenarios in which you should consider neonatal HSV in the differential diagnosis?
A
- Infants started on IV antibiotics for suspected sepsis (especially infants with seizure or yielding abnormal CSF) who do not improve rapidly and have negative bacterial cultures at 24 hr incubation
- Infants admitted with pneumonia who do not improve after 24 hr on antibiotics
- Infants with unexplained bleeding or coagulopathy
- Infants started on IV antibiotics for suspected sepsis who are found to have unexplained hepatitis
21
Q
What is the management of HSV CNS disease?
A
- IV acyclovir x 21 days minimum
- Repeat CSF sampling near the end of 21-day course of therapy: if PCR remains positive, treatment should be extended with weekly CSF sampling and acyclovir stopped when negative PCR is obtained
- Suppressive therapy oral acyclovir x 6 months should be given to infants with CNS disease (double-blind RCT showing benefit in neurodev outcome)
22
Q
For infants on suppressive oral acyclovir treatment, what surveillance should they have?
A
Monthly CBC, BUN, Cr to rule out neutropenia and nephrotoxicity
23
Q
What are 4 risks of RBC transfusion in neonates?
A
- Transfusion-transmitted infections
- Acute volume or electrolyte disturbances
- Blood group incompatibilities (often mistransfusion errors)
- Adverse effects of leukocytes
- GVHD
- transfusion related acute lung injury (TRALI)
- Alloimmunization
24
Q
What is the combined risk of RBC contamination with viruses (Hep A, B, C, HIV)?
A
1 in 1-1.3 million
25
Two steps in treatment of perinatal hemorrhagic shock?
1. NS bolus at 10 ml/kg while waiting for blood
2. O neg PRBC 10-15 ml/kgCan give as a 1 min push of 20 ml to stabilize if acutely hypotensive, then 10 ml/kg/h
26
What are the suggested hemoglobin levels for transfusing infants with anemia of prematurity?-Week 1-Week 2-Week 3 and older(Cochrane review & Pint study)
\*\*\*Resp support = O2 need \> 25% or CPAP/I&V
Week 1:
- Resp support: 115
- No resp support: 100
Week 2:-
Resp support: 100
-No resp support: 85
Week =/\>3:
- Resp support: 85
- No resp support: 75
27
What were the short-term outcomes of neonatal transfusion trials (restrictive vs. liberal transfusion thresholds)? (5)
No difference in outcomes of mortality or morbidity in:
1. BPD
2. ROP
3. Growth
4. IVH
5. \*\*some reports of increased NEC with recent transfusion but unclear significance (found with restrictive policies)
28
What were the long-term outcomes of neonatal transfusion trials (restrictive vs. liberal transfusion thresholds)?
No difference in death or disability at 18-21 months CGA
29
Is there any evidence to support the use of Erythropoietin in anemia of prematurity?
Not currently except for families who withhold consent to transfuse with blood products
30
At what age does cross-matching blood become necessary for infants?
At 4 months of age they need a **FULL** cross match
-Prior to 4 months of age, if they get a **type and screen** AND there are **NO** antibodies, then you can give them **group-specific & Rh-compatible** blood **_without_** cross matching
31
In cases of massive hemorrhage, what kind of transfusion and blood products should neonatal patient receive?
If a large volume of blood is required, must use combined:
1. Blood transfusion
2. Replacement with **FFP** in order to avoid hyperkalemia and dilution of coagulation factors
32
Can transfusions be helpful to improve **weight gain** or to address **apnea of prematurity** when Hgb levels are higher than recommended thresholds?
NO!
Trials have shown no improvement in weight gain and only mild improvements in apnea (which are thought to actually be related to volume repletion). Only transfuse at recommended thresholds.
33
What are the 4 physiological competencies preterm babies must achieve before being eligible for discharge home?
1. **Thermoregulation:** maintain normal body temperature when fully clothed in an open cot
2. Control of breathing: **apnea free period** of at least 5-7 days
3. **Respiratory stability:** maintenance of SaO2 \> 90-95% in RA
4. Feeding s**kills/weight gain**
34
What is the definition of apnea of prematurity?
Cessation of breathing for:
1. Greater than 20 seconds OR
2. 10-20 seconds accompanied by bradycardia (HR \< 80) or desaturation (SaO2 \< 80% in infants \< 37 wks PMA)
35
Why do we wait up to 7 days spell free after discontinuing caffeine before saying apnea of prematurity has resolved?
Caffeine has prolonged half-life in neonates (up to 100 h) and infants may be at risk for recurrence of apnea for several days after discontinuation
36
How long does apnea of prematurity generally last for?
Most resolve by 36 wks PCA but in very preterm infants, may take up to 44 wks PCA
37
Is apnea of prematurity a risk factor for SIDS?
No!
38
Is there a difference in morbidity for preterm infants where SaO2 targets are low (89-94%) vs. high (95-100%)?
**Yes** - for babies with higher target SaO2,
* increased **respiratory morbidity** (pneumonia, acute exacerbations of chronic lung disease, need for diuretics and/or oxygen)
- No difference in growth or neurodevelopment in either group-Might have reduction in ROP with higher SaO2 targets (but results were nonsignificant)
39
What is the target SaO2 for infants with BPD?
90-95%
40
Before discharge home, what 8 things must be completed for a preterm infant?
1. **Screening procedures:**
a. Provincial newborn screening- NMS
b. Hearing screen
c. HUS at near-term (if indicated by GA)
d. ROP screening (if indicated by GA or BW)
2. **Immunisations**:
a. Assessment for RSV prophylaxis
b. Immunizations: Hepatitis B etc
3. **Exam**: Predischarge physical examination including measurement of weight, length and head circumference:
4. **Other**; Successful SaO2 monitoring in car seat..??
7.
8.
41
Before discharge of a **preterm infant,** what education should the family receive (4)?
1. Safe **sleep practices and SIDS** prevention
2. Infant **CPR** (highly recommended)
3. Understand **infection** control measures
4. Understand importance of **smoke**-free environment
42
Why is early (ie. in the first week of life) postnatal corticosteroid therapy NOT recommended in preterm infants to prevent CLD?
Increased risk of cerebral palsy and poor neurodevelopmental outcome-multiple systemic reviews reported this finding, especially with dexamethasone
43
What is the commonly used definition of chronic lung disease/bronchopulmonary displasia?
Need for O2 at CGA of 36 weeks + respiratory symptoms + compatible changes on CXR
44
What is the DART trial?
Dexamethasone: a randomized trial-looked at low-dose dexamethasone (0.15 mg/kg/d, tapered over 10 days for cumulative exposure of 0.9 mg/kg) for decreasing CLD-found low dose dex shortened duration of intubation for ventilator-dependent infants-unfortunately study was terminated early due to declining enrolment and was not sufficiently powered to detect long term outcomes
45
What is the current evidence on use of low-dose dexamethasone in preventing CLD?
Currently, there is insufficient evidence to demonstrate the safety of ROUTINE low-dose dexamethasone use
46
What is the current evidence on use of high-dose dexamethasone in preventing CLD?
This is NOT recommended!-grade A evidence
47
What is the current evidence on:-routine use of hydrocortisone in preventing CLD?-routine use of inhaled corticosteroids in preventing CLD?
Hydrocortisone: NOT recommended! -multiple meta-analyses showing no benefits compared to dexamethasoneInhaled corticosteroids: NOT recommended-no RCTs available
48
When may be an appropriate time to use late dexamethasone therapy for preventing CLD?
Can consider use for infants who are at high risk of severe CLD or who are ventilator-dependent for severe CLD-low dose dexamethasone (0.15-0.2 mg/kg/day) in tapering doses over a short course (7-10 d)
49
What is the risk of congenital malformations seen with the use of SSRIs during pregnancy? -with which SSRI is there inconclusive evidence for causing congenital malformations?
Multiple studies show that SSRIs are unlikely to be associated with an increased risk of congenital malformations -some studies found that paroxitine may lead to small increased risk of cardiac malformations but evidence is inconclusive
50
What are the clinical features of SSRI neonatal behavioural syndrome (SNBS)? -does timing of SSRI use in pregnancy affect the risk of developing SNBS?
Tachypnea, cyanosis, tremors, increased muscle tone, feeding disturbance seizures, in 10-30% of babies exposed to SSRIs in utero -s/s present within hours, are mild and usually resolve within two weeks -unclear whether related to withdrawal, toxicity following in utero exposure or combo of both -increased risk of SNBS if exposure to SSRI is late in gestation as opposed to early
51
What are the possible side effects on newborn from SSRI exposure in utero (2)?
1. SSRI neonatal behavioural syndrome
2. PPHN (this is negligible though since absolute risk is \< 1%)
52
What is the recommendation for use of **paroxetine** in pregnancy?
No conclusive evidence that paroxetine use causes cardiac malformations -BUT care providers may choose to switch them to another antidepressant or reducing the dose if they wish
53
What is the recommendation regarding **monitoring** for newborns exposed to SSRI in utero?
Babies with **late trimester SSRI** exposure should be observed in hospital for **neurobehavioural or respiratory symptoms** for a minimum of 48 hrs
54
What are the physiological responses to laryngoscopy/intubation? (4)
1. **Bradycardia** (vagal response)
2. **Hypoxia**
3. Intracranial **hypertension** (coughing/struggling)
4. **Systemic** and **pulmonary** **hypertension** (catecholamine release in response to pain)
55
What premedications can dampen physiologic responses to intubation in a newborn?
1. Bradycardia --\> atropine
2. Hypoxia --\> oxygen
3. Intracranial hypertension --\> muscle relaxants
4. Systemic hypertension --\> analgesia
56
Under what 2 clinical circumstances is it acceptable to intubate an infant without the use of premedication?
1. Resuscitation in delivery room or during acute deterioration 2. Infants with severely abnormal airways who will be difficult to intubate
57
What is a rare potential side effect of fentanyl?
Chest wall rigidity: can be treated with immediate administration of rapid acting muscle relaxant
58
What are 2 contraindications to the use of succinylcholine in neonatal intubation?
1. Family hx of malignant hyperthermia (autosomal dominant) 2. Hyperkalemia
59
What is the recommended protocol for neonatal premedication (agent and dose)?
1. Fentanyl 3 mcg/kg slow infusion over 1 minute 2. Succinylcholine 1 mg/kg 3. Atropine 0.02 mg/kg IV (minimum dose available is 0.1 mg)
60
What is the definition of late prematurity?
GA 34+0-36+6
61
After the birth of a late prem baby, what monitoring should take place?
1. Core temperature 2. Blood glucose at 2 hr of life 3. Vital signs Overall short term observation for cardioresp stability and ability to feed before transfer to low risk nursery
62
List the postdischarge problems of the late preterm that may lead to readmission (5)
1. Hypothermia 2. Apnea/ALTE 3. Hyperbilirubinemia 4. Suspected sepsis 5. Respiratory issues
63
How do bilirubin levels differ in late prem infants compared to term infants? (4)
1. Peaks later (at 7 days as opposed to 5 days) 2. Reaches higher peak 3. Stays elevated for longer 4. Risk of kernicterus at lower levels of bilirubin
64
What is the discharge criteria for late preterm infants?
1. Bilirubin must be checked by 48 hrs of birth 2. 24 hrs of successful feeding must be established -first time moms need careful supervision and should have a room-in experience when leaving NICU -individual feedings should not be \> 20 mins -feeding and prep for feeding should not \> 6 hrs of the day at discharge -early weight loss should not \> 10% of body weight 3. If hx of apnea, needs to be apnea free \> 8 days 4. No hypoglycemia 5. Able to maintain normal body temperature
65
What is the recommendation on monitoring for apnea of prematurity in late prem infants?
Babies 34+0-34+6 wks GA require cardioresp monitoring x 12-24 hrs -if apnea is identified, need a period of 8 days apnea free -discharge on caffeine is not recommended
66
When should a follow up appointment occur post discharge of a late prem baby?
Within 48 hrs
67
In a clinically unwell newborn, what is the approach for ruling out early-onset sepsis?
Full septic work-up REGARDLESS of what risk factors were or were not present (ie. GBS status, intrapartum abx = even if GBS negative, woman could become colonized after swab was done; IAP with penicillin does not affect frequency of other bacterial causes of sepsis), then immediate start of empiric abx
68
What is the gram stain result of the following organisms: -GBS -Listeria -E coli
GBS: gram positive cocci Listeria: gram positive rods E coli: gram negative rods
69
What is the management of a well-appearing infant of a GBS positive mother who received IAP of penicillin \> 4 hrs before delivery?
No intervention! -\> 4 hrs intrapartum penicillin significantly reduces risk of early onset GBS
70
What is the management of a well-appearing infant of a GBS-positive mother who received IAP
Do a CBC: if WBC 5, then clinical observation x 24 hrs. \*\*Risk of early onset GBS in this population is 1% -if WBC
71
What is the management of a well-appearing infant of a GBS-negative mother who had risk factors at delivery?
CBC: if normal, monitor x 24 hrs. If WBC \< 5, FWSU
72
What are the risk factors for early GBS sepsis? (6)
1. Intrapartum fever 2. ROM \> 18 hrs 3. GBS bacteruria 4. Previous child with invasive GBS disease 5. Maternal chorioamnionitis 6. Prematurity \< 36 wks
73
What is the management of a well-appearing infant of a mother with unknown GBS status and no risk factors?
No intervention
74
What is the management of a well-appearing infant of a mother with unknown GBS status with risk factors?
If mom received adequate intrapartum abx, then no intervention. If not, then check CBC: if WBC \< 5, FSWU. If WBC normal, then monitor x 24 hrs.
75
What is the definition of: -severe hyperbilirubinemia -critical hyperbilirubinemia
Severe: TSB \> 340 at any time during the first 28 days of life Critical: TSB \> 425 at any time during the first 28 days of life (risk of kernicterus)
76
What is the definition of acute bilirubin encephalopathy? -chronic bilirubin encephalopathy?
Acute bilirubin encephalopathy: in severe hyperbilirubinemia, clinical features of lethargy, hypotonia, poor suck --\> may progress to hypertonia, high pitched cry, fever, seizures and coma Chronic bilirubin encephalopathy: sequelae of acute encephalopathy with athetoid cerebral palsy +/- seizures, developmental delay, hearing deficit, oculomotor disturbances
77
When should a DAT be performed for jaundiced neonate?
DAT should be performed only if: 1. Mom's blood group is O -and- 2. Baby is clinically jaundiced -and- 3. Baby's bilirubin level is in low-intermediate or high-intermediate zone (risk of needing PT)
78
What are the risk factors (8) on the phototherapy graph that affects whether you use the lower, medium or high risk line?
Lower risk: \> 38 weeks and well Medium risk: \> 38 weeks with risk factors or 35-37+6 wks and well Higher risk: 35-37+6 wks and risk factors Risk factors: 1. Isoimmune hemolytic disease 2. Respiratory distress 3. Significant lethargy 4. Acidosis 5. Sepsis 6. G6PD deficiency 7. Asphyxia 8. Temperature instability
79
What are the 4 ethnic groups in which you should consider ordering G6PD testing in cases of hyperbilirubinemia?
1. Middle eastern 2. Mediterranean 3. African 4. Southeast Asian
80
If G6PD deficiency is X-linked, do you need to order this test for female babies with jaundice if they fit into the ethnic groups at risk?
YES! Still order because females can have X inactivation and thus have 50% of their red cells be deficient in G6PD and have severe jaundice from this
81
When should you consider G6PD deficiency testing in neonatal jaundice?
1. In babies with clinical jaundice who belong to at risk ethnic groups 2. Babies with severe hyperbilirubinemia (TSB \> 380) \*\*\*note: in active hemolysis, G6PD testing is not reliable due to increased reticulocytes obscuring the results
82
When should the first bilirubin level be checked in infants?
Within 24-72 hrs of life
83
Are transcutaneous bilirubins acceptable? -limitations?
Transcutaneous bilirubin as a screening device is reasonable -more accurate at lower levels of bilirubin -may be unreliable after initiation of phototherapy and changes in skin color and thickness
84
What are the side effects of phototherapy? (3)
1. Temp instability 2. Intestinal hypermotility/diarrhea 3. Disrupted maternal-infant bonding \*\*mild increase in water loss from skin but this is not clinically important in term babies who are drinking well
85
What is the recommendations for the use of IVIG in neonatal jaundice?
Useful for newborns with hemolytic jaundice (positive DAT who have predicted severe disease based on antenatal investigation) -1 g/kg
86
What is the recommendation for supplemental fluids for neonatal jaundice?
Supplemental fluids can be administered orally or IV in infants receiving phototherapy who are at elevated risk of progressing to exchange transfusion
87
After the initiation of phototherapy for neonatal jaundice, when should the first repeat of bilirubin be completed?
Within 2-6 hr of initiation of treatment to confirm response
88
What blood tests should be completed prior to exchange transfusion?
Since exchange transfusion means giving the infant someone else's blood, need to collect blood to investigate for hemoglobinopathies, enzymopathies, and membranopathies.
89
What is the management for an infant with clinical signs of acute bilirubin encephalopathy?
Immediate exchange transfusion
90
Perinatal brachial plexus palsy has been associated with what risk factors? (4)
1. Shoulder dystocia 2. LGA 3. Maternal diabetes 4. Instrumental delivery \*\*No proven causative correlations though and it is not always preventable (might have occurred in utero)
91
What percentage of babies with perinatal brachial plexus palsy will have permanent impairment and disability
25% -if physical examination shows incomplete recovery by 1st month, full recovery is unlikely
92
If perinatal brachial plexus palsy shows incomplete recovery by the end of the first month, what are the management steps?
Referral to multi-d brachial plexus team: neurologists/rehab/plastic surgeons -no RCTs evaluating nonsurgical management vs surgical management
93
What changes are seen on CXR for a baby with RDS (3)?
1. Ground glass opacities 2. Decreased lung volume 3. Air bronchograms
94
What are the proven benefits of surfactant therapy (5)?
1. Reduced mortality 2. Decreased duration of ventilatory support 3. Decreased incidence of pneumothorax and pulmonary interstitial emphysema 4. Decreased hypoxia 5. Improved neurodevelopmental outcome
95
Which clinical circumstances warrant the use of exogenous surfactant therapy? (4)
1. Intubated infants with RDS 2. Intubated infants with meconium aspiration syndrome requiring more than 50% oxygen -meconium deactivates surfactant leading to secondary surfactant deficiency 3. Sick newborns with pneumonia and an oxygenation index \> 15 -decreases the need for ECMO 4. Intubated newborn infants with pulmonary hemorrhage leading to clinical deterioration (not great evidence)
96
What are the three short-term risks of surfactant administration?
1. Bradycardia and hypoxemia during instillation 2. ETT blockage 3. Increased risk in pulmonary hemorrhage
97
Which is better: natural or synthetic surfactants? Why?
Natural has been found to be better: improve survival with lower incidence of airleak
98
Should surfactant be given prophylactically or as rescue therapy?
For infants who are at significant risk of RDS, prophylactic natural surfactant therapy should occur as soon as they are stable within a few minutes after intubation
99
What is the evidence on using multiple or single doses of surfactant? -criteria and timing of multiple doses?
In infants with RDS who have persistent or recurrent oxygen and ventilatory requirements within the first 72 hours of life, they should have repeated doses of surfactant -using more than 3 doses does not have any benefit \*\*\*For repeated doses, criteria to give would be if there is persistent or recurrent O2 requirement of 30% or more \*\*\*Can give surfactant as early as 2 hr or 4-6 hrs after first dose
100
After prophylactic surfactant therapy is given, what are the next management steps for ventilation?
Remember that giving surfactant can cause rapid improvement in lung compliance so must be able to wean vent settings appropriately -can consider rapid weaning and extubation to CPAP within 1 hr of surfactant if clinically well
101
What is the recommendation for antenatal steroids in threatened preterm labor?
Threatened preterm labor \< 34 weeks should all be given antenatal steroids -reduces RDS and IVH
102
What is the recommendation on whether prems should receive surfactant prior to transport?
They SHOULD!
103
What is kangeroo care? -benefits?
Practice of skin-to-skin contact between infant and parent -Benefits for prems/low birth weight in low income countries: reduced mortality, severe illness, infection, length of hospital stay -Benefits in high income countries for same population: cardioresp and temp stability, improved sleep, neurodevelopmental outcomes, breastfeeding, maternal bonding and family health
104
At a cellular level, what are the 3 phases of brain injury in hypoxic ischemic encephalopathy?
1. Primary phase: reduced blood flow and oxygen supply --\> anaerobic metabolism in the brain --\> lactic acidosis, release of excitatory amino acids, possible cell necrosis 2. Latent phase (after resuscitation and reperfusion): normalization of oxidative metabolism lasting 6-12 hr (therapeutic window for neuroprotective interventions) 3. Secondary phase: develops at 12-36 hr, lasting 7-14 days with cell apoptosis, edema, release of free radicals and cell death
105
What are the 4 neuroprotective mechanisms of mild hypothermia in HIE?
1. Cessation of cell apoptosis 2. Reduced oxygen consumption 3. Reduced release of free radicals/nitric oxide/glutamate/excitatory neurotransmitters 4. Induction of genes that reduce neuronal death
106
Name 2 ways to provide brain hypothermia for HIE patients?
1. Selective head cooling (cooling cap for head and radiant heater for body) 2. Total body cooling (cooling blankets) \*\*Both have been shown to be effective in clinical trials
107
What are 2 concerns with use of hypothermia in infants with severe encephalopathy?
1. Decreased benefit 2. Delays end of life decision making for infants with extremely poor prognosis
108
What are the criteria that must be met in order to quality for hypothermia in HIE? -4 categories
1. Gestational age 36 wks and older AND 2. Age \< 6 hrs AND 3. Meet both criteria A and B Criteria A (think ABG): need 2/3 -APGAR score \< 5 at 10 mins of age -Breathing: continued need for ventilation and resuscitation at 10 mins of age -Gas: metabolic acidosis with pH \< 7 or base deficit \> 16 in cord or ABG measured within 1 hr of birth Criteria B (think encephalopathy): -moderate (Sarnat stage II) or severe (Sarnat stage III) demonstrated by presence of seizures OR one sign in at least 3/6 categories of the clinical features chart (LOC, spontaneous activity, neuromuscular control, primary reflexes, autonomic system, seizures, EEG findings)
109
Where should hypothermia be provided for HIE?
Level III NICU or in consultation with level III neonatologist before transport
110
What are 2 contraindications to cooling for HIE?
1. Severe head trauma 2. Intracranial bleeding \*\*\*Hypothermia can induce mild platelet dysfunction, disrupt coagulation cascade
111
What is the target temperature to be reached during cooling for HIE?
34 +/- 0.5 degrees rectal
112
How long does cooling last in management of HIE?
48-72 hrs
113
How should an infant be rewarmed in hypothermia management for HIE?
Increase rectal temperature by 0.5 degrees celcius every 2 hrs
114
What are 2 risks of rewarming in HIE?
1. Seizures 2. Worsening encephalopathy
115
What are the possible side effects of hypothermia (4)?
1. Bradycardia 2. Hypotension 3. Cardiac arrhythmias 4. Thrombocytopenia
116
What 4 groups are at risk for neonatal hypoglycemia?
1. SGA: decreased substrate 2. LGA: usually increased insulin 3. Prematurity: usually decreased substrate 4. Infants of diabetic mothers
117
What is the definition of SGA and LGA?
SGA: weight \< 10th% LGA: weight \> 90th%
118
How long should hypoglycemia monitoring continue for infants of diabetic mothers and LGA infants?
If these babies present with hypoglycemia, studies have shown that they present within the first 12 hrs of birth -if BG maintained \> 2.6 by 12 hr of age, can d/c BG checks
119
How long should hypoglycemia monitoring continue for SGA and premature infants?
These babies are vulnerable to hypoglycemia up to 36 hrs of age (and beyond if feeding not well established) -if glucoses have been \>2.6 and feeding has been established, can d/c glucose checks at 36 hr
120
Which babies should be tested for hypoglycemia after delivery and when should testing occur?
1. At-risk babies at 2 hrs of age (after an initial feed) and continued until the period of risk is considered over 2. Symptomatic infants
121
Are glucose levels \< 2.0 worrisome in healthy newborns?
Population data suggests that blood glucose levels as low as 2.0 or even 1.8 at 1 hr of age are not uncommon and there is no evidence that there are adverse effects! -in at risk infants however, persistent hypoglycemia at this level may have negative neurodevelopmental outcomes
122
What are the recommendations for hypoglycemia monitoring in asymptomatic, at-risk babies?
1. Asymptomatic at risk babies should receive at least one effective feed before a BG check at 2 hrs of age -if BG \< 1.8 at 2 hr of age despite one feed OR \< 2.0 at subsequent feeding, start IV dextrose infusion (D10W at TFI 80); can also try a mini-bolus of 2 cc/kg of D10W 2. Check BG q3-6 hr after. 3. For at risk babies who repeatedly have BG levels \< 2.6 despite subsequent feeds, start IV dextrose infusion (D10W at TFI 80)
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In hypoglycemic babies being treated with IV dextrose infusion, what should the target BG be? -when should BG be rechecked after making a change in glucose infusion rate?
\> 2.6 -check BG 30 minutes after making a change to GIR
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If glucose infusion rate needed to maintain BG \> 2.6 in a neonate is \>10.4 mg/kg/min (D12.5 at TFI 120), what are the next management steps?
1. Specialist referral 2. Pharmacological intervention (IV glucagon, hydrocortisone, diazoxide, octreotide) 3. Critical sample
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What is the dose for glucagon IV? -bolus -infusion
Glucagon IV bolus 0.1-0.3 mg/kg Glucagon infusion 10-20 mcg/kg/h
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In a hypoglycemic baby, when can IV dextrose be weaned?
Wean when BG levels have been stable for 12 hr
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Should screening glucoses be checked in term, appropriate for gestational age infants?
NO!
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Which newborns should be routinely screened for neonatal hypoglycemia? (4)
1. LGA 2. SGA 3. Prem 4. IDM
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When should babies with symptomatic hypoglycemia be treated?
If BG \< 2.6
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What is the management of asymptomatic at risk infants with blood glucose levels of 1.8-2.5?
Enteral supplementation may be used to augment caloric intake with rechecks of BG in 60 minutes -if fails to respond, then must be treated with IV dextrose infusion
131
What are the 3 phases of grief and mourning?
1. Avoidance or protest 2. Confrontation and disorganization 3. Accomodation or reorganization
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Which babies should be car-seat tested prior to discharge home from hospital?
1. Premature babies born at \< 37 wks 2. Babies with cardiorespiratory or neurological abnormalities (ie. hypotonia) \*\*Overall, little evidence available for health care benefits or economic impact of recommendations for testing infants in car seats before hospital discharge
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What is the generally accepted definition of cardiorespiratory abnormalities during a pre discharge car seat testing? -what happens to babies who fail car seat testing?
Two or more episodes of oxygen desaturation (\<88%) for 10 seconds or more during a 90 minute monitoring period -if babies fail car seat testing but are otherwise healthy, may be sent home in a recumbent car restraint if repeat testing in the recumbent position is satisfactory -if not, then need continued hospitalization
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Where is endogenous nitric oxide produced and how does it work?
NO is made by lung endothelium by NO synthase --\> diffuses into vascular muscle cells --\> activates guanylate cyclase --\> pulmonary vasodilation and improved V/Q matching
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What are the benefits of iNO for PPHN shown by multiple prospective clinical trials? (2)
1. Decresaed incidence of death 2. Decreased need for ECMO
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What are the indications for use of iNO? -OI threshold to start iNO?
Infants equal to or greater than 35 wks GA with hypoxemic respiratory failure who fail to respond to appropriate respiratory management (ie. optimizing mechanical ventilation, surfactant, HFO/JET) -start for OI \> 20-25 or if PaO2 remains less than 100 mmHg, despite optimal ventilation with 100% oxygen
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What is the evidence for use of iNO in preterm infants?
Not effective as rescue or routine treatment for preterm infants -don't use in prems!
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What is the recommended starting dose of iNO for term infants?
20 ppm -expected response is rapid given half life of iNO is 2-6 s -if no response, can increase up to 40 ppm
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What criteria should be met before iNO is weaned? (3) How do you wean iNO?
1. Improved oxygenation with inspired O2 need down to 60-80% 2. 4-6 h of stability 3. OI \< 10 Wean iNO: 1. Decrease by 50% at 4-6 hr intervals until reach 5 ppm 2. Once at 5 ppm, need to decrease more gradually --\> decrease by 1 ppm q4h and discontinue at 1 ppm if infant remains well oxygenated in \< 60% oxygen
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What are the toxic side effects of iNO? (4)
1. Nitrogen dioxide production -cytotoxic and can cause pulmonary injury -unlikely with iNO \< 80 ppm 2. Methemoglobin production -NO in blood binds to ion of heme protein which is oxidized to methemoglobin -should be measured frequently and kept \< 2.5% -unlikely with standard iNO doses 3. Decreased platelet function and increased risk of bleeding 4. Surfactant dysfunction
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Who should get ROP screening? -when do you start screening?
Who? 1. 30+6 wks or less 2. 1250 g or less When? -If 26+6 or less, screen at 31 weeks -if 27 wks or greater, screen at 4 wks of age
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What are the normal retic levels in term baby?
5% in term
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What is the definition of and causes of the following types of hemorrhagic disease of the newborn? -"early"? -"classic"? -"late"?
Early: occurs within the 1st 24 hrs -caused by mothers taking drugs that impair vitamin K metabolism Classic: occurs within the 1st week of life -caused by no vitamin K administration at birth Late: occurs at 3-8 wks of life -caused by breastfeeding from mom with vitamin K deficiency OR late effects of not receiving vitamin K at birth
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Does IM vitamin K provide complete protection from hemorrhagic disease of the newborn?
Does not provide compelte protection from late HDNB, especially in breastfed infants whose oral intake of vitamin K is low
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What is the recommendation on vitamin K administration for neonates?
Vitamin K should be given as a single IM dose (0.5 mg for BW \< 1500, 1 mg for BW \> 1500) to all newborns within the first 6 hrs after birth
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What is the recommendation for neonates in which parents refuse the IM Vitamin K?
Offer oral dose of 2 mg vitamin K at the first feeding -conflicting evidence regarding efficacy of oral vitamin K versus IM (some studies show it is just as good, other studies show it doesn't protect as well against late HDNB) -needs to be repeated at 1 and 2 months -need to warn parents that their baby is at risk of late HDNB with potential for intracranial hemorrhage using the oral vitamin K
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What are the long term effects of late postnatal corticosteroids?
1. HOCM 2. Increases ROP but NOT blindness
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What is the diagnostic criteria for FAS? (3)
1. Prenatal or postnatal growth restriction 2. CNS involvement: neurological abnormalities, developmental delay, behavioural issues, etc. 3. Characteristic facial features: a. short palpebral fissures b. thin upper lip c. indistinct philtrum d. flattened cheek bones
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What is the definition of "possible fetal alcohol effects"?
FAE = alcohol is considered as one of the possible causes of a child's birth defects -for children with prenatal exposure to alcohol but only some FAS characteristics
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What is the incidence of UTI in uncircumcised boys vs. circumcised boys?
Incidence of UTI in 1st year of life for uncircumcised = 1% for circumcised = 0.1%. -Circumcision decreases the incidence rate of UTI by 10-fold or more. BUT... the incidence rate of UTI among infant boys is only 1-2% overall
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What are the complications of circumcision? (5) -what is the rate of complications? -why is the rate important to know when discussing circumcision with parents?
1. Bleeding 2. Amputation of glans 3. Sepsis 4. Acute renal failure 5. Death -rate of complications: 2% -important to know and tell parents because the rate of complications of circumcision approaches or even exceeds the incidence of UTI among uncircumcised male infants
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What is the strongest factor associated with the decision about whether to circumcise a male infant for a parent?
Whether his father was circumcised
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What are the effects of circumcision on penile cancer and HIV?
Some reports that circumcision reduces incidence of penile cancer and HIV transmission - however, there is inadequate info to recommend it routinely as a public health measure
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What is the classification of ROP?
5 stages and pre-plus disease or plus disease 1. Stage 1: LINE separating avascular from vascularized retina 2. Stage 2: RIDGE in region of demarcation line 3. Stage 3: NEOVASCULARIZATION 4. Stage 4: Partial retinal detachment 5. Stage 5: Total retinal detachment Pre-plus disease: more vascular tortuosity than normal but insufficient for diagnosis of plus disease Plus disease: vascular dilatation and tortuosity of at least 2 quadrants of the eye
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What is the treatment for ROP?
Retinal ablative therapy = decreases production of angiogenic growth factor to decrease abnormal blood vessel growth
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What are the risks of early postnatal steroids for CLD? ie. WHY DO WE NOT GIVE THEM? (4)
1. Increased CP and neurological outcomes 2. Hyperglycemia 3. Hypertension 4. Increased GI hemorrhage
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What are the pros of late postnatal low dose steroids for CLD? (5)
1. Decreased O2 need 2. Decreased ventilation time 3. Decreased mortality 4. Decreased number of babies discharged on O2 5. Decreased CLD at 36 wks
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What factors have effect on prognosis of extremely premature infants? (6)
1. Gestational age: strongest effect2. Birth at tertiary perinatal centre3. Female sex4. Birth weight5. Multiplicity6. Antenatal corticosteroid therapy
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What are the recommendations on C-sections for possible delivery of extremely preterm infants?
Not recommended before 24 weeks GA unless for maternal indications
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What level of care is recommended for infants born at 22+0 - 22+6 wks GA?
Since survival is uncommon, a non interventional approach is recommended with a focus on comfort care
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What level of care is recommended for infants born at 23-25 wks GA?
Should be joint decision made by family and health care team (individualized plan)
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What level of care is recommended for infants born \> 25 wks GA?
Most infants \> 25 wks GA have improved survival and neurodevelopmental outcomes so active treatment is appropriate except when there are significant additional risk factors (weak recommendation)
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What 3 questions should you ask when called to newborn delivery? (ie. start of NRP algorithm)?
1. Term? 2. Crying or breathing? 3. Tone?
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What are the initial steps of NRP when the newborn is delivered?
1. Warm 2. Dry 3. Clear the airway if needed 4. Stimulate 5. Then check HR and breathing
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What is the "Golden Minute" of NRP?
PPV if needed should be provided within 1 minute of delivery!
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What is the most important indicator of PPV effectiveness?
Rise in HR!
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When you initiate PPV for a neonate, what should also be completed? -starting oxygen level for all babies? -when do you crank up to 100%?
Preductal oxygen saturation placed! -starting O2 level = Room Air!!! -for very preterm babies, may use 30-90% guided by pulse oximetry but evidence is unclear -crank up to 100% if chest compressions are needed
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In what babies can laryngeal mask airway be used?
Must be \> 34 weeks and \> 2000 g
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A baby is born and has no detectable heart rate despite resuscitative efforts. When is it appropriate to consider discontinuing resuscitative efforts?
After 10 minutes of resuscitative efforts with no detectable heart rate.
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True or false: infants who deliver at less than 29 wks GA outside of a tertiary centre should be considered for immediate intubation followed by surfactant administration after stabilization, regardless of whether they are symptomatic or not, as long as competent personnel are available.
TRUE!!!! This is one of the MCQs.
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What is a possible complication of Epo in neonates?
Increased ROP (this is POSSIBLE, not certain though)
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What are the risks of a prolonged NICU stay? (5)
1. Poor coping by parents 2. Financial burden on family 3. Nosocomial infection 4. FTT 5. Poor parental bonding
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What is the most accurate way of estimating GA?
Early U/S
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What is the survival rate of the following: -23 wk -24 wk -25 wk
23 wk: 40% 24 wk: 60% 25: 80%
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What are the risks for fetus/newborn in a depressed mother? (6)
1. Risk of preterm labor 2. Risk of miscarriage 3. Risk of resp distress at birth 4. Maternal suicide 5. IUGR 6. Increased length of hospital stay for baby
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Which baby is more likely to be readmitted for issues? -34 wk -35 wk -36 wk -what is the risk of CP in a late preterm baby compared to term baby?
36 wker because they're the ones who are most likely to be sent home early! -3x risk of CP in late preterm baby compared to term baby
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What should the temperature of the home be for a lightly dressed infant sleeping in a cot?
18 degrees celcius
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What is the classical triad of chorioamnionitis?
1. Fever 2. Left shift 3. Lower uterine tenderness
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What GA should you consider prophylactic surfactant administration outside of a tertiary care centre?
Infants who deliver \< 29 wks outside tertiary care centre should be considered for immediate intubation and prophylactic surfactant if competent personnel are available.
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Newborn has first BG 1.9. You feed and check again in an hour and the BG is 2.4. What do you do?
IV treatment! Subsequent BG should be 2.6 or more!
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Which babies should get retinal ablative treatment for ROP? -when should treatment be performed in regards to when you discovered the finding?
1. Any stage of ROP with plus disease in zone 1 (because this is closest to your optic nerve) 2. Stage 3 with or without plus disease in zone 1 3. Stage 2 or 3 ROP with plus disease in zone 2 \*\*\*Treatment should be performed within 72 hrs of exam
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When do you stop screening for ROP?
1. Complete vascularizatino 2. 45 wks of age 3. Zone III vascularization without previous zone 1 or 2 issues 4. Regression of ROP \*\*\*zone 1 is closest to optic nerve, then zone 2, then zone 3
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Oximetry newborn What lesions are detectable using pulse oximetry screening? Mostly cyanotic
**Mostly cyanotic**
Hypoplastic left heart syndrome
Pulmonary atresia with intact ventricular septum
Total anomalous pulmonary venous return
Tetralogy of Fallot
Transposition of the great arteries
Tricuspid atresia
Truncus arteriosus
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Oximetry newborn What lesions are detectable using pulse oximetry screening? **May be cyanotic**
**May be cyanotic**
## Footnote
Coarctation of the aorta
Double outlet right ventricle
Ebstein’s anomaly
Interrupted aortic arch
Defects with single ventricle physiology
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Oximetry WHAT IS CRITICAL CONGENITAL HEART DISEASE and incidence?
* CHDis the most common congenital malformation, with a prevalence of 12/1000 live births in Canada.
* Approx25% these newborns have CCHD, defined as more severe and often duct-dependantlesions that require intervention early in life for optimal outcome
* In Alberta, from 2007 to 2010, only 50% of newborns with CHD requiring surgery before 1 year of age were diagnosed prenatally.
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Oximetry newborn How is it done?
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Oximetry newborn What gestational age is it done at at what age post birth?
Recommended for all newborns ≥34 wks
Between 24-36 hours post-birth (to lower false positives)
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Oximetry newborn What is the accuracy?
Why include one foot?
– 99% specificity
– 76% sensiitivity
• Right hand and one foot ensures a lower false positive
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Oximetry Newborn WHAT TO DO WITH A FAILED **POS** SCREEN?
1. thorough assessment by the most responsible health care provider, (nurse practitioner, Dr,/pediatrician).
2. An assessment -4 limb BP, an ECG and a CXR
3. if apears to be cardiac/unclear, a consult with **paediatric cardiology** followed by an **echocardiogram** is required to rule out CCHD.
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HSV What is the worldwide incidence of Neonatal HSV (NHSV)
75% of NHSV cases are caused by HSV-2
and 25% by HSV-1
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HSV How do you classify Maternal genital HSV?
1.**Newly acquired**
First-episode **primary** infection (mother has no serum antibodies to HSV-1 or -2 at onset);
First-episode **nonprimary** infection (mother has a new infection with one HSV type in the presence of antibodies to the other type); or
2. **Recurrent** (mother has pre-existing antibodies to the HSV type that is isolated from the genital tract).
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HSV How does the category of maternal HSV infection at time of delivery influences the likelihood of NHSV acquisition?
1. **first-episode primary** -transmission rates 60%,
2. **first-episode nonprimary,** transmission rates ≤30%
(because crossreactive antibodies are present)
3. maternal **recurrent infection** (at \<2%)
(because type-specific antibodies are present)
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HSV What type of HSV has the highest mortality?
Disseminated
(more common with newly acquired maternal HSV, presumably because there has not been sufficient time to transfer neutralizing antibodies in utero)
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Levels of care What are the Levels of care for the extremely preterm infant, based on risks for anticipated mortality or NDD
Infant born at 22 weeks GA, irrespective of additional risk factors\*\*\*
Infant born at 24 weeks GA, with an estimated weight of 350 g
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Levels of care What are the Levels of care for the extremely preterm infant, based on risks for anticipated mortality or NDD
Infant born at **23–24 weeks GA,** irrespective of most additional risk factors\*\*\*
Infant born at **25 weeks** GA, with signs of **fetal anemia** and **abnormal placental blood flow**
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Levels of care What are the Levels of care for the extremely preterm infant, based on risks for anticipated mortality or NDD
Infant born at **25 weeks** GA, without additional risk factors\*\*\*
Infant born **late in 24th week** of gestation (e.g., 24+5), **well grown with ANCS** given, born in a **tertiary care centre**
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Levels of care of extreme premature infants
What are the risk factors to consider?
1. **Baby:** SGA, multiple gestation, GA early within week of gestation, major congenital anomalies present on ultrasound.
2. M**aternal care:** absence of antenatal corticosteroids (ANCS), birth outside of a tertiary centre, acute chorioamnionitis,
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Levels of care
What is the "Survivors to NICU discharge" in newborns who received early NICU fo the following gesttaional ages?
22 +6
23-23+6
24-24+6
25-25+6
22 +6. 18%
23-23+6 41%
24-24+6 67%
25-25+6 79%
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Jaundice What are the phototherapy and Exch levels for term babies?
Day **Photo****Exch**
1 200. 325
2 260. 370
3 300 410
4 340 428
5 360
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Steroids in RDS What are the benefits?
Mortality and/or BPD at 36 wk decrease with moderately early (7-14 days) administration of corticosteroids.
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Steroids in RDS What are the short-term adverse effects?
1. **Metabolic**: hyperglycemia,
2. **CVS**: hypertension, HOCM
3. **GIT**: GIT bleeding, perforation, poor weight gain,
4. **Neuro**: poor growth of the head, higher incidence of PVL
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Steroids in RDS What are the long-term adverse effects?
Increased neurodevelopmental delay and CP
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What defines prematurity in newborns?
Liveborn infants delivered before 37 wk
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What defines LBW in newborns?
Birthweight of \< 2.5 kg (prem or IUGR, also ..SGA)
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What is the Prognosis of IUGR babies?
1. In the absence of congenital abnormalities, CNS injury, VLBW, the physical growth of LBW infants tends to **approximate that of term infants by the 2nd yr**
2. Infrequently, infants with IUGR (SGA) grow poorly and do not demonstrate catch-up growth. These infants may benefit from recombinant human GH therapy beginning **at age 4 yr.**
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Surfactant What are the indications for surfactant - CPS
1. **Intubated infants with RDS** should receive exogenous surfactant therapy
2. Intubated infants with **meconium aspiration syndrome** requiring \> 50% oxygen should receive exogenous surfactant therapy
3. Sick newborn infants with **pneumonia** and an **oxygenation index \> than 15** should receive exogenous surfactant therapy
4. Intubated newborn infants with **pulmonary hemorrhage** which leads to clinical **deterioration** should receive exogenous surfactant therapy as one aspect of clinical care
5. Infants who deliver at **less than 29 weeks gestation** outside of a tertiary centre should be considered for immediate intubation followed by surfactant administration after stabilization, if competent personnel are available
6. Intubated infants with RDS should receive exogenous surfactant therapy before transport
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Surfactant What are recommendations for retreatment and other issues?
1. Infants with **RDS** who have **persistent or recurrent oxygen and ventilatory requirements within the first 72 h** of life should have repeated doses of surfactant. Administering \> 3 doses **has not been** shown to have a benefit
2. Retreatment should be considered when there is a persistent or recurrent oxygen requirement of 30% or more, and it may be given as early as 2 h after the initial dose or, more commonly, 4 h to 6 h after the initial dose
3. Options for ventilatory management that are to be considered after prophylactic surfactant therapy include very rapid weaning and extubation to CPAP within 1 h
**Other**:
Natural surfactants should be used in preference to any of the artificial surfactants available at the time of publication of this statement
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Neonatal jaundice What are the CPS Blood test recommendations?
1. All mothers should be tested for **ABO and Rh(D) blood types** and be screened for red cell antibodies during pregnancy
2. If the **mother was not tested,** **cord** blood from the infant should be sent for evaluation of the blood group and a DAT (Coombs test)
3. B**lood group** evaluation and a **DAT** should be performed in infants with **early jaundice** of **mothers of blood group O**
4. Selected at-risk infants (**Mediterranean, Middle Eastern, African or Southeast Asian origin**) should be screened for **G6PD deficiency**
5. A test for G6PD deficiency should be considered in all infants with severe hyperbilirubinemia (recommendation grade
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Neonatal jaundice What are the CPS definitions?
1. **Kernicterus**
2. **Acute bilirubin encephalopathy**
3. **Chronic bilirubin encephalopathy**
4. **Severe hyperbilirubinemia**
5**. Critical hyperbilirubinemia**
Neonatal jaundice What are the CPS definitions?
1. **Kernicterus** – the pathological finding of deep-yellow staining of neurons and neuronal necrosis of the basal ganglia and brainstem nuclei.
2. **Acute bilirubin encephalopathy** – a clinical syndrome, in the presence of severe hyperbilirubinemia, of lethargy, hypotonia and poor suck, which may progress to hypertonia (with opisthotonos and retrocollis) with a high-pitched cry and fever, and eventually to seizures and coma.
3. **Chronic bilirubin encephalopathy** – the clinical sequelae of acute encephalopathy with athetoid cerebral palsy with or without seizures, developmental delay, hearing deficit, oculomotor disturbances, dental dysplasia and mental deficiency
4. **Severe hyperbilirubinemia** – a total serum bilirubin (TSB) concentration greater than 340 µmol/L at any time during the first 28 days of life.
5**. Critical hyperbilirubinemia** – a TSB concentration greater than 425 µmol/L during the first 28 days of life
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Neonatal jaundice Who should have their bilirubin concentration measured, when and how?
1. Either TSB or TcB (skin) concentration should be measured in all infants during the first 72 h of life.
2. If the TSB concentration does not require immediate intervention, the results should be plotted on the predictive nomogram. The result of the TSB measurement, the time at which it was obtained and the zone should be recorded, and a copy should be given to the parents. Follow-up of the infant should be individualized according to the risk assessment
3. Any infant discharged before 24 h of life should be **reviewed within 24 h** by an individual with experience in the care of the newborn who has access to testing and treatment facilities
4. All newborns who are visibly jaundiced in the first 24 h of life should have their bilirubin level determined
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Neonatal jaundice How do you manage a baby with severe hyperbilirubinemia?
1. immediate intensive phototherapy.
2. Check SBR concentration within 2 h to 6 h \> Thrx Consideration of further therapy should commence and
3. Supplemental fluids are indicated
4. **IVIG** should be given if not already commenced for the infant with **isoimmunization**.
5. Preparations for **exchange transfusion** may be indicated.
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HSV Suppressive antiviral therapy What is the recommendation?
1. Babes with **CNS HSV or disseminated HSV with CNS involvement,** improved developmental outcomes if they were Rx **6 months of treatment of oral Acyclovir** after their treatment
2. Babes with SEM - decreased incidence of **skin recurrences** if they are given **6 mo. of oral Acyclovir**
**Both need** HSV Suppressive antiviral therapy, but for different reasons :)
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HSV Managing asymptomatic term infants whose mothers have active lesions at delivery- how do you decide what type of HSV the mother has?
N.B. Antibodies to HSV-1 / 2 (type specific HSV antibodies) take ~3wks to develop following infection
1. P**rimary infection:** When a mom has active lesions at time of delivery but **does not have type specific antibodies,** clinicians should presume it a newly acquired first-episode primary infection
2. **Non primary disease**: When she only has antibodies to the HSV type other than the type she is shedding, assume it is a 1st episode non primary disease
3. R**ecurrent disease:** When she has antibodies to both HSV-1 / HSV-2 this is likely to be a case of **recurrent disease**
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HSV How do you manage Neonates with HSV infection and exposed neonates (ID control)?
1. Neonates with **HSV infection** should be managed using **contact** precautions when mucocutaneous lesions are present and **until** lesions have crusted.
2. Asymptomatic neonates whose **mothers have active HSV lesions** should be managed using **contact precautions until the end of the incubation period (day 14)** or until s**amples from the infant taken after the first 24 h of life are negative.**
N.B. Some experts do not recommend contact precautions if an infected infant is born by Cesarean section and membranes are ruptured \<4 h to 6 h.
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HSV How do you manage Mothers with active HSV ID control? (5)
1. Mothers who are in hospital should be on **contact** precautions until their lesions have **crusted**.
2. Mothers with **herpes labialis** should wear a disposable **mask** when caring for their infant \<6 weeks of age, **until lesions are crusted.**
3. Advise these mothers **not to kiss** their infant.
4. There is **no contraindication** to breastfeeding **unless there**
**are herpetic lesions on the breast.**
5. Mothers with skin **lesions should keep them covered** whenever their newborn is present
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HSV How do you manage Staff with orofacial or skin HSV lesions? (3)
1. Staff with skin lesions due to HSV must practice **meticulous hand hygiene** & keep their **lesions covered,** If
this is not possible, direct care of neonates **should be avoided.**
2. Some experts recommend wearing a surgical mask to cover **orolabial lesions** because these cannot be covered by dressings.
3. Staff with active **herpetic whitlow s**hould avoid contact with neonates.
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