Fetus and Newborn Flashcards
Define the criteria for ROP screening
- GA of less than or equal to 30+6
- BW less than or equal to 1250g
- physician discretion
What risks factors increase a baby’s risk of developing ROP?
- GA less than or equal to 30+6
- BW less than or equal to 1250g
- severe and unstable respiratory disease
- hypotension requiring inotropes
- prolonged ventilators or oxygen therapy
When should the first screening for ROP be conducted?
At 31 weeks corrected gestational age or at 4 weeks chronological age - whichever comes later.
When can ROP screening stop?
- complete vascularization
- vascularization of Zone III without precious Zone I or II ROP
- CGA of 45 weeks and no prethreshold disease or worse ROP
- regression of ROP
Retinal ablation therapy should be considered for what conditions?
- Zone I - any stage of ROP with plus disease
- Zone I - stage 3 ROP with or without plus disease
- Zone II - stage 2 or 3 ROP with plus disease
- Threshold ROP (five or more contiguous or eight cumulative clock hours of stage 3 ROP in zone 1 or 2 in presence of plus disease)
What are the stages of ROP?
Stage 1: demarcation line between avascular and vascularized retina
Stage 2: ridge arises along demarcation line
Stage 3: extra retinal fibrovascular proliferation/neovascularization
Stage 4: partial retinal detachment
Stage 5: total retinal detachment
Pre-Plus: increase vessel tortuousity
Plus: vascular dilatation and tortuousity of at least 2 quadrants of the eye
List the zones of ROP staging from closest to retina outwards
Zone 1, 2, 3
What adverse events occur in greater frequency when a nonspecialized team transports a critically ill newborn, compared with a specialized team?
- airway problems
- loss of vascular access
- hypotension
- need for CPR
- increased mortality rate
What is the ideal composition of a neonatal transport team?
- one nurse and either: a) a second nurse, b) an RT, c) an EMT
Describe the qualities of a successful neonatal transport team.
- good leadership
- flexible
- independent
- critical thinking
- timely judgement
- problem solving skills
- strong interpersonal and communication skills
- appropriate crisis resource management skills
What are the benefits of transport teams having their own dedicated vehicles?
- more customization of equipment and supplies
- faster response times
How can a neonatal transport team reduce the environmental exposure of the neonate during transport?
- hypothermia: use warming mattress
- ambient noise: use ear muffs
- vibration: use air-foam mattress, gel pillows
What types of team policies and procedures are adhered to in neonatal transport teams?
- safety reporting
- risk management
- morbidity and mortality reviews
- uniform code
- professional codes of conduct
What is the primary goal for improving infant outcomes?
To minimize the response time and the transport time
Describe the types of training transport team members should receive.
- airway management
- procedural skills
- refresher skills courses
What is the best way to coordinate neonatal transports?
A single centralized access point with provincial/territorial coordination and integration of transport modes.
What are the most frequent indications for blood transfusion in the newborn?
- acute treatment of perinatal or surgical hemorrhagic shock
- “top-ups” for the recurrent correction of anemia of prematurity
How long are stored RBCs safe and effective for?
42 days
List the risks of transfusion.
- Transfusion-transmitted infections (viral, bacterial, parasitical, prional)
- Adverse effects of leukocytes (immunomodulation, GVHD, TRALI, alloimmunization)
- Acute volume or electrolyte disturbances
- Blood group incompatibilities
- ** GVHD, hemolytic rxns, alloimmunization, TRALI are rare in neonates, compared with adults***
What is the combined risk of RBC contamination with viruses (Hep A/B/C, HIV, HTLV)/
1 in 1.3 million
What is involved in pre transfusion testing?
- ABO grouping
- Rh typing
- screen for antibodies of maternal origin
List some of the etiologies of hemorrhagic shock in the neonate
- placental hemorrhage
- twin-to-twin transfusion
- fetomaternal hemorrhage
- velamentous insertion of the cord (at risk of vasa previa)
- cord rupture
What is the conventional volume range used for blood transfusion?
10-20cc/kg
What blood type should be used in the case of emergent blood transfusion?
O negative
What is a major risk of rapid and massive transfusion?
Hyperkalemia (due to wash contents, older blood = increased K content and increased risk of hyperkalemia)
What factors contribute to anemia of prematurity?
- physiologic anemia of the newborn
- suppressed postnatal response to erythropoietin
- increased blood sampling
- short RBC span in the newborn
- rapid increase in blood volume with growth
What are the transfusion thresholds recommended by the PINT study for a neonate without respiratory support?
- Week 1: 100
- Week 2: 85
- Week 3 and older: 75
What are the transfusion thresholds recommended by the PINT study for a neonate without respiratory support?
- Week 1: 115
- Week 2: 100
- Week 3 and older: 85
What is the dosage for iron supplementation and when should it be introduced for neonatal anemia?
- 2mg/kg/day
- between 4-6 weeks of age (at onset of reticulocytosis)
When is cross-matching of donor blood required?
Starting at 4 months
What are potential alternatives for transfusion in patients whose parents want to avoid transfusion?
- placental transfusion
- limited blood draws
- erythropoietin
- optimizing hematinics
What group of infants may require higher transfusion thresholds?
- infants with cyanotic heart disease
- infants with hemodynamic disorders
There was no difference in which outcomes when comparing restrictive and liberal transfusion thresholds?
- BPD
- signs of hemorrhagic or ischemic brain injury
- severe retinopathy of prematurity
Define chronic lung disease
The need for oxygen at 36 weeks postmenstrual age, together with respiratory symptoms and compatible changes on chest X-ray.
If dexamethasone is to be used to prevent CLD in at-risk infants, how and to whom should it be prescribed?
- after 7 days of age
- low-dose (0.15-0.2mg/kg/day)
- infants who are ventilator-dependent
- after receiving parental informed consent
List complications related to maternal depression during pregnancy
- risk of miscarriage
- preterm birth
- low birth weight
- respiratory distress
- increased length of hospital stay
What is SSRI neonatal behavioural syndrome?
A syndrome of respiratory, motor, CNS and GI symptoms, including tachypnea, cyanosis, jitteriness/tremors, increased muscle tone, feeding disturbance in infants exposed to SSRIs in utero. Generally mild and self-limiting
What are the risks of SSRI use in pregnancy?
- No risk of congenital malformations
- Inconclusive evidence that Paroxetine MAY be associated with small increased risk of cardiac malformations
- SSRI neonatal behavioural syndrome
- PPHN (especially with SSRI use in second half of pregnancy)
Are SSRIs a contraindication for breastfeeding?
No
Define extreme prematurity
22+0 to 25+6 weeks GA at birth
When counselling regarding the anticipated of extremely preterm birth, what information do parents report as being useful?
- likelihood of survival
- risk of disability
- medical treatments
- anticipated problems
- NICU experience
- Parenting and coping with stress
- Acknowledgement of their distress
In which pregnant women should antenatal corticosteroids be offered?
- at risk of extremely preterm birth up to 34 weeks
List the survival for an infant born at 22, 23, 24, 25 weeks GA.
- 22: 8%
- 23: 36%
- 24: 62%
- 25: 78%
List the severe adverse neurodevelopment outcomes related to extreme prematurity
- CP
- cognitive impairment
- seizures
- blindness
- deafness
List the predictive factors that contribute to prognosis when counselling anticipated extremely preterm delivery
- GA
- birth at tertiary perinatal centre
- antenatal corticosteroids
- female sex
- multiplicity
Define mourning
- cultural and/or public display of grief through one’s behaviour
List the three phases of grief and mourning
- Avoidance or protest
- Confrontation and disorganization
- Accommodation or reorganization
What is the average period of recovering from the loss of a baby for parents?
- 2 to 4 years
Who should initiate the discussion regarding withdrawal of care of an infant?
- medical team
List 5 critical attributes of the attentive care provider
- knowing
- being with or emotionally present to another
- doing for another
- enabling the other
- maintaining belief
How can we prevent early hemolytic disease of the newborn?
- Early HDNB occurs in first 24 hours of life
- Due to maternal vitamin K deficiency or use of medications that impair vitamin K metabolism
- Administer vitamin K to these mothers
How can we prevent classic hemolytic disease of the newborn?
- Classic HDNB occurs 2-7 days of life
- Due to infant’s deficiency of vitamin K
- Administer vitamin K to newborn infants
How can we prevent late hemolytic disease of the newborn?
- Late HDNB occurs at 3-8 weeks of life
- Occurs almost exclusively among infants who are breastfed, possibly also higher risk with oral vitamin K (instead of IM)
- Administration of IM vitamin K preferred over oral vitamin K
Which infants are considered at high risk of hemolytic disease of the newborn?
- those with failure to thrive
- those with longterm diarrhea
- those with liver disease
- those with pancreatic insufficiency
- ***In these infants, it is reasonable to consider administering further doses of Vitamin K
When should we give oral vitamin K? What is the dose?
- Repeated oral doses of vitamin K should be reserved for infants whose parents refuse IM administration of vitamin K following birth
- Vitamin K 2.0mg po at time of first feeding, repeated at 2-4 weeks and 6-8 weeks of life.
- Warn parents their infant is at increased risk for late HDNB and potential intracranial hemorrhage with this regimen
What is the recommended dose of Vitamin K at birth?
- Infants 1500g = 1.0mg IM
- Within first 6 hours of birth
Define RDS
- presence of acute respiratory distress with disturbed gas exchange in a preterm infant with a typical clinical course or X-ray (ground glass appearance, air bronchograms and reduced lung volume)
How does surfactant therapy alter mortality and morbidity in infants RDS?
- decreased mortality
- decreased air leaks
- decreased duration of ventilatory support
- improves oxygenation
- increases likelihood of surviving without BPD
- shorter hospital stays
- lower costs of intensive care treatment
- no increase in adverse neurodevelopment outcomes
Which infants should receive surfactant?
- Intubated infants with RDS
- Sick newborns with pneumonia and OI >15
- Infants with pulmonary hemorrhage and clinical deterioration
- Infants with meconium aspiration on >50% FiO2
- Infants at significant risk of RDS should receive it prophylactically as soon as they are stable within a few minutes after intubation
- Infants outborn and
How is surfactant administered?
- Natural preferred over synthetic
- Instilled in liquid form via endotracheal tube
- No evidence to support placing infant in multiple different positions during administration
- Max 3 doses, within 72 hours
- Consider repeat doses if persistent FiO2 requirement of >30%, may be given as early as 2h after initial dose
List risks of untreated maternal depression during pregnancy
- miscarriage
- preterm birth
- low birth weight
- respiratory distress
- increased length of hospital stay
- negative maternal-child bonding
- negative outcomes on cognitive emotional and behavioural consequences
List the risks of SSRI use during pregnancy
- SSRI neonatal behavioural syndrome (commonly seen, but mild and transient)
- PPHN (absolute risk is negligible)
- Cardiac malformations with paroxetine (contradictory)
- No evidence that SSRIs as a group increase risk of congenital malformations
- Not a contraindication to breastfeeding
List the symptoms of the SSRI neonatal behavioural syndrome
- Respiratory: tachypnea, cyanosis, distress
- Motor/CNS: jitteriness, tremors, increased muscle tone
- GI: feeding disturbance
- Present within hours
- Mild
- Resolve within 2 weeks
List the physiological responses to intubation/laryngoscopy
- bradycardia
- hypertension (systemic and pulmonary)
- increased intracranial pressure
- hypoxia
List ways the physiological responses to intubation can be reduced
- vagolytics (atropine for bradycardia)
- muscle relaxants
- analgesics
- preoxygenation
- gentle technique
Under what clinical circumstances is it acceptable to intubate an infant without use of premedication?
- If risks of medications exceed risks to infant of being intubated without premedication, such as:
- During resuscitation
- Infants with extremely difficult vascular access (more attempts will cause more distress/discomfort than intubation)
- Infants with severely abnormal airways who are likely to be difficult intubations, need to breathe on their own
List the suggested protocol for administration of premedication for intubation
- Atropine
- Fentanyl
- Succinylcholine
List the recommendations for car seat tests before discharge of infants
- Educate parents regarding proper placement and supervision of infant in car seat. Never leave unattended.
- No specific recommendations regarding monitoring before discharge
- Possibly reasonable to do car seat test in infants born before 37 weeks GA
- Possibly reasonable for test to be considered “fail” if: 2 or more desats
Describe Erb’s palsy and Klumpke’s palsy
- Erb’s: C5-C7 “waiter’s tip” - adducted arm, extended elbow, flexed wrist, absent biceps reflex, moro of hand but not affected arm
List the negative impact of prolonged hospitalization of neonate
- poorer parent-child relationships
- failure to thrive
- child abuse
- parental grief and feelings of inadequacy
List the criteria that must be met for discharge of preterm infants
- maintenance of normal body temperature when fully clothed in open cot (approximately 37C)
- an apnea-free period of 5-7 days
- maintenance of SaO2 >90% to 95% in room air
- sustained weight gain
- successful feeding by breast and/or bottle without major cardiorespiratory compromise
List the evaluations that must have taken place before the discharge of preterm infants
- hearing screen
- car seat test
- ROP screening
- HUS at corrected term
- Newborn screening
- RSV assessment and administration
- Immunizations
- pre discharge physical with growth parameters
Describe the primary and secondary phase of HIE
- Primary phase: follows reduction in blood flow and oxygen supply with fall in ATP, failure of Na+/K+ pump, depolarization of cells, lactic acidosis, release of excitatory amino acids, calcium entry into the cell and if severe, cell necrosis
- WINDOW OF OPPORTUNITY (6h-12h): normalization of oxidative metabolism
- Secondary Phase: develops at 12h-36h, can last 7-14 days. Initiation of apoptosis, mitochondrial failure, cytotoxic edema, accumulation of excitatory amino acids, release of free radicals terminating in cell death. Secondary phase associated with worsening of HIE and correlates with poor outcomes
List the benefit of mild hypothermia on the pathophysiology of HIE
- amelioration of apoptosis
- decreased loss of high-energy phosphates
- reduced O2 consumption
- reduced release of NO, glutamate, free radicals and excitatory amino acid neurotransmitters
- induction of genes that reduce neuronal death
What are the benefits of head or total body cooling in infants with HIE
- decrease death and disability in infants with moderate HIE
- less impact on infants with severe HIE
When should cooling be considered in HIE?
- Criteria A (2 of): pH 16, Apgar 36 weeks GA
Describe the cooling process
- Cool to optimal rectal temp of 34 +0.5C
- Duration 48-72 hours
- Rewarm by 0.5C every 2h
What are the side effects of mild hypothermia in infants with HIE?
- mild hypotension
- mild bradycardia
- arrhythmias
- mild thrombocytopenia
- scleredema/edema
What are issues that may present in a late preterm infant?
- inadequate thermoregulation
- immature and weak suck and swallow patterns
- incomplete adaptation of certain enzyme systems
- poor immunological and respiratory defines systems
What should be included in the evaluation of a late preterm infant?
- core temp monitoring
- vital monitoring
- glucose at 2h
- bilirubin within 48h
- hold off on bathing until core body temp of at least 36.5C
- early feeding should be attempted
For what are late pre terms at risk?
- readmission with hyperbilirubineamia
- feeding problems
- apnea or ALTEs
- suspected sepsis
- respiratory problems
- hypothermia
Regarding feeding of the late preterm infant, what are the recommendations?
- Must demonstrate 24 hours of successful feeding before discharge home
- encourage rooming-in
- feedings should not exceed 20min
- early weight loss should not exceed 10% of birth weight
Which infants qualify for iNO?
- > or equal to 35 weeks GA at birth
- hypoxemic respiratory failure who respond to appropriate respiratory management
- need echo before starting to assess for pHTN and cardiac function, r/o cyanotic CHD
- infants with OI >20-25 or when PaO2 remains
How to administer iNO?
- Start with 20ppm
- No response? Increase to 40ppm
- Response? wean by 50% at 4-6hr intervals as long as OI 50mmHg
- Mean duration of therapy in trials 48-96 hrs
What are the potential risks of iNO
- methemoglobinemia (keep
What are the benefits of iNO in infants with severe hypoxic respiratory failure?
- improves oxygenation
- decreases combined outcome of death and need for ECMO
What are the benefits of kangaroo care?
- reduced mortality at discharge
- reduced severe illness, infections, length of hospital stay
- improved mother-infant bonding, breastfeeding, maternal satisfaction
- helps to humanize the NICU experience
What should be included in an institution’s protocol for kangaroo care?
- criteria for GA and weight
- assessing readiness and tolerance
- appropriate physiological monitoring for signs of stability and stress
- protocols describing safe transfer of neonate between isolate and parent
List barriers to implementation of kangaroo care
- poor staff knowledge
- inadequate training
- discomfort with the process
- lack of time and/or resources
- lack of privacy and parental reluctance
In which infants should kangaroo care be delayed?
-
Define acute bilirubin encephalopathy
- Clinical syndrome of lethargy, hypotonia, poor suck, which may progress to hypertonia, with opisthotonos and retrocollis, with a high-pitched cry and fever, eventually leading to seizures and coma
Define severe hyperbilirubinemia, critical hyperbilirubinemia
TSB >340, TSB >425
List the side effects of phototherapy
- temperature instability
- intestinal hypermotility
- interference with maternal-infant interaction
- diarrhea
- bronze discolouration of skin (rare)
Describe the pathophysiological aetiologies of hypoglycaemia in infants
- excess insulin production
- altered counter-regulatory hormone production
- inadequate substrate supply
List groups of infants at risk for hypoglycemia
- SGA
- LGA
- IDM
- preterm
- infants with perinatal asphyxia
- infants with inborn errors of metabolism or endocrine disorders (rare)
- 2h glucose for these groups (or sooner if symptomatic)
How long to LGA/IDM infants need to be monitored for hypoglycaemia?
- first at 2h
- q3-4h prefeeds
- discontinue if stably >2.6 at 12h
How long to SGA/preterm infants need to be monitored for hypoglycaemia?
- first at 2h
- q3-4h prefeeds
- discontinue if stable >2.6 at 36h
