Fetus and Newborn Flashcards
1
Q
What is surfactant and what does it do?
A
Lines alveolar surfaces in the lung and reduces surface tension and prevents atelectasis.
2
Q
What are the benefits of surfactant therapy?
A
- reduces mortality
- decreases oxygen deficits
- decreases incidence of pulmonary air leaks (pneumo and PIE)
- decreases duration of ventilation
- increases likelihood of surviving without BPD
- has NOT changed the incidence of BPD
3
Q
What are the indications for surfactant therapy?
A
1) intubated infants with RDS
2) intubated with meconium aspiration needing more than 50% oxygen
3) sick newborn with pneumonia and an oxygenation index of >15
4) intubated newborn with pulmonary hemorrhage causing clinical deterioration
4
Q
What are the side effects of surfactant?
A
- bradycardia
- hypoxemia during administration
- blocking ETT
- pulmonary hemorrhage
- is a animal protein so some families may be opposed to this
- accidentally hyperventilating b/c not weaning quick enough
5
Q
Which are better synthetic or natural surfactants and why?
A
Natural surfactants are better.
-lower O2 needs, air leaks less common, improved survival without BPD
6
Q
Should surfactant be given prophylactically or as rescue?
A
- infants at significant risk of RDS should be given surfactant as soon as they are stable and within a few minutes of intubation
- if managed on nasal CPAP then if showing clinical signs of RDS with elevated oxygen needs then intubate and give surfactant
7
Q
When should you consider giving a second dose of surfactant?
A
- infants with RDS with persistent or recurrent oxygen and ventilatory requirements in the first 72 hrs of life
- consider if persistent or recurrent O2 requirement >30%
- can give as early as 2 hrs since the initial dose (4-6hrs more common)
8
Q
How quickly should a vent be weaned after giving surfactant?
A
-can do very rapid weaning with extubation to CPAP within 1 hr
9
Q
Do mum’s still need antenatal steroids if surfactant is available?
A
yep. any mum at risk for preterm labour before 34 wks
10
Q
If baby is in outside centre and needing to be transported when do you give surfactant?
A
–before transport for any baby who is intubated with RDS and for baby
11
Q
If baby born preterm (
A
-consider immediate intubation followed by surfactant if competent personnel available
12
Q
What are the signs and symptoms of hypoglycaemia in a neonate?
A
- jitteriness
- tremors
- apathy
- cyanosis
- convulsions
- intermittent apneic spells
- tachypnea
- weak or high pitched ry
- limpness
- difficulty feeding
- sweating
- sudden pallor
- hypothermia
- cardiac arrest
13
Q
What is the natural course of blood glucose in a term baby after they are born and are transitioning?
A
-glucose falls immediately after birth to 1.8 at 1 hr of age and then subsequent rise to levels over 2
14
Q
Which newborns are at risk for hypoglycemia?
A
- SGA (wt 90th %ile)
- IDM
- prems
- perinatal asphyxia
15
Q
How long are LGA and IDM infants at risk for hypoglycaemia aka when can you stop checking their glucose if they are stable (>2.6)?
A
12 hours
16
Q
How long are SGA and pre infants at risk for hypoglycaemia aka when can you stop checking their glucose if they are stable (>2.6)?
A
36 hours
17
Q
When should the first glucose be checked in an at risk baby? (LGA, SGA, etc)
A
at 2 hrs after an initial feed unless are symptomatic earlier
18
Q
What is the cut off for glucose in a newborn below which intervention is required and why?
A
at 2 hr check:
19
Q
What do you do if an at-risk baby has a glucose of
A
Treat with IV dextrose:
- start with D10W at TFI 80ml/kg/day
- recheck glucose after 30 minutes
20
Q
What do you do if a baby has a glucose of 1.8-2.0 at the first 2 hr mark or 2.0-2.5 on subsequent checks?
A
Refeed the baby and recheck in 1 hr. If the BG is still 2.6 after the feed than check in 3 hrs before next feed.
21
Q
How many times are babies allowed to
A
once
22
Q
What do you do if a baby has a glucose of >2.0 at the first 2 hr mark or >2.6 on subsequent checks?
A
No intervention required but keep check BG in at risk babies until their high-risk time is over.
23
Q
What are strategies to prevent and treat asymptomatic hypoglycaemia?
A
- increase breastfeeding frequency
- supplement with breastmilk or formula
- IV glucose
24
Q
How soon after feeding a baby who had a low sugar should you recheck the sugar? How soon after making a change to IV therapy for hypoglycaemia should you recheck the sugar?
A
- 1 hr after feeding
- 30 minus after any IV change
25
If you are going to bolus dextrose IV how much do you give in a newborn?
2ml/kg of D10
26
If you want to escalate IV therapy how do you do it?
- Start with D10 at TFI 80ml/kg/day (GiR of 5.5 mg/kg/min)
- increase to D10 at TFI 100ml/kg/day or change to D12.5 at TFI 80 ml/kg/day (GiR 8.7mg/kg/min)
* *don't really want to go up past TFI 100
- if go up to D12.5W at TFI 120ml/kg/day and cannot keep BG >2.6 consider IV glucagon and talk to a specialist
27
What is the dose for IV glucagon bolus and infusion?
Glucagon bolus: 0.1-0.3 mg/kg
| Glucagon infusion: 10-20 microg/kg/hr
28
What are your options if you have maxed out on IV dextrose for neonatal hypoglycaemia?
- glucagon
- HCT
- diazoxide
- ocreotide
29
Can you breastfeed a baby while treating with IV dextrose for hypoglycaemia?
- can continue breastfeeding b/c volume of colostrum is so small
- PO+IV should not exceed 100ml/kg/day unless are monitoring for dilution hyponatremia
30
When can you start to wean IV dextrose for neonatal hypoglycemia?
-when levels have been stable for 12 hrs
31
Do all newborns need to be screened with a blood glucose?
no. appropriate for gestational age infants at term do not need it unless are symptomatic
32
How often do you screen at risk infants for neonatal hypoglycaemia?
at 2 hrs (post-feed) then q3-6hrs after (check prefeeds)
33
What is grief?
What is mourning?
What is bereavement?
grief-process of experiencing psychological, behavioural, social and physical reactions to loss which may change over time
mourning - cultural and/or public display of grief through ones behaviour
bereavement - entire process precipitated by the loss of a loved one through death
34
What are the 3 phases of grief and mourning?
1) avoidance or protest - lasts for hrs or days; anger and hostility may occur
2) confrontation and disorganization - grief most intense, awareness of finality
3) accommodation or reorganization - gradual decline in symptoms of acute grief; process lasts for few years
35
What is the average period of time to recover from the loss of a baby?
2-4 years is average for parents; their grief may be incongruence
36
What are the 6 "R" processes of mourning?
```
Recognizing the loss
Reacting to the separation
Recollecting and Re-experiencing the deceased
Relinquishing old attachments
Readjusting to new work
Reinvesting in new relationships
```
37
What are some things healthcare providers can do to help with the dying/grieving process?
- assure parents that it is normal to feel uncomfortable at this time
- allow parents to spend as much time as they need with the baby
- make repeated offers for holding the baby
- name the baby
- provide privacy but do not abandon parents
- encourage relatives/friends to see the baby according to parents' wishes
- warn about gasping and muscle contractions
- reassure parents that baby was not alone, afraid or in pain
- reassure parents that nothing more could be done
- take pictures
- provide momentos to create memories
- ensure spiritual support is available
- explain the need and procedure for an autopsy
- explain topics and procedures for memorial services
- follow up with the parents after discharge
38
Which babies are at increased risk of having an adverse cardiorespiratory event when put in a car seat?
- preterm
- low birth weight
- significant cardioresp or neurologic problems (incl hypotonia)
39
Which babies need to have a carseat test and how is it done?
- no specific recommendation about which babies should undergo monitoring before discharge
- done by putting baby in car seat and monitoring of 90 minutes with O2 sats and cardioresp monitoring
40
What is considered a failure of the carseat test and what can you do about it?
- no clear definition of significant cardioresp abnormality
- in studies considered 2 or more episodes of o2 desaturation retest them in the recumbent position (if this is ok then get a carseat that can be at 30 degrees)
- if still abnormal then need further investigation and management
41
When does classic hemorrhagic disease of the newborn occur?
| When does late hemorrhagic disease of the newborn occur and in what population?
Classic - in the 1st wk, (rare if got IM Vit K)
| Late - age 3-8 wks; almost exclusively in infants who are breastfed
42
What are the recommendations for vitamin K including doses for newborns?
Vit K 0.5mg IM for babies 1500g within the first 6 hrs of life.
43
What alternatives can you offer parents who refuse IM vit K?
- Vit K 2mg PO at time of first feeding
- repeat at 2-4 wks of age and 6-8 wks of age
- tell parents baby is at increased risk for late hemorrhagic disease of the newborn including for intracranial hemorrhage
44
What is the definition of fetal alcohol syndrome?
Minimum criteria are:
1) prenatal and/or postnatal growth restriction
2) CNS involvement (neuro abnormlities, dev delay, behavioural problems, skull/brin malformation, learning disabilities)
3) characteristic facial features
45
What are the characteristic facial features of fetal alcohol syndrome?
- short eye slits (palpebral fissures)
- thin upper lip
- flattened cheek bones
- indistinct groove btwn upper lip and nose
46
What is possible fetal alcohol effects (FAE)?
Children with prenatal exposure to alcohol but only some of FAS characteristics
47
What type of alcohol drinking can cause FAS?
- any trimester not just the first
- more likely after continuous or heavy intake
- have seen with intermittent or binge drinking
48
What is primary, secondary and tertiary prevention as it refers to FAS?
Primary = actions that avert health problem before it occurs (eg. informing public about dangers of drinking)
Secondary = actions that identify per at risk (eg. screening and early intervention for pregnant women)
Tertiary = actions that prevent recurrent through treatment and attempts to lessen the impact (eg. treating women and partners who already have a child with FAS/FAE)
49
What is kangaroo care?
-infant in a diaper and cap held in upright prone position against bare chest of the parents and covered with clothing and/or a blanket, usually for 1-3 hrs which having cardioresp and temp monitoring during that time
50
What are the benefits to kangaroo care? What are the risks?
BENEFITS
- reduced mortality
- reduced severity of illness
- reduced infections (esp nosocomial)
- reduced length of hospital stay
- improved breastfeeding
- improved mother-infant bonding
- improved maternal satisfaction
- decreased arousal and REM sleep
- possible improved neurodevelopment outcomes at 6 and 12 months
- reduced pain associated with bedside procedures
RISKS
-no detrimental effects on physiological stability
51
Who can get kangaroo care?
-babies as young as 26 weeks even if are ventilated
52
How does inhaled nitric oxide work and why do we use it?
- pulmonary vasodilatory
- improved ventilation/perfusion matching
-decreased death and need for ECMO
53
Who should be treated with iNO?
infants >35 weeks at birth with hypoxemic respiratory failure who fail to respond to appropriate rest management
- kids with OI >20-25 or when PaO2 remains less than 100mmHg despite 100% FiO2
- NOT effective for kids with congenital diaphragmatic hernia
54
How do you calculate oxygen index?
OI = (FiO2 x mean airway pressure div PaO2) x100
55
What is persistent pulmonary HTN of the newborn?
-hypoxemic rest failure associated with persistent high pulmonary vascular pressure and resultant R to L shunting of blood through PFO, PDA and intrapulmonary channels
56
How do you administer iNO, starting and weaning?
- inhaled start at 20 ppm (expect a response in less than 30 min with a PaO2 increase ≥20 mmHg)
- if stable for 4-6 hrs then can start to wean but 50% until get to 5ppm and then wean q4 hrs by 1 ppm
57
What are the side effects of inhaled NO? How do we monitor for them?
-methemoglobin - measure these, should be
58
What are the benefits of cooling babies with HIE? What are the side effects?
- decreased mortality
- improved neurodevelopmental outcomes
- no serious side effects reported, can have mild bradycardia, hypotension, arrhythmia, mild thrombocytopenia, sclera/edema
59
What are the 2 phases of brain injury following intrapartum hypoxia-ischemia?
1) reduced blood flow and oxygen causes increased lactic acidosis and if severe cell necrosis
2) normalization of oxidative metabolism lasting 6-12 hrs
3) at 12-36 hrs get apoptosis, mitochondrial failure, cytotoxic deem, release of free radicals; can last up 7-14 days
60
What are the criteria for cooling in HIE?
-term or late preterm (>36 wks) with HIE who are 16 in cord gas or art gas within 1 hr of life
AND
CRITERIA B
- moderate or severe encephalopathy (Sarnat stage II or III)
- need either seizures or one sign in at least 3 of the 6 categories
61
What are the different categories for Sarnat scoring for HIE?
1) LOC
2) spontaneous activity
3) neuromuscular control
4) primary reflexes
5) autonomic system
6) Seizures
62
What criteria in each of the following makes a baby mild, moderate or severe HIE?
1) LOC
2) spontaneous activity
3) neuromuscular control
4) primary reflexes
5) autonomic system
6) Seizures
MILD
1) LOC - hyperalert
2) spontaneous activity - normal
3) neuromuscular control - normal tone, mild distal flexion, overactive stretch reflexes, segmental myoclonus present
4) primary reflexes - weak suck, strong moro, normal oculovestibular
5) autonomic system - sympathtic, mydriasis, tachycardia normal RR
63
What are contraindications to cooling for HIE?
- severe head trauma
- intracranial bleed
- no studies showing benefit if in kids 6hrs
- increased mortality of cooling with prems
64
How can cooling be done and which method is better?
No difference between the 2.
1) selective head cooling with mild systemic hypothermia (cooling caps with aim of keeping fontanelle temp
65
How long should babies with HIE be cooled?
48-72 hrs. Most centres use 72 hrs.
66
How should you rewarm a baby who has been cooled for HIE?
- controversial
- slowly
- by 0.5 degrees C q1-4 hrs
67
For who is cooling in HIE the most beneficial?
-babies with moderate encephalopathy, the evidence is less clear for severe
68
What is ROP?
-disorder of the developing retinal blood vessels of the preterm infant which can lead to poor visual acuity or blindness
69
How is ROP classified?
- zones I-III (zone I is closest to optic nerve)
- stages 1-5
- pre-plus and plus disease (related to tortuosity)
70
What are the stages of ROP?
- Stage 1 - demarcation line separates avascular from vascularized retina
- Stage 2 - ridge arising in region of demarcation line
- Stage 3 - extra retinal fibrovascular proliferation/neovascualrization
- Stage 4 - partial retinal detachment
- Stage 5 - total retinal detachment
71
What is pre-plus versus plus disease in ROP?
- pre-plus = more vascular tortuosity than normal but not enough to be plus disease
- plus = vascular dilatation and tortuosity of at least 2 quadrants of the eye
72
Who should be screened for ROP?
- infants born at 30+6 or less (regardless or BW)
| - infants 1250 g or less
73
When can you stop screening for ROP?
-when risk no longer there (avg is 45 wks corrected)
74
How do you treat ROP?
-retinal ablation with cryotherapy and laser photocoagulation to decrease the production of angiogenic growth factors
75
When do you start screening for ROP?
-in infants born
76
How should you control pain during ROP exam?
- topical anesthetic
- sucrose
- swaddling
77
When do we treat ROP?
- Zone I - any stage ROP with PLUS
- Zone I - stage 3 ROP with or without PLUS
- Zone II - stage 2 or 3 with PLUS
- need to treat within 72 hrs of exam
- even if are treated still have risk for poor visual acuity
78
What are the most frequent indications of blood transfusion in the newborn?
1) perinatal or surgical hemorrhagic shock
| 2) 'top-ups' for the recurrent correction of anemia of prematurity
79
Do we transfuse fresh whole blood in Canada?
-No. RBCs are separated from other blood components right after collection
80
How long is a blood good for after it has been donated? How long is blood good for once it has been released from blood services?
42 days
| 4 hrs
81
What are the risk of transfusion in the neonate?
1) transfusion-transmitted infections
2) adverse effects of leukocytes (immunomodulation, GVHD, TRALI)
3) blood group incompatibilities
4) CMV has more serious consequences for prems
82
What is done by blood services to decrease the risk of CMV in blood products?
1) universal leukoreduction
| - most centres gamma-irradiate blood to deactivate lymphocytes and prevent GVHD
83
What type of blood should be given to neonates?
- O neg in emergencies
| - O Rh-compatible or group-specific Rh-compatible
84
When do you need to cross-match donor blood for infants if their initial antibody screen is negative?
-at 4 months corrected
85
How much blood do we transfuse at once? What are the risks of over transfusing? If having a massive hemorrhage what can you do to prevent these complications?
- 10-20ml/kg (usually 15 ml/kg)
- Risks: hyperkalemia, volume overload, dilution of coats
- if massive hemorrhage give FFP
86
What is the management of a newborn with hemorrhagic shock?
- give NS 10-20ml/kg while waiting for blood
- give O neg blood 10-20 ml/kg when available
- collect cord or pre transfusion blood for typing
87
What is anemia of prematurity?
-exacerbation of physiologic anemia of newborn, combined with suppressed postnatal response to EPO, increased blood sampling, short RBC span, rapid increase in blood volume and growth
88
What are the cut offs for blood transfusion in neonates? What counts as resp support?
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
*kids with CHD may need higher levels
Resp support = O2 need >25% or mechanical increase in airway pressure
89
What is the role of erythropoietin in neonates who need blood transfusions? Risks? When do we use it?
- stimulates erythropoiesis
- risk of significant increase in ROP
- little role for it except for families who refuse to transfuse with blood products (some types of EPO are prepared in human albumin)
90
How do we treat anemia of prematurity?
Iron supplementation 2 mg/kg/day of elemental iron introduced btw 4-6 wks of age at onset of reticulocytosis
91
What are the downsides of a prolonged NICU stay?
- poor parent-child relationships
- FTT
- child abuse
- parental grief and feelings of inadequacy
92
What are the physiological milestones a premature baby (born
1) thermoregulation (about 37 degrees when fully clothed in an open cot)
2) sufficient apnea free period (at least 5-7 days)
3) maintenance of sats >90-95% on room air
4) sustained weight gain
5) successful feeding at breast/bottle without major cardiorespiratory compromise
93
What is the definition of apnea of prematurity?
-cessation of breathing for >20s or 10-20sec with associated bradycardia (HR
94
When does apnea of prematurity resolved?
-in most by 36 weeks corrected but in very preterm babies it can be up to 44 wks corrected
95
What is the half-life of caffeine in neonates?
-100hrs
96
How long does a prem have to be apnea free before they can go home?
-variable but usually at least 5-7 days
97
Is apnea of prematurity a risk factor for SIDS?
no.
No evidence for routine home monitoring to prevent sids.
98
When are prems at the most risk of having cardiorespiratory events (spells)?
- during feeding
| - when semiupright in a car seat
99
What % of prems with BW
25%
100
What is target sat for infants with BPD?
90-95%
101
Is there an association between GER and apnea?
evidence is variable.
102
What are important family factors to consider when discharging home a prem?
- evaluate the supports at home
- ask parents to take increased time off work in the 1-2 wks before discharge to help with the transition
- promote a family environment
103
If a prem
4
104
What logistical things and tests need to be done before a prem is discharged home?
- newborn screen
- Head US near term if meets criteria
- assess if needs RSV
- ROP screen
- hearing screen
- car seat test
- immunizations
- pre discharge exam including growth parameters
- appropriate f/u in place including ROP screen, GP appoint
- f/u with health professional within 72 hrs of d/c
- CPR training for parents is desirable
105
What are the side effects (both short and long term ) of systemic steroids given to prems?
Increased risk of cerebral palsy and neurodevelopment impairment.
Hyperglycemia, HTN, GI hemorrhage, GI perf. Risk of adrenal suppression
106
In what cases do we give postnatal dexamethasone to prems?
- never for prevention of chronic lung disease
- never in the first 7 days of life b/c increased poor outcomes
-consider low-dose dexamethasone after age 7 days in babies at high risk for chronic lung disease or those with prolonged ventilator dependence (-unclear if benefits outweigh the risk)
107
Which steroid and what dose do we give for infants at high risk for or with severe chronic lung disease?
Dexamethasone (low-dose) 0.15mg/kg/day tapered over 10 days
| -no evidence for hydrocortisone or for inhaled steroids
108
When statistics are presented about gestational age in the CPS statement related to resuscitation what does 22 weeks encompass?
22+0 to 22+6
109
What is an extremely preterm birth?
Occurs between 22+0 to 25+6
110
What information do you need to include in a discussion with parents about extreme preterm birth?
- likelihood of survival
- anticipated problems
- risk of disability
- NICU experience
- parenting
- coping with stress
111
What model should be used when counselling parents with anticipated extreme preterm birth?
Shared decision making btw health professional and parents. Decision aids can be helpful.
112
What is the most accurate method for establishing gestational age and during what period? What is the accuracy in the first trimester, 16-22 weeks?
Ultrasound btw 8-14 wks.
Accuracy in first trimester is +/- 5 days.
Accuracy at 16-22 wks is +/- 10 days.
113
How accurate are ultrasound measurements of estimated fetal weight?
+/- 10%
114
What medications should be considered for administration to mum with threatened preterm labour and why?
- antenatal steroids for lung maturation
- tocolysis (short term) for transport
- MgSO4 for neuroprotection
115
What is the likelihood of survival of an infant born at
>5%
116
What is the likelihood of survival of an infant born at 25 weeks?
approx 80% (this is NOT a poor outcome)
117
What is the risk of severe disability in the smallest and most immature preterm infatns?
18-60%
118
What types of long term morbidity are prems at risk for?
- Grade III or IV IVH
- PVL
- ROP
- CLD
- CP
- cognitive impairement
- blindness/deafness
- seizures
- behavioural difficulties
- ADHD
- language deals
- more frequent hospital admission
119
What are favourable prognostic factors related to preterm birth?
- mum receiving antenatal steroids
- female gender
- birth at tertiary care centre
- single fetus
120
If a decision is made not to resuscitate a newborn what do you need to ensure happens?
- compassionate palliative support
- pain free
- warmth
- opportunity for parent to hold baby
- warn parents that baby might live for days
121
Which pregnant women with threatened preterm labour should be transferred to a tertiary care centre?
Any women with threatened preterm labour thought to be 23 wks
122
What is the recommended resuscitation plan in a 22 wker?
non-interventional
123
What is the recommended resuscitation plan in babies 23, 24 ?
-shared decision making with parents
124
What is the recommended resuscitation plan in babies >25 wks?
CPS statement says shared decision making for 25 wkers but they have improved survival so realistically we resuscitate those
125
Name 6 SSRIs.
```
Fluoxetine
Paroxetine
Citalopram
Escitalopram
Fluvoxamine
Sertraline
```
126
What is the baseline risk of major malformations in the general population?
1-3%
127
Are there any risks of congenital malformations with SSRI use in pregnancy?
- SSRI use in first trimester not associated with major congenital malformations.
- Paroxetine use in frist trimester may be associated with increased risk of cardiovascular malformation. (studies are inconclusive)
128
What are the risks for the baby of maternal SSRI use in pregnancy?
- possible increased risk of cardiac malformations with paroxetine in first trimester
- SSRI neonatal behavioural syndrome (SNBS)
- possible risk of PPHN
129
What is SSRI neonatal behavioural syndrome (SNBS)? What % of babies exposed get it? Which SSRIs have been implicated the most?
- seen in 10-30%
- respiratory, motor, central nervous system and GI symptoms
- tachypnea, cyanosis, jitteriness/tremors, increased tone, feeding disturbance
-fluoxetine and paroxetine implicated the most
130
What is the most worrisome possible side effect of SSRI use in pregnancy and how common is it?
- PPHN
- may be a rare expression of association
- due to SSRI use in second half of pregnancy
131
What is the management of a newborn born to a mum who took an SSRI?
- monitor in hospital for a minimum of 48 hrs
| - give families anticipatory guidance on possible effects of SSRIs
132
Should women with depression be treated with SSRIs?
-yes. important to treat if the benefit outweighs the risk. If mum is on paroxetine consider decreasing dose or picking a different agent.
133
What are the physiologic responses to intubation in newborns? Why do they occur?
1) systemic and pulmonary HTN - increased systemic vascular resistance due to catecholamine release in response to pain
2) bradycardia - vagal
3) intracranial HTN
4) hypoxia - obstruction of airway during procedure
134
What medications do we use for intubation of neonates? At what dose?
Fentanyl - 3-5 micrograms/kg IV slow infusion
Atropine - 20 micrograms/kg IV
Succinylcholine - 2mg/kg IV
135
What are the physiologic effects of premedication for intubation?
- atropine (vagolytic) to prevent bradycardia
- analgesia (fentanyl) can decrease pain and systemic HTN
- muscle relaxant (succ) results in faster intubation so less hypoxia
136
Why do we use fentanyl instead of morphine as sedative and analgesia for neonatal intubation? What is its major side effect and what can you do if it occurs?
- Fentanyl is faster acting
- chest freeze (and resp depression)
- give muscle relaxant right away or give reversal agent (naloxone)
137
What kind of drug is Midazolam? What are its side effects? Why don't we use it for intubation in newborns?
- non-analgesic sedative
- does NOT reduce pain
- side effects: hypotension, decreased cardiac output, decreased cerebral blood flow velocity,
- we do not use it b/c variable half life and has been associated with increase in adverse neurological outcomes
138
Under what circumstances is it acceptable to intubate an infant without premedication?
- if risk of meds exceeds the risk of intubation without premedication (eg. in delivery room, during acute deterioration)
- severely abnormal airways who you suspect will have a difficult intubation
139
What are alternatives for preintubation meds in a neonate in whom you cannot get IV access?
- intranasal fentanyl
| - inhanted gasses (NO or sevoflurane)
140
What type of drug is atropine, what are its side effects and why do we use it in intubation?
- vagolytic
- side effect - potential for CNS complications in overdose
- used to prevent bradycardia
141
What type of drug is succinylcholine, what are the side effects and why do we use it in intubation?
- muscle relaxant (depolarizing agent)
- malignant hyperthermia, hyperkalemia, rhabdomyolysis
- used to decreased intracranial pressure, shortens duration of procedure, reduces # of attempts, reduces trauma
142
Why don't we use rocuronium in neonatal intubation?
-prolonged and variable duration (up to 1 hr)
143
What is considered a late preterm by CPS?
34+0 to 36+6 wks
144
What are the risks/complications associated with being a late preterm?
- increased morbidity and mortality (esp comparing 34 to 35 wks)
- higher rates of cerebral palsy
- higher rates of developmental delay
- inadequate thermoregulation
- immature and weak suck and swallow/difficulty establishing feeds
- hyperbilirubinemia (which peaks later)
- increased apnea and SIDS
- increased risk of sepsis
- increased risk of readmission
145
How should a later preterm baby be triaged at birth?
-need short-term observation for cardiorespiratory stability, ability to feed and maintain temp before triage to a low-risk or intermediate/high risk nursery
146
When should you first feed and first bath a late preterm baby?
- attempt early feeding
| - do not bath until establish a core temp of at least 36.5
147
What are differences in hyperbili levels in late preterm compared to term infants? How do we monitor for this?
- bili levels peak later (at 7 rather than 5 days)
- stay elevated longer
- suspect are at risk for kernicterus at lower levels
- exclusive breastfeeding increases the risk for extreme hyperbili
Monitor
- extend observation of a late preterm baby throughout the first week of life
- check bill within 48 hrs of life
- phototherapy and exchange transfusion should be initiated at lower bill thresholds than those used for term babies
- frequent assessments of feeding, weight gain and jaundice in the first 10 days
148
What are guidelines for adequate establishment of feeding in the late preterm before they can go home? How long should feeds and feed+prep time be?
1) 24 hrs of successful feeds before d/c
2) first time mums should have a rooming-in experience
3) feeds should not exceed 20 mins
4) feeds and prep for feeds should not take more than 6 hrs of the day
5) early weight loss should not exceed 10%
149
Any special monitoring regarding apnea for late preterm?
-late preterm of 34 wks GA may be considered for a period of cardiorespiratory monitoring in a NICU before transfer to a low risk nursery
150
Why are late preterm infants at increased risk for sepsis compared to term babies? Is this for early or late?
Increased risk for BOTH early and late onset sepsis.
- born to mum with chorioamniotis
- born before mum's GBS status known
151
How soon after discharge should a late preterm baby be followed up?
48 hrs
152
What is the most common bug that causes early-onset sepsis and what is the case-fatality if intrapartum antibiotics are not given?
GBS
| 2-13%
153
What is considered a limited diagnostic evaluation for infants at increased risk for sepsis? And what results are considered significant?
- CBC and observation of vitals q4h for at least 24 hrs
| - if WBC
154
What is the role of intrapartum penicillin given to pregnant mums?
- prevention of early-onset invasive GBS disease
| - it does not affect frequency of sepsis caused by other organisms
155
What does gram positive cocci in the CSF suggest? What is the empiric tx of choice?
- GBS, or Stpah or enterococci
| - Amp + Gent
156
What does gram positive rods in the CSF suggest? What is the empiric tx of choice?
- Listeria
| - Amp + Gent
157
What does gram negative rods in the CSF suggest? What is the empiric tx of choice?
```
E coli (less commonly Klebsiella, Pseudomonas, Citrobacter)
-Cefotaxime + Gent
```
158
What does gram negative cocci in the CSF suggest? What is the empiric tx of choice?
- uncommon
| - Cefotaxime
159
What is the management of a well-appearing infant >35 wks of a GBS-positive mother who received IAP more than 4 hrs before delivery?
-routine care
160
What if a mum is pregnant, GBS negative and penicillin-allergic, how do you manage the infant?
-Treat as if the mother received incomplete intrapartum antibiotics
161
What is the management of a well-appearing infant of a GBS-positive mother who received IAP less than 4 hrs prior to delivery or not at all? What is that babies risk of invasive disease?
- limited diagnostic evaluation is required (CBC) and must be in hospital for at least 24 hrs
- risk of invasive GBS disease is 1%
162
What is the management of a well-appearing infant of a GBS-negative mother who had risk factors at delivery?
Recommendations section says do not do anything.
| -body of text in CPS statement says limited diagnostic evaluation with CBC
163
What are the risk factors for sepsis in the newborn?
1) ROM >18 hr
| 2) premature labour
164
What is the management of a well-appearing infant of a mother with unknown GBS status and no risk factors?
Routine care. No specific intervention required.
165
What is the management of a well-appearing infant of a mother with unknown GBS status with risk factors?
- these mums should have received IAP if GBS is unknown
| - if mum not treated or treated
166
What is the management of a baby delivered
- if well this baby was the risk factor of prematurity so needs a CBC (limited diagnostic evaluation)
- baby should not be discharged before 48 hrs
167
What is considered the triad of 'definite' chorioamnionitis? What is the risk of sepsis in an infant whose mum had definite chorio? What is the management of such an infant?
- fever
- left-shift in WBC
- lower uterine tenderness
- risk of sepsis in infant is 8%
- baby should have CBC and be monitored q4h and not d/c before 24 hrs
168
What is kernicturus?
pathologic finding of deep yellow staining of neutrons and neuronal necrosis of the basal ganglia and brainstem nuclei
169
What is acute bilirubin encephalopathy?
-severe hyperbilirubinemia with lethargy, hypotonia, poor suck, can progress to hypertonia with opisthotonos and retrocollis with a high pitched cry and fever, can lead to seizures and coma
170
What is chronic bilirubin encephalopathy?
- is the sequelae of acute bili encephalopathy.
- athetoid CP with or without seizures, developmental delay, hearing deficit, oculomotor disturbances, dental dysplasia and mental deficiency
171
What is the cut off for severe hyperbili? critical hyperbili?
- severe hyperbili = total bili > 340 micromol/L at any time in first 28 days
- critical hyperbili = total bili >425 micromol/L at any time in first 28 days
172
What are the risk factors for development of severe hyperbilirubinemia? How do they help guide investigation and therapy?
- visible jaundice at 25 yrs
- asian, european background
- dehydration
- exclusive and partial breastfeeding
- are of limited use in directing surveillance, investigation or therapy by themselves but can be useful in conjunction with bill level
- these do NOT change your line when plotting bili
173
ABO isoimmunization is a common cause of hyperbili. What blood type is mum and infant most commonly when this occurs?
- mum usually O
- baby usually A or B
-risk is even higher of needing phototx if DAT is positive
174
What are the risk factors that change your line on the bill graph (risk of low, med, high)?
- isoimmune hemolytic disease
- G6PD deficiency
- asphyxia
- resp distress
- significant lethargy
- temp instability
- sepsis
- acidosis
175
Who should be screened for G6PD deficiency and why?
- any infant with severe hyperbilirubinemia
- infants of Mediterranean, Middle Eastern, African or Southeast Asian origin both boys and girls
- even though is X-linked females can have more than 50% of their red cells deficient b/c of random X inactivation
- babies with G6PD deficiency are at higher risk of needing an exchange transfusion
176
All mums should be tested for ABO and Rh blood types and screened for antibodies. How do you manage the infant if this was not done?
-send cord blood for blood group and DAT (Coombs)
177
Which babies should have a blood type and DAT done?
- babies born to mum's whose blood type is unknown
| - babies with early jaundice whose mum's are O blood group
178
When does the peak total bill serum concentration usually occur?
3-5 days
179
For all infants when should total serum bill be measured?
-for all infants btwn 24-72 hr of life and plot on the nomogram to determine risk for progression to severe hyperbili
180
If a baby is >37 wks and DAT negative and plots in the high zone what do you do? high-intermediate? low-intermediate? low?
- high = further testing or tx
- high-intermediate = routine care
- high/low-intermediate/low = routine care
181
If a baby is 35-37+6 wks OR DAT positive and plots in high risk zone on nomogram what do you do? high-intermediate? low-intermediate? low?
```
high = further testing or tx
high-intermiedaite = f/u in 24-48 hr
low-intermediate = routine care
low = routine care
```
182
If a baby is 35-37+6 wks AND DAT positive and plots in high risk zone on nomogram what do you do? high-intermediate? low-intermediate? low?
```
high = needs phototx
high-intermediate = further testing or treatment required
low-intermediate = further testing or treatment required
low = routine care
```
183
What are the different methods that bili can be measured? Which is the best
- cap
- venous
- transcutaneous
-no difference btwn cap and venous
184
What are the limits of transcutaneous bili measurements? How do you interpret the results?
- unreliable after initiation of phototx
- may be unreliable with changes in skin colour and thickness
- more accurate at lower levels of bili
- 95% CI is 37-78 micromol/L so if the value you get with the transcutaneous bili is >37-78 below the treatment line than ok not to treat
185
What are some causes of elevated conjugated bilirubin?
- rhesus erythroblastosis
- liver disease
- cholestasis
186
Which babies should have a conjugated bili level measured?
- persistent jaundice (longer than 2 wks)
| - hepatosplenomegaly
187
What level of conjugated bili is concerning?
-total conjugated bili >18 micromol/L or greater than 20% of the total serum bili concentration
188
At what day of life do exclusively breastfed infants experience their maximum weight loss and how much do they typically lose?
- day 3
| - 6-8% of birth weight
189
How does phototx help treat hyperbili?
- light induces conformational change in the bili molecule making it water soluble
- effectiveness of phototx is related to the area of skin exposed and the intensity of the light
190
What are side effects of phototherapy?
- temperature instability
- intestinal hypermotility
- diarrhea
- interference with maternal-infant interaction
- bronze discolouration (rare)
191
How do you manage feeds while baby is on phototx?
- continue enteral feeds
| - encourage continued breastfeeding
192
What 3 graphs do you use when managing an infant with hyperbili?
- nomogram to determine their risk
- graph to determine if need treatment with phototx
- graph to determine if need exchange transfusion
193
What online tool can be used to decide if intensive phototx is needed?
bilitool.org
194
When is IVIG used in babies with hyperbilirubinemia?
- infants with positive DAT and predicted severe disease based on antenatal investigation
- infants with elevated risk of needing exchange transfusion based on postnatal progression of bili
- IVIG 1g/kg
195
What is the fluid management of babies being treated with phototx?
-if at increased risk for exchange transfusion give supplemental PO or IV fluids
196
How soon after initiating phototherapy should a bili be checked in a baby with severe hyperbili?
2-6hrs to ensure is repsonding
197
What investigations should be done before starting an exchange transfusion?
- red cell fragility
- enzyme deficiency (G6PD deficiency or pyruvate kinase deficiency)
- metabolic work up
- hemoglobin electrophoresis
- chromosome analysis
198
How should you manage a baby who needs exchange transfusion while the exchange transfusion is being set up?
- intensive phototx
- supplemental fluids
- IVIG if isoimmunizaiton
199
Who should get an exchange transfusion?
- any baby with clinical signs of acute bilirubin encephalopathy
- infants with bili above the threshold on the exchange transfusion graph
200
When should you recheck a CBC in infants with isoimmunization?
- CBC at 2 wks if hgb low at discharge
| - CBC at 4 wks if hgb normal at discharge
201
What are parts of routine NICU care that are considered painful procedures?
- needle insertion
- suctioning
- gavage tube placement
- tape removal
- diaper cahnges
- chest phyiso
- physical exams
- environmental stimuli
202
What are some nonpharmacologic strategies to minimize pain in the NICU?
- nonnutritive sucking
- kangaroo care
- facilitated tuck
- swaddling
- developmental care
203
What is the role of topical anesthetics and how often should they be used?
- can use for venipuncture, LP, IV insertion
| - repeated use of topical anesthetic should be limited
204
What is the role for infusions for intubated babies in the NICU?
-midaz, morphine or fenatnyl infusions in chronically ventilated preterm neonates is not recommended due to concern about short term side effects and lack of long term data
205
What is the management of pain in a post-op neonate?
- ensure sufficient anesthesia intra-op
- routinely assess pain using a scale
- opioids should be the basis of analgesia after major surgery
- can use acetaminophen as an adjunct (insufficient data on pharmacokinetics at age
206
What anesthesia should be used for chest tube insertion? removal?
- INSERTION: local anesthetic in the skin before incision; if time does not permit then put it in after chest tube is inserted
- give a systemic rapid acting opiate like fentanyl
REMOVAL:
-short acting, rapid onset systemic analgesia
207
What is perinatal brachial plexus palsy?
- flaccid paralysis of the arm at birth
| - affects nerves of brachial plexus (C5-T1)
208
What are things that have been associated with perinatal brachial plexus palsy?
- birth trauma (most common)
- shoulder dystocia
- large for gestational age
- maternal diabetes
- instrumental delivery
209
Is perinatal brachial plexus palsy preventable?
-not alway
210
What % of infants with perinatal brachial plexus palsy recover and when?
75% recover completely in the first month
| 25% experience permanent disability and impairment
211
If a baby with perinatal brachial plexus palsy has not recovered fully by the 1st month what do you do?
- refer to a multi-D brachial plexus team (neurology, +/- physiatry, rehab, plastic surgeons)
- will need to decide about primary surgical vs nonsurgical management
212
What are the 3 questions you ask at the very beginning of the NRP algorithm?
term?
crying?
good tone?
213
What is the most important predictor of effective PPV?
increase in HR
214
What amount of FiO2 should be used in a term infant for resuscitation? very preterm?
21% in term
| -unclear for very preterm but somewhere 30-90% FiO2
215
What do you do in a baby whose HR is
compressions 3:1
| increase to FiO2 100%
216
Who should attend all deliveries from a baby perspective?
- one person responsible for the newborn who is capable of initiating rests, PPV, and CPR
- second advanced skilled person should be readily available to assist
217
What is MR SOPA?
- mask readjustment
- reposition the airway
- suction
- open mouth
- pressure increase
- alternate airway
218
What is the preferred method for CPR in a neonate?
2 thumb encircling technique
219
When do you intubate below the cords for meconium?
if the baby is flat
220
When do you stop resuscitation efforts in a neonate?
if no HR for 10 mins
221
When should you clamp the cord?
-after 1 minute in a baby who does not need resuscitation
222
What is the natural history of foreskin and when it becomes retractile?
- in newborns the foreskin and glans penis adhere to one another
- by 6 yrs 50% of boys can retract their foreskin
- 95% have retractile foreskin by age 17 yrs
223
What is circumcision?
partial or complete removal of the foreskin (prepuce)
224
What are the benefits of circumcision?
- do not get phimosis or paraphimosis
- decreased risk of UTIs
- lower risk of HIV and HSV2 in developing countries
- decreased risk of squamous cell carcinoma of the penis
225
What is phimosis and paraphimosis and how do you treat it?
phimosis = scarring and thickening of the foreskin that prevents retraction back over the glans (can be due to recurrent infections, inflammation or lichen sclerosis)
paraphimosis = foreskin entrapped behind the glans
-topical steroid bid to foreskin with gentle traction (releases adhesions)
-can also hasten foreskin retraction in boys with non retractile foreskin
(betamethasone 0.05% to 0.1%)
226
What is the evidence for UTIs and circumcision?
- preputial sac provides an environment for colonization of urethra
- 1 in 100 boys get UTI in first month of life, is 1 in 1000 by age 1 yr
- UTI decreased by 90% in cricumcised infants
-circumcision may be of greater benefit in boys with higher risk of UTI (e.g. with underlying urinary tract anomaly)
227
What is the evidence for circumcision and STI reduction?
Circumcision is partially effective in decreasing the risk for heterosexually-acquired HIV infection among men in sub-Saharan Africa
- unclear if this applies to developed countries
- circumcision not protective against G+C
228
What is the evidence for circumsicion and cancer reduction?
- female partners of circumsized males have reduced cervical cancer risk
- squamous cell carcinoma of the penis occurs almost exclusively in uncircumcised males
229
What are potential risk of circumcision?
- pain (need to treat during and post)
- minor bleeding
- local infection
- unsatisfactory cosmetic result
- rarely partial amputation of the penis, death or sepsis
230
What are late complications of circumcision and how can they be prevented?
- meatal stenosis (2-10%) can be prevented by applying petroleum jelly to glans for up to 6 mo post
- adhesions (some resolve spontaneously, some need topical steroids)
-complication rate post circumcision is lower in infants than in kids
231
What are contraindications to circumcision?
- hypospadias
| - bleeding diathesis
232
What are the CPS recommendations regarding circumcision?
* CPS does NOT recommend the routine circumcision of all newborn boys
* Parents who choose to have their sons circumcised should be referred to a practitioner who is trained in the procedure
* Trained practitioners who perform circumcisions must adhere to hygienic and analgesic best practices
* Close follow up in the early postcircumcision time period is critical
* Important to inform parents before discharge that it is normal for the foreskin to remain nonretractile until puberty
