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CPS Statements > Fetus and Newborn > Flashcards

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.

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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
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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

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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
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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

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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
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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)
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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

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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

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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

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11
Q

If baby born preterm (

A

-consider immediate intubation followed by surfactant if competent personnel available

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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
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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

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14
Q

Which newborns are at risk for hypoglycemia?

A
  • SGA (wt 90th %ile)
  • IDM
  • prems
  • perinatal asphyxia
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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

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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

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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

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18
Q

What is the cut off for glucose in a newborn below which intervention is required and why?

A

at 2 hr check:

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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
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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.

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21
Q

How many times are babies allowed to

A

once

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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.

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23
Q

What are strategies to prevent and treat asymptomatic hypoglycaemia?

A
  • increase breastfeeding frequency
  • supplement with breastmilk or formula
  • IV glucose
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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

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25
Q

If you are going to bolus dextrose IV how much do you give in a newborn?

A

2ml/kg of D10

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26
Q

If you want to escalate IV therapy how do you do it?

A
  • 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
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27
Q

What is the dose for IV glucagon bolus and infusion?

A

Glucagon bolus: 0.1-0.3 mg/kg

Glucagon infusion: 10-20 microg/kg/hr

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28
Q

What are your options if you have maxed out on IV dextrose for neonatal hypoglycaemia?

A
  • glucagon
  • HCT
  • diazoxide
  • ocreotide
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29
Q

Can you breastfeed a baby while treating with IV dextrose for hypoglycaemia?

A
  • 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
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30
Q

When can you start to wean IV dextrose for neonatal hypoglycemia?

A

-when levels have been stable for 12 hrs

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31
Q

Do all newborns need to be screened with a blood glucose?

A

no. appropriate for gestational age infants at term do not need it unless are symptomatic

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32
Q

How often do you screen at risk infants for neonatal hypoglycaemia?

A

at 2 hrs (post-feed) then q3-6hrs after (check prefeeds)

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33
Q

What is grief?
What is mourning?
What is bereavement?

A

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

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34
Q

What are the 3 phases of grief and mourning?

A

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

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35
Q

What is the average period of time to recover from the loss of a baby?

A

2-4 years is average for parents; their grief may be incongruence

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36
Q

What are the 6 “R” processes of mourning?

A 
Recognizing the loss
Reacting to the separation
Recollecting and Re-experiencing the deceased
Relinquishing old attachments
Readjusting to new work
Reinvesting in new relationships
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37
Q

What are some things healthcare providers can do to help with the dying/grieving process?

A
  • 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
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38
Q

Which babies are at increased risk of having an adverse cardiorespiratory event when put in a car seat?

A
  • preterm
  • low birth weight
  • significant cardioresp or neurologic problems (incl hypotonia)
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39
Q

Which babies need to have a carseat test and how is it done?

A
  • 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
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40
Q

What is considered a failure of the carseat test and what can you do about it?

A
  • 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
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41
Q

When does classic hemorrhagic disease of the newborn occur?

When does late hemorrhagic disease of the newborn occur and in what population?

A

Classic - in the 1st wk, (rare if got IM Vit K)

Late - age 3-8 wks; almost exclusively in infants who are breastfed

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42
Q

What are the recommendations for vitamin K including doses for newborns?

A

Vit K 0.5mg IM for babies 1500g within the first 6 hrs of life.

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43
Q

What alternatives can you offer parents who refuse IM vit K?

A
  • 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
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44
Q

What is the definition of fetal alcohol syndrome?

A

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

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45
Q

What are the characteristic facial features of fetal alcohol syndrome?

A
  • short eye slits (palpebral fissures)
  • thin upper lip
  • flattened cheek bones
  • indistinct groove btwn upper lip and nose
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46
Q

What is possible fetal alcohol effects (FAE)?

A

Children with prenatal exposure to alcohol but only some of FAS characteristics

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47
Q

What type of alcohol drinking can cause FAS?

A
  • any trimester not just the first
  • more likely after continuous or heavy intake
  • have seen with intermittent or binge drinking
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48
Q

What is primary, secondary and tertiary prevention as it refers to FAS?

A

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)

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49
Q

What is kangaroo care?

A

-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

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50
Q

What are the benefits to kangaroo care? What are the risks?

A

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

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51
Q

Who can get kangaroo care?

A

-babies as young as 26 weeks even if are ventilated

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52
Q

How does inhaled nitric oxide work and why do we use it?

A
  • pulmonary vasodilatory
  • improved ventilation/perfusion matching

-decreased death and need for ECMO

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53
Q

Who should be treated with iNO?

A

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
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54
Q

How do you calculate oxygen index?

A

OI = (FiO2 x mean airway pressure div PaO2) x100

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55
Q

What is persistent pulmonary HTN of the newborn?

A

-hypoxemic rest failure associated with persistent high pulmonary vascular pressure and resultant R to L shunting of blood through PFO, PDA and intrapulmonary channels

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56
Q

How do you administer iNO, starting and weaning?

A
  • 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
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57
Q

What are the side effects of inhaled NO? How do we monitor for them?

A

-methemoglobin - measure these, should be

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58
Q

What are the benefits of cooling babies with HIE? What are the side effects?

A
  • decreased mortality
  • improved neurodevelopmental outcomes
  • no serious side effects reported, can have mild bradycardia, hypotension, arrhythmia, mild thrombocytopenia, sclera/edema
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59
Q

What are the 2 phases of brain injury following intrapartum hypoxia-ischemia?

A

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

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60
Q

What are the criteria for cooling in HIE?

A

-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
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61
Q

What are the different categories for Sarnat scoring for HIE?

A

1) LOC
2) spontaneous activity
3) neuromuscular control
4) primary reflexes
5) autonomic system
6) Seizures

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62
Q

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

A

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

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63
Q

What are contraindications to cooling for HIE?

A
  • severe head trauma
  • intracranial bleed
  • no studies showing benefit if in kids 6hrs
  • increased mortality of cooling with prems
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64
Q

How can cooling be done and which method is better?

A

No difference between the 2.

1) selective head cooling with mild systemic hypothermia (cooling caps with aim of keeping fontanelle temp

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65
Q

How long should babies with HIE be cooled?

A

48-72 hrs. Most centres use 72 hrs.

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66
Q

How should you rewarm a baby who has been cooled for HIE?

A
  • controversial
  • slowly
  • by 0.5 degrees C q1-4 hrs
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67
Q

For who is cooling in HIE the most beneficial?

A

-babies with moderate encephalopathy, the evidence is less clear for severe

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68
Q

What is ROP?

A

-disorder of the developing retinal blood vessels of the preterm infant which can lead to poor visual acuity or blindness

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69
Q

How is ROP classified?

A
  • zones I-III (zone I is closest to optic nerve)
  • stages 1-5
  • pre-plus and plus disease (related to tortuosity)
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70
Q

What are the stages of ROP?

A
  • 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
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71
Q

What is pre-plus versus plus disease in ROP?

A
  • 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
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72
Q

Who should be screened for ROP?

A
  • infants born at 30+6 or less (regardless or BW)

- infants 1250 g or less

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73
Q

When can you stop screening for ROP?

A

-when risk no longer there (avg is 45 wks corrected)

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74
Q

How do you treat ROP?

A

-retinal ablation with cryotherapy and laser photocoagulation to decrease the production of angiogenic growth factors

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75
Q

When do you start screening for ROP?

A

-in infants born

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76
Q

How should you control pain during ROP exam?

A
  • topical anesthetic
  • sucrose
  • swaddling
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77
Q

When do we treat ROP?

A
  • 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
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78
Q

What are the most frequent indications of blood transfusion in the newborn?

A

1) perinatal or surgical hemorrhagic shock

2) ‘top-ups’ for the recurrent correction of anemia of prematurity

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79
Q

Do we transfuse fresh whole blood in Canada?

A

-No. RBCs are separated from other blood components right after collection

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80
Q

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?

A

42 days

4 hrs

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81
Q

What are the risk of transfusion in the neonate?

A

1) transfusion-transmitted infections
2) adverse effects of leukocytes (immunomodulation, GVHD, TRALI)
3) blood group incompatibilities
4) CMV has more serious consequences for prems

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82
Q

What is done by blood services to decrease the risk of CMV in blood products?

A

1) universal leukoreduction

- most centres gamma-irradiate blood to deactivate lymphocytes and prevent GVHD

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83
Q

What type of blood should be given to neonates?

A
  • O neg in emergencies

- O Rh-compatible or group-specific Rh-compatible

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84
Q

When do you need to cross-match donor blood for infants if their initial antibody screen is negative?

A

-at 4 months corrected

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85
Q

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?

A
  • 10-20ml/kg (usually 15 ml/kg)
  • Risks: hyperkalemia, volume overload, dilution of coats
  • if massive hemorrhage give FFP
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86
Q

What is the management of a newborn with hemorrhagic shock?

A
  • 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
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87
Q

What is anemia of prematurity?

A

-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

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88
Q

What are the cut offs for blood transfusion in neonates? What counts as resp support?

A

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

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89
Q

What is the role of erythropoietin in neonates who need blood transfusions? Risks? When do we use it?

A
  • 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)
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90
Q

How do we treat anemia of prematurity?

A

Iron supplementation 2 mg/kg/day of elemental iron introduced btw 4-6 wks of age at onset of reticulocytosis

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91
Q

What are the downsides of a prolonged NICU stay?

A
  • poor parent-child relationships
  • FTT
  • child abuse
  • parental grief and feelings of inadequacy
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92
Q

What are the physiological milestones a premature baby (born

A

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

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93
Q

What is the definition of apnea of prematurity?

A

-cessation of breathing for >20s or 10-20sec with associated bradycardia (HR

94
Q

When does apnea of prematurity resolved?

A

-in most by 36 weeks corrected but in very preterm babies it can be up to 44 wks corrected

95
Q

What is the half-life of caffeine in neonates?

A

-100hrs

96
Q

How long does a prem have to be apnea free before they can go home?

A

-variable but usually at least 5-7 days

97
Q

Is apnea of prematurity a risk factor for SIDS?

A

no.

No evidence for routine home monitoring to prevent sids.

98
Q

When are prems at the most risk of having cardiorespiratory events (spells)?

A
  • during feeding

- when semiupright in a car seat

99
Q

What % of prems with BW

A

25%

100
Q

What is target sat for infants with BPD?

A

90-95%

101
Q

Is there an association between GER and apnea?

A

evidence is variable.

102
Q

What are important family factors to consider when discharging home a prem?

A
  • 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
Q

If a prem

A

4

104
Q

What logistical things and tests need to be done before a prem is discharged home?

A
  • 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
Q

What are the side effects (both short and long term ) of systemic steroids given to prems?

A

Increased risk of cerebral palsy and neurodevelopment impairment.
Hyperglycemia, HTN, GI hemorrhage, GI perf. Risk of adrenal suppression

106
Q

In what cases do we give postnatal dexamethasone to prems?

A
  • 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
Q

Which steroid and what dose do we give for infants at high risk for or with severe chronic lung disease?

A

Dexamethasone (low-dose) 0.15mg/kg/day tapered over 10 days

-no evidence for hydrocortisone or for inhaled steroids

108
Q

When statistics are presented about gestational age in the CPS statement related to resuscitation what does 22 weeks encompass?

A

22+0 to 22+6

109
Q

What is an extremely preterm birth?

A

Occurs between 22+0 to 25+6

110
Q

What information do you need to include in a discussion with parents about extreme preterm birth?

A
  • likelihood of survival
  • anticipated problems
  • risk of disability
  • NICU experience
  • parenting
  • coping with stress
111
Q

What model should be used when counselling parents with anticipated extreme preterm birth?

A

Shared decision making btw health professional and parents. Decision aids can be helpful.

112
Q

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?

A

Ultrasound btw 8-14 wks.

Accuracy in first trimester is +/- 5 days.
Accuracy at 16-22 wks is +/- 10 days.

113
Q

How accurate are ultrasound measurements of estimated fetal weight?

A

+/- 10%

114
Q

What medications should be considered for administration to mum with threatened preterm labour and why?

A
  • antenatal steroids for lung maturation
  • tocolysis (short term) for transport
  • MgSO4 for neuroprotection
115
Q

What is the likelihood of survival of an infant born at

A

> 5%

116
Q

What is the likelihood of survival of an infant born at 25 weeks?

A

approx 80% (this is NOT a poor outcome)

117
Q

What is the risk of severe disability in the smallest and most immature preterm infatns?

A

18-60%

118
Q

What types of long term morbidity are prems at risk for?

A
  • Grade III or IV IVH
  • PVL
  • ROP
  • CLD
  • CP
  • cognitive impairement
  • blindness/deafness
  • seizures
  • behavioural difficulties
  • ADHD
  • language deals
  • more frequent hospital admission
119
Q

What are favourable prognostic factors related to preterm birth?

A
  • mum receiving antenatal steroids
  • female gender
  • birth at tertiary care centre
  • single fetus
120
Q

If a decision is made not to resuscitate a newborn what do you need to ensure happens?

A
  • compassionate palliative support
  • pain free
  • warmth
  • opportunity for parent to hold baby
  • warn parents that baby might live for days
121
Q

Which pregnant women with threatened preterm labour should be transferred to a tertiary care centre?

A

Any women with threatened preterm labour thought to be 23 wks

122
Q

What is the recommended resuscitation plan in a 22 wker?

A

non-interventional

123
Q

What is the recommended resuscitation plan in babies 23, 24 ?

A

-shared decision making with parents

124
Q

What is the recommended resuscitation plan in babies >25 wks?

A

CPS statement says shared decision making for 25 wkers but they have improved survival so realistically we resuscitate those

125
Q

Name 6 SSRIs.

A 
Fluoxetine
Paroxetine
Citalopram
Escitalopram
Fluvoxamine 
Sertraline
126
Q

What is the baseline risk of major malformations in the general population?

A

1-3%

127
Q

Are there any risks of congenital malformations with SSRI use in pregnancy?

A
  • 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
Q

What are the risks for the baby of maternal SSRI use in pregnancy?

A
  • possible increased risk of cardiac malformations with paroxetine in first trimester
  • SSRI neonatal behavioural syndrome (SNBS)
  • possible risk of PPHN
129
Q

What is SSRI neonatal behavioural syndrome (SNBS)? What % of babies exposed get it? Which SSRIs have been implicated the most?

A
  • 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
Q

What is the most worrisome possible side effect of SSRI use in pregnancy and how common is it?

A
  • PPHN
  • may be a rare expression of association
  • due to SSRI use in second half of pregnancy
131
Q

What is the management of a newborn born to a mum who took an SSRI?

A
  • monitor in hospital for a minimum of 48 hrs

- give families anticipatory guidance on possible effects of SSRIs

132
Q

Should women with depression be treated with SSRIs?

A

-yes. important to treat if the benefit outweighs the risk. If mum is on paroxetine consider decreasing dose or picking a different agent.

133
Q

What are the physiologic responses to intubation in newborns? Why do they occur?

A

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
Q

What medications do we use for intubation of neonates? At what dose?

A

Fentanyl - 3-5 micrograms/kg IV slow infusion
Atropine - 20 micrograms/kg IV
Succinylcholine - 2mg/kg IV

135
Q

What are the physiologic effects of premedication for intubation?

A
  • atropine (vagolytic) to prevent bradycardia
  • analgesia (fentanyl) can decrease pain and systemic HTN
  • muscle relaxant (succ) results in faster intubation so less hypoxia
136
Q

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?

A
  • Fentanyl is faster acting
  • chest freeze (and resp depression)
  • give muscle relaxant right away or give reversal agent (naloxone)
137
Q

What kind of drug is Midazolam? What are its side effects? Why don’t we use it for intubation in newborns?

A
  • 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
Q

Under what circumstances is it acceptable to intubate an infant without premedication?

A
  • 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
Q

What are alternatives for preintubation meds in a neonate in whom you cannot get IV access?

A
  • intranasal fentanyl

- inhanted gasses (NO or sevoflurane)

140
Q

What type of drug is atropine, what are its side effects and why do we use it in intubation?

A
  • vagolytic
  • side effect - potential for CNS complications in overdose
  • used to prevent bradycardia
141
Q

What type of drug is succinylcholine, what are the side effects and why do we use it in intubation?

A
  • muscle relaxant (depolarizing agent)
  • malignant hyperthermia, hyperkalemia, rhabdomyolysis
  • used to decreased intracranial pressure, shortens duration of procedure, reduces # of attempts, reduces trauma
142
Q

Why don’t we use rocuronium in neonatal intubation?

A

-prolonged and variable duration (up to 1 hr)

143
Q

What is considered a late preterm by CPS?

A

34+0 to 36+6 wks

144
Q

What are the risks/complications associated with being a late preterm?

A
  • 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
Q

How should a later preterm baby be triaged at birth?

A

-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
Q

When should you first feed and first bath a late preterm baby?

A
  • attempt early feeding

- do not bath until establish a core temp of at least 36.5

147
Q

What are differences in hyperbili levels in late preterm compared to term infants? How do we monitor for this?

A
  • 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
Q

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?

A

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
Q

Any special monitoring regarding apnea for late preterm?

A

-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
Q

Why are late preterm infants at increased risk for sepsis compared to term babies? Is this for early or late?

A

Increased risk for BOTH early and late onset sepsis.

  • born to mum with chorioamniotis
  • born before mum’s GBS status known
151
Q

How soon after discharge should a late preterm baby be followed up?

A

48 hrs

152
Q

What is the most common bug that causes early-onset sepsis and what is the case-fatality if intrapartum antibiotics are not given?

A

GBS

2-13%

153
Q

What is considered a limited diagnostic evaluation for infants at increased risk for sepsis? And what results are considered significant?

A
  • CBC and observation of vitals q4h for at least 24 hrs

- if WBC

154
Q

What is the role of intrapartum penicillin given to pregnant mums?

A
  • prevention of early-onset invasive GBS disease

- it does not affect frequency of sepsis caused by other organisms

155
Q

What does gram positive cocci in the CSF suggest? What is the empiric tx of choice?

A
  • GBS, or Stpah or enterococci

- Amp + Gent

156
Q

What does gram positive rods in the CSF suggest? What is the empiric tx of choice?

A
  • Listeria

- Amp + Gent

157
Q

What does gram negative rods in the CSF suggest? What is the empiric tx of choice?

A 
E coli (less commonly Klebsiella, Pseudomonas, Citrobacter)
-Cefotaxime + Gent
158
Q

What does gram negative cocci in the CSF suggest? What is the empiric tx of choice?

A
  • uncommon

- Cefotaxime

159
Q

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?

A

-routine care

160
Q

What if a mum is pregnant, GBS negative and penicillin-allergic, how do you manage the infant?

A

-Treat as if the mother received incomplete intrapartum antibiotics

161
Q

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?

A
  • limited diagnostic evaluation is required (CBC) and must be in hospital for at least 24 hrs
  • risk of invasive GBS disease is 1%
162
Q

What is the management of a well-appearing infant of a GBS-negative mother who had risk factors at delivery?

A

Recommendations section says do not do anything.

-body of text in CPS statement says limited diagnostic evaluation with CBC

163
Q

What are the risk factors for sepsis in the newborn?

A

1) ROM >18 hr

2) premature labour

164
Q

What is the management of a well-appearing infant of a mother with unknown GBS status and no risk factors?

A

Routine care. No specific intervention required.

165
Q

What is the management of a well-appearing infant of a mother with unknown GBS status with risk factors?

A
  • these mums should have received IAP if GBS is unknown

- if mum not treated or treated

166
Q

What is the management of a baby delivered

A
  • 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
Q

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?

A
  • 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
Q

What is kernicturus?

A

pathologic finding of deep yellow staining of neutrons and neuronal necrosis of the basal ganglia and brainstem nuclei

169
Q

What is acute bilirubin encephalopathy?

A

-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
Q

What is chronic bilirubin encephalopathy?

A
  • 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
Q

What is the cut off for severe hyperbili? critical hyperbili?

A
  • 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
Q

What are the risk factors for development of severe hyperbilirubinemia? How do they help guide investigation and therapy?

A
  • 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
Q

ABO isoimmunization is a common cause of hyperbili. What blood type is mum and infant most commonly when this occurs?

A
  • mum usually O
  • baby usually A or B

-risk is even higher of needing phototx if DAT is positive

174
Q

What are the risk factors that change your line on the bill graph (risk of low, med, high)?

A
  • isoimmune hemolytic disease
  • G6PD deficiency
  • asphyxia
  • resp distress
  • significant lethargy
  • temp instability
  • sepsis
  • acidosis
175
Q

Who should be screened for G6PD deficiency and why?

A
  • 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
Q

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?

A

-send cord blood for blood group and DAT (Coombs)

177
Q

Which babies should have a blood type and DAT done?

A
  • babies born to mum’s whose blood type is unknown

- babies with early jaundice whose mum’s are O blood group

178
Q

When does the peak total bill serum concentration usually occur?

A

3-5 days

179
Q

For all infants when should total serum bill be measured?

A

-for all infants btwn 24-72 hr of life and plot on the nomogram to determine risk for progression to severe hyperbili

180
Q

If a baby is >37 wks and DAT negative and plots in the high zone what do you do? high-intermediate? low-intermediate? low?

A
  • high = further testing or tx
  • high-intermediate = routine care
  • high/low-intermediate/low = routine care
181
Q

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?

A 
high = further testing or tx
high-intermiedaite = f/u in 24-48 hr
low-intermediate = routine care
low = routine care
182
Q

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?

A 
high = needs phototx
high-intermediate = further testing or treatment required
low-intermediate = further testing or treatment required
low = routine care
183
Q

What are the different methods that bili can be measured? Which is the best

A
  • cap
  • venous
  • transcutaneous

-no difference btwn cap and venous

184
Q

What are the limits of transcutaneous bili measurements? How do you interpret the results?

A
  • 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
Q

What are some causes of elevated conjugated bilirubin?

A
  • rhesus erythroblastosis
  • liver disease
  • cholestasis
186
Q

Which babies should have a conjugated bili level measured?

A
  • persistent jaundice (longer than 2 wks)

- hepatosplenomegaly

187
Q

What level of conjugated bili is concerning?

A

-total conjugated bili >18 micromol/L or greater than 20% of the total serum bili concentration

188
Q

At what day of life do exclusively breastfed infants experience their maximum weight loss and how much do they typically lose?

A
  • day 3

- 6-8% of birth weight

189
Q

How does phototx help treat hyperbili?

A
  • 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
Q

What are side effects of phototherapy?

A
  • temperature instability
  • intestinal hypermotility
  • diarrhea
  • interference with maternal-infant interaction
  • bronze discolouration (rare)
191
Q

How do you manage feeds while baby is on phototx?

A
  • continue enteral feeds

- encourage continued breastfeeding

192
Q

What 3 graphs do you use when managing an infant with hyperbili?

A
  • nomogram to determine their risk
  • graph to determine if need treatment with phototx
  • graph to determine if need exchange transfusion
193
Q

What online tool can be used to decide if intensive phototx is needed?

A

bilitool.org

194
Q

When is IVIG used in babies with hyperbilirubinemia?

A
  • 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
Q

What is the fluid management of babies being treated with phototx?

A

-if at increased risk for exchange transfusion give supplemental PO or IV fluids

196
Q

How soon after initiating phototherapy should a bili be checked in a baby with severe hyperbili?

A

2-6hrs to ensure is repsonding

197
Q

What investigations should be done before starting an exchange transfusion?

A
  • red cell fragility
  • enzyme deficiency (G6PD deficiency or pyruvate kinase deficiency)
  • metabolic work up
  • hemoglobin electrophoresis
  • chromosome analysis
198
Q

How should you manage a baby who needs exchange transfusion while the exchange transfusion is being set up?

A
  • intensive phototx
  • supplemental fluids
  • IVIG if isoimmunizaiton
199
Q

Who should get an exchange transfusion?

A
  • any baby with clinical signs of acute bilirubin encephalopathy
  • infants with bili above the threshold on the exchange transfusion graph
200
Q

When should you recheck a CBC in infants with isoimmunization?

A
  • CBC at 2 wks if hgb low at discharge

- CBC at 4 wks if hgb normal at discharge

201
Q

What are parts of routine NICU care that are considered painful procedures?

A
  • needle insertion
  • suctioning
  • gavage tube placement
  • tape removal
  • diaper cahnges
  • chest phyiso
  • physical exams
  • environmental stimuli
202
Q

What are some nonpharmacologic strategies to minimize pain in the NICU?

A
  • nonnutritive sucking
  • kangaroo care
  • facilitated tuck
  • swaddling
  • developmental care
203
Q

What is the role of topical anesthetics and how often should they be used?

A
  • can use for venipuncture, LP, IV insertion

- repeated use of topical anesthetic should be limited

204
Q

What is the role for infusions for intubated babies in the NICU?

A

-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
Q

What is the management of pain in a post-op neonate?

A
  • 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
Q

What anesthesia should be used for chest tube insertion? removal?

A
  • 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
Q

What is perinatal brachial plexus palsy?

A
  • flaccid paralysis of the arm at birth

- affects nerves of brachial plexus (C5-T1)

208
Q

What are things that have been associated with perinatal brachial plexus palsy?

A
  • birth trauma (most common)
  • shoulder dystocia
  • large for gestational age
  • maternal diabetes
  • instrumental delivery
209
Q

Is perinatal brachial plexus palsy preventable?

A

-not alway

210
Q

What % of infants with perinatal brachial plexus palsy recover and when?

A

75% recover completely in the first month

25% experience permanent disability and impairment

211
Q

If a baby with perinatal brachial plexus palsy has not recovered fully by the 1st month what do you do?

A
  • refer to a multi-D brachial plexus team (neurology, +/- physiatry, rehab, plastic surgeons)
  • will need to decide about primary surgical vs nonsurgical management
212
Q

What are the 3 questions you ask at the very beginning of the NRP algorithm?

A

term?
crying?
good tone?

213
Q

What is the most important predictor of effective PPV?

A

increase in HR

214
Q

What amount of FiO2 should be used in a term infant for resuscitation? very preterm?

A

21% in term

-unclear for very preterm but somewhere 30-90% FiO2

215
Q

What do you do in a baby whose HR is

A

compressions 3:1

increase to FiO2 100%

216
Q

Who should attend all deliveries from a baby perspective?

A
  • 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
Q

What is MR SOPA?

A
  • mask readjustment
  • reposition the airway
  • suction
  • open mouth
  • pressure increase
  • alternate airway
218
Q

What is the preferred method for CPR in a neonate?

A

2 thumb encircling technique

219
Q

When do you intubate below the cords for meconium?

A

if the baby is flat

220
Q

When do you stop resuscitation efforts in a neonate?

A

if no HR for 10 mins

221
Q

When should you clamp the cord?

A

-after 1 minute in a baby who does not need resuscitation

222
Q

What is the natural history of foreskin and when it becomes retractile?

A
  • 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
Q

What is circumcision?

A

partial or complete removal of the foreskin (prepuce)

224
Q

What are the benefits of circumcision?

A
  • 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
Q

What is phimosis and paraphimosis and how do you treat it?

A

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
Q

What is the evidence for UTIs and circumcision?

A
  • 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
Q

What is the evidence for circumcision and STI reduction?

A

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
Q

What is the evidence for circumsicion and cancer reduction?

A
  • female partners of circumsized males have reduced cervical cancer risk
  • squamous cell carcinoma of the penis occurs almost exclusively in uncircumcised males
229
Q

What are potential risk of circumcision?

A
  • pain (need to treat during and post)
  • minor bleeding
  • local infection
  • unsatisfactory cosmetic result
  • rarely partial amputation of the penis, death or sepsis
230
Q

What are late complications of circumcision and how can they be prevented?

A
  • 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
Q

What are contraindications to circumcision?

A
  • hypospadias

- bleeding diathesis

232
Q

What are the CPS recommendations regarding circumcision?

A
  • 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

CPS Statements (14 decks)

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