Fetus and Newborn Flashcards
What could be a correct explanation for elevated AFP?
Incorrect dates
What are some associations with increased AFP?
RAIN
Renal (nephrosis, renal agenesis, polycystic kidney disease)
Abdominal wall defects
Incorrect dating/Multiple pregnancy
Neurological (anencephaly and spina bifida)
What is low AFP associated with?
Chromosomal abnormalities like trisomy 21 or trisomy 18
AFP is what type of test?
Screening…may need additional studies like US to confirm suspected findings
What does the non stress test measure?
Spontaneous fetal movements and heart rate nativity
Which test measures fetal autonomic nervous system integrity?
Non stress test
What does the contraction stress test measure?
Fetal heart rate in response to uterine contraction
What test measures uteroplacental insufficiency and tolerance of labor?
Contraction stress test
For the CST, is a positive or negative test good, and what constitutes each?
Negative is good…
Negative/Normal means no late or significant decelerations and is reassuring
Positive means late decelerations after 50% of contractions and would require further investigation
What % of fetuses experience arrhythmias?
1%… Most of them are benign
What is the most common cause of fetal bradycardia and what maternal condition is seen with this?
Heart block, may be seen with maternal lupus
When should you treat mom with antiarrhythmic medications and why?
SVT with heart rates exceeding 240bpm…the treatment is to avoid congestive heart failure and hydrops in the fetus
What is the biophysical profile test?
Includes the non stress test, plus an US evaluation of fetal movement, reactive HR, breathing, tone, and volume of amniotic fluid
What is the definition of apnea?
No breath for greater than 20 seconds (less than this would be considered periodic breathing)
Name causes of apnea
- Abnormal metabolism (hypoglycemia, hypocalcemia, anemia, maternal medications)
- PDA and other cardiac causes
- Neurological (seizures, intracranial hemorrhage, apnea of prematurity)
- Epidemiological/Infectious (sepsis, pertussis, RSV, and other respiratory infections)
- Abnormal swallowing/GERD
What is central apnea?
When there is no respiratory effort because there is no signal from the CNS
What is apnea of prematurity?
A subset of central apnea, diagnosis of exclusion
*If there is another cause of apnea, have to provide hint…sepsis, medications, profound anemia, electrolyte abnormality
How do you treat apnea of prematurity?
Caffeine or theophylline
What is the post delivery pattern of primary apnea?
Gasping…with increased depth and rate of respiration…followed by apnea
*At this point, if blow by blow oxygen and stimulation are given, there should be a good response
How can primary apnea be reversed?
Tactile stimulation
If primary apnea doesn’t resolve, what happens and what do you do?
- Another round of gasping, followed by more apnea
- Positive pressure ventilation (oxygen and stimulation won’t work)
Can primary apnea occur in utero?
Yes, so it is difficult to determine if the newborn is experiencing primary or secondary apnea
All apneic newborns who fail to respond to tactile stimulation and remain apneic 30 seconds after delivery require what?
Positive pressure ventilation (under assumption you are dealing with secondary apnea)
What pressure is needed to inflate the lungs with the first breath?
60mmHg
What is transient tachypnea of the newborn?
Tachypnea in otherwise healthy infants
What causes TTN?
Retained fetal fluid
Which babies is TTN more commonly seen in?
Infants delivered by C-section
What does an XR in an infant with TTN show?
Fluid in the interlobar fissures and increased interstitial pulmonary markings
What are signs of TTN and how is it diagnosed?
Presents within first few hours with tachypnea, retractions, nasal flaring, and grunting
Diagnosis of exclusion
What is the respiratory rate in TTN?
Greater than 60
When does TTN resolve?
Within 72 hours
How do you manage TTN?
NPO status and close monitoring
Once symptoms improve, can start feeds. Advance feeds slowly until the respiratory rate falls below 60 breaths per minute
What are the most common causes of coma and lethargy in infants?
Sepsis, metabolic disturbances, asphyxia (distinguish by looking for signs in history)
What has to be included in the history for neonatal hypoxic-ischemic encephalopathy?
Complicated delivery
What are some features of neonatal HIE?
Metabolic disturbances like elevated serum ammonia, lactic acidosis, hypoglycemia, hypocalcemia, and hyponatremia
What is the anion gap in neonatal HIE?
Normal
What is the result of deficient surfactant in the lining of the alveoli?
RDS
When does the surge in surfactant production occur?
Usually after 33-36 weeks gestation
Surfactant levels gradually increase until 33-36 weeks gestation, after this there is a surge
*If an infant is born prior to this, they will be surfactant deficient and suffer from RDS
Why is RDS also known as Hyaline Membrane Disease?
The cellular debris that covers the terminal bronchioles in RDS forms a hyaline membrane
What is the typical presentation of RDS?
Tachypnea, nasal flaring, expiratory grunting, retractions, cyanosis (can be part of picture as well)
What does CXR look like for RDS?
Granular opacifications, air bronchograms, obscure heart/diaphragm borders, ground glass
What is the difference in CXR between RDS and meconium aspiration?
RDS is symmetric findings and meconium aspiration is asymmetrical
What does surfactant do?
Keeps the alveoli open during expiration
If symptoms of RDS persist beyond 3 days, what could be a complicating factor?
PDA
What condition has indistinguishable CXR findings to RDS?
Pneumonia secondary to group B strep
*Have to note something in history like prolonged and progressively worsening symptoms despite respiratory assistance
What coexistent conditions can worsen RDS?
Hypoglycemia (can also mimic RDS), hypocalcemia, anemia, acidosis, extremes of temperature
What can happen if you have hyperbilirubinemia with RDS?
The threshold for kernicterus is lowered
Risk for RDS is increased with what 3 things?
- Infants of diabetic mothers
- C-Section delivery
- Birth asphyxia
Risk for RDS is decreased with what 2 things?
- Prolonged rupture of membranes
2. Prenatally administered steroids
What L:S ratio (lecithin:sphingomyelin) suggests low risk for RDS?
Greater than 2
What can be done before delivery to help decrease the risk for RDS in premature infants?
Prenatal steroids
What maternal condition can interfere with the accuracy of the L:S ratio?
Diabetes
When is mechanical ventilation indicated for infants with RDS (and/or other signs of respiratory failure)?
pH lower than 7.2 and PCO2 greater than 60
What equipment problem is common in infants on a vent?
Air leaks
What else can be used for infants with RDS or respiratory failure besides ventilation?
Exogenous surfactant, high frequency ventilators, ECMO (extracorporeal membrane oxygenation…temporary heart/lung bypass)
What is the goal PO2 with treatment for RDS/respiratory failure?
Maintain PO2 between 50-70mmHG
Once you diagnose RDS, what do you do?
Administer surfactant
If a baby is under 30 weeks or at risk for RDS, do you give surfactant?
Yes, therapy is prophylactic (just after delivery), or early (within two hours of delivery)
If you give surfactant once a diagnosis of RDS is made, what type of treatment is that?
Rescue
What are non-distinguishable things between RDS and GBS pneumonia?
CXR, tachypnea, grunting, respiratory distress
What is one reliable sign of sepsis in the newborn period?
Ratio of bands to total neutrophils
A ratio of bands to total neutrophils greater than what is suggestive of sepsis or pneumonia versus RDS?
0.2 (remember to calculate this ratio when given CBC values)
What is an exam finding in history that is a good clue to consider pneumonia over RDS?
Temperature instability
After giving surfactant, clinical improvement is expected in what 3 forms?
- Decreased oxygen requirement
- Reduced inspiratory pressure
- Improved lung compliance
What changes to pulmonary compliance and inspiratory pressure happen with expected improvement with surfactant?
Increased pulmonary compliance and decreased inspiratory pressure go with improvement
(Decreased pulmonary compliance and increased inspiratory pressure are not expected improvements with surfactant)
What can account for some deterioration in infants with RDS on ventilators and is air leaking into the interstitium (often precedes a full-blown pneumothorax)
Pulmonary interstitial emphysema (PIE)
What is bronchopulmonary dysplasia?
A chronic lung disease
Used to think it was due to prolonged mechanical ventilation and oxygen exposure
Now believed to be due to arrest of normal lung development in premature infants (with therapeutic advances)
What is chronic lung disease definition for infants?
CLD is present in infants who still have an oxygen requirement 28 days after birth and/or continued oxygen requirement at 36 weeks corrected gestation
How is BPD treated and what is a possible side effect of treatment?
Diuretics…risk for hypocalcemia
What type of twins are at a higher risk for complications and why?
Monozygotic twins…because they share a chorion and an amnion
Which twin is at higher risk for developing respiratory problems?
B twins at higher risk than A twins
When/who is ECMO used for?
Primarily for infants with reversible lung disease of less than 10-14 days duration, with failure of other methods
What 2 things must an infant NOT have to be eligible for ECMO?
No systemic or intracranial bleeding or congenital heart disease
What is the typical CXR description for an infant with BPD?
Diffuse opacities, cystic areas with streaky infiltrates, ground glass appearance
What are 2 things to consider in a lethargic and floppy baby with weird labs besides sepsis?
Congenital adrenal hyperplasia and inborn errors of metabolism
What is the empirical treatment of suspected neonatal sepsis?
Ampicillin and gentamicin (don’t choose cefotaxime…it is responsible for outbreaks of drug resistant enterobacter and serratia)
Infant with classic signs of sepsis, labor and delivery unremarkable, mom had slight fever and flulike symptoms, placental had white nodules…bug and drug?
Listeria, ampicillin and gentamicin
How can group B strep present?
Anything from asymptomatic bacteremia to septic shock
What is group B strep?
Strep agalactiae
What are the initial clinical findings in 80% of newborns regardless of the site of infection with group B strep?
Respiratory symptoms, tachypnea, grunting, flaring, apnea, cyanosis
When does GBS early onset infection present?
First 7 days after birth
When does GBS late onset disease present?
Generally in first month of life, may present up to 90 days after birth
Is late onset GBS usually associated with obstetric or birth complications?
No
Who does late-late onset GBS disease present in and when?
Preterm infants, may appear at up to 6 months
She do you screen mom for GBS?
35-37 weeks gestation
What is done for mom who is GBS positive, or wasn’t tested but has sepsis risk factors?
Intrapartum antibiotic prophylaxis unless c-section is done before onset of labor or rupture of membranes
What do you do for infants of mothers with suspected chorioamnionitis?
Get a CBC and blood cultures and start antibiotics pending culture results
What to do for well appearing infant with mom who had inadequate treatment of GBS?
Monitor for 48 hours prior to discharge
What is the drug of choice for treatment of proven GBS?
Penicillin…no known resistance
What are risk factors for early onset disease with GBS?
- Maternal colonization at birth
- Preterm birth under 37 weeks
- ROM over 18 hours before delivery
- Chorioamnionitis
- Multiple gestation
- Nonwhite maternal race
- Intrapartum fever over 38
- Intrauterine monitoring
- Postpartum maternal bacteremia
- Previous infant with invasive GBS disease
If mom is described as asymptomatic during pregnancy what is the likely bug for newborn sepsis?
GBS
If mom was described as having flu like illness during pregnancy, what is the likely bug causing newborn sepsis?
Listeria
What is usually necessary for a birth trauma clavicular fracture?
Watchful observation
When can you expect the clavicular fracture callus to recede from birth trauma?
Within 2 years
If you get a neonatal CXR, what should you make sure not to miss?
Clavicular fracture (easy to focus on lungs and GI and miss this)
What 2 nerve issues can result from a clavicular fracture?
Erb’s palsy and phrenic nerve palsy
What % of deliveries do brachial plexus injuries occur in?
Half a percent
Where does Erb’s palsy occur?
C5-C7
How does Erb’s palsy present?
Classic waiter’s tip…adducted, internally rotated, wrist and fingers flexed, limited shoulder movement
What birth problem is Erb’s palsy associated with?
Clavicular fractures
What to think of in infant with Erb’s palsy and respiratory distress?
Phrenic nerve paralysis (leads to respiratory distress…clavicular fractures can cause both)
Where does Klumpke palsy occur?
C8-T1
How does Klumpke palsy present?
Claw hand…affects muscles in hand
Someone being born grabbing a Klump of sand
What can happen to hand mobility in Klumpke palsy?
They can lose ability to grasp, despite initial presentation of claw hand
What eye issue can Klumpke palsy be associated with?
Horner syndrome
Which is more common, Erb’s or Klumpke palsy?
Erb’s palsy
What happens to grasp with Erb’s palsy?
Ability to grasp is preserved, so grasp reflex remains intact (with Erb’s palsy, the nerve is stretched, not broken)
When should the umbilical cord fall off?
By the 2-week visit
What should you be concerned for if the umbilical cord stays attached beyond one month?
Leukocyte adhesion deficiency or low WBC count
What do you do for care for the umbilical stump?
Wash with soap and water and pat dry (no decreased infection risk by applying alcohol to stump)
Are cultural remedies okay for umbilical stump?
They are okay, as long as they don’t do any harm (like applying mercurochrome…which contains mercury…this isn’t available in U.S., but could be on boards)
What do you do for a newborn with a single umbilical artery?
Renal ultrasound
*In real world, most instances of a single umbilical artery aren’t associated with renal disease
Where should the baby be before clamping the cord?
The baby should be kept below the cord for around 30 seconds to prevent decreased red cell volume
What could the obstetrician milking the cord towards the baby cause?
Polycythemia…obstetrician should not milk the cord towards the baby
Is breast hypertrophy in a newborn a benign finding?
Yes…even if milk is produced (witch’s milk)
What do you do for an infant with breast hypertrophy and milk production?
Leave it alone…don’t express milk by squeezing it out. This makes it worse because it stimulates prolactin and oxytocin secretion and prolongs it. Also increases risk for mastitis.
What is an SGA baby?
In lower 10th percentile for weight for gestational age
What is an LGA baby?
Above the 90th percentile for weight for gestational age
LGA is greater than how many grams?
3900g
SGA is less than how many grams?
2500g
Which babies have a higher morbidity and mortality risk than AGA babies?
SGA
In short term, SGA babies are at higher risk for what?
Temperature instability, polycythemia, and fasting hypoglycemia
SGA stands for…
Small for gestational age
SGA infants are born with what?
Intrauterine growth retardation
Are all preemies SGA?
No, preemies won’t be SGA if their weight is appropriate for their gestational age
Why is IUGR often associated with perinatal asphyxia?
Because IUGR babies tend to have more difficulty tolerating labor
Infants of mothers with chronic illness are at higher risk for being what?
SGA
Teenage mothers are at higher risk for delivering what type of babies?
SGA
When do SGA babies catch up on growth?
May catch up once removed from the restrictive uterine environment
If the growth failure is due to an inherent infant condition (congenital infection), growth will likely not catch up
What is the definition of full term?
40 weeks plus or minus 2 weeks…any baby born in range of 38-42 weeks is considered full term (42 week baby is considered term)
What is considered post term?
More than 2 weeks post dates
Dry skin that is peeling, long fingernails, decreased lanugo on the back, ears with strong recoil
Post term newborns
What are the most common causes of fetal demise?
Chromosomal abnormalities, congenital malformations
What is normal arterial pO2 and pCO2 for a newborn infant?
PO2: 60-90mmHg
PCO2: 35-45mmHg
Scalp pH of 7.29, what do you do next?
Nothing but reassure
Normal scalp pH is 7.25 or higher (they can present you with normal pH and imply in question that it is abnormal)
Scalp pH less than what is a bad sign?
7.20
Why are newborns at risk for heat loss?
Because of high surface area to body mass ratio
How do you reduce heat loss in newborns?
Use radiant warmer and drying with warm blankets
What is the best source of warmth for a newborn?
Skin to skin contact with mom (emotional benefits as well)
Why should cold stress be avoided in a newborn?
It can lead to depletion of fat and glycogen stores
What is the one exception to radiant heat warmer being the best choice?
Extreme premies (extremely low gestational age newborn…ELGAN)
Why do you not put ELGANs under radiant heat warmers?
If they are in an open air radiant heat warmer it can cause too much evaporative fluid loss…need a closed humidified environment for at least the first 24-72 hours of life
*Isolette is better than open air radiant heat, even though access for procedures is less convenient
Does the 1 minute Apgar score reflect long term problems if the 5 minute Apgar score is fine?
No
What does the 1 minute Apgar score reflect?
Life in the uterus and his/her endurance of the delivery process to the harsh life outside of the uterus
What does the 5 minute Apgar reflect?
Transition and adjustment to the new world
What 5 minute Apgar score is reflective of a difficult adjustment?
7 or less
What should you think if an infant has bilateral ankle clonus?
It can be a normal finding in an infant…don’t let them trick you into thinking its some sort of neurological sign or seizure
How do you use Apgar to decide about whether to do CPR?
You don’t use Apgar…you would never wait one minute before making that decision
What assistance is required in presence of bradycardia and impaired ventilatory efforts?
Positive pressure ventilation
If you are adequately ventilating with oxygen and the heart rate is under 60, what do you do?
Chest compressions
What is the rate for chest compressions and ventilation in neonates?
Compressions at a rate of 100 per minute, one ventilation per 3 compressions
What is the weight to be a very low birthweight infant?
Under 1500 grams
What do VLBW infants need to get glucose without fluid overload?
D10
What factors impact prognosis in VLBW infants?
- Gestational age (most important)
- Morbidity while in NICU
- Intracranial hemorrhage
What’s the norm for a preemie’s BP?
Preterm baby’s MAP shouldn’t be less than the corrected gestational age in weeks
28 week preemie shouldn’t have a MAP under 28
What Apgar score would you not expect for a VLBW infant and why?
Anything greater than 6… Neurological immaturity (including poor tone)
What do you have to rule out in the VLBW infant unless an alternative cause of the preterm birth seems clear (pre-eclampsia or placenta previa)?
Sepsis…infection must be considered as a trigger for premature delivery
What do you use if you suspect a premature delivery was do to sepsis/infection?
Ampicillin and gentamicin
What should you think/do if you get an infant presenting with vesicular lesions?
Neonatal herpes, treat with acyclovir
What are 2 signs of neonatal herpes besides the vesicular lesions?
Thrombocytopenia or a bloody spinal tap
*Don’t let fact that mom doesn’t have a history of herpes throw you off…still could be this
What babies does meconium aspiration occur almost exclusively in?
Term and postterm infants
Passage of meconium in utero may represent what?
Fetal hypoxemia
What does CXR in meconium aspiration look like?
Patchy areas of atelectasis alternating with areas of hyperinflation
What % of infants with meconium aspiration have pneumothorax?
10-20%
Present with respiratory distress, “barrel chest”, rales and rhonchi on auscultation
Meconium aspiration
Is intubation necessary for a meconium baby if the baby is vigorous?
No…visualization is okay
If you have a meconium baby who is floppy, what do you do?
Suction the orophrynx (at delivery), then intubate and suction below the cords
What do you initially for a meconium delivery that is different from a normal delivery?
Do not stimulate the baby at first
Why is careful observation still required for meconium babies even if you visualized and it was clear?
You can still have no meconium at the cord level with meconium deeper in the bronchial tree
Do you suction at the perineum before shoulders are delivered?
Prior research showed suctioning at the perineum before the shoulders are delivered was critical
Recent study showed no difference in outcome between suctioning on the perineum and no suctioning prior to delivery of shoulders
What can initially be difficult to distinguish congenital heart disease from?
Pulmonary hypertension without meconium
If a newborn has meconium in its amniotic fluid and any signs of distress at birth, what do you do?
Direct tracheal visualization and suctioning (remove meconium from airway)
What is the most likely complication from full blown meconium aspiration syndrome?
Persistent pulmonary hypertension
When do you start investigating if baby hasn’t passed meconium?
First 48 hours
What are possible causes of delayed passing of meconium?
- Meconium plug syndrome
- Hirschprung’s disease
- Imperforate anus
6 steps for evaluating an infant who hasn’t stooled within 48 hours?
- Repeat examination of abdomen and rectum
- Assess for adequacy of feeding
- Check barium enema to rule out Hirschsprung’s disease
- Order surgical consultation for rectal biopsy
- Watch for signs of intestinal obstruction, hydration
- Hydration and feeding until a diagnosis is established
What 2 things is NEC associated with?
- Hypoxic injury (RDS, birth asphyxia, and/or prolonged apnea)
- Bacterial infection
What lab test is often off with NEC?
Blood cultures, often positive
What is a common XR finding with NEC?
Pneumatosis intestinalis
How long should you keep baby NPO after an episode of NEC?
For at least 3 weeks
Name some general findings associated with NEC.
Lethargy, apnea, poor feeding
Name some specific findings with NEC.
Bloody stools, erythema of abdominal wall, thrombocytopenia
The combination of what 2 findings on XR would be sufficient for an assumption of a diagnosis of NEC?
Pneumatosis intestinalis and pneumoperitoneum (air in the biliary tree)
What is pneumatosis intestinalis?
Gas in the bowel wall (not specific to NEC and can occur with other disorders…although it should be present on a board question with NEC)
What is a long term complication of NEC?
Intestinal strictures
What is included in management of NEC?
NG tube to intermittent suction, IV fluids and antibiotics, CBC, electrolytes, coagulation studies, and serial abdominal films as indicated
How often is surgical intervention required for NEC?
Up to half the time
What is an anuric infant?
No urine output for 24 hours
Name 7 steps to evaluate an anuric infant
- Recheck the plumbing by evaluating abdomen and genitalia
- Make sure fluid intake has been adequate
- Obtain a cath urine specimen for analysis
- Check BUN and creatinine
- Order a renal US
If you do all the evaluation for an anuric infant and everything is normal and baby starts to pee, what do you do?
Stop, you’re good
What do you do for an anuric baby who has some wacky test results or normal results, but still isn’t peeing?
Call in the urologist (only if you are provided with the normal lab results that would be part of the initial workup)
A bilirubin up to what within the first 24 hours can normal in a full term newborn?
12.4
Can you use visual diagnosis for jaundice in neonate?
No, visual diagnosis is generally unreliable, even more so in darker skinned infants
Which infants are at a higher risk for jaundice?
Near term infants at 35-38 weeks
Which cultural group neonates are at a higher risk for hyperbilirubinemia?
East Asian decent
When does breastfeeding jaundice occur?
First days of life
What is the most common cause of unconjugated hyperbilirubinemia?
Breastfeeding jaundice
What is the pathophysiology of breastfeeding jaundice?
Decreased caloric intake leads to an increase in enterohepatic circulation
What 2 things can contribute to the appearance of breastfeeding jaundice?
Mild dehydration and delayed passage of meconium
How do you treat breastfeeding jaundice?
If infant has lost more than 10% of birth weight, poor urine or stool output, not nursing adequately then you want to increase breastfeeding to 8-12 times a day in the first few days along with formula supplementation
What did human milk jaundice use to be called?
Breast milk jaundice
When does human milk jaundice occur?
From 6-14th day after birth, may persist for 1-3 months
What is human milk jaundice due to?
Inherent human milk factors
What do you do if human milk jaundice reaches a threshold that requires treatment?
Withold breast milk to document decrease in jaundice and have mom pump…breastfeeding can resume after a decrease in jaundice is noted
Unconjugated hyperbilirubinemia that occurs on day 2 through day 5, usually peaks on day 3, and may last one week in an otherwise healthy infant with no other pathological explanation…
Physiological jaundice
What type of diagnosis is physiologic jaundice?
Diagnosis of exclusion (but very common)
Can an elevated bilirubin during the first 24 hours of life be called physiologic jaundice?
No…it is abnormal
Can a bilirubin of 17 after 120 hours of life be considered physiologic?
No
What is the first step in evaluating a baby whose jaundice?
Check a total and direct bili (checking direct bilirubin is important before starting phototherapy)
When is phototherapy contraindicated?
In infants with an elevated direct (conjugated) bilirubin, or a family history of light sensitive porphyria
What causes Bronze Baby Syndrome?
When a baby with direct (conjugated) hyperbilirubinemia gets phototherapy
What things reduce the incidence of neonatal jaundice?
Maternal heroin use, smoking, alcohol, phenobarbital, phenytoin
What 2 things can worsen neonatal jaundice?
Medications that compete for space on albumin (Sulfonamides) and severe acidosis…these increase levels of bilirubin
What are the causes of indirect hyperbilirubinemia? (Pneumonic)
YELLOW
- You never know: Gilbert disease, Gilbert goes yellow
- Endocrine: Hypothyroid, hypopituitarism, Enterohepatic Circulation Increased: Obstruction, pyloric stenosis, meconium ileus, ileus, Hirschprung’s disease
- Lucy Driscoll Syndrome
- Lysed Blood Cells: Hemolytic disease, defects of red cell metabolism, isoimmunization
- Overdrive: Some are both direct and indirect…galactosemia, tyrosinosis, hypermethionemia (cystic fibrosis)
- Wasted Blood: Petechiae, hematomas, hemorrhages anywhere, cephalohematomas, swallowed maternal blood
With acidosis and medications that compete for albumin (like sulfonamides), why can kernicterus result at lower documented serum levels?
Much of the bilirubin isn’t bound to albumin
How can a PDA cause increased indirect bilirubin?
Blood is shunted from liver, resulting in decreased metabolism of bilirubin and increased indirect bilirubin
What is the LIE and GLOW pneumonic?
Causes of indirect hyperbilirubinemia
- Lynsey blood cells: Hemolytic disease, defects of red cell metabolism, isoimmunization
- Increased Enterohepatic circulation: Obstruction, pyloric stenosis, meconium ileus, ileus, Hirschprung’s disease (Endocrine: Hypothyroid, hypopituitarism)
- Gilbert disease
- Lucy Driscoll Syndrome
- bOth direct and indirect: Galactosemia, tyrosinosis, hypermethioninemia, Cystic Fibrosis
- Wasted Blood: Petechiae, hematomas, hemorrhages anywhere, cephalohematomas, swallowed maternal blood
What are the complications of an exchange transfusion?
Transfusion imPaCT NO!
- Potassium high
- Calcium low
- Thrombocytopenia
- Volume No! (Hypovolemia)
With ABO incompatibility, does a large percentage result in significant hemolysis leading to jaundice?
No, only a small percentage (remember this even with a setup…mom with blood type O and baby with A or B)
ABO incompatibility can cause anemia in which child?
First born
When would Rh incompatibility cause anemia in a first born child?
If they mention a previous miscarriage (otherwise, it does not usually cause anemia in a first born child)
When do the anemias of both ABO incompatibility and Rh incompatibility occur?
1-2 months of age…these can be severe
What is hypoglycemia in preemies and full terms?
Serum glucose less than 25 in a preemie and less than 35 in a full term newborn
In practice, what is hypoglycemia?
Less than 40
Why is a very low birthweight infant at risk for hypoglycemia?
Small muscle mass and low glycogen stores
What are the most important steps for initial management of babies at risk for hypoglycemia (VLBW)?
Maintaining adequate glucose levels and maintaining good body temperature
Name some ways hypoglycemia can present?
Any number of ways…jitteriness, lethargy, apnea, cyanosis, seizures
How do you manage hypoglycemia in neonate?
With a 2-3 mL/kg D10 Bolus… Glucocorticoids (hydrocortisone or prednisone) is another option
What could be given to mom that could cause hypoglycemia in baby and why?
Tocolytics (to arrest labor)…these agents stimulate fetal insulin, resulting in hypoglycemia
Blood samples contaminated with what can result in falsely elevated glucose on the Deztrostix?
IV solution containing glucose
What can cause a false low glucose on the Dextrostix?
Shortened sample time on the strip
If you are only given a value for a blood glucose from a “d” stick and it is off, what do you do next?
Verify the result with serum glucose…“d” sticks aren’t totally accurate
What vital can be a sign of hypoglycemia?
Tachypnea…it can be the only sign
Why do babies of diabetic mothers often develop hypoglycemia for several hours after delivery?
As fetuses, these guys are exposed to high glucose from mom and thus make a lot of insulin…after delivery, they keep making lots of insulin, but their sugar source (mom) is gone
Why are infants of diabetic mothers typically LGA?
The increased insulin also promotes growth
What are other manifestations of infants of diabetic mothers besides hypoglycemia and LGA?
Polycythemia (possibly due to increased EPO) and hypoplastic left colon
*Large body, small left colon, lots of red blood cellsw
What is the definition of hypocalcemia?
Ionized calcium lower than 4.5 mg/dL (1 mcmol/L) and a total calcium lower than 8.5 mg/dL
Name signs of hypocalcemia.
Jitteriness, Chvostek’s sign (facial muscle twitching on tapping plus cheek shake sign), Trousseau’s sign (carpopedal spasm), prolonged QT interval can be seen on EKG
What is Trousseu’s sign?
Carpopedal spasm…think, you need your wrist to row
What can cause late hypocalcemia and why?
An infant mistakenly given cow’s milk…hypocalcemia due to high phosphate load on the kidneys
How to treat hypocalcemia in neonate?
Increase calcium in the IV or bolus with calcium gluconate
What manifestations of hypocalcemia and hypoglycemia can have long-term consequences?
Seizures…can have long term CNS consequences
Jitteriness will have no long term consequences
If mom was on Mg sulfate, what should you consider in infant?
Hypocalcemia
If baby has hypocalcemia and isn’t responding to calcium, what should you check?
Magnesium level…(especially if mom was on Mg sulfate)
Infant with hypocalcemia been receiving calcium replacement and is still showing signs of hypocalcemia…what next?
Give magnesium…serum Mg and Ca levels directly correlated
- Elevated Mg will decrease PTH…hypomagnesemia can result in intractable hypocalcemia that won’t respond to calcium replacement until you correct the magnesium
- Don’t fall for choosing administering calcium or getting repeat value of calcium
What % of Hgb at birth is fetal HgbF?
50%
For a full term infant, Hgb less than what at birth is considered anemia?
13
What test detects for the presence of fetal cells in the mother’s blood?
Kleihauer Betke Test (used to evaluate neonatal anemia)
What is the definition of polycythemia?
Central venous HCT of 65 or higher
Can polycythemia be diagnosed from heel stick?
No…heel stick might be hemoconcentrated and polycythemia is central venous HCT of 65 or higher
Polycythemia must be from what type of sample?
Venous…if they give you a capillary measurement, it isn’t valid and they are trying to deceive you into working it up inappropriately…especially true if infant is also acidotic and hypotensive
When do you treat polycythemia?
When hematocrit is greater than 70
What 3 things does polycythemia often lead to?
Hypoglycemia, hyperbilirubinemia, thrombocytopenia
*Yellow bananas aren’t very sweet…jaundiced kids can have hypoglycemia
What is treatment for symptomatic polycythemia?
Partial exchange transfusion
What does hyperviscosity syndrome result from?
Polycythemia
What are symptoms of hyperviscosity syndrome?
Lethargy, hypotonia, irritability
What 4 circumstances would you consider hyperviscosity syndrome?
Infant with history of twin twin transfusion, delayed clamping of cord, Down syndrome, or infant of a diabetic mother
What two labs are off often with polycythemia?
Hyperbilirubinemia and hypoglycemia
*For question of complications with hyperviscosity syndrome, don’t be fooled and pick hyperglycemia…it is hypoglycemia that occurs with polycythemia
When do the bottoming out levels of “physiologic” anemia occur in preterm versus term infants?
Lower and occur earlier in preterm
*Preterm infants have lower HCT values than full term infants
How low can Hgb drop in a full term infant and when do they reach their “nadir”?
As low as 11 or even 9, nadir at 2-3 months
How low can Hgb drop in a pre-term infant and when do they reach their “nadir”?
Low as 7 to 8, reach nadir in 1-2 months
*In preemies, the initial HCT is lower and they bottom out earlier
How to remember hypoglycemia with polycythemia?
RBCs eating up all the glucose
What is the Apt test for?
Tests blood in the neonates gastric aspirate to determine if it is actually maternal blood
What test do you order for a neonate who is being garage fed and there is blood in the residuals?
Apt test (see if blood is actually maternal blood)
What is the definition of thrombocytopenia in neonate?
Platelet count lower than 100,000
What is a main cause of thrombocytopenia and how long can it last?
Maternal ITP…can last several weeks until mother’s IgG is cleared out
A prolonged PTT can be a normal finding in neonates until when?
9 months
What should you think with a prolonged PT in a bleeding infant?
Vitamin K deficiency
What causes hemorrhagic disease of the newborn?
Vitamin K deficiency
If the describe an infant who has been treated with antibiotics, what issue could cause bleeding?
Vitamin K deficiency… Antibiotics removes the normal GI flora, resulting in decreased absorption of vitamin K
When and who gets early onset hemorrhagic disease of newborn?
Occurs within 7 days of birth in newborns who are breast-fed exclusively and not given IM vitamin K (think if delivered at home)
How does early onset hemorrhagic disease of newborn present?
Bleeding at circumcision or from the umbilical cord
Why are screening vitamin K levels unreliable?
They are low in all infants
How is diagnosis of Vitamin K deficiency made?
Noting bleeding and elevated PT and documenting resolution of both after administration of Vitamin K
When does late onset hemorrhagic disease of newborn occur?
Up to 3 months of age
What form of vitamin K is insufficient for preventing hemorrhagic disease of the newborn?
Oral
What maternal medications (3) can increase the risk for hemorrhagic disease in the newborn?
- Anticoagulants
- Anticonvulsants: These can induce liver microsomal activity
- Antibiotics: Quinolones, cephalosporins, TB medications
What 3 things should you think if you see the phrase “home delivery”?
- Hemorrhage
- Sepsis
- Bleeding secondary to vitamin K deficiency (IM vitamin K wouldn’t be given at a home delivery)
If a neonatal seizure occurs within 24 hours of birth, it is likely secondary to?
Birth asphyxia (often there will be a hint of this in the presented history)
Are most neonatal seizures big and dramatic?
No…most neonatal seizures are subtle
What is a typical description of a neonatal seizure?
Staring spells, decreased motor activity, lip smacking, abnormal facial movements
Do most full-term newborn infants who have neonatal seizures secondary to asphyxia have any long-term neurodevelopmental sequelae?
No
There is more concern for impaired neurodevelopmental outcome in which infants who develop seizures?
Infants with hypoxic ischemic injury
Nearly half of infants with hypoxic ischemic injury who develop seizures may have abnormal outcomes manifested by what 3 things?
Cognitive problems, motor problems, and/or epilepsy
What 2 things are the most frequent causes of neonatal seizures in the full term infant?
- Neonatal encephalopathy
2. Hypoxic-ischemic encephalopathy (HIE)
What has to be ruled out in the case of neonatal seizures?
Metabolic causes
If you have a kid with neonatal seizures and you ruled out metabolic causes, what is the correct treatment?
Phenobarbital
What can neonatal asphyxia/intrapartum asphyxiation lead to?
Multiple organ system failure…brain isn’t only organ involved…intestine, kidney, lung, liver, and heart can all be affected
Does a full term newborn infant presenting with seizures due to asphyxia usually manifest long-term neurodevelopmental problems?
No
What is an omphalocele?
Protrusion of bowel through the umbilicus
Which abdominal wall defect is covered with a membrane?
Omphalocele (presence of membranous cover is key to distinguishing an omphalocele from gastrochisis)
*O in omphalocele is the membranous cover from belly button
Which abdominal wall defect is associated with chromosomal defects/abnormalities?
Omphalocele
*Think of membrane being made of DNA strands
What is omphalocele often associated with?
Other anomalies like Beckwith Wiedemann Syndrome with additional features including macroglossia, macrosomia, and hypoglycemia
How to remember features associated its Beckwith Wiedemann Syndrome?
Think Big Width Wiedemann syndrome…picture a big man eating M & M’s (macroglossia and macrosomia) with his “big tongue” and “big body”, getting so large that he ends up with eviscerated bowel covered with a membrane…hypoglycemia is the driving force behind his ferocious appetite
What is gastrochisis?
Herniation of bowel through a defect in abdominal musculature near the umbilicus
What is usually in a gastrochisis?
Usually limited to intestinal contents (omphaloceles can involve intestines and other organs like the liver)
Which abdominal wall defect is not covered with a membrane?
Gastrochisis
What is the most important initial management for gastrochisis?
Keep bowel contents moist
Besides keeping the bowel contents moist, what else is important for gastrochisis?
NG tube placement
Scaphoid abdomen, decreased breath sounds on left side, heart sounds on right side?
Diaphragmatic hernia
What is the initial management for diaphragmatic hernia?
Intubation and ventilation, placement of NG tube to maintain stomach decompressed, parenteral nutrition to stabilize infant until surgical repair
What is the first thing you do with interventricular hemorrhage?
ABC’s…should be managed like any other potentially unstable situation (same for any intracerebral hemorrhage)
What type of imagines for unstable newborn with suspected IVH?
Cranial US at bedside
If you have a stable infant with suspected subarachnoid or subdural hemorrhage, what imaging do you do?
Head CT
What are symptoms of IVH?
Many times it is asymptomatic…but if present, symptoms can include anemia, hyperglycemia, thrombocytopenia, hyponatremia, and/or acidemia
IVH usually occurs when for preemies?
Within the first 96 hours of life
What is grade 1 for IVH?
Germinal matrix bleeding
What is grade 2 IVH?
IVH without dilation
What is grade 3 IVH?
IVH with dilation
What is grade 4 IVH?
IVH with dilation plus parenchymal involvement
Which head bleeding crosses suture lines and is described as soft, boggy pitting?
Caput Succedaneum
Describe a cephalohematoma
More localized, firm, tense, unilateral, does not cross suture lines
*Has pH in word to remember it is phirm and L to remember is is localized
Which is slower to heal, cephalohematoma or caput succedaneum?
Cephalohematoma
What can be used for short-term tocolysis and what can happen to infant from this?
Beta adrenergics (terbutaline)
Neonatal hyperinsulinism resulting in hypoglycemia (risk factor)
What is the risk of general anesthesia for newborn?
Considered to carry little risk
A single one-time use of corticosteroids imparts a reduced risk of what 3 things?
- Intraventricular hemorrhage
- Necrotizing enterocolitis
- RDS
Repeated corticosteroid use carries increased risk for what?
Growth impairment of head…although long term significance of this and other possible risks are unknown at this time
Which specific corticosteroid may carry some increased risk for growth impairment of the head compared to others?
Dexamethasone
What is used to reverse the respiratory depression that can be seen if mom got narcotic-based analgesics during delivery?
Narcan
When do you not use narcan for respiratory depression in neonate and why?
When mom is addicted to drugs…it might cause seizures (rapid withdrawal symptoms)
Why is monitoring after administration of Narcan important?
The half-life of Narcan is shorter than that of narcotics
What is neonatal abstinence syndrome?
Refers to postnatal withdrawal effects in an infant after drug exposure in utero
*Used to just refer to opioid withdrawal, but has been expanded (need to distinguish between drug effects and withdrawal effects…withdrawal effects vary from drug to drug)
Is early discharge an option for an infant who has been exposed to drug use in utero?
No
When should you get a urine drug screen from an infant exposed to drugs in utero?
Within 24 hours of delivery
What are symptoms of infants exposed to phenobarbital in utero and what are they at lower risk for?
Jittery and irritable, lower risk for hyperbilirubinemia
Withdrawal profile for alcohol in neonates?
Hyperactivity, irritability, hypoglycemia
Withdrawal profile for cocaine in neonates?
No official withdrawal or abstinence syndrome exists…although there is no known official withdrawal syndrome or teratogenic effects, these kids are at increased risk for anomalies due to vascular constriction
- Cerebral infarctions, limb anomalies, urogenital defects
- Increased risk for placental abruption
Withdrawal profile for marijuana in neonates?
Maternal merijuana use hasn’t been definitively shown to be associated with any specific infant features or developmental issues at this time…few studies show low fetal growth concerns, but this is unconfirmed
-Has been suggestion of abnormal vision response to light, and/or infant tremulousness (probably won’t be tested on exam)
Withdrawal profile for amphetamines in neonates?
No established withdrawal syndrome…but kids exposed in utero are irritable and easily agitated with routine environmental stimulation
Often experience IUGR and are prone to developmental and cognitive impairment
Withdrawal profile for barbiturates?
Hyperactivity, hyperphagia, irritability, crying and poor suck swallow coordination
Withdrawal profile for opioids?
Hyperirritability, tremors, jitteriness, hypertonia, loose stools, emesis, and feeding difficulties, seizure activity
What can be used to manage opioid withdrawal?
Methadone and/or oral morphine
What organ are cocaine and amphetamine harmful to even though there is no official withdrawal syndrome?
Developing brain
What issues do cocaine and amphetamines cause in utero?
They impair uteroplacental circulation
When are most newborns stable enough to be discharged after a vaginal delivery…after a C-section?
48 hours after vaginal delivery
72 hours after C-section
When can early discharge be okay?
After an uncomplicated vaginal delivery if newborn has been feeding well and has voided and stooled
Family has to be deemed reliable to follow up
*Watch for signs in question that would make the infant ineligible for for early discharge (prior to 48-72 hours)
If you are doing an early discharge, what do you have to assess for prior to discharge?
Jaundice
If an infant is discharged early, when do they have to return for follow up and what needs to be completed?
Must return for follow up in 24-48 hours, especially to complete their neonatal screen 48 hours after enteral feedings are started
