Neonatal Flashcards
In preterm infants which of the following is the MOST significant benefit of delayed cord clamping?
A. Reduced risk of early onset sepsis
B. Reduced risk of necrotizing enterocolitis
C. Reduced risk of bronchopulmonary dysplasia
D. Reduced risk of intracranial hemorrhage
E. Reduced risk of anemia
D. Despite many advances in neonatal care over the past 2 decades, preterm infants remain at increased risk for major morbidity and mortality. Increasing neonatal blood volume via delayed cord clamping at birth is 1 of the strategies promoted for early hemodynamic stabilization and reduction of major morbidity. Delayed cord clamping is generally defined as umbilical cord clamping performed 30‒120 seconds after birth, although the ideal timing is debated. Systematic reviews of trials comparing early umbilical cord clamping versus delayed cord clamping have shown significantly increased newborn hematocrit and blood pressure and fewer red blood cell transfusions in preterm infants. A significant reduction in intraventricular hemorrhage has also been demonstrated (10 trials, 539 infants; relative risk [RR], 0.59; 95% confidence interval [CI], 0.41-0.85). Although reduction of other morbidities, such as necrotizing enterocolitis and late-onset sepsis, has been demonstrated in some trials, results have been inconsistent. Based on these results, many Canadian and European centers have adopted delayed cord clamping in preterm neonates. However, delayed cord clamping has not gained wide acceptance in the US, in part because many obstetricians and neonatologists are unwilling to delay resuscitation until the cord is clamped and cut 60‒120 seconds after delivery. To circumvent this concern, recent studies have evaluated the process of milking the umbilical cord as an alternative to delayed cord clamping. In several small studies comparing cord milking to early cord clamping, cord milking has been shown to result in similar hemoglobin levels after birth and improvement in hemodynamic parameters. However, more studies are needed to evaluate the relative risks and benefits of umbilical cord milking before it can be recommended. The American Congress of Obstetricians and Gynecologists Committee Opinion #543 (December 2012), ‘Timing of Umbilical Cord Clamping After Birth,’ concludes:
“…Evidence supports delayed umbilical cord clamping in preterm infants. As with term infants, delaying the umbilical cord clamping to 30‒60 seconds after birth with the infant at a level below the placenta is associated with neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume, and decreased need for blood transfusion. The single most important clinical benefit for preterm infants is the possibility for a nearly 50% reduction in intraventricular hemorrhage.”
On a newborn physical examination, an infant has translucent skin. Lanugo is sparse and plantar creases are not visible. The eyelids are open and the ar pinnae are flat and stay folded. The scrotum is empty and smooth. The breast is barely perceptible. The newborn scores no points for neuromuscular maturity. What is the most likely gestational age?
A. 20 weeks
B. 24 weeks
C. 28 weeks
D. 32 weeks
E. 36 weeks
B.
Nationally, approximately 12% of babies are born preterm. In situations in which gestational age is uncertain, a targeted physical examination should be performed soon after delivery. The principal method used to estimate the gestational age of a newborn is the new Ballard score (NBS). The NBS estimates gestational age using neonatal neuromuscular and physical features. The scores for each feature are added to calculate a maturity rating that correlates with gestational age. The physical criteria used are: the extent of creases on the sole of the foot, the presence and size of a breast nodule, hair features, characteristics of ear cartilage, and appearance of genitalia. These physical criteria can be evaluated immediately after delivery. The neurologic examination includes the assessment of posture, active and passive tone, and reflexes. In infants of at least 26 weeks gestation, correlation with gestational age is consistent when the examination is performed within 96 hours. However, the examination should be done before 12 hours of age in infants less than 26 weeks gestation. The scores of each feature are added to calculate a maturity rating that correlates with gestational age and is accurate within 2 weeks. Neurological findings in the newly born infant can be affected by certain maternal medications during labor, such as magnesium sulfate or narcotics, which can affect their NBS. In addition, babies born compromised may have neurological findings that make gestational age determination less accurate. This question describes a newborn whose total physical maturity score is -1; neuromuscular maturity score is also zero. A total score of -1 puts this infant at approximately 24 weeks gestation.
. In preterm infants which of the following is the MOST significant benefit of delayed cord clamping?
A. Reduced risk of early onset sepsis
B. Reduced risk of necrotizing enterocolitis
C. Reduced risk of bronchopulmonary dysplasia
D. Reduced risk of intracranial hemorrhage
E. Reduced risk of anemia
D. Despite many advances in neonatal care over the past 2 decades, preterm infants remain at increased risk for major morbidity and mortality. Increasing neonatal blood volume via delayed cord clamping at birth is 1 of the strategies promoted for early hemodynamic stabilization and reduction of major morbidity. Delayed cord clamping is generally defined as umbilical cord clamping performed 30‒120 seconds after birth, although the ideal timing is debated. Systematic reviews of trials comparing early umbilical cord clamping versus delayed cord clamping have shown significantly increased newborn hematocrit and blood pressure and fewer red blood cell transfusions in preterm infants. A significant reduction in intraventricular hemorrhage has also been demonstrated (10 trials, 539 infants; relative risk [RR], 0.59; 95% confidence interval [CI], 0.41-0.85). Although reduction of other morbidities, such as necrotizing enterocolitis and late-onset sepsis, has been demonstrated in some trials, results have been inconsistent. Based on these results, many Canadian and European centers have adopted delayed cord clamping in preterm neonates. However, delayed cord clamping has not gained wide acceptance in the US, in part because many obstetricians and neonatologists are unwilling to delay resuscitation until the cord is clamped and cut 60‒120 seconds after delivery. To circumvent this concern, recent studies have evaluated the process of milking the umbilical cord as an alternative to delayed cord clamping. In several small studies comparing cord milking to early cord clamping, cord milking has been shown to result in similar hemoglobin levels after birth and improvement in hemodynamic parameters. However, more studies are needed to evaluate the relative risks and benefits of umbilical cord milking before it can be recommended. The American Congress of Obstetricians and Gynecologists Committee Opinion #543 (December 2012), ‘Timing of Umbilical Cord Clamping After Birth,’ concludes:
“…Evidence supports delayed umbilical cord clamping in preterm infants. As with term infants, delaying the umbilical cord clamping to 30‒60 seconds after birth with the infant at a level below the placenta is associated with neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume, and decreased need for blood transfusion. The single most important clinical benefit for preterm infants is the possibility for a nearly 50% reduction in intraventricular hemorrhage.”
You have been following up a fetus with microcephaly and intrauterine growth restriction. In early life, the neonate has been affected by deafness, cataracts, and supravalvular pulmonic stenosis. What is the most likely diagnosis?
A. Coxackie virus infection
B. Congenital rubella syndome
C. Congenital varicella syndrome
D. Parvovirus infection
E. Congenital syphilis
C. The correct response is congenital rubella syndrome (CRS). Rubella was first discovered as a potential teratogen in 1941 by an ophthalmologist Norman McAlister Gregg. Infection was associated with congenital abnormalities including heart defects (10-20%), deafness (60‒75%), eye defects/ cataracts (10‒30%), and central nervous system defects (10‒25%). In CRS, the most common cardiac abnormality is a patent ductus arteriosus but supravalvular pulmonic stenosis is the most pathognomonic. Other abnormalities include microcephaly, mental retardation, developmental delay, pneumonia, fetal growth restriction, anemia, thrombocytopenia, and hepatosplenomegaly. Timing of the exposure to the virus is critically important to the frequency and effect of the congenital infection. CRS is common when maternal infection occurs during the first 2 months of pregnancy. Up to 12 weeks gestation, about 80% of exposed fetuses are affected, and between 12 and 16 weeks, about half of exposed fetuses are affected. During this latter period of gestation, deafness is the most common abnormality. Both anomalies and growth restriction are uncommon when the infection occurs after 16th week of gestation.
The incidence of CRS decreased markedly with the widespread use of rubella vaccine. Re-infection with rubella can occur in as many as 80% of vaccinated subjects, but only in about 3% of those who have had a previous rubella infection. Two percent of women do not have sufficient antibody production after vaccination to develop immunity. The risk of fetal infection after rubella re-infection in early pregnancy has been estimated to be less than 5%. Although women who receive the rubella vaccine are advised not to conceive for 1 month, the risk of CRS from vaccine exposure is theoretical and has not been documented.
Creasy RK, Resnik R, Iams JD, Lockwood CJ, Moore TR. Creasy and Resnik’s Maternal-Fetal Medicine ‒ Priniciples and Practice. 6th ed., 2009.
Webster WS. Teratogen update: congenital rubella. Teratology 1998;58:13-23.
Morgan-Capner P, Miller E, Vurdien JE, Ramsay MEB. Outcome of pregnancy after maternal reinfection with rubella. Commun Dis Rep 1991;1:R57-R59.
Which of the following neonatal conditions is MOST likely to be a contraindication for extracorporeal membrane oxygenation (ECMO)?
A. Persistent pulmonary hypertension
B. Cyanotic congenital cardiac disease
C. Early neonatal sepsis
D. Intraventricular hemorrhage
E. Congenital diaphragmatic hernia
D. The primary indication for extracorporeal membrane oxygenation (ECMO) is a failure of traditional cardiopulmonary resuscitation with persistently poor oxygen saturations, high airway pressures, refractory hypotension, and/or persistent metabolic acidosis. ECMO is used for neonates in imminent danger of death from a range of conditions that result in respiratory or cardiac failure, including meconium aspiration syndrome, persistent pulmonary hypertension of the neonate (PPHN), congenital heart disease, diaphragmatic hernia, and refractory septic shock. The expectation is for a short period of support as a bridge to more definitive medical or surgical therapy (the disease should be reversible). Traditional inclusion criteria include:
Birth weight >2 kg
Gestational age >34 weeks
Absence of significant intracranial or other hemorrhage
Absence of lethal congenital or chromosomal abnormalities
Although exclusion criteria vary between institutions, most centers exclude patients with lethal chromosomal abnormalities, severe intracranial hemorrhage, active bleeding, and coagulopathy. The pump, oxygenation membrane, and large-bore catheters used in ECMO can induce thrombosis, which necessitates administration of high-dose systemic anticoagulation. Because neonates on ECMO are continuously anticoagulated, there is an ongoing risk of hemorrhage. Significant intracranial hemorrhage is therefore a contraindication to initiating ECMO. Although neonatal ECMO treatment shows improved outcomes compared with conservative treatment in cases of severe respiratory insufficiency, ECMO has been associated with increased risk for cerebral hemorrhage and ischemia and subsequent neurodevelopmental problems. Whether this is related to the underlying disease process, the ECMO treatment itself, or a combination of the 2, is uncertain. Because of the potential short- and long-term risks of the procedure, ECMO is reserved for infants who are not expected to survive without treatment.
- Patients who experience intrauterine growth restriction in utero are at risk for all of the following long term consequences EXCEPT:
A. Ischemic heart disease
B. Delays in cognitive impairment
C. Hypertension
D. Growth disturbances into childhood
E. Childhood cancer
E.
Children who were small for gestational age infants do not necessarily outgrow their developmental differences: at least into adolescence, they have a greater chance of having behavioural difficulties, and of lagging behind in cognitive performance. Although SGA infants catch up in growth to some degree in the first year of life, most of these infants remain smaller than appropriately grown infants throughout childhood. Infants who fail both ante‐ and postnatally to reach adequate growth are at risk to develop hypertension, ischemic heart disease, and infection later in life. The risk of cancers in children who were growth restricted in utero remains unknown, therefore this is the answer of choice. There is inconsistent data regarding the risk of childhood cancers in people who were growth restricted in utero therefore this is the answer choice that should be selected.
All of the following neurologic deficits in childhood have been linked to being a growth restricted fetus EXCEPT?
A. Lower IQ
B. Impaired motor ability in adolescence
C. School-age cognitive delay
D. Increased rate of epilepsy
E. Attention deficits in childhood
D.
In both humans and animals, neurodevelopmental outcomes are influenced by the timing of the onset of FGR, the severity of FGR, and gestational age at delivery. FGR is broadly associated with reduced total brain volume and altered cortical volume and structure, decreased total number of cells and myelination deficits. Brain connectivity is also impaired, evidenced by neuronal migration deficits, reduced dendritic processes, and less efficient networks with decreased long-range connections. Subsequent to these structural alterations, short- and long-term functional consequences have been described in school children who had FGR, most commonly including problems in motor skills, cognition, memory and neuropsychological dysfunctions. Epilepsy has not been associated with FGR, therefore his is the most appropriate answer.
All of the following are true about children who experienced intrauterine growth restriction (IUGR) except:
A. Placentally restricted fetuses are chronically hypoxemic and hypoglycemic and have increased blood lactate concentrations.
B. Placental infarcts and accelerated villous maturation are present in the placentae of 40% of infants with IUGR, as compared with 11% of controls.
C. Abnormal umbilical artery Dopplers are helpful in timing delivery, but do not predict poorer outcomes when compared to gestational age and weight matched cohorts with normal Dopplers.
D. IUGR is a predictor of neurologic impairment at 1 year of age when confounding factors are controlled.
E. Children with IUGR have linguistic and motor delay at 2 years. Gestational age and birth weight are predominant factors for poorer neurodevelopment in infants with IUGR.
C.
Abnormal Doppler studies are significantly associated with adverse obstetric and neonatal outcomes, regardless of estimated fetal weight or abdominal circumference measurements.
Adults who experienced intrauterine growth restriction (IUGR) as fetuses have been shown to be at risk for developing all of the following diseases EXCEPT?
A. Cardio-renal disease and hypertension
B. Systemic lupus erythematosus (SLE)
C. Obesity
D. Diabetes
E. Dyslipidemia
B.
After Barker’s hypothesis an increasing number of subsequent epidemiological studies have confirmed the link among LBW, rapid weight gain in the first years of life, obesity in adolescent period and increased risk of CVD, stroke, glucose intolerance and type II diabetes in adult life. The developing kidneys appear to be extremely susceptible to IUGR disease and several studies in animals and humans have described a reduced number of nephrons in proportion to body weight. Several studies in IUGR children, adolescents, and young adults at-risk for premature cardiovascular and kidney diseases underlie these associations between IUGR and glomerular damage.
For which of the following scenarios would it be best practice to discard banked human milk?
A. Expressed human milk from a donor who stopped taking antihistamines one week before donating
B. Expressed human milk stored in a home deep freezer for 3 months
C. Visible foreign bodies on the outside of a milk container
D. Expressed human milk stored in a home refrigerator 1 month
E. Expressed human milk prepared for donation in a patient care area
E.
All approved donors should be educated about clean and safe pumping techniques and guidelines for safe storage of expressed human milk and should be provided with sterile collection and storage containers and labels preprinted with the donor’s last name and identification number. All human milk stored in a human milk bank should be done under the following conditions. (1) The refrigerator should be set to maintain temperatures between 2° C and 4° C for the duration of storage in the refrigerator (96 hours) before moving the milk to a freezer controlled at 20° C (Academy of Breastfeeding Medicine Protocol Committee, 2010. (2) Milk expressed at home by approved donors should be immediately placed in freezers until processing. (3) Expressed milk stored in the home can be accepted up to 3 months from the pump date when stored in a combination refrigerator/freezer unit and up to 6 months when stored in a separate deep freezer (HMBANA, 2015). (4) Human milk should be prepared for processing and pasteurization in a clean space with the use of a one-step disinfectant wipe and a water-resistant barrier. Containers should be sorted by pump date and inspected for possible contamination (eg, cracks or tears, visible foreign bodies in the milk). Milk is discarded if there is concern about contamination, if the pump date is not marked on the container, or if the pump date marked on the container falls within the donor’s established deferral period(s). Deferral periods are periods of time in which expressed milk for an individual donor cannot be accepted, often because of short-term medication use. (5) The total volume of the frozen milk should be estimated, logged, and placed in clean plastic bins for storage. Next, each bin should be labeled with the donor’s last name and identification number, the pump dates of the milk in the bin (range: earliest to latest pump date), the deferral dates (if applicable), and the estimated total volume of milk in the bin. (6) Each new individual batch of milk should be pasteurized and cultured before being pooled with milk from another donor. This procedure limits the possible contamination of pooled batches of milk. (7) Technicians should wear gloves, gowns, caps, and masks when working with the donated milk. Gloves should be changed and hand hygiene performed as necessary to ensure a clean process. (8) A 3-day process designed to meet the HMBANA guidelines involves thawing milk over a 24-hour period on the first day; straining, pouring, and manually homogenizing and replacing into refrigerator on the second day; and manually homogenizing a second time and undergoing Holder pasteurization at 62.5° C for 30 minutes, with five stages of cooling and storing. Some banks perform a culture for each batch and if any growth is present in the milk sample after pasteurization, the entire batch is discarded. (9) Records of each microbiological culture performed should be maintained. For handling of human milk, preparation location and practices that minimize microbial growth are critical. A location dedicated for the purpose of handling human milk feedings that is separate from patient care areas reduces risk of contamination and is considered a best practice. Expressed human milk or donor human milk feedings should not be prepared in any patient care area, including the patient’s bedside, due to risk of contamination.
Which of the following is the BEST statement about the safety and handling of banked human milk?
A. Breast milk donors do not undergo screening for infectious disease and therefore banked milk should be avoided in most cases.
B. Pasteurization is not possible as it breaks down essential components of human breast milk.
C. Premature infants should not be fed donated breast milk due to its infectious risks.
D. Banked milk is most often pooled from multiple donors.
E. Donated breast milk must be delivered fresh to the bank, greatly limiting the availability of breast milk in the United States.
D.
Human milk banks play an essential role by providing human milk to infants who would otherwise not be able to receive human milk. Pasteurization is one of the most important steps in its processing. The largest group of recipients are premature infants who derive very substantial benefits from it. Human milk protects premature infants from necrotizing enterocolitis and from sepsis, two devastating medical conditions. Milk banks collect, screen, store, process, and distribute human milk. Donating women usually nurse their own infants and often have a milk supply that exceeds their own infants’ needs. Donor women are carefully selected and are screened for HIV-1, HIV-2, human T-cell leukemia virus 1 and 2, hepatitis B, hepatitis C, and syphilis. In the milk bank, handling, storing, processing, pooling, and bacterial screening follow standardized algorithms. Heat treatment of human milk diminishes anti-infective properties, cellular components, growth factors, and nutrients. However, the beneficial effects of donor milk remain significant and donor milk is still highly preferable compared with formula.
