Neonate Flashcards
TORCH definition
Pregnacy Hx/Congenital Infections Toxoplasmosis Other Rubella CMV HSV
Other - GBS, HIV, HVB, B19, GC TB
Definition of perinatal/neonatal mortaility
Fetal death 20w EGA - 28D post delivery
Definition of premature birth
Birth <38wk (pre-term infant)
MC factors to Perinatal mortality
Congenital anomalies and prematurity
Reasons for fetal demise (in utero)
Intrauterine asphyxia
Multiple gestation
Intrauterine infection
Placental insufficiency
Preterm - perinatal mortality reasons
RDS
Immaturity
Intraventricular hemorrhage
Necrotizing enterocolitis
Term infant - perinatal mortality
Birth asphyxia
Congenital anomalies
Infection
RFs for low birth weights?
Black - (doubles risk)
<16 or >35yo
Common sense items
Causes of neonatal asphyxia
D/O of respiratory drive
CNS depression
Occlusions of up/low AW
Extreme prematurity
During AW positioning ensure not to?
Hyperextend neck too much
Neonatal Intubation intervention if?
No chest rise w/ BVM
No IV route of Rx admin established
Preferred if transporting
3 methods of O2 administration
Blow by
BVM (PPV)
Intubation
2 techniques of Chest compressions? Preferred method?
Two thumb - preferred
Two fingers
Purpose of Ductus arteriosus? And how it works?
Blood bypasses lungs via R-vent to descending aorta
Is PDA patent at birth?
Yes
When does the PDA typically close?
24-48hrs
What patient population typically has a PDA that fails to close?
Preterm infants
What can occur if PDA remains patent and nev er closes?
Heart failure
In what situation would a HCP leave a PDA open?
Cyanotic heart disease
Neonatal resuscitation medications
O2
IV fluids
Epinephrine
Narcan (PRN)
Neonatal resuscitation - epinephrine Route/dosing/purpose.
1:10k IV or Inhaled ETT for Asystole or bradycardia
When is F-hgb fully replaced by adult Hgb?
3-6mo
Which has a higher affinity for O2 - F-hgb vs Adult Hgb?
F-Hgb
NL Neonatal physiological shunts
Ductus Venosus
Ductus Arteriosus
Foramen Ovale
Purpose of Ductus Venosus?
Shunts fresh O2 from Placenta to IVC bypassing Liver
Bypasses what?
Ductus Venosus
Ductus Arteriosus
Foramen Ovale
Ductus Venosus - past liver
Ductus Arteriosus - past lungs 85%
Foramen Ovale - past lungs
Closes when?
Ductus Venosus
Ductus Arteriosus
Foramen Ovale
Ductus Venosus - Mins after birth
Ductus Arteriosus - w/in 1-2D
Foramen Ovale - 1st fetal breath
How can you prevent GC conjunctivitis w/ a newborn in a nursery setting?
Erythromycin - Ophthalmic ointment (Better than AgNO3)
What are screenings/shots/labs of newborn in nursery setting?
Hearing
HVB
Genetic/metabolic - PKU/TSH/CF/SCA
Vit K
Purpose of vitamin K?
PVT Vit K deficiency (Hemorrhagic disease of the newborn (HDN)).
Appearance of HDN (S/S)?
Generalized ecchymosis
GI bleeding
Bleeding from umibilical stump or circumcision
What two supplementations are required if breast feeding?
Iron and Vit D
When is Iron supplementation required for breast feeding infants?
At 4 months (until child is eating sufficent iron in diet)
IF giving formula for diet what must you supplement with?
Vit D (Iron is added to formula)
What is the dosage/day for Vit D and iron?
Vit D - 400IU/day
Iron - 1mg/kg/day (Max 15mg)
Severe Vit D deficiency will result in?
Rickets
Childhood Rickets presents as?
Thickening at wrist and ankles Rachitic Rosary Enlarged anterior fontanelle Bow legs or knocked knees Craniotabes
How can you estimate gestational age?
Using the Ballard score (Physical and neurological characteristics score added)
Purpose of Ballard score is to?
Identify abnormal growth patterns
Predict neonatal complications
Estimate GA
Small for EGA is what percentile?
<10%
Large for EGA is what percentile?
> 90%
SGA is also known as?
Intrauterine growth restriction
SGA is associated w/?
Increased risk of…
- temperature instability
- perinatal asphyxia
- hypoglycemia
- polycythemia
- pulmonary hemorrhage
LGA is associated with?
Maternal DM
Neonatal hypoglycemia
Post-term delivery is also known as how many weeks?
> 42
Ballard score maturity rating? Baseline? Increments?
40=40 baseline
Every 5 point change = 2wk change
Scaphoid abdomen may indicate?
Diaphragmatic hernia
NL umbilical cord anatomy?
3 vessels ( 2 arteries and 1 venous)
Barlows maneuver checks for? Performed how
Congenital hip dysplasia-
Adduct w/ Downward force to dislocate hip
Ortalani maneuver checks for? Performed how?
Congenital hip dysplasia - clunks when hip relocates back into acetabulum
ABduct with lateral pressure over greater trochanter
Barlows/Ortalini reqs what to indicate congenital hip dysplasia?
Multiple F/U visits that have reproducible clunks
Congenital hip dysplasia can lead to?
Pathological changes
- Flattening acetabulum
- Muscle contractures limiting motion
- Joint Capsule tightening
Congenital hip dysplasia MCs?
Left hip 3x
Female 9x
Congenital hip dysplasia risk factors?
Breech presentation
1st born child
Oligohydraminos
Tight swaddling
Positive Barlows/ortalini reflex to?
Ultrasound of hips for congenital hip dysplasia after 6wks of age to avoid NL laxity confusion.
Congenital hip dysplasia TXT?
Refer to PEDs ortho - Pavlics Harness (up to 6mo) Abduction orthosis Closed reduction w/ hip spica cast Open reduction
Newborn Back ABNL findings?
Lumbosacral hair tuft = spina bifida
Gluteal fold dimples (sacral dimples)
Rooting reflex is gone by?
4-6mo
Fencer reflex is gone by?
3mo
Moro reflex is gone by?
6mo
Grasp reflex is gone by?
6mo
Placing reflex is gone by?
4-6mo
Galant reflex is gone by?
4mo
Babinski reflex is gone by?
12-18mo
Which reflex is a “true reflex”
Sucking reflex
Umbilical cord w/ 2 vessels should cause you to…?
Perform a more detailed exam
Enlarged anterior fontanelle >5cm may suggests?
Hypothyroidism
Closed sutures/fontanelles is also known as?
Carniosynostosis
ABNL red reflex that is white is AKA?
White reflex (Leukokoria)
White eye reflex is associated w/?
Cataracts
Ocular tumors
Severe chorioretinitis
Immature retinas
Neck cysts per location will indicate?
Anterior midline on neck?
Anterior SCM?
Posterior SCM?
Anterior midline on neck? - Thyroid disorder
Anterior SCM? - Brachial cleft cysts
Posterior SCM? - Cystic hygroma
Will murmurs be initially heard upon newborn exam auscultation?
Maybe - (Maybe not!)
Single second heart sound may indicate?
Cyanotic heart disease
What are the pathological Murmurs?
Holosystolic, continuous harsh murmur
Grade 3 or higher
All diastolic murmurs
Hepatomegaly may indicate?
Left sided heart failure
When does the umbilical cord typically fall off?
At 3-4weeks post delivery
Is jaundice abnormal or normal w/in the 1st 24hr?
Abnormal
Overriding sutures are?
When sutures overlap creating a ridge palpable on exam
NL eye alignment of a infant usually occurs at?
4mo
Strabismus is?
Eyes not aligned properly - ABNL light reflex
Pseudostrabismus is?
Eyes aligned - NL light reflex, +- epicanthal folds
Epicanthal folds are notable w/ what population?
Asians and downs
Newborn gum/palate NL 2 benign findings? Resolves w/in?
Epstein pearls and Bohn nodules - Resolves w/in 1st few wks
Epstein Pearls are?
Gum/palate - Keratin cysts (Benign) (looks like teeth)
Bohn Nodules are?
Salivary tissue (Benign) (looks like teeth)
Desquamation of newborn epithelial occurs when?
24-48hrs
Vernix Caseosa is?
Chalky-white to gray mix of Epithelial, Sebum, Keratin common in preterm infants
Milia is?
<2mm White smooth papules on face and scalp from trapped keratin occluding pores that resolves 1st few wks
Milia Rubra is?
- Overheating/febrile infants that present w/ Erythematous 1-3mm papules
- “heat rash”
- does not involve follicles
Monglolian spots are?
Blue to black pigmented maclues that fade over several years of life.
Cafe-Au-Lait spots are?
Light to dark sharply defined macules.
When does Cafe-Au-Lait spots require further eval?
> = 6 spots
5mm diameter
Not confined to a segmental region
What are Cafe-au-Lait spots ass/w?
Neurofibromatosis
Nevus Simplex is AKA?
Salmon Patch
Nevus Simplex locations?
Stork Bite - Nape of neck
Forehead or eyelids - Angel kiss
Is nevus simplex Benign or concerning?
Benign
Nevus Fameus is AKA?
Port Wine Stain
Nevus Fameus pathogenesis?
Malformation of capillary bed
Nevus Fameus is ass/w?
Sturge-Weber Syndrome on face in the trigeminal nerve distribution.
Difference between Nevus Fameus/simplex
Simplex - Transient and Benign (symmetrical) light pigmentation
Fameus - Persistent through life (Asymmetrical) darker pigmentation
Erythema Toxicum Neonatorum is?
Pustules w/ erythematous base located on trunk/back that contain EOS
When does Erythema Toxium Neonatorum Begin/Resolve?
Starts 24-48hrs of life
Resolves w/in 14d
Neonatal acne pathogenesis?
Exposure to maternal estrogen
Neonatal acne is?
Self limiting pustules appearing w/in birth to 1st few weeks of life found on cheecks and scalp.
Cutis Marmorata AKA?
Mottling
Cutis Marmorata pathogenesis?
Physiologic response to cold
Cutis Marmorata resolves when?
As neonate ages or exposed to warmth
Persistent Cutis Marmorata may be ass/w?
Hypothyroidism,
Vascular malformation,
Congenital conditions
Cradle Cap is AKA?
Seborrheic Dermatitis
Cradle cap may be first sign of?
Atopic Dermatitis
TXT for severe cradle cap?
Mineral oil
Emollient (white petrolatum)
Medicated shampoo w/ soft brush to remove scales.
Cradle cap can take how long to resolve?
Months
Umbilical Granuloma is? And TXT how?
Friable red papule - TXT w/ silver nitrate
DDx to consider w/ umbilical granuloma?
Urachus - (W/ intermittent urinary discharge)
Meckles diverticulum
Persistent Vitelline duct - (Malodorous discharge)
Umbilical polyp - (W/ sticky surface due to mucus)
Talc Granulomas _ ( Use of talc on umbilical)
Metatarsus adductus is?
Medial deviation of mid and forefoot
To Dx metatarsus adductus?
Mid line heel bisector - line goes between 2 and 3 toes
V-finger test - should not gap at 5th Metatarsal
Txt of Metatarsus adductus?
Conservative management or if severe serial casting
Clubfoot is AKA?
Talipes equinovarus
Clubfoot is classified as either?
Extrinsic (supple)
Intrinsic (rigid)
Clubfoot anatomical position is?
Inversion, adduction, plantar flexion
Extrinsic clubfoot is due to?
Uterine molding
Intrinsic clubfoot is due to?
Idiopathic abnormal bone structure
Key differences between intrinsic vs extrinsic clubfoot?
Extrinsic - able to reduce
Intrinsic - not able to reduce
TXT for clubfoot
Serial casting - if intrinsic many need surgery to correct bone ABNLs
Spina bifida is AKA?
Cleft Spine
Spina bifida is?
Lumbosacral neural tube defect of spinal cord or meninges
DX for spina bifida usually occurs when? And how?
2nd trimester
Fetal U/S and Alpha fetoprotein
Alpha fetoprotein is?
Protein secreted from fetal yolk sac, GI tract, and liver into mothers serum.
Low vs High results of Alpha fetoprotein indicate?
High - neural tube defects (Spina bifida)
Low - Aneuloploidy (Trisomy’s 18, 13 and downs)
Quad test components?
Alpha fetoprotein
Unconjugated Estriol
Inhibin A
HCG
Spina bifida occulta is def? AKA?
Rachischisis - minor defect (hair tuft) w/out neuro S/S
Spina bifida occulta requires a eval for? to avoid what?
A connecting sinus - to avoid meningitis.
Meningo-cele def?
Meninges herniates (w/out spinal cord protrusion)
Meningo-myelocele def?
Meninges and spinal cord herniates
Myeloschisis def?
Open skin w/ exposed spinal cord
Spina bifida TXT is?
Neurosurgery
Neuro tube defect prevention in pregnancy?
Folate
Delivery w/ physicians forceps may result in what condition?
Facial nerve palsy (CN VII)
Erb-Duchenne palsy affects what spinal cord level?
C5-6 (phrenic nerve lesions w/in brachial plexus)
Erb-Duchenne palsy may be due to?
Shoulder dystocia
Erb-Duchenne palsy is AKA?
Waiters tip palsy
Erb-Duchenne palsy affects what reflexes?
Grasp reflex - present
Biceps reflex - absent
Erb-Duchenne palsy TXT?
PT and close observation > SL resolves
Brachial plexus lesions?
Erb-Duchenne Palsy (MC - 90%) or Klumpke Palsy (<1%)
Klumpke Palsy affects what spinal cord level?
C8-T1
Klumpke Palsy is AKA?
Claw hand
Klumpke Palsy affects what reflexes?
Grasp reflex -
Bicep reflex -
Klumpke Palsy is ass/w what other condition?
Horners syndrome ipsilaterally
Differences between Klumpke Palsy VS Erb-Duchenne palsy
Klumpke “Claw hand” - (C8-T1, Reflex Grasp - absent/bicep present)
VS
Erb-Duchenne “ Waiter-tip” - (C5-6, Reflex Grasp - present/bicep absent)
Hydrocephalus def?
Increased CSF volume
Types of Hydrocephalus?
- Communicating (w/ subarachnoid)
2. Non-communicating (Obstructed)
TXT for hydrocephalus?
Ventriculoperitoneal shunt
Key hydrocephalus S/S presentations?
Papilledema
Setting Sun Gaze
Lower extremity Spasticity
Bulging fontanelle
Highest incidence of neonatal sepsis? Term vs Preterm?
Preterm 1:250
Biggest RFs of neonatal sepsis?
Prematurity x6
Prolonged ruptured membranes >24hrs
GBS
Classifications of neonatal sepsis? Timeframe?
Early (0-7d) and Late onset (8-28d)
S/S of “early” onset neonatal sepsis
Rapid onset of - Fever, Hypothermia, Hypotonia, Resp distress(pneumonia)
S/S of “late” onset neonatal sepsis
Insidious onset of - Fever, lethargy, seizure, increased direct bili, bulging fontanelle, poor muscle tone.
Which classification is more likely associated w/ late onset neonatal sepsis?
Late onset neonatal sepsis
Organisms associated w/ EARLY onset neonatal sepsis?
#1 - GBS E. Coli Klebsiella L. Mono Salmonella Mycoplasmas
Organisms associated w/ LATE onset neonatal sepsis?
H. Influenzae Staph HSV, CMV Enterovirus S. Pneumoniae N. Meningitidis
Eval components for Neonatal sepsis evaluation?
CBC Bld Cx X2 UA/Cx Blood glucose CXR CSF
Neonatal Sepsis Rx TXT? If + Meningitis? If + HSV?
IV Ampicillin AND Gentamicin OR IV Ampicillin AND Cefotaxime as soon as labs are drawn and continue until... NEG Cxs (+- Vancomycin if meningitis present) (Acyclovir if HSV present)
How long does Rx TXT go on for Neonatal sepsis and if meningitis is associated?
Sepsis only -14D
Sepsis w/ Meningitis - 21D (+- Add Vancomycin)
TXT HSV w/ what Rx?
Acyclovir
GBS positive mother requirements per what 3 steps?
- Neonate S/S of sepsis/infection? Empiricly TXT/Eval
- <35wks EGA? 48hr hold/limited eval
- Did mom receive 2 doses of ABX?
- - Y-48h observe w/out txt - No-48h hold/limited eval
At a minimum how long do you hold a baby born to GBS positive mother?
48h
What is a sign of neonatal respiratory distress?
Grunting or subtle soft meowing
Respiratory distress syndrome is AKA?
Hyaline membrane disease
RDS pathophys?
Insufficient surfactant synth by type II pneumatocytes.
EGA cutoff RDS is commonly seen?
<34w
What is the physiological outcome to lungs from RDS?
End-Expiration atelectasis
RDS CXR will appear?
Bilateral, Ground glass appearance
Prior to birth what will help prevent RDS occuring in neonate?
CCS given to mom 32-34wks
TXT for RDS after birth?
Intubate - vent w/ artificial surfactant via ET tube.
Complications of RDS?
Persistent PDA
PTX
Bronchopulm dysplasia
Retinopathy of prematurity
What is PDA typically noticed?
2-4d of life
PDA can lead to what complications?
Pulmonary edema and hepatomegaly
TXT of PDA?
Restrict fluids
Diuretics (lessen burden)
Indomethacin or Ibuprofen - closes PDA
Symptomatic pneumothorax TXT?
Chest tube
Bronchopulm dysplasia pathophys?
Damage to lungs caused by mechanical ventilation and long-term oxygen (O2 toxicity/barotrauma)
Retinopathy of prematurity pathophys?
O2 toxicity on developing retinal blood vessels
Apnea of prematurity causes?
MC - Central - Phrenic nerve not stimulated by Medulla/Pons
Periph - Malformation/positioning causes AW obstruct
TXT of Apnea of prematurity?
o2,
Stimulants - caffeine or theophylline
Transfusions for anemia
Tracheomalacia pathophys? Worse w/?
Weak/floppy cartilage or tracheal wall causing collapse of trachea.
Worse w/ coughing, crying, feeding, URI
Breath sounds ass/w Tracheomalacia?
+- high pitched rattling/noisy breath sound
What is Meconium aspiration syndrome?
Respiratory distress
Pneumonia/Pneumonitis
Pneumothorax
Nonvigorous child w/ suspected meconium aspiration requires what TXT?
Intubation and suction (if this fails)
BVM w/ PPV
How does Meconium aspiration syndrome occur?
Meconium is mixed w/in amniotic fluid
CXR of Meconium aspiration syndrome neonates look like?
Coarse irregular infilitrates
Transient tachy-P is defined as?
Retained amniotic fluid causes mild hypoxia then tachy-P shortly after birth.
When does Transient tachy-P of neonate resolve typically?
In 24h
CXR of a neonate w/ Transient tachy-P appears?
Fluid in fissures (distinct linear marking between lobes)
Transient tachy-P occurs in what kind of neonates MCLY? Why these neonates?
C- Section or LGA (large gestational age).
- Due to the lack of squeeze during delivery to force fluid out of lungs
MC cause of a serious neonatal anemia?
Hemolytic Dz of newborn (ABO/Rh/antigen incompatibilities)
Why do all newborns have Jaundice?
Elevated bilirubin from
- Increased RBC mass turnover
- Insufficient hepatic clearance
- Decreased gut motility/excretion
Hyperbilirubinemia is defined as what lab result?
> 5mg/dL
MC cause of neonatal jaundice is?
Hemolytic dz of newborn
Normal physiologic causes of neonatal jaundice?
Breastfeeding jaundice
Breast milk jaundice
Difference between Breastfeeding jaundice vs Breast milk jaundice?
- Breastfeeding jaundice - 1st wk of life - Insufficent milk synth by mom/intake by baby > Baby retains bilirubin due to decreased gut motility
- Breast milk jaundice - After 1st wk of life lasting 1-2w - Milk has a factor or enzyme that inhibits bilirubin conjugation or causes increases bilirubin absorption on intestines.
How does jaundice begin and progress?
Mucosa/sclera of head then skin head > toe
What physical evidence suggests concern that jaundice is bad?
Yellow skin at/below umbilicus
NL bilirubin levels for a full term infant? Breastfed infant?
Bili <13 on day 3
or
Up to 17 if breastfed
NL bilirubin levels for a pre-term infant?
Bili <15 on day 5
Pathologic bilirubin lab values?
> 13 on 1st day of life in term infant
Bilirubin rate rises >0.5/h OR >5/d
Jaundice starts w/in 24h of life
Severe signs of neonatal jaundice?
Hepatosplenomegaly AND anemia
Jaundice on 1st day of life is NL physiologic or pathologic?
Always pathologic
Breast feeding jaundice typically occurs in what type of moms?
1st baby Moms
Breastmilk jaundice physiology?
Fatty acids from milk displaces Bili from ALB = unconjugated w/out hemolysis
1st > 2nd place jaundice will show on the body
1st - Under tongue
2nd - Sclera
Coomb’s test in the eval of neonatal jaundice will detect?
ABO incompatiability due to ABs attached to fetal RBCs
Kernicterus is AKA?
Bilirubin Encephalopathy
Pathophys of Kernicterus?
Lipid soluble unconjugated (indirect) Bili deposits in brain cells and is toxic to CNS
Kernicterus will occur if bili value is?
Bili > 20-25 or less if comorbid conditions are present
Early S/S of Kernicterus?
Lethargy, Hypotonia, poor Moro’s, vomiting, high-pitched cry.
Early S/S of Kernicterus typically occur when?
4th day of life
Late S/S of Kernicterus
Fontanelle bulge
Opisthotonic posture (arched back)
Fever, seizure
Upward gaze is paralyzed in position
TXT of (mild,mod,severe) neonatal Jaundice
Mild - lifestyle (sun exposure, increase/improve feeding)
Mod - Phototherapy
Severe - Transfuse
Transfusion of neonate w/ severe jaundice occurs if?
Indirect bili =20 or more for infants w/ hemolysis and >2kg
Indirect bili >25 in asymptomatic infants w/ physiologic jaundice
SEs of phototherapy?
Diarrhea/gas, temperature instability, bonding w/ mom
Asthma - long term
DM1 - long term
Follow up times post discharge of neonate w/ jaundice?
Discharge before 24hr life - F/U in 3d
Discharge between 24-48h of life - F/U in 4d
Discharge between 48-72h of life - F/U in 5d