Neonate - Jaundice + Neuro

Question 1

Jaundice occurs when ____ exceeds _____

Answer 1

serum biliruben, albumin binding capacity

Question 2

At how many hours after birth should serum bilirubin be checked when assessing for jaundice

Answer 2

Newborns examined (PE) every 8-12 hours

Serum bilirubin checked at 24 hours, 36 hours

Obtain the first serum bilirubin level at 24 hours of life, unless the newborn looks jaundiced before that or has additional has risk factors for jaundice: pallor, petechiae, cephalohematoma, bruising, hepatosplenomegaly, weight loss, dehydration, sepsis

Question 3

Bilirubin acute vs permanent neurotoxicity

Answer 3

Acute = bilirubin encephalopathy 
Permanent = Kernicterus

Question 4

Physical expression of jaundice

Answer 4

Goes from head to toe

Question 5

Steps in bilirubin metabolism which make newborns more prone to jaundice

Answer 5

1. RBC catabolism and heme release
   - more RBCs with faster turnover rate-
2. Bilirubin conjugated in liver
   * *UGTA1 <1% functional at birth, decreased clearance**
3. Intestinal bacteria convert conjugated bilirubin to urobilinogen
   - no intestinal bacteria = increased enterohepatic circulation bilirubin -

Question 6

3 factors that make newborns more prone to jaundice

Answer 6

Increased production of bilirubin
Decreased clearance (UGTA <1%)
Increased enterohepatic circulation

Question 7

Ethnic variation in UGT1A1

Total bilirubin peaks a little bit higher and later in______ newborns

Answer 7

East Asian

Question 8

In physiologic jaundice:

Answer 8

The infant does not appear jaundiced until after 24 hours of age

The total bilirubin level does not peak high enough to warrant treatment

The total bilirubin level is elevated because the unconjugated/indirect bilirubin fraction is elevated

The jaundice typically self-resolves by 2 to 3 weeks of age

Question 9

Physiologic jaundice in hispanic black and white infants

Answer 9

On average, total bilirubin peaks at 7-9 mg/dL around 48-96 hours of life and resolves by the fifth day of life in black, Hispanic and white infants

Question 10

Physiologic jaundice in East Asian infants

Answer 10

On average, total bilirubin peaks at 10-14 mg/dL around 72-120 hours of life and resolves by the tenth day of life in East Asian infants

Question 11

Etiology of direct hyperbilirubinemia

Answer 11

Cholestasis

Question 12

Pathologic jaundice is due to

Answer 12

either an abnormally elevated indirect (unconjugated) bilirubin or to any elevation of direct (conjugated) bilirubin (a.k.a. cholestasis)

Question 13

Causes of increased production of bilirubin

Answer 13

Hemolysis, <24 hrs

1. Hemolytic disease of the fetus and newborn
2. Heritable RBC membrane defects (spherocytosis)
3. RBC enzyme defects (G6PD deficiency)
4. SEPSIS
5. Polycythemia
6. Cephalohematoma
7. Macrosomia - birth weight > 4kg / 9lb

Question 14

Causes of decreased clearance of bilirubin

Answer 14

UGT1A1

Infant of a diabetic mother
Congenital hypothyroidism
Galactosemia

Crigler-Najjar Syndrome Type 1 - no UGTA function
Crigler Najjar Syndrome Type 2 - limited UGTA function
Gilbert Syndrome - decreased production UGTA

Question 15

Causes of increased enterohepatic circulation of bilirubin

Answer 15

Breast milk jaundice

Breast feeding jaundice

Intestinal obstruction or ileus

Question 16

Breast milk jaundice

Answer 16

Due to an unknown substance in breastmilk, increases reabsorption of bilirubin from intestine

Presents after first week of life
Resolves by 12 weeks
Continue breastfeeding, monitor w blood tests

Question 17

Breast feeding jaundice

Answer 17

Deficient breastfeeding > weight loss and dehydration

Presents during first week of life
Consider temporary supplementation with banked human milk or formula

Question 18

Jaundice w pale stools and dark urine indicates

Answer 18

Direct hyperbilirubinemia / cholestasis

Question 19

Lab definition of direct hyperbilirubinemia

Answer 19

Direct bilirubin > 1.0 mg/dL if TsB < 5.0 mg/dL

Direct bilirubin > 20% of TsB if TsB > 5.0 mg/dL

Question 20

Causes of direct hyperbilirubinemia

Answer 20

HEPATOBILIARY DISEASE

Hepatitis
Endocrinopathy
Inborn errors of metabolism
Alpha-1 antitrypsin deficiency
Total parenteral nutrition 
Sepsis
Biliary atresia

Question 21

The Bhutani nomogram estimates a newborn’s risk of _____ which is defined as a total serum bilirubin ______

Answer 21

severe hyperbilirubinemia,
>25 mg/dL
(when unbound/free bilirubin is highly likely to cross the blood-brain barrier and cause acute bilirubin encephalopathy )

Question 22

A mother with what blood type puts a baby at risk of HDFN

Answer 22

ABO Type O mother > produces anti A + anti B IgG, which can cross placenta

Question 23

If HDFN suspected, what tests other than DAT should be ordered

Answer 23

obtain a CBC and peripheral smear, to look for evidence of anemia and hemolysis, respectively

Phototherapy should be started before confirming the diagnosis, to prevent the bilirubin level from getting too high

Question 24

Monitoring TsB during phototherapy

Answer 24

TsB should be rechecked 2-4 hours after initiation of phototherapy to ensure that it is decreasing

If TsB has decreased at this time, then the next bilirubin check can be in 8-12 hours

If TsB is stable at this time but not decreased, then recheck in 2-4 hours

Question 25

When to stop phototherapy

Answer 25

There are no firm guidelines for when to discontinue phototherapy Most providers discontinue phototherapy once TsB has fallen below the level at which phototherapy was initially started Many providers check a rebound TsB once the infant has been off phototherapy for 4 hours, just to make sure that it has not started to rise quickly again

Question 26

When newborn jaundice requires treatment

Answer 26

Direct hyperbilirubinemia always requires treatment When indirect bilirubin is at or within 3 points of the phototherapy threshold

Question 27

Universal method to assess status of newborn after birth

Answer 27

APGAR score Used to assess response to transition / resuscitation Not diagnostic, not used to make diagnoses or predict morbidity / mortality

Question 28

5 Categories of APGAR score

Answer 28

``` Appearance / Skin color Pulse / HR Respirations Grimace / Reflex Irritability Activity / Muscle tone ```

Question 29

Skin color / appearance scoring

Answer 29

``` 0 = Blue 1 = Acrocyanosis (hands and feet) 2 = Pink ```

Question 30

Pulse scoring

Answer 30

``` 0 = Absent 1 = < 100 2 = 100 + ```

Question 31

Respiration scoring

Answer 31

``` 0 = Absent 1 = Weak cry, slow irregular breaths 2 = Strong cry, normal rate / regular pattern ```

Question 32

Grimace / Reflex irritability scoring

Answer 32

``` 0 = No response 1 = Weak cry, facial grimace, small motion 2 = Strong cry, cough, sneeze, withdraw ```

Question 33

Activity / Muscle tone scoring

Answer 33

``` 0 = Flaccid, limp 1 = Some flexion of extremities 2 = Good flexion, active motion ```

Question 34

At what points after birth is the Apgar score used

Answer 34

1 and 5 minutes after birth Additional Apgar scores can be assigned every 5 minutes thereafter that resuscitation is taking place, until the newborn is stabilized

Question 35

Normal APGAR score

Answer 35

A normal Apgar score is between 7 and 10

Question 36

Normal HR and RR for newborn

Answer 36

Normal heart rate is 100-160 bpm awake, 80-90 asleep A normal respiratory rate for a newborn is 30 to 60 breaths per minute

Question 37

O2 takes how long to reach normal levels in newborns

Answer 37

10 mins

Question 38

Example of normal BP for average newborn

Answer 38

For a 40 week infant weighing 3 kg a typical blood pressure immediately after delivery would range systolic 75-95 mmHg and diastolic 37-55 mmHg

Question 39

New Ballard Score

Answer 39

Estimates gestational age based on 6 physical, 6 neurological criteria The individual criteria scores are summed to produce the total score, which accurately estimates the gestational age to within ±2 weeks E.g., a total score of 40 corresponds to a gestational age of 40 ± 2 weeks (38 - 42 weeks)

Question 40

6 physical criteria of New Ballard score

Answer 40

``` Skin Lanugo Plantar surface Breast Eye/Ear Genitals ```

Question 41

With increasing gestational age there is (concerning 6 physical factors in New Ballard)

Answer 41

Decreased translucency and increased wrinkling of the skin Decreased lanugo hair More creases on the sole of the foot Larger and more well-defined breast tissue Loss of fusion of the eyelids and firming of the pinna of the ear Increased rugae and pendulousness of the scrotum (as th Formation of the labia minora, then the labia majora

Question 42

6 Neurological criteria of New Ballard Score

Answer 42

Posture (straight arms legs > frog/baby arms legs) Square window (wrist less flexible, 90 deg > more flex) Arm recoil Popliteal angle Scarf sign Heel to ear

Question 43

With increasing gestational age, there is (concerning NEURO criteria of New Ballard)

Answer 43

Posture – Increased flexion of the legs, hips, arms, and shoulders Square window – Increased laxity of the joints (as measured in the wrist) Arm recoil – Increased passive flexor tone of the biceps Popliteal angle – Increased passive flexor tone of the hamstrings Scarf sign – Increased passive flexor tone of the shoulder girdle Heel to ear sign – Increased passive flexor tone of the pelvic girdle **The neurologic criteria make sense if you think about a fetus in the womb. As the fetus gets older and larger, it needs increased joint laxity and increased flexor tone in order to continue to fit inside the uterus**

Question 44

Vertebrae malformed

Answer 44

Spina bifida occulta

Question 45

Vertebrae malformed and meningeal sac protruding

Answer 45

Meningocele

Question 46

Vertebrae malformed and both the meningeal sac and spinal cord are protruding

Answer 46

Myelomeningocele

Question 47

Skin lesions which might indicate presence of spina bifida occulta

Answer 47

Two or more midline skin lesions increases the risk. | Such lesions include a sacral dimple, hemangioma, nevus, skin tag, or hair tuft.

Question 48

A sacral dimple is likely benign if

Answer 48

midline, located ≤2.5cm from the anus, visible base, less than 0.5 cm in diameter, no other midline skin lesion present

Question 49

Noxious stimuli include

Answer 49

gentle and persistent shaking, gentle pinching, perioral stroking, noise, or shining a light in the eyes

Question 50

newborn appears sleepy and has slightly diminished arousal and noxious stimulus responses

Answer 50

Mild stupor (lethargy)

Question 51

newborn is unresponsive and has moderately diminished arousal and noxious stimulus responses

Answer 51

Moderate stupor

Question 52

newborn is unresponsive and has an absent arousal response and a markedly diminished noxious stimulus response

Answer 52

Deep stupor

Question 53

newborn is unresponsive and has absent arousal response and absent noxious stimulus response

Answer 53

Coma

Question 54

Normal newborn movements (but can be mistaken for seizure)

Answer 54

Non-sustained jitteriness and tremulousness Choreoathetoid movements of the hands (looks like repetitive circling at the wrist) Migrating myoclonus during sleep Facial twitching during sleep

Question 55

Muscle strength is typically assessed against gravity using the following maneuvers:

Answer 55

Ventral suspension (neck and back strength) Vertical suspension (shoulder girdle strength) Stepping (pelvic girdle strength)

Question 56

Newborn can lift and plant her feet on a flat surface when held above it in a standing position

Answer 56

Stepping - pelvic girdle strength

Question 57

Newborn can be held upright by her axilla with no support for her feet without slipping through the examiner’s hands

Answer 57

Vertical suspensions - shoulder girdle strength

Question 58

Newborn can lift his head and hip girdle in line with his trunk for a couple of seconds while suspended ventrally

Answer 58

Ventral suspension - neck and back strength

Question 59

How are optic (II) and oculomotor (III) nerves assessed in newborns

Answer 59

By direct and indirect pupillary light responses and ability to fix and briefly follow a light or object

Question 60

How are oculomotor (III), trochlear (IV), abducens (VI) vestibulochochlear (VIII) nerves assessed in newborns

Answer 60

Observe spontaneous eye movements. Normal for newborns to intermittently cross eyes, bc can only see clearly for about 12 inches Observe doll's eye phenomenon for eye muscle + vestibulo-ocular reflex (move head to right, both eyes deviate to the left) Hearing can be assessed w startling / blinking to loud noise

Question 61

Cranial nerves needed for successful feeding

Answer 61

V, VII, IX (glosso, vagus), X (vagus), XII (hypoglossal)

Question 62

CN V (trigeminal nerve) – assessment

Answer 62

Facial sensation is assessed by the infant turning his head to the side of the face being stroked

Question 63

CN VII (facial nerve) – assessment

Answer 63

Facial motor function is assessed by sucking ability, symmetry of the nasolabial folds, and being able to tightly close the eyes while crying. Ex of malfunction: the left eye does not close, there is loss of the left nasolabial fold, and the mouth is pulled toward the normal side

Question 64

CN IX and X (glossopharyngeal and vagus nerves) – assessment

Answer 64

Both nerves are needed for normal swallowing, palatal movements and gag reflex. CN X needed for normal vocalization and crying

Question 65

CN XII (hypoglossal nerve) – assessment

Answer 65

Responsible for normal tongue movements. Deviation of the tongue to one side indicates ipsilateral CN 12 palsy. Atrophy and fasciculation of the tongue are seen in Type 1 Spinal Muscular Atrophy

Question 66

Masseter reflex –

Answer 66

Tapping the mandible just beneath the lower lip causes the open mouth to close

Question 67

Biceps reflex –

Answer 67

Tapping the biceps tendon causes flexion at the elbow elbow

Question 68

Brachioradialis reflex –

Answer 68

Tapping the radial aspect of the forearm causes slight flexion and radial deviation at the wrist and slight supination and flexion at the elbow

Question 69

Patellar reflex –

Answer 69

Tapping the quadriceps tendon below the patella causes extension at the knee

Question 70

Babinski is normally ______ in newborns

Answer 70

extensor | upgoing great toe and fanning of the other toes

Question 71

Newborn reflexes are controlled by the ____, _____, and _____

Answer 71

basal ganglia, brainstem and spinal cord

Question 72

Newborn reflexes are present at birth and disappear by

Answer 72

4-6 months age

Question 73

Sudden dropping of the head in relation to the trunk causes abduction and extension of the arms and opening of the hands, followed by flexion

Answer 73

Moro reflex

Question 74

Tactile stimulation near the infant’s mouth causes the infant to turn her head and move the mouth in search of food

Answer 74

Rooting reflex

Question 75

Infant will suck on objects placed in the mouth, including a gloved finger, which can be soothing to the newborn during the exam

Answer 75

Sucking reflex

Question 76

When the newborn is supine, turning her head results in ipsilateral extension of her arm and leg and contralateral flexion (a fencing posture

Answer 76

Asymmetric tonic neck reflex

Question 77

Newborn’s hand reflexively closes on an object placed in the palm

Answer 77

Palmer grasp reflex

Question 78

Stroking the paraspinous muscles causes the infant’s trunk to curve toward the ipsilateral side

Answer 78

Gallant reflex

Question 79

Behavior is an indication of cortical functioning and is assessed by:

Answer 79

Habituation – Newborns should stop startling to a loud noise repeated 4 or 5 times Consolability – Upset newborns should be consoled by sucking, swaddling, shushing, swinging, side-lying or stomach position. Newborns with neurologic dysfunction are difficult to console.