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Special Pops, Ped final > Neonate - Jaundice + Neuro > Flashcards

Neonate - Jaundice + Neuro Flashcards

1
Q

Jaundice occurs when ____ exceeds _____

A

serum biliruben, albumin binding capacity

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2
Q

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

A

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

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3
Q

Bilirubin acute vs permanent neurotoxicity

A 
Acute = bilirubin encephalopathy 
Permanent = Kernicterus
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4
Q

Physical expression of jaundice

A

Goes from head to toe

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5
Q

Steps in bilirubin metabolism which make newborns more prone to jaundice

A
  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 -
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6
Q

3 factors that make newborns more prone to jaundice

A

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

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7
Q

Ethnic variation in UGT1A1

Total bilirubin peaks a little bit higher and later in______ newborns

A

East Asian

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8
Q

In physiologic jaundice:

A

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

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9
Q

Physiologic jaundice in hispanic black and white infants

A

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

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10
Q

Physiologic jaundice in East Asian infants

A

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

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11
Q

Etiology of direct hyperbilirubinemia

A

Cholestasis

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12
Q

Pathologic jaundice is due to

A

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

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13
Q

Causes of increased production of bilirubin

A

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
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14
Q

Causes of decreased clearance of bilirubin

A

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

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15
Q

Causes of increased enterohepatic circulation of bilirubin

A

Breast milk jaundice

Breast feeding jaundice

Intestinal obstruction or ileus

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16
Q

Breast milk jaundice

A

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

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17
Q

Breast feeding jaundice

A

Deficient breastfeeding > weight loss and dehydration

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

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18
Q

Jaundice w pale stools and dark urine indicates

A

Direct hyperbilirubinemia / cholestasis

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19
Q

Lab definition of direct hyperbilirubinemia

A

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

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

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20
Q

Causes of direct hyperbilirubinemia

A

HEPATOBILIARY DISEASE

Hepatitis
Endocrinopathy
Inborn errors of metabolism
Alpha-1 antitrypsin deficiency
Total parenteral nutrition 
Sepsis
Biliary atresia
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21
Q

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

A

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

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22
Q

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

A

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

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23
Q

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

A

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

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24
Q

Monitoring TsB during phototherapy

A

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

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25
Q

When to stop phototherapy

A

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

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26
Q

When newborn jaundice requires treatment

A

Direct hyperbilirubinemia always requires treatment

When indirect bilirubin is at or within 3 points of the phototherapy threshold

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27
Q

Universal method to assess status of newborn after birth

A

APGAR score

Used to assess response to transition / resuscitation

Not diagnostic, not used to make diagnoses or predict morbidity / mortality

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28
Q

5 Categories of APGAR score

A 
Appearance / Skin color
Pulse / HR
Respirations
Grimace / Reflex Irritability 
Activity / Muscle tone
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29
Q

Skin color / appearance scoring

A 
0 = Blue
1 = Acrocyanosis (hands and feet)
2 = Pink
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30
Q

Pulse scoring

A 
0 = Absent
1 = < 100
2 = 100 +
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31
Q

Respiration scoring

A 
0 = Absent
1  = Weak cry, slow irregular breaths
2 = Strong cry, normal rate / regular pattern
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32
Q

Grimace / Reflex irritability scoring

A 
0 = No response
1 = Weak cry, facial grimace, small motion
2 = Strong cry, cough, sneeze, withdraw
33
Q

Activity / Muscle tone scoring

A 
0 =  Flaccid, limp
1 = Some flexion of extremities 
2 = Good flexion, active motion
34
Q

At what points after birth is the Apgar score used

A

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

35
Q

Normal APGAR score

A

A normal Apgar score is between 7 and 10

36
Q

Normal HR and RR for newborn

A

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

37
Q

O2 takes how long to reach normal levels in newborns

A

10 mins

38
Q

Example of normal BP for average newborn

A

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

39
Q

New Ballard Score

A

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)
40
Q

6 physical criteria of New Ballard score

A 
Skin
Lanugo
Plantar surface
Breast
Eye/Ear
Genitals
41
Q

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

A

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

42
Q

6 Neurological criteria of New Ballard Score

A

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

43
Q

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

A

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

44
Q

Vertebrae malformed

A

Spina bifida occulta

45
Q

Vertebrae malformed and meningeal sac protruding

A

Meningocele

46
Q

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

A

Myelomeningocele

47
Q

Skin lesions which might indicate presence of spina bifida occulta

A

Two or more midline skin lesions increases the risk.

Such lesions include a sacral dimple, hemangioma, nevus, skin tag, or hair tuft.

48
Q

A sacral dimple is likely benign if

A

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

49
Q

Noxious stimuli include

A

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

50
Q

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

A

Mild stupor (lethargy)

51
Q

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

A

Moderate stupor

52
Q

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

A

Deep stupor

53
Q

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

A

Coma

54
Q

Normal newborn movements (but can be mistaken for seizure)

A

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

55
Q

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

A

Ventral suspension (neck and back strength)

Vertical suspension (shoulder girdle strength)

Stepping (pelvic girdle strength)

56
Q

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

A

Stepping - pelvic girdle strength

57
Q

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

A

Vertical suspensions - shoulder girdle strength

58
Q

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

A

Ventral suspension - neck and back strength

59
Q

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

A

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

60
Q

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

A

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

61
Q

Cranial nerves needed for successful feeding

A

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

62
Q

CN V (trigeminal nerve) – assessment

A

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

63
Q

CN VII (facial nerve) – assessment

A

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

64
Q

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

A

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

65
Q

CN XII (hypoglossal nerve) – assessment

A

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

66
Q

Masseter reflex –

A

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

67
Q

Biceps reflex –

A

Tapping the biceps tendon causes flexion at the elbow elbow

68
Q

Brachioradialis reflex –

A

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

69
Q

Patellar reflex –

A

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

70
Q

Babinski is normally ______ in newborns

A

extensor

upgoing great toe and fanning of the other toes

71
Q

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

A

basal ganglia, brainstem and spinal cord

72
Q

Newborn reflexes are present at birth and disappear by

A

4-6 months age

73
Q

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

A

Moro reflex

74
Q

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

A

Rooting reflex

75
Q

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

A

Sucking reflex

76
Q

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

A

Asymmetric tonic neck reflex

77
Q

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

A

Palmer grasp reflex

78
Q

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

A

Gallant reflex

79
Q

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

A

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.

Special Pops, Ped final (4 decks)

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