Neonates Flashcards
APGAR Score
POSSIBLE 2 PTS EA
- Heart Rate - absent, <100 (1 pt), > 100 (2 pts)
- Resp Effort - absent, slow/irregular, good/regular
- Color - blue/pale, only extremities blue, all pink
- Muscle Tone - limp, some flexion, good flexion and movement
- Reflex Irritability - no response, grimace only, cough or sneeze
Choanal Atresia
- infant only having trouble when not crying then suspect
- Intubate until can perform surgery
- Crying allows breath thru mouth v. feeding (obligate nose breather)
Hyperinsulin in Fetus / Newborn
- Hyperglycemia in organogenesis - neural tube defects, cardiac defects and caudal regression syndrome - (hypoplasia of sacrum and lower extremities)
- Fetal insulin production by 2nd trimester - leads to inc glycogen which deposits in liver, lungs, heart, kidney, muscle as well as macrosomia and inc oxygen requirement
- Hypertrophic cardiomyopathy - deposits in heart muscle
- Inc oxygen requirement leads to polycythemia (HCT>65 and ruddy skin); can cause jaundice and venous thrombosis because viscosity increased
- Macrosomia - inc chance shoulder dystocia and clavicle fractures
- Insulin interferes with cortisol effect on lung maturity / surfactant production - predisposes to respiratory distress syndrome
- Once delivered no longer in hyperglycemia environment but still high insulin so HYPOGLYCEMIA (seizures, jitter)
- May also have hypocalcemia - sweating, seizures and irritability
Reasons for Jittery Newborn
may be normal on first day of life
hypoglycemia (get bedside glucose) or
hypocalcemia or
drug withdrawal
Caput Succedaneum
Cephalohematoma
- Caput succedaneum - head edema that crosses suture lines (edema so does not contribute to inc bilirubin)
- Cephalohematoma - bleeding into sub-periosteal space so does not cross suture lines (blood so may inc bilirubin)
Normal Umbilical Cord
Should have 1 vein and 2 arteries
Should fall off after 3-4 wks (>8 wks is abnormal)
Ortolani and Barlow
- Barlow - flex knee and hip and try to displace
- Ortolani - guided abduction
Polyhydramnios v. Oligohydramnios
- Polyhydramnios - often due to pulmonary problem (cannot swallow) or inc production
- Oligohydramnios - too little fluid; leads to restriction and Potter syndrome (compressional deformity of face, limbs, abdomen and lung hypoplasia); often due to kidney problem like obstruction, agenesis or cysts
Congenital CMV
- IUGR/microcephaly, blueberry muffin rash,peri-ventricular calcifications in brain, seizures, chorioretinitis
- May use gancyclovir (mainly to prevent hearing loss)
- Long-term #1 infectious cause of sensorineural hearing loss
- Get urine or saliva sample w/in 21 days
Congenital Rubella
cataracts, sensorineural hearing loss, cardiac defects, developmental delay, IUGR
Congenital Toxoplasmosis
intracranial calcification and chorioretinitis, anemia, jaundice, hepatosplenomegaly
Tx = Pyrimethamine, sulfadiazine, leucovorin for 12 mo
Transient Tachypnea of Newborn
- transient pulmonary edema from delayed clearing of fluid from lungs
- both term and preterm babies; inc risk if C section (esp w/o labor)
- tachypnea, nasal flaring and grunting shortly after birth
- respiratory acidosis w/ mild to moderate hypoxia
- CXR: interstitial markings, fluid in tissues, perihilar streaking
- Give O2 and pos pressure if needed
- Spont recovery in few days
Respiratory Distress Syndrome
- insufficient surfactant
- more common in preterm
- progressive tachypnea and respiratory distress shortly after birth
- resp acidosis and hypoxia
- CXR: ground glass
- Resp support w/ mechanical ventilation as needed
- Prevention w/ antenatal steroids for lung maturation, can give exogenous surfactant at birth as ppx or w/in 6 hrs of birth as rescue therapy
Neonatal Pneumonia
- may be in utero or shortly after birth (GBS)
- signs of respiratory distress +/- sepsis (can be almost identical RDS)
- resp acidosis and hypoxia
- CXR: consolidation (localized, patchy or diffuse), may have pleural effusion (CXR of GBS pneumonia is almost identical to RDS CXR)
- IV abx w/ ampicillin + cefotaxime until sensitivities grow; 10-21 day course
- prognosis depends on CNS involvement
Meconium Aspiration Syndrome
- Meconium in lungs leads to airway obstruction, pneumonitis and inactivation of surfactant
- uncommon b/f 37 wks (not developed enough to have meconium); inc risk if post-term
- progressive tachypnea, flaring, grunting w/in 12 hours; may have rhonchi or rales; barrel chest
- sig hypoxemia and hypercapnia
- CXR: patchy atelectasis, coarse densities throughout and areas of hyperinflation
- suction, mechanical vent, high flow oxygen, high airway pressure
- may lead to chronic lung disease depending on degree and duration of ventilation needed
What is meconium? What do you do if meconium-stained amniotic fluid?
- In fetal intestine by second trimester but not able to pass until about 37 weeks; if fetus asses meconium in utero there may be meconium-stained amniotic fluid a birth - may cause fetal stress
- If meconium-stained amniotic fluid …
- If vigorous (>100 BPM, crying, good tone) then just suction oropharynx w/ bulb
- If not vigorous (<100 BPM, poor cry or tone) then endotracheal suctioning
Early Onset Neonatal Sepsis (timing, presentation, labs, tx)
- First 5 days
- Mainly organisms from mom’s vaginal tract (GBS, E coli, Listeria)
- Presentation - cyanosis, pallor, petechiae, ileus, resp distress or apnea, hypotension
- May be subtle at first (temp instability, poor feeding, irritability, dec tone, hypoglycemia, lethargy)
- Labs - CBC and blood cultures; may get serial CRPs; CSF culture, differential and protein/glucose content
- Tx (start b/f confirmed) - 10-14 days amp + gentamicin; may add ceftriaxone if meningitis
Definition and Common Causes Conjugated Inc Bilirubin
(if direct bilirubin > 2 or more than 15% total) SOLUBLE
CAUSES
- Biliary atresia
- Neonatal hepatitis
- Congenital infections
- Alpha-1 Antitrypsin
- Galactosemia
Definition and Common Causes Unconjugated Bilirubin
- (if direct bilirubin < 2 or less than 15% total) NOT SOLUBLE
CAUSES
- Physiologic
- Breastfeeding Jaundice
- Breast Milk Jaundice - similar presentation to physiologic but higher peak level and lasts a little longer; peaks at day 10-14
- Hemolysis - ABO or Rh (Coomb’s),
- G6PD def or pyruvate kinase def, spherocytosis
- Metabolic Disorders
- Crigler-Najjar
- Gilbert Syndrome
Kernicterus
- When unconjugated bilirubin exceed albumin binding capacity so crosses BBB –> basal ganglia, cerebellum, hippocampus
- Presents w/ lethargy, irritability, hypotonia, seizures, opisthotonus (abnormal posturing that involves rigidity and severe arching of the back, with the head thrown backward)
Physiologic v. Breast Feeding v. Breast Milk Jaundice
1 - Physiologic - never present b/f 24 hrs; peaks at 3 to 5 days; usually level normalizes by 3 wks
- Relative deficiency of hepatocyte proteins and UDPGT - Lack of intestinal flora to metabolize bile
2 - Breastfeeding Jaundice - early in first wk of life when milk production is low so dec GI motility which leads to more meconium reabsorption (the β-glucuronidase in meconium deconjugates bilirubin and the unconjugated bilirubin is reabsorbed via the enterohepatic circulation, causing an elevation of serum levels)
- May result in dehydration or malnourishment
3 - Breast Milk Jaundice - similar presentation to physiologic but higher peak level and lasts a little longer; peaks at day 10-14
- Might be due to β-glucuronidase in breast milk - Can last 12 weeks
Diaphragmatic Hernia
- Defect in diaphragm –> abdominal contents in thorax –> compromise lung function –>pulmonary hypoplasia and pulmonary hypertension
- L > R because no protection by liver
- Present w/ respiratory distress, dec breath sounds on affected side, heart sounds shifted to R (because contents on L)
- Dx - fetal US or CXR
- Tx - ventilate, intubate, place tube to minimize GI distention so that it does not further compress lungs, ultimately surgical correction
Omphalocele v. Gastroschisis
- Omphalocele - herniation thru abdominal wall w/ covering by peritoneal membrane; may rupture during delivery
- Gastroschisis - herniation thru abdominal wall w/o covering; surgical emergency
Duodenal Atresia
- Failure of lumen to re-canalize at 8-10 weeks gestation
- Polyhydramnios on fetal US
- Associated w/ other GI anomalies (annular pancreas) and trisomy 21
- Present w/ bilious emesis and double bubble on Xray
- Surgical correction
Biliary Atresia
- Absence of common bile duct which normally transports bile from liver to intestine
- Present w/ high direct bilirubin, clay-colored stools (no bilirubin), dark urine (backs up into urine), hepatosplenomegaly
- High LFTs
- Technetium scan confirms lack of bile flow from liver
- Tx - may do Kasai procedure if early, later conduit surgery or liver transplant (from portal HTN, fibrosis)
Trachea-Esophageal Fistula
- Esophageal atresia commonly accompanied by a communication between the trachea and esophagus
- VACTERL (40% have other abnormalities) - vertebral, anal, cardiac, trachea, esophagus, renal, limb
- Present w/ excessive oral secretion, inability to feed, gagging, respiratory distress, etc
- If H-type fistula + no esophageal atresia - may present later w/ chronic cough and recurrent aspiration pneumonia
- Imaging w/ insertion of tube shows esophagus ending in blind pouch
- Often have polyhydramnios on fetal US (cannot swallow amniotic fluid)
- Surgical correction - complicated by strictures
What is the most common type of trachea-esophageal fistula?
esophageal atresia + distal fistula (trachea connected to distal portion of esophagus)
When can an infant be considered for d/c before 48 hrs? (10)
- Full term
- Normal PE and maintained normal vitals
- Urinating and stooling
- 2 consecutive successful breastfeeding sessions
- Hyperbilirubin assessment
- Circumcision site is healed and not bleeding
- GBS and prenatal labs are reassuring
- No pos drug screen for mom
- Metabolic screening, hearing screening and 1st Hep B vaccine
- Parent education has been completed (back to sleep, breastfeeding, circumcision care, car seat use)
What should voiding and stooling look like in first week of life?
VOIDING
- Day 3 - should be voiding 3-4X/day
- Day 6 - should be voiding 6-8X/day
- Should be pale yellow by this time
STOOLING
- Day 3 - no more meconium; poops should be yellow
- Day 6 - 3 to 4 stools per day; may have stool with every feed
- Concerned if loses color (acholic)
Normal Newborn RR and HR
HR 90-160
RR 30-60
Necrotizing Enterocolitis (pathophysiology, findings and tx)
- Ischemic necrosis of premature gut –> inflammation; may also have gas forming organisms in muscular propria
- Metabolic acidosis
- Ab Xray - pneumatosis intestinalis (gas in bowel wall) + dilated loops of bowel
- Tx
- NPO, IV nutrition, gastric decompression, IV abx
- If perforation … surgical consult +/- resection (may lead to short gut syndrome and malabsorption)
Beckwith-Wiedemann Syndrome
- On differential for large newborn (LGA) v. mom with DM
- Macroglossia, hemi-hypertrophy, ab wall defects, GU abnormalities
Neonatal Abstinence Syndrome (how do babies present? score used? tx?)
- Sx (24-48 hrs after birth)
- Vomiting, diarrhea, poor wt gain
- Irritable, jittery, shrill cry, hypertonic, myotonic, seizures
- Fever, sweating, tachypnea
- Finnegan Score - serial scores to assess response to treatment
- Tx
- Low lights, swaddle, minimal stimulation
- May give opiates then wean by 10% ea day as sx improve
Congenital Syphilis
- Rash (bullous, peeling)
- Metaphyseal lucencies (get Xray of long bones)
- Rhinitis (snuffles)
- Pneumonia
- Later Hutchinson teeth, saddle nose, saber shins
Tx = IV PCN
Congenital HSV
- vesicular rash or scarring
- calcifications throughout cortex
- meningitis
- brain destruction
- chorioretinitis
Tx = 21+ days high dose acyclovir
