Neonatology Flashcards
1
Q
Two major and minor manifestations of neonatal lupus
A
- Cardiac: heart block
- Cutaneous: peri-orbital and scalp rash
- Minor: hepatic, hematologic
2
Q
Antenatal screening results that suggest trisomies
A
- High HCG
- Low PAPP-A
- Low AFP
3
Q
What class of medications impairs maternal vitamin K metabolism?
A
AEDs
4
Q
If parents refuse IM vitamin K injection then what is the next best step?
A
Give 2.0mg PO vitamin K during first feeding –> repeat at 2-4 weeks –> repeat at 6-8 weeks
5
Q
Who should we not give soy-based infant formulas to and why?
A
- Congenital hypothyroidism
- Due to phytoestrogens
6
Q
Most common long term complication of NEC
A
Stricture
7
Q
GA cut off for HIE cooling
A
Greater than 36wk
8
Q
TTTS vs TAPS
A
- TTTS = overarching term, characterized by volume differences from large AV anastomoses
- TAPS = atypical chronic form, characterized by recipient/polycythemic twin
9
Q
If mom has untreated gonorrhea, what would you do for the baby?
A
CTX IM and eye culture
10
Q
Discontinuing resus efforts when no detectable heart rate
A
20 minutes
11
Q
Most common cause of HTN in neonates
A
Renovascular
12
Q
Why do we irradiate blood for prems?
A
Decrease rates of GVHD
13
Q
Criteria for polycythemia with HCT
A
> 0.65
14
Q
What is the first step in symptomatic polycythemia?
A
IV dextrose
15
Q
When to treat congenital CMV (x3)
A
- CNS disease
- chorioretinitis
- severe single or multi-organ disease
16
Q
When do signs of Neonatal Myasthenia Gravis present?
A
By day 3 of life
17
Q
TORCH
A
- Toxoplasma
- Other
- Rubella
- CMV
- HSV
18
Q
When do you ONLY give the Hep B vaccine in the NICU?
A
If primary caregiver other than the mother is a known carrier (e.g., Father)
19
Q
What and when to give to a newborn if mother is HbsAg+ or at high risk?
A
HBIG + Hep B vaccine - within 12 hours of birth
20
Q
What is the time-line for neonatal HSV symptoms to present?
A
Within 4-6 weeks
21
Q
Chance of transmission of HSV for first primary occurrence and with recurrent episode for mother?
A
60% and <2%
22
Q
What to do if baby born to mother with presumed first primary genital HSV infection following a cold C/S?
A
Mucous membrane swab >24 hours of life
23
Q
When to give baby VZIG? And what is the alternative treatment?
A
If signs of maternal chickenpox develop from 5 days before to 2 days after delivery. Can give IVIG.
24
Q
What nerves could be involved with Brachial Plexus Injury?
A
C5-T1
25
What type of twins is most likely to have TTTS?
Monochorionic diamniotic twins
26
TAPS vs TTTS
TAPS - chronic intertwin transfusion to create a twin anemia-polycythemia sequence
27
Grades of IVH
```
I = germinal matrix
II = ventricle
III = enlarged ventricle
IV = parenchymal bleed
```
28
What should you think about when IVH in term infants?
Sinovenous thrombosis
| Consider NAIT
29
Most common ischemic brain injury in premature infants and long-term complication
Periventricular leukomalacia
| CP
30
When does PVL really start to appear on cranial ultrasound after insult?
4-6 weeks
31
Most common form of CP in premature infants with PVL
Spastic diplegia
32
What stage of encephalopathy of HIE would you consider for cooling to fulfill "criteria C"?
Sarnat stage 2 and 3
33
With what complications would you consider stopping cooling for HIE?
Coagulopathy develops, severe hypotension, increased ICP, PHTN
34
Risks of cooling
```
Hypotension/bradycardia
Thrombocytopenia
PHTN
Prolonged bleeding time
Pain/discomfort
Subcutaneous fat necrosis +/- hypercalcemia
```
35
Who will get NEC first - prem or term babe?
Term (within first few days)
| Pre-term (within weeks)
36
Why may a term or late preterm have NEC?
Poor perfusion - cardiac (consider echo) and CNS (HIE)
37
What type of TEF/EA has x2 fistulas?
Type D
38
What system has abnormalities most closely associated with TEF?
Cardiac
39
What syndrome is most closely associated with TEF?
VACTERL
40
What side is most likely to be involved with CDH?
80% of the time = left
41
What are the associated genetic syndromes with omphalocele?
VACTERL, BW, Trisomy 13/18/21
42
Difference between meconium ileus vs plug? How to differentiate? Associated condition.
Ileus at level of small bowel - CF
Plug at the level of the colon - CF, Hirschsprungs
Water soluble contrast enema
43
Why do we not give EPO for anemia in newborn?
Increase risk of ROP
44
Volume of blood to given to newborn during transfusion
20 mL/kg
45
Types of vitamin K deficiency
```
Early = first 24h of life
Classic = between 24h to 7 days
Late = between 2nd week and 6th month
```
46
Timeframe to give vitamin K to newborn
Within first 6 hours after birth
47
DDH risk factors
- First pregnancy
- +fmhx
- Female infant
- Oligohydramnios
- Breech
- Increased BW
48
7th N palsy ddx for peripheral causes
Trauma, hypoplasia/aplasia, Bell palsy, infection (e.g., AOM), GBS, inflammatory disorder, tumor of brainstem
49
Peripheral vs central 7th N palsy
Peripheral - no forehead furrow + cannot close affected eye
| Central - facial nucleus cells receive bilateral innervation from both hemispheres
50
x2 dx for neonatal asymmetric crying facies
Congenital absence or hypoplasia of depressor anguli oris muscle and facial nerve palsy secondary to forceps delivery
51
Benefits of circumcision
- Ease of hygiene
- Decreased risk of UTI, phimosis, infection, STI
- Avoidance of procedure later in life
- Cancer reduction (penile, female cervical)
52
Risks of circumcision
- Minor bleeding
- Pain
- Local infection
- Unfavourable cosmetic result
- Meatal stenosis
53
Contraindication of circumcision
-Hypospadias
54
What is included in First Trimester Screen + timing?
FTS = nuchal translucency + B-hCG/PAPP-A (12 weeks)
55
What is included in maternal serum screen + timing?
-B-hCG, E, AFP (15-20 weeks)
56
Integrated prenatal screen - what is included
FTS + MSS
57
NIPT - what does it stand for, what is it, and what does it look for?
- Non-invasive prenatal testing
- Looks at fetal DNA within maternal blood
- Trisomies + sex chromosome aneuploidy
58
What x2 assessments are considered "fetal assessments" in antenatal screening? And when are they performed?
- Choriovillus = 9-12 weeks
| - Amniocentesis = >16 weeks
59
What is the pathophysiology for blueberry muffin rash?
= extra-medullary hematopoiesis
60
Neonatal effect of maternal Graves Disease (x3)?
- Hyperthyroidism (because Ab's cross placenta)
- IUGR
- Prematurity
61
Neonatal effect of maternal PIH (x3)?
- Thrombocytopenia
- Neutropenia
- IUGR (from placental insufficiency)
62
Neonatal effect of maternal hyperparathyroidism (x2)?
- Hypoparathyroidism
| - HypoCa
63
Effects on fetus/newborn with maternal NSAID use (x2)?
- PDA closure
| - PPHN
64
Effects on fetus/newborn with maternal AED (x3)?
- Midface hypoplasia
- NTD
- Hemorrhage (vitamin K deficiency)
65
Effects on fetus/newborn with maternal ACEi use (x3)?
- Renal failure
- Oligohydramnios
- Fetal hypocalvaria
66
Effects on fetus/newborn with maternal B-blockers use (x2)?
- Bradycardia
| - Hypoglycemia
67
Effects on fetus/newborn with maternal lithium use (x2)?
- Hypothyroidism
| - Ebstein's anomaly
68
Effects on fetus/newborn with maternal cocaine use (x1)?
-Placental abruption
69
What is a potential amniotic fluid complication in setting of IUGR?
Oligohydramnios - secondary to placental insufficiency or syndrome
70
x4 new questions to ask prior to delivery in NRP 8th edition?
1. Gestational age
2. Fluid - clear?
3. Any risk factors?
4. Umbilical cord plan
71
ETT size and depth for neonates
- Size: >35 weeks (3.5-4.0), >1kg (3.0), <1.0kg (2.5)
| - Depth = weight + 6cm
72
When to consider d/c resus during neonatal resus?
After 20 minutes of no HR following appropriate resus
73
At what gestational age threshold do you consider using a plastic bag?
<32 weeks
74
Management (including things to avoid) for PPHN?
- Mgmt = iNO, oxygen, vasopressor support, prostaglandins to keep duct open
- Avoid = stress/cold, hypercarbia, acidosis
75
What associated anomalies to look for with TEF?
VACTERL
76
Does surfactant prevent chronic lung pathology?
No
77
Risks of surfactant therapy?
- Bradycardia
- Plugged ETT
- Pulmonary hemorrhage
- Pneumothorax
78
Definition of BPD
O2 dependence by 28 days or 36 weeks post-GA
79
Weight categorization for preterm infants - LBW, VLBW, and ELBW
- LBW <2500kg
- VLBW <1500kg
- ELBW <1000kg
80
x3 types of apnea
Central, obstructive, and mixed
81
Typical time of PDA closure
5-7 day of life
82
Contraindications of indomethacin
- Thrombocytopenia
| - Renal insufficiency
83
Presentation of a PDA (including timing of symptoms)
- Term = 4-6 weeks onset
- Preterm = 1-2 weeks onset
- Machinery/continuous murmur, active precordium, bounding pulses, cardiac decompensation (resp distress, apnea, HSM, CHF, tachycardia, hypoxia)
84
Threshold for preterm infants for routine neonatal brain imaging
<1500g or <31+6 weeks
85
If preterm baby meets criteria for routine brain imaging, when is the first HUS?
4-7 days of life
86
Four stages of neonatal IVH
1. Subependymal/germinal matrix
2. Intraventricular involvement, <50% volume, no ventricular dilation
3. Ventricular dilation, >50% volume
4. Parenchymal involvement
87
What is periventricular leukomalacia, when does it show up on imaging, and what is the prognosis?
=softening of white matter around ventricles
- 10-21 days of life
- CP
88
x2 criteria for ROP screening
- <1250g
| - <31 weeks GA
89
When do you screen for ROP
- At 4 weeks of life
| - OR at 31 weeks corrected
90
x2 therapies for ROP
- Laser photocoagulation
| - Anti-vascular endothelial growth factor
91
x4 risk factors for ROP (apart from preterm)
- Hypotension
- Ventilation (prolonged)
- Oxygen therapy
- Slow post-natal growth
92
If incomplete recovery, when should you refer a patient with brachial plexus injury?
If incomplete recovery by 1 month of age
93
What x3 risk factors are most important to consider for brachial plexus injury? hint: in terms of events/injuries that occur at delivery
- Shoulder dystocia
- Clavicle fracture
- Humeral fracture
94
HIE criteria
-Must have A or B plus C and be >35 weeks GA
A = ph <7 and BE > -16
B = pH 7.01-7.15 or BE -10 to -15 AND perinatal insult AND APGAR <5 at 10 min or x10min of PPV
C = moderate to severe encephalopathy
95
Side effects of cooling in HIE
- Fat necrosis
- Hypotension
- Bradycardia
- Coagulopathy
- PPHN
96
How to stage HIE
-With Sarnat clinical staging - state 1-3 (mild to severe)
97
Renal and metabolic systemic effects of HIE
Oliguria, hematuria, ATN, hyperK, hypoCa, hyperPO4, hypoglycemia
98
Window to start cooling for HIE
within 6 hours
99
x4 causes of HIE
- Disruption of umbilical flow = prolapse
- Failure of placental gas exchange = abruption
- Compromised fetus (not tolerating labour) = IUGR, anemia
- Failure of post-natal transition
100
Causes of neonatal seizures
- HIE
- IVH
- Metabolic: hypoglycemia, hypoCa, IEM
- Other: stroke, NAS, infection, brain malformations
101
DDx for a floppy baby
- CNS: perinatal depression, HIE, stroke/bleed
- Spine: trauma, stenosis
- Anterior horn: SMA
- Nerve root: brachial plexus
- NMJ: myasthenia gravis
- Muscle: congenital muscular dystrophy, congenital myotonic dystrophy
- Genetic: T21, Prader Willi
102
x3 types of brachial plexus injury with associated features and prognosis
- Upper/middle, C5/6/7 = Erb Palsy, favourable prognosis, watch for phrenic nerve involvement (respiratory distress)
- Lower, C8-T1 = Klumpke's palsy, rare
- Complete, C5-T1, less favourable prognosis, associated with Horner's
103
Spectrum of nerve injury in neonatal brachial plexus injury
- Neuropraxia = temporary conduction block due to interruption of sheath, will full recovery
- Axonotmesis = disruption of nerve fibers, incomplete recovery
- Neurotmesis = nerve disruption + avulsion, no recovery
104
If the first HUS in abnormal for a preterm infant, when should this be repeated?
7-10 days
105
When to consider HUS in infant who is moderate to late preterm (x6 RF's)?
- Complicated monochorionic twin pregnancy
- Lower GA
- HC <3rd%tile
- Need for resuscitation at birth
- Complicated critical care course
- Post-natal complications (sepsis, NEC, surgery)
106
Risk factors (x7) that lead to fluctuations in cerebral blood flow in neonates?
- Acidosis
- PDA
- Variation in BP
- Anemia
- Hypo/hypercarbia
- Severe RDS
- PTX
107
When does the GM completely involute by?
34-36 weeks
108
x11 recommendations from CPS for neuroprotection of preterm infants
- PPROM + preterm delivery anticipated = Abx; Infants should be investigated + treated especially if chorio
- <35 weeks with risk of delivery = CC's within 7 days
- Consider MgSO4 if imminent delivery
- Delayed cord clamping if no need for immediate resus
- Prevent hypothermia - bag, thermal mattress, warmer, hat for all <32 weeks
- Avoid inotropes to treat hypotension unless other clinical signs present
- Prophylactic indomethacin - targets to high risk, extremely preterm infants with RF's
- Prevent PVL and IVH, a PCO2 45-55 mmHg should be targeted
- Volume targeted ventilation during first 72 hours
- Neutral, midline, and 30 deg elevation for HOB
- Transfer at risk mothers to tertiary care center
109
GIR calculation
(%dextrose x IV rate in mL/hr) / (wt x 6)
110
DDx for neonatal hypoglycemia
- Decreased substrate: SGA, preterm
- Increased utilization: stress (asphyxia), hyperinsulinism, polycythemia
- Abnormal utilization: IEM
- Other: CAH, hypopit
111
When do you discontinue BG testing in (a) LGA/IDM vs (b) SGA?
(a) After 12 hours
| (b) After 24 hours
112
What is the initial therapeutic target for a neonatal glucose level (a) initially after birth vs (b) after transition period?
(a) <2.6
| (b) <3.3
113
Dosing for dextrose gel for neonatal hypoglycemia
5 mL/kg D40W
114
if neonate is symptomatic secondary to hypoglycemia, what bolus dosing do you give?
2 mL/kg D10W
115
Findings that you would see on gas and ammonia level for (1) Urea cycle defect, (2) organic acidemias, and (3) galactosemia?
(1) Normal gas, high ammonia
(2) Acidosis, +/- high ammonia
(3) Hypoglycemia, normal gas, normal ammonia
116
Red flag features for hyperbilirubinemia?
- Onset before 24 hours
- Hemolysis
- Pallor
- Unwell
- HSM
- Pale stools, dark urine
- Conjugated
117
TSB threshold for (a) severe and (b) critical
(a) >340
| (b) >425
118
Transfusion Hb threshold for week 1 of age (a) with respiratory support and (b) without respiratory support
(a) 115
| (b) 100
119
Transfusion Hb threshold for week 2 of age (a) with respiratory support and (b) without respiratory support
(a) 100
| (b) 85
120
Transfusion Hb threshold for week 3 of age (a) with respiratory support and (b) without respiratory support
(a) 85
| (b) 75
121
Hydrops fetalis - definition
-Fluid in 2 or more fetal compartments
122
Hydrops fetalis - causes
- Immune: hemolytic disease of the newborn
- Non-immune: chronic anemia (a-thal), renal failure, cardiac failure, TORCH (CMV), congenital malformations, genetic syndromes (Turner, Noonan, Trisomy)
123
DDx for neonatal thrombocytopenia
- Increased destruction: NAIT, maternal (SLE, ITP, drugs, toxins), infection (TORCH = CMV, bacterial), pre-eclampsia
- Decreased production: BM failure syndromes, BM suppression, IUGR
- Increased consumption: DIC, Kassabach-Merritt
124
Complications of polycythemia
- Hyper-viscosity: CNS (apnea, lethargy, seizures), renal (RVT, decreased GFR, oliguria), CVS (PPHN), GI (NEC)
- Hypoglycemia
- Hyperbilirubinemia
- Other: low platelets, hypoxia, acidosis
125
What is the recipient twin at risk for in TTS?
- Polyhydramnios
- CHF
- Hydrops
- CHD - valves/septum
- Polycythemia
126
Scoring threshold + dosing of morphine for NAS (including titration scheme)
- If scores =/>8 x3 or =/>12 x2
- 0.32 mg/kg divided q4-6
- Increase by 0.16 mg/kg or decrease by 10%
127
Why is naloxone not used in neonatal resuscitation?
Seizures
128
CPS recommended NAS scoring system
Finnegan scoring system
129
DDx for NAS (x4)
- Hyperthyroidism
- Hypoglycemia, hypoCa
- CNS injury
- Infection
130
When do NAS symptoms typically present for most opioids vs methadone?
- Within 72 hours
| - Within 5-7 days
131
What population is at decreased risk of NAS?
Preterm infants
132
What would a borderline result be on pulse oximetry screening for neonatal CHD?
Sats 90-94% OR >3% difference between right hand + foot
133
How many borderline assessments until you declare a failed pulse oximetry neonatal screening?
x3
134
What neonates should we do pulse oximetry screen for and what is the best timeframe?
- ALL term and preterm infants
| - Between 24-36 hours of life
135
Suggested protocol for premedication for neonatal intubation (including drug class)
- Vagolytic = Atropine 20 ug/kg IV
- Analgesic = Fentanyl 3-5 ug/kg IV
- Muscle relaxant = succinylcholine 2mg/kg
136
What x4 physiological changes occur with intubation?
- Systemic + pulmonary hypertension
- Bradycardia
- Intracranial hypertension
- Hypoxia
137
Most common presentation of neonatal cortical stroke
Focal seizure
138
Rubella eye thing
Cataract
139
IDM - neuro and GI affects
- Caudal regression
| - Small left colon syndrome
140
What oxygen saturation differential do you need for persistent pulmonary hypertension diagnosis?
>20 mmHg between pre + post-ductal
141
How long do you observe a newborn exposed to SSRI?
x48 hours
142
If neonate remains hypoxemic despite supplemental oxygen what is the other dx you must think about in addition to congenital cardiac disease?
Pulmonary hypertension
143
What timing of HUS is recommended for <32 weeks?
- First = 4-7 days of life
- Repeat = 4-6 weeks post-birth
- Term corrected imaging = only for <26 weeks
144
What timing of HUS is recommended for 32-36 weeks?
- First = 4-7 days of life
| - Repeat = 4-6 weeks if first imaging is abnormal
145
How many pharmacological trials can be attempted for PDA before moving on to surgical intervention?
x2
146
What is first and second line for PDA treatment?
```
First = ibuprofen
Second = indomethacin, tylenol
```
147
Complications of PDA?
- Pulmonary congestion = BPD, respiratory failure, pulm hemorrhage, PHTN, death
- Systemic hypoperfusion = NEC, renal failure/acidosis, white matter brain injury, delayed feeding
148
Why do we not want to use NSAIDs and steroids for neonates at the same time?
Increases risk for spontaneous intestinal perforation
149
Early onset neonatal sepsis - timeline for (a) preterms and (b) terms
(a) <72 hours
| (b) <7 days
150
Categories of HIE Sarnat scoring
1. Mild
2. Moderate
3. Severe
151
Difference in pupils for Sarnat scoring
1. Mydriasis
2. Miosis
3. Variable, asymmetric
152
Difference in reflexes for Sarnat scoring
1. Hyper
2. Hyper
3. Hypo/absent
153
Differences in potential for seizures for Sarnat scoring
1. None
2. Common
3. Uncommon
154
Term newborn born to a with mother with GDM. First glucose done at 2 hours of life is 2.1. What is the next step in management?
-Feed + check in 30 minutes
155
What is the minimum time for observation for NAS? And what to consider if long-acting opioid (e.g., methadone)?
72 hours
| 120 hours
156
When should the first ROP assessment be done for a 29 weeker?
At 33 weeks (4 weeks chronological age)
157
When should the first ROP assessment be done for a 26 weeker?
At 31 weeks (5 weeks chronological age)
158
Incubation period for HSV neonatal infection?
2 weeks
159
When can you discontinue neonatal resuscitation efforts if no HR has been confirmed?
20 minutes
160
Threshold for when ROP assessments should be done
<31 weeks
| <1250 grams
161
Approximate bili thresholds for low risk term babe at (a) 24 hours, (b) 48 hours, (c) 72 hours, and (d) >72 hours?
(a) 200
(b) 250
(c) 300
(d) 360
162
Approximate bili thresholds for low risk term babe at >72 hours?
306
163
When does the germinal matrix involute?
GA 34-36 weeks
164
If the first HUS is abnormal for a neonate, when should you repeat the imaging?
in 7-10 days
165
In what group of neonates will you do a third HUS at corrected term GA?
For <26 weeks
166
When will you consider HUS for late prem (32-36 wk)?
If there are other risk factors present
