Neonatology Flashcards
What are the three types of Vitamin K deficiency bleeding (VKBD)?
- Early onset = <24h after birth (often due to maternal medications that inhibit Vit K activity, e.g. anti-epileptics)
- Classic = occurs 2-7 days of life (associated with low Vit K intake, i.e. breastfeeding)
- Late onset = occurs 2-12 weeks after birth (associated with chronic malabsorption and low Vit K intake)
What are the pros and cons of giving Vitamin K via IV for preterm babies?
Pros: reduces pain compared to IM dose
Cons: studies have shown prems who receive IV doses have lower Vit K values at DOL 25
What do you do if a parent declines a vitamin K injection?
- Counsel on the serious health risks of vitamin K deficiency bleeding
- Recommend PO dose of 2mg vit K with first feeding, then at 2-4wk & 6-8wk of age
- Also counsel that: 1. PO is less effective than IM, 2. Make sure infant receives FU doses, 3. Infant remains at risk for late VKDB (e.g. IVH) despite PO
What is the recommended management for babies who’s mothers are GBS+ with inadequate IAP, no other RFs?
- Monitor for at minimum 24h (vitals Q3-4H)
- No CBC
- Can be discharged at 24h if well, counsel on signs of sepsis
What is the recommended management of babies for mothers who are GBS+ without IAP + other RFs?
- No clear specific guidelines
- Monitor for 24-48h and reassess before discharge
- CBC at 4h can be considered
- Some infants may warrant investigations and treatment (no specific rules)
What is the management of babies from mothers who are GBS- with other RFs?
- Asymptomatic: early onset sepsis low
- 1 RF: manage similarly to GBS+ mothers
>1 RF: management should be individualized
What is the recommended management for babies born to a mother with suspected chorioamnionitis?
Chorio: maternal fever + 2 other signs (uterine tenderness, maternal or fetal tachycardia, leukocytosis, foul/purulent AF)
- AAP: culture and antibiotics
- CPS: close observation for 24h for term infants
- If multiple RFs + no IAP + mother unwell: consider Ix + ABx (defer LP if baby well)
What is the management of late preterm infants who’s mothers have infectious RFs (e.g. GBS)
- If born at 35-36wk: manage similarly to term babies
- Observe longer - at least 48h
What are the risk factors for severe hyperbilirubinemia (on phototherapy graph)?
Isoimmune hemolytic disease, G6PD, asphyxia, respiratory distress, significant lethargy, temperature instability, sepsis, acidosis
If you suspect subcutaneous fat necrosis, what electrolyte do you worry about?
Hypercalcemia - check Ca level
There is a maternal history of methadone use, how long do you have to watch the baby for?
5 days
What are the benefits of surfactant?
- Ventilation support
- Risk of pulmonary air leak
- Mortality
- Combined outcome of death or BPD at 28 days
HR notes:
- Give early / rescue (<2h, FiO2 > 50%)
- Decreases mortality, pneumothorax, PIE
- Decreases duration of vent support, LOS, hospital costs
- No effect on IVH, BPD, NEC, ROP
What are the benefits of delayed cord clamping?
CPS recommends delayed cord clamping for 30-180s for premature infants who are not in need of resuscitation
- Decreased risk of IVH
- Decreased risk of NEC
- Possibly decreases need for RBC transfusions
- Decreased mortality
Name 3 hypoglycemic conditions in which glucose requirement is expected to be normal for a term baby.
Name 3 hypoglycemic conditions in which glucose requirement is expected to be higher than for a term baby.
Normal glucose requirement:
SGA (decreased substrate availability)
Preterm (decreased substrate availability)
Metabolic - glycogen storage, galactosemia (inability to use glucose)
Endo - GH deficiency, cortisol deficiency, hypopituitarism
Higher glucose requirement:
Beckwith-wiedemann - pancreatic hyperplasia - hyperinsulinism
Congenital hyperinsulinism
IDM
Polycythemia - more RBC eating glucose
What are complications from polycythemia?
Specific to neonates: NEC, hypoglycemia, hypocalcemia
Thrombosis, end organ damage (heart failure, altered LOC, renal insufficiency, DIC), headache, joint pain
What are the options for managing pain for neonates?
- Minimize painful disruptions as much as possible
- Oral sucrose/glucose
- Non-pharmacological pain reduction methods - kangaroo care, non-nutritive sucking, swaddling → routine, minor procedures
- Topical anesthetics → can be used for venipuncture, LP, IV insertion (not heel pokes)
- More major procedures (chest drain remove) → short-acting, rapid-onset systemic analgesic
What is the treatment for PPHN?
- Goals: 1. Decrease pulmonary vascular resistance, 2. Increase systemic vascular pressure
- Pulmonary vasodilators
- Oxygen (aim PaO2 70-100)
- Nitric oxide
- Pulmonary vasoconstriction
- Reduce → acidosis, hypercarbia, cold/stress
- Sedation
- Systemic: ++ volume (NS, blood), inotropes
- PGE: keeping the duct open can be helpful
- May need ECMO
What are congenital features of syphilis?
-
Peri-natal
- Spontaneous abortion/stillbirth/hydrops fetalis → highest risk during 1st trimester infection
- Nec funisitis (at birth) - umbilical cord looks like a barbershop pole
-
Post-natal/neonate
- Rhinitis +/- snuffles - often first manifestation, occurs in 40% of cases
- Rash (first 8 wks of life) - maculopapular rash; may also see desquamation alone, vesicular, bullous, papulosquamous or mucosal lesions
- Hepatomegaly/splenomegaly (first 8 wks)
- LAD
- Neurosyphilis (birth or delayed)
- MSK → Osteochondritis or perichondritis, seen initially radiographically (25% of cases) and later as pseudoparalysis. Other manifestations include frontal bossing, poorly developed maxillas, saddle nose, winged scapulas, sabre shins. Recurrent arthropathy & painless knee effusions after 2 yoa
- Heme (at birth or delayed) → anemia, thrombocytopenia
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Infancy/childhood
- Interstitial keratitis
- Hutchinson’s teeth
- Mulberry molars
- Sensory neural deafness
What are the main risk factors for SNHL in neonates?
- Congenital infections - e.g. CMV, rubella, toxoplasma, syphilis, herpes simplex
- Extreme prematurity
- Ototoxic medications - e.g. aminoglycosides
- Kernicterus
- Bacterial meningitis
- Mechanical ventilation, ECMO
How do the following maternal diseases affect the infant? Diabetes, Graves, Hyperparathyroid, Obesity, Vit D deficient, PIH, ITP, Rh/ABO, SLE, PKU
What are the risks of giving surfactant?
Pneumothorax, bradycardia, blocked tube, hemorrhage (rare)
What findings of integrated prenatal screening is concerning?
- Trisomies: high HCG, low PAPP-A, low AFP
- Open NTD: high AFP
- Placental insufficiency: low PAPP-A
How do the following maternal factors/diseases affect the fetus?
Radiation, hyperthermia, CMV, Toxoplasmosis, Parvovirus B19, Varicella, Syphilis, Hep B, HIV, Rubella
What are major congenital anomalies or medical issues that may not be picked up in the first 24h of life?
- Up to 30% nonsyndromic CHD may not be diagnosed in first 3 days of life
- GI obstruction or hyperbilirubinemia may present later
When should a newborn baby receive a full physical exam?
- Full physical exam must be completed between first 24-72h of life before discharge
- If examined in first 6h, some findings may change (e.g. murmur often heard early on)
- If baby is low-risk, no need to reexamine after 6h if full exam done
-
Purpose of exam: identify issues with transition, identify abnormal clinical findings, obtain HC/Ht/Wt, confirm GA
- An abnormality is found in 8-10% of infants (e.g. cleft lip, imperforate anus)
What must be ensured prior to discharging a newborn at less than 24h of age?
- Infant has transitioned appropriately
- No RFs that require close monitoring
- Necessary screening occurs
- Has follow-up and support is readily available
What are the benefits of PHDM in premature babies?
- Lower NEC rates
- Improved feeding tolerance
- Shorter time to full feeds
- Shorter LOS
What is the effect of pasteurization on donor human milk?
- Deactivates CMV -> Bacillus species can survive, but is detectable on cultures performed
- Would also deactivate HBV, HCV, HIV, SARS if present
- Degraded some water-soluble vitamins (e.g. vit C, folate)
What are some of the differences between newborn care for late prems vs. term babies?
- Feeding → 24h of successful feeds should be established
- Apnea → consider a period of cardiomonitoring prior to transfer to low-risk room (if apnea, will need at least 7 days of monitoring)
- Sepsis → consider all infants born at < 36wk high risk
- Hypoglycemia → routine monitoring for hypoglycemia
- Follow-up → ensure follow-up within 48 hours
What are ways to address pain for neonates?
- Combination of oral sucrose/glucose + non-pharmacological methods (kangaroo care, sucking, swaddling) → use for minor, routine procedures
- Topical anesthetics → consider in venipuncture, LP and IV insertion (NOT in heel sticks), limit repeated use
- Continuous infusions (e.g. opioids) → NOT recommended in chronically mechanically ventilated babies (lacking data)
What are ways to address pain for neonates?
- Combination of oral sucrose/glucose + non-pharmacological methods (kangaroo care, sucking, swaddling) → use for minor, routine procedures
- Topical anesthetics → consider in venipuncture, LP and IV insertion (NOT in heel sticks), limit repeated use
- Continuous infusions (e.g. opioids) → NOT recommended in chronically mechanically ventilated babies (lacking data)
What are the benefits of Kangaroo care?
- In low or middle income countries → reduces mortality at discharge, severe illness, infections, LOS + improves mother-infant bonding
- In developed countries: promotes maternal-infant bonding and BF
- Helps to humanize the NICU experience
- May facilitate more mature sleep organization in prems + possibly improved neurodevelopmental outcomes
- Promotes longer duration of BF -> benefits of BF
- Better colonization with maternal flora
- May modulate perception of pain
What is the sensitivity and specificity of the CCHD screening?
What do you do if the screen is positive?
- 99% specificity, 76% sensitivity
- If + screen → consult pediatrician → if cardiac diagnosis cannot be excluded, then consult pediatric cardiology for consultation and echo
What are signs of physiological maturity that premature infants must demonstrate prior to discharge home?
- Thermoregulation → Transfer from isolette to cot -> evidence that 1600g is ok (room temp in studies 22°C)
-
Control of breathing
- Most preterm infants are apnea free by 36wk cGA
- Some extreme premature infants may not be apnea-free until 44wk cGA
- Caffeine half-life is ~100h -> require a few days post-monitoring once discontinued
- “Apnea”-free period varies among NICUs -> 75% neonatal specialists say 5-7 days
-
Respiratory stability
- ~¼ of preterm infants with BW < 1500g need O2 >36wk
- Most authors use target 90-95%
-
Feedings skills and weight gain
- Safe oral feeds: coordinate suck, swallowing, breathing
What must be completed before premature infants are discharged?
- Provincial newborn screening;
- Assessment for respiratory syncytial virus (RSV) prophylaxis and administration, if indicated;
- Cranial imaging at near-term, if indicated by gestational age;
- Retinopathy of prematurity (ROP) screening, if indicated by gestational age or birthweight;
- Hearing screening (*no longer);
- Immunizations according to chronological age and provincial/territorial schedule; and
- Predischarge physical examination, including measurement of weight, length and head circumference
What is the evidence and indications for iNO in neonates?
Evidence for iNO
- iNO can significantly improve oxygenation and decrease mortality & ECMO
- iNO did not improve mortality/ECMO in diaphragmatic hernia
- iNO had no impact of adverse neurodevelopmental outcomes (long-term studies needed)
Who should be treated with iNO?
- Accepted population: ⪰35wk GA at birth → on-going hypoxemia after optimizing Vt, recruiting lung maneuvers (surfactant, HFO/jet)
- Typical indication: OI > 20-25, or PaO2 < 100mmHg despite optimal ventilation with 100% O2
- Conflicting evidence for premature infants → does NOT appears to be effective as rescue treatment or routine treatment → use in small # of critically ill infants in defined scenarios (e.g. respiratory failure associated with oligohydramnios)
What are the risk factors for TTN?
- C/S without labour
- Maternal diabetes
- Maternal asthma
- Male sex
- Low birth weight
- Macrosomia
What are the recommended indications for surfactant therapy based on the CPS statement?
- Infants with RDS whose oxygen requirements exceed 50% should receive surfactant
- Intubated infants with RDS should receive exogenous surfactant before inter facility transport
- Repeated dosing of surfactant should be provided to infants only with evidence of ongoing moderate to severe RDS
- For spontaneously breathing infants on CPAP with RDS, LISA (less invasive surfactant administration) /MIST (minimally invasive surfactant administration) are preferable
- Surfactant replacement therapy for infants with MAS/pulmonary hemorrhage may be considered
What are the side effects of PGE?
- Apnea dose-dependent
- Hypotension
- Tachycardia
- Fever
- Jitteriness/seizures
- Coagulopathy
- NEC
What are the definitions of: kernicterus, acute bilirubin encephalopathy, chronic bilirubin encephalopathy, severe hyperbilirubinemia, critical hyperbilirubinemia
- Kernicterus - pathological finding of deep-yellow staining of neutrons & neuronal necrosis of the basal ganglia and brainstem nuclei
-
Acute bilirubin encephalopathy - clinical syndrome of severe hyperbilirubinemia + lethargy, hypotonia, poor suck, high-pitched cry, fever, and eventually seizures & coma
- Does NOT occur at < 340umol/L
- Very rare until > 425 umol/L
- However, less severe complications can be seen with lower levels —> threshold unknown
- Chronic bilirubin encephalopathy - clinical sequelae of acute encephalopathy with athetoid CP +/- seizures, DD, hearing deficit, oculomotor disturbance, mental deficiency
- Severe hyperbilirubinemia - TSB > 340 umol/L in first 28 days of life
- Critical hyperbilirubinemia - TSB > 425 umol/L in first 28 days of life
What are risk factors for the development of severe hyperbilirubinemia?
- Visible jaundice at <24h
- Visible jaundice before discharge at any age
- Shorter gestation (<38wk)
- Previous sibling with severe hyperbilirubinemia
- Visible bruising
- Cephalohematoma
- Male sex
- Asian or European background
- Dehydration
- Exclusive or partial breastfeeding
What are the indications for exchange transfusion in hyperbilirubinemia?
- Healthy term newborn without risk factors with TSB between 375 and 425umol/L
- If phototherapy fails to control rising bilirubin in severe hyperbilirubinemia
- Clinical signs of acute bilirubin encephalopathy
What is the pathophysiology of G6PD?
G6PD catalyzes a reaction that produces NADPH which protects RBCs from oxidant threats that otherwise damage the RBC membrane. Causes precipitation of Hgb to make Heinz bodies
What are triggers for acute attacks in G6PD?
- Infections (DKA, hepatitis, sepsis)
- Drugs (ASA, sulfonamides, rasburicase, antimalarials)
- Fava beans
What are investigations to consider in hyperbilirubinemia?
- Total and conjugated bilirubin
- CBC, blood group, Coombs test
- +/- G6PD, blood film
- Liver function, metabolic/endocrine work-up
- MRI if signs of acute encephalopathy
What are complications of IUGR?
- Hypothermia (>36.5)
- Hypoglycemia
- Polycythemia
- Jaundice
- Learning issues
- Future metabolic conditions as adult (obesity, type 2 DM, cardiovascular disorders)
What is the criteria for initiating cooling?
- Infants: Late preterm infants ≥36wk with HIE who are ≤6 hours old and who meet either criteria A or criteria B, and also meet criteria C:
- Criteria A: Cord pH ≤7.0 or base deficit ≥−16 OR
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Criteria B: pH 7.0 to 7.15 or base deficit -10 to -15.9 on cord gas or blood gas w/in 1h AND
- Hx of acute perinatal event (i.e. cord prolapse, placental abruption, uterine rupture) AND
- Apgar score ≤5 at 10 min or at least 10 min of PPV
-
Criteria C: Evidence of moderate-to-severe encephalopathy
- I.e. presence of seizures (w/ EEG if possible) OR at least one sign in 3+ of six categories shown in Table 1
Who is contraindicated from receiving cooling?
- < 35 wk GA
- Major congenital or genetic abnormalities or where no aggressive tx is planned
- Severe IUGR
- Significant coagulopathy
- Severe head trauma or intracranial bleeding
What are reasons to stop cooling early (occurs < 10% of the time)?
- Hypotension despite inotropic support
- Persistent pulmonary hypertension with hypoxemia
- Clinically significant coagulopathy, despite treatment
- Subcutaneous fat necrosis +/- hypercalcemia
What is the disability risk for newborns with HIE?
- >30% of HIE-affected newborns develop CP or severe disability (higher risk if severe encephalopathy)
- 25% of mod-severe HIE cases have severe visual impairment or blindness (especially if hypoglycaemia)
- 30-50% of moderate encephalopathy have cognitive deficits (i.e. reading, spelling, arithmetic)
- 13% of moderate-to-severe HIE developed epilepsy (7% needing medication)
What is the definition of neonatal encephalopathy and what is the differential diagnosis?
- Definition: a clinically defined syndrome of disturbed neurological function in the earliest day of life in the term infant
- Signs/symptoms: apnea, abnormal tone, altered reflexes, altered consciousness, or seizures in term baby
- MEDICAL EMERGENCY = significant mortality and morbidity
- Treatable condition: HIE, IEM, infection, bilirubin toxicity, and metabolic disturbances
- Other causes: cerebral dysgenesis, congenital infection, and stroke
When should routine head ultrasound screening be done in neonates?
- Prematurity: routine in ≤ 32wk GA
- Consider in all infants with abnormal neurological signs (e.g. altered LOC), a critical illness or significant RFs
-
Risk factors:
- Low birth weight < 1000g
- Rapid changes in BP (see above)
- HC < 3rd %
- Complicated monochorionic twin (e.g. selective IUGR)
- Postnatal complications (NEC, major surgery, sepsis)
When would you consider reimaging at term in an infant born at < 31wk?
- Routinely in babies born at < 26wk
- 26-32wk: re-image if Grade 3+, PHVD or Grade 3-4 PVL or additional RFs*
- RF: illness requiring mechanical ventilation or vasopressors, NEC, major surgery
When should a brain MRI at term be considered in premature infants?
- Moderate-to-severe anomalies on HUS (Grade 3 or higher IVH, PHVD, or Grades 3 to 4 PVL), when clinical risk for WMI is increased, or when parental reassurance is needed
If an abnormality (Grade 2 or higher IVH or WMI) is detected on routine imaging, when should a repeat HUS should be performed?
7-10 days later
What are the maternal risk factors for early onset bacterial sepsis? How is a CBC helpful?
- RF: GBS+, PROM >18h, >T38, previous infant with GBS
- CBC: WBC < 5, ANC < 1.5 or increased I:T ratio or high total WBC is associated with EOS
- If low pretest probability, don’t rely on WBC → more helpful if multiple RFs are present
How are the following scenarios managed (neonatal HSV):
- Infection, when an infant is delivered by C/S before ROM
- 1st genital herpes infection, infant delivered vaginally or C/S after ROM
- Recurrent HSV at delivery - C/S
- Recurrent HSV at delivery - SVD
- Infection, when an infant is delivered by C/S before ROM
- NHSV risk is very low
- If infant is well, can be discharged while awaiting swab results
- Educate caregiver on symptoms of NHSV infection
- 1st genital herpes infection, infant delivered vaginally or C/S after ROM
- Swab of mucous membranes should be obtained and acyclovir started
- If swab for MM or blood PCR are positive, CSF should be obtained —> determine length of therapy
- If negative, infant should receive 10 days of acyclovir
- Recurrent HSV at delivery - C/S
- Same approach as 1st episode before ROM
- Recurrent HSV at delivery - SVD
- Obtain MM swabs at 24h then discharge home awaiting results
- Acyclovir only if swabs or blood PCR are positive or symptoms of HSV infection
What are risk factors for hypoglycemia?
- Weight <10th percentile (SGA)
- Intrauterine growth restriction (IUGR)
- Weight >90th percentile (LGA)
- Infants of diabetic mothers (IDMs)
- Preterm infants <37 weeks GA
- Maternal labetalol use
- Late preterm exposure to antenatal steroids
- Perinatal asphyxia
- Metabolic conditions (e.g., CPT-1 deficiency, particularly in Inuit infants)
- Syndromes associated with hypoglycemia (e.g., Beckwith-Wiedemann)
What are mortality rates of premature infants by GA - 24wk, 25wk, > 30wk?
- 24wk: 40-50%
- 25wk: 25%
- >30wk: <1%
In which premature infants do we consider giving a course of low dose hydrocortisone starting in the first 24-48h to prevent BPD?
- Consider low-dose HC (1mg/kg/day x7d, 0.5mg/kg/d x3d) in first 24-48h x10d to infants at higher risk of BPD (e.g. < 28wk GA or exposed to chorioamnionitis)
- May be an increased risk of late onset sepsis
- Do NOT combine HC with indomethacin prophylaxis
- HC use after 1wk is NOT recommended
In which premature infants do we consider giving a course of low dose dexamethasone to prevent BPD?
- Routine use of dexamethasone after 1st week of life for evolving BPD is NOT recommended
- If infants are ventilated >1wk with increased O2 needs + worsening lung disease -> benefits of dex seem to outweigh potential adverse effects
- Consider low-dose dex (0.15mg/kg/day-0.2mg/kg/day tapered over short course)
What are concerning findings for a spinal dimple?
- Cutaneous lesion + skin dimple (hypertrichosis, hemangioma, atretic meningocele, subcutaneous mass (e.g. lipoma), caudal appendage)
- Deviated or “split” gluteal cleft
- Multiple dimples
- Dimple diameter >5mm
- Location >2.5cm above the anal verge or above the gluteal cleft
