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MCQ Questions > Neonatology > Flashcards

Neonatology Flashcards

1
Q

What are the three types of Vitamin K deficiency bleeding (VKBD)?

A
  1. Early onset = <24h after birth (often due to maternal medications that inhibit Vit K activity, e.g. anti-epileptics)
  2. Classic = occurs 2-7 days of life (associated with low Vit K intake, i.e. breastfeeding)
  3. Late onset = occurs 2-12 weeks after birth (associated with chronic malabsorption and low Vit K intake)
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2
Q

What are the pros and cons of giving Vitamin K via IV for preterm babies?

A

Pros: reduces pain compared to IM dose
Cons: studies have shown prems who receive IV doses have lower Vit K values at DOL 25

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3
Q

What do you do if a parent declines a vitamin K injection?

A
  • 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
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4
Q

What is the recommended management for babies who’s mothers are GBS+ with inadequate IAP, no other RFs?

A
  • Monitor for at minimum 24h (vitals Q3-4H)
  • No CBC
  • Can be discharged at 24h if well, counsel on signs of sepsis
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5
Q

What is the recommended management of babies for mothers who are GBS+ without IAP + other RFs?

A
  • 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)
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6
Q

What is the management of babies from mothers who are GBS- with other RFs?

A
  • Asymptomatic: early onset sepsis low
  • 1 RF: manage similarly to GBS+ mothers

>1 RF: management should be individualized

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7
Q

What is the recommended management for babies born to a mother with suspected chorioamnionitis?

A

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)
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8
Q

What is the management of late preterm infants who’s mothers have infectious RFs (e.g. GBS)

A
  • If born at 35-36wk: manage similarly to term babies
  • Observe longer - at least 48h
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9
Q

What are the risk factors for severe hyperbilirubinemia (on phototherapy graph)?

A

Isoimmune hemolytic disease, G6PD, asphyxia, respiratory distress, significant lethargy, temperature instability, sepsis, acidosis

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10
Q

If you suspect subcutaneous fat necrosis, what electrolyte do you worry about?

A

Hypercalcemia - check Ca level

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11
Q

There is a maternal history of methadone use, how long do you have to watch the baby for?

A

5 days

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12
Q

What are the benefits of surfactant?

A
  • 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
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13
Q

What are the benefits of delayed cord clamping?

A

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
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14
Q

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.

A

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

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15
Q

What are complications from polycythemia?

A

Specific to neonates: NEC, hypoglycemia, hypocalcemia

Thrombosis, end organ damage (heart failure, altered LOC, renal insufficiency, DIC), headache, joint pain

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16
Q

What are the options for managing pain for neonates?

A
  1. Minimize painful disruptions as much as possible
  2. Oral sucrose/glucose
  3. Non-pharmacological pain reduction methods - kangaroo care, non-nutritive sucking, swaddling → routine, minor procedures
  4. Topical anesthetics → can be used for venipuncture, LP, IV insertion (not heel pokes)
  5. More major procedures (chest drain remove) → short-acting, rapid-onset systemic analgesic
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17
Q

What is the treatment for PPHN?

A
  • 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
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18
Q

What are congenital features of syphilis?

A
  • 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
  • Infancy/childhood
    • Interstitial keratitis
    • Hutchinson’s teeth
    • Mulberry molars
    • Sensory neural deafness
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19
Q

What are the main risk factors for SNHL in neonates?

A
  1. Congenital infections - e.g. CMV, rubella, toxoplasma, syphilis, herpes simplex
  2. Extreme prematurity
  3. Ototoxic medications - e.g. aminoglycosides
  4. Kernicterus
  5. Bacterial meningitis
  6. Mechanical ventilation, ECMO
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20
Q

How do the following maternal diseases affect the infant? Diabetes, Graves, Hyperparathyroid, Obesity, Vit D deficient, PIH, ITP, Rh/ABO, SLE, PKU

A
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21
Q

What are the risks of giving surfactant?

A

Pneumothorax, bradycardia, blocked tube, hemorrhage (rare)

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22
Q

What findings of integrated prenatal screening is concerning?

A
  • Trisomies: high HCG, low PAPP-A, low AFP
  • Open NTD: high AFP
  • Placental insufficiency: low PAPP-A
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23
Q

How do the following maternal factors/diseases affect the fetus?

Radiation, hyperthermia, CMV, Toxoplasmosis, Parvovirus B19, Varicella, Syphilis, Hep B, HIV, Rubella

A
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24
Q

What are major congenital anomalies or medical issues that may not be picked up in the first 24h of life?

A
  • Up to 30% nonsyndromic CHD may not be diagnosed in first 3 days of life
  • GI obstruction or hyperbilirubinemia may present later
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25
Q

When should a newborn baby receive a full physical exam?

A
  • 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)
26
Q

What must be ensured prior to discharging a newborn at less than 24h of age?

A
  • Infant has transitioned appropriately
  • No RFs that require close monitoring
  • Necessary screening occurs
  • Has follow-up and support is readily available
27
Q

What are the benefits of PHDM in premature babies?

A
  • Lower NEC rates
  • Improved feeding tolerance
  • Shorter time to full feeds
  • Shorter LOS
28
Q

What is the effect of pasteurization on donor human milk?

A
  • 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)
29
Q

What are some of the differences between newborn care for late prems vs. term babies?

A
  • 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
30
Q

What are ways to address pain for neonates?

A
  • 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)
31
Q

What are ways to address pain for neonates?

A
  • 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)
32
Q

What are the benefits of Kangaroo care?

A
  • 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
33
Q

What is the sensitivity and specificity of the CCHD screening?

What do you do if the screen is positive?

A
  • 99% specificity, 76% sensitivity
  • If + screen → consult pediatrician → if cardiac diagnosis cannot be excluded, then consult pediatric cardiology for consultation and echo
34
Q

What are signs of physiological maturity that premature infants must demonstrate prior to discharge home?

A
  • 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
35
Q

What must be completed before premature infants are discharged?

A
  • 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
36
Q

What is the evidence and indications for iNO in neonates?

A

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)
37
Q

What are the risk factors for TTN?

A
  • C/S without labour
  • Maternal diabetes
  • Maternal asthma
  • Male sex
  • Low birth weight
  • Macrosomia
38
Q

What are the recommended indications for surfactant therapy based on the CPS statement?

A
  • 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
39
Q

What are the side effects of PGE?

A
  • Apnea dose-dependent
  • Hypotension
  • Tachycardia
  • Fever
  • Jitteriness/seizures
  • Coagulopathy
  • NEC
40
Q

What are the definitions of: kernicterus, acute bilirubin encephalopathy, chronic bilirubin encephalopathy, severe hyperbilirubinemia, critical hyperbilirubinemia

A
  • 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
41
Q

What are risk factors for the development of severe hyperbilirubinemia?

A
  • 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
42
Q

What are the indications for exchange transfusion in hyperbilirubinemia?

A
  • 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
43
Q

What is the pathophysiology of G6PD?

A

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

44
Q

What are triggers for acute attacks in G6PD?

A
  • Infections (DKA, hepatitis, sepsis)
  • Drugs (ASA, sulfonamides, rasburicase, antimalarials)
  • Fava beans
45
Q

What are investigations to consider in hyperbilirubinemia?

A
  • Total and conjugated bilirubin
  • CBC, blood group, Coombs test
  • +/- G6PD, blood film
  • Liver function, metabolic/endocrine work-up
  • MRI if signs of acute encephalopathy
46
Q

What are complications of IUGR?

A
  • Hypothermia (>36.5)
  • Hypoglycemia
  • Polycythemia
  • Jaundice
  • Learning issues
  • Future metabolic conditions as adult (obesity, type 2 DM, cardiovascular disorders)
47
Q

What is the criteria for initiating cooling?

A
  • 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
    • 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
48
Q

Who is contraindicated from receiving cooling?

A
  • < 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
49
Q

What are reasons to stop cooling early (occurs < 10% of the time)?

A
  • Hypotension despite inotropic support
  • Persistent pulmonary hypertension with hypoxemia
  • Clinically significant coagulopathy, despite treatment
  • Subcutaneous fat necrosis +/- hypercalcemia
50
Q

What is the disability risk for newborns with HIE?

A
  • >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)
51
Q

What is the definition of neonatal encephalopathy and what is the differential diagnosis?

A
  • 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
52
Q

When should routine head ultrasound screening be done in neonates?

A
  • 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)
53
Q

When would you consider reimaging at term in an infant born at < 31wk?

A
  • 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
54
Q

When should a brain MRI at term be considered in premature infants?

A
  • 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
55
Q

If an abnormality (Grade 2 or higher IVH or WMI) is detected on routine imaging, when should a repeat HUS should be performed?

A

7-10 days later

56
Q

What are the maternal risk factors for early onset bacterial sepsis? How is a CBC helpful?

A
  • 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
57
Q

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
A
  • 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
58
Q

What are risk factors for hypoglycemia?

A
  • 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)
59
Q

What are mortality rates of premature infants by GA - 24wk, 25wk, > 30wk?

A
  • 24wk: 40-50%
  • 25wk: 25%
  • >30wk: <1%
60
Q

In which premature infants do we consider giving a course of low dose hydrocortisone starting in the first 24-48h to prevent BPD?

A
  • 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
61
Q

In which premature infants do we consider giving a course of low dose dexamethasone to prevent BPD?

A
  • 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)
62
Q

What are concerning findings for a spinal dimple?

A
  • 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

MCQ Questions (23 decks)

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