Neonatology Flashcards
1
Q
What is the effect of smoking and alcohol use during pregnancy on the newborn?
A
Lower birth weight, IUGR, reduced head circumference (microcephaly)
2
Q
What are the main screening tests for antenatal diagnosis? What can they detect?
Give a few specialized
A
Maternal blood (Hepatitis, any trisomy, blood groups, syphilis)
Ultrasound (for structural anomalies including neural tube defects, facies, and cardiac malformations)
NIPT - Non-invasive prenatal testing
Fetoscopy
Amniocentesis
Chorionic villus sampling
3
Q
Why is folic acid given to pregnant mothers?
A
reduce risks of neural tube defects such as spina bifida
4
Q
What is spina bifida?What would you see on an ultrasound of spina bifida? What are some clinical findings?
A
Chiari malformations on US
Bladder/bowel incontinence
Weakness and loss of sensation below the defect
Talipes Equinovarus (Club foot)
Meningocoele
5
Q
What is Gastroschisis
A
This is when there is a defect in the abdominal wall during gestation allowing for an opening. Some of the bowel will then be pushed through this hole and develop outside the body in the amniotic fluid.
6
Q
How long does a normal pregnancy last?
A
40 weeks
7
Q
What is considered a “term infant”
A
37-42 weeks of gestation
8
Q
What is considered
Pre-term?
Late Pre-term?
Very Pre-term?
Extreme preterm?
A
Pre-term? <37 weeks (<3.5kg)
Late Pre-term? 34-36 weeks (2.2kg)
Very Pre-term? <32 weeks (<2.2kg)
Extreme preterm? <28 (1.1kg)
9
Q
What is the normal birth weight, head circumference, and height of a baby born at 40 weeks gestation? When is the weight expected to double? triple?
A
Birth weight = 3.5 (doubled by 5 months and tripled by 1 year)
Head circumference = 35 (32-37)
Height = 50
10
Q
What is the typical resp and pulse rate of full term neonate?
A
Resp = 30-60/40-60
Heart/pulse = 110-160
11
Q
How is newborn bloodspot screening performed? What is included (6/10)?
A
Heel-Prick Test
3 congenital and 7 inherited
Congenital hypothyroidism
Hemoglobinopathies (sickle cell and thalassemia)
Cystic Fibrosis
1) Phenylketonuria
2) Homocystinuria
3) Glutaric Aciduria Type 1
4) Classical Galactosaemia
5) ADA-SCID - Adenosine deaminase Deficiency - Severe Combined Immunodeficiency
6) Maple syrup urine disease
7) Medium chain acyl-coa dehydrogenase deficiency
12
Q
What is the weight AGA for 34 weeks gestation. What is SGA (in general)
A
Weight Appropriate for Gestational Age = 2.2
SGA = Small for gestational age => <10th centile
13
Q
What is Eclampsia? include symptoms and findings of pre-eclampsia (5)
A
Eclampsia is seizures that occur in pregnant people with Pre-eclampsia
These symptoms include persistent high blood pressure (130/80 or 140/90) with proteinuria, thrombocytopenia, pulmonary oedema, blurry vision and headaches
14
Q
Give the 3 most common causes of preterm delivery and list 2 others
A
1) Spontaneous preterm labor - no reason (50%)
2) Maternal or foetal infection (incl. UTI) or complication (30%)
3) PPROM - Premature Preterm Rupture Of Membranes
- Antepartum haemorrhage
- Multiple pregnancy
- Cervical incompetence
15
Q
What is cervical incompetence
A
Recurrent painless dilatation and spontaneous mid-trimester birth (preterm delivery)
16
Q
What is considered Hypotension in the new born?
A
Systolic BP <60
17
Q
What is an endotracheal tube used for?
A
An endotracheal tube is inserted through the mouth and into the trachea to
1) Maintain a clear and open airway
2) Administering oxygen, medicine, or anesthesia
18
Q
What is Respiratory Distress Syndrome? Who typically develops it? How is it treated?
A
Preterm babies may present with difficulty breathing due to immature lung structure and weak chest wall. RDS is due to a Surfactant deficiency which is responsible for keeping the lungs fully expanded. Without this, neonatal lungs may collapse.
This is treated by replacing surfactant via ET tube (endotracheal tube) or can be resolved within 72 hours if not treated.
19
Q
When a baby is born preterm, their organs are immature and hence they function poorly. How would this impact the respiratory system?
A
Neonatal respiratory distress syndrome
Sleep apnoea
20
Q
When a baby is born preterm, their organs are immature and hence they function poorly. How would this impact the Cardiovascular system?
A
PDA - Patent Ductus Arteriosis
Hypotension (<60 systolic)
21
Q
What is PDA (Patent Ductus Arteriosis)
A
Blood vessel connecting the pulmonary artery to the aorta
22
Q
When a baby is born preterm, their organs are immature and hence they function poorly. How would this impact the Brain?
A
IVH - Intraventricular haemorrhage (Bleeding into ventricles of the brain)
PVL - Periventricular leukomalacia (cause of Cerebral palsy)
Note: IVH may lead to PVL. These arent 2 completely separate points
23
Q
When a baby is born preterm, their organs are immature and hence they function poorly. How would this impact the GI system
A
Poor absorption
Neonatal ileus
Necrotising Enterocolitis
Neonatal Jaundice (Cholestatic jaundice especially in VLBW)
24
Q
What is Neonatal Ileus and what is it an early sign of?
A
Also called Meconium Ileus where Meconium is the first stool/bowel movements that the newborn has. This may cause obstructions in the ileus as it is thick and sticky.
Early sign of Cystic Fibrosis
25
What is necrotising enterocolitis and what is the first thing you do?
Necrotising enterocolitis is the ischemic necrosis of the intestinal mucosa (remember necrosis leads to cell death and invasion of microorganisms causing gas within). There will be a sudden change in feeding tolerance as an early sign and confirmed with Doppler ultrasound. With this, it is important to switch to TPN and remove enteral feeding or normal feeding.
26
When a baby is born preterm, their organs are immature and hence they function poorly. How would this impact the Renal system?
Immature kidneys =>Poor urinary output and often diluted
Hypoglycemia
Hypocalcemia
27
When a baby is born preterm, their organs are immature and hence they function poorly. How would this impact the eyes
Retinopathy of Prematurity (esp in VLBW)
28
When a baby is born preterm, their organs are immature and hence they function poorly. How would this impact the Immune system
Much weaker immune system as there are low maternal antibodies. Maternal antibodies are transferred across the placenta during the third term of gestation
29
When a baby is born preterm, their organs are immature and hence they function poorly. How would this impact skin functioning?
Think increased permeability
Increased water and heat loss
Increased risk of infection
30
What is considered an extremely low birth weight? Where should thes babies be delivered
<1kg at birth. These babies should be delivered in tertiary level unit with experienced resuscitation
31
How long after membrane rupture should the baby be delivered. What should be the immediate management?
Under 48 hours (preferably under 24). if premature, administer antibiotics (ceftriaxone, clarithromycin, and metronidazole) Erythromycin also works
32
What is the benefit of giving magnesium sulphate before delivery?
infant neuroprotection. reduces risk of cerebral palsy
33
What is the benefit of administering antenatal steroids before birth?
Helps increase surfactant production ahead of birth => reduces the risk of RDS and chronic lung disease
34
What preparations can be made before birth to modify the effects of prematurity? (AKA how to prolong pregnancy and others considerations given before birth)
1) Antenatal steroids given over 24 hours before delivery in 2 doses, 12 hours apart.
2) Magnesium sulphate
3) Antibiotics !if PPROM! (Ceftriaxone)
4) Progesterone and Tocolytics
5) Deliver in tertiary centre !if Extremely premature <28!
35
A premature baby has just been delivered via induced vaginal delivery. What are the key immediate issues that must be addressed in the delivery room?
Temperature (increased heat and water loss from skin +reduced subcutaneous fat etc...)
+ ABC(D)
Airway: Usually managed alone after positioning and gentle resp support. Few will need endotracheal intubation to keep airway open
Breathing: Pulse oximetry must be monitored to achieve target O2 sat of 95% 10 minutes after delivery.
If breathing is present but well enough then support breathing via Nasal cannula, CPAP, BiPAP, mechanical ventilation.
If there is no breathing => apnoea => needs resuscitation of mechanical ventilation to survive.
Cardiovascular: Monitor HR (a good heart rate indicates that the resuscitation is going well. Check BP as well and if not then also resus.
D: Dedicating a bed/incubator in NICU for the baby
36
What are tocolytics? When are they used?
Tocolytics are drugs that slow the uterine contractions of the mother and are used to delay pregnancy by 1-2 days in preterm cases.
37
What is delayed cord clamping? it cannot be done if....
Delaying cord clamping for 30-60 seconds allows additional blood to flow from placenta to infant making them more stable in first few days of life
It cannot be done if breathing isnt already established
38
On delivery, neonates are often monitored via pulse oximetry. Describe the change in oxygen saturation in neonates from birth onwards?
Babies transition slowly from 65% O2 sat (cyanosed in utero even) to >95% O2 sats within 10 minutes
39
How is ventilation typically administered in neonates?
Via ET tube
40
Describe what you see in this image. This is a baby delivered on 28 weeks gestation
Premature baby:
small size in frogleg position on an open top table
Pink skin as it is underdeveloped (increase loss of water, heat and increased risk of infection)
Breathing support via nasal cannula
Extensive monitoring for pulse oximetry on left foot
Temperature taken on the abdomen
Multiple IV lines and vascular access point (brachial)
41
This is a premature baby delivered at 27 weeks gestation describe what you see.
Small baby in an incubator having contact with a parent
Baby is on breathing support via the endotracheal tube
Orogastric (not nasogastric) tube also inserted
IV line inserted in right hand
Umbilical lines coming out just above the nappy
42
What is a plethora. What can it be caused by?
Plethora is the red complexion on skin typically caused by polycythemia (significantly increased RBC mass)
43
What is the ideal temp and humidity for premature infants (in an incubator)
35 degrees with 80-90% humidity
44
How is pulse oximetry measured in NICU?
Extensive monitoring from the foot rather than finger in adults.
45
The Golden hour in the NICU represents the first hour after arrival. What should be completed during this hour for a premature infant?
What would be required to be maintained for homeostasis?
1) Check glucose
2) Apply monitoring
3) Attempt vascular access (UAC, UVC, PICC)
4) Aim to maintain stability of breathing (RDS) and circulation (BP)
Maintain Homeostasis (temperature in incubator, monitor electrolytes and clinical signs, early nutrition/TPN, Urine output and fluid balance (in vs out), glucose control. Checked every 6 hours
46
In terms of vascular access why would you require venous access and why would you require arterial?
Venous access is used to deliver fluids, nutrition, and medications
Arterial access is used to monitor BP, blood gas, and obtain blood samples.
47
What is PICC, where is it inserted?
What is PIVC and where is it inserted?
Percutaneous inserted central catheter
PICC optimally in superior or inferior vena cava (starts in antecubital fossa)
Peripheral intravenous catheter
PIVC usually in Dorsal venus plexus can be accessed through antecubital, basilic or long saphenous vein as well
48
What is the taping used in this picture? Why?
This taping is just temporary until the placement of the lines are confirmed via x-ray. More permanent stickers will be used then
49
This is a picture of a premature baby. What do you see?
Baby is in an incubator, receiving contact with parents and is receiving CPAP via nasal prongs
Single umbilical line in place
1 ECG and resp lead on the right shoulder
50
Neonatal Resuscitation: In the first 30 seconds of life, what should be carried out?
Dry, Stimulate, and suction the oropharynx
51
What is the significance of tactile stimulation in the first steps of neonatal resuscitation. Explain using primary and secondary apnea or the physiology of asphyxia
When a newborn is first deprived on oxygen, an initial period of rapid breathing is followed by primary apnea. This is resolved via tactile stimulation. But if stimulation doesnt work, secondary apnea ensues => HR begins to fall and bp follows => assisted ventilation is required.
52
Neonatal Resuscitation: You've now dried and stimulated the baby, and suctioned the oropharynx. You move on to assessing the breathing and Circulation (HR). What are you looking out for (including cutoff if present)? And what will you do given deterioration?
Assess Breathing and Heart rate
If heart rate <100, or apneic, or irregular breathing effort, then start IPPV (Intermittent positive pressure ventilation)
PIP (peak inspiratory pressure) = 20-25 cmH2O in term
PEEP (Positive End Expiratory Pressure) = Start at 5cmH2O
FiO2: Start at 21% in term babies and 30% in preterm babies (often increased as we monitor SPO2)
53
Neonatal Resuscitation: What is IPPV. What are the 2 ways that it may be delivered?
Intermittent positive pressure ventilation
May be delivered using bag and mask or "Neopuff" T-Piece resuscitator
54
Neonatal Resuscitation: You have begun IPPV and noticed that the SPO2 levels are still relatively low but there is a good chest lift. What do you do?
Increase FiO2
55
Neonatal Resuscitation: You have begun IPPV and noticed that the there is not a good enough chest lift. What is to be done next?
MR SOPA
Mask readjustment
Re-position the head to open the airway (chin lift/jaw thrust)
Suction the mouth then nose
Open mouth and jaw lift
Pressure increase
Alternative airway (endotracheal)
56
Neonatal Resuscitation: Youve begun IPPV but realize that the Heart rate is still low. When should you intervene (timing and heart rate) and what should be done in this intervention?
If after 30 seconds of effective ventilation, the heart rate is still <60bpm, then
begin chest compressions. This is done with 3 compressions per breath
Raise FiO2 to 100%
57
Neonatal Resuscitation: You notice that the child has a systolic pressure <90. What do you do?
you would give saline bolus (0.9% NaCl), emergency O Rh-ve blood and at 10mls/kg
58
Neonatal Resuscitation: Youve begun IPPV but realize that the Heart rate is still low. you initiate chest compressions yet after 60 seconds of chest compressions , the HR is still <60. What is the next step?
Give Adrenaline every 3-5 minutes. 0.5mls/kg if via endotracheal route and 0.1-0.3ml/kg if via established IV route
Also consider evidence of hypovolemia. In this case, you would give saline bolus (0.9% NaCl), emergency O Rh-ve blood and at 10mls/kg
59
Neonatal Resuscitation: When would Adrenaline be indicated during this? How much? How do you administer
When youve begun IPPV but realize that the Heart rate is still low. you initiate chest compressions yet after 60 seconds of chest compressions , the HR is still <60.
Give Adrenaline every 3-5 minutes. 0.5mls/kg if via endotracheal route and 0.1-0.3 if via established IV route
60
Neonatal Resuscitation: The baby that has just been delivered is at 31 weeks. What additional support would you give?
Interms of Oxygen, how much % FiO2 would you administer
Starting FiO2 should be at 30%
Thermal control: Plastic bag, hat, or thermal mattress
61
The transition to extra-uterine life requires significant physiologic changes in the cardiovascular and respiratory systems. Most of these occur in the first few minutes after birth.
Around 90% of babies make these changes without requiring any special assistance. Around 10% percent of infants need some intervention. Roughly 1% require extensive resuscitation e.g. intubation. Which babies are more likely to require resuscitation? (5)
Fetal conditions e.g. prematurity, !IUGR!, congenital anomalies (ductus arteriosis)
Pregnancy complications e.g. chorioamnionitis (infection), placental abruption
Delivery complications e.g. meconium-stained liquor, abnormal fetal HR on CTG, shoulder dystocia, multiple births
Maternal conditions e.g. advanced maternal age, gestational diabetes, severe pre-eclampsia
Note: Maternal medications such as analgesics, sedatives, and anesthetics may also cause this)
62
What is measured in the APGAR score (go into specifics)? When is it recorded? What is it used for. Can it be used to assess the need for resuscitation?
APGAR scores are measured at 1 and 5 minutes after every birth
Appearance (Blue/pale all over vs extremities or pink
Pulse (Absent <100, >100)
Grimace (No response, grimace, cry)
Activity (tone) (none, semiflexed, fully flexed)
Respiration (Absent, weak, strong cry)
The Apgar score is useful for conveying information about overall status and response to resuscitation but not to assess the need. That is via tone, crying, and term.
63
Resuscitation is the restoration of a stable physiological condition to a person whose heart action, blood pressure or body oxygenation have dropped to critical levels. How do you know if the baby requires resuscitation vs staying with motheron delivery (not SPO2 which is used for discharge)?
Term
Tone
Crying
Term babies with good tone who are crying regularly should stay with their mother.
64
What is Twin-twin transfusion syndrome? How is it treated?
It is due to plancental atriovenous anastomoses where there is a donor and recipient twin. The donor twin will have low perfusion pressures giving them oliguria and oligohydramnios whereas the recipient will have hypervolemia => polyuria and polyhydramnios => high output cardiac failure
Treated with fetoscopic laser to divide the placenta or early delivery.
65
Multiple births are on the rise. What conditions are they associated with?
A/w increased risk of
prematurity
IUGR
Congenital malformations
Twin-twin transfusion syndrome
66
Women with pre-existing diabetes find it hard to control their glucose levels during pregnancy. Which type of diabetes carries a larger risk of fetal mortality and why?
Type 1 due to risk of ketoacidosis
67
Poorly controlled diabetes in pregnant women may cause associated fetal problems. What are they?
IUGR
Congenital malformations
Macrosomia (big baby)
68
Explain the pathophysiology of Macrosomia in poorly controlled diabetic pregnancies
Glucose passes the placenta but insulin does not. This glucose promotes secretion of insulin in baby and hence promoting growth (using the glucose). This may then cause transient hypoglycemia at birth, resp distress syndrome (more demand for oxygen), Hypertrophic cardiomyopathy (to keep up support), and polycythemia. Note an obese mother is also susceptible to gestational diabetes which can have the same effect
69
What are some (groups of) medications that are contraindicated in pregnant women?
Mood stabilisers, SSRIs, Radioactive Iodine, Vitamin A, Warfarin, Thalidomide, tetracycline
70
What are the TORCH organisms and what do they represent?
Congenital Infections
Toxoplasmosis
Other - Syphilis HIV, Hepatitis, Parvovirus
Rubella
CMV (cytomegalovirus)
Herpes Simplex
71
What is the classical triad of taxoplasmosis?
Chorioretinitis (retinopathy) on eye exam
Hydrocephalus
Intracranial calcifications on US
+ petechial blueberry muffin rash
72
What TORCH organisms have the blueberry muffin rash?
Taxoplasmosis, Rubella, CMV (not HSV)
73
What are the common findings of a neonatal congenital infection?
Hepatosplenomegaly
Jaundice and Thrombocytopenia
Lethargy
IUGR
74
What congenital infections are present in the urine?
Rubella and CMV
75
Congenital infection with the highest likelihood of sensoryneural deafness?
CMV although rubella also has this
76
How are intracranial calcifications verified? Which TORCH organisms have it
via ultrasound
CMV (especially periventricular), taxoplasmosis, HSV (not rubella)
77
Congenital infections: baby with cataracts on eye exam. What is the most likely organism?
Rubella
78
Congenital infections: baby with vesicular lesions and keratoconjunctivitis. What is the most likely organism?
HSV
79
What is a petechial rash?
tiny pinpoint non-blanching spots due to hemorrhage into dermis.
80
What rash is this? Where is it seen?
Blueberry muffin petechial rash
Taxoplasmosis, Rubella, CMV
Note the jaundice in the image (neonatal jaundice and hepatosplenomegaly)
81
What is the major finding of this xray? What congenital infection most likely caused this
Blunting of the costophrenic angle indicating pleural effusion. This is evident most likely in Parvovirus.
How? it can lead to severe fetal anaemia (aplastic anaemia), causing fetal hydrops (oedema and ascites from heart failure)
Can also occur from vesicoureteric reflux
82
How would you diagnose CMV or Rubella?
Either maternal serology for IgM antibodies or DNA PCR urine and blood
83
How would you diagnose syphilis?
Dark-field microscopy or PCR
84
You have now confirmed CMV infection via urine DNA PCR. Would you treat the baby? How would you treat the baby?
Treatment is only given if there is CNS involvement or hearing loss. In that case, you would give Ganciclovir IV or PO for 6 weeks
85
What is the usual source for a maternal Taxoplasmosis infection? (1-2)
Raw/undercooked meat, contaminated vegetables and water, cat litter, soil contact. => suggest handwashing (also for CMV)
86
Congenital infections: After an eye exam, you have figured out that the patient has Chorioretinitis. What is the most likely organism and which other organisms may exhibit this sign?
Just like the intracranial calcifications it is present in Taxoplasmosis, CMV, and HSV (not rubella)
Taxoplasmosis is most common
87
What is the most relevant vaccine to recommend to mothers to prevent congenital infections?
Rubella.
88
What is included in antenatal infection screening? If detected what measures would you implement?
Rubella, treponemal antibody, Hep B and C, HIV
Prevent vertical transmission e.g. C-section instead of vaginal delivery for HSV
Antiretroviral therapy and avoid breast feeding in HIV
89
You see a term baby struggling to breathe. What is your immediate management?
Relevant history: Age, complications, gestation, septic indications...
Check vitals (HR, RR, O2 sats, CRT, BP)
CXR
Capillary Blood gas (not arterial)
CPAP/mechanical ventilation
Sepsis workup and antibiotics as required
90
What are the signs of respiratory distress?
Tachypnea
Tachycardia
Labored breathing : Intercostal/subcostal recession and nasal flaring (accessory muscles)
Expiratory grunting
Cyanosis
91
You are asked to see a term infant with peripheral cyanosis, nasal flaring, and expiratory grunting. What are your differential diagnoses?
No Respiratory Distress syndrome as this is a term baby
Pulmonary:
Transient Tachypnea of the newborn (most common)
Meconium aspiration/milk aspiration => pneumonia
Pneumothorax
Persistent pulmonary hypertension of the newborn
Non-pulmonary:
- Congenital Heart Disease (AVSD/ ductus arteriosis)
- Congenital Diaphragmatic Hernia
- Intracranial birth trauma/asphyxia
- Severe anemia
- Metabolic Acidosis
- Heart failure
92
Transient tachypnea of the newborn is the most common cause of respiratory distress.
What is it caused by?
What is a major RF for this?
What would you expect to find on CXR?
What would you do to manage a patient with this?
This is caused by delayed reabsorption of amniotic fluid in the lungs
More common with C-section births as amniotic fluid is forced out of the lungs as the baby passes through the birth canal
CXR: image in general more opaque (hypolucent) Fluid in horizontal fissure (5th rib right lung only)
Tx: may require oxygen support but resolves after few days
93
Meconium is passed before birth and can lead to the fetus inhaling and aspirating the meconium when they gasp at birth.
What can this cause?
What is expected on X-ray?
How would this impact resuscitation?
This may lead to mechanical obstruction and irritation => chemical pneumonitis => predisposing the infant to infection.
The damage to the lung from this allows for air leak and hence may cause pneumothorax
This is evident on CXR with overinflated lungs (obstruction) and patches of consolidation all over (inflammation)
The obstruction and air leak makes it extremely difficult to oxygenate due to ventilation/perfusion mismatch leading to persistent pulmonary hypertension of the new born => during resuscitation, it will be hard to perfuse (large bore suction catheter)
94
Infection and Pneumonia in the newborn is often non-specific and presents with symptoms of respiratory distress.
What are the main risk factors for this?
How would you manage pneumonia?
1. Prolonged rupture of the membrane => Chorioamnionitis
2. Maternal pyrexia
3. Guillian Barr Syndrome (CMV, EBV, campylobacter)
4. Prematurity
Antibiotics: Benzylpenicillin (+) and gentamicin (-)
95
Pneumothorax is the presence of air in the lungs and occurs in 2% of deliveries. They are usually asymptomatic but may cause respiratory compromise
What can this be secondary to?
How would you diagnose it?
How would you treat it?
Secondary to Meconium aspiration, RDS, or iatrogenically through mechanical ventilation
Diagnosis is via Transillumination and CXR
If no resp compromise => supplemental O2 and Needle Thoracocenthesis (2nd ICS, MCL)
If tension pneumothorax w/ resp compromise => intubation (ET tube) + Chest drain insertion (4/5th ICS MAL)
96
PPHN - Persistent pulmonary hypertension of the newborn. Normally, the newborn has progressive decline in pulmonary vascular resistance and immediate rise in systemic vascular resistance.
1 - What are the conditions that can interfere with this decline?
2- What occurs as a consequence of this increased pulmonary vascular resistance?
3- How would you confirm the diagnosis?
4- How would you manage the patient?
5- In severe cases, what would you resort to?
1- Birth Asphyxia
Meconium aspiration
Septicemia
RDS
2. This causes right to left shunting of deoxygenated blood (bypassing oxygenation) within the lungs and through the persistent foramen ovale in AVSD and persistent ductus arteriosis
3. ECHO (also excludes congenital heart disease)
4. The aim of managing the patient is to maintain systolic BP while reducing pulmonary arterial pressure. This is done by
a) Mechanical ventilation
b) Vasopressors to increase systemic resistance (Vasopressin)
c) Nitric Oxide (NO) for pulmonary vasodilation => reducing pulmonary resistance
5. HFOV (high frequency oscillatory ventilation) or ECMO( Extracorporeal membrane oxygenation)
97
What is the most common diaphragmatic hernia that may occur in neonates?
What would you expect to find on a cardio exam and resp exam
What do you expect to see on xray (used to diagnose)
How would you treat this patient?
Bochdalek hernia in the posterolateral foramen of the diaphragm
Cardio exam (displaced apex beat and heart sounds on right side)
Resp exam (Poor air entry on left side)
Xray: bowel contents, spleen, stomach in chest
Treat: Large NGT passed and suctioned to decompress intrathoracic bowel followed by surgical repair.
98
What do you expect to see on CXR that would diagnose RDS (respiratory distress syndrome)
Homogenous ground glass appearance bilaterally
very opaque due to poor aeration. Second picture shows after surfactant given.
99
You are conducting a vascular exam on a neonate and notice a reduced femoral pulse. What does this indicate?
Coarctation of the aorta
100
What is IUGR?
Define the typical centiles of an IUGR neonate
What are potential causes? (3)
What risks is IUGR associated with? (3)
Intrauterine growth restriction where the baby fails to reach their genetically determined growth potential
Typically, growth is asymmetrically restricted where the head is spared at the expense of glycogen and fat stores. This means that the head circumference is spared by the height and weight of the baby is not => lower centiles in height and weight but normal head circumference
Causes: Pre-eclampsia, smoking/alcohol, congenital infection (more symmetrical), malnutrition
a/w: Intrauterine asphyxia/hypoxia, neonatal hypothermia (SA), hypoglycemia (poor fat and glycogen stores), and polycythemia (high hematocrit)
Note: Big babies have the same issues but for different reasons e.g. hypoglycemia from hyperinsulinism.
101
A baby has a known vitamin K deficiency. What is the most likely disease?
What findings may you expect?
How would you manage?
Hemorrhagic disease of the newborn
easy bruising with prolonged bleeding. May have Malena, or intracranial hemorrhage from birth trauma.
Manage with switching to formula instead of breath milk if low risk deficiency. Otherwise IM injection.
102
What is this?
Omphalitis
103
What is the typical presentation of neonatal infection/sepsis?
Fever
Poor color/perfusion (pale)
Tachycardia
Tachypnea/respiratory distress (incl. grunting)
Hypo/hyperglycemia
Periumbilical flare
Poor feeding
Irritable/high pitched cry
104
A 34 y/o lady was admitted at 35 weeks gestation with rupture of membranes. A baby girl was delivered by SVD 24 hours later. You are called to review the baby for grunting, sunken fontanelle and poor colour at 20 minutes of life. What diagnosis (1) would you consider?
Early onset sepsis
105
Why might a neonate be more susceptible to sepsis (normal neonate). think logically
Immature immune system, transplacental spread of organisms, microorganism exposure in genital tract, trauma during delivery allows infection, overcrowding, invasive procedures (ET tube, catheters, any artificial ventilation...)
Also preterm increases risk
106
An ex 26/40 gestation infant in NICU
Day 14 of life is noted to have a low grade fever and raised sugars
Incidental note was also made of some discomfort of his left leg while undergoing a nappy change
He has had a PICC (peripherally inserted central catheter) line in since day 2 of life
What is the likely diagnosis? (Not organism)
Late onset sepsis
107
Differentiate between early and late onset sepsis
Early: first 48 hours of life, usually due maternal RFs, rapid onset, fulminant multisystem disease, pneumonia common
Late: after first 48 hours, usually due to iatrogenic/birth-related, slow onset, focal infection, pneumonia not common
108
A term infant is born by SVD following PROM for 48 hours. He becomes acutely unwell at 10 hours of age and is treated for sepsis. What is the likely organism?
Early onset sepsis (usually +resp distress)=> Group B strep
109
A 1/7 old infant was admitted to the neonatal unit with severe sepsis requiring ventilation and inotropic support. Mum had a history of recurrent UTI’s in pregnancy. What is the likely organism?
Early onset sepsis with hx of recurrent UTIs => Gram -ve organism such as E.coli
110
Intrapartum antibiotic prophylaxis (IAP) is typically given to mothers at risk. What is the antibiotic? When would this be indicated?
Benzylpenicillin
Recommended for
1) women who had a previous infant with GBS infection
2) Positive maternal urine/blood isolate
3) Preterm labor <37 weeks gestation (prematurity RF)
4) Premature rupture of membrane (PPROM) OR rupture >18 hours regardless of gestation (RF)
5) Multiple birth (RF)
111
When should Intrapartum antibiotic prophylaxis (IAP) be administered. Why?
Must be administered >2hrs before delivery as it is a RF for neonatal early onset sepsis.
112
A 10 day old term baby was brought to POPD with persistently sticky eyes. The discharge was blood stained and the baby was also noted to be tachypnoeic. What is the likely organism?
Late onset sepsis + conjunctivitis => Gonorrhea and Chlamydia. As the onset was 10 days later + respiratory symptoms shift the diagnosis more in favor of chlamydia
113
When is meconium stained amniotic fluid considered to be a red flag?
20% of normal term babies have meconium stained amniotic fluid but it is extremely rare to be present in a preterm baby => it is a red flag as it is likely an infection when there is a preterm baby with meconium stain
114
A pregnant febrile woman went into preterm labour at 30 weeks. The amniotic fluid was noted to be meconium stained. The baby developed respiratory distress and a transient pink, papular rash on the trunk. What is the likely organism?
Early onset sepsis + papular rash on trunk + discoloured amniotic fluid =>
Listeria
115
Any preterm labour is considered what until proven otherwise?
Infection
116
Early onset sepsis + papular rash on trunk + discoloured amniotic fluid. What is the most likely organism and what advise would you give a mother to avoid this?
Listeria (Same presentation as Group B strep but with discoloured amniotic fluid)
Avoid soft cheeses and pate during pregnancy
117
An ex 27/40 prem in NICU develops recurrent apnoeas and pallor on day 14 of life. What is the most likely organism?
Late onset sepsis + NICU => coag-ve staph, staph aureus
118
An ex 26/40 is now 25 days old. He had an initial 2 day course of penicillin and gentamicin for preterm delivery. Subsequently he was treated with 10 days of antibiotics for suspected necrotizing enterocolitis. He is now pale, quiet and is bleeding for a prolonged period after blood sampling. What is the likely organism?
Late onset sepsis + Necrotizing enterocolitis => Gram-ve bacilli from gut
119
What are the typical organisms that affect neonates with early onset sepsis?
Group B / E. coli /Listeria monocytogenes
120
Early onset sepsis. What is your empirical choice of AB?
benzylpenicillin + Gentamicin (+ cefotaxime -3rd gen if meningitis suspected)
121
Late onset sepsis. What is your empirical choice of AB?
Flucloxacillin + Gentamicin (+ cefotaxime -3rd gen if meningitis suspected)
122
What is your typical duration of treatment for non-complicated neonatal sepsis? What if meningitis suspected?
7-10 days normal
14-21 days if meningitis
123
What are the most common reasons for admission of term babies into NICU?
Respiratory distress
Infection
Hypoglycemia
Jaundice
Hypoxic Ischemic encephalopathy
124
What is the effect of surfactant deficiency? How is this prophylactically managed?
relevant in RDS, this leads to alveolar collapse and inadequate gas exchange. Managed by prophylactically giving glucocorticoids antenatally (also reduced intraventricular hemorrhage for some reason). Post-natally, we give surfactant through an Endotracheal or nasotracheal tube
125
What is being shown in this xray? Must explain through a systematic approach for 5/5
Diffuse granular or ground-glass appearance of the lungs.
It is so opaque that the borders of the heart is indistinct.
Tracheal tube is present in the image
126
What can low O2 sat (<91%) cause (1). How about high saturation (>95%) (1).
In terms of a diseases that the neonate can be predisposed to in these conditions
Low: necrotizing enterocolitis
High: retinopathy of prematurity
127
What is the most common cause of a "Bounding" pulse in a neonate?
Patent ductus arteriosis
128
What is significant in terms of feeding in neonates born <34 weeks gestation?
Suckling reflex is not fully formed yet => feeding must be via nasogastric tube.
129
Formula milk provides better balance of nutrients for the preterm baby especially the additional calories. What is the main advantage of feeding via breastmilk over formula?
Breast milk provides protection against infection (passive immunity). this is very important in the prevention of necrotizing enterocolitis!!!
130
What is the main reason for reduced bone strength and immunity in premature babies?
iron and IgG are usually transferred across the placenta during the third trimester and therefore preterm infants haven't been exposed to them for as long
131
What are the main findings of necrotizing enterocolitis on x-ray?
132
What color is vomit and meconium in necrotizing enterocolitis
green vomit
red/dark meconium
133
What are 3 major RFs for intraventricular hemorrhage? If not resolved what will this lead to
RDS - respiratory distress syndrome
Pneumothorax (caused by RDS)
Premature infants
May lead to hydrocephalus and even periventricular leukomalacia (spastic diplegia - cerebral palsy)
134
Come take a nice look at this!
and this!
135
Term baby has labored breathing and no signs of jaundice. What is the most likely diagnosis? What is a major risk factor for this?
Transient tachypnea of the newborn
This is RDS but for the term baby!!! Instead of surfactant, the issue here is that there is a delay in the resorption of lung liquid => C-section would be a major RF as the baby wouldn't go through the birth canal.
136
Aspiration, whether milk or meconium typically occurs during asphyxiation causing a gasp. What are RFs for aspiration?
Preterm infants
Resp distress (hard to eat properly when distressed)
Cleft palate
Neurodisability
137
What is DDH?
What is the spectrum of severity of the disorder?
Give 5 RFs for DDH
Which of these RFs would directly indicate an US regardless of clinical findings?
It is the partial or full dislocation of the femoral head due to failure of the acetabulum to fully develop
Severity: Dysplasia>subluxation>Dislocation
RFs: Female, oligohydramnios, family hx, breech delivery, multiple birth, neural tube defect, talipes
Fam hx and breech birth always get an US.
138
You perform Barlow and Ortolani's sign, whats next?
What is needed for diagnosis?
Galleazi's sign which is the difference in knee levels which is lower on the side of the dislocated hip.
Ultrasound is needed to diagnose. Can detect instability and dysplasia
139
20% of cases with DDH resolve spontaneously but 40-50% of untreated cases will have long-term dysplasia. What are these consequences (4)?
To prevent this what is the treatment for a
newborn
6 week old
4 month old
18 month old
Teenager/young adult
Abnormal gait
Osteoarthritis of hip joint => pain and early total hip replacement
Hip pain
Limitation of hip movement
newborn: Pavlik Harness x6/52
6 week old: Pavlik Harness x8/52
4 month old: Spica cast x4/12
18 month old: Triple osteotomy of acetabulum
Teenager/young adult: Gantz Osteotomy
140
What is a rare complication of the Pavlik harness?
1% avascular necrosis of the femoral head
141
What is the position of the foot in Talipes Equinovarus?
How would you treat a positional TEV
How would you treat a fixed congenital TEV
How long does it take for the deformity to fully be fixed via non-operative methods?
Inversion, adduction, plantar flexion (equinus)
Positional = physiotherapy
Fixed = physiotherapy +
Non-operative: Splinting/casting (can take up to 4 years)
Operative: Surgical correction
142
What is this?
Why would this occur?
Treatment?
Talipes calcaneovalgus which is the eversion and dorsiflexion of the foot.
This, like DDH (+familial ligamentous laxity in ddh) and TEV, occurs due to positioning in the uterus
Tx: physiotherapy to stretch out tibialis anterior
143
On average, how many kcals and protein does an infant need per day if they are
preterm
term
adult?
Preterm: 135 (4g) kcal/kg/day
Term: 100 (2g) kcal/kg/day
adult: 30 (1g) kcal/kg/day
144
What is the max acceptable percentage of their birth weight can be lost in the first week of life? Why is that? When do you expect the baby to regain the weight?
<10% birth weight
This is due to loss of water through the skin as well as the loss of remaining amniotic fluid
Should be regained within 10-14 days (faster if on formula)
145
What is the average gain of height in
first year
second year
third year
4th till puberty
first year = 25cm
second year = 10cm
third year = 7cm
4th till puberty = 5cm
146
What is the OFC?
What is the average gain/month in cm in the
first year
second year
First year = 1cm/month
Second year = 2cm/month
147
Baby Jack was born at 41 weeks in the Rotunda. Jack is just a few hours old and is well. Jack is with his mother on the postnatal ward. Jacks Mother is considering breastfeeding but is nervous and is asking for advice.
What advice would you give her?
What are the benefits (5) and negatives (5) of breastfeeding?
What support is available for Jack’s mother?
Advice:
exclusive breastfeeding is recommended up to 6 months of age by the WHO
Positives:
Nutrition and growth: Contains all the necessary parts of a complete diet
Immunity: Protects against allergies, eczema, diarrhoea, resp diseases, NEC, obesity and HTN
Maternal: Aids in bonding and attachment, allows uterus to return to original size, reduces risk of breast and ovarian cancer. Reduces risk of osteoporosis
Economic: Free and less hospital fees with the immunity
Negatives: !Unknown volume and intake!, risk of transmitted diseases, medications, and alcohol, deficient in vitamin D and K, may cause jaundice.
Supports: All HCP, Lactation consultants, family, local support groups and websites such as mychild.ie
148
After 2 days on the postnatal ward, Jack and his mother have been discharged home and Jack is being exclusively breastfed. The community midwife comes to review Jack when he is a few days old and notices that Jack is not being offered a vitamin supplement.
What vitamin supplement do you think this is?
Vitamin D (HSE suggests supplementing all infants with Vit D for first 12 months)
although vitamin K is another thing that breastmilk is deficient in (they usually would have received their IM injection of Vitamin K at birth
149
What are the 2 types of standard infant formula?
Whey Based (First infant formula) and Casein Based (Hungry baby)
150
What is the first infant formula?
What is the Protein whey:casein ratio similar to breastmilk?
What is the primary carb?
What makes up the majority of calories?
When is it suitable till? What happens after that?
Whey Based formula
60:40
Lactose
Fat (50-60%)
Suitable till 1 year before transitioning to Cow's milk
151
What is Casein based standard infant formula market as? Marketed for?
Whey to casein ratio similar to cow’s milk
A patient not meeting growth milestones presents to the OD would you suggest this formula?
Marketed as "hungry baby milk" for hungrier babies as casein increases satiety
(20:80)
No not recommended for faltering growth.
152
What is the difference between standard infant formula and Follow On formulas?
What advantages/disadvantages does it provide?
Made from modified cow's milk with extra protein, vitamins, and minerals compared to the others but offers no added benefit
153
What are all standard infant formulas made from? What is the concern?
Derived from cow's milk => be aware of cow milk PROTEIN allergy and advise mothers to look for rashes and blood in stools as a result.
154
What part of the cow's milk is most concerning for the allergy?
Protein
155
Who is indicated for Low Lactose Formula? Is it suitable for CMPA?
Suitable for lactose intolerance but not for CMPA
156
Who is indicated for comfort Formula? Is it suitable for CMPA?
Designed for babies with mild digestive problems such as reflux and constipation and includes prebiotics. Not suitable for CMPA
157
Who is indicated for Soya Formula? Is it suitable for CMPA?
Galactosemia babies (heel prick)
there is some allogenicity and cross reaction between it and cow protein therefore not completely recommended for cow protein
158
Jack is now 7 months old and Jack has a suspected cows milk protein allergy. He needs to change his infant formula. He was previously drinking a first infant formula.
Which infant formula would you suggest?
Low lactose infant formula
“Comfort” infant formula
Soya infant formula
Hydrolysed infant formula
Hydrolysed infant formula
159
What are the types of hydrolyzed protein formulas?
What are the indications to use these?
Breast milk, amino acids and extensively hydrolyzed
CMPA and malabsorption and intolerance as they are easier to absorb.
Note that Breast milk then extensively hydrolyzed and then amino acids. They should be used in this order.
160
What biochemical induces contractions of smooth muscle in the breast to secrete milk via the lactiferous ducts?
oxytocin
161
What are the inhibitors and stimulators of lactogenesis. State their role
Inhibitors:
Progesterone: Influences the growth of alveoli and lobes of the breast. It inhibits lactation during pregnancy and levels fall directly after delivery to allow for breastfeeding
Oestrogen: Stimulates development of ductal system. Note that high levels inhibit lactation during pregnancy
Human placental lactogen: (made by placenta) Pro-lactin effect =>growth and differentiation of alveoli but inhibits milk production
Stimulators: positive feedback loop with suckling
Prolactin: (secreted by ant. pituitary) Growth and differentiation of alveoli during pregnancy and stimulates milk production after delivery
Oxytocin: (secreted by post-pituitary) Promotes smooth muscle contraction to secrete milk via lactiferous ducts.
162
What are the stages of lactogenesis and what is included in each stage?
Stage 1: Colostrum is produced initially and is hormone dependent
Stage 2: 500mls/day of milk produced but is dependent on breast emptying to continue production
163
What is colostrum? When? How much? What is included?
Colostrum is the rich substance secreted in the first 48-72 hours after delivery. It is secreted in very small volumes but is high in protein and immunoglobulins
164
What are the essential vitamin supplementation given to all infants?
Vitamin K given IM at birth
Vitamin D given as supplementations until 1 year of age
165
When does the transition to breast milk usually occur? While feeding the baby, what they receive in the beginning of their feed is different than what is received at the end. highlight these differences.
Transitions from 72 hours of age
Foremilk = watery, rich in lactose and protein and important for hydration
Hindmilk = creamy, rich in fat and important for satiety
166
What are some reasons that milk production may be delayed? Give 4
C-section! - can delay by 24 hours
Inhibitors of prolactin: Postpartum hemorrhage, retained placenta (HPL), poor latch and suckling (positive feedback for prolactin and oestrogen)
Maternal RFs: Gestational diabetes, Polycystic ovaries, breast reduction/augmentation
167
What part of the breast is responsible for the majority of milk production/highest conc. of glandular tissue?
Anterior third.
168
Give an overview of the typical early neonatal feeding pattern up to Day 3 of life.
They must latch on within the first hour of life to improve milk supply.
By 4-6 hours of life the infant should be alert and have a strong suck.
They spend the next 24 hours sleepy
Day 2-3 involves cluster feeds overnight (constant feeding)
169
What is the reason behind the infants cluster feeding at night over the first few days of life?
Mother's prolactin levels are higher at night to optimize milk production leading to constant feeds
170
One of the major benefits of formula milk is the fact that it is easy to tell the intake. How do you know if the baby is getting enough breast milk?
Urine: Should pass 1 wet nappy first 24 hours which increases by 1/day => 2 on day 2 and 3 on day 3... up to 6-8 from day 5
Stool: Should pass 1 dirty nappy first 24 hours and meconium until day 3 where transitional stool kicks in but should transition to seedy stools by end of 1st week. On average, by day 4, 3-4 dirty nappies are made per day
Weight: Lose less than 10% of body weight and have it regained by end of 2 weeks
171
How do the bowel patterns differ in babies on breastmilk vs formula?
Gut transit time for
Breast = 40 minutes
Formula = 120 minutes
172
Read this
Thank you
173
How do you treat breastmilk jaundice? (simple)
exclude other pathologies and continue to breastfeed
174
A patient on the post-natal ward complained of cracked and dry nipples what would you give them?
Lanolin cream
175
When is Breastfeeding fully contraindicated?
Maternal HIV infection
Galactosemia (Give soya formula milk)
Mother receiving chemotherapy
176
Doctor, I’m taking medication X, can I breast feed my baby?
There are some medications you cannot take. I would check with the hospital pharmacy department and get back to you
177
Doctor, my baby has a tongue tie, can I breastfeed them?
What is the medical term?
ankyloglossia
Most babies with tongue tie can breastfeed successfully but if there are any feeding difficulties like nipple pain, mastitis, or inability to latch, we can intervene with surgery (frenulotomy)
178
What are the indications of a frenulotomy
If the infant has ankyloglossia, and there is a presence of any of the following, a frenulotomy is indicated
nipple pain
mastitis
inability to latch
179
Mary brings her baby back to the Rotunda for her Newborn Bloodspot Screen on day 5
Johnny is her first baby and she is exclusively breast feeding him
She tells the midwife that she is worried Johnny isn’t getting enough milk because he’s feeding all the time and she’s exhausted
What questions would you ask Mary about feeding?
What assessment tool will you use
Breast feeding assessment toolkit
