Neonatology Flashcards
Low birth weight
< 2500g
Very low birth weight
< 1500 g
Extremely low birth weight
< 1000 g
What do you need to look for in a baby with single artery in the cord?
Congenital anomalies
Consider renal US
4 conditions associated with a single umbilical artery
Trisomy 18
Renal anomalies
Cardiac anomalies
Twins
Conditions associated with
1. High AFP
2. Low AFP
- Neural tube defects, multiple gestation
- Trisomies 21, 13, and 18
Symptoms of hypermagensemia
(in babies whose mothers needed Mg Sulf for pre-eclampsia)
Resp depression
Hyporeflexia
Poor feeding
Failure to pass meconium
Lethargy
Flaccidity
What is POTTER syndrome?
Pulmonary hypoplasia
Oligohydramnios
Twisted skin (wrinkly)
Twisted face (Potter facies - low set ears, posteriorly rotated ears, micro/retrognathia, hypertelorism, flattened nose)
Extremity deformities (joint contractures, club hands/feet)
Renal agenesis (bilateral)
Causes of severe fetal bradycardia
Fetal hypoxia
Maternal fever
Hyperthyroidism
Maternal or fetal anemia
Drugs (atropine, hydroxyzine, ritodrine, terbutaline)
Chorioamnionitis
Fetal tachyarrhythmia
Prematurity
Causes of fetal tachycardia
Prolonged cord compression
Cord prolapse
Tetanic uterine contractions
Paracervical block
Epidural and spinal anesthesia
Maternal seizures
Rapid descent in the birth canal
Vigorous vaginal examination
APGAR scoring
Appearance (2=pink, 1=acro, 0=blue/pale)
Pulse (2= >100, 1=<100, 0= absent)
Grimace (2=cry/sneeze, 1=grimace, 0=nothing)
Activity (2=active, 1=flexion, 0=limp)
Respirations (2=good, crying, 1=slow, irregular, 0=absent)
What age do you need to give
1. Antenatal steroids
2. Antenatal Mg sulf
- < 35 (IVH, nec, lung development, mortality)
- < 34 (neuroprotection)
2 anti-epileptic medications that cause neural tube defects
Carbamazepine
Valproic acid
Neonatal effects of maternal lithium
Ebstein anomaly
Hypothyroid
Diabetes insipidus
What do babies born to mothers with lupus need
1. Antenatally
2. Postnatally
- Fetal echo in 2nd trimester, dex if heart block is present
- ECG at birth, echo if abnormal, repeat ECG by 12 months of age, CBC and platelets monitored until normal
What do you need to check in babies born to mothers with hyperthyroidism
TSH, T3, T4 on days 3-5 of life
Should be transient and resolve in 4-6 weeks
Do the umbilical arteries or veins close first?
Arteries then veins
Most common sequelae of NEC
Strictures
Well baby but maternal chorio, no other risk factors. What is needed?
Close observation for 24 hours
Vitals every 3-4 hours
+/- CBC at 4 hours
What does a baby born to a mom with known Hep B need?
Hep B vaccine and immunoglobulin within 12 hours of birth
Timing of
1. Early onset
2. Classic
3. Late onset
Vitamin K deficiency bleeding
- first 24 hours
- 2-7 days
- > 2 weeks
Causes of
1. Early onset
2. Classic
3. Late onset
Vitamin K deficiency bleeding
- Maternal drugs (phenytoin, warfarin, phenobarb)
- No prophylaxis, exclusive breastfeeding
- Conditions that cause malabsorption (CF, hepatitis, BA)
How to give PO vit K if parents are refusing IM
Dose at first feeding to be repeated at 2-4 weeks and 6-8 weeks
Still at risk for late onset bleeding
Are premature infants at higher or lower risk for NAS
Lower
Shorter duration of exposure, minimal fat stores, immature kidneys and liver, etc
How long does monitoring for NAS need to be
Minimum of 72 hours
Up to 120 hours if exposed to longer acting opioid
Congenital anomalies associated with IDM
Neural tube defects
Cardiac defects
Cadual regression (sacral agenesis or higher)
Intestinal atresia
Hydronephrosis
Cystic kidneys
Small left colon syndrome
Jitters vs seizures
Jitteriness can be ended by flexion or holding the limb
Jitters are typically induced by a stimulus
Seizures often involve eye deviation and autonomic changes
Group 4 classification of brachial plexus palsy
Complete flaccid paralysis AND
Horner’s syndrome (miosis, ptosis, anhidrosis)
When to refer to surgery team if incomplete recovery of brachial plexus palsy
1 month old
Investigations required for two vessel cord
None as long as no dysmorphisms or other red flags
What do to for infant born to mom with untreated
1. Gonorrhea
2. Chlamydia
- Take cultures, treat with CTX if well, FSWU if unwell
- Close monitoring, only treat if signs of infection occur
Why do premature babies need irradiated blood
To prevent GHD
Immature immune system is susceptible to GVHD
Electrolyte abnormalities in CAH
Hyponatremia
Hyperkalemia
Hypoglycemia
NAIT (neonatal alloimmune thrombocytopenia) cause and treatment
Maternal antibodies against the HPA-1a platelet antigen
Can lead to thrombocytopenia, hemorrhage, and death
Tx is washed maternal platelets (can also try IVIG or antigen-compatible donor platelets)
Which TORCH infections have
1. Microcephaly
2. Possible macrocephaly
- Rubella, CMV, Zika
- Toxo
T21 screening needed in first month of life (5)
Echo
Red reflex check
Hearing test
CBC
TSH
Enzyme involved in galactosemia
Deficiency of galactose 1 phosphate uridyl transferase
Neonatal autoimmune thrombocytopenia
Mom has ITP or SLE, platelets cross the placenta
Babies platelets then get destroyed in the spleen
Nadir is 3-5 days
Treat severe with IVIG
When should apnea of prematurity resolve
In extreme prems, should resolve by 44 weeks CGA
Most will resolve by 37 weeks though
Which cardiac defect has the pre ductal sats lower than post ductal
TGA
Hemoglobin threshold for recovering (“convalescent”) prem
75
When to investigate sacral dimples
Above gluteal folds (> 2.5 cm from anal verge)
> 5 mm
Associated with other cutaneous markers
Most common type of TEF and what it looks like
C
Proximal atresia
Distal esophagus connected to trachea
Complication of subcutaneous fat necrosis
Hypercalcemia
Must follow for several months
Side effect of corticosteroids for BPD (old cps statement)
Hypertrophic cardiomyopathy
Complications from UACs and UVCs
Thrombosis
Embolization
Spasm
Perforation
Renovascular HTN
Impaired circulation to abdomen or legs
UVCs: same plus cardiac perforation, portal vein thrombosis
How to manage spasm of UAVs
Remove line, try other artery
For persistent spasm = topical nitroglycerin paste, warm other leg
Galactosemia presentation and treatment
Typically in first few days of life after lactose meal
Jaundice, HSM, vomiting, FTT< hypoglycemia, seizures, lethargy, ID
Increased risk of E coli sepsis
Give soy based formula, no BF, Ca supps
How to tell between neonatal alloimmune thrombocytopenia and neonatal autoimmune thrombocytopenia
Look at maternal platelets
Allo (NAIT): maternal platelets normal
Auto: maternal platelets low
Sarnat scoring
Way to measure encephalopathy
1 = mild (hyperalert, mydriasis)
2 = moderate (lethargic or obtunded, hypotonic, miosis)
3 = severe (stuporous, flaccid, variable pupils)
Findings suggestive of congenital hypothyroidism
Feeding issues, choking spells
Sluggish, somnolent
Resp issues (large tongue)
Constipation
Open posterior fontanelle
Hypotonia
How to diagnose congenital hypothyroidism
If newborn screen is abnormal, do serum free T4 and TSH
Can then do a thyroid scan to prove absence of thyroid tissue or ectopic thyroid
Lab findings in thyroid-binding globulin deficiency
Total T4 is low but free T4 and TSH are normal
Clinically euthyroid, do not require treatment
X-linked, more in males (congenital hypothyroid more in females)
Lab findings of hyperinsulinemia
Low glucose
No ketones, FFAs
No acidosis
Elevated C peptide
Inappropriate/very quick response to glucagon
How to manage
Asymptomatic with glucose < 1.8 or unwell/symptomatic from hypoglycemia
IV glucose
Can give D10W bolus of 2 mL/kg over 15 mins if symptomatic, or 40% dextrose gel (same glucose)
Infusion start at 80 mL/kg/day
What is a pass/fail for CCHD screening
Pass: 95% or higher in right hand OR foot, AND 3% or less difference
Fail: Any limb < 90%
How long to screen
1. At risk
2. LGA/IDM
3. SGA/prem
infants for glucose?
- At 2 hours, every 3-6 hours
- 12 hours
- 24 hours
Initial PPV settings in NRP
PIP 20-25
PEEP 5
Flow 10 L/min
Rate 40-60
FiO2 21% if > 35 weeks, 21-30% if < 35 weeks
RBC transfusion threshold on and off respiratory support for ages
1. Week 1
2. Week 2
3. Week 3 or older
- ON: 115, OFF: 100
- ON: 100, OFF: 85
- ON: 85, OFF: 75
How long to monitor infants for NOWS/NAS
72, up to 120 hours if long acting opioid
How to manage
1. Well infants with first glucose < 2.6
2. Next low (< 2.6 but 1.8 or higher)
- Dextrose gel and breastfeed OR breastfeed plus 5 mL/kg feed
- Dextrose gel AND feed 5mL/kg AND breastfeed OR feed 8mL/kg AND breastfeed
Signs of PPHN
Severe cyanosis out of proportion to CXR findings (normal, can see reduced pulmonary markings)
Respiratory distress
Usually term or post term infants
Pre > post sat differentiation, shunting through PDA
Neonatal thyrotoxicosis labs and management
High total T4, free T4, T3, and TRAbs
Low TSH
Maternal antibody level determines severity, not TSH/T4
Resolves over 3-12 weeks
Can use methimazole, iodine, or propranolol
Erbs palsy vs extended Erb’s palsy vs Klumpke’s palsy
Erbs: C5/6 (arm positioning)
Extended: C5-7 (arm and hand)
Klumpke’s: C7-T1 (claw hand)
When do infants <32 weeks need head imaging
HUS at days 4-7 of life
Repeat 4-6 weeks post birth
Term imaging routinely for babies born < 26 weeks
When do infants 32- 36+6 weeks get head imaging
Only if they have additional risk factors (complicated course, microcephaly, complicated monochorionic twin preg)
Then: HUS at 4-7 days, repeat 4-6 weeks if first image abnormal
Asymmetric crying facies
Same as congenital unilateral lower lip palsy
Unilateral mouth droop during crying (symmetric forehead movement, nasolabial folds, eye opening)
Can be associated with CV anomalies (do echo)
Can be associated with genetic syndromes - often should screen for DiGeorge
