Neonatology Flashcards
APGAR
2 points = heart rate > 100, resp good crying, muscle tone active motion, reflex irritability- cough/sneeze, cry, color pink!
1 point = brady, slow irreg breath, some flexion, grimace, body pink w/ blue extremities
Exam
General observation, skin exam w/ lanugo in preemies, vernix caseosa (thick creamy in preterm infant), acrocyanosis pretty normal, cutis marmorata (mottling) b/c of vasomotor instability
Pallor can ban be asphyxia/shock/sepsis
Jaundice
always abnormal in first 24 hours
subsequently often seen during first few days after birth, no serious disease
Milia
small cysts around pilosebaceous cysts
Mongolian spots
dark blue bruise areas, lumbosacral/buttocks, no pathologic, hispanic, asian, AA
Pust
Benign transient rash dry superficial vesicles over dark macular base, often in AAs, different from viral infections like HSV and impetigo
Erythema toxicum neonatorum
Benign rash in first 72 hours after birth, fela bites on trunk/extrmeities (not palms and soles), 50% of ful-term infants, much less in preterm. eosinophils in lesions
Nevus simplex
salmon patch, most common vasc lesion, 30-40% of newborns, pink macular lesion on nabe of neck, upper eyelids, glabella (between eyebrows), nasolabial region
Nevus flammeus
Port wine stain, dilated capillary like vessles over face/trunk, maybe in area of opthalmic branch of trigem/maybe as part of Sturge-Weber (intracranial/spinal vasc malform)
Strawberry hemangiomas
Benign prolif vascular tumors in 10% infants, often noticed after birth, grown, then resolve in 18-24 months
Neonatal acne
0% of newborns, 1-2 weeks after life, never present at birth. no tx needed
Microcephaly
head circ below 10th percentile, familial, structural brain malform, chromosomal/malform syndromes, fas
Caput succedaneium
Diffuse edema of soft tissue, crosses cranial sutures, involving parietal/occiptial bones
Craniosynostosis
Premature fusion of cranial sututres which may result in abnormal shape and size of skull
Craniotabes
Soft areas of skull w/ ping-pong ball feel, maybe parietal bones, not related to rickets, usually disappear
Ears
assess maturity, should be firm w/ characteristic shape, look for preauricular tags/sinuses, and appropriate shape/location
Eyes
Abnormal red reflex= cataracts, glaucoma, retinoblastoma, severe chorioretinitis
Nose
examine immediately, rule out choanal atreasia (try to pass ng tube if suspct)
Clefts
lip/soft/hard palate inspect
submucous clefs in soft portion of the palate ruled out by digital palpation
clefts may be associated w/ other dysmorphic features
Micrognathia
small chin + cleft palate + glossoptosis, upper airway obstruction in Pierre Robin syndrome
Macroglassia
Beckwith-Wiedemann syndrome (hemihypertrophy visceromegaly, macroglossia), or hypothyroidism, or a mucopolysaccharoidosis)
Neonatal teeth
rare, usually in lower area of incisors
Epstein pearls
small white epidermoid mucoid cysts, disappear on own
Neck cysts
Lateral neck cycst = branchial cleft and cystic hygroma
Midline clefts/masses
Thyroglossal duct/goiter secondary to maternal antithyroid meds/transplacental passage of long-acting thyroid abs
Neonatal torticollis
asym shortening of SCM, from fixed position in utero or postnatal hematoma birth injury
Accessory nipples
along anterior axillary or midclav lines, may grow in presence of glandular tissue
Chest deformities
Perua pectus carinatum- bulging sternum, pectus excavatum benign. Chest assym from agenesis of pec muscle (poland syndrome), or rib formation are more serious
Respiratory neonate
Tachypnea is resp rate > 60 , deep resp, cyanosis, grunting, retractions
Preterms have short apneic bursts of 5-10 secs (periodic breathing)
Cardiac exam
want normal hr 95-180, rhythm, murmur
Dimished fem pulses = coarctation of aorta. Increased fem pulses- maybe PDA
Umbilical cord
2 arteries, one vein
No urachus
Only one artery may be renal issue
Diastasis recti
Sep of L and R of rectus abdominus, common in preemies and AA infants. Disappears eventually
Umbilical hernia
incomplete closure of umbilical ring, nbd, protrudes during crying/straining
Most close spontaneously/no tx required
Persist beyond 4-5 years, cause sx maybe surg tx
Persistent urachus
failure of duct to close, fistula between bladder/umbilicus, urine draining from umbilicus
Meconium issues
plug = Obstruction of left colon/rectum from dense dehydrated mec
ileus = inspissated (thick/dry), viscid, deficiency in panc enzymes, CF.
Usually passed meconium in 24 hours 90% of infants, 48 hours 99%
Abdominal masses
think hydronephrosis, multicystic kidneys, ovarian cysts, other lesions
if liver on wrong side, situs inversus, asplenia, or polyspleania syndrome
Anus
look for patency! Confirm with a catheter if needed
Female genitalia
hypertrophy clit from adrenal hyperplasia. Hydrometrocolpos = imperf hymen with retained vag secretions (cyst between labia at birth or lower ab mass during childhood)
Male genitalia
hypospadias = urethral meatus on ventral surface, no assoc of urinary issues
Epspadias = meatus on DORSAL sid, assoc w/ bladder extrophy
Hydrocele = swelling, isolated, can be associated w/ hernia
Cryptorchid- may be hernia, gu malform, hypospad, genetic..usuallly comes down by 12 mo
Extremities
Absense/hypoplasia of radius? TAR syndrome, Fanconi anemia or Holt Oram
Plydactly- isolated or syndrome
Edema - w/ hypoplastic toe nails = Turner and Noonan
Rocker bottom feet - trisomy 18
Exam hips for DD of hips
Spine exam
hair tufts/dimples? bifida
Pilonida dimple- identify base to rule out neuro-cutaneous tract
myelomeningocele- hernia of cord + meninges, obvious at birth
Preterm
less than 37 weeks, 7% of births,, many complication
Asphysxia, hypothermia, hypoglycemia, hypocalcemia, RDS, fluid/electro/indirect hyperbili, PDA, ICH, Nec enterc, infetions, Retino/prematurity, BPD, anemia
Post term
42 weeks, complications = fetal/nenoatal morbidiy/death (placental insuff, severe intrauterine asphyxia, meconium aspiration syndrome, polycythemia)
SGA/IUGR
below 5th percentile as a result of IUGR = SGA
Type I IUGR = early interference, chromo, fetal infec, maternal drugs, chronic illness
Type II- mlanut from 24-32, inadequate intrauterine space, placental insuff from maternal vasc disease, small placenta
Type III- late intrauterine malnut after 32 weeks, placental infarct, mama malnut, pre-eclampsia, hypoxemia
SGA issues- hypotherm/hypoglytcp/polycy hypocal, aspirate meconium, IUFD, hypermag
LGA
> 90th%ile different than just high birth weight (>4000g) b/c dep on gestational age
Why? maternal diabetes, Beckwith-Wiedemann, PRader-Willi, nesidioblastosis
Complications- hypoglycemia + polycythemia + congen malformations
Cyanosis
Blue, b/ unox hemoglobin or reduced hb more than 3g/dl in arterial or more than 5 in capillary blood
Always an emergency! Why? 5Ts tetralogy, transposition, truncus arteriosis, tricuspid atresia, total anomalous PV connection, OR cntral nervous system, hematologic, metabolic
Eval w/ h/p, chem, abg, cbc, cxr, maybe pa02, ekg, echo
100% oxygen test- do an abg after giving 100% (can tell if its cards or resp disease)
w/ heart disease and down pulm flow, 100% o2 increases pao2 only slightly, usually less than 10-15 mm HG. But w/ truncus arteriosus it increases more (to 150)
w/ lung disease- paO2 increases a lot!! except severel lung disease or pulm HTN w/ R to L shunt…
MGMT - o2, rapid correct things, maybe intubate/mech vent
Resp Distress Syndrome
Lack of surfactant! most surfact made after 30-32 weeks
Assess w/ L:S ration (greater than 2:1 is good), and presence of phosphatidylglycerol
Epid- .5% neonates, most freq cause of RDS, higher in white males
Risk = increases w/ low L;S, prematurity, previous preterm infant w/ RDS, DM, neonatal hypotherm/asphyxia
Clin fx- increasing resp distress, etc
Eval- CXR shows diffuse atelectasis w/ up density in both lungs, find ground glass appearnce, air bronchograms
MGMT = o2, CPAP, mech vent, exog surfactant
Compx = air leaks, IVH, sepsis, R-to-L shunt (acute)
BPD altering lung growht (need mech vent, persistent resp compromise, need o2 beyond 28 days, cxr)
Retinopathy of prematurity :(
PPHN (persistent pulm htn)
low blood flow to lungs after birth
Etio- perinatal asphyxia and MAS
R-to-L shunt through FO/DA w/ hypox
Clin fx- cyanosis to resp failure, pa02 down
eval- CXR variable, pulm asc markings down initially if not MAS/asphyxia. Do an echo to r/o congen heart
MGMT = prevent hyoxemia, mech vent, maybe ecmo, nitric oxide to pulm vasodil
Meconium Asp Syndrome
Meconium = first stools w/ water, desquam skin, bile salts, often passed when baby in distress, and after 42 weeks gest,
degree of MSAF (fluid stain) varies, if reaches distal airwas, bad!
Eval- hx of meconium at delivery/before, increased lung vol/diffuse patchy atelectasis/infiltrates w/ hyperinfla. Maybe pneumothor/mediastinum
PREVENT w/ suctioning perinum and direct suck trachea w/ endotrachintubation. O2 or mech vent, maybe ecmo
Apnea of Prematurity
15-20 sec respiratory pause, or any pause w/ bradycardia/cynosis/desat
Central apnea = no mvt/no airflow, obstructed = efforts but no airflow, mixed = combo! most frequent
Why?infection, lung disease, hyptoherm, hypertherm, hypogly, maternal drugs, drug withdrawal, anemia, gerd
idiopathic frequent, <28 ga, 85% have it! 25% at 33-34 weeks, clin fx- no cause, resolves on it own
MGMT= neutral thermal enviro, give caffeine or theophylline resp stim, vent as needed, CPAP/mech vent
Neonatal Jaundice
Yellow discolor, most frequently indirect that is PHYSIOLOGIC. visible when 5mg/dL or greater
Physiologic = benign/self-lim b/c increased bili load on hepatocytes and delayed hepatic enzyme GT function, peaks at 5-16 at 3-4 days of life, then decrease. In preemies, peak at 5-7 days, 10-20 days before decreasing
Nonphysio- indirect when conjugated is 15%. Direct = always pathologic
Ddx of indirect hyperbili
Physio, excessive production, impaired clearance, defective conjugation
Breastfeeding jaundice- first week of life w/ increased levels, suboptimal milk intake, dehydration, more stool, less excretion of bili in stool
Breast milk jaundice- after first week of life b/c of high B-glucoronidase and lipase, highest in second week, lower levels persist till 100 weeks
Ddx direct hyperbili
Obstruction of hepatobili tree, neonatal infection, metabolic disorders (galactosemia, hereditary fructose intol, tyrosinemia, alpha1-antitrypsin), CF
Eval/MGMT of jaundice
always eval if before 24 hours, bili rises 5-8 in one day, or rate of rise is .5mg/dl/hour!
Eval indirect w/ CBC, reticulocyte count/smear/sepsis eval
Direct- hepatic u/s, iral hep, biliary tree scan
MGMT = serial bili assess, obs/reassurance for physio. Phototherapy makes water-sol photoisomers of indirect bili, excreted better, exchange transfusion if real bad
Complications = kernicterus + encephalopathy in BASAL ganglia hippo brainstem. Choreoathetoid cp, hearing loss, opisthotonus (neck arch), seizure, oculomotor paralysis
Drug abusing momma
10-15% babies exposed, usually etoh, cocaine, pcp, narcotics
ob compx of abruption, precipitous delivery, ptl
Clin fx- jitteriness, hyperreflex, irritability, tremulousness, feeding intol, excessive wakeful. do tox sreen
mortal 3-10% :( asphyxia, congen anomalies, child abuse, SIDS
Esoph Atresia w/ TEF
1 in 2k, assoc w/ polyhydram, common type of esoph atresia = prox pouch + distal TEF
copious oropharyng secretions + up risk choking/asp pneumo
VACTER malfrom (heart anorectal, renal)
Eval/dx w/ og tube until meets resistance, do x-ray. Type III means air crossed through distal fisutal from trachea in stomach
Surg repair! close fistula and connect esoph
Congen Diaphragm hernia
Diaphram from 5-8 weeks gestation, abnormal deelopment => low hern of abdominal contents into thorax, mostly Left diaphragm,
1:4K, scaphoid abdomen, resp insuff from pulm hypoplasia, breath sounds decreased,b owel soudns in chest
CXR- no abdominal gas, medistinal shift to other side
DO NOT bag-mask b/c may distent bowel! Intubate + mech vent, correct hypox/acid/hypercarb, then surgically reduce
Compx = pphn, pneumothor, gi, prog related to defect size,hernia volume, duration of hernia..high mort even if diagnosed erly
Ab wall issues
10th week- midgut enters abdomen. if disturbed…
Omphalocele- 1 in 7k, central abdomen with peritoneal sac covering, often other heart issues, bw, choromosome
gastroschiss- congen fissure in ab wall, right paraumbilical, no true hernia sac, increased risk bowel damage
Intestinal obstruction
Functional or mechanial
Intestinal atresia in large/small bowel
Mec ileus = cf, ab distention, vom, no poop, look at xray with distention, no air-fluid, SOAP BUBBLE, manage w/ enemas, early tx
Malrot from volvulus w/ restricted circulation
Hirschprung- aganglionic, lack of caudal migration of ganglion cells, contraction of distal segment, 1 in 5k, more in males, rectlal biopsy, resect
NEC- preemies 8-10% get it! ab distent, tender, residual gastric contents, bloody stool, ab erhtyemia, can ==> DIC, tcp, death
Dx w/ xr- pneumatosis intestinalis, portal gas, give bowel rest, no feeds, decompression, abx, surg management w/ exlap if pneumoperitoneum! late compx = osbstruction, short gut, cholestasis
HYPOGLYCEMIA
below 40 mg/dl, b/c of insulin excess- from diabetic momma, nesidioblastosis (insulin producing tumor)
Dimished glucose supply from IUGR, preemies w/ poor gluconeo, stressed infants asphyxiated, inborn mets errors (galactosemia, herediatry fructose, aminoacidopathies, endocrine issues)
Fx- jittery, diaphor, feeding issue, tachy, hypotherm, hypotonia, seizures, MI
MGMT = feed more, iv glucose
Diabetic Momma (IDM)
pathophys- maternal hypergly -> fetal hypergly + HI, makes hepatic glucose uptake and glcogen synthesis up, accel lpogenesis, aug protein synthesis/macrosom
IDM large, visceromegaly, fatty, head and face disprop small, plethoric/round facies, usually LGA but could be SGA if severe diabetic vascular issues
Compx- perinatal difficulties, congen abnormalities (2-4x more), small left colon syndrome!
Polycythemia
Central venous hematocrit > 65%, epid in 2-4% babies at sea level, form increased EPO if placental insuff, or respond to hypox, or delayed cord clamping
Plethora, poor perfusion, cyanosis, poor feeding, lethargy, jitteriness, seizures, renal vein thrombo, mets acidosis, more chance of NEC
MGMT = partial exchange transfusion, replace with normal saline
