neonatology Flashcards
What is primary vs secondary apnea?
Primary is reversed with tactile stimulation but secondary requires positive pressure ventilation
What are the 5 basic causes of apnea?
Metabolic, infectious, neurological, cardiac and Gi
What is the diagnosis in a healthy newborn with respirations>60, retractions and grunting but normal CXR?
Transient tachypnea of the newborn
Newborn had increased anion gap metabolic acidosis, thrombocytopenia, high serum ammonia and elevated urine ketones, what is the likely diagnosis?
Organic acidemias
Newborn with high ammonia, high PT/PTT and serum glutamic oxaloacetic transaminase who presents with respiratory alkalosis?
Citrullinemia
What could be the cause of elevated AFP?
RAIN= renal disease, abdominal wall defects, incorrect dates /multiple pregnancy and neuro defects (anencephaly or spina bifida)
Low AFP is associated with what?
Trisomy 21 and 18
What is a measure of fetal autonomic nervous system integrity?
Non stress test
What measures uteroplacental insufficiency and tolerance of labor?
Stress test
What is included in the biophysical profile?
Non stress test + ultrasound for fetal movement, HR, breathing, tone and amniotic fluid
What is the result of deficient surfactant in alveolar lining?
Rds
What is the diagnosis and what should you do of the fetus has HR>240?
Svt- Give anti arrhythmic to mother to avoid congestive Heart failure and hydrops
What condition causes X-ray findings of granular lung opacification and air bronchograms? What is the classic description on chest xray
Rds - ground glass appearance
What are symptoms or rds?
Respiratory distress in the newborn. Cyanosis is possible
How can you distinguish RDS from pneumonia in a newborn ?
Calculate ratio of bands to neutrophils. If >0.2, think sepsis !
What 6 coexisting conditions can worsen RDS?
PDA Hypoglycemia Hypocalcemia Anemia Acidosis Hyperbili
What can occur in a patient with RDS and hyperbilirubinemia?
Threshold for kernicterus is lower
What 3 factors increase the risk for RDS?
Diabetes, c sections, birth asphyxia
What 2 factors decrease the risk for RDS?
Prolonged rupture of membranes, prenatal steroids
What test can predict the risk of RDS?
L:S ratio > 2 suggests a low risk for RDS
When is mechanical ventilation indicated in a patient with RDS?
Ph <7.2 and pCo2 > 60
What 3 things does administration of surfactant cause in the lungs?
Decreased oxygen requirements, reduces inspiratory pressure and improved lung compliance
What is pulmonary interstitial emphysema ?
Air leak into the interstitium due to mechanical ventilation – leads to PTX
What is the goal po2 in an infant with RDS?
50-70
Patients on prolonged ventilator support are at risk for what and why?
Bronchopulmonary dysplasia due to prolonged oxygen exposure and barotrauma
What are the indications for ECMO?
Infant with reversible lung disease for less than 14 days and failure of other methods. Pt can not have intracranial bleed or congenital heart disease
What is the treatment of BPD and what is a side effect of this treatment?
Diuretics - can increase risk of hypocalcemia
What is found on X-ray in a newborn with BPD?
Diffuse opacities, cystic areas with streaky infiltrates and ground glass appearance
What is the name of a chronic lung disease of the newborn that is not associated with prolonged ventilator use?
Wilson Mikity syndrome
What is the difference between BPD and Wilson Mikity syndrome ?
BPD has inflammatory changes in lung tissues but MKS does not
What is the empiric treatment of neonatal sepsis?
Ampicillin and gentamicin
What bacteria should you be concerned about if infants mother had flu like illness during pregnancy?
Listeria
When toxoplasmosis infection occurs early in pregnancy, what is the risk and severity of infant infection?
Lower chance of infection but more severe disease
What are some symptoms of toxoplasmosis in a newborn?
Microcephaly, hydrocephaly, chorioretinitis, cerebral calcifications, jaundice and hepatosplenomegaly
How is diagnosis of toxoplasmosis made?
Immunofluorescence
What is the best imaging study for toxoplasmosis?
MRI to diagnose encephalitis if ring enhancing lesions
What is the difference between cmv and toxo when looking at MRI?
Cmv calcifications are peri ventricular but with toxoplasmosis are diffuse
If asymptomatic at birth, what later signs can toxoplasmosis cause?
Deafness, blindness, seizures, MR
What is the treatment for toxoplasmosis?
Pyrimethamine, sulfadiazine and folinic acid
What two palsied are associated with clavicle fracture in the newborn?
Erbs and phrenic nerve
What is the injury associated with the arm internally rotated and addicted with flexed wrist?
Erbs palsy, c5-7 Injury
What should you be concerned about if clavicle fracture leads to respiratory distress?
Phrenic nerve palsy
What is the injury associated with claw hand?
Klumpke palsy at C8 T1
What is the difference between klumpke and Erb palsy in relation to reflexes?
In Erb palsy the grasp reflex is intact but is lost in klumpke
Which palsy can be associated with Horner syndrome?
Klumpke
What two maternal conditions can cause neonatal heart block?
Lupus and sjogren
What do you do if you find a newborn with a single umbilical artery?
Renal ultrasound
What are the common complications of umbilical artery and vein catheter placement?
NEO CATH = Necrosis , embolize ruin (liver), omphalitis, compromised femoral pulse, accidental hemorrhage, traumatic perforation thrombosis and hepatic (dysfunction)
When should the umbilical cord fall of and what is the concern if it does not?
Should fall off by 2 weeks ; if attached past 1 month, consider leukocyte adhesion deficiency
When is a baby considered SGA?
In the lower 10th percentile for gestational age
When is a baby considered LGA?
In the upper 10th percentile for weight for gestational age
What is considered a full term baby?
38-42 weeks
What is seen in a post term newborn?
Dry peeling skin, long fingernails, decreased lanugo, ears with strong recoil
What is the most common cause of fetal demise?
Chromosomal abnormalities and congenital malformations
What is a normal scalp pH?
7.25 or higher
What are some causes of delayed passage of meconium?
Meconium plug syndrome
Hirschsprung
Imperforate anus
For the purpose of boards, when do you intubate a meconium baby?
If baby is floppy, suction and intubate
What is the presentation and How do you diagnose Hirschsprung’s disease?
No meconium passage after 48 hours or abdominal distention with diarrhea may be present - diagnosis with biopsy
What condition is Hirschsprung’s disease associated with?
Down’s syndrome
What is meconium ileus associated with?
Cystic fibrosis
What occurs in the affected segment of bowel with Hirschsprung’s ?
The recto-sigmoid colon is contracted and the region proximal is distended
What do you do in an infant with bilateral ankle clonus?
Nothing - can be normal
How much pressure is needed to inflate the lungs for the first breath?
60 mmHg
What should you do in the presence of bradycardia and impaired ventilators efforts in a newborn?
Positive pressure ventilation
How should apgars be used to determine use of CPR?
Do NOT wait for one minute apgar scores to decide to start CPR !
What is the normal fetal placental weight ratio of a term baby? How should it change during pregnancy?
6.5 - 7
The ratio should increase progressively - if not, think of decreased fetal growth
When should chest compressions be started in a newborn?
If HR <60 despite adequate ventilation
How should chest compressions be delivered in a neonate?
100 per minute with one ventilation per 3 compressions
What should you look out for in a newborn who was born at home??
Hemorrhage
Sepsis
Vit K deficiency and bleeding
What is the difference between silver nitrate and erythromycin ophthalmic eye ointment
Silver nitrate only protects against Gonorrhea. Erythromycin is needed to prevent chlamydia infection
What do you do for an anuric infant?
Evaluate abdomen and genitals Make sure adequate fluid intake Cath urine specimen Bun/creatinine Renal ultrasound
What is a very low birth weight infant?
Infant <1500 g
What is an appropriate arterial BP of a preterm baby?
Should not be less than the corrected gestational age
What must be done for every VLBW infant with no obvious cause for preterm birth?
Septic workup + amp and gent
What type of fluid is appropriate for VLBW infants?
D10
What bone disease is at increased risk in premies and why?
Rickets because of inadequate intake and absorption of calcium and phosphorus
What is the caloric requirement for a premie?
120 kcal/kg/day
What are some classic signs of NEC?
Bloody stool, abdominal wall erythema and thrombocytopenia
What is the classic X-ray finding in NEC?
Air in the biliary tree & pneumatosis intestinalis
What is the long term complication of NEC?
Intestinal strictures
How should NEC be managed?
NG tube to LIS, IVF, antibiotics
Possible surgical intervention
NPO x 3 weeks
Up to What bilirubin level is considered normal in the first 24 hours in a full term newborn?
12.4
Up to what age can anemia of ABO or Rh incompatibility be seen?
Up to 2 months
Which type of blood incompatibility can occur in a first born child?
ABO or
Rh only if previous miscarriage
What jaundice occurs in the first few days of life due to dehydration?
Breast feeding jaundice
In which type of jaundice should newborns not be given breast milk?
Breast milk jaundice
When is phototherapy contraindicated?
Elevated direct bili or family hx of light sensitive porphyria
What causes bronze baby syndrome ?
Phototherapy in a child with high conjugated (direct) bilirubin
What should you do in a newborn <24 hours old with jaundice and why ?
Total and direct bili levels - elevated bili in first 24 hours is never normal
What risk factors DECREASE incidence of neonatal jaundice?
Maternal heroin, smoking, alcohol and phenobarbital
What types of endocrine disorders can cause jaundice?
Hypothyroid and hypopituitary
What are two syndromes that can cause jaundice?
Gilbert disease and Lucy Driscoll syndrome
What 4 causes of increased enterohepatic Circulation can lead to jaundice?
Obstruction, pyloric stenosis, meconium ileus, Hirschsprung’s
What are 4 causes of jaundice that lead to elevated direct and indirect bili?
Galactosemia, tyrosinosis, hypermethioninemia and cystic fibrosis
What medication can cause high bilirubin and why?
Sulfonamides - compete for space on albumin
What are 4 complications of exchange transfusion ?
Elevated potassium, thrombocytopenia, hypocalcemia and hypovolemia
If dextrostix accucheck read is abnormal, what is the next step?
Verify with serum glucose
What is the definition of hypoglycemia in premies and full term newborns ?
<25 in a premie
<35 in full term newborn
What is the most important initial step for management of very low birth weight infant?
Maintaining euglycemia and body temp
How would you treat hypoglycemia in a newborn?
2-3 ml/kg of D10 bolus or glucagon IM
What abnormalities should you be concerned about in a newborn born to a mother treated with tocolytics? Why?
Hypoglycemia ( tocolytics stimulate fetal insulin )
What are some classic exam findings in a newborn with hypoglycemia ?
Jitteriness, lethargy, apnea,
Cyanosis, seizures
Tachypnea
What are 3 common complications seen in an LGA baby?
Hypoglycemia , polycythemia and hypo plastic left colon
What EKG finding may indicate hypocalcemia?
Prolonged QT
What are two classic signs of hypocalcemia?
Chvosteks - facial twitching on tapping
Trousseau - carpopedal spasm
What may be the cause of late onset hypocalcemia on an infant?
Giving cows milk causes high phosphate load on the kidneys
What is the definition of hypocalcemia?
Ionized Ca < 4.5 or
Total Ca < 8.5
What problem should you think of in an infant born to a mother on mag sulfate? Why?
Hypocalcemia - high mag will decrease PTH secretion
How do you treat hypocalcemia ?
Increase calcium in IV or with calcium gluconate
What test will detect fetal cells in mothers blood?
Kleihauer Betke
What percentage of hgb is fetal hgb at birth?
50%
What hgb level is considered to be “anemia” in a full term infant?
< 13
What meets the criteria for polycythemia ?
Central venous hct >65 (not valid in heelstick)
What are the complications of having polycythemia in a newborn?
Hypoglycemia, hyperbilirubinemia and thrombocytopenia
When and what is the treatment for polycythemia ?
HCT >70 needs partial exchange transfusion
What is the apt test?
Test for maternal blood in neonatal gastric aspirate
What is a common cause of thrombocytopenia in a newborn?
Maternal ITP
When do you see early onset hemorrhage in a newborn?
Within 3 days in Breast fed babies not given vitamin K
What 3 medications may increase risk of hemorrhagic disease in the newborn?
Anticoagulants
Anticonvulsants
Antibiotics (tb meds, cephalosporins and quinolones)
When should you give oral vitamin k in a newborn?
Never - it is insufficient for preventing hemorrhagic disease
What test would you order in a newborn with protein and blood in the urine?
Renal ultrasound - look for ATN
What is the cause and prognosis of a newborn with a seizure in the first 24 hours of life?
Birth asphyxia - likely to NOT have long term neuro developmental sequelae
What is the initial drug of choice in a newborn with seizure ?
Phenobarbital
What causes hyperalimentation induced cholestasis?
Protein intake > 2g/kg/day
What medication can be used to treat hyperalimentation induced cholestasis?
Phenobarbital to stimulate bile secretion and decrease serum bili level
What are some syndromes associated with cleft lip/palate?
Crouzon syndrome, apert and treacher Collins
What are 4 common findings in beckwith wiedemann syndrome?
Omphalocele
Macroglossia
Macrosomia
Hypoglycemia
How is gastroschisis different than omphalocele?
It is not covered by a membrane and only involves intestinal contents because it is near the umbilicus (not through the umbilicus like omphalocele)
What is the most important goal in management of gastroschisis ?
Keep bowel moist!
Which is associated with chromosomal defect, omphalocele or gastroschisis ?
Omphalocele
What syndrome is TE fistula commonly associated with?
VACTERL
What should you think in a patient with scaphoid abdomen?
Diaphragmatic hernia
How do you manage TE fistula?
Protect the airway from secretions with auctioning and elevating the head
What is an imperforate anus with a high obstruction?
Fistula connects into vagina or urinary tract
What are grades 1-4 of IVH?
Grade 1 = germinal matrix
Grade 2 = IVH without dilation
Grade 3 = IVH with dilation
Grade 4 = IVH plus parenchymal involvement
What is soft putting that crosses suture lines?
Caput succedaneum
what is a firm bulge on the scalp that does not cross suture lines?
Ceohalohematoma
How do you image an unstable vs stable newborn with suspected IVH?
Ultrasound if unstable
CT if stable
What May terbutaline increase the risk for in a newborn?
Hyperinsulinemia and hypoglycemia
What are 4 neonatal complications associated with maternal cocaine use?
Placental abruption
Cerebral infarction
Limb anomalies
Urogenital defects
What symptoms are associated with alcohol withdrawal?
Hyperactivity, irritability and hypoglycemia
What 4 symptoms are associated with barbiturate withdrawal?
Hyperactivity
Hyperphagia
Irritability
Poor suck swallow
Cigarette smoking is associated with increased risk for what?
Low birthweight
Miscarriage
Prematurity
Cleft lip/palate
What 6 symptoms are associated with opioid withdrawal ?
Irritability Tremors Hypertonic Diarrhea/vomiting Feeding difficulties Seizures
Of the following choices, What is the most important thing to do within the first hour of life?
A. Vitamin K
B. Erythromycin eye drops
C. Skin to skin contact w mother
Skin to skin contact
You are presented with a 2 month old infant who “cries continuously”. Mother reports 1 hour of crying at 1 am and then 2 hours of crying at 5 am. What should you do?
Reassurance.
Crying of up to 3 hours per day is normal in infants >6 weeks old
