Neonatology Flashcards
1
Q
How do you evaluate general appearance in a newborn?
A
-
Careful observation
- Spontaneous activity, passive muscle tone, respirations, abnormal signs (cyanosis, intercostal muscle retractions, meconium staining)
-
Apgar scores
- Assessment of intrapartum stress & neurologic depression at birth
- 1-5 min after birth
- Continue every 5 min until final score _>_7
2
Q
What are the 5 components of the Apgars?
A
- Heart rate
- Respirations
- Muscle tone
- Reflex irritability
- Color
3
Q
How is the Apgars scored?
- heart rate
- respirations
- muscle tone
- reflex irritability
- color
A
-
heart rate
- 0 - absent
- 1 - <100/min
- 2 - >100/min
-
respirations
- 0 - absent
- 1 - slow, irregular
- 2 - good, crying
-
muscle tone
- 0 - limp
- 1 - some flexion
- 2 - active motion
-
reflex irritability (catheter in nose)
- 0 - no response
- 1 - grimace
- 2 - cough, sneeze, cry
-
color
- 0 - blue, pale
- 1 - body pink, blue extremities
- 2 - completely pink
4
Q
What are the 13 variations in the newborn skin exam?
A
- Lanugo
- Vernix caseosa
- Color
- Pallor
- Jaundice
- Milia
- Mongolian spots
- Pustular melanosis
- Erythema toxicum neonatorum
- Nevus simplex
- Nevus flammeus
- Strawberry hemangiomas
- Neonatal acne
5
Q
Lanugo
A
thin hair that covers the skin of preterm infants
minimally present in term infants
6
Q
Vernix caseosa
A
- Thick, white, creamy material in term infants
- Covers large areas of the skin in preterm infants
- Usually absent in postterm infants
7
Q
Describe color in newborns
What are some signs of instability?
A
- Pink a few hrs after birth
-
Acrocyanosis
- Cyanosis of the hands & feet
- First 48-72 hrs
- Cold infant: through 1st mo of life
-
Cutis marmorata
- Mottling of the skin w/ venous prominence
- Intermittent signs of vasomotor instability
8
Q
Pallor
A
neonatal asphyxia, shock, sepsis, anemia
9
Q
Jaundice
A
- Abnormal w/i first 24 hrs of birth
- Frequently seen during first few days after birth
- Not associated w/ serious disease
10
Q
Milia
A
- Very small cysts formed around the pilosebaceous follicles
- Tiny, whitish papules
- Nose, cheeks, forehead, chin
- Disappear w/i a few wks, no treatment
11
Q
Mongolian spots
A
- Dark blue hyperpigmented macules
- Lumbosacral area & buttocks
- No pathologic significance
- Hispanic, Asian, African American infants
12
Q
Pustular melanosis
A
- Benign transient rash
- Small, dry superficial vesicles
- Dark macular base
- African American infants
- Differentiation from HSV & impetigo
13
Q
Erythema toxicum neonatorum
A
- Benign rash
- First 72 hrs after birth
-
Erythematous macules, papules, pustules
- “flea bites”
- Trunk, extremities (not palms or soles)
- 50% of full-term infants
- Lesions filled w/ eosinophils
- No treatment required
14
Q
Nevus simplex
A
- “salmon patch” or telangiectatic nevus
- Most common vascular lesion of infancy
- 30-40% of newborns
-
Pink macular lesion
- Nape of neck (“stork bite”)
- Upper eyelids
- Glabella
- Nasolabial region
- Often transient
15
Q
Nevus flammeus
A
- “port wine stain”
- Congenital vascular malformation
- Dilated capillary-like vessels
- Capillary hemangioma
- Face or trunk
- Darker w/ increasing post-natal age
-
Sturge-Weber syndrome
- Area of opthalmic branch of trigeminal nerve (V1)
- Intracranial or spinal vascular malformations, seizures, intracranial calcifications
16
Q
Strawberry hemangiomas
A
- Benign proliferative vascular tumors
- 10% of infants
- First noticed a few days after birth
- Increase in size after birth
- Resolve w/i 18-24 mo
- Compromise airway or vision –> intervention
17
Q
Neonatal acne
A
- 20% of newborns
- Appears after 1-2 wks of life
- Virtually never present at birth
- Lesions are comeones
- Inflammatory pustules & papules may be present
- No treatment necessary
18
Q
What are 5 examples of newborn head abnormalities?
A
- Microcephaly
- Caput succedaneum
- Cephalohematomas
- Craniosynostosis
- Craniotabes
19
Q
Microcephaly
A
- Head circumference below 10th %ile
- Causes
- Familial
- Structural brain malformations
- Chromosomal & malformation syndromes
- Congenital infections (CMV, toxo)
- Fetal alcohol syndrome
20
Q
Caput succedaneum
A
- Diffuse edema or swelling of soft tissue of scalp
- Crosses cranial sutures & the midline
21
Q
Cephalohematomas
A
- Subperiosteal hemorrhages
- Secondary to birth trauma
- Confined & limited by cranial sutures
- Involve parietal or occipital bones
22
Q
Craniosynostosis
A
- Premature fusion of the cranial sutures
- Abnormal shape & size of skull
23
Q
Craniotabes
A
- Soft areas of the skull w/ “ping-pong ball” feel
- Occur in the parietal bones
- Not related to rickets
- Disappear w/i wks or mo
24
Q
How are ears inspected in a newborn?
A
- Must be examined to assess maturity
- Should be firm & have characteristic shape
- Inspection for preauricular tags or sinuses
- Inspection for appropriate shape & location
25
What does an **abnormal red reflex** of the retina indicate?
* Cataracts
* Glaucoma
* Retinoblastoma
* Severe chorioretinitis
26
The nose should be examined immediately to rule out.......
* Unilateral or bilateral choanal atresia
* Exclude by passing NG tube through nostrils
27
What are 5 newborn anomalies of the mouth?
* Clefts
* Micrognathia
* Macroglossia
* Neonatal teeth
* Epstein pearls
28
What types of clefts can be present in the newborn?
* Clefts of the lip & soft/hard palates
* Inspection
* Submucous clefts in the soft portion of the palate
* Digital palpation
29
What is micrognathia?
* Small chin
* **Pierre Robin syndrome**
* Micrognathia
* Cleft palate
* Glossoptosis: downward displacement or retraction of the tongue
* Obstruction of the upper airway
30
What can macroglossia suggest?
* Beckwith-Wiedemann syndrome
* Hemi-hypertrophy
* Visceromegaly
* Macroglossia
* Hypothyroidism
* Mucopolysaccharidosis
31
Where are neonatal teeth typically seen?
Area of the lower incisors
32
Epstein pearls
* Small, white epidermoid-mucoid cysts
* Found on the hard palate
* Disappear w/i a few wks
33
What are 5 abnormalities that can be found on neck & clavicle examination?
* Lateral neck cysts/sinuses
* Branchial cleft cysts
* Cystic hydromas
* Midline clefts or masses
* Neonatal torticollis
* Edema & webbing of the neck
* Turner syndrome
* Clavicles (rule out fractures)
34
What are midline clefts/masses caused by?
* Cysts of the thyroglossal duct
* Goiter
* Maternal antithyroid medication
* Transplacental passage of long-acting thyroid-stimulating antibodies
35
Neonatal torticollis
* Asymmetric shortening of the SCM
* Results from being in a fixed position in utero
* Postnatal hematoma from birth injury
36
Accessory nipples
* Anterior axillary or midclavicular lines
* May later grow due to glandular tissue
37
What are some examples of congenital deformities of the chest?
* **Pectus carinatum**
* Prominent & bulging sternum
* Benign
* **Pectus excavatum**
* Depressed sternum
* Benign
* **Chest asymmetry**
* Absence of formation of ribs
* More serious
* **Poland syndrome**
* Agenesis of the pectoralis muscle
* More serious
38
How is respiratory distress diagnosed?
* Tachypnea (RR \>60 breaths/min)
* Deep respirations
* Cyanosis
* Respiratory gruntint
* Intercostal or sternal retractions
* Preterm infants: **periodic breathing**
* Short, apneic bursts
* \<5-10 seconds
* No clinical significance
39
What is the cardiac exam in a newborn?
* Heart rate
* Normal: 95-180 beats/min
* Varies during feeding, sleep, crying
* Rhythm
* Assessment of murmurs & peripheral pulses
* **Diminished femoral pulses**
* Coarctation of the aorta
* **Increased femoral pulses**
* Patent ductus arteriosus
40
What are 6 possible anomalies on **abdominal** examination of the newborn?
* Diastasis recti
* Umbilical hernia
* Omphalocele & gastroschisis
* Persistent urachus
* Meconium plug, meconium ileus
* Abdominal mass
41
The **umbilical cord** should be inspected to confirm the presence of _______ & _______ and the absence of the \_\_\_\_\_\_\_\_.
2 arteries & 2 vein
absence of a urachus
1 umbilical artery = congenital renal anomalies
42
What is **Diastasis recti**?
* **Separation** of the L & R side of the rectus abdominus at the midline of the abdomen
* **Premature & African American infants**
* No treatment necessary
* Diastasis recti disappears
* Rectus abdominis muscles grow
43
What is an **umbilical hernia**?
* **Incomplete closure of the umbilical ring**
* Soft swelling beneath skin around umbilicus
* Protrudes during _crying_ or _straining_
* African American children
* No treatment, closes spontaneously
* Persistance \>4-5 YO
* Surgery
44
What is a **persistent urachus**?
* Complete failure of the urachal duct to close
* Fistula btwn bladder & umbilicus
* Urine drains from umbilicus (pressure)
45
Meconium plug vs. meconium ileus
* **Meconium plug**
* Obstruction of the L colon & rectum
* Dense dehydrated meconium
* **Meconium ileus**
* Occlusion of the distal ileum
* Inspissated (thick/dry) & viscid meconium
* Deficiency of pancreatic enzymes
* High protein content of intestinal secretions
* Manifestations of **cystic fibrosis**
* Delay in elimination: abd distension
* Normal meconium w/i 24 hrs of birth (90%)
* w/i 48 hrs (99%)
46
What can abdominal masses be caused by?
* **Hydronephrosis (most common)**
* Multicystic kidneys
* Ovarian cysts
* Liver on L side
* Situs inversus
* Asplenia
* Polysplenia syndrome
47
The anus must be examined for......
* Patency
* Soft rubber catheter
* Rectal thermometer
* Imperforate anus
48
What are 2 newborn abnormalities of female genitalia?
* Hypertrophied clitoris
* Hydrometrocolpos
49
What causes a hypertrophied clitoris?
* Virilization from androgen excess
* Virilizing adrenal hyperplasia
* Premature infants
50
What causes hydrometrocolpos?
* **Imperforate hymen w/ retention of vaginal secretions**
* Small cyst btwn labia at the time of birth [OR]
* Lower midline abdominal mass during childhood
51
What are 4 newborn abnormalities of male genitalia?
* Hypospadias
* Epispadias
* Hydrocele
* Cryptorchidism
52
What is hypospadias?
* Urethral meatus on the **ventral surface** of the penis in varying locations along the shaft
* _Not_ associated w/ increased incidence of associated urinary malformations
53
What is epispadias?
* Urethral meatus located on the **dorsal surface** of the penis
* Often associated w/ **bladder extrophy** (bladder protrusion from the abdominal wall w/ exposure of its mucosa)
54
What is a hydrocele?
* Scrotal swelling caused by _fluid accumulation in the tunica vaginalis_ adjacent to the testis
* Isolated hydroceles do not cause clinical problems usually (resolve spontaneously)
* Some hydroceles associated w/ **inguinal hernias**
55
What is cryptorchidism?
* **Undescended testes**
* Associated with:
* Inguinal hernia
* GU malformations
* Hypospadias
* Genetic syndromes
* Most males have testes descend spontaneously before 12 mo
* Testes that don't descend by this age are predisposed to _future malignancy_
56
Absence or hypoplasia of the radius may be associated with......
* TAR syndrome
* Thrombocytopenia Absent Radii
* Fanconi anemia
* Holt-Oram syndrome
57
**Polydactyly** may occur as an isolated anomaly or as part of a \_\_\_\_\_\_\_\_.
genetic syndrome
58
Edema of the feet w/ hypoplasia nails is characteristic of .......
Turner & Noonan syndromes
59
Rocker bottom feet is frequently seen in.....
trisomy 18
60
The hips of a newborn should be examined for.....
developmental dysplasia of the hips
61
What should a newborn **spine** be examined for?
* **Spina bifida**: hair tufts, lipomas, dimples in lumbosacral area
* **Sacrococcygeal pilonidal dimple**
* Identify base to rule out cutaneous sinus tract
* **Myelomeningocele**
* Hernial protrusion of the cord & its meninges through a defect in the vertebral canal
* Anywhere along the spine
* Obvious at birth
62
What does the neuro exam of a newborn consist of?
* Evaluation of muscle tone
* Level of alertness
* Primitive reflexes
63
**Preterm delivery**
* definition
* incidence
* complications
* \<37 completed wks from 1st day of last period
* 7% of all births
* High in lower SES populations & women w/o prenatal care
* Complications from time of birth to 1st several wks of life
64
**Post-term delivery**
definition
complications
* _\>_42 wks from 1st day of last period
* Complications: increased incidence of fetal & neonatal mortality & death from consequences of placental insufficiency
* Severe intrauterine asphyxia
* Meconium aspiration syndrome
* Polycythemia
65
What are some frequent problems of pre-term infants?
* Disrupted mother-father-infant interaction
* Perinatal asphyxia
* Hypothermia
* Hypoglycemia
* Hypocalcemia
* RDS (hyaline membrane disease, surfactant deficiency syndrome)
* Fluid & electrolyte abnormalities
* Indirect hyperbilirubinemia
* Patent ductus arteriosus
* Intracranial hemorrhage
* Necrotizing enterocolitis
* Infections
* Retinopathy of prematurity
* Bronchopulmonary dysplasia
* Anemia
66
**Small for gestational age infants & IUGR**
definition
significance
* Infants born weighing **\<5th %ile** for corresponding gestational age as a result of IUGR
* SGA is a sign that IUG has stopped or slowed significantly some time during pregnancy
67
What are the 3 types of IUGR?
* Early interference w/ fetal growth from conception to 24 wks gestation
* Intrauterine malnutrition from 24-32 wks gestation
* Late intrauterine malnutrition after 32 wks gestation
68
Early interference w/ fetal growth from conception to 24 wks gestation
* **Chromosomal anomalies**
* Trisomy 21, 13-15, 18, etc.
* **Fetal infections** (TORCH)
* **Maternal drugs**
* Chronic alcoholism, heroin
* **Maternal chronic illness**
* HTN, severe DM
69
Intrauterine malnutrition from 24-32 wks gestation
* **Inadequate intrauterine space**
* Multiple pregnancies
* Uterine tumors
* Uterine anomalies
* **Placental insufficiency from maternal vasc. dis.**
* Renal failure
* Chronic essential HTN
* Collagen vascular diseases
* Pregnancy-induced HTN
* **Small placenta w/ abnormal cellularity**
70
Late intrauterine malnutrition after 32 wks gestation
* Placental infarct or fibrosis
* Maternal malnutrition
* Pregnancy-induced HTN
* Maternal hypoxemia (lung disease, smoking)
71
What are the **clinical problems** for small-for-gestational-age infants?
* Perinatal asphyxia
* Hypothermia
* Hypoglycemia
* Polycythemia
* Thrombocytopenia
* Meconium aspiration syndrome
* Intrauterine fetal death
* Hypermagnesemia
* Mom treated w/ Mg for HTN or preterm labor
72
What is the definition of a large-for-gestational-age infant?
* Birth weight \>90th %ile for gestational age at birth
* Should be distinguished from those born w/ **high birth weight** (\>4,000 g)
* Newborn can be LGA w/ birth weight \>90th %ile withouth being \>4,000g
73
What is the etiology of LGA infants?
What are the complications?
* Causes of increased weight & LGA
* Maternal DM
* Beckwith-Wiedemann syndrome
* Prader-Willi syndrome
* Nesidioblastosis (diffuse proliferation of pancreatic islet cells)
* Complications
* Hypoglycemia
* Polycythemia
* Congenital malformations
74
**Cyanosis**
definition
clinical significance
* Bluish discoloration of skin & mucous membranes
* Directly related to absolute concentration of **unoxygenated or reduced Hgb**
* \>3 g/dL of reduced Hgb in arterial blood
* \>5 g/dL in capillary blood
* **Cyanosis = EMERGENCY**
75
What is the etiology of **cyanosis** in a newborn?
* **Respiratory pathology** (pneumothorax)
* "5 T's" of **cyanotic congenital heart disease**
* Tetralogy of Fallot
* Transposition of the great vessels
* Truncus arteriosus
* Tricuspid atresia
* Total anomalous pulmonary venous conn.
* **CNS pathology** (intraventricular hemorrhage)
* **Hematologic disorders** (polycythemia)
* **Metabolic disorders** (hypoglycemia, hypocalcemia, hypothyroidism, hypothermia)
76
What are the initial steps in evaluation of **cyanosis** in a newborn?
* Detailed hx & physical
* Serum electrolytes w/ serum glucose
* ABG, _+_ 100% oxygen test
* CBC, CXR
* Sometimes:
* Cultures
* Pre/post-ductal PaO2
* ECG, EKG
77
What is the **100% oxygen test**?
* ABG performed after admin of 100% O2
* Evaluates whether cyanosis is caused by cardiac or respiratory disease
78
100% oxygen test in infants with **heart disease**
* _Reduced_ pulmonary blood flow (TOF)
* Increases the PaO2 slightly
* \<10-15 mmHg
* _Normal/increased_ pulmonary blood flow (TA)
* PaO2 increases \>15-20 mmHg
* Levels \>150 mmHg unusual
79
100% oxygen test in infants with **lung disease**
* PaO2 increases **considerably** (\>150 mmHg)
* Exception
* Severe lung disease
* Persistant pulmonary HTN of newborn
* Large R-L shunts through foramen ovale or ductus arteriosus
* PaO2 may not increase by \>10-15 mmHg
80
How is **cyanosis** managed?
* Administration of oxygen
* Rapid correction of abnormalities of temperature, hematocrit, glucose & calcium levels
* Severely cyanotic infants
* Intubation & mechanical ventilation
81
What are the 3 most common causes of respiratory distress in newborns?
1. **Respiratory distress syndrome (RDS)**
1. Hyaline membrane disease
2. Surfactant deficiency syndrome
2. **Meconium aspiration syndrome (MAS)**
3. **Persistent pulmonary HTN of the newborn**
1. Full-term infants
82
What are the clinical features of respiratory distress?
Etiology?
* **Features**
* Tachypnea
* Decreased air entry or gas exchange
* Retractions (intercostal, subcostal, suprasternal)
* Grunting
* Stridor
* Flaring of the alae nasi
* Cyanosis
* Many conditions that produce neonatal respiratory distress are **not** primary diseases of the lungs
83
What is Respiratory Distress Syndrome?
Respiratory distress or respiratory insufficiency caused by lack of surfactant (preterm infants)
84
**Differential Diagnosis of Respiratory Distress**
Infections
* Sepsis
* Meningitis
* Pneumonia
85
**Differential Diagnosis of Respiratory Distress**
Hematologic Pathology
* Anemia
* Polycythemia
86
**Differential Diagnosis of Respiratory Distress**
Cardiovascular Pathology
* Congenital heart disease
* Cardiomyopathies
* Myocarditis
* Arrythmias
87
**Differential Diagnosis of Respiratory Distress**
Respiratory Pathology
* **Lungs**
* BPD
* RDS
* MAS
* PPHN
* TTN
* **Airways**
* Choanal atresia
* Pierre Robin Syndrome
* Laryngo-tracheomalacia
* Vocal cord paralysis
88
**Differential Diagnosis of Respiratory Distress**
CNS Pathology
* Intraventricular hemorrhage
* Apnea
* Congenital lesions
* Meningoencephalitis
89
**Differential Diagnosis of Respiratory Distress**
Abdominal Pathology
* Omphalocele
* Gastroschisis
* Ascites
* Diaphragmatic hernia
90
**Differential Diagnosis of Respiratory Distress**
Metabolic Pathology
* Hypoglycemia (DM)
* Hypothermia
* Metabolic acidosis
* Inborn errors of metabolism
91
What is the function of pulmonary surfactant?
When are infants less susceptible to RDS?
* Pulmonary surfactant
* Decreases alveolar surface tension
* Prevents atelectasis
* Surfactant noted at **23-24 wks** gestation
* Sufficient quantity produced at **30-32 wks** gestation (RDS decreases after this period)
92
How can fetal lung maturity be assessed?
* Presence of surfactant in amniotic fluid obtained by amniocentesis
* Lecithin-to-sphingomyelin **(L:S) ratio \>2:1** PLUS presence of **phosphatidylglycerol** (minor phospholipid in surfactant) are indicators of fetal lung maturity
93
What is the incidence of RDS?
* 0.5% of all neonates
* Most frequent cause of respiratory distress in preterm infants
* Higher incidence: white males
* Risk higher the younger the gestational age
* \<30 wks = 50% risk
* 35-36 wks = 10%
94
What are the risk factors for RDS?
* Low L:S ratio
* Prematurity
* Mother w/ previous preterm infant w/ RDS
* Mother w/ DM
* Neonatal hypothermia
* Neonatal asphyxia
95
What are the clinical features of RDS?
* Increasing respiratory distress first 24-48 hrs
* Tachypnea
* Retractions
* Expiratory grunting
* Cyanosis
* More severe & prolonged features in preterm infants \<31 wks
96
How is RDS evaluated?
**CXR**
* Diagnostic
* Diffuse atelectasis w/ increased density in both lungs
* Fine, granular, ground-glass appearance
* Small airways filled w/ air
* Increased density of pulmonary field
* "air bronchograms"
97
How is RDS managed?
* **Supplemental oxygen**
* **CPAP**
* Maintains positive end-expiratory pressure greater than atmospheric pressure
* Promotes air exchange
* Nasal prongs or nasopharyngeal tubes
* **Mechanical ventilation**
* If hypercarbia & respiratory acidosis
* **Exogenous surfactant in trachea often curative**
98
What are some acute complications of RDS?
* Air leaks
* Pneumothroax, pulmonary interstitial emphysema
* Intraventricular hemorrhage
* Sepsis
* R-L shunt across PDA
99
What are some chronic complications of RDS?
* Bronchopulmonary dysplasia (BPD)
* Retinopathy of prematurity
100
What is bronchpulmonary dysplasia (**BPD**)?
How is it diagnosed?
* Chronic lung disease
* Progressive pathologic changes in the immature lung (affecting parenchyma & airways, altering normal lung growth)
* Diagnosis:
* Mechanical ventilation 1st 2 wks of life
* Clinical signs of resp compromise
* Need for supp O2 \>28 days of life
* Characteristic CXR
101
With aggressive treatment in the NICU, \>\_\_\_% of infants with RDS survive
90
102
What is Persistent Pulmonary Hypertension of the Newborn (**PPHN**)?
* Any condition (other than congenital heart disease) associated w/ **low blood flow to the lungs after birth**
* Most frequently in near-term, full-term or post-term infants
103
PPHN etiology & pathophysiology
* Causes: perinatal asphyxia & MAS
* Increased pulmonary vascular resistance
* Significant R-L shunting through foramen ovale or ductus arteriosus with resulting hypoxemia
104
What are the clinical features of PPHN?
* Severity is variable (cyanosis to resp failure)
* PaO2 significantly decreased in response to minimal inspired oxygen changes or stimulation
* Pre/post-ductal PaO2 are notably different
105
How is PPHN evaluated?
* CXR
* Increased pulmonary vascular markings in infants w/ idiopathic PPHN
* Not caused by MAS or perinatal asphyxia
* ECG
* Important to rule out congenital heart disease & assess the degree of pulmonary HTN & R-L shunting
106
How is PPHN managed?
* **Prevention of hypoxemia**
* Potent pulmonary vasoconstrictor
* O2 is the most potent pulmonary dilator
* **Mechanical ventilation**
* If O2 alone insufficient
* High frequency ventilation & extracorporeal membrane oxygenation (**ECMO**)
* Severe cases
* **Inhaled NO**
* Potent pulmonary dilator
107
What is meconium?
* First stools, material in fetal gut
* Consists of:
* Water
* Mucopolysaccharides
* Desquamated skin & GI mucosal epithelial cells
* Vernix
* Bile salts
* Amniotic fluid
108
What is Meconium Aspiration Syndrome (**MAS**)?
Acute respiratory disorder caused by aspiration of meconium in the airways of the fetus or neonate
109
What is the pathophysiology of MAS?
* Meconium passes as a consequence of distress (hypoxemia) in the fetus at term
* **More frequent \>42 wks gestation**
* Degree of MSAF (meconium stained amniotic fluid) ranges from slighly green to dark green and thick consistency (pea soup)
* May reach the distal airways & alveoli in utero if fetus becomes hypoxic & develops gasping or deep respiratory movements
* May occur at time of birth w/ 1st inspirations
110
What are the clinical features of MAS?
What is the evaluation?
* Signs & symptoms of mild/moderate RD
* Some have severe respiratory failure w/ severe hypoxemia & cyanosis
111
How is MAS evaluated?
* Hx of meconium noted at or before delivery & presence of respiratory distress
* CXR
* Increased lung volume
* Diffuse patchy areas of atelectasis & parenchymal infiltrates alternating w/ hyperinflation
* Pneumothorax or pneumomediastinum may occur
112
How is **MAS** managed?
What are some possible complications?
* Combined OB & Peds approach
* Suctioning the perineum & direct suctioning of the trachea via endotracheal intubation
* Generally O2 is required
* Mechanical vent or ECMO if severe
* **Complications**
* PPHN
* Bacterial pneumonia
* Long-term reactive airway disease
113
What is apnea of prematurity?
* Respiratory pause w/o airflow lasting more than 15-20 seconds [**OR**]
* Respiratory pause of any duration if accompanied by bradycardia & cyanosis or oxygen desaturation (pulse ox)
114
What are the 3 categories of apnea?
* **Central apnea**
* Complete cessation of chest wall movements and no airflow
* **Apnea secondary to airway obstruction**
* Chest wall movements or respiratory efforts but w/o airflow
* Apnea monitors don't detect this
* **Mixed apnea**
* Central + obstructive
* Most _frequent_ type in preterm infants
115
What is the etiology of apnea of prematurity?
* Neonatal infections
* Lung disease
* Hypothermia
* Hyperthermia
* Hypoglycemia
* Seizures
* Maternal drugs
* Drug withdrawal
* Anemia
* GERD
* Idiopathic
116
What is the incidence of idiopathic apnea of prematurity?
* Frequency increases w/ decreasing gestational age
* \<28 wks gestation = 85%
* 33-34 wks gestation = 25%
117
What are the clinical features of idiopathic apnea of prematurity?
* Absence of any identifiable cause
* 24 hrs after birth & during 1st wk of life
* Resolves by postconceptional age of 38-44 wks
* Gestational age at birth + # wks postnatal
118
How is idiopathic apnea of prematurity managed?
* Maintenance of neutral thermal environment, treatment of hypoxia, proprioceptive stimulation
* Respiratory stimulant medications
* Caffeine, theophylline
* Ventilation as needed
* Bag & mask after severe apneic episode
* CPAP or mechanical ventilation
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What is neonatal jaundice?
* Jaundice: yellowish discoloration of mucous membranes & skin from increased bili levels
* First wk of life, **indirect (unconjugated) hyperbilirubinemia** that is physiologic in nature
* Visible jaundice: serum bili \>5 mg/dL
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How is neonatal jaundice classified?
* Physiologic jaundice
* Nonphysiologic jaundice
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What is **physiologic** jaundice?
How is it caused?
* **Benign indirect hyperbilirubinemia**
* Resolves by end of 1st wk of life, no treatment
* Causes
* Increased bilirubin load on hepatocytes
* Delayed activity of the hepatic enzyme glucuronyl transferase
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What are the clinical features of physiologic jaundice?
* Jaundice in well-appearing infants
* Elevated indirect bilirubin levels
* **Full-term infants**
* Peak bilirubin 5-16 mg/dL at 3-4 days of life
* Start to decrease before 1st wk of life
* **Pre-term infants**
* Peak bilirubin after 5-7 days
* 10-20 days before decreasing
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How is nonphysiologic jaundice classified?
* **Indirect hyperbilrubinemia**
* Elevated bilirubin
* Conjugated/direct \<15% of total
* **Direct hyperbilirubinemia**
* Conjugated/direct \>15% of total
* Always PATHOLOGIC in neonates
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What is the differential diagnosis of indirect hyperbilirubinemia?
* Physiologic jaundice
* Increased RBC load from bruising
* Increased bilirubin from hemolysis
* Upper GI obstruction (increased enterohepatic recirculation)
* Breastfeeding jaundice
* Breast milk jaundice
* Sepsis
* Inborn errors of metabolism (hypothyroidism)
* Inherited disorders of bilirubin uptake & conjugation
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What is Breastfeeding jaundice?
* First wk of life
* Increased bilirubin levels
* Suboptimal milk intake
* Poor intake --\> weight loss, dehydration, decreased passage of stool
* Resultant decreased excretion of bilirubin in the stool
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What is Breast milk jaundice?
* After 1st wk of life
* Related to breast milk's high levels of ß-glucuronidase and high lipase content
* Elevated bilirubin is highest in the second and thrid weeks of life
* Lower levels of bilirubin may persist until 10 wks of life
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What is the differential diagnosis of direct hyperbilirubinemia?
* Obstructive jaundice secondary to choledochal cyst
* Obstructive jaundice secondary to biliary atresia
* Sepsis
* Neonatal hepatitis
* Metabolic causes
* Cholestasis associated w/ parenteral nutrition
* Cystic fibrosis
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Jaundice should always be evaluated under the following circumstances....
* Jaundice appears \<24 hrs of age
* Bilirubin rises \>5-8 mg/dL in 24 hr period
* Rate of rise of bilirubin exceeds 0.5 mg/dL per hour (suggesting hemolysis)
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How do you **evaluate** for indirect hyperbilirubinemia?
* CBC
* Reticulocyte count
* Smear (for hemolysis)
* Evaluation for sepsis
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How do you evaluate for direct hyperbilirubinemia?
* Hepatic ultrasound (choledochal cyst)
* Serologies for viral hepatitis
* Radioisotope scans of the hepatobiliary tree
* Evaluation for sepsis
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How is neonatal jaundice managed?
* Serial bilirubin assessments, observation, reassurance (physiologic jaundice)
* **Phototherapy**
* Water-soluble photoisomers of indirect bilirubin that are more readily excreted
* Depends on gestational maturity, age, bili levels, risk factors, etc.
* **Exchange transfusion**
* Rapidly rising bili levels secondary to hemolytic disease
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What are the complications from neonatal jaundice?
**kernicterus & bilirubin encephalopathy**
* Indirect bili can pass BBB (irreversible damage)
* Bili localizes to **basal ganglia**, hippocampus, some brainstem nuclei
* Clinical features
* _Choreoathetoid cerebral palsy_
* _Hearing loss_
* _Opisthotonus_
* Seizures
* Oculomotor paralysis
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In approximately \_\_\_% of pregnancies in the US, fetuses are exposed to illicit drugs while in utero.
10-15
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Most women who use illicit drugs use.....
Compounds fetal risk if using tobacco, caffeine, prescribed drugs
* Alcohol
* Cocaine
* Amphetamines
* PCP
* Narcotics
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What are maternal risk factors for drug abuse?
What are some obstetric complications?
* **Maternal risk factors**
* Inadequate prenatal care
* Anemia
* Endocarditis
* Hepatitis
* TB
* HIV
* STIs
* Low self-esteem
* Depression
* **Obstetric complications**
* Abruptio placentae
* Precipitous delivery
* Preterm labor & delivery
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What are the clinical features of infants of drug-abusing mothers?
Mortality rates and cause of death?
* Jitteriness, hyperreflexia
* Irritability, tremulousness, feeding intolerance, excessive weakness
* 3-10% mortality
* Cause of death
* Perinatal asphyxia
* Congenital anomalies
* Child abuse
* SIDS
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What is the epidemiology of esphageal atresia w/ TEF?
* 1:2,000-3,000 infants
* Associated w/ polyhydramnios
* Most common type of esophageal atresia (\>90%)
* Atresia of the esophagus (proximal pouch)
* Distal tracheoesophageal fistula
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What are the clinical features of esophageal atresia with TEF?
* Hx of polyhydramnios
* Copious oropharyngeal secretions
* Increased risk of choking & aspiration pneumonia
* Associated malformations (50%)
* Congenital heart disease
* Anorectal, skeletal, renal malformations
* VACTERL association
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How is esophageal atresisa w/ TEF evaluated?
How is it managed?
* Oral gastric tube inserted until meets resistance
* Radiographs show tube in upper thorax
* Type III
* Air that has crosses through the distal fistula from the trachea is seen in the stomach
* Surgical repair
* Closure of the fistula
* Anastomosis of the 2 esophageal segments
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What is a congenital diaphragmatic hernia?
What is the epidemiology?
*
