Neonatology Flashcards
Apgar scoring
Rapid scoring system that helps evaluate need for neonatal resuscitation. 5 parameters get 0-2 points each.
8-10: Typically reflect good cardiopulm function
4-7: Possible need for resuscitation. Infants should be observed, stimulated and possible given ventilatory support
0-3: Indicate the need for immediate resuscitation
1) A: Apperance (blue/pale, pink trunk, all pink)
2) P: Pulse (0, less than 100, greater than 100)
3) G: Grimace with stimulation (0, grimace, grimace and cough)
4) A: Activity (limp, some, active)
5) R: Respiratory effort (0, irregular, regular)
Neonatal jaundice
An elevated serum bili (over 5) due to increased hemolysis or lower excretion.
1) Conjugated (direct): Always pathologic
2) Unconjugated (indirect): May be physio or pathologic
3) Kernicterus: Caused by unconjugated elevations. Results from irreversible bili deposits in basal ganglia, pons, and cerebellum. Typically at levels of over 25-30 and can be fatal. Risks are prematurity, asyphxia, and sepsis.
Conjugated hyperbili ddx
1) Extrahepatic cholestasis (biliary atresia, choledochal cysts)
2) Intrahepatic cholestasis (neonatal hepatitis, inborn errors of metabolism, TPN cholestasis)
3) Dubin-Johnson
4) Rotor’s
5) TORCH
Unconjugated hyperbili ddx
1) Physiologic jaundice
2) breast milk jaundice
3) Increased enterohepatic circulation (GI obstruction)
4) disorders of bilirubin metabolism
5) hemolysis
6) sepsis
7) Crigler-Najjar
8) Gilbert
History in neonatal jaundice
History should focus on diet (breast milk or formula), intrauterine drug exposure, and FHx (hemoglobinopathies, enzyme deficiencies, RBC defects)
Exam in neonatal jaundice
May reveal signs of hepatic or GI dysfunction (abdominal distention, delayed passage of meconium, light stools, dark urine), infection, or hemoglobinopathies (cephalohematomas, bruising, pallor, petechiae, hepatomegaly)
Kernicterus presents with lethargy, poor feeding, a high-pitched cry, hypertonicity, and seizures. Jaundice may follow a cephalopedal progression as bili concentrations increase.
Dx of neonatal jaundice
1) CBC with peripheral smear; blood typing of mom and infant (for ABO or Rh incompatibility); Coomb’s test and bili levels
2) US and/or HIDA can confirm suspected cholestatic disease
3) For direct hyperbilirubinemia, check LFTs, bile acids, blood Cx, sweat test, and tests for aminoacidopathies and a1 antitrypsin deficiency
4) A jaundiced neonate who is febrile, hypotensive, and/or tachypneic needs a full sepsis workup and ICU monitoring
Tx of neonatal jaundice
1) Treat underlying causes
2) Treat unconjungated hyperbili with phototherapy (for mild elevation) or exchange transfusion (for severe over 20). Start photo earlier (10-15) for preterm infants. Phototherapy is NOT indicated for conjugated hyperbili and can lead to skin bronzing.
Respiratory Distress Syndrome
The most common cause of respiratory failure in preterm infants (affects more than 70% of infants born at 28-30w); formerly called hyaline membrane disease.
Surfactant deficiency leads to poor lung compliance, alveolar collapse, and atelectasis
Risk factors include: Maternal DM, male gender, and the second born of twins.
History and exam for RDS
Presents in first 48-72h of life with a RR above 60, progressive hypoxemia, cyanosis, nasal flaring, intercostal retractions, and expiratory grunting
Dx of RDS
1) Check ABGs, CBC, and BCx to r/o infection
2) Dx is clinical and confirmed with characteristic CXR findings.
For RDS, this is ground glass appearance, diffuse atelectasis and air bronchograms on CXR.
For Transient Tachypnea of Newborn: Retained amniotic fluid results in prominent perihilar streaking in interlobular fissures. Resolves with O2 administration.
For meconium aspiration: Coarse, irregular infiltrates; hyperexpansion and pneumothoraces
For congenital pneumonia: Nonspecific patchy infiltrates; neutropenia, tracheal aspirate, and gram stain suggests the dx
Tx of RDS
1) CPAP or intubation and mechanical ventilation
2) Artificial surfactant administration lowers mortality
3) Pretreat mothers at risk for preterm delivery (less than 30w) with steroids. If less than 30w, monitor fetal lung maturity via a lecithin-sphingomyelin ratio and presence of phosphatidylglycerol in amniotic fluid. L/S ratio less than 2 indicates need for maternal steroid administration
Complications of RDS
Persistent PDA, bronchopulmonary dysplasia, retinopathy of prematurity, barotrauma from positive pressure vent, IV hemorrhage, and NEC are complications of treatment
