Neonatology Flashcards
When to treat polycythemia in neonate?
If Hct > 70% = partial exchange transfusion
If 65% to 69% + asymptomatic = observed.
If > 60% + symptomatic then treat.
Risk Factors: delivery in high-elevation areas; gestational age of >40 weeks; small size for gestational age; maternal diabetes, hypertension, and history of cigarette smoking; trisomy 13, 18, or 21; neonatal Graves disease and hypothyroidism; congenital adrenal hyperplasia; cyanotic congenital heart disease.
What cause jejunal atresia?
Maternal smoking! Smoking put you at risk for LBW and intestinal abnormalities.
Due to impaired vascular supply -> ischemia.
VS: duodenal atresia due to failure of recanalization - associated with T21.
VACTERL
Vertebral anomalies, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal anomalies, and limb anomalies.
At least 3
No genetic mutation has been identified for the VACTERL association.
CHARGE
Coloboma, Heart defects, Abnl Palate, Retarded growth, Genitourinary, Ear
Autosomal Dominant
DiGeorge (CATCH-22)
Cardiac Abnl facies Thymic aplasia Cleft palate HypoCa/Hypoparathyroidism 22q11.2 deletion
Predictors of early-onset sepsis
EOS: sepsis (bacteremia or meningitis) within 72 hours of birth
- prematurity (<37 weeks of gestation)
- post-term gestation (>40 weeks of gestation)
- intrapartum maternal fever.
Brachial Plexus Injury
- swelling of the nerve sheath, resulting in temporarily decreased motor and sensory conduction
Sx: decreased abduction of the shoulder, decreased supination of the forearm, and decreased external rotation of the arm.
Of note, palmar grasp and biceps reflexes on the injured side remain intact.
Initial management of suspected BPI includes minimal handling of the affected arm and short-term immobilization. In the absence of fracture, continued immobilization is controversial and passive range of motion exercises are recommended beginning at 7 to 10 days after birth w referral to PT. Usually resolves in 2-4 wks.
NRP guidelines
Initial steps: warming, drying, and stimulating.
If heart rate > 100 and resp distress -> CPAP.
If heart rate remains < 100 beats/min after these steps, PPV must be initiated. The initial pressure required to inflate neonatal lungs after delivery can be as high as 40 cm H2O. FiO2 titrated for targets for age.
If heart rate < 60 beats/min with adequate ventilation, the neonate should undergo endotracheal intubation, and chest compressions should be started. FIO2 should be at 100%.
Alagille syndrome
Direct cholestasis (due to paucity of bile ducts), cardiac murmur (usually peripheral pulm stenosis), and vertebral anomalies. Also facial - hypertelorism, prominent forehead and pointed chin. AD mutation in JAG1.
Cholestasis work-up
Cholestasis = conjugated bilirubin level greater than 20% of the total bilirubin
- abdominal ultrasonography to evaluate for biliary atresia.
- check IMDS for galactosemia (FTT, cataracts, feeding intolerance)
- UA for UTI
Risk factors for IVH
Pneumothorax!
- disease of premature neonates born before 32 weeks of gestation.
The germinal matrix is a structure present in the periventricular region of the developing fetus. This highly vascularized region, with limited perivascular support, typically involutes by term. After birth, premature neonates have impaired autoregulation of their cerebral vasculature, unlike term neonates, whose cerebral perfusion is maintained at a constant value as systemic blood pressure varies. Therefore, in premature neonates, fluctuations in systemic blood pressure can cause acute increases and decreases in cerebral perfusion that increase the risk of bleeding into the vascularized germinal matrix, resulting in IVH. - Grades:
Grade 1: Involves only the germinal matrix
Grade 2: Involves the ventricle without ventricular dilation
Grade 3: Involves at least 50% of the ventricle with associated dilation
Grade 4: Involves periventricular brain parenchyma - Pneumothorax is associated with increased risk of IVH in premature neonates.
- Antenatal corticosteroid administration and delayed cord clamping reduce the risk of IVH among premature neonates.
Malformed distal fingers/toes
Amniotic band syndrome = interruption of the normal sequence of development during the third trimester.
Others have hypothesized that a band of amnion constricts developing tissue, interrupting normal progression of development. The result is abnormal growth and development in the limb distal to the insult. Infants may present with fused or partially amputated digits.
Infants with amniotic band syndrome should be referred to a plastic surgeon for reconstructive surgery.
What is early discharge criteria for an neonate?
Minimum criteria must be met for early discharge of a newborn (< 48 hours after delivery). If discharging after 24 hours, needs follow-up care within 48 to 72 hours.
Adequate intrapartum antibiotic treatment for the prevention of group B streptococcal disease is required to meet early discharge criteria.
CXR findings for different RDS, MDS, TTN
RDS - ground glass opacities
MDS - fluffy asymmetric patchy infiltration
TTN - perihilar markings and fluid in the fissure
Eval for neonate born to mom with chorio
Complete blood cell count and blood culture.
Depending on clinical status, these neonates could be started on empiric antibiotic coverage.
Ranula
pseudocyst associated with anomalous drainage of the sublingual glands and/or submandibular ducts.
translucent to bluish, nonblanching, fluctuant swelling lateral to the midline of the lower mouth.
TX: complete surgical excision
Cutis marmorata telangiectatica congenita is associated with?
- Limb hypoplasia is often associated with the disorder.
- generalized reddish-violaceous or bluish-purple mottling in a reticulated pattern. Localized lesions are typically distributed in a segmental pattern with sharp demarcation at the midline
- different than physiologic cutis marmorata (the normal vascular response to cold in the newborn) which disappears with warming
SSRIs in pregnancy is associated with
Persistent pulmonary hypertension
Jitteriness and tremors
Phenytoin is associated with
Fetal hydantoin syndrome
- craniofacial “anticonvulsant facies”
- distal limb abnormalities (finger stiffness, nail hypoplasia).
- Bleeding related to decreased levels of vitamin K–dependent clotting factors may occur in newborns exposed in utero to phenytoin.
Elevated AFP
elevated AFP
- neural tube defects
- multiple gestation
- abdominal wall defects (omphalocele and gastroschisis)
Low levels of alpha-fetoprotein may be associated with both trisomy 18 and 21.
Harlequin color change
Benign finding in preterm infants. Can also be in term infants in first few days of life.
Due to imbalance in the autonomic vascular regulatory mechanism of cutaneous blood vessel tone.
upper half of the body becomes pale while the dependent half takes on a dark reddish hue. Color usually returns to normal within several minutes after the infant is repositioned.
Methotrexate
Craniosynostosis
Limb defects
Can be misdiagnosed as T18
Retinoic acid
- microcephaly
- external auditory canal anomalies or microtia
- cardiac defects, thymic hypoplasia, facial nerve palsies, and/or genitourinary malformations.
Caudal regression syndrome associated with what maternal condition?
Maternal diabetes - IDM
Caudal regression syndrome
- incomplete/absent sacrum and lumbar vertebrae
- due to associated spinal cord dysfunction -> neurologic impairment and growth impairment
ACEi in pregnancy associated with
Potter syndrome
- oligohydramnios
- limb and hand anomalies; widely separated eyes; small, low-set, and posteriorly rotated ears; and facial deformities (e.g., small chin, beaked nose, unusual facial creases) resulting from compression of the fetus within the uterine cavity (Potter syndrome). Many affected infants also have severe pulmonary hypoplasia,
Also CV and CNS symptoms and fetal defects in kidneys
Cystic Hygroma
Lymphangioma due to abnormal development of the lymphatic system leading to obstruction of normal lymphatic flow and sequestration of lymphatic fluid.
Located in the posterior (and sometimes anterior) triangle of the neck (75%) or axilla (20%)
Prune Belly Syndrome
Hypoplasia of abdominal muscles
Bilateral cryptorchidism
Urinary tract abnormalities
Complications of IUGR and what maternal condition associated with it
- increased risk of HTN and metabolic syndrome in adults
- small decreases in IQ (not clinically significant) and reduced scores for executive function
Chronic alcohol abuse
Insulin associated with
small left colon syndrome
Congenital syphilis
pseudoparalysis—a painful osteochondritis associated with congenital syphilis. Cerebrospinal fluid abnormalities include reactive VDRL, pleocytosis, and elevated protein.
Sudden onset of hematuria with a mass in one or both flanks
Renal vein thrombosis
How long does breast milk jaundice last?
May persist up to 2-3 months.
What electrolyte abnormality in small left colon syndrome?
Small left colon associated with IDM which is associated with hypoglycemia
Estimation of gestational age: Breast
Nothing prior to 34 wks
34-35 wks: areola
36-37 wks: breast tissue that increases with increasing gestational age
Estimation of gestational age: Ears
Nothing prior to 32 wks
32-35: scant cartilage, slow return from folding
36-39: thin cartilage
40: pinna erect from head
Incurving
34-35: superior incurving
36-38: upper 2/3 of ear incurved
39: entire lobe
Estimation of gestational age: Soles of feet
Nothing until 32 weeks, 32–33 weeks: 1-2 creases 34-35: 2–3 creases 36–37 weeks: 2/3 of the anterior sole is covered by creases 38–41 weeks, they cover the entire sole.
When is physiologic nadir for anemia?
In full-term infants, the hemoglobin typically reaches a nadir of approximately 11 g/dL (110 g/L) at 8 to 12 weeks after birth. `
Gastroschisis associated with maternal ingestion of
Cocaine and other vasoactive substances like nicotine and pseudoephedrine
gastroschisis due to vascular accident that leads to necrosis of abd wall allowing bowel to enter amniotic cavity
abd distension + bilious vomiting with XR showing “soap bubble” appearance of intestines, distended loops of varying degrees, absence of air fluid levels
Meconium Ileus from Pancreatic Insufficiency from CF
What developmental reflex can be elicited in healthy 1 year old child?
Parachute reflex
Appears at 6-9 months and persists throughout life.
VS newborn reflexes that disappear:
- Neck reflex - disappears by 3-4 mo
- Moro - by 5-6 mo
- Palmar grasp -3 mo
- Plantar grasp - 8-9 mo
- Stepping - 1-2 mo
IDM associated with:
- cardiomyopathy (hypertorphy of intraventricular septum or ventricular walls)
- caudal regression syndrome
- neural tube defects
- small left colon syndrome
- urinary track malformations
- hyaline membrane disease (insulin blocks surfactant precursors)
Renal Vein Thrombosis
RF: perinatal asphxia with low apgar scores
Triad:
- Gross hematuria
- Flank mass (unilateral or bilateral enlargement of kidneys)
- thrombocytopenia
Laboratory tests may reveal hematuria, proteinuria, polycythemia, hemolytic anemia, thrombocytopenia, and possibly acute kidney injury.
HTN and oliguria as well
Trisomy 13 or 18 is associated with what drug
Methotrexate
T13 or 18: low-set malformed ears, a prominent occiput, rocker bottom feet, clenched hands with overlapping fingers, nail hypoplasia, a heart murmur, and hypotonia.
20% can have normal chromosomes (and is resulting from autosomal dominant or autosomal recessive inheritance)
ERb’s vs Klumpke
Erb “waiters tip”
- C5-7
- upper extremity adducted and internally rotated, with the elbow extended, the forearm pronated, and the wrist flexed. The hand is often in a fist. Grasp is maintained,
Klumpke “claw hand
- C8-T1
- supination with the elbow bent and the wrist extended. Function of the hand is lost while use of the arm is maintained to varying degrees.
Horner’s
- injury to T1
- ptosis, miosis, anhidrosis
Developmental Dysplasia of the Hip - what sign at 5 months old?
Galeazzi sign = after 2 months of age
- asymmetry of the height of the knees due to shortening of the thigh on the affected side. best observed after placing both hips in 90 degree flexion
Also limited hip ABDUCTION is seen at this age.
Barlow and Ortolani only btwn 8-10 wks
ambulatory patient = trendelenberg
Ultrasonography of the hips is the preferred method of evaluation in infants < 4 months of age because the femoral head has not yet ossified, and cartilage and soft tissues are better delineated on ultrasound.
Twin-Twin transfusion syndrome
TTTS - when a vascular anastomosis occurs btwn placenta of the 2 fetuses.
Hydrops fetalis can occur in BOTH children.
TTTS only occurs in monochorionic set-ups
Polyhydramnios is frequent in recipient
Oligohydramnios is frequent in the donor
Warfarin Exposure
Nasal hypoplasia and stippled epiphyses
Ideal delivery room temperature
77-78ish (22-26ish)
How to work up jaundice in first 24 hours of life?
If in the first 24 hours, likely pathologic!!
Bili, CBC/R, direct coombs, blood culture
Physiologic 48-72 hours (2-3 days)
Breastfeeding 4-7 days
Congenital Varicella
- central nervous system (e.g., aplasia, microcephaly, hydrocephaly, calcifications)
- eyes (e.g., microphthalmia, optic atrophy, cataracts, chorioretinitis)
- extremities (limb atrophy and malformations)
- skin (e.g., cicatricial scarring—often in a dermatomal distribution, hypopigmentation).
intrauterine growth restriction, microcephaly, ventriculomegaly, echogenic foci in the liver, and circular (cicatrix) scarring and deformities of the extremities.
ROP screening
Gestational age < 30 wks
BW < 1500 g
Complicated clinical course (prolonged intubation, NEC, BPD)
Screen at 31-32 wks or chronological age of 4 wks whichever is first
