Neonatology Flashcards
1
Q
classification by GA
A
■ preterm: <37 wk
■ near-term: 35-37 wk
■ term: 37-42 wk
■ post-term: >42 wk
2
Q
Pre-terms infants problems
A
RDS,
apnea of prematurity, chronic lung disease, bronchopulmonary dysplasia
Feeding difficulties, NEC
Hypocalcemia, hypoglycemia, hypothermia Anemia, jaundice
Retinopathy of prematurity
ICH/IVH
PDA
3
Q
Routine Neonatal Care
A
- erythromycin ointment: applied to both eyes for prophylaxis of ophthalmia neonatorum
- vitamin K IM: prophylaxis against HDNB
- newborn screening tests
■ metabolic disorders (amino acid disorders, organic acid disorders, fatty acid oxidation defects,
biotinidase deficiency, galactosemia)
■ blood disorders (SCD, other hemoglobinopathies)
■ endocrine disorders (CAH, congenital hypothyroidism)
■ others (CF, severe combined immunodeficiency) ■ congenital hearing loss - if mother Rh negative: send cord blood for blood group and direct antiglobulin test
- if mother hepatitis B surface antigen positive: HBIg and start hepatitis B vaccine series
4
Q
Apgar Score
A
0,1,2 score/10 Appearance (colour) Pulse (heart rate) Grimace (irritability) Activity (tone) Respiration (respiratory effort)
5
Q
steps to takefor all infants resuscitation
A
Warm and dry
Position and clear airway (if needed)
stimulate infant: rub back and fleet EXCEPT if meconium present (in which tracheal suction first)
assess breathing and heart rate
6
Q
Caput seccedaneum
A
- diffuse swelling of sof tissues
- can CROSS suture
- from pressure of uterus or vaginal wall
- resolves within days
7
Q
Cephalohematoma
A
subperiostal hemorrhage
- NEVER CROSS
- traumatic, forceps
- monitor bilirubin + hematocrit level as can lead to blood take up and then break down
- resolves 2-3 weeks
8
Q
Fontanelles
A
Posterior closes approx. 2 months
Anterior 18-24 months
9
Q
Subgaleal hematoma
A
- below epicranial aponeurosis
- CROSS midline + into neck or ear
- baby can exsanguinate; may need transfusion
10
Q
ATNR reflex
A
Fencing position
Ipsilateral extension of the limbs on the side where head is turn and contralateral flexion
*primitive reflex present at birth and disappear by 4-6 months
11
Q
Newborn screening
A
ARE NOT diagnostic
- if positive = follow up
- if negative but has symptoms = should undergo further testing
- phenylketonuria, galactosemia, congenital hypothyroidism, congenital adrenal hyperplasia, cystic fibrosis, sickle cell disease, thalassemia
12
Q
Erythema toxium
A
- Etiology unknown (Smears = esoinophils)
- onset: 2-3 days of life
- then wax + wane for 3-6 days
- present: small erythematous papule / postule/ vesicule
- no treatment, self-limiting
13
Q
Hip: DDH exam
A
Bartlow
-adduction + lateral pressure exerted by thumb + downward pressure (out = +ve)
Ortolani -Abduction with medial pressure by middle finger (in = +ve)
i
14
Q
CPS feeding recommendations:
A
1/ Breast feed exclusively for first 6 months
2/ 400 IU daily vit-D supplement for breastfed infants
3/ First foods = iron rich (meat, meat alternative, iron-fortified cereals)
4/ Baby does not need additional water
15
Q
Contraindications to breast feeding
A
1/ HIV + (in developed countries) 2/ HTLV-1 (T cell lymphoma virus) 3/ Herpes on breasts (both) 4/ Child with Galactosemia (metabolic disorder) 5/ Medications (some) 6/ Disease: TB, Varicella, Measles
16
Q
Milk: 9-12 months
A
Homogenized milk (3.25% M.F.) Cows milk until 2 years of age
- Max 3/day
- Partly skimmed or low fat NOT recommended in the first 2 years
17
Q
Newborn weight gain
A
NORMAL
20-30g/day
18
Q
Long term complications of preterm
A
- Cerebral palsy from ABN brain development
- mental retardation
- speech and language problems
- blindness
- hearing problems
- behavioural + learning disabilities
19
Q
NEC
*breast milk protective
A
intestinal inflammation with ulceration and necrosis
- terminal illeum + colon
- xray shows intramural air
- tx: NPO, IV, NG decompression, supportive therapy, TPN, abx
20
Q
Apnea of prematurity
A
> 20 sec or less if bradycardia <70-80 or desaturation <80-85%
- inversely proportional to gestational age: Immature ventilatory drive in infants = lack of response to increased CO2 in blood along with hypoxia –> central apnea
- usually resolve by 35-37w
- tx: caffeine
21
Q
Respiratory Distress Syndrome (RDS)
A
- Etiology: Surfactant deficiency (Surfactant = from type 2 pneumocytes) ** sufficient amount by ~36 weeks of GA**
- Only found in pre-term babies
Prevention
- Prenatal Corticosteroids (CELESTONE 12mg q24h x2) if risk pre-term <34w
- Lecithin:Sphingomyelin on Amnio (L:S >2:1) = lung maturity
Treatment
- Resuscitation - O2 + Ventilation
- Surfactant
22
Q
Intra-Ventricular Hemorrhage:
A
Brain hemorrhage in the periventricular Subependymal Germinal Matrix
Subependymal GM = right next to lateral ventricles
Risk factos
a. ↑With ↓Gestational age (< 32 weeks)
b. Low birth weight < 1500g
c. Vigorous resuscitation at birth
d. pneumothroax
e. instability
f. RDS
g. coagulopathy
Routine US
i. <1500 g OR
ii. 32 weeks
23
Q
Most serious complication of hyperbilirubinemia in the newborn
A
Encephalopathy
24
Q
Jaundice within 24 hours in a first born child
Most likely etiology?
A
ABO incompatibility
25
Jaundice within 24 hours in a second born child
| Most likely etiology?
Rh incompatibility
26
Jaundice within 24 hours
History of prolonged second stage of labor
No prenatal check-up
Most likely etiology?
Sepsis
27
Jaundice within 24 hours
History of maternal infection during pregnancy
Most likely etiology?
TORCH
[Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infection]
28
______________ Jaundice
| - attributed to the presence of _______________ in some breast milk
Breast Milk Jaundice
| - attributed to the presence of glucuronidase in some breast milk
29
Breastfeeding jaundice or breast milk jaundice?
| Onset at 3rd to 4th DOL
BFJ
30
Breastfeeding jaundice or breast milk jaundice?
| Onset at 7th day of life
BMJ
31
Breastfeeding jaundice or breast milk jaundice?
| Duration is a few days
BFJ
32
Breastfeeding jaundice or breast milk jaundice?
| Duration is 3 weeks to 3 months
BMJ
33
Physiologic Neonatal Jaundice
- most common cause of jaundice in neonates
- presents after the ___th hour of life
- resolves in ___ week (term), ___ weeks (preterm)
Physiologic Neonatal Jaundice
- presents after the 48th hour of life
- resolves in 1 week (term), 2 weeks (preterm)
34
Physiologic Neonatal Jaundice Physiology
- increased production of bilirubin and decreased elimination of bilirubin
- increased production due to increased hematocrit and decreased RBC lifespan in newborns
- decreased elimination due to slow conjugation of bilirubin by immature glucuronyl transferase enzyme in newborn
35
Pathologic neonatal jaundice
| TB increases by greater than ____ umol/L/day
Pathologic neonatal jaundice
| TB increases by greater than 85 umol/L/day
36
______________ Jaundice
- early-onset and accentuated, caused by decreased milk intake with dehydration and/or reduced caloric intake
- One way to reduce incidence: frequent breastfeeding (>___ in 24 hours)
Breastfeeding Jaundice
- early-onset and accentuated, caused by decreased milk intake with dehydration and/or reduced caloric intake
- One way to reduce incidence: frequent breastfeeding (>10 in 24 hours)
37
Kernicterus
- results form the deposition of ________________ bilirubin in the ____________ and _____________
- Phase 1: seizure, poor sucking, stupor, hypotonia
- Phase 2: hypertonia, opisthotonus, Fever
- Phase 3: hypertonia
Kernicterus
- results form the deposition of unconjugated bilirubin in the basal ganglia and brainstem (the brain)
- Phase 1: seizure, poor sucking, stupor, hypotonia
- Phase 2: hypertonia, opisthotonus, Fever
- Phase 3: hypertonia
38
_________ Coombs Test
- used to detect antibodies that are bound to the surface of RBCs
_________ Coombs Test
- detects antibodies against RBCs that are present unbound to the patient's serum
DIRECT Coombs Test
- used to detect antibodies that are bound to the surface of RBCs
INDIRECT Coombs Test
- detects antibodies against RBCs that are present unbound to the patient's serum
39
Direct Hyperbilirubinemia - caused by
_____________ cholestasis
- sepsis / TORCH infection
- prolonged TPN
- hypothyroidism
- galactosemia
- cystic fibrosis
- alpha-1 antitrypsin deficiency
______________ cholestasis
- choledochal cyst
- biliary atresia (paucity of bile ducts)
Direct Hyperbilirubinemia - caused by
HEPATIC cholestasis
- sepsis / TORCH infection
- prolonged TPN
- hypothyroidism
- galactosemia
- cystic fibrosis
- alpha-1 antitrypsin deficiency
POST-HEPATIC cholestasis
- choledochal cyst
- biliary atresia (paucity of bile ducts)
40
in which type of hyperbilirubinemia would you have a weird stool color
conjugated hyperbilirubinemia ==> hepatic / excretory cause
== pale stools b/c not being colored with bili
41
What are the 4 physiological competencies preterm babies must achieve before being eligible for discharge home?
1. Thermoregulation: maintain normal body temperature when fully clothed in an open cot
2. Control of breathing: apnea free period of at least 5-7 days
3. Respiratory stability: maintenance of SaO2 > 90-95% in RA
4. Feeding skills/weight gain
42
What is the commonly used definition of chronic lung disease/bronchopulmonary displasia?
Need for O2 at CGA of 36 weeks + respiratory symptoms + compatible changes on CXR
43
How do bilirubin levels differ in late prem infants compared to term infants? (4)
1. Peaks later (at 7 days as opposed to 5 days)
2. Reaches higher peak
3. Stays elevated for longer
4. Risk of kernicterus at lower levels of bilirubin
44
What are the risk factors for early GBS sepsis? (6)
1. Intrapartum fever
2. ROM > 18 hrs
3. GBS bacteruria
4. Previous child with invasive GBS disease
5. Maternal chorioamnionitis
6. Prematurity
45
Pathological jaundice
CONJUGATED + if jaundice <24h
| *<24h: Hemolytic (ABO, Rh), Sepsis (GBS, TORCH)
46
SGA symmetric
```
<10th percentile
<2500g
Symmetric= reduction in both weigh, length and head
- causes
1st trimester infection TORCH
Chromosomal abnormality
*PDA usually only in SYMMETRIC
```
47
SGA asymmetrical
```
weight manly affected with HEAD GROWTH PRESERVED
-causes
placental insufficiency
poor nutrition
HTN
multiple pregnancies
drugs/smoking/alcohol
```
48
Screening hypoglycaemia in newborn
a. Any symptoms = test baby
b. Any Asymptomatic with risk factors (premature, SGA, LGA, IDM)--> blood sugar checked 2 hrs after birth + eery 3-6 hrs before feeds until feeds are established and blood glucose > 2.6
c. Hypoglycemia diagnosed based on blood glucose <2.6
49
Clinical presentation hypoglycemia
a. Apathy + irritability
b. Weak or high pitched cry
c. Low tone / limpless
d. Lethargy
e. Tremor or seizure
f. Poor feeding
g. Apnea or tachypnea
h. cyanosis
50
Albumin can be saturated and bili can be displaced with medications
1. Ceftriaxone
2. Streptomycin
3. NSAIDS
4. Warfarin
51
**Babies can have an increased enterohepatic circulation = more Unconjugated Bilirubin (UCB) resorption
Cause:
1. Meconium
2. Dehydration
3. Decreased GI motility
52
Jaundice (Hyperbilirubinemia): yellowing of skin from bilirubin
Visible at levels of 85-120umol/L
53
Notable Risk Factors for Severe Hyperbili:
1. <38 weeks GA
2. Previous siblings with severe hyperbili
3. Visible burising
4. Cephalhematoma
5. Male
6. Maternal age > 25 years old
7. Asian or European background
8. Dehydration
54
Breast milk jaundice
1 in 200 breast fed infants
- B-glycuronidases in breast milk --> unconjugates --> causes increase enterohepatic uptake of UCB
- Onset 4-7 days of life --> Peak 2-3 weeks of life --> resolve by 6w
- Levels reached are NOT concerning
iv.
55
Indications for work up of jaundice
a. <24 hrs
b. Conjugated bili (>35umol/L)
c. Unconjugated that rises rapidly or excess of age or weight
d. Persistent jaundice >1-2 weeks age
