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GME - Residency > Neonatology > Flashcards

Neonatology Flashcards

1
Q

What warmer steps do you need to check prior to a delivery?

A

Warmer steps:
• Turn warmer and lights on
• Set towels on bed
• Set O2 flow to 5 LPM and 21%
• Turn suction on and set to 80-100
• Set PIP to 20 and PEEP to 5
• Connect oxymetry/telemetry
• Check that you know where the code button is!

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2
Q

What equipment other than the warmer do you need for a delivery?

A

• Stethoscope
• Masks for term and preterm babies
• Bulb suction
• Intubation supplies (laryngoscope, ET tube, stylet, syringe, capnography, tape, scissors)
• UVC kit

• For < 32 weeks: warming bag, surfactant

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3
Q

When a baby is first delivered, you look for __________________. If these are all reassuring, the baby can go back to the mother.

A

term (does it look term?), tone (is the baby active and flexing/extending limbs?), and tantrum (is the baby crying?)

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4
Q

If the first three items are not all reassuring (e.g., the baby looks preterm, is not moving appropriately, or is no crying), then you should get the cord clamped and cut by ____________ seconds.

A

30

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5
Q

When the baby is first brought to the warmer, the first thing you should do is _______________.

A

dry and stimulate the baby

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6
Q

If the baby is not vigorous with drying and stimulating, then __________________.

A

suction mouth and nose (in that order!), reposition airway, auscultate for HR, and place on telemetry

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7
Q

If the baby is not vigorous, has labored breathing, or has HR <100 after 60 seconds of life and has undergone 30 seconds of suctioning/repositioning, then ______________.

A

initiate PPV

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8
Q

If a baby’s HR is less than ____ after 30 seconds of adequate PPV, then call a code and initiate compressions.

A

60 BPM

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9
Q

What is MRSOPA?

A

A mnemonic for remembering how to troubleshoot ventilation:
• Mask adjustment
• Reposition airway (“sniffing position”)
• Suction mouth/nose
• Open mouth
• PIP increase
• Airway escalation (ETT)

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10
Q

____________ before progressing to compressions.

A

Intubate

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11
Q

After 30 s of compressions, give _____________ if the baby fails to correct.

A

epinephrine

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12
Q

What is one formula for GIR?

A

(ml/kg/d of TPN x % dextrose of TPN) / 144

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13
Q

What’s a good rule-of-thumb for dealing with residuals?

A

• First, assess the residual: is there bile or blood in it? If so, consider what’s going on.
• Second, assess the baby: is the baby distended, uncomfortable, vomiting, or constipated? If so, this may change your DDx.
• Third, if the residual is < 50% of the feed and there are no concerning features (like those listed above), then you’re ok to give the residual and the next feed.
• Fourth, if the residual is >50% of the feed and there are no concerning features, then give the residual plus whatever would equal the next feed.

  • Also consider spacing out the duration of the feeds.
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14
Q

The cutoff for duration of apnea between periodic breathing and apnea is ___________.

A

20 seconds

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15
Q

The dosage range of caffeine for apnea of prematurity is _______________.

A

5 - 10 mg/kg/d

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16
Q

Review normal neonatal vitals.

A

• HR: 100 - 180
• RR: 40 - 70
• BP: MAP = gestational age (e.g., a 25-weeker should have MAP ~ 25)
• SpO2: >95%

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17
Q

Normal UOP for a neonate is _________.

A

> 1.0 ml/kg/hr

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18
Q

The one thing to be aware of when a preemie is trying to breastfeed is _______________.

A

that the milk letdown can actually overwhelm the kid and make them desat; as such, have moms tell RNs so that they can assess for respiratory distress/hypoxia/bradycardia

• A sidenote: if this becomes a problem, moms can pump before trying to feed so that the kid is not flooded with milk letdown.

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19
Q

Review the types of cranial birth injuries.

A

Here they are from superficial to deep:
• Caput succedaneum: soft tissue swelling (above the skull bones)
• Subgaleal hematoma: bleeding above the periosteum but below the subcutaneous aponeurosis – caused by bleeding of the emissary veins from the dural sinuses to the scalp (crosses suture lines)
• Cephalohematoma: periosteal bleeding (i.e., bleeding under the periosteum of one skull bone – follows one bone line)
• Epidural hematoma: bleeding beneath the bones but above the dura (no superficial findings)

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20
Q

In a head US, it is normal to see what in the septum pellucidum?

A

The septum cavum – a cavity within the developing septum pellucidum

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21
Q

What is the neonatal gastric decompression tube called?

A

Replogle

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22
Q

Caffeine is often continued until ______ weeks.

A

32

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23
Q

Caffeine has been shown to decrease what negative outcomes?

A

• Neurodevelopmental delay
• CP
• Need of supplemental oxygenation
• Intubation rates
• BPD (which is thought to be due to decreased intubation rates with caffeine use)

The landmark study was a 2007 RCT in NEJM: “Long-Term Effects of Caffeine Therapy for Apnea of Prematurity”

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24
Q

Review the different types of formula.

A

• Similac Special Care (SSC): standard energy is 24 kcal/oz; may be fortified to 30 kcal/oz; typically used for preemies <2 kg
• Similac Neosure: standard energy is 22 kcal/oz; may be fortified; typically used for preemies > 2 kg
• Similac Advance: standard caloric density is 20 kcal/oz; typically used for term kids
• Alimentum: this is a peptide product with elementals that is used for malabsorption or suspected milk intolerance
• Elecare: an elemental formula used for kids with severe food allergies or GI impairment

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25
Q

When should you automatically go to the Newborn Critical Care Center’s feeding protocols?

A

When the child is younger than 32 weeks or 2 kg

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26
Q

In evaluating neonatal hyperbilirubinemia, you should think of what two things?

A

• Light level (using BiliTool or preemie weight charts)
• Rate of rise (to calculate when to recheck levels)

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27
Q

Infants less than _________ always get intubated in the delivery room.

A

25 weeks

At 25 weeks you can try CPAP, and above 25 weeks you should try CPAP before intubation.

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28
Q

What are the indications for vitamin A treatment?

A

• Born < 27 weeks
• Born > 27 weeks and < 1000 g and needing supplemental O2 at 24 hours life

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29
Q

Vitamin A is given for ___________.

A

4 weeks (three times a week)

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30
Q

Vitamin A has been shown to be associated with ______________.

A

decreased mortality and decreased use of O2 at one month of life (from decreased BPD)

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31
Q

______________________ need to be given through UALs to keep them open.

A

Isotonic amino acids

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32
Q

What is the +6 rule?

A

ET tube depth:
• 1 kg: 7 cm
• 2 kg: 8 cm
• 3 kg: 9 cm

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33
Q

What is the rule of thumb for ETT size?

A

The week of gestation +/- 2:
• Size 2.5: 22 - 27 weeks (because 25 +/- 2)
• Size 3.0: 28 - 32 weeks (because 30 +/- 2)
• Size 3.5: 33 - 37 weeks (because 35 +/- 2)
• Size 4.0: 38 - 42 weeks (because 40 +/- 2)

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34
Q

You should use CPAP in kids younger than __________.

A

35 weeks gestation

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35
Q

Review APGAR.

A

• Done at times 1 minute, 5 minute, and ten minute or until > 8
• Score:
- Appearance: 2 = pink all over, 1 = acrocyanosis, 0 = cyanotic/pale all over
- Pulse: 2 = > 100, 1 = < 100, 0 = pulseless
- Grimace: 2 = cries when stimulated, 1 = grimace when stimulated, 0 = no response
- Activity: 2 = flexing against resistance, 1 = some flexing, 0 = floppy
- Respiration: 2 = good cry, 1 = weak cry or slow breathin, 0 = no cry, apneic

36
Q

What are initial fluid goals for preterm and term infants?

A

• Preterm: 80 ml/kg/d
• Term: 60 ml/kg/d

37
Q

Giving bicarb to a patient who can’t _________ will actually make them acidotic.

A

ventilate

If they can’t breathe off CO2, then giving bicarb will actually increase CO2 and thus make them acidotic.

38
Q

Preemie babies typically have what kind of metabolic acidosis?

A

Non-gap secondary to loss of bicarb at the proximal and distal tubules.

39
Q

Capillary blood gases are like ABGs but ______________.

A

the pCO2 is 5-10 higher

40
Q

How is the base excess affected in metabolic alkalosis?

A

It is positive.

41
Q

It’s ok for preemies to have what blood-gas abnormality when they are on a vent/NIPPV?

A

Permissive hypercapnia (with pH 7.25 7.30)

This allows for decreased ventilation which decreases the risk of BPD.

Be sure to not go too much more acidotic than this because excessive pCO2 can cause increased ICP and thus increased risk of IVH.

42
Q

Respiratory alkalosis leads to increased risk of what long-term outcome?

A

Periventricular leukomalacia

This happens because decreased CO2 causes cerebral vasoconstriction.

43
Q

Why do preemies have anemia?

A

There are two reasons:
• EPO production is suppressed in utero. The PaO2 of placental blood is 20! Because of this, babies would have erythrocytosis if the EPO weren’t suppressed.
• Low iron stores. The third trimester is the iron-storing trimester.

44
Q

Compare and contrast omphalocele and gastroschisis.

A

Omphaloceles are membrane covered, midline, more likely to contain extra-intestinal organs, and associated with aneuploidies.

Gastroschisis is uncovered, shifted to the right, and not associated with syndromes.

45
Q

In what cases should you screen a baby for recreational drugs?

A

• Known or suspected maternal drug use (UNC policy says within 3 years prior to delivery)
• Little or absent prenatal care
• Baby exhibiting symptoms that could be related to maternal drug use (e.g., high-pithced cry, hypertonia, yawning/sneezing, poor feeding, vomiting/diarrhea, sweating, temperature instability, seizures)
• Bloodborne disease

46
Q

True or false: buprenorphine shows up on standard urine toxicology assays.

A

False

As such, babies may have opiate withdrawal even with a negative opiate screen.

47
Q

True or false: UNC policy says that mothers on medication-assisted treatment should not breastfeed.

A

False

UNC policy encourages mothers who are suspected to be well-controlled on MAT to breastfeed.

48
Q

What prescription medicine can cause newborns to have withdrawal-like symptoms?

A

SSRIs

49
Q

For chorioamnionitis, it’s best if mom gets ____ hours of antibiotics prior to delivery.

A

greater than 4

50
Q

What antibiotics are preferred for chorioamnionitis?

A

• First line: ampicillin and gentamicin
• If penicillin allergic: clindamycin or vancomycin and gentamicin

51
Q

Neonatal jitteriness can be caused by __________________.

A

hypoglycemia, withdrawals (if > ~48 hours), in utero SSRI exposure

52
Q

What is an important feature to assess when generating a differential for neonatal jitteriness?

A

Do the jitters extinguish with pressure. If the jitteriness does not abate when the mom holds the child (i.e., she feels the child beat against her hands) then that is concerning for seizure.

53
Q

Healthy term babies should have _____ feeds per day.

A

8-12

54
Q

Which babies need to be screened for asymptomatic hypoglycemia?

A

• LGA
• SGA
• Infants of diabetic mothers
• Preemies (<37 weeks)
• Any FMH of hypoglycemic disorders

55
Q

Trivia time: What is the eponym associated with the bilirubin nomogram?

A

The Bhutani nomogram

56
Q

Why do babies have hyperbilirubinemia?

A

• Liver enzymes have yet to mature. In utero, babies use the maternal hepatic enzymes. When we’re born, the expression of uridine glucuronosyltransferase is only 1% of adult levels. It matures to 100% by around day 14 of life.
• Increased enterohepatic recirculation. In adults the gut bacteria convert bilirubin to excretable forms. In babies the bilirubin doesn’t get converted and is able to be recirculated.
• RBCs have a shorter half-life and the turnover is increased (thus increasing production).

57
Q

What is the differential for unconjugated hyperbilirubinemia in the neonate?

A

• Increased RBC production:
— Erythrocytosis (itself secondary to LGA status)

• Increased RBC destruction:
— Hematoma
— Sepsis
— G6PD
— Spherocytosis

• Impaired bilirubin conversion:
— Crigler Najjar
— Gilbert’s

• Impaired bilirubin excretion:
— Breastfeeding jaundice (not eating enough to poop it out)
— Breast milk jaundice (persistent hyperbilirubinemia secondary to albumin displacement)

58
Q

What workup might you do in diagnosing unconjugated hyperbilirubinemia?

A

• RBC production/destruction:
— CBC
— Reticulocyte count
— Blood smear
— Sepsis w/u (blood/urine cultures, chest x-ray, CBC, TORCH screens)

• Hepatic dysfunction:
— LFTs
— RUQ US

• Risk stratification:
— Albumin
— VBG (acidosis portends worse outcomes in extreme hyperbilirubinemia)

59
Q

What is a good rule of thumb for light levels in healthy term babies?

A

• 24 hours: 12 (10 for medium risk)
• 48 hours: 15 (13 for medium risk)
• 72 hours: 18 (15 for medium risk)

60
Q

What is a good rule of thumb for transfusion levels in healthy term babies?

A

• 24 hours: 19
• 48 hours: 22
• 72 hours: 24

61
Q

Review the recommendations for evaluating babies of mom’s with HSV.

A

First, ensure that the mom has no active lesions. If mom has no active lesions, then baby is not at significant risk of HSV.

Second, if mom has active lesions, assess the baby for signs of infection. If baby has lesions (which is unlikely) then test those lesions and full workup (including LP) and consider preemptive treatment with acyclovir.

Third, if mom has active lesions and baby has no obvious lesions, then test baby’s mucous membranes (mouth, nose, and rectum) for HSV. If baby is positive, then get an LP and treat with acyclovir (duration pending CNS involvement).

62
Q

Start fortifying formula in what situations?

A

• < 35 weeks at birth
• < 2 kg birth weight
• Struggling with volume
• FTT

63
Q

What factors predispose preemies to IVH?

A

• The germinal matrix is present in preemies <32 weeks and involutes after that. It is highly vascular with limited perivascular support, thus with a high risk of bleed.
• Premature infants have poor ability to autoregulate cerebral blood flow and thus cerebral perfusion can vary to a greater degree than in older children and adults.

64
Q

Infants born before ___ weeks are at highest risk of IVH.

A

32

65
Q

Most commonly, babies with IVH will have ___________.

A

no symptoms

Less commonly, babies will present with lethargy, hypotension, and/or bulging fontanelles.

66
Q

Bad intraventricular hemorrhage can lead to what long-term neurologic outcome?

A

Periventricular leukomalacia

67
Q

What clinical factors increase the risk of IVH?

A

• Pneumothorax
• Bolus administration of IVF
• Male sex
• Age < 32 weeks

68
Q

Review the basic interpretation of fetal heart tracings?

A

• Category I: reassuring
• Category II: indeterminate, keep monitoring closely
• Category III: non-reassuring -> intervene immediately

69
Q

The initial pressure needed to inflate neonatal lungs may be as high as _________________.

A

40 cm H2O

70
Q

___________________ presents with acute torticollis, high-pitched cry, fever, and opisthotonos (arching and spasm of the muscles of the back and neck).

A

Acute bilirubin encephalopathy

71
Q

Hypothermia in a neonate is defined as < __ celsius.

A

36.5

72
Q

What is the mechanism of benefit of therapeutic hypothermia?

A

Decreased apoptosis and oxidative stress

73
Q

What congenital problems are infants born to women with pre-gestational diabetes prone to?

A

• Macrosomia
• Hypoglycemia
• Small left colon syndrome
• Asymmetric septal hypertrophy causing ventricular outflow obstruction
• Transposition of the great vessels
• Caudal regression syndrome

74
Q

A newborn hasn’t stooled in two days. The contrast enema shows a transition zone (large -> small) from the splenic flexure to the left colon. Diagnosis?

A

Small left colon syndrome

Commonest in babies of diabetic mothers. Often resolves after meconium plug passes.

75
Q

True or false: bradycephaly means shortening to the vertical axis of the head.

A

False

Bradycephaly is a flattening of the backside of the head. It’s seen in trisomy 21.

76
Q

___________ should be performed in all babies with trisomy 21.

A

Echocardiogram (even if the fetal echo was negative)

77
Q

What is NRP dose of epinephrine?

A

It’s the same as in PALS: 0.01 mg/kg IV or 0.1 mg/kg ETT

78
Q

What is the initial management of NEC?

A

NG decompression and antibiotics

79
Q

Jaundice before what age is always pathologic?

A

24 hours of life

80
Q

What is the concentration of epinephrine that you use for NRP code?

A

1:10,000

81
Q

Review the mnemonic “THE MISFITS” for the critically ill infant.

A

Trauma: RUSH, head CT head, fundoscopy, skeletal survey, and trauma labs
Heart disease: pre and post sats, CXR, POCUS
Endocrine (CAH): if BMP shows hyponatremia and hyperkalemia, then get a cortisol and give hydrocortisone
Metabolic
Inborn errors of metabolism: get a pH, ammonia, urinary ketones
Sepsis
Formula
Intestinal
Toxins
Seizures

82
Q

What nonvascular structure might you see in the umbilical cord?

A

Persistent urachus

83
Q

In NRP, intubate for HR < what?

A

60

84
Q

What two medications are first-line for neonatal seizures?

A

Phenobarbital and short-acting benzos (like midaz)

85
Q

Infection of the umbilical stumped is called what?

A

Omphalitis

86
Q

What adverse effect can NSAIDs cause after 32 weeks gestation?

A

Premature closure of the PDA

87
Q

What is a serious side effect of prostaglandin?

A

Apnea

GME - Residency (112 decks)

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