Neonatology Flashcards
Describe routine care for a newborn
APGAR: Appearence, Pulse, Grimace, Activity, Respiratory
- Weight, height, head circumference
- warmed and patted dry
- topical erythromycin eye drops within 2 hours
- vitamin K1 injection within 1 hour
- skin to skin contact
- Heel prick between 48-72hrs of life: phenylketonuria, galactosemia, congenital hypothyroidism, congenital adrenal hyperplasia, cystic fibrosis, sickle cell, thalassemia
Discuss the presentation and management of erythema toxicum
- is a benign self-limited asymptomatic skin condition occurring after birth and lasting for 2 weeks
- small erythematous papules, vesicles with surrounding erythematous halo that are transient
List some contraindications to breast feeding
- HIV positive mother
- HTLV-1 positive mother
- Herpes lesion of breast
- Child with galactosemia
- Mother taking penicillin, anti-metabolite or recreational drugs
Discuss the benefits of breastmilk
- contains many calories, hydration, antimicrobial and immunologic properties
Colostrum - high level of antibodies, low fat and high protein
- IgA that protects GI tract and increase GI motility
Mature milk (2-5 days) - change according to child needs
- do not require supplement as long as output is normal for baby
- recommended for 6 months
- decreased change of constipation or diarrhea
What are the normal inputs and outputs for a newborn
- Feed every 2-3hrs
- 6-8 wet diapers
- Stool every 1-3 days
When should you begin to initiate solid foods
- > 6 months with better head control, can sit up, ability to tell caregiver when full, pick up food and place in mouth
Discuss order of introducing foods
- iron rich foods first
- add common allergen foods at this time
- avoid juice, honey and sugary drinks
What are the caloric, vitamin and mineral needs in <1 year old
Caloric: 100 kcal/kg/day for first 6 months
Vitamin: 400IU of vitamin D
Minerals:
- Na 3mEq/kg, K 2mEq/kg, Cl 5mEq/kg
- Ca: 210 from 0-6 and then increases as get older
- Iron 1mg/kg
List preventive risk factors of breast feeding for baby and for mom
Baby have lower risk of: - asthma - allergy - diabetes - obesity - sudden infant death syndrome Mother have lower risk of: - breast cancer - hypertension - diabetes - cardiovascular diseae - uterine and ovarian cancer
Discuss the differences between a food intolerance and food allergy
Food Allergy:
- caused by IgE mediated event to even small amount of food
- diagnosed with skin prick test or history of anaphylaxis
Food Intolerance:
- caused by GI mediated response
- symptoms dependent on frequency and amount of intake
- diagnosed with trial elimination
What qualifies as pre-term?
<37 weeks gestation
Discuss pre-term intraventicular hemorrhage
Risk:
- vigourous resuscitatin
- pneumothorax
- hypotensive and hypertensive with fluctuating cerebral blood flow
- coagulopathy
Presentation
- begin 8 hours to 3 days of life and majority are asymptomatic
- routine head ultrasound in all infants <32 weeks to diagnose if do not have any neurologic, cardioresp, or metabolic signs
Management
- supportive and follow up
Discuss retinopathy of prematurity
Risk: high oxygen exposure at birth
Pathophysiology:
- interruption of growth in developing retinal blood vessels -> early vasoconstriction and obliteration of capillary bed -> neovascularization -> macular edema, tear and retinal detachment
Management:
- crytherapy, laser photocoagulation, anti-VEGF
- surgical vitrectomy or scleral buckle
Discuss apnea of prematurity
- is the cessation of breathing for >20 seconds or shorter respiratory pause with hypoxia and/or bradycardia
Management: - usually resolves on its own
- environmental temperature control, proper neck positioning
- oxygenation via nasal prong, CPAP
- Caffeine to increase ventilatory drive by inhibiting adenosine receptor
Discuss respiratory distress syndrome in a preterm
Risk Factors: - low birth weight - maternal diabetes - C-section without labour - meconium aspiration - acidosis, sepsis Pathophysiology: - surfactant deficiency -> high alveolar surface tension -> poor lung compliance -> atelectasis -> hypoxia Presentation: - respiratory distress that onsets within first few hours and worsens Investigation - x-ray: decreased aeration and lung volumes, reticulonodular pattern, atelectasis Management: - steroids for prevention - prophylactic surfactant in <28 week old - supportive O2
Discuss bronchopulmonary dysplasia for preterm
- is an oxygen requirement for >28days at 30 weeks with abnormal chest x-ray
Risks - prolonged intubation and ventilation with high pressure and oxygen
Presentation: - respiratory distress
- rales
- improvement over 2-4 months
X-ray: lung opacification with hyperinflation
Treatment: - reduce risk factors
- furosemide, bronchodilators, corticosteroids
Discuss patent ductus arteriosus
- normally closes within first 15 hours of life due to decreased prostoglandins and then anatomically closes within 2-3 weeks of age
Presentation: - poor feeding with increased fatiguability
- failure to thrive
- machine like murmur at LUSB
Investigations: - left atrial and ventricular hypertrophy on ECG
- increased pulmonary vasculature on CXR
Treatment: - PDE2 antagonist in premature (indomethacin)
- surgical ligation in term or older infants
Discuss necrotizing enterocolitis
Risks: - poor bowel perfusion - hyperosmolar feeds or formula feeds - sepsis Pathophysiology: - bowel ischemia -> mucosal damage -> further enteral feeding lead to bacterial proliferation -> bacterial invasion into bowel wall leading to necrosis and perforation Presentation: - feeding intolerance - increased gastric aspirate or bile - blood in stool - respiratory failure - temperature instability Investigations: - X-ray: pneumatosis intestinalis (intraluminal air), free air, dilated bowel loops Treatment: - NPO minimum one week with TPN - NG tube decompression - IV fluids - IV Amp and Gentamycin for 7-10 days - peritoneal drain if perforation
What is small for gestation age
Infant weight <10th percentile
Symmetric SGA:
- weight, height and HC <10th percentile
- due to 1st trimester congenital infection, chromosomal abnormality, or severe placental insufficiency
Asymmetric SGA:
- weight is only thing affected
- due to 2nd and 3rd trimester from maternal factors or placental insufficiency
Discuss how to differentiate causes of SGA
Maternal Factors: - malnutrition - smoking, drug use, alcohol - vasculopathy - TORCH Placental Factors: - insufficiency - abruption Neonatal: - chromosomal - multiple gestations
List some complications of SGA
- peri-natal: asyphyxiation, meconium aspiration
- metabolic: hypoglycemia, hypothermia, hypocalcemia
What is the management of SGA
- antenetal corticosteroids between 24-34 weeks in week before delivery
- peri-natal: prevent asphyxia by clearing airway
- prevent hypothermia by drying and warming
- serial glucose and calcium checks
- begin feeding
What is large for gestational age
Weight >90th percentile
- genetic causes
- maternal factors: obesity, excessive gestational weight gain, diabetes
- prolonged gestation
List some of the complications of LGA
- increases risk of morbidity and mortality
- increased birth injury risk
- respiratory: respiratory distress syndrome, transient tachypnea of the newborn
- metabolic: hypoglycemia, polycythemia and increased viscosity
- obesity and diabetes later in life
- neurodevelopmental disorder
Discuss the metabolism of bilirubin
Heme oxygenase breaks down RBC into iron, CO, an biliverdin -> biliverdin converted to bilirubin -> bilirubin binds to albumin which transports it to the liver -> conjugated to glucuronic acid by glucuronosyltransferase -> conjugated bilirubin can then be secreted into the bile -> can have enterohepatic circulation as beta-glucuronidase can deconjugate the bilirubin
Discuss the causes of hyperbilirubinemia
Increased production:
- isoimune-mediated hemolysis: ABO or Rh incompatibility
- RBC membrane defects: herediatroy spherocytosis or elliptocytosis
- Erythrocyte enzymatic defects: G6PD deficiency, pyruvate kinase deficiency
- Sepsis
- Polycythemia
- Cephalohematoma or bruising
Decreased clearance:
- Crigler-Najjar
- Gilbert
- Congenital hypothyroidism or galactosemia
Increased enterohepatic circulation:
- intestinal obstruction
- breast feeding failure
- breast milk jaundice
Discuss the presentation of hyperbilirubinemia
Jaundice: progresses cephalocaudal Acute bilirubin encephalopathy: - Phase 1: fatigue, mild hypotonia - Phase 2: febrile and lethargic with poor suck - Phase 3: apnea, inability to feed, fever, seizures, hypertonicity Kernicterus: after first year - cerebral palsy - hearing loss
Discuss the management of hyperbilirubinemia
- Both plotted based on gestational age, risk factors (asphyxia, resp distress, acidosis, sepsis, temperature instability, isoimmune, G6PD) and post-natal age
Phototherapy: - first line and require complete exposure - if severe will not take out to feed
Exchange transfusion:
Discuss the transition of the neonatal blood circulation
labour increases catelcholmines which stop pulmonary secretion and increase resorption -> mechanical pressure from birth pushes fluid out -> first breath air displaces fluid and air entry dilate pulmonary blood vessels decreasing resistance -> umbilical vein clamp increases systemic vascular resistance closing right to left shunts
Discuss neonatal resuscitation algorithm
Good APGAR score can move onto routine care (warmth, clear airway, dry, ongoing evaluation)
- If not breathing or poor tone in first 30 seconds begin to warm, dry and stimulate with rubbing and toe flicking
- if no response, if HR below 100, gasping or apnea present begin PPV and Sp02 monitoring
- if HR below 100 take ventilation steps by intubation, CPAP and high FiO2
- if HR below 60 than chest compressions with 3 every 2 seconds and 2 breaths with 100% FiO2
- continue for 15-20 minutes or until resuscitation successful
Discuss the causes of neonatal respiratory distress
- CNS (asphyxia encephalopathy)
- Respiratory (ARDS, TTN, pneumothorax)
- infection
- cardiac
List the causes of hypoxic ischemic encephalopathy
Maternal Factors: - impaired oxygenation - inadequate perfusion: shock, pre-eclampsia, chronic vascular disease Placental Causes: - placental abruption - tight nuchal cord - cord prolapse - uterine rupture Fetal causes: - hemorrhage, bradycardia or thrombus preventing oxygenation
Discuss presentation of neonatal encephalopathy
- poor tone with abnormal posturing and diminished spontaneous movements
- abnormal level of consciousness
- absent primitive reflexes
- low APGAR scores
List the common causes of neonatal seizures
- Hypoxic-ischemic encephalopathy
- intracranial hemorrhage
- CNS infection (TORCH, meningitis)
- Metabolic: hypoglycemia, hypocalcemia, hypomagnesemia
Discuss the investigations and management for neonatal hypoglycemia
- those with risk factors should have glucose examined from 1 hr of life ever 3-6 hours before feeds for 12 hours
Treatment: - symptomatic hypoglycemia (<2.6): IV dextrose
- asymptomatic severe (<1.8 at 2hrs or <2 anytime): IV dextrose
- asymptomatic, mild (1.8-2 at 2 hours or 2-2.5) then re-feed and check in 1 hour
Discuss the presentation and red flags for poor feeding in neonates
- lack of interest in feeding or problem with receiving proper amount of nutrition
Red flags: - fever
- respiratory distress
- inconsolable crying, irritability, lethargy, decreased LOC
- failure to thrive
Discuss the differential for poor feeding in neonates
Behavioural: - inappropriate feeding technique - insufficient lactation - maternal/infant dysfunction Interference with Physical Eating - CP, neuromuscular disorder, hypotonia - upper airway: nasal obstruction, cleft palate, adenoid hypertrophy - GERD - esophageal dysmotility syndrome Systemic: - infection - metabolic - congenital heart disease - vomiting or constipation
What is lethargy in neonates?
Reduced alertness and awareness due to generalized brain dysfunction
Discuss the presentation of cow’s milk protein allergy
- subacute or delayed colitis
- vomiting
- diarrhea
- bloody stool
- failure to thrive
Discuss the three types of non-pathological jaundice and when they most likely appear
Physiologic Jaundice:
- Occurs >1 day to 1 week
- Pathophysiology: decreased bilirubin excretion from immature liver and increased enterohepatic circulation.
- also have increased bilirubin production due to increased RBC volume and shorter RBC lifespan
Breastfeeding Jaundice:
- occurs 3-4 days to 10 days
- due to poor milk supply or insufficient feeding resulting in increased enterohepatic circulation and dehydration resulting in greater jaundice
Breastmilk Jaundice
- occurs 1-2 weeks to 1-3 months
- human milk may inhibit enzymes of conjugation
