Neonatology Flashcards
What is the most common long term complication of Necrotizing Enterocolitis?
- Stricture formation
Others: short gut syndrome (following resection), bacterial overgrowth
Why are anencephalic infants poor candidates for organ donations?
- Do not satisfy the standard brain death criteria because of adequate brainstem function that maintains spontaneous respiration and heart rate after birth
- By the time death has been declared, the organs will have undergone ischemic damage, making them unsuitable for transplantation
- Use of life support does not improve the chance of successful organ donation from anencephalic infants
How is apnea defined?
Absence of respiratory effort for >20 seconds, or of any duration with associated cyanosis or bradycardia
When does apnea of prematurity usually resolve?
37 wks GA (but may persist for longer in those infants born <28 wks)
What medication should be given in the case of apnea of prematurity?
Caffeine (20 mg/kg loading, 5 mg/kg thereafter)
How to APGAR score?
- Colour- cyanosis, acrocyanosis, pink
- Tone - flat, weak, strong
- Respiratory effort - absent, laboured, regular
- Response to suction - none, grimace, cry
- HR - absent, <100, >100
What virus is most likely to be responsible for Bronchiolitis?
RSV
followed by human metapneumovirus, rhinovirus, influenza, adenovirus, parainfluenza
What is the most common cause for admission to hospital in the first year of life?
Bronchiolitis
Indications for hospitalization in bronchiolitis
- Signs of severe respiratory distress (eg, indrawing, grunting, RR >70/min)
- Supplemental O2 required to keep saturations >90%
- Dehydration or history of poor fluid intake
- Cyanosis or history of apnea
- Infant at high risk for severe disease
- Family unable to cope
What treatments are recommended by the CPS for treatment of bronchiolitis?
Hydration and O2 (HHHFNC is not routinely recommended)
Equivocal evidence is seen for epinephrine, nasal suctioning, dexamethasone + epi
What is the definition for Bronchopulmonary Dysplasia?
Disease process of respiratory insufficiency secondary to prematurity and arrested lung development rather than damage from prolonged ventilation
Mild: previously requiring oxygen for >28 days but now on RA at 36 wks PMA
Mod: <30% O2 at 36 weeks PMA
Severe: requiring >30% O2 at 36 wks PMA
Should dexamethasone be used routinely in the treatment of infants with BPD?
No, as it has many side effects and may worsen neurodevelopment and the increase the risk of CP; only to be considered in the case of severe respiratory distress
What treatments are routine used to prevent BPD in the case of premature infants?
- Goal directed ventilation i.e. reduce barotrauma
- Vitamin A
- Nutritional support
- Surfactant
- Caffeine
- Avoidance of PPHN
How is medication metabolism different in neonates?
- Slower gut motility results in longer half life
- Thinner skin results in faster and greater dermal absorbtion
- Rectal absorption is also increased in neonates
- Decreased drug-protein binding capacity, resulting in more active circulating drug
What is adequate intrapartum antibiotic coverage?
- Penicillin V
- Ampicillin
- Cefazolin
What are the risk factors for early onset sepsis?
1) Maternal GBS colonization
2) GBS bacteriuria
3) Previous infant with invasive GBS dx
4) PROM >18h
5) Maternal intrapartum fever (T >= 38.0C)
How does the CPS suggest community paediatricians manage children based on GBS status?
If well: GBS unknown, GBS+ with 1 risk factor - d/c at 24 hours, if preterm, must monitor for at least 48 hours
If unwell: FSWU unless only respiratory symptoms, then 6 hours observation +/- investigations/BCx
How does transmission rate change based on maternal history of HSV?
- First episode primary: 60%
- First episode nonprimary: 30%
- Recurrent episode: 2%
How should children born to mothers with HSV at birth be managed?
- Deliver first episode primary mothers by C/S if possible and swab MM and NP at 24 hours of life; may d/c home with close follow up if well
- If first episode non-primary or recurrent and delivered SVD or by C/S, swab at 24 hours of life; d/c home with close follow up if well
If first episode primary and SVD, admit, swab and give IV acyclovir x 10 days
If HSV is detected, re-admit for Blood PCR, LP, transaminases and IV acyclovir
- If Blood PCR is positive, 21 days of acyclovir, otherwise, 14 days
How long should children with HSV be observed?
Up to 42 days of age
How to prevent spread of HSV?
- Good handwashing/gloves
- Healthcare workers should take precautions when caring for high-risk patients such as newborns, immunocompromised individuals, and patients with chronic skin conditions
- Patients and parents should be advised re: handwashing and avoiding contact with lesions and secretions, during active herpes outbreaks
- Schools and daycare centers should clean shared toys and athletic equipment at least daily after use
- Athletes with active herpes infections who participate in contact sports such as wrestling and rugby should be excluded from practice or games until the lesions are completely healed
- Genital herpes can be prevented by avoiding genital-genital and oral-genital contact
- Male circumcision is associated with a reduced risk of acquiring genital HSV infection
What are known adverse effects of phototherapy?
- Temp instability
- Gut hypermotility/diarrhea
- Interference/disruption of maternal-child bond
- Bronze discolouration of skin (rare)
- > parental anxiety/healthcare use
What is the most common cause of hemolytic disease of the newborn?
ABO incompatibility
What precautions can be taken to prevent future Rh incompatibility?
- Rh- mom: 300μg IM RhoGAM (anti-D globulin) within 72h of delivery of a Rh+ infant, ectopic pregnancy, abdo trauma in pregnancy, amnio, abortion
- All women who are Rh- and fetal blood type is unknown or known to be Rh+ should have Rhogam at 28 weeks and at 34 weeks
What are the bilirubin thresholds for phototherapy and for exchange transfusion?
Phototherapy: 250, 300, 350
Exchange transfusion: 325, 375, 425
What are the criteria to qualify for cooling?
Term and late preterm infants ≥36 weeks GA, ≤6 hours old and who:
A. Cord pH ≤7.0 or base deficit ≥−16
OR
B. pH 7.01 to 7.15 or base deficit −10 to −15.9 on cord gas or blood gas within 1 h AND
1) Hx of acute perinatal event (cord prolapse, placental abruption or uterine rupture)
2) Apgar score ≤5 at 10 mins or at least 10 mins of PPV
AND
C. Evidence of moderate-to-severe encephalopathy (seizures OR at least one sign in 3 or more of “SPLATR”)
Spontaneous activity Posture Level of consciousness Autonomic dysfunction Tone Reflexes (primitive)
Which infants should not qualify for cooling?
Exclusion criteria include:
• Moribund infants or infants with major congenital or genetic abnormalities for whom no further aggressive treatment is planned
• Infants with severe IUGR
• Infants with clinically significant coagulopathy
• Infants with evidence of severe head trauma or intracranial bleeding
What areas of the brain are affected in HIE?
Cerebral arteries shunt blood flow from the anterior circulation to the posterior circulation to maintain adequate perfusion of the brainstem, cerebellum, and basal ganglia
As a result, damage is restricted to the cerebral cortex and watershed areas of the cerebral hemispheres
What are the side effects of hypothermia/cooling?
- Sinus bradycardia (HR 80 to 100 bpm)
- Hypotension
- Mild thrombocytopenia
- PPHN with impaired oxygenation
- Prolonged bleeding time
- Subcutaneous fat necrosis, +/- hypercalcemia
What is the optimal temperature of whole body cooling?
33.5 C
What are the potential side effects of indomethicin?
- Renal dysfunction i.e. oliguria
- GI dysfunction i.e. bleeding, ulceration, reduction of blood flow, association with NEC
- Abnormal platelet aggregation
- Hyponatremia
- Hyperkalemia
- Hypoglycemia
What are the teratogenic effects of poorly controlled diabetes during pregnancy?
- Septal hypertrophy (ASD, VSD and other malformations)
- Caudal regression syndrome
- Small L colon syndrome
- Hypoglycemia
- Renal agenesis or malformation
- LGA
- Hyperinsulinism and associated hypoglycemia
- Polycythemia as a result of extramedullary hematopoiesis
- Holoprosencephaly
When is acne concerning in a child/infant?
Between 3 months and 7 years
must look for abnormal source of androgens
What is the greatest risk factor for development of NEC?
Prematurity
• Immature mucosal barrier
• Immature local host defenses i.e. low [ ] of IgA, mucosal enzymes (eg, pepsin and proteases), and other protective agents (eg, lactoferrin)
• Increased gastric pH (promotes bacterial overgrowth)
• Immature bowel motility
What signs of NEC can be seen on AXR?
- Portal venous gas
- Pneumoperitoneum/free air
- Dilated bowel loops (asymmetric)
- Bowel wall edema (+/- thumbprinting)
What is the underlying cause of neonatal thyrotoxicosis?
Transplacental movement of TRSAb (Neonatal Grave’s Disease)
What is the treatment for neonatal thyrotoxicosis?
- Propranolol 1-2 mg/kg/24 hrs PO divided TID
- Methimazole 0.25-1 mg/kg/24hr PO divided q 12hr
- Saturated KI (1 drop per day) may also be added
- Other treatments
- IV fluids and corticosteroids
- Digitalis if heart failure is present
Basic principle: Antithyroid medications until euthyroid state is achieved (x3-4 months), as antibodies break down will remit spontaneously
If persistent consider genetic cause i.e. McCune-Albright syndrome
What are the clinical manifestations of neonatal thyrotoxicosis?
- Prematurity
- Goiter
- Exophthalmia
- Extreme tachycardia and tachypnea
- Hyperthermia
- Weight loss despite ravenous appetite
- Hepatosplenomegaly
- Jaundice
- Hypertension and cardiac decompensation
- High T4 and T3, low TSH
- Advanced bone age
- Frontal bossing with triangular facies
- Craniosynostosis
What are 4 systems that are affected by Neonatal Lupus?
- Cardiac - complete heart block
- Dermatologic - annular, erythematous papulosquamous rash with fine scale and central clearing
- Hematologic - thrombocytopenia
- Hepatic - elevated liver enzymes, cholestatic hepatitis, hepatomegaly
- Neurologic - macrocephaly, hydrocephalus, spastic paraparesis
What are the treatment measures for Neonatal Lupus?
- Fetal echo to assess heart block and endocardial fibroelastosis; may require treatment with dexamethasone / betamethasone +/- sympathomimetics
- Pacemaker may be required soon after birth for neonates with complete heart block
- Classic NLE rash does not require treatment; steroids may hasten healing but may increase risk of telangiectasias
- Severe cytopenias may require treatment with IVIG
- Future pregnancies require expectant management with FHR monitoring and mothers with autoantibodies may be treated with hydroxychloroquine (17% chance recurrence)
What are some causes of PPHN that lie in the functional vasoconstriction category?
- Hypoxia/asphyxia
- Aspiration
- Infection
- RDS
What are some causes of PPHN that lie in the functional obstruction category?
- Polycythemia
* Hyperfibrinogenemia
What are some maladaptive causes of PPHN?
- IUGR
- Placental insufficiency
- Postdates
- Premature closure of PDA
What are some underdevelopment causes of PPHN?
- CDH
- Hypoplastic lung
- Congenital lung malformation
What is the gold diagnostic tool for PPHN?
ECHO
Should sedation be used in PPHN?
Yes, to facilitate ease of ventilation, but no paralysis as this is associated with increased mortality
What are the benefits and side effects of nitric oxide?
Benefits:
• Potent and selective pulmonary vasodilation without decreasing systemic vascular tone
• Combines with hemoglobin to form methemoglobin, which prevents systemic vasodilation (selective effect)
• Reduces V/Q mismatch by entering only ventilated alveoli and redirecting pulmonary blood by dilating adjacent pulmonary arterioles
Potential side effects: • Platelet dysfunction • Pulmonary edema • Methemoglobinemia • Production of toxic byproducts such as nitrates
What drugs can be used in the management of PPHN?
- Surfactant
- Corticosteroids
- Bosentan
- Sildenafil
- Nitric Oxide
- Milrinone
- ECMO
What are the clinical indications for using BLES?
- Prophylactically to all infants < 26 weeks and to those 26-27 weeks who have not received antenatal steroids
- Consider retreatment if persistent / recurrent O2 requirement of 30% or more and may be given as early as 2 hours after the initial dose (more commonly 4-6 hours after initial dose)
- Intubated infants with RDS
- Intubated infants with MAS requiring >50% oxygen should receive exogenous surfactant therapy
What is the clinical definition of Respiratory Distress Syndrome (hyaline membrane disease)?
The presence of acute respiratory distress with disturbed gas exchange in a preterm infant with a typical clinical course or x-ray (ground glass appearance, air bronchograms and reduced lung volume)
When does the CPS suggest resuscitative efforts in a newborn can be discontinued?
In infants with an Apgar score of 0 after 10 mins of resuscitation, if the HR remains undetectable, it may be reasonable to stop assisted ventilation; however, the decision to continue or discontinue resuscitative efforts must be individualized
