Newborn Flashcards
Risk factors in newborns for potential issues
- Maternal medical and mental health concerns, positive family history
- Psychosocial and/or socio-economic stressors, domestic violence
- Maternal medications, smoking, alcohol, or substance use
- Abnormal prenatal screening and ultrasound findings
- Birth weight
- Maternal hepatitis B surface antigen, syphilis, HIV, or rubella status
- Maternal blood group and antibodies
- Risk factors for infection, including maternal Group B streptococcal colonization status or intrapartum antibiotic prophylaxis
- Abnormal glucose homeostasis
Developmental dysplasia of the hip - Birth injury
- Apgar score, need for stabilization at birth, and/or low umbilical cord pH
- Risk factors for early-onset neonatal jaundice
What are abnormalities sometimes missed on newborn exam
cleft palate and imperforate anus
Term newborn discharge - what is on check list
Maternal readiness
- Mother provides routine infant care, including feeding, in a safe and confident manner
- Mother demonstrates knowledge of how to recognize illness in her infant and when to seek help
- Psychosocial and environmental risk-factors have been assessed, with an appropriate follow-up plan
Infant health
- Physical examination by health care provider
- Birth weight, length and head circumference measurements obtained
- Normal, stable temperature, heart rate and respiratory rate
- Passed urine
- Passed meconium
- Weight loss <10%; if approaching or >10%, a follow-up plan has been arranged
- Minimum of 2 successful feeds
- Antenatal and perinatal risk factors (e.g., sepsis) have been evaluated
- Maternal serology reviewed
- If circumcision performed, no excessive bleeding at site
What tests need to be done before discharge of healthy term infant (4)
- Newborn screen at 24 h (must be repeated within 7 days if administered before 24 h)
- Hearing assessment completed or arranged
- Bilirubin screening – results reviewed and follow-up arranged, if required
- Pulse oximetry screen performed
What parental education needs to be done before discharge of health term infant
- Routine infant care
- Infant safety and injury prevention (including car seat safety, safe sleep practices, sudden infant death syndrome risk reduction)
- Feeding
- When to seek medical help
- Care of circumcision site, if infant is circumcised
Types of Vit K deficiency B
early onset (first 24 hours): maternal meds that inhibit vitamin K activity, ex antiepileptics classic (days 2 to 7): associated with low intake of vitamin K late onset (2-12 w - 6 mo): breastfed babies
Vit K prophylaxis doses
- 5 mg (≤1,500 g)
- 0 mg (>1,500g)
If decline:
2 mg Vit K PO at first feed, repeat at 2 to 4 and 6 to 8 weeks of age.
When to image in HIE
DOL 3-5 or when rewarming has taken place
Repeat at DOL 10-14 if clinical uncertainty
HIE/Encephalopathy - areas of brain injury
Basal ganglia/thalamic lesions: cognitive and motor disability
High risk CP
Watershed pattern: more associated with cognitive issues
Why do we give IAP for GBS+
To decrease risk of early onset sepsis
NOT late onset
What to do - GBS+ no RF:
GBS+ mother w adeq IAP + no other RF
GBS+ mother w inadeq IAP + no other RF
GBS+ mother w adeq IAP + no other RF: No investigations or tx
GBS+ mother w inadeq IAP + no other RF: Careful P/E, Vitals q3-4h x24h, no CBC
GBS+ mom w or w/o adeq IAP + other RF:
Not clear, Observe 24-48h, consider CBC at 4 h
GBS unknown or negative + other RF
If single RF, can be managed same as GBS+ mother w/wo adeq IAP
If multiple RF, mgmt should be individualized
Maternal and neonatal risk factors for early onset bacterial sepsis in term infants
- Maternal intrapartum GBS colonization during the current pregnancy
- GBS bacteruria at any time during the current pregnancy
- A previous infant with invasive GBS disease
- Prolonged rupture of membranes ≥18 h
- Maternal fever (temperature ≥ 38oC)
Car seat challenge - for who?
no one
What threshold should you use for pRBC transfusion in preterm infants
No resp support:
1st week of life: 100
2nd week of life: 85
3rd week and older: 75
Resp support:
1st week of life: 115
2nd week of life: 100
3rd week and older: 85
What volume of pRBC for transfusion in preterm infants
20ml/kg
Risks of neonatal circumcision
Minor bleeding Local infection (minor) Severe infection Death from unrecognized bleeding Unsatisfactory cosmetic results Meatal stenosis
Benefits of neonatal circumcision
Prevention of phimosis Decrease in early UTI Decrease in UTI in males with risk factors (anomaly or recurrent infection) Decreased acquisition of HIV Decreased acquisition of HSV Decreased acquisition of HPV Decreased penile cancer risk Decreased cervical cancer risk in female partners
What are risks associated with rbc transfusions
Infection (viral, bacterial, etc) – viral risk 1/1 million
CMV: risk for premature infants; risk reduced with leukoreduction
Leukocyte adverse effects (graft-vs-host, TRALI, allo-immunization all rare in neonates)
Volume and electrolyte disturbances
Blood group incompatibility (transfusion errors)
Indications for RBC transfusion in newborns
hemorrhagic shock
anemia
Key competencies for discharge of preterm infant
Thermoregulation
Control of breathing (5-7days apnea free)
Respiratory stability
Feeding skills and weight gain
Sarnat scoring
Sarnat 1
Hyperalert, normal tone, tachycardia
Sarnat 2
Lethargic, mild hypotonia, weak moro, seizures, bradycardia
Sarnat 3
Stuporous, flaccid, no reflexes
Late preterm - at risk for?
Hyperbilirubinemia Feeding and growth Apnea SIDS Sepsis Hypoglycemia Temperature control
What to do w newborn if mom had chorio
individual
observe at least 24h
vitals q3-4h
consider CBC at 4h
when should you monitor vitals of a newborn
chorio
multiple RF
GBS+ and RF
Risk factors for hyperbilirubinemia
Visible jaundice at younger than 24 hours Visible jaundice before discharge at any age Shorter gestation <38 weeks Previous sibling with severe hyperbili Visible bruising Cephalhematoma Male sex Maternal age >25 years Asian/European background Dehydration Exclusive/partial breastfeeding
When does TSB peak
DOL 3-5
When to check first bili
In 24-72h
Side effects of phototherapy
temperature instability, intestinal hypermotility, diarrhea,
interference with maternal-infant interaction and,
rarely, bronze discolouration of the skin
increased anxiety and health care use in parents
When to refer brachial plexus injury?
1 month
What nerves for Brachial plexus
C5-T1
What percent of neonatal brachial plexus injury will have full injury?
75% full recovery
Indications for surfactant therapy
Intubated infants with RDS
Intubated babies with meconium aspiration syndrome and > 50% FiO2 need
Sick newborns with pneumonia and oxygenation index >15
Intubated newborns with pulmonary hemorrhage and clinical deterioration
Xray of RDS
ground glass appearance,
air bronchograms,
↓ lung vol
Who should receive prophylactic surfactant?
<26 WGA
26-27 WGA If no steroids
Risks of surfactant
Short term: bradycardia, hypoxemia, block ETT, pulm hemorrhage, hyperventilation secondary to spontaneously increased FRC and lung compliance Long term: antibody formation against surfactant, possible transmission of infection (prions)
What systems does NAS affect?
CNS, respiratory and GI effects
what % of infants of moms on opioids will require tx for NAS
50-75%
When do sx of NAS present?
usually within 48-72 hours,
up to 5-7 days
can last up to 30 days, with mild symptoms up to 6 months
Finnegan score
- what are sx
- how long/often
CNS: cry, sleep, exaggerated moro, tremors, tone, myoclonus, seizures.
Metabolic/Resp: sweating, fever, yawning, mottling, stuffiness, nasal flare, tachypnea
GI: excessive sucking, poor feeding, emesis, loose stools
Non-Pharm interventions for NAS
Skin-to-skin, swaddling, gentle waking, quiet environment, minimal stimulation, low lighting, music and massage.
Encourage breastfeeding
Pharm interventions for NAS
Morphine and Methadone
Adjuncts: phenobarbitals and clonidine
Factors important in Communicating w Families w a Perinatal Loss
Should be guided by honesty and respect
Info should be provided in a clear, timely and sensitive way to enhance SDM
Both parents should be present if possible
If diff language, should have interpreter present
Should have enough time for dialogue, questions and emotional expression
More than one encounter is usually needed
Should occur in quiet, private space
Small group > large, conference style
“Baby” instead of “fetus” - use name if named
Lesions detectable using pulse ox screening
HLHS Pulmonary atresia w intact vent septum TOF TGA Tricuspid Atresia TAPVR Truncus arteriosus
Pulse oximetry screening - who and when
WHO: all term and late preterm
For asymptomatic infants in nonacute setting
WHEN: recommended 24-36 hours after birth
Flexible - can be done during day, with other tests/events
**Should be done after 24 hours
Pulse ox screening
- how
- pass/fail
Should test RIGHT HAND and ONE FOOT
FAIL: SaO2 < 90%
BORDERLINE: SaO2 in any limb of 90-94% or >3% difference btwn limbs
Who to screen for ROP and when
Either GA <31 wga
OR BW ≤ 1250g
at 31 wga or at 4 weeks old, whichever is first
Tx for ROP
Tx: retinal ablation (conventional) and intravitreal injection of antivascular endothelial growth factor (anti-VEGF)
advantages of kangaroo care
helps stabilize vitals
KC increases sleep time and more organized sleep
Long term - improved neurodevelopmental outcomes
assoc w better Breastfeeding
Decreased infections, NEC and improved growth and neurodevel outcomes
Decreases incidence of nosocomial infections
Improves mother infant bonding b/c NICU separates
How prem can you do kangaroo care
26wga
complications of iNO
production of NO2 and methemoglobin, decreased platelet aggregation, increased risk of bleeding and surfactant dysfunction.
Who to treat with iNO
age
indications
Infants >35 weeks GA (not as effective in prem)
Hypoxemic respiratory failure
Echo to rule out cyanotic heart disease, and to assess for Pulm HTN/cardiac function
OI > 20-25, or PaO2 < 100 despite ventilation with 100% oxygen
What percent of preterm infants born at ≤32+6 weeks gestational age (GA) show an abnormal brain image (IVH or parenchymal lesions) on cranial ultrasound
21%
Who should receive steroids
≤34+6 wga with risk of delivery in the next 7 days
Who should receive MgSO4
mothers at risk for imminent delivery of an infant ≤33+6 weeks GA in the next 24 hours
What to do if PPROM or chorio and infant <33wga
BCx and Abx
What gestation to use polyethylene bag
<32 wga
Preterm infants - what type of ventilation
Target pCO2
Volume targeted
Target PCO2 of 45-55 mmHg
How to reduce risk of brain injury in preterm infant?
Treat mother with PPROM or chorio BCx and Abx for infant of mom w chorio Steroids <35wga MgSO4 <32 wga DCC Avoid inotropes Consider indomethacin Target pCO2 45-55 Volume controlled ventilation Head neutral, midline, HOB 30 deg At tertiary centre
Cut offs for hypoglycaemia
First 72h: <2.6
>72h: <3.3
Infants at risk for hypoglycemia
Weight <10th percentile (SGA)
IUGR
Weight >90th percentile (LGA)
IDM
Preterm infants <37 weeks GA
Maternal labetalol use
Late preterm exposure to antenatal steroids
Perinatal asphyxia
Metabolic conditions (e.g., CPT-1 deficiency, particularly in Inuit infants)
Syndromes associated with hypoglycemia (e.g., Beckwith-Wiedemann)
NRP Resusc:
what FiO2 to start with
For the term infant, resuscitation should start with 21% oxygen.
For preterm infants <35 wga, recommended initial gas is 21%–30% oxygen
NRP: what technique for compressions
two thumb
what gestation do you do thermoregulation measures and what are they
maintaining room temperature at 23°C, preheating the radiant warmer, use of a hat, placing a thermal mattress under the radiant warmer and using a polyethylene wrap
What do steroids do for neuroprotection
IVH
What does MgSO4 do for neuroprotection
CP
