Newborn and Neonatal Medicine Flashcards
Differentiate term newborn, prematurity, and post mature
Newborn (37-42 wks gestation)
Prematurity (< 37 wks)
Post mature (+42 wks)
What is gestational age and how is it determined?
= Number of weeks after mother’s last menstrual period
Estimated via last 1st trimester U/S (Obstetric dating) or by physical exam (Ballard Scoring)
_____ weeks gestation considered compatible with life.
24
Complications of prematurity
- Intraventricular hemorrhages
- ARDS = surfactant deficiency = Hyaline Membrane disease
- Retinopathy
- Necrotizing Enterocolitis
- Fluid and lyte imbalances
What are the birth weight ranges of normal vs preterm infants?
Normal: 2500 to 4500 grams (5lbs 8oz to 9lbs 4oz)
Low birth weight (LBW): < 2500 grams (5lbs 8oz)
Very low birth weight (VLBW): < 1500 grams (3lbs 5oz)
Extremely low birth weight (ELBW), “micro-premies”: < 1000 grams (2lbs 4oz)
Causes of prematurity
Maternal: premature rupture, trauma, cervical incompetence, vaginal infection, multiple birth, smoking/drugs, eclampsia
Fetal: fetal growth restriction/ fetal distress, macrosomia/LGA, polyhydramnios
Complications of post maturity
growth failure, meconium aspiration, neonatal hypoglycemia
Percentile of gestational weights of SGA, AGA, and LGA
SGA: Birth weight < 10th percentile for gestational age
AGA: Appropriate for gestational age, between 10th and 90th percentile
LGA: > 90th percentile for gestational age; infant of diabetic mother (IDM)
APGAR Score
Score measured at 1 and 5 mins that indicates newborn current status and response to resuscitation efforts
effects of oligohydramnios and polyhydramnios
too little or too much amniotic fluid around fetus
Oligohydraminos think renal or pulmonary defect
Polyhydramnios think abdominal defect
mild symptoms of Fetal Alcohol Syndrome or “fetal alcohol effects”
ADHD, learning delays, behavioral problems, conduct d/o, increased risk of criminal activity
Signs of Fetal Alcohol Syndrome
THIN UPPER LIP WITH SMOOTH PHILTRUM (FAS until disproven) Microcephaly Growth retardation Short nose Cardiac Defects Micropthalmia - small eyes Small distal phalanges Cleft lip/palate
Causes of increased and decreased AFP (alpha-fetoprotein)
increased: Neural Tube Defects, Abdominal wall defects
decreased: Trisomies; primarily Down’s syndrome
What maternal serum samples make up the quad screen for Down syndrome?
aFP
hCG
Unconjugated estriol
Inhibin A
Group of congenitally acquired infections which may cause significant morbidity and mortality in neonates
TORCH infections
- Toxoplasmosis
- Other (Syphilis, Parvovirus, VZV, Hep B, HIV)
- Rubella
- CMV
- HSV
How are infants positive for Toxoplasmosis treated?
IV PCN G and undergo spinal tap
If mother positive for Hep B or unknown at delivery ________ given to infant at birth.
Hep B vaccine and immunoglobins
What happens if pregnant women gets Varicella Zoster virus?
before 20 wks: in utero death
after 20 wks: high mortality; variable presentation - CNS infections, limb anomalies, blindness, pneumonias, cutaneous lesions/scarring
tx of Varicella Zoster virus
ZV Ig and Acyclovir for mother and infant
Which vaccines are live and can’t be given to pregnant women?
MMR, Varicella, and live attenuated influenza
What does parvovirus cause?
Erythema infectiosum (Fifth Disease, Slapped Cheek)
Treatment for parvovirus infection (erythema infectiosum)
supportive; can’t do much for this
Per AAP and CDC, all pregnant women HIV+ will start on _________. Her child will also be treated similarly until confirmation at _____ old.
antiretroviral therapy
6 weeks
Which viruses are contraindicated for nursing?
HIV, Hep B
Signs of Rubella in 1st trimester and after?
1st trimester: microcephaly, blueberry muffin spots
After: congenital rubella triad- carditis, ophthalmitis, sensorineural hearing loss
dx and tx of infant rubella infection
dx: infant rubella IgM titers
Tx: supportive
types of scalp hematomas
Caput Succadaneum: edema of scalp secondary to birth trauma
Cephalohematoma: blood along periosteum contained w/i suture lines
Subgaleal bleed: beneath epicranial aponeurosis; uncommon but can cause hemorrhagic shock
epicanthal folds indicate ________.
Down syndrome
No Red reflex on newborn eye exam could indicate _______.
retinal blastoma
Things to look for on newborn neuro exam
Tone
Primitive reflexes
Nerve Palsies
Primitive reflexes that appear at birth? When do they usually disappear?
Moro, hand/toe grasp, Galant reflex
* ATNR at 2 wks
Usually disappear about 6 months
Why is erythromycin ophthalmic ointment AAP required for all newborns?
Prevents gonococcal ophthalmia neonatorium which can cause ocular perforation and blindness
Vit K required for what?
synthesis of coag factors II, VII, IX, and X
conversion of inactive precursors into active clotting factors
Why is there a Vit K decrease after birth?
- Poor placental transfer of maternal Vit K
- Immature liver function
- Delayed synthesis of Vit K in colon
Signs of Vit K deficiency in neonates
sites of bleeding; oozing from injection sites, umbilical stump, circumcision, vaginal/rectal, intracranial
elevated PT/INR, PTT
What does Vit K protect against?
hemorrhagic disease of newborn
Which bilirubin levels can be measured directly?
total and conjugated
Pathophysiology behind neonatal jaundice
- Increased breakdown of fetal erythrocytes which have shorter lifespan than non-fetal RBCs
- Low excretory capacity of immature liver
unconjugated vs conjugated bilirubin
unconjugated/indirect: before liver; RBC breakdown in blood
conjugated/direct: after liver; secreted to bile and small intestines
Kernicterus
aka Bilirubin encephalopathy
bilirubin mostly deposits in basal ganglia, so first sign is movement disorder
sx: hypotonia, lethargy, vomiting, seizures, death
caused by elevated unconjugated bilirubin that can cross BBB
Hyperbilirubinemia treatment
Phototherapy:
- Follow nomogram
- Converts indirect bilirubin into a water soluble form
- Encourage increased hydration
Exchange Transfusion if phototherapy doesn’t work (rarely used)
DDX of hyperbilirubinemia
Indirect:
- Physio, breast feeding, or breast milk jaundice
- Increased RBC breakdown
- RBC hemolysis (ABO or Rh incompatibility)
Direct:
- Liver/biliary system
- Biliary atresia (r/o with U/S)
- Hypothyroid
Breast feeding vs. Breast milk Jaundice
Breast feeding due to inadequate intake or production that causes bilirubin concentration (“dehydration”); day 2-4
tx: increase feeds
Breast milk due to enzyme in milk which inhibits conjugation; week 1-3
tx: self-limiting
AAP recommendations for when to get total bilirubin levels
- every infant who is jaundiced in the first 24 hours after birth
- excessive jaundice for age
- Before discharge, every newborn should be assessed for risk of developing severe hyperbilirubinemia with a nursery protocol
Bilirubin discharge planning
Ensure f/u within first few days for total bilirubin
< 24 hrs old: within 3 days (may require 2 visits)
24-48 hrs: within 4 days
48-72 hrs: within 5 days
Standard of care management prior to hospital discharge
erythromycin eye ointment, Vitamin K, bilirubin screen, hearing screen, newborn screen, Hep B vaccine
Newborn/Infant anticipatory Guidance for parents
Infant Care Injury prevention Nutrition Parental/infant bonding Vaccinations
omphalitis
nosocomial or acquired infection of umbilical cord and skin
Most common bacteria: G+ staph
Medical emergency! need IV abx
umbilical hernia tx
as long as soft then don’t do anything
should naturally regress by 4-5 yo
gastroschisis
Defect in abdominal wall allowing extrusion of abdominal contents
increased risk of infection and sepsis
Tx: Broad spectrum abx and surgery
omphalocele
Results in protrusion of abdominal contents covered by an amniotic sac
Associated with chromosomal anomalies and cardiac, diaphragmatic, and bladder anomalies
Normal crying characteristics
birth to 6 weeks: 2-3 hr/day
can be soothed by swaddling, feeding, changing diaper
Colic crying characteristics
Lasting > 3 hours in a day, > 3 episodes in a week
Unable to sooth
May be gassy, otherwise normal exam and hx
colic crying treatment
Parental reassurance
Soothing Techniques
Empirical changing of formula
Simethicone (gas drops)
When is spitting up a concern?
forceful, larger than couple teaspoons (5mL), poor weight gain, projectile vomit
DDX if parent comes in complaining that newborn is spitting up
Normal Overfeeding (most common) GER GERD Formula intolerance or allergy Hiatal Hernia GI obstruction
erythema toxicum neonatorum
Affects 60% of newborns 2-3 days old
Diffuse rash with small, erythematous papules/vesciles
Self resolves within 48-72 hours
seborrhea dermatitis
“cradle cap”
greasy, crusty flakes of skin
tx: diluted sells blue, self resolves
Common newborn rashes that are self-limiting
erythema toxicum neonatorum
seborrhea dermatitis
neonatal acne
milia/miliaria
milia/miliaria causes
Milia: 1-2 mm pearly white or yellow papules caused by retention of keratin within the dermis
Miliaria: sweat retention from partial closure of eccrine structures; heat rash from over bundling
Most likely DDX of diaper rashes
Irritant/contact dermatitis
Yeast/Candida dermatitis
Seborrhea dermatitis
Impetigo/Staph infection
contact dermatitis tx
topical zinc or Vit E creams
difference between contact and Candidal diaper dermatitis
Candidal and seborrhea occur in creases while contact spares the creases
Candidas is more beefy red and may have associated oral thrush
Which diaper rash may involve body and scalp
seborrhea dermatitis
seborrhea dermatitis tx
anti-fungal cream (Nystatin)
Parental co-sleeping allowed?
controversial
AAP doesn’t recommend; supports having crib in same room
Proper sleeping position of newborns to reduce SID
always place sleep face up on back with pacifier
SIDS vs SUIDS
SID = sudden death of infant under age 1 that cannot be explained
SUDI = sudden unexpected death in infancy, whether explained or unexplained
50% of cases of SUIDS can be attributed to SIDS
The remainder of SUIDs attributed to suffocation, asphyxia, entrapment, infection, ingestions, metabolic dz, and trauma
Pathophysiology of SIDS
poorly understood
Immature brain with immature arousal centers converging with “stressors” –> progressive asphyxia, bradycardia, hypotension, metabolic acidosis, and ineffectual gasping, leading to death
Risk factors of SIDS
Prematurity SGA / IUGR Smoke exposure Male Infant African American or Native American Time of year (winter season) Age (2-4 months) Lower socioeconomic status Young maternal age Co-Sleeping, Prone sleeping
How to prevent SIDS?
supine sleep, safety-approved cribs, awake tummy time, no bed sharing, no wedges or bumper pads, no excessive pillows or comforters in crib
causes of plagiocephaly
supine sleeping position without varied sleep position, decreased tummy time
Tobacco exposure in newborns increases risk of what?
URI, reactive airway disease, otitis media, pneumonia, SIDs
car seat guidelines
- 0-2 yo = face rear
- 2-5 yo = forward facing with harness, five point restraints
- Up to 4’ 9” = Sit inclined (booster seat)
- All children younger than 13 in back seat with lap and shoulder seat belts
Daily caloric intake for term normal newborn and premature/LBW infant?
term normal newborn = 100 kcal/kg/day
premature/LBW infant = 120-140 kcal/kg/day
Infants should double birth weight by _______, triple by ______.
6 months
1 year
Beneficial contents of breastmilk
- IgA immunoglobins and macrophages
- Reduces adherence of viruses and bacteria to intestinal wall
- Reduces URIs
- Inhibits growth of E. coli
Breast feeding recommendations
Exclusive breastfeeding for first 6 months and continued for at least 12 months and thereafter as long as it is mutually desired
Breast feeding advantages for mother and baby
Mother: decreased bleeding, delayed ovulation, decreased risk of ovarian/breast cancer, increased bonding with baby, promotes weight loss, inexpensive
Baby: controls needs, increased immunologic factors, decreased infections, decreased chronic disease, higher IQ, better vision, decreased SIDS, less fussy eaters
Contraindications for breast feeding
Infant with galactosemia Mother with HIV Mother with untreated, active TB Mother using illicit drugs Mother on chemo agents or undergoing radiation
Infant infections with intracranial calcifications
CMV (periventricular)
Toxoplasmosis (diffuse)
Infant infections with blueberry muffin spots
CMV and Rubella
What is vertical transmission of infection?
transmitted during labor
instead of transplacental
How is CMV dx’d?
viral shedding in bodily fluids by viral culture
CMV treatment
Gancyclovir (off-label)
Dx of Herpes Simplex
HSV titers, viral culture, or PCR of CSF
Tx of HSV
prevention: C-section
suppressive therapy for mother (Acyclovir, Valtrex at 36 wks)
Acyclovir IV for infant
When is it ok if mother with HSV delivers baby vaginally?
if no active lesions and if she is on suppressive tx
How does congenital syphilis present in infant?
asx at birth
rash at 2 months
if untreated after 2 yrs begin seeing deformities (periositis, Hutchinson teeth, saddle nose, perforated hard palate)
Which reflexes are present at 4-9 months and persist with age?
Head righting
Protective equilibrium
Parachute
What if infants born to mother with known gonorrhea infection?
infant requires IV or IM antibiotics, as topical prophylaxis alone is inadequate
Standard of Care management prior to newborn hospital discharge
erythromycin ointment Vit K Total bilirubin Hearing Screen Newborn Screen Hep B vaccine
Most common cause of hemolytic anemia in neonates
ABO incompatibility -> jaundice
Regular infant formula yields ______ kcal/oz
20
Infants should gain at least what weight per day?
20 grams/day
