Newborn Management Flashcards
At delivery:
Before discharge:
Delivery: Silver nitrate drops or Erythromycin ointment and IM Vitamin K
Discharge: Hearing test, PKU, Galactosemia, Hypothyroid screening
Apgar: Need to and effectiveness of resuscitation
1 minute: During labor and Delivery (7+ is reassuring)
5 minutes: Response to resuscitation (9+ is reassuring)
Port Wine Stain: Permanent vascular malformation on head/neck (Nevus Flemmus; “stork bite” or “angel kisses”)
Association w/: Sturge Weber syndrome (AV malformation)
-Seizures, retardation, glaucoma
Tx: anticonvulsants, evaluate for glaucoma
Caput Succedaneum vs Cephalohematoma
Caput Succedaneum: Crosses suture lines, presents early
- resolves within first few weeks of life
Cephalohematoma: Does not cross sutures lines
-resolves in 2 wks - 3 mos
Coloboma of the iris: hole in structure of eye
Associated w/: CHARGE syndrome - screen for CHD7 gene
Coloboma; Heart defects; Atresia of nasal choanae;
growth Retardation; GU abnormalities; Ear abnormalities
Anridia: Absence of iris
Highly associated w/: Wilms Tumor - screen for with abdominal U/S Q3 months until 8 yo.
Omphalocele
GIT protrusion through umbilicus WITH sac
defect: abdominal wall musculature
association: screen for trisomy 13, 18, 21
Gastroschisis
Abdominal defect lateral to midline WITHOUT sac
tx: immediate surgical gradual introduction
Umbilical Hernia
Association: Congenital Hypothyroidism; screen with TSH
- 90% close by age 3yo
- 4yo: surgery req’d to prevent strangulation/necrosis
Hydrocele
Inguinal Hernia
- Hydrocele: Remnant of tunica vaginalis - differentiate from:
- Inguinal Hernia: Failure of processes vaginalis to close (reducible scrotal swelling) Tx: surgery
Undescended testes (cryptorchidism)
- Associated with malignancy if > 1 year of age
- No treatment until 1 yo to avoid sterility; then orchiopexy
Hyospadias: urethral opening is below/ventral
Epispadias: urtheral opening is on top/dorsal
Hypospadias: do not circumcise (surgery difficulties)
Epispadias: surgical evaluation for bladder exstrophy
Infant of Diabetic Mother: large, plethora, jitteriness
1st step: Check glucose level; hypoglycemia; hypocalcemia; hypomagnesemia; hyperbilirubinemia; polycythemia
Infant of Diabetic Mother: Risks
cardiac abnormalities (truncus arteriosis); small left colon syndrome (and distention); RDS; shoulder dystocia; – increased risk of diabetes & childhood obesity
RDS: (Respiratory Distress Syndrome; newborn)
- hypoxemia; nasal grunting; tachypnea; IC retractions
initial: CXR (ground-glass), atelectasis, air bronchograms
predictive: L/S ratio of amniotic fluid prior to birth
RDS: treatment
initial: O2 + nasal CPAP (prevent barotrauma/dysplasia)
most effective: exogenous surfactant decreases mortality
RDS: Primary prevention
Antenatal Betamethasone: > 24 hrs before delivery; < 34 wks gestation & Avoid prematurity: give tocolytics
Corticosteroids - role in pregnancy
Give immediately to any fetus in danger of preterm delivery < 34 weeks!!! (do not help/not indicated postnatal)
Transient Tachypnea of Newborn (TTN) - retained lung fluid in term birth by C-section or rapid second stage of labor
Dx: CXR (air trapping, fluid, perihilar streaking)
Tx: oxygen (rapid improvement; resolves in 24-48 hrs)
Tachypnea > 4 hours: considered sepsis
+) Neurological signs (lethargy, temp, feeding problems
> 4 hrs = sepsis: blood cultures/urine cultures
(+) neurological signs: LP with CSF analysis
Empiric antibiotics for sepsis < 1 month old
MCC: E.Coli & Group B Strept
- No signs of meningitis: Ampicillin + Gentamicin
- Meningitis possible: Ampicillin + Cefotaxime
Meconium Aspiration (in utero or with first postnatal breath) -prevent by: ET intubation & suction in depressed infants
- Severe respiratory distress, hypoxemia, hypoxia
CXR: patchy infiltrates, increased AP diameter
Tx: +pressure vent; high-freq vent; nitric oxide; ECMO
Diaphragmatic Hernia:
respiratory distress + scaphoid abdomen + bowel sounds in chest
CXR: loops of bowel visible in chest; air fluid levels, mediastinal shift to affected side, hypoplastic lung
Tx: Immediate intubation, surgical correction
Diaphragmatic Paralysis
Due to phrenic N. injury
h/o birth injury (Erb’s) or cardiothoracic injury
Meconium Plugs (lower colon): IODM- small left colon, Hirschsprungs, CF, Maternal drug abuse Meconium Ileus (lower ileum): Cystic Fibrosis
Dx: abdominal XR
Tx: Ileus with gastografin enema
Tracheoesophageal Fistula
Non-bilous vomiting, choking, gagging on 1st feeding
Dx: nasogastric tube placement will be coiled in chest
Associated with VACTERL syndrome
Duodenal Actresia
Bilous vomiting w/i 12 hrs of birth, no relation to 1st feeding
Dx: CXR (double bubble sign - air in stomach & duodenum)
Tx: IVF; NG decompression, Surgical duodenostomy
VACTERL syndrome -
associated with TE and Duodenal atresia:
Order XR spine, Abd U/S, Echo
Vertebral defects; Anal atresia; Cardiac abnormalities; TE fistula with Esophageal atresia; Radial/Renal anomalies; Limb Syndrome
Necrotizing Enterocolitis (NEC):
Premature infant with low apgar scores
(decreased immunity, decreased birth weight)
- Bowel undergoes necrosis, bacteria invades intestinal wall: ischemia, inflammation, ultimately perforation.
- Bloody stools, apena, lethargy when feeding is started; vomiting, abdominal distention
Necrotizing Enterocolitis: Dx, Tx
-True medical/surgical emergency with 50% mortality
Pathognomonic sign: Abdominal XR - Pneumatosis Intestinalis or air within bowel wall (not lumen)
Tx: NPO; Decompress gut; Broad spectrum Abx; Surg eval
Failure to pass meconium (Hirschprung Disease)
- do not pass stool for over 48 hours or not at all
- frequent association with down syndrome
(1) rectal examination (patent rectum with passage of large voluminous stool after digital exam suggests hirschprungs) (2) barium enema (megacolon proximal to obstruction)
(3) best confirmatory test: rectal biopsy (absent ganglionic cells/auerbach plexus)
Failure to pass meconium (imperforate anus)
Rectum ends in blind pouch with conservation of sphincter
P/E: No anus
Tx: Surgery is curative
Jaundice: Physiologic Jaundice (undersecretion)
-Starts @ day 2-3; peaks @ < 10mg day 3-5
Jaundice: Exaggerated Physiologic Jaundice aka breastfeeding jaundice (not enough milk/dehydration)
-occurs in first week of life, peaks @ 12-15mg
Tx: Increase feedings Q 20 mins/1-2 hrs
Jaundice: Breast milk Jaundice (due to factor in breast milk that increases enterohepatic circulation of bilirubin)
-starts @ days 4-14; (usually after 1 week)
-may continue weeks/months while breastfeeding
Tx: continue breastfeeding, usually resolves by week 12
When is hyperbilirubinemia considered pathologic?
- First day of life or *After second week of life
- Bilirubin rises >5 mg/dL/day
- Bilirubin >12 mg/dL in term infant
- Direct > 2mg/dL at any time
Most feared complication of jaundice?
*indirect bilirubin can cross BBB, deposit in basal ganglia
Kernicterus/Neurologic dysfunction.
-Hypotonia, seizures, delayed motor skills, choreoathetosis
Tx: Immediate exchange transfusion
Jaundice Tx:
- Phototherapy: bilirubin > 10-12 mg/dL
(normally decreases by 2mg/dL every 4-6 hours) - Exchange transfusion: failure of above, kernicterus risk
Neonoatal Sepsis:
fever, poor appetite, increased WBC, hyperbilirubinemia
Workup: CXR before antibiotics; CBC w/diff; blood culture; UA/urine culture. If lethargic/irritable: LP & CSF analysis.
Sepsis: Early Onset (within 24 hours; < 1 month old)
MCC: Pneumonia
Group B Strept, E.Coli, H. influenzae, L. monocytogenes
Sepsis: Late Onset (after 24 hours; < 1 month old)
MCC: Meningitis, Bacteremia
E. Coli, S. Aureus, Klebsiella, Pseudomonas
Sepsis: Empiric antibiotics < 1 month old:
Ampicillin (+) Gentamicin (if no evidence of meningitis)
Ampicillin (+) Cefotaxime (if meningitis suspected)
Sepsis: Empiric antibiotics > 1 month old:
MCC > 1 mo: S. Pneumoniae, N. Meningitidis
Tx: Cefotaxime +/- Vancomycin if meningeal involvement
Seizures: Work up
EEG; CBC, Electrolytes, Ca+, Mg2+, Po4-, Glucose;
Blood/urine cultures; LP if meningitis suspected;
Amino Acid assay, Urine organic acids;
Total cord blood IgM (t.o.r.c.h.)
Seizures: Treatment
DOC: Phenobarbital
Persistent: Phenytoin
Withdrawal: Heroin, Cocaine, Amphetamine
Withdrawal: Methadone (high risk seizures)
Best initial treatmentL
-Presents within 48 hours of life
- Presents within 96 hours (up to 2 weeks)
TX: Opioids, Phenobarbital
Anesthetics, Barbituates: Respiratory/CNS depression
Magnesium sulfate: Respiratory depression
Phenobarbital: Vit K deficiency
Sulfonamides: displaces bilirubin from albumin
NSAIDS: premature closure of ductus arterioles
ACE inhibitors: Craniofacial abnormalities
Isotretinoin: facial/ear anomalies, congenital heart disease
Phenytoin: hypoplastic nails, typical facies, IUGR
Tetracycline: enamel hypoplasia, discolored teeth
DES: Vaginal adenocarcinoma
Lithium: Ebstein’s anomaly
Valproate/Carbamazepine: MR, NT defects
Warfarin: Facial dysmorphism, chondrodysplasia
