Association: Congenital Hypothyroidism; screen with TSH - 90% close by age 3yo - 4yo: surgery req'd to prevent strangulation/necrosis

Newborn Management Flashcards by Kristen Wisler

At delivery:

Before discharge:

Delivery: Silver nitrate drops or Erythromycin ointment and IM Vitamin K
Discharge: Hearing test, PKU, Galactosemia, Hypothyroid screening

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Apgar: Need to and effectiveness of resuscitation

1 minute: During labor and Delivery (7+ is reassuring)

5 minutes: Response to resuscitation (9+ is reassuring)

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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

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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

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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

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Anridia: Absence of iris

Highly associated w/: Wilms Tumor - screen for with abdominal U/S Q3 months until 8 yo.

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Omphalocele

GIT protrusion through umbilicus WITH sac

defect: abdominal wall musculature
association: screen for trisomy 13, 18, 21

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Gastroschisis

Abdominal defect lateral to midline WITHOUT sac

tx: immediate surgical gradual introduction

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Umbilical Hernia

Association: Congenital Hypothyroidism; screen with TSH

90% close by age 3yo
4yo: surgery req’d to prevent strangulation/necrosis

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Hydrocele

Inguinal Hernia

Hydrocele: Remnant of tunica vaginalis - differentiate from:
Inguinal Hernia: Failure of processes vaginalis to close (reducible scrotal swelling) Tx: surgery

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Undescended testes (cryptorchidism)

Associated with malignancy if > 1 year of age

- No treatment until 1 yo to avoid sterility; then orchiopexy

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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

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Infant of Diabetic Mother: large, plethora, jitteriness

1st step: Check glucose level; hypoglycemia; hypocalcemia; hypomagnesemia; hyperbilirubinemia; polycythemia

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Infant of Diabetic Mother: Risks

cardiac abnormalities (truncus arteriosis); small left colon syndrome (and distention); RDS; shoulder dystocia; – increased risk of diabetes & childhood obesity

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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

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RDS: treatment

initial: O2 + nasal CPAP (prevent barotrauma/dysplasia)

most effective: exogenous surfactant decreases mortality

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RDS: Primary prevention

Antenatal Betamethasone: > 24 hrs before delivery; < 34 wks gestation & Avoid prematurity: give tocolytics

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Corticosteroids - role in pregnancy

Give immediately to any fetus in danger of preterm delivery < 34 weeks!!! (do not help/not indicated postnatal)

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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)

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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