NICU Flashcards
1
Q
7. An 7 day old term Asian baby presents with jaundice. He looks well. Mom’s blood type AB+, baby B+. Hgb 104, bilirubin 207, retics 8%. Most likely etiology: A. Sepsis B. ABO incompatibility C. G6PD D. Thalassemia
A
G6PD
No ABO incompatability
Looks well, 7do, less likely EOS
No anemia to suggest thalasemia
2
Q
58. Primiparous Asian mom with blood group A+. Her term newborn is jaundiced at 12h of life. What is the most likely diagnosis? A. G6PD B. Physiologic jaundice C. ABO incompatibility D. Rh incompatibility
A
G6PD
A+, unlikely to be ABO incompatability
Mother Rh+, not Rh incompatability
Unlikely physiologic jaundice at this point
3
Q
An Asian baby presents at 12 hours of life with jaundice. Mother is O+, the baby is A+. The bilirubin is 200. What is the diagnosis? A. ABO incompatibility B. G6PD C. Rh incompatibility D. Physiological jaundice
A
ABO incompatibility
4
Q
Term 2 day old looks pale but well CBC shows Hb 70. Mom O+, hemodynamically stable what is most likely diagnosis? (Sick Kids Review) A. Chronic fetal maternal hemorrhage B. ABO incompatibility C. RH incompatibility D. beta thal
A
Chronic fetal maternal hemorrhage
ABO - expect to be jaundiced, not just pale. Also, wouldn’t expect such a big drop in Hgb
Rh - mother is Rh pos, not incompatibility
Beta thal - HbF is 2a, 2g. Beta thal only a problem once beta-globulin used to make HbA
5
Q
- 39 week old baby at 30 hours of life. Bili 270. No G6PD, CBC normal showing no hemolysis, DAT negative. What should you do? (Photo and exchange graphs given)
a) Give IVIg and prepare for exchange
b) Start intensive photo and recheck bili in 6 hours
c) Ensure good feeding and check bili in 12 hours
d) Start exchange transfusion
A
Start intensive photo, recheck in 6H
Above phototherapy line, but below exchange transfusion line
6
Q
- 48 hour old term newborn is jaundiced, bili 221 (total). He has lost 8% of birth weight. Coombs negative. What is your management? (phototherapy charts provided)
a) Weight + check bili in 24 hours
b) Start phototherapy
c) Exchange transfusion
- ————– - Baby at 48 hour of age bili 210. Need to plot on bili chart and mgmt?
a) Weigh and reassess bili in 24 hr
b) Bili in 72 hr
c) Nothing
A
Weight and check bili in 24H
Bili below low risk line
7
Q
59 Term baby well on exam, bili 221 at 48h; DAT neg. what do you do? (given 2 bili charts; graph it, see it doesn’t meet photo level, but is in high intermediate zone)
a) Conventional photo
b) Intensive photo
c) Arrange f/u in 72h
d) f/u in 24h for rep bili & wt check
A
F/U in 24H for repeat bili + wt check
8
Q
- Bili question. 37 weeker. Mild lethargy. Total bili 280 @ 30 hours. No ABO. Give 3 bili charts. Mgt?
a) Follow-up in 24 hours
b) Phototherapy and repeat bili in 6 hours
c) Exchange
d) IVIG
- ————————– - 30 hr old, 37 week baby, with unconjugated bilirubin 275. Graphs provided for bili reference. What do you do now? No hemolysis on smear, no ABO incompatibility
a) Re-check bili in 6 hrs
b) IV fluids and prepare for exchange transfusion
c) IV fluids and prepare for IVIG
A
Phototherapy + repeat bili in 6h
9
Q
- A term 2 day old baby boy who is breastfeeding well is jaundiced. He is ready for discharge. His bilirubin at 48 hours is 271. What would be your management? (they provide the bilirubin risk chart as well as the chart for phototherapy from the CPS guidelines)
a) Regular phototherapy
b) Intensive phototherapy
c) Follow up bilirubin in 48 hours
d) Follow up weight and bilirubin in 24 hours
A
Intensive phototherapy
10
Q
- Term baby with bili of 221 at 48 hrs
a) Photo now
b) Coombs + bloodwork
c) f/u at 24 hrs
d) f/u at 72 hrs
A
Coombs + bloodwork
11
Q
- Neonate 1 month old presents with feeding well, but the following BW: total bili 228, Conjugated 200, Unconjugated. Gaining weight
a) Galactosemia
b) Neonatal hepatitis
c) Breastmilk jaundice
A
Neonatal hepatitis
Conjugated hyperbili
12
Q
- What are risk factors for unconjugated hyperbilirubinemia in a neonate?
A. Prematurity
B. LGA
C. Male
A
Prematurity
13
Q
- Which is best predictor of severity of Rh disease?
a) Gestational age
b) Cord haemoglobin
c) Cord bilirubin
d) ?maternal antibody titres
- ————————- - Which of the following is the best predictor of risk of Rh autoimmune hemolytic disease at the time of delivery?
a) Bili in the cord
b) Hb in the cord
c) Mom’s Ant-Rh titres
d) Gestational age
A
Hgb in cord (vs bili in cord)
14
Q
- Infant with brachial plexus injury. Persists after 1 month. What to do?
a) Refer
b) MRI of spine
c) Observe
A
Refer
- 75% recover completely within first mo
- 25% have permanent impairment or disability
- If incomplete recovery on PEx by 3-4wks, then full recovery unlikely
- Refer to multi-D team
15
Q
- Infant with horner syndrome and not moving arm. What investigations?
a) MRI
b) Nerve conduction studies
A
?MRI
Horner => Klumpke
For brachial plexus
- Carefully monitor for clinical recovery of function
- If no recovery by 3mo, do MRI at 4mo pre-op to r/o structural anomalies. Not for prognostication
- If poor recovery by 4mo, surgery at 6-9mo d/t concerns for muscle atrophy
- EMG not helpful
16
Q
- A baby is diagnosed with Erb’s palsy. What are you likely to see:
a) Symmetric Moro
b) Intact biceps reflex
c) Intact grasp reflex
d) Intact wrist extension
A
Intact grasp reflex
Erb: no biceps reflex, grasp intact
Klumpke: biceps reflex intact, no grasp (claw hand)
Both have asymmetric Moro
17
Q
- Newborn with an Erb’s palsy. Which is true?
a) Extension at the wrist
b) Preserved grasp
c) Symmetric moro
A
Preserved grasp
18
Q
- Baby born with inability to open one eye and pupillary constriction - which nerves are likely to have been injured at birth?
a) C5,C6,C7
b) C5,C6,C7,C8,T1 [likely an error on the exam must have meant T1!]
c) C7,C8,T1
A
C7, C8, T1 = Klumpke
Horner syndrome due to disruption of sympathetic chain via C8+ T1
19
Q
- Which brachial plexus injury is most likely associated with horners syndrome (miosis and ptosis).
a) Upper C5/6
b) Middle C6/7/8
c) Lower C7,8 T1 – Klumpke
d) Total C5/C6/C7/C8/T1
A
Klumpke
20
Q
- 28 week infant, 32 weeks currently. Feeding well on gavage feeds. Using HF 4L/min room air. What should his transfusion threshold be?
a) 100
b) 75
c) 85
d) 115
A
85
Age, with resp support, [no resp support]. Cap samples (central samples are ~10 below)
1-7d: 115, [100]
8-14d: 100, [85]
>=15d: 85, [75]
(115 minus 15 going down and across table)
21
Q
- Why do we irradiate blood given to prems?
a) Decrease CMV
b) Decreased GVHD
c) Sterilize RBC
d) Decrease hemolytic reactions
- ———————– - Why do premature babies receive irradiated blood?
a) To avoid CMV
b) To prevent GVHD
c) To decrease the risk of febrile transfusion reactions
A
Decrease GVHD
Gamma irradiation deactivates lymphocytes and prevents GVHD
22
Q
- Baby with petechiae. Plt 12. After transfusion, Plt are 16. Mom’s CBC normal. What is best management?
a) PLA1 negative platelets
b) IVIG
- ————————— - A full term newborn develops petichiae and bruising. The baby is otherwise well appearing. On bloodwork, platelets are 12, WBCs are 18, Hgb 140. He is given a platelet transfusion and a repeat platelet count is 16. The mother’s CBC shows platelets of 240. What is the best treatment? (NB Washed maternal platelets was not an answer)
a) PIA-1 negative platelets
b) IVIG
c) Pooled donor platelets
- ————————— - Newborn with platelets of 12, transfused and post-transfusion platelets were 16. Mom’s CBC was normal. What do you do?
a) Transfuse single donor platelets
b) Transfuse PIA-1 negative platelets
c) Give IVIG
d) Give steroids
- ————————— - A baby is born and has low platelets ( <20). He is given random donor platelets but after the count is still less than 20. His mother’s platelets are normal. Baby is stable and there is no bleeding. What should be done now?
a) Transfuse PLA-1 negative platelets
b) Transfuse single donor platelets
c) IVIG
d) Do nothing
A
PLA1 negative platelets = HPA 1a neg platlets
NAIT = neonatal ALLOimmune thrombocytopenia
Maternal washed platelets (share maternal alloantigens) also an option
Or IVIG in mother prenatally
23
Q
- 3-4 day old newborn infant with petechiae/purpura in mouth, normal CBC and Hb, but platelets 12; after one random-donor platelet transfusion, platelets 16. Mother has platelets 80, CBC otherwise normal. Baby stable, no active bleeding. How would you treat this baby?
a) Give single donor platelets
b) Give PLA-1 negative platelets
c) Exchange transfusion
d) IVIG
- ————————- - Neonate with petechiae. CBC = normal Hgb & wbc but platelets 20. Mom’s CBC also shows low platelets. How to treat baby?
a) Regular plt transfusion
b) IVIG
c) Transfusion with special platelets (some antigen I can’t remember)
- ————————- - Neonate with thrombocytopenia. No response to platelet transfusion. Mom has low platelets too. Treatment?
a) Transfuse with platelets again.
b) Transfuse with PLA-1 negative platelets
c) IVIG
d) Exchange transfusion
- ————————– - A newborn baby presents with very low platelets (10,000). On platelet transfusion, platelets only rise to 16,000. Mother’s platelet count is 80,000. What is the most appropriate therapy?
a) Single-donor platelet transfusion
b) PL1a-negative platelet transfusion
c) Intravenous immune globulin
A
IVIG
Mom’s plts are low, which means that she has autoimmune process, like ITP
24
Q
- Term baby, 4500g. Plethoric and lethargic. HGb 270ish, Hct 0.72. Gas normal. WBC normal, plts in 500s.
a) IV antibiotics
b) IV fluids with D10
c) Partial exchange transfusion
A
Partial exchange transfusion
Polycythemia with HCT >65%
Symptomatic (lethargy)
25
Q
- Newborn receives vit K at birth. At what time does classic hemorrhagic disease of the newborn present? (similar previous question on vitamin K but did not ask about timing) [CPS]
a) Within the first 24
b) Within the first week
c) After the Third week of life
A
Classic HDNB 2-7d
Early HDNB in first 24H
Late onset in 2-12wks, up to 6mo
26
Q
- Term newborn has petechiae and bruising. The baby is well. On bloodwork his platelets are low at 16, WBCs are 18 and his Hgb is 140. He is given a platelet transfusion and a repeat platelet count is 16. The mother’s CBC shows platelets are normal. What is the best treatment:
a) Random donor platelets
b) PLA-1 negative platelets
c) IVIG
d) Washed maternal platelets
A
Washed maternal plats vs PLA-1 negative plts
NAIT b/c mother’s plts are normal
27
Q
- Which of the following predisposes to early hemorrhagic disease of the newborn:
a) Breastfeeding
b) Prematurity
c) Cystic fibrosis
d) Maternal phenytoin
e) Diarrhea
A
Maternal phenytoin
Early onset: first 24H, d/t mat meds (AEDs)
Classic onset: 2-7 DOL, low intake of vit K (breastfeeding)
Late onset: 2-12wks, up to 6mo, d/t chronic malabsorption of vit K
Overall prems at higher risk (
28
Q
- Which of the following predisposes to late hemorrhagic disease of the newborn:
a) Breastfeeding
b) Prematurity
c) Cystic fibrosis
d) Maternal phenytoin
e) Oral antibiotics
A
Breastfeeding
late onset due to chronic malabsorption + low intake
“Late (2 to 12wks + up to 6mo of age) VKDB, which occurs almost exclusively in breastfed infants, is a serious condition that manifests predominantly as ICH”
29
Q
- Baby with plts 16 at birth, mother 280. plts still 16 after plt transfusion, next best step:
a) IVIG
b) PLA-1-negative plts
c) DIC work-up…
- ———————– - Newborn baby with thrombocytopenia, platelet 12g/L. transfused, and platelet count still 16g/L. mom’s platelets 220g/L. how to manage?
a) PLA-1 negative platelets
b) IVIG
A
PLA-1 neg plts
30
Q
- Klehauer betke test question about what it is.
- —————– - Newborn baby with low hemoglobin. Kleihauer-Betke test ordered. What does this test?
a) Mom’s blood for fetal hemoglobin
b) Baby’s blood for maternal hemoglobin
c) Mom’s blood for blood type and reactivity to baby blood type
d) Baby’s blood for blood type and reactivity to mother’s blood type
A
Mom’s blood for fetal hemoglobin
HbF = 2a + 2g
- resistant to denaturation by strong acid
- Kleihauer-Betke takes RBCs from mat blood onto slide + exposes to acidic pH solution
- HbA loses colour, HbF stays pink
- detects fetal RBCs in maternal circulation
31
Q
- A mother with untreated Nisseria gonorrhoea gives birth to a newborn via a vaginal delivery. What should be the next step?
a) Conjunctival culture, CBC, blood culture, CSF, IV Ceftriaxone
b) Conjunctival culture, CBC, blood culture, IV Ceftriaxone
c) Conjunctival culture, IM ceftriaxone
d) Conjunctival culture and await results for treatment
A
Conjunctival culture, IM ceftriaxone (if baby is well)
If uwell, then conjunctival, blood + CSF cultures
32
Q
- 35+6 week infant born to a mother who is GBS unknown. ROM x 12 hours. Infant is well. What do you do?
a) CBC, Cx and Empiric abx x 36h.
b) CBC and observe if WBC <5
c) CBC and observe if WBC >5
A
Would choose close observation x48H
Late prem infants
If GBS status unknown, should get IAP
Infants 35-36wk GA who are stable enough to be admitted to mother-baby unit, can be managed similarly to >=37wk GA. However must be monitored for at least 48H prior to D/C
33
Q
- You are informed that a mother in labour is GBS +, and during her last delivery she developed a maculopapular rash when she was given penicillin. Which of the following is the appropriate antibiotic for her now?
a) Clindamycin
b) Penicillin
c) Cefazolin
d) Cloxacillin
- ———————————— - Mom with GBS and hx of maculopapular rash when given Pen in last delivery. What antibiotic
a) Penicillin
b) Cefazolin
c) Clinda
d) Erythromycin
A
Cefazolin
Adequate IAP At least 1 dose 4H prior to birth of: Pen G Or amp Or cefazolin (if mother pen allergic but low risk for anaphylaxis)
If high risk of anaphylaxis,
IV clinda (if susceptible)
or IV vanco (if not clinda susceptible)
but these are INADEQUATE IAP
34
Q
- Mom has fever (38.5) in labour and delivers baby. OB says chorioamniotis. What do you want to do with baby?
a) Observe
b) CBC + observe 24h
c) CBC, blood culture and antibiotics
d) CBC, blood culture, LP and antibiotics
A
If baby unwell, FSWU
If baby well, CBC + observe 24H b/c with at least 2 other RFs, regardless of GBS status, would need individualized therapy
= close observation (examine at birth, vitals Q3-4H for min 24H, reassess + counsel before D/C)
AND consider CBC after 4H
35
Q
- Mother comes in at 6pm and delivers 39wk baby at 8pm. Received antibiotics and is GBS positive. Baby’s initial CBC is normal, baby looks well. She wants to go home next morning with the baby and says she lives very close to the hospital. You should:
a) Keep baby in hospital for 24 hours and then reassess
b) Discharge baby in morning and do CBC prior to d/c.
c) Keep baby in hospital for 48 hours for observation.
d) Do a full septic workup and start baby on antibiotics.
- —————————– - Pregnant mom who has a previous child. She is GBS positive, comes in at 6:00pm and gets IV penicillin. At 8:00pm, she delivers a healthy baby boy at 39 weeks. Babe is well and has a normal CBC. She is wondering when she can go home (she lives close to the hospital)?
a) Start amp/gent
b) Observe until 24 hours
c) Observe until 48 hours
d) Full septic work-up
A
Term, well. ROM 2H.
GBS pos, no other RFs, inadeq IAP (<4H before birth)
Close observation = examine at birth, vitals Q3-4H for min 24H, reassess + counsel pre-D/C
36
Q
- 32 wk prem, now 9 days old, born to GBS +ve mother who did not receive intrapartum antibiotics, increasing apneas for 24 hours. Gram stain shows gram +ve cocci in clusters. What is the organism?
a) GBS
b) Staph aureus
c) Staph epi
d) E. Coli
- ——————- - Mother with +ve GBS never got treated intrapartum abx. Baby born 32 wk now 9 days. Has been having increasing apneas in the past 24 h. Blood culture done shows GP cocci in clusters after 18 h of culture. What most diagnosis
a) GBS
b) Strep viridans
c) S aureus
d) Coag neg staph
A
CoNS = staph epi
Staph aureus = gram pos diplococci
E coli = gram neg cocci
GBS = gram pos cocci in chains
37
Q
- A newborn with 37.8 axillary temperature. What should be done next?
a) Repeat after 20 minutes of unbundling
b) Do a tympanic temperature
c) Do CBC
d) Full Septic W/U
- —————— - A newborn with 37.3 axillary temperature. What should be done next?
a) Repeat after 20 minutes of unbundling
b) Do a tympanic temperature
c) Do CBC
d) Full Septic W/U
A
Repeat after 20min of unbundling
If rectal temp available, do that
Ax 36.5 - 37.5
PO 35.5 - 37.5
Tymp 35.8 - 38
Rectal 36.6 - 38
0-2yo - Rectal (definitive) - Axillary (screening) 2-5yo - Rectal - Ax, tymp, (or temporal artery in hospital) >5yo - oral - ax, tymp, (or temporal artery)
38
Q
- Six day old baby presents in shock, afebrile. Glucose 1.6 and cardiomegaly on CXR. What is the most likely etiology of the shock? (no consensus)
a) Congenital heart disease
b) Sepsis
c) Inborn error of metabolism
d) Adrenal insufficiency
- ——————- - Newborn with low glucose and CXR with cardiomyopathy:
a) Metabolic
b) Encephalopathy
c) Sepsis
- ——————- - Glucose of 1.2, cardiomegaly on chest x-ray. What is the most likely etiology of this presentation? (repeat and the wording doesn’t get any better)
a) Cardiac lesion
b) Sepsis
c) Inborn error of metabolism
- ——————- - Newborn with cardiomegaly and glucose of 1.9, now in failure. What is the most likely reason for shock?
a) Sepsis
b) Cardiogenic
c) Metabolic
d) Adrenal
- ——————— - 6 d old baby in shock. Gluc 1.2. Big heart on CXR. Most likely type of shock?
a) Cardiogenic
b) Metabolic
c) Adrenal
d) Septic
A
IEM
39
Q
- A 3-month old baby presents with in shock with tachypnea, normal pulses, cap refill of 3 seconds, and a liver palpable 5 cm below the right costal margin. Most likely origin of his shock:
a) Cardiogenic
b) Metabolic
A
? cardiogenic
No mention of low sugar
40
Q
- Term BB, mom with gestational diabetes. DOL 1. Glucose 1.4. What is your next step in management?
a) Bolus glucose by NG
b) Bolus 1 cc/kg of D50W
c) Run IV D10 @ 80 cc/kg/day
d) Frequent breastfeeding
- ——————– - 1 day old baby from IDM mother. Blood glucose 1.4 mM, lethargic.
a) IV D10W at 80cc/kg
b) Bolus feed via NG
c) Increase frequency of breastfeeding
d) 1cc/kg of D50W
- ——————- - Baby boy presents lethargic with a serum glucose of 1.4. Pregnancy, labour and delivery were all uncomplicated. What do you do next:
a) Breast feed on demand
b) Top up cup feed
c) Give 1 ml/kg of D50W
d) Start D10W at 80cc/kg/day
- ——————– - Newborn with BWT 2.5 kg. Hypoglycemic. Next magt
A
D10 at TFI 80mL/kg/d
Can consider mini bolus 2mL/kg D10W at beginning of infusiion but . not well studied
41
Q
- 5 kg baby born to diabetic mother, has early feed, but 2 hours later, blood glucose 1.9 and baby asymptomatic. What do you do?
a) Re-feed and check in 1 h
b) Bolus NS
c) Bolus D10W 2ml/kg and start IV infusion
d) Supplement breast feed with formula and check sugar in one hour
- ——————- - Management of neonate (2500g, 40wks) with BG=1.9 1 hour after first breastfeed. Asymptomatic. What is your management?
a) Breastfeed
b) bolus D10W then run IV D10W
c) Give feed with formula or EBM
d) IV D10W @ 4cc/hr
A
Refeed and check in 1H
42
Q
- 4.2 kg infant born to a mother with gestational diabetes. Glucose at 2 hours of age is 2.1. What is your management?
a) Continue to measure glucose every 3-4 hours for the next 36 hours.
b) Feed the infant. Recheck glucose in 1 hour.
c) Feed the infant. Recheck glucose before next feed in 3-4 hours.
d) Continue to monitor glucose every 3-4 hours for the next 12 hours.
A
Continue to monitor glucose Q3-6H for next 12H
vs. Feed the infant, recheck glucose before next feed in 3-4H (same concept, but the point of the other thing is that it needs 12H of monitoring for IDM)
43
Q
- SGA baby with increasing glucose requirement. GIR ~11 mg/kg/min with BG 1.8. What is the diagnosis.
a) Cortisol deficiency
b) Growth hormone deficiency
c) Hyperinsulinism
- ———————— - SGA baby with high glucose intake up to 12.5 mg/kg/min. Ketones negative. Diagnosis?
A
Hyperinsulinism
44
Q
- You attend delivery of a 33 week infant, who requires 15 minutes of resuscitation including PPV, CPR and 2 rounds of epinephrine. Apgars are 2, 4 and 4. Initial gas is 6.98. What disqualifies this patient from cooling?
a) Gestational age
b) Length of resuscitation
c) APGAR at 10 min
d) Gas
- —————– - Baby 33 weeks GA, apgars 2,4,4, at 1,5,10 minutes, ph 6.8, base excess 20 what excludes child from cooling?
a) Gestation age
A
GA
Needs to be >=36wk GA (and considered for 35-35+6wk GA)
45
Q
- Term baby with difficult labour and delivery (required resuscitation, asphyxiated). Baby found to be irritable and hyperreflexic. What is the Sarnat stage?
a) 0
b) 1
c) 2
d) 3
- ————————————— - A baby was born with perinatal distress. He is currently irritable, hyperreflexic and has mydriasis. What Sarnat stage is he?
a) Sarnat stage 0
b) Sarnat stage 1
c) Sarnat stage 2
d) Sarnat stage 3
A
Stage 1 (mild) (see your cue cards)
46
Q
- 2 y.o. diagnosed with spastic diplegia. Born at term, with APGARS of 6 at 1 minute, and 8 at 5 minutes. Parents are asking if this is related to “perinatal asphyxia” – how would you counsel them:
a) Low probability – Apgars of 6 and 8 rule out the possibility of perinatal asphyxia
b) Low probability – most cases of cerebral palsy are related to an event occurring before labour
c) High probability – most cases of CP are caused by perinatal asphyxia
d) Cannot form an opinion, because you cannot diagnose CP before 2 yrs
A
Low probability. Most causes of CP are related to an event occurring before labour
Asphyxia assoc’d with athethoid + dyskinetic CP
Spastic diplegia assoc’d with prem, ischemia, infection, endo/metabolic. PVLs! (26-30wk GA)
47
Q
- 24h old newborn with the picture shown above. What to do/tell parents? (Googled: cephalohematoma)
a) Head imaging to see extent
b) No further intervention and it will resolve spontaneously in 2-12 weeks
c) Provide analgesia and it will resolve spontaneously in the next few days
d) Monitor head circumference and Hgb x 24 hours as can become hemorrhagic shock
A
No further intervention. It will spontaneously resolve in 2-12 weeks
48
Q
- (Googled: erythema toxicum - this is the exact picture that was on the exam!) You are called to see a newborn with the following rash. What is it?
a) Herpes simplex virus
b) Miliaria
c) Erythema toxicum
d) Neonatal pustular melanosis
A
Erythema toxicum
49
Q
Term baby is 36 hours old and well. She now has a rash on her chest that is not isolated to folds. The most likely diagnosis is: (Sick Kids Review)
a) erythema toxicum
b) transient neonatal pustular melanosis
c) miliaria
d) neonatal HSV
A
erythema toxicum
50
Q
- You are called to a twin delivery. Twin A is 2800g with Hct 0.70 and Twin B is 2100g and Hct 0.40 What are you most likely to see in Twin A:
a) Hypoglycemia
b) RDS
c) CHF
- —————– - In twin to twin transfusion syndrome, what does the recipient twin have?
a) CHF
b) RDS
c) High output failure
A
CHF
Twin A is the recipient
Polycythemia
CHF = high output failure
51
Q
- What other test would do immediately in an 8-hour neonate with elevated 17 OHP
a) Glucose
b) Sodium
c) Testosterone
d) Karyotype
A
Glucose
Too early to salt waste - occurs at 7-14d
52
Q
- 8 day old baby, exclusively breastfed with the following bloodwork: Na 161, K 4.4, Cl 99. What is the reason?
a) Hypernatremia due to breastfeeding dehydration
b) CAH
- ——————————- - 2 day old with hypernatremia (154), K+ 4.1, glucose 3.3. Most likely cause?
a) Breastfeeding dehydration
b) RTA
c) CAH
- ——————————- - 1 week old breastfed infant comes with Na 165, K 4.1, Cl 120. What is the Diagnosis?
a) CAH
b) RTA
c) Munchausen
d) Breastfeeding dehydration
A
Hypernatremia due to breastfeeding dehydration
CAH: low Na, high K
RTA: low K (usually), high Cl
53
Q
- Newborn screen positive for congenital hypothyroidism. TSH is very high (47). What to do?
a) Repeat TSH, fT4
b) Start therapy
c) Bring in for examination
- ——————– - One of your patients, a newborn baby, has a positive newborn thyroid screen with a TSH of 27. Next step?
a) Repeat the screen
b) Start thyroxine
c) Bring the patient in for a full exam
d) Do a nuclear thyroid scan
- ——————— - Newborn thyroid screen TSH = 24. most important next step:
a) Repeat TSH, T4
b) Return to office for physical exam
- ——————– - Newborn with a TSH of 25. What do you do? (repeat)
a) Start thyroxine
b) Repeat neonatal screen
c) Bring them into the office as soon as possible
d) Thyroid ultrasound
- ——————– - You are informed that a newborn sibling of a patient in your practice has received a positive thyroid screen. His TSH was 27.6. The MOST IMPORTANT step would be to:
a) Repeat the screen
b) Start thyroxine
c) Bring patient in for a full physical exam
d) Do a nuclear thyroid scan
A
Do TSH, fT4 (no point repeating the screen)
Start thyroxine while awaiting test
TSH >15 on NBS in Ontario is considered positive
54
Q
- Mother has recurrent HSV. THere were no active lesion at delivery. For how long after delivery is the infant at risk for PERINATAL transmission?
a) 2 weeks
b) 6 weeks
c) 16 weeks
d) 36 weeks
A
Incubation period is 14d
Symptoms present for up to 6wks of life
55
Q
- Nurse call you because a 2 day old baby in nursery has a vesicle on the upper lip. Most likely diagnosis:
a) Varicella
b) Herpes
c) Sucking blister
- —————— - 2 day old with a vesicle noted on the upper lip?
a) Sucking blister
b) HSV
c) Varicella
d) Epidermolysis bullosa
A
Sucking blister
56
Q
- A baby is born by c-section at 6h since membranes ruptured. Mother has active HSV lesions. The baby is asymptomatic. When should cultures of the baby be done?
a) Immediately and start Acyclovir
b) After 48h
c) When the baby is symptomatic
d) Observe only
A
Immediately and start acyclovir
C/S after ROM, need to do swabs of conjunctiva, nose, mouth at 24HOL for Cx/PCR (first 12-24H will have contamination from maternal sample)
- Start on empiric acyclovir
- If swabs pos: full W/U + Tx (2wks for SEM, 3 wks for CNS + disseminated)
- If swabs neg: complete 10d IV acyclovir
57
Q
- Baby born at 42 weeks after placental abruption, asystolic since birth and ongoing appropriate resus. After how long can you stop resuscitating?
a) 15 minutes
b) 10 minutes
c) 20 minutes
d) 30 minutes
A
10 minutes
NRP
“The persistent absence of a detectable heat rate (Apgar 0) at 10 minutes is a strong, but not absolute, predictor of mortality and serious morbidity in late preterm and term newborns. If there is a confirmed absence of heart rate after 10 minutes of resuscitation, it is reasonable to stop resuscitative efforts; however the decision to continue or discontinue should be individualized”
58
Q
- A term baby is born by emergency C/S for placental abruption. Appropriate resuscitation is conducted. What is the earliest that the resuscitation can be discontinued?
a) 5 minutes
b) 10 minutes
c) 20 minutes
d) 30 minutes
A
10 minutes
59
Q
- 41 weeker, mom has placental abruption, baby born asystolic, when can you stop resuscitation?
a) 5 minutes
b) 10 minutes
c) 15 minutes
d) 20 minutes
A
10 minutes
60
Q
- APGAR scores for a baby. 1 minute: HR 80, grimace with suction, blue, limp, irregular resps. 5 minute: HR 140, no response to suction, acrocyanosis, limp, irregular resps.
a) 4,4
b) 3,4
c) 3,5
d) ?
A
1min Appearance: blue =0 Pulse: HR <100 = 1 Grimace: grimace with suction = 1 Activity: limp = 0 Resp: irregular = 1 3
5min Appearance: acrocyanosis = 1 Pulse: HR >100 = 2 Grimace: no response = 0 Activity: limp = 0 Resp: irregular = 1 4
Grimace
- 2 = sneezing, coughing or pulling away when stimulated
- 1 = grimace or feeble cry when stimulated
- 0 = no response
Activity
- 2 = active mvmt
- 1 = some mvmt
- 0 = no mvmt
Resp
- 2 = strong cry
- 1 = weak, slow, or irregular breathing
- 0 = no breathing
61
Q
- You attend the delivery of a 36 week baby. There was some nonreassuring fetal heart rate tracing. After initial cleaning and stimulation, baby has no respiratory effort, HR was 48 bpm. What do you do next?
a) CRP + bag-mask ventilation in 100%O2
b) CPR + bag-mask ventilation in RA
c) Bag-mask ventilation in 100%O2
d) Bag-mask ventilation in RA
- ——————————- - 37wk GA newborn in L&D. After 30 seconds of drying, warming and stimulating, he is apneic, flaccid and cyanotic with HR 48. What is your next step? [cps]
a) Chest compressions and ventilated with RA
b) CPR and ventilate with 100% O2
c) PPV with 100% O2
d) PPV with room air
A
PPV with RA
If >=35wk GA, then 21% If <35wk GA, then 21-30% Set flowmeter to 10Lpm Target sats using preductal sat 1 min: 60-65 2min: +5 3min 4min 5min 10min
62
Q
- Baby born at 27 weeks GA via spontaneous vaginal delivery. Baby is apneic, cyanotic, low tone. Heart rate is 100. Your next step is:
a) Dry, stimulate, suction baby.
b) Polyethylene bag, stimulate, suction baby.
c) PPV with O2 and chest compressions.
d) PPV with room air and chest compressions.
- ———————– - Newborn baby born at 27 weeks, no spontaneous resps. What to do?
a) Put in polyethylene plastic bag and stimulate
b) Warm, dry and stimulate
c) Positive-pressure ventilation
A
Polyethylene bag, simulate, suction baby
63
Q
- You are called to the resuscitation of a 26 weeker. Needs PPV in the case room. How to administer?
a) Flow inflating bag with oxygen
b) Self inflating bag with oxygen
c) Self inflating bag without oxygen
d) Self inflating bag with reservoir with oxygen
- ——————— - You are resuscitating a 27-weeker at birth after stimulation and drying. What do you use:
a) Self-inflating bag with no O2 source
b) Self-inflating bag with O2 source
c) Flow inflating bag with O2 source
- ———————- - Newborn, a 30-week premie. Not breathing after stimulation. What do you do?
a) Self-inflating bag, room air
b) Self-inflating bag, oxygen reservoir
c) Self-inflating bag, oxygen reservoir with O2 being blown through
d) Anesthesia bag, connected to oxygen source
- ———————- - You are present at the resuscitation of a 27 week infant. After initial resuscitation the patient still has a poor respiratory effort. What would you use for your initial resuscitation?
a) Self inflating bag with no oxygen source
b) Self inflating bag connected to an oxygen source
c) Self inflating bag with oxygen reservoir connected to an oxygen source
d) Flow inflating bag connected to an oxygen source
A
Flow inflating bag/anesthesia bag with O2
64
Q
- 7 day old being resuscitated. Rate of compressions to ventilations. Patient is intubated.
a) 3:1
b) 5:1
c) 15:2
d) 100:1
A
3:1
90 compressions: 30 breaths = 120 events per min
1 -and-2-and-3 -and-BREATHE -and
65
Q
126. Newborn in DR asystole since birth despite appropriate resuscitation for 10 minutes. When can you stop? At 10 min At 20 min At 30 min At 40 min ---------------------- 127. You are in the resuscitation of a premature infant. There is continued apnea with no heart rate despite aggressive measures. After what amount of time would you stop resuscitative efforts. 10 minutes 15 minutes 20 minutes 30 minutes
A
10 minutes
66
Q
- A 29+2 week GA infant in the NICU. When should ROP screening start?
a) 31 weeks
b) 32 weeks
c) 33 weeks
d) 34 weeks
A
33 wks GA
ROP screening for <31wk GA or <=1250g
For <=27wk GA -> 31wk GA (+4)
Increase by 1wk until 34wk GA
67
Q
60. Who to check ROP? [CPS] <31 wk or 1250g -------------------- 22. When is it indicated an eye screening in newborn? a) Newborns <31 weeks and <1250g b) Newborns < 1500gr c) Patients who had received Indo and ibuprofen treatment and are less than <31 weeks d) Newborns <31 weeks
A
<31wk GA OR <=1250g
68
Q
- 4.4 kg on day of life 2, in the NICU due to profound hypotonia requiring tube feeds. Has swelling of the hands and feet and bilateral undescended testes. Likely Cause:
a) Noonan
b) SMA
c) Congenital myotonic dystrophy
d) Prader-Willi
A
Prader-Willi
Significant hypotonia + cryptorchidism
Noonan: cryptorchidism + peripheral lymphedema, can have hypotonia but not prominent
SMA + congenital myotonic dystrophy: severe hypotonia + feeding issues
69
Q
- New born baby born with refractory hypoglycemia and attached photo (no photo in notes). What is the most at risk for?
a) Hirschprung’s disease
b) Wilm’s tumour
c) Hypothyroid
A
Wilm’s tumour
Beckwith-Wiedemann syndrome
70
Q
- Child with bubbling oral secretions, difficulties passing an NG tube. Also noted to have a hemivertebrae. What to do?
a) Echocardiography
b) Spine MRI
c) MRI head
- ——————— - Baby with increased secretions from mouth, cough. CXR shows hemivertebrae. What else do you order?
a) Abdo U/S
b) Echo
A
ECHO
VACTERL
Choanal atresia vs TEF
Hemivertebrae
Esophageal atresia = bubbling + frothing at mouth + nose after birth
71
Q
- A newborn baby has copious oral secretions and respiratory distress. What is the most appropriate next test?
a) Insertion of orogastric catheter
b) CXR
c) Abdominal U/S
d) Barium swallow
A
Insertion of orogastric catheter
Would then do CXR
- no stomach bubble => EA
- if OG coiled in eso +/ stomach bubble => possible TEF
H-type TEF
- Barium swallow
- OR methylene blue injected into ETT during endoscopy (seen in eso during forced insp)
- OR bronchoscopy
Esophageal atresia = bubbling + frothing at mouth + nose after birth
72
Q
- An infant has a sacral dimple. What would make you more concerned about spinal dysraphism?
a) Mongolian spot over dimple
b) Located above gluteal cleft
c) Located 2 cm from anus
d) 3mm in diameter
A
? above gluteal cleft
Worrisome signs
- > 2.5cm from anus
- > 5mm diameter
- Multiple
- Can’t see the end
- Bifurcation or asymmetry of gluteal crease
- Cutaneous markers
- hypertrichosis within dimple
- telangiectasia
- hemangioma
- abnormal pigmentation
- skin tags
- subcutaneous mass or lump
- aplasia cutis
- NOTE: overlying CAL or slate grey nevi are NOT abN
Do spine U/S in first 3mo
MRI if strong suspicion of spinal dysraphism
73
Q
- 4 day old male presents with acidosis (pH 7.10, PC02 28) with hepatomegaly and poor feeding. His oxygen saturations are 88% in room air. What is the next step in your management.
a) Antibiotics
b) Prostaglandins
c) NPO and IV Fluids (D12.5)
- ———————————— - 6 day old baby with enlarged liver, hypotonic, lethargic. Unsure if gave temperature. 02 88% on 100% FI02. Next step?
a) Start PGE
b) Start antibiotics
A
Prostaglandin
74
Q
- Newborn has the above-shown ECG. What is the underlying etiology?
a) Maternal propranolol
b) Maternal infection
c) Maternal anti-Rho antibody
d) Maternal phenytoin
A
Maternal
Propranolol = bradycardia; (hypoglycemia, apnea)
Infection = tachycardia
Anti-rho = congenital heart block, endocardial fibroelastosis on ECHO
Phenytoin = CHD + dysarrhythmias; (early vit K def)
75
Q
- A newborn baby has significant resp distress, then respiratory rate drops, then HR drops. There is minimal air entry on one side. What do you do first?
a) Needle the chest
b) Bag the baby
c) Intubate
A
Needle the chest
b/c decrease HR suggests tension PTX
Nelson’s: Emergency evacuation of a pneumothorax without radiographic confirmation is indicated in an infant who is unresponsive to resuscitation efforts, and has asymmetric breath sounds, bradycardia, and cyanosis
76
Q
- You have just given surfactant to a 28 week old prem baby. You tell the parents that surfactant:
a) Increases the risk of IVH
b) Decreases the risk of chronic lung disease
c) Decreases mortality from RDS
d) Increases the risk of pneumothorax
A
Decreases mortality from RDS
Decreases risk of pulmonary air leaks
Doesn’t decrease risk of BPD/CLD, just decreases overall mortality, so it increases likelihood of surviving without BPD
77
Q
- Newborn 36+4wks GA in respiratory distress in labour and delivery. At 1h of life, still has mild increased work of breathing with RR80, SpO2 89% on RA, HR 150, BP 65/33. CXR shows fluid in the fissure on the R and a small pleural effusion on the L. What is the next step?
a) O2 as required
b) CPAP
c) Furosemide
d) Prostaglandins
A
CPAP
Also O2 as required
78
Q
- Kid with TEF on CXR, what to do?
a) Continuous suction and surgery
A
Continuous suction + surgery
79
Q
- Term newborn female is born vigorous and is pink with crying. As she settles, she progressively becomes cyanotic. She is bagged on RA and becomes pink but when the bagging is stopped, she becomes cyanotic again. What is the most likely diagnosis?
a) Bilateral choanal atresia
b) Congenital heart disease
c) Tracheoesophageal fistula
d) Tracheal web
How to Dx?
How to Tx?
A
Bilateral choanal atresia
Dx confirmed by inability to pass firm catheter through each nostril
CT is best to evaluate the anatomy
Tx
- oral airway or intubation
- Surgery: transnasal repair, stents
- Tracheostomy if bilateral and surgical repair not feasible
80
Q
- A newborn infant had thin meconium at delivery but had good Apgars and required only 2 minutes of free flow O2. Now at 12 hours of age he has increasing work of breathing. On CXR there is hyperinflation of the RUL with mediastinal shift. What is the most likely diagnosis?
a) Meconium aspiration syndrome
b) Neonatal pneumonia
c) CCAM
d) Congenital lobar emphysema
- —————————– - Newborn delivered with thin mec, initially fine but then begins to decompensate about 1 hour later. CXR reveals lucent area in one lobe, with mild mediastinal shift. Most likely diagnosis?
a) Meconium aspiration
b) Congenital lobar emphysema
c) CCAM
d) Pneumonia
A
Congenital lobar emphysema
81
Q
- 2 day old with bubbling oral secretions, also noted to have 2 cord vessel. What is the best management?
a) Orogastric tube
b) Renal ultrasound
c) CXR
A
Orogastric tube
82
Q
- Most common reason for delayed respiratory effort in a newborn
a) Maternal opiods in labour
- ———————- - Newborn doesn’t breathe at birth. What is the most likely cause?
a) Maternal morphine use
A
Maternal opioid use
83
Q
- ELBW infant. What causes CLD?
a) PPV
b) Oxygen use
c) Barotrauma
d) Surfactant deficiency
- ———————- - What is important in the direct pathogenesis of BPD in a VLBW infant?
a) PPV
b) Barotrauma
c) Surfactant deficiency
d) Oxygen toxicity
A
Surfactant deficiency
GO BACK TO THIS CPS STATMENT ON STEROIDS
84
Q
- Which of the following is true about surfactant?
a) Increases risk for intraventricular hemorrhage
b) Decreases mortality secondary to respiratory distress syndrome
c) Decreases incidence of BPD
A
Decreases mortality secondary to RDS
85
Q
- Unstable premature neonate on Ventilator with significant oxygen needs. Desaturates with handling but recovers with bagging. What is the best management.
a) Increase sedation
b) Give surfactant
c) Give prostaglandins
d) Give indomethacin
A
Increase sedation
Suspected pulmonary HTN
86
Q
- Which would be indications for giving surfactant?
a. Preterm baby with meconium aspiration FiO2 28%
b. Preterm baby born 72 hours ago who received 3 doses of surfactant
c. Preterm baby on ventilation with FiO2 of 50%
d. 29 week old baby with no respiratory symptoms who is being transferred
- —————————— - Question about who should get surfactant:
a. 29 wk old with no breathing troubles who needs transport
b. Anyone being transferred to a tertiary care center
c. A really sick prem baby who’s had surfactant 3 times in the past 18 hours
- ——————————– - In infants, under what circumstance do the guidelines recommend surfactant administration?
a. Still requiring more than FiO2 0.5 at 3 days of life
b. A 29-week premature infant without respiratory distress requiring transfer to another centre
c. Premature infants who have received 3 doses of surfactant in the past 2 days and are still requiring ventilation.
A
- Prem with MAS FIO2 28: incorrect, should be if >50%
- Prem born 72h ago + 3 surfactant: no evidence for >3 doses of surfactant
- Prem baby on ventilation with FiO2 50%: yes, if RDS
- 29wk with no resp Sx who is being transferred: to be considered if available personnel
- Intubated infants with RDS
- Intubated infants with RDS before transport
- Intubated infant with MAS requiring FiO2 >50%
- Intubated infant with pulmonary hemorrhage leading to clinical deterioration
- Sick newborn with pneumonia and OI >15 (OI = (FIO2 % x MAP)/PaO2)
Consider immediate intubation + surfactant in <29wk GA born outside tertiary care centre, if competent personnel are available
Consider prophylactic surfactant in <26wk GA and to 26-27wk GA without anetenatal steroids
87
Q
- A newborn infant is noted to be in respiratory distress following a c-section delivery. The pregnancy was significant for mild polyhydramnios. The baby responds temporarily to suctioning.
a) Hypoglycemia
b) Tracheoesophageal fistula
A
TEF
88
Q
- A term newborn has bilateral infiltrates on CXR and is currently intubated. He desaturates significantly with handling but improves with bagging. What would you do?
a) Increase sedation
b) Give surfactant
c) Start prostaglandins
A
Increase sedation
Suspect pulm HTN
89
Q
- Which of the following scenarios is an indication to intubate and suction for a meconium delivery?
a) Thick meconium
b) Apgars <5
c) No spontaneous respiratory effort
A
We don’t suction below the cords anymore
Maybe APGARS <5 depending on why and when
90
Q
- What is true about surfactant therapy in premature infants?
a) Use of surfactant decreases morbidity
b) Use of surfactant decreases mortality
c) There is no benefitrenal
A
Use of surfactant decreases mortality
91
Q
- An ex-preterm baby is now 8 weeks old but is still in the NICU. When do you give his first vaccines?
a) Now
b) When he is 8 weeks corrected
c) When he is discharged from the NICU
A
Now
- Immunize stable prem (<37wk GA), regardless of birth wt, based on chronological age using same schedule as term infants
- Prems (esp <1500 BW) have higher risk of apnea + bradycardia vs term
- Passive transfer of mat AB occur at 28wk GA
- Special considerations
1) Hep B
2) Pneumococcal
3) rotaviurs
4) BCG
5) RSV
92
Q
- Maternal history of methadone use, how long you have to watch the baby
a) 5 days
b) 10 days
c) 21 days
d) 2 days
A
5 days
93
Q
- NAS baby, treatment
a) Morphine
- —————————- - 3 day old baby with tachypnea, jitteriness, myoclonus and normal glucose. Treatment?
a) Amp/gent
b) Vit B
c) Morphine
- —————————- - Term newborn baby in the nursery is found to be jittery, tachypneic with nasal flaring, with myoclonus. Normal glucose. Based on the most likely diagnosis, what is your next management?
a) Morphine
b) Benzos
A
Morphine for NAS
94
Q
- Breastfeeding mom on SSRI, what should she do?
a) Continue breastfeeding
A
Continue breastfeeding
- Treatment of depression in pregnancy is important
- no evidence that SSRI increases risk of congenital malformation
- absolute risk for PPHN is negligible
- Higher risk of SSRI neonatal behavioural syndrome if SSRI taken in later pregnancy, but usually mild + transient effects (observe for neurobehavioural or resp Sx for min 48H)
- SSRI is not a contraindication to breastfeeding
95
Q
- Baby was tachypneic, increased HR, then RR =6 and HR and BP drops. Can’t hear murmur in lung field. Mgt?
a) Needle
b) IV epi
c) Intubate
d) Bag mask valve
- ———————- - 9 month old baby presents with respiratory distress, indrawing. HR 150. Given 100% non-rebreathing mask initially. Acute deterioration, RR =6, diminished air entry, cyanotic, and HR 96. Can’t hear murmur in lung field. What would be your next management?
a) Intubate and ventilate
b) Bag mask ventilation
c) Needle thoracentesis
A
Needle vs BMV
What’s the significance of no murmur in lung field?
Emergency evacuation of a pneumothorax without radiographic confirmation is indicated in an infant who is unresponsive to resuscitation efforts, and has asymmetric breath sounds, bradycardia, and cyanosis.
96
Q
- 36 hours of life, newborn found to be sneezing, has diarrhea and jittery. Mother most likely abused which drug:
a) Valproic acid
b) Lithium
c) Methadone
d) Cocaine
- ———————– - Baby born to drug abuse. Presents with tachycardia, sneezing. Which drug did mom use:
a) Methadone
- ———————– - Newborn is sneezing, what could this be associated with?
a) Methadone
A
Methadone
Lithium
- Ebstein anomaly
- fetal goitre
- hypotonia
- arrhythmia
- sz
- DI
- prem
97
Q
Abstinence from methadone? Neonatal sx?
a) Hyporeflexia
b) Constipation
c) Sneezing
d) Lethargy
A
Sneezing
Hyperreflexia
Waking frequently
High pitched cry
Loose stools
98
Q
- 3 day old infant with HR 200, BP 90/60. Irritable and poor feeding. Mom hypothyroid on replacement. Most likely dx?
a) SVT
b) Sepsis
c) CAH
d) Thyrotoxicosis
- ——————— - Mom with hypothyroidism on thyroid replacement. Baby with increased HR, irritable, poor feeding.
a) NAI
b) Thyrotoxicosis
c) SVT
- ——————— - Mother with longstanding hypothyroidism on L-thyroxine treatment. Denies any other drug use and is otherwise healthy. Term infant at day 1 is irritable with poor feeding. Heart rate is 220 and blood pressure is 96/60. What is the most likely cause?
a) Abstinence
b) Thyrotoxicosis
c) SVT
A
Thyrotoxicosis
Causes
- Neonatal Graves due to maternal graves + passive transfer of AB is most common
- genetic defects of TSH receptors
- thyrotropin receptor activating mutations
- alpha subunit G protein activating mutation (McCune Albright) - Mat meeds: MMI, BB
- Mother may not have Graves or may even be hypothyroid requiring supplemenation (s/p thyroidectomy +/ radioactive iodine)
Present with prem, LBW, irritability, microcephaly (premature fusion of cranial bones), exophthalmos, tachycardia, arrhythmia, hyperphagia, diarrhea, goitre, HSM
99
Q
- Baby born to mother who is a known heroin addict. After 3 minutes of bagging, there is no self-initiated respiratory efforts. What would you do next?
a) Give Narcan
b) Continue bagging until there is respiratory effort
A
Continue bagging until there is resp effort
NRP: if newborn has resp depression after maternal opiate exposure, manage baby’s airway and provide resp support with PPV
If baby has prolonged apnea, insert ETT or LMA for ongoing resp support
No Narcan especially in case of chronic use b/c risk of sz from withdrawal
100
Q
- Microcephaly and 3 lb baby. What was the fetus most likely exposed to in utero?
a) Pre-eclampsia
b) Maternal infection
c) Smoking – low birth weight
A
Maternal infection
Symmetric IUGR
- problems with fetus
- chromosomal
- teratogenic
- infectious (TORCH)
Asymmetric IUGR
- maternal problem
- maternal: poor nutrition, chronic illness, drugs/smoking
- placental: preeclampsia, chronic HTN, placental insufficiency
Smoking can contribute to LBW but not microcephaly
101
Q
- Teen Parents with a 23 weeker what do you do?
a) They are Teens so their opinion doesn’t matter
b) Respect their decisions for resuc
c) Decide what to do because you’re the doc
d) Must resuc all babies over 22 GA
A
Respect their decisions for resusc
102
Q
- You are counseling a mother who is 24 weeks pregnancy, with threatened pre-term labour. Which of the following is true?
a) All 24 weekers are resuscitated
b) Resuscitation is based on parental wishes
c) 24 weekers are not resuscitated due to poor outcomes at this GA
d) Resus is up to the team based on how baby does at birth
- ————————– - Counseling parents of a 23-weeker re: resuscitation:
a) Federal law prohibits resusc of 22weeks GA
b) Decision made with parents
c) You tell them because of high morbidity and mortality that you won’t resuscitate
- ————————– - What to do with a mom who is about to deliver at 23-weeks?
a) Resuscitation is not indicated
b) All babies born >22 completed weeks should be resuscitated
c) Parents ideas about resuscitation and palliation should be taken into account
- ———————— - You are counseling a pregnant teenage girl and her boyfriend at 23 weeks gestation. She is in labour. You discuss the high morbidity at this gestational age, if the baby survives at all. What is true about the resuscitation of this newborn:
a) Since they are teenagers, the physician decides.
b) There is legislation in Canada that says all babies 22 weeks and older require resuscitation.
c) The parents’ wishes should be supported whether they want to resuscitate or not.
d) Given the high mortality at this gestation, the baby should not be resuscitated.
A
Decision made with parents
103
Q
- Kid with NEC features, you’re in the periphery, what would you do next?
a) Arrange for urgent transfer to tertiary care center
b) Give broad spectrum antibiotics
c) Change formula
d) Start TPN
A
Give broad spectrum antibiotics
THEN arrange for urgent transfer to tertiary care centre
104
Q
- A 3 day old baby has a new onset of seizures. The delivery was uncomplicated (not 100% sure this was in question). The baby is lethargic and tachypneic on exam. She started vomiting. Her blood work includes a normal ammonia and lactate. PH is 7.25, base deficit neg 10. CSF is normal. Cause of seizure:
a) Inborn error of metabolism
b) HIE
c) IVH
d) GBS sepsis or meningitis
A
GBS sepsis
Can have normal CSF. Lethargy, tachypnea, sz, met acidosis are part of clinical signs of sepsis
CPS statement. Clinical signs of sepsis: sz, hypotonia, lethargy, temp instability, tachycardia, hypotension, poor peripheral perfusion, acidosis, resp distress
IEM - unlikely with normal ammonia + lactate
IVH - expect bloody CSF
HIE - less likely with uncomplicated delivery, also expect sz within 12H of birth
105
Q
- Baby is 12hrs old Presents with two afebrile seizures – generalized tonic-clonic seizures. Mother had a remote history of drug abuse. Baby born at term without complications. Your next step after admission to the NICU and oxygen for baby is:
a) Administer morphine IV
b) Administer Phenobarbital 20 mg/kg bolus
c) Administer methadone
- ———————– - Baby born to a mom with no prenatal care and remote history of IV drug use. At 4-6 hours of life, baby is irritable, then develops seizures x 2 (eye deviation and stiffening of body) x 60 seconds each. You give:
a) Phenobarb 20mg/kg
b) Morphine 0.05mg/kg
- ——————— - Newborn, mom poor PNC, remote history of IVDU. Kid is having a seizure:
a) Give pyridoxine
b) Phenobarbital 20 mg/kg
c) Morphine infusion
A
Phenobarb 20mg/kg bolus
106
Q
- Baby born after hypoxic event because of a prolapsed cord. On the first day of life he is hyperreflexic and has an exaggerated Moro reflex. He does not have any seizures. He is discharged on day four of life. His EEG and MRI are normal. What can you tell his parents about his prognosis.
a) Impossible to determine his prognosis at this time
b) He will have a good neurological outcome
c) It is likely that he will have some neurodevelopmental delay
d) He will likely have severe impairments
A
He will have a good neurological outcome
B/c signs of mild encephalopathy (Sarnat 1)
107
Q
- Description of a child with renal stones. Was a prem. Which medication was the child likely on in the neonatal period that would contribute to this picture?
a) Gentamicin
b) Furosemide
c) Thiazide
A
Furosemide
Tx
- Stop the loop diuretic
- Can give thiazide if still need diuretic
108
Q
- Baby now corrected 39 weeks. GA 25 weeks. had unremarkable NICU stay. Treated with caffeine for apnea of prematurity. Now still has 5-6 episodes of apnea, with transient bradycardia. What is the problem?
a) Persistent apnea of prematurity
b) Seizures
c) Hypoglycemia
- ————————- - An ex-32 week prem is on caffeine, now 39 weeks, but continues to have episodes of apnea – what is the reason?
a) Apnea of prematurity
b) Seizures
c) GERD
- ———————— - Ex-30 week prem, treated with caffeine for apneas since 5 days of life. He is still having apneas with occasional bradycardia 5-6 times a day. What is the likely cause?
a) Apnea of prematurity
b) Seizures
c) GERD
- ———————— - Ex-30 week prem, now at 39 weeks corrected has had an uneventful course. He had apnea of prematurity treated with caffeine. He is still having apneas with occasional bradycardia 5-6 times a day. What is the likely cause?
a) Apnea of prematurity
b) Seizures
c) GERD
A
Apnea of prematurity
- spell = apnea for >20s OR any duration if accompanied by cyanosis + bradycardia
- usually mixed apnea (central b/c immature brainstem resp centres + obstructive)
- If onset of apnea in 2nd wk of life in previously well prem OR any time in term infant, needs further IVx
- Tx: tactile stim, caffeine, CPAP (for mixed or obstructive apneas)
- usually resolves by 37wk chronological age, but may persist beyond term, esp in extreme preterm
109
Q
- 24-hour-old neonate with little urine output and CR of 80. Best explanation?
a) Cr represents mom’s value
A
Cr represents mother’s value
110
Q
- Neonate with E. coli bacteremia, midline abdominal mass on physical examination. Increased serum creatinine. What investigation would most likely confirm the diagnosis?
a) Renal ultrasound
b) VCUG
c) CT abdomen
d) Urine culture
A
RBUS for next diagnostic test
VCUG for confirming PUV
111
Q
21. You are seeing a 2 day old term baby. Their delivery was complicated by perinatal asphyxia requiring resuscitation. They are doing well now however you note the following findings on physical exam: (PAGE 225) What is your next step in management? a) Serum calcium b) Admit baby for observation c) Serum glucose d) Draw CBC and start antibiotics
A
Serum calcium
Subcutaneous fat necrosis
- Mat preeclampsia, birth trauma, asphyxia, prolonged hypothermia
- occurs in first mo of life in term/post term
- red/violaceous, indurated, sharply dmarcated plaques or nodules
- cheeks, upper arms, back, thighs, butt
- Focal or extensive. ASYMPTOMATIC
- Spont involute in wks to mos
- Rare life-threatening complication: hypercalcemia (1-6mo of age) => need to monitor
112
Q
- 33 week premature infant is born to a mother with hypertension. Baby is SGA. What other associated findings do you expect?
a) Polycythemia
b) Hyperglycemia
c) Hypomagnesemia
d) Hypercalcemia
A
Polycythemia to compensate for hypoxia from HTN
113
Q
- 2 month old ex 32 weeker who was ventilated with Ua/Uv lines. Now has HSM but has an otherwise normal physical exam. What is the likely cause?
a) Hepatic hemangioma
b) Portal vein thrombosis
c) Hereditary spherocytosis
d) Congenital CMV
e) Fungal infection
A
Portal vein thrombosis -> portal HTN -> HSM
114
Q
Which of the following is true regarding transition from fetal to neonatal life? (Sick Kids review)
a) PFO persists in 10% of adults
b) UV closes before UA
c) Fetal PaO2 is 25-30
d) None of the above
A
Fetal PaO2 is 25-30
PFO persists in 15-20%
UA closes before UV
