NICU Flashcards
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
G6PD
No ABO incompatability
Looks well, 7do, less likely EOS
No anemia to suggest thalasemia
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
G6PD
A+, unlikely to be ABO incompatability
Mother Rh+, not Rh incompatability
Unlikely physiologic jaundice at this point
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
ABO incompatibility
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
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
- 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
Start intensive photo, recheck in 6H
Above phototherapy line, but below exchange transfusion line
- 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
Weight and check bili in 24H
Bili below low risk line
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
F/U in 24H for repeat bili + wt check
- 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
Phototherapy + repeat bili in 6h
- 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
Intensive phototherapy
- 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
Coombs + bloodwork
- 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
Neonatal hepatitis
Conjugated hyperbili
- What are risk factors for unconjugated hyperbilirubinemia in a neonate?
A. Prematurity
B. LGA
C. Male
Prematurity
- 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
Hgb in cord (vs bili in cord)
- Infant with brachial plexus injury. Persists after 1 month. What to do?
a) Refer
b) MRI of spine
c) Observe
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
- Infant with horner syndrome and not moving arm. What investigations?
a) MRI
b) Nerve conduction studies
?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
- 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
Intact grasp reflex
Erb: no biceps reflex, grasp intact
Klumpke: biceps reflex intact, no grasp (claw hand)
Both have asymmetric Moro
- Newborn with an Erb’s palsy. Which is true?
a) Extension at the wrist
b) Preserved grasp
c) Symmetric moro
Preserved grasp
- 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
C7, C8, T1 = Klumpke
Horner syndrome due to disruption of sympathetic chain via C8+ T1
- 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
Klumpke
- 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
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)
- 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
Decrease GVHD
Gamma irradiation deactivates lymphocytes and prevents GVHD
- 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
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
- 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
IVIG
Mom’s plts are low, which means that she has autoimmune process, like ITP
- 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
Partial exchange transfusion
Polycythemia with HCT >65%
Symptomatic (lethargy)
- 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
Classic HDNB 2-7d
Early HDNB in first 24H
Late onset in 2-12wks, up to 6mo
- 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
Washed maternal plats vs PLA-1 negative plts
NAIT b/c mother’s plts are normal
- Which of the following predisposes to early hemorrhagic disease of the newborn:
a) Breastfeeding
b) Prematurity
c) Cystic fibrosis
d) Maternal phenytoin
e) Diarrhea
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 (
- 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
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”
- 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
PLA-1 neg plts
- 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
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
- 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
Conjunctival culture, IM ceftriaxone (if baby is well)
If uwell, then conjunctival, blood + CSF cultures
- 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
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
- 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
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
- 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
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
- 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
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
- 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
CoNS = staph epi
Staph aureus = gram pos diplococci
E coli = gram neg cocci
GBS = gram pos cocci in chains
- 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
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)
- 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
IEM
- 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
? cardiogenic
No mention of low sugar
- 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
D10 at TFI 80mL/kg/d
Can consider mini bolus 2mL/kg D10W at beginning of infusiion but . not well studied
- 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
Refeed and check in 1H
- 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.
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)
- 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?
Hyperinsulinism
- 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
GA
Needs to be >=36wk GA (and considered for 35-35+6wk GA)
- 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
Stage 1 (mild) (see your cue cards)
