NICU Flashcards
what is the recommended dose of vitamin K
0.5mg <1500g
1mg >1500g
give within 6 hours
what is the recommended dose of PO vitamin K
2mg at birth, 2-4 week and 6-8 weeks
what are 3 things you should tell parents if they opt for PO vitamin k
PO vitamin K is less effective than IM vitamin K for preventing VKDB
Making sure their infant receives all follow-up doses is important
Their infant remains at risk for developing late VKDB (potentially with intracranial hemorrhage) despite use of the parenteral form of vitamin K for PO administration
what are the two predominant patterns of brain injury seen with HIE
watershed (prolonged partial hypoxia-ischemia)
basal ganglia/thalamic (acute profound hypoxia)
When HIE is severe when does generalized brain edema peak?
72 hours (Can be seen on CT and MRI)
when should MRI be obtained in term newborns with NE
between 3 and 5 days of life to confirm diagnosis and determine the extent of hypoxic-ischemic injury (or after rewarming)
A repeat MRI at 10 to 14 days is a helpful adjunct when clinical examination or clinical evolution is not consistent with early MRI findings or when diagnostic ambiguity persists.
what is the neurodevelopment outcome for watershed injury
cognitive impairment
The watershed pattern of injury also appears to predict language outcomes
what is the neurodevelopment outcome for basal ganglia/thalamic
severe cognitive and motor disability
when CT is used for infants with HIE when should it be performed
as close to 72 hours of the suspected insult as possible, ideally within 72 ± 12 hours. A subsequent MRI is also recommended
what is the preferred imaging technique for examining the brain of term neonates who present with encephalopathy or a suspected brain injury or abnormality
MRI
what are 3 indications to stop cooling
Hypotension despite inotropes
Persistent pulm hypertension with hypoxemia, despite adequate support
Clinically significant coagulopathy, despite treatment
should you do whole body cooling or selective head cooling
whole body cooling
what temperature is recommended for whole body cooling
core Temp 33°C ± 0.5°C
when should whole body cooling be initiated
within 6 hours
how long should cooling persist? how should they rewarm?
72 hours
rewarm 0.5C ever 1-2 hours (so rewarm over 6-12 hours)
how old does a baby have to be to consider cooling
> 36 weeks!
consider for 35 weeks
increased mortality in preterm
what are some of the outcomes for HIE
CP or severe disability cognitive impairments visual impairment or blindness sensorineural hearing loss behavioral difficulties (ADHD) epilepsy
what is the criteria for cooling
A. Cord pH ≤7.0 or base deficit ≥−16, OR
B. pH 7.01 to 7.15 or base deficit −10 to −15.9 on cord gas or blood gas within 1 h AND
History of acute perinatal event (such as but not limited to cord prolapse, placental abruption or uterine rupture) AND
Apgar score ≤5 at 10 minutes or at least 10 minutes of
positive-pressure ventilation
C. Evidence of moderate-to-severe encephalopathy, demonstrated by the presence of seizures OR at least one sign in three or more of the six categories
what are the 6 criteria for defining mod-severe encephalopathy
LSPTPA L- level of consciousness S- spontaneous activity P- posture T- tone P- primitive relaxes A- autonomic system (pupils, HR, respirations)
what are some side effects of cooling (5)
hypotension bradycardia, coagulopathy PPHN Fat necrosis
when do we see max efficiency for antenatal steroids
within 7 days
how old should a baby be before you’d consider giving antenatal steroids
> 22 weeks
survival to NICU discharge >22+6 23 24 25
> 22+6: 20
23: 40
24: 70
25: 80
Neurodevelopmental outcomes: Most children have no or mild NDD: 22 weeks 23 weeks 24 weeks 25 weeks
Most children have no or mild NDD:
- 57% at 22 weeks
- 60% at 23 weeks
- 72% at 24 weeks
- 76% at 25 weeks
Extremely high likelihood of mortality or severe NDD, what care is recommended
palliative care
ex: born at 22 weeks or 24 weeks and <350g
Moderate-to-high likelihood of mortality or moderate-to-severe NDD
Intensive care or palliative care are both usual care options
ex: 23-24 weeks
Low likelihood of mortality or moderate-to-severe NDD
intensive care is recommended
>25 weeks without additional risk factors
what are the risk factors for early onset sepsis
- maternal fever >38
- GBS+
- GBS bacteriuria at any time during current pregnancy
- previous child with invasive GBS disease
- ROM >18 hours
chorioamionitis
Maternal temperature >38 + two of: uterine tenderness maternal or fetal tachycardia foul/purulent amniotic fluid maternal leukocytosis
what is the empiric treatment for early onset sepsis in a neonate
amp+ gent
what is the treatment for mom prior to delivery for GBS
no allergy: penicillin
mild allergy: cefazolin
severe allergy: clindamycin or vancomycin
Does the Canadian Paediatric Society recommend routine car seat testing before discharge for preterm infants?
No!
Infants should only be placed in a car seat for travel in a moving vehicle and removed promptly once the destination is reached
is routine use of EPO recommended?
No!
Concern for more severe ROP
Does enteral iron supplementation reduce need for blood transfusions?
No evidence that using iron supplementation prevents or reduces the need for transfusions in the neonatal period
what volume of blood should be considered when transfusing a preterm baby
A higher volume of transfused blood (20 mL/kg) should be considered when transfusing a preterm baby, if the hemodynamic and respiratory status of the patient permits
is cord milking recommended?
the technique cannot be recommended as routine practice at the present time
how long is delayed cord clamping
30-180S
What dose of iron is recommended to prevent iron deficiency anemia is preterm babies
Elemental iron supplementation (2 mg/kg/day to 3 mg/kg/day once full oral feeds are achieved) is recommended to prevent later iron deficiency anemia
what are some risks of circumcision (7)
pain local infection severe infection minor bleeding death from unrecognized bleeding poor cosmetic result most common late complication: meatal stenosis
what are some benefits of circumcision (5)
prevention of phimosis decreased UTI decreased STI (HIV, HPV, HSV)- no effect on chlamydia/gonorrhoea decreased cervical cancer decreased penile cancer
what is the most common late complication of circumcision
meatal stenosis
what are two contraindications to circumcision
hypospadias
bleeding disorder
what is the transfusion volume for pRBCs for newborn
10-20ml/kg over 3-4 hours
what is the major risk of rapid and massive transfusion?
hyperkalemia
what are the two most frequent indications for blood transfusion in the newborn?
perinatal hemorrhagic shock
recurrent correction of anemia of prematurity.
how is the risk of CMV transmission from transfusion reduced
leukoreduction
what process prevents graft versus host disease
irradiation
what type of blood is used for emergency transfusion of newborns
O, rh negative
at what age is crossmatching of blood required
starting at 4 months of age
what are 4 risks associated with RBC transfusion
- infection
- leukocyte adverse effects (graft versus host, TRALI)
- volume and electrolyte disturbance
- blood group incompatibility
What hemoglobin level is recommended for the following weeks off of respiratory support
week 1
week 2
week 3
1- 100
2- 85
3- 75
What hemoglobin level is recommended for the following weeks on respiratory support
week 1
week 2
week 3
1- 115
2- 100
3- 85
what are 4 important competencies prior to discharge of a preterm infant
- Thermoregulation (temp >37)
- No apnea for 5-7d
- No oxygen required to maintain sats 90-95% for 1 week on RA
- Feeding and gaining weight (vit d and iron supplementation)
parents must feel confident and prepared
Preterm infants with a birthweight <2000 g who receive hepatitis B vaccine require how many doses??
Preterm infants with a birthweight <2000 g who receive hepatitis B vaccine require four doses.
Why is early Dex not recommended to prevent BPD?
associated with increased risk of CP
therefore early steroids are NOT recommended
when could you consider late dose Dex (>7 day)
low dose late dose Dex (0.15mg/kg/day)
has been shown to reduce duration of ventilator therapy
not recommended for everyone
can be used on case-by-case basis for infants at high risk of CLD who are ventilator dependent
0.15-0.2mg/kg/day, tapering course over 7-10 days
Is hydrocortisone recommended for treating CLD
No!
Are inhaled corticosteroids recommended to prevent CLD?
No!
Babies with late-trimester SSRI exposure should be observed for how long?
observed in hospital for neurobehavioural or respiratory symptoms for a minimum of 48 h.
Is SSRI use a contraindication to breastfeeding?
Postpartum use of SSRIs is not a contraindication to breastfeeding, and women who choose to breastfeed should be supported
Is there an increased risk of congenital malformations with SSRI use in pregnancy?
No!
Paroxetine use in mom- may have small increased risk of cardiac malformations but evidence is inconclusive
what syndrome can be seen in a baby born to a mother taking an SSRI
SSRI neonatal behavioral syndrome
seen in 10-30% of infants exposed to SSRIs in late gestation
Symptoms within hours of birth, generally mild, and resolves in 2 weeks
Signs of SSRI neonatal behavioral syndrome
tachypnea, cyanosis, jitteriness/tremors, increased muscle tone, and feeding disturbance
what is the most concerning possible post-natal association with SSRI exposure?
PPHN
what is the suggested protocol for premeditation intubation in a neonate
atropine 20mcg/kg (vagolytic)
fentanyl 3-5mcg/kg (analgesic)
succinylcholine 2mg/kg (muscle relaxant)
Late preterm infants are particularly at risk for readmission with what? (6)
hyperbilirubinemia- Reassess for feeding, weight gain, and jaundice repeatedly in first 10 days, later peak (7 days)
feeding problems apnea or acute life-threatening events suspected sepsis respiratory problems hypothermia
what is late preterm
34-36 weeks
when should a late preterm infant that was discharged from hospital be seen in follow-up
within 72 hours
what is the minimum body temp for a bath
36.5C
what are some non pharmacological/pharmacological interventions for pain relief in a newborn (5)
oral sucrose
Kangaroo care
facilitated tuck, swaddle and developmental care
non-nutritive sucking
Topical anesthetics can be used to reduce pain associated with venipuncture, lumbar puncture and intravenous catheter
what is the most common cause of brachial plexus palsy
birth trauma
what are some risk factors for brachial plexus palsy (4)
LGA
instrumentation
IDM
shoulder dystocia
what is the prognosis for brachial plexus injury
75% recover completely within the first month
25% with permanent impairment and disability
when should you refer brachial plexus injury to a multidisciplinary team?
Refer to multidisciplinary brachial plexus team if ongoing deficit by 1 month
what nerves are associated with Erbs palsy
C5, C6, C7
adducted, internally rotated shoulder, extended elbow
what nerves are associated with Klumpke
C8, T1
extreme wrist extension
flexion at IP
C5-T1
flail arm
often associated with horner’s syndrome
what are 4 indications for surfactant
Intubated infants with RDS should receive surfactant therapy
Intubated babies with meconium aspiration syndrome and > 50% FiO2 need should receive surfactant
Sick newborns with pneumonia and oxygenation index >15 should receive surfactant
Intubated newborns with pulmonary hemorrhage and clinical deterioration should receive surfactant
Infants who deliver at less than 29 weeks gestation outside of a tertiary centre should be considered for immediate intubation followed by surfactant administration after stabilization
what are 4 risks associated with giving surfactant
Bradycardia
hypoxia, or ETT blockage during instillation
Pulmonary hemorrhage
Over-distension and air leak
should we use natural or synthetic surfactant?
Natural surfactants should be preferred over synthetic surfactants
what is severe hyperbilirubinemia
> 340umol/L during the first 28 days of life
what is critical hyperbilirubinemia
> 425umol/L during the first 28 days of life
What are the risk factors for the development of severe hyperbilirubinemia (11)
visible jaundice before 24h visible jaundice before discharge at any age shorter gestation previous sibling with severe hyperbilirubinemia visible bruising cephalohematoma male sex maternal age >25 Asian or European background Dehydration Exclusive and partial breastfeeding
what investigations should be performed in infants with early jaundice of mothers of blood group O (2)
Blood group and DAT
when should bilirubin be checked
within the first 72 hours of life or prior to discharge
Infants with a positive DAT who have predicted severe disease based on antenatal investigation or an elevated risk of progressing to exchange transfusion based on the postnatal progression of TSB concentration should receive?
IVIG 1g/kg
what infants are at risk for G6PD
Mediterranean Middle Eastern African South East Asian all babies with severe hyperbilirubinemia
What are some ways that health care professionals can support families through perinatal loss?
compassionate communication shared decision-making creating meaningful memories acknowledging grief sibling care family care
cyanotic heart disease (8)
may be cyanotic
T- Transposition of the great arteries T- Tetralogy of Fallot T- Tricuspid atresia T- Total anomalous pulmonary venous connections T- Truncus arteriosus T- 'Tingle' ventricle (single ventricle)
A- pulmonary atresia
A- Ebstein’s anomaly
May be cyanotic: Coarctation of the aorta Double outlet right ventricle Ebstein’s anomaly Interrupted aortic arch Defects with single ventricle physiology
who should get pulse oximetry screening
all term and late term babies (>34 weeks)
when should pulse oximetry screening be completed
ideally between 24-36 hours of age (after 24h but before 36h)
- although screening before 24 hours of age is better than no screening at all
What is required to pass CCHD screen
sat >95% and <3% difference between right hand and foot
what is a borderline CCHD screen
90-94% OR >3% diff between right hand and foot
should be repeated in 1 hour (x2)- if remains abnormal call health care provider
- IF BORDERLINE ON 3 CHECKS THEN COMPLETE CLINICAL EVALUATION
what is considered a fail on CCHD screen
sat <90%
should undergo a complete CLINICAL EVALUATION by the most responsible health care provider, which could include consultation with a paediatrician if the initial assessment did not involve one. If a cardiac diagnosis cannot be excluded, referral to a paediatric cardiologist for consultation and echocardiogram is advised.
what limbs are used for CCHD screen
right and and either foot
who needs ROP screening
infants <31 weeks
< 1250g
when is ROP screening performed
4 weeks of age or minimum of 31 weeks
when should treatment for type 1 ROP begin
within 72h of detection
what is the difference between type 1 ROP and type 2 ROP
type 1- significant changes requiring treatment
type 2- significant changes not requiring treatment, close followup
Who needs treatment for ROP?
Indications for treatment:
Zone I – any stage ROP with plus disease
Zone I – stage 3 ROP without plus disease
Zone II – stage 2 or 3 ROP with plus disease
when do you stop screening for ROP (3)
Vascularization in zone III without previous zone I or II ROP
Full retinal vascularization
Postmenstrual age of 50 weeks and no prethreshold or worse ROP
Regression of ROP
what is type 1 ROP
zone 1- any stage ROP with plus disease
zone 1- stage 3 without plus disease
zone 2- stage 2, 3 with plus disease
what is type 2 ROP
Zone I – stage 1 or 2 ROP without plus disease
Zone II – stage 3 ROP without plus disease
what is plus disease
Increased vascular dilatation and tortuosity of posterior retinal vessels in at least two quadrants of the retina
what are the two treatment options for ROP
laser therapy
anti-VEGF
who needs followup for ROP in 1 week
type 2 ROP
immature vascularization, immature retina and aggressive posterior ROP
who needs followup for ROP in 2 to 3 weeks
stage 1 or 2 ROP, no plus disease in zone 3
regressing ROP zone 3
easiest way is if it is zone 3 then followup in 2-3 weeks
what are 4 benefits of kangaroo care
Pain Breastfeeding Prevents nosocomial infections Mother-baby bonding Sleep Neurodevelopmental outcomes Decreased neonatal morbidity and mortality
what is kangaroo care?
the practice of skin-to-skin contact between infant and parent (as young as 26 weeks)
how does iNO work?
it causes pulmonary vasodilation
used to treat persistent pulmonary hypertension of the newborn
who should get iNO
Infants ≥ 35 weeks GA with hypoxemic respiratory failure who fail to respond to appropriate respiratory management
* role in prems has not been established
iNO is usually started in infants with an OI > 20-25, or PaO2 < 100 despite ventilation with 100% oxygen
what investigation should be done prior to starting iNO ideally
echo to rule out cyanotic heart disease
what is the recommended starting dose of iNO in term infants? what is the expected response? how quick do you see a response?
20ppm (short half life 2-6s)
PaO2 increase ≥ 20mmHg, rapid response occurring within 30 min
If no response then the dose can be increased to 40ppm
dose 20-80ppm (>40ppm associated with increased toxicity)
how should you wean iNO
by 50% every 4 hours (as long as OI<10) until down to 5ppm, then decrease by 1ppm every 4 hours
then stop as long as PaO2>50mmHg and FiO2<60%
if unable to wean by 7 days look for other causes (cardiac or pulmonary)
what are 4 toxicities associated with iNO
methemoglobinemia (measure frequently, keep <2.5%)
Decreased platelet aggregation / bleeding
Surfactant dysfunction
NO2 production (pulmonary injury if >5ppm)
at doses 20-40ppm- associated with minimal toxicity
what can happen with abrupt cessation of iNO
severe hypoxemia secondary to the downregulation of endogenous NO production and should be avoided
is iNO use effective for most infants with congenital diaphragmatic hernia?
No! iNO use is not effective for most infants with congenital diaphragmatic hernia.
what 2 drugs can be recommended for opioid-dependent pregnant women
methadone
buprenorphine
what percentage of infants of mom’s on opioids during pregnancy will require treatment for symptoms of NAS
50-75%
when do NAS symptoms present? how long do they last?
Symptoms usually present within 48-72 hours, up to 5-7 days, and can last up to 30 days, with mild symptoms up to 6 months
when should NAS scoring be done? what is the minimum duration?
1-2 hours post delivery, then q3-4 hours for minimum of 72-102 hours.
why is Naloxone not recommended for NAS
can cause seizures
when would you consider treating a NAS baby with morphine?
NAS >8 x 3 or
>12 x 2
- short half life (9h)
- start at 0.32 mg/kg/day, divided every 4 h–6 h, orally
- If score persists ≥ 8 on 3 (or ≥ 12 on 2) consecutive evaluations, increase by 0.16 mg/kg/day every 4 h–6 h, to a maximum of 1.0 mg/kg/day.
Taper by 10% of total daily dose q48-72 hours when scores <8 for 48 hours
what scoring system is used for NAS
modified Finnigan scoring system
What medications can be used to treat NAS (5)
*table in CPS statement
morphine
methadone (long half life)
phenobarbitol- may be used in addition to morphine, especially with poly substance abuse cases
clonidine- requires gradual weaning (can cause rapid increase in BP and HR)
buprenorphine (30% alcohol)
what are some nonpharmological treatments for NAS (8)
Skin-to-skin swaddling gentle waking quiet environment minimal stimulation low lighting music and massage breastfeeding
what are some signs and symptoms of NAS
high pitched cry tremors increased tone sweating fever yawning stuffiness RR>60 excessive sucking poor feeding regurgitation loose stools
(CNS, Resp, GI symptoms)
what is the compression to ventilation ratio for NRP
3:1
NRP: If HR is <100 what should you do?
PPV
NRP: what percentage oxygen for <35 weeks
21-30%
For infants <32 weeks how can you prevent hypothermia
maintaining room temperature at 23°C preheating the radiant warmer use of a hat placing a thermal mattress under the radiant warmer use a polyethylene wrap
NRP: when would you consider giving epi?
Administer epi if HR <60 despite effective ventilation and 60sec of chest compressions (0.01mg/kg IV or 0.1mg/kg ETT)
For the term infant, resuscitation should start with ____ oxygen.
21%
what is the preferred method for assessment of HR during chest compressions
ECG
what technique is recommended for chest compressions
The two-thumb technique is recommended for chest compressions. The compressor should move to head of bed once airway is secured. Reassessment of heart rate should occur after 60 s of chest compressions.
For vigorous term and preterm infants, delayed cord clamping for ______ is recommended
30-60s
What percentage of kids will present with intracranial bleed with late HDN?
50%
if metabolic screening is done before 24h of age when does it have to be repeated?
within the first week
which medication has been shown to reduce the length of stay in hospital in symptomatic infants born to mothers on methadone
sublingual buphrenorphine has been shown to reduce length of stay in hospital by 42% in symptomatic infants born to mothers on methadone
- sublingual
- half life 24-60h
- contains 30% alcohol
is NAS scoring more or less severe in preterm infants?
less severe
