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NICU Flashcards

1
Q

List 5 examples of infants at risk of hypoglycemia

A
  1. Infant of a diabetic mother
  2. Weight <10th percentile (SGA)
  3. Weight >90th percentile (LGA)
  4. Intrauterine growth restriction (IUGR)
  5. Perinatal asphyxia
  6. Preterm infants (<37 weeks GA)
  7. Maternal labetalol use
  8. Late preterm exposure to antenatal steroids
  9. Metabolic conditions (CPT-1 deficiency [Inuit infants in particular])
  10. Syndromes associated with hypoglycemia (e.g. Beckwith-Wiedemann)
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2
Q

List 5 clinical signs of neonatal hypoglycemia

A
  • Jitteriness
  • Irritability
  • Cyanosis
  • Respiratory distress (apnea or tachypnea)
  • Tachycardia
  • Temperature instability
  • Feeding difficulties
  • Neuro symptoms: hypotonia, poor suck, and seizures or coma
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3
Q

Describe the expected physiological response to hypoglycemia for ketones, growth hormone, insulin, cortisol and catecholamines

A

Ketones: ↑

Growth hormone: ↑

Catecholamines:`↑

Cortisol: ↑

Insulin: ↓

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4
Q

What is considered a low blood glucose measurement in the following populations?

<72 HOURS OF LIFE

DOCUMENTED HYPERINSULINISM

>72 HOURS OF LIFE

A

<72h = <2.8

Documented hyperinsulinism, >72h = <3.3

  • If <2.8, do critical sample (if not already done)
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5
Q

How long do you have to screen the following populations for hypoglycemia?:

IDM/LGA

SGA/preterm infants (<36wk GA)

A

IDM/LGA = 12 hours if levels remain ≥2.6

SGA/preterm infants (<36wks GA) = 24 hours if no feeding concerns and infant is well

  • If there has been ≥1 reading <2.6, it is reasonable to screen 1-2 times on Day 2 to ensure levels remain above 2.6

Once 2 consecutive BG ≥2.6, continue monitoring pre-feed or every 3-6h.

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6
Q

You plan on sending an infant home from the hospital who has been experiencing persistent hypoglycemia. What should you do prior to discharge?

A
  1. A 5-6 hour fast prior to discharge
    • Maintenance of glucose level ≥3.3 at 4 and 5 hours postfeed should be documented before discharge is considered.
  2. Underlying diagnosis for neonatal hypoglycemia should be ascertained and specific medical management initiated (e.g. diazoxide in hyperinsulinism)
  3. Counsel parents regarding frequency of feeding, home blood glucose monitoring, medication delivery (if needed) or other treatment measures for hypoglycemia
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7
Q

Describe the essential approaches to treating hypoglycemia in the newborn and their corresponding treatment options.

What are conjunctive treatments for hyperinsulinism and GH deficiency?

A
  1. Increasing energy intake
    • Orally
      • Increase frequency of breasfeeding
      • Supplementing feeds (order of preference): EBM, donor milk, formula
        • 5mL/kg with 1st BG <2.6 (asymptomatic)
          • can be used for 2nd BG <2.6 WITH gel
        • 8mL/kg with 2nd BG <2.6 (asymptomatic)
      • Intrabuccal 40% dextrose gel (0.5mL/kg)
    • Intravenously
      • IV glucose
        • Wean once glucose levels stable for 12h
  2. Mobilizing energy stores
    • Glucagon
    • Corticosteroids

Conjunctive treatments

  • Hyperinsulinism
    • Diazoxide
    • Octreotide
  • GH deficiency
    • recombinant GH
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8
Q

What is one non-pharmacological measure that has been associated with reducing the incidence of hypoglycemia and may be considered in at-risk infants

A

Delaying the first bath

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9
Q

List 3 indications for initiation of IV dextrose in a hypoglycemic infant.

What orders would you provide to initiate IV intervention? How would you change your management for persistent hypoglycemia?

A
  1. Symptomatic or unwell
    • Give bolus 2mL/kg over 15 minutes, as well
  2. If BG <1.8
  3. Not tolerating feeds
  4. BG <2.6 x 3 (failed 2 interventions PO)

Initial IV: 80mL/kg/day of D10W, repeat glucose check in 30 minutes (if delay in IV insertion, give 40% dextrose gel 0.5mL/kg)

  • Increase D10W infusion q30min by 1mL/kg/h until within target range
  • Then, calculate the lowest GIR the BG is within target range
    • GIR = infusion rate (ml/kg/h) x [dextrose] (%)/6
  • Then, calculate the [D%W] needed to stay within maximum daily TFI
    • Can give up to D20W in peripheral line
  • Check electrolytes in 8-12h
  • Introduce enteral feeds as tolerated
    • Can breastfeed above TFI during transitional period (risk of over-hydration is low)
    • If supplemented: do not exceed 100mL/kg/day total
  • Once glucose ≥2.6 x 12h, can start to wean IV
    • Repeat BG q3h until full enteral feeds and 2 normal BGs

HIGH GIR

  • 8-10 → consider level 3 care + CVL
  • >10 →
    • Medication
      • Initial: Glucagon 0.1-0.3mg/kg bolus or 10-30µg/kg/h)
      • Others: hydrocortisone, diazoxide, octreotide
    • if >72h need further investigation
      • Critical sample
        • plasma glucose, beta-hydroxybutyrate, insulin, GH, cortisol, acylcarnitine + carnitine profiles, bicarbonate, FFA, lactate
      • Endocrinology referral
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10
Q

List 5 risk factors for Intraventricular or Intraparenchymal Hemorrhage

A
  1. ROM > 72h
  2. Breech delivery via SVD
  3. Increased urgency of delivery
  4. Hypothermia
  5. Use of vasopressors and inotropes
  6. HD-PDA
  7. Hypocapnia
    • PCO2 <35mmHg = risk of PVL
    • PCO2 >60mmHg = risk of IVH
  8. Pressure-limited ventilation
  9. Early use of HFO
  10. Transportation of preterm infant (noise, vibration, acceleration)
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11
Q

What is the highest risk period for acute preterm brain injury?

A

First 72 hours = critical window

95% IVH/intraparenchymal lesions are detected by Day 5

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12
Q

List 5 ways to prevent acute brain injury in preterm infants

A
  1. Maintain PCO2 between 45-55mmHg (minimize lung injury/ BPD)
  2. Normothermia
  3. Antenatal corticosteroids (if ≥48h prior to birth)
  4. Umbilical cord milking
  5. Delayed cord clamping up to 180s
  6. Neutral, midline head position with ↑HOB 30˚
  7. Volume-targeted ventilation (for first 72h)
  8. Nurturing environment (skin-to-skin contact, maternal voice exposure and interaction, light cycling, low noise level)
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13
Q

What strategies can be used to prevent acute brain injury for all premature neonates < 35 weeks?

A
  • Transfer at-risk mothers to tertiary care centre to deliver (if able)
  • C-section for very preterm + malpresenting infant
  • Delayed cord clamping (30-120s) if not in need of immediate resuscitation (consider cord milking in this case)
  • Avoid inotropes with hypotension unless a combination of other signs are present (↑lactate, ↑CRT, ↓u/o, ↓cardiac output)
  • Avoid lung hyperinflation (use volume-targeted ventilation)
  • Treat hypotension with slowly infused bolus before inotropes + CXR
  • Target PCO2 45-55mmHg to minimize lung injury + BPD
  • Maintain head in neutral, midline position with ↑HOB 30˚

<35 weeks

  • If risk of delivery in ≤7 days offer antenatal corticosteroids

<34 weeks

  • If delivery imminent (≤24h) consider intrapartum MgSO4 (↓ risk of cerebral palsy)

<33 weeks

  • Maternal antibiotic prophylaxis if PPROM and expecting to deliver
    • Penicillin + macrolide (if allergic to PCN → macrolide only)
  • If PPROM, preterm labour, unexplained NRFHR or chorio:
    • BCx + Abx prophylaxis x 36-48h (until BCx negative)

<32 weeks

  • Prevent hypothermia
    • Polyethylene bag or wrapping
    • Hat
    • Maintain room temperature between 25-26˚C
    • preheated radiant warmer with servo-control
    • Thermal mattress
  • Consider prophylactic indomethacin or ibuprofen for high-risk extremely preterm infants
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14
Q

List 3 goals of postnatal period care

A
  1. Foster development of parenting skills
  2. Promote physical well-being of mother and infant
  3. Support relationship among mother, infant and family members
  4. Strengthen the mother’s knowledge and confidence
  5. Facilitate development of feeding skills

All parents should receive counselling on:

  • Infant care
  • Signs of illness and how to respond
  • Infant safety - including safe sleep practices
  • Importance of smoke-free environment
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15
Q

What is the role of the health-care provider during the postnatal course?

A
  1. Evaluate the infant’s physical health
  2. Identify early problems
  3. Assist with establishment of feeding
  4. Observe parent-infant interaction
  5. Identify psychosocial stressors
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16
Q

Identify 2 populations that are at increased risk for readmission after postpartum discharge.

A
  1. First-time parent
  2. Low household income
  3. Younger GA
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17
Q

Identify 5 criteria that must be met prior to discharge of a healthy term infant.

A
  1. CCHD performed and normal
  2. Physical exam (with measurements) complete and documented with no additional in-hospital or ongoing observations or treatments needed
  3. Temperature is stable (open cot, appropriately dressed)
  4. Urine and at least 1 stool have been passed
  5. ≥2 successful feeds documented
  6. Maternal serologies reviewed and mother received all immunizations and/or medications
  7. NBS complete at ≥24h (or arrangements to screen within first 7d confirmed)
  8. Successful cardiorespiratory adaptation with normal, stable HR and RR
  9. Hearing screen completed or scheduled
  10. Bilirubin screening complete with appropriate follow-up PRN
  11. Vitamin K and ophthalmia neonatorum prophylaxis given
  12. Approved car seat in place + parents have demonstrated they can position the seat and secure infant properly

Must have an appropriate follow-up plan with scheduled visit 24-72h postdischarge

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18
Q

List 2 PROS and 2 CONS of early discharge of dyad following delivery

A

PROS

  • Facilitates family integration
  • Enhances parent-infant bonding
  • Allows mother to recover in quieter home environment with family support
  • Decreases exposure to nosocomial infection

CONS

  • Decreased parental education time
  • Untimely identification of postnatal problems
  • Increased readmissions for jaundice and dehydration
  • Shorter duration of breastfeeding
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19
Q

List 5 maternal and 5 infant risk factors for safe discharge after delivery

A

MATERNAL

  • Young age
  • Language barrier
  • Inadequate housing
  • Lack of family support
  • Inadequate prenatal care
  • Unstable parental relationships
  • Medications/substance use - ETOH, drugs
  • Depression
  • Low educational level

INFANT

  • Abnormal prenatal screen/ultrasound findings
  • Birth weight
  • Serologies not protective
  • Risk factors for infection/sepsis
  • Abnormal glucose homeostasis
  • DDH
  • Birth injury
  • Apgar score, need for stabilization at birth +/- low umbilical pH
  • Risk factors for early-onset neonatal jaundice
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20
Q

Describe the types of hemorrhagic disease of the newborn, their expected time course and etiology

A
  1. Early onset (<24h)
    • Maternal medications that inhibit vitamin K activity (antiepileptics)
  2. Classic (2-7 days)
    • Low intake of vitamin K
  3. Late onset (2-12 weeks up to 6mo) - typically ICH (50%)
    • Almost exclusively breastfed infants
      • low vitamin K intake
      • chronic malabsorption
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21
Q

Describe the recommended management options to prevent hemorrhagic disease of the newborn including dosing.

A
  • Parenteral Vitamin K
    • IM injection x 1 within 6h of delivery + after initial stabilization and maternal/newborn interaction
      • use pain minimizing strategies
    • Dosing
      • ≤1500g = 0.5mg
      • >1500g = 1mg
  • Oral Vitamin K (less effective, ↑failure rate, takes 5 days to achieve same effect as IM)
    • 2mg with first feed, 2-4 weeks and 6-8 weeks
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22
Q

List 4 indications for imaging the neonatal brain

A
  1. Infection
  2. Unexplained apneas
  3. Neonatal encephalopathy (NE)
  4. Suspected structural brain abnormalities
  5. Metabolic disorders
  6. Birth injuries
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23
Q

List the imaging modalities available for imaging the neonatal brain, indications for their use and disadvantages

A
  • Head Ultrasound
    • Indication: assessment for intraventricular hemorrhage
    • Advantages: safe, portable, readily available
    • Disadvantages: posterior fossa may not be well visualized, operator dependent, not useful for encephalopathy
  • CT Head
    • Indication: Urgent situations (unstable infant), suspicion of trauma or skull fracture
    • Advantages: offers imaging when patient too unstable
    • Disadvantages: ionizing radiation, grey/white contrast is poor, underestimates severity of injuries to white matter
  • MRI Brain (modality of choice for TERM brain)
    • Indications: Neonatal encephalopathy, metabolic disorders, structural concerns
    • Advantages: no radiation, improved diagnostic accuracy, no need for sedation
    • Disadvantages: higher costs
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24
Q

Describe the recommended timing for imaging of the neonatal brain following hypoxic ischemic encephalopathy

What are the 2 patterns of injury that can be seen with HIE, their location and the type of impairment associated with it?

A

Timing: DOL 3-5 (if cooled → DOL 4-5) to confirm diagnosis + extent (if exam not consistent with MRI findings or diagnostic ambiguity exists, repeat MRI in 10-14 days [maximal injury visible at this time for watershed injuries])

Patterns of Injury

  1. Watershed (50%) → cognitive impairment/language
    • Location: between major arterial supplies and deep in the sulci → cortical necrosis
    • Seen with prolonged partial hypoxia-ischemia
    • Impairment: cognitive impairment, predicts language outcomes
  2. Basal ganglia/thalamic (25%) → CP
    • Location: deep grey matter → sensorimotor cortex
    • Seen with acute, profound hypoxia-ischemia
    • Impairment: If loss of normal signal intensity in PLIC (posterior limb of internal capsule) → associated with severe motor and cogntivie disability → CP
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25
Q

What is the best imaging for neonatal stroke?

What type of stroke is most common and where is its common location?

A

MRI

Arterial infarction → LEFT MCA

1-2mo: injury evolves into tissue loss & cysts

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26
Q

Where would you expect to find the injury caused from a bilirubin encephalopathy on MRI?

A

Globus pallidus + subthalamic nuclei

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27
Q

What is the inclusion criteria for therapeutic cooling for HIE?

What are exclusions for therapeutic cooling? List 2.

A

Must be:

  • ≥36 weeks GA (possibly 35)
  • ≤6h of life
  • Meet Criteria A+C or B+C

If meets criteria, but then returns to normal within 30-45min after birth, cooling may be deferred with careful ongoing observation for signs of returning encephalopathy.

CRITERIA

  • A:​ pH ≤7.0 or BE ≥-16
  • B: pH 7.01-7.15 or BE -10 to -15.9 AND Apgar ≤5 at 10min or ≥10min PPV AND History of acute perinatal event (e.g. uterine rupture, placental abruption, cord prolapse)
  • C: Evidence of mod-severe encephalopathy - seizures or ≥3/6 categories with ≥1 sign present

If criteria met, offer therapeutic cooling. If difficult to categorize, consult tertiary care neonatologist

EXCLUSIONS

  • <35 weeks GA
  • Clinically significant coagulopathy
  • Evidence of severe head trauma or intracranial bleeding
  • Moribund (in terminal decline)
  • Major congenital or genetic abnormalities for whom no further aggressive treatment is planned
  • Severe IUGR
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28
Q

You are working in a community hospital and are caring for an infant with HIE who you have just determined meets criteria for therapeutic cooling. Describe strategies for initiation of cooling while awaiting transportation.

A
  • Initiate passive cooling
    • Turn off warmer
    • Take off hat/blanket
    • Check rectal temperature q15min to prevent ≤33˚C (target is 33.5˚C ± 0.5˚C)
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29
Q

Describe the possible complications with HIE/therapeutic cooling

When would you consider discontinuing therapeutic cooling prematurely?

A
  • Seizures
  • Discomfort (treat w/low dose morphine ≤10mcg/kg/h)
  1. Hypotension despite inotropic support
  2. PPHN with hypoxiemia despite adequate treatment
  3. Clinically significant coagulopathy, despite treatment
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30
Q

List 4 goals of therapeutic cooling for HIE

How quickly should the baby be rewarmed?

A
  1. Minimize fluctuations in CO2
  2. Avoid hyperoxia
  3. Ensure adequate tissue perfusion with appropriate use of vasopressors/intropes
  4. Maintain normal blood glucose
  5. Treat hyperbilirubinemia
  6. Minimize unnecessary stimulation or handling

Rewarming

  • After 72h of cooling, rewarm 0.5˚C q1-2h
    • if seizures/worsening encephalopathy - recool x 24h then resume warming
      • treat with antiepileptics - obtain serum levels in first 72h if redosing is needed
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31
Q

How should follow-up be arranged for an infant with HIE who has received therapeutic cooling?

What consequences/morbidity are you screening for with follow-up appointments?

A
  • NNFU for minimum of 2y (ideally until school age)
  • Care by community pediatrician

Consequences/morbidity

  1. Cerebral palsy (30%)
  2. Severe visual impairment/blindness (25%)
  3. Hearing loss (~18%)
  4. Learning disability (30-50%)
  5. Behavioural difficulties
  6. Epilepsy (13%, 7% require antiepileptics at school age)
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32
Q

What is the most common type of neonatal sepsis?

When does it typically present?

What is the most common mechanism?

What bacteria is most commonly responsible?

What is the most common presenting symptom?

What percentage of infants born to mothers colonized with GBS develop this type of sepsis without intrapartum antibiotic prophylaxis?

A

Early-onset neonatal bacterial sepsis

Symptomatic within 24h of birth

Cause: vertical transmission of organisms colonizing birth canal

GBS,Escherichia coli, GAS, S. pneumoniae, Enterococcus, Enterobacter, Staph aureux, H. influenzae

Respiratory distress

1-2%

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33
Q

List 4 risk factors for early-onset sepsis in the neonate

A
  • Prolonged ROM >18h
  • History of previous infant with invasive GBS disease
  • Maternal fever ≥38˚C
  • GBS bacteriuria at any time during the current pregnancy
  • Intrapartum GBS colonization during current pregnancy
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34
Q

When should screening for GBS colonization be performed?

If screening positive or history of GBS bacteriuria during the pregnancy, what is considered adequate prophylaxis?

Does IAP decrease the incidence of late-onset GBS disease?

A

Between 35-37 weeks GA.

Adequate prophylaxis = ≥4h prior to delivery for SVD or ROM (not needed for cold section)

  • IV Pen G 5 million units OR Ampicillin 2g (If allergy: Cefazolin IV 2g [low risk], or IV erythromycin/clindamycin or IV vancomycin)
  • Should be considered inadequate if IV clindamycin or IV vancomycin used (due to lack of clinical trials)

No - does not decrease incidence of late-onset GBS disease

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35
Q

What tests should be performed when concerned for early-onset bacterial sepsis in the neonate?

A

Tests

  • Blood culture
    • WBC <5 x 10^9/L or ANC <1.5 x 10^9/L
  • CBC/diff
  • If blood culture positive:
    • LP (should be done if BCx positive)
      • Considered positive if: WBC >20-25cells/mm3
      • pleocytosis, low glucose, high protein
    • CSF culture
  • If respiratory distress:
    • CXR
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36
Q

List 5 signs of sepsis in a neonate.

A
  1. Respiratory distress
  2. Temperature instability
  3. Tachycardia
  4. Seizures
  5. Hypotonia
  6. Lethargy
  7. Poor peripheral perfusion
  8. Hypotension
  9. Acidosis
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37
Q

What is the management for early-onset neonatal sepsis?

A

Preterm (35-36wks)

  • if stable enough to remain with their mother, manage similar to term, but observe for 48h rather than 24h

Term (≥37wks)

  • See photo

Before discharge

  • Parents to understand signs of sepsis and are able to seek medical care if signs develop
  • Ready access to health care
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38
Q

List 5 risk factors for acute encephalopathy in the presence of severe hyperbilirubinemia

A
  1. Acidosis
  2. Prematurity
  3. Dehydration
  4. Hyperosmolarity
  5. Respiratory distress
  6. Hydrops
  7. Hypoalbuminemia
  8. Hypoxia
  9. Seizures
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39
Q

List 5 risk factors for the development of severe hyperbilirubinemia in the newborn

A
  • <38wks gestational age
  • Previous sibling with severe hyperbilirubinemia
  • visible jaundice <24h or before discharge
  • visible bruising
  • Male sex
  • Cephalohematoma
  • Maternal age ≥25yo
  • Asian or European background
  • Dehydration
  • Exclusive and partial breastfeeding
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40
Q

When should a direct antiglobulin test be performed?

When should a G6PD deficiency test be performed?

A
  1. Clinically jaundiced infants of mothers with group O blood
  2. Infants with elevated risk of needing therapy (high-intermediate risk zone)
  3. Antenatal maternal antibodies

G6PD

  • all infants with severe hyperbilirubinemia
  • screen at-risk infants (Mediterranean, Middle Eastern, African or Southeast Asian origin)
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41
Q

At what level should a total conjugated bilirubin concentration prompt further investigation?

A

>18 µmol/L or >20% TSB concentration

42
Q

List 4 side effects of phototherapy.

A
  1. Temperature instability
  2. Intestinal hypermotility
  3. Diarrhea
  4. Interference with maternal-infant interaction
  5. Bronze discolouration of the skin (rare)
43
Q

How should you manage an infant who presents with severe hyperbilirubinemia?

Once ready for discharge, what follow-up should you arrange?

A
  • Place under intensive phototherapy
  • Continue breastfeeding
  • Repeat bilirubin concentration within 2-6h of initiating treatment to confirm treatment response
  • Consider supplemental fluids administered orally or by IV infusion
  • If isoimmunization present, provide IVIG
  • If unsuccessful in controlling the rising bilirubin concentration, initiate exchange transfusion (consider in healthy term infant between 375-425 µmol/L)
    • Before starting: Collect blood for red cell fragility, enzyme deficiency and metabolic disorders, hemoglobin electrophoresis and chromosome analysis

Follow-up

  • Breastfeeding support in community
  • Infants with isoimmunization: order repeat hemoglobin
    • If low at discharge: at 2 weeks
    • If normal at discharge: at 4 weeks
  • If exchange transfusion:
    • Refer for NNFU
    • Ensure hearing screen with brainstem auditory evoked potentials is completed
44
Q

Describe the recommended management for neonatal ocular prophylaxis during a shortage of erythromycin ointment

What is the contraindication to administering Ceftriaxone in a neonate?

What is the best means of preventing ophthalmia neonatorum?

A
  • Gonorrhea
    • No test done → test mother at delivery**
    • Positive test
      • Treated but not followed up → test mother at delivery**
      • No treatment
        • Baby asymptomatic → assume baby is infected: test with conjunctival swab for gonococcus + IM/IV Ceftriaxone x 1 dose
        • Baby unwell →
          • Conjunctival swab + BCx + CSF Cx
          • Paediatric ID consult
    • Negative test
      • Low risk → no treatment
      • High-risk → test mother at delivery**

**Discharge infant if close follow-up can be assured while awaiting results (counsel to contact immediately if develops eye irritation/discharge)

If close follow-up CANNOT BE ASSURED AND it is NOT POSSIBLE for the infant to remain in hospital while awaiting results → treat with IM Ceftriaxone (50mg/kg [max 125mg]) x 1 before discharge

  • Chlamydia
    • Positive, no treatment → closely monitor for symptoms (conjunctivitis, pneumonitis) + treat if infection occurs

Contraindication - if neonate is receiving IV calcium (administer cefotaxime 100mg/kg IM or IV)

Best prevention: Screen pregnant mothers for gonorrhea and chlamydia infection (treat and follow-up those infected)

  • if positive, test after treatment to ensure therapeutic success
    • test again in 3rd trimester or at delivery
45
Q

What is the appropriate management of an infant exposed to Chlamydia trachomatis?

A

Close clinical follow-up

Test conjunctival and nasopharygeal secretions of symptomatic infants → treat if positive

Erythromycin PO 50mg/kg divided QID x 14 days

46
Q

What level of hematocrit is required for neonatal polycythemia?

List 4 causes of neonatal polycythemia.

A

≥65%

Causes

  1. Passive fetal RBC transfusion
    • Twin-twin transfusion
    • Delayed cord clamping
    • Maternal-fetal transfusion
  2. Increased fetal erythropoiesis
    • postdates
    • SGA
    • LGA
    • Infant of diabetic mother
    • Chromosomal abnormalities (trisomies 13, 18, 21)
    • Androgenital syndrome
    • Neonatal Graves disease
    • Hypothyroidism
    • Infants of hypertensive mothers (or taking propranolol)
    • Beckwith-Wiedemann Syndrome
47
Q

What is the most common cause of perinatal brachial plexus palsy (PBPP)?

List 3 risk factors for PBPP.

What is the prognosis?

A

Birth trauma

Risk factors for PBPP

  • Shoulder dystocia
  • Large for gestational age
  • Maternal diabetes
  • Instrumental delivery

Prognosis:

  • 75% recover completely within the first month of life
  • 25% will have residual deficits (if incomplete recovery by 3-4 weeks, full recovery is unlikely)
    • refer to multidisciplinary team
48
Q

What are the most frequent indications for blood transfusions in the newborn?

Describe strategies to decrease risk of transfusion.

What is a major risk of rapid and massive transfusion?

A
  1. Acute treatment of perinatal or surgical hemorrhagic shock
  2. ‘top-ups’ for recurrent correction of anemia of prematurity (used to maintain levels >75)

Strategies to decrease risk of transfusion

  1. Leukoreduction (decreases CMV risk)
  2. Irradiated (decreases GVHD risk)
  3. Screening donors
  4. Cross-matching (starting at 4mo)

Implementing iron supplementation between 4-6wks of age (physiological 2-3mg/kg/day; if deficient: 4-6mg/kg/day) at onset of reticulocytosis, results in higher Hgb and iron stores after 6mo.

Risk of rapid/massive transfusion = hyperkalemia

49
Q

What are the transfusion thresholds for anemia of prematurity?

A

Week 1

  • Resp support = 115
  • No support = 100

Week 2

  • Resp support = 100
  • No support = 85

Week ≥3

  • Resp support = 85
  • No support = 75
50
Q

What are strategies to minimize iatrogenic blood loss in premature infants?

A
  • Noninvasive CO2 monitoring for ventilated preterm infants
  • Noninvasive bilirubin monitoring devices before phototherapy is recommended
  • Point-of-care testing
  • Limit blood sampling to the minimum required for safe clinical care
    • Use marked tubes to indicate minimum volume to collect
    • Cluster blood samples to reduce skin breaks and painful procedures
51
Q

In what time period can Neonatal HSV infections present?

List 2 prevention strategies for neonatal HSV.

Describe 2 clinical presentations of neonates where you should consider neonatal HSV.

A

In the first 6 weeks of life (typically initial sx in first 4wks)

Prevention strategies

  • C-section delivery
  • Maternal antiviral therapy
  • Anticipatory guidance for prospective mothers/partners
  • Identification of high-risk pregnancies

Clinical Presentations

  • <6wks
  • Suspected sepsis (esp. if presenting w/seizure, AbN CSF, not improving rapidly, -ve CSF at 24h, unexplained hepatitis)
  • Unexplained coagulopathy or bleeding from venipuncture sites
  • Pneumonia NYD, not improving after 24h Abx
52
Q

List the 3 classifications of maternal HSV and their risk of transmission.

A
  1. Newly acquired
    • First-episode primary infection (no hx of antibodies)
      • 60% transmission
    • First-episode non-primary infection
      • ≤30% transmission
  2. Recurrent
    • < 2% transmission
53
Q

List the 3 classifications of neonatal HSV infections and the duration of treatment

Which is most common in newly acquired maternal HSV?

What indicates a poor prognosis?

A
  • Disseminated HSV (involves multiple organs) - 21 days
    • **More common in newly acquired maternal HSV**
    • Highest mortality rate (29%)
    • If nasopharyngeal PCR+ and pneumonia = presume disseminated
  • Localized CNS HSV - 21 days
    • ​If fever, irritability and abnormal CSF findings (**seizures)
    • Mortality rate (14%)
  • Skin, eye and mucous membrane (SEM) infection - 14 days

Poor prognosis

  • Higher viral loads in CSF
  • Persistence of HSV in CSF in patients on acyclovir
54
Q

What is the recommended investigations/managements for:

  • Asymptomatic term infant potential exposed to HSV
    • Suspected 1st-episode genital HSV at delivery
    • Recurrent genital HSV
  • Symptomatic HSV
A
  • Asymptomatic term infant potential exposed to HSV
    • Suspected 1st-episode genital HSV at delivery
      • Initial management
        • Mucous membrane swabs (conjunctivae, mouth, nasopharynx) at 24-hours of life regardless of delivery type +/- blood PCR (if available)
        • ​Treatment with IV Acyclovir x 10 days for:
          • Vaginal delivery
          • C-Section delivery with ROM
        • C-section delivery NO ROM or Recurrent genital HSV:
          • Discharge to reliable caregiver aware of NHSV symptoms
      • Ongoing management
        • If HSV testing negative → continue observation
        • If HSV testing positive → admit to hospital
          • Do CSF + blood PCR + transaminases
          • Start Acyclovir IV
            • If CSF/blood positive → 21 days (min)
              • Repeat CSF near end of 21-day course, if remains positive, continue with weekly sampling until negative
            • If CSF/blood negative → 14 days
  • Symptomatic HSV (or positive test in asymptomatic)
    • Testing:
      • PCR testing:
        • CSF, mucous membrane swabs, vesicular lesions blood
          • Nasopharyngeal PCR if pneumonia present
        • Transaminases (evidence for disseminated)
    • ​Start Acyclovir IV 60mg/kg/day divided q8h
    • If ocular involvement:
      • Treat with topical ophthalmic agent→ trifluridine
      • Ophthalmology consult
    • Suppressive therapy for CNS disease (consider for disseminated)
      • PO Acyclovir (300mg/m^2/dose TID) x 6 months
        • adjust for growth
      • CBC, urea/Cr monthly
    • Neonatal follow-up clinic
55
Q

Provide 1 infection control recommendation for each specific target group:

Neonates with HSV infection and exposed neonates

Mothers with active HSV

Staff with orofacial or skin lesions

A
  • Neonates with HSV infection and exposed neonates
    • ​Use contact precautions with:
      • Mucocutaneous lesions until crusted
      • Asymptomatic neonates whose mothers have active HSV lesions (until end of incubation period - 14 days) or until samples are negative
  • Mothers with active HSV
    • ​Use contact precautions until lesions crusted
    • If herpes labialis, wear disposable mask when caring for infant <6wks or until lesions healed (crusted and dried)
      • No kissing infant
    • Keep skin lesions covered whenever newborn present
  • Staff with orofacial or skin lesions
    • ​Meticulous hand hygiene + keep lesions covered (if not possible, avoid direct care)
    • Wear surgical mask for orolabial lesions
    • Avoid contact if active herpetic whitlow
56
Q

Describe adverse effects associated with retinopathy of prematurity screening.

List 2 methods to decrease these risks.

A
  1. Distress
  2. Pain
  3. Apnea

Decrease risks

  • Topical anesthetics
  • Pacifiers
  • Swaddling
  • Sucrose
57
Q

What are the screening recommendations for ROP?

A
  • Screening:
    • <31 weeks BGA
      • <27wks → at 31wks CGA
      • ≥27wks → 4 weeks of life
    • BW≤1250g
    • BW 1251-2000g with unstable clinical course (respiratory disease, hypotension w/inotropes, prolonged ventilatory or oxygen therapy)

Use of specialized digital retinal photography (RetCam)

  • should have ≥1 indirect ophthalmoscopic examination by an ophthalmologist before treatment or cessation of screening

Discharged infants with ROP should be followed by an ophthalmologist (often have strabismus, cataracts, amblyopia and refractive errors)

58
Q

List 4 risks of surfactant replacement therapy

A

Short-term risks

  • During instillation
    • Bradycardia
    • Hypoxemia
    • Blockage of endotracheal tube
  • Pulmonary hemorrhage
  • Overdistension
  • Hyperventilation
59
Q

List 2 indications for surfactant replacement therapy

A
  1. Intubated infants with RDS
    • should be administered before transport
    • <29 weeks: consider immediate intubation followed by surfactant
  2. Intubated infants with MAS requiring >50% FiO2
  3. Sick newborn infants with pneumonia and Oi >15
  4. Intubated infants with pulmonary hemorrhage which leads to clinical deterioration
  5. Infants with RDS with persistent or recurrent oxygen (≥30%) and ventilatory requirements within the first 72h of life should have repeated doses of surfactant (maximum 3)
    • Can be considered as early as 2h after initial dose (more commonly 4-6h after)
60
Q

List 3 complications of maternal depression in the neonate

Which SSRI may have an associated risk of increased cardiac malformations (septal, RVOT, conotruncal and LVOT defects)?

How long should babies with late-trimester SSRI exposure be observed in hospital for neurobehavioural or respiratory symptoms?

A
  1. Low birth weight
  2. Preterm birth
  3. Slightly higher risk of miscarriage
  4. Respiratory distress
  5. Increased length of hospital stay
  6. Poor maternal-child bonding
  7. Cognitive, behavioural and emotional consequences
  8. With SSRI use:
    • PPHN (risk is negligible)
    • Admission to NICU

Paroxetine

Minimum of 48 hours

61
Q

List 4 signs or symptoms associated with SSRI exposure in the neonate (SSRI neonatal behavioural syndrome [SNBS]).

When are these symptoms typically present and how long do they last?

A
  1. Tachypnea
  2. Cyanosis
  3. Jitteriness/tremors
  4. Increased muscle tone
  5. Feeding disturbance

Present within hours

Resolve within 2 weeks

62
Q

Regarding twin-twin transfusion syndrome which vessel from the placenta is supplying the donor and recipient?

List 4 complications associated with the donor

List 4 complications associated with the recipient

A
  • Donor→ arterial
  • Recipient → venous

Complications

  • Donor
    • Oligohydramnios
    • Small for gestational age
    • Malnourished
    • Pale
    • Anemic
    • Hypovolemia
    • Hypoglycemia
    • Microcardia
    • Small glomeruli
    • Thin walled arterioles
  • Recipient
    • Polyhydramnios
    • Hydrops
    • Large for gestational age
    • Plethoric
    • Polycythemia
    • Hypervolemia
    • Cardiac hypertrophy
    • Myocardial dysfunction
    • Tricuspid regurgitation
    • Right ventricular outflow obstruction
    • Thick-walled arterioles
    • Large glomeruli
63
Q

Which 2 populations of infants are at highest risk for BPD?

When are postnatal corticosteroids used to prevent BPD?

What complication is associated with use of dexamethasone in the first 7 days of life?

A

Highest risk for BPD

  1. Exposed to chorioamnionitis
  2. <28 weeks GA

When postnatal CS are used:

  1. Infants at highest risk for BPD: Hydrocortisone in the first 24-48h after birth x 10 days (risk of late-onset sepsis; do not combine with indomethacin)
    • Physiologic replacement: 1mg/kg/d x 7d→ 0.5mg/kg/d x 3d
    • associated with increased survival without BPD
  2. Infants who remain ventilated after 7d post birth with INCREASING O2 requirements + WORSENING lung disease
    • Low-dose Dexamethasone: 0.15-0.2mg/kg/d tapered over a short course (7-10d)

Dex <7d of life: increased risk of cerebral palsy

64
Q

List 4 contributing factors to BPD.

A
  1. Early gestational age
  2. Low birth weight
  3. Lung barotrauma
  4. Exposure to hyperoxia
  5. Lung inflammation
  6. Pre- and post-natal infections
65
Q

What is the criteria of an apnea in apnea of prematurity?

Below what gestational age is at risk for apnea of prematurity?

When should it resolve?

How long should an infant have no apneas before considered safe for discharge

A

Cessation of breathing for ≥20s OR 10-20s if accompanied by bradycardia (<80 bpm) or SpO2 <37wks BGA

<35 weeks GA

Typically by 40wks CGA (most by 36wks)

(if BGA <28wks, can continue until 44wks CGA)

At least 5-7 days is suggested

66
Q

In infants born <34 wks GA, what 4 factors indicate readiness for discharge? Parental factors?

What is the recommended target SpO2 for infants with BPD?

A
  1. Thermoregulation - maintain body temperature (~37˚C) fully clothed in an open cot
  2. Respiratory stability - maintenance of SpO2 >90-95% RA
  3. Feeding skills and sustained weight gain - successful feeding by breast and/or bottle without major cardiorespiratory compromise
  4. Control of breathing - apnea free for 5-7 days

Parental (are able to:)

  1. Independently and confidentaly care for their infant
  2. Provide medications, nutritional supplements and any special medical care
  3. Recognize signs and symptoms of illness and respond appropriately, especially in emergency situations
  4. Understand the importance of infection control measures and a smoke-free environment

SpO2 90-95%

67
Q

List 3 physiological changes associated with intubation

List 2 ways these physiological responses can be reduced or eliminated.

A
  1. Systemic and pulmonary hypertension
    • Systemic HTN → adequate analgesia
  2. Bradycardia
    • Can be avoided with atropine
  3. Intracranial hypertension
    • Avoided with muscle relaxants
  4. Hypoxia
    • Can be avoided with:
      • Preoxygenation
      • Use of blade that allows continuous oxygen insufflation into pharynx during procedure

Reduced/Eliminated

  1. Vagolytics
  2. Muscle relaxants
  3. Analgesic
  4. Preoxygenation
  5. Gentle technique
68
Q

What are the complications of premedicating an infant for intubation?

When is it acceptable to intubate an infant without premedication?

A
  1. Chest wall rigidity (chest freeze) → potent short-acting opiates (avoided if given slowly, treated by giving a muscle relaxant or opioid antagonist)
  2. Respiratory depression
  3. Malignant hyperthermia, hyperkalemia, rhabdomyolysis → succinylcholine
  • Emergency intubations during resuscitation
  • Infants in whom instrumentation of the airway is likely to be extremely difficult (e.g. with severely abnormal airways + need to breathe on their own)
69
Q

List 2 indications for treatment with inhaled nitric oxide (iNO)

What is the starting dose recommended?

When should you consider weaning?

A
  1. ≥35wks GA + hypoxemic respiratory failure failing to respond to respiratory management
  2. OI (oxygenation index) >20 to 25
  3. PaO2 <100mmHg despite 100% FiO2
  4. May consider in premature infants with respiratory failure 2˚ oligohydramnios

Not effective for most infants with CDH.

Starting dose: 20ppm (should expect ↑PaO2 ≥20mmHg in ≤30min)

  • If no response, increase to 40ppm ( >40ppm → potential for ↑toxicity without additional benefit)

Weaning: Improvement in oxygenation AND 4-6h period of stability of ↓FiO2 to 60-80% or OI falls to ≤10.

  • ↓50% q4-6h (as long as OI ≤10)
  • Once 5ppm, ↓1ppm q4h and d/c at 1ppm if <60% FiO2 w/PaO2 >50mmHg constantly

If cannot be weaned after 7 days, consider other lung/cardiac disease

70
Q

Name 2 risk factors associated with inhaled nitric oxide (iNO)

A
71
Q

List 2 populations where kangaroo care should be delayed

A
  1. <27wks GA who require high humidification
  2. Abdominal wall defect (pre-op)
  3. Neural tube defect (pre-op)
  4. Newly postoperative patients (stability NYD)
  5. Significant HD instability (wide BP swings, significant bradycardia, apnea or oxygen desaturation with handling, associated with prolonged recovery)
72
Q

List 4 benefits of kangaroo care in preterm infants

Identify 2 barriers to implementation of kangaroo care.

A
  1. Promotes maternal-infant bonding and breastfeeding
    • Breastfeeding: longer duration, higher volumes of milk expression, higher exclusive breastfeeding rates
  2. Promotes stability of cardiorespiratory function and temperature
  3. ↑ mature sleep organization (↑sleep time [quiet sleep], ↓active sleep)
  4. ↓nosocomial infections
  5. ↓pain with bedside procedures

Barriers to implementation

  1. Poor staff knowledge
  2. Inadequate training
  3. Discomfort with the process
  4. Lack of time and/or resources
  5. Lack of privacy
  6. Parental reluctance
73
Q

List 2 reasons preterm infants are at lower risk for opioid withdrawal

A
  1. Shorter in utero exposure time
  2. Decreased placental transmission
  3. Inability to fully excrete drugs by immature kidneys/liver
  4. Minimal fat stores leading to lower deposition/activity of opioids
74
Q

What are 3 adverse effects of opioid use in pregnancy?

How long should opioid-exposed babies be screened after delivery for withdrawal symptoms?

A
  1. Prematurity
  2. Low birth weight
  3. Spontaneous abortion
  4. SIDS
  5. Infant neurobehavioural abnormalities

3-5 days

75
Q

List 4 non-pharmacological strategies to decrease symptoms from neonatal abstinence syndrome (NAS).

What are 3 benefits of having the dyad room-in together during monitoring of NAS?

A
  1. Skin-to-skin contact
  2. Safe Swaddling
  3. Quiet environment (lower lighting, minimal stimulation)
  4. Music or Massage therapy
  5. Gentle waking
  6. Developmental positioning
  7. Parent rooming in with baby (near term/term, medically stable, adequate support in place, ongoing assessment needed)

Benefits of Rooming-in

  1. Increased breastfeeding initiation rates
  2. Lower NICU admissions
  3. Less need for pharmacotherapy
  4. Shorter hospital stays
76
Q

When should pharmacotherapy be initiated in Neonatal Abstinence Syndrome (NAS)?

What is the recommended first line management? Describe available adjuncts for management.

When can discharge be considered?

A

Using Finnegan scoring: 3 scores ≥8 OR 2 scores ≥12

  • 1st line: morphine or methadone
    • morphine: 0.32mg/kg/day q4-6h PO (↓10% daily dose q48-72h)
  • 2nd line: Buprenorphine
  • Adjuncts:
    • Phenobarbital - polysubstance abuse cases
    • Clonidine - autonomic symptoms present

Discharge

  • 72h if asymptomatic and no medication started
  • If phamacotherapy started:
    • Tolerating morphine wean
    • Consistent withdrawal scores < 8
    • Clear, documented weaning plan
    • When adequate medical and social follow-up available
      • Referral to PCP
      • Nutritional and family supportive resources
      • Infant neurodevelopmental assessment
      • Ensure safe, supportive home for discharge
77
Q

What is the most accurate assessment for determining gestational age?

Describe the situations where palliative care, shared-care and intensive care would be recommended for extremely preterm infants.

What are additional risk factors that would increase the likelihood of mortality in an extremely preterm infant.

A

First trimester crown-rump length with ultrasound (accurate within 3-8d)

Palliative Care

  • 24wk GA w/ELBW (350g)
  • ≤22wks

Shared-care

  • 23-24wks
  • 25wk w/fetal anemia and abnormal placental blood flow

Intensive Care (antenatal CS should be given if this is an option + risk of delivery is high)

  • ≥25 wks
  • Late 24th wk, well growth with antenatal corticosteroids, born in a tertiary centre

Risk Factor

  • SGA
  • No antenatal corticosteroids
  • Multiple gestations
  • GA early within week of gestation
  • Birth outside of a tertiary centre
  • Acute chorioamnionitis
  • Major congenital anomalies present on ultrasound
78
Q

List 2 benefits of human breast milk in the preterm infant.

List 2 risks associated with donor breast milk.

List 3 indications for donor breast milk.

A
  1. Lower incidence of necrotizing enterocolitis
  2. Lower incidence of severe infections
  3. Reduced colonization by pathogenic organisms
  4. Decreased length of hospital stay
  5. Improved neurodevelopmental outcomes

Risks with PHDM

  1. Infection - screened for HBV, HCV, HIV, Human T cell leukemia virus
  2. Contamination - “food poisoining”
  3. Allergy

13% of protein content is denatured in PHDM. Carbohydrates, fats and solids are unchanged.

All beneficial immune cells are inactivated (IgM antibodies completely removed)

Indications

  • Prematurity
  • GI surgery
  • Malabsorption or Feeding intolerance
  • Immunodeficiency
79
Q

In standard-risk women of child-bearing age, what is recommended to prevent neural tube defects (NTD)?

List 4 factors associated with increased risk for neural tube defect.

What is recommended to prevent NTD in high-risk women?

A
  • Encourage eating folate-rich foods (leafy vegetables, legumes, red meat, offal), fortified grain products
  • Daily multivitamin → Folate 0.4-1.0mg + Vitamin B12
    • SOGC: 2-3mo before conception, throughout pregnancy + ≥6wks postpartum (or until breastfeeding stops)

Risk Factors

  1. Birth of previous child with NTD (highest risk factor)
  2. Family history of NTD
  3. Maternal obesity
  4. Maternal Hispanic origin (or eat flour alternatives)
  5. Use of some anticonvulsants
  6. Low socioeconomic status (greatest burden of NTD)

As above, except with Folate 5.0mg

  • SOGC: ≥3mo before conception → 10-12wks postpartum
80
Q

List 5 conditions that have been associated with Vitamin D deficiency

List 2 conditions in the neonate that are associated with maternal Vitamin D deficiency

A
  1. Osteoporosis
  2. Asthma
  3. Autoimmune diseases (RA, MS, IBD)
  4. Diabetes
  5. Disturbed muscle function
  6. Resistance to Tuberculosis
  7. Pathogenesis of certain types of cancer
  8. Weak dental enamel

Neonatal conditions 2˚ Maternal Vit D Deficiency

  1. Rickets
  2. Hypocalemia
  3. Dental malformations
81
Q

What populations should receive 800IU/day of Vitamin D between October and April?

What is the recommended dosing of Vitamin D for premature infants and infants during first year?

What are the recommendations regarding maternal Vitamin D supplementation (pregnant/lactating women) to maintain sufficiency?

A
  1. North of 55th parallel
  2. Between 40th-55th parallel + RFs for Vit D deficiency (dark skin, breastfed, maternal deficiency)

Premature: 200 IU/kg/day (max 400 IU/d)

Infants: 400IU daily

Maternal: Consider 2000 IU/day with monitoring of 25-OH Vit D and calcium for side effects.

82
Q

List 5 benefits of breastfeeding.

A
  1. ↓ incidence of bacterial infections
  2. ↓ hospital admissions 2˚ infection
  3. ↓ severe respiratory illnesses
  4. ↓ SIDS
  5. ↑ performance on neurocognitive testing
  6. Economical

Maternal benefits

  1. ↓ breast + ovarian cancers
  2. ↑ postpartum weight loss
  3. Delay in return of ovulation
83
Q

List 4 contraindications to breastfeeding excluding medications.

List 4 medications or drugs contraindicated in breastfeeding.

A

Mothers:

  1. HIV-positive
  2. Human T-cell lymphotropic virus type 1 and 2
  3. Active tuberculosis (until treated ≥2 weeks + not contagious)
  4. Active HSV lesions on both breasts
  5. Receiving cytotoxic chemotherapy (for duration of treatment)
  6. Receiving radioactive isotopes or radiation therapy (during treatment course)

Infants

  1. Galactosemia

Medications

  1. Amphetamines
  2. Cocaine
  3. Cyclophosphamide
  4. Clozapine
  5. Doxorubicin
  6. Ecstasy (MDMA)
  7. Immunosuppressants
  8. Heroin
  9. Gold salts
  10. Thiouracil
84
Q

At what age have children developed the advanced oral motor coordination required to properly handle chunky food pieces such as nuts, whole grapes and hot dog wheels?

A

3 years

85
Q

Identify the 2 types of approaches to cessation of breastfeeding.

A
  1. Gradual weaning (infant-led)
    • occurs as the infant begins to accept increasing amounts of foods while still breastfeeding on demand.
    • Wean usually completes between 2-4yo
  2. Planned weaning (mother-led)
    • Reasons: inadequate supply, concerns regarding infant growth, painful feedings or mastitis, returning to work, new pregnancy, wishing an alternate caregiver to give feedings, eruption of baby’s teeth
86
Q

What guidance would you provide a mother whose infant has suddenly refused to breastfeed

A

“Nursing Strike”

  • Minimize Distractions: Make feeding time quiet and special
  • Increase cuddling and soothing of baby
  • Offer breast when infant is very sleepy or just waking up
  • Offer breast using different nursing positions, alternating sides or nursing in different rooms

If this is not effective, a physician should evaluate the infant for presence of possible illness.

87
Q

In regards to hearing screening, what is the ideal timing for screening, confirmation of diagnosis and intervention?

What is the average age at diagnosis in areas of Canada without screening programs?

What is the most common type and cause of hearing loss in children?

A
  • Screening: ≤1mo
  • Confirmation of diagnosis: ≤3mo
  • Intervention: ≤6mo

Average age at diagnosis = ~24 months (2yo)

Most common type: Sensorineural hearing loss

Most common cause: 50% genetics (most common → error in production of gap junction protein connexin 26)

88
Q

List 4 risk factors for neonatal sensorineural hearing loss

A
  • ABCDs
    • Affected family member
    • Bilirubin
    • Congenital intrauterine infection (CMV, rubella, toxo, HSV)
    • Defects of ear, nose and throat - Branchial Oto Renal syndrome + CHARGE syndrome (most common)
    • Small at birth (<1500g), low apgar, NICU
      • NICU stay >2 days OR involving any of the following (regardless of duration):
        • ECMO
        • Assisted ventilation
        • Ototoxic drug use
        • Hyperbilirubinemia requiring exchange transfusion
89
Q

List 4 infections associated with congenital sensorineural hearing loss

A
90
Q

List 3 functional outcomes of delayed diagnosis/intervention of neonatal sensorineural hearing loss

A
  1. Impaired socioemotional development
    • Low academic achievement
    • Underemployment
    • Increased social maladaption
    • Psychological distress
  2. Decreased literacy
91
Q

What are the 2 types of hearing screening tests performed?

Which is performed first in an newborn with no risk factors?

Describe intervention strategies if hearing loss is detected.

A
  1. OAE - otoacoustic emission (1st if no RFs)
  2. AABR - automated auditory brainstem response (if RFs)
    • ​​tests for auditory neuropathy (vestibular nerve function)

Hearing loss intervention

  • Audiological
  • Medical/surgical
    • Hearing aid
    • Cochlear implant
      • eligible children for bilateral implants should receive them between 8-12mo + auditory oral therapy
    • Bone-anchored hearing aid
    • Brainstem-implanted auditory device
  • Educational/(re)habilitation
  • Child and family support
92
Q

What is the recommended compression to ventilation ratio for neonatal resuscitation

What is the preferred method of heart rate assessment when administering chest compressions?

What initial FiO2 should you use for infants <35 weeks

What is the recommended dosing for epinephrine in neonatal resucitation?

At what gestational age should you use strategies to optimize thermoregulation?

What ETT tube size is recommended for a 3.75kg infant?

A

3 compressions: 1 ventilation

Cardiac monitor

21-30%

Epinephrine (1:10 000) ETT 1mL/kg (0.1mg/kg) [max 3mL]; IV 0.1mL/kg (0.01mg/kg)

<32 weeks GA

ETT 3.5

93
Q

Describe the treatment for polycythemia

A

Treatment

  • Confirm hematocrit with venous sample
  • Treat dehydration
  • Closely monitor ins/outs, blood glucose and bilirubin levels
  • Hct 60-70%
    • Monitor closely
    • Hydrate with enteral intake/administration of IV fluids
  • Hct 70-75% + symptoms worsen despite aggressive IV hydration
    • Partial exchange transfusion (with NS)
94
Q

List 4 signs or symptoms of neonatal polycythemia.

What are 2 complications associated with neonatal polycythemia?

A

Signs/Symptoms

  • Irritability
  • Lerthargy
  • Tachypnea
  • Respiratory distress
  • Cyanosis
  • Feeding disturbances
  • Hyperbilirubinemia
  • Hypoglycemia
  • Thrombocytopenia

Complications

  • Stroke
  • Seizures
  • Pulmonary hypertension
  • Necrotizing enterocolitis
  • Renal vein thrombosis
  • Renal failure
95
Q

What 4 things can you do while waiting for the neonatal transport team to transfer your baby with PPHN (pH 7.32, pCO2 48, HCO3 18, FiO2 80%, SpO2 91% preductal, 82% postductal)?

A
  1. Intubate and secure airway
  2. Target normocarbia and correct acidosis
  3. Obtain secure vascular access - insert UVC, possible UAC
  4. Minimize handling
  5. Provide sedation

Transportation

  1. Obtain copies of pertinent records and medical images
  2. Obtain a maternal blood sample and colostrum for early feeding, if able
  3. Retain the placenta, double-bagged in a sealed container without formaldehyde, for pathology examination
96
Q

What characteristic findings are seen on this CXR?

A
  • Air bronchograms
  • Diffuse, fine reticular granularity of the parenchyma (ground-glass appearance)
  • Low lung volumes

= Respiratory Distress Syndrome

97
Q

What characteristic findings are seen on this CXR?

A
  • Prominent perihilar pulmonary vascular markings
  • Fluid in intralobar fissures
  • Rarely, small pleural effusions

= Transient tachypnea of the newborn

98
Q

What characteristic findings are seen on this CXR?

A
  • Patchy infiltrates
  • coarse streaking of both lung fields
  • increased AP diameter
  • Flattening of the hemidiaphram

= Meconium aspiration syndrome

99
Q

List 4 clinical signs associated with neonatal thyrotoxicosis.

How will you manage this infant?

A
  1. Irritability
  2. Tachycardia (including SVT +/- cardiac failure simulating cardiomyopathy)
  3. Polycythemia
  4. Craniosynostosis
  5. Bone age advancement
  6. Poor feeding
  7. Failure to thrive

Management:

  • Self-limited disease (can take up to 6mo)
  • May need methimazole and beta-blockers to control hyperthyroidism and cardiovascular symptoms
  • If minimally affected, observe without treatment
100
Q

What features are associated with / at risk in Infant of a Diabetic Mother?

A
  • Preterm labour
  • LGA (or IUGR if vascular disease associated)
  • Hypoglycemia (25-50%)
    • Presents as jittery, tremulous, hyperexcitable
  • Hypocalcaemia
  • Hypomagnesemia
  • Tachypnea
    • Can be due to RDS (higher incidence)
    • Can be due to hypoglycemia, hypothermia, polycythemia, cardiac failure, TTN or cerebral edema from asphyxia/HIE
  • Cardiomegaly
    • 30% with 5-10% in heart failure
    • Asymmetric septal hypertrophy or transient hypertrophic subaortic stenosis
  • Hyperbilirubinemia from polycythemia
  • Renal vein thrombosis
    • Suspect if flank mass, hematuria and thrombocytopenia
  • Congenital anomalies
    • Congenital heart
      • VSD, ASD, TGA, truncus, DORV, tricuspid atresia, coarct
    • Lumbosacral agenesis
    • Neural tube defects
    • Hydronephrosis
    • Renal agenesis and dysplasia
    • Duodenal or anorectal atresia
    • Situs inversus
    • Double ureter
    • Holoprosencephaly
    • Small left colon syndrome (delayed development of left colon, transient, can have abdo distension)

RC Study Cards (20 decks)

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