NICU Baby Nelson Flashcards
IUGR
< placental abruption
vs. SGA
<10th percentile or 2SD below
Problems associated with babies who are IUGR or SGA
(table pg 189)
- intrauterine fetal demise
- temperature instability
- perinatal asphyxia
- hypoglycemia
- polycythemia (from fetal hypoxia with increased epo)
- dysmorphology associated
- pulmonary hemorrhage
What are the hormones abnormalities that suggest chromosome anomalies
- low estriols
- low AFP
- elevated chorionic gonadotropin levels (placental)
What are the main differences between fetal and adult hemoglobin?
fetal hemoglobin (2 alpha and 2 gamma) has higher affinity for O2 than adult Hg (this is why the baby steals all the O2) , the curve is shifted to the left - fetal hemoglobin is saturated with lots of O2, but harder to unload O2 to the tissue, but in the placenta, easier to unload the O2
when does the body start to make more adult Hg?
in the third trimester , body begins to decrease making fetal Hg and makes more adult (usually full adult by 3-6 months of life as per baby nelson) and at this point have adult Hg O2 dissociation curves
What are the effects of fever, acidosis, high PCO2 and 2,3 diphosphoglycerate on the Hg dissociation curve?
shifts the O2 dissociation curve to the right
because this means the body can unload O2 to the tissues more easily
and in these stressed states the tissues need more O2
which is the dominant ventricle in utero?
right ventricle
Why do we give babies silver nitrate? To prevent
a) chlamydia
b) gonorrhea
c) both
to prevent gonorrhoea - can cause panophthalmitis and blindness
not effective against C trachoma tis
Why do we give erythromycin drops? To prevent
a) chlamydia
b) gonorrhea
c) both
both
what comes back first after resuscitation of neonate who has arrested?
first get your heart rate, then cyanosis and perfusion improves
also remember that newborns respond to hypoxia with apnea rather than tachypnea
does of epi for neonatal resuscitation
1:10000 0.1-0.3 ml/kg
if giving endotracheal (less predictable, can try higher ode)
Large fontanelle, name 3 conditions to think of
hydrocephalus
hypothyroid
rickets
What are congenital melanocytic nevi
pigemented lesions
in 1% of neonates
true or false - giant pigmented nevi have malignant potential
true but they are rare (also the pics are intense)
leukocoria in newborn, differential
cataracts, chorioretinitis, ROP, ocular tumor, persistent hyperplastic primary vitreous
What does the TM look like in first 1-4 weeks?
dull, gray opaque adn imobile int eh first 1-4 weeks
supernumerary nipples, what organn should you look at?
renal anomalies
when do most term babies have their first pee
within first day of life in 95% of normal term babies
Abdominal mass in the neonate, most common 2 causes? other causes?
most common: hydronephrosis, muticystic dysplastic kidney disease
less common: ovarian cysts, intestinal duplication, neuroblastoma, mesoblastic nephroma
should do an U/S for masses asap
when do 99% of term babies pass their med
within 48 hours of birth in 99%
Differential of scrotal swelling in the neonate
(pg 200 baby Nelson)
- hernia
- hydrocele - eaily illuminate and clear
- in utero torsion of testicle - painless dark swelling
- meconium from meconium ileum and peritonitis
what is epispadias? what is hypospadias?should you worry about pseudohermaphroditism when these are present?
- epispadias: opening at top of penis
- hypospadias: opening at bottom of penis **don’t circumcize, may need foreskin
don’t need to worry if only this finding on own, however if can’t palpate testes, then worry about DSD
bloody discharge from baby girl’s newborn vagina, worry or not?
not worry, can be normal either blood streaked or clear (from withdrawal of maternal hormones)
do newborns shiver?
no
difference between central facial nerve injury, peripheral facial nerve injury (i.e. from compression ) and from absence of depressor anguli
- central facial nerve - forehead NOT involved, lower 2/3 involved
- facial nerve peripheral - whole face (including forehead, eye, nasolabial fold, mouth etc)
3) depressor anguli - nasolabial fold and upwards should all be normal, just the mouth moves funny, can be associated with cardiac (double check this)
What is hemorrhagic stroke encephalopathy syndrome?
rare condition
with excessive temperatures
Type of neonatal hypocalcemia
- early : within first 3 days of life, often no symptoms; Groups affected (special ones, all babies do have a transient decrease 24-48 hours or so)
a) . prems
b). IDMa - from transient hypoparathyroidism and reduced parathyroid response (for prems and IDMs)
(early in prem and IDM often resolves on its own)
c) DiGeorge (absence of parathyroid
**can also get hypoMg - risk in IDM especially
d) associated with asphyxia - late :
a) from drinking high phosphate milk, or inability to excrete phosphate ; usually will get hyperphosphatemia after first week of life in these infants
b) vitamin D deficiency states and malabsorption
**all infants have decrease in Ca at 24-48 hours or so
Clinical features of hypocalcemia
apnea, muscle twitching, seizures, laryngospasm
Chvostek sign - facial muscle spasm when 7th nerve tapped
Trousseau sign -
(no usually in newborn)
To prevent in high risk - gee Ca
symptomatic hypocalcemia, treatment
2-4 ml/kg 10% calcium gluconate
also give mg if both
for late hypoCa, same as above, but should also do low phosphate feedings
subcutaneous infiltration of IV calcium can cause tissue necrosis
oral can irritate the intestinal mucosa
When will a baby born to a heroin using mom withdraw
1-5 days
methadone mom, when withdraw
1-4 weeks
name symptoms of withdrawal from opiate
jittery, sneezing, irritable, diarrhea, poor feeding (but starving) , poor sleep, cry lots (high pitched), tachypnea
**often methadone withdrawal is worse
Treatment of withdrawing baby
start with swaddling, no light if significant (i.e. constant hyperactive, irritability doesn't allow sleeping and feeding, or when diarrhea/seizures present, treatment with meds 1. seizures - treat with phenobarb 2. other symptoms - with opiod weaning can take 1-2 months
Effects of cocaine use during pregnancy
preterm labor placental abruption decreased attentiveness irritable newborn SGA small heads usually no treatment needed
What type of antibody can cross placenta
IgG (which is usually the type that autoantibodies are)
Treatment of neonate with ITP with hemorrhage (and mom has ITP also
(table 205) can give platelets if hemorrhage can try IVIG usually resolves in 4-6 weeks risk is intracranial hemorrhage
Problems of Diabetic Pregnancy (pg 206) for baby
- LGA
- hypoglycemia
- hypocalcemia
- hypomagnesemia
- birth asphyxia/shoulder dystocia
- congenital heart defects - hypertrophy of septum
- tachypnea (RDS or TTN)
- small left colon
- renal disorders
- polycythemia
others also include lubosacral dysgenesis, neural tube defects
contrindications to indomethacin for PDA
thrombocytopenia
bleeding
creatinine >1.8
oliguria
how much blood do babies have?
70-90 ml/kg for term
90-100ml/kg for preterm
Delayed cord clamping advantages and disadvantages?
- can increase blood volume transiently for first few days, improves glomerular filtration
- disadvantage: can increase jaundice
early: can lead to anemia, murmur, poor perfusion, less tachypneas
**should hold the baby below the placenta (otherwise the baby will give too much blood back to the placenta)
Causes of anemia in the newborn period
- decreased production (low retics 0-2%)
Ddx: bone marrow failure (Diamond-Blackfan anemia), infection (congenital viral infections, i.e. parvo/rubella, sepsis), nutritional deficiencies (protein, iron, folate, vitamin B12), congenital leukemia - increased Destruction of RBC (normal or elevated retics (>5-10%)
Immune mediated: (Coombs positive)
- hemolytic disease of the newborn (anemia and hyperbili mainly) ABO incompatibility (less severe than Rh disease, doesn’t get worse in subsequent pregnancies )
- Erythroblastosis fetalis (Rh incompatibility)
make anti-D antibody (which is the antibody which is most likely to be present)
Non Immune mediated (Coombs negative) - RBC enzyme deficiencies - ie pyruvate kinase or G6PD
- RBC membrane disorders - ie hereditary spherocytosis (autosomal recessive is severe, less severe autosomal dominant form)
- hemoglobinopathies - ie thalassemias
**see chart pg 217
Clinical manifestations of erythroblastosis fettles
anemia, hyperbili in first pregnancy, then worse because will start hemolysing in utero
fetal anemia, heart failure, portal vein obstruction, hypoalbuminemia- i.e. fetal hydrous - ascites, pleural and pericardial effusions, anasarca
How to tell difference between acute and chronic blood loss at birth
- Acute blood loss - after fetal maternal hemorrhage, rupture of the umbilical cord, placenta pre via or internal hemorrhage
- pallor, diminished peripheral pulses, shock
- no signs of extra medullary hematopoesis, no HSM
- ininitial Hg can be normal but then decline over 24 hours - Chronic blood loss: i.e. chronic fetal-maternal hemorrhage, twin twin transfusion: marked pallor, heart failure, HSM with or without hydrous, a low hemoglobin level at birth
fetal-maternal bleedin is very common - 50-75% , blood losses range from 1-50 ml
What is the Kleihauer-Betke acid test
look at the mom’s blood smear - will see fetal pink pRBCs and counted (because fetal Hg is resistant to acid and adult hemoglobin is eluted)
false positive Kleihauer Betke: sickle cell or hereditary persistence of fetal hemoglobin
false negative - ABO incompatibility (since all will be negative)
What is Crigler-Najjar syndrome
serius, rare autosomal REcessive, permanent deficiency of glucoronosyltransferase that results in severe indirect hyperbilirubinemia
Type 2 - responds to phenobarbital (so randome)
Type 1 - persistent indirect hyperbili - can lead to kernicterus
What is Gilbert disease
mutation of glucoronosyltransferase and results in a mild indirect hyperbilirubinemia
How high is the bill in typically breast milk jaundice
shouldn’t be more than 20 mg/dL (which equals 20 x 17 = 340) I think
interupt fo 1-2 days will result in rapid decline
At what levels of bill is jaundice observed?
5-10 mg/dL
Work up to do for direct (conjugated hyperbili)
conjugated hyperbili is >20% of total bill do liver enzymes - AST/ALT ALP GGT bacterial and viral cultures metabolic screening hepatic U/S sweat chloride occasionally liver biopsy
Causes of conjugated hyperbili
Common 1. hyperalimentation cholestasis 2. CMV infection and other TORCH infections 3. Inspissated bile from prolonged hemolysis 4. neonatal hepatitis 5. sepsis Uncommon: 1. hepatic infarcation 2. IEMs - galactosemia, tyrosinemia 3. CF 4. biliary atresia 5. choledochal cyst 6. alpha 1 -antitrypsin deficiency 7. neonatal iron storage disease 8. alagille syndrome 9. Byler disease
early sign of kernicterus vs late
early : lethargy, hypotonia, irritability, poor moro ad feeding
later signs: bulging fontanelle, opisthotonus, pulmonary hemorrhage, fever, hypertonicity, paralysis of upward gaze and seizures
Complications of exchange transfusion
related to glood: transfusion reaction, metabolic instability, infection
catheter - vessel perforation hemorrhage
procdure: hypotension or NEC -
unusual: thrombocytopenia, GVHD
Polycythemia in neonate (pg 221)
Hematocrit >65% People at risk: SGA IDM delayed cord clamping hyperthyroidism adrenogenital syndrome T13, T18, T21 Twin twin (recipient) Beckwith - Wiedemann
Symptoms of polycythemia
- plethoric/ruddy may have acrocyanosis
Symptoms are from vascular stasis, hypo perfusion and schema
seizures, lethargy, irritability
hyperbili - poor hepatic circulation of Hg broken down into bill
Resp distress PPHN
NEC, hypoglycemia, thrombocytopenia, pripism, testicular infarction, stroke, feeding intolerance
Long term sequelae of polycythemia
neurodevelopment abnomalities
partial exchange transfusion how to calculate the volume:
how to calculate amount of blood for partial exchange transfusion pg 222 nelson baby
volume to exchange (mL) =
[blood volume x (observed hematocrit - desired hematocrit)/ observed hematocrit
desired hematocrit is 50%, blood volume is 85 ml/kg
pg 222 baby nelson
need to use central venous hematocrit (peripheral might be falsely elevated)
eye discharge at day 1 of life, initially clear then purulent, also have chemises and hyperaemia, more likely gonorrhoea or chlamydia
gonorrhea
gonorrhea presents in first 5 days of life, chlamydia is ted 5-14 days of life
chlaydia can last 1-2 weeks
gonorhea auses your eye to perforate and go blind
staccato cough, which infection
chlamydia pneumonia
CXR - hyperinflation with diffuse infiltrates
prophylaxis does not treat the chlamydia
when you have pneumonia +/- pneumonia with chlamyda, need to treat systemically with erythromycin
drugs which can impair vitamin K metabolism
warfarin, antibiotic
baby with late hemorrhagic disease of newborn, things to think of
breastfed
also might have vitamin K problems
ie CF, biliary atreisia, hepatitis, antibiotic suppression of colonic bacteria that make vitamin K
Treatment of bleeding from vitamin K deficiency
IV 1mg vitamin K
if severe, also can do FFP
Differential of bleeding in the newborn
- sick newborn: DIC< hepatic failure, thrombocytopenia (including consumption i.e. Kasabach-Merritt)
- Well child: hemophilia (cutaneous or mucosa bleeding and no systemic illness) , thrombocytopenia from syndromes (i.e. Fanconi anemia with no thumbs, radial aplasia-thrombocytopenia syndrome (thumbs present0 or Wiskott-Aldrich syndrome , maternal drugs can reduce platelet count (i.e. sulfonamids, quinidin, quinine, thiazide)
most common thrombocytopenia; isoimmune thrombocytopenia (mom has anti platelet but her platelets are find) treat with transfusion and/or IVIG , sometimes need to do C/S
and transient neonatal thrombocytopenia
neonatal thrombocytopenia in babies of mom’s with ITP
Lab findings in baby with DIC
prolonged PTT and PT (minutes rather than seconds ), thrombocytopenia and bood smear suggesting MAHA (burr or fragmented blood cells)
low fibrinogen
elevated levels of fibrin degradation products
labs in vitamin K deficiecy
PT most prolonged - X, VII, V, II, I
in hemophilia - factors XII, IX, VIII, X , V, II, and I
PTT most prolonged
