NICU CPS Flashcards
Which infants are at highest risk of acquiring HSV?
Infants born to mothers who have a first-episode primary infection at the time of delivery since the mother had no pre-existing neutralizing antibodies to transmit to the baby through placenta-remember that most newly acquired cases are asymptomatic
What steps may reduce risk of neonatal HSV transmission during pregnancy or at time of delivery?
- Acyclovir from 36 wks GA until delivery (no clear evidence on whether this reduces risk)2. Delivery by elective C-section in woman with active HSV lesions at delivery3. Avoid procedures that may break baby’s skin: forceps, vaccuum, fetal scalp monitoring
What are the 3 categories of HSV infections?
- Disseminated2. Localized CNS3. Skin, eye and mucous membrane
When should HSV be considered as a diagnosis in neonates?
Fever with irritability, seizures, liver dysfunction, or abnormal CSF fluid**Remember that in most cases, there is no known history of maternal HSV and infant has no skin vesicles!
What is the dose of acyclovir for treatment of neonatal HSV? What is the duration of treatment?
Dose: 60 mg/kg/day or 20 mg/kg/dose IV q8hDuration: -SEM: 14 days IV-CNS/disseminated: 21 days minimum IV(Oral ACV has limited bioavailability thus IV is required)
What is the definitive diagnostic test for non-CNS HSV?
Isolation of HSV by viral culture (from oropharynx, nasopharyn, skin lesions, mucous membranes)
What is the definitive diagnostic test for CNS HSV?
HSV PCR (more sensitive than culture)
Why is infant serology not useful for diagnosing neonatal HSV infection?
- Transplacental IgG antibodies cannot be differentiated from IgG produced by baby2. Production of antibodies is impaired in severely affected infants3. Commercially available assays for HSV IgM abs are of limited reliability
What are two side effects of acyclovir?
- Nephrotoxicity2. Neutropenia
What is the management of ocular HSV in neonates?
- IV acyclovir x 14 days2. Topical 1% trifluridine3. Ophtho consult
What follow-up should infants with neonatal HSV infections have?
Because of potential for neurological sequelae, f/u should include:1. Neurodevelopment2. Ophtho3. Audiology
When a diagnosis of neonatal HSV is suspected, what diagnostic investigations should be ordered? (3)
- Swabs of vesicular lesions and mucous membranes for culture or PCR2. CSF HSV PCR3. Liver enzymes to assess for disseminated HSV
When evaluating for neonatal HSV infection in exposed asymptomatic infants, what diagnostic investigation should be ordered? (1)
- Mucous membrane swabs from mouth, nasopharynx and conjunctivae at least 24 hrs after delivery (so that maternal HSV virus on baby’s skin from delivery has time to clear)
How long does it take for antibodies to HSV to develop following an infection?
Approximately 3 weeks
What is the management for an infant delivered by C-section before ROM to a mother with presumed first-episode primary or first-episode nonprimary HSV infection at delivery?
Risk of NHSV is very low. If baby is well:1. Swab the baby’s mucous membranes at > 24 hrs of age2. If swabs are negative, then baby can be discharged home3. If swabs are positive, then the infant is managed as a case of neonatal HSV(Some experts recommending doing CSF analysis as well)
What is the management for an infant delivered by SVD or C-section after ROM to a mother with presumed first-episode primary or first-episode nonprimary HSV infection at time of delivery?
- Test mom for HSV-1 and HSV-2 antibodies to figure out if she has primary (no prior HSV antibodies), nonprimary (HSV antibodies present but to the other type of HSV), or recurrent (antibodies present)2. Swab baby’s mucous membranes and start acyclovir (controversial whether to do this at birth with risk of surface contamination or at 24 hr of life)3. If swabs are positive, need to obtain CSF PCR to r/o CNS HSV4. If swabs are negative and mom’s serologies show she has recurrent HSV, then d/c acyclovir5. If swabs are negative and mom has primary HSV or serology testing is not available, baby needs acyclovir x 10 days
What is the management for an infant born by C-section to a mother with recurrent HSV at delivery?
- Swab mucous membranes at 24 hrs of life2. If positive, treat as neonatal HSV3. If negative, d/c home
What is the management for an infant born by SVD to a mom with recurrent HSV at delivery?
- Swab mucous membranes at 24 hrs2. If positive, treat as neonatal HSV3. If negative, d/c home**This is because baby is presumed to have HSV antibodies from transplacental transfer
What is the management of asymptomatic infants whose mothers have no active lesions at delivery?
Does not swabs or acyclovir therapy
Name 4 clinical scenarios in which you should consider neonatal HSV in the differential diagnosis?
- Infants started on IV antibiotics for suspected sepsis (especially infants with seizure or yielding abnormal CSF) who do not improve rapidly and have negative bacterial cultures at 24 hr incubation2. Infants admitted with pneumonia who do not improve after 24 hr on antibiotics3. Infants with unexplained bleeding or coagulopathy4. Infants started on IV antibiotics for suspected sepsis who are found to have unexplained hepatitis
What is the management of HSV CNS disease?
- IV acyclovir x 21 days minimum2. Repeat CSF sampling near the end of 21-day course of therapy: if PCR remains positive, treatment should be extended with weekly CSF sampling and acyclovir stopped when negative PCR is obtained3. Suppressive therapy oral acyclovir x 6 months should be given to infants with CNS disease (double-blind RCT showing benefit in neurodev outcome)
For infants on suppressive oral acyclovir treatment, what surveillance should they have?
Monthly CBC, BUN, Cr to rule out neutropenia and nephrotoxicity
What are 4 risks of RBC transfusion in neonates?
- Transfusion-transmitted infections2. Acute volume or electrolyte disturbances3. Blood group incompatibilities (often mistransfusion errors)4. Adverse effects of leukocytes (graft versus host disease, transfusion related acute lung injury and alloimmunization)
What is the combined risk of RBC contamination with viruses (Hep A, B, C, HIV)?
1 in 1-1.3 million
Two steps in treatment of perinatal hemorrhagic shock?
- NS bolus at 10 ml/kg while waiting for blood2. O neg PRBC 10-15 ml/kgCan give as a 1 min push of 20 ml to stabilize if acutely hypotensive, then 10 ml/kg/h
What are the suggested hemoglobin levels for transfusing infants with anemia of prematurity?-Week 1-Week 2-Week 3 and older(Cochrane review & Pint study)
***Resp support = O2 need > 25% or CPAP/I&VWeek 1: -Resp support: 115-No resp support: 100Week 2:-Resp support: 100-No resp support: 85Week =/>3:-Resp support: 85-No resp support: 75
What were the short-term outcomes of neonatal transfusion trials (restrictive vs. liberal transfusion thresholds)? (5)
No difference in outcomes of mortality or morbidity in:1. BPD2. ROP3. Growth4. IVH5. **some reports of increased NEC with recent transfusion but unclear significance (found with restrictive policies)
What were the long-term outcomes of neonatal transfusion trials (restrictive vs. liberal transfusion thresholds)?
No difference in death or disability at 18-21 months CGA
Is there any evidence to support the use of Erythropoietin in anemia of prematurity?
Not currently except for families who withhold consent to transfuse with blood products
At what age does cross-matching blood become necessary for infants?
At 4 months of age-Prior to 4 months of age, if they get a type and screen and there is no antibodies, then you can give them group-specific Rh-compatible blood without cross matching
In cases of massive hemorrhage, what kind of transfusion should neonatal patient receive?
If a large volume of blood is required, must use combined replacement with fresh frozen plasma in order to avoid hyperkalemia and dilution of coagulation factors
Can transfusions be helpful to improve weight gain or to address apnea of prematurity when Hgb levels are higher than recommended thresholds?
NO! Trials have shown no improvement in weight gain and only mild improvements in apnea (which are thought to actually be related to volume repletion). Only transfuse at recommended thresholds.
What are the 4 physiological competencies preterm babies must achieve before being eligible for discharge home?
- Thermoregulation: maintain normal body temperature when fully clothed in an open cot2. Control of breathing: apnea free period of at least 5-7 days3. Respiratory stability: maintenance of SaO2 > 90-95% in RA4. Feeding skills/weight gain
What is the definition of apnea of prematurity?
Cessation of breathing for:1. Greater than 20 secondsOR2. 10-20 seconds accompanied by bradycardia (HR 37 wks PCA)
Why do we wait up to 7 days spell free after discontinuing caffeine before saying apnea of prematurity has resolved?
Caffeine has prolonged half-life in neonates (up to 100 h) and infants may be at risk for recurrence of apnea for several days after discontinuation
How long does apnea of prematurity generally last for?
Most resolve by 36 wks PCA but in very preterm infants, may take up to 44 wks PCA
Is apnea of prematurity a risk factor for SIDS?
No!
Is there a difference in morbidity for preterm infants where SaO2 targets are low (89-94%) vs. high (95-100%)?
Yes - for babies with higher target SaO2, increased respiratory morbidity (pneumonia, acute exacerbations of chronic lung disease, need for diuretics and/or oxygen)-No difference in growth or neurodevelopment in either group-Might have reduction in ROP with higher SaO2 targets (but results were nonsignificant)
What is the target SaO2 for infants with BPD?
90-95%
Before discharge home, what 8 things must be completed for a preterm infant?
- Provincial newborn screening2. Hearing screen3. Assessment for RSV prophylaxis4. HUS at near-term (if indicated by GA)5. Successful SaO2 monitoring in car seat6. ROP screening (if indicated by GA or BW)7. Immunizations 8. Predischarge physical examination including measurement of weight, length and head circumference
Before discharge of a preterm infant, what education should the family receive (4)?
- Safe sleep practices and SIDS prevention2. Infant CPR (highly recommended)3. Understand infection control measures4. Understand importance of smoke-free environment
Why is early (ie. in the first week of life) postnatal corticosteroid therapy NOT recommended in preterm infants to prevent CLD?
Increased risk of cerebral palsy and poor neurodevelopmental outcome-multiple systemic reviews reported this finding, especially with dexamethasone
What is the commonly used definition of chronic lung disease/bronchopulmonary displasia?
Need for O2 at CGA of 36 weeks + respiratory symptoms + compatible changes on CXR
What is the DART trial?
Dexamethasone: a randomized trial-looked at low-dose dexamethasone (0.15 mg/kg/d, tapered over 10 days for cumulative exposure of 0.9 mg/kg) for decreasing CLD-found low dose dex shortened duration of intubation for ventilator-dependent infants-unfortunately study was terminated early due to declining enrolment and was not sufficiently powered to detect long term outcomes
What is the current evidence on use of low-dose dexamethasone in preventing CLD?
Currently, there is insufficient evidence to demonstrate the safety of ROUTINE low-dose dexamethasone use
What is the current evidence on use of high-dose dexamethasone in preventing CLD?
This is NOT recommended!-grade A evidence
What is the current evidence on:-routine use of hydrocortisone in preventing CLD?-routine use of inhaled corticosteroids in preventing CLD?
Hydrocortisone: NOT recommended! -multiple meta-analyses showing no benefits compared to dexamethasoneInhaled corticosteroids: NOT recommended-no RCTs available
When may be an appropriate time to use late dexamethasone therapy for preventing CLD?
Can consider use for infants who are at high risk of severe CLD or who are ventilator-dependent for severe CLD-low dose dexamethasone (0.15-0.2 mg/kg/day) in tapering doses over a short course (7-10 d)
What is the risk of congenital malformations seen with the use of SSRIs during pregnancy?-with which SSRI is there inconclusive evidence for causing congenital malformations?
Multiple studies show that SSRIs are unlikely to be associated with an increased risk of congenital malformations-some studies found that paroxitine may lead to small increased risk of cardiac malformations but evidence is inconclusive
What are the clinical features of SSRI neonatal behavioural syndrome (SNBS)?-does timing of SSRI use in pregnancy affect the risk of developing SNBS?
Tachypnea, cyanosis, tremors, increased muscle tone, feeding disturbance seizures, in 10-30% of babies exposed to SSRIs in utero-s/s present within hours, are mild and usually resolve within two weeks-unclear whether related to withdrawal, toxicity following in utero exposure or combo of both-increased risk of SNBS if exposure to SSRI is late in gestation as opposed to early
What are the possible side effects on newborn from SSRI exposure in utero (2)?
- SSRI neonatal behavioural syndrome2. PPHN (this is negligible though since absolute risk is
What is the recommendation for use of paroxetine in pregnancy?
No conclusive evidence that paroxetine use causes cardiac malformations-BUT care providers may choose to switch them to another antidepressant or reducing the dose if they wish
What is the recommendation regarding monitoring for newborns exposed to SSRI in utero?
Babies with late trimester SSRI exposure should be observed in hospital for neurobehavioural or respiratory symptoms for a minimum of 48 hrs
What are the physiological responses to laryngoscopy/intubation? (4)
- Bradycardia (vagal response)2. Hypoxia3. Intracranial hypertension (coughing/struggling)4. Systemic and pulmonary hypertension (catecholamine release in response to pain)
What premedications can dampen physiologic responses to intubation in a newborn?
- Bradycardia –> atropine2. Hypoxia –> muscle relaxants3. Intracranial hypertension –> muscle relaxants4. Systemic hypertension –> analgesia
Under what 2 clinical circumstances is it acceptable to intubate an infant without the use of premedication?
- Resuscitation in delivery room or during acute deterioration2. Infants with severely abnormal airways who will be difficult to intubate
What is a rare potential side effect of fentanyl?
Chest wall rigidity: can be treated with immediate administration of rapid acting muscle relaxant
What are 2 contraindications to the use of succinylcholine in neonatal intubation?
- Family hx of malignant hyperthermia (autosomal dominant)2. Hyperkalemia
What is the recommended protocol for neonatal premedication (agent and dose)?
- Fentanyl 3 mcg/kg slow infusion over 1 minute2. Succinylcholine 1 mg/kg3. Atropine 0.02 mg/kg IV (minimum dose available is 0.1 mg)
What is the definition of late prematurity?
GA 34+0-36+6
After the birth of a late prem baby, what monitoring should take place?
- Core temperature2. Blood glucose at 2 hr of life3. Vital signsOverall short term observation for cardioresp stability and ability to feed before transfer to low risk nursery
List the postdischarge problems of the late preterm that may lead to readmission (5)
- Hypothermia2. Apnea/ALTE3. Hyperbilirubinemia4. Suspected sepsis5. Respiratory issues
How do bilirubin levels differ in late prem infants compared to term infants? (4)
- Peaks later (at 7 days as opposed to 5 days)2. Reaches higher peak3. Stays elevated for longer4. Risk of kernicterus at lower levels of bilirubin
What is the discharge criteria for late preterm infants?
- Bilirubin must be checked by 48 hrs of birth2. 24 hrs of successful feeding must be established-first time moms need careful supervision and should have a room-in experience when leaving NICU-individual feedings should not be > 20 mins-feeding and prep for feeding should not > 6 hrs of the day at discharge-early weight loss should not > 10% of body weight3. If hx of apnea, needs to be apnea free > 8 days4. No hypoglycemia5. Able to maintain normal body temperature
What is the recommendation on monitoring for apnea of prematurity in late prem infants?
Babies 34+0-34+6 wks GA require cardioresp monitoring x 12-24 hrs-if apnea is identified, need a period of 8 days apnea free -discharge on caffeine is not recommended
When should a follow up appointment occur post discharge of a late prem baby?
Within 48 hrs
In a clinically unwell newborn, what is the approach for ruling out early-onset sepsis?
Full septic work-up REGARDLESS of what risk factors were or were not present (ie. GBS status, intrapartum abx = even if GBS negative, woman could become colonized after swab was done; IAP with penicillin does not affect frequency of other bacterial causes of sepsis), then immediate start of empiric abx
What is the gram stain result of the following organisms:-GBS-Listeria-E coli
GBS: gram positive cocciListeria: gram positive rodsE coli: gram negative rods
What is the management of a well-appearing infant of a GBS positive mother who received IAP of penicillin > 4 hrs before delivery?
No intervention!-> 4 hrs intrapartum penicillin significantly reduces risk of early onset GBS
What is the management of a well-appearing infant of a GBS-positive mother who received IAP
Do a CBC: if WBC 5, then clinical observation x 24 hrs.**Risk of early onset GBS in this population is 1%-if WBC
What is the management of a well-appearing infant of a GBS-negative mother who had risk factors at delivery?
CBC: if normal, monitor x 24 hrs. If WBC
What are the risk factors for early GBS sepsis? (6)
- Intrapartum fever2. ROM > 18 hrs3. GBS bacteruria4. Previous child with invasive GBS disease5. Maternal chorioamnionitis6. Prematurity