Problems Common to the Newborn

Question 1

What are the common newborn problems?

Answer 1

1. Hypoglycemia
2. Neonatal Jaundice
3. Respiratory Distress of Newborn
   A. Hyaline Membrane Disease
   B. Most common cause

Question 2

What are the general characteristics of hypoglycemia in infants?

Answer 2

1. Defined as blood glucose less than 40-45

Question 3

What is the pathophys of hypoglycemia in infants?

Answer 3

Infant does not have sufficient glycogen stores in muscle or liver nor sufficient fat for release of fatty acids for energy

Question 4

What are the sxs of hypoglycemia in infants?

Answer 4

Asymptomatic 
Poor feeding
Lethargy
Tremulousness
Irritability
Apnea
Seizures

Question 5

What are the dx studies for hypoglycemic infants?

Answer 5

1. Heel blood tested w/glucometer
2. Abnormal results should be confirmed w/ serum blood glucose
3. Normal glucose level is 50-80 mg/dL @ 3 hrs of age
4. Abnormal level is glucose

Question 6

What are the rx for hypoglycemic infants?

Answer 6

1. Bolus of dextrose & water (D10W) & IV glucose as needed
2. Continue to monitor
3. Usually resolves by day 5
4. Failure to resolve should prompt investigation for less likely causes

Question 7

What is the pathophys of infant jaundice?

Answer 7

1. Newborns produce bilirubin 2X the rate as adults
   A. Due to polycythemia & ↑ RBC turnover
   B. ↓ to adult level w/in 10-14 days after birth

Question 8

What is the normal physiology of bilirubin

Answer 8

1/ Bilirubin is final product of heme degradation

2. Insoluble in plasma & requires protein binding w/ albumin
3. After conjugation in liver, it’s excreted in bile

Question 9

What is level of bilirubin can cause neonatal jaundice?

Answer 9

1. Total serum bilirubin > 5 mg/dL

2. Typically results from deposition of unconjugated bilirubin pigment in the skin & mucus membranes

Question 10

When is neonatal jaundice pathologic?

Answer 10

1. Presents w/in 1st 24 hrs after birth
2. Total serum bilirubin rises by > 5 mg/dL per day
3. > 17 mg/dL
4. (+) signs & sx’s suggestive of serious illness

Question 11

What are the most common causes of neonatal jaundice in the first wk of life?

Answer 11

1. Physiologic
A. Appears after 24 hr
B. Peaks @ 3-5 days
2. Prematurity
A. Appears w/in 24 hr of birth
3. Breast feeding problems
A. Appears 2nd – 3rd day of life
B. ↓ volume & frequency of feedings → dehydration & delayed passage of meconium

Question 12

What can cause an overproduction of bilirubin and elevated reticulocyte count?

Answer 12

1. Hemolysis 2° to blood group sensitizations
2. Hemolysis 2° to congenital hemolytic anemia
3. Hemolysis 2° to sepsis

Question 13

Hemolysis 2° to blood group sensitizations is asst w/?

Answer 13

1. (+) Coombs test
   A. ABO incompatibility
   B. Rh incompatibility

Question 14

Hemolysis 2° to congenital hemolytic anemia is asst w/?

Answer 14

1. (-) Coombs test
   A. Hereditary spherocytosis
   B. G6PD deficiency

Question 15

What can cause jaundice with a decreased rate of conjugation and a normal reticulocyte count?

Answer 15

1. Physiologic jaundice 2° to ABO incompatibility

2. Bilirubin increases by

Question 16

What may be seen on the pe of an infant with jaundice?

Answer 16

1. Jaundice begins @ head
   A. Extends to chest & extremities as bilirubin increases
2. Scleral icterus & jaundiced oral mucosa help distinguish jaundice in dark skinned infants
3. Splenomegaly may be present in hereditary spherocytosis

Question 17

What dx studies are ordered for an infant w/ jaundice?

Answer 17

1.CBC: Anemia
A. Monitor H&H if acute hemolysis
2. Peripheral smear
A. Poikilocytosis, schistocytes, nucleated RBC’s
3. Bili – total, direct, indirect
4. Retic count
5. Coombs test
6. G6PD test
A. African, Asian or Mediterranean descent
7. Septic work-up if indicated

Question 18

What complications can arise from jaundice and elevated bilirubin?

Answer 18

1. Kernicterus
   A. Abnormal accumulation of bile pigment in the brain & other nerve tissue
   B. Leads to encephalopathy
   C. Bilirubin > 20-25 mg/dL

Question 19

What are the early sxs of bilirubin toxicity?

Answer 19

1. lethargy
2. poor feeding
3. high pitched cry
4. hypotonia

Question 20

What are the late sxs of bilirubin toxicity?

Answer 20

1. irritability
2. Opisthotonos
3. Seizures
4. Apnea
5. hypertonia
6. fever

Question 21

What are the chronic sxs of bilirubin toxicity?

Answer 21

1. Cerebral palsy
2. Highfrequency hearing loss
3. Paralysis of upward gaze
4. Dental dysplasia
5. Mild mental retardation

Question 22

How is rh incompatibility treated?

Answer 22

Transfusion

Phototherapy

Question 23

How is hereditary sphereocytosis treated?

Answer 23

Phototherapy

Question 24

How is G6PD treated?

Answer 24

Phototherapy

Question 25

How is physiologic jaundice treated?

Answer 25

1.Usually resolves w/out intervention if bili 10 mg/dL or not decreasing

Question 26

How is breast feeding jaundice treated?

Answer 26

1. Supplement w/ formula | 2. Phototherapy if bili > 10 mg/dL

Question 27

Describe phototherapy treatment?

Answer 27

1. Blue wavelengths of light alter unconjugated bilirubin in the skin A. Bilirubin is converted to less toxic water-soluble photo-isomers that are excreted in bile & urine w/out conjugation

Question 28

When is phototherapy instituted?

Answer 28

1. Phototherapy instituted when the total serum bilirubin level is: A. ≥ 15 mg/dL if 25-48 hours old B. 18 mg/dL if 49-72 hours old C. 20 mg/dL if > 72 hours old

Question 29

When is phototherapy discontinued?

Answer 29

D/C when total serum bilirubin level less than 15

Question 30

What are the pulmonary causes of respiratory distress in infants?

Answer 30

1. Chonal atresia 2. Transient tachypnea of newborn A. Resolves in 24 hr 3. Fluid aspiration A. Blood or meconium 4. Hyaline membrane disease

Question 31

What is hyaline membrane disease?

Answer 31

1. Most common cause of resp distress in preterm infant 2. Deficiency of lung surfactant A. Poorly developed pneumocytes cause low surfactant production needed to keep alveoli open

Question 32

What are the cardiovascular causes of respiratory distress in infants?

Answer 32

``` 1. Cyanotic lesions A. Tetralogy of Fallot B. Tranposition of great arteries 2. Mild cyanosis A. Hypoplastic left heart syndrome B. Coarctation of aorta ```

Question 33

What are the non pulmonary/cardiovascular causes of respiratory distress in infants?

Answer 33

``` 1. Hyperthermia or hypothermia A. Premature infants 2. Intrauterine exposure to cocaine 3. Metabolic acidosis 4. Hemorrhage or asphyxia resulting in damage to CNS A. Traumatic delivery ```

Question 34

What may be seen on the pe of an infant with respiratory distress?

Answer 34

1. Cyanosis A. If improves w/ oxygen, suspect pulmonary or non-cardiac cause 2. RR > 60 breaths/min 3. Grunting A. Usually occurs w/ nasal flaring, intercostal & sternal retractions

Question 35

What are the dx studies for an infant with respiratory distress?

Answer 35

1. CXR 2. Pulse oximetry 3. ABG 4. CBC & blood cultures A. If sepsis suspected 5. CMP 6. ECHO

Question 36

What are the Classic CXR results in hyaline membrane disease?

Answer 36

Air bronchograms, diffuse atelectasis causing ground glass appearance, & doming of diaphragm

Question 37

How is an infant with respiratory distress managed?

Answer 37

1. Supplemental oxygen 2. Administration of exogenous surfactants 3. Intubation & mechanical ventilation if necessary A. Recommended treatment for hyaline membrane disease 4. Determine underlying cause & treat appropriately