Volume 1

Question 1

Which of the following statements is false?

a) classic hemorrhagic disease of the newborn rarely occurs if babies receive vitamin K at birth
b) women who are on drugs that impair vitamin K metabolism should receive vitamin K supplementation during pregnancy
c) late hemorrhagic disease of the newborn can occur in both breast and formula fed infants
d) a recent increase in late hemorrhagic disease of the newborn has correlated with increased implementation of oral vitamin K supplementation

Answer 1

c) false - happens almost exclusively in breastfed infants
late HDNB - 50% chance of intracranial hemorrhage

the others
- a) true, classic hemorrhagic disease refers to hemorrhagic disease in 1st week of life
characterized by GI hemorrhage and in some cases intracranial bleeding
b) drugs that impair include warfarin and anticonvulsants, this prevents early HDNB (within 1st 24 hours)
d) in numerous countries including Germany, Australia, Britain, Sweden -> increase at the same time that increase in oral vitamin K use happened, late hemorrhagic disease of the newborn refers to disease between 3-8 weeks of age

historically
1961 - AAP recommended vitamin K1 for neonates 0.5-1 mg IM for all neonates
1988 - CPS said that 2.0 mg PO vitamin K was acceptable alternative ->at the time there were concerns about pain etc. this was before the (since retracted) study suggesting IM vitamin K caused childhood cancer, was released
**now we are revising the suggestions

Question 2

Which of the following is the timing of presentation for late hemorrhagic disease of the newborn?

a) week 1 of life
b) 3-8 weeks
c) within 6-12 weeks
d) within 1st 24 hours

Answer 2

b) answer is 3-8 weeks for late disease

the others

a) classic - within week 1
d) early - within first 24 hours

**Note this is way different in Nelson

Question 3

Which of the following is false?

a) IM vitamin K is more effective than oral vitamin K at prevention of HDNB
b) in the first 5 days, both IM and oral vitamin K induce the same levels biochemical indicators of vitamin K deficiency
c) a mixed micelle form of vitamin K may work better than current oral formulations but is likely still not as good as IM vitamin K
d) biochemical indicators of vitamin K deficiency correlate well with the clinical risk of bleeding from HDNB
e) A meta-analysis of cohort studies regarding vitamin K suggests an increased relative risk of up to 13% with oral vitamin K administration

Answer 3

d) false
- problem is that these have poor correlation

the rest are true

a) overall studies
- failure rate 0.25/100 000 vs. 1.4/ 100000 in one epidemiological study from Germany, in countries where oral vitamin K is the norm, incidence of late HDNB varied – 1.5 (Britain), 6.0 (Sweden) and 6.4 (Switzerland) /100000
- some might have underlying vitamin K disorders
- in Canada we don’t know the specific incidence(as of 1997 when statement came out)
b) in the absence of adequate vitamin K, an induced protein PIVKA -II can be measured in the blood, protein disappears by 5 days with 1.0 mg oral vitamin K; at 5 days, no difference between oral and IM vitamin K, however at 4-6 weeks, biochemical signs of vit K deficiency in 19% of babies who received 2.0 mg PO at birth vs. 5.5% of those who received 1.0 mg IM
c) true
e) compared oral with IM - RR 13.82; even when excluding for liver disease (which can’t usually be determined at birth, was 8%

Question 4

Which of the following infants does not need to be considered for repeated doses of vitamin K?

a) kidney disease
b) chronic diarrhea
c) liver disease
d) failure to thrive

Answer 4

a) not true, the other indications may want to consider repeated doses

breastfed babies more risk of late HDNB from vitamin K deficiency - some have suggested to give lactating mothers vitamin K
one study from Denmark showed that giving repeated doses of oral vitamin K until 3months reduced incidence of late HDNB compared to single oral dose , may not be practical because of poor patient compliance
one epidemiological study: Netherlands, Germany, Switzerland and Australia, three oral doses of 1 mg vitamin K less effective than IM vitamin K, but daily oral dose of 25 mg after an initial dose of 1 mg vitamin K may be as effective
reasons for better benefit from IM vitamin K not clear
vitamin K doesn’t protect completely from HDNB, especially in breastfed infants
consider vitamin K deficiency for any infant with bleeding in 1st 6 months of life

Question 5

Which of the following is the optimal dose and administration of vitamin K for a 3 kg baby?

a) 0.5 mg vitamin K1 IM within 1st 6 hours
b) 1.0 mg vitamin K1 IM within 1st 6 hours
c) 2.0 mg vitamin K1 IM within 1st 8 hours
d) 2.0 mg vitamin K1 PO within 1st 8 hours

Answer 5

b) 1.0 mg for >1500 g, 0.5 mg for

Question 6

Which of the following about nitric oxide is false?

a) generated in the vascular muscle cells
b) made from L-arginine by NO synthase enzymes
c) NO diffuses into vascular cells and activates guanylate cyclase
d) NO leads to increased cGMP, pulmonary vasodilation and improved V/Q mismatching

Answer 6

a) false - generated in the lung endothelium
b) NO synthase enzyme

the rest are true

Question 7

Which of the following is not one of the research findings regarding inhaled nitric oxide

a) improves oxygenation in term infants without significant toxicity
b) reduces incidence of death in PPHN
c) reduces incidence of death CDH
d) reduces need for ECMO

Answer 7

c) false - did not reduce the incidence of death in CDH based on Cochrane study

iNO as a selective pulmonary vasodilator for term newborn infants with hypoxemic respiratory failure and PPHN was introduced in 1992
several reports - improved oxygenation without significant toxicity or effect on systemic circulation
after that, single and multi centre prospective trials of late preterm and term infants showed:
- improved oxygenation
-improved incidence of death and ECMO
Cochrane Systematic review
- iNO at doses 10-80 ppm improves oxygenation as assessed by OI when compared to placebo or standard care
- decreases incidence of death and ECMO in infants with PPHN (mainly through the reduction in ECMO)
-did not reduce the incidence of death in CDH
- iNO no impact on adverse neurodevelopment outcomes although long term effects not studied
-earlier initiation of iNO at OI of 15-25 improved oxygenation but didn’t help with death/ECMO

Question 8

Which of the following is the correct formula for Oxygenation Index (OI)?

a) [PaO2 x MAP x 100] /FiO2
b) [PaO2 x FiO2 x 100]/MAP
c) {PaO2}/[FiO2 x MAP x 100]
d) [FiO2 x MAP x 100]/PaO2

Answer 8

d) is the answer

remember that it’s how much help they are needing (i.e. FiO2 and MAP) over how successful it is (PaO2)

Question 9

What are the criteria for using iNO

1) resp failure on max support at GA > or equal to 35 weeks
2) OI>20-25
3) PaO2<100 mmHg on max vent support on 100% O2

Answer 9

b) is one of the criteria, best types of ventilation optimizes Tv and Pressures, consider surfactant, HFO and/or JET to optimize lung recruitment, when you do all this and it still don’t work, consider iNO. ideally - should do an echo to rule out cyanotic heart disease and to assess the pulmonary hypertension and cardiac function in all babies that are candidates for nitric oxide
a) false - usually OI 20-25
c) false - so far, evidence supports use for infants greater than or equal to 35 weeks at birth, with hypoxic respiratory failure not responding to appropriate management

iNO in prems: Cochrane review of 14 trials, conflicted evidence

• overall- does not appear affective as rescue (no effect on reducing mortality or BPD, in sick infants minor increase in IVH/PVL) OR routine treatment (minor reduction in death/BPD for >1000g intubated babies, no increase in IVH/PVL in these less sick babies ) for perms who need assisted ventilation
• routine use in moderately ill >1000g - one study showed reduced CP, another study (non Cochrane) improved neurodevelopment outcomes at 2 years old
• may be beneficial in small number of clinical situations - i.e. respiratory failure with oligohydramnios

Question 10

Which of the following is the best starting dose of iNO in term newborns?

a) 10 ppm
b) 15 ppm
c) 20 ppm
d) 40 ppm

Answer 10

c) 20 ppm is the answer - has been used from 1-80 ppm, then titrated to desired effect, short half life 2-6 s. doses>40 ppm have increased toxicity without additional benefits

• iNO should be in level 3 NICUs supervised by experienced physicians, should have ECMO and other ventilatory support
• can be used on transport to level 3 NICU
• constant source of iNO gas, can use with conventional, JET or HFO
• very expensive

Question 11

Which of the following is the expected response from iNO?

a) improvement in PaO2 by >20 mmHg in less than 30 minutes
b) improvement in PaO2 by >10 mmHg in less than 60 minutes
c) improvement in PaO2 by >30 mmHg in less than 30 minutes
d) improvement in PaO2 by >20 mmHg in less than 60 minutes

Answer 11

a) is the answer for the expected response, should be quick. if no response, should increase dose to 40 mmhg

in prems - starting dose was 10 ppm and increased to 20 ppm in non responders, should keep concentration of No2 in mixture as low as possible 0.5 ppm

Question 12

When is the appropriate time to wean iNO?

Answer 12

a) after improvement in oxygenation, 4-6 hours of stability, with wean to 60-80% FiO2 or OI 50 mmHg consistently)
if you stop too abruptly - can get hypoxia because of down regulation of endogenous NO
if fails wean, then go back to previous dose and wean more slowly over 24-48 hours

generally - in studies, patients on NO for approx 48-92 hours, if you can’t wean in a week then should look for other lung and heart problems

Question 13

Which of the following is not a potential toxicity of iNO?

a) production of methemoglobin
b) production of NO2
c) increased platelet aggregation
d) surfactant dysfunction

Answer 13

c) DECREASED platelet aggregation and increased risk of bleeding

no severe side effects reported, at starting dose of 20 ppm with increase to 40 ppm, minimal toxicity

NO2 : produced by chemical reaction with O2 in ventilator circuit and airways, is cytotoxic, can cause pulmonary injury at > 5ppm, peak level of NO2 is 0.8 +/- 1.2 ppm, no gas was discontinued due to toxicity; iNO doses at <20 ppm not elevated levels (and remember that for pre terms we start at lower dose of iNO - usually 10 in studies )

Question 14

Which of the following is not one of the reasons to prevent pain in the neonate?

a) ethical obligation
b) potential neuroanatomical consequences
c) potential behaviour consequences
d) altered pain sensitivity which resolves by adolescence

Answer 14

d) false - altered pain sensitivity is one of the reasons but this does persist into adolescence
can be altered with effective pain relief
the others have been found in animal studies

Question 15

Which of the following is an appropriate use of pain relief in the NICU?

a) IV fentanyl infusion for the chronically ventilated preterm neonate
b) use of topical anaesthetics for heel stick draws and other procedures
c) use of non nutritive sucking, oral glucose and kangaroo care for minor procedures
d) repeated use of topical anaesthetics for multiple procedures
e) acetaminophen is a good option for post surgical pain in neonates after major surgery

Answer 15

c) other ones are swaddling and developmental care

the rest are false

b) not effective for heel stick draws, should limit use of topical anaesthetics (try not to do too much repeated use) can use them for venipunture and LPS (but don’t use super repeat)
a) not recommended continuous infusion of midas, fentanyl or morphine in this population because of concern of short term side effects and lack of long term data
e) opioids should be used post operatively for major surgery without a regional anaesthesia, use post op analgesia as long as needed based on pain scales, acetaminophen should be used as an adjust to opioids and regional anaesthesia, hard to calculate dosages for

Question 16

Which is an appropriate pain management for the procedure listed?

a) retinal examination - oral sucrose and local anaesthetic eye drops
b) retinal surgery - oral sucrose and local anaesthetic eye drops
c) chest drain insertion- local anaesthetic into skin
d) chest drain removal - non pharmacological interventions

Answer 16

a) is appropriate - no perfect evidence, but this would be a reasonable approach

the rest are not appropriate

c) local anaesthetic into skin unless life threatening reaction,if inadequate time to put local anaesthetic, putting it in after might help with later pain responses and analgesic requirements, ALSO should have fast acting opiate such as fentanyl
d) should give fast acting systemic analgesic ALSO non pharmacological measures
b) retinal surgery should be considered major surgery and should have pain control with opiates

Question 17

Which of the following is the criteria for retinopathy of prematurity screening in Canada as per the CPS?

Answer 17

b) is the answer all infants < 30 week 6/7 or <1250 g at birth (at the end it says AND)
based on this, UK and Canada say b) is the best criteria

Question 18

Which of the following is incorrectly matched ?

a) stage 1: demarkation line separates avascular from vascular retina
b) stage 2: extra retinal fibrovascular proliferation/neonvascularization
c) stage 4: partial retinal detachment
d) plus disease: vascular tortuosity of at least 2 quadrants of the eye

Answer 18

B) FALSE - this is stage 3

the rest are true
retinopathy of prematurity - abnormal development of blood vessels of the preterm infant
stage 1: demarkation line separates avascular from vascular retina
stage 2: ridge arising in area of demarcation line
stage 3: extra retinal fibrovascular proliferation/neonvascularization
stage 4: partial retinal detachment
stage 5: complete retinal detachment
pre-plus disease: more vascular tortuosity than normal but not enough for plus disease
plus disease: vascular tortuosity of at least 2 quadrants of the eye

zone 1,2, and 3 describe the different areas of the retina -see diagram in the statement; zone 3 is lateral, zone 1 is the centre

Question 19

When should a ex 26 week baby be screened for the first time for ROP?

a) 8 weeks chronological (24 weeks CGA)
b) 6 weeks chronological (32 weeks CGA)
c) 4 weeks chronological (30 weeks CGA)
d) 5 weeks chronological (31 weeks CGA)

Answer 19

d) 31 weeks corrected GA

these guidelines are to detect 99% of infants at risk of poor visual outcome; 1st exam between 4-9 weeks of age depending on GA at birth
more mature infants - screen at 4 weeks for 1st exam
stop screening when no more risk of severe ROP
99% develop by 45 weeks GA

for all

Question 20

When should an ex 29 week baby be screened for the first time for ROP?

a) 8 weeks chronological (37 weeks CGA)
b) 6 weeks chronological (35 weeks CGA)
c) 4 weeks chronological (33 weeks CGA)
d) 2 weeks chronological (31 weeks CGA)

Answer 20

c) is the answer, for all 27 weeks onwards do at 4 weeks chronological (so corrected CGA increases for each increase in GA at birth)

at the moment, not any clear screening criteria of who is at increased risk for ROP, so can’t modify these guidelines
poor postnatal weight gain as a predictive factor for ROP is being studied and is promising but further confirmation is required
digitalized ROP not yet figured out

Question 21

Which of the following is false of treatment for ROP?

a) retinal ablation is the basis of treatment using cryotherapy and laser photocoagulation
b) goal is to decrease production of angiogenic factors at the avascular part of the retina
c) intravitreal injection of anti vascular endothelial growth factor antibodies is an effective option
d) even with treatment, there is significant negative outcome for babies with ROP

Answer 21

c) is being studied

Results of the Early Treatment for Treatment of ROP Trial - showed that treatment pre-threshold reduces unfavourable visual acuity and structural outcomes, indications for trial have been refined

Question 22

Which of the following ROP disease needs to be followed < 1 week

a) stage 1 or 2 ROP in zone 1
b) immature vascularization in zone 1
c) stage 2 ROP in zone 2
d) stage 1 ROP in zone 2

Answer 22

a) needs to be followed one week or less - i remember it as the closer to the optic nerve, the closer the follow up needs to be even if the ROP isn’t as bad

< 1 week follow up: stage 1 or 2 in zone 1, stage 3 ROP in zone 2
1-2 weeks follow up: immature vascularization in zone 1, stage 2 ROP in zone 2, regressing ROP in zone 1 (make sure keeps regressing)

Question 23

Which of the following ROP diseases need to be followed 2-3 weeks?

a) stage 1 ROP in zone II
b) stage 1-2 ROP in zone 3
c) regressing ROP in zone II
d) regressing ROP in zone 1

Answer 23

b) stage 1-2 ROP in zone 3; again, far away from the optic nerve so less intense follow up
regressing ROP in zone 3 also needs follow up every 2-3 weeks

the others options are 2 week follow up: for stage 1 ROP in zone 2, regressing ROP in zone II, regressing ROP in zone I

Question 24

Which of the following cases do you not need to consider retinal ablative therapy for?

a) stage 1 ROP in zone 1
b) stage 1 ROP in zone 1 with plus disease
c) stage 3 ROP in zone 1
d) stage 2-3 ROP in zone 2 with plus disease

Answer 24

a) don’t need to consider
consider for pre-threshold retinal ablative therapy are as followed:

zone 1: any stage ROP with plus disease
zone 1: stage 3 ROP with or without plus disease
zone II: stage 2-3 ROP with plus disease

should perform for retinal ablation for all threshold ROP:
- 5 or 8 clock hours of stage 3 ROP in zone 1 or 2 in the presence of plus disease
treatment should be within 72 hours of the examination

Question 25

Which of the following is not a criteria to stop ROP screening?

a) complete vascularization
b) zone 3 vascularization without previous zone I or II ROP
c) PMA of 40 weeks and no pre-threshold disease or worsening ROP
d) regression of ROP

Answer 25

c) is supposed to be 45 weeks and no pre-threshold disease or worsening ROP

infants with ROP - at risk for poor visual acuity and other visual disturbances regardless of whether they needed treatment; risk of poor visual outcome even with treatment

Question 26

How long are stored RBCs safe and effective for?

a) 7 days
b) 2 weeks
c) 30 days
d) 42 days

Answer 26

d) safe and effective for up to 42 days, permit the use of donor packs

blood in Canada is now component specific - fresh whole blood no longer available

Question 27

Which of the following is a concern of blood transfusions particularly in the newborn period?

a) graft vs. host disease
b) CMV infection
c) TRALI
d) hemolytic reaction

Answer 27

b) for newborns - CMV may have very important consequences for newborn babies, chance reduced by universal leukoreduction

the others:
- irradiation - to reduce GVHD (but not common in babies)
- TRALI - not common in babies
- hemolytic - rare, may have maternal antibodies in 1st two months, but babies own unlikely until 6 months of age
adverse reactions:
- infections - risk is 1/1.3 million by viruses
- leucocyte causing acute injury
- acute volume or electrolyte disturbances
-blood group incompatibilities (often error)

Question 28

When do you need to start crossmatching a baby for blood?

a) at birth
b) at 2 months
c) at 4 months
d) at 6 months

Answer 28

c) start crossmatching at 4 months

prior to this - (for newborns)
ER: O, RH-blood
for O babies, Rh compatible blood
for type specific babies, type specific blood with Rh compatibility, make sure there are no passive antibodies to the other type of blood

pretransfusion testing: ABO and Rh, with testing of antibodies of maternal origin (direct and indirect anti globulin tests) ->if negative initial antibody screen, don’t need to repeat the screen till 4 months of age

Question 29

Which is not a risk of high volume transfusions of RBCs in neonates?

a) fluctuating hemoglobin level
b) fluctuating platelets
c) fluctuating viscosity
d) increase RBC volume by 50%

Answer 29

b) not a risk, the others are

typically for newborn transfuse 10ml-20 ml/kg
alternative approach - by target selection (conventionally 150, more recent 130)

Question 30

In an emergency of hemorrhagic shock, how should you manage?

a) wait for blood then give 5-10 ml/kg
b) give 10-20 ml/kg of NS while awaiting blood then give 5-10 ml/kg of pRBCs O-
c) give 10-20 ml/kg of NS while awaiting blood then give 10-20 ml/kg of pRBCs O-
d) check for Hg level then transfuse if levels are

Answer 30

c) is the answer give 10-20 ml/kg of NS while awaiting blood, then give same volumes of blood
hg only provides help when chronic bleeding is happening

cord, pre-transfusion blood can collect for typing

traumatic bleeding (i.e. from placental hemorrhage, twin-to-twin transfusion, fetomaternal hemorrhage, velamentous insertion of the cord or cord rupture) - RARELY an ongoing source of blood loss - bleeding is terminated by deliver itself

Question 31

Which of the following is a major risk of massive pRBC transfusion?

a) hyperkalemia
b) hypercalcemia
c) hyponatremia
d) clotting

Answer 31

a) is a risk
the others aren’t listed (but should read to make sure not the case)
not clotting, rather, dilution of clotting factors is a risk

Question 32

Based on the Cochrane review study, which of the following infants should be transfused?

a) 10 day old ex 28 weaker on room air with hemoglobin 90
b) 21 day old ex 28 weaker on room air with hemoglobin 80
c) 8 day old ex 28 weaker on CPAP with hemoglobin 110
d) 6 day old ex 28 weaker on 30% oxygen with hemoglobin 110

Answer 32

d)should be transfused
1st week: resp support Hg 115(Hct 35) no resp supprt Hg 100 (Hct 30)
2nd week: resp support Hg 100 (Hct 30) no resp support Hg 85 (Hct 25)
3rd week and beyond: resp support Hg 85 (Hct 25) no resp support Hg 75 (Hct 23)

resp support >25% FiO2 or need for increased airway pressure

babies with cyanotic heart disease may need higher thresholds (weak recommendation)

anemia of prematurity - physiological anemia of the newborn, combining a suppressed postnatal response to erythropoietin, increased blood sampling, short RBC span in the newborn and the rapid increase in blood volume with growth.

90% of ELBW infants get transfused, on average 5 transfusions each

the studies have not shown significant difference between the need for transfusions and level of Hg using generous vs more restrictive thresholds

Question 33

Which of the following statements is false?

a) using more restrictive Hg thresholds doesn’t have a big effect on growth or growth related outcomes
b) using more restrictive Hg thresholds significantly reduces BPD
c) in some observational studies, the onset of NEC appears to be associated with an RBC transfusion
d) the best research studies have not shown a reduction in apneas after transfusion
e) EPO may increase the risk of ROP and should only be used when patients don’t consent to blood
f) iron supplentation at 4-6 weeks of age increases the hemoglobin levels and iron stores after 6 months of age

Answer 33

b) is false - within the narrow confines of the levels used, doesn’t seem to make a big difference in morbidity or mortality, including BPD, ROP, brain injury
- these studies didn’t look at using threshold

Question 34

Which of the following evidence is not true about kangaroo care?
a) a systemic review of infants

Answer 34

c) decreases incidence of nosocomial infections, but more in developing countries
early KC increase the chance of baby being colonized by maternal flora rather than the flora in the nursery

need guidelines for kangaroo care
generally 1-3 hours with monitoring
baby generally vertical

helps with better breast-feeding
increases stability, better sleep
d)**one study DID describe and increase in brady and desats
e) need more research in younger babies

can do for ventilated babies also considering delaying KC for infants

Question 35

Which of the following statements is false?

a) prolonging hospital stay is always beneficial for perms
b) the four most important criteria for discharge is thermoregulation, control of breathing, respiratory stability, feeding and weight gain
c) early transfer to a cot did not affect temperature stability or weight gain
d) most premature babies achieve the stability criteria achieve this between 34-36 weeks post menstrual age

Answer 35

a) not always beneficial, can have risks including bonding, infection (including resistant pathogens), etc.; R
50% of babies discharge from tertiary NICU, 50% to community hospital first; early discharge programs have shown better emotional well being and home life, reduces financial costs for hospital and parents
most discharged between 37-40 weeks

the rest true

c) 1700, but did not always lead to earlier on discharge timing, should avoid overheating (RF for SIDS0)
d) may be later for super perms

cot- temperature 37 C

Question 36

Which of the following is not true of apnea of prematurity?

a) apnea lasting 10-20 seconds with drop in HR (

Answer 36

c) false, can persist as long as 44 weeks PMA in very preterm babies (can have some variability)

the rest are true
most clinicians d/c caffeine before discharge to see an apnea free interval
caffeine half life is prolonged in neonates (100 hrs), so babies at risk for recurrence after it is discontinued

Apnea of prematurity is defined as cessation of breathing for ≥20 s or 10 s to 20 s if accompanied by bradycardia (heart rate

Question 37

Which of the following is not a reasonable recommendation regarding apnea for premature babies?

a) should be apnea free for a reasonable period (at least 5-7 days) prior to discharge
b) apnea of prematurity is not a risk factor for SIDS
c)
d) cardiorespiratory monitoring should be routinely recommended for premature babies

Answer 37

d) false - rarely indicated, only for babies with unusually prolonged and recurrent apnea and even then with discussion with the family

the others are true - evidence:
a) studies to determine how long need to be apnea free - not a great consensus, one study 74% of neonatologists said 5-7 days, 9% 10 days, retrospective study - 5% experienced apnea up to 8 days after, more recent retrospective said 96% of premies no spell after 7 day spell free
b) true - not a risk factor for sids
-

Question 38

Which of the following statements regarding respiratory disease in premies is true?
a) very few babies BW

Answer 38

b) true - there isn’t much difference in the babies growth and development using each of these targets
a) false - 25% of babies with BW

Question 39

Which of the following is false?

a) scheduled feeding leads to earlier attainment of target feeds
b) non nutritive sucking during gavage feeding facilitates transition from tube to oral feeding
c) there is insufficient evidence that tube feeds alone to supplement breast feeds increases breastfeeding success for preterm infants.
d) iron supplementation improves hemoglobin levels and iron stores

Answer 39

a) false, individualized feeding based on cues is a better idea

the rest are true

c) true, supplementation with cup feeds may increase the number of babies fully breastfeeding, but also delays discharge by 10 days
d) further studies to determine if there is benefit to nutrient fortification of breast milk

relationship between GERD and apnea - inconclusive, mixed evidence

Question 40

Which of the following is not an increased risk from preterm birth and prolonged hospitalization?

a) obesity in infancy
b) RSV
c) neglect
d) adverse developmental outcomes

Answer 40

a) false, in fact failure to thrive is the risk

preterm babies<2000g need 4 doses of hep B vaccine when they are going to need it
need SaO2 car seat monitoring before discharge, cranial U/S, RSV screen, hearing test

neonatal follow up clinic, may need support for primary physician

should get regular follow up within 72 hours

Question 41

Which of the following is not a risk of untreated maternal depression?

a) increased preterm birth
b) increased miscarriage
c) decreased chance of respiratory distress
d) increased hospital stay

Answer 41

c) increased chance of respiratory distress

the rest are risks of depression, independent of anti depressant use

Question 42

Which of the following is an association of SSRI use?

a) contradictory evidence n between paroxetine use in the first trimester and cardiac malformations
b) an overall increase between SSRI use and congenital malformations
c) an association with neonatal withdrawal
d) a significant increase in PPHN risk

Answer 42

a) conflicting evidence with paroxetine and cardiac malformations, may be associated with slight increase in 
cardiac malformations (grade A recommendation)

the others are false:
b) not an overall increase in congenital malformation
individual studies may be associated with certain increased risks (omphalocele or craniosynostosis) but not replicated in other studies
c) serotonin neonatal behavioural syndrome, unsure if related to withdrawal or toxicity
d) negligible absolute risk of PPHN (likely

Question 43

Which of the following is not a symptoms of serotonin neonatal behavioural syndrome?

a) tachypnea
b) cyanosis
c) decreased muscle tone
d) jitteriness

Answer 43

c) in fact, increased muscle tone is part of the symptoms, rarely we see seizures, feeding disturbance
usually reported within hours, and resolve within 2 weeks
unclear if symptoms are from withdrawal, toxicity or both
much more risk from exposure late in gestation
some studies showed increased risk of PPHN, other studies didn’t show this

other possible negative effects is lower birth weight and gestational age, no adverse effects from breastfeeding (even though secreted in breast milk)
no increased risk of adverse neurodevelopmental outcomes

Question 44

Which of the following is not an appropriate management plan?

a) mother took SSRI in 3rd trimester - observe baby for 48 hours
b) care providers may want to consider switching the SSRI of a woman or lowering the dose
c) care providers should discontinue an SSRI when a woman is found to be pregnant because of the risk of cardiac malformations
d) women on SSRI can continue to breastfeed

Answer 44

c) false this evidence is contradictory (between paroxetine and cardiac malformations) and untreated depression is very risky

Question 45

Which of the following statements is false?

a) being a late preterm significantly increases chance of death from asphyxia, infection and SIDS
b) the mean birth weight of 34 weekers is higher than 2500 g
c) late perms experience significantly higher life threatening morbidity than term babies (as much as 7x in one study)
d) 34 week babies have much more significant morbidity than 35 weekers)
e) late perms have 3x risk of cerebral palsy

Answer 45

b)false - while late pre terms often have weight>2500 g (lowest limit of low birth weight), in the table, BW mean for 34 weeks is 2319 g; 35 week onwards is >2500

late preterm - 34,35,36, weeks inclusive, in canada, 238 -258 days inclusively, different by 1 day in us
late perm increasing
late preterm - late enough that allow labour to progress, or for ob intervention if risks of pregnancy are great- but no studies on this to see how it affects outcomes

the rest are true statements, table goes through the details of the morbidities (pretty much includes all NICU diagnosis, including risk of NEC)34 % of 34 weekers have one or more of the negative outcomes listed vs 24% for 35 weeker
3x cerebral palsy, moderate increase in developmental delay, early school age outcome also show more Ddx and special needs

Question 46

Which of the following GA babies has the greatest risk of readmission?

a) 34 weeks
b) 35 weeks
c) 36 weeks
d) 37 weeks

Answer 46

c) 36 weeks

late pre terms more readmits than term, and paradoxically, highest for 36 weeks (maybe because they get discharged earlier than the more perms

Question 47

Which of the following is not necessary to do for a late preterm baby?

a) glucose at 2 hours
b) delay feeding
c) assessment of gestational age using U/S if possible
d) bath only if core temperature >36.5

Answer 47

b) early feeding should be tried

most 34 weekers will need 24 hour assessment of respiratory status
observe for cardioresp stability and ability to feed before triage to either nursery or low-risk

Question 48

Which of the following is false of hyperbilirubinemia management in the late preterm?

a) check the bilirubin within 72 hours as per the CPS guidelines
b) late pre terms who score in or above the low-intermediate zone should be reevaluated in 24-48 hours
c) lower thresholds for phototherapy and exchange transfusion should be used for late pre terms than term babies
d) late preterm infants should be followed for 10 days for jaundice until weight gain, feeding are established

Answer 48

a)false - for late perms should check within 48 hours of birth, for everyone else CPS says 72 hours

late preterm babies more risk of kernicterus and extreme hyperbili

extreme bili is bili >428
a baby who is identified as being in a risk zone should be observed for the first week of life
median age when reached bill >428 was 4.5 days of age
generally bill for late perms peaks later (7 days vs 5 days for term) and is more likely to be severe.
late pre terms more likely to have trouble with feeding, dehydration = increased enterohepatic circulation = higher bill, rehydration and re-establishing breastfeeding is important for treatment

Question 49

Which of the following statements is false?

a) individual feeding shouldn’t take longer than 20 minutes
b) early weight loss shouldn’t exceed >10 % of birth weight
c) 24 hours of good feeding should be established before discharge of the later preterm infant
d) total feeding time should not take more than 8 hours of the day

Answer 49

d) false, shouldn’t take more than 6 hours (feeding and preparation for feeding)

the rest are true
first time mom’s should have a rooming in experience prior to leaving the NICU
sometimes people fortify BM or use enriched formula - help with weight gain but no evidence that this helps long term

Question 50

Which of the following is true of apnea management in late preterm infants?

a) late preterm infants at 34 weeks gestation may be considered for a period of cardiorespiratory monitoring prior to transfer to low risk nursery
b) apnea of prematurity is very common in late preterm infants
c) late pre term babies who have identified apnea should be monitored for at least 10 days in a NICU setting
d) SIDS is equally common in late preterm babies as term babies

Answer 50

a) true - since apnea more common in 34 weaker (although not super common in late perms and rarely a cause of readmission

b) false - not a common diagnosis but is more common in 34 weaker than later GA, unusual and rarely a cause of readmission
c) false - monitor for at least 8 days for recurrence
d) false - SIDS is not a prolongation of apnea of perm, occurs many weeks after term, SIDS is more common in late preterm infants; should take special care that SIDS guidelines are followed by this population

Question 51

A young baby is born vaginally at 35 weeks to a mom with unknown GBS status who has not received antibiotic prophylaxis, and is well, what is your management plan?

a) CBC at birth then d/c home
b) CBC at birth then vitals q4h x 24 hours
c) close monitoring with vitals q4 hours
d) full septic work up

Answer 51

b) follow same guidelines as per algorithm
baby with unknown GBS and no antibiotics who is perm, CBC at birth then vitals q4 hour x 24 hours at least

also at high risk of other infections, so should avoid sick people for at least 1 year
important to emphasize hand washing

unrelated also should demonstrate late perms to be euglycemic prior to discharge (check same as other kids as per CPS statement)
suitable thermal environment (18 C) for lightly dressed infants - overdressing infants increases the chance of SIDS
follow up should be within 48 hours

Question 52

benefits of kangaroo care for preterm infants

Answer 52

1. better sleep
2. less irritable and fussy
3. improved development
4. better breastfeeding with kangaroo care (more milk, longer duration, more milk, more percentage breastfeeding)
5. better bonding /parents feel more empowered
6. helps with pain

Question 53

benefits of breast milk for preterm infant

Answer 53

less infections
less NEC
improved growth
improved neurodevelopment

Question 54

which gestational age are we happy with kangaroo care

Answer 54

> 26 weeks

< that is still being studied

Question 55

You are going to discharge a ex prem who is now at corrected age, what are some tests and considerations?

Answer 55

RSV vaccine
car seat test
term head US
ensure they have a physician who can follow their development
support for parents in transition - get them to come spend some time, especially get used to feeding
hearing screen
ROP screen if applicable
newborn screen
immunizations
physical exam including all 3 growth parameters

Question 56

when should you arrange follow up for the above child

Answer 56

within 72 hours

Question 57

What are the symptoms of SSRIs on neonates

Answer 57

possible associations: lower birth weight, gestational age, respiratory distress and admission to NICU
SSRI neonatal behavioural syndrome: onsisting of central nervous system, respiratory, motor and gastrointestinal symptoms, is seen in 10% to 30 % of newborns exposed to SSRIs in late gestation, usually mild and self limited, can be severe in 10%
tachypnea, cyanosis, jitteriness/tremors, increased muscle tone, and feeding disturbances
usually present within hours
usually resolve within 2 weeks
seizures rarely reported
**unclear if mechanism is toxicity or withdrawal

Question 58

some problems to anticipate for late pre terms

Answer 58

temperature instability
hypoglycemia
feeding difficulties
hyperbili
sepsis
respiratory distress
also have risk of readmission for apnea/alte

Question 59

A mother is worried about SIDS for her baby who is 34 weeker and had apneas, what should you tell her

Answer 59

same precautions for SIDS as for other babies
especially important to tell her them
both SIDS and apnea of prematurity are more common in late prems, but they are not the same thing
SIDS usually happens many weeks after term

Question 60

How to reduce chance of infection of late prems

Answer 60

if GBS unknown without adequate prophylaxis, do CBC then vitals q4h
avoid sick people with viruses
emphasize handwashing

Question 61

when should you ensure follow up for late perm you are discharging?

Answer 61

48 hours (sooner than others) (vs says 72 hours in the other one)

Question 62

Definition of apnea of prematurity

Answer 62

<80

Question 63

half life of caffeine

Answer 63

100 hours

Question 64

O2 sats for perm being discharged

Answer 64

90-95%

Question 65

Why is early post natal postnatal corticosteroid therapy not recommended in infants?

Answer 65

bad CP and poor neurodevelopment outcome

Question 66

What is the definition of chronic lung disease

Answer 66

1) O2 at >36 weeks gestation
2) CXR findings
3) Respiratory distress
* *need all 3 of these

Question 67

Who to use low dose DART on

Answer 67

1) at risk of severe CLD (perm, no steroids, prolonged ventilation)
2) prolonged ventilatory

Question 68

Benefits of steroids

Answer 68

1) reduced mortality
2) reduced discharge on O2
3) faster extubation

Question 69

short term bad side effects of steroids in premies

Answer 69

1) hyperglycemia
2) hypertension
3) GI bleeding
4) HOCM

increase in severe ROP but no change in blindness
with late steroids - no differences in rates of CP with that