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Flashcards in Neonatology Deck (13):

Apgar scoring

Rapid scoring system that helps evaluate need for neonatal resuscitation. 5 parameters get 0-2 points each.

8-10: Typically reflect good cardiopulm function
4-7: Possible need for resuscitation. Infants should be observed, stimulated and possible given ventilatory support
0-3: Indicate the need for immediate resuscitation

1) A: Apperance (blue/pale, pink trunk, all pink)
2) P: Pulse (0, less than 100, greater than 100)
3) G: Grimace with stimulation (0, grimace, grimace and cough)
4) A: Activity (limp, some, active)
5) R: Respiratory effort (0, irregular, regular)


Neonatal jaundice

An elevated serum bili (over 5) due to increased hemolysis or lower excretion.

1) Conjugated (direct): Always pathologic
2) Unconjugated (indirect): May be physio or pathologic
3) Kernicterus: Caused by unconjugated elevations. Results from irreversible bili deposits in basal ganglia, pons, and cerebellum. Typically at levels of over 25-30 and can be fatal. Risks are prematurity, asyphxia, and sepsis.


Conjugated hyperbili ddx

1) Extrahepatic cholestasis (biliary atresia, choledochal cysts)

2) Intrahepatic cholestasis (neonatal hepatitis, inborn errors of metabolism, TPN cholestasis)

3) Dubin-Johnson

4) Rotor's



Unconjugated hyperbili ddx

1) Physiologic jaundice

2) breast milk jaundice

3) Increased enterohepatic circulation (GI obstruction)

4) disorders of bilirubin metabolism

5) hemolysis

6) sepsis

7) Crigler-Najjar

8) Gilbert


History in neonatal jaundice

History should focus on diet (breast milk or formula), intrauterine drug exposure, and FHx (hemoglobinopathies, enzyme deficiencies, RBC defects)


Exam in neonatal jaundice

May reveal signs of hepatic or GI dysfunction (abdominal distention, delayed passage of meconium, light stools, dark urine), infection, or hemoglobinopathies (cephalohematomas, bruising, pallor, petechiae, hepatomegaly)

Kernicterus presents with lethargy, poor feeding, a high-pitched cry, hypertonicity, and seizures. Jaundice may follow a cephalopedal progression as bili concentrations increase.


Dx of neonatal jaundice

1) CBC with peripheral smear; blood typing of mom and infant (for ABO or Rh incompatibility); Coomb's test and bili levels

2) US and/or HIDA can confirm suspected cholestatic disease

3) For direct hyperbilirubinemia, check LFTs, bile acids, blood Cx, sweat test, and tests for aminoacidopathies and a1 antitrypsin deficiency

4) A jaundiced neonate who is febrile, hypotensive, and/or tachypneic needs a full sepsis workup and ICU monitoring


Tx of neonatal jaundice

1) Treat underlying causes

2) Treat unconjungated hyperbili with phototherapy (for mild elevation) or exchange transfusion (for severe over 20). Start photo earlier (10-15) for preterm infants. Phototherapy is NOT indicated for conjugated hyperbili and can lead to skin bronzing.


Respiratory Distress Syndrome

The most common cause of respiratory failure in preterm infants (affects more than 70% of infants born at 28-30w); formerly called hyaline membrane disease.

Surfactant deficiency leads to poor lung compliance, alveolar collapse, and atelectasis

Risk factors include: Maternal DM, male gender, and the second born of twins.


History and exam for RDS

Presents in first 48-72h of life with a RR above 60, progressive hypoxemia, cyanosis, nasal flaring, intercostal retractions, and expiratory grunting


Dx of RDS

1) Check ABGs, CBC, and BCx to r/o infection

2) Dx is clinical and confirmed with characteristic CXR findings.

For RDS, this is ground glass appearance, diffuse atelectasis and air bronchograms on CXR.

For Transient Tachypnea of Newborn: Retained amniotic fluid results in prominent perihilar streaking in interlobular fissures. Resolves with O2 administration.

For meconium aspiration: Coarse, irregular infiltrates; hyperexpansion and pneumothoraces

For congenital pneumonia: Nonspecific patchy infiltrates; neutropenia, tracheal aspirate, and gram stain suggests the dx


Tx of RDS

1) CPAP or intubation and mechanical ventilation

2) Artificial surfactant administration lowers mortality

3) Pretreat mothers at risk for preterm delivery (less than 30w) with steroids. If less than 30w, monitor fetal lung maturity via a lecithin-sphingomyelin ratio and presence of phosphatidylglycerol in amniotic fluid. L/S ratio less than 2 indicates need for maternal steroid administration


Complications of RDS

Persistent PDA, bronchopulmonary dysplasia, retinopathy of prematurity, barotrauma from positive pressure vent, IV hemorrhage, and NEC are complications of treatment