NEONATOLOGY Flashcards by Kash Yap

Premature infant

Inabilty to generate intrathoracic pressure necessary to inflate lungs without surfactant

Hyaline Membrane Disease/

Respiratory Distress Syndrome

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Term and late preterm
Benign, self limited respiratory distress sydrome
Related to delayed clearance of fluid

Transient tachypnea of the newborn

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Persistent Fetal Circulation

Persistent Pulmonary Hypertension of the Newborn (PPHN)

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Term, posterm, SGA

Mild to severe respiratory distress with cardiopulmonary failure

Meconium Aspiration Syndrome

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Premature

chronic lung disease

Bronchopulmonary dysplasia

neonatal chronic lung disease

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Defect in pleuroperitoneal canal

Bochdalek Hernia

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Posterior defect of diaphragm, more common on left

Bochdalek Hernia

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Central anterior defect of the diaphragm

Morgagni Hernia

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Cessation of breathing for longer than 20 secs or any duration accompanied by cyanosis and bradycardia

Apnea

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CXR: bowel gas pattern in hemithorax

Congenital Diaphragmatic Hernia

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CXR: prominent pulmonary vascular markings (fuzzy vessels)

TTN

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CXR: bubbly lungs (cystic lucencies)

BPD

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CXR: coarse streaking granular pattern of both lung fields

MAS

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CXR: perihilar streaking

Neonatal Pneumonia

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CXR: underaerated atelectasis

RDS

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CXR: hyperaerated

TTN

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CXR: hyperexpansion with flat diaphragm and widened rib spaces

MAS

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CXR: fluid in intralobular fissures

TTN

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CXR: streaky interstitial markings, patchy atelectasis, cystic areas, hyperinflation

BPD

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CXR: finely granular lungs, ground glass

RDS

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CXR: sunburst pattern

TTN

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CXR: may be normal

PPHN

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Overaerated conditions

BPD
TTN
MAS
Neonatal pneumonia

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Surfactant in fetal lung is present at

20 weeks AOG

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Surfactant appears in amniotic fluid at

28 - 32 wks AOG

Mature level of lung surfactant at

35 weeks aog

Most abundant component of surfactant

Phosphatidylcholine (65%)

Target SpO2 at 10 minutes of life

85-95%

Target SpO2 at 4 minutes of life

75-80%

Target SpO2 at 2 minutes of life

65-70%

Target SpO2 at 5 minutes of life

80-85%

Early onset of tachypnea | Relieved by O2

TTN

Onset within first 12 hours of birth | Cyanosis

PPHN

Early onset respiratory distress | with meconium stained amniotic fluids

MAS

Worsening respiratory status with increased work of breathing

BPD

Respiratory distress within first few hours of life

CDH

Within minutes of birth | Grunting

RDS

Difficulty with mouth breathing

Choanal atresis

Most common perinatal respiratory disorder (40%)

TTN

Most common type of congenital diaphragmatic hernia (95%)

Bochdalek Hernia

Most common cause of apnea

Idiopathic apnea of prematurity

Most common congenital anomaly of the nose

Choanal atresia

Target SpO2 at 1 minutes of life

60-65%

Target SpO2 at 3 minutes of life

70-75%

Barrel chest

TTN

Scaphoid abdomen

CDH

Progressive worsming of cyanosis and dyspnea | Peak within 3 days then improves

RDS

Recovers rapidly within 3 days

TTN

Failure of normal circulatory transition after birth due to high pulmonary vascular resistance

PPHN

Distal progression of meconium stained fluid in conjunction with reabsorption of lung fluid

MAS

Exagerrated inflammatory response

BPD

Persistence od buccopharyngeal membranes

Choanal atresia

Maladaptation from acute injury

PPHN

Volutrauma or barotrauma during mech vent

BPD

Underdevelopment of the lungs due to compression

CDH

Deficiency of surfactant with overcompliant chest wall

RDS

Conditions associated with Choanal Atresia

CHARGE Syndrome VACTERL Treacher-Collins Kallman syndrome

Most common congenital anomaly associated with choanal atresia

CHARGE Syndrome

``` Coloboma Heart defect Atresia, choanae Retardation Genital anomaly Ear defects ```

VACTERL

``` Verterbal defect Anus, imperforate Cardiac defect Tracheo- Esophageal fistula Renal defect Limb and radial anomaly ```

Choanal atresia is more common in which gender?

Females

History of chronic sinusitis Purulent nasal discharge Obstruction

Unilateral choanal atresia (60%)

Difficulty mouth breathing Suck in their lips Difficulty feeding, may develop cyanosis

Bilateral choanal atresia (40%)

Clinical diagnosis of choanal atresia is established by

Failure to pass firm catheter through each nostril 3-4 cm into the nasopharynx

Fiberoptic rhinoscopy finding in choanal atresia

Atretic plate (seen directly)

Best modality for anatomic abnormality in choanal atresia?

High resolution CT scan

Surgery in choanal atresia

Transnasal repair (no serious medical problems) Tracheotomy - if severe Elective - unilateral

Mild, moderate, severe BPD? | Breathing room air at 56 days old (36 wks AOG, if delivered <32 wks AOG) or discharged home

MILD BPD

Mild, moderate, severe BPD? | Need for O2 >30% at 56 days old (36 wks AOG, if delivered <32 wks AOG) or discharged home

SEVERE BPD

Mild, moderate, severe BPD? | Need for PPV at 56 days old (36 wks AOG, if delivered <32 wks AOG) or discharged home

SEVERE BPD

Mild, moderate, severe BPD? | Need for O2 <30% at 56 days old (36 wks AOG, if delivered <32 wks AOG) or discharged home

Moderate BPD

Modality needed for worsening or non-improving BPD?

ECG and 2D echo to detect cor pulmonale and/or pulmonary hypertension

First intestinal discharge of a newborn

Meconium

Early consequences of MAS

``` Airway obstruction Chemical pneumonitis Release of inflammatory mediators Surfactant dysfunction Increase in pulmonary vascular resistance and pulmonary hypertension ```

How long is meconium exposure in neonates with Stained umbilical cord

15 minutes - thick | 1 hr - thin

How long is meconium exposure in neonates with YELLOW STAINED NAILS

4-6 hours

How long is meconium exposure in neonates with STAINED VERNIX CASEOSA

12 hours

TRUE OR FALSE: routine intubation to aspirate lungs of vigorous infants is ineffective in reducing MAS

True

TRUE OR FALSE: meconium is sterile

True | But it may inhibit normally bacteriostatic quality of amniotic fluid

Why sedate infants on Mech Vent?

Pain precipitates hypoxia and right to left shunting

Respiratory distress with cyanosis despite adequate ventilation

PPHN

Pathogenesis of PPHN

``` Maladaptation from acute injury Remodeling of pulmonary vasculature (thickened vascular walls, smooth muscle hyperplasia) Pulmonary hypoplasia (CDH, POTTER SYNDROME) Obstruction (TAPVR, Polycythemia) ```

Risk factors for PPHN

``` Lung disease Systemic disorders Congenital heart disease Perinatal factors — asphyxia — perinatal hypoxia — maternal ASPIRIN or INDOMETHACIN ```

Gold standard to confirm PPHN

2D echo

Pathogenesis of PPHN

Marked pulmonary HPN due to elevated PVR and altered pulmonary vasoreactivity, leading to RIGHT TO LEFT shunting across foramen ovale and ductus arteriosus

Management of PPHN

Mech vent Pressors Inhaled Nitric oxide (reduce PVR, improves V/Q mismatch) Adequate hydration (prevent aggravation of shunt)

Suggestive of R to L shunting through ductus arteriosus

PaO2 or O2 sat gradient between pre- (right radial artery) and postductal (umbilical artery)

Poorly ventilated alveoli

TTN

Alveolar collapse

RDS

Why are infants born via CS more at risk for TTN?

``` No stress (lack of cathecolamine surge and active Na+ reabsorption in lung) No uterine contractions (contractions result in high transpulmonary pressure leading to lung fluid efflux) ```

Modality that is Diagnostic of TTN

Lung ultrasound Double lung point Comet tail artifacts

Management of TTN

Supportive O2, thermoregulation Beta agonists

Effects of surfactant deficience

``` Increased surface tension leading to alveolar collapse Progressive atelectasis V/Q mismatch Hypoxia Failure to develop effective FRC ```

CXR: Low lung volumes and air bronchograms within first 24 hrs of life

RDS

When to do surfactant replacement?

<26 wks AOG: Within 15 mins | All preterm infants intubated in DR

INSURE technique

Intubate SURfactant via ETT Extubate to CPAP

Mainstay therapy for RDS

CPAP

Indications for mech vent in RDS

Severe Respiratory failure Persistent Apnea

Causes of Apnea

``` Idiopathic apnea of prematurity Direct depression of CNS respiratory drive — hypoglycemia, meningitis — drugs, hemorrhage, seizures Disturbance in O2 delivery — shock, sepsis, anemia Ventilation defections — obstruction of airway — pneumonia — muscle weakness ```

Apnea management

Stimulation PPV CPR Methylxanthines — increase resp drive by lowering threshold response to hypercapnia, enhances diaphragm contractility, prevents fatigue

23 year old primigravid, delivered at 33 wks AOG, male NB via NSVD. Several minutes after birth, NB developed tachypnea, prominent grunting, intercostal and subcostal retractions, nasal flaring, which progressed to cyanosis. Upon auscultation, diminshed breath sounds, harsh tubular quality and fine crackles on inspiration. What is your initial diagnosis?

RDS

Surfactant deficiency

Fine reticular granularity of lung parenchyma, ground glass appearance, air bronchogram

23 year old primigravid, delivered at 38 wks AOG, male NB via CS. Several minutes after birth, NB developed tachypnea, expiratory grunting, retractions. Upon auscultation, clear breath sounds. What is your initial diagnosis?

TTN

slow absorption of fetal lung fluid

Hyperaerated lung, prominent pulmonary vascular markings, sunburst pattern, flat diaphragms, fluid in interlobar fissures

A 32 yo G4P3 gave birth to a 42 week male neonate via NSVD after 18 hours of labor. (+) meconium staining. 12 hours after birth, neonate noted to have grunting, nasal flaring, and intercostal retractions. He was tachycardic and hypoxemic at 80% O2 sats. Blood deawn from right radial artery and umbilical artery showed PaO2 gradient. What is your initial diagnosis?

PPHN

Right to left shunting through foramen ovale and ductus arteriosus after birth

Normal lung

``` A 32 yo G4P3 gave birth to a 42 week male neonate via NSVD after 18 hours of labor. (+) meconium staining. 12 hours after birth, neonate noted to have grunting, nasal flaring, and intercostal retractions. He was tachycardic and hypoxemic at 80% O2 sats. Blood deawn from right radial artery and umbilical artery showed PaO2 gradient. Which modality is useful in evaluation? A. CT scan B. 2D echo C. 12L ECG D. CXR ```

B. Real time echocardiography with doppler flow

A 30 week premature baby was treated for severe RDS. The patient was on mech vent for 2 weeks, subsequently extubated but never completely weaned off O2. At 36 weeks postmenstrual, can tolerate O2 at 1 lpm. What is the pathophysiology?

Chronic lung injury due to hypoxia, generation of free radicals from O2 supplementation and inflammation

MILD BPD

Interstitial emphysema, wandering atelectasis with concomitant hyperinflation and cyst formation

Supportive

``` Early use of CPAP Early surfactant therapy Caffeine to prevent apnea Vitamin A Systemic corticosteroids (not routine) ```

Hyperoxia due to prolonged (>150 hrs) exposure to FiO2 >60%

BPD

Delayed fluid resorption (central mechanism)

TTN

Memorize APGAR SCORE

``` ACTIVITY 0 - limp 1 - flexion 2 - active PULSE 0 - absent 1 - <100 2 - >100 GRIMACE 0 - no response 1 - Grimace 2 - cry, cough, sneeze, pull away APPEARANCE 0 - blue 1 - pink body, blue ext 2 - pink all over RESPIRATION 0 - absent 1 - slow, regular 2 - good, crying ```

Low Birth Weight

<2500

Very Low Birth Weight

<1500

Extremely Low Birth Weight

<1000

Fine soft immature hair, | Replaced by vellus hair in term infants

Lanugo

Flat blue gray, well-defined margins | Over buttocks and back

Mongolian spots

Benign, small papules or pustules on an erythematous base, usually 1-3 weeks after birth and persist for as long as 1 week, filled with eosinophils, found on trunk, face, ext

Erythema toxicum

Small pearly white inclusion cysts | Usually on the face

Milia

Lacy pattern on skin Cobblestone Vasomotor response to cold stress

Cutis marmorata

Open and closed comedones | From circulating acne

Neonatal acne

Vesiculopustular eruption around chin, neck, back, ext Palms and soles Benign lesions 2-3 days

Pustular melanosis

Division of body from forehead to pubis into red and pale halves, transient and harmless

Harlequin color change

Salmon patch, disappears with time

Birthmarks

Edema if scalp skin Crosses suture lines Minimal bleeding

Caput succedaneum

When does caput succedaneum resolve?

2-3 days

Subperiosteal location | No edema or discoloration in scalp

Cephalhematoma

Bleed in scalp, does not cross suture lines

Cephalhematoma

When does cephalhematoma resolve

2-3 weeks

Beneath epicranial aponeurosis, may extend to orbit and nape | Bleeding

Subgaleal hemorrhage

When does subgaleal hemorrhage resolve?

2-3 weeks

Congenital defect of the eye causing defects in the iris, lens, or retina

Coloboma

Temporary accumulations of epithelial cells on the hard palate or either side of the raphe

Epstein pearls

Redundant skin or webbing of the neck

Turner syndrome

PMI in infants

4th ICS just medial to midclavicular line

Bounding pulses and wide pulse pressure is suggestive of

PDA

Stronger pulses in upper extremity is suggestive of

Coarctation of the aorta

Soft vibratory, intermittent murmurs

Innocent murmurs

Redness, foul odor, discharge on umbilical stump

Omphalitis

Herniation of abdominal contents into the base of the umbilical cord

Omphalocoele

Herniation on abdomen, covered by a sac

Omphalocoele

Laterally located full thickness abdominal wall defect, usually right sided

Gastrochisis

Intraabdominal contents protrude through a fascial defect at the umbilicus that is covered by skin

Umbilical hernia

Urethral orifice in male located on the glans or ventral surface of the shaft

Hypospadia

Caudal curvature of the penis due to incomplete development of the foreskin

Chordee

Persistent processus vaginalis | Narrow opening at the inguinal ring allows peritoneal fluid to leave the abdominal cavity and accumulate in the scrotum

Hydrocele

Persistent processus vaginalis | opening at the inguinal ring allows extrusion of the abdominal viscera with increased intra abdominal pressure

Inguinal hernia

Single transverse palmar crease

Simian crease

Palsy involving C5-C6 | Upper trunk

Erb Duchenne palsy

Palsy involving C7-C8, T1 | Lower trunk

Klumpke palsy

Arm abducted and Pronated | Forearm internally rotated

Erb Duchenne

Absent biceps reflex, absent moro reflex on affected side

Erb duchenne

ipsilateral alteration in diaphragm excursion is due to involvement of which brachial nerve in Erb Duchenne palsy

Claw hand

Klumpke

Paralyzed, no wrist. Movement | Absent grasp reflex on hand

Klumpke

Klumpke paralysis with involvement of T1 sympathetic nerves

Horner syndrome | Ptosis, miosis, enophthalmos

Most commonly fractured bone during labor and delivery

Clavicle

Appearance? Disappearance? | Rooting Reflex

32 weeks aog | 1 mo

Appearance? Disappearance? | Palmar Grasp

28 weeks | 2-3 months

Appearance? Disappearance? | Placing or Stepping Reflex

37 weeks | 4-5 mos

Appearance? Disappearance? | Moro Reflex

28-32 weeks | 5-6 months

``` Appearance? Disappearance? Tonic neck (fencing) Reflex ```

35 weeks | 6-7 mos

Appearance? Disappearance? | Plantar Grasp Reflex

11 weeks | 7-9 mos

Appearance? Disappearance? | Landau Reflex

3 mos | Covered up by voluntary action

Appearance? Disappearance? | Parachute Reflex

4-9 mos | Covered up by voluntary action

Appearance? Disappearance? | Crawling Reflex

28 weeks | Disappear just after a few weeks

This reflex is a prerequisite to walking

Parachute reflex

Which reflex normally persists throughout life

Parachute reflex

Assymetric moro reflex response suggests

Fractured clavicle Brachial plexus injury Hemiparesis

Components of EINC

Immediate and thorough drying Skin to skin contact Properly timed cord clamping Non separation of newborn and mother

Eye prophylaxis is indicated for?

Protection vs gonococcal ophthalmia neonatorum

Credes prophylaxis

1% silver nitrate solution

When is Hep B ig given?

Mother is HBsAg positive | Or HBsAg status is unknown and bw is <2 kg

Newborn screening act of 2004

RA 9288

The Universal Newborn Screening and Intervention Act of 2009

RA 9709

Most common cause of congenital hypothyroidism

Thyroid dysgenesis

Most common cause of Congenital adrenal hyperplasia

21-hydroxylase deficiency (cortisol)

Episodic or chronic hemolytic anemia after exposure to oxidants

G6PD

Enzyme deficiency in PKU

Phenylalanine hydroxylase

Unpleasant musty odor

PKU

Burnt sugar odor

MSUD

Deficiency of branch chain a-ketoacid dehydrogenase

MSUD

Which Enzymes accumulate in MSUD

Isoleucine Leucine Valine

Associated defects in omphalocele

``` OEIS complex Omphalocele Imperforate anus Exstrophy of cloaca Spine defects ```

What is the normal amniotic fluid L/S ratio

2:1

Milk that is high lactose, and high protein content

Foremilk

Milk that is creamy with high fat content

Hind milk

Earliest milk produced and secreted for 3 days

Colostrum

Protein rich milk, 80% water High content of secretory igA, lactoferrin, lysozyme Low fat and carbs

Colostrum

Casein:whey ratio of human milk

Low 10: 90 in early milk 40: 60 in mature (2:3)

Contraindications to breastfeeding

``` Illicit drugs - ABSOLUTE HIV Tb - until after 2 weeks of tx HSV varicella Cancer chemo Galactosemia, MSUD, PKU ```

Micronutrients found more in formula milk

Vitamin D, K and iron

Clinically apparent jaundice when serum bilirubin concentration is

5 mg/dl or higher

Most common cause of jaundice in healthy infants

Physiologic jaundice

Elevated conjugated bilirubin suggests

Pathologic causes

Dreaded complication of unconjugated hyperbilirubinemis

Kernicterus | >20 mg/dl

Jaundice from insufficient caloric intake

Breastfeeding jaundice

Presence of glucoronidase in breastmilk

Breast milk jaundice

Breastfeeding baby, on 3rd day of life develops jaundice | How do you advice the mother?

``` Breastfeeding jaundice Frequent breastfeeding (>10/24 hrs) ```

Breastfeeding baby, on 8th day of life develops jaundice | How do you advice the mother?

Breast milk jaundice | Temporary interruption of breastfeeding (2 days)

Most common cause of hemolytic disease of newborn

ABO incompatibility

Hemolytic anemia due to D antigrn

Rh incompatibility

Hyperbilirubinemia Increased B1 (indirect bb) Difect coombs test positive

Rh incompatibility | ABO incompatibility

Hyperbilirubinemia | Increased direct bb

Cholestatic jaundice Intrahepatic (sepsis, hypothyroid, prolonged tpn, galactosemia, CF, A1 antitrypsin deficiency) Extrahepatic (choledocal cys, biliary atresia)

A 3-day old infant is jaundiced from the head down to upper trunk. What is the estimated serum bb?

9-12

A newborn, 38 wks AOG, developed jaundice at 12 hrs of life. Within the next 8 hours, it spreads to mid abdomen. Careful examination revealed hepatosplenomegaly, chorioretinitis, and mild hydrocephalus. What is the estimated bb levels? What is the possible cause? Bhutani chart risk stratification? Management? Diagnostic modality and expected finding?

``` 15 mg/dl TORCH infection High risk Phototherapy CT scan - intracranial calcifications ```

``` Jaundice appearing between the second and third day of life in full term infants is most likely due to? A. Normal changes B. Acute hemolysis C. Sepsis neonatorum D. Erythroblastosis fetalis ```

A. Normal changes

Complication of phototherapy

Bronze baby syndrome with photodestruction of copper porphyrins causing retinal destruction

When to do exchange transfusion?

- ongoing hemolysis despite Phototherapy of 4-6 hrs - bb increases up to 25 mg/dl in 48 hrs - signs of bb encephalopathy - hydrops fetalis or anemia

Early signs of bilirubin encephalopathy

``` Hypertonia Arching Torticollis Opisthotonus Fever High pitched cry ```

RH - mother delivers RH + child | What should be done?

Injection of Anti-D gamma globulin (rhogam) after each Rh+ child

The most important risk factor that predisposes an infant to sepsis is?

Prematurity

Antibiotic of choice for gram neg sepsis

Ampi-Amik

IUGR BABY BORN TO A MOTHER WITH INFECTION DURING PREGNANCY | Vesicular lesions on face and mouth

HSV

IUGR BABY BORN TO A MOTHER WITH INFECTION DURING PREGNANCY | Purpuric lesions all over the body

Rubella

IUGR BABY BORN TO A MOTHER WITH INFECTION DURING PREGNANCY Maculopapular rash Imaging: periostitis of the bone

Syphilis

IUGR BABY BORN TO A MOTHER WITH INFECTION DURING PREGNANCY Chorioretinitis Imaging: periventricular calcifications

CMV

``` IUGR BABY BORN TO A MOTHER WITH INFECTION DURING PREGNANCY Chorioretinitis Microcephaly Hepatosplenomegaly Imaging: intracerebral calcifications ```

Toxoplasmosis

IUGR BABY BORN TO A MOTHER WITH INFECTION DURING PREGNANCY Cutaneous scars Imaging: cortical atrophy

Varicella

Ophthalmia neonatorum caused by C. Trachomatis | Medication?

Erythromycin or ethylsuccinate | Azithromycin

Ophthalmia neonatorum caused by N. gonorrhea | Medication?

Ceftriaxone Cefotaxime And treat also for C. trachomatis

Ophthalmia neonatorum caused by gram positive bacteria | Medication?

Erythromycin or bacitracin ointment

Ophthalmia neonatorum caused by Gram neg bacteria | Medication?

Gentamicin, tobramycin, ciprofloxacin

Ophthalmia neonatorum caused by herpes simplex | Medication?

Suspect if not responding to antibiotics Vidarabine, trifluridine. Iododeocyuridine Acyclovir

Early onset sepsis

Birth to 7 days of life

Late onset sepsis

Day 8 to 30

Most common lifethreatening infection of the GIT in neonates

Necrotizing enterocolitis

Triad of NEC

Intestinal ischemia Enteral nutrition Pathogen

Most common involved area in NEC

Distal ileum | Proximal colon

Histologic finding characteristic of NEC

Coagulation necrosis

Most common congenital infection

CMV

Triad of CMV congenital

Chorioretinitis Microcephaly Periventricular calcifications

Triad of toxoplasmosis

Chorioretinitis Hydrocephalus Intracranial calcifications

Leading cause of deafness in neonates

CMV

Most common cause of STDs

C. Trachomatis

Complication of erythromycin in Infants <6 wks

Infantile hypertrophic pyloric stenosis

NEONATOLOGY Flashcards

(242 cards)