NICU - 2019 Updated!

Question 1

Newborn with persistent bradycardia. ECG given. Looks like heart block… identify the problem. What 2 things is this child at risk for?

Answer 1

1. Cardiac arrest/Death
2. Syncope
3. Dizziness
4. For infants and toddlers → night terrors, tiredness with frequent naps & irritability

Question 2

Newborn baby, a few hours old, is cyanotic. You suspect cyanotic heart disease but you don’t have access to an echo at the community hospital you’re working at.

a) Aside from an EKG and CXR, what are two tests that you could do to confirm cyanotic heart disease?
b) What treatment would you start while awaiting the transport team?

Answer 2

a) HyperO2 test
Pre- and post-ductal sats
4 limb BP
Physical exam

b) O2, manage BP
* Prostin (TAPVR with obstruction may get worse = more blood flow to lungs that cant get back)

Question 3

32 Week infant born and mother wants to know when they can take baby home. List 4 physiologic measures of stability that baby must have:

Answer 3

• Themoregulation : maintenance of normal body temp when fully clothed in open cot
• Respiratory stability: maintain sats >90-95 in room air
• Control of Breathing: apnea free period (~5-7 days)
• Feeding Established w/o cardio resp compromise and sustained weight gain

Question 4

33 weeker with HIE. Bad gas. Apgar at 10 minutes =4. What is the contraindication to cooling?

1. Gestational age
2. Apgar at 10 minutes
3. Gas

Answer 4

1. Gestational age

Cooling: For infants who are >36 weeks, < 6 hours old and meet inclusion criteria (basically a bad gas or moderate gas and bad apgars, plus S/S of encephalopathy).

No benefit in <35 weeks

Question 5

An infant born at 28 weeks of gestation is currently 2 months old (chronological age) and well. He is in your level 2 nursery on supplemental oxygen via low flow nasal cannulae and learning how to feed at the breast and bottle. When will you prescribe his first series of immunizations?

a) At 2 months corrected gestational age
b) Today
c) Once he is off oxygen
d) On the day of discharge home

Answer 5

b) Today

Go by chronological age.

Question 6

Which of the following is associated with polyhydramnios

a. IUGR
b. Hirschsprung’s disease
c. esophageal atresia
d. renal agenesis

Answer 6

c. esophageal atresia (can’t swallow fluid)
* renal issues - get oligohydramnios (can’t pee fluid out)
* IUGR + polyhydramnios - think trisomy 18

Question 7

Male 3 weeks old. Presents with shock, hyperpigmented scrotum, low NA 115, K 6.8. What is your most important investigation? What is your immediate management?

Answer 7

Concern for CAH

• ABCs - in shock therefore needs IV access and fluid bolus
• hydrocortisone
• Ix: 17-OHP

Question 8

You are taking care of a newborn ventilated baby born at 26 weeks who is now 29 weeks CGA with pulmonary interstitial emphysema on CXR. He is currently ventilated with the following settings: rate 40, PIP 18, PEEP 4, 60% O2. You receive the following blood gas: pH 7.20, pCO2 58, pO2 56, HCO3 19, base deficit -6.
a. What change in ventilator settings do you make?
b. 48 hours later the baby is suddenly mottled, and has the following bloodwork: Na 139, K6.8, pH 7.18, pCO2 38, pO2 68, HCO3 12, base deficit -12. The baby’s urine output is 2.5 cc/kg/hr. What complication has most
likely occurred?

Answer 8

a. increase rate (best strategy for ventilation in PIE is permissive hypercapnia since escalating support can worsen PIE - increase rate over pressures to control ventilation)
b. Metabolic acidosis from poor cardiac output from bad PIE or pneumothorax

Question 9

Newborn with trisomy 21, non-bilious vomiting after feeds. What’s the test?

a. Abdominal ultrasound
b. Barium swallow with follow through
c. Abdominal Xray
d. observe for now

Answer 9

c. Abdominal Xray

Usually duodenal atresia would present with bilious emesis, but initially may be non bilious and then progress to bilious
- AXR shows double bubble

Question 10

Newborn with an Erb’s palsy. Which is true?

a. extension at the wrist
b. preserved grasp
c. symmetric moro

Answer 10

b. preserved grasp

Question 11

Baby born at home. No healthcare contact. Comes in with lethargy and bruising. Elevated PT/PTT.

a) What is likely cause?
b) How much vitamin K should be given at birth?
c) What investigation would you do immediately?

Answer 11

a) Vitamin K Deficiency
b) 0.5 mg IM (if BW < 1500g) or
1. 0 mg (if BW>1500g) IM x1
c) Head US/CT

Oral Dosing:
2mg at birth, repeat at 2-4 weeks and again at 6-8 weeks

Question 12

Infant with R arm sat of 90% and L leg sat of 70%. Pt tachypneic, RR 70, no distress. Dx?

a. CoA
b. truncus
c. TGA
d. TOF

Answer 12

a. CoA

Question 13

37 weeker. Mild lethargy. Total bili 280 @ 30 weeks (?meant hours). No ABO. Give 3 bili charts. Mgt?

a. Follow-up in 24 hours
b. Phototherapy and repeat bili in 6 hours
c. Exchange
d. IVIG

Answer 13

b. Phototherapy and repeat bili in 6 hours
- medium risk line (only significant lethargy counts as a risk factor)
- at/above exchange line; no use for IVIG if no ABO

Question 14

3 week old baby, not moving R arm. Not opening R eye very well, ptosis and miosis. What to do to work this up?

a. Thoracic MRI
b. Visual evoked Potentials
c. Urine Catecholamines
d. Observe

Answer 14

?d ) Observe

As per CPS - you’re going to wait 3-4 weeks then refer. If you were going to image, do an MRI

Klumpke paralysis with Horner Syndrome

Question 15

What to do with a mom who is about to deliver at 23-weeks?

a. resuscitation is not indicated
b. all babies born >22 completed weeks should be resuscitated
c. parents ideas about resuscitation and palliation should be taken into account

Answer 15

c. parents ideas about resuscitation and palliation should be taken into account

Question 16

A term baby was born following an uncomplicated pregnancy to a healthy mother. The delivery was complicated by decelerations. At birth, the baby was stunned and required resuscitation with IPPV, but recovered. At 2 hours of life, the neonate is irritable, has a flexed posture, increased deep tendon reflexes and a brisk Moro. What is his Sarnat Stage?

a) 0
b) 1
c) 2
d) 3

Answer 16

Stage 1

Stage 1:
Hyper-alert, normal tone, hyperactive reflexes, strong moro, mydriasis.
No seizures. Normal EEG.

Stage 2:
Lethargic. Hypotonic. Flexed posture. Hyperactive reflexes. Myoclonus. Weak moro. Miosis. ± seizures. Low voltage change on EEG.

Stage 3:
Coma. Flaccid. Decerebrate. Absent reflexes, absent myoclonus, absent moro. Unequal unreactive pupils, EEG burst suppression or isoelectric.

Question 17

Newborn weighs 1.8 kg. Jittery and found to have glucose 1.3. Repeat glucose is 0.8 What is this baby’s glucose requirement in mg/kg/min (1)?. Write your IV order (1)

Answer 17

1. GIR = 5.5mg/kg/min
2. bolus 2cc/kg of D10W IV over 5 minutes, then run D10W at TFI of 80ml/kg/day

Calculating Fluids from GIR:
D10W = 10 g dextrose/100 mL = 100 mg/mL

For D10W —> X mg/kg/min (1 ml/100 mg)(60 min/hr)(weight)

Fluids = GIR (ml/kg/min) x 0.6 x weight

Calculating GIR from Fluids
For D10W —> X ml/hr (100 mg/mL)(1hr/60min)(1/weight)
GIR = Fluids (ml/kg/hr) x 1.6666667

Question 18

Child with difficult delivery, shoulder dystocia, forceps, now has increased work of breathing…CXR shows poor movement of L hemidiaphragm and child L arm pronated what is the prognosis

Spont recovery in a few weeks
Persistence of brachial
Persistence of thoracic
Will need surgical exploration

Answer 18

Spont recovery in a few weeks

Question 19

3 days of age. Feeding, vomiting & lethargy. Glucose of 3. Ph 7.25. Ammonia normal. Full septic w/u – normal CBC and normal LP. Normal Apgars at birth.

Examines normally except for slightly lethargic. What is most likely diagnosis.

a. Inborn Error of Metabolism
b. GBS Sepsis
c. HIE
d. IVH

Answer 19

a) IEM

Question 20

Which of the following predisposes to late hemorrhagic disease of the newborn:

1. breastfeeding
2. prematurity
3. cystic fibrosis
4. maternal phenytoin
5. oral antibiotics

Answer 20

1. breastfeeding

- maternal phenytoin is a risk factor for early HDN

Question 21

PGE1 (prostin) being started for a duct-dependent lesion in a newborn. Which of the following is the following is MOST important to monitor for?

1. Hypertension
2. Hypoglycemia
3. Hypoventilation
4. Lactic acidosis

Answer 21

3. Hypoventilation

Apnea, flushing, fever, bradycardia, and/or hypotension may indicate excessive prostaglandin effect and the need for dose reduction

Question 22

Resuscitating 36 weeker. After drying and stimulating not breathing and HR 48 what do you do next?

a. Chest compressions
b. Start ventilation with 100% 02
c. Start ventilating with room air
d. Start ventilation with 100% o2 and chest compressions

Answer 22

c. Start ventilating with room air

Question 23

4 risk factors for increased chance of kernicterus in a baby with hyperbilirubinemia.

Answer 23

Visible at <24 h
Visible before discharge
Born < 38 weeks
Previous sibling with severe
Male
Visible bruising
Cephalohematoma
Mom > 25 years old
Asian or European 
Dehydration
Exclusive and partial breast feeding

Question 24

Newborn with platelets of 12, transfused and post-transfusion platelets were 16. Mom’s CBC was normal. What do you do?

a. transfuse single donor platelets
b. transfuse PLA-1 negative platelets
c. give IVIG
d. give steroids

Answer 24

b. transfuse PLA-1 negative platelets (same thing as HPA-1: for alloimmune)

Question 25

A 3 day old is tachypneic, cyanosed despite 100% O2. Bilateral crackles on exam with weak peripheral pulses and no heart murmur. What is the diagnosis: 1. HLHS 2. Sepsis 3. AV fistula

Answer 25

1. HLHS

Question 26

Baby born after hypoxic event because of a prolapsed cord. On the first day of life he is hyperreflexic and has a exaggerated Moro reflex. He does not have any seizures. He is discharged on day four of life. His EEG and MRI are normal. What can you tell his parents about his prognosis. (2008 Toronto) 1) Impossible to determine his prognosis at this time 2) He will have a good neurological outcome 3) It is likely that he will have some neurodevelopmental delay 4) He will likely have severe impairments

Answer 26

2) He will have a good neurological outcome

Question 27

A 6 day old infant presents in shock with a glucose of 1.8 and cardiomegaly on CXR. Which of the following is the most likely etiology of the shock: a. Cardiac b. Sepsis c. Endocrine d. Metabolic

Answer 27

d. Metabolic - big heart? either muscle cell hypertrophy or deposition of lipids or glycogen IEMs: - amino acid: maple syrup urine disease - glycogen: hepatic glycogen storage disease - glucose: hereditary fructose intolerance - fatty acid: galactosemia, MCAD/SCAD/LCAD/VLCAD deficiency, carnitine palmitoyl transferase deficiency

Question 28

Full term baby delivered after traumatic forceps delivery. Now 1 month old with vomiting, lethargy and red plaque on back of hand. What lab test would you check. 1. Glucose 2. calcium 3. potassium 4. alp 5. creatinine

Answer 28

2. calcium - subcutaneous fat necrosis - rubbery/firm red/violaceous plaques or nodules on cheek, butt, back, thigh, arm A rare but potentially life-threatening complication is hypercalcemia. It manifests at 1-6 mo of age as lethargy, poor feeding, vomiting, failure to thrive, irritability, seizures, shortening of the QT interval on electrocardiography, or renal failure

Question 29

You are called to the newborn nursery to see a 4 hour old newborn female in respiratory distress. The RR is 70 and you note increased working of breathing. The nurses have also noted that the baby has a significant amount of oral secretions. What one test is required to make the diagnosis?

Answer 29

First test: try to pass OG tube. Second test plain film CXR/Abdo Xray. Best test esophagogram.

Question 30

A baby is referred to your clinic for a “funny head shape”. The resident working with you diagnoses a positional plagiocephaly. What would be a worrisome sign of physical examination? a) The ipsilateral ear is anteriorly displaced b) The ipsilateral ear is posteriorly displaced c) The baby has a tendency to look more towards the affected side d) The baby has a symmetric Moro

Answer 30

The ipsilateral ear is posteriorly displaced

Question 31

Description of a newborn with respiratory distress. What are your 4 management options.

Answer 31

1. suction mouth and nose and ensure nares patent 2. supplemental O2 by nasal prongs 3. CPAP 4. intubate and ventilate ? surfactant if FiO2 high

Question 32

In utero exposure to cocaine results in which of the following in the newborn: a) hearing deficits b) microcephaly c) hypotension d) spinal dysraphism

Answer 32

b) microcephaly ``` Cocaine abuse during pregnancy: abruption fetal asphyxia premature labor IUGR Neurobehavioural Deficits ```

Question 33

Baby born to heroin addicted mom. Apneic despite bag and mask ventilation. Best management? a. Narcan b. Intubate until baby breathes on his own c. Bag and mask ventilation until baby breathes on his own

Answer 33

b. Intubate until baby breathes on his own

Question 34

A baby was found to have CPT2 deficiency on newborn screen. What do you advise? a) frequent feedings (q3h) b) continuous feeding c) cornstarch overnight

Answer 34

a) Frequent feedings CPT2 = carnitine cycle defect = fatty acid oxidation defect

Question 35

GBS positive mom with antibiotics given 4hrs before delivery. Would like to go home. What would be your plan? (no risk factors were given!) a. can be discharged at 48 hrs b. normal newborn care

Answer 35

b. normal newborn care

Question 36

A 4-hour-old term infant has developed tachypnea, RR 60, and has had several episodes of apnea. After initial investigations, what would you do: a) observe for further deterioration b) intubate c) antibiotics d) prostaglandins

Answer 36

c) antibiotics

Question 37

Mom is IVDU. Her blood work: HEB B + HepC +. Baby’s blood work at 6 mo, hep B and hep C ab negative. What to do: a) Rest Hepc in 6 months b) No further investigations c) PCR

Answer 37

b) No further investigations - for a child at any age born to a mother with hep C who has absent Hep C antibodies, there is no need to test PCR and the interpretation is that either vertical transmission did not occur or the child cleared the infection

Question 38

Term newborn, has 2 vessel cord, clinically well and otherwise normal exam. What should you do? 1. Renal ultrasound 2. ABR 3. Nothing 4. Renal function tests

Answer 38

Nothing - Associated with diaphragmatic hernia, cloaca exstrophy sequence, sinenomelia sequence, VACTERL, however 70-80% are isolated finding. Infant should have had prenatal anatomic US if identified, but otherwise, no benefit in additional imaging after birth

Question 39

Which of the following scenarios is an indication to intubate and suction for a meconium delivery? a) thick meconium b) apgars <5 c) no spontaneous respiratory effort

Answer 39

a) thick mec - kinda NEW NRP Routing intubation for suction is not suggested. -Position, dry, stimulate, suction nose and mouth - If < 100 start PPV - MR SOPA as needed If thick Mec obstructing the airway then intubate and suction

Question 40

A newborn presents with poor feeding and decreased level of consciousness. Gas demonstrates a respiratory alkalosis. What is the most likely cause?

Answer 40

Urea cycle defect

Question 41

In counseling a woman who has had a child with a meningomyelocele, what would you tell her as regards her next pregnancy: a. take folic acid prior to conception and then for 10 weeks afterwards b. ultrasound at 16 weeks c. amniocentesis at 16 weeks d. alpha-fetoprotein at 16 weeks

Answer 41

ANSWER: a. take folic acid prior to conception and then for 10 weeks afterwards CPS: Increase FA intake to 5mg daily for at least 3 mos prior to conception to 10-12 weeks post partum! * b. ultrasound at 16 weeks (typically week 18-22) c. amniocentesis at 16 weeks (no only if US (+) then discuss) d. alpha-fetoprotein at 16 weeks (PIR routine in past; SOGC not routine now)

Question 42

Which of the following is the best predictor of risk of Rh autoimmune hemolytic disease at the time of delivery? a. Bili in the cord b. Hb in the cord c. Mom’s Anti-Rh titres d. Gestational age

Answer 42

c. Mom’s Anti-Rh titres o Any infant of Rh-negative mom should be tested for DAT, type, Hg ▪ If DAT positive, baseline bili should be measured

Question 43

Breastfed babe born to vegan mom. What should baby take. (2010 Winnipeg) a) Iron b) Vit B12 c) zinc

Answer 43

b) Vit B12

Question 44

3 week old with previous e coli sepsis and persistent jaundice. What is the likely problem. 1. Increased osmotic fragility 2. RBC galactose phosphate uradyl transferase deficiency 3. RBC glu – 1 – phosphate dehydrogenase deficiency

Answer 44

2. RBC galactose phosphate uradyl transferase deficiency - galactosemia - dx: positive reducing substances in urine (galactosuria) tx: soy formula (NO lactose)

Question 45

4-week baby presents with poor feeding and poor weight gain. He is jaundiced and has hepatosplenomegaly. His bilirubin is 150 with conjugated 100. Which imaging test would you do next? U/S with Doppler’s MRI CT abdomen HIDA scan / Nuclear med biliary excretion scan

Answer 45

u/s with doppler

Question 46

Newborn with head circumference <3rd centile and 1800g birth weight, term. Which is most likely to explain this? 1. Maternal preeclampsia 2. Maternal smoking 3. Maternal infection 4. Maternal malnutrition

Answer 46

3. Maternal Infection Symmetric IUR

Question 47

Baby with constipation. Barium enema shows rectal ampulla narrow with dilated proximal bowel. a. ) 2 investigations to confirm the diagnosis. b. ) What would you expect as the result of each investigation.

Answer 47

- rectal suction biopsy: aganglionic cells | - anal manometry: failure of internal anal sphincter to relax with rectal distension

Question 48

Abstinence from methadone? Neonatal symptoms? a. Hyporeflexia b. Constipation c. Sneezing d. Lethargy

Answer 48

c. Sneezing

Question 49

2-week old child with a 1 week history of stool mixed with blood in an infant? Bottlefeeding well, passed stool in first 24 hours. Most likely dx? a. anal fissure b. cow milk protein allergy enterocolitis c. Meckel’s diverticulum

Answer 49

b. cow milk protein allergy enterocolitis

Question 50

All of the following are normal in term newborns except: a) Hypotonia post feed b) Irregular respiratory pattern in REM sleep c) Sigh following a brief period of apnea d) Mild cyanosis with feeding

Answer 50

d) Mild cyanosis with feeding

Question 51

You are examining a newborn infant, born at full term, 2600g. He has a flat nasal bridge, a thin upper lip and a smooth philtrum. He is mildly hyptonic. Which of the following ingestions is it important to inquire about in your history of the mother’s pregnancy: a. Cocaine b. Alcohol c. Marijuana d. Heroin

Answer 51

b. Alcohol

Question 52

What is the number one cause of central apnea in a 34 week prem who is now at 8 week of age? a) Seizure b) RSV c) Apnea of prematurity d) IEM

Answer 52

c) Apnea of prematurity

Question 53

35week baby ready for d/c after a very uncomplicated NICU stay (feeding and growing I think). Name five things this baby is at risk for being re-admitted for:

Answer 53

``` Hyperbilirubinemia Feeding problems Apnea BRUE Suspected sepsis Bronchiolitis Respiratory problems Hypothermia ```

Question 54

Baby with bili of 280 and conjugated 200? What is the most likely cause based on incidence? a. Breastfeeding jaundice b. Hemolysis ABO c. Neonatal hepatitis d. Galactosemia

Answer 54

c. Neonatal hepatitis The most common cause of neonatal cholestasis are: - extrahepatic biliary atresia (25%) - idiopathic neonatal hepatitis (25%) - infectious hepatitis, e.g. CMV (11%) - TPN (6%) - metabolic disease, including galactosemia (4%) - Alagille (1%) - PFIC (1%)

Question 55

Neonate with BPD being treated with furosemide. List 4 side effects.

Answer 55

1. hyponatremia 2. hypokalemia 3. hypochloremia 4. hypercalciuria 5. nephrocalcinosis 6. dehydration 7. ototoxic - IV high dose

Question 56

Picture of rocker bottom feet (aka congenital vertical talus)– what condition do you need to think about?

Answer 56

T18 (Classic) T13 18q deletion syndrome spina bifida, arthrogryposis

Question 57

Mom ivdu. Early latent syphilis. Titer from 6 months ago and now. They have dropped by 8 times. Baby is born. What do you do to for the baby: a) Observe b) Tryomonial screen and RPR c) CSF RPR d) Swab baby

Answer 57

b) Treponemal screen and RPR - mom with primary, secondary or early latent syphilis treated at least 4 weeks prior to delivery with at least 4 fold drop in titres - RPR and TT at 0, 3, 6, 18 months as well as clinical assessment monthly x3 months and with each additional serum screen

Question 58

A 3-day-old infant develops poor perfusion, diminished peripheral pulses, and decreased urine output. What medication would you administer: a) atropine b) morphine c) bicarbonate d) furosemide e) prostaglandins

Answer 58

e) prostaglandins In neonates with severe coarctation of the aorta, closure of the ductus often results in hypoperfusion, acidosis, and rapid deterioration. These patients should be given an infusion of prostaglandin E1 to reopen the ductus and re-establish adequate lower limb blood flow.

Question 59

Newborn baby has copious oral secretions and respiratory distress. What is the most appropriate next test? a) Insertion of orogastric catheter b) CXR c) Abdominal U/S d) Barium swallow

Answer 59

a) Insertion of orogastric catheter | - concern with lots of secretions and resp distress is TEF

Question 60

4 months old ex 28 weeks with stridor (positional). History of PDA ligation. Aside from laryngomalacia name 3 things on DDX

Answer 60

``` Tracheomalacia Vocal cord paralysis Infantile hemangioma Vascular Ring Subglottic stenosis Foreign body Croup ```

Question 61

A baby with hypoglycemia needing GIR >10mg/kg/min Please list 3 types of hypoglycemia that would have a normal GIR requirement and 3 needed a higher than normal GIR

Answer 61

Hypoglycemia with NORMAL GIR: - Transitional hypoglycaemia - Inborn Errors of Metabolism - Prolonged Fasting - Glycogen storage disease - Prematurity - Panhypopit - Hypothyroid Hypothyroid with HIGH GIR: - IDM - Hyperinsulinism - Beckwith-Weideman - Hyperthyroidism - Birth asphyxia - Exchange transfusion - Polycythemia - Abrupt cessation of IV glucose - Sepsis

Question 62

7 day old being resuscitated. Rate of compressions to ventillations. Patient is intubated. a. 3:1 b. 5:1 c. 15:2 d. 100:1

Answer 62

a. 3:1 NRP guidelines

Question 63

OpHtho assessment in NICU indicated in which of the following: a) 31 weeks and <1250g b) < 1500g c) less than 35 weeks

Answer 63

a) 31 weeks and <1250g Screen for all <31 weeks and infants <1250g

Question 64

baby at 48 hour of age bili 210. Need to plot on bili chart and mgmt? (2008 Toronto) a. weigh and reassess bili in 24 hr b. bili in 72 hr c. nothing

Answer 64

a. weigh and reassess bili in 24 hr

Question 65

Name 3 complications for post-term baby born at 42 weeks

Answer 65

Shoulder dystocia - brachial plexus injury Hypoglycemia Meconium Aspiration Syndrome Failure to progress- prolonged labour and asphyxia risk Polycythemia Dry Skin

Question 66

A term IDM newborn is seen at 48 hours of age with a grade 3/6 SEM at the LSB. On echo there is hypertrophy of the septal muscle but no decrease in function. What is the clinical course: a. Will resolve with no treatment b. Corticosteroids c. Will improve with digoxin

Answer 66

a. Will resolve with no treatment

Question 67

You are called to see a 2.5 kg term newborn with jitteriness. You do a bedside glucose, which is 1.7. You decided to insert an IV and give the baby a bolus of 2cc/kg of D10. a. Please write an ongoing fluid order for this baby, to be started after the bolus is complete (1 line).

Answer 67

D10W IV at TFI 80ml/kg/day

Question 68

2 month old cholestatic jaundice, frontal bossing, murmur, butterfly vertebrae. What is the most likely ocular finding a. Aniridia b. Cataracts c. chorioretinitis d. posterior embryotoxon

Answer 68

d. posterior embryotoxon Alagille - Autosomal Dominant - Jag1 or NOTCH2 - Bile duct paucity - Broad forehead, deep-set wide spaced eyes, long straight nose, small mandible - Posterior embryotoxon, micro cornea, optic disk drusen, shallow anterior chamber - Pulm Stenosis, TOF, Pulm Atresia, VSD/ASD, Coarct - Butterfly vertebrae - Tubulointerstitial nephropathy etc.

Question 69

What is the most common complication after gastroschisis repair? (2008 Toronto) 1) Bowel obstruction 2) Abdominal compartment syndrome

Answer 69

1. Bowel obstruction

Question 70

Pregnant mom who has a previous child. She is GBS positive, comes in at 6:00pm and gets IV penicillin. At 8:00pm, she delivers a healthy baby boy at 39 weeks. Babe is well and has a normal CBC. She is wondering when she can go home (she lives close to the hospital) a. start amp/gent b. observe until 24 hours c. observe until 48 hours d. full septic work-up

Answer 70

b. observe until 24 hours → for at least 24 h and then reassess prior to discharge.

Question 71

Baby born at 41 wks. Meconium staining. Flat babe requiring resuc. Apgars 2 at 1 min 3 at 5 min and 6 at 7 min. what 5 things may you expect with this baby in the near future. What 2 tests at discharge, if normal would suggets a good neurological outcome for this child

Answer 71

1. seizures, hypotonia, hypertonia, hypotension, respiratory distress, acute tubular necrosis/AKI, GI perforation, SIADH or electrolyte abnormalities (low Na, Ca, hypoglycemia), DIC 2. Good neuro outcome: normal EEG and MRI

Question 72

Baby APGARs. At 1 minute he is limp and breathing irregularly, with heart rate 80 and he is blue. He grimaces with nasal suctioning. At 5 minutes, his HR is 140, with acrocyanosis. He does not grimace with nasal suctioning. His respirations is irregular. His tone improved to mild flexion. What is his APGARs? 2,4 3,4 3,5 4,5

Answer 72

3,5 ``` Scores (0,1,2) Appearance Pulse Grimace Activity Respiration ```

Question 73

Preterm 29 weeks with RDS FiO2 0.8, intubated, hypoglycemia, baby develops respiratory distress and febrile. Is intubated and on antibiotics. What 5 things are you going to do to get the infant ready for transport, CBC done, sat 89%.

Answer 73

``` give surfactant sedate optimize ventilation (pressures) increase FiO2 to 1.0% run D10W at 80ml/kd/d +/- bolus thermoregulation ```

Question 74

Newborn diagnosed with interrupted aortic arch, what to start? a. dopamine b. prostaglandin c. nitric oxide d. indomethacin

Answer 74

b. prostaglandin

Question 75

SGA prem, now 2 weeks old in NICU, baby presents with septic picture. a. ) List 3 bacteria that could be responsible. b. ) Initial choice of antibiotic treatment

Answer 75

a. GBS, E. coli, staph aureus, coag negative staph, listeria | b. Amp and Gent

Question 76

Description of newborn twins with weight discrepancy. Larger twin had hematocrit of 70, smaller hematocrit of 40. ``` What is smaller twin at risk for? 1. CHF 2. Hypervolemia 3. Hyperviscosity 4, Cyanosis ```

Answer 76

CHF from anemia? Could also have cyanosis

Question 77

Newborn term, AGA baby , cried at birth, Apgars 9 and 9. Few hours later found to be in respiratory distress. RR 80, HR high. Cap refill 4-5 seconds, BP 48/32. Hyperinflated chest with minimal indrawing. Cannot hear breath sounds on left, cannot hear heart sounds. Baby is turning cyanotic. What investigation do you do (1)? What is your possible diagnosis (1) Baby’s heart rate is now 80 and is more cyanotic. What one investigation do you want to do

Answer 77

1. transillumination 2. pneumothorax 3. needle decompression

Question 78

Well appearing baby born at 35+5 baby born to mom with GBS unknown status. Mom febrile 38.1, ROM x 12 hrs, did not receive antibiotics. What’s your next step in management? a. CBC+D now, and observe x48 hr. if WBC <5, must observe x 48 hr. b. CBC+D now, and observe x48 hr. if WBC >5, must observe x 48 hr. c. CBC, blood culture and IV antibiotics now, for minimum 36 hr. d. Must be monitored for 48 hours

Answer 78

d. Must be monitored for 48 hours Late Prem 35-37 must be monitored for 48 hours.

Question 79

16 week male born at 28 weeks GA. Hospitalized with RSV bronchiolitis. pCO2=60; pO2=94 in 50% oxygen. Chest X-ray shows RML infiltrate. Tachypneic. Best management: a. intubate and ventilate b. humidified oxygen and monitor closely c. ribavirin d. steroids e. antibiotics

Answer 79

a. intubate and ventilate | - best option, IRL would probably try HFNC/CPAP first

Question 80

Baby with thrombocytopenia. Mom’s plts are normal. What do you give? Maternal PLA-1 neg plts IVIG Steroids

Answer 80

Maternal PLA-1 neg platelets Alloimmuno thrombocytopenia - baby's platelets have antigen from father (usually HPA-1a) that mother doesn't have. Mom makes anti platelet antibodies, cross placenta and destroy fetal/neonatal platelets. - Mom is asymptomatic (not destroying her own) with Normal PLTS Well baby: transfuse for PLT <30 or signs of bleeding Unwell baby: transfuse for PLT <50

Question 81

A newborn with 37.3 axillary temperature. What should be done next? a) Repeat after 20 minutes of unbundling b) Do a tympanic temperature c) Do CBC d) Full Septic W/U

Answer 81

a) Repeat after 20 minutes of unbundling

Question 82

Baby in the NICU with significant hypotonia, requiring gavage feeding. Puffy hands and feet. What is the most likely diagnosis? a. Prader Willi b. Turner’s c. Trisomy 21

Answer 82

b. turner

Question 83

Premature baby with apneas, temp instability, abdo distention with bowel loops palpable, not tolerating feeds. a.) Management/treatment x4 lines

Answer 83

a. NPO - NG to LIS - Ab - vanco, cefotax, flagyl (or mero/vanco) - IV fluids/TPN - blood culture - refer to tertiary care centre with pediatric surgery

Question 84

10 day old baby with failure to thrive, jaundice, hepatomegaly, blood culture positive for E.Coli. What underlying disorder may the child have? What test can you do to confirm this diagnosis (1)?

Answer 84

1. galactosemia | 2. RBC GALT (galactose-1-phosphate uridyl transferase) activity

Question 85

Mom hep B positive. What do you do for baby ?

Answer 85

- Hep B vaccine at birth, 1-2m, 6m and HBIG as soon after delivery as possible (<12h)

Question 86

A baby was found to have rhabdomyoma. On examination, they have multiple hypopigmented lesions on their skin. What is the syndrome? a) Tuberous sclerosis b) NF-1 c) Beckwith-Wiedeman

Answer 86

a) TS

Question 87

Picture of a CT scan of the head with intracranial calcifications. What is the diagnosis?

Answer 87

Congenital CMV (periventricular calcifications, ventriculomegaly, microcephaly, HSM, TCP, SNHL, chorioretinitis), congenital toxoplasmosis (chorioretinitis, hydrocephalus and CNS lesions), HIV

Question 88

A 32 week gestation infant with Rh incompatibility has received 5 exchange transfusions. He now has vomiting, diarrhea, and abdominal distension. Most likely diagnosis: a) sepsis b) acute gastroenteritis c) portal vein thrombosis d) necrotizing enterocolitis

Answer 88

d) necrotizing enterocolitis | - exchange transfusion or any blood transfusion is a risk factor for NEC

Question 89

Mom on carbamazepine, what do you get in baby? 1. NTD 2. cardiac defects

Answer 89

1. NTD | VPA has worse risk for NTD

Question 90

3 day old infant with HR 200, BP 90/60. Irritable and poor feeding. Mom hypothyroid on replacement. Most likely dx? a. SVT b. sepsis c. CAH d. thyrotoxicosis

Answer 90

b. sepsis – most common thing in neonates.. or d. thyrotoxicosis a. SVT – would be more typically >220 c. CAH – could be secondary to hyperkalemia, although not hypotensive so less likely d. thyrotoxicosis

Question 91

Mum blood type A+, DAT negative, Hb low, male child, Asian with jaundice requiring phototherapy, what is most likely diagnosis 1. G6PD 2. ABO incompatability 3. RH incomatability

Answer 91

1. G6PD

Question 92

You are working in the NICU, and are called to see a 4 day old female born at 28 weeks. She has vomited with her last 2 NG feeds and now is noted to be distended with discoloration of the abdominal skin. You are concerned about necrotizing enterocolitis. You place the baby NPO, start antibiotic treatment and order an abdominal XR. a. Name 3 XR signs of NEC.

Answer 92

a. pneumatosis intestinalis - portal venous air - pneumoperitoneum - loss of normal bowel gas pattern (distended bowel, loss of hexagonal pattern, stacking of bowel loops) - bowel wall edema

Question 93

newborn with BWT 2.5 kg. Hypoglycemic. Next management?

Answer 93

?Asymptomatic after one feed - < 1.8 start IV - 1.8-2.5 then feed and re-check in 30 mins, If still <2.6 start IV D10 at 80ml/kg/day ?Symptomatic <2.6 Start IV 80ml/kg/day D10 Consider mini bolus of 4 ml/kg of D10 first. Check q30mins Goal > 2.6 Can use dextrose gel as alternative to IV for asympt <2.6, give with enteral feed. If symptomatic use as a temporizing measure while preparing IV.

Question 94

Term neonate at 1 hour of life still sat 88%, good response to O2,C-Section, Resp rate 80, CXR shown fluid in fissure, small R pleural effusion, grunting, normal heart, normal exam what to do next: 1. O2 supportive 2. CPAP 3. Lasix 4. Intubate

Answer 94

2. CPAP TTN: Slow absorption of fetal lung fluid.

Question 95

Baby with low apgars at birth. Picture of hypoxia. What complications would you expect over the next few days

Answer 95

Neurological - Seizures, HIE, ischemic brain injury Pulmonary - RDS, PPHN Cardiac - cardiac ischemia leading to dysfunction → muscle and conduction Renal - AKI GI - feeding intolerance, increased risk of NEC Metabolic - mitochondrial dysfunction leading to a catabolic state, decreased energy reserve Heme - thrombocytopenia, polycythemia, coagulopathies

Question 96

Newborn has significant respiratory distress and CXR that is consistent with pneumonia. She is ventilated with PIP 36, PEEP 5 rate 60 bpm, FiO2 1.0, she is not saturating very well. What is the likely diagnosis? What intervention should you start now?

Answer 96

1. Hypoxic Respiratory failure or PPHN | 2. iNO - effective in term infants with hypoxemic resp failure

Question 97

IUGR neonate with bony changes, cataracts and hepatosplenomegaly. What’s the most likely diagnosis? a. congenital syphilis b. congenital rubella c. congenital CMV d. congenital toxoplasmosis

Answer 97

b. congenital rubella - neonatal findings: - IUGR, interstitial pneumonitis, radiolucent bone disease, HSM, TCP, dermal erythropoiesis (blueberry muffin lesions)

Question 98

12h old Newborn has a sat of 80%. Increases to 85% with 100% 02. Mild tachypnea rr65. CXR has no abnormalities. What next initial management should be done? a. Intubate and ventilate b. Prostaglandins c. Antibiotics

Answer 98

b. Prostaglandins

Question 99

Klehauer betke test - question about what it is

Answer 99

Used to determine if there is fetal blood in maternal circulation such as fetal maternal haemorrhage (test done on maternal blood sample)

Question 100

Baby born at home at 38 wks by midwife. Now presents at 7 days with melena. Hb 70, MCV 112, plts normal. What is the most likely diagnosis?

Answer 100

Vitamin K deficient bleeding (previously hemorrhagic disease of the newborn)

Question 101

Infantile cystinosis. What do you get? a. cataracts b. end stage renal failure c. nephrocalcinosis

Answer 101

c. nephrocalcinosis (the first clinical signs of infantile cystinosis appear between three and six months of age; they are largely due to impaired proximal tubular reabsorptive capacity - hypercalciuria part of this) - renal failure is later presentation if not treated - cataracts by 12-16 months

Question 102

TPN – list four metabolic complications

Answer 102

1. hypernatremia 2. TPN cholestasis 3. hypertriglyceridemia 4. hypoalbuminemia

Question 103

Newborn in DR asystole since birth despite appropriate resuscitation for 10 minutes. When can you stop? (2008 Toronto) a. at 10 min b. at 20 min c. at 30 min d. at 40 min

Answer 103

a. at 10 mins

Question 104

Baby born to mom on 40mg methadone daily during pregnancy. What is minimum time you have to watch baby? 2 days 5 days 10 days

Answer 104

b. 5 days Scores should be taken for at least 72 hours, AND up to 120 hours if long acting option was taken (buprenorphine or methadone)

Question 105

3 week old who is brought to the office because mother thinks he is too yellow. Breastfed. Otherwise well. Total bili is 180. Direct is 8. What do you do? A) septic workup B) investigate for blood group incompatibility C) reassure mother that condition may last for 4-12 weeks D) investigate for metabolic disease

Answer 105

C) reassure mother that condition may last for 4-12 weeks - breastfeeding jaundice

Question 106

Mother with +ve GBS never got treated intrapartum abx. Baby born 32 wk now 9 days. Has been having increasing apneas in the past 24 h. Blood culture done shows GP cocci in clusters after 18 h of culture. What most diagnosis a. GBS b. Strep viridans c. S aureus d. Coag neg staph

Answer 106

d. Coag neg staph (clusters) - staph in cluster, strep in chains - CONS is most common cause of late onset sepsis, especially in very low BW infants

Question 107

Newborn was recently extubated after a course of systemic corticosteroids. What is the likely side effect? 1. hypotension 2. hypoglycemia 3. leucopenia 4. hypertrophic cardiomyopathy

Answer 107

4. hypertrophic cardiomyopathy | - SE of steroids include HTN, hyperglycaemia, GI bleed and perforation

Question 108

``` You are seeing a 1 wk old Chinese boy with 1 day of jaundice. His bili is 270 (mostly indirect), Hg 95 retics 9%, Mom is AB+ and he is B+. He otherwise looks well. What is the diagnosis? a. Sepsis b. Thalassemia c. G6PD def d. ABO incompatibility ```

Answer 108

c. G6PD def

Question 109

What are 4 ways in which meconium aspiration causes respiratory problems?

Answer 109

1. inactivation of surfactant 2. airway obstruction - can lead to distal atelectasis/ball valve mechanism can lead to pneumothorax 3. reactive pneumonitis 4. pneumonia (meconium is sterile but an excellent growth medium for bacteria like e. coli, and inhibits phagocytosis by PMNs) 5. Increase area leak, pneumothorax/emphysema

Question 110

(CXR of a newborn with ?narrow mediastinum and ?normal pulmonary vasculature) You are asked to see a term newborn in the delivery room after an uneventful delivery and resuscitation. The baby has a RR of 70 and is cyanotic. a. What is the most likely diagnosis? b. What one treatment will you start immediately?

Answer 110

a. Cyanotic congenital heart disease (?TGA given narrow mediastinum) b. PGE

Question 111

A newborn term infant had thin meconium at delivery but had good APGAR scores and required only 2 minutes of free flow O2. Now at 12 hours of age he has increasing work of breathing. On CXR there is hyperinflation of the RUL with mediastinal shift. What is the most likely diagnosis: a. Meconium aspiration syndrome b. Neonatal pneumonia c. CCAM d. Congenital lobar emphysema

Answer 111

d. Congenital lobar emphysema ● Congenital lobar emphysema (CLE), also known as congenital alveolar overdistension, is a developmental anomaly respiratory tract that is characterized by hyperinflation of one or more of the pulmonary lobes - intrinsic obstruction creates ball-valve mechanism. Most commonly affects middle/upper left. atelectasis of ipsilateral lung, distension causes mediastinal shift. CXR - radiolucent lobe and mediastinal shift.

Question 112

ELBW infant. What causes CLD? (2008 Toronto) a. PPV b. oxygen use c. barotrauma d. surfactant deficiency

Answer 112

? d) surfactant deficiency

Question 113

Mom with unknown GBS. First baby. List 3 criteria for offering intrapartum abx therapy.

Answer 113

- preterm labour with imminent risk of delivery - preterm, prelabour rupture of membranes - rupture of membranes >18 hours - intrapartum fever 38 or higher

Question 114

2 month old baby with poor feeding, hepatomegaly, crackles, soft systolic murmur. What is the most likely diagnosis? 1. congenital infection 2. CHF 3. Sepsis

Answer 114

2. CHF

Question 115

Most likely cause of late hemorrhagic disease of the newborn? a. phenytoin use in mom b. baby did not get Vit K prophylaxis c. oral antibiotics d. cystic fibrosis

Answer 115

b. baby did not get Vit K prophylaxis

Question 116

Jittery neonate age 6 hr with glucose 1.8 What to do: (2010 Winnipeg) a) feed and recheck in 1 hour b) bolus with D50 2 cc/kg c) IV D10 at TFI 80

Answer 116

c) IV D10 at TFI 80 The baby is symptomatic so treat.

Question 117

Mother of 2 hour newborn who has a mass on the scalp that crosses suture lines. The mother took phenytoin during pregnancy and the child was delivered via vacuum delivery. Give two reasons why the child has this lesion.

Answer 117

Vacuum delivery | Early onset vitamin K deficiency bleeding from phenytoin

Question 118

A baby is born by spontaneous vaginal delivery with thick meconium. As part of the neonatal resuscitation, he undergoes endotracheal intubation with suctioning for meconium below the cords. He is admitted to the nursery due to oxygen requirements (FIO2 100%). Umbilical catheters are inserted and blood gases are performed. A radial arterial gas reveals pH 7.26, PaO2 90. The UAC gas reveals pH 7.25, PaO2 60. You diagnose: a) PPHN b) Cyanotic congenital heart disease c) Meconium aspiration syndrome d) Non-cyanotic congenital heart disease

Answer 118

a) PPHN Right upper extremity is Pre-Ductal (90) Umbilical artery is post ductal (60) Right to Left shunting (going from PA through ductus to systemic circulation)

Question 119

Term BB, mom with gestational diabetes. DOL 1. Glucose 1.4. What is your next step in management? a. Bolus glucose by NG b. Bolus 1 cc/kg of D50W c. Run IV D10 @ 80 cc/kg/day d. Frequent breastfeeding

Answer 119

c. Run IV D10 @ 80 cc/kg/day

Question 120

The outcome in neonates since the introduction of surfactant is best described as: a. decreased mortality b. decreased BPD c. increased air leaks d. increased IVH e. decreased PDA

Answer 120

a. decreased mortality | * and decreased air leaks

Question 121

Newborn with T21 and petechiae, HSM. CBC showed elevated WBC, anemia, thrombocytopenia. What is the most likely diagnosis? a) ALL b) Fanconi anemia c) transient myeloproliferative syndrome d) sepsis

Answer 121

c) transient myeloproliferative disorder 10% with T21 - High leuks, blasts, anemia and thrombocytopenia. HSM. - resolves in 1-3 mos - Sometimes need transfusions - 20-30% will go on to develop typical leukaemia by 3 years

Question 122

Newborn with plethora and lethargy. HCR 0.72, Hb 240, Glu 3.2 on venous blood. What to do? a) Exchange transfusion b) IV D10W c) Septic workup

Answer 122

a) Exchange transfusion

Question 123

EcG: baby is thrombocytopenic, mild elevated liver enzymes, ecg shows complete heart block. What does mom have?

Answer 123

SLE (or other autoimmune condition like RA or Sjogren) - baby has congenital lupus

Question 124

4 biologic determinants of child development.

Answer 124

1. genetics 2. in utero exposure to teratogens 3. low birth weight 4. post natal illness 5. prematurity 6. exposure to toxic/hazardous substances

Question 125

Neonate term, drying them off and stimulating, HR 40 and apnea what is next step 1. PPV 2. Intubate 3. start compression 4. give epi

Answer 125

1. PPV

Question 126

``` 2-day old baby with antenatal hydro, confirmed on post-natal U/S to have moderate-severe hydronephrosis. BW shows normal renal function, baby seems to be peeing well. a. consult urology prior to discharge b. DMSA c. arrange for an outpatient VCUG d. follow up in 2 months ```

Answer 126

a. consult urology prior to discharge

Question 127

Ex-29 week prem with hyperreflexia and gross motor delay. Had history of Grade II IVH and PVL. Advise the mother about the likely cause of CP in this child. What would you see on a CT that is specific to this?

Answer 127

- IVH leading to PVL is the cause of this child's CP (PVL in prems is the most common cause of spastic diplegia) - CT would show White matter injury surrounding the ventricles, sometimes with cystic changes

Question 128

A term 2 day old baby boy who is breastfeeding well is jaundiced. He is ready for discharge. His bilirubin at 48 hours is 271. What would be your management? (2008 Toronto) 1) Regular phototherapy 2) Intensive phototherapy 3) Follow up bilirubin in 48 hours 4) Follow up weight and bilirubin in 24 hours

Answer 128

Intensive phototherapy (usually means 2 phototherapy units) should be used for infants with severe hyperbili and those at increased risk of developing it. Recheck TSB in 2-6h

Question 129

A newborn is found to have decreased tone and tongue fasciculations with decreased reflexes. The child is otherwise alert and bright. What do you do to establish diagnosis? a) TSH b) genetic testing c) metabolic screen d) MRI head and spine

Answer 129

b) Genetic Testing | -Gold standard for SMA SMN1 gene

Question 130

An ex-1500g premature infant presents with a prolonged apnea spell at 5 weeks of age. Extensive laboratory workup is unremarkable. On sending the parents home, you suggest: a. infant should always sleep on side b. infant should sleep in parents' room c. infant should sleep in own room, but parents should check on infant hourly d. an audio monitor should be placed on infant's room e. parents should not use heavy blankets in the crib

Answer 130

b. infant should sleep in parents' room

Question 131

List 4 non-infectious risk factors of hearing loss in the newborn period.

Answer 131

1. hyperbilirubinemia 2. anatomic ear abnormalities (atresia or stenosis of ear canal) 3. ototoxic medications (aminoglycosides, loop diuretics) 4. family history of childhood SNHL 5. mechanical ventilation >5 days 6. BW <1500g 7. apgars <5 at 1 minute, <7 at 5 minutes

Question 132

Baby prem 33 weeks with RDS. Heart rate is 50 apneic and limp? What are your next 2 management steps? Name 2 findings on X ray. What does this baby likely have?

Answer 132

1. give positive pressure ventilation with flow-inflatig bag and prepare for intubation 2. start chest compressions Ground glass, air bronchograms, low lung volumes with RDS

Question 133

You are counseling a pregnant teenage girl and her boyfriend at 23 weeks gestation. She is in labour. You discuss the high morbidity at this gestational age, if the baby survives at all. What is true about the resuscitation of this newborn: a. Since they are teenagers, the physician decides. b. There is legislation in Canada that says all babies 22 weeks and older require resuscitation. c. The parents’ wishes should be supported whether they want to resuscitate or not. d. Given the high mortality at this gestation, the baby should not be resuscitated.

Answer 133

c. The parents’ wishes should be supported whether they want to resuscitate or not. 22 weeks - palliative care recommended 23-24 weeks - could go either way (parent preference) 25+ weeks - recommend early intensive care as default Above is in context of no additional risk factors (SGA, multiple gestation, no antenatal corticosteroids, delivering outside tertiary care centre)

Question 134

Kleihauer-Betke Test—how does it work. (2010 Winnipeg) a) test baby for mom’s blood b) test mom for baby’s blood c) test cord blood

Answer 134

b) Test mom for baby's blood | Looking for transplacental hemorrhage fetal -> maternal

Question 135

A baby has a direct hyperbilirubinemia. He was treated for an E. coli sepsis. He has hepatomegaly on exam. Which test will likely yield the diagnosis a. RBC GALT function b. G6PD level c. Osmotic Fragility d. RBC glucose-phosphate-1 deficiency

Answer 135

a. RBC GALT function Galactosemia - Decreased metabolism of GALT 1 most common defect Manifestations include lethargy, hypotonia, jaundice, hypoglycemia, elevated liver enzymes

Question 136

A mother is given Demerol 90 minutes prior to delivery. The baby is suctioned and stimulated but remains apneic with a pulse of 80. Next step in management: a. bag and mask b. more stimulation c. Narcan d. Antibiotics

Answer 136

a. bag and mask

Question 137

An infant is born at 28+2 wk. GA. When should ROP screening be initiated? A. 32 weeks B. 33weeks C. 31 weeks

Answer 137

a. 32 weeks ROP at 31 weeks or 4 weeks of life, whatever is later.

Question 138

Term baby with bili of 221 at 48 hrs (2008 Toronto) a) photo now b) coombs + bloodwork c) f/u at 24 hrs d) f/u at 72 hrs

Answer 138

b) Coombs and bloodwork ?

Question 139

Newborn is sneezing, what medication in mom could this be associated with? a. methadone b. IDM on insulin c. clindamycin

Answer 139

a. methadone

Question 140

A 12 hour old infant born at term had mild polyhydramnios on 20 week U/S. Now the baby is grunting intermittently with lots of secretions. He improves with intermittent suctioning. What diagnosis is this most consistent with: a. TEF/esophageal atresia b. Duodenal atresia

Answer 140

a. TEF/esophageal atresia hyperglycemia, hypertension, GI bleeds/ perforation, infection, increased risk of CP, risk of adrenal insufficiency, hypertrophic cardiomyopathy and increase RoP severity

Question 141

Description of newborn with petechiae. WBC normal, Hgb normal, plt 9. Rest of exam is normal. List 3 most likely causes aside from sepsis.

Answer 141

1. neonatal alloimmune thrombocytopenia 2. autoimmune thrombocytopenia (maternal ITP) 3. TORCH infection - congenital rubella or CMV

Question 142

What is true about neonatal chest compressions: 1. ? Required after 30 seconds of PPV with HR less than 60 2. Chest compressions to be done at a ratio of 5:1 with every breath 3. 2 finger technique is preferred 4. Required after no response to stimulation

Answer 142

1. Required after 30 seconds of PPV with HR less than 60 → there should effective ventilation PPV and an advanced airway before chest compressions

Question 143

33 week premature infant is born to a mother with hypertension. Baby is SGA. What other associated findings do you expect? a) polycythemia b) hyperglycemia c) hypomagnesimia d) hypercalcemia

Answer 143

a) polycythemia

Question 144

You are treating a 38 week old newborn who was flat at birth but improved with 2 minutes of PPV. Now at 12 hours of age the baby is tachypneic at 70, BP is 38/20 (mean 32). You take the following CXR. (CXR with left-sided pneumothorax, RUL collapse but no mediastinal shift) c. What is your management?

Answer 144

Needle decompression

Question 145

After having breastfed for several weeks and wanting to get back to an easier routine, the mother of an ex-33 week premature baby girl decides to implement formula feeding. She purchases powdered formula which she prepares at home. Bacterial contamination is most likely with which of the following pathogens? a) Listeria monocytogenes b) Escherichia coli c) Staphylococcus aureus d) Enterobacter sakazakii

Answer 145

d) Enterobacter sakazakii

Question 146

BB 3 day old East Asian, born at 36 wks, breastfed, well jaundiced 240- 4 things to ask the family MD before you give him advice/before DC baby and 2 things to do on follow up

Answer 146

Questions to ask: 1) Baby’s gender 2) Mom’s prenatal care, prenatal screening results, ABO group, Rh status, other children 3) Delivery type, birth trauma, hematoma 4) Baby’s clinical status, feeding behavior, urine output 5) Natural history of the jaundice (onset, getting better, worse, breakdown) 6) Family history of jaundice, ethnicity, hemoglobinopathies, transfusions requirements Two things to do on follow-up: 1) Repeat with breakdown every 2 days until falling steadily 2) Monitor feeding behavior, hydration, growth

Question 147

Newborn with axillary temperature of 37.8 degrees, well normal exam. What do you do? a) Full septic work up and antibiotics b) Rectal temperature c) Take off all clothes for 20 minutes and recheck temperature d) CBC and diff

Answer 147

b) Rectal temperature | - axillary temp recommended for screening given very small risk of perforation with rectal temp

Question 148

Baby with jaundice, low platelet count, looks septic. What is the cause? (Lab values given). (a) TORCH infection (b) galactosemia (c) bacterial sepsis

Answer 148

could be TORCH infection or sepsis | - might lean toward sepsis since that would be worse to miss

Question 149

A woman in labour has a history of maculopapular rash in the context of penicillin use during the birth of her first child. She is in active labour and tested positive for group B strep at 36weeks of gestation. The antibiotic of choice for this labouring mum is: a) Amoxicillin b) Cefazolin c) Clindamycin d) Penicillin

Answer 149

b. Cefazolin If allergic but not anaphylactic: give IV cefazolin (still adequate IAP) If allergic and anaphylactic: give vanco or Glinda (not adequate IAP)

Question 150

You are called from a family doctor about a 5 day old jaundiced baby. Well looking. Total bili is 355, direct is normal. He is breastfed. What do you recommend? 1. septic work up 2. investigate for a metabolic disease 3. coombs test and hg 4. start phototherapy 5. observe

Answer 150

4. start phototherapy

Question 151

Which of the following newborns requires surfactant administration according to recent guidelines: a. Any newborn being transferred between centres b. A 29 week infant with no symptoms being transferred between centres c. A critically ill infant who has required 3 doses of surfactant in the first 18 hours d. An infant with RDS who is intubated and requiring more than 50% O2 after 72 hours

Answer 151

b. A 29 week infant with no symptoms being transferred between centres - ?best answer, none are really right - CPS: - infants delivered at <29 weeks gestation outside tertiary care centre should be considered for immediate intubation and surfactant after stabilization NRP- prior studies suggested babies born at <30 weeks should get prophylactic surfactant even if they weren’t intubated… now immediate use of CPAP is considered an alternative to surfactant administration

Question 152

You are called to see a 2 day old newborn male with jitteriness. At birth he was found to have a cleft palate, but has been bottle feeding well since. On physical examination, you note that the baby has a harsh systolic murmur. a. What is the most likely diagnosis? b. What is the reason for the baby’s jitteriness?

Answer 152

a. Di George | b. Hypocalcemia

Question 153

Newborn, a 30-week premie. Not breathing after stimulation. What do you do? a. self-inflating bag, room air b. self-inflating bag, oxygen reservoir c. self-inflating bag, oxygen reservoir with O2 being blown through d. anesthesia bag, connected to oxygen source

Answer 153

d. anesthesia bag, connected to oxygen source

Question 154

A 12 hour old baby is found to have choanal atresia. What are you most likely to find on examination? a) a key-hole appearing pupil and a heart murmur b) inability to pass an NG tube and imperforate anus c) vertebral anomalies d) omphalocoele

Answer 154

a) key-hole pupil and heart murmur. CHARGE (CHD7 gene -AD) ``` Coloboma Heart Defect Atresia of Choanae Retardation of Growth GU abnormalities Ear Abnormalities ```

Question 155

Newborn baby born at 27 weeks, no spontaneous resps. What to do? a. put in polyethylene plastic bag and stimulate b. warm, dry and stimulate c. positive-pressure ventilation

Answer 155

a. put in polyethylene plastic bag and stimulate | - plastic bag for all babies <32 weeks, stimulate, if apneic then start PPV

Question 156

Which is true of ophthalmia neonatorum a) The most common organism is Neisseria Gonorrhea, but it is now almost always resistant to the prophylaxis, therefore prophylaxis is not indicated b) Ophthalmia neonatorum can lead to significant eye injuries and blindness, therefore antibiotic prophylaxis is indicated c) The most efficient way of preventing it is through screening and treatment of pregnant women rather than the current prophylaxis.

Answer 156

The most efficient way of preventing it is through screening and treatment of pregnant women rather than the current prophylaxis. We screen at first prenatal visit, do a test of cure, and repeat in 3rd trimester.

Question 157

Baby with right aortic arch on CXR, suspect a vascular ring. What test is diagnostic?

Answer 157

ECHO - verify cardiac anatomy, rule out other CHD | Followed by CTA or Cardiac MRI for surgical evaluation

Question 158

A 1 week old breastfed baby comes in to your office for newborn care. There is bright red blood mixed in with the stool. The baby did not have any bleeding or bruising with the Vitamin K injection at birth or with the newborn screen. The anus appears normal and there is no evidence of a fissure. List the most likely cause of the blood in the stool.

Answer 158

Cow’s milk protein intolerance

Question 159

``` Transfusion threshold for convalescent prem in NICU? A. Hgb 65 B. Hgb 75 C. Hgb 85 D. Hgb 115 ```

Answer 159

b. 75 If >3 weeks and NO respiratory support.

Question 160

You are called to the newborn nursery to see a 4 hour old newborn female in respiratory distress. The RR is 70 and you note increased working of breathing. The nurses have also noted that the baby has a significant amount of oral secretions. a. What one test is required to make the diagnosis?

Answer 160

a. attempt to insert NG with CXR showing NG coiled in esophagus

Question 161

What are risk factors for unconjugated hyperbilirubinemia in a neonate? a) Prematurity b) LGA c) male

Answer 161

a) Prematurity

Question 162

What advice should you give to parents to prevent positional plagiocephaly: a. Children should be put to sleep in car seats b. Children should be put to sleep on their sides c. Children should be put on their stomachs as much as possible when awake

Answer 162

c. Children should be put on their stomachs as much as possible when awake

Question 163

BB born at 28 weeks now 9 weeks old-do you give iron and why

Answer 163

Babies born premature are at risk for earlier, more severe nadir in hemoglobin level as they have reduced iron stores. Iron stores are transferred from mom to baby in the third trimester, and if born early this has not likely happened fully. Iron is important for generation of red blood cells and in this period, very important for maximizing developmental potential.

Question 164

A term infant was the product of an uncomplicated pregnancy to a healthy mother with protective serologies, normal ultrasounds, and routine prenatal care. The delivery was marked by a slow 2nd stage due to cephalopelvic disproportion. A shoulder dystocia required multiple maneuvers to extract the baby. He was born vigorous, without need for resuscitation, but the obstetricians are concerned that he may have an Erb’s palsy. Should that be the case, what are you likely to find on your physical exam? a) Presence of a grasping reflex in the affected limb b) Presence of a symmetric Moro reflex c) Presence of brachial deep tendon reflexes in the affected limb d) Significant swelling of the affected limb

Answer 164

a) Presence of grasping reflex in affected limb Erb's palsy: - areflexive or hyporeflexive in involved arm - grasp usually intact - asymmetric moro - affected arm atrophy - limb may be cool

Question 165

``` A child’s newborn screen was positive, with the following pattern: HbA – None HbF – 70% HbA2 – 10% HbS – 20% ``` ``` What is your diagnosis: alpha thalsemia sickle cell trait beta thalasemmia sickle cell disease ```

Answer 165

Sickle Cell Disease Adult hemoglobin = HgbA = 2 alpha, 2 beta in term neonate, normally accounts for 30% of Hgb Fetal hemoglobin = HgbF = 2 alpha, 2 gamma ( α2 γ2 ) accounts for 70% neonatal Hgb, declines to <2% by 6-12 months HbA2 = 2 alpha and 2 delta Normal variant of Hgb A <1% of Hgb at birth, but rises to adult levels (2.0 to 3.4%) by 1 year. Increased in beta-thalassemia. Normal in sickle cell HbS = 2 alpha, and a sickle-beta is present. Normally, there is no hemoglobin S

Question 166

You are discussing with a mother the prognosis of her child born at 31 weeks gestation. There was thin meconium at birth. APGARs were 8 and 9. Head ultrasound showed a small intraventricular hemorrhage at one week of age. She is concerned because he is not yet walking and has stiff legs. a) the child likely has spastic diplegia which is often associated with prematurity and intraventricular hemorrhage b) the history is unusual in that children with CP usually have a history suggestive of birth asphyxia c) IVH would cause PVL which would result in hemiplegia d) there will be progressive decline in his development

Answer 166

a) the child likely has spastic diplegia which is often associated with prematurity and intraventricular hemorrhage

Question 167

Expected survival rate for an infant born at 25 weeks gestation: a) >90% b) 75% c) 50% d) 25% e) <10%

Answer 167

b) 75%

Question 168

``` Picture of baby with gastroschisis. What is an associated defect? (MCQ 2009) a. intestinal atresia b. cardiac anomalies c. renal anomalies d. mental retardation ```

Answer 168

a. Intestinal atresia

Question 169

Infant in NICU admission with stone in kidney. What medication was used?

Answer 169

Lasix

Question 170

6 day old baby presents bili 300/180 (total and conjugated), not feeding well for the past several days. Temperature of 35 C. What is the most likely cause? Biliary Atresia Sepsis Galactosemia Hepatitis

Answer 170

Sepsis

Question 171

Baby with symmetric IUGR. Cause? a) smoking b) preeclampsia c) congenital infection d) placental insufficiency

Answer 171

c) congenital infection

Question 172

Which of the following are true? (a) fetal p02 is 25-30 (b) the incidence of asymptomatic PFO in the adult population is 10% c) Umbilical veins close before umbilical arteries

Answer 172

ANSWER: (a) fetal p02 is 25-30 (umbilical venous pO2 is 30-35 (highest pO2 in fetus), but it mixes with systemic blood so pO2 entering the RA is 26-28mmHg) For: (b) the incidence of asymptomatic PFO in the adult population is 25-30%

Question 173

3 week old has hypocalcemia. Most likely diagnosis?

Answer 173

transient hypoparathyroidism

Question 174

Baby with persistent hypoglycemia, now on D10 at TFI 120. What is most likely cause? 1. Hyperinsulinism 2. GH def 3. Cortisol def 4. Fatty acid oxidation defect

Answer 174

1. Hyperinsulinsim As per CPS low BG statement: Start at D10 80 ml/kg/day, increase to D12.5 or increase rate up to 120 mg/kg/day When you are > 100 ml/kg/day you should monitor for dilution hyponatremia and consider more investigations to look for hyperinsulinism and IEM.

Question 175

3 week male infant with vomiting, lethargy, decr. po intake. Na 118, K 8. ``` Most important lab test? A) vasopression B) 17OHP C) cortisol D) calcium E) renin ```

Answer 175

B) 17OHP presentation of CAH (classic) → high testosterone; low cortisol, and low aldosterone in the classic case → can get hyponatremia and hyperkalemia, metabolic acidosis, hypoglycemia

Question 176

Fullterm baby delivered to an O+ mom. Looks well but pale. Hb is 70, he is hemodynamically stable. What is the most likely diagnosis? 1. ABO incompatability 2. Chronic fetal maternal hemorrhage 3. Rh incompatability

Answer 176

1. ABO incompatability

Question 177

Antenatal U/S shows moderate hydro. U/S at 24 hrs normal. What to do next and why.

Answer 177

repeat U/S after first 3 days of life, as can have false negative results prior to this while baby still digressing

Question 178

36 wk baby 2.1 kg (5lbs) at birth, day 7 jittery, irritable, on exam HR 218, T 37.5, RR 70 bp 90/60. Face is flushed, eyes wide open, alert but irritable, normal tone and normal cry, jaundiced, DTR's 2/4 and symmetric. There is hepatosplenomegaly. What is the likely diagnosis (1), List 2 tests to confirm your diagnosis

Answer 178

1. Likely diagnosis is congenital hyperthyroidism. Neonatal graves. 2. Two tests to confirm= T4 and TSH. TSH receptor stimulating antibodies. - mom with Graves - antibodies that bind to TSH receptor in thyroid (stimulating release of T3 and T4 even though there is no TSH) cross placenta - Ix: low TSH, high T3 and T4

Question 179

Mom with fever, PROM and inadequate abx therapy. Unknown GBS. Babe is born and perfectly well. Obstetrician tells you mom has chorio. What do you do: a) Cultures and abx b) CBC and observe 24 hrs c) Observe 24 hrs d) Full septic work up

Answer 179

b) CBC and observe 24 hrs I think since >1 RF (no IAP, Fever, PROM, Unknown GBS, Chorio) you should do a CBC (Statement says to consider)

Question 180

``` An ex-25 week premature infant is now 18 months old. She has bilateral increased reflexes in the lower limbs. What can you make the definitive diagnosis? (2008 Toronto) 18m 24m 36m 40m ```

Answer 180

24 mos

Question 181

3 day old baby with tachypnea, jitteriness, myoclonus and normal glucose. Treatment? a. Amp/gent b. Vit B c. Morphine

Answer 181

c. Morphine (NAS)

Question 182

nfant born to mom with no PNC. Babe has mydriasis. What did mom take: (2010 Winnipeg) a) heroin b) cigarettes c) cocaine d) alcohol

Answer 182

a) heroin (acute opioid = miosis; withdrawal = mydriasis)

Question 183

Child with brachial plexus injury. How long before if no change in exam is prognosis poor? a. 1 month b. 3 month c. 9 month d. 1 year

Answer 183

b. 1 month | - CPS statement : recovery is unlikely if not normal by 3-4 weeks, refer if incomplete recovery by 1 month

Question 184

Ex-30 week prem, now at 39 weeks corrected has had an uneventful course. He had apnea of prematurity treated with caffeine. He is still having apneas with occasional bradycardia 5-6 times a day. What is the likely cause? a) Apnea of prematurity b) Seizures c) GERD

Answer 184

a) Apnea of prematurity

Question 185

A 24 hr old newborn is seen with a report of scant U/O, the creat is 85. What is this most consistent with: a. Maternal creat b. Creat cannot be interpreted without a urea c. Creat is elevated for this newborn d. Creat cannot be interpreted without a urine creat

Answer 185

a. Maternal creat

Question 186

A term newborn is born to a heroin addicted mom. On initial assessment the baby is apneic but HR is greater than 100. After 30 seconds, the baby continues to be apneic despite adequate bag and mask ventilation. What is the next step in your management? a. IM Narcan b. Intubate and give Narcan down the ETT c. Continues to support ventilation until baby breathes on his own d. Epinephrine 1:10000

Answer 186

c. Continues to support ventilation until baby breathes on his own

Question 187

Newborn, mom poor prenatal care, remote history of IVDU. Kid having a seizure. (MCQ 2009) a) give pyridoxine b) Phenobarbital 20mg/kg c) morphine infusion

Answer 187

b) phenobarbital

Question 188

How do you clinically determine gestational age of premature baby

Answer 188

Ballard Score

Question 189

Polycythemic newborn. Hb 240, Hct 0.75. Wt 2000g. Child requires a partial exchange transfusion. What fluid do you use as the diluent? How much blood do you replace to decrease the Hct to 0.5?

Answer 189

1. NS 2. Volume = blood volume x (observed-desired hct)/observed hct = (2kg x 80ml/kg) x (0.75-0.5)/0.75 = 160ml x 0.25 / 0.75 = 40/0.75 = 53.3ml

Question 190

3 week old infant has jaundice. His birth weight was 3250g and he now weighs 3490g. He is breastfeeding well. Hemoglobin is 127 and total bilirubin is 270, conjugated bilirubin is 8. Coombs test is negative. What should be done? a) Admit for phototherapy b) Referral to gastroenterology c) Reassess in 1 week d) Recommend switching from breastfeeding to formula

Answer 190

c) Reassess in 1 week Breast milk jaundice

Question 191

``` Which is an indication of seizure activity in a neonate? A. tachycardia B. abnormal eye movements C. irregular breathing D. irritability E. vomiting ```

Answer 191

B. abnormal eye movements

Question 192

Baby with renal mass and hematuria. Most likely associated with? a. IDM b. polycythemia c. dehydration d. UVC

Answer 192

a. IDM Presentation of RVT: Sudden onset gross hematuria (can also be microscopic), Unilateral or bilateral flank masses, Hypertension, Oliguria - perinatal risk factors including asphyxia present in 31% of cases - maternal diabetes in 8% - dehydration in 1.5% - polycythemia not mentioned

Question 193

A 2.2 kg term newborn breast feeds well at birth and then is seen at 2 hours of age with a BS of 1.9. He is asymptomatic. What is the best initial management: a. feed and recheck BS in 1 hour b. IV dextrose at 4-6 mg/kg/hr c. IV D10 2cc/kg then dextrose at 4-6 mg/kg/hr d. Supplement BF with bottle and recheck BS

Answer 193

a. feed and recheck BS in 1 hour

Question 194

6 week brought in with umbilical mass, present since stump separation at 10 days. 3 things on Ddx Management plan for each

Answer 194

Umbilical granuloma - silver nitrate 1-2 x per week ``` Umbilical polyp - mesenteric duct remnant - surgical excision Ectopic tissue (pancreas or liver) - surgical excision. ```

Question 195

Unstable premature neonate on Ventilator with ++02 needs. Desating frequently with handling and recovering with bagging. What do you do? d) Increase sedation e) Steroids f) surfactant a) Minimize handling, increase sedation

Answer 195

a) Minimize handling, increase sedation - suspect PPHN - labile sats that recover well with bagging ? Could also consider surfactant depending on the age of the baby (first 72 hours)

Question 196

``` 3 day infant cyanosis with crying, investigation a ECG b CXR c ABG d bld cx e echo ```

Answer 196

e echo | - crying increases right sided pressure which increases right to left shunting (and therefore increases cyanosis)

Question 197

1 mo 2 day old with a vesicle noted on the upper lip? a. Sucking blister b. HSV c. Varicella d. Epidermolysis bullosa

Answer 197

a. Sucking blister - Sucking Pads o Calluses/vesicles found on lips in first few months o Confirmed by observing neonate sucking the affected area

Question 198

Child with cyanosis, O2 sat 80% doesn’t improve with oxygen. Pan systolic murmur grade III/IV. CXR normal and ECG shows right axis deviation. What is the diagnosis?

Answer 198

Some kind of CHD with R -> L shunting. Babies all have RAD. ``` ?TOF (boot shape) ?TGA (egg on string) Tricuspid Atresia Pulm Stenosis ?If pulm pressures high still ASD R->L could do this too ```

Question 199

An infant born at 26 weeks gestation is now 28 weeks (2 weeks old). He is doing well and is going to be transferred to a level II nursery. When should he be screened for ROP. a) if normal now, no need to do further follow-up b) do eye exam now c) do eye exam at 32 weeks d) do eye exam at 38 weeks e) do eye exam at 52 weeks

Answer 199

c) do eye exam at 32 weeks - if born at less than 28 weeks, screen at 31 weeks CGA, if born at 28+ weeks, screen at 4 weeks of life CPS suggests screening all infants born before 31 weeks GA, or <1250 g, or older with risk factors. Screen at 4 weeks of age or 31 weeks CGA, whichever is later. No infants found to have ROP prior to 31 weeks CGA!

Question 200

Newborn with a TSH of 25. What do you do? a. start thyroxine b. repeat neonatal screen c. bring them into the office as soon as possible d. thyroid ultrasound

Answer 200

c. bring them into the office as soon as possible

Question 201

Term male, delivered by emergency C-section for fetal distress. Meconium present, suctioned below cords. Now needing 100% O2. Radial Gas PaO2 80. Umbilical gas PaO2 40. What is the diagnosis? a) PPHN b) Meconium aspiration c) TGA

Answer 201

a) PPHN - PPHN should be suspected in all infants with cyanosis - hypoxemia is present in all cases - intermittently unresponsive to 100% O2 - oxygen saturation or PAO2 gradient between preductal (right radial artery) and post ductal (umbilical artery) sites of sampling imply shunting across PDA

Question 202

Description of child with prune belly. Weak abdominal musculature. Cryptocidism. Baby in intubated in NICU. Bilateral abdominal masses on exam. What is this associated with. a) Bilateral wilms b) Polycystic kidneys c) Multicystic kidneys d) Hydronephrosis

Answer 202

d) Hydronephrosis

Question 203

``` Newborn with hypoglycaemia and omphalocele. What is he at risk for? a) Neuroblastoma b) Wilm's tumor c) Leukemia d) Duodenal atresia ```

Answer 203

b) Wilm's tumour Beckwith-Wiedemann - Overgrowth syndrome - 15% familial, 85% sporadic Hallmark: omphalocele, macroglossia, macrossomia, neonatal hypoglycemia Increased risk of Neoplasms - Do AFP q 2-3 mos until 4 years, Abdo US q3mos until 8 years Developmentally N unless a/w chromosomal abnormality

Question 204

3 week old child breast feeding and growing well, jaundiced now. Mom is O and baby is A+. What is the cause? a. ABO incompatibility b. breastmilk jaundice c. hypothyroidism

Answer 204

b. breast milk

Question 205

2 day old infant presents with fever of 39.5 ax. He is breastfed and his weight has fallen from 3.8 to 3.5 kg. He is lethargic but rouses during the examination. His fontanelle is normal. Na 150, K 7.3, Cl 110, BUN 8, Cr 110, uncong bili 190, normal CBC. What is the likely diagnosis? a) hypernatremic dehydration due to decreased fluid intake b) hypertonic breast milk c) diabetes insipidus d) sepsis e) meningitis

Answer 205

d) sepsis

Question 206

Question where neonate has thrombocytopenia and mom’s plts are normal. Mgt?

Answer 206

Neonatal alloimmune thrombocytopenia | - mgmt: platelet transfusion with maternal washed platelets or HPA1a (PLA1) negative platelets

Question 207

2 month old ex 32 weeker who was ventilated with Ua/Uv lines. Now has HSM but has an otherwise normal physical exam. What is the likely cause? 1. hepatic hemangioma 2. portal vein thrombosis 3. hereditary spherocytosis 4. congenital CMV 5. fungal infection

Answer 207

2. portal vein thrombosis | - leading to portal hypertension

Question 208

``` A baby is born pale, limp, with no respiratory effort. Grimace and cry with stimulation. Heart rate 90 bpm. What is the Apgar score? 2 3 4 5 ```

Answer 208

3 ``` Appearance - 0 Pulse - 1 Grimace - 2 Activity - 0 Respirations - 0 ```

Question 209

Child with distress, can’t pass NG through nare. List 3 other findings on physical exam you’d look for?

Answer 209

50% associated with other anomalies; 10-20% have full CHARGE - coloboma - heart murmur - GU abnormalities (or hypogonadism) - ear abnormalities - deafness - square face, arched eyebrows, prominent forehead

Question 210

Child with bubbling oral secretions, difficulties passing an NG tube. Also noted to have a hemivertebrae. What to do? a. echocardiography b. spine MRI c. MRI head

Answer 210

a. echocardiography VACTERL association - cardiac abnormalities in 50% of patients with TEF