NICU Baby Nelson

Question 1

IUGR

Answer 1

< placental abruption

vs. SGA
<10th percentile or 2SD below

Question 2

Problems associated with babies who are IUGR or SGA

Answer 2

(table pg 189)

1. intrauterine fetal demise
2. temperature instability
3. perinatal asphyxia
4. hypoglycemia
5. polycythemia (from fetal hypoxia with increased epo)
6. dysmorphology associated
7. pulmonary hemorrhage

Question 3

What are the hormones abnormalities that suggest chromosome anomalies

Answer 3

1. low estriols
2. low AFP
3. elevated chorionic gonadotropin levels (placental)

Question 4

What are the main differences between fetal and adult hemoglobin?

Answer 4

fetal hemoglobin (2 alpha and 2 gamma) has higher affinity for O2 than adult Hg (this is why the baby steals all the O2) , the curve is shifted to the left - fetal hemoglobin is saturated with lots of O2, but harder to unload O2 to the tissue, but in the placenta, easier to unload the O2

Question 5

when does the body start to make more adult Hg?

Answer 5

in the third trimester , body begins to decrease making fetal Hg and makes more adult (usually full adult by 3-6 months of life as per baby nelson) and at this point have adult Hg O2 dissociation curves

Question 6

What are the effects of fever, acidosis, high PCO2 and 2,3 diphosphoglycerate on the Hg dissociation curve?

Answer 6

shifts the O2 dissociation curve to the right
because this means the body can unload O2 to the tissues more easily
and in these stressed states the tissues need more O2

Question 7

which is the dominant ventricle in utero?

Answer 7

right ventricle

Question 8

Why do we give babies silver nitrate? To prevent

a) chlamydia
b) gonorrhea
c) both

Answer 8

to prevent gonorrhoea - can cause panophthalmitis and blindness
not effective against C trachoma tis

Question 9

Why do we give erythromycin drops? To prevent

a) chlamydia
b) gonorrhea
c) both

Answer 9

both

Question 10

what comes back first after resuscitation of neonate who has arrested?

Answer 10

first get your heart rate, then cyanosis and perfusion improves
also remember that newborns respond to hypoxia with apnea rather than tachypnea

Question 11

does of epi for neonatal resuscitation

Answer 11

1:10000 0.1-0.3 ml/kg

if giving endotracheal (less predictable, can try higher ode)

Question 12

Large fontanelle, name 3 conditions to think of

Answer 12

hydrocephalus
hypothyroid
rickets

Question 13

What are congenital melanocytic nevi

Answer 13

pigemented lesions

in 1% of neonates

Question 14

true or false - giant pigmented nevi have malignant potential

Answer 14

true but they are rare (also the pics are intense)

Question 15

leukocoria in newborn, differential

Answer 15

cataracts, chorioretinitis, ROP, ocular tumor, persistent hyperplastic primary vitreous

Question 16

What does the TM look like in first 1-4 weeks?

Answer 16

dull, gray opaque adn imobile int eh first 1-4 weeks

Question 17

supernumerary nipples, what organn should you look at?

Answer 17

renal anomalies

Question 18

when do most term babies have their first pee

Answer 18

within first day of life in 95% of normal term babies

Question 19

Abdominal mass in the neonate, most common 2 causes? other causes?

Answer 19

most common: hydronephrosis, muticystic dysplastic kidney disease
less common: ovarian cysts, intestinal duplication, neuroblastoma, mesoblastic nephroma
should do an U/S for masses asap

Question 20

when do 99% of term babies pass their med

Answer 20

within 48 hours of birth in 99%

Question 21

Differential of scrotal swelling in the neonate

Answer 21

(pg 200 baby Nelson)

1. hernia
2. hydrocele - eaily illuminate and clear
3. in utero torsion of testicle - painless dark swelling
4. meconium from meconium ileum and peritonitis

Question 22

what is epispadias? what is hypospadias?should you worry about pseudohermaphroditism when these are present?

Answer 22

1. epispadias: opening at top of penis
2. hypospadias: opening at bottom of penis **don’t circumcize, may need foreskin

don’t need to worry if only this finding on own, however if can’t palpate testes, then worry about DSD

Question 23

bloody discharge from baby girl’s newborn vagina, worry or not?

Answer 23

not worry, can be normal either blood streaked or clear (from withdrawal of maternal hormones)

Question 24

do newborns shiver?

Answer 24

no

Question 25

difference between central facial nerve injury, peripheral facial nerve injury (i.e. from compression ) and from absence of depressor anguli

Answer 25

1. central facial nerve - forehead NOT involved, lower 2/3 involved 2. facial nerve peripheral - whole face (including forehead, eye, nasolabial fold, mouth etc) 3) depressor anguli - nasolabial fold and upwards should all be normal, just the mouth moves funny, can be associated with cardiac (double check this)

Question 26

What is hemorrhagic stroke encephalopathy syndrome?

Answer 26

rare condition | with excessive temperatures

Question 27

Type of neonatal hypocalcemia

Answer 27

1. early : within first 3 days of life, often no symptoms; Groups affected (special ones, all babies do have a transient decrease 24-48 hours or so) a) . prems b). IDMa - from transient hypoparathyroidism and reduced parathyroid response (for prems and IDMs) (early in prem and IDM often resolves on its own) c) DiGeorge (absence of parathyroid **can also get hypoMg - risk in IDM especially d) associated with asphyxia 2. late : a) from drinking high phosphate milk, or inability to excrete phosphate ; usually will get hyperphosphatemia after first week of life in these infants b) vitamin D deficiency states and malabsorption **all infants have decrease in Ca at 24-48 hours or so

Question 28

Clinical features of hypocalcemia

Answer 28

apnea, muscle twitching, seizures, laryngospasm Chvostek sign - facial muscle spasm when 7th nerve tapped Trousseau sign - (no usually in newborn) To prevent in high risk - gee Ca

Question 29

symptomatic hypocalcemia, treatment

Answer 29

2-4 ml/kg 10% calcium gluconate also give mg if both for late hypoCa, same as above, but should also do low phosphate feedings subcutaneous infiltration of IV calcium can cause tissue necrosis oral can irritate the intestinal mucosa

Question 30

When will a baby born to a heroin using mom withdraw

Answer 30

1-5 days

Question 31

methadone mom, when withdraw

Answer 31

1-4 weeks

Question 32

name symptoms of withdrawal from opiate

Answer 32

jittery, sneezing, irritable, diarrhea, poor feeding (but starving) , poor sleep, cry lots (high pitched), tachypnea **often methadone withdrawal is worse

Question 33

Treatment of withdrawing baby

Answer 33

``` start with swaddling, no light if significant (i.e. constant hyperactive, irritability doesn't allow sleeping and feeding, or when diarrhea/seizures present, treatment with meds 1. seizures - treat with phenobarb 2. other symptoms - with opiod weaning can take 1-2 months ```

Question 34

Effects of cocaine use during pregnancy

Answer 34

``` preterm labor placental abruption decreased attentiveness irritable newborn SGA small heads usually no treatment needed ```

Question 35

What type of antibody can cross placenta

Answer 35

IgG (which is usually the type that autoantibodies are)

Question 36

Treatment of neonate with ITP with hemorrhage (and mom has ITP also

Answer 36

``` (table 205) can give platelets if hemorrhage can try IVIG usually resolves in 4-6 weeks risk is intracranial hemorrhage ```

Question 37

Problems of Diabetic Pregnancy (pg 206) for baby

Answer 37

1. LGA 2. hypoglycemia 3. hypocalcemia 4. hypomagnesemia 5. birth asphyxia/shoulder dystocia 6. congenital heart defects - hypertrophy of septum 7. tachypnea (RDS or TTN) 8. small left colon 9. renal disorders 10. polycythemia others also include lubosacral dysgenesis, neural tube defects

Question 38

contrindications to indomethacin for PDA

Answer 38

thrombocytopenia bleeding creatinine >1.8 oliguria

Question 39

how much blood do babies have?

Answer 39

70-90 ml/kg for term | 90-100ml/kg for preterm

Question 40

Delayed cord clamping advantages and disadvantages?

Answer 40

1. can increase blood volume transiently for first few days, improves glomerular filtration 2. disadvantage: can increase jaundice early: can lead to anemia, murmur, poor perfusion, less tachypneas **should hold the baby below the placenta (otherwise the baby will give too much blood back to the placenta)

Question 41

Causes of anemia in the newborn period

Answer 41

1. decreased production (low retics 0-2%) Ddx: bone marrow failure (Diamond-Blackfan anemia), infection (congenital viral infections, i.e. parvo/rubella, sepsis), nutritional deficiencies (protein, iron, folate, vitamin B12), congenital leukemia 2. increased Destruction of RBC (normal or elevated retics (>5-10%) Immune mediated: (Coombs positive) - hemolytic disease of the newborn (anemia and hyperbili mainly) ABO incompatibility (less severe than Rh disease, doesn't get worse in subsequent pregnancies ) - Erythroblastosis fetalis (Rh incompatibility) make anti-D antibody (which is the antibody which is most likely to be present) Non Immune mediated (Coombs negative) 1. RBC enzyme deficiencies - ie pyruvate kinase or G6PD 2. RBC membrane disorders - ie hereditary spherocytosis (autosomal recessive is severe, less severe autosomal dominant form) 3. hemoglobinopathies - ie thalassemias **see chart pg 217

Question 42

Clinical manifestations of erythroblastosis fettles

Answer 42

anemia, hyperbili in first pregnancy, then worse because will start hemolysing in utero fetal anemia, heart failure, portal vein obstruction, hypoalbuminemia- i.e. fetal hydrous - ascites, pleural and pericardial effusions, anasarca

Question 43

How to tell difference between acute and chronic blood loss at birth

Answer 43

1. Acute blood loss - after fetal maternal hemorrhage, rupture of the umbilical cord, placenta pre via or internal hemorrhage - pallor, diminished peripheral pulses, shock - no signs of extra medullary hematopoesis, no HSM - ininitial Hg can be normal but then decline over 24 hours 2. Chronic blood loss: i.e. chronic fetal-maternal hemorrhage, twin twin transfusion: marked pallor, heart failure, HSM with or without hydrous, a low hemoglobin level at birth fetal-maternal bleedin is very common - 50-75% , blood losses range from 1-50 ml

Question 44

What is the Kleihauer-Betke acid test

Answer 44

look at the mom's blood smear - will see fetal pink pRBCs and counted (because fetal Hg is resistant to acid and adult hemoglobin is eluted) false positive Kleihauer Betke: sickle cell or hereditary persistence of fetal hemoglobin false negative - ABO incompatibility (since all will be negative)

Question 45

What is Crigler-Najjar syndrome

Answer 45

serius, rare autosomal REcessive, permanent deficiency of glucoronosyltransferase that results in severe indirect hyperbilirubinemia Type 2 - responds to phenobarbital (so randome) Type 1 - persistent indirect hyperbili - can lead to kernicterus

Question 46

What is Gilbert disease

Answer 46

mutation of glucoronosyltransferase and results in a mild indirect hyperbilirubinemia

Question 47

How high is the bill in typically breast milk jaundice

Answer 47

shouldn't be more than 20 mg/dL (which equals 20 x 17 = 340) I think interupt fo 1-2 days will result in rapid decline

Question 48

At what levels of bill is jaundice observed?

Answer 48

5-10 mg/dL

Question 49

Work up to do for direct (conjugated hyperbili)

Answer 49

``` conjugated hyperbili is >20% of total bill do liver enzymes - AST/ALT ALP GGT bacterial and viral cultures metabolic screening hepatic U/S sweat chloride occasionally liver biopsy ```

Question 50

Causes of conjugated hyperbili

Answer 50

``` Common 1. hyperalimentation cholestasis 2. CMV infection and other TORCH infections 3. Inspissated bile from prolonged hemolysis 4. neonatal hepatitis 5. sepsis Uncommon: 1. hepatic infarcation 2. IEMs - galactosemia, tyrosinemia 3. CF 4. biliary atresia 5. choledochal cyst 6. alpha 1 -antitrypsin deficiency 7. neonatal iron storage disease 8. alagille syndrome 9. Byler disease ```

Question 51

early sign of kernicterus vs late

Answer 51

early : lethargy, hypotonia, irritability, poor moro ad feeding later signs: bulging fontanelle, opisthotonus, pulmonary hemorrhage, fever, hypertonicity, paralysis of upward gaze and seizures

Question 52

Complications of exchange transfusion

Answer 52

related to glood: transfusion reaction, metabolic instability, infection catheter - vessel perforation hemorrhage procdure: hypotension or NEC - unusual: thrombocytopenia, GVHD

Question 53

Polycythemia in neonate (pg 221)

Answer 53

``` Hematocrit >65% People at risk: SGA IDM delayed cord clamping hyperthyroidism adrenogenital syndrome T13, T18, T21 Twin twin (recipient) Beckwith - Wiedemann ```

Question 54

Symptoms of polycythemia

Answer 54

1. plethoric/ruddy may have acrocyanosis Symptoms are from vascular stasis, hypo perfusion and schema seizures, lethargy, irritability hyperbili - poor hepatic circulation of Hg broken down into bill Resp distress PPHN NEC, hypoglycemia, thrombocytopenia, pripism, testicular infarction, stroke, feeding intolerance

Question 55

Long term sequelae of polycythemia

Answer 55

neurodevelopment abnomalities | partial exchange transfusion how to calculate the volume:

Question 56

how to calculate amount of blood for partial exchange transfusion pg 222 nelson baby

Answer 56

volume to exchange (mL) = [blood volume x (observed hematocrit - desired hematocrit)/ observed hematocrit desired hematocrit is 50%, blood volume is 85 ml/kg pg 222 baby nelson need to use central venous hematocrit (peripheral might be falsely elevated)

Question 57

eye discharge at day 1 of life, initially clear then purulent, also have chemises and hyperaemia, more likely gonorrhoea or chlamydia

Answer 57

gonorrhea gonorrhea presents in first 5 days of life, chlamydia is ted 5-14 days of life chlaydia can last 1-2 weeks gonorhea auses your eye to perforate and go blind

Question 58

staccato cough, which infection

Answer 58

chlamydia pneumonia CXR - hyperinflation with diffuse infiltrates prophylaxis does not treat the chlamydia when you have pneumonia +/- pneumonia with chlamyda, need to treat systemically with erythromycin

Question 59

drugs which can impair vitamin K metabolism

Answer 59

warfarin, antibiotic

Question 60

baby with late hemorrhagic disease of newborn, things to think of

Answer 60

breastfed also might have vitamin K problems ie CF, biliary atreisia, hepatitis, antibiotic suppression of colonic bacteria that make vitamin K

Question 61

Treatment of bleeding from vitamin K deficiency

Answer 61

IV 1mg vitamin K | if severe, also can do FFP

Question 62

Differential of bleeding in the newborn

Answer 62

1. sick newborn: DIC< hepatic failure, thrombocytopenia (including consumption i.e. Kasabach-Merritt) 2. Well child: hemophilia (cutaneous or mucosa bleeding and no systemic illness) , thrombocytopenia from syndromes (i.e. Fanconi anemia with no thumbs, radial aplasia-thrombocytopenia syndrome (thumbs present0 or Wiskott-Aldrich syndrome , maternal drugs can reduce platelet count (i.e. sulfonamids, quinidin, quinine, thiazide) most common thrombocytopenia; isoimmune thrombocytopenia (mom has anti platelet but her platelets are find) treat with transfusion and/or IVIG , sometimes need to do C/S and transient neonatal thrombocytopenia neonatal thrombocytopenia in babies of mom's with ITP

Question 63

Lab findings in baby with DIC

Answer 63

prolonged PTT and PT (minutes rather than seconds ), thrombocytopenia and bood smear suggesting MAHA (burr or fragmented blood cells) low fibrinogen elevated levels of fibrin degradation products

Question 64

labs in vitamin K deficiecy

Answer 64

PT most prolonged - X, VII, V, II, I

Question 65

in hemophilia - factors XII, IX, VIII, X , V, II, and I

Answer 65

PTT most prolonged