NICU SAQ

Question 1

1. You are called shortly after a 42 week gestation infant was born - what are 3 perinatal complications of being post dates?

Answer 1

1. Shoulder dystocia
2. Clavicular fracture
3. Brachial plexus injury
4. Perinatal asphyxia
5. LGA
6. Hypoglycemia
7. Polycythemia
8. MAS
9. PPHN
10. Sz
11. CP

Long thin body, long nails. Skin is dry, parchment like, mec-stained, peeling. Sparse lanugo. More scalp hair.

Question 2

2. A 2 hour old 27 week premature baby is born in your community center. You are taking care of her before the transport team arrives.
   What one management plan will you do to prevent each of these complications:
   A. Hypothermia/hyperthermia
   B. IVH
   C. Hypoglycemia
   D. BPD
   E. ROP

Answer 2

A. Hypothermia/hyperthermia - place in plastic bag, use warmer/incubator with temperature probe
B. IVH - antenatal steroids, delayed cord clamping, maintain hemodynamic stability
C: Hypoglycemia - D10W via IV at TFI 60
D: BDP - avoid intubation, minimize pressure, consider surfactant if intubated
E: ROP: titrate O2 to maintain age appropriate sats. Avoid hyperoxemia.

Question 3

3. Mom and dad are refusing IV vitamin K. What alternative can offer them for their newborn? (Be specific)

Answer 3

Counsel on serious health risks of VKDB

If still decline, Vitamin K 2mg PO with first feed, then at 2-4wk, 6-8wk

Question 4

4. A term baby is born to a mother with maternal lupus. He is noted to have congenital heart block.
   A. Name the 2 most common antibodies in congenital heart block.
   B. Name 3 other manifestations of neonatal lupus.

Answer 4

A. Anti-Rho and Anti-La
B. 1) Rash
2) Cytopenias (anemia, thrombocytopenia)
3) Transaminitis

Question 5

5. A 4.3kg neonate is born at 39 weeks. He has a 1.5cm omphalocele and a slightly protuberant tongue. His glucose is 0.8mmol/L and IV glucose is started.
   A. Name 3 hypoglycemic conditions in which the glucose requirement is expected to be normal for a term baby.
   B. Name 3 hypoglycemic conditions in which you would expect the glucose requirements to be higher than expected for a term baby.

Answer 5

A. Hypoglycemia with normal GIR

1. FAOD
2. GSD
3. Prematurity
4. GH deficiency
5. Hypopit

B. Hypoglycemia with increased GIR

1. IDM
2. Beckwith-Wiedeman
3. Perinatal asphyxia
4. Pre-eclampsia

Question 6

7. A one hour old boy has a plethoric face, marked acrocyanosis, and respiratory distress. His hematocrit is 75%.
   a) What is his diagnosis?
   b) How would you treat him?
   c) What are 3 complications of the problem?

Answer 6

A) Polycythemia
B) Partial exchange transfusion (Sx + Hct 75%)
C) 
1. Sz
2. Stroke
3. Pulm HTN
4. NEC
5. RVT
6. Renal failure

Question 7

8. What are 4 measures for pain control in a neonate who is getting an IV start?

Answer 7

1. Breastfeeding
2. Sucrose
3. Non-nutritive sucking (e.g. soother)
4. Swaddling
5. Kangaroo care (skin to skin)
6. Facilitated tuck that holds arms + legs in flex position
7. Topical anesthetics (venipuncture, IV, LP; limit repeated use)

NO Tylenol in <28wk (inadeq pharmokinetic data to calculate dose)

Question 8

9. 6 week old baby presents with bruising and lethargy. Mom had minimal antenatal care and had a home delivery. She has not been to see a healthcare practitioner. The baby’s labs show a normal CBC, but INR of 4.2 and PTT of 57?
   a) What is the diagnosis?
   b) What one test would you do right now?
   c) What is the best way to prevent this? (be specific)
   d) If parents refuse, what is the alternative and be specific? (be specific)

Answer 8

A) Hemorrhagic disease of the newborn
B) CT head to assess for ICH
C) Vitamin K 1mg (if >1500g; 0.5mg if <1500g) IM in first 6HOL
D) Vitamin K 2mg PO with first feed, 2-4wk, 6-8wk

Question 9

10. Baby with hypoglycemia, name 10 bloodwork that needs to be done BEFORE treatment to diagnose the cause of the hypoglycemia

Answer 9

1. Glucose
2. Ketones - BHB
3. gas
4. lactate
5. Insulin, c-peptide
6. GH
7. Cortisol
8. Ammonia
9. FFA
10. Plasma amino acids
11. Acyl carnitine profile
12. Carnitine total + free
13. TSH, fT4

U/A
urine organic acids

Question 10

11. Picture of baby with back with a large red firm plaque; in question mentions baby was healthy term but had a difficult and prolonged delivery.
    a) What is the diagnosis?
    b) What one blood test would you check for?

Answer 10

A. Subcutaneous fat necrosis

B. Calcium (hypercalcemia in 1-6mo)

Question 11

12.Baby with PPHN, 7.32, pco2 48, bicarb 18, fio2 0.8, sat 91 preductal, 82 postductal
A. What’s your diagnosis?
B. What 4 things can you do while waiting for the transport team

Answer 11

A. PPHN. Metabolic acidosis with R to L shunt
B.
1. Avoid hypoxemia. Maintain age appropriate saturations, then keep SpO2 95-99% to maintain preductal PaO2 90-100mmHg
2. Consider I+V with permissive hypercarbia
3. Temperature control (avoid hypothermia b/c can increase PVR + metabolic demand)
4. Sedation if I+V
5. Give IVF +/- inotropes (dopamine) to correct hypotension (and overcome right sided pressure)
6. Maintain normoglycemia, avoid acidosis + correct if needed

Nitric oxide should NOT be given unless in tertiary care centre

Question 12

13. A 12-hour old infant is noted to have abnormal movements, lasting 10-20 sec, observed by a nurse. Name THREE things that would make this activity UNlikely to be epileptic in nature.

Answer 12

1. Movements suppressible by restraint or repositioning
2. No vital sign or autonomic changes
3. No EEG change
4. No abnormal eye movements
5. Provoked by stimulation of the infant

Question 13

14. A newborn baby present with the following rash. He has thrombocytopenia and mild hepatitis. What is the diagnosis?
    (Page 240 - LOOK AT THIS)

Answer 13

Neonatal lupus

Question 14

16. 7 day old baby presents with cyanosis and tachypnea. O2 sats 80% after given 100% O2. CXR – clear. S1 and single S2. ECG shows right axis deviation. Systolic murmur Grade III/VI over LSB. What is the most likely diagnosis?

Answer 14

Failed hyperoxia test, suggests CHD
ECG: RAD

TOF

• PS causes harsh Gr 2-3/6 systolic murmur in LUSB
• ECG: RAD, RVH

Question 15

18. (Picture of a baby with an elongated skull in AP diameter). Mother brings in her baby with concerns regarding the shape of his head. What should you consider? On exam, what do you look for to confirm?

Answer 15

A. Craniosynostosis vs plagiocephaly

• Scaphocephaly/dolichocephaly - premature fusion of sagittal suture (50% of craniosynostosis)
• sutures: metopic, coronal, sagittal, lambdoid

B. O/E
- Palpate for overriding sutures
- premature closing of anterior fontanelle
- look at shape of head from above - frontal bossing + ear displacement
- measure occipital-frontal circumference (normal in craniosynostosis)
- measure biparietal diameter (reduced)
(parallelogram with ipsilateral frontal bossing + ipsilateral ear anterior suggests plagiocephaly
vs trapezoid with contralateral frontal bossing + ipsilateral ear posterior suggests lambdoid craniosynostosis)

C. Imaging

• Plain x-ray
• CT to further characterize

D. Assoc’d conditions with craniosynostosis

1. Hypophosphatemia
2. Rickets
3. Syndromes (crouzon, carpenters)

Question 16

19. List 4 ways to minimize pain in a neonate from procedures (e.g. heelprick, IV, venipuncture, suction) in a level 2 NICU.

Answer 16

Minimize number of painful procedures

1. Breastfeeding
2. Sucrose
3. Non-nutritive sucking (soother)
4. Swaddling
5. Kangaroo care (skin to skin)
6. Facilitated tuck that holds arms + legs in flex position
7. Topical anesthetics (limit repeated use)

NO Tylenol in <28wk (inadeq pharmokinetic data to calculate dose)

Question 17

20. A GP calls you about a 36 week baby that is now 3 days old. The physical exam is normal except for jaundice. The bilirubin on day 3 is 280. The family is of East Asian origin.
    a) What are four questions you would ask him?
    b) What are two pieces of advice you would give him to manage this patient.

Answer 17

A. Questions

1. Baby + mother’s blood types, DAT status, any Ab identified on antenatal investigation
2. Baby’s status: sepsis, temp instability, lethargy, resp distress, asphyxia, acidosis, bruising, cephalohematoma
3. Breastfeeding? Wet diapers? Weight?
4. FHx of G6PD or jaundice in other sibling?

B. Advice

1. Admit baby for intensive phototherapy
2. Investigate: bili (total, conj), baby’s blood type, DAT, CBC, blood smear, G6PD
3. Breastfeeding support

Question 18

21. A newborn baby has a brachial plexus injury after a traumatic birth.
    a) What would you tell his mother about his prognosis?
    b) You see the baby in one month and there is no improvement in his arm movements.
    c) What would you do now?

Answer 18

a) 75% recover in first month, 25% experience permanent impairment or disability
b) If no complete recovery by 3-4wks, unlikely for full recovery
c) Refer to multidisciplinary brachial plexus team (neuro +/ physiatrist, plastics, rehab therapists)

Question 19

22. Infant born at 33 weeks, apneic, HR < 50
    a) What 2 things do you do in your initial management?
    b) CXR shown – name 2 abnormalities (bad x-ray – hazy white-out of all lung-fields c/w RDS):
    c) What is the underlying problem?

Answer 19

a) 1. warm, dry, stimulate, suction mouth + nose
2. If HR<100, irregular resp effort, gasping, then PPV 20-25/5, 40-60bpm, FiO2 21% to start and titrate to age-appropriate sats

b) Ground glass appearance, air bronchograms
c) RDS = surfactant deficiency

Question 20

23. Newborn infant with Apgars of 1 and 6: ** this question remembered wrong- probably getting at HIE
    a) What 5 complications would you anticipate in the next few days
    b) What 2 tests at discharge, if normal, would likely indicate a normal neurological outcome

Answer 20

A) Complications of asphyxia
1. Seizures
2. CHF, cardiogenic shock 
4. Apnea
5. PPHN
6. RDS
7. AKI
8. GI perforation
B.
1. EEG
2. MRI head

Question 21

24. Mom with no prenatal care gives birth to kid with anencephaly. She asks if the kid’s organs (heart, kidneys) could be donated. What answer do you give her (1 point)? Why (1 point)?

Answer 21

The policies of the Canadian Paediatric Society (1990, reaffirmed in 2005) and of the American Academy of Pediatrics (1992) stated that anencephalic infants were not appropriate organ donors, and held firm to the prevailing legal and medical criteria for brain death.[6] The AMA changed course, and its current policy now also affirms the “dead donor rule,” but it does allow mechanical support to keep the organs viable until death is declared

Question 22

25. Neonate is jittery and has cleft palate and heart murmur.
    a) What is the reason for his jitteriness?
    b) What is the underlying condition?

Answer 22

a) Hypocalcemia
b) DiGeorge syndrome

If asked how to manage sz

1. Calcium infusion (PO calcium takes too long to work)
2. Vit D (allows gut to absorb calcium, which is caused by vit D deficiency secondary to PTH)

Question 23

26. Neonate with glucose of 0.9. Not interested in feeding. You decide to treat & give a 2cc/kg bolus of D10W. Write your orders for fluids to run next (be specific.)

Answer 23

D10W at TFI 80mL/kg/hr

Check glucose in 30min

Question 24

27. Neonate has lots of secretions needing suctioning and some respiratory distress. What is the single MOST important investigation to diagnose this disorder.

Answer 24

Insert NG/OG, do CXR to see if it passes through to stomach

R/O esophageal atresia

Question 25

28. Neonate with lung disease on ventilator (ACVG). Settings given, RR 40. Gas given (something like pH 7.2, CO2 58, bicarb I don’t remember) Hct 0.48. a) What vent change would you make? b) Same baby does well for 48hrs then becomes mottled with poor BP and new gas: pH 7.1, CO2 40, base deficit really high, Hct 0.3. What has happened?

Answer 25

a) Increase rate (if not breathing above) or increase VG (ensure 4-6mL/kg) or PIP b) Could be overdistension impeding preload. However etabolic acidosis with significant decrease in hematocrit suggests ICH/IVH.

Question 26

29. Name four contraindications to breastfeeding (not including drugs).

Answer 26

1. HIV positive, in non-developing country 2. HTLV 1 + 2 3. Brucellosis 4. HSV lesions on breast. Can feed EBM. 5. Active untreated TB - delay until 2 weeks of Tx + provide TB ppx for infant. Can feed EBM.

Question 27

30. Three ways that maternal SLE can affect neonate.

Answer 27

1. Congenital heart block 2. Rash 3. Anemia + thrombocytopenia 4. Hepatitis

Question 28

31. Name 4 perinatal risk factors for the development of sensorineural hearing loss.

Answer 28

1. TORCH infection 2. Hyperbilirubinemia (at levels requiring exchange transfusion) 3. Bacterial menignitis 4. Ototoxic medications 5. Genetic

Question 29

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

Answer 29

a) 4-6mg/kg/min b) D10W at TFI 80mL/kg/hr Check BG in 30min Consider D10W with 2mL/kg bolus

Question 30

33. 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. a) What investigation do you do? (1) b) What is your possible diagnosis? (1) c) Baby’s heart rate is now 80 and is more cyanotic. What one investigation do you want to do (1)

Answer 30

Tachypneic, tachycardic, hypotensive, hyperinflated a) transillumination b) Tension pnuemothorax c) ?Needle decompression

Question 31

34. 10 day old baby with failure to thrive, jaundice, hepatomegaly, blood culture positive for E.Coli. a) What underlying disorder may the child have? b) What test can you do to confirm this diagnosis? (1)

Answer 31

a) Galactosemia | b) RBC GALT activity (gold standard for diagnosis)