NICU Topic Reviews

Question 1

What is the most common class of drug inducing a withdrawal state in the newborn?

Answer 1

Opioids

Question 2

Is there duty to report a pending birth for intervention?

Answer 2

Birth alerts have been abolished in most of Canada - no duty to report for a fetus

Question 3

Is OAT (opioid agonist therapy) recommended in pregnancy?

Answer 3

Yes - OAT during pregnancy reduces the risk of overdose and use of unregulated substances overlal, decreases infectious morbidity and improves prenatal care and obsetric/ neonatal outcomes
Buprenorphine preferred over methadone - less NAS

Question 4

Preterm infants at higher or lower risk for NAS

Answer 4

Lower
Although symptoms may not be as apparent in prem infants

Question 5

Signs/symptoms of neonatal abstinence syndrome?

Answer 5

• Wakefulness
• Irritability, tone, Moro reflex increased, inability to console, inability to coordinate oral feeding
• Tremors, temp instability or fever, tachypnea
• Hyperactivity, high pitched or excessive crying, hiccups, hypersensitivty to sounds, hyperreflexia (including yawning)
• Diaphoresis, disorganized suck, diarrhea (explosive), disturbed sleep, disruptive feeding behaviours (including excessive non-nutritive sucking and decreased oral intake)
• Respiratory distress, runny nose, regurgitation, rub marks (excoriation), rejecting feeds
• Apnea, autonomic dysfunction (heart and respiratory rate)
• Weight loss resulting in increased caloric demands
• Alkalosis (respiratory)
• Lethargy and lacrimation (eye-tearing)
• Snuffles, sneezing, seizures

Question 6

Which agent has the most variable onseet to timing of symptoms of NAS?

Answer 6

Benzos - can be hours to weeks
All others 24 hours or 24-72 hours.

Methadone - 24 to 72 hours

Buprenorphine - 24 to 72 hours

Heroin - 24 hours

Fentanyl - 24 hours

Benzodiazepines - Hours to weeks depending on agent

Question 7

When to check NAS score?

Answer 7

Within first 1-2 hours post-delivery, then every 3-4 hours thereafter (coordinate with sleep/wake cycles)

Question 8

Evidence based alternative to Finnegan scoring?

Answer 8

Eat, Sleep, Console

ESC has been shown to decrease hospital length of stay (from 15 to 8 days) and need for pharmacological treatment, without increasing adverse events or readmissions significantly

Question 9

Minimum duration that NAS scores should be conducted?

Answer 9

72 hours

Continue up to 120 hours with exposure to longer acting opioid

Continue throughout the initiation, duration, and discontinuation of pharmacological treatment, if prescribed

Question 10

Examples of non-pharamacological interventions to implement at delivery for babies with risk for NAS:

Answer 10

Examples include skin-to-skin care, newborn-led care, safe swaddling, gentle waking, quiet environment, minimal stimulation, lower lighting, and developmental positioning

Question 11

What intervention can delay the onset and decrease the severity of withdrawal symptoms and reduce the need for pharmacological treatment in NAS?

Answer 11

Human milk feeding (breastfeeding or expressed milk)

Question 12

Which medication class has been associated with reduced treatment failure in NAS?

Answer 12

A 2021 Cochrane review - use of an opioid was associated with reduced treatment failure compared with phenobarbital, diazepam, or chlorpromazine

Question 13

Name two acceptable / common first line medication options that are similarly safe and effective in NAS?

Answer 13

Morphine
Methadone

A few studies have reported shorter hospital length of stay with methadone compared to morphine

Question 14

Name two commonly prescribed adjunct agents to opioids with NAS symptoms are not adequately controlled using a single agent?

Answer 14

Phenobarbital
Clonidine

Not enough evidence to guide which is preferable

Question 15

Preferred adjunctive agent for NAS from polysubstance exposure including sedatives and hyponotics (benzos)?

Answer 15

Phenobarbital

Question 16

Where opioid exposure has occurred prenatally or at time of delivery, or for the treatment of NAS, should naloxone be administered to a newborn?

Answer 16

No
- Naloxone can exacerbate underlying withdrawal syndrome including development of seizures

Question 17

Dose of morphine in NAS?

Answer 17

0.03 to 0.05 mg/kg/dose every 3 to 4 h, orally

Increase by 0.03 to 0.05 mg/kg/dose as needed [58]

Weans are variable and patient-specific: Decrease by 10% to 20% every 24 to 48 h as tolerated

Question 18

When is a newborn with NAS eligible for discharge?

Answer 18

When pharmacotherapy is not required within 72 hours for short- to 120 hours for long-acting opioids

However some practitioners opt to discharge newborns receiving pharmacological treatment to the community to continue to wean
- shown to be associated with fewer return visits to hospital to manage NAS
- saves $$$
- without increased adverse events or readmissions

Question 19

Which infants are at the highest risk for repeated pain and related distress associated with physiological instability?

Answer 19

Very preterm infants

Question 20

List at least 5 adverse outcomes of repeated exposure to pain in infancy:

Answer 20

• altered pain processing, cognition, and behaviour including executive function and visual abilities
• altered hypothalamic-pituitary-adrenal axis development and cortisol dysregulation
• reduced brain growth and structure
• altered thalamic development
• decreased frontal and parietal brain width
• altered diffusion measures and functional connectivity in the temporal lobes
• abnormalities in motor behaviour
• reduced cerebellar size

Question 21

Which pain scoring tools have been most used in clinical trials in infants?

Answer 21

Premature Infant Pain Profile (PIPP / PIPP-R)
Neonatal Infant Pain Scale (NIPS)

Question 22

Which non-pharmacological intervention is likely the most effective in reducing or preventing pain in neonates?

Answer 22

Direct breastfeeding before a procedure

• More effective in preventing pain than placebo or no treatment, swaddling, maternal holding, or skin-to-skin contact, topical anaesthetics, cooling spray, non-nutritive sucking, heel warming, music therapy, and sucrose

Question 23

Name 4 non-pharmacological interventions to reduce pain in infants other than breastfeeding:

Answer 23

Skin to skin care
Non-nutritive sucking
Facilitated “tucking” or “containment” - better when combined with other interventions
Sucrose - small volumes repeatedly likely more benefit than a larger volume

Question 24

Benefit to applying topical local anesthetic to skin before a heel lance or frenotomy?

Answer 24

No benefit seen in 8 RCTs

Some benefit before an LP but should be used with caution due to potential for systemic absorption especially in prem infants

Question 25

Pain management strategies specifically for circumcision?

Answer 25

Topical anesthetics alone are insufficient Must be combined with other interventions such as a regional nerve block

Question 26

Evidence for opioids or NSAIDS in reducing pain compared to non-pharmacological interventions or other analgesics in infants?

Answer 26

Very uncertain evidence for both opioids or NSAIDS May not be that helpful Also have side effects - eg opioids may cause apnea

Question 27

When should opioids be considered for pain management in infants?

Answer 27

After a major invasive procedure (eg Chest Tube insertion) Post-operatively use regular schedule Tylenol as an adjunct

Question 28

How long should skin to skin care be continued after birth?

Answer 28

SSC should begin immediately after birth regardless of method of delivery, and continue for least an hour post-birth

Question 29

What is the minimum amount of skin to skin time that HCPs should aim for (including in prem infants)?

Answer 29

8 hours minimum Up to 24 hours per day

Question 30

Benefits of skin to skin care for infants?

Answer 30

- improved rates of exclusive breastfeeding - lower mortality - lower rates of hypothermia and sepsis - better cardiopulmonary stability - infection prevention (modifies gut microbiota) - improves pain management - stress regulation - promotes better infant mental health - neurodevelopmental benefits - improves parental mental health

Question 31

Reasons to interrupt skin to skin care between parent and infant?

Answer 31

Infant or mother becomes unstable Infant or parent is too fatigued to maintain safe positioning Parental drowsiness or lack of safety due to using medications or substance use

Question 32

In which infant population should skin to skin care be potentially avoided for 72 hours?

Answer 32

In extremely preterm infants, delaying SSC may be warranted due to concerns regarding handling and neuroprotection However some research suggesting no increase in IVH Individualized interprofessional team approach

Question 33

Relative contraindications to skin to skin care in infants?

Answer 33

- Presence of abdominal wall or neural tube defect - Post-op instability - Significant instability associated with clinical handling or prolonged recovery However in almost all medically complex situations, the benefits of skin to skin care outweighs the risks

Question 34

Risk factors for vertical transmission of COVID-19?

Answer 34

- severe maternal COVID-19 infection - maternal death from COVID-19 - maternal admission to ICU

Question 35

Which procedures related to NRP represent higher risk for SARS-CoV-2 transmission?

Answer 35

AGMPs - PPV - CPAP - intubation

Question 36

Cord clamping in an infant whose mother has SARS-CoV-2?

Answer 36

No changes to cord management plan Unlikely that COVID infection will be transmitted during delayed cord clamping

Question 37

Likelihood that COVID-19 is cause of respiratory distress in newborns?

Answer 37

Very unlikely

Question 38

Guidelines for infant admitted to NICU for unrelated condition such as hyperbilirubinemia or hypoglycemia, whose mothers are positive for COVID-19?

Answer 38

Test these infants for SARS-CoV-2 Consult IPAC for recommendations around precautions

Question 39

If mother has COVID, does infant need to be transported in isolette?

Answer 39

Ok to transfer infant in open bassinet if newborn is asymptomatic

Question 40

Guidelines for transport to hospital of outborn infants to hospital if mother has COVID-19 infection?

Answer 40

Newborns of mothers testing positive for SARS-CoV-2 should be transported as suspected COVID cases, even if the likelihood of their being infected appears low

Question 41

Breastfeeding and COVID-19 infection - recommendations?

Answer 41

Mothers should still practice skin to skin care and breastfeed Should practice good hand hygeine and wear a mask within 2 metres of their infant Clean hands before skin to skin, breastfeeding and other routine infant care No cases of COVID-19 have been attributed to breast milk transmission Maternal antibodies to SARS-CoV-2 are believed to pass to the baby in the breastmilk

Question 42

How long should correction for gestational age be used in extremely preterm infants?

Answer 42

Up to 36 months of age (3 years)

Question 43

For infants born < 29 weeks, what is the likelihood of significant neurodevelopmental impairment at 21 months corrected age?

Answer 43

about 16-17%

Question 44

For infants born <29 weeks, what is the likelihood of mild-moderate neurodevelopmental impairment at 21 months corrected GA?

Answer 44

about 28-29%

Question 45

Which infants should be followed in neonatal follow up clinics (inter-professional teams who follow infants for several years)?

Answer 45

Infants born < 29 weeks GA

Question 46

How often should growth, feed intake, and quality of feeding be assessed after discharge of extremely preterm infants?

Answer 46

Every 2-4 weeks after discharge until a trend is established

Question 47

Which growth chart should be used in the early post-discharge setting for extremely preterm infants?

Answer 47

Fenton

Question 48

How much iron should predominantly breastfed premature infants receive?

Answer 48

2 mg/kg/day to 3 mg/kg/day elemental iron for the first year

Question 49

How much iron does formula provide?

Answer 49

Formula provides 2 mg/kg/day to 3 mg/kg/day of elemental iron (typical formulas designated for preterm infants contain 10 mg/L to 14 mg/L of iron)

Question 50

Which infants should receive 800IU of vitamin D?

Answer 50

Higher risk for metabolic bone disease Darker skin pigmentation Live in northern communities

Question 51

Early signs of cerebral palsy?

Answer 51

Early hand preference (eg 9 months) Stiffness or tightness in the legs Inability to sit by 9 months Persistent fisting of the hands beyond 4 months Delayed or asymmetrical movement

Question 52

Rates of postnatal depression among parents of extremely preterm infants?

Answer 52

30-60% Screening parents' mental health should be considered when they have a child in the NICU

Question 53

When should extremely preterm infants receive immunizations?

Answer 53

Immunizations should be based on chronological age

Question 55

ASD evaluation in extremely preterm infants?

Answer 55

Extremely challenging as often EP infants do have behavioural challenges - Infants born EP should receive an early focused evaluation including specialist evaluation for autism spectrum disorder to determine need for further assessment, detect common co-morbid conditions, and plan treatment

Question 56

What is the cord management plan for < 37 weeks and < 28 weeks?

Answer 56

DCC 60-120s (minimum 30s if possible)

Question 57

Positioning of baby prior to clamping umbilical cord?

Answer 57

Babies should be at or below the level of the introitus (at or below C-section incision) prior to clamping

Question 58

Cord management plan for babies 37+ weeks GA?

Answer 58

DCC 60 seconds DCC > 60s increases risk for hyperbili requiring photo

Question 59

Position on umbilical cord milking?

Answer 59

Increases IVH risk in very preterm infants NOT recommended for any age group

Question 60

When to give uterotonic medications in relation to cord clamping?

Answer 60

Preterm infants --> give medication AFTER cord clamped, concern for potential bolus of blood to infants Term infants --> give uterotonic medication (eg Oxytocin IM) with delivery of the anterior shoulder

Question 61

What are 5 absolute contraindications to delayed cord clamping?

Answer 61

- fetal hydrops - fetal anomalies (eg CDH) - need for immediate resuscitation (mom or baby) - disrupted utero-placental circulation (ie bleeding, vasa previa, abruption) - known TTTS or twin anemia polycythemia sequence

Question 62

What are 3 relative contraindications to delayed cord clamping?

Answer 62

- Risk for significant hyperbilirubinemia (significant polycythemia, severe IUGR, pregestational DM) - Maternal antibody titers are high - first infant in a pair of monochorionic twins

Question 63

Benefits vs relative contraindications of delayed cord clamping in preterm infants --> how to balance?

Answer 63

In preterm infants, there may be more benefit for reduction in morbidity and mortality to delayed cord clamping - improves hematologic parameters - the same relative contraindications apply but may warrant more discussion with the newborn's care providers and consider DCC of 30 seconds in these infants to get some of the benefit despite some risk - consider especially prior to transfer to tertiary care center

Question 64

At what minimum weight can infants be transferred to an open cot (if showing thermostability and otherwise ready)?

Answer 64

1700 grams Any earlier does not lead to earlier discharge

Question 65

What are the age cut-offs for mod-late preterm, very preterm, and extremely preterm?

Answer 65

Extremely preterm = < 28 weeks GA Very preterm = 28-32+6 weeks GA Mod-late preterm = 33-36+6 weeks GA

Question 66

What is the mean half-life of caffeine?

Answer 66

100 hours

Question 67

What is the minimum length of time to monitor a baby in the NICU after caffeine discontinuation?

Answer 67

5-7 days

Question 68

Which infants may need a longer period of monitoring (longer than 5-7 days) in the NICU after caffeine discontinuation?

Answer 68

Infants born < 29 weeks GA

Question 69

What is the minimum length of time a baby with apnea of prematurity who has NOT been treated with caffeine should be monitored in the NICU for apnea-free period prior to discharge?

Answer 69

3 days

Question 70

Relationship between apnea of prematurity and SIDS?

Answer 70

AOP is NOT an identified risk factor for SIDS

Question 71

Clinical diagnosis of BPD can be made when?

Answer 71

When supplemental oxygen or mechanical ventilation is provided beyond 36 weeks GA

Question 72

At what gestational age do infants typically start showing signs of organized non-nutritive sucking?

Answer 72

28-29 weeks

Question 73

At what gestational age do infants typically manage to attain exclusive breastfeeding?

Answer 73

32-38 weeks Median is 37.1 weeks and 34.7 weeks for extremely preterm and very preterm infants, respectively

Question 74

When should promotion of breastfeeding begin?

Answer 74

Immediately after birth, regardless of gestational age or sickness in the baby --> moms should be supported to pump, do skin to skin care as early as possible, etc

Question 75

What are two medication options to increase breast milk supply in mom?

Answer 75

Metoclopramide Domperidone

Question 76

At what age babies have solid foods introduced?

Answer 76

4-6 months

Question 77

What weight criteria should be met before an infant can be discharged from NICU?

Answer 77

There is no standard minimum weight at which an infant can be discharged, but timing is guided by weight criteria for infant car seats. Families who anticipate going home before their infant weighs 2.2 kg (5 lbs) must make sure they have a car seat with a ~1.8 kg (4 lb) minimum weight.

Question 78

What specific measures of physiologic maturity should a late-preterm infant demonstrate prior to discharge?

Answer 78

Respiratory stability Temp stability Adequate feeding skills Euglycemia Stable bilirubin levels

Question 79

What is the ideal temperature range an infant in NICU should maintain body temp at?

Answer 79

36.5-37.5 degrees C

Question 80

Infants with BPD need to be evaluated for what?

Answer 80

BPD-associated hypertension

Question 81

Name at least 3 associated adverse outcomes of having a PDA

Answer 81

- prolongation of assisted ventilation - pulmonary hemorrhage - chronic lung disease - NEC - IVH - death

Question 82

In which population can prophylactic use of indomethacin be considered (PDA prophylaxis)?

Answer 82

Extremely low birth weight infants with risk factors for severe IVH - extremely low GA - lack of antenatal corticosteroids - being born outside a tertiary care centre

Question 83

Role of ibuprofen and/or acetaminophen prophylaxis in preterm infants?

Answer 83

Ibuprofen --> not recommended due to minimal benefits (may marginally reduce severe IVH and PDA ligation but not substantial), and risk of possible harm related to GI hemorrhage, acute severe pulmonary HTN Acetaminophen --> not shown to be beneficial

Question 85

Name two echocardiographic measures most commonly used to define hemodynamic significance of a PDA

Answer 85

On echo: - PDA size > 1.5 mm (a PDA less than 1.5mm is unlikely to be hemodynamically significant and may not need treatment) - aortic root ratio > 1.4

Question 86

What test should be completed prior to treating a PDA?

Answer 86

All PDAs should be confirmed with echo prior to considering treatment (even if very clinically apparent)

Question 87

Should all symptomatic PDAs be treated?

Answer 87

No - some evidence that conservative management of PDA may be beneficial. Exercise caution with conservative management in clinically unstable extremely preterm infants <26 weeks GA for whom earlier pharmacotherapy may be advised

Question 88

Options for conservative PDA management?

Answer 88

Consider use of diuretics to reduce pulmonary edema and improve lung function Can increase PEEP to reduce L > R shunting

Question 89

Role of restricting fluids in conservative management of PDA?

Answer 89

NO evidence to support fluid restriction and potential harms associated - do not use this as a strategy for symptomatic PDA

Question 90

Which COX-1 drug should be the pharmacotherapy of choice to treat a symptomatic PDA?

Answer 90

Ibuprofen (superior to acetaminophen or indomethacin) High-dose may be the preferred dosage, especially for preterm infants beyond the first 3-5 days of life

Question 91

Should invasive management (surgical or percutaneous catheter closure) or repeat pharmacotherapy be used for a persistent, symptomatic PDA?

Answer 91

A second course of COX-1 therapy (eg repeat course ibuprofen) should be considered over invasive management A third course of pharmacotherapy with acetaminophen could be considered while awaiting invasive PDA closure (if did not close after two courses)

Question 92

When to consider procedural closure of a PDA?

Answer 92

PDA is - persistent after 2 courses of pharmacotherapy - OR contraindications to pharmacotherapy - clinically significant - echo shows signs of a large shunt > 1.5mm and pulmonary overcirculation

Question 93

What is the intervention of choice for invasive management of a persistently symptomatic PDA?

Answer 93

Percutaneous transcatheter PDA closure may be considered as an alternative to surgical PDA ligation IF institutional expertise is available and patient characteristics are suitable

Question 94

When should referral to a tertiary care centre be considered for a preterm infant with persistent PDA?

Answer 94

Routine referral to a tertiary care centre for echocardiographic evaluation of a persistent PDA in an otherwise clinically stable, growing, preterm infant before term-corrected GA is not recommended Paediatric cardiology referral should be sought for ongoing evaluation and follow-up when the PDA is deemed to be present at discharge

Question 95

Injury to which nerve roots can cause newborn brachial plexus palsy?

Answer 95

C5-T1

Question 96

What is the strongest modifiable risk factor for newborn brachial plexus injury?

Answer 96

Shoulder dystocia (although increasingly recognized that brachial plexus injury can occur in the absence of shoulder dystocia)

Question 97

What are two postulated mechanisms of injury of newborn brachial plexus injury (apart from shoulder dystocia)?

Answer 97

1) Injury sustained in utero and during descent (especially with uterine anomalies such as bicornuate uterus) 2) Injury sustained at the time of expulsion

Question 98

What are some risk factors for brachial plexus injury?

Answer 98

pre-existing maternal diabetes forceps or vacuum assisted delivery episiotomy fetal or birth asphyxia macrosomia > 4.5kg LGA infants

Question 99

Which Narakas classification groups are associated with higher rates of spontaneous recovery of brachial plexus injury?

Answer 99

Groups I and II

Question 100

Which nerve roots are injured in Narakas group 1 injury (Classic Erb's Palsy) and how does it present?

Answer 100

C5 or C6 Absent shoulder abduction, external rotation, elbow flexion, and forearm supination

Question 101

Which nerve roots are injured in Narakas group 2 injury (Extended Erb's Palsy) and how does it present?

Answer 101

C5 to C7 (wrist held in flexion) The same as group 1, with absence of wrist and digital extension

Question 102

Which nerve roots are injuryed in Narakas group 3 injury (total palsy without Horner's syndrome) and how does it present?

Answer 102

C5–T1 Complete flaccid paralysis (flail extremity) involving all plexus roots

Question 103

Which nerve roots are injured in Narakas group 4 injury and how does it present?

Answer 103

C5–T1 and sympathetic chain involvement Complete flaccid paralysis (flail extremity) with Horner’s syndrome indicating sympathetic chain involvement and avulsion injury Sometimes, phrenic nerve palsy and an elevated ipsilateral hemi-diaphragm

Question 104

Which Narakas groups (in brachial plexus injury) will need reconstructive microsurgery?

Answer 104

Groups III and IV

Question 105

Which infants with brachial plexus injury are managed conservatively?

Answer 105

Infants with a neuropraxic injury who recover by 1 month of age

Question 106

The evidence supports nerve repair for infants with deficits from brachial plexus injury as early as what age?

Answer 106

3 months of age

Question 107

What is the next best step when there is concern for bony injury in a newborn?

Answer 107

1) Chest and humeral x-ray 2) Assess respiratory status and symmetry of the chest movements to assess for phrenic nerve injury 3) Assess for brachial plexus injury

Question 108

When should an infant be referred to a brachial plexus multidisciplinary health care team?

Answer 108

Incomplete recovery of any upper extremity movement by 1 month of age - suggests nerve injury beyond neuropraxia - suggests more severe NBPP

Question 109

What are some adverse outcomes of untreated maternal depression and anxiety in pregnancy?

Answer 109

Poor nutrition Lack of medical care Increased smoking Increased substance use SGA newborn Preterm infant Lower rates of breastfeeding Poor mother-infant interactions / bonding

Question 110

Which SSRIs are considered the least safe in pregnancy - have been associated with anencephaly, ASD, RVOTO, gastroschisis, omphalocele, craniosynostosis when taken in pregnancy?

Answer 110

Paroxetine Fluoxetine Although overall absolute risk is still considered to be LOW

Question 111

SSRIs taken in which trimester of pregnancy are associated with higher risk for CHD?

Answer 111

1st trimester Although overall absolute risk for CHD with exposure to SSRI use is considered to be LOW

Question 112

Summary of research on teratogenic effects and pregnancy outcomes with antenatal SSRI use?

Answer 112

In summary, it remains difficult to determine whether SSRIs or SNRIs are associated with increased risk for teratogenic effects, because some studies appear to demonstrate an association, whereas others do not. When an association has been found, the absolute risk was still low and the number needed to harm was high.

Question 113

What is the % of newborns exposed to maternal SSRI or SNRI use in utero who experience poor neonatal adaptation syndrome (PNAS)?

Answer 113

30%

Question 114

Symptoms of poor neonatal adaptation syndrome?

Answer 114

Poor muscle tone Tremors Jitteriness Irritability Seizures Feeding difficulties Sleep disturbances Hypoglycemia Respiratory distress Usually presents within hours of delivery, resolves within days to 2 weeks post birth

Question 115

Which SSRIs are considered safest in pregnancy specifically regarding least risk for major malformations and CV malformations?

Answer 115

Sertraline Citalopram

Question 116

SSRIs taken in which trimester of pregnancy are associated with higher risk for PPHN?

Answer 116

Late in pregnancy / 3rd trimester However overall risk of PPHN is still LOW

Question 117

Association of prenatal exposure to SSRIs / SNRIs and neurodevelopmental outcomes?

Answer 117

Inconsistent evidence of any increased risk for adverse neurodevelopmental outcomes with SSRI/SNRI exposure - confounded by genetic factors, familial environment, maternal mental illness history Not convincingly associated

Question 118

Management of PNAS (poor neonatal adaptation syndrome)?

Answer 118

Quiet environment Swaddling Skin to skin care Frequent small feeds Breastfeeding Other supportive newborn care

Question 119

What monitoring is required in the neonatal period for infants exposed to an SSRI or SNRI in utero?

Answer 119

No need for fetal echocardiogram during pregnancy No need for routine echocardiogram of newborns exposed to SSRIs during first trimester of pregnancy All newborns should receive routine pulse oximetry to detect CCHD Observe infants for 24-48 hours

Question 120

Should mothers discontinue or taper SSRI/SNRI in pregnancy towards the end of pregnancy prior to delivery in order to prevent PNAS?

Answer 120

Not currently recommended

Question 121

SSRI/SNRIs and breastfeeding

Answer 121

Data is lacking but the transfer of medications into breastmilk is known to be low, and uptake by the infant even lower BFing recommended Sertraline --> considered safest Fluoxetine --> considered least preferred

Question 122

Surfactant has been shown in decades of clinical trials to decrease which 4 outcomes in neonates with RDS?

Answer 122

Ventilation support, risk of pulmonary air leak, mortality, and the combined outcome of death or bronchopulmonary dysplasia (BPD) at 28 days

Question 123

Role of prophylactic surfactant in preventing RDS in preterm neonates?

Answer 123

NOT recommended Shown to have trend towards increasing mortality and BPD

Question 124

Should all preterm / very preterm infants be intubated or not?

Answer 124

Using CPAP alone as the primary mode of respiratory support is an acceptable alternative to elective intubation

Question 125

Early vs late surfactant administration (early = within 2 hours of birth, late = RDS is established, usually > 2 hours) ?

Answer 125

EARLY surfactant administration shown to be more beneficial

Question 126

Infants with RDS whose oxygen requirements exceed what FiO2 should receive surfactant?

Answer 126

0.50 Although the CPS statement also talks about evidence that providing surfactant with FiO2 between 0.30 - 0.50 is beneficial, but it isn't included in their formal recommendation

Question 127

What type of surfactant is preferable – Natural or synthetic?

Answer 127

Synthetic surfactant is inferior to animal - derived surfactants

Question 128

Bovine vs porcine surfactant - which one is preferable?

Answer 128

Evidence shows porcine may be superior to bovine surfactant for improving acute respiratory status and reducing mortality or BPD

Question 129

When should doses of surfactant be repeated?

Answer 129

Evidence of ongoing RDS based on ventilation and oxygen requirements

Question 130

Name two instances when it would not be acceptable to wait to re-dose surfactant in an infant with RDS that continues to have elevated FiO2 requirements?

Answer 130

In the case of sepsis or hypoxic-ischemic injury

Question 131

What are two options for less-invasive delivery of surfactant?

Answer 131

LISA MIST Also, LMA is an option to guide the catheter for LISA or MIST rather than direct laryngoscopy

Question 132

What is the only true non-invasive method of surfactant delivery?

Answer 132

Nebulization Newer neb device is showing good results / quite effective

Question 133

Name two reasons to consider giving surfactant OTHER than RDS:

Answer 133

Meconium aspiration syndrome Pulmonary hemorrhage Meconium Aspiration Syndrome: Natural surfactants are rendered inactive by mec and plasma protein, some evidence that surfactant decreased ECMO need. Can also use surfactant lavage to remove mec particles from airways. (Some people use same principles in neonatal pneumonia, but no evidence) Pulmonary hemorrhages: observational studies, may improve OI (but pulm hemorrhage can also be a complication of surfactant therapy

Question 134

What factor makes administering prophylactic surfactant more risky / more likely to increase mortality?

Answer 134

High rates of antenatal corticosteroid administration

Question 135

Is either dexamethasone in the first 7 days post birth OR inhaled corticosteroids indicated to prevent BPD?

Answer 135

NEITHER Both shown to have evidence of harm

Question 136

What medication can be considered as an option for BPD prophylaxis for infants < 28 weeks GA at the highest risk of BPD?

Answer 136

Hydrocortisone x 10 days if initiated in the first 48h post-birth Particularly helpful if infant exposed to chorioamnionitis Do NOT combine with prophylactic indomethacin

Question 137

What medication could be considered AFTER 7 days of life for infants at high risk for BPD (e.g., who remain ventilated beyond the first week post-birth with increasing oxygen requirements and worsening lung disease)?

Answer 137

Short course of low dose dexamethasone 0.15-0.2mg/kg/day Only give when the risk for BPD is >60% Treat before 21 days of life

Question 138

What potential complication is associated with hydrocortisone to prevent BPD in infants at the highest risk for BPD (eg < 28 weeks GA or exposed to chorioamnionitis)?

Answer 138

Potential increased risk of late-onset sepsis

Question 139

Name at least 4 risk factors for fluctuations in cerebral blood flow that increase risk for IVH:

Answer 139

Variation in systemic BP Anemia Hyper or hypocarbia Acidosis PDA Severe RDS Pneumothorax

Question 140

What is the area that is the primary source of bleeding causing IVH in premature infants?

Answer 140

Subependymal GM GM involutes with time, almost gone by 34-36wks PMA, so IVH rare past this age

Question 141

What is the name of a parenchymal lesion associated with severe IVH that usually leads to cystic changes?

Answer 141

Periventricular hemorrhagic infarction

Question 142

Routine head ultrasound examination is recommended for all infants born at what GA?

Answer 142

< 32+0 (At or before 31+6)

Question 143

When is head US screening recommended for infants between 32+0 and 36+6 weeks GA?

Answer 143

Only in the presence of risk factors for ICH or ischemia

Question 144

When is the best time period for initial HUS screen?

Answer 144

First 4-7 days post-birth

Question 145

What are the two most significant brain injuries that can affect the preterm brain?

Answer 145

Intracranial hemorrhage White matter insult

Question 146

MRI has been shown to be superior to HUS in detecting which lesions in the preterm brain?

Answer 146

Non-cystic white matter lesions HUS reliably detects IVH and cystic periventricular leukomalacia (PVL)

Question 147

30-50% of infants with severe IVH develop which complication?

Answer 147

Post hemorrhagic ventricular dilation - may stop spontaneously (non-progressive) or continue (requires intervention) Typically seen 7-14 days after a severe IVH has occurred

Question 148

What type of injury has been increasingly recognized as a relatively frequent form of brain injury in the preterm infant (not previously talked about as much)?

Answer 148

Cerebellar injury

Question 149

Papile's grading system for IVH - grade 1?

Answer 149

IVH limited to GM

Question 150

Papile's grading system for IVH - grade 2?

Answer 150

IVH with blood in the ventricles

Question 151

Papile's grading system for IVH - grade 3?

Answer 151

Blood filling and distending the ventricular system

Question 152

Papile's grading system for IVH - grade 4?

Answer 152

Parenchymal involvement

Question 153

Which grades of IVH are considered mild vs severe?

Answer 153

Grade 1-2 = mild Grade 3-4 = severe

Question 154

Additional risk factors for IVH other than prematurity?

Answer 154

Low birth weight < 1000g Lack of maternal prenatal corticosteroid use Birth outside a tertiary care centre Histological chorioamnionitis

Question 155

List 5 risk factors for abnormal brain imaging in mod-late preterm infants who don't have the same prematurity risk factor as early prems:

Answer 155

- Head circumference < 3 %ile - Need for resuscitation at birth - Critical care out of keeping with the usual neonatal course (eg mechanical ventilation, inotropes) - Complicated monochorionic twin pregnancy (eg IUGR, fetal demise) - Postnatal complications (sepsis, NEC, major surgery, etc)

Question 156

Which imaging modality is best for detecting GMH-IVH, large cerebellar bleeds, large cysts and echogenic areas in white matter?

Answer 156

US

Question 157

When is a CT scan used in newborn brain imaging?

Answer 157

Emergencies only - typically not preferred compared to US / MRI

Question 158

Which imaging modality is best for detecting white matter injury, low grade IVH, cerebral malformations, and posterior fossa abnormalities in the neonatal brain?

Answer 158

MRI

Question 159

What are findings on US that are the strongest predictors of abnormal neuromotor function?

Answer 159

Severe IVH grade 3-4 Cystic PVL PHVD

Question 160

What findings on MRI at term-equivalent age predict abnormal neuromotor function?

Answer 160

Moderate-severe white matter injury Cerebellar injury Abnormal myelination in the posterior limb of the internal capsule

Question 161

Difference between HUS and MRI imaging of neonatal brain in predicting neurodevelopmental impairment?

Answer 161

Benefit of MRI only marginal but significantly more difficult to access / more expensive etc

Question 162

When should the first HUS imaging be done for infants 31+6 weeks or less?

Answer 162

4-7 days post birth

Question 163

When should the first head im

Answer 163

4-7 days post birth

Question 164

Who should receive repeat HUS imaging 4-6 weeks post-birth?

Answer 164

All infants 31+6 weeks GA or less Infants 32+0 to 36+6 weeks should only have US repeated at 4-6 weeks post birth if first image is abnormal

Question 165

Which infants should have a term corrected HUS?

Answer 165

All infants born < 26 weeks OR infants with mod-severe anomalies on HUS (grade 3 or higher IVH, PHVD, grade 3-4 PVL, or additional risk factors like mechanical ventilation, vasopressors, NEC, major surgery)

Question 166

If an abnormality (grade 2 or higher IVH or WMI) is detected on first head imaging, when should a repeat HUS be done?

Answer 166

7-10 days later

Question 167

When should repeat HUS be done outside of the typical schedule?

Answer 167

If ventricular dilation or worsening IVH/WMI is detected --> increase frequency to at least weekly and as clinically indicated thereafter If grade 2 or higher IVH --> repeat in 7-10 days If an acute illness (eg NEC or sepsis) --> should have repeat HUS in weeks following

Question 168

List at least 5 risk factors for hypoglycemia in newborns:

Answer 168

Weight <10th percentile (SGA) Intrauterine growth restriction (IUGR) Weight >90th percentile (LGA) Infants of diabetic mothers (IDMs) Preterm infants <37 weeks GA Maternal labetalol use Late preterm exposure to antenatal steroids Perinatal asphyxia Metabolic conditions (e.g., CPT-1 deficiency, particularly in Inuit infants) Syndromes associated with hypoglycemia (e.g., Beckwith-Wiedemann)

Question 169

What is the most common cause (pathophysiology) of hypoglycemia in infants?

Answer 169

Impairment of gluconeogenesis

Question 170

What blood glucose target may infants with documented hyperinsulinsm require (within the first 72 hours of life)?

Answer 170

3.3 or greater

Question 171

Why is it safe to take a more conservative approach to treating blood glucose between 1.8 to 2.5 mmol/L in neonates?

Answer 171

No evidence showing adverse effects of glucose levels between 1.8-2.5 in ASYMPTOMATIC infants

Question 172

In which population is screening for hypoglycemia no longer required after 12 hours of age if blood glucose has remained stable?

Answer 172

IDM --> most likely to develop hypoglycemia in the first few hours, so if stable at 12 hours can stop checking By inference, this also includes LGA infants

Question 173

In which populations is screening for hypoglycemia still required until 24 hours of age even with stable sugars?

Answer 173

SGA infants Preterm infants

Question 174

Is it unusual for a healthy newborn to have blood glucose levels as low as 1.8-2.0

Answer 174

No, actually quite common Which is why we don't test healthy newborns - if feeding well, asymptomatic, and not at risk, no need to check sugar

Question 175

What neurodevelopmental outcomes can be associated with repeated episodes of hypoglycemia?

Answer 175

Lower head circumference at 12 and 18 months as well as at 5 years of age Lower executive functioning and visual motor function Lower psychometric scoring on the McCarthy's test at 3.5 years of age

Question 176

What is the blood sugar level which needs treatment in neonates within the first 72 hours?

Answer 176

< 2.6

Question 177

Infants requiring ongoing treatment for persistent hypoglycemia should have therapeutic blood glucose targets of what?

Answer 177

3.3 and above

Question 178

When should a critical sample be collected to aid diagnosis for persistent hypoglycemia at ≥72 hours?

Answer 178

When BG is < 2.8

Question 179

At glucose levels < 2.8, what would the following hormone levels be: Insulin Ketones Growth hormone Cortisol

Answer 179

Low insulin High ketones High GH High Cortisol

Question 180

How to decide if a neonate being monitored for persistent hypoglycemia is safe for discharge?

Answer 180

Need a 5-6 hour fast before being discharged from hospital Maintenance of glucose levels ≥3.3 mmol/L at 4 and 5 hours postfeed should be documented before discharge is considered

Question 181

Hypoglycemia in the first 72 hours vs > 72 hours after birth - what is the BG investigation threshold for each time period?

Answer 181

< 72 hours = < 2.6 72+ hours = < 2.8

Question 182

Benefit to delaying the first bath?

Answer 182

Less risk for hypoglycemia

Question 183

When the IV route is chosen to respond to low blood glucose, what should the initial rate be?

Answer 183

80 ml/kg/day D10

Question 184

How to calculate GIR?

Answer 184

(Dextrose concentration, g/dL) x (Infusion rate, mL/hr) x (1000) / (Weight, kg) x (60 min/hr) x (100 mL/hr)

Question 185

Normal GIR in infants?

Answer 185

4-8 mg/kg/min

Question 186

If wanting to raise blood glucose levels rapidly in a newborn, what is the bolus that can be given?

Answer 186

2ml/kg D10

Question 187

After an intervention for blood glucose, when should BG be re-checked?

Answer 187

after 30 minutes

Question 188

At what GIR (to maintain BG) should specialist referral be considered?

Answer 188

Above 8-10 mg/kg/min - If GIR > 8 to 10 mg/kg/min, central access and level 3 care - If GIR > 10 to 12 mg/kg/min, consider medication - If GIR > 10 to 12 mg/kg/min and infant is > 72 h old, further investigation is required

Question 189

What medication can raise blood glucose and prevent recurrent hypoglycemia?

Answer 189

IV glucagon by bolus (0.1-0.3mg/kg) or by infusion (10-30 mcg/kg/hour)

Question 190

Peripheral veins can support dextrose concentrations as high as ____

Answer 190

20% (recent evidence)

Question 191

To avoid hyponatremia in supplemented newborn infants, oral + IV intake should not exceed what TFI

Answer 191

100ml/kg/day The statement doesn't say until how many hours of age this is the maximum

Question 192

How much glucose does 0.5ml/kg of 40% dextrose gel provide

Answer 192

200 mg/kg glucose Equivalent to an IV bolus of 2ml/kg D10W

Question 193

Which infants should be screened for hypoglycemia?

Answer 193

IDM (gestational, type 1, type 2) Asphyxiated infants Preterm <37 weeks GA SGA infants LGA (although in future this recommendation might change)

Question 194

If baby meets criteria for screening for hypoglycemia, how often should BG be checked

Answer 194

At 2 hours of age and every 3 to 6 hours after that, in conjunction with breastfeeding.

Question 195

Name two options for treating fist episode hypoglycemia in the neonate if BG is between 1.8 - 2.5?

Answer 195

- 40% dextrose gel 0.5ml/kg and breastfeed - 5ml/kg formula or EBM and breastfeed

Question 196

Name two options for treating a second episode of hypoglycemia between 1.8 - 2.5 in a neonate?

Answer 196

- 40% dextrose gel 0.5ml/kg and breastfeed - 8ml/kg formula or EBM and breastfeed

Question 197

Which form of brain injury is being recognized more often in preterm infants (replacing previous brain injury which used to be noted more)?

Answer 197

Cystic periventricular leukomalacia (cPVL), is in decline, whereas the noncystic form of PVL is becoming increasingly recognized

Question 198

What is the highest risk time period for acute preterm brain injury?

Answer 198

The first 72 hours after birth

Question 199

How does the recommendation for antibiotic prophylaxis change if a mother presents in labour at 32+6 weeks GA or less?

Answer 199

- She should receive penicillin AND a macrolide (or a macrolide alone if she is allergic to penicillin)

Question 200

Which preterm infants should all be worked up for sepsis and started on empiric antibiotics?

Answer 200

All infants 32+6 weeks or less born to mothers with suspected or confirmed chorioamnionitis, PPROM, or an unexplained onset of non-reassuring fetal status

Question 201

What is the recommendation regarding receipt of antenatal corticosteroids?

Answer 201

All mothers <34+6 should receive antenatal corticosteroids if they are expected to deliver infant within next 7 days, optimal is to have >48h between last dose and birth. Reduces rate of IVH Reduces neonatal morbidities and mortality

Question 202

What outcome can antenatal magnesium sulphate improve?

Answer 202

Decreased risk for CP

Question 203

Which women should receive antental magnesium sulphate?

Answer 203

All pregnant women 33+6 weeks GA or less

Question 204

Any benefit of C/S over vaginal delivery for preterm infants?

Answer 204

Not currently shown in literature No improvement in IVH unless in the breech position

Question 205

All preterm infants of any GA who do not need immediate resuscitation should receive delayed cord clamping for how long?

Answer 205

60-120 seconds Reduces risk of brain injury Appears to protect against motor disabilities later in life

Question 206

What should the temperature of the delivery room be for a preterm infant < 33 weeks GA?

Answer 206

25-26 degrees

Question 207

What are some measures that can prevent hypothermia for preterm infants?

Answer 207

- Keep temp of room 25-26 degrees - Use preheated servo-controlled radiant warmer with a temperature sensor - Use a thermal mattress - Hat on the infant - Preheated transport incubator

Question 208

Easy way to remember hypotension definition for each GA?

Answer 208

SBP = weeks GA Eg at 32 weeks, SBP should be 32 mmHg

Question 209

Why should we use caution when treating hypertension in premature infants?

Answer 209

Use of inotropes is a significant risk factor for acute brain injury in preterm infants Consider inotropes if low BP is combined with delayed CR, decreased urine output, elevated lactate or echo findings

Question 210

PCO2 goal for premature infants to minimize risk for lung injury and BPD, and prevent extremes (hyper or hypocapnia which have been associated with long term brain injury)?

Answer 210

45-55 mmHg in the first 72 hours postdelivery

Question 211

Head position for premature infant in the first 72 hours?

Answer 211

Neutral head position avoid jugular venous obstruction and potentially lower risk for IVH

Question 212

Why is umbilical cord milking not recommended in very preterm infants < 32 weeks?

Answer 212

Increased risk for severe IVH

Question 213

If infant is examined within the first 6 hours of birth, when should they be examined again?

Answer 213

Within the first 24 hours after birth and definitely before discharge

Question 214

Do well appearing low risk infants need to be examined again before discharge when the initial routine exam was performed between 24-72 hours postbirth?

Answer 214

No Main evidence is to re-examine infants if the first exam was done within the first 6 hours of birth

Question 215

Which abnormal findings in newborns are most commonly missed?

Answer 215

Cleft palate Imperforate anus

Question 216

Which checklist provides guidance on specific items to include with the physical assessment during the first week of life?

Answer 216

Rourke Baby Record

Question 217

Important components of parent education prior to infant being discharged?

Answer 217

Infant feeding, including importance of breastfeeding Normal newborn behaviour and care Recognition of early signs of illness, including jaundice and dehydration, and how to respond Infant safety, including car seat use, safe sleep practices and other measures to decrease risk of sudden infant death syndrome [42] Infection control measures Importance of a smoke-free environment Many others - vit D - vaccines - etc

Question 218

When should a screening NMS be repeated within the first week post-birth?

Answer 218

If collected before 24 hours of age

Question 219

Which vaccine can be considered for infants born to mothers with infectious TB disease?

Answer 219

BCG vaccine can be given to newborns before discharge

Question 220

If a newborn is discharged < 48 hours post-delivery, when should the next newborn assessment take place?

Answer 220

Between 24-72 hours after discharge

Question 221

What is the most effective way to prevent hemorrhagic disease of the newborn?

Answer 221

Single dose IM vit K at birth

Question 222

What is the difference in dosing of vitamin K for infants < or = 1500g and > 1500 g

Answer 222

0.5mg 1500g

Question 223

What option is available to parents who decline IM Vitamin K at birth

Answer 223

Oral (PO) dose of 2.0 mg vitamin K at the time of the first feeding, to be repeated at 2 to 4 and 6 to 8 weeks of age. Health care providers should advise parents that: PO vitamin K is less effective than IM vitamin K for preventing VKDB Making sure their infant receives all follow-up doses is important, and Their infant remains at risk for developing late VKDB (potentially with intracranial hemorrhage) despite use of the parenteral form of vitamin K for PO administration, which is the only alternate formulation available at this time.

Question 224

What is the cause of early onset hemorrhagic disease of the newborn?

Answer 224

Typically related to maternal medications (especially anti-seizure medications) which inhibit vit K absorption

Question 225

What is the cause of classic onset hemorrhagic disease of the newborn?

Answer 225

Typically low vitamin K intake

Question 226

What is the cause of late onset hemorrhagic disease of the newborn?

Answer 226

Typically chronic malabsorption and low vitamin K intake

Question 227

What do you have to keep on your differential for any bleeding that occurs in the first 6 months of life?

Answer 227

Vitamin K deficiency Even with prophylaxis

Question 228

Any evidence for PO vitamin K for pregnant mothers on medications impairing vit K absorption?

Answer 228

No

Question 229

In term newborns, comparison of MRI vs CT for neuroimaging findings? Benefits vs downsides?

Answer 229

MRI has more readily detected cortical injury, focal/multifocal lesions, brainstem and cerebellar injuries, and even HIE, CVST, masses, structural abnormalities Generally MRI > CT unless baby is too unstable for long MRI procedure, MRI not available, or baby has contraindication to MRI such as implanted device. More radiation and less diagnostic accuracy so not preferred.

Question 230

Which pattern of brain injury in infants poses the highest risk for adverse neurodevelopmental outcomes?

Answer 230

Basal nuclei pattern of injury

Question 231

How do water and fat show up on T1 and T2 weighted images

Answer 231

T1 - water = darker - fat = lighter T2 - water = lighter - fat = darker

Question 232

Causes of neonatal encephalopathy?

Answer 232

HIE IEMs Infection Bilirubin toxicity Metabolic disturbances Cerebral dysgenesis Stroke

Question 233

Two predominant patterns of brain injury with HIE?

Answer 233

Watershed Basal ganglia / Thalamic

Question 234

How does watershed injury show up on MRI at DOL 3-5?

Answer 234

Best seen as areas of restricted diffusion on DWI MRI may show a lactate peak in white matter in watershed areas Conventional T1-T2 weighted images may still be normal at this point (may take until day 8, with maximal evidence on T1-T2 weighted images day 10-14)

Question 235

Which structures in the newborn brain have the highest metabolic rate and the greatest need for energy substrates, and are likely to sustain injury first?

Answer 235

Deep grey matter structures

Question 236

When is restricted diffusion maximal in profound HIE caused by basal ganglia/thalamic injuries?

Answer 236

Third day after the insult Seen as hyperintense signal on DWI in the basal ganglia/thalamic region

Question 237

What is a helpful neuroradiological sign in neonates more than 37 weeks gestation that indicates HIE?

Answer 237

Loss of normal signal intensity in the posterior limb of the internal capsule

Question 238

What optimal MRI sequence and what day of life should be done to image a newborn's brain with suspected HIE?

Answer 238

Day 3-5 MRI with DWI and MRSI Repeat MRI at day 10-14 is helpful when clinical exam is not helpful with MRI findings (day 10-14 is when T1-T2 weighted images will be maximal, whereas day 5 is when DWI images will be maximal)

Question 239

How does stroke typically present clinically in neonates?

Answer 239

with seizures

Question 240

Where are MRI changes seen in newborns with acute bilirubin encephalopathy?

Answer 240

Globus pallidus Subthalamic nuclei

Question 241

In moderate - severe encephalopathy, seizures or neurological signs suggestive of inborn errors of metabolism, brain injury or brain malformation, what is the preferred imaging modality in newborns?

Answer 241

MRI Preferred over US because the extent of injury is underestimated relative to MRI

Question 242

When a CT is used for imaging patients with HIE, when should it be performed?

Answer 242

As close to 72 hours of the suspected insult as possible, ideally within 72 ± 12 hours. A subsequent MRI is also recommended

Question 243

Cooling for infants under which gestational age is NOT recommended?

Answer 243

< 35 weeks Typically reserved for infants 36+ weeks GA but some studies included infants 35+ weeks GA so okay to include these infants if they meet other criteria

Question 244

What core temp to maintain during cooling for HIE, and for how long?

Answer 244

The optimal rectal or esophageal temperature appears to be 33.5°C ± 0.5°C for whole body cooling and 34.5°C ± 0.5°C for selective head cooling. Cooling should last 72 hours

Question 245

Timing that cooling has to be initiated in HIE?

Answer 245

6 hours old or less

Question 246

HIE Therapeutic Hypothermia Criteria A:

Answer 246

A. Cord pH ≤7.0 or base deficit ≥−16

Question 247

HIE therapeutic hypothermia Criteria B:

Answer 247

B.
 pH 7.01 to 7.15 or base deficit −10 to −15.9 on cord gas or 
blood gas within 1 h AND 
History of acute perinatal event (such as but not limited to cord prolapse, placental abruption or uterine rupture) AND Apgar score ≤5 at 10 minutes or at least 10 minutes of 
positive-pressure ventilation

Question 248

HIE therapeutic cooling Criteria C:

Answer 248

C. Evidence of moderate-to-severe encephalopathy, demonstrated by the presence of seizures OR at least one sign in three or more of the six categories shown in Table 1. 


Question 249

Which infants should be treated with hypothermia (as neuroprotective measure in HIE)?

Answer 249

Current evidence shows that the infants who benefit from hypothermia are term and late preterm infants ≥36 weeks GA with HIE who are ≤6 hours old and who meet EITHER treatment criteria A OR treatment criteria B, AND also meet criteria C

Question 250

Criteria for defining moderate encephalopathy?

Answer 250

1. Level of consciousness: Lethargy 2. Spontaneous activity: Decreased activity 3. Posture: Distal flexion, full extension 4. Tone: Hypotonia (focal, general) 5. Primitive reflexes: Suck- weak. Moro - incomplete. 6. Autonomic system Pupils - constricted Heart rate (HR) - bradycardia Respirations - periodic breathing

Question 251

Criteria for defining severe encephalopathy?

Answer 251

1. Level of consciousness: Stupor / coma 2. Spontaneous activity: No activity 3. Posture: Decerebrate (arms extended and internally rotated, legs extended with feet in forced plantar flexion) 4. Tone: Flaccid 5. Primitive reflexes: Suck- absent. Moro - absent. 6. Autonomic system Pupils - skew deviation / dilated / nonreactive to light Heart rate (HR) - variable Respirations - apnea

Question 252

In what clinical scenario should therapeutic cooling be deferred?

Answer 252

If infant's neurological status returns to fully normal within 30-45 minutes after birth

Question 253

Which infants should not receive hypothermia (exclusion criteria):

Answer 253

Major congenital or genetic abnormalities for whom no further aggressive treatment is planned Severe IUGR Significant coagulopathy Evidence of severe head trauma or intracranial bleeding

Question 254

Possible side effects of therapeutic hypothermia?

Answer 254

Sinus bradycardia (80-100bpm) Hypotension with possible need for inotropes Mild thrombocytopenia PPHN Prolonged bleeding time Subcutaneous fat necrosis with or without hypercalcemia

Question 255

Infants with HIE are more at risk for what other morbidities?

Answer 255

Arrhythmias Anemia Leukopenia Hypoglycemia Hypokalemia Urinary retention Coagulopathy

Question 256

Indications to STOP therapeutic cooling and rewarm an infant with HIE include:

Answer 256

Hypotension despite inotropic support PPHN with hypoxemia despite adequate treatment Clinically significant coagulopathy despite treatment

Question 257

Which method of cooling is recommended in HIE?

Answer 257

Whole body cooling and selective head cooling are both effective, but whole body warming is easier set up and use, less expensive and provides access to EEG, so typically recommended over selective head cooling

Question 258

How long to take to rewarm infants after therapeutic cooling for HIE?

Answer 258

6-12 hours Slow down to 24 hours if complications arise during rewarming eg seizures

Question 259

Adjunctive therapies that are recommended during therapeutic cooling for HIE?

Answer 259

Low infusion of morphine / analgesia Antiepileptic drugs if seizures noted Early minimal enteral feeding 10ml/kg/day during hypothermia Avoid hyperoxia, hyper/hypocapnia Minimize unnecessary stimulation or handling

Question 260

When should brain imaging occur after therapeutic cooling for HIE?

Answer 260

MRI after rewarming has taken place, on DOL 4-5 Consider a repeat MRI between DOL 10-14 when the imaging and clinical features are discordant or diagnostic ambiguity persists

Question 261

Palliative care is accepted as the usual approach when an infant is born at what GA?

Answer 261

21 weeks GA or less

Question 262

What is the most accurate US measurement in utero for determining GA?

Answer 262

First trimester crown-rump length is the most accurate for dating within 3 to 8 days The degree of imprecision increases with advancing GA (± 10 days at 16 to 22 weeks and ± 2 weeks at 24 weeks)

Question 263

Role of antenatal corticosteroids for mothers < 24 weeks?

Answer 263

ANCS should be offered to women at risk for extremely preterm birth at ≥22 weeks GA when early intensive care is a management option

Question 264

What is the maximal period of efficacy for antenatal corticosteroids?

Answer 264

Within 7 days of the last dose

Question 265

Mode of delivery for extremely preterm births 22-25 weeks GA ?

Answer 265

No benefit to C/S over vaginal delivery in terms of neonatal outcomes

Question 266

What is the MINIMUM required for obtaining informed consent for a management plan regarding delivery of an extremely preterm infant?

Answer 266

Sharing accurate information tailored to the parents’ needs regarding the risk of death and NDD (neurodevelopmental impairment), and the opportunity of having a surviving child with or without NDD

Question 267

If a parent wants to proceed with an option for managing an extremely preterm infant and it goes against what the majority of HCPs would feel comfortable with or recommend based on typical practice, in such situations how should a HCP proceed?

Answer 267

Consider seeking a second opinion from a colleague and/or support from an ethics consultation, or applying for an institutional board review to determine the infant’s and family’s best interests.

Question 268

What percentage of surviving infants born at 22 weeks have moderate-severe neurodevelopmental impairment?

Answer 268

43% !! 57% have no or mild NDD However in this age group mortality is much higher. But if they do survive, rates of significant neurodevelopmental impairment are < 50%

Question 269

Definition of early onset sepsis?

Answer 269

Sepsis occurring within the first 7 days of life (most are symptomatic within 24 hours)

Question 270

what does type 1 and type 2 mean in ROP classification?

Answer 270

Type 1 = ROP requiring treatment Type 2 = ROP requiring monitoring but no treatment

Question 271

what age group do we screen for retinopathy of prematurity?

Answer 271

<31 wks GA (regardless of BW), and birth weight ≤1250 g

Question 272

when do we screen for retinopathy of prematurity?

Answer 272

31 weeks post-menstrual age or 4 weeks chronological age (whichever is later) the goal is not to screen to early, ROP takes time to develop and we want to avoid unnecessary testing examples 25 weeker is screened at 31 weeks postmenstrual age 28 weeker and above are screen at 4 weeks of age

Question 273

eye exams for ROP cause distress, pain and apnea. What do we do to reduce discomfort?

Answer 273

Topical anesthetics, pacifiers, swaddling and sucrose

Question 274

Availability of appropriately trained ophthalmologists for ROP eye exams is a challenge, esp in community settings. What technology exists to help with this?

Answer 274

digital retinal photography (RetCam), which captures images that can be transmitted electronically for newborns screened with RetCam, the must have at least one indirect ophthalmoscopic examination by an ophthalmologist before treatment or cessation of screening RetCam: -family-centered and cost efficient as families can stay in their communities - high accuracy for detection of clinically significant ROP - sensitivity for detection of mild ROP is less certain

Question 275

What is the treatment of ROP?

Answer 275

retinal ablation for type 1 ROP within 72 h of its detection = laser photocoagulation directed toward the avascular part of the retina To decrease production of angiogenic growth factors (recall ROP is a proliferation of retinal blood vessels) New treatment for ROP = Antivascular endothelial growth factor (anti-VEGF) therapy ^not standard of practice given some concerns

Question 276

prognosis for discharged infants with ROP?

Answer 276

ongoing eye problems (regardless of whether treatment was required or not) = strabismus, cataracts, amblyopia and refractive errors Even preterm infants WITHOUT ROP are more likely than term infants to experience visual problems follow up visual examination with optho for ALL preterm infants who have been SCREENED for ROP

Question 277

how do we detect critical congenital heart disease (CCHD)?

Answer 277

Pulse oximetry screening (POS) to identify clinically undetectable cyanosis in addition to prenatal US and newborn physical exam Early diagnosis is crucial for CCHD to decrease morbidity, mortality and disability A study from Norway showed that hospitals without POS were only able to detect 77% of CCHDs by clinical features before discharge CPS states that Alberta in particular sucks at screening for CCHD lol

Question 278

what is critical congenital heart disease (CCHD)?

Answer 278

severe and often duct-dependent lesions that require intervention early in life for optimal outcome

Question 279

who should be screened for critical congenital heart disease (CCHD)?

Answer 279

All term and late preterm (>34wk) infants pulse oximetry screening has not been adequately studied in preterm newborns or in the NICU - can be used to monitor but not as a standard screening tool for asympto infants

Question 280

when should we screen for critical congenital heart disease (CCHD)?

Answer 280

24 - 36 hours of life 10x higher false positive rate <24 hrs old (better to wait until at least 24 hrs old) Some centres administer pulse ox screen at the time of the newborn hearing assessment and first bath Screening for infants discharged before 24 hours and for home births - arrange public health nurse visit at 24 to 36 hours postbirth Despite the risk for higher FP rates, screening before 24 hours is preferable to not screening at all

Question 281

What constitutes a failed pulse oximetry screening for critical congenital heart disease (CCHD)?

Answer 281

apply pulse ox to right hand and either foot SpO2 <90% in right hand or foot is ABNORMAL

Question 282

Review the process of pulse oximetry screening for critical congenital heart disease (CCHD)?

Answer 282

pulse ox on right hand and either foot in late preterm/term 24-36 hour old newborn (Testing using the right hand and one foot minimizes false-negative rates) ≥ 95% in right hand and ≤3% difference between right hand and foot is NORMAL - no further screen required if failed or borderline, repeat in an hour, if still fail or borderline, repeat in an hour again, if still fail or borderline, it is a failed screen

Question 283

What constitutes a borderline pulse oximetry screening for critical congenital heart disease (CCHD)?

Answer 283

90-94% in right hand and foot or >3% difference between right hand and food is borderline

Question 284

Next steps after a failed pulse ox screen for critical congenital heart disease (CCHD)?

Answer 284

4 limb BP, ECG and CXR, peds consult if cardiac etiology suspected --> pediatric cardiology consult and ECHO For many centres in Canada, the need for ground or air transport to access cardiac services, including an echocardiogram, underlines the importance of minimizing false positive pulse ox screening results.

Question 285

Which pathogens are most likely in early onset sepsis?

Answer 285

GBS E Coli Strep viridans Strep pneumo Enterococcus Enterobacter Staph aureus H flu Listeria

Question 286

List 5 risk factors that increase liklihood for early onset sepsis

Answer 286

1. Maternal GBS colonization in current pregnancy 2. GBS bacteruria anytime in current pregnancy 3. Previous infant with invasive GBS disease 4. Prolonged ROM (>18h) 5. Maternal fever (temp >38)

Question 287

Define miscarriage vs stillbirth

Answer 287

Perinatal loss < 20 weeks (miscarriage ) or ≥ 20 weeks gestation( stillbirth) neonatal death = death of a newborn through 28 days of life

Question 288

Without intrapartum antibiotics, what % of infants born to GBS colonized mothers will develop early onset GBS sepsis?

Answer 288

1-2%

Question 289

When communicating a perinatal loss to parents, health care providers should use the word "baby" over fetus, use the baby's name and correct pronouns - if appropriate to the parents' faith/beliefs After the loss, parents should be offered the choice to hold their deceased baby or have the baby taken away. Grief counselling or spiritual guidance should be offered to help parents navigate existential Q like "why us?" "Meaning-making" activities should be offered to parents - what does this mean? (CPS Statement on perinatal loss)

Answer 289

"Meaning-making" Activities in perinatal loss: talking to, holding, bathing or dressing the baby religious or naming ceremonies introducing the baby to other family members Mementos (hand/footprints, a lock of hair or hospital bracelet) Photographs taken when their baby’s face is free of medical equipment, even if these images cannot be taken until after the baby has died

Question 290

Definition of adequate IAP?

Answer 290

Adequate IAP = 1 dose given at least 4h before the birth (don’t need for C-section with intact membranes)

Question 291

If it is determined that continuing treatment for a newborn will prolong suffering without improving quality of life, how should physicians approach this?

Answer 291

introduce the idea of withdrawal of life support of the newborn to the parents (reduces parental guilt and regret by the HCP bringing it up) eg if CPR is highly unlikely to achieve the therapeutic goal or will merely prolong dying - physicians should assume responsibility of the decision to forgo life-saving protocols and use an "informed assent model with parents" (allowing for disagreement) prepare parents for the dying process (pain management, difficulty of predicting how soon a baby will die following withdrawal of life support, tissue/organ donation) palliative consult (palliative training for those working in this population) (all of this direct from CPS statement)

Question 292

Name two primary options for adequate intrapartum antibiotics.

Answer 292

IV Pen G 5 million units / Ampicillin 2g

Question 293

Steps required following the death of newborn or still birth?

Answer 293

death and stillbirth registration (required by law) autopsy can be offered guidance about lactation suppression and human milk donation contact family doctor for mental health follow up for parents +/- genetic testing sibling support (ensure they know it is not their fault)

Question 294

Name one option for intrapartum antibiotics if allergic to penicillin but low risk anaphylaxis. Name two options for IAP if penicillin allergic with high risk anaphylaxis.

Answer 294

IV Cefazolin 2g (if allergic to pen but low risk anaphylaxis) If pen allergic with high risk anaphylaxis: IV clindamycin (if GBS sensitive to clindamycin and erythromycin) OR IV vancomycin (if resistant to clindamycin or unknown susceptibilities) **efficacy of these options unknown so consider them inadequate prophylaxis

Question 295

high risk pregnancy features

Answer 295

fetal growth abnormalities maternal diabetes (pre-existing has higher risk birth defects) maternal hypertension maternal autoimmune diseases (i.e. lupus) history of intrauterine demise or previous fetal deaths fluid abnormalities multiple gestations

Question 296

Trisomy 21 Surveillance relevant to NICU

Answer 296

Birth: eye exam (red reflex—cataracts), echo, TSH (included in NMS), CBC to look for transient myeloproliferative disorder Refer infants with significant hypotonia, choking or feeding difficulties for swallowing assessment

Question 297

Long term trisomy 21 surveillance (AAP)

Answer 297

Annual tests: TSH, HgB & ferritin Hearing Audiology at 6 months & 1 year, then annual Ophthalmology at 6 months, age 1-5y annual, age 5-13y every 2y, age >13y every 3y Sleep study by age 4 All visits: Check for celiac symptoms Check for OSA symptoms (all have sleep study by age 4y) Check for signs/symptoms of CHD Discuss: Cervical spine positioning Risk of respiratory infection If myopathic sx - Xray c-spine in neutral → if Normal flex/ext xray and refer to neurosurg

Question 298

what needs to happen 2-3 months after the death of a newborn?

Answer 298

evidence firmly establishes importance of parents being invited to review their infant’s care and death 2 to 3 months after the loss opportunity to explain autopsy findings check in with coping of parents establish risk in future pregnancies

Question 299

Impact of IAP on late onset GBS sepsis?

Answer 299

No impact - does not decrease late onset GBS disease

Question 300

For which condition do we use inhaled nitric oxide in newborns?

Answer 300

persistent pulmonary hypertension of the newborn (PPHN) - diagnosed by ECHO =hypoxemic respiratory failure with persistent high pulmonary vascular resistance and resultant right-to-left shunting of blood through the foramen ovale, ductus arteriosus and/or intrapulmonary channels iNO is a selective pulmonary vasodilator that improves V/Q mismatch

Question 301

Gold standard for diagnosing neonatal sepsis:

Answer 301

Positive blood culture

Question 302

Initial dosing of inhaled nitric oxide?

Answer 302

20 ppm in near-term and term infants Expect improved oxygenation and cardio-resp stability within <30 min if not, increase to 40 ppm if still no improvement 30min later, discontinue iNO very or extreme preterm infants, initiate iNO at 5 to 10 ppm and increase up to 20 ppm (concentration of NO2 (nitrogen dioxide) in the inspired mixture should be maintained below 0.5 ppm)

Question 303

How much blood is needed for optimal recovery of micro-organisms in low-colony count neonatal sepsis?

Answer 303

1ml

Question 304

what defines an iNO responder?

Answer 304

improved oxygenation and cardio-resp stability within <30 min

Question 305

Which infants at risk for early onset sepsis should receive LPs?

Answer 305

Overall meningitis uncommon in newly born infants. LP should only be performed when there is clinical suspicion (symptomatic) for EOS or when signs of meningitis (seizures, bulging fontanelle, irritability, altered neurological status) LP must always be done when the blood culture is positive

Question 306

why do we need to carefully wean iNO? In general, what is the process of weaning?

Answer 306

abrupt discontinuation of iNO can cause severe rebound hypoxemia wean by half (provided OI <10 and sats/oxygen stable) once at 5ppm, decrease by 1ppm q0.5-2hr if deterioration, go back to last effective iNO dose

Question 307

If a symptomatic infant is being worked up for early onset sepsis, if they only have this specific symptom the LP can be deferred and they can be monitored closely:

Answer 307

Respiratory distress only

Question 308

Side effects of inhaled nitric oxide?

Answer 308

no severe side effects, iNO half life only 2-6 seconds possible side effects - nitrogen dioxide (NO2) causing lung cytotoxicity - methemoglobin production (>2.5% is toxic) - decreased platelet function - bleeding -surfactant dysfunction -?cancer (study had confounders)

Question 309

Which investigations for early onset sepsis are NOT recommended

Answer 309

Cultures of urine, gastric aspirates and body surface

Question 310

Indications for iNO use in newborns?

Answer 310

hypoxemic respiratory failure with OI >15 (or PaO2 <100) on 100% oxygen and ECHO confirms normal Left Ventricle fxn and absence of CHD with ductal-dependent lesion (bc iNO decreases Pulm vascular resistance, thus systemic blood flow if ductal dependent lesion) Possible Indications where iNO can be used as rescue modality Refractory hypoxemic resp failure in Preterms with: - PROM or oligohydramnios - RV failure in bronchopulmonary dysplasia-pulmonary HTN (BPD-PH) failing ventilator and steroids - congenital diaphragmatic hernia with pulmonary HTN

Question 311

After how many hours after birth is the WBC count more helpful

Answer 311

After 4 hours However, if baby symptomatic before 4 hours of life should not delay workup and antibiotics

Question 312

Neonatal isoimmune hemolytic disease from red cell incompatibilities is a leading cause of severe hyperbilirubinemia in newborns Moms are screened with ABO blood group, RhD type and antibody screen in early pregnancy At delivery, if unknown maternal testing or positive maternal red cell antibody, what testing needs to be done for the neonate?

Answer 312

Cord Blood: ABO blood type Rh Blood type red blood cell antigen (if maternal antibody screen is positive) direct antiglobulin test (DAT) total serum bilirubin (TSB) If DAT positive, confirm hemolysis with hemoglobin, blood smear, reticulocyte count and bilirubin Monitor for early (<24 hours postnatal age) hyperbilirubinemia

Question 313

Role of CRP in early onset sepsis

Answer 313

May be helpful if measured serially to help determine duration of empiric antibiotic therapy Single CRP should not be used for clinical decision making

Question 314

Describe the direct antiglobulin test (DAT)? False positive?

Answer 314

detects the presence of antibodies on the red blood cell surface positive testing does not confirm hemolysis false pos if mom received Rh immune globulin (RhIG) false neg after profound hemolysis or antibody clearance you can have ABO incompatibility with a negative DAT on occasion

Question 315

WBC values which have highest PPV for sepsis in newborns:

Answer 315

WBC: - Low <5x109 - High >30x109 ANC: Low <1.5x109

Question 316

All newborns are screened for hyperbilirubinemia with total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) at >12 hours of life - what calculation do we need to do? Why is it useful?

Answer 316

infants >12 hrs old: delta-TSB (△TSB): the difference between the timed TSB concentration and the phototherapy threshold at age of sampling (to determine the most appropriate care plan) The smaller the △TSB, the closer an infant is to requiring phototherapy treatment If △TSB is ≤30 µmol/L, must initiate phototherapy or delay discharge for more screening

Question 317

What workup and which antibiotics should be started in symptomatic infant with suspected early onset sepsis?

Answer 317

Workup: - CBC, BCx, LP +/- CXR if resp distress Antibiotics: - Ampicillin and aminoglycoside If meningitis suspected, give antibiotics that penetrate into CSF

Question 318

What are risk factors to developing hyperbilirubinemia (6)

Answer 318

<38wks GA Hemolysis (DAT, peripheral blood smea, Hgb, G6PD, pyruvate kinase) fam hx of phototherapy or red cell hemolytic disorders poor feeding or excessive weight loss (CPS recommends breastfeeding support to prevent jaundice) cephalohematoma or excessive bruising polycythemia

Question 319

Approach to infants born to GBS positive mothers with adequate IAP, no additional risk factors:

Answer 319

No investigation/treatment required Discharge after 24h provided well, parents counselled sings/symptoms of sepsis, ready access to healthcare

Question 320

What are the risk factors for neurotoxicity from bilirubin? (5) (will change phototherapy threshold for a baby)

Answer 320

<38wks GA serum albumin <30g/L suspected hemolytic condition - suspect if TSB rate of rise ≥5 µmol/L/h (within 24 hours post-birth) or ≥3.5 µmol/L/h (beyond 24 hours post-birth) Sepsis Hemodynamic or Respiratory instability in preceding 24 hours

Question 321

Approach to infants born to GBS positive mothers with INadequate IAP, no additional risk factors:

Answer 321

Risk 1-2% Careful physical assessment, close in-hospital observation (vital signs 3-4h) x 24 hour Reassessment before discharge if planned between 24-48 hours Discharge after 24 hours if well appearing, parents counselled and ready access to healthcare

Question 322

Describe the process of screening for hyperbilirubinemia

Answer 322

TCB/TSB at >12hrs of life assess for neurotoxicity risk factors assess phototherapy threshold per age if not, measure Delta TSB Delta TSB <30, delay discharge and consider phototherapy >30, repeat TSB in 4-12 hr, future interval repeats depending on results exam at 24 hours old for jaundice and assess for bilirubin neurotoxicity risk factors

Question 323

Approach to infants born to GBS positive mothers WITH additional risk factors, with or without adequate IAP:

Answer 323

At minimum, close observation in hospital 24-48 hours with reassessment prior to discharge CBC after 4 hours of life may be of some utility Individualized plan - treatment may be warranted in some babies

Question 324

when do peak serum bilirubin levels peak?

Answer 324

3-5 days (usually when babies are already home) timely post-discharge follow-up of newborns at intervals based on the △TSB is essential in addition to exams for jaundice

Question 325

Approach to infants born to mothers who are GBS negative OR GBS unknown status with risk factors

Answer 325

If GBS unknown and risk factor present - mom should receive IAP IF single risk factor - infants can be managed similarly to those born to GBS positive mothers If multiple risk factors - mgmt should be individualized

Question 326

when do we need to confirm transcutaneous bilirubin (TCB) with total serum bilirubin (TSB)?

Answer 326

TcB level is within 50 µmol/L of phototherapy threshold OR if the TcB is above 250 µmol/L (less reliable at higher values) Recall we CANNOT use TCB once a baby has had phototherapy

Question 327

Approach to babies born to mothers with chorioamnionitis?

Answer 327

- Term infants otherwise well - close observation x 24 hours, could do vitals q3-4h and reexamine prior to DC - IF mother has multiple risk factors including chorio, has not received intrapartum antibiotics or is unwell herself then consider investigation and antibiotics

Question 328

Treatment for hyperbilirubinemia in newborn?

Answer 328

Intensive phototherapy if severe: NG feeds (reducing enterohepatic circulation of bilirubin) or IV fluids 10-25% above maintenance over 4-8hr (treating dehydration) repeat serum bili level 12-24 hr after starting phototherapy to calculate the rate of rise

Question 329

features to suspect hemolysis in a baby with hyperbilirubinemia?

Answer 329

increasing rate of rise of bilirubin despite being on phototherapy rate of rise >5mmol/L/hour in first 24 hr (or 3.5 if >24hrs old) (if hemolysis suspected, check serum bili q4-6hr to assess need for pre-exchange transfusion)

Question 330

what is G6PD deficiency?

Answer 330

X-linked recessive red cell enzyme defect leading cause of kernicterus from severe neonatal hyperbilirubinemia consider G6PD if worsening hyperbilirubinemia despite phototherapy

Question 331

when can we stop phototherapy?

Answer 331

if delta TSB >30 mmol/L below treatment threshold (or >60 below tx threshold if 35 to 37 wks) *remember to check serum bili 12-24hr after stopping photo to assess for rebound hyperbili

Question 332

what should infants be investigated for if persistent hyperbilirubinemia beyond 14 days old?

Answer 332

UTI, thyroid disease, hemolytic disease, inborn error of metabolism

Question 333

what needs to happen for hyperbili infants nearing the exchange transfusion threshold?

Answer 333

continue phototherapy IV fluids, hold feeds rpt TSB in 2-3 hours hemolysis work up and type/crossmatch notify blood bank to prepare blood for BET

Question 334

features of acute bilirubin encephalopathy?

Answer 334

hypertonia, opisthotonus, retrocollis, high-pitched cry, fever, irritability, stupor, seizures, coma, or apnea these babies need urgent blood exchange transfusion (BET)

Question 335

what is blood exchange transfusion (BET)?

Answer 335

treatment for extremely severe hyperbilirubinemia to minimize risk for bilirubin neurotoxicity BET-associated risks include cardiorespiratory instability, catheter-related complications (e.g., thrombosis, infections), hypoglycemia, electrolyte imbalances, thrombocytopenia, coagulopathy, and necrotizing enterocolitis

Question 336

what follow up is required in babies following hyperbilirubinemia?

Answer 336

if immune hemolytic cause: Hgb at 4 and 10 wks old to assess for anemia if severe (TSB >400 or at pre-exchange transf threshold), audiology follow up and neurodevelopmental monitoring

Question 337

Birth less than what GA is considered a risk factor for sepsis:

Answer 337

< 37 weeks GA Infants < 37 weeks with GBS unknown should receive antibiotics Should observe these infants at least 48 hours prior to discharge home

Question 338

CPS position on the infant car-seat challenge proposed by the AAP:

Answer 338

NOT recommended as the evidence is not clear

Question 339

Reliability of the ICSC car seat test?

Answer 339

Significant doubt exists as to the reliability and reproducibility of the ICSC

Question 340

Car seat safety recommendations for parents?

Answer 340

Infants should only be placed in a car seat for travel in a moving vehicle and removed promptly once the destination is reached Parents and other care providers should be counselled regarding safe car seat use and be able to demonstrate appropriate technique and practice

Question 341

List 3 complications of PRBC transfusions in very preterm / low birth weight infants?

Answer 341

Acute lung injury GVHD Increased in-hospital mortality

Question 342

Name one intervention which can be done for all infants (that don't need immediate resuscitation at birth) that can reduce the number of preterm / low birth weight infants requiring a PRBC transfusion

Answer 342

Delayed cord clamping 30-180 seconds

Question 343

What are the hemoglobin transfusion thresholds at postnatal age 1, 2, and 3?

Answer 343

Hb concentration of 115 g/L (respiratory support) or 100 g/L (no support) in the first week Hb concentration of 100 g/L (respiratory support) or 85 g/L (no support) in the second week Hb concentration of 85 g/L (respiratory support) or 75 g/L (no support) in the third week

Question 344

Does the volume of blood transfused reduce the need for further PRBC transfusions in low birth weight infants?

Answer 344

No significant difference in need for further transfusion However transfusing a higher volume of blood may decrease the risk for exposure to >1 donor

Question 345

Does treatment with recombinant human erythropoietin safely reduce the need for PRBC transfusions in preterm/ low birth weight infants?

Answer 345

EPO does reduce need for transfusions but has risk for more severe ROP - NOT recommended routinely

Question 346

Does enteral iron supplementation reduce the need for blood transfusions in preterm infants?

Answer 346

- No evidence that using supplemental iron helps prevent or reduce need for blood transfusion HOWEVER it does improve ferritin and Hgb levels and reduces risk for iron-deficiency anemia if infant continues on it for first year of life

Question 347

What is the dose of iron supplement and duration that is recommended for low birth weight infants between 2.0-2.5kg?

Answer 347

1-2 mg/kg/day for the first 6 months

Question 348

What is the dose of iron supplement and duration that is recommended for low birth weight infants < 2.0kg?

Answer 348

2-3mg/kg/day for the first YEAR of age

Question 349

Is there evidence to support the use of point-of-care testing techniques for reducing PRBC transfusions?

Answer 349

YES - Using more point of care devices decreases the number of transfusions per infant in NICU

Question 350

Is there evidence to support the use of in-line or other continuous monitoring techniques for reducing PRBC transfusions in NICU?

Answer 350

Evidence conflicting In-line sometimes less reliable (eg blood glucose) Higher risk infection Consider noninvasive CO2 monitoring for ventilated infants

Question 351

Is there evidence to support limiting routine blood sampling for extremely premature infants in NICU?

Answer 351

No evidence exists as to what a safe / routine blood sampling amount is for extremely premature infants in the NICU Significant variability between centres Should be limited to the minimum required for safe clinical care. Minimum volume should be collected

Question 352

Benefits of newborn male circumcision?

Answer 352

Reduced UTI incidence in young boys (NNT 111-125). More evidence if recurrent or high grade VUR/obstructive uropathy (NNT 4) Eliminates need for medical circumcision in later childhood to tx: recurrent balanopotheitis, paraphimosis, phimosis Lower risk of penile cancer (and cervical CA in female partners) Decreased rate of trichomonas, bacterial vaginosis and cervical cancer in female partners Reduced risk of acquiring STI (HIV, HSV, HPV specifically, not protective against G or C). Less risk of Trichomonas vaginalis in female partners

Question 353

Potential complications of newborn male circumcision?

Answer 353

Acute: Pain, Minor bleeding, local infection, unsatisfactory cosmetic result Rare: partial amputation of penis, death from hemorrhage/sepsis Later: meatal stenosis (2-10%)- may require surgical dilation, adhesions/partial re-adherence No data that it affects sensory nerves or sensory functioning Risk lower in younger children (1.5% complication rate infants, 6% older age)

Question 354

Ethics discussed in CPS statement related to newborn male circumcision?

Answer 354

Contentious Lifelong consequences, performed on a child who cannot consent SDM (usually parents) who is acting in their best interest This is not a medical necessity… and usually in cases in which medical necessity is not established, and treatment is based on personal preference, intervention should be deferred until the individual concerned is able to make their own choices While not a medical necessity, there are some health benefits particularly in certain populations. Older age circumcision(when they can consent) has higher risk and costs --> therefore parents may feel its in their infant's best interest

Question 355

What are three principles of circumcision which should be adhered to for the lowest risk possible of the procedure

Answer 355

Trained provider Good pain control Strict hygiene

Question 356

% of boys who can retract their foreskins by age 6?

Answer 356

Only 50% Improves to 95% by age 17

Question 357

Difference between phimosis, paraphimosis, posthitis, balanoposthitis?

Answer 357

Phimosis - scarring and thickening of the foreskin that prevents retraction back over the glans Paraphimosis - foreskin becomes entrapped behind the glans Posthitis - Foreskin becomes inflamed or infected Balanoposthitis - foreskin inflamed or infected in association with the glans

Question 358

First line treatment for phimosis?

Answer 358

Topical steroid BID to the foreskin with gentle traction - betamethasone 0.05 to 0.1% - triamcinolone 0.1% - mometasone furoate 0.1%

Question 359

CPS official position on newborn male circumcision?

Answer 359

the CPS does not recommend the routine circumcision of every newborn male

Question 360

Counselling to give parents who choose not to circumcise?

Answer 360

At the time of hospital discharge, health professionals should ensure that the parents of uncircumcised newborn boys know how to appropriately care for their son’s penis and are aware that the normal foreskin can remain nonretractile until puberty.

Question 361

what physiologic responses can occur in neonates undergoing awake laryngoscopy/intubation?

Answer 361

*intubation is PAINFUL and NEEDS pre-medication* hypertension pulm HTN bradycardia (vagal response) hypoxia (need to pre-oxygenate before intubation!) intracranial HTN ("from coughing and struggling of the infant")

Question 362

which medications should be administered to neonates prior to intubation?

Answer 362

Atropine ("vagolytic" ie reduces the bradycardia which is vagal induced) Fentanyl infusion over 1 minute (to reduce pain) Succinylcholine (muscle relaxant)

Question 363

what are the 2 most frequent indications for blood transfusion in the newborn?

Answer 363

- perinatal hemorrhagic shock - "top ups" in anemia of prematurity to maintain Hgb >75 g/L * * exceptions: - 1st week of life maintain Hgb 100g/L - 2nd week of life maintain Hgb 85g/L - babies on resp support have higher hgb thresholds (~15g/L higher) - cyanotic heart disease also have higher Hgb thresholds

Question 364

what are blood transfusion-related adverse effects?

Answer 364

infection (viral, bact, parasite, prion) - 1 in 1.3 million graft vs host disease, alloimmunization Transfusion-related Acute Lung Injury (TRALI) Blood group incompatibilities electrolyte disturbances

Question 365

Newborns (especially very low birth weight) are at higher risk with blood transfusions bc they are immunologically compromised and neurodevelopmentally vulnerable. Which pathogen exposure from blood transfusion has the greatest consequence for immature infants?

Answer 365

CMV - the risk of CMV infection from blood transfusion is reduced as blood is "leukoreduced" in Canada (WBC are removed) (also gamma radiation is used to prevent transfusion-associated graft-versus-host disease)

Question 366

we use O Rh-negative blood for transfusions in neonates. At what age must we use cross-matched blood?

Answer 366

4 months old

Question 367

Describe the hemoglobin thresholds for transfusion in anemia of prematurity (with and without respiratory support)

Answer 367

75g/L (85g/L if on resp support) Higher thresholds for first 2 wks of life and add 15g/L if on resp support 1st wk of life 100g/L (115g if resp support) 2nd wk of life 85g/L (100g/L if resp support)

Question 368

Name 3 ways that Trisomy 21 develops

Answer 368

Meiotic nondisjunction - ~95% of cases. Not inherited. Occurs wherein 3 complete copies of chromosome 21 are present in all cells (total of 46 chromosomes) and is usually caused by maternal nondysjunction during meiosis 1 Translocation - 3-4% of cases. Can be inherited (25%) or de novo (75%). If the fetus inherits an unbalanced translocation of chr 21 they will have the down syndrome phenotype. In translocation trisomy 21 the fetus has 1x chr 21 inherited from Dad + 1x chr 21 inherited from Mom + 1x extra translocated chr 21 long arm onto another chromosome (Usually chr 14. Or rarely chr 21 or chr 22) from Mom or Dad. In the familial inherited form, the extra translocated chr 21 is inherited from Mom (or rarely Dad) as this parent is the carrier for the translocation but the parent themselves has a balanced translocation of chr 21. In the de novo form, both parents have a normal karyotype and the extra translocated chr 21 is due to a spontaneous chromatid translocation event in maternal meiosis 1. Chance of passing it on is 25%. Mosaicism - 1-2% of cases. Not inherited. The fetus genotype has 2x different cell lines (normal cell line and T21 cell line) throughout various parts of their body depending on the timing of the mitotic error

Question 369

Name 5 prenatal findings on US that could suggest trisomy 21

Answer 369

Thick NT Absent nasal bone short long bones Decreased AFP Increased HCG

Question 370

List at least 5+ postnatal findings on exam in an infant with Trisomy 21

Answer 370

Hypotonia Upslanting epicanthal folds Brushfield spots low set ears Flat nasal bridge Protruding tongue Single palmer crease Sandal gap toes

Question 371

Systemic complications affecting infants with Trisomy 21?

Answer 371

Cardiac - AVSD, ASD, VSD HEENT - macroglossia, cataracts, glaucoma GI - Hirschsprungs, Celiac, duodenal atresia, Megacolon, feeding difficulties, inguinal/umbilical hernias Urogenital - cryptorchidism ,hypogonadism Endo - hypothyroidism (congenital) Heme - transient myeloproliferative disorder

Question 372

Newborn investigations / monitoring if suspected Trisomy 21

Answer 372

Postnatal Karyotyping + RAD (FISH) Refer to Genetics Monitor growth and feeding CBC and Diff by 3 days of life --> monitor for Transient myeloproliferative disorder ECHO TSH + T4 +/- Refer to Endo Red Reflec Newborn hearing test Assess eligibility for RSV prophylaxis

Question 373

Trisomy 18 - more common in males or females?

Answer 373

Female:male 3:1

Question 374

Prenatal findings indicating possible Trisomy 18?

Answer 374

Decreased AFP Decreased HCG IUGR Fluid abnormalities Absent nasal bone Limb abnormalities

Question 375

Postnatal findings of trisomy 18 in an infant?

Answer 375

SGA/IUGR Microcephaly Hypotonia Seizures Short palpebral fissures Malformed ears Clenched hands with overlapping digits Rocker-bottom feet 2-3 syndactyly ASD VSD PS CoA horseshoe kidney

Question 376

Prenatal findings of Trisomy 13?

Answer 376

Increased NT IUGR CNS/Facial abnormalities Absent nasal bone

Question 377

Postnatal findings in an infant with Trisomy 13?

Answer 377

SGA Microcephaly Apnea Seizures Cutis aplasia Cleft lip / palate single palmer crease Postaxial polydactyly Clenched hands / overlapping digits VSD ASD Omphalocele Polycystic kidneys Horseshoe kidneys

Question 378

Prenatal findings in an infant in utero with Turner syndrome?

Answer 378

Cystic hygroma Hydrops Increased NT Cardiac defects - left sided

Question 379

Postnatal findings in a baby with Turners

Answer 379

webbed neck high arched palate hearing loss low hairline lymphedema (may have cystic hygroma) hydrops

Question 380

Risks to infants born to mothers with diabetes?

Answer 380

Risk for hyperinsulinemia --> fetal macrosomia Stillbirth / IUFD Hypoglycemia Birth trauma Hypocalcemia (hypoPTH) RDS Polycythemia Hyperbili Cardiac disease (VSD, TGA, hypertrophy) Caudal regression syndrome - > rare but strongly associated

Question 381

Risks to infants born to mothers with hypertension?

Answer 381

Growth restriction, oligohydramnios, IUFD, premature birth

Question 382

Features of neonatal lupus?

Answer 382

Hydrocephalus Rash: annular, erythematous papulosquamous rash with fine scale and central clearing Cytopenias - thrombocytopenia, neutropenia, usually resolve without treatment Hepatitis - typically resolves by 6mo Congenital heart block (30% of cases) - may lead to CHF, hydrops - this is the only manifestation of neonatal lupus that does not resolve 30-50% of infants will require a pacemaker

Question 383

Monitoring during pregnancy for mothers with known +SSA/Ro, SSB/La, RNP (ENA panel) antibodies or known rheumatic disease?

Answer 383

Serial screening after 16 weeks for fetal heart block

Question 384

Differential for hydrops?

Answer 384

Immune - Isoimmunization - RH, ABO, Anti-c, C, e, E - Duffy, Kell Non-immune - TTTS (both twins can develop hydrops - one from anemia, one from polycythemia) - cardiac (arrhythmia, structural) - chromosomal (Turner, Noonan, Down, Edward) - Lymphatic - Infectious (B19, CMV, Syphilis) - Maternal disease (DM, hyperthyroid) - Hematologic disorders (G6PD, PKD, Diamond-Blackfan, Fanconi, HS, HE, Alpha thal, etc)

Question 385

Complications of the donor twin in TTTS?

Answer 385

Anemia Hypotension Oliguria Oligohydramnios Circulatory insufficiency Heart failure Growth restriction Renal failure Fetal demise

Question 386

Complications of the Recipient twin in TTTS?

Answer 386

Polycythemia (hypoglycemia, jaundice) Hypertension Polyuria Polyhydramnios Circulatory overload Heart failure Hydrops fetalis Fetal demise

Question 387

Teratogenic effects of isotretinoin? ** RC favourite

Answer 387

Hydrocephalus CNS defects Small / absent ears Absent thymus Migrognathia Miscarriage Stillbirth Developmental delay Congenital heart defects

Question 388

Teratogenic effects of Lithium?

Answer 388

Ebstein anomaly, altered thyroid function, cardiac arrhythmia, hypoglycemia, polyhydramnios

Question 389

Teratogenic effects of Phenytoin? ** RC favourite

Answer 389

"Fetal hydantoin syndrome," growth and mental deficiencies, limb anomalies, hypoplastic nails, dysmorphic facies (low nasal bridge, short nose, ptosis), vitamin K deficiency and bleeding

Question 390

Teratogenic effects of tetracyclines?

Answer 390

Discolouration of fetal teeth, inhibition of bone growth

Question 391

Teratogenic effects of Thalidomide

Answer 391

Limb reduction defects, limb hypoplasia, eye/ear abnormalities, cardiac defects, developmental delay

Question 392

Teratogenic effects of VPA?

Answer 392

Neural tube defects, cardiac defects, developmental delay

Question 393

Teratogenic effects of Warfarin?

Answer 393

Nasal hypoplasia, stippled epiphyses, developmental delay, spontaneous abortion, fetal hemorrhage

Question 394

Diagnostic Criteria for FASD

Answer 394

Need: - prenatal alcohol exposure or suspected / unknown - if NO alcohol exposure, then no diagnosis - If UNKNOWN alcohol exposure, need 3 facial features (smooth philtrum, thin upper lip, small palpebral fissures) to continue investigation - if YES alcohol exposure, then need CNS impairment OR 3 facial features to continue investigation / assessment If history YES or UNKNOWN, PLUS 3 facial features PLUS CNS impairment = definitely FASD If history YES or UNKNOWN, plus 3 facial features but NO CNS impairment - look for microcephaly - if yes, then FASD - if no, then child is "at risk" if history UNKNOWN, but no 3 facial features, cannot make diagnosis if history YES, but no 3 facial features, can make diagnosis if there is CNS impairment