volume 3

Question 1

Name 5 risk factors for neonatal hypoglycaemia

Answer 1

1. small for gestational age
2. large for gestational age (90th % (controversy if non IDM LGA infants truly at risk)
3. IDM
4. preterm infants <37 week
   Can also get from : perinatal asphyxia, inborn metabolic or endocrine conditions

Question 2

Infant is identified as at risk (based on above) when should you check the glucose?

Answer 2

start at 2 hours of age (after an initial feed)

**for symptomatic infant, check at any point

Question 3

How long should you continue checking the sugar for infants at risk (as mentioned above)

Answer 3

for the at risk period

1. for IDM and LGA - 12 hours
2. for small GA and preterm - 36 hours

Question 4

delay in processing a blood sample, what do you expect will happen to the glucose level?

Answer 4

will get lower

Question 5

we rely a lot on point of care

Answer 5

new POC likely better
don’t rely to much on the oleo ones
exam answer is trust the lab

Question 6

symptoms of hypoglycaemia

Answer 6

jittery 
tremor
seizure
cyanosis
apnea/tachypnea
limp
high pitched or weak cry
trouble feeding
eye rolling can have sweating, pallor, hypothermia and cardiac arrest and failure

Question 7

SGA baby feeds at 2 hours, glucose is 1.7, what to do? no symptoms

1) IV dextrose
2) feed again

Answer 7

IV dextrose

Question 8

IDM baby feeds at 2 hours, glucose is 1.9, fed again, continues to be 1.9, what to do?

Answer 8

IV dextrose

since subsequent still < 2.0

Question 9

symptomatic baby with glucose 2.5 what to do
feed and repeat
treat asap

Answer 9

if symptomatic and <2.6, treat asap

Question 10

stable baby who is SGA but having repeated glucose of 2.4, what to do?

Answer 10

IV therapy since consistently <2.6

Question 11

What to start glucose at?

Answer 11

IV D10 at tfi 80 cc/kg/day (GIR 5.5 mg/kg/min)

increase up to IV D12.5 at 100 (GIR 10) at this point should consult speciality, consider glucagon

Question 12

how many babies with brachial plexus palsy will have residual deficits?

Answer 12

20-30% (before used to say that 90% will recover completely)

Question 13

who should you refer to multi D team with brachial plexus palsy

Answer 13

if incomplete recovery by 3-4 weeks, full recovery unlikely should refer to multi D team

Question 14

who many will recover within 1st month of life from brachial plexus injury?

Answer 14

75%, 25% will have permanent impairment and disability

Question 15

favorable prognostic signs for neonatal brachial plexus palsy?

Answer 15

onset of recover within 2 weeks

involvement of only proximal upper extremity

Question 16

Brachial Plexus Palsy C5-7

Answer 16

Erb (remember Erb 57)

Erb is a waiter

Question 17

Brachial Plexus Palsy C8-T1

Answer 17

Klumpke Klumpke has a claw

Question 18

When will you recover from brachial plexus injury?

Answer 18

75%, 25% have disability

Question 19

When to refer ?

Answer 19

> 1 month of symptoms

Question 20

What increases risk of brachial plexus injury?

Answer 20

fat baby
diabetes
shoulder dystocia
instrumentation

Question 21

Benefits of Surfactant

Answer 21

1. decreases pneumothorax
2. reduce mortality
3. decrease ventilation
4. decrease pneumo and interstitial emphysema
5. better neurodevelopment

Question 22

get to max D12.5 at 120, but still glucose low, what to do

Answer 22

1. endo
2. pharm intervention (IV glucagon, hydrocortisone, diazoxide, octreotide)
3. Critical sample

Question 23

How often does HIE happen

Answer 23

1/1000-6/1000, often without warning can happen in community hospitals

Question 24

What are some clinical features of HIE

Answer 24

1. CNS injury - with or without other involvement, severe will always involve other organs, moderate can be isolated
2. Renal (42%) oliguria/anuria/ATN, renal failure
3. Pulmonary (26%) : RDS, surfactant dysfunction, PPHN
4. GI (29%): paralytic ileus or delayed, NEC
5. Hepatic - increased ammonia, gill, GGT, decreased clotting factors at 3-4 days
6. Heme - thrombocytopenia
7. Metabolic: acidosis (lactate), hypoglycemia (hyperinsulinism), hypocalcemia (increased phosphate load, correction of metabolic acidosis
8. CVS: shock, hypotension, ventricular dysfunction, CHF

Question 25

Who should get cooled for HIE

Answer 25

1. moderate to severe HIE - standard of care 2. term and late preterm greater or equal to 36 weeks 3. less than 6 hours of age 4. meet criteria A AND B (see below)

Question 26

what is the therapeutic window for interventions in HIE?

Answer 26

phase 1: reduction blood flow and O2 supply, gal in ATP, fall in Na/K pump, depolarization etc LATEN period - after resuscitation and repercussion 6-12 hours - this the window for intervention to help reduce cell death

Question 27

What are the criteria for cooling?

Answer 27

``` criteria A (need 2) : apgar16 in gases within 1 hour of birth criteria B: moderate or severe (sarnat II or III) demonstrate by seizures or at least one sign in 3 categories in the table in the statement ``` if they meet the criteria then should offer cooling can consider doing EEG at 5.5 hours to help see if there are seizures

Question 28

Contraindications to cooling

Answer 28

1. IC bleeding/severe head trauma 2. > 6 hours of age or <36 hours gestation (no evidence) Initiation of cooling for infants with very severe encephalopathy, congenital anomalies or abnormal chromosomes is best performed in consultation with a tertiary centre.

Question 29

Which type of cooling is best?

Answer 29

no difference in outcomes for both head and total body cooling

Question 30

What is total body cooling vs selective head cooling

Answer 30

1. head - cooling caps, fontanelle < 30 C, rectal temp 34 +/- 0.5 , expensive, lots of work, can cause scalp edema, skin breakdown 2. total body - to temp 34 +/- 0.5 C, cheaper, can do EEGs, easier to do - can do it with passive cooling, cool packs and/or cooling blankets

Question 31

What temperature should you target for cooling?

Answer 31

34 +/- 0.5 C

Question 32

Sarnat staging - what stage of HIE most likely to have seizures? a) mild b) moderate c) severe

Answer 32

moderate - uncommon in severe (and none in mild)

Question 33

level of consciousness is hyper alert, what stage of HIE?

Answer 33

mild - is hyperalert (vs lethargic in moderate and coma in severe)

Question 34

Pupils are small but reactive in which stage of HIE?

Answer 34

small in moderate (large in stage 1, non reactive in 3) remember that mild is sympathetic (so big pupils, tachy, normal RR, not may secretions) moderate is parasympathetic (i.e. starting to give up) - small pupils, brady, slow breathing, lots of secretions severe is nada

Question 35

strong distal flexion, what stage of HIE?

Answer 35

moderate | in mild you have weak distal flexion, and in severe decerebrate

Question 36

How long should cooling last?

Answer 36

optimal unknown - most use 48-72 hours in the studies, 72 hours most common

Question 37

How quickly should you rewarm a baby after cooling them?

Answer 37

0.5 every 2 hours in most don't want to go too fast can get worsening of seizures and encephalopathy

Question 38

What are some side effects of cooling?

Answer 38

``` overall pretty safe - no serious SEs 1. hypotension 2. arrythmias 3. thrombocytopenia 4. edema have been described ```

Question 39

Why is cooling unsafe in preterm infant?

Answer 39

associated with increased mortality no evidence in <36 weeks doing studies in late preterm now

Question 40

Why do we do cooling for IE?

Answer 40

because it reduces mortality and negative neurodevelopment consequences in kids with moderate HIE severe is less likely to benefit from treatment should do it either in a level 3 NICU or after talking to a level 3 NICU