1
Q
Which infants are at highest risk of acquiring HSV?
A
Infants born to mothers who have a first-episode primary infection at the time of delivery since the mother had no pre-existing neutralizing antibodies to transmit to the baby through placenta-remember that most newly acquired cases are asymptomatic
2
Q
What steps may reduce risk of neonatal HSV transmission during pregnancy or at time of delivery?
A
- Acyclovir from 36 wks GA until delivery (no clear evidence on whether this reduces risk)2. Delivery by elective C-section in woman with active HSV lesions at delivery3. Avoid procedures that may break baby’s skin: forceps, vaccuum, fetal scalp monitoring
3
Q
What are the 3 categories of HSV infections?
A
- Disseminated2. Localized CNS3. Skin, eye and mucous membrane
4
Q
When should HSV be considered as a diagnosis in neonates?
A
Fever with irritability, seizures, liver dysfunction, or abnormal CSF fluid**Remember that in most cases, there is no known history of maternal HSV and infant has no skin vesicles!
5
Q
What is the dose of acyclovir for treatment of neonatal HSV? What is the duration of treatment?
A
Dose: 60 mg/kg/day or 20 mg/kg/dose IV q8hDuration: -SEM: 14 days IV-CNS/disseminated: 21 days minimum IV(Oral ACV has limited bioavailability thus IV is required)
6
Q
What is the definitive diagnostic test for non-CNS HSV?
A
Isolation of HSV by viral culture (from oropharynx, nasopharyn, skin lesions, mucous membranes)
7
Q
What is the definitive diagnostic test for CNS HSV?
A
HSV PCR (more sensitive than culture)
8
Q
Why is infant serology not useful for diagnosing neonatal HSV infection?
A
- Transplacental IgG antibodies cannot be differentiated from IgG produced by baby2. Production of antibodies is impaired in severely affected infants3. Commercially available assays for HSV IgM abs are of limited reliability
9
Q
What are two side effects of acyclovir?
A
- Nephrotoxicity2. Neutropenia
10
Q
What is the management of ocular HSV in neonates?
A
- IV acyclovir x 14 days2. Topical 1% trifluridine3. Ophtho consult
11
Q
What follow-up should infants with neonatal HSV infections have?
A
Because of potential for neurological sequelae, f/u should include:1. Neurodevelopment2. Ophtho3. Audiology
12
Q
When a diagnosis of neonatal HSV is suspected, what diagnostic investigations should be ordered? (3)
A
- Swabs of vesicular lesions and mucous membranes for culture or PCR2. CSF HSV PCR3. Liver enzymes to assess for disseminated HSV
13
Q
When evaluating for neonatal HSV infection in exposed asymptomatic infants, what diagnostic investigation should be ordered? (1)
A
- Mucous membrane swabs from mouth, nasopharynx and conjunctivae at least 24 hrs after delivery (so that maternal HSV virus on baby’s skin from delivery has time to clear)
14
Q
How long does it take for antibodies to HSV to develop following an infection?
A
Approximately 3 weeks
15
Q
What is the management for an infant delivered by C-section before ROM to a mother with presumed first-episode primary or first-episode nonprimary HSV infection at delivery?
A
Risk of NHSV is very low. If baby is well:1. Swab the baby’s mucous membranes at > 24 hrs of age2. If swabs are negative, then baby can be discharged home3. If swabs are positive, then the infant is managed as a case of neonatal HSV(Some experts recommending doing CSF analysis as well)
16
Q
What is the management for an infant delivered by SVD or C-section after ROM to a mother with presumed first-episode primary or first-episode nonprimary HSV infection at time of delivery?
A
- Test mom for HSV-1 and HSV-2 antibodies to figure out if she has primary (no prior HSV antibodies), nonprimary (HSV antibodies present but to the other type of HSV), or recurrent (antibodies present)2. Swab baby’s mucous membranes and start acyclovir (controversial whether to do this at birth with risk of surface contamination or at 24 hr of life)3. If swabs are positive, need to obtain CSF PCR to r/o CNS HSV4. If swabs are negative and mom’s serologies show she has recurrent HSV, then d/c acyclovir5. If swabs are negative and mom has primary HSV or serology testing is not available, baby needs acyclovir x 10 days
17
Q
What is the management for an infant born by C-section to a mother with recurrent HSV at delivery?
A
- Swab mucous membranes at 24 hrs of life2. If positive, treat as neonatal HSV3. If negative, d/c home
18
Q
What is the management for an infant born by SVD to a mom with recurrent HSV at delivery?
A
- Swab mucous membranes at 24 hrs2. If positive, treat as neonatal HSV3. If negative, d/c home**This is because baby is presumed to have HSV antibodies from transplacental transfer
19
Q
What is the management of asymptomatic infants whose mothers have no active lesions at delivery?
A
Does not swabs or acyclovir therapy
20
Q
Name 4 clinical scenarios in which you should consider neonatal HSV in the differential diagnosis?
A
- Infants started on IV antibiotics for suspected sepsis (especially infants with seizure or yielding abnormal CSF) who do not improve rapidly and have negative bacterial cultures at 24 hr incubation2. Infants admitted with pneumonia who do not improve after 24 hr on antibiotics3. Infants with unexplained bleeding or coagulopathy4. Infants started on IV antibiotics for suspected sepsis who are found to have unexplained hepatitis
21
Q
What is the management of HSV CNS disease?
A
- IV acyclovir x 21 days minimum2. Repeat CSF sampling near the end of 21-day course of therapy: if PCR remains positive, treatment should be extended with weekly CSF sampling and acyclovir stopped when negative PCR is obtained3. Suppressive therapy oral acyclovir x 6 months should be given to infants with CNS disease (double-blind RCT showing benefit in neurodev outcome)
22
Q
For infants on suppressive oral acyclovir treatment, what surveillance should they have?
A
Monthly CBC, BUN, Cr to rule out neutropenia and nephrotoxicity
23
Q
What are 4 risks of RBC transfusion in neonates?
A
- Transfusion-transmitted infections2. Acute volume or electrolyte disturbances3. Blood group incompatibilities (often mistransfusion errors)4. Adverse effects of leukocytes (graft versus host disease, transfusion related acute lung injury and alloimmunization)
24
Q
What is the combined risk of RBC contamination with viruses (Hep A, B, C, HIV)?
A
1 in 1-1.3 million
25
Two steps in treatment of perinatal hemorrhagic shock?
1. NS bolus at 10 ml/kg while waiting for blood2. O neg PRBC 10-15 ml/kgCan give as a 1 min push of 20 ml to stabilize if acutely hypotensive, then 10 ml/kg/h
26
What are the suggested hemoglobin levels for transfusing infants with anemia of prematurity?-Week 1-Week 2-Week 3 and older(Cochrane review & Pint study)
***Resp support = O2 need > 25% or CPAP/I&VWeek 1: -Resp support: 115-No resp support: 100Week 2:-Resp support: 100-No resp support: 85Week =/>3:-Resp support: 85-No resp support: 75
27
What were the short-term outcomes of neonatal transfusion trials (restrictive vs. liberal transfusion thresholds)? (5)
No difference in outcomes of mortality or morbidity in:1. BPD2. ROP3. Growth4. IVH5. **some reports of increased NEC with recent transfusion but unclear significance (found with restrictive policies)
28
What were the long-term outcomes of neonatal transfusion trials (restrictive vs. liberal transfusion thresholds)?
No difference in death or disability at 18-21 months CGA
29
Is there any evidence to support the use of Erythropoietin in anemia of prematurity?
Not currently except for families who withhold consent to transfuse with blood products
30
At what age does cross-matching blood become necessary for infants?
At 4 months of age-Prior to 4 months of age, if they get a type and screen and there is no antibodies, then you can give them group-specific Rh-compatible blood without cross matching
31
In cases of massive hemorrhage, what kind of transfusion should neonatal patient receive?
If a large volume of blood is required, must use combined replacement with fresh frozen plasma in order to avoid hyperkalemia and dilution of coagulation factors
32
Can transfusions be helpful to improve weight gain or to address apnea of prematurity when Hgb levels are higher than recommended thresholds?
NO! Trials have shown no improvement in weight gain and only mild improvements in apnea (which are thought to actually be related to volume repletion). Only transfuse at recommended thresholds.
33
What are the 4 physiological competencies preterm babies must achieve before being eligible for discharge home?
1. Thermoregulation: maintain normal body temperature when fully clothed in an open cot2. Control of breathing: apnea free period of at least 5-7 days3. Respiratory stability: maintenance of SaO2 > 90-95% in RA4. Feeding skills/weight gain
34
What is the definition of apnea of prematurity?
Cessation of breathing for:1. Greater than 20 secondsOR2. 10-20 seconds accompanied by bradycardia (HR < 80) or desaturation (SaO2 < 80% in infants & > 37 wks PCA)
35
Why do we wait up to 7 days spell free after discontinuing caffeine before saying apnea of prematurity has resolved?
Caffeine has prolonged half-life in neonates (up to 100 h) and infants may be at risk for recurrence of apnea for several days after discontinuation
36
How long does apnea of prematurity generally last for?
Most resolve by 36 wks PCA but in very preterm infants, may take up to 44 wks PCA
37
Is apnea of prematurity a risk factor for SIDS?
No!
38
Is there a difference in morbidity for preterm infants where SaO2 targets are low (89-94%) vs. high (95-100%)?
Yes - for babies with higher target SaO2, increased respiratory morbidity (pneumonia, acute exacerbations of chronic lung disease, need for diuretics and/or oxygen)-No difference in growth or neurodevelopment in either group-Might have reduction in ROP with higher SaO2 targets (but results were nonsignificant)
39
What is the target SaO2 for infants with BPD?
90-95%
40
Before discharge home, what 8 things must be completed for a preterm infant?
1. Provincial newborn screening2. Hearing screen3. Assessment for RSV prophylaxis4. HUS at near-term (if indicated by GA)5. Successful SaO2 monitoring in car seat6. ROP screening (if indicated by GA or BW)7. Immunizations 8. Predischarge physical examination including measurement of weight, length and head circumference
41
Before discharge of a preterm infant, what education should the family receive (4)?
1. Safe sleep practices and SIDS prevention2. Infant CPR (highly recommended)3. Understand infection control measures4. Understand importance of smoke-free environment
42
Why is early (ie. in the first week of life) postnatal corticosteroid therapy NOT recommended in preterm infants to prevent CLD?
Increased risk of cerebral palsy and poor neurodevelopmental outcome-multiple systemic reviews reported this finding, especially with dexamethasone
43
What is the commonly used definition of chronic lung disease/bronchopulmonary displasia?
Need for O2 at CGA of 36 weeks + respiratory symptoms + compatible changes on CXR
44
What is the DART trial?
Dexamethasone: a randomized trial-looked at low-dose dexamethasone (0.15 mg/kg/d, tapered over 10 days for cumulative exposure of 0.9 mg/kg) for decreasing CLD-found low dose dex shortened duration of intubation for ventilator-dependent infants-unfortunately study was terminated early due to declining enrolment and was not sufficiently powered to detect long term outcomes
45
What is the current evidence on use of low-dose dexamethasone in preventing CLD?
Currently, there is insufficient evidence to demonstrate the safety of ROUTINE low-dose dexamethasone use
46
What is the current evidence on use of high-dose dexamethasone in preventing CLD?
This is NOT recommended!-grade A evidence
47
What is the current evidence on:-routine use of hydrocortisone in preventing CLD?-routine use of inhaled corticosteroids in preventing CLD?
Hydrocortisone: NOT recommended! -multiple meta-analyses showing no benefits compared to dexamethasoneInhaled corticosteroids: NOT recommended-no RCTs available
48
When may be an appropriate time to use late dexamethasone therapy for preventing CLD?
Can consider use for infants who are at high risk of severe CLD or who are ventilator-dependent for severe CLD-low dose dexamethasone (0.15-0.2 mg/kg/day) in tapering doses over a short course (7-10 d)
49
What is the risk of congenital malformations seen with the use of SSRIs during pregnancy?-with which SSRI is there inconclusive evidence for causing congenital malformations?
Multiple studies show that SSRIs are unlikely to be associated with an increased risk of congenital malformations-some studies found that paroxitine may lead to small increased risk of cardiac malformations but evidence is inconclusive
50
What are the clinical features of SSRI neonatal behavioural syndrome (SNBS)?-does timing of SSRI use in pregnancy affect the risk of developing SNBS?
Tachypnea, cyanosis, tremors, increased muscle tone, feeding disturbance seizures, in 10-30% of babies exposed to SSRIs in utero-s/s present within hours, are mild and usually resolve within two weeks-unclear whether related to withdrawal, toxicity following in utero exposure or combo of both-increased risk of SNBS if exposure to SSRI is late in gestation as opposed to early
51
What are the possible side effects on newborn from SSRI exposure in utero (2)?
1. SSRI neonatal behavioural syndrome2. PPHN (this is negligible though since absolute risk is < 1%)
52
What is the recommendation for use of paroxetine in pregnancy?
No conclusive evidence that paroxetine use causes cardiac malformations-BUT care providers may choose to switch them to another antidepressant or reducing the dose if they wish
53
What is the recommendation regarding monitoring for newborns exposed to SSRI in utero?
Babies with late trimester SSRI exposure should be observed in hospital for neurobehavioural or respiratory symptoms for a minimum of 48 hrs
54
What are the physiological responses to laryngoscopy/intubation? (4)
1. Bradycardia (vagal response)2. Hypoxia3. Intracranial hypertension (coughing/struggling)4. Systemic and pulmonary hypertension (catecholamine release in response to pain)
55
What premedications can dampen physiologic responses to intubation in a newborn?
1. Bradycardia --> atropine2. Hypoxia --> muscle relaxants3. Intracranial hypertension --> muscle relaxants4. Systemic hypertension --> analgesia
56
Under what 2 clinical circumstances is it acceptable to intubate an infant without the use of premedication?
1. Resuscitation in delivery room or during acute deterioration2. Infants with severely abnormal airways who will be difficult to intubate
57
What is a rare potential side effect of fentanyl?
Chest wall rigidity: can be treated with immediate administration of rapid acting muscle relaxant
58
What are 2 contraindications to the use of succinylcholine in neonatal intubation?
1. Family hx of malignant hyperthermia (autosomal dominant)2. Hyperkalemia
59
What is the recommended protocol for neonatal premedication (agent and dose)?
1. Fentanyl 3 mcg/kg slow infusion over 1 minute2. Succinylcholine 1 mg/kg3. Atropine 0.02 mg/kg IV (minimum dose available is 0.1 mg)
60
What is the definition of late prematurity?
GA 34+0-36+6
61
After the birth of a late prem baby, what monitoring should take place?
1. Core temperature2. Blood glucose at 2 hr of life3. Vital signsOverall short term observation for cardioresp stability and ability to feed before transfer to low risk nursery
62
List the postdischarge problems of the late preterm that may lead to readmission (5)
1. Hypothermia2. Apnea/ALTE3. Hyperbilirubinemia4. Suspected sepsis5. Respiratory issues
63
How do bilirubin levels differ in late prem infants compared to term infants? (4)
1. Peaks later (at 7 days as opposed to 5 days)2. Reaches higher peak3. Stays elevated for longer4. Risk of kernicterus at lower levels of bilirubin
64
What is the discharge criteria for late preterm infants?
1. Bilirubin must be checked by 48 hrs of birth2. 24 hrs of successful feeding must be established-first time moms need careful supervision and should have a room-in experience when leaving NICU-individual feedings should not be > 20 mins-feeding and prep for feeding should not > 6 hrs of the day at discharge-early weight loss should not > 10% of body weight3. If hx of apnea, needs to be apnea free > 8 days4. No hypoglycemia5. Able to maintain normal body temperature
65
What is the recommendation on monitoring for apnea of prematurity in late prem infants?
Babies 34+0-34+6 wks GA require cardioresp monitoring x 12-24 hrs-if apnea is identified, need a period of 8 days apnea free -discharge on caffeine is not recommended
66
When should a follow up appointment occur post discharge of a late prem baby?
Within 48 hrs
67
In a clinically unwell newborn, what is the approach for ruling out early-onset sepsis?
Full septic work-up REGARDLESS of what risk factors were or were not present (ie. GBS status, intrapartum abx = even if GBS negative, woman could become colonized after swab was done; IAP with penicillin does not affect frequency of other bacterial causes of sepsis), then immediate start of empiric abx
68
What is the gram stain result of the following organisms:-GBS-Listeria-E coli
GBS: gram positive cocciListeria: gram positive rodsE coli: gram negative rods
69
What is the management of a well-appearing infant of a GBS positive mother who received IAP of penicillin > 4 hrs before delivery?
No intervention!-> 4 hrs intrapartum penicillin significantly reduces risk of early onset GBS
70
What is the management of a well-appearing infant of a GBS-positive mother who received IAP
Do a CBC: if WBC 5, then clinical observation x 24 hrs.**Risk of early onset GBS in this population is 1%-if WBC
71
What is the management of a well-appearing infant of a GBS-negative mother who had risk factors at delivery?
CBC: if normal, monitor x 24 hrs. If WBC < 5, FWSU
72
What are the risk factors for early GBS sepsis? (6)
1. Intrapartum fever2. ROM > 18 hrs3. GBS bacteruria4. Previous child with invasive GBS disease5. Maternal chorioamnionitis6. Prematurity < 36 wks
73
What is the management of a well-appearing infant of a mother with unknown GBS status and no risk factors?
No intervention
74
What is the management of a well-appearing infant of a mother with unknown GBS status with risk factors?
If mom received adequate intrapartum abx, then no intervention. If not, then check CBC: if WBC < 5, FSWU. If WBC normal, then monitor x 24 hrs.
75
What is the definition of:-severe hyperbilirubinemia-critical hyperbilirubinemia
Severe: TSB > 340 at any time during the first 28 days of lifeCritical: TSB > 425 at any time during the first 28 days of life (risk of kernicterus)
76
What is the definition of acute bilirubin encephalopathy?-chronic bilirubin encephalopathy?
Acute bilirubin encephalopathy: in severe hyperbilirubinemia, clinical features of lethargy, hypotonia, poor suck --> may progress to hypertonia, high pitched cry, fever, seizures and comaChronic bilirubin encephalopathy: sequelae of acute encephalopathy with athetoid cerebral palsy +/- seizures, developmental delay, hearing deficit, oculomotor disturbances
77
When should a DAT be performed for jaundiced neonate?
DAT should be performed only if:1. Mom's blood group is O-and-2. Baby is clinically jaundiced-and-3. Baby's bilirubin level is in low-intermediate or high-intermediate zone (risk of needing PT)
78
What are the risk factors (8) on the phototherapy graph that affects whether you use the lower, medium or high risk line?
Lower risk: > 38 weeks and wellMedium risk: > 38 weeks with risk factors or 35-37+6 wks and wellHigher risk: 35-37+6 wks and risk factorsRisk factors:1. Isoimmune hemolytic disease2. Respiratory distress3. Significant lethargy4. Acidosis5. Sepsis6. G6PD deficiency7. Asphyxia8. Temperature instability
79
What are the 4 ethnic groups in which you should consider ordering G6PD testing in cases of hyperbilirubinemia?
1. Middle eastern2. Mediterranean3. African4. Southeast Asian
80
If G6PD deficiency is X-linked, do you need to order this test for female babies with jaundice if they fit into the ethnic groups at risk?
YES! Still order because females can have X inactivation and thus have 50% of their red cells be deficient in G6PD and have severe jaundice from this
81
When should you consider G6PD deficiency testing in neonatal jaundice?
1. In babies with clinical jaundice who belong to at risk ethnic groups2. Babies with severe hyperbilirubinemia (TSB > 380)***note: in active hemolysis, G6PD testing is not reliable due to increased reticulocytes obscuring the results
82
When should the first bilirubin level be checked in infants?
Within 24-72 hrs of life
83
Are transcutaneous bilirubins acceptable?-limitations?
Transcutaneous bilirubin as a screening device is reasonable-more accurate at lower levels of bilirubin-may be unreliable after initiation of phototherapy and changes in skin color and thickness
84
What are the side effects of phototherapy? (3)
1. Temp instability2. Intestinal hypermotility/diarrhea3. Disrupted maternal-infant bonding**mild increase in water loss from skin but this is not clinically important in term babies who are drinking well
85
What is the recommendations for the use of IVIG in neonatal jaundice?
Useful for newborns with hemolytic jaundice (positive DAT who have predicted severe disease based on antenatal investigation)-1 g/kg
86
What is the recommendation for supplemental fluids for neonatal jaundice?
Supplemental fluids can be administered orally or IV in infants receiving phototherapy who are at elevated risk of progressing to exchange transfusion
87
After the initiation of phototherapy for neonatal jaundice, when should the first repeat of bilirubin be completed?
Within 2-6 hr of initiation of treatment to confirm response
88
What blood tests should be completed prior to exchange transfusion?
Since exchange transfusion means giving the infant someone else's blood, need to collect blood to investigate for hemoglobinopathies, enzymopathies, and membranopathies.
89
What is the management for an infant with clinical signs of acute bilirubin encephalopathy?
Immediate exchange transfusion
90
Perinatal brachial plexus palsy has been associated with what risk factors? (4)
1. Shoulder dystocia2. LGA3. Maternal diabetes4. Instrumental delivery**No proven causative correlations though and it is not always preventable (might have occurred in utero)
91
What percentage of babies with perinatal brachial plexus palsy will have permanent impairment and disability
25%-if physical examination shows incomplete recovery by 1st month, full recovery is unlikely
92
If perinatal brachial plexus palsy shows incomplete recovery by the end of the first month, what are the management steps?
Referral to multi-d brachial plexus team: neurologists/rehab/plastic surgeons-no RCTs evaluating nonsurgical management vs surgical management
93
What changes are seen on CXR for a baby with RDS (3)?
1. Ground glass opacities2. Decreased lung volume3. Air bronchograms
94
What are the proven benefits of surfactant therapy (5)?
1. Reduced mortality2. Decreased duration of ventilatory support3. Decreased incidence of pneumothorax and pulmonary interstitial emphysema4. Decreased hypoxia5. Improved neurodevelopmental outcome
95
Which clinical circumstances warrant the use of exogenous surfactant therapy? (4)
1. Intubated infants with RDS 2. Intubated infants with meconium aspiration syndrome requiring more than 50% oxygen-meconium deactivates surfactant leading to secondary surfactant deficiency3. Sick newborns with pneumonia and an oxygenation index > 15 -decreases the need for ECMO4. Intubated newborn infants with pulmonary hemorrhage leading to clinical deterioration (not great evidence)
96
What are the three short-term risks of surfactant administration?
1. Bradycardia and hypoxemia during instillation2. ETT blockage3. Increased risk in pulmonary hemorrhage
97
Which is better: natural or synthetic surfactants? Why?
Natural has been found to be better: improve survival with lower incidence of airleak
98
Should surfactant be given prophylactically or as rescue therapy?
For infants who are at significant risk of RDS, prophylactic natural surfactant therapy should occur as soon as they are stable within a few minutes after intubation
99
What is the evidence on using multiple or single doses of surfactant?-criteria and timing of multiple doses?
In infants with RDS who have persistent or recurrent oxygen and ventilatory requirements within the first 72 hours of life, they should have repeated doses of surfactant-using more than 3 doses does not have any benefit***For repeated doses, criteria to give would be if there is persistent or recurrent O2 requirement of 30% or more***Can give surfactant as early as 2 hr or 4-6 hrs after first dose
100
After prophylactic surfactant therapy is given, what are the next management steps for ventilation?
Remember that giving surfactant can cause rapid improvement in lung compliance so must be able to wean vent settings appropriately-can consider rapid weaning and extubation to CPAP within 1 hr of surfactant if clinically well
101
What is the recommendation for antenatal steroids in threatened preterm labor?
Threatened preterm labor < 34 weeks should all be given antenatal steroids-reduces RDS and IVH
102
What is the recommendation on whether prems should receive surfactant prior to transport?
They SHOULD!
103
What is kangeroo care?-benefits?
Practice of skin-to-skin contact between infant and parent-Benefits for prems/low birth weight in low income countries: reduced mortality, severe illness, infection, length of hospital stay-Benefits in high income countries for same population: cardioresp and temp stability, improved sleep, neurodevelopmental outcomes, breastfeeding, maternal bonding and family health
104
At a cellular level, what are the 3 phases of brain injury in hypoxic ischemic encephalopathy?
1. Primary phase: reduced blood flow and oxygen supply --> anaerobic metabolism in the brain --> lactic acidosis, release of excitatory amino acids, possible cell necrosis2. Latent phase (after resuscitation and reperfusion): normalization of oxidative metabolism lasting 6-12 hr (therapeutic window for neuroprotective interventions)3. Secondary phase: develops at 12-36 hr, lasting 7-14 days with cell apoptosis, edema, release of free radicals and cell death
105
What are the 4 neuroprotective mechanisms of mild hypothermia in HIE?
1. Cessation of cell apoptosis2. Reduced oxygen consumption3. Reduced release of free radicals/nitric oxide/glutamate/excitatory neurotransmitters4. Induction of genes that reduce neuronal death
106
Name 2 ways to provide brain hypothermia for HIE patients?
1. Selective head cooling (cooling cap for head and radiant heater for body)2. Total body cooling (cooling blankets)**Both have been shown to be effective in clinical trials
107
What are 2 concerns with use of hypothermia in infants with severe encephalopathy?
1. Decreased benefit2. Delays end of life decision making for infants with extremely poor prognosis
108
What are the criteria that must be met in order to quality for hypothermia in HIE?-4 categories
1. Gestational age 36 wks and olderAND2. Age < 6 hrsAND 3. Meet both criteria A and BCriteria A (think ABG): need 2/3-APGAR score < 5 at 10 mins of age-Breathing: continued need for ventilation and resuscitation at 10 mins of age-Gas: metabolic acidosis with pH < 7 or base deficit > 16 in cord or ABG measured within 1 hr of birthCriteria B (think encephalopathy):-moderate (Sarnat stage II) or severe (Sarnat stage III) demonstrated by presence of seizures OR one sign in at least 3/6 categories of the clinical features chart (LOC, spontaneous activity, neuromuscular control, primary reflexes, autonomic system, seizures, EEG findings)
109
Where should hypothermia be provided for HIE?
Level III NICU or in consultation with level III neonatologist before transport
110
What are 2 contraindications to cooling for HIE?
1. Severe head trauma2. Intracranial bleeding***Hypothermia can induce mild platelet dysfunction, disrupt coagulation cascade
111
What is the target temperature to be reached during cooling for HIE?
34 +/- 0.5 degrees rectal
112
How long does cooling last in management of HIE?
48-72 hrs
113
How should an infant be rewarmed in hypothermia management for HIE?
Increase rectal temperature by 0.5 degrees celcius every 2 hrs
114
What are 2 risks of rewarming in HIE?
1. Seizures2. Worsening encephalopathy
115
What are the possible side effects of hypothermia (4)?
1. Bradycardia2. Hypotension3. Cardiac arrhythmias4. Thrombocytopenia
116
What 4 groups are at risk for neonatal hypoglycemia?
1. SGA: decreased substrate2. LGA: usually increased insulin3. Prematurity: usually decreased substrate4. Infants of diabetic mothers
117
What is the definition of SGA and LGA?
SGA: weight < 10th%LGA: weight > 90th%
118
How long should hypoglycemia monitoring continue for infants of diabetic mothers and LGA infants?
If these babies present with hypoglycemia, studies have shown that they present within the first 12 hrs of birth-if BG maintained > 2.6 by 12 hr of age, can d/c BG checks
119
How long should hypoglycemia monitoring continue for SGA and premature infants?
These babies are vulnerable to hypoglycemia up to 36 hrs of age (and beyond if feeding not well established)-if glucoses have been >2.6 and feeding has been established, can d/c glucose checks at 36 hr
120
Which babies should be tested for hypoglycemia after delivery and when should testing occur?
1. At-risk babies at 2 hrs of age (after an initial feed) and continued until the period of risk is considered over2. Symptomatic infants
121
Are glucose levels < 2.0 worrisome in healthy newborns?
Population data suggests that blood glucose levels as low as 2.0 or even 1.8 at 1 hr of age are not uncommon and there is no evidence that there are adverse effects! -in at risk infants however, persistent hypoglycemia at this level may have negative neurodevelopmental outcomes
122
What are the recommendations for hypoglycemia monitoring in asymptomatic, at-risk babies?
1. Asymptomatic at risk babies should receive at least one effective feed before a BG check at 2 hrs of age-if BG < 1.8 at 2 hr of age despite one feed OR < 2.0 at subsequent feeding, start IV dextrose infusion (D10W at TFI 80); can also try a mini-bolus of 2 cc/kg of D10W2. Check BG q3-6 hr after.3. For at risk babies who repeatedly have BG levels < 2.6 despite subsequent feeds, start IV dextrose infusion (D10W at TFI 80)
123
In hypoglycemic babies being treated with IV dextrose infusion, what should the target BG be?-when should BG be rechecked after making a change in glucose infusion rate?
> 2.6 -check BG 30 minutes after making a change to GIR
124
If glucose infusion rate needed to maintain BG > 2.6 in a neonate is >10.4 mg/kg/min (D12.5 at TFI 120), what are the next management steps?
1. Specialist referral2. Pharmacological intervention (IV glucagon, hydrocortisone, diazoxide, octreotide)3. Critical sample
125
What is the dose for glucagon IV?-bolus-infusion
Glucagon IV bolus 0.1-0.3 mg/kgGlucagon infusion 10-20 mcg/kg/h
126
In a hypoglycemic baby, when can IV dextrose be weaned?
Wean when BG levels have been stable for 12 hr
127
Should screening glucoses be checked in term, appropriate for gestational age infants?
NO!
128
Which newborns should be routinely screened for neonatal hypoglycemia? (4)
1. LGA2. SGA3. Prem4. IDM
129
When should babies with symptomatic hypoglycemia be treated?
If BG < 2.6
130
What is the management of asymptomatic at risk infants with blood glucose levels of 1.8-2.5?
Enteral supplementation may be used to augment caloric intake with rechecks of BG in 60 minutes-if fails to respond, then must be treated with IV dextrose infusion
131
What are the 3 phases of grief and mourning?
1. Avoidance or protest2. Confrontation and disorganization3. Accomodation or reorganization
132
Which babies should be car-seat tested prior to discharge home from hospital?
1. Premature babies born at < 37 wks2. Babies with cardiorespiratory or neurological abnormalities (ie. hypotonia)**Overall, little evidence available for health care benefits or economic impact of recommendations for testing infants in car seats before hospital discharge
133
What is the generally accepted definition of cardiorespiratory abnormalities during a pre discharge car seat testing?-what happens to babies who fail car seat testing?
Two or more episodes of oxygen desaturation (<88%) for 10 seconds or more during a 90 minute monitoring period-if babies fail car seat testing but are otherwise healthy, may be sent home in a recumbent car restraint if repeat testing in the recumbent position is satisfactory-if not, then need continued hospitalization
134
Where is endogenous nitric oxide produced and how does it work?
NO is made by lung endothelium by NO synthase --> diffuses into vascular muscle cells --> activates guanylate cyclase --> pulmonary vasodilation and improved V/Q matching
135
What are the benefits of iNO for PPHN shown by multiple prospective clinical trials? (2)
1. Decresaed incidence of death2. Decreased need for ECMO
136
What are the indications for use of iNO?-OI threshold to start iNO?
Infants equal to or greater than 35 wks GA with hypoxemic respiratory failure who fail to respond to appropriate respiratory management (ie. optimizing mechanical ventilation, surfactant, HFO/JET)-start for OI > 20-25 or if PaO2 remains less than 100 mmHg, despite optimal ventilation with 100% oxygen
137
What is the evidence for use of iNO in preterm infants?
Not effective as rescue or routine treatment for preterm infants-don't use in prems!
138
What is the recommended starting dose of iNO for term infants?
20 ppm-expected response is rapid given half life of iNO is 2-6 s-if no response, can increase up to 40 ppm
139
What criteria should be met before iNO is weaned? (3)How do you wean iNO?
1. Improved oxygenation with inspired O2 need down to 60-80%2. 4-6 h of stability3. OI < 10Wean iNO:1. Decrease by 50% at 4-6 hr intervals until reach 5 ppm2. Once at 5 ppm, need to decrease more gradually --> decrease by 1 ppm q4h and discontinue at 1 ppm if infant remains well oxygenated in < 60% oxygen
140
What are the toxic side effects of iNO? (4)
1. Nitrogen dioxide production-cytotoxic and can cause pulmonary injury-unlikely with iNO < 80 ppm2. Methemoglobin production-NO in blood binds to ion of heme protein which is oxidized to methemoglobin-should be measured frequently and kept < 2.5%-unlikely with standard iNO doses3. Decreased platelet function and increased risk of bleeding4. Surfactant dysfunction
141
Who should get ROP screening?-when do you start screening?
Who?1. 30+6 wks or less 2. 1250 g or lessWhen?-If 26+6 or less, screen at 31 weeks-if 27 wks or greater, screen at 4 wks of age
142
What are the normal retic levels in term baby?
5% in term
143
What is the definition of and causes of the following types of hemorrhagic disease of the newborn?-"early"?-"classic"?-"late"?
Early: occurs within the 1st 24 hrs-caused by mothers taking drugs that impair vitamin K metabolismClassic: occurs within the 1st week of life-caused by no vitamin K administration at birthLate: occurs at 3-8 wks of life-caused by breastfeeding from mom with vitamin K deficiency OR late effects of not receiving vitamin K at birth
144
Does IM vitamin K provide complete protection from hemorrhagic disease of the newborn?
Does not provide compelte protection from late HDNB, especially in breastfed infants whose oral intake of vitamin K is low
145
What is the recommendation on vitamin K administration for neonates?
Vitamin K should be given as a single IM dose (0.5 mg for BW < 1500, 1 mg for BW > 1500) to all newborns within the first 6 hrs after birth
146
What is the recommendation for neonates in which parents refuse the IM Vitamin K?
Offer oral dose of 2 mg vitamin K at the first feeding-conflicting evidence regarding efficacy of oral vitamin K versus IM (some studies show it is just as good, other studies show it doesn't protect as well against late HDNB)-needs to be repeated at 1 and 2 months-need to warn parents that their baby is at risk of late HDNB with potential for intracranial hemorrhage using the oral vitamin K
147
What are the long term effects of late postnatal corticosteroids?
1. HOCM2. Increases ROP but NOT blindness
148
What is the diagnostic criteria for FAS? (3)
1. Prenatal or postnatal growth restriction2. CNS involvement: neurological abnormalities, developmental delay, behavioural issues, etc.3. Characteristic facial features:a. short palpebral fissuresb. thin upper lipc. indistinct philtrumd. flattened cheek bones
149
What is the definition of "possible fetal alcohol effects"?
FAE = alcohol is considered as one of the possible causes of a child's birth defects-for children with prenatal exposure to alcohol but only some FAS characteristics
150
What is the incidence of UTI in uncircumcised boys vs. circumcised boys?
Incidence of UTI in 1st year of life for uncircumcised = 1% for circumcised = 0.1%.-Circumcision decreases the incidence rate of UTI by 10-fold or more. BUT... the incidence rate of UTI among infant boys is only 1-2% overall
151
What are the complications of circumcision? (5)-what is the rate of complications?-why is the rate important to know when discussing circumcision with parents?
1. Bleeding2. Amputation of glans3. Sepsis4. Acute renal failure5. Death -rate of complications: 2%-important to know and tell parents because the rate of complications of circumcision approaches or even exceeds the incidence of UTI among uncircumcised male infants
152
What is the strongest factor associated with the decision about whether to circumcise a male infant for a parent?
Whether his father was circumcised
153
What are the effects of circumcision on penile cancer and HIV?
Some reports that circumcision reduces incidence of penile cancer and HIV transmission - however, there is inadequate info to recommend it routinely as a public health measure
154
What is the classification of ROP?
5 stages and pre-plus disease or plus disease1. Stage 1: LINE separating avascular from vascularized retina2. Stage 2: RIDGE in region of demarcation line3. Stage 3: NEOVASCULARIZATION4. Stage 4: Partial retinal detachment5. Stage 5: Total retinal detachmentPre-plus disease: more vascular tortuosity than normal but insufficient for diagnosis of plus diseasePlus disease: vascular dilatation and tortuosity of at least 2 quadrants of the eye
155
What is the treatment for ROP?
Retinal ablative therapy = decreases production of angiogenic growth factor to decrease abnormal blood vessel growth
156
What are the risks of early postnatal steroids for CLD? ie. WHY DO WE NOT GIVE THEM? (4)
1. Increased CP and neurological outcomes2. Hyperglycemia3. Hypertension4. Increased GI hemorrhage
157
What are the pros of late postnatal low dose steroids for CLD? (5)
1. Decreased O2 need2. Decreased ventilation time3. Decreased mortality4. Decreased number of babies discharged on O25. Decreased CLD at 36 wks
158
What factors have effect on prognosis of extremely premature infants? (6)
1. Gestational age: strongest effect2. Birth at tertiary perinatal centre3. Female sex4. Birth weight5. Multiplicity6. Antenatal corticosteroid therapy
159
What are the recommendations on C-sections for possible delivery of extremely preterm infants?
Not recommended before 24 weeks GA unless for maternal indications
160
What level of care is recommended for infants born at 22+0 - 22+6 wks GA?
Since survival is uncommon, a non interventional approach is recommended with a focus on comfort care
161
What level of care is recommended for infants born at 23-25 wks GA?
Should be joint decision made by family and health care team (individualized plan)
162
What level of care is recommended for infants born > 25 wks GA?
Most infants > 25 wks GA have improved survival and neurodevelopmental outcomes so active treatment is appropriate except when there are significant additional risk factors (weak recommendation)
163
What 3 questions should you ask when called to newborn delivery? (ie. start of NRP algorithm)?
1. Term?2. Crying or breathing?3. Tone?
164
What are the initial steps of NRP when the newborn is delivered?
1. Warm2. Dry3. Clear the airway if needed4. Stimulate5. Then check HR and breathing
165
What is the "Golden Minute" of NRP?
PPV if needed should be provided within 1 minute of delivery!
166
What is the most important indicator of PPV effectiveness?
Rise in HR!
167
When you initiate PPV for a neonate, what should also be completed?-starting oxygen level for all babies?-when do you crank up to 100%?
Preductal oxygen saturation placed!-starting O2 level = Room Air!!!-for very preterm babies, may use 30-90% guided by pulse oximetry but evidence is unclear-crank up to 100% if chest compressions are needed
168
In what babies can laryngeal mask airway be used?
Must be > 34 weeks and > 2000 g
169
A baby is born and has no detectable heart rate despite resuscitative efforts. When is it appropriate to consider discontinuing resuscitative efforts?
After 10 minutes of resuscitative efforts with no detectable heart rate.
170
True or false: infants who deliver at less than 29 wks GA outside of a tertiary centre should be considered for immediate intubation followed by surfactant administration after stabilization, regardless of whether they are symptomatic or not, as long as competent personnel are available.
TRUE!!!! This is one of the MCQs.
171
What is a possible complication of Epo in neonates?
Increased ROP (this is POSSIBLE, not certain though)
172
What are the risks of a prolonged NICU stay? (5)
1. Poor coping by parents2. Financial burden on family3. Nosocomial infection4. FTT5. Poor parental bonding
173
What is the most accurate way of estimating GA?
Early U/S
174
What is the survival rate of the following:-23 wk-24 wk-25 wk
23 wk: 40%24 wk: 60%25: 80%
175
What are the risks for fetus/newborn in a depressed mother? (6)
1. Risk of preterm labor2. Risk of miscarriage3. Risk of resp distress at birth4. Maternal suicide5. IUGR6. Increased length of hospital stay for baby
176
Which baby is more likely to be readmitted for issues?-34 wk-35 wk-36 wk-what is the risk of CP in a late preterm baby compared to term baby?
36 wker because they're the ones who are most likely to be sent home early!-3x risk of CP in late preterm baby compared to term baby
177
What should the temperature of the home be for a lightly dressed infant sleeping in a cot?
18 degrees celcius
178
What is the classical triad of chorioamnionitis?
1. Fever2. Left shift3. Lower uterine tenderness
179
What GA should you consider prophylactic surfactant administration outside of a tertiary care centre?
Infants who deliver < 29 wks outside tertiary care centre should be considered for immediate intubation and prophylactic surfactant if competent personnel are available.
180
Newborn has first BG 1.9. You feed and check again in an hour and the BG is 2.4. What do you do?
IV treatment! Subsequent BG should be 2.6 or more!
181
Which babies should get retinal ablative treatment for ROP?-when should treatment be performed in regards to when you discovered the finding?
1. Any stage of ROP with plus disease in zone 1 (because this is closest to your optic nerve)2. Stage 3 with or without plus disease in zone 13. Stage 2 or 3 ROP with plus disease in zone 2***Treatment should be performed within 72 hrs of exam
182
When do you stop screening for ROP?
1. Complete vascularizatino2. 45 wks of age3. Zone III vascularization without previous zone 1 or 2 issues4. Regression of ROP***zone 1 is closest to optic nerve, then zone 2, then zone 3
