Pediatrics Neonatology Flashcards

Terms Definitions
Apgar Score
meconium aspiration complications
pneumothorax
aspiration pneumonitis
pulmonary artery hypertension
neonatal sepsis presentation
irritability
poor feeding
fever
grunting
bulging fontanel
delayed capillary filling
Causes of neonatal hyperbilirubinemia
gastroschisis
uncovered protrusion lateral to abdominal midline; may have intestinal atresia
hydrocele
transitory; palpation and illumination of testes diffrentiated from inguinal hernia
congenital torticollis
knotted-up sternocleidomastoid; treat with passive ROM exercises
indirect hyperbilirubinemia, Coombs test -, low hb
spherocytosis
eliptocytosis
G6PD deficiency
pyruvate kinase
necrotizing enterocolitis
transmural intestinal necrosis associated with prematurity
bloody stools, apnea, lethargy, abdominal distention
pneumatosis intestinalis on abdominal x-ray is pathognomonic
erythema toxicum
firm yellow-white papules/pustules with erythematous base; self-limited; differentiate from SSSS
Drugs used in neonatal resuscitation
cephalohematoma
diffuse edematous swelling of scalp which does not cross suture lines; spontaneously dissapears
Poland syndrome
amastia, pectoralis muscle aplasia, rib deformities, webbed fingers, radial nerve aplasia
suppernumerary nipples
usually along mammary gland; associated with renal and cardiovascular anomalies
cutis marmorata
lacy, reticulated vascular pattern over skin on most of the body; improves but may be associated with syndromes
umbilical hernia
most close spontaneously; consider congenital hypothyroidism
subcutaneous fat necrosis
difficult labor/delivery, perinatal asphixia, prolonged hypothermia; hypocalcemia
Intraventricular Hemorrhage
Intracranial hemorrhage originating in the periventricular subependymal germinal matrix

Risk Factors
- extreme prematurity
- need for vigorous resuscitation at birth
- pneumothorax
- ventilated preterm infants
- sudden increase in arterial blood pressure with volume expansion
- hypotensive event
- hypertension
- RDS
- fluctuating cerebral bllod flow
- coagulopathy

Clinical Presentation
- many infants with IVH are asymptomatic
- subtle signs : apnea, bradycardia, changes in tone or activity, altered level of consciousness
- catastrophic presentation : bulging fontanelle, drop in hematocrit, acidosis, seizures, hypotension


Screening
Routine head ultrasound screening of all preterm infants <32 weeks gestation throughout NICU stay
Chronic non bacterial perinatal infections
TORCH

Toxoplasmosis
Others
Rubella virus
Cytomegalovirus, Chickenpox, Coxsackievirus
HSV, HIV, HBV
Erythema infectiosum (Parvovirus B19), EBV
Syphillis
routine newborn care
cleanse and rinse
bacterocidal agent to cord
1% silver nitrate or 0.5% erythromycin for eyes
1mg vitamin K IM
neonatal sepsis work-up and diagnosis
CBC
blood culture
urinalysis
urine culture
chest x-ray
if meningitis is suspected --> lumbar puncture
caput succedaneum
diffuse edematous swelling of scalp which crosses suture lines; spontaneously dissapears
hernias in newborn
usually inguinal and indirect; surgical treatment
intrauterine growth restriction
symmetric --> genetic syndromes, chromosomal abnormalities, congenital infections, teratogens
assymetric --> uteroplacental insufficiency due to maternal diseases; placental dysfunction
infants of diabetic mothers
fetal hyperinsulinemia --> hypoglycemia
large for gestational age and plethoric
hyperbilirubinemia
tachypnea
cardiomegaly - assymetric septal hypertrophy
birth trauma - macrosomia
polycythemia
renal vein thrombosis
salmon patch
nevus simplex; pale pink vascular macules usually symmetric; facial ones dissapear
mongolian spots
blue to slate-gray macules on presacral, back or posterior thighs; improves; differentiate from child abuse
Newborn Cyanosis
2 Major types

1) Peripheral cyanosis : can be normal transiently but may indicate sepsis, temperature instability

2) Central cyanosis (deoxygenated hemoglobin or abnormal hemoglobin)

- Upper respiratory : choanal atresia, macroglossia, airway hypoplasia, laryngeal web/cyst, foreign body
- Lower respiratory : pneumonia, meconium aspiration syndrome, pneumothorax, diaphragmatic hernia, AV fistula, pulmonary hypoplasia

- Congenital heart disease, PPHN
- CNS (asphyxia, seizure, narcotics, sedatives)
- Myasthenia gravis, botulism
- Polycythemia
- Sepsis
- Methemoglobinemia, Carboxyhemoglobinemia
Milia
Lesions 1-2 mm firm white pearly papules on nasal bridge, cheeks and palate; self resolving
Neonatal alloimmune thrombocytopenia
Pathophysiology
- platelet equivalent of Rh disease of the newborn
- occurs when mother is negative for human platelet antigen (HPA) and fetus is positive
- developmental of maternal IgG antibodies against GPA antigens on fetal platelets

Clinical features
- petechiae, purpura, thrombocytopenia in otherwise healthy neonate
- severe NAIT can lead to intracranial bleeding

Diagnosis
- Maternal and paternal platelet typing and identification of platelet alloantibodies

Treatment
- IVIG to mother prenatally, starts in second trimester; treat neonate with IVIG and trasnfusion of infant with washed maternal platelets or donor HPA negative platelets.
Complications of respiratory distress syndrome
Bronchopulmonary dysplasia
Pulmonary air leaks (pneumothorax)
Increased risk of chronic lung disease
newborn screening
do before discharge or fourth day
more realiable after 48 hours
examples: phenylketonuria, galactosemia, hypothyroidism
preauricular tags/pits
may indicate hearing loss and GU anomalies
nevus sebaceous
area of alopecia with nodular orange skin; possible malignancy; remove before adolescence
neonatal acne
erythematous papules on face from high maternal androgens; no treatment
congenital syphilis
before 2 --> fever, anemia, rash, jaundice, anemia
after 2 --> Hutchinson teeth, Clutton joints, saber shins, saddle nose, osteochondritis, rhagades
diagnosis --> radiographic bone changes, treponema in scrapings from lesions; most specific --> FTA-ABS
treatment --> penicillin
Hirchsprung disease
initial test --> barium enema shws megaacolon proximal to aganglionic segment
best test --> rectal biopsy shows absent ganglionic cells
meconium aspiration diagnosis
chest x-ray --> patchy infiltrates, increased AP diameter, flattening of diaphragm
neonatal seizures work-up
EEG --> may be normal
CBC, electrolytes, glucose
if meningitis --> lumbar puncture
if infection --> blood and urine cultures
if preterm --> ultrasound of the head for intraventricular hemorrhage
Management of newborn cyanosis
ABGs
Hyperoxic test to r/o CHD
CXR
Capillary hemangioma
Raised red lesion, which increases in size after birth and involutes; 50% resolved by 5 years, 90% by 9 years
Diagnosis of necrotizing entercolitis
Abdominal X-Ray : pneumonitis intestinalis (intramural air, hallmark of NEC), free air, fixed loop, ileus, thickened bowell wall, portal venous gas
meconium aspiration presentation
meconium passes as result of fetal hypoxia and distress
severe respiratory distress
hypoxemia
barrel chest
TORCH work-up if suspected
total cord IgM
urine CMV culture --> if negative, excludes CMV
IgM --> toxoplasmosis, rubella
maternal rubella status --> if positive, excludes it
PCR --> for herpes
Pathognomonic sign of respiratory distress syndrome on CXR
"Ground glass" appearance of lungs
Problems with pre-term newborns
- Respiratory distress syndrome, apnea of prematurity, chronic lung disease, bronchopulmonary displasia
- Feeding difficulties, necrotizing enterocolitis (NEC)
- Hypocalcemia, Hypoglycemia, Hypothermia
- Anemia, jaundice
- Retinopathy of prematurity
- Intracranial/ hemorrhage
- Patent ductus arteriosus
respiratory distress syndrome of newborn presentation
due to surfactant deficiency in premature
tachypnea, nasal flaring, grunting
hypoxemia, hypercabia and respiratory acidosis
Biliary atresia in newborns
- Pathophysiology
- Presentation
- Diagnosis
- Treatment
Atresia of extra-hepatic bile ducts
Cholestasis and increased conjugated bilirubin after the first week of life
Incidence : 1/10 000-15 000 live births

Clinical Presentation
- Dark urine, pale stool, jaundice (persisting > 2 weeks), abdominal distention, hepatomegaly

Diagnosis
- HIDA scan
- Liver biopsy

Treatment
- Surgical drainage procedure
- Hepatoportoenterostomy (Kasai procedure most successful if before 8 weeks of age)
- Usually requires liver transplantation
- Vitamins A, D, E and K, diet should be enriched with medium-chain triglycerides to ensure adequate fat ingestion
Presentation of bleeding disorders in children
Oozing from the umbilical stump
Excessive bleeding from peripheral venipuncture/heel stick sites / IV sites
Large caput succedaneum
Cephalohematomas
Prolonged bleeding following circumcision
Causes of SGA
- Most common cause : idiopathic
- Maternal disease e.g. pre-eclampsia
- Drugs, EtOH, smoking, TORCH
- Chromosomal
- Multiple pregnancy
- Placental insufficiency
Risk factors for neonatal jaundice
Maternal factors
- Ethnic group (asian, native american)
- Complications during pregnancy (diabetic mother, Rh or ABO incompatibility
- Breast feeding

Perinatal factors
- Birth trauma (cephalohematoma, ecchymoses)
- Prematurity

Neonatal factors
- Infection
- Genetic factors
- Polycythemia
- Drugs
- Difficulty establishing breastfeeding
Meconium Aspiration Syndrome (MAS)


Pathophysiology
Risk Factors
Presentation
Treatment
Prognosis
10-15% of all infants are meconium stained at birth; 5% of meconium stained infants get MAS
Usually associated with fetal distress in Utero or post-term infant

+ Clinical presentation
- respiratory distress within hours of birth
- small airway obstruction, chemical pneumonitis --> tachypnea, barrel chest with audible crackles
- CXR : hyperinflation, streaky atelectasis, patchy and coarse infiltrates

+ Complications
- Hypoxemia, hypercapnia, acidosis, PPHN, pneumothoarx, pneumomediastinum, pneumonia, sepsis, respiratory failure, death.

+ Treatment
- supportive care, assisted ventilation
- ventilated infants often require sedation
- may benefit from surfactant replacement (surfactant function is inhibited by presence of meconium)
- inhaled nitric oxyde, extracorporeal membrane oxygenation at some centres

+ Prevention
- in utero : careful monitoring
- after delivery of the head : suction oro / naspharynx
- at birth : intubate and suction below cords if infant is depressed
- note : presence of meconium staining alone is NOT and indication for tracheal suctioning. If the infant is vigorous, intubation and suctioning of lower airway is unnecessary.
Principles of treatment of rehydration
- Provision of maintenance daily fluid and electrolyte requirements
- Plus replacement of deficit fluids and electrolytes
- Plus replacement of ongoing losses
Physiologic jaundice pathophysiology and presentation
Term infants : 2-3 days of life, resolution by 7 days of life

Pathophysiology
- Increased hematocrit
- Decreased RBC span
- Immature glucuronyl transferase enzyme system (slow conjugation of bilirubin)
- Increased enterohepatic circulation
Important elements at maternal history
- Prenatal care
- Illnesses
- Uses of drugs
- Labour
- Previous high risk pregnancies
- Infections during pregnancy
- Current infections
- Duration of ruptured membranes
- Blood type and Rh status
- Amniotic fluid status
- Gestational age
- Meconium
- Apgar scores
Differential diagnosis of respiratory distress
Pulmonary
- RDS
- Transient tachypnea of the newborn
- Meconium aspiration syndrome
- Pleural effusions, pneumothorax
- Congenital lung malformations

Infectious
- sepsis
- pneumonia

Cardiac
- congenital heart disease
- PPHN

Hematologic
- blood loss
- polycythemia

Anatomic
-TE fistula
- Congenital diaphragmatic hernia
- Upper airway obstruction (choanal atresia, Pierre-Robin sequence, cleft palate)

Metabolic
- hypoglycemia
- inborn errors of metabolism

Neurologic
- CNS damage
- Drugs withdrawal syndromes
Etiology of hypoglycemia in newborns and presentation
Glucose < 2.6 mmol/L

Etiology
- Decreased carbohydrate storage (premature, IUGR)
- Infant of a diabetic mother : maternal hyperglycemia --> fetal hyperglycemia and hyperinsulinism --> hypoglycemia in the newborn infant because of high insulin levels
- Endocrine : hyperinsulinism due to islet cell hyperplasia (Beckwith-Wiedemann syndrome), panhypopituitarism
- inborn errors of metabolism : fatty acid oxidation defects, galactosemia


Presentation : signs often non specific and subtle
- lethargy
- poor feeding
- irritability
- tremors
- apnea
- seizures
When to assess Apgar scores
at 1 and 5 minutes

If < 7 at 5 minutes then reassess q5 minutes, until >7

do not wait to assign Apgar score before initiating resuscitation
Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death

J Perinatol 2009; 29(1):57-62
A reduction in the risk of necrotizing enterocolitis or death among extremely low birth weight infants was associated with human milk feeding. A possible dose-dependant beneficial effect of HM is suggestive in extremely low birth weight infants.
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